Comprehensive PREFERRED DRUG LIST - Envolve Health...DECON-A LIQUID 2-5 MG/ML BRAND ... complete...

Comprehensive

PREFERRED DRUG LIST CountyCare

PAGE 1 LAST UPDATED 02/2016

LEGEND

TYPE DESCRIPTION

QL Quantity LimitThere is a limit on the amount of drug covered per prescription, orwithin a specific time frame.

PA Prior Authorization Prior Authorization required before prescription can be filled.

ST Step TherapyRequires trial and failure of one or more preferred products prior tocoverage.

GL Gender Limit Drug is limited to specific gender.

AL Age Limit Drug is limited to specific age.

MDD Max Daily Dose A limit on the number of times the drug can be taken per day.

MPL Max Package Limit A limit on the amount of drug covered per prescription.

MFL Max Fill Limit There is a limit on the number of times this drug can be refilled.

MDS Max Days Supply There is a limit on the amount of this drug that is covered.

C Custom This drug has unique restrictions.


LIST OF COVERED OVER-THE-COUNTER MEDICATIONS PRODUCT DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

PIN-X CHEW TAB 720.5 MG BRANDQL 4 / claim

MFL 1 / 30 days

pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv) genericQL 60 / claim

MFL 1 / 30 days

REESES PINWORM MEDICINE TAB 180 MG BRANDQL 16 / claim

MFL 1 / 30 days

ENDOCRINE AND METABOLIC DRUGS

CONTRACEPTIVES

levonorgestrel tab 1.5 mg generic

QL 1 / 21 Days

GL Female

MFL 4 / 365 days

ANTIDIABETICS

BD GLUCOSE CHEW TAB 5 GM BRAND QL 50 / 30 days

glucose chew tab 4 gm generic QL 50 / 30 days

RESPIRATORY AGENTS

ANTIHISTAMINES

ALER-DRYL TAB 50 MG BRAND MDD 4 per day

ALLEGRA ALLERGY CHILDRENS TAB DISP 30 MG BRAND MDD 2 per day

cetirizine hcl (cap 10 mg, tab 5 mg) generic MDD 1 per day

cetirizine hcl allergy child solution 5 mg/5ml genericQL 240 / claim

AL Up to 12 yrs old


PRODUCT DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS

cetirizine hcl chew tab 10 mg generic MDD 1 per day

cetirizine hcl chew tab 5 mg generic MDD 1 per day

cetirizine hcl tab 10 mg generic MDD 1 per day

childrens loratadine syrup 5 mg/5ml generic QL 240 / claim

chlorpheniramine maleate syrup 2 mg/5ml generic MDD 60 per day

chlorpheniramine maleate tab 4 mg generic QL 120 / claim

chlorpheniramine maleate tab 4 mg generic QL 120 / claim

clemastine fumarate tab 1.34 mg generic MDD 2 per day

diphenhydramine hcl cap 25 mg generic MDD 4 per day


diphenhydramine hcl elixir 12.5 mg/5ml generic QL 240 / claim

diphenhydramine hcl liquid 12.5 mg/5ml generic QL 240 / claim

diphenhydramine hcl syrup 12.5 mg/5ml generic QL 240 / claim

diphenhydramine hcl tab 25 mg generic MDD 4 per day

fexofenadine hcl tab 180 mg generic MDD 1 per day

fexofenadine hcl tab 60 mg generic MDD 2 per day

loratadine allergy relief tab disp 10 mg generic

loratadine tab 10 mg generic

NASAL AGENTS - SYSTEMIC AND TOPICAL

cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) generic QL 26 / claim

CVS NASAL MIST AERO SOLN 0.9 % BRAND QL 240 / claim

nasal moisturizing spray solution 0.65 % generic MPL 1 / claim

phenylephrine hcl tab 10 mg generic QL 24 / claim

pseudoephedrine hcl (liq 15 mg/5ml, liq 30 mg/5ml, syrup30 mg/5ml, tab 60 mg) generic



pseudoephedrine hcl er tab er 12h 120 mg generic QL 62 / 31 days

pseudoephedrine hcl tab 30 mg generic

SUDAFED PE CHILDRENS SOLUTION 2.5 MG/5ML BRAND QL 120 / claim

triamcinolone acetonide nasal aerosol suspension 55mcg/act generic

QL 17 / claim

AL At least 2 yrs old

C OTC Covered Only

COUGH/COLD/ALLERGY

acetaminophen w/ dm liq 160-5 mg/5ml generic

BIOSPEC DMX LIQUID 15-25 MG/5ML BRAND

brompheniramine & phenylephrine elixir 1-2.5 mg/5ml genericQL 120 / claim

MFL 1 / 30 days

brompheniramine & pseudoephedrine elixir 1-15 mg/5ml genericQL 120 / claim

MFL 1 / 30 days

cetirizine-pseudoephedrine tab sr 12hr 5-120 mg generic MDD 2 per day

chlorphen-pseudoephedrine w/ apap cap 2-30-325 mg generic

chlorpheniramine & phenylephrine liquid 1-3.5 mg/ml generic QL 30 / claim

chlorpheniramine-dm liquid 2-15 mg/5ml generic QL 240 / claim

DECON-A LIQUID 2-5 MG/ML BRAND

dextromethorphan polistirex er liquid er 30 mg/5ml generic QL 240 / 6 days

dextromethorphan-doxylamine-apap liquid 30-12.5-1000mg/30ml generic

dextromethorphan-guaifenesin (liquid 10-200 mg/5ml,liquid 10-100 mg/5ml, syrup 10-100 mg/5ml) generic QL 240 / claim

dextromethorphan-guaifenesin (liquid 5-100 mg/5ml, liquid30-200 mg/5ml) generic

dextromethorphan-guaifenesin tab sr 12hr 30-600 mg generic MDD 2 per day

dextromethorphan-phenylephrine-apap cap 10-5-325 mg generic

DIMETAPP LONG ACT COUGH/COLD SYRUP 1-7.5MG/5ML BRAND QL 240 / claim



guaifenesin liquid 100 mg/5ml genericQL 240 / 6 days

MFL 1 / 30 days

guaifenesin syrup 100 mg/5ml generic QL 240 / 6 days

guaifenesin tab sr 12hr 1200 mg generic

guaifenesin tab sr 12hr 600 mg genericQL 40 / claim

MFL 1 / 30 days

guaifenesin-codeine soln 100-10 mg/5ml generic

LITTLE REMEDIES FOR COLDS LIQUID 2.5-1.25-80MG/ML BRAND

LOHIST-D LIQUID 2-30 MG/5ML BRAND QL 240 / claim

loratadine & pseudoephedrine tab sr 12hr 5-120 mg genericQL 62 / 31 days

MDD 2 per day

loratadine & pseudoephedrine tab sr 24hr 10-240 mg generic MDD 1 per day

MEDI-GRAINE TAB 500-75-5 MG BRAND QL 120 / 30 days

phenylephrine-dm soln 2.5-5 mg/5ml generic QL 240 / claim

phenylephrine-guaifenesin liqd 5-100 mg/5ml generic QL 240 / 6 days

pseudoephed-bromphen-dm (elixir 15-1-5 mg/5ml, syrup30-2-10 mg/5ml) generic QL 240 / claim

pseudoephed-chlorphen-dm liq 15-1-5 mg/5ml generic QL 240 / claim

pseudoephed-doxyl-dm w/apap (w/ apap cap 30-6.25-15-325 mg, w/apap liq 60-12.5-30-1000 mg/30ml) generic

pseudoephedrine w/ apap-dm cap 30-325-15 mg generic

pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml generic QL 240 / 6 days

pseudoephedrine w/ dm-gg liquid 30-10-100 mg/5ml generic QL 240 / 6 days

pseudoephedrine-guaifenesin syrup 30-100 mg/5ml generic QL 240 / claim

pseudoephedrine-guaifenesin tab sr 12hr 60-600 mg generic

pseudoephedrine-ibuprofen (susp 15-100 mg/5ml, tab 30-200 mg) generic



SCOT-TUSSIN SENIOR LIQUID 15-200 MG/5ML BRAND

sodium chloride aero soln 0.9% generic QL 240 / claim

TRIAMINIC COLD/COUGH DAY TIME (COLD/COUGHSOLUTION MG/5ML, COLD/COUGH SYRUP MG/5ML) BRAND QL 240 / claim

GASTROINTESTINAL AGENTS

LAXATIVES

bisacodyl ec tab dr 5 mg generic MDD 1 per day

bisacodyl laxative suppos 10 mg generic QL 12 / claim

calcium polycarbophil tab 625 mg generic MDD 10 per day

complete ready-to-use enema enema 7-19 gm/118ml generic

docusate sodium (cap 250 mg, tab 100 mg) generic MDD 3 per day

docusate sodium (cap 50 mg, liquid 150 mg/15ml, syrup 60mg/15ml) generic

docusate sodium cap 100 mg generic MDD 3 per day

fiber cap 0.52 gm generic

glycerin suppos 2 gm generic

magnesium citrate solution 1.745 gm/30ml generic

milk of magnesia suspension 400 mg/5ml generic QL 992 / 31 days

polyethylene glycol 3350 oral packet generic

polyethylene glycol 3350 oral powder generic MDD 34 per day

psyllium (powder 28.3%, powder 30%, powder 30.9%,powder 33%, powder 48.57%, powder 50%, powder58.6%, powder 68%, powder 100%)

generic

senna tab 8.6 mg generic

senna-docusate sodium tab 8.6-50 mg generic MDD 4 per day

sennosides cap 8.6 mg generic

sorbitol (laxative) (oral solution, rectal solution) generic



ANTIDIARRHEALS

bismuth subsalicylate (chew tab 262 mg, susp 262mg/15ml, tab 262 mg) generic

loperamide hcl (cap 2 mg, liq 1 mg/5ml (0.2 mg/ml)) generic

loperamide hcl tab 2 mg generic MDD 2 per day

ANTACIDS

alum & mag hydroxide-simethicone susp 200-200-20mg/5ml generic QL 496 / 31 days

aluminum hydroxide gel susp 320 mg/5ml generic

calcium carbonate (antacid) chew tab 500 mg generic

magnesium oxide tab 400 mg generic

sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg) generic QL 496 / 31 days

ULCER DRUGS

AXID AR TAB 75 MG BRAND

cimetidine tab 200 mg generic

famotidine (tab 10 mg, tab 20 mg) generic

lansoprazole cap delayed release 15 mg generic MDD 4 per day

NEXIUM 24HR CAP DR 20 MG BRAND MDD 2 per day

omeprazole delayed release tab 20 mg generic MDD 4 per day

PRILOSEC OTC TAB DR 20 MG BRAND MDD 4 per day

ranitidine hcl (tab 75 mg, tab 150 mg) generic MDD 2 per day

ANTIEMETICS

dimenhydrinate tab 50 mg generic QL 24 / claim

DRAMAMINE CHEW TAB 50 MG BRAND QL 24 / claim

meclizine hcl (chew tab 25 mg, tab 12.5 mg, tab 25 mg) generic



GASTROINTESTINAL AGENTS - MISC.

simethicone (chew tab 80 mg, liquid 40 mg/0.6ml, susp 40mg/0.6ml) generic

GENITOURINARY PRODUCTS

VAGINAL PRODUCTS

clotrimazole vaginal (cream 1%, cream 2%) generic

CONCEPTROL INSERTS INSERT 150 MG BRAND

ENCARE SUPPOS 100 MG BRAND MPL 1 / claim

GYNOL II GEL 2 % BRAND MPL 1 / claim

miconazole nitrate vaginal (cream 2%, cream 4% (200mg/5gm), suppos 100 mg) generic

miconazole nitrate vaginal supp 200 mg & 2% cream 9 gmkit generic MPL 1 / claim

OPTIONS GYNOL II CONTRACEPTIVE GEL 3 % BRAND

tioconazole vaginal oint 6.5% generic

VCF VAGINAL CONTRACEPTIVE (FILM 28 %, FOAM12.5 %) BRAND MPL 1 / claim

CENTRAL NERVOUS SYSTEM DRUGS

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

diphenhydramine hcl (sleep) (cap 50 mg, tab 50 mg, tabdisp 25 mg) generic

diphenhydramine hcl (sleep) tab 25 mg generic MDD 1 per day

diphenhydramine-acetaminophen tab 25-500 mg (sleep) generic MDD 1 per day

doxylamine succinate (sleep) tab 25 mg generic

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISCELLANEOUS

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

nicotine (patch 24hr 7 mg/24hr, patch 24hr 21 mg/24hr,patch 24hr 14 mg/24hr) generic

MDD 1 per day

MDS 180 / 365 DAYS



NICOTINE KIT 21-14-7 MG/24HR BRANDQL 2 / 365 days

MDS 180 / 365 DAYS

nicotine polacrilex (gum 2 mg, gum 4 mg) genericMDD 24 per day

MDS 180 / 365 DAYS

nicotine polacrilex (lozenge 2 mg, lozenge 4 mg) genericMDD 20 per day

MDS 180 / 365 DAYS

ANALGESICS AND ANESTHETICS

ANALGESICS - NONNARCOTIC

acetaminophen (cap 500 mg, chew tab 80 mg, chew tab160 mg, dispersible tab 80 mg, elixir 160 mg/5ml, liquid160 mg/5ml, soln 160 mg/5ml, susp 80 mg/0.8ml, susp 160mg/5ml, tab 325 mg, tab 500 mg)

generic

acetaminophen (suppos 120 mg, suppos 325 mg, suppos650 mg) generic QL 12 / 31 days

acetaminophen soln 100 mg/ml generic QL 30 / 30 days

aspirin (chew tab 81 mg, tab 81 mg, tab 325 mg, tabdelayed release 81 mg, tab delayed release 325 mg) generic

aspirin (suppos 300 mg, suppos 600 mg) generic QL 12 / 31 days

aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg generic

aspirin buffered tab 325 mg generic

aspirin tab chew 81 mg generic

ANALGESICS - ANTI-INFLAMMATORY

ibuprofen (chew tab 100 mg, susp 40 mg/ml, susp 100mg/5ml, tab 100 mg, tab 200 mg) generic

ibuprofen cap 200 mg generic

ibuprofen tab 200 mg generic

naproxen sodium cap 220 mg generic QL 62 / 31 days

naproxen sodium tab 220 mg generic QL 62 / 31 days



NUTRITIONAL PRODUCTS

VITAMINS

ascorbic acid (chew tab 250 mg, chew tab 500 mg, tab 250mg, tab 500 mg, tab 1000 mg, tab cr 500 mg, tab cr 1000mg)

generic QL 100 / 31 days

cholecalciferol (cap 1000, cap 2000, chew tab 1000, chewtab 2000, tab 1000, tab 2000) generic QL 100 / claim

cholecalciferol (cap 5000, chew tab 5000, tab 5000) generic MDD 2 per day

cholecalciferol cap 50000 unit generic QL 8 / 30 days

cholecalciferol tab 50000 unit generic

niacin (cap cr 250 mg, cap cr 500 mg, tab 500 mg, tab cr250 mg, tab cr 500 mg, tab cr 750 mg, tab cr 1000 mg) generic

pyridoxine hcl (tab 25 mg, tab 50 mg, tab 100 mg) generic

riboflavin (tab 25 mg, tab 50 mg, tab 100 mg) generic QL 100 / 31 days

thiamine hcl (tab 50 mg, tab 100 mg, tab 250 mg, tab 500mg) generic QL 100 / 31 days

thiamine mononitrate tab 100 mg generic QL 100 / 31 days

vitamin e (cap 100, cap 200, cap 400, chw tab 400, tab400) generic QL 62 / 31 days

MULTIVITAMINS

*multiple vitamin tab** generic MDD 1 per day

*multiple vitamins w/ iron tab** generic MDD 1 per day

*pediatric multiple vitamin w/ c & fa chew tab** generic MDD 1 per day

*pediatric multiple vitamin w/ c soln 35 mg/ml** generic QL 50 / claim

*pediatric multiple vitamins w/ iron drops 10 mg/ml** generic QL 60 / claim

*pediatric vitamins adc drops 1500 unit-400 unit-35mg/ml*** generic QL 50 / claim

*prenatal vit w/ fe fumarate-fa tab 28-0.8 mg*** generic

GL Female

AL Up to 45 yrs old

MDD 1 per day



b complex w/ c (w/ ap**, w/ tab**) generic MDD 1 per day

b-complex vitamins (cap**, sublingual liquid**, tab**) generic MDD 1 per day

KPN PRENATAL TAB 0.1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

MISSION PRENATAL FA TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

MISSION PRENATAL HP TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

MISSION PRENATAL TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

multiple vitamins w/ minerals (w/ cap**, w/ chew tab**, w/liquid**, w/ tab**) generic MDD 1 per day

NUTRICION PORVIDA 0.25 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

PERRY PRENATAL CAP 13.5-0.4 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

THERANATAL CORE NUTRITION TAB 27-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

TRI-VI-SOL/IRON SOLUTION 10 MG/ML BRAND QL 50 / claim



vitamins w/ lipotropics (w/ cap**, w/ tab**) generic MDD 1 per day

MINERALS & ELECTROLYTES

*oral electrolyte solution*** generic

calcium carbonate susp 1250 mg/5ml (500 mg/5mlelemental ca) generic QL 500 / 30 days

calcium carbonate-cholecalciferol (chew tab 500 mg-100,tab 500 mg-200) generic

calcium carbonate-cholecalciferol (tab 600 mg-800, tab600 mg-400, tab 600 mg-200) generic QL 62 / 31 days

calcium carbonate-vitamin d (cap 600 mg-200, chew tab600 mg-400, tab 600 mg-400, tab 600 mg-200) generic QL 62 / 31 days

calcium carbonate-vitamin d (tab 250 mg-125, tab 500 mg-125, tab 500 mg-200) generic

magnesium oxide (mg supplement) (cap 400 mg(elemental (mg supplement), tab 400 mg (241.3 mgelemental, tab 400 mg (240 mg elemental)

generic

oyster shell calcium tab 500 mg generic

PARVA-CAL TAB 500-200 MG-UNIT BRAND

RA CALCIUM HI-CAL/VITAMIN D TAB 500-200 MG-UNIT BRAND

zinc sulfate cap 220 mg (50 mg elemental zn) generic

NUTRIENTS

omega-3 fatty acids (cap 500, cap 1000, cap 1200, capdelayed release 1000, cap delayed release 1200) generic MDD 6 per day

POLYCOSE (, LIQUID, POWDER) BRAND MPL 1 / 30 days

HEMATOLOGICAL AGENTS

HEMATOPOIETIC AGENTS

ferrous fumarate tab 325 mg (106 mg elemental fe) generic MDD 2 per day

ferrous gluconate (tab 240 mg (27 mg elemental fe), tab324 mg (38 mg elemental iron), tab 325 mg) generic

FERROUS GLUCONATE TAB 225 (27 FE) MG BRAND



ferrous sulfate (tab 28 mg (elemental fe), tab 325 mg (65mg elemental fe), tab ec 324 mg (65 mg fe equivalent), tabec 325 mg (65 mg fe equivalent))

generic

ferrous sulfate dried tab cr 160 mg (50 mg fe equivalent) generic

ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) generic MDD 16 per day

ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) generic MDD 3.4 per day

folic acid (tab 400 mcg, tab 800 mcg) generic MDD 1 per day

folic acid tab 1 mg generic

IRON CHEWS PEDIATRIC CHEW TAB 15 MG BRAND

IRON TAB 246 (28 FE) MG BRAND

polysaccharide iron complex cap 150 mg (iron equivalent) generic MDD 1 per day

TOPICAL PRODUCTS

OPHTHALMIC AGENTS

*artificial tear ophth ointment*** generic QL 4 / claim

*artificial tear ophth solution*** generic QL 4 / claim

*white petrolatum-mineral oil ophth ointment*** generic MPL 1 / claim

hypromellose ophth soln 0.4% generic QL 15 / claim

ketotifen fumarate ophth soln 0.025% (base equiv) generic MPL 1 / claim

naphazoline w/ pheniramine ophth soln 0.025-0.3% generic MFL 1 / 30 days

naphazoline w/ pheniramine ophth soln 0.027-0.315% generic QL 15 / 30 days

polyvinyl alcohol ophth soln 1.4% generic QL 15 / claim

tetrahydrozoline hcl ophth soln 0.05% generic MPL 1 / 30 days

OTIC AGENTS

carbamide peroxide 6.5% otic soln generic QL 15 / 31 days



MOUTH/THROAT/DENTAL AGENTS

BIOTENE MOISTURIZING MOUTH SOLUTION BRAND QL 900 / claim

BIOTENE ORALBALANCE DRY MOUTH LIQUID BRAND QL 900 / claim

CVS DRY MOUTH SOLUTION BRAND QL 900 / claim

DRY MOUTH SPRAY SOLUTION BRAND QL 900 / claim

MOI-STIR SOLUTION BRAND QL 900 / claim

MOUTH KOTE SOLUTION BRAND QL 900 / claim

ORAL RELIEF SPRAY SOLUTION BRAND QL 900 / claim

RA DRY MOUTH SOLUTION BRAND QL 900 / claim

sodium fluoride rinse 0.2% generic

stannous fluoride conc 0.63% generic

zinc lozenge 15 mg generic

ANORECTAL AGENTS

dibucaine rectal ointment 1% generic QL 30 / claim

phenyleph-shark liver oil-cocoa butter suppos 0.25-3-85.5% generic QL 12 / 31 days

phenylephrine-shark liver oil-mo-pet oint 0.25-3-14-71.9% generic QL 31 / 31 days

pramoxine hcl rectal foam 1% generic QL 15 / claim

DERMATOLOGICALS

*dermatological products misc - cream** generic

*lanolin cream*** generic

*neomycin-bacitracin-polymyxin oint*** generic MPL 1 / claim

*skin protectants misc - cream*** generic

A-200 GEL 0.33-4 % BRAND

ACNE MEDICATION 5 LOTION 5 % BRAND

bacitracin oint 500 unit/gm generic C

Pkg Size 30: PackageLimit=1/claim; Pkg Size15: PackageLimit=2/claim; Pkg Size28: PackageLimit=1/claim



bacitracin zinc oint 500 unit/gm generic

QL 30 / claim

C


benzoyl peroxide (gel 5%, gel 10%, liq 5%, liq 10%, lotion10%) generic

camphor & menthol lotion 0.5-0.5% generic MPL 1 / claim

capsaicin (cream 0.075%, cream 0.1%) generic MPL 1 / claim

capsaicin cream 0.025% generic

CAPZASIN-P CREAM 0.035 % BRAND MPL 1 / claim

CASTIVA WARMING LOTION 0.035 % BRAND MPL 1 / claim

CLEAN & CLEAR ADVANTAGE 3-IN-1 LOTION 5 % BRAND

clotrimazole cream 1% generic

clotrimazole soln 1% generic MPL 1 / claim

coal tar shampoo 0.5% generic

dibucaine oint 1% generic QL 30 / claim

diphenhydramine hcl cream 2% generic

emollient (cream**, lotion**) generic

hydrocortisone (topical) (cream, lotion, soln) generic MPL 1 / claim

hydrocortisone (topical) (cream, oint) generic QL 30 / claim

hydrocortisone (topical) (gel, oint) genericQL 60 / 30 days

MPL 1 / 30 days

hydrocortisone-aloe vera cream 1% generic QL 30 / claim

KERALYT GEL 3 % BRAND QL 30 / claim

lactic acid (ammonium lactate) cream 12% generic MPL 1 / claim

lactic acid (ammonium lactate) lotion 12% generic MPL 1 / 31 days



LICIDE TREATMENT KIT BRAND

lidocaine hcl gel 2% generic QL 30 / claim

miconazole nitrate (topical) (aerosol, cream, powder) generic MPL 1 / claim

miconazole nitrate aerosol pow 2% generic

neomycin-polymyxin w/ pramoxine cream 1% generic MPL 1 / claim

NIX LICE CONTROL LIQUID 0.25 % BRAND

NIZORAL A-D SHAMPOO 1 % BRAND MPL 1 / claim

permethrin (aerosol 0.5%, creme rinse 1%) generic

permethrin lotion 1% generic MPL 1 / claim

permethrin spray & pyrethins-piperonyl butoxide shamp kit generic

POLYSPORIN POWDER 500-10000 UNIT/GM BRAND

pyreth-piperonyl butox sham-permeth aero-nit remover gelkit generic

pyrethrins-piperonyl butoxide (liq 0.3-3%, shampoo 0.33-4%) generic

pyrethrins-piperonyl butoxide liq 0.33-4% generic MPL 1 / claim

pyrithione zinc shampoo 1% generic QL 240 / claim

RID ESSENTIAL LICE ELIMINATION KIT 0.33-4 % BRAND

SCHOOLTIME SHAMPOO SHAMPOO BRAND

selenium sulfide lotion 1% generic QL 240 / claim

soap & cleansers (liquid***, lotion***) generic

terbinafine hcl cream 1% generic MPL 1 / claim

tolnaftate (aerosol, aerosol pow) genericQL 30 / claim

MPL 1 / claim

tolnaftate (cream, powder, soln) generic QL 30 / claim

zinc oxide oint 20% generic MPL 1 / claim



MISCELLANEOUS PRODUCTS

ANTISEPTICS & DISINFECTANTS

chlorhexidine gluconate liquid 4% generic

DIAGNOSTIC PRODUCTS

NOVA MAX PLUS KETONE TEST STRIP BRAND QL 30 / 30 days

PRECISION XTRA KETONE STRIP BRAND QL 30 / 30 days

PTS PANELS KETONE TEST STRIP BRAND QL 30 / 30 days

ALTERNATIVE MEDICINES

ginger (zingiber officinalis) cap 250 mg generic MDD 4 per day

melatonin (cap 3 mg, cap 5 mg, tab 3 mg, tab 5 mg, tabletdispersible 5 mg) generic MDD 1 per day

MEDICAL DEVICES AND SUPPLIES

*alcohol swabs*** generic QL 400 / claim

*respiratory therapy supplies - misc** generic QL 1 / 360 Days

AIMSCO LUBRICATED MISC BRAND QL 36 / claim

ARIAL CHAMBER DEVICE BRAND QL 2 / 360 days

ELEXA NATURAL FEEL MISC BRAND QL 36 / claim

ELEXA STIMULATING MISC BRAND QL 36 / claim

ELEXA ULTRA SENSITIVE MISC BRAND QL 36 / claim

FANTASY LUBRICATED MISC BRAND QL 36 / claim

FANTASY LUBRICATED/SPERMICIDE MISC BRAND QL 36 / claim

gauze pads & dressings (pads pads 2" 2"***, pads pads 3"3"***, pads pads 4" 4"***) generic

KAMELEON LUBRICATED MISC BRAND QL 36 / claim

KIMONO MICRO THIN MISC BRAND QL 36 / claim



KIMONO MICRO THIN PLUS MISC BRAND QL 36 / claim

KIMONO MISC BRAND QL 36 / claim

KIMONO PLUS MISC BRAND QL 36 / claim

KIMONO PS MISC BRAND QL 36 / claim

KIMONO PS PLUS MISC BRAND QL 36 / claim

KIMONO SENSATION MISC BRAND QL 36 / claim

KIMONO SENSATION PLUS MISC BRAND QL 36 / claim

MAXX MISC BRAND QL 36 / claim

MAXX PLUS MISC BRAND QL 36 / claim

NESSI SPACER WITH MASK LARGE DEVICE BRAND QL 2 / 360 days

NESSI SPACER WITH MASK SM/MED DEVICE BRAND QL 2 / 360 days

NESSI SPACER WITH MOUTHPIECE DEVICE BRAND QL 2 / 360 days

OPTICHAMBER FACE MASK-LARGE MISC BRAND QL 2 / 360 days

OPTICHAMBER FACE MASK-MEDIUM MISC BRAND QL 2 / 360 days

OPTICHAMBER FACE MASK-SMALL MISC BRAND QL 2 / 360 days

PREMIUM CONDOMS LUBRICATED MISC BRAND QL 36 / claim

REALITY LATEX/ULTRA TEXTURED DEVICE BRAND QL 36 / claim

REALITY LATEX/ULTRA THIN DEVICE BRAND QL 36 / claim

TROJAN MAGNUM WARM SENSATIONS DEVICE BRAND QL 36 / claim

TROJAN SUPRAS SPERMICIDAL DEVICE BRAND QL 36 / claim

TROJAN TWISTED PLEASURE DEVICE BRAND QL 36 / claim

TRUSTEX COLOR CONDOMS + LUBE MISC BRAND QL 36 / claim

TRUSTEX LUB/RIBBED/STUDDED MISC BRAND QL 36 / claim

TRUSTEX LUB/SPERMICIDE EX ST MISC BRAND QL 36 / claim



TRUSTEX LUB/SPERMICIDE XL MISC BRAND QL 36 / claim

TRUSTEX LUBRICATED EX LARGE MISC BRAND QL 36 / claim

TRUSTEX LUBRICATED EXTRA ST MISC BRAND QL 36 / claim

TRUSTEX LUBRICATED MISC BRAND QL 36 / claim

TRUSTEX LUBRICATED/SPERMICIDE MISC BRAND QL 36 / claim

TRUSTEX NATURAL CONDOMS + LUBE MISC BRAND QL 36 / claim

TRUSTEX NON-LUBRICATED MISC BRAND QL 36 / claim

TRUSTEX RIA LUB/SPERMICIDE MISC BRAND QL 36 / claim

TRUSTEX RIA LUBRICATED MISC BRAND QL 36 / claim

TRUSTEX RIA NON-LUBRICATED MISC BRAND QL 36 / claim

TRUSTEX-NONOXYNOL-9/RIB/STUD MISC BRAND QL 36 / claim

PHARMACEUTICAL ADJUVANTS

lanolin generic

polyethylene glycol 3350 powder generic MDD 34 per day

SIMPLYTHICK GEL BRANDQL 1816 / claim


sorbitol solution (bulk) generic


LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS

ANTI-INFECTIVE AGENTS

PENICILLINS

amoxicillin & k clavulanate for susp 400-57 mg/5ml generic C


amoxicillin & k clavulanate for susp 600-42.9 mg/5ml generic MPL 2 / claim

amoxicillin & k clavulanate tab 250-125 mg generic QL 30 / claim

amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg generic QL 40 / 30 days

amoxicillin & pot clavulanate (chew tab 200-28.5 mg, chewtab 400-57 mg, tab 500-125 mg, tab 875-125 mg) generic QL 20 / claim

amoxicillin & pot clavulanate (susp 200-28.5 mg/5ml, susp250-62.5 mg/5ml) generic MPL 1 / claim

amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg,chew tab 250 mg, for susp 125 mg/5ml, for susp 200mg/5ml, for susp 250 mg/5ml, for susp 400 mg/5ml, tab875 mg)

generic

ampicillin (cap 250 mg, cap 500 mg) generic

AMPICILLIN (RECON SUSP 125 MG/5ML, RECON SUSP250 MG/5ML) BRAND

dicloxacillin sodium (cap 250 mg, cap 500 mg) generic

penicillin v potassium (for soln 125 mg/5ml, for soln 250mg/5ml, tab 250 mg, tab 500 mg) generic

CEPHALOSPORINS

cefaclor (cap 250 mg, cap 500 mg) generic

CEFACLOR (RECON SUSP 125 MG/5ML, RECON SUSP250 MG/5ML, RECON SUSP 375 MG/5ML) BRAND

cefadroxil (cap 500 mg, for susp 250 mg/5ml, for susp 500mg/5ml, tab 1 gm) generic



cefdinir (susp 125 mg/5ml, susp 250 mg/5ml) generic MPL 1 / claim

cefdinir cap 300 mg generic QL 20 / claim

cefprozil (tab 250 mg, tab 500 mg) generic QL 20 / claim

cefprozil for susp 125 mg/5ml genericAL Up to 12 yrs old

MPL 2 / claim

cefprozil for susp 250 mg/5ml genericAL Up to 12 yrs old

MPL 1 / claim

CEFTIN RECON SUSP 250 MG/5ML BRAND

QL 100 / claim

ST

AL Up to 12 yrs old

ceftriaxone sodium (inj 1 gm, inj 250 mg, inj 500 mg, iv soln1 gm) generic

QL 3 / claim

MFL 1 / 30 days

cefuroxime axetil (tab 250 mg, tab 500 mg) generic QL 20 / claim

cefuroxime axetil for susp 125 mg/5ml generic

QL 100 / claim

ST

AL Up to 12 yrs old

cephalexin (cap 250 mg, cap 500 mg, for susp 125mg/5ml, for susp 250 mg/5ml) generic

MACROLIDES

azithromycin (iv for soln 500 mg, tab 500 mg) generic MDD 4 per day

azithromycin for susp 100 mg/5ml generic QL 15 / claim

azithromycin for susp 200 mg/5ml generic C

Pkg Size 15: PackageLimit=1/claim; Pkg Size30: PackageLimit=2/claim; Pkg Size22.5: PackageLimit=2/claim

azithromycin tab 250 mg generic QL 6 / claim

azithromycin tab 600 mg generic QL 8 / 28 days



clarithromycin (tab 250 mg, tab 500 mg) generic QL 28 / claim

clarithromycin for susp 125 mg/5ml generic MPL 1 / claim

clarithromycin for susp 250 mg/5ml generic CPkg Size 50: PackageLimit=1/claim; Pkg Size100: PackageLimit=2/claim

clarithromycin tab sr 24hr 500 mg generic QL 14 / claim

E.E.S. GRANULES RECON SUSP 200 MG/5ML BRAND QL 6 / claim

ERY-TAB (TAB DR 250 MG, TAB DR 333 MG, TAB DR500 MG) BRAND

ERYPED 200 RECON SUSP 200 MG/5ML BRAND QL 6 / claim

ERYPED 400 RECON SUSP 400 MG/5ML BRAND MDD 4 per day

ERYTHROCIN STEARATE TAB 250 MG BRAND

erythromycin w/ delayed release particles cap 250 mg generic

PCE (TAB DR 333 MG, TAB DR 500 MG) BRAND

TETRACYCLINES

doxycycline hyclate (cap 50 mg, cap 100 mg, for inj 100mg, tab 100 mg, tab delayed release 100 mg) generic

minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg) generic

FLUOROQUINOLONES

ciprofloxacin hcl (tab 250 mg, tab 500 mg, tab 750 mg) generic

ciprofloxacin hcl tab 100 mg (base equiv) generic QL 6 / claim

levofloxacin (tab 250 mg, tab 500 mg, tab 750 mg) genericQL 14 / claim

MDD 1 per day

ofloxacin (tab 200 mg, tab 300 mg, tab 400 mg) generic QL 56 / claim

AMINOGLYCOSIDES

neomycin sulfate tab 500 mg generic

tobramycin nebu soln 300 mg/5ml generic PA



tobramycin sulfate (for inj 1.2 gm, inj 1.2 gm/30ml (40mg/ml), inj 2 gm/50ml (40 mg/ml), inj 10 mg/ml, inj 80mg/2ml (40 mg/ml))

generic PA

TOBRAMYCIN SULFATE IN SALINE SOLUTION 1.2-0.9MG/ML-% BRAND PA

ANTIMYCOBACTERIAL AGENTS

ethambutol hcl (tab 100 mg, tab 400 mg) generic

isoniazid (tab 100 mg, tab 300 mg) generic

ISONIAZID SYRUP 50 MG/5ML BRAND

pyrazinamide tab 500 mg generic

rifampin (cap 150 mg, cap 300 mg) generic

TRECATOR TAB 250 MG BRAND

ANTIFUNGALS

fluconazole (susp 10 mg/ml, susp 40 mg/ml) generic QL 70 / claim

fluconazole tab 100 mg generic MDD 1 per day

fluconazole tab 150 mg generic QL 2 / claim

fluconazole tab 200 mg generic MDD 2 per day

fluconazole tab 50 mg generic QL 7 / claim

griseofulvin microsize (susp 125 mg/5ml, tab 500 mg) generic

griseofulvin ultramicrosize (tab 125 mg, tab 250 mg) generic

itraconazole cap 100 mg genericPA

MDD 1 per day

nystatin tab 500000 unit generic MDD 6 per day

terbinafine hcl tab 250 mg genericQL 90 / 120 days

MDD 1 per day

ANTIVIRALS

abacavir sulfate tab 300 mg (base equiv) generic MDD 2 per day



abacavir sulfate-lamivudine-zidovudine tab 300-150-300mg generic MDD 2 per day

acyclovir (cap 200 mg, tab 800 mg) generic QL 50 / 30 days

acyclovir susp 200 mg/5ml generic QL 400 / 30 days

acyclovir tab 400 mg generic MDD 2 per day

APTIVUS CAP 250 MG BRAND MDD 4 per day

APTIVUS SOLUTION 100 MG/ML BRAND MDD 10 per day

ATRIPLA TAB 600-200-300 MG BRAND MDD 1 per day

COMPLERA TAB 200-25-300 MG BRAND MDD 1 per day

CRIXIVAN CAP 200 MG BRAND MDD 9 per day

CRIXIVAN CAP 400 MG BRAND MDD 6 per day

didanosine (capsule 125 mg, capsule 200 mg, capsule 250mg, capsule 400 mg) generic MDD 1 per day

EDURANT TAB 25 MG BRAND MDD 1 per day

EMTRIVA CAP 200 MG BRAND MDD 1 per day

EMTRIVA SOLUTION 10 MG/ML BRAND MDD 24 per day

EPZICOM TAB 600-300 MG BRAND MDD 1 per day

HARVONI TAB 90-400 MG BRAND PA

INTELENCE (TAB 25 MG, TAB 100 MG) BRAND MDD 4 per day

INTELENCE TAB 200 MG BRAND MDD 2 per day

INVIRASE CAP 200 MG BRAND MDD 10 per day

INVIRASE TAB 500 MG BRAND MDD 4 per day

ISENTRESS TAB 400 MG BRAND MDD 2 per day

KALETRA SOLUTION 400-100 MG/5ML BRAND QL 320 / 32 days

KALETRA TAB 100-25 MG BRAND MDD 4 per day



KALETRA TAB 200-50 MG BRAND MDD 6 per day

lamivudine oral soln 10 mg/ml generic MDD 30 per day

lamivudine tab 150 mg generic MDD 2 per day

lamivudine tab 300 mg generic MDD 1 per day

lamivudine-zidovudine tab 150-300 mg generic MDD 2 per day

LEXIVA SUSPENSION 50 MG/ML BRAND MDD 56 per day

LEXIVA TAB 700 MG BRAND MDD 4 per day

nevirapine susp 50 mg/5ml generic MDD 40 per day

nevirapine tab 200 mg generic MDD 2 per day

nevirapine tab sr 24hr 400 mg generic MDD 1 per day

NORVIR (CAP 100 MG, TAB 100 MG) BRAND MDD 12 per day

NORVIR SOLUTION 80 MG/ML BRAND MDD 15 per day

PREZISTA (TAB 75 MG, TAB 400 MG, TAB 600 MG) BRAND MDD 2 per day

PREZISTA TAB 150 MG BRAND MDD 3 per day

PREZISTA TAB 800 MG BRAND MDD 1 per day

RELENZA DISKHALER AER POW BA 5 MG/BLISTER BRANDAL At least 5 yrs old

MPL 1 / 30 days

RESCRIPTOR TAB 100 MG BRAND MDD 12 per day

RESCRIPTOR TAB 200 MG BRAND MDD 6 per day

REYATAZ (CAP 100 MG, CAP 150 MG, CAP 200 MG,CAP 300 MG) BRAND MDD 2 per day

SELZENTRY TAB 150 MG BRAND MDD 2 per day

SELZENTRY TAB 300 MG BRAND MDD 4 per day

SOVALDI TAB 400 MG BRAND PA

stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap 40 mg) generic MDD 2 per day



stavudine for oral soln 1 mg/ml generic MDD 80 per day

STRIBILD TAB 150-150-200-300 MG BRAND MDD 1 per day

SUSTIVA (CAP 200 MG, TAB 600 MG) BRAND MDD 1 per day

SUSTIVA CAP 50 MG BRAND MDD 2 per day

TAMIFLU (CAP 45 MG, CAP 75 MG) BRANDQL 10 / 30 days

MFL 1 / 80 days

TAMIFLU CAP 30 MG BRANDQL 20 / 30 days

MFL 1 / 80 days

TAMIFLU RECON SUSP 6 MG/ML BRANDQL 120 / 30 days

MFL 1 / 80 days

TRUVADA TAB 200-300 MG BRAND MDD 1 per day

valacyclovir hcl tab 1 gm generic QL 21 / 21 Days

valacyclovir hcl tab 500 mg generic QL 42 / 21 days

valganciclovir hcl tab 450 mg generic MDD 2 per day

VIDEX (RECON SOLN 2 GM, RECON SOLN 4 GM) BRAND MDD 20 per day

VIRACEPT TAB 250 MG BRAND MDD 9 per day

VIRACEPT TAB 625 MG BRAND MDD 4 per day

VIREAD (TAB 150 MG, TAB 200 MG, TAB 250 MG, TAB300 MG) BRAND MDD 1 per day

VIREAD POWDER 40 MG/GM BRAND QL 240 / 30 days

ZIAGEN SOLUTION 20 MG/ML BRAND MDD 30 per day

zidovudine cap 100 mg generic MDD 6 per day

zidovudine syrup 10 mg/ml generic MDD 60 per day

zidovudine tab 300 mg generic MDD 2 per day



ANTIMALARIALS

chloroquine phosphate tab 250 mg generic QL 60 / 30 days

chloroquine phosphate tab 500 mg generic QL 8 / 56 days

COARTEM TAB 20-120 MG BRAND QL 24 / claim

hydroxychloroquine sulfate tab 200 mg generic

mefloquine hcl tab 250 mg generic

primaquine phosphate tab 26.3 mg (15 mg base) generic

ANTI-INFECTIVE AGENTS - MISC.

clindamycin hcl (cap 150 mg, cap 300 mg) generic

clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) generic QL 300 / claim

dapsone (tab 25 mg, tab 100 mg) generic

erythromycin-sulfisoxazole for susp 200-600 mg/5ml generic

FIRST-VANCOMYCIN 25 SOLUTION 25 MG/ML BRAND

FIRST-VANCOMYCIN 50 SOLUTION 50 MG/ML BRAND

metronidazole (tab 250 mg, tab 500 mg) generic

SIVEXTRO TAB 200 MG BRANDQL 6 / claim

PA

sulfamethoxazole-trimethoprim (susp 200-40 mg/5ml, tab400-80 mg, tab 800-160 mg) generic

trimethoprim tab 100 mg generic

vancomycin hcl for inj 1000 mg generic QL 14 / claim

vancomycin hcl for inj 500 mg generic QL 14 / 30 days

BIOLOGICALS

PASSIVE IMMUNIZING AGENTS

HYPERRHO S/D SOLN PRSYR 1500 UNIT BRAND

RHOGAM ULTRA-FILTERED PLUS SOLN PRSYR 1500UNIT BRAND



ANTINEOPLASTIC AGENTS

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

ALKERAN TAB 2 MG BRAND

anastrozole tab 1 mg generic

bicalutamide tab 50 mg generic MDD 1 per day

cyclophosphamide (cap 25 mg, cap 50 mg, tab 25 mg, tab50 mg) generic

exemestane tab 25 mg generic ST

FARESTON TAB 60 MG BRAND

flutamide cap 125 mg generic

hydroxyurea cap 500 mg generic

letrozole tab 2.5 mg generic ST

leucovorin calcium (tab 5 mg, tab 10 mg, tab 15 mg, tab 25mg) generic

LEUKERAN TAB 2 MG BRAND

megestrol acetate (susp 40 mg/ml, tab 20 mg, tab 40 mg) generic

mercaptopurine tab 50 mg generic

methotrexate sodium (inj 25 mg/ml, inj pf 25 mg/ml, tab 2.5mg (base equiv)) generic

MYLERAN TAB 2 MG BRAND

PURIXAN 20 MG/ML ORAL SUSP BRAND AL Up to 8 yrs old

tamoxifen citrate (tab 10 mg, tab 20 mg) generic

temozolomide (cap 180 mg, cap 250 mg) generic MDD 2 per day

TREXALL (TAB 5 MG, TAB 7.5 MG, TAB 10 MG, TAB 15MG) BRAND

ENDOCRINE AND METABOLIC DRUGS

CORTICOSTEROIDS

cortisone acetate tab 25 mg generic



dexamethasone (elixir 0.5 mg/5ml, soln 0.5 mg/5ml, tab 0.5mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg, tab 2 mg, tab 4 mg,tab 6 mg)

generic

DEXAMETHASONE INTENSOL CONC 1 MG/ML BRAND

dexamethasone sodium phosphate (inj 4 mg/ml, inj 20mg/5ml, inj 120 mg/30ml) generic QL 150 / 30 days

fludrocortisone acetate tab 0.1 mg generic

hydrocortisone (tab 5 mg, tab 10 mg, tab 20 mg) generic

methylprednisolone (tab 4 mg, tab 4 mg dose pack, tab 8mg) generic

MILLIPRED TAB 5 MG BRAND

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5mlbase) generic

prednisolone sod phosphate oral soln 15 mg/5ml (baseequiv) generic QL 240 / claim

prednisolone syrup 15 mg/5ml (usp solution equivalent) generic

prednisone (oral soln 5 mg/5ml, tab 1 mg, tab 2.5 mg, tab 5mg, tab 5 mg dose pack, tab 10 mg, tab 10 mg dose pack,tab 20 mg, tab 50 mg)

generic

PREDNISONE INTENSOL CONC 5 MG/ML BRAND

VERIPRED 20 SOLUTION 20 MG/5ML BRAND QL 150 / claim

ANDROGENS-ANABOLIC

ANDRODERM (PATCH 24HR 4 MG/24HR, PATCH 24HR2 MG/24HR) BRAND MDD 1 per day

ANDROXY TAB 10 MG BRAND

METHITEST TAB 10 MG BRAND

testosterone cypionate im inj in oil 200 mg/ml generic QL 4 / 30 days

ESTROGENS

ALORA (PATCH TW 0.025 MG/24HR, PATCH TW 0.05MG/24HR, PATCH TW 0.075 MG/24HR, PATCH TW 0.1MG/24HR)

BRAND MDD 0.29 per day

COMBIPATCH (PATCH TW 0.05-0.14 MG/DAY, PATCHTW 0.05-0.25 MG/DAY) BRAND

QL 8 / 28 days

GL Female



esterified estrogens & methyltestosterone (tab 0.625-1.25mg, tab 1.25-2.5 mg) generic MDD 1 per day

ESTRADERM (PATCH TW 0.05 MG/24HR, PATCH TW0.1 MG/24HR) BRAND MDD 0.29 per day

estradiol & norethindrone acetate (tab 0.5-0.1 mg, tab 1-0.5 mg) generic MDD 1 per day

estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr(37.5 mcg/24hr), patch 0.05 mg/24hr, patch 0.06 mg/24hr,patch 0.075 mg/24hr, patch 0.1 mg/24hr)

genericQL 4 / 28 days

GL Female

estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg) generic GL Female

estropipate (tab 0.75 mg, tab 1.5 mg) genericGL Female

MDD 1 per day

estropipate tab 3 mg genericGL Female

MDD 2 per day

MINIVELLE (PATCH TW 0.0375 MG/24HR, PATCH TW0.05 MG/24HR, PATCH TW 0.075 MG/24HR, PATCH TW0.1 MG/24HR)

BRAND MDD 0.29 per day

PREMARIN (TAB 0.3 MG, TAB 0.45 MG, TAB 0.625 MG,TAB 0.9 MG, TAB 1.25 MG) BRAND

GL Female

MDD 1 per day

PREMPHASE TAB 0.625-5 MG BRANDQL 28 / 28 days

GL Female

PREMPRO (TAB 0.3-1.5 MG, TAB 0.45-1.5 MG, TAB0.625-5 MG, TAB 0.625-2.5 MG) BRAND

GL Female

MDD 1 per day

CONTRACEPTIVES

DEPO-SUBQ PROVERA 104 SUSPENSION 104MG/0.65ML BRAND

QL 1 / claim

GL Female

desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg generic

GL Female

MDD 1 per day

DESOGESTREL-ETHINYL ESTRADIOL TAB 0.15-0.02/0.01 MG (AZURETTE, KARIVA, PIMTREA,VIORELE, CAZIANT, CESIA, VELIVET)

BRANDGL Female

MDD 1 per day



DESOGESTREL-ETHINYL ESTRADIOL TAB 0.15-30 MG-MCG (APRI, EMOQUETTE, ENSKYCE, RECLIPSEN,SOLIA)

BRANDGL Female

MDD 1 per day

drospirenone-ethinyl estradiol tab 3-0.03 mg genericGL Female

MDD 1 per day

DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG(GIANVI, LORYNA, NIKKI, VESTURA, OCELLA, SYEDA,ZARAH)

BRAND GL Female

ELLA TAB 30 MG BRAND QL 4 / 365 days

ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB1 MG-35 MCG (KELNOR, ZOVIA) BRAND

GL Female

MDD 1 per day

LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH ESTTAB 0.01MG(7) (AMETHIA, CAMRESE, DAYSEE) BRAND

GL Female

MDD 1 per day

LEVONORGEST-ETH ESTRAD 91-DAY TAB 0.15-0.03MG (INTROVALE, JOLESSA, QUASENSE) BRAND

QL 91 / claim

GL Female

levonorgestrel tab 0.75 mg genericGL Female

MFL 4 / 365 days

LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG (ENPRESSE, LEVONEST, MYZILRA,TRIVORA)

BRANDGL Female

MDD 1 per day

LEVONORGESTREL-ETHINYL ESTRAD TAB 0.1-20 MG(AUBRA, AVIANE, DELYLA, FALMINA, LESSINA,LUTERA, ORSYTHIA, SRONYX)

BRANDGL Female

MDD 1 per day

LEVONORGESTREL-ETHINYL ESTRAD TAB 0.15-30 MG(ALTAVERA, CHATEAL, KURVELO, LEVORA,MARLISSA, PORTIA)

BRANDGL Female

MDD 1 per day

medroxyprogesterone acetate im susp 150 mg/ml genericQL 1 / claim

GL Female

NECON 1/50 (28) TAB 1-50 MG-MCG BRANDGL Female

MDD 1 per day

NECON 10/11 (28) TAB 35 MCG BRANDGL Female

MDD 1 per day



NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK150-35 MCG/24HR (XULANE) BRAND

QL 3 / claim

GL Female

NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4MG-35 MCG (BALZIVA, BRIELLYN, GILDAGIA, PHILITH,VYFEMLA, ZENCHENT)

BRANDGL Female

MDD 1 per day

NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5MG-35 MCG (NECON, NORTREL, WERA) BRAND

GL Female

MDD 1 per day

NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG (ALYACEN, CYCLAFEM, DASETTA, NECON,NORTREL, PIRMELLA)

BRANDGL Female

MDD 2 per day

NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1MG-20 MCG (GILDESS, JUNEL, LARIN, MICROGESTIN) BRAND

GL Female

MDD 1 per day

NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,MICROGESTIN)

BRANDGL Female

MDD 1 per day

NORETHINDRONE ACE & ETHINYL ESTRADIOL-FETAB 1 MG-20 MCG (GILDESS, JUNEL, LARIN,MICROGESTIN)

BRANDGL Female

MDD 1 per day

NORETHINDRONE ACE & ETHINYL ESTRADIOL-FETAB 1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,MICROGESTIN)

BRANDGL Female

MDD 1 per day

NORETHINDRONE TAB 0.35 MG (CAMILA, DEBLITANE,ERRIN, HEATHER, JENCYCLA, JOLIVETTE, LYZA,NORA-BE, NORLYROC, SHAROBEL)

BRANDGL Female

MDD 1 per day

NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG (ALYACEN, CYCLAFEM, DASETTA, NECON,NORTREL, PIRMELLA)

BRANDGL Female

MDD 1 per day

NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG (ARANELLE, LEENA) BRAND

GL Female

MDD 1 per day

NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG (ESTARYLLA, MONO-LINYAH, MONONESSA,PREVIFEM, SPRINTEC)

BRANDGL Female

MDD 1 per day

NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG (TRI-ESTARYLLA, TRI-LINYAH, TRI-PREVIFEM, TRI-SPRINTEC, TRINESSA)

BRANDGL Female

MDD 1 per day

NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30MCG (CRYSELLE, ELINEST, LOW-OGESTREL) BRAND

GL Female

MDD 2 per day



NORINYL 1+50 (28) TAB 1-50 MG-MCG BRANDGL Female

MDD 1 per day

NUVARING RING 0.12-0.015 MG/24HR BRANDQL 1 / claim

GL Female

OGESTREL TAB 0.5-50 MG-MCG BRANDGL Female

MDD 1 per day

ZOVIA 1/50E (28) TAB 1-50 MG-MCG BRANDGL Female

MDD 1 per day

PROGESTINS

medroxyprogesterone acetate (tab 2.5 mg, tab 5 mg, tab10 mg) generic

norethindrone acetate tab 5 mg generic

progesterone micronized cap 100 mg generic QL 30 / 30 days

progesterone micronized cap 200 mg generic QL 20 / 30 days

ANTIDIABETICS

APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML BRAND QL 30 / 30 days

APIDRA SOLUTION 100 UNIT/ML BRAND QL 40 / 30 days

AVANDAMET (TAB 2-1000 MG, TAB 2-500 MG, TAB 4-500 MG, TAB 4-1000 MG) BRAND MDD 2 per day

AVANDARYL (TAB 4-4 MG, TAB 4-2 MG, TAB 4-1 MG,TAB 8-4 MG, TAB 8-2 MG) BRAND MDD 1 per day

AVANDIA (TAB 2 MG, TAB 4 MG, TAB 8 MG) BRAND MDD 1 per day

BYDUREON PEN 2 MG BRAND

QL 4 / 28 days

ST


BYDUREON RECON SUSP 2 MG BRAND

QL 4 / 28 days

PA




BYETTA 10 MCG PEN SOLN PEN 10 MCG/0.04ML BRAND

QL 2.4 / 30 days

ST


BYETTA 5 MCG PEN SOLN PEN 5 MCG/0.02ML BRAND

QL 1.2 / 30 days

ST


glimepiride (tab 1 mg, tab 2 mg) generic MDD 1 per day

glimepiride tab 4 mg generic MDD 2 per day

glipizide (tab 5 mg, tab 10 mg, tab sr 24hr 2.5 mg, tab sr24hr 5 mg, tab sr 24hr 10 mg) generic

glipizide-metformin hcl (tab 2.5-500 mg, tab 2.5-250 mg,tab 5-500 mg) generic

GLUCAGEN HYPOKIT RECON SOLN 1 MG BRAND

GLUCAGON EMERGENCY KIT 1 MG BRAND QL 1 / claim

glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg) generic

glyburide micronized (tab 1.5 mg, tab 3 mg, tab 6 mg) generic

glyburide-metformin (tab 1.25-250 mg, tab 2.5-500 mg, tab5-500 mg) generic

HUMALOG KWIKPEN SOLN PEN 100 UNIT/ML BRAND QL 30 / 30 days

HUMALOG MIX 50/50 KWIKPEN SUSP PEN (50-50) 100UNIT/ML BRAND QL 30 / 30 days

HUMALOG MIX 50/50 PEN SUSP PEN (50-50) 100UNIT/ML BRAND QL 30 / 30 days

HUMALOG MIX 50/50 SUSPENSION (50-50) 100UNIT/ML BRAND QL 40 / 30 days

HUMALOG MIX 75/25 KWIKPEN SUSP PEN (75-25) 100UNIT/ML BRAND QL 30 / 30 days

HUMALOG MIX 75/25 PEN SUSP PEN (75-25) 100UNIT/ML BRAND QL 30 / 30 days

HUMALOG MIX 75/25 SUSPENSION (75-25) 100UNIT/ML BRAND QL 40 / 30 days

HUMALOG PEN SOLN PEN 100 UNIT/ML BRAND QL 30 / 30 days



HUMALOG SOLN CART 100 UNIT/ML BRAND QL 30 / 30 days

HUMALOG SOLUTION 100 UNIT/ML BRAND QL 40 / 30 days

HUMULIN 70/30 SUSPENSION (70-30) 100 UNIT/ML BRAND QL 40 / 30 days

HUMULIN N KWIKPEN SUSP PEN 100 UNIT/ML BRAND QL 30 / 30 days

HUMULIN N PEN SUSP PEN 100 UNIT/ML BRAND QL 30 / 30 days

HUMULIN N SUSPENSION 100 UNIT/ML BRAND QL 40 / 30 days

HUMULIN R SOLUTION 100 UNIT/ML BRAND QL 40 / 30 days

JENTADUETO (TAB 2.5-1000 MG, TAB 2.5-850 MG, TAB2.5-500 MG) BRAND


MDD 2 per day

KOMBIGLYZE XR (TAB ER 24H 5-500 MG, TAB ER 24H5-1000 MG) BRAND


MDD 1 per day

KOMBIGLYZE XR TAB ER 24H 2.5-1000 MG BRANDAL At least 8 yrs old

MDD 2 per day

LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML BRAND QL 30 / 30 days

LANTUS SOLUTION 100 UNIT/ML BRAND QL 30 / 30 days

LEVEMIR FLEXPEN SOLN PEN 100 UNIT/ML BRAND QL 30 / 30 days

LEVEMIR FLEXTOUCH SOLN PEN 100 UNIT/ML BRAND QL 30 / 30 days

LEVEMIR SOLUTION 100 UNIT/ML BRAND QL 30 / 30 days

metformin hcl (tab 1000 mg, tab sr 24hr 750 mg) generic MDD 2 per day

metformin hcl tab 500 mg generic MDD 5 per day

metformin hcl tab 850 mg generic MDD 3 per day

metformin hcl tab sr 24hr 500 mg generic MDD 4 per day

nateglinide (tab 60 mg, tab 120 mg) generic MDD 3 per day

NOVOLIN 70/30 RELION SUSPENSION (70-30) 100UNIT/ML BRAND QL 40 / 30 days

NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML BRAND QL 40 / 30 days



NOVOLIN N RELION SUSPENSION 100 UNIT/ML BRAND QL 40 / 30 days

NOVOLIN N SUSPENSION 100 UNIT/ML BRAND QL 40 / 30 days

NOVOLIN R RELION SOLUTION 100 UNIT/ML BRAND QL 40 / 30 days

NOVOLIN R SOLUTION 100 UNIT/ML BRAND QL 40 / 30 days

NOVOLOG FLEXPEN SOLN PEN 100 UNIT/ML BRAND QL 30 / 30 days

NOVOLOG MIX 70/30 FLEXPEN SUSP PEN (70-30) 100UNIT/ML BRAND QL 30 / 30 days

NOVOLOG MIX 70/30 SUSPENSION (70-30) 100UNIT/ML BRAND QL 40 / 30 days

NOVOLOG PENFILL SOLN CART 100 UNIT/ML BRAND QL 30 / 30 days

NOVOLOG SOLUTION 100 UNIT/ML BRAND QL 40 / 30 days

ONGLYZA TAB 2.5 MG BRANDAL At least 8 yrs old

MDD 2 per day

ONGLYZA TAB 5 MG BRANDAL At least 8 yrs old

MDD 3 per day

pioglitazone hcl (tab 15 mg, tab 30 mg, tab 45 mg) generic MDD 1 per day

pioglitazone hcl-metformin hcl (-metformin tab 15-500 mg, -metformin tab 15-850 mg) generic MDD 2 per day

RELION 70/30 SUSPENSION (70-30) 100 UNIT/ML BRAND QL 40 / 30 days

RELION N SUSPENSION 100 UNIT/ML BRAND QL 40 / 30 days

RELION R SOLUTION 100 UNIT/ML BRAND QL 40 / 30 days

SYMLINPEN 120 SOLN PEN 2700 MCG/2.7ML BRANDQL 10.8 / 30 days

PA

SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML BRANDQL 6 / 30 days

PA

TRADJENTA TAB 5 MG BRANDAL At least 8 yrs old

MDD 1 per day



THYROID AGENTS

ARMOUR THYROID (TAB 15 MG, TAB 120 MG, TAB 180MG, TAB 240 MG, TAB 300 MG) BRAND

levothyroxine sodium (tab 25 mcg, tab 50 mcg, tab 75 mcg,tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300mcg)

generic

liothyronine sodium (tab 5 mcg, tab 25 mcg, tab 50 mcg) generic

methimazole (tab 5 mg, tab 10 mg) generic

NATURE-THROID (TAB 32.5 MG, TAB 130 MG, TAB 195MG) BRAND

propylthiouracil tab 50 mg generic

thyroid (tab 30 mg (1/2, tab 60 mg (1, tab 90 mg (1 1/2) generic

THYROLAR-1 TAB 60 (12.5-50) MG (MCG) BRAND

THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG) BRAND

THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG) BRAND

THYROLAR-2 TAB 120 (25-100) MG (MCG) BRAND

THYROLAR-3 TAB 180 (37.5-150) MG (MCG) BRAND

WESTHROID (TAB 32.5 MG, TAB 130 MG, TAB 195 MG) BRAND

WESTHROID-P (TAB 32.5 MG, TAB 130 MG) BRAND

WP THYROID (TAB 32.5 MG, TAB 130 MG) BRAND

OXYTOCICS

methylergonovine maleate tab 0.2 mg generic

ENDOCRINE AND METABOLIC AGENTS - MISC.

alendronate sodium (tab 35 mg, tab 70 mg) generic MDD 0.15 per day

alendronate sodium (tab 5 mg, tab 10 mg, tab 40 mg) generic MDD 1 per day

alendronate sodium oral soln 70 mg/75ml generic MDD 10.8 per day

calcitonin (salmon) nasal soln 200 unit/act generic QL 4 / 30 days

calcitriol (cap 0.25 mcg, cap 0.5 mcg) generic



desmopressin acetate (tab 0.1 mg, tab 0.2 mg) generic MDD 3 per day

desmopressin acetate nasal soln 0.01% (refrigerated) genericQL 5 / claim

PA

desmopressin acetate nasal spray soln 0.01% genericQL 5 / claim

PA

desmopressin acetate nasal spray soln 0.01%(refrigerated) generic

QL 5 / claim

PA

levocarnitine oral soln 1 gm/10ml (10%) generic MDD 30 per day

levocarnitine tab 330 mg generic MDD 3 per day

MIACALCIN SOLUTION 200 UNIT/ML BRAND QL 2 / 30 days

NORDITROPIN (SOLUTION 5 MG/1.5ML, SOLUTION 15MG/1.5ML) BRAND PA

NORDITROPIN FLEXPRO (SOLUTION 5 MG/1.5ML,SOLUTION 10 MG/1.5ML, SOLUTION 15 MG/1.5ML) BRAND PA

NORDITROPIN NORDIFLEX PEN (PEN SOLUTION 5MG/1.5ML, PEN SOLUTION 10 MG/1.5ML, PENSOLUTION 15 MG/1.5ML, PEN SOLUTION 30 MG/3ML)

BRAND PA

raloxifene hcl tab 60 mg generic MDD 1 per day

risedronate sodium (tab 5 mg, tab 30 mg) genericPA

MDD 1 per day

risedronate sodium tab 35 mg genericQL 4 / 28 days

PA

CARDIOVASCULAR AGENTS

CARDIOTONICS

digoxin (oral soln 0.05 mg/ml, tab 125 mcg (0.125 mg), tab250 mcg (0.25 mg)) generic



ANTIANGINAL AGENTS

isosorbide dinitrate (sl tab 2.5 mg, sl tab 5 mg, tab 5 mg,tab 10 mg, tab 20 mg, tab 30 mg, tab cr 40 mg) generic

isosorbide mononitrate (tab 10 mg, tab 20 mg) generic MDD 2 per day

isosorbide mononitrate (tab 24hr 120 mg, tab 24hr 60 mg,tab 24hr 30 mg) generic MDD 1 per day

NITRO-BID OINTMENT 2 % BRAND

nitroglycerin (cap cr 2.5 mg, cap cr 6.5 mg, cap cr 9 mg, tdpatch 24hr 0.4 mg/hr, td patch 24hr 0.2 mg/hr, td patch24hr 0.1 mg/hr, td patch 24hr 0.6 mg/hr)

generic

BETA BLOCKERS

acebutolol hcl (cap 200 mg, cap 400 mg) generic

atenolol (tab 25 mg, tab 50 mg, tab 100 mg) generic MDD 2 per day

bisoprolol fumarate (tab 5 mg, tab 10 mg) generic MDD 1 per day

carvedilol (tab 3.125 mg, tab 6.25 mg, tab 12.5 mg) generic MDD 3 per day

carvedilol tab 25 mg generic MDD 4 per day

COREG CR (CAP ER 24H 20 MG, CAP ER 24H 40 MG,CAP ER 24H 10 MG, CAP ER 24H 80 MG) BRAND MDD 1 per day

HEMANGEOL SOLUTION 4.28 MG/ML BRAND PA

labetalol hcl tab 100 mg generic MDD 3 per day



metoprolol succinate (tab 24hr 100 mg, tab 24hr 50 mg,tab 24hr 25 mg) generic MDD 1 per day

metoprolol succinate tab sr 24hr 200 mg generic MDD 2 per day

metoprolol tartrate (tab 25 mg, tab 100 mg) generic MDD 2 per day

metoprolol tartrate tab 50 mg generic MDD 3 per day

nadolol (tab 20 mg, tab 40 mg, tab 80 mg) generic MDD 2 per day



pindolol (tab 5 mg, tab 10 mg) generic

propranolol hcl (cap 24hr 80 mg, cap 24hr 60 mg, cap 24hr120 mg, cap 24hr 160 mg) generic MDD 2 per day

propranolol hcl (oral soln 20 mg/5ml, oral soln 40 mg/5ml,tab 10 mg, tab 20 mg, tab 40 mg, tab 60 mg, tab 80 mg) generic

sotalol hcl (afib/afl) ((afib/afl) tab 80 mg, (afib/afl) tab 120mg, (afib/afl) tab 160 mg) generic MDD 2 per day

sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg) generic MDD 2 per day

sotalol hcl tab 240 mg generic

timolol maleate (tab 5 mg, tab 10 mg, tab 20 mg) generic

CALCIUM CHANNEL BLOCKERS

amlodipine besylate (tab 2.5 mg, tab 5 mg, tab 10 mg) generic MDD 1 per day

diltiazem hcl (cap 12hr 90 mg, cap 12hr 120 mg, cap 12hr60 mg, cap 24hr 240 mg) generic MDD 2 per day

diltiazem hcl (cap 24hr 120 mg, cap 24hr 180 mg) generic MDD 1 per day

diltiazem hcl (tab 30 mg, tab 60 mg, tab 90 mg, tab 120mg) generic MDD 3 per day

diltiazem hcl coated beads (beads cap 24hr 240 mg, beadstab 24hr 240 mg) generic MDD 2 per day

diltiazem hcl coated beads (beads cap 24hr 300 mg, beadscap 24hr 180 mg, beads cap 24hr 120 mg, beads tab 24hr300 mg, beads tab 24hr 180 mg)

generic MDD 1 per day

diltiazem hcl extended release beads (beads cap 24hr 360mg, beads cap 24hr 180 mg, beads cap 24hr 300 mg,beads cap 24hr 120 mg, beads cap 24hr 420 mg)


diltiazem hcl extended release beads cap sr 24hr 240 mg generic MDD 2 per day

felodipine (tab 24hr 10 mg, tab 24hr 5 mg, tab 24hr 2.5 mg) generic MDD 1 per day

nicardipine hcl (cap 20 mg, cap 30 mg) generic

nifedipine (cap 10 mg, cap 20 mg) generic MDD 4 per day

nifedipine (tab 24hr 60 mg, tab 24hr osmotic 60 mg) generic MDD 2 per day

nifedipine (tab 24hr osmotic 30 mg, tab 24hr osmotic 90mg, tab 24hr 30 mg, tab 24hr 90 mg) generic MDD 1 per day



verapamil hcl (cap sr 24hr 120 mg, cap sr 24hr 180 mg,cap sr 24hr 240 mg, tab cr 120 mg, tab cr 180 mg, tab cr240 mg)


verapamil hcl (tab 40 mg, tab 80 mg, tab 120 mg) generic MDD 3 per day

verapamil hcl cap sr 24hr 360 mg generic MDD 1 per day

ANTIARRHYTHMICS

amiodarone hcl tab 200 mg generic

disopyramide phosphate (cap 100 mg, cap 150 mg) generic

flecainide acetate (tab 50 mg, tab 100 mg, tab 150 mg) generic

mexiletine hcl (cap 150 mg, cap 200 mg, cap 250 mg) generic

NORPACE CR CAP ER 12H 150 MG BRAND

propafenone hcl (tab 150 mg, tab 225 mg, tab 300 mg) generic

quinidine gluconate tab cr 324 mg generic

quinidine sulfate (tab 200 mg, tab 300 mg, tab cr 300 mg) generic

TIKOSYN (CAP 125 MCG, CAP 250 MCG, CAP 500 MCG) BRAND

ANTIHYPERTENSIVES

amlodipine besylate-benazepril hcl (cap 2.5-10 mg, cap 5-10 mg, cap 5-20 mg, cap 10-20 mg) generic MDD 1 per day

atenolol & chlorthalidone (tab 50-25 mg, tab 100-25 mg) generic MDD 1 per day

benazepril & hydrochlorothiazide (tab 5-6.25 mg, tab 10-12.5 mg, tab 20-12.5 mg, tab 20-25 mg) generic MDD 1 per day

benazepril hcl (tab 5 mg, tab 10 mg, tab 20 mg) generic MDD 1 per day

benazepril hcl tab 40 mg generic MDD 2 per day

bisoprolol & hydrochlorothiazide (tab 5-6.25 mg, tab 10-6.25 mg) generic MDD 1 per day

captopril (tab 12.5 mg, tab 25 mg, tab 50 mg, tab 100 mg) generic MDD 3 per day

clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg) generic

doxazosin mesylate (tab 1 mg, tab 2 mg, tab 4 mg, tab 8mg) generic



DUTOPROL (TAB ER 24H 50-12.5 MG, TAB ER 24H 100-12.5 MG, TAB ER 24H 25-12.5 MG) BRAND MDD 1 per day

enalapril maleate & hydrochlorothiazide (tab 5-12.5 mg, tab10-25 mg) generic MDD 2 per day

enalapril maleate (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20mg) generic MDD 2 per day

EPANED RECON SOLN 1 MG/ML BRAND AL Up to 8 yrs old

fosinopril sodium & hydrochlorothiazide (tab 10-12.5 mg,tab 20-12.5 mg) generic MDD 1 per day

fosinopril sodium (tab 10 mg, tab 20 mg, tab 40 mg) generic MDD 1 per day

guanabenz acetate (tab 4 mg, tab 8 mg) generic

guanfacine hcl (tab 1 mg, tab 2 mg) generic

hydralazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100mg) generic

irbesartan (tab 75 mg, tab 150 mg, tab 300 mg) generic MDD 1 per day

irbesartan-hydrochlorothiazide (tab 150-12.5 mg, tab 300-12.5 mg) generic MDD 1 per day

lisinopril & hydrochlorothiazide (tab 10-12.5 mg, tab 20-12.5 mg) generic MDD 2 per day

lisinopril & hydrochlorothiazide tab 20-25 mg generic MDD 1 per day

lisinopril (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg, tab30 mg, tab 40 mg) generic MDD 2 per day

losartan potassium & hydrochlorothiazide (tab 50-12.5 mg,tab 100-25 mg, tab 100-12.5 mg) generic MDD 1 per day

losartan potassium (tab 25 mg, tab 50 mg, tab 100 mg) generic MDD 1 per day

methyldopa (tab 250 mg, tab 500 mg) generic

metoprolol & hydrochlorothiazide (tab 50-25 mg, tab 100-25 mg, tab 100-50 mg) generic MDD 2 per day

minoxidil (tab 2.5 mg, tab 10 mg) generic

prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg) generic

propranolol & hydrochlorothiazide (tab 40-25 mg, tab 80-25mg) generic



quinapril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg) generic MDD 1 per day

ramipril (cap 1.25 mg, cap 2.5 mg, cap 5 mg, cap 10 mg) generic MDD 2 per day

reserpine (tab 0.1 mg, tab 0.25 mg) generic

terazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg) generic

trandolapril (tab 1 mg, tab 2 mg, tab 4 mg) generic MDD 4 per day

valsartan (tab 40 mg, tab 80 mg, tab 160 mg, tab 320 mg) generic MDD 1 per day

valsartan-hydrochlorothiazide (tab 80-12.5 mg, tab 160-25mg, tab 160-12.5 mg, tab 320-25 mg, tab 320-12.5 mg) generic MDD 1 per day

DIURETICS

acetazolamide (cap sr 12hr 500 mg, tab 125 mg, tab 250mg) generic

amiloride & hydrochlorothiazide tab 5-50 mg generic MDD 1 per day

amiloride hcl tab 5 mg generic MDD 4 per day

bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg) generic

chlorothiazide tab 250 mg generic MDD 2 per day

chlorothiazide tab 500 mg generic MDD 4 per day

chlorthalidone tab 50 mg generic

furosemide (inj 10 mg/ml, oral soln 8 mg/ml, oral soln 10mg/ml, tab 20 mg, tab 40 mg, tab 80 mg) generic

hydrochlorothiazide (cap 12.5 mg, tab 12.5 mg, tab 25 mg,tab 50 mg) generic

indapamide (tab 1.25 mg, tab 2.5 mg) generic

methazolamide (tab 25 mg, tab 50 mg) generic

metolazone (tab 2.5 mg, tab 5 mg, tab 10 mg) generic

spironolactone & hydrochlorothiazide tab 25-25 mg generic

spironolactone (tab 25 mg, tab 50 mg, tab 100 mg) generic

torsemide (tab 5 mg, tab 10 mg, tab 20 mg, tab 100 mg) generic MDD 1 per day

triamterene & hydrochlorothiazide (cap 37.5-25 mg, tab37.5-25 mg, tab 75-50 mg) generic MDD 1 per day



VASOPRESSORS

ADRENACLICK SOLN A-INJ 0.3 MG/0.3ML BRAND QL 2 / 30 days

EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML BRAND QL 2 / 30 days

EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML BRAND QL 2 / 30 days

EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML BRAND QL 2 / 30 days

EPIPEN JR SOLN A-INJ 0.15 MG/0.3ML BRAND QL 2 / 30 days

EPIPEN SOLN A-INJ 0.3 MG/0.3ML BRAND QL 2 / 30 days

midodrine hcl (tab 2.5 mg, tab 5 mg, tab 10 mg) generic

TWINJECT SOLN A-INJ 0.3 MG/0.3ML BRAND QL 2 / 30 days

ANTIHYPERLIPIDEMICS

atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab80 mg) generic MDD 1 per day

cholestyramine (powder 4 gm/dose, powder packets 4 gm) generic

cholestyramine light (powder 4 gm/dose, powder packets 4gm) generic

colestipol hcl (granule packets 5 gm, granules 5 gm) generic

colestipol hcl tab 1 gm generic MDD 2 per day

fenofibrate micronized (cap 134 mg, cap 200 mg) generic MDD 1 per day

fenofibrate micronized cap 67 mg generic MDD 2 per day

fenofibrate tab 160 mg generic MDD 1 per day

fenofibrate tab 54 mg generic MDD 3 per day

gemfibrozil tab 600 mg generic MDD 2 per day

lovastatin (tab 10 mg, tab 20 mg) generic MDD 1 per day

lovastatin tab 40 mg generic MDD 2 per day

NIACOR TAB 500 MG BRAND

pravastatin sodium (tab 10 mg, tab 20 mg, tab 40 mg, tab80 mg) generic MDD 1 per day



simvastatin (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg) generic MDD 1 per day

RESPIRATORY AGENTS

ANTIHISTAMINES

cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg) generic

DEXCHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML BRAND


promethazine hcl (tab 12.5 mg, tab 25 mg, tab 50 mg) generic AL At least 2 yrs old

promethazine hcl suppos 12.5 mg genericQL 12 / claim


promethazine hcl suppos 25 mg genericQL 12 / claim


promethazine hcl suppos 50 mg genericQL 2 / claim


promethazine hcl syrup 6.25 mg/5ml genericQL 240 / claim


NASAL AGENTS - SYSTEMIC AND TOPICAL

ADRENALIN SOLUTION 0.1 % BRAND

azelastine hcl (0.1% (137 mcg/), 0.15% (205.5 mcg/), 137mcg/(1 mg/ml)) generic MPL 1 / 30 days

BACTROBAN NASAL OINTMENT 2 % BRAND

flunisolide nasal soln 25 mcg/act (0.025%) generic QL 25 / claim

flunisolide nasal soln 29 mcg/act (0.025%) generic

fluticasone propionate nasal susp 50 mcg/act generic QL 16 / claim

ipratropium bromide nasal soln 0.03% (21 mcg/spray) generic QL 30 / 25 days

ipratropium bromide nasal soln 0.06% (42 mcg/spray) generic QL 15 / 30 days



COUGH/COLD/ALLERGY

acetylcysteine (soln 10%, soln 20%) generic

benzonatate cap 100 mg generic AL At least 10 yrs old

benzonatate cap 200 mg generic

QL 30 / 30 days


MFL 1 / 30 days

chlorpheniramine tan-phenylephrine tan susp 4.5-5 mg/5ml generic


CFrom age 6 and Older:Daily Dosage=20;From age 3 through 5:Daily Dosage=10

DECON-A ELIXIR 2-5 MG/5ML BRAND

hydrocodone w/ homatropine syrup 5-1.5 mg/5ml generic

phenyleph-chlorphen w/ dm-gg syrup 10-2-7.5-100 mg/5ml generic

phenylephrine-promethazine w/ codeine syrup 5-6.25-10mg/5ml generic

QL 240 / claim


promethazine & phenylephrine syrup 6.25-5 mg/5ml genericQL 240 / claim


promethazine w/ codeine syrup 6.25-10 mg/5ml genericQL 240 / claim


promethazine-dm syrup 6.25-15 mg/5ml genericQL 240 / claim


pseudoephed-bromphen-dm syrup 45-4-15 mg/5ml generic QL 240 / claim

sodium chloride (inhalant) (soln nebu 0.9%, soln nebu 3%,soln nebu 10%) generic

ANTIASTHMATIC AND BRONCHODILATOR AGENTS

ADVAIR DISKUS (AER POW BA 100-50 MCG/DOSE,AER POW BA 250-50 MCG/DOSE, AER POW BA 500-50MCG/DOSE)

BRAND QL 60 / 30 days

ADVAIR HFA (AEROSOL 45-21 MCG/ACT, AEROSOL115-21 MCG/ACT, AEROSOL 230-21 MCG/ACT) BRAND QL 12 / 30 days



AEROSPAN AERO SOLN 80 MCG/ACT BRAND QL 8.9 / 30 days

albuterol sulfate (soln nebu 0.63 mg/3ml, soln nebu 1.25mg/3ml) generic QL 375 / 30 days

albuterol sulfate (syrup 2 mg/5ml, tab 2 mg, tab 4 mg, tabsr 12hr 4 mg, tab sr 12hr 8 mg) generic

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) generic QL 375 / 25 days

albuterol sulfate soln nebu 0.5% (5 mg/ml) generic MDD 2 per day

aminophylline (tab 100 mg, tab 200 mg) generic

ATROVENT HFA AERO SOLN 17 MCG/ACT BRAND QL 26 / 30 days

BREO ELLIPTA AER POW BA 100-25 MCG/INH BRAND AL At least 18 yrs old

budesonide (inhalation) (susp 0.25 mg/2ml, susp 0.5mg/2ml) generic

QL 120 / 30 days

AL Up to 6 yrs old

budesonide inhalation susp 1 mg/2ml genericQL 60 / 30 days

AL Up to 6 yrs old

COMBIVENT AEROSOL 18-103 MCG/ACT BRAND MDD 1 per day

COMBIVENT RESPIMAT AERO SOLN 20-100 MCG/ACT BRAND QL 4 / 30 days

cromolyn sodium soln nebu 20 mg/2ml generic QL 240 / 30 days

DULERA (AEROSOL 100-5 MCG/ACT, AEROSOL 200-5MCG/ACT) BRAND QL 13 / claim

ELIXOPHYLLIN ELIXIR 80 MG/15ML BRAND

FLOVENT DISKUS (AER POW BA 100 MCG/BLIST, AERPOW BA 250 MCG/BLIST) BRAND MDD 2 per day

FLOVENT DISKUS AER POW BA 50 MCG/BLIST BRAND QL 60 / 25 days

FLOVENT HFA (AEROSOL 110 MCG/ACT, AEROSOL220 MCG/ACT) BRAND QL 12 / 25 days

FLOVENT HFA AEROSOL 44 MCG/ACT BRAND QL 11 / 25 Days

FORADIL AEROLIZER CAP 12 MCG BRAND MDD 2 per day

ipratropium bromide inhal soln 0.02% generic QL 375 / 25 days



ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml generic MDD 12 per day

LUFYLLIN (TAB 200 MG, TAB 400 MG) BRAND

metaproterenol sulfate (tab 10 mg, tab 20 mg) generic

metaproterenol sulfate syrup 10 mg/5ml generic MDD 30 per day

montelukast sodium (chew tab 4 mg, chew tab 5 mg, oralgranules packet 4 mg, tab 10 mg) generic MDD 1 per day

PROAIR HFA AERO SOLN 108 (90 BASE) MCG/ACT BRAND MPL 2 / 30 days

PROVENTIL HFA AERO SOLN 108 (90 BASE) MCG/ACT BRAND MPL 2 / 30 days

PULMICORT FLEXHALER (AER POW BA 90 MCG/ACT,AER POW BA 180 MCG/ACT) BRAND QL 1 / 25 Days

SEREVENT DISKUS AER POW BA 50 MCG/DOSE BRAND MDD 2 per day

SYMBICORT (AEROSOL 80-4.5 MCG/ACT, AEROSOL160-4.5 MCG/ACT) BRAND QL 11 / claim

terbutaline sulfate (tab 2.5 mg, tab 5 mg) generic

THEO-24 (CAP ER 24H 400 MG, CAP ER 24H 100 MG,CAP ER 24H 200 MG, CAP ER 24H 300 MG) BRAND

theophylline (tab 12hr 200 mg, tab 12hr 450 mg, tab 12hr300 mg, tab 12hr 100 mg, tab 24hr 600 mg, tab 24hr 400mg)

generic

theophylline soln 80 mg/15ml generic QL 475 / claim

TUDORZA PRESSAIR AER POW BA 400 MCG/ACT BRAND MPL 1 / month

VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT BRAND MPL 2 / 30 days

RESPIRATORY AGENTS - MISC.

ORKAMBI TAB 200-125 MG BRAND PA

GASTROINTESTINAL AGENTS

LAXATIVES

lactulose solution 10 gm/15ml generic

peg 3350-kcl-sod bicarb-nacl for soln 420 gm generic MPL 1 / claim



peg 3350-kcl-sod bicarb-sod chloride-sod sulfate(soln236gm, soln240gm) generic MPL 1 / claim

ANTIDIARRHEALS

diphenoxylate w/ atropine (w/ liq mg/5ml, w/ tab mg) generic

ULCER DRUGS

CARAFATE SUSPENSION 1 GM/10ML BRANDQL 420 / claim

AL Up to 6 yrs old

cimetidine (tab 300 mg, tab 400 mg, tab 800 mg) generic

cimetidine hcl soln 300 mg/5ml generic MDD 27 per day

dicyclomine hcl (cap 10 mg, tab 20 mg) generic

dicyclomine hcl oral soln 10 mg/5ml generic MDD 40 per day

famotidine tab 40 mg generic

FIRST-OMEPRAZOLE SUSPENSION 2 MG/ML BRAND QL 300 / 30 days

glycopyrrolate (tab 1 mg, tab 2 mg) generic MDD 4 per day

hyoscyamine sulfate (elixir 0.125 mg/5ml, soln 0.125mg/ml, tab 0.125 mg, tab disp 0.125 mg, tab sl 0.125 mg) generic

hyoscyamine sulfate tab sr 12hr 0.375 mg generic MDD 4 per day

lansoprazole cap delayed release 15 mg generic MDD 4 per day

misoprostol (tab 100 mcg, tab 200 mcg) generic

omeprazole cap delayed release 20 mg generic MDD 4 per day

omeprazole cap delayed release 40 mg generic MDD 2 per day

OMEPRAZOLE+SYRSPEND SF ALKA SUSPENSION 2MG/ML BRAND QL 300 / 30 days

pantoprazole sodium ec tab 20 mg (base equiv) generic MDD 1 per day

pantoprazole sodium ec tab 40 mg (base equiv) generic MDD 2 per day

phenobarbital-hyoscyamine-atropine-scopolamine (elixmg/5ml, tab mg) generic

ranitidine hcl (cap 150 mg, tab 150 mg, tab 300 mg) generic MDD 2 per day



ranitidine hcl cap 300 mg generic MDD 1 per day

ranitidine hcl syrup 15 mg/ml (75 mg/5ml) genericAL Up to 6 yrs old

MDD 20 per day

sucralfate tab 1 gm generic MDD 4 per day

ANTIEMETICS

ondansetron hcl (oral soln 4 mg/5ml, tab 24 mg) generic

ondansetron hcl (tab 4 mg, tab 8 mg) genericMDD 2 per day

MDS 90 / 365 DAYS

ondansetron orally disintegrating tab 4 mg genericMDD 2 per day

MDS 90 / 365 DAYS

ondansetron orally disintegrating tab 8 mg generic MDS 90 / 365 DAYS

DIGESTIVE AIDS

CREON (CP DR PART 6000, CP DR PART 12000, CP DRPART 24000) BRAND

PANCREAZE (CP DR PART 4200, CP DR PART 10500,CP DR PART 16800, CP DR PART 21000) BRAND

pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit generic

ZENPEP (CP DR PART 3000-10000, CP DR PART 10000,CP DR PART 15000, CP DR PART 20000, CP DR PART25000)

BRAND

GASTROINTESTINAL AGENTS - MISC.

ASACOL TAB DR 400 MG BRAND MDD 12 per day

balsalazide disodium cap 750 mg generic MDD 9 per day

calcium acetate (phosphate binder) cap 667 mg (169 mgca) generic

CHOLBAM (CAP 50 MG, CAP 250 MG) BRANDPA

MDD 5 per day

DELZICOL CAP DR 400 MG BRAND MDD 6 per day



lactulose (encephalopathy) solution 10 gm/15ml generic

mesalamine enema 4 gm generic MDD 60 per day

metoclopramide hcl (soln 5 mg/5ml (10 mg/10ml), tab 5mg, tab 10 mg) generic

PENTASA (CAP ER 250 MG, CAP ER 500 MG) BRAND MDD 8 per day

SFROWASA ENEMA 4 GM/60ML BRAND

sulfasalazine (tab 500 mg, tab delayed release 500 mg) generic

ursodiol cap 300 mg generic MDD 3 per day

ursodiol tab 250 mg generic MDD 7 per day

GENITOURINARY PRODUCTS

URINARY ANTI-INFECTIVES

*methenamine-hyos-meth blue-sod phos-phen sal tab 81.6mg*** generic

methenamine mandelate (tab 0.5 gm, tab 1 gm) generic

nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg) generic

nitrofurantoin monohydrate macrocrystalline cap 100 mg generic

nitrofurantoin susp 25 mg/5ml genericAL Up to 6 yrs old

MDD 40 per day

URINARY ANTISPASMODICS

bethanechol chloride (tab 5 mg, tab 10 mg, tab 25 mg, tab50 mg) generic

flavoxate hcl tab 100 mg generic

oxybutynin chloride (tab 24hr 15 mg, tab 24hr 10 mg, tab24hr 5 mg) generic MDD 2 per day

oxybutynin chloride syrup 5 mg/5ml generic

oxybutynin chloride tab 5 mg generic MDD 3 per day

tolterodine tartrate (cap 24hr 4 mg, cap 24hr 2 mg) generic MDD 1 per day

tolterodine tartrate (tab 1 mg, tab 2 mg) generic MDD 2 per day



trospium chloride tab 20 mg generic MDD 2 per day

VAGINAL PRODUCTS

clindamycin phosphate vaginal cream 2% generic MPL 1 / claim

ESTRACE CREAM 0.1 MG/GM BRAND

GYNAZOLE-1 CREAM 2 % BRAND

metronidazole vaginal gel 0.75% generic QL 45 / claim

MICONAZOLE 3 SUPPOS 200 MG BRAND QL 3 / claim

PREMARIN CREAM 0.625 MG/GM BRAND GL Female

terconazole vaginal (cream 0.4%, cream 0.8%, suppos 80mg) generic

GENITOURINARY AGENTS - MISCELLANEOUS

ELMIRON CAP 100 MG BRAND MDD 3 per day

finasteride tab 5 mg generic MDD 1 per day

phenazopyridine hcl (tab 100 mg, tab 200 mg) generic

potassium citrate & citric acid powder pack 3300-1002 mg generic

potassium citrate (alkalinizer) (tab 5 (540, tab 10 (1080) generic

sodium chloride irrigation soln 0.9% generic

sodium citrate & citric acid soln 500-334 mg/5ml generic

tamsulosin hcl cap 0.4 mg generic MDD 2 per day

CENTRAL NERVOUS SYSTEM DRUGS

ANTIANXIETY AGENTS

alprazolam (orally disintegrating tab 0.25 mg, orallydisintegrating tab 0.5 mg, orally disintegrating tab 1 mg,orally disintegrating tab 2 mg, tab 0.25 mg, tab 0.5 mg, tab1 mg, tab 2 mg)


buspirone hcl (tab 7.5 mg, tab 10 mg, tab 15 mg, tab 30mg) generic MDD 3 per day

buspirone hcl tab 5 mg generic MDD 1 per day



chlordiazepoxide hcl (cap 5 mg, cap 10 mg, cap 25 mg) generic MDD 4 per day

clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg, tab 15mg) generic MDD 3 per day

diazepam (tab 2 mg, tab 5 mg, tab 10 mg) generic MDD 4 per day

diazepam soln 1 mg/ml generic

hydroxyzine hcl (syrup 10 mg/5ml, tab 10 mg, tab 25 mg,tab 50 mg) generic

hydroxyzine pamoate (cap 25 mg, cap 50 mg, cap 100 mg) generic

lorazepam (conc 2 mg/ml, inj 2 mg/ml, tab 0.5 mg, tab 2mg) generic MDD 3 per day

lorazepam tab 1 mg generic MDD 4 per day

meprobamate (tab 200 mg, tab 400 mg) generic

oxazepam (cap 10 mg, cap 15 mg, cap 30 mg) generic MDD 4 per day

ANTIDEPRESSANTS

amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75mg, tab 100 mg, tab 150 mg) generic

amoxapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 150mg) generic

BRINTELLIX (TAB 5 MG, TAB 10 MG, TAB 20 MG) BRAND

ST


MDD 1 per day

bupropion hcl (tab 24hr 150 mg, tab 24hr 300 mg) generic MDD 1 per day

bupropion hcl (tab 75 mg, tab 100 mg) generic MDD 3 per day

bupropion hcl er (sr) tab er 12h 100 mg generic MDD 2 per day

bupropion hcl er (sr) tab er 12h 150 mg generic MDD 2 per day

bupropion hcl tab sr 12hr 200 mg generic MDD 2 per day

citalopram hydrobromide (tab 10 mg, tab 20 mg, tab 40mg) generic MDD 1.5 per day

citalopram hydrobromide oral soln 10 mg/5ml generic



clomipramine hcl (cap 25 mg, cap 50 mg, cap 75 mg) generic

desipramine hcl (tab 10 mg, tab 50 mg, tab 75 mg, tab 100mg, tab 150 mg) generic

desipramine hcl tab 25 mg generic MDD 2 per day

doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75mg, cap 100 mg, cap 150 mg, conc 10 mg/ml) generic

duloxetine hcl (cap 20 mg, cap 30 mg, cap 60 mg) genericAL At least 18 yrs old

MDD 1 per day

escitalopram oxalate (tab 5 mg, tab 10 mg, tab 20 mg) generic MDD 1 per day

fluoxetine hcl (cap 10 mg, cap 20 mg, tab 20 mg) generic MDD 4 per day

fluoxetine hcl cap 40 mg genericAL At least 7 yrs old

MDD 2 per day

fluoxetine hcl solution 20 mg/5ml generic AL Up to 6 yrs old

fluoxetine hcl tab 10 mg genericAL Up to 12 yrs old

MDD 1 per day

fluvoxamine maleate (tab 25 mg, tab 50 mg) generic MDD 2 per day

fluvoxamine maleate tab 100 mg generic MDD 3 per day

imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg) generic

maprotiline hcl (tab 25 mg, tab 50 mg, tab 75 mg) generic

mirtazapine (orally disintegrating tab 15 mg, orallydisintegrating tab 30 mg, orally disintegrating tab 45 mg,tab 7.5 mg, tab 15 mg, tab 30 mg, tab 45 mg)


nefazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab200 mg, tab 250 mg) generic

nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75mg) generic

nortriptyline hcl soln 10 mg/5ml generic MDD 20 per day

paroxetine hcl (tab 10 mg, tab 20 mg, tab 30 mg, tab 40mg) generic

MDD 2 per day

MFL 1 / 30 days



paroxetine hcl oral susp 10 mg/5ml (base equiv) genericMDD 40 per day

MFL 1 / 30 days

phenelzine sulfate tab 15 mg generic

sertraline hcl (tab 25 mg, tab 50 mg) genericMDD 1.5 per day

MFL 1 / 30 days

sertraline hcl oral conc 20 mg/ml genericMDD 10 per day

MFL 1 / 30 days

sertraline hcl tab 100 mg genericMDD 2 per day

MFL 1 / 30 days

tranylcypromine sulfate tab 10 mg generic

trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg) generic

trazodone hcl tab 300 mg generic MDD 2 per day

venlafaxine hcl (cap 24hr 150 mg, cap 24hr 37.5 mg, cap24hr 75 mg, tab 24hr 150 mg) generic MDD 2 per day

venlafaxine hcl (tab 24hr 75 mg, tab 24hr 37.5 mg) generic MDD 1 per day

venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50 mg, tab 75mg, tab 100 mg) generic

VENLAFAXINE HCL ER TAB ER 24H 225 MG BRAND MDD 1 per day

VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40 MG) BRANDPA

MDD 1 per day

VIIBRYD KIT 10 & 20 & 40 MG BRAND PA

ANTIPSYCHOTICS/ANTIMANIC AGENTS

aripiprazole (oral solution 1 mg/ml, orally disintegrating tab10 mg, orally disintegrating tab 15 mg) generic

aripiprazole (tab 2 mg, tab 5 mg, tab 10 mg, tab 15 mg, tab20 mg, tab 30 mg) generic

PA


MDD 1 per day

chlorpromazine hcl (inj 25 mg/ml, inj 50 mg/2ml) generic MDD 12 per day



chlorpromazine hcl (tab 25 mg, tab 50 mg, tab 100 mg, tab200 mg) generic MDD 3 per day

chlorpromazine hcl tab 10 mg generic MDD 10 per day

clozapine (tab 25 mg, tab 50 mg, tab 200 mg) genericAL At least 18 yrs old

MDD 3 per day

clozapine odt 100 mg genericAL At least 18 yrs old

MDD 9 per day


MDD 3 per day


MDD 3 per day

clozapine orally disintegrating tab 100 mg genericAL At least 18 yrs old

MDD 9 per day

clozapine orally disintegrating tab 25 mg genericAL At least 18 yrs old

MDD 3 per day

clozapine tab 100 mg genericAL At least 18 yrs old

MDD 9 per day

fluphenazine decanoate inj 25 mg/ml generic

fluphenazine hcl (tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10mg) generic

haloperidol (tab 0.5 mg, tab 1 mg, tab 10 mg) generic MDD 3 per day

haloperidol (tab 2 mg, tab 5 mg, tab 20 mg) generic

haloperidol decanoate (soln 50 mg/ml, soln 100 mg/ml) generic

haloperidol lactate inj 5 mg/ml generic MDD 6 per day

haloperidol lactate oral conc 2 mg/ml generic

lithium carbonate (cap 150 mg, cap 300 mg, cap 600 mg,tab 300 mg, tab cr 300 mg, tab cr 450 mg) generic

lithium oral solution 8 meq/5ml generic

loxapine succinate (cap 5 mg, cap 10 mg, cap 25 mg, cap50 mg) generic MDD 4 per day



olanzapine (for im inj 10 mg, orally disintegrating tab 5 mg,orally disintegrating tab 10 mg, orally disintegrating tab 15mg, orally disintegrating tab 20 mg, tab 5 mg, tab 7.5 mg,tab 10 mg, tab 15 mg, tab 20 mg)

genericAL At least 13 yrs old

MDD 1 per day

olanzapine tab 2.5 mg generic


MDD 1 per day

MFL 1 / 30 days

perphenazine (tab 2 mg, tab 4 mg, tab 8 mg, tab 16 mg) generic MDD 4 per day

prochlorperazine maleate (tab 5 mg, tab 10 mg) generic

prochlorperazine suppos 25 mg generic

quetiapine fumarate (tab 100 mg, tab 200 mg, tab 300 mg,tab 400 mg) generic


MDD 2 per day

quetiapine fumarate (tab 25 mg, tab 50 mg) generic


MDD 2 per day

C From age 18 through64: Max Fills=1/year

risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg,tab 3 mg, tab 4 mg) generic


MDD 2 per day

risperidone odt (tab 3 mg, tab 4 mg) genericAL At least 5 yrs old

MDD 2 per day

risperidone orally disintegrating tab 0.25 mg genericAL At least 5 yrs old

MDD 2 per day

risperidone orally disintegrating tab 0.5 mg genericAL At least 5 yrs old

MDD 2 per day

risperidone orally disintegrating tab 1 mg genericAL At least 5 yrs old

MDD 2 per day

risperidone orally disintegrating tab 2 mg genericAL At least 5 yrs old

MDD 2 per day

risperidone soln 1 mg/ml genericAL At least 5 yrs old

MDD 4 per day



thioridazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100mg) generic MDD 3 per day

thiothixene (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg) generic MDD 3 per day

trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10mg) generic MDD 3 per day

ziprasidone hcl (cap 20 mg, cap 40 mg, cap 60 mg, cap 80mg) generic


MDD 2 per day

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

flurazepam hcl (cap 15 mg, cap 30 mg) generic MDD 1 per day

midazolam hcl (inj 2 mg/2ml, inj 5 mg/ml, inj 5 mg/5ml, inj10 mg/2ml, inj 10 mg/10ml, inj 25 mg/5ml, inj 50 mg/10ml) generic

phenobarbital (elixir 20 mg/5ml, tab 15 mg, tab 16.2 mg,tab 30 mg, tab 32.4 mg, tab 60 mg, tab 64.8 mg, tab 97.2mg, tab 100 mg)

generic

temazepam (cap 15 mg, cap 30 mg) generic MDD 1 per day

triazolam (tab 0.125 mg, tab 0.25 mg) generic MDD 1 per day

zaleplon (cap 5 mg, cap 10 mg) genericAL At least 18 yrs old

MDD 1 per day

zolpidem tartrate (tab 5 mg, tab 10 mg) generic MDD 1 per day

ADHD/ANTI-NARCOLEPSY /ANTI-OBESITY/ANOREXIANT AGENTS

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

amphetamine-dextroamphetamine (cap 24hr 30 mg, cap24hr 15 mg, cap 24hr 5 mg, cap 24hr 25 mg, cap 24hr 10mg)

genericAL 6 to 18 yrs old

MDD 1 per day

amphetamine-dextroamphetamine (tab 5 mg, tab 7.5 mg,tab 10 mg, tab 12.5 mg, tab 15 mg, tab 20 mg, tab 30 mg) generic

AL 3 to 18 yrs old

MDD 2 per day

amphetamine-dextroamphetamine cap sr 24hr 20 mg genericAL 6 to 18 yrs old

MDD 2 per day

caffeine citrate (inj 60 mg/3ml mg/ml, oral soln 60 mg/3mlmg/ml) generic MFL 2 / lifetime



dextroamphetamine sulfate (cap 24hr 15 mg, cap 24hr 10mg) generic

AL 6 to 18 yrs old

MDD 2 per day

dextroamphetamine sulfate (tab 5 mg, tab 10 mg) genericAL 3 to 18 yrs old

MDD 3 per day

dextroamphetamine sulfate cap sr 24hr 5 mg genericAL 6 to 18 yrs old

MDD 1 per day

methylphenidate hcl (cap cr 10 mg, cap cr 20 mg, cap cr30 mg, cap cr 40 mg, cap cr 50 mg, cap cr 60 mg, tab cr 20mg, tab sa osm 18 mg, tab sa osm 27 mg, tab sa osm 54mg, tab sr 24hr 54 mg, tab sr 24hr 27 mg, tab sr 24hr 18mg)

genericAL 6 to 18 yrs old

MDD 1 per day

methylphenidate hcl (tab 5 mg, tab 10 mg, tab 20 mg) genericAL 3 to 18 yrs old

MDD 3 per day

methylphenidate hcl (tab cr 10 mg, tab sa osm 36 mg, tabsr 24hr 36 mg) generic

AL 6 to 18 yrs old

MDD 2 per day

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISCELLANEOUS

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

AVONEX KIT 30 MCG BRAND PA

AVONEX PEN AUT-IJ KIT 30 MCG/0.5ML BRAND PA

AVONEX PREFILLED PREF SY KT 30 MCG/0.5ML BRAND PA

bupropion hcl (smoking deterrent) tab sr 12hr 150 mg genericMDD 2 per day

MDS 180 / 365 DAYS

CHANTIX (TAB 0.5 MG, TAB 1 MG) BRANDMDD 2 per day

MDS 180 / 365 DAYS

CHANTIX CONTINUING MONTH PAK TAB 1 MG BRANDMDD 2 per day

MDS 180 / 365 DAYS

CHANTIX STARTING MONTH PAK TAB 0.5 MG X 11 & 1MG X 42 BRAND

MFL 2 / 365 days

MDS 180 / 365 DAYS



COPAXONE SOLN PRSYR 40 MG/ML BRAND PA

disulfiram tab 250 mg generic

donepezil hydrochloride (orally disintegrating tab 5 mg,orally disintegrating tab 10 mg, tab 5 mg, tab 10 mg) generic MDD 1 per day

ergoloid mesylates tab 1 mg generic

EXELON SOLUTION 2 MG/ML BRANDPA

MDD 6 per day

galantamine hydrobromide (cap 24hr 8 mg, cap 24hr 24mg, cap 24hr 16 mg) generic MDD 1 per day

galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg) generic MDD 2 per day

galantamine hydrobromide oral soln 4 mg/ml generic MDD 6 per day

GILENYA CAP 0.5 MG BRAND PA

glatiramer acetate soln prefilled syringe 20 mg/ml generic PA

memantine hcl (tab 5 mg, tab 10 mg) generic MDD 2 per day

memantine hcl oral solution 2 mg/ml generic

memantine hcl tab 5 mg (28) & 10 mg (21) titration pak generic MPL 1 / 28 days

NICOTROL INHALER 10 MG BRANDQL 504 / 30 days

MDS 180 / 365 DAYS

NICOTROL NS SOLUTION 10 MG/ML BRANDQL 120 / 30 days

MDS 180 ML / 365 DAYS

perphenazine-amitriptyline (tab 2-10 mg, tab 2-25 mg, tab4-10 mg, tab 4-25 mg) generic MDD 4 per day

PLEGRIDY (SOLN PEN 125 MCG/0.5ML, SOLN PRSYR125 MCG/0.5ML) BRAND PA

PLEGRIDY STARTER PACK (PACK SOLN PEN 63 94MCG/0.5ML, PACK SOLN PRSYR 63 94 MCG/0.5ML) BRAND PA

rivastigmine (patch 24hr 4.6 mg/24hr, patch 24hr 9.5mg/24hr) generic

PA

MDD 1 per day

rivastigmine tartrate (cap 1.5 mg, cap 3 mg, cap 4.5 mg,cap 6 mg) generic

PA

MDD 2 per day



SAVELLA (TAB 12.5 MG, TAB 25 MG, TAB 50 MG, TAB100 MG) BRAND

PA

MDD 2 per day

SAVELLA TITRATION PACK MISC 12.5 & 25 & 50 MG BRANDQL 55 / 365 days

PA

TECFIDERA (CAP DR 120 MG, CAP DR 240 MG, MISC120 & 240 MG) BRAND PA

ANALGESICS AND ANESTHETICS

ANALGESICS - NONNARCOTIC

butalbital-acetaminophen tab 50-325 mg generic

butalbital-acetaminophen tab 50-650 mg generic MDD 6 per day

butalbital-acetaminophen-caffeine (cap 50-325-40 mg, tab50-500-40 mg, tab 50-325-40 mg) generic MDD 4 per day

butalbital-aspirin-caffeine (cap mg, tab mg) generic MDD 4 per day

choline & mag salicylate (liq 500 mg/5ml, tab 500 mg, tab750 mg, tab 1000 mg) generic

diflunisal tab 500 mg generic

PHRENILIN FORTE CAP 50-650 MG BRAND

salsalate (tab 500 mg, tab 750 mg) generic

ANALGESICS - OPIOID

acetaminophen w/ codeine (w/ tab 300-60 mg, w/ tab 300-30 mg, w/ tab 300-15 mg) generic MDD 6 per day

acetaminophen w/ codeine soln 120-12 mg/5ml generic MDD 30 per day

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg generic MDD 4 per day

butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg generic MDD 4 per day

codeine sulfate (tab 15 mg, tab 60 mg) generic MDD 2 per day

fentanyl (patch 72hr 25 mcg/hr, patch 72hr 12 mcg/hr,patch 72hr 100 mcg/hr, patch 72hr 75 mcg/hr, patch 72hr50 mcg/hr)

generic MDD 0.33 per day

hydrocodone-acetaminophen (tab 5-500 mg, tab 7.5-325mg) generic MDD 8 per day



hydrocodone-acetaminophen (tab 7.5-650 mg, tab 7.5-500mg, tab 10-500 mg, tab 10-660 mg, tab 10-650 mg, tab 10-325 mg)


hydrocodone-acetaminophen soln 7.5-325 mg/15ml generic MDD 180 per day

hydrocodone-acetaminophen soln 7.5-500 mg/15ml generic MDD 120 per day

hydrocodone-acetaminophen tab 5-325 mg generic MDD 12 per day

hydrocodone-acetaminophen tab 7.5-750 mg generic MDD 5 per day

hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg) generic MDD 8 per day

hydromorphone hcl suppos 3 mg generic QL 12 / claim

meperidine hcl (tab 50 mg, tab 100 mg) generic MDD 6 per day

meperidine hcl oral soln 50 mg/5ml generic QL 500 / claim

methadone hcl tab 10 mg generic MDD 10 per day

methadone hcl tab 5 mg generic MDD 4 per day

morphine sulfate ((concentrate) soln 20 mg/ml, soln 100mg/5ml (20 mg/ml)) generic QL 240 / claim

morphine sulfate (cap sr 24hr 30 mg, cap sr 24hr 60 mg,cap sr 24hr 100 mg, tab cr 15 mg, tab cr 30 mg, tab cr 60mg, tab cr 100 mg, tab cr 200 mg)


morphine sulfate (soln 10 mg/5ml, soln 20 mg/5ml) generic QL 500 / 30 days

morphine sulfate (suppos 5 mg, suppos 10 mg, suppos 20mg, suppos 30 mg, tab 30 mg) generic QL 24 / claim

oxycodone hcl (cap 5 mg, tab 5 mg, tab 10 mg, tab 15 mg,tab 20 mg, tab 30 mg) generic MDD 6 per day

oxycodone hcl conc 100 mg/5ml (20 mg/ml) generic MDD 2 per day

oxycodone hcl tab er 12hr deter 40 mg genericPA

MDD 2 per day

oxycodone w/ acetaminophen (w/ cap 5-500 mg, w/ tab 5-325 mg, w/ tab 7.5-325 mg, w/ tab 7.5-500 mg, w/ tab 10-650 mg, w/ tab 10-325 mg)


oxycodone-aspirin tab 4.8355-325 mg generic MDD 6 per day



OXYCONTIN (TB12 DETER 60 MG, TB12 DETER 30 MG,TB12 DETER 80 MG, TB12 DETER 20 MG, TB12 DETER10 MG, TB12 DETER 15 MG)

BRANDPA

MDD 2 per day

ROXICET SOLUTION 5-325 MG/5ML BRAND MDD 30 per day

SUBOXONE (FILM 2-0.5 MG, FILM 4-1 MG) BRANDPA

MDD 1 per day

SUBOXONE (FILM 8-2 MG, FILM 12-3 MG) BRANDPA

MDD 2 per day

tramadol hcl tab 50 mg generic MDD 8 per day

tramadol-acetaminophen tab 37.5-325 mg generic MDD 4 per day

ANALGESICS - ANTI-INFLAMMATORY

celecoxib (cap 100 mg, cap 200 mg) generic

QL 62 / 31 days

PA

MDD 2 per day

celecoxib (cap 50 mg, cap 400 mg) genericQL 62 / 31 days

PA

diclofenac potassium tab 50 mg generic

diclofenac sodium (tab delayed release 25 mg, tab delayedrelease 50 mg, tab delayed release 75 mg, tab sr 24hr 100mg)

generic

ENBREL (KIT 25 MG, SOLN PRSYR 25 MG/0.5ML, SOLNPRSYR 50 MG/ML) BRAND PA

ENBREL SURECLICK SOLN A-INJ 50 MG/ML BRAND PA

etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500mg, tab sr 24hr 600 mg, tab sr 24hr 400 mg, tab sr 24hr500 mg)

generic

flurbiprofen (tab 50 mg, tab 100 mg) generic

HUMIRA (PREF SY KT 10 MG/0.2ML, PREF SY KT 20MG/0.4ML, PREF SY KT 40 MG/0.8ML) BRAND PA

HUMIRA PEDIATRIC CROHNS START PREF SY KT 40MG/0.8ML BRAND PA



HUMIRA PEN PEN KIT 40 MG/0.8ML BRAND PA

HUMIRA PEN-CROHNS STARTER PEN KIT 40MG/0.8ML BRAND PA

HUMIRA PEN-PSORIASIS STARTER PEN KIT 40MG/0.8ML BRAND PA

ibuprofen (tab 400 mg, tab 600 mg, tab 800 mg) generic

indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg) generic

ketoprofen (cap 50 mg, cap 75 mg, cap sr 24hr 200 mg) generic

ketorolac tromethamine tab 10 mg genericQL 20 / 30 days


leflunomide (tab 10 mg, tab 20 mg) generic

meloxicam tab 15 mg generic MDD 2 per day

meloxicam tab 7.5 mg generic

nabumetone tab 500 mg generic MDD 2 per day

nabumetone tab 750 mg generic

naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab500 mg, tab ec 375 mg, tab ec 500 mg) generic

naproxen sodium (tab 275 mg, tab 550 mg) generic

oxaprozin tab 600 mg generic

piroxicam (cap 10 mg, cap 20 mg) generic

RHEUMATREX TAB 2.5 MG BRAND

sulindac (tab 150 mg, tab 200 mg) generic

tolmetin sodium (cap 400 mg, tab 200 mg, tab 600 mg) generic

MIGRAINE PRODUCTS

dihydroergotamine mesylate (inj 1 mg/ml, nasal spray 4mg/ml) generic

naratriptan hcl (tab 1 mg, tab 2.5 mg) genericQL 9 / 30 days


RELPAX (TAB 20 MG, TAB 40 MG) BRAND QL 6 / 30 days



rizatriptan benzoate (tab 5 mg, tab 10 mg) genericQL 12 / 30 days


sumatriptan nasal spray (5 mg/act, 20 mg/act) genericQL 6 / 30 days


sumatriptan succinate (inj 6 mg/0.5ml, solution auto-injector 6 mg/0.5ml, solution prefilled syringe 6 mg/0.5ml) generic

QL 2 / 30 days


sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg) genericQL 9 / 30 days


zolmitriptan (tab 2.5 mg, tab 5 mg) genericQL 6 / 30 days


zolmitriptan (tab 2.5 mg, tab 5 mg) generic QL 6 / 30 days

ZOMIG SOLUTION 5 MG BRANDQL 6 / 30 days


GOUT AGENTS

allopurinol (tab 100 mg, tab 300 mg) generic

colchicine tab 0.6 mg genericQL 6 / claim

MFL 1 / 30 days

colchicine w/ probenecid tab 0.5-500 mg generic

probenecid tab 500 mg generic

NEUROMUSCULAR DRUGS

ANTICONVULSANTS

carbamazepine (cap sr 12hr 200 mg, chew tab 100 mg,susp 100 mg/5ml, tab 200 mg, tab sr 12hr 200 mg, tab sr12hr 400 mg)

generic

clonazepam (orally disintegrating tab 0.5 mg, orallydisintegrating tab 1 mg, orally disintegrating tab 2 mg, tab0.5 mg, tab 1 mg, tab 2 mg)


diazepam (anticonvulsant) (gel 2.5 mg, gel 10 mg, gel 20mg) generic

QL 1 / claim

AL Up to 21 yrs old



DILANTIN CAP 30 MG BRAND

divalproex sodium (cap sprinkle 125 mg, tab delayedrelease 125 mg, tab delayed release 250 mg, tab delayedrelease 500 mg, tab sr 24 hr 500 mg, tab sr 24 hr 250 mg)

generic

ethosuximide (cap 250 mg, soln 250 mg/5ml) generic

felbamate (susp 600 mg/5ml, tab 400 mg, tab 600 mg) generic

gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, tab 600mg, tab 800 mg) generic MDD 4 per day

gabapentin oral soln 250 mg/5ml generic

GABITRIL (TAB 12 MG, TAB 16 MG) BRAND

lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200mg, tab chewable dispersible 5 mg, tab chewabledispersible 25 mg)

generic

levetiracetam (tab 250 mg, tab 500 mg, tab 750 mg) generic MDD 4 per day

levetiracetam oral soln 100 mg/ml generic MDD 30 per day

oxcarbazepine (susp 300 mg/5ml (60 mg/ml), tab 150 mg,tab 300 mg, tab 600 mg) generic

phenytoin (chew tab 50 mg, susp 125 mg/5ml) generic

phenytoin sodium extended cap 100 mg generic

primidone (tab 50 mg, tab 250 mg) generic

TEGRETOL-XR TAB ER 12H 100 MG BRAND

tiagabine hcl (tab 2 mg, tab 4 mg) generic

topiramate (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) generic MDD 3 per day

topiramate sprinkle cap 15 mg generic MDD 6 per day

topiramate sprinkle cap 25 mg generic MDD 8 per day

valproate sodium syrup 250 mg/5ml (base equiv) generic

valproic acid cap 250 mg generic

zonisamide (cap 25 mg, cap 50 mg, cap 100 mg) generic

ANTIPARKINSON AGENTS

amantadine hcl (cap 100 mg, syrup 50 mg/5ml) generic



benztropine mesylate (tab 0.5 mg, tab 1 mg, tab 2 mg) generic

bromocriptine mesylate (cap 5 mg, tab 2.5 mg) generic

carbidopa & levodopa odt 10-100 mg generic



carbidopa tab 25 mg generic

carbidopa-levodopa (tab 10-100 mg, tab 25-100 mg, tab25-250 mg, tab cr 25-100 mg, tab cr 50-200 mg) generic

pramipexole dihydrochloride (tab 0.125 mg, tab 0.25 mg,tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg) generic


MDD 3 per day

ropinirole hydrochloride (tab 0.25 mg, tab 3 mg, tab 4 mg) generic MDD 6 per day

ropinirole hydrochloride (tab 0.5 mg, tab 1 mg, tab 2 mg,tab 5 mg) generic MDD 3 per day

selegiline hcl (cap 5 mg, tab 5 mg) generic

trihexyphenidyl hcl (tab 2 mg, tab 5 mg) generic

trihexyphenidyl hcl elixir 0.4 mg/ml generic QL 500 / 31 days

MUSCULOSKELETAL THERAPY AGENTS

baclofen (tab 10 mg, tab 20 mg) generic

chlorzoxazone tab 500 mg generic

cyclobenzaprine hcl (tab 5 mg, tab 10 mg) generic MDD 3 per day

methocarbamol (tab 500 mg, tab 750 mg) generic

tizanidine hcl (tab 2 mg (base equivalent), tab 2 mg, tab 4mg (base equivalent), tab 4 mg) generic

ANTIMYASTHENIC/CHOLINERGIC AGENTS

pyridostigmine bromide (tab 60 mg, tab cr 180 mg) generic

NUTRITIONAL PRODUCTS

VITAMINS

ergocalciferol cap 50000 unit generic



MEPHYTON TAB 5 MG BRAND

MULTIVITAMINS

*pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml** genericQL 50 / claim

AL Up to 13 yrs old

*pediatric multiple vitamins w/ fluoride chew tab 1 mg*** genericQL 30 / 30 days

AL Up to 13 yrs old

*pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml*** genericQL 50 / claim

AL Up to 13 yrs old

b-complex w/ c & folic acid (w/ ap 1, w/ tab 1) generic MDD 1 per day

CAVAN PRENATAL/EC CALCIUM TAB DR 28-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

CAVAN-FOLATE OB TAB 65-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

CO-NATAL FA TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

COMPLETE-RF PRENATAL TAB 90-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

COMPLETENATE CHEW TAB 29-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

ESCAVITE LQ LIQUID 0.25-6 MG/ML BRANDQL 50 / claim

AL Up to 13 yrs old

GESTICARE TAB DR 28-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day



LACTOCAL-F TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

MARNATAL-F PLUS DUO PACK MISC 60-1-250 & 250MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

MYNATAL CAP BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

MYNATAL PLUS TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

MYNATAL-Z TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

MYNATE 90 PLUS TAB ER BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

NATACHEW CHEW TAB 29-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

NATAL-V RX TAB 29-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

NATALVIT TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

O-CAL PRENATAL TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day



pediatric multivitamins w/fl (w/ chew tab 0.25, w/ chew tab0.5) generic

AL Up to 13 yrs old

MDD 1 per day

pediatric multivitamins w/fl (w/ soln 0.25 mg/ml***, w/ soln0.5 mg/ml***) generic

QL 50 / claim

AL Up to 13 yrs old

pediatric vitamins acd w/ fluoride (w/ soln 0.25 mg/ml***, w/soln 0.5 mg/ml***) generic

QL 50 / claim

AL Up to 13 yrs old

PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

PRENAFIRST TAB 17-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

PRENATABS FA TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

PRENATABS RX TAB 29-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

PRENATAL 19 (19 CHEW TAB, 19 CHEW TAB 29-1 MG,19 TAB 29-1 MG, 19 TAB) BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

PRENATAL PLUS IRON TAB 29-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

RE PRENATAL MULTIVITAMIN/IRON CHEW TAB 29-1MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

RE-NATA 29 OB TAB 29-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day



SE-NATAL 19 (19 TAB MG, 19 CHEW TAB MG) BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

SE-NATAL 90 TAB ER 90-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

SE-NATAL ONE TAB 60-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

TARON-EC CAL TAB DR 28-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

TRINATAL RX 1 TAB 60-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

VENATAL-FA TAB 29-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

VINATE CALCIUM TAB 27-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

VINATE M TAB 27-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

VINATE ONE TAB 60-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

VITAFOL-OB TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day



VITAFOL-PN TAB BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

VITASPIRE TAB 29-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

VOL-TAB RX TAB 29-1 MG BRAND

GL Female

AL Up to 45 yrs old

MDD 1 per day

MINERALS & ELECTROLYTES

FLURA-DROPS SOLUTION 0.55 (0.25 F) MG/DROP BRAND

KLOR-CON M15 TAB ER 15 MEQ BRAND

pot phos monobasic w/sod phos di & monobas tab 155-852-130mg generic MDD 8 per day

potassium bicarbonate effer tab 25 meq generic

potassium chloride (cap cr 10 meq, oral liq 10% (20meq/15ml), oral soln 10% (20 meq/15ml), oral soln 20%(40 meq/15ml), powder packet 20 meq, tab cr 8 meq (600mg), tab cr 10 meq)

generic

potassium chloride cap cr 8 meq generic MDD 1 per day

potassium chloride microencapsulated crystals cr(mioencapsulated ys tab 10, mioencapsulated ys tab 20) generic

sodium chloride (inj 0.9%, inj 3%, iv soln 0.9%) generic

sodium chloride flush iv soln 0.9% generic

sodium fluoride (chew tab 0.25 mg f (from 0.55 mg, chewtab 0.5 mg f (from 1.1 mg, chew tab 1 mg f (from 2.2 mg,soln 0.125 mg/drop f (0.275 mg/drop, soln 0.5 mg/ml f(from 1.1 mg/ml)

generic

SSKI SOLUTION 1 GM/ML BRAND



HEMATOLOGICAL AGENTS

HEMATOPOIETIC AGENTS

*ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1mg*** generic MDD 1 per day

cyanocobalamin inj 1000 mcg/ml generic

DROXIA (CAP 200 MG, CAP 300 MG, CAP 400 MG) BRAND

ANTICOAGULANTS

enoxaparin sodium (inj 100 mg/ml, inj 150 mg/ml) generic

QL 14 / 7 days

MFL 3 / 180 days

C PA required if > 7 daysof therapy

enoxaparin sodium (inj 80 mg/0.8ml, inj 120 mg/0.8ml) generic

QL 12 / 7 days

MFL 3 / 180 days


enoxaparin sodium inj 30 mg/0.3ml generic

QL 5 / 7 days

MFL 3 / 180 days


enoxaparin sodium inj 300 mg/3ml generic

QL 42 / 7 days

MFL 3 / 180 days



QL 6 / 7 days

MFL 3 / 180 days



QL 9 / 7 days

MFL 3 / 180 days




heparin sodium (porcine) (inj 1000 unit/ml, inj 5000 unit/ml,inj 10000 unit/ml, inj 20000 unit/ml, pf inj 5000 unit/0.5ml) generic

warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5 mg, tab 3 mg,tab 4 mg, tab 5 mg, tab 6 mg, tab 7.5 mg, tab 10 mg) generic

XARELTO TAB 10 MG BRANDQL 35 / 180 days

MDD 1 per day

XARELTO TAB 15 MG BRANDQL 21 / 180 Days

MDD 2 per day

XARELTO TAB 20 MG BRAND MDD 1 per day

HEMOSTATICS

aminocaproic acid syrup 25% generic QL 60 / claim

aminocaproic acid tab 500 mg generic QL 24 / claim

tranexamic acid tab 650 mg generic

QL 30 / 5 days

GL Female

AL 12 to 49 yrs old

MFL 1 / month

HEMATOLOGICAL AGENTS - MISC.

cilostazol (tab 50 mg, tab 100 mg) generic MDD 2 per day

clopidogrel bisulfate tab 75 mg (base equiv) generic MDD 1 per day

dipyridamole (tab 25 mg, tab 50 mg, tab 75 mg) generic

EFFIENT (TAB 5 MG, TAB 10 MG) BRAND MDD 1 per day

pentoxifylline tab cr 400 mg generic

TOPICAL PRODUCTS

OPHTHALMIC AGENTS

ALOCRIL SOLUTION 2 % BRANDQL 5 / claim

ST

ALOMIDE SOLUTION 0.1 % BRANDQL 10 / claim

ST



apraclonidine hcl ophth soln 0.5% (base equivalent) generic

atropine sulfate ophth soln 1% generic MPL 1 / claim

azelastine hcl ophth soln 0.05% genericQL 6 / claim

MPL 1 / 30 days

AZOPT SUSPENSION 1 % BRAND MPL 1 / claim

bacitracin ophth oint 500 unit/gm generic QL 4 / claim

bacitracin-polymyxin b ophth oint generic QL 4 / claim

betaxolol hcl ophth soln 0.5% generic MPL 1 / claim

BETOPTIC-S SUSPENSION 0.25 % BRAND MPL 1 / claim

BLEPHAMIDE S.O.P. OINTMENT 10-0.2 % BRAND QL 4 / claim

BLEPHAMIDE SUSPENSION 10-0.2 % BRAND MPL 1 / claim

brimonidine tartrate ophth soln 0.2% generic MPL 1 / claim

carteolol hcl ophth soln 1% generic MFL 1 / 30 days

CILOXAN OINTMENT 0.3 % BRAND QL 4 / claim

ciprofloxacin hcl ophth soln 0.3% generic

cromolyn sodium ophth soln 4% generic QL 10 / claim

CYCLOGYL SOLUTION 0.5 % BRAND QL 15 / claim

cyclopentolate hcl (soln 1%, soln 2%) generic MPL 1 / claim

dexamethasone sodium phosphate ophth soln 0.1% generic QL 5 / claim

diclofenac sodium ophth soln 0.1% generic MPL 1 / claim

dorzolamide hcl ophth soln 2% generic QL 10 / claim

dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml generic QL 10 / claim

erythromycin ophth oint 5 mg/gm generic QL 4 / claim

fluorometholone ophth susp 0.1% generic MPL 1 / claim

flurbiprofen sodium ophth soln 0.03% generic QL 3 / claim



FML OINTMENT 0.1 % BRAND QL 4 / claim

gentamicin sulfate ophth oint 0.3% generic QL 4 / claim

gentamicin sulfate ophth soln 0.3% generic MPL 1 / claim

homatropine hbr ophth soln 5% generic MPL 1 / claim

IOPIDINE SOLUTION 1 % BRAND

ISOPTO CARBACHOL (SOLUTION 1.5 %, SOLUTION 3%) BRAND

ISOPTO HOMATROPINE SOLUTION 2 % BRAND QL 5 / claim

ketorolac tromethamine ophth soln 0.4% generic MFL 1 / 30 days

ketorolac tromethamine ophth soln 0.5% generic MPL 1 / claim

latanoprost ophth soln 0.005% generic QL 3 / claim

levobunolol hcl ophth soln 0.5% generic MPL 1 / claim

metipranolol ophth soln 0.3% generic

neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000untop oin generic QL 4 / claim

neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml generic QL 10 / claim

neomycin-polymyxin-dexamethasone ophth oint 0.1% generic QL 4 / claim

neomycin-polymyxin-dexamethasone ophth susp 0.1% generic QL 5 / claim

neomycin-polymyxin-hc ophth susp generic QL 8 / claim

NEVANAC SUSPENSION 0.1 % BRANDQL 3 / claim

PA

ofloxacin ophth soln 0.3% generic MPL 1 / claim

phenylephrine hcl ophth soln 2.5% generic MPL 1 / claim

pilocarpine hcl (soln 1%, soln 2%, soln 4%) generic

polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% generic QL 10 / claim

PRED MILD SUSPENSION 0.12 % BRAND QL 10 / claim



PRED-G SUSPENSION 0.3-1 % BRAND MPL 1 / claim

prednisolone acetate ophth susp 1% generic MPL 1 / 30 days

PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1 % BRAND MPL 1 / 30 days

sulfacetamide sodium ophth oint 10% generic QL 4 / claim

sulfacetamide sodium ophth soln 10% genericQL 15 / claim

MPL 1 / claim

sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% generic MPL 1 / claim

timolol maleate (ophth) (gel forming soln 0.25%, gelforming soln 0.5%, soln 0.25%, soln 0.5%) generic MPL 1 / claim

TIMOPTIC OCUDOSE (SOLUTION 0.25 %, SOLUTION0.5 %) BRAND MPL 1 / claim

TOBRADEX OINTMENT 0.3-0.1 % BRAND QL 4 / claim

tobramycin ophth soln 0.3% generic QL 5 / claim

tobramycin-dexamethasone ophth susp 0.3-0.1% generic MPL 1 / claim

TOBREX OINTMENT 0.3 % BRAND QL 4 / claim

trifluridine ophth soln 1% generic QL 8 / claim

tropicamide ophth soln 0.5% generic QL 15 / claim

tropicamide ophth soln 1% generic MPL 1 / claim

VEXOL SUSPENSION 1 % BRAND MPL 1 / claim

VIGAMOX SOLUTION 0.5 % BRAND QL 3 / claim

OTIC AGENTS

acetic acid otic soln 2% generic QL 15 / claim

antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) generic MPL 1 / claim

CIPRODEX SUSPENSION 0.3-0.1 % BRAND QL 8 / claim

fluocinolone acetonide (otic) oil 0.01% generic MPL 1 / 30 days



hydrocortisone w/ acetic acid otic soln 1-2% generic QL 10 / claim

neomycin-polymyxin-hc otic soln 1% generic QL 10 / claim

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% generic MPL 1 / claim

ofloxacin otic soln 0.3% generic MPL 1 / claim

pramoxine-chloroxylenol otic liquid 1-0.1% generic MFL 1 / 30 days

pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1mg/ml generic MPL 1 / 30 days

pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml generic MPL 1 / 30 days

MOUTH/THROAT/DENTAL AGENTS

chlorhexidine gluconate soln 0.12% generic

lidocaine hcl viscous soln 2% generic QL 100 / claim

nystatin susp 100000 unit/ml generic QL 120 / claim

pilocarpine hcl tab 5 mg generic MDD 6 per day

sodium fluoride (dental) (cream, gel (0.5% f)) generic MPL 1 / claim

sodium fluoride paste 1.1% generic QL 106 / claim

stannous fluoride conc 0.63% generic

triamcinolone acetonide dental paste 0.1% generic QL 5 / claim

ANORECTAL AGENTS

ANALPRAM-HC LOTION 1-2.5 % BRAND QL 60 / claim

hydrocortisone enema 100 mg/60ml generic QL 420 / claim

hydrocortisone rectal cream 2.5% generic MPL 1 / claim

DERMATOLOGICALS

acyclovir oint 5% generic QL 30 / 30 days

aluminum chloride soln 20% generic MPL 1 / claim



APEXICON E CREAM 0.05 % BRAND MPL 1 / claim

betamethasone dipropionate augmented cream 0.05% generic MPL 1 / claim

betamethasone valerate (cream, oint) generic MPL 1 / claim

betamethasone valerate lotion 0.1% generic QL 60 / claim

calcipotriene (cream, oint, soln (50 mcg/ml)) generic QL 60 / claim

clindamycin phosphate (topical) (foam, gel, lotion, soln,swab) generic MPL 1 / claim

clindamycin phosphate-benzoyl peroxide gel 1-5% generic MPL 1 / 30 days

clobetasol propionate (cream, foam, gel, lotion, oint,shampoo, soln) generic MPL 1 / claim

clobetasol propionate emollient base cream 0.05% generic MPL 1 / claim

clotrimazole w/ betamethasone cream 1-0.05% generic MPL 1 / claim

clotrimazole w/ betamethasone lotion 1-0.05% generic QL 30 / claim

diflorasone diacetate (cream, oint) generic MPL 1 / claim

DRITHO-CREME HP CREAM 1 % BRAND

econazole nitrate cream 1% generic QL 30 / claim

ELIDEL CREAM 1 % BRAND

QL 30 / 30 days

PA


EPIFOAM FOAM 1-1 % BRAND

erythromycin (acne aid) (pads, soln) generic

erythromycin gel 2% generic MPL 1 / claim

EURAX CREAM 10 % BRAND QL 60 / claim

EURAX LOTION 10 % BRAND MPL 1 / claim

fluocinonide (cream, gel, oint, soln) generic MPL 1 / claim

fluocinonide emulsified base cream 0.05% generic MPL 1 / claim



fluorouracil (topical) (soln 2%, soln 5%) generic QL 10 / claim

fluorouracil cream 0.5% generic

fluorouracil cream 5% generic QL 40 / claim

fluticasone propionate (cream, lotion) generic MPL 1 / 30 days

fluticasone propionate oint 0.005% generic MPL 1 / claim

gentamicin sulfate (topical) (cream, oint) generic MPL 1 / claim

hydrocortisone (topical) (lotion, oint) generic MPL 1 / claim

hydrocortisone butyrate soln 0.1% generic MPL 1 / claim

hydrocortisone cream 2.5% generic

hydroquinone (cream, emulsion) generic MPL 1 / claim

imiquimod cream 5% generic QL 48 / 180 days

isotretinoin (cap 10 mg, cap 20 mg, cap 40 mg) generic

PA

AL 12 to 22 yrs old

MDD 2 per day

ketoconazole (topical) (cream, foam) generic MPL 1 / claim

ketoconazole shampoo 2% generic QL 120 / claim

lidocaine hcl cream 3% generic MPL 1 / claim

lidocaine oint 5% generic MPL 1 / claim

lidocaine-prilocaine cream 2.5-2.5% generic MPL 1 / claim

malathion lotion 0.5% genericQL 59 / claim

MFL 2 / 30 days

metronidazole cream 0.75 % generic QL 45 / claim

metronidazole gel 0.75 % generic QL 45 / claim

metronidazole lotion 0.75% generic

mometasone furoate (cream, oint, solution (lotion)) generic MPL 1 / claim



mupirocin calcium cream 2% generic MPL 1 / claim

mupirocin oint 2% generic CPkg Size 22: PackageLimit=1/claim; Pkg Size.9: PackageLimit=72/30 days

nystatin (topical) (*nystatin topical powder**, nystatincream 100000 unit/gm, nystatin oint 100000 unit/gm) generic MPL 1 / claim

nystatin-triamcinolone (cream unit/gm-%, oint unit/gm-%) generic MPL 1 / claim

permethrin cream 5% generic MPL 1 / claim

podofilox soln 0.5% generic QL 4 / claim

pramoxine-hc cream 1-2.5% generic QL 30 / claim

prednicarbate (cream, oint) generic MPL 1 / claim

selenium sulfide lotion 2.5% generic QL 120 / claim

silver sulfadiazine cream 1% generic MPL 1 / claim

SPINOSAD SUSPENSION 0.9 % BRANDQL 120 / claim

MFL 2 / 30 days

sulfacetamide sodium liquid 10% generic MPL 1 / claim

sulfacetamide sodium lotion 10% (acne) generic QL 120 / claim

sulfacetamide sodium w/ sulfur (w/ cleansing cloth, w/cream, w/ emulsion, w/ foam, w/ lotion) generic MPL 1 / claim

sulfacetamide sodium w/ sulfur susp 10-5% generic QL 30 / claim

tacrolimus oint 0.03% generic

QL 30 / 30 days

PA


tacrolimus oint 0.1% generic

QL 30 / 30 days

PA


TAZORAC (CREAM 0.05 %, CREAM 0.1 %, GEL 0.05 %,GEL 0.1 %) BRAND MPL 1 / claim



tretinoin (cream 0.05%, cream 0.1%) genericQL 20 / 30 days

AL Up to 21 yrs old

tretinoin cream 0.025% genericQL 20 / claim

AL Up to 21 yrs old

tretinoin gel 0.01% genericQL 15 / 30 days

AL Up to 21 yrs old

tretinoin gel 0.025% genericAL Up to 21 yrs old

MPL 1 / 30 days

triamcinolone acetonide (topical) (cream 0.1%, oint0.025%, oint 0.1%) generic MPL 1 / claim

triamcinolone acetonide (topical) (lotion 0.025%, lotion0.1%) generic

QL 60 / claim

MPL 1 / claim

triamcinolone acetonide cream 0.025% generic C


triamcinolone acetonide cream 0.5% genericQL 15 / claim

MPL 1 / claim

urea (cream, gel, lotion) generic MPL 1 / claim

ZOVIRAX CREAM 5 % BRAND MPL 1 / claim

MISCELLANEOUS PRODUCTS

ANTISEPTICS & DISINFECTANTS

formaldehyde solution 10% generic QL 90 / claim

ANTIDOTES

CHEMET CAP 100 MG BRAND

JADENU (TAB 90 MG, TAB 180 MG, TAB 360 MG) BRAND PA

naltrexone hcl tab 50 mg generic



DIAGNOSTIC PRODUCTS

CHEK-STIX CONTROL STRIP BRAND

CHEMSTRIP K STRIP BRAND

GLUCAGEN DIAGNOSTIC RECON SOLN 1 MG BRAND

KETOCARE (, STRIP) BRAND

KETOSTIX STRIP BRAND

ONETOUCH ULTRA BLUE STRIP BRAND MDD 5 per day

ONETOUCH VERIO STRIP BRAND MDD 5 per day

RELION KETONE STRIP BRAND

CHEMICALS

AZELASTINE HCL POWDER BRAND MPL 1 / 30 days

sodium polystyrene sulfonate (bulk) powder generic QL 454 / claim

MEDICAL DEVICES AND SUPPLIES

*lancet devices*** generic QL 1 / 180 Days

*lancets*** generic QL 200 / 30 days

BD AUTOSHIELD MISC 29G X 8MM BRAND MDD 5 per day

BD INSULIN SYRINGE MICROFINE (MISC 27G 5/8" 1ML, MISC 28G 1/2" 0.3 ML) BRAND MDD 5 per day

BD INSULIN SYRINGE MISC 26G X 1/2" 1 ML BRAND MDD 5 per day

BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 1ML BRAND QL 150 / 30 days

INSPIREASE BAGS MISC BRAND QL 3 / 180 days

INSPIREASE MOUTHPIECE MISC BRAND QL 1 / 180 Days

INSPIREASE RESERVOIR BAGS MISC BRAND QL 3 / 180 days

insulin pen needle 29 g x 12 mm (1/2") generic MDD 5 per day

insulin pen needle 29 g x 12.7 mm generic MDD 5 per day



insulin pen needle 30 g x 8 mm (1/3" or 5/16") generic MDD 5 per day







insulin syringe (disp) u-100 1 ml generic MDD 5 per day

INSULIN SYRINGE MISC 29G X 1" 0.3 ML BRAND MDD 5 per day

insulin syringe/needle u-100 0.3 ml 30 x 1/2" generic MDD 5 per day



insulin syringe/needle u-100 1 ml 25 x 1" generic MDD 5 per day

insulin syringe/needle u-100 1 ml 25 x 5/8" generic MDD 5 per day




insulin syringe/needle u-100 1/2 ml 27 x 1/2" generic MDD 5 per day




ONETOUCH ULTRA 2 KIT W/DEVICE BRAND QL 1 / 365 Days

ONETOUCH ULTRA MINI KIT W/DEVICE BRAND QL 1 / 365 Days

ONETOUCH ULTRA SYSTEM KIT W/DEVICE BRAND QL 1 / 365 Days



ONETOUCH ULTRASMART KIT W/DEVICE BRAND QL 1 / 365 Days

ORTHO DIAPHRAGM ALL-FLEX (DIAPHRAGMDIAPHRAGM 65, DIAPHRAGM DIAPHRAGM 70,DIAPHRAGM DIAPHRAGM 75, DIAPHRAGMDIAPHRAGM 80)

BRAND

ORTHO DIAPHRAGM COIL (DIAPHRAGM KIT 100,DIAPHRAGM KIT 105) BRAND QL 1 / 180 Days

ORTHO DIAPHRAGM COIL KIT 50 MM BRAND QL 1 / 365 Days

ORTHO DIAPHRAGM FLAT (DIAPHRAGM KIT 55,DIAPHRAGM KIT 60, DIAPHRAGM KIT 65, DIAPHRAGMKIT 70, DIAPHRAGM KIT 75, DIAPHRAGM KIT 80,DIAPHRAGM KIT 85, DIAPHRAGM KIT 90, DIAPHRAGMKIT 95)

BRAND QL 1 / 180 Days

ULTILET INSULIN SYRINGE (MISC 7/16" 0.5 ML, MISC7/16" 0.3 ML, MISC 7/16" 1 ML) BRAND MDD 5 per day

ASSORTED CLASSES

*sodium polystyrene sulfonate powder** generic QL 454 / claim

AZASAN (TAB 75 MG, TAB 100 MG) BRAND MDD 3 per day

azathioprine tab 50 mg generic

CUPRIMINE CAP 250 MG BRAND

cyclosporine (cap 25 mg, cap 100 mg) generic MDD 4 per day

cyclosporine modified (for microemulsion) (cap 25 mg, cap50 mg, cap 100 mg) generic MDD 4 per day

cyclosporine modified oral soln 100 mg/ml generic MDD 8 per day

mycophenolate mofetil cap 250 mg generic MDD 2 per day

mycophenolate mofetil for oral susp 200 mg/ml generic MDD 15 per day

mycophenolate mofetil tab 500 mg generic MDD 4 per day

mycophenolate sodium tab dr 180 mg (mycophenolic acidequiv) generic MDD 2 per day

mycophenolate sodium tab dr 360 mg (mycophenolic acidequiv) generic MDD 4 per day



RAPAMUNE SOLUTION 1 MG/ML BRAND MDD 4 per day

sirolimus tab 0.5 mg generic

sirolimus tab 1 mg generic MDD 6 per day

sirolimus tab 2 mg generic MDD 2 per day

sodium polystyrene sulfonate oral susp 15 gm/60ml generic

tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg) generic MDD 3 per day


Index of covered drugsAA-200 15abacavir sulfate 24abacavir sulfate-lamivudine-zidovudine 25acebutolol hcl 40acetaminophen 10acetaminophen w/ codeine 62acetaminophen w/ dm 5acetazolamide 44acetic acid (otic) 78acetylcysteine 47ACNE MEDICATION 5 15acyclovir 25acyclovir topical 79ADRENACLICK 45ADRENALIN 46ADVAIR DISKUS 47ADVAIR HFA 47AEROSPAN 48AIMSCO LUBRICATED 18albuterol sulfate 48alcohol swabs 18alendronate sodium 38ALER-DRYL 3ALKERAN 29ALLEGRA ALLERGY CHILDRENS 3allopurinol 66ALOCRIL 75ALOMIDE 75ALORA 30alprazolam 53alum & mag hydrox-simethicone 8aluminum chloride 79aluminum hydroxide gel 8amantadine hcl 67amiloride & hydrochlorothiazide 44amiloride hcl 44aminocaproic acid 75aminophylline 48amiodarone hcl 42

amitriptyline hcl 54amlodipine besylate 41amlodipine besylate-benazepril hcl 42amoxapine 54amoxicillin 21amoxicillin & pot clavulanate 21amphetamine-dextroamphetamine 59ampicillin 21AMPICILLIN 21ANALPRAM-HC 79anastrozole 29ANDRODERM 30ANDROXY 30antipyrine-benzocaine 78APEXICON E 80APIDRA 34APIDRA SOLOSTAR 34apraclonidine hcl 76APTIVUS 25ARIAL CHAMBER 18aripiprazole 56ARMOUR THYROID 38artificial tear ointment 14artificial tear solution 14ASACOL 51ascorbic acid 11aspirin 10aspirin buffered 10aspirin buffered (cal carb-mag carb-mag oxide) 10aspirin tab chew 81 mg 10atenolol 40atenolol & chlorthalidone 42atorvastatin calcium 45ATRIPLA 25atropine sulfate (ophthalmic) 76ATROVENT HFA 48AVANDAMET 34AVANDARYL 34AVANDIA 34AVONEX 60AVONEX PEN 60


AVONEX PREFILLED 60AXID AR 8AZASAN 86azathioprine 86azelastine hcl 46AZELASTINE HCL 84azelastine hcl (ophth) 76azithromycin 22AZOPT 76

Bb complex w/ c 12b-complex vitamins 12b-complex w/ c & folic acid 69bacitracin (ophthalmic) 76bacitracin (topical) 15bacitracin zinc 16bacitracin-polymyxin b (ophth) 76baclofen 68BACTROBAN NASAL 46balsalazide disodium 51BD AUTOSHIELD 84BD GLUCOSE 3BD INSULIN SYRINGE 84BD INSULIN SYRINGE MICROFINE 84BD INSULIN SYRINGE ULTRAFINE 84benazepril & hydrochlorothiazide 42benazepril hcl 42benzonatate 47benzoyl peroxide 16benztropine mesylate 68betamethasone dipropionate augmented 80betamethasone valerate 80betaxolol hcl (ophth) 76bethanechol chloride 52BETOPTIC-S 76bicalutamide 29BIOSPEC DMX 5BIOTENE MOISTURIZING MOUTH 15BIOTENE ORALBALANCE DRY MOUTH 15bisacodyl ec tab dr 5 mg 7

bisacodyl laxative suppos 10 mg 7bismuth subsalicylate 8bisoprolol & hydrochlorothiazide 42bisoprolol fumarate 40BLEPHAMIDE 76BLEPHAMIDE S.O.P. 76BREO ELLIPTA 48brimonidine tartrate 76BRINTELLIX 54bromocriptine mesylate 68brompheniramine & phenyleph 5brompheniramine & pseudoeph 5budesonide (inhalation) 48bumetanide 44bupropion hcl 54bupropion hcl (smoking deterrent) 60bupropion hcl er (sr) tab er 12h 100 mg 54bupropion hcl er (sr) tab er 12h 150 mg 54buspirone hcl 53butalbital-acetaminophen 62butalbital-acetaminophen-caffeine 62butalbital-acetaminophen-caffeine w/ codeine 62butalbital-aspirin-caffeine 62butalbital-aspirin-caffeine w/cod 62BYDUREON 34BYETTA 10 MCG PEN 35BYETTA 5 MCG PEN 35

Ccaffeine citrate 59calcipotriene 80calcitonin (salmon) 38calcitriol 38calcium acetate (phosphate binder) 51calcium carbonate 13calcium carbonate (antacid) 8calcium carbonate-cholecalciferol 13calcium carbonate-vitamin d 13calcium polycarbophil 7camphor & menthol 16capsaicin 16


captopril 42CAPZASIN-P 16CARAFATE 50carbamazepine 66carbamide peroxide (otic) 14carbidopa 68carbidopa & levodopa odt 10-100 mg 68carbidopa & levodopa odt 25-100 mg 68carbidopa & levodopa odt 25-250 mg 68carbidopa-levodopa 68carteolol hcl (ophth) 76carvedilol 40CASTIVA WARMING 16CAVAN PRENATAL/EC CALCIUM 69CAVAN-FOLATE OB 69cefaclor 21CEFACLOR 21cefadroxil 21cefdinir 22cefprozil 22CEFTIN 22ceftriaxone sodium 22cefuroxime axetil 22celecoxib 64cephalexin 22cetirizine hcl 3cetirizine hcl allergy child solution 5 mg/5ml 3cetirizine hcl chew tab 10 mg 4cetirizine hcl chew tab 5 mg 4cetirizine hcl tab 10 mg 4cetirizine-pseudoephedrine 5CHANTIX 60CHANTIX CONTINUING MONTH PAK 60CHANTIX STARTING MONTH PAK 60CHEK-STIX CONTROL 84CHEMET 83CHEMSTRIP K 84childrens loratadine syrup 5 mg/5ml 4chlordiazepoxide hcl 54chlorhexidine gluconate 18chlorhexidine gluconate (mouth-throat) 79

chloroquine phosphate 28chlorothiazide 44chlorpheniramine & phenylephrine 5chlorpheniramine maleate 4chlorpheniramine maleate tab 4 mg 4chlorpheniramine tannate-phenylephrine tannate 47chlorpheniramine-dm 5chlorpheniramine-pseudoephedrine-acetaminophen 5chlorpromazine hcl 56,57chlorthalidone 44chlorzoxazone 68CHOLBAM 51cholecalciferol 11cholestyramine 45cholestyramine light 45choline & mag salicylate 62cilostazol 75CILOXAN 76cimetidine 8,50cimetidine hcl 50CIPRODEX 78ciprofloxacin hcl 23ciprofloxacin hcl (ophth) 76citalopram hydrobromide 54clarithromycin 23CLEAN & CLEAR ADVANTAGE 3-IN-1 16clemastine fumarate tab 1.34 mg 4clindamycin hcl 28clindamycin palmitate hydrochloride 28clindamycin phosphate (topical) 80clindamycin phosphate vaginal 53clindamycin phosphate-benzoyl peroxide 80clobetasol propionate 80clobetasol propionate emollient base 80clomipramine hcl 55clonazepam 66clonidine hcl 42clopidogrel bisulfate 75clorazepate dipotassium 54clotrimazole (topical) 16clotrimazole vaginal 9


clotrimazole w/ betamethasone 80clozapine 57clozapine odt 100 mg 57clozapine odt 25 mg 57clozapine odt 50 mg 57clozapine orally disintegrating tab 100 mg 57clozapine orally disintegrating tab 25 mg 57CO-NATAL FA 69coal tar extract 16COARTEM 28codeine sulfate 62colchicine 66colchicine w/ probenecid 66colestipol hcl 45COMBIPATCH 30COMBIVENT 48COMBIVENT RESPIMAT 48COMPLERA 25complete ready-to-use enema enema 7-19 gm/118ml 7COMPLETE-RF PRENATAL 69COMPLETENATE 69CONCEPTROL INSERTS 9COPAXONE 61COREG CR 40cortisone acetate 29CREON 51CRIXIVAN 25cromolyn sodium 48cromolyn sodium (nasal) 4cromolyn sodium (ophth) 76CUPRIMINE 86CVS DRY MOUTH 15CVS NASAL MIST 4cyanocobalamin 74cyclobenzaprine hcl 68CYCLOGYL 76cyclopentolate hcl 76cyclophosphamide 29cyclosporine 86cyclosporine modified (for microemulsion) 86cyproheptadine hcl 46

Ddapsone 28DECON-A 5,47DELZICOL 51DEPO-SUBQ PROVERA 104 31dermatological products, misc. 15desipramine hcl 55desmopressin acetate 39desmopressin acetate refrigerated 39desmopressin acetate spray 39desmopressin acetate spray refrigerated 39desogestrel-ethinyl estradiol (triphasic) 31Desogestrel-Ethinyl Estradiol TAB 0.15-0.02/0.01 MG(Azurette, Kariva, Pimtrea, Viorele, Caziant, Cesia,Velivet) 31Desogestrel-Ethinyl Estradiol TAB 0.15-30 MG-MCG(Apri, Emoquette, Enskyce, Reclipsen, Solia) 32dexamethasone 30DEXAMETHASONE INTENSOL 30dexamethasone sodium phosphate 30dexamethasone sodium phosphate (ophth) 76DEXCHLORPHENIRAMINE MALEATE 46dextroamphetamine sulfate 60dextromethorphan polistirex er liquid er 30 mg/5ml 5dextromethorphan-doxylamine-acetaminophen 5dextromethorphan-guaifenesin 5dextromethorphan-phenylephrine-acetaminophen 5dextrose (diabetic use) 3diazepam 54diazepam (anticonvulsant) 66dibucaine 16dibucaine (rectal) 15diclofenac potassium 64diclofenac sodium 64diclofenac sodium (ophth) 76dicloxacillin sodium 21dicyclomine hcl 50didanosine 25diflorasone diacetate 80diflunisal 62


digoxin 39dihydroergotamine mesylate 65DILANTIN 67diltiazem hcl 41diltiazem hcl coated beads 41diltiazem hcl extended release beads 41dimenhydrinate 8DIMETAPP LONG ACT COUGH/COLD 5diphenhydramine hcl 4diphenhydramine hcl (sleep) 9diphenhydramine hcl (topical) 16diphenhydramine hcl cap 25 mg 4diphenhydramine hcl cap 50 mg 4,46diphenhydramine hcl elixir 12.5 mg/5ml 4diphenhydramine hcl liquid 12.5 mg/5ml 4diphenhydramine-acetaminophen (sleep) 9diphenoxylate w/ atropine 50dipyridamole 75disopyramide phosphate 42disulfiram 61divalproex sodium 67docusate sodium 7docusate sodium cap 100 mg 7donepezil hydrochloride 61dorzolamide hcl 76dorzolamide hcl-timolol maleate 76doxazosin mesylate 42doxepin hcl 55doxycycline hyclate 23doxylamine succinate (sleep) 9DRAMAMINE 8DRITHO-CREME HP 80drospirenone-ethinyl estradiol 32Drospirenone-Ethinyl Estradiol TAB 3-0.03 MG (Gianvi,Loryna, Nikki, Vestura, Ocella, Syeda, Zarah) 32DROXIA 74DRY MOUTH SPRAY 15DULERA 48duloxetine hcl 55DUTOPROL 43

EE.E.S. GRANULES 23econazole nitrate 80EDURANT 25EFFIENT 75ELEXA NATURAL FEEL 18ELEXA STIMULATING 18ELEXA ULTRA SENSITIVE 18ELIDEL 80ELIXOPHYLLIN 48ELLA 32ELMIRON 53emollient 16EMTRIVA 25enalapril maleate 43enalapril maleate & hydrochlorothiazide 43ENBREL 64ENBREL SURECLICK 64ENCARE 9enoxaparin sodium 74EPANED 43EPIFOAM 80EPINEPHRINE 45EPIPEN 45EPIPEN 2-PAK 45EPIPEN JR 45EPIPEN JR 2-PAK 45EPZICOM 25ergocalciferol 68ergoloid mesylates 61ERY-TAB 23ERYPED 200 23ERYPED 400 23ERYTHROCIN STEARATE 23erythromycin (acne aid) 80erythromycin (ophth) 76erythromycin base 23erythromycin-sulfisoxazole 28ESCAVITE LQ 69escitalopram oxalate 55


esterified estrogens & methyltestosterone 31ESTRACE 53ESTRADERM 31estradiol 31estradiol & norethindrone acetate 31estropipate 31ethambutol hcl 24ethosuximide 67Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35MCG (Kelnor, Zovia) 32etodolac 64EURAX 80EXELON 61exemestane 29

Ffamotidine 8,50FANTASY LUBRICATED 18FANTASY LUBRICATED/SPERMICIDE 18FARESTON 29felbamate 67felodipine 41fenofibrate 45fenofibrate micronized 45fentanyl 62ferrous fumarate 13ferrous fumarate-fa-b complex-c-zn-mg-mn-cu 74ferrous gluconate 13FERROUS GLUCONATE 13ferrous sulfate 14ferrous sulfate dried 14fexofenadine hcl tab 180 mg 4fexofenadine hcl tab 60 mg 4fiber cap 0.52 gm 7finasteride 53FIRST-OMEPRAZOLE 50FIRST-VANCOMYCIN 25 28FIRST-VANCOMYCIN 50 28flavoxate hcl 52flecainide acetate 42FLOVENT DISKUS 48

FLOVENT HFA 48fluconazole 24fludrocortisone acetate 30flunisolide (nasal) 46fluocinolone acetonide (otic) 78fluocinonide 80fluocinonide emulsified base 80fluorometholone (ophth) 76fluorouracil (topical) 81fluoxetine hcl 55fluphenazine decanoate 57fluphenazine hcl 57FLURA-DROPS 73flurazepam hcl 59flurbiprofen 64flurbiprofen sodium 76flutamide 29fluticasone propionate 81fluticasone propionate (nasal) 46fluvoxamine maleate 55FML 77folic acid 14FORADIL AEROLIZER 48formaldehyde 83fosinopril sodium 43fosinopril sodium & hydrochlorothiazide 43furosemide 44

Ggabapentin 67GABITRIL 67galantamine hydrobromide 61gauze pads & dressings 18gemfibrozil 45gentamicin sulfate (ophth) 77gentamicin sulfate (topical) 81GESTICARE 69GILENYA 61ginger (zingiber officinalis) 18glatiramer acetate 61glimepiride 35


glipizide 35glipizide-metformin hcl 35GLUCAGEN DIAGNOSTIC 84GLUCAGEN HYPOKIT 35GLUCAGON EMERGENCY 35glyburide 35glyburide micronized 35glyburide-metformin 35glycerin (laxative) 7glycopyrrolate 50griseofulvin microsize 24griseofulvin ultramicrosize 24guaifenesin 6guaifenesin-codeine 6guanabenz acetate 43guanfacine hcl 43GYNAZOLE-1 53GYNOL II 9

Hhaloperidol 57haloperidol decanoate 57haloperidol lactate 57HARVONI 25HEMANGEOL 40heparin sodium (porcine) 75homatropine hbr 77HUMALOG 36HUMALOG KWIKPEN 35HUMALOG MIX 50/50 35HUMALOG MIX 50/50 KWIKPEN 35HUMALOG MIX 50/50 PEN 35HUMALOG MIX 75/25 35HUMALOG MIX 75/25 KWIKPEN 35HUMALOG MIX 75/25 PEN 35HUMALOG PEN 35HUMIRA 64HUMIRA PEDIATRIC CROHNS START 64HUMIRA PEN 65HUMIRA PEN-CROHNS STARTER 65HUMIRA PEN-PSORIASIS STARTER 65

HUMULIN 70/30 36HUMULIN N 36HUMULIN N KWIKPEN 36HUMULIN N PEN 36HUMULIN R 36hydralazine hcl 43hydrochlorothiazide 44hydrocodone w/ homatropine 47hydrocodone-acetaminophen 62,63hydrocortisone 30hydrocortisone (intrarectal) 79hydrocortisone (rectal) 79hydrocortisone (topical) 16,81hydrocortisone butyrate 81hydrocortisone w/acetic acid 79hydrocortisone-aloe vera 16hydromorphone hcl 63hydroquinone 81hydroxychloroquine sulfate 28hydroxyurea 29hydroxyzine hcl 54hydroxyzine pamoate 54hyoscyamine sulfate 50HYPERRHO S/D 28hypromellose (ophth) 14

Iibuprofen 10,65ibuprofen cap 200 mg 10ibuprofen tab 200 mg 10imipramine hcl 55imiquimod 81indapamide 44indomethacin 65INSPIREASE BAGS 84INSPIREASE MOUTHPIECE 84INSPIREASE RESERVOIR BAGS 84insulin pen needle 29 g x 12 mm (1/2") 84insulin pen needle 29 g x 12.7 mm 84insulin pen needle 30 g x 8 mm (1/3" or 5/16") 85insulin pen needle 31 g x 5 mm (3/16") 85


insulin pen needle 31 g x 6 mm (1/4") 85insulin pen needle 31 g x 8 mm (1/3" or 5/16") 85insulin pen needle 32 g x 4 mm (5/32") 85insulin pen needle 32 g x 5 mm (1/5" or 3/16") 85insulin pen needle 32 g x 6 mm (1/4") 85INSULIN SYRINGE 85insulin syringe (disp) u-100 1 ml 85insulin syringe/needle u-100 85insulin syringe/needle u-100 0.3 ml 30 x 1/2" 85insulin syringe/needle u-100 0.3 ml 30 x 3/8" 85insulin syringe/needle u-100 0.3 ml 31 x 5/16" 85insulin syringe/needle u-100 1 ml 25 x 1" 85insulin syringe/needle u-100 1 ml 25 x 5/8" 85insulin syringe/needle u-100 1 ml 27 x 1/2" 85insulin syringe/needle u-100 1 ml 30 x 1/2" 85insulin syringe/needle u-100 1/2 ml 27 x 1/2" 85insulin syringe/needle u-100 1/2 ml 30 x 1/2" 85insulin syringe/needle u-100 1/2 ml 30 x 3/8" 85insulin syringe/needle u-100 1/2 ml 31 x 5/16" 85INTELENCE 25INVIRASE 25IOPIDINE 77ipratropium bromide 48ipratropium bromide (nasal) 46ipratropium-albuterol 49irbesartan 43irbesartan-hydrochlorothiazide 43IRON 14IRON CHEWS PEDIATRIC 14ISENTRESS 25isoniazid 24ISONIAZID 24ISOPTO CARBACHOL 77ISOPTO HOMATROPINE 77isosorbide dinitrate 40isosorbide mononitrate 40isotretinoin 81itraconazole 24

JJADENU 83

JENTADUETO 36

KKALETRA 25,26KAMELEON LUBRICATED 18KERALYT 16KETOCARE 84ketoconazole (topical) 81ketoprofen 65ketorolac tromethamine 65ketorolac tromethamine (ophth) 77KETOSTIX 84ketotifen fumarate (ophth) 14KIMONO 19KIMONO MICRO THIN 18KIMONO MICRO THIN PLUS 19KIMONO PLUS 19KIMONO PS 19KIMONO PS PLUS 19KIMONO SENSATION 19KIMONO SENSATION PLUS 19KLOR-CON M15 73KOMBIGLYZE XR 36KPN PRENATAL 12

Llabetalol hcl 40lactic acid (ammonium lactate) 16LACTOCAL-F 70lactulose 49lactulose (encephalopathy) 52lamivudine 26lamivudine-zidovudine 26lamotrigine 67lancet devices 84lancets 84lanolin 20lanolin (topical) 15lansoprazole 8,50LANTUS 36LANTUS SOLOSTAR 36


latanoprost 77leflunomide 65letrozole 29leucovorin calcium 29LEUKERAN 29LEVEMIR 36LEVEMIR FLEXPEN 36LEVEMIR FLEXTOUCH 36levetiracetam 67levobunolol hcl 77levocarnitine (metabolic modifiers) 39levofloxacin 23Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab0.01MG(7) (Amethia, Camrese, Daysee) 32Levonorgest-Eth Estrad 91-Day TAB 0.15-0.03 MG(Introvale, Jolessa, Quasense) 32levonorgestrel (emergency oc) 3,32Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-30MG (Enpresse, Levonest, Myzilra, Trivora) 32Levonorgestrel-Ethinyl Estrad TAB 0.1-20 MG (Aubra,Aviane, Delyla, Falmina, Lessina, Lutera, Orsythia,Sronyx) 32Levonorgestrel-Ethinyl Estrad TAB 0.15-30 MG(Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia)32levothyroxine sodium 38LEXIVA 26LICIDE TREATMENT 17lidocaine 81lidocaine hcl 17,81lidocaine hcl (mouth-throat) 79lidocaine-prilocaine 81liothyronine sodium 38lisinopril 43lisinopril & hydrochlorothiazide 43lithium 57lithium carbonate 57LITTLE REMEDIES FOR COLDS 6LOHIST-D 6loperamide hcl 8loperamide hcl tab 2 mg 8loratadine & pseudoephedrine 6

loratadine allergy relief tab disp 10 mg 4loratadine tab 10 mg 4lorazepam 54losartan potassium 43losartan potassium & hydrochlorothiazide 43lovastatin 45loxapine succinate 57LUFYLLIN 49

Mmagnesium citrate solution 1.745 gm/30ml 7magnesium oxide 8magnesium oxide (mg supplement) 13malathion 81maprotiline hcl 55MARNATAL-F PLUS DUO PACK 70MAXX 19MAXX PLUS 19meclizine hcl 8MEDI-GRAINE 6medroxyprogesterone acetate 34medroxyprogesterone acetate (contraceptive) 32mefloquine hcl 28megestrol acetate 29melatonin 18meloxicam 65memantine hcl 61meperidine hcl 63MEPHYTON 69meprobamate 54mercaptopurine 29mesalamine 52metaproterenol sulfate 49metformin hcl 36methadone hcl 63methazolamide 44methenamine mandelate 52methenamine-hyosc-methylene blue-sod phos-phenylsal 52methimazole 38METHITEST 30


methocarbamol 68methotrexate sodium 29methyldopa 43methylergonovine maleate 38methylphenidate hcl 60methylprednisolone 30metipranolol 77metoclopramide hcl 52metolazone 44metoprolol & hydrochlorothiazide 43metoprolol succinate 40metoprolol tartrate 40metronidazole 28metronidazole (topical) 81metronidazole cream 0.75 % 81metronidazole gel 0.75 % 81metronidazole vaginal 53mexiletine hcl 42MIACALCIN 39MICONAZOLE 3 53miconazole nitrate (topical) 17miconazole nitrate vaginal 9midazolam hcl 59midodrine hcl 45milk of magnesia suspension 400 mg/5ml 7MILLIPRED 30MINIVELLE 31minocycline hcl 23minoxidil 43mirtazapine 55misoprostol 50MISSION PRENATAL 12MISSION PRENATAL FA 12MISSION PRENATAL HP 12MOI-STIR 15mometasone furoate 81montelukast sodium 49morphine sulfate 63MOUTH KOTE 15multiple vitamin 11multiple vitamins w/ iron 11

multiple vitamins w/ minerals 12mupirocin 82mupirocin calcium (topical) 82mycophenolate mofetil 86mycophenolate sodium 86MYLERAN 29MYNATAL 70MYNATAL PLUS 70MYNATAL-Z 70MYNATE 90 PLUS 70

Nnabumetone 65nadolol 40naltrexone hcl 83naphazoline w/ pheniramine 14naproxen 65naproxen sodium 10,65naproxen sodium tab 220 mg 10naratriptan hcl 65nasal moisturizing spray solution 0.65 % 4NATACHEW 70NATAL-V RX 70NATALVIT 70nateglinide 36NATURE-THROID 38NECON 1/50 (28) 32NECON 10/11 (28) 32nefazodone hcl 55neomycin sulfate 23neomycin-bacitracin zn-polymyxin 77neomycin-bacitracin-polymyxin 15neomycin-polymy-dexameth 77neomycin-polymyxin w/ pramoxine 17neomycin-polymyxin-gramicidin 77neomycin-polymyxin-hc (ophth) 77neomycin-polymyxin-hc (otic) 79NESSI SPACER WITH MASK LARGE 19NESSI SPACER WITH MASK SM/MED 19NESSI SPACER WITH MOUTHPIECE 19NEVANAC 77


nevirapine 26NEXIUM 24HR 8niacin 11NIACOR 45nicardipine hcl 41nicotine 9NICOTINE 10nicotine polacrilex 10NICOTROL 61NICOTROL NS 61nifedipine 41NITRO-BID 40nitrofurantoin 52nitrofurantoin macrocrystal 52nitrofurantoin monohyd macro 52nitroglycerin 40NIX LICE CONTROL 17NIZORAL A-D 17NORDITROPIN 39NORDITROPIN FLEXPRO 39NORDITROPIN NORDIFLEX PEN 39Norelgestromin-Ethinyl Estradiol TD PTWK 150-35MCG/24HR (Xulane) 33Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG(Balziva, Briellyn, Gildagia, Philith, Vyfemla,Zenchent) 33Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG(Necon, Nortrel, Wera) 33Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG(Alyacen, Cyclafem, Dasetta, Necon, Nortrel,Pirmella) 33Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20MCG (Gildess, Junel, Larin, Microgestin) 33Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG-30MCG (Gildess, Junel, Larin, Microgestin) 33Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20MCG (Gildess, Junel, Larin, Microgestin) 33Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG-30 MCG (Gildess, Junel, Larin, Microgestin) 33norethindrone acetate 34

Norethindrone Tab 0.35 MG (Camila, Deblitane, Errin,Heather, Jencycla, Jolivette, Lyza, Nora-BE, Norlyroc,Sharobel) 33Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35MG (Alyacen, Cyclafem, Dasetta, Necon, Nortrel,Pirmella) 33Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35MG (Aranelle, Leena) 33Norgestimate & Ethinyl Estradiol Tab 0.25 MG-35 MCG(Estarylla, Mono-Linyah, MonoNessa, Previfem,Sprintec) 33Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35MG (Tri-Estarylla, Tri-Linyah, Tri-Previfem, Tri-Sprintec, Trinessa) 33Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30 MCG(Cryselle, Elinest, Low-Ogestrel) 33NORINYL 1+50 (28) 34NORPACE CR 42nortriptyline hcl 55NORVIR 26NOVA MAX PLUS KETONE TEST 18NOVOLIN 70/30 36NOVOLIN 70/30 RELION 36NOVOLIN N 37NOVOLIN N RELION 37NOVOLIN R 37NOVOLIN R RELION 37NOVOLOG 37NOVOLOG FLEXPEN 37NOVOLOG MIX 70/30 37NOVOLOG MIX 70/30 FLEXPEN 37NOVOLOG PENFILL 37NUTRICION PORVIDA 12NUVARING 34nystatin 24nystatin (mouth-throat) 79nystatin (topical) 82nystatin-triamcinolone 82

OO-CAL PRENATAL 70


ofloxacin 23ofloxacin (ophth) 77ofloxacin (otic) 79OGESTREL 34olanzapine 58omega-3 fatty acids 13omeprazole 50omeprazole delayed release tab 20 mg 8OMEPRAZOLE+SYRSPEND SF ALKA 50ondansetron hcl 51ondansetron orally disintegrating tab 4 mg 51ondansetron orally disintegrating tab 8 mg 51ONETOUCH ULTRA 2 85ONETOUCH ULTRA BLUE 84ONETOUCH ULTRA MINI 85ONETOUCH ULTRA SYSTEM 85ONETOUCH ULTRASMART 86ONETOUCH VERIO 84ONGLYZA 37OPTICHAMBER FACE MASK-LARGE 19OPTICHAMBER FACE MASK-MEDIUM 19OPTICHAMBER FACE MASK-SMALL 19OPTIONS GYNOL II CONTRACEPTIVE 9oral electrolytes 13ORAL RELIEF SPRAY 15ORKAMBI 49ORTHO DIAPHRAGM ALL-FLEX 86ORTHO DIAPHRAGM COIL 86ORTHO DIAPHRAGM FLAT 86oxaprozin 65oxazepam 54oxcarbazepine 67oxybutynin chloride 52oxycodone hcl 63oxycodone w/ acetaminophen 63oxycodone-aspirin 63OXYCONTIN 64oyster shell 13

PPANCREAZE 51

pancrelipase (lipase-protease-amylase) 51pantoprazole sodium 50paroxetine hcl 55,56PARVA-CAL 13PCE 23ped multivitamins w/fl & iron 69pediatric multiple vitamin w/ c 11pediatric multiple vitamin w/ c & fa 11pediatric multiple vitamins w/ iron 11pediatric multivitamins w/fl 69,71pediatric vitamins acd fluoride & iron 69pediatric vitamins acd w/ fluoride 71pediatric vitamins adc 11peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 50peg 3350-potassium chloride-sod bicarbonate-sodchloride 49penicillin v potassium 21PENTASA 52pentoxifylline 75permethrin 17,82permethrin & pyrethrins-piperonyl butoxide 17perphenazine 58perphenazine-amitriptyline 61PERRY PRENATAL 12phenazopyridine hcl 53phenelzine sulfate 56phenobarbital 59phenobarbital-hyoscyamine-atropine-scopolamine 50phenyleph-promethazine w/ cod 47phenylephrine hcl (ophth) 77phenylephrine hcl tab 10 mg 4phenylephrine-chlorpheniramine w/ dm-gg 47phenylephrine-dm 6phenylephrine-guaifenesin 6phenylephrine-shark liver oil-cocoa butter 15phenylephrine-shark liver oil-mineral oil-petrolatum 15phenytoin 67phenytoin sodium extended 67PHRENILIN FORTE 62pilocarpine hcl 77pilocarpine hcl (oral) 79


PIN-X 3pindolol 41pioglitazone hcl 37pioglitazone hcl-metformin hcl 37piroxicam 65PLEGRIDY 61PLEGRIDY STARTER PACK 61PNV FE FUM/DOCUSATE/FOLIC ACID 71PNV PRENATAL PLUS MULTIVITAMIN 12podofilox 82POLYCOSE 13polyethylene glycol 3350 7polyethylene glycol 3350 (bulk) 20polymyxin b-trimethoprim 77polysaccharide iron complex 14POLYSPORIN 17polyvinyl alcohol 14pot phosphate monobasic w/ sod phosphate dibasic &monobasic 73potassium bicarbonate 73potassium chloride 73potassium chloride microencapsulated crystals cr 73potassium citrate (alkalinizer) 53potassium citrate-citric acid 53pramipexole dihydrochloride 68pramoxine hcl (rectal) 15pramoxine-chloroxylenol 79pramoxine-hc 82pramoxine-hc-chloroxylenol 79pramoxine-hc-chloroxylenol aqueous 79pravastatin sodium 45prazosin hcl 43PRECISION XTRA KETONE 18PRED MILD 77PRED-G 78prednicarbate 82prednisolone 30prednisolone acetate (ophth) 78prednisolone sodium phosphate 30PREDNISOLONE SODIUM PHOSPHATE 78prednisone 30

PREDNISONE INTENSOL 30PREMARIN 31,53PREMIUM CONDOMS LUBRICATED 19PREMPHASE 31PREMPRO 31PRENAFIRST 71PRENATABS FA 71PRENATABS RX 71PRENATAL 19 71PRENATAL PLUS IRON 71prenatal vit w/ ferrous fumarate-folic acid 11PREZISTA 26PRILOSEC OTC 8primaquine phosphate 28primidone 67PROAIR HFA 49probenecid 66prochlorperazine 58prochlorperazine maleate 58progesterone micronized 34promethazine & phenylephrine 47promethazine hcl 46promethazine hcl suppos 25 mg 46promethazine hcl suppos 50 mg 46promethazine w/codeine 47promethazine-dm 47propafenone hcl 42propranolol & hydrochlorothiazide 43propranolol hcl 41propylthiouracil 38PROVENTIL HFA 49pseudoephed-bromphen-dm 6,47pseudoephed-doxyl-dm w/apap 6pseudoephedrine hcl 4pseudoephedrine hcl er tab er 12h 120 mg 5pseudoephedrine hcl tab 30 mg 5pseudoephedrine w/ codeine-gg 6pseudoephedrine w/ dm-gg 6pseudoephedrine-acetaminophen-dextromethorphan 6pseudoephedrine-chlorphen-dm 6pseudoephedrine-guaifenesin 6


pseudoephedrine-ibuprofen 6psyllium 7PTS PANELS KETONE TEST 18PULMICORT FLEXHALER 49PURIXAN 29pyrantel pamoate 3pyrazinamide 24pyrethrins-piperonyl butoxide 17pyrethrins-piperonyl butoxide-permethrin-nit remover17pyridostigmine bromide 68pyridoxine hcl 11pyrithione zinc 17

Qquetiapine fumarate 58quinapril hcl 44quinidine gluconate 42quinidine sulfate 42

RRA CALCIUM HI-CAL/VITAMIN D 13RA DRY MOUTH 15raloxifene hcl 39ramipril 44ranitidine hcl 8,50,51RAPAMUNE 87RE PRENATAL MULTIVITAMIN/IRON 71RE-NATA 29 OB 71REALITY LATEX/ULTRA TEXTURED 19REALITY LATEX/ULTRA THIN 19REESES PINWORM MEDICINE 3RELENZA DISKHALER 26RELION 70/30 37RELION KETONE 84RELION N 37RELION R 37RELPAX 65RESCRIPTOR 26reserpine 44respiratory therapy supplies 18REYATAZ 26

RHEUMATREX 65RHOGAM ULTRA-FILTERED PLUS 28riboflavin 11RID ESSENTIAL LICE ELIMINATION 17rifampin 24risedronate sodium 39risperidone 58risperidone odt (tab 3 mg, tab 4 mg) 58risperidone orally disintegrating tab 0.25 mg 58risperidone orally disintegrating tab 0.5 mg 58risperidone orally disintegrating tab 1 mg 58risperidone orally disintegrating tab 2 mg 58rivastigmine 61rivastigmine tartrate 61rizatriptan benzoate 66ropinirole hydrochloride 68ROXICET 64

Ssalsalate 62SAVELLA 62SAVELLA TITRATION PACK 62SCHOOLTIME SHAMPOO 17SCOT-TUSSIN SENIOR 7SE-NATAL 19 72SE-NATAL 90 72SE-NATAL ONE 72selegiline hcl 68selenium sulfide 17,82SELZENTRY 26senna tab 8.6 mg 7senna-docusate sodium tab 8.6-50 mg 7sennosides 7SEREVENT DISKUS 49sertraline hcl 56SFROWASA 52silver sulfadiazine 82simethicone 9SIMPLYTHICK 20simvastatin 46sirolimus 87


SIVEXTRO 28skin protectants, misc. 15soap & cleansers 17sodium bicarbonate (antacid) 8sodium chloride 73sodium chloride (gu irrigant) 53sodium chloride (inhalant) 7,47sodium chloride flush 73sodium citrate & citric acid 53sodium fluoride 73sodium fluoride (dental) 15,79sodium polystyrene sulfonate 86,87sodium polystyrene sulfonate (bulk) 84sorbitol 20sorbitol (laxative) 7sotalol hcl 41sotalol hcl (afib/afl) 41SOVALDI 26SPINOSAD 82spironolactone 44spironolactone & hydrochlorothiazide 44SSKI 73stannous fluoride 15,79stavudine 26,27STRIBILD 27SUBOXONE 64sucralfate 51SUDAFED PE CHILDRENS 5sulfacetamide sod-prednisolone 78sulfacetamide sodium 82sulfacetamide sodium (acne) 82sulfacetamide sodium (ophth) 78sulfacetamide sodium w/ sulfur 82sulfamethoxazole-trimethoprim 28sulfasalazine 52sulindac 65sumatriptan nasal spray (5 mg/act, 20 mg/act) 66sumatriptan succinate 66SUSTIVA 27SYMBICORT 49SYMLINPEN 120 37

SYMLINPEN 60 37

Ttacrolimus 87tacrolimus (topical) 82TAMIFLU 27tamoxifen citrate 29tamsulosin hcl 53TARON-EC CAL 72TAZORAC 82TECFIDERA 62TEGRETOL-XR 67temazepam 59temozolomide 29terazosin hcl 44terbinafine hcl 24terbinafine hcl (topical) 17terbutaline sulfate 49terconazole vaginal 53testosterone cypionate 30tetrahydrozoline hcl (ophth) 14THEO-24 49theophylline 49THERANATAL CORE NUTRITION 12thiamine hcl 11thiamine mononitrate 11thioridazine hcl 59thiothixene 59thyroid 38THYROLAR-1 38THYROLAR-1/2 38THYROLAR-1/4 38THYROLAR-2 38THYROLAR-3 38tiagabine hcl 67TIKOSYN 42timolol maleate 41timolol maleate (ophth) 78TIMOPTIC OCUDOSE 78tioconazole vaginal 9tizanidine hcl 68


TOBRADEX 78tobramycin 23tobramycin (ophth) 78tobramycin sulfate 24TOBRAMYCIN SULFATE IN SALINE 24tobramycin-dexamethasone 78TOBREX 78tolmetin sodium 65tolnaftate 17tolterodine tartrate 52topiramate 67torsemide 44TRADJENTA 37tramadol hcl 64tramadol-acetaminophen 64trandolapril 44tranexamic acid 75tranylcypromine sulfate 56trazodone hcl 56TRECATOR 24tretinoin 83TREXALL 29TRI-VI-SOL/IRON 12triamcinolone acetonide (mouth) 79triamcinolone acetonide (nasal) 5triamcinolone acetonide (topical) 83TRIAMINIC COLD/COUGH DAY TIME 7triamterene & hydrochlorothiazide 44triazolam 59trifluoperazine hcl 59trifluridine 78trihexyphenidyl hcl 68trimethoprim 28TRINATAL RX 1 72TROJAN MAGNUM WARM SENSATIONS 19TROJAN SUPRAS SPERMICIDAL 19TROJAN TWISTED PLEASURE 19tropicamide 78trospium chloride 53TRUSTEX COLOR CONDOMS + LUBE 19TRUSTEX LUB/RIBBED/STUDDED 19

TRUSTEX LUB/SPERMICIDE EX ST 19TRUSTEX LUB/SPERMICIDE XL 20TRUSTEX LUBRICATED 20TRUSTEX LUBRICATED EX LARGE 20TRUSTEX LUBRICATED EXTRA ST 20TRUSTEX LUBRICATED/SPERMICIDE 20TRUSTEX NATURAL CONDOMS + LUBE 20TRUSTEX NON-LUBRICATED 20TRUSTEX RIA LUB/SPERMICIDE 20TRUSTEX RIA LUBRICATED 20TRUSTEX RIA NON-LUBRICATED 20TRUSTEX-NONOXYNOL-9/RIB/STUD 20TRUVADA 27TUDORZA PRESSAIR 49TWINJECT 45

UULTILET INSULIN SYRINGE 86urea 83ursodiol 52

Vvalacyclovir hcl 27valganciclovir hcl 27valproate sodium 67valproic acid 67valsartan 44valsartan-hydrochlorothiazide 44vancomycin hcl 28VCF VAGINAL CONTRACEPTIVE 9VENATAL-FA 72venlafaxine hcl 56VENLAFAXINE HCL ER 56VENTOLIN HFA 49verapamil hcl 42VERIPRED 20 30VEXOL 78VIDEX 27VIGAMOX 78VIIBRYD 56VINATE CALCIUM 72


VINATE M 72VINATE ONE 72VIRACEPT 27VIREAD 27VITAFOL-OB 72VITAFOL-PN 73vitamin e 11vitamins w/ lipotropics 13VITASPIRE 73VOL-TAB RX 73

Wwarfarin sodium 75WESTHROID 38WESTHROID-P 38white petrolatum-mineral oil 14WP THYROID 38

XXARELTO 75

Zzaleplon 59ZENPEP 51ZIAGEN 27zidovudine 27zinc (mouth-throat) 15zinc oxide (topical) 17zinc sulfate 13ziprasidone hcl 59zolmitriptan 66zolpidem tartrate 59ZOMIG 66zonisamide 67ZOVIA 1/50E (28) 34ZOVIRAX 83


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