2021

FORMULARYLIST OF COVERED DRUGSALOHACARE QUEST INTEGRATION DUAL

The AlohaCare QUEST Integration Formulary is a list of drugs that AlohaCare covers if the drug restriction(s) (or limits) are met. The formulary is reviewed every 3 months or as needed. The formulary is approved by a group of doctors and pharmacists on the Pharmacy & Therapeutics (P&T) Committee. This formulary is for drugs that a member can get with a prescription at a pharmacy. It does not apply to drugs used in the hospital or drugs given at a doctor’s office.

The drugs or products listed in this formulary may not include all drugs and may change. Some drugs may reject at the pharmacy because of other edits such as drug interactions and therapeutic duplication. A drug interaction may happen when 2 or more drugs may work against each other. A therapeutic duplication may happen when 2 or more drugs are the same or works the same way as another. Drugs that are not listed on this formulary are either not covered by AlohaCare QUEST Integration or are non-formulary.

EFFECTIVE 11/01/2021

AlohaCare QUEST Integration Dual

Table of Contents

*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* ....................................................................... 4*ANALGESICS - ANTI-INFLAMMATORY* ........................................................................................................... 4*ANALGESICS - NONNARCOTIC* .........................................................................................................................4*ANALGESICS - OPIOID* ........................................................................................................................................5*ANORECTAL AND RELATED PRODUCTS* ....................................................................................................... 5*ANTACIDS* ..............................................................................................................................................................5*ANTHELMINTICS* .................................................................................................................................................5*ANTIANXIETY AGENTS* .......................................................................................................................................6*ANTIDIABETICS* ................................................................................................................................................... 6*ANTIDIARRHEAL/PROBIOTIC AGENTS* .......................................................................................................... 6*ANTIEMETICS* .......................................................................................................................................................7*ANTIHISTAMINES* ................................................................................................................................................7*ANTIPARKINSON AND RELATED THERAPY AGENTS* ................................................................................. 8*ANTIPSYCHOTICS/ANTIMANIC AGENTS* ....................................................................................................... 8*ANTISEPTICS & DISINFECTANTS* .....................................................................................................................8*CHEMICALS* .......................................................................................................................................................... 8*CONTRACEPTIVES* .............................................................................................................................................. 8*COUGH/COLD/ALLERGY* ....................................................................................................................................9*DERMATOLOGICALS* ........................................................................................................................................ 10*DIAGNOSTIC PRODUCTS* ................................................................................................................................. 13*ENDOCRINE AND METABOLIC AGENTS - MISC.* ........................................................................................ 13*GASTROINTESTINAL AGENTS - MISC.* .......................................................................................................... 13*HEMATOPOIETIC AGENTS* .............................................................................................................................. 13*HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* ................................................................................14*LAXATIVES* .......................................................................................................................................................... 14*MEDICAL DEVICES AND SUPPLIES* ............................................................................................................... 15*MINERALS & ELECTROLYTES* ........................................................................................................................ 17*MISCELLANEOUS THERAPEUTIC CLASSES* ................................................................................................19*MULTIVITAMINS* ............................................................................................................................................... 19*NASAL AGENTS - SYSTEMIC AND TOPICAL* ................................................................................................ 22*OPHTHALMIC AGENTS* .................................................................................................................................... 22*OXYTOCICS* .........................................................................................................................................................23*PHARMACEUTICAL ADJUVANTS* ...................................................................................................................23*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* ............................................................ 23*TOXOIDS* .............................................................................................................................................................. 23*ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* ........................................................................ 23*URINARY ANTISPASMODICS* .......................................................................................................................... 24*VACCINES* ............................................................................................................................................................ 24*VAGINAL AND RELATED PRODUCTS* ............................................................................................................24*VITAMINS* ............................................................................................................................................................ 24

2

3

Drug Name Drug Tier Requirements/Limits

*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*

*ANALEPTICS***

caffeine citrate intravenous solution

Preferred MB

caffeine citrate oral solution

Preferred

*LIPASE INHIBITORS***

ALLI ORAL CAPSULE PreferredPA; OTC; QL (6 capsules per 1 day)

*ANALGESICS - ANTI-INFLAMMATORY*

*NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)***

fenoprofen calcium oral capsule 200 mg

PreferredQL (6 capsules per 1 day)

flurbiprofen oral tablet 50 mg

PreferredQL (4 tablets per 1 day)

ibuprofen oral capsule PreferredOTC; QL (100 capsules per 30 days)

ibuprofen oral tablet 200 mg

PreferredOTC; QL (100 tablets per 30 days)

naproxen sodium oral capsule

PreferredOTC; QL (100 capsules per 90 days)

naproxen sodium oral tablet 220 mg

PreferredOTC; QL (100 tablets per 90 days)

Drug Name Drug Tier Requirements/Limits

*ANALGESICS - NONNARCOTIC*

*ANALGESICS OTHER***

acetaminophen childrens oral suspension

PreferredOTC; QL (480 mL per 30 days)

acetaminophen childrens oral tablet chewable

Preferred OTC

acetaminophen er oral tablet extended release

PreferredOTC; QL (100 tablets per 90 days)

acetaminophen infants oral suspension

PreferredOTC; QL (480 mL per 30 days)

acetaminophen oral liquid PreferredOTC; QL (120 mL per 30 days)

acetaminophen oral solution 160 mg/5ml

PreferredOTC; QL (100 mL per 25 days)

acetaminophen oral suspension 160 mg/5ml, 650 mg/20.3ml

PreferredOTC; QL (480 mL per 30 days)

acetaminophen oral tablet325 mg

Preferred OTC

acetaminophen oral tablet500 mg

PreferredOTC; QL (100 tablets per 30 days)

acetaminophen oral tablet chewable 160 mg

Preferred OTC

acetaminophen rectal suppository

Preferred OTC

FEVERALL INFANTS RECTAL SUPPOSITORY

Preferred OTC

FEVERALL JUNIOR STRENGTH RECTAL SUPPOSITORY

Preferred OTC

gnp acetaminophen ex st oral tablet

PreferredOTC; QL (100 tablets per 30 days)

*SALICYLATES***

aspirin ec oral tablet delayed release 325 mg

Preferred90DS; OTC; QL (100 tablets per 25 days)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

4

Drug Name Drug Tier Requirements/Limits

aspirin ec oral tablet delayed release 81 mg

Preferred90DS; OTC; QL (100 tablets per 90 days)

aspirin oral tablet Preferred 90DS; OTC

aspirin oral tablet chewable

Preferred90DS; OTC; QL (100 tablets per 90 days)

aspirin oral tablet delayed release 325 mg

Preferred90DS; OTC; QL (100 tablets per 25 days)

aspirin oral tablet delayed release 81 mg

Preferred90DS; OTC; QL (100 tablets per 90 days)

aspirin rectal suppository Preferred OTC

goodsense aspirin adults oral tablet

Preferred 90DS; OTC

*ANALGESICS - OPIOID*

*OPIOID AGONISTS***

methadone hcl oral tablet soluble

PreferredPA; C; QL (1 tablet per 1 day)

METHADOSE ORAL TABLET SOLUBLE

PreferredPA; C; QL (1 tablet per 1 day)

*ANORECTAL AND RELATED PRODUCTS*

*RECTAL COMBINATIONS - MISC.***

gnp hemorrhoidal rectal ointment

Preferred OTC; OTC

*ANTACIDS*

*ANTACID & SIMETHICONE***

alum & mag hydroxide-simeth oral suspension

Preferred OTC

antacid & antigas oral suspension

Preferred OTC

Drug Name Drug Tier Requirements/Limits

*ANTACIDS - ALUMINUM SALTS***

aluminum hydroxide gel oral suspension

Preferred OTC

*ANTACIDS - BICARBONATE***

sodium bicarbonate oral tablet

Preferred OTC

*ANTACIDS - CALCIUM SALTS***

calcium carbonate antacid oral suspension

Preferred OTC

calcium carbonate antacid oral tablet

PreferredOTC; QL (4 tablets per 1 day)

calcium carbonate antacid oral tablet chewable

PreferredOTC; QL (5 tablets per 1 day)

calcium carbonate oral tablet chewable 500 mg

PreferredOTC; QL (5 tablets per 1 day)

*ANTACIDS - MAGNESIUM SALTS***

magnesium oxide (antacid) oral capsule

Preferred OTC

magnesium oxide oral tablet 250 mg, 420 mg

Preferred OTC

magnesium oxide oral tablet 400 mg

PreferredOTC; QL (4 tablets per 1 day)

*ANTHELMINTICS*

*ANTHELMINTICS***

reeses pinworm medicine oral suspension

Preferred OTC

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

5

Drug Name Drug Tier Requirements/Limits

*ANTIANXIETY AGENTS*

*BENZODIAZEPINES***

LOREEV XR ORAL CAPSULE ER 24 HOUR SPRINKLE 1 MG

PreferredC; QL (1 capsule per 1 day)

LOREEV XR ORAL CAPSULE ER 24 HOUR SPRINKLE 2 MG, 3 MG

PreferredC; QL (2 capsules per 1 day)

*ANTIDIABETICS*

*DIABETIC OTHER - COMBINATIONS***

DEX4 GLUCOSE ORAL TABLET CHEWABLE

Preferred OTC

DEX4 NATURALS ORAL TABLET CHEWABLE

Preferred OTC

DEX4 ORAL TABLET CHEWABLE

Preferred OTC

DEX4 POUCH PACK ORAL TABLET CHEWABLE

Preferred OTC

glucose instant energy oral tablet chewable

Preferred OTC

glucose oral tablet chewable 4-6 gm-mg

Preferred OTC

glucose-vitamin c oral tablet chewable

Preferred OTC

gnp glucose oral tablet chewable 4-6 gm-mg

Preferred OTC

goodsense glucose oral tablet chewable

Preferred OTC

leader glucose oral tablet chewable

Preferred OTC

longs glucose oral tablet chewable

Preferred OTC

Drug Name Drug Tier Requirements/Limits

RELION GLUCOSE ORAL TABLET CHEWABLE

Preferred OTC

SMART SENSE GLUCOSE ORAL TABLET CHEWABLE

Preferred OTC

up & up glucose oral tablet chewable

Preferred OTC

*DIABETIC OTHER***

DEX4 QUICK DISSOLVE GLUCOSE ORAL TABLET CHEWABLE

Preferred OTC

glucose oral gel 40 % Preferred OTC

glucose oral tablet chewable 4 gm

Preferred OTC

gnp glucose oral tablet chewable 4 gm

Preferred OTC

gnp quick dissolve glucose oral tablet chewable

Preferred OTC

leader quick dissolve glucose oral tablet chewable

Preferred OTC

*ANTIDIARRHEAL/PROBIOTIC AGENTS*

*ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.***

bismuth subsalicylate oral suspension

PreferredOTC; QL (80 mL per 30 days)

bismuth subsalicylate oral tablet chewable

Preferred OTC

pink bismuth maximum strength oral suspension

Preferred OTC

*ANTIPERISTALTIC AGENTS***

loperamide hcl oral tablet PreferredOTC; QL (8 tablets per 1 day)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

6

Drug Name Drug Tier Requirements/Limits

*DIARRHEA COMBINATIONS - OPIATES***

loperamide-simethicone oral tablet

Preferred OTC

*ANTIEMETICS*

*ANTIEMETIC COMBINATIONS***

nausea relief oral solution Preferred OTC

*ANTIEMETICS - ANTICHOLINERGIC***

meclizine hcl oral tablet chewable

Preferred

*ANTIHISTAMINES*

*ANTIHISTAMINES - ALKYLAMINES***

chlorpheniramine maleate er oral tablet extended release

Preferred OTC

chlorpheniramine maleate oral tablet

Preferred OTC

DIABETIC TUSSIN ALLERGY ORAL SYRUP

Preferred OTC

*ANTIHISTAMINES - ETHANOLAMINES***

allergy relief childrens oral tablet dispersible

Preferred C; OTC

diphenhydramine hcl oral capsule 25 mg

PreferredC; QL (120 capsules per 30 days)

diphenhydramine hcl oral capsule 50 mg

Preferred C

Drug Name Drug Tier Requirements/Limits

diphenhydramine hcl oral liquid 12.5 mg/5ml

PreferredC; OTC; QL (120 mL per 30 days)

diphenhydramine hcl oral liquid 6.25 mg/ml

Preferred C; OTC

diphenhydramine hcl oral tablet

PreferredC; OTC; QL (4 tablets per 1 day)

diphenhydramine hcl oral tablet chewable

Preferred C; OTC

gnp allergy childrens oral liquid

PreferredC; OTC; OTC; QL (120 mL per 30 days)

*ANTIHISTAMINES - NON-SEDATING***

ALLEGRA ALLERGY CHILDRENS ORAL TABLET DISPERSIBLE

PreferredOTC; QL (2 tablets per 1 day)

allergy relief (loratadine) oral tablet

PreferredOTC; QL (1 tablet per 1 day)

allergy relief oral tablet dispersible

PreferredOTC; QL (1 tablet per 1 day)

fexofenadine hcl oral tablet 180 mg

PreferredOTC; QL (1 tablet per 1 day)

fexofenadine hcl oral tablet 60 mg

PreferredOTC; QL (2 tablets per 1 day)

loratadine oral capsule PreferredOTC; QL (1 capsule per 1 day)

loratadine oral syrup PreferredOTC; QL (10 mL per 1 day)

loratadine oral tablet PreferredOTC; QL (1 tablet per 1 day)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

7

Drug Name Drug Tier Requirements/Limits

*ANTIPARKINSON AND RELATED THERAPY AGENTS*

*ANTIPARKINSON DOPAMINERGICS***

amantadine hcl oral solution

PreferredQL (40 mL per 1 day)

*ANTIPSYCHOTICS/ANTIMANIC AGENTS*

*BENZISOXAZOLES***

INVEGA HAFYERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PreferredPA; C; QL (1 kit per 6 monthss)

*DIBENZOXAZEPINES***

ADASUVE INHALATION AEROSOL POWDER BREATH ACTIVATED

Preferred ST; AL; C

*ANTISEPTICS & DISINFECTANTS*

*ANTISEPTICS & DISINFECTANTS***

hydrogen peroxide external solution

Preferred OTC

*CHEMICALS*

*SOLVENTS***

gnp isopropyl rubbing alcohol solution 70 %

Preferred OTC

Drug Name Drug Tier Requirements/Limits

*CONTRACEPTIVES*

*EMERGENCY CONTRACEPTIVES***

AFTERA ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

AFTERPILL ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

ECONTRA EZ ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

ECONTRA ONE-STEP ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

levonorgestrel oral tablet PreferredOTC; QL (1 tablet per 30 days)

MY CHOICE ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

MY WAY ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

NEW DAY ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

OPCICON ONE-STEP ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

OPTION 2 ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

PREVENTEZA ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

REACT ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

TAKE ACTION ORAL TABLET

PreferredOTC; QL (1 tablet per 30 days)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

8

Drug Name Drug Tier Requirements/Limits

*COUGH/COLD/ALLERGY*

*ANTITUSSIVE - NONNARCOTIC***

benzonatate oral capsule100 mg, 200 mg

Preferred AL

daytime cough oral liquid Preferred AL; OTC

dextromethorphan polistirex er oral suspension extended release

Preferred AL; OTC

tussin cough oral syrup Preferred AL; OTC

WAL-TUSSIN COUGH LONG ACTING ORAL LIQUID

Preferred AL; OTC

*ANTITUSSIVE - OPIOID***

hydrocodone-homatropine oral tablet

Preferred AL

*ANTITUSSIVE-EXPECTORANT - DECONGEST-ANALGESIC***

cold & flu severe daytime oral tablet

Preferred AL; OTC

gnp cold max severe oral tablet

Preferred AL; OTC

*ANTITUSSIVE-EXPECTORANT***

dextromethorphan-guaifenesin oral liquid 10-100 mg/5ml

PreferredAL; OTC; QL (120 mL per 30 days)

guaifenesin-codeine oral solution

PreferredAL; OTC; QL (120 mL per 30 days)

guaifenesin-dm oral syrup PreferredAL; OTC; QL (120 mL per 30 days)

Drug Name Drug Tier Requirements/Limits

intense cough reliever oral liquid 30-200 mg/5ml

Preferred AL; OTC

m-clear wc oral solution Preferred AL; OTC

mucus relief cough childrens oral liquid

Preferred AL; OTC

mucus relief dm oral tablet extended release 12 hour 30-600 mg

Preferred AL; OTC

trymine cg oral liquid Preferred AL; OTC

*ANTITUSSIVE-EXPECTORANTS-DECONGESTANT***

biogtuss oral liquid Preferred AL; OTC

g-supress dx pediatric oral liquid

Preferred OTC

TUSNEL C ORAL SYRUP

Preferred AL; OTC

*DECONGESTANT & ANTIHISTAMINE***

ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HOUR

PreferredAL; OTC; QL (2 tablets per 1 day)

APRODINE ORAL TABLET

Preferred AL; OTC

fexofenadine-pseudoephed er oral tablet extended release 12 hour

PreferredAL; OTC; QL (2 tablets per 1 day)

fexofenadine-pseudoephed er oral tablet extended release 24 hour

PreferredAL; OTC; QL (1 tablet per 1 day)

LOHIST-D ORAL LIQUID

Preferred AL; OTC

loratadine-d 24hr oral tablet extended release 24 hour

PreferredAL; OTC; QL (1 tablet per 1 day)

WAL-TAP CHILDRENS ORAL ELIXIR 1-2.5 MG/5ML

PreferredOTC; OTC; QL (120 mL per 30 days)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

9

Drug Name Drug Tier Requirements/Limits

*EXPECTORANTS***

guaifenesin oral liquid PreferredAL; OTC; QL (240 mL per 1 fill)

guaifenesin oral tablet Preferred AL; OTC

*MISC. RESPIRATORY INHALANTS***

nasal mist inhalation aerosol solution

Preferred OTC

*NON-NARC ANTITUSSIVE-ANTIHISTAMINE***

promethazine-dm oral syrup

PreferredAL; QL (120 mL per 30 days)

*OPIOID ANTITUSSIVE-ANTIHISTAMINE***

promethazine-codeine oral solution

PreferredAL; QL (240 mL per 30 days)

promethazine-codeine oral syrup

PreferredAL; QL (240 mL per 30 days)

*OPIOID ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE***

promethazine-phenyleph-codeine oral syrup

PreferredAL; QL (240 mL per 30 days)

*DERMATOLOGICALS*

*ACNE PRODUCTS***

acne medication 10 external lotion

PreferredOTC; QL (177 mL per 30 days)

acne medication 5 external lotion

PreferredOTC; QL (177 mL per 30 days)

Drug Name Drug Tier Requirements/Limits

adapalene external gel 0.1 %

PreferredPA; QL (45 grams per 30 days)

advanced acne wash external liquid extended release

Preferred OTC

benzoyl peroxide cleanser external liquid

PreferredOTC; QL (171 grams per 30 days)

benzoyl peroxide external gel 10 %

Preferred

benzoyl peroxide external gel 2.5 %, 5 %

Preferred OTC

benzoyl peroxide wash external liquid 10 %

Preferred

effaclar duo external solution

Preferred OTC

NEUTROGENA CLEAR PORE EXTERNAL LIQUID

Preferred OTC

NEUTROGENA ON-THE-SPOT EXTERNAL CREAM

Preferred OTC

PANOXYL EXTERNAL LIQUID

Preferred OTC

*ANTIBIOTIC MIXTURES TOPICAL***

poly bacitracin external ointment

Preferred OTC; OTC

*ANTIBIOTICS - TOPICAL***

bacitracin external ointment

Preferred OTC

bacitracin zinc external ointment

Preferred

bacitracin zinc-aloe external ointment

Preferred OTC

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

10

Drug Name Drug Tier Requirements/Limits

*ANTIFUNGALS - TOPICAL COMBINATIONS***

g-myco nail external solution

Preferred OTC

MYCO NAIL EXTERNAL SOLUTION

Preferred OTC

*ANTIFUNGALS - TOPICAL***

GORDOCHOM EXTERNAL SOLUTION

Preferred OTC

LOTRIMIN AF EXTERNAL POWDER

PreferredOTC; QL (67.5 grams per 30 days)

MYCO NAIL A EXTERNAL SOLUTION

Preferred OTC

MYCOZYL AL EXTERNAL SOLUTION

Preferred OTC

terbinafine hcl external cream

PreferredOTC; QL (42 grams per 30 days)

tolnaftate external aerosol powder

PreferredOTC; QL (133 grams per 30 days)

tolnaftate external cream PreferredOTC; QL (30 grams per 30 days)

tolnaftate external powder

PreferredOTC; QL (67.5 grams per 30 days)

*ANTI-INFLAMMATORY AGENTS - TOPICAL***

diclofenac sodium external gel 1 %

PreferredQL (1000 grams per 30 days)

Drug Name Drug Tier Requirements/Limits

*ANTIVIRALS - TOPICAL***

ABREVA EXTERNAL CREAM

PreferredOTC; QL (2 grams per 30 days)

docosanol external cream PreferredOTC; QL (2 grams per 30 days)

gnp docosanol external cream

PreferredOTC; QL (2 grams per 30 days)

*ASTRINGENTS***

calamine phenolated external lotion

Preferred OTC

gnp calamine phenolated external lotion

Preferred OTC

zinc oxide external ointment 20 %

PreferredOTC; QL (480 grams per 30 days)

zinc oxide external ointment 40 %

PreferredOTC; QL (120 grams per 90 days)

*CORTICOSTEROIDS - TOPICAL***

DESRX EXTERNAL GEL

PreferredQL (60 grams per 30 days)

hydrocortisone acetate external cream

PreferredOTC; QL (30 grams per 30 days)

hydrocortisone external cream 0.5 %

PreferredOTC; QL (100 grams per 30 days)

hydrocortisone external lotion 1 %

PreferredPA; OTC; QL (120 mL per 30 days)

hydrocortisone external ointment 0.5 %

PreferredOTC; QL (60 grams per 30 days)

hydrocortisone max st external ointment

PreferredOTC; QL (454 grams per 30 days)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

11

Drug Name Drug Tier Requirements/Limits

*DIAPER RASH PRODUCTS***

AVEENO BABY SOOTHING MULTI-PUR EXTERNAL OINTMENT

Preferred OTC

*EMOLLIENT COMBINATIONS***

mineral oil-hydrophil petrolat external ointment

Preferred OTC

*EMOLLIENTS***

glycerin external liquid Preferred OTC

vitamin a & d external ointment

Preferred OTC

vitamin a & d skin protectant external ointment

Preferred OTC

vitamin a&d external ointment

Preferred OTC

vitamin e-vit a & d external cream

Preferred OTC

vitamins a & d external ointment

Preferred OTC

*IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL***

alevazol external ointment

PreferredOTC; QL (60 grams per 30 days)

LOTRIMIN AF EXTERNAL POWDER2 %

PreferredOTC; OTC; QL (90 grams per 30 days)

miconazole nitrate external cream

PreferredQL (200 grams per 30 days)

MYCOZYL AC EXTERNAL CREAM

PreferredOTC; OTC; QL (60 grams per 30 days)

Drug Name Drug Tier Requirements/Limits

*LOCAL ANESTHETICS - TOPICAL***

afterburn external gel Preferred OTC

ALOCANE EMERGENCY BURN MAX STR EXTERNAL PAD

Preferred OTC

ASPERCREME MAX STRENGTH EXTERNAL AEROSOL

Preferred OTC

burn relief external gel Preferred OTC

lidocaine external cream4 %, 5 %

Preferred OTC

lidocaine external patch 4 %

Preferred OTC

lidocaine hcl external cream 4 %

Preferred OTC

LIDODOSE EXTERNAL GEL

Preferred OTC

LIDODOSE PEDIATRIC BULK PACK EXTERNAL GEL

Preferred OTC

REGENECARE HA EXTERNAL LIQUID

Preferred OTC

SUN BURNT PLUS EXTERNAL GEL

Preferred OTC

xolido external cream Preferred OTC

*TOPICAL STEROID COMBINATIONS***

hydrocortisone-aloe external cream

PreferredOTC; QL (30 grams per 30 days)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

12

Drug Name Drug Tier Requirements/Limits

*DIAGNOSTIC PRODUCTS*

*DIAGNOSTIC TESTS***

GNP TRUE METRIX GLUCOSE STRIPS IN VITRO STRIP

PreferredOTC; QL (50 strips per 30 days)

RELION TRUE METRIX TEST STRIPS IN VITRO STRIP

PreferredOTC; QL (50 strips per 30 days)

TRUE METRIX BLOOD GLUCOSE TEST IN VITRO STRIP

PreferredOTC; QL (50 strips per 30 days)

*MULTIPLE URINE TESTS***

CHEMSTRIP UGK IN VITRO STRIP

Preferred OTC

KETO-DIASTIX IN VITRO STRIP

Preferred OTC

*ENDOCRINE AND METABOLIC AGENTS - MISC.*

*SOMATOSTATIC AGENTS***

octreotide acetate subcutaneous solution prefilled syringe 100 mcg/ml, 500 mcg/ml

Preferred PA; SP

*GASTROINTESTINAL AGENTS - MISC.*

*ANTIFLATULENTS***

simethicone extra strength oral capsule

Preferred OTC

simethicone oral capsule Preferred OTC

simethicone oral suspension

Preferred OTC

Drug Name Drug Tier Requirements/Limits

simethicone oral tablet chewable

Preferred OTC

*HEMATOPOIETIC AGENTS*

*COBALAMINS***

B-12 DOTS ORAL TABLET DISPERSIBLE

Preferred OTC

b-12 oral tablet 250 mcg, 50 mcg

Preferred OTC

b-12 sublingual tablet sublingual 1000 mcg

Preferred OTC

cyanocobalamin injection solution 1000 mcg/ml

Preferred

cyanocobalamin sublingual tablet sublingual

Preferred OTC

hydroxocobalamin acetate intramuscular solution

Preferred

vitamin b-12 er oral tablet extended release 2000 mcg

Preferred OTC

vitamin b-12 oral liquid Preferred OTC

vitamin b-12 oral lozenge500 mcg

Preferred OTC

vitamin b-12 oral tablet Preferred OTC

vitamin b12 oral tablet extended release

Preferred OTC

vitamin b12 sublingual liquid

Preferred OTC

vitamin b-12 sublingual liquid

Preferred OTC

vitamin b-12 sublingual tablet sublingual 1000 mcg, 5000 mcg

Preferred OTC

*FOLIC ACID/FOLATE COMBINATIONS***

fa-vitamin b-6-vitamin b-12 oral tablet

Preferred PA

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

13

Drug Name Drug Tier Requirements/Limits

*FOLIC ACID/FOLATES***

folic acid injection solution

Preferred

folic acid oral tablet 1 mg Preferred 90DS

folic acid oral tablet 400 mcg, 800 mcg

Preferred OTC

*IRON COMBINATIONS***

iron-vitamin c oral tablet Preferred PA; OTC

*IRON***

easy iron oral capsule Preferred OTC

ferretts oral tablet Preferred OTC

ferrous fumarate oral tablet 324 (106 fe) mg

Preferred 90DS; OTC

ferrous gluconate oral tablet 240 (27 fe) mg, 324 (37.5 fe) mg

Preferred90DS; OTC; QL (4 tablets per 1 day)

ferrous sulfate er oral tablet extended release 50 mg

Preferred 90DS; OTC

ferrous sulfate oral elixir Preferred 90DS; OTC

ferrous sulfate oral solution 75 (15 fe) mg/ml

Preferred 90DS; OTC

ferrous sulfate oral syrup Preferred 90DS; OTC

ferrous sulfate oral tablet27 mg

Preferred 90DS; OTC

ferrous sulfate oral tablet325 (65 fe) mg

Preferred90DS; OTC; QL (3 tablets per 1 day)

ferrous sulfate oral tablet delayed release 325 (65 fe) mg

Preferred 90DS; OTC

INFED INJECTION SOLUTION

Preferred PA; SP

iron (ferrous sulfate) oral tablet

Preferred90DS; OTC; QL (3 tablets per 1 day)

iron high-potency oral tablet

Preferred90DS; OTC; QL (3 tablets per 1 day)

Drug Name Drug Tier Requirements/Limits

iron oral tablet 240 (27 fe) mg

Preferred90DS; OTC; QL (4 tablets per 1 day)

iron oral tablet 325 (65 fe) mg

Preferred90DS; OTC; QL (3 tablets per 1 day)

na ferric gluc cplx in sucrose intravenous solution

PreferredPA; SP; QL (80 mL per 56 days)

polysaccharide iron complex oral capsule

Preferred 90DS; OTC

polysaccharide-iron complex oral capsule

Preferred 90DS; OTC

VENOFER INTRAVENOUS SOLUTION

Preferred PA; SP

*HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS*

*ANTIHISTAMINE HYPNOTICS***

diphenhydramine hcl (sleep) oral tablet

Preferred OTC

*LAXATIVES*

*BULK LAXATIVES***

fiber (corn dextrin) oral powder

Preferred OTC

fiber laxative oral tablet PreferredOTC; QL (8 tablets per 1 day)

fiber oral powder Preferred OTC

fiber oral tablet PreferredOTC; QL (8 tablets per 1 day)

fiber therapy oral powder Preferred OTC

fiber therapy oral tablet Preferred OTC

goodsense psyllium fiber oral powder

Preferred OTC

natural fiber laxative oral powder 30.9 %

Preferred OTC

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

14

Drug Name Drug Tier Requirements/Limits

natural fiber oral powder Preferred OTC

SOLUBLE FIBER THERAPY ORAL POWDER

Preferred OTC

*LAXATIVES - MISCELLANEOUS***

glycerin (adult) rectal suppository

Preferred OTC

glycerin (infants & children) rectal suppository 1 gm

Preferred OTC

glycerin (pediatric) rectal suppository 1 gm

Preferred OTC

polyethylene glycol 3350 oral packet 17 gm

PreferredQL (34 grams per 1 day)

polyethylene glycol 3350 oral powder

PreferredQL (2 packets per 1 day)

*LAXATIVES & DSS***

senna plus oral capsule Preferred OTC

sennosides-docusate sodium oral tablet

Preferred OTC

stool softener/laxative oral capsule

Preferred OTC

*LUBRICANT LAXATIVES***

mineral oil oral oil Preferred OTC

*SALINE LAXATIVE MIXTURES***

enema rectal enema 7-19 gm/118ml

Preferred OTC

*SALINE LAXATIVES***

epsom salt oral granules Preferred OTC

magnesium citrate oral solution

Preferred OTC

milk of magnesia concentrate oral suspension

Preferred OTC

Drug Name Drug Tier Requirements/Limits

milk of magnesia oral suspension 400 mg/5ml, 7.75 %

Preferred OTC

*STIMULANT LAXATIVES***

bisacodyl ec oral tablet delayed release

PreferredOTC; QL (100 tablets per 90 days)

bisacodyl rectal suppository

Preferred OTC

chocolated laxative oral tablet chewable

Preferred OTC

senna oral capsule Preferred OTC

senna oral syrup 8.8 mg/5ml

Preferred

senna oral tablet Preferred OTC

*SURFACTANT LAXATIVES***

docusate calcium oral capsule

Preferred OTC

docusate sodium oral capsule 100 mg

PreferredOTC; QL (3 capsules per 1 day)

docusate sodium oral syrup

Preferred OTC

docusate sodium oral tablet

Preferred OTC

dss oral capsule 250 mg Preferred OTC

*MEDICAL DEVICES AND SUPPLIES*

*DIAPHRAGMS***

CAYA VAGINAL DIAPHRAGM

Preferred

OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM

Preferred

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

15

Drug Name Drug Tier Requirements/Limits

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM

Preferred

WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM

Preferred

WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM

Preferred

WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM

Preferred

WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM

Preferred

WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM

Preferred

WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM

Preferred

WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM

Preferred

*GLUCOSE MONITORING TEST SUPPLIES***

GNP TRUE METRIX AIR METER KIT

Preferred OTC

GNP TRUE METRIX GLUCOSE METER KIT

Preferred OTC

lancets 33g PreferredOTC; QL (102 lancets per 30 days)

Drug Name Drug Tier Requirements/Limits

RELION TRUE MET AIR GLUC METER KIT

Preferred OTC

TRUE METRIX AIR GLUCOSE METER DEVICE

Preferred OTC

TRUE METRIX AIR GLUCOSE METER KIT

Preferred OTC

TRUE METRIX GO GLUCOSE METER KIT

Preferred OTC

TRUE METRIX LEVEL 1 IN VITRO SOLUTION

Preferred OTC

TRUE METRIX LEVEL 2 IN VITRO SOLUTION

Preferred OTC

TRUE METRIX LEVEL 3 IN VITRO SOLUTION

Preferred OTC

TRUE METRIX METER DEVICE

Preferred OTC

TRUE METRIX METER KIT

Preferred OTC

*PEAK FLOW METERS***

AEROGEAR ACTION ASTHMA KIT KIT

PreferredQL (102 lancets per 30 days)

*RESPIRATORY THERAPY SUPPLIES***

ACTIVITY POUCH PreferredQL (2 units per 365 days)

AIRS PEDIATRIC AEROSOL MASK

PreferredQL (2 units per 365 days)

ALL FLOW 1000 PFT FILTER

PreferredQL (2 units per 365 days)

breathe ease neb mask/child

PreferredQL (2 units per 365 days)

breathe ease neb mask/infant

PreferredQL (2 units per 365 days)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

16

Drug Name Drug Tier Requirements/Limits

CARETOUCH 2 CPAP HOSE HANGER

PreferredQL (2 units per 365 days)

CARETOUCH CPAP & BIPAP HOSE

PreferredQL (2 units per 365 days)

CARETOUCH CPAP MASK WIPES

PreferredQL (2 units per 365 days)

CARETOUCH CPAP PRE-WASH SOLN

PreferredQL (2 units per 365 days)

CARETOUCH CPAP TUBE BRUSH

PreferredQL (2 units per 365 days)

CARETOUCH UNIVERSL CPAP FILTER

PreferredQL (2 units per 365 days)

co monitor replacement pieces

PreferredQL (2 units per 365 days)

EBASE CONTROLLER KIT

PreferredQL (2 units per 365 days)

filter air pp PreferredQL (2 units per 365 days)

full kit nebulizer set PreferredQL (2 units per 365 days)

HUDSON RCI AEROSOL MASK ADULT

PreferredQL (2 units per 365 days)

LITETOUCH MASK LARGE

PreferredQL (2 units per 365 days)

nebulizer air tube/plugs PreferredQL (2 units per 365 days)

PARI ALTERA NEBULIZER HANDSET

PreferredQL (2 units per 365 days)

PARI BABY CONVERSION KIT

PreferredQL (2 units per 365 days)

PARI ERAPID NEBULIZER HANDSET

PreferredQL (2 units per 365 days)

PARI EXPIRATORY FILTER SET DEVICE

PreferredQL (2 units per 365 days)

PARI MASK SET PreferredQL (2 units per 365 days)

PARI SOFT PLASTIC ADULT MASK

PreferredQL (2 units per 365 days)

Drug Name Drug Tier Requirements/Limits

PARI SOFT PLASTIC PED MASK

PreferredQL (2 units per 365 days)

pillow mask/adult PreferredQL (2 units per 365 days)

pillow mask/child PreferredQL (2 units per 365 days)

pillow mask/pediatric PreferredQL (2 units per 365 days)

replacement air filter PreferredQL (2 units per 365 days)

silicone mask/adult PreferredQL (2 units per 365 days)

silicone mask/infant PreferredQL (2 units per 365 days)

silicone mask/pediatric PreferredQL (2 units per 365 days)

WINDMILL TRAINER PreferredQL (2 units per 365 days)

*MINERALS & ELECTROLYTES*

*CALCIUM COMBINATIONS***

calcium carb-cholecalciferol oral tablet chewable

Preferred OTC

calcium carbonate-vitamin d oral capsule

PreferredOTC; QL (2 capsules per 1 day)

calcium carbonate-vitamin d oral tablet

PreferredOTC; QL (2 tablets per 1 day)

calcium citrate-vitamin d oral tablet 200-125 mg-unit, 315-200 mg-unit, 315-250 mg-unit

Preferred OTC

calcium citrate-vitamin d3 oral tablet 315-6.25 mg-mcg

Preferred OTC

calcium/c/d oral tablet chewable

PreferredOTC; QL (4 tablets per 1 day)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

17

Drug Name Drug Tier Requirements/Limits

calcium-magnesium oral tablet 500-250 mg

Preferred OTC

calcium-magnesium-zinc oral tablet 333-133-5 mg

Preferred AL; OTC

calcium-magnesium-zinc oral tablet 333-133-8.3 mg

Preferred OTC

calcium-vitamin d oral tablet 500-400 mg-unit

Preferred OTC

calcium-vitamin d oral tablet 600-400 mg-unit

PreferredOTC; QL (2 tablets per 1 day)

calcium-vitamin d3 oral capsule 600-400 mg-unit

PreferredOTC; QL (2 capsules per 1 day)

calcium-vitamin d3 oral tablet 500-400 mg-unit

Preferred OTC

calcium-vitamin d-minerals oral tablet chewable 600-400 mg-unit

PreferredOTC; QL (2 tablets per 1 day)

citrus calcium/vitamin d oral tablet

Preferred OTC

oyster shell calcium oral tablet 500-400 mg-unit

Preferred OTC

oyster shell calcium/d oral tablet 250-125 mg-unit

PreferredOTC; QL (4 tablets per 1 day)

oyster shell calcium/d oral tablet 500-200 mg-unit, 500-5 mg-mcg

Preferred OTC

oyster shell calcium/vitamin d oral tablet 500-200 mg-unit

Preferred OTC

risacal-d oral tablet Preferred OTC

*CALCIUM***

calcium carbonate oral tablet 1250 (500 ca) mg

PreferredOTC; QL (4 tablets per 1 day)

calcium carbonate oral tablet 1500 (600 ca) mg, 600 mg

Preferred OTC

calcium citrate oral tablet250 mg, 950 (200 ca) mg

Preferred OTC

Drug Name Drug Tier Requirements/Limits

calcium oyster shell oral tablet 500 mg

PreferredOTC; QL (4 tablets per 1 day)

oyster shell calcium oral tablet 500 mg

PreferredOTC; QL (4 tablets per 1 day)

*ELECTROLYTES ORAL***

pediatric electrolyte oral solution

PreferredOTC; QL (6000 mL per 30 days)

*MAGNESIUM***

MAG64 ORAL TABLET DELAYED RELEASE

PreferredOTC; QL (2 tablets per 1 day)

magnesium gluconate oral tablet 27.5 mg, 500 mg

Preferred OTC

magnesium oral tablet200 mg, 250 mg

Preferred OTC

magnesium oral tablet400 mg

PreferredOTC; QL (4 tablets per 1 day)

magnesium oxide -mg supplement oral tablet

Preferred OTC

magnesium oxide oral tablet 400 (240 mg) mg, 400 (241.3 mg) mg

PreferredOTC; QL (4 tablets per 1 day)

magnesium oxide oral tablet 500 mg

Preferred OTC

*PHOSPHATE***

phosphorous oral tablet Preferred

*POTASSIUM***

potassium gluconate oral tablet 595 (99 k) mg

PreferredOTC; QL (4 tablets per 1 day)

sd potassium gluconate oral tablet

PreferredOTC; OTC; QL (4 tablets per 1 day)

*ZINC***

chelated zinc oral tablet PreferredOTC; QL (4 tablets per 1 day)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

18

Drug Name Drug Tier Requirements/Limits

zinc chelated oral tablet50 mg

PreferredOTC; QL (4 tablets per 1 day)

zinc gluconate oral tablet100 mg, 30 mg

Preferred OTC

zinc gluconate oral tablet50 mg

PreferredOTC; QL (4 tablets per 1 day)

zinc oral capsule 220 (50 zn) mg

Preferred OTC

zinc oral tablet 30 mg Preferred OTC

zinc oral tablet 50 mg PreferredOTC; QL (4 tablets per 1 day)

zinc sulfate oral capsule Preferred OTC

zinc sulfate oral tablet220 (50 zn) mg

Preferred OTC

*MISCELLANEOUS THERAPEUTIC CLASSES*

*CHELATING AGENTS***

CLOVIQUE ORAL CAPSULE 250 MG

PreferredPA; SP; QL (8 capsules per 1 day)

*MULTIVITAMINS*

*B-COMPLEX VITAMINS***

b complex oral capsule Preferred PA; C; OTC

b complex vitamins oral capsule

Preferred PA; C; OTC

*B-COMPLEX W/ C & FOLIC ACID***

b-complex/vitamin c oral tablet

PreferredPA; C; OTC; QL (1 tablet per 1 day)

DIALYVITE 800 ORAL TABLET

Preferred PA; C; OTC

Drug Name Drug Tier Requirements/Limits

NEPHRONEX ORAL LIQUID

Preferred PA; C; OTC

*B-COMPLEX W/ C***

b complex-c oral tablet PreferredPA; C; OTC; QL (1 tablet per 1 day)

b-complex-c oral tablet PreferredPA; C; OTC; QL (1 tablet per 1 day)

super b-complex + vitamin c oral tablet

PreferredPA; C; OTC; QL (1 tablet per 1 day)

*B-COMPLEX W/ C-BIOTIN-E & FOLIC ACID***

b complex-c-biotin-e-fa oral tablet

Preferred PA; C; OTC

*B-COMPLEX W/ IRON***

APETIGEN-PLUS ORAL SOLUTION

Preferred PA; C; OTC

*B-COMPLEX W/BIOTIN & FOLIC ACID***

b complex-biotin-fa oral tablet

Preferred PA; C; OTC

b-complex oral tablet Preferred PA; C; OTC

*MULTIPLE VITAMINS W/ IRON***

multiple vitamins/iron oral tablet

PreferredOTC; QL (1 tablet per 1 day)

*MULTIPLE VITAMINS W/ MINERALS***

multi vitamin/minerals oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

19

Drug Name Drug Tier Requirements/Limits

vitamins a-d-e/selenium oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

*MULTIVITAMINS***

multi vitamin oral tablet PreferredAL; OTC; QL (1 tablet per 1 day)

multiple vitamin-folic acid oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

multiple vitamins oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

vit e-vit c-beta carotene oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

*PED MV W/ IRON***

BPROTECTED PEDIA POLY-VITE/FE ORAL SOLUTION

PreferredOTC; QL (50 mL per 45 days)

pc pediatric poly-vita/fe drop oral solution

PreferredOTC; QL (50 mL per 45 days)

POLY-VI-SOL/IRON ORAL SOLUTION

Preferred OTC

poly-vita/iron oral solution

PreferredOTC; QL (50 mL per 45 days)

poly-vite/iron oral solution

Preferred OTC

*PRENATAL MV & MIN W/FE-FA & COENZYME Q10***

THERANATAL OVAVITE ORAL THERAPY PACK

PreferredAL; OTC; QL (2 tablets per 1 day)

*PRENATAL MV & MIN W/FE-FA***

ATABEX ORAL TABLET CHEWABLE

PreferredAL; OTC; QL (1 tablet per 1 day)

Drug Name Drug Tier Requirements/Limits

classic prenatal oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

CLINICAL NUTRIENTS PRENATAL ORAL TABLET

PreferredAL; OTC; QL (1 tablet per 1 day)

eql prenatal formula oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

gnp prenatal oral tablet PreferredAL; OTC; QL (1 tablet per 1 day)

HEALTHY MAMA BE WELL ROUNDED ORAL THERAPY PACK

PreferredAL; OTC; QL (1 pack per 1 day)

kp prenatal multivitamins oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

kpn prenatal oral tablet PreferredAL; OTC; QL (1 tablet per 1 day)

multi prenatal oral tablet PreferredAL; OTC; QL (1 tablet per 1 day)

NEONATAL VITAMIN ORAL TABLET

PreferredAL; OTC; QL (1 tablet per 1 day)

OBTREX ORAL TABLET

PreferredAL; OTC; QL (1 tablet per 1 day)

one vite womens oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

ONE-A-DAY WOMENS PRENATAL 1 ORAL CAPSULE

PreferredAL; OTC; QL (1 tablet per 1 day)

ONE-A-DAY WOMENS PRENATAL ORAL

PreferredAL; OTC; QL (2 tablets per 1 day)

PERRY PRENATAL ORAL CAPSULE

PreferredAL; OTC; QL (1 capsule per 1 day)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

20

Drug Name Drug Tier Requirements/Limits

prenatal (w/iron & fa) oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal complete oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal formula a-free oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal formula oral capsule

PreferredAL; OTC; QL (1 capsule per 1 day)

pre-natal formula oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal forte oral tablet PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal multi +dha oral capsule 27-0.8-228 mg

PreferredAL; OTC; QL (1 capsule per 1 day)

prenatal one daily oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal oral tablet 27-0.8 mg

PreferredAL; QL (1 tablet per 1 day)

prenatal oral tablet 28-0.8 mg, 6.75-0.2 mg

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal vitamin and mineral oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal vitamin oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal vitamins oral tablet

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal/iron oral tablet PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal/omega-3/fa/iron oral capsule

PreferredAL; OTC; QL (1 capsule per 1 day)

Drug Name Drug Tier Requirements/Limits

UPSPRING PRENATAL COMPLETE ORAL CAPSULE

PreferredAL; OTC; QL (1 capsule per 1 day)

VINATE CARE ORAL TABLET CHEWABLE

PreferredAL; OTC; QL (1 tablet per 1 day)

YOUR LIFE MULTI PRENATAL ORAL CAPSULE

PreferredAL; OTC; QL (1 capsule per 1 day)

*PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OIL***

prenatal + complete multi oral therapy pack 18-0.8 & 290 mg

PreferredAL; OTC; QL (2 capsules per 1 day)

*PRENATAL MV & MIN W/FE-FA-DHA***

BRAINSTRONG PRENATAL ORAL

PreferredAL; OTC; QL (2 units per 1 day)

cadeau dha oral capsule PreferredAL; OTC; QL (1 capsule per 1 day)

CENTRUM SPECIALIST PRENATAL ORAL

PreferredAL; OTC; QL (2 tablets per 1 day)

ENFAMIL EXPECTA ORAL

PreferredAL; OTC; QL (2 tablets per 1 day)

prenatal multi +dha oral capsule 27-0.8-200 mg, 27-0.8-250 mg

PreferredAL; OTC; QL (1 capsule per 1 day)

PRENATAL MULTIVITAMIN + DHA ORAL

PreferredAL; OTC; QL (2 tablets per 1 day)

prenatal multivitamin plus dha oral capsule

PreferredAL; OTC; QL (1 capsule per 1 day)

prenatal+dha oral PreferredAL; OTC; QL (2 tablets per 1 day)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

21

Drug Name Drug Tier Requirements/Limits

SIMILAC PRENATAL EARLY SHIELD ORAL

PreferredAL; OTC; QL (2 tablets per 1 day)

STUART ONE ORAL CAPSULE

PreferredAL; OTC; QL (1 capsule per 1 day)

THERANATAL COMPLETE ORAL

PreferredAL; OTC; QL (3 units per 1 day)

THERANATAL ONE ORAL CAPSULE

PreferredAL; OTC; QL (1 capsule per 1 day)

ultra prenatal + dha oral capsule

PreferredAL; OTC; QL (1 capsule per 1 day)

*PRENATAL MV & MINERALS W/FA WITHOUT IRON***

ALIVE PRENATAL ORAL TABLET CHEWABLE

PreferredAL; OTC; QL (1 tablet per 1 day)

ONE A DAY PRENATAL ORAL TABLET CHEWABLE

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal + complete multi oral therapy pack 0.267 & 373 mg

PreferredAL; OTC; QL (2 tablets per 1 day)

prenatal adult gummy/dha/fa oral tablet chewable

PreferredAL; OTC; QL (1 tablet per 1 day)

prenatal gummies/dha & fa oral tablet chewable

PreferredAL; OTC; QL (1 tablet per 1 day)

*NASAL AGENTS - SYSTEMIC AND TOPICAL*

*NASAL AGENTS - MISC.***

AYR SALINE NASAL DROPS NASAL SOLUTION

PreferredOTC; QL (2 fills per 30 days)

Drug Name Drug Tier Requirements/Limits

saline nasal spray nasal solution

PreferredOTC; QL (2 fills per 30 days)

*NASAL MAST CELL STABILIZERS***

cromolyn sodium nasal aerosol solution

Preferred OTC

*NASAL STEROIDS***

fluticasone propionate nasal suspension

Preferred

*SYSTEMIC DECONGESTANTS***

pseudoephedrine hcl er oral tablet extended release 12 hour

PreferredAL; OTC; QL (2 fills per 30 days)

pseudoephedrine hcl oral tablet 30 mg

PreferredAL; OTC; QL (2 fills per 30 days)

pseudoephedrine hcl oral tablet 60 mg

Preferred AL

*OPHTHALMIC AGENTS*

*ARTIFICIAL TEARS AND LUBRICANTS***

carboxymethylcellulose sodium ophthalmic solution

Preferred OTC

polyvinyl alcohol ophthalmic solution

Preferred

*OPHTHALMIC ANTIALLERGIC***

ketotifen fumarate ophthalmic solution

PreferredQL (1 bottle per 30 days)

olopatadine hcl ophthalmic solution

Preferred

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

22

Drug Name Drug Tier Requirements/Limits

PATADAY OPHTHALMIC SOLUTION 0.1 %

PreferredOTC; QL (5 mL per 30 days)

PATADAY OPHTHALMIC SOLUTION 0.2 %

PreferredQL (1 bottle per 1 day)

*OXYTOCICS*

*OXYTOCICS***

methylergonovine maleate injection solution

Preferred MB

*PHARMACEUTICAL ADJUVANTS*

*SEMI SOLID VEHICLES***

petroleum jelly external gel

Preferred OTC

white petrolatum external ointment

Preferred

*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*

*SMOKING DETERRENTS***

nicotine polacrilex mini mouth/throat lozenge

PreferredC; OTC; QL (20 lozenges per 1 day)

nicotine polacrilex mouth/throat gum

PreferredC; OTC; QL (20 units per 1 day)

nicotine polacrilex mouth/throat lozenge

PreferredC; OTC; QL (20 lozenges per 1 day)

nicotine transdermal kit PreferredC; OTC; QL (1 patch per 1 day)

nicotine transdermal patch 24 hour

PreferredC; OTC; QL (1 patch per 1 day)

Drug Name Drug Tier Requirements/Limits

*TOXOIDS*

*TOXOID COMBINATIONS***

BOOSTRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

Preferred AL

KINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

Preferred AL

*ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS*

*H-2 ANTAGONISTS***

famotidine oral tablet 10 mg

PreferredOTC; QL (2 tablets per 1 day)

famotidine oral tablet 20 mg

Preferred

*PROTON PUMP INHIBITOR-ANTACID COMBINATIONS***

omeprazole-sodium bicarbonate oral capsule20-1100 mg

PreferredQL (1 capsule per 1 day)

*PROTON PUMP INHIBITORS***

esomeprazole magnesium oral capsule delayed release 20 mg

PreferredQL (1 capsule per 1 day)

lansoprazole oral capsule delayed release 15 mg

PreferredQL (1 capsule per 1 day)

lansoprazole oral tablet delayed release dispersible 15 mg

PreferredQL (1 tablet per 1 day)

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

23

Drug Name Drug Tier Requirements/Limits

NEXIUM 24HR CLEAR MINIS ORAL CAPSULE DELAYED RELEASE

PreferredOTC; QL (2 capsules per 1 day)

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE

PreferredOTC; QL (2 capsules per 1 day)

omeprazole oral capsule delayed release 20 mg

Preferred

PREVACID 24HR ORAL CAPSULE DELAYED RELEASE

PreferredOTC; QL (1 capsule per 1 day)

*URINARY ANTISPASMODICS*

*URINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)***

OXYTROL FOR WOMEN TRANSDERMAL PATCH TWICE WEEKLY

Preferred OTC

*VACCINES*

*BACTERIAL VACCINES***

BIOTHRAX INTRAMUSCULAR SUSPENSION

Preferred

PREVNAR 20 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

Preferred MB

VAXNEUVANCE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

Preferred MB

Drug Name Drug Tier Requirements/Limits

*VAGINAL AND RELATED PRODUCTS*

*IMIDAZOLE-RELATED ANTIFUNGALS***

clotrimazole vaginal cream

PreferredOTC; QL (45 grams per 30 days)

miconazole 1 vaginal kit Preferred OTC

miconazole nitrate vaginal cream

Preferred OTC

*SPERMICIDES***

TODAY SPONGE VAGINAL

Preferred OTC

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM

Preferred OTC

VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM

Preferred OTC

*VITAMINS*

*VITAMIN D***

vitamin d oral liquid PreferredPA; OTC; QL (50 mL per 30 days)

vitamin d3 oral liquid 10 mcg/ml

PreferredPA; OTC; QL (50 mL per 30 days)

vitamin d3 oral liquid5000 unit/ml

Preferred PA; OTC; OTC

QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

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QL = Quantity Limit; ST = Step Therapy; PA = Prior Authorization; AL = Age Limit; SP = Specialty Pharmacy;         C = CCS members - Bill Ohana; 90DS = 90 day generic

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Index

ABREVA ......................................11acetaminophen ................................ 4acetaminophen childrens ..................4acetaminophen er ............................ 4acetaminophen infants .....................4acne medication 10 ........................10acne medication 5 ..........................10ACTIVITY POUCH ....................16adapalene ......................................10ADASUVE .....................................8advanced acne wash .......................10AEROGEAR ACTION ASTHMA KIT .............................16AFTERA ........................................8afterburn .......................................12AFTERPILL ..................................8AIRS PEDIATRIC AEROSOL MASK ..........................................16ALAVERT ALLERGY/SINUS ..... 9alevazol .........................................12ALIVE PRENATAL ....................22ALL FLOW 1000 PFT FILTER .. 16ALLEGRA ALLERGY CHILDRENS ................................ 7allergy relief ....................................7allergy relief (loratadine) ............... 7allergy relief childrens ..................... 7ALLI ..............................................4ALOCANE EMERGENCY BURN MAX STR ........................ 12alum & mag hydroxide-simeth ......... 5aluminum hydroxide gel .................. 5amantadine hcl ................................8antacid & antigas ............................ 5APETIGEN-PLUS ...................... 19APRODINE ...................................9ASPERCREME MAX STRENGTH ................................ 12aspirin .............................................5aspirin ec .....................................4, 5ATABEX ......................................20AVEENO BABY SOOTHING MULTI-PUR ............................... 12AYR SALINE NASAL DROPS .. 22b complex ..................................... 19b complex vitamins ........................19b complex-biotin-fa ....................... 19b complex-c ...................................19b complex-c-biotin-e-fa ..................19b-12 .............................................. 13B-12 DOTS .................................. 13bacitracin ......................................10bacitracin zinc ...............................10bacitracin zinc-aloe ....................... 10

b-complex ..................................... 19b-complex/vitamin c ...................... 19b-complex-c .................................. 19benzonatate .....................................9benzoyl peroxide ........................... 10benzoyl peroxide cleanser .............. 10benzoyl peroxide wash ...................10biogtuss .......................................... 9BIOTHRAX .................................24bisacodyl .......................................15bisacodyl ec ...................................15bismuth subsalicylate ...................... 6BOOSTRIX ................................. 23BPROTECTED PEDIA POLY-VITE/FE ...................................... 20BRAINSTRONG PRENATAL ... 21breathe ease neb mask/child ...........16breathe ease neb mask/infant ......... 16burn relief ..................................... 12cadeau dha .................................... 21caffeine citrate ................................ 4calamine phenolated ...................... 11calcium carb-cholecalciferol .......... 17calcium carbonate ......................5, 18calcium carbonate antacid ............... 5calcium carbonate-vitamin d ..........17calcium citrate .............................. 18calcium citrate-vitamin d ............... 17calcium citrate-vitamin d3 ............. 17calcium oyster shell ....................... 18calcium/c/d ....................................17calcium-magnesium ....................... 18calcium-magnesium-zinc ................18calcium-vitamin d ..........................18calcium-vitamin d3 ........................ 18calcium-vitamin d-minerals ............18carboxymethylcellulose sodium ......22CARETOUCH 2 CPAP HOSE HANGER .....................................17CARETOUCH CPAP & BIPAP HOSE .......................................... 17CARETOUCH CPAP MASK WIPES .........................................17CARETOUCH CPAP PRE-WASH SOLN .............................. 17CARETOUCH CPAP TUBE BRUSH ........................................17CARETOUCH UNIVERSL CPAP FILTER ............................ 17CAYA .......................................... 15CENTRUM SPECIALIST PRENATAL ................................ 21chelated zinc ................................. 18CHEMSTRIP UGK .....................13

chlorpheniramine maleate ................7chlorpheniramine maleate er ............7chocolated laxative ........................15citrus calcium/vitamin d .................18classic prenatal ..............................20CLINICAL NUTRIENTS PRENATAL ................................ 20clotrimazole .................................. 24CLOVIQUE ................................ 19co monitor replacement pieces ....... 17cold & flu severe daytime .................9cromolyn sodium ........................... 22cyanocobalamin ............................ 13daytime cough .................................9DESRX ........................................ 11DEX4 ............................................. 6DEX4 GLUCOSE ..........................6DEX4 NATURALS ....................... 6DEX4 POUCH PACK ...................6DEX4 QUICK DISSOLVE GLUCOSE .................................... 6dextromethorphan polistirex er ....... 9dextromethorphan-guaifenesin ........ 9DIABETIC TUSSIN ALLERGY .. 7DIALYVITE 800 ..........................19diclofenac sodium ..........................11diphenhydramine hcl ....................... 7diphenhydramine hcl (sleep) ......... 14docosanol ...................................... 11docusate calcium ........................... 15docusate sodium ............................ 15dss ................................................ 15easy iron ....................................... 14EBASE CONTROLLER KIT ......17ECONTRA EZ .............................. 8ECONTRA ONE-STEP ................ 8effaclar duo ...................................10enema ........................................... 15ENFAMIL EXPECTA .................21epsom salt ..................................... 15eql prenatal formula ...................... 20esomeprazole magnesium ...............23famotidine .....................................23fa-vitamin b-6-vitamin b-12 ........... 13fenoprofen calcium ..........................4ferretts ..........................................14ferrous fumarate ........................... 14ferrous gluconate ...........................14ferrous sulfate ............................... 14ferrous sulfate er ........................... 14FEVERALL INFANTS ................. 4FEVERALL JUNIOR STRENGTH ..................................4fexofenadine hcl .............................. 7

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fexofenadine-pseudoephed er ........... 9fiber .............................................. 14fiber (corn dextrin) .......................14fiber laxative .................................14fiber therapy ................................. 14filter air pp ....................................17flurbiprofen .....................................4fluticasone propionate ................... 22folic acid ....................................... 14full kit nebulizer set ....................... 17glucose ............................................6glucose instant energy ..................... 6glucose-vitamin c .............................6glycerin .........................................12glycerin (adult) .............................15glycerin (infants & children) ......... 15glycerin (pediatric) .......................15g-myco nail ................................... 11gnp acetaminophen ex st ................. 4gnp allergy childrens ....................... 7gnp calamine phenolated ................11gnp cold max severe ........................ 9gnp docosanol ................................11gnp glucose ..................................... 6gnp hemorrhoidal ............................ 5gnp isopropyl rubbing alcohol ..........8gnp prenatal .................................. 20gnp quick dissolve glucose ............... 6GNP TRUE METRIX AIR METER ....................................... 16GNP TRUE METRIX GLUCOSE METER ....................16GNP TRUE METRIX GLUCOSE STRIPS .................... 13goodsense aspirin adults .................. 5goodsense glucose ............................6goodsense psyllium fiber ................ 14GORDOCHOM .......................... 11g-supress dx pediatric ......................9guaifenesin .................................... 10guaifenesin-codeine ......................... 9guaifenesin-dm ................................9HEALTHY MAMA BE WELL ROUNDED ..................................20HUDSON RCI AEROSOL MASK ADULT ............................17hydrocodone-homatropine ............... 9hydrocortisone .............................. 11hydrocortisone acetate ...................11hydrocortisone max st ................... 11hydrocortisone-aloe .......................12hydrogen peroxide ...........................8hydroxocobalamin acetate .............13ibuprofen ........................................ 4INFED ......................................... 14

intense cough reliever ...................... 9INVEGA HAFYERA .....................8iron ............................................... 14iron (ferrous sulfate) .................... 14iron high-potency .......................... 14iron-vitamin c ................................14KETO-DIASTIX ..........................13ketotifen fumarate .........................22KINRIX ....................................... 23kp prenatal multivitamins .............. 20kpn prenatal ..................................20lancets 33g .................................... 16lansoprazole ..................................23leader glucose ................................. 6leader quick dissolve glucose ............6levonorgestrel ..................................8lidocaine ....................................... 12lidocaine hcl .................................. 12LIDODOSE .................................12LIDODOSE PEDIATRIC BULK PACK ............................... 12LITETOUCH MASK LARGE .... 17LOHIST-D .................................... 9longs glucose ...................................6loperamide hcl .................................6loperamide-simethicone ................... 7loratadine ....................................... 7loratadine-d 24hr ............................ 9LOREEV XR ................................. 6LOTRIMIN AF ......................11, 12MAG64 ........................................ 18magnesium .................................... 18magnesium citrate ......................... 15magnesium gluconate .................... 18magnesium oxide ....................... 5, 18magnesium oxide (antacid) .............5magnesium oxide -mg supplement ..18m-clear wc ...................................... 9meclizine hcl ................................... 7methadone hcl ................................. 5METHADOSE .............................. 5methylergonovine maleate ............. 23miconazole 1 ................................. 24miconazole nitrate ................... 12, 24milk of magnesia ........................... 15milk of magnesia concentrate ........ 15mineral oil .....................................15mineral oil-hydrophil petrolat ........ 12mucus relief cough childrens ............ 9mucus relief dm ...............................9multi prenatal ................................20multi vitamin .................................20multi vitamin/minerals ...................19multiple vitamin-folic acid ............. 20multiple vitamins ........................... 20

multiple vitamins/iron ....................19MY CHOICE ................................ 8MY WAY .......................................8MYCO NAIL ...............................11MYCO NAIL A ........................... 11MYCOZYL AC ........................... 12MYCOZYL AL ........................... 11na ferric gluc cplx in sucrose ..........14naproxen sodium .............................4nasal mist ......................................10natural fiber .................................. 15natural fiber laxative .....................14nausea relief ....................................7nebulizer air tube/plugs ..................17NEONATAL VITAMIN ..............20NEPHRONEX .............................19NEUTROGENA CLEAR PORE .10NEUTROGENA ON-THE-SPOT ...........................................10NEW DAY .....................................8NEXIUM 24HR ...........................24NEXIUM 24HR CLEAR MINIS .24nicotine ......................................... 23nicotine polacrilex .........................23nicotine polacrilex mini ................. 23OBTREX ..................................... 20octreotide acetate ..........................13olopatadine hcl ..............................22omeprazole ....................................24omeprazole-sodium bicarbonate .....23OMNIFLEX DIAPHRAGM ....... 15ONE A DAY PRENATAL ...........22one vite womens ............................ 20ONE-A-DAY WOMENS PRENATAL ................................ 20ONE-A-DAY WOMENS PRENATAL 1 ..............................20OPCICON ONE-STEP .................8OPTION 2 .....................................8OXYTROL FOR WOMEN .........24oyster shell calcium ....................... 18oyster shell calcium/d .................... 18oyster shell calcium/vitamin d ........ 18PANOXYL .................................. 10PARI ALTERA NEBULIZER HANDSET ...................................17PARI BABY CONVERSION KIT ...............................................17PARI ERAPID NEBULIZER HANDSET ...................................17PARI EXPIRATORY FILTER SET ..............................................17PARI MASK SET ........................17PARI SOFT PLASTIC ADULT MASK ..........................................17

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PARI SOFT PLASTIC PED MASK ..........................................17PATADAY ...................................23pc pediatric poly-vita/fe drop ......... 20pediatric electrolyte .......................18PERRY PRENATAL ...................20petroleum jelly .............................. 23phosphorous .................................. 18pillow mask/adult .......................... 17pillow mask/child ...........................17pillow mask/pediatric .................... 17pink bismuth maximum strength ......6poly bacitracin .............................. 10polyethylene glycol 3350 ................15polysaccharide iron complex ..........14polysaccharide-iron complex ......... 14polyvinyl alcohol ........................... 22POLY-VI-SOL/IRON ................. 20poly-vita/iron ................................ 20poly-vite/iron .................................20potassium gluconate ...................... 18prenatal ........................................ 21prenatal (w/iron & fa) ...................21prenatal + complete multi ........ 21, 22prenatal adult gummy/dha/fa .........22prenatal complete ..........................21prenatal formula ........................... 21pre-natal formula .......................... 21prenatal formula a-free ..................21prenatal forte ................................ 21prenatal gummies/dha & fa ............ 22prenatal multi +dha .......................21PRENATAL MULTIVITAMIN + DHA ......................................... 21prenatal multivitamin plus dha .......21prenatal one daily ..........................21prenatal vitamin ............................ 21prenatal vitamin and mineral ......... 21prenatal vitamins ...........................21prenatal/iron ................................. 21prenatal/omega-3/fa/iron ............... 21prenatal+dha ................................ 21PREVACID 24HR ....................... 24PREVENTEZA ............................. 8PREVNAR 20 .............................. 24promethazine-codeine ....................10promethazine-dm ...........................10promethazine-phenyleph-codeine ... 10pseudoephedrine hcl .......................22pseudoephedrine hcl er ...................22REACT .......................................... 8reeses pinworm medicine ................. 5REGENECARE HA .................... 12RELION GLUCOSE .....................6

RELION TRUE MET AIR GLUC METER ............................16RELION TRUE METRIX TEST STRIPS ........................................13replacement air filter ..................... 17risacal-d ........................................18saline nasal spray .......................... 22sd potassium gluconate .................. 18senna ............................................ 15senna plus ..................................... 15sennosides-docusate sodium ........... 15silicone mask/adult ........................ 17silicone mask/infant .......................17silicone mask/pediatric .................. 17simethicone ................................... 13simethicone extra strength .............13SIMILAC PRENATAL EARLY SHIELD .......................................22SMART SENSE GLUCOSE .........6sodium bicarbonate ......................... 5SOLUBLE FIBER THERAPY ....15stool softener/laxative ................... 15STUART ONE ............................ 22SUN BURNT PLUS .................... 12super b-complex + vitamin c ..........19TAKE ACTION .............................8terbinafine hcl ............................... 11THERANATAL COMPLETE .... 22THERANATAL ONE ................. 22THERANATAL OVAVITE ........ 20TODAY SPONGE .......................24tolnaftate ...................................... 11TRUE METRIX AIR GLUCOSE METER ....................16TRUE METRIX BLOOD GLUCOSE TEST ........................ 13TRUE METRIX GO GLUCOSE METER ....................................... 16TRUE METRIX LEVEL 1 .......... 16TRUE METRIX LEVEL 2 .......... 16TRUE METRIX LEVEL 3 .......... 16TRUE METRIX METER ............16trymine cg .......................................9TUSNEL C .................................... 9tussin cough .................................... 9ultra prenatal + dha ...................... 22up & up glucose ...............................6UPSPRING PRENATAL COMPLETE ............................... 21VAXNEUVANCE ........................24VCF VAGINAL CONTRACEPTIVE .................... 24VENOFER ...................................14VINATE CARE ........................... 21vit e-vit c-beta carotene ................. 20

vitamin a & d .................................12vitamin a & d skin protectant .........12vitamin a .................................. 12vitamin b12 ................................... 13vitamin b-12 .................................. 13vitamin b-12 er .............................. 13vitamin d .......................................24vitamin d3 ..................................... 24vitamin e-vit a & d ......................... 12vitamins a & d ............................... 12vitamins a-d-e/selenium ................. 20WAL-TAP CHILDRENS ..............9WAL-TUSSIN COUGH LONG ACTING ........................................ 9white petrolatum ........................... 23WIDE-SEAL DIAPHRAGM 60 ..16WIDE-SEAL DIAPHRAGM 65 ..16WIDE-SEAL DIAPHRAGM 70 ..16WIDE-SEAL DIAPHRAGM 75 ..16WIDE-SEAL DIAPHRAGM 80 ..16WIDE-SEAL DIAPHRAGM 85 ..16WIDE-SEAL DIAPHRAGM 90 ..16WIDE-SEAL DIAPHRAGM 95 ..16WINDMILL TRAINER .............. 17xolido ........................................... 12YOUR LIFE MULTI PRENATAL ................................ 21zinc ............................................... 19zinc chelated ................................. 19zinc gluconate ............................... 19zinc oxide ......................................11zinc sulfate ....................................19

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1357 KAPIOLANI BLVD., STE G101 HONOLULU, HI 96814