2020 LIST OF COVERED DRUGS (FORMULARY)
Prescription drug list information
UnitedHealthcare® Senior Care Options (HMO D-SNP)
UnitedHealthcare® Senior Care Options NHC (HMO D-SNP)
Important Notes: This document has information about the drugs covered by this plan. For more recent information or if you have questions, please call Customer Service at:
Toll-free 1-888-867-5511, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week
www.UHCCommunityPlan.com
Formulary ID Number 00020047, Version 19 H2226_190701_012345_C v01.10 UHCSCO 190701_012345 Last updated October 1, 2020
UnitedHealthcare® Senior Care Options (HMO D-SNP)
UnitedHealthcare® Senior Care Options NHC (HMO D-SNP)
2020 List of Covered Drugs (Formulary)
IntroductionThis document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs are covered by UnitedHealthcare Senior Care Options. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UnitedHealthcare Senior Care Options. Key terms and their definitions appear in the last chapter of the Evidence of Coverage.
Our contact information, along with the date we last updated the Drug List, appears on the front and back cover pages.
Table of Contents
A. Disclaimers..............................................................................................................................................4
B. Frequently Asked Questions (FAQ)...................................................................................................... 5
B1. What prescription drugs are on the List of Covered Drugs? (We call the List of CoveredDrugs the �“Drug List” for short.)................................................................................................ 5
B2. Does the Drug List ever change?...............................................................................................5
B3. What happens when there is a change to the Drug List?........................................................ 6
B4. Are there any restrictions or limits on drug coverage or any required actions to take to getcertain drugs?.............................................................................................................................. 7
B5. How will you know if the drug you want has limitations or if there are any actions requiredto get the drug?........................................................................................................................... 7
B6. What happens if we change our rules about how we cover some drugs (for example, priorauthorization (approval), quantity limits, and/or step therapy restrictions)?.......................... 8
B7. How can you find a drug on the Drug List?...............................................................................8
B8. What if the drug you want to take is not on the Drug List?...................................................... 8
B9. What if you are a new UnitedHealthcare Senior Care Options member and can’t find yourdrug on the Drug List or have a problem getting your drug?.................................................. 8
B10. Can you ask for an exception to cover your drug?...................................................................9
B11. How can you ask for an exception?.........................................................................................10
B12. How long does it take to get an exception?............................................................................10
B13. What are generic drugs?.......................................................................................................... 10
This section is continued on the next page.
B14. What are over-the-counter (OTC) drugs?................................................................................ 10
B15. Does UnitedHealthcare Senior Care Options cover non-drug OTC products?................... 10
B16. Can you get a long-term supply of drugs?.............................................................................. 10
B17. What is your copay?..................................................................................................................11
C. Overview of the List of Covered Drugs...............................................................................................12
C1. List of Drugs by Medical Condition......................................................................................... 12
C2. Covered drugs with a quantity limit (QL).................................................................................91
C3. Over-the-counter (OTC) Drug List.......................................................................................... 119
D. Index of Covered Drugs.....................................................................................................................189
If you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more
information, visit www.UHCCommunityPlan.com.
A. Disclaimers
This is a list of drugs that members can get in UnitedHealthcare Senior Care Options.
v UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare.
v The Drug List (formulary) may change on January 1 of each year, and from time to time during the plan year. You will receive notice when necessary.
v You can always check UnitedHealthcare Senior Care Options’ up-to-date List of Covered Drugs online at www.UHCCommunityPlan.com or by calling Customer Service toll-free at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.
v ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free.
v ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame a Servicio al Cliente de UnitedHealthcare Senior Care Options al 1-888-867-5511, TTY 711, de 8 a.m. a 8 p.m., hora local, los 7 días de la semana. La llamada es gratuita.
v You can get this document for free in other formats, such as large print, braille, or audio. Call Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.
v You can call Customer Service and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future.
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B. Frequently Asked Questions (FAQ)
Find answers to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more or look for a question and answer.
B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the Drug List that starts on page 12 are the drugs covered by UnitedHealthcare Senior Care Options. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”
· UnitedHealthcare Senior Care Options will cover all medically necessary drugs on the Drug List if:
o Your doctor or other prescriber says you need them to get better or stay healthy,
o The plan agrees that the drug is medically necessary for you, and
o You fill the prescription at a UnitedHealthcare Senior Care Options network pharmacy.
· UnitedHealthcare Senior Care Options may have additional steps to access certain drugs. See question B4 for more information.
You can also see an up-to-date list of drugs we cover on our website at www.UHCCommunityPlan.com or call Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.
B2. Does the Drug List ever change?
Yes. UnitedHealthcare Senior Care Options may add or remove drugs on the Drug List during the year. We must follow Medicare rules in making these changes.
We may also change our rules about drugs. For example we could:
· Decide to require or not require prior authorization (approval) for a drug. (Prior authorization (approval) is permission from UnitedHealthcare Senior Care Options before you can get a drug.)
· Add or change the amount of a drug you can get (called quantity limits).
· Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)
For more information on these drug rules, see question B4.
If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:
This section is continued on the next page.
If you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more
information, visit www.UHCCommunityPlan.com.
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· A new, cheaper drug comes on the market that works as well as a drug on the Drug List now, or
· We learn that a drug is not safe, or
· A drug is removed from the market.
Questions B3 and B6 have more information on what happens when the Drug List changes.
· You can always check UnitedHealthcare Senior Care Options’ current Drug List online at www.UHCCommunityPlan.com.
· You can also call Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week to check the current Drug List.
B3. What happens when there is a change to the Drug List?
Some changes to the Drug List will happen immediately. For example:
· A new generic drug becomes available. Sometimes, a new generic drug comes on the market that works as well as a brand name drug on the Drug List now. When that happens, we may remove the brand name drug and add the new generic drug. When we add the new generic drug, we may also decide to keep the brand name drug on the list but change its coverage rules or limits.
o We may not tell you before we make this change, but we will send you information about the specific change we made once it happens.
o You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see questions B10 - B12 for more information on exceptions.
· A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Contact your doctor or other prescriber and ask about your other options.
We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:
· The FDA provides new guidance or there are new clinical guidelines about a drug.
· We add a generic drug that is new to the market and
· Replace a brand name drug currently on the Drug List or
· Change the coverage rules or limits for the brand name drug.
When these changes happen, we will:
· Tell you at least 30 days before we make the change to the Drug List or
· Let you know and give you a 30-day supply of the drug after you ask for a refill.
This section is continued on the next page.
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This will give you time to talk to your doctor or other prescriber. He or she can help you decide:
· If there is a similar drug on the Drug List you can take instead or
· Whether to ask for an exception from these changes. To learn more about exceptions, see questions B10 - B12 for more information about exceptions.
B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?
Yes. Some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example:
· Prior authorization (approval): For some drugs, you, your doctor or other prescriber must get authorization (approval) from UnitedHealthcare Senior Care Options before you fill your prescription. Prior authorization is different from a referral. UnitedHealthcare Senior Care Options may not cover the drug if you don’t get authorization (approval).
· Quantity limits: Sometimes UnitedHealthcare Senior Care Options limits the amount of a drug you can get.
· Step therapy: Sometimes UnitedHealthcare Senior Care Options requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’t work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on pages 14 - 90. You can also get more information by visiting our website at www.UHCCommunityPlan.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.
You can ask for an exception to these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10 - B12 for more information about exceptions.
B5. How will you know if the drug you want has limitations or if there are any actions required to get the drug?
The Drug List on pages 14 - 90 has a column labeled “Necessary actions, restrictions, or limits on use.”
This section is continued on the next page.
If you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more
information, visit www.UHCCommunityPlan.com.
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B6. What happens if we change our rules about how we cover some drugs (for
example, prior authorization (approval), quantity limits, and/or step therapy
restrictions)?
In some cases, we will tell you in advance if we add or change prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.
B7. How can you find a drug on the Drug List?
There are two ways to find a drug:
· You can search alphabetically (if you know how to spell the drug), or
· You can search by medical condition.
To search alphabetically, go to the Index of Covered Drugs section that begins on page 189. The Index is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. To search by medical condition, find the section labeled “List of Drugs by Medical Condition” on page 12. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.
B8. What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Customer Service at 1-888-867-5511, TTY 711 and ask about it. If you learn that UnitedHealthcare Senior Care Options will not cover the drug, you can do one of these things:
· Ask Customer Service for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or
· You can ask the health plan to make an exception to cover your drug. Please see questions B10 - B12 for more information about exceptions.
B9. What if you are a new UnitedHealthcare Senior Care Options member and can’t find your drug on the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Senior Care Options. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead, or whether to ask for an exception.
This section is continued on the next page.
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If your prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 30 days of medication.
We will cover a temporary 30-day supply of your drug if:
.
If
1-
in
· You are taking a drug that is not on our Drug List, or
· Health plan rules do not let you get the amount ordered by your prescriber, or
· The drug requires prior authorization (approval) by UnitedHealthcare Senior Care Options, or
· You are taking a drug that is part of a step therapy restriction.
If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:
· We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Senior Care Options member.
· This is in addition to the temporary supply during the first 90 days you are a member of UnitedHealthcare Senior Care Options.
If you are going through a change in your level of care, such as being transferred from a hospital to a long-term care facility, any time during the year, we may cover a temporary 31-day supply of the drug you need. This will give you time to talk to your doctor or other prescriber about other treatment options or to try to get an exception. Please see questions B10 - B12 for more information about exceptions.
We will not pay for more of your drug after you get a temporary supply unless you receive authorization from the plan.
B10. Can you ask for an exception to cover your drug?
Yes. You can ask UnitedHealthcare Senior Care Options to make an exception to cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.
· For example, UnitedHealthcare Senior Care Options may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.
· Other examples: You can ask us to drop step therapy restrictions or prior authorization (approval) requirements.
This section is continued on the next page
you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more
formation, visit www.UHCCommunityPlan.com.
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B14. What are over-the-counter (OTC) drugs?
OTC stands for “over-the-counter.” UnitedHealthcare Senior Care Options covers some OTC drugs when they are written as prescriptions by your provider. These OTC drugs are listed in this Drug List starting on page 119.
B15. Does UnitedHealthcare Senior Care Options cover non-drug OTC products?
Yes. UnitedHealthcare Senior Care Options covers some non-drug OTC products when they are written as prescriptions by your provider. These non-drug OTC products are listed in the Drug List.
B16. Can you get a long-term supply of drugs?
Yes. UnitedHealthcare Senior Care Options offers two ways to get a long-term supply of “maintenance” drugs on our plan’s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)
· Retail pharmacy. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Pharmacy Directory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs.
B11. How can you ask for an exception?
To ask for an exception, call Customer Service. A Customer Service representative will work with you and your provider to help you ask for an exception. You can also read Chapter 8 of the Evidence of Coverage to learn more about exceptions.
B12. How long does it take to get an exception?
First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.
B13. What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).
UnitedHealthcare Senior Care Options covers both brand name drugs and generic drugs.
· Mail-order. For certain kinds of drugs, you can use the plan’s network mail-order services. Our plan’s mail-order service allows you to get up to a 90-day supply. To get order forms and information about filling your prescriptions by mail, please reference your Pharmacy
Directory to find the mail service pharmacies in our network.
This section is continued on the next page.
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For more information about getting a long-term supply of drugs, call Customer Service at 1-888-867-5511, TTY 711.
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B17. What is your copay?
UnitedHealthcare Senior Care Options members have no copays for prescription and over-the-counter (OTC) drugs and non-drug products as long as the member follows the plan’s rules. See questions B14 and B15 for more information about OTC drugs and non-drug products.
Tiers are groups of drugs on our Drug List. Your plan has 1 tier named “Covered Drugs.” All covered drugs are in this tier.
· Tier 1 Generic drugs have $0 copay.
· Tier 1 Brand name drugs have $0 copay.
OTCs have $0 copay.
f you have questions, call Customer Service at 1-888-867-5511, TTY 711.
f you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more
nformation, visit www.UHCCommunityPlan.com.
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C. Overview of the List of Covered Drugs
The List of Covered Drugs gives you information about the drugs covered by UnitedHealthcare Senior Care Options. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 189. The index alphabetically lists all drugs covered by UnitedHealthcare Senior Care Options.
C1. List of Drugs by Medical Condition
The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the “Antimigraine Agents” category. That is where you will find drugs that treat migraines.
The first column of the table lists the name of the drug. Generic drugs are listed in plain type (e.g., Simvastatin) and brand name drugs are in bold type (e.g., Humalog).
The second column lists the Medicare Part D drug tier. Your plan has 1 tier named “Covered Drugs.” All covered drugs are in this tier. As a member of this plan, you have no copays for
covered, prescribed drugs when obtained from network pharmacies.
The information in the “Necessary actions, restrictions, or limits on use” column tells you if UnitedHealthcare Senior Care Options has any rules for covering your drug.
Coverage Rules and Limits
PA – Prior authorization (approval)
For some drugs, you, your doctor or other prescriber must get authorization (approval) from UnitedHealthcare Senior Care Options before you fill your prescription. Prior authorization is different from a referral. UnitedHealthcare Senior Care Options may not cover the drug if you don’t get authorization (approval).
QL – Quantity limits
Sometimes UnitedHealthcare Senior Care Options limits the amount of a drug you can get.
ST – Step therapy
Sometimes UnitedHealthcare Senior Care Options requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’t work for you, then we will cover the second.
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This section is continued on the next page.
2Other Special Coverage Rules
B/D – Medicare Part B or Part D
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.
LA – Limited access
Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.
MME – Morphine milligram equivalent
Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.
7D – 7-Day limit
An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan.
DL – Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription.
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You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
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A1
B1
C1Butalbital-Acetaminophen-Caffeine
C1Butalbital-Aspirin-Caffeine
B1
C1Celecoxib
C1Diclofenac Epolamine
C1Diclofenac Potassium
C1Diclofenac Sodium ER
C1Diclofenac Sodium
C1Diclofenac Sodium
C1Diflunisal
C1Etodolac ER
C1Etodolac
C1Etodolac
C1Flector
C1Flurbiprofen
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ibu
C1Ibuprofen
C1Ibuprofen
C1Indomethacin
C1Ketoprofen
C1Meloxicam
C1Nabumetone
C1Naproxen DR
C1Naproxen
C1Naproxen
C1Piroxicam
C1Sulindac
B1
C1Buprenorphine
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Analgesics
Analgesics
Butalbital-Acetaminophen-Caffeine (Oral Tablet)
1 QL
Butalbital-Aspirin-Caffeine (Oral Capsule)
1 QL
Nonsteroidal Anti-inflammatory Drugs
Celecoxib (Oral Capsule)
1 QL
Diclofenac Epolamine (Transdermal Patch)
1 PA; QL
Diclofenac Potassium (Oral Tablet)
1
Diclofenac Sodium ER (Oral Tablet Extended Release 24 Hour)
1
Diclofenac Sodium (Oral Tablet Delayed Release)
1
Diclofenac Sodium (1% Transdermal Gel)
1
Diflunisal (Oral Tablet) 1
Etodolac ER (Oral Tablet Extended Release 24 Hour)
1
Etodolac (Oral Capsule)
1
Etodolac (Oral Tablet Immediate Release)
1
Flector (Transdermal
Patch)1 PA; QL
Flurbiprofen (100MG Oral Tablet)
1
Ibu (600MG Oral Tablet, 800MG Oral Tablet)
1
Ibuprofen (Oral Suspension)
1
Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet, 800MG Oral Tablet)
1
Indomethacin (25MG Oral Capsule Immediate Release, 50MG Oral Capsule Immediate Release)
1
Ketoprofen (Oral Capsule Immediate Release)
1
Meloxicam (Oral Tablet)
1
Nabumetone (Oral Tablet)
1
Naproxen DR (Oral Tablet Delayed Release) (Generic EC-Naprosyn)
1
Naproxen (Oral Suspension)
1
Naproxen (Oral Tablet Immediate Release)
1
Piroxicam (Oral Capsule)
1
Sulindac (Oral Tablet) 1
Opioid Analgesics, Long-acting
Buprenorphine (Transdermal Patch Weekly)
1 7D; DL; QL
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4
Bold type = Brand name drug Plain type = Generic drug
C1Fentanyl
C1Hydromorphone HCl ER
C1Hysingla ER
C1Levorphanol Tartrate
C1Methadone HCl
C1Methadone HCl
C1Morphine Sulfate ER
C1Morphine Sulfate ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Nucynta ER
C1Tramadol HCl ER
C1Tramadol HCl ER
C1Xtampza ER
B1
C1Acetaminophen-Codeine
C1Acetaminophen-Codeine
C1Butorphanol Tartrate
C1Codeine Sulfate
C1Codeine Sulfate
C1Endocet
C1Fentanyl Citrate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)
17D; MME;
DL; QL
Hydromorphone HCl ER (Oral Tablet ER 24 Hour Abuse-Deterrent)
17D; MME;
DL; QL
Hysingla ER (Oral
Tablet ER 24 Hour
Abuse-Deterrent)
17D; MME;
DL; QL
Levorphanol Tartrate (Oral Tablet)
17D; MME;
DL; QL
Methadone HCl (Oral Solution)
17D; MME;
DL; QL
Methadone HCl (Oral Tablet)
17D; MME;
DL; QL
Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release, 30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)
17D; MME;
DL; QL
Morphine Sulfate ER (200MG Oral Tablet Extended Release) (Generic MS Contin)
17D; MME;
DL; QL
Nucynta ER (Oral
Tablet Extended
Release 12 Hour)
17D; MME;
DL; QL
Tramadol HCl ER (Biphasic) (Oral Tablet Extended Release 24 Hour)
17D; MME;
DL; QL
Tramadol HCl ER (Oral Tablet Extended Release 24 Hour)
17D; MME;
DL; QL
Xtampza ER (Oral
Capsule ER 12 Hour
Abuse-Deterrent)
17D; MME;
DL; QL
Opioid Analgesics, Short-acting
Acetaminophen-Codeine (120-12MG/ 5ML Oral Solution)
17D; MME;
DL; QL
Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Tablet)
17D; MME;
DL; QL
Butorphanol Tartrate (Nasal Solution)
17D; MME;
DL; QL
Codeine Sulfate
(15MG Oral Tablet)1
7D; MME; DL; QL
Codeine Sulfate (30MG Oral Tablet, 60MG Oral Tablet)
17D; MME;
DL; QL
Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)
17D; MME;
DL; QL
Fentanyl Citrate (Buccal Lozenge On A Handle)
1 PA; DL; QL
tRACK 15
5
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Hydrocodone-Acetaminophen
C1Hydrocodone-Acetaminophen
C1Hydrocodone-Ibuprofen
C1Hydromorphone HCl
C1Hydromorphone HCl
C1Hydromorphone HCl Preservative Free
C1Lorcet HD
C1Lorcet
C1Morphine Sulfate
C1Morphine Sulfate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Oxycodone HCl
C1Oxycodone HCl
C1Oxycodone HCl
C1Oxycodone-Acetaminophen
C1Oxycodone-Aspirin
C1Tramadol HCl
C1Tramadol-Acetaminophen
C1Trezix
A1
B1
C1Lidocaine
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral Solution)
17D; MME;
DL; QL
Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)
17D; MME;
DL; QL
Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet)
17D; MME;
DL; QL
Hydromorphone HCl (1MG/ML Oral Liquid)
17D; MME;
DL; QL
Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release, 8MG Oral Tablet Immediate Release)
17D; MME;
DL; QL
Hydromorphone HCl Preservative Free (10MG/ML Injection Solution, 50MG/5ML Injection Solution)
1 DL
Lorcet HD (Oral Tablet) 17D; MME;
DL; QL
Lorcet (Oral Tablet) 17D; MME;
DL; QL
Morphine Sulfate (Oral Solution)
17D; MME;
DL; QL
Morphine Sulfate
(Oral Tablet
Immediate Release)
17D; MME;
DL; QL
Oxycodone HCl (100MG/5ML Oral Concentrate)
17D; MME;
DL; QL
Oxycodone HCl (5MG/ 5ML Oral Solution)
17D; MME;
DL; QL
Oxycodone HCl (10MG Oral Tablet Immediate Release, 15MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)
17D; MME;
DL; QL
Oxycodone-Acetaminophen (10-325MG Oral Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)
17D; MME;
DL; QL
Oxycodone-Aspirin (Oral Tablet)
17D; MME;
DL; QL
Tramadol HCl (50MG Oral Tablet Immediate Release)
17D; MME;
DL; QL
Tramadol-Acetaminophen (Oral Tablet)
17D; MME;
DL; QL
Trezix (Oral Capsule) 17D; MME;
DL; QL
Anesthetics
Local Anesthetics
Lidocaine (5% External Ointment)
1 QL
tRACK16
6
Bold type = Brand name drug Plain type = Generic drug
C1Lidocaine
C1Lidocaine HCl
C1Lidocaine HCl
C1Lidocaine Viscous
C1Lidocaine-Prilocaine
A1
B1
C1Acamprosate Calcium
C1Disulfiram
C1Naltrexone HCl
C1Vivitrol
B1
C1Buprenorphine HCl
C1Buprenorphine HCl-Naloxone HCl
C1Buprenorphine HCl-Naloxone HCl
C1Suboxone
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Naloxone HCl
C1Naloxone HCl
C1Naloxone HCl
C1Narcan
B1
C1Bupropion HCl SR
C1Chantix Continuing Month Pak
C1Chantix
C1Chantix Starting Month Pak
C1Nicotrol
C1Nicotrol NS
A1
B1
C1Amikacin Sulfate
C1Gentak
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Lidocaine (5% External Patch)
1 PA; QL
Lidocaine HCl (4% External Solution)
1
Lidocaine HCl (External Gel)
1
Lidocaine Viscous (2% Mouth/Throat Solution)
1
Lidocaine-Prilocaine (External Cream)
1
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
Acamprosate Calcium (Oral Tablet Delayed Release)
1
Disulfiram (Oral Tablet) 1
Naltrexone HCl (Oral Tablet)
1
Vivitrol (Intramuscular
Suspension
Reconstituted)
1
Opioid Dependence Treatments
Buprenorphine HCl (Tablet Sublingual)
1 QL
Buprenorphine HCl-Naloxone HCl (Sublingual Film)
1 QL
Buprenorphine HCl-Naloxone HCl (Tablet Sublingual)
1 QL
Suboxone (Sublingual
Film)1 QL
Opioid Reversal Agents
Naloxone HCl (0.4MG/ ML Injection Solution)
1
Naloxone HCl (Injection Solution Cartridge)
1
Naloxone HCl (Injection Solution Prefilled Syringe)
1
Narcan (Nasal Liquid) 1
Smoking Cessation Agents
Bupropion HCl SR (150MG Oral Tablet Extended Release 12 Hour Smoking-Deterrent)
1
Chantix Continuing
Month Pak (Oral
Tablet)
1
Chantix (Oral Tablet) 1
Chantix Starting
Month Pak (Oral
Tablet)
1
Nicotrol (Inhalation
Inhaler)1
Nicotrol NS (Nasal
Solution)1
Antibacterials
Aminoglycosides
Amikacin Sulfate (500MG/2ML Injection Solution)
1
Gentak (Ophthalmic Ointment)
1
tRACK 17
7
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Gentamicin Sulfate-0.9% Sodium Chloride
C1Gentamicin Sulfate
C1Gentamicin Sulfate
C1Gentamicin Sulfate
C1Gentamicin Sulfate
C1Neomycin Sulfate
C1Paromomycin Sulfate
C1Streptomycin Sulfate
C1Tobramycin
C1Tobramycin Sulfate
C1Tobrex
B1
C1Bacitracin
C1Clindamycin HCl
C1Clindamycin Palmitate HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Clindamycin Phosphate in D5W
C1Clindamycin Phosphate
C1Clindamycin Phosphate
C1Colistimethate Sodium
C1Dalvance
C1Daptomycin
C1Daptomycin
C1Linezolid
C1Linezolid
C1Linezolid
C1Methenamine Hippurate
C1Metronidazole
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Gentamicin Sulfate-0.9% Sodium Chloride (Intravenous Solution)
1
Gentamicin Sulfate (External Cream)
1
Gentamicin Sulfate (External Ointment)
1
Gentamicin Sulfate (40MG/ML Injection Solution)
1
Gentamicin Sulfate (Ophthalmic Solution)
1
Neomycin Sulfate (Oral Tablet)
1
Paromomycin Sulfate (Oral Capsule)
1
Streptomycin Sulfate (Intramuscular Solution Reconstituted)
1
Tobramycin (Ophthalmic Solution)
1
Tobramycin Sulfate (10MG/ML Injection Solution, 80MG/2ML Injection Solution)
1
Tobrex (Ophthalmic
Ointment)1
Antibacterials, Other
Bacitracin (Ophthalmic Ointment)
1
Clindamycin HCl (Oral Capsule)
1
Clindamycin Palmitate HCl (Oral Solution Reconstituted)
1
Clindamycin Phosphate in D5W (Intravenous Solution)
1
Clindamycin Phosphate (300MG/ 2ML Injection Solution, 600MG/4ML Injection Solution, 900MG/6ML Injection Solution)
1
Clindamycin Phosphate (Vaginal Cream)
1
Colistimethate Sodium (CBA) (Injection Solution Reconstituted)
1
Dalvance (Intravenous
Solution
Reconstituted)
1 PA
Daptomycin (350MG
Intravenous Solution
Reconstituted)
1
Daptomycin (500MG Intravenous Solution Reconstituted)
1
Linezolid (Intravenous Solution)
1
Linezolid (Oral Suspension Reconstituted)
1
Linezolid (Oral Tablet) 1 QL
Methenamine Hippurate (Oral Tablet)
1
Metronidazole (0.75% External Cream)
1
tRACK18
8
Bold type = Brand name drug Plain type = Generic drug
C1Metronidazole
C1Metronidazole
C1Metronidazole in NaCl 0.79%
C1Metronidazole
C1Metronidazole
C1Mupirocin Calcium
C1Mupirocin
C1Nitrofurantoin Macrocrystal
C1Nitrofurantoin Monohydrate
C1Nitrofurantoin
C1Polymyxin B Sulfate
C1Sulfamylon
C1Tigecycline
C1Tinidazole
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Trimethoprim
C1Vancomycin HCl
C1Vancomycin HCl
C1Vancomycin HCl
C1Vandazole
B1
C1Cefaclor
C1Cefadroxil
C1Cefadroxil
C1Cefazolin Sodium
C1Cefdinir
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Metronidazole (0.75% External Gel, 1% External Gel)
1
Metronidazole (0.75% External Lotion)
1
Metronidazole in NaCl 0.79% (Intravenous Solution)
1
Metronidazole (250MG Oral Tablet, 500MG Oral Tablet)
1
Metronidazole (0.75% Vaginal Gel)
1
Mupirocin Calcium (External Cream)
1
Mupirocin (External Ointment)
1
Nitrofurantoin Macrocrystal (100MG Oral Capsule, 50MG Oral Capsule) (Generic Macrodantin)
1
Nitrofurantoin Monohydrate (Generic Macrobid)
1
Nitrofurantoin (Oral Suspension)
1
Polymyxin B Sulfate (Injection Solution Reconstituted)
1
Sulfamylon (External
Cream)1
Tigecycline (Intravenous Solution Reconstituted)
1
Tinidazole (Oral Tablet) 1
Trimethoprim (Oral Tablet)
1
Vancomycin HCl (10GM Intravenous Solution Reconstituted, 1GM Intravenous Solution Reconstituted, 500MG Intravenous Solution Reconstituted, 750MG Intravenous Solution Reconstituted)
1
Vancomycin HCl
(250MG Intravenous
Solution
Reconstituted)
1
Vancomycin HCl (Oral Capsule)
1 QL
Vandazole (Vaginal
Gel)1
Beta-lactam, Cephalosporins
Cefaclor (Oral Capsule)
1
Cefadroxil (Oral Capsule)
1
Cefadroxil (Oral Suspension Reconstituted)
1
Cefazolin Sodium (10GM Injection Solution Reconstituted, 1GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)
1
Cefdinir (Oral Capsule) 1
tRACK 19
9
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Cefdinir
C1Cefepime HCl
C1Cefixime
C1Cefixime
C1Cefotetan Disodium
C1Cefoxitin Sodium
C1Cefoxitin Sodium
C1Cefpodoxime Proxetil
C1Cefpodoxime Proxetil
C1Cefprozil
C1Cefprozil
C1Ceftazidime
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ceftriaxone Sodium
C1Ceftriaxone Sodium
C1Cefuroxime Axetil
C1Cefuroxime Sodium
C1Cefuroxime Sodium
C1Cephalexin
C1Cephalexin
C1Suprax
C1Suprax
C1Suprax
C1Tazicef
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Cefdinir (Oral Suspension Reconstituted)
1
Cefepime HCl (Injection Solution Reconstituted)
1
Cefixime (Oral Capsule)
1
Cefixime (Oral Suspension Reconstituted)
1
Cefotetan Disodium (Injection Solution Reconstituted)
1
Cefoxitin Sodium (Injection Solution Reconstituted)
1
Cefoxitin Sodium (Intravenous Solution Reconstituted)
1
Cefpodoxime Proxetil (Oral Suspension Reconstituted)
1
Cefpodoxime Proxetil (Oral Tablet)
1
Cefprozil (Oral Suspension Reconstituted)
1
Cefprozil (Oral Tablet) 1
Ceftazidime (Injection Solution Reconstituted)
1
Ceftriaxone Sodium (1GM Injection Solution Reconstituted, 250MG Injection Solution Reconstituted, 2GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)
1
Ceftriaxone Sodium (10GM Intravenous Solution Reconstituted)
1
Cefuroxime Axetil (Oral Tablet)
1
Cefuroxime Sodium (Injection Solution Reconstituted)
1
Cefuroxime Sodium (Intravenous Solution Reconstituted)
1
Cephalexin (Oral Capsule)
1
Cephalexin (Oral Suspension Reconstituted)
1
Suprax (Oral Capsule) 1
Suprax (500MG/5ML
Oral Suspension
Reconstituted)
1
Suprax (Oral Tablet Chewable)
1
Tazicef (Injection Solution Reconstituted)
1
tRACK20
10
Bold type = Brand name drug Plain type = Generic drug
C1Zerbaxa
B1
C1Aztreonam
C1Ertapenem Sodium
C1Imipenem-Cilastatin
C1Meropenem
B1
C1Amoxicillin
C1Amoxicillin
C1Amoxicillin
C1Amoxicillin
C1Amoxicillin-Potassium Clavulanate ER
C1Amoxicillin-Potassium Clavulanate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Amoxicillin-Potassium Clavulanate
C1Amoxicillin-Potassium Clavulanate
C1Ampicillin
C1Ampicillin Sodium
C1Ampicillin Sodium
C1Ampicillin-Sulbactam Sodium
C1Ampicillin-Sulbactam Sodium
C1Bicillin C-R 900/300
C1Bicillin C-R
C1Bicillin L-A
C1Dicloxacillin Sodium
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Zerbaxa (Intravenous
Solution
Reconstituted)
1 PA
Beta-lactam, Other
Aztreonam (1GM Injection Solution Reconstituted)
1
Ertapenem Sodium (Injection Solution Reconstituted)
1
Imipenem-Cilastatin (Intravenous Solution Reconstituted)
1
Meropenem (Intravenous Solution Reconstituted)
1
Beta-lactam, Penicillins
Amoxicillin (Oral Capsule)
1
Amoxicillin (Oral Suspension Reconstituted)
1
Amoxicillin (Oral Tablet Immediate Release)
1
Amoxicillin (Oral Tablet Chewable)
1
Amoxicillin-Potassium Clavulanate ER (Oral Tablet Extended Release 12 Hour)
1
Amoxicillin-Potassium Clavulanate (Oral Suspension Reconstituted)
1
Amoxicillin-Potassium Clavulanate (Oral Tablet Immediate Release)
1
Amoxicillin-Potassium Clavulanate (Oral Tablet Chewable)
1
Ampicillin (Oral Capsule)
1
Ampicillin Sodium (125MG Injection Solution Reconstituted, 1GM Injection Solution Reconstituted)
1
Ampicillin Sodium (10GM Intravenous Solution Reconstituted)
1
Ampicillin-Sulbactam Sodium (Injection Solution Reconstituted)
1
Ampicillin-Sulbactam Sodium (15 (10-5)GM Intravenous Solution Reconstituted)
1
Bicillin C-R 900/300
(Intramuscular
Suspension)
1
Bicillin C-R
(Intramuscular
Suspension)
1
Bicillin L-A
(Intramuscular
Suspension)
1
Dicloxacillin Sodium (Oral Capsule)
1
tRACK 21
11
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Nafcillin Sodium
C1Nafcillin Sodium
C1Oxacillin Sodium in Dextrose
C1Oxacillin Sodium
C1Oxacillin Sodium
C1Penicillin G Potassium
C1Penicillin G Procaine
C1Penicillin G Sodium
C1Penicillin V Potassium
C1Penicillin V Potassium
C1Piperacillin-Tazobactam
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Azasite
C1Azithromycin
C1Azithromycin
C1Azithromycin
C1Clarithromycin ER
C1Clarithromycin
C1Clarithromycin
C1Dificid
C1E.E.S. Granules
C1Erythrocin Lactobionate
C1Erythromycin Base
C1Erythromycin Base
C1Erythromycin Base
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Nafcillin Sodium (1GM Injection Solution Reconstituted, 2GM Injection Solution Reconstituted)
1
Nafcillin Sodium (10GM Intravenous Solution Reconstituted)
1
Oxacillin Sodium in
Dextrose (Intravenous
Solution)
1
Oxacillin Sodium (Injection Solution Reconstituted)
1
Oxacillin Sodium (Intravenous Solution Reconstituted)
1
Penicillin G Potassium (20000000UNIT Injection Solution Reconstituted)
1
Penicillin G Procaine (Intramuscular Suspension)
1
Penicillin G Sodium (Injection Solution Reconstituted)
1
Penicillin V Potassium (Oral Solution Reconstituted)
1
Penicillin V Potassium (Oral Tablet)
1
Piperacillin-Tazobactam (Intravenous Solution Reconstituted)
1
Macrolides
Azasite (Ophthalmic
Solution)1
Azithromycin (Intravenous Solution Reconstituted)
1
Azithromycin (Oral Suspension Reconstituted)
1
Azithromycin (Oral Tablet)
1
Clarithromycin ER (Oral Tablet Extended Release 24 Hour)
1
Clarithromycin (Oral Suspension Reconstituted)
1
Clarithromycin (Oral Tablet Immediate Release)
1
Dificid (Oral Tablet) 1
E.E.S. Granules (Oral
Suspension
Reconstituted)
1
Erythrocin Lactobionate (Intravenous Solution Reconstituted)
1
Erythromycin Base (Oral Capsule Delayed Release Particles)
1
Erythromycin Base (Oral Tablet Immediate Release)
1
Erythromycin Base (Oral Tablet Delayed Release)
1
tRACK22
12
Bold type = Brand name drug Plain type = Generic drug
C1Erythromycin Ethylsuccinate
C1Erythromycin Ethylsuccinate
C1Erythromycin
B1
C1Besivance
C1Ciloxan
C1Ciprofloxacin HCl
C1Ciprofloxacin HCl
C1Ciprofloxacin HCl
C1Ciprofloxacin in D5W
C1Gatifloxacin
C1Levofloxacin in D5W
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Levofloxacin
C1Levofloxacin
C1Levofloxacin
C1Levofloxacin
C1Moxifloxacin HCl in NaCl
C1Moxifloxacin HCl
C1Moxifloxacin HCl
C1Ofloxacin
C1Ofloxacin
C1Ofloxacin
B1
C1Silver Sulfadiazine
C1SSD
C1Sulfacetamide Sodium
C1Sulfacetamide Sodium
C1Sulfadiazine
C1Sulfamethoxazole-Trimethoprim
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Erythromycin Ethylsuccinate (200MG/5ML Oral Suspension Reconstituted)
1
Erythromycin Ethylsuccinate (Oral Tablet)
1
Erythromycin (Ophthalmic Ointment)
1
Quinolones
Besivance
(Ophthalmic
Suspension)
1
Ciloxan (Ophthalmic
Ointment)1
Ciprofloxacin HCl (Ophthalmic Solution)
1
Ciprofloxacin HCl (100MG Oral Tablet Immediate Release)
1
Ciprofloxacin HCl (250MG Oral Tablet Immediate Release, 500MG Oral Tablet Immediate Release, 750MG Oral Tablet Immediate Release)
1
Ciprofloxacin in D5W (200MG/100ML Intravenous Solution)
1
Gatifloxacin (Ophthalmic Solution)
1
Levofloxacin in D5W (500MG/100ML Intravenous Solution, 750MG/150ML Intravenous Solution)
1
Levofloxacin (25MG/ ML Intravenous Solution)
1
Levofloxacin (0.5% Ophthalmic Solution)
1
Levofloxacin (25MG/ ML Oral Solution)
1
Levofloxacin (250MG Oral Tablet, 500MG Oral Tablet, 750MG Oral Tablet)
1
Moxifloxacin HCl in NaCl (Intravenous Solution)
1
Moxifloxacin HCl (Ophthalmic Solution) (Generic Vigamox)
1
Moxifloxacin HCl (Oral Tablet)
1
Ofloxacin (Ophthalmic Solution)
1
Ofloxacin (Oral Tablet) 1
Ofloxacin (Otic Solution)
1
Sulfonamides
Silver Sulfadiazine (External Cream)
1
SSD (External Cream) 1
Sulfacetamide Sodium (Ophthalmic Ointment)
1
Sulfacetamide Sodium (Ophthalmic Solution)
1
Sulfadiazine (Oral Tablet)
1
Sulfamethoxazole-Trimethoprim (Oral Suspension)
1
tRACK 23
13
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Sulfamethoxazole-Trimethoprim
B1
C1Demeclocycline HCl
C1Doxy 100
C1Doxycycline Hyclate
C1Doxycycline Hyclate
C1Doxycycline Monohydrate
C1Doxycycline Monohydrate
C1Doxycycline Monohydrate
C1Minocycline HCl
C1Minocycline HCl
C1Tetracycline HCl
C1Vibramycin
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useA1
B1
C1BRIVIACT
C1BRIVIACT
C1Epidiolex
C1Fintepla
C1Levetiracetam ER
C1Levetiracetam
C1Levetiracetam
C1Nayzilam
C1Roweepra
C1Roweepra XR
C1Spritam ODT
C1Xcopri
C1Xcopri
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Sulfamethoxazole-Trimethoprim (Oral Tablet)
1
Tetracyclines
Demeclocycline HCl (Oral Tablet)
1
Doxy 100 (Intravenous Solution Reconstituted)
1
Doxycycline Hyclate (Oral Capsule)
1
Doxycycline Hyclate (100MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release)
1
Doxycycline Monohydrate (100MG Oral Capsule, 50MG Oral Capsule)
1
Doxycycline Monohydrate (Oral Suspension Reconstituted)
1
Doxycycline Monohydrate (100MG Oral Tablet, 50MG Oral Tablet, 75MG Oral Tablet)
1
Minocycline HCl (Oral Capsule)
1
Minocycline HCl (Oral Tablet Immediate Release)
1
Tetracycline HCl (Oral Capsule)
1
Vibramycin (50MG/
5ML Oral Syrup)1
Anticonvulsants
Anticonvulsants, Other
BRIVIACT (Oral
Solution)1 PA; QL
BRIVIACT (Oral
Tablet)1 PA; QL
Epidiolex (Oral
Solution)1 PA
Fintepla (Oral
Solution)1 PA; QL
Levetiracetam ER (Oral Tablet Extended Release 24 Hour)
1
Levetiracetam (Oral Solution)
1
Levetiracetam (Oral Tablet Immediate Release)
1
Nayzilam (Nasal
Solution)1
Roweepra (Oral Tablet Immediate Release)
1
Roweepra XR (Oral Tablet Extended Release 24 Hour)
1
Spritam ODT (Oral
Tablet Disintegrating
Soluble)
1
Xcopri (250 MG Daily
Dose) (Oral Tablet
Therapy Pack)
1 PA; QL
Xcopri (350 MG Daily
Dose) (Oral Tablet
Therapy Pack)
1 PA; QL
tRACK24
14
Bold type = Brand name drug Plain type = Generic drug
C1Xcopri
C1Xcopri
C1Xcopri
C1Xcopri
B1
C1Celontin
C1Ethosuximide
C1Ethosuximide
C1Zonisamide
B1
C1Clobazam
C1Clobazam
C1Clobazam
C1Diastat AcuDial
C1Diastat Pediatric
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Diazepam
C1Gabapentin
C1Gabapentin
C1Gabapentin
C1Phenobarbital
C1Phenobarbital
C1Primidone
C1Sympazan
C1Tiagabine HCl
C1Valproic Acid
C1Valproic Acid
C1Valtoco 10 MG Dose
C1Valtoco 15 MG Dose
C1Valtoco 20 MG Dose
C1Valtoco 5 MG Dose
C1Vigabatrin
C1Vigabatrin
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Xcopri (100MG Oral
Tablet, 150MG Oral
Tablet, 50MG Oral
Tablet)
1 PA; QL
Xcopri (200MG Oral
Tablet)1 PA; QL
Xcopri (14x12.5MG &
14x25MG Oral Tablet
Therapy Pack)
1 PA; QL
Xcopri (14x150MG &
14x200MG Oral
Tablet Therapy Pack,
14x50MG &
14x100MG Oral
Tablet Therapy Pack)
1 PA; QL
Calcium Channel Modifying Agents
Celontin (Oral
Capsule)1
Ethosuximide (Oral Capsule)
1
Ethosuximide (Oral Solution)
1
Zonisamide (Oral Capsule)
1
Gamma-aminobutyric Acid (GABA) Augmenting Agents
Clobazam (2.5MG/ML Oral Suspension)
1 PA; QL
Clobazam (10MG Oral Tablet)
1 PA; QL
Clobazam (20MG Oral Tablet)
1 PA; QL
Diastat AcuDial
(Rectal Gel)1
Diastat Pediatric
(Rectal Gel)1
Diazepam (10MG Rectal Gel, 2.5MG Rectal Gel, 20MG Rectal Gel)
1
Gabapentin (Oral Capsule)
1
Gabapentin (250MG/ 5ML Oral Solution)
1
Gabapentin (Oral Tablet)
1
Phenobarbital (Oral Elixir)
1
Phenobarbital (Oral Tablet)
1
Primidone (Oral Tablet) 1
Sympazan (Oral Film) 1 PA; QL
Tiagabine HCl (Oral Tablet)
1
Valproic Acid (Oral Capsule)
1
Valproic Acid (Oral Solution)
1
Valtoco 10 MG Dose
(Nasal Liquid)1 QL
Valtoco 15 MG Dose
(Nasal Liquid Therapy
Pack)
1 QL
Valtoco 20 MG Dose
(Nasal Liquid Therapy
Pack)
1 QL
Valtoco 5 MG Dose
(Nasal Liquid)1 QL
Vigabatrin (Oral Packet)
1 PA; LA; QL
Vigabatrin (Oral Tablet) 1 PA; LA; QL
tRACK 25
15
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Vigadrone
B1
C1Felbamate
C1Felbamate
C1Fycompa
C1Fycompa
C1Lamotrigine
C1Lamotrigine
C1Topiramate
C1Topiramate
B1
C1Aptiom
C1Banzel
C1Banzel
C1Carbamazepine ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Carbamazepine ER
C1Carbamazepine
C1Carbamazepine
C1Carbamazepine
C1Dilantin INFATABS
C1Dilantin
C1Epitol
C1Oxcarbazepine
C1Oxcarbazepine
C1Peganone
C1Phenytek
C1Phenytoin
C1Phenytoin
C1Phenytoin Sodium Extended
C1Vimpat
C1Vimpat
A1
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Vigadrone (Oral Packet)
1 PA; LA; QL
Glutamate Reducing Agents
Felbamate (Oral Suspension)
1
Felbamate (Oral Tablet)
1
Fycompa (Oral
Suspension)1
Fycompa (Oral Tablet) 1
Lamotrigine (100MG Oral Tablet Immediate Release, 150MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 25MG Oral Tablet Immediate Release)
1
Lamotrigine (25MG Oral Tablet Chewable, 5MG Oral Tablet Chewable)
1
Topiramate (Oral Capsule Sprinkle Immediate Release)
1
Topiramate (Oral Tablet)
1
Sodium Channel Agents
Aptiom (Oral Tablet) 1 QL
Banzel (Oral
Suspension)1
Banzel (Oral Tablet) 1
Carbamazepine ER (Oral Capsule Extended Release 12 Hour)
1
Carbamazepine ER (Oral Tablet Extended Release 12 Hour)
1
Carbamazepine (Oral Suspension)
1
Carbamazepine (Oral Tablet Immediate Release)
1
Carbamazepine (Oral Tablet Chewable)
1
Dilantin INFATABS (Oral Tablet Chewable)
1
Dilantin (Oral Capsule) 1
Epitol (Oral Tablet) 1
Oxcarbazepine (300MG/5ML Oral Suspension)
1
Oxcarbazepine (150MG Oral Tablet, 300MG Oral Tablet, 600MG Oral Tablet)
1
Peganone (Oral
Tablet)1
Phenytek (Oral Capsule)
1
Phenytoin (125MG/ 5ML Oral Suspension)
1
Phenytoin (Oral Tablet Chewable)
1
Phenytoin Sodium Extended (Oral Capsule)
1
Vimpat (Oral Solution) 1 QL
Vimpat (Oral Tablet) 1 QL
Antidementia Agents
Cholinesterase Inhibitors
tRACK26
16
Bold type = Brand name drug Plain type = Generic drug
C1Donepezil HCl
C1Donepezil HCl ODT
C1Galantamine Hydrobromide ER
C1Galantamine Hydrobromide
C1Galantamine Hydrobromide
C1Rivastigmine Tartrate
C1Rivastigmine
B1
C1Memantine HCl ER
C1Memantine HCl
C1Memantine HCl
C1Memantine HCl Titration Pak
A1
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Bupropion HCl SR
C1Bupropion HCl XL
C1Bupropion HCl
C1Mirtazapine
C1Mirtazapine ODT
B1
C1Emsam
C1Marplan
C1Phenelzine Sulfate
C1Tranylcypromine Sulfate
B1
C1Citalopram Hydrobromide
C1Citalopram Hydrobromide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Donepezil HCl (Oral Tablet)
1 QL
Donepezil HCl ODT (Oral Tablet Dispersible)
1 QL
Galantamine Hydrobromide ER (Oral Capsule Extended Release 24 Hour)
1 QL
Galantamine Hydrobromide (Oral Solution)
1 QL
Galantamine Hydrobromide (Oral Tablet)
1 QL
Rivastigmine Tartrate (Oral Capsule)
1 QL
Rivastigmine (Transdermal Patch 24 Hour)
1 ST; QL
N-methyl-D-aspartate (NMDA) Receptor Antagonist
Memantine HCl ER (Oral Capsule Extended Release 24 Hour)
1 PA; QL
Memantine HCl (2MG/ ML Oral Solution)
1 PA; QL
Memantine HCl (10MG Oral Tablet, 5MG Oral Tablet)
1 PA; QL
Memantine HCl
Titration Pak (Oral
Tablet)
1 PA
Antidepressants
Antidepressants, Other
Bupropion HCl SR (Oral Tablet Extended Release 12 Hour)
1
Bupropion HCl XL (150MG Oral Tablet Extended Release 24 Hour, 300MG Oral Tablet Extended Release 24 Hour)
1
Bupropion HCl (Oral Tablet Immediate Release)
1
Mirtazapine (Oral Tablet)
1
Mirtazapine ODT (Oral Tablet Dispersible)
1
Monoamine Oxidase Inhibitors
Emsam (Transdermal
Patch 24 Hour)1 QL
Marplan (Oral Tablet) 1
Phenelzine Sulfate (Oral Tablet)
1
Tranylcypromine Sulfate (Oral Tablet)
1
SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Citalopram Hydrobromide (Oral Solution)
1
Citalopram Hydrobromide (Oral Tablet)
1
tRACK 27
17
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Desvenlafaxine Succinate ER
C1Escitalopram Oxalate
C1Escitalopram Oxalate
C1Fetzima
C1Fetzima Titration
C1Fluoxetine HCl
C1Fluoxetine HCl
C1Fluoxetine HCl
C1Fluvoxamine Maleate
C1Maprotiline HCl
C1Nefazodone HCl
C1Paroxetine HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Paxil
C1Sertraline HCl
C1Sertraline HCl
C1Trazodone HCl
C1Trazodone HCl
C1Trintellix
C1Venlafaxine HCl ER
C1Venlafaxine HCl
C1Viibryd
C1Viibryd Starter Pack
B1
C1Amitriptyline HCl
C1Amoxapine
C1Clomipramine HCl
C1Desipramine HCl
C1Doxepin HCl
C1Doxepin HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Desvenlafaxine Succinate ER (Oral Tablet Extended Release 24 Hour) (Generic Pristiq)
1 QL
Escitalopram Oxalate (Oral Solution)
1
Escitalopram Oxalate (Oral Tablet)
1
Fetzima (Oral Capsule
Extended Release 24
Hour)
1 ST; QL
Fetzima Titration
(Oral Capsule ER 24
Hour Therapy Pack)
1 ST
Fluoxetine HCl (10MG Oral Capsule Immediate Release, 20MG Oral Capsule Immediate Release, 40MG Oral Capsule Immediate Release)
1
Fluoxetine HCl (90MG Oral Capsule Delayed Release)
1
Fluoxetine HCl (20MG/ 5ML Oral Solution)
1
Fluvoxamine Maleate (Oral Tablet)
1
Maprotiline HCl (Oral Tablet)
1
Nefazodone HCl (Oral Tablet)
1
Paroxetine HCl (Oral Tablet Immediate Release)
1
Paxil (Oral
Suspension)1
Sertraline HCl (Oral Concentrate)
1
Sertraline HCl (Oral Tablet)
1
Trazodone HCl (100MG Oral Tablet, 150MG Oral Tablet, 50MG Oral Tablet)
1
Trazodone HCl (300MG Oral Tablet)
1
Trintellix (Oral Tablet) 1 QL
Venlafaxine HCl ER (Oral Capsule Extended Release 24 Hour)
1
Venlafaxine HCl (Oral Tablet Immediate Release)
1
Viibryd (Oral Tablet) 1 QL
Viibryd Starter Pack
(Oral Kit)1 QL
Tricyclics
Amitriptyline HCl (Oral Tablet)
1
Amoxapine (Oral Tablet)
1
Clomipramine HCl (Oral Capsule)
1
Desipramine HCl (Oral Tablet)
1
Doxepin HCl (Oral Capsule)
1
Doxepin HCl (Oral Concentrate)
1
tRACK28
18
Bold type = Brand name drug Plain type = Generic drug
C1Imipramine HCl
C1Imipramine Pamoate
C1Nortriptyline HCl
C1Nortriptyline HCl
C1Protriptyline HCl
C1Trimipramine Maleate
A1
B1
C1Compro
C1Hydroxyzine Pamoate
C1Meclizine HCl
C1Metoclopramide HCl
C1Metoclopramide HCl
C1Perphenazine
C1Prochlorperazine Maleate
C1Prochlorperazine
C1Scopolamine
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Transderm-Scop
B1
C1Aprepitant
C1Dronabinol
C1Granisetron HCl
C1Ondansetron HCl
C1Ondansetron HCl
C1Ondansetron ODT
C1Sancuso
A1
B1
C1Abelcet
C1AmBisome
C1Amphotericin B
C1Ciclopirox
C1Ciclopirox
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Imipramine HCl (Oral Tablet)
1
Imipramine Pamoate (Oral Capsule)
1
Nortriptyline HCl (Oral Capsule)
1
Nortriptyline HCl (Oral Solution)
1
Protriptyline HCl (Oral Tablet)
1
Trimipramine Maleate (Oral Capsule)
1
Antiemetics
Antiemetics, Other
Compro (Rectal Suppository)
1
Hydroxyzine Pamoate (Oral Capsule)
1
Meclizine HCl (Oral Tablet)
1
Metoclopramide HCl (10MG/10ML Oral Solution)
1
Metoclopramide HCl (Oral Tablet)
1
Perphenazine (Oral Tablet)
1
Prochlorperazine Maleate (Oral Tablet)
1
Prochlorperazine (Rectal Suppository)
1
Scopolamine (Transdermal Patch 72 Hour)
1
Transderm-Scop
(1.5MG) (Transdermal
Patch 72 Hour)
1
Emetogenic Therapy Adjuncts
Aprepitant (Oral Therapy Pack, Oral Capsule)
1 PA
Dronabinol (Oral Capsule)
1 PA
Granisetron HCl (Oral Tablet)
1 B/D, PA; QL
Ondansetron HCl (Oral Solution)
1 B/D, PA
Ondansetron HCl (Oral Tablet)
1 B/D, PA
Ondansetron ODT (Oral Tablet Dispersible)
1 B/D, PA
Sancuso
(Transdermal Patch)1
Antifungals
Antifungals
Abelcet (Intravenous
Suspension)1 B/D, PA
AmBisome
(Intravenous
Suspension
Reconstituted)
1 B/D, PA
Amphotericin B (Intravenous Solution Reconstituted)
1 B/D, PA
Ciclopirox (External Gel)
1
Ciclopirox (External Shampoo)
1
tRACK 29
19
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Ciclopirox
C1Ciclopirox Olamine
C1Ciclopirox Olamine
C1Clotrimazole
C1Clotrimazole
C1Clotrimazole
C1Econazole Nitrate
C1Eraxis
C1Eraxis
C1Fluconazole in Sodium Chloride
C1Fluconazole
C1Fluconazole
C1Flucytosine
C1Griseofulvin Microsize
C1Griseofulvin Microsize
C1Griseofulvin Ultramicrosize
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Itraconazole
C1Itraconazole
C1Jublia
C1Ketoconazole
C1Ketoconazole
C1Ketoconazole
C1Mentax
C1Micafungin Sodium
C1Miconazole 3
C1Mycamine
C1Naftifine HCl
C1Naftin
C1Natacyn
C1Noxafil
C1Noxafil
C1Nyamyc
C1Nystatin
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Ciclopirox (External Solution)
1
Ciclopirox Olamine (External Cream)
1
Ciclopirox Olamine (External Suspension)
1
Clotrimazole (External Cream)
1
Clotrimazole (External Solution)
1
Clotrimazole (Mouth/ Throat Troche)
1
Econazole Nitrate (External Cream)
1 QL
Eraxis (100MG
Intravenous Solution
Reconstituted)
1
Eraxis (50MG
Intravenous Solution
Reconstituted)
1
Fluconazole in Sodium Chloride (Intravenous Solution)
1
Fluconazole (Oral Suspension Reconstituted)
1
Fluconazole (Oral Tablet)
1
Flucytosine (Oral Capsule)
1
Griseofulvin Microsize (Oral Suspension)
1
Griseofulvin Microsize (Oral Tablet)
1
Griseofulvin Ultramicrosize (Oral Tablet)
1
Itraconazole (Oral Capsule)
1 PA; QL
Itraconazole (Oral Solution)
1 PA
Jublia (External
Solution)1
Ketoconazole (External Cream)
1 QL
Ketoconazole (External Shampoo)
1
Ketoconazole (Oral Tablet)
1
Mentax (External
Cream)1
Micafungin Sodium (Intravenous Solution Reconstituted)
1
Miconazole 3 (Vaginal Suppository)
1
Mycamine
(Intravenous Solution
Reconstituted)
1
Naftifine HCl (External Cream)
1
Naftin (External Gel) 1
Natacyn (Ophthalmic
Suspension)1
Noxafil (Oral
Suspension)1 QL
Noxafil (Oral Tablet
Delayed Release)1 PA; QL
Nyamyc (External Powder)
1
Nystatin (External Cream)
1
tRACK30
20
Bold type = Brand name drug Plain type = Generic drug
C1Nystatin
C1Nystatin
C1Nystatin
C1Nystatin
C1Nystop
C1Posaconazole
C1Terbinafine HCl
C1Terconazole
C1Terconazole
C1Voriconazole
C1Voriconazole
C1Voriconazole
A1
B1
C1Allopurinol
C1Colchicine
C1Colchicine
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Colcrys
C1Febuxostat
C1Probenecid
C1Probenecid-Colchicine
A1
B1
C1Dihydroergotamine Mesylate
C1Ergotamine-Caffeine
C1Migergot
B1
C1Aimovig
C1Emgality
C1Emgality
C1Emgality
C1Timolol Maleate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Nystatin (External Ointment)
1
Nystatin (External Powder)
1
Nystatin (Mouth/Throat Suspension)
1
Nystatin (Oral Tablet) 1
Nystop (External Powder)
1
Posaconazole (Oral Tablet Delayed Release)
1 PA; QL
Terbinafine HCl (Oral Tablet)
1
Terconazole (Vaginal Cream)
1
Terconazole (Vaginal Suppository)
1
Voriconazole (Intravenous Solution Reconstituted)
1
Voriconazole (Oral Suspension Reconstituted)
1
Voriconazole (Oral Tablet)
1
Antigout Agents
Antigout Agents
Allopurinol (Oral Tablet)
1
Colchicine (0.6MG
Oral Capsule) (Brand
Equivalent Mitigare)
1 QL
Colchicine (0.6MG Oral Tablet) (Generic Colcrys)
1 QL
Colcrys (Oral Tablet) 1 QL
Febuxostat (Oral Tablet)
1 ST
Probenecid (Oral Tablet)
1
Probenecid-Colchicine (Oral Tablet)
1
Antimigraine Agents
Ergot Alkaloids
Dihydroergotamine Mesylate (Nasal Solution)
1
Ergotamine-Caffeine (Oral Tablet)
1
Migergot (Rectal Suppository)
1
Prophylactic
Aimovig
(Subcutaneous
Solution Auto-
Injector)
1 PA; QL
Emgality (300MG
Dose) (100MG/ML
Subcutaneous
Solution Prefilled
Syringe)
1 PA; QL
Emgality
(Subcutaneous
Solution Auto-
Injector)
1 PA; QL
Emgality (120MG/ML
Subcutaneous
Solution Prefilled
Syringe)
1 PA; QL
Timolol Maleate (Oral Tablet)
1
tRACK 31
21
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
B1
C1Naratriptan HCl
C1Rizatriptan Benzoate
C1Rizatriptan Benzoate ODT
C1Sumatriptan
C1Sumatriptan Succinate
C1Sumatriptan Succinate Refill
C1Sumatriptan Succinate
C1Sumatriptan Succinate
C1Sumatriptan Succinate
C1Sumatriptan Succinate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useA1
B1
C1Guanidine HCl
C1Pyridostigmine Bromide ER
C1Pyridostigmine Bromide
C1Pyridostigmine Bromide
A1
B1
C1Dapsone
C1Rifabutin
B1
C1Ethambutol HCl
C1Isoniazid
C1Isoniazid
C1Paser
C1Priftin
C1Pyrazinamide
C1Rifampin
C1Rifampin
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Serotonin (5-HT) 1b/1d Receptor Agonists
Naratriptan HCl (Oral Tablet)
1 QL
Rizatriptan Benzoate (Oral Tablet)
1 QL
Rizatriptan Benzoate ODT (Oral Tablet Dispersible)
1 QL
Sumatriptan (Nasal Solution)
1 QL
Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)
1 QL
Sumatriptan
Succinate Refill
(Subcutaneous
Solution Cartridge)
1 QL
Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution)
1 QL
Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/ 0.5ML Subcutaneous Solution Auto-Injector)
1 QL
Sumatriptan
Succinate (6MG/
0.5ML Subcutaneous
Solution Auto-
Injector) (Generic
Imitrex STATdose)
1 QL
Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Prefilled Syringe)
1 QL
Antimyasthenic Agents
Parasympathomimetics
Guanidine HCl (Oral
Tablet)1
Pyridostigmine Bromide ER (Oral Tablet Extended Release)
1
Pyridostigmine Bromide (Oral Solution)
1
Pyridostigmine Bromide (60MG Oral Tablet Immediate Release)
1
Antimycobacterials
Antimycobacterials, Other
Dapsone (Oral Tablet) 1
Rifabutin (Oral Capsule)
1
Antituberculars
Ethambutol HCl (Oral Tablet)
1
Isoniazid (Oral Syrup) 1
Isoniazid (Oral Tablet) 1
Paser (Oral Packet) 1
Priftin (Oral Tablet) 1
Pyrazinamide (Oral Tablet)
1
Rifampin (600MG Intravenous Solution Reconstituted)
1
Rifampin (150MG Oral Capsule, 300MG Oral Capsule)
1
tRACK32
22
Bold type = Brand name drug Plain type = Generic drug
C1Sirturo
C1Trecator
A1
B1
C1Cyclophosphamide
C1Gleostine
C1Gleostine
C1Leukeran
C1Matulane
C1Valchlor
B1
C1Abiraterone Acetate
C1Bicalutamide
C1Erleada
C1Flutamide
C1Nilutamide
C1Nubeqa
C1Xtandi
B1
C1Pomalyst
C1Revlimid
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Tabrecta
C1Thalomid
B1
C1Emcyt
C1Soltamox
C1Tamoxifen Citrate
C1Toremifene Citrate
B1
C1Droxia
C1Hydroxyurea
C1Mercaptopurine
C1Purixan
C1Tabloid
B1
C1Xpovio
C1Xpovio
C1Xpovio
C1Xpovio
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Sirturo (Oral Tablet) 1 PA; LA
Trecator (Oral Tablet) 1
Antineoplastics
Alkylating Agents
Cyclophosphamide (Oral Capsule)
1 B/D, PA
Gleostine (100MG
Oral Capsule)1
Gleostine (10MG Oral
Capsule, 40MG Oral
Capsule)
1
Leukeran (Oral
Tablet)1
Matulane (Oral
Capsule)1 LA
Valchlor (External
Gel)1 PA; LA
Antiandrogens
Abiraterone Acetate (Oral Tablet)
1 PA; QL
Bicalutamide (Oral Tablet)
1
Erleada (Oral Tablet) 1 PA; QL
Flutamide (Oral Capsule)
1
Nilutamide (Oral Tablet)
1
Nubeqa (Oral Tablet) 1 PA; QL
Xtandi (Oral Capsule) 1 PA; LA; QL
Antiangiogenic Agents
Pomalyst (Oral
Capsule)1 PA; QL
Revlimid (Oral
Capsule)1 PA; LA; QL
Tabrecta (Oral Tablet) 1 PA; QL
Thalomid (Oral
Capsule)1 PA; QL
Antiestrogens/Modifiers
Emcyt (Oral Capsule) 1
Soltamox (Oral
Solution)1
Tamoxifen Citrate (Oral Tablet)
1
Toremifene Citrate (Oral Tablet)
1
Antimetabolites
Droxia (Oral Capsule) 1
Hydroxyurea (Oral Capsule)
1
Mercaptopurine (Oral Tablet)
1
Purixan (Oral
Suspension)1 PA
Tabloid (Oral Tablet) 1 PA
Antineoplastics
Xpovio (100MG Once
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
Xpovio (40 MG Once
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
Xpovio (40 MG Twice
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
Xpovio (60MG Once
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
tRACK 33
23
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Xpovio
C1Xpovio
C1Xpovio
B1
C1Copiktra
C1Inrebic
C1Kisqali
C1Kisqali
C1Kisqali
C1Kisqali Femara
C1Kisqali Femara
C1Kisqali Femara
C1Leucovorin Calcium
C1Leucovorin Calcium
C1Lonsurf
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Lorbrena
C1Ninlaro
C1Pemazyre
C1Piqray
C1Piqray
C1Piqray
C1Qinlock
C1Retevmo
C1Rozlytrek
C1Synribo
C1Tazverik
C1Tukysa
C1Verzenio
C1Zolinza
B1
C1Anastrozole
C1Exemestane
C1Letrozole
B1
C1Balversa
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Xpovio (60 MG Twice
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
Xpovio (80MG Once
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
Xpovio (80MG Twice
Weekly) (Oral Tablet
Therapy Pack)
1 PA; QL
Antineoplastics, Other
Copiktra (Oral
Capsule)1 PA; QL
Inrebic (Oral Capsule) 1 PA; QL
Kisqali (200MG Dose)
(Oral Tablet)1 PA; QL
Kisqali (400MG Dose)
(Oral Tablet)1 PA; QL
Kisqali (600MG Dose)
(Oral Tablet)1 PA; QL
Kisqali Femara
(400MG Dose) (Oral
Tablet Therapy Pack)
1 PA; QL
Kisqali Femara
(600MG Dose) (Oral
Tablet Therapy Pack)
1 PA; QL
Kisqali Femara
(200MG Dose) (Oral
Tablet Therapy Pack)
1 PA; QL
Leucovorin Calcium (10MG Oral Tablet, 15MG Oral Tablet, 5MG Oral Tablet)
1
Leucovorin Calcium (25MG Oral Tablet)
1
Lonsurf (Oral Tablet) 1 PA; LA; QL
Lorbrena (Oral Tablet) 1 PA; QL
Ninlaro (Oral Capsule) 1 PA; QL
Pemazyre (Oral
Tablet)1 PA; QL
Piqray (200MG Daily
Dose) (Oral Tablet
Therapy Pack)
1 PA; QL
Piqray (250MG Daily
Dose) (Oral Tablet
Therapy Pack)
1 PA; QL
Piqray (300MG Daily
Dose) (Oral Tablet
Therapy Pack)
1 PA; QL
Qinlock (Oral Tablet) 1 PA; QL
Retevmo (Oral
Capsule)1 PA; QL
Rozlytrek (Oral
Capsule)1 PA; QL
Synribo
(Subcutaneous
Solution
Reconstituted)
1 PA
Tazverik (Oral Tablet) 1 PA; QL
Tukysa (Oral Tablet) 1 PA; QL
Verzenio (Oral Tablet) 1 PA; LA; QL
Zolinza (Oral Capsule) 1 PA
Aromatase Inhibitors, 3rd Generation
Anastrozole (Oral Tablet)
1
Exemestane (Oral Tablet)
1
Letrozole (Oral Tablet) 1
Enzyme Inhibitors
Balversa (Oral Tablet) 1 PA; QL
tRACK34
24
Bold type = Brand name drug Plain type = Generic drug
C1Rubraca
C1Talzenna
C1Zejula
B1
C1Afinitor Disperz
C1Afinitor
C1Alecensa
C1Alunbrig
C1Alunbrig
C1Ayvakit
C1Bosulif
C1Braftovi
C1Brukinsa
C1Cabometyx
C1Calquence
C1Caprelsa
C1Cometriq
C1Cometriq
C1Cometriq
C1Cotellic
C1Daurismo
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Erivedge
C1Erlotinib HCl
C1Everolimus
C1Farydak
C1Gilotrif
C1Ibrance
C1Ibrance
C1Iclusig
C1IDHIFA
C1Imatinib Mesylate
C1Imbruvica
C1Imbruvica
C1Inlyta
C1Iressa
C1Jakafi
C1Koselugo
C1Lenvima 10MG Daily Dose
C1Lenvima 12MG Daily Dose
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Rubraca (Oral Tablet) 1 PA; LA; QL
Talzenna (Oral
Capsule)1 PA; LA; QL
Zejula (Oral Capsule) 1 PA; LA; QL
Molecular Target Inhibitors
Afinitor Disperz (Oral
Tablet Soluble)1 PA
Afinitor (Oral Tablet) 1 PA
Alecensa (Oral
Capsule)1 PA; LA; QL
Alunbrig (Oral Tablet) 1 PA; LA; QL
Alunbrig (Oral Tablet
Therapy Pack)1 PA; LA; QL
Ayvakit (Oral Tablet) 1 PA; LA; QL
Bosulif (Oral Tablet) 1 PA; QL
Braftovi (Oral
Capsule)1 PA
Brukinsa (Oral
Capsule)1 PA; LA; QL
Cabometyx (Oral
Tablet)1 PA; LA; QL
Calquence (Oral
Capsule)1 PA; QL
Caprelsa (Oral Tablet) 1 PA; LA
Cometriq (100MG
Daily Dose) (Oral Kit)1 PA; LA
Cometriq (140MG
Daily Dose) (Oral Kit)1 PA; LA
Cometriq (60MG Daily
Dose) (Oral Kit)1 PA; LA
Cotellic (Oral Tablet) 1 PA; LA; QL
Daurismo (Oral
Tablet)1 PA; LA; QL
Erivedge (Oral
Capsule)1 PA; LA; QL
Erlotinib HCl (Oral Tablet)
1 PA; QL
Everolimus (2.5MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)
1 PA
Farydak (Oral
Capsule)1 PA
Gilotrif (Oral Tablet) 1 PA; LA
Ibrance (Oral
Capsule)1 PA; LA; QL
Ibrance (Oral Tablet) 1 PA; LA; QL
Iclusig (Oral Tablet) 1 PA; LA; QL
IDHIFA (Oral Tablet) 1 PA; LA; QL
Imatinib Mesylate (Oral Tablet)
1 PA; QL
Imbruvica (Oral
Capsule)1 PA; LA; QL
Imbruvica (Oral
Tablet)1 PA; QL
Inlyta (Oral Tablet) 1 PA; LA; QL
Iressa (Oral Tablet) 1 PA; LA; QL
Jakafi (Oral Tablet) 1 PA; LA; QL
Koselugo (Oral
Capsule)1 PA; QL
Lenvima 10MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 12MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
tRACK 35
25
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Lenvima 14MG Daily Dose
C1Lenvima 18MG Daily Dose
C1Lenvima 20MG Daily Dose
C1Lenvima 24MG Daily Dose
C1Lenvima 4MG Daily Dose
C1Lenvima 8MG Daily Dose
C1Lynparza
C1Mekinist
C1Mektovi
C1Nerlynx
C1Nexavar
C1Odomzo
C1Rydapt
C1Sprycel
C1Stivarga
C1Sutent
C1Tafinlar
C1Tagrisso
C1Tasigna
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Tibsovo
C1Turalio
C1Tykerb
C1Venclexta
C1Venclexta
C1Venclexta Starting Pack
C1Vitrakvi
C1Vitrakvi
C1Vizimpro
C1Votrient
C1Xalkori
C1Xospata
C1Zelboraf
C1Zydelig
C1Zykadia
B1
C1Bexarotene
C1Panretin
C1Targretin
C1Tretinoin
B1
C1Mesnex
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Lenvima 14MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 18MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 20MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 24MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 4MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lenvima 8MG Daily
Dose (Oral Capsule
Therapy Pack)
1 PA; LA
Lynparza (Oral Tablet) 1 PA; LA; QL
Mekinist (Oral Tablet) 1 PA; LA
Mektovi (Oral Tablet) 1 PA
Nerlynx (Oral Tablet) 1 PA; LA; QL
Nexavar (Oral Tablet) 1 PA; LA
Odomzo (Oral
Capsule)1 PA; LA; QL
Rydapt (Oral Capsule) 1 PA; QL
Sprycel (Oral Tablet) 1 PA; QL
Stivarga (Oral Tablet) 1 PA; LA; QL
Sutent (Oral Capsule) 1 PA; QL
Tafinlar (Oral
Capsule)1 PA; LA
Tagrisso (Oral Tablet) 1 PA; LA; QL
Tasigna (Oral
Capsule)1 PA; QL
Tibsovo (Oral Tablet) 1 PA; QL
Turalio (Oral Capsule) 1 PA; LA; QL
Tykerb (Oral Tablet) 1 PA; LA
Venclexta (100MG
Oral Tablet, 50MG
Oral Tablet)
1 PA; LA; QL
Venclexta (10MG Oral
Tablet)1 PA; LA; QL
Venclexta Starting
Pack (Oral Tablet
Therapy Pack)
1 PA; LA
Vitrakvi (Oral
Capsule)1 PA; LA; QL
Vitrakvi (Oral
Solution)1 PA; LA; QL
Vizimpro (Oral Tablet) 1 PA; LA; QL
Votrient (Oral Tablet) 1 PA; LA; QL
Xalkori (Oral Capsule) 1 PA; LA
Xospata (Oral Tablet) 1 PA; QL
Zelboraf (Oral Tablet) 1 PA; LA; QL
Zydelig (Oral Tablet) 1 PA; LA; QL
Zykadia (Oral Tablet) 1 PA; QL
Retinoids
Bexarotene (Oral Capsule)
1 PA
Panretin (External
Gel)1
Targretin (External
Gel)1 PA
Tretinoin (Oral Capsule)
1
Treatment Adjuncts
Mesnex (Oral Tablet) 1
tRACK36
26
Bold type = Brand name drug Plain type = Generic drug
A1
B1
C1Albendazole
C1Ivermectin
C1Praziquantel
B1
C1Alinia
C1Alinia
C1Atovaquone
C1Atovaquone-Proguanil HCl
C1Benznidazole
C1Chloroquine Phosphate
C1Coartem
C1DARAPRIM
C1Hydroxychloroquine Sulfate
C1Mefloquine HCl
C1Nebupent
C1PENTAM 300
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Pentamidine Isethionate
C1Pentamidine Isethionate
C1Primaquine Phosphate
C1Pyrimethamine
C1Quinine Sulfate
B1
C1Lindane
C1Malathion
C1Permethrin
A1
B1
C1Benztropine Mesylate
C1Trihexyphenidyl HCl
C1Trihexyphenidyl HCl
B1
C1Amantadine HCl
C1Amantadine HCl
C1Amantadine HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Antiparasitics
Anthelmintics
Albendazole (Oral Tablet)
1 QL
Ivermectin (Oral Tablet)
1
Praziquantel (Oral Tablet)
1
Antiprotozoals
Alinia (Oral
Suspension
Reconstituted)
1
Alinia (Oral Tablet) 1
Atovaquone (Oral Suspension)
1
Atovaquone-Proguanil HCl (Oral Tablet)
1
Benznidazole (Oral
Tablet)1
Chloroquine Phosphate (Oral Tablet)
1
Coartem (Oral Tablet) 1
DARAPRIM (Oral
Tablet)1
Hydroxychloroquine Sulfate (Oral Tablet)
1
Mefloquine HCl (Oral Tablet)
1
Nebupent (Inhalation
Solution
Reconstituted)
1 B/D, PA; QL
PENTAM 300
(Injection Solution
Reconstituted)
1
Pentamidine Isethionate (Inhalation Solution Reconstituted)
1 B/D, PA; QL
Pentamidine Isethionate (Injection Solution Reconstituted)
1
Primaquine Phosphate (Oral Tablet)
1
Pyrimethamine (Oral Tablet)
1
Quinine Sulfate (Oral Capsule)
1 PA
Pediculicides/Scabicides
Lindane (External Shampoo)
1
Malathion (External Lotion)
1
Permethrin (External Cream)
1
Antiparkinson Agents
Anticholinergics
Benztropine Mesylate (Oral Tablet)
1
Trihexyphenidyl HCl (Oral Solution)
1
Trihexyphenidyl HCl (Oral Tablet)
1
Antiparkinson Agents, Other
Amantadine HCl (Oral Capsule)
1
Amantadine HCl (Oral Syrup)
1
Amantadine HCl (Oral Tablet)
1
tRACK 37
27
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Entacapone
C1Tolcapone
B1
C1Apokyn
C1Bromocriptine Mesylate
C1Bromocriptine Mesylate
C1Neupro
C1Pramipexole Dihydrochloride
C1Ropinirole HCl
B1
C1Carbidopa
C1Carbidopa-Levodopa ER
C1Carbidopa-Levodopa
C1Carbidopa-Levodopa ODT
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Carbidopa-Levodopa-Entacapone
C1Rytary
B1
C1Rasagiline Mesylate
C1Selegiline HCl
C1Selegiline HCl
C1Zelapar ODT
A1
B1
C1Chlorpromazine HCl
C1Fluphenazine Decanoate
C1Fluphenazine HCl
C1Fluphenazine HCl
C1Fluphenazine HCl
C1Fluphenazine HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Entacapone (Oral Tablet)
1
Tolcapone (Oral Tablet)
1 QL
Dopamine Agonists
Apokyn
(Subcutaneous
Solution Cartridge)
1 PA; LA; QL
Bromocriptine Mesylate (Oral Capsule)
1
Bromocriptine Mesylate (Oral Tablet)
1
Neupro (Transdermal
Patch 24 Hour)1
Pramipexole Dihydrochloride (Oral Tablet Immediate Release)
1
Ropinirole HCl (Oral Tablet Immediate Release)
1
Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors
Carbidopa (Oral Tablet)
1
Carbidopa-Levodopa ER (Oral Tablet Extended Release)
1
Carbidopa-Levodopa (Oral Tablet Immediate Release)
1
Carbidopa-Levodopa ODT (Oral Tablet Dispersible)
1
Carbidopa-Levodopa-Entacapone (Oral Tablet)
1
Rytary (Oral Capsule
Extended Release)1 ST
Monoamine Oxidase B (MAO-B) Inhibitors
Rasagiline Mesylate (Oral Tablet)
1
Selegiline HCl (Oral Capsule)
1
Selegiline HCl (Oral Tablet)
1
Zelapar ODT (Oral
Tablet Dispersible)1
Antipsychotics
1st Generation/Typical
Chlorpromazine HCl (Oral Tablet)
1
Fluphenazine Decanoate (Injection Solution)
1
Fluphenazine HCl (2.5MG/ML Injection Solution)
1
Fluphenazine HCl (5MG/ML Oral Concentrate)
1
Fluphenazine HCl (2.5MG/5ML Oral Elixir)
1
Fluphenazine HCl (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 5MG Oral Tablet)
1
tRACK38
28
Bold type = Brand name drug Plain type = Generic drug
C1Haloperidol Decanoate
C1Haloperidol Lactate
C1Haloperidol Lactate
C1Haloperidol
C1Loxapine Succinate
C1Molindone HCl
C1Pimozide
C1Thioridazine HCl
C1Thiothixene
C1Trifluoperazine HCl
B1
C1Abilify Maintena
C1Abilify Maintena
C1Aripiprazole
C1Aripiprazole
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Aripiprazole ODT
C1Aristada Initio
C1Aristada
C1Caplyta
C1Fanapt
C1Fanapt
C1Fanapt Titration Pack
C1Geodon
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Haloperidol Decanoate (Intramuscular Solution)
1
Haloperidol Lactate (Injection Solution)
1
Haloperidol Lactate (Oral Concentrate)
1
Haloperidol (Oral Tablet)
1
Loxapine Succinate (Oral Capsule)
1
Molindone HCl (Oral Tablet)
1
Pimozide (Oral Tablet) 1
Thioridazine HCl (Oral Tablet)
1
Thiothixene (Oral Capsule)
1
Trifluoperazine HCl (Oral Tablet)
1
2nd Generation/Atypical
Abilify Maintena
(Intramuscular
Prefilled Syringe)
1
Abilify Maintena
(Intramuscular
Suspension
Reconstituted ER)
1
Aripiprazole (1MG/ML Oral Solution)
1 QL
Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)
1 QL
Aripiprazole ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible)
1 QL
Aristada Initio
(Intramuscular
Prefilled Syringe)
1
Aristada
(Intramuscular
Prefilled Syringe)
1
Caplyta (Oral
Capsule)1 ST; QL
Fanapt (10MG Oral
Tablet, 12MG Oral
Tablet, 4MG Oral
Tablet, 6MG Oral
Tablet, 8MG Oral
Tablet)
1 ST; QL
Fanapt (1MG Oral
Tablet, 2MG Oral
Tablet)
1 ST; QL
Fanapt Titration Pack
(Oral Tablet)1 ST
Geodon
(Intramuscular
Solution
Reconstituted)
1
tRACK 39
29
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Invega Sustenna
C1Invega Sustenna
C1Invega Trinza
C1Latuda
C1Nuplazid
C1Nuplazid
C1Olanzapine
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Olanzapine
C1Olanzapine ODT
C1Paliperidone ER
C1Perseris
C1Quetiapine Fumarate ER
C1Quetiapine Fumarate
C1Rexulti
C1Risperdal Consta
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Invega Sustenna
(117MG/0.75ML
Intramuscular
Suspension Prefilled
Syringe, 156MG/ML
Intramuscular
Suspension Prefilled
Syringe, 234MG/
1.5ML Intramuscular
Suspension Prefilled
Syringe, 78MG/0.5ML
Intramuscular
Suspension Prefilled
Syringe)
1
Invega Sustenna
(39MG/0.25ML
Intramuscular
Suspension Prefilled
Syringe)
1
Invega Trinza
(Intramuscular
Suspension Prefilled
Syringe)
1
Latuda (Oral Tablet) 1 QL
Nuplazid (Oral
Capsule)1 PA; QL
Nuplazid (10MG Oral
Tablet)1 PA; QL
Olanzapine (10MG Intramuscular Solution Reconstituted)
1
Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)
1 QL
Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)
1 QL
Paliperidone ER (Oral Tablet Extended Release 24 Hour)
1 QL
Perseris
(Subcutaneous
Prefilled Syringe)
1
Quetiapine Fumarate ER (Oral Tablet Extended Release 24 Hour)
1 QL
Quetiapine Fumarate (Oral Tablet Immediate Release)
1 QL
Rexulti (Oral Tablet) 1 QL
Risperdal Consta
(12.5MG
Intramuscular
Suspension
Reconstituted ER,
25MG Intramuscular
Suspension
Reconstituted ER)
1
tRACK40
30
Bold type = Brand name drug Plain type = Generic drug
C1Risperdal Consta
C1Risperidone
C1Risperidone
C1Risperidone ODT
C1Saphris
C1Secuado
C1Vraylar
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Vraylar
C1Ziprasidone HCl
C1Ziprasidone Mesylate
C1Zyprexa Relprevv
B1
C1Clozapine
C1Clozapine ODT
C1Versacloz
A1
B1
C1Valganciclovir HCl
C1Valganciclovir HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Risperdal Consta
(37.5MG
Intramuscular
Suspension
Reconstituted ER,
50MG Intramuscular
Suspension
Reconstituted ER)
1
Risperidone (1MG/ML Oral Solution)
1
Risperidone (0.25MG Oral Tablet, 0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet, 3MG Oral Tablet, 4MG Oral Tablet)
1
Risperidone ODT (0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible, 3MG Oral Tablet Dispersible, 4MG Oral Tablet Dispersible)
1
Saphris (Tablet
Sublingual)1 QL
Secuado
(Transdermal Patch
24 Hour)
1 PA; QL
Vraylar (1.5MG Oral
Capsule, 3MG Oral
Capsule, 4.5MG Oral
Capsule, 6MG Oral
Capsule)
1 ST; QL
Vraylar (Oral Capsule
Therapy Pack)1 ST
Ziprasidone HCl (Oral Capsule)
1 QL
Ziprasidone Mesylate (Intramuscular Solution Reconstituted)
1
Zyprexa Relprevv
(210MG
Intramuscular
Suspension
Reconstituted)
1
Treatment-Resistant
Clozapine (100MG Oral Tablet, 200MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)
1
Clozapine ODT (100MG Oral Tablet Dispersible, 12.5MG Oral Tablet Dispersible, 150MG Oral Tablet Dispersible, 200MG Oral Tablet Dispersible, 25MG Oral Tablet Dispersible)
1 QL
Versacloz (Oral
Suspension)1
Antivirals
Anti-cytomegalovirus (CMV) Agents
Valganciclovir HCl (Oral Solution Reconstituted)
1 QL
Valganciclovir HCl (Oral Tablet)
1 QL
tRACK 41
31
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Zirgan
B1
C1Adefovir Dipivoxil
C1Baraclude
C1Entecavir
C1Epivir HBV
C1Lamivudine
C1Vemlidy
B1
C1Intron A
C1Intron A
C1Pegasys ProClick
C1Pegasys
C1Ribavirin
B1
C1Epclusa
C1Mavyret
C1Sofosbuvir-Velpatasvir
C1Sovaldi
C1Sovaldi
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Vosevi
B1
C1Acyclovir
C1Acyclovir
C1Acyclovir
C1Acyclovir
C1Acyclovir Sodium
C1Denavir
C1Famciclovir
C1Trifluridine
C1Valacyclovir HCl
B1
C1Dovato
C1Genvoya
C1Isentress HD
C1Isentress
C1Isentress
C1Isentress
C1Isentress
C1Stribild
C1Tivicay
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Zirgan (Ophthalmic
Gel)1
Anti-hepatitis B (HBV) Agents
Adefovir Dipivoxil (Oral Tablet)
1
Baraclude (Oral
Solution)1
Entecavir (Oral Tablet) 1
Epivir HBV (Oral
Solution)1
Lamivudine (100MG Oral Tablet)
1
Vemlidy (Oral Tablet) 1 QL
Anti-hepatitis C (HCV) Agents, Other
Intron A (Injection
Solution)1 PA; LA
Intron A (Injection
Solution
Reconstituted)
1 PA; LA
Pegasys ProClick
(Subcutaneous
Solution)
1 PA
Pegasys
(Subcutaneous
Solution)
1 PA
Ribavirin (Oral Tablet) 1
Anti-hepatitis C (HCV) Direct Acting Agents
Epclusa (Oral Tablet) 1 PA; QL
Mavyret (Oral Tablet) 1 PA; QL
Sofosbuvir-Velpatasvir (Oral Tablet)
1 PA; QL
Sovaldi (Oral Packet) 1 PA; QL
Sovaldi (400MG Oral
Tablet)1 PA; QL
Vosevi (Oral Tablet) 1 PA; QL
Antiherpetic Agents
Acyclovir (External Ointment)
1 QL
Acyclovir (Oral Capsule)
1
Acyclovir (Oral Suspension)
1
Acyclovir (Oral Tablet) 1
Acyclovir Sodium (Intravenous Solution)
1 B/D, PA
Denavir (External
Cream)1 QL
Famciclovir (Oral Tablet)
1 QL
Trifluridine (Ophthalmic Solution)
1
Valacyclovir HCl (Oral Tablet)
1 QL
Anti-HIV Agents, Integrase Inhibitors (INSTI)
Dovato (Oral Tablet) 1 QL
Genvoya (Oral Tablet) 1 QL
Isentress HD (Oral
Tablet)1 QL
Isentress (Oral
Packet)1 QL
Isentress (Oral Tablet) 1 QL
Isentress (100MG
Oral Tablet Chewable)1 QL
Isentress (25MG Oral
Tablet Chewable)1 QL
Stribild (Oral Tablet) 1 QL
Tivicay (10MG Oral
Tablet)1 QL
tRACK42
32
Bold type = Brand name drug Plain type = Generic drug
C1Tivicay
C1Tivicay PD
C1Triumeq
C1Tybost
B1
C1Atripla
C1Complera
C1Delstrigo
C1Edurant
C1Efavirenz
C1Efavirenz
C1Intelence
C1Intelence
C1Juluca
C1Nevirapine ER
C1Nevirapine
C1Nevirapine
C1Odefsey
C1Pifeltro
C1Symfi Lo
C1Symfi
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useB1
C1Abacavir Sulfate
C1Abacavir Sulfate
C1Abacavir Sulfate-Lamivudine
C1Abacavir-Lamivudine-Zidovudine
C1Biktarvy
C1Cimduo
C1Descovy
C1Didanosine
C1Emtriva
C1Emtriva
C1Lamivudine
C1Lamivudine
C1Lamivudine-Zidovudine
C1Stavudine
C1Tenofovir Disoproxil Fumarate
C1Truvada
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Tivicay (25MG Oral
Tablet, 50MG Oral
Tablet)
1 QL
Tivicay PD (Oral
Tablet Soluble)1 QL
Triumeq (Oral Tablet) 1 QL
Tybost (Oral Tablet) 1 QL
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
Atripla (Oral Tablet) 1 QL
Complera (Oral
Tablet)1 QL
Delstrigo (Oral Tablet) 1 QL
Edurant (Oral Tablet) 1 QL
Efavirenz (Oral Capsule)
1 QL
Efavirenz (Oral Tablet) 1 QL
Intelence (100MG
Oral Tablet, 200MG
Oral Tablet)
1 QL
Intelence (25MG Oral
Tablet)1 QL
Juluca (Oral Tablet) 1 QL
Nevirapine ER (Oral Tablet Extended Release 24 Hour)
1 QL
Nevirapine (Oral Suspension)
1 QL
Nevirapine (Oral Tablet Immediate Release)
1 QL
Odefsey (Oral Tablet) 1 QL
Pifeltro (Oral Tablet) 1 QL
Symfi Lo (Oral Tablet) 1 QL
Symfi (Oral Tablet) 1 QL
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
Abacavir Sulfate (Oral Solution)
1 QL
Abacavir Sulfate (Oral Tablet)
1 QL
Abacavir Sulfate-Lamivudine (Oral Tablet)
1 QL
Abacavir-Lamivudine-Zidovudine (Oral Tablet)
1 QL
Biktarvy (Oral Tablet) 1 QL
Cimduo (Oral Tablet) 1 QL
Descovy (Oral Tablet) 1 QL
Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Release)
1 QL
Emtriva (Oral
Capsule)1 QL
Emtriva (Oral
Solution)1 QL
Lamivudine (10MG/ML Oral Solution)
1 QL
Lamivudine (150MG Oral Tablet, 300MG Oral Tablet)
1 QL
Lamivudine-Zidovudine (Oral Tablet)
1 QL
Stavudine (Oral Capsule)
1 QL
Tenofovir Disoproxil Fumarate (Oral Tablet)
1 QL
Truvada (Oral Tablet) 1 QL
tRACK 43
33
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Viread
C1Viread
C1Zidovudine
C1Zidovudine
C1Zidovudine
B1
C1Fuzeon
C1Rukobia
C1Selzentry
C1Selzentry
C1Selzentry
B1
C1Aptivus
C1Aptivus
C1Atazanavir Sulfate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Crixivan
C1Evotaz
C1Fosamprenavir Calcium
C1Invirase
C1Kaletra
C1Kaletra
C1Lexiva
C1Lopinavir-Ritonavir
C1Norvir
C1Norvir
C1Prezcobix
C1Prezista
C1Prezista
C1Prezista
C1Reyataz
C1Ritonavir
C1Symtuza
C1Viracept
B1
C1Oseltamivir Phosphate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Viread (Oral Powder) 1 QL
Viread (150MG Oral
Tablet, 200MG Oral
Tablet, 250MG Oral
Tablet)
1 QL
Zidovudine (Oral Capsule)
1 QL
Zidovudine (Oral Syrup)
1 QL
Zidovudine (Oral Tablet)
1 QL
Anti-HIV Agents, Other
Fuzeon
(Subcutaneous
Solution
Reconstituted)
1 QL
Rukobia (Oral Tablet
Extended Release 12
Hour)
1 QL
Selzentry (Oral
Solution)1 QL
Selzentry (150MG
Oral Tablet, 300MG
Oral Tablet, 75MG
Oral Tablet)
1 QL
Selzentry (25MG Oral
Tablet)1 QL
Anti-HIV Agents, Protease Inhibitors
Aptivus (Oral
Capsule)1 QL
Aptivus (Oral
Solution)1 QL
Atazanavir Sulfate (Oral Capsule)
1 QL
Crixivan (Oral
Capsule)1 QL
Evotaz (Oral Tablet) 1 QL
Fosamprenavir Calcium (Oral Tablet)
1 QL
Invirase (Oral Tablet) 1 QL
Kaletra (100-25MG
Oral Tablet)1 QL
Kaletra (200-50MG
Oral Tablet)1 QL
Lexiva (Oral
Suspension)1 QL
Lopinavir-Ritonavir (Oral Solution)
1 QL
Norvir (Oral Packet) 1 QL
Norvir (Oral Solution) 1 QL
Prezcobix (Oral
Tablet)1 QL
Prezista (Oral
Suspension)1 QL
Prezista (150MG Oral
Tablet, 75MG Oral
Tablet)
1 QL
Prezista (600MG Oral
Tablet, 800MG Oral
Tablet)
1 QL
Reyataz (Oral Packet) 1 QL
Ritonavir (Oral Tablet) 1 QL
Symtuza (Oral Tablet) 1 QL
Viracept (Oral Tablet) 1 QL
Anti-influenza Agents
Oseltamivir Phosphate (Oral Capsule)
1 QL
tRACK44
34
Bold type = Brand name drug Plain type = Generic drug
C1Oseltamivir Phosphate
C1Relenza Diskhaler
C1Rimantadine HCl
C1Xofluza
C1Xofluza
A1
B1
C1Buspirone HCl
C1Hydroxyzine HCl
C1Hydroxyzine HCl
B1
C1Alprazolam
C1Chlordiazepoxide HCl
C1Clonazepam
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Clonazepam ODT
C1Clorazepate Dipotassium
C1Diazepam Intensol
C1Diazepam
C1Diazepam
C1Lorazepam
C1Lorazepam
A1
B1
C1Divalproex Sodium ER
C1Divalproex Sodium
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Oseltamivir Phosphate (Oral Suspension Reconstituted)
1 QL
Relenza Diskhaler
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Rimantadine HCl (Oral Tablet)
1
Xofluza (40 MG Dose)
(Oral Tablet Therapy
Pack)
1 QL
Xofluza (80 MG Dose)
(Oral Tablet Therapy
Pack)
1 QL
Anxiolytics
Anxiolytics, Other
Buspirone HCl (Oral Tablet)
1
Hydroxyzine HCl (Oral Syrup)
1
Hydroxyzine HCl (Oral Tablet)
1
Benzodiazepines
Alprazolam (Oral Tablet Immediate Release)
1 QL
Chlordiazepoxide HCl (Oral Capsule)
1
Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)
1 QL
Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible)
1 QL
Clorazepate Dipotassium (Oral Tablet)
1 QL
Diazepam Intensol (5MG/ML Oral Concentrate)
1 QL
Diazepam (5MG/5ML Oral Solution)
1
Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)
1 QL
Lorazepam (2MG/ML Oral Concentrate)
1 QL
Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)
1 QL
Bipolar Agents
Mood Stabilizers
Divalproex Sodium ER (Oral Tablet Extended Release 24 Hour)
1
Divalproex Sodium (Oral Capsule Delayed Release Sprinkle)
1
tRACK 45
35
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Divalproex Sodium
C1Lithium Carbonate ER
C1Lithium Carbonate
C1Lithium Carbonate
C1Lithium
A1
B1
C1Acarbose
C1Bydureon BCise
C1Bydureon
C1Byetta 10MCG Pen
C1Byetta 5MCG Pen
C1Cycloset
C1Glimepiride
C1Glipizide ER
C1Glipizide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Glipizide-Metformin HCl
C1Glyxambi
C1Invokamet
C1Invokamet XR
C1Invokana
C1Janumet
C1Janumet XR
C1Januvia
C1Jardiance
C1Jentadueto
C1Jentadueto XR
C1Metformin HCl ER
C1Metformin HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Divalproex Sodium (Oral Tablet Delayed Release)
1
Lithium Carbonate ER (Oral Tablet Extended Release)
1
Lithium Carbonate (Oral Capsule)
1
Lithium Carbonate (Oral Tablet Immediate Release)
1
Lithium (Oral
Solution)1
Blood Glucose Regulators
Antidiabetic Agents
Acarbose (Oral Tablet) 1 QL
Bydureon BCise
(Subcutaneous Auto-
Injector)
1 QL
Bydureon
(Subcutaneous Pen-
Injector)
1 QL
Byetta 10MCG Pen
(Subcutaneous
Solution Pen-Injector)
1 QL
Byetta 5MCG Pen
(Subcutaneous
Solution Pen-Injector)
1 QL
Cycloset (Oral Tablet) 1 PA; QL
Glimepiride (Oral Tablet)
1 QL
Glipizide ER (Oral Tablet Extended Release 24 Hour)
1 QL
Glipizide (Oral Tablet Immediate Release)
1 QL
Glipizide-Metformin HCl (Oral Tablet)
1 QL
Glyxambi (Oral
Tablet)1 QL
Invokamet (Oral
Tablet Immediate
Release)
1 QL
Invokamet XR (Oral
Tablet Extended
Release 24 Hour)
1 QL
Invokana (Oral Tablet) 1 QL
Janumet (Oral Tablet
Immediate Release)1 QL
Janumet XR (Oral
Tablet Extended
Release 24 Hour)
1 QL
Januvia (Oral Tablet) 1 QL
Jardiance (Oral
Tablet)1 QL
Jentadueto (Oral
Tablet Immediate
Release)
1 QL
Jentadueto XR (Oral
Tablet Extended
Release 24 Hour)
1 QL
Metformin HCl ER (Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)
1 QL
Metformin HCl (500MG/5ML Oral Solution)
1 QL
tRACK46
36
Bold type = Brand name drug Plain type = Generic drug
C1Metformin HCl
C1Miglitol
C1Nateglinide
C1Ozempic
C1Ozempic
C1Pioglitazone HCl
C1Pioglitazone HCl-Glimepiride
C1Pioglitazone HCl-Metformin HCl
C1Repaglinide
C1Riomet ER
C1Riomet
C1Rybelsus
C1Soliqua
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1SymlinPen 120
C1SymlinPen 60
C1Synjardy
C1Synjardy XR
C1Tradjenta
C1Trulicity
C1Victoza
B1
C1Baqsimi Two Pack
C1Diazoxide
C1GlucaGen HypoKit
C1Glucagon
C1Gvoke HypoPen 2-Pack
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Metformin HCl (1000MG Oral Tablet Immediate Release, 500MG Oral Tablet Immediate Release, 850MG Oral Tablet Immediate Release)
1 QL
Miglitol (Oral Tablet) 1 QL
Nateglinide (Oral Tablet)
1 QL
Ozempic (0.25 or
0.5MG/DOSE)
(Subcutaneous
Solution Pen-Injector)
1 QL
Ozempic (1MG/
DOSE)
(Subcutaneous
Solution Pen-Injector)
1 QL
Pioglitazone HCl (Oral Tablet)
1 QL
Pioglitazone HCl-Glimepiride (Oral Tablet)
1 QL
Pioglitazone HCl-Metformin HCl (Oral Tablet)
1 QL
Repaglinide (Oral Tablet)
1 QL
Riomet ER (Oral
Suspension
Reconstituted ER)
1 QL
Riomet (Oral Solution) 1 QL
Rybelsus (Oral Tablet) 1 QL
Soliqua
(Subcutaneous
Solution Pen-Injector)
1 QL
SymlinPen 120
(Subcutaneous
Solution Pen-Injector)
1 PA
SymlinPen 60
(Subcutaneous
Solution Pen-Injector)
1 PA
Synjardy (Oral Tablet
Immediate Release)1 QL
Synjardy XR (Oral
Tablet Extended
Release 24 Hour)
1 QL
Tradjenta (Oral
Tablet)1 QL
Trulicity
(Subcutaneous
Solution Pen-Injector)
1 QL
Victoza
(Subcutaneous
Solution Pen-Injector)
1 QL
Glycemic Agents
Baqsimi Two Pack
(Nasal Powder)1
Diazoxide (Oral Suspension)
1
GlucaGen HypoKit
(Injection Solution
Reconstituted)
1
Glucagon (Injection
Kit) (Lilly)1
Gvoke HypoPen 2-
Pack (Subcutaneous
Solution Auto-
Injector)
1
tRACK 47
37
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Gvoke PFS
C1Proglycem
B1
C1Humalog Junior KwikPen
C1Humalog KwikPen
C1Humalog Mix 50/50 KwikPen
C1Humalog Mix 50/50
C1Humalog Mix 75/25 KwikPen
C1Humalog Mix 75/25
C1Humalog
C1Humalog
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Humulin 70/30 KwikPen
C1Humulin 70/30
C1Humulin N KwikPen
C1Humulin N
C1Humulin R
C1Humulin R U-500
C1Humulin R U-500 KwikPen
C1Insulin Lispro
C1Insulin Lispro Junior KwikPen
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Gvoke PFS
(Subcutaneous
Solution Prefilled
Syringe)
1
Proglycem (Oral
Suspension)1
Insulins
Humalog Junior
KwikPen
(Subcutaneous
Solution Pen-Injector)
1
Humalog KwikPen
(Subcutaneous
Solution Pen-Injector)
1
Humalog Mix 50/50
KwikPen
(Subcutaneous
Suspension Pen-
Injector)
1
Humalog Mix 50/50
(Subcutaneous
Suspension)
1
Humalog Mix 75/25
KwikPen
(Subcutaneous
Suspension Pen-
Injector)
1
Humalog Mix 75/25
(Subcutaneous
Suspension)
1
Humalog
(Subcutaneous
Solution)
1
Humalog
(Subcutaneous
Solution Cartridge)
1
Humulin 70/30
KwikPen
(Subcutaneous
Suspension Pen-
Injector)
1
Humulin 70/30
(Subcutaneous
Suspension)
1
Humulin N KwikPen
(Subcutaneous
Suspension Pen-
Injector)
1
Humulin N
(Subcutaneous
Suspension)
1
Humulin R (Injection
Solution)1
Humulin R U-500
(Concentrated)
(Subcutaneous
Solution)
1
Humulin R U-500
KwikPen
(Subcutaneous
Solution Pen-Injector)
1
Insulin Lispro (1 Unit
Dial) (Subcutaneous
Solution Pen-Injector)
(Brand Equivalent
Humalog)
1
Insulin Lispro Junior
KwikPen
(Subcutaneous
Solution Pen-Injector)
(Brand Equivalent
Humalog)
1
tRACK48
38
Bold type = Brand name drug Plain type = Generic drug
C1Insulin Lispro Prot & Lispro
C1Insulin Lispro
C1Lantus SoloStar
C1Lantus
C1Levemir FlexTouch
C1Levemir
C1Toujeo Max SoloStar
C1Toujeo SoloStar
C1Tresiba FlexTouch
C1Tresiba
A1
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Eliquis Starter Pack
C1Eliquis
C1Enoxaparin Sodium
C1Fondaparinux Sodium
C1Fondaparinux Sodium
C1Heparin Sodium
C1Heparin Sodium
C1Jantoven
C1Warfarin Sodium
C1Xarelto
C1Xarelto Starter Pack
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Insulin Lispro Prot &
Lispro (Subcutaneous
Suspension Pen-
Injector) (Brand
Equivalent Humalog)
1
Insulin Lispro
(Subcutaneous
Solution) (Brand
Equivalent Humalog)
1
Lantus SoloStar
(Subcutaneous
Solution Pen-Injector)
1
Lantus
(Subcutaneous
Solution)
1
Levemir FlexTouch
(Subcutaneous
Solution Pen-Injector)
1
Levemir
(Subcutaneous
Solution)
1
Toujeo Max SoloStar
(Subcutaneous
Solution Pen-Injector)
1
Toujeo SoloStar
(Subcutaneous
Solution Pen-Injector)
1
Tresiba FlexTouch
(Subcutaneous
Solution Pen-Injector)
1
Tresiba
(Subcutaneous
Solution)
1
Blood Products/Modifiers/Volume Expanders
Anticoagulants
Eliquis Starter Pack
(Oral Tablet)1 QL
Eliquis (Oral Tablet) 1 QL
Enoxaparin Sodium (Subcutaneous Solution)
1 QL
Fondaparinux Sodium (10MG/0.8ML Subcutaneous Solution, 5MG/0.4ML Subcutaneous Solution, 7.5MG/ 0.6ML Subcutaneous Solution)
1
Fondaparinux Sodium (2.5MG/0.5ML Subcutaneous Solution)
1
Heparin Sodium (10000UNIT/ML Injection Solution, 20000UNIT/ML Injection Solution, 5000UNIT/ML Injection Solution)
1
Heparin Sodium (1000UNIT/ML Injection Solution)
1 B/D, PA
Jantoven (Oral Tablet) 1
Warfarin Sodium (Oral Tablet)
1
Xarelto (Oral Tablet) 1 QL
Xarelto Starter Pack
(Oral Tablet Therapy
Pack)
1 QL
Blood Formation Modifiers
tRACK 49
39
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Anagrelide HCl
C1Aranesp
C1Aranesp
C1Aranesp
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Aranesp
C1Granix
C1Granix
C1Leukine
C1Neulasta
C1Neupogen
C1Neupogen
C1Procrit
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Anagrelide HCl (Oral Capsule)
1
Aranesp (Albumin
Free) (100MCG/ML
Injection Solution,
200MCG/ML
Injection Solution,
300MCG/ML
Injection Solution,
60MCG/ML Injection
Solution)
1 PA
Aranesp (Albumin
Free) (25MCG/ML
Injection Solution,
40MCG/ML Injection
Solution)
1 PA
Aranesp (Albumin
Free) (100MCG/
0.5ML Injection
Solution Prefilled
Syringe, 150MCG/
0.3ML Injection
Solution Prefilled
Syringe, 200MCG/
0.4ML Injection
Solution Prefilled
Syringe, 300MCG/
0.6ML Injection
Solution Prefilled
Syringe, 500MCG/ML
Injection Solution
Prefilled Syringe,
60MCG/0.3ML
Injection Solution
Prefilled Syringe)
1 PA
Aranesp (Albumin
Free) (10MCG/0.4ML
Injection Solution
Prefilled Syringe,
25MCG/0.42ML
Injection Solution
Prefilled Syringe,
40MCG/0.4ML
Injection Solution
Prefilled Syringe)
1 PA
Granix (Subcutaneous
Solution)1 ST
Granix (Subcutaneous
Solution Prefilled
Syringe)
1 ST
Leukine (Injection
Solution
Reconstituted)
1 PA
Neulasta
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Neupogen (Injection
Solution)1 ST
Neupogen (Injection
Solution Prefilled
Syringe)
1 ST
Procrit (10000UNIT/
ML Injection Solution,
2000UNIT/ML
Injection Solution,
3000UNIT/ML
Injection Solution,
4000UNIT/ML
Injection Solution)
1 PA
tRACK50
40
Bold type = Brand name drug Plain type = Generic drug
C1Procrit
C1Promacta
C1Promacta
C1Retacrit
C1Retacrit
C1Udenyca
C1Zarxio
B1
C1Tranexamic Acid
B1
C1Aspirin-Dipyridamole ER
C1Brilinta
C1Cablivi
C1Cilostazol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Clopidogrel Bisulfate
C1Prasugrel HCl
A1
B1
C1Clonidine HCl
C1Clonidine
C1Methyldopa
C1Midodrine HCl
C1Northera
B1
C1Doxazosin Mesylate
C1Phenoxybenzamine HCl
C1Prazosin HCl
B1
C1Candesartan Cilexetil
C1Edarbi
C1Irbesartan
C1Losartan Potassium
C1Olmesartan Medoxomil
C1Telmisartan
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Procrit (20000UNIT/
ML Injection Solution,
40000UNIT/ML
Injection Solution)
1 PA
Promacta (Oral
Packet)1 PA; LA; QL
Promacta (Oral
Tablet)1 PA; LA; QL
Retacrit (10000UNIT/
ML Injection Solution,
2000UNIT/ML
Injection Solution,
3000UNIT/ML
Injection Solution,
4000UNIT/ML
Injection Solution)
1 PA
Retacrit (40000UNIT/
ML Injection Solution)1 PA
Udenyca
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Zarxio (Injection
Solution Prefilled
Syringe)
1
Hemostasis Agents
Tranexamic Acid (Oral Tablet)
1
Platelet Modifying Agents
Aspirin-Dipyridamole ER (Oral Capsule Extended Release 12 Hour)
1 QL
Brilinta (Oral Tablet) 1 QL
Cablivi (Injection Kit) 1 PA; QL
Cilostazol (Oral Tablet) 1
Clopidogrel Bisulfate (75MG Oral Tablet)
1 QL
Prasugrel HCl (Oral Tablet)
1 QL
Cardiovascular Agents
Alpha-adrenergic Agonists
Clonidine HCl (Oral Tablet Immediate Release)
1
Clonidine (Transdermal Patch Weekly)
1
Methyldopa (Oral Tablet)
1
Midodrine HCl (Oral Tablet)
1
Northera (Oral
Capsule)1 PA; LA; QL
Alpha-adrenergic Blocking Agents
Doxazosin Mesylate (Oral Tablet)
1
Phenoxybenzamine HCl (Oral Capsule)
1
Prazosin HCl (Oral Capsule)
1
Angiotensin II Receptor Antagonists
Candesartan Cilexetil (Oral Tablet)
1 QL
Edarbi (Oral Tablet) 1 QL
Irbesartan (Oral Tablet) 1 QL
Losartan Potassium (Oral Tablet)
1 QL
Olmesartan Medoxomil (Oral Tablet)
1 QL
Telmisartan (Oral Tablet)
1 QL
tRACK 51
41
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Valsartan
B1
C1Benazepril HCl
C1Captopril
C1Enalapril Maleate
C1Fosinopril Sodium
C1Lisinopril
C1Moexipril HCl
C1Perindopril Erbumine
C1Quinapril HCl
C1Ramipril
C1Trandolapril
B1
C1Amiodarone HCl
C1Dofetilide
C1Flecainide Acetate
C1Mexiletine HCl
C1Multaq
C1Pacerone
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Propafenone HCl ER
C1Propafenone HCl
C1Quinidine Gluconate ER
C1Quinidine Sulfate
C1Sotalol HCl AF
C1Sotalol HCl
B1
C1Acebutolol HCl
C1Atenolol
C1Betaxolol HCl
C1Bisoprolol Fumarate
C1Bystolic
C1Carvedilol
C1Labetalol HCl
C1Metoprolol Succinate ER
C1Metoprolol Tartrate
C1Nadolol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Valsartan (Oral Tablet) 1 QL
Angiotensin-converting Enzyme (ACE) Inhibitors
Benazepril HCl (Oral Tablet)
1 QL
Captopril (Oral Tablet) 1 QL
Enalapril Maleate (Oral Tablet)
1 QL
Fosinopril Sodium (Oral Tablet)
1 QL
Lisinopril (Oral Tablet) 1 QL
Moexipril HCl (Oral Tablet)
1 QL
Perindopril Erbumine (Oral Tablet)
1 QL
Quinapril HCl (Oral Tablet)
1 QL
Ramipril (Oral Capsule) 1 QL
Trandolapril (Oral Tablet)
1 QL
Antiarrhythmics
Amiodarone HCl (200MG Oral Tablet)
1
Dofetilide (Oral Capsule)
1
Flecainide Acetate (Oral Tablet)
1
Mexiletine HCl (Oral Capsule)
1
Multaq (Oral Tablet) 1 QL
Pacerone (200MG Oral Tablet)
1
Propafenone HCl ER (Oral Capsule Extended Release 12 Hour)
1
Propafenone HCl (Oral Tablet)
1
Quinidine Gluconate ER (Oral Tablet Extended Release)
1
Quinidine Sulfate (Oral Tablet)
1
Sotalol HCl AF (Oral Tablet)
1
Sotalol HCl (Oral Tablet)
1
Beta-adrenergic Blocking Agents
Acebutolol HCl (Oral Capsule)
1
Atenolol (Oral Tablet) 1
Betaxolol HCl (Oral Tablet)
1
Bisoprolol Fumarate (Oral Tablet)
1
Bystolic (Oral Tablet) 1 QL
Carvedilol (Oral Tablet) 1
Labetalol HCl (Oral Tablet)
1
Metoprolol Succinate ER (Oral Tablet Extended Release 24 Hour)
1
Metoprolol Tartrate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)
1
Nadolol (Oral Tablet) 1
tRACK52
42
Bold type = Brand name drug Plain type = Generic drug
C1Pindolol
C1Propranolol HCl ER
C1Propranolol HCl
C1Propranolol HCl
B1
C1Amlodipine Besylate
C1Cartia XT
C1Diltiazem HCl ER Beads
C1Diltiazem HCl ER Coated Beads
C1Diltiazem HCl ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Diltiazem HCl
C1Dilt-XR
C1Felodipine ER
C1Matzim LA
C1Nicardipine HCl
C1Nifedipine ER
C1Nifedipine ER Osmotic Release
C1Nimodipine
C1Nymalize
C1Taztia XT
C1Tiadylt ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Pindolol (Oral Tablet) 1
Propranolol HCl ER (Oral Capsule Extended Release 24 Hour)
1
Propranolol HCl (Oral Solution)
1
Propranolol HCl (Oral Tablet)
1
Calcium Channel Blocking Agents
Amlodipine Besylate (Oral Tablet)
1
Cartia XT (Oral Capsule Extended Release 24 Hour)
1
Diltiazem HCl ER Beads (360MG Oral Capsule Extended Release 24 Hour, 420MG Oral Capsule Extended Release 24 Hour)
1
Diltiazem HCl ER Coated Beads (120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)
1
Diltiazem HCl ER (Oral Capsule Extended Release 12 Hour)
1
Diltiazem HCl (Oral Tablet Immediate Release)
1
Dilt-XR (Oral Capsule Extended Release 24 Hour)
1
Felodipine ER (Oral Tablet Extended Release 24 Hour)
1
Matzim LA (Oral Tablet Extended Release 24 Hour)
1
Nicardipine HCl (Oral Capsule)
1
Nifedipine ER (Oral Tablet Extended Release 24 Hour)
1 QL
Nifedipine ER Osmotic Release (Oral Tablet Extended Release 24 Hour)
1 QL
Nimodipine (Oral Capsule)
1
Nymalize (6MG/ML
Oral Solution)1
Taztia XT (Oral Capsule Extended Release 24 Hour)
1
Tiadylt ER (Oral Capsule Extended Release 24 Hour)
1
tRACK 53
43
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Verapamil HCl ER
C1Verapamil HCl ER
C1Verapamil HCl ER
C1Verapamil HCl
B1
C1Aliskiren Fumarate
C1Amiloride-Hydrochlorothiazide
C1Amlodipine-Atorvastatin
C1Amlodipine-Benazepril
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Amlodipine-Olmesartan
C1Amlodipine-Valsartan
C1Amlodipine-Valsartan-HCTZ
C1Atenolol-Chlorthalidone
C1Benazepril-Hydrochlorothiazide
C1BiDil
C1Bisoprolol-Hydrochlorothiazide
C1Candesartan Cilexetil-HCTZ
C1Captopril-Hydrochlorothiazide
C1Corlanor
C1Corlanor
C1Demser
C1Digitek
C1Digox
C1Digoxin
C1Digoxin
C1Edarbyclor
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Verapamil HCl ER (100MG Oral Capsule Extended Release 24 Hour, 120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended Release 24 Hour, 200MG Oral Capsule Extended Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)
1
Verapamil HCl ER
(360MG Oral Capsule
Extended Release 24
Hour)
1
Verapamil HCl ER (Oral Tablet Extended Release)
1
Verapamil HCl (Oral Tablet Immediate Release)
1
Cardiovascular Agents, Other
Aliskiren Fumarate (Oral Tablet)
1 QL
Amiloride-Hydrochlorothiazide (Oral Tablet)
1
Amlodipine-Atorvastatin (Oral Tablet)
1 QL
Amlodipine-Benazepril (Oral Capsule)
1 QL
Amlodipine-Olmesartan (Oral Tablet)
1 QL
Amlodipine-Valsartan (Oral Tablet)
1 QL
Amlodipine-Valsartan-HCTZ (Oral Tablet)
1 QL
Atenolol-Chlorthalidone (Oral Tablet)
1
Benazepril-Hydrochlorothiazide (Oral Tablet)
1 QL
BiDil (Oral Tablet) 1 QL
Bisoprolol-Hydrochlorothiazide (Oral Tablet)
1 QL
Candesartan Cilexetil-HCTZ (Oral Tablet)
1 QL
Captopril-Hydrochlorothiazide (Oral Tablet)
1 QL
Corlanor (Oral
Solution)1 PA; QL
Corlanor (Oral Tablet) 1 PA; QL
Demser (Oral
Capsule)1
Digitek (Oral Tablet) 1
Digox (Oral Tablet) 1
Digoxin (Oral
Solution)1
Digoxin (Oral Tablet) 1
Edarbyclor (Oral
Tablet)1 QL
tRACK54
44
Bold type = Brand name drug Plain type = Generic drug
C1Enalapril-Hydrochlorothiazide
C1Entresto
C1Fosinopril Sodium-HCTZ
C1Irbesartan-Hydrochlorothiazide
C1Lanoxin
C1Lisinopril-Hydrochlorothiazide
C1Losartan Potassium-HCTZ
C1Methyldopa-Hydrochlorothiazide
C1Metoprolol-Hydrochlorothiazide
C1Olmesartan Medoxomil-HCTZ
C1Olmesartan-Amlodipine-HCTZ
C1Pentoxifylline ER
C1Propranolol-HCTZ
C1Quinapril-Hydrochlorothiazide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ranolazine ER
C1Spironolactone-HCTZ
C1Telmisartan-Amlodipine
C1Telmisartan-HCTZ
C1Triamterene-HCTZ
C1Triamterene-HCTZ
C1Valsartan-Hydrochlorothiazide
C1Vyndamax
C1Vyndaqel
B1
C1Acetazolamide ER
C1Acetazolamide
C1Methazolamide
B1
C1Bumetanide
C1Bumetanide
C1Ethacrynic Acid
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Enalapril-Hydrochlorothiazide (Oral Tablet)
1 QL
Entresto (Oral Tablet) 1 QL
Fosinopril Sodium-HCTZ (Oral Tablet)
1 QL
Irbesartan-Hydrochlorothiazide (Oral Tablet)
1 QL
Lanoxin (Oral Tablet) 1
Lisinopril-Hydrochlorothiazide (Oral Tablet)
1 QL
Losartan Potassium-HCTZ (Oral Tablet)
1 QL
Methyldopa-Hydrochlorothiazide (Oral Tablet)
1
Metoprolol-Hydrochlorothiazide (Oral Tablet)
1
Olmesartan Medoxomil-HCTZ (Oral Tablet)
1 QL
Olmesartan-Amlodipine-HCTZ (Oral Tablet)
1 QL
Pentoxifylline ER (Oral Tablet Extended Release)
1
Propranolol-HCTZ (Oral Tablet)
1
Quinapril-Hydrochlorothiazide (Oral Tablet)
1 QL
Ranolazine ER (Oral Tablet Extended Release 12 Hour)
1 QL
Spironolactone-HCTZ (Oral Tablet)
1
Telmisartan-Amlodipine (Oral Tablet)
1 QL
Telmisartan-HCTZ (Oral Tablet)
1 QL
Triamterene-HCTZ (Oral Capsule)
1
Triamterene-HCTZ (Oral Tablet)
1
Valsartan-Hydrochlorothiazide (Oral Tablet)
1 QL
Vyndamax (Oral
Capsule)1 PA; QL
Vyndaqel (Oral
Capsule)1 PA; QL
Diuretics, Carbonic Anhydrase Inhibitors
Acetazolamide ER (Oral Capsule Extended Release 12 Hour)
1
Acetazolamide (Oral Tablet)
1
Methazolamide (Oral Tablet)
1
Diuretics, Loop
Bumetanide (Injection Solution)
1
Bumetanide (Oral Tablet)
1
Ethacrynic Acid (Oral Tablet)
1
tRACK 55
45
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Furosemide
C1Furosemide
C1Furosemide
C1Torsemide
B1
C1Amiloride HCl
C1Eplerenone
C1Spironolactone
C1Triamterene
B1
C1Chlorthalidone
C1Diuril
C1Hydrochlorothiazide
C1Hydrochlorothiazide
C1Indapamide
C1Metolazone
B1
C1Fenofibrate Micronized
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Fenofibrate
C1Fenofibrate
C1Fenofibric Acid
C1Gemfibrozil
B1
C1Atorvastatin Calcium
C1Fluvastatin Sodium
C1Livalo
C1Lovastatin
C1Pravastatin Sodium
C1Rosuvastatin Calcium
C1Simvastatin
B1
C1Cholestyramine Light
C1Cholestyramine
C1Colesevelam HCl
C1Colesevelam HCl
C1Colestipol HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Furosemide (Injection Solution)
1 B/D, PA
Furosemide (Oral Solution)
1
Furosemide (Oral Tablet)
1
Torsemide (Oral Tablet)
1
Diuretics, Potassium-sparing
Amiloride HCl (Oral Tablet)
1
Eplerenone (Oral Tablet)
1
Spironolactone (Oral Tablet)
1
Triamterene (Oral Capsule)
1
Diuretics, Thiazide
Chlorthalidone (Oral Tablet)
1
Diuril (Oral
Suspension)1
Hydrochlorothiazide (Oral Capsule)
1
Hydrochlorothiazide (Oral Tablet)
1
Indapamide (Oral Tablet)
1
Metolazone (Oral Tablet)
1
Dyslipidemics, Fibric Acid Derivatives
Fenofibrate Micronized (134MG Oral Capsule, 200MG Oral Capsule, 67MG Oral Capsule)
1
Fenofibrate (145MG Oral Tablet, 48MG Oral Tablet)
1
Fenofibrate (160MG Oral Tablet, 54MG Oral Tablet)
1
Fenofibric Acid (Oral Capsule Delayed Release)
1
Gemfibrozil (Oral Tablet)
1
Dyslipidemics, HMG CoA Reductase Inhibitors
Atorvastatin Calcium (Oral Tablet)
1 QL
Fluvastatin Sodium (Oral Capsule)
1 QL
Livalo (Oral Tablet) 1 QL
Lovastatin (Oral Tablet) 1 QL
Pravastatin Sodium (Oral Tablet)
1 QL
Rosuvastatin Calcium (Oral Tablet)
1 QL
Simvastatin (Oral Tablet)
1 QL
Dyslipidemics, Other
Cholestyramine Light (Oral Powder)
1
Cholestyramine (Oral Packet)
1
Colesevelam HCl (Oral Packet)
1
Colesevelam HCl (Oral Tablet)
1
Colestipol HCl (Oral Packet)
1
tRACK56
46
Bold type = Brand name drug Plain type = Generic drug
C1Colestipol HCl
C1Ezetimibe
C1Ezetimibe-Simvastatin
C1Juxtapid
C1Niacin ER
C1Niacor
C1Omega-3-Acid Ethyl Esters
C1Praluent
C1Prevalite
C1Repatha Pushtronex System
C1Repatha
C1Repatha SureClick
C1Vascepa
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Hydralazine HCl
C1Minoxidil
B1
C1Isosorbide Dinitrate
C1Isosorbide Mononitrate ER
C1Isosorbide Mononitrate
C1Minitran
C1Nitro-Bid
C1Nitroglycerin
C1Nitroglycerin
C1Nitroglycerin
C1Nitrostat
C1Rectiv
A1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Colestipol HCl (Oral Tablet)
1
Ezetimibe (Oral Tablet) 1 QL
Ezetimibe-Simvastatin (Oral Tablet)
1 QL
Juxtapid (Oral
Capsule)1 PA; LA
Niacin ER (Antihyperlipidemic) (Oral Tablet Extended Release)
1
Niacor (Oral Tablet) 1
Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic Lovaza)
1 QL
Praluent
(Subcutaneous
Solution Auto-
Injector)
1 PA; LA; QL
Prevalite (Oral Packet) 1
Repatha Pushtronex
System
(Subcutaneous
Solution Cartridge)
1 PA; QL
Repatha
(Subcutaneous
Solution Prefilled
Syringe)
1 PA; QL
Repatha SureClick
(Subcutaneous
Solution Auto-
Injector)
1 PA; QL
Vascepa (Oral
Capsule)1
Vasodilators, Direct-acting Arterial
Hydralazine HCl (Oral Tablet)
1
Minoxidil (Oral Tablet) 1
Vasodilators, Direct-acting Arterial/Venous
Isosorbide Dinitrate (10MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)
1
Isosorbide Mononitrate ER (Oral Tablet Extended Release 24 Hour)
1
Isosorbide Mononitrate (Oral Tablet Immediate Release)
1
Minitran (Transdermal Patch 24 Hour)
1
Nitro-Bid (Transdermal Ointment)
1
Nitroglycerin (Tablet Sublingual)
1
Nitroglycerin (Transdermal Patch 24 Hour)
1
Nitroglycerin (Translingual Solution)
1
Nitrostat (Tablet
Sublingual)1
Rectiv (Rectal
Ointment)1
Central Nervous System Agents
tRACK 57
47
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
B1
C1Amphetamine-Dextroamphetamine ER
C1Amphetamine-Dextroamphetamine
C1Dextroamphetamine Sulfate ER
C1Dextroamphetamine Sulfate
C1Vyvanse
C1Vyvanse
B1
C1Atomoxetine HCl
C1Clonidine HCl ER
C1Dexmethylphenidate HCl ER
C1Dexmethylphenidate HCl
C1Guanfacine HCl ER
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Methylphenidate HCl ER
C1Methylphenidate HCl
C1Methylphenidate HCl
B1
C1Austedo
C1Ingrezza
C1Ingrezza
C1Namzaric
C1Namzaric
C1Nuedexta
C1Riluzole
C1Tetrabenazine
B1
C1Drizalma Sprinkle
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)
1 QL
Amphetamine-Dextroamphetamine (Oral Tablet)
1 QL
Dextroamphetamine Sulfate ER (Oral Capsule Extended Release 24 Hour)
1 QL
Dextroamphetamine Sulfate (Oral Tablet)
1 QL
Vyvanse (Oral
Capsule)1
Vyvanse (Oral Tablet
Chewable)1
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
Atomoxetine HCl (Oral Capsule)
1 QL
Clonidine HCl ER (Oral Tablet Extended Release 12 Hour)
1 PA
Dexmethylphenidate HCl ER (Oral Capsule Extended Release 24 Hour)
1
Dexmethylphenidate HCl (Oral Tablet)
1 QL
Guanfacine HCl ER (Oral Tablet Extended Release 24 Hour)
1
Methylphenidate HCl ER (10MG Oral Tablet Extended Release, 20MG Oral Tablet Extended Release)
1 QL
Methylphenidate HCl (Oral Solution)
1 QL
Methylphenidate HCl (Oral Tablet Immediate Release) (Generic Ritalin)
1 QL
Central Nervous System, Other
Austedo (Oral Tablet) 1 PA; LA; QL
Ingrezza (Oral
Capsule)1 PA; QL
Ingrezza (Oral
Capsule Therapy
Pack)
1 PA; QL
Namzaric (Oral
Capsule ER 24 Hour
Therapy Pack)
1 PA; QL
Namzaric (Oral
Capsule Extended
Release 24 Hour)
1 PA; QL
Nuedexta (Oral
Capsule)1 PA
Riluzole (Oral Tablet) 1
Tetrabenazine (Oral Tablet)
1 PA; LA; QL
Fibromyalgia Agents
Drizalma Sprinkle
(Oral Capsule
Delayed Release
Sprinkle)
1 ST; QL
tRACK58
48
Bold type = Brand name drug Plain type = Generic drug
C1Duloxetine HCl
C1Pregabalin
C1Pregabalin
C1Savella
C1Savella Titration Pack
B1
C1Ampyra
C1Aubagio
C1Avonex Pen
C1Avonex Prefilled
C1Betaseron
C1Dalfampridine ER
C1Gilenya
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Glatiramer Acetate
C1Glatopa
C1Mayzent
C1Rebif Rebidose
C1Rebif Rebidose Titration Pack
C1Rebif
C1Rebif Titration Pack
C1Tecfidera Starter Pack
C1Tecfidera
A1
B1
C1Chlorhexidine Gluconate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule Delayed Release Particles)
1 QL
Pregabalin (Oral Capsule)
1 QL
Pregabalin (Oral Solution)
1 QL
Savella (Oral Tablet) 1
Savella Titration Pack
(Oral Tablet)1
Multiple Sclerosis Agents
Ampyra (Oral Tablet
Extended Release 12
Hour)
1 QL
Aubagio (Oral Tablet) 1 LA; QL
Avonex Pen
(Intramuscular Auto-
Injector Kit)
1 QL
Avonex Prefilled
(Intramuscular
Prefilled Syringe Kit)
1 QL
Betaseron
(Subcutaneous Kit)1 QL
Dalfampridine ER (Oral Tablet Extended Release 12 Hour)
1 QL
Gilenya (0.5MG Oral
Capsule)1 QL
Glatiramer Acetate (Subcutaneous Solution Prefilled Syringe)
1 QL
Glatopa (Subcutaneous Solution Prefilled Syringe)
1 QL
Mayzent (Oral Tablet) 1 QL
Rebif Rebidose
(Subcutaneous
Solution Auto-
Injector)
1 QL
Rebif Rebidose
Titration Pack
(Subcutaneous
Solution Auto-
Injector)
1 QL
Rebif (Subcutaneous
Solution Prefilled
Syringe)
1 QL
Rebif Titration Pack
(Subcutaneous
Solution Prefilled
Syringe)
1 QL
Tecfidera Starter
Pack (Oral)1 LA
Tecfidera (Oral
Capsule Delayed
Release)
1 LA; QL
Dental and Oral Agents
Dental and Oral Agents
Chlorhexidine Gluconate (Mouth Solution)
1
tRACK 59
49
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Pilocarpine HCl
C1Triamcinolone Acetonide
A1
B1
C1Acitretin
C1Adapalene
C1Adapalene
C1Ammonium Lactate
C1Ammonium Lactate
C1Azelaic Acid
C1Benzoyl Peroxide-Erythromycin
C1Calcipotriene
C1Calcipotriene
C1Calcipotriene
C1Calcitriol
C1Carac
C1Claravis
C1Clindamycin Phosphate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Clindamycin Phosphate
C1Clindamycin Phosphate
C1Clindamycin Phosphate
C1Clindamycin Phosphate-Benzoyl Peroxide
C1Clotrimazole-Betamethasone
C1Clotrimazole-Betamethasone
C1Cortisporin
C1Cortisporin
C1Cosentyx
C1Cosentyx Sensoready
C1Diclofenac Sodium
C1Doxepin HCl
C1Ery
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Pilocarpine HCl (Oral Tablet)
1
Triamcinolone Acetonide (Dental Paste)
1
Dermatological Agents
Dermatological Agents
Acitretin (Oral Capsule) 1
Adapalene (External Cream)
1
Adapalene (0.1% External Gel)
1
Ammonium Lactate (External Cream)
1
Ammonium Lactate (External Lotion)
1
Azelaic Acid (External Gel)
1
Benzoyl Peroxide-Erythromycin (External Gel)
1
Calcipotriene (External Cream)
1
Calcipotriene (External Ointment)
1
Calcipotriene (External Solution)
1
Calcitriol (External
Ointment)1
Carac (External
Cream)1 PA
Claravis (Oral Capsule) 1 PA
Clindamycin Phosphate (External Gel)
1
Clindamycin Phosphate (External Lotion)
1
Clindamycin Phosphate (External Solution)
1
Clindamycin Phosphate (External Swab)
1
Clindamycin Phosphate-Benzoyl Peroxide (1-5% External Gel)
1
Clotrimazole-Betamethasone (External Cream)
1
Clotrimazole-Betamethasone (External Lotion)
1
Cortisporin (External
Cream)1
Cortisporin (External
Ointment)1
Cosentyx (300 MG
Dose) (Subcutaneous
Solution Prefilled
Syringe)
1 PA; LA
Cosentyx Sensoready
(300 MG)
(Subcutaneous
Solution Auto-
Injector)
1 PA; LA
Diclofenac Sodium (3% Transdermal Gel)
1 PA
Doxepin HCl (External Cream)
1 PA; QL
Ery (External Pad) 1
tRACK60
50
Bold type = Brand name drug Plain type = Generic drug
C1Erythromycin
C1Erythromycin
C1Finacea
C1Fluorouracil
C1Fluorouracil
C1Fluorouracil
C1Imiquimod
C1Imiquimod Pump
C1Isotretinoin
C1Methoxsalen Rapid
C1Mirvaso
C1Oxsoralen Ultra
C1Picato
C1Pimecrolimus
C1Podofilox
C1Regranex
C1Santyl
C1Selenium Sulfide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Stelara
C1Stelara
C1Tacrolimus
C1Tazarotene
C1Tazorac
C1Tazorac
C1Tazorac
C1Tolak
C1Tretinoin
C1Tretinoin
C1Tretinoin Microsphere
C1Zyclara Pump
A1
B1
C1Aminosyn II
C1Aminosyn-PF
C1Carbaglu
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Erythromycin (External Gel)
1
Erythromycin (External Solution)
1
Finacea (External
Foam)1
Fluorouracil (0.5% External Cream)
1
Fluorouracil (5% External Cream)
1
Fluorouracil (External Solution)
1
Imiquimod (5% External Cream)
1
Imiquimod Pump (3.75% External Cream)
1 PA
Isotretinoin (Oral Capsule)
1 PA
Methoxsalen Rapid (Oral Capsule)
1
Mirvaso (External Gel) 1
Oxsoralen Ultra (Oral
Capsule)1
Picato (External Gel) 1
Pimecrolimus (External Cream)
1 ST
Podofilox (External Solution)
1
Regranex (External
Gel)1 PA
Santyl (External
Ointment)1
Selenium Sulfide (External Lotion)
1
Stelara
(Subcutaneous
Solution)
1 PA
Stelara
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Tacrolimus (External Ointment)
1 ST
Tazarotene (External Cream)
1 PA
Tazorac (0.05%
External Cream)1 PA
Tazorac (0.05%
External Gel)1 PA
Tazorac (0.1%
External Gel)1 PA
Tolak (External
Cream)1
Tretinoin (External Cream)
1 PA
Tretinoin (0.01% External Gel, 0.025% External Gel)
1 PA
Tretinoin Microsphere (External Gel)
1 PA
Zyclara Pump
(External Cream)1 PA
Electrolytes/Minerals/Metals/Vitamins
Electrolyte/Mineral Replacement
Aminosyn II
(Intravenous Solution)1 B/D, PA
Aminosyn-PF (7%
Intravenous Solution)1 B/D, PA
Carbaglu (Oral Tablet) 1 LA
tRACK 61
51
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Dextrose
C1Dextrose
C1Dextrose-NaCl
C1Dextrose-NaCl
C1FreAmine HBC
C1HepatAmine
C1Intralipid
C1Isolyte-P in D5W
C1Isolyte-S
C1KCl in Dextrose-NaCl
C1KCl-Lactated Ringers-D5W
C1Klor-Con 10
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Klor-Con M10
C1Klor-Con M15
C1Klor-Con M20
C1Klor-Con
C1Klor-Con 8
C1Levocarnitine
C1Levocarnitine
C1Magnesium Sulfate
C1Magnesium Sulfate
C1NephrAmine
C1Normosol-M in D5W
C1Normosol-R pH 7.4
C1Nutrilipid
C1Plasma-Lyte 148
C1Plasma-Lyte A
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Dextrose (10%
Intravenous Solution)1
Dextrose (5% Intravenous Solution)
1 B/D, PA
Dextrose-NaCl
(10-0.2% Intravenous
Solution, 10-0.45%
Intravenous Solution,
2.5-0.45%
Intravenous Solution,
5-0.2% Intravenous
Solution, 5-0.45%
Intravenous Solution)
1
Dextrose-NaCl
(5-0.9% Intravenous
Solution)
1 B/D, PA
FreAmine HBC
(Intravenous Solution)1 B/D, PA
HepatAmine
(Intravenous Solution)1 B/D, PA
Intralipid (Intravenous
Emulsion)1 B/D, PA
Isolyte-P in D5W
(Intravenous Solution)1
Isolyte-S (Intravenous
Solution)1
KCl in Dextrose-NaCl
(Intravenous Solution)1
KCl-Lactated Ringers-
D5W (Intravenous
Solution)
1
Klor-Con 10 (Oral
Tablet Extended
Release)
1
Klor-Con M10 (Oral Tablet Extended Release)
1
Klor-Con M15 (Oral Tablet Extended Release)
1
Klor-Con M20 (Oral Tablet Extended Release)
1
Klor-Con (Oral Packet) 1
Klor-Con 8 (Oral
Tablet Extended
Release)
1
Levocarnitine (1GM/ 10ML Oral Solution)
1
Levocarnitine (330MG
Oral Tablet)1
Magnesium Sulfate
(50% Injection
Solution)
1
Magnesium Sulfate (50% (10ML Syringe) Injection Solution)
1
NephrAmine
(Intravenous Solution)1 B/D, PA
Normosol-M in D5W
(Intravenous Solution)1
Normosol-R pH 7.4
(Intravenous Solution)1
Nutrilipid
(Intravenous
Emulsion)
1 B/D, PA
Plasma-Lyte 148
(Intravenous Solution)1
Plasma-Lyte A
(Intravenous Solution)1
tRACK62
52
Bold type = Brand name drug Plain type = Generic drug
C1Plenamine
C1Potassium Chloride CR
C1Potassium Chloride ER
C1Potassium Chloride in Dextrose
C1Potassium Chloride in NaCl
C1Potassium Chloride in NaCl
C1Potassium Chloride
C1Potassium Chloride
C1Potassium Chloride
C1Potassium Chloride
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Potassium Citrate ER
C1Premasol
C1Procalamine
C1Prosol
C1Sodium Chloride
C1Sodium Chloride
C1Sodium Chloride
C1Sodium Chloride
C1Sodium Fluoride
C1TPN Electrolytes
C1Travasol
C1TrophAmine
B1
C1Chemet
C1Clovique
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Plenamine (Intravenous Solution)
1 B/D, PA
Potassium Chloride CR (Oral Tablet Extended Release)
1
Potassium Chloride ER (Oral Capsule Extended Release)
1
Potassium Chloride in
Dextrose (20MEQ/L
Intravenous Solution)
1 B/D, PA
Potassium Chloride in NaCl (20-0.45MEQ/L-% Intravenous Solution)
1 B/D, PA
Potassium Chloride in
NaCl (20-0.9MEQ/L-%
Intravenous Solution,
40-0.9MEQ/L-%
Intravenous Solution)
1 B/D, PA
Potassium Chloride
(10MEQ/100ML
Intravenous Solution,
20MEQ/100ML
Intravenous Solution,
40MEQ/100ML
Intravenous Solution)
1 B/D, PA
Potassium Chloride (2MEQ/ML Intravenous Solution, 2MEQ/ML (20ML) Intravenous Solution)
1 B/D, PA
Potassium Chloride (Oral Packet)
1
Potassium Chloride (Oral Solution)
1
Potassium Citrate ER (Oral Tablet Extended Release)
1
Premasol (Intravenous Solution)
1 B/D, PA
Procalamine
(Intravenous Solution)1 B/D, PA
Prosol (Intravenous
Solution)1 B/D, PA
Sodium Chloride
(0.45% Intravenous
Solution)
1
Sodium Chloride (0.9% Intravenous Solution)
1 B/D, PA
Sodium Chloride (3%
Intravenous Solution,
5% Intravenous
Solution)
1 B/D, PA
Sodium Chloride
(Irrigation Solution)1
Sodium Fluoride (Oral Tablet)
1
TPN Electrolytes
(Intravenous
Concentrate)
1
Travasol (Intravenous
Solution)1 B/D, PA
TrophAmine (10%
Intravenous Solution)1 B/D, PA
Electrolyte/Mineral/Metal Modifiers
Chemet (Oral
Capsule)1
Clovique (Oral Capsule)
1 PA; QL
tRACK 63
53
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Deferasirox
C1Deferasirox
C1Ferriprox
C1Ferriprox
C1Jadenu
C1Jadenu Sprinkle
C1Kionex
C1Lokelma
C1Sodium Polystyrene Sulfonate
C1Sodium Polystyrene Sulfonate
C1SPS
C1Trientine HCl
C1Veltassa
B1
C1Auryxia
C1Calcium Acetate
C1Calcium Acetate
C1Lanthanum Carbonate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Phoslyra
C1Sevelamer Carbonate
C1Sevelamer Carbonate
C1Velphoro
B1
C1VP-PNV-DHA
A1
B1
C1Cuvposa
C1Dicyclomine HCl
C1Dicyclomine HCl
C1Dicyclomine HCl
C1Methscopolamine Bromide
B1
C1Chenodal
C1Cromolyn Sodium
C1Diphenoxylate-Atropine
C1Diphenoxylate-Atropine
C1Gattex
C1Loperamide HCl
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Deferasirox (Oral Tablet) (Generic Jadenu)
1 PA
Deferasirox (Oral Tablet Soluble) (Generic Exjade)
1 PA
Ferriprox (Oral
Solution)1 PA
Ferriprox (Oral Tablet) 1 PA
Jadenu (Oral Tablet) 1 PA
Jadenu Sprinkle (Oral
Packet)1 PA
Kionex (Oral Suspension)
1
Lokelma (Oral Packet) 1 QL
Sodium Polystyrene Sulfonate (Oral Powder)
1
Sodium Polystyrene Sulfonate (Oral Suspension)
1
SPS (Oral Suspension) 1
Trientine HCl (Oral Capsule)
1 PA; QL
Veltassa (Oral Packet) 1 QL
Phosphate Binders
Auryxia (Oral Tablet) 1 PA
Calcium Acetate (Phosphate Binder) (Oral Capsule)
1
Calcium Acetate (Phosphate Binder) (Oral Tablet)
1
Lanthanum Carbonate (Oral Tablet Chewable)
1
Phoslyra (Oral
Solution)1
Sevelamer Carbonate (Oral Packet)
1
Sevelamer Carbonate (Oral Tablet) (Generic Renvela)
1
Velphoro (Oral Tablet
Chewable)1
Vitamins
VP-PNV-DHA (Oral Capsule)
1
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
Cuvposa (Oral
Solution)1 PA
Dicyclomine HCl (Oral Capsule)
1
Dicyclomine HCl (Oral Solution)
1
Dicyclomine HCl (Oral Tablet)
1
Methscopolamine Bromide (Oral Tablet)
1
Gastrointestinal Agents, Other
Chenodal (Oral Tablet) 1
Cromolyn Sodium (Oral Concentrate)
1
Diphenoxylate-Atropine (Oral Liquid)
1
Diphenoxylate-Atropine (Oral Tablet)
1
Gattex (Subcutaneous
Kit)1 PA; LA
Loperamide HCl (Oral Capsule)
1
tRACK64
54
Bold type = Brand name drug Plain type = Generic drug
C1Myalept
C1Relistor
C1Relistor
C1Serostim
C1Ursodiol
C1Ursodiol
C1Zorbtive
B1
C1Cimetidine HCl
C1Cimetidine
C1Famotidine
C1Famotidine
B1
C1Alosetron HCl
C1Amitiza
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Linzess
C1Xifaxan
B1
C1Clenpiq
C1Constulose
C1Enulose
C1GaviLyte-C
C1GaviLyte-G
C1GaviLyte-N with Flavor Pack
C1Generlac
C1Lactulose
C1PEG-3350-NaCl-Na Bicarbonate-KCl
C1PEG-3350-Electrolytes
C1Suprep Bowel Prep Kit
C1TriLyte
B1
C1Carafate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Myalept
(Subcutaneous
Solution
Reconstituted)
1 PA; LA
Relistor (Oral Tablet) 1 PA; QL
Relistor
(Subcutaneous
Solution)
1 PA
Serostim
(Subcutaneous
Solution
Reconstituted)
1 PA; LA
Ursodiol (Oral Capsule)
1
Ursodiol (Oral Tablet) 1
Zorbtive
(Subcutaneous
Solution
Reconstituted)
1 PA; LA
Histamine2 (H2) receptor Antagonists
Cimetidine HCl (Oral Solution)
1
Cimetidine (Oral Tablet)
1
Famotidine (Oral Suspension Reconstituted)
1
Famotidine (20MG Oral Tablet, 40MG Oral Tablet)
1
Irritable Bowel Syndrome Agents
Alosetron HCl (Oral Tablet)
1 PA
Amitiza (Oral
Capsule)1 QL
Linzess (Oral
Capsule)1 QL
Xifaxan (Oral Tablet) 1 PA
Laxatives
Clenpiq (Oral
Solution)1
Constulose (Oral Solution)
1
Enulose (Oral Solution) 1
GaviLyte-C (Oral Solution Reconstituted)
1
GaviLyte-G (Oral Solution Reconstituted)
1
GaviLyte-N with Flavor Pack (Oral Solution Reconstituted)
1
Generlac (Oral Solution)
1
Lactulose (10GM/ 15ML Oral Solution)
1
PEG-3350-NaCl-Na Bicarbonate-KCl (Oral Solution) (Generic NuLYTELY)
1
PEG-3350-Electrolytes (Oral Solution) (Generic GoLYTELY)
1
Suprep Bowel Prep
Kit (Oral Solution)1
TriLyte (Oral Solution Reconstituted)
1
Protectants
Carafate (Oral
Suspension)1
tRACK 65
55
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Misoprostol
C1Sucralfate
C1Sucralfate
B1
C1Dexilant
C1Esomeprazole Magnesium
C1Lansoprazole
C1Omeprazole
C1Pantoprazole Sodium
C1Prilosec
C1Rabeprazole Sodium
A1
B1
C1Aralast NP
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Cholbam
C1Creon
C1Cystadane
C1Cystagon
C1Glassia
C1Kuvan
C1Kuvan
C1Miglustat
C1Nitisinone
C1Ocaliva
C1Orfadin
C1Orfadin
C1Procysbi
C1Prolastin-C
C1RAVICTI
C1Sodium Phenylbutyrate
C1Sodium Phenylbutyrate
C1Sucraid
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Misoprostol (Oral Tablet)
1
Sucralfate (Oral Suspension)
1
Sucralfate (Oral Tablet) 1
Proton Pump Inhibitors
Dexilant (Oral
Capsule Delayed
Release)
1 QL
Esomeprazole Magnesium (Oral Capsule Delayed Release) (Generic Nexium)
1 QL
Lansoprazole (Oral Capsule Delayed Release)
1 QL
Omeprazole (20MG Oral Capsule Delayed Release, 40MG Oral Capsule Delayed Release)
1
Pantoprazole Sodium (Oral Tablet Delayed Release)
1 QL
Prilosec (Oral Packet) 1 PA
Rabeprazole Sodium (Oral Tablet Delayed Release)
1
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
Aralast NP (1000MG
Intravenous Solution
Reconstituted)
1 PA; LA
Cholbam (Oral
Capsule)1 PA
Creon (Oral Capsule
Delayed Release
Particles)
1
Cystadane (Oral
Powder)1
Cystagon (Oral
Capsule)1 LA
Glassia (Intravenous
Solution)1 PA; LA
Kuvan (Oral Packet) 1 LA
Kuvan (Oral Tablet
Soluble)1 LA
Miglustat (Oral Capsule)
1 PA; LA
Nitisinone (Oral Capsule)
1
Ocaliva (Oral Tablet) 1 PA; QL
Orfadin (Oral
Capsule)1 LA
Orfadin (Oral
Suspension)1 LA
Procysbi (Oral
Packet)1 LA
Prolastin-C
(Intravenous Solution
Reconstituted)
1 PA; LA
RAVICTI (Oral Liquid) 1 LA; QL
Sodium Phenylbutyrate (Oral Powder)
1
Sodium Phenylbutyrate (Oral Tablet)
1
Sucraid (Oral
Solution)1 LA
tRACK66
56
Bold type = Brand name drug Plain type = Generic drug
C1Tegsedi
C1Zemaira
C1Zenpep
A1
B1
C1Myrbetriq
C1Oxybutynin Chloride ER
C1Oxybutynin Chloride
C1Oxybutynin Chloride
C1Solifenacin Succinate
B1
C1Alfuzosin HCl ER
C1Dutasteride
C1Finasteride
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Silodosin
C1Tamsulosin HCl
C1Terazosin HCl
B1
C1Bethanechol Chloride
C1Depen Titratabs
C1Elmiron
C1Lithostat
C1Penicillamine
C1Penicillamine
A1
B1
C1Ala-Cort
C1Alclometasone Dipropionate
C1Alclometasone Dipropionate
C1Betamethasone Dipropionate Aug
C1Betamethasone Dipropionate Aug
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Tegsedi
(Subcutaneous
Solution Prefilled
Syringe)
1 PA; LA
Zemaira (Intravenous
Solution
Reconstituted)
1 PA; LA
Zenpep (Oral Capsule
Delayed Release
Particles)
1
Genitourinary Agents
Antispasmodics, Urinary
Myrbetriq (Oral Tablet
Extended Release 24
Hour)
1
Oxybutynin Chloride ER (Oral Tablet Extended Release 24 Hour)
1 QL
Oxybutynin Chloride (Oral Syrup)
1
Oxybutynin Chloride (Oral Tablet Immediate Release)
1
Solifenacin Succinate (Oral Tablet)
1 QL
Benign Prostatic Hypertrophy Agents
Alfuzosin HCl ER (Oral Tablet Extended Release 24 Hour)
1
Dutasteride (Oral Capsule)
1 QL
Finasteride (5MG Oral Tablet) (Generic Proscar)
1
Silodosin (Oral Capsule)
1 QL
Tamsulosin HCl (Oral Capsule)
1
Terazosin HCl (Oral Capsule)
1
Genitourinary Agents, Other
Bethanechol Chloride (Oral Tablet)
1
Depen Titratabs (Oral
Tablet)1
Elmiron (Oral
Capsule)1
Lithostat (Oral Tablet) 1
Penicillamine (250MG Oral Capsule)
1 PA
Penicillamine (250MG Oral Tablet)
1
Hormonal Agents, Stimulant/Replacement/ Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Ala-Cort (1% External Cream)
1
Alclometasone Dipropionate (External Cream)
1
Alclometasone Dipropionate (External Ointment)
1
Betamethasone Dipropionate Aug (External Cream)
1
Betamethasone Dipropionate Aug (External Gel)
1
tRACK 67
57
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Betamethasone Dipropionate Aug
C1Betamethasone Dipropionate Aug
C1Betamethasone Dipropionate
C1Betamethasone Dipropionate
C1Betamethasone Dipropionate
C1Betamethasone Valerate
C1Betamethasone Valerate
C1Betamethasone Valerate
C1Clobetasol Propionate Emollient Base
C1Clobetasol Propionate
C1Clobetasol Propionate
C1Clobetasol Propionate
C1Clobetasol Propionate
C1Clobetasol Propionate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Cordran
C1Cortisone Acetate
C1Desonide
C1Desoximetasone
C1Dexamethasone Intensol
C1Dexamethasone
C1Dexamethasone
C1Fludrocortisone Acetate
C1Fluocinolone Acetonide
C1Fluocinolone Acetonide
C1Fluocinolone Acetonide
C1Fluocinolone Acetonide Scalp
C1Fluocinonide Emulsified Base
C1Fluocinonide
C1Fluocinonide
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Betamethasone Dipropionate Aug (External Lotion)
1
Betamethasone Dipropionate Aug (External Ointment)
1
Betamethasone Dipropionate (External Cream)
1
Betamethasone Dipropionate (External Lotion)
1
Betamethasone Dipropionate (External Ointment)
1
Betamethasone Valerate (External Cream)
1
Betamethasone Valerate (External Lotion)
1
Betamethasone Valerate (External Ointment)
1
Clobetasol Propionate Emollient Base (External Cream)
1
Clobetasol Propionate (External Cream)
1
Clobetasol Propionate (External Gel)
1
Clobetasol Propionate (External Ointment)
1
Clobetasol Propionate (External Shampoo)
1
Clobetasol Propionate (External Solution)
1
Cordran (External
Tape)1
Cortisone Acetate (Oral Tablet)
1
Desonide (External Ointment)
1
Desoximetasone (External Cream)
1
Dexamethasone Intensol (Oral Concentrate)
1
Dexamethasone (Oral Elixir)
1
Dexamethasone (Oral Tablet)
1
Fludrocortisone Acetate (Oral Tablet)
1
Fluocinolone Acetonide (External Cream)
1
Fluocinolone Acetonide (External Ointment)
1
Fluocinolone Acetonide (External Solution)
1
Fluocinolone Acetonide Scalp (External Oil)
1
Fluocinonide Emulsified Base (External Cream)
1
Fluocinonide (External Gel)
1
Fluocinonide (External Ointment)
1
tRACK68
58
Bold type = Brand name drug Plain type = Generic drug
C1Fluocinonide
C1Fluticasone Propionate
C1Fluticasone Propionate
C1Halobetasol Propionate
C1Halobetasol Propionate
C1Hydrocortisone Butyrate
C1Hydrocortisone
C1Hydrocortisone
C1Hydrocortisone
C1Hydrocortisone
C1Hydrocortisone Valerate
C1Hydrocortisone Valerate
C1Methylprednisolone
C1Methylprednisolone
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Mometasone Furoate
C1Mometasone Furoate
C1Mometasone Furoate
C1Prednicarbate
C1Prednicarbate
C1Prednisolone
C1Prednisolone Sodium Phosphate
C1Prednisone Intensol
C1Prednisone
C1Prednisone
C1Prednisone
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Fluocinonide (External Solution)
1
Fluticasone Propionate (External Cream)
1
Fluticasone Propionate (External Ointment)
1
Halobetasol Propionate (External Cream)
1
Halobetasol Propionate (External Ointment)
1
Hydrocortisone Butyrate (External Ointment)
1
Hydrocortisone (1% External Cream, 2.5% External Cream)
1
Hydrocortisone (2.5% External Lotion)
1
Hydrocortisone (1% External Ointment, 2.5% External Ointment)
1
Hydrocortisone (Oral Tablet)
1
Hydrocortisone Valerate (External Cream)
1
Hydrocortisone Valerate (External Ointment)
1
Methylprednisolone (Oral Tablet)
1
Methylprednisolone (Oral Tablet Therapy Pack)
1
Mometasone Furoate (External Cream)
1
Mometasone Furoate (External Ointment)
1
Mometasone Furoate (External Solution)
1
Prednicarbate (External Cream)
1
Prednicarbate (External Ointment)
1
Prednisolone (Oral Solution)
1
Prednisolone Sodium Phosphate (25MG/ 5ML Oral Solution, 6.7MG/5ML Oral Solution)
1
Prednisone Intensol (Oral Concentrate)
1
Prednisone (5MG/5ML Oral Solution)
1
Prednisone (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 50MG Oral Tablet, 5MG Oral Tablet)
1
Prednisone (10MG (21) Oral Tablet Therapy Pack, 10MG (48) Oral Tablet Therapy Pack, 5MG (21) Oral Tablet Therapy Pack, 5MG (48) Oral Tablet Therapy Pack)
1
tRACK 69
59
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Triamcinolone Acetonide
C1Triamcinolone Acetonide
C1Triamcinolone Acetonide
C1Triderm
A1
B1
C1Desmopressin Acetate
C1Desmopressin Acetate Spray
C1Genotropin MiniQuick
C1Genotropin
C1Humatrope
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Increlex
C1Norditropin FlexPro
C1Nutropin AQ NuSpin 10
C1Nutropin AQ NuSpin 20
C1Nutropin AQ NuSpin 5
C1Saizen
C1Saizenprep
A1
B1
C1Korlym
A1
B1
C1Anadrol-50
C1Androderm
C1Danazol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Triamcinolone Acetonide (External Cream)
1
Triamcinolone Acetonide (External Lotion)
1
Triamcinolone Acetonide (0.025% External Ointment, 0.1% External Ointment, 0.5% External Ointment)
1
Triderm (0.1% External Cream)
1
Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Desmopressin Acetate (Oral Tablet)
1
Desmopressin Acetate Spray (Nasal Solution)
1
Genotropin MiniQuick
(Subcutaneous
Solution
Reconstituted)
1 PA
Genotropin
(Subcutaneous
Solution
Reconstituted)
1 PA
Humatrope (Injection
Solution
Renconstituted),
Humatrope Combo
Pack (Injection)
1 PA
Increlex
(Subcutaneous
Solution)
1 PA; LA
Norditropin FlexPro
(Subcutaneous
Solution)
1 PA
Nutropin AQ NuSpin
10 (Subcutaneous
Solution)
1 PA
Nutropin AQ NuSpin
20 (Subcutaneous
Solution)
1 PA
Nutropin AQ NuSpin 5
(Subcutaneous
Solution)
1 PA
Saizen (Injection
Solution
Reconstituted)
1 PA; LA
Saizenprep (Injection
Solution
Reconstituted)
1 PA; LA
Hormonal Agents, Stimulant/Replacement/ Modifying (Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
Korlym (Oral Tablet) 1 PA; LA; QL
Hormonal Agents, Stimulant/Replacement/ Modifying (Sex Hormones/Modifiers)
Androgens
Anadrol-50 (Oral
Tablet)1 PA
Androderm
(Transdermal Patch
24 Hour)
1 QL
Danazol (Oral Capsule) 1
tRACK70
60
Bold type = Brand name drug Plain type = Generic drug
C1Oxandrolone
C1Oxandrolone
C1Testosterone Cypionate
C1Testosterone Enanthate
C1Testosterone
C1Testosterone
B1
C1Altavera
C1Alyacen 1/35
C1Amethia Lo
C1Amethia
C1Apri
C1Aranelle
C1Ashlyna
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Aubra
C1Aviane
C1Balziva
C1Blisovi 24 Fe
C1Blisovi Fe 1.5/30
C1Briellyn
C1Camrese Lo
C1Caziant
C1Climara Pro
C1Cryselle-28
C1Cyclafem 1/35
C1Cyclafem 7/7/7
C1Cyred
C1Depo-Estradiol
C1Desogestrel-Ethinyl Estradiol
C1Drospirenone-Ethinyl Estradiol
C1Duavee
C1Elestrin
C1EluRyng
C1Emoquette
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Oxandrolone (10MG Oral Tablet)
1 PA; QL
Oxandrolone (2.5MG Oral Tablet)
1 PA; QL
Testosterone Cypionate (Intramuscular Solution)
1
Testosterone Enanthate (Intramuscular Solution)
1
Testosterone (25MG/ 2.5GM 1% Transdermal Gel, 50MG/5GM 1% Transdermal Gel), Testosterone Pump (1% Transdermal Gel)
1
Testosterone (20.25MG/1.25GM 1.62% Transdermal Gel, 40.5MG/2.5GM 1.62% Transdermal Gel), Testosterone Pump (1.62% Transdermal Gel)
1
Estrogens
Altavera (Oral Tablet) 1
Alyacen 1/35 (Oral Tablet)
1
Amethia Lo (Oral Tablet)
1
Amethia (Oral Tablet) 1
Apri (Oral Tablet) 1
Aranelle (Oral Tablet) 1
Ashlyna (Oral Tablet) 1
Aubra (Oral Tablet) 1
Aviane (Oral Tablet) 1
Balziva (Oral Tablet) 1
Blisovi 24 Fe (Oral Tablet)
1
Blisovi Fe 1.5/30 (Oral Tablet)
1
Briellyn (Oral Tablet) 1
Camrese Lo (Oral Tablet)
1
Caziant (Oral Tablet) 1
Climara Pro
(Transdermal Patch
Weekly)
1
Cryselle-28 (Oral Tablet)
1
Cyclafem 1/35 (Oral Tablet)
1
Cyclafem 7/7/7 (Oral Tablet)
1
Cyred (Oral Tablet) 1
Depo-Estradiol (Intramuscular Oil)
1
Desogestrel-Ethinyl Estradiol (0.15-0.02/0.01MG (21/5) Oral Tablet)
1
Drospirenone-Ethinyl Estradiol (Oral Tablet)
1
Duavee (Oral Tablet) 1
Elestrin (Transdermal
Gel)1
EluRyng (Vaginal Ring) 1
Emoquette (Oral Tablet)
1
tRACK 71
61
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Enpresse-28
C1Enskyce
C1Estarylla
C1Estradiol
C1Estradiol
C1Estradiol
C1Estradiol
C1Estradiol Valerate
C1Estring
C1Ethynodiol Diacetate-Ethinyl Estradiol
C1Etonogestrel-Ethinyl Estradiol
C1Falmina
C1Fayosim
C1Femring
C1Femynor
C1Fyavolv
C1Gianvi
C1Hailey 24 Fe
C1Imvexxy Maintenance Pack
C1Imvexxy Starter Pack
C1Introvale
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Isibloom
C1Jasmiel
C1Jinteli
C1Juleber
C1Junel 1.5/30
C1Junel 1/20
C1Junel Fe 1.5/30
C1Junel Fe 1/20
C1Junel Fe 24
C1Kaitlib Fe
C1Kariva
C1Kelnor 1/35
C1Kelnor 1/50
C1Kurvelo
C1LARIN 1.5/30
C1LARIN 1/20
C1LARIN Fe 1.5/30
C1LARIN Fe 1/20
C1Larissia
C1Layolis Fe
C1Leena
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Enpresse-28 (Oral Tablet)
1
Enskyce (Oral Tablet) 1
Estarylla (Oral Tablet) 1
Estradiol (Oral Tablet) 1
Estradiol (Transdermal Patch Weekly)
1 QL
Estradiol (Vaginal Cream)
1
Estradiol (Vaginal Tablet)
1 QL
Estradiol Valerate (Intramuscular Oil)
1
Estring (Vaginal Ring) 1
Ethynodiol Diacetate-Ethinyl Estradiol (Oral Tablet)
1
Etonogestrel-Ethinyl Estradiol (Vaginal Ring)
1
Falmina (Oral Tablet) 1
Fayosim (Oral Tablet) 1
Femring (Vaginal
Ring)1
Femynor (Oral Tablet) 1
Fyavolv (Oral Tablet) 1
Gianvi (Oral Tablet) 1
Hailey 24 Fe (Oral Tablet)
1
Imvexxy Maintenance
Pack (Vaginal Insert)1 PA; QL
Imvexxy Starter Pack
(Vaginal Insert)1 PA; QL
Introvale (Oral Tablet) 1
Isibloom (Oral Tablet) 1
Jasmiel (Oral Tablet) 1
Jinteli (Oral Tablet) 1
Juleber (Oral Tablet) 1
Junel 1.5/30 (Oral Tablet)
1
Junel 1/20 (Oral Tablet)
1
Junel Fe 1.5/30 (Oral Tablet)
1
Junel Fe 1/20 (Oral Tablet)
1
Junel Fe 24 (Oral Tablet)
1
Kaitlib Fe (Oral Tablet Chewable)
1
Kariva (Oral Tablet) 1
Kelnor 1/35 (Oral Tablet)
1
Kelnor 1/50 (Oral Tablet)
1
Kurvelo (Oral Tablet) 1
LARIN 1.5/30 (Oral Tablet)
1
LARIN 1/20 (Oral Tablet)
1
LARIN Fe 1.5/30 (Oral Tablet)
1
LARIN Fe 1/20 (Oral Tablet)
1
Larissia (Oral Tablet) 1
Layolis Fe (Oral
Tablet Chewable)1
Leena (Oral Tablet) 1
tRACK72
62
Bold type = Brand name drug Plain type = Generic drug
C1Lessina
C1Levonest
C1Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol
C1Levonorgestrel-Ethinyl Estradiol 91-Day
C1Levonorgestrel-Ethinyl Estradiol
C1Levora 0.15/30
C1Loryna
C1Low-Ogestrel
C1Lutera
C1Marlissa
C1Melodetta 24 Fe
C1Menest
C1Mibelas 24 Fe
C1Microgestin 1.5/30
C1Microgestin 1/20
C1Microgestin Fe 1.5/30
C1Microgestin Fe 1/20
C1Mili
C1Necon 0.5/35
C1Nikki
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Norethindrone Acetate-Ethinyl Estradiol
C1Norethindrone Acetate-Ethinyl Estradiol
C1Norethindrone Acetate-Ethinyl Estradiol-Fe
C1Norgestimate-Ethinyl Estradiol
C1Norgestimate-Ethinyl Estradiol Triphasic
C1Nortrel 0.5/35
C1Nortrel 1/35
C1Nortrel 1/35
C1Nortrel 7/7/7
C1Ocella
C1Orsythia
C1Pimtrea
C1Pirmella 1/35
C1Portia-28
C1Premarin
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Lessina (Oral Tablet) 1
Levonest (Oral Tablet) 1
Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol (Oral Tablet)
1
Levonorgestrel-Ethinyl Estradiol 91-Day (Oral Tablet)
1
Levonorgestrel-Ethinyl Estradiol (Oral Tablet)
1
Levora 0.15/30 (28) (Oral Tablet)
1
Loryna (Oral Tablet) 1
Low-Ogestrel (Oral Tablet)
1
Lutera (Oral Tablet) 1
Marlissa (Oral Tablet) 1
Melodetta 24 Fe (Oral Tablet Chewable)
1
Menest (Oral Tablet) 1
Mibelas 24 Fe (Oral Tablet Chewable)
1
Microgestin 1.5/30 (Oral Tablet)
1
Microgestin 1/20 (Oral Tablet)
1
Microgestin Fe 1.5/30 (Oral Tablet)
1
Microgestin Fe 1/20 (Oral Tablet)
1
Mili (Oral Tablet) 1
Necon 0.5/35 (28) (Oral Tablet)
1
Nikki (Oral Tablet) 1
Norethindrone Acetate-Ethinyl Estradiol (0.5-2.5MG-MCG Oral Tablet, 1-5MG-MCG Oral Tablet)
1
Norethindrone Acetate-Ethinyl Estradiol (1-20MG-MCG Oral Tablet)
1
Norethindrone Acetate-Ethinyl Estradiol-Fe (0.4-35MG-MCG Oral Tablet Chewable, 0.8-25MG-MCG Oral Tablet Chewable, 1-20MG-MCG(24) Oral Tablet Chewable)
1
Norgestimate-Ethinyl Estradiol (Oral Tablet)
1
Norgestimate-Ethinyl Estradiol Triphasic (Oral Tablet)
1
Nortrel 0.5/35 (28) (Oral Tablet)
1
Nortrel 1/35 (21) (Oral Tablet)
1
Nortrel 1/35 (28) (Oral Tablet)
1
Nortrel 7/7/7 (Oral Tablet)
1
Ocella (Oral Tablet) 1
Orsythia (Oral Tablet) 1
Pimtrea (Oral Tablet) 1
Pirmella 1/35 (Oral Tablet)
1
Portia-28 (Oral Tablet) 1
Premarin (Oral Tablet) 1 QL
tRACK 73
63
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Premarin
C1Premphase
C1Prempro
C1Previfem
C1Reclipsen
C1Rivelsa
C1Setlakin
C1Sprintec 28
C1Sronyx
C1Syeda
C1Tarina 24 Fe
C1Tarina Fe 1/20
C1Tri-Estarylla
C1Tri-Legest Fe
C1Tri-Lo-Estarylla
C1Tri-Lo-Sprintec
C1Tri-Mili
C1Tri-Previfem
C1Tri-Sprintec
C1Trivora
C1Tri-VyLibra Lo
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Tri-VyLibra
C1Velivet
C1Vienva
C1Vyfemla
C1VyLibra
C1WYMZYA Fe
C1Xulane
C1Yuvafem
C1Zarah
C1Zovia 1/35E
B1
C1Camila
C1Crinone
C1Deblitane
C1Depo-Provera
C1Errin
C1Incassia
C1Lyza
C1Medroxyprogesterone Acetate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Premarin (Vaginal
Cream)1
Premphase (Oral
Tablet)1 QL
Prempro (Oral Tablet) 1 QL
Previfem (Oral Tablet) 1
Reclipsen (Oral Tablet) 1
Rivelsa (Oral Tablet) 1
Setlakin (Oral Tablet) 1
Sprintec 28 (Oral Tablet)
1
Sronyx (Oral Tablet) 1
Syeda (Oral Tablet) 1
Tarina 24 Fe (Oral Tablet)
1
Tarina Fe 1/20 (Oral Tablet)
1
Tri-Estarylla (Oral Tablet)
1
Tri-Legest Fe (Oral Tablet)
1
Tri-Lo-Estarylla (Oral Tablet)
1
Tri-Lo-Sprintec (Oral Tablet)
1
Tri-Mili (Oral Tablet) 1
Tri-Previfem (Oral Tablet)
1
Tri-Sprintec (Oral Tablet)
1
Trivora (28) (Oral Tablet)
1
Tri-VyLibra Lo (Oral Tablet)
1
Tri-VyLibra (Oral Tablet)
1
Velivet (Oral Tablet) 1
Vienva (Oral Tablet) 1
Vyfemla (Oral Tablet) 1
VyLibra (Oral Tablet) 1
WYMZYA Fe (Oral Tablet Chewable)
1
Xulane (Transdermal Patch Weekly)
1
Yuvafem (Vaginal Tablet)
1 QL
Zarah (Oral Tablet) 1
Zovia 1/35E (28) (Oral Tablet)
1
Progestins
Camila (Oral Tablet) 1
Crinone (Vaginal Gel) 1 PA
Deblitane (Oral Tablet) 1
Depo-Provera
(400MG/ML
Intramuscular
Suspension)
1
Errin (Oral Tablet) 1
Incassia (Oral Tablet) 1
Lyza (Oral Tablet) 1
Medroxyprogesterone Acetate (150MG/ML Intramuscular Suspension)
1
tRACK74
64
Bold type = Brand name drug Plain type = Generic drug
C1Medroxyprogesterone Acetate
C1Medroxyprogesterone Acetate
C1Megestrol Acetate
C1Megestrol Acetate
C1Megestrol Acetate
C1Nora-BE
C1Norethindrone Acetate
C1Norethindrone
C1Progesterone Micronized
C1Sharobel
B1
C1Osphena
C1Raloxifene HCl
A1
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Euthyrox
C1Levo-T
C1Levothyroxine Sodium
C1Levoxyl
C1Liothyronine Sodium
C1Synthroid
C1Unithroid
A1
B1
C1Lysodren
A1
B1
C1Cabergoline
C1Firmagon
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Medroxyprogesterone Acetate (150MG/ML Intramuscular Suspension Prefilled Syringe)
1
Medroxyprogesterone Acetate (10MG Oral Tablet, 2.5MG Oral Tablet, 5MG Oral Tablet)
1
Megestrol Acetate (40MG/ML Oral Suspension)
1
Megestrol Acetate (625MG/5ML Oral Suspension)
1
Megestrol Acetate (Oral Tablet)
1
Nora-BE (Oral Tablet) 1
Norethindrone Acetate (5MG Oral Tablet)
1
Norethindrone (0.35MG Oral Tablet)
1
Progesterone Micronized (Oral Capsule)
1
Sharobel (Oral Tablet) 1
Selective Estrogen Receptor Modifying Agents
Osphena (Oral Tablet) 1 PA; QL
Raloxifene HCl (Oral Tablet)
1 QL
Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Euthyrox (Oral Tablet) 1
Levo-T (Oral Tablet) 1
Levothyroxine Sodium (Oral Tablet)
1
Levoxyl (Oral Tablet) 1
Liothyronine Sodium (Oral Tablet)
1
Synthroid (Oral
Tablet)1
Unithroid (100MCG
Oral Tablet, 112MCG
Oral Tablet, 125MCG
Oral Tablet, 150MCG
Oral Tablet, 175MCG
Oral Tablet, 200MCG
Oral Tablet, 25MCG
Oral Tablet, 300MCG
Oral Tablet, 50MCG
Oral Tablet, 75MCG
Oral Tablet, 88MCG
Oral Tablet)
1
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
Lysodren (Oral
Tablet)1
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
Cabergoline (Oral Tablet)
1
Firmagon (240MG
Dose) (120MG/Vial
Subcutaneous
Solution
Reconstituted)
1 PA
tRACK 75
65
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Firmagon
C1Leuprolide Acetate
C1Lupaneta Pack
C1Lupron Depot
C1Lupron Depot
C1Lupron Depot
C1Lupron Depot
C1Octreotide Acetate
C1Octreotide Acetate
C1Signifor
C1Somatuline Depot
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Somavert
C1Synarel
C1Trelstar Mixject
A1
B1
C1Methimazole
C1Propylthiouracil
A1
B1
C1Berinert
C1Cinryze
C1Firazyr
C1Haegarda
C1Icatibant Acetate
C1Ruconest
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Firmagon (80MG
Subcutaneous
Solution
Reconstituted)
1 PA
Leuprolide Acetate (Injection Kit)
1 PA
Lupaneta Pack
(Combination Kit)1 PA
Lupron Depot (1-
Month)
(Intramuscular Kit)
1 PA
Lupron Depot (3-
Month)
(Intramuscular Kit)
1 PA
Lupron Depot (4-
Month)
(Intramuscular Kit)
1 PA
Lupron Depot (6-
Month)
(Intramuscular Kit)
1 PA
Octreotide Acetate (1000MCG/ML Injection Solution, 500MCG/ML Injection Solution)
1 PA
Octreotide Acetate (100MCG/ML Injection Solution, 200MCG/ML Injection Solution, 50MCG/ML Injection Solution)
1 PA
Signifor
(Subcutaneous
Solution)
1 PA; LA
Somatuline Depot
(Subcutaneous
Solution)
1
Somavert
(Subcutaneous
Solution
Reconstituted)
1 PA; LA; QL
Synarel (Nasal
Solution)1
Trelstar Mixject
(Intramuscular
Suspension
Reconstituted)
1 PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
Methimazole (Oral Tablet)
1
Propylthiouracil (Oral Tablet)
1
Immunological Agents
Angioedema Agents
Berinert (Intravenous
Kit)1 PA; LA
Cinryze (Intravenous
Solution
Reconstituted)
1 PA; LA
Firazyr
(Subcutaneous
Solution)
1 PA; QL
Haegarda
(Subcutaneous
Solution
Reconstituted)
1 PA; LA
Icatibant Acetate (Subcutaneous Solution)
1 PA; QL
Ruconest
(Intravenous Solution
Reconstituted)
1 PA; LA
tRACK76
66
Bold type = Brand name drug Plain type = Generic drug
B1
C1Azathioprine
C1Cimzia Prefilled
C1Cimzia
C1Cyclosporine Modified
C1Cyclosporine Modified
C1Cyclosporine
C1Enbrel Mini
C1Enbrel
C1Enbrel
C1Enbrel SureClick
C1Envarsus XR
C1Everolimus
C1Gengraf
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Gengraf
C1Humira Pediatric Crohns Start
C1Humira Pen
C1Humira Pen Crohns Disease Starter
C1Humira Pen Psoriasis Starter
C1Humira
C1Kineret
C1Methotrexate
C1Methotrexate Sodium
C1Methotrexate Sodium
C1Mycophenolate Mofetil
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Immune Suppressants
Azathioprine (Oral Tablet)
1 B/D, PA
Cimzia Prefilled
(Subcutaneous Kit)1 PA
Cimzia
(Subcutaneous Kit)1 PA
Cyclosporine Modified (Oral Capsule)
1 B/D, PA
Cyclosporine Modified (Oral Solution)
1 B/D, PA
Cyclosporine (Oral Capsule)
1 B/D, PA
Enbrel Mini
(Subcutaneous
Solution Cartridge)
1 PA
Enbrel
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Enbrel
(Subcutaneous
Solution
Reconstituted)
1 PA
Enbrel SureClick
(Subcutaneous
Solution Auto-
Injector)
1 PA
Envarsus XR (Oral
Tablet Extended
Release 24 Hour)
1 B/D, PA
Everolimus (0.25MG Oral Tablet, 0.5MG Oral Tablet, 0.75MG Oral Tablet)
1 B/D, PA
Gengraf (Oral Capsule) 1 B/D, PA
Gengraf (Oral Solution) 1 B/D, PA
Humira Pediatric
Crohns Start
(Subcutaneous
Prefilled Syringe Kit)
1 PA
Humira Pen
(Subcutaneous Pen-
Injector Kit)
1 PA
Humira Pen Crohns
Disease Starter
(Subcutaneous Pen-
Injector Kit)
1 PA
Humira Pen Psoriasis
Starter
(Subcutaneous Pen-
Injector Kit)
1 PA
Humira
(Subcutaneous
Prefilled Syringe Kit)
1 PA
Kineret
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Methotrexate (Oral Tablet)
1
Methotrexate Sodium (50MG/2ML Injection Solution Prefilled Syringe)
1
Methotrexate Sodium (50MG/2ML Injection Solution)
1
Mycophenolate Mofetil (Oral Capsule)
1 B/D, PA
tRACK 77
67
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Mycophenolate Mofetil
C1Mycophenolate Mofetil
C1Mycophenolate Sodium
C1Orencia ClickJect
C1Orencia
C1Prograf
C1Rasuvo
C1Sandimmune
C1Simponi
C1Simponi
C1Sirolimus
C1Sirolimus
C1Tacrolimus
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Trexall
C1Xatmep
C1Xeljanz
C1Xeljanz XR
C1Zortress
B1
C1BIVIGAM
C1Flebogamma DIF
C1Gammagard
C1Gammagard S/D Less IgA
C1Gammaked
C1Gammaplex
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Mycophenolate Mofetil (Oral Suspension Reconstituted)
1 B/D, PA
Mycophenolate Mofetil (Oral Tablet)
1 B/D, PA
Mycophenolate Sodium (Oral Tablet Delayed Release)
1 B/D, PA
Orencia ClickJect
(Subcutaneous
Solution Auto-
Injector)
1 PA
Orencia
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Prograf (Oral Packet) 1 B/D, PA
Rasuvo
(Subcutaneous
Solution Auto-
Injector)
1 PA
Sandimmune (Oral
Solution)1 B/D, PA
Simponi
(Subcutaneous
Solution Auto-
Injector)
1 PA
Simponi
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Sirolimus (Oral Solution)
1 B/D, PA
Sirolimus (Oral Tablet) 1 B/D, PA
Tacrolimus (Oral Capsule)
1 B/D, PA
Trexall (Oral Tablet) 1
Xatmep (Oral
Solution)1 PA
Xeljanz (Oral Tablet
Immediate Release)1 PA; QL
Xeljanz XR (Oral
Tablet Extended
Release 24 Hour)
1 PA; QL
Zortress (Oral Tablet) 1 B/D, PA
Immunizing Agents, Passive
BIVIGAM (Intravenous
Solution)1 PA
Flebogamma DIF
(5GM/50ML
Intravenous Solution)
1 PA
Gammagard (2.5GM/
25ML Injection
Solution)
1 PA
Gammagard S/D Less
IgA (Intravenous
Solution
Reconstituted)
1 PA
Gammaked (1GM/
10ML Injection
Solution)
1 PA
Gammaplex (10GM/
100ML Intravenous
Solution, 10GM/
200ML Intravenous
Solution, 20GM/
200ML Intravenous
Solution, 5GM/50ML
Intravenous Solution)
1 PA
tRACK78
68
Bold type = Brand name drug Plain type = Generic drug
C1Gamunex-C
C1Octagam
C1Panzyga
C1Privigen
C1Varizig
B1
C1Actemra ACTPen
C1Actemra
C1Actimmune
C1Arcalyst
C1Benlysta
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Benlysta
C1Leflunomide
C1Otezla
C1Otezla
C1Ridaura
C1Xolair
C1Xolair
B1
C1ActHIB
C1Adacel
C1BCG Vaccine
C1Bexsero
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Gamunex-C (1GM/
10ML Injection
Solution)
1 PA
Octagam (1GM/20ML
Intravenous Solution,
2GM/20ML
Intravenous Solution)
1 PA
Panzyga (Intravenous
Solution)1 PA
Privigen (20GM/
200ML Intravenous
Solution)
1 PA
Varizig (Intramuscular
Solution)1
Immunomodulators
Actemra ACTPen
(Subcutaneous
Solution Auto-
Injector)
1 PA
Actemra
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Actimmune
(Subcutaneous
Solution)
1 LA
Arcalyst
(Subcutaneous
Solution
Reconstituted)
1 PA; LA
Benlysta
(Subcutaneous
Solution Auto-
Injector)
1 PA
Benlysta
(Subcutaneous
Solution Prefilled
Syringe)
1 PA
Leflunomide (Oral Tablet)
1
Otezla (Oral Tablet) 1 PA; LA
Otezla (Oral Tablet
Therapy Pack)1 PA; LA
Ridaura (Oral
Capsule)1
Xolair (Subcutaneous
Solution Prefilled
Syringe)
1 PA; LA
Xolair (Subcutaneous
Solution
Reconstituted)
1 PA; LA
Vaccines
ActHIB
(Intramuscular
Solution
Reconstituted)
1
Adacel (Intramuscular
Suspension)1
BCG Vaccine
(Injection)1
Bexsero
(Intramuscular
Suspension Prefilled
Syringe)
1
tRACK 79
69
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Boostrix
C1Daptacel
C1Diphtheria-Tetanus Toxoids DT
C1Engerix-B
C1Gardasil 9
C1Gardasil 9
C1Havrix
C1Hiberix
C1Imovax Rabies
C1Infanrix
C1IPOL
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ixiaro
C1Kinrix
C1Menactra
C1Menveo
C1M-M-R II
C1Pediarix
C1Pedvax HIB
C1ProQuad
C1Quadracel
C1RabAvert
C1Recombivax HB
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Boostrix (5-2.5-18.5
Intramuscular
Suspension,
5-2.5-18.5 (0.5ML
Syringe)
Intramuscular
Suspension)
1
Daptacel
(Intramuscular
Suspension)
1
Diphtheria-Tetanus
Toxoids DT
(Intramuscular
Suspension)
1
Engerix-B (Injection
Suspension)1 B/D, PA
Gardasil 9
(Intramuscular
Suspension)
1
Gardasil 9
(Intramuscular
Suspension Prefilled
Syringe)
1
Havrix (Intramuscular
Suspension)1 PA
Hiberix (Injection
Solution
Reconstituted)
1
Imovax Rabies
(Intramuscular
Injectable)
1 B/D, PA
Infanrix
(Intramuscular
Suspension)
1
IPOL (Injection) 1
Ixiaro (Intramuscular
Suspension)1
Kinrix (Intramuscular
Suspension)1
Menactra
(Intramuscular
Injectable)
1
Menveo
(Intramuscular
Solution
Reconstituted)
1
M-M-R II (Injection
Solution
Reconstituted)
1
Pediarix
(Intramuscular
Suspension)
1
Pedvax HIB
(Intramuscular
Suspension)
1
ProQuad
(Subcutaneous
Suspension
Reconstituted)
1
Quadracel
(Intramuscular
Suspension)
1
RabAvert
(Intramuscular
Suspension
Reconstituted)
1 B/D, PA
Recombivax HB
(Injection
Suspension)
1 B/D, PA
tRACK80
70
Bold type = Brand name drug Plain type = Generic drug
C1Rotarix
C1RotaTeq
C1Shingrix
C1TDVAX
C1Tenivac
C1Trumenba
C1Twinrix
C1Typhim Vi
C1VAQTA
C1Varivax
C1YF-Vax
A1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useB1
C1Apriso
C1Balsalazide Disodium
C1Canasa
C1Dipentum
C1Mesalamine ER
C1Mesalamine
C1Mesalamine
C1Mesalamine
C1Pentasa
B1
C1Budesonide ER
C1Budesonide
C1Hydrocortisone
C1Procto-Med HC
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Rotarix (Oral
Suspension
Reconstituted)
1
RotaTeq (Oral
Solution)1
Shingrix
(Intramuscular
Suspension
Reconstituted)
1 PA
TDVAX
(Intramuscular
Suspension)
1
Tenivac
(Intramuscular
Injectable)
1
Trumenba
(Intramuscular
Suspension Prefilled
Syringe)
1
Twinrix
(Intramuscular
Suspension Prefilled
Syringe)
1
Typhim Vi
(Intramuscular
Solution)
1
VAQTA
(Intramuscular
Suspension)
1 PA
Varivax
(Subcutaneous
Injectable)
1
YF-Vax
(Subcutaneous
Injectable)
1
Inflammatory Bowel Disease Agents
Aminosalicylates
Apriso (Oral Capsule
Extended Release 24
Hour)
1 QL
Balsalazide Disodium (Oral Capsule)
1
Canasa (Rectal
Suppository)1
Dipentum (Oral
Capsule)1
Mesalamine ER (0.375MG Oral Capsule Extended Release 24 Hour) (Generic Apriso)
1 QL
Mesalamine (1.2GM Oral Tablet Delayed Release) (Generic Lialda)
1 QL
Mesalamine (Rectal Enema)
1 QL
Mesalamine (Rectal Suppository)
1
Pentasa (Oral
Capsule Extended
Release)
1 QL
Glucocorticoids
Budesonide ER (Oral Tablet Extended Release 24 Hour)
1 ST
Budesonide (Oral Capsule Delayed Release Particles)
1
Hydrocortisone (Rectal Enema)
1
Procto-Med HC (External Cream)
1
tRACK 81
71
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Procto-Pak
C1Proctosol HC
C1Proctozone-HC
B1
C1Sulfasalazine
C1Sulfasalazine
A1
B1
C1Alendronate Sodium
C1Alendronate Sodium
C1Binosto
C1Calcitonin Salmon
C1Calcitriol
C1Calcitriol
C1Cinacalcet HCl
C1Cinacalcet HCl
C1Doxercalciferol
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Forteo
C1Ibandronate Sodium
C1Natpara
C1Paricalcitol
C1Prolia
C1Rayaldee
C1Risedronate Sodium
C1Teriparatide
C1Tymlos
C1Xgeva
A1
B1
C1Alcohol Prep Pads
C1Gauze
C1Insulin Syringes, Needles
A1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Procto-Pak (External Cream)
1
Proctosol HC (External Cream)
1
Proctozone-HC (External Cream)
1
Sulfonamides
Sulfasalazine (Oral Tablet Immediate Release)
1
Sulfasalazine (Oral Tablet Delayed Release)
1
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
Alendronate Sodium (Oral Solution)
1
Alendronate Sodium (10MG Oral Tablet, 35MG Oral Tablet, 70MG Oral Tablet)
1 QL
Binosto (Oral Tablet
Effervescent)1 QL
Calcitonin Salmon (Nasal Solution)
1 QL
Calcitriol (Oral Capsule)
1 B/D, PA
Calcitriol (Oral Solution)
1 B/D, PA
Cinacalcet HCl (30MG Oral Tablet)
1 B/D, PA; QL
Cinacalcet HCl (60MG Oral Tablet, 90MG Oral Tablet)
1 B/D, PA; QL
Doxercalciferol (Oral Capsule)
1 B/D, PA; QL
Forteo (Subcutaneous
Solution Pen-Injector)1 PA; QL
Ibandronate Sodium (Oral Tablet)
1 QL
Natpara
(Subcutaneous
Cartridge)
1 PA; LA
Paricalcitol (Oral Capsule)
1 B/D, PA
Prolia (Subcutaneous
Solution Prefilled
Syringe)
1 QL
Rayaldee (Oral
Capsule Extended
Release)
1 QL
Risedronate Sodium (Oral Tablet Immediate Release)
1 QL
Teriparatide
(Recombinant)
(Subcutaneous
Solution Pen-Injector)
1 PA; QL
Tymlos
(Subcutaneous
Solution Pen-Injector)
1 PA; QL
Xgeva (Subcutaneous
Solution)1 PA
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Alcohol Prep Pads 1
Gauze (Non-medicated 2X2 Pad)
1
Insulin Syringes, Needles
1
Ophthalmic Agents
tRACK82
72
Bold type = Brand name drug Plain type = Generic drug
B1
C1Atropine Sulfate
C1Bacitracin-Polymyxin B
C1Neomycin-Polymyxin-Bacitracin-Hydrocortisone
C1Blephamide
C1Blephamide S.O.P.
C1Cystaran
C1Lacrisert
C1Lastacaft
C1Neomycin-Bacitracin-Polymyxin
C1Neomycin-Polymyxin-Dexamethasone
C1Neomycin-Polymyxin-Dexamethasone
C1Neomycin-Polymyxin-Gramicidin
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Neomycin-Polymyxin-HC
C1Polymyxin B-Trimethoprim
C1Pred-G
C1Pred-G S.O.P.
C1Proparacaine HCl
C1Restasis Single-Use Vials
C1Rhopressa
C1Sulfacetamide-Prednisolone
C1TobraDex
C1TobraDex ST
C1Tobramycin-Dexamethasone
C1Xiidra
B1
C1Alocril
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Ophthalmic Agents, Other
Atropine Sulfate (1%
Ophthalmic Solution)1
Bacitracin-Polymyxin B (Ophthalmic Ointment)
1
Neomycin-Polymyxin-Bacitracin-Hydrocortisone (Ophthalmic Ointment)
1
Blephamide
(Ophthalmic
Suspension)
1
Blephamide S.O.P. (Ophthalmic Ointment)
1
Cystaran (Ophthalmic
Solution)1 LA
Lacrisert (Ophthalmic
Insert)1
Lastacaft (Ophthalmic
Solution)1
Neomycin-Bacitracin-Polymyxin (5-400-10000 Ophthalmic Ointment)
1
Neomycin-Polymyxin-Dexamethasone (Ophthalmic Ointment)
1
Neomycin-Polymyxin-Dexamethasone (3.5-10000-0.1 Ophthalmic Suspension)
1
Neomycin-Polymyxin-Gramicidin (Ophthalmic Solution)
1
Neomycin-Polymyxin-HC (Ophthalmic Suspension)
1
Polymyxin B-Trimethoprim (Ophthalmic Solution)
1
Pred-G (Ophthalmic
Suspension)1
Pred-G S.O.P.
(Ophthalmic
Ointment)
1
Proparacaine HCl (Ophthalmic Solution)
1
Restasis Single-Use
Vials (Ophthalmic
Emulsion)
1 QL
Rhopressa
(Ophthalmic Solution)1 ST
Sulfacetamide-Prednisolone (Ophthalmic Solution)
1
TobraDex
(Ophthalmic
Ointment)
1
TobraDex ST
(Ophthalmic
Suspension)
1
Tobramycin-Dexamethasone (Ophthalmic Suspension)
1
Xiidra (Ophthalmic
Solution)1 QL
Ophthalmic Anti-allergy Agents
Alocril (Ophthalmic
Solution)1
tRACK 83
73
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Alomide
C1Azelastine HCl
C1Bepreve
C1Cromolyn Sodium
C1Epinastine HCl
C1Olopatadine HCl
C1Pazeo
B1
C1Alphagan P
C1Apraclonidine HCl
C1Azopt
C1Betaxolol HCl
C1Betimol
C1Brimonidine Tartrate
C1Brimonidine Tartrate
C1Carteolol HCl
C1Combigan
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Cosopt PF
C1Dorzolamide HCl
C1Dorzolamide HCl-Timolol Maleate
C1Dorzolamide HCl-Timolol Maleate Preservative Free
C1Levobunolol HCl
C1Phospholine Iodide
C1Pilocarpine HCl
C1Rocklatan
C1Simbrinza
C1Timolol Maleate Ophthalmic Gel Forming
C1Timolol Maleate
B1
C1Dexamethasone Sodium Phosphate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Alomide (Ophthalmic
Solution)1
Azelastine HCl (Ophthalmic Solution)
1
Bepreve (Ophthalmic
Solution)1
Cromolyn Sodium (Ophthalmic Solution)
1
Epinastine HCl (Ophthalmic Solution)
1
Olopatadine HCl (Ophthalmic Solution)
1
Pazeo (Ophthalmic
Solution)1
Ophthalmic Antiglaucoma Agents
Alphagan P (0.1%
Ophthalmic Solution)1
Apraclonidine HCl (Ophthalmic Solution)
1
Azopt (Ophthalmic
Suspension)1
Betaxolol HCl (Ophthalmic Solution)
1
Betimol (Ophthalmic
Solution)1
Brimonidine Tartrate
(0.15% Ophthalmic
Solution)
1
Brimonidine Tartrate (0.2% Ophthalmic Solution)
1
Carteolol HCl (Ophthalmic Solution)
1
Combigan
(Ophthalmic Solution)1
Cosopt PF
(Ophthalmic Solution)1
Dorzolamide HCl (Ophthalmic Solution)
1
Dorzolamide HCl-Timolol Maleate (Ophthalmic Solution)
1
Dorzolamide HCl-Timolol Maleate Preservative Free (Ophthalmic Solution)
1
Levobunolol HCl (Ophthalmic Solution)
1
Phospholine Iodide
(Ophthalmic Solution
Reconstituted)
1
Pilocarpine HCl (Ophthalmic Solution)
1
Rocklatan
(Ophthalmic Solution)1 ST
Simbrinza
(Ophthalmic
Suspension)
1
Timolol Maleate Ophthalmic Gel Forming (Ophthalmic Solution) (Generic Timoptic-XE)
1
Timolol Maleate (0.25% Ophthalmic Solution, 0.5% Ophthalmic Solution) (Generic Timoptic)
1
Ophthalmic Anti-inflammatories
Dexamethasone Sodium Phosphate (Ophthalmic Solution)
1
tRACK84
74
Bold type = Brand name drug Plain type = Generic drug
C1Diclofenac Sodium
C1Durezol
C1Flarex
C1Fluorometholone
C1Flurbiprofen Sodium
C1FML Forte
C1FML
C1Ilevro
C1Ketorolac Tromethamine
C1Lotemax
C1Lotemax
C1Lotemax
C1Lotemax SM
C1Loteprednol Etabonate
C1Pred Mild
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Prednisolone Acetate
C1Prednisolone Sodium Phosphate
C1Prolensa
B1
C1Latanoprost
C1Lumigan
C1Travoprost
C1Vyzulta
C1Zioptan
A1
B1
C1Acetic Acid
C1Cipro HC
C1Ciprodex
C1Flac
C1Fluocinolone Acetonide
C1Hydrocortisone-Acetic Acid
C1Neomycin-Polymyxin-HC
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Diclofenac Sodium (Ophthalmic Solution)
1
Durezol (Ophthalmic
Emulsion)1
Flarex (Ophthalmic
Suspension)1
Fluorometholone (Ophthalmic Suspension)
1
Flurbiprofen Sodium (Ophthalmic Solution)
1
FML Forte
(Ophthalmic
Suspension)
1
FML (Ophthalmic
Ointment)1
Ilevro (Ophthalmic
Suspension)1
Ketorolac Tromethamine (Ophthalmic Solution)
1
Lotemax (Ophthalmic
Gel)1
Lotemax (Ophthalmic
Ointment)1
Lotemax (Ophthalmic
Suspension)1
Lotemax SM
(Ophthalmic Gel)1
Loteprednol Etabonate (Ophthalmic Suspension)
1
Pred Mild
(Ophthalmic
Suspension)
1
Prednisolone Acetate (Ophthalmic Suspension)
1
Prednisolone Sodium Phosphate (1% Ophthalmic Solution)
1
Prolensa (Ophthalmic
Solution)1
Ophthalmic Prostaglandin and Prostamide Analogs
Latanoprost (Ophthalmic Solution)
1
Lumigan (Ophthalmic
Solution)1
Travoprost (BAK Free) (Ophthalmic Solution)
1
Vyzulta (Ophthalmic
Solution)1
Zioptan (Ophthalmic
Solution)1
Otic Agents
Otic Agents
Acetic Acid (Otic Solution)
1
Cipro HC (Otic
Suspension)1
Ciprodex (Otic
Suspension)1
Flac (Otic Oil) 1
Fluocinolone Acetonide (Otic Oil)
1
Hydrocortisone-Acetic Acid (Otic Solution)
1
Neomycin-Polymyxin-HC (1% Otic Solution)
1
tRACK 85
75
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Neomycin-Polymyxin-HC
A1
B1
C1Azelastine HCl
C1Cetirizine HCl
C1Cyproheptadine HCl
C1Cyproheptadine HCl
C1Levocetirizine Dihydrochloride
C1Promethazine HCl
C1Promethazine HCl
C1Promethazine HCl
C1Promethegan
B1
C1Arnuity Ellipta
C1Budesonide
C1Flovent Diskus
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Flovent HFA
C1Flunisolide
C1Fluticasone Propionate
C1Mometasone Furoate
B1
C1Montelukast Sodium
C1Montelukast Sodium
C1Montelukast Sodium
C1Zafirlukast
C1Zileuton ER
C1Zyflo
B1
C1Atrovent HFA
C1Incruse Ellipta
C1Ipratropium Bromide
C1Ipratropium Bromide
C1Lonhala Magnair
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Neomycin-Polymyxin-HC (Otic Suspension)
1
Respiratory Tract/Pulmonary Agents
Antihistamines
Azelastine HCl (0.1% Nasal Solution, 0.15% Nasal Solution)
1
Cetirizine HCl (1MG/ ML Oral Solution)
1
Cyproheptadine HCl (Oral Syrup)
1
Cyproheptadine HCl (Oral Tablet)
1
Levocetirizine Dihydrochloride (Oral Tablet)
1 QL
Promethazine HCl (Oral Syrup)
1
Promethazine HCl (Oral Tablet)
1
Promethazine HCl (Rectal Suppository)
1
Promethegan (25MG Rectal Suppository)
1
Anti-inflammatories, Inhaled Corticosteroids
Arnuity Ellipta
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Budesonide (Inhalation Suspension)
1 B/D, PA
Flovent Diskus
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Flovent HFA
(Inhalation Aerosol)1 QL
Flunisolide (Nasal Solution)
1
Fluticasone Propionate (Nasal Suspension)
1
Mometasone Furoate (Nasal Suspension)
1
Antileukotrienes
Montelukast Sodium (Oral Packet)
1 QL
Montelukast Sodium (Oral Tablet)
1 QL
Montelukast Sodium (Oral Tablet Chewable)
1 QL
Zafirlukast (Oral Tablet)
1 QL
Zileuton ER (Oral Tablet Extended Release 12 Hour)
1 ST
Zyflo (Oral Tablet
Immediate Release)1 ST
Bronchodilators, Anticholinergic
Atrovent HFA
(Inhalation Aerosol
Solution)
1
Incruse Ellipta
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Ipratropium Bromide (Inhalation Solution)
1 B/D, PA
Ipratropium Bromide (Nasal Solution)
1
Lonhala Magnair
(Inhalation Solution)1 QL
tRACK86
76
Bold type = Brand name drug Plain type = Generic drug
C1Spiriva HandiHaler
C1Spiriva Respimat
B1
C1Albuterol Sulfate HFA
C1Albuterol Sulfate
C1Albuterol Sulfate
C1Albuterol Sulfate
C1Epinephrine
C1EpiPen 2-Pak
C1EpiPen Jr 2-Pak
C1Levalbuterol HCl
C1Metaproterenol Sulfate
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Perforomist
C1ProAir HFA
C1ProAir RespiClick
C1Serevent Diskus
B1
C1Bethkis
C1Cayston
C1Orkambi
C1Orkambi
C1TOBI Podhaler
C1Tobramycin
B1
C1Cromolyn Sodium
B1
C1Daliresp
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Spiriva HandiHaler
(Inhalation Capsule)1 QL
Spiriva Respimat
(Inhalation Aerosol
Solution)
1 QL
Bronchodilators, Sympathomimetic
Albuterol Sulfate HFA (108 (90 Base)MCG/ ACT Inhalation Aerosol Solution (Generic Proair), 108 (90 Base)MCG/ACT Inhalation Aerosol Solution) (Generic Proventil)
1
Albuterol Sulfate (Inhalation Nebulization Solution)
1 B/D, PA
Albuterol Sulfate (Oral Syrup)
1
Albuterol Sulfate (Oral Tablet Immediate Release)
1
Epinephrine (Injection Solution Auto-Injector)
1 QL
EpiPen 2-Pak
(Injection Solution
Auto-Injector)
1 QL
EpiPen Jr 2-Pak
(Injection Solution
Auto-Injector)
1 QL
Levalbuterol HCl (Inhalation Nebulization Solution)
1 B/D, PA
Metaproterenol Sulfate (Oral Syrup)
1
Perforomist
(Inhalation
Nebulization Solution)
1 B/D, PA; QL
ProAir HFA
(Inhalation Aerosol
Solution)
1
ProAir RespiClick
(Inhalation Aerosol
Powder Breath
Activated)
1
Serevent Diskus
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Cystic Fibrosis Agents
Bethkis (Inhalation
Nebulization Solution)1 B/D, PA; QL
Cayston (Inhalation
Solution
Reconstituted)
1 PA; LA
Orkambi (Oral Packet) 1 PA; LA; QL
Orkambi (Oral Tablet) 1 PA; LA; QL
TOBI Podhaler
(Inhalation Capsule)1 PA; QL
Tobramycin (Inhalation Nebulization Solution)
1 B/D, PA; QL
Mast Cell Stabilizers
Cromolyn Sodium (Inhalation Nebulization Solution)
1 B/D, PA
Phosphodiesterase Inhibitors, Airways Disease
Daliresp (Oral Tablet) 1 PA; QL
tRACK 87
77
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Theophylline ER
C1Theophylline ER
C1Theophylline
B1
C1Adempas
C1Alyq
C1Ambrisentan
C1Bosentan
C1Opsumit
C1Orenitram
C1Orenitram
C1Sildenafil Citrate
C1Tadalafil
C1Tracleer
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Ventavis
B1
C1Esbriet
C1Esbriet
C1Ofev
B1
C1Acetylcysteine
C1Advair Diskus
C1Advair HFA
C1Anoro Ellipta
C1Azelastine-Fluticasone
C1Bevespi Aerosphere
C1Breo Ellipta
C1Combivent Respimat
C1Dulera
C1Dymista
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Theophylline ER (300MG Oral Tablet Extended Release 12 Hour)
1
Theophylline ER (Oral Tablet Extended Release 24 Hour)
1
Theophylline (Oral Solution)
1
Pulmonary Antihypertensives
Adempas (Oral
Tablet)1 PA; LA
Alyq (Oral Tablet) 1 PA; QL
Ambrisentan (Oral Tablet)
1 PA; LA; QL
Bosentan (Oral Tablet) 1 PA; LA; QL
Opsumit (Oral Tablet) 1 PA; LA
Orenitram (0.125MG
Oral Tablet Extended
Release)
1 PA; LA
Orenitram (0.25MG
Oral Tablet Extended
Release, 1MG Oral
Tablet Extended
Release, 2.5MG Oral
Tablet Extended
Release, 5MG Oral
Tablet Extended
Release)
1 PA; LA
Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio)
1 PA; QL
Tadalafil (PAH) (20MG Oral Tablet)
1 PA; QL
Tracleer (Oral Tablet
Soluble)1 PA; LA; QL
Ventavis (Inhalation
Solution)1 PA; LA; QL
Pulmonary Fibrosis Agents
Esbriet (Oral Capsule) 1 PA; LA; QL
Esbriet (Oral Tablet) 1 PA; LA; QL
Ofev (Oral Capsule) 1 PA; LA; QL
Respiratory Tract Agents, Other
Acetylcysteine (Inhalation Solution)
1 B/D, PA
Advair Diskus
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Advair HFA
(Inhalation Aerosol)1 QL
Anoro Ellipta
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Azelastine-Fluticasone (Nasal Suspension)
1
Bevespi Aerosphere
(Inhalation Aerosol)1 QL
Breo Ellipta
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Combivent Respimat
(Inhalation Aerosol
Solution)
1 QL
Dulera (Inhalation
Aerosol)1 QL
Dymista (Nasal
Suspension)1
tRACK88
78
Bold type = Brand name drug Plain type = Generic drug
C1Fasenra Pen
C1Fasenra
C1Fluticasone-Salmeterol
C1Ipratropium-Albuterol
C1Kalydeco
C1Kalydeco
C1Nucala
C1Nucala
C1Nucala
C1Pulmozyme
C1Stiolto Respimat
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Symbicort
C1Trelegy Ellipta
C1Wixela Inhub
A1
B1
C1Baclofen
C1Chlorzoxazone
C1Cyclobenzaprine HCl
C1Cyclobenzaprine HCl
C1Dantrolene Sodium
C1Tizanidine HCl
A1
B1
C1Temazepam
C1Zaleplon
C1Zolpidem Tartrate
B1
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Fasenra Pen
(Subcutaneous
Solution Auto-
Injector)
1 PA; LA
Fasenra
(Subcutaneous
Solution Prefilled
Syringe)
1 PA; LA
Fluticasone-Salmeterol (Inhalation Aerosol Powder Breath Activated)
1 QL
Ipratropium-Albuterol (Inhalation Solution)
1 B/D, PA
Kalydeco (Oral
Packet)1 PA; LA; QL
Kalydeco (Oral
Tablet)1 PA; LA; QL
Nucala
(Subcutaneous
Solution Auto-
Injector)
1 PA; LA; QL
Nucala
(Subcutaneous
Solution Prefilled
Syringe)
1 PA; LA; QL
Nucala
(Subcutaneous
Solution
Reconstituted)
1 PA; LA; QL
Pulmozyme
(Inhalation Solution)1 B/D, PA; QL
Stiolto Respimat
(Inhalation Aerosol
Solution)
1 QL
Symbicort (Inhalation
Aerosol)1 QL
Trelegy Ellipta
(Inhalation Aerosol
Powder Breath
Activated)
1 QL
Wixela Inhub (Inhalation Aerosol Powder Breath Activated) (Generic Advair)
1 QL
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
Baclofen (Oral Tablet) 1
Chlorzoxazone (500MG Oral Tablet)
1
Cyclobenzaprine HCl (10MG Oral Tablet, 5MG Oral Tablet)
1
Cyclobenzaprine HCl (7.5MG Oral Tablet)
1
Dantrolene Sodium (Oral Capsule)
1
Tizanidine HCl (Oral Tablet)
1
Sleep Disorder Agents
GABA Receptor Modulators
Temazepam (15MG Oral Capsule, 30MG Oral Capsule)
1 QL
Zaleplon (Oral Capsule)
1 QL
Zolpidem Tartrate (Oral Tablet Immediate Release)
1 QL
Sleep Disorders, Other
tRACK 89
79
You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.
C1Belsomra
C1Hetlioz
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
useC1Modafinil
C1Ramelteon
C1Xyrem
tRACK
Drug NameDrug
Tier
Necessary
actions,
restriction,
or limits on
use
Belsomra (Oral
Tablet)1 QL
Hetlioz (Oral Capsule) 1 PA; LA; QL
Modafinil (Oral Tablet) 1 PA; QL
Ramelteon (Oral Tablet)
1 QL
Xyrem (Oral Solution) 1 PA; LA; QL
tRACK90
Bold type = Brand name drug Plain type = Generic drug
C2. Covered drugs with a quantity limit (QL)
This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. These limits may be in place to ensure your safety.
Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain number of days. For more information about quantity limits, talk with your doctor or pharmacist. You can also call Customer Service. Our contact information is on the cover.
Drugs are listed in alphabetical order in the tables below.
Drug Name Quantity Limit
Abacavir Sulfate (Oral Solution) Maximum of 32 ml per day
Abacavir Sulfate (Oral Tablet) Maximum of 2 tablets per day
Abacavir Sulfate-Lamivudine (Oral Tablet) Maximum of 1 tablet per day
Abacavir-Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day
Abiraterone Acetate (Oral Tablet) Maximum of 4 tablets per day
Acarbose (100MG Oral Tablet) Maximum of 3 tablets per day
Acarbose (25MG Oral Tablet) Maximum of 12 tablets per day
Acarbose (50MG Oral Tablet) Maximum of 6 tablets per day
Acetaminophen-Codeine (120-12MG/5ML Oral Solution)
Maximum of 150 ml per day
Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Tablet)
Maximum of 13 tablets per day
Acyclovir (External Ointment) Maximum of 1 tube (30 grams) per 30 days
Advair Diskus (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days
Advair HFA (Inhalation Aerosol) Maximum of 1 inhaler (12 grams) per 30 days
Aimovig (140MG/ML Subcutaneous Solution
Auto-Injector)Maximum of 1 pen (1 ml) per 30 days
Aimovig (70MG/ML Subcutaneous Solution
Auto-Injector)Maximum of 2 pens (2 ml) per 30 days
Albendazole (Oral Tablet) Maximum of 16 tablets per day
Alecensa (Oral Capsule) Maximum of 8 capsules per day
Alendronate Sodium (10MG Oral Tablet) Maximum of 1 tablet per day
Alendronate Sodium (35MG Oral Tablet) Maximum of 8 tablets per 28 days
Alendronate Sodium (70MG Oral Tablet) Maximum of 4 tablets per 28 days
Aliskiren Fumarate (Oral Tablet) Maximum of 1 tablet per day
91
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Alprazolam (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate Release, 1MG Oral Tablet Immediate Release)
Maximum of 4 tablets per day
Alprazolam (2MG Oral Tablet Immediate Release)
Maximum of 5 tablets per day
Alunbrig (180MG Oral Tablet, 90MG Oral
Tablet)Maximum of 1 tablet per day
Alunbrig (30MG Oral Tablet) Maximum of 4 tablets per day
Alunbrig (Oral Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days
Alyq (Oral Tablet) Maximum of 2 tablets per day
Ambrisentan (Oral Tablet) Maximum of 1 tablet per day
Amitiza (Oral Capsule) Maximum of 2 capsules per day
Amlodipine-Atorvastatin (Oral Tablet) Maximum of 1 tablet per day
Amlodipine-Benazepril (Oral Capsule) Maximum of 1 capsule per day
Amlodipine-Olmesartan (Oral Tablet) Maximum of 1 tablet per day
Amlodipine-Valsartan (Oral Tablet) Maximum of 1 tablet per day
Amlodipine-Valsartan-HCTZ (Oral Tablet) Maximum of 1 tablet per day
Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)
Maximum of 2 capsules per day
Amphetamine-Dextroamphetamine (10MG Oral Tablet, 12.5MG Oral Tablet, 15MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)
Maximum of 2 tablets per day
Amphetamine-Dextroamphetamine (20MG Oral Tablet)
Maximum of 3 tablets per day
Ampyra (Oral Tablet Extended Release 12
Hour)Maximum of 2 tablets per day
Androderm (Transdermal Patch 24 Hour) Maximum of 1 patch per day
Anoro Ellipta (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days
Apokyn (Subcutaneous Solution Cartridge) Maximum of 3 ml per day
Apriso (Oral Capsule Extended Release 24
Hour)Maximum of 4 capsules per day
Aptiom (200MG Oral Tablet, 400MG Oral
Tablet)Maximum of 1 tablet per day
Aptiom (600MG Oral Tablet, 800MG Oral
Tablet)Maximum of 2 tablets per day
Aptivus (Oral Capsule) Maximum of 4 capsules per day
Aptivus (Oral Solution) Maximum of 4 bottles (380 ml) per 30 days
Aripiprazole (1MG/ML Oral Solution) Maximum of 25 ml per day
92
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)
Maximum of 1 tablet per day
Aripiprazole ODT (10MG Oral Tablet Dispersible)
Maximum of 3 tablets per day
Aripiprazole ODT (15MG Oral Tablet Dispersible)
Maximum of 2 tablets per day
Arnuity Ellipta (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (30 blisters) per 30 days
Aspirin-Dipyridamole ER (Oral Capsule Extended Release 12 Hour)
Maximum of 2 capsules per day
Atazanavir Sulfate (150MG Oral Capsule, 300MG Oral Capsule)
Maximum of 1 capsule per day
Atazanavir Sulfate (200MG Oral Capsule) Maximum of 2 capsules per day
Atomoxetine HCl (100MG Oral Capsule, 60MG Oral Capsule, 80MG Oral Capsule)
Maximum of 1 capsule per day
Atomoxetine HCl (10MG Oral Capsule, 18MG Oral Capsule, 25MG Oral Capsule, 40MG Oral Capsule)
Maximum of 2 capsules per day
Atorvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day
Atripla (Oral Tablet) Maximum of 1 tablet per day
Aubagio (Oral Tablet) Maximum of 1 tablet per day
Austedo (Oral Tablet) Maximum of 4 tablets per day
Avonex Pen (Intramuscular Auto-Injector Kit) Maximum of 1 kit per 28 days
Avonex Prefilled (Intramuscular Prefilled
Syringe Kit)Maximum of 1 kit per 28 days
Ayvakit (Oral Tablet) Maximum of 1 tablet per day
Balversa (3MG Oral Tablet) Maximum of 3 tablets per day
Balversa (4MG Oral Tablet) Maximum of 2 tablets per day
Balversa (5MG Oral Tablet) Maximum of 1 tablet per day
Belsomra (Oral Tablet) Maximum of 1 tablet per day
Benazepril HCl (Oral Tablet) Maximum of 2 tablets per day
Benazepril-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day
Betaseron (Subcutaneous Kit) Maximum of 1 kit (15 vials) per 30 days
Bethkis (Inhalation Nebulization Solution) Maximum of 2 ampules (8 ml) per day
Bevespi Aerosphere (Inhalation Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days
BiDil (Oral Tablet) Maximum of 6 tablets per day
Biktarvy (Oral Tablet) Maximum of 1 tablet per day
Binosto (Oral Tablet Effervescent) Maximum of 4 tablets per 28 days
93
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Bisoprolol-Hydrochlorothiazide (Oral Tablet) Maximum of 2 tablets per day
Bosentan (Oral Tablet) Maximum of 2 tablets per day
Bosulif (100MG Oral Tablet) Maximum of 6 tablets per day
Bosulif (400MG Oral Tablet, 500MG Oral
Tablet)Maximum of 1 tablet per day
Breo Ellipta (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days
Brilinta (Oral Tablet) Maximum of 2 tablets per day
BRIVIACT (10MG/ML Oral Solution) Maximum of 20 ml per day
BRIVIACT (100MG Oral Tablet, 10MG Oral
Tablet, 25MG Oral Tablet, 50MG Oral Tablet,
75MG Oral Tablet)
Maximum of 2 tablets per day
Brukinsa (Oral Capsule) Maximum of 4 capsules per day
Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day
Buprenorphine HCl-Naloxone HCl (12-3MG Sublingual Film, 4-1MG Sublingual Film)
Maximum of 2 films per day
Buprenorphine HCl-Naloxone HCl (2-0.5MG Sublingual Film, 8-2MG Sublingual Film)
Maximum of 3 films per day
Buprenorphine HCl-Naloxone HCl (Tablet Sublingual)
Maximum of 3 tablets per day
Buprenorphine (Transdermal Patch Weekly) Maximum of 4 patches per 28 days
Butalbital-Acetaminophen-Caffeine (Oral Tablet)
Maximum of 6 tablets per day
Butalbital-Aspirin-Caffeine (Oral Capsule) Maximum of 6 capsules per day
Butorphanol Tartrate (Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days
Bydureon BCise (Subcutaneous Auto-
Injector)Maximum of 4 pens (3.4 ml) per 28 days
Bydureon (Subcutaneous Pen-Injector) Maximum of 4 pens per 28 days
Byetta 10MCG Pen (Subcutaneous Solution
Pen-Injector)Maximum of 1 pen (2.4 ml) per 30 days
Byetta 5MCG Pen (Subcutaneous Solution
Pen-Injector)Maximum of 1 pen (1.2 ml) per 30 days
Bystolic (10MG Oral Tablet, 2.5MG Oral
Tablet, 5MG Oral Tablet)Maximum of 1 tablet per day
Bystolic (20MG Oral Tablet) Maximum of 2 tablets per day
Cablivi (Injection Kit) Maximum of 1 kit per day
Cabometyx (20MG Oral Tablet, 60MG Oral
Tablet)Maximum of 1 tablet per day
Cabometyx (40MG Oral Tablet) Maximum of 2 tablets per day
Calcitonin Salmon (Nasal Solution) Maximum of 1 bottle per 28 days
94
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Calquence (Oral Capsule) Maximum of 2 capsules per day
Candesartan Cilexetil (16MG Oral Tablet, 32MG Oral Tablet, 4MG Oral Tablet)
Maximum of 1 tablet per day
Candesartan Cilexetil (8MG Oral Tablet) Maximum of 3 tablets per day
Candesartan Cilexetil-HCTZ (Oral Tablet) Maximum of 1 tablet per day
Caplyta (Oral Capsule) Maximum of 1 capsule per day
Captopril (100MG Oral Tablet) Maximum of 4 tablets per day
Captopril (12.5MG Oral Tablet, 25MG Oral Tablet)
Maximum of 3 tablets per day
Captopril (50MG Oral Tablet) Maximum of 9 tablets per day
Captopril-Hydrochlorothiazide (25-15MG Oral Tablet, 50-15MG Oral Tablet)
Maximum of 3 tablets per day
Captopril-Hydrochlorothiazide (25-25MG Oral Tablet, 50-25MG Oral Tablet)
Maximum of 2 tablets per day
Celecoxib (Oral Capsule) Maximum of 2 capsules per day
Cimduo (Oral Tablet) Maximum of 1 tablet per day
Cinacalcet HCl (30MG Oral Tablet, 60MG Oral Tablet)
Maximum of 2 tablets per day
Cinacalcet HCl (90MG Oral Tablet) Maximum of 4 tablets per day
Clobazam (2.5MG/ML Oral Suspension) Maximum of 16 ml per day
Clobazam (10MG Oral Tablet, 20MG Oral Tablet)
Maximum of 2 tablets per day
Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet)
Maximum of 4 tablets per day
Clonazepam (2MG Oral Tablet) Maximum of 10 tablets per day
Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible)
Maximum of 4 tablets per day
Clonazepam ODT (2MG Oral Tablet Dispersible)
Maximum of 10 tablets per day
Clopidogrel Bisulfate (75MG Oral Tablet) Maximum of 4 tablets per day
Clorazepate Dipotassium (15MG Oral Tablet) Maximum of 6 tablets per day
Clorazepate Dipotassium (3.75MG Oral Tablet) Maximum of 24 tablets per day
Clorazepate Dipotassium (7.5MG Oral Tablet) Maximum of 12 tablets per day
Clovique (Oral Capsule) Maximum of 8 capsules per day
Clozapine ODT (100MG Oral Tablet Dispersible)
Maximum of 9 tablets per day
Clozapine ODT (12.5MG Oral Tablet Dispersible)
Maximum of 2 tablets per day
95
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Clozapine ODT (150MG Oral Tablet Dispersible)
Maximum of 6 tablets per day
Clozapine ODT (200MG Oral Tablet Dispersible)
Maximum of 4 tablets per day
Clozapine ODT (25MG Oral Tablet Dispersible) Maximum of 3 tablets per day
Codeine Sulfate (15MG Oral Tablet) Maximum of 6 tablets per day
Codeine Sulfate (30MG Oral Tablet, 60MG Oral Tablet)
Maximum of 6 tablets per day
Colchicine (0.6MG Oral Capsule) (Brand
Equivalent Mitigare)Maximum of 4 capsules per day
Colchicine (0.6MG Oral Tablet) (Generic Colcrys)
Maximum of 4 tablets per day
Colcrys (Oral Tablet) Maximum of 4 tablets per day
Combivent Respimat (Inhalation Aerosol
Solution)Maximum of 1 inhaler (4 grams) per 20 days
Complera (Oral Tablet) Maximum of 1 tablet per day
Copiktra (Oral Capsule) Maximum of 2 capsules per day
Corlanor (Oral Solution) Maximum of 15 ml per day
Corlanor (Oral Tablet) Maximum of 2 tablets per day
Cotellic (Oral Tablet) Maximum of 3 tablets per day
Crixivan (200MG Oral Capsule) Maximum of 9 capsules per day
Crixivan (400MG Oral Capsule) Maximum of 6 capsules per day
Cycloset (Oral Tablet) Maximum of 6 tablets per day
Dalfampridine ER (Oral Tablet Extended Release 12 Hour)
Maximum of 2 tablets per day
Daliresp (Oral Tablet) Maximum of 1 tablet per day
Daurismo (100MG Oral Tablet) Maximum of 1 tablet per day
Daurismo (25MG Oral Tablet) Maximum of 2 tablets per day
Delstrigo (Oral Tablet) Maximum of 1 tablet per day
Denavir (External Cream) Maximum of 1 tube (5 grams) per 30 days
Descovy (Oral Tablet) Maximum of 1 tablet per day
Desvenlafaxine Succinate ER (100MG Oral Tablet Extended Release 24 Hour) (Generic Pristiq)
Maximum of 4 tablets per day
Desvenlafaxine Succinate ER (25MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) (Generic Pristiq)
Maximum of 1 tablet per day
Dexilant (Oral Capsule Delayed Release) Maximum of 1 capsule per day
96
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Dexmethylphenidate HCl (Oral Tablet) Maximum of 2 tablets per day
Dextroamphetamine Sulfate ER (10MG Oral Capsule Extended Release 24 Hour)
Maximum of 6 capsules per day
Dextroamphetamine Sulfate ER (15MG Oral Capsule Extended Release 24 Hour)
Maximum of 4 capsules per day
Dextroamphetamine Sulfate ER (5MG Oral Capsule Extended Release 24 Hour)
Maximum of 3 capsules per day
Dextroamphetamine Sulfate (Oral Tablet) Maximum of 6 tablets per day
Diazepam Intensol (5MG/ML Oral Concentrate) Maximum of 8 ml per day
Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)
Maximum of 4 tablets per day
Diclofenac Epolamine (Transdermal Patch) Maximum of 2 patches per day
Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Release)
Maximum of 1 capsule per day
Donepezil HCl (10MG Oral Tablet) Maximum of 2 tablets per day
Donepezil HCl (23MG Oral Tablet, 5MG Oral Tablet)
Maximum of 1 tablet per day
Donepezil HCl ODT (10MG Oral Tablet Dispersible)
Maximum of 2 tablets per day
Donepezil HCl ODT (5MG Oral Tablet Dispersible)
Maximum of 1 tablet per day
Dovato (Oral Tablet) Maximum of 1 tablet per day
Doxepin HCl (External Cream) Maximum of 90 grams per 30 days
Doxercalciferol (0.5MCG Oral Capsule) Maximum of 3 capsules per day
Doxercalciferol (1MCG Oral Capsule, 2.5MCG Oral Capsule)
Maximum of 4 capsules per day
Drizalma Sprinkle (20MG Oral Capsule
Delayed Release Sprinkle, 30MG Oral
Capsule Delayed Release Sprinkle, 60MG
Oral Capsule Delayed Release Sprinkle)
Maximum of 2 capsules per day
Drizalma Sprinkle (40MG Oral Capsule
Delayed Release Sprinkle)Maximum of 3 capsules per day
Dulera (120 Inhalation Aerosol) Maximum of 1 inhaler (13 grams) per 30 days
Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule Delayed Release Particles)
Maximum of 2 capsules per day
Dutasteride (Oral Capsule) Maximum of 1 capsule per day
Econazole Nitrate (External Cream) Maximum of 90 grams per 30 days
97
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Edarbi (Oral Tablet) Maximum of 1 tablet per day
Edarbyclor (Oral Tablet) Maximum of 1 tablet per day
Edurant (Oral Tablet) Maximum of 1 tablet per day
Efavirenz (Oral Capsule) Maximum of 3 capsules per day
Efavirenz (Oral Tablet) Maximum of 1 tablet per day
Eliquis Starter Pack (Oral Tablet) Maximum of 1 pack (74 tablets) per 30 days
Eliquis (Oral Tablet) Maximum of 2 tablets per day
Emgality (300MG Dose) (100MG/ML
Subcutaneous Solution Prefilled Syringe)
Maximum of 3 syringes or pens (3 ml) per 30 days
Emgality (Subcutaneous Solution Auto-
Injector)
Maximum of 2 syringes or pens (2 ml) per 30 days
Emgality (120MG/ML Subcutaneous
Solution Prefilled Syringe)
Maximum of 2 syringes or pens (2 ml) per 30 days
Emsam (Transdermal Patch 24 Hour) Maximum of 1 patch per day
Emtriva (Oral Capsule) Maximum of 1 capsule per day
Emtriva (Oral Solution) Maximum of 5 bottles (850 ml) per 30 days
Enalapril Maleate (Oral Tablet) Maximum of 2 tablets per day
Enalapril-Hydrochlorothiazide (10-25MG Oral Tablet)
Maximum of 2 tablets per day
Enalapril-Hydrochlorothiazide (5-12.5MG Oral Tablet)
Maximum of 1 tablet per day
Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)
Maximum of 12 tablets per day
Enoxaparin Sodium (100MG/ML Subcutaneous Solution, 150MG/ML Subcutaneous Solution)
Maximum of 2 syringes (2 ml) per day
Enoxaparin Sodium (120MG/0.8ML Subcutaneous Solution, 80MG/0.8ML Subcutaneous Solution)
Maximum of 2 syringes (1.6 ml) per day
Enoxaparin Sodium (30MG/0.3ML Subcutaneous Solution)
Maximum of 2 syringes (0.6 ml) per day
Enoxaparin Sodium (40MG/0.4ML Subcutaneous Solution)
Maximum of 2 syringes (0.8 ml) per day
Enoxaparin Sodium (60MG/0.6ML Subcutaneous Solution)
Maximum of 2 syringes (1.2 ml) per day
Entresto (Oral Tablet) Maximum of 2 tablets per day
Epclusa (Oral Tablet) Maximum of 1 tablet per day
Epinephrine (Injection Solution Auto-Injector) Maximum of 4 pens (2 boxes) per 30 days
EpiPen 2-Pak (Injection Solution Auto-
Injector)Maximum of 4 pens (2 boxes) per 30 days
98
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
EpiPen Jr 2-Pak (Injection Solution Auto-
Injector)Maximum of 4 pens (2 boxes) per 30 days
Erivedge (Oral Capsule) Maximum of 1 capsule per day
Erleada (Oral Tablet) Maximum of 4 tablets per day
Erlotinib HCl (100MG Oral Tablet, 150MG Oral Tablet)
Maximum of 1 tablet per day
Erlotinib HCl (25MG Oral Tablet) Maximum of 3 tablets per day
Esbriet (Oral Capsule) Maximum of 9 capsules per day
Esbriet (267MG Oral Tablet) Maximum of 9 tablets per day
Esbriet (801MG Oral Tablet) Maximum of 3 tablets per day
Esomeprazole Magnesium (20MG Oral Capsule Delayed Release) (Generic Nexium)
Maximum of 3 capsules per day
Esomeprazole Magnesium (40MG Oral Capsule Delayed Release) (Generic Nexium)
Maximum of 2 capsules per day
Estradiol (Transdermal Patch Weekly) Maximum of 4 patches per 28 days
Estradiol (Vaginal Tablet) Maximum of 1 tablet per day
Evotaz (Oral Tablet) Maximum of 1 tablet per day
Ezetimibe (Oral Tablet) Maximum of 1 tablet per day
Ezetimibe-Simvastatin (Oral Tablet) Maximum of 1 tablet per day
Famciclovir (125MG Oral Tablet, 250MG Oral Tablet)
Maximum of 2 tablets per day
Famciclovir (500MG Oral Tablet) Maximum of 3 tablets per day
Fanapt (10MG Oral Tablet, 12MG Oral
Tablet, 1MG Oral Tablet, 2MG Oral Tablet,
4MG Oral Tablet, 6MG Oral Tablet, 8MG Oral
Tablet)
Maximum of 2 tablets per day
Fentanyl Citrate (Buccal Lozenge On A Handle) Maximum of 4 lozenges per day
Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)
Maximum of 15 patches per 30 days
Fetzima (Oral Capsule Extended Release 24
Hour)Maximum of 1 capsule per day
Fintepla (Oral Solution) Maximum of 12 ml per day
Firazyr (Subcutaneous Solution) Maximum of 3 syringes (9 ml) per day
Flector (Transdermal Patch) Maximum of 2 patches per day
Flovent Diskus (Inhalation Aerosol Powder
Breath Activated)
Maximum of 2 inhalers (120 blisters) per 30 days
99
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Flovent HFA (110MCG/ACT Inhalation
Aerosol)Maximum of 1 inhaler (12 grams) per 30 days
Flovent HFA (220MCG/ACT Inhalation
Aerosol)Maximum of 2 inhalers (24 grams) per 30 days
Flovent HFA (44MCG/ACT Inhalation
Aerosol)Maximum of 1 inhaler (10.6 grams) per 30 days
Fluticasone-Salmeterol (100-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 250-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 500-50MCG/DOSE Inhalation Aerosol Powder Breath Activated) (Generic Advair)
Maximum of 1 inhaler (60 blisters) per 30 days
Fluticasone-Salmeterol (113-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 232-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 55-14MCG/ACT Inhalation Aerosol Powder Breath Activated) (Brand Equivalent AirDuo)
Maximum of 1 inhaler per 30 days
Fluvastatin Sodium (20MG Oral Capsule) Maximum of 1 capsule per day
Fluvastatin Sodium (40MG Oral Capsule) Maximum of 2 capsules per day
Forteo (Subcutaneous Solution Pen-Injector) Maximum of 1 pen (2.4 ml) per 28 days
Fosamprenavir Calcium (Oral Tablet) Maximum of 4 tablets per day
Fosinopril Sodium (Oral Tablet) Maximum of 2 tablets per day
Fosinopril Sodium-HCTZ (Oral Tablet) Maximum of 4 tablets per day
Fuzeon (Subcutaneous Solution
Reconstituted)Maximum of 2 vials per day
Galantamine Hydrobromide ER (Oral Capsule Extended Release 24 Hour)
Maximum of 1 capsule per day
Galantamine Hydrobromide (Oral Solution) Maximum of 2 bottles (200 ml) per 30 days
Galantamine Hydrobromide (Oral Tablet) Maximum of 2 tablets per day
Genvoya (Oral Tablet) Maximum of 1 tablet per day
Gilenya (0.5MG Oral Capsule) Maximum of 1 pack (30 capsules) per 30 days
Glatiramer Acetate (20MG/ML Subcutaneous Solution Prefilled Syringe)
Maximum of 1 syringe (1 ml) per day
Glatiramer Acetate (40MG/ML Subcutaneous Solution Prefilled Syringe)
Maximum of 12 syringes (12 ml) per 28 days
Glatopa (20MG/ML Subcutaneous Solution Prefilled Syringe)
Maximum of 1 syringe (1 ml) per day
Glatopa (40MG/ML Subcutaneous Solution Prefilled Syringe)
Maximum of 12 syringes (12 ml) per 28 days
100
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Glimepiride (1MG Oral Tablet) Maximum of 8 tablets per day
Glimepiride (2MG Oral Tablet) Maximum of 4 tablets per day
Glimepiride (4MG Oral Tablet) Maximum of 2 tablets per day
Glipizide ER (10MG Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Glipizide ER (2.5MG Oral Tablet Extended Release 24 Hour)
Maximum of 8 tablets per day
Glipizide ER (5MG Oral Tablet Extended Release 24 Hour)
Maximum of 4 tablets per day
Glipizide (10MG Oral Tablet Immediate Release)
Maximum of 4 tablets per day
Glipizide (5MG Oral Tablet Immediate Release) Maximum of 8 tablets per day
Glipizide-Metformin HCl (2.5-250MG Oral Tablet)
Maximum of 8 tablets per day
Glipizide-Metformin HCl (2.5-500MG Oral Tablet, 5-500MG Oral Tablet)
Maximum of 4 tablets per day
Glyxambi (Oral Tablet) Maximum of 1 tablet per day
Granisetron HCl (Oral Tablet) Maximum of 2 tablets per day
Hetlioz (Oral Capsule) Maximum of 1 capsule per day
Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral Solution)
Maximum of 180 ml per day
Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)
Maximum of 12 tablets per day
Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet)
Maximum of 5 tablets per day
Hydromorphone HCl ER (Oral Tablet ER 24 Hour Abuse-Deterrent)
Maximum of 2 tablets per day
Hydromorphone HCl (1MG/ML Oral Liquid) Maximum of 50 ml per day
Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release)
Maximum of 8 tablets per day
Hydromorphone HCl (8MG Oral Tablet Immediate Release)
Maximum of 6 tablets per day
Hysingla ER (Oral Tablet ER 24 Hour Abuse-
Deterrent)Maximum of 1 tablet per day
Ibandronate Sodium (Oral Tablet) Maximum of 1 tablet per 28 days
Ibrance (Oral Capsule) Maximum of 1 capsule per day
Ibrance (Oral Tablet) Maximum of 1 tablet per day
Icatibant Acetate (Subcutaneous Solution) Maximum of 3 syringes (9 ml) per day
101
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Iclusig (15MG Oral Tablet) Maximum of 2 tablets per day
Iclusig (45MG Oral Tablet) Maximum of 1 tablet per day
IDHIFA (Oral Tablet) Maximum of 1 tablet per day
Imatinib Mesylate (Oral Tablet) Maximum of 3 tablets per day
Imbruvica (140MG Oral Capsule) Maximum of 4 capsules per day
Imbruvica (70MG Oral Capsule) Maximum of 1 capsule per day
Imbruvica (Oral Tablet) Maximum of 1 tablet per day
Imvexxy Maintenance Pack (Vaginal Insert) Maximum of 1 vaginal insert per day
Imvexxy Starter Pack (Vaginal Insert) Maximum of 1 vaginal insert per day
Incruse Ellipta (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (30 blisters) per 30 days
Ingrezza (Oral Capsule) Maximum of 1 capsule per day
Ingrezza (Oral Capsule Therapy Pack) Maximum of 1 pack (28 capsules) per 28 days
Inlyta (Oral Tablet) Maximum of 4 tablets per day
Inrebic (Oral Capsule) Maximum of 4 capsules per day
Intelence (100MG Oral Tablet, 200MG Oral
Tablet)Maximum of 2 tablets per day
Intelence (25MG Oral Tablet) Maximum of 4 tablets per day
Invirase (Oral Tablet) Maximum of 4 tablets per day
Invokamet (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Invokamet XR (Oral Tablet Extended Release
24 Hour)Maximum of 2 tablets per day
Invokana (Oral Tablet) Maximum of 1 tablet per day
Irbesartan (150MG Oral Tablet, 300MG Oral Tablet)
Maximum of 1 tablet per day
Irbesartan (75MG Oral Tablet) Maximum of 3 tablets per day
Irbesartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day
Iressa (Oral Tablet) Maximum of 2 tablets per day
Isentress HD (Oral Tablet) Maximum of 2 tablets per day
Isentress (Oral Packet) Maximum of 2 packets per day
Isentress (Oral Tablet) Maximum of 2 tablets per day
Isentress (Oral Tablet Chewable) Maximum of 6 tablets per day
Itraconazole (Oral Capsule) Maximum of 4 capsules per day
Jakafi (Oral Tablet) Maximum of 2 tablets per day
Janumet (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Janumet XR (100-1000MG Oral Tablet
Extended Release 24 Hour)Maximum of 1 tablet per day
102
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Janumet XR (50-1000MG Oral Tablet
Extended Release 24 Hour, 50-500MG Oral
Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Januvia (Oral Tablet) Maximum of 1 tablet per day
Jardiance (Oral Tablet) Maximum of 1 tablet per day
Jentadueto (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Jentadueto XR (2.5-1000MG Oral Tablet
Extended Release 24 Hour)Maximum of 2 tablets per day
Jentadueto XR (5-1000MG Oral Tablet
Extended Release 24 Hour)Maximum of 1 tablet per day
Juluca (Oral Tablet) Maximum of 1 tablet per day
Kaletra (100-25MG Oral Tablet) Maximum of 8 tablets per day
Kaletra (200-50MG Oral Tablet) Maximum of 4 tablets per day
Kalydeco (Oral Packet) Maximum of 2 packets per day
Kalydeco (Oral Tablet) Maximum of 2 tablets per day
Ketoconazole (External Cream) Maximum of 90 grams per 30 days
Kisqali (200MG Dose) (Oral Tablet) Maximum of 3 tablets per day
Kisqali (400MG Dose) (Oral Tablet) Maximum of 3 tablets per day
Kisqali (600MG Dose) (Oral Tablet) Maximum of 3 tablets per day
Kisqali Femara (400MG Dose) (Oral Tablet
Therapy Pack)Maximum of 1 pack (91 tablets) per 28 days
Kisqali Femara (600MG Dose) (Oral Tablet
Therapy Pack)Maximum of 1 pack (91 tablets) per 28 days
Kisqali Femara (200MG Dose) (Oral Tablet
Therapy Pack)Maximum of 1 pack (91 tablets) per 28 days
Korlym (Oral Tablet) Maximum of 4 tablets per day
Koselugo (10MG Oral Capsule) Maximum of 8 capsules per day
Koselugo (25MG Oral Capsule) Maximum of 4 capsules per day
Lamivudine (10MG/ML Oral Solution) Maximum of 32 ml per day
Lamivudine (150MG Oral Tablet) Maximum of 2 tablets per day
Lamivudine (300MG Oral Tablet) Maximum of 1 tablet per day
Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day
Lansoprazole (Oral Capsule Delayed Release) Maximum of 2 capsules per day
Latuda (120MG Oral Tablet, 20MG Oral
Tablet, 40MG Oral Tablet, 60MG Oral Tablet)Maximum of 1 tablet per day
Latuda (80MG Oral Tablet) Maximum of 2 tablets per day
Levocetirizine Dihydrochloride (Oral Tablet) Maximum of 1 tablet per day
Levorphanol Tartrate (Oral Tablet) Maximum of 6 tablets per day
Lexiva (Oral Suspension) Maximum of 60 ml per day
103
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Lidocaine (5% External Ointment) Maximum of 152 grams per 30 days
Lidocaine (5% External Patch) Maximum of 3 patches per day
Linezolid (Oral Tablet) Maximum of 2 tablets per day
Linzess (Oral Capsule) Maximum of 1 capsule per day
Lisinopril (Oral Tablet) Maximum of 2 tablets per day
Lisinopril-Hydrochlorothiazide (10-12.5MG Oral Tablet)
Maximum of 1 tablet per day
Lisinopril-Hydrochlorothiazide (20-12.5MG Oral Tablet)
Maximum of 4 tablets per day
Lisinopril-Hydrochlorothiazide (20-25MG Oral Tablet)
Maximum of 2 tablets per day
Livalo (Oral Tablet) Maximum of 1 tablet per day
Lokelma (Oral Packet) Maximum of 90 packets per 30 days
Lonhala Magnair (Inhalation Solution) Maximum of 2 vials (2 ml) per day
Lonsurf (15-6.14MG Oral Tablet) Maximum of 10 tablets per day
Lonsurf (20-8.19MG Oral Tablet) Maximum of 8 tablets per day
Lopinavir-Ritonavir (Oral Solution) Maximum of 2 bottles (320 ml) per 30 days
Lorazepam (2MG/ML Oral Concentrate) Maximum of 5 ml per day
Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet)
Maximum of 4 tablets per day
Lorazepam (2MG Oral Tablet) Maximum of 5 tablets per day
Lorbrena (100MG Oral Tablet) Maximum of 1 tablet per day
Lorbrena (25MG Oral Tablet) Maximum of 3 tablets per day
Lorcet HD (Oral Tablet) Maximum of 12 tablets per day
Lorcet (Oral Tablet) Maximum of 12 tablets per day
Losartan Potassium (100MG Oral Tablet) Maximum of 1 tablet per day
Losartan Potassium (25MG Oral Tablet, 50MG Oral Tablet)
Maximum of 2 tablets per day
Losartan Potassium-HCTZ (100-12.5MG Oral Tablet, 100-25MG Oral Tablet)
Maximum of 1 tablet per day
Losartan Potassium-HCTZ (50-12.5MG Oral Tablet)
Maximum of 2 tablets per day
Lovastatin (10MG Oral Tablet, 20MG Oral Tablet)
Maximum of 1 tablet per day
Lovastatin (40MG Oral Tablet) Maximum of 2 tablets per day
Lynparza (Oral Tablet) Maximum of 4 tablets per day
Mavyret (Oral Tablet) Maximum of 3 tablets per day
Mayzent (0.25MG Oral Tablet) Maximum of 8 tablets per day
Mayzent (2MG Oral Tablet) Maximum of 1 tablet per day
104
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Memantine HCl ER (Oral Capsule Extended Release 24 Hour)
Maximum of 1 capsule per day
Memantine HCl (2MG/ML Oral Solution) Maximum of 10 ml per day
Memantine HCl (10MG Oral Tablet) Maximum of 2 tablets per day
Memantine HCl (5MG Oral Tablet) Maximum of 3 tablets per day
Mesalamine ER (0.375MG Oral Capsule Extended Release 24 Hour) (Generic Apriso)
Maximum of 4 capsules per day
Mesalamine (1.2GM Oral Tablet Delayed Release) (Generic Lialda)
Maximum of 4 tablets per day
Mesalamine (Rectal Enema) Maximum of 1 bottle (60 ml) per day
Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)
Maximum of 4 tablets per day
Metformin HCl ER (750MG Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)
Maximum of 2 tablets per day
Metformin HCl (500MG/5ML Oral Solution) Maximum of 25.5 ml per day
Metformin HCl (1000MG Oral Tablet Immediate Release)
Maximum of 2.5 tablets per day
Metformin HCl (500MG Oral Tablet Immediate Release)
Maximum of 5 tablets per day
Metformin HCl (850MG Oral Tablet Immediate Release)
Maximum of 3 tablets per day
Methadone HCl (10MG/5ML Oral Solution) Maximum of 60 ml per day
Methadone HCl (5MG/5ML Oral Solution) Maximum of 120 ml per day
Methadone HCl (10MG Oral Tablet) Maximum of 12 tablets per day
Methadone HCl (5MG Oral Tablet) Maximum of 8 tablets per day
Methylphenidate HCl ER (10MG Oral Tablet Extended Release)
Maximum of 4 tablets per day
Methylphenidate HCl ER (20MG Oral Tablet Extended Release)
Maximum of 3 tablets per day
Methylphenidate HCl (10MG/5ML Oral Solution)
Maximum of 30 ml per day
Methylphenidate HCl (5MG/5ML Oral Solution) Maximum of 60 ml per day
Methylphenidate HCl (Oral Tablet Immediate Release) (Generic Ritalin)
Maximum of 3 tablets per day
Miglitol (100MG Oral Tablet) Maximum of 3 tablets per day
Miglitol (25MG Oral Tablet) Maximum of 12 tablets per day
Miglitol (50MG Oral Tablet) Maximum of 6 tablets per day
Modafinil (100MG Oral Tablet) Maximum of 1 tablet per day
105
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Modafinil (200MG Oral Tablet) Maximum of 2 tablets per day
Moexipril HCl (Oral Tablet) Maximum of 2 tablets per day
Montelukast Sodium (Oral Packet) Maximum of 1 packet per day
Montelukast Sodium (Oral Tablet) Maximum of 1 tablet per day
Montelukast Sodium (Oral Tablet Chewable) Maximum of 1 tablet per day
Morphine Sulfate (100MG/5ML Oral Solution) Maximum of 10 ml per day
Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release) (Generic MS Contin)
Maximum of 3 tablets per day
Morphine Sulfate ER (200MG Oral Tablet Extended Release) (Generic MS Contin)
Maximum of 2 tablets per day
Morphine Sulfate ER (30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)
Maximum of 4 tablets per day
Morphine Sulfate (10MG/5ML Oral Solution) Maximum of 100 ml per day
Morphine Sulfate (20MG/5ML Oral Solution) Maximum of 50 ml per day
Morphine Sulfate (15MG Oral Tablet
Immediate Release)Maximum of 8 tablets per day
Morphine Sulfate (30MG Oral Tablet
Immediate Release)Maximum of 6 tablets per day
Multaq (Oral Tablet) Maximum of 2 tablets per day
Namzaric (Oral Capsule ER 24 Hour Therapy
Pack)Maximum of 1 capsule per day
Namzaric (Oral Capsule Extended Release
24 Hour)Maximum of 1 capsule per day
Naratriptan HCl (Oral Tablet) Maximum of 12 tablets per 30 days
Nateglinide (120MG Oral Tablet) Maximum of 3 tablets per day
Nateglinide (60MG Oral Tablet) Maximum of 6 tablets per day
Nebupent (Inhalation Solution Reconstituted) Maximum of 1 vial (300 mg) per 28 days
Nerlynx (Oral Tablet) Maximum of 6 tablets per day
Nevirapine ER (100MG Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Nevirapine ER (400MG Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Nevirapine (Oral Suspension) Maximum of 40 ml per day
Nevirapine (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Nifedipine ER (Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Nifedipine ER Osmotic Release (Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
106
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Ninlaro (Oral Capsule) Maximum of 3 capsules per 28 days
Northera (100MG Oral Capsule) Maximum of 3 capsules per day
Northera (200MG Oral Capsule, 300MG Oral
Capsule)Maximum of 6 capsules per day
Norvir (Oral Packet) Maximum of 12 packets per day
Norvir (Oral Solution) Maximum of 16 ml per day
Noxafil (Oral Suspension) Maximum of 20 ml per day
Noxafil (Oral Tablet Delayed Release) Maximum of 6 tablets per day
Nubeqa (Oral Tablet) Maximum of 4 tablets per day
Nucala (Subcutaneous Solution Auto-
Injector)Maximum of 3 ml per 28 days
Nucala (Subcutaneous Solution Prefilled
Syringe)Maximum of 3 ml per 28 days
Nucala (Subcutaneous Solution
Reconstituted)Maximum of 3 vials per 28 days
Nucynta ER (Oral Tablet Extended Release
12 Hour)Maximum of 2 tablets per day
Nuplazid (Oral Capsule) Maximum of 1 capsule per day
Nuplazid (10MG Oral Tablet) Maximum of 1 tablet per day
Ocaliva (Oral Tablet) Maximum of 1 tablet per day
Odefsey (Oral Tablet) Maximum of 1 tablet per day
Odomzo (Oral Capsule) Maximum of 1 capsule per day
Ofev (Oral Capsule) Maximum of 2 capsules per day
Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)
Maximum of 1 tablet per day
Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)
Maximum of 1 tablet per day
Olmesartan Medoxomil (20MG Oral Tablet, 40MG Oral Tablet)
Maximum of 1 tablet per day
Olmesartan Medoxomil (5MG Oral Tablet) Maximum of 2 tablets per day
Olmesartan Medoxomil-HCTZ (Oral Tablet) Maximum of 1 tablet per day
Olmesartan-Amlodipine-HCTZ (Oral Tablet) Maximum of 1 tablet per day
Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic Lovaza)
Maximum of 4 capsules per day
Orkambi (Oral Packet) Maximum of 56 packets per 28 days
Orkambi (Oral Tablet) Maximum of 112 tablets per 28 days
107
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Oseltamivir Phosphate (Oral Capsule) Maximum of 2 capsules per day
Oseltamivir Phosphate (Oral Suspension Reconstituted)
Maximum of 26 ml per day
Osphena (Oral Tablet) Maximum of 1 tablet per day
Oxandrolone (10MG Oral Tablet) Maximum of 2 tablets per day
Oxandrolone (2.5MG Oral Tablet) Maximum of 4 tablets per day
Oxybutynin Chloride ER (10MG Oral Tablet Extended Release 24 Hour)
Maximum of 3 tablets per day
Oxybutynin Chloride ER (15MG Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Oxybutynin Chloride ER (5MG Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Oxycodone HCl (100MG/5ML Oral Concentrate)
Maximum of 6 ml per day
Oxycodone HCl (5MG/5ML Oral Solution) Maximum of 130 ml per day
Oxycodone HCl (10MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)
Maximum of 12 tablets per day
Oxycodone HCl (15MG Oral Tablet Immediate Release)
Maximum of 8 tablets per day
Oxycodone HCl (20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release)
Maximum of 6 tablets per day
Oxycodone-Acetaminophen (10-325MG Oral Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)
Maximum of 12 tablets per day
Oxycodone-Aspirin (Oral Tablet) Maximum of 12 tablets per day
Ozempic (0.25 or 0.5MG/DOSE)
(Subcutaneous Solution Pen-Injector)Maximum of 1 pen (1.5 ml) per 28 days
Ozempic (1MG/DOSE) (Subcutaneous
Solution Pen-Injector)Maximum of 2 pens (3 ml) per 28 days
Paliperidone ER (1.5MG Oral Tablet Extended Release 24 Hour, 3MG Oral Tablet Extended Release 24 Hour, 9MG Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Paliperidone ER (6MG Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Pantoprazole Sodium (20MG Oral Tablet Delayed Release)
Maximum of 3 tablets per day
Pantoprazole Sodium (40MG Oral Tablet Delayed Release)
Maximum of 2 tablets per day
Pemazyre (Oral Tablet) Maximum of 1 tablet per day
108
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Pentamidine Isethionate (Inhalation Solution Reconstituted)
Maximum of 1 vial (300 mg) per 28 days
Pentasa (250MG Oral Capsule Extended
Release)Maximum of 12 capsules per day
Pentasa (500MG Oral Capsule Extended
Release)Maximum of 8 capsules per day
Perforomist (Inhalation Nebulization
Solution)Maximum of 2 vials (4 ml) per day
Perindopril Erbumine (Oral Tablet) Maximum of 2 tablets per day
Pifeltro (Oral Tablet) Maximum of 1 tablet per day
Pioglitazone HCl (15MG Oral Tablet) Maximum of 3 tablets per day
Pioglitazone HCl (30MG Oral Tablet, 45MG Oral Tablet)
Maximum of 1 tablet per day
Pioglitazone HCl-Glimepiride (Oral Tablet) Maximum of 1 tablet per day
Pioglitazone HCl-Metformin HCl (Oral Tablet) Maximum of 3 tablets per day
Piqray (200MG Daily Dose) (Oral Tablet
Therapy Pack)Maximum of 1 tablet per day
Piqray (250MG Daily Dose) (Oral Tablet
Therapy Pack)Maximum of 2 tablets per day
Piqray (300MG Daily Dose) (Oral Tablet
Therapy Pack)Maximum of 2 tablets per day
Pomalyst (Oral Capsule) Maximum of 1 capsule per day
Posaconazole (Oral Tablet Delayed Release) Maximum of 6 tablets per day
Praluent (Subcutaneous Solution Auto-
Injector)Maximum of 2 pens (2 ml) per 28 days
Prasugrel HCl (Oral Tablet) Maximum of 1 tablet per day
Pravastatin Sodium (Oral Tablet) Maximum of 1 tablet per day
Pregabalin (100MG Oral Capsule, 150MG Oral Capsule, 200MG Oral Capsule, 25MG Oral Capsule, 50MG Oral Capsule, 75MG Oral Capsule)
Maximum of 3 capsules per day
Pregabalin (225MG Oral Capsule, 300MG Oral Capsule)
Maximum of 2 capsules per day
Pregabalin (Oral Solution) Maximum of 30 ml per day
Premarin (Oral Tablet) Maximum of 1 tablet per day
Premphase (Oral Tablet) Maximum of 1 tablet per day
Prempro (Oral Tablet) Maximum of 1 tablet per day
Prezcobix (Oral Tablet) Maximum of 1 tablet per day
Prezista (Oral Suspension) Maximum of 2 bottles (400 ml) per 30 days
Prezista (150MG Oral Tablet) Maximum of 6 tablets per day
109
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Prezista (600MG Oral Tablet, 75MG Oral
Tablet)Maximum of 2 tablets per day
Prezista (800MG Oral Tablet) Maximum of 1 tablet per day
Prolia (Subcutaneous Solution Prefilled
Syringe)Maximum of 1 syringe per 180 days
Promacta (Oral Packet) Maximum of 6 packets per day
Promacta (12.5MG Oral Tablet, 25MG Oral
Tablet)Maximum of 1 tablet per day
Promacta (50MG Oral Tablet, 75MG Oral
Tablet)Maximum of 2 tablets per day
Pulmozyme (Inhalation Solution) Maximum of 2 ampules (5 ml) per day
Qinlock (Oral Tablet) Maximum of 3 tablets per day
Quetiapine Fumarate ER (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Quetiapine Fumarate ER (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Quetiapine Fumarate (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 50MG Oral Tablet Immediate Release)
Maximum of 3 tablets per day
Quetiapine Fumarate (25MG Oral Tablet Immediate Release)
Maximum of 4 tablets per day
Quetiapine Fumarate (300MG Oral Tablet Immediate Release, 400MG Oral Tablet Immediate Release)
Maximum of 2 tablets per day
Quinapril HCl (Oral Tablet) Maximum of 2 tablets per day
Quinapril-Hydrochlorothiazide (10-12.5MG Oral Tablet)
Maximum of 1 tablet per day
Quinapril-Hydrochlorothiazide (20-12.5MG Oral Tablet, 20-25MG Oral Tablet)
Maximum of 2 tablets per day
Raloxifene HCl (Oral Tablet) Maximum of 1 tablet per day
Ramelteon (Oral Tablet) Maximum of 1 tablet per day
Ramipril (Oral Capsule) Maximum of 2 capsules per day
Ranolazine ER (Oral Tablet Extended Release 12 Hour)
Maximum of 2 tablets per day
RAVICTI (Oral Liquid) Maximum of 17.5 ml per day
Rayaldee (Oral Capsule Extended Release) Maximum of 2 capsules per day
110
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Rebif Rebidose (Subcutaneous Solution
Auto-Injector)Maximum of 12 pens (6 ml) per 28 days
Rebif Rebidose Titration Pack
(Subcutaneous Solution Auto-Injector)Maximum of 1 pack (4.2 ml) per 28 days
Rebif (Subcutaneous Solution Prefilled
Syringe)Maximum of 12 syringes (6 ml) per 28 days
Rebif Titration Pack (Subcutaneous Solution
Prefilled Syringe)Maximum of 1 pack (4.2 ml) per 28 days
Relenza Diskhaler (Inhalation Aerosol
Powder Breath Activated)Maximum of 3 inhalers (60 blisters) per 30 days
Relistor (Oral Tablet) Maximum of 3 tablets per day
Repaglinide (0.5MG Oral Tablet) Maximum of 32 tablets per day
Repaglinide (1MG Oral Tablet) Maximum of 16 tablets per day
Repaglinide (2MG Oral Tablet) Maximum of 8 tablets per day
Repatha Pushtronex System (Subcutaneous
Solution Cartridge)Maximum of 1 cartridge (3.5 ml) per 28 days
Repatha (Subcutaneous Solution Prefilled
Syringe)Maximum of 3 syringes (3 ml) per 28 days
Repatha SureClick (Subcutaneous Solution
Auto-Injector)Maximum of 3 pens (3 ml) per 28 days
Restasis Single-Use Vials (Ophthalmic
Emulsion)Maximum of 2 vials per day
Retevmo (40MG Oral Capsule) Maximum of 6 capsules per day
Retevmo (80MG Oral Capsule) Maximum of 4 capsules per day
Revlimid (Oral Capsule) Maximum of 1 capsule per day
Rexulti (Oral Tablet) Maximum of 1 tablet per day
Reyataz (Oral Packet) Maximum of 6 packets per day
Riomet ER (Oral Suspension Reconstituted
ER)Maximum of 20 ml per day
Riomet (Oral Solution) Maximum of 25.5 ml per day
Risedronate Sodium (150MG Oral Tablet Immediate Release)
Maximum of 1 tablet per 30 days
Risedronate Sodium (30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)
Maximum of 1 tablet per day
Risedronate Sodium (35MG Oral Tablet Immediate Release, 35MG (12 PACK) Oral Tablet Immediate Release, 35MG (4 PACK) Oral Tablet Immediate Release)
Maximum of 4 tablets per 28 days
Ritonavir (Oral Tablet) Maximum of 12 tablets per day
111
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Rivastigmine Tartrate (Oral Capsule) Maximum of 2 capsules per day
Rivastigmine (Transdermal Patch 24 Hour) Maximum of 1 patch per day
Rizatriptan Benzoate (Oral Tablet) Maximum of 12 tablets per 30 days
Rizatriptan Benzoate ODT (Oral Tablet Dispersible)
Maximum of 12 tablets per 30 days
Rosuvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day
Rozlytrek (100MG Oral Capsule) Maximum of 5 capsules per day
Rozlytrek (200MG Oral Capsule) Maximum of 3 capsules per day
Rubraca (Oral Tablet) Maximum of 4 tablets per day
Rukobia (Oral Tablet Extended Release 12
Hour)Maximum of 2 tablets per day
Rybelsus (Oral Tablet) Maximum of 1 tablet per day
Rydapt (Oral Capsule) Maximum of 8 capsules per day
Saphris (Tablet Sublingual) Maximum of 2 tablets per day
Secuado (Transdermal Patch 24 Hour) Maximum of 1 patch per day
Selzentry (Oral Solution) Maximum of 8 bottles (1840 ml) per 30 days
Selzentry (150MG Oral Tablet, 75MG Oral
Tablet)Maximum of 2 tablets per day
Selzentry (25MG Oral Tablet, 300MG Oral
Tablet)Maximum of 4 tablets per day
Serevent Diskus (Inhalation Aerosol Powder
Breath Activated)
Maximum of 1 inhaler (60 inhalations) per 30 days
Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio)
Maximum of 3 tablets per day
Silodosin (Oral Capsule) Maximum of 1 capsule per day
Simvastatin (Oral Tablet) Maximum of 1 tablet per day
Sofosbuvir-Velpatasvir (Oral Tablet) Maximum of 1 tablet per day
Solifenacin Succinate (Oral Tablet) Maximum of 1 tablet per day
Soliqua (Subcutaneous Solution Pen-
Injector)Maximum of 6 pens (18 ml) per 30 days
Somavert (Subcutaneous Solution
Reconstituted)Maximum of 1 vial per day
Sovaldi (150MG Oral Packet) Maximum of 1 carton (28 packets) per 28 days
Sovaldi (200MG Oral Packet) Maximum of 2 cartons (56 packets) per 28 days
Sovaldi (400MG Oral Tablet) Maximum of 1 tablet per day
Spiriva HandiHaler (Inhalation Capsule) Maximum of 1 capsule per day
Spiriva Respimat (Inhalation Aerosol
Solution)Maximum of 1 inhaler (4 grams) per 30 days
112
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Sprycel (100MG Oral Tablet, 140MG Oral
Tablet, 70MG Oral Tablet)Maximum of 1 tablet per day
Sprycel (20MG Oral Tablet, 50MG Oral
Tablet)Maximum of 3 tablets per day
Sprycel (80MG Oral Tablet) Maximum of 2 tablets per day
Stavudine (Oral Capsule) Maximum of 2 capsules per day
Stiolto Respimat (Inhalation Aerosol
Solution)Maximum of 1 inhaler (4 grams) per 30 days
Stivarga (Oral Tablet) Maximum of 4 tablets per day
Stribild (Oral Tablet) Maximum of 1 tablet per day
Suboxone (12-3MG Sublingual Film, 4-1MG
Sublingual Film)Maximum of 2 films per day
Suboxone (2-0.5MG Sublingual Film, 8-2MG
Sublingual Film)Maximum of 3 films per day
Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days
Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)
Maximum of 12 tablets per 30 days
Sumatriptan Succinate Refill (Subcutaneous
Solution Cartridge)Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution)
Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/0.5ML Subcutaneous Solution Auto-Injector)
Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate (6MG/0.5ML
Subcutaneous Solution Auto-Injector)
(Generic Imitrex STATdose)
Maximum of 12 injections (6 ml) per 30 days
Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Prefilled Syringe)
Maximum of 12 injections (6 ml) per 30 days
Sutent (12.5MG Oral Capsule, 25MG Oral
Capsule, 50MG Oral Capsule)Maximum of 1 capsule per day
Sutent (37.5MG Oral Capsule) Maximum of 2 capsules per day
Symbicort (120 Inhalation Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days
Symfi Lo (Oral Tablet) Maximum of 1 tablet per day
Symfi (Oral Tablet) Maximum of 1 tablet per day
Sympazan (Oral Film) Maximum of 2 films per day
Symtuza (Oral Tablet) Maximum of 1 tablet per day
Synjardy (Oral Tablet Immediate Release) Maximum of 2 tablets per day
113
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Synjardy XR (10-1000MG Oral Tablet
Extended Release 24 Hour, 25-1000MG Oral
Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Synjardy XR (12.5-1000MG Oral Tablet
Extended Release 24 Hour, 5-1000MG Oral
Tablet Extended Release 24 Hour)
Maximum of 2 tablets per day
Tabrecta (Oral Tablet) Maximum of 4 tablets per day
Tadalafil (PAH) (20MG Oral Tablet) Maximum of 2 tablets per day
Tagrisso (Oral Tablet) Maximum of 1 tablet per day
Talzenna (0.25MG Oral Capsule) Maximum of 3 capsules per day
Talzenna (1MG Oral Capsule) Maximum of 1 capsule per day
Tasigna (150MG Oral Capsule) Maximum of 5 capsules per day
Tasigna (200MG Oral Capsule) Maximum of 4 capsules per day
Tasigna (50MG Oral Capsule) Maximum of 14 capsules per day
Tazverik (Oral Tablet) Maximum of 8 tablets per day
Tecfidera (Oral Capsule Delayed Release) Maximum of 2 capsules per day
Telmisartan (Oral Tablet) Maximum of 1 tablet per day
Telmisartan-Amlodipine (Oral Tablet) Maximum of 1 tablet per day
Telmisartan-HCTZ (40-12.5MG Oral Tablet, 80-25MG Oral Tablet)
Maximum of 1 tablet per day
Telmisartan-HCTZ (80-12.5MG Oral Tablet) Maximum of 2 tablets per day
Temazepam (15MG Oral Capsule, 30MG Oral Capsule)
Maximum of 1 capsule per day
Tenofovir Disoproxil Fumarate (Oral Tablet) Maximum of 1 tablet per day
Teriparatide (Recombinant) (Subcutaneous
Solution Pen-Injector)Maximum of 1 pen (2.48 ml) per 28 days
Tetrabenazine (12.5MG Oral Tablet) Maximum of 3 tablets per day
Tetrabenazine (25MG Oral Tablet) Maximum of 4 tablets per day
Thalomid (100MG Oral Capsule, 50MG Oral
Capsule)Maximum of 1 capsule per day
Thalomid (150MG Oral Capsule, 200MG Oral
Capsule)Maximum of 2 capsules per day
Tibsovo (Oral Tablet) Maximum of 2 tablets per day
Tivicay (10MG Oral Tablet, 25MG Oral
Tablet)Maximum of 1 tablet per day
Tivicay (50MG Oral Tablet) Maximum of 2 tablets per day
Tivicay PD (Oral Tablet Soluble) Maximum of 6 tablets per day
TOBI Podhaler (Inhalation Capsule) Maximum of 8 capsules per day
Tobramycin (Inhalation Nebulization Solution) Maximum of 2 ampules (10 ml) per day
114
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Tolcapone (Oral Tablet) Maximum of 6 tablets per day
Tracleer (Oral Tablet Soluble) Maximum of 8 tablets per day
Tradjenta (Oral Tablet) Maximum of 1 tablet per day
Tramadol HCl ER (Biphasic) (Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Tramadol HCl ER (Oral Tablet Extended Release 24 Hour)
Maximum of 1 tablet per day
Tramadol HCl (50MG Oral Tablet Immediate Release)
Maximum of 8 tablets per day
Tramadol-Acetaminophen (Oral Tablet) Maximum of 8 tablets per day
Trandolapril (1MG Oral Tablet, 2MG Oral Tablet)
Maximum of 1 tablet per day
Trandolapril (4MG Oral Tablet) Maximum of 2 tablets per day
Trelegy Ellipta (Inhalation Aerosol Powder
Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days
Trezix (Oral Capsule) Maximum of 10 capsules per day
Trientine HCl (Oral Capsule) Maximum of 8 capsules per day
Trintellix (Oral Tablet) Maximum of 1 tablet per day
Triumeq (Oral Tablet) Maximum of 1 tablet per day
Trulicity (Subcutaneous Solution Pen-
Injector)Maximum of 4 pens (2 ml) per 28 days
Truvada (Oral Tablet) Maximum of 1 tablet per day
Tukysa (150MG Oral Tablet) Maximum of 4 tablets per day
Tukysa (50MG Oral Tablet) Maximum of 12 tablets per day
Turalio (Oral Capsule) Maximum of 4 capsules per day
Tybost (Oral Tablet) Maximum of 1 tablet per day
Tymlos (Subcutaneous Solution Pen-Injector) Maximum of 1.56 ml per 30 days
Valacyclovir HCl (1GM Oral Tablet) Maximum of 4 tablets per day
Valacyclovir HCl (500MG Oral Tablet) Maximum of 2 tablets per day
Valganciclovir HCl (50MG/ML Oral Solution Reconstituted)
Maximum of 36 ml per day
Valganciclovir HCl (450MG Oral Tablet) Maximum of 4 tablets per day
Valsartan (160MG Oral Tablet, 40MG Oral Tablet, 80MG Oral Tablet)
Maximum of 2 tablets per day
Valsartan (320MG Oral Tablet) Maximum of 1 tablet per day
Valsartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day
Valtoco 10 MG Dose (Nasal Liquid)Maximum of 10 blister packs (10 spray devices) per 30 days
115
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Valtoco 15 MG Dose (Nasal Liquid Therapy
Pack)
Maximum of 10 blister packs (20 spray devices) per 30 days
Valtoco 20 MG Dose (Nasal Liquid Therapy
Pack)
Maximum of 10 blister packs (20 spray devices) per 30 days
Valtoco 5 MG Dose (Nasal Liquid)Maximum of 10 blister packs (10 spray devices) per 30 days
Vancomycin HCl (125MG Oral Capsule) Maximum of 4 capsules per day
Vancomycin HCl (250MG Oral Capsule) Maximum of 8 capsules per day
Veltassa (Oral Packet) Maximum of 1 packet per day
Vemlidy (Oral Tablet) Maximum of 1 tablet per day
Venclexta (100MG Oral Tablet) Maximum of 6 tablets per day
Venclexta (10MG Oral Tablet) Maximum of 2 tablets per day
Venclexta (50MG Oral Tablet) Maximum of 1 tablet per day
Ventavis (10MCG/ML Inhalation Solution) Maximum of 7 ml per day
Ventavis (20MCG/ML Inhalation Solution) Maximum of 3 ml per day
Verzenio (Oral Tablet) Maximum of 2 tablets per day
Victoza (Subcutaneous Solution Pen-Injector) Maximum of 3 pens (9 ml) per 30 days
Vigabatrin (Oral Packet) Maximum of 6 packets per day
Vigabatrin (Oral Tablet) Maximum of 6 tablets per day
Vigadrone (Oral Packet) Maximum of 6 packets per day
Viibryd (Oral Tablet) Maximum of 1 tablet per day
Viibryd Starter Pack (Oral Kit) Maximum of 1 pack (30 tablets) per 30 days
Vimpat (Oral Solution) Maximum of 40 ml per day
Vimpat (Oral Tablet) Maximum of 2 tablets per day
Viracept (250MG Oral Tablet) Maximum of 10 tablets per day
Viracept (625MG Oral Tablet) Maximum of 4 tablets per day
Viread (Oral Powder) Maximum of 4 bottles (240 grams) per 30 days
Viread (150MG Oral Tablet, 200MG Oral
Tablet, 250MG Oral Tablet)Maximum of 1 tablet per day
Vitrakvi (100MG Oral Capsule) Maximum of 4 capsules per day
Vitrakvi (25MG Oral Capsule) Maximum of 6 capsules per day
Vitrakvi (Oral Solution) Maximum of 20 ml per day
Vizimpro (Oral Tablet) Maximum of 1 tablet per day
Vosevi (Oral Tablet) Maximum of 1 tablet per day
Votrient (Oral Tablet) Maximum of 4 tablets per day
Vraylar (1.5MG Oral Capsule, 3MG Oral
Capsule, 4.5MG Oral Capsule, 6MG Oral
Capsule)
Maximum of 1 capsule per day
116
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Vyndamax (Oral Capsule) Maximum of 1 capsule per day
Vyndaqel (Oral Capsule) Maximum of 4 capsules per day
Wixela Inhub (Inhalation Aerosol Powder Breath Activated) (Generic Advair)
Maximum of 1 inhaler (60 blisters) per 30 days
Xarelto (10MG Oral Tablet, 20MG Oral
Tablet)Maximum of 1 tablet per day
Xarelto (15MG Oral Tablet, 2.5MG Oral
Tablet)Maximum of 2 tablets per day
Xarelto Starter Pack (Oral Tablet Therapy
Pack)Maximum of 1 pack (51 tablets) per 30 days
Xcopri (250 MG Daily Dose) (Oral Tablet
Therapy Pack)Maximum of 1 pack (56 tablets) per 28 days
Xcopri (350 MG Daily Dose) (Oral Tablet
Therapy Pack)Maximum of 1 pack (56 tablets) per 28 days
Xcopri (100MG Oral Tablet, 50MG Oral
Tablet)Maximum of 1 tablet per day
Xcopri (150MG Oral Tablet, 200MG Oral
Tablet)Maximum of 2 tablets per day
Xcopri (Oral Tablet Titration Therapy Pack) Maximum of 1 pack (28 tablets) per 28 days
Xeljanz (Oral Tablet Immediate Release) Maximum of 2 tablets per day
Xeljanz XR (Oral Tablet Extended Release 24
Hour)Maximum of 1 tablet per day
Xiidra (Ophthalmic Solution) Maximum of 2 vials per day
Xofluza (40 MG Dose) (Oral Tablet Therapy
Pack)Maximum of 2 tablets per 30 days
Xofluza (80 MG Dose) (Oral Tablet Therapy
Pack)Maximum of 2 tablets per 30 days
Xospata (Oral Tablet) Maximum of 3 tablets per day
Xpovio (100MG Once Weekly) (Oral Tablet
Therapy Pack)Maximum of 20 tablets per 28 days
Xpovio (40 MG Once Weekly) (Oral Tablet
Therapy Pack)Maximum of 8 tablets per 28 days
Xpovio (40 MG Twice Weekly) (Oral Tablet
Therapy Pack)Maximum of 16 tablets per 28 days
Xpovio (60MG Once Weekly) (Oral Tablet
Therapy Pack)Maximum of 12 tablets per 28 days
Xpovio (60 MG Twice Weekly) (Oral Tablet
Therapy Pack)Maximum of 24 tablets per 28 days
Xpovio (80MG Once Weekly) (Oral Tablet
Therapy Pack)Maximum of 16 tablets per 28 days
117
Bold type = Brand name drug Plain type = Generic drug
Drug Name Quantity Limit
Xpovio (80MG Twice Weekly) (Oral Tablet
Therapy Pack)Maximum of 32 tablets per 28 days
Xtampza ER (13.5MG Oral Capsule ER 12
Hour Abuse-Deterrent, 18MG Oral Capsule
ER 12 Hour Abuse-Deterrent, 9MG Oral
Capsule ER 12 Hour Abuse-Deterrent)
Maximum of 3 capsules per day
Xtampza ER (27MG Oral Capsule ER 12 Hour
Abuse-Deterrent, 36MG Oral Capsule ER 12
Hour Abuse-Deterrent)
Maximum of 6 capsules per day
Xtandi (Oral Capsule) Maximum of 4 capsules per day
Xyrem (Oral Solution) Maximum of 18 ml per day
Yuvafem (Vaginal Tablet) Maximum of 1 tablet per day
Zafirlukast (Oral Tablet) Maximum of 2 tablets per day
Zaleplon (10MG Oral Capsule) Maximum of 2 capsules per day
Zaleplon (5MG Oral Capsule) Maximum of 1 capsule per day
Zejula (Oral Capsule) Maximum of 3 capsules per day
Zelboraf (Oral Tablet) Maximum of 8 tablets per day
Zidovudine (Oral Capsule) Maximum of 6 capsules per day
Zidovudine (Oral Syrup) Maximum of 64 ml per day
Zidovudine (Oral Tablet) Maximum of 2 tablets per day
Ziprasidone HCl (Oral Capsule) Maximum of 2 capsules per day
Zolpidem Tartrate (Oral Tablet Immediate Release)
Maximum of 1 tablet per day
Zydelig (Oral Tablet) Maximum of 2 tablets per day
Zykadia (Oral Tablet) Maximum of 3 tablets per day
118
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C3. Over-the-counter (OTC) Drug List
UnitedHealthcare Senior Care Options covers some prescription OTC drugs that aren’t normally covered under our Medicare Part D benefit.
You need a prescription from your doctor to have drugs on this list covered. If your prescription is for a brand name drug, you will get the generic version of the drug if it’s available. Your doctor should write “no substitution” on the prescription to get the brand name drug.
Some of these drugs may need prior authorization. Please check with your doctor and the plan. If the drug requires a prior authorization, you or your doctor will need to get approval from the plan before the drug may be covered.
The list below shows the prescription OTC drugs covered by the plan.
tRACK
OTC Drug Name OTC Drug Name C1
Analgesics Acetaminophen/Extra Strength (Tablet) C1
Analgesics Aminofen (Tablet) C1
8 Hour Arthritis Pain Reliever (Tablet Apap (Elixir) C1 Extended-Release)
Apra (Elixir) C1 8 Hour Pain Relief (Tablet Extended-
Arthritis Pain (Tablet Extended-Release) Release) C1
Arthritis Pain Relief (Tablet Extended-8 Hour Pain Reliever (Tablet Extended-Release) Release) C1
Arthritis Pain Reliever (Tablet Extended-8 Hr Arthritis Pain Relief (Tablet Extended-Release) Release) C1
Betatemp Children's (Suspension) 8Hr Muscle Aches & Pain (Tablet C1
Chewable Acetaminophen Children's Extended-Release) (Tablet Chewable) Acephen (Suppository)
C1
Children's Acetaminophen (Suspension) Acetaminophen (160mg/5ml Liquid, C1
Children's Apap (Tablet Chewable) 160mg/5ml Solution, 120mg Suppository, C1
650mg Suppository, 325mg Tablet) Children's Chewable Acetaminophen (Tablet Chewable) Acetaminophen Children's (Suspension)
C1
Children's Medi-Tabs (Tablet Chewable) Acetaminophen ER (Tablet Extended-C1
Release) Children's Pain Reliever (Tablet Chewable) C1
Acetaminophen Extra Strength (Tablet) Children's Pain Reliever (Tablet Disintegrating) Acetaminophen Infants (Suspension)
C1
Children's Silapap (Liquid) Acetaminophen Junior Strength (Tablet C1
Disintegrating) Children's Tactinal (Tablet Chewable) C1
Acetaminophen Rapid Tabs Children's Chloraseptic Sore Throat (Liquid) (Tablet Disintegrating)
Bold type = Brand name drug Plain type = Generic drug
119
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
CVS 8Hr Arthritis Pain Relief (Tablet Extended-Release)
C1
CVS 8Hr Muscle Aches & Pain (Tablet Extended-Release)
C1
CVS Acetaminophen (Liquid)C1
CVS Acetaminophen Extra Strength (Tablet)
C1
CVS Arthritis Pain Relief (Tablet Extended-Release)
C1
CVS Children's Pain Relief (Suspension)C1
CVS Fever Reducing Children's (Suppository)
C1
CVS Infants Pain Relief (Suspension)C1
CVS Pain & Fever Children's (Suspension)C1
CVS Pain & Fever Infants (Suspension)C1
CVS Pain Relief 8 Hour (Tablet Extended-Release)
C1
CVS Pain Relief Adult/Rapid Burst (Liquid)C1
CVS Pain Relief Children's (Suspension)C1
CVS Pain Relief Children's (Tablet Chewable)
C1
CVS Pain Relief Extra Strength (Tablet)C1
CVS Pain Relief Regular Strength (Capsule)
C1
CVS Pain Relief Regular Strength (Tablet)C1
ED-Apap (Liquid)C1
EQ 8Hr Arthritis Pain Relief (Tablet Extended-Release)
C1
EQ Acetaminophen (Tablet)C1
EQ Acetaminophen Children's (Suspension)
C1
EQ Acetaminophen Children's (Tablet Disintegrating)
C1
EQ Acetaminophen Extra Strength (Tablet)C1
EQ Acetaminophen Junior (Tablet Disintegrating)
OTC Drug NameC1
EQ Arthritis Pain (Tablet Extended-Release)
C1
EQ Children's Pain Reliever (Tablet Chewable)
C1
EQ Pain & Fever Children's (Suspension)C1
EQ Pain & Fever Children's (Tablet Chewable)
C1
EQ Pain & Fever Infants (Suspension)C1
EQ Pain Relief Adult/Rapid Burst (Liquid)C1
EQ Pain Reliever (Tablet)C1
EQ Pain Reliever Junior (Tablet Chewable)C1
EQL Acetaminophen (Tablet Disintegrating)
C1
EQL Acetaminophen (Tablet)C1
EQL Acetaminophen Children's (Suspension)
C1
EQL Acetaminophen Extra Strength (Tablet)
C1
EQL Acetaminophen Infants (Suspension)C1
EQL Acetaminophen Rapid Tabs (Tablet Disintegrating)
C1
EQL Arthritis Pain Relief (Tablet Extended-Release)
C1
Extra Strength Pain Relief (Tablet)C1
Fever Reducer Children's (Suppository)C1
Feverall Adults (Suppository)C1
Feverall Children's (Suppository)C1
Feverall Infants (Suppository)C1
Feverall Junior Strength (Suppository)C1
GNP 8 Hour Pain Reliever (Tablet Extended-Release)
C1
GNP Acetaminophen (Tablet)C1
GNP Acetaminophen Extra Strength (Capsule)
C1
GNP All Day Pain Relief (Tablet)C1
GNP Arthritis Pain Relief (Tablet Extended-Release)
120
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
GNP Children's Easy-Melts (Tablet Disintegrating)
C1
GNP Children's Pain Relief (Suspension)C1
GNP Infants Pain Relief (Suspension)C1
GNP Infants Pain/Fever (Suspension)C1
GNP Pain & Fever Children's (Suspension)C1
GNP Pain Relief (160mg Tablet Chewable, 325mg Tablet)
C1
GNP Pain Relief Extra Strength (167mg/5ml Liquid, 500mg Tablet)
C1
GNP Pain Reliever Extra Strength (Tablet)C1
Goodsense Arthritis Pain (Tablet Extended-Release)
C1
Goodsense Pain & Fever Children's (Suspension)
C1
Goodsense Pain & Fever Infants (Suspension)
C1
Goodsense Pain Relief (Tablet Extended-Release)
C1
Goodsense Pain Relief Extra Strength (Tablet)
C1
Healthy Mama Shake That Ache (Tablet)C1
HM Acetaminophen Children's (Tablet Chewable)
C1
HM Arthritis Pain Relief (Tablet Extended-Release)
C1
HM Pain & Fever Children's (Suspension)C1
HM Pain & Fever Infants (Suspension)C1
HM Pain Relief (Tablet Extended-Release)C1
HM Pain Relief Extra Strength (Tablet)C1
HM Pain Reliever (Tablet)C1
HM Rapid Melts Junior (Tablet)C1
Infants Pain & Fever (Suspension)C1
KLS Acetaminophen Extra Strength (Tablet)
C1
KLS Rapid Release Pain Reliever (Tablet)C1
Liquid Pain Relief (Liquid)
OTC Drug NameC1
Little Remedies Fever/Pain Reliever Children's (Liquid)
C1
Little Remedies For Fevers Fever/Pain Reliever Children's (Liquid)
C1
Little Remedies For Fevers Fever/Pain Reliever Infant (Liquid)
C1
Mapap (500mg Capsule, 80mg Tablet Chewable, 160mg/5ml Liquid, 325mg Tablet, 500mg Tablet)
C1
Mapap Acetaminophen Extra Strength (Liquid)
C1
Mapap Arthritis Pain (Tablet Extended-Release)
C1
Mapap Children's (Suspension)C1
Mapap Children's (Tablet Chewable)C1
Mapap Children's (Tablet)C1
Mapap Extra Strength (Tablet)C1
Maxapap Maximum Strength (Tablet)C1
Maxapap Regular Strength (Tablet)C1
Medi-Tabs Children's (Elixir)C1
Medi-Tabs Extra Strength (Tablet)C1
Medi-Tabs Junor Strength (Tablet Chewable)
C1
Midol (Tablet Extended-Release)C1
Non-Aspirin Children's (Suspension)C1
Nortemp (Suspension)C1
Nortemp Infants (Suspension)C1
Pain & Fever (Tablet)C1
Pain & Fever Children's (Solution)C1
Pain & Fever Children's (Suspension)C1
Pain & Fever Children's (Tablet Chewable)C1
Pain & Fever Children's Dye-Free (Suspension)
C1
Pain & Fever Children's/Dye-Free (Suspension)
C1
Pain & Fever Extra Strength (Tablet)
121
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Pain & Fever Infants (Suspension)C1
Pain Relief (325mg Tablet, 500mg Tablet)C1
Pain Relief 8 Hour (Tablet Extended-Release)
C1
Pain Relief Children's (Suspension)C1
Pain Relief Extra Strength (Tablet)C1
Pain Relief Regular Strength (Tablet)C1
Pain Reliever (Liquid)C1
Pain Reliever (Tablet)C1
Pain Reliever Extra Strength (Tablet)C1
Pain Reliever/Fever Reducer Children's (Suppository)
C1
Pediacare Children (Suspension)C1
Pediacare Fever Reducer/Pain Reliever/Infant (Suspension)
C1
Pediacare Infants (Suspension)C1
Pharbetol (Tablet)C1
Pharbetol Extra Strength (Tablet)C1
PX Arthritis Pain Relief (Tablet Extended-Release)
C1
PX Children's Pain Relief (Suspension)C1
PX Pain Relief Extra Strength (Tablet)C1
QC Acetaminophen 8 Hours (Tablet Extended-Release)
C1
QC Arthritis Pain Relief (Tablet Extended-Release)
C1
QC Non-Aspirin Children's (Suspension)C1
QC Non-Aspirin Extra Strength (Tablet)C1
QC Non-Aspirin Jr Strength (Tablet)C1
QC Pain Relief (Tablet)C1
QC Pain Relief Children's (Suspension)C1
QC Pain Relief Extra Strength (Tablet)C1
QC Pain Relief Infants (Suspension)C1
RA 8 Hour Pain Relief (Tablet Extended-Release)
C1
RA Acetaminophen (Tablet)
OTC Drug NameC1
RA Acetaminophen Children's (Tablet Chewable)
C1
RA Acetaminophen ER (Tablet Extended-Release)
C1
RA Acetaminophen Extra Strength (Tablet)C1
RA Acetaminophen Rapid Melts Children's (Tablet Disintegrating)
C1
RA Acetaminophen Rapid Melts Junior (Tablet Disintegrating)
C1
RA Arthritis Pain Relief (Tablet Extended-Release)
C1
RA Arthritis Pain Relief Acetaminophen (Tablet Extended-Release)
C1
RA Fever Reducer & Pain Reliever Infants (Suspension)
C1
RA Fever Reducer/Pain Reliever Children's (Suspension)
C1
RA Fever Reducer/Pain Reliever Infants (Suspension)
C1
RA Pain Relief Acetaminophen (Tablet)C1
RA Pain Reliever Extra Strength Adult (Liquid)
C1
SB Arthritis Pain Relief (Tablet Extended-Release)
C1
SB Pain Reliever Children's (Suspension)C1
SB Pain Reliever Extra Strength (Tablet)C1
SM 8 Hour Pain Relief (Tablet Extended-Release)
C1
SM Arthritis Pain Relief (Tablet Extended-Release)
C1
SM Arthritis Pain Reliever (Tablet Extended-Release)
C1
SM Pain & Fever Children's (Suspension)C1
SM Pain & Fever Infants (Suspension)C1
SM Pain Relief Extra Strength (Tablet)C1
SM Pain Reliever (Tablet)
122
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
SM Pain Reliever Extra Strength (500mg Capsule, 500mg Tablet, 650mg Tablet Extended-Release)
C1
SM Rapid Melts Junior (Tablet)C1
Tactinal (Tablet)C1
Tactinal Extra Strength (Tablet)C1
TGT Acetaminophen Children's (Suspension)
C1
TGT Acetaminophen Extra Strength (Tablet)
C1
TGT Acetaminophen Extra Strength Quick Release (Tablet)
C1
TGT Acetaminophen Melts Children's (Tablet Disintegrating)
C1
TGT Arthritis Pain Relief (Tablet Extended-Release)
C1
TGT Children's Acetaminophen (Suspension)
C1
TGT Pain Reliever Jr Strength Melts (Tablet Disintegrating)
B1
Analgesics, TopicalC1
Arthritis Pain Relieving (Cream)C1
Aspercreme Warming Pain Relief Patch (Pad)
C1
Capsagel (Gel)C1
Capsagel Extra Strength (Gel)C1
Capsagel Maximum Strength (Gel)C1
Capsaicin (Cream)C1
Capsaicin Hot Patch (Pad)C1
Capsaicin HP (Cream)C1
Capzasin-HP (Cream)C1
Capzasin-P (Cream)C1
Castiva Warming (Lotion)C1
CVS Capsaicin HP (Cream)C1
CVS Medicated Heat Patch (Pad)C1
GNP Capsaicin (0.1% Cream)
OTC Drug NameC1
GNP Capsaicin (0.15% Liquid)C1
RA Capsicum Hot Patch (Pad)C1
Sure Result Sr Relief (Cream)C1
Zostrix High Potency (Cream)C1
Zostrix High Potency Footpain Relief (Cream)
C1
Zostrix Natural Pain Relief (Cream)C1
Zostrix-HPB1
Non-Steroidal Anti Inflammatory Drugs (NSAIDs)
C1
Adult Aspirin Regimen (Tablet)C1
Addaprin (Tablet)C1
Adult Aspirin EC Low Strength (Tablet Delayed-Release)
C1
Advil Junior Strength (Tablet)C1
All Day Pain Relief (Tablet)C1
All Day Relief (Tablet)C1
Aspirin (120mg Suppository, 200mg Suppository, 300mg Suppository, 600mg Suppository, 325mg Tablet, 325mg Tablet Delayed-Release, 81mg Tablet Delayed-Release)
C1
Aspirin (81mg Tablet Chewable)C1
Aspirin 81 (Tablet Delayed-Release)C1
Aspirin 81 Low Dose (Tablet Chewable)C1
Aspirin Adult (Tablet)C1
Aspirin Adult Low Dose (81mg Tablet Chewable, 81mg Tablet Delayed-Release)
C1
Aspirin Adult Low Strength (Tablet Chewable)
C1
Aspirin Children's (Tablet Chewable)C1
Aspirin DR (Tablet Delayed-Release)C1
Aspirin EC (Tablet Delayed-Release)C1
Aspirin EC Low Dose (Tablet Delayed-Release)
C1
Aspirin Enteric Coated Adult Low Strength (Tablet Delayed-Release)
123
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Aspirin Low Dose (Tablet Chewable)C1
Aspirin Low Dose (Tablet Delayed-Release)C1
Aspirin Low Strength (Tablet Chewable)C1
Aspirin Regimen Low Dose/Adult (Tablet Delayed-Release)
C1
Aspirin Regular Strength (Tablet Delayed-Release)
C1
Aspir-Low (Tablet Delayed-Release)C1
Aspirtab (Tablet Delayed-Release)C1
Aspirtab Maximum Strength (Tablet)C1
Bayer Advanced Aspirin Extra Strength
(Tablet)C1
Bayer Advanced Aspirin Regular Strength (Tablet)
C1
Bayer Aspirin (Tablet Delayed-Release)C1
Bayer Aspirin (Tablet)C1
Bayer Aspirin EC Low Dose (Tablet Delayed-Release)
C1
Bayer Aspirin Extra Strength (Tablet)C1
Bayer Low Dose (Tablet Delayed-Release)C1
Bayer Plus (Tablet)C1
Careall Aspirin (Tablet Chewable)C1
Children's Aspirin (Tablet Chewable)C1
Children's Aspirin Free (Elixir)C1
Children's Aspirin Low Strength (Tablet Chewable)
C1
Children's Non-Aspirin (Suspension)C1
Children's Non-Aspirin (Tablet Chewable)C1
CVS All Day Pain Relief (Tablet)C1
CVS Aspirin (Tablet Delayed-Release)C1
CVS Aspirin (Tablet)C1
CVS Aspirin Adult Low Dose (Tablet Chewable)
C1
CVS Aspirin Adult Low Strength (Tablet Delayed-Release)
C1
CVS Aspirin Ec (Tablet Delayed-Release)
OTC Drug NameC1
CVS Aspirin Low Dose (Tablet Delayed-Release)
C1
CVS Aspirin Low Strength (Tablet Delayed-Release)
C1
CVS Childs Non-Aspirin (Tablet Chewable)C1
CVS Ibuprofen (Capsule)C1
CVS Ibuprofen (Tablet)C1
CVS Ibuprofen IB (Tablet)C1
CVS Ibuprofen Infants (Suspension)C1
CVS Ibuprofen Junior Strength (Tablet Chewable)
C1
CVS Ibuprofen Liquid Filled (Capsule)C1
CVS Naproxen Sodium (Capsule)C1
CVS Naproxen Sodium (Tablet)C1
CVS Non-Aspirin Children's (Tablet Chewable)
C1
CVS Non-Aspirin Extra Strength (Tablet)C1
Dyspel (Tablet)C1
EC-81 Aspirin (Tablet Delayed-Release)C1
Ecotrin (Tablet Delayed-Release)C1
Ecotrin Low Strength (Tablet Delayed-Release)
C1
Ecotrin Maximum Strength (Tablet
Delayed-Release)C1
Ecpirin (Tablet Delayed-Release)C1
Enovarx-Ibuprofen (Cream)C1
Enteric Coated Aspirin (Tablet Delayed-Release)
C1
EQ Adult Aspirin Low Strength (Tablet Delayed-Release)
C1
EQ All Day Pain Relief (Tablet)C1
EQ Aspirin (Tablet Delayed-Release)C1
EQ Aspirin Adult Low Dose (Tablet Delayed-Release)
C1
EQ Aspirin EC (Tablet Delayed-Release)C1
EQ Aspirin Low Dose (Tablet Chewable)
124
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
EQ Aspirin Low Dose (Tablet Delayed-Release)
C1
EQ Children's Aspirin (Tablet Chewable)C1
EQ Ibuprofen (Capsule)C1
EQ Ibuprofen (Tablet)C1
EQ Ibuprofen Infants (Suspension)C1
EQ Ibuprofen Junior Strength (Tablet Chewable)
C1
EQ Naproxen Sodium (Capsule)C1
EQ Naproxen Sodium (Tablet)C1
EQL Aspirin (Tablet)C1
EQL Aspirin EC (Tablet Delayed-Release)C1
EQL Aspirin Low Dose (Tablet Chewable)C1
EQL Aspirin Low Dose (Tablet Delayed-Release)
C1
EQL Ibuprofen (Capsule)C1
EQL Ibuprofen (Tablet)C1
EQL Ibuprofen Infants (Suspension)C1
EQL Ibuprofen Junior Strength (Tablet Chewable)
C1
EQL Naproxen Sodium (Capsule)C1
EQL Naproxen Sodium (Tablet)C1
Flanax Pain Relief (Tablet)C1
Genpril (Tablet)C1
GNP Adult Aspirin Low Strength (Tablet Chewable)
C1
GNP Aspirin (325mg Tablet, 81mg Tablet Delayed-Release, 325mg Delayed-Release)
C1
GNP Aspirin Low Dose (Tablet Delayed-Release)
C1
GNP Ibuprofen (200mg Capsule, 200mg Tablet)
C1
GNP Ibuprofen Infants (Suspension)C1
GNP Ibuprofen Junior Strength (Tablet Chewable)
C1
GNP Naproxen (Tablet)
OTC Drug NameC1
GNP Naproxen Sodium (220mg Capsule, 220mg Tablet)
C1
Goodsense Aspirin (81mg Tablet Chewable, 325mg Tablet)
C1
Goodsense Aspirin Adult Low Strength (Tablet Chewable)
C1
Goodsense Aspirin Low Dose (Tablet Delayed-Release)
C1
Goodsense Ibuprofen (Tablet)C1
Goodsense Ibuprofen Infants (Suspension)C1
Goodsense Ibuprofen Junior Strength (Tablet Chewable)
C1
Goodsense Naproxen Sodium (Tablet)C1
H-E-B Aspirin (Tablet Delayed-Release)C1
HM Aspirin (81mg Tablet Chewable, 325mg Tablet)
C1
HM Aspirin EC (Tablet Delayed-Release)C1
HM Aspirin EC Low Dose (Tablet Delayed-Release)
C1
HM Ibuprofen (Capsule)C1
HM Ibuprofen (Tablet Chewable)C1
HM Ibuprofen (Tablet)C1
HM Ibuprofen IB (Tablet)C1
HM Ibuprofen IB/Junior Strength (Tablet Chewable)
C1
HM Ibuprofen Infants (Suspension)C1
HM Naproxen Sodium (220mg Capsule, 220mg Tablet)
C1
Hy-Vee All Day Relief (Tablet)C1
Ibu-200 (Tablet)C1
Ibu-Drops Infants (Suspension)C1
Ibuprofen (200mg Capsule, 200mg Tablet)C1
Ibuprofen 100 Junior Strength (Tablet Chewable)
C1
Ibuprofen 200 (Tablet)C1
Ibuprofen Infants (Suspension)
125
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Ibuprofen Infants Drops (Suspension)C1
Ibuprofen Junior Strength (Tablet Chewable)
C1
Ibuprofen Lysine (Solution)C1
Infants Ibuprofen (Suspension)C1
I-Prin (Tablet)C1
KLS Aspirin EC (Tablet Delayed-Release)C1
KLS Aspirin Low Dose (Tablet Delayed-Release)
C1
KLS Ibuprofen (Tablet)C1
KLS Naproxen Sodium (Tablet)C1
KP Aspirin (Tablet Delayed-Release)C1
KS Ibuprofen (Capsule)C1
Medi-Profen (Capsule)C1
Medi-Profen (Suspension)C1
Medi-Profen (Tablet)C1
Mediproxen (Tablet)C1
Medique Aspirin (Tablet)C1
Meijer Aspirin EC (Tablet Delayed-Release)C1
Meijer Aspirin Free (Tablet)C1
Meijer Ibuprofen (Tablet)C1
Meijer Jr Strength Aspirin Free (Tablet Chewable)
C1
Miniprin Low Dose (Tablet Delayed-Release)
C1
MM Aspirin (Tablet)C1
Motrin IB (Capsule)C1
Naproxen Sodium (Capsule)C1
Naproxen Sodium (Tablet)C1
Naproxen Sodium CR (Tablet Extended-Release)
C1
Naproxen Sodium ER (Tablet Extended-Release)
C1
Non-Aspirin (Tablet)C1
Non-Aspirin Extra Strength (Tablet)
OTC Drug NameC1
Non-Aspirin Junior Strength (Tablet Chewable)
C1
Non-Aspirin Pain Relief (Tablet)C1
Non-Aspirin Pain Relief Extra Strength (Tablet)
C1
Norwich Aspirin (Tablet)C1
Pamprin All Day Maximum Strength (Tablet)
C1
Provil (Tablet)C1
PX All Day Relief (Tablet)C1
PX Aspirin (Tablet Chewable)C1
PX Aspirin (Tablet)C1
PX Enteric Aspirin (Tablet Delayed-Release)
C1
PX Ibuprofen (Tablet)C1
PX Ibuprofen Junior Strength (Tablet Chewable)
C1
PX Infants Profen IB (Suspension)C1
QC Aspirin (Tablet)C1
QC Aspirin Low Dose (Tablet Delayed-Release)
C1
QC Chewable Aspirin Low Dose (Tablet Chewable)
C1
QC Children's Aspirin (Tablet Chewable)C1
QC Enteric Aspirin (Tablet Delayed-Release)
C1
QC Ibuprofen (Tablet)C1
QC Ibuprofen IB (Tablet)C1
QC Ibuprofen Infants (Suspension)C1
QC Naproxen Sodium (Tablet)C1
QC Non-Aspirin 8 Hour (Tablet Extended-Release)
C1
RA Aspirin (Tablet)C1
RA Aspirin Adult Low Dose (Tablet Chewable)
C1
RA Aspirin Adult Low Strength (Tablet Chewable)
126
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
RA Aspirin Children's (Tablet Chewable)C1
RA Aspirin EC (Tablet Delayed-Release)C1
RA Aspirin EC Adult Low Strength (Tablet Delayed-Release)
C1
RA Children's Aspirin (Tablet Chewable)C1
RA Children's Non-Aspirin (Suspension)C1
RA Ibuprofen (Capsule)C1
RA Ibuprofen (Tablet)C1
RA Ibuprofen Infants (Suspension)C1
RA Ibuprofen Junior Strength (Tablet Chewable)
C1
RA Naproxen Sodium (Capsule)C1
RA Naproxen Sodium (Tablet)C1
RA Pain Relief Aspirin (Tablet)C1
RA Pain Relief Ibuprofen (Tablet)C1
SB Aspirin (Tablet)C1
SB Aspirin Adult Low Strength (Tablet Delayed-Release)
C1
SB Aspirin EC (Tablet Delayed-Release)C1
SB Children's Aspirin (Tablet Chewable)C1
SB Children's Non-Aspirin (Tablet Disintegrating)
C1
SB Ibuprofen (Tablet)C1
SB Infants Ibuprofen (Suspension)C1
SB Low Dose ASA EC (Tablet Delayed-Release)
C1
SB Naproxen Sodium (Tablet)C1
SB Non-Aspirin (Tablet Chewable)C1
SB Non-Aspirin (Tablet)C1
SB Non-Aspirin Extra Strength (Tablet)C1
SB Non-Aspirin Jr Strength (Tablet Disintegrating)
C1
SM Aspirin (Tablet)C1
SM Aspirin Adult Low Strength (81mg Tablet Chewable, 81mg Tablet Delayed-Release)
OTC Drug NameC1
SM Aspirin EC Low Strength (Tablet Delayed-Release)
C1
SM Aspirin Enteric Coated (Tablet Delayed-Release)
C1
SM Aspirin Low Dose (Tablet Chewable)C1
SM Children's Aspirin (Tablet Chewable)C1
SM Ibuprofen (200mg Capsule, 200mg Tablet)
C1
SM Ibuprofen IB (100mg Tablet Chewable, 200mg Tablet)
C1
SM Ibuprofen Jr (Tablet)C1
SM Infants Ibuprofen (Suspension)C1
SM Naproxen Sodium (Tablet)C1
St Joseph Aspirin (Tablet Delayed-Release)C1
St Joseph Low Dose Aspirin (Tablet Chewable)
C1
TGT Aspirin (Tablet Chewable)C1
TGT Aspirin (Tablet Delayed-Release)C1
TGT Aspirin (Tablet)C1
TGT Aspirin Low Dose (Tablet Delayed-Release)
C1
TGT Children's Aspirin (Tablet Chewable)C1
TGT Enteric-Coated Aspirin (Tablet Delayed-Release)
C1
TGT Ibuprofen (Capsule)C1
TGT Ibuprofen (Tablet)C1
TGT Ibuprofen Junior Strength (Tablet Chewable)
C1
TGT Infants Ibuprofen (Suspension)C1
TGT Naproxen Sodium (Capsule)C1
TGT Naproxen Sodium (Tablet)C1
Wal-Profen (Capsule)C1
Wal-Profen (Tablet)A1
Anti-Addiction/Substance Abuse Treatment Agents
B1
Smoking Cessation Agents
127
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
CVS Nicotine (Gum)C1
CVS Nicotine Lozenge (Lozenge)C1
CVS Nicotine Polacrilex (Gum)C1
CVS Nicotine Polacrilex (Lozenge)C1
CVS Nicotine Polacrilex Starter (Gum)C1
CVS Nicotine Transdermal System (Patch)C1
CVS Nicotine Transdermal System Step 1 (Patch)
C1
CVS Nicotine Transdermal System Step 2 (Patch)
C1
CVS Nicotine Transdermal System/Step 3 (Patch)
C1
EQ Nicotine (Lozenge)C1
EQ Nicotine (Patch)C1
EQ Nicotine Gum Refill (Gum)C1
EQ Nicotine Gum Starter (Gum)C1
EQ Nicotine Lozenges (Lozenge)C1
EQ Nicotine Polacrilex (Gum)C1
EQ Nicotine Polacrilex (Lozenge)C1
EQ Nicotine Step 3 (Patch)C1
EQL Nicotine Polacrilex (Gum)C1
EQL Nicotine Polacrilex (Lozenge)C1
GNP Nicotine Gum (Gum)C1
GNP Nicotine Mini Lozenge (Lozenge)C1
GNP Nicotine Polacrilex (Gum)C1
GNP Nicotine Polacrilex (Lozenge)C1
GNP Nicotine Polacrilex Mini (Lozenge)C1
GNP Nicotine Transdermal System (Patch)C1
GNP Nicotine Transdermal System Step 2 (Patch)
C1
Goodsense Nicotine (Lozenge)C1
Goodsense Nicotine Gum (Gum)C1
Goodsense Nicotine Polacrilex (Lozenge)C1
HM Nicotine Polacrilex (Gum)C1
HM Nicotine Polacrilex (Lozenge)
OTC Drug NameC1
HM Nicotine Transdermal System (Patch)C1
HM Nicotine Transdermal System Step 1 (Patch)
C1
HM Nicotine Transdermal System Step 2 (Patch)
C1
HM Nicotine Transdermal System Step 3 (Patch)
C1
KLS Quit2 (Gum)C1
KLS Quit2 (Lozenge)C1
KLS Quit4 (Gum)C1
KLS Quit4 (Lozenge)C1
Nicorelief (Gum)C1
Nicotine (Gum)C1
Nicotine (Lozenge)C1
Nicotine (Patch)C1
Nicotine Mini Lozenge (Lozenge)C1
Nicotine Polacrilex (Gum)C1
Nicotine Polacrilex (Lozenge)C1
Nicotine Polacrilex Refill (Gum)C1
Nicotine Polacrilex Starter Kit (Gum)C1
Nicotine Step 1 (Patch)C1
Nicotine Step 2 (Patch)C1
Nicotine Step 3 (Patch)C1
Nicotine Transdermal System (Patch)C1
Nicotine Transdermal System Step 1 (Patch)
C1
Nicotine Transdermal System Step 2 (Patch)
C1
Nicotine Transdermal System Step 3 (Patch)
C1
PX Stop Smoking Aid (Gum)C1
PX Stop Smoking Aid (Lozenge)C1
RA Mini Nicotine (Lozenge)C1
RA Nicotine (Gum)C1
RA Nicotine (Patch)
128
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
RA Nicotine Gum (Gum)C1
RA Nicotine Polacrilex (Gum)C1
RA Nicotine Polacrilex (Lozenge)C1
RA Nicotine Transdermal System (Patch)C1
RA Nicotine Transdermal System Step 3 (Patch)
C1
SM Nicotine (Gum)C1
SM Nicotine (Lozenge)C1
SM Nicotine Polacrilex (Gum)C1
SM Nicotine Polacrilex (Lozenge)C1
SM Nicotine Transdermal System (Patch)C1
SM Nicotine Transdermal System/Step 1/Clear (Patch)
C1
SM Nicotine Transdermal System/Step 2/Clear (Patch)
C1
SM Nicotine Transdermal System/Step 3/Clear (Patch)
C1
Sr Nicotine Gum (Gum)C1
TGT Nicotine Gum (Gum)C1
TGT Nicotine Polacrilex (Gum)C1
TGT Nicotine Polacrilex (Lozenge)C1
TGT Nicotine Step One (Patch)C1
TGT Nicotine Step Three (Patch)C1
TGT Nicotine Step Two (Patch)C1
Thrive (Gum)A1
Antimicrobial AgentsB1
Antimicrobials, TopicalC1
Alevazol (Ointment)C1
Aloe Vesta Clear Antifungal (Ointment)C1
Antibiotic + Pain Relief Maximum Strength (Cream)
C1
Antifungal (1% Aerosol, 1% Cream, 2% Cream)
C1
Anti-Fungal Powder (Powder)C1
Antiseptic Skin Cleanser (Solution)C1
Aplicare Povidone/Iodine (Solution)
OTC Drug NameC1
Aplicare Povidone-Iodine Scrub (Solution)C1
Athletes Foot Antifungal Powder Spray (Aerosol Powder)
C1
Athletes Foot Powder (Powder)C1
Athletes Foot Powder Spray (Aerosol Powder)
C1
Athletes Foot Spray (Aerosol)C1
Bacitracin (Ointment)C1
Bacitracin Zinc (Ointment)C1
Bacitracin/Neomycin/Polymyxin (Ointment)
C1
Bacitracin/Polymyxin (Ointment)C1
Bacitraycin Plus (Ointment)C1
Band-Aid Plus Antibiotic (Pad)C1
Band-Aid Plus Antibiotic/Extra Large
(Pad)C1
Baza Antifungal (Cream)C1
Betadine (Solution)C1
Betadine Surgical Scrub (Solution)C1
Betadine Swabsticks (Swab)C1
Betasept Surgical Scrub (Liquid)C1
Biopatch Antimicrobial Dressing/1"
Disk/4Mm Hole C1
Biopatch Antimicrobial Dressing/1"
Disk/7Mm Hole C1
Biopatch Antimicrobial Dressing/3/4"
Disk/1.5Mm Hole C1
Biopatch Protective Disk With Chg/
1"Disk/4Mm Hole C1
Blis-To-Sol (Solution)C1
Carrington Antifungal (Cream)C1
Cavilon (Cream)C1
Chlorhexidine Gluconate (2% Liquid,
20% Solution)C1
Chlorhexidine Gluconate Cloth (Pad)C1
Clorox Nasal Antiseptic Swabs (Swabs)
129
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Clotrimazole-7 (Cream)C1
Critic-Aid Clear AF (Ointment)C1
Cruex Prescription Strength (Aerosol Powder)
C1
Curad Triple Antibiotic (Ointment)C1
CVS 3-Day Vaginal Cream (Cream)C1
CVS Af Spray Powder (Aerosol Powder)C1
CVS Antibiotic (Ointment)C1
CVS Antibiotic Plus (Cream)C1
CVS Antifungal (Cream)C1
CVS Anti-Fungal Powder (Powder)C1
CVS Antiseptic Skin Cleanser (Solution)C1
CVS Athletes Foot Powder Spray (Aerosol Powder)
C1
CVS Bacitracin (Ointment)C1
CVS Clotrimazole 3 (Cream)C1
CVS Foot & Sneaker Powder Spray (Aerosol Powder)
C1
CVS Hand Wash Advanced Antibacterial (Solution)
C1
CVS Hydrogen Peroxide (Solution)C1
CVS Peroxide Sore Mouth Cleanser (Solution)
C1
CVS Poly Bacitracin (Ointment)C1
CVS Povidone-Iodine (Solution)C1
CVS Triple Antibiotic (Ointment)C1
Dermafungal (Ointment)C1
Desenex (Powder)C1
Desenex Jock Itch Spray Powder (Aerosol Powder)
C1
Desenex Shake Powder (Powder)C1
Double Antibiotic (Ointment)C1
Dr G's Clear Nail (Solution)C1
Dyna-Hex 2 (Solution)C1
Dyna-Hex 4 (Solution)
OTC Drug NameC1
Ear Dry (Liquid)C1
EQ Antibiotic + Pain Relief Maximum Strength (Cream)
C1
EQ Athletes Foot (Aerosol Powder)C1
EQ Athletes Foot (Cream)C1
EQ Athletes Foot Powder Spray (Aerosol Powder)
C1
EQ Bacitracin Zinc (Ointment)C1
EQ First Aid Antiseptic (Solution)C1
EQ Hydrogen Peroxide (Solution)C1
EQ Povidone-Iodine (Solution)C1
EQ Tolnaftate (Aerosol)C1
EQ Triple Antibiotic (Ointment)C1
EQL Antibiotic + Pain Relief Maximum Strength (Cream)
C1
EQL Antifungal (Cream)C1
EQL Bacitracin Zinc (Ointment)C1
EQL First Aid Antibiotic (Ointment)C1
EQL Hydrogen Peroxide (Solution)C1
First Aid Antibiotic (Ointment)C1
Foot Repair Serum (Solution)C1
Fungal Nail Eraser (Solution)C1
Fungi-Guard (Cream)C1
Fungoid Tincture (2% Kit, 2% Solution)C1
Fungoid-D (Cream)C1
GNP Antibiotic Plus Pramoxine (Cream)C1
GNP Antiseptic Skin Cleanser (Solution)C1
GNP Athlete's Foot Relief (Aerosol Powder)C1
GNP Bacitracin Zinc (Ointment)C1
GNP Hydrogen Peroxide (Solution)C1
GNP Hydrogen Peroxide Wipes C1
GNP Iodides Tincture (Tincture)C1
GNP Iodine Tincture (Tincture)C1
GNP Miconazole Nitrate (Aerosol Powder)
130
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
GNP Miconazorb AF (Powder)C1
GNP Povidone-Iodine (Solution)C1
GNP Tolnaftate (Cream)C1
GNP Triple Antibiotic (Ointment)C1
Goodsense Hydrogen Peroxide (Solution)C1
HM Antiseptic Skin Cleanser (Solution)C1
HM Bacitracin (Ointment)C1
HM Double Antibiotic (Ointment)C1
HM Hydrogen Peroxide (Solution)C1
HM Iodides Tincture (Tincture)C1
HM Iodine Tincture (Tincture)C1
HM Povidone-Iodine (Solution)C1
HM Triple Antibiotic (Ointment)C1
Hydrogen Peroxide (Solution)C1
Hydrogen Peroxide Spray (Solution)C1
Hylamend First Aid Antiseptic (Gel)C1
Instaclean (Liquid)C1
Iodex (Ointment)C1
Iodides Tincture (Tincture)C1
Iodine Tincture (Tincture)C1
Iodine Tincture Mild (Tincture)C1
Iodine Tincture Strong (Tincture)C1
Iodine Tincture Strong Decolorized
(Tincture)C1
Iso-Blu (Liquid)C1
Isopropyl Alcohol Spray C1
Jock Itch Spray (Aerosol Powder)C1
Jock Itch Spray Powder (Aerosol Powder)C1
Kelp (Tablet)C1
KP Bacitracin Zinc (Ointment)C1
KP Double Antibiotic (Ointment)C1
KP Miconazole Nitrate (Cream)C1
KP Tolnaftate (Cream)C1
Lamisil AF Defense (Aerosol Powder)
OTC Drug NameC1
Lanabiotic (Ointment)C1
Lotrimin AF (Aerosol)C1
Lotrimin AF Deodorant Powder (Aerosol Powder)
C1
Lotrimin AF Jock Itch Powder (Aerosol Powder)
C1
Lotrimin AF Powder (Aerosol Powder)C1
Lugols Strong Iodine (Tincture)C1
Medicated Anti-Fungal (Solution)C1
Medi-First Triple Antibiotic (Ointment)C1
Meijer Hydrogen Peroxide (Solution)C1
Meijer Triple Antibiotic (Ointment)C1
Micaderm (Cream)C1
Miconazole (Cream)C1
Miconazole Antifungal (Cream)C1
Miconazole Nitrate (Cream)C1
Micro Guard (Powder)C1
Multi Antibiotic Plus (Cream)C1
Mycocide Clinical NS Antifungal Treatment (Solution)
C1
Odor Control Foot & Sneaker Spray (Aerosol Powder)
C1
Odor Eaters Antifungal (Powder)C1
Odor Eaters Foot & Sneaker Spray (Aerosol Powder)
C1
Operand Chlorhexidine Gluconate (Liquid)C1
Perox-A-Mint (Solution)C1
Peroxyl Oral Spot Treatment (Gel)C1
Podactin (Cream)C1
Podactin Powder (Powder)C1
Poly Bacitracin (Ointment)C1
Polysporin (Ointment)C1
Povidone Iodine (Solution)C1
Povidone/Iodine Swabsticks (Swabs)
131
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Povidone-Iodine (10% Ointment, 10% Solution)
C1
Povidone-Iodine Antiseptic (Swabs)C1
Povidone-Iodine Antiseptic Swabsticks (Swabs)
C1
Povidone-Iodine Paint Sponge Swabstick (Swabs)
C1
PVP Prep (Solution)C1
PX Hydrogen Peroxide (Solution)C1
PX Triple Ointment (Ointment)C1
QC Bacitracin (Ointment)C1
QC Hydrogen Peroxide (Solution)C1
QC Iodides Tincture (Tincture)C1
QC Iodine Tincture (Tincture)C1
QC Povidone Iodine (Solution)C1
QC Tolnaftate (Cream)C1
RA Antibiotic Plus (Cream)C1
RA Antifungal (Cream)C1
RA Antifungal Spray (Aerosol)C1
RA Antiseptic (Solution)C1
RA Antiseptic Skin Cleanser (Solution)C1
RA Athletes Foot (Cream)C1
RA Athletes Foot Powder Spray (Aerosol Powder)
C1
RA Bacitracin (Ointment)C1
RA Bacitracin Zinc First Aid (Ointment)C1
RA Clotrimazole 3 (Cream)C1
RA Clotrimazole 7 (Cream)C1
RA Double Antibiotic (Ointment)C1
RA First Aid Iodine (Tincture)C1
RA Foot Care Antifungal (Cream)C1
RA Hydrogen Peroxide (Solution)C1
Ra Hydrogen Peroxide Wipes C1
RA Jock Itch Maximum Strength Powder (Aerosol Powder)
OTC Drug NameC1
RA Povidone Iodine (Ointment)C1
RA Triple Antibiotic (Ointment)C1
RA Triple Antibiotic Spray (Aerosol)C1
Remedy Antifungal (Cream)C1
Remedy Antifungal Clear/Phytoplex (Ointment)
C1
Remedy Phytoplex Antifungal (Powder)C1
SB Anti-Fungal (Cream)C1
SB Bacitracin (Ointment)C1
SB Povidone-Iodine (Solution)C1
SB Triple Antibiotic (Ointment)C1
Secura Antifungal (Cream)C1
Secura Antifungal Extra Thick (Cream)C1
SM Antibiotic (Ointment)C1
SM Antibiotic Plus Pain Relief Maximum Strength (Cream)
C1
SM Antifungal Miconazole (Cream)C1
SM Antifungal Tolnaftate (Cream)C1
SM Double Antibiotic (Ointment)C1
SM Hydrogen Peroxide (Solution)C1
SM Iodides Tincture (Tincture)C1
SM Iodine Tincture (Tincture)C1
SM Povidone-Iodine (Solution)C1
SM Swimmers Ear Drops (Otic Solution)C1
SM Triple Antibiotic (Ointment)C1
SM Triple Antibiotic Original Strength (Ointment)
C1
Soothe & Cool Inzo Antifungal Cream (Cream)
C1
Soothe (Tablet Chewable)C1
Swim Ear (Liquid)C1
Swimmers Ear Drops (Otic Solution)C1
Swimmers Instant Ear Dry (Otic Solution)C1
Tegaderm Chg Dressing/2-3/4"X3-3/8" C1
Tegaderm Chg Dressing/3-1/2"X4-1/2"
132
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Tegaderm Chg Dressing/4"X4-3/4" C1
Tegaderm Chg Dressing/4"X6-1/8" C1
Tetterine (Ointment)C1
TGT Antifungal (Cream)C1
TGT Antifungal Spray Powder (Aerosol Powder)
C1
TGT First Aid Antibiotic Maximum Strength (Cream)
C1
TGT Hydrogen Peroxide (Solution)C1
The Treatment Formula 3 (Solution)C1
Tinaspore (Solution)C1
Tineacide (Cream)C1
Tolnaftate (1% Cream, 1% Powder)C1
Triple Antibiotic (Ointment)C1
Triple Antibiotic First Aid (Ointment)C1
Triple Paste AF (Ointment)C1
Wal-Sporin (Ointment)C1
Zeasorb-AF (Powder)B1
Antimicrobials, VaginalC1
3 Day Vaginal (Cream)C1
Clotrimazole (Cream)C1
Clotrimazole 3 (Cream)C1
GNP Clotrimazole 3 (Cream)C1
SM 3-Day Vaginal (Cream)C1
SM Clotrimazole Vaginal (Cream)A1
AntiparasiticsB1
Anthelmintic AgentsC1
CVS Pinworm Treatment (Suspension)C1
Pinworm Medicine (Suspension)C1
Reeses Pinworm Medicine (144mg/ml Suspension)
C1
Reeses Pinworm Medicine (180mg
Tablet)B1
Pediculicides/ScabicidesC1
Bedding Spray Lice Treat Ment (Aerosol)
OTC Drug NameC1
Bedding Spray Lice Treatment Step 3 (Aerosol)
C1
CVS Bedding Spray Lice Treatment (Aerosol)
C1
CVS Lice Killing (Shampoo)C1
CVS Lice Treatment (Rinse)C1
EQ Lice Killing Maximum Strength (Shampoo)
C1
EQL Lice Killing Maximum Strength (Shampoo)
C1
GNP Lice Bedding (Aerosol)C1
GNP Lice Treatment (1% Rinse, 0.33-4% Shampoo)
C1
HM Lice Killing Maximum Strength (Shampoo)
C1
HM Lice Treatment (Rinse)C1
Lice Killing Maximum Strength (Shampoo)C1
Lice Killing Shampoo (Shampoo)C1
Lice Treatment (Lotion)C1
Lice Treatment Creme Rinse (Liquid)C1
LiceMD Complete Kit (Gel)C1
Licide (Aerosol)C1
Licide Maximum Strength (Liquid)C1
RA Lice Bedding (Aerosol)C1
RA Lice Maximum Strength (Shampoo)C1
RA Lice Treatment (Lotion)C1
Rid Lice Killing Shampoo (Shampoo)C1
SB Lice Killing Maximum Strength (Shampoo)
C1
SB Lice Treatment (Liquid)C1
SB Lice Treatment (Rinse)C1
SM Bedding Lice Treatment (Aerosol)C1
SM Lice Killing (Liquid)C1
SM Lice Killing Maximum Strength (Shampoo)
C1
SM Lice Treatment (Lotion)
133
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Stop Lice (Aerosol)C1
Stop Lice Maximum Strength (Liquid)C1
Stop Lice Step 3 (Aerosol)C1
TGT Lice Killing Maximum Strength (Shampoo)
C1
Vanalice (Gel)A1
Dermatological AgentsB1
Dermatologic Agents, TopicalC1
Acne Maximum Strength (Cream)C1
Acne Foaming Wash (Liquid)C1
Acne Medication 10 (Gel)C1
Acne Medication 10 (Lotion)C1
Acne Medication 5 (Gel)C1
Acne Medication 5 (Lotion)C1
Acne Treatment Cleansing Bar Maximum Strength
C1
Acne Treatment Gel (Gel)C1
Acne-Clear (Gel)C1
Acnefree 24 Hour Acne Clearing System C1
Acnefree Severe 24 Hour Clearing
System C1
Advanced Acne Wash (Liquid)C1
Anti-Dandruff Shampoo (Lotion)C1
Anti-Itch Intensive Healing (Lotion)C1
Aquanil HC (Lotion)C1
Baby Diaper Rash Cream (Cream)C1
Baby Ease (Ointment)C1
Baby Vitamin A & D (Ointment)C1
Baza Clear (Ointment)C1
Benzefoam (Foam)C1
Benzefoam Ultra (Foam)C1
Benzefoamultra (Foam)C1
Benzepro (Foam)C1
Benzepro Creamy Wash (Liquid)C1
Benzepro Foaming Cloths (Cloth)
OTC Drug NameC1
Benzepro Short Contact (Foam)C1
Benziq (Gel)C1
Benziq LS (Gel)C1
Benziq Wash (Liquid)C1
Benzoyl Peroxide (5% Gel)C1
Benzoyl Peroxide (5.3% Foam, 9.8% Foam, 10% Gel, 2.5% Gel, 6.5% Gel)
C1
Benzoyl Peroxide Cleanser (3% Lotion,
9% Lotion)C1
Benzoyl Peroxide Cleanser (Liquid)C1
Benzoyl Peroxide Wash (10% Liquid, 5% Liquid)
C1
Beta HC (Lotion)C1
Boudreauxs Butt Paste Maximum Strength (Ointment)
C1
BP Foam (5.3% Foam, 9.8% Foam)C1
BP Foaming Wash (Liquid)C1
BP Gel (Gel)C1
BP Wash (2.5% Liquid, 7% Liquid)C1
BPO (4% Gel, 8% Gel)C1
BPO 6% Foaming Cloths C1
BPO Creamy Wash Complete Pack (Cream)
C1
BPO Foaming Cloths C1
Calamine (Lotion)C1
Clean & Clear Continuous Control Acne Cleanser (Cream)
C1
Clearasil Daily Clear Vanishing Acne Treatment (Cream)
C1
Clearskin (Cream)C1
Corticool (Gel)C1
Cortizone-10 (Gel)C1
Cortizone-10 Diabetics Skin (Lotion)C1
Cortizone-10 Eczema (Lotion)C1
Cortizone-10 Hydratensivehealing (Lotion)
134
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Cortizone-10 Hydratensivesoothing (Lotion)
C1
Cottontails Diaper Rash (Ointment)C1
Cottontails Diaper Rash Creamy W/Vitamin E (Ointment)
C1
Curad Vitamin A & D (Ointment)C1
CVS Acne (Cream)C1
CVS Acne Cleansing Bar C1
CVS Acne Control Cleanser (Cream)C1
CVS Acne Foaming Face Wash (Liquid)C1
CVS Acne Treatment/Maximum Strength (Gel)
C1
CVS Advanced 3-In-1 Exfoliating Cleanser (Liquid)
C1
CVS Anti-Dandruff (Lotion)C1
CVS Cortisone Maximum Strength (Gel)C1
CVS Creamy Acne Face Wash (Liquid)C1
CVS Diaper Rash (Ointment)C1
CVS Eczema Relief (Cream)C1
CVS Foaming Acne Face Wash (Liquid)C1
CVS Hydrocortisone Anti-Itch (Cream)C1
CVS Medicated Pads (Pad)C1
CVS Medicated Wipes (Pad)C1
CVS Petroleum Jelly (Gel)C1
CVS Quick Relief Diaper Rash Cream (Cream)
C1
CVS Targeted Acne Spot Treatment (Cream)
C1
CVS Vitamin A&D Ointment (Ointment)C1
CVS Witch Hazel (Liquid)C1
CVS Zinc Oxide (Ointment)C1
Daily Care Skin Protectant (Ointment)C1
Dandruff Shampoo (Lotion)C1
Delbase Compounding (Ointment)C1
Dermarest Eczema (Lotion)
OTC Drug NameC1
Desitin (Cream)C1
Desitin Rapid Relief (Cream)C1
Diaper Rash (Ointment)C1
Diaper Rash Paste (Paste)C1
Dickinsons Witch Hazel (Liquid)C1
Effaclar Duo (Solution)C1
EQ Diaper Rash (Ointment)C1
EQ Hemorrhoidal Pads (Pad)C1
EQ Hygienic Cleansing Wipes (Pad)C1
EQ Petroleum Jelly (Gel)C1
EQ Vitamins A & D (Ointment)C1
EQL Baby Basics Diaper Rash (Ointment)C1
EQL Medicated Dandruff (Lotion)C1
EQL Witch Hazel (Solution)C1
Eucerin Eczema Relief (Cream)C1
GNP Acne Treatment Maximum Strength (Cream)
C1
GNP Diaper Rash (Cream)C1
GNP Diaper Rash Creamy (Ointment)C1
GNP Hydrocortisone (Cream)C1
GNP Hydro-Lotion (Lotion)C1
GNP Hygienic Cleansing (Pad)C1
GNP Hygienic Cleansing Pads (Pad)C1
GNP Medicated Wipes (Pad)C1
GNP Petroleum Jelly (Gel)C1
GNP Soothing Bath Treatment (Packet)C1
GNP Zinc Oxide (Ointment)C1
Goodsense Petroleum Jelly (Gel)C1
Gynecort 10 (Cream)C1
Hemorrhoidal (Pad)C1
Hemorrhoidal Hygiene Pads (Pad)C1
HM Medicated Cooling Pads (Pad)C1
HM Petroleum Jelly (Gel)C1
HM Witch Hazel (Liquid)
135
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Hydrocortisone (0.5% Cream, 0.5% Ointment)
C1
Hydrocortisone Acetate (Cream)C1
Hydrophilic (Ointment)C1
Hydroskin (Lotion)C1
Instacort 5 (Cream)C1
Invisible Acne Treatment (Cream)C1
KP Benzoyl Peroxide (Gel)C1
KP Benzoyl Peroxide Wash (Liquid)C1
Lanacort 10 (Cream)C1
Lanolin Hydrous-GRX (Ointment)C1
Lan-O-Soothe (Cream)C1
Medicated Cleansing Pads (Pad)C1
Medicated Wipes Pre-Moistened (Pad)C1
Medi-First Hydrocortisone (Cream)C1
Medi-Pads (Pad)C1
Meijer Calamine (Lotion)C1
Meijer Zinc Oxide (Ointment)C1
MG217 Psoriasis Anti-Itch (Gel)C1
Natural Oatmeal Bath Treatment (Packet)C1
Neutrogena Clear Pore Cleanser/Mask C1
Neutrogena On-The-Spot Acne
Treatment (Cream)C1
Noble Formula HC (Solution)C1
OC8 (Gel)C1
Occluvan (Ointment)C1
Panoxyl (Liquid)C1
Panoxyl Creamy Wash (Liquid)C1
Panoxyl Foaming Wash (Liquid)C1
Panoxyl Wash (Liquid)C1
Panoxyl-4 Creamy Wash (Liquid)C1
Petrolatum (Ointment)C1
Petrolatum White (Gel)C1
Petroleum Jelly (Gel)
OTC Drug NameC1
Pinxav (Ointment)C1
PR Benzoyl Peroxide Wash (Liquid)C1
Pre-Moistened Witch Hazel (Pad)C1
Preparation H (Pad)C1
Preparation H For Women (Pad)C1
Preparation H Totables (Pad)C1
QC Calamine (Lotion)C1
QC Medicated Pads Pre-Moistened (Pad)C1
QC Witch Hazel (Liquid)C1
RA Acne Treatment (Cream)C1
RA Baby Care Vitamins A&D to Go (Ointment)
C1
RA Dandruff Shampoo (Lotion)C1
RA Daylogic Acne Foaming Wash Maximum Strength (Foam)
C1
RA Diaper Rash (Ointment)C1
RA First Aid Anti-Itch Spray (Solution)C1
RA Hemorrhoid Relief Medicated Wipes Maximum Strength (Pad)
C1
RA Medicated Wipes Pre-Moistened (Pad)C1
RA Petroleum Jelly (Gel)C1
RA Renewal Dandruff Shampoo (Lotion)C1
RA Renewal Dandruff Shampoo Clinical (Lotion)
C1
RA Renewal Eczema Moisturizing Cream (Cream)
C1
RA Renewal Soothing Bath Treatment (Packet)
C1
RA Tugaboos Creamy Petroleum Jelly/Shea Butter (Gel)
C1
RA Tugaboos Petroleum Jelly (Gel)C1
RA Vanishing Acne Treatment/Maximum Strength (Cream)
C1
RA Vitamin A & D (Ointment)C1
RA Vitamins A & D (Ointment)C1
RA Witch Hazel (Solution)
136
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
RA Zinc Oxide (Ointment)C1
Riax (5.5% Foam, 9.5% Foam)C1
Sarnol-HC (Lotion)C1
Scalp Relief Maximum Strength (Solution)C1
Scalpicin Maximum Strength (Solution)C1
Secura Protective (Cream)C1
Selenium Sulfide (Shampoo)C1
Selenium Sulfide Shampoo (Shampoo)C1
Skin Protectant Moisture Barrier (Cream)C1
SM Calamine (Lotion)C1
SM Hydrocortisone (Cream)C1
SM Hydrocortisone (Ointment)C1
SM Medicated Wipes (Pad)C1
SM Oatmeal Bath (Packet)C1
SM Petroleum Jelly (Gel)C1
SM Witch Hazel (Liquid)C1
SM Witch Hazel (Solution)C1
Spot Acne Treatment (Cream)C1
TGT Medicated Hemorrhoidal Pads (Pad)C1
TGT Medicated Wipe/Witch Hazel/Aloe (Pad)
C1
Tippy Toes Diaper Rash (Ointment)C1
TN Dickinsons Witch Hazel (Liquid)C1
TN Dickinsons Witch Hazel Cleansing Pads (Pad)
C1
TN Dickinsons Witch Hazel Hemorrhoidal (Pad)
C1
Vagisil (Cream)C1
Vaseline (Gel)C1
Vaseline Pure Ultra White Petroleum Jelly (Gel)
C1
Vitamin A (Tablet)C1
White Petrolatum (Gel)C1
White Petrolatum (Ointment)C1
White Petroleum Jelly (Gel)
OTC Drug NameC1
Witch Hazel (Solution)C1
Zaclir Cleansing (Lotion)C1
Zinc Oxide (Ointment)A1
Gastrointestinal AgentsB1
AntacidsC1
Acid Controller (Tablet)C1
Acid Controller Original Strength (Tablet)C1
Acid Reducer (10mg Tablet, 75mg Tablet)C1
Acidophilus (Capsule)C1
Acidophilus (Tablet Chewable)C1
Acidophilus (Tablet)C1
Acidophilus (Wafer)C1
Acidophilus Extra Strength (Capsule)C1
Acidophilus Lactobacilli (Capsule)C1
Acidophilus Probiotic (Capsule)C1
Acidophilus Probiotic (Tablet)C1
Acidophilus Probiotic Formula (Tablet)C1
Acidophilus With Bifidus (Tablet Chewable)
C1
Acidophilus/Bifidus (Wafer)C1
Acidophilus/L-Sporogenes Extra Strength (Tablet)
C1
Acidophilus/Pectin (Capsule)C1
Align (Capsule)C1
Aluminum Hydroxide C1
Antacid (Tablet Chewable)C1
Antacid Calcium Extra Strength (Tablet Chewable)
C1
Antacid Calcium Regular Strength (Tablet Chewable)
C1
Antacid Extra Strength (Tablet Chewable)C1
Antacid Flavor Chews (Tablet Chewable)C1
Antacid Maximum (Tablet Chewable)C1
Antacid Ultra Strength (Tablet Chewable)C1
Calcium Antacid (Tablet Chewable)
137
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Calcium Antacid Extra Strength (Tablet Chewable)
C1
Calcium Antacid Ultra Maximum Strength (Tablet Chewable)
C1
Calcium Antacid Ultra Strength (Tablet Chewable)
C1
Calcium Carbonate (Suspension)C1
Calcium Carbonate (Tablet Chewable)C1
Calcium Carbonate (Tablet)C1
Calcium Carbonate Extra Strength (Tablet Chewable)
C1
Cal-Gest Antacid (Tablet Chewable)C1
Children's Pepto (Tablet Chewable)C1
Children's Soothe (Tablet Chewable)C1
CVS Acid Controller (Tablet)C1
CVS Acid Reducer (Tablet)C1
CVS Acidophilus (Capsule)C1
CVS Acidophilus Probioticformula (Tablet)C1
CVS Antacid & Anti-Gas Fast Relief (Tablet Chewable)
C1
CVS Antacid Extra (Tablet Chewable)C1
CVS Antacid Extra Strength (Tablet Chewable)
C1
CVS Antacid Kids (Tablet Chewable)C1
CVS Antacid Maximum Strength (Tablet Chewable)
C1
CVS Antacid Supreme (Suspension)C1
CVS Antacid Ultra Strength (Tablet Chewable)
C1
CVS Chewy Not Chalky Flavor Chews (Tablet Chewable)
C1
CVS Probiotic Acidophilus (Capsule)C1
CVS Smooth Antacid Extra Strength (Tablet Chewable)
C1
EQ Acid Reducer (Tablet)C1
EQ Antacid (Tablet Chewable)
OTC Drug NameC1
EQ Antacid Extra Strength (Tablet Chewable)
C1
EQ Antacid Ultra Strength (Tablet Chewable)
C1
EQL Acid Reducer (Tablet)C1
EQL Antacid (Tablet Chewable)C1
EQL Antacid Extra Strength (Tablet Chewable)
C1
EQL Antacid Ultra Strength (Tablet Chewable)
C1
Famotidine (Tablet)C1
Florajen Acidophilus (Capsule)C1
Freeze Dried Acidophilus (Capsule)C1
Geri-Lanta Supreme (Suspension)C1
GNP Acid Reducer (10mg Tablet, 75mg Tablet)
C1
GNP Antacid & Anti-Gas Maximum Strength (Tablet Chewable)
C1
GNP Antacid (Tablet Chewable)C1
GNP Antacid Extra Strength (Tablet Chewable)
C1
GNP Antacid Ultra Strength (Tablet Chewable)
C1
GNP Heartburn Relief (Tablet)C1
Goodsense Acid Reducer (Tablet)C1
Healthy Mama Tame The Flame (Tablet Chewable)
C1
Heartburn Relief (10mg Tablet, 75mg Tablet, 200mg Tablet)
C1
HM Acid Reducer (Tablet)C1
HM Acidophilus Probiotic Formula (Tablet)C1
HM Calcium Antacid (Tablet Chewable)C1
HM Calcium Antacid Extra Strength (Tablet Chewable)
C1
HM Calcium Antacid Smooth Dissolve (Tablet Chewable)
138
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
HM Calcium Antacid Smooth Dissolve Extra Strength (Tablet Chewable)
C1
HM Calcium Antacid Ultra Strength (Tablet Chewable)
C1
HM Famotidine (Tablet)C1
KLS Acid Reducer (Tablet)C1
Long Lasting Antacid (Tablet Chewable)C1
Maalox Children's (Tablet Chewable)C1
Mi-Acid (Tablet Chewable)C1
More-Dophilus Acidophilus (Powder)C1
Probiotic Acidophilus (Capsule)C1
Probiotic Acidophilus Super Strength (Tablet)
C1
PX Acid Reducer (Tablet)C1
PX Antacid Extra Strength (Tablet Chewable)
C1
PX Antacid Maximum Strength (Tablet Chewable)
C1
PX Calcium Antacid Regular Strength (Tablet Chewable)
C1
QC Acid Controller (Tablet)C1
QC Antacid (Tablet Chewable)C1
QC Antacid Extra Strength (Tablet Chewable)
C1
RA Acid Reducer (Tablet)C1
RA Acidophilus (Capsule)C1
RA Antacid (Tablet Chewable)C1
RA Antacid Extra Strength (Tablet Chewable)
C1
RA Antacid Ultra Strength (Tablet Chewable)
C1
RA Multihealth Fiber Supplement (Powder)C1
RA Probiotic Digestive Care (Capsule)C1
RA Probiotic Gummies (Tablet Chewable)C1
RA Saline Enema (Enema)C1
RA Senna (Capsule)
OTC Drug NameC1
RA Senna (Tablet)C1
RA Smooth Antacid Extra Strength (Tablet Chewable)
C1
RA Stomach Relief Kids (Tablet Chewable)C1
Ranitidine 75 (Tablet)C1
Ranitidine Acid Reducer (Tablet)C1
Rolaids (Tablet Chewable)C1
SB Acid Controller (Tablet)C1
SB Acid Reducer (Tablet)C1
SB Acid Reducer Ranitidine 75 (Tablet)C1
SB Antacid (Tablet Chewable)C1
SB Antacid Extra Strength (Tablet Chewable)
C1
SM Acid Reducer (10mg Tablet, 75mg Tablet, 200mg Tablet)
C1
SM Acidophilus (Capsule)C1
SM Calcium Antacid (Tablet Chewable)C1
SM Calcium Antacid Extra Strength (Tablet Chewable)
C1
SM Calcium Antacid Ultra Strength (Tablet Chewable)
C1
SM Smooth Antacid Extra Strength (Tablet Chewable)
C1
Sodium Bicarbonate (325mg Tablet, 650mg Tablet)
C1
Sodium Bicarbonate (Powder)C1
TGT Acid Reducer (Tablet)C1
TGT Antacid (Tablet Chewable)C1
TGT Antacid Extra Strength (Tablet Chewable)
C1
Titralac (Tablet Chewable)C1
Tums Freshers (Tablet Chewable)C1
Tums Gas Relief Chewy Bites (Tablet Chewable)
C1
Zantac 75 (Tablet)B1
Gastrointestinal Agents, Other
139
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Align (Tablet Chewable)C1
Align Extra Strength (Capsule)C1
Align Jr For Kids (Tablet Chewable)C1
Anti-Diarrheal (1mg/7.5ml Liquid, 2mg Tablet)
C1
Bismatrol (262mg/15ml Suspension, 262mg Tablet Chewable)
C1
Bismatrol Maximum Strength (Suspension)C1
Bismuth (Tablet Chewable)C1
Bismuth Subsalicylate (Tablet Chewable)C1
Culturelle (Capsule)C1
Culturelle Immunity Support Formula
(Capsule)C1
Culturelle Kids (Packet)C1
Culturelle Kids (Tablet Chewable)C1
Culturelle Kids Regularity (Packet)C1
Culturelle Probiotics Kids (Packet)C1
CVS Bismuth (Tablet Chewable)C1
CVS Dairy Relief (Chewable Tablet)C1
CVS Dairy Relief Fast Acting (Tablet)C1
CVS Easy Fiber/Calcium (Tablet Chewable)
C1
CVS Lactase (Tablet)C1
CVS Lactase Enzyme Ultra Strength (Tablet)
C1
CVS Stomach Relief (Tablet Chewable)C1
Dairy Digest Ultra (Tablet)C1
Dairy Digestive Supplement Fast Acting (Tablet)
C1
Dairy Digestive Ultra (Tablet)C1
Dairy Relief (Tablet)C1
Dairy-Digestive (Chewable Tablet)C1
EQ Dairy Digestive Supplement Fast Acting (Chewable Tablet)
C1
EQ Dairy Digestive Supplement Fast Acting (Tablet)
OTC Drug NameC1
EQ Pink-Bismuth (Tablet Chewable)C1
EQ Stomach Relief (Tablet Chewable)C1
EQL Dairy Digest Fast Acting (Tablet)C1
EQL Stomach Relief (Tablet Chewable)C1
Fast Acting Dairy Aid (Tablet)C1
Florastor (Capsule)C1
Florastor Kids (Packet)C1
Florastormax (Packet)C1
Gas Relief (40mg/0.6ml Suspension, 80mg Tablet Chewable)
C1
Gas Relief Extra Strength (Capsule)C1
Gas Relief Maximum Strength (Tablet Chewable)
C1
Gas Relief Ultra Strength (Capsule)C1
Gas-X Extra Strength (Capsule)C1
Gas-X Ultra Strength (Capsule)C1
GNP Anti-Diarrheal (Tablet)C1
GNP Anti-Gas (Capsule)C1
GNP Dairy Relief (Tablet)C1
GNP Fast Acting Dairy Relief (Chewable Tablet)
C1
GNP Gas Relief (Tablet Chewable)C1
GNP Gas Relief Extra Strength (125mg Capsule, 125mg Tablet Chewable)
C1
GNP Infants Gas Relief (Suspension)C1
GNP Loperamide HCL (Liquid)C1
GNP Pink Bismuth (262mg Tablet Chewable, 262mg Tablet)
C1
GNP Stomach Relief (Suspension)C1
GNP Stomach Relief Maximum Strength (Suspension)
C1
Goodsense Stomach Relief (Tablet Chewable)
C1
HM Anti-Diarrheal (Tablet)C1
HM Gas Relief (80mg Tablet Chewable, 125mg Tablet Chewable)
140
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
HM Gas Relief Extra Strength (Capsule)C1
HM Gas Relief Infants (Suspension)C1
HM Loperamide HCL (Liquid)C1
HM Stomach Relief (262mg Tablet Chewable, 262mg/15ml Suspension)
C1
HM Stomach Relief Maximum Strength (Suspension)
C1
Infants Gas Relief (Suspension)C1
Infants Simethicone (Suspension)C1
Kao-Tin (Suspension)C1
KLS Fast Acting Lactase (Tablet)C1
Lac-Dose (Tablet)C1
Lactase (Tablet)C1
Lactase Enzyme (Tablet)C1
Lactase Fast Acting (Tablet)C1
Lactinex (Tablet Chewable)C1
Lactobacillus (Packet)C1
Lactobacillus (Tablet)C1
Lactobacillus Extra Strength (Capsule)C1
Lacto-Key-100 (Capsule)C1
Lacto-Key-600 (Capsule)C1
Lactose Fast Acting Relief (Chewable Tablet)
C1
Lactose Fast Acting Relief (Tablet)C1
Little Remedies For Tummys Gas Relief (Suspension)
C1
Little Tummys Gas Relief (Suspension)C1
Loperamide A-D (Tablet)C1
Loperamide HCL (1mg/5ml Liquid, 1mg/7.5ml Liquid)
C1
Loperamide Hydrochloride (Tablet)C1
Meclizine (Tablet Chewable)C1
Meclizine HCL (Tablet Chewable)C1
Meclizine Hydrochloride (Tablet Chewable)C1
Medi-Bismuth (Tablet Chewable)
OTC Drug NameC1
Medi-Lax (Tablet)C1
Medi-Mucil (Capsule)C1
Medi-Natural (Tablet)C1
Meijer Anti-Diarrheal (Tablet)C1
Meta Biotic/Bio-Active 12 (Capsule)C1
Metamucil (Powder)C1
Metamucil Smooth Texture (Powder)C1
Metamucil Smooth Texture Sugar Free (Powder)
C1
Mi-Acid Gas Relief (Tablet Chewable)C1
Mineral Oil (Enema)C1
Mineral Oil (Oil)C1
Mineral Oil Heavy (Oil)C1
MM Anti-Diarrheal (Tablet)C1
MM Stool Softener (Capsule)C1
Mommys Bliss Gas Relief Drops (Suspension)
C1
Motion Sickness Relief (Tablet Chewable)C1
Motion-Time (Tablet Chewable)C1
Mytab Gas (Tablet Chewable)C1
Natural Psyllium Seed Indian Husks (Powder)
C1
Natural Vegetable Fiber (Powder)C1
Pediacare Gas Relief Drops Infants (Suspension)
C1
Pediatric Enema (Enema)C1
Peptic Relief (Suspension)C1
Peptic Relief (Tablet Chewable)C1
Pepto-Bismol (Tablet Chewable)C1
Pepto-Bismol Instacool (Tablet
Chewable)C1
Pepto-Bismol To-Go (Tablet Chewable)C1
Phazyme (Tablet Chewable)C1
Phillips Stool Softener (Capsule)C1
Pink Bismuth (Tablet Chewable)
141
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Pink Bismuth Maximum Strength (Suspension)
C1
Primadophilus (Capsule)C1
Probiotic (Capsule)C1
Probiotic Chewable Children's (Tablet Chewable)
C1
Probiotic Choclate Bears Children's (Tablet Chewable)
C1
Probiotic Gold Extra Strength (Capsule)C1
Probiotic Packets Children's (Packet)C1
Probiotic-10 Chewable (Tablet Chewable)C1
Promolaxin (Tablet)C1
Psyldex (Powder)C1
Psyllium Fiber (Capsule)C1
Psyllium Husk (Powder)C1
Pure & Gentle Enema (Enema)C1
PX Anti-Diarrheal (Tablet)C1
PX Dairy Digestive (Tablet)C1
PX Docusate Sodium (Capsule)C1
PX Fiber (Capsule)C1
PX Gas Relief Extra Strength (Capsule)C1
PX Gas Relief Infants (Suspension)C1
PX Gas Relief Ultra Strength (Capsule)C1
PX Ranitidine (Tablet)C1
PX Stomach Relief (Tablet Chewable)C1
PX Stomach Relief Maximum Strength (Suspension)
C1
QC Anti-Diarrheal (Tablet)C1
QC Anti-Gas Ultra Strength (Capsule)C1
QC Diarrhea Relief (Suspension)C1
QC Gas Relief (Capsule)C1
QC Gas Relief (Tablet Chewable)C1
QC Gas Relief Extra Strength (Tablet Chewable)
C1
QC Natural Vegetable (Powder)
OTC Drug NameC1
QC Pink Bismuth (Tablet Chewable)C1
QC Senna (Tablet)C1
RA Anti-Diarrheal (Liquid)C1
RA Anti-Diarrheal (Tablet)C1
RA Col-Rite (Capsule)C1
RA Dairy Aid (Tablet)C1
RA Dairy Relief Fast Acting (Chewable Tablet)
C1
RA Dairy Relief Fast Acting (Tablet)C1
RA Digestive Health (Capsule)C1
RA Enema (Enema)C1
RA Fiber (Capsule)C1
RA Fiber (Powder)C1
RA Fiber Supplement (Powder)C1
RA Fiber Therapy (Capsule)C1
RA Gas Relief (Capsule)C1
RA Gas Relief (Suspension)C1
RA Gas Relief (Tablet Chewable)C1
RA Gas Relief Extra Strength (Capsule)C1
RA Gas Relief Extra Strength (Tablet Chewable)
C1
RA Gas Relief Maximum Strength (Tablet Chewable)
C1
RA Gas Relief Ultra Strength (Capsule)C1
RA Gas Relief/Infants (Suspension)C1
RA K-Pec (Suspension)C1
RA Loperamide HCl (Liquid)C1
RA Mineral Oil (Oil)C1
RA Motion Sickness Relief (Tablet Chewable)
C1
RA Pink Bismuth (Tablet Chewable)C1
RA Soluble Fiber (Tablet)C1
RA Stomach Relief (Tablet Chewable)C1
RA Stomach Relief Maximum Strength (Suspension)
142
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
RA Stool Softener (Capsule)C1
Ranitidine HCl (Tablet)C1
Reliable-1 Psyllium (Capsule)C1
SB Anti-Diarrhea (Tablet)C1
SB Anti-Gas (Capsule)C1
SB Bismuth (Tablet)C1
SB Docusate Sodium (Capsule)C1
SB Fib Lax Orange (Powder)C1
SB Gas Relief (Suspension)C1
SB Gas Relief (Tablet Chewable)C1
SB Gentle Lax-Women (Tablet Delayed-Release)
C1
SB Senna-Lax (Tablet)C1
Senna Lax (Tablet)C1
Senna Regular Strength (Tablet)C1
Senna Smooth (Tablet)C1
Sennacon (Tablet)C1
Senna-GRX (Syrup)C1
Sennazon (Syrup)C1
Sennosides (Senna) (Tablet)C1
Sennosides (Tablet)C1
Simeped (Suspension)C1
Simethicone (180mg Capsule, 40mg/0.6ml Suspension)
C1
Simethicone Extra Strength (Capsule)C1
SM Anti-Diarrheal (Tablet)C1
SM Fiber Powder (Powder)C1
SM Gas Relief (80mg Tablet Chewable, 125mg Tablet Chewable)
C1
SM Gas Relief Antiflatuent (Capsule)C1
SM Gas Relief Drops Infants (Suspension)C1
SM Gas Relief Extra Strength (Capsule)C1
SM Gas Relief Infants Drops (Suspension)C1
SM Loperamide HCL (Liquid)
OTC Drug NameC1
SM Mineral Oil (Enema)C1
SM Mineral Oil (Oil)C1
SM Probiotic (Capsule)C1
SM Stomach Relief (262mg/15ml Suspension, 262mg Tablet Chewable, 262mg Tablet)
C1
SM Stomach Relief Liquid (Suspension)C1
SM Stomach Relief Maximum Strength (Suspension)
C1
SM Ultra Dairy Digestive (Tablet)C1
Smarty Pants Kids Probiotic Complete (Tablet Chewable)
C1
Sodium Bicarbonate Partial Fill (Solution)C1
Soluble Fiber/Probiotics (Tablet Chewable)C1
Soothe Maximum Strength (Suspension)C1
Sorbulax (Powder)C1
SR Anti-Diarrheal (Tablet)C1
Stablegi (Capsule)C1
Stomach Relief (262mg/15ml Suspension, 262mg Tablet Chewable)
C1
Stomach Relief Maximum Strength (Suspension)
C1
Stomach Relief Plus (Suspension)C1
Surelac (Tablet)C1
TGT Anti-Diarrheal (Tablet)C1
TGT Dairy Digestive Aid (Tablet)C1
TGT Fiber Therapy (Powder)C1
TGT Gas Relief Extra Strength (Capsule)C1
TGT Gas Relief Extra Strength (Tablet Chewable)
C1
TGT Gas Relief Infants Drops (Liquid)C1
TGT Psyllium Fiber (Capsule)C1
TGT Senna (Tablet)C1
TGT Stomach Relief (Tablet)C1
The Magic Bullet (Suppository)C1
Travel Sickness (Tablet Chewable)
143
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Trunature Probiotic For Kids (Tablet Chewable)
C1
Ultimate Probiotic Formula (Capsule)C1
Veracolate (Tablet Delayed-Release)C1
Wal-Mucil (Capsule)C1
Wal-Mucil (Powder)C1
Wal-Mucil Plus Calcium (Capsule)C1
Wal-Zan 75 (Tablet)B1
LaxativesC1
Abatinex (Capsule)C1
Alophen (Tablet Delayed-Release)C1
AZO Complete Feminine Balance (Capsule)
C1
Benefiber On The Go (Powder)C1
Biohm Children's Probiotic Supplement (Tablet Chewable)
C1
Biotinex (Capsule)C1
Bisac-Evac (Suppository)C1
Bisacodyl (Suppository)C1
Bisacodyl EC (Tablet Delayed-Release)C1
Bisacodyl Laxative (Suppository)C1
Biscolax (Suppository)C1
Bonine (Tablet Chewable)C1
Carters Little Pills (Tablet Delayed-Release)C1
Children's Probiotic (Tablet Chewable)C1
Chocolated Laxative (Tablet Chewable)C1
Citrucel (Tablet)C1
Citrucel Fiber Laxative (Powder)C1
Clear Soluble Fiber (Powder)C1
Clearlax (Powder)C1
Colace (Capsule)C1
Colace Clear (Capsule)C1
Correct (Tablet Delayed-Release)C1
Correctol (Tablet Delayed-Release)C1
Correctol Extra Gentle (Capsule)
OTC Drug NameC1
CVS Advanced Probiotic Gummies (Tablet Chewable)
C1
CVS Anti-Diarrheal (Suspension)C1
CVS Anti-Diarrheal (Tablet)C1
CVS Bisacodyl (Suppository)C1
CVS Bisacodyl (Tablet Delayed-Release)C1
CVS Bismuth Maximum Strength (Suspension)
C1
CVS Chocolate Laxative Pieces (Tablet Chewable)
C1
CVS C-Lax Laxative (Tablet Delayed-Release)
C1
CVS Daily Fiber (Capsule)C1
CVS Digestive Probiotic (Capsule)C1
CVS Easy Fiber (Powder)C1
CVS Enema Disposable (Enema)C1
CVS Enema Ready-To-Use (Enema)C1
CVS Fiber (Capsule)C1
CVS Gas Relief (Capsule)C1
CVS Gas Relief (Tablet Chewable)C1
CVS Gas Relief Drops Extra Strength (Liquid)
C1
CVS Gas Relief Extra Strength (Capsule)C1
CVS Gas Relief Extra Strength (Tablet Chewable)
C1
CVS Gas Relief Infants (Suspension)C1
CVS Gas Relief Ultra Strength (Capsule)C1
CVS Gentle Laxative (Suppository)C1
CVS Gentle Laxative (Tablet Delayed-Release)
C1
CVS Gentle Laxative Womens (Tablet Delayed-Release)
C1
CVS Glycerin Adult (Suppository)C1
CVS Glycerin Child (Suppository)C1
CVS Infants Gas Relief (Suspension)C1
CVS Laxative Pills (Tablet)
144
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
CVS Loperamide HCl (Liquid)C1
CVS Loperamide Hydrochloride (Liquid)C1
CVS Mineral Oil (Oil)C1
CVS Mineral Oil Enema (Enema)C1
CVS Mini Enema Kids (Enema)C1
CVS Motion Sickness Relief (Tablet Chewable)
C1
CVS Natural Daily Fiber (Powder)C1
CVS Natural Fiber Supplement (Powder)C1
CVS Probiotic (Capsule)C1
CVS Probiotic (Tablet Chewable)C1
CVS Probiotic Children's (Tablet Chewable)
C1
CVS Ranitidine (Tablet)C1
CVS Senna (Tablet)C1
CVS Senna-Extra (Tablet)C1
CVS Soluble Fiber Therapy (Tablet)C1
CVS Stomach Relief Maximum Strength (Suspension)
C1
CVS Stool Softener (Capsule)C1
Dialyvite Chewable Probiotic (Tablet Chewable)
C1
Diamode (Tablet)C1
Diarrhea (Suspension)C1
Digestive Advantage Probiotic Gummies (Tablet Chewable)
C1
Digestive Health Probiotic (Capsule)C1
Diocto (Liquid)C1
Diocto (Syrup)C1
Docqlace (Capsule)C1
Docu (Liquid)C1
Docu Soft (Capsule)C1
Docuprene (Tablet)C1
Docusate Sodium (100mg Capsule, 150mg/15ml Liquid)
OTC Drug NameC1
Docusate Sodium Extra Strength (Capsule)C1
Docusil (Capsule)C1
Docusol Kids (Enema)C1
Docusol Mini (Enema)C1
Dofus (Capsule)C1
DOK (100mg Capsule, 250mg Capsule, 100mg Tablet)
C1
Dr Edwards Olive Laxative (Tablet)C1
DRx Choice Gas Relief (Tablet Chewable)C1
DSS (Capsule)C1
Ducodyl (Tablet Delayed-Release)C1
Dulcolax Pink Stool Softener (Capsule)C1
Dulcolax Stool Softener (Capsule)C1
Easy Fiber (Powder)C1
Easy-Lax (Capsule)C1
Enema (Enema)C1
Enema Disposable (Enema)C1
Enema Mineral Oil (Enema)C1
Enema Mineral Oil Ready-To-Use (Enema)C1
Enema Ready-To-Use (Enema)C1
Enemeez Mini (Enema)C1
EQ Anti-Diarrheal (Liquid)C1
EQ Anti-Diarrheal (Tablet)C1
EQ Daily Fiber (Capsule)C1
EQ Enema (Enema)C1
EQ Fiber Powder (Powder)C1
EQ Fiber Therapy (Capsule)C1
EQ Fiber Therapy (Powder)C1
EQ Fiber Therapy (Tablet)C1
EQ Gas Relief (Capsule)C1
EQ Gas Relief (Tablet Chewable)C1
EQ Gas Relief Extra Strength (Tablet Chewable)
145
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
EQ Gentle Laxative (Tablet Delayed-Release)
C1
EQ Infants Gas Relief (Suspension)C1
EQ Laxative (Tablet Chewable)C1
EQ Laxative Maximum Strength (Tablet)C1
EQ Loperamide HCl (Liquid)C1
EQ Mineral Oil (Oil)C1
EQ Natural Fiber Laxative (Powder)C1
EQ Natural Laxative (Tablet)C1
EQ Natural Vegetable Laxative (Tablet)C1
EQ Probiotic Digestive System Support (Capsule)
C1
EQ Ranitidine (Tablet)C1
EQ Stool Softener (Capsule)C1
EQ Vegetable Laxative (Tablet)C1
EQ Womans Laxative (Tablet Delayed-Release)
C1
EQ Womens Laxative (Tablet Delayed-Release)
C1
EQL Anti-Diarrheal (Tablet)C1
EQL Digestive Probiotic (Capsule)C1
EQL Fiber Supplement (Powder)C1
EQL Fiber Therapy (Powder)C1
EQL Fiber Therapy (Tablet)C1
EQL Gas Gone Extra Strength (Tablet Chewable)
C1
EQL Gas Relief (Capsule)C1
EQL Gas Relief Extra Strength (Capsule)C1
EQL Gas Relief Ultra Strength (Capsule)C1
EQL Gentle Laxative (Tablet Delayed-Release)
C1
EQL Heartburn Prevention (Tablet)C1
EQL Infants Gas Relief (Suspension)C1
EQL Laxative (Tablet Delayed-Release)C1
EQL Laxative EQL Laxative (Tablet Chewable)
OTC Drug NameC1
EQL Laxative Maximum Strength (Tablet)C1
EQL Loperamide HCl (Liquid)C1
EQL Natural Fiber (Powder)C1
EQL Ready-To-Use Enema (Enema)C1
EQL Senna Laxative (Tablet)C1
EQL Stomach Relief Maximum Strength (Suspension)
C1
EQL Stool Softener (Capsule)C1
Evac-U-Gen (Tablet)C1
Ex-Lax (15mg Tablet Chewable, 15mg
Tablet)C1
Ex-Lax Ultra (Tablet Delayed-Release)C1
Feenamint (Tablet Delayed-Release)C1
Fiber Laxative (Capsule)C1
Fiber Powder (Powder)C1
Fiber Therapy (Powder)C1
Fiber Therapy (Tablet)C1
Fleet Bisacodyl (Enema)C1
Fleet Enema (Enema)C1
Fleet Liquid Glycerin Suppositories
(Enema)C1
Fleet Oil (Enema)C1
Fleet Pediatric (Enema)C1
Flora Assist (Packet)C1
Floranex (Packet)C1
Floranex (Tablet)C1
Gas Relief Drops Infants (Suspension)C1
Gas Relief Infants (Liquid)C1
Gas Relief Infants (Suspension)C1
Gas-X Infant Drops (Liquid)C1
Gavilax (Powder)C1
Gentle Laxative (Suppository)C1
Gentle Laxative (Tablet Delayed-Release)C1
Gentle Laxative For Women (Tablet Delayed-Release)
146
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Gentle Laxative Overnight Relief (Tablet Delayed-Release)
C1
Geri-Kot (Tablet)C1
Geri-Mucil (Powder)C1
Geri-Pectate (Suspension)C1
Glycerin Adult (2gm Suppository, 2.1gm Suppository)
C1
Glycerin Adult (Suppository)C1
Glycerin Children (Suppository)C1
Glycerin Children's (Suppository)C1
Glycerin Infants & Children (Suppository)C1
Glycerin Pediatric (Suppository)C1
Glycolax (Powder)C1
GNP Best Fiber (Powder)C1
GNP Bisa-Lax (Tablet Delayed-Release)C1
GNP Clearlax (Packet)C1
GNP Clearlax (Powder)C1
GNP Enema (Enema)C1
GNP Enema Mineral Oil Laxative (Enema)C1
GNP Fiber Therapy (Tablet)C1
GNP Gas Relief Maximum Strength (Tablet Chewable)
C1
GNP Gentle Laxative (Suppository)C1
GNP Glycerin Adult (Suppository)C1
GNP Glycerin Child (Suppository)C1
GNP Glycerin Infant (Suppository)C1
GNP K-Pec (Suspension)C1
GNP Laxative (Tablet Delayed-Release)C1
GNP Laxative Pills (Tablet)C1
GNP Loperamide Hydrochloride (Liquid)C1
GNP Mineral Oil (Oil)C1
GNP Mineral Oil Heavy (Oil)C1
GNP Natural Fiber (Powder)C1
GNP Senna-Lax (Tablet)
OTC Drug NameC1
GNP Stool Softener (100mg Capsule, 250mg Capsule, 150mg/15ml Liquid, 60mg/15ml Syrup)
C1
GNP Stool Softener Extra Strength (Capsule)
C1
GNP Womens Gentle Laxative (Tablet Delayed-Release)
C1
GNP Womens Laxative (Tablet Delayed-Release)
C1
Goodsense Best Fiber (Powder)C1
Goodsense Bisacodyl Ec (Tablet Delayed-Release)
C1
Goodsense Clearlax (Powder)C1
Goodsense Fiber (Tablet)C1
Goodsense Gas Relief Extra Strength (Tablet Chewable)
C1
Goodsense Laxative Pills (Tablet)C1
Goodsense Mineral Oil Lubricant Laxative (Oil)
C1
Goodsense Natural Fiber (Powder)C1
Goodsense Psyllium Fiber (Powder)C1
Goodsense Senna Laxative (Tablet)C1
Healthy Mama Move It Along (Tablet)C1
Healthylax (Packet)C1
HM Clear Fiber (Powder)C1
HM Clearlax (Packet)C1
HM Clearlax (Powder)C1
HM Enema (Enema)C1
HM Enema Mineral Oil (Enema)C1
HM Enema Ready-To-Use (Enema)C1
HM Enema Saline Laxative (Enema)C1
HM Fiber (0.52gm Capsule, 500mg Tablet, 28.3% Powder, 30.9% Powder, 48.57% Powder, 58.6% Powder)
C1
HM Fiber Powder (Powder)C1
HM Gas Relief Infants Drops (Suspension)
147
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
HM Laxative (Tablet Delayed-Release)C1
HM Mineral Oil (Oil)C1
HM Probiotic Digestive Health (Capsule)C1
HM Senna (Tablet)C1
HM Stomach Relief Ultra (Suspension)C1
HM Stool Softener (100mg Capsule, 100mg Tablet)
C1
HM Stool Softener Maximum Strength (Capsule)
C1
Intestinex (Capsule)C1
Kaopectate (Suspension)C1
Kaopectate (Tablet)C1
Kaopectate Extra Strength (Suspension)C1
KLS Anti-Diarrheal (Tablet)C1
KLS Natural Psyllium Fiber (Powder)C1
KLS Stool Softener (Capsule)C1
Kondremul (Oil)C1
Konsyl (Capsule)C1
Konsyl (Powder)C1
Konsyl Daily Fiber (100% Powder)C1
Konsyl Daily Fiber (28.3% Powder, 28.3% Powder Packet, 100% Powder Packet)
C1
Konsyl Original Formula Daily Fiber
(Powder)C1
Konsyl-D (Powder)C1
KP Bisacodyl (Tablet Delayed-Release)C1
KP Senna (Tablet)C1
KS Stool Softener (Capsule)C1
Laxa Basic (Capsule)C1
Laxative (10mg Suppository, 5mg Tablet Delayed-Release, 25mg Tablet)
C1
Laxative Feminine (Tablet Delayed-Release)
C1
Laxative Maximum Strength (Tablet)C1
Laxative Pills Maximum Strength (Tablet)
OTC Drug NameC1
Laxative Pills Regular Strength (Tablet)C1
Laxative With Senna (Tablet)C1
Natural Fiber (Powder)C1
Natural Fiber Laxative (48.57% Powder, 58.6% Powder)
C1
Natural Fiber Therapy (28.3% Powder, 48.57% Powder)
C1
Natural Senna Laxative (Tablet)C1
Oral Saline Laxative (Solution)C1
Pedia-Lax (1gm Suppository, 2.8gm
Suppository)C1
Peg 3350 (Packet)C1
Peg 3350 (Powder)C1
Perdiem Overnight Relief (Tablet)C1
Polyethylene Glycol 3350 (Packet)C1
Polyethylene Glycol 3350 (Powder)C1
PX Glycerin (Suppository)C1
PX Laxative (Tablet Delayed-Release)C1
PX Vegetable Laxative (Tablet)C1
QC Enema (Enema)C1
QC Fiber Laxative (Capsule)C1
QC Gentle Laxative (Suppository)C1
QC Laxative (Tablet)C1
QC Mineral Oil Heavy (Oil)C1
QC Natural Vegetable Laxative (Tablet)C1
QC Natura-Lax (Powder)C1
QC Stool Softener (Capsule)C1
RA Fast Relief Laxative (Suppository)C1
RA Fiber Laxative (Powder)C1
RA Glycerin Adult (Suppository)C1
RA Glycerin Child (Suppository)C1
RA Laxative (Tablet Chewable)C1
RA Laxative (Tablet Delayed-Release)C1
RA Laxative (Tablet)
148
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
RA Laxative Extra Strength (Tablet)C1
RA Laxative Maximum Strength (Tablet)C1
RA Stimulant Laxative (Suppository)C1
RA Womens Laxative (Tablet Delayed-Release)
C1
Reguloid (28.3% Powder, 48.57% Powder, 58.6% Powder)
C1
SB Bisacodyl Laxative EC (Tablet Delayed-Release)
C1
SB Fiber Laxative (Powder)C1
SB Gentle Laxative Womens (Tablet Delayed-Release)
C1
SB Glycerin Adult (Suppository)C1
SB Glycerin Pediatric (Suppository)C1
SB Laxative (Suppository)C1
SB Natural Fiber Laxative (Powder)C1
Senexon (Tablet)C1
Senna (Tablet)C1
Senna Laxative (Tablet)C1
Senna-Lax (Tablet)C1
Senna-Tabs (Tablet)C1
Senna-Time (Tablet)C1
Senno (Tablet)C1
Senokot (Tablet)C1
Senokot Extra Strength (Tablet)C1
Silace (150mg/15ml Liquid, 60mg/15ml Syrup)
C1
SM Clearlax (Powder)C1
SM Enema (Enema)C1
SM Fiber (28.3% Powder, 48.57% Powder, 58.6% Powder)
C1
SM Fiber Laxative (Tablet)C1
SM Gentle Laxative (Tablet Delayed-Release)
C1
SM Glycerin Laxative Pediatric (Suppository)
OTC Drug NameC1
SM Glycerin Pediatric (Suppository)C1
SM Laxative (Suppository)C1
SM Laxative Maximum Strength (Tablet)C1
SM Senna Laxative (Tablet)C1
SM Senna Laxative Maximum Strength (Tablet)
C1
SM Stool Softener (Capsule)C1
SM Womans Laxative (Tablet Delayed-Release)
C1
Soluble Fiber (Powder)C1
Stimulant Laxative (Tablet Delayed-Release)
C1
Stool Softener (Capsule)C1
Stool Softener Extra Strength (Capsule)C1
Stool Softener Laxative (Capsule)C1
Stool Softener Laxative Extra Strength (Capsule)
C1
TGT Gentle Laxative (Tablet Delayed-Release)
C1
TGT Laxative Pills Maximum Strength (Tablet)
C1
TGT Natural Laxative Pills Maximum Strength (Tablet)
C1
TGT Saline Laxative (Enema)C1
TGT Senna Laxative (Tablet)C1
TGT Womens Laxative (Tablet Delayed-Release)
C1
Total Fiber (Powder)C1
Womans Laxative (Tablet Delayed-Release)C1
Womens Laxative (Tablet Delayed-Release)
A1
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
B1
Contraceptives, OralC1
Aftera (Tablet)C1
Econtra EZ (Tablet)C1
Econtra One-Step (Tablet)
149
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Levonorgestrel (Tablet)C1
My Choice (Tablet)C1
My Way (Tablet)C1
New Day (Tablet)C1
Next Choice One Dose (Tablet)C1
Opcicon One-Step (Tablet)C1
Option 2 (Tablet)C1
Preventeza (Tablet)C1
React (Tablet)C1
Take Action (Tablet)B1
Contraceptives, TopicalC1
Encare (Suppository)C1
Options Conceptrol Vaginal
Contraceptive (Gel)C1
Options Gynol II Vaginal Contraceptive
(Gel)C1
Shur-Seal (Gel)C1
Today Sponge C1
VCF Vaginal Contraceptive Film C1
VCF Vaginal Contraceptive Foam (Foam)C1
VCF Vaginal Contraceptive Gel (Gel)A1
Miscellaneous Therapeutic AgentsB1
Devices / Other Therapeutic AgentsC1
Aerochamber Mini Aerosol Chamber
(Device)C1
Aerochamber MV (Device)C1
Aerochamber Plus (Device)C1
Aerochamber Plus Flow Vu (Device)C1
Aerochamber Plus Flow-Vu (Device)C1
Aerochamber Plus Flow-Vu/Large Mask
(Device)C1
Aerochamber Plus Flow-Vu/Mask
(Device)C1
Aerochamber Plus Flow-Vu/Medium
Mask (Device)
OTC Drug NameC1
Aerochamber Plus Flow-Vu/Small Mask
(Device)C1
Aerochamber Plus/Small Mask (Device)C1
Aerochamber Z-Stat Plus Valved Holding
Chamber W/Flow Vu (Device)C1
Aerochamber Z-Stat Plus/Flowsignal
(Device)C1
Aerochamber Z-Stat Plus/Large Mask
(Device)C1
Aerochamber Z-Stat Plus/Medium Mask
(Device)C1
Aerochamber Z-Stat Plus/Small Mask
(Device)C1
Aerochamber/Flowsignal (Device)C1
Aerovent Plus Holding Chamber/
Collapsible (Device)C1
Arial Chamber (Device)C1
Breathe Ease/Large Mask (Device)C1
Breathe Ease/Medium Mask (Device)C1
Breathe Ease/Small Mask (Device)C1
Breatherite (Device)C1
Breatherite Collapsible Adult Spacer W/
Mask (Device)C1
Breatherite Collapsible Child Spacer W/
Mask (Device)C1
Breatherite Collapsible Infant Spacer W/
Mask (Device)C1
Breatherite Collapsible Small Child
Spacer W/Mask (Device)C1
Breatherite Collapsible Spacer W/
Neonate Mask (Device)C1
Breatherite Rigid Spacer W/Mask
(Device)C1
Breatherite W/Large Mask (Device)C1
Breatherite W/Medium Mask (Device)C1
Breatherite W/Small Mask (Device)C1
Clever Choice Anti-Staticvalved Holding
Chamber/Adult Large (Device)
150
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Clever Choice Anti-Staticvalved Holding
Chamber/Medium (Device)C1
Clever Choice Anti-Staticvalved Holding
Chamber/Small (Device)C1
Compact Space Chamber/Anti-Static
(Device)C1
Compact Space Chamber/Anti-Static/
Large Mask (Device)C1
Compact Space Chamber/Anti-Static/
Medium Mask (Device)C1
Compact Space Chamber/Anti-Static/
Small Mask (Device)C1
Easivent (Device)C1
Easivent/Mask-Large (Device)C1
Easivent/Mask-Medium (Device)C1
Easivent/Mask-Small (Device)C1
Flexichamber (Device)C1
Flexichamber Adult Mask/Small (Mask)C1
Flexichamber Child Mask/Large (Mask)C1
Flexichamber Child Mask/Small (Mask)C1
Hyper-Sal (3.5% Solution, 7% Solution)C1
Inspirachamber/Anti-Static Valved/
Mouthpiece (Device)C1
Inspirachamber/Large (Device)C1
Inspirachamber/Soothermask/
Inspiramask/Medium (Device)C1
Inspirachamber/Soothermask/
Inspiramask/Small (Device)C1
Inspirease Drug Delivery System
(Device)C1
Inspirease Reservoir Bags (Aerosol)C1
Liteaire (Device)C1
Lma Mad Nasal (Device)C1
Mask Vortex/Baby Whirl Duckling (Mask)C1
Mask Vortex/Child/Frog (Mask)C1
Mask Vortex/Spinner The Duck (Mask)
OTC Drug NameC1
Mask Vortex/Toddler/Lady Bug (Mask)C1
Microchamber (Device)C1
Microspacer (Device)C1
Nebusal (3% Solution)C1
Nebusal (6% Solution)C1
Optichamber Advantage/Large Mask
(Device)C1
Optichamber Advantage/Medium Face
Mask (Device)C1
Optichamber Advantage/Small Face
Mask (Device)C1
Optichamber Diamond (Device)C1
Optichamber Diamond/Largeface Mask
(Device)C1
Optichamber Diamond/Medium Face
Mask (Device)C1
Optichamber Diamond/Smallface Mask
(Device)C1
Optichamber Face Mask/Large (Device)C1
Optichamber Face Mask/Medium
(Device)C1
Optichamber Face Mask/Small (Device)C1
Optihaler (Device)C1
Optihaler MDI Drug Delivery System
(Device)C1
Panda Mask Large (Mask)C1
Panda Mask Medium (Mask)C1
Panda Mask Small (Mask)C1
Pediatric Panda Mask (Mask)C1
Pocket Chamber (Device)C1
Pocket Spacer (Device)C1
Pro Comfort Inhaler Spacer Chamber
Adult (Device)C1
Pro Comfort Inhaler Spacer Chamber
Child (Device)C1
Riteflo (Device)
151
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Valved Holding Chamber (Device)C1
Vortex Valved Holding Chamber (Device)C1
Watchhaler (Device)B1
Saliva Replacement AgentsC1
Act Dry Mouth (Lozenge)C1
Biotene Dry Mouth (Lozenge)C1
Oral Relief For Dry Mouth (Lozenge)C1
Oral Relief For Dry Mouth& Discomfort (Kit)C1
Oral Relief For Dry Mouth& Discomfort (Lozenge)
C1
Salese/Xylitol (Lozenge)C1
Salivasure (Lozenge)C1
Therabreath Dry Mouth (Lozenge)A1
Ophthalmic AgentsB1
Allergy Agents, OphthalmicC1
Alaway (Ophthalmic Solution)C1
Alaway (Ophthalmic Solution)C1
Alaway Children's Allergy Eye Itch Relief
(Ophthalmic Solution)C1
Allergy Eye Drops (Ophthalmic Solution)C1
Clear Eyes Pure Relief For Dry Eyes
(Solution)C1
Computer Eye Drops (Solution)C1
CVS Allergy Eye Drops (Ophthalmic Solution)
C1
CVS Eye Allergy Relief (Ophthalmic Solution)
C1
CVS Eye Itch Relief (Ophthalmic Solution)C1
EQ Eye Allergy Relief (Ophthalmic Solution)
C1
Eye Allergy Relief (Ophthalmic Solution)C1
Eye Itch Relief (Ophthalmic Solution)C1
GNP Eye Itch Relief (Ophthalmic Solution)C1
GNP Itchy Eye (Ophthalmic Solution)C1
Goodsense Itchy Eye (Ophthalmic Solution)
OTC Drug NameC1
HM Eye Itch Relief (Ophthalmic Solution)C1
Ketotifen Fumarate (Ophthalmic Solution)C1
Ketotifen Fumarate (Solution)C1
KP Ketotifen Fumarate (Solution)C1
Naphcon-A (Ophthalmic Solution)C1
Opcon-A (Ophthalmic Solution)C1
RA Antihistamine Eye Drops (Ophthalmic Solution)
C1
RA Eye Allergy Relief (Ophthalmic Solution)
C1
RA Eye Itch Relief (Ophthalmic Solution)C1
SM Eye Itch Relief (Ophthalmic Solution)C1
TGT Eye Allergy Relief (Ophthalmic Solution)
C1
Theratears Allergy Eye Itch Relief (Ophthalmic Solution)
C1
Visine-A (Ophthalmic Solution)C1
Zaditor (Ophthalmic Solution)B1
Ophthalmic Agents, OtherC1
Akwa Tears (Ointment)C1
Artificial Tears (Ophthalmic Solution)C1
CVS Artificial Tears (Ophthalmic Solution)C1
EQ Artificial Tears (Ophthalmic Solution)C1
Genteal Tears Liquid Drops Moderate (Solution)
C1
RA Artificial Tears Eye Care (Ophthalmic Solution)
C1
RA Lubricant Eye Drops (Ophthalmic Solution)
C1
TGT Lubricant Eye Drops/Mild To Moderate (Ophthalmic Solution)
A1
Otic AgentsB1
Otic AgentsC1
Auraphene-B (Otic Solution)C1
Clearcanal Earwax Softener (Otic Solution)C1
CVS Ear Drops (Otic Solution)
152
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
CVS Ear Wax Removal Kit (Otic Solution)C1
CVS Earwax Removal Kit (Otic Solution)C1
CVS Earwax Removal System (Otic Solution)
C1
Ear Drops (Solution)C1
Ear Drops Earwax Removal Aid (Otic Solution)
C1
Ear Wax Cleansing (Otic Solution)C1
Ear Wax Cleansing Kit (Solution)C1
Ear Wax Drops (Otic Solution)C1
Ear Wax Removal Drops (Otic Solution)C1
Ear Wax Removal Kit (Otic Solution)C1
Ear Wax Removal System (Otic Solution)C1
Earwax Removal (Otic Solution)C1
Earwax Removal Aid (Otic Solution)C1
Earwax Removal Kit (Solution)C1
Earwax Treatment Drops (Solution)C1
EQ Ear Wax Removal Aid (Otic Solution)C1
GNP Ear Drops (Otic Solution)C1
GNP Ear Systems (Solution)C1
GNP Earwax Removal Drops (Otic Solution)
C1
GNP Earwax Removal Kit (Otic Solution)C1
Goodsense Ear Wax Removal (Otic Solution)
C1
HM Earwax Removal Aid (Solution)C1
HM Earwax Removal Kit (Solution)C1
Murine Ear (Otic Solution)C1
Murine For Ear Wax Removal System (Otic Solution)
C1
Otix (Otic Solution)C1
QC Ear Wax Removal Drops (Otic Solution)C1
QC Earwax Removal (Otic Solution)C1
RA Ear Drops (Otic Solution)
OTC Drug NameC1
RA Ear Wax Cleansing System (Otic Solution)
C1
RA Earwax Removal Kit (Otic Solution)C1
SB Ear Wax Remover (Otic Solution)C1
SM Ear Drops (Solution)A1
Respiratory Tract/Pulmonary AgentsB1
Antihistamines / DecongestantsC1
12 Hour Decongestant (Tablet Extended-Release)
C1
12 Hour Allergy-D (Tablet Extended-Release)
C1
12 Hour Nasal Decongestant/Maximum Strength (Tablet Extended-Release)
C1
Alavert (Tablet Disintegrating)C1
Aler-Cap (Capsule)C1
Aler-Dryl (Tablet)C1
Alertab (Tablet)C1
Alka-Seltzer Plus Allergy Fast Relief Formula (Tablet)
C1
All Day Allergy (Tablet)C1
All Day Allergy D-12 (Tablet Extended-Release)
C1
All Day Allergy-D (Tablet Extended-Release)
C1
Aller-Chlor (Tablet)C1
Allergy & Congestion Relief (Tablet Extended-Release)
C1
Allergy (12mg Tablet Extended-Release, 4mg Tablet, 10mg Tablet)
C1
Allergy 24 Hour Indoor/Outdoor (Tablet)C1
Allergy Children's (Syrup)C1
Allergy D-12 (Tablet Extended-Release)C1
Allergy Medication (Capsule)C1
Allergy Medication (Tablet)C1
Allergy Medication Children's (Liquid)C1
Allergy Non-Drowsy (Tablet)
153
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Allergy Relief (4mg Tablet, 25mg Tablet, 10mg Tablet Disintegrating, 10mg Tablet)
C1
Allergy Relief Child (Syrup)C1
Allergy Relief Children's (12.5mg/5ml Liquid, 12.5mg Tablet Disintegrating)
C1
Allergy Relief D (Tablet Extended-Release)C1
Allergy Relief D-24 (Tablet Extended-Release)
C1
Allergy Relief Loratadine (Tablet)C1
Allergy Relief Nasal Decongestant (Tablet Extended-Release)
C1
Allergy Relief Nighttime (Tablet)C1
Allergy Relief/Indoor/Outdoor (Tablet)C1
Allergy Relief/Nasal Decongestant (Tablet Extended-Release)
C1
Allergy Relief-D (Tablet Extended-Release)C1
Allergy Tablets (Tablet)C1
Allergy-Relief-D (Tablet Extended-Release)C1
Allergy-Time (Tablet)C1
Anti-Hist Allergy (Tablet)C1
Banophen (Liquid)C1
Banophen (Tablet)C1
Cetirizine HCL (10mg Tablet Chewable, 5mg Tablet Chewable, 5mg Tablet)
C1
Cetirizine HCL Children's (10mg Tablet Chewable, 5mg Tablet Chewable)
C1
Cetirizine HCL/Pseudoephedrine HCL ER (Tablet Extended-Release)
C1
Cetirizine Hydrochloride (Tablet)C1
Children's Allergy (Liquid)C1
Children's Loratadine (Syrup)C1
Children's Silfedrine (Liquid)C1
Chlorhist (Tablet)C1
Chlorphen SR (Tablet Extended-Release)C1
Chlorpheniramine Maleate (Tablet Extended-Release)
OTC Drug NameC1
Claritin Allergy Children's (Syrup)C1
Complete Allergy Medication (Tablet)C1
Complete Allergy Medicine (Capsule)C1
Complete Allergy Medicine (Tablet)C1
Complete Allergy Relief (Tablet)C1
Cough Daytime/Nighttime (Liquid)C1
CVS 12 Hour Nasal Decongestant (Tablet Extended-Release)
C1
CVS Allergy (Capsule)C1
CVS Allergy (Tablet)C1
CVS Allergy Relief (Tablet Extended-Release)
C1
CVS Allergy Relief Adult Maximum Strength (Liquid)
C1
CVS Allergy Relief Children's (Tablet)C1
CVS Allergy Relief Nighttime (Tablet)C1
CVS Allergy Relief-D (Tablet Extended-Release)
C1
CVS Allergy Relief-D12 (Tablet Extended-Release)
C1
CVS Children's Allergy (Liquid)C1
CVS Children's Allergy Relief (Liquid)C1
CVS Daytime/Nighttime Cough Relief (Liquid)
C1
CVS Dye-Free Allergy (Tablet)C1
CVS Indoor/Outdoor Allergy Relief (Tablet)C1
CVS Indoor/Outdoor Allergy Relief Children's (Tablet Chewable)
C1
CVS Loratadine (Tablet)C1
CVS Nasal Decongestant (Tablet)C1
CVS Nighttime Cough (Liquid)C1
CVS Nighttime Tussin DM (Liquid)C1
CVS Sleep-Aid Nighttime (Tablet)C1
CVS Ultra Sleep (Tablet)C1
Decongestant (Tablet)
154
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Decongestant 12Hour Maximum Strength (Tablet Extended-Release)
C1
Diabetic Tussin Allergy (Syrup)C1
Diphen (Tablet)C1
Diphenhist (12.5mg/5ml Liquid, 25mg Tablet)
C1
Diphenhydramine HCL (Tablet)C1
Diphenhydramine Hydrochloride (Liquid)C1
Diphenhydramine Hydrochloride Children's Dye Free (Liquid)
C1
Dye-Free Allergy Relief Children's (Liquid)C1
ED Chlorped Jr (Syrup)C1
EQ Allergy & Congestion Relief (Tablet Extended-Release)
C1
EQ Allergy (Capsule)C1
EQ Allergy Children's (Syrup)C1
EQ Allergy Relief (Capsule)C1
EQ Allergy Relief (Tablet)C1
EQ Allergy Relief Children's (Tablet)C1
EQ Allergy Relief D 24 Hour (Tablet Extended-Release)
C1
EQ Cetirizine Hydrochloride Children's (Tablet Chewable)
C1
EQ Children's Loratadine (Syrup)C1
EQ Chlortabs (Tablet)C1
EQ Loratadine (Tablet Disintegrating)C1
EQ Loratadine (Tablet)C1
EQ Loratadine Children's (Tablet Chewable)
C1
EQ Night Time Cough (Liquid)C1
EQ Suphedrine (Tablet)C1
EQL All Day Allergy (Tablet)C1
EQL All Day Allergy-D (Tablet Extended-Release)
C1
EQL Allergy (Tablet)C1
EQL Allergy Relief (Capsule)
OTC Drug NameC1
EQL Allergy Relief (Tablet)C1
EQL Allergy Relief Children's (Tablet)C1
EQL Allergy/Congestion Relief (Tablet Extended-Release)
C1
EQL Children's Allergy (Liquid)C1
EQL Nasal Decongestant (Tablet)C1
EQL Nasal Decongestant Maximum Strength (Tablet)
C1
EQL Nighttime Cough Relief (Liquid)C1
EQL Nighttime Sleep Aid (Tablet)C1
Genahist (Capsule)C1
Genaphed (Tablet)C1
Geri-Dryl (Capsule)C1
Geri-Dryl (Liquid)C1
Geri-Dryl Allergy Relief (Tablet)C1
GNP All Day Allergy (Tablet)C1
GNP All Day Allergy-D (Tablet Extended-Release)
C1
GNP Allergy & Congestion Relief (Tablet Extended-Release)
C1
GNP Allergy (4mg Tablet, 25mg Tablet)C1
GNP Allergy AntihistamineChildren's (Liquid)
C1
GNP Allergy Relief (12.5mg Tablet Chewable, 10mg Tablet)
C1
GNP Allergy Relief For Kids (Tablet)C1
GNP Children's Allergy (Liquid)C1
GNP Loratadine (5mg/5ml Syrup, 10mg Tablet)
C1
GNP Loratadine Children's (Syrup)C1
GNP Loratadine-D 12Hr (Tablet Extended-Release)
C1
GNP Loratadine-D 24 Hour (Tablet Extended-Release)
C1
GNP Nasal Decongestant (Tablet)
155
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
GNP Nasal Decongestant/Maximum Strength (Tablet)
C1
GNP Night Time Cough (Liquid)C1
GNP Pseudoephedrine HCL 12 Hour (Tablet Extended-Release)
C1
GNP Pseudoephedrine HCL ER (Tablet Extended-Release)
C1
GNP Sleep Aid (Tablet)C1
GNP Suphedrin (Liquid)C1
GNP Tussin DM Max (Liquid)C1
Goodsense All Day Allergy (Tablet)C1
Goodsense Allergy Relief (Tablet)C1
HM All Day Allergy (Tablet)C1
HM Allergy & Congestion (Tablet Extended-Release)
C1
HM Allergy (Tablet)C1
HM Allergy Children's (Liquid)C1
HM Allergy Complete-D (Tablet Extended-Release)
C1
HM Allergy Relief & Nasal Decongestant (Tablet Extended-Release)
C1
HM Allergy Relief (4mg Tablet, 25mg Tablet)
C1
HM Allergy Relief Children's (Liquid)C1
HM Allgery Multi Symptom (Capsule)C1
HM Cetirizine Hydrochloride (Tablet)C1
HM Loratadine (Tablet)C1
HM Loratadine Children's (Syrup)C1
HM Nasal Decongestant (Tablet)C1
HM Nasal Decongestant 12 Hour (Tablet Extended-Release)
C1
HM Sleep Aid (Tablet)C1
KLS Allerclear (Tablet)C1
KLS Allerclear D-12 Hr (Tablet Extended-Release)
OTC Drug NameC1
KLS Allerclear D-12Hr (Tablet Extended-Release)
C1
KLS Allerclear D-24Hr (Tablet Extended-Release)
C1
KLS Allerclear-D 24Hr (Tablet Extended-Release)
C1
KLS Allergy Medicine (Tablet)C1
KLS Aller-Tec (Tablet)C1
KLS Aller-Tec D (Tablet Extended-Release)C1
KP Cetirizine HCl (Tablet)C1
KP Cetirizine Hydrochloride (Tablet)C1
KP Diphenhydramine HCl (Capsule)C1
KP Loratadine (Tablet)C1
KP Pseudoephedrine HCl (Tablet)C1
Loradamed (Tablet)C1
Loratadine (Tablet)C1
Loratadine Children's (5mg/ml Syrup, 5mg Tablet Chewable)
C1
Loratadine Hives Relief (Syrup)C1
Loratadine/Pseudoephedrine (Tablet Extended-Release)
C1
Loratadine-D 12Hr (Tablet Extended-Release)
C1
Loratadine-D 24Hr (Tablet Extended-Release)
C1
Medi-Phedryl (Capsule)C1
Meijer Allergy Relief (Tablet Disintegrating)C1
Meijer Allergy Relief (Tablet)C1
Meijer Allergy Relief-D (Tablet Extended-Release)
C1
Meijer Allergy/Congestion Relief (Tablet Extended-Release)
C1
Meijer Antihistamine Allergy (Capsule)C1
Meijer Loratadine (Syrup)C1
Meijer Nasal Decongestant (Tablet)C1
MM Cetirizine Hydrochloride (Tablet)
156
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
MM Loratadine-D 24 Hour (Tablet Extended-Release)
C1
Naramin (Liquid)C1
Nasal Decongestant (30mg/5ml Liquid, 30mg/5ml Syrup, 30mg Tablet)
C1
Nasal Decongestant 12 Hour Sinus (Tablet Extended-Release)
C1
Nasal Decongestant Maximum Strength (Tablet)
C1
Nighttime Cough (Liquid)C1
Nite Time Cough (Liquid)C1
Pediacare Children's Allergy (Liquid)C1
Pediaclear Cough Children's (Liquid)C1
Pharbechlor (Tablet)C1
Pharbedryl (Capsule)C1
Pseudoephedrine (Syrup)C1
Pseudoephedrine HCL (Tablet)C1
Pseudoephedrine HCL ER (Tablet Extended-Release)
C1
Pseudoephedrine Hydrochloride (Tablet)C1
PX Allergy (Capsule)C1
PX Allergy (Liquid)C1
PX Allergy (Tablet)C1
PX Allergy Relief (Tablet Disintegrating)C1
PX Allergy Relief (Tablet)C1
PX Allergy Relief D (Tablet Extended-Release)
C1
PX Nasal Decongestant (Tablet Extended-Release)
C1
PX Nasal Decongestant (Tablet)C1
PX Nitetime Cough (Liquid)C1
QC All Day Allergy (Tablet)C1
QC Allergy Relief (Tablet Disintegrating)C1
QC Allergy Relief (Tablet)C1
QC Allergy Relief Children's (Syrup)C1
QC Chlor-Pheniramine (Tablet)
OTC Drug NameC1
QC Complete Allergy Medicine (Tablet)C1
QC Loratadine Allergy Relief (Tablet)C1
QC Loratadine-D (Tablet Extended-Release)
C1
QC Nighttime Cough (Liquid)C1
QC Suphedrine (Tablet)C1
QC Suphedrine Maximum Strength (Tablet Extended-Release)
C1
RA Allergy (Liquid)C1
RA Allergy (Tablet)C1
RA Allergy Medication (Capsule)C1
RA Allergy Medication (Tablet)C1
RA Allergy Medication Children's (Liquid)C1
RA Allergy Relief (Capsule)C1
RA Allergy Relief (Tablet Disintegrating)C1
RA Allergy Relief (Tablet)C1
RA Allergy Relief 24 Hour (Tablet)C1
RA Allergy Relief Children's (Tablet)C1
RA Allergy/Congestion Relief (Tablet Extended-Release)
C1
RA Cetiri-D (Tablet Extended-Release)C1
RA Cetirizine (Tablet)C1
RA Cetirizine Children's (Tablet Chewable)C1
RA Chlorpheniramine Maleate (Tablet)C1
RA Complete Allergy (Tablet)C1
RA Diphedryl Allergy (Liquid)C1
RA Lorata-D (Tablet Extended-Release)C1
RA Loratadine (Syrup)C1
RA Loratadine (Tablet Disintegrating)C1
RA Loratadine (Tablet)C1
RA Loratadine Children's (Syrup)C1
RA Night Sleep Aid (Tablet)C1
RA Nighttime Cough Relief (Liquid)C1
RA Nite Time Cough (Liquid)
157
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
RA Sleep Aid (Tablet)C1
RA Suphedrine (Tablet Extended-Release)C1
RA Suphedrine (Tablet)C1
RA Tussin Nighttime Cough DM/Maximum Strength/Adult (Liquid)
C1
Robitussin Nightime Cough DM Maximum Strength (Liquid)
C1
Robitussin Nighttime Cough DM (Liquid)C1
Safe Tussin PM (Liquid)C1
SB Allergy (Capsule)C1
SB Allergy (Tablet)C1
SB Allergy Medicine (Liquid)C1
SB Allergy Medicine (Tablet)C1
SB Allergy Relief (Tablet Disintegrating)C1
SB Allergy Relief/Nasal Decongestant (Tablet Extended-Release)
C1
SB Chlorpheniramine (Tablet)C1
SB Loratadine (Syrup)C1
SB Loratadine (Tablet)C1
SB Loratadine Allergy Relief (Tablet)C1
SB Nighttime Cough (Liquid)C1
Shopko Allergy Relief-D (Tablet Extended-Release)
C1
Shopko Nasal Decongestant (Tablet Extended-Release)
C1
Shopko Nasal Decongestant Maximum Strength (Tablet)
C1
Siladryl Allergy (Liquid)C1
Silphen Cough (Syrup)C1
Sleep Aid (Tablet)C1
SM 12 Hour Sinus Decongestant (Tablet Extended-Release)
C1
SM All Day Allergy (Tablet)C1
SM All Day Allergy-D (Tablet Extended-Release)
C1
SM Allergy 4 Hour (Tablet)
OTC Drug NameC1
SM Allergy Children's (Syrup)C1
SM Allergy Relief (12.5mg/ml Liquid, 25mg Tablet)
C1
SM Allergy Relief Children's (Liquid)C1
SM Children's Loratadine (Syrup)C1
SM Loratadine (Syrup)C1
SM Loratadine (Tablet)C1
SM Loratadine Allergy Relief (Tablet Disintegrating)
C1
SM Lorata-Dine D (Tablet Extended-Release)
C1
SM Loratadine D 12Hr (Tablet Extended-Release)
C1
SM Nasal Decongestant Maximum Strength (Tablet)
C1
SM Sleep Aid (Tablet)C1
Sudafed 12 Hour (Tablet Extended-Release)
C1
Sudafed Sinus Congestion 12 Hour (Tablet Extended-Release)
C1
Sudogest (30mg Tablet, 60mg Tablet)C1
Sudogest 12 Hour (Tablet Extended-Release)
C1
Sudogest Maximum Strength (Tablet)C1
SW Allergy Relief-D (Tablet Extended-Release)
C1
TGT All Day Allergy Relief (Tablet)C1
TGT All Day Allergy-D (Tablet Extended-Release)
C1
TGT Allergy & Congestion Relief (Tablet Extended-Release)
C1
TGT Allergy Melts Children's (Tablet)C1
TGT Allergy Relief (Capsule)C1
TGT Allergy Relief (Tablet Disintegrating)C1
TGT Allergy Relief (Tablet)C1
TGT Allergy Relief Children's (Liquid)
158
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
TGT Allergy Relief Children's Dye Free (Liquid)
C1
TGT Allergy+ Congestion Relief-D (Tablet Extended-Release)
C1
TGT Loratadine Children's (Syrup)C1
TGT Sinus 12 Hour (Tablet Extended-Release)
C1
Total Allergy (Tablet)C1
Total Allergy Medicine (Liquid)C1
Triaminic Allerchews (Tablet Disintegrating)
C1
Vicks Dayquil/Nyquil Cough (Liquid)C1
Wal-Dryl Allergy (Capsule)C1
Wal-Dryl Allergy (Liquid)C1
Wal-Dryl Allergy (Tablet)C1
Wal-Dryl Allergy Children's (Liquid)C1
Wal-Dryl Allergy Dye-FreeChildren's (Liquid)
C1
Wal-Dryl Allergy Relief Children's (Tablet)C1
Wal-Finate (Tablet)C1
Wal-Itin (Syrup)C1
Wal-Itin (Tablet Disintegrating)C1
Wal-Itin (Tablet)C1
Wal-Itin Allergy Relief Reditabs (Tablet Disintegrating)
C1
Wal-Itin Aller-Melts (Tablet Disintegrating)C1
Wal-Itin Children's (Syrup)C1
Wal-Itin D (Tablet Extended-Release)C1
Wal-Itin D 24 Hour (Tablet Extended-Release)
C1
Wal-Phed (Tablet)C1
Wal-Phed 12 Hour (Tablet Extended-Release)
C1
Wal-Phed D (Tablet Extended-Release)C1
Wal-Som (Tablet)C1
Wal-Vert (Tablet Disintegrating)
OTC Drug NameC1
Wal-Zyr (Tablet)C1
Wal-Zyr Children's (Tablet Chewable)C1
Wal-Zyr D (Tablet Extended-Release)C1
Zephrex-D (Tablet)B1
Intranasal SpraysC1
Allergy Nasal Spray 24 Hour (Suspension)C1
Budesonide Nasal Spray (Suspension)C1
CVS Budesonide Nasal Spray (Suspension)
C1
CVS Nasal Allergy Spray (Suspension)C1
EQ Budesonide Nasal Spray (Suspension)C1
EQ Nasal Allergy Spray (Suspension)C1
GNP 24 Hour Nasal Allergy Spray (Suspension)
C1
GNP Budesonide Nasal Spray (Suspension)
C1
Goodsense Nasal Allergy Spray (Suspension)
C1
Nasacort Allergy 24Hr (Suspension)C1
Nasacort Allergy 24Hr Children's
(Suspension)C1
Nasal Allergy 24 Hour (Suspension)C1
Nasal Allergy 24 Hour Multi-Symptom (Suspension)
C1
RA Budesonide Nasal Spray (Suspension)C1
RA Nasal Allergy Spray (Suspension)C1
Rhinocort Allergy (Suspension)B1
Respiratory AgentsC1
Nasal Mist (Solution)C1
Pulmosal (Solution)C1
Simply Saline Baby (Solution)C1
Sodium Chloride (0.9% Solution, 10%, Solution, 3% Solution, 7% Solution)
C1
Triamcinolone Acetonide (Suspension)A1
Therapeutic Nutrients/Minerals/ElectrolytesB1
Vitamins / Nutrients / Supplements
159
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
600+D3 Plus Minerals (Tablet Chewable)C1
50+ Adult Eye Health (Capsule)C1
A Thru Z Advanced (Tablet)C1
A Thru Z Advanced Adult Formula (Tablet)C1
A Thru Z High Potency (Tablet)C1
A Thru Z Select (Tablet Chewable)C1
A Thru Z Select (Tablet)C1
A Thru Z Select 50+ Advanced Formula (Tablet)
C1
A Thru Z Select 50+ Mens (Tablet)C1
A Thru Z Select Advanced (Tablet)C1
A Thru Z Select Ultimate Womens (Tablet)C1
A Thru Z Ultimate Mens (Tablet)C1
A-10000 (Capsule)C1
A-25 (Capsule)C1
ABC Plus (Tablet)C1
ABC Plus Senior (Tablet)C1
ABC Plus Senior Adults 50+ (Tablet)C1
Abdek (Tablet Chewable)C1
Abdek Pediatric (Drops)C1
Acerola C-500 (Tablet Chewable)C1
Act Anticavity Fluoride Rinse (Rinse)C1
Act Anticavity Fluoride Rinse Kids (Rinse)C1
Act Restoring Fluoride Rinse (Rinse)C1
Act Total Care (Rinse)C1
Act Total Care Dry Mouth (Rinse)C1
Actical (Capsule)C1
ADC/Fluoride (Solution)C1
Adult Gummy (Tablet Chewable)C1
Advanced Calcium Formula (Tablet)C1
Advanced Eye Health (Capsule)C1
Advanced Multi EA (Tablet Chewable)C1
Advantage Care Oral Electrolyte Pediatric (Oral Solution)
OTC Drug NameC1
Airborne (Tablet Chewable)C1
Airborne (Tablet)C1
Airborne Gummies (Tablet Chewable)C1
Airborne Immune System (Tablet Chewable)
C1
Alive Gummies For Children (Tablet Chewable)
C1
Alive Multi-Vitamin Children's Chewable (Tablet Chewable)
C1
Alph-E (Capsule)C1
Alph-E-Mixed (200unit Capsule, 400unit Capsule)
C1
Alph-E-Mixed 1000 (Capsule)C1
Amoryn Mood Booster (Capsule)C1
Animal Chews (Tablet Chewable)C1
Animal Shapes (Tablet Chewable)C1
Animal Shapes/Iron (Tablet Chewable)C1
Antioxidant (Capsule)C1
Anti-Oxidant (Tablet)C1
Anti-Oxidant Formula (Capsule)C1
Antioxidant Formula/Minerals (Capsule)C1
Antioxidant Protection Formula (Tablet)C1
Antioxidant Vitamins (Tablet)C1
Antioxin 4000 (Capsule)C1
Aqueous Vitamin D Infants (Liquid)C1
Aqueous Vitamin E (Solution)C1
Ascocid-Iso-Ph (Powder)C1
Ascorbic Acid (250mg Tablet Chewable, 250mg Tablet, 500mg Tablet, 1000mg Tablet)
C1
Asco-Tabs-1000 (Tablet)C1
Avoria Cal+D (Packet)C1
B Complex (Capsule)C1
B-1 (100mg, 250mg Tablet)C1
B-1 (Tablet)
160
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
B-1 High Potency (Tablet)C1
B-1 Natural (Tablet)C1
B-12 (Capsule)C1
B-12 (Lozenge)C1
B-12 (Tablet Extended-Release)C1
B-12 (Tablet)C1
B-12 Fast Dissolve (Tablet)C1
B-12 Super Strength (Liquid)C1
B-12 TR (Tablet Extended-Release)C1
B-12-Sl (Tablet)C1
B-2 (Tablet)C1
B-6 (Tablet)C1
B-6 Natural (Tablet)C1
Baby Super Daily D3 (Drops)C1
Baby Vitamin D3 Drops (Drops)C1
B-Complex (Capsule)C1
B-Complex 50 (Tablet)C1
B-Complex 50 TR (Tablet Extended-Release)
C1
B-Complex High Potency (Tablet Extended-Release)
C1
B-Complex Plus Vitamin C (Tablet)C1
B-Complex With B-12 (Tablet)C1
B-Complex/B-12 (Liquid)C1
B-Complex/B-12 (Tablet)C1
BD Posiflush (Solution)C1
Berocca (Tablet)C1
Biocel (Tablet)C1
Bio-D-Mulsion (Drops)C1
Bio-D-Mulsion Forte (Drops)C1
Biosupp (Liquid)C1
Biotin Plus/Calcium/Vit D3 (Tablet)C1
Bite-A-Mins (Tablet Chewable)C1
Bite-A-Mins/Iron (Tablet Chewable)
OTC Drug NameC1
Body/Hair/Skin/Nails (Capsule)C1
Bone Density (Tablet)C1
Bone Meal (Tablet)C1
Bounty Bears/C (Tablet Chewable)C1
BP Multinatal Plus (Tablet Chewable)C1
BP Multinatal Plus (Tablet)C1
B-Plex Plus (Tablet)C1
BProtected Multi-Vite (Liquid)C1
Bprotected Pedia D-Vite (Liquid)C1
Bprotected Pedia Iron (Solution)C1
Bprotected Pedia Poly-Vite (Solution)C1
Bprotected Pedia Poly-Vite/Iron (Drops)C1
Bprotected Pedia Tri-Vite (Drops)C1
Bprotected Vitamin C/Rosehips (Liquid)C1
B-Redi/Red Hearts/Red Roosters (Tablet)C1
Brewers Yeast (Tablet)C1
Buffered Vitamin C (Capsule)C1
C 1000 (Tablet)C1
C 250 (Tablet Chewable)C1
C 250 (Tablet)C1
C 500 (Tablet Chewable)C1
C 500 (Tablet)C1
C 500/Rose Hips (Tablet)C1
C-1000 (Tablet)C1
C-1000 Prolonged Release (Tablet Extended-Release)
C1
C-1000 SR (Tablet Extended-Release)C1
C-1000/Rose Hips (Tablet)C1
C-1000/Rose Hips SR (Tablet Extended-Release)
C1
C-1500/Rose Hips SR (Tablet Extended-Release)
C1
C-250 (Tablet Chewable)C1
C-250 (Tablet)
161
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
C-500 (Tablet Chewable)C1
C-500 (Tablet)C1
C-500 Non-Acid (Tablet)C1
C-500 Prolonged Release (Tablet Extended-Release)
C1
C-500 SR (Capsule)C1
C-500 SR (Tablet Extended-Release)C1
C-500/Rose Hips (Tablet)C1
Cal/Mag (Tablet)C1
Cal/Mag Citrate (Tablet)C1
Cal-Carb Forte (Tablet)C1
Calcet Creamy Bites (Tablet Chewable)C1
Calcet Petites (Tablet)C1
Calcidol (Solution)C1
Calciferol (Solution)C1
Calcifol (Wafer)C1
Calci-Max (Capsule)C1
Calcitrate (Tablet)C1
Calcitrate Plus D (Tablet)C1
Cal-Citrate Plus Vitamin D (Tablet)C1
Calcium & Magnesium + Zinc (Tablet)C1
Calcium (Capsule)C1
Calcium (Tablet Chewable)C1
Calcium (Tablet)C1
Calcium + D (Tablet Chewable)C1
Calcium + D + K (Tablet)C1
Calcium + D3 (Tablet)C1
Calcium 1000 + D (Tablet)C1
Calcium 1200 (Tablet Chewable)C1
Calcium 500 (Tablet)C1
Calcium 500 + D (Tablet)C1
Calcium 500 + D3 (Tablet Chewable)C1
Calcium 500 +D (Tablet)C1
Calcium 500 +D3 (Tablet)
OTC Drug NameC1
Calcium 500/D (Tablet Chewable)C1
Calcium 500/D (Tablet)C1
Calcium 500/Vitamin D (Tablet)C1
Calcium 500/Vitamin D3 (Tablet)C1
Calcium 500+D (Tablet)C1
Calcium 500+D High Potency (Tablet)C1
Calcium 500+D3 (Tablet)C1
Calcium 600 (Tablet)C1
Calcium 600 + D (Tablet)C1
Calcium 600 + Minerals (Tablet)C1
Calcium 600 High Potency (Tablet)C1
Calcium 600 With Vitamin D (Tablet Chewable)
C1
Calcium 600 With Vitamin D (Tablet)C1
Calcium 600/Magnesium 300/Vitamin D
(Capsule)C1
Calcium 600/Vitamin D (Tablet)C1
Calcium 600/Vitamin D3 (Tablet)C1
Calcium 600+D (Tablet)C1
Calcium 600+D High Potency (Tablet)C1
Calcium 600+D Plus Minerals (Tablet Chewable)
C1
Calcium 600+D Plus Minerals (Tablet)C1
Calcium 600+D3 (Tablet)C1
Calcium 600+D3 Plus Minerals (Tablet Chewable)
C1
Calcium 600+D3 Plus Minerals (Tablet)C1
Calcium 600-D (Tablet)C1
Calcium Acetate (Tablet)C1
Calcium Ascorbate (Tablet)C1
Calcium Aspartate (Tablet)C1
Calcium Carbonate (Tablet)C1
Calcium Carbonate (Wafer)C1
Calcium Carbonate/D3 (Tablet)C1
Calcium Carbonate/Vitamin D (Tablet)
162
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Calcium Chews (Tablet Chewable)C1
Calcium Citrate (Oral Granules)C1
Calcium Citrate (Tablet)C1
Calcium Citrate + (Tablet)C1
Calcium Citrate + D (Tablet)C1
Calcium Citrate + D3 (Tablet)C1
Calcium Citrate + D3 Maximum (Tablet)C1
Calcium Citrate +D (Tablet)C1
Calcium Citrate Chewy Bite (Tablet Chewable)
C1
Calcium Citrate Malate/Vitamin D (Tablet)C1
Calcium Citrate Petite/Vitamin D (Tablet)C1
Calcium Citrate W/D (Tablet)C1
Calcium Citrate W/Vitamin D (Tablet)C1
Calcium Citrate/D3 (Tablet)C1
Calcium Citrate/Magnesium/Vitamin D
Chewable Wafers (Wafer)C1
Calcium Citrate/Vitamin D (Tablet)C1
Calcium Citrate/Vitamin D3 (Liquid)C1
Calcium Citrate/Vitamin D3 (Tablet)C1
Calcium Citrate+D (Tablet)C1
Calcium Citrate+D3 (Tablet)C1
Calcium Citrate+D3 Petites (Tablet)C1
Calcium Creamies (Tablet Chewable)C1
Calcium Extra D3 (Tablet)C1
Calcium For Women (Tablet Chewable)C1
Calcium Gluconate (Tablet)C1
Calcium Gluconate/Dextrose (Solution)C1
Calcium Gluconate/Sodium Chloride
(Solution)C1
Calcium Gummies (Tablet Chewable)C1
Calcium High Potency (Tablet)C1
Calcium High Potency + Vitamin D (Tablet)C1
Calcium Lactate (Tablet)
OTC Drug NameC1
Calcium Magnesium & Zinc (Tablet)C1
Calcium Magnesium 750 (Tablet)C1
Calcium Oyster Shell (Tablet)C1
Calcium Plus D3 Absorbable (Capsule)C1
Calcium Plus Vitamin D (Capsule)C1
Calcium Plus Vitamin D3 (Capsule)C1
Calcium Plus Vitamin D3 (Tablet)C1
Calcium Soft Chews (Tablet Chewable)C1
Calcium Soft Chews (Tablet Chewable)C1
Calcium/C/D (Tablet Chewable)C1
Calcium/D (Wafer)C1
Calcium/D3 Adult Gummies (Tablet Chewable)
C1
Calcium/Magnesium (Tablet)C1
Calcium/Magnesium (Tablet)C1
Calcium/Magnesium Citrate (Tablet)C1
Calcium/Magnesium/Vitamind (Tablet)C1
Calcium/Magnesium/Zinc (Tablet)C1
Calcium/Vitamin D (Capsule)C1
Calcium/Vitamin D (Tablet)C1
Calcium/Vitamin D/Minerals (Tablet Chewable)
C1
Calcium/Vitamin D3 (Capsule)C1
Calcium/Vitamin D-3 (Tablet Chewable)C1
Calcium/Vitamin D3 (Tablet)C1
Calcium/Vitamin D3 Gummies (Tablet
Chewable)C1
Calcium/Vitamin D3 Gummies (Tablet Chewable)
C1
Calcium/Vitamin D3/Adult Gummy (Tablet Chewable)
C1
Calcium+D3 (Tablet)C1
Calcium+D3 Gradual Release (Tablet Extended-Release)
C1
Calcium+Menaq7 (Tablet)
163
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Calcium-Folic Acid Plus D (Wafer)C1
Calciumvitamin D3 Plus Minerals (Tablet Chewable)
C1
Cal-Mag (Tablet)C1
Cal-Mag Aspartate (Tablet)C1
Cal-Mag Chela-Max (Capsule)C1
Cal-Mag Complex (Tablet)C1
Calmag Thins (Tablet)C1
Cal-Quick (Liquid)C1
Caltrate 600 (Tablet)C1
Caltrate 600+D Plus Minerals (Tablet
Chewable)C1
Caltrate 600+D Plus Minerals (Tablet)C1
Caltrate 600+D3 (Tablet)C1
Caltrate 600+D3 Soft Chews (Tablet
Chewable)C1
Caltrate Gummy Bites (Tablet Chewable)C1
Caltrate Minis Plus Minerals (Tablet)C1
Carravite (Tablet)C1
C-Chewable (Tablet Chewable)C1
Celebrate Calcium Citrate (Tablet Chewable)
C1
Celebrate Calcium Plus 500 (Tablet
Chewable)C1
Cemill (Tablet Extended-Release)C1
Cemill SR (Tablet Extended-Release)C1
Centamin (Liquid)C1
Centavite (Liquid)C1
Centavite A-Z Complete Multivitamin/Minerals (Tablet)
C1
Centravites (Tablet)C1
Centravites 50 Plus (Tablet)C1
Centrum Kids Complete (Tablet Chewable)C1
Century (Tablet)C1
Century Mature (Tablet)
OTC Drug NameC1
Ceralyte 70 (Oral Solution)C1
Cerovite Advanced Formula (Tablet)C1
Cerovite Jr (Tablet Chewable)C1
Cerovite Senior (Tablet)C1
Certa Plus (Tablet)C1
Certagen (Tablet)C1
Certavite/Antioxidants (Tablet)C1
Chelated Calcium (Tablet)C1
Chelated Magnesium (Tablet)C1
Chelated Potassium (Tablet)C1
Chewable Calcium (Tablet Chewable)C1
Chewable Vitamin C (Tablet Chewable)C1
Chewable Vitamins Children's (Tablet Chewable)
C1
Chewable Vite Children's (Tablet Chewable)
C1
Chewable Vite With Iron/Children's (Tablet Chewable)
C1
Chew-C (Tablet Chewable)C1
Children's Animal Shapes Complete (Tablet Chewable)
C1
Children's Chewable Multivitamin (Tablet Chewable)
C1
Children's Chewable Multivitamin With Iron (Tablet Chewable)
C1
Children's Chewable Vitamin (Tablet Chewable)
C1
Children's Chewable Vitamins (Tablet Chewable)
C1
Children's Chewable Vitamins/Iron (Tablet Chewable)
C1
Children's Gummies (Tablet Chewable)C1
Children's Multivitamin (Tablet Chewable)C1
Chlorocaps (Capsule)C1
Citracal + D3 Maximum (Tablet)
164
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Citracal Calcium Gummies (Tablet
Chewable)C1
Citracal Calcium+D Slow Release (Tablet
Extended-Release)C1
Citracal Maximum (Tablet)C1
Citracal Petites/Vitamin D (Tablet)C1
Citracal+D3 (Tablet Chewable)C1
Citrate Of Magnesia (Solution)C1
Citroma (Solution)C1
Citrus Calcium +D (Tablet)C1
Citrus Calcium/Vitamin D (Tablet)C1
Classic Prenatal (Tablet)C1
Co Q-10 (Capsule)C1
Co Q-10 Maximum Strength (Capsule)C1
Cod Liver Oil (Capsule)C1
Cod Liver Oil W/Vitamins A&D (Capsule)C1
Cod Liver Oil/Low Vitamin A (Capsule)C1
Cod Liver Oil/Vitamins A & D (Capsule)C1
Co-Enzyme Q-10 (Capsule)C1
Coenzyme Q10 (Liquid)C1
Co-Enzyme Q-10 (Tablet)C1
Coenzyme Q-10 High Potency (Capsule)C1
Companion (Tablet)C1
Compete (Tablet)C1
Complere (Tablet)C1
Complete (Tablet)C1
Complete Daily With Lutein (Tablet)C1
Complete Energy (Tablet)C1
Complete Multi-Vitamin Gummies (Tablet Chewable)
C1
Complete Multivitamin/Multimineral Supplement (Liquid)
C1
Complete PMS Support Complex (Capsule)
C1
Complete Womens (Tablet)
OTC Drug NameC1
Coq-10 (Capsule)C1
Coq-10 Fast Dissolve (Tablet)C1
Coq10 Gummies Adult (Tablet Chewable)C1
Coq10 Maximum Strength (Capsule)C1
Coral Calcium (Capsule)C1
Coral Calcium (Capsule)C1
Coral Calcium Plus (Capsule)C1
Coral Calcium Plus (Capsule)C1
Corvite Free (Tablet)C1
Crest Complete (Paste)C1
Crest Pro-Health Complete (Rinse)C1
Crush Vitamin C Drops (Lozenge)C1
C-Time SR (Capsule)C1
CVS Airshield (Tablet)C1
CVS B-1 (Tablet)C1
CVS B-12 (Liquid)C1
CVS B-12 (Tablet Chewable)C1
CVS B-12 (Tablet)C1
CVS B-12 Gummies (Tablet Chewable)C1
CVS B-6 (Tablet)C1
CVS Balanced B100 (Tablet Extended-Release)
C1
CVS Calcium (Tablet Chewable)C1
CVS Calcium (Tablet)C1
CVS Calcium 600 & Vitamind3 (Tablet)C1
CVS Calcium 600 + D Plus Minerals (Tablet Chewable)
C1
CVS Calcium 600 + D Plus Minerals (Tablet)
C1
CVS Calcium 600+D (Tablet)C1
CVS Calcium Carbonate (Tablet)C1
CVS Calcium Citrate + D (Tablet)C1
CVS Calcium Citrate +D3 Miniatures (Tablet)
165
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
CVS Calcium Soft Chews (Tablet Chewable)
C1
CVS Calcium/Magnesium/Zinc (Tablet)C1
CVS Chewable Children's Vitamin (Tablet Chewable)
C1
CVS Children's Chewable Complete (Tablet Chewable)
C1
CVS Citrate Of Magnesia (Solution)C1
CVS Cod Liver Oil (Capsule)C1
CVS Coenzyme Q-10 (Capsule)C1
CVS Coq-10 (Capsule)C1
CVS D3 (Capsule)C1
CVS D3 (Tablet Chewable)C1
CVS Daily Gummies (Tablet Chewable)C1
CVS Daily Multiple (Tablet)C1
CVS Daily Multiple For Men (Tablet)C1
CVS Daily Multiple For Women (Tablet)C1
CVS Daily Multiple For Women 50+ (Tablet)
C1
CVS Daily Multiple Plus Iron/Calcium/Zinc (Tablet)
C1
CVS Diabetes Health Support (Pack)C1
CVS E (Capsule)C1
CVS Electrolyte Solution (Oral Solution)C1
CVS Eye Health & Lutein (Tablet)C1
CVS Folic Acid (Tablet)C1
CVS Glucose (Gel)C1
CVS Glucose Liquid Shot (Liquid)C1
CVS Glucose Shot (Liquid)C1
CVS Gummy Dinos (Tablet Chewable)C1
CVS Gummy Dinos Children's (Tablet Chewable)
C1
CVS Gummy Multivitamin Kids (Tablet Chewable)
C1
CVS Iron (Tablet)C1
CVS Magnesium (Tablet)
OTC Drug NameC1
CVS Magnesium Citrate (Capsule)C1
CVS Melatonin (Capsule)C1
CVS Melatonin (Liquid)C1
CVS Melatonin (Tablet)C1
CVS Melatonin Extra Strength (Liquid)C1
CVS Melatonin Gummies (Tablet Chewable)
C1
CVS Melatonin Instant Dissolving (Tablet)C1
CVS Melatonin Quick Dissolve (Tablet)C1
CVS Melatonin TR (Tablet Extended-Release)
C1
CVS Mens Daily Gummies (Tablet Chewable)
C1
CVS One Daily Essential (Tablet)C1
CVS One Daily Womens Formula (Tablet)C1
CVS Oyster Shell Calcium +Vitamin D (Tablet)
C1
CVS Pediatric Electrolyte (Oral Solution)C1
CVS Pediatric Electrolyte Freezer Pops (Oral Solution)
C1
CVS Prenatal (Tablet)C1
CVS Prenatal Gummies (Tablet Chewable)C1
CVS Prenatal Gummy/DHA/Folic Acid (Tablet Chewable)
C1
CVS Prenatal Multi+DHA (Capsule)C1
CVS Quality Sleep (Capsule)C1
CVS Slow Release Iron (Tablet Extended-Release)
C1
CVS Spectravite Adult 50+ (Tablet)C1
CVS Spectravite Advanced Formula (Tablet)
C1
CVS Spectravite Senior (Tablet)C1
CVS Spectravite Ultra Health Mens (Tablet)C1
CVS Spectravite Ultra Men50+ (Tablet)C1
CVS Spectravite Ultra Mens Health Senior (Tablet)
166
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
CVS Spectravite Ultra Women (Tablet)C1
CVS Spectravite Ultra Womens Health Senior (Tablet)
C1
CVS Vision Formula (Tablet)C1
CVS Vitamin A (Capsule)C1
CVS Vitamin B-12 (Tablet Extended-Release)
C1
CVS Vitamin B12 (Tablet)C1
CVS Vitamin B-12 (Tablet)C1
CVS Vitamin B-12 TR (Tablet Extended-Release)
C1
CVS Vitamin B-2 (Tablet)C1
CVS Vitamin C (Tablet)C1
CVS Vitamin C/Rose Hips (Tablet)C1
CVS Vitamin D Children's Gummies (Tablet Chewable)
C1
CVS Vitamin D3 (Capsule)C1
CVS Vitamin D3 (Tablet Chewable)C1
CVS Vitamin D3 Drops/Infants (Drops)C1
CVS Vitamin E (Capsule)C1
CVS Womens Active Daily (Tablet)C1
CVS Womens Daily Gummies (Tablet Chewable)
C1
CVS Womens Prenatal+DHA (Capsule)C1
CVS Yogurt+Calcium Gummies (Tablet
Chewable)C1
Cyanocobalamin (Injection)C1
D 1000 (Capsule)C1
D 1000 (Tablet Chewable)C1
D 1000 (Tablet)C1
D 10000 (Capsule)C1
D 2000 (Tablet)C1
D 400 (Tablet Chewable)C1
D 400 (Tablet)C1
D 5000 (Capsule)
OTC Drug NameC1
D 5000 (Tablet)C1
D-1000 Extra Strength (Tablet)C1
D-2000 Maximum Strength (Tablet)C1
D2000 Ultra Strength (Capsule)C1
D3 (Capsule)C1
D3 (Tablet Chewable)C1
D3 (Tablet)C1
D3 2000 (Tablet)C1
D3 Adult (Tablet Chewable)C1
D3 Adult Gummy (Tablet Chewable)C1
D3 High Potency (Capsule)C1
D3 High Potency (Tablet)C1
D3 Kids (Tablet Chewable)C1
D3 Maximum Strength (Capsule)C1
D3 Maximum Strength (Drops)C1
D3 Super Strength (Capsule)C1
D3 Ultra Strength (Capsule)C1
D3 Vitamin (Liquid)C1
D3-1000 (Capsule)C1
D3-1000 (Tablet)C1
D-3-5 (Capsule)C1
D3-50 (Capsule)C1
D-400 (Tablet)C1
D-5000 (Tablet)C1
Daily Betic (Tablet)C1
Daily Combo Multi Vitamin (Tablet)C1
Daily Heart Health Support (Pack)C1
Daily Mens Health Formula (Tablet)C1
Daily Multi (Tablet)C1
Daily Multi 50+ (Tablet)C1
Daily Multiple Vitamins (Tablet)C1
Daily Multiple Vitamins/Minerals (Tablet)C1
Daily Multivitamin (Capsule)C1
Daily Value Multivitamin (Tablet)
167
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Daily Vitamin Plus (Capsule)C1
Daily Vitamins (Tablet)C1
Daily Womens Health Formula (Tablet)C1
Daily-Vitamin (Tablet)C1
Daily-Vitamin Maximum Formula (Tablet)C1
Daily-Vite (Tablet)C1
Decara (Capsule)C1
Dekas Plus (Liquid)C1
Delta D3 (Tablet)C1
Diabetes Health Formula (Tablet)C1
Dialyvite 800/Ultra D (Tablet)C1
Dialyvite Vitamin D 5000 (Capsule)C1
Dialyvite Vitamin D3 Max (Tablet)C1
Dino-Life (Tablet Chewable)C1
Dino-Life W Extra C (Tablet Chewable)C1
Disney Calcium + Vitamin D3 Gummies
(Tablet Chewable)C1
Disney Cars Gummies (Tablet Chewable)C1
Disney Princess Gummies (Tablet Chewable)
C1
Doctors Choice Multivitamins Men (Tablet)C1
Dolomite (Tablet)C1
Dry Eye Formula (Capsule)C1
E-1000 (Capsule)C1
E-200 (Capsule)C1
E-400 (Capsule)C1
E-400-Clear (Capsule)C1
E-400-Mixed (Capsule)C1
E600 (Capsule)C1
Electrolyte Solution (Oral Solution)C1
Elite Ca/Mg (Tablet)C1
Elite Calcium (Tablet)C1
Elite Magnesium (Tablet)C1
E-Max-1000 (Capsule)
OTC Drug NameC1
Endur-Acin (Tablet Extended-Release)C1
Endur-Amide (Tablet Extended-Release)C1
Endur-C/Rose Hips (Tablet Extended-Release)
C1
Enviro-Stress (Tablet)C1
E-Oil (Oil)C1
E-Pherol (Tablet)C1
EQ Calcium 500+D (Tablet)C1
EQ Calcium 600+D (Tablet)C1
EQ Calcium 600+D+Minerals (Tablet)C1
EQ Calcium Citrate+D (Tablet)C1
EQ Calcium Citrate+D3 (Tablet)C1
EQ Calcium Citrate+D3/Petites (Tablet)C1
EQ Complete Chewable Multivitamin Children's (Tablet Chewable)
C1
EQ Complete Multivitamin Adults 50+ (Tablet)
C1
EQ Complete Multivitamin Adults Under 50 (Tablet)
C1
EQ Magnesium Citrate (Solution)C1
EQ Multivitamin Gummies Children's (Tablet Chewable)
C1
EQ Multivitamins Children's Gummy (Tablet Chewable)
C1
EQ One Daily Womens Health (Tablet)C1
EQ One Daily Womens Pro-Active (Tablet)C1
EQ Slow-Release Iron (Tablet Extended-Release)
C1
EQ Vision Formula 50+ (Capsule)C1
EQL Air Protector (Tablet)C1
EQL Anticavity Fluoride Rinse Kids (Rinse)C1
EQL Anticavity Mouthwash/Multiple Benefit (Rinse)
C1
EQL B-12 (Tablet)C1
EQL B-6 (Tablet)C1
EQL Calcium 600mg/Vitamin D3 (Tablet)
168
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
EQL Calcium Citrate W/Vitamin D (Tablet)C1
EQL Calcium Citrate/ Vitamin D3 (Tablet)C1
EQL Calcium Gummies (Tablet Chewable)C1
EQL Calcium Soft Chews (Tablet Chewable)
C1
EQL Calcium/Vitamin D (Capsule)C1
EQL Calcium/Vitamin D (Tablet)C1
EQL Century (Tablet)C1
EQL Century Mature (Tablet)C1
EQL Century Mature Men 50+ (Tablet)C1
EQL Century Mature Women 50+ (Tablet)C1
EQL Children's Multivitamins/Minerals (Tablet Chewable)
C1
EQL Coq10 (Capsule)C1
EQL Dental Travel Pack (Paste)C1
EQL Gummies Children's (Tablet Chewable)
C1
EQL Iron Supplement Therapy (Tablet)C1
EQL Magnesium Citrate (Solution)C1
EQL Melatonin/Vitamin B-6 (Tablet)C1
EQL One Daily Mens 50+ Advanced (Tablet)
C1
EQL One Daily Mens Health Formula (Tablet)
C1
EQL One Daily Womens (Tablet)C1
EQL One Daily Womens 50+ Advanced (Tablet)
C1
EQL Prenatal Formula (Tablet)C1
EQL Slow Release Iron (Tablet Extended-Release)
C1
EQL Vision Formula (Tablet)C1
EQL Vitamin B-12 (Tablet)C1
EQL Vitamin B-12 TR (Tablet Extended-Release)
C1
EQL Vitamin C (Tablet)
OTC Drug NameC1
EQL Vitamin C Gummies (Tablet Chewable)
C1
EQL Vitamin C/Rose Hips (Tablet)C1
EQL Vitamin D3 (Capsule)C1
EQL Vitamin D3 Gummies (Tablet Chewable)
C1
EQL Vitamin E (Capsule)C1
Equalyte (Oral Solution)C1
Ergocalciferol (Solution)C1
Essentia (Tablet)C1
Essential Balance (Tablet)C1
Essential One Daily Multivitamin (Tablet)C1
Ester-E (Capsule)C1
Eye Vitamins (Capsule)C1
Eyeprotect (Tablet)C1
Eye-Vites (Tablet)C1
Fa-8 (Capsule)C1
Fa-8 (Tablet)C1
Fe Gluconate (Tablet)C1
Fe Tabs (Tablet)C1
Ferate (Tablet)C1
Fergon (Tablet)C1
Ferosul (Elixir)C1
Ferosul (Tablet)C1
Ferretts (Tablet)C1
Ferro-Bob (Tablet)C1
Ferrocite (Tablet)C1
Ferrotabs (Tablet)C1
Ferrous Fumarate (Tablet)C1
Ferrous Fumarate 324 (Tablet)C1
Ferrous Gluconate (Tablet)C1
Ferrous Sulfate (Elixir)C1
Ferrous Sulfate (Liquid)C1
Ferrous Sulfate (Solution)
169
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Ferrous Sulfate (Tablet Extended-Release)C1
Ferrous Sulfate (Tablet)C1
Ferrous Sulfate Iron (Tablet)C1
Ferrousul (Tablet)C1
Flintstones Complete (Tablet Chewable)C1
Flintstones Gummies Plus Bone Building Support (Tablet Chewable)
C1
Flintstones Gummies Plus Omega-3 DHA (Tablet Chewable)
C1
Flintstones Plus Calcium (Tablet Chewable)
C1
Flintstones Plus Extra C (Tablet Chewable)C1
Flintstones Plus Iron (Tablet Chewable)C1
Flintstones/My First (Tablet Chewable)C1
Fluoride Mouth Rinse (Rinse)C1
Folic Acid (Capsule)C1
Folic Acid (Tablet)C1
Formula E 400 (Capsule)C1
Fruit C 500 (Tablet Chewable)C1
Fruit C-100 (Tablet Chewable)C1
Fruity C (Tablet Chewable)C1
Fruity Chewables Multivitamin (Tablet Chewable)
C1
Fruity Chews (Tablet Chewable)C1
Fruity Chews/Iron (Tablet Chewable)C1
Gerivite Complete (Tablet)C1
Gluco Burst (Gel)C1
Glucose (Gel)C1
Glucose Liquid (Liquid)C1
Glucoten (Capsule)C1
Glutose 15 (Gel)C1
Glutose 45 (Gel)C1
Glutose 5 (Gel)C1
GNP Animal Shapes (Tablet Chewable)
OTC Drug NameC1
GNP Animal Shapes Plus Extra C (Tablet Chewable)
C1
GNP Animal Shapes Plus Iron (Tablet Chewable)
C1
GNP B-12 (Tablet)C1
GNP B-Complex Plus Vitamin C (Tablet)C1
GNP Calcium (Tablet)C1
GNP Calcium 1200 (Tablet Chewable)C1
GNP Calcium 500 +D3 (Tablet)C1
GNP Calcium 500/D (Tablet)C1
GNP Calcium 600 +D/Minerals (Tablet)C1
GNP Calcium 600 +D3 (Tablet)C1
GNP Calcium 600 +D3/Minerals (Tablet Chewable)
C1
GNP Calcium 600 Plus D/Minerals (Tablet)C1
GNP Calcium 600/D (Tablet)C1
GNP Calcium Citrate +D3 (Tablet)C1
GNP Calcium Citrate+D Maximum (Tablet)C1
GNP Calcium Citrate+D3 Maximum (Tablet)
C1
GNP Calcium Plus 600 +D (Tablet)C1
GNP Calcium/Magnesium/Zinc (Tablet)C1
GNP Calcuim/Vitamin D/Minerals (Tablet Chewable)
C1
GNP Century (Tablet)C1
GNP Century Adult Formula (Tablet)C1
GNP Century Adults 50+ Senior (Tablet)C1
GNP Century Cardio Healthformula (Tablet)
C1
GNP Century Mature (Tablet)C1
GNP Century Mature Formula/Women'S 50+ (Tablet)
C1
GNP Century Ultimate Mens Complete (Tablet)
C1
GNP Century Ultimate Mens Senior Formula (Tablet)
170
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
GNP Century Ultimate Womens Complete (Tablet)
C1
GNP Century Ultimate Womens Senior Formula (Tablet)
C1
GNP Children's Chewables W/Extra C (Tablet Chewable)
C1
GNP Children's Chewables/Extra C (Tablet Chewable)
C1
GNP Children's Chewables/Iron (Tablet Chewable)
C1
GNP Children's Complete Chewables (Tablet Chewable)
C1
GNP Co Q10 (Capsule)C1
GNP Cod Liver Oil (Capsule)C1
GNP Coenzyme Q-10 (Capsule)C1
GNP D 1000 (Capsule)C1
GNP D 2000 (Tablet Chewable)C1
GNP Daily Prenatal (Capsule)C1
GNP Diabetic Support Formula (Tablet)C1
GNP Essential One Daily (Tablet)C1
GNP Folic Acid (Tablet)C1
GNP Hair/Skin/Nails (Tablet)C1
GNP Healthy Eyes (Tablet)C1
GNP Healthy Eyes Supervision (Capsule)C1
GNP Healthy Eyes Supervision 2 (Capsule)C1
GNP Immune Support (Tablet)C1
GNP Iron (Tablet Extended-Release)C1
GNP Iron (Tablet)C1
GNP Little Ones Children's (Tablet Chewable)
C1
GNP Magnesium (Tablet)C1
GNP Magnesium Citrate (Solution)C1
GNP Maximum One Daily (Tablet)C1
GNP Mega Multi For Men (Tablet)C1
GNP Mega Multi For Women (Tablet)C1
GNP Melatonin (Tablet)
OTC Drug NameC1
GNP Melatonin Maximum Strength (Tablet)C1
GNP Niacin (Tablet)C1
GNP Niacin TR (Tablet Extended-Release)C1
GNP Norwegian Cod Liver Oil (Capsule)C1
GNP One Daily Maximum (Tablet)C1
GNP One Daily Mens 50+ Advanced (Tablet)
C1
GNP One Daily Mens Health 50+ (Tablet)C1
GNP One Daily Mens Health/Lycopene (Tablet)
C1
GNP One Daily Womens 50+ Advanced (Tablet)
C1
GNP One Daily Womens Health (Tablet)C1
GNP One Daily Womens Health 50+ (Tablet)
C1
GNP One Daily Womens Metabolism Support (Tablet)
C1
GNP Opti-Vitamins (Tablet)C1
GNP Pediatric Electrolyte (Oral Solution)C1
GNP Potassium (Tablet)C1
GNP Prenatal (Tablet)C1
GNP Slow Release Iron (Tablet Extended-Release)
C1
GNP Therapeutic-M (Tablet)C1
GNP Vitamin A & D (Ointment)C1
GNP Vitamin A (Capsule)C1
GNP Vitamin B1 (Tablet)C1
GNP Vitamin B-1 (Tablet)C1
GNP Vitamin B-12 (Tablet)C1
GNP Vitamin B-12 Prolonged Release (Tablet Extended-Release)
C1
GNP Vitamin B-12 TR (Tablet Extended-Release)
C1
GNP Vitamin B-6 (Tablet)C1
GNP Vitamin C (Tablet Chewable)C1
GNP Vitamin C (Tablet)
171
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
GNP Vitamin C Drops (Lozenge)C1
GNP Vitamin C PR (Tablet Extended-Release)
C1
GNP Vitamin C TR (Tablet Extended-Release)
C1
GNP Vitamin C W/Rose Hips (Tablet)C1
GNP Vitamin C W/Rose Hips TR (Tablet Extended-Release)
C1
GNP Vitamin C/Rose Hips (Tablet)C1
GNP Vitamin D (Tablet Chewable)C1
GNP Vitamin D (Tablet)C1
GNP Vitamin D Maximum Strength (Tablet)C1
GNP Vitamin D Super Strength (Tablet)C1
GNP Vitamin D3 Extra Strength (Tablet)C1
GNP Vitamin D-400 (Tablet)C1
GNP Vitamin E (Capsule)C1
GNP Vitamin E Water Dispersible (Capsule)
C1
GNP Womens One Daily (Tablet)C1
GNP Zoochews Gummies (Tablet Chewable)
C1
Goodsense Iron (Tablet)C1
Goodsense Magnesium Citrate (Solution)C1
Goodsense Prenatal Vitamins (Tablet)C1
Gummi Bear Multivitamin/Mineral (Tablet Chewable)
C1
H2Q (Capsule)C1
Hair Formula Extra Strength (Tablet)C1
Hair Skin And Nails Formula (Tablet)C1
Hair Vitamins (Tablet)C1
Hair/Skin/Nails (Capsule)C1
Hair/Skin/Nails (Tablet)C1
Hair/Skin/Nails/Biotin (Tablet)C1
Halls Defense Vitamin C Drops (Lozenge)C1
Healthy Eyes (Tablet)
OTC Drug NameC1
Healthy Eyes/Lutein (Tablet)C1
Healthy Hair Skin & Nails (Tablet)C1
Healthy Kids Gummies (Tablet Chewable)C1
Healthy Kids Overall Health Multivitamins (Tablet Chewable)
C1
Healthy Kids Vitamin D3 (Tablet Chewable)C1
H-E-B Oral Electrolyte Solution (Oral Solution)
C1
Hemenatal OB + DHA (Capsule)C1
High Potency Calcium (Tablet)C1
High Potency Iron (Tablet)C1
Hi-Kovite 2-Part Formula (Tablet)C1
Hi-Potency Multi-Vitamin/Mineral Supplement (Tablet)
C1
HM Animal Shapes (Tablet Chewable)C1
HM Antioxidant Vitamins (Tablet)C1
HM Calcium 600 & Vitamin D3 (Tablet)C1
HM Calcium 600 + D Plus Minerals (Tablet Chewable)
C1
HM Calcium 600 + Vitamin D3 (Tablet)C1
HM Calcium Citrate + Vitamin D (Tablet)C1
HM Calcium Citrate+D3 Petite (Tablet)C1
HM Calcium Magnesium & Zinc (Tablet)C1
HM Calcium/Vitamin D (Tablet)C1
HM Calcium/Vitamin D/Minerals (Tablet)C1
HM Complete (Tablet)C1
HM Complete 50+ (Tablet)C1
HM Complete 50+ Mens Ultimate (Tablet)C1
HM Complete 50+ Womens Ultimate (Tablet)
C1
HM Complete Women (Tablet)C1
HM Coq10 (Capsule)C1
HM E Vitamin (Capsule)C1
HM Folic Acid (Tablet)C1
HM Hair/Skin/Nails (Tablet)
172
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
HM Iron (Tablet)C1
HM Iron Slow Release (Tablet Extended-Release)
C1
HM Magnesium Citrate (Solution)C1
HM Melatonin (Tablet)C1
HM Melatonin Quick Dissolve (Tablet)C1
HM Mens 50+ Advanced One Daily (Tablet)
C1
HM Multivitamin Adult Gummy (Tablet Chewable)
C1
HM Niacin (Tablet Extended-Release)C1
HM Niacin TR (Tablet Extended-Release)C1
HM One Daily Essential (Tablet)C1
HM One Daily Mens (Tablet)C1
HM One Daily Prenatal Combo (Capsule)C1
HM One Daily Womens (Tablet)C1
HM Pediatric Electrolyte (Oral Solution)C1
HM Prenatal (Tablet)C1
HM Slow Release Iron (Tablet Extended-Release)
C1
HM Super Vitamin B12 (Tablet Chewable)C1
HM Vitamin B1 (Tablet)C1
HM Vitamin B12 (Tablet Extended-Release)C1
HM Vitamin B12 (Tablet)C1
HM Vitamin B12 TR (Tablet Extended-Release)
C1
HM Vitamin B12 Ultra Strength (Tablet)C1
HM Vitamin B6 (Tablet)C1
HM Vitamin C (Tablet Chewable)C1
HM Vitamin C (Tablet)C1
HM Vitamin C TR (Tablet Extended-Release)
C1
HM Vitamin C/Rose Hips (Tablet)C1
HM Vitamin D (Tablet)C1
HM Vitamin D3 (Capsule)
OTC Drug NameC1
HM Vitamin E (Capsule)C1
HM Vita-Mini Multi Complete (Tablet)C1
HM Womens 50+ Advanced One Daily (Tablet)
C1
Icaps (Capsule)C1
Icaps Areds 2 (Capsule)C1
Icaps Lutein & Omega-3 (Capsule)C1
Icaps MV (Tablet)C1
Iron (Tablet Extended-Release)C1
Iron (Tablet)C1
Iron 27 (Tablet)C1
Iron ER (Tablet Extended-Release)C1
Iron High-Potency (Tablet Extended-Release)
C1
Iron High-Potency (Tablet)C1
Iron Slow Release (Tablet Extended-Release)
C1
Iron Supplement (Elixir)C1
Iron Supplement Children's (Solution)C1
I-Vite (Tablet)C1
I-Vite Protect (Tablet)C1
Kids First Vitamin D3 Gummies (Tablet Chewable)
C1
Kosher Prenatal Plus Iron (Tablet)C1
KP Adults 50+ Daily Formula (Tablet)C1
KP Adults Daily Formula (Tablet)C1
KP Calcium 600+D (Capsule)C1
KP Calcium 600+D (Tablet)C1
KP Calcium 600+D3 (Capsule)C1
KP Calcium Citrate+D (Tablet)C1
KP Calcium/Magnesium/Zinc (Tablet)C1
KP Ferrous Gluconate (Tablet)C1
KP Ferrous Sulfate (Tablet)C1
KP Folic Acid (Tablet)C1
KP Mag-Oxide Magnesium (Tablet)
173
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
KP Melatonin (Tablet)C1
KP Mens 50+ Daily Formula (Tablet)C1
KP Mens Daily Formula (Tablet)C1
KP Niacin (Tablet)C1
KP Prenatal Multivitamins (Tablet)C1
KP Vision Formula (Tablet)C1
KP Vision Formula W/Lutein (Tablet)C1
KP Vitamin B-12 (Tablet)C1
KP Vitamin B-6 (Tablet)C1
KP Vitamin D (Capsule)C1
KP Vitamin D (Tablet Chewable)C1
KP Vitamin D3 (Capsule)C1
KP Vitamin E (Capsule)C1
KP Womens 50+ Daily Formula (Tablet)C1
KP Womens Daily Formula (Tablet)C1
KPN Prenatal (Tablet)C1
Land Before Time Multivitamin/Iron (Tablet Chewable)
C1
Land Before Time Multivitamin/Vitamin C (Tablet Chewable)
C1
Liquid B12 (Liquid)C1
Liquid Calcium With D3 Maximum Strength (Capsule)
C1
Liquid Calcium/D3 (Capsule)C1
Liquid Calcium/Magnesium Citrate Plus Vitamin D3 (Liquid)
C1
Liquid Calcium/Vitamin D (Capsule)C1
Liquid Calcium/Vitamins A & D (Capsule)C1
Listerine Healthy White Gentle (Rinse)C1
Listerine Healthy White Vibrant (Rinse)C1
Listerine Naturals With Fluoride (Rinse)C1
Listerine Nightly Reset (Rinse)C1
Listerine Restoring (Rinse)C1
Listerine Smart Rinse (Rinse)C1
Listerine Smart Rinse Anticavity (Rinse)
OTC Drug NameC1
Listerine Total Care (Rinse)C1
Listerine Total Care Pluswhitening
(Rinse)C1
Listerine Total Care Zero (Rinse)C1
Listerine Whitening/Restoring (Rinse)C1
Little Animals (Tablet Chewable)C1
Little Animals Plus Iron (Tablet Chewable)C1
Localnesium (Tablet)C1
Localnesium-C (Tablet)C1
Lysiplex Plus (Tablet)C1
M2 Magnesium (Capsule)C1
Macular Health Formula (Capsule)C1
Macuvite (Tablet)C1
Macuvite Eye Care (Tablet)C1
Macuvite/Lutein (Tablet)C1
Magdelay (Tablet)C1
Mag-G (Tablet)C1
Magnacaps (Capsule)C1
Magnebind 300 (Tablet)C1
Magnesium (Capsule)C1
Magnesium (Tablet)C1
Magnesium 27 (Tablet)C1
Magnesium Carbonate (Powder)C1
Magnesium Chloride (Injection)C1
Magnesium Citrate (Capsule)C1
Magnesium Citrate (Solution)C1
Magnesium Citrate (Tablet)C1
Magnesium Elemental (Capsule)C1
Magnesium Elemental (Tablet)C1
Magnesium Gluconate (Tablet)C1
Magnesium L-Lactate Dihyrate (Tablet Extended-Release)
C1
Magnesium Oxide (Capsule)C1
Magnesium Oxide (Powder)
174
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Magnesium Oxide (Tablet)C1
Magnesium Oxide 400 (Powder)C1
Magnesium Oxide 400 (Tablet)C1
Magnesium-Oxide (Tablet)C1
Magnum-75 (Tablet)C1
Mag-Oxide (Tablet)C1
Maximum Blue Label (Tablet)C1
Maximum Daily Green (Tablet)C1
Maximum Green Label (Tablet)C1
Maximum Red Label (Tablet)C1
Mediplex Plus (Tablet)C1
Mega Coq10 (Capsule)C1
Mega Coq-10 (Capsule)C1
Mega VM-80 (Tablet)C1
Mega-Marathon 100 TR (Tablet Extended-Release)
C1
Megavite Golden Years 55+ (Tablet)C1
Meijer Advanced Formula (Tablet)C1
Meijer Advanced Formula For Adults 50+ (Tablet)
C1
Meijer C (Tablet)C1
Meijer Ferrous Sulfate (Tablet)C1
Meladox (Tablet Extended-Release)C1
Melatin (Tablet)C1
Melatonex (Tablet Extended-Release)C1
Melatonin (Capsule)C1
Melatonin (Liquid)C1
Melatonin (Lozenge)C1
Melatonin (Tablet Chewable)C1
Melatonin (Tablet Extended-Release)C1
Melatonin (Tablet)C1
Melatonin Adult Gummies (Tablet Chewable)
C1
Melatonin Adult Gummy (Tablet Chewable)
OTC Drug NameC1
Melatonin CR (Tablet Extended-Release)C1
Melatonin Extra Strength (Liquid)C1
Melatonin Fast Dissolve (Tablet)C1
Melatonin Fast Meltz (Tablet)C1
Melatonin Gummies (Tablet Chewable)C1
Melatonin Maximum Strength (Capsule)C1
Melatonin Maximum Strength (Tablet)C1
Melatonin Quick Dissolve (Tablet)C1
Melatonin TR (Tablet Extended-Release)C1
Melatonin TR/Vitamin B6 (Tablet Extended-Release)
C1
Melatonin TR/Vitamin B-6 (Tablet Extended-Release)
C1
Melatonin/Vitamin B-6 Extra Strength (Tablet)
C1
Mens Daily Formula/Lycopene (Capsule)C1
Mens Hair Formula Ultra Man (Tablet)C1
Mens Life Pack (Tablet)C1
MGO (Tablet)C1
MH Macular Health (Pack)C1
Milltrium Advanced Formula With Beta Carotene (Tablet)
C1
Milltrium Cardio (Tablet)C1
Milltrium Senior (Tablet)C1
MM Melatonin TR (Tablet Extended-Release)
C1
Monoject Pharma Grade Flush Syringe (Solution)
C1
Monoject Sodium Chloride Flush (Solution)C1
Multi + Omega-3 Adult Gummies (Tablet Chewable)
C1
Multi Adult Gummies (Tablet Chewable)C1
Multi Complete (Capsule)C1
Multi Complete/Iron (Tablet)C1
Multi For Her (Capsule)C1
Multi For Her (Tablet)
175
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Multi For Her 50+ (Capsule)C1
Multi For Her 50+ (Tablet)C1
Multi For Him (Capsule)C1
Multi For Him (Tablet)C1
Multi For Him 50+ (Tablet)C1
Multi Prenatal (Tablet)C1
Multi Vit/Fl (Tablet Chewable)C1
Multi Vita-Bets/Fluoride (Tablet Chewable)C1
Multi Vitamin (Tablet)C1
Multi Vitamin And Minerals (Tablet)C1
Multi Vitamin Daily (Tablet)C1
Multi Vitamin Mens (Tablet)C1
Multi Vitamin/D-3 (Tablet)C1
Multi Vitamin/Minerals Full Spectrum (Tablet)
C1
Multi-Day (Tablet)C1
Multi-Day Plus Minerals (Tablet)C1
Multi-Day Vitamins (Tablet)C1
Multi-Day W/Calcium And Extra Iron (Tablet)
C1
Multi-Day Weight Trim (Tablet)C1
Multi-Delyn (Liquid)C1
Multi-Delyn/Iron (Liquid)C1
Multi-Lean (Tablet)C1
Multilex (Tablet)C1
Multilex-T&M (Tablet)C1
Multimineral Plus (Tablet)C1
Multi-Minerals (Tablet)C1
Multiple Vitamin (Tablet)C1
Multiple Vitamin/Folic Acid (Tablet)C1
Multiple Vitamin/Minerals/No Iron (Tablet)C1
Multiple Vitamins (Tablet)C1
Multiple Vitamins Essential (Tablet)C1
Multiple Vitamins Plain (Tablet)
OTC Drug NameC1
Multiple Vitamins/Fluoride (Tablet Chewable)
C1
Multiple Vitamins/Iron (Tablet Chewable)C1
Multiple Vitamins/Womens (Tablet)C1
Multi-Vit/Fluoride (Solution)C1
Multi-Vit/Iron/Fluoride (Drops)C1
Multivitamin & Mineral (Liquid)C1
Multivitamin (Liquid)C1
Multi-Vitamin (Tablet)C1
Multivitamin Adults (Tablet)C1
Multivitamin Adults 50+ (Tablet)C1
Multivitamin Children's (Tablet Chewable)C1
Multi-Vitamin Daily (Tablet)C1
Multivitamin Drops/Iron Infant & Toddler (Drops)
C1
Multi-Vitamin Gummies (Tablet Chewable)C1
Multivitamin Gummies Adult (Tablet Chewable)
C1
Multivitamin Gummies Children's (Tablet Chewable)
C1
Multivitamin Gummies Mens (Tablet Chewable)
C1
Multivitamin Gummies Womens (Tablet Chewable)
C1
Multivitamin Infant & Toddler (Drops)C1
Multivitamin Iron-Free (Tablet)C1
Multivitamin Men 50+ (Tablet)C1
Multivitamin Mens (Tablet)C1
Multi-Vitamin Monocaps (Tablet)C1
Multivitamin Plus Iron Children's (Tablet Chewable)
C1
Multivitamin With Fluoride (Solution)C1
Multivitamin With Fluoride (Tablet Chewable)
C1
Multivitamin With Fluoride (Tablet)C1
Multivitamin Women (Tablet)
176
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Multivitamin Women 50+ (Tablet)C1
Multivitamin Womens (Tablet)C1
Multivitamin/Extra Vitamin D3 Adult (Tablet Chewable)
C1
Multivitamin/Fluoride (Solution)C1
Multivitamin/Fluoride (Tablet Chewable)C1
Multi-Vitamin/Fluoride Drops (Solution)C1
Multivitamin/Fluoride/Iron (Drops)C1
Multi-Vitamin/Fluoride/Iron (Drops)C1
Multi-Vitamin/Menopausal Formula (Tablet)
C1
Multi-Vitamin/Multi-Mineral Adult/High Potency (Liquid)
C1
Multivitamins (Capsule)C1
Multi-Vitamins (Tablet)C1
Multivitamins/Fluoride (Tablet Chewable)C1
Mult-Vitamin/Fluoride (Tablet Chewable)C1
MVC-Fluoride (Tablet Chewable)C1
MV-One (Capsule)C1
MVW Complete Formulation (Tablet Chewable)
C1
MVW Complete Formulation D3000 (Tablet Chewable)
C1
MVW Complete Formulation D5000 (Tablet Chewable)
C1
Myamulti (Tablet)C1
My-Vitalife (Capsule)C1
Nanovm 1-3 Years (Powder)C1
Nanovm 4-8 Years (Powder)C1
Nanovm 9-18 Years (Powder)C1
Nanovm T/F (Liquid)C1
Nanovm T/F (Powder)C1
Nat-Rul Coenzyme Q-10 (Capsule)C1
Nat-Rul Iron (Tablet)C1
Natrul Magnesium (Tablet)
OTC Drug NameC1
Nat-Rul Oyster Calcium + D (Tablet)C1
Nat-Rul Vitamin D (Tablet)C1
Natural C/Rose Hips (Tablet)C1
Natural Coenzyme Q10 (Capsule)C1
Natural Vitamin A (Capsule)C1
Natural Vitamin D-3 (Tablet)C1
Natural Vitamin E (Capsule)C1
Natural Vitamin E (Tablet)C1
Naturalyte (Oral Solution)C1
Neuro-K-250 Vitamin B6 (Tablet)C1
Neuro-K-50 (Tablet)C1
Neuro-K-500 (Tablet)C1
Niacin (Tablet)C1
Niacin ER (Capsule Extended-Release)C1
Niacin ER (Tablet Extended-Release)C1
Niacin PR (Tablet Extended-Release)C1
Niacin SR (Capsule)C1
Niacin TD (Capsule Extended-Release)C1
Niacin TD (Tablet Extended-Release)C1
Niacin Time Release (Tablet Extended-Release)
C1
Niacin Timed Release (Tablet Extended-Release)
C1
Niacin TR (Capsule Extended-Release)C1
Niacin TR (Tablet Extended-Release)C1
Niacin-50 (Tablet)C1
Niacinamide (Tablet)C1
Niacinamide Prolonged Release (Tablet Extended-Release)
C1
Normal Saline Flush (Solution)C1
Normal Saline Flush For Flushing Vascular Access Devices (Solution)
C1
Normal Saline I.V. Flush (Solution)C1
Norwegian Cod Liver Oil (Capsule)C1
Novaferrum Pediatric Multivitamin (Liquid)
177
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Novaferrum Pediatric Multi-Vitamin/Iron (Drops)
C1
Nutr-E-Sol (Liquid)C1
Nutricion Porvida (Tablet)C1
Nutrifac ZX (Tablet)C1
Ocutabs (Tablet)C1
Ocutabs Vision Formula (Tablet)C1
Ocutabs/Lutein (Tablet)C1
Ocuvite Extra (Tablet)C1
Ocuvite Eye + Multi (Tablet)C1
Ocuvite Eye Health Formula (Capsule)C1
Ocuvite Eye Health Gummies (Tablet Chewable)
C1
Ocuvite/Lutein (Tablet)C1
Omnicap (Tablet)C1
Once Daily (Tablet)C1
One Daily (Tablet)C1
One Daily 50 Plus (Tablet)C1
One Daily Adults 50+ (Tablet)C1
One Daily Complete (Tablet)C1
One Daily Complete For Men (Tablet)C1
One Daily Essential (Tablet)C1
One Daily For Men 50+ Advanced (Tablet)C1
One Daily For Men/Lycopene (Tablet)C1
One Daily For Women (Tablet)C1
One Daily For Women 50+A Dvanced (Tablet)
C1
One Daily Healthy Weight (Tablet)C1
One Daily Healthy Weight Advanced (Tablet)
C1
One Daily Maximum (Tablet)C1
One Daily Mens (Tablet)C1
One Daily Mens 50+ Multivitamin (Tablet)C1
One Daily Mens Health/Lycopene (Tablet)C1
One Daily Multivitamin Adult (Tablet)
OTC Drug NameC1
One Daily Multivitamin Men (Tablet)C1
One Daily Multivitamin Mens 50+/Lycopene (Tablet)
C1
One Daily Multivitamin Women (Tablet)C1
One Daily Multivitamin/Iron-Free (Tablet)C1
One Daily Plus Iron (Tablet)C1
One Daily Plus Minerals (Tablet)C1
One Daily Womens (Tablet)C1
One Daily Womens 50 Plus (Tablet)C1
One Daily Womens 50+ (Tablet)C1
One Daily/Iron/Calcium (Tablet)C1
One Daily/Minerals (Tablet)C1
One-A-Day Teen Advantage For Her (Tablet)
C1
One-Daily Multi Vitamins (Tablet)C1
Optic-Vites (Tablet)C1
Optic-Vites With Lutein (Tablet)C1
Optimal-D (Capsule)C1
Optimal-D Pack (Capsule)C1
Optimum Airvites (Tablet Chewable)C1
Optimum Pms (Tablet)C1
Opurity Calcium Citrate Plus (Tablet
Chewable)C1
Opurity Vitamin D (Tablet Chewable)C1
Oral Electrolyte Solutionfreezer Pops Pediatric (Oral Solution)
C1
Oralyte (Oral Solution)C1
Oralyte Freezer Pops (Oral Solution)C1
Os-Cal (Tablet Chewable)C1
Os-Cal (Tablet Chewable)C1
Oscal 500/200 D-3 (Tablet)C1
Os-Cal Calcium + D3 (Tablet)C1
Os-Cal Extra D3 (Tablet)C1
Os-Cal Ultra (Tablet)C1
Osteo-Poretical (Tablet)
178
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Osteoprime Ultra (Tablet)C1
Ostigen C1
Oysco 500 (Tablet)C1
Oysco 500+D (Tablet Chewable)C1
Oysco 500+D (Tablet)C1
Oyst-Cal-D 500 (Tablet)C1
Oyster Calcium (Tablet)C1
Oyster Calcium/D3 (Tablet)C1
Oyster Calcium/Vitamin D (Tablet)C1
Oyster Shell (Tablet)C1
Oyster Shell Calcium (Tablet)C1
Oyster Shell Calcium + D (Tablet)C1
Oyster Shell Calcium + D3 (Tablet)C1
Oyster Shell Calcium + Vitamin D (Tablet)C1
Oyster Shell Calcium 250+D (Tablet)C1
Oyster Shell Calcium 500 (Tablet)C1
Oyster Shell Calcium 500 + D (Tablet)C1
Oyster Shell Calcium 500/D (Tablet)C1
Oyster Shell Calcium 500+D (Tablet Chewable)
C1
Oyster Shell Calcium Plus Vitamin D (Tablet)
C1
Oyster Shell Calcium Plusvitamin D (Tablet)
C1
Oyster Shell Calcium/D (Tablet)C1
Oyster Shell Calcium/D3 (Tablet)C1
Oyster Shell Calcium/Magnesium (Tablet)C1
Oyster Shell Calcium/Vitamin D (Powder)C1
Oyster Shell Calcium/Vitamin D (Tablet)C1
Oyster Shell Calcium+D (Tablet)C1
Oyster Shell/Vitamin D (Tablet)C1
Oystercal (Tablet)C1
Oystercal-D (Tablet)C1
PA B-Complex With B-12 (Tablet)
OTC Drug NameC1
PA Calcium 600/Vitamin D (Tablet)C1
PA Coenzyme Q-10 (Capsule)C1
PA Melatonin (Tablet)C1
PA Oyster Shell Calcium (Tablet)C1
PA Prenatal Formula (Tablet)C1
PA Vitamin B-12 TR (Tablet Extended-Release)
C1
PA Vitamin D-3 (Capsule)C1
PA Vitamin D-3 (Tablet)C1
PA Vitamin D-3 Gummy (Tablet Chewable)C1
PA Vitamin E (Capsule)C1
Parva-Cal (Tablet)C1
Parva-Cal 250 (Tablet)C1
PC Pediatric Electrolyte (Oral Solution)C1
Pedia Vance (Oral Solution)C1
Pediatric Electrolyte (Oral Solution)C1
Pediatric Electrolyte Freeze Pops (Oral Solution)
C1
Pediatric Electrolyte Freezer Pops (Oral Solution)
C1
Pediatric Electrolyte/With Zinc (Oral Solution)
C1
Pediatric Electrolyte/Zinc (Oral Solution)C1
Pediavit (Liquid)C1
Phos-Nak Powder Concentrate (Powder)C1
Phosphorus Supplement (Powder)C1
Plain Niacin (Tablet)C1
Pnv-Total (Capsule)C1
Poly Vitamin (Tablet Chewable)C1
Polyvitamin (Solution)C1
Poly-Vitamin/Fluoride (Solution)C1
Poly-Vitamin/Fluoride (Tablet Chewable)C1
Polyvitamin/Iron (Tablet Chewable)C1
Poly-Vitamin/Iron Drops (Drops)C1
Posture (Tablet)
179
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Posture-D Calcium/Magnesium (Tablet)C1
Potassimin (Tablet)C1
Potassium (Tablet)C1
Prenatal (Tablet)C1
Prenatal + Complete Multi/DHA/Choline/Folate (Capsule)
C1
Prenatal + Complete Multi/DHA/Choline/Folate (Tablet Chewable)
C1
Prenatal Adult Gummy/DHA/Folic Acid (Tablet Chewable)
C1
Prenatal And Iron (Tablet)C1
Prenatal Complete (Tablet)C1
Prenatal Formula (Capsule)C1
Pre-Natal Formula (Tablet)C1
Prenatal Formula A-Free (Tablet)C1
Prenatal Forte (Tablet)C1
Prenatal Gummies/DHA & Folic Acid (Tablet Chewable)
C1
Prenatal Low Iron (Tablet)C1
Prenatal Multi + DHA (Capsule)C1
Prenatal Multivitamin (Tablet)C1
Prenatal Multivitamin Plus DHA (Capsule)C1
Prenatal One Daily (Tablet)C1
Prenatal Tablets (Tablet)C1
Prenatal Vitamin & Mineral (Tablet)C1
Prenatal Vitamin (Tablet)C1
Prenatal Vitamin/Iron (Tablet)C1
Prenatal Vitamins (Tablet)C1
Prenatal/Omega-3/Folic Acid/Iron (Capsule)
C1
Prenatal+DHA (Capsule)C1
Prevent (Capsule)C1
Pronutrients Calcium+D3 (Tablet)C1
Pronutrients Coq10 (Capsule)C1
Pronutrients Vitamin D3 (Capsule)
OTC Drug NameC1
Prosight (Tablet)C1
Prosight W/Lutein (Capsule)C1
Pure C 500 (Capsule)C1
Pureway-C (Tablet)C1
PX Advanced Formula Multivitamins/Lycopene (Tablet)
C1
PX Calcium & D (Tablet)C1
PX Children's Vitamin (Tablet Chewable)C1
PX Complete Senior Multivitamins (Tablet)C1
PX Folic Acid (Tablet)C1
PX Iron (Tablet)C1
PX Mens Multivitamins (Tablet)C1
PX Niacin (Tablet)C1
PX Prenatal Multivitamins (Tablet)C1
PX Vitamin A (Capsule)C1
PX Vitamin C (Tablet)C1
PX Vitamin E (Capsule)C1
Pyri 500 (Tablet)C1
Pyridoxine HCl (Tablet)C1
Pyridoxine Hydrochloride (Tablet)C1
QC B-Complex + Vitamin C (Tablet)C1
QC C With Rose Hips (Tablet)C1
QC Calcium 600 +D3 Plus Minerals (Tablet Chewable)
C1
QC Calcium Fast Dissolution (Tablet)C1
QC Calcium Magnesium & Zinc +D3 (Tablet)
C1
QC Calcium/Minerals/Vitamin D (Tablet)C1
QC Children's Chewable Complete (Tablet Chewable)
C1
QC Children's Chewable Vitamins/Extra C (Tablet Chewable)
C1
QC Children's Chewable Vitamins/Iron (Tablet Chewable)
C1
QC Co Q-10 (Capsule)
180
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
QC Cod Liver Oil (Capsule)C1
QC Essentials (Tablet)C1
QC Ferrous Sulfate (Tablet)C1
QC Folic Acid (Tablet)C1
QC Hair Skin & Nails (Tablet)C1
QC Magnesium Citrate (Solution)C1
QC Maximum Daily Multivitamin/Multimineral (Tablet)
C1
QC Melatonin Maximum Strength (Tablet)C1
QC Mens Daily Multivitamin (Tablet)C1
QC Multi-Vite (Tablet)C1
QC Multi-Vite 50 & Over (Tablet)C1
QC Multi-Vite Plus (Tablet)C1
QC Niacin (Tablet)C1
QC Prenatal (Tablet)C1
QC Therin-M (Tablet)C1
QC Vitamin B1 (Tablet)C1
QC Vitamin B12 (Tablet Extended-Release)C1
QC Vitamin B12 (Tablet)C1
QC Vitamin B6 (Tablet)C1
QC Vitamin C (Tablet Chewable)C1
QC Vitamin C (Tablet)C1
QC Vitamin D3 (Tablet)C1
QC Vitamin E (Capsule)C1
QC Womens Daily Multivitamin (Tablet)C1
Q-Gel Forte (Capsule)C1
Q-Gel Mega (Capsule)C1
Q-Gel Ultra (Capsule)C1
Q-Sorb (Capsule)C1
Q-Sorb Co Q-10 (Capsule)C1
Quin B Strong (Tablet)C1
Quintabs (Tablet)C1
Quintabs-M (Tablet)C1
RA Anticavity Fluoride Rinse (Rinse)
OTC Drug NameC1
RA B-Complex (Tablet)C1
RA B-Complex With B-12 (Tablet)C1
RA Calcium (Tablet)C1
RA Calcium 600 (Tablet)C1
RA Calcium 600 Plus Vitamin D-3 & Minerals (Tablet Chewable)
C1
RA Calcium 600 Plus Vitamin D-3 (Tablet)C1
RA Calcium 600/Vit D/Minerals (Tablet)C1
RA Calcium Citrate Plus Vitamin D (Tablet)C1
RA Calcium Citrate Plus Vitamin D-3 (Tablet)
C1
RA Calcium Citrate/Vitamin D-3 Petites (Tablet)
C1
RA Calcium Hi-Cal (Tablet)C1
RA Calcium Hi-Cal/Vitamind (Tablet)C1
RA Calcium High Potency (Tablet)C1
RA Calcium Plus Vitamin D (Tablet)C1
RA Calcium Soft Chews (Tablet Chewable)C1
RA Calcium/Boron (Tablet)C1
RA Calcium/Magnesium/Zinc (Tablet)C1
RA Calcium/Magnesium/Zinc/Copper (Tablet)
C1
RA Calcium/Minerals/Vitamin D (Tablet)C1
RA Central-Vite (Tablet)C1
RA Central-Vite Energy (Tablet)C1
RA Central-Vite Mens Mature (Tablet)C1
RA Central-Vite Select (Tablet)C1
RA Central-Vite Select Mature (Tablet)C1
RA Central-Vite Senior (Tablet)C1
RA Central-Vite Womens Mature (Tablet)C1
RA Central-Vite/Antioxidants (Tablet)C1
RA Chewable Vitamins Complete Children's (Tablet Chewable)
C1
RA Children's Chewable Vitamins/Iron (Tablet Chewable)
181
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
RA Coenzyme Q-10 (Capsule)C1
RA Coral Calcium (Capsule)C1
RA Folic Acid (Tablet)C1
RA Glucose (Gel)C1
RA Gummy Vitamins & Minerals Children's (Tablet Chewable)
C1
RA Hair/Skin/Nails (Tablet)C1
RA Hi Cal (Tablet)C1
RA Hi-Cal (Tablet)C1
RA Hi-Cal Plus Vitamin D (Tablet)C1
RA High Potency Iron (Tablet)C1
RA Iron (Tablet)C1
RA Magnesium (Capsule)C1
RA Magnesium Citrate (Solution)C1
RA Mature Womens Dietary Supplement (Tablet)
C1
RA Melatonin (Tablet)C1
RA Natural Magnesium (Tablet)C1
RA Natural Vitamin E (Capsule)C1
RA Niacin (Tablet)C1
RA No Flush Niacin 500 (Tablet)C1
RA One Daily (Capsule)C1
RA One Daily Energy Formula (Tablet)C1
RA One Daily Essential (Tablet)C1
RA One Daily Gummy Vites (Tablet Chewable)
C1
RA One Daily Maximum (Tablet)C1
RA One Daily Mens 50+ With Vitamin D-3 (Tablet)
C1
RA One Daily Mens Multi (Tablet)C1
RA One Daily Mens/Vitamin D-3 (Tablet)C1
RA One Daily Multi-Vitamin (Tablet)C1
RA One Daily Womens/Vitamin D-3 (Tablet)
C1
RA Oyster Shell Calcium (Tablet)
OTC Drug NameC1
RA Oyster Shell Calcium/Vitamin D
(Tablet)C1
RA Pediatric Electrolyte (Oral Solution)C1
RA Pediatric Electrolyte Freezer Pops (Oral Solution)
C1
RA Prenatal (Tablet)C1
RA Prenatal Formula/Folicacid (Tablet)C1
RA Slow Release Iron (Tablet Extended-Release)
C1
RA Stress Formula Advanced (Tablet)C1
RA Stress Formula Energy (Tablet)C1
RA Therapeutic M Plus Beta Carotene (Tablet)
C1
RA Tooth Shield (Rinse)C1
RA Vision Vite Plus Zinc (Tablet)C1
RA Vitamin A (Capsule)C1
RA Vitamin B-1 (Tablet)C1
RA Vitamin B-12 (Liquid)C1
RA Vitamin B12 (Tablet Extended-Release)C1
RA Vitamin B-12 (Tablet)C1
RA Vitamin B-12 TR (Tablet Extended-Release)
C1
RA Vitamin B-6 (Tablet)C1
RA Vitamin B-6 TR (Tablet Extended-Release)
C1
RA Vitamin C (Tablet Chewable)C1
RA Vitamin C (Tablet)C1
RA Vitamin C Drops (Lozenge)C1
RA Vitamin C TR (Tablet Extended-Release)
C1
RA Vitamin C/Acerola (Tablet Chewable)C1
RA Vitamin C/Rose Hips (Tablet)C1
RA Vitamin C/Rose Hips TR (Tablet Extended-Release)
C1
RA Vitamin D-3 (Capsule)C1
RA Vitamin D-3 (Tablet)
182
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
RA Vitamin E (Capsule)C1
RA Vitamin E Blend (Capsule)C1
RA Vitamin E Natural (Capsule)C1
RA Whole Source Complete Formula For Men (Tablet)
C1
RA Whole Source Dietary (Tablet)C1
RA Whole Source Dietary For Men (Tablet)C1
RA Whole Source Dietary Mature (Tablet)C1
RA Whole Source Womens (Tablet)C1
Rehydralyte (Oral Solution)C1
Relion Glucose (Gel)C1
Relion Glucose Drink (Liquid)C1
Renal Multivitamin Formula/Zinc (Tablet)C1
Renaplex (Tablet)C1
Revital Freezer Pops (Oral Solution)C1
Revital Jell Cups (Oral Solution)C1
Revital Liquid Squeezers (Oral Solution)C1
Riboflavin (Tablet)C1
Risacal-D (Tablet)C1
Saline Flush (Solution)C1
Saline Flush ZR/Sterile Field (Solution)C1
Savision (Tablet)C1
SB Calcium + D (Tablet)C1
SB Magnesium Citrate (Solution)C1
SB Oyster Shell Calcium (Tablet)C1
SB Pediatric Electrolyte (Oral Solution)C1
SB Vitamin C (Tablet)C1
Sclerex (Tablet)C1
Sea Buddies Daily Multiple (Tablet Chewable)
C1
Senior Tabs (Tablet)C1
Sentry (Tablet)C1
Sentry Adults Under 50 (Tablet)C1
Sentry Senior (Tablet)
OTC Drug NameC1
Signacal (Tablet)C1
Sigtab (Tablet)C1
Slo-Niacin (Tablet Extended-Release)C1
Slow Fe (Tablet Extended-Release)C1
Slow Iron (Tablet Extended-Release)C1
Slow Release Iron (Tablet Extended-Release)
C1
SM Animal Shapes Complete (Tablet Chewable)
C1
SM Animal Shapes Kids First (Tablet Chewable)
C1
SM Anticavity Fluoride Rinse (Rinse)C1
SM Antioxidant Vitamins (Tablet)C1
SM Calcium /Vitamin D (Tablet)C1
SM Calcium 500/Vitamin D3 (Tablet)C1
SM Calcium 600 + D Plus Minerals (Tablet Chewable)
C1
SM Calcium 600/Vitamin D (Tablet)C1
SM Calcium 600+D3 (Tablet)C1
SM Calcium Citrate + D (Tablet)C1
SM Calcium Citrate W/Vitamin D3 (Tablet)C1
SM Calcium Citrate/Vitamin D3 Petite (Tablet)
C1
SM Calcium Citrate+ W/Vitamin D (Tablet)C1
SM Calcium Soft Chews (Tablet Chewable)C1
SM Calcium/Magnesium/Zinc (Tablet)C1
SM Calcium/Vitamin D (Tablet)C1
SM Calcium/Vitamin D3 (Tablet)C1
SM Chewable Vitamin C (Tablet Chewable)C1
SM Co Q-10 (Capsule)C1
SM Cod Liver Oil (Capsule)C1
SM Coenzyme Q-10 (Capsule)C1
SM Complete (Tablet)C1
SM Complete 50+ (Tablet)C1
SM Complete 50+ Ultimate Mens (Tablet)
183
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
SM Complete 50+ Ultimate Womens (Tablet)
C1
SM Complete Advanced Formula (Tablet)C1
SM Complete Senior Formula (Tablet)C1
SM Coq-10 (Capsule)C1
SM Daily Diet Support (Tablet)C1
SM Folic Acid (Tablet)C1
SM Hair/Skin/Nails (Tablet)C1
SM Iron (Tablet)C1
SM Iron Slow Release (Tablet Extended-Release)
C1
SM Magnesium (Tablet)C1
SM Magnesium Citrate (Solution)C1
SM Melatonin (Tablet)C1
SM Multiple Vitamins Essential (Tablet)C1
SM Niacin CR (Tablet Extended-Release)C1
SM One Daily Essential (Tablet)C1
SM One Daily Mens (Tablet)C1
SM One Daily Prenatal (Capsule)C1
SM One Daily Womens (Tablet)C1
SM Opti-Vitamins (Tablet)C1
SM Oyster Shell Calcium/Vitamin D (Tablet)
C1
SM Oyster Shell Calcium/Vitamin D3 (Tablet)
C1
SM Pediatric Electrolyte (Oral Solution)C1
SM Prenatal Vitamins (Tablet)C1
SM Slow Release Iron (Tablet Extended-Release)
C1
SM Vit C/Rose Hips (Tablet)C1
SM Vitamin B1 (Tablet)C1
SM Vitamin B-12 (Tablet)C1
SM Vitamin B12 TR (Tablet Extended-Release)
C1
SM Vitamin B-6 (Tablet)
OTC Drug NameC1
SM Vitamin C (Tablet Chewable)C1
SM Vitamin C (Tablet)C1
SM Vitamin C TR (Tablet Extended-Release)
C1
SM Vitamin C/Rose Hips (Tablet)C1
SM Vitamin D (Tablet)C1
SM Vitamin D3 (Capsule)C1
SM Vitamin D3 (Tablet)C1
SM Vitamin D3 Maximum Strength (Capsule)
C1
SM Vitamin E (Capsule)C1
SM Vitamin E Blended (Capsule)C1
Smarty Pants Kids Complete And Fiber (Tablet Chewable)
C1
Sodium Chloride (Tablet)C1
Sodium Chloride Flush (Solution)C1
Soluvita E (Solution)C1
Spider-Man Complete Multivitamin Gummies (Tablet Chewable)
C1
Spongebob Squarepants Gummies (Tablet Chewable)
C1
Stress B-Complex/C/Zinc (Tablet)C1
Stress Formula (Tablet)C1
Stress Formula/Iron (Tablet)C1
Stress Formula/Zinc (Tablet)C1
Stresstabs Advanced (Tablet)C1
Stresstabs Energy (Tablet)C1
Sunkist Vitamin C (Tablet Chewable)C1
Sunvite Active Adult 50+ (Tablet)C1
Sunvite Advanced (Tablet)C1
Super 28 Formula (Tablet)C1
Super Antioxidant/A/C/E/Selenium (Tablet)
C1
Super Antioxidants Protector (Capsule)C1
Super Aytinal 50 Plus (Tablet)
184
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Super Aytinal For Active Adults (Tablet)C1
Super Cal/Mag (Tablet)C1
Super Calcium (Tablet)C1
Super Calcium 600 + D3 (Tablet)C1
Super Calcium 600+D 400 (Tablet)C1
Super Calcium 600+D3 400 (Tablet)C1
Super Cal-Mag-D (Tablet)C1
Super Multiple (Capsule)C1
Super Multiple (Tablet)C1
Super Natrul-100 (Tablet Extended-Release)
C1
Super Nu-Thera (Tablet)C1
Super Thera Vite M (Tablet)C1
Super Vikaps (Tablet)C1
Super Vita-Mins (Tablet)C1
Superior 35 (Tablet Extended-Release)C1
Support (Liquid)C1
SV Melatonin (Tablet)C1
SV Vitamin B12 TR (Tablet Extended-Release)
C1
Swabflush Saline Flush (Solution)C1
Tab-A-Vite (Tablet)C1
Tab-A-Vite W/Beta Carotene (Tablet)C1
TGT Calcium + Vitamin D3 (Tablet)C1
TGT Calcium Dietary Supplement (Tablet Chewable)
C1
TGT Daily Multivitamin Womens (Tablet)C1
TGT Multivitamin/Multimineral Adults/Lycopene (Tablet)
C1
TGT Multivitamin/Multimineral/Adult (Tablet)
C1
TGT Vitamin C Drops (Lozenge)C1
Thera (Tablet)C1
Thera M Plus (Tablet)C1
Thera Vital M (Tablet)
OTC Drug NameC1
Thera Vital-M (Tablet)C1
Therabasic-M (Tablet)C1
Thera-D 2000 (Tablet)C1
Thera-D Rapid Repletion (Tablet)C1
Theradex "M" (Tablet)C1
Theradex "M"/Beta Carotene (Tablet)C1
Thera-M (Tablet)C1
Thera-Mill (Tablet)C1
Thera-Mill M (Tablet)C1
Theramill Plus (Capsule)C1
Therapeutic (Tablet)C1
Therapeutic Formula/Hematinics (Tablet)C1
Therapeutic M (Tablet)C1
Therapeutic Multi Vitaminmineral (Tablet)C1
Therapeutic-M (Tablet)C1
Therapeutic-M/Lutein (Tablet)C1
Thera-Tabs (Tablet)C1
Thera-Tabs M (Tablet)C1
Theratrum Complete (Tablet)C1
Theratrum Complete 50 Plus (Tablet)C1
Theravim -M (Tablet)C1
Therems (Tablet)C1
Therems-H (Tablet)C1
Therems-M (Tablet)C1
Thiamine HCL (Tablet)C1
Thrive For Life Womens (Tablet)C1
Total Formula (Tablet)C1
Total Formula 2 (Tablet)C1
Total Formula 3 (Tablet)C1
Totalday Multiple (Tablet Extended-Release)
C1
Tri-Vit/Fluoride (Solution)C1
Tri-Vit/Fluoride/Iron (Drops)C1
Tri-Vitamin/Fluoride (Solution)
185
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Tri-Vite/Fluoride (Solution)C1
Tropical Liquid Nutrition (Liquid)C1
Trueplus Diabetic Multivitamin (Tablet)C1
Ultra Antioxidant Formula (Tablet)C1
Ultra Choice Multivitamin Kids (Tablet Chewable)
C1
Ultra Freeda (Tablet)C1
Ultra Freeda/Iron (Tablet)C1
Ultra Multi Formula/Iron (Capsule)C1
Ultra Vita-Time (Tablet)C1
Ultrachoice Advanced Formula (Tablet)C1
Ultrachoice Advanced Formula Mature (Tablet)
C1
Ultra-Mega (Tablet Extended-Release)C1
Unicomplex-M (Tablet)C1
Upcal D (Powder)C1
UpSpring Baby Multivitamin/Iron (Liquid)C1
Value Plus Glucose (Gel)C1
Viactiv (Tablet Chewable)C1
Vicap Forte (Capsule)C1
Vic-Forte (Capsule)C1
Vinate II (Tablet)C1
Vinate M (Tablet)C1
Vision Formula 2 (Tablet)C1
Vision Formula Eye Health (Capsule)C1
Vision Formula/Lutein (Tablet)C1
Vision Plus (Capsule)C1
Vision Vitamins (Tablet)C1
Visivites (Tablet)C1
Visivites/Lutein (Tablet)C1
Vita Hair (Tablet)C1
Vita S Forte (Tablet)C1
Vitabasic Complete (Tablet)C1
Vitabasic Senior (Tablet)
OTC Drug NameC1
Vita-Calcium (Wafer)C1
Vitacel (Tablet)C1
Vitachew Multiple Vitamin Children's (Tablet Chewable)
C1
Vitachew Vitamin C Citrusburst Gummies (Tablet Chewable)
C1
Vitajoy Daily D Gummies (Tablet Chewable)
C1
Vitajoy Gummies (Tablet Chewable)C1
Vitalee (Tablet)C1
Vitaline Coq10 (Tablet)C1
Vitamelts Energy Vitamin B-12 (Tablet)C1
Vita-Min (Capsule)C1
Vitamin A & D (Ointment)C1
Vitamin A (Capsule)C1
Vitamin A Palmitate (Tablet)C1
Vitamin B 12 (Lozenge)C1
Vitamin B 6 (Tablet)C1
Vitamin B Complex (Tablet)C1
Vitamin B-1 (Tablet)C1
Vitamin B12 (Liquid)C1
Vitamin B-12 (Lozenge)C1
Vitamin B-12 (Tablet Extended-Release)C1
Vitamin B-12 (Tablet)C1
Vitamin B-12 CR (Tablet Extended-Release)
C1
Vitamin B-12 ER (Tablet Extended-Release)C1
Vitamin B-12 LA (Tablet Extended-Release)C1
Vitamin B-12 Natural (Tablet)C1
Vitamin B12 TR (Tablet Extended-Release)C1
Vitamin B-12 TR (Tablet Extended-Release)C1
Vitamin B-2 (Tablet)C1
Vitamin B-6 (Tablet Extended-Release)C1
Vitamin B-6 (Tablet)C1
Vitamin B-6 Repack (Tablet)
186
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Vitamin B-6 TR (Tablet Extended-Release)C1
Vitamin B-Complex (Tablet)C1
Vitamin B-Complex 100 (Injection)C1
Vitamin C (Liquid)C1
Vitamin C (Powder)C1
Vitamin C (Tablet Chewable)C1
Vitamin C (Tablet Extended-Release)C1
Vitamin C (Tablet)C1
Vitamin C Adult Gummies (Tablet Chewable)
C1
Vitamin C CR (Capsule)C1
Vitamin C Drops (Lozenge)C1
Vitamin C Gummie (Tablet Chewable)C1
Vitamin C Gummies (Tablet Chewable)C1
Vitamin C Immune Health (Tablet Chewable)
C1
Vitamin C Plus Bioflavonoids/Wild Rose Hips (Tablet)
C1
Vitamin C Plus Wild Rose Hips (Tablet Chewable)
C1
Vitamin C SR (Capsule)C1
Vitamin C TR (Capsule)C1
Vitamin C TR (Tablet Extended-Release)C1
Vitamin C TR/Rose Hips (Tablet Extended-Release)
C1
Vitamin C/Acerola (Tablet Chewable)C1
Vitamin C/Acerola (Tablet)C1
Vitamin C/Rose Hips (Tablet Chewable)C1
Vitamin C/Rose Hips (Tablet)C1
Vitamin C/Rose Hips TR (Tablet Extended-Release)
C1
Vitamin C-500 Timed Release (Capsule Extended-Release)
C1
Vitamin D (Capsule)C1
Vitamin D (Liquid)C1
Vitamin D (Tablet)
OTC Drug NameC1
Vitamin D 400 (Tablet Chewable)C1
Vitamin D High Potency (Capsule)C1
Vitamin D Infant (Liquid)C1
Vitamin D-1000 (Tablet)C1
Vitamin D-1000 Maximum Strength (Tablet)C1
Vitamin D2 (Tablet)C1
Vitamin D-3 (Capsule)C1
Vitamin D3 (Drops)C1
Vitamin D3 (Liquid)C1
Vitamin D3 (Tablet Chewable)C1
Vitamin D3 (Tablet)C1
Vitamin D-3 (Tablet)C1
Vitamin D3 400 (Capsule)C1
Vitamin D3 Adult Gummies (Tablet Chewable)
C1
Vitamin D3 Gummies (Tablet Chewable)C1
Vitamin D3 High Potency (Capsule)C1
Vitamin D3 Maximum Strength (Capsule)C1
Vitamin D3 Super Strength (Capsule)C1
Vitamin D3 Super Strength (Tablet)C1
Vitamin D3 Ultra Potency (Tablet)C1
Vitamin D3 Ultra Strength (Capsule)C1
Vitamin D-400 (Tablet)C1
Vitamin E (Capsule)C1
Vitamin E (Oil)C1
Vitamin E (Solution)C1
Vitamin E (Tablet)C1
Vitamin E Blend (Capsule)C1
Vitamin E Complex (Capsule)C1
Vitamin E Complex Natural (Capsule)C1
Vitamin E High Potency (Capsule)C1
Vitamin E Water Dispersible (Capsule)C1
Vitamin E Water Solubilized (Capsule)C1
Vitamin E Water Soluble (Capsule)
187
Bold type = Brand name drug Plain type = Generic drug
OTC Drug NameC1
Vitamin E/D-Alpha (Capsule)C1
Vitamin E/D-Alpha Natural (Capsule)C1
Vitamin E/Dl-Alpha (Capsule)C1
Vitamin E/Folic Acid/B-6/B-12 (Capsule)C1
Vitamin E/Vitamin C/Beta Carotene (Tablet)
C1
Vitamin E-200 (Capsule)C1
Vitamin E-400 (Capsule)C1
Vitamin Supplement E-1000 (Capsule)C1
Vitamin Supplement E-400 (Capsule)C1
Vitamin-D3 (Tablet)C1
Vitamins A/C/D/Fluoride (Solution)C1
Vitamins A/D/C/Fluoride (Solution)C1
Vitamins A-D-E/Selenium (Tablet)C1
Vita-Plus E (Capsule)C1
Vitatrum (Tablet Chewable)C1
Vitatrum (Tablet)C1
Vitatrum Complete (Tablet)C1
Viteyes Areds Advanced (Capsule)C1
Viteyes Areds Formula (Capsule)C1
Viteyes Areds Formula Plus Lutein (Capsule)
C1
Viteyes Complete (Capsule)C1
Viteyes Multivitamin Areds Companion With Lycopene (Tablet)
C1
Viteyes Smokers Advanced (Capsule)C1
Viteyes Smokers Formula Plus Lutein (Capsule)
C1
Vitrum 50+ Senior Multi (Tablet)C1
Vitrum Senior (Tablet)C1
VP-GGR-B6 Prenatal (Tablet)
OTC Drug NameC1
VP-Heme OB + DHA (Tablet)C1
Wegmans Complete Prenatal+DHA (Capsule)
C1
Womens 50+ Advanced (Capsule)C1
Womens Daily Formula (Tablet)C1
Womens Daily Formula/Folic Acid/Calcium/Iron (Tablet)
C1
Womens Life Pack (Tablet)C1
Womens Multi (Capsule)C1
Womens Multivitamin (Tablet)C1
Womens One Daily (Tablet)C1
Yl Coenzyme Q10 (Capsule)C1
Yl Folic Acid (Tablet)C1
Yl Vitamin B-6 (Tablet)C1
Yl Vitamin C (Tablet)C1
Yl Vitamin C/Rose Hips (Tablet)C1
Yl Vitamin E (Capsule)C1
Your Life Multi Mens 50+ (Tablet)C1
Your Life Multi Womens 50+ (Tablet)C1
Zoo Friends (Tablet Chewable)C1
Zoo Friends Complete (Tablet Chewable)C1
Zoo Friends Gummies (Tablet Chewable)C1
Zoo Friends Gummies Plus Extra C (Tablet Chewable)
C1
Zoo Friends Gummies Plus Extra D (Tablet Chewable)
C1
Zoo Friends Multi Gummies (Tablet Chewable)
C1
Zoo Friends Plus Iron (Tablet Chewable)C1
Zoo Friends/Extra C (Tablet Chewable)
188
Trackedtrack
D. Index of Covered Drugs
In this section, you can find a drug by searching for its name alphabetically. This will tell you the page number where you can find additional coverage information for your drug.
A
Abacavir Sulfate...................... 43
Abacavir Sulfate-Lamivudine............................................... 43
Abacavir-Lamivudine-Zidovudine............................ 43
Abelcet.....................................29
Abilify Maintena...................... 39
Abiraterone Acetate................33
Acamprosate Calcium............ 17
Acarbose................................. 46
Acebutolol HCl........................ 52
Acetaminophen-Codeine....... 15
Acetazolamide........................ 55
Acetazolamide ER.................. 55
Acetic Acid.............................. 85
Acetylcysteine......................... 88
Acitretin................................... 60
Actemra................................... 79
Actemra ACTPen.................... 79
ActHIB......................................79
Actimmune.............................. 79
Acyclovir.................................. 42
Acyclovir Sodium.................... 42
Adacel......................................79
Adapalene............................... 60
Adefovir Dipivoxil.................... 42
Adempas................................. 88
Advair Diskus.......................... 88
Advair HFA.............................. 88
Afinitor..................................... 35
Afinitor Disperz........................35
Aimovig.................................... 31
Ala-Cort.................................... 67
Albendazole............................ 37
Albuterol Sulfate..................... 87
Albuterol Sulfate HFA............. 87
Alclometasone Dipropionate............................................... 67
Alcohol Prep Pads.................. 82
Alecensa.................................. 35
Alendronate Sodium...............82
Alfuzosin HCl ER.....................67
Alinia........................................ 37
Aliskiren Fumarate..................54
Allopurinol............................... 31
Alocril....................................... 83
Alomide....................................84
Alosetron HCl.......................... 65
Alphagan P.............................. 84
Alprazolam.............................. 45
Altavera....................................71
Alunbrig................................... 35
Alyacen 1/35........................... 71
Alyq.......................................... 88
Amantadine HCl......................37
AmBisome............................... 29
Ambrisentan............................ 88
Amethia....................................71
Amethia Lo.............................. 71
Amikacin Sulfate..................... 17
Amiloride HCl.......................... 56
Amiloride-Hydrochlorothiazide............................................... 54
Aminosyn II.............................. 61
Aminosyn-PF........................... 61
Amiodarone HCl..................... 52
Amitiza..................................... 65
Amitriptyline HCl..................... 28
Amlodipine Besylate...............53
Amlodipine-Atorvastatin......... 54
Amlodipine-Benazepril........... 54
Amlodipine-Olmesartan..........54
Amlodipine-Valsartan............. 54
Amlodipine-Valsartan-HCTZ...54
Ammonium Lactate................ 60
Amoxapine.............................. 28
Amoxicillin............................... 21
Amoxicillin-Potassium Clavulanate........................... 21
Amoxicillin-Potassium Clavulanate ER..................... 21
Amphetamine-Dextroamphetamine.............58
Amphetamine-Dextroamphetamine ER.......58
Amphotericin B....................... 29
Ampicillin................................. 21
Ampicillin Sodium...................21
Ampicillin-Sulbactam Sodium............................................... 21
189
Tracked
Ampyra.................................... 59
Anadrol-50............................... 70
Anagrelide HCl........................ 50
Anastrozole............................. 34
Androderm.............................. 70
Anoro Ellipta............................ 88
Apokyn.....................................38
Apraclonidine HCl...................84
Aprepitant................................ 29
Apri...........................................71
Apriso.......................................81
Aptiom..................................... 26
Aptivus..................................... 44
Aralast NP................................66
Aranelle....................................71
Aranesp................................... 50
Arcalyst.................................... 79
Aripiprazole............................. 39
Aripiprazole ODT.................... 39
Aristada....................................39
Aristada Initio.......................... 39
Arnuity Ellipta.......................... 86
Ashlyna.................................... 71
Aspirin-Dipyridamole ER........ 51
Atazanavir Sulfate................... 44
Atenolol....................................52
Atenolol-Chlorthalidone..........54
Atomoxetine HCl.....................58
Atorvastatin Calcium.............. 56
Atovaquone............................. 37
Atovaquone-Proguanil HCl.....37
Atripla.......................................43
Atropine Sulfate...................... 83
Atrovent HFA........................... 86
Aubagio................................... 59
Aubra....................................... 71
Auryxia..................................... 64
Austedo................................... 58
Aviane...................................... 71
Avonex Pen............................. 59
Avonex Prefilled...................... 59
Ayvakit..................................... 35
Azasite..................................... 22
Azathioprine............................ 77
Azelaic Acid.............................60
Azelastine HCl...................84, 86
Azelastine-Fluticasone............88
Azithromycin........................... 22
Azopt........................................84
Aztreonam............................... 21
B
Bacitracin.................................18
Bacitracin-Polymyxin B...........83
Baclofen...................................89
Balsalazide Disodium............. 81
Balversa................................... 34
Balziva......................................71
Banzel...................................... 26
Baqsimi Two Pack.................. 47
Baraclude................................ 42
BCG Vaccine...........................79
Belsomra................................. 90
Benazepril HCl........................ 52
Benazepril-Hydrochlorothiazide............................................... 54
Benlysta................................... 79
Benznidazole...........................37
Benzoyl Peroxide-Erythromycin............................................... 60
Benztropine Mesylate............. 37
Bepreve................................... 84
Berinert.................................... 76
Besivance................................ 23
Betamethasone Dipropionate............................................... 68
Betamethasone Dipropionate Aug.................................. 67, 68
Betamethasone Valerate........ 68
Betaseron................................ 59
Betaxolol HCl.................... 52, 84
Bethanechol Chloride.............67
Bethkis..................................... 87
Betimol.....................................84
Bevespi Aerosphere............... 88
Bexarotene.............................. 36
Bexsero....................................79
Bicalutamide........................... 33
Bicillin C-R............................... 21
Bicillin C-R 900/300................21
Bicillin L-A................................ 21
BiDil..........................................54
Biktarvy.................................... 43
Binosto.....................................82
Bisoprolol Fumarate............... 52
Bisoprolol-Hydrochlorothiazide............................................... 54
BIVIGAM.................................. 78
Blephamide............................. 83
Blephamide S.O.P.................. 83
Blisovi 24 Fe............................ 71
Blisovi Fe 1.5/30..................... 71
Boostrix....................................80
190
Tracked
Bosentan................................. 88
Bosulif...................................... 35
Braftovi.....................................35
Breo Ellipta.............................. 88
Briellyn..................................... 71
Brilinta......................................51
Brimonidine Tartrate...............84
BRIVIACT.................................24
Bromocriptine Mesylate......... 38
Brukinsa...................................35
Budesonide.......................81, 86
Budesonide ER....................... 81
Bumetanide............................. 55
Buprenorphine........................ 14
Buprenorphine HCl.................17
Buprenorphine HCl-Naloxone HCl......................................... 17
Bupropion HCl........................ 27
Bupropion HCl SR............ 17, 27
Bupropion HCl XL...................27
Buspirone HCl.........................45
Butalbital-Acetaminophen-Caffeine................................. 14
Butalbital-Aspirin-Caffeine......14
Butorphanol Tartrate.............. 15
Bydureon................................. 46
Bydureon BCise...................... 46
Byetta 10MCG Pen................. 46
Byetta 5MCG Pen................... 46
Bystolic.................................... 52
C
Cabergoline.............................75
Cablivi...................................... 51
Cabometyx.............................. 35
Calcipotriene........................... 60
Calcitonin Salmon...................82
Calcitriol............................ 60, 82
Calcium Acetate......................64
Calquence............................... 35
Camila......................................74
Camrese Lo............................. 71
Canasa.....................................81
Candesartan Cilexetil............. 51
Candesartan Cilexetil-HCTZ............................................... 54
Caplyta.....................................39
Caprelsa.................................. 35
Captopril.................................. 52
Captopril-Hydrochlorothiazide............................................... 54
Carac........................................60
Carafate................................... 65
Carbaglu.................................. 61
Carbamazepine.......................26
Carbamazepine ER.................26
Carbidopa................................38
Carbidopa-Levodopa..............38
Carbidopa-Levodopa ER........38
Carbidopa-Levodopa ODT..... 38
Carbidopa-Levodopa-Entacapone...........................38
Carteolol HCl........................... 84
Cartia XT.................................. 53
Carvedilol.................................52
Cayston....................................87
Caziant..................................... 71
Cefaclor................................... 19
Cefadroxil................................ 19
Cefazolin Sodium....................19
Cefdinir.............................. 19, 20
Cefepime HCl.......................... 20
Cefixime...................................20
Cefotetan Disodium................20
Cefoxitin Sodium.................... 20
Cefpodoxime Proxetil............. 20
Cefprozil.................................. 20
Ceftazidime............................. 20
Ceftriaxone Sodium................ 20
Cefuroxime Axetil....................20
Cefuroxime Sodium................20
Celecoxib.................................14
Celontin................................... 25
Cephalexin...............................20
Cetirizine HCl.......................... 86
Chantix.....................................17
Chantix Continuing Month Pak............................................... 17
Chantix Starting Month Pak... 17
Chemet.................................... 63
Chenodal................................. 64
Chlordiazepoxide HCl............ 45
Chlorhexidine Gluconate....... 59
Chloroquine Phosphate......... 37
Chlorpromazine HCl............... 38
Chlorthalidone.........................56
Chlorzoxazone........................ 89
Cholbam.................................. 66
Cholestyramine....................... 56
Cholestyramine Light............. 56
Ciclopirox.......................... 29, 30
Ciclopirox Olamine................. 30
Cilostazol................................. 51
Ciloxan..................................... 23
191
Tracked
Cimduo.................................... 43
Cimetidine............................... 65
Cimetidine HCl........................ 65
Cimzia...................................... 77
Cimzia Prefilled....................... 77
Cinacalcet HCl........................ 82
Cinryze..................................... 76
Cipro HC.................................. 85
Ciprodex.................................. 85
Ciprofloxacin HCl....................23
Ciprofloxacin in D5W..............23
Citalopram Hydrobromide..... 27
Claravis.................................... 60
Clarithromycin......................... 22
Clarithromycin ER................... 22
Clenpiq.................................... 65
Climara Pro..............................71
Clindamycin HCl..................... 18
Clindamycin Palmitate HCl.... 18
Clindamycin Phosphate... 18, 60
Clindamycin Phosphate in D5W............................................... 18
Clindamycin Phosphate-Benzoyl Peroxide..................60
Clobazam................................ 25
Clobetasol Propionate............68
Clobetasol Propionate Emollient Base...................... 68
Clomipramine HCl.................. 28
Clonazepam............................ 45
Clonazepam ODT................... 45
Clonidine................................. 51
Clonidine HCl.......................... 51
Clonidine HCl ER.................... 58
Clopidogrel Bisulfate.............. 51
Clorazepate Dipotassium....... 45
Clotrimazole............................ 30
Clotrimazole-Betamethasone............................................... 60
Clovique...................................63
Clozapine.................................41
Clozapine ODT........................41
Coartem................................... 37
Codeine Sulfate...................... 15
Colchicine................................31
Colcrys..................................... 31
Colesevelam HCl.................... 56
Colestipol HCl................... 56, 57
Colistimethate Sodium........... 18
Combigan................................ 84
Combivent Respimat.............. 88
Cometriq..................................35
Complera................................. 43
Compro....................................29
Constulose.............................. 65
Copiktra................................... 34
Cordran....................................68
Corlanor................................... 54
Cortisone Acetate................... 68
Cortisporin...............................60
Cosentyx..................................60
Cosentyx Sensoready.............60
Cosopt PF................................84
Cotellic..................................... 35
Creon....................................... 66
Crinone.................................... 74
Crixivan.................................... 44
Cromolyn Sodium...... 64, 84, 87
Cryselle-28...............................71
Cuvposa...................................64
Cyclafem 1/35.........................71
Cyclafem 7/7/7....................... 71
Cyclobenzaprine HCl..............89
Cyclophosphamide.................33
Cycloset................................... 46
Cyclosporine........................... 77
Cyclosporine Modified........... 77
Cyproheptadine HCl............... 86
Cyred....................................... 71
Cystadane................................66
Cystagon..................................66
Cystaran...................................83
D
Dalfampridine ER....................59
Daliresp....................................87
Dalvance.................................. 18
Danazol.................................... 70
Dantrolene Sodium.................89
Dapsone.................................. 32
Daptacel.................................. 80
Daptomycin............................. 18
DARAPRIM.............................. 37
Daurismo................................. 35
Deblitane................................. 74
Deferasirox.............................. 64
Delstrigo.................................. 43
Demeclocycline HCl............... 24
Demser.................................... 54
Denavir.....................................42
Depen Titratabs...................... 67
Depo-Estradiol.........................71
Depo-Provera.......................... 74
Descovy................................... 43
192
Tracked
Desipramine HCl.....................28
Desmopressin Acetate........... 70
Desmopressin Acetate Spray............................................... 70
Desogestrel-Ethinyl Estradiol............................................... 71
Desonide................................. 68
Desoximetasone..................... 68
Desvenlafaxine Succinate ER............................................... 28
Dexamethasone...................... 68
Dexamethasone Intensol........68
Dexamethasone Sodium Phosphate............................. 84
Dexilant.................................... 66
Dexmethylphenidate HCl....... 58
Dexmethylphenidate HCl ER............................................... 58
Dextroamphetamine Sulfate............................................... 58
Dextroamphetamine Sulfate ER............................................... 58
Dextrose.................................. 62
Dextrose-NaCl......................... 62
Diastat AcuDial........................25
Diastat Pediatric...................... 25
Diazepam.......................... 25, 45
Diazepam Intensol.................. 45
Diazoxide................................. 47
Diclofenac Epolamine............ 14
Diclofenac Potassium.............14
Diclofenac Sodium.....14, 60, 85
Diclofenac Sodium ER........... 14
Dicloxacillin Sodium............... 21
Dicyclomine HCl..................... 64
Didanosine.............................. 43
Dificid....................................... 22
Diflunisal.................................. 14
Digitek......................................54
Digox........................................54
Digoxin.....................................54
Dihydroergotamine Mesylate............................................... 31
Dilantin.....................................26
Dilantin INFATABS..................26
Dilt-XR...................................... 53
Diltiazem HCl...........................53
Diltiazem HCl ER.....................53
Diltiazem HCl ER Beads.........53
Diltiazem HCl ER Coated Beads............................................... 53
Dipentum................................. 81
Diphenoxylate-Atropine.......... 64
Diphtheria-Tetanus Toxoids DT............................................... 80
Disulfiram.................................17
Diuril.........................................56
Divalproex Sodium........... 45, 46
Divalproex Sodium ER........... 45
Dofetilide................................. 52
Donepezil HCl......................... 27
Donepezil HCl ODT................ 27
Dorzolamide HCl.....................84
Dorzolamide HCl-Timolol Maleate..................................84
Dorzolamide HCl-Timolol Maleate Preservative Free... 84
Dovato......................................42
Doxazosin Mesylate................51
Doxepin HCl...................... 28, 60
Doxercalciferol........................ 82
Doxy 100..................................24
Doxycycline Hyclate............... 24
Doxycycline Monohydrate......24
Drizalma Sprinkle....................58
Dronabinol............................... 29
Drospirenone-Ethinyl Estradiol............................................... 71
Droxia.......................................33
Duavee..................................... 71
Dulera...................................... 88
Duloxetine HCl........................ 59
Durezol.....................................85
Dutasteride.............................. 67
Dymista.................................... 88
E
E.E.S. Granules....................... 22
Econazole Nitrate....................30
Edarbi.......................................51
Edarbyclor............................... 54
Edurant.................................... 43
Efavirenz.................................. 43
Elestrin..................................... 71
Eliquis...................................... 49
Eliquis Starter Pack................ 49
Elmiron.....................................67
EluRyng................................... 71
Emcyt....................................... 33
Emgality................................... 31
Emoquette............................... 71
Emsam..................................... 27
Emtriva..................................... 43
Enalapril Maleate.................... 52
Enalapril-Hydrochlorothiazide............................................... 55
193
Tracked
Enbrel.......................................77
Enbrel Mini.............................. 77
Enbrel SureClick..................... 77
Endocet................................... 15
Engerix-B................................. 80
Enoxaparin Sodium................ 49
Enpresse-28............................ 72
Enskyce................................... 72
Entacapone............................. 38
Entecavir.................................. 42
Entresto................................... 55
Enulose.................................... 65
Envarsus XR............................ 77
Epclusa.................................... 42
Epidiolex.................................. 24
Epinastine HCl.........................84
Epinephrine............................. 87
EpiPen 2-Pak........................... 87
EpiPen Jr 2-Pak.......................87
Epitol........................................ 26
Epivir HBV............................... 42
Eplerenone.............................. 56
Eraxis....................................... 30
Ergotamine-Caffeine............... 31
Erivedge...................................35
Erleada.....................................33
Erlotinib HCl............................ 35
Errin..........................................74
Ertapenem Sodium.................21
Ery............................................ 60
Erythrocin Lactobionate......... 22
Erythromycin..................... 23, 61
Erythromycin Base..................22
Erythromycin Ethylsuccinate............................................... 23
Esbriet......................................88
Escitalopram Oxalate............. 28
Esomeprazole Magnesium.... 66
Estarylla................................... 72
Estradiol...................................72
Estradiol Valerate....................72
Estring......................................72
Ethacrynic Acid....................... 55
Ethambutol HCl.......................32
Ethosuximide...........................25
Ethynodiol Diacetate-Ethinyl Estradiol................................ 72
Etodolac...................................14
Etodolac ER.............................14
Etonogestrel-Ethinyl Estradiol............................................... 72
Euthyrox...................................75
Everolimus.........................35, 77
Evotaz...................................... 44
Exemestane.............................34
Ezetimibe................................. 57
Ezetimibe-Simvastatin............ 57
F
Falmina.................................... 72
Famciclovir.............................. 42
Famotidine...............................65
Fanapt......................................39
Fanapt Titration Pack............. 39
Farydak.................................... 35
Fasenra.................................... 89
Fasenra Pen............................ 89
Fayosim................................... 72
Febuxostat...............................31
Felbamate................................26
Felodipine ER..........................53
Femring....................................72
Femynor...................................72
Fenofibrate.............................. 56
Fenofibrate Micronized.......... 56
Fenofibric Acid........................ 56
Fentanyl................................... 15
Fentanyl Citrate....................... 15
Ferriprox.................................. 64
Fetzima.................................... 28
Fetzima Titration..................... 28
Finacea.................................... 61
Finasteride...............................67
Fintepla.................................... 24
Firazyr...................................... 76
Firmagon........................... 75, 76
Flac...........................................85
Flarex....................................... 85
Flebogamma DIF.................... 78
Flecainide Acetate.................. 52
Flector...................................... 14
Flovent Diskus.........................86
Flovent HFA............................. 86
Fluconazole............................. 30
Fluconazole in Sodium Chloride............................................... 30
Flucytosine.............................. 30
Fludrocortisone Acetate.........68
Flunisolide............................... 86
Fluocinolone Acetonide... 68, 85
Fluocinolone Acetonide Scalp............................................... 68
Fluocinonide..................... 68, 69
194
Tracked
Fluocinonide Emulsified Base............................................... 68
Fluorometholone.....................85
Fluorouracil............................. 61
Fluoxetine HCl.........................28
Fluphenazine Decanoate....... 38
Fluphenazine HCl................... 38
Flurbiprofen............................. 14
Flurbiprofen Sodium...............85
Flutamide.................................33
Fluticasone Propionate.... 69, 86
Fluticasone-Salmeterol........... 89
Fluvastatin Sodium................. 56
Fluvoxamine Maleate..............28
FML.......................................... 85
FML Forte................................ 85
Fondaparinux Sodium............ 49
Forteo.......................................82
Fosamprenavir Calcium......... 44
Fosinopril Sodium...................52
Fosinopril Sodium-HCTZ........55
FreAmine HBC........................ 62
Furosemide............................. 56
Fuzeon..................................... 44
Fyavolv..................................... 72
Fycompa.................................. 26
G
Gabapentin..............................25
Galantamine Hydrobromide............................................... 27
Galantamine Hydrobromide ER............................................... 27
Gammagard............................ 78
Gammagard S/D Less IgA..... 78
Gammaked..............................78
Gammaplex............................. 78
Gamunex-C..............................79
Gardasil 9................................ 80
Gatifloxacin..............................23
Gattex.......................................64
Gauze.......................................82
GaviLyte-C............................... 65
GaviLyte-G............................... 65
GaviLyte-N with Flavor Pack............................................... 65
Gemfibrozil.............................. 56
Generlac.................................. 65
Gengraf....................................77
Genotropin.............................. 70
Genotropin MiniQuick............ 70
Gentak..................................... 17
Gentamicin Sulfate................. 18
Gentamicin Sulfate-0.9% Sodium Chloride...................18
Genvoya...................................42
Geodon.................................... 39
Gianvi....................................... 72
Gilenya..................................... 59
Gilotrif...................................... 35
Glassia..................................... 66
Glatiramer Acetate..................59
Glatopa.................................... 59
Gleostine................................. 33
Glimepiride.............................. 46
Glipizide................................... 46
Glipizide ER.............................46
Glipizide-Metformin HCl......... 46
GlucaGen HypoKit.................. 47
Glucagon................................. 47
Glyxambi..................................46
Granisetron HCl...................... 29
Granix.......................................50
Griseofulvin Microsize............ 30
Griseofulvin Ultramicrosize.... 30
Guanfacine HCl ER.................58
Guanidine HCl.........................32
Gvoke HypoPen 2-Pack......... 47
Gvoke PFS...............................48
H
Haegarda................................. 76
Hailey 24 Fe.............................72
Halobetasol Propionate..........69
Haloperidol.............................. 39
Haloperidol Decanoate.......... 39
Haloperidol Lactate................ 39
Havrix....................................... 80
Heparin Sodium...................... 49
HepatAmine............................ 62
Hetlioz...................................... 90
Hiberix......................................80
Humalog.................................. 48
Humalog Junior KwikPen.......48
Humalog KwikPen.................. 48
Humalog Mix 50/50................ 48
Humalog Mix 50/50 KwikPen............................................... 48
Humalog Mix 75/25................ 48
Humalog Mix 75/25 KwikPen............................................... 48
Humatrope.............................. 70
Humira..................................... 77
Humira Pediatric Crohns Start............................................... 77
Humira Pen..............................77
195
Tracked
Humira Pen Crohns Disease Starter.................................... 77
Humira Pen Psoriasis Starter............................................... 77
Humulin 70/30........................ 48
Humulin 70/30 KwikPen........ 48
Humulin N................................48
Humulin N KwikPen................48
Humulin R................................48
Humulin R U-500.....................48
Humulin R U-500 KwikPen..... 48
Hydralazine HCl...................... 57
Hydrochlorothiazide............... 56
Hydrocodone-Acetaminophen............................................... 16
Hydrocodone-Ibuprofen......... 16
Hydrocortisone................. 69, 81
Hydrocortisone Butyrate........ 69
Hydrocortisone Valerate.........69
Hydrocortisone-Acetic Acid... 85
Hydromorphone HCl.............. 16
Hydromorphone HCl ER........ 15
Hydromorphone HCl Preservative Free.................. 16
Hydroxychloroquine Sulfate............................................... 37
Hydroxyurea............................ 33
Hydroxyzine HCl..................... 45
Hydroxyzine Pamoate.............29
Hysingla ER............................. 15
I
Ibandronate Sodium............... 82
Ibrance.....................................35
Ibu............................................ 14
Ibuprofen................................. 14
Icatibant Acetate..................... 76
Iclusig.......................................35
IDHIFA......................................35
Ilevro........................................ 85
Imatinib Mesylate....................35
Imbruvica................................. 35
Imipenem-Cilastatin................ 21
Imipramine HCl....................... 29
Imipramine Pamoate.............. 29
Imiquimod............................... 61
Imiquimod Pump.................... 61
Imovax Rabies.........................80
Imvexxy Maintenance Pack... 72
Imvexxy Starter Pack.............. 72
Incassia....................................74
Increlex.................................... 70
Incruse Ellipta..........................86
Indapamide............................. 56
Indomethacin.......................... 14
Infanrix..................................... 80
Ingrezza................................... 58
Inlyta.........................................35
Inrebic...................................... 34
Insulin Lispro.....................48, 49
Insulin Lispro Junior KwikPen............................................... 48
Insulin Lispro Prot & Lispro....49
Insulin Syringes, Needles.......82
Intelence.................................. 43
Intralipid................................... 62
Intron A.................................... 42
Introvale................................... 72
Invega Sustenna..................... 40
Invega Trinza........................... 40
Invirase.....................................44
Invokamet................................ 46
Invokamet XR.......................... 46
Invokana.................................. 46
IPOL......................................... 80
Ipratropium Bromide.............. 86
Ipratropium-Albuterol..............89
Irbesartan................................ 51
Irbesartan-Hydrochlorothiazide............................................... 55
Iressa........................................35
Isentress.................................. 42
Isentress HD............................ 42
Isibloom................................... 72
Isolyte-P in D5W...................... 62
Isolyte-S................................... 62
Isoniazid...................................32
Isosorbide Dinitrate................ 57
Isosorbide Mononitrate.......... 57
Isosorbide Mononitrate ER.... 57
Isotretinoin...............................61
Itraconazole............................. 30
Ivermectin................................ 37
Ixiaro........................................ 80
J
Jadenu..................................... 64
Jadenu Sprinkle...................... 64
Jakafi........................................35
Jantoven.................................. 49
Janumet................................... 46
Janumet XR............................. 46
Januvia.....................................46
Jardiance................................. 46
Jasmiel.....................................72
196
Tracked
Jentadueto...............................46
Jentadueto XR.........................46
Jinteli........................................72
Jublia........................................30
Juleber..................................... 72
Juluca...................................... 43
Junel 1.5/30............................ 72
Junel 1/20............................... 72
Junel Fe 1.5/30....................... 72
Junel Fe 1/20.......................... 72
Junel Fe 24.............................. 72
Juxtapid................................... 57
K
Kaitlib Fe.................................. 72
Kaletra......................................44
Kalydeco.................................. 89
Kariva....................................... 72
KCl in Dextrose-NaCl.............. 62
KCl-Lactated Ringers-D5W.... 62
Kelnor 1/35............................. 72
Kelnor 1/50............................. 72
Ketoconazole.......................... 30
Ketoprofen...............................14
Ketorolac Tromethamine....... 85
Kineret......................................77
Kinrix........................................ 80
Kionex...................................... 64
Kisqali...................................... 34
Kisqali Femara........................ 34
Klor-Con................................... 62
Klor-Con 10..............................62
Klor-Con 8................................62
Klor-Con M10.......................... 62
Klor-Con M15.......................... 62
Klor-Con M20.......................... 62
Korlym......................................70
Koselugo..................................35
Kurvelo.....................................72
Kuvan....................................... 66
L
Labetalol HCl...........................52
Lacrisert................................... 83
Lactulose................................. 65
Lamivudine........................42, 43
Lamivudine-Zidovudine.......... 43
Lamotrigine............................. 26
Lanoxin.................................... 55
Lansoprazole...........................66
Lanthanum Carbonate........... 64
Lantus...................................... 49
Lantus SoloStar.......................49
LARIN 1.5/30.......................... 72
LARIN 1/20............................. 72
LARIN Fe 1.5/30..................... 72
LARIN Fe 1/20........................ 72
Larissia.....................................72
Lastacaft.................................. 83
Latanoprost............................. 85
Latuda......................................40
Layolis Fe.................................72
Leena....................................... 72
Leflunomide............................ 79
Lenvima 10MG Daily Dose.....35
Lenvima 12MG Daily Dose.....35
Lenvima 14MG Daily Dose.....36
Lenvima 18MG Daily Dose.....36
Lenvima 20MG Daily Dose.....36
Lenvima 24MG Daily Dose.....36
Lenvima 4MG Daily Dose.......36
Lenvima 8MG Daily Dose.......36
Lessina.....................................73
Letrozole.................................. 34
Leucovorin Calcium................34
Leukeran..................................33
Leukine.................................... 50
Leuprolide Acetate................. 76
Levalbuterol HCl..................... 87
Levemir.................................... 49
Levemir FlexTouch................. 49
Levetiracetam..........................24
Levetiracetam ER....................24
Levo-T...................................... 75
Levobunolol HCl..................... 84
Levocarnitine...........................62
Levocetirizine Dihydrochloride............................................... 86
Levofloxacin............................ 23
Levofloxacin in D5W............... 23
Levonest.................................. 73
Levonorgestrel-Ethinyl Estradiol............................................... 73
Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol................ 73
Levonorgestrel-Ethinyl Estradiol 91-Day....................................73
Levora 0.15/30........................73
Levorphanol Tartrate.............. 15
Levothyroxine Sodium............75
Levoxyl..................................... 75
Lexiva....................................... 44
Lidocaine...........................16, 17
Lidocaine HCl..........................17
Lidocaine Viscous...................17
197
Tracked
Lidocaine-Prilocaine............... 17
Lindane.................................... 37
Linezolid.................................. 18
Linzess..................................... 65
Liothyronine Sodium.............. 75
Lisinopril.................................. 52
Lisinopril-Hydrochlorothiazide............................................... 55
Lithium..................................... 46
Lithium Carbonate.................. 46
Lithium Carbonate ER............ 46
Lithostat................................... 67
Livalo........................................56
Lokelma................................... 64
Lonhala Magnair..................... 86
Lonsurf.....................................34
Loperamide HCl......................64
Lopinavir-Ritonavir.................. 44
Lorazepam...............................45
Lorbrena.................................. 34
Lorcet.......................................16
Lorcet HD................................ 16
Loryna...................................... 73
Losartan Potassium................ 51
Losartan Potassium-HCTZ..... 55
Lotemax................................... 85
Lotemax SM............................ 85
Loteprednol Etabonate...........85
Lovastatin................................ 56
Low-Ogestrel........................... 73
Loxapine Succinate................ 39
Lumigan...................................85
Lupaneta Pack........................ 76
Lupron Depot.......................... 76
Lutera.......................................73
Lynparza.................................. 36
Lysodren..................................75
Lyza.......................................... 74
M
M-M-R II....................................80
Magnesium Sulfate................. 62
Malathion................................. 37
Maprotiline HCl....................... 28
Marlissa................................... 73
Marplan....................................27
Matulane..................................33
Matzim LA................................53
Mavyret.................................... 42
Mayzent................................... 59
Meclizine HCl.......................... 29
Medroxyprogesterone Acetate......................................... 74, 75
Mefloquine HCl....................... 37
Megestrol Acetate...................75
Mekinist................................... 36
Mektovi.................................... 36
Melodetta 24 Fe...................... 73
Meloxicam............................... 14
Memantine HCl....................... 27
Memantine HCl ER................. 27
Memantine HCl Titration Pak............................................... 27
Menactra..................................80
Menest..................................... 73
Mentax..................................... 30
Menveo.................................... 80
Mercaptopurine...................... 33
Meropenem............................. 21
Mesalamine............................. 81
Mesalamine ER....................... 81
Mesnex.................................... 36
Metaproterenol Sulfate...........87
Metformin HCl...................46, 47
Metformin HCl ER................... 46
Methadone HCl....................... 15
Methazolamide........................55
Methenamine Hippurate........ 18
Methimazole............................ 76
Methotrexate........................... 77
Methotrexate Sodium............. 77
Methoxsalen Rapid.................61
Methscopolamine Bromide....64
Methyldopa..............................51
Methyldopa-Hydrochlorothiazide............. 55
Methylphenidate HCl.............. 58
Methylphenidate HCl ER........ 58
Methylprednisolone................ 69
Metoclopramide HCl.............. 29
Metolazone.............................. 56
Metoprolol Succinate ER....... 52
Metoprolol Tartrate................. 52
Metoprolol-Hydrochlorothiazide............................................... 55
Metronidazole................... 18, 19
Metronidazole in NaCl 0.79%............................................... 19
Mexiletine HCl......................... 52
Mibelas 24 Fe.......................... 73
Micafungin Sodium................ 30
Miconazole 3........................... 30
Microgestin 1.5/30................. 73
Microgestin 1/20.....................73
198
Tracked
Microgestin Fe 1.5/30............ 73
Microgestin Fe 1/20............... 73
Midodrine HCl......................... 51
Migergot.................................. 31
Miglitol..................................... 47
Miglustat.................................. 66
Mili............................................73
Minitran....................................57
Minocycline HCl...................... 24
Minoxidil.................................. 57
Mirtazapine..............................27
Mirtazapine ODT..................... 27
Mirvaso.................................... 61
Misoprostol..............................66
Modafinil.................................. 90
Moexipril HCl...........................52
Molindone HCl........................ 39
Mometasone Furoate....... 69, 86
Montelukast Sodium...............86
Morphine Sulfate.................... 16
Morphine Sulfate ER.............. 15
Moxifloxacin HCl..................... 23
Moxifloxacin HCl in NaCl....... 23
Multaq...................................... 52
Mupirocin................................ 19
Mupirocin Calcium................. 19
Myalept.................................... 65
Mycamine................................ 30
Mycophenolate Mofetil.... 77, 78
Mycophenolate Sodium......... 78
Myrbetriq................................. 67
N
Nabumetone........................... 14
Nadolol.................................... 52
Nafcillin Sodium......................22
Naftifine HCl............................ 30
Naftin........................................30
Naloxone HCl.......................... 17
Naltrexone HCl........................ 17
Namzaric..................................58
Naproxen................................. 14
Naproxen DR...........................14
Naratriptan HCl....................... 32
Narcan..................................... 17
Natacyn....................................30
Nateglinide.............................. 47
Natpara.................................... 82
Nayzilam.................................. 24
Nebupent.................................37
Necon 0.5/35.......................... 73
Nefazodone HCl......................28
Neomycin Sulfate....................18
Neomycin-Bacitracin-Polymyxin............................................... 83
Neomycin-Polymyxin-Bacitracin-Hydrocortisone..................... 83
Neomycin-Polymyxin-Dexamethasone....................83
Neomycin-Polymyxin-Gramicidin.............................83
Neomycin-Polymyxin-HC....... 83, 85, 86
NephrAmine............................ 62
Nerlynx.....................................36
Neulasta...................................50
Neupogen................................50
Neupro..................................... 38
Nevirapine............................... 43
Nevirapine ER......................... 43
Nexavar....................................36
Niacin ER................................. 57
Niacor...................................... 57
Nicardipine HCl.......................53
Nicotrol.................................... 17
Nicotrol NS.............................. 17
Nifedipine ER.......................... 53
Nifedipine ER Osmotic Release............................................... 53
Nikki......................................... 73
Nilutamide............................... 33
Nimodipine.............................. 53
Ninlaro..................................... 34
Nitisinone.................................66
Nitro-Bid...................................57
Nitrofurantoin.......................... 19
Nitrofurantoin Macrocrystal... 19
Nitrofurantoin Monohydrate...19
Nitroglycerin............................ 57
Nitrostat................................... 57
Nora-BE....................................75
Norditropin FlexPro................ 70
Norethindrone......................... 75
Norethindrone Acetate........... 75
Norethindrone Acetate-Ethinyl Estradiol................................ 73
Norethindrone Acetate-Ethinyl Estradiol-Fe........................... 73
Norgestimate-Ethinyl Estradiol............................................... 73
Norgestimate-Ethinyl Estradiol Triphasic................................73
Normosol-M in D5W............... 62
Normosol-R pH 7.4................. 62
Northera...................................51
199
Tracked
Nortrel 0.5/35.......................... 73
Nortrel 1/35............................. 73
Nortrel 7/7/7........................... 73
Nortriptyline HCl......................29
Norvir....................................... 44
Noxafil...................................... 30
Nubeqa.................................... 33
Nucala......................................89
Nucynta ER..............................15
Nuedexta................................. 58
Nuplazid...................................40
Nutrilipid.................................. 62
Nutropin AQ NuSpin 10......... 70
Nutropin AQ NuSpin 20......... 70
Nutropin AQ NuSpin 5............70
Nyamyc.................................... 30
Nymalize.................................. 53
Nystatin..............................30, 31
Nystop......................................31
O
Ocaliva..................................... 66
Ocella....................................... 73
Octagam.................................. 79
Octreotide Acetate..................76
Odefsey................................... 43
Odomzo................................... 36
Ofev..........................................88
Ofloxacin..................................23
Olanzapine.............................. 40
Olanzapine ODT......................40
Olmesartan Medoxomil.......... 51
Olmesartan Medoxomil-HCTZ............................................... 55
Olmesartan-Amlodipine-HCTZ............................................... 55
Olopatadine HCl..................... 84
Omega-3-Acid Ethyl Esters.....57
Omeprazole.............................66
Ondansetron HCl.................... 29
Ondansetron ODT.................. 29
Opsumit................................... 88
Orencia.................................... 78
Orencia ClickJect....................78
Orenitram.................................88
Orfadin..................................... 66
Orkambi................................... 87
Orsythia....................................73
Oseltamivir Phosphate..... 44, 45
Osphena.................................. 75
Otezla.......................................79
Oxacillin Sodium..................... 22
Oxacillin Sodium in Dextrose............................................... 22
Oxandrolone............................71
Oxcarbazepine........................ 26
Oxsoralen Ultra....................... 61
Oxybutynin Chloride............... 67
Oxybutynin Chloride ER......... 67
Oxycodone HCl.......................16
Oxycodone-Acetaminophen............................................... 16
Oxycodone-Aspirin................. 16
Ozempic.................................. 47
P
Pacerone................................. 52
Paliperidone ER...................... 40
Panretin................................... 36
Pantoprazole Sodium............. 66
Panzyga................................... 79
Paricalcitol............................... 82
Paromomycin Sulfate............. 18
Paroxetine HCl........................ 28
Paser........................................ 32
Paxil..........................................28
Pazeo....................................... 84
Pediarix.................................... 80
Pedvax HIB.............................. 80
PEG-3350-Electrolytes............ 65
PEG-3350-NaCl-Na Bicarbonate-KCl....................65
Peganone................................ 26
Pegasys................................... 42
Pegasys ProClick.................... 42
Pemazyre................................. 34
Penicillamine........................... 67
Penicillin G Potassium............22
Penicillin G Procaine.............. 22
Penicillin G Sodium................ 22
Penicillin V Potassium............ 22
PENTAM 300...........................37
Pentamidine Isethionate.........37
Pentasa.................................... 81
Pentoxifylline ER..................... 55
Perforomist.............................. 87
Perindopril Erbumine..............52
Permethrin...............................37
Perphenazine.......................... 29
Perseris.................................... 40
Phenelzine Sulfate.................. 27
Phenobarbital.......................... 25
Phenoxybenzamine HCl......... 51
Phenytek..................................26
200
Tracked
Phenytoin.................................26
Phenytoin Sodium Extended............................................... 26
Phoslyra................................... 64
Phospholine Iodide.................84
Picato....................................... 61
Pifeltro......................................43
Pilocarpine HCl................. 60, 84
Pimecrolimus.......................... 61
Pimozide.................................. 39
Pimtrea.....................................73
Pindolol....................................53
Pioglitazone HCl..................... 47
Pioglitazone HCl-Glimepiride............................................... 47
Pioglitazone HCl-Metformin HCl............................................... 47
Piperacillin-Tazobactam......... 22
Piqray....................................... 34
Pirmella 1/35...........................73
Piroxicam.................................14
Plasma-Lyte 148......................62
Plasma-Lyte A......................... 62
Plenamine................................63
Podofilox..................................61
Polymyxin B Sulfate................ 19
Polymyxin B-Trimethoprim.....83
Pomalyst.................................. 33
Portia-28.................................. 73
Posaconazole..........................31
Potassium Chloride................ 63
Potassium Chloride CR.......... 63
Potassium Chloride ER.......... 63
Potassium Chloride in Dextrose............................................... 63
Potassium Chloride in NaCl... 63
Potassium Citrate ER..............63
Praluent................................... 57
Pramipexole Dihydrochloride............................................... 38
Prasugrel HCl.......................... 51
Pravastatin Sodium.................56
Praziquantel............................ 37
Prazosin HCl............................51
Pred Mild................................. 85
Pred-G......................................83
Pred-G S.O.P........................... 83
Prednicarbate..........................69
Prednisolone........................... 69
Prednisolone Acetate............. 85
Prednisolone Sodium Phosphate.......................69, 85
Prednisone.............................. 69
Prednisone Intensol................69
Pregabalin............................... 59
Premarin............................ 73, 74
Premasol..................................63
Premphase.............................. 74
Prempro...................................74
Prevalite................................... 57
Previfem...................................74
Prezcobix................................. 44
Prezista.................................... 44
Priftin........................................32
Prilosec.................................... 66
Primaquine Phosphate...........37
Primidone................................ 25
Privigen.................................... 79
ProAir HFA...............................87
ProAir RespiClick....................87
Probenecid.............................. 31
Probenecid-Colchicine........... 31
Procalamine............................ 63
Prochlorperazine.....................29
Prochlorperazine Maleate...... 29
Procrit................................ 50, 51
Procto-Med HC....................... 81
Procto-Pak............................... 82
Proctosol HC........................... 82
Proctozone-HC........................ 82
Procysbi................................... 66
Progesterone Micronized.......75
Proglycem............................... 48
Prograf..................................... 78
Prolastin-C............................... 66
Prolensa...................................85
Prolia........................................ 82
Promacta................................. 51
Promethazine HCl................... 86
Promethegan...........................86
Propafenone HCl.................... 52
Propafenone HCl ER.............. 52
Proparacaine HCl....................83
Propranolol HCl...................... 53
Propranolol HCl ER................ 53
Propranolol-HCTZ................... 55
Propylthiouracil....................... 76
ProQuad.................................. 80
Prosol....................................... 63
Protriptyline HCl...................... 29
Pulmozyme..............................89
Purixan..................................... 33
Pyrazinamide...........................32
201
Tracked
Pyridostigmine Bromide.........32
Pyridostigmine Bromide ER...32
Pyrimethamine........................ 37
Q
Qinlock.....................................34
Quadracel................................ 80
Quetiapine Fumarate.............. 40
Quetiapine Fumarate ER........ 40
Quinapril HCl........................... 52
Quinapril-Hydrochlorothiazide............................................... 55
Quinidine Gluconate ER.........52
Quinidine Sulfate.................... 52
Quinine Sulfate........................37
R
RabAvert..................................80
Rabeprazole Sodium.............. 66
Raloxifene HCl........................ 75
Ramelteon............................... 90
Ramipril................................... 52
Ranolazine ER.........................55
Rasagiline Mesylate................38
Rasuvo..................................... 78
RAVICTI................................... 66
Rayaldee..................................82
Rebif.........................................59
Rebif Rebidose....................... 59
Rebif Rebidose Titration Pack............................................... 59
Rebif Titration Pack................ 59
Reclipsen.................................74
Recombivax HB...................... 80
Rectiv....................................... 57
Regranex................................. 61
Relenza Diskhaler................... 45
Relistor.....................................65
Repaglinide............................. 47
Repatha................................... 57
Repatha Pushtronex System............................................... 57
Repatha SureClick..................57
Restasis Single-Use Vials....... 83
Retacrit.................................... 51
Retevmo.................................. 34
Revlimid................................... 33
Rexulti...................................... 40
Reyataz.................................... 44
Rhopressa............................... 83
Ribavirin...................................42
Ridaura.................................... 79
Rifabutin.................................. 32
Rifampin.................................. 32
Riluzole.................................... 58
Rimantadine HCl.....................45
Riomet..................................... 47
Riomet ER............................... 47
Risedronate Sodium...............82
Risperdal Consta.............. 40, 41
Risperidone............................. 41
Risperidone ODT.................... 41
Ritonavir...................................44
Rivastigmine............................27
Rivastigmine Tartrate............. 27
Rivelsa..................................... 74
Rizatriptan Benzoate.............. 32
Rizatriptan Benzoate ODT..... 32
Rocklatan................................ 84
Ropinirole HCl.........................38
Rosuvastatin Calcium.............56
Rotarix......................................81
RotaTeq................................... 81
Roweepra................................ 24
Roweepra XR.......................... 24
Rozlytrek..................................34
Rubraca................................... 35
Ruconest................................. 76
Rukobia................................... 44
Rybelsus.................................. 47
Rydapt..................................... 36
Rytary....................................... 38
S
Saizen...................................... 70
Saizenprep.............................. 70
Sancuso................................... 29
Sandimmune........................... 78
Santyl....................................... 61
Saphris.....................................41
Savella......................................59
Savella Titration Pack............. 59
Scopolamine........................... 29
Secuado.................................. 41
Selegiline HCl..........................38
Selenium Sulfide..................... 61
Selzentry.................................. 44
Serevent Diskus...................... 87
Serostim...................................65
Sertraline HCl.......................... 28
Setlakin.................................... 74
Sevelamer Carbonate............. 64
Sharobel.................................. 75
Shingrix....................................81
Signifor.................................... 76
202
Tracked
Sildenafil Citrate......................88
Silodosin.................................. 67
Silver Sulfadiazine...................23
Simbrinza.................................84
Simponi....................................78
Simvastatin.............................. 56
Sirolimus..................................78
Sirturo...................................... 33
Sodium Chloride..................... 63
Sodium Fluoride......................63
Sodium Phenylbutyrate.......... 66
Sodium Polystyrene Sulfonate............................................... 64
Sofosbuvir-Velpatasvir............ 42
Solifenacin Succinate............. 67
Soliqua..................................... 47
Soltamox..................................33
Somatuline Depot................... 76
Somavert................................. 76
Sotalol HCl...............................52
Sotalol HCl AF......................... 52
Sovaldi..................................... 42
Spiriva HandiHaler.................. 87
Spiriva Respimat..................... 87
Spironolactone........................56
Spironolactone-HCTZ.............55
Sprintec 28.............................. 74
Spritam ODT........................... 24
Sprycel..................................... 36
SPS.......................................... 64
Sronyx...................................... 74
SSD.......................................... 23
Stavudine.................................43
Stelara......................................61
Stiolto Respimat......................89
Stivarga....................................36
Streptomycin Sulfate.............. 18
Stribild......................................42
Suboxone................................ 17
Sucraid.....................................66
Sucralfate................................ 66
Sulfacetamide Sodium........... 23
Sulfacetamide-Prednisolone............................................... 83
Sulfadiazine............................. 23
Sulfamethoxazole-Trimethoprim......................................... 23, 24
Sulfamylon...............................19
Sulfasalazine........................... 82
Sulindac...................................14
Sumatriptan.............................32
Sumatriptan Succinate........... 32
Sumatriptan Succinate Refill............................................... 32
Suprax......................................20
Suprep Bowel Prep Kit........... 65
Sutent.......................................36
Syeda....................................... 74
Symbicort................................ 89
Symfi........................................ 43
Symfi Lo...................................43
SymlinPen 120........................ 47
SymlinPen 60.......................... 47
Sympazan................................ 25
Symtuza................................... 44
Synarel..................................... 76
Synjardy................................... 47
Synjardy XR............................. 47
Synribo.....................................34
Synthroid................................. 75
T
Tabloid..................................... 33
Tabrecta.................................. 33
Tacrolimus........................ 61, 78
Tadalafil................................... 88
Tafinlar..................................... 36
Tagrisso................................... 36
Talzenna.................................. 35
Tamoxifen Citrate................... 33
Tamsulosin HCl.......................67
Targretin.................................. 36
Tarina 24 Fe............................ 74
Tarina Fe 1/20.........................74
Tasigna.................................... 36
Tazarotene...............................61
Tazicef..................................... 20
Tazorac.................................... 61
Taztia XT.................................. 53
Tazverik....................................34
TDVAX..................................... 81
Tecfidera..................................59
Tecfidera Starter Pack............59
Tegsedi.................................... 67
Telmisartan..............................51
Telmisartan-Amlodipine......... 55
Telmisartan-HCTZ...................55
Temazepam.............................89
Tenivac.................................... 81
Tenofovir Disoproxil Fumarate............................................... 43
Terazosin HCl..........................67
Terbinafine HCl....................... 31
Terconazole.............................31
203
Tracked
Teriparatide............................. 82
Testosterone........................... 71
Testosterone Cypionate......... 71
Testosterone Enanthate......... 71
Tetrabenazine......................... 58
Tetracycline HCl......................24
Thalomid..................................33
Theophylline............................88
Theophylline ER......................88
Thioridazine HCl..................... 39
Thiothixene..............................39
Tiadylt ER................................ 53
Tiagabine HCl......................... 25
Tibsovo.................................... 36
Tigecycline.............................. 19
Timolol Maleate................ 31, 84
Timolol Maleate Ophthalmic Gel Forming.......................... 84
Tinidazole................................ 19
Tivicay................................42, 43
Tivicay PD................................ 43
Tizanidine HCl......................... 89
TOBI Podhaler.........................87
TobraDex................................. 83
TobraDex ST........................... 83
Tobramycin....................... 18, 87
Tobramycin Sulfate.................18
Tobramycin-Dexamethasone............................................... 83
Tobrex......................................18
Tolak........................................ 61
Tolcapone................................38
Topiramate.............................. 26
Toremifene Citrate.................. 33
Torsemide............................... 56
Toujeo Max SoloStar.............. 49
Toujeo SoloStar...................... 49
TPN Electrolytes..................... 63
Tracleer....................................88
Tradjenta................................. 47
Tramadol HCl.......................... 16
Tramadol HCl ER.................... 15
Tramadol-Acetaminophen..... 16
Trandolapril............................. 52
Tranexamic Acid..................... 51
Transderm-Scop..................... 29
Tranylcypromine Sulfate........ 27
Travasol................................... 63
Travoprost............................... 85
Trazodone HCl........................ 28
Trecator................................... 33
Trelegy Ellipta..........................89
Trelstar Mixject........................76
Tresiba..................................... 49
Tresiba FlexTouch.................. 49
Tretinoin............................ 36, 61
Tretinoin Microsphere............ 61
Trexall...................................... 78
Trezix....................................... 16
Tri-Estarylla.............................. 74
Tri-Legest Fe............................74
Tri-Lo-Estarylla.........................74
Tri-Lo-Sprintec.........................74
Tri-Mili...................................... 74
Tri-Previfem............................. 74
Tri-Sprintec.............................. 74
Tri-VyLibra............................... 74
Tri-VyLibra Lo.......................... 74
Triamcinolone Acetonide...... 60, 70
Triamterene............................. 56
Triamterene-HCTZ.................. 55
Triderm.................................... 70
Trientine HCl........................... 64
Trifluoperazine HCl................. 39
Trifluridine............................... 42
Trihexyphenidyl HCl............... 37
TriLyte...................................... 65
Trimethoprim...........................19
Trimipramine Maleate............ 29
Trintellix................................... 28
Triumeq................................... 43
Trivora...................................... 74
TrophAmine.............................63
Trulicity.................................... 47
Trumenba................................ 81
Truvada....................................43
Tukysa..................................... 34
Turalio...................................... 36
Twinrix......................................81
Tybost...................................... 43
Tykerb...................................... 36
Tymlos..................................... 82
Typhim Vi.................................81
U
Udenyca...................................51
Unithroid.................................. 75
Ursodiol................................... 65
V
Valacyclovir HCl...................... 42
Valchlor....................................33
Valganciclovir HCl...................41
204
Tracked
Valproic Acid........................... 25
Valsartan.................................. 52
Valsartan-Hydrochlorothiazide............................................... 55
Valtoco 10 MG Dose...............25
Valtoco 15 MG Dose...............25
Valtoco 20 MG Dose...............25
Valtoco 5 MG Dose.................25
Vancomycin HCl..................... 19
Vandazole................................ 19
VAQTA..................................... 81
Varivax..................................... 81
Varizig...................................... 79
Vascepa................................... 57
Velivet...................................... 74
Velphoro.................................. 64
Veltassa................................... 64
Vemlidy.................................... 42
Venclexta................................. 36
Venclexta Starting Pack......... 36
Venlafaxine HCl.......................28
Venlafaxine HCl ER.................28
Ventavis................................... 88
Verapamil HCl......................... 54
Verapamil HCl ER................... 54
Versacloz................................. 41
Verzenio................................... 34
Vibramycin...............................24
Victoza..................................... 47
Vienva...................................... 74
Vigabatrin................................ 25
Vigadrone................................ 26
Viibryd...................................... 28
Viibryd Starter Pack................ 28
Vimpat......................................26
Viracept....................................44
Viread.......................................44
Vitrakvi..................................... 36
Vivitrol...................................... 17
Vizimpro...................................36
Voriconazole............................31
Vosevi...................................... 42
Votrient.................................... 36
VP-PNV-DHA............................64
Vraylar...................................... 41
Vyfemla.................................... 74
VyLibra.....................................74
Vyndamax................................55
Vyndaqel..................................55
Vyvanse....................................58
Vyzulta..................................... 85
W
Warfarin Sodium..................... 49
Wixela Inhub............................89
WYMZYA Fe............................ 74
X
Xalkori...................................... 36
Xarelto......................................49
Xarelto Starter Pack................49
Xatmep.....................................78
Xcopri................................ 24, 25
Xeljanz..................................... 78
Xeljanz XR............................... 78
Xgeva....................................... 82
Xifaxan..................................... 65
Xiidra........................................ 83
Xofluza..................................... 45
Xolair........................................ 79
Xospata....................................36
Xpovio................................33, 34
Xtampza ER.............................15
Xtandi....................................... 33
Xulane...................................... 74
Xyrem....................................... 90
Y
YF-Vax...................................... 81
Yuvafem................................... 74
Z
Zafirlukast................................ 86
Zaleplon................................... 89
Zarah........................................74
Zarxio....................................... 51
Zejula....................................... 35
Zelapar ODT............................ 38
Zelboraf................................... 36
Zemaira....................................67
Zenpep.................................... 67
Zerbaxa....................................21
Zidovudine...............................44
Zileuton ER..............................86
Zioptan.....................................85
Ziprasidone HCl...................... 41
Ziprasidone Mesylate............. 41
Zirgan.......................................42
Zolinza..................................... 34
Zolpidem Tartrate................... 89
Zonisamide..............................25
Zorbtive....................................65
Zortress....................................78
Zovia 1/35E............................. 74
Zyclara Pump.......................... 61
Zydelig..................................... 36
205
Tracked
Zyflo......................................... 86 Zykadia.................................... 36 Zyprexa Relprevv.................... 41
206
UHMA20HM4535866_011 Last updated October 1, 2020
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