Medicaid Drug Formulary - McLaren Health Plan€¦ · G-3245 Beecher Road • Flint, Michigan •...

G-3245 Beecher Road • Flint, Michigan • 48532 tel 888-327-0671 • fax 833-540-8648

McLarenHealthPlan.org

MHP20190104

Rev. 04/2020

Medicaid Drug Formulary

April 2020

Key

* Generic Available

AG Age Limits F Females Only

M Males Only

OTC Over the Counter P Preventive

PA Prior Authorization

QL Quantity Limit SP Specialty Pharmacy

ST Step Therapy

Table of Contents

Allergy.......................................................................................................................................................................................3Antiemesis/Antivertigo.............................................................................................................................................................. 7Asthma And Copd.................................................................................................................................................................... 8Autonomic Nervous System Disorders...................................................................................................................................13Behavioral Health - Antidepressants...................................................................................................................................... 13Behavioral Health - Other....................................................................................................................................................... 21Cardiovascular Disease - Arrhythmia..................................................................................................................................... 43Cardiovascular Disease - Cardiac Stimulant.......................................................................................................................... 44Cardiovascular Disease - Hypertension................................................................................................................................. 44Cardiovascular Disease - Lipid Irregularity.............................................................................................................................49Cardiovascular Disease - Miscellaneous Agents................................................................................................................... 52Cardiovascular Disease - Vasodilation...................................................................................................................................52Contraception/Oxytocics.........................................................................................................................................................53Cough And Cold..................................................................................................................................................................... 61Dermatology - Acne................................................................................................................................................................61Dermatology - Antiinfective.....................................................................................................................................................62Dermatology - Antiinflammatory............................................................................................................................................. 65Dermatology - Miscellaneous................................................................................................................................................. 67Dermatology - Psoriasis/Eczema........................................................................................................................................... 70Diabetes................................................................................................................................................................................. 70Ear - General Disorders..........................................................................................................................................................74Electrolyte Regulation.............................................................................................................................................................75Endocrine Disorder - Fertility .................................................................................................................................................. 76Endocrine Disorder - Other.....................................................................................................................................................76Endocrine Disorder - Thyroid..................................................................................................................................................78Eye - General Disorders......................................................................................................................................................... 79Eye - Glaucoma......................................................................................................................................................................81Eye - Miscellaneous............................................................................................................................................................... 82Gout And Related Diseases................................................................................................................................................... 84Hematological Disorders........................................................................................................................................................ 84Hormonal Deficiency.............................................................................................................................................................. 93Immunization.......................................................................................................................................................................... 94Immunosuppression/Modulation.............................................................................................................................................95Infectious Disease - Bacterial ................................................................................................................................................. 96Infectious Disease - Fungal .................................................................................................................................................... 99Infectious Disease - Miscellaneous........................................................................................................................................ 99Infectious Disease - Parasitic ............................................................................................................................................... 100Infectious Disease - Viral ......................................................................................................................................................101Inflammatory Disease...........................................................................................................................................................111Local Anesthesia.................................................................................................................................................................. 116Lower Gastrointestinal Disorders - Bowel Inflammat............................................................................................................116Lower Gastrointestinal Disorders - Other............................................................................................................................. 117Medical Supplies.................................................................................................................................................................. 125

1

Miscellaneous Agents...........................................................................................................................................................138Neoplastic Disease...............................................................................................................................................................139Neurological Disease - Miscellaneous..................................................................................................................................146Oral/Pharyngeal Disorders................................................................................................................................................... 147Other Drugs..........................................................................................................................................................................147Other Respiratory Disorders.................................................................................................................................................156Pain Management - Analgesics............................................................................................................................................157Parkinsons Disease..............................................................................................................................................................164Seizure Disorder...................................................................................................................................................................165Skeletal Muscle Disorder......................................................................................................................................................177Smoking Cessation...............................................................................................................................................................178Upper Gastrointestinal Disorders - Digestive....................................................................................................................... 179Upper Gastrointestinal Disorders - Spastic Disease............................................................................................................ 182Upper Gastrointestinal Disorders - Ulcer Disease................................................................................................................183Urinary Tract - Functional Disorders.....................................................................................................................................187Vaginal Disorders................................................................................................................................................................. 188Vitamin And/Or Mineral Deficiency.......................................................................................................................................189

2

Drug Status Notes

Allergy

Antihistamines - 1St GenerationALER-CAP ORAL CAPSULE 25 MG Tier 1 Age (Max 64 Years)

ALLER-CHLOR ORAL TABLET 4 MG Tier 1

ALLER-G-TIME ORAL TABLET 25 MG Tier 1 Age (Max 64 Years)

ALLERGY (CHLORPHENIRAMINE) ORAL TABLET 4 MG

Tier 1

ALLERGY (DIPHENHYDRAMINE) ORAL CAPSULE 25 MG

Tier 1 Age (Max 64 Years)

ALLERGY (DIPHENHYDRAMINE) ORAL LIQUID 12.5 MG/5 ML

Tier 1

ALLERGY (DIPHENHYDRAMINE) ORAL TABLET 25 MG


ALLERGY 4-HOUR ORAL TABLET 4 MG

Tier 1

ALLERGY MEDICATION ORAL CAPSULE 25 MG


ALLERGY MEDICINE ORAL TABLET 25 MG


ALLERGY ORAL LIQUID 12.5 MG/5 ML Tier 1

ALLERGY ORAL TABLET 25 MG Tier 1 Age (Max 64 Years)

ALLERGY RELIEF (CLEMASTINE) ORAL TABLET 1.34 MG

Tier 1

ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET 4 MG

Tier 1

ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL CAPSULE 25 MG


ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL LIQUID 12.5 MG/5 ML

Tier 1

ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL TABLET 25 MG


ALLERGY-TIME ORAL TABLET 4 MG Tier 1

BANOPHEN ORAL CAPSULE 25 MG, 50 MG


BANOPHEN ORAL TABLET 25 MG Tier 1 Age (Max 64 Years)

BENADRYL ALLERGY ORAL TABLET 25 MG


carbinoxamine maleate oral liquid 4 mg/5 ml

Tier 1

carbinoxamine maleate oral tablet 4 mg Tier 1

CHILDREN'S ALLERGY (DIPHENHYD) ORAL LIQUID 12.5 MG/5 ML

Tier 1

CHILDREN'S AURODRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML

Tier 1

CHILDREN'S DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/5 ML

Tier 1

CHILDREN'S WAL-DRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML

Tier 1

CHLORHIST ORAL TABLET 4 MG Tier 1

3

Drug Status Notes

chlorpheniramine maleate oral tablet 4 mg

(Aller-Chlor) Tier 1

chlorpheniramine maleate oral tablet extended release 12 mg

Tier 1

CHLORTABS ORAL TABLET 4 MG Tier 1

clemastine oral tablet 2.68 mg Tier 1

COMPLETE ALLERGY MEDICINE ORAL CAPSULE 25 MG


COMPLETE ALLERGY MEDICINE ORAL TABLET 25 MG


COMPLETE ALLERGY ORAL CAPSULE 25 MG


COMPLETE ALLERGY ORAL TABLET 25 MG


cyproheptadine oral syrup 2 mg/5 ml Tier 1 Age (Max 64 Years)

cyproheptadine oral tablet 4 mg Tier 1 Age (Max 64 Years)

DAYHIST ALLERGY ORAL TABLET 1.34 MG

Tier 1

DIPHEDRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML

Tier 1

DIPHEDRYL ORAL CAPSULE 25 MG Tier 1 Age (Max 64 Years)

DIPHEDRYL ORAL LIQUID 12.5 MG/5 ML

Tier 1

DIPHEDRYL ORAL TABLET 25 MG Tier 1 Age (Max 64 Years)

DIPHEN ORAL TABLET 25 MG Tier 1 Age (Max 64 Years)

DIPHENHIST ORAL CAPSULE 25 MG Tier 1 Age (Max 64 Years)

diphenhydramine hcl injection solution50 mg/ml


diphenhydramine hcl injection syringe 50 mg/ml


diphenhydramine hcl oral capsule 25 mg (Aler-Cap) Tier 1 Age (Max 64 Years)

diphenhydramine hcl oral capsule 50 mg (Banophen) Tier 1 Age (Max 64 Years)

diphenhydramine hcl oral liquid 12.5 mg/5 ml

(Allergy) Tier 1

diphenhydramine hcl oral syrup 12.5 mg/5 ml

Tier 1

diphenhydramine hcl oral tablet 25 mg (Aller-G-Time) Tier 1 Age (Max 64 Years)

GERI-DRYL ORAL LIQUID 12.5 MG/5 ML

Tier 1

GERI-DRYL ORAL TABLET 25 MG Tier 1 Age (Max 64 Years)

hydroxyzine hcl oral solution 10 mg/5 ml Tier 1 Age (Max 12 Years)

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg


hydroxyzine pamoate oral capsule 25 mg, 50 mg

(Vistaril) Tier 1 Age (Max 64 Years)

M-DRYL ORAL LIQUID 12.5 MG/5 ML Tier 1

NIGHTTIME ALLERGY RELIEF ORAL TABLET 25 MG


PHARBECHLOR ORAL TABLET 4 MG Tier 1

4

Drug Status Notes

PHARBEDRYL ORAL CAPSULE 25 MG, 50 MG


promethazine oral syrup 6.25 mg/5 ml Tier 1 Age (Min 2 Years and Max 64 Years)

promethazine oral tablet 12.5 mg, 25 mg, 50 mg

Tier 1 Age (Min 2 Years and Max 64 Years)

SILADRYL SA ORAL LIQUID 12.5 MG/5 ML

Tier 1

TOTAL ALLERGY MEDICINE ORAL TABLET 25 MG


VALU-DRYL ALLERGY ORAL CAPSULE 25 MG


WAL-DRYL ALLERGY ORAL CAPSULE 25 MG


WAL-DRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML

Tier 1

WAL-DRYL ALLERGY ORAL TABLET 25 MG


WAL-FINATE ORAL TABLET 4 MG Tier 1Antihistamines - 2Nd Generation24HOUR ALLERGY ORAL TABLET 10 MG

Tier 1 QL (1 EA per 1 day)

ALL DAY ALLERGY (CETIRIZINE) ORAL SOLUTION 1 MG/ML

Tier 1 QL (300 ML per 30 days); Age (Max 12 Years)

ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET 10 MG


ALLERCLEAR ORAL TABLET 10 MG Tier 1 QL (1 EA per 1 day)

ALLER-EASE ORAL TABLET 180 MG Tier 1 ST: Requires prior prescription for Cetirizine 10mg or Loratadine 10mg within the past 120 days

ALLER-FEX ORAL TABLET 180 MG Tier 1 ST: Requires prior prescription for Cetirizine 10mg or Loratadine 10mg within the past 120 days

ALLERGY RELIEF (CETIRIZINE) ORAL SOLUTION 1 MG/ML


ALLERGY RELIEF (CETIRIZINE) ORAL TABLET 10 MG


ALLERGY RELIEF (FEXOFENADINE) ORAL TABLET 180 MG

Tier 1 ST: Requires prior prescription for Cetirizine 10mg or Loratadine 10mg within the past 120 days

ALLERGY RELIEF (LORATADINE) ORAL SOLUTION 5 MG/5 ML

Tier 1 QL (10 ML per 1 day); Age (Max 12 Years)

ALLERGY RELIEF (LORATADINE) ORAL TABLET 10 MG


ALLER-TEC ORAL TABLET 10 MG Tier 1 QL (1 EA per 1 day)

cetirizine oral solution 1 mg/ml (All Day Allergy (cetirizine)) Tier 1 QL (300 ML per 30 days); Age (Max 12 Years)

5

Drug Status Notes

cetirizine oral solution 5 mg/5 ml Tier 1 QL (300 ML per 30 days); Age (Max 12 Years)

cetirizine oral tablet 10 mg (24Hour Allergy) Tier 1 QL (1 EA per 1 day)

cetirizine oral tablet 5 mg Tier 1 QL (1 EA per 1 day)

CHILD ALLERGY RELF(CETIRIZINE) ORAL SOLUTION 1 MG/ML


CHILDREN'S ALLERGY RELIEF(LOR) ORAL SOLUTION 5 MG/5 ML


CHILDREN'S ALLERGY(CETIRIZINE) ORAL SOLUTION 1 MG/ML


CHILDREN'S CETIRIZINE ORAL SOLUTION 1 MG/ML


CHILDREN'S WAL-ZYR ORAL SOLUTION 1 MG/ML


CHILD'S ALL DAY ALLERGY(CETIR) ORAL SOLUTION 1 MG/ML


CLARITIN ORAL TABLET 10 MG Tier 1 QL (1 EA per 1 day)

fexofenadine oral tablet 180 mg (Aller-ease) Tier 1 ST: Requires prior prescription for Cetirizine 10mg or Loratadine 10mg within the past 120 days; QL (2 EA per 1 day)

LORADAMED ORAL TABLET 10 MG Tier 1 QL (1 EA per 1 day)

loratadine oral solution 5 mg/5 ml (Allergy Relief (loratadine)) Tier 1 QL (10 ML per 1 day); Age (Max 12 Years)

loratadine oral tablet 10 mg (Allerclear) Tier 1 QL (1 EA per 1 day)

WAL-FEX ALLERGY ORAL TABLET 180 MG

Tier 1 ST: Requires prior prescription for Cetirizine 10mg or Loratadine 10mg within the past 120 days

WAL-ITIN ORAL SOLUTION 5 MG/5 ML Tier 1 QL (10 ML per 1 day); Age (Max 12 Years)

WAL-ITIN ORAL TABLET 10 MG Tier 1 QL (1 EA per 1 day)

WAL-ZYR (CETIRIZINE) ORAL SOLUTION 1 MG/ML


WAL-ZYR (CETIRIZINE) ORAL TABLET 10 MG


Nasal Antihistamineazelastine nasal aerosol,spray 137 mcg (0.1 %)

Tier 1 QL (30 ML per 30 days)

Nasal Anti-Inflammatory Steroids24 HOUR ALLERGY RELIEF NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION


24 HOUR NASAL ALLERGY NASAL AEROSOL,SPRAY 55 MCG


ALLER-FLO NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION


6

Drug Status Notes

ALLERGY RELIEF (FLUTICASONE) NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION


CHILDREN'S NASACORT NASAL AEROSOL,SPRAY 55 MCG


CLARISPRAY NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION


flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)


fluticasone propionate nasal spray,suspension 50 mcg/actuation

(24 Hour Allergy Relief) Tier 1 QL (16 GM per 30 days)

NASAL ALLERGY NASAL AEROSOL,SPRAY 55 MCG


triamcinolone acetonide nasal aerosol,spray 55 mcg

(24 Hour Nasal Allergy) Tier 1 QL (17 ML per 30 days)

Nasal Mast Cell Stabilizers Agentscromolyn nasal spray,non-aerosol 5.2 mg/spray (4 %)

(Nasal Allergy Symptom Control)

Tier 1

NASAL ALLERGY SYMPTOM CONTROL NASAL SPRAY,NON-AEROSOL 5.2 MG/SPRAY (4 %)

Tier 1

Antiemesis/Antivertigo

Antiemetic, Cannibinoid-Typedronabinol oral capsule 10 mg Tier 1 PA

dronabinol oral capsule 2.5 mg, 5 mg Tier 1 PA; QL (2 EA per 1 day)Antiemetic/Antivertigo AgentsCOMPRO RECTAL SUPPOSITORY 25 MG


dimenhydrinate oral tablet 50 mg (Dramamine) Tier 1

DRAMAMINE LESS DROWSY ORAL TABLET 25 MG

Tier 1

DRAMAMINE ORAL TABLET 50 MG Tier 1

DRIMINATE ORAL TABLET 50 MG Tier 1

granisetron hcl oral tablet 1 mg Tier 1 ST: Requires prior prescription for Ondansetron HCL or Ondansetron within the past 180 days; QL (4 EA per 30 days)

meclizine oral tablet 12.5 mg Tier 1

meclizine oral tablet 25 mg (Dramamine Less Drowsy) Tier 1

meclizine oral tablet,chewable 25 mg (Motion Sickness Relief(mecliz))

Tier 1

MEDI-MECLIZINE ORAL TABLET 25 MG

Tier 1

MOTION RELIEF (MECLIZINE) ORAL TABLET 25 MG

Tier 1

MOTION SICKNESS (MECLIZINE) ORAL TABLET 25 MG

Tier 1

7

Drug Status Notes

MOTION SICKNESS II ORAL TABLET 25 MG

Tier 1

MOTION SICKNESS ORAL TABLET 50 MG

Tier 1

MOTION SICKNESS RELIEF ORAL TABLET 50 MG

Tier 1

MOTION SICKNESS RELIEF(MECLIZ) ORAL TABLET 25 MG

Tier 1

MOTION SICKNESS RELIEF(MECLIZ) ORAL TABLET,CHEWABLE 25 MG

Tier 1

MOTION-TIME ORAL TABLET,CHEWABLE 25 MG

Tier 1

ondansetron hcl oral solution 4 mg/5 ml Tier 1 QL (10 ML per 1 day); Age (Max 12 Years)

ondansetron hcl oral tablet 24 mg Tier 1 QL (1 EA per 1 day)

ondansetron hcl oral tablet 4 mg, 8 mg (Zofran) Tier 1 QL (3 EA per 1 day)

ondansetron oral tablet,disintegrating 4 mg, 8 mg


PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG


prochlorperazine maleate oral tablet 10 mg, 5 mg

(Compazine) Tier 1 QL (4 EA per 1 day)

prochlorperazine rectal suppository 25 mg

(Compro) Tier 1 QL (2 EA per 1 day)

promethazine rectal suppository 12.5 mg, 25 mg

(Phenadoz) Tier 1 Age (Min 1 Years and Max 64 Years)

promethazine rectal suppository 50 mg (Promethegan) Tier 1 Age (Min 1 Years and Max 64 Years)

PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG


TRAVEL SICKNESS (MECLIZINE) ORAL TABLET,CHEWABLE 25 MG

Tier 1

TRAVEL SICKNESS ORAL TABLET 50 MG

Tier 1

TRAVEL-EASE (MECLIZINE) ORAL TABLET 25 MG

Tier 1

VERTICALM ORAL TABLET 25 MG Tier 1

WAL-DRAM 2 ORAL TABLET 25 MG Tier 1

WAL-DRAM ORAL TABLET 50 MG Tier 1Asthma And Copd

Anticholinergic, Orally Inhaled Short ActingATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION

Tier 1 QL (13 GM per 30 days)

ipratropium bromide inhalation solution0.02 %

Tier 1 QL (2 ML per 1 day)

8

Drug Status Notes

Anticholinergics, Orally Inhaled Long ActingINCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION

Tier 1 QL (30 EA per 30 days)

SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION

Tier 1 PA; QL (4 GM per 30 days); Age (Min 6 Years)

Beta-Adrenergic Agentsalbuterol sulfate oral syrup 2 mg/5 ml Tier 1

terbutaline oral tablet 2.5 mg, 5 mg Tier 1Beta-Adrenergic Agents, Inhaled, Short Actingalbuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation

(ProAir HFA) Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml


albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %)


albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml

Tier 1

levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation

(Xopenex HFA) Tier 1 ST: Requires prior prescription for Albuterol Sulfate, Proair HFA, Proventil HFA, or Ventolin HFA within the past 180 days; QL (15 GM per 25 days)

Beta-Adrenergic Agents, Orally Inhaled,Long ActingSEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE


Beta-Adrenergic And Anticholinergic CombinationsBEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-4.8 MCG

Tier 1 ST: Requires prior prescription for Incruse Ellipta or Serevent Diskus within the past 120 days

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION


ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml


Beta-Adrenergic And Glucocorticoid Combinationsbudesonide-formoterol inhalation hfa aerosol inhaler 160-4.5 mcg/actuation, 80-4.5 mcg/actuation

(Symbicort) Tier 1 QL (10.2 GM per 30 days); Age (Max 17 Years)

9

Drug Status Notes

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION


fluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

(AirDuo RespiClick) Tier 1 QL (1 EA per 30 days)

fluticasone propion-salmeterol inhalation blister with device 100-50 mcg/dose

(Wixela Inhub) Tier 1 QL (60 EA per 30 days); Age (Min 4 Years)

fluticasone propion-salmeterol inhalation blister with device 250-50 mcg/dose, 500-50 mcg/dose

(Wixela Inhub) Tier 1 QL (60 EA per 30 days); Age (Min 12 Years)

WIXELA INHUB INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE

Tier 1 QL (60 EA per 30 days); Age (Min 4 Years)

WIXELA INHUB INHALATION BLISTER WITH DEVICE 250-50 MCG/DOSE, 500-50 MCG/DOSE


Glucocorticoids, Orally InhaledARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 232 MCG/ACTUATION, 55 MCG/ACTUATION


budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

(Pulmicort) Tier 1 QL (120 ML per 30 days); Age (Max 6 Years)

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION

Tier 1 QL (12 GM per 30 days); Age (Max 12 Years)




Tier 1 QL (10.6 GM per 30 days); Age (Max 12 Years)

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION


QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION

Tier 1 QL (10.6 GM per 30 days)

Leukotriene Receptor Antagonistsmontelukast oral granules in packet 4 mg

(Singulair) Tier 1 QL (1 EA per 1 day); Age (Max 5 Years)

montelukast oral tablet 10 mg (Singulair) Tier 1 QL (1 EA per 1 day)

montelukast oral tablet,chewable 4 mg, 5 mg

(Singulair) Tier 1 QL (1 EA per 1 day)

10

Drug Status Notes

Mast Cell Stabilizers, Orally Inhaledcromolyn inhalation solution for nebulization 20 mg/2 ml

Tier 1

Respiratory Aids,Devices,EquipmentACE AEROSOL CLOUD ENHANCER SPACER


AEROCHAMBER MINI SPACER Tier 1 QL (4 EA per 365 days)

AEROCHAMBER MV SPACER Tier 1 QL (4 EA per 365 days)

AEROCHAMBER PLUS FLOW-VU SPACER


AEROCHAMBER PLUS FLOW-VU,L MSK SPACER


AEROCHAMBER PLUS FLOW-VU,M MSK SPACER


AEROCHAMBER PLUS FLOW-VU,S MSK SPACER


AEROCHAMBER PLUS Z STAT LG MSK SPACER


AEROCHAMBER PLUS Z STAT MD MSK SPACER


AEROCHAMBER PLUS Z STAT SM MSK SPACER


AEROCHAMBER PLUS Z STAT SPACER


AEROCHAMBER WITH FLOWSIGNAL SPACER


AEROCHAMBER Z-STAT PLUS-FLW SG SPACER


AEROTRACH PLUS SPACER Tier 1 QL (4 EA per 365 days)

AIRZONE PEAK FLOW METER DEVICE

Tier 1

ASTHMA CHECK METER DEVICE Tier 1

BREATHERITE MDI SPACER SPACER Tier 1 QL (4 EA per 365 days)

BREATHERITE VALVED MDI CHAMBER SPACER


BREATHERITE VALVED MDI SPACER SPACER


COMPACT SPACE CHAMBER PLUS SPACER


EASIVENT HOLDING CHAMBER SPACER


EASIVENT MASK LARGE DEVICE Tier 1 QL (4 EA per 365 days)

EASIVENT MASK MEDIUM DEVICE Tier 1 QL (4 EA per 365 days)

EASIVENT MASK SMALL DEVICE Tier 1 QL (4 EA per 365 days)

IN-CHECK NASAL WITH MASK DEVICE

Tier 1

IN-CHECK ORAL FLOW METER DEVICE

Tier 1

INSPIRACHAMBER SPACER Tier 1 QL (4 EA per 365 days)

11

Drug Status Notes

INSPIRACHAMBER WITH MASK-LARGE SPACER


INSPIRACHAMBER WITH MASK-MED SPACER


INSPIRACHAMBER WITH MASK-SMALL SPACER


LITE TOUCH-MEDIUM MASK DEVICE Tier 1 QL (4 EA per 365 days)

LITEAIRE MDI CHAMBER SPACER Tier 1 QL (4 EA per 365 days)

LITETOUCH-LARGE MASK DEVICE Tier 1 QL (4 EA per 365 days)

LITETOUCH-SMALL MASK DEVICE Tier 1 QL (4 EA per 365 days)

MICROCHAMBER SPACER Tier 1 QL (4 EA per 365 days)

MICROLIFE PEAK FLOW METER DEVICE

Tier 1

MICROSPACER SPACER Tier 1 QL (4 EA per 365 days)

MINI WRIGHT PEAK FLOW METER DEVICE

Tier 1

MOUTHPIECE DEVICE Tier 1 QL (4 EA per 365 days)

ONE WAY VALVED MOUTHPIECE DEVICE


OPTICHAMBER ADULT MASK-LARGE DEVICE


OPTICHAMBER DIAMOND LG MASK SPACER


OPTICHAMBER DIAMOND VHC SPACER


OPTICHAMBER DIAMOND-MED MSK SPACER


OPTICHAMBER DIAMOND-SML MASK SPACER


PANDA MASK DEVICE Tier 1 QL (4 EA per 365 days)

PEAK AIR PEAK FLOW METER DEVICE

Tier 1

PEDIATRIC MEDIUM MASK DEVICE Tier 1 QL (4 EA per 365 days)

PEDIATRIC PANDA MASK DEVICE Tier 1 QL (4 EA per 365 days)

PEDIATRIC SMALL MASK DEVICE Tier 1 QL (4 EA per 365 days)

PERSONAL BEST FULL RANGE DEVICE

Tier 1

PIKO 1 DEVICE Tier 1

POCKET CHAMBER SPACER Tier 1 QL (4 EA per 365 days)

POCKET PEAK FLOW METER DEVICE Tier 1

PRIMEAIRE SPACER Tier 1 QL (4 EA per 365 days)

PRO COMFORT SPACER-ADULT MASK SPACER


PRO COMFORT SPACER-CHILD MASK SPACER


PROCHAMBER SPACER Tier 1 QL (4 EA per 365 days)

RITEFLO AEROCHAMBER SPACER Tier 1 QL (4 EA per 365 days)

SIDESTREAM PEDIATRIC FACE MASK DEVICE


12

Drug Status Notes

SILICONE MASK - INFANT DEVICE Tier 1 QL (4 EA per 365 days)

SILICONE MASK - PEDIATRIC DEVICE Tier 1 QL (4 EA per 365 days)

SPACE CHAMBER PLUS SPACER Tier 1 QL (4 EA per 365 days)

TRUZONE PEAK FLOW METER DEVICE

Tier 1

VORTEX ADULT MASK DEVICE Tier 1 QL (4 EA per 365 days)

VORTEX FROG MASK-CHILD DEVICE Tier 1 QL (4 EA per 365 days)

VORTEX HOLDING CHAMBER SPACER


VORTEX LADYBUG MASK-TODDLER DEVICE


VORTEX VHC FROG MASK-CHILD SPACER


VORTEX VHC LADYBUG MASK-TODDLR SPACER


Xanthinescaffeine citrate oral solution 60 mg/3 ml (20 mg/ml)


THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 300 MG

Tier 1

theophylline oral elixir 80 mg/15 ml (Elixophyllin) Tier 1

theophylline oral solution 80 mg/15 ml Tier 1

theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg

Tier 1

theophylline oral tablet extended release 24 hr 400 mg, 600 mg


Autonomic Nervous System Disorders

Alzheimer's Therapy, Nmda Receptor Antagonistsmemantine oral tablet 10 mg, 5 mg (Namenda) Tier 1 QL (2 EA per 1 day); Age

(Min 40 Years)

memantine oral tablets,dose pack 5-10 mg

(Namenda Titration Pak) Tier 1 QL (49 EA per 365 days); Age (Min 40 Years)

Cholinesterase Inhibitorsdonepezil oral tablet 10 mg (Aricept) Tier 1 QL (2 EA per 1 day); Age

(Min 40 Years)

donepezil oral tablet 5 mg (Aricept) Tier 1 QL (1 EA per 1 day); Age (Min 40 Years)

pyridostigmine bromide oral tablet 60 mg (Mestinon) Tier 1

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

Tier 1 QL (2 EA per 1 day); Age (Min 40 Years)

Behavioral Health - Antidepressants

Alpha-2 Receptor Antagonist Antidepressantsmirtazapine oral tablet 15 mg, 30 mg (Remeron) Carve Out CARVE OUT

MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

13

Drug Status Notes

mirtazapine oral tablet 45 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

mirtazapine oral tablet 7.5 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg

(Remeron SolTab) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

REMERON ORAL TABLET 15 MG, 30 MG

Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

REMERON SOLTAB ORAL TABLET,DISINTEGRATING 15 MG, 30 MG, 45 MG


Maois - Non-Selective & IrreversibleMARPLAN ORAL TABLET 10 MG Carve Out CARVE OUT

MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

NARDIL ORAL TABLET 15 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

PARNATE ORAL TABLET 10 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

phenelzine oral tablet 15 mg (Nardil) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

tranylcypromine oral tablet 10 mg (Parnate) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Norepinephrine And Dopamine Reuptake Inhib (Ndris)APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG


14

Drug Status Notes

bupropion hcl oral tablet 100 mg, 75 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg

(Wellbutrin XL) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

bupropion hcl oral tablet extended release 24 hr 450 mg

(Forfivo XL) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 150 mg, 200 mg

(Wellbutrin SR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG


WELLBUTRIN SR ORAL TABLET SUSTAINED-RELEASE 12 HR 100 MG, 150 MG, 200 MG


WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG


Selective Serotonin Reuptake Inhibitor (Ssris)CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG


citalopram oral solution 10 mg/5 ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

citalopram oral tablet 10 mg, 20 mg, 40 mg

(Celexa) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

escitalopram oxalate oral solution 5 mg/5 ml


escitalopram oxalate oral tablet 10 mg, 5 mg

(Lexapro) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

15

Drug Status Notes

escitalopram oxalate oral tablet 20 mg (Lexapro) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

fluoxetine oral capsule 10 mg, 20 mg, 40 mg

(Prozac) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

fluoxetine oral capsule,delayed release(dr/ec) 90 mg


fluoxetine oral solution 20 mg/5 ml (4 mg/ml)


fluoxetine oral tablet 10 mg, 20 mg (Sarafem) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

fluoxetine oral tablet 60 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg


fluvoxamine oral tablet 100 mg, 25 mg, 50 mg


LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG


paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

(Paxil) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg

(Paxil CR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 MG, 25 MG, 37.5 MG


16

Drug Status Notes

PAXIL ORAL SUSPENSION 10 MG/5 ML


PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG


PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG


PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG


SARAFEM ORAL TABLET 10 MG, 20 MG


sertraline oral concentrate 20 mg/ml (Zoloft) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

sertraline oral tablet 100 mg, 25 mg, 50 mg

(Zoloft) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

st. john's wort oral capsule 150 mg, 300 mg


st. john's wort oral tablet 300 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ZOLOFT ORAL CONCENTRATE 20 MG/ML


ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG


Serotonin-2 Antagonist/Reuptake Inhibitors (Saris)nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg


17

Drug Status Notes

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg


Serotonin-Norepinephrine Reuptake-Inhib (Snris)CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 30 MG, 60 MG


desvenlafaxine oral tablet extended release 24 hr 100 mg, 50 mg


desvenlafaxine oral tablet extended release 24hr 100 mg, 50 mg


desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg

(Pristiq) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 40 MG, 60 MG


duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

(Cymbalta) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

duloxetine oral capsule,delayed release(dr/ec) 40 mg


EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG, 37.5 MG, 75 MG


FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)


FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG


PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG


18

Drug Status Notes

venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg

(Effexor XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg


venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg


Ssri & 5Ht1a Partial Agonist AntidepressantVIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG


VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)


Ssri & Serotonin Receptor Modulator AntidepressantTRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG


Tricyclic Antidepressant/Benzodiazepine Combinatnsamitriptyline-chlordiazepoxide oral tablet12.5-5 mg, 25-10 mg

Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

Tricyclic Antidepressant/Phenothiazine Combinatnsperphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg


Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhibamitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg


19

Drug Status Notes

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg


ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG


clomipramine oral capsule 25 mg, 50 mg, 75 mg

(Anafranil) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

desipramine oral tablet 10 mg, 25 mg (Norpramin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

desipramine oral tablet 100 mg, 150 mg, 50 mg, 75 mg


doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg


doxepin oral capsule 150 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

doxepin oral concentrate 10 mg/ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg


imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg


maprotiline oral tablet 25 mg, 50 mg, 75 mg


NORPRAMIN ORAL TABLET 10 MG, 25 MG


20

Drug Status Notes

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg

(Pamelor) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

nortriptyline oral solution 10 mg/5 ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG


protriptyline oral tablet 10 mg, 5 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

trimipramine oral capsule 100 mg, 25 mg, 50 mg


Behavioral Health - Other

Adrenergics, Aromatic, Non-CatecholamineADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG


ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG


ADZENYS ER ORAL SUSPEN, IR - ER, BIPHASIC 24HR 1.25 MG/ML


ADZENYS XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 MG


amphetamine oral suspen, ir - er, biphasic 24hr 1.25 mg/ml

(Adzenys ER) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

amphetamine sulfate oral tablet 10 mg, 5 mg

(Evekeo) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

DESOXYN ORAL TABLET 5 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

21

Drug Status Notes

DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 10 MG, 15 MG, 5 MG


dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg

(Dexedrine Spansule) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

dextroamphetamine oral solution 5 mg/5 ml

(ProCentra) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

dextroamphetamine oral tablet 10 mg, 5 mg

(Zenzedi) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

(Adderall XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

(Adderall) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR 2.5 MG/ML


EVEKEO ODT ORAL TABLET,DISINTEGRATING 10 MG, 15 MG, 20 MG, 5 MG


EVEKEO ORAL TABLET 10 MG, 5 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

methamphetamine oral tablet 5 mg (Desoxyn) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

MYDAYIS ORAL CAPSULE, ER TRIPHASIC 24 HR 12.5 MG, 25 MG, 37.5 MG, 50 MG


PROCENTRA ORAL SOLUTION 5 MG/5 ML


22

Drug Status Notes

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG


VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG


ZENZEDI ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 30 MG, 5 MG, 7.5 MG


Anti-Alcoholic Preparationsacamprosate oral tablet,delayed release (dr/ec) 333 mg


ANTABUSE ORAL TABLET 250 MG, 500 MG


disulfiram oral tablet 250 mg, 500 mg (Antabuse) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG


Anti-Anxiety - BenzodiazepinesALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML


alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

(Xanax) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg

(Xanax XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg


ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG


23

Drug Status Notes

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg


clorazepate dipotassium oral tablet 15 mg, 3.75 mg


clorazepate dipotassium oral tablet 7.5 mg

(Tranxene T-Tab) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

diazepam injection solution 5 mg/ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

diazepam injection syringe 5 mg/ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML


diazepam oral concentrate 5 mg/ml (Diazepam Intensol) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

diazepam oral solution 5 mg/5 ml (1 mg/ml)


diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML


lorazepam oral concentrate 2 mg/ml (Lorazepam Intensol) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg

(Ativan) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

24

Drug Status Notes

oxazepam oral capsule 10 mg, 15 mg, 30 mg


TRANXENE T-TAB ORAL TABLET 7.5 MG


VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG


XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG


XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR 0.5 MG, 1 MG, 2 MG, 3 MG


Anti-Anxiety Drugsbuspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg


meprobamate oral tablet 200 mg, 400 mg


Anti-Mania DrugsEQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG


lithium carbonate oral capsule 150 mg, 300 mg, 600 mg


lithium carbonate oral tablet 300 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

lithium carbonate oral tablet extended release 300 mg

(Lithobid) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

25

Drug Status Notes

lithium carbonate oral tablet extended release 450 mg


lithium citrate oral solution 8 meq/5 ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG


Anti-Narcolepsy & Anti-Cataplexy,Sedative-Type AgtXYREM ORAL SOLUTION 500 MG/ML Tier 1 PA; SP; QL (540 ML per 30

days)Antipsych,Dopamine Antag.,Diphenylbutylpiperidinespimozide oral tablet 1 mg, 2 mg Carve Out CARVE OUT


Antipsychotic-Atypical,D3/D2 Partial Ag-5Ht MixedVRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG


VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6)


Antipsychotics, Atyp, D2 Partial Agonist/5Ht MixedABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG


ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG


ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG


26

Drug Status Notes

aripiprazole oral solution 1 mg/ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

(Abilify) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

aripiprazole oral tablet,disintegrating 10 mg, 15 mg


ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML


ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML, 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML


REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG


Antipsychotics, Dopamine & Serotonin AntagonistsADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED 10 MG


loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg


Antipsychotics,Atypical,Dopamine,& Serotonin AntagCAPLYTA ORAL CAPSULE 42 MG Carve Out CARVE OUT


clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

(Clozaril) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

clozapine oral tablet,disintegrating 100 mg, 25 mg


27

Drug Status Notes

clozapine oral tablet,disintegrating 12.5 mg, 150 mg, 200 mg


CLOZARIL ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG


FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG


FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)


GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.)


GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG


INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 6 MG, 9 MG


INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML


INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML


LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG


olanzapine intramuscular recon soln 10 mg

(Zyprexa) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

(Zyprexa) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

28

Drug Status Notes

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg

(Zyprexa Zydis) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 6 mg, 9 mg

(Invega) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSION,EXTEND REL SYR KIT 120 MG, 90 MG


quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

(Seroquel) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

(Seroquel XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML


RISPERDAL ORAL SOLUTION 1 MG/ML


RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG


risperidone oral solution 1 mg/ml (Risperdal) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

risperidone oral tablet 0.25 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

risperidone oral tablet 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

(Risperdal) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

29

Drug Status Notes

risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg


SAPHRIS SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG


SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24 HOUR, 5.7 MG/24 HOUR, 7.6 MG/24 HOUR


SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG


SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG


SEROQUEL XR ORAL TABLET, EXT REL 24HR DOSE PACK 50 MG(3)-200 MG (1)-300 MG(11)


VERSACLOZ ORAL SUSPENSION 50 MG/ML


ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

(Geodon) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ziprasidone mesylate intramuscular recon soln 20 mg/ml (final conc.)

(Geodon) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ZYPREXA INTRAMUSCULAR RECON SOLN 10 MG


ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG


ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG, 405 MG


ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING 10 MG, 15 MG, 20 MG, 5 MG


30

Drug Status Notes

Antipsychotics,Dopamine Antagonists, Thioxanthenesthiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg


Antipsychotics,Dopamine Antagonists,Butyrophenonesdroperidol injection solution 2.5 mg/ml Carve Out CARVE OUT


HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/ML


HALDOL INJECTION SOLUTION 5 MG/ML


haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml

(Haldol Decanoate) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

haloperidol lactate injection solution 5 mg/ml

(Haldol) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

haloperidol lactate intramuscular syringe5 mg/ml


haloperidol lactate oral concentrate 2 mg/ml


haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg


Antipsychotics,Dopamine Antagonst,Dihydroindolonesmolindone oral tablet 10 mg, 25 mg, 5 mg


31

Drug Status Notes

Anti-Psychotics,Phenothiazineschlorpromazine injection solution 25 mg/ml


chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg


fluphenazine decanoate injection solution 25 mg/ml


fluphenazine hcl injection solution 2.5 mg/ml


fluphenazine hcl oral concentrate 5 mg/ml


fluphenazine hcl oral elixir 2.5 mg/5 ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg


perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg


thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg


trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg


BarbituratesAMYTAL INJECTION RECON SOLN 500 MG


32

Drug Status Notes

LUMINAL INJECTION SYRINGE 130 MG/ML


NEMBUTAL SODIUM INJECTION SOLUTION 50 MG/ML


pentobarbital sodium injection solution50 mg/ml

(Nembutal Sodium) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

phenobarbital oral elixir 20 mg/5 ml (4 mg/ml)


phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg


phenobarbital sodium injection solution130 mg/ml, 65 mg/ml


SECONAL SODIUM ORAL CAPSULE 100 MG


Central Nervous System Stimulantsammonia aromatic inhalation solution 15 % (w/v)


ammonia aromatic inhalation spirit Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

DOPRAM INTRAVENOUS SOLUTION 20 MG/ML


doxapram intravenous solution 20 mg/ml (Dopram) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Hypnotics, Melatonin Mt1/Mt2 Receptor AgonistsHETLIOZ ORAL CAPSULE 20 MG Carve Out CARVE OUT


33

Drug Status Notes

ramelteon oral tablet 8 mg (Rozerem) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ROZEREM ORAL TABLET 8 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Monoamine Oxidase(Mao) InhibitorsEMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR


Narcolepsy And Sleep Disorder Therapy Agentsarmodafinil oral tablet 150 mg, 250 mg, 50 mg

(Nuvigil) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

armodafinil oral tablet 200 mg (Nuvigil) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

modafinil oral tablet 100 mg, 200 mg (Provigil) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG


PROVIGIL ORAL TABLET 100 MG, 200 MG


SUNOSI ORAL TABLET 150 MG, 75 MG


Narcotic Antagonistsnaloxone injection solution 0.4 mg/ml Tier 1 QL (2 ML per 90 days)

naloxone injection syringe 0.4 mg/ml, 1 mg/ml


naltrexone oral tablet 50 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION


34

Drug Status Notes

Sedative-Hypnotics - BenzodiazepinesATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML


DORAL ORAL TABLET 15 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

estazolam oral tablet 1 mg, 2 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

flurazepam oral capsule 15 mg, 30 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

HALCION ORAL TABLET 0.25 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

lorazepam injection solution 2 mg/ml, 4 mg/ml

(Ativan) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

lorazepam injection syringe 2 mg/ml, 4 mg/ml


midazolam oral syrup 2 mg/ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

quazepam oral tablet 15 mg (Doral) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG


temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

(Restoril) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

triazolam oral tablet 0.125 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

35

Drug Status Notes

triazolam oral tablet 0.25 mg (Halcion) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Sedative-Hypnotics,Non-BarbiturateAMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE 12.5 MG, 6.25 MG


AMBIEN ORAL TABLET 10 MG, 5 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG


dexmedetomidine in 0.9 % nacl intravenous solution 200 mcg/50 ml (4 mcg/ml), 400 mcg/100 ml (4 mcg/ml), 80 mcg/20 ml (4 mcg/ml)

(Precedex in 0.9 % sodium chlor)


dexmedetomidine in dextrose 5% intravenous solution 200 mcg/50 ml (4 mcg/ml), 400 mcg/100 ml (4 mcg/ml)


dexmedetomidine intravenous solution100 mcg/ml

(Precedex) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

doxepin oral tablet 3 mg, 6 mg (Silenor) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

EDLUAR SUBLINGUAL TABLET 10 MG, 5 MG


eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

EZ NITE SLEEP ORAL CAPSULE 25 MG

Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; Age (Max 64 Years)

INTERMEZZO SUBLINGUAL TABLET 1.75 MG, 3.5 MG


36

Drug Status Notes

ketamine sublingual troche 100 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG


LYDIA PINKHAM HERBAL ORAL ELIXIR


MKO (MIDAZOLAM-KETAMINE-ONDAN) SUBLINGUAL TROCHE 3-25-2 MG


NIGHTIME SLEEP ORAL CAPSULE 50 MG


NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 25 MG


NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG


NIGHTTIME SLEEP AID (DIPHEN) ORAL LIQUID 50 MG/30 ML


NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET 25 MG


NIGHTTIME SLEEP-AID (DOXYLAMN) ORAL TABLET 25 MG


PRECEDEX IN 0.9 % SODIUM CHLOR INTRAVENOUS SOLUTION 200 MCG/50 ML (4 MCG/ML), 400 MCG/100 ML (4 MCG/ML), 80 MCG/20 ML (4 MCG/ML)


PRECEDEX INTRAVENOUS SOLUTION 100 MCG/ML


37

Drug Status Notes

SILENOR ORAL TABLET 3 MG, 6 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

SIMPLY SLEEP ORAL TABLET 25 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 25 MG


SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG


SLEEP AID (DIPHENHYDRAMINE) ORAL LIQUID 50 MG/30 ML


SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET 25 MG


SLEEP AID (DOXYLAMINE) ORAL TABLET 25 MG


SLEEP AID MAX STR (DIPHENHYDR) ORAL CAPSULE 50 MG


SLEEP TIME ORAL CAPSULE 25 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; Age (Max 64 Years)

SLEEP TIME ORAL LIQUID 50 MG/30 ML


SLEEPING ORAL CAPSULE 50 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

tryptophan oral capsule 500 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

38

Drug Status Notes

tryptophan oral tablet 500 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

UNISOM (DIPHENHYDRAMINE) ORAL LIQUID 50 MG/30 ML


UNISOM (DOXYLAMINE) ORAL TABLET 25 MG


UNISOM SLEEPGELS ORAL CAPSULE 50 MG


UNISOM SLEEPMELTS ORAL TABLET,DISINTEGRATING 25 MG


WAL-SLEEP Z ORAL CAPSULE 25 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; Age (Max 64 Years)

WAL-SLEEP Z ORAL LIQUID 50 MG/30 ML


WAL-SLEEP Z ORAL TABLET,DISINTEGRATING 25 MG


WAL-SOM (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG


WAL-SOM (DOXYLAMINE) ORAL TABLET 25 MG


zaleplon oral capsule 10 mg, 5 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

zolpidem oral tablet 10 mg, 5 mg (Ambien) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

39

Drug Status Notes

zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg

(Ambien CR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

zolpidem sublingual tablet 1.75 mg, 3.5 mg

(Intermezzo) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ZOLPIMIST ORAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML)


Z-SLEEP ORAL CAPSULE 25 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; Age (Max 64 Years)

Z-SLEEP ORAL LIQUID 50 MG/30 ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ZZZQUIL ORAL CAPSULE 25 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; Age (Max 64 Years)

ZZZQUIL ORAL LIQUID 50 MG/30 ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Selective Serotonin 5-Ht2a Inverse Agonists (Ssia)NUPLAZID ORAL CAPSULE 34 MG Carve Out CARVE OUT


NUPLAZID ORAL TABLET 10 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Ssri &Antipsych,Atyp,Dopamine&Serotonin Antag Combolanzapine-fluoxetine oral capsule 12-25 mg


olanzapine-fluoxetine oral capsule 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

(Symbyax) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

40

Drug Status Notes

SYMBYAX ORAL CAPSULE 12-50 MG, 3-25 MG, 6-25 MG, 6-50 MG


Tx For Adhd - Selective Alpha-2A Receptor Agonistclonidine hcl oral tablet extended release 12 hr 0.1 mg

(Kapvay) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg

(Intuniv ER) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR 1 MG, 2 MG, 3 MG, 4 MG


KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR 0.1 MG


Tx For Attention Deficit-Hyperact(Adhd)/NarcolepsyADHANSIA XR ORAL CAPSULE, ER BIPHASIC 20-80 25 MG, 35 MG, 45 MG, 55 MG, 70 MG, 85 MG


APTENSIO XR ORAL CAP,ER SPRINKLE,BIPHASIC 40-60 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG


CONCERTA ORAL TABLET EXTENDED RELEASE 24HR 18 MG, 27 MG, 36 MG, 54 MG


COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 17.3 MG, 25.9 MG, 8.6 MG


DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9 HR, 30 MG/9 HR


dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg

(Focalin XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

41

Drug Status Notes

dexmethylphenidate oral capsule,er biphasic 50-50 25 mg, 35 mg

(Focalin XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg

(Focalin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG


FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG


JORNAY PM ORAL CAPSULE,DEL REL,EXT REL SPRINK 100 MG, 20 MG, 40 MG, 60 MG, 80 MG


METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG


METHYLIN ORAL SOLUTION 10 MG/5 ML, 5 MG/5 ML


methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg


methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 30 mg, 40 mg

(Ritalin LA) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

methylphenidate hcl oral capsule,er biphasic 50-50 60 mg


methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml

(Methylin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg

(Ritalin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

methylphenidate hcl oral tablet extended release 10 mg


42

Drug Status Notes

methylphenidate hcl oral tablet extended release 20 mg

(Metadate ER) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

(Concerta) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

methylphenidate hcl oral tablet extended release 24hr 72 mg

(Relexxii) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

methylphenidate hcl oral tablet,chewable10 mg, 2.5 mg, 5 mg


QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 20 MG, 30 MG, 40 MG


QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML)


RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG


RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 20 MG, 30 MG, 40 MG


RITALIN ORAL TABLET 10 MG, 20 MG, 5 MG


Tx For Attention Deficit-Hyperact.(Adhd), Nri-Typeatomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg

(Strattera) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG


Cardiovascular Disease - Arrhythmia

Antiarrhythmicsamiodarone oral tablet 100 mg, 200 mg, 400 mg

(Pacerone) Tier 1

43

Drug Status Notes

disopyramide phosphate oral capsule100 mg, 150 mg

(Norpace) Tier 1 Age (Max 64 Years)

flecainide oral tablet 100 mg, 150 mg, 50 mg

Tier 1

mexiletine oral capsule 150 mg, 200 mg, 250 mg

Tier 1

PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG

Tier 1

propafenone oral tablet 150 mg, 225 mg, 300 mg

Tier 1

quinidine sulfate oral tablet 200 mg, 300 mg

Tier 1

Cardiovascular Disease - Cardiac Stimulant

Digitalis GlycosidesDIGITEK ORAL TABLET 125 MCG (0.125 MG), 250 MCG (0.25 MG)


DIGOX ORAL TABLET 125 MCG (0.125 MG), 250 MCG (0.25 MG)

Tier 1

digoxin oral tablet 125 mcg (0.125 mg), 250 mcg (0.25 mg)

(Digitek) Tier 1

Cardiovascular Disease - Hypertension

Ace Inhibitor/Calcium Channel Blocker Combinationamlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg, 5-40 mg

(Lotrel) Tier 1 QL (1 EA per 1 day)

amlodipine-benazepril oral capsule 2.5-10 mg


Ace Inhibitor/Thiazide & Thiazide-Like Diureticenalapril-hydrochlorothiazide oral tablet10-25 mg

(Vaseretic) Tier 1 QL (2 EA per 1 day)

enalapril-hydrochlorothiazide oral tablet5-12.5 mg


lisinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg

(Zestoretic) Tier 1 QL (2 EA per 1 day)

quinapril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg

(Accuretic) Tier 1

Alpha/Beta-Adrenergic Blocking Agentscarvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

(Coreg) Tier 1 QL (2 EA per 1 day)

labetalol oral tablet 100 mg, 200 mg, 300 mg

Tier 1

Alpha-Adrenergic Blocking Agentsdoxazosin oral tablet 1 mg, 2 mg, 4 mg (Cardura) Tier 1 QL (1 EA per 1 day)

doxazosin oral tablet 8 mg (Cardura) Tier 1 QL (2 EA per 1 day)

prazosin oral capsule 1 mg, 2 mg, 5 mg (Minipress) Tier 1 QL (2 EA per 1 day)

terazosin oral capsule 1 mg, 5 mg Tier 1 QL (1 EA per 1 day)

44

Drug Status Notes

terazosin oral capsule 10 mg, 2 mg Tier 1 QL (2 EA per 1 day)Angiotensin Receptor Antag./Thiazide Diuretic CombHYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG


irbesartan-hydrochlorothiazide oral tablet150-12.5 mg, 300-12.5 mg

(Avalide) Tier 1 QL (1 EA per 1 day)

losartan-hydrochlorothiazide oral tablet100-12.5 mg, 100-25 mg, 50-12.5 mg

(Hyzaar) Tier 1 QL (1 EA per 1 day)

valsartan-hydrochlorothiazide oral tablet160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

(Diovan HCT) Tier 1 QL (1 EA per 1 day)

Angiotensin Receptor Antgnst & Calc.Channel Blockramlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

(Exforge) Tier 1 QL (2 EA per 1 day)

Antihypertensives, Ace Inhibitorsbenazepril oral tablet 10 mg, 20 mg (Lotensin) Tier 1 QL (1.5 EA per 1 day)

benazepril oral tablet 40 mg (Lotensin) Tier 1 QL (2 EA per 1 day)

benazepril oral tablet 5 mg Tier 1 QL (1.5 EA per 1 day)

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg


enalapril maleate oral tablet 10 mg, 2.5 mg, 5 mg

(Vasotec) Tier 1 QL (1.5 EA per 1 day)

enalapril maleate oral tablet 20 mg (Vasotec) Tier 1 QL (2 EA per 1 day)

EPANED ORAL SOLUTION 1 MG/ML Tier 1 Age (Max 12 Years)

fosinopril oral tablet 10 mg, 20 mg Tier 1 QL (1.5 EA per 1 day)

fosinopril oral tablet 40 mg Tier 1 QL (2 EA per 1 day)

lisinopril oral tablet 10 mg, 20 mg, 5 mg (Prinivil) Tier 1 QL (1.5 EA per 1 day)

lisinopril oral tablet 2.5 mg, 30 mg (Zestril) Tier 1 QL (1.5 EA per 1 day)

lisinopril oral tablet 40 mg (Zestril) Tier 1 QL (2 EA per 1 day)

perindopril erbumine oral tablet 2 mg, 4 mg

Tier 1 QL (1.5 EA per 1 day)

QBRELIS ORAL SOLUTION 1 MG/ML Tier 1 Age (Max 12 Years)

quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg

(Accupril) Tier 1 QL (1 EA per 1 day)

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

(Altace) Tier 1 QL (1 EA per 1 day)

trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1 QL (1 EA per 1 day)Antihypertensives, Angiotensin Receptor Antagonistirbesartan oral tablet 150 mg, 300 mg, 75 mg

(Avapro) Tier 1 QL (1 EA per 1 day)

losartan oral tablet 100 mg, 25 mg, 50 mg

(Cozaar) Tier 1 QL (1 EA per 1 day)

valsartan oral tablet 160 mg, 40 mg, 80 mg

(Diovan) Tier 1 QL (2 EA per 1 day)

valsartan oral tablet 320 mg (Diovan) Tier 1 QL (1 EA per 1 day)

45

Drug Status Notes

Antihypertensives, Sympatholyticclonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg

(Catapres) Tier 1

guanfacine oral tablet 1 mg, 2 mg Tier 1 QL (2 EA per 1 day)

methyldopa oral tablet 250 mg, 500 mg Tier 1 QL (2 EA per 1 day); Age (Max 64 Years)

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg


Antihypertensives, Vasodilatorshydralazine injection solution 20 mg/ml Tier 1

hydralazine oral tablet 10 mg, 25 mg, 50 mg


hydralazine oral tablet 100 mg Tier 1 QL (3 EA per 1 day)

minoxidil oral tablet 10 mg, 2.5 mg Tier 1Beta-Adrenergic Blocking Agentsacebutolol oral capsule 200 mg, 400 mg Tier 1 QL (2 EA per 1 day)

atenolol oral tablet 100 mg, 25 mg, 50 mg

(Tenormin) Tier 1 QL (2 EA per 1 day)

betaxolol oral tablet 10 mg, 20 mg Tier 1

bisoprolol fumarate oral tablet 10 mg Tier 1 QL (2 EA per 1 day)

bisoprolol fumarate oral tablet 5 mg Tier 1 QL (1.5 EA per 1 day)

HEMANGEOL ORAL SOLUTION 4.28 MG/ML


metoprolol succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg

(Toprol XL) Tier 1 QL (1.5 EA per 1 day)

metoprolol succinate oral tablet extended release 24 hr 200 mg

(Toprol XL) Tier 1 QL (2 EA per 1 day)

metoprolol tartrate oral tablet 100 mg, 50 mg

(Lopressor) Tier 1 QL (3 EA per 1 day)

metoprolol tartrate oral tablet 25 mg Tier 1 QL (3 EA per 1 day)

nadolol oral tablet 20 mg, 40 mg, 80 mg (Corgard) Tier 1 QL (2 EA per 1 day)

propranolol oral capsule,extended release 24 hr 120 mg, 160 mg

(Inderal LA) Tier 1 QL (2 EA per 1 day)

propranolol oral capsule,extended release 24 hr 60 mg


propranolol oral capsule,extended release 24 hr 80 mg


propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml)

Tier 1

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg


SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG


SOTALOL AF ORAL TABLET 120 MG, 160 MG, 80 MG


sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg

(Sorine) Tier 1 QL (2 EA per 1 day)

46

Drug Status Notes

Beta-Adrenergic Blocking Agents/Thiazide & Relatedatenolol-chlorthalidone oral tablet 100-25 mg

(Tenoretic 100) Tier 1 QL (2 EA per 1 day)

atenolol-chlorthalidone oral tablet 50-25 mg

(Tenoretic 50) Tier 1 QL (2 EA per 1 day)

bisoprolol-hydrochlorothiazide oral tablet10-6.25 mg

(Ziac) Tier 1 QL (2 EA per 1 day)

bisoprolol-hydrochlorothiazide oral tablet2.5-6.25 mg, 5-6.25 mg

(Ziac) Tier 1 QL (1.5 EA per 1 day)

Calcium Channel Blocking Agentsamlodipine oral tablet 10 mg, 2.5 mg, 5 mg

(Norvasc) Tier 1 QL (1 EA per 1 day)

CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 240 MG, 300 MG


CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 180 MG


diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

(Taztia XT) Tier 1 QL (1 EA per 1 day)

diltiazem hcl oral capsule,extended release 24 hr 420 mg

(Tiadylt ER) Tier 1 QL (1 EA per 1 day)

diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg

(Cartia XT) Tier 1 QL (1 EA per 1 day)

diltiazem hcl oral capsule,extended release 24hr 180 mg

(Cartia XT) Tier 1 QL (2 EA per 1 day)

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg

(Cardizem) Tier 1 QL (2 EA per 1 day)

diltiazem hcl oral tablet 90 mg Tier 1 QL (2 EA per 1 day)

diltiazem hcl oral tablet extended release 24 hr 180 mg, 300 mg

(Matzim LA) Tier 1 QL (1 EA per 1 day)

DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE 120 MG, 180 MG, 240 MG


felodipine oral tablet extended release 24 hr 10 mg


felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg


isradipine oral capsule 2.5 mg, 5 mg Tier 1 QL (2 EA per 1 day)

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 300 MG


nicardipine oral capsule 20 mg, 30 mg Tier 1 QL (1 EA per 1 day)

nifedipine oral capsule 10 mg (Procardia) Tier 1 QL (4 EA per 1 day); Age (Max 64 Years)

nifedipine oral capsule 20 mg Tier 1 QL (4 EA per 1 day); Age (Max 64 Years)

nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg

(Procardia XL) Tier 1 QL (1 EA per 1 day)

47

Drug Status Notes

nifedipine oral tablet extended release30 mg, 60 mg, 90 mg

(Adalat CC) Tier 1 QL (1 EA per 1 day)

nimodipine oral capsule 30 mg Tier 1

TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG


TIADYLT ER ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG


verapamil oral capsule, 24 hr er pellet ct100 mg, 200 mg, 300 mg

(Verelan PM) Tier 1 QL (1 EA per 1 day)

verapamil oral capsule,ext rel. pellets 24 hr 120 mg

(Verelan) Tier 1 QL (1 EA per 1 day)

verapamil oral capsule,ext rel. pellets 24 hr 180 mg, 240 mg

(Verelan) Tier 1

verapamil oral tablet 120 mg, 40 mg, 80 mg

Tier 1

verapamil oral tablet extended release120 mg, 180 mg, 240 mg

(Calan SR) Tier 1 QL (1 EA per 1 day)

Loop Diureticsbumetanide oral tablet 0.5 mg, 1 mg, 2 mg

Tier 1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)


furosemide oral tablet 20 mg, 40 mg, 80 mg

(Lasix) Tier 1 QL (2 EA per 1 day)

torsemide oral tablet 10 mg, 20 mg Tier 1 QL (4 EA per 1 day)

torsemide oral tablet 100 mg, 5 mg Tier 1 QL (2 EA per 1 day)Potassium Sparing Diureticsamiloride oral tablet 5 mg Tier 1 QL (1 EA per 1 day)

spironolactone oral tablet 100 mg, 25 mg, 50 mg

(Aldactone) Tier 1 QL (2 EA per 1 day)

Potassium Sparing Diuretics In Combinationamiloride-hydrochlorothiazide oral tablet5-50 mg


spironolacton-hydrochlorothiaz oral tablet 25-25 mg

(Aldactazide) Tier 1 QL (3 EA per 1 day)

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

(Dyazide) Tier 1 QL (2 EA per 1 day)

triamterene-hydrochlorothiazid oral tablet37.5-25 mg

(Maxzide-25mg) Tier 1 QL (2 EA per 1 day)

triamterene-hydrochlorothiazid oral tablet75-50 mg

(Maxzide) Tier 1 QL (2 EA per 1 day)

Pulm Anti-Htn,Soluble Guanylate Cyclase StimulatorADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG

Tier 1 PA; SP; QL (3 EA per 1 day)

48

Drug Status Notes

Pulm.Anti-Htn,Sel.C-Gmp Phosphodiesterase T5 InhibADCIRCA ORAL TABLET 20 MG Tier 1 PA; SP; QL (2 EA per 1

day)

ALYQ ORAL TABLET 20 MG Tier 1 PA; SP; QL (2 EA per 1 day)

sildenafil (pulm.hypertension) oral tablet20 mg

(Revatio) Tier 1 PA; QL (2 EA per 1 day)

tadalafil (pulm. hypertension) oral tablet20 mg

(Adcirca) Tier 1 PA; SP; QL (2 EA per 1 day)

Pulmonary Anti-Htn, Endothelin Receptor Antagonistambrisentan oral tablet 10 mg, 5 mg (Letairis) Tier 1 PA; SP; QL (1 EA per 1

day)

bosentan oral tablet 125 mg, 62.5 mg (Tracleer) Tier 1 PA; SP; QL (2 EA per 1 day)

LETAIRIS ORAL TABLET 10 MG, 5 MG Tier 1 PA; SP; QL (1 EA per 1 day)

TRACLEER ORAL TABLET 125 MG, 62.5 MG


TRACLEER ORAL TABLET FOR SUSPENSION 32 MG

Tier 1 PA; SP; Age (Min 3 Years and Max 12 Years)

Renin Inhibitor, Directaliskiren oral tablet 150 mg, 300 mg (Tekturna) Tier 1 PA; QL (1 EA per 1 day)

Thiazide And Related Diureticschlorothiazide oral tablet 500 mg Tier 1

chlorthalidone oral tablet 25 mg, 50 mg Tier 1 QL (4 EA per 1 day)

DIURIL ORAL SUSPENSION 250 MG/5 ML


hydrochlorothiazide oral capsule 12.5 mg


hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

Tier 1

indapamide oral tablet 1.25 mg, 2.5 mg Tier 1 QL (1 EA per 1 day)

metolazone oral tablet 10 mg, 2.5 mg, 5 mg


Cardiovascular Disease - Lipid Irregularity

Antihyperlipidemic - Hmg Coa Reductase Inhibitorsatorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

(Lipitor) Tier 1 QL (1 EA per 1 day)

lovastatin oral tablet 10 mg, 20 mg, 40 mg


pravastatin oral tablet 10 mg, 80 mg Tier 1 QL (1 EA per 1 day)

pravastatin oral tablet 20 mg, 40 mg (Pravachol) Tier 1 QL (1 EA per 1 day)

rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

(Crestor) Tier 1 QL (1 EA per 1 day)

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

(Zocor) Tier 1 QL (1 EA per 1 day)

49

Drug Status Notes

simvastatin oral tablet 5 mg Tier 1 QL (1 EA per 1 day)Bile Salt Sequestrantscholestyramine (with sugar) oral powder4 gram

(Questran) Tier 1 QL (378 GM per 30 days)

cholestyramine (with sugar) oral powder in packet 4 gram

(Questran) Tier 1 QL (2 EA per 1 day)

CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM


CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM


colestipol oral granules 5 gram (Colestid) Tier 1

colestipol oral tablet 1 gram (Colestid) Tier 1

PREVALITE ORAL POWDER 4 GRAM Tier 1 QL (240 GM per 30 days)

PREVALITE ORAL POWDER IN PACKET 4 GRAM


LipotropicsALGAL OMEGA-3 DHA ORAL CAPSULE 200 MG

Tier 1

ATABEX DHA 200 ORAL CAPSULE 200 MG

Tier 1

ezetimibe oral tablet 10 mg (Zetia) Tier 1 QL (1 EA per 1 day); Age (Min 10 Years)

fenofibrate micronized oral capsule 134 mg, 200 mg, 43 mg, 67 mg


fenofibrate nanocrystallized oral tablet145 mg, 48 mg

(Tricor) Tier 1 QL (1 EA per 1 day)

fenofibrate oral capsule 50 mg (Lipofen) Tier 1 QL (1 EA per 1 day)

fenofibrate oral tablet 160 mg, 54 mg Tier 1 QL (1 EA per 1 day)

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg

(Trilipix) Tier 1 QL (1 EA per 1 day)

FISH OIL CONCENTRATE ORAL CAPSULE 1,000 MG

Tier 1

FISH OIL EXTRA STRENGTH ORAL CAPSULE 435-880 MG

Tier 1

FISH OIL ORAL CAPSULE 1,000 MG (120 MG-180 MG), 100-160-1,000 MG, 300-1,000 MG, 300-500 MG, 340-1,000 MG, 360-1,200 MG, 60-90-500 MG

Tier 1

FISH OIL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG-180 MG- 60 MG-1,200 MG, 300-1,000 MG, 360-1,200 MG, 60-90-500 MG

Tier 1

gemfibrozil oral tablet 600 mg (Lopid) Tier 1 QL (2 EA per 1 day)

MAXEPA ORAL CAPSULE 500 MG Tier 1

omega 3-dha-epa-fish oil oral capsule1,000 mg (120 mg-180 mg), 300-1,000 mg

(Fish Oil) Tier 1

omega 3-dha-epa-fish oil oral capsule1,200 (144-216) mg

Tier 1

50

Drug Status Notes

omega 3-dha-epa-fish oil oral capsule500-1,000 mg

(Ultra Omega-3) Tier 1

omega 3-dha-epa-fish oil oral capsule,delayed release(dr/ec) 300 mg (120 mg- 180mg)-1,000 mg

Tier 1

omega 3-dha-epa-fish oil oral capsule,delayed release(dr/ec) 300-1,000 mg

(Fish Oil) Tier 1

omega-3 acid ethyl esters oral capsule 1 gram

(Triklo) Tier 1 PA; QL (4 EA per 1 day)

omega-3 fatty acids oral capsule 1,000 mg

(Fish Oil Concentrate) Tier 1

omega-3 fatty acids-fish oil oral capsule300-1,000 mg

Tier 1

omega-3 fatty acids-fish oil oral capsule360-1,200 mg

(Fish Oil) Tier 1

omega-3 fatty acids-fish oil oral capsule,delayed release(dr/ec) 360-1,200 mg

Tier 1

PRENATAL DHA ORAL CAPSULE 200 MG

Tier 1

SALMON OIL-1000 ORAL CAPSULE 1,000-200 MG

Tier 1

SEA-OMEGA 30 ORAL CAPSULE 360-1,200 MG

Tier 1

SUPER OMEGA-3 ORAL CAPSULE 1,000 MG

Tier 1

TRIKLO ORAL CAPSULE 1 GRAM Tier 1 PA; QL (4 EA per 1 day)

ULTRA OMEGA-3 ORAL CAPSULE 500-1,000 MG

Tier 1

Niacin PreparationsENDUR-ACIN ORAL TABLET EXTENDED RELEASE 250 MG, 500 MG, 750 MG

Tier 1

ENDUR-AMIDE ORAL TABLET EXTENDED RELEASE 500 MG

Tier 1

niacin (inositol niacinate) oral capsule400 mg niacin (500 mg)

(Niacin Flush Free) Tier 1

niacin (inositol niacinate) oral capsule500 mg

Tier 1

niacin (inositol niacinate) oral tablet 500 mg

Tier 1

NIACIN (NIACINAMIDE) ORAL TABLET 500 MG

Tier 1

NIACIN FLUSH FREE ORAL CAPSULE 400 MG NIACIN (500 MG), 750 MG

Tier 1

niacin oral capsule, extended release250 mg, 500 mg

Tier 1

niacin oral tablet 100 mg, 250 mg, 50 mg Tier 1

niacin oral tablet 500 mg (Niacor) Tier 1

51

Drug Status Notes

niacin oral tablet extended release 1,000 mg

Tier 1

niacin oral tablet extended release 250 mg, 500 mg, 750 mg

(Endur-Acin) Tier 1

niacinamide oral tablet 500 mg (Niacin (niacinamide)) Tier 1

niacinamide oral tablet extended release500 mg

(Endur-amide) Tier 1

Cardiovascular Disease - Miscellaneous Agents

Adrenergic Vasopressor Agentsmidodrine oral tablet 10 mg, 2.5 mg, 5 mg


Angiotensin Recept-Neprilysin Inhibitor Comb(Arni)ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG


Antianginal & Anti-Ischemic Agents,Non-Hemodynamicranolazine oral tablet extended release 12 hr 1,000 mg, 500 mg

(Ranexa) Tier 1 PA; QL (2 EA per 1 day)

Protein StabilizersVYNDAMAX ORAL CAPSULE 61 MG Tier 1 PA; SP; QL (30 EA per 30

days); Age (Min 18 Years)

VYNDAQEL ORAL CAPSULE 20 MG Tier 1 PA; SP; QL (120 EA per 30 days); Age (Min 18 Years)

Cardiovascular Disease - Vasodilation

Vasodilators,Coronaryisosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg

Tier 1

isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) Tier 1

isosorbide dinitrate oral tablet extended release 40 mg

(ISOCHRON) Tier 1

isosorbide mononitrate oral tablet 10 mg, 20 mg

Tier 1

isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 60 mg


isosorbide mononitrate oral tablet extended release 24 hr 30 mg


MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR


NITRO-BID TRANSDERMAL OINTMENT 2 %

Tier 1

nitroglycerin oral capsule, extended release 2.5 mg, 6.5 mg, 9 mg

(Nitro-Time) Tier 1

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg

(Nitrostat) Tier 1

nitroglycerin transdermal patch 24 hour0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

(Minitran) Tier 1 QL (1 EA per 1 day)

52

Drug Status Notes

nitroglycerin translingual spray,non-aerosol 400 mcg/spray

(Nitrolingual) Tier 1 ST: Requires prior prescription for Nitroglycerin within the past 180 days

NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG

Tier 1

NITRO-TIME ORAL CAPSULE, EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG

Tier 1

Contraception/Oxytocics

Contraceptives, Intravaginal, SystemicELURYNG VAGINAL RING 0.12-0.015 MG/24 HR

Tier 1 Female Only; QL (3 EA per 84 days)

etonogestrel-ethinyl estradiol vaginal ring0.12-0.015 mg/24 hr

(EluRyng) Tier 1 Female Only; QL (3 EA per 84 days)

Contraceptives,Injectablemedroxyprogesterone intramuscular suspension 150 mg/ml

(Depo-Provera) Tier 1 QL (1 ML per 75 days)

Contraceptives,IntravaginalGYNOL II VAGINAL GEL 3 % Tier 1 Female Only

TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1,000 MG

Tier 1 Female Only

VAGINAL CONTRACEPTIVE FOAM VAGINAL FOAM 12.5 %

Tier 1 Female Only

Contraceptives,OralAFIRMELLE ORAL TABLET 0.1-20 MG-MCG


AFTERA ORAL TABLET 1.5 MG Tier 1 Female Only

ALTAVERA (28) ORAL TABLET 0.15-0.03 MG


ALYACEN 1/35 (28) ORAL TABLET 1-35 MG-MCG


ALYACEN 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG


AMETHYST (28) ORAL TABLET 90-20 MCG (28)


APRI ORAL TABLET 0.15-0.03 MG Tier 1 Female Only; QL (84 EA per 84 days)

ARANELLE (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG


AUBRA EQ ORAL TABLET 0.1-20 MG-MCG


AUBRA ORAL TABLET 0.1-20 MG-MCG Tier 1 Female Only; QL (84 EA per 84 days)

AUROVELA 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

Tier 1

AUROVELA 1/20 (21) ORAL TABLET 1-20 MG-MCG


53

Drug Status Notes

AUROVELA 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)


AUROVELA FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)


AUROVELA FE 1-20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)


AVIANE ORAL TABLET 0.1-20 MG-MCG


AYUNA ORAL TABLET 0.15-0.03 MG Tier 1 Female Only; QL (84 EA per 84 days)

AZURETTE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5


BALZIVA (28) ORAL TABLET 0.4-35 MG-MCG


BEKYREE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5


BLISOVI 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)


BLISOVI FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)


BLISOVI FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)


BRIELLYN ORAL TABLET 0.4-35 MG-MCG


CAMILA ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

CAZIANT (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG


CHATEAL (28) ORAL TABLET 0.15-0.03 MG


CHATEAL EQ (28) ORAL TABLET 0.15-0.03 MG


CRYSELLE (28) ORAL TABLET 0.3-30 MG-MCG


CYCLAFEM 1/35 (28) ORAL TABLET 1-35 MG-MCG


CYCLAFEM 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG


CYRED EQ ORAL TABLET 0.15-0.03 MG


CYRED ORAL TABLET 0.15-0.03 MG Tier 1 Female Only; QL (84 EA per 84 days)

DASETTA 1/35 (28) ORAL TABLET 1-35 MG-MCG


DASETTA 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG


DEBLITANE ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

54

Drug Status Notes

desog-e.estradiol/e.estradiol oral tablet0.15-0.02 mgx21 /0.01 mg x 5

(Azurette (28)) Tier 1 Female Only; QL (84 EA per 84 days)

desogestrel-ethinyl estradiol oral tablet0.15-0.03 mg

(Apri) Tier 1 Female Only; QL (84 EA per 84 days)

drospirenone-ethinyl estradiol oral tablet3-0.02 mg

(Gianvi (28)) Tier 1 Female Only; QL (84 EA per 84 days)

drospirenone-ethinyl estradiol oral tablet3-0.03 mg

(Ocella) Tier 1 Female Only; QL (84 EA per 84 days)

ECONTRA EZ ORAL TABLET 1.5 MG Tier 1 Female Only

ECONTRA ONE-STEP ORAL TABLET 1.5 MG

Tier 1 Female Only

ELINEST ORAL TABLET 0.3-30 MG-MCG


ELLA ORAL TABLET 30 MG Tier 1 Female Only

EMOQUETTE ORAL TABLET 0.15-0.03 MG


ENPRESSE ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)


ENSKYCE ORAL TABLET 0.15-0.03 MG


ERRIN ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG


ethynodiol diac-eth estradiol oral tablet1-35 mg-mcg

(Kelnor 1/35 (28)) Tier 1 Female Only; QL (84 EA per 84 days)

ethynodiol diac-eth estradiol oral tablet1-50 mg-mcg

(Kelnor 1-50) Tier 1 Female Only; QL (84 EA per 84 days)

FALMINA (28) ORAL TABLET 0.1-20 MG-MCG


FEMYNOR ORAL TABLET 0.25-35 MG-MCG


GIANVI (28) ORAL TABLET 3-0.02 MG Tier 1 Female Only; QL (84 EA per 84 days)

HAILEY 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)


HAILEY ORAL TABLET 1.5-30 MG-MCG

Tier 1

HEATHER ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

INCASSIA ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

INTROVALE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91)


ISIBLOOM ORAL TABLET 0.15-0.03 MG


JASMIEL (28) ORAL TABLET 3-0.02 MG


JENCYCLA ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

55

Drug Status Notes

JOLESSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91)


JULEBER ORAL TABLET 0.15-0.03 MG Tier 1 Female Only; QL (84 EA per 84 days)

JUNEL 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

Tier 1

JUNEL 1/20 (21) ORAL TABLET 1-20 MG-MCG


JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)


JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)


JUNEL FE 24 ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)


KAITLIB FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4)

Tier 1 Female Only

KALLIGA ORAL TABLET 0.15-0.03 MG Tier 1 Female Only; QL (84 EA per 84 days)

KARIVA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5


KELNOR 1/35 (28) ORAL TABLET 1-35 MG-MCG


KELNOR 1-50 ORAL TABLET 1-50 MG-MCG


KURVELO (28) ORAL TABLET 0.15-0.03 MG


LARIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

Tier 1

LARIN 1/20 (21) ORAL TABLET 1-20 MG-MCG


LARIN 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)


LARIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)


LARIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)


LARISSIA ORAL TABLET 0.1-20 MG-MCG


LAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4)

Tier 1 Female Only

LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG


LESSINA ORAL TABLET 0.1-20 MG-MCG


LEVONEST (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)


levonorgestrel oral tablet 1.5 mg (Aftera) Tier 1 Female Only

56

Drug Status Notes

levonorgestrel-ethinyl estrad oral tablet0.1-20 mg-mcg

(Afirmelle) Tier 1 Female Only; QL (84 EA per 84 days)

levonorgestrel-ethinyl estrad oral tablet0.15-0.03 mg

(Altavera (28)) Tier 1 Female Only

levonorgestrel-ethinyl estrad oral tablet90-20 mcg (28)

(Amethyst (28)) Tier 1 Female Only; QL (84 EA per 84 days)

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)

(Introvale) Tier 1 Female Only; QL (84 EA per 84 days)

levonorg-eth estrad triphasic oral tablet50-30 (6)/75-40 (5)/125-30(10)

(Enpresse) Tier 1 Female Only; QL (84 EA per 84 days)

LEVORA-28 ORAL TABLET 0.15-0.03 MG


LILLOW (28) ORAL TABLET 0.15-0.03 MG


LORYNA (28) ORAL TABLET 3-0.02 MG


LOW-OGESTREL (28) ORAL TABLET 0.3-30 MG-MCG


LO-ZUMANDIMINE (28) ORAL TABLET 3-0.02 MG


LUTERA (28) ORAL TABLET 0.1-20 MG-MCG


LYZA ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

MARLISSA (28) ORAL TABLET 0.15-0.03 MG


MELODETTA 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4)


MIBELAS 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4)


MICROGESTIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

Tier 1

MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG


MICROGESTIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)


MICROGESTIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)


MILI ORAL TABLET 0.25-35 MG-MCG Tier 1 Female Only; QL (84 EA per 84 days)

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG


MY CHOICE ORAL TABLET 1.5 MG Tier 1 Female Only

MY WAY ORAL TABLET 1.5 MG Tier 1 Female Only

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG


57

Drug Status Notes

NEW DAY ORAL TABLET 1.5 MG Tier 1 Female Only

NIKKI (28) ORAL TABLET 3-0.02 MG Tier 1 Female Only; QL (84 EA per 84 days)

NORA-BE ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7)

(Wymzya Fe) Tier 1 Female Only; QL (2 EA per 1 day)

noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

(Kaitlib Fe) Tier 1 Female Only; QL (2 EA per 1 day)

norethindrone (contraceptive) oral tablet0.35 mg

(Camila) Tier 1 Female Only; QL (84 EA per 84 days)

norethindrone ac-eth estradiol oral tablet1.5-30 mg-mcg

(Aurovela 1.5/30 (21)) Tier 1 QL (2 EA per 1 day)

norethindrone ac-eth estradiol oral tablet1-20 mg-mcg

(Aurovela 1/20 (21)) Tier 1 QL (84 EA per 84 days)

norethindrone-e.estradiol-iron oral tablet1 mg-20 mcg (21)/75 mg (7)

(Aurovela Fe 1-20 (28)) Tier 1 Female Only; QL (84 EA per 84 days)

norethindrone-e.estradiol-iron oral tablet1.5 mg-30 mcg (21)/75 mg (7)

(Aurovela Fe 1.5/30 (28)) Tier 1 Female Only; QL (84 EA per 84 days)

norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

(Melodetta 24 Fe) Tier 1 Female Only; QL (84 EA per 84 days)

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-25 mcg

(Tri-Lo-Estarylla) Tier 1 Female Only; QL (84 EA per 84 days)

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-35 mcg (28)

(Tri Femynor) Tier 1 Female Only; QL (84 EA per 84 days)

norgestimate-ethinyl estradiol oral tablet0.25-35 mg-mcg

(Estarylla) Tier 1 Female Only; QL (84 EA per 84 days)

NORLYDA ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG


NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG (21)


NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG


NORTREL 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG


OCELLA ORAL TABLET 3-0.03 MG Tier 1 Female Only; QL (84 EA per 84 days)

OGESTREL (28) ORAL TABLET 0.5-50 MG-MCG


OPCICON ONE-STEP ORAL TABLET 1.5 MG

Tier 1 Female Only

OPTION-2 ORAL TABLET 1.5 MG Tier 1 Female Only

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG


58

Drug Status Notes

PHILITH ORAL TABLET 0.4-35 MG-MCG


PIMTREA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5


PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35 MCG, 1-35 MG-MCG


PORTIA 28 ORAL TABLET 0.15-0.03 MG


PREVIFEM ORAL TABLET 0.25-35 MG-MCG


RECLIPSEN (28) ORAL TABLET 0.15-0.03 MG


SETLAKIN ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91)


SHAROBEL ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

SIMLIYA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5


SPRINTEC (28) ORAL TABLET 0.25-35 MG-MCG


SRONYX ORAL TABLET 0.1-20 MG-MCG


SYEDA ORAL TABLET 3-0.03 MG Tier 1 Female Only; QL (84 EA per 84 days)

TAKE ACTION ORAL TABLET 1.5 MG Tier 1 Female Only

TARINA 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)


TARINA FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)


TARINA FE 1-20 EQ (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)


TILIA FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9)


TRI FEMYNOR ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)


TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)


TRI-LEGEST FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9)


TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)


TRI-LO-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG


TRI-LO-MARZIA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG


TRI-LO-MILI ORAL TABLET 0.18/0.215/0.25 MG-25 MCG


TRI-LO-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-25 MCG


59

Drug Status Notes

TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)


TRI-PREVIFEM (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)


TRI-SPRINTEC (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)


TRIVORA (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)


TRI-VYLIBRA LO ORAL TABLET 0.18/0.215/0.25 MG-25 MCG


TRI-VYLIBRA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)


TULANA ORAL TABLET 0.35 MG Tier 1 Female Only; QL (84 EA per 84 days)

VELIVET TRIPHASIC REGIMEN (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG


VIENVA ORAL TABLET 0.1-20 MG-MCG


VIORELE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5


VOLNEA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5


VYFEMLA (28) ORAL TABLET 0.4-35 MG-MCG


VYLIBRA ORAL TABLET 0.25-35 MG-MCG


WERA (28) ORAL TABLET 0.5-35 MG-MCG


WYMZYA FE ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7)

Tier 1 Female Only

ZARAH ORAL TABLET 3-0.03 MG Tier 1 Female Only; QL (84 EA per 84 days)

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG


ZUMANDIMINE (28) ORAL TABLET 3-0.03 MG


Contraceptives,TransdermalXULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24 HR


Diaphragms/Cervical CapCAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM

Tier 1

FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM

Tier 1

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM

Tier 1


Tier 1

60

Drug Status Notes


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1

OxytocicsMETHERGINE ORAL TABLET 0.2 MG Tier 1 QL (28 EA per 180 days);

Age (Min 12 Years)

methylergonovine oral tablet 0.2 mg (Methergine) Tier 1 QL (28 EA per 180 days); Age (Min 12 Years)

Cough And Cold

Antitussives,Non-Narcoticbenzonatate oral capsule 100 mg (Tessalon Perles) Tier 1 QL (30 EA per 10 days)

benzonatate oral capsule 150 mg, 200 mg


Dermatology - Acne

Acne Agents,SystemicCLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

Tier 1 PA; QL (2 EA per 1 day)

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg

(Claravis) Tier 1 PA; QL (2 EA per 1 day)

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG


ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG


Rosacea Agents, Topicalmetronidazole topical cream 0.75 % (Rosadan) Tier 1

metronidazole topical gel 0.75 % (Rosadan) Tier 1

ROSADAN TOPICAL CREAM 0.75 % Tier 1Vitamin A DerivativesAVITA TOPICAL CREAM 0.025 % Tier 1 ST: Requires prior

prescription for Adapalene 0.1% gel OTC within the past 120 days; QL (20 GM per 30 days); Age (Max 30 Years)

DIFFERIN TOPICAL GEL 0.1 % Tier 1 QL (45 GM per 30 days)

tretinoin topical cream 0.025 % (Avita) Tier 1 ST: Requires prior prescription for Adapalene 0.1% gel OTC within the past 120 days; QL (20 GM per 30 days); Age (Max 30 Years)

61

Drug Status Notes

Dermatology - Antiinfective

Topical AntibioticsANTIBIOTIC (BACITRACIN ZINC) TOPICAL OINTMENT 500 UNIT/GRAM

Tier 1

ANTIBIOTIC (NEOMY-BACIT-POLYM) TOPICAL OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM

Tier 1

bacitracin topical ointment 500 unit/gram (Bacitraycin Plus) Tier 1

bacitracin topical packet 500 unit/gram Tier 1

bacitracin zinc topical ointment 500 unit/gram

(Antibiotic (bacitracin zinc)) Tier 1

bacitracin zinc topical packet 500 unit/gram

Tier 1

BACITRAYCIN PLUS TOPICAL OINTMENT 500 UNIT/GRAM

Tier 1

clindamycin phosphate topical gel 1 % (Cleocin T) Tier 1 ST: Requires prior prescription for Clindamycin 1% sollution or pledgets within the past 120 days

clindamycin phosphate topical lotion 1 % (Cleocin T) Tier 1 ST: Requires prior prescription for Clindamycin 1% sollution or pledgets within the past 120 days

clindamycin phosphate topical solution 1 %

(Cleocin T) Tier 1 QL (180 ML per 30 days)

clindamycin phosphate topical swab 1 % (Clindacin ETZ) Tier 1

erythromycin with ethanol topical solution 2 %

Tier 1

FIRST AID ANTIBIOTIC TOPICAL OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM

Tier 1

gentamicin topical cream 0.1 % Tier 1

gentamicin topical ointment 0.1 % Tier 1

mupirocin topical ointment 2 % (Centany) Tier 1 QL (22 GM per 30 days)

NEOSPORIN (NEO-BAC-POLYM) TOPICAL OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM

Tier 1

TRIPLE ANTIBIOTIC PLUS TOPICAL OINTMENT 3.5-500-10,000 MG-UNIT-UNIT/G

Tier 1

TRIPLE ANTIBIOTIC TOPICAL OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM

Tier 1

TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET 3.5-400-5,000 MG-UNIT-UNIT

Tier 1

62

Drug Status Notes

Topical Antifungal/Antiinflammatory,Steriod Agentclotrimazole-betamethasone topical cream 1-0.05 %

(Lotrisone) Tier 1 QL (45 GM per 30 days)

Topical AntifungalsAF TOPICAL AEROSOL POWDER 1 % Tier 1

ANTIFUNGAL (CLOTRIMAZOLE) TOPICAL CREAM 1 %

Tier 1

ANTIFUNGAL (TERBINAFINE) TOPICAL CREAM 1 %

Tier 1

ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM 1 %

Tier 1

ANTIFUNGAL (TOLNAFTATE) TOPICAL POWDER 1 %

Tier 1

ANTIFUNGAL CREAM (MICONAZOLE) TOPICAL CREAM 2 %

Tier 1

ANTIFUNGAL RINGWORM TOPICAL CREAM 1 %

Tier 1

ANTIFUNGAL SPRAY TOPICAL AEROSOL POWDER 1 %

Tier 1

ATHLETE'S FOOT (CLOTRIMAZOLE) TOPICAL CREAM 1 %

Tier 1

ATHLETE'S FOOT (TERBINAFINE) TOPICAL CREAM 1 %

Tier 1

ATHLETE'S FOOT (TOLNAFTATE) TOPICAL AEROSOL POWDER 1 %

Tier 1

ATHLETE'S FOOT (TOLNAFTATE) TOPICAL CREAM 1 %

Tier 1

ATHLETIC FOOT CREAM TOPICAL CREAM 1 %

Tier 1

BAZA ANTIFUNGAL TOPICAL CREAM 2 %

Tier 1

ciclopirox topical solution 8 % (Ciclodan) Tier 1 QL (6.6 ML per 28 days)

CLOTRIMAZOLE AF TOPICAL CREAM 1 %

Tier 1

clotrimazole topical cream 1 % (Antifungal (clotrimazole)) Tier 1

clotrimazole topical solution 1 % Tier 1

econazole topical cream 1 % Tier 1 QL (30 GM per 30 days)

FOOT AND SNEAKER TOPICAL AEROSOL POWDER 1 %

Tier 1

FUNGOID-D TOPICAL CREAM 1 % Tier 1

INZO ANTIFUNGAL TOPICAL CREAM 2 %

Tier 1

ITCH RELIEF (CLOTRIMAZOLE) TOPICAL CREAM 1 %

Tier 1

JOCK ITCH (CLOTRIMAZOLE) TOPICAL CREAM 1 %

Tier 1

JOCK ITCH (TERBINAFINE) TOPICAL CREAM 1 %

Tier 1

63

Drug Status Notes

JOCK ITCH TOPICAL AEROSOL POWDER 1 %

Tier 1

ketoconazole topical cream 2 % Tier 1 QL (60 GM per 30 days)

ketoconazole topical shampoo 2 % (Nizoral) Tier 1 QL (4 ML per 1 day)

LAMISIL AF TOPICAL AEROSOL POWDER 1 %

Tier 1

MICATIN TOPICAL CREAM 2 % Tier 1

miconazole nitrate topical cream 2 % (Antifungal Cream (miconazole))

Tier 1

NYAMYC TOPICAL POWDER 100,000 UNIT/GRAM


nystatin topical cream 100,000 unit/gram Tier 1

nystatin topical ointment 100,000 unit/gram

Tier 1

nystatin topical powder 100,000 unit/gram

(Nyamyc) Tier 1 QL (60 GM per 30 days)

NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM


ODOR CONTROL FOOT-SNEAKER TOPICAL AEROSOL POWDER 1 %

Tier 1

REMEDY ANTIFUNGAL TOPICAL CREAM 2 %

Tier 1

RINGWORM TOPICAL CREAM 1 % Tier 1

SECURA ANTIFUNGAL EXTRA THICK TOPICAL CREAM 2 %

Tier 1

SECURA ANTIFUNGAL TOPICAL CREAM 2 %

Tier 1

terbinafine hcl topical cream 1 % (Antifungal (terbinafine)) Tier 1

tolnaftate topical aerosol powder 1 % (AF) Tier 1

tolnaftate topical cream 1 % (Antifungal (tolnaftate)) Tier 1

tolnaftate topical powder 1 % (Antifungal (tolnaftate)) Tier 1Topical AntiparasiticsLICE KILLING (PERMETHRIN) TOPICAL LIQUID 1 %


LICE KILLING TOPICAL SHAMPOO 0.33-4 %


LICE PYRINYL SHAMPOO TOPICAL SHAMPOO 0.33-4 %


LICE TREATMENT (PERMETHRIN) TOPICAL LIQUID 1 %


LICE TREATMENT TOPICAL LIQUID 1 %


LICE TREATMENT TOPICAL SHAMPOO 0.33-4 %


lindane topical shampoo 1 % Tier 1 QL (60 ML per 30 days)

64

Drug Status Notes

malathion topical lotion 0.5 % (Ovide) Tier 1 ST: Requires prior prescription for Permethrin or Piperonyl Butoxide/pyrethrins within the past 180 days; QL (59 ML per 30 days)

NIX CREME RINSE TOPICAL LIQUID 1 %


permethrin topical cream 5 % (Elimite) Tier 1 QL (60 GM per 30 days)

RID LICE KILLING TOPICAL SHAMPOO 0.33-4 %


spinosad topical suspension 0.9 % (Natroba) Tier 1 ST: Requires prior prescription for Lindane or Permethrin (1% or 5%) within the past 180 days; QL (240 ML per 180 days)

Topical AntiviralsABREVA TOPICAL CREAM 10 % Tier 1

docosanol topical cream 10 % (Abreva) Tier 1Topical Sulfonamidessilver sulfadiazine topical cream 1 % (SSD) Tier 1

SSD TOPICAL CREAM 1 % Tier 1

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)

(Avar) Tier 1

sulfacetamide sod-sulfur-urea topical cleanser 10-5-10 %

Tier 1

Dermatology - Antiinflammatory

Topical Anti-Inflammatory SteroidalALA-CORT TOPICAL CREAM 1 % Tier 1

ANTI-ITCH (HC) TOPICAL CREAM 1 % Tier 1

ANTI-ITCH (HC) TOPICAL OINTMENT 1 %

Tier 1

betamethasone dipropionate topical cream 0.05 %


betamethasone dipropionate topical lotion 0.05 %


betamethasone dipropionate topical ointment 0.05 %


betamethasone valerate topical cream0.1 %


betamethasone valerate topical lotion0.1 %


betamethasone valerate topical ointment0.1 %


betamethasone, augmented topical cream 0.05 %


betamethasone, augmented topical gel0.05 %


betamethasone, augmented topical lotion 0.05 %


65

Drug Status Notes

betamethasone, augmented topical ointment 0.05 %

(Diprolene) Tier 1 QL (50 GM per 30 days)

clobetasol scalp solution 0.05 % Tier 1 PA; QL (50 ML per 30 days)

clobetasol topical cream 0.05 % (Temovate) Tier 1 PA; QL (60 GM per 30 days)

clobetasol topical ointment 0.05 % (Temovate) Tier 1 PA; QL (60 GM per 30 days)

CORTAID TOPICAL CREAM 1 % Tier 1

CORTISONE (HYDROCORTISONE) TOPICAL CREAM 1 %

Tier 1

CORTISONE WITH ALOE TOPICAL CREAM 1 %

Tier 1

CORTIZONE-10 PLUS TOPICAL CREAM 1 %

Tier 1

CORTIZONE-10 TOPICAL CREAM 1 % Tier 1

CORTIZONE-10 TOPICAL OINTMENT 1 %

Tier 1

fluocinonide topical cream 0.05 % Tier 1 QL (30 GM per 30 days)

fluocinonide topical ointment 0.05 % Tier 1 QL (30 GM per 30 days)

fluocinonide topical solution 0.05 % Tier 1 QL (60 ML per 30 days)

FLUOCINONIDE-E TOPICAL CREAM 0.05 %


fluocinonide-emollient topical cream 0.05 %

(Fluocinonide-E) Tier 1 QL (30 GM per 30 days)

fluticasone propionate topical cream0.05 %

(Cutivate) Tier 1 QL (45 GM per 30 days)

fluticasone propionate topical ointment0.005 %


halobetasol propionate topical cream0.05 %


halobetasol propionate topical ointment0.05 %


hydrocortisone acetate topical cream 0.5 %

Tier 1

hydrocortisone acetate topical cream 1 %

(Vanicream HC) Tier 1

hydrocortisone acetate topical ointment1 %

Tier 1

hydrocortisone topical cream 0.5 %, 2.5 %

Tier 1

hydrocortisone topical cream 1 % (Ala-Cort) Tier 1

hydrocortisone topical cream in packet 1 %

Tier 1

hydrocortisone topical cream with perineal applicator 2.5 %

(Procto-Med HC) Tier 1 QL (90 GM per 365 days)

hydrocortisone topical lotion 2.5 % Tier 1

hydrocortisone topical ointment 0.5 %, 2.5 %

Tier 1

hydrocortisone topical ointment 1 % (Anti-Itch (HC)) Tier 1

66

Drug Status Notes

hydrocortisone-aloe vera topical cream 1 %

(Cortisone with Aloe) Tier 1

HYDROCREAM TOPICAL CREAM 1 % Tier 1

mometasone topical cream 0.1 % (Elocon) Tier 1 QL (45 GM per 30 days)

mometasone topical ointment 0.1 % Tier 1 QL (45 GM per 30 days)

mometasone topical solution 0.1 % Tier 1 QL (60 ML per 30 days)

NOBLE FORMULA HC TOPICAL CREAM 1 %

Tier 1

PREPARATION H HYDROCORTISONE TOPICAL CREAM 1 %

Tier 1

PROCTO-MED HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %


PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %


SOOTHING CARE (HYDROCORTISONE) TOPICAL CREAM 1 %

Tier 1

triamcinolone acetonide topical cream0.025 %


triamcinolone acetonide topical cream0.1 %, 0.5 %

(Triderm) Tier 1 QL (480 GM per 30 days)

triamcinolone acetonide topical lotion0.025 %

Tier 1

triamcinolone acetonide topical lotion 0.1 %


triamcinolone acetonide topical ointment0.025 %, 0.1 %


triamcinolone acetonide topical ointment0.5 %

Tier 1

TRIDERM TOPICAL CREAM 0.1 %, 0.5 %


VANICREAM HC TOPICAL CREAM 1 % Tier 1Topical Anti-Inflammatory, Nsaidsdiclofenac sodium topical gel 1 % (Voltaren) Tier 1 QL (100 GM per 30 days)

Dermatology - Miscellaneous

AntiperspirantsDRYSOL DAB-O-MATIC TOPICAL SOLUTION 20 %

Tier 1

DRYSOL TOPICAL SOLUTION 20 % Tier 1Antiseborrheic Agentsselenium sulfide topical lotion 2.5 % Tier 1

Antiseptics,GeneralALCOHOL PADS TOPICAL PADS, MEDICATED

Tier 1

ALCOHOL PREP PADS TOPICAL PADS, MEDICATED

Tier 1

alcohol swabs topical pads, medicated (Alcohol Pads) Tier 1

ALCOHOL WIPES TOPICAL PADS, MEDICATED

Tier 1

67

Drug Status Notes

BD ALCOHOL SWABS TOPICAL PADS, MEDICATED

Tier 1

CARETOUCH ALCOHOL PREP PAD TOPICAL PADS, MEDICATED

Tier 1

CURITY ALCOHOL SWABS TOPICAL PADS, MEDICATED

Tier 1

EASY COMFORT ALCOHOL PAD TOPICAL PADS, MEDICATED

Tier 1

EASY TOUCH ALCOHOL PREP PADS TOPICAL PADS, MEDICATED

Tier 1

INCONTROL ALCOHOL PADS TOPICAL PADS, MEDICATED

Tier 1

IV PREP WIPES TOPICAL PADS, MEDICATED

Tier 1

PRO COMFORT ALCOHOL PADS TOPICAL PADS, MEDICATED

Tier 1

PURE COMFORT ALCOHOL PADS TOPICAL PADS, MEDICATED

Tier 1

SURE COMFORT ALCOHOL PREP PADS TOPICAL PADS, MEDICATED

Tier 1

SURE-PREP ALCOHOL PREP PADS TOPICAL PADS, MEDICATED

Tier 1

TRUE COMFORT ALCOHOL PADS TOPICAL PADS, MEDICATED

Tier 1

ULTILET ALCOHOL SWAB TOPICAL PADS, MEDICATED

Tier 1

WEBCOL TOPICAL PADS, MEDICATED

Tier 1

Emollientsammonium lactate topical cream 12 % (Geri-Hydrolac) Tier 1 QL (140 GM per 30 days)

ammonium lactate topical lotion 12 % (Geri-Hydrolac) Tier 1 QL (225 GM per 30 days)

GERI-HYDROLAC TOPICAL CREAM 12 %


KeratolyticsACNE CONTROL CLEANSER TOPICAL CLEANSER 10 %

Tier 1

ACNE FOAMING WASH TOPICAL CLEANSER 10 %

Tier 1

ACNE MEDICATION TOPICAL GEL 10 %

Tier 1 QL (3.78 GM per 1 day)

ACNE MEDICATION TOPICAL GEL 5 % Tier 1

ACNE TREATMENT (BENZOYL PEROX) TOPICAL GEL 10 %


ACNE-CLEAR TOPICAL GEL 10 % Tier 1 QL (3.78 GM per 1 day)

ADVANCED EXFOLIATING CLEANSER TOPICAL CLEANSER 5 %

Tier 1

benzoyl peroxide topical cleanser 10 % (Acne Control Cleanser) Tier 1

benzoyl peroxide topical cleanser 5 % (Advanced Exfoliating Cleanser)

Tier 1

benzoyl peroxide topical gel 10 % (Acne Medication) Tier 1 QL (3.78 GM per 1 day)

68

Drug Status Notes

benzoyl peroxide topical gel 5 % (Acne Medication) Tier 1

BP TOPICAL GEL 10 % Tier 1 QL (3.78 GM per 1 day)

BP TOPICAL GEL 5 % Tier 1

BPO-10 TOPICAL CLEANSER 10 % Tier 1

BPO-5 TOPICAL CLEANSER 5 % Tier 1

CLEAN-CLEAR CONTINUOUS CONTROL TOPICAL CLEANSER 10 %

Tier 1

CREAMY ACNE FACE TOPICAL CLEANSER 4 %

Tier 1

DAYLOGIC ACNE FOAMING WASH TOPICAL CLEANSER 10 %

Tier 1

DAYLOGIC ACNE TREATMENT TOPICAL GEL 10 %


FOAMING ACNE FACE WASH TOPICAL CLEANSER 10 %

Tier 1

PANOXYL TOPICAL CLEANSER 10 %, 4 %

Tier 1

PERSA-GEL TOPICAL GEL 10 % Tier 1 QL (3.78 GM per 1 day)

podofilox topical solution 0.5 % Tier 1Topical Antineoplastic & Premalignant Lesion Agntsdiclofenac sodium topical gel 3 % (Solaraze) Tier 1 PA; QL (100 GM per 30

days)

fluorouracil topical cream 0.5 % (Carac) Tier 1 PA; QL (30 GM per 30 days)

fluorouracil topical cream 5 % (Efudex) Tier 1 PA; QL (40 GM per 30 days)

Topical Local AnestheticsASPERCREME (LIDOCAINE) TOPICAL ADHESIVE PATCH,MEDICATED 4 %


LIDO KING TOPICAL ADHESIVE PATCH,MEDICATED 4 %


lidocaine hcl topical cream 4 % (Lidocaine Plus) Tier 1 QL (153 GM per 30 days)

LIDOCAINE PAIN RELIEF TOPICAL ADHESIVE PATCH,MEDICATED 4 %


LIDOCAINE PLUS TOPICAL CREAM 4 %


lidocaine topical adhesive patch,medicated 4 %

(Aspercreme (lidocaine)) Tier 1 QL (1 EA per 1 day)

lidocaine-prilocaine topical cream 2.5-2.5 %


LIDOCARE TOPICAL ADHESIVE PATCH,MEDICATED 4 %


PAIN RELIEF (LIDOCAINE) TOPICAL CREAM 4 %


SALONPAS (LIDOCAINE) TOPICAL ADHESIVE PATCH,MEDICATED 4 %


69

Drug Status Notes

Topical/Mucous Membr./Subcut. EnzymesSANTYL TOPICAL OINTMENT 250 UNIT/GRAM


Dermatology - Psoriasis/Eczema

Antipsoriatic Agents,Systemicacitretin oral capsule 10 mg, 25 mg (Soriatane) Tier 1 PA; SP; QL (2 EA per 1

day)

acitretin oral capsule 17.5 mg Tier 1 PA; SP; QL (2 EA per 1 day)

SILIQ SUBCUTANEOUS SYRINGE 210 MG/1.5 ML

Tier 1 PA; SP; QL (3 ML per 28 days)

Antipsoriatics Agentscalcipotriene scalp solution 0.005 % Tier 1 PA; QL (60 ML per 30

days)

calcipotriene topical ointment 0.005 % Tier 1 PA; QL (4 GM per 1 day)Topical Immunosuppressive Agentspimecrolimus topical cream 1 % (Elidel) Tier 1 PA; QL (30 GM per 30

days)

tacrolimus topical ointment 0.03 % (Protopic) Tier 1 PA; QL (30 GM per 30 days); Age (Min 2 Years)

tacrolimus topical ointment 0.1 % (Protopic) Tier 1 PA; QL (30 GM per 30 days); Age (Min 16 Years)

Diabetes

Antihypergly, (Dpp-4) Inhibitor & Biguanide Comb.alogliptin-metformin oral tablet 12.5-1,000 mg, 12.5-500 mg

(Kazano) Tier 1 ST: Requires prior prescription for Metformin HCL within the past 180 days; QL (2 EA per 1 day)

JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG


JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG


KAZANO ORAL TABLET 12.5-1,000 MG, 12.5-500 MG


Antihypergly,Dpp-4 Enzyme Inhib &Thiazolidinedionealogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg

(Oseni) Tier 1 ST: Requires prior prescription for Metformin HCL within the past 180 days; QL (1 EA per 1 day)

Antihypergly,Incretin Mimetic(Glp-1 Recep.Agonist)OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML)

Tier 1 PA; QL (1.5 ML per 28 days)

70

Drug Status Notes

OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML)

Tier 1 PA; QL (3 ML per 28 days)

TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML


VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


Antihyperglycemc-Sod/Gluc Cotransport2(Sglt2)InhibINVOKANA ORAL TABLET 100 MG, 300 MG


JARDIANCE ORAL TABLET 10 MG, 25 MG


STEGLATRO ORAL TABLET 15 MG, 5 MG

Tier 1 PA

Antihyperglycemic, Alpha-Glucosidase Inhib (N-S)acarbose oral tablet 100 mg (Precose) Tier 1 QL (4 EA per 1 day)

acarbose oral tablet 25 mg, 50 mg (Precose) Tier 1 QL (3 EA per 1 day)Antihyperglycemic, Dpp-4 Inhibitorsalogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg

(Nesina) Tier 1 ST: Requires prior prescription for Metformin HCL within the past 180 days; QL (1 EA per 1 day)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG


TRADJENTA ORAL TABLET 5 MG Tier 1 PA; QL (1 EA per 1 day)Antihyperglycemic, Insulin-Release Stimulant Typeglimepiride oral tablet 1 mg, 2 mg, 4 mg (Amaryl) Tier 1

glipizide oral tablet 10 mg, 5 mg (Glucotrol) Tier 1 QL (2 EA per 1 day)

glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg

(Glucotrol XL) Tier 1

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

(Glynase) Tier 1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg

Tier 1

nateglinide oral tablet 120 mg, 60 mg (Starlix) Tier 1 QL (3 EA per 1 day)

repaglinide oral tablet 0.5 mg Tier 1 QL (4 EA per 1 day)

repaglinide oral tablet 1 mg, 2 mg (Prandin) Tier 1 QL (4 EA per 1 day)Antihyperglycemic, Insulin-Response Enhancer (N-S)pioglitazone oral tablet 15 mg, 30 mg, 45 mg

(Actos) Tier 1 QL (1 EA per 1 day)

71

Drug Status Notes

Antihyperglycemic, Sglt-2 & Dpp-4 Inhibitor Comb.STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG

Tier 1 PA; Age (Min 18 Years)

Antihyperglycemic,Biguanide Type(Non-Sulfonylurea)metformin oral tablet 1,000 mg (Glucophage) Tier 1 QL (2 EA per 1 day)

metformin oral tablet 500 mg (Glucophage) Tier 1 QL (3 EA per 1 day)

metformin oral tablet 850 mg (Glucophage) Tier 1 QL (4 EA per 1 day)

metformin oral tablet extended release 24 hr 500 mg, 750 mg

(Glucophage XR) Tier 1

Antihyperglycemic,Insulin-Rel Stim.& Biguanide Cmbglipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

Tier 1

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

Tier 1

Antihyperglycemic-Sglt2 Inhibitor & Biguanide CombINVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG


INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG


SEGLUROMET ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 7.5-1,000 MG, 7.5-500 MG

Tier 1 PA

SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-1,000 MG, 5-1,000 MG


Blood Sugar DiagnosticsBREEZE 2 TEST STRIPS STRIP Tier 1 QL: 300 IN 30 DAYS IF 20

YEARS OF AGE OR YOUNGER|200 IN 30 DAYS WITH HISTORY OF INSULINS OR 100 IN 30 DAYS WITH NO HISTORY OF INSULINS IF 21 YEARS OF AGE OR OLDER

72

Drug Status Notes

CONTOUR NEXT TEST STRIPS STRIP Tier 1 QL: 300 IN 30 DAYS IF 20 YEARS OF AGE OR YOUNGER|200 IN 30 DAYS WITH HISTORY OF INSULINS OR 100 IN 30 DAYS WITH NO HISTORY OF INSULINS IF 21 YEARS OF AGE OR OLDER

CONTOUR TEST STRIPS STRIP Tier 1 QL: 300 IN 30 DAYS IF 20 YEARS OF AGE OR YOUNGER|200 IN 30 DAYS WITH HISTORY OF INSULINS OR 100 IN 30 DAYS WITH NO HISTORY OF INSULINS IF 21 YEARS OF AGE OR OLDER

HyperglycemicsBAQSIMI NASAL SPRAY,NON-AEROSOL 3 MG/ACTUATION


GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG


GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG


InsulinsADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML


ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS SOLUTION 100 UNIT/ML


BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50)


HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50)


HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25)


HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25)


HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)


73

Drug Status Notes

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)


HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML


HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML


HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML

Tier 1 PA

insulin asp prt-insulin aspart subcutaneous insulin pen 100 unit/ml (70-30)

(Novolog Mix 70-30FlexPen U-100)


insulin asp prt-insulin aspart subcutaneous solution 100 unit/ml (70-30)

(Novolog Mix 70-30 U-100 Insuln)


NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)


NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)


NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)


NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML


NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML


NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30)


NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)


Urine Glucose Test AidsDIASTIX STRIP Tier 1

NO-STICK GLUCOSE STRIP Tier 1Urine Glucose/Acetone Test Aids,StripsKETO-DIASTIX STRIP Tier 1

Ear - General Disorders

Ear Preparations, Misc. Anti-Infectivesacetic acid otic (ear) solution 2 % Tier 1

hydrocortisone-acetic acid otic (ear) drops 1-2 %

Tier 1

74

Drug Status Notes

Ear Preparations,Antibioticsciprofloxacin hcl otic (ear) dropperette0.2 %

(Cetraxal) Tier 1 QL (14 EA per 30 days)

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

Tier 1

neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-%

Tier 1

ofloxacin otic (ear) drops 0.3 % Tier 1 QL (5 ML per 30 days)Otic Preparations,Anti-Inflammatory-AntibioticsCIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 %

Tier 1 QL (7.5 ML per 30 days)

Electrolyte Regulation

Electrolyte Depleterscalcium acetate(phosphat bind) oral capsule 667 mg

Tier 1

calcium acetate(phosphat bind) oral tablet 667 mg

Tier 1

KIONEX (WITH SORBITOL) ORAL SUSPENSION 15-19.3 GRAM/60 ML

Tier 1

lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg

(Fosrenol) Tier 1 PA

sevelamer carbonate oral tablet 800 mg (Renvela) Tier 1 PA

sevelamer hcl oral tablet 400 mg Tier 1 PA

sevelamer hcl oral tablet 800 mg (Renagel) Tier 1 PA

SODIUM POLYSTYRENE (SORB FREE) ORAL SUSPENSION 15 GRAM/60 ML

Tier 1

sodium polystyrene sulfonate oral powder

Tier 1

SPS (WITH SORBITOL) ORAL SUSPENSION 15-20 GRAM/60 ML

Tier 1

Electrolyte Maintenanceelectrolytes-dextrose oral solution (Enfamil Enfalyte) Tier 1

ENFAMIL ENFALYTE ORAL SOLUTION Tier 1

ORALYTE ORAL SOLUTION Tier 1

PEDIALYTE ADVANCED CARE ORAL SOLUTION

Tier 1

PEDIALYTE FREEZER POPS ORAL SOLUTION

Tier 1

PEDIALYTE ORAL SOLUTION Tier 1

PEDIALYTE SINGLES ORAL SOLUTION

Tier 1

PEDIATRIC ELECTROLYTE ORAL SOLUTION

Tier 1

PEDIATRIC FREEZER POPS ORAL SOLUTION

Tier 1

PEDIAVANCE ORAL CONCENTRATED SOLN IN A PACKET 5.3-2.35-4.15 MEQ

Tier 1

75

Drug Status Notes

Phosphate ReplacementPHOS-NAK ORAL POWDER IN PACKET 280-160-250 MG

Tier 1

PHOSPHOROUS SUPPLEMENT ORAL POWDER IN PACKET 280-160-250 MG

Tier 1

potassium, sodium phosphates oral powder in packet 280-160-250 mg

(Phos-NaK) Tier 1

Potassium ReplacementEFFER-K ORAL TABLET, EFFERVESCENT 25 MEQ

Tier 1

KLOR-CON M10 ORAL TABLET,ER PARTICLES/CRYSTALS 10 MEQ

Tier 1

KLOR-CON M20 ORAL TABLET,ER PARTICLES/CRYSTALS 20 MEQ

Tier 1

potassium chloride oral capsule, extended release 10 meq, 8 meq

Tier 1

potassium chloride oral tablet extended release 10 meq, 8 meq

(K-Tab) Tier 1 QL (2 EA per 1 day)

potassium chloride oral tablet,er particles/crystals 10 meq

(Klor-Con M10) Tier 1

potassium chloride oral tablet,er particles/crystals 20 meq

(Klor-Con M20) Tier 1

Endocrine Disorder - Fertility

Pregnancy Maintaining Agent,Hormonalhydroxyprogest(pf)(preg presv) intramuscular oil 250 mg/ml (1 ml)

(Makena) Tier 1 SP; Maximum quantity allowed is 20mL in 365 days; QL (4 ML per 28 days)

Endocrine Disorder - Other

Adrenocorticotrophic HormonesACTHAR INJECTION GEL 80 UNIT/ML Carve Out CARVE OUT


ACTHREL INTRAVENOUS RECON SOLN 100 MCG


CORTROSYN INJECTION RECON SOLN 0.25 MG


cosyntropin injection recon soln 0.25 mg (Cortrosyn) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Antidiuretic And Vasopressor HormonesDDAVP NASAL SOLUTION 0.1 MG/ML (REFRIGERATE)

Tier 1

76

Drug Status Notes

desmopressin nasal spray with pump 10 mcg/spray (0.1 ml)

(DDAVP) Tier 1 PA

desmopressin nasal spray,non-aerosol10 mcg/spray (0.1 ml)

Tier 1 PA

desmopressin oral tablet 0.1 mg, 0.2 mg (DDAVP) Tier 1 QL (6 EA per 1 day)

STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML)

Tier 1 PA

Antineoplastic Lhrh(Gnrh) Agonist,Pituitary Suppr.leuprolide subcutaneous kit 1 mg/0.2 ml Tier 1 PA; SP

Bone Formation Stim. Agents - Parathyroid HormoneFORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML

Tier 1 PA; SP; QL (2.4 ML per 30 days)

Bone Formation Stimulating Agts - Pth Rel PeptidesTYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML)

Tier 1 PA; SP

Bone Resorption Inhibitorsalendronate oral tablet 10 mg, 5 mg Tier 1 QL (1 EA per 1 day)

alendronate oral tablet 35 mg Tier 1 QL (4 EA per 28 days)

alendronate oral tablet 70 mg (Fosamax) Tier 1 QL (4 EA per 28 days)

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation

Tier 1 QL (3.7 ML per 30 days)

ibandronate oral tablet 150 mg (Boniva) Tier 1 QL (1 EA per 28 days)

raloxifene oral tablet 60 mg (Evista) Tier 1 QL (1 EA per 1 day); Age (Min 40 Years)

Calcimimetic,Parathyroid Calcium Enhancercinacalcet oral tablet 30 mg, 60 mg (Sensipar) Tier 1 PA; SP; QL (2 EA per 1

day)

cinacalcet oral tablet 90 mg (Sensipar) Tier 1 PA; SP; QL (4 EA per 1 day)

Growth HormonesNORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)

Tier 1 PA; SP

Insulin-Like Growth Factor-1 (Igf-1) HormonesINCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML

Tier 1 PA; SP

Leptin Hormone AnalogsMYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.)


77

Drug Status Notes

Pituitary Suppressive Agentscabergoline oral tablet 0.5 mg Tier 1 QL (2 EA per 1 day)

danazol oral capsule 100 mg, 200 mg, 50 mg

Tier 1

Endocrine Disorder - Thyroid

Antithyroid Preparationsmethimazole oral tablet 10 mg, 5 mg (Tapazole) Tier 1

propylthiouracil oral tablet 50 mg Tier 1Thyroid HormonesARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG


EUTHYROX ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 1

LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 1 ST: Requires prior prescription for formulary generic oral Levothyroxine within the past 120 days if 12 years of age and older; QL (1 EA per 1 day)

levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

(Euthyrox) Tier 1 QL (2 EA per 1 day)

levothyroxine oral tablet 300 mcg (Levo-T) Tier 1 QL (2 EA per 1 day)

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG


liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg

(Cytomel) Tier 1

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG


NP THYROID ORAL TABLET 120 MG, 15 MG, 30 MG, 60 MG, 90 MG


SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG


thyroid (pork) oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

(Armour Thyroid) Tier 1 Age (Max 64 Years)

78

Drug Status Notes

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG


WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG


WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG


Eye - General Disorders

Eye Antibiotic-Corticoid Combinationsneomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

(Neo-Polycin HC) Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension3.5mg/ml-10,000 unit/ml-0.1 %

(Maxitrol) Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

(Maxitrol) Tier 1

NEO-POLYCIN HC OPHTHALMIC (EYE) OINTMENT 3.5-400-10,000 MG-UNIT/G-1%

Tier 1

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 %

(TobraDex) Tier 1

Eye AntihistaminesALAWAY OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %)


ALLERGY EYE (KETOTIFEN) OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %)


azelastine ophthalmic (eye) drops 0.05 %

Tier 1 ST: Requires prior prescription for Ketotifen Fumarate within the past 180 days; QL (6 ML per 30 days)

CHILDREN'S ALAWAY OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %)


EYE ITCH RELIEF OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %)


ITCHY EYE DROPS OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %)


ketotifen fumarate ophthalmic (eye) drops 0.025 % (0.035 %)

(Alaway) Tier 1 QL (10 ML per 30 days)

WAL-ZYR (KETOTIFEN) OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %)


ZADITOR OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %)


79

Drug Status Notes

Eye Antihistamine-Vasoconstrictor CombinationsALLERGY EYE (NAPHAZOLINE-PHEN) OPHTHALMIC (EYE) DROPS 0.025-0.3 %

Tier 1

EYE ALLERGY RELIEF OPHTHALMIC (EYE) DROPS 0.025-0.3 %, 0.02675-0.315 %

Tier 1

Eye Antiinflammatory Agentsdexamethasone sodium phosphate ophthalmic (eye) drops 0.1 %

Tier 1

diclofenac sodium ophthalmic (eye) drops 0.1 %

Tier 1

fluorometholone ophthalmic (eye) drops,suspension 0.1 %

(FML Liquifilm) Tier 1 QL (15 ML per 30 days)

flurbiprofen sodium ophthalmic (eye) drops 0.03 %

Tier 1

ketorolac ophthalmic (eye) drops 0.5 % (Acular) Tier 1 QL (10 ML per 25 days)

prednisolone acetate ophthalmic (eye) drops,suspension 1 %

(Pred Forte) Tier 1

prednisolone sodium phosphate ophthalmic (eye) drops 1 %

Tier 1

Eye Antiviralstrifluridine ophthalmic (eye) drops 1 % Tier 1

Eye Local AnestheticsALCAINE OPHTHALMIC (EYE) DROPS 0.5 %

Tier 1

proparacaine ophthalmic (eye) drops 0.5 %

(Alcaine) Tier 1

Eye SulfonamidesBLEPH-10 OPHTHALMIC (EYE) DROPS 10 %

Tier 1

sulfacetamide sodium ophthalmic (eye) drops 10 %

(Bleph-10) Tier 1

sulfacetamide sodium ophthalmic (eye) ointment 10 %

Tier 1

sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %)

Tier 1

Eye Vasoconstrictors (Rx Only)phenylephrine hcl ophthalmic (eye) drops 2.5 %

Tier 1

Ophthalmic AntibioticsAK-POLY-BAC OPHTHALMIC (EYE) OINTMENT 500-10,000 UNIT/GRAM

Tier 1

bacitracin ophthalmic (eye) ointment 500 unit/gram

Tier 1

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram

(AK-Poly-Bac) Tier 1

ciprofloxacin hcl ophthalmic (eye) drops0.3 %

(Ciloxan) Tier 1 QL (10 ML per 30 days)

80

Drug Status Notes

erythromycin ophthalmic (eye) ointment5 mg/gram (0.5 %)

Tier 1

GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM)

Tier 1

gentamicin ophthalmic (eye) drops 0.3 % Tier 1

levofloxacin ophthalmic (eye) drops 0.5 %

Tier 1

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

(Neo-Polycin) Tier 1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml

Tier 1

NEO-POLYCIN OPHTHALMIC (EYE) OINTMENT 3.5-400-10,000 MG-UNIT-UNIT/G

Tier 1

ofloxacin ophthalmic (eye) drops 0.3 % (Ocuflox) Tier 1

POLYCIN OPHTHALMIC (EYE) OINTMENT 500-10,000 UNIT/GRAM

Tier 1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml

(Polytrim) Tier 1

tobramycin ophthalmic (eye) drops 0.3 % (Tobrex) Tier 1Ophthalmic Mast Cell Stabilizerscromolyn ophthalmic (eye) drops 4 % Tier 1

Ophthalmic Preparations, MiscellaneousALTACHLORE OPHTHALMIC (EYE) DROPS 5 %

Tier 1

ALTACHLORE OPHTHALMIC (EYE) OINTMENT 5 %

Tier 1

MURO 128 OPHTHALMIC (EYE) DROPS 5 %

Tier 1

MURO 128 OPHTHALMIC (EYE) OINTMENT 5 %

Tier 1

sodium chloride ophthalmic (eye) drops5 %

(Altachlore) Tier 1

sodium chloride ophthalmic (eye) ointment 5 %

(Altachlore) Tier 1

Eye - Glaucoma

Carbonic Anhydrase Inhibitorsacetazolamide oral capsule, extended release 500 mg


acetazolamide oral tablet 125 mg, 250 mg


Miotics/Other Intraoc. Pressure Reducersapraclonidine ophthalmic (eye) drops 0.5 %


betaxolol ophthalmic (eye) drops 0.5 % Tier 1

81

Drug Status Notes

brimonidine ophthalmic (eye) drops 0.2 %

Tier 1

carteolol ophthalmic (eye) drops 1 % Tier 1

COSOPT OPHTHALMIC (EYE) DROPS 22.3-6.8 MG/ML


dorzolamide ophthalmic (eye) drops 2 % (Trusopt) Tier 1 QL (10 ML per 30 days)

dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml

(Cosopt) Tier 1 QL (10 ML per 30 days)

latanoprost ophthalmic (eye) drops 0.005 %

(Xalatan) Tier 1 QL (2.5 ML per 25 days)

levobunolol ophthalmic (eye) drops 0.5 %

Tier 1

metipranolol ophthalmic (eye) drops 0.3 %

Tier 1

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 %

Tier 1

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

(Isopto Carpine) Tier 1

timolol maleate ophthalmic (eye) drops0.25 %, 0.5 %

(Timoptic) Tier 1

Mydriaticsatropine ophthalmic (eye) drops 1 % (Isopto Atropine) Tier 1

atropine ophthalmic (eye) ointment 1 % Tier 1

cyclopentolate ophthalmic (eye) drops 1 %, 2 %

(Cyclogyl) Tier 1

HOMATROPAIRE OPHTHALMIC (EYE) DROPS 5 %

Tier 1

tropicamide ophthalmic (eye) drops 0.5 %

Tier 1

tropicamide ophthalmic (eye) drops 1 % (Mydriacyl) Tier 1Eye - Miscellaneous

Artificial TearsARTIFICIAL TEARS (PF) OPHTHALMIC (EYE) DROPPERETTE , 0.1-0.3 %

Tier 1

ARTIFICIAL TEARS (POLYVIN ALC) OPHTHALMIC (EYE) DROPS 1.4 %

Tier 1

ARTIFICIAL TEARS(DEXT70-HYPRO) OPHTHALMIC (EYE) DROPS , 0.1-0.3 %

Tier 1

ARTIFICIAL TEARS(GLYCERIN-PEG) OPHTHALMIC (EYE) DROPS 1-0.3 %

Tier 1

ARTIFICIAL TEARS(PVALCH-POVID) OPHTHALMIC (EYE) DROPS 0.5-0.6 %

Tier 1

BION TEARS (PF) OPHTHALMIC (EYE) DROPPERETTE 0.1-0.3 %

Tier 1

CLEAR EYES NATURAL TEARS OPHTHALMIC (EYE) DROPS 0.5-0.6 %

Tier 1

GENTEAL TEARS MILD OPHTHALMIC (EYE) DROPS 0.1-0.3 %

Tier 1

82

Drug Status Notes

GENTEAL TEARS MODERATE (PF) OPHTHALMIC (EYE) DROPPERETTE 0.1-0.3 %

Tier 1

LUBRICANT (P-GLYCOL-GLYCERIN) OPHTHALMIC (EYE) DROPS 1-0.3 %

Tier 1

LUBRICANT EYE (PG-PEG 400) OPHTHALMIC (EYE) DROPS 0.4-0.3 %

Tier 1

LUBRICANT EYE DROPS OPHTHALMIC (EYE) DROPPERETTE 0.5 %

Tier 1

LUBRICANT EYE DROPS OPHTHALMIC (EYE) DROPS 0.5 %

Tier 1

LUBRICATING PLUS OPHTHALMIC (EYE) DROPPERETTE 0.5 %

Tier 1

NATURAL TEARS (PF) OPHTHALMIC (EYE) DROPPERETTE 0.1-0.3 %

Tier 1

polyvinyl alcohol ophthalmic (eye) drops1.4 %

(Artificial Tears (polyvin alc))

Tier 1

RESTORE PLUS (CMCELLULOSE) OPHTHALMIC (EYE) DROPPERETTE 0.5 %

Tier 1

RESTORE TEARS OPHTHALMIC (EYE) DROPS 0.5 %

Tier 1

REVIVE PLUS OPHTHALMIC (EYE) DROPPERETTE 0.5 %

Tier 1

SYSTANE (PROPYLENE GLYCOL) OPHTHALMIC (EYE) DROPS 0.4-0.3 %

Tier 1

SYSTANE GEL OPHTHALMIC (EYE) DROPS,GEL 0.4-0.3 %

Tier 1

SYSTANE ULTRA OPHTHALMIC (EYE) DROPS 0.4-0.3 %

Tier 1

ULTRA FRESH OPHTHALMIC (EYE) DROPS 0.5 %

Tier 1

Eye Preparations, Miscellaneous (Otc)FOR STY RELIEF OPHTHALMIC (EYE) OINTMENT

Tier 1

GENTEAL TEARS SEVERE(PETROLAT) OPHTHALMIC (EYE) OINTMENT 94-3 %

Tier 1

LUBRICANT EYE OPHTHALMIC (EYE) OINTMENT 57.3-42.5 %

Tier 1

NIGHTTIME DRY-EYE RELIEF OPHTHALMIC (EYE) OINTMENT 57.3-42.5 %

Tier 1

OVERNIGHT LUBRICATING EYE OPHTHALMIC (EYE) OINTMENT 94-3 %

Tier 1

REFRESH LACRI-LUBE OPHTHALMIC (EYE) OINTMENT 56.8-42.5 %

Tier 1

83

Drug Status Notes

REFRESH P.M. OPHTHALMIC (EYE) OINTMENT 57.3-42.5 %

Tier 1

RESTORE PM OPHTHALMIC (EYE) OINTMENT 57.3-42.5 %

Tier 1

SYSTANE NIGHTTIME OPHTHALMIC (EYE) OINTMENT 94-3 %

Tier 1

Gout And Related Diseases

Colchicinecolchicine oral capsule 0.6 mg (Mitigare) Tier 1 QL (2 EA per 1 day)

colchicine oral tablet 0.6 mg (Colcrys) Tier 1 QL (2 EA per 1 day)Hyperuricemia Tx - Purine Inhibitorsallopurinol oral tablet 100 mg (Zyloprim) Tier 1 QL (3 EA per 1 day)

allopurinol oral tablet 300 mg (Zyloprim) Tier 1 QL (2.5 EA per 1 day)

febuxostat oral tablet 40 mg, 80 mg (Uloric) Tier 1 PA; QL (1 EA per 1 day)Uricosuric Agentsprobenecid oral tablet 500 mg Tier 1 QL (2 EA per 1 day)

probenecid-colchicine oral tablet 500-0.5 mg

Tier 1

Hematological Disorders

Anticoagulants,Coumarin TypeJANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

Tier 1

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

(Jantoven) Tier 1

Antifibrinolytic AgentsAMICAR ORAL SOLUTION 250 MG/ML (25 %)


AMICAR ORAL TABLET 1,000 MG, 500 MG


aminocaproic acid intravenous solution250 mg/ml


aminocaproic acid oral solution 250 mg/ml (25 %)

(Amicar) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

aminocaproic acid oral tablet 1,000 mg, 500 mg

(Amicar) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

CYKLOKAPRON INTRAVENOUS SOLUTION 1,000 MG/10 ML (100 MG/ML)


84

Drug Status Notes

FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1,300 MG)


LYSTEDA ORAL TABLET 650 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1,300MG)


tranexamic acid in nacl,iso-os intravenous piggyback 1,000 mg/100 ml (10 mg/ml)


tranexamic acid intravenous solution1,000 mg/10 ml (100 mg/ml)

(Cyklokapron) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

tranexamic acid oral tablet 650 mg (Lysteda) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Antihemophilic FactorsADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT


ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT


AFSTYLA INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT RANGE, 1,500 (+/-) UNIT RANGE, 2,000 (+/-) UNIT RANGE, 2,500 (+/-) UNIT RANGE, 250 (+/-) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE


ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML


ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT


85

Drug Status Notes

ESPEROCT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT


FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 350-650 UNIT, 700-1,300 UNIT


HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1,500 UNIT


HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT


HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT


HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1,501-2,000 UNIT


HUMATE-P INTRAVENOUS RECON SOLN 1,000-2,400 UNIT, 250-600 UNIT, 500-1,200 UNIT


JIVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT


KOATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT


KOGENATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT


KOVALTRY INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT


NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT


NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG)


86

Drug Status Notes

NUWIQ INTRAVENOUS RECON SOLN 1000 (+/-) UNIT, 2,000 (+/-) UNIT, 2,500 UNIT, 250 (+/-) UNIT, 3,000 UNIT, 4,000 UNIT, 500 (+/-) UNIT


OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE


RECOMBINATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT


WILATE INTRAVENOUS RECON SOLN 1,000-1,000 UNIT, 500-500 UNIT


XYNTHA INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT


XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT


Antiporphyria FactorsPANHEMATIN INTRAVENOUS RECON SOLN 350 MG


Blood Factors,MiscellaneousVONVENDI INTRAVENOUS RECON SOLN 1,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE


Direct Factor Xa InhibitorsELIQUIS DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 5 MG (74 TABS)

Tier 1 PA; QL (74 EA per 90 days); Age (Min 18 Years)

ELIQUIS ORAL TABLET 2.5 MG, 5 MG Tier 1 PA; QL (2 EA per 1 day); Age (Min 18 Years)

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

Tier 1 PA; QL (1 EA per 1 day); Age (Min 18 Years)

XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9)


Factor Ix Complex (Pcc) PreparationsKCENTRA INTRAVENOUS RECON SOLN 1,000 UNIT (800-1240 UNIT), 500 UNIT (400-620 UNIT)


87

Drug Status Notes

PROFILNINE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT


Factor Ix PreparationsALPHANINE SD INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT


ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT


BENEFIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT


IDELVION INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,500 (+/-) UNIT, 500 (+/-) UNIT


IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT


MONONINE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT


REBINYN INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 500 (+/-) UNIT


RIXUBIS INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT


Factor Xiii PreparationsCORIFACT INTRAVENOUS RECON SOLN 1,000-1,600 UNIT


TRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT


Hematinics,OtherARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

Tier 1 PA; SP

88

Drug Status Notes

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML

Tier 1 PA; SP

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

Tier 1 PA; SP

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

Tier 1 PA; SP

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

Tier 1 PA; SP

Hemophilia Treatment Agents,Non-Factor ReplacementHEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7 ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4 ML


Hemorrheologic Agentspentoxifylline oral tablet extended release 400 mg

Tier 1

Heparin And Related Preparationsenoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

(Lovenox) Tier 1 PA REQUIRED IF DAYS SUPPLY IS GREATER THAN 10

heparin (porcine) injection solution10,000 unit/ml, 5,000 unit/ml

Tier 1

Human Monoclonal Antibody Complement(C5) InhibitorSOLIRIS INTRAVENOUS SOLUTION 300 MG/30 ML


ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/30 ML (10 MG/ML)


Leukocyte (Wbc) StimulantsFULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML

Tier 1 PA; SP

GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6 ML

Tier 1 PA; SP

89

Drug Status Notes

GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

Tier 1 PA; SP

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML

Tier 1 PA; SP

NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

Tier 1 PA; SP

NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

Tier 1 PA; SP

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

Tier 1 PA; SP

Plasma ProteinsALBUKED-25 INTRAVENOUS PARENTERAL SOLUTION 25 %


ALBUKED-5 INTRAVENOUS PARENTERAL SOLUTION 5 %


albumin, human 20 % intravenous parenteral solution 20 %



(Albuked-25) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID


(Albuked-5) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ALBUMINAR 25 % INTRAVENOUS PARENTERAL SOLUTION 25 %


ALBUMINEX INTRAVENOUS SOLUTION 25 %, 5 %


ALBURX (HUMAN) 25 % INTRAVENOUS PARENTERAL SOLUTION 25 %


ALBURX (HUMAN) 5 % INTRAVENOUS PARENTERAL SOLUTION 5 %


90

Drug Status Notes

ALBUTEIN 25 % INTRAVENOUS PARENTERAL SOLUTION 25 %


ALBUTEIN 5 % INTRAVENOUS PARENTERAL SOLUTION 5 %


ATRYN INTRAVENOUS RECON SOLN 1,750 UNIT, 525 UNIT


BUMINATE 25 % INTRAVENOUS PARENTERAL SOLUTION 25 %


BUMINATE 5 % INTRAVENOUS PARENTERAL SOLUTION 5 %


FLEXBUMIN 25 % INTRAVENOUS PARENTERAL SOLUTION 25 %


FLEXBUMIN 5 % INTRAVENOUS PARENTERAL SOLUTION 5 %


OCTAPLAS (BLOOD GROUP A) INTRAVENOUS SOLUTION 45 TO 70 MG/ML


OCTAPLAS (BLOOD GROUP AB) INTRAVENOUS SOLUTION 45 TO 70 MG/ML


OCTAPLAS (BLOOD GROUP B) INTRAVENOUS SOLUTION 45 TO 70 MG/ML


OCTAPLAS (BLOOD GROUP O) INTRAVENOUS SOLUTION 45 TO 70 MG/ML


PLASBUMIN 25 % INTRAVENOUS PARENTERAL SOLUTION 25 %


PLASBUMIN 5 % INTRAVENOUS PARENTERAL SOLUTION 5 %


91

Drug Status Notes

PLASMANATE INTRAVENOUS PARENTERAL SOLUTION 5 %


THROMBATE III INTRAVENOUS RECON SOLN 500 (+/-) UNIT


Platelet Aggregation InhibitorsADULT ASPIRIN REGIMEN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG


ADULT LOW DOSE ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG


ASPIR-81 ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG


ASPIRIN CHILDRENS ORAL TABLET,CHEWABLE 81 MG


ASPIRIN LOW DOSE ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG


aspirin oral tablet,chewable 81 mg (Aspirin Childrens) Tier 1 QL (1 EA per 1 day)

aspirin oral tablet,delayed release (dr/ec)81 mg

(Adult Aspirin Regimen) Tier 1 QL (1 EA per 1 day)

ASPIR-LOW ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG


CHILDREN'S ASPIRIN ORAL TABLET,CHEWABLE 81 MG


cilostazol oral tablet 100 mg, 50 mg Tier 1 QL (2 EA per 1 day)

clopidogrel oral tablet 300 mg Tier 1 QL (1 EA per 30 days)

clopidogrel oral tablet 75 mg (Plavix) Tier 1 QL (1 EA per 1 day)

dipyridamole oral tablet 25 mg, 50 mg, 75 mg


ECOTRIN LOW STRENGTH ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG


LO-DOSE ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG


ST JOSEPH ASPIRIN ORAL TABLET,CHEWABLE 81 MG


ST. JOSEPH ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG


Platelet Reducing Agentsanagrelide oral capsule 0.5 mg (Agrylin) Tier 1

anagrelide oral capsule 1 mg Tier 1

92

Drug Status Notes

Protein C PreparationsCEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT


CEPROTIN (GREEN BAR) INTRAVENOUS RECON SOLN 1,000 UNIT


Sickle Cell Anemia AgentsDROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

Tier 1

ENDARI ORAL POWDER IN PACKET 5 GRAM

Tier 1 PA; SP

Vitamin K PreparationsMEPHYTON ORAL TABLET 5 MG Tier 1 QL (3 EA per 30 days)

phytonadione (vitamin k1) oral tablet 5 mg

(Mephyton) Tier 1 QL (3 EA per 30 days)

Hormonal Deficiency

Androgenic Agentstestosterone cypionate intramuscular oil100 mg/ml, 200 mg/ml

(Depo-Testosterone) Tier 1

Estrogenic AgentsALORA TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR

Tier 1 QL (8 EA per 28 days); Age (Max 64 Years)

AMABELZ ORAL TABLET 0.5-0.1 MG, 1-0.5 MG


DOTTI TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR

Tier 1 QL (8 EA per 28 days); Age (Max 64 Years)

estradiol oral tablet 0.5 mg, 1 mg, 2 mg (Estrace) Tier 1 QL (2 EA per 1 day); Age (Max 64 Years)

estradiol transdermal patch semiweekly0.025 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

(Alora) Tier 1 QL (8 EA per 28 days); Age (Max 64 Years)

estradiol transdermal patch semiweekly0.0375 mg/24 hr

(Dotti) Tier 1 QL (8 EA per 28 days); Age (Max 64 Years)

estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

(Climara) Tier 1 QL (4 EA per 28 days); Age (Max 64 Years)

estradiol-norethindrone acet oral tablet0.5-0.1 mg, 1-0.5 mg

(Amabelz) Tier 1 QL (2 EA per 1 day); Age (Max 64 Years)

FYAVOLV ORAL TABLET 0.5-2.5 MG-MCG

Tier 1 QL (1 EA per 1 day); Age (Max 64 Years)

FYAVOLV ORAL TABLET 1-5 MG-MCG Tier 1 Age (Max 64 Years)

JINTELI ORAL TABLET 1-5 MG-MCG Tier 1 Age (Max 64 Years)

LOPREEZA ORAL TABLET 1-0.5 MG Tier 1 Age (Max 64 Years)

93

Drug Status Notes

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG


MIMVEY ORAL TABLET 1-0.5 MG Tier 1 Age (Max 64 Years)

norethindrone ac-eth estradiol oral tablet0.5-2.5 mg-mcg

(Fyavolv) Tier 1 QL (1 EA per 1 day); Age (Max 64 Years)

norethindrone ac-eth estradiol oral tablet1-5 mg-mcg

(Fyavolv) Tier 1 Age (Max 64 Years)

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG


PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14)


PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG


Progestational Agentsmedroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg

(Provera) Tier 1

norethindrone acetate oral tablet 5 mg (Aygestin) Tier 1 QL (2 EA per 1 day)

progesterone micronized oral capsule100 mg

(Prometrium) Tier 1 QL (1 EA per 1 day)

progesterone micronized oral capsule200 mg

(Prometrium) Tier 1 QL (2 EA per 1 day)

Immunization

Influenza Virus VaccinesAFLURIA QD 2019-20(3YR UP)(PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

AFLURIA QD 2019-20(6-35MO)(PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML

Tier 1

AFLURIA QUAD 2019-20(6MO UP) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUAD 2019-2020 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

Tier 1

FLUARIX QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUBLOK QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 180 MCG (45 MCG X 4)/0.5 ML

Tier 1

FLUCELVAX QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUCELVAX QUAD 2019-2020 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLULAVAL QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

94

Drug Status Notes

FLULAVAL QUAD 2019-2020 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUMIST QUAD 2019-2020 NASAL NASAL SPRAY SYRINGE 10EXP6.5-7.5 FF UNIT/0.2 ML

Tier 1

FLUZONE HIGH-DOSE 2019-20 (PF) INTRAMUSCULAR SYRINGE 180 MCG/0.5 ML

Tier 1

FLUZONE QUAD 2019-2020 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUZONE QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUZONE QUAD 2019-2020 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

Tier 1

FLUZONE QUAD PEDI 2019-20 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML

Tier 1

Viral/Tumorigenic VaccinesHAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML

Tier 1 Age (Min 19 Years)

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML


VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML


VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML


Immunosuppression/Modulation

Immunomodulatorsimiquimod topical cream in packet 5 % (Aldara) Tier 1 QL (12 EA per 28 days)

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

Tier 1 PA; SP

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML

Tier 1 PA; SP

Immunosuppressivesazathioprine oral tablet 50 mg (Imuran) Tier 1 QL (8 EA per 1 day)

cyclosporine modified oral capsule 100 mg, 25 mg

(Gengraf) Tier 1 SP

cyclosporine modified oral capsule 50 mg

Tier 1 SP

cyclosporine modified oral solution 100 mg/ml

(Gengraf) Tier 1 SP; Age (Max 12 Years)

cyclosporine oral capsule 100 mg, 25 mg (Sandimmune) Tier 1 SP

95

Drug Status Notes

mycophenolate mofetil (hcl) intravenous recon soln 500 mg

(CellCept Intravenous) Tier 1

mycophenolate mofetil oral capsule 250 mg

(CellCept) Tier 1 QL (2 EA per 1 day)

mycophenolate mofetil oral suspension for reconstitution 200 mg/ml

(CellCept) Tier 1 Age (Max 12 Years)

mycophenolate mofetil oral tablet 500 mg

(CellCept) Tier 1 QL (2 EA per 1 day)

mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg

(Myfortic) Tier 1 ST: Requires prior prescription for Mycophenolate 250mg or 500mg or suspension within the past 180 days; QL (2 EA per 1 day)

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG

Tier 1

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg (Rapamune) Tier 1 SP

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg

(Prograf) Tier 1 QL (2 EA per 1 day)

Infectious Disease - Bacterial

Absorbable Sulfonamidessulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml

(Sulfatrim) Tier 1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

(Bactrim) Tier 1

sulfamethoxazole-trimethoprim oral tablet 800-160 mg

(Bactrim DS) Tier 1

SULFATRIM ORAL SUSPENSION 200-40 MG/5 ML

Tier 1

BetalactamsCAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML

Tier 1 PA; SP

Cephalosporins - 1St Generationcefadroxil oral capsule 500 mg Tier 1

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml


cefadroxil oral tablet 1 gram Tier 1

cephalexin oral capsule 250 mg, 500 mg (Keflex) Tier 1

cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

Tier 1

Cephalosporins - 2Nd Generationcefaclor oral capsule 250 mg, 500 mg Tier 1

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml


cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml


cefprozil oral tablet 250 mg, 500 mg Tier 1

cefuroxime axetil oral tablet 250 mg, 500 mg

Tier 1

96

Drug Status Notes

Cephalosporins - 3Rd Generationcefdinir oral capsule 300 mg Tier 1

cefdinir oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml


cefixime oral capsule 400 mg (Suprax) Tier 1

cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

(Suprax) Tier 1 Age (Max 12 Years)

cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml


cefpodoxime oral tablet 100 mg, 200 mg Tier 1

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML


Chemotherapeutics, Antibacterial, Misc.methenamine hippurate oral tablet 1 gram

(Hiprex) Tier 1

methenamine mandelate oral tablet 0.5 g, 1 gram

Tier 1

trimethoprim oral tablet 100 mg Tier 1Macrolidesazithromycin oral packet 1 gram (Zithromax) Tier 1

azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

(Zithromax) Tier 1

azithromycin oral tablet 250 mg, 500 mg (Zithromax) Tier 1

azithromycin oral tablet 600 mg Tier 1

clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml


clarithromycin oral tablet 250 mg, 500 mg

Tier 1

Nitrofuran Derivativesnitrofurantoin macrocrystal oral capsule100 mg, 50 mg

(Macrodantin) Tier 1 QL (2 EA per 1 day); Age (Max 64 Years)

nitrofurantoin monohyd/m-cryst oral capsule 100 mg

(Macrobid) Tier 1 QL (2 EA per 1 day); Age (Max 64 Years)

nitrofurantoin oral suspension 25 mg/5 ml

(Furadantin) Tier 1 Age (Max 12 Years)

Oxazolidinoneslinezolid oral suspension for reconstitution 100 mg/5 ml

(Zyvox) Tier 1 PA

linezolid oral tablet 600 mg (Zyvox) Tier 1 PAPenicillinsamoxicillin oral capsule 250 mg, 500 mg Tier 1

amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

Tier 1

amoxicillin oral tablet 500 mg, 875 mg Tier 1

amoxicillin oral tablet,chewable 125 mg, 250 mg


97

Drug Status Notes

amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml


amoxicillin-pot clavulanate oral suspension for reconstitution 250-62.5 mg/5 ml

(Augmentin) Tier 1 Age (Max 12 Years)

amoxicillin-pot clavulanate oral suspension for reconstitution 600-42.9 mg/5 ml

(Augmentin ES-600) Tier 1 Age (Max 12 Years)

amoxicillin-pot clavulanate oral tablet250-125 mg

Tier 1

amoxicillin-pot clavulanate oral tablet500-125 mg, 875-125 mg

(Augmentin) Tier 1

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg

(Augmentin XR) Tier 1

amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg


ampicillin oral capsule 250 mg, 500 mg Tier 1

dicloxacillin oral capsule 250 mg, 500 mg

Tier 1

penicillin v potassium oral recon soln125 mg/5 ml, 250 mg/5 ml


penicillin v potassium oral tablet 250 mg, 500 mg

Tier 1

QuinolonesCIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML, 500 MG/5 ML


ciprofloxacin hcl oral tablet 100 mg, 750 mg

Tier 1

ciprofloxacin hcl oral tablet 250 mg (Cipro) Tier 1

ciprofloxacin hcl oral tablet 500 mg (Cipro) Tier 1 QL (2 EA per 1 day)

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml

(Cipro) Tier 1 Age (Max 12 Years)

levofloxacin oral solution 250 mg/10 ml Tier 1 Age (Max 12 Years)

levofloxacin oral tablet 250 mg Tier 1

levofloxacin oral tablet 500 mg, 750 mg (Levaquin) Tier 1

ofloxacin oral tablet 400 mg Tier 1Tetracyclinesdoxycycline hyclate oral tablet 100 mg Tier 1 QL (2 EA per 1 day)

doxycycline monohydrate oral capsule100 mg

(Mondoxyne NL) Tier 1

doxycycline monohydrate oral capsule50 mg

(Monodox) Tier 1

doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml

(Vibramycin) Tier 1 Age (Max 12 Years)

doxycycline monohydrate oral tablet 100 mg

(Avidoxy) Tier 1

98

Drug Status Notes

doxycycline monohydrate oral tablet 50 mg

Tier 1

minocycline oral capsule 100 mg, 75 mg Tier 1

minocycline oral capsule 50 mg (Minocin) Tier 1

MONDOXYNE NL ORAL CAPSULE 100 MG

Tier 1

tetracycline oral capsule 250 mg, 500 mg

Tier 1

Infectious Disease - Fungal

Antifungal Agentsclotrimazole mucous membrane troche10 mg


fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml

(Diflucan) Tier 1 Age (Max 12 Years)

fluconazole oral tablet 100 mg, 150 mg, 200 mg

(Diflucan) Tier 1 QL (2 EA per 1 day)

fluconazole oral tablet 50 mg (Diflucan) Tier 1

itraconazole oral capsule 100 mg (Sporanox) Tier 1 QL (2 EA per 1 day)

ketoconazole oral tablet 200 mg Tier 1 QL (2 EA per 1 day)

terbinafine hcl oral tablet 250 mg Tier 1 QL (1 EA per 1 day)Antifungal Antibioticsgriseofulvin microsize oral suspension125 mg/5 ml

Tier 1

griseofulvin microsize oral tablet 500 mg Tier 1

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

Tier 1

nystatin oral suspension 100,000 unit/ml Tier 1

nystatin oral tablet 500,000 unit Tier 1Infectious Disease - Miscellaneous

AminoglycosidesBETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML

Tier 1 PA; SP

KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION 300 MG/5 ML

Tier 1 PA; SP

neomycin oral tablet 500 mg Tier 1

TOBI PODHALER INHALATION CAPSULE 28 MG

Tier 1 PA; SP

TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG

Tier 1 PA; SP

tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml

(Tobi) Tier 1 PA; SP

tobramycin with nebulizer inhalation solution for nebulization 300 mg/5 ml

(Kitabis Pak) Tier 1 PA; SP

Antileproticsdapsone oral tablet 100 mg, 25 mg Tier 1

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

Tier 1 PA; SP

99

Drug Status Notes

Anti-Mycobacterium Agentsethambutol oral tablet 100 mg Tier 1

ethambutol oral tablet 400 mg (Myambutol) Tier 1

isoniazid oral solution 50 mg/5 ml Tier 1 Age (Max 12 Years)

isoniazid oral tablet 100 mg, 300 mg Tier 1

pyrazinamide oral tablet 500 mg Tier 1

rifabutin oral capsule 150 mg (Mycobutin) Tier 1

TRECATOR ORAL TABLET 250 MG Tier 1Antitubercular Antibioticscycloserine oral capsule 250 mg Tier 1

PRIFTIN ORAL TABLET 150 MG Tier 1 QL (112 EA per 180 days); Age (Min 2 Years)

rifampin oral capsule 150 mg, 300 mg (Rifadin) Tier 1Lincosamidesclindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

(Cleocin HCl) Tier 1

clindamycin palmitate hcl oral recon soln75 mg/5 ml

(Clindamycin Pediatric) Tier 1 Age (Max 12 Years)

CLINDAMYCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML


Vancomycin And DerivativesFIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML

Tier 1

Infectious Disease - Parasitic

2Nd Gen. Anaerobic Antiprotozoal-Antibacterialtinidazole oral tablet 250 mg, 500 mg Tier 1

Amebacidesparomomycin oral capsule 250 mg Tier 1

Anaerobic Antiprotozoal-Antibacterial Agentsmetronidazole oral tablet 250 mg, 500 mg

(Flagyl) Tier 1

Anthelminticsivermectin oral tablet 3 mg (Stromectol) Tier 1

PINAWAY ORAL SUSPENSION 50 MG/ML

Tier 1

PINWORM TREATMENT ORAL SUSPENSION 50 MG/ML

Tier 1

REESE'S PINWORM MEDICINE ORAL SUSPENSION 50 MG/ML

Tier 1

Antimalarial Drugschloroquine phosphate oral tablet 250 mg, 500 mg


DARAPRIM ORAL TABLET 25 MG Tier 1 PA; SP; QL (3 EA per 1 day)

hydroxychloroquine oral tablet 200 mg (Plaquenil) Tier 1 QL (2 EA per 1 day)

KRINTAFEL ORAL TABLET 150 MG Tier 1 PA; QL (2 EA per 365 days); Age (Min 16 Years)

100

Drug Status Notes

mefloquine oral tablet 250 mg Tier 1 PA; QL (5 EA per 30 days)

primaquine oral tablet 26.3 mg Tier 1

pyrimethamine oral tablet 25 mg (Daraprim) Tier 1 PA; SP; QL (3 EA per 1 day)

Antiprotozoal Drugs,Miscellaneousatovaquone oral suspension 750 mg/5 ml

(Mepron) Tier 1 PA

benznidazole oral tablet 100 mg, 12.5 mg

Tier 1 PA

Infectious Disease - Viral

Antiretroviral - Anti-Cd4 Domain 2 Monoclonal AbTROGARZO INTRAVENOUS SOLUTION 200 MG/1.33 ML (150 MG/ML)


Antiretroviral-Integrase Inhibitor And Nnrti Comb.JULUCA ORAL TABLET 50-25 MG Carve Out CARVE OUT


Antiretroviral-Nucleoside,Nucleotide,Protease Inh.SYMTUZA ORAL TABLET 800-150-200-10 MG


Antivirals, Generalacyclovir oral capsule 200 mg Tier 1 QL (5 EA per 1 day)

acyclovir oral suspension 200 mg/5 ml (Zovirax) Tier 1 QL (2 ML per 1 day); Age (Max 12 Years)

acyclovir oral tablet 400 mg, 800 mg Tier 1 QL (5 EA per 1 day)

famciclovir oral tablet 125 mg, 250 mg, 500 mg


oseltamivir oral capsule 30 mg, 45 mg, 75 mg

(Tamiflu) Tier 1 10 CAPSULES PER FILL; QL (20 EA per 180 days)

oseltamivir oral suspension for reconstitution 6 mg/ml

(Tamiflu) Tier 1 120mL PER FILL; QL (120 ML per 180 days)

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION


rimantadine oral tablet 100 mg (Flumadine) Tier 1

valacyclovir oral tablet 1 gram (Valtrex) Tier 1 QL (3 EA per 1 day)

valacyclovir oral tablet 500 mg (Valtrex) Tier 1 QL (1 EA per 1 day)

valganciclovir oral tablet 450 mg (Valcyte) Tier 1 PA; QL (2 EA per 1 day)

101

Drug Status Notes

Antivirals, Hiv-Spec, Non-Peptidic Protease InhibAPTIVUS (WITH VITAMIN E) ORAL SOLUTION 100 MG/ML


APTIVUS ORAL CAPSULE 250 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

PREZCOBIX ORAL TABLET 800-150 MG-MG


PREZISTA ORAL SUSPENSION 100 MG/ML


PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG


Antivirals, Hiv-Spec, Nucleoside-Nucleotide AnalogCIMDUO ORAL TABLET 300-300 MG Carve Out CARVE OUT


DESCOVY ORAL TABLET 200-25 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

TEMIXYS ORAL TABLET 300-300 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG


Antivirals, Hiv-Spec., Nucleoside Analog, Rti Combabacavir-lamivudine oral tablet 600-300 mg

(Epzicom) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

(Trizivir) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

102

Drug Status Notes

COMBIVIR ORAL TABLET 150-300 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

EPZICOM ORAL TABLET 600-300 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

lamivudine-zidovudine oral tablet 150-300 mg

(Combivir) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

TRIZIVIR ORAL TABLET 300-150-300 MG


Antivirals, Hiv-Specific, Ccr5 Co-Receptor Antag.SELZENTRY ORAL SOLUTION 20 MG/ML


SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG


Antivirals, Hiv-Specific, Fusion InhibitorsFUZEON SUBCUTANEOUS RECON SOLN 90 MG


Antivirals, Hiv-Specific, Non-Nucleoside, RtiEDURANT ORAL TABLET 25 MG Carve Out CARVE OUT


efavirenz oral capsule 200 mg, 50 mg (Sustiva) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

efavirenz oral tablet 600 mg (Sustiva) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG


103

Drug Status Notes

nevirapine oral suspension 50 mg/5 ml (Viramune) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

nevirapine oral tablet 200 mg (Viramune) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

nevirapine oral tablet extended release 24 hr 100 mg


nevirapine oral tablet extended release 24 hr 400 mg

(Viramune XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

PIFELTRO ORAL TABLET 100 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

SUSTIVA ORAL CAPSULE 200 MG, 50 MG


SUSTIVA ORAL TABLET 600 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

VIRAMUNE ORAL SUSPENSION 50 MG/5 ML


VIRAMUNE ORAL TABLET 200 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG


Antivirals, Hiv-Specific, Nucleoside Analog, Rtiabacavir oral solution 20 mg/ml (Ziagen) Carve Out CARVE OUT


104

Drug Status Notes

abacavir oral tablet 300 mg (Ziagen) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

didanosine oral capsule,delayed release(dr/ec) 125 mg, 250 mg

(Videx EC) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

didanosine oral capsule,delayed release(dr/ec) 200 mg, 400 mg


EMTRIVA ORAL CAPSULE 200 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

EMTRIVA ORAL SOLUTION 10 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

EPIVIR ORAL SOLUTION 10 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

EPIVIR ORAL TABLET 150 MG, 300 MG


lamivudine oral solution 10 mg/ml (Epivir) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

lamivudine oral tablet 150 mg, 300 mg (Epivir) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

RETROVIR INTRAVENOUS SOLUTION 10 MG/ML


RETROVIR ORAL CAPSULE 100 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

RETROVIR ORAL SYRUP 10 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

105

Drug Status Notes

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg


VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL)


VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG, 250 MG


ZIAGEN ORAL SOLUTION 20 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ZIAGEN ORAL TABLET 300 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

zidovudine oral capsule 100 mg (Retrovir) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

zidovudine oral syrup 10 mg/ml (Retrovir) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

zidovudine oral tablet 300 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Antivirals, Hiv-Specific, Nucleotide Analog, Rtitenofovir disoproxil fumarate oral tablet300 mg

(Viread) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM)


VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG


Antivirals, Hiv-Specific, Protease Inhibitor CombKALETRA ORAL SOLUTION 400-100 MG/5 ML


106

Drug Status Notes

KALETRA ORAL TABLET 100-25 MG, 200-50 MG


lopinavir-ritonavir oral solution 400-100 mg/5 ml

(Kaletra) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Antivirals, Hiv-Specific, Protease Inhibitorsatazanavir oral capsule 150 mg, 200 mg, 300 mg

(Reyataz) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG


EVOTAZ ORAL TABLET 300-150 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

fosamprenavir oral tablet 700 mg (Lexiva) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

INVIRASE ORAL TABLET 500 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

LEXIVA ORAL SUSPENSION 50 MG/ML


LEXIVA ORAL TABLET 700 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

NORVIR ORAL POWDER IN PACKET 100 MG


NORVIR ORAL SOLUTION 80 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

NORVIR ORAL TABLET 100 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

107

Drug Status Notes

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG


REYATAZ ORAL POWDER IN PACKET 50 MG


ritonavir oral tablet 100 mg (Norvir) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

VIRACEPT ORAL TABLET 250 MG, 625 MG


Antivirals,Hiv-1 Integrase Strand Transfer InhibtrISENTRESS HD ORAL TABLET 600 MG


ISENTRESS ORAL POWDER IN PACKET 100 MG


ISENTRESS ORAL TABLET 400 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG


TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG


Artv Cmb Nucleoside,Nucleotide,&Non-Nucleoside RtiATRIPLA ORAL TABLET 600-200-300 MG


COMPLERA ORAL TABLET 200-25-300 MG


DELSTRIGO ORAL TABLET 100-300-300 MG


108

Drug Status Notes

ODEFSEY ORAL TABLET 200-25-25 MG


SYMFI LO ORAL TABLET 400-300-300 MG


SYMFI ORAL TABLET 600-300-300 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Arv Cmb-Nrti,N(T)Rti, Integrase InhibitorBIKTARVY ORAL TABLET 50-200-25 MG


GENVOYA ORAL TABLET 150-150-200-10 MG


STRIBILD ORAL TABLET 150-150-200-300 MG


Arv Comb-Nrtis & Integrase InhibitorTRIUMEQ ORAL TABLET 600-50-300 MG


Cytochrome P450 InhibitorsTYBOST ORAL TABLET 150 MG Carve Out CARVE OUT


Hep C - Ns5a, Ns3/4A, Nucleotide Ns5b Inhib ComboVOSEVI ORAL TABLET 400-100-100 MG


Hep C Virus - Ns5a & Ns5b Polymerase Inhib. Combo.EPCLUSA ORAL TABLET 400-100 MG Carve Out CARVE OUT


HARVONI ORAL TABLET 45-200 MG, 90-400 MG


109

Drug Status Notes

ledipasvir-sofosbuvir oral tablet 90-400 mg

(Harvoni) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

sofosbuvir-velpatasvir oral tablet 400-100 mg

(Epclusa) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Hep C Virus,Nucleotide Analog Ns5b Polymerase InhSOVALDI ORAL TABLET 200 MG, 400 MG


Hepatitis B Treatment Agentsadefovir oral tablet 10 mg (Hepsera) Tier 1 SP; QL (1 EA per 1 day)

entecavir oral tablet 0.5 mg, 1 mg (Baraclude) Tier 1 SP; QL (1 EA per 1 day)

lamivudine oral tablet 100 mg (Epivir HBV) Tier 1 QL (1 EA per 1 day)

VEMLIDY ORAL TABLET 25 MG Tier 1 PA; SP; QL (1 EA per 1 day)

Hepatitis C Treatment AgentsPEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML


PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML


PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML


ribavirin oral capsule 200 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ribavirin oral tablet 200 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Hepatitis C Virus - Ns5a, Ns3/4A, Ns5b Inhib Cmb.VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG-75 MG -50 MG/250 MG


110

Drug Status Notes

Hepatitis C Virus- Ns5a And Ns3/4A Inhibitor CombMAVYRET ORAL TABLET 100-40 MG Carve Out CARVE OUT


ZEPATIER ORAL TABLET 50-100 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Inflammatory Disease

Anti-Flam. Interleukin-1 Receptor AntagonistARCALYST SUBCUTANEOUS RECON SOLN 220 MG


KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML


Anti-Inflammatory Tumor Necrosis Factor InhibitorCIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

Tier 1 PA; SP; QL (1 EA per 28 days)

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)


CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)


ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)


ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5)


ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML)


ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML)


HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML


111

Drug Status Notes





HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML


HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML


HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML


HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4 ML


Anti-Inflammatory, Interleukin-1 Beta BlockersILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML


Anti-Inflammatory, Pyrimidine Synthesis Inhibitorleflunomide oral tablet 10 mg, 20 mg (Arava) Tier 1 QL (1 EA per 1 day)

Anti-Inflammatory,Phosphodiesterase-4(Pde4) Inhib.OTEZLA ORAL TABLET 30 MG Tier 1 PA; SP; QL (2 EA per 1

day); Age (Min 18 Years)

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19)

Tier 1 PA; SP; 2 WEEK STARTER PACK; QL (27 EA per 365 days); Age (Min 18 Years)

Antinflammatory, Sel.Costim.Mod.,T-Cell InhibitorORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML


ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML


ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML


ORENCIA SUBCUTANEOUS SYRINGE 87.5 MG/0.7 ML


112

Drug Status Notes

C1 Esterase InhibitorsBERINERT INTRAVENOUS KIT 500 UNIT (10 ML)


BERINERT INTRAVENOUS RECON SOLN 500 UNIT (10 ML)


CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)


HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT


RUCONEST INTRAVENOUS RECON SOLN 2,100 UNIT


GlucocorticoidsDECADRON ORAL TABLET 0.5 MG, 0.75 MG, 4 MG, 6 MG

Tier 1

dexamethasone oral elixir 0.5 mg/5 ml Tier 1

dexamethasone oral solution 0.5 mg/5 ml

Tier 1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg, 6 mg

(Decadron) Tier 1

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg

Tier 1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

(Cortef) Tier 1

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

(Medrol) Tier 1

methylprednisolone oral tablets,dose pack 4 mg

(Medrol (Pak)) Tier 1

prednisolone oral solution 15 mg/5 ml Tier 1

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml)

Tier 1

prednisolone sodium phosphate oral solution 5 mg base/5 ml (6.7 mg/5 ml)

(Pediapred) Tier 1

prednisone oral solution 5 mg/5 ml Tier 1

prednisone oral tablet 1 mg, 2.5 mg, 50 mg

Tier 1

prednisone oral tablet 10 mg, 20 mg, 5 mg


prednisone oral tablets,dose pack 10 mg, 5 mg

Tier 1

113

Drug Status Notes

Interleukin-6 (Il-6) Receptor InhibitorsACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML


ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML


Janus Kinase (Jak) InhibitorsOLUMIANT ORAL TABLET 1 MG, 2 MG Tier 1 PA; SP; QL (1 EA per 1

day)

XELJANZ ORAL TABLET 10 MG, 5 MG Tier 1 PA; SP; QL (2 EA per 1 day)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG


Mineralocorticoidsfludrocortisone oral tablet 0.1 mg Tier 1

Nsaids, Cyclooxygenase 2 Inhibitor - Typecelecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

(Celebrex) Tier 1 QL (1 EA per 1 day)

Nsaids, Cyclooxygenase Inhibitor-TypeADDAPRIN ORAL TABLET 200 MG Tier 1

ALEVE ORAL TABLET 220 MG Tier 1 QL (3 EA per 1 day)

ALL DAY PAIN RELIEF ORAL TABLET 220 MG


ALL DAY RELIEF ORAL TABLET 220 MG


CHILDREN'S IBUPROFEN ORAL SUSPENSION 100 MG/5 ML


CHILDREN'S PROFEN IB ORAL SUSPENSION 100 MG/5 ML


diclofenac sodium oral tablet extended release 24 hr 100 mg

(Voltaren-XR) Tier 1

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg

Tier 1

EC-NAPROXEN ORAL TABLET,DELAYED RELEASE (DR/EC) 375 MG, 500 MG

Tier 1

etodolac oral capsule 200 mg, 300 mg Tier 1 QL (2 EA per 1 day)

etodolac oral tablet 400 mg (Lodine) Tier 1 QL (2 EA per 1 day)

etodolac oral tablet 500 mg Tier 1 QL (2 EA per 1 day)

FLANAX (NAPROXEN) ORAL TABLET 220 MG


flurbiprofen oral tablet 100 mg Tier 1

IBU ORAL TABLET 400 MG, 600 MG, 800 MG

Tier 1

IBU-200 ORAL TABLET 200 MG Tier 1

IBUPROFEN IB ORAL TABLET 200 MG Tier 1

IBUPROFEN IB ORAL TABLET,CHEWABLE 100 MG

Tier 1

IBUPROFEN JR STRENGTH ORAL TABLET,CHEWABLE 100 MG

Tier 1

114

Drug Status Notes

ibuprofen oral capsule 200 mg (Wal-Profen) Tier 1 QL (2 EA per 1 day)

ibuprofen oral drops,suspension 50 mg/1.25 ml

(Infant's Advil) Tier 1

ibuprofen oral suspension 100 mg/5 ml (Children's Ibuprofen) Tier 1 QL (480 ML per 30 days)

ibuprofen oral tablet 100 mg (Advil) Tier 1

ibuprofen oral tablet 200 mg (Addaprin) Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

(IBU) Tier 1

ibuprofen oral tablet,chewable 100 mg (Ibuprofen IB) Tier 1

indomethacin oral capsule 25 mg, 50 mg Tier 1 Age (Max 64 Years)

indomethacin oral capsule, extended release 75 mg


INFANT'S ADVIL ORAL DROPS,SUSPENSION 50 MG/1.25 ML

Tier 1

INFANT'S IBUPROFEN ORAL DROPS,SUSPENSION 50 MG/1.25 ML

Tier 1

INFANT'S MOTRIN ORAL DROPS,SUSPENSION 50 MG/1.25 ML

Tier 1

INFANTS PROFENIB ORAL DROPS,SUSPENSION 50 MG/1.25 ML

Tier 1

I-PRIN ORAL TABLET 200 MG Tier 1

ketorolac oral tablet 10 mg Tier 1 QL (2 EA per 1 day); Age (Max 64 Years)

MEDIPROXEN ORAL TABLET 220 MG Tier 1 QL (3 EA per 1 day)

meloxicam oral tablet 15 mg, 7.5 mg (Mobic) Tier 1 QL (1 EA per 1 day)

nabumetone oral tablet 500 mg, 750 mg Tier 1 QL (2 EA per 1 day)

naproxen oral suspension 125 mg/5 ml (Naprosyn) Tier 1 PA; Age (Max 12 Years)

naproxen oral tablet 250 mg Tier 1 QL (4 EA per 1 day)

naproxen oral tablet 375 mg Tier 1 QL (2 EA per 1 day)

naproxen oral tablet 500 mg (Naprosyn) Tier 1

naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg

(EC-Naproxen) Tier 1

naproxen sodium oral capsule 220 mg (Aleve) Tier 1

naproxen sodium oral tablet 220 mg (Aleve) Tier 1 QL (3 EA per 1 day)

piroxicam oral capsule 10 mg, 20 mg (Feldene) Tier 1 QL (1 EA per 1 day)

PROVIL ORAL TABLET 200 MG Tier 1

sulindac oral tablet 150 mg, 200 mg Tier 1 QL (2 EA per 1 day)

WAL-PROFEN ORAL CAPSULE 200 MG


WAL-PROFEN ORAL TABLET 200 MG Tier 1

WAL-PROXEN ORAL TABLET 220 MG Tier 1 QL (3 EA per 1 day)Plasma Kallikrein InhibitorsKALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML (1 ML)


115

Drug Status Notes

TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2 ML (150 MG/ML)


Local Anesthesia

Local AnestheticsGLYDO MUCOUS MEMBRANE JELLY IN APPLICATOR 2 %

Tier 1

lidocaine hcl mucous membrane jelly 2 %

Tier 1

lidocaine hcl mucous membrane jelly in applicator 2 %

(Glydo) Tier 1

LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 %

Tier 1

Lower Gastrointestinal Disorders - Bowel Inflammat

Chronic Inflam. Colon Dx, 5-A-Salicylat,Rectal Txmesalamine rectal enema 4 gram/60 ml (Rowasa) Tier 1

mesalamine rectal suppository 1,000 mg (Canasa) Tier 1 ST: Requires prior prescription for Mesalamine 4gm/60mL within the past 120 days; QL (60 EA per 180 days)

Drug Tx-Chronic Inflam. Colon Dx,5-AminosalicylatAPRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM

Tier 1 ST: Requires prior prescription for Balsalazide Disodium or Sulfasalazine within the past 180 days; QL (4 EA per 1 day)

balsalazide oral capsule 750 mg (Colazal) Tier 1 QL (2 EA per 1 day)

mesalamine oral capsule (with del rel tablets) 400 mg

(Delzicol) Tier 1 ST: Requires prior prescription for Balsalazide Disodium or Sulfasalazine within the past 180 days; QL (6 EA per 1 day)

mesalamine oral capsule,extended release 24hr 0.375 gram

(Apriso) Tier 1 ST: Requires prior prescription for Balsalazide Disodium or Sulfasalazine within the past 180 days; QL (4 EA per 1 day)

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

(Lialda) Tier 1 ST: At least 2 prior prescriptions for Apriso, Balsalazide Disodium, Delzicol, Mesalamine, or Sulfasalazine within the past 180 days; QL (4 EA per 1 day)

116

Drug Status Notes

mesalamine oral tablet,delayed release (dr/ec) 800 mg

(Asacol HD) Tier 1 ST: Requires prior prescription for Delzicol or Apriso within the past 180 days; QL (6 EA per 1 day)

PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG

Tier 1 ST: Requires prior prescription for Apriso or Mesalamine within the past 180 days; QL (8 EA per 1 day)

sulfasalazine oral tablet 500 mg (Azulfidine) Tier 1

sulfasalazine oral tablet,delayed release (dr/ec) 500 mg

(Azulfidine EN-tabs) Tier 1

Rectal PreparationsANUCORT-HC RECTAL SUPPOSITORY 25 MG

Tier 1 ST: Requires prior prescription for Hydrocortisone 2.5% cream within the past 120 days; QL (2 EA per 1 day)

hydrocortisone acetate rectal suppository 25 mg

(Anucort-HC) Tier 1 ST: Requires prior prescription for Hydrocortisone 2.5% cream within the past 120 days; QL (2 EA per 1 day)

Lower Gastrointestinal Disorders - Other

Ammonia InhibitorsAMMONUL INTRAVENOUS SOLUTION 10-10 %


BUPHENYL ORAL POWDER 0.94 GRAM/GRAM


BUPHENYL ORAL TABLET 500 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG


ENULOSE ORAL SOLUTION 10 GRAM/15 ML


GENERLAC ORAL SOLUTION 10 GRAM/15 ML


117

Drug Status Notes

LITHOSTAT ORAL TABLET 250 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

RAVICTI ORAL LIQUID 1.1 GRAM/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

sodium benzoate-sod phenylacet intravenous solution 10-10 %

(Ammonul) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

sodium phenylbutyrate oral powder 0.94 gram/gram

(Buphenyl) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

sodium phenylbutyrate oral tablet 500 mg

(Buphenyl) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

AntidiarrhealsANTI-DIARRHEAL (LOPERAMIDE) ORAL CAPSULE 2 MG

Tier 1

ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/7.5 ML

Tier 1

ANTI-DIARRHEAL ORAL SUSPENSION 262 MG/15 ML

Tier 1

BISMATROL ORAL SUSPENSION 262 MG/15 ML, 525 MG/15 ML

Tier 1

BISMATROL ORAL TABLET,CHEWABLE 262 MG

Tier 1

BISMUTH ORAL TABLET,CHEWABLE 262 MG

Tier 1

bismuth subsalicylate oral tablet,chewable 262 mg

(Bismatrol) Tier 1

DIARRHEA RELIEF (BISMUTH SUBS) ORAL SUSPENSION 262 MG/15 ML

Tier 1

DIGESTIVE RELIEF ORAL SUSPENSION 262 MG/15 ML

Tier 1

DIGESTIVE RELIEF ORAL TABLET 262 MG

Tier 1

DIOTAME ORAL TABLET,CHEWABLE 262 MG

Tier 1

diphenoxylate-atropine oral tablet 2.5-0.025 mg

(Lomotil) Tier 1 QL (2 EA per 1 day)

GERI-PECTATE ORAL SUSPENSION 262 MG/15 ML

Tier 1

IMODIUM A-D ORAL CAPSULE 2 MG Tier 1

IMODIUM A-D ORAL LIQUID 1 MG/7.5 ML

Tier 1

118

Drug Status Notes

KAOPECTATE (BISMUTH SUBSALICY) ORAL SUSPENSION 262 MG/15 ML

Tier 1

KAOPECTATE EX STR (BISMUTH SS) ORAL SUSPENSION 525 MG/15 ML

Tier 1

K-PEC ANTIDIARRHEAL (BISM SUB) ORAL SUSPENSION 262 MG/15 ML

Tier 1

loperamide oral capsule 2 mg (Anti-Diarrheal (loperamide))


loperamide oral liquid 1 mg/7.5 ml (Anti-Diarrheal (loperamide))

Tier 1

PEPTIC RELIEF ORAL TABLET,CHEWABLE 262 MG

Tier 1

PEP-T-MED ORAL TABLET,CHEWABLE 262 MG

Tier 1

PEPTO-BISMOL ORAL TABLET,CHEWABLE 262 MG

Tier 1

PEPTO-BISMOL TO-GO ORAL TABLET,CHEWABLE 262 MG

Tier 1

PINK BISMUTH MAXIMUM STRENGTH ORAL SUSPENSION 525 MG/15 ML

Tier 1

PINK BISMUTH ORAL SUSPENSION 262 MG/15 ML, 525 MG/15 ML

Tier 1

PINK BISMUTH ORAL TABLET 262 MG Tier 1

PINK BISMUTH ORAL TABLET,CHEWABLE 262 MG

Tier 1

SOOTHE (BISMUTH SUBSALICYLATE) ORAL TABLET 262 MG

Tier 1

SOOTHE (BISMUTH SUBSALICYLATE) ORAL TABLET,CHEWABLE 262 MG

Tier 1

SOOTHE REGULAR STRENGTH ORAL SUSPENSION 262 MG/15 ML

Tier 1

STOMACH RELIEF MAX STRENGTH ORAL SUSPENSION 525 MG/15 ML

Tier 1

STOMACH RELIEF ORAL SUSPENSION 262 MG/15 ML, 525 MG/15 ML

Tier 1

STOMACH RELIEF ORAL TABLET 262 MG

Tier 1

STOMACH RELIEF ORAL TABLET,CHEWABLE 262 MG

Tier 1

STOMACH RELIEF ORIGINAL ORAL SUSPENSION 262 MG/15 ML

Tier 1

Bile Saltsursodiol oral capsule 300 mg (Actigall) Tier 1 QL (5 EA per 1 day)

ursodiol oral tablet 250 mg (URSO 250) Tier 1

ursodiol oral tablet 500 mg (URSO Forte) Tier 1Laxatives And CatharticsALOPHEN (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG

Tier 1

119

Drug Status Notes

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG


bisacodyl oral tablet,delayed release (dr/ec) 5 mg

(Alophen (bisacodyl)) Tier 1

BISA-LAX (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG

Tier 1

calcium polycarbophil oral tablet 625 mg (Fiber (calcium polycarbophil))

Tier 1

CITRATE OF MAGNESIA ORAL SOLUTION

Tier 1

CITROMA ORAL SOLUTION Tier 1

C-LAX LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG

Tier 1

CLEARLAX ORAL POWDER 17 GRAM/DOSE

Tier 1

COLACE CLEAR ORAL CAPSULE 50 MG

Tier 1

COL-RITE ORAL CAPSULE 100 MG, 250 MG

Tier 1

CONSTULOSE ORAL SOLUTION 10 GRAM/15 ML

Tier 1

DAILY FIBER (PSYLLIUM-SUCROSE) ORAL POWDER 3.4 GRAM/12 GRAM, 3.4 GRAM/7 GRAM

Tier 1

DIOCTO ORAL LIQUID 50 MG/5 ML Tier 1

DOCU ORAL LIQUID 50 MG/5 ML Tier 1

DOCUPRENE ORAL TABLET 100 MG Tier 1

docusate calcium oral capsule 240 mg (Kao-Tin (docusate calcium))

Tier 1

docusate sodium oral capsule 100 mg, 250 mg

(Col-Rite) Tier 1

docusate sodium oral liquid 50 mg/5 ml (Diocto) Tier 1

docusate sodium oral tablet 100 mg (Docuprene) Tier 1

DOCUSIL ORAL CAPSULE 100 MG Tier 1

DOCUZEN ORAL TABLET 8.6-50 MG Tier 1

DOK ORAL CAPSULE 100 MG, 250 MG Tier 1

DOK ORAL TABLET 100 MG Tier 1

DOK PLUS ORAL TABLET 8.6-50 MG Tier 1

DSS ORAL CAPSULE 250 MG Tier 1

DUCODYL (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG

Tier 1

DULCOEASE ORAL CAPSULE 100 MG Tier 1

DULCOLAX STOOL SOFTENER (DSS) ORAL CAPSULE 100 MG

Tier 1

EVAC-U-GEN (SENNOSIDES) ORAL TABLET 8.6 MG

Tier 1

120

Drug Status Notes

EX-LAX (SENNOSIDES) ORAL TABLET 15 MG

Tier 1

FIBER (CALCIUM POLYCARBOPHIL) ORAL TABLET 625 MG

Tier 1

FIBER (PSYLLIUM HUSK/SUGAR) ORAL POWDER 3.4 GRAM/11 GRAM, 3.4 GRAM/12 GRAM, 3.4 GRAM/7 GRAM

Tier 1

FIBER (WITH ASPARTAME) ORAL POWDER 3.4 GRAM/5.8 GRAM

Tier 1

FIBER LAXATIVE (CA POLYCARBO) ORAL TABLET 625 MG

Tier 1

FIBER ORAL POWDER Tier 1

FIBER SMOOTH (SUCROSE) ORAL POWDER

Tier 1

FIBER SMOOTH ORAL POWDER Tier 1

FIBER THERAPY (CA POLYCARBOPH) ORAL TABLET 625 MG

Tier 1

FIBER THERAPY(PSYL SEED-SUGAR) ORAL POWDER

Tier 1

FIBER-LAX ORAL TABLET 625 MG Tier 1

FIBER-TABS ORAL TABLET 625 MG Tier 1

FLEET LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG

Tier 1

GAVILYTE-C ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM

Tier 1

GAVILYTE-G ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM

Tier 1

GAVILYTE-N ORAL RECON SOLN 420 GRAM

Tier 1

GENTLE LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG

Tier 1

GENTLELAX ORAL POWDER 17 GRAM/DOSE

Tier 1

GERI-KOT ORAL TABLET 8.6 MG Tier 1

GERI-MUCIL (ASPARTAME) ORAL POWDER 3.4 GRAM/5.8 GRAM

Tier 1

GERI-MUCIL (SUGAR) ORAL POWDER 3.4 GRAM/12 GRAM, 3.4 GRAM/7 GRAM

Tier 1

GLYCOLAX ORAL POWDER 17 GRAM/DOSE

Tier 1

HYDROCIL ORAL POWDER Tier 1

KAO-TIN (DOCUSATE CALCIUM) ORAL CAPSULE 240 MG

Tier 1

KONSYL (SUGAR) ORAL POWDER 3.4 GRAM/12 GRAM

Tier 1

KONSYL FIBER ORAL TABLET 625 MG Tier 1

121

Drug Status Notes

lactulose oral solution 10 gram/15 ml (Constulose) Tier 1

lactulose oral solution 10 gram/15 ml (15 ml), 20 gram/30 ml

Tier 1

LAX STOOL SOFTENER WITH SENNA ORAL TABLET 8.6-50 MG

Tier 1

LAXA BASIC ORAL CAPSULE 100 MG Tier 1

LAXACLEAR ORAL POWDER 17 GRAM/DOSE

Tier 1

LAXATIVE (BISACODYL) ORAL TABLET 5 MG

Tier 1

LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG

Tier 1

LAXATIVE (SENNOSIDES) ORAL TABLET 15 MG, 25 MG

Tier 1

LAXATIVE PEG 3350 ORAL POWDER 17 GRAM/DOSE

Tier 1

LAXATIVE PILLS ORAL TABLET 25 MG Tier 1

LAXATIVE PILLS REGULAR ORAL TABLET 15 MG

Tier 1

LAXATIVE PLUS STOOL SOFTENER ORAL TABLET 8.6-50 MG

Tier 1

magnesium citrate oral solution (Citrate of Magnesia) Tier 1

magnesium hydroxide oral suspension400 mg/5 ml

(Milk of Magnesia) Tier 1

METAMUCIL (SUGAR) ORAL POWDER Tier 1

METAMUCIL (WITH SUGAR) ORAL POWDER 3.4 GRAM/7 GRAM

Tier 1

METAMUCIL MULTIHEALTH FIBER ORAL POWDER 3.4 GRAM/5.8 GRAM

Tier 1

METAMUCIL SUGAR-FREE (ASPART) ORAL POWDER 3.4 GRAM/5.8 GRAM

Tier 1

METAMUCIL SUNRISE ORAL POWDER

Tier 1

MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5 ML

Tier 1

MOVE IT ALONG ORAL TABLET 100 MG

Tier 1

MULTIHEALTH FIBER (SUGAR) ORAL POWDER 3.4 GRAM/7 GRAM

Tier 1

MULTIHEALTH FIBER ORAL POWDER 3.4 GRAM/5.8 GRAM

Tier 1

NATURAL DAILY FIBER ORAL POWDER 3.4 GRAM/5.8 GRAM

Tier 1

NATURAL FIBER LAXATIVE (SUGAR) ORAL POWDER , 3.4 GRAM/12 GRAM, 3.4 GRAM/7 GRAM

Tier 1

NATURAL FIBER LAXATIVE THERAPY ORAL POWDER

Tier 1

122

Drug Status Notes

NATURAL FIBER LAXATIVE(ASPART) ORAL POWDER

Tier 1

NATURAL PSYLLIUM FIBER ORAL POWDER 3.4 GRAM/5.8 GRAM

Tier 1

NATURAL SENNA LAXATIVE ORAL TABLET 8.6 MG

Tier 1

NATURAL VEG LAXATIVE(SENNOSID) ORAL TABLET 8.6 MG

Tier 1

NATURAL VEGETABLE (PSYLLIUM) ORAL POWDER

Tier 1

NATURAL VEGETABLE ORAL POWDER

Tier 1

NATURAL VEGETABLE POWDER ORAL POWDER 3.4 GRAM/12 GRAM

Tier 1

NATURA-LAX ORAL POWDER 17 GRAM/DOSE

Tier 1

P-COL RITE ORAL TABLET 8.6-50 MG Tier 1

peg 3350-electrolytes oral recon soln236-22.74-6.74 -5.86 gram

(GaviLyte-G) Tier 1

peg-electrolyte soln oral recon soln 420 gram

(GaviLyte-N) Tier 1

PERDIEM OVERNIGHT RELIEF ORAL TABLET 15 MG

Tier 1

PHILLIPS' LIQUI-GELS ORAL CAPSULE 100 MG

Tier 1

polyethylene glycol 3350 oral powder 17 gram/dose

(ClearLax) Tier 1

POWDERLAX ORAL POWDER 17 GRAM/DOSE

Tier 1

PROMOLAXIN ORAL TABLET 100 MG Tier 1

PURELAX ORAL POWDER 17 GRAM/DOSE

Tier 1

REGULOID (PSYLLIUM HUSK-SUCRO) ORAL POWDER 3.4 GRAM/12 GRAM, 3.4 GRAM/7 GRAM

Tier 1

REGULOID, SUGAR FREE ORAL POWDER

Tier 1

SENEXON-S ORAL TABLET 8.6-50 MG Tier 1

SENNA LAX ORAL TABLET 8.6 MG Tier 1

SENNA LAXATIVE ORAL TABLET 8.6 MG

Tier 1

SENNA ORAL SYRUP 8.8 MG/5 ML Tier 1

SENNA ORAL TABLET 8.6 MG Tier 1

SENNA PLUS ORAL TABLET 8.6-50 MG

Tier 1

SENNA-S ORAL TABLET 8.6-50 MG Tier 1

SENNA-TIME S ORAL TABLET 8.6-50 MG

Tier 1

SENNO ORAL TABLET 8.6 MG Tier 1

123

Drug Status Notes

sennosides-docusate sodium oral tablet8.6-50 mg

(Docuzen) Tier 1

SENOKOT EXTRA STRENGTH ORAL TABLET 17.2 MG

Tier 1

SENOKOT ORAL TABLET 8.6 MG Tier 1

SENOKOT-S ORAL TABLET 8.6-50 MG Tier 1

SEN-O-TAB ORAL TABLET 8.6 MG Tier 1

SILACE ORAL LIQUID 50 MG/5 ML Tier 1

SMOOTHLAX ORAL POWDER 17 GRAM/DOSE

Tier 1

STIMULANT LAXATIVE PLUS ORAL TABLET 8.6-50 MG

Tier 1

STOOL SOFTENER (DOCUSATE CAL) ORAL CAPSULE 240 MG

Tier 1

STOOL SOFTENER ORAL CAPSULE 100 MG, 250 MG, 50 MG

Tier 1

STOOL SOFTENER ORAL LIQUID 50 MG/5 ML

Tier 1

STOOL SOFTENER ORAL TABLET 100 MG

Tier 1

STOOL SOFTENER-LAXATIVE ORAL TABLET 8.6-50 MG

Tier 1

STOOL SOFTENER-STIMULANT LAXAT ORAL TABLET 8.6-50 MG

Tier 1

TRILYTE WITH FLAVOR PACKETS ORAL RECON SOLN 420 GRAM

Tier 1

VEGETABLE LAXATIVE ORAL TABLET 8.6 MG

Tier 1

VEGETABLE LAX-STOOL SOFTENER ORAL TABLET 8.6-50 MG

Tier 1

WAL-MUCIL FIBER (ASPARTAME) ORAL POWDER 3.4 GRAM/5.8 GRAM

Tier 1

WAL-MUCIL FIBER (SUGAR) ORAL POWDER 3.4 GRAM/7 GRAM

Tier 1

WAL-MUCIL NATURAL FIBER LAX ORAL POWDER 3.4 GRAM/12 GRAM

Tier 1

WOMAN'S LAXATIVE (BISACODYL) ORAL TABLET 5 MG

Tier 1

WOMEN'S GENTLE LAXATIVE(BISAC) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG

Tier 1

WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET 5 MG

Tier 1

WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG

Tier 1

Laxatives, Local/Rectalbisacodyl rectal suppository 10 mg (Gentle Laxative

(bisacodyl))Tier 1

124

Drug Status Notes

docusate sodium rectal enema 283 mg/5 ml

(Enemeez) Tier 1

DOCUSOL RECTAL ENEMA 283 MG Tier 1

ENEMA DISPOSABLE RECTAL ENEMA 19-7 GRAM/118 ML

Tier 1

ENEMA RECTAL ENEMA 19-7 GRAM/118 ML

Tier 1

ENEMEEZ PLUS RECTAL ENEMA 283-20 MG/5 ML

Tier 1

ENEMEEZ RECTAL ENEMA 283 MG/5 ML

Tier 1

FLEET ENEMA RECTAL ENEMA 19-7 GRAM/118 ML

Tier 1

FLEET MINERAL OIL RECTAL ENEMA Tier 1

FLEET PEDIATRIC RECTAL ENEMA 9.5-3.5 GRAM/59 ML

Tier 1

GENTLE LAXATIVE (BISACODYL) RECTAL SUPPOSITORY 10 MG

Tier 1

LAXATIVE (BISACODYL) RECTAL SUPPOSITORY 10 MG

Tier 1

mineral oil rectal enema (Fleet Mineral Oil) Tier 1

PEDIATRIC ENEMA RECTAL ENEMA 9.5-3.5 GRAM/59 ML

Tier 1

PURE AND GENTLE DISPOSABLE RECTAL ENEMA 19-7 GRAM/118 ML

Tier 1

READY-TO-USE ENEMA (MIN OIL) RECTAL ENEMA

Tier 1

READY-TO-USE ENEMA RECTAL ENEMA 19-7 GRAM/118 ML

Tier 1

THE MAGIC BULLET RECTAL SUPPOSITORY 10 MG

Tier 1

Medical Supplies

Durable Medical Equipment,Misc(Group 1)1ST TIER UNILET COMFORTOUCH 28 GAUGE, 30 GAUGE

Tier 1 QL (100 EA per 1 FILL)

ACCU-CHEK FASTCLIX LANCET DRUM


ACCU-CHEK MULTICLIX LANCET Tier 1 QL (100 EA per 1 FILL)

ACCU-CHEK SAFE-T-PRO 23 GAUGE Tier 1 QL (100 EA per 1 FILL)

ACCU-CHEK SAFE-T-PRO PLUS 23 GAUGE


ACCU-CHEK SOFTCLIX LANCETS Tier 1 QL (100 EA per 1 FILL)

ACTI-LANCE LANCETS 17 GAUGE, 23 GAUGE, 28 GAUGE


ADVANCED TRAVEL LANCETS 28 GAUGE, 30 GAUGE


ADVOCATE LANCET 26 GAUGE, 30 GAUGE


ALTERNATE SITE LANCET 26 GAUGE Tier 1 QL (100 EA per 1 FILL)

125

Drug Status Notes

ASSURE HAEMOLANCE PLUS 1.2 MM, 18 GAUGE, 21 GAUGE, 25 GAUGE, 28 GAUGE


ASSURE LANCE 25 GAUGE, 28 GAUGE


ASSURE LANCE PLUS 21 GAUGE, 25 GAUGE, 30 GAUGE


BD MICROTAINER LANCET 1.5 X 2 MM, 21 GAUGE, 30 GAUGE


BD ULTRA FINE LANCETS 33 GAUGE Tier 1 QL (100 EA per 1 FILL)

BD ULTRA-FINE II LANCETS 30 GAUGE


BULLSEYE MINI SAFETY LANCETS 21 GAUGE, 25 GAUGE, 28 GAUGE


CAREONE THIN LANCET Tier 1 QL (100 EA per 1 FILL)

CAREONE ULTRA THIN LANCET Tier 1 QL (100 EA per 1 FILL)

CARESENS LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

CARETOUCH SAFETY LANCETS 26 GAUGE, 28 GAUGE


CARETOUCH TWIST LANCET 28 GAUGE, 30 GAUGE, 33 GAUGE


CLEVER CHEK LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

COAGUCHEK LANCETS Tier 1 QL (100 EA per 1 FILL)

COLOR LANCETS 21 GAUGE Tier 1 QL (100 EA per 1 FILL)

COMFORT EZ LANCETS 21 GAUGE, 23 GAUGE, 28 GAUGE


COMFORT LANCETS Tier 1 QL (100 EA per 1 FILL)

DROPLET LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

EASY COMFORT LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

EASY TOUCH LANCETS 26 GAUGE, 28 GAUGE, 30 GAUGE, 32 GAUGE


EASY TOUCH SAFETY LANCETS 21 GAUGE, 23 GAUGE, 26 GAUGE, 28 GAUGE, 30 GAUGE, 32 GAUGE


EASY TOUCH TWIST LANCETS 26 GAUGE, 28 GAUGE, 30 GAUGE, 32 GAUGE, 33 GAUGE


EASY TWIST AND CAP LANCETS 28 GAUGE


EMBRACE LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

E-Z JECT LANCETS , 26 GAUGE, 30 GAUGE, 32 GAUGE, 33 GAUGE


E-Z JECT THIN LANCETS 28 GAUGE Tier 1 QL (100 EA per 1 FILL)

EZ SMART LANCETS 28 GAUGE Tier 1 QL (100 EA per 1 FILL)

EZ-LETS 26 GAUGE Tier 1 QL (100 EA per 1 FILL)

FIFTY50 SAFETY SEAL LANCETS 30 GAUGE, 32 GAUGE


FINE 30 UNIVERSAL LANCETS 30 GAUGE


126

Drug Status Notes

FINGERSTIX LANCETS Tier 1 QL (100 EA per 1 FILL)

FORACARE LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

FREESTYLE LANCETS 28 GAUGE Tier 1 QL (100 EA per 1 FILL)

FREESTYLE UNISTIK 2 Tier 1 QL (100 EA per 1 FILL)

GLUCOCOM LANCETS 28 GAUGE, 30 GAUGE, 33 GAUGE


HEALTHY ACCENTS UNILET LANCET 30 GAUGE


INCONTROL SUPER THIN LANCETS 30 GAUGE


INCONTROL ULTRA THIN LANCETS 28 GAUGE


INJECT EASE LANCETS 28 GAUGE, 30 GAUGE


INVACARE LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

lancets (Accu-Chek Fastclix Lancet Drum)


lancets 21 gauge (Assure Haemolance Plus) Tier 1 QL (100 EA per 1 FILL)

lancets 26 gauge (Advocate Lancet) Tier 1 QL (100 EA per 1 FILL)

lancets 28 gauge, 30 gauge (1st Tier Unilet ComforTouch)


lancets 33 gauge (BD Ultra Fine Lancets) Tier 1 QL (100 EA per 1 FILL)

LANCETS, SUPER THIN Tier 1 QL (100 EA per 1 FILL)

LANCETS,THIN , 23 GAUGE, 28 GAUGE


LANCETS,ULTRA THIN , 26 GAUGE Tier 1 QL (100 EA per 1 FILL)

lancets-blood glucose strips combo pack30 gauge

(Fora V10-V12-D10-D20 strp-lnct)


LITE TOUCH LANCETS 28 GAUGE, 30 GAUGE, 33 GAUGE


MEDISENSE THIN LANCETS 28 GAUGE


MEDLANCE PLUS LANCETS 21 GAUGE, 25 GAUGE, 30 GAUGE


MEDLANCE PLUS SPECIAL BLADE 0.8 X 2 MM


MICRO THIN LANCETS 33 GAUGE Tier 1 QL (100 EA per 1 FILL)

MICROLET LANCET Tier 1 QL (100 EA per 1 FILL)

MONOLET LANCETS 21 GAUGE Tier 1 QL (100 EA per 1 FILL)

MONOLET THIN LANCETS 28 GAUGE Tier 1 QL (100 EA per 1 FILL)

MYGLUCOHEALTH LANCETS 30 GAUGE


NOVA SAFETY LANCETS 23 GAUGE, 28 GAUGE


NOVA SUREFLEX LANCETS Tier 1 QL (100 EA per 1 FILL)

ON CALL LANCET 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

ON CALL PLUS LANCET 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

ONETOUCH DELICA LANCETS 30 GAUGE, 33 GAUGE


127

Drug Status Notes

ONETOUCH DELICA PLUS LANCET 30 GAUGE, 33 GAUGE


ONETOUCH SURESOFT LANCING DEV 28 GAUGE


ONETOUCH ULTRASOFT LANCETS Tier 1 QL (100 EA per 1 FILL)

ON-THE-GO LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

PIP LANCET 28 GAUGE, 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

PRESSURE ACTIVATED LANCETS 21 GAUGE, 28 GAUGE


PRO COMFORT LANCET 30 GAUGE, 31 GAUGE


PRODIGY LANCETS 26 GAUGE, 28 GAUGE


PRODIGY TWIST TOP LANCET 28 GAUGE


PURE COMFORT LANCETS 30 GAUGE


PURE COMFORT SAFETY LANCETS 30 GAUGE


PUSH BUTTON SAFETY LANCETS 21 GAUGE, 28 GAUGE


READYLANCE SAFETY LANCETS 21 GAUGE, 23 GAUGE, 26 GAUGE, 28 GAUGE, 30 GAUGE


RELIAMED LANCET 23 GAUGE, 28 GAUGE, 30 GAUGE


RELIAMED SAFETY SEAL LANCETS 28 GAUGE, 30 GAUGE


RELIAMED TWIST AND CAP LANCET 28 GAUGE


RELION THIN LANCETS 26 GAUGE Tier 1 QL (100 EA per 1 FILL)

RELION ULTRA THIN PLUS LANCETS Tier 1 QL (100 EA per 1 FILL)

RIGHTEST GL300 LANCETS 30 GAUGE


SAFETY LANCETS 21 GAUGE, 26 GAUGE, 28 GAUGE


SAFETY SEAL LANCETS 28 GAUGE, 30 GAUGE


SAFETY-LET LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

SINGLE-LET Tier 1 QL (100 EA per 1 FILL)

SMART SENSE LANCETS 21 GAUGE, 26 GAUGE, 33 GAUGE


SMARTEST LANCET Tier 1 QL (100 EA per 1 FILL)

SOFT TOUCH LANCETS Tier 1 QL (100 EA per 1 FILL)

SOLUS V2 LANCETS 28 GAUGE, 30 GAUGE


STERILANCE TL 30 GAUGE, 32 GAUGE


SUPER THIN LANCETS , 28 GAUGE, 30 GAUGE


128

Drug Status Notes

SURE COMFORT LANCETS 18 GAUGE, 21 GAUGE, 23 GAUGE, 28 GAUGE, 30 GAUGE


SURE-LANCE , 26 GAUGE, 28 GAUGE Tier 1 QL (100 EA per 1 FILL)

SURE-LANCE ULTRA THIN 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

SURE-TOUCH LANCET Tier 1 QL (100 EA per 1 FILL)

TECHLITE LANCETS 25 GAUGE, 28 GAUGE, 30 GAUGE


TELCARE LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

THIN LANCETS 26 GAUGE Tier 1 QL (100 EA per 1 FILL)

TOPCARE UNIVERSAL1 LANCET , 33 GAUGE


TRUE COMFORT LANCET 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

TRUEPLUS LANCETS 26 GAUGE, 28 GAUGE, 30 GAUGE, 33 GAUGE


TWIST LANCETS 30 GAUGE, 32 GAUGE


ULTILET BASIC LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

ULTILET CLASSIC LANCETS , 28 GAUGE, 30 GAUGE, 33 GAUGE


ULTILET LANCETS 28 GAUGE, 30 GAUGE, 33 GAUGE


ULTILET SAFETY LANCETS 23 GAUGE


ULTRA FINE LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

ULTRA THIN II LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

ULTRA THIN LANCETS , 28 GAUGE, 30 GAUGE, 31 GAUGE, 33 GAUGE


ULTRA THIN PLUS LANCETS 33 GAUGE


ULTRA TLC LANCETS Tier 1 QL (100 EA per 1 FILL)

ULTRA-CARE LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

ULTRALANCE LANCETS 26 GAUGE, 28 GAUGE


ULTRA-THIN II LANCETS 28 GAUGE Tier 1 QL (100 EA per 1 FILL)

UNILET COMFORTOUCH LANCET , 26 GAUGE


UNILET EXCELITE II LANCET Tier 1 QL (100 EA per 1 FILL)

UNILET EXCELITE LANCET Tier 1 QL (100 EA per 1 FILL)

UNILET GP LANCET Tier 1 QL (100 EA per 1 FILL)

UNILET LANCET 28 GAUGE, 33 GAUGE


UNILET LANCETS 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

UNILET SUPER THIN LANCETS 30 GAUGE


UNISTIK 3 COMFORT LANCET Tier 1 QL (100 EA per 1 FILL)

UNISTIK 3 EXTRA LANCET 21 GAUGE Tier 1 QL (100 EA per 1 FILL)

UNISTIK 3 GENTLE 30 GAUGE Tier 1 QL (100 EA per 1 FILL)

UNISTIK 3 LANCETS 21 GAUGE Tier 1 QL (100 EA per 1 FILL)

129

Drug Status Notes

UNISTIK 3 NORMAL LANCET 23 GAUGE


UNISTIK CZT LANCET 23 GAUGE, 28 GAUGE


UNISTIK PRO LANCET 21 GAUGE, 25 GAUGE, 28 GAUGE


UNISTIK SAFETY 28 GAUGE, 30 GAUGE


UNISTIK TOUCH LANCETS 21 GAUGE, 23 GAUGE, 28 GAUGE, 30 GAUGE


UNIVERSAL 1 LANCETS 21 GAUGE, 26 GAUGE, 30 GAUGE, 33 GAUGE


VIVAGUARD LANCET 30 GAUGE Tier 1 QL (100 EA per 1 FILL)Syringes And AccessoriesADVOCATE SYRINGES SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16


ASSURE ID INSULIN SAFETY SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"


BD ECLIPSE LUER-LOK SYRINGE 1 ML 30 GAUGE X 1/2"


BD INSULIN SYRINGE HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 5/16"


BD INSULIN SYRINGE MICRO-FINE SYRINGE 1 ML 28 GAUGE X 1/2"


BD INSULIN SYRINGE SAFETY-LOK SYRINGE 1 ML 29 GAUGE X 1/2"


BD INSULIN SYRINGE SLIP TIP SYRINGE 1 ML


BD INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 25 GAUGE X 5/8", 1 ML 25 X 1", 1 ML 26 X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"


BD INSULIN SYRINGE U-500 SYRINGE 1/2 ML 31 GAUGE X 15/64"


BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16


130

Drug Status Notes

BD LO-DOSE MICRO-FINE IV SYRINGE 1/2 ML 28 GAUGE X 1/2"


BD LO-DOSE ULTRA-FINE SYRINGE 0.5 ML 29 GAUGE X 1/2"


BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 1 ML 29 GAUGE X 1/2", 1 ML 31 GAUGE X 15/64"


BD SAFETYGLIDE SYRINGE SYRINGE 1 ML 27 GAUGE X 5/8"


BD VEO INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 15/64"


BD VEO INSULIN SYRINGE UF SYRINGE 0.3 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 15/64", 1/2 ML 31 GAUGE X 15/64"


CARETOUCH INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 X 5/16", 1 ML 29 GAUGE X 5/16, 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16


COMFORT EZ INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"


DROPLET INSULIN SYR HALF UNIT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 5/16", 0.5ML 30 GAUGE X 15/64"


DROPLET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 15/64", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 15/64", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16


131

Drug Status Notes

EASY COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1 ML 32 GAUGE X 5/16", 1/2 ML 32 GAUGE X 5/16"


EASY GLIDE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 15/64", 1/2 ML 31 GAUGE X 15/64"


EASY TOUCH FLIPLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16"


EASY TOUCH INSULIN SAFETY SYR SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2"


EASY TOUCH INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 27 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2"


EASY TOUCH LUER LOCK INSULIN SYRINGE 1 ML


EASY TOUCH SHEATHLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16"


EASY TOUCH UNI-SLIP SYRINGE 1 ML


EXEL INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"


FREESTYLE PRECISION SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16


132

Drug Status Notes

HEALTHWISE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16


insulin syr/ndl u100 half mark syringe 0.3 ml 31 gauge x 1/4"

(UltiCare Insulin Syr Half Unit)


INSULIN SYRINGE MICROFINE SYRINGE 1 ML 27 GAUGE X 5/8", 1/2 ML 28 GAUGE X 1/2"


insulin syringe needleless syringe 1 ml (BD Insulin Syringe Slip Tip)


INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"


insulin syringe-needle u-100 syringe 0.3 ml 29 gauge

(Ultilet Insulin Syringe) Tier 1 QL (100 EA per 1 FILL)

insulin syringe-needle u-100 syringe 0.3 ml 29 gauge x 1/2", 0.3 ml 30 gauge x 5/16", 0.3 ml 31 gauge x 5/16", 0.5 ml 29 gauge x 1/2", 0.5 ml 30 gauge x 5/16", 0.5 ml 31 gauge x 5/16", 1 ml 29 gauge x 1/2", 1 ml 30 gauge x 5/16, 1 ml 31 gauge x 5/16

(Advocate Syringes) Tier 1 QL (100 EA per 1 FILL)

insulin syringe-needle u-100 syringe 0.3 ml 30

(Ultra Comfort Insulin Syringe)


insulin syringe-needle u-100 syringe 0.3 ml 30 gauge x 1/2", 0.5 ml 30 gauge x 1/2"

(BD Insulin Syringe Ultra-Fine)


insulin syringe-needle u-100 syringe 0.3 ml 31 gauge x 1/4", 1 ml 31 gauge x 1/4", 1/2 ml 31 gauge x 1/4"

(Sure Comfort Insulin Syringe)


insulin syringe-needle u-100 syringe 0.3 ml 31 gauge x 15/64", 1 ml 31 gauge x 15/64", 1/2 ml 31 gauge x 15/64"

(BD Veo Insulin Syringe UF)


insulin syringe-needle u-100 syringe 1 ml 27 gauge x 1/2", 1 ml 28 gauge x 1/2"

(BD Insulin Syringe) Tier 1 QL (100 EA per 1 FILL)

insulin syringe-needle u-100 syringe 1 ml 28 gauge, 1 ml 30 gauge x 7/16", 1/2 ml 28 gauge, 1/2 ml 29 , 1/2 ml 30 gauge

(Lite Touch Insulin Syringe)


insulin syringe-needle u-100 syringe 1 ml 29 gauge x 7/16"



(BD Eclipse Luer-Lok) Tier 1 QL (100 EA per 1 FILL)


(Thinpro Insulin Syringe) Tier 1 QL (100 EA per 1 FILL)

insulin syringe-needle u-100 syringe 1/2 ml 27 gauge x 1/2"

(Easy Touch Insulin Syringe)


insulin syringe-needle u-100 syringe 1/2 ml 28 gauge x 1/2"

(BD Lo-Dose Micro-Fine IV)


133

Drug Status Notes

LITE TOUCH INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE


MAGELLAN INSULIN SAFETY SYRNG SYRINGE 0.3 ML 29 X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16"


MAGELLAN SYRINGE SYRINGE 0.3 ML 30 X 5/16", 0.5 ML 30 GAUGE X 5/16"


MAXICOMFORT INSULIN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1/2 ML 27 GAUGE X 1/2"


MAXI-COMFORT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2"


MONOJECT INSULIN SAFETY SYRING SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 29 GAUGE X 1/2"


MONOJECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML , 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"


MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE


MONOJECT ULTRA COMFORT INSULIN SYRINGE 1/2 ML 28 GAUGE


PRO COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16


134

Drug Status Notes

PRODIGY INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2"


SAFESNAP INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"


SURE COMFORT INS. SYR. U-100 SYRINGE 0.5 ML 29 GAUGE X 1/2"


SURE COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 1/4", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 31 GAUGE X 1/4"


SURE-JECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"


TECHLITE INSULIN SYR HALF UNIT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 5/16"


TECHLITE INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16


135

Drug Status Notes

TERUMO INSULIN SYRINGE SYRINGE 0.3 ML 30 X 3/8", 0.5 ML 29 GAUGE X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1/2 ML 27 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 30 X 3/8"


THINPRO INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 X 3/8", 0.3 ML 31 X 3/8", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 X 3/8", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 3/8", 1 ML 31 X 3/8", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 30 X 3/8"


TOPCARE ULTRA COMFORT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16


TRUE COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 31 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16


TRUEPLUS INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"


ULTICARE INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 1/4"


ULTICARE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 1/4", 1/2 ML 31 GAUGE X 1/4"


ULTICARE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16


136

Drug Status Notes

ULTILET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 29


ULTRA CMFT INS SYR HALF UNIT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16"


ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30, 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE


ULTRA FLO INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2"


ULTRACARE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16


ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16


ULTRA-THIN II INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"


VANISHPOINT INSULIN SYRINGE SYRINGE 1 ML 30 GAUGE X 3/16"


VANISHPOINT SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"


137

Drug Status Notes

Miscellaneous Agents

Anaphylaxis Therapy AgentsAUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML


epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml

(Auvi-Q) Tier 1 QL (2 EA per 90 days)

epinephrine injection auto-injector 0.15 mg/0.3 ml

(EpiPen Jr) Tier 1 QL (2 EA per 90 days)

EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML


EPIPEN INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML


EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML


EPIPEN JR INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML


SYMJEPI INJECTION SYRINGE 0.3 MG/0.3 ML


Genetic D/O Tx-Exon Inclusion Antisense OligonucleSPINRAZA (PF) INTRATHECAL SOLUTION 12 MG/5 ML

Carve Out PA; CONTACT THE PROGRAM REVIEW DIVISION (PRD) AT 800-622-0276 TO OBTAIN A SPINRAZA DOCUMENTATION CHECKLIST ONCE ALL DOCUMENTATION IS COLLATED, PLEASE FAX IT TO 517-335-0075 FOR REVIEW

Genetic D/O Tx-Exon Skipping Antisense OligonucleoEXONDYS-51 INTRAVENOUS SOLUTION 50 MG/ML


VYONDYS-53 INTRAVENOUS SOLUTION 50 MG/ML


Parasympathetic Agentsbethanechol chloride oral tablet 10 mg, 5 mg


bethanechol chloride oral tablet 25 mg, 50 mg

(Urecholine) Tier 1 QL (4 EA per 1 day)

pilocarpine hcl oral tablet 5 mg, 7.5 mg (Salagen (pilocarpine)) Tier 1

138

Drug Status Notes

Pharmacological Chaperone-Alpha-Galactosid.A StabzGALAFOLD ORAL CAPSULE 123 MG Carve Out CARVE OUT


Pku Tx Agent-Cofactor Of Phenylalanine HydroxylaseKUVAN ORAL POWDER IN PACKET 100 MG, 500 MG


KUVAN ORAL TABLET,SOLUBLE 100 MG


Neoplastic Disease

Alkylating AgentsALKERAN ORAL TABLET 2 MG Tier 1 PA

cyclophosphamide oral capsule 25 mg, 50 mg

Tier 1 PA; SP

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

Tier 1 PA; SP

hydroxyurea oral capsule 500 mg (Hydrea) Tier 1

LEUKERAN ORAL TABLET 2 MG Tier 1 PA; SP

melphalan oral tablet 2 mg (Alkeran) Tier 1 PA

MYLERAN ORAL TABLET 2 MG Tier 1 PA; SP

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

(Temodar) Tier 1 PA; SP

Antiandrogenic Agentsabiraterone oral tablet 250 mg (Zytiga) Tier 1 PA; SP; QL (4 EA per 1

day)

bicalutamide oral tablet 50 mg (Casodex) Tier 1 Male Only; QL (1 EA per 1 day)

ERLEADA ORAL TABLET 60 MG Tier 1 PA; SP; QL (4 EA per 1 day)

flutamide oral capsule 125 mg Tier 1 PA

nilutamide oral tablet 150 mg (Nilandron) Tier 1 PA; SP

NUBEQA ORAL TABLET 300 MG Tier 1 PA; SP

XTANDI ORAL CAPSULE 40 MG Tier 1 PA; SP; QL (4 EA per 1 day)

Antimetabolitescapecitabine oral tablet 150 mg, 500 mg (Xeloda) Tier 1 PA; SP; QL (2 EA per 1

day)

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG

Tier 1 PA; SP

mercaptopurine oral tablet 50 mg Tier 1 QL (2 EA per 1 day)

methotrexate sodium (pf) injection solution 25 mg/ml

Tier 1

139

Drug Status Notes

methotrexate sodium injection solution25 mg/ml

Tier 1

methotrexate sodium oral tablet 2.5 mg Tier 1 QL (2 EA per 1 day)

TABLOID ORAL TABLET 40 MG Tier 1 PA; SP

XATMEP ORAL SOLUTION 2.5 MG/ML Tier 1 PA; SPAntineoplastic Aromatase Inhibitorsanastrozole oral tablet 1 mg (Arimidex) Tier 1 QL (2 EA per 1 day)

exemestane oral tablet 25 mg (Aromasin) Tier 1 QL (2 EA per 1 day)

letrozole oral tablet 2.5 mg (Femara) Tier 1 QL (1 EA per 1 day); Age (Min 18 Years)

Antineoplastic - Braf Kinase InhibitorsBRAFTOVI ORAL CAPSULE 50 MG, 75 MG

Tier 1 PA; SP

Antineoplastic - Hedgehog Pathway InhibitorDAURISMO ORAL TABLET 100 MG, 25 MG

Tier 1 PA; SP

ERIVEDGE ORAL CAPSULE 150 MG Tier 1 PA; SP; QL (1 EA per 1 day)

ODOMZO ORAL CAPSULE 200 MG Tier 1 PA; SPAntineoplastic - Janus Kinase (Jak) InhibitorsJAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG


Antineoplastic - Mek1 And Mek2 Kinase InhibitorsCOTELLIC ORAL TABLET 20 MG Carve Out CARVE OUT


MEKINIST ORAL TABLET 0.5 MG, 2 MG


MEKTOVI ORAL TABLET 15 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Antineoplastic - Mtor Kinase InhibitorsAFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG


AFINITOR ORAL TABLET 10 MG, 2.5 MG


everolimus (antineoplastic) oral tablet2.5 mg, 5 mg, 7.5 mg

(Afinitor) Tier 1 PA; SP; QL (1 EA per 1 day)

Antineoplastic - Topoisomerase I InhibitorsHYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG

Tier 1 PA; SP

140

Drug Status Notes

Antineoplastic Immunomodulator AgentsPOMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG


REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG


Antineoplastic Systemic Enzyme InhibitorsALECENSA ORAL CAPSULE 150 MG Carve Out CARVE OUT


ALIQOPA INTRAVENOUS RECON SOLN 60 MG


ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG


ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23)


AYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG


BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG


bortezomib intravenous recon soln 3.5 mg


BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG


BRUKINSA ORAL CAPSULE 80 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG


CALQUENCE ORAL CAPSULE 100 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

141

Drug Status Notes

CAPRELSA ORAL TABLET 100 MG, 300 MG


COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)


COPIKTRA ORAL CAPSULE 15 MG, 25 MG


erlotinib oral tablet 100 mg, 150 mg, 25 mg

(Tarceva) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG


GLEEVEC ORAL TABLET 100 MG, 400 MG


IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG


IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG


ICLUSIG ORAL TABLET 15 MG, 45 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

imatinib oral tablet 100 mg, 400 mg (Gleevec) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG


IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG


142

Drug Status Notes

INLYTA ORAL TABLET 1 MG, 5 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

INREBIC ORAL CAPSULE 100 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

IRESSA ORAL TABLET 250 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3)


KYPROLIS INTRAVENOUS RECON SOLN 10 MG, 30 MG, 60 MG


LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2)


LORBRENA ORAL TABLET 100 MG, 25 MG


LYNPARZA ORAL TABLET 100 MG, 150 MG


NERLYNX ORAL TABLET 40 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

NEXAVAR ORAL TABLET 200 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG


PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1), 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)


143

Drug Status Notes

ROZLYTREK ORAL CAPSULE 100 MG, 200 MG


RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG


RYDAPT ORAL CAPSULE 25 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG


STIVARGA ORAL TABLET 40 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG


TAGRISSO ORAL TABLET 40 MG, 80 MG


TALZENNA ORAL CAPSULE 0.25 MG, 1 MG


TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG


TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG


TURALIO ORAL CAPSULE 200 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

TYKERB ORAL TABLET 250 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

VELCADE INJECTION RECON SOLN 3.5 MG


144

Drug Status Notes

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG


VITRAKVI ORAL CAPSULE 100 MG, 25 MG


VITRAKVI ORAL SOLUTION 20 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG


VOTRIENT ORAL TABLET 200 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

XALKORI ORAL CAPSULE 200 MG, 250 MG


XOSPATA ORAL TABLET 40 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ZEJULA ORAL CAPSULE 100 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ZYDELIG ORAL TABLET 100 MG, 150 MG


ZYKADIA ORAL TABLET 150 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Antineoplastic,Histone Deacetylase Inhibitors,HdisFARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG

Tier 1 PA; SP

ZOLINZA ORAL CAPSULE 100 MG Tier 1 PA; SPAntineoplastic-B Cell Lymphoma-2(Bcl-2) InhibitorsVENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG

Tier 1 PA; SP

145

Drug Status Notes

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG

Tier 1 PA; SP

Antineoplastic-Isocitrate Dehydrogenase InhibitorsIDHIFA ORAL TABLET 100 MG, 50 MG Tier 1 PA; SP

TIBSOVO ORAL TABLET 250 MG Tier 1 PA; SP; QL (2 EA per 1 day)

Antineoplastics,Miscellaneousetoposide oral capsule 50 mg Tier 1 PA; QL (2 EA per 1 day)

LYSODREN ORAL TABLET 500 MG Tier 1 PA; SP

MATULANE ORAL CAPSULE 50 MG Tier 1 PA; SPAntineoplastic-Select Inhib Of Nuclear Exp (Sine)XPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5), 160 MG/WEEK (20 MG X 8), 60 MG/WEEK (20 MG X 3), 80 MG/WEEK (20 MG X 4)

Tier 1 PA; SP

Chemotherapy Rescue/Antidote Agentsleucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

Tier 1

MESNEX ORAL TABLET 400 MG Tier 1 PASelective Estrogen Receptor Modulators (Serm)tamoxifen oral tablet 10 mg, 20 mg Tier 1 QL (2 EA per 1 day)

toremifene oral tablet 60 mg (Fareston) Tier 1 PA; SPSelective Retinoid X Receptor Agonists (Rxr)bexarotene oral capsule 75 mg (Targretin) Tier 1 PA; SP; QL (2 EA per 1

day)Steroid AntineoplasticsEMCYT ORAL CAPSULE 140 MG Tier 1 PA; SP

megestrol oral tablet 20 mg, 40 mg Tier 1Neurological Disease - Miscellaneous

Agents To Treat Multiple SclerosisAUBAGIO ORAL TABLET 14 MG, 7 MG Tier 1 PA; SP; QL (1 EA per 1

day)

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML


AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML


GILENYA ORAL CAPSULE 0.5 MG Tier 1 PA; SP; QL (1 EA per 1 day)

glatiramer subcutaneous syringe 20 mg/ml

(Glatopa) Tier 1 PA; SP; QL (1 ML per 1 day)

glatiramer subcutaneous syringe 40 mg/ml

(Glatopa) Tier 1 PA; SP; QL (12 ML per 28 days)

GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML

Tier 1 PA; SP; QL (1 ML per 1 day)

146

Drug Status Notes

GLATOPA SUBCUTANEOUS SYRINGE 40 MG/ML


TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG


Agts Tx Neuromusc Transmission Dis,Pot-Chan BlkrAMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG


dalfampridine oral tablet extended release 12 hr 10 mg

(Ampyra) Tier 1 PA; SP; QL (2 EA per 1 day)

FIRDAPSE ORAL TABLET 10 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Neuropathic AgentsLYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 330 MG, 82.5 MG


Oral/Pharyngeal Disorders

Dental Aids And Preparationschlorhexidine gluconate mucous membrane mouthwash 0.12 %

(Paroex Oral Rinse) Tier 1

ORALONE DENTAL PASTE 0.1 % Tier 1 QL (5 GM per 30 days)

PAROEX ORAL RINSE MUCOUS MEMBRANE MOUTHWASH 0.12 %

Tier 1

PERIOGARD MUCOUS MEMBRANE MOUTHWASH 0.12 %

Tier 1

triamcinolone acetonide dental paste 0.1 %

(Oralone) Tier 1 QL (5 GM per 30 days)

Nose Preparations, Miscellaneous (Rx)ipratropium bromide nasal spray,non-aerosol 0.03 %


ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06 %)


Other Drugs

Appetite Stim. For Anorexia,Cachexia,Wasting Synd.megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml)

Tier 1

CondomsAIMSCO LATEX CONDOM DEVICE Tier 1 QL (36 EA per 30 days)

CONDOMS-PREM LUBRICATED DEVICE


DUREX AVANTI BARE REAL FEEL Tier 1 QL (36 EA per 30 days)

FANTASY CONDOM DEVICE Tier 1 QL (36 EA per 30 days)

FC2 FEMALE CONDOM Tier 1 QL (36 EA per 30 days)

147

Drug Status Notes

KIMONO CONDOMS(NON-LUBRICATED) DEVICE


KIMONO MAXX CONDOMS DEVICE Tier 1 QL (36 EA per 30 days)

KIMONO MICROTHIN AQUA LUBE CON DEVICE


KIMONO MICROTHIN CONDOMS DEVICE


KIMONO MICROTHIN LARGE CONDOMS DEVICE


KIMONO TEXTURED CONDOMS DEVICE


TRUSTEX LATEX CONDOM DEVICE Tier 1 QL (36 EA per 30 days)

TRUSTEX LUBRICATED CONDOMS DEVICE


TRUSTEX NON-LUB CONDOMS DEVICE


TRUSTEX-RIA LUB/SPERMICIDE DEVICE


TRUSTEX-RIA LUBRICATED CONDOMS DEVICE


TRUSTEX-RIA NON-LUB CONDOMS DEVICE


Drugs To Treat Hereditary Tyrosinemianitisinone oral capsule 10 mg, 2 mg, 5 mg

(Orfadin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

NITYR ORAL TABLET 10 MG, 2 MG, 5 MG


ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG


ORFADIN ORAL SUSPENSION 4 MG/ML


Drugs To Tx Gaucher Dx-Type 1, Substrate ReducingCERDELGA ORAL CAPSULE 84 MG Carve Out CARVE OUT


miglustat oral capsule 100 mg (Zavesca) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

148

Drug Status Notes

ZAVESCA ORAL CAPSULE 100 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

General Anesthetics - Benzodiazepine, Injectablemidazolam (pf) injection solution 5 mg/ml Tier 1 QL (4 ML per 30 days)

midazolam injection solution 5 mg/ml Tier 1 QL (4 ML per 30 days)General Inhalation Agentssodium chloride inhalation solution for nebulization 0.9 %


sodium chloride inhalation solution for nebulization 7 %

(Hyper-Sal) Tier 1

Menopausal Symptoms Suppressant - SsrisBRISDELLE ORAL CAPSULE 7.5 MG Carve Out CARVE OUT


paroxetine mesylate(menop.sym) oral capsule 7.5 mg

(Brisdelle) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Metabolic Deficiency AgentsCARNITOR (SUGAR-FREE) ORAL SOLUTION 100 MG/ML


CARNITOR INTRAVENOUS SOLUTION 200 MG/ML


CARNITOR ORAL SOLUTION 100 MG/ML


CARNITOR ORAL TABLET 330 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

CYSTADANE ORAL POWDER 1 GRAM/1.7 ML


levocarnitine (with sugar) oral solution100 mg/ml

(Carnitor) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

149

Drug Status Notes

levocarnitine oral solution 100 mg/ml (Carnitor (sugar-free)) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

levocarnitine oral tablet 330 mg (Carnitor) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Metabolic Disease Enzyme Replacement, Fabry's DxFABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG


Metabolic Disease Enzyme Replacement, Gaucher's DxCEREZYME INTRAVENOUS RECON SOLN 400 UNIT


ELELYSO INTRAVENOUS RECON SOLN 200 UNIT


VPRIV INTRAVENOUS RECON SOLN 400 UNIT


Metabolic Disease Enzyme Replacement,Pompe DiseaseLUMIZYME INTRAVENOUS RECON SOLN 50 MG


Metabolic Dx Enzyme Replace, MucopolysaccharidosisALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML


ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML


MEPSEVII INTRAVENOUS SOLUTION 2 MG/ML


NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML


150

Drug Status Notes

VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML)


Metabolic Dx Enzyme Replacemt,Sev.Comb.Immune Def.REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5 ML (1.6 MG/ML)


Metallic Poison,Agents To TreatCHEMET ORAL CAPSULE 100 MG Tier 1

Needles/Needleless Devices1ST TIER UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"


1ST TIER UNIFINE PENTIPS PLUS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"


ABOUTTIME PEN NEEDLE NEEDLE 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"


ADVOCATE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 33 GAUGE X 5/32"


ASSURE ID PEN NEEDLE NEEDLE 30 GAUGE X 3/16", 30 GAUGE X 5/16", 31 GAUGE X 3/16"


BD AUTOSHIELD DUO PEN NEEDLE NEEDLE 30 GAUGE X 3/16"


BD NANO 2ND GEN PEN NEEDLE NEEDLE 32 GAUGE X 5/32"


BD ULTRA-FINE MICRO PEN NEEDLE NEEDLE 32 GAUGE X 1/4"


BD ULTRA-FINE MINI PEN NEEDLE NEEDLE 31 GAUGE X 3/16"


BD ULTRA-FINE NANO PEN NEEDLE NEEDLE 32 GAUGE X 5/32"


BD ULTRA-FINE ORIG PEN NEEDLE NEEDLE 29 GAUGE X 1/2"


BD ULTRA-FINE SHORT PEN NEEDLE NEEDLE 31 GAUGE X 5/16"


CAREFINE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32"


151

Drug Status Notes

CARETOUCH PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 3/16", 32 GAUGE X 5/32"


CLICKFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 5/32"


COMFORT EZ PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/16", 33 GAUGE X 5/32"


DROPLET PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 29 GAUGE X 3/8", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32"


DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16"


EASY COMFORT PEN NEEDLES NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/32"


EASY GLIDE PEN NEEDLE NEEDLE 33 GAUGE X 5/32"


EASY TOUCH NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32"


EASY TOUCH PEN NEEDLE NEEDLE 30 GAUGE X 5/16"


EASY TOUCH SAFETY PEN NEEDLE NEEDLE 30 GAUGE X 3/16"


HEALTHWISE PEN NEEDLE NEEDLE 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"


HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"


INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"


152

Drug Status Notes

INSUPEN NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32"


LITE TOUCH INSULIN PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16"


MAXICOMFORT II PEN NEEDLE NEEDLE 31 GAUGE X 1/4"


MAXICOMFORT SAFETY PEN NEEDLE NEEDLE 29 GAUGE X 3/16", 29 GAUGE X 5/16"


MICRODOT INSULIN PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32"


MINI ULTRA-THIN II NEEDLE 31 GAUGE X 3/16"


NOVOFINE 32 NEEDLE 32 GAUGE X 1/4"


NOVOFINE AUTOCOVER NEEDLE 30 GAUGE X 1/3"


NOVOFINE PLUS NEEDLE 32 GAUGE X 1/6"


NOVOTWIST NEEDLE 32 GAUGE X 1/5"


PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"


pen needle, diabetic needle 29 gauge x 1/2", 31 gauge x 1/4", 31 gauge x 3/16", 31 gauge x 5/16", 32 gauge x 5/32"

(1st Tier Unifine Pentips) Tier 1 QL (100 EA per 1 FILL)

pen needle, diabetic needle 31 gauge x 1/3", 31 gauge x 1/6"


pen needle, diabetic needle 32 gauge x 1/4"

(BD Ultra-Fine Micro Pen Needle)



(CareFine Pen Needle) Tier 1 QL (100 EA per 1 FILL)


(Advocate Pen Needle) Tier 1 QL (100 EA per 1 FILL)

PENTIPS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"


PREVENT DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16"


153

Drug Status Notes

PRO COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32"


PURE COMFORT PEN NEEDLE NEEDLE 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32"


RELION NEEDLES NEEDLE 31 GAUGE X 1/4"


RELION PEN NEEDLES NEEDLE 32 GAUGE X 5/32"


SAFETY PEN NEEDLE NEEDLE 31 GAUGE X 3/16"


SURE COMFORT PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32"


SURE-FINE PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16"


TECHLITE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 29 GAUGE X 3/8", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", 32 GAUGE X 5/32"


TOPCARE CLICKFINE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16"


TRUE COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 32 GAUGE X 5/32"


TRUEPLUS PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"


ULTICARE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32"


ULTIGUARD SAFE PACK NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32"


ULTILET PEN NEEDLE NEEDLE 29 GAUGE, 32 GAUGE X 5/32"


ULTRA FLO PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16"


ULTRA THIN PEN NEEDLE NEEDLE 32 GAUGE X 5/32"


154

Drug Status Notes

ULTRACARE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32"


ULTRA-THIN II (SHORT) PEN NDL NEEDLE 31 GAUGE X 5/16"


ULTRA-THIN II INS PEN NEEDLES NEEDLE 29 GAUGE X 1/2"


UNIFINE PENTIPS MAXFLOW NEEDLE 30 GAUGE X 3/16"


UNIFINE PENTIPS NEEDLE 29 GAUGE, 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32"


UNIFINE PENTIPS PLUS MAXFLOW NEEDLE 30 GAUGE X 3/16"


UNIFINE PENTIPS PLUS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32"


VERIFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 3/16", 32 GAUGE X 5/32"


Nose Preparations, Miscellaneous (Otc)ALTAMIST NASAL AEROSOL,SPRAY 0.65 %

Tier 1

AYR SALINE NASAL AEROSOL,SPRAY 0.65 %

Tier 1

BABY AYR SALINE NASAL DROPS 0.65 %

Tier 1

CHILDREN'S SALINE NASAL SPRAY NASAL AEROSOL,SPRAY 0.65 %

Tier 1

DEEP SEA NASAL NASAL AEROSOL,SPRAY 0.65 %

Tier 1

LITTLE REMEDIES NASAL AEROSOL,SPRAY 0.65 %

Tier 1

NASAL MOISTURIZING NASAL AEROSOL,SPRAY 0.65 %

Tier 1

NASAL SPRAY (SODIUM CHLORIDE) NASAL AEROSOL,SPRAY 0.65 %

Tier 1

OCEAN NASAL NASAL AEROSOL,SPRAY 0.65 %

Tier 1

SALINE MIST NASAL AEROSOL,SPRAY 0.65 %

Tier 1

SALINE NASAL MIST NASAL AEROSOL,SPRAY 0.65 %

Tier 1

SALINE NASAL NASAL AEROSOL,SPRAY 0.65 %

Tier 1

155

Drug Status Notes

SALINE NOSE NASAL AEROSOL,SPRAY 0.65 %

Tier 1

Somatostatic Agentsoctreotide acetate injection solution1,000 mcg/ml, 200 mcg/ml

Tier 1 PA; SP

octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml

(Sandostatin) Tier 1 PA; SP

Urine Acetone Test AidsKETONE CARE STRIP Tier 1

KETONE URINE TEST STRIP Tier 1

KETOSTIX STRIP Tier 1

TRUEPLUS KETONE STRIP Tier 1Other Respiratory Disorders

Cystic Fib.Transmemb Conduct.Reg.(Cftr)PotentiatorKALYDECO ORAL GRANULES IN PACKET 25 MG, 50 MG, 75 MG


KALYDECO ORAL TABLET 150 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Cystic Fibrosis-Cftr Potentiator & Corrector Comb.ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG


ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG


SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N)


TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 MG(D) /150 MG (N)


Mucolyticsacetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)

Tier 1

PULMOZYME INHALATION SOLUTION 1 MG/ML

Tier 1 PA; SP; QL (2.5 ML per 1 day)

156

Drug Status Notes

Pain Management - Analgesics

Analgesic, Non-Salicylate & Barbiturate Comb.butalbital-acetaminophen oral tablet 50-325 mg

(Tencon) Tier 1 QL (4 EA per 1 day); Age (Min 10 Years and Max 64 Years)

TENCON ORAL TABLET 50-325 MG Tier 1 QL (4 EA per 1 day); Age (Min 10 Years and Max 64 Years)

Analgesic, Salicylate, Barbiturate,& Xanthine Cmbbutalbital-aspirin-caffeine oral capsule50-325-40 mg

(Fiorinal) Tier 1 QL (4 EA per 1 day); Age (Max 64 Years)

Analgesic,Non-Salicylate,Barbiturate,&Xanthine Cmbbutalbital-acetaminophen-caff oral tablet50-325-40 mg

(Esgic) Tier 1 QL (4 EA per 1 day); Age (Min 10 Years and Max 64 Years)

Analgesic/Antipyretics, Salicylatesaspirin oral tablet 325 mg (Lite Coat Aspirin) Tier 1 QL (1 EA per 1 day); Age

(Min 40 Years and Max 79 Years)

aspirin oral tablet,delayed release (dr/ec)325 mg

(Aspir-Trin) Tier 1 QL (1 EA per 1 day); Age (Min 40 Years and Max 79 Years)

aspirin rectal suppository 300 mg, 600 mg

Tier 1

aspirin,buffd-calcium carb-mag oral tablet 325 mg

(Buffered Aspirin) Tier 1 Age (Min 40 Years and Max 79 Years)

ASPIR-TRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG

Tier 1 QL (1 EA per 1 day); Age (Min 40 Years and Max 79 Years)

BUFFERED ASPIRIN ORAL TABLET 325 MG


BUFFERIN ORAL TABLET 325 MG Tier 1 Age (Min 40 Years and Max 79 Years)

choline,magnesium salicylate oral liquid500 mg/5 ml

Tier 1

E.C. PRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG


ECOTRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG


LITE COAT ASPIRIN ORAL TABLET 325 MG


TRI-BUFFERED ASPIRIN ORAL TABLET 325 MG


157

Drug Status Notes

Analgesic/Antipyretics,Non-Salicylate8 HOUR PAIN RELIEVER ORAL TABLET EXTENDED RELEASE 650 MG

Tier 1

8HR MUSCLE ACHES-PAIN ORAL TABLET EXTENDED RELEASE 650 MG

Tier 1

ACETAMINOPHEN EXTRA STRENGTH ORAL TABLET 500 MG

Tier 1

acetaminophen oral elixir 160 mg/5 ml (Non-Aspirin) Tier 1

acetaminophen oral liquid 160 mg/5 ml (Children's Acetaminophen)

Tier 1

acetaminophen oral solution 160 mg/5 ml (5 ml)

Tier 1

acetaminophen oral suspension 160 mg/5 ml

(BetaTemp) Tier 1 QL (125 ML per 1 day)

acetaminophen oral tablet 325 mg (Athenol) Tier 1

acetaminophen oral tablet 500 mg (Acetaminophen Extra Strength)

Tier 1

acetaminophen oral tablet extended release 650 mg

(8 Hour Pain Reliever) Tier 1

acetaminophen oral tablet,disintegrating160 mg

(Children's Pain-Fever Relief)

Tier 1

acetaminophen oral tablet,disintegrating80 mg

(Children's Acetaminophen)

Tier 1

ACETAMINOPHEN PAIN RELIEF ORAL TABLET 500 MG

Tier 1

acetaminophen rectal suppository 120 mg

(Child Pain Rel-Fever Reducer)

Tier 1

acetaminophen rectal suppository 650 mg

(Feverall) Tier 1

ARTHRITIS PAIN RELIEF (ACETAM) ORAL TABLET EXTENDED RELEASE 650 MG

Tier 1

ARTHRITIS PAIN RELIEVER ORAL TABLET EXTENDED RELEASE 650 MG

Tier 1

ATHENOL ORAL TABLET 325 MG Tier 1

BETATEMP ORAL SUSPENSION 160 MG/5 ML


CHILD PAIN REL-FEVER REDUCER RECTAL SUPPOSITORY 120 MG

Tier 1

CHILDREN'S ACETAMINOPHEN ORAL LIQUID 160 MG/5 ML

Tier 1

CHILDREN'S ACETAMINOPHEN ORAL SUSPENSION 160 MG/5 ML, 160 MG/5 ML (5 ML)


CHILDREN'S ACETAMINOPHEN ORAL TABLET,CHEWABLE 80 MG

Tier 1

158

Drug Status Notes

CHILDREN'S ACETAMINOPHEN ORAL TABLET,DISINTEGRATING 80 MG

Tier 1

CHILDREN'S AUROPHEN PAIN-FEVER ORAL SUSPENSION 160 MG/5 ML


CHILDREN'S EASY-MELTS ORAL TABLET,DISINTEGRATING 80 MG

Tier 1

CHILDREN'S FEVER REDUCING RECTAL SUPPOSITORY 120 MG

Tier 1

CHILDREN'S MAPAP ORAL TABLET,CHEWABLE 80 MG

Tier 1

CHILDREN'S NON-ASPIRIN ORAL SUSPENSION 160 MG/5 ML


CHILDREN'S PAIN RELIEF ORAL SUSPENSION 160 MG/5 ML


CHILDREN'S PAIN RELIEVER ORAL SUSPENSION 160 MG/5 ML


CHILDREN'S PAIN-FEVER RELIEF ORAL SUSPENSION 160 MG/5 ML


CHILDREN'S PAIN-FEVER RELIEF ORAL TABLET,DISINTEGRATING 160 MG

Tier 1

CHILDREN'S SILAPAP ORAL LIQUID 160 MG/5 ML

Tier 1

CHILDREN'S TACTINAL ORAL TABLET,CHEWABLE 80 MG

Tier 1

ED-APAP ORAL LIQUID 160 MG/5 ML Tier 1

FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION 160 MG/5 ML


FEVER REDUCER RECTAL SUPPOSITORY 120 MG

Tier 1

FEVERALL RECTAL SUPPOSITORY 120 MG, 325 MG, 650 MG

Tier 1

INFANT FEVER REDUCER-PAIN RELF ORAL SUSPENSION 160 MG/5 ML


INFANT PAIN RELIEVER ORAL SUSPENSION 160 MG/5 ML


INFANT'S ACETAMINOPHEN ORAL SUSPENSION 160 MG/5 ML


INFANTS' PAIN AND FEVER ORAL SUSPENSION 160 MG/5 ML


INFANT'S PAIN RELIEF ORAL DROPS,SUSPENSION 80 MG/0.8 ML

Tier 1

INFANTS' PAIN RELIEF ORAL SUSPENSION 160 MG/5 ML


INFANT'S PAIN RELIEF ORAL SUSPENSION 160 MG/5 ML


INFANT'S PAIN RELIEVER ORAL DROPS,SUSPENSION 80 MG/0.8 ML

Tier 1

JR. ACETAMINOPHEN ORAL TABLET,DISINTEGRATING 160 MG

Tier 1

159

Drug Status Notes

JR. STR NON-ASPIRIN PAIN ORAL TABLET,DISINTEGRATING 160 MG

Tier 1

JR. STRENGTH PAIN RELIEVER ORAL TABLET,DISINTEGRATING 160 MG

Tier 1

LITTLE REMEDIES FEVER AND PAIN ORAL LIQUID 160 MG/5 ML


MAPAP (ACETAMINOPHEN) ORAL CAPSULE 500 MG

Tier 1

MAPAP (ACETAMINOPHEN) ORAL TABLET 325 MG

Tier 1

MAPAP ARTHRITIS PAIN ORAL TABLET EXTENDED RELEASE 650 MG

Tier 1

MAPAP EXTRA STRENGTH ORAL TABLET 500 MG

Tier 1

MASOPHEN ORAL TABLET 325 MG, 500 MG

Tier 1

M-PAP ORAL LIQUID 160 MG/5 ML Tier 1

NON-ASPIRIN CHILDRENS ORAL DROPS 100 MG/ML

Tier 1

NON-ASPIRIN EXTRA STRENGTH ORAL TABLET 500 MG

Tier 1

NON-ASPIRIN ORAL ELIXIR 160 MG/5 ML

Tier 1

NON-ASPIRIN ORAL SUSPENSION 160 MG/5 ML


NON-ASPIRIN ORAL TABLET 325 MG Tier 1

NON-ASPIRIN ORAL TABLET,CHEWABLE 80 MG

Tier 1

NON-ASPIRIN PAIN RELIEF ORAL TABLET 500 MG

Tier 1

NORTEMP ORAL DROPS 80 MG/0.8 ML

Tier 1

NORTEMP ORAL SUSPENSION 160 MG/5 ML


PAIN AND FEVER ORAL TABLET 325 MG

Tier 1

PAIN RELIEF EXTRA STRENGTH ORAL TABLET 500 MG

Tier 1

PAIN RELIEF ORAL LIQUID 160 MG/5 ML

Tier 1

PAIN RELIEF ORAL TABLET 500 MG Tier 1

PAIN RELIEF ORAL TABLET EXTENDED RELEASE 650 MG

Tier 1

PAIN RELIEF REGULAR STRENGTH ORAL TABLET 325 MG

Tier 1

PAIN RELIEVER EXTRA STRENGTH ORAL TABLET 500 MG

Tier 1

PAIN RELIEVER ORAL TABLET 325 MG, 500 MG

Tier 1

160

Drug Status Notes

PEDIACARE FEVER REDUCER ORAL SUSPENSION 160 MG/5 ML


PHARBETOL ORAL TABLET 325 MG, 500 MG

Tier 1

SHAKE THAT ACHE ORAL TABLET 500 MG

Tier 1

TACTINAL EXTRA STRENGTH ORAL TABLET 500 MG

Tier 1

TACTINAL ORAL TABLET 325 MG Tier 1

TYLENOL ORAL TABLET 325 MG Tier 1

TYLOPHEN ORAL CAPSULE 500 MG Tier 1Analgesics,Narcoticscodeine sulfate oral tablet 15 mg, 30 mg, 60 mg


fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

(Duragesic) Tier 1 PA; QL (10 EA per 30 days)

hydromorphone oral liquid 1 mg/ml (Dilaudid) Tier 1 QL (32 ML per 1 day)

hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) Tier 1 QL (8 EA per 1 day)

hydromorphone rectal suppository 3 mg Tier 1 QL (8 EA per 1 day)

meperidine oral solution 50 mg/5 ml Tier 1 QL (10 ML per 1 day); Age (Max 64 Years)

meperidine oral tablet 100 mg (Demerol) Tier 1 QL (1 EA per 1 day); Age (Max 64 Years)

meperidine oral tablet 50 mg Tier 1 QL (1 EA per 1 day); Age (Max 64 Years)

METHADONE INTENSOL ORAL CONCENTRATE 10 MG/ML


methadone oral concentrate 10 mg/ml (Methadone Intensol) Tier 1 QL (8 ML per 1 day)

methadone oral solution 10 mg/5 ml Tier 1 QL (20 ML per 1 day)

methadone oral solution 5 mg/5 ml Tier 1 QL (30 ML per 1 day)

methadone oral tablet 10 mg, 5 mg (Dolophine) Tier 1 QL (4 EA per 1 day)

morphine concentrate oral solution 100 mg/5 ml (20 mg/ml)


morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)


morphine oral tablet 15 mg, 30 mg Tier 1 QL (8 EA per 1 day)

morphine oral tablet extended release100 mg, 15 mg, 200 mg, 30 mg, 60 mg

(MS Contin) Tier 1 QL (2 EA per 1 day)

oxycodone oral solution 5 mg/5 ml Tier 1 QL (20 ML per 1 day)

oxycodone oral tablet 5 mg (Roxicodone) Tier 1 QL (8 EA per 1 day)

pentazocine-naloxone oral tablet 50-0.5 mg


tramadol oral tablet 50 mg (Ultram) Tier 1 QL (8 EA per 1 day)Antimigraine PreparationsAIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML, 70 MG/ML

Tier 1 PA

161

Drug Status Notes

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML


naratriptan oral tablet 1 mg, 2.5 mg (Amerge) Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS

rizatriptan oral tablet 10 mg (Maxalt) Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS

rizatriptan oral tablet 5 mg Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS

rizatriptan oral tablet,disintegrating 10 mg

(Maxalt-MLT) Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS

rizatriptan oral tablet,disintegrating 5 mg Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS

sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation

(Imitrex) Tier 1 PA; QL (6 EA per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

(Imitrex) Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml

(Imitrex STATdose Refill) Tier 1 PA; QL (4 ML per 30 days)

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml

(Imitrex STATdose Pen) Tier 1 PA; QL (4 ML per 30 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5 ml

(Imitrex) Tier 1 PA; QL (4 ML per 30 days)

zolmitriptan oral tablet 2.5 mg, 5 mg (Zomig) Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS; ST: At least 2 prior prescriptions for Naratriptan HCL, Rizatriptan Benzoate, or Sumatriptan Succinate within the past 180 days

162

Drug Status Notes

zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg

(Zomig ZMT) Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS; ST: At least 2 prior prescriptions for Naratriptan HCL, Rizatriptan Benzoate, or Sumatriptan Succinate within the past 180 days

Calcitonin Gene-Related Peptide (Cgrp) InhibitorsEMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML (100 MG/ML X 3)


Narc.& Non-Sal.Analgesic,Barbiturate &Xanthine Cmbbutalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg


Narcotic & Salicylate Analgesics, Barb.& XanthineASCOMP WITH CODEINE ORAL CAPSULE 30-50-325-40 MG


BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE 30-50-325-40 MG


codeine-butalbital-asa-caff oral capsule30-50-325-40 mg

(Ascomp with Codeine) Tier 1 QL (8 EA per 1 day)

Narcotic Analgesic & Non-Salicylate Analgesic Combacetaminophen-codeine oral solution120-12 mg/5 ml


acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg


acetaminophen-codeine oral tablet 300-30 mg

(Tylenol-Codeine #3) Tier 1 QL (8 EA per 1 day)

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG


hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml


hydrocodone-acetaminophen oral tablet10-325 mg

(Lorcet HD) Tier 1 QL (8 EA per 1 day)

hydrocodone-acetaminophen oral tablet5-325 mg

(Lorcet (hydrocodone)) Tier 1 QL (8 EA per 1 day)

hydrocodone-acetaminophen oral tablet7.5-325 mg

(Lorcet Plus) Tier 1 QL (8 EA per 1 day)

LORCET (HYDROCODONE) ORAL TABLET 5-325 MG


LORCET HD ORAL TABLET 10-325 MG Tier 1 QL (8 EA per 1 day)

LORCET PLUS ORAL TABLET 7.5-325 MG


163

Drug Status Notes

oxycodone-acetaminophen oral tablet10-325 mg, 5-325 mg, 7.5-325 mg

(Endocet) Tier 1 QL (8 EA per 1 day)

Narcotic Withdrawal Therapy AgentsBUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 MG


buprenorphine hcl sublingual tablet 2 mg, 8 mg


buprenorphine-naloxone sublingual film12-3 mg, 8-2 mg

(Suboxone) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

buprenorphine-naloxone sublingual film2-0.5 mg, 4-1 mg

(Suboxone) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg


SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 300 MG/1.5 ML


SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG


ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG


Opioid Withdrawal Ther, Alpha-2 Adrenergic AgonistLUCEMYRA ORAL TABLET 0.18 MG Tier 1 PA; QL (224 EA per 14

days); Age (Min 18 Years)Parkinsons Disease

Antiparkinsonism Drugs,Anticholinergicbenztropine injection solution 1 mg/ml (Cogentin) Carve Out CARVE OUT


benztropine oral tablet 0.5 mg, 1 mg, 2 mg


164

Drug Status Notes

COGENTIN INJECTION SOLUTION 1 MG/ML


trihexyphenidyl oral elixir 0.4 mg/ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

trihexyphenidyl oral tablet 2 mg, 5 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Antiparkinsonism Drugs,Otheramantadine hcl oral capsule 100 mg Tier 1 QL (4 EA per 1 day)

amantadine hcl oral solution 50 mg/5 ml Tier 1 QL (40 ML per 1 day)

bromocriptine oral capsule 5 mg (Parlodel) Tier 1 QL (3 EA per 1 day)

bromocriptine oral tablet 2.5 mg (Parlodel) Tier 1 QL (6 EA per 1 day)

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

(Sinemet) Tier 1 QL (2 EA per 1 day)

carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg

(Sinemet CR) Tier 1 QL (2 EA per 1 day)

carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg


entacapone oral tablet 200 mg (Comtan) Tier 1 QL (4 EA per 1 day)

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

(Mirapex) Tier 1 QL (3 EA per 1 day)

ropinirole oral tablet 0.25 mg, 3 mg, 5 mg

(Requip) Tier 1 QL (3 EA per 1 day)

ropinirole oral tablet 0.5 mg, 1 mg, 2 mg, 4 mg


selegiline hcl oral capsule 5 mg Tier 1 QL (2 EA per 1 day)Seizure Disorder

Anticonvulsant - Benzodiazepine Typeclobazam oral suspension 2.5 mg/ml (Onfi) Carve Out CARVE OUT

MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 ML per 1 day)

clobazam oral tablet 10 mg, 20 mg (Onfi) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg

(Klonopin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

clonazepam oral tablet,disintegrating0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg


165

Drug Status Notes

DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG, 5-7.5-10 MG


DIASTAT RECTAL KIT 2.5 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 mg

(Diastat AcuDial) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

diazepam rectal kit 2.5 mg (Diastat) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG


NAYZILAM NASAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML)


ONFI ORAL SUSPENSION 2.5 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ONFI ORAL TABLET 10 MG, 20 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG


VALTOCO NASAL SPRAY,NON-AEROSOL 10 MG/SPRAY (0.1 ML), 15 MG/2 SPRAY (7.5/0.1ML X 2), 20 MG/2 SPRAY (10MG/0.1ML X2), 5 MG/SPRAY (0.1 ML)


Anticonvulsant - Cannabinoid TypeEPIDIOLEX ORAL SOLUTION 100 MG/ML


AnticonvulsantsACTIVE-PAC KIT,GEL AND CAPSULE 300-4-1 MG-%-%


166

Drug Status Notes

APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG


BANZEL ORAL SUSPENSION 40 MG/ML


BANZEL ORAL TABLET 200 MG, 400 MG


BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML


BRIVIACT ORAL SOLUTION 10 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG


carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg

(Carbatrol) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

carbamazepine oral suspension 100 mg/5 ml

(Tegretol) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

carbamazepine oral tablet 200 mg (Epitol) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg

(Tegretol XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

carbamazepine oral tablet,chewable 100 mg


CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG


CELONTIN ORAL CAPSULE 300 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

167

Drug Status Notes

CEREBYX INJECTION SOLUTION 100 MG PE/2 ML, 500 MG PE/10 ML


DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR 250 MG, 500 MG


DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG, 250 MG, 500 MG


DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 125 MG


DIACOMIT ORAL CAPSULE 250 MG, 500 MG


DIACOMIT ORAL POWDER IN PACKET 250 MG, 500 MG


DILANTIN EXTENDED ORAL CAPSULE 100 MG


DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG


DILANTIN ORAL CAPSULE 30 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML


divalproex oral capsule, delayed rel sprinkle 125 mg

(Depakote Sprinkles) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

divalproex oral tablet extended release 24 hr 250 mg, 500 mg

(Depakote ER) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

168

Drug Status Notes

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg

(Depakote) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

EPITOL ORAL TABLET 200 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ethosuximide oral capsule 250 mg (Zarontin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ethosuximide oral solution 250 mg/5 ml (Zarontin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

felbamate oral suspension 600 mg/5 ml (Felbatol) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

felbamate oral tablet 400 mg, 600 mg (Felbatol) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

FELBATOL ORAL SUSPENSION 600 MG/5 ML


FELBATOL ORAL TABLET 400 MG, 600 MG


fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml

(Cerebyx) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

FYCOMPA ORAL SUSPENSION 0.5 MG/ML


FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG


GABACAINE KIT 300 MG-5 % Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

169

Drug Status Notes

gabapentin oral capsule 100 mg, 300 mg, 400 mg

(Neurontin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

gabapentin oral solution 250 mg/5 ml (Neurontin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml)


gabapentin oral tablet 600 mg, 800 mg (Neurontin) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG


KEPPRA INTRAVENOUS SOLUTION 500 MG/5 ML


KEPPRA ORAL SOLUTION 100 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

KEPPRA ORAL TABLET 1,000 MG, 250 MG, 500 MG, 750 MG


KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG


LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 MG, 200 MG, 25 MG, 50 MG


LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK 25 MG (21) -50 MG (7)


LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 50 MG (42) -100 MG (14)


170

Drug Status Notes

LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 25 MG(14)-50 MG (14)-100 MG (7)


LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG


LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG


LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 25 MG (35)


LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 25 MG (84) -100 MG (14)


LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 25 MG (42) -100 MG (7)


LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG


LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 25 MG (21) -50 MG (7)


LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(14)-100MG (14)-200 MG (7)


LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 25MG (14)-50 MG (14)-100MG (7)


lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

(Lamictal) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

lamotrigine oral tablet disintegrating, dose pk 25 mg (21) -50 mg (7)

(Lamictal ODT Starter (Blue))


171

Drug Status Notes

lamotrigine oral tablet disintegrating, dose pk 25 mg(14)-50 mg (14)-100 mg (7)

(Lamictal ODT Starter (Orange))


lamotrigine oral tablet disintegrating, dose pk 50 mg (42) -100 mg (14)

(Lamictal ODT Starter (Green))


lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

(Lamictal XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg

(Lamictal) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg

(Lamictal ODT) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

lamotrigine oral tablets,dose pack 25 mg (35)

(Lamictal Starter (Blue) Kit) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

lamotrigine oral tablets,dose pack 25 mg (42) -100 mg (7)

(Lamictal Starter (Orange) Kit)


lamotrigine oral tablets,dose pack 25 mg (84) -100 mg (14)

(Lamictal Starter (Green) Kit)


levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml


levetiracetam intravenous solution 500 mg/5 ml

(Keppra) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

levetiracetam oral solution 100 mg/ml (Keppra) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

levetiracetam oral solution 500 mg/5 ml (5 ml)


172

Drug Status Notes

levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg

(Keppra) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg

(Keppra XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG


LYRICA ORAL SOLUTION 20 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

MYSOLINE ORAL TABLET 250 MG, 50 MG


NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG


NEURONTIN ORAL SOLUTION 250 MG/5 ML


NEURONTIN ORAL TABLET 600 MG, 800 MG


oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml)

(Trileptal) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

(Trileptal) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG


PEGANONE ORAL TABLET 250 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

173

Drug Status Notes

PHENYTEK ORAL CAPSULE 200 MG, 300 MG


phenytoin oral suspension 100 mg/4 ml Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

phenytoin oral suspension 125 mg/5 ml (Dilantin-125) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

phenytoin oral tablet,chewable 50 mg (Dilantin Infatabs) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

phenytoin sodium extended oral capsule100 mg

(Dilantin Extended) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID; QL (2 EA per 1 day)

phenytoin sodium extended oral capsule200 mg, 300 mg

(Phenytek) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

phenytoin sodium intravenous solution50 mg/ml


phenytoin sodium intravenous syringe 50 mg/ml


pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

(Lyrica) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

pregabalin oral solution 20 mg/ml (Lyrica) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

primidone oral tablet 250 mg, 50 mg (Mysoline) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 150 MG, 200 MG, 25 MG, 50 MG


174

Drug Status Notes

ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG


ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG


SABRIL ORAL POWDER IN PACKET 500 MG


SABRIL ORAL TABLET 500 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG, 750 MG


SUBVENITE ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG


SUBVENITE STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 25 MG (35)


SUBVENITE STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 25 MG (84) -100 MG (14)


SUBVENITE STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 25 MG (42) -100 MG (7)


TEGRETOL ORAL SUSPENSION 100 MG/5 ML


TEGRETOL ORAL TABLET 200 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 400 MG


tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg

(Gabitril) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

175

Drug Status Notes

TOPAMAX ORAL CAPSULE, SPRINKLE 15 MG, 25 MG


TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG


topiramate oral capsule, sprinkle 15 mg, 25 mg

(Topamax) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

topiramate oral capsule,sprinkle,er 24hr100 mg, 150 mg, 200 mg, 25 mg, 50 mg

(Qudexy XR) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

(Topamax) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

TRILEPTAL ORAL SUSPENSION 300 MG/5 ML (60 MG/ML)


TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG


TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG


valproate sodium intravenous solution500 mg/5 ml (100 mg/ml)


valproic acid (as sodium salt) oral solution 250 mg/5 ml, 500 mg/10 ml (10 ml)


valproic acid oral capsule 250 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

vigabatrin oral powder in packet 500 mg (Sabril) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

vigabatrin oral tablet 500 mg (Sabril) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

176

Drug Status Notes

VIGADRONE ORAL POWDER IN PACKET 500 MG


VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML


VIMPAT ORAL SOLUTION 10 MG/ML Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG


VIMPAT ORAL TABLETS,DOSE PACK 50 MG (14)- 100 MG (14)


ZARONTIN ORAL CAPSULE 250 MG Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

ZARONTIN ORAL SOLUTION 250 MG/5 ML


ZONEGRAN ORAL CAPSULE 100 MG, 25 MG


zonisamide oral capsule 100 mg, 25 mg (Zonegran) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

zonisamide oral capsule 50 mg Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

Skeletal Muscle Disorder

Skeletal Muscle Relaxantsbaclofen oral tablet 10 mg, 20 mg Tier 1 QL (2 EA per 1 day)

chlorzoxazone oral tablet 500 mg Tier 1 Age (Min 18 Years and Max 64 Years)

cyclobenzaprine oral tablet 10 mg, 5 mg Tier 1 QL (2 EA per 1 day); Age (Min 15 Years and Max 64 Years)

dantrolene oral capsule 100 mg Tier 1 QL (4 EA per 1 day)

dantrolene oral capsule 25 mg, 50 mg (Dantrium) Tier 1 QL (4 EA per 1 day)

177

Drug Status Notes

methocarbamol oral tablet 500 mg Tier 1 Age (Min 16 Years and Max 64 Years)

methocarbamol oral tablet 750 mg (Robaxin-750) Tier 1 Age (Min 16 Years and Max 64 Years)

orphenadrine citrate oral tablet extended release 100 mg


tizanidine oral tablet 2 mg Tier 1 QL (2 EA per 1 day); Age (Min 18 Years)

tizanidine oral tablet 4 mg (Zanaflex) Tier 1 QL (2 EA per 1 day); Age (Min 18 Years)

Smoking Cessation

Smoking Deterrent Agents (Ganglionic Stim,Others)NICORELIEF BUCCAL GUM 2 MG Tier 1 QL (30 EA per 1 day)

nicotine (polacrilex) buccal gum 2 mg (Nicorelief) Tier 1 QL (30 EA per 1 day)

nicotine (polacrilex) buccal gum 4 mg (Quit 4) Tier 1 QL (24 EA per 1 day)

nicotine (polacrilex) buccal lozenge 2 mg (Quit 2) Tier 1 QL (20 EA per 1 day)

nicotine (polacrilex) buccal lozenge 4 mg (Quit 4) Tier 1 QL (20 EA per 1 day)

nicotine (polacrilex) buccal mini lozenge2 mg, 4 mg

(Nicorette) Tier 1 QL (20 EA per 1 day)

nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr

(Nicoderm CQ) Tier 1 QL (1 EA per 1 day)

nicotine transdermal patch, td daily, sequential 21-14-7 mg/24 hr


NICOTROL INHALATION CARTRIDGE 10 MG


NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML


QUIT 2 BUCCAL GUM 2 MG Tier 1 QL (30 EA per 1 day)

QUIT 2 BUCCAL LOZENGE 2 MG Tier 1 QL (20 EA per 1 day)

QUIT 4 BUCCAL GUM 4 MG Tier 1 QL (24 EA per 1 day)

QUIT 4 BUCCAL LOZENGE 4 MG Tier 1 QL (20 EA per 1 day)

STOP SMOKING AID BUCCAL LOZENGE 2 MG, 4 MG


Smoking Deterrent-Nicotinic Recept.Partial AgonistCHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG

Tier 1 MAXIMUM TWO 12 WEEK COURSES OF THERAPY PER YEAR; QL (2 EA per 1 day)

CHANTIX ORAL TABLET 0.5 MG, 1 MG Tier 1 MAXIMUM TWO 12 WEEK COURSES OF THERAPY PER YEAR; QL (2 EA per 1 day)

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

Tier 1 MAXIMUM TWO 12 WEEK COURSES OF THERAPY PER YEAR; QL (2 EA per 1 day)

178

Drug Status Notes

Smoking Deterrents, Otherbupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg


Upper Gastrointestinal Disorders - Digestive

AntiflatulentsGAS RELIEF (SIMETHICONE) ORAL DROPS,SUSPENSION 40 MG/0.6 ML

Tier 1

GAS RELIEF (SIMETHICONE) ORAL TABLET,CHEWABLE 125 MG, 80 MG

Tier 1

GAS RELIEF 80 (SIMETHICONE) ORAL TABLET,CHEWABLE 80 MG

Tier 1

GAS RELIEF EXTRA STRENGTH ORAL TABLET,CHEWABLE 125 MG

Tier 1

INFANTS GAS RELIEF ORAL DROPS,SUSPENSION 40 MG/0.6 ML

Tier 1

LITTLE REMEDIES GAS RELIEF ORAL DROPS,SUSPENSION 40 MG/0.6 ML

Tier 1

LITTLE TUMMYS GAS RELIEF ORAL DROPS,SUSPENSION 40 MG/0.6 ML

Tier 1

MI-ACID GAS RELIEF(SIMETHICON) ORAL TABLET,CHEWABLE 80 MG

Tier 1

simethicone oral drops,suspension 40 mg/0.6 ml

(Gas Relief (simethicone)) Tier 1

simethicone oral tablet,chewable 125 mg, 80 mg

(Gas Relief (simethicone)) Tier 1

Gastric EnzymesANTI-GAS ORAL CAPSULE 600 UNIT Carve Out CARVE OUT


BEANO ORAL TABLET 150 UNIT Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

BEANO ORAL TABLET,DISINTEGRATING 300 UNIT


DAIRY AID ORAL TABLET,CHEWABLE 3,000 UNIT


DAIRY DIGESTIVE ORAL TABLET 9,000 UNIT


DAIRY DIGESTIVE ORAL TABLET,CHEWABLE 9,000 UNIT


179

Drug Status Notes

DAIRY DIGESTIVE SUPPLEMENT ORAL TABLET 9,000 UNIT


DAIRY RELIEF ORAL TABLET 3,000 UNIT, 9,000 UNIT


DAIRY RELIEF ORAL TABLET,CHEWABLE 9,000 UNIT


DIGESTIVE ENZYME (ACIDOPH,PEC) ORAL TABLET 50 MILLION CELL-100 MG


DIGESTIVE ENZYMES(MAL,LAC,INV) ORAL CAPSULE 220 MG


ENZYMATIC DIGESTANT ORAL TABLET


ENZYMATIC DIGESTANT ORAL TABLET EXTENDED RELEASE 450-60-32-32 MG


ENZYME DIGEST ORAL CAPSULE Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

GAS RELIEF-PREVENTION ORAL CAPSULE 600 UNIT


LAC-DOSE ORAL TABLET 3,000 UNIT Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

LACTAID FAST ACT ORAL TABLET 9,000 UNIT


LACTAID FAST ACT ORAL TABLET,CHEWABLE 9,000 UNIT


LACTAID ORAL TABLET 3,000 UNIT Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

180

Drug Status Notes

LACTASE ENZYME ORAL TABLET 4,500 UNIT


LACTASE FAST ACTING ORAL TABLET 9,000 UNIT


LACTASE FAST ACTING ORAL TABLET,CHEWABLE 9,000 UNIT


lactase oral tablet 3,000 unit (Dairy Relief) Carve Out CARVE OUT MEDICATION RESUBMIT PHARMACY CLAIM TO FFS MEDICAID

LACTOSE FAST ACTING RELIEF ORAL TABLET 9,000 UNIT


PAPAYA ENZYME (AMYLAS-PROTEAS) ORAL TABLET,CHEWABLE 50 MCG-1 MG- 10 MG-10 MG


SUCRAID ORAL SOLUTION 8,500 UNIT/ML


SUPERIOR DIGESTIVE ENZYME ORAL CAPSULE


ULTRA DAIRY DIGESTIVE ORAL TABLET 9,000 UNIT


Pancreatic EnzymesCREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 36,000-114,000- 180,000 UNIT


CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 3,000-9,500- 15,000 UNIT, 6,000-19,000 -30,000 UNIT


PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 21,000-54,700- 83,900 UNIT


181

Drug Status Notes

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2,600-6,200- 10,850 UNIT, 4,200-14,200- 24,600 UNIT


PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 24,000-86,250- 90,750 UNIT


PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 8,000-28,750- 30,250 UNIT


VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT, 20,880-78,300- 78,300 UNIT


ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 3,000-10,000 -14,000-UNIT, 5,000-17,000- 24,000 UNIT


ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 40,000-126,000- 168,000 UNIT


Upper Gastrointestinal Disorders - Spastic Disease

Anticholinergics/Antispasmodicsdicyclomine oral capsule 10 mg Tier 1 QL (2 EA per 1 day); Age

(Max 64 Years)

dicyclomine oral solution 10 mg/5 ml Tier 1 Age (Max 64 Years)

dicyclomine oral tablet 20 mg Tier 1 QL (2 EA per 1 day); Age (Max 64 Years)

Belladonna AlkaloidsED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG


hyoscyamine sulfate oral drops 0.125 mg/ml

(Hyosyne) Tier 1 Age (Max 64 Years)

hyoscyamine sulfate oral elixir 0.125 mg/5 ml

(Hyosyne) Tier 1 Age (Max 64 Years)

hyoscyamine sulfate oral tablet 0.125 mg (Oscimin) Tier 1 Age (Max 64 Years)

hyoscyamine sulfate oral tablet extended release 12 hr 0.375 mg

(Oscimin SR) Tier 1 Age (Max 64 Years)

hyoscyamine sulfate oral tablet,disintegrating 0.125 mg

(Ed-Spaz) Tier 1 Age (Max 64 Years)

hyoscyamine sulfate sublingual tablet0.125 mg

(Oscimin SL) Tier 1 Age (Max 64 Years)

HYOSYNE ORAL DROPS 0.125 MG/ML Tier 1 Age (Max 64 Years)

HYOSYNE ORAL ELIXIR 0.125 MG/5 ML


OSCIMIN ORAL TABLET 0.125 MG Tier 1 Age (Max 64 Years)

OSCIMIN ORAL TABLET,DISINTEGRATING 0.125 MG


182

Drug Status Notes

OSCIMIN SL SUBLINGUAL TABLET 0.125 MG


OSCIMIN SR ORAL TABLET EXTENDED RELEASE 12 HR 0.375 MG


Upper Gastrointestinal Disorders - Ulcer Disease

AntacidsACID GONE ANTACID ORAL SUSPENSION 95-358 MG/15 ML

Tier 1

ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML

Tier 1

ALMACONE ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

ALMACONE-2 ORAL SUSPENSION 400-400-40 MG/5 ML

Tier 1

aluminum hydroxide gel oral suspension320 mg/5 ml

Tier 1

alum-mag hydroxide-simeth oral suspension 200-200-20 mg/5 ml, 400-400-40 mg/5 ml

(Advanced Antacid-Antigas)

Tier 1

ANTACID (CALCIUM CARBONATE) ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG), 215 MG CALCIUM (500 MG), 320 MG CALCIUM (750 MG)

Tier 1

ANTACID ANTI-GAS ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML

Tier 1

ANTACID CALCIUM ORAL TABLET,CHEWABLE 215 MG CALCIUM (500 MG)

Tier 1

ANTACID EXT STR (CALCIUM CARB) ORAL TABLET,CHEWABLE 300 MG (750 MG)

Tier 1

ANTACID EXTRA-STRENGTH ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 300 MG (750 MG)

Tier 1

ANTACID LIQUID ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

ANTACID M ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

ANTACID MAXIMUM STRENGTH ORAL SUSPENSION 400-400-40 MG/5 ML

Tier 1

ANTACID ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

ANTACID PLUS ANTI-GAS ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML

Tier 1

183

Drug Status Notes

ANTACID REGULAR STRENGTH ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

ANTACID ULTRA STRENGTH ORAL TABLET,CHEWABLE 400 MG CALCIUM (1,000 MG)

Tier 1

ANTACID-ANTIGAS ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML

Tier 1

ANTACID-SIMETHICONE ORAL SUSPENSION 400-400-40 MG/5 ML

Tier 1

BAN-ACID ORAL TABLET,CHEWABLE 300 MG (750 MG)

Tier 1

CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG), 300 MG (750 MG), 320 MG CALCIUM (750 MG), 400 MG CALCIUM (1,000 MG)

Tier 1

CALCIUM ANTACID TROPICAL ORAL TABLET,CHEWABLE 300 MG (750 MG)

Tier 1

CALCIUM ANTACID ULTRA MAX ST ORAL TABLET,CHEWABLE 400 MG CALCIUM (1,000 MG)

Tier 1

calcium carbonate oral tablet,chewable200 mg calcium (500 mg), 320 mg calcium (750 mg)

(Antacid (calcium carbonate))

Tier 1

calcium carbonate oral tablet,chewable300 mg (750 mg)

(Antacid Ext Str (calcium carb))

Tier 1

calcium carbonate oral tablet,chewable400 mg calcium (1,000 mg)

(Antacid Ultra Strength) Tier 1

CAL-GEST ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG)

Tier 1

COMFORT GEL EXTRA STRENGTH ORAL SUSPENSION 400-400-40 MG/5 ML

Tier 1

COMFORT GEL ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

FLAVOR CHEWS ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG)

Tier 1

FOAMING ANTACID ORAL SUSPENSION 95-358 MG/15 ML

Tier 1

FOAMING ANTACID ORAL TABLET,CHEWABLE 80-20 MG

Tier 1

GAVISCON ORAL SUSPENSION 95-358 MG/15 ML

Tier 1

GERI-LANTA ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML

Tier 1

GERI-MOX ANTACID-ANTIGAS ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

184

Drug Status Notes

LIQUID ANTACID ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML

Tier 1

MAALOX ADVANCED ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

MAALOX MAXIMUM STRENGTH ORAL SUSPENSION 400-400-40 MG/5 ML

Tier 1

MAG-AL PLUS EXTRA STRENGTH ORAL SUSPENSION 400-400-40 MG/5 ML

Tier 1

MAG-AL PLUS ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

MAGLOX ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

MASANTI DOUBLE STRENGTH ORAL SUSPENSION 400-400-40 MG/5 ML

Tier 1

MI-ACID ORAL SUSPENSION 200-200-20 MG/5 ML, 400-400-40 MG/5 ML

Tier 1

MINTOX MAXIMUM STRENGTH ORAL SUSPENSION 400-400-40 MG/5 ML

Tier 1

MINTOX ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

MYLANTA MAXIMUM STRENGTH ORAL SUSPENSION 400-400-40 MG/5 ML

Tier 1

RI-GEL II ORAL SUSPENSION 400-400-40 MG/5 ML

Tier 1

RI-GEL ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

RIGINIC ORAL SUSPENSION 131-31.7 MG/5 ML

Tier 1

RI-MOX ORAL SUSPENSION 200-200-20 MG/5 ML

Tier 1

SMOOTH ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG)

Tier 1

sodium bicarbonate oral tablet 325 mg, 650 mg

Tier 1

ULTRA STRENGTH ANTACID ORAL TABLET,CHEWABLE 400 MG CALCIUM (1,000 MG)

Tier 1

ULTRA STRENGTH CALCIUM ANTACID ORAL TABLET,CHEWABLE 400 MG CALCIUM (1,000 MG)

Tier 1

Anticholinergics,Quaternary Ammoniumglycopyrrolate oral tablet 1 mg, 2 mg Tier 1

Anti-Ulcer Preparationsmisoprostol oral tablet 100 mcg, 200 mcg

(Cytotec) Tier 1 QL (4 EA per 1 day)

sucralfate oral tablet 1 gram (Carafate) Tier 1 QL (4 EA per 1 day)

185

Drug Status Notes

Histamine H2-Receptor InhibitorsACID CONTROL (RANITIDINE) ORAL TABLET 150 MG

Tier 1

ACID CONTROLLER ORAL TABLET 10 MG, 20 MG

Tier 1

ACID REDUCER (CIMETIDINE) ORAL TABLET 200 MG

Tier 1

ACID REDUCER (FAMOTIDINE) ORAL TABLET 10 MG, 20 MG

Tier 1

ACID REDUCER (RANITIDINE) ORAL TABLET 150 MG, 75 MG

Tier 1

cimetidine oral tablet 200 mg (Acid Reducer (cimetidine))


cimetidine oral tablet 300 mg, 400 mg, 800 mg


famotidine oral suspension 40 mg/5 ml (8 mg/ml)


famotidine oral tablet 10 mg, 20 mg (Acid Controller) Tier 1

famotidine oral tablet 40 mg (Pepcid) Tier 1

HEARTBURN PREVENTION ORAL TABLET 10 MG, 20 MG

Tier 1

HEARTBURN RELIEF (CIMETIDINE) ORAL TABLET 200 MG

Tier 1

HEARTBURN RELIEF (FAMOTIDINE) ORAL TABLET 10 MG, 20 MG

Tier 1

HEARTBURN RELIEF (RANITIDINE) ORAL TABLET 150 MG, 75 MG

Tier 1

ranitidine hcl oral syrup 15 mg/ml Tier 1 QL (10 ML per 1 day)

ranitidine hcl oral tablet 150 mg, 300 mg, 75 mg

Tier 1

WAL-ZAN 150 ORAL TABLET 150 MG Tier 1

WAL-ZAN 75 ORAL TABLET 75 MG Tier 1

ZANTAC 75 ORAL TABLET 75 MG Tier 1Intestinal Motility Stimulantsmetoclopramide hcl oral solution 5 mg/5 ml

Tier 1

metoclopramide hcl oral tablet 10 mg, 5 mg

(Reglan) Tier 1

MOTEGRITY ORAL TABLET 1 MG, 2 MG


Proton-Pump InhibitorsACID REDUCER (OMEPRAZOLE) ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG


esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg

(Nexium) Tier 1 ST: Requires prior prescription for Omeprazole AND Pantoprazole within the past 120 days; QL (2 EA per 1 day)

186

Drug Status Notes

HEARTBURN TREATMENT 24 HOUR ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15 MG

Tier 1 ST: Requires prior prescriptions for Omeprazole OTC/RX AND Pantoprazole within the past 180 days; QL (1 EA per 1 day)

lansoprazole oral capsule,delayed release(dr/ec) 15 mg

(Heartburn Treatment 24 Hour)

Tier 1 ST: Requires prior prescriptions for Omeprazole OTC/RX AND Pantoprazole within the past 180 days; QL (1 EA per 1 day)

lansoprazole oral capsule,delayed release(dr/ec) 30 mg

(Prevacid) Tier 1 ST: Requires prior prescriptions for Omeprazole OTC/RX AND Pantoprazole within the past 180 days; QL (1 EA per 1 day)

omeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg

(Acid Reducer (omeprazole))


omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg


pantoprazole oral tablet,delayed release (dr/ec) 20 mg

(Protonix) Tier 1 QL (1 EA per 1 day)

pantoprazole oral tablet,delayed release (dr/ec) 40 mg

(Protonix) Tier 1 QL (2 EA per 1 day)

Urinary Tract - Functional Disorders

Benign Prostatic Hypertrophy/Micturition Agentsalfuzosin oral tablet extended release 24 hr 10 mg

(Uroxatral) Tier 1

finasteride oral tablet 5 mg (Proscar) Tier 1 Male Only; QL (1 EA per 1 day)

tamsulosin oral capsule 0.4 mg (Flomax) Tier 1 QL (2 EA per 1 day)Urinary Ph ModifiersCYTRA-2 ORAL SOLUTION 500-334 MG/5 ML

Tier 1

CYTRA-K ORAL SOLUTION 1,100-334 MG/5 ML

Tier 1

K-PHOS NO 2 ORAL TABLET 305-700 MG

Tier 1

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE 500 MG

Tier 1

potassium citrate oral tablet extended release 10 meq (1,080 mg)

(Urocit-K 10) Tier 1

potassium citrate oral tablet extended release 5 meq (540 mg)

(Urocit-K 5) Tier 1

potassium citrate-citric acid oral solution1,100-334 mg/5 ml

(Cytra-K) Tier 1

sodium citrate-citric acid oral solution500-334 mg/5 ml

(Cytra-2) Tier 1

187

Drug Status Notes

VIRTRATE-2 ORAL SOLUTION 500-334 MG/5 ML

Tier 1

VIRTRATE-K ORAL SOLUTION 1,100-334 MG/5 ML

Tier 1

Urinary Tract Analgesic AgentsELMIRON ORAL CAPSULE 100 MG Tier 1 PA; QL (3 EA per 1 day)

Urinary Tract Anesthetic/Analgesic Agnt (Azo-Dye)phenazopyridine oral tablet 100 mg, 200 mg

(Pyridium) Tier 1

Urinary Tract Antispasmodic/Antiincontinence Agentflavoxate oral tablet 100 mg Tier 1

oxybutynin chloride oral syrup 5 mg/5 ml Tier 1 QL (5 ML per 1 day)

oxybutynin chloride oral tablet 5 mg Tier 1 QL (3 EA per 1 day)

oxybutynin chloride oral tablet extended release 24hr 10 mg

(Ditropan XL) Tier 1 QL (2 EA per 1 day)




(Ditropan XL) Tier 1 QL (1 EA per 1 day)

OXYTROL FOR WOMEN TRANSDERMAL PATCH 4 DAY 3.9 MG/24 HOUR

Tier 1

tolterodine oral capsule,extended release 24hr 2 mg, 4 mg

(Detrol LA) Tier 1 ST: Requires prior prescription for Oxybutynin Chloride within the past 180 days; QL (1 EA per 1 day)

tolterodine oral tablet 1 mg, 2 mg (Detrol) Tier 1 ST: Requires prior prescription for Oxybutynin Chloride within the past 180 days; QL (2 EA per 1 day)

trospium oral capsule,extended release 24hr 60 mg

Tier 1 ST: Requires prior prescription for Gelnique or Oxybutynin Chloride within the past 180 days

trospium oral tablet 20 mg Tier 1 ST: Requires prior prescription for Oxybutynin Chloride within the past 180 days; QL (2 EA per 1 day)

Vaginal Disorders

Vaginal Antibioticsclindamycin phosphate vaginal cream 2 %

(Cleocin) Tier 1 Female Only

metronidazole vaginal gel 0.75 % (Vandazole) Tier 1 Female Only

VANDAZOLE VAGINAL GEL 0.75 % Tier 1 Female OnlyVaginal Antifungals3-DAY VAGINAL VAGINAL CREAM 2 % Tier 1 Female Only

188

Drug Status Notes

CLOTRIMAZOLE 3 DAY VAGINAL CREAM 2 %

Tier 1 Female Only

clotrimazole vaginal cream 1 % (Clotrimazole-7) Tier 1 Female Only

CLOTRIMAZOLE-3 VAGINAL CREAM 2 %

Tier 1 Female Only

CLOTRIMAZOLE-7 VAGINAL CREAM 1 %

Tier 1 Female Only

MICONAZOLE 7 VAGINAL CREAM 2 % Tier 1 Female Only

MICONAZOLE 7 VAGINAL SUPPOSITORY 100 MG

Tier 1 Female Only

miconazole nitrate vaginal comb pack,prefill appl, cream 4 % (200 mg)- 2 % (9 gram)

(Miconazole-3) Tier 1 Female Only

miconazole nitrate vaginal cream 2 % (Miconazole 7) Tier 1 Female Only

MICONAZOLE-3 PREFIL,CREAM,WIPE VAGINAL KIT 4 % (200 MG)- 2 % (9 GRAM)

Tier 1 Female Only

MICONAZOLE-3 VAGINAL COMB PACK,PREFILL APPL, CREAM 4 % (200 MG)- 2 % (9 GRAM)

Tier 1 Female Only

MICONAZOLE-3 VAGINAL KIT 200 MG- 2 % (9 GRAM)

Tier 1 Female Only

miconazole-skin clnsr17 vaginal kit 4 % (200 mg)- 2 % (9 gram)

(Miconazole-3 prefil,cream,wipe)

Tier 1 Female Only

MONISTAT 3 VAGINAL COMB PACK,PREFILL APPL, CREAM 4 % (200 MG)- 2 % (9 GRAM)

Tier 1 Female Only

MONISTAT 3 VAGINAL KIT 200 MG- 2 % (9 GRAM)

Tier 1 Female Only

MONISTAT 7 VAGINAL COMB PACK,PREFILL APPL, CREAM 2 % (100 MG)- 2 % (9 GRAM)

Tier 1 Female Only

MONISTAT 7 VAGINAL CREAM 2 % Tier 1 Female Only

terconazole vaginal cream 0.4 %, 0.8 % Tier 1 Female OnlyVaginal Estrogen Preparationsestradiol vaginal cream 0.01 % (0.1 mg/gram)

(Estrace) Tier 1 QL (42.5 GM per 30 days)

estradiol vaginal tablet 10 mcg (Yuvafem) Tier 1

YUVAFEM VAGINAL TABLET 10 MCG Tier 1Vitamin And/Or Mineral Deficiency

Antioxidant Multivitamin CombinationsI-VITE ORAL TABLET 1,000 UNIT-200 MG-60 UNIT-2 MG

Tier 1

OPTI-VITAMINS ORAL TABLET 1,000 UNIT-200 MG-60 UNIT-2 MG

Tier 1

Calcium ReplacementACTICAL ORAL CAPSULE Tier 1

BIOCAL ORAL CAPSULE 500-100-45-800 MG-UNIT-MG-MCG

Tier 1

189

Drug Status Notes

CALCIUM 500 + D ORAL TABLET 500 MG(1,250MG) -200 UNIT, 500 MG(1,250MG) -400 UNIT

Tier 1

CALCIUM 500 ORAL TABLET 500 MG CALCIUM (1,250 MG)

Tier 1

CALCIUM 500 ORAL TABLET,CHEWABLE 500 MG CALCIUM (1,250 MG)

Tier 1

CALCIUM 500 WITH D ORAL TABLET 500 MG(1,250MG) -400 UNIT

Tier 1

CALCIUM 600 + D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG(1,500MG) -400 UNIT, 600-125 MG-UNIT

Tier 1

CALCIUM 600 ORAL TABLET 600 MG CALCIUM (1,500 MG)

Tier 1

calcium carbonate oral suspension 500 mg/5 ml (1,250 mg/5 ml)

Tier 1

calcium carbonate oral tablet 500 mg calcium (1,250 mg)

(Calcium 500) Tier 1

calcium carbonate oral tablet 600 mg calcium (1,500 mg)


calcium carbonate oral tablet,chewable260 mg calcium (650 mg)

(Cal-Mint) Tier 1

calcium carbonate oral tablet,chewable500 mg calcium (1,250 mg)


calcium carbonate-vitamin d3 oral tablet250-125 mg-unit

(Oyster Shell + D3) Tier 1

calcium carbonate-vitamin d3 oral tablet500 mg(1,250mg) -125 unit

Tier 1

calcium carbonate-vitamin d3 oral tablet500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit

(Calcium 500 + D) Tier 1

calcium carbonate-vitamin d3 oral tablet500mg (1,250mg) -600 unit

(Os-Cal 500 + D3) Tier 1

calcium carbonate-vitamin d3 oral tablet600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit

(Calcium 600 + D(3)) Tier 1

calcium carbonate-vitamin d3 oral tablet600 mg(1,500mg) -800 unit

(Caltrate with Vitamin D3) Tier 1

calcium carbonate-vitamin d3 oral tablet,chewable 500-100 mg-unit

Tier 1

CALCIUM CITRATE + D ORAL TABLET 315-200 MG-UNIT

Tier 1

calcium citrate oral tablet 200 mg (950 mg)

(Calcitrate) Tier 1

calcium citrate-vitamin d3 oral tablet 315 mg- 250 unit

(Citracal + D Maximum) Tier 1

calcium citrate-vitamin d3 oral tablet315-200 mg-unit

(Calcium Citrate + D) Tier 1

190

Drug Status Notes

CALCIUM WITH VITAMIN D ORAL TABLET 600 MG(1,500MG) -400 UNIT

Tier 1

CAL-MINT ORAL TABLET,CHEWABLE 260 MG CALCIUM (650 MG)

Tier 1

CALTRATE WITH VITAMIN D3 ORAL TABLET 600 MG(1,500MG) -800 UNIT

Tier 1

CITRACAL + D MAXIMUM ORAL TABLET 315 MG- 250 UNIT

Tier 1

FOSFREE ORAL TABLET 175.5-14.5 MG

Tier 1

HI-CAL PLUS VIT D ORAL TABLET 500 MG(1,250MG) -200 UNIT

Tier 1

NATURAL CALCIUM ORAL TABLET 500 MG CALCIUM (1,250 MG)

Tier 1

OYSCO 500/D ORAL TABLET 500 MG(1,250MG) -200 UNIT

Tier 1

OYSCO-500 ORAL TABLET 500 MG CALCIUM (1,250 MG)

Tier 1

OYSTER SHELL + D3 ORAL TABLET 250-125 MG-UNIT

Tier 1

OYSTER SHELL CALCIUM 500 ORAL TABLET 500 MG CALCIUM (1,250 MG)

Tier 1

OYSTER SHELL CALCIUM ORAL TABLET 500 MG CALCIUM (1,250 MG)

Tier 1

OYSTER SHELL CALCIUM-VIT D2 ORAL TABLET 250 (625)-125 MG-UNIT

Tier 1

OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET 250-125 MG-UNIT, 500 MG(1,250MG) -200 UNIT, 500 MG(1,250MG) -400 UNIT

Tier 1

OYSTERCAL-D ORAL TABLET 500 MG(1,250MG) -400 UNIT

Tier 1

PARVA-CAL 500 ORAL TABLET 500 MG CALCIUM -200 UNIT

Tier 1

PRO-CAL ORAL TABLET 187.5-40-7.5 MG

Tier 1

SUPER CALCIUM ORAL TABLET 600 MG CALCIUM (1,500 MG)

Tier 1

Fluoride PreparationsDENTA 5000 PLUS DENTAL CREAM 1.1 %

Tier 1

DENTAGEL DENTAL GEL 1.1 % Tier 1

fluoride (sodium) dental cream 1.1 % (Denta 5000 Plus) Tier 1

fluoride (sodium) dental gel 1.1 % (DentaGel) Tier 1

fluoride (sodium) oral drops 0.5 mg (1.1 mg sod.fluorid)/ml


fluoride (sodium) oral tablet,chewable0.25 mg(0.55 mg sod. fluoride)

(Ludent Fluoride) Tier 1 QL (1 EA per 1 day); Age (Max 16 Years)

191

Drug Status Notes

fluoride (sodium) oral tablet,chewable0.5 mg (1.1 mg sodium fluorid), 1 mg (2.2 mg sod. fluoride)

(Fluoritab) Tier 1 QL (1 EA per 1 day); Age (Max 16 Years)

FLUORITAB ORAL TABLET,CHEWABLE 0.5 MG (1.1 MG SODIUM FLUORID)


LUDENT FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG(0.55 MG SOD. FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID)


PREVIDENT DENTAL GEL 1.1 % Tier 1

SF 5000 PLUS DENTAL CREAM 1.1 % Tier 1

SF DENTAL GEL 1.1 % Tier 1

SODIUM FLUORIDE 5000 PLUS DENTAL CREAM 1.1 %

Tier 1

Folic Acid PreparationsBIOCEL (WITH LUTEIN) ORAL TABLET 800-250-750 MCG

Tier 1

folic acid oral tablet 1 mg, 800 mcg Tier 1

folic acid oral tablet 400 mcg Tier 1 QL (1 EA per 1 day)

VITACEL (WITH LUTEIN) ORAL TABLET 800-250-750 MCG

Tier 1

Geriatric Vitamin PreparationsCENTRAVITES 50 PLUS ORAL TABLET

Tier 1

CEROVITE SENIOR ORAL TABLET Tier 1

CERTAVITE SENIOR-ANTIOXIDANT ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

COMPLETE SENIOR ORAL TABLET Tier 1

THERATRUM COMPLETE 50 PLUS/LUT ORAL TABLET

Tier 1

THERATRUM COMPLETE 50 PLUS-LYC ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

Iron ReplacementAPETIGEN PLUS ORAL LIQUID 12.5-16.9-790 MG/15 ML

Tier 1

CHILDREN'S IRON ORAL DROPS 15 MG IRON (75 MG)/ML

Tier 1

FE C PLUS ORAL TABLET 100-250-25-1 MG-MG-MCG-MG


FEOSOL ORAL TABLET 325 MG (65 MG IRON)

Tier 1

FERATE ORAL TABLET 240 MG (27 MG IRON)

Tier 1

FERGON ORAL TABLET 240 MG (27 MG IRON)

Tier 1

FEROSUL ORAL TABLET 325 MG (65 MG IRON)

Tier 1

192

Drug Status Notes

FERRO-TIME ORAL TABLET 325 MG (65 MG IRON)

Tier 1

ferrous gluconate oral tablet 236 mg (27 mg iron), 256 mg (28 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron)

Tier 1

ferrous gluconate oral tablet 240 mg (27 mg iron)

(Ferate) Tier 1

ferrous sulfate oral drops 15 mg iron (75 mg)/ml

(Children's Iron) Tier 1

ferrous sulfate oral elixir 220 mg (44 mg iron)/5 ml


ferrous sulfate oral liquid 300 mg (60 mg iron)/5 ml


ferrous sulfate oral solution 220 mg (44 mg iron)/5 ml


ferrous sulfate oral tablet 325 mg (65 mg iron)

(Feosol) Tier 1

ferrous sulfate oral tablet,delayed release (dr/ec) 324 mg (65 mg iron), 325 mg (65 mg iron)

Tier 1

FERROUSUL ORAL TABLET 325 MG (65 MG IRON)

Tier 1

ICAR-C PLUS ORAL TABLET 100-250-25-1 MG-MG-MCG-MG


IRON (DRIED) ORAL TABLET EXTENDED RELEASE 160 MG (50 MG IRON)

Tier 1

IRON (FERROUS SULFATE) ORAL TABLET 325 MG (65 MG IRON)

Tier 1

IRON 100 PLUS ORAL TABLET 100-250-25-1 MG-MG-MCG-MG


IRON ORAL TABLET 325 MG (65 MG IRON)

Tier 1

IRON ORAL TABLET EXTENDED RELEASE 159 MG (45 MG IRON)

Tier 1

PEDIA IRON ORAL DROPS 15 MG IRON (75 MG)/ML

Tier 1

SIDEROL ORAL TABLET Tier 1

SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 142 MG (45 MG IRON), 143 MG (45 MG IRON), 159 MG (45 MG IRON), 160 MG (50 MG IRON), 250 MG (50 MG IRON)

Tier 1

STRESS FORMULA WITH IRON ORAL TABLET 500 MG-400 MCG- 18 MG IRON

Tier 1

STRESS FORMULA WITH IRON(SULF) ORAL TABLET 500 MG-400 MCG- 27 MG IRON

Tier 1

193

Drug Status Notes

Magnesium Salts ReplacementBEELITH ORAL TABLET 362-20 MG Tier 1

MAG 64 ORAL TABLET,DELAYED RELEASE (DR/EC) 64 MG

Tier 1

MAG GLYCINATE ORAL TABLET 100 MG

Tier 1

MAG-G ORAL TABLET 27 MG MAGNESIUM (500 MG)

Tier 1

MAGINEX ORAL TABLET,DELAYED RELEASE (DR/EC) 61 MG (615 MG)

Tier 1

MAGNESIUM (OXIDE/AA CHELATE) ORAL CAPSULE 300 MG

Tier 1

magnesium amino acid chelate oral tablet 100 mg

Tier 1

magnesium chloride injection solution200 mg/ml (20 %)

Tier 1

magnesium chloride oral tablet,delayed release (dr/ec) 70 mg

Tier 1

magnesium citrate oral tablet 100 mg Tier 1

magnesium gluconate oral tablet 27 mg magnesium (500 mg)

(Mag-G) Tier 1

magnesium gluconate oral tablet 27.5 mg magnesium (500 mg), 30 mg (550 mg)

Tier 1

magnesium l-lactate oral tablet extended release 84 mg

(Magtab) Tier 1

magnesium oral tablet 200 mg, 250 mg, 30 mg

Tier 1

magnesium oxide oral capsule 400 mg magnesium, 500 mg

Tier 1

magnesium oxide oral tablet 250 mg magnesium, 400 mg magnesium, 420 mg

Tier 1

magnesium oxide oral tablet 400 mg (241.3 mg magnesium)

(MagOx) Tier 1

magnesium oxide oral tablet 500 mg (Phillips) Tier 1

magnesium sulfate injection solution 4 meq/ml (50 %)

Tier 1

magnesium sulfate injection syringe 4 meq/ml

Tier 1

MAGONATE (MAGNESIUM CARB) ORAL LIQUID 54 MG/5 ML

Tier 1

MAGOX ORAL TABLET 400 MG (241.3 MG MAGNESIUM)

Tier 1

MAGTAB ORAL TABLET EXTENDED RELEASE 84 MG

Tier 1

MGO ORAL TABLET 400 MG (241.3 MG MAGNESIUM)

Tier 1

NU-MAG ORAL TABLET,DELAYED RELEASE (DR/EC) 71.5 MG

Tier 1

194

Drug Status Notes

PHILLIPS ORAL TABLET 500 MG Tier 1

SLOW-MAG ORAL TABLET,DELAYED RELEASE (DR/EC) 71.5 MG

Tier 1

URO-MAG ORAL CAPSULE 84.5 MG MAG (140 MG)

Tier 1

Multivitamin PreparationsA THRU Z ADVANCED FORMULA ORAL TABLET 18-400 MG-MCG

Tier 1

A THRU Z MEN'S ULTIMATE ORAL TABLET 8 MG IRON- 200 MCG-600 MCG

Tier 1

A THRU Z ORAL TABLET 18-500-300-250 MG-MCG-MCG-MCG

Tier 1

A THRU Z SELECT 50PLUS FORMULA ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

A THRU Z SELECT ORAL TABLET 300-600-300 MCG, 500-300-250 MCG

Tier 1

A THRU Z SELECT WOMEN'S ORAL TABLET

Tier 1

ABC PLUS ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

ADULT MULTIVITAMIN (W-LUTEIN) ORAL TABLET,CHEWABLE 200-137.5 MCG

Tier 1

ADULT MULTIVITAMIN GUMMIES ORAL TABLET,CHEWABLE 200 MCG

Tier 1

ADULT ONE DAILY GUMMIES ORAL TABLET,CHEWABLE 200 MCG

Tier 1

ADULT ONE DAILY MULTIVITAMIN ORAL TABLET 0.4 MG

Tier 1

ADULTS 50 PLUS ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

AQUADEKS ORAL TABLET,CHEWABLE 100-350-5 MCG-MCG-MG

Tier 1

AQUADEKS PEDIATRIC ORAL DROPS 400 MCG/ML

Tier 1

B COMPLEX PLUS VITAMIN C ORAL CAPSULE 15-10-50-5-300 MG

Tier 1

BACMIN ORAL TABLET 27 MG IRON- 1 MG

Tier 1

b-complex with vitamin c oral tablet (Super B Complex-Vitamin C)

Tier 1

b-complex with vitamin c oral tablet extended release

Tier 1

BIO-35, GLUTEN FREE ORAL CAPSULE 3-133-33-33 MG-MCG-MCG-MCG

Tier 1

195

Drug Status Notes

BIOTIN PLUS-CALCIUM AND VIT D3 ORAL TABLET 200-450-400 MG-MCG-UNIT

Tier 1

BODY, HAIR, SKIN AND NAILS ORAL CAPSULE 3-133 MG-MCG

Tier 1

CENTRAL-VITE ORAL TABLET Tier 1

CENTRAL-VITE WOMEN'S MATURE ORAL TABLET 8 MG IRON-400 MCG-300 MCG

Tier 1

CENTRAVITES 50 PLUS ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

CENTRAVITES ORAL TABLET 0.4-162-18 MG

Tier 1

CENTRUM COMPLETE ORAL TABLET 18-400 MG-MCG

Tier 1

CENTRUM MEN ORAL TABLET 8 MG IRON- 200 MCG-600 MCG

Tier 1

CENTRUM ORAL TABLET 18-400 MG-MCG

Tier 1

CENTRUM SILVER ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

CENTRUM SILVER ULTRA MEN'S ORAL TABLET 300-600-300 MCG

Tier 1

CENTRUM SPECIALIST HEART ORAL TABLET 3-200-400 MG-MCG-MG

Tier 1

CENTRUM ULTRA MEN'S ORAL TABLET 8 MG IRON- 200 MCG-600 MCG

Tier 1

CENTRUM VITAMINTS ORAL TABLET,CHEWABLE 200 MCG

Tier 1

CENTRUM WOMEN ORAL TABLET 18-400 MG-MCG

Tier 1

CENTURY ADULTS 50 PLUS ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

CENTURY CARDIO ORAL TABLET 3-200-400 MG-MCG-MG

Tier 1

CENTURY MATURE ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

CENTURY ORAL TABLET 18-400 MG-MCG

Tier 1

CENTURY ULTIMATE MEN'S ORAL TABLET 300-600-300 MCG, 8 MG IRON- 200 MCG-600 MCG

Tier 1

CENTURY ULTIMATE WOMEN'S ORAL TABLET 18-400 MG-MCG, 8 MG IRON-400 MCG-300 MCG

Tier 1

CEROVITE ADVANCED FORMULA ORAL TABLET 18-400 MG-MCG

Tier 1

CERTA PLUS ORAL TABLET 18-0.4-250 MG-MG-MCG

Tier 1

196

Drug Status Notes

CERTAVITE-ANTIOXIDANT ORAL TABLET 18-400 MG-MCG

Tier 1

COMPETE ORAL TABLET Tier 1

COMPLETE 50 PLUS ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

COMPLETE MEN 50 PLUS ORAL TABLET 300-600-300 MCG

Tier 1

COMPLETE MEN ORAL TABLET 8 MG IRON- 200 MCG-600 MCG

Tier 1

COMPLETE MULTI 50+ ORAL TABLET 500-300-250 MCG

Tier 1

COMPLETE MULTI ORAL TABLET 18-500-300-250 MG-MCG-MCG-MCG

Tier 1

COMPLETE MULTIVITAMIN ORAL TABLET

Tier 1

COMPLETE MULTIVITAMIN-MINERAL ORAL TABLET 18-400 MG-MCG

Tier 1

COMPLETE MV ADULT 50 PLUS ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

COMPLETE ORAL TABLET 18-500-300-250 MG-MCG-MCG-MCG, 27-0.4 MG

Tier 1

COMPLETE PREMIUM VITAMIN ORAL TABLET

Tier 1

COMPLETE SENIOR ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

COMPLETE WOMEN ORAL TABLET 18-400 MG-MCG

Tier 1

CORVITE FREE ORAL TABLET 1.25-400-125-35 MG-MCG-MCG-MG

Tier 1

DAILY GUMMIES ORAL TABLET,CHEWABLE 200 MCG

Tier 1

DAILY MULTIPLE FOR MEN ORAL TABLET 0.4 MG

Tier 1

DAILY MULTIPLE FOR WOMEN ORAL TABLET 18 MG IRON-400 MCG-500 MG CA

Tier 1

DAILY MULTIPLE ORAL TABLET , 18-400 MG-MCG, 400-120 MCG-MG

Tier 1

DAILY MULTIPLE VITAMINS/IRON ORAL TABLET

Tier 1

DAILY MULTIVITAMIN ORAL CAPSULE 200-100-500 MCG

Tier 1

DAILY MULTI-VITAMIN ORAL TABLET Tier 1

DAILY MULTIVITAMIN WITH IRON ORAL TABLET 18-400 MG-MCG

Tier 1

DAILY MULTIVITAMIN-MINERALS ORAL TABLET

Tier 1

DAILY VALUE ORAL TABLET Tier 1

197

Drug Status Notes

DAILY VITAMIN FORMULA ORAL TABLET

Tier 1

DAILY VITAMIN FORMULA-IRON ORAL TABLET 18-400 MG-MCG

Tier 1

DAILY VITAMIN FORMULA-MINERALS ORAL TABLET

Tier 1

DAILY VITAMIN WITH IRON ORAL TABLET

Tier 1

DAILY VITES/IRON ORAL TABLET Tier 1

DAILY-VITE ORAL TABLET Tier 1

DECUBI VITE ORAL CAPSULE 400-50-500 MCG-MG-MG

Tier 1

DIABETES HEALTH FORMULA ORAL TABLET 500-250 MCG

Tier 1

ESSENTIA ORAL TABLET 18-400 MG-MCG

Tier 1

ESSENTIAL BALANCE WITH LUTEIN ORAL TABLET

Tier 1

ESSENTIAL DAILY ORAL TABLET 18-0.4 MG

Tier 1

ESSENTIAL MAN 50+ ORAL TABLET 0.4-2-250 MG-MG-MCG

Tier 1

ESSENTIAL MAN ORAL TABLET 0.4-2-250 MG-MG-MCG

Tier 1

ESSENTIAL WOMAN 50+ ORAL TABLET 0.4-250 MG-MCG

Tier 1

EYE HEALTH PLUS LUTEIN ORAL TABLET 1,000 UNIT-200 MG-60 UNIT-2 MG

Tier 1

FORTAVIT ORAL CAPSULE Tier 1

FREEDAVITE ORAL TABLET 1.8 MG IRON-400 MCG

Tier 1

HAIR VITAMINS ORAL TABLET Tier 1

HAIR, SKIN AND NAILS-ARGAN OIL ORAL CAPSULE 66.7-1,666.7 MCG

Tier 1

HAIR,SKIN AND NAILS ORAL TABLET , 1 MG IRON-66.7 MCG-1,000 MCG

Tier 1

HAIR,SKIN AND NAILS(FA-BIOTIN) ORAL TABLET 66.7-1,000 MCG

Tier 1

HAIR-SKIN-NAILS (PABA) ORAL CAPSULE 3-133 MG-MCG

Tier 1

ICAPS MV ORAL TABLET,DELAYED RELEASE (DR/EC) 100-1.66-0.83 MCG-MG-MG

Tier 1

K-PAX IMMUNE SUPPORT ORAL TABLET 2.25 MG IRON- 100 MCG

Tier 1

K-PAX ORAL CAPSULE 4.5 MG IRON-200 MCG, 9 MG IRON-400 MCG

Tier 1

MAXIMUM DAILY MULTIVITAMIN ORAL TABLET 18-0.4 MG

Tier 1

198

Drug Status Notes

MEGA MULTI FOR WOMEN ORAL TABLET 13.5-200-250 MG-MCG-MCG

Tier 1

MEGA MULTIPLE/CHELATED MINERAL ORAL TABLET

Tier 1

MEGA MULTIVITAMIN FOR MEN ORAL TABLET 200-175-250 MCG

Tier 1

MEN 50 PLUS ADVANCED ONE DAILY ORAL TABLET 400-20-370 MCG

Tier 1

MEN 50 PLUS MULTIVITAMIN ORAL TABLET 300-600-300 MCG

Tier 1

MEN UNDER 50 MULTIVITAMIN ORAL TABLET 8 MG IRON- 200 MCG-600 MCG

Tier 1

MEN'S 50 PLUS DAILY FORMULA ORAL TABLET 400-20-370 MCG

Tier 1

MEN'S 50 PLUS MULTIVITAMIN ORAL TABLET 400-20-370 MCG

Tier 1

MEN'S DAILY FORMULA ORAL TABLET 400-20-300 MCG

Tier 1

MEN'S DAILY GUMMIES ORAL TABLET,CHEWABLE 200 MCG

Tier 1

MEN'S DAILY MULTIVIT-MINERAL ORAL TABLET 0.4-600 MG-MCG

Tier 1

MEN'S DAILY ORAL CAPSULE 0.4-600 MG-MCG

Tier 1

MEN'S MULTIVITAMIN GUMMIES ORAL TABLET,CHEWABLE 200 MCG

Tier 1

MEN'S MULTIVITAMIN ORAL TABLET 400-20-300 MCG

Tier 1

MEN'S ONE DAILY ORAL TABLET , 400-20-300 MCG

Tier 1

MONOCAPS ORAL TABLET 14 MG IRON- 400 MCG

Tier 1

MULTI COMPLETE WITH IRON ORAL TABLET 18-400 MG-MCG

Tier 1

MULTI FOR HER ORAL TABLET 18 MG IRON-600 MCG-80 MCG

Tier 1

MULTI-DAY WITH IRON ORAL TABLET 18-400 MG-MCG

Tier 1

MULTI-DELYN WITH IRON ORAL LIQUID 10 MG IRON/5 ML

Tier 1

MULTILEX ORAL TABLET 15 MG IRON Tier 1

MULTILEX-T AND M ORAL TABLET 15 MG IRON

Tier 1

MULTIPLE VITAMIN, WOMENS ORAL TABLET

Tier 1

MULTIPLE VITAMIN-MINERALS ORAL TABLET

Tier 1

MULTIPLE VITAMINS ORAL TABLET Tier 1

multivitamin oral tablet (Daily Multi-Vitamin) Tier 1

199

Drug Status Notes

multivitamin with iron oral tablet (Daily Multiple Vitamins/Iron)

Tier 1

multivitamin with minerals oral tablet (Daily Multivitamin-Minerals)

Tier 1

MULTIVITAMIN WOMEN 50 PLUS ORAL TABLET 8 MG IRON-400 MCG-300 MCG

Tier 1

mv-min-folic acid-lutein oral tablet,chewable 200-137.5 mcg

(Adult Multivitamin (w-lutein))

Tier 1

MY-VITALIFE ORAL CAPSULE Tier 1

OCUTABS ORAL TABLET Tier 1

OMNICAP ORAL TABLET 0.4 MG Tier 1

ONCCOR ORAL TABLET 200-10-10 MCG

Tier 1

ONCE DAILY ORAL TABLET Tier 1

ONCOVITE ORAL TABLET Tier 1

ONE DAILY CALCIUM/IRON ORAL TABLET

Tier 1

ONE DAILY COMPLETE ORAL TABLET , 18-0.4 MG

Tier 1

ONE DAILY ENERGY ORAL TABLET , 9 MG IRON-400 MCG-200 MG

Tier 1

ONE DAILY ESSENTIAL ORAL TABLET , 0.4 MG, 400 MCG

Tier 1

ONE DAILY FOR MEN 50+ ADVANCED ORAL TABLET 400-600-120 MCG-MCG-MG

Tier 1

ONE DAILY FOR MEN ORAL TABLET 0.4-600 MG-MCG

Tier 1

ONE DAILY FOR WOMEN ORAL TABLET 18-0.4 MG

Tier 1

ONE DAILY HEALTHY WEIGHT ORAL TABLET 200-18-0.4 MG

Tier 1

ONE DAILY MAXIMUM ORAL TABLET 18-0.4 MG

Tier 1

ONE DAILY MEN'S 50 PLUS MEMORY ORAL TABLET 400-600-120 MCG-MCG-MG

Tier 1

ONE DAILY MEN'S 50 PLUS W-D3 ORAL TABLET 400-20-370 MCG

Tier 1

ONE DAILY MULTIVITAMIN ORAL TABLET , 400 MCG

Tier 1

ONE DAILY MULTIVIT-IRON(FOLIC) ORAL TABLET 18-400 MG-MCG

Tier 1

ONE DAILY ORAL TABLET 0.4-600 MG-MCG

Tier 1

ONE DAILY PLUS IRON ORAL TABLET 18-400 MG-MCG

Tier 1

ONE DAILY PLUS MINERALS ORAL TABLET

Tier 1

200

Drug Status Notes

ONE DAILY WITH IRON ORAL TABLET Tier 1

ONE DAILY WOMEN 50 PLUS ORAL TABLET 400-120 MCG-MG

Tier 1

ONE DAILY WOMEN 50 PLUS(VIT K) ORAL TABLET 400 MCG-500 MG CALCIUM-20 MCG

Tier 1

ONE DAILY WOMENS 50 PLUS ORAL TABLET 0.4 MG

Tier 1

ONE DAILY WOMEN'S HEALTH ORAL TABLET 18 MG IRON-400 MCG-450 MG CA

Tier 1

ONE DAILY WOMEN'S ORAL TABLET 18 MG IRON-400 MCG-450 MG CA, 27-0.4 MG

Tier 1

ONE-A-DAY CHOLESTEROL PLUS ORAL TABLET 0.4 MG

Tier 1

ONE-A-DAY ENERGY ORAL TABLET 9 MG IRON-400 MCG-200 MG

Tier 1

ONE-A-DAY ESSENTIAL ORAL TABLET

Tier 1

ONE-A-DAY MAXIMUM FORMULA ORAL TABLET

Tier 1

ONE-A-DAY MEN 50 PLUS (GINKGO) ORAL TABLET 400-300-120 MCG-MCG-MG

Tier 1

ONE-A-DAY MEN VITACRAVES ORAL TABLET,CHEWABLE 200 MCG

Tier 1

ONE-A-DAY MENOPAUSE FORMULA ORAL TABLET 400-60 MCG-MG

Tier 1

ONE-A-DAY MEN'S 50 PLUS ORAL TABLET 400-20-370 MCG

Tier 1

ONE-A-DAY MEN'S MULTIVITAMIN ORAL TABLET 400-20-300 MCG

Tier 1

ONE-A-DAY TEEN ADVANTAGE ORAL TABLET 18-400 MG-MCG, 9 MG IRON-400 MCG

Tier 1

ONE-A-DAY VITACRAVES IMMUNITY ORAL TABLET,CHEWABLE 200 MCG

Tier 1

ONE-A-DAY VITACRAVES OMEGA-3 ORAL TABLET,CHEWABLE 200-16 MCG-MG

Tier 1

ONE-A-DAY VITACRAVES ORAL TABLET,CHEWABLE 200 MCG

Tier 1

ONE-A-DAY WEIGHTSMART ORAL TABLET 200-18-0.4 MG

Tier 1

ONE-A-DAY WOMEN VITACRAVES ORAL TABLET,CHEWABLE 200 MCG

Tier 1

ONE-A-DAY WOMEN'S ACTIVE ORAL TABLET 18 MG IRON- 400 MCG-180 MG

Tier 1

201

Drug Status Notes

ONE-A-DAY WOMENS FORMULA ORAL TABLET 18 MG IRON-400 MCG-500 MG CA

Tier 1

ONE-A-DAY WOMEN'S HEALTHY SKIN ORAL TABLET 18 MG IRON-400 MCG-6 MG

Tier 1

ONE-A-DAY WOMEN'S PETITES ORAL TABLET 9 MG IRON-200 MCG

Tier 1

OPTISOURCE ORAL TABLET,CHEWABLE 9 MG IRON-200 MCG-40 MCG

Tier 1

OPURITY MULTIVITAMIN ORAL TABLET,CHEWABLE 30 MG IRON- 800 MCG

Tier 1

PARVLEX ORAL TABLET 29 MG IRON- 400 MCG

Tier 1

PROCERV HP ORAL TABLET 9 MG IRON- 300 MCG-50 MCG

Tier 1

PRORENAL QD ORAL CAPSULE 400-500 MCG-UNIT

Tier 1

PROSIGHT ORAL TABLET 5,000-60-30 UNIT-MG-UNIT

Tier 1

PROTECT CARDIO AF ORAL CAPSULE 0.5-30-60-90 MG

Tier 1

PROTECT PLUS SO ORAL CAPSULE 0.5-15 MG

Tier 1

QUINTABS ORAL TABLET 400 MCG Tier 1

QUINTABS-M IRON FREE ORAL TABLET 0.4 MG

Tier 1

QUINTABS-M ORAL TABLET 10 MG IRON-400 MCG

Tier 1

SENIOR TABS ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

SENTRY ORAL TABLET 18-400 MG-MCG

Tier 1

SENTRY SENIOR ORAL TABLET 0.4-300-250 MG-MCG-MCG, 500-300-250 MCG

Tier 1

SOLO ORAL TABLET 400-80 MCG Tier 1

SPECTRAVITE ADULT 50 PLUS ORAL TABLET 0.4-300-250 MG-MCG-MCG

Tier 1

SPECTRAVITE ADVANCED FORMULA ORAL TABLET 18-400 MG-MCG

Tier 1

SPECTRAVITE MEN'S ORAL TABLET 8 MG IRON- 200 MCG-600 MCG

Tier 1

SPECTRAVITE SENIOR ORAL TABLET 500-300-250 MCG

Tier 1

SPECTRAVITE ULTRA MEN 50+ ORAL TABLET 300-600-300 MCG

Tier 1

202

Drug Status Notes

SPECTRAVITE ULTRA MEN'S SR ORAL TABLET 300-600-300 MCG

Tier 1

SPECTRAVITE ULTRA WOMEN ORAL TABLET 18-400 MG-MCG

Tier 1

SPECTRAVITE ULTRA WOMEN'S SR ORAL TABLET 8 MG IRON-400 MCG-300 MCG

Tier 1

STRESS FORMULA 600 C ORAL TABLET

Tier 1

STRESS FORMULA ORAL TABLET Tier 1

STROVITE FORTE ORAL TABLET 10-1 MG

Tier 1

STROVITE ONE ORAL TABLET 1-1,000-15-5 MG-UNIT-MG-MG

Tier 1

SUNVITE ORAL TABLET 18 MG IRON-400 MCG-25 MCG

Tier 1

SUPER B COMPLEX-VITAMIN C ORAL TABLET

Tier 1

SUPER GINSENG MULTIVITAMIN ORAL CAPSULE

Tier 1

SUPER MULTIPLE - LOW IRON ORAL TABLET 400 MCG

Tier 1

SUPER MULTIPLE ORAL CAPSULE 0.4 MG

Tier 1

SUPER MULTIPLE ORAL TABLET Tier 1

SUPER MULTIVITAMIN ORAL TABLET Tier 1

SUPER THERA VITE M ORAL TABLET Tier 1

SUPERPLEX-T ORAL TABLET Tier 1

TAB-A-VITE MULTIVITAMIN W-IRON ORAL TABLET 18-400 MG-MCG

Tier 1

TAB-A-VITE ORAL TABLET Tier 1

TAB-A-VITE/IRON ORAL TABLET Tier 1

THERA M PLUS (FERROUS FUMARAT) ORAL TABLET 9 MG IRON-400 MCG

Tier 1

THERA ORAL TABLET , 400 MCG Tier 1

THERADEX M ORAL TABLET 27-0.4 MG

Tier 1

THERAGRAN-M PREMIER 50 PLUS ORAL TABLET 400-250-375 MCG

Tier 1

THERALOGIX COMPANION ORAL TABLET 0.4 MG

Tier 1

THERA-M ORAL TABLET , 27-0.4 MG, 9 MG IRON-400 MCG

Tier 1

THERAPEUTIC-M ORAL TABLET 9 MG IRON-400 MCG

Tier 1

THERAPEUTIC-M VITAMIN/MINERALS ORAL TABLET 27-0.4 MG

Tier 1

THERA-TABS M ORAL TABLET 27 MG IRON-400 MCG

Tier 1

203

Drug Status Notes

THERA-TABS ORAL TABLET Tier 1

THERATRUM COMPLETE WITH LUTEIN ORAL TABLET

Tier 1

THEREMS ORAL TABLET Tier 1

THEREMS-M ORAL TABLET 27-0.4 MG Tier 1

TOTAL B/C ORAL TABLET Tier 1

TRUEPLUS DIABETIC MULTIVITAMIN ORAL TABLET 500-10 MCG

Tier 1

ULTIMATE MEN'S COMPLETE 50+ ORAL TABLET 300-600-300 MCG

Tier 1

ULTIMATE WOMEN'S COMPLETE 50+ ORAL TABLET 8 MG IRON-400 MCG-300 MCG

Tier 1

ULTRA FREEDA ORAL TABLET 267 MCG, 6 MG IRON-267 MCG

Tier 1

UNICOMPLEX-M ORAL TABLET Tier 1

V-C FORTE ORAL CAPSULE 1 MG Tier 1

VIC-FORTE ORAL CAPSULE 1 MG Tier 1

VISION ORAL TABLET Tier 1

VITALEE ORAL TABLET 0.4 MG Tier 1

VITAMINS A-D-E SELENIUM ORAL TABLET 10,000-400 UNIT-UNIT

Tier 1

VITAMINS AND MINERALS ORAL TABLET

Tier 1

VITAMINS FOR HAIR ORAL TABLET Tier 1

WOMEN'S 50 PLUS DAILY FORMULA ORAL TABLET 400 MCG-500 MG CALCIUM-20 MCG

Tier 1

WOMEN'S 50 PLUS MULTIVITAMIN ORAL TABLET 400 MCG-500 MG CALCIUM-20 MCG

Tier 1

WOMEN'S COMPLEX ORAL TABLET Tier 1

WOMEN'S DAILY CAPLET ORAL TABLET 27 MG IRON-400 MCG

Tier 1

WOMEN'S DAILY FORMULA ORAL TABLET 18 MG IRON-400 MCG-500 MG CA, 27-0.4 MG

Tier 1

WOMENS DAILY GUMMIES ORAL TABLET,CHEWABLE 200 MCG

Tier 1

WOMEN'S MULTIVITAMIN GUMMIES ORAL TABLET,CHEWABLE 200 MCG

Tier 1

WOMEN'S ONE DAILY ORAL TABLET 18 MG IRON-400 MCG-500 MG CA

Tier 1

YELETS ORAL TABLET 18-400 MG-MCG

Tier 1

Pediatric Vitamin PreparationsMULTI-VIT WITH FLUORIDE-IRON ORAL DROPS 0.25MG FLUORIDE -10 MG IRON/ML


204

Drug Status Notes

MULTI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG/ML, 0.5 MG/ML


MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG


MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG


MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG


MVC-FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG


PEDIA POLY-VITE ORAL DROPS 750 UNIT-35 MG- 400 UNIT/ML

Tier 1

PEDIA TRI-VITE ORAL DROPS 750 UNIT-35 MG -400 UNIT/ML


POLY-VI-SOL ORAL DROPS 750-35-400 UNIT-MG-UNIT/ML

Tier 1

TRI-VI-SOL ORAL DROPS 750 UNIT-35 MG -400 UNIT/ML


TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML


TRI-VITE WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML


VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML


Prenatal Vitamin PreparationsCLASSIC PRENATAL ORAL TABLET 28 MG IRON- 800 MCG

Tier 1 Female Only; QL (1 EA per 1 day); Age (Min 12 Years and Max 55 Years)

COMPLETENATE ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG


KPN ORAL TABLET Tier 1 Female Only; QL (1 EA per 1 day); Age (Min 12 Years and Max 55 Years)

M-NATAL PLUS ORAL TABLET 27 MG IRON- 1 MG


MYNATAL ADVANCE ORAL TABLET 90-1-50 MG


205

Drug Status Notes

MYNATAL ORAL TABLET 90-1-50 MG Tier 1 Female Only; QL (1 EA per 1 day); Age (Min 12 Years and Max 55 Years)

MYNATAL PLUS ORAL TABLET 65 MG IRON- 1 MG


MYNATAL-Z ORAL TABLET 65 MG IRON- 1 MG


MYNATE 90 PLUS ORAL TABLET EXTENDED RELEASE 90 MG IRON-1 MG


NESTABS DHA ORAL COMBO PACK 32 MG IRON- 1,000 MCG-230MG


NESTABS ORAL TABLET 32-1,000 MG-MCG


NEWGEN ORAL TABLET 32-1,000 MG-MCG


NIVA-PLUS ORAL TABLET 27 MG IRON- 1 MG


OBSTETRIX DHA ORAL COMBO PACK,TABLET AND CAP,DR 29 MG IRON-1 MG -50 MG


OBSTETRIX EC ORAL TABLET,DELAYED RELEASE (DR/EC) 29 MG IRON-1 MG -50 MG


O-CAL F.A. ORAL TABLET 27 MG IRON- 1 MG


PERRY PRENATAL ORAL CAPSULE 13.5-0.4 MG


PNV 29-1 ORAL TABLET 29 MG IRON- 1 MG


pnv cmb#95-ferrous fumarate-fa oral tablet 28 mg iron- 800 mcg

(Prenatal) Tier 1 Female Only; QL (1 EA per 1 day); Age (Min 12 Years and Max 55 Years)

PRENATABS FA ORAL TABLET 29-1 MG


PRENATABS RX ORAL TABLET 29 MG IRON- 1 MG


PRENATAL 19 (WITH DOCUSATE) ORAL TABLET 29 MG IRON- 1 MG-25 MG


206

Drug Status Notes

PRENATAL 19 ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG


PRENATAL COMPLETE ORAL TABLET 14 MG IRON- 400 MCG


PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG


PRENATAL GUMMY ORAL TABLET,CHEWABLE 400 MCG-35 MG -25 MG-5 MG


PRENATAL LOW IRON ORAL TABLET 27 MG IRON- 1 MG


PRENATAL ONE DAILY ORAL TABLET 27 MG IRON- 800 MCG


PRENATAL ORAL TABLET 28 MG IRON- 800 MCG


PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 27 MG IRON- 1 MG


PRENATAL PLUS ORAL TABLET 29 MG IRON- 1 MG


PRENATAL TABLET ORAL TABLET 28 MG IRON- 800 MCG


PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG


PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET 27 MG IRON- 1 MG


PRENATAL VITAMIN WITH MINERALS ORAL TABLET 28 MG IRON- 800 MCG


prenatal vit-iron fum-folic ac oral tablet28 mg iron- 800 mcg

(Prenatal Tablet) Tier 1 Female Only; QL (1 EA per 1 day); Age (Min 12 Years and Max 55 Years)

prenatal vits96-iron fum-folic oral tablet27 mg iron- 800 mcg


PRENATAL-U ORAL CAPSULE 106.5-1 MG


PREPLUS ORAL TABLET 27 MG IRON- 1 MG


207

Drug Status Notes

PRETAB ORAL TABLET 29-1 MG Tier 1 Female Only; QL (1 EA per 1 day); Age (Min 12 Years and Max 55 Years)

THERANATAL ORAL TABLET 27 MG IRON- 1 MG


THRIVITE RX ORAL TABLET 29 MG IRON- 1 MG


THRIVITE-19 ORAL TABLET 29 MG IRON-1 MG -25 MG


TRICARE ORAL TABLET 27 MG IRON- 1 MG


TRINATAL RX 1 ORAL TABLET 60 MG IRON-1 MG


TRINATE ORAL TABLET 28 MG IRON- 1 MG


VINATE GT ORAL TABLET 90-1-50 MG Tier 1 Female Only; QL (1 EA per 1 day); Age (Min 12 Years and Max 55 Years)

VINATE M ORAL TABLET 27 MG IRON-1 MG


VINATE ONE ORAL TABLET 60 MG IRON-1 MG


VINATE ULTRA ORAL TABLET 90-1-50 MG


Vitamin B PreparationsALBA-LYBE ORAL LIQUID Tier 1

APETEX ORAL LIQUID 790 MG/15 ML Tier 1

APETIGEN ORAL LIQUID 790 MG/15 ML

Tier 1

ARKALIOX ORAL TABLET 200 MG Tier 1

B COMPLEX 1 (WITH FOLIC ACID) ORAL TABLET 0.4 MG

Tier 1

B COMPLEX 100 INJECTION SOLUTION 100-2-100-2-2 MG/ML

Tier 1

B COMPLEX 100 ORAL TABLET 0.4 MG

Tier 1

B COMPLEX SUBLINGUAL LIQUID 1.7-20-2-1.2 MG/ML

Tier 1

B COMPLEX W-VIT C ORAL TABLET 18-10-45-5-250 MG

Tier 1

B COMPLEX-VITAMIN B12 ORAL TABLET

Tier 1

208

Drug Status Notes

b complex-vitamin c-folic acid oral tablet400 mcg

Tier 1

b complex-vitamin c-folic acid oral tablet extended release 400 mcg

Tier 1

B-100 COMPLEX ORAL TABLET EXTENDED RELEASE 100 MG

Tier 1

BALANCE B-100 (FOLIC ACID) ORAL TABLET 0.4 MG

Tier 1

BALANCE B-50 (WITH FOLIC ACID) ORAL TABLET 0.4 MG

Tier 1

BALANCED B-100 COMPLEX ORAL TABLET EXTENDED RELEASE 100 MG

Tier 1

BALANCED B-100 ORAL TABLET 0.4 MG

Tier 1

BALANCED B-100 ORAL TABLET EXTENDED RELEASE 400 MCG

Tier 1

BALANCED B-50 ORAL TABLET Tier 1

B-COMPLEX ORAL TABLET Tier 1

B-COMPLEX WITH B-12 ORAL TABLET 2.5 MG-2.5 MG- 5 MG-100 MCG

Tier 1

B-COMPLEX WITH VITAMIN C ORAL TABLET 400-500 MCG-MG

Tier 1

BIOPETIT ORAL LIQUID 790 MG/15 ML Tier 1

biotin oral capsule 1 mg Tier 1

biotin oral capsule 10,000 mcg (Mega Biotin) Tier 1

biotin oral capsule 2,500 mcg (Hard Nails) Tier 1

biotin oral capsule 5 mg (Meribin) Tier 1

biotin oral tablet 1 mg, 10 mg, 300 mcg, 5 mg, 800 mcg

Tier 1

BREWER'S YEAST ORAL TABLET 680 MG

Tier 1

CEREFOLIN ORAL TABLET 6-5-50-1 MG

Tier 1

COMPLEX B-100 ORAL TABLET EXTENDED RELEASE , 400 MCG

Tier 1

COMPLEX B-50 ORAL TABLET EXTENDED RELEASE 115-50-0.4 MG

Tier 1

CYTO B7 ORAL LIQUID 5 MG/ML Tier 1

DIALYVITE 3000 ORAL TABLET 3-70-15 MG-MCG-MG

Tier 1

DIALYVITE 5000 ORAL TABLET 5 MG Tier 1

DIALYVITE 800 ORAL TABLET 0.8 MG Tier 1

DIALYVITE 800 PLUS D ORAL TABLET,CHEWABLE 800 MCG- 2,000 UNIT

Tier 1

DIALYVITE 800 WITH ZINC 15 ORAL TABLET 0.8-15 MG

Tier 1

DIALYVITE 800 WITH ZINC 50 ORAL TABLET 0.8-50 MG

Tier 1

209

Drug Status Notes

DIALYVITE 800-ULTRA D ORAL TABLET 0.8-2,000 MG-UNIT

Tier 1

DIALYVITE ORAL TABLET 1-100-300-50 MG-MG-MCG-MG, 100-1 MG

Tier 1

DIALYVITE SUPREME D ORAL TABLET 3-2,000 MG-UNIT

Tier 1

ELFOLATE PLUS ORAL TABLET 3-35-2 MG

Tier 1

ENDUR-B COMPLEX ORAL TABLET EXTENDED RELEASE 400 MCG

Tier 1

FABB ORAL TABLET 2.2-25-1 MG Tier 1

FOLBEE ORAL TABLET 2.5-25-1 MG Tier 1

FOLBEE PLUS ORAL TABLET 5 MG, 5-1.5-25 MG

Tier 1

FOLBIC ORAL TABLET 2.5-25-2 MG Tier 1

FOLBIC RF ORAL TABLET 2-1.13-25 MG

Tier 1

FOLINIC-PLUS ORAL TABLET 4-50-2 MG

Tier 1

FOLPLEX 2.2 ORAL TABLET 2.2-25-0.5 MG

Tier 1

FOLTABS 800 ORAL TABLET 0.8-10-115 MG-MG-MCG

Tier 1

FOLTANX ORAL TABLET 3-35-2 MG Tier 1

FOLTX ORAL TABLET 2-1.13-25 MG Tier 1

FULL SPECTRUM B-VITAMIN C ORAL TABLET 0.8 MG

Tier 1

HARD NAILS ORAL CAPSULE 2,500 MCG

Tier 1

HOMOCYSTEINE FORMULA ORAL TABLET 0.8-50-100 MG-MG-MCG

Tier 1

KOBEE ORAL TABLET 0.4 MG Tier 1

lmefol ca-acetyl-meb12-algal oral tablet6 mg-600 mg- 2 mg-90.314 mg

(Metafolbic Plus RF) Tier 1

L-METHYL-B6-B12 ORAL TABLET 3-35-2 MG

Tier 1

L-METHYL-MC ORAL TABLET 6-5-50-1 MG

Tier 1

MEDTYCHOLL-B COMPLEX-LIVER ORAL CAPSULE

Tier 1

MEGA BIOTIN ORAL CAPSULE 10,000 MCG

Tier 1

MERIBIN ORAL CAPSULE 5 MG Tier 1

METAFOLBIC ORAL TABLET 6-5-50-1 MG

Tier 1

METAFOLBIC PLUS RF ORAL TABLET 6 MG-600 MG- 2 MG-90.314 MG

Tier 1

MYNEPHROCAPS ORAL CAPSULE 1 MG

Tier 1

MYNEPHRON ORAL CAPSULE 1 MG Tier 1

210

Drug Status Notes

NATURAL B-100 COMPLEX ORAL TABLET 100 MG

Tier 1

NEPHPLEX RX ORAL TABLET 1-60-300-12.5 MG-MG-MCG-MG

Tier 1

NEPHRONEX ORAL LIQUID 900 MCG/5 ML

Tier 1

NEPHRONEX-SL ORAL TABLET,DISINTEGRATING 800-2,000 MCG-UNIT

Tier 1

NEPHRO-VITE ORAL TABLET 0.8 MG Tier 1

NIVA-FOL ORAL TABLET 2.5-25-2 MG Tier 1

PODIAPN ORAL CAPSULE 35-5-2-300 MG

Tier 1

PRORENAL ORAL TABLET 8 MG IRON-800 MCG-1,000 UNIT

Tier 1

QUIN B STRONG ORAL TABLET 500-400-15 MG-MCG-MG

Tier 1

RENAL CAPS ORAL CAPSULE 1 MG Tier 1

RENAL VITAMIN ORAL TABLET 0.8 MG

Tier 1

RENAL-VITE ORAL TABLET 0.8 MG Tier 1

RENA-VITE ORAL TABLET 0.8 MG Tier 1

RENA-VITE RX ORAL TABLET 1-60-300 MG-MG-MCG

Tier 1

RENO CAPS ORAL CAPSULE 1 MG Tier 1

STRESS B PLUS ZINC ORAL TABLET Tier 1

SUPER B MAXI COMPLEX ORAL TABLET 0.4 MG

Tier 1

SUPER B-50 COMPLEX ORAL CAPSULE

Tier 1

SUPER QUINTS B-50 ORAL TABLET Tier 1

SUPER QUINTS ORAL TABLET 0.4 MG Tier 1

SUPERVITE ORAL LIQUID 1,000-75-1 MG-MG-MG/15 ML

Tier 1

TRIPHROCAPS ORAL CAPSULE 1 MG Tier 1

ULTRA B-100 COMPLEX ORAL TABLET EXTENDED RELEASE

Tier 1

VIRT-CAPS ORAL CAPSULE 1 MG Tier 1

VIRT-GARD ORAL TABLET 2.2-25-1 MG

Tier 1

VIRT-VITE ORAL TABLET 2.5-25-1 MG Tier 1

VIRT-VITE PLUS ORAL TABLET 5 MG Tier 1

VITAL-D RX ORAL TABLET 1,750-60-1-12.5 UNIT-MG-MG-MG

Tier 1

vitamin b complex oral capsule (Super B-50 Complex) Tier 1

vitamin b complex oral tablet (B Complex-Vitamin B12) Tier 1

vitamin b complex-folic acid oral tablet0.4 mg

(B Complex 1 (with folic acid))

Tier 1

211

Drug Status Notes

vitamin b complex-folic acid oral tablet extended release 400 mcg

(Balanced B-100) Tier 1

VITAMINS B COMPLEX ORAL CAPSULE

Tier 1

VITAMINS B COMPLEX ORAL TABLET , 500 MG-400 MCG- 18 MG IRON

Tier 1

VITA-RESPA ORAL TABLET 2.2-25-1.3 MG

Tier 1

VP-VITE RX ORAL TABLET 1-60-300 MG-MG-MCG

Tier 1

WESTAB MAX ORAL TABLET 2.5-25-2 MG

Tier 1

WESTAB ONE ORAL TABLET 2.5-25-1 MG

Tier 1

WEST-VITE WITH FOLIC ACID ORAL TABLET 0.8 MG

Tier 1

Vitamin B12 Preparationscyanocobalamin (vitamin b-12) injection solution 1,000 mcg/ml

Tier 1

Vitamin D Preparationscalcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) Tier 1 QL (4 EA per 1 day)

calcitriol oral solution 1 mcg/ml (Rocaltrol) Tier 1 Age (Max 12 Years)

cholecalciferol (vitamin d3) oral capsule1,250 mcg (50,000 unit)

(D3-50 Cholecalciferol) Tier 1

cholecalciferol (vitamin d3) oral capsule10 mcg (400 unit), 25 mcg (1,000 unit)

(Vitamin D3) Tier 1

cholecalciferol (vitamin d3) oral capsule125 mcg (5,000 unit)

(Dialyvite Vitamin D) Tier 1

cholecalciferol (vitamin d3) oral capsule50 mcg (2,000 unit)

(D3-2000) Tier 1

cholecalciferol (vitamin d3) oral drops 10 mcg/ml (400 unit/ml)

(D-Vi-Sol) Tier 1

cholecalciferol (vitamin d3) oral tablet 10 mcg (400 unit)

(Delta D3) Tier 1

cholecalciferol (vitamin d3) oral tablet125 mcg (5,000 unit), 25 mcg (1,000 unit)

(Vitamin D3) Tier 1

cholecalciferol (vitamin d3) oral tablet 50 mcg (2,000 unit)

(D3 DOTS) Tier 1

cholecalciferol (vitamin d3) oral tablet,chewable 10 mcg (400 unit)

(Vitamin D3) Tier 1

D3 DOTS ORAL TABLET 50 MCG (2,000 UNIT)

Tier 1

D3-2000 ORAL CAPSULE 50 MCG (2,000 UNIT)

Tier 1

D3-50 CHOLECALCIFEROL ORAL CAPSULE 1,250 MCG (50,000 UNIT)

Tier 1

DECARA ORAL CAPSULE 1,250 MCG (50,000 UNIT)

Tier 1

212

Drug Status Notes

DELTA D3 ORAL TABLET 10 MCG (400 UNIT)

Tier 1

DIALYVITE VITAMIN D ORAL CAPSULE 125 MCG (5,000 UNIT)

Tier 1

DIALYVITE VITAMIN D3 MAX ORAL TABLET 1,250 MCG (50,000 UNIT)

Tier 1

D-VI-SOL ORAL DROPS 10 MCG/ML (400 UNIT/ML)

Tier 1

ergocalciferol (vitamin d2) oral capsule1,250 mcg (50,000 unit)

(Vitamin D2) Tier 1

OPTIMAL D3 ORAL CAPSULE 1,250 MCG (50,000 UNIT)

Tier 1

PEDIA D-VITE ORAL DROPS 10 MCG/ML (400 UNIT/ML)

Tier 1

THERA-D ORAL TABLET 50 MCG (2,000 UNIT)

Tier 1

VITAMIN D2 ORAL CAPSULE 1,250 MCG (50,000 UNIT)

Tier 1

VITAMIN D3 ORAL CAPSULE 10 MCG (400 UNIT), 25 MCG (1,000 UNIT), 50 MCG (2,000 UNIT)

Tier 1

VITAMIN D3 ORAL TABLET 10 MCG (400 UNIT), 125 MCG (5,000 UNIT), 25 MCG (1,000 UNIT), 50 MCG (2,000 UNIT)

Tier 1

VITAMIN D3 ORAL TABLET,CHEWABLE 10 MCG (400 UNIT)

Tier 1

WEEKLY-D ORAL CAPSULE 1,250 MCG (50,000 UNIT)

Tier 1

Vitamin E PreparationsAQUA-E ORAL EMULSION 30-2 MG/ML Tier 1

E-200 ORAL CAPSULE 200 UNIT Tier 1

SOLUVITA-E ORAL DROPS 22.5 MG (50 UNIT)/ML

Tier 1

vitamin e (dl, acetate) oral capsule 1,000 unit, 400 unit

Tier 1

vitamin e (dl, acetate) oral capsule 200 unit

(E-200) Tier 1

vitamin e (dl, acetate) oral drops 100 unit/0.25 ml

Tier 1

vitamin e (dl, acetate) oral drops 22.5 mg (50 unit)/ml

(SoluVita-E) Tier 1 Age (Max 12 Years)

vitamin e acetate oral capsule 200 unit Tier 1

vitamin e mixed oral capsule 1,000 unit, 400 unit

Tier 1

vitamin e mixed oral tablet 100 unit, 200 unit, 400 unit

Tier 1

vitamin e oral capsule 1,000 unit, 100 unit, 200 unit, 400 unit, 600 unit

Tier 1

213

Drug Status Notes

vitamin e oral drops 100 unit/0.25 ml Tier 1

vitamin e oral liquid 1,150 unit/1.25 ml Tier 1

vitamin e succinate oral tablet 100 unit, 200 unit, 400 unit

Tier 1

214

Index

1ST TIER UNIFINE PENTIPS....... 1511ST TIER UNIFINE PENTIPS PLUS............................................. 1511ST TIER UNILET COMFORTOUCH.......................... 12524 HOUR ALLERGY RELIEF............624 HOUR NASAL ALLERGY.............624HOUR ALLERGY...........................53-DAY VAGINAL............................1888 HOUR PAIN RELIEVER.............1588HR MUSCLE ACHES-PAIN.........158A THRU Z...................................... 195A THRU Z ADVANCED FORMULA....................................................... 195A THRU Z MEN'S ULTIMATE....... 195A THRU Z SELECT....................... 195A THRU Z SELECT 50PLUS FORMULA..................................... 195A THRU Z SELECT WOMEN'S.....195abacavir ................................. 104, 105abacavir-lamivudine .......................102abacavir-lamivudine-zidovudine .... 102ABC PLUS.....................................195ABILIFY........................................... 26ABILIFY MAINTENA........................26ABILIFY MYCITE.............................26abiraterone .....................................139ABOUTTIME PEN NEEDLE.......... 151ABREVA.......................................... 65acamprosate ....................................23acarbose ..........................................71ACCU-CHEK FASTCLIX LANCET DRUM............................................125ACCU-CHEK MULTICLIX LANCET....................................................... 125ACCU-CHEK SAFE-T-PRO...........125ACCU-CHEK SAFE-T-PRO PLUS 125ACCU-CHEK SOFTCLIX LANCETS...................................... 125ACE AEROSOL CLOUD ENHANCER.....................................11acebutolol ........................................ 46acetaminophen .............................. 158ACETAMINOPHEN EXTRA STRENGTH...................................158

ACETAMINOPHEN PAIN RELIEF 158acetaminophen-codeine ................ 163acetazolamide ..................................81acetic acid ........................................74acetylcysteine ................................ 156ACID CONTROL (RANITIDINE)....186ACID CONTROLLER.....................186ACID GONE ANTACID..................183ACID REDUCER (CIMETIDINE)... 186ACID REDUCER (FAMOTIDINE)..186ACID REDUCER (OMEPRAZOLE)....................................................... 186ACID REDUCER (RANITIDINE)....186acitretin ............................................ 70ACNE CONTROL CLEANSER........68ACNE FOAMING WASH................. 68ACNE MEDICATION....................... 68ACNE TREATMENT (BENZOYL PEROX)...........................................68ACNE-CLEAR..................................68ACTEMRA..................................... 114ACTEMRA ACTPEN......................114ACTHAR..........................................76ACTHREL........................................76ACTICAL........................................189ACTI-LANCE LANCETS................125ACTIVE-PAC................................. 166acyclovir .........................................101ADASUVE........................................27ADCIRCA.........................................49ADDAPRIN.................................... 114ADDERALL......................................21ADDERALL XR................................21adefovir ..........................................110ADEMPAS....................................... 48ADHANSIA XR................................ 41ADMELOG SOLOSTAR U-100 INSULIN...........................................73ADMELOG U-100 INSULIN LISPRO............................................73ADULT ASPIRIN REGIMEN............92ADULT LOW DOSE ASPIRIN......... 92ADULT MULTIVITAMIN (W-LUTEIN).........................................195

ADULT MULTIVITAMIN GUMMIES....................................................... 195ADULT ONE DAILY GUMMIES.....195ADULT ONE DAILY MULTIVITAMIN............................. 195ADULTS 50 PLUS......................... 195ADVANCED ANTACID-ANTIGAS.183ADVANCED EXFOLIATING CLEANSER..................................... 68ADVANCED TRAVEL LANCETS.. 125ADVATE.......................................... 85ADVOCATE LANCET....................125ADVOCATE PEN NEEDLE........... 151ADVOCATE SYRINGES............... 130ADYNOVATE...................................85ADZENYS ER..................................21ADZENYS XR-ODT.........................21AEROCHAMBER MINI.................... 11AEROCHAMBER MV...................... 11AEROCHAMBER PLUS FLOW-VU.11AEROCHAMBER PLUS FLOW-VU,L MSK........................................11AEROCHAMBER PLUS FLOW-VU,M MSK.......................................11AEROCHAMBER PLUS FLOW-VU,S MSK........................................11AEROCHAMBER PLUS Z STAT.....11AEROCHAMBER PLUS Z STAT LG MSK........................................... 11AEROCHAMBER PLUS Z STAT MD MSK.......................................... 11AEROCHAMBER PLUS Z STAT SM MSK...........................................11AEROCHAMBER WITH FLOWSIGNAL................................. 11AEROCHAMBER Z-STAT PLUS-FLW SG...........................................11AEROTRACH PLUS........................11AF.................................................... 63AFINITOR......................................140AFINITOR DISPERZ..................... 140AFIRMELLE.....................................53AFLURIA QD 2019-20(3YR UP)(PF)............................................94

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AFLURIA QD 2019-20(6-35MO)(PF).......................................94AFLURIA QUAD 2019-20(6MO UP)...................................................94AFSTYLA.........................................85AFTERA...........................................53AIMOVIG AUTOINJECTOR.......... 161AIMSCO LATEX CONDOM...........147AIRZONE PEAK FLOW METER..... 11AK-POLY-BAC.................................80ALA-CORT.......................................65ALAWAY..........................................79ALBA-LYBE................................... 208ALBUKED-25...................................90ALBUKED-5.....................................90albumin, human 20 % ......................90albumin, human 25 % ......................90albumin, human 5 % ........................90ALBUMINAR 25 %...........................90ALBUMINEX....................................90ALBURX (HUMAN) 25 %.................90ALBURX (HUMAN) 5 %...................90ALBUTEIN 25 %..............................91ALBUTEIN 5 %................................91albuterol sulfate ................................. 9ALCAINE......................................... 80ALCOHOL PADS.............................67ALCOHOL PREP PADS..................67alcohol swabs .................................. 67ALCOHOL WIPES...........................67ALDURAZYME.............................. 150ALECENSA....................................141alendronate ......................................77ALER-CAP.........................................3ALEVE........................................... 114alfuzosin .........................................187ALGAL OMEGA-3 DHA...................50ALIQOPA.......................................141aliskiren ............................................49ALKERAN......................................139ALL DAY ALLERGY (CETIRIZINE)...5ALL DAY PAIN RELIEF.................114ALL DAY RELIEF.......................... 114ALLER-CHLOR..................................3ALLERCLEAR................................... 5ALLER-EASE.....................................5ALLER-FEX....................................... 5ALLER-FLO....................................... 6ALLER-G-TIME..................................3

ALLERGY.......................................... 3ALLERGY (CHLORPHENIRAMINE)...................3ALLERGY (DIPHENHYDRAMINE)....3ALLERGY 4-HOUR........................... 3ALLERGY EYE (KETOTIFEN)........ 79ALLERGY EYE (NAPHAZOLINE-PHEN)..............................................80ALLERGY MEDICATION...................3ALLERGY MEDICINE........................3ALLERGY RELIEF (CETIRIZINE)..... 5ALLERGY RELIEF (CLEMASTINE).. 3ALLERGY RELIEF (FEXOFENADINE)............................ 5ALLERGY RELIEF (FLUTICASONE)............................... 7ALLERGY RELIEF (LORATADINE).. 5ALLERGY RELIEF(CHLORPHENIRAMN)..........3ALLERGY RELIEF(DIPHENHYDRAMIN)........... 3ALLERGY-TIME................................ 3ALLER-TEC.......................................5allopurinol ........................................ 84ALMACONE...................................183ALMACONE-2............................... 183alogliptin ...........................................71alogliptin-metformin ......................... 70alogliptin-pioglitazone ...................... 70ALOPHEN (BISACODYL)..............119ALORA.............................................93ALPHANATE................................... 85ALPHANINE SD.............................. 88alprazolam ....................................... 23ALPRAZOLAM INTENSOL..............23ALPROLIX....................................... 88ALTACHLORE.................................81ALTAMIST..................................... 155ALTAVERA (28)...............................53ALTERNATE SITE LANCET......... 125aluminum hydroxide gel .................183alum-mag hydroxide-simeth .......... 183ALUNBRIG.................................... 141ALYACEN 1/35 (28).........................53ALYACEN 7/7/7 (28)........................53ALYQ............................................... 49AMABELZ........................................93amantadine hcl .............................. 165AMBIEN...........................................36

AMBIEN CR.....................................36ambrisentan .....................................49AMETHYST (28)..............................53AMICAR...........................................84amiloride .......................................... 48amiloride-hydrochlorothiazide ..........48aminocaproic acid ............................84amiodarone ......................................43AMITIZA.........................................120amitriptyline ......................................19amitriptyline-chlordiazepoxide ......... 19amlodipine ....................................... 47amlodipine-benazepril ......................44amlodipine-valsartan ........................45ammonia aromatic ........................... 33ammonium lactate ........................... 68AMMONUL.................................... 117amoxapine ....................................... 20amoxicillin ........................................ 97amoxicillin-pot clavulanate ...............98amphetamine ...................................21amphetamine sulfate ....................... 21ampicillin ..........................................98AMPYRA........................................147AMYTAL.......................................... 32ANAFRANIL.....................................20anagrelide ........................................92anastrozole .................................... 140ANTABUSE..................................... 23ANTACID.......................................183ANTACID (CALCIUM CARBONATE)............................... 183ANTACID ANTI-GAS.....................183ANTACID CALCIUM......................183ANTACID EXT STR (CALCIUM CARB)............................................183ANTACID EXTRA-STRENGTH..... 183ANTACID LIQUID..........................183ANTACID M...................................183ANTACID MAXIMUM STRENGTH 183ANTACID PLUS ANTI-GAS...........183ANTACID REGULAR STRENGTH 184ANTACID ULTRA STRENGTH..... 184ANTACID-ANTIGAS......................184ANTACID-SIMETHICONE.............184ANTIBIOTIC (BACITRACIN ZINC)..62ANTIBIOTIC (NEOMY-BACIT-POLYM)...........................................62ANTI-DIARRHEAL.........................118

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ANTI-DIARRHEAL (LOPERAMIDE).............................118ANTIFUNGAL (CLOTRIMAZOLE)...63ANTIFUNGAL (TERBINAFINE).......63ANTIFUNGAL (TOLNAFTATE)....... 63ANTIFUNGAL CREAM (MICONAZOLE)...............................63ANTIFUNGAL RINGWORM............ 63ANTIFUNGAL SPRAY.....................63ANTI-GAS......................................179ANTI-ITCH (HC).............................. 65ANUCORT-HC...............................117APETEX.........................................208APETIGEN.....................................208APETIGEN PLUS.......................... 192APLENZIN....................................... 14apraclonidine ................................... 81APRI................................................ 53APRISO......................................... 116APTENSIO XR.................................41APTIOM.........................................167APTIVUS....................................... 102APTIVUS (WITH VITAMIN E)........102AQUADEKS...................................195AQUADEKS PEDIATRIC...............195AQUA-E.........................................213ARANELLE (28)...............................53ARANESP (IN POLYSORBATE)................................................... 88, 89ARCALYST....................................111aripiprazole ...................................... 27ARISTADA.......................................27ARISTADA INITIO........................... 27ARKALIOX.....................................208armodafinil ....................................... 34ARMONAIR RESPICLICK............... 10ARMOUR THYROID........................78ARTHRITIS PAIN RELIEF (ACETAM)..................................... 158ARTHRITIS PAIN RELIEVER........158ARTIFICIAL TEARS (PF)................ 82ARTIFICIAL TEARS (POLYVIN ALC).................................................82ARTIFICIAL TEARS(DEXT70-HYPRO)...........................................82ARTIFICIAL TEARS(GLYCERIN-PEG)................................................82ARTIFICIAL TEARS(PVALCH-POVID)............................................ 82

ASCOMP WITH CODEINE............163ASPERCREME (LIDOCAINE).........69ASPIR-81.........................................92aspirin ...................................... 92, 157ASPIRIN CHILDRENS.....................92ASPIRIN LOW DOSE......................92aspirin,buffd-calcium carb-mag ......157ASPIR-LOW.....................................92ASPIR-TRIN.................................. 157ASSURE HAEMOLANCE PLUS... 126ASSURE ID INSULIN SAFETY..... 130ASSURE ID PEN NEEDLE............151ASSURE LANCE...........................126ASSURE LANCE PLUS.................126ASTHMA CHECK METER...............11ATABEX DHA 200...........................50atazanavir ...................................... 107atenolol ............................................ 46atenolol-chlorthalidone .....................47ATHENOL......................................158ATHLETE'S FOOT (CLOTRIMAZOLE).......................... 63ATHLETE'S FOOT (TERBINAFINE)...............................63ATHLETE'S FOOT (TOLNAFTATE)...............................63ATHLETIC FOOT CREAM.............. 63ATIVAN......................................23, 35atomoxetine ..................................... 43atorvastatin ...................................... 49atovaquone ....................................101ATRIPLA........................................108atropine ............................................82ATROVENT HFA...............................8ATRYN.............................................91AUBAGIO...................................... 146AUBRA............................................ 53AUBRA EQ...................................... 53AUROVELA 1.5/30 (21)...................53AUROVELA 1/20 (21)......................53AUROVELA 24 FE...........................54AUROVELA FE 1.5/30 (28)............. 54AUROVELA FE 1-20 (28)................54AUVI-Q.......................................... 138AVIANE............................................54AVITA.............................................. 61AVONEX........................................146AYR SALINE..................................155AYUNA............................................ 54

AYVAKIT........................................141azathioprine ..................................... 95azelastine .....................................6, 79azithromycin .....................................97AZURETTE (28).............................. 54B COMPLEX..................................208B COMPLEX 1 (WITH FOLIC ACID).............................................208B COMPLEX 100...........................208B COMPLEX PLUS VITAMIN C.... 195B COMPLEX W-VIT C...................208B COMPLEX-VITAMIN B12...........208b complex-vitamin c-folic acid ........209B-100 COMPLEX...........................209BABY AYR SALINE.......................155bacitracin ................................... 62, 80bacitracin zinc ..................................62bacitracin-polymyxin b ..................... 80BACITRAYCIN PLUS...................... 62baclofen ......................................... 177BACMIN.........................................195BALANCE B-100 (FOLIC ACID)....209BALANCE B-50 (WITH FOLIC ACID).............................................209BALANCED B-100.........................209BALANCED B-100 COMPLEX...... 209BALANCED B-50...........................209balsalazide .....................................116BALVERSA....................................141BALZIVA (28)...................................54BAN-ACID......................................184BANOPHEN.......................................3BANZEL.........................................167BAQSIMI..........................................73BASAGLAR KWIKPEN U-100 INSULIN...........................................73BAZA ANTIFUNGAL........................63B-COMPLEX..................................209B-COMPLEX WITH B-12...............209b-complex with vitamin c ................195B-COMPLEX WITH VITAMIN C.... 209BD ALCOHOL SWABS....................68BD AUTOSHIELD DUO PEN NEEDLE........................................ 151BD ECLIPSE LUER-LOK...............130BD INSULIN SYRINGE................. 130BD INSULIN SYRINGE HALF UNIT.............................................. 130

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BD INSULIN SYRINGE MICRO-FINE...............................................130BD INSULIN SYRINGE SAFETY-LOK................................................130BD INSULIN SYRINGE SLIP TIP..130BD INSULIN SYRINGE U-500.......130BD INSULIN SYRINGE ULTRA-FINE...............................................130BD LO-DOSE MICRO-FINE IV......131BD LO-DOSE ULTRA-FINE.......... 131BD MICROTAINER LANCET........ 126BD NANO 2ND GEN PEN NEEDLE........................................ 151BD SAFETYGLIDE INSULIN SYRINGE.......................................131BD SAFETYGLIDE SYRINGE.......131BD ULTRA FINE LANCETS.......... 126BD ULTRA-FINE II LANCETS....... 126BD ULTRA-FINE MICRO PEN NEEDLE........................................ 151BD ULTRA-FINE MINI PEN NEEDLE........................................ 151BD ULTRA-FINE NANO PEN NEEDLE........................................ 151BD ULTRA-FINE ORIG PEN NEEDLE........................................ 151BD ULTRA-FINE SHORT PEN NEEDLE........................................ 151BD VEO INSULIN SYR HALF UNIT.............................................. 131BD VEO INSULIN SYRINGE UF...131BEANO.......................................... 179BEELITH........................................194BEKYREE (28)................................ 54BELSOMRA.....................................36BENADRYL ALLERGY......................3benazepril ........................................ 45BENEFIX......................................... 88benznidazole ..................................101benzonatate .....................................61benzoyl peroxide ........................68, 69benztropine ....................................164BERINERT.....................................113betamethasone dipropionate ........... 65betamethasone valerate .................. 65betamethasone, augmented ......65, 66BETATEMP................................... 158betaxolol .................................... 46, 81bethanechol chloride ......................138

BETHKIS......................................... 99BEVESPI AEROSPHERE................. 9bexarotene .....................................146bicalutamide ...................................139BIKTARVY.....................................109BIO-35, GLUTEN FREE................ 195BIOCAL..........................................189BIOCEL (WITH LUTEIN)............... 192BION TEARS (PF)...........................82BIOPETIT...................................... 209biotin .............................................. 209BIOTIN PLUS-CALCIUM AND VIT D3.................................................. 196bisacodyl ................................120, 124BISA-LAX (BISACODYL)...............120BISMATROL..................................118BISMUTH.......................................118bismuth subsalicylate .....................118bisoprolol fumarate .......................... 46bisoprolol-hydrochlorothiazide .........47BLEPH-10........................................80BLISOVI 24 FE................................ 54BLISOVI FE 1.5/30 (28)...................54BLISOVI FE 1/20 (28)......................54BODY, HAIR, SKIN AND NAILS....196bortezomib .....................................141bosentan ..........................................49BOSULIF....................................... 141BP....................................................69BPO-10............................................69BPO-5..............................................69BRAFTOVI.....................................140BREATHERITE MDI SPACER........ 11BREATHERITE VALVED MDI CHAMBER.......................................11BREATHERITE VALVED MDI SPACER..........................................11BREEZE 2 TEST STRIPS............... 72BREWER'S YEAST....................... 209BRIELLYN....................................... 54brimonidine ...................................... 82BRISDELLE...................................149BRIVIACT...................................... 167bromocriptine .................................165BRUKINSA.................................... 141budesonide ...................................... 10budesonide-formoterol .......................9BUFFERED ASPIRIN....................157BUFFERIN.....................................157

BULLSEYE MINI SAFETY LANCETS...................................... 126bumetanide ......................................48BUMINATE 25 %.............................91BUMINATE 5 %...............................91BUNAVAIL.....................................164BUPHENYL................................... 117buprenorphine hcl ..........................164buprenorphine-naloxone ................164bupropion hcl ................................... 15bupropion hcl (smoking deter) ....... 179buspirone .........................................25BUTALBITAL COMPOUND W/CODEINE..................................163butalbital-acetaminop-caf-cod ........163butalbital-acetaminophen ...............157butalbital-acetaminophen-caff ........157butalbital-aspirin-caffeine ...............157cabergoline ...................................... 78CABOMETYX................................ 141caffeine citrate ................................. 13calcipotriene .....................................70calcitonin (salmon) ...........................77calcitriol ..........................................212CALCIUM 500................................190CALCIUM 500 + D.........................190CALCIUM 500 WITH D..................190CALCIUM 600................................190CALCIUM 600 + D(3).................... 190calcium acetate(phosphat bind) .......75CALCIUM ANTACID......................184CALCIUM ANTACID TROPICAL...184CALCIUM ANTACID ULTRA MAX ST.................................................. 184calcium carbonate ..................184, 190calcium carbonate-vitamin d3 ........190calcium citrate ................................190CALCIUM CITRATE + D............... 190calcium citrate-vitamin d3 .............. 190calcium polycarbophil .................... 120CALCIUM WITH VITAMIN D......... 191CAL-GEST ANTACID....................184CAL-MINT......................................191CALQUENCE................................ 141CALTRATE WITH VITAMIN D3.....191CAMILA........................................... 54capecitabine ...................................139CAPLYTA........................................ 27CAPRELSA....................................142

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captopril ........................................... 45CARBAGLU...................................117carbamazepine .............................. 167CARBATROL.................................167carbidopa-levodopa ....................... 165carbinoxamine maleate ......................3CAREFINE PEN NEEDLE.............151CAREONE THIN LANCET............ 126CAREONE ULTRA THIN LANCET126CARESENS LANCETS................. 126CARETOUCH ALCOHOL PREP PAD................................................. 68CARETOUCH INSULIN SYRINGE131CARETOUCH PEN NEEDLE........ 152CARETOUCH SAFETY LANCETS126CARETOUCH TWIST LANCET.....126CARNITOR....................................149CARNITOR (SUGAR-FREE)......... 149carteolol ........................................... 82CARTIA XT......................................47carvedilol ..........................................44CAYA CONTOURED.......................60CAYSTON....................................... 96CAZIANT (28)..................................54cefaclor ............................................ 96cefadroxil ......................................... 96cefdinir ............................................. 97cefixime ............................................97cefpodoxime .................................... 97cefprozil ........................................... 96cefuroxime axetil ..............................96celecoxib ........................................114CELEXA...........................................15CELONTIN.....................................167CENTRAL-VITE.............................196CENTRAL-VITE WOMEN'S MATURE........................................196CENTRAVITES..............................196CENTRAVITES 50 PLUS...... 192, 196CENTRUM.....................................196CENTRUM COMPLETE................ 196CENTRUM MEN............................196CENTRUM SILVER.......................196CENTRUM SILVER ULTRA MEN'S............................................196CENTRUM SPECIALIST HEART..196CENTRUM ULTRA MEN'S............196CENTRUM VITAMINTS.................196CENTRUM WOMEN......................196

CENTURY..................................... 196CENTURY ADULTS 50 PLUS.......196CENTURY CARDIO...................... 196CENTURY MATURE..................... 196CENTURY ULTIMATE MEN'S...... 196CENTURY ULTIMATE WOMEN'S 196cephalexin ........................................96CEPROTIN (BLUE BAR)................. 93CEPROTIN (GREEN BAR)..............93CERDELGA...................................148CEREBYX......................................168CEREFOLIN.................................. 209CEREZYME...................................150CEROVITE ADVANCED FORMULA..................................... 196CEROVITE SENIOR......................192CERTA PLUS................................ 196CERTAVITE SENIOR-ANTIOXIDANT...............................192CERTAVITE-ANTIOXIDANT......... 197cetirizine .........................................5, 6CHANTIX.......................................178CHANTIX CONTINUING MONTH BOX............................................... 178CHANTIX STARTING MONTH BOX............................................... 178CHATEAL (28).................................54CHATEAL EQ (28)...........................54CHEMET........................................151CHILD ALLERGY RELF(CETIRIZINE)........................... 6CHILD PAIN REL-FEVER REDUCER.....................................158CHILDREN'S ACETAMINOPHEN............................................... 158, 159CHILDREN'S ALAWAY................... 79CHILDREN'S ALLERGY (DIPHENHYD)................................... 3CHILDREN'S ALLERGY RELIEF(LOR).................................... 6CHILDREN'S ALLERGY(CETIRIZINE)....................6CHILDREN'S ASPIRIN....................92CHILDREN'S AURODRYL ALLERGY.......................................... 3CHILDREN'S AUROPHEN PAIN-FEVER...........................................159CHILDREN'S CETIRIZINE................ 6

CHILDREN'S DIPHENHYDRAMINE........................3CHILDREN'S EASY-MELTS......... 159CHILDREN'S FEVER REDUCING 159CHILDREN'S IBUPROFEN........... 114CHILDREN'S IRON....................... 192CHILDREN'S MAPAP....................159CHILDREN'S NASACORT................ 7CHILDREN'S NON-ASPIRIN.........159CHILDREN'S PAIN RELIEF.......... 159CHILDREN'S PAIN RELIEVER..... 159CHILDREN'S PAIN-FEVER RELIEF.......................................... 159CHILDREN'S PROFEN IB.............114CHILDREN'S SALINE NASAL SPRAY...........................................155CHILDREN'S SILAPAP................. 159CHILDREN'S TACTINAL...............159CHILDREN'S WAL-DRYL ALLERGY.......................................... 3CHILDREN'S WAL-ZYR.................... 6CHILD'S ALL DAY ALLERGY(CETIR).............................6chlordiazepoxide hcl ........................ 24chlorhexidine gluconate .................147CHLORHIST......................................3chloroquine phosphate .................. 100chlorothiazide ...................................49chlorpheniramine maleate ................. 4chlorpromazine ................................ 32CHLORTABS.....................................4chlorthalidone .................................. 49chlorzoxazone ................................177cholecalciferol (vitamin d3) ............ 212cholestyramine (with sugar) .............50CHOLESTYRAMINE LIGHT............50choline,magnesium salicylate ........157ciclopirox ..........................................63cilostazol ..........................................92CIMDUO........................................ 102cimetidine .......................................186CIMZIA...........................................111CIMZIA POWDER FOR RECONST....................................................... 111CIMZIA STARTER KIT.................. 111cinacalcet .........................................77CINRYZE.......................................113CIPRO............................................. 98CIPRODEX......................................75

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ciprofloxacin .....................................98ciprofloxacin hcl ................... 75, 80, 98citalopram ........................................ 15CITRACAL + D MAXIMUM............191CITRATE OF MAGNESIA............. 120CITROMA...................................... 120CLARAVIS.......................................61CLARISPRAY....................................7clarithromycin ...................................97CLARITIN.......................................... 6CLASSIC PRENATAL................... 205C-LAX LAXATIVE (BISACODYL)..120CLEAN-CLEAR CONTINUOUS CONTROL....................................... 69CLEAR EYES NATURAL TEARS... 82CLEARLAX....................................120clemastine ..........................................4CLEVER CHEK LANCETS............126CLICKFINE PEN NEEDLE............ 152clindamycin hcl .............................. 100clindamycin palmitate hcl ...............100CLINDAMYCIN PEDIATRIC..........100clindamycin phosphate ............ 62, 188clobazam ....................................... 165clobetasol .........................................66clomipramine ................................... 20clonazepam ................................... 165clonidine hcl ...............................41, 46clopidogrel ....................................... 92clorazepate dipotassium ..................24clotrimazole ........................63, 99, 189CLOTRIMAZOLE 3 DAY............... 189CLOTRIMAZOLE AF....................... 63CLOTRIMAZOLE-3........................189CLOTRIMAZOLE-7........................189clotrimazole-betamethasone ............63clozapine ....................................27, 28CLOZARIL....................................... 28COAGUCHEK LANCETS.............. 126codeine sulfate ...............................161codeine-butalbital-asa-caff .............163COGENTIN....................................165COLACE CLEAR...........................120colchicine .........................................84colestipol ..........................................50COLOR LANCETS........................ 126COL-RITE......................................120COMBIVENT RESPIMAT.................. 9COMBIVIR.....................................103

COMETRIQ................................... 142COMFORT EZ INSULIN SYRINGE....................................................... 131COMFORT EZ LANCETS............. 126COMFORT EZ PEN NEEDLES.....152COMFORT GEL............................ 184COMFORT GEL EXTRA STRENGTH...................................184COMFORT LANCETS................... 126COMPACT SPACE CHAMBER PLUS............................................... 11COMPETE.....................................197COMPLERA...................................108COMPLETE...................................197COMPLETE 50 PLUS....................197COMPLETE ALLERGY..................... 4COMPLETE ALLERGY MEDICINE...4COMPLETE MEN..........................197COMPLETE MEN 50 PLUS...........197COMPLETE MULTI....................... 197COMPLETE MULTI 50+................ 197COMPLETE MULTIVITAMIN.........197COMPLETE MULTIVITAMIN-MINERAL.......................................197COMPLETE MV ADULT 50 PLUS 197COMPLETE PREMIUM VITAMIN. 197COMPLETE SENIOR............ 192, 197COMPLETE WOMEN....................197COMPLETENATE......................... 205COMPLEX B-100...........................209COMPLEX B-50.............................209COMPRO...........................................7CONCERTA.....................................41CONDOMS-PREM LUBRICATED.147CONSTULOSE..............................120CONTOUR NEXT TEST STRIPS....73CONTOUR TEST STRIPS.............. 73COPIKTRA.................................... 142CORIFACT...................................... 88CORTAID.........................................66CORTISONE (HYDROCORTISONE).................... 66CORTISONE WITH ALOE...............66CORTIZONE-10.............................. 66CORTIZONE-10 PLUS....................66CORTROSYN..................................76CORVITE FREE............................ 197COSOPT..........................................82cosyntropin ...................................... 76

COTELLIC..................................... 140COTEMPLA XR-ODT...................... 41CREAMY ACNE FACE....................69CREON..........................................181CRIXIVAN......................................107cromolyn ................................ 7, 11, 81CRYSELLE (28)...............................54CURITY ALCOHOL SWABS........... 68cyanocobalamin (vitamin b-12) ......212CYCLAFEM 1/35 (28)......................54CYCLAFEM 7/7/7 (28).....................54cyclobenzaprine .............................177cyclopentolate ..................................82cyclophosphamide .........................139cycloserine .....................................100cyclosporine .....................................95cyclosporine modified ...................... 95CYKLOKAPRON............................. 84CYMBALTA..................................... 18cyproheptadine .................................. 4CYRED............................................ 54CYRED EQ......................................54CYSTADANE.................................149CYTO B7....................................... 209CYTRA-2....................................... 187CYTRA-K.......................................187D3 DOTS....................................... 212D3-2000.........................................212D3-50 CHOLECALCIFEROL......... 212DAILY FIBER (PSYLLIUM-SUCROSE)....................................120DAILY GUMMIES.......................... 197DAILY MULTIPLE..........................197DAILY MULTIPLE FOR MEN........ 197DAILY MULTIPLE FOR WOMEN..197DAILY MULTIPLE VITAMINS/IRON............................197DAILY MULTIVITAMIN..................197DAILY MULTI-VITAMIN.................197DAILY MULTIVITAMIN WITH IRON..............................................197DAILY MULTIVITAMIN-MINERALS....................................................... 197DAILY VALUE................................197DAILY VITAMIN FORMULA.......... 198DAILY VITAMIN FORMULA-IRON 198DAILY VITAMIN FORMULA-MINERALS.................................... 198DAILY VITAMIN WITH IRON.........198

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DAILY VITES/IRON.......................198DAILY-VITE................................... 198DAIRY AID.....................................179DAIRY DIGESTIVE........................179DAIRY DIGESTIVE SUPPLEMENT....................................................... 180DAIRY RELIEF.............................. 180dalfampridine ................................. 147danazol ............................................ 78dantrolene ......................................177dapsone ...........................................99DARAPRIM....................................100DASETTA 1/35 (28).........................54DASETTA 7/7/7 (28)........................54DAURISMO................................... 140DAYHIST ALLERGY..........................4DAYLOGIC ACNE FOAMING WASH..............................................69DAYLOGIC ACNE TREATMENT.... 69DAYTRANA..................................... 41DDAVP............................................ 76DEBLITANE.....................................54DECADRON.................................. 113DECARA........................................212DECUBI VITE................................ 198DEEP SEA NASAL........................155DELSTRIGO..................................108DELTA D3......................................213DENTA 5000 PLUS....................... 191DENTAGEL................................... 191DEPAKOTE................................... 168DEPAKOTE ER............................. 168DEPAKOTE SPRINKLES..............168DESCOVY..................................... 102desipramine ..................................... 20desmopressin .................................. 77desog-e.estradiol/e.estradiol ............55desogestrel-ethinyl estradiol ............55DESOXYN....................................... 21desvenlafaxine .................................18desvenlafaxine succinate .................18dexamethasone ............................. 113dexamethasone sodium phosphate .80DEXEDRINE SPANSULE................22dexmedetomidine ............................ 36dexmedetomidine in 0.9 % nacl .......36dexmedetomidine in dextrose 5% ....36dexmethylphenidate ...................41, 42dextroamphetamine .........................22

dextroamphetamine-amphetamine ..22DIABETES HEALTH FORMULA... 198DIACOMIT..................................... 168DIALYVITE.................................... 210DIALYVITE 3000........................... 209DIALYVITE 5000........................... 209DIALYVITE 800............................. 209DIALYVITE 800 PLUS D............... 209DIALYVITE 800 WITH ZINC 15.....209DIALYVITE 800 WITH ZINC 50.....209DIALYVITE 800-ULTRA D.............210DIALYVITE SUPREME D..............210DIALYVITE VITAMIN D................. 213DIALYVITE VITAMIN D3 MAX...... 213DIARRHEA RELIEF (BISMUTH SUBS)............................................118DIASTAT........................................166DIASTAT ACUDIAL.......................166DIASTIX...........................................74diazepam ................................. 24, 166DIAZEPAM INTENSOL................... 24diclofenac sodium ........67, 69, 80, 114dicloxacillin .......................................98dicyclomine ....................................182didanosine ..................................... 105DIFFERIN........................................ 61DIGESTIVE ENZYME (ACIDOPH,PEC)............................180DIGESTIVE ENZYMES(MAL,LAC,INV).............180DIGESTIVE RELIEF......................118DIGITEK.......................................... 44DIGOX............................................. 44digoxin ............................................. 44DILANTIN...................................... 168DILANTIN EXTENDED..................168DILANTIN INFATABS....................168DILANTIN-125............................... 168diltiazem hcl .....................................47DILT-XR...........................................47dimenhydrinate .................................. 7DIOCTO.........................................120DIOTAME...................................... 118DIPHEDRYL...................................... 4DIPHEDRYL ALLERGY.....................4DIPHEN............................................. 4DIPHENHIST.....................................4diphenhydramine hcl ..........................4diphenoxylate-atropine .................. 118

dipyridamole .................................... 92disopyramide phosphate ..................44disulfiram ......................................... 23DIURIL.............................................49divalproex .............................. 168, 169docosanol ........................................ 65DOCU............................................ 120DOCUPRENE................................120docusate calcium ...........................120docusate sodium ....................120, 125DOCUSIL.......................................120DOCUSOL.....................................125DOCUZEN.....................................120DOK...............................................120DOK PLUS.....................................120donepezil ......................................... 13DOPRAM.........................................33DORAL............................................ 35dorzolamide ..................................... 82dorzolamide-timolol ..........................82DOTTI..............................................93doxapram .........................................33doxazosin .........................................44doxepin ...................................... 20, 36doxycycline hyclate ..........................98doxycycline monohydrate .......... 98, 99DRAMAMINE.....................................7DRAMAMINE LESS DROWSY......... 7DRIMINATE.......................................7DRIZALMA SPRINKLE....................18dronabinol ..........................................7droperidol .........................................31DROPLET INSULIN SYR HALF UNIT.............................................. 131DROPLET INSULIN SYRINGE..... 131DROPLET LANCETS.................... 126DROPLET PEN NEEDLE..............152DROPSAFE PEN NEEDLE........... 152drospirenone-ethinyl estradiol ..........55DROXIA...........................................93DRYSOL..........................................67DRYSOL DAB-O-MATIC................. 67DSS............................................... 120DUCODYL (BISACODYL)............. 120DULCOEASE.................................120DULCOLAX STOOL SOFTENER (DSS).............................................120DULERA.......................................... 10duloxetine ........................................ 18

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DUREX AVANTI BARE REAL FEEL..............................................147D-VI-SOL....................................... 213DYANAVEL XR................................22E.C. PRIN...................................... 157E-200............................................. 213EASIVENT HOLDING CHAMBER...11EASIVENT MASK LARGE...............11EASIVENT MASK MEDIUM............ 11EASIVENT MASK SMALL...............11EASY COMFORT ALCOHOL PAD. 68EASY COMFORT INSULIN SYRINGE.......................................132EASY COMFORT LANCETS........ 126EASY COMFORT PEN NEEDLES 152EASY GLIDE INSULIN SYRINGE.132EASY GLIDE PEN NEEDLE..........152EASY TOUCH............................... 152EASY TOUCH ALCOHOL PREP PADS...............................................68EASY TOUCH FLIPLOCK INSULIN.........................................132EASY TOUCH INSULIN SAFETY SYR............................................... 132EASY TOUCH INSULIN SYRINGE....................................................... 132EASY TOUCH LANCETS..............126EASY TOUCH LUER LOCK INSULIN.........................................132EASY TOUCH PEN NEEDLE........152EASY TOUCH SAFETY LANCETS....................................................... 126EASY TOUCH SAFETY PEN NEEDLE........................................ 152EASY TOUCH SHEATHLOCK INSULIN.........................................132EASY TOUCH TWIST LANCETS..126EASY TOUCH UNI-SLIP............... 132EASY TWIST AND CAP LANCETS....................................................... 126EC-NAPROXEN............................ 114econazole ........................................ 63ECONTRA EZ..................................55ECONTRA ONE-STEP....................55ECOTRIN.......................................157ECOTRIN LOW STRENGTH...........92ED-APAP.......................................159EDLUAR.......................................... 36ED-SPAZ....................................... 182

EDURANT..................................... 103efavirenz ........................................ 103EFFER-K......................................... 76EFFEXOR XR..................................18ELAPRASE....................................150electrolytes-dextrose ........................75ELELYSO...................................... 150ELFOLATE PLUS..........................210ELINEST..........................................55ELIQUIS...........................................87ELIQUIS DVT-PE TREAT 30D START.............................................87ELLA................................................55ELMIRON...................................... 188ELOCTATE......................................85ELURYNG....................................... 53EMBRACE LANCETS................... 126EMCYT.......................................... 146EMGALITY PEN............................ 162EMGALITY SYRINGE................... 163EMOQUETTE..................................55EMSAM............................................34EMTRIVA.......................................105enalapril maleate ............................. 45enalapril-hydrochlorothiazide ...........44ENBREL........................................ 111ENBREL SURECLICK...................111ENDARI........................................... 93ENDOCET..................................... 163ENDUR-ACIN.................................. 51ENDUR-AMIDE............................... 51ENDUR-B COMPLEX....................210ENEMA..........................................125ENEMA DISPOSABLE.................. 125ENEMEEZ..................................... 125ENEMEEZ PLUS...........................125ENFAMIL ENFALYTE......................75enoxaparin .......................................89ENPRESSE..................................... 55ENSKYCE........................................55entacapone ....................................165entecavir ........................................ 110ENTRESTO..................................... 52ENULOSE......................................117ENZYMATIC DIGESTANT............ 180ENZYME DIGEST......................... 180EPANED..........................................45EPCLUSA......................................109EPIDIOLEX....................................166

epinephrine ....................................138EPIPEN..........................................138EPIPEN 2-PAK.............................. 138EPIPEN JR.................................... 138EPIPEN JR 2-PAK.........................138EPITOL..........................................169EPIVIR...........................................105EPOGEN......................................... 89EPZICOM...................................... 103EQUETRO.......................................25ergocalciferol (vitamin d2) ..............213ERIVEDGE.................................... 140ERLEADA......................................139erlotinib .......................................... 142ERRIN..............................................55erythromycin .................................... 81erythromycin with ethanol ................62escitalopram oxalate ..................15, 16esomeprazole magnesium .............186ESPEROCT.....................................86ESSENTIA.....................................198ESSENTIAL BALANCE WITH LUTEIN..........................................198ESSENTIAL DAILY........................198ESSENTIAL MAN..........................198ESSENTIAL MAN 50+...................198ESSENTIAL WOMAN 50+.............198ESTARYLLA....................................55estazolam ........................................ 35estradiol ................................... 93, 189estradiol-norethindrone acet ............93eszopiclone ......................................36ethambutol .....................................100ethosuximide ..................................169ethynodiol diac-eth estradiol ............55etodolac ......................................... 114etonogestrel-ethinyl estradiol ...........53etoposide ....................................... 146EUTHYROX.....................................78EVAC-U-GEN (SENNOSIDES)..... 120EVEKEO..........................................22EVEKEO ODT................................. 22everolimus (antineoplastic) ............140EVOTAZ........................................ 107EXEL INSULIN.............................. 132exemestane ................................... 140EX-LAX (SENNOSIDES)...............121EXONDYS-51................................138EYE ALLERGY RELIEF.................. 80

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EYE HEALTH PLUS LUTEIN........ 198EYE ITCH RELIEF...........................79E-Z JECT LANCETS..................... 126E-Z JECT THIN LANCETS............ 126EZ NITE SLEEP.............................. 36EZ SMART LANCETS...................126ezetimibe ......................................... 50EZ-LETS........................................126FABB............................................. 210FABRAZYME.................................150FALMINA (28)..................................55famciclovir ......................................101famotidine ...................................... 186FANAPT...........................................28FANTASY CONDOM.....................147FARYDAK......................................145FC2 FEMALE CONDOM............... 147FE C PLUS.................................... 192febuxostat ........................................ 84FEIBA NF.........................................86felbamate .......................................169FELBATOL.................................... 169felodipine ......................................... 47FEMCAP..........................................60FEMYNOR.......................................55fenofibrate ........................................50fenofibrate micronized ..................... 50fenofibrate nanocrystallized .............50fenofibric acid (choline) ....................50fentanyl .......................................... 161FEOSOL........................................ 192FERATE.........................................192FERGON....................................... 192FEROSUL......................................192FERRO-TIME................................ 193ferrous gluconate ...........................193ferrous sulfate ................................193FERROUSUL.................................193FETZIMA......................................... 18FEVER REDUCER........................159FEVER REDUCER AN PAIN RELIEVER.....................................159FEVERALL.................................... 159fexofenadine ...................................... 6FIBER............................................ 121FIBER (CALCIUM POLYCARBOPHIL)....................... 121

FIBER (PSYLLIUM HUSK/SUGAR)....................................................... 121FIBER (WITH ASPARTAME)........ 121FIBER LAXATIVE (CA POLYCARBO)............................... 121FIBER SMOOTH........................... 121FIBER SMOOTH (SUCROSE)...... 121FIBER THERAPY (CA POLYCARBOPH).......................... 121FIBER THERAPY(PSYL SEED-SUGAR).........................................121FIBER-LAX.................................... 121FIBER-TABS..................................121FIBRYGA.........................................85FIFTY50 SAFETY SEAL LANCETS...................................... 126finasteride ...................................... 187FINE 30 UNIVERSAL LANCETS...126FINGERSTIX LANCETS................127FIRDAPSE.....................................147FIRST AID ANTIBIOTIC.................. 62FIRVANQ.......................................100FISH OIL..........................................50FISH OIL CONCENTRATE............. 50FISH OIL EXTRA STRENGTH........ 50FLANAX (NAPROXEN)................. 114FLAVOR CHEWS ANTACID......... 184flavoxate ........................................ 188flecainide ..........................................44FLEET ENEMA..............................125FLEET LAXATIVE (BISACODYL). 121FLEET MINERAL OIL....................125FLEET PEDIATRIC....................... 125FLEXBUMIN 25 %...........................91FLEXBUMIN 5 %.............................91FLOVENT HFA................................10FLUAD 2019-2020 (65 YR UP)(PF) 94FLUARIX QUAD 2019-2020 (PF)....94FLUBLOK QUAD 2019-2020 (PF)...94FLUCELVAX QUAD 2019-2020...... 94FLUCELVAX QUAD 2019-2020 (PF)..................................................94fluconazole .......................................99fludrocortisone ............................... 114FLULAVAL QUAD 2019-2020......... 95FLULAVAL QUAD 2019-2020 (PF). 94FLUMIST QUAD 2019-2020............95flunisolide ...........................................7fluocinonide ......................................66

FLUOCINONIDE-E..........................66fluocinonide-emollient ......................66fluoride (sodium) ....................191, 192FLUORITAB...................................192fluorometholone ...............................80fluorouracil ....................................... 69fluoxetine ......................................... 16fluphenazine decanoate ...................32fluphenazine hcl ...............................32flurazepam .......................................35flurbiprofen .....................................114flurbiprofen sodium .......................... 80flutamide ........................................ 139fluticasone propionate ..................7, 66fluticasone propion-salmeterol .........10fluvoxamine ......................................16FLUZONE HIGH-DOSE 2019-20 (PF)..................................................95FLUZONE QUAD 2019-2020.......... 95FLUZONE QUAD 2019-2020 (PF).. 95FLUZONE QUAD PEDI 2019-20 (PF)..................................................95FOAMING ACNE FACE WASH.......69FOAMING ANTACID..................... 184FOCALIN......................................... 42FOCALIN XR................................... 42FOLBEE.........................................210FOLBEE PLUS.............................. 210FOLBIC..........................................210FOLBIC RF....................................210folic acid .........................................192FOLINIC-PLUS..............................210FOLPLEX 2.2.................................210FOLTABS 800............................... 210FOLTANX...................................... 210FOLTX........................................... 210FOOT AND SNEAKER....................63FOR STY RELIEF............................83FORACARE LANCETS................. 127FORFIVO XL................................... 15FORTAVIT.....................................198FORTEO..........................................77fosamprenavir ................................107FOSFREE......................................191fosinopril .......................................... 45fosphenytoin .................................. 169FREEDAVITE................................ 198FREESTYLE LANCETS................ 127FREESTYLE PRECISION.............132

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FREESTYLE UNISTIK 2................127FULL SPECTRUM B-VITAMIN C..210FULPHILA........................................89FUNGOID-D.................................... 63furosemide .......................................48FUZEON........................................103FYAVOLV........................................ 93FYCOMPA.....................................169GABACAINE..................................169gabapentin .....................................170GABITRIL...................................... 170GALAFOLD....................................139GAS RELIEF (SIMETHICONE)..... 179GAS RELIEF 80 (SIMETHICONE) 179GAS RELIEF EXTRA STRENGTH 179GAS RELIEF-PREVENTION......... 180GAVILYTE-C................................. 121GAVILYTE-G................................. 121GAVILYTE-N................................. 121GAVISCON....................................184gemfibrozil ....................................... 50GENERLAC...................................117GENTAK..........................................81gentamicin ................................. 62, 81GENTEAL TEARS MILD................. 82GENTEAL TEARS MODERATE (PF)..................................................83GENTEAL TEARS SEVERE(PETROLAT).....................83GENTLE LAXATIVE (BISACODYL)............................................... 121, 125GENTLELAX..................................121GENVOYA.....................................109GEODON.........................................28GERI-DRYL....................................... 4GERI-HYDROLAC...........................68GERI-KOT..................................... 121GERI-LANTA................................. 184GERI-MOX ANTACID-ANTIGAS...184GERI-MUCIL (ASPARTAME)........ 121GERI-MUCIL (SUGAR)................. 121GERI-PECTATE............................ 118GIANVI (28)..................................... 55GILENYA....................................... 146GILOTRIF...................................... 142glatiramer .......................................146GLATOPA..............................146, 147GLEEVEC......................................142GLEOSTINE.................................. 139

glimepiride ....................................... 71glipizide ............................................71glipizide-metformin ...........................72GLUCAGEN HYPOKIT....................73GLUCAGON EMERGENCY KIT (HUMAN)......................................... 73GLUCOCOM LANCETS................ 127glyburide .......................................... 71glyburide micronized ........................71glyburide-metformin .........................72GLYCOLAX................................... 121glycopyrrolate ................................ 185GLYDO.......................................... 116granisetron hcl ................................... 7GRANIX.....................................89, 90griseofulvin microsize ...................... 99griseofulvin ultramicrosize ............... 99guanfacine ................................. 41, 46GYNOL II ......................................... 53HAEGARDA...................................113HAILEY............................................55HAILEY 24 FE................................. 55HAIR VITAMINS............................ 198HAIR, SKIN AND NAILS-ARGAN OIL.................................................198HAIR,SKIN AND NAILS.................198HAIR,SKIN AND NAILS(FA-BIOTIN)..........................................198HAIR-SKIN-NAILS (PABA)............ 198HALCION.........................................35HALDOL.......................................... 31HALDOL DECANOATE...................31halobetasol propionate .................... 66haloperidol ....................................... 31haloperidol decanoate ..................... 31haloperidol lactate ............................31HARD NAILS................................. 210HARVONI...................................... 109HAVRIX (PF)................................... 95HEALTHWISE INSULIN SYRINGE....................................................... 133HEALTHWISE PEN NEEDLE........152HEALTHY ACCENTS UNIFINE PENTIP..........................................152HEALTHY ACCENTS UNILET LANCET.........................................127HEARTBURN PREVENTION........ 186HEARTBURN RELIEF (CIMETIDINE)................................186

HEARTBURN RELIEF (FAMOTIDINE).............................. 186HEARTBURN RELIEF (RANITIDINE)................................186HEARTBURN TREATMENT 24 HOUR............................................ 187HEATHER........................................55HEMANGEOL..................................46HEMLIBRA...................................... 89HEMOFIL M HIGH...........................86HEMOFIL M LOW............................86HEMOFIL M MID............................. 86HEMOFIL M SUPER HIGH............. 86heparin (porcine) ..............................89HETLIOZ..........................................33HI-CAL PLUS VIT D...................... 191HOMATROPAIRE............................82HOMOCYSTEINE FORMULA....... 210HUMALOG MIX 50-50 INSULN U-100...................................................73HUMALOG MIX 50-50 KWIKPEN... 73HUMALOG MIX 75-25 KWIKPEN... 73HUMALOG MIX 75-25(U-100)INSULN.................................... 73HUMATE-P......................................86HUMIRA.................................111, 112HUMIRA PEN................................ 111HUMIRA PEN CROHNS-UC-HS START...........................................111HUMIRA PEN PSOR-UVEITS-ADOL HS.......................................111HUMIRA(CF)................................. 112HUMIRA(CF) PEDI CROHNS STARTER......................................112HUMIRA(CF) PEN......................... 112HUMIRA(CF) PEN CROHNS-UC-HS..................................................112HUMIRA(CF) PEN PSOR-UV-ADOL HS.......................................112HUMULIN 70/30 U-100 INSULIN.... 73HUMULIN 70/30 U-100 KWIKPEN..74HUMULIN N NPH INSULIN KWIKPEN........................................ 74HUMULIN N NPH U-100 INSULIN.. 74HUMULIN R REGULAR U-100 INSULN............................................74HUMULIN R U-500 (CONC) INSULIN...........................................74HYCAMTIN....................................140

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hydralazine ...................................... 46hydrochlorothiazide ..........................49HYDROCIL.................................... 121hydrocodone-acetaminophen ........ 163hydrocortisone ......................... 66, 113hydrocortisone acetate ............ 66, 117hydrocortisone-acetic acid ...............74hydrocortisone-aloe vera ................. 67HYDROCREAM...............................67hydromorphone ..............................161hydroxychloroquine ........................100hydroxyprogest(pf)(preg presv) ....... 76hydroxyurea ...................................139hydroxyzine hcl ..................................4hydroxyzine pamoate .........................4hyoscyamine sulfate ...................... 182HYOSYNE..................................... 182HYZAAR.......................................... 45ibandronate ......................................77IBRANCE.......................................142IBU.................................................114IBU-200..........................................114ibuprofen ........................................115IBUPROFEN IB............................. 114IBUPROFEN JR STRENGTH........114ICAPS MV......................................198ICAR-C PLUS................................193ICLUSIG........................................ 142IDELVION........................................88IDHIFA...........................................146ILARIS (PF)................................... 112imatinib .......................................... 142IMBRUVICA...................................142imipramine hcl ..................................20imipramine pamoate ........................ 20imiquimod ........................................ 95IMODIUM A-D................................118INCASSIA........................................55IN-CHECK NASAL WITH MASK..... 11IN-CHECK ORAL FLOW METER....11INCONTROL ALCOHOL PADS.......68INCONTROL PEN NEEDLE..........152INCONTROL SUPER THIN LANCETS...................................... 127INCONTROL ULTRA THIN LANCETS...................................... 127INCRELEX.......................................77INCRUSE ELLIPTA........................... 9indapamide ...................................... 49

indomethacin ................................. 115INFANT FEVER REDUCER-PAIN RELF..............................................159INFANT PAIN RELIEVER..............159INFANT'S ACETAMINOPHEN...... 159INFANT'S ADVIL........................... 115INFANTS GAS RELIEF................. 179INFANT'S IBUPROFEN.................115INFANT'S MOTRIN....................... 115INFANTS' PAIN AND FEVER........159INFANTS' PAIN RELIEF................159INFANT'S PAIN RELIEF................159INFANT'S PAIN RELIEVER.......... 159INFANTS PROFENIB....................115INJECT EASE LANCETS..............127INLYTA.......................................... 143INREBIC........................................ 143INSPIRACHAMBER........................ 11INSPIRACHAMBER WITH MASK-LARGE.............................................12INSPIRACHAMBER WITH MASK-MED.................................................12INSPIRACHAMBER WITH MASK-SMALL.............................................12insulin asp prt-insulin aspart ............ 74insulin syr/ndl u100 half mark ........ 133INSULIN SYRINGE....................... 133INSULIN SYRINGE MICROFINE.. 133insulin syringe needleless ..............133insulin syringe-needle u-100 ..........133INSUPEN.......................................153INTELENCE...................................103INTERMEZZO................................. 36INTRON A........................................95INTROVALE.................................... 55INTUNIV ER.................................... 41INVACARE LANCETS...................127INVEGA........................................... 28INVEGA SUSTENNA.......................28INVEGA TRINZA............................. 28INVIRASE......................................107INVOKAMET....................................72INVOKAMET XR..............................72INVOKANA...................................... 71INZO ANTIFUNGAL........................ 63ipratropium bromide ...................8, 147ipratropium-albuterol ..........................9I-PRIN............................................115irbesartan .........................................45

irbesartan-hydrochlorothiazide ........ 45IRESSA..........................................143IRON..............................................193IRON (DRIED)............................... 193IRON (FERROUS SULFATE)........193IRON 100 PLUS............................ 193ISENTRESS.................................. 108ISENTRESS HD............................ 108ISIBLOOM....................................... 55isoniazid .........................................100isosorbide dinitrate ...........................52isosorbide mononitrate .................... 52isotretinoin ....................................... 61isradipine ......................................... 47ITCH RELIEF (CLOTRIMAZOLE)... 63ITCHY EYE DROPS........................79itraconazole ..................................... 99IV PREP WIPES..............................68ivermectin ...................................... 100I-VITE.............................................189IXINITY............................................ 88JAKAFI...........................................140JANTOVEN......................................84JANUMET........................................70JANUMET XR..................................70JANUVIA..........................................71JARDIANCE.................................... 71JASMIEL (28).................................. 55JENCYCLA......................................55JENTADUETO.................................70JINTELI............................................93JIVI...................................................86JOCK ITCH......................................64JOCK ITCH (CLOTRIMAZOLE)...... 63JOCK ITCH (TERBINAFINE)...........63JOLESSA.........................................56JORNAY PM....................................42JR. ACETAMINOPHEN................. 159JR. STR NON-ASPIRIN PAIN....... 160JR. STRENGTH PAIN RELIEVER 160JULEBER.........................................56JULUCA.........................................101JUNEL 1.5/30 (21)...........................56JUNEL 1/20 (21)..............................56JUNEL FE 1.5/30 (28)..................... 56JUNEL FE 1/20 (28)........................ 56JUNEL FE 24...................................56KAITLIB FE......................................56KALBITOR.....................................115

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KALETRA.............................. 106, 107KALLIGA..........................................56KALYDECO................................... 156KAOPECTATE (BISMUTH SUBSALICY)................................. 119KAOPECTATE EX STR (BISMUTH SS).................................................119KAO-TIN (DOCUSATE CALCIUM)121KAPVAY.......................................... 41KARIVA (28).................................... 56KAZANO..........................................70KCENTRA........................................87KELNOR 1/35 (28)...........................56KELNOR 1-50..................................56KEPPRA........................................ 170KEPPRA XR.................................. 170ketamine .......................................... 37ketoconazole ..............................64, 99KETO-DIASTIX................................74KETONE CARE.............................156KETONE URINE TEST..................156ketorolac .................................. 80, 115KETOSTIX.....................................156ketotifen fumarate ............................79KIMONO CONDOMS(NON-LUBRICATED)...............................148KIMONO MAXX CONDOMS......... 148KIMONO MICROTHIN AQUA LUBE CON.................................... 148KIMONO MICROTHIN CONDOMS....................................................... 148KIMONO MICROTHIN LARGE CONDOMS....................................148KIMONO TEXTURED CONDOMS 148KINERET....................................... 111KIONEX (WITH SORBITOL)........... 75KISQALI.........................................143KITABIS PAK...................................99KLONOPIN.................................... 166KLOR-CON M10..............................76KLOR-CON M20..............................76KOATE.............................................86KOBEE.......................................... 210KOGENATE FS............................... 86KONSYL (SUGAR)........................121KONSYL FIBER.............................121KOVALTRY......................................86K-PAX............................................198K-PAX IMMUNE SUPPORT.......... 198

K-PEC ANTIDIARRHEAL (BISM SUB).............................................. 119K-PHOS NO 2................................187K-PHOS ORIGINAL.......................187KPN............................................... 205KRINTAFEL...................................100KURVELO (28)................................ 56KUVAN.......................................... 139KYPROLIS.....................................143labetalol ........................................... 44LAC-DOSE.................................... 180LACTAID........................................180LACTAID FAST ACT..................... 180lactase ........................................... 181LACTASE ENZYME...................... 181LACTASE FAST ACTING..............181LACTOSE FAST ACTING RELIEF181lactulose .........................................122LAMICTAL..................................... 171LAMICTAL ODT.............................170LAMICTAL ODT STARTER (BLUE)...........................................170LAMICTAL ODT STARTER (GREEN)........................................170LAMICTAL ODT STARTER (ORANGE).....................................171LAMICTAL STARTER (BLUE) KIT 171LAMICTAL STARTER (GREEN) KIT................................................. 171LAMICTAL STARTER (ORANGE) KIT................................................. 171LAMICTAL XR............................... 171LAMICTAL XR STARTER (BLUE).171LAMICTAL XR STARTER (GREEN)........................................171LAMICTAL XR STARTER (ORANGE).....................................171LAMISIL AF..................................... 64lamivudine ..............................105, 110lamivudine-zidovudine ................... 103lamotrigine ............................. 171, 172lancets ........................................... 127LANCETS, SUPER THIN.............. 127LANCETS,THIN.............................127LANCETS,ULTRA THIN................ 127lancets-blood glucose strips .......... 127lansoprazole .................................. 187lanthanum ........................................75LARIN 1.5/30 (21)............................56

LARIN 1/20 (21)...............................56LARIN 24 FE....................................56LARIN FE 1.5/30 (28)...................... 56LARIN FE 1/20 (28)......................... 56LARISSIA.........................................56latanoprost .......................................82LATUDA...........................................28LAX STOOL SOFTENER WITH SENNA.......................................... 122LAXA BASIC..................................122LAXACLEAR..................................122LAXATIVE (BISACODYL)......122, 125LAXATIVE (SENNOSIDES)...........122LAXATIVE PEG 3350....................122LAXATIVE PILLS...........................122LAXATIVE PILLS REGULAR........ 122LAXATIVE PLUS STOOL SOFTENER................................... 122LAYOLIS FE.................................... 56ledipasvir-sofosbuvir ......................110LEENA 28........................................56leflunomide .................................... 112LENVIMA.......................................143LESSINA..........................................56LETAIRIS.........................................49letrozole ......................................... 140leucovorin calcium ......................... 146LEUKERAN................................... 139leuprolide ......................................... 77levalbuterol tartrate ............................9levetiracetam ......................... 172, 173levetiracetam in nacl (iso-os) ......... 172levobunolol .......................................82levocarnitine ...................................150levocarnitine (with sugar) ...............149levofloxacin ................................81, 98LEVONEST (28).............................. 56levonorgestrel .................................. 56levonorgestrel-ethinyl estrad ............57levonorg-eth estrad triphasic ........... 57LEVORA-28.....................................57LEVO-T............................................78levothyroxine ....................................78LEVOXYL........................................ 78LEXAPRO........................................16LEXIVA.......................................... 107LICE KILLING..................................64LICE KILLING (PERMETHRIN).......64LICE PYRINYL SHAMPOO.............64

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LICE TREATMENT..........................64LICE TREATMENT (PERMETHRIN)...............................64LIDO KING.......................................69lidocaine ...........................................69lidocaine hcl .............................69, 116LIDOCAINE PAIN RELIEF.............. 69LIDOCAINE PLUS...........................69LIDOCAINE VISCOUS.................. 116lidocaine-prilocaine ..........................69LIDOCARE...................................... 69LILLOW (28).................................... 57lindane ............................................. 64linezolid ............................................97liothyronine ...................................... 78LIQUID ANTACID..........................185lisinopril ............................................45lisinopril-hydrochlorothiazide ........... 44LITE COAT ASPIRIN.....................157LITE TOUCH INSULIN PEN NEEDLES......................................153LITE TOUCH INSULIN SYRINGE.134LITE TOUCH LANCETS................127LITE TOUCH-MEDIUM MASK........ 12LITEAIRE MDI CHAMBER.............. 12LITETOUCH-LARGE MASK............12LITETOUCH-SMALL MASK............ 12lithium carbonate ....................... 25, 26lithium citrate ....................................26LITHOBID........................................ 26LITHOSTAT...................................118LITTLE REMEDIES....................... 155LITTLE REMEDIES FEVER AND PAIN.............................................. 160LITTLE REMEDIES GAS RELIEF.179LITTLE TUMMYS GAS RELIEF.... 179lmefol ca-acetyl-meb12-algal .........210L-METHYL-B6-B12........................210L-METHYL-MC.............................. 210LO-DOSE ASPIRIN......................... 92LONSURF......................................139loperamide .....................................119lopinavir-ritonavir ........................... 107LOPREEZA......................................93LORADAMED....................................6loratadine ...........................................6lorazepam ..................................24, 35LORAZEPAM INTENSOL................24LORBRENA...................................143

LORCET (HYDROCODONE)........ 163LORCET HD..................................163LORCET PLUS..............................163LORYNA (28)...................................57losartan ............................................45losartan-hydrochlorothiazide ............45lovastatin ..........................................49LOW-OGESTREL (28).................... 57loxapine succinate ........................... 27LO-ZUMANDIMINE (28).................. 57LUBRICANT (P-GLYCOL-GLYCERIN)..................................... 83LUBRICANT EYE............................ 83LUBRICANT EYE (PG-PEG 400)....83LUBRICANT EYE DROPS.............. 83LUBRICATING PLUS...................... 83LUCEMYRA...................................164LUDENT FLUORIDE..................... 192LUMINAL......................................... 33LUMIZYME.................................... 150LUNESTA........................................ 37LUTERA (28)................................... 57LYDIA PINKHAM HERBAL..............37LYNPARZA....................................143LYRICA..........................................173LYRICA CR....................................147LYSODREN...................................146LYSTEDA........................................ 85LYZA................................................57MAALOX ADVANCED...................185MAALOX MAXIMUM STRENGTH.185MAG 64..........................................194MAG GLYCINATE......................... 194MAG-AL PLUS...............................185MAG-AL PLUS EXTRA STRENGTH...................................185MAGELLAN INSULIN SAFETY SYRNG..........................................134MAGELLAN SYRINGE..................134MAG-G...........................................194MAGINEX...................................... 194MAGLOX....................................... 185magnesium .................................... 194MAGNESIUM (OXIDE/AA CHELATE).....................................194magnesium amino acid chelate ..... 194magnesium chloride .......................194magnesium citrate ................. 122, 194magnesium gluconate ....................194

magnesium hydroxide ....................122magnesium l-lactate .......................194magnesium oxide ...........................194magnesium sulfate .........................194MAGONATE (MAGNESIUM CARB)............................................194MAGOX......................................... 194MAGTAB........................................194malathion ......................................... 65MAPAP (ACETAMINOPHEN)....... 160MAPAP ARTHRITIS PAIN.............160MAPAP EXTRA STRENGTH........ 160maprotiline ....................................... 20MARLISSA (28)............................... 57MARPLAN....................................... 14MASANTI DOUBLE STRENGTH.. 185MASOPHEN.................................. 160MATULANE................................... 146MATZIM LA......................................47MAVYRET..................................... 111MAXEPA..........................................50MAXICOMFORT II PEN NEEDLE.153MAXICOMFORT INSULIN SYRINGE.......................................134MAXI-COMFORT INSULIN SYRINGE.......................................134MAXICOMFORT SAFETY PEN NEEDLE........................................ 153MAXIMUM DAILY MULTIVITAMIN198M-DRYL.............................................4meclizine ............................................7MEDI-MECLIZINE............................. 7MEDIPROXEN...............................115MEDISENSE THIN LANCETS.......127MEDLANCE PLUS LANCETS.......127MEDLANCE PLUS SPECIAL BLADE...........................................127medroxyprogesterone ................53, 94MEDTYCHOLL-B COMPLEX-LIVER............................................ 210mefloquine ..................................... 101MEGA BIOTIN............................... 210MEGA MULTI FOR WOMEN.........199MEGA MULTIPLE/CHELATED MINERAL.......................................199MEGA MULTIVITAMIN FOR MEN 199megestrol ...............................146, 147MEKINIST......................................140MEKTOVI.......................................140

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MELODETTA 24 FE........................ 57meloxicam ......................................115melphalan ...................................... 139memantine .......................................13MEN 50 PLUS ADVANCED ONE DAILY............................................ 199MEN 50 PLUS MULTIVITAMIN..... 199MEN UNDER 50 MULTIVITAMIN..199MENEST..........................................94MEN'S 50 PLUS DAILY FORMULA....................................................... 199MEN'S 50 PLUS MULTIVITAMIN..199MEN'S DAILY................................ 199MEN'S DAILY FORMULA..............199MEN'S DAILY GUMMIES.............. 199MEN'S DAILY MULTIVIT-MINERAL.......................................199MEN'S MULTIVITAMIN................. 199MEN'S MULTIVITAMIN GUMMIES....................................................... 199MEN'S ONE DAILY....................... 199meperidine .....................................161MEPHYTON.................................... 93meprobamate ...................................25MEPSEVII ......................................150mercaptopurine ..............................139MERIBIN........................................210mesalamine ........................... 116, 117MESNEX........................................146METADATE ER............................... 42METAFOLBIC................................210METAFOLBIC PLUS RF................210METAMUCIL (SUGAR)................. 122METAMUCIL (WITH SUGAR)....... 122METAMUCIL MULTIHEALTH FIBER............................................ 122METAMUCIL SUGAR-FREE (ASPART)......................................122METAMUCIL SUNRISE.................122metformin .........................................72methadone .....................................161METHADONE INTENSOL.............161methamphetamine ...........................22methenamine hippurate ...................97methenamine mandelate ................. 97METHERGINE.................................61methimazole .................................... 78methocarbamol ..............................178methotrexate sodium ..................... 140

methotrexate sodium (pf) ...............139methyldopa ...................................... 46methyldopa-hydrochlorothiazide ......46methylergonovine ............................ 61METHYLIN.......................................42methylphenidate hcl ...................42, 43methylprednisolone ........................113metipranolol ..................................... 82metoclopramide hcl ........................186metolazone ...................................... 49metoprolol succinate ........................46metoprolol tartrate ............................46metronidazole .................. 61, 100, 188mexiletine .........................................44MGO.............................................. 194MI-ACID.........................................185MI-ACID GAS RELIEF(SIMETHICON)................. 179MIBELAS 24 FE...............................57MICATIN..........................................64MICONAZOLE 7............................189miconazole nitrate ....................64, 189MICONAZOLE-3............................189MICONAZOLE-3 PREFIL,CREAM,WIPE..................189miconazole-skin clnsr17 ................ 189MICRO THIN LANCETS................127MICROCHAMBER...........................12MICRODOT INSULIN PEN NEEDLE........................................ 153MICROGESTIN 1.5/30 (21).............57MICROGESTIN 1/20 (21)................57MICROGESTIN FE 1.5/30 (28)....... 57MICROGESTIN FE 1/20 (28).......... 57MICROLET LANCET.....................127MICROLIFE PEAK FLOW METER..12MICROSPACER..............................12midazolam ............................... 35, 149midazolam (pf) ...............................149midodrine .........................................52miglustat ........................................ 148MILI..................................................57MILK OF MAGNESIA.................... 122MIMVEY...........................................94mineral oil ...................................... 125MINI ULTRA-THIN II ......................153MINI WRIGHT PEAK FLOW METER............................................ 12MINITRAN....................................... 52

minocycline ......................................99minoxidil ...........................................46MINTOX.........................................185MINTOX MAXIMUM STRENGTH..185mirtazapine ................................ 13, 14misoprostol .................................... 185MKO (MIDAZOLAM-KETAMINE-ONDAN)...........................................37M-NATAL PLUS.............................205modafinil .......................................... 34molindone ........................................ 31mometasone ....................................67MONDOXYNE NL............................99MONISTAT 3................................. 189MONISTAT 7................................. 189MONOCAPS..................................199MONOJECT INSULIN SAFETY SYRING.........................................134MONOJECT INSULIN SYRINGE.. 134MONOJECT SYRINGE................. 134MONOJECT ULTRA COMFORT INSULIN.........................................134MONOLET LANCETS................... 127MONOLET THIN LANCETS.......... 127MONO-LINYAH............................... 57MONONINE.....................................88montelukast ..................................... 10morphine ........................................161morphine concentrate ....................161MOTEGRITY................................. 186MOTION RELIEF (MECLIZINE)........ 7MOTION SICKNESS......................... 8MOTION SICKNESS (MECLIZINE)...7MOTION SICKNESS II ...................... 8MOTION SICKNESS RELIEF............8MOTION SICKNESS RELIEF(MECLIZ)...............................8MOTION-TIME...................................8MOUTHPIECE.................................12MOVE IT ALONG.......................... 122M-PAP........................................... 160MULTI COMPLETE WITH IRON...199MULTI FOR HER...........................199MULTI-DAY WITH IRON............... 199MULTI-DELYN WITH IRON...........199MULTIHEALTH FIBER.................. 122MULTIHEALTH FIBER (SUGAR)..122MULTILEX..................................... 199MULTILEX-T AND M..................... 199

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MULTIPLE VITAMIN, WOMENS...199MULTIPLE VITAMIN-MINERALS..199MULTIPLE VITAMINS................... 199MULTI-VIT WITH FLUORIDE-IRON..............................................204multivitamin ....................................199MULTIVITAMIN WITH FLUORIDE 205MULTI-VITAMIN WITH FLUORIDE....................................................... 205multivitamin with iron ..................... 200multivitamin with minerals ..............200MULTIVITAMIN WOMEN 50 PLUS....................................................... 200MULTIVITAMINS WITH FLUORIDE.....................................205mupirocin ......................................... 62MURO 128.......................................81MVC-FLUORIDE........................... 205mv-min-folic acid-lutein .................. 200MY CHOICE.................................... 57MY WAY.......................................... 57MYALEPT........................................77mycophenolate mofetil .....................96mycophenolate mofetil (hcl) .............96mycophenolate sodium ....................96MYDAYIS.........................................22MYGLUCOHEALTH LANCETS.....127MYLANTA MAXIMUM STRENGTH....................................................... 185MYLERAN..................................... 139MYNATAL......................................206MYNATAL ADVANCE................... 205MYNATAL PLUS........................... 206MYNATAL-Z.................................. 206MYNATE 90 PLUS........................ 206MYNEPHROCAPS........................ 210MYNEPHRON............................... 210MYORISAN......................................61MYSOLINE.................................... 173MY-VITALIFE.................................200nabumetone ...................................115nadolol ............................................. 46NAGLAZYME.................................150naloxone .......................................... 34naltrexone ........................................34naproxen ........................................115naproxen sodium ........................... 115naratriptan ......................................162NARCAN..........................................34

NARDIL............................................14NASAL ALLERGY............................. 7NASAL ALLERGY SYMPTOM CONTROL......................................... 7NASAL MOISTURIZING................155NASAL SPRAY (SODIUM CHLORIDE)...................................155nateglinide ....................................... 71NATURAL B-100 COMPLEX.........211NATURAL CALCIUM.....................191NATURAL DAILY FIBER...............122NATURAL FIBER LAXATIVE (SUGAR)........................................122NATURAL FIBER LAXATIVE THERAPY......................................122NATURAL FIBER LAXATIVE(ASPART).....................123NATURAL PSYLLIUM FIBER........123NATURAL SENNA LAXATIVE...... 123NATURAL TEARS (PF)................... 83NATURAL VEG LAXATIVE(SENNOSID)................ 123NATURAL VEGETABLE................123NATURAL VEGETABLE (PSYLLIUM)...................................123NATURAL VEGETABLE POWDER....................................................... 123NATURA-LAX................................123NATURE-THROID........................... 78NAYZILAM.....................................166NECON 0.5/35 (28)......................... 57nefazodone ......................................17NEMBUTAL SODIUM......................33neomycin ......................................... 99neomycin-bacitracin-poly-hc ............ 79neomycin-bacitracin-polymyxin ........81neomycin-polymyxin b-dexameth .... 79neomycin-polymyxin-gramicidin .......81neomycin-polymyxin-hc ................... 75NEO-POLYCIN................................81NEO-POLYCIN HC..........................79NEOSPORIN (NEO-BAC-POLYM)..62NEPHPLEX RX..............................211NEPHRONEX................................211NEPHRONEX-SL.......................... 211NEPHRO-VITE.............................. 211NERLYNX......................................143NESINA........................................... 71NESTABS......................................206

NESTABS DHA............................. 206NEUPOGEN.................................... 90NEURONTIN................................. 173nevirapine ...................................... 104NEW DAY........................................58NEWGEN.......................................206NEXAVAR......................................143niacin ......................................... 51, 52niacin (inositol niacinate) ................. 51NIACIN (NIACINAMIDE)..................51NIACIN FLUSH FREE..................... 51niacinamide ......................................52nicardipine ....................................... 47NICORELIEF................................. 178nicotine .......................................... 178nicotine (polacrilex) ........................178NICOTROL.................................... 178NICOTROL NS.............................. 178nifedipine ................................... 47, 48NIGHTIME SLEEP...........................37NIGHTTIME ALLERGY RELIEF........4NIGHTTIME DRY-EYE RELIEF...... 83NIGHTTIME SLEEP AID (DIPHEN) 37NIGHTTIME SLEEP-AID (DOXYLAMN).................................. 37NIKKI (28)........................................58nilutamide ...................................... 139nimodipine ....................................... 48NINLARO.......................................143nitisinone ........................................148NITRO-BID...................................... 52nitrofurantoin ....................................97nitrofurantoin macrocrystal .............. 97nitrofurantoin monohyd/m-cryst ....... 97nitroglycerin ............................... 52, 53NITROSTAT.................................... 53NITRO-TIME....................................53NITYR............................................148NIVA-FOL...................................... 211NIVA-PLUS....................................206NIVESTYM...................................... 90NIX CREME RINSE.........................65NOBLE FORMULA HC....................67NON-ASPIRIN............................... 160NON-ASPIRIN CHILDRENS......... 160NON-ASPIRIN EXTRA STRENGTH...................................160NON-ASPIRIN PAIN RELIEF........ 160NORA-BE........................................ 58

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NORDITROPIN FLEXPRO..............77noreth-ethinyl estradiol-iron ............. 58norethindrone (contraceptive) ..........58norethindrone acetate ......................94norethindrone ac-eth estradiol ...58, 94norethindrone-e.estradiol-iron ..........58norgestimate-ethinyl estradiol ..........58NORLYDA....................................... 58NORPRAMIN...................................20NORTEMP.....................................160NORTREL 0.5/35 (28)..................... 58NORTREL 1/35 (21)........................ 58NORTREL 1/35 (28)........................ 58NORTREL 7/7/7 (28)....................... 58nortriptyline ...................................... 21NORVIR.........................................107NO-STICK GLUCOSE.....................74NOVA SAFETY LANCETS............127NOVA SUREFLEX LANCETS....... 127NOVOEIGHT................................... 86NOVOFINE 32...............................153NOVOFINE AUTOCOVER............ 153NOVOFINE PLUS..........................153NOVOLIN 70/30 U-100 INSULIN.....74NOVOLIN 70-30 FLEXPEN U-100.. 74NOVOLIN N FLEXPEN....................74NOVOLIN N NPH U-100 INSULIN.. 74NOVOLIN R REGULAR U-100 INSULN............................................74NOVOLOG MIX 70-30 U-100 INSULN............................................74NOVOLOG MIX 70-30FLEXPEN U-100...............................................74NOVOSEVEN RT............................ 86NOVOTWIST.................................153NP THYROID...................................78NUBEQA........................................139NU-MAG........................................ 194NUPLAZID.......................................40NUVIGIL.......................................... 34NUWIQ............................................ 87NYAMYC......................................... 64nystatin ...................................... 64, 99NYSTOP..........................................64OBIZUR........................................... 87OBSTETRIX DHA..........................206OBSTETRIX EC............................ 206O-CAL F.A..................................... 206OCEAN NASAL............................. 155

OCELLA...........................................58OCTAPLAS (BLOOD GROUP A).... 91OCTAPLAS (BLOOD GROUP AB)..91OCTAPLAS (BLOOD GROUP B).... 91OCTAPLAS (BLOOD GROUP O)....91octreotide acetate .......................... 156OCUTABS..................................... 200ODEFSEY......................................109ODOMZO.......................................140ODOR CONTROL FOOT-SNEAKER........................................64ofloxacin ...............................75, 81, 98OGESTREL (28)..............................58olanzapine ................................. 28, 29olanzapine-fluoxetine .......................40OLUMIANT.................................... 114omega 3-dha-epa-fish oil ...........50, 51omega-3 acid ethyl esters ................51omega-3 fatty acids ......................... 51omega-3 fatty acids-fish oil ..............51omeprazole ....................................187omeprazole magnesium ................ 187OMNICAP......................................200ON CALL LANCET........................ 127ON CALL PLUS LANCET..............127ONCCOR.......................................200ONCE DAILY.................................200ONCOVITE....................................200ondansetron .......................................8ondansetron hcl ................................. 8ONE DAILY....................................200ONE DAILY CALCIUM/IRON........ 200ONE DAILY COMPLETE...............200ONE DAILY ENERGY................... 200ONE DAILY ESSENTIAL...............200ONE DAILY FOR MEN..................200ONE DAILY FOR MEN 50+ ADVANCED...................................200ONE DAILY FOR WOMEN............200ONE DAILY HEALTHY WEIGHT...200ONE DAILY MAXIMUM................. 200ONE DAILY MEN'S 50 PLUS MEMORY.......................................200ONE DAILY MEN'S 50 PLUS W-D3.................................................. 200ONE DAILY MULTIVITAMIN......... 200ONE DAILY MULTIVIT-IRON(FOLIC).................................200ONE DAILY PLUS IRON............... 200

ONE DAILY PLUS MINERALS......200ONE DAILY WITH IRON............... 201ONE DAILY WOMEN 50 PLUS.....201ONE DAILY WOMEN 50 PLUS(VIT K)................................................... 201ONE DAILY WOMEN'S................. 201ONE DAILY WOMENS 50 PLUS...201ONE DAILY WOMEN'S HEALTH.. 201ONE WAY VALVED MOUTHPIECE.................................12ONE-A-DAY CHOLESTEROL PLUS............................................. 201ONE-A-DAY ENERGY...................201ONE-A-DAY ESSENTIAL..............201ONE-A-DAY MAXIMUM FORMULA..................................... 201ONE-A-DAY MEN 50 PLUS (GINKGO)......................................201ONE-A-DAY MEN VITACRAVES..201ONE-A-DAY MENOPAUSE FORMULA..................................... 201ONE-A-DAY MEN'S 50 PLUS....... 201ONE-A-DAY MEN'S MULTIVITAMIN............................. 201ONE-A-DAY TEEN ADVANTAGE.201ONE-A-DAY VITACRAVES........... 201ONE-A-DAY VITACRAVES IMMUNITY.....................................201ONE-A-DAY VITACRAVES OMEGA-3...................................... 201ONE-A-DAY WEIGHTSMART.......201ONE-A-DAY WOMEN VITACRAVES................................201ONE-A-DAY WOMEN'S ACTIVE.. 201ONE-A-DAY WOMENS FORMULA....................................................... 202ONE-A-DAY WOMEN'S HEALTHY SKIN.............................................. 202ONE-A-DAY WOMEN'S PETITES 202ONETOUCH DELICA LANCETS...127ONETOUCH DELICA PLUS LANCET.........................................128ONETOUCH SURESOFT LANCING DEV.............................. 128ONETOUCH ULTRASOFT LANCETS...................................... 128ONFI.............................................. 166ON-THE-GO LANCETS.................128OPCICON ONE-STEP.....................58

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OPTICHAMBER ADULT MASK-LARGE.............................................12OPTICHAMBER DIAMOND LG MASK...............................................12OPTICHAMBER DIAMOND VHC....12OPTICHAMBER DIAMOND-MED MSK.................................................12OPTICHAMBER DIAMOND-SML MASK...............................................12OPTIMAL D3................................. 213OPTION-2........................................58OPTISOURCE...............................202OPTI-VITAMINS............................ 189OPURITY MULTIVITAMIN............ 202ORALONE..................................... 147ORALYTE........................................75ORENCIA...................................... 112ORENCIA CLICKJECT..................112ORFADIN.......................................148ORKAMBI...................................... 156orphenadrine citrate .......................178ORSYTHIA...................................... 58OSCIMIN....................................... 182OSCIMIN SL..................................183OSCIMIN SR................................. 183oseltamivir ......................................101OTEZLA.........................................112OTEZLA STARTER.......................112OVERNIGHT LUBRICATING EYE..83oxazepam ........................................ 25oxcarbazepine ............................... 173OXTELLAR XR..............................173oxybutynin chloride ........................188oxycodone ..................................... 161oxycodone-acetaminophen ............164OXYTROL FOR WOMEN..............188OYSCO 500/D............................... 191OYSCO-500...................................191OYSTER SHELL + D3...................191OYSTER SHELL CALCIUM.......... 191OYSTER SHELL CALCIUM 500... 191OYSTER SHELL CALCIUM-VIT D2.................................................. 191OYSTER SHELL CALCIUM-VIT D3.................................................. 191OYSTERCAL-D............................. 191OZEMPIC.................................. 70, 71PACERONE.....................................44PAIN AND FEVER.........................160

PAIN RELIEF.................................160PAIN RELIEF (LIDOCAINE)............ 69PAIN RELIEF EXTRA STRENGTH....................................................... 160PAIN RELIEF REGULAR STRENGTH...................................160PAIN RELIEVER............................160PAIN RELIEVER EXTRA STRENGTH...................................160paliperidone ..................................... 29PAMELOR....................................... 21PANCREAZE.........................181, 182PANDA MASK................................. 12PANHEMATIN................................. 87PANOXYL........................................69pantoprazole ..................................187PAPAYA ENZYME (AMYLAS-PROTEAS).................................... 181PARNATE........................................14PAROEX ORAL RINSE.................147paromomycin ................................. 100paroxetine hcl .................................. 16paroxetine mesylate(menop.sym) ..149PARVA-CAL 500........................... 191PARVLEX...................................... 202PAXIL...............................................17PAXIL CR........................................ 16P-COL RITE...................................123PEAK AIR PEAK FLOW METER.....12PEDIA D-VITE............................... 213PEDIA IRON..................................193PEDIA POLY-VITE........................ 205PEDIA TRI-VITE............................205PEDIACARE FEVER REDUCER.. 161PEDIALYTE.....................................75PEDIALYTE ADVANCED CARE..... 75PEDIALYTE FREEZER POPS........ 75PEDIALYTE SINGLES.................... 75PEDIATRIC ELECTROLYTE...........75PEDIATRIC ENEMA......................125PEDIATRIC FREEZER POPS.........75PEDIATRIC MEDIUM MASK...........12PEDIATRIC PANDA MASK............. 12PEDIATRIC SMALL MASK..............12PEDIAVANCE..................................75peg 3350-electrolytes .................... 123PEGANONE.................................. 173PEGASYS......................................110peg-electrolyte soln ........................123

PEGINTRON................................. 110PEN NEEDLE................................153pen needle, diabetic .......................153penicillin v potassium .......................98PENTASA......................................117pentazocine-naloxone ....................161PENTIPS....................................... 153pentobarbital sodium ....................... 33pentoxifylline ....................................89PEPTIC RELIEF............................ 119PEP-T-MED...................................119PEPTO-BISMOL............................119PEPTO-BISMOL TO-GO...............119PERDIEM OVERNIGHT RELIEF.. 123perindopril erbumine ........................45PERIOGARD................................. 147permethrin ........................................65perphenazine ...................................32perphenazine-amitriptyline ...............19PERRY PRENATAL...................... 206PERSA-GEL.................................... 69PERSERIS.......................................29PERSONAL BEST FULL RANGE... 12PERTZYE...................................... 182PEXEVA.......................................... 17PHARBECHLOR............................... 4PHARBEDRYL.................................. 5PHARBETOL.................................161PHENADOZ.......................................8phenazopyridine ............................ 188phenelzine ....................................... 14phenobarbital ...................................33phenobarbital sodium ...................... 33phenylephrine hcl .............................80PHENYTEK................................... 174phenytoin ....................................... 174phenytoin sodium ...........................174phenytoin sodium extended ...........174PHILITH...........................................59PHILLIPS.......................................195PHILLIPS' LIQUI-GELS................. 123PHOS-NAK......................................76PHOSPHOLINE IODIDE................. 82PHOSPHOROUS SUPPLEMENT...76phytonadione (vitamin k1) ................93PIFELTRO..................................... 104PIKO 1............................................. 12pilocarpine hcl ..........................82, 138pimecrolimus ....................................70

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pimozide .......................................... 26PIMTREA (28)................................. 59PINAWAY...................................... 100PINK BISMUTH............................. 119PINK BISMUTH MAXIMUM STRENGTH...................................119PINWORM TREATMENT.............. 100pioglitazone ......................................71PIP LANCET..................................128PIQRAY......................................... 143PIRMELLA.......................................59piroxicam ....................................... 115PLASBUMIN 25 %...........................91PLASBUMIN 5 %.............................91PLASMANATE.................................92PNV 29-1....................................... 206pnv cmb#95-ferrous fumarate-fa ... 206POCKET CHAMBER.......................12POCKET PEAK FLOW METER...... 12PODIAPN.......................................211podofilox .......................................... 69POLYCIN.........................................81polyethylene glycol 3350 ............... 123polymyxin b sulf-trimethoprim .......... 81polyvinyl alcohol ...............................83POLY-VI-SOL................................ 205POMALYST................................... 141PORTIA 28...................................... 59potassium chloride ...........................76potassium citrate ............................187potassium citrate-citric acid ........... 187potassium, sodium phosphates ....... 76POWDERLAX................................123pramipexole ................................... 165pravastatin ....................................... 49prazosin ........................................... 44PRECEDEX.....................................37PRECEDEX IN 0.9 % SODIUM CHLOR............................................ 37prednisolone .................................. 113prednisolone acetate ....................... 80prednisolone sodium phosphate................................................. 80, 113prednisone .....................................113pregabalin ......................................174PREMARIN......................................94PREMPHASE.................................. 94PREMPRO.......................................94PRENATABS FA........................... 206

PRENATABS RX...........................206PRENATAL....................................207PRENATAL 19...............................207PRENATAL 19 (WITH DOCUSATE)..................................206PRENATAL COMPLETE...............207PRENATAL DHA............................. 51PRENATAL FORMULA................. 207PRENATAL GUMMY.....................207PRENATAL LOW IRON.................207PRENATAL ONE DAILY................207PRENATAL PLUS......................... 207PRENATAL PLUS (CALCIUM CARB)............................................207PRENATAL TABLET..................... 207PRENATAL VITAMIN.................... 207PRENATAL VITAMIN PLUS LOW IRON..............................................207PRENATAL VITAMIN WITH MINERALS.................................... 207prenatal vit-iron fum-folic ac ...........207prenatal vits96-iron fum-folic ..........207PRENATAL-U................................207PREPARATION H HYDROCORTISONE...................... 67PREPLUS......................................207PRESSURE ACTIVATED LANCETS...................................... 128PRETAB........................................ 208PREVALITE.....................................50PREVENT DROPSAFE PEN NEEDLE........................................ 153PREVIDENT.................................. 192PREVIFEM...................................... 59PREZCOBIX..................................102PREZISTA..................................... 102PRIFTIN.........................................100primaquine .....................................101PRIMEAIRE.....................................12primidone .......................................174PRISTIQ.......................................... 18PRO COMFORT ALCOHOL PADS.68PRO COMFORT INSULIN SYRINGE.......................................134PRO COMFORT LANCET.............128PRO COMFORT PEN NEEDLE....154PRO COMFORT SPACER-ADULT MASK...............................................12

PRO COMFORT SPACER-CHILD MASK...............................................12probenecid .......................................84probenecid-colchicine ......................84PRO-CAL.......................................191PROCENTRA.................................. 22PROCERV HP...............................202PROCHAMBER...............................12prochlorperazine ................................8prochlorperazine maleate .................. 8PROCRIT.........................................89PROCTO-MED HC.......................... 67PROCTOZONE-HC......................... 67PRODIGY INSULIN SYRINGE......135PRODIGY LANCETS.....................128PRODIGY TWIST TOP LANCET.. 128PROFILNINE................................... 88progesterone micronized ................. 94PROGRAF.......................................96promethazine .................................5, 8PROMETHEGAN...............................8PROMOLAXIN...............................123propafenone .....................................44proparacaine ....................................80propranolol .......................................46propylthiouracil .................................78PRORENAL...................................211PRORENAL QD.............................202PROSIGHT....................................202PROTECT CARDIO AF................. 202PROTECT PLUS SO.....................202protriptyline ...................................... 21PROVIGIL........................................34PROVIL..........................................115PROZAC..........................................17PULMICORT FLEXHALER..............10PULMOZYME................................156PURE AND GENTLE DISPOSABLE................................125PURE COMFORT ALCOHOL PADS...............................................68PURE COMFORT LANCETS........ 128PURE COMFORT PEN NEEDLE..154PURE COMFORT SAFETY LANCETS...................................... 128PURELAX......................................123PUSH BUTTON SAFETY LANCETS...................................... 128pyrazinamide ................................. 100

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pyridostigmine bromide ....................13pyrimethamine ............................... 101QBRELIS......................................... 45quazepam ........................................35QUDEXY XR..................................174quetiapine ........................................ 29QUILLICHEW ER............................ 43QUILLIVANT XR..............................43QUIN B STRONG..........................211quinapril ........................................... 45quinapril-hydrochlorothiazide ...........44quinidine sulfate ...............................44QUINTABS.................................... 202QUINTABS-M................................ 202QUINTABS-M IRON FREE............202QUIT 2........................................... 178QUIT 4........................................... 178QVAR REDIHALER.........................10raloxifene ......................................... 77ramelteon .........................................34ramipril .............................................45ranitidine hcl ...................................186ranolazine ........................................ 52RAVICTI.........................................118READYLANCE SAFETY LANCETS...................................... 128READY-TO-USE ENEMA..............125READY-TO-USE ENEMA (MIN OIL)................................................125REBINYN.........................................88RECLIPSEN (28).............................59RECOMBINATE.............................. 87REESE'S PINWORM MEDICINE.. 100REFRESH LACRI-LUBE................. 83REFRESH P.M................................ 84REGULOID (PSYLLIUM HUSK-SUCRO).........................................123REGULOID, SUGAR FREE...........123RELENZA DISKHALER.................101RELEXXII .........................................43RELIAMED LANCET..................... 128RELIAMED SAFETY SEAL LANCETS...................................... 128RELIAMED TWIST AND CAP LANCET.........................................128RELION NEEDLES........................154RELION PEN NEEDLES............... 154RELION THIN LANCETS.............. 128

RELION ULTRA THIN PLUS LANCETS...................................... 128REMEDY ANTIFUNGAL..................64REMERON...................................... 14REMERON SOLTAB....................... 14RENAL CAPS................................211RENAL VITAMIN........................... 211RENAL-VITE..................................211RENA-VITE....................................211RENA-VITE RX..............................211RENO CAPS..................................211repaglinide ....................................... 71RESTORE PLUS (CMCELLULOSE)............................83RESTORE PM.................................84RESTORE TEARS.......................... 83RESTORIL.......................................35RETACRIT.......................................89RETROVIR.................................... 105REVCOVI.......................................151REVIVE PLUS................................. 83REVLIMID......................................141REXULTI..........................................27REYATAZ...................................... 108RIASTAP......................................... 85ribavirin .......................................... 110RID LICE KILLING...........................65rifabutin ..........................................100rifampin ..........................................100RI-GEL...........................................185RI-GEL II ........................................185RIGHTEST GL300 LANCETS....... 128RIGINIC......................................... 185rimantadine ....................................101RI-MOX..........................................185RINGWORM....................................64RISPERDAL.................................... 29RISPERDAL CONSTA.................... 29risperidone .................................29, 30RITALIN...........................................43RITALIN LA......................................43RITEFLO AEROCHAMBER............ 12ritonavir ..........................................108rivastigmine tartrate ......................... 13RIXUBIS.......................................... 88rizatriptan .......................................162ropinirole ........................................165ROSADAN.......................................61rosuvastatin ..................................... 49

ROWEEPRA..................................175ROWEEPRA XR............................175ROZEREM.......................................34ROZLYTREK................................. 144RUBRACA..................................... 144RUCONEST...................................113RYDAPT........................................ 144SABRIL..........................................175SAFESNAP INSULIN SYRINGE... 135SAFETY LANCETS....................... 128SAFETY PEN NEEDLE.................154SAFETY SEAL LANCETS.............128SAFETY-LET LANCETS............... 128SALINE MIST................................ 155SALINE NASAL............................. 155SALINE NASAL MIST....................155SALINE NOSE...............................156SALMON OIL-1000..........................51SALONPAS (LIDOCAINE)...............69SANTYL...........................................70SAPHRIS.........................................30SARAFEM....................................... 17SEA-OMEGA 30..............................51SECONAL SODIUM........................ 33SECUADO.......................................30SECURA ANTIFUNGAL.................. 64SECURA ANTIFUNGAL EXTRA THICK..............................................64SEGLUROMET................................72selegiline hcl .................................. 165selenium sulfide ...............................67SELZENTRY..................................103SENEXON-S..................................123SENIOR TABS...............................202SENNA.......................................... 123SENNA LAX...................................123SENNA LAXATIVE........................ 123SENNA PLUS................................123SENNA-S.......................................123SENNA-TIME S............................. 123SENNO..........................................123sennosides-docusate sodium ........ 124SENOKOT..................................... 124SENOKOT EXTRA STRENGTH... 124SENOKOT-S..................................124SEN-O-TAB................................... 124SENTRY........................................ 202SENTRY SENIOR......................... 202SEREVENT DISKUS.........................9

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SEROQUEL.....................................30SEROQUEL XR...............................30sertraline ..........................................17SETLAKIN....................................... 59sevelamer carbonate ....................... 75sevelamer hcl ...................................75SF.................................................. 192SF 5000 PLUS...............................192SHAKE THAT ACHE..................... 161SHAROBEL..................................... 59SIDEROL.......................................193SIDESTREAM PEDIATRIC FACE MASK...............................................12SILACE..........................................124SILADRYL SA....................................5sildenafil (pulm.hypertension) ..........49SILENOR.........................................38SILICONE MASK - INFANT.............13SILICONE MASK - PEDIATRIC...... 13SILIQ................................................70silver sulfadiazine ............................ 65simethicone ....................................179SIMLIYA (28)................................... 59SIMPLY SLEEP...............................38simvastatin .................................49, 50SINGLE-LET..................................128sirolimus ...........................................96SLEEP AID (DIPHENHYDRAMINE)................... 38SLEEP AID (DOXYLAMINE)........... 38SLEEP AID MAX STR (DIPHENHYDR)...............................38SLEEP TIME....................................38SLEEPING.......................................38SLOW RELEASE IRON.................193SLOW-MAG...................................195SMART SENSE LANCETS........... 128SMARTEST LANCET....................128SMOOTH ANTACID...................... 185SMOOTHLAX................................ 124sodium benzoate-sod phenylacet ..118sodium bicarbonate ....................... 185sodium chloride ........................81, 149sodium citrate-citric acid ................ 187SODIUM FLUORIDE 5000 PLUS..192sodium phenylbutyrate ...................118SODIUM POLYSTYRENE (SORB FREE)..............................................75sodium polystyrene sulfonate .......... 75

sofosbuvir-velpatasvir ....................110SOFT TOUCH LANCETS..............128SOLIRIS...........................................89SOLO.............................................202SOLUS V2 LANCETS....................128SOLUVITA-E................................. 213SOOTHE (BISMUTH SUBSALICYLATE)........................ 119SOOTHE REGULAR STRENGTH 119SOOTHING CARE (HYDROCORTISONE).................... 67SORINE...........................................46sotalol .............................................. 46SOTALOL AF...................................46SOVALDI....................................... 110SPACE CHAMBER PLUS............... 13SPECTRAVITE ADULT 50 PLUS..202SPECTRAVITE ADVANCED FORMULA..................................... 202SPECTRAVITE MEN'S..................202SPECTRAVITE SENIOR...............202SPECTRAVITE ULTRA MEN 50+.202SPECTRAVITE ULTRA MEN'S SR....................................................... 203SPECTRAVITE ULTRA WOMEN..203SPECTRAVITE ULTRA WOMEN'S SR..................................................203spinosad .......................................... 65SPINRAZA (PF).............................138SPIRIVA RESPIMAT......................... 9spironolactone ................................. 48spironolacton-hydrochlorothiaz ........48SPRINTEC (28)............................... 59SPRITAM.......................................175SPRYCEL......................................144SPS (WITH SORBITOL)..................75SRONYX..........................................59SSD................................................. 65ST JOSEPH ASPIRIN..................... 92st. john's wort ...................................17ST. JOSEPH ASPIRIN.................... 92stavudine ....................................... 106STEGLATRO...................................71STEGLUJAN....................................72STERILANCE TL...........................128STIMATE......................................... 77STIMULANT LAXATIVE PLUS......124STIVARGA.....................................144STOMACH RELIEF....................... 119

STOMACH RELIEF MAX STRENGTH...................................119STOMACH RELIEF ORIGINAL..... 119STOOL SOFTENER......................124STOOL SOFTENER (DOCUSATE CAL)...............................................124STOOL SOFTENER-LAXATIVE....124STOOL SOFTENER-STIMULANT LAXAT........................................... 124STOP SMOKING AID....................178STRATTERA................................... 43STRESS B PLUS ZINC................. 211STRESS FORMULA......................203STRESS FORMULA 600 C........... 203STRESS FORMULA WITH IRON..193STRESS FORMULA WITH IRON(SULF).................................. 193STRIBILD.......................................109STROVITE FORTE........................203STROVITE ONE............................203SUBLOCADE.................................164SUBOXONE.................................. 164SUBVENITE.................................. 175SUBVENITE STARTER (BLUE) KIT................................................. 175SUBVENITE STARTER (GREEN) KIT................................................. 175SUBVENITE STARTER (ORANGE) KIT.............................. 175SUCRAID.......................................181sucralfate ....................................... 185sulfacetamide sodium ......................80sulfacetamide sodium-sulfur ............65sulfacetamide sod-sulfur-urea ......... 65sulfacetamide-prednisolone .............80sulfamethoxazole-trimethoprim ........96sulfasalazine ..................................117SULFATRIM.................................... 96sulindac ..........................................115sumatriptan ....................................162sumatriptan succinate ....................162SUNOSI...........................................34SUNVITE....................................... 203SUPER B COMPLEX-VITAMIN C.203SUPER B MAXI COMPLEX...........211SUPER B-50 COMPLEX............... 211SUPER CALCIUM......................... 191

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SUPER GINSENG MULTIVITAMIN....................................................... 203SUPER MULTIPLE........................203SUPER MULTIPLE - LOW IRON.. 203SUPER MULTIVITAMIN................ 203SUPER OMEGA-3...........................51SUPER QUINTS............................211SUPER QUINTS B-50................... 211SUPER THERA VITE M................ 203SUPER THIN LANCETS............... 128SUPERIOR DIGESTIVE ENZYME 181SUPERPLEX-T..............................203SUPERVITE.................................. 211SUPRAX..........................................97SURE COMFORT ALCOHOL PREP PADS.................................... 68SURE COMFORT INS. SYR. U-100.................................................135SURE COMFORT INSULIN SYRINGE.......................................135SURE COMFORT LANCETS........ 129SURE COMFORT PEN NEEDLE..154SURE-FINE PEN NEEDLES......... 154SURE-JECT INSULIN SYRINGE.. 135SURE-LANCE................................129SURE-LANCE ULTRA THIN......... 129SURE-PREP ALCOHOL PREP PADS...............................................68SURE-TOUCH LANCET................129SUSTIVA....................................... 104SUTENT........................................ 144SYEDA.............................................59SYMBYAX....................................... 41SYMDEKO.....................................156SYMFI............................................109SYMFI LO......................................109SYMJEPI....................................... 138SYMPAZAN...................................166SYMTUZA......................................101SYNJARDY......................................72SYNJARDY XR................................72SYNTHROID....................................78SYSTANE (PROPYLENE GLYCOL).........................................83SYSTANE GEL................................83SYSTANE NIGHTTIME................... 84SYSTANE ULTRA........................... 83TAB-A-VITE...................................203

TAB-A-VITE MULTIVITAMIN W-IRON..............................................203TAB-A-VITE/IRON.........................203TABLOID....................................... 140tacrolimus .................................. 70, 96TACTINAL..................................... 161TACTINAL EXTRA STRENGTH....161tadalafil (pulm. hypertension) ...........49TAGRISSO.................................... 144TAKE ACTION.................................59TAKHZYRO................................... 116TALZENNA....................................144tamoxifen ....................................... 146tamsulosin ......................................187TARCEVA......................................144TARINA 24 FE.................................59TARINA FE 1/20 (28).......................59TARINA FE 1-20 EQ (28)................ 59TASIGNA.......................................144TAZTIA XT.......................................48TECFIDERA.................................. 147TECHLITE INSULIN SYR HALF UNIT.............................................. 135TECHLITE INSULIN SYRINGE..... 135TECHLITE LANCETS....................129TECHLITE PEN NEEDLE..............154TEGRETOL................................... 175TEGRETOL XR............................. 175TELCARE LANCETS.....................129temazepam ......................................35TEMIXYS.......................................102temozolomide ................................ 139TENCON........................................157tenofovir disoproxil fumarate ..........106terazosin .................................... 44, 45terbinafine hcl ............................ 64, 99terbutaline ..........................................9terconazole .................................... 189TERUMO INSULIN SYRINGE.......136testosterone cypionate .....................93tetracycline .......................................99THALOMID...................................... 99THE MAGIC BULLET.................... 125THEOCHRON..................................13theophylline ......................................13THERA...........................................203THERA M PLUS (FERROUS FUMARAT).................................... 203THERA-D.......................................213

THERADEX M............................... 203THERAGRAN-M PREMIER 50 PLUS............................................. 203THERALOGIX COMPANION........ 203THERA-M...................................... 203THERANATAL...............................208THERAPEUTIC-M......................... 203THERAPEUTIC-M VITAMIN/MINERALS.....................203THERA-TABS................................204THERA-TABS M............................203THERATRUM COMPLETE 50 PLUS/LUT......................................192THERATRUM COMPLETE 50 PLUS-LYC..................................... 192THERATRUM COMPLETE WITH LUTEIN..........................................204THEREMS..................................... 204THEREMS-M.................................204THIN LANCETS.............................129THINPRO INSULIN SYRINGE...... 136thioridazine ...................................... 32thiothixene ....................................... 31THRIVITE RX................................ 208THRIVITE-19................................. 208THROMBATE III .............................. 92thyroid (pork) ....................................78TIADYLT ER....................................48tiagabine ........................................ 175TIBSOVO.......................................146TILIA FE...........................................59timolol maleate .................................82tinidazole ........................................100TIVICAY.........................................108tizanidine ........................................178TOBI PODHALER............................99tobramycin ....................................... 81tobramycin in 0.225 % nacl ..............99tobramycin with nebulizer ................ 99tobramycin-dexamethasone ............ 79TODAY CONTRACEPTIVE SPONGE......................................... 53tolnaftate ..........................................64tolterodine ......................................188TOPAMAX..................................... 176TOPCARE CLICKFINE..................154TOPCARE ULTRA COMFORT..... 136

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TOPCARE UNIVERSAL1 LANCET....................................................... 129topiramate ......................................176toremifene ......................................146torsemide .........................................48TOTAL ALLERGY MEDICINE........... 5TOTAL B/C.................................... 204TRACLEER......................................49TRADJENTA....................................71tramadol .........................................161trandolapril .......................................45tranexamic acid ................................85tranexamic acid in nacl,iso-os ..........85TRANXENE T-TAB..........................25tranylcypromine ............................... 14TRAVEL SICKNESS..........................8TRAVEL SICKNESS (MECLIZINE)...8TRAVEL-EASE (MECLIZINE)........... 8trazodone .........................................18TRECATOR...................................100tretinoin ............................................61TRETTEN........................................ 88TRI FEMYNOR................................59triamcinolone acetonide .......7, 67, 147triamterene-hydrochlorothiazid ........ 48triazolam .................................... 35, 36TRI-BUFFERED ASPIRIN............. 157TRICARE.......................................208TRIDERM........................................ 67TRI-ESTARYLLA.............................59trifluoperazine .................................. 32trifluridine ......................................... 80trihexyphenidyl ...............................165TRIKAFTA..................................... 156TRIKLO............................................51TRI-LEGEST FE..............................59TRILEPTAL....................................176TRI-LINYAH.....................................59TRI-LO-ESTARYLLA.......................59TRI-LO-MARZIA.............................. 59TRI-LO-MILI.....................................59TRI-LO-SPRINTEC..........................59TRILYTE WITH FLAVOR PACKETS......................................124trimethoprim .....................................97TRI-MILI...........................................60trimipramine .....................................21TRINATAL RX 1............................ 208TRINATE....................................... 208

TRINTELLIX.................................... 19TRIPHROCAPS.............................211TRIPLE ANTIBIOTIC.......................62TRIPLE ANTIBIOTIC PLUS.............62TRI-PREVIFEM (28)........................60TRI-SPRINTEC (28)........................ 60TRIUMEQ...................................... 109TRI-VI-SOL....................................205TRI-VITAMIN WITH FLUORIDE....205TRI-VITE WITH FLUORIDE.......... 205TRIVORA (28)................................. 60TRI-VYLIBRA...................................60TRI-VYLIBRA LO.............................60TRIZIVIR........................................103TROGARZO.................................. 101TROKENDI XR.............................. 176tropicamide ...................................... 82trospium .........................................188TRUE COMFORT ALCOHOL PADS...............................................68TRUE COMFORT INSULIN SYRINGE.......................................136TRUE COMFORT LANCET...........129TRUE COMFORT PEN NEEDLE..154TRUEPLUS DIABETIC MULTIVITAMIN............................. 204TRUEPLUS INSULIN.................... 136TRUEPLUS KETONE....................156TRUEPLUS LANCETS..................129TRUEPLUS PEN NEEDLE............154TRULICITY...................................... 71TRUSTEX LATEX CONDOM........ 148TRUSTEX LUBRICATED CONDOMS....................................148TRUSTEX NON-LUB CONDOMS.148TRUSTEX-RIA LUB/SPERMICIDE148TRUSTEX-RIA LUBRICATED CONDOMS....................................148TRUSTEX-RIA NON-LUB CONDOMS....................................148TRUVADA......................................102TRUZONE PEAK FLOW METER....13tryptophan ..................................38, 39TULANA...........................................60TURALIO....................................... 144TWIST LANCETS..........................129TYBOST........................................ 109TYKERB........................................ 144TYLENOL...................................... 161

TYLOPHEN................................... 161TYMLOS..........................................77ULTICARE.....................................136ULTICARE INSULIN SYR HALF UNIT.............................................. 136ULTICARE INSULIN SYRINGE.....136ULTICARE PEN NEEDLE............. 154ULTIGUARD SAFE PACK.............154ULTILET ALCOHOL SWAB.............68ULTILET BASIC LANCETS...........129ULTILET CLASSIC LANCETS...... 129ULTILET INSULIN SYRINGE........ 137ULTILET LANCETS.......................129ULTILET PEN NEEDLE.................154ULTILET SAFETY LANCETS........129ULTIMATE MEN'S COMPLETE 50+.................................................204ULTIMATE WOMEN'S COMPLETE 50+............................204ULTOMIRIS..................................... 89ULTRA B-100 COMPLEX..............211ULTRA CMFT INS SYR HALF UNIT.............................................. 137ULTRA COMFORT INSULIN SYRINGE.......................................137ULTRA DAIRY DIGESTIVE...........181ULTRA FINE LANCETS................ 129ULTRA FLO INSULIN SYRINGE...137ULTRA FLO PEN NEEDLE........... 154ULTRA FREEDA........................... 204ULTRA FRESH................................83ULTRA OMEGA-3........................... 51ULTRA STRENGTH ANTACID..... 185ULTRA STRENGTH CALCIUM ANTACID.......................................185ULTRA THIN II LANCETS............. 129ULTRA THIN LANCETS................ 129ULTRA THIN PEN NEEDLE..........154ULTRA THIN PLUS LANCETS......129ULTRA TLC LANCETS..................129ULTRACARE INSULIN SYRINGE.137ULTRA-CARE LANCETS.............. 129ULTRACARE PEN NEEDLE......... 155ULTRALANCE LANCETS............. 129ULTRA-THIN II (SHORT) INS SYR....................................................... 137ULTRA-THIN II (SHORT) PEN NDL................................................155

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ULTRA-THIN II INS PEN NEEDLES......................................155ULTRA-THIN II INSULIN SYRINGE.......................................137ULTRA-THIN II LANCETS.............129UNICOMPLEX-M...........................204UNIFINE PENTIPS........................155UNIFINE PENTIPS MAXFLOW.....155UNIFINE PENTIPS PLUS..............155UNIFINE PENTIPS PLUS MAXFLOW.....................................155UNILET COMFORTOUCH LANCET.........................................129UNILET EXCELITE II LANCET..... 129UNILET EXCELITE LANCET........ 129UNILET GP LANCET.....................129UNILET LANCET...........................129UNILET LANCETS........................ 129UNILET SUPER THIN LANCETS..129UNISOM (DIPHENHYDRAMINE)....39UNISOM (DOXYLAMINE)............... 39UNISOM SLEEPGELS.................... 39UNISOM SLEEPMELTS..................39UNISTIK 3 COMFORT LANCET... 129UNISTIK 3 EXTRA LANCET......... 129UNISTIK 3 GENTLE...................... 129UNISTIK 3 LANCETS....................129UNISTIK 3 NORMAL LANCET...... 130UNISTIK CZT LANCET................. 130UNISTIK PRO LANCET.................130UNISTIK SAFETY..........................130UNISTIK TOUCH LANCETS......... 130UNITHROID.....................................79UNIVERSAL 1 LANCETS..............130URO-MAG..................................... 195ursodiol .......................................... 119VAGINAL CONTRACEPTIVE FOAM.............................................. 53valacyclovir .................................... 101valganciclovir ................................. 101VALIUM........................................... 25valproate sodium ........................... 176valproic acid ...................................176valproic acid (as sodium salt) ........ 176valsartan .......................................... 45valsartan-hydrochlorothiazide ..........45VALTOCO......................................166VALU-DRYL ALLERGY.....................5VANDAZOLE.................................188

VANICREAM HC............................. 67VANISHPOINT INSULIN SYRINGE.......................................137VANISHPOINT SYRINGE............. 137VAQTA (PF).....................................95V-C FORTE................................... 204VEGETABLE LAXATIVE............... 124VEGETABLE LAX-STOOL SOFTENER................................... 124VELCADE......................................144VELIVET TRIPHASIC REGIMEN (28).................................................. 60VEMLIDY.......................................110VENCLEXTA................................. 145VENCLEXTA STARTING PACK... 146venlafaxine .......................................19verapamil ......................................... 48VERIFINE PEN NEEDLE.............. 155VERSACLOZ...................................30VERTICALM...................................... 8VERZENIO.................................... 145VIC-FORTE................................... 204VICTOZA 2-PAK..............................71VICTOZA 3-PAK..............................71VIDEX 2 GRAM PEDIATRIC......... 106VIDEX EC......................................106VIEKIRA PAK................................ 110VIENVA............................................60vigabatrin ....................................... 176VIGADRONE................................. 177VIIBRYD.......................................... 19VIMIZIM......................................... 151VIMPAT......................................... 177VINATE GT....................................208VINATE M......................................208VINATE ONE.................................208VINATE ULTRA.............................208VIOKACE.......................................182VIORELE (28)..................................60VIRACEPT.....................................108VIRAMUNE....................................104VIRAMUNE XR..............................104VIREAD......................................... 106VIRT-CAPS....................................211VIRT-GARD...................................211VIRTRATE-2..................................188VIRTRATE-K................................. 188VIRT-VITE..................................... 211VIRT-VITE PLUS...........................211

VISION...........................................204VITACEL (WITH LUTEIN)............. 192VITAL-D RX...................................211VITALEE........................................204vitamin b complex ..........................211vitamin b complex-folic acid ...211, 212VITAMIN D2...................................213VITAMIN D3...................................213vitamin e ................................ 213, 214vitamin e (dl, acetate) .................... 213vitamin e acetate ............................213vitamin e mixed ..............................213vitamin e succinate ........................ 214VITAMINS A,C,D AND FLUORIDE205VITAMINS A-D-E SELENIUM........204VITAMINS AND MINERALS..........204VITAMINS B COMPLEX................212VITAMINS FOR HAIR....................204VITA-RESPA................................. 212VITRAKVI...................................... 145VIVAGUARD LANCET.................. 130VIVITROL........................................ 23VIZIMPRO..................................... 145VOLNEA (28)...................................60VONVENDI......................................87VORTEX ADULT MASK..................13VORTEX FROG MASK-CHILD....... 13VORTEX HOLDING CHAMBER......13VORTEX LADYBUG MASK-TODDLER........................................13VORTEX VHC FROG MASK-CHILD..............................................13VORTEX VHC LADYBUG MASK-TODDLR..........................................13VOSEVI......................................... 109VOTRIENT.....................................145VPRIV............................................150VP-VITE RX...................................212VRAYLAR........................................26VYFEMLA (28).................................60VYLIBRA..........................................60VYNDAMAX.....................................52VYNDAQEL..................................... 52VYONDYS-53................................138VYVANSE........................................23WAL-DRAM....................................... 8WAL-DRAM 2.................................... 8WAL-DRYL ALLERGY.......................5WAL-FEX ALLERGY......................... 6

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WAL-FINATE.....................................5WAL-ITIN...........................................6WAL-MUCIL FIBER (ASPARTAME).............................. 124WAL-MUCIL FIBER (SUGAR).......124WAL-MUCIL NATURAL FIBER LAX................................................124WAL-PROFEN...............................115WAL-PROXEN...............................115WAL-SLEEP Z.................................39WAL-SOM (DIPHENHYDRAMINE).39WAL-SOM (DOXYLAMINE).............39WAL-ZAN 150................................186WAL-ZAN 75..................................186WAL-ZYR (CETIRIZINE)................... 6WAL-ZYR (KETOTIFEN)................. 79warfarin ............................................84WEBCOL......................................... 68WEEKLY-D....................................213WELLBUTRIN SR............................15WELLBUTRIN XL............................ 15WERA (28).......................................60WESTAB MAX...............................212WESTAB ONE...............................212WESTHROID...................................79WEST-VITE WITH FOLIC ACID....212WIDE-SEAL DIAPHRAGM 60......... 60WIDE-SEAL DIAPHRAGM 65......... 60WIDE-SEAL DIAPHRAGM 70......... 61WIDE-SEAL DIAPHRAGM 75......... 61WIDE-SEAL DIAPHRAGM 80......... 61WIDE-SEAL DIAPHRAGM 85......... 61WIDE-SEAL DIAPHRAGM 90......... 61WIDE-SEAL DIAPHRAGM 95......... 61WILATE........................................... 87WIXELA INHUB...............................10WOMAN'S LAXATIVE (BISACODYL)................................124WOMEN'S 50 PLUS DAILY FORMULA..................................... 204WOMEN'S 50 PLUS MULTIVITAMIN............................. 204WOMEN'S COMPLEX...................204WOMEN'S DAILY CAPLET........... 204WOMEN'S DAILY FORMULA....... 204WOMENS DAILY GUMMIES.........204WOMEN'S GENTLE LAXATIVE(BISAC)........................ 124

WOMEN'S LAXATIVE (BISACODYL)................................124WOMEN'S MULTIVITAMIN GUMMIES......................................204WOMEN'S ONE DAILY................. 204WP THYROID..................................79WYMZYA FE................................... 60XALKORI....................................... 145XANAX.............................................25XANAX XR.......................................25XARELTO........................................87XATMEP........................................140XELJANZ.......................................114XELJANZ XR.................................114XOSPATA......................................145XPOVIO.........................................146XTANDI..........................................139XULANE.......................................... 60XYNTHA.......................................... 87XYNTHA SOLOFUSE......................87XYREM............................................26YELETS.........................................204YUVAFEM..................................... 189ZADITOR.........................................79zaleplon ........................................... 39ZANTAC 75................................... 186ZARAH.............................................60ZARONTIN.................................... 177ZARXIO........................................... 90ZAVESCA......................................149ZEJULA......................................... 145ZENATANE......................................61ZENPEP........................................ 182ZENZEDI......................................... 23ZEPATIER..................................... 111ZIAGEN......................................... 106zidovudine ......................................106ziprasidone hcl .................................30ziprasidone mesylate .......................30ZOLINZA........................................145zolmitriptan ............................ 162, 163ZOLOFT...........................................17zolpidem .................................... 39, 40ZOLPIMIST......................................40ZONEGRAN.................................. 177zonisamide .....................................177ZOVIA 1/35E (28)............................ 60Z-SLEEP..........................................40ZUBSOLV......................................164

ZUMANDIMINE (28)........................ 60ZYDELIG....................................... 145ZYKADIA....................................... 145ZYPREXA........................................30ZYPREXA RELPREVV....................30ZYPREXA ZYDIS............................ 30ZZZQUIL..........................................40

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Medicaid Drug Formulary - McLaren Health Plan€¦ · G-3245 Beecher Road • Flint, Michigan •...

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Transcript of Medicaid Drug Formulary - McLaren Health Plan€¦ · G-3245 Beecher Road • Flint, Michigan •...