Pharmacy Program Preferred Drug List › content › dam › centene › ... · 2020-05-21 ·...

Pharmacy Program NH Healthy Families is committed to providing appropriate, high quality, and cost effective drug therapy to all NH Healthy Families members. NH Healthy Families works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. NH Healthy Families covers prescription medications and certain over-the-counter (OTC) medications when ordered by a practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.

Preferred Drug List The NH Healthy Families Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at retail pharmacies. The NH Healthy Families PDL is continually evaluated by the NH Healthy Families Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the NH Healthy Families Medical Director, NH Healthy Families Pharmacy Director, and several New Hampshire physicians, pharmacists, and other healthcare professionals.

Pharmacy Benefit Manager NH Healthy Families works with Envolve Pharmacy Solutions to process pharmacy claims for prescribed drugs. Some drugs on the NH Healthy Families PDL may require PA, and Envolve Pharmacy Solutions is responsible for administering this process. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager (PBM).

Specialty Drugs NH Healthy Families contracts with a number of specialty pharmacies, such as AcariaHealth Specialty Pharmacy, to ensure members have adequate access to the specialty drugs they require. Specialty drugs, such as biopharmaceuticals and injectables, may require PA to be approved for payment by NH Healthy Families. PA requirements are programmed specific to the drug.

Dispensing Limits Drugs may be dispensed up to a maximum of thirty-four (34) day supply for each new prescription or refill. A total of 85% of the day supply must have elapsed before the prescription can be refilled for PDL drugs except for ophthalmic drugs.

Appropriate Use and Safety Edits The health and safety of the member are top priorities for NH Healthy Families. One of the ways we address member safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

Prior Authorizations Some medications listed on the NH Healthy Families PDL may require PA. The information should be submitted by the practitioner to Envolve Pharmacy Solutions on the Medication Prior Authorization Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document can be found on the NH Healthy Families website.

NH Healthy Families will cover the medication if it is determined that:

1. There is a medical reason the member needs the specific medication.

2. Depending on the medication, other medications on the PDL have not worked.

Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the NH Healthy Families P&T Committee. If the request is approved, Envolve Pharmacy Solutions notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, NH Healthy Families will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Quantity Limits NH Healthy Families may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a PA may be requested. If NH Healthy Families does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Age Limits Some medications on the NH Healthy Families PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Non-Preferred NH Healthy Families incorporates a Preferred Drug List. A notation of ‘Non-Preferred’ corresponds to drugs identified on the NH Healthy Families PDL indicating the trial and failure of preferred alternatives. The number of preferred drugs that must be tried prior to approval of non-preferred drugs varies by therapeutic drug class. To request the approval of a non-preferred drug please submit rationale via prior authorization request form to Envolve Pharmacy Solutions (fax 1-866-399-0929).

Medical Necessity Requests If the member requires a medication that does not appear on the PDL, the member’s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare as the PDL medications are appropriate to treat the vast majority of medical conditions.

For a MN request NH Healthy Families requires:

- Documentation of failure of PDL agent(s) within the same therapeutic class (provided agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or

- Documented intolerance or contraindication to PDL agent(s) within the same therapeutic class (provided agents exist in the therapeutic category with comparable labeled indications); or

- Documented clinical history or presentation where the patient is not a candidate for PDL agents for the indication.

These requests are reviewed by a licensed clinical pharmacist using the criteria established by the NH Healthy Families P&T Committee. If the request is approved, Envolve Pharmacy Solutions will notify the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, the member and their practitioner will be notified of alternatives and provide information regarding the appeal process.

72 Hour Emergency Supply Policy State and Federal law require that a pharmacy dispense at least t 72-hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. A provision of a 72-hour supply does not guarantee that the medication will be approved after a PA review. All participating pharmacies are authorized to provide a 72-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72-hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call Envolve Pharmacy Solutions at 1-866-862-8615 for a prescription override to submit the 72-hour medication supply for payment.

Newly Approved Products New Hampshire Healthy Families reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If NH Healthy Families does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Over-the-Counter Medications NH Healthy Families covers a variety of OTC medications. These medications can be found throughout the NH Healthy Families PDL. NH Healthy Families covers OTC products listed on the PDL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

Drug Efficacy Study and Implementation (DESI) Drugs DESI products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all

labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by NH Healthy Families.

Filling a Prescription A member can have prescriptions filled at a NH Healthy Families network pharmacy. If the member decides to have a prescription filled at a network pharmacy, they can locate a pharmacy near them by contacting NH Healthy Families Member Services. At the pharmacy, the member will need to provide the pharmacist with the prescription and their NH Healthy Families ID card.

Step Therapy

Some medications listed on the NH Healthy Families’ PDL may require specific medications to be used before the member can receive the step therapy medication. If NH Healthy Families has a record that the required medication was tried first the step therapy medications are automatically covered. If NH Healthy Families does not have a record that the required medication was tried, the member’s practitioner may be required to provide additional information. If authorization is not granted, NH Healthy Families will notify the member and their practitioner and provide information regarding the appeal process.

Abbreviations The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column.

DS/DU: Day Supply per Dosage Unit

Max Days Sply: Maximum Day Supply

Max Fills: Maximum Fills (per a designated time period)

Max Qty: Maximum Quantity (per claim or designated time period)

Min DS: Minimum Day Supply

PA: Prior Authorization

Pkg Size: Package Size

SP Specialty Drug

PV Preventative

QL Quantity Limit

ST Step Therapy

AL Age Limit

RX/OTC Over-the-Counter Medication (prescription required)

Contact Information NH Healthy Families Phone: 1-866-769-3085

Website: www.nhhealthyfamilies.com

Tier Definitions

0 $0 Copay 1 Preferred Generic 2 Preferred Brand

CO Carve-Out Drug - Covered by State Medicaid NP Non- Preferred

http://www.nhhealthyfamilies.com/

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating Disorders

Amphetamines ADDERALL TABS (Use amphetamine-dextroamphetamine)

2 QL(90 ea per30 days retail)

ADDERALL XR CP24 (Use amphetamine-dextroamphetamine)

NP QL(1 ea daily);AL(At least 6yrs old)

ADZENYS ER SUER NP

ADZENYS XR-ODT TBED NP

AMPHETAMINE ER SUER NP

amphetamine sulfate tabs 1 PA

amphetamine-dextroamphetamine cp24 5mg-5 mg-5 mg-5 mg, 2.5mg-2.5 mg-2.5 mg-2.5 mg,7.5 mg-7.5 mg-7.5 mg-7.5mg, 1.25 mg-1.25 mg-1.25mg-1.25 mg, 3.75 mg-3.75mg-3.75 mg-3.75 mg, 6.25mg-6.25 mg-6.25 mg-6.25 mg

1

QL(1 ea daily);AL(At least 6yrs old)

amphetamine-dextroamphetamine tabs 5mg-5 mg-5 mg-5 mg, 2.5mg-2.5 mg-2.5 mg-2.5 mg,7.5 mg-7.5 mg-7.5 mg-7.5mg, 1.25 mg-1.25 mg-1.25mg-1.25 mg, 3.75 mg-3.75mg-3.75 mg-3.75 mg,1.875 mg-1.875 mg-1.875mg-1.875 mg, 3.125 mg-3.125 mg-3.125 mg-3.125 mg

1

QL(90 ea per30 days retail)

DESOXYN TABS (Use methamphetamine hcl) NP PA

DEXEDRINE CP24 10 MG, 15 MG (Use dextroamphetaminesulfate)

NP


DEXEDRINE CP24 5 MG (Use dextroamphetaminesulfate)


Drug Name DrugTier

Requirements/Limits

dextroamphetamine sulfatecp24 10 mg, 15 mg 1


dextroamphetamine sulfatecp24 5 mg 1


dextroamphetamine sulfatesoln 5 mg/5ml 1 PA

dextroamphetamine sulfatetabs 5 mg, 10 mg 1 AL(At least 3

yrs old) dextroamphetamine sulfatetabs 5 mg, 10 mg NP AL(At least 3

yrs old)

DYANAVEL XR SUER 2 PA

EVEKEO TABS (Use amphetamine sulfate) NP PA

methamphetamine hcl tabs 1 PA

VYVANSE CAPS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

2 PA; QL(1 eadaily)

VYVANSE CHEW 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

2 PA

ZENZEDI TABS NP

Analeptics caffeine citrate soln or 20 mg/ml, 60 mg/3ml 1 QL(45 ml per

fill retail) Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps 1 AL(At least 6yrs old)

clonidine hcl (adhd) tb12 1

guanfacine hcl (adhd) tb24 1 QL(1 ea daily);AL(At least 6yrs old)

INTUNIV TB24 (Use guanfacine hcl (adhd)) NP


KAPVAY TB12 (Use clonidine hcl (adhd)) NP

STRATTERA CAPS (Use atomoxetine hcl) NP AL(At least 6

yrs old) Stimulants - Misc.

New Hampshire Healthy Families Updated June 1, 2020

1

Drug Name DrugTier

Requirements/Limits

APTENSIO XR CP24 2 PA

CONCERTA TBCR (Use methylphenidate hcl) NP AL(At least 6

yrs old)

DAYTRANA PTCH NP

dexmethylphenidate hclcp24 5 mg, 10 mg, 15 mg,20 mg, 25 mg, 30 mg, 35mg, 40 mg

1

PA

dexmethylphenidate hcltabs 5 mg, 10 mg, 2.5 mg 1


FOCALIN TABS (Use dexmethylphenidate hcl) 2


FOCALIN XR CP24 (Use dexmethylphenidate hcl) 2 PA

METHYLIN SOLN (Use methylphenidate hcl) 2 PA

METHYLPEHNIDATE HYDROCHLORIDE ER CP24

2 PA

methylphenidate hcl chewor 5 mg, 10 mg, 2.5 mg 1 PA

methylphenidate hcl cp24or 10 mg, 20 mg, 30 mg,40 mg, 60 mg

1 PA

methylphenidate hcl cpcr or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg

1 AL(At least 6yrs old)

methylphenidate hcl soln or5 mg/5ml, 10 mg/5ml 1 PA

methylphenidate hcl tabs or5 mg, 10 mg, 20 mg 1 AL(At least 3

yrs old) methylphenidate hcl tb24or 27 mg, 36 mg, 54 mg 1

methylphenidate hcl tbcr or10 mg, 18 mg, 20 mg, 27mg, 36 mg, 54 mg


METHYLPHENIDATE HYDROCHLORIDE ER CP24 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG

2

PA

METHYLPHENIDATE HYDROCHLORIDE ER TB24 18 MG

2

Drug Name DrugTier

Requirements/Limits

QUILLICHEW ER CHER 2 PA

QUILLIVANT XR SRER 2 PA

RITALIN LA CP24 (Use methylphenidate hcl) NP PA

RITALIN TABS (Use methylphenidate hcl) NP AL(At least 3

yrs old)

ALLERGENIC EXTRACTS/BIOLOGICALS MISC

Allergenic Extracts ORALAIR ADULT SAMPLE KIT SUBL 2 PA; SP

ORALAIR ADULT STARTER PACK SUBL 2 PA; SP

ORALAIR SUBL 2 PA; SP

Biologicals Misc

ADAGEN SOLN 2 PA; SP

ALTERNATIVE MEDICINES

Alternative Medicine - G's ginger (zingiber officinalis)caps 250 mg 1 QL(4 ea daily)

Alternative Medicine - K's KRILL OIL CAPS 30 MG-1000 MG-30 MG-40 MG-20 MG-300 MCG, 130 MG-20 MG-1000 MG-5 MG-80 MG-40 MG-1500 MCG

2


2

Drug Name DrugTier

Requirements/Limits

krill oil caps 500 mg, 90mg-300 mg-45 mg-27 mg,90 mg-300 mg-75 mg-50mg-24 mg, 90 mg-300 mg-130 mg-50 mg-24 mg, 115mg-500 mg-167 mg-64 mg-30 mg, 500 mg-202 mg-40mg-25 mg-101 mcg, 90mg-300 mg-130 mg-50 mg-24 mg-17 mcg, 110 mg-500 mg-200 mg-60 mg-28mg-40 mcg, 115 mg-500mg-167 mg-64 mg-30 mg-25 mcg, 90 mg-300 mg-120 mg-45 mg-27 mg-450mcg, 133 mg-33 mg-6 mg-500 mg-210 mg-75 mg-45mg-0.5 mg-28 mg-32 unit

1

KRILL OIL OMEGA-3 CAPS 2

KRILL OIL TRIPLE STRENGTH RED CAPS 2

KRILL OIL ULTRA STRENGTH CAPS 2

KRILL OIL WITH ASTAXANTHIN TRIPLE STRENGTH CAPS

2

OMEGA-3 KRILL OIL CAPS 2

RA KRILL OIL CAPS 2

Alternative Medicine - M's melatonin tabs or 3 mg, 5mg, 22 mg-3 mg 1 QL(1 ea daily)

Alternative Medicine Combinations ADULT OMEGA PLUS DHA CHEW 2

CARDIOSTEROL CAPS 2

fish oil-cholecalciferol caps 1

fish oil-krill oil caps 1

FLAX + DHA CAPS 2

flaxseed oil-fish oil-borageoil caps 1

Drug Name DrugTier

Requirements/Limits

GNP TRIPLE OMEGA COMPLEX CPDR 2

HM OMEGA-3-6-9 FATTY ACIDS CAPS 2

OMEGA 3-6-9 COMPLEX CAPS 2

OMEGA DHA CHEW 2

OMEGA-3 + D CAPS 2

OMEGA-3 EXTRA STRENGTH +VITAMIN D3 CAPS

2

OMEGA-3 GUMMIES CHEW 2

OMEGA-3-6-9 CAPS 2

PA FISH OIL/PHYTOSTEROLSTRIPLE STRENGTH CAPS

2

RA OMEGA 3-6-9 CAPS 2

SM OMEGA-3 CAPS 2

SM OMEGA-3-6-9 FATTY ACIDS CAPS 2

SUPER OMEGA-3 CAPS 2

TRIPLE OMEGA COMPLEX CPDR 2

TRIPLE OMEGA-3-6-9 CAPS 2

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections

Aminoglycosides

ARIKAYCE SUSP 2 PA; SP

BETHKIS NEBU 2 PA; SP

KITABIS PAK NEBU 2 PA; SP

neomycin sulfate tabs or 1

TOBI NEBU (Use tobramycin) NP PA; SP

TOBI PODHALER CAPS 2 PA; SP


3

Drug Name DrugTier

Requirements/Limits

TOBRAMYCIN NEBU IN 2 PA; SP

tobramycin nebu in 1 PA; SP

TOBRAMYCIN SULFATE SOLN IJ 10 MG/ML, 40MG/ML

2 PA

tobramycin sulfate soln ij80 mg/2ml, 1.2 gm/30ml 1 PA

tobramycin sulfate solr ij1.2 gm 1 PA

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditions

Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

2 PA; SP

HUMIRA PEN PNKT 2 PA; SP

HUMIRA PEN-CD/UC/HSSTARTER PNKT 2 PA; SP

HUMIRA PEN-PS/UVSTARTER PNKT 2 PA; SP

HUMIRA PSKT 2 PA; SP

SIMPONI ARIA SOLN NP SP

SIMPONI SOAJ NP SP

SIMPONI SOSY NP SP

Antirheumatic - Enzyme Inhibitors

OLUMIANT TABS 2 MG NP SP

RINVOQ TB24 2 PA; SP

XELJANZ TABS NP SP

XELJANZ XR TB24 11 MG NP SP

Antirheumatic Antimetabolites METHOTREXATE TABS OR 2

OTREXUP SOAJ 2 PA; SP

Drug Name DrugTier

Requirements/Limits

RASUVO SOAJ 2 PA; SP

Interleukin-1 Blockers

ARCALYST SOLR NP SP

Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET SOSY NP SP

Interleukin-1beta Blockers

ILARIS SOLN NP SP

Interleukin-6 Receptor Inhibitors

ACTEMRA ACTPEN SOAJ 0 SP

ACTEMRA SOLN 0 SP

ACTEMRA SOSY 0 SP

KEVZARA SOAJ 0 SP

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL TABS (Use ibuprofen) NP

ALEVE ARTHRITIS TABS (Use naproxen sodium) NP QL(2 ea daily)

ALEVE TABS (Use naproxen sodium) NP QL(2 ea daily)

ANAPROX DS TABS (Use naproxen sodium) NP

CELEBREX CAPS (Use celecoxib) NP PA; QL(2 ea

daily) celecoxib caps or 50 mg,100 mg, 200 mg, 400 mg 1 PA; QL(2 ea

daily) CHILDRENS ADVIL SUSP (Use ibuprofen) NP RX/OTC

CHILDRENS MOTRIN SUSP (Use ibuprofen) NP RX/OTC

DAYPRO TABS (Use oxaprozin) NP

diclofenac potassium tabs 1

diclofenac sodium tb24 or 100 mg 1

diclofenac sodium tbec or 25 mg, 50 mg, 75 mg 1


4

Drug Name DrugTier

Requirements/Limits

EC-NAPROSYN TBEC (Use naproxen) NP QL(2 ea daily)

EC-NAPROXEN TBEC (Use naproxen) NP QL(2 ea daily)

etodolac caps 1

etodolac tabs 1

etodolac tb24 1

FELDENE CAPS (Use piroxicam) NP

flurbiprofen tabs or 50 mg,100 mg 1

ibuprofen chew or 100 mg 1

ibuprofen susp or 100mg/5ml 1 RX/OTC

ibuprofen susp or 40mg/ml, 50 mg/1.25ml 1

ibuprofen tabs or 200 mg,400 mg, 600 mg, 800 mg 1

indomethacin caps or 25mg, 50 mg 1

indomethacin cpcr or 75 mg 1

INFANTS ADVIL SUSP (Use ibuprofen) NP

KETOPROFEN CAPS OR 50 MG, 75 MG 2

KETOPROFEN ER CP24 2

ketorolac tromethamine tabs or 10 mg 1

QL(20 ea perfill retail); AL(Atleast 17 yrsold)

LODINE TABS (Use etodolac) NP

meloxicam tabs or 15 mg,7.5 mg 1

MOBIC TABS (Use meloxicam) NP

MOTRIN CHILDRENS CHEW (Use ibuprofen) NP

MOTRIN INFANTS DROPS SUSP (Use ibuprofen)

NP

Drug Name DrugTier

Requirements/Limits

nabumetone tabs or 500 mg, 750 mg 1

NAPROSYN SUSP (Use naproxen) NP

NAPROSYN TABS (Use naproxen) NP

naproxen sodium tabs or220 mg 1 QL(2 ea daily)

naproxen sodium tabs or275 mg, 550 mg 1

naproxen susp or 125mg/5ml 1

naproxen tabs or 250 mg,375 mg, 500 mg 1

naproxen tbec or 375 mg,500 mg 1 QL(2 ea daily)

naproxen-esomeprazolemagnesium tbec NP

oxaprozin tabs 1

piroxicam caps or 10 mg,20 mg 1

sulindac tabs or 150 mg,200 mg 1

TOLMETIN SODIUM CAPS 2

TOLMETIN SODIUM TABS 2

VIMOVO TBEC (Use naproxen-esomeprazolemagnesium)

NP

VIVLODEX CAPS NP

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS NP SP

OTEZLA TBPK NP SP

Pyrimidine Synthesis Inhibitors ARAVA TABS (Use leflunomide) NP QL(1 ea daily)

leflunomide tabs or 10 mg,20 mg 1 QL(1 ea daily)

Selective Costimulation Modulators ORENCIA CLICKJECT SOAJ NP SP


5

Drug Name DrugTier

Requirements/Limits

ORENCIA SOLR NP SP

ORENCIA SOSY NP SP

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL MINI SOCT 2 PA; SP

ENBREL SOLR 2 PA; SP

ENBREL SOSY 2 PA; SP

ENBREL SURECLICK SOAJ 2 PA; SP

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions

Analgesic Combinations butalbital-acetaminophentabs 325 mg-50 mg 1

butalbital-acetaminophen-caffeine caps 325 mg-50mg-40 mg

1 QL(4 ea daily)

butalbital-acetaminophen-caffeine tabs 325 mg-50mg-40 mg

1 QL(4 ea daily)

butalbital-aspirin-caffeine caps 1 QL(4 ea daily)

BUTALBITAL/ASPIRIN/CAFFEINE TABS 2 QL(4 ea daily)

ESGIC TABS (Use butalbital-acetaminophen-caffeine)

NP QL(4 ea daily)

FIORINAL CAPS (Use butalbital-aspirin-caffeine) NP QL(4 ea daily)

TENCON TABS 2

Analgesics Other acetaminophen chew or 80mg, 160 mg 0

acetaminophen elix or 160mg/5ml, 80 mg/2.5ml 0

acetaminophen liqd or 160mg/5ml 0

acetaminophen soln or 100mg/ml 0 QL(30 ml per

fill retail)

Drug Name DrugTier

Requirements/Limits

acetaminophen soln or 160mg/5ml, 650 mg/20.3ml,325 mg/10.15ml

0

acetaminophen supp re120 mg, 650 mg 0 QL(12 ea per

fill retail) acetaminophen susp or160 mg/5ml, 80 mg/2.5ml,650 mg/20.3ml

0

acetaminophen tabs or 325mg, 500 mg 0

FEVERALL JUNIOR STRENGTH SUPP 0 QL(12 ea per

fill retail) NORTEMP INFANTS SUSP 0

TYLENOL CHILDRENS CHEWABLES/PAIN +FEVER CHEW (Use acetaminophen)

NP

TYLENOL CHILDRENS SUSP (Use acetaminophen)

NP

TYLENOL EXTRA STRENGTH TABS (Use acetaminophen)

NP

TYLENOL INFANTS PAIN+FEVER SUSP (Use acetaminophen)

NP

TYLENOL INFANTS SUSP (Use acetaminophen) NP

TYLENOL TABS (Use acetaminophen) NP

Analgesics-Peptide Channel Blockers

PRIALT SOLN 2 PA; SP

Salicylates aspirin buffered (cal carb-mag carb-mag oxide) tabs 1

aspirin chew or 81 mg 0

ASPIRIN SUPP RE 300 MG, 600 MG 0 QL(12 ea per

fill retail)

aspirin tabs or 325 mg 0

aspirin tbec or 81 mg, 324mg, 325 mg, 500 mg 0


6

Drug Name DrugTier

Requirements/Limits

BUFFERIN TABS (Use aspirin buffered (cal carb-mag carb-mag oxide))

NP

choline & mag salicylateliqd 1

CHOLINE MAGNESIUM TRISALICYLATE LIQD OR 2

diflunisal tabs 1

ECOTRIN MAXIMUM STRENGTH TBEC (Use aspirin)

NP

ECOTRIN REGULAR STRENGTH TBEC (Use aspirin)

NP

salsalate tabs or 500 mg,750 mg 1

ST JOSEPH ADULT ANALGESICLOW DOSE BITE SIZE CHEW

NP

ST JOSEPH ADULT CHEW NP

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint Conditions

Opioid Agonists

ARYMO ER TBEA NP

CODEINE SULFATE TABS 15 MG, 60 MG 2 QL(2 ea daily)

CODEINE SULFATE TABS 30 MG (Use codeine sulfate)

NP QL(2 ea daily)

codeine sulfate tabs 30 mg,60 mg 1 QL(2 ea daily)

CONZIP CP24 NP

DILAUDID TABS OR 2 MG, 4 MG, 8 MG (Use hydromorphone hcl)

NP QL(8 ea daily)

DOLOPHINE TABS 10 MG (Use methadone hcl) NP PA; QL(10 ea

daily) DOLOPHINE TABS 5 MG (Use methadone hcl) NP PA; QL(4 ea

daily)

DURAGESIC PT72 (Use fentanyl) NP

10 permonth;QL(0.34ea daily)

Drug Name DrugTier

Requirements/Limits

EMBEDA CPCR 2 PA

EXALGO T24A (Use hydromorphone hcl) NP PA

fentanyl pt72 12 mcg/hr, 25mcg/hr, 50 mcg/hr, 75mcg/hr, 100 mcg/hr

1 10 permonth;QL(0.34ea daily)

fentanyl pt72 37.5 mcg/hr,62.5 mcg/hr, 87.5 mcg/hr 1 PA

hydrocodone bitartratec12a or 10 mg, 15 mg, 20mg, 30 mg, 40 mg, 50 mg

NP

HYDROMORPHONE HCL SUPP RE 3 MG 2 QL(12 ea per

fill retail) hydromorphone hcl t24a or8 mg, 12 mg, 16 mg, 32 mg 1 PA

hydromorphone hcl tabs or2 mg, 4 mg, 8 mg 1 QL(8 ea daily)

HYSINGLA ER T24A NP

KADIAN CP24 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG, 100 MG (Use morphine sulfate)

NP

PA

KADIAN CP24 200 MG NP

MEPERIDINE HCL SOLN OR 50 MG/5ML 2 QL(500 ml per

fill retail) MEPERIDINE HCL TABS OR 50 MG, 100 MG 2 QL(6 ea daily)

meperidine hcl tabs or 50mg, 100 mg 1 QL(6 ea daily)

methadone hcl tabs or 10 mg 1 PA; QL(10 ea

daily) methadone hcl tabs or 5 mg 1 PA; QL(4 ea

daily) morphine sulfate cp24 or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg, 80 mg,100 mg

1

PA

MORPHINE SULFATE ER CP24 2 PA

morphine sulfate soln or 10mg/5ml, 20 mg/5ml 1 QL(16.67 ml

daily) morphine sulfate soln or 20mg/ml, 100 mg/5ml 1 QL(240 ml per

fill retail)


7

Drug Name DrugTier

Requirements/Limits

MORPHINE SULFATE SUPP RE 5 MG, 10 MG, 20 MG, 30 MG

2 QL(24 ea perfill retail)

morphine sulfate tabs or 15mg, 30 mg 1 QL(6 ea daily)

MORPHINE SULFATE TABS OR 15 MG, 30 MG (Use morphine sulfate)

NP QL(6 ea daily)

morphine sulfate tbcr or 15mg, 30 mg, 60 mg, 100 mg,200 mg

1 QL(3 ea daily)

MS CONTIN TBCR (Use morphine sulfate) NP QL(3 ea daily)

NUCYNTA ER TB12 NP

NUCYNTA TABS NP

oxycodone hcl caps or 5 mg 1 QL(6 ea daily)

oxycodone hcl conc or 100mg/5ml 1 QL(6 ml daily)

OXYCODONE HCL ER T12A 2 PA; QL(2 ea

daily) oxycodone hcl soln or 5mg/5ml 1

oxycodone hcl tabs or 5mg, 10 mg, 15 mg, 20 mg,30 mg

1 QL(6 ea daily)

OXYCODONE HYDROCHLORIDE ER T12A

2 PA; QL(2 eadaily)

OXYCONTIN T12A NP QL(2 ea daily)

OXYMORPHONE HYDROCHLORIDE ER TB12

2 PA

OXYMORPHONE HYDROCHLORIDEER TB12

2 PA

ROXICODONE TABS (Use oxycodone hcl) NP QL(6 ea daily)

TRAMADOL HCL ER CP24 2 PA

tramadol hcl tabs or 50 mg 1 QL(8 ea daily)

tramadol hcl tb24 or 100 mg, 200 mg, 300 mg 1 PA

Drug Name DrugTier

Requirements/Limits

ULTRAM TABS (Use tramadol hcl) NP QL(8 ea daily)

XTAMPZA ER C12A NP

ZOHYDRO ER C12A (Use hydrocodone bitartrate) NP

Opioid Combinations acetaminophen w/ codeinesoln 120 mg/5ml-12mg/5ml

1 QL(30 ml daily)

acetaminophen w/ codeinetabs 300 mg-15 mg, 300mg-30 mg, 300 mg-60 mg

1 QL(6 ea daily)

butalbital-acetaminophen-caffeine w/ codeine caps325 mg-50 mg-40 mg-30 mg

1

QL(4 ea daily)

butalbital-aspirin-caffeinew/cod caps 1 QL(4 ea daily)

FIORINAL/CODEINE #3CAPS (Use butalbital-aspirin-caffeine w/cod)

NP QL(4 ea daily)

hydrocodone-acetaminophen soln 2.5mg/5ml-108 mg/5ml, 5mg/10ml-217 mg/10ml, 7.5mg/15ml-325 mg/15ml

1

QL(180 mldaily)

hydrocodone-acetaminophen tabs 10mg-325 mg

1 QL(6 ea daily)

hydrocodone-acetaminophen tabs 5 mg-325 mg

1 QL(12 ea daily)

hydrocodone-acetaminophen tabs 7.5mg-325 mg

1 QL(8 ea daily)

NORCO TABS 10 MG-325 MG (Use hydrocodone-acetaminophen)

NP QL(6 ea daily)

NORCO TABS 5 MG-325 MG (Use hydrocodone-acetaminophen)

NP QL(12 ea daily)

NORCO TABS 7.5 MG-325 MG (Use hydrocodone-acetaminophen)

NP QL(8 ea daily)


8

Drug Name DrugTier

Requirements/Limits

oxycodone w/acetaminophen tabs 5 mg-325 mg, 10 mg-325 mg,7.5 mg-325 mg

1

QL(6 ea daily)

oxycodone-aspirin tabs 1 QL(6 ea daily)

OXYCODONE/ACETAMINOPHEN SOLN 2 QL(30 ml daily)

OXYCODONE/ASPIRINTABS 2 QL(6 ea daily)

PERCOCET TABS 5 MG-325 MG, 10 MG-325 MG, 7.5 MG-325 MG (Use oxycodone w/acetaminophen)

NP

QL(6 ea daily)

ROXICET SOLN 2 QL(30 ml daily)

tramadol-acetaminophentabs 1 QL(4 ea daily)

TYLENOL/CODEINE #3TABS (Use acetaminophenw/ codeine)

NP QL(6 ea daily)

TYLENOL/CODEINE #4TABS (Use acetaminophenw/ codeine)

NP QL(6 ea daily)

ULTRACET TABS (Use tramadol-acetaminophen) NP QL(4 ea daily)

Opioid Partial Agonists

BELBUCA FILM NP

BUNAVAIL FILM NP

buprenorphine hcl subl sl 2mg, 8 mg 1 PA

buprenorphine hcl-naloxone hcl dihydrate film12 mg-3 mg

1 QL(1.33 eadaily)

buprenorphine hcl-naloxone hcl dihydrate film2 mg-0.5 mg

1 QL(8 ea daily)


1 QL(4 ea daily)


1 QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

buprenorphine hcl-naloxone hcl dihydrate subl2 mg-0.5 mg

1 QL(8 ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl8 mg-2 mg

1 QL(2 ea daily)

buprenorphine ptwk td 5mcg/hr, 10 mcg/hr, 15mcg/hr, 20 mcg/hr

1 PA

buprenorphine ptwk td 7.5mcg/hr 2 PA

buprenorphine ptwk td 7.5mcg/hr NP

BUTRANS PTWK 5 MCG/HR, 10 MCG/HR, 15MCG/HR, 20 MCG/HR(Use buprenorphine)

NP

PA

BUTRANS PTWK 7.5 MCG/HR (Use buprenorphine)

NP

PROBUPHINE IMPLANT KIT IMPL 2 PA

SUBLOCADE SOSY 2 PA; 1 rtl MAX fill,30 rtl day(s)supply,

SUBOXONE FILM 12 MG-3 MG (Use buprenorphinehcl-naloxone hcl dihydrate)

2 QL(1.33 eadaily)

SUBOXONE FILM 2 MG-0.5 MG (Use buprenorphine hcl-naloxone hcl dihydrate)

2

QL(8 ea daily)


2 QL(4 ea daily)


2 QL(2 ea daily)

ZUBSOLV SUBL NP

ANDROGENS-ANABOLIC - Drugs to RegulateHormones

Androgens

ANDRODERM PT24 NP QL(1 ea daily)


9

Drug Name DrugTier

Requirements/Limits

ANDROGEL GEL 40.5 MG/2.5GM, 20.25MG/1.25GM (Use testosterone)

NP

PA

ANDROGEL GEL 50 MG/5GM, 25 MG/2.5GM(Use testosterone)

2 PA

ANDROGEL PUMP GEL (Use testosterone) NP PA

AVEED SOLN 2 PA; SP

DEPO-TESTOSTERONE SOLN 200 MG/ML (Use testosterone cypionate)

NP QL(4 ml per 30days retail)

FORTESTA GEL (Use testosterone) NP PA

METHITEST TABS 2

TESTIM GEL (Use testosterone) NP

TESTOPEL PLLT 2 PA; SP

testosterone cypionate solnim 200 mg/ml 1 QL(4 ml per 30

days retail) testosterone gel td 1 %, 50mg/5gm 1

TESTOSTERONE GEL TD 1 %, 50 MG/5GM, 25MG/2.5GM

2 PA

testosterone gel td 1.62 %,10 mg/act, 25 mg/2.5gm,40.5 mg/2.5gm, 20.25mg/1.25gm

1

PA

testosterone gel td 20.25mg/1.25gm NP

TESTOSTERONE PUMP GEL 2 PA

testosterone soln td 30 mg/act 1 PA

VOGELXO GEL NP

VOGELXO PUMP GEL NP

ANORECTAL AND RELATED PRODUCTS -Rectal Drugs to Treat Pain, Swelling and Itching

Intrarectal Steroids

Drug Name DrugTier

Requirements/Limits

CORTENEMA ENEM (Use hydrocortisone (intrarectal)) NP QL(420 ml per

fill retail) hydrocortisone (intrarectal) enem 1 QL(420 ml per

fill retail) UCERIS FOAM RE 2 MG/ACT NP

Rectal Combinations phenylephrine-shark liveroil-cocoa butter supp 1 QL(48 ea per

fill retail) phenylephrine-shark liveroil-mineral oil-petrolatumoint

1 QL(12 gm perfill retail)

Rectal Local Anesthetics

pramoxine hcl (rectal) foam 1 QL(15 gm perfill retail)

PROCTOFOAM FOAM (Use pramoxine hcl(rectal))

NP QL(15 gm perfill retail)

Rectal Steroids ANUSOL-HC CREA (Use hydrocortisone (rectal)) 2 QL(30 gm per

fill retail) hydrocortisone (rectal) crea1 % 1

hydrocortisone (rectal) crea2.5 % 1 QL(30 gm per

fill retail) PROCTOCORT CREA EX 1 % (Use hydrocortisone(rectal))

2

ANTACIDS

Antacid Combinations alum & mag hydrox-simethicone liqd 200mg/5ml-20 mg/5ml-200mg/5ml

1

QL(16.53 mldaily)

alum & mag hydrox-simethicone susp 200mg/5ml-20 mg/5ml-200mg/5ml, 400 mg/10ml-40mg/10ml-400 mg/10ml-0.2%, 200 mg/5ml-200mg/5ml-20 mg/5ml-20mg/5ml-200 mg/5ml-200mg/5ml

1

QL(16.53 mldaily)

Antacids - Aluminum Salts


10

Drug Name DrugTier

Requirements/Limits

ALUMINUM HYDROXIDE SUSP OR 2

Antacids - Bicarbonate sodium bicarbonate (antacid) tabs 1 QL(16.53 ea

daily) Antacids - Calcium Salts calcium carbonate (antacid) chew 500 mg 1

TUMS CHEW (Use calcium carbonate (antacid)) NP

TUMS LASTING EFFECTS CHEW (Use calcium carbonate (antacid))

NP

Antacids - Magnesium Salts magnesium oxide tabs 400 mg 1

ANTHELMINTICS - Drugs to Treat WormInfections

Anthelmintics

BENZNIDAZOLE TABS 2 PA; SP

EMVERM CHEW 2 QL(1 ea per 14days retail)

pyrantel pamoate susp or 1 QL(60 ml perfill retail)

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial Infections

Anti-infective Agents - Misc. FLAGYL TABS 250 MG, 500 MG (Use metronidazole)

NP

metronidazole tabs or 250 mg, 500 mg 1

trimethoprim tabs or 1

vancomycin hcl solr iv 1000 mg 1 QL(14 ea per

fill retail) vancomycin hcl solr iv 500 mg 1 QL(0.467 ea

daily) Anti-infective Misc. - Combinations BACTRIM DS TABS (Use sulfamethoxazole-trimethoprim)

NP

Drug Name DrugTier

Requirements/Limits

BACTRIM TABS (Use sulfamethoxazole-trimethoprim)

NP

sulfamethoxazole-trimethoprim susp or 40mg/5ml-200 mg/5ml

1

sulfamethoxazole-trimethoprim tabs or 80 mg-400 mg, 160 mg-800 mg

1

Carbapenems

ertapenem sodium solr 1 PA; SP

INVANZ SOLR IJ (Use ertapenem sodium) NP PA; SP

INVANZ SOLR IV 2 PA; SP

Glycopeptides FIRVANQ SOLR 25 MG/ML 2 QL(300 ml per

fill retail) VANCOCIN CAPS (Use vancomycin hcl) NP QL(8 ea daily)

VANCOCIN HCL CAPS (Use vancomycin hcl) NP QL(4 ea daily)

vancomycin hcl caps or125 mg 1 QL(4 ea daily)

vancomycin hcl caps or250 mg 1 QL(8 ea daily)

vancomycin hcl solr iv 1gm, 1000 mg 1 QL(14 ea per

fill retail) vancomycin hcl solr iv 500 mg 1 QL(0.467 ea

daily) Leprostatics dapsone tabs or 25 mg,100 mg 1

Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG (Use clindamycin hcl)

NP

CLEOCIN PEDIATRIC GRANULES SOLR (Use clindamycin palmitatehydrochloride)

NP

QL(100 ml perfill retail)

clindamycin hcl caps or 150mg, 300 mg 1


11

Drug Name DrugTier

Requirements/Limits

clindamycin palmitatehydrochloride solr 1 QL(100 ml per

fill retail) Monobactams

CAYSTON SOLR 2 PA; SP

Oxazolidinones

SIVEXTRO TABS OR 2 PA; QL(6 eaper fill retail)

ANTIANGINAL AGENTS - Drugs to Treat ChestPain

Nitrates ISORDIL TITRADOSE TABS 5 MG (Use isosorbide dinitrate)

NP

ISOSORBIDE DINITRATE ER TBCR 2

isosorbide dinitrate tabs 5 mg, 10 mg, 20 mg, 30 mg 1

isosorbide mononitrate tabs 10 mg, 20 mg 1 QL(2 ea daily)

isosorbide mononitrate tb24 30 mg, 60 mg, 120 mg 1 QL(1 ea daily)

NITRO-BID OINT 2

NITRO-DUR PT24 0.1 MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.6 MG/HR (Use nitroglycerin)

NP

NITRO-TIME CPCR 2

nitroglycerin cpcr or 9 mg,2.5 mg, 6.5 mg 1

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

1

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg 1

NITROSTAT SUBL (Use nitroglycerin) NP

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc. buspirone hcl tabs or 5 mg,10 mg, 15 mg, 30 mg, 7.5 mg

1

Drug Name DrugTier

Requirements/Limits

droperidol soln ij 1

HYDROXYZINE HCL SOLN IM 25 MG/ML 2

hydroxyzine hcl syrp or 10mg/5ml 1

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg 1

HYDROXYZINE HYDROCHLORIDE SOLN 2

HYDROXYZINE PAMOATE CAPS OR 100 MG

2

hydroxyzine pamoate capsor 25 mg, 50 mg 1

meprobamate tabs 1

VISTARIL CAPS (Use hydroxyzine pamoate) NP

Benzodiazepines ALPRAZOLAM INTENSOL CONC 2

alprazolam tabs or 0.25mg, 0.5 mg, 1 mg, 2 mg 1 QL(4 ea daily)

alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg 1

alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg, 2 mg 1

ATIVAN TABS OR 0.5 MG, 2 MG (Use lorazepam) NP QL(3 ea daily)

ATIVAN TABS OR 1 MG (Use lorazepam) NP QL(4 ea daily)

chlordiazepoxide hcl caps 1 QL(4 ea daily)

clorazepate dipotassiumtabs 1 QL(3 ea daily)

diazepam conc or 5 mg/ml 1

DIAZEPAM SOAJ IM 10 MG/2ML 2

diazepam soln ij 5 mg/ml 1

DIAZEPAM SOLN IJ 5 MG/ML 2

DIAZEPAM SOLN OR 5 MG/5ML 2 QL(500 ml per

fill retail)


12

Drug Name DrugTier

Requirements/Limits

diazepam tabs or 2 mg, 5mg, 10 mg 1 QL(4 ea daily)

lorazepam conc or 2 mg/ml 1

lorazepam tabs or 0.5 mg,2 mg 1 QL(3 ea daily)

lorazepam tabs or 1 mg 1 QL(4 ea daily)

oxazepam caps 10 mg, 15 mg 1 QL(4 ea daily)

OXAZEPAM CAPS 10 MG, 15 MG, 30 MG 2 QL(4 ea daily)

TRANXENE T TABS (Use clorazepate dipotassium) NP QL(3 ea daily)

VALIUM TABS (Use diazepam) NP QL(4 ea daily)

XANAX TABS (Use alprazolam) NP QL(4 ea daily)

XANAX XR TB24 (Use alprazolam) NP

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms

Antiarrhythmics Type I-A disopyramide phosphate caps 1

NORPACE CAPS (Use disopyramide phosphate) 2

quinidine gluconate tbcr or324 mg 1

QUINIDINE SULFATE TABS OR 200 MG, 300 MG

2

Antiarrhythmics Type I-B MEXILETINE HCL CAPS 150 MG, 200 MG, 250 MG 2

mexiletine hcl caps 200mg, 250 mg 1

Antiarrhythmics Type I-C

flecainide acetate tabs 1

propafenone hcl tabs 150mg, 225 mg, 300 mg 1

Antiarrhythmics Type III amiodarone hcl tabs or 200 mg 1

Drug Name DrugTier

Requirements/Limits

CORDARONE TABS (Use amiodarone hcl) 2

dofetilide caps 1 PA; SP

TIKOSYN CAPS (Use dofetilide) NP PA; SP

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Anti-Inflammatory Agents CROMOLYN SODIUM NEBU IN 2 QL(8 ml daily)

cromolyn sodium nebu in 1 QL(8 ml daily)

Antiasthmatic - Monoclonal Antibodies

CINQAIR SOLN 2 PA; SP

NUCALA SOAJ 2 PA; SP

NUCALA SOLR 2 PA; SP

NUCALA SOSY 2 PA; SP

XOLAIR SOLR 2 PA; SP

XOLAIR SOSY 2 PA; SP

Bronchodilators - Anticholinergics

ATROVENT HFA AERS 2 QL(0.867 gmdaily)

INCRUSE ELLIPTA AEPB NP QL(30 ea per30 days retail)

INCRUSE ELLIPTA AEPB NP QL(7 ea per 30days retail)

ipratropium bromide soln in 1 QL(15 ml daily)

SEEBRI NEOHALER CAPS NP

SPIRIVA HANDIHALER CAPS 2

SPIRIVA RESPIMAT AERS NP

TUDORZA PRESSAIR AEPB NP QL(1 ea per 30

days retail)

YUPELRI SOLN NP

Leukotriene Modulators


13

Drug Name DrugTier

Requirements/Limits

ACCOLATE TABS (Use zafirlukast) NP

montelukast sodium chew or 4 mg, 5 mg 1 QL(1 ea daily)

montelukast sodium packor 4 mg 1 QL(1 ea daily)

montelukast sodium tabs or 10 mg 1 QL(1 ea daily)

SINGULAIR CHEW (Use montelukast sodium) NP QL(1 ea daily)

SINGULAIR PACK (Use montelukast sodium) NP QL(1 ea daily)

SINGULAIR TABS (Use montelukast sodium) NP QL(1 ea daily)

zafirlukast tabs 1

zileuton tb12 1

ZYFLO CR TB12 (Use zileuton) NP

ZYFLO TABS NP

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS NP

Steroid Inhalants

ALVESCO AERS NP

ARNUITY ELLIPTA AEPB NP

ASMANEX HFA AERO 100 MCG/ACT, 200 MCG/ACT NP

ASMANEX TWISTHALER 120 METERED DOSES AEPB

2


2


2


2


2

Drug Name DrugTier

Requirements/Limits

budesonide (inhalation) susp 1

QL(4 ml daily);AL(At least 1yrs old - Up to8 yrs old)

FLOVENT DISKUS AEPB 2 QL(2 ea daily)

FLOVENT HFA AERO 110 MCG/ACT, 220 MCG/ACT 2 QL(12 gm per

30 days retail) FLOVENT HFA AERO 44 MCG/ACT 2 QL(11 gm per

30 days retail)

PULMICORT FLEXHALER AEPB 2

QL(1 ea per 25days retail);AL(Up to 5 yrsold )

PULMICORT SUSP (Use budesonide (inhalation)) NP

QL(4 ml daily);AL(At least 1yrs old - Up to8 yrs old)

QVAR REDIHALER AERB NP

Sympathomimetics ADVAIR DISKUS AEPB (Use fluticasone-salmeterol)

2 QL(2 ea daily)

ADVAIR HFA AERO 2

albuterol sulfate aers in 108 mcg/act 0

albuterol sulfate aers in 108 mcg/act 0 QL(0.45 gm

daily) ALBUTEROL SULFATE ER TB12 2

albuterol sulfate nebu in 0.083 % 1 QL(375 ml per

25 days retail) albuterol sulfate nebu in 0.5 %, 2.5 mg/0.5ml 1 QL(2 ml daily)

albuterol sulfate nebu in 0.63 mg/3ml, 1.25 mg/3ml 1 QL(375 ml per

30 days retail) albuterol sulfate syrp or 2mg/5ml 1

albuterol sulfate tabs or 2 mg, 4 mg 1

ANORO ELLIPTA AEPB NP

ARCAPTA NEOHALER CAPS NP


14

Drug Name DrugTier

Requirements/Limits

BEVESPI AEROSPHERE AERO 2

BREO ELLIPTA AEPB NP

BROVANA NEBU NP

BUDESONIDE/FORMOTEROL FUMARATE DIHYDRATE AERO

2 QL(11 gm per30 days retail)

COMBIVENT RESPIMAT AERS 2 QL(4 gm per 30

days retail) DULERA AERO 5 MCG/ACT-100 MCG/ACT,5 MCG/ACT-200MCG/ACT

2

QL(13 gm per30 days retail)

fluticasone-salmeterol aepb 1 QL(2 ea daily)

ipratropium-albuterol soln 1 QL(12 ml daily)

levalbuterol hcl nebu in 0.31 mg/3ml, 0.63 mg/3ml,1.25 mg/3ml, 1.25mg/0.5ml

1

LEVALBUTEROL TARTRATE HFA AERO 2

METAPROTERENOL SULFATE SYRP OR 10 MG/5ML

2 QL(30 ml daily)

METAPROTERENOL SULFATE TABS OR 10 MG, 20 MG

2

PERFOROMIST NEBU NP

PROAIR HFA AERS (Use albuterol sulfate) NP QL(0.57 gm

daily) PROAIR RESPICLICK AEPB NP

PROVENTIL HFA AERS (Use albuterol sulfate) NP

SEREVENT DISKUS AEPB 2 QL(2 ea daily)

STIOLTO RESPIMAT AERS 2

STRIVERDI RESPIMAT AERS NP

SYMBICORT AERO 2 QL(11 gm per30 days retail)

Drug Name DrugTier

Requirements/Limits

terbutaline sulfate tabs or 5 mg, 2.5 mg 1

TRELEGY ELLIPTA AEPB NP

UTIBRON NEOHALER CAPS NP

VENTOLIN HFA AERS (Use albuterol sulfate) NP QL(1.2 gm

daily) VENTOLIN HFA AERS (Use albuterol sulfate) NP QL(0.54 gm

daily) XOPENEX CONCENTRATE NEBU (Use levalbuterol hcl)

NP

XOPENEX HFA AERO NP

XOPENEX NEBU (Use levalbuterol hcl) NP

Xanthines

ELIXOPHYLLIN ELIX 2

THEO-24 CP24 2

THEOPHYLLINE ER TB12 2

theophylline soln 80mg/15ml 1 QL(475 ml per

fill retail) theophylline tb12 100 mg,200 mg, 300 mg, 450 mg 1

theophylline tb24 400 mg,600 mg 1

ANTICOAGULANTS - Blood Thinners

Anticoagulants - Misc. DEFITELIO SOLN 2 PA; SP

Coumarin Anticoagulants COUMADIN TABS (Use warfarin sodium) NP

warfarin sodium tabs 0

Direct Factor Xa Inhibitors ELIQUIS STARTER PACK TABS 0 QL(4 ea daily)

ELIQUIS TABS 0 QL(4 ea daily)


15

Drug Name DrugTier

Requirements/Limits

SAVAYSA TABS NP

XARELTO STARTER PACK TBPK NP

XARELTO TABS 10 MG 0 QL(1 eadaily,35 ea per180 days retail)

XARELTO TABS 15 MG 0 QL(2 ea daily)

XARELTO TABS 2.5 MG 0

XARELTO TABS 20 MG 0 QL(1 ea daily)

Heparins And Heparinoid-Like Agents ARIXTRA SOLN (Use fondaparinux sodium) NP PA; SP

enoxaparin sodium soln ij300 mg/3ml 0

PA;QL(42 mlper 7 daysretail); SP

enoxaparin sodium soln sc100 mg/ml, 150 mg/ml 0


enoxaparin sodium soln sc30 mg/0.3ml 0

PA;QL(5 ml per7 days retail);SP





enoxaparin sodium soln sc80 mg/0.8ml, 120 mg/0.8ml 0


fondaparinux sodium soln 0 PA; SP

FRAGMIN SOLN 0 PA; SP

heparin sodium (porcine)soln 1

LOVENOX SOLN IJ 300 MG/3ML (Use enoxaparinsodium)

NP PA;QL(42 mlper 7 daysretail); SP

LOVENOX SOLN SC 100 MG/ML, 150 MG/ML (Use enoxaparin sodium)


Drug Name DrugTier

Requirements/Limits

LOVENOX SOLN SC 30 MG/0.3ML (Use enoxaparinsodium)

NP PA;QL(5 ml per7 days retail);SP





LOVENOX SOLN SC 80 MG/0.8ML, 120 MG/0.8ML(Use enoxaparin sodium)


Thrombin Inhibitors

PRADAXA CAPS 0

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists

FYCOMPA SUSP NP

FYCOMPA TABS NP

Anticonvulsants - Benzodiazepines

clobazam susp 1

clobazam tabs 1

clonazepam tabs or 0.5mg, 1 mg, 2 mg 1 QL(4 ea daily)

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg,2 mg

1

DIASTAT ACUDIAL GEL 2 QL(1 ea per fillretail); AL(Atleast 2 yrs old)

DIASTAT PEDIATRIC GEL 2 QL(1 ea per fillretail); AL(Atleast 2 yrs old)

DIAZEPAM RECTAL GEL GEL 2

QL(1 ea per fillretail); AL(Atleast 2 yrs old)

KLONOPIN TABS (Use clonazepam) NP QL(4 ea daily)

ONFI SUSP (Use clobazam) NP

ONFI TABS (Use clobazam) NP


16

Drug Name DrugTier

Requirements/Limits

Anticonvulsants - Misc. APTIOM TABS NP

BANZEL SUSP NP SP

BANZEL TABS NP SP

BRIVIACT SOLN IV 50 MG/5ML 2 PA; SP

BRIVIACT SOLN OR 10 MG/ML NP

BRIVIACT TABS OR 10 MG, 25 MG, 50 MG, 75 MG, 100 MG

NP

carbamazepine chew or100 mg 1

carbamazepine cp12 or100 mg, 200 mg, 300 mg 1

carbamazepine susp or100 mg/5ml 1

carbamazepine tabs or 200 mg 1

carbamazepine tb12 or 100mg, 200 mg, 400 mg 1

CARBATROL CP12 (Use carbamazepine) NP

DIACOMIT CAPS 250 MG 2 PA; QL(12 eadaily)

DIACOMIT CAPS 500 MG 2 PA; QL(6 eadaily)

DIACOMIT PACK 250 MG 2 PA; QL(12 eadaily)

DIACOMIT PACK 500 MG 2 PA; QL(6 eadaily)

EPIDIOLEX SOLN 2 PA; SP

gabapentin caps or 100 mg 1 QL(9 ea daily)

gabapentin caps or 300mg, 400 mg 1

gabapentin soln or 250mg/5ml, 300 mg/6ml 1

gabapentin tabs or 600 mg,800 mg 1

KEPPRA SOLN OR 100 MG/ML (Use levetiracetam) NP QL(30 ml daily)

Drug Name DrugTier

Requirements/Limits

KEPPRA TABS OR 250 MG, 500 MG, 750 MG, 1000 MG (Use levetiracetam)

NP

KEPPRA XR TB24 (Use levetiracetam) NP

LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use lamotrigine)

NP

LAMICTAL ODT KIT NP

LAMICTAL ODT TBDP 25 MG, 50 MG, 100 MG, 200 MG (Use lamotrigine)

NP

LAMICTAL STARTER/NOTTAKING CARBAMAZEPINE KIT (Use lamotrigine)

NP

LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATE KIT (Use lamotrigine)

NP

LAMICTAL STARTER/TAKINGVALPROATE KIT (Use lamotrigine)

NP

LAMICTAL TABS (Use lamotrigine) NP

LAMICTAL XR KIT NP

LAMICTAL XR TB24 25 MG, 50 MG, 100 MG, 200 MG, 250 MG, 300 MG (Use lamotrigine)

NP

lamotrigine chew or 5 mg,25 mg 1

lamotrigine kit or 25 mg, 1

lamotrigine tabs or 25 mg,100 mg, 150 mg, 200 mg 1

lamotrigine tb24 or 25 mg,50 mg, 100 mg, 200 mg,250 mg, 300 mg

1

lamotrigine tbdp or 25 mg,50 mg, 100 mg, 200 mg 1

levetiracetam soln or 100 mg/ml, 500 mg/5ml 1 QL(30 ml daily)


17

Drug Name DrugTier

Requirements/Limits

levetiracetam tabs or 250 mg, 500 mg, 750 mg, 1000 mg

1

levetiracetam tb24 or 500 mg, 750 mg 1

LYRICA CAPS (Use pregabalin) NP PA

LYRICA SOLN (Use pregabalin) NP PA

MYSOLINE TABS (Use primidone) NP

NEURONTIN CAPS 100 MG (Use gabapentin) NP QL(9 ea daily)

NEURONTIN CAPS 300 MG, 400 MG (Use gabapentin)

NP

NEURONTIN SOLN 250 MG/5ML (Use gabapentin) NP

NEURONTIN TABS 600 MG, 800 MG (Use gabapentin)

NP

oxcarbazepine susp 1

oxcarbazepine tabs 1

OXTELLAR XR TB24 NP

pregabalin caps or 25 mg,50 mg, 75 mg, 100 mg, 150mg, 200 mg, 225 mg, 300 mg

1

PA

pregabalin soln or 20mg/ml 1 PA

primidone tabs or 50 mg,250 mg 1

QUDEXY XR CS24 NP

SPRITAM TB3D NP

TEGRETOL SUSP (Use carbamazepine) NP

TEGRETOL TABS (Use carbamazepine) NP

TEGRETOL-XR TB12 (Use carbamazepine) NP

TOPAMAX SPRINKLE CPSP (Use topiramate) NP

Drug Name DrugTier

Requirements/Limits

TOPAMAX TABS 25 MG (Use topiramate) NP QL(6 ea daily)

TOPAMAX TABS 50 MG, 100 MG, 200 MG (Use topiramate)

NP

topiramate cpsp or 15 mg,25 mg 1

TOPIRAMATE ER CS24 2

topiramate tabs or 25 mg 1 QL(6 ea daily)

topiramate tabs or 50 mg,100 mg, 200 mg 1

TRILEPTAL SUSP (Use oxcarbazepine) NP

TRILEPTAL TABS (Use oxcarbazepine) NP

TROKENDI XR CP24 NP

VIMPAT SOLN OR 10 MG/ML NP

VIMPAT TABS OR 50 MG, 100 MG, 150 MG, 200 MG NP

ZONEGRAN CAPS (Use zonisamide) NP

zonisamide caps or 25 mg,50 mg, 100 mg 1

Carbamates

felbamate susp 1

felbamate tabs 1

FELBATOL SUSP (Use felbamate) NP

FELBATOL TABS (Use felbamate) NP

GABA Modulators GABITRIL TABS (Use tiagabine hcl) 2

SABRIL PACK (Use vigabatrin) NP PA; SP

SABRIL TABS (Use vigabatrin) NP PA; SP

tiagabine hcl tabs 1


18

Drug Name DrugTier

Requirements/Limits

vigabatrin pack 1 PA; SP

vigabatrin tabs 1 PA; SP

Hydantoins DILANTIN CAPS 100 MG (Use phenytoin sodiumextended)

NP

DILANTIN CAPS 30 MG NP

DILANTIN INFATABS CHEW (Use phenytoin) 2

DILANTIN-125 SUSP (Use phenytoin) NP

PEGANONE TABS NP

PHENYTEK CAPS (Use phenytoin sodiumextended)

NP

phenytoin chew or 50 mg 1

phenytoin sodium extended caps 1

phenytoin susp or 125mg/5ml 1

Succinimides

CELONTIN CAPS 2

ethosuximide caps or 250 mg 1

ethosuximide soln or 250 mg/5ml 1

ZARONTIN CAPS (Use ethosuximide) NP

ZARONTIN SOLN (Use ethosuximide) NP

Valproic Acid DEPAKENE CAPS (Use valproic acid) NP

DEPAKENE SOLN (Use valproate sodium) NP

DEPAKOTE ER TB24 (Use divalproex sodium) NP

DEPAKOTE SPRINKLES CSDR (Use divalproexsodium)

2

Drug Name DrugTier

Requirements/Limits

DEPAKOTE TBEC (Use divalproex sodium) NP

divalproex sodium csdr 1

divalproex sodium tb24 1

divalproex sodium tbec 1

valproate sodium soln or250 mg/5ml 1

valproic acid caps or 1

ANTIDEPRESSANTS - Drugs to TreatDepression

Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs or 15 mg,30 mg, 45 mg, 7.5 mg 1

mirtazapine tbdp or 15 mg,30 mg, 45 mg 1

REMERON SOLTAB TBDP (Use mirtazapine) NP

REMERON TABS (Use mirtazapine) NP

Antidepressants - Misc. APLENZIN TB24 NP

bupropion hcl tabs or 75mg, 100 mg 1

bupropion hcl tb12 or 100 mg 1 QL(4 ea daily)





BUPROPION HYDROCHLORIDE ER (XL) TB24

2

FORFIVO XL TB24 NP

MAPROTILINE HCL TABS 2


19

Drug Name DrugTier

Requirements/Limits

WELLBUTRIN SR TB12 100 MG (Use bupropionhcl)

NP QL(4 ea daily)


NP QL(3 ea daily)


NP QL(2 ea daily)

WELLBUTRIN XL TB24 150 MG (Use bupropionhcl)

NP QL(3 ea daily)

WELLBUTRIN XL TB24 300 MG (Use bupropionhcl)

NP QL(1 ea daily)

GABA Receptor Modulator - Neuroactive Steroid

ZULRESSO SOLN 2 PA; SP

Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 NP

NARDIL TABS (Use phenelzine sulfate) NP

PARNATE TABS (Use tranylcypromine sulfate) NP

phenelzine sulfate tabs or 1

tranylcypromine sulfatetabs 1

N-Methyl-D-aspartic acid (NMDA) Receptor SPRAVATO 56MG DOSE SOPK 2 PA; SP

SPRAVATO 84MG DOSE SOPK 2 PA; SP

Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS (Use citalopram hydrobromide) NP

citalopram hydrobromidesoln 1

citalopram hydrobromidetabs 1

escitalopram oxalate soln 1

escitalopram oxalate tabs 1

Drug Name DrugTier

Requirements/Limits

FLUOXETINE DR CPDR 2

fluoxetine hcl caps or 10mg, 20 mg, 40 mg 1

fluoxetine hcl soln or 20 mg/5ml 1

fluoxetine hcl tabs or 10 mg 1 AL(At least 7yrs old)

fluoxetine hcl tabs or 20 mg 1 QL(4 ea daily);AL(At least 7yrs old)

fluoxetine hcl tabs or 60 mg 1

FLUOXETINE HYDROCHLORIDE TABS (Use fluoxetine hcl)

2

fluvoxamine maleate cp24 1

fluvoxamine maleate tabs 1

LEXAPRO TABS (Use escitalopram oxalate) NP

paroxetine hcl tabs 1

paroxetine hcl tb24 1

PAXIL CR TB24 (Use paroxetine hcl) NP

PAXIL SUSP 10 MG/5ML 2

PAXIL TABS 10 MG, 20 MG, 30 MG, 40 MG (Use paroxetine hcl)

NP

PEXEVA TABS NP

PROZAC CAPS (Use fluoxetine hcl) NP

sertraline hcl conc or 20 mg/ml 1

sertraline hcl tabs or 25 mg, 50 mg, 100 mg 1

ZOLOFT CONC (Use sertraline hcl) NP

ZOLOFT TABS (Use sertraline hcl) NP

Serotonin Modulators


20

Drug Name DrugTier

Requirements/Limits

NEFAZODONE HCL TABS 100 MG, 150 MG 2

nefazodone hcl tabs 50 mg, 250 mg 1

NEFAZODONE HYDROCHLORIDE TABS 2

trazodone hcl tabs or 50 mg, 100 mg, 150 mg, 300 mg

1

TRINTELLIX TABS NP

VIIBRYD STARTER PACK KIT NP

VIIBRYD TABS NP

Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA CPEP (Use duloxetine hcl) NP


DESVENLAFAXINE ER TB24 50 MG, 100 MG 2

desvenlafaxine succinate tb24 100 mg 1 QL(4 ea daily)

desvenlafaxine succinate tb24 25 mg, 50 mg 1 QL(1 ea daily)

duloxetine hcl cpep or 20mg, 30 mg, 40 mg, 60 mg 1


EFFEXOR XR CP24 150 MG (Use venlafaxine hcl) NP QL(2 ea daily)

EFFEXOR XR CP24 37.5 MG (Use venlafaxine hcl) NP QL(4 ea daily)

EFFEXOR XR CP24 75 MG (Use venlafaxine hcl) NP QL(5 ea daily)

FETZIMA CP24 NP

FETZIMA TITRATION PACK C4PK NP

KHEDEZLA TB24 NP

PRISTIQ TB24 100 MG (Use desvenlafaxine succinate)

NP QL(4 ea daily)

PRISTIQ TB24 25 MG, 50 MG (Use desvenlafaxine succinate)

NP QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

venlafaxine hcl cp24 150 mg 1 QL(2 ea daily)

venlafaxine hcl cp24 37.5 mg 1 QL(4 ea daily)

venlafaxine hcl cp24 75 mg 1 QL(5 ea daily)

venlafaxine hcl tabs 25 mg,50 mg, 75 mg, 100 mg,37.5 mg

1

venlafaxine hcl tb24 75 mg,150 mg, 225 mg, 37.5 mg 1 QL(1 ea daily)

Tricyclic Agents amitriptyline hcl tabs or 10mg, 25 mg, 50 mg, 75 mg,100 mg, 150 mg

1

AMOXAPINE TABS 2

ANAFRANIL CAPS (Use clomipramine hcl) NP

clomipramine hcl caps or25 mg, 50 mg, 75 mg 1

desipramine hcl tabs or 10mg, 25 mg, 50 mg, 75 mg,100 mg, 150 mg

1

doxepin hcl caps or 10 mg,25 mg, 50 mg, 75 mg, 100mg, 150 mg

1

DOXEPIN HCL CAPS OR 150 MG 2

doxepin hcl conc or 10mg/ml 1

imipramine hcl tabs or 10mg, 25 mg, 50 mg 1

imipramine pamoate caps 1

NORPRAMIN TABS (Use desipramine hcl) NP

nortriptyline hcl caps or 10mg, 25 mg, 50 mg, 75 mg 1

NORTRIPTYLINE HCL SOLN OR 10 MG/5ML 2

nortriptyline hcl soln or 10mg/5ml 1

PAMELOR CAPS (Use nortriptyline hcl) NP

protriptyline hcl tabs 1


21

Drug Name DrugTier

Requirements/Limits

SURMONTIL CAPS (Use trimipramine maleate) NP

TOFRANIL TABS (Use imipramine hcl) NP

trimipramine maleate capsor 25 mg, 50 mg, 100 mg 1

ANTIDIABETICS - Drugs to Regulate BloodSugar Alpha-Glucosidase Inhibitors

acarbose tabs 1

GLYSET TABS (Use miglitol) 2

miglitol tabs 1

PRECOSE TABS (Use acarbose) NP

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN 2 PA; QL(11 mlper 30 daysretail)

SYMLINPEN 60 SOPN 2 PA; QL(6 mlper 30 daysretail)

Antidiabetic Combinations ACTOPLUS MET TABS (Use pioglitazone hcl-metformin hcl)

NP QL(2 ea daily)

ACTOPLUS MET XR TB24 NP

alogliptin-metformin hcltabs 1 QL(2 ea daily)

alogliptin-pioglitazone tabs 1 QL(1 ea daily)

D-CARE DM2 KIT NP

DUETACT TABS (Use pioglitazone hcl-glimepiride)

NP

glipizide-metformin hcl tabs 1

GLUCOVANCE TABS (Use glyburide-metformin) NP

glyburide-metformin tabs 1

Drug Name DrugTier

Requirements/Limits

GLYXAMBI TABS NP

INVOKAMET TABS NP

INVOKAMET XR TB24 NP

JANUMET TABS 2

JANUMET XR TB24 2

JENTADUETO TABS 2 QL(2 ea daily);AL(At least 18yrs old)

JENTADUETO XR TB24 NP

KAZANO TABS NP QL(2 ea daily)

KOMBIGLYZE XR TB24 2

OSENI TABS NP QL(1 ea daily)

pioglitazone hcl-glimepiridetabs 1

pioglitazone hcl-metforminhcl tabs 1 QL(2 ea daily)

REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS

2

SEGLUROMET TABS NP QL(2 ea daily)

SOLIQUA 100/33 SOPN NP

SYNJARDY TABS NP

XIGDUO XR TB24 NP

XULTOPHY 100/3.6 SOPN NP

Biguanides FORTAMET TB24 (Use metformin hcl) NP

GLUCOPHAGE TABS (Use metformin hcl) NP

GLUCOPHAGE XR TB24 (Use metformin hcl) NP

GLUMETZA TB24 (Use metformin hcl) NP


22

Drug Name DrugTier

Requirements/Limits

metformin hcl soln or 500 mg/5ml NP

metformin hcl soln or 500 mg/5ml 2

metformin hcl tabs or 500 mg, 850 mg, 1000 mg 1

metformin hcl tb24 or 500 mg, 750 mg, 1000 mg 1

RIOMET SOLN (Use metformin hcl) NP

Diabetic Other

BD GLUCOSE CHEW 2 QL(1.67 eadaily)

CVS GLUCOSE CHEW 4 GM 2 QL(1.67 ea

daily) CVS SOFT GLUCOSE CHEW 2 QL(1.67 ea

daily) DEX4 QUICK DISSOLVE GLUCOSE CHEW 2 QL(1.67 ea

daily) GLUCAGEN HYPOKIT SOLR 2

GLUCAGON EMERGENCY KIT KIT 2 QL(1 ea per fill

retail)

GLUCOSE CHEW 4 GM 2 QL(1.67 eadaily)

GNP GLUCOSE CHEW 4 GM 2 QL(1.67 ea

daily) GNP QUICK DISSOLVE GLUCOSE CHEW 2 QL(1.67 ea

daily)

KORLYM TABS 2 PA; SP

LEADER QUICK DISSOLVE GLUCOSE CHEW

2 QL(1.67 eadaily)

SM GLUCOSE CHEW 4 GM 2 QL(1.67 ea

daily) WALGREENS GLUCOSE CHEW 4 GM 2 QL(1.67 ea

daily) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

alogliptin benzoate tabs 1 QL(1 ea daily)

JANUVIA TABS 2

NESINA TABS NP QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

ONGLYZA TABS NP

TRADJENTA TABS 2 QL(1 ea daily);AL(At least 18yrs old)

Incretin Mimetic Agents (GLP-1 Receptor ADLYXIN SOPN NP

ADLYXIN STARTER PACK PNKT NP

BYDUREON PEN PEN 2

QL(4 ea per 28days retail);AL(At least 18yrs old)

BYDUREON SRER 2

QL(0.143 eadaily); AL(Atleast 18 yrsold)

BYETTA SOPN 10 MCG/0.04ML 2

QL(2 ml per 30days retail);AL(At least 18yrs old)

BYETTA SOPN 5 MCG/0.02ML 2

QL(1 ml per 30days retail);AL(At least 18yrs old)

TANZEUM PEN NP

TRULICITY SOPN NP

VICTOZA SOPN 2 QL(0.3 mldaily)

Insulin Sensitizing Agents ACTOS TABS (Use pioglitazone hcl) NP QL(1 ea daily)

AVANDIA TABS NP QL(1 ea daily)

pioglitazone hcl tabs 1 QL(1 ea daily)

Insulin

ADMELOG SOLN NP QL(40 ml per30 days retail)

ADMELOG SOLOSTAR SOPN NP

ADMELOG SOLOSTAR SOPN NP QL(30 ml per

30 days retail)


23

Drug Name DrugTier

Requirements/Limits

AFREZZA POWD NP

BASAGLAR KWIKPEN SOPN NP QL(30 ml per

30 days retail) HUMALOG JUNIOR KWIKPEN SOPN 2

HUMALOG KWIKPEN SOPN NP

HUMALOG MIX 50/50KWIKPEN SUPN 2 QL(30 ml per

30 days retail) HUMALOG MIX 50/50SUSP 2 QL(40 ml per

30 days retail) HUMALOG MIX 75/25KWIKPEN SUPN 2 QL(30 ml per

30 days retail) HUMALOG MIX 75/25SUSP 2 QL(40 ml per

30 days retail) HUMULIN 70/30 KWIKPENSUPN 2 QL(30 ml per

30 days retail)

HUMULIN 70/30 SUSP 2 QL(40 ml per30 days retail)

HUMULIN N KWIKPEN SUPN NP QL(30 ml per

30 days retail)

HUMULIN N SUSP 2 QL(40 ml per30 days retail)

HUMULIN R SOLN 2 QL(40 ml per30 days retail)

HUMULIN R U-500 (CONCENTRATED) SOLN NP

INSULIN ASPART PROTAMINE/INSULINASPART FLEXPEN SUPN

2 QL(30 ml per30 days retail)

INSULIN ASPART PROTAMINE/INSULINASPART SUSP


INSULIN LISPRO JUNIOR KWIKPEN SOPN NP

INSULIN LISPRO KWIKPEN SOPN 2

INSULIN LISPRO KWIKPEN SOPN NP

INSULIN LISPRO PROTAMINE/INSULINLISPRO KWIKPEN SUPN


INSULIN LISPRO SOLN NP

INSULIN LISPRO SOLN 2

Drug Name DrugTier

Requirements/Limits

LANTUS SOLOSTAR SOPN 2

LEVEMIR FLEXTOUCH SOPN 2

LEVEMIR SOLN 2

NOVOLIN 70/30 FLEXPENRELION SUPN NP QL(30 ml per

30 days retail) NOVOLIN 70/30 FLEXPENSUPN NP QL(30 ml per

30 days retail) NOVOLIN 70/30 RELIONSUSP NP QL(40 ml per

30 days retail)

NOVOLIN 70/30 SUSP NP QL(40 ml per30 days retail)

NOVOLIN N FLEXPEN RELION SUPN NP QL(30 ml per

30 days retail) NOVOLIN N FLEXPEN SUPN NP QL(30 ml per

30 days retail) NOVOLIN N RELION SUSP NP QL(40 ml per

30 days retail)

NOVOLIN N SUSP NP QL(40 ml per30 days retail)

NOVOLIN R RELION SOLN NP QL(40 ml per

30 days retail)

NOVOLIN R SOLN NP QL(40 ml per30 days retail)

NOVOLOG MIX 70/30PREFILLED FLEXPEN SUPN


NOVOLOG MIX 70/30SUSP 2 QL(40 ml per

30 days retail) TOUJEO MAX SOLOSTAR SOPN NP

TOUJEO SOLOSTAR SOPN NP

TRESIBA FLEXTOUCH SOPN NP

TRESIBA SOLN NP

Meglitinide Analogues

nateglinide tabs 1 QL(3 ea daily)

PRANDIN TABS (Use repaglinide) NP

repaglinide tabs 1


24

Drug Name DrugTier

Requirements/Limits

STARLIX TABS (Use nateglinide) NP QL(3 ea daily)

Sodium-Glucose Co-Transporter 2 (SGLT2) FARXIGA TABS 2

INVOKANA TABS 2

JARDIANCE TABS 2 QL(1 ea daily)

STEGLATRO TABS NP QL(1 ea daily)

Sulfonylureas AMARYL TABS 1 MG, 2 MG (Use glimepiride) NP QL(4 ea daily)

AMARYL TABS 4 MG (Use glimepiride) NP QL(2 ea daily)

glimepiride tabs 1 mg, 2 mg 1 QL(4 ea daily)

glimepiride tabs 4 mg 1 QL(2 ea daily)

glipizide tabs or 5 mg, 10 mg 1

glipizide tb24 or 5 mg, 10mg, 2.5 mg 1

GLUCOTROL TABS (Use glipizide) NP

GLUCOTROL XL TB24 (Use glipizide) NP

glyburide micronized tabs 1

glyburide tabs or 5 mg, 2.5mg, 1.25 mg 1

GLYNASE TABS (Use glyburide micronized) NP

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat Diarrhea

Antidiarrheal/Probiotic Agents - Misc. ACIDOPHILUS CAPS 2 RX/OTC

ACIDOPHILUS HIGH-POTENCY CAPS 2 RX/OTC

ACIDOPHILUS PEARLS CAPS 2 RX/OTC

ACIDOPHILUS PROBIOTIC BLEND CAPS 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

ACIDOPHILUS SUPER PROBIOTIC CAPS 2 RX/OTC

ACIDOPHILUS/GOATMILK CAPS 2 RX/OTC

ADVANCED PROBIOTIC 10 CAPS 2 RX/OTC

ADVANCED PROBIOTIC CAPS 2 RX/OTC

ADVANCED PROBIOTIC-14 CAPS 2 RX/OTC

ALIGN CAPS 2 RX/OTC

ALIGN EXTRA STRENGTH CAPS 2 RX/OTC

ALOE 10000 & PROBIOTICS CAPS 2 RX/OTC

BACID CAPS 2 RX/OTC

BIO-KULT CAPS 2 RX/OTC

BIOHM PROBIOTIC SUPPLEMENT CAPS 2 RX/OTC

BIOHM PROBIOTIC SUPPLEMENT/VITAMIN CCAPS

2 RX/OTC

bismuth subsalicylate chewor 262 mg 1

bismuth subsalicylate suspor 262 mg/15ml, 525mg/15ml, 525 mg/30ml,527 mg/30ml, 1050mg/30ml

1

CHILDRENS PROBIOTIC PEARLS CAPS 2 RX/OTC

CULTURELLE ADVANCED IMMUNE DEFENSE CAPS

2 RX/OTC

CULTURELLE KIDS CHEW 2

CULTURELLE KIDS PACK 2

CULTURELLE KIDS REGULARITY PACK 2

CULTURELLE PRO-WELL CAPS 70 MG-240 MG-5 MG-8 MG

2 RX/OTC


25

Drug Name DrugTier

Requirements/Limits

CULTURELLE PROBIOTICS KIDS PACK 2

CVS ADULT 50+ PROBIOTIC CAPS 2 RX/OTC

CVS ADULT PROBIOTIC CAPS 2 RX/OTC

CVS DIGESTIVE PROBIOTIC CAPS 2 RX/OTC

CVS MOOD SUPPORT PROBIOTIC CAPS 2 RX/OTC

CVS PROBIOTIC CAPS 2 RX/OTC

CVS PROBIOTIC MAXIMUM STRENGTH CAPS

2 RX/OTC

CVS PROBIOTIC PEARLS EXTRA STRENGTH CAPS 2 RX/OTC

CVS SENIOR PROBIOTIC CAPS 2 RX/OTC

DAILY PROBIOTIC CAPS 2 RX/OTC

DIFF-STAT CAPS 2 RX/OTC

DIGESTIVE ADVANTAGE CAPS 2 RX/OTC

DIGESTIVE ADVANTAGE LACTOSE DEFENSE FORMULA CAPS

2 RX/OTC

EQ PROBIOTIC DIGESTIVE SYSTEM SUPPORT CAPS

2 RX/OTC

EQL DAILY PROBIOTIC CAPS 2 RX/OTC

EQL PROBIOTIC COLON SUPPORT CAPS 2 RX/OTC

FLORA VANCE CAPS 2 RX/OTC

FLORAJEN3 CAPS 2 RX/OTC

FLORAJEN4KIDS CAPS 2 RX/OTC

FLORASTOR PLUS CAPS 2 RX/OTC

FLORASTOR PRE CAPS 2 RX/OTC

FORTIFY DAILY PROBIOTIC CAPS 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

GNP ACIDOPHILUS HIGH POTENCY CAPS 2 RX/OTC

GNP PROBIOTIC COLON SUPPORT CAPS 2 RX/OTC

GNP PROBIOTIC DIGESTIVE SUPPORT CAPS

2 RX/OTC

HIGH POTENCY PROBIOTIC CAPS 2 RX/OTC

HM ACIDOPHILUS CAPS 2 RX/OTC

LACTO-PECTIN CAPS 2 RX/OTC

MEGA PROBIOTIC CAPS 2 RX/OTC

META BIOTIC/BIO-ACTIVE 12 CAPS 2 RX/OTC

MOMMYS BLISS PROBIOTIC PACK 2

NATRUL PROBIOTIC CAPS 2 RX/OTC

PEARLS IC CAPS 2 RX/OTC

PEPTO-BISMOL CHEW (Use bismuth subsalicylate) NP

PEPTO-BISMOL MAX STRENGTH SUSP (Use bismuth subsalicylate)

NP

PEPTO-BISMOL SUSP (Use bismuth subsalicylate) NP

PEPTO-BISMOL TO-GO CHEW (Use bismuth subsalicylate)

NP

PHILLIPS COLON HEALTH CAPS 2 RX/OTC

PREORBOTIC CAPS 2 RX/OTC

PRO-BIOTIC BLEND CAPS 2 RX/OTC

PRO-FLORA IMMUNE CAPS 2 RX/OTC

PROBIOMAX DAILY DF CAPS 2 RX/OTC

PROBIOTIC & ACIDOPHILUS FORMULA EXTRA STRENGTH CAPS

2 RX/OTC


26

Drug Name DrugTier

Requirements/Limits

PROBIOTIC + OMEGA-3 CAPS 2 RX/OTC

PROBIOTIC ACIDOPHILUS BEADS CAPS

2 RX/OTC

PROBIOTIC ACIDOPHILUS CAPS 2 RX/OTC

PROBIOTIC ADVANCED ULTRAPOTENCY CAPS 2 RX/OTC

PROBIOTIC CAPS 2 RX/OTC

PROBIOTIC COLON SUPPORT CAPS 2 RX/OTC

PROBIOTIC COMPLEX/ACIDOPHILUSCAPS

2 RX/OTC

PROBIOTIC DAILY CAPS 2 RX/OTC

PROBIOTIC MATURE ADULT CAPS 2 RX/OTC

PROBIOTIC PEARLS ADVANTAGE CAPS 2 RX/OTC

PROBIOTIC PEARLS CAPS 2 RX/OTC

PROBIOTIC+TURMERIC EXTRACT CAPS 2 RX/OTC

PROBIOTIC-10 ULTIMATE CAPS 2 RX/OTC

PROBIOTIC/PREBIOTIC/CRANBERRY CAPS 2 RX/OTC

PRODIGEN CAPS 2 RX/OTC

PROMELLA IN PREBIOTIC CAPS 2 RX/OTC

PROVAD CAPS 2 RX/OTC

QUAD-PROBIOTIC CAPS 2 RX/OTC

RA PROBIOTIC COLON CARE CAPS 2 RX/OTC

RA PROBIOTIC COMPLEX CAPS 2 RX/OTC

RA PROBIOTIC DIGESTIVE SUPPORT CAPS

2 RX/OTC

RA PROBIOTIC MAXIMUM STRENGTH CAPS 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

RESTORA CAPS 2 RX/OTC

RISAQUAD CAPS 2 RX/OTC

RISAQUAD-2 CAPS 2 RX/OTC

SD PROBIOTIC-10 COMPLEXULTRA CAPS 2 RX/OTC

SM ACIDOPHILUS PEARLS CAPS 2 RX/OTC

SUPER PROBIOTIC CAPS 2 RX/OTC

SUPER PROBIOTIC DIGESTIVE SUPPORT CAPS

2 RX/OTC

TRUBIOTICS CAPS 2 RX/OTC

TRUNATURE DIGESTIVE PROBIOTIC CAPS 2 RX/OTC

ULTRAFLORA IMMUNE HEALTH CAPS 2 RX/OTC

UP4 PROBIOTICS ADULT CAPS 2 RX/OTC

UP4 PROBIOTICS ULTRA CAPS 2 RX/OTC

UP4 PROBIOTICS WOMENS CAPS 2 RX/OTC

VISBIOME PROBIOTIC HIGH POTENCY CAPS 2 RX/OTC

VSL#3 CAPS 2 RX/OTC

ZELAC CAPS 2 RX/OTC

Antidiarrheal/Probiotic Combinations CULTURELLE ADULT ULTIMATEBALANCE CAPS

2

CULTURELLE DIGESTIVE HEALTH CAPS 2

CULTURELLE DIGESTIVE HEALTH CHEW 2

CULTURELLE DIGESTIVE HEALTH PROBIOTIC CAPS

2

CULTURELLE HEALTH & WELLNESS CAPS 2


27

Drug Name DrugTier

Requirements/Limits

PROBIOTIC DIGESTIVE SUPPORT EXTRA STRENGTH CAPS

2

VIACTIV DIGESTIVE HEALTH CHEW 2

Antiperistaltic Agents diphenoxylate w/ atropinetabs 1

DIPHENOXYLATE/ATROPINE LIQD 2

IMODIUM A-D CAPS 2 MG (Use loperamide hcl) NP QL(8 ea daily);

RX/OTC IMODIUM A-D TABS 2 MG (Use loperamide hcl) NP QL(8 ea daily)

LOMOTIL TABS (Use diphenoxylate w/ atropine) NP

loperamide hcl caps or 2 mg 1 QL(8 ea daily);

RX/OTC loperamide hcl liqd or 1mg/5ml 1 QL(40 ml daily)

loperamide hcl tabs or 2 mg 1 QL(8 ea daily)

PAREGORIC TINC 2

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

CHEMET CAPS 2

deferasirox tabs 1 PA; SP

deferasirox tbso 1 PA; SP

EXJADE TBSO (Use deferasirox) NP PA; SP

FERRIPROX SOLN 2 PA; SP

FERRIPROX TABS 2 PA; SP

JADENU SPRINKLE PACK 2 PA; SP

JADENU TABS (Use deferasirox) NP PA; SP

Antidotes and Specific Antagonists

ANDEXXA SOLR 2 PA; SP

Drug Name DrugTier

Requirements/Limits

BRIDION SOLN 2 PA; SP

deferoxamine mesylate solr 1 PA; SP

DESFERAL SOLR (Use deferoxamine mesylate) NP PA; SP

SM IPECAC SYRUP SYRP 2

VISTOGARD PACK 2

Opioid Antagonists NALOXONE HCL SOCT IJ 0.4 MG/ML 2 QL(4 ml per 90

days retail) naloxone hcl soln ij 0.4mg/ml 0 QL(2 ml per 90

days retail) naloxone hcl soln ij 4mg/10ml 1 QL(4 ml per 90

days retail) naloxone hcl sosy ij 2mg/2ml 1 QL(4 ml per 30

days retail)

naltrexone hcl tabs or 1

NALTREXONE IMPL SC 2 PA

NARCAN LIQD 2 QL(2 ea per 90days retail)

VIVITROL SUSR 2

ANTIEMETICS - Drugs to Treat Nausea andVomiting

5-HT3 Receptor Antagonists

ANZEMET TABS NP

granisetron hcl tabs or 1 mg 1

ondansetron hcl soln or 4 mg/5ml 1 QL(50 ml per

fill retail) ONDANSETRON HCL TABS OR 24 MG 2

ondansetron hcl tabs or 24 mg 1

ondansetron hcl tabs or 4 mg, 8 mg 1 QL(2 ea daily)

ondansetron tbdp 1 QL(2 ea daily)

SANCUSO PTCH NP


28

Drug Name DrugTier

Requirements/Limits

ZOFRAN ODT TBDP (Use ondansetron) NP QL(2 ea daily)

ZOFRAN SOLN 4 MG/5ML(Use ondansetron hcl) NP QL(50 ml per

fill retail) ZOFRAN TABS 4 MG, 8 MG (Use ondansetron hcl) NP QL(2 ea daily)

ZUPLENZ FILM NP

Antiemetics - Anticholinergic meclizine hcl chew or 25 mg 1

meclizine hcl tabs or 25 mg, 12.5 mg 1 RX/OTC

Antiemetics - Miscellaneous AKYNZEO CAPS OR 300 MG-0.5 MG NP

DICLEGIS TBEC (Use doxylamine-pyridoxine) NP

doxylamine-pyridoxine tbec NP

Substance P/Neurokinin 1 (NK1) Receptor aprepitant caps 1

EMEND CAPS OR 40 MG, 80 MG, 125 MG (Use aprepitant)

NP

EMEND SUSR OR 125 MG NP

EMEND TRIPACK CAPS (Use aprepitant) NP

VARUBI TBPK NP

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungals GRIS-PEG TABS (Use griseofulvin ultramicrosize) NP

griseofulvin microsize susp 1

griseofulvin microsize tabs 1

griseofulvin ultramicrosizetabs 1

nystatin tabs or 1 QL(6 ea daily)

Drug Name DrugTier

Requirements/Limits

terbinafine hcl tabs or 1 QL(1 eadaily,90 ea per120 days retail)

Imidazole-Related Antifungals DIFLUCAN SUSR 10 MG/ML, 40 MG/ML (Use fluconazole)

NP QL(70 ml perfill retail)

DIFLUCAN TABS 100 MG (Use fluconazole) NP QL(1 ea daily)

DIFLUCAN TABS 150 MG (Use fluconazole) NP QL(2 ea daily)

DIFLUCAN TABS 200 MG (Use fluconazole) NP

DIFLUCAN TABS 50 MG (Use fluconazole) NP QL(7 ea per fill

retail) fluconazole susr or 10 mg/ml, 40 mg/ml 1 QL(70 ml per

fill retail)

fluconazole tabs or 100 mg 1 QL(1 ea daily)

fluconazole tabs or 150 mg 1 QL(2 ea daily)

fluconazole tabs or 200 mg 1

fluconazole tabs or 50 mg 1 QL(7 ea per fillretail)

itraconazole caps or 100 mg 1 PA; QL(1 ea

daily) itraconazole soln or 10 mg/ml 1 PA

ONMEL TABS NP

SPORANOX CAPS 100 MG (Use itraconazole) NP PA; QL(1 ea

daily) SPORANOX PULSEPAK CAPS (Use itraconazole) NP PA; QL(1 ea

daily) SPORANOX SOLN 10 MG/ML (Use itraconazole) NP PA

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines CHLOR-TRIMETON SYRP 2 MG/5ML (Use chlorpheniramine maleate)

NP QL(60 ml daily)

CHLOR-TRIMETON TABS 4 MG (Use chlorpheniramine maleate)

NP QL(120 ea perfill retail)


29

Drug Name DrugTier

Requirements/Limits

chlorpheniramine maleatesyrp or 2 mg/5ml 1 QL(60 ml daily)

chlorpheniramine maleatetabs or 4 mg 1 QL(120 ea per

fill retail) DEXCHLORPHENIRAMIN E MALEATE SOLN OR 2

RYCLORA SOLN 2

Antihistamines - Ethanolamines

ALER-DRYL TABS 2 QL(4 ea daily)

BENADRYL ALLERGY CAPS (Use diphenhydramine hcl)

NP QL(4 ea daily)

BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML (Use diphenhydramine hcl)

NP


BENADRYL ALLERGY TABS (Use diphenhydramine hcl)

NP QL(4 ea daily)

clemastine fumarate tabs or 1.34 mg 1 QL(2 ea daily)

diphenhydramine hcl capsor 25 mg, 50 mg 1 QL(4 ea daily)

diphenhydramine hcl elix or12.5 mg/5ml 1

QL(240 ml perfill retail);RX/OTC

diphenhydramine hcl liqd or25 mg/10ml, 50 mg/20ml,12.5 mg/5ml

1 QL(240 ml perfill retail)

diphenhydramine hcl tabsor 25 mg 1 QL(4 ea daily)

Antihistamines - Non-Sedating ALLEGRA ALLERGY CHILDRENS SUSP 30 MG/5ML (Use fexofenadine hcl)

NP

ALLEGRA ALLERGY CHILDRENS TBDP 30 MG 2

ALLEGRA ALLERGY TABS 180 MG (Use fexofenadine hcl)

NP QL(1 ea daily)

ALLEGRA ALLERGY TABS 60 MG (Use fexofenadine hcl)

NP QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

cetirizine hcl caps 10 mg 1

cetirizine hcl chew 5 mg, 10 mg 1 QL(1 ea daily)

cetirizine hcl soln 1 mg/ml,5 mg/5ml 1


cetirizine hcl syrp 1 mg/ml,5 mg/5ml 1


cetirizine hcl tabs 5 mg, 10 mg 1 QL(1 ea daily)

CLARINEX SYRP NP

CLARITIN ALLERGY CHILDRENS SYRP (Use loratadine)


CLARITIN CAPS 10 MG (Use loratadine) NP

CLARITIN CHEW 5 MG (Use loratadine) NP

CLARITIN CHILDRENS CHEW (Use loratadine) NP

CLARITIN REDITABS TBDP 10 MG (Use loratadine)

NP

CLARITIN SYRP 5 MG/5ML (Use loratadine) NP QL(240 ml per

fill retail) CLARITIN TABS 10 MG (Use loratadine) NP

DESLORATADINE ODT TBDP 2

fexofenadine hcl susp or 30mg/5ml 1

fexofenadine hcl tabs or 180 mg 1 QL(1 ea daily)

fexofenadine hcl tabs or 60 mg 1 QL(2 ea daily)

levocetirizine dihydrochloride soln or 1 RX/OTC

loratadine caps or 10 mg 1

loratadine chew or 5 mg 1

loratadine soln or 5 mg/5ml 1 QL(240 ml perfill retail)


30

Drug Name DrugTier

Requirements/Limits

loratadine syrp or 5 mg/5ml 1 QL(240 ml perfill retail)

loratadine tabs or 10 mg 1

loratadine tbdp or 10 mg 1

XYZAL ALLERGY 24HR CHILDRENS SOLN (Use levocetirizine dihydrochloride)

NP

RX/OTC

ZYRTEC ALLERGY CAPS (Use cetirizine hcl) NP

ZYRTEC ALLERGY TABS (Use cetirizine hcl) NP QL(1 ea daily)

ZYRTEC CHILDRENS ALLERGY SOLN (Use cetirizine hcl)

NP QL(240 ml perfill retail);RX/OTC

Antihistamines - Phenothiazines

promethazine hcl soln or6.25 mg/5ml 1

QL(240 ml perfill retail); AL(Atleast 2 yrs old)

promethazine hcl supp re25 mg, 50 mg, 12.5 mg 1

QL(12 ea perfill retail); AL(Atleast 2 yrs old)

promethazine hcl syrp or6.25 mg/5ml 1


promethazine hcl tabs or25 mg, 50 mg, 12.5 mg 1 AL(At least 2

yrs old)

PROMETHEGAN SUPP 2 QL(12 ea perfill retail); AL(Atleast 2 yrs old)

Antihistamines - Piperidines cyproheptadine hcl syrp or2 mg/5ml 1

cyproheptadine hcl tabs or4 mg 1

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Antihyperlipidemics - Combinations

ezetimibe-simvastatin tabs 1

VYTORIN TABS (Use ezetimibe-simvastatin) NP

Antihyperlipidemics - Misc.

Drug Name DrugTier

Requirements/Limits

KYNAMRO SOSY 2 PA; SP

LOVAZA CAPS (Use omega-3-acid ethyl esters) NP

omega-3-acid ethyl esters caps 1

VASCEPA CAPS NP

Bile Acid Sequestrants

cholestyramine light pack 1

cholestyramine light powd 1

cholestyramine pack or 4 gm 1

cholestyramine powd or 4gm/dose 1

COLESTID FLAVORED GRAN 5 GM (Use colestipol hcl)

NP

COLESTID GRAN 5 GM (Use colestipol hcl) NP

COLESTID TABS 1 GM (Use colestipol hcl) NP

colestipol hcl gran 5 gm 1

colestipol hcl tabs 1 gm 1

QUESTRAN LIGHT POWD (Use cholestyramine light) NP

QUESTRAN PACK (Use cholestyramine) NP

QUESTRAN POWD (Use cholestyramine) NP

Fibric Acid Derivatives

ANTARA CAPS NP

FENOFIBRATE CAPS OR 50 MG, 150 MG 2

fenofibrate micronized caps134 mg, 200 mg 1 QL(1 ea daily)

fenofibrate micronized caps43 mg, 130 mg 1

fenofibrate micronized caps67 mg 1 QL(2 ea daily)


31

Drug Name DrugTier

Requirements/Limits

FENOFIBRATE TABS OR 160 MG 2 QL(1 ea daily)

fenofibrate tabs or 160 mg NP

fenofibrate tabs or 160 mg 1 QL(1 ea daily)

fenofibrate tabs or 40 mg,120 mg 1

fenofibrate tabs or 54 mg 1 QL(3 ea daily)

FENOFIBRIC ACID TABS 35 MG, 105 MG 2

FENOGLIDE TABS (Use fenofibrate) NP

FIBRICOR TABS 35 MG, 105 MG NP

gemfibrozil tabs or 1 QL(2 ea daily)

LIPOFEN CAPS NP

LOPID TABS (Use gemfibrozil) NP QL(2 ea daily)

TRIGLIDE TABS NP QL(1 ea daily)

HMG CoA Reductase Inhibitors

ALTOPREV TB24 NP

atorvastatin calcium tabs or 10 mg, 20 mg, 40 mg, 80 mg

1 QL(1 ea daily)

CRESTOR TABS (Use rosuvastatin calcium) NP QL(1 ea daily)

fluvastatin sodium caps 1

fluvastatin sodium tb24 1

LESCOL XL TB24 (Use fluvastatin sodium) NP

LIPITOR TABS (Use atorvastatin calcium) NP QL(1 ea daily)

LIVALO TABS NP

lovastatin tabs 10 mg, 20 mg 1 QL(1 ea daily)

lovastatin tabs 40 mg 1 QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

PRAVACHOL TABS (Use pravastatin sodium) NP QL(1 ea daily)

pravastatin sodium tabs 1 QL(1 ea daily)

rosuvastatin calcium tabs 1 QL(1 ea daily)

simvastatin tabs or 5 mg,10 mg, 20 mg, 40 mg 1 QL(1 ea daily)

simvastatin tabs or 80 mg 1

ZOCOR TABS 5 MG, 10 MG, 20 MG, 40 MG (Use simvastatin)

NP QL(1 ea daily)

ZOCOR TABS 80 MG (Use simvastatin) NP

Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs 1

ZETIA TABS (Use ezetimibe) NP

Microsomal Triglyceride Transfer Protein (MTP) JUXTAPID CAPS 2 PA; SP

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr 1

NIACIN TABS OR 500 MG NP

NIACOR TABS NP

NIASPAN TBCR (Use niacin (antihyperlipidemic)) 2

Proprotein Convertase Subtilisin/Kexin Type 9

PRALUENT SOAJ 2 PA; SP

REPATHA SOSY 2 PA; SP

REPATHA SURECLICK SOAJ 2 PA; SP

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure

ACE Inhibitors ACCUPRIL TABS (Use quinapril hcl) NP QL(1 ea daily)


32

Drug Name DrugTier

Requirements/Limits

ALTACE CAPS (Use ramipril) NP QL(2 ea daily)

benazepril hcl tabs or 40 mg 1 QL(2 ea daily)

benazepril hcl tabs or 5mg, 10 mg, 20 mg 1 QL(1 ea daily)

captopril tabs or 25 mg, 50mg, 100 mg, 12.5 mg 1 QL(3 ea daily)

enalapril maleate tabs or 5mg, 10 mg, 20 mg, 2.5 mg 1 QL(2 ea daily)

EPANED SOLN NP

fosinopril sodium tabs 1 QL(1 ea daily)

lisinopril tabs or 5 mg, 10mg, 20 mg, 30 mg, 40 mg,2.5 mg

1

LOTENSIN TABS 10 MG, 20 MG (Use benazepril hcl) NP QL(1 ea daily)

LOTENSIN TABS 40 MG (Use benazepril hcl) NP QL(2 ea daily)

moexipril hcl tabs 1

perindopril erbumine tabs 1

PRINIVIL TABS (Use lisinopril) NP

QBRELIS SOLN NP

quinapril hcl tabs 1 QL(1 ea daily)

ramipril caps 1 QL(2 ea daily)

trandolapril tabs 1 mg, 2 mg 1 QL(1 ea daily)

trandolapril tabs 4 mg 1 QL(2 ea daily)

VASOTEC TABS (Use enalapril maleate) NP QL(2 ea daily)

ZESTRIL TABS (Use lisinopril) NP

Agents for Pheochromocytoma

DEMSER CAPS 2 PA; SP

Angiotensin II Receptor Antagonists ATACAND TABS (Use candesartan cilexetil) NP

Drug Name DrugTier

Requirements/Limits

AVAPRO TABS (Use irbesartan) NP QL(1 ea daily)

BENICAR TABS (Use olmesartan medoxomil) NP

candesartan cilexetil tabs 1

COZAAR TABS (Use losartan potassium) NP QL(1 ea daily)

DIOVAN TABS (Use valsartan) 2 QL(1 ea daily)

EDARBI TABS NP

EPROSARTAN MESYLATE TABS 2

irbesartan tabs 1 QL(1 ea daily)

losartan potassium tabs or25 mg, 50 mg, 100 mg 1 QL(1 ea daily)

MICARDIS TABS (Use telmisartan) NP

olmesartan medoxomil tabs 1

telmisartan tabs 1

valsartan tabs 1 QL(1 ea daily)

Antiadrenergic Antihypertensives CARDURA TABS (Use doxazosin mesylate) NP

CATAPRES TABS (Use clonidine hcl) NP

clonidine hcl tabs or 0.1 mg, 0.2 mg, 0.3 mg 1

doxazosin mesylate tabs or1 mg, 2 mg, 4 mg, 8 mg 1

guanfacine hcl tabs 1

methyldopa tabs 1

MINIPRESS CAPS (Use prazosin hcl) NP

prazosin hcl caps 1

terazosin hcl caps 1

Antihypertensive Combinations


33

Drug Name DrugTier

Requirements/Limits

ACCURETIC TABS 10 MG-12.5 MG (Use quinapril-hydrochlorothiazide)

NP

QL(3 ea daily)

ACCURETIC TABS 20 MG-12.5 MG (Use quinapril-hydrochlorothiazide)

NP

QL(4 ea daily)

ACCURETIC TABS 20 MG-25 MG (Use quinapril-hydrochlorothiazide)

NP QL(2 ea daily)

amlodipine besylate-benazepril hcl caps 1 QL(1 ea daily)

amlodipine besylate-olmesartan medoxomil tabs 1

amlodipine besylate-valsartan tabs 1

amlodipine-valsartan-hydrochlorothiazide tabs 1

ATACAND HCT TABS (Use candesartan cilexetil-hydrochlorothiazide)

NP

atenolol & chlorthalidone tabs 1 QL(1 ea daily)

AVALIDE TABS (Use irbesartan-hydrochlorothiazide)

NP QL(1 ea daily)

AZOR TABS (Use amlodipine besylate-olmesartan medoxomil)

NP

benazepril &hydrochlorothiazide tabs 1 QL(1 ea daily)

BENICAR HCT TABS (Use olmesartan medoxomil-hydrochlorothiazide)

NP

bisoprolol &hydrochlorothiazide tabs 1 QL(1 ea daily)

BYVALSON TABS NP

candesartan cilexetil-hydrochlorothiazide tabs 1

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS 2 QL(2 ea daily)

CORZIDE TABS 40 MG-5 MG NP

CORZIDE TABS 80 MG-5 MG NP

Drug Name DrugTier

Requirements/Limits

DIOVAN HCT TABS (Use valsartan-hydrochlorothiazide)

NP QL(1 ea daily)

DUTOPROL TB24 NP QL(1 ea daily)

EDARBYCLOR TABS NP

enalapril maleate &hydrochlorothiazide tabs 1 QL(2 ea daily)

EXFORGE HCT TABS (Use amlodipine-valsartan-hydrochlorothiazide)

NP

EXFORGE TABS (Use amlodipine besylate-valsartan)

NP

fosinopril sodium &hydrochlorothiazide tabs 1 QL(1 ea daily)

HYZAAR TABS (Use losartan potassium &hydrochlorothiazide)

NP QL(1 ea daily)

irbesartan-hydrochlorothiazide tabs 1 QL(1 ea daily)

lisinopril &hydrochlorothiazide tabs 1

LOPRESSOR HCT TABS (Use metoprolol &hydrochlorothiazide)

NP QL(2 ea daily)

losartan potassium &hydrochlorothiazide tabs 1 QL(1 ea daily)

LOTENSIN HCT TABS (Use benazepril &hydrochlorothiazide)

NP QL(1 ea daily)

LOTREL CAPS (Use amlodipine besylate-benazepril hcl)

NP QL(1 ea daily)

metoprolol &hydrochlorothiazide tabs 1 QL(2 ea daily)

METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE TB24

2

QL(1 ea daily)

METOPROLOL/HYDROCHLOROTHIAZIDE TABS 2 QL(2 ea daily)

MICARDIS HCT TABS (Use telmisartan-hydrochlorothiazide)

NP QL(1 ea daily)


34

Drug Name DrugTier

Requirements/Limits

moexipril-hydrochlorothiazide tabs 1

NADOLOL/BENDROFLUMETHIAZIDE TABS 2

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

1

olmesartan medoxomil-hydrochlorothiazide tabs 1

PRESTALIA TABS NP

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS 2 QL(2 ea daily)

quinapril-hydrochlorothiazide tabs 10mg-12.5 mg

1 QL(3 ea daily)

quinapril-hydrochlorothiazide tabs 20mg-12.5 mg

1 QL(4 ea daily)

quinapril-hydrochlorothiazide tabs 20mg-25 mg

1 QL(2 ea daily)

TARKA TBCR (Use trandolapril-verapamil hcl) NP

telmisartan-amlodipine tabs 1

telmisartan-hydrochlorothiazide tabs 1 QL(1 ea daily)

TENORETIC 100 TABS (Use atenolol & chlorthalidone)

NP QL(1 ea daily)

TENORETIC 50 TABS (Use atenolol & chlorthalidone)

NP QL(1 ea daily)

trandolapril-verapamil hcltbcr 1

TRANDOLAPRIL/VERAPAMIL HCL ER TBCR 2

TRIBENZOR TABS (Use olmesartan medoxomil-amlodipine-hydrochlorothiazide)

NP

TWYNSTA TABS (Use telmisartan-amlodipine) NP

valsartan-hydrochlorothiazide tabs 1 QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

VASERETIC TABS (Use enalapril maleate &hydrochlorothiazide)

NP QL(2 ea daily)

ZESTORETIC TABS (Use lisinopril &hydrochlorothiazide)

NP

ZIAC TABS (Use bisoprolol& hydrochlorothiazide) NP QL(1 ea daily)

Antihypertensives - Misc. VECAMYL TABS 2 PA; SP

Vasodilators hydralazine hcl tabs or 10mg, 25 mg, 50 mg, 100 mg 1

minoxidil tabs or 10 mg, 2.5 mg 1

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations

COARTEM TABS 2 QL(24 ea perfill retail)

Antimalarials chloroquine phosphate tabsor 250 mg 0 QL(2 ea daily)

CHLOROQUINE PHOSPHATE TABS OR 500 MG

0 QL(8 ea per 56days retail)

chloroquine phosphate tabsor 500 mg 0 QL(8 ea per 56

days retail) DARAPRIM TABS (Use pyrimethamine) NP PA; SP

hydroxychloroquine sulfatetabs or 0

KRINTAFEL TABS 2 QL(2 ea per 30days retail)

MEFLOQUINE HCL TABS 2

PLAQUENIL TABS (Use hydroxychloroquine sulfate) NP

pyrimethamine tabs or 1 PA; SP

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents


35

Drug Name DrugTier

Requirements/Limits

FIRDAPSE TABS 2 PA; SP

MESTINON TABS 60 MG (Use pyridostigminebromide)

NP

MESTINON TIMESPAN TBCR (Use pyridostigminebromide)

NP

pyridostigmine bromidetabs or 60 mg 1

pyridostigmine bromidetbcr or 180 mg 1

RUZURGI TABS 2 PA; QL(10 eadaily); SP

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Antimycobacterial Agents ethambutol hcl tabs or 100 mg, 400 mg 1

ISONIAZID SYRP OR 50 MG/5ML 2

isoniazid tabs or 100 mg,300 mg 1

MYAMBUTOL TABS (Use ethambutol hcl) NP

pyrazinamide tabs or 1

RIFADIN CAPS OR 150 MG, 300 MG (Use rifampin)

NP

rifampin caps or 150 mg,300 mg 1

TRECATOR TABS 2

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN SOLR IV 50 MG (Use melphalan hcl) NP PA; SP

ALKERAN TABS OR 2 MG (Use melphalan) NP

BELRAPZO SOLN 2 PA; SP

BENDAMUSTINE HYDROCHLORIDE SOLN 2 PA; SP

Drug Name DrugTier

Requirements/Limits

BENDEKA SOLN 2 PA; SP

carboplatin soln 1 PA; SP

CISPLATIN SOLN 200 MG/200ML 2 PA; SP

cisplatin soln 50 mg/50ml,100 mg/100ml 1 PA; SP

CISPLATIN SOLR 50 MG 2 PA; SP

EVOMELA SOLR 2 PA; SP

LEUKERAN TABS 2

melphalan hcl solr 1 PA; SP

melphalan tabs 1

MUSTARGEN SOLR 2 PA; SP

MYLERAN TABS 2

TEMODAR CAPS OR 5 MG, 20 MG, 100 MG, 140 MG, 180 MG, 250 MG (Use temozolomide)

NP

PA; SP

TEMODAR SOLR IV 100 MG 2 PA; SP

temozolomide caps 1 PA; SP

TEPADINA SOLR 2 PA; SP

TEPADINA SOLR (Use thiotepa) NP PA; SP

thiotepa solr ij 1 PA; SP

TREANDA SOLR 2 PA; SP

YONDELIS SOLR 2 PA; SP

Antimetabolites

ALIMTA SOLR 2 PA; SP

azacitidine susr 1 PA; SP

capecitabine tabs 1 PA; SP

cladribine soln 1 PA; SP


36

Drug Name DrugTier

Requirements/Limits

cytarabine soln 1 PA; SP

CYTARABINEAQUEOUS SOLN 2 PA; SP

DACOGEN SOLR (Use decitabine) NP PA; SP

decitabine solr 1 PA; SP

fludarabine phosphate soln 1 PA; SP

fludarabine phosphate solr 1 PA; SP

FOLOTYN SOLN 2 PA; SP

mercaptopurine tabs or 1

methotrexate sodium soln ij25 mg/ml, 1 gm/40ml, 50mg/2ml, 250 mg/10ml

1

METHOTREXATE SODIUM SOLN IJ 250 MG/10ML

2

methotrexate sodium tabs or 2.5 mg 1

PURIXAN SUSP 2

TABLOID TABS 2 PA; SP

TREXALL TABS 2

VIDAZA SUSR (Use azacitidine) NP PA; SP

XELODA TABS (Use capecitabine) NP PA; SP

Antineoplastic - Angiogenesis Inhibitors

AVASTIN SOLN 2 PA; SP

CYRAMZA SOLN 2 PA; SP

MVASI SOLN 2 PA; SP

ZALTRAP SOLN 2 PA; SP

Antineoplastic - Antibodies

ADCETRIS SOLR 2 PA; SP

ARZERRA CONC 2 PA; SP

Drug Name DrugTier

Requirements/Limits

BLINCYTO SOLR 2 PA; SP

DARZALEX SOLN 2 PA; SP

EMPLICITI SOLR 2 PA; SP

ERBITUX SOLN 2 PA; SP

GAZYVA SOLN 2 PA; SP

HERCEPTIN SOLR 2 PA; SP

KADCYLA SOLR 2 PA; SP

KANJINTI SOLR 420 MG 2 PA; SP

KEYTRUDA SOLN 2 PA; SP

LARTRUVO SOLN 2 PA; SP

LIBTAYO SOLN 2 PA; SP

LUMOXITI SOLR 2 PA; SP

OPDIVO SOLN 2 PA; SP

PERJETA SOLN 2 PA; SP

POLIVY SOLR 2 PA; SP

PORTRAZZA SOLN 2 PA; SP

POTELIGEO SOLN 2 PA; SP

RITUXAN SOLN 2 PA; SP

TECENTRIQ SOLN 2 PA; SP

UNITUXIN SOLN 2 PA; SP

VECTIBIX SOLN 2 PA; SP

YERVOY SOLN 2 PA; SP

ZEVALIN Y-90 KIT 2 PA; SP

Antineoplastic - BCL-2 Inhibitors VENCLEXTA STARTING PACK TBPK 2 PA; SP


37

Drug Name DrugTier

Requirements/Limits

VENCLEXTA TABS 2 PA; SP

Antineoplastic - Cellular Immunotherapy

PROVENGE SUSP 2 PA; SP

Antineoplastic - Hedgehog Pathway Inhibitors

DAURISMO TABS 2 PA; SP

ERIVEDGE CAPS 2 PA; SP

ODOMZO CAPS 2 PA; SP

Antineoplastic - Hormonal and Related Agents

abiraterone acetate tabs 1 PA; SP

anastrozole tabs or 1

ARIMIDEX TABS (Use anastrozole) NP

AROMASIN TABS (Use exemestane) NP SP

bicalutamide tabs 1 QL(1 ea daily)

CASODEX TABS (Use bicalutamide) NP QL(1 ea daily)

ELIGARD KIT 2 PA; SP

EMCYT CAPS 2 PA; SP

ERLEADA TABS 2 PA; SP

exemestane tabs 1 SP

FARESTON TABS (Use toremifene citrate) NP PA

FEMARA TABS (Use letrozole) NP

FENSOLVI KIT 2 PA; SP

FIRMAGON SOLR 2 PA; SP

flutamide caps 1

HYDROXYPROGESTERO NE CAPROATE SOLN IM 1.25 GM/5ML

2

PA; QL(41.67ml daily); AL(Atleast 16 yrsold); SP

Drug Name DrugTier

Requirements/Limits

letrozole tabs or 1

leuprolide acetate kit ij 1 PA; SP

LEUPROLIDE ACETATE/BUPIVACAINEHYDROCHLORIDE SOLN

2 PA; SP

LUPRON DEPOT (1-MONTH) KIT 2 PA; SP




LYSODREN TABS 2 PA; SP

megestrol acetate susp or40 mg/ml, 400 mg/10ml 1

megestrol acetate tabs or20 mg, 40 mg 1

tamoxifen citrate tabs or 10 mg, 20 mg 1

toremifene citrate tabs 1 PA

TRELSTAR MIXJECT SUSR 2 PA; SP

VANTAS KIT 2 PA; SP

XTANDI CAPS 2 PA; SP

ZOLADEX IMPL 2 PA; SP

ZYTIGA TABS (Use abiraterone acetate) NP PA; SP

Antineoplastic - Immunomodulators

POMALYST CAPS 2 PA; SP

Antineoplastic Antibiotics

daunorubicin hcl soln 1 PA; SP

DAUNORUBICIN HYDROCHLORIDE SOLN 20 MG/4ML (Use daunorubicin hcl)

NP

PA; SP


38

Drug Name DrugTier

Requirements/Limits

DAUNORUBICIN HYDROCHLORIDE SOLN 20 MG/4ML, 50 MG/10ML

2 PA; SP

ELLENCE SOLN (Use epirubicin hcl) NP PA; SP

epirubicin hcl soln 1 PA; SP

mitoxantrone hcl conc 1 PA; SP

valrubicin soln 1 PA; SP

VALSTAR SOLN (Use valrubicin) NP PA; SP

Antineoplastic Combinations HERCEPTIN HYLECTA SOLN 2 PA; SP

LONSURF TABS 2 PA; SP

Antineoplastic Enzyme Inhibitors

AFINITOR DISPERZ TBSO 2 PA; SP

AFINITOR TABS 10 MG 2 PA; SP

AFINITOR TABS 5 MG, 2.5 MG, 7.5 MG (Use everolimus)

NP PA; SP

ALECENSA CAPS 2 PA; SP

BELEODAQ SOLR 2 PA; SP

BORTEZOMIB SOLR 2 PA; SP

BOSULIF TABS 2 PA; SP

BRAFTOVI CAPS 2 PA; SP

CABOMETYX TABS 2 PA; SP

CAPRELSA TABS 2 PA; SP

COMETRIQ KIT 2 PA; SP

COTELLIC TABS 2 PA; SP

erlotinib hcl tabs 1 PA; SP

everolimus tabs 1 PA; SP

Drug Name DrugTier

Requirements/Limits

FARYDAK CAPS 2 PA; SP

GILOTRIF TABS 2 PA; SP

GLEEVEC TABS (Use imatinib mesylate) NP PA; SP

IBRANCE CAPS 75 MG, 100 MG, 125 MG 2 PA; SP

ICLUSIG TABS 2 PA; SP

imatinib mesylate tabs 1 PA; SP

IMBRUVICA CAPS 140 MG 2 PA; SP

IMBRUVICA CAPS 70 MG 2 PA; QL(1 eadaily); SP

IMBRUVICA TABS 140 MG, 280 MG, 420 MG, 560 MG

2 PA; QL(1 eadaily); SP

INLYTA TABS 2 PA; SP

INREBIC CAPS 2 PA; SP

IRESSA TABS 2 PA; SP

ISTODAX (OVERFILL) SOLR 2 PA; SP

JAKAFI TABS 2 PA; SP

KYPROLIS SOLR 2 PA; SP

LENVIMA 10 MG DAILY DOSE CPPK 2 PA; SP

LENVIMA 12MG DAILY DOSE CPPK 2 PA; SP








39

Drug Name DrugTier

Requirements/Limits

LORBRENA TABS 2 PA; SP

LYNPARZA CAPS 2 PA; SP

MEKINIST TABS 2 PA; SP

MEKTOVI TABS 2 PA; SP

NEXAVAR TABS 2 PA; SP

NINLARO CAPS 2 PA; SP

ROMIDEPSIN SOLR 10 MG 2 PA; SP

ROZLYTREK CAPS 2 PA; SP

RUBRACA TABS 2 PA; SP

SPRYCEL TABS 2 PA; SP

STIVARGA TABS 2 PA; SP

SUTENT CAPS 2 PA; SP

TAFINLAR CAPS 2 PA; SP

TAGRISSO TABS 2 PA; SP

TALZENNA CAPS 2 PA; SP

TARCEVA TABS (Use erlotinib hcl) NP PA; SP

TASIGNA CAPS 2 PA; SP

temsirolimus soln 1 PA; SP

TIBSOVO TABS 2 PA; SP

TORISEL SOLN (Use temsirolimus) NP PA; SP

TYKERB TABS 2 PA; SP

VELCADE SOLR 2 PA; SP

VITRAKVI CAPS 2 PA; SP

VITRAKVI SOLN 2 PA; SP

Drug Name DrugTier

Requirements/Limits

VIZIMPRO TABS 2 PA; SP

VOTRIENT TABS 2 PA; SP

XALKORI CAPS 2 PA; SP

XOSPATA TABS 2 PA; SP

ZELBORAF TABS 2 PA; SP

ZOLINZA CAPS 2 PA; SP

ZYDELIG TABS 2 PA; SP

ZYKADIA CAPS 2 PA; SP

Antineoplastic Enzymes

ERWINAZE SOLR 2 PA; SP

ONCASPAR SOLN 2 PA; SP

Antineoplastic Radiopharmaceuticals AZEDRA DOSIMETRIC SOLN 2 PA; SP

AZEDRA THERAPEUTIC SOLN 2 PA; SP

LUTATHERA SOLN 2 PA; SP

Antineoplastics Misc. ACTIMMUNE SOLN 2 PA; SP

ALFERON N SOLN 2 PA; SP

arsenic trioxide soln iv 12 mg/6ml 1 PA; SP

bexarotene caps 1 PA; SP

HYDREA CAPS (Use hydroxyurea) NP

hydroxyurea caps or 1

INTRON A SOLN 2 PA; SP

INTRON A SOLR 2 PA; SP

MATULANE CAPS 2 PA; SP


40

Drug Name DrugTier

Requirements/Limits

PHOTOFRIN SOLR 2 PA; SP

PROLEUKIN SOLR 2 PA; SP

SYLATRON KIT 2 PA; SP

SYNRIBO SOLR 2 PA; SP

TARGRETIN CAPS OR 75 MG (Use bexarotene) NP PA; SP

tretinoin (chemotherapy) caps 1 PA; SP

TRISENOX SOLN (Use arsenic trioxide) NP PA; SP

Chemotherapy Adjuncts

KEPIVANCE SOLR 2 PA; SP

Chemotherapy Rescue/Antidote Agents

dexrazoxane hcl solr 1 PA; SP

FUSILEV SOLR (Use levoleucovorin calcium) NP PA; SP

KHAPZORY SOLR 2 PA; SP

LEUCOVORIN CALCIUM TABS OR 10 MG, 15 MG 2

leucovorin calcium tabs or 5 mg, 25 mg 1

levoleucovorin calcium soln 1 PA; SP

levoleucovorin calcium solr 1 PA; SP

LEVOLEUCOVORIN SOLR 2 PA; SP

mesna soln 1 PA; SP

MESNEX SOLN IV 100 MG/ML (Use mesna) NP PA; SP

MESNEX TABS OR 400 MG 2 PA; SP

TOTECT SOLR 2 PA; SP

VORAXAZE SOLR 2 PA; SP

ZINECARD SOLR (Use dexrazoxane hcl) NP PA; SP

Mitotic Inhibitors

Drug Name DrugTier

Requirements/Limits

ABRAXANE SUSR 2 PA; SP

DOCETAXEL (NON-ALCOHOL FORMULA) SOLN

2 PA; SP

DOCETAXEL CONC 160 MG/8ML (Use docetaxel) NP PA; SP

DOCETAXEL CONC 20 MG/ML, 80 MG/2ML, 80MG/4ML, 160 MG/8ML, 20MG/0.5ML

2

PA; SP

docetaxel conc 20 mg/ml,80 mg/4ml, 160 mg/8ml 1 PA; SP

docetaxel soln 20 mg/2ml,80 mg/8ml, 160 mg/16ml 1 PA; SP

DOCETAXEL SOLN 20 MG/2ML, 80 MG/8ML, 160MG/16ML

2 PA; SP

DOCETAXEL SOLN 20 MG/2ML, 80 MG/8ML, 160MG/16ML (Use docetaxel)

NP PA; SP

ETOPOSIDE CAPS OR 50 MG 2 PA; SP

etoposide soln iv 1gm/50ml, 100 mg/5ml, 500mg/25ml

1 PA; SP

HALAVEN SOLN 2 PA; SP

IXEMPRA KIT SOLR 2 PA; SP

JEVTANA SOLN 2 PA; SP

MARQIBO SUSP 2 PA; SP

TAXOTERE CONC (Use docetaxel) NP PA; SP

vincristine sulfate soln 1 PA; SP

VINCRISTINE SULFATE SOLN 2 PA; SP

Oncolytic Viral Agents

IMLYGIC SUSP 2 PA; SP

Topoisomerase I Inhibitors CAMPTOSAR SOLN (Use irinotecan hcl) NP PA; SP


41

Drug Name DrugTier

Requirements/Limits

HYCAMTIN CAPS OR 0.25 MG, 1 MG 2 PA; SP

HYCAMTIN SOLR IV 4 MG (Use topotecan hcl) NP PA; SP

irinotecan hcl soln 1 PA; SP

IRINOTECAN SOLN 2 PA; SP

TOPOTECAN HCL SOLN 4 MG/4ML 2 PA; SP

topotecan hcl soln 4mg/4ml 1 PA; SP

TOPOTECAN HCL SOLN 4 MG/4ML (Use topotecanhcl)

NP PA; SP

topotecan hcl solr 4 mg 1 PA; SP

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease

Antiparkinson Adjunctive Therapy

carbidopa tabs or 1

LODOSYN TABS (Use carbidopa) NP

Antiparkinson Anticholinergics benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg 1

trihexyphenidyl hcl soln 1

trihexyphenidyl hcl tabs 1

Antiparkinson Dopaminergics amantadine hcl caps or100 mg 1

amantadine hcl syrp or 50mg/5ml 1

APOKYN SOCT 2 PA; SP

bromocriptine mesylatecaps or 5 mg 1

bromocriptine mesylatetabs or 2.5 mg 1

carbidopa-levodopa tabs10 mg-100 mg, 25 mg-100mg, 25 mg-250 mg

1

Drug Name DrugTier

Requirements/Limits

carbidopa-levodopa tbcr 25mg-100 mg, 50 mg-200 mg 1

MIRAPEX ER TB24 (Use pramipexoledihydrochloride)

NP

MIRAPEX TABS (Use pramipexoledihydrochloride)


NEUPRO PT24 NP

PARLODEL CAPS (Use bromocriptine mesylate) NP

PARLODEL TABS (Use bromocriptine mesylate) NP

pramipexoledihydrochloride tabs 0.125mg, 0.25 mg, 0.75 mg, 0.5mg, 1 mg, 1.5 mg

1


pramipexoledihydrochloride tb24 0.375mg, 0.75 mg, 3 mg, 1.5 mg,4.5 mg, 2.25 mg, 3.75 mg

1

REQUIP TABS 0.25 MG, 3 MG, 4 MG (Use ropinirolehydrochloride)

NP QL(6 ea daily)

REQUIP TABS 0.5 MG, 1 MG, 2 MG, 5 MG (Use ropinirole hydrochloride)

NP QL(3 ea daily)

REQUIP XL TB24 (Use ropinirole hydrochloride) NP

ropinirole hydrochloridetabs 0.25 mg, 3 mg, 4 mg 1 QL(6 ea daily)

ropinirole hydrochloridetabs 0.5 mg, 1 mg, 2 mg, 5 mg

1 QL(3 ea daily)

ropinirole hydrochloridetb24 2 mg, 4 mg, 6 mg, 8mg, 12 mg

1

SINEMET CR TBCR (Use carbidopa-levodopa) NP

SINEMET TABS (Use carbidopa-levodopa) NP

Antiparkinson Monoamine Oxidase Inhibitors ELDEPRYL CAPS (Use selegiline hcl) NP

selegiline hcl caps or 1


42

Drug Name DrugTier

Requirements/Limits

selegiline hcl tabs or 1

SELEGILINE HCL TABS OR 2

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents lithium carbonate caps or150 mg, 300 mg, 600 mg 1

LITHIUM CARBONATE CAPS OR 150 MG, 600 MG (Use lithium carbonate)

2

lithium carbonate tabs or 300 mg 1

lithium carbonate tbcr or 300 mg, 450 mg 1

LITHIUM SOLN 2

LITHOBID TBCR (Use lithium carbonate) 2

Antipsychotics - Misc. EQUETRO CP12 NP

GEODON CAPS (Use ziprasidone hcl) NP

GEODON SOLR (Use ziprasidone mesylate) NP

LATUDA TABS NP

NUPLAZID CAPS 34 MG 2 PA; QL(1 eadaily)

NUPLAZID TABS 10 MG 2 PA; QL(1 eadaily)

NUPLAZID TABS 17 MG 2 PA; QL(2 eadaily)

VRAYLAR CAPS NP

VRAYLAR CPPK NP

ziprasidone hcl caps 1

ziprasidone mesylate solr NP

Benzisoxazoles

FANAPT TABS NP

Drug Name DrugTier

Requirements/Limits

FANAPT TITRATION PACK TABS NP

INVEGA SUSTENNA SUSY 2 AL(At least 18

yrs old); SP INVEGA TB24 (Use paliperidone) NP

INVEGA TRINZA SUSY 2

PA; 1 rtl MAX fill,84 rtl day(s)supply,; AL(Atleast 18 yrsold); SP

paliperidone tb24 1

PERSERIS PRSY NP SP

RISPERDAL CONSTA SRER 2

1 rtl MAX fill,28 rtl day(s)supply,; AL(Atleast 18 yrsold); SP

RISPERDAL M-TAB TBDP (Use risperidone) NP

RISPERDAL SOLN (Use risperidone) NP

RISPERDAL TABS (Use risperidone) NP

RISPERIDONE ODT TBDP 2

risperidone soln 1

risperidone tabs 1

risperidone tbdp 1

Butyrophenones HALDOL DECANOATE 100 SOLN (Use haloperidoldecanoate)

NP

HALDOL DECANOATE 50 SOLN (Use haloperidoldecanoate)

NP

HALDOL SOLN (Use haloperidol lactate) NP

haloperidol decanoate solnim 50 mg/ml, 100 mg/ml 1

haloperidol lactate conc 1


43

Drug Name DrugTier

Requirements/Limits

haloperidol lactate soln 1

haloperidol tabs or 0.5 mg,1 mg, 2 mg, 5 mg, 10 mg,20 mg

1

Dibenzapines

ADASUVE AEPB NP

CLOZAPINE ODT TBDP 2

clozapine tabs 25 mg, 50mg, 100 mg, 200 mg 0

clozapine tbdp 25 mg, 100 mg 1

CLOZARIL TABS (Use clozapine) NP

FAZACLO TBDP 150 MG, 200 MG NP

FAZACLO TBDP 25 MG, 100 MG, 12.5 MG (Use clozapine)

NP

loxapine succinate caps 1

olanzapine solr im 10 mg 1

olanzapine tabs or 5 mg,10 mg, 15 mg, 20 mg, 2.5mg, 7.5 mg


olanzapine tbdp or 5 mg,10 mg, 15 mg, 20 mg 1

quetiapine fumarate tabs 1

quetiapine fumarate tb24 1

SAPHRIS SUBL NP

SEROQUEL TABS (Use quetiapine fumarate) NP

SEROQUEL XR TB24 (Use quetiapine fumarate) NP

VERSACLOZ SUSP NP

ZYPREXA RELPREVV SUSR NP SP

ZYPREXA SOLR IM 10 MG (Use olanzapine) NP

Drug Name DrugTier

Requirements/Limits

ZYPREXA TABS OR 5 MG, 10 MG, 15 MG, 20 MG, 2.5 MG, 7.5 MG (Use olanzapine)

NP

AL(At least 10yrs old)

ZYPREXA ZYDIS TBDP (Use olanzapine) NP

Dihydroindolones MOLINDONE HYDROCHLORIDE TABS 10 MG

2

Phenothiazines chlorpromazine hcl tabs or10 mg, 25 mg, 50 mg, 100mg, 200 mg

1

fluphenazine decanoatesoln ij 1

FLUPHENAZINE HCL TABS OR 1 MG, 5 MG, 10 MG, 2.5 MG

2

fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg 1

perphenazine tabs or 2 mg,4 mg, 8 mg, 16 mg 1

prochlorperazine edisylatesoln ij 10 mg/2ml 1

prochlorperazine maleatetabs or 5 mg, 10 mg 1

prochlorperazine supp 1

thioridazine hcl tabs or 10 mg, 25 mg, 50 mg, 100 mg 1

trifluoperazine hcl tabs 1

Quinolinone Derivatives

ABILIFY MAINTENA PRSY 300 MG, 400 MG 2

PA; QL(1 eaper 28 daysretail); AL(Atleast 18 yrsold); SP

ABILIFY MAINTENA SRER 300 MG 2

PA; QL(1 eaper 28 daysretail); AL(Atleast 18 yrsold); SP

ABILIFY MAINTENA SRER 400 MG 2 PA; SP


44

Drug Name DrugTier

Requirements/Limits

ABILIFY MYCITE TABS NP SP

ABILIFY TABS (Use aripiprazole) NP QL(1 ea daily)

aripiprazole soln 1 mg/ml 1 QL(30 ml daily)

aripiprazole tabs 2 mg, 5mg, 10 mg, 15 mg, 20 mg,30 mg

1 QL(1 ea daily)

aripiprazole tbdp 10 mg, 15 mg 1 QL(2 ea daily)

ARISTADA INITIO PRSY NP SP

ARISTADA PRSY NP

QL(1 ml per 28days retail);AL(At least 18yrs old); SP

REXULTI TABS NP

Thioxanthenes

thiothixene caps 1

ANTISEPTICS & DISINFECTANTS

Antiseptics & Disinfectants FORMALDEHYDE SOLN 10 % 2 QL(90 ml per

fill retail)

formaldehyde soln 10 % 1 QL(90 ml perfill retail)

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals abacavir sulfate soln 20 mg/ml 0 QL(30 ml

daily); SP abacavir sulfate tabs 300 mg 0 QL(2 ea daily);

SP abacavir sulfate-lamivudine tabs 0 QL(1 ea daily);

SP abacavir sulfate-lamivudine-zidovudine tabs 0 QL(2 ea daily);

SP

APTIVUS CAPS 250 MG 0 QL(4 ea daily);SP

APTIVUS SOLN 100 MG/ML 0 QL(10 ml

daily); SP

atazanavir sulfate caps 0 QL(2 ea daily);SP

Drug Name DrugTier

Requirements/Limits

ATRIPLA TABS 0 QL(1 ea daily);SP

BIKTARVY TABS 0 QL(1 ea daily)

COMBIVIR TABS (Use lamivudine-zidovudine) NP QL(2 ea daily);

SP

COMPLERA TABS 0 QL(1 ea daily);SP

CRIXIVAN CAPS 200 MG 0 QL(9 ea daily);SP

CRIXIVAN CAPS 400 MG 0 QL(6 ea daily);SP

DELSTRIGO TABS 0 QL(1 ea daily)

DESCOVY TABS 0 QL(1 ea daily)

DIDANOSINE CPDR 0 QL(1 ea daily);SP

DOVATO TABS 0

EDURANT TABS 0 QL(1 ea daily);SP

efavirenz caps 200 mg 0 QL(1 ea daily);SP

efavirenz caps 50 mg 0 QL(2 ea daily);SP

efavirenz tabs 600 mg 0 QL(1 ea daily);SP

EMTRIVA CAPS 200 MG 0 QL(1 ea daily);SP

EMTRIVA SOLN 10 MG/ML 0 QL(24 ml

daily); SP EPIVIR SOLN 10 MG/ML(Use lamivudine) NP QL(30 ml

daily); SP EPIVIR TABS 150 MG (Use lamivudine) NP QL(2 ea daily);

SP EPIVIR TABS 300 MG (Use lamivudine) NP QL(1 ea daily);

SP EPZICOM TABS (Use abacavir sulfate-lamivudine)

NP QL(1 ea daily);SP

EVOTAZ TABS 0 QL(1 ea daily);SP

fosamprenavir calcium tabs 0 QL(4 ea daily);SP

FUZEON SOLR 2 PA; SP


45

Drug Name DrugTier

Requirements/Limits

GENVOYA TABS 0 QL(1 ea daily);SP

INTELENCE TABS 200 MG 0 QL(2 ea daily);

SP INTELENCE TABS 25 MG, 100 MG 0 QL(4 ea daily);

SP

INVIRASE CAPS 200 MG 0 QL(10 eadaily); SP

INVIRASE TABS 500 MG 0 QL(4 ea daily);SP

ISENTRESS CHEW 100 MG 0 QL(6 ea daily);

SP

ISENTRESS CHEW 25 MG 0 QL(12 eadaily); SP

ISENTRESS PACK 100 MG 0 QL(2 ea daily);

SP ISENTRESS TABS 400 MG 0 QL(2 ea daily);

SP KALETRA SOLN 400 MG/5ML-100 MG/5ML(Use lopinavir-ritonavir)

NP QL(160 ml perfill retail); SP

KALETRA TABS 100 MG-25 MG 0 QL(4 ea daily);

SP KALETRA TABS 200 MG-50 MG 0 QL(6 ea daily);

SP

lamivudine soln 10 mg/ml 0 QL(30 mldaily); SP

lamivudine tabs 150 mg 0 QL(2 ea daily);SP

lamivudine tabs 300 mg 0 QL(1 ea daily);SP

lamivudine-zidovudine tabs 0 QL(2 ea daily);SP

LEXIVA SUSP 50 MG/ML 0 QL(56 mldaily); SP

LEXIVA TABS 700 MG (Use fosamprenavircalcium)


lopinavir-ritonavir soln 0 QL(160 ml perfill retail); SP

NEVIRAPINE ER TB24 0 QL(3 ea daily);SP

nevirapine susp 50 mg/5ml 0 QL(40 mldaily); SP

nevirapine tabs 200 mg 0 QL(2 ea daily);SP

Drug Name DrugTier

Requirements/Limits

nevirapine tb24 100 mg 0 QL(3 ea daily);SP

nevirapine tb24 400 mg 0 QL(1 ea daily);SP

NORVIR CAPS 100 MG 0 QL(12 eadaily); SP

NORVIR SOLN 80 MG/ML 0 QL(15 mldaily); SP

NORVIR TABS 100 MG (Use ritonavir) NP QL(12 ea

daily); SP

ODEFSEY TABS 2 PA; SP

PIFELTRO TABS 0 QL(1 ea daily)

PREZCOBIX TABS 0 QL(1 ea daily);SP

PREZISTA SUSP 100 MG/ML 0 QL(12 ml

daily); SP

PREZISTA TABS 150 MG 0 QL(3 ea daily);SP

PREZISTA TABS 75 MG, 600 MG, 800 MG 0 QL(2 ea daily);

SP RESCRIPTOR TABS 100 MG 0 QL(12 ea

daily); SP RESCRIPTOR TABS 200 MG 0 QL(6 ea daily);

SP RETROVIR CAPS 100 MG (Use zidovudine) NP QL(6 ea daily);

SP RETROVIR IV INFUSION SOLN 2 PA; SP

RETROVIR SYRP 50 MG/5ML (Use zidovudine) NP QL(60 ml

daily); SP REYATAZ CAPS 150 MG, 200 MG, 300 MG (Use atazanavir sulfate)


REYATAZ PACK 50 MG 0 QL(6 ea daily);SP

ritonavir tabs 0 QL(12 eadaily); SP

SELZENTRY SOLN 20 MG/ML 0 QL(35 ml daily)

SELZENTRY TABS 150 MG 0 QL(2 ea daily);

SP SELZENTRY TABS 300 MG 0 QL(4 ea daily);

SP


46

Drug Name DrugTier

Requirements/Limits

stavudine caps 0 QL(2 ea daily);SP

STRIBILD TABS 0 SP

SUSTIVA CAPS 200 MG (Use efavirenz) NP QL(1 ea daily);

SP SUSTIVA CAPS 50 MG (Use efavirenz) NP QL(2 ea daily);

SP SUSTIVA TABS 600 MG (Use efavirenz) NP QL(1 ea daily);

SP

SYMFI LO TABS 0 QL(1 ea daily)

SYMFI TABS 0 QL(1 ea daily)

SYMTUZA TABS 0 QL(1 ea daily)

tenofovir disoproxilfumarate tabs 0 QL(1 ea daily);

SP

TIVICAY TABS 0 SP

TRIUMEQ TABS 0 SP

TRIZIVIR TABS (Use abacavir sulfate-lamivudine-zidovudine)


TRUVADA TABS 0 QL(1 ea daily);SP

TYBOST TABS 0 QL(1 ea daily);SP

VIDEX EC CPDR 125 MG 0 QL(1 ea daily);SP

VIDEX EC CPDR 200 MG, 250 MG, 400 MG NP QL(1 ea daily);

SP

VIDEXPEDIATRIC SOLR 0 QL(20 mldaily); SP

VIRACEPT TABS 250 MG 0 QL(9 ea daily);SP

VIRACEPT TABS 625 MG 0 QL(4 ea daily);SP

VIRAMUNE SUSP 50 MG/5ML (Use nevirapine) NP QL(40 ml

daily); SP VIRAMUNE TABS 200 MG (Use nevirapine) NP QL(2 ea daily);

SP VIRAMUNE XR TB24 100 MG (Use nevirapine) NP QL(3 ea daily);

SP VIRAMUNE XR TB24 400 MG (Use nevirapine) NP QL(1 ea daily);

SP

Drug Name DrugTier

Requirements/Limits

VIREAD POWD 40 MG/GM 0 SP

VIREAD TABS 150 MG, 200 MG, 250 MG 0 QL(1 ea daily);

SP VIREAD TABS 300 MG (Use tenofovir disoproxilfumarate)


ZERIT CAPS 15 MG, 20 MG, 30 MG, 40 MG (Use stavudine)


ZERIT SOLR 1 MG/ML 0 QL(80 mldaily); SP

ZIAGEN SOLN 20 MG/ML(Use abacavir sulfate) NP QL(30 ml

daily); SP ZIAGEN TABS 300 MG (Use abacavir sulfate) NP QL(2 ea daily);

SP

zidovudine caps 100 mg 0 QL(6 ea daily);SP

zidovudine syrp 50 mg/5ml 0 QL(60 mldaily); SP

zidovudine tabs 300 mg 0 QL(2 ea daily);SP

CMV Agents

PREVYMIS SOLN 2 PA; SP

PREVYMIS TABS 2 PA; SP

VALCYTE TABS 450 MG (Use valganciclovir hcl) NP QL(2 ea daily)

valganciclovir hcl tabs 450 mg 1 QL(2 ea daily)

Hepatitis Agents

DAKLINZA TABS NP SP

EPCLUSA TABS 2 PA; SP

HARVONI TABS 400 MG-90 MG 2 PA; SP

LEDIPASVIR/SOFOSBUVIR TABS 2 PA; SP

MAVYRET TABS 2 PA; SP

MODERIBA 1200 DOSE PACK TBPK NP

OLYSIO CAPS NP SP


47

Drug Name DrugTier

Requirements/Limits

PEGASYS PROCLICK SOLN 2 PA; SP

PEGASYS SOLN 2 PA; SP

PEGINTRON KIT NP SP

REBETOL CAPS 200 MG (Use ribavirin (hepatitis c)) NP PA; SP

REBETOL SOLN 40 MG/ML NP SP

RIBASPHERE RIBAPAK TBPK NP SP

RIBASPHERE RIBAPAK TBPK 400 MG, 600 MG NP

RIBASPHERE TABS NP SP

ribavirin (hepatitis c) caps 1 PA; SP

ribavirin (hepatitis c) tabs 1 PA; SP

SOFOSBUVIR/VELPATASVIR TABS 2 PA; SP

SOVALDI TABS 400 MG NP SP

TECHNIVIE TABS NP SP

VEMLIDY TABS NP SP

VIEKIRA PAK TBPK NP SP

ZEPATIER TABS NP SP

Herpes Agents

acyclovir caps or 200 mg 1 QL(50 ea per30 days retail)

acyclovir susp or 200mg/5ml 1 QL(400 ml per

30 days retail)

acyclovir tabs or 400 mg 1 QL(3 ea daily)

acyclovir tabs or 800 mg 1 QL(50 ea per30 days retail)

famciclovir tabs or 125 mg,250 mg, 500 mg 1

SITAVIG TABS NP

valacyclovir hcl tabs or 1gm, 1000 mg 1 QL(42 ea per

21 days retail)

Drug Name DrugTier

Requirements/Limits

valacyclovir hcl tabs or 500 mg 1 QL(2 ea daily)

VALTREX TABS 1 GM (Use valacyclovir hcl) NP QL(42 ea per

21 days retail) VALTREX TABS 500 MG (Use valacyclovir hcl) NP QL(2 ea daily)

ZOVIRAX CAPS OR 200 MG (Use acyclovir) NP QL(50 ea per

30 days retail) ZOVIRAX SUSP OR 200 MG/5ML (Use acyclovir) NP QL(400 ml per

30 days retail) ZOVIRAX TABS OR 400 MG (Use acyclovir) NP QL(3 ea daily)

ZOVIRAX TABS OR 800 MG (Use acyclovir) NP QL(50 ea per

30 days retail) Influenza Agents

FLUMADINE TABS NP PA

oseltamivir phosphate capsor 30 mg 1 QL(20 ea per

fill retail) oseltamivir phosphate capsor 45 mg, 75 mg 1 QL(10 ea per

fill retail) oseltamivir phosphate susror 6 mg/ml 1 QL(120 ml per

fill retail)

RELENZA DISKHALER AEPB 2

QL(20 ea perfill retail); AL(Atleast 6 yrs old)

RIMANTADINE HYDROCHLORIDE TABS 2 PA

TAMIFLU CAPS 30 MG (Use oseltamivir phosphate)


TAMIFLU CAPS 45 MG, 75 MG (Use oseltamivir phosphate)


TAMIFLU SUSR 6 MG/ML(Use oseltamivir phosphate)


XOFLUZA TBPK NP

BETA BLOCKERS - Drugs to Treat High BloodPressure

Alpha-Beta Blockers

carvedilol phosphate cp24 1 QL(1 ea daily)

carvedilol tabs 12.5 mg,6.25 mg, 3.125 mg 1 QL(3 ea daily)


48

Drug Name DrugTier

Requirements/Limits

carvedilol tabs 25 mg 1 QL(4 ea daily)

COREG CR CP24 (Use carvedilol phosphate) NP QL(1 ea daily)

COREG TABS 12.5 MG, 6.25 MG, 3.125 MG (Use carvedilol)

NP QL(3 ea daily)

COREG TABS 25 MG (Use carvedilol) NP QL(4 ea daily)

labetalol hcl tabs or 100 mg 1 QL(3 ea daily)



Beta Blockers Cardio-Selective acebutolol hcl caps or 200mg, 400 mg 1

atenolol tabs or 25 mg, 50mg, 100 mg 1 QL(2 ea daily)

betaxolol hcl tabs 1

bisoprolol fumarate tabs 1 QL(1 ea daily)

BYSTOLIC TABS NP

KAPSPARGO SPRINKLE CS24 NP

LOPRESSOR TABS 100 MG (Use metoprolol tartrate)

NP QL(4.5 eadaily)

LOPRESSOR TABS 50 MG (Use metoprolol tartrate)

NP QL(4 ea daily)

metoprolol succinate tb24200 mg 1 QL(2 ea daily)

metoprolol succinate tb2425 mg, 50 mg, 100 mg 1 QL(4 ea daily)

metoprolol tartrate tabs or100 mg 1 QL(4.5 ea

daily) metoprolol tartrate tabs or25 mg, 50 mg 1 QL(4 ea daily)

metoprolol tartrate tabs or75 mg, 37.5 mg 1

TENORMIN TABS (Use atenolol) NP QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

TOPROL XL TB24 200 MG (Use metoprolol succinate) NP QL(2 ea daily)

TOPROL XL TB24 25 MG, 50 MG, 100 MG (Use metoprolol succinate)

NP QL(4 ea daily)

Beta Blockers Non-Selective BETAPACE AF TABS (Use sotalol hcl (afib/afl)) NP QL(2 ea daily)

BETAPACE TABS (Use sotalol hcl) NP QL(2 ea daily)

CORGARD TABS (Use nadolol) NP

HEMANGEOL SOLN NP SP

INDERAL LA CP24 (Use propranolol hcl) NP QL(2 ea daily)

INDERAL XL CP24 80 MG, 120 MG 2

INNOPRAN XL CP24 80 MG, 120 MG NP

nadolol tabs or 20 mg, 40mg, 80 mg 1

pindolol tabs 1

propranolol hcl cp24 or 60mg, 80 mg, 120 mg, 160 mg

1 QL(2 ea daily)

PROPRANOLOL HCL SOLN OR 20 MG/5ML, 40MG/5ML

2

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

1

sotalol hcl (afib/afl) tabs 1 QL(2 ea daily)

sotalol hcl tabs 240 mg 1

sotalol hcl tabs 80 mg, 120mg, 160 mg 1 QL(2 ea daily)

SOTYLIZE SOLN NP

timolol maleate tabs or 5 mg, 10 mg, 20 mg 1

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure

Calcium Channel Blockers


49

Drug Name DrugTier

Requirements/Limits

ADALAT CC TB24 30 MG, 90 MG (Use nifedipine) NP QL(1 ea daily)

ADALAT CC TB24 60 MG (Use nifedipine) NP QL(2 ea daily)

amlodipine besylate tabs or5 mg, 10 mg, 2.5 mg 1 QL(1 ea daily)

CALAN SR TBCR (Use verapamil hcl) NP QL(2 ea daily)

CALAN TABS (Use verapamil hcl) NP QL(3 ea daily)

CARDIZEM CD CP24 120 MG, 180 MG, 300 MG (Use diltiazem hcl coated beads)

NP QL(1 ea daily)

CARDIZEM CD CP24 240 MG (Use diltiazem hcl coated beads)

NP QL(2 ea daily)

CARDIZEM CD CP24 360 MG (Use diltiazem hcl coated beads)

NP

CARDIZEM LA TB24 120 MG NP

CARDIZEM LA TB24 180 MG, 240 MG, 300 MG, 360 MG, 420 MG (Use diltiazem hcl coated beads)

NP

CARDIZEM TABS (Use diltiazem hcl) NP QL(3 ea daily)

DILT-XR CP24 2 QL(1 ea daily)

diltiazem hcl coated beads cp24 120 mg, 180 mg, 300 mg

1 QL(1 ea daily)

diltiazem hcl coated beads cp24 240 mg 1 QL(2 ea daily)

diltiazem hcl coated beads cp24 360 mg 1

diltiazem hcl coated beads tb24 180 mg, 240 mg, 300mg, 360 mg, 420 mg

1

diltiazem hcl cp12 or 60mg, 90 mg, 120 mg 1 QL(2 ea daily)

diltiazem hcl cp24 or 120mg, 180 mg, 240 mg 1 QL(1 ea daily)

diltiazem hcl extended release beads cp24 1 QL(1 ea daily)

diltiazem hcl tabs or 30 mg,60 mg, 90 mg, 120 mg 1 QL(3 ea daily)

Drug Name DrugTier

Requirements/Limits

felodipine tb24 1 QL(1 ea daily)

isradipine caps 1

nicardipine hcl caps or 20mg, 30 mg 1

nifedipine caps or 10 mg,20 mg 1 QL(4 ea daily)

nifedipine tb24 or 30 mg,90 mg 1 QL(1 ea daily)

nifedipine tb24 or 60 mg 1 QL(2 ea daily)

nimodipine caps or 1

NISOLDIPINE ER TB24 2

nisoldipine tb24 1

NORVASC TABS (Use amlodipine besylate) NP QL(1 ea daily)

NYMALIZE SOLN 30 MG/10ML, 60 MG/20ML NP

PROCARDIA CAPS (Use nifedipine) NP QL(4 ea daily)

PROCARDIA XL TB24 30 MG, 90 MG (Use nifedipine)

NP QL(1 ea daily)

PROCARDIA XL TB24 60 MG (Use nifedipine) NP QL(2 ea daily)

SULAR TB24 (Use nisoldipine) NP

TIAZAC CP24 (Use diltiazem hcl extended release beads)

NP QL(1 ea daily)

verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 240 mg

1 QL(2 ea daily)

verapamil hcl cp24 or 300 mg 1 QL(1 ea daily)

VERAPAMIL HCL ER CP24 100 MG 2 QL(2 ea daily)

VERAPAMIL HCL ER CP24 300 MG 2 QL(1 ea daily)

VERAPAMIL HCL SR CP24 2 QL(1 ea daily)

verapamil hcl tabs or 40mg, 80 mg, 120 mg 1 QL(3 ea daily)


50

Drug Name DrugTier

Requirements/Limits

verapamil hcl tbcr or 120mg, 180 mg, 240 mg 1 QL(2 ea daily)

VERAPAMIL HYDROCHLORIDE ER CP24

2 QL(2 ea daily)

VERELAN CP24 120 MG, 180 MG, 240 MG (Use verapamil hcl)

NP QL(2 ea daily)

VERELAN CP24 360 MG NP QL(1 ea daily)

VERELAN PM CP24 100 MG NP QL(2 ea daily)

VERELAN PM CP24 200 MG 2 QL(2 ea daily)

VERELAN PM CP24 300 MG NP QL(1 ea daily)

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Cardiac Glycosides

digoxin soln or 0.05 mg/ml 1

DIGOXIN SOLN OR 0.05 MG/ML (Use digoxin) 2

digoxin tabs or 0.125 mg,0.25 mg, 125 mcg, 250 mcg

1

LANOXIN TABS OR 125 MCG, 250 MCG (Use digoxin)

2

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation Conditions

Cardiovascular Agents Misc. - Combinations amlodipine besylate-atorvastatin calcium tabs 1

CADUET TABS (Use amlodipine besylate-atorvastatin calcium)

NP

ENTRESTO TABS 2

Prostaglandin Vasodilators

epoprostenol sodium solr 1 PA; SP

FLOLAN SOLR (Use epoprostenol sodium) NP PA; SP

ORENITRAM TBCR NP SP

Drug Name DrugTier

Requirements/Limits

REMODULIN SOLN (Use treprostinil) NP PA; SP

treprostinil soln 1 PA; SP

TYVASO REFILL SOLN NP SP

TYVASO SOLN NP SP

TYVASO STARTER SOLN NP SP

VELETRI SOLR 2 PA; SP

VENTAVIS SOLN NP SP

Pulmonary Hypertension - Endothelin Receptor ambrisentan tabs 1 PA; SP

bosentan tabs 1 PA; SP

LETAIRIS TABS (Use ambrisentan) 2 PA; SP

OPSUMIT TABS NP SP

TRACLEER TABS 125 MG, 62.5 MG (Use bosentan)

2 PA; SP

TRACLEER TBSO 32 MG NP SP

Pulmonary Hypertension - Phosphodiesterase ADCIRCA TABS (Use tadalafil (pulmonaryhypertension))

NP PA; SP

REVATIO SOLN IV 10 MG/12.5ML (Use sildenafil citrate (pulmonaryhypertension))

NP

PA; SP

REVATIO SUSR OR 10 MG/ML (Use sildenafil citrate (pulmonaryhypertension))

NP

SP

REVATIO TABS OR 20 MG (Use sildenafil citrate (pulmonary hypertension))

NP PA; SP

sildenafil citrate (pulmonaryhypertension) soln iv 10mg/12.5ml

1 PA; SP


51

Drug Name DrugTier

Requirements/Limits

sildenafil citrate (pulmonaryhypertension) susr or 10mg/ml

NP SP

sildenafil citrate (pulmonaryhypertension) tabs or 20 mg

1 PA; SP

tadalafil (pulmonaryhypertension) tabs 1 PA; SP

Pulmonary Hypertension - Prostacyclin Receptor UPTRAVI TABS NP SP

UPTRAVI TBPK NP SP

Pulmonary Hypertension - Sol Guanylate Cyclase

ADEMPAS TABS NP SP

Transthyretin Stabilizers

VYNDAMAX CAPS 2 PA; QL(1 eadaily); SP

VYNDAQEL CAPS 2 PA; QL(4 eadaily); SP

CEPHALOSPORINS - Drugs to Treat BacterialInfections

Cephalosporins - 1st Generation

cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1

cephalexin caps 250 mg,500 mg 1

cephalexin susr 125mg/5ml, 250 mg/5ml 1

KEFLEX CAPS 250 MG, 500 MG (Use cephalexin) NP

Cephalosporins - 2nd Generation cefaclor caps 250 mg, 500 mg 1

CEFACLOR ER TB12 2

CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML,375 MG/5ML

2

Drug Name DrugTier

Requirements/Limits

cefprozil susr 125 mg/5ml,250 mg/5ml 1

QL(75 ml perfill retail);AL(Up to 12 yrsold )

cefprozil tabs 250 mg, 500 mg 1 QL(20 ea per

fill retail)

cefuroxime axetil tabs 1 QL(20 ea perfill retail)

Cephalosporins - 3rd Generation

cefdinir caps 300 mg 1 QL(20 ea perfill retail)

cefdinir susr 125 mg/5ml,250 mg/5ml 1 QL(60 ml per

fill retail) CEFDITOREN PIVOXIL TABS 200 MG, 400 MG 2

cefixime caps 1

cefixime susr 1

cefpodoxime proxetil susr 1

cefpodoxime proxetil tabs 1

ceftriaxone sodium solr ij 1gm, 250 mg, 500 mg 1 QL(3 ea per fill

retail)

SPECTRACEF TABS NP

SUPRAX CAPS 400 MG (Use cefixime) NP

SUPRAX CHEW 100 MG, 200 MG NP

SUPRAX SUSR 100 MG/5ML, 200 MG/5ML(Use cefixime)

2

SUPRAX SUSR 500 MG/5ML 2

CONTRACEPTIVES - Drugs to PreventPregnancy

Combination Contraceptives - Oral

BEYAZ TABS (Use drospirenone-ethinylestradiol-levomefolate calcium)

NP

Up to 12-monthsupply ofcontraceptivesand devices allowed; $0 copay; PV


52

Drug Name DrugTier

Requirements/Limits

DESOGEN TABS (Use desogestrel & ethinylestradiol)

NP


desogestrel & ethinylestradiol tabs 0


desogestrel-ethinylestradiol (biphasic) tabs 0


desogestrel-ethinylestradiol (triphasic) tabs 0

Up to 12-monthsupply ofcontraceptivesand devices allowed; $0 copay;QL(4 eaper fill retail);PV

drospirenone-ethinylestradiol tabs 0


drospirenone-ethinylestradiol-levomefolate calcium tabs

0


ESTROSTEP FE TABS (Use norethindrone acetate-ethinyl estradiol-fe)

NP


Drug Name DrugTier

Requirements/Limits

ethynodiol diacet & ethestrad tabs 0

Up to 12-monthsupply ofcontraceptivesand devices allowed; $0 copay;QL(12ea per fillretail); PV

FALESSA KIT 0


GENERESS FE CHEW (Use norethindrone & ethinyl estradiol-fe)

NP


levonorgestrel & ethestradiol tabs 0


levonorgestrel-eth estradiol(triphasic) tabs 0


levonorgestrel-ethinylestradiol (91-day) tabs 0

Up to 12-monthsupply ofcontraceptivesand devices allowed; $0 copay;4 rtl packlmt amt,365 rtl pack lmtday(s),4 rtlpack lmt perfill,; PV

levonorgestrel-ethinylestradiol (91-day) tabs 0



53

Drug Name DrugTier

Requirements/Limits

levonorgestrel-ethinylestradiol (continuous) tabs 0


LO LOESTRIN FE TABS 0


LOESTRIN 1.5/30-21TABS (Use norethindrone acet & eth estra)

NP


LOESTRIN 1/20-21 TABS(Use norethindrone acet & eth estra)

NP


LOESTRIN FE 1.5/30TABS (Use norethin acet & estrad-fe)

NP


LOESTRIN FE 1/20 TABS(Use norethin acet & estrad-fe)

NP

LOSEASONIQUE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NP

Up to 12-monthsupply ofcontraceptivesand devices allowed; $0 copay;4 rtl packlmt amt,365 rtl pack lmtday(s),4 rtlpack lmt perfill,; PV

MINASTRIN 24 FE CHEW 0


Drug Name DrugTier

Requirements/Limits

MINASTRIN 24 FE CHEW (Use norethin acet & estrad-fe)

NP


MIRCETTE TABS (Use desogestrel-ethinylestradiol (biphasic))

NP


NATAZIA TABS 0


norethin acet & estrad-fe chew 75 mg-20 mcg-1 mg 0


norethin acet & estrad-fe tabs 75 mg-20 mcg-1 mg 0

norethin acet & estrad-fe tabs 75 mg-20 mcg-1 mg,75 mg-30 mcg-1.5 mg

0


norethindrone & eth estradiol tabs 0.4 mg-35mcg, 0.5 mg-35 mcg

0


norethindrone & eth estradiol tabs 1 mg-35 mcg 0

norethindrone & ethinylestradiol-fe chew 0



54

Drug Name DrugTier

Requirements/Limits

norethindrone acet & eth estra tabs 0


norethindrone acetate-ethinyl estradiol-fe tabs 0


norethindrone-eth estradiol (triphasic) tabs 0


norgestimate-ethinylestradiol (triphasic) tabs 0


norgestimate-ethinylestradiol tabs 0


norgestrel & ethinylestradiol tabs 0


OGESTREL TABS 0


ORTHO TRI-CYCLEN LO TABS (Use norgestimate-ethinyl estradiol (triphasic))

NP


Drug Name DrugTier

Requirements/Limits

ORTHO TRI-CYCLEN TABS (Use norgestimate-ethinyl estradiol (triphasic))

NP


ORTHO-CYCLEN TABS (Use norgestimate-ethinylestradiol)

NP


ORTHO-NOVUM 1/35TABS (Use norethindrone & eth estradiol)

NP

ORTHO-NOVUM 7/7/7TABS (Use norethindrone-eth estradiol (triphasic))

NP


QUARTETTE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NP


SAFYRAL TABS (Use drospirenone-ethinylestradiol-levomefolate calcium)

NP


SEASONIQUE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NP


TAYTULLA CAPS 0



55

Drug Name DrugTier

Requirements/Limits

TRI-NORINYL 28 TABS (Use norethindrone-eth estradiol (triphasic))

NP


YASMIN 28 TABS (Use drospirenone-ethinylestradiol)

NP


YAZ TABS (Use drospirenone-ethinylestradiol)

NP


Combination Contraceptives - Transdermal

XULANE PTWK 0


Combination Contraceptives - Vaginal

etonogestrel-ethinylestradiol ring 0


NUVARING RING (Use etonogestrel-ethinylestradiol)

NP


Copper Contraceptives - IUD

PARAGARD INTRAUTERINE COPPER CONTRACEPTIVE T380A IUD

0


Drug Name DrugTier

Requirements/Limits

Emergency Contraceptives

ELLA TABS 0


levonorgestrel (emergencyoc) tabs 0


PLAN B ONE-STEP TABS (Use levonorgestrel(emergency oc))

NP


Progestin Contraceptives - IUD

KYLEENA IUD 0

Up to 12-monthsupply ofcontraceptivesand devices allowed; $0 copay; SP; PV

LILETTA IUD 0


MIRENA IUD 0


SKYLA IUD 0


Progestin Contraceptives - Implants


56

Drug Name DrugTier

Requirements/Limits

NEXPLANON IMPL 0


Progestin Contraceptives - Injectable

DEPO-PROVERA CONTRACEPTIVE SUSP (Use medroxyprogesteroneacetate (contraceptive))

NP

Up to 12-monthsupply ofcontraceptivesand devices allowed; $0 copay;QL(4 mlper fill retail);PV

DEPO-PROVERA CONTRACEPTIVE SUSY (Use medroxyprogesteroneacetate (contraceptive))

NP


DEPO-SUBQ PROVERA 104 SUSY 0


medroxyprogesteroneacetate (contraceptive) susp

0


medroxyprogesteroneacetate (contraceptive) susy

0


Progestin Contraceptives - Oral

Drug Name DrugTier

Requirements/Limits

norethindrone (contraceptive) tabs 0


ORTHO MICRONOR TABS (Use norethindrone (contraceptive))

NP


CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions

Glucocorticosteroids

budesonide tb24 or 9 mg 1

CORTEF TABS (Use hydrocortisone) NP

CORTISONE ACETATE TABS OR 2

dexamethasone elix or 0.5 mg/5ml 1

DEXAMETHASONE INTENSOL CONC 2

dexamethasone sodium phosphate soln ij 4 mg/ml,20 mg/5ml, 120 mg/30ml


DEXAMETHASONE SOLN OR 0.5 MG/5ML 2

dexamethasone tabs or 0.75 mg, 0.5 mg, 4 mg, 6mg, 1.5 mg

1

DEXAMETHASONE TABS OR 1 MG, 2 MG 2

EMFLAZA SUSP 2 PA; SP

EMFLAZA TABS 2 PA; SP

hydrocortisone tabs or 5mg, 10 mg, 20 mg 1

MEDROL DOSEPAK TBPK (Use methylprednisolone) NP

MEDROL TABS 4 MG, 8 MG (Use methylprednisolone)

NP


57

Drug Name DrugTier

Requirements/Limits

methylprednisolone tabs or4 mg, 8 mg 1

methylprednisolone tbpk or4 mg 1

PEDIAPRED SOLN (Use prednisolone sodiumphosphate)

NP

prednisolone sodiumphosphate soln or 15mg/5ml





1

PREDNISOLONE SOLN OR 2

PREDNISONE INTENSOL CONC 2

PREDNISONE SOLN OR 5 MG/5ML 2

prednisone tabs or 1 mg, 5mg, 10 mg, 20 mg, 50 mg,2.5 mg

1

prednisone tbpk or 5 mg,10 mg 1

UCERIS TB24 OR 9 MG (Use budesonide) NP

VERIPRED 20 SOLN (Use prednisolone sodiumphosphate)


ZILRETTA SRER 2 PA; SP

Mineralocorticoids fludrocortisone acetate tabs or 1

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy Symptoms

Antitussives

benzonatate caps 100 mg 1 AL(At least 10yrs old)

benzonatate caps 200 mg 1 QL(1 ea daily);AL(At least 10yrs old)

Drug Name DrugTier

Requirements/Limits

hydrocodone w/homatropine syrp 5mg/5ml-1.5 mg/5ml

1

TESSALON PERLES CAPS (Use benzonatate) NP AL(At least 10

yrs old) Cough/Cold/Allergy Combinations ADVIL COLD & SINUS TABS (Use pseudoephedrine-ibuprofen)

NP

ALLEGRA-D 12 HOUR ALLERGY & CONGESTION TB12 (Use fexofenadine-pseudoephedrine)

NP

ALLEGRA-D 24 HOUR ALLERGY & CONGESTION TB24 (Use fexofenadine-pseudoephedrine)

NP

brompheniramine &phenyleph elix 1 mg/5ml-2.5 mg/5ml, 1 mg/5ml-1mg/5ml-2.5 mg/5ml-2.5mg/5ml

1


brompheniramine &pseudoeph elix 1 QL(120 ml per

fill retail) brompheniramine &pseudoeph liqd 1 QL(120 ml per

fill retail) cetirizine-pseudoephedrinetb12 1 QL(2 ea daily)

CHERACOL PLUS LIQD (Use dextromethorphan-guaifenesin)


CHERACOL-D COUGH LIQD (Use dextromethorphan-guaifenesin)

NP


CLARINEX-D 12 HOUR TB12 NP

CLARITIN-D 12 HOUR TB12 (Use loratadine & pseudoephedrine)

NP QL(2 ea daily)

CLARITIN-D 24 HOUR TB24 (Use loratadine & pseudoephedrine)

NP QL(1 ea daily)

DECON-A ELIX 2


58

Drug Name DrugTier

Requirements/Limits

DECON-A LIQD 2

dextromethorphan-guaifenesin liqd 10 mg/5ml-100 mg/5ml, 20 mg/10ml-200 mg/10ml, 15 mg/7.5ml-150 mg/7.5ml

1


DIMETAPP COLD & ALLERGY ELIX (Use brompheniramine &phenyleph)

NP


fexofenadine-pseudoephedrine tb12 1

fexofenadine-pseudoephedrine tb24 1

guaifenesin-codeine liqd100 mg/5ml-10 mg/5ml 1 QL(240 ml per

fill retail) guaifenesin-codeine soln100 mg/5ml-10 mg/5ml 1 QL(240 ml per

fill retail) guaifenesin-codeine syrp100 mg/5ml-10 mg/5ml 1 QL(240 ml per

fill retail) loratadine & pseudoephedrine tb12 5mg-120 mg

1 QL(2 ea daily)

loratadine & pseudoephedrine tb24 10mg-240 mg, 10 mg-10 mg-240 mg-240 mg

1

QL(1 ea daily)

phenylephrine-dm liqd 1 QL(240 ml perfill retail)

phenylephrine-dm soln 1 QL(240 ml perfill retail)

promethazine &phenylephrine soln 1


promethazine w/codeinesoln 1


promethazine w/codeine syrp 1


promethazine-phenylephrine-codeine syrp

1 QL(240 ml perfill retail); AL(Atleast 6 yrs old)

PROMETHAZINE/PHENYLEPHRINE SYRP 2


Drug Name DrugTier

Requirements/Limits

PROMETHAZINE/PHENYLEPHRINE/CODEINE SYRP 2


pseudoephedrine w/codeine-gg soln 1 QL(240 ml per

fill retail) pseudoephedrine w/codeine-gg soln NP

pseudoephedrine-ibuprofentabs 1

ZYRTEC-D ALLERGY/CONGESTIONTB12 (Use cetirizine-pseudoephedrine)

NP

QL(2 ea daily)

Misc. Respiratory Inhalants HYPER-SAL NEBU (Use sodium chloride (inhalant)) NP

HYPERSAL NEBU 7 % (Use sodium chloride (inhalant))

NP

sodium chloride (inhalant)aers 0.9 % 1 QL(240 ml per

fill retail) sodium chloride (inhalant)nebu 0.9 %, 7 % 1

Mucolytics acetylcysteine soln in 10 %,20 % 1

DERMATOLOGICALS - Drugs to Treat SkinConditions

Acne Products

ABSORICA CAPS 10 MG, 20 MG, 40 MG NP


ACANYA GEL (Use clindamycin phosphate-benzoyl peroxide)

NP

ACNE MEDICATION 10 LOTN 2

ACNE MEDICATION 5 LOTN 2

adapalene crea 0.1 % 1

adapalene gel 0.1 % 1 RX/OTC

adapalene gel 0.3 % 1


59

Drug Name DrugTier

Requirements/Limits

ADAPALENE LOTN 0.1 % 2

ADAPALENE PADS 0.1 % 2

ADAPALENE SOLN 0.1 % 2

adapalene-benzoylperoxide gel 1

ALTRENO LOTN NP

ATRALIN GEL (Use tretinoin) NP

BENZAC AC WASH LIQD (Use benzoyl peroxide) NP RX/OTC

BENZACLIN GEL (Use clindamycin phosphate-benzoyl peroxide)

2

BENZACLIN WITH PUMP GEL (Use clindamycinphosphate-benzoylperoxide)

2

BENZOYL PEROXIDE GEL EX 2.5 % 2

benzoyl peroxide gel ex 5%, 10 % 1

benzoyl peroxide liqd ex 10% 1

benzoyl peroxide liqd ex 5% 1 RX/OTC

CLEOCIN-T GEL (Use clindamycin phosphate(topical))


CLEOCIN-T LOTN (Use clindamycin phosphate(topical))


CLEOCIN-T SOLN (Use clindamycin phosphate(topical))

NP

CLINDAGEL GEL NP QL(75 ml perfill retail)

clindamycin phosphate(topical) gel 1 QL(75 ml per

fill retail) clindamycin phosphate(topical) lotn 1 QL(60 ml per

fill retail) clindamycin phosphate(topical) soln 1

Drug Name DrugTier

Requirements/Limits

CLINDAMYCIN PHOSPHATE GEL EX 1 % NP QL(75 ml per

fill retail) clindamycin phosphate-benzoyl peroxide(refrigerate) gel

1

clindamycin phosphate-benzoyl peroxide gel 1

clindamycin phosphate-tretinoin gel 1

DIFFERIN CREA 0.1 % (Use adapalene) 2

DIFFERIN GEL 0.1 % (Use adapalene) 2 RX/OTC

DIFFERIN GEL 0.3 % (Use adapalene) 2

DIFFERIN LOTN 0.1 % 2

DUAC GEL (Use clindamycin phosphate-benzoyl peroxide(refrigerate))

NP

EPIDUO FORTE GEL NP

EPIDUO GEL (Use adapalene-benzoylperoxide)

NP

ERYGEL GEL (Use erythromycin (acne aid)) NP QL(60 gm per

fill retail)

erythromycin (acne aid) gel 1 QL(60 gm perfill retail)

erythromycin (acne aid)soln 1

FABIOR FOAM NP

isotretinoin caps or 10 mg,20 mg, 40 mg 1


KLARON LOTN (Use sulfacetamide sodium (acne))


ONEXTON GEL NP

PLIXDA PADS NP

RETIN-A CREA 0.025 % (Use tretinoin) 2 AL(Up to 35 yrs

old )


60

Drug Name DrugTier

Requirements/Limits

RETIN-A CREA 0.025 %, 0.05 %, 0.1 % (Use tretinoin)

2

QL(20 gm perfill retail);AL(Up to 35 yrsold )

RETIN-A GEL 0.01 % (Use tretinoin) 2


RETIN-A GEL 0.025 % (Use tretinoin) 2 AL(Up to 35 yrs

old ) RETIN-A MICRO GEL (Use tretinoin microsphere) NP

RETIN-A MICRO PUMP GEL 0.04 %, 0.1 % (Use tretinoin microsphere)

NP

RETIN-A MICRO PUMP GEL 0.08 % NP

SODIUM SULFACETAMIDE/SULFUR LOTN


SODIUM SULFACETAMIDE/SULFUR SUSP


sulfacetamide sodium (acne) lotn 1 QL(120 ml per

fill retail)

tretinoin crea ex 0.025 % NP AL(Up to 35 yrsold )

tretinoin crea ex 0.025 % NP


tretinoin crea ex 0.025 % 1 AL(Up to 35 yrsold )

tretinoin crea ex 0.025 %,0.05 %, 0.1 % 1


tretinoin gel ex 0.01 % 1


tretinoin gel ex 0.025 % 1 AL(Up to 35 yrsold )

tretinoin gel ex 0.025 % NP AL(Up to 35 yrsold )

tretinoin gel ex 0.05 % 1

Drug Name DrugTier

Requirements/Limits

tretinoin microsphere gel 1

VELTIN GEL NP

ZIANA GEL (Use clindamycin phosphate-tretinoin)

NP

Anti-inflammatory Agents - Topical diclofenac sodium (topical)gel 1 % 1 QL(6.68 gm

daily); RX/OTC VOLTAREN GEL (Use diclofenac sodium (topical)) NP QL(6.68 gm

daily); RX/OTC

Antibiotics - Topical ALTABAX OINT NP

BACIGUENT OINT (Use bacitracin (topical)) NP QL(453.9 gm

per fill retail)

bacitracin (topical) oint 1 QL(453.9 gmper fill retail)

bacitracin zinc oint ex 1 QL(453.6 gmper fill retail)

BACTROBAN CREA (Use mupirocin calcium (topical)) 2

CENTANY AT KIT NP

CENTANY OINT NP QL(30 gm perfill retail)

gentamicin sulfate (topical) crea 1 QL(30 gm per

fill retail) gentamicin sulfate (topical)oint 1 QL(30 gm per

fill retail) mupirocin calcium (topical) crea 1

mupirocin oint ex 1 QL(30 gm perfill retail)

neomycin-bacitracin-polymyxin oint 1 QL(56 gm per

fill retail) neomycin-polymyxin w/pramoxine crea 1 QL(28.3 gm per

fill retail) NEOSPORIN ORIGINAL OINT (Use neomycin-bacitracin-polymyxin)



61

Drug Name DrugTier

Requirements/Limits

NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH CREA (Use neomycin-polymyxin w/pramoxine)

NP

QL(28.3 gm perfill retail)

Antifungals - Topical CICLODAN CREAM KIT KIT NP

CICLODAN SOLUTION KIT KIT NP

ciclopirox gel 1

ciclopirox olamine crea ex NP

ciclopirox olamine crea ex 1

ciclopirox olamine susp ex 1

ciclopirox sham 1

ciclopirox soln 1

CICLOPIROX TREATMENT KIT 2

clotrimazole (topical) crea 1 QL(60 gm perfill retail);RX/OTC

clotrimazole (topical) soln 1 QL(60 ml perfill retail);RX/OTC

clotrimazole w/betamethasone crea 1 QL(45 gm per

fill retail) clotrimazole w/betamethasone lotn 1 QL(30 ml per

fill retail)

econazole nitrate crea ex 1 QL(85 gm perfill retail)

JUBLIA SOLN NP

KERYDIN SOLN NP

ketoconazole (topical) crea2 % 1 QL(60 gm per

fill retail) ketoconazole (topical)sham 1 % 1 QL(200 ml per

fill retail) ketoconazole (topical)sham 2 % 1 QL(120 ml per

fill retail)

Drug Name DrugTier

Requirements/Limits

LAMISIL AT CREA (Use terbinafine hcl (topical)) NP QL(42 gm per

fill retail) LAMISIL AT JOCK ITCH CREA (Use terbinafine hcl (topical))


LOPROX CREA (Use ciclopirox olamine) NP

LOPROX KIT NP

LOPROX SHAMPOO SHAM (Use ciclopirox) NP

LOPROX SUSP (Use ciclopirox olamine) NP

LOTRIMIN AF CREA (Use clotrimazole (topical)) NP

QL(60 gm perfill retail);RX/OTC

LOTRIMIN AF JOCK ITCH CREA (Use clotrimazole (topical))

NP QL(60 gm perfill retail);RX/OTC

LOTRISONE CREA (Use clotrimazole w/betamethasone)


LULICONAZOLE CREA 2

LUZU CREA NP

MICATIN CREA (Use miconazole nitrate (topical)) NP QL(92 ml per

fill retail) miconazole nitrate (topical) crea 1 QL(92 ml per

fill retail) NIZORAL SHAM (Use ketoconazole (topical)) NP QL(120 ml per

fill retail)

nystatin (topical) crea 1 QL(30 gm perfill retail)

nystatin (topical) oint 1 QL(30 gm perfill retail)

nystatin (topical) powd 1

nystatin-triamcinolone crea 1 QL(60 gm perfill retail)

nystatin-triamcinolone oint 1 QL(60 gm perfill retail)

oxiconazole nitrate crea 1

OXISTAT CREA (Use oxiconazole nitrate) NP


62

Drug Name DrugTier

Requirements/Limits

OXISTAT LOTN NP

PENLAC NAIL LACQUER SOLN (Use ciclopirox) NP

terbinafine hcl (topical) crea 1 QL(42 gm per

fill retail) TINACTIN CREA (Use tolnaftate) NP QL(30 gm per

fill retail)

tolnaftate crea ex 1 QL(30 gm perfill retail)

Antihistamines-Topical ITCH RELIEF CREA 2

Antineoplastic or Premalignant Lesion Agents -

CARAC CREA 2 QL(30 gm perfill retail)

EFUDEX CREA (Use fluorouracil (topical)) NP QL(40 gm per

fill retail)

fluorouracil (topical) crea 1 QL(40 gm perfill retail)

FLUOROURACIL CREA EX 0.5 % 2 QL(30 gm per

fill retail) FLUOROURACIL SOLN EX 2 %, 5 % 2 QL(10 ml per

fill retail) LEVULAN KERASTICK SOLR 2 PA; SP

TARGRETIN GEL EX 1 % 2 PA; SP

Antipruritics - Topical camphor & menthol lotn 0.5%-0.5 % 1 QL(59 ml per

fill retail) SARNA LOTN (Use camphor & menthol) NP QL(59 ml per

fill retail) Antipsoriatics

calcipotriene crea ex 1 QL(60 gm perfill retail)

CALCIPOTRIENE FOAM EX NP

calcipotriene oint ex NP

calcipotriene oint ex 1

calcipotriene soln ex 1 QL(60 ml perfill retail)

Drug Name DrugTier

Requirements/Limits

CALCITRIOL OINT EX 3 MCG/GM 2

COSENTYX SENSOREADY PEN SOAJ NP SP

COSENTYX SOSY NP SP

DOVONEX CREA (Use calcipotriene) NP QL(60 gm per

fill retail)

ILUMYA SOSY NP SP

SKYRIZI PSKT 2 PA; SP

SORILUX FOAM NP

STELARA SOSY NP SP

TALTZ SOAJ NP SP

TALTZ SOSY NP SP

tazarotene crea ex NP


TAZORAC CREA 0.05 % NP


TAZORAC CREA 0.1 % (Use tazarotene) NP


TAZORAC GEL 0.05 %, 0.1 % NP


TREMFYA SOPN NP SP

VECTICAL OINT NP

Antiseborrheic Products OVACE PLUS WASH LIQD (Use sulfacetamide sodium)


OVACE WASH LIQD (Use sulfacetamide sodium) NP QL(480 ml per

fill retail) selenium sulfide lotn ex 1 % 1 QL(240 ml per

fill retail)


63

Drug Name DrugTier

Requirements/Limits

selenium sulfide lotn ex 2.5 % 1 QL(120 ml per

fill retail) selenium sulfide sham ex 1 % 1 QL(240 ml per

fill retail) SELSUN BLUE DAILY LOTN (Use selenium sulfide)


SELSUN BLUE LOTN (Use selenium sulfide) NP QL(240 ml per

fill retail) SELSUN BLUE MEDICATED LOTN (Use selenium sulfide)


SELSUN BLUE MOISTURIZING LOTN (Use selenium sulfide)


sulfacetamide sodium liqd ex 1 QL(480 ml per

fill retail) Antivirals - Topical acyclovir topical crea 1 QL(1 gm daily)

acyclovir topical oint 1

DENAVIR CREA 2

XERESE CREA NP

ZOVIRAX CREA EX 5 % (Use acyclovir topical) NP QL(1 gm daily)

ZOVIRAX OINT EX 5 % (Use acyclovir topical) 2

Burn Products SILVADENE CREA (Use silver sulfadiazine) NP QL(85 gm per

fill retail)

silver sulfadiazine crea ex 1 QL(85 gm perfill retail)

Corticosteroids - Topical alclometasone dipropionate crea 1

alclometasone dipropionateoint 1

AMCINONIDE CREA 2

AMCINONIDE LOTN 2

AMCINONIDE OINT 2

Drug Name DrugTier

Requirements/Limits

APEXICON E CREA NP QL(60 gm perfill retail)

AUGMENTED BETAMETHASONE DIPROPIONATE GEL

2

betamethasone dipropionate (topical) crea 1

1 rtl pack lmtamt,30 rtl packlmt day(s),

betamethasone dipropionate (topical) lotn 1

betamethasone dipropionate (topical) oint 1

betamethasone dipropionate augmented crea


betamethasone dipropionate augmentedgel

1

betamethasone dipropionate augmentedlotn

1

betamethasone dipropionate augmentedoint

1

betamethasone valerate crea ex 0.1 % 1 QL(45 gm per

fill retail) betamethasone valerate foam ex 0.12 % 1

betamethasone valerate lotn ex 0.1 % 1 QL(60 ml per

fill retail) betamethasone valerate oint ex 0.1 % 1 QL(45 gm per

fill retail) calcipotriene-betamethasone dipropionate oint

1

calcipotriene-betamethasone dipropionate susp

NP

CAPEX SHAM NP

clobetasol propionate crea ex 1 QL(60 gm per

fill retail) clobetasol propionateemollient base crea 1 QL(60 gm per

fill retail) clobetasol propionateemulsion foam 1


64

Drug Name DrugTier

Requirements/Limits

clobetasol propionate foam ex 1

clobetasol propionate gel ex 1 QL(60 gm per

fill retail) clobetasol propionate liqd ex 1

clobetasol propionate lotn ex 1

clobetasol propionate oint ex 1 QL(60 gm per

fill retail) clobetasol propionate sham ex 1

clobetasol propionate soln ex 1 QL(50 ml per

fill retail) CLOBEX LIQD (Use clobetasol propionate) NP

CLOBEX LOTN (Use clobetasol propionate) NP

CLOBEX SHAM (Use clobetasol propionate) NP

CLOCORTOLONE PIVALATE CREA 2

CLOCORTOLONE PIVALATE CREA NP

CLOCORTOLONE PIVALATE PUMP CREA 2

CLODERM CREA NP

CLODERM PUMP CREA NP

CORDRAN CREA 0.025 % NP

CORDRAN CREA 0.05 % (Use flurandrenolide) NP

CORDRAN LOTN 0.05 % (Use flurandrenolide) NP

CORDRAN OINT 0.05 % (Use flurandrenolide) NP

CORDRAN TAPE 4 MCG/SQCM NP

CUTIVATE LOTN (Use fluticasone propionate) NP

DERMA-SMOOTHE/FSBODY OIL (Use fluocinolone acetonide)

NP

Drug Name DrugTier

Requirements/Limits

DERMA-SMOOTHE/FSSCALP OIL (Use fluocinolone acetonide)

NP

DERMACINRX SILAPAK KIT (Use triamcinolone acetonide-dimethicone-silicone)

NP

DERMAZONE THPK 2

DESONATE GEL NP

desonide crea ex 1 1 rtl pack lmtper fill,

desonide lotn ex 1

desonide oint ex 1 1 rtl pack lmtper fill,

DESOWEN CREA (Use desonide) NP 1 rtl pack lmt

per fill, DESOWEN LOTN (Use desonide) NP

DESOXIMETASONE CREA EX 0.05 % 2 QL(60 gm per

fill retail) desoximetasone crea ex 0.05 % 1 QL(60 gm per

fill retail) desoximetasone crea ex 0.25 % 1

desoximetasone gel ex0.05 % 1

desoximetasone liqd ex0.25 % 1

desoximetasone oint ex 0.05 %, 0.25 % 1

DIFLORASONE DIACETATE CREA 2 QL(60 gm per

fill retail)

diflorasone diacetate oint 1 QL(60 gm perfill retail)

DIPROLENE AF CREA (Use betamethasone dipropionate augmented)


DIPROLENE OINT (Use betamethasone dipropionate augmented)

NP

ELOCON CREA (Use mometasone furoate) NP QL(50 gm per

fill retail) ELOCON OINT (Use mometasone furoate) NP QL(45 gm per

fill retail)


65

Drug Name DrugTier

Requirements/Limits

ENSTILAR FOAM NP

EPIFOAM FOAM 2

fluocinolone acetonide crea ex 0.025 %, 0.01 % 1

fluocinolone acetonide oil ex 0.01 % NP

fluocinolone acetonide oint ex 0.025 % 1

fluocinolone acetonide soln ex 0.01 % 1

fluocinonide crea ex 0.05 % 1 QL(60 gm per

fill retail)

fluocinonide crea ex 0.1 % 1

fluocinonide emulsified base crea 1 QL(60 gm per

fill retail)

fluocinonide gel ex 0.05 % 1 QL(60 gm perfill retail)

fluocinonide oint ex 0.05 % 1 QL(60 gm perfill retail)

fluocinonide soln ex 0.05 % 1 QL(60 ml perfill retail)

flurandrenolide crea 1

flurandrenolide lotn 1

flurandrenolide oint 1

fluticasone propionate creaex 0.05 % 1 QL(60 gm per

fill retail) fluticasone propionate lotnex 0.05 % 1

fluticasone propionate ointex 0.005 % 1 QL(60 gm per

fill retail)

HALAC KIT NP

halcinonide crea NP

halobetasol propionate crea 1

HALOBETASOL PROPIONATE FOAM 2

halobetasol propionate oint 1

Drug Name DrugTier

Requirements/Limits

HALOG CREA (Use halcinonide) NP

HALOG OINT NP

hydrocortisone (topical)crea 0.5 % 1 QL(30 gm per

fill retail)

hydrocortisone (topical)crea 1 % 1

QL(85.2 gm perfill retail);RX/OTC

hydrocortisone (topical)crea 2.5 % 1 QL(453.6 gm

per fill retail) hydrocortisone (topical) gel1 % 1

hydrocortisone (topical) lotn1 % 1 QL(99 ml per

fill retail) hydrocortisone (topical) lotn2.5 % 1 QL(59 ml per

fill retail) hydrocortisone (topical) oint0.5 % 1

hydrocortisone (topical) oint1 % 1

QL(2 gmdaily,56 gm perfill retail);RX/OTC

hydrocortisone (topical) oint2.5 % 1 QL(454 gm per

fill retail) hydrocortisone (topical)soln 1 % 1

hydrocortisone butyrate crea 1

hydrocortisone butyratehydrophilic lipo base crea 1

hydrocortisone butyratelotn 1

hydrocortisone butyrateoint 1

hydrocortisone butyratesoln 1 QL(60 ml per

fill retail) hydrocortisone valerate crea 1

hydrocortisone valerate oint 1

hydrocortisone-aloe veracrea 0.5 % 1

hydrocortisone-aloe veracrea 1 % 1 QL(56.8 gm per

fill retail)


66

Drug Name DrugTier

Requirements/Limits

KENALOG AERS (Use triamcinolone acetonide (topical))

NP

LEXETTE FOAM 2

LOCOID CREA (Use hydrocortisone butyrate) NP

LOCOID LIPOCREAM CREA (Use hydrocortisonebutyrate hydrophilic lipobase)

NP

LOCOID LOTN (Use hydrocortisone butyrate) NP

LOCOID OINT (Use hydrocortisone butyrate) NP

LOCOID SOLN (Use hydrocortisone butyrate) NP QL(60 ml per

fill retail) LUXIQ FOAM (Use betamethasone valerate) NP

MICORT-HC CREA 2

mometasone furoate crea ex 1 QL(50 gm per

fill retail) mometasone furoate oint ex 1 QL(45 gm per

fill retail) mometasone furoate soln ex 1 QL(60 ml per

fill retail) MONISTAT SOOTHING CARE ITCH RELIEF CREA (Use hydrocortisone(topical))

2

QL(85.2 gm perfill retail);RX/OTC

OLUX FOAM (Use clobetasol propionate) NP

OLUX-E FOAM (Use clobetasol propionateemulsion)

NP

PANDEL CREA NP

PREDNICARBATE CREA 2 QL(60 gm perfill retail)

PREDNICARBATE OINT 2 QL(60 gm perfill retail)

PSORCON CREA 2 QL(60 gm perfill retail)

SERNIVO EMUL NP

Drug Name DrugTier

Requirements/Limits

SILALITE PAK THPK NP

SILAZONE PHARMAPAK THPK 2

SILAZONE-II THPK 2

SYNALAR CREA (Use fluocinolone acetonide) NP

SYNALAR CREAM KIT KIT NP

SYNALAR OINT (Use fluocinolone acetonide) NP

SYNALAR OINTMENT KIT KIT NP

SYNALAR SOLN (Use fluocinolone acetonide) NP

SYNALAR TS KIT NP

TACLONEX OINT (Use calcipotriene-betamethasone dipropionate)

NP

TACLONEX SUSP (Use calcipotriene-betamethasone dipropionate)

NP

TEMOVATE CREA (Use clobetasol propionate) NP QL(60 gm per

fill retail) TEMOVATE OINT (Use clobetasol propionate) NP QL(60 gm per

fill retail)

TEXACORT SOLN NP

TOPICORT CREA 0.05 % (Use desoximetasone) NP QL(60 gm per

fill retail) TOPICORT CREA 0.25 % (Use desoximetasone) NP

TOPICORT GEL 0.05 % (Use desoximetasone) NP

TOPICORT LIQD 0.25 % (Use desoximetasone) NP

TOPICORT OINT 0.05 %, 0.25 % (Use desoximetasone)

NP

triamcinolone acetonide (topical) aers 0.147 mg/gm 1

triamcinolone acetonide (topical) crea 0.025 % 1 QL(160 gm per

fill retail)


67

Drug Name DrugTier

Requirements/Limits

triamcinolone acetonide (topical) crea 0.1 % 1 QL(85.2 gm per

fill retail) triamcinolone acetonide (topical) crea 0.5 % 1 QL(15 gm per

fill retail) triamcinolone acetonide (topical) lotn 0.025 %, 0.1%


triamcinolone acetonide (topical) oint 0.025 %, 0.1%


triamcinolone acetonide (topical) oint 0.05 % NP

triamcinolone acetonide (topical) oint 0.5 % 1 QL(15 gm per

fill retail) triamcinolone acetonide-dimethicone-silicone kit 1

TRIANEX OINT NP

TRIDESILON CREA (Use desonide) NP 1 rtl pack lmt

per fill, ULTRAVATE CREA (Use halobetasol propionate) NP

ULTRAVATE LOTN NP

ULTRAVATE OINT (Use halobetasol propionate) NP

VANOS CREA (Use fluocinonide) NP

VERDESO FOAM NP

Eczema Agents

DUPIXENT SOSY NP SP

Emollient/Keratolytic Agents

urea crea ex 40 % 1 QL(85.05 gmper fill retail);RX/OTC

urea lotn ex 40 % 1 QL(325 ml perfill retail)

Emollients A + D PERSONAL CARE LOTION LOTN 2

ALOE AFTERSUN LOTION LOTN 2

AQUA GLYCOLIC HAND & BODYLOTION LOTN 2

Drug Name DrugTier

Requirements/Limits

AQUA LACTEN LOTN 2

AQUADERM TREATMENT/MOISTURIZER LOTN

2

AQUAMED LOTN 2

AVEENO ACTIVE NATURALS DAILY MOISTURIZING BODY YOGURT LOTN

2

AVEENO ACTIVE NATURALS DAILY MOISTURIZING BODY YOGURT/APRICO LOTN

2

AVEENO DAILY MOISTURIZINGSPF 15 LOTN

2

AVEENO POSITIVELY AGELESSFIRMING BODY LOTN

2

AVEENO POSITIVELY RADIANT LOTN 2

AVEENO STRESS RELIEF MOISTURIZING LOTN 2

BETA CARE LOTN 2

CAM LOTN 2

CERAVE AM SPF 30 LOTN 2

CERAVE LOTN 2

CERAVE PM LOTN 2

CERAVE SA RENEWING LOTN 2

CETAPHIL DAILY ADVANCE ULTRA HYDRATING LOTN

2

CETAPHIL DAILY FACIAL MOISTURIZER LOTN 2

CETAPHIL DERMACONTROL MOISTURIZER/SPF 30LOTN

2

CETAPHIL MOISTURIZING LOTN 2


68

Drug Name DrugTier

Requirements/Limits

CETAPHIL RESTORADERM LOTN 2

CLN FACIAL MOISTURIZER NOURISHING LOTN

2

COCOA BUTTER HAND & BODYLOTION LOTN 2

COCOA BUTTER LOTN EX 2

CVS BEAUTY 360 DRY SKIN LOTN 2

CVS DAILY ULTRA MOISTURELOTION LOTN 2

DAILY MOISTURIZING LOTN 2

DERMAL THERAPY EXTRA STRENGTH BODY LOTION LOTN

2

DERMAL THERAPY FACE CAREMOISTURIZING LOTION LOTN

2

DERMAL THERAPY FOOT MASSAGE LOTN 2

DERMAL THERAPY HAND ELBOW & KNEE CREAM LOTN

2

DERMAL THERAPY HEEL CARE LOTN 2

DIABETIDERM HAND & BODY LOTN 2

DIABETIDERM LOTN 2

EMOLLIA-LOTION LOTN 2

emollient lotn 1.25 %, 1

EPILYT LOTN 2

EQL ADVANCED RECOVERY SKIN CARE LOTN

2

EQL ULTRA MOISTURIZING DAILY LOTION LOTN

2

EUCERIN BABY LOTN 2

Drug Name DrugTier

Requirements/Limits

EUCERIN DAILY PROTECTION/SPF 30LOTN

2

EUCERIN INTENSIVE REPAIR LOTN 2

EUCERIN LOTN 2

EUCERIN ORIGINAL HEALINGSOOTHING REPAIR LOTN

2

EUCERIN PLUS LOTN 5 %-5 % 2

EUCERIN PROFESSIONAL REPAIR RICH FEEL LOTN

2

EUCERIN SMOOTHING REPAIRADVANCED FORMULA LOTN

2

GNP ADVANCED RECOVERY LOTN 2

GOLD BOND MEDICATED BODYLOTION EXTRA STRENGTH LOTN

2

GOLD BOND MEDICATED BODYLOTION LOTN 2

GOLD BOND ULTIMATE DIABETICS DRY SKIN RELIEF LOTN

2

GOLD BOND ULTIMATE DIABETICS' DRY RELIEF LOTN

2

GOLD BOND ULTIMATE HEALING LOTN 2

GOLD BOND ULTIMATE LOTN 2

GOLD BOND ULTIMATE OVERNIGHT LOTN 2

GOLD BOND ULTIMATE PROTECTION LOTN 2

GOLD BOND ULTIMATE RESTORING LOTN 2

GOLD BOND ULTIMATE SHEERRIBBONS PEARLRADIANCE LOTN

2

GOLD BOND ULTIMATE SHEERRIBBONS SILKSOFTNESS LOTN

2


69

Drug Name DrugTier

Requirements/Limits

GOLD BOND ULTIMATE SOFTENING LOTN 2

GOLD BOND ULTIMATE SOOTHING LOTN 2

GRX VITAMIN E LOTN 2

HYDRAZONE LOTION LOTN 2

KERI ADVANCED MOISTURE THERAPY LOTN

2

KERI BASIC ESSENTIALS LOTN 2

KERI NOURISHING SHEA BUTTER LOTN 2

KERI ORIGINAL LOTN 2

KERI OVERNIGHT LOTN 2

KERI RENEWAL MILK BODY LOTN 2

KERI RENEWAL SKIN FIRMING LOTN 2

KERI RENEWAL STRETCH MARK MINIMIZER LOTN

2

KERI SENSITIVE SKIN LOTN 2

LAC-HYDRIN CREA (Use lactic acid (ammoniumlactate))

NP QL(385 gm perfill retail);RX/OTC

LAC-HYDRIN TWELVE LOTN (Use lactic acid (ammonium lactate))

NP QL(57 ml perfill retail);RX/OTC

lactic acid (ammoniumlactate) crea 12 % 1

QL(385 gm perfill retail);RX/OTC

lactic acid (ammoniumlactate) lotn 12 % 1


LUBRIDERM ADVANCED THERAPY LOTN 2

LUBRIDERM DAILY MOISTURE/NORMAL TODRY SKIN LOTN

2

Drug Name DrugTier

Requirements/Limits

LUBRIDERM DAILY MOISTURESHEA + CALMING LAVENDER JASMINE LOTN

2

LUBRIDERM INTENSE SKIN REPAIR LOTN 2

LUBRIDERM LOTN 2

LUBRIDERM MENS 3-IN-1 LOTN 2

LUBRIDERM SERIOUSLY SENSITIVE LOTN 2

LUBRIDERM SKIN NOURISHINGWITH SHEA AND COCOA BUTTERS LOTN

2

LUBRISOFT LOTN 2

MAXAM LOTN 2

MEDERMA AG HAND & BODY LOTION LOTN 2

MOTHERS FRIEND LOTN 2

MSM SKIN LOTION LOTN 2

NEUTROGENA BODY LIGHT SESAME FORMULA LOTN

2

NEUTROGENA HEALTHY SKIN FACE SPF 15 LOTN 2

NEUTROGENA MOISTURE SENSITIVE SKIN LOTN

2

NIVEA EXTRA ENRICHED LOTION LOTN 2

NIVEA EXTRA ENRICHED LOTN 2

NIVEA GENTLE BODY EXFOLIATOR LOTN 2

NIVEA LIGHT LOTN 2

NIVEA LOTN 2

NIVEA ORIGINAL LOTN 2

NIVEA ORIGINAL MOISTURE LOTN 2


70

Drug Name DrugTier

Requirements/Limits

NIVEA VISAGE LOTN 2

NUTRADERM ADVANCED FORMULA LOTN 2

NUTRADERM LOTN 2.5 %-2.5 %-2.5 %-2.5 %-2.5 %

2

PALMERS COCOA BUTTER FORMULA LOTION FRAGRANCE FREE LOTN

2

PALMERS COCOA BUTTER FORMULA LOTION LOTN

2

PALMERS COCOA BUTTER FORMULA MASSAGE LOTION/STRETCHMARKS LOTN

2

PALMERS COCONUT OIL FORMULA BODY LOTION LOTN

2

RA DAYLOGIC HEALING DRY SKIN THERAPY LOTN

2

RA RENEWAL DRY SKIN THERAPY LOTN 2

RADIAGUARD ADVANCED LOTN 2

RESTA LITE LOTN 2

ROC DEEP WRINKLE SERUM LOTN 2

ROSE MILK LOTN 2

SKIN REPAIR LOTN 2

SOOTHE & COOL MOISTURIZING BODY LOTION WITH ALOE LOTN

2

ST IVES SWISS FORMULA 24HOUR MOISTURE LOTN

2

STUDIO 35 EXTRA MOISTURIZING LOTION LOTN

2

Drug Name DrugTier

Requirements/Limits

THERABETIC SKIN CARE LOTN 2

THERAPLEX HYDROLOTION LOTN 2

VANICREAM LITE LOTN 2

WIBI LOTN 2

Immunomodulating Agents - Topical ALDARA CREA (Use imiquimod) NP QL(48 ea per

180 days retail)

imiquimod crea ex 1 QL(48 ea per180 days retail)

Immunosuppressive Agents - Topical

ELIDEL CREA (Use pimecrolimus) 2

PA; QL(1 gmdaily); AL(Atleast 2 yrs old)

pimecrolimus crea 1 PA; QL(1 gmdaily); AL(Atleast 2 yrs old)

PROTOPIC OINT 0.03 % (Use tacrolimus (topical)) NP


PROTOPIC OINT 0.1 % (Use tacrolimus (topical)) NP PA

tacrolimus (topical) oint0.03 % 1


tacrolimus (topical) oint 0.1% 1 PA

Keratolytic/Antimitotic Agents KERALYT GEL 6 % (Use salicylic acid) NP QL(40 gm per

fill retail)

podofilox soln ex 1 QL(4 ml per fillretail)

salicylic acid gel ex 6 % 1 QL(40 gm perfill retail)

Local Anesthetics - Topical ARTHRITIS PAIN RELIEVING CREA 2 QL(60 gm per

fill retail)

capsaicin crea ex 0.025 % 1 QL(60 ml perfill retail)

capsaicin crea ex 0.075 % 1 QL(60 gm perfill retail)


71

Drug Name DrugTier

Requirements/Limits

capsaicin crea ex 0.1 % 1 QL(56.6 gm perfill retail)

CAPZASIN-HP CREA (Use capsaicin) NP QL(56.6 gm per

fill retail)

CAPZASIN-P CREA 2 QL(42.5 gm perfill retail)

CASTIVA WARMING LOTN 2 QL(113 gm per

fill retail)

dibucaine oint ex 1 QL(56.7 gm perfill retail)

LIDOCAINE CREA EX 3 % 2 QL(85 gm perfill retail)

lidocaine crea ex 4 % 1 QL(76.5 gm perfill retail)

lidocaine hcl crea ex 3 % 1 QL(85 gm perfill retail);RX/OTC

lidocaine hcl crea ex 4 % 1 QL(63 ml perfill retail)

lidocaine hcl gel ex 2 % 1 QL(85 ml perfill retail)

lidocaine hcl gel ex 2 % 1 QL(85 ml perfill retail);RX/OTC

LIDOCAINE HCL JELLY GEL 2 QL(85 ml per

fill retail)

lidocaine hcl prsy ex 2 % 1 QL(85 ml perfill retail)

lidocaine-prilocaine crea 1 QL(5800 gmper fill retail)

LMX 4 CREA (Use lidocaine) NP QL(76.5 gm per

fill retail) PREDATOR CREA (Use lidocaine hcl) NP QL(63 ml per

fill retail) Misc. Topical COLEMAN 100 MAX INSECT REPELLENT/CONTINUOUS SPRAY AERO

NP

COLEMAN INSECT REPELLENT/HIGH & DRYAERO

NP

COLEMAN INSECT REPELLENT/SPORTSMEN AERO

NP

Drug Name DrugTier

Requirements/Limits

CUTTER AERO NP

CUTTER ALL FAMILY AERO NP

CUTTER BACKWOODS AERO NP

CUTTER BACKWOODS DRY AERO NP

CUTTER DRY AERO NP

CUTTER SKINSATIONS AERO NP

CUTTER SPORT AERO NP

CVS INSECT REPELLENT AERO NP

CVS TOTAL HOME INSECT REPELLENT AERO 30 %

NP

DRYSOL SOLN 2 QL(60 ml perfill retail)

lanolin (topical) crea 1

lanolin (topical) oint 1

OFF ACTIVE AERO NP

OFF DEEP WOODS AERO 2

OFF DEEP WOODS AERO NP

OFF DEEP WOODS DRY AERO NP

OFF DEEP WOODS DRY AERO 2

OFF DEEP WOODS SPORTSMEN AERO 30 % NP

OFF FAMILYCARE SMOOTH & DRY AERO NP

OFF SMOOTH & DRY AERO NP

REPEL FAMILY AERO NP

REPEL FAMILY DRY AERO NP

REPEL HUNTERS FORMULA AERO NP


72

Drug Name DrugTier

Requirements/Limits

REPEL SPORTSMEN AERO NP

REPEL SPORTSMEN DRY AERO NP

REPEL SPORTSMEN MAX AERO NP

REPEL SPORTSMEN MAX LOTN NP

SAWYER INSECT REPELLENT AERO NP

SAWYER INSECT REPELLENT CONTROLLED RELEASE LOTN

NP

ULTRATHON INSECT REPELLENT 8 AERO 2

ULTRATHON INSECT REPELLENT LOTN 2

zinc oxide (topical) oint 20% 1 QL(60 gm per

fill retail) Phosphodiesterase 4 (PDE4) Inhibitors - Topical EUCRISA OINT NP

Rosacea Agents METROCREAM CREA (Use metronidazole (topical))


METROLOTION LOTN (Use metronidazole (topical))

NP

metronidazole (topical)crea 0.75 % 1 QL(45 gm per

fill retail) metronidazole (topical) gel0.75 % 1 QL(45 gm per

fill retail) metronidazole (topical) lotn0.75 % 1

Scabicides & Pediculicides

CROTAN LOTN NP QL(60 gm perfill retail)

ELIMITE CREA (Use permethrin) NP QL(60 gm per

fill retail)

EURAX CREA NP QL(60 gm perfill retail)

EURAX LOTN NP QL(60 gm perfill retail)

Drug Name DrugTier

Requirements/Limits

LICEMD GEL 2

LICIDE TREATMENT KIT KIT 2

LINDANE SHAM 2

malathion lotn NP QL(59 ml perfill retail)

NATROBA SUSP 2 QL(120 ml perfill retail); AL(Atleast 2 yrs old)

NIX CREME RINSE LIQD (Use permethrin) 2

OVIDE LOTN (Use malathion) NP QL(59 ml per

fill retail)

permethrin aero xx 0.5 % 1

permethrin crea ex 5 % 1 QL(60 gm perfill retail)

permethrin liqd ex 1 % 1

permethrin lotn ex 1 % 1 QL(59 ml perfill retail)

pyrethrins-piperonylbutoxide liqd 0.33 %-4 % 1 QL(59 ml per

fill retail) pyrethrins-piperonylbutoxide liqd 1.2 %-0.3 %-0.3 %-2.4 %-3 %

1

pyrethrins-piperonylbutoxide sham 0.3 %-0.33 %-4 %, 0.33 %-4 %

1

pyrethrins-piperonylbutoxide sham 0.33 %-4 % 1 QL(59 ml per

fill retail) pyrethrins-piperonylbutoxide-permethrin-nitremover kit

1

RA LICE SOLUTION KIT KIT 2

RID AERO XX 0.5 % (Use permethrin) NP

RID COMPLETE LICE ELIMINATION KIT (Use pyrethrins-piperonylbutoxide-permethrin-nit remover)

NP

RID ESSENTIAL LICE ELIMINATION KIT KIT 2


73

Drug Name DrugTier

Requirements/Limits

RID LIQD EX 0.33 %-4 % (Use pyrethrins-piperonylbutoxide)


SCHOOLTIME SHAMPOO SHAM 2

SKLICE LOTN 2

SPINOSAD SUSP 2 QL(120 ml perfill retail); AL(Atleast 2 yrs old)

ULESFIA LOTN NP

Tar Products

coal tar extract sham 0.5 % 1

DHS TAR GEL SHAM (Use coal tar extract) NP

DHS TAR SHAM (Use coal tar extract) NP

NEUTROGENA T/GELSHAM (Use coal tar extract)

NP

NEUTROGENA T/GELSTUBBORN ITCH CONTROL SHAM (Use coal tar extract)

NP

Wound Care Products

APLIGRAF DISK 2 PA; SP

DERMAGRAFT SHEE 2 PA; SP

DIAGNOSTIC PRODUCTS

Diagnostic Drugs CORTROSYN SOLR (Use cosyntropin) NP PA; SP

cosyntropin solr 1 PA; SP

THYROGEN SOLR 2 PA; SP

Diagnostic Tests ACCU-CHEK AVIVA PLUS STRP VI NP QL(6.67 ea

daily); RX/OTC ACCU-CHEK COMPACT PLUS STRP NP QL(6.67 ea

daily); RX/OTC

Drug Name DrugTier

Requirements/Limits

ACCU-CHEK GUIDE STRP VI NP RX/OTC

ACCU-CHEK SMARTVIEW STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ACCUTREND GLUCOSE STRP NP QL(6.67 ea

daily); RX/OTC ADVANCE INTUITION TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ADVANCE MICRO-DRAW TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ADVOCATE REDI-CODE STRP VI NP QL(6.67 ea

daily); RX/OTC ADVOCATE REDI-CODE+ TESTSTRIPS STRP NP QL(6.67 ea

daily); RX/OTC ADVOCATE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC AGAMATRIX AMP NO CODE TEST STRIPS STRP

NP QL(6.67 eadaily); RX/OTC

AGAMATRIX JAZZ TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC AGAMATRIX KEYNOTE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC AGAMATRIX PRESTO TEST STRIPS STRP NP RX/OTC

AGAMATRIX PRESTO TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ASSURE 3 TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ASSURE 4 TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ASSURE II CHECK STRIP STRP NP QL(6.67 ea

daily); RX/OTC

ASSURE II STRP NP QL(6.67 eadaily); RX/OTC

ASSURE II TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ASSURE PLATINUM TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ASSURE PLATINUM TEST STRIPS STRP NP RX/OTC

ASSURE PRISM MULTI TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ASSURE PRO TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC


74

Drug Name DrugTier

Requirements/Limits

BIOSCANNER GLUCOSE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NP QL(6.67 ea

daily); RX/OTC BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC

BLOOD GLUCOSE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM STRP


CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE STRP


CARESENS N BLOOD GLUCOSETEST STRIPS STRP


CARETOUCH BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

CHEMSTRIP-K STRP 2

CLEVER CHEK AUTO-CODE TEST STRIPS STRP


CLEVER CHEK AUTO-CODE VOICE TEST STRIPS STRP


CLEVER CHEK TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC CLEVER CHOICE AUTO-CODE PRO TEST STRIPS STRP


CLEVER CHOICE MICRO TESTSTRIPS STRP NP QL(6.67 ea

daily); RX/OTC CONTOUR BLOOD GLUCOSE TEST STRIPS STRP


CONTOUR NEXT BLOOD GLUCOSE TEST STRP NP RX/OTC

CONTOUR NEXT BLOOD GLUCOSE TEST STRP NP QL(6.67 ea

daily); RX/OTC COOL BLOOD GLUCOSE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC CVS ADVANCED GLUCOSE METER TEST STRIPS STRP

NP RX/OTC

Drug Name DrugTier

Requirements/Limits

CVS ADVANCED GLUCOSE METER TEST STRIPS STRP


CVS GLUCOSE METER TEST STRIPS STRP NP RX/OTC

D-CARE BLOOD GLUCOSE STRP NP RX/OTC

DIATHRIVE BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS STRP


DUO-CARE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EASY PLUS BLOOD GLUCOSE TEST STRIPS STRP


EASY PLUS II BLOOD GLUCOSE TEST STRP NP QL(6.67 ea

daily); RX/OTC EASY STEP TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EASY TALK BLOOD GLUCOSE TEST STRIPS STRP


EASY TOUCH GLUCOSE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EASY TRAK BLOOD GLUCOSE TEST STRIPS STRP


EASY TRAK II BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

EASYGLUCO PLUS STRP NP QL(6.67 eadaily); RX/OTC

EASYGLUCO STRP VI NP QL(6.67 eadaily); RX/OTC

EASYMAX 15 TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EASYMAX TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EASYPLUS BLOOD GLUCOSE TEST STRIP STRP


EASYPRO BLOOD GLUCOSE TEST STRIPS STRP



75

Drug Name DrugTier

Requirements/Limits

EASYPRO PLUS STRP VI NP QL(6.67 eadaily); RX/OTC

ELEMENT COMPACT TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ELEMENT TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EMBRACE BLOOD GLUCOSE TEST STRIPS STRP


EMBRACE EVO BLOOD GLUCOSETEST STRIPS STRP


EMBRACE PRO BLOOD GLUCOSETEST STRIPS STRP


EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

EQ BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC

EQ BLOOD GLUCOSE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EVENCARE + BLOOD GLUCOSETEST STRIP STRP


EVENCARE BLOOD GLUCOSE TEST STRIP STRP


EVENCARE G2 TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EVENCARE G3 TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EVENCARE MINI BLOOD GLUCOSE TEST STRIPS STRP


EVENCARE PROVIEW BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

EVOLUTION AUTOCODE STRP VI NP QL(6.67 ea

daily); RX/OTC EXACTECH R-S-G TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EXACTECH TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC EZ SMART BLOOD GLUCOSE TEST STRIPS STRP


Drug Name DrugTier

Requirements/Limits

EZ SMART PLUS BLOOD GLUCOSE TEST STRIPS STRP


FIFTY50 GLUCOSE TEST STRIP 2.0 STRP NP QL(6.67 ea

daily); RX/OTC FORA BLOOD GLUCOSE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC FORA D15G BLOOD GLUCOSE TEST STRIPS STRP


FORA D20 BLOOD GLUCOSE TEST STRIPS STRP


FORA D40/G31 BLOODGLUCOSE TEST STRIPS STRP


FORA G20 BLOOD GLUCOSE TEST STRIPS STRP


FORA G30/PREMIUM V10BLOOD GLUCOSE TEST STRIPS STRP


FORA GD20 TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC FORA GD50 BLOOD GLUCOSE TEST STRIPS STRP


FORA GTEL BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

FORA TN'G/TN'G VOICEBLOOD GLUCOSE TEST STRIPS STRP


FORA V10 BLOOD GLUCOSE TEST STRIPS STRP






FORA V30A BLOOD GLUCOSE TEST STRIPS STRP


FORACARE GD40 STRP NP QL(6.67 eadaily); RX/OTC


76

Drug Name DrugTier

Requirements/Limits

FORACARE PREMIUM V10 TESTSTRIPS STRP NP QL(6.67 ea

daily); RX/OTC FORACARE TEST N GO TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC FORTISCARE BLOOD GLUCOSETEST STRIP STRP


FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS STRP


FREESTYLE INSULINX BLOODGLUCOSE TEST STRP


FREESTYLE LITE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS STRP


FREESTYLE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC GE100 BLOOD GLUCOSE TESTSTRIPS STRP NP QL(6.67 ea

daily); RX/OTC GENULTIMATE TEST STRIPS STRP NP RX/OTC

GHT TEST STRIPS STRP NP QL(6.67 eadaily); RX/OTC

GLUCO PERFECT 3 TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC GLUCOCARD 01 SENSOR PLUS STRP NP QL(6.67 ea

daily); RX/OTC GLUCOCARD 01 SENSOR PLUSTEST STRIPS STRP


GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS STRP

NP

QL(6.67 eadaily); RX/OTC

GLUCOCARD SHINE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC GLUCOCARD VITAL TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC GLUCOCARD X-SENSOR STRP NP QL(6.67 ea

daily); RX/OTC GLUCOCOM TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC

Drug Name DrugTier

Requirements/Limits

GLUCONAVII BLOOD GLUCOSETEST STRIPS STRP


GLUCOSE METER TEST STRIPS ADVANCED STRP


GNP EASY TOUCH GLUCOSE TEST STRIPS STRP


GOJJI BLOOD GLUCOSE TESTSTRIPS STRP NP RX/OTC

GOJJI BLOOD GLUCOSE TESTSTRIPS/GOJJISTERILE LANCETS 30G STRP

NP

RX/OTC

HARMONY BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

IN TOUCH BLOOD GLUCOSE TEST STRIPS STRP


INFINITY BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

INFINITY BLOOD GLUCOSE TEST STRIPS STRP


INFINITY VOICE STRP VI NP RX/OTC

KETONE STRP 2

KETONE TEST STRIPS STRP 2

KETOSTIX STRP 2

KROGER BLOOD GLUCOSE TESTSTRIPS STRP


KROGER HEALTHPRO GLUCOSETEST STRIPS STRP

NP RX/OTC


77

Drug Name DrugTier

Requirements/Limits

KROGER HEALTHPRO GLUCOSETEST STRIPS STRP


KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP


KROGER TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS STRP

NP


LIBERTY TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC MEIJER BLOOD GLUCOSE TESTSTRIPS STRP


MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS STRP


MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP


MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS STRP


MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS STRP


MICRODOT TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC MICRODOT XTRA TEST STRIPS STRP NP RX/OTC

MYGLUCOHEALTH BLOOD GLUCOSE TEST STRP


NEUTEK 2TEK TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC NOVA MAX GLUCOSE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS STRP


ON CALL PLUS BLOOD GLUCOSE TEST STRP NP QL(6.67 ea

daily); RX/OTC

Drug Name DrugTier

Requirements/Limits

ON CALL VIVID BLOOD GLUCOSE TEST STRIPS STRP


ON CALL VIVID BLOOD GLUCOSE TEST STRP NP QL(6.67 ea

daily); RX/OTC ONE DROP BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

ONETOUCH ULTRA STRP NP QL(6.67 eadaily); RX/OTC

ONETOUCH VERIO TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC OPTIUM TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC OPTIUMEZ TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC OPTUMRX BLOOD GLUCOSE TEST STRP NP QL(6.67 ea

daily); RX/OTC PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS STRP

NP


PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS STRP

NP


POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS STRP


PRECISION PCX PLUS TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC

PRECISION PCX STRP NP QL(6.67 eadaily); RX/OTC

PRECISION POINT OF CARE TEST STRIPS STRP


PRECISION QID TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC PRECISION SOF-TACT TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP


PREMIUM BLOOD GLUCOSE TEST STRIPS STRP



78

Drug Name DrugTier

Requirements/Limits

PRO VOICE V8/V9BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS STRP


PTS PANELS GLUCOSE TEST STRP NP QL(6.67 ea

daily); RX/OTC QUICKTEK TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC QUINTET AC BLOOD GLUCOSETEST STRIPS STRP


QUINTET BLOOD GLUCOSE TEST STRIPS STRP


RA TRUETEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC REFUAH PLUS BLOOD GLUCOSETEST STRIPS STRP


RELION BLOOD GLUCOSE TESTSTRIPS STRP


RELION CONFIRM/MICROTEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC

RELION KETONE STRP NP

RELION KETONE TEST STRIPS STRP NP

RELION PREMIER BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

RELION PRIME BLOOD GLUCOSE TEST STRIPS STRP


RELION ULTIMA BLOOD GLUCOSE TEST STRIPS STRP


RELION ULTIMA TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC REVEAL BLOOD GLUCOSE TEST STRP NP QL(6.67 ea

daily); RX/OTC REXALL BLOOD GLUCOSE TEST STRIPS STRP


Drug Name DrugTier

Requirements/Limits

RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS STRP






SMART SENSE PREMIUM BLOODGLUCOSE STRIPS STRP


SMART SENSE VALUE BLOOD GLUCOSE STRIPS STRP


SMARTEST BLOOD GLUCOSE TEST STRIPS STRP


SOLUS V2 AUDIBLE TEST STRP NP QL(6.67 ea

daily); RX/OTC SUPREME TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC SURE EDGE BLOOD GLUCOSE TEST STRIPS STRP


SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS STRP


SURECHEK BLOOD GLUCOSE TEST STRIPS STRP


TELCARE BLOOD GLUCOSE TEST STRIPS STRP


TGT BLOOD GLUCOSE TEST STRIPS PREMIUM STRP


TGT BLOOD GLUCOSE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS STRP

NP

RX/OTC

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP



79

Drug Name DrugTier

Requirements/Limits

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

2

INSULIN USERS LIMITED TO 200 PER 30 DAYS, NON-INSULIN USERS LIMITED TO 100 PER 90 DAYS;RX/OTC

TRUE METRIX PRO GLUCOSE TEST STRIPS STRP

NP RX/OTC

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP

2


TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP


TRUETEST STRIPS STRP NP QL(6.67 eadaily); RX/OTC

TRUETRACK BLOOD GLUCOSE TEST STRP 2


TRUETRACK TEST STRP NP QL(6.67 eadaily); RX/OTC

TRUETRACK TEST STRP 2


Drug Name DrugTier

Requirements/Limits

ULTIMA TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ULTRATRAK PRO TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC ULTRATRAK ULTIMATE TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC UNISTRIP1 GENERIC STRP NP QL(6.67 ea

daily); RX/OTC VICTORY AGM-4000 TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

VOCAL POINT BLOOD GLUCOSE TEST STRIPS STRP


WAVESENSE PRESTO TEST STRIPS STRP NP QL(6.67 ea

daily); RX/OTC

DIETARY PRODUCTS/DIETARY MANAGEMENTPRODUCTS

Dietary Management Products

ENLYTE CAPS 2

FOSTEUM PLUS CAPS 2

FOVEX CAPS 2

GABADONE CAPS 2

HYPERTENSA CAPS 2

LEXAZIN CAPS 2

LIPICHOL 540 CAPS 2

LISTER-V CAPS 2

LORMATE CAPS 2

MACUZIN CAPS 2

METHAVER CAPS 2

METHAZEL CAPS 2

NEUREPA CAPS 2


80

Drug Name DrugTier

Requirements/Limits

OMNIQUIN CAPS 2

PERCURA CAPS 2

PULMONA CAPS 2

RHEUMATE CAPS 2

RIBOZEL CAPS 2

SENTRA AM CAPS 2

SENTRA PM CAPS 2

SULFZIX CAPS 2

T-SUPPORT MAX CAPS 2

THERAMINE CAPS 2

TL-ICARE CAPS 2

TOBAKIENT CAPS 2

TREPADONE CAPS 2

VAYARIN PLUS CAPS 2

VAYAROL CAPS 2

ZAVITROL CAPS 2

Nutritional Supplements

AMINO PM RMS CAPS 2 RX/OTC

ANTI-INFLAMMATORY ENZYMEFORMULA CAPS 2 RX/OTC

ANTIOXIDANT FORMULA CAPS 2 RX/OTC

BIO-IMMUNEX CAPS 2 RX/OTC

BROMASE CAPS 2 RX/OTC

CARDIO COMPLETE CAPS 2 RX/OTC

CHRONOVISION CAPS 2 RX/OTC

ESTROVEN WEIGHT MANAGEMENT CAPS 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

HOMOCYSTEINE SUPPORT CAPS 2 RX/OTC

KIDNEY CAPS 2 RX/OTC

LITHATE CAPS 2 RX/OTC

MALE SUPPORT CAPS 2 RX/OTC

METHIONINE-200 CAPS 2 RX/OTC

nutritional supplementscaps 140 mg, 750 mg, 15mg-50 mg, 30 mg-300 mg,50 mg-500 mg, 700 mg-50mg, 166.67 mg-500 mg,400 mg-90 mg-200 mg-60mg, 160 mg-5 mg-1 mg-50mcg-50 unit-7.5 mg-75 mcg,

1

RX/OTC

OVARY CAPS 2 RX/OTC

PROS-TECH PLUS CAPS 2 RX/OTC

PROSTATE 2.4 CAPS 2 RX/OTC

PROTEOLIN CAPS 2 RX/OTC

SALMON OIL CAPS 200 MG-1000 MG-90 MG-110 MG

2 RX/OTC

SILICA CAPS 2 RX/OTC

SODIUM BENZOATE CAPS OR 2 RX/OTC

SYTRINOL CAPS 2 RX/OTC

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

Digestive Enzymes

CREON CPEP 2

PANCREAZE CPEP NP

PERTZYE CPEP NP

SUCRAID SOLN 2 PA; SP

VIOKACE TABS NP


81

Drug Name DrugTier

Requirements/Limits

ZENPEP CPEP 2

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood Pressure

Carbonic Anhydrase Inhibitors acetazolamide cp12 or 500 mg 1

acetazolamide tabs or 125 mg, 250 mg 1

methazolamide tabs or 25 mg, 50 mg 1

NEPTAZANE TABS (Use methazolamide) NP

Diuretic Combinations ALDACTAZIDE TABS 25 MG-25 MG (Use spironolactone &hydrochlorothiazide)

NP

amiloride & hydrochlorothiazide tabs 1 QL(1 ea daily)

DYAZIDE CAPS (Use triamterene & hydrochlorothiazide)

NP QL(1 ea daily)

MAXZIDE TABS (Use triamterene & hydrochlorothiazide)

NP QL(1 ea daily)

MAXZIDE-25 TABS (Use triamterene & hydrochlorothiazide)

NP QL(1 ea daily)

spironolactone &hydrochlorothiazide tabs 1

triamterene & hydrochlorothiazide caps 1 QL(1 ea daily)

triamterene & hydrochlorothiazide tabs 1 QL(1 ea daily)

Loop Diuretics bumetanide tabs or 0.5 mg,1 mg, 2 mg 1

BUMEX TABS (Use bumetanide) NP

DEMADEX TABS 10 MG (Use torsemide) NP QL(1 ea daily)

DEMADEX TABS 20 MG (Use torsemide) NP

Drug Name DrugTier

Requirements/Limits

furosemide soln or 10 mg/ml 1

FUROSEMIDE SOLN OR 8 MG/ML 2

furosemide tabs or 20 mg,40 mg, 80 mg 1

LASIX TABS (Use furosemide) NP

torsemide tabs 20 mg 1

torsemide tabs 5 mg, 10mg, 100 mg 1 QL(1 ea daily)

Potassium Sparing Diuretics ALDACTONE TABS (Use spironolactone) NP

amiloride hcl tabs or 1 QL(4 ea daily)

spironolactone tabs or 25mg, 50 mg, 100 mg 1

Thiazides and Thiazide-Like Diuretics CHLOROTHIAZIDE TABS 250 MG 2 QL(2 ea daily)

CHLOROTHIAZIDE TABS 500 MG 2 QL(4 ea daily)

chlorothiazide tabs 500 mg 1 QL(4 ea daily)

chlorthalidone tabs 1

hydrochlorothiazide caps or12.5 mg 1

hydrochlorothiazide tabs or25 mg, 50 mg 1

indapamide tabs 1

metolazone tabs 1

MICROZIDE CAPS (Use hydrochlorothiazide) NP

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate Hormones

Bone Density Regulators ACTONEL TABS 150 MG (Use risedronate sodium) NP


82

Drug Name DrugTier

Requirements/Limits

ACTONEL TABS 35 MG (Use risedronate sodium) NP

4 per 28days;QL(4 eaper 28 daysretail)

ACTONEL TABS 5 MG, 30 MG (Use risedronate sodium)

NP QL(1 ea daily)

ALENDRONATE SODIUM SOLN 70 MG/75ML 2 QL(10.8 ml

daily) alendronate sodium tabs 35 mg, 70 mg 1 QL(0.15 ea

daily) alendronate sodium tabs 5 mg, 10 mg 1 QL(1 ea daily)

ALENDRONATE SODIUM TABS 5 MG, 40 MG 2 QL(1 ea daily)

ATELVIA TBEC (Use risedronate sodium) NP

BINOSTO TBEF NP

BONIVA SOLN IV 3 MG/3ML (Use ibandronate sodium)

NP PA; SP

BONIVA TABS OR 150 MG (Use ibandronate sodium) NP PA

calcitonin (salmon) soln 1 QL(4 ml per 30days retail)

ETIDRONATE DISODIUM TABS 2

EVENITY SOSY 2 PA; SP

FORTEO SOPN 2 PA; SP

FOSAMAX PLUS D TABS NP

FOSAMAX TABS (Use alendronate sodium) NP QL(0.15 ea

daily) ibandronate sodium soln iv 3 mg/3ml 1 PA; SP

ibandronate sodium tabs or 150 mg 1 PA

MIACALCIN SOLN 2 QL(2 ml per 30days retail)

NATPARA CART 2 PA; SP

pamidronate disodium soln30 mg/10ml, 90 mg/10ml 1 PA; SP

Drug Name DrugTier

Requirements/Limits

PAMIDRONATE DISODIUM SOLN 6 MG/ML

2 PA; SP

PAMIDRONATE DISODIUM SOLR 30 MG, 90 MG

2 PA; SP

PROLIA SOSY 2 PA; SP

RECLAST SOLN (Use zoledronic acid) NP PA; SP

risedronate sodium tabs 150 mg 1

risedronate sodium tabs 35 mg 1

4 per 28days;QL(4 eaper 28 daysretail)

risedronate sodium tabs 5 mg, 30 mg 1 QL(1 ea daily)

risedronate sodium tbec 35 mg 1

XGEVA SOLN 2 PA; SP

zoledronic acid conc 4 mg/5ml 1 PA; SP

ZOLEDRONIC ACID SOLN 4 MG/100ML 2 PA; SP

zoledronic acid soln 5 mg/100ml 1 PA; SP

ZOLEDRONIC ACID SOLR 4 MG 2 PA; SP

ZOMETA CONC 4 MG/5ML (Use zoledronic acid)

NP PA; SP

ZOMETA SOLN 4 MG/100ML 2 PA; SP

Corticotropin

ACTHAR GEL 2 PA; SP

Fertility Regulators CHORIONIC GONADOTROPIN SOLR IM

2 PA; SP

HCG SOLR 2 PA; SP

NOVAREL SOLR 2 PA; SP


83

Drug Name DrugTier

Requirements/Limits

PREGNYL W/DILUENTBENZYLALCOHOL/NACLSOLR

2 PA; SP

GnRH/LHRH Antagonists

CETROTIDE KIT 2 PA; SP

ganirelix acetate sosy 1 PA; SP

GANIRELIX ACETATE SOSY (Use ganirelix acetate)

NP PA; SP

ORILISSA TABS 2 PA; SP

Growth Hormone Receptor Antagonists

SOMAVERT SOLR 2 PA; SP

Growth Hormone Releasing Hormones (GHRH) EGRIFTA SOLR 2 PA; SP

Growth Hormones GENOTROPIN MINIQUICK SOLR 2 PA; SP

GENOTROPIN SOLR 2 PA; SP

HUMATROPE COMBO PACK SOLR NP SP

HUMATROPE SOLR NP SP

NORDITROPIN FLEXPRO SOLN 2 PA; SP

NUTROPIN AQ NUSPIN 10 SOLN NP SP



OMNITROPE SOLN NP SP

OMNITROPE SOLR NP SP

SAIZEN CLICK.EASY SOLR NP SP

SAIZEN SOLR NP SP

Drug Name DrugTier

Requirements/Limits

SAIZENPREP RECONSTITUTIONKIT SOLR

NP SP

SEROSTIM SOLR NP SP

ZOMACTON SOLR NP SP

ZORBTIVE SOLR NP SP

Hormone Receptor Modulators EVISTA TABS (Use raloxifene hcl) NP QL(1 ea daily)

raloxifene hcl tabs 1 QL(1 ea daily)

Insulin-Like Growth Factors (Somatomedins) INCRELEX SOLN 2 PA; SP

LHRH/GnRH Agonist Analog Pituitary

LUPANETA PACK KIT 2 PA; SP

LUPRON DEPOT-PED (1-MONTH) KIT 2 PA; SP

LUPRON DEPOT-PED (3-MONTH) KIT 2 PA; SP

SUPPRELIN LA KIT 2 PA; SP

SYNAREL SOLN 2 PA; SP

Metabolic Modifiers

ALDURAZYME SOLN 2 PA; SP

BUPHENYL POWD (Use sodium phenylbutyrate) NP PA; SP

BUPHENYL TABS (Use sodium phenylbutyrate) NP PA; SP

calcitriol caps or 0.25 mcg,0.5 mcg 1

CARBAGLU TABS CO

CARNITOR SF SOLN (Use levocarnitine (metabolicmodifiers))

NP QL(30 ml daily)

CARNITOR SOLN OR 1 GM/10ML (Use levocarnitine (metabolicmodifiers))

NP

QL(30 ml daily)


84

Drug Name DrugTier

Requirements/Limits

CARNITOR TABS OR 330 MG (Use levocarnitine (metabolic modifiers))

NP QL(3 ea daily);RX/OTC

cinacalcet hcl tabs 1 PA; SP

CRYSVITA SOLN 2 PA; SP

CYSTADANE POWD 2 PA; SP

ELAPRASE SOLN 2 PA; SP

FABRAZYME SOLR 2 PA; SP

GALAFOLD CAPS 2 PA; QL(0.5 eadaily); SP

KANUMA SOLN 2 PA; SP

KUVAN PACK 2 PA; SP

KUVAN TBSO 2 PA; SP

levocarnitine (metabolicmodifiers) soln 1 gm/10ml 1 QL(30 ml daily)

levocarnitine (metabolicmodifiers) tabs 330 mg 1 QL(3 ea daily);

RX/OTC

LUMIZYME SOLR 2 PA; SP

MYALEPT SOLR 2 PA; SP

NAGLAZYME SOLN 2 PA; SP

nitisinone caps 1 PA; SP

ORFADIN CAPS 2 MG, 5 MG, 10 MG (Use nitisinone)

NP PA; SP

ORFADIN CAPS 20 MG 2 PA; SP

ORFADIN SUSP 4 MG/ML 2 PA; SP

PALYNZIQ SOSY 2 PA; SP

paricalcitol soln iv 2mcg/ml, 5 mcg/ml 1 PA; SP

PARSABIV SOLN 2 PA; SP

RAVICTI LIQD CO

Drug Name DrugTier

Requirements/Limits

REVCOVI SOLN 2 PA; SP

ROCALTROL CAPS 0.25 MCG, 0.5 MCG (Use calcitriol)

NP

SENSIPAR TABS (Use cinacalcet hcl) NP PA; SP

sodium phenylbutyratepowd or 3 gm/tsp 1 PA; SP

sodium phenylbutyrate tabsor 500 mg 1 PA; SP

STRENSIQ SOLN 2 PA; SP

VIMIZIM SOLN 2 PA; SP

ZEMPLAR SOLN IV 2 MCG/ML, 5 MCG/ML (Use paricalcitol)

NP PA; SP

Posterior Pituitary Hormones DDAVP SOLN IJ 4 MCG/ML (Use desmopressin acetate)

NP PA; SP

DDAVP SOLN NA 0.01 % 2 QL(5 ml per fillretail)

DDAVP SOLN NA 0.01 % (Use desmopressin acetate spray)

NP QL(5 ml per fillretail)

DDAVP TABS OR 0.1 MG, 0.2 MG (Use desmopressin acetate)

NP QL(6 ea daily)

desmopressin acetate solnij 4 mcg/ml 1 PA; SP

desmopressin acetatespray refrigerated soln 1 QL(5 ml per fill

retail) desmopressin acetatespray soln 1 QL(5 ml per fill

retail) desmopressin acetate tabsor 0.1 mg, 0.2 mg 1 QL(6 ea daily)

STIMATE SOLN CO

Somatostatic Agents OCTREOTIDE ACETATE SOLN 200 MCG/ML, 1000MCG/ML (Use octreotide acetate)

NP

PA; SP


85

Drug Name DrugTier

Requirements/Limits

octreotide acetate soln 50 mcg/ml, 100 mcg/ml, 200mcg/ml, 500 mcg/ml, 1000mcg/ml, 1000 mcg/5ml

1

PA; SP

SANDOSTATIN LAR DEPOT KIT 2 PA; SP

SANDOSTATIN SOLN (Use octreotide acetate) NP PA; SP

SIGNIFOR LAR SRER 2 PA; SP

SIGNIFOR SOLN 2 PA; SP

SOMATULINE DEPOT SOLN 2 PA; SP

Vasopressin Receptor Antagonists JYNARQUE TABS 15 MG, 30 MG 2 PA; SP

JYNARQUE TBPK 2 PA; SP

SAMSCA TABS 15 MG 2 PA; SP

SAMSCA TABS 30 MG (Use tolvaptan) NP PA; SP

tolvaptan tabs 1 PA; SP

ESTROGENS - Hormone Replacement/ModifyingDrugs

Estrogen Combinations ACTIVELLA TABS (Use estradiol & norethindrone acetate)

NP

COMBIPATCH PTTW 2 QL(8 ea per 28days retail)

estradiol & norethindrone acetate tabs 1

FEMHRT LOW DOSE TABS (Use norethindrone acetate-ethinyl estradiol)

NP

norethindrone acetate-ethinyl estradiol tabs 0

PREMPHASE TABS 2 QL(1 ea daily)

PREMPRO TABS 2 QL(1 ea daily)

Estrogens

Drug Name DrugTier

Requirements/Limits

ALORA PTTW 2 QL(0.29 eadaily)

CLIMARA PTWK (Use estradiol) NP QL(12 ea per

90 days retail) ESTRACE TABS OR 0.5 MG, 1 MG, 2 MG (Use estradiol)

NP

estradiol pttw td 0.0375mg/24hr, 0.025 mg/24hr,0.075 mg/24hr, 0.05mg/24hr, 0.1 mg/24hr

1

QL(0.29 eadaily)

estradiol ptwk td 0.025mg/24hr, 0.075 mg/24hr,0.05 mg/24hr, 0.06mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

1


estradiol tabs or 0.5 mg, 1mg, 2 mg 1

ESTROPIPATE TABS 2 QL(1 ea daily)

MINIVELLE PTTW (Use estradiol) NP QL(0.29 ea

daily) PREMARIN TABS OR 0.625 MG, 0.45 MG, 0.3 MG, 0.9 MG, 1.25 MG

2 QL(1 ea daily)

VIVELLE-DOT PTTW (Use estradiol) NP QL(0.29 ea

daily) FLUOROQUINOLONES - Drugs to Treat BacterialInfections

Fluoroquinolones AVELOX TABS OR 400 MG (Use moxifloxacin hcl) NP

CIPRO SUSR 5 GM/100ML, 500 MG/5ML 2

CIPRO TABS 250 MG, 500 MG (Use ciprofloxacin hcl) NP

CIPROFLOXACIN ER TB24 2

CIPROFLOXACIN HCL TABS OR 100 MG 2 QL(6 ea per fill

retail) ciprofloxacin hcl tabs or250 mg, 500 mg, 750 mg 1

ciprofloxacin susr or 500mg/5ml 1


86

Drug Name DrugTier

Requirements/Limits

LEVAQUIN TABS (Use levofloxacin) NP

QL(1 eadaily,14 ea perfill retail)

levofloxacin soln or 25 mg/ml 1

levofloxacin tabs or 250 mg, 500 mg, 750 mg 1

QL(1 eadaily,14 ea perfill retail)

moxifloxacin hcl tabs or 1

OFLOXACIN TABS 300 MG 2 QL(56 ea per

fill retail)

ofloxacin tabs 400 mg 1 QL(56 ea perfill retail)

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal Drugs

Antiflatulents GAS-X CHEW (Use simethicone) NP

MYLICON INFANTS GAS RELIEF DYE FREE SUSP (Use simethicone)


MYLICON INFANTS GAS RELIEF SUSP (Use simethicone)


simethicone chew or 80 mg 1

simethicone liqd or 20mg/0.3ml, 40 mg/0.6ml 1 QL(30 ml per

fill retail) simethicone susp or 20mg/0.3ml, 40 mg/0.6ml 1 QL(45 ml per

fill retail) Bile Acid Synthesis Disorder Agents

CHOLBAM CAPS 2 PA; QL(5 eadaily); SP

Farnesoid X Receptor (FXR) Agonists

OCALIVA TABS 2 PA; SP

Gallstone Solubilizing Agents ACTIGALL CAPS (Use ursodiol) NP QL(3 ea daily)

CHENODAL TABS 2 PA; SP

URSO 250 TABS (Use ursodiol) NP QL(7 ea daily)

ursodiol caps or 300 mg 1 QL(3 ea daily)

Drug Name DrugTier

Requirements/Limits

ursodiol tabs or 250 mg 1 QL(7 ea daily)

Gastrointestinal Stimulants metoclopramide hcl soln or5 mg/5ml, 10 mg/10ml 1

metoclopramide hcl tabs or5 mg, 10 mg 1

REGLAN TABS (Use metoclopramide hcl) NP

Inflammatory Bowel Agents AZULFIDINE EN-TABS TBEC (Use sulfasalazine) NP

AZULFIDINE TABS (Use sulfasalazine) NP

balsalazide disodium caps 1 QL(9 ea daily)

CANASA SUPP (Use mesalamine) 2

CIMZIA KIT NP SP

CIMZIA STARTER KIT KIT NP SP

COLAZAL CAPS (Use balsalazide disodium) NP QL(9 ea daily)

DIPENTUM CAPS NP

ENTYVIO SOLR NP SP

GIAZO TABS NP

INFLECTRA SOLR NP SP

LIALDA TBEC (Use mesalamine) 2

mesalamine enem re 4 gm 1 QL(60 ml daily)

mesalamine supp re 1000 mg 1

mesalamine tbec or 1.2 gm, 800 mg 1

mesalamine tbec or 800 mg 1 QL(3 ea daily)

mesalamine w/ cleanser kit 1

REMICADE SOLR NP SP


87

Drug Name DrugTier

Requirements/Limits

ROWASA KIT (Use mesalamine w/ cleanser) NP

SFROWASA ENEM NP

sulfasalazine tabs or 1

sulfasalazine tbec or 1

Intestinal Acidifiers lactulose (encephalopathy)soln 1

Irritable Bowel Syndrome (IBS) Agents LINZESS CAPS 145 MCG, 290 MCG 2 PA; SP

Phosphate Binder Agents

AURYXIA TABS NP

calcium acetate (phosphatebinder) caps 1

calcium acetate (phosphatebinder) tabs 1 RX/OTC

FOSRENOL CHEW 500 MG, 750 MG, 1000 MG (Use lanthanum carbonate)

NP

FOSRENOL PACK 750 MG, 1000 MG NP

lanthanum carbonate chew 1

PHOSLYRA SOLN NP

RENAGEL TABS (Use sevelamer hcl) 2

RENVELA PACK (Use sevelamer carbonate) NP

RENVELA TABS (Use sevelamer carbonate) NP

sevelamer carbonate pack 1

sevelamer carbonate tabs 1

sevelamer hcl tabs 1

SEVELAMER HYDROCHLORIDE TABS 2

VELPHORO CHEW NP

Drug Name DrugTier

Requirements/Limits

Short Bowel Syndrome (SBS) Agents

GATTEX KIT 2 PA; SP

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System

Alkalinizers potassium citrate(alkalinizer) tbcr 540 mg,1080 mg

1

potassium citrate-citric acidpack 3300 mg-1002 mg 1

sodium citrate & citric acid soln 1 QL(16.67 ml

daily); RX/OTC UROCIT-K 10 TBCR (Use potassium citrate(alkalinizer))

NP

UROCIT-K 5 TBCR (Use potassium citrate(alkalinizer))

NP

Cystinosis Agents

CYSTAGON CAPS 2 PA; SP

PROCYSBI CPDR 25 MG, 75 MG 2 PA; SP

Genitourinary Irrigants sodium chloride (guirrigant) soln 1

Interstitial Cystitis Agents

ELMIRON CAPS 2 QL(3 ea daily)

Prostatic Hypertrophy Agents

alfuzosin hcl tb24 1

AVODART CAPS (Use dutasteride) NP

dutasteride caps or 1

dutasteride-tamsulosin hcl caps 1

finasteride tabs or 1 QL(1 ea daily)

FLOMAX CAPS (Use tamsulosin hcl) NP QL(2 ea daily)


88

Drug Name DrugTier

Requirements/Limits

JALYN CAPS (Use dutasteride-tamsulosin hcl) NP

PROSCAR TABS (Use finasteride) NP QL(1 ea daily)

RAPAFLO CAPS 4 MG NP

RAPAFLO CAPS 4 MG, 8 MG (Use silodosin) NP

silodosin caps 1

tamsulosin hcl caps 1 QL(2 ea daily)

UROXATRAL TB24 (Use alfuzosin hcl) NP

Urinary Analgesics phenazopyridine hcl tabs or100 mg, 200 mg 1

PYRIDIUM TABS (Use phenazopyridine hcl) NP

Urinary Stone Agents

THIOLA TABS 2 PA; SP

Vesicoureteral Reflux (VUR) Agents

DEFLUX PRSY 2 PA; SP

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations colchicine w/ probenecidtabs 1

Gout Agents allopurinol tabs or 100 mg,300 mg 1

colchicine tabs or 1 1 fill per 30days;QL(6 eaper fill retail)

colchicine tabs or NP

COLCRYS TABS (Use colchicine) NP

KRYSTEXXA SOLN 2 PA; SP

ZYLOPRIM TABS (Use allopurinol) NP

Uricosurics

Drug Name DrugTier

Requirements/Limits

probenecid tabs 1

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood Disorders

Antihemophilic Products

ADVATE SOLR CO

ADYNOVATE SOLR CO

AFSTYLA KIT CO

ALPHANATE/VONWILLEBRANDFACTOR COMPLEX/HUMAN SOLR

CO

ALPHANINE SD SOLR CO

ALPROLIX SOLR CO

BEBULIN SOLR CO

BENEFIX KIT CO

COAGADEX SOLR CO

CORIFACT KIT CO

ELOCTATE SOLR CO

FEIBA SOLR CO

FIBRYGA SOLR CO

HELIXATE FS KIT CO

HEMLIBRA SOLN CO

HEMOFIL M SOLR CO

HUMATE-P SOLR CO

IDELVION SOLR 250 UNIT, 500 UNIT, 1000 UNIT, 2000 UNIT

CO

IDELVION SOLR 3500 UNIT CO SP

IXINITY SOLR CO

KCENTRA KIT CO SP


89

Drug Name DrugTier

Requirements/Limits

KOATE SOLR CO

KOATE-DVI SOLR CO

KOGENATE FS BIO-SET KIT CO

KOGENATE FS KIT CO

KOVALTRY SOLR CO

MONOCLATE-P KIT CO

MONONINE SOLR CO

NOVOEIGHT SOLR CO

NOVOSEVEN RT SOLR CO

NUWIQ KIT CO

NUWIQ SOLR CO

OBIZUR SOLR CO

PROFILNINE SD SOLR CO

PROFILNINE SOLR CO

REBINYN SOLR CO SP

RECOMBINATE SOLR CO

RIASTAP SOLR CO

RIXUBIS SOLR CO

TRETTEN SOLR CO

VONVENDI SOLR CO

WILATE KIT CO

XYNTHA KIT CO

XYNTHA SOLOFUSE KIT CO

Bradykinin B2 Receptor Antagonists FIRAZYR SOLN (Use icatibant acetate) NP PA; SP

Drug Name DrugTier

Requirements/Limits

icatibant acetate soln 1 PA; SP

Complement Inhibitors

BERINERT KIT 2 PA; SP

CINRYZE SOLR 2 PA; SP

RUCONEST SOLR 2 PA; SP

SOLIRIS SOLN 2 PA; SP

ULTOMIRIS SOLN 2 PA; SP

Hemataologic - Tyrosine Kinase Inhibitors

TAVALISSE TABS 2 PA; SP

Hematorheologic Agents

pentoxifylline tbcr or 1

Human Protein C

CEPROTIN SOLR 2 PA; SP

Plasma Kallikrein Inhibitors

KALBITOR SOLN 2 PA; SP

TAKHZYRO SOLN 2 PA; SP

Plasma Proteins

THROMBATE III SOLR 2 PA; SP

THROMBATE III W/10 MLSTERILE WATER SOLR 2 PA; SP

THROMBATE III W/20 MLSTERILE WATER SOLR 2 PA; SP

Platelet Aggregation Inhibitors AGGRENOX CP12 (Use aspirin-dipyridamole) 2

aspirin-dipyridamole cp12 1

ASPIRIN/OMEPRAZOLEER TBEC 2

ASPIRIN/OMEPRAZOLETBEC 40 MG-81 MG, 40 MG-325 MG

NP

BRILINTA TABS 2 QL(2 ea daily)


90

Drug Name DrugTier

Requirements/Limits

cilostazol tabs 1 QL(2 ea daily)

clopidogrel bisulfate tabs300 mg 1

clopidogrel bisulfate tabs75 mg 1 QL(1 ea daily)

dipyridamole tabs or 25mg, 50 mg, 75 mg 1

DURLAZA CP24 NP

EFFIENT TABS (Use prasugrel hcl) NP QL(1 ea daily)

PLAVIX TABS 300 MG (Use clopidogrel bisulfate) NP

PLAVIX TABS 75 MG (Use clopidogrel bisulfate) NP QL(1 ea daily)

prasugrel hcl tabs 1 QL(1 ea daily)

YOSPRALA TBEC 40 MG-81 MG, 40 MG-325 MG NP

ZONTIVITY TABS NP

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Agents for Gaucher Disease

CERDELGA CAPS 2 PA; SP

CEREZYME SOLR 2 PA; SP

ELELYSO SOLR 2 PA; SP

miglustat caps 1 PA; SP

VPRIV SOLR 2 PA; SP

ZAVESCA CAPS (Use miglustat) NP PA; SP

Agents for Sickle Cell Disease

DROXIA CAPS 2

SIKLOS TABS 2 PA

Cobalamins cyanocobalamin soln ij1000 mcg/ml 1

Folic Acid/Folates

Drug Name DrugTier

Requirements/Limits

folic acid tabs or 1 mg 1 RX/OTC

folic acid tabs or 400 mcg,800 mcg 1 QL(1 ea daily)

Hematopoietic Growth Factors ARANESP ALBUMIN FREE SOLN NP SP

ARANESP ALBUMIN FREE SOSY NP SP

DOPTELET TABS 2 PA; SP

EPOGEN SOLN 2 PA; SP

FULPHILA SOSY 2 PA; SP

GRANIX SOLN 2 PA; SP

GRANIX SOSY 2 PA; SP

LEUKINE SOLR 2 PA; SP

MIRCERA SOSY 2 PA; SP

MULPLETA TABS 2 PA; SP

NEULASTA ONPRO KIT PSKT 2 PA; SP

NEULASTA SOSY 2 PA; SP

NEUPOGEN SOLN 2 PA; SP

NEUPOGEN SOSY 2 PA; SP

NIVESTYM SOLN 2 PA; SP

NIVESTYM SOSY 2 PA; SP

NPLATE SOLR 250 MCG, 500 MCG 2 PA; SP

PROCRIT SOLN 2000 UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML, 10000UNIT/ML, 20000 UNIT/ML,40000 UNIT/ML

NP

SP

PROMACTA PACK 12.5 MG 2 PA; SP

PROMACTA TABS 25 MG, 50 MG, 75 MG, 12.5 MG 2 PA; SP


91

Drug Name DrugTier

Requirements/Limits

RETACRIT SOLN 2000 UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML, 10000UNIT/ML, 40000 UNIT/ML

2

PA; SP

UDENYCA SOSY 2 PA; SP

ZARXIO SOSY 2 PA; SP

Hematopoietic Mixtures ferrous fumarate-fa-b complex-c-zn-mg-mn-cutabs

1 QL(1 ea daily)

Iron FER-IN-SOL SOLN (Use ferrous sulfate) NP QL(3.4 ml

daily)

FERRETTS TABS 2 QL(2 ea daily)

ferrous fumarate tabs or 324 mg 1 QL(2 ea daily)

ferrous gluconate tabs or27 mg, 240 mg 1

FERROUS GLUCONATE TABS OR 324 MG 2

ferrous sulfate dried tbcr 160 mg 1

ferrous sulfate elix or 220 mg/5ml 1 QL(16 ml daily)

ferrous sulfate soln or 15 mg/ml 1 QL(3.4 ml

daily) ferrous sulfate tabs or 28 mg, 65 mg, 325 mg 1

FERROUS SULFATE TBEC OR 324 MG 2

ferrous sulfate tbec or 325 mg 1

HEMOCYTE TABS (Use ferrous fumarate) NP QL(2 ea daily)

IRON CHEWS PEDIATRIC CHEW 2

polysaccharide ironcomplex caps 1 QL(1 ea daily)

Stem Cell Mobilizers

MOZOBIL SOLN 2 PA; SP

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood Disorders

Drug Name DrugTier

Requirements/Limits

Hemostatics - Systemic AMICAR SOLN 0.25 GM/ML (Use aminocaproicacid)

NP PA; SP

AMICAR TABS 1000 MG (Use aminocaproic acid) NP PA; SP

AMICAR TABS 500 MG (Use aminocaproic acid) NP

PA; QL(24 eaper fill retail);SP

aminocaproic acid soln iv250 mg/ml 1 PA; SP

aminocaproic acid soln or0.25 gm/ml 1 PA; SP

aminocaproic acid tabs or1000 mg 1 PA; SP

aminocaproic acid tabs or500 mg 1

PA; QL(24 eaper fill retail);SP

LYSTEDA TABS (Use tranexamic acid) NP


tranexamic acid tabs or 650 mg 1


HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS

Antihistamine Hypnotics ADVIL PM CAPS (Use ibuprofen-diphenhydraminehcl)

NP

ADVIL PM TABS (Use ibuprofen-diphenhydraminecitrate)

NP

ALEVE PM TABS (Use naproxen sodium-diphenhydramine hcl)

NP

diphenhydramine hcl(sleep) caps 25 mg, 50 mg 1

diphenhydramine hcl(sleep) liqd 50 mg/30ml 1

diphenhydramine hcl(sleep) tabs 25 mg 1 QL(1 ea daily)

diphenhydramine hcl(sleep) tabs 50 mg 1


92

Drug Name DrugTier

Requirements/Limits

diphenhydramine hcl(sleep) tbdp 25 mg 1

diphenhydramine-acetaminophen (sleep)tabs 25 mg-500 mg, 38mg-500 mg, 25 mg-25 mg-500 mg-500 mg, 30 unit-50mg-15 mg-1.5 mg-25 mg-18 mg-2500 unit-500 mg-10 mg-1.7 mg-6 mcg-400mcg-2 mg

1

doxylamine succinate(sleep) tabs 1

EXCEDRIN PM TABS (Use diphenhydramine-acetaminophen (sleep))

NP

ibuprofen-diphenhydraminecitrate tabs 1

ibuprofen-diphenhydraminehcl caps 1

naproxen sodium-diphenhydramine hcl tabs 1

NYTOL MAXIMUM STRENGTH TABS (Use diphenhydramine hcl(sleep))

NP

PAIN RELIEF DAY & NIGHT EXTRA STRENGTH MISC

2

TYLENOL PM EXTRA STRENGTH TABS 25 MG-500 MG (Use diphenhydramine-acetaminophen (sleep))

NP

UNISOM SLEEPGELS CAPS (Use diphenhydramine hcl(sleep))

NP

UNISOM SLEEPMELTS TBDP (Use diphenhydramine hcl(sleep))

NP

UNISOM SLEEPTABS TABS (Use doxylaminesuccinate (sleep))

NP

ZZZQUIL CAPS (Use diphenhydramine hcl(sleep))

NP

Drug Name DrugTier

Requirements/Limits

ZZZQUIL LIQD (Use diphenhydramine hcl(sleep))

NP

Barbiturate Hypnotics phenobarbital elix or 20mg/5ml 1

phenobarbital soln or 20mg/5ml 1

phenobarbital tabs or 15mg, 30 mg, 60 mg, 100 mg,16.2 mg, 32.4 mg, 64.8 mg,97.2 mg

1

Hypnotics - Tricyclic Agents

doxepin hcl (sleep) tabs 1

SILENOR TABS (Use doxepin hcl (sleep)) NP

Non-Barbiturate Hypnotics AMBIEN CR TBCR (Use zolpidem tartrate) NP

AMBIEN TABS (Use zolpidem tartrate) NP QL(1 ea daily)

dexmedetomidine hcl in sodium chloride soln 1

dexmedetomidine hcl soln 200 mcg/2ml 1

DORAL TABS NP

EDLUAR SUBL NP

estazolam tabs 1

eszopiclone tabs 1

FLURAZEPAM HCL CAPS 2 QL(1 ea daily)

HALCION TABS (Use triazolam) NP QL(1 ea daily)

INTERMEZZO SUBL (Use zolpidem tartrate) NP

LUNESTA TABS (Use eszopiclone) NP

MIDAZOLAM HCL SOLN IJ 5 MG/5ML 2


93

Drug Name DrugTier

Requirements/Limits

midazolam hcl soln ij 5mg/ml, 2 mg/2ml, 5mg/5ml, 10 mg/2ml, 25mg/5ml, 10 mg/10ml, 50mg/10ml

1

PRECEDEX SOLN (Use dexmedetomidine hcl in sodium chloride)

NP

PRECEDEX SOLN (Use dexmedetomidine hcl) NP

QUAZEPAM TABS NP

RESTORIL CAPS 15 MG, 30 MG (Use temazepam) NP


RESTORIL CAPS 7.5 MG, 22.5 MG (Use temazepam) NP

SONATA CAPS (Use zaleplon) NP QL(1 ea daily)

temazepam caps 15 mg,30 mg 1


temazepam caps 7.5 mg,22.5 mg 1

triazolam tabs 1 QL(1 ea daily)

zaleplon caps 1 QL(1 ea daily)

zolpidem tartrate subl sl 3.5mg, 1.75 mg 1

zolpidem tartrate tabs or 5mg, 10 mg 1 QL(1 ea daily)

zolpidem tartrate tbcr or12.5 mg, 6.25 mg 1

ZOLPIMIST SOLN NP

Orexin Receptor Antagonists

BELSOMRA TABS NP

Selective Melatonin Receptor Agonists

HETLIOZ CAPS 2 PA; SP

ramelteon tabs 1

ROZEREM TABS (Use ramelteon) NP

Drug Name DrugTier

Requirements/Limits

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil tabs 1 QL(10 ea daily)

EVAC POWD (Use psyllium) NP

FIBERCON TABS (Use calcium polycarbophil) NP QL(10 ea daily)

KONSYL DAILY FIBER POWD 100 % (Use psyllium)

NP

KONSYL ORIGINAL FORMULADAILY FIBER POWD (Use psyllium)

NP

METAMUCIL CAPS 0.52 GM (Use psyllium) NP

METAMUCIL ORIGINAL TEXTURE POWD (Use psyllium)

NP

METAMUCIL POWD 48.57 % (Use psyllium) NP

psyllium caps 0.52 gm, 520 mg 1

psyllium powd 30 %, 33 %,68 %, 100 %, 28.3 %, 30.9%, 58.6 %, 48.57 %,

1

Laxative Combinations COLYTE-FLAVOR PACKS SOLR (Use peg 3350-kcl-sod bicarb-sod chloride-sod sulfate)

NP


GAVILYTE-C SOLR 2 QL(4000 ml perfill retail)

GOLYTELY SOLR 236 GM-22.74 GM-5.86 GM-2.97 GM-6.74 GM (Use peg 3350-kcl-sod bicarb-sod chloride-sod sulfate)

NP


NULYTELY/FLAVORPACKS SOLR (Use peg3350-potassium chloride-sod bicarbonate-sod chloride)

NP


peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr



94

Drug Name DrugTier

Requirements/Limits

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr


sennosides-docusate sodium tabs 1 QL(4 ea daily)

SENOKOT S TABS (Use sennosides-docusate sodium)

NP QL(4 ea daily)

Laxatives - Miscellaneous glycerin (laxative) supp 2 gm 1

GLYCERIN ADULT SUPP (Use glycerin (laxative)) NP

lactulose soln 10 gm/15ml,20 gm/30ml 1

MIRALAX PACK (Use polyethylene glycol 3350) NP RX/OTC

MIRALAX POWD (Use polyethylene glycol 3350) NP QL(34 gm

daily); RX/OTC polyethylene glycol 3350pack or 1 RX/OTC

polyethylene glycol 3350powd or 1 QL(34 gm

daily); RX/OTC SORBITOL SOLN OR 70 % 2

Saline Laxatives FLEET ENEMA ENEM (Use sodium phosphates) NP

FLEET ENEMA SIX PACK ENEM (Use sodium phosphates)

NP

FLEET PEDIATRIC ENEM (Use sodium phosphates) NP

magnesium citrate soln or1.745 gm/30ml, 1

magnesium hydroxide suspor 7.75 %, 400 mg/5ml,1200 mg/15ml, 2400mg/30ml,

1

QL(33 ml daily)

sodium phosphates enem 1

Stimulant Laxatives

bisacodyl supp re 10 mg 1 QL(12 ea perfill retail)

bisacodyl tbec or 5 mg 1 QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

DULCOLAX SUPP RE 10 MG (Use bisacodyl) NP QL(12 ea per

fill retail) DULCOLAX TBEC OR 5 MG (Use bisacodyl) NP QL(1 ea daily)

sennosides tabs 8.6 mg 1

SENOKOT TABS (Use sennosides) NP

Surfactant Laxatives COLACE CAPS (Use docusate sodium) NP QL(3 ea daily)

COLACE CLEAR CAPS (Use docusate sodium) NP

docusate sodium caps or100 mg, 250 mg 1 QL(3 ea daily)

docusate sodium caps or50 mg 1

docusate sodium liqd or 50mg/5ml, 150 mg/15ml 1

docusate sodium syrp or 60mg/15ml 1

docusate sodium tabs or 100 mg 1

MACROLIDES - Drugs to Treat BacterialInfections

Azithromycin AZITHROMYCIN PACK OR 1 GM 2

azithromycin susr or 100mg/5ml 0 QL(15 ml per

fill retail) azithromycin susr or 200mg/5ml 0 QL(30 ml per

fill retail) azithromycin tabs or 250 mg 0 QL(6 ea per fill

retail) azithromycin tabs or 500 mg 0 QL(4 ea daily)

azithromycin tabs or 600 mg 0 QL(8 ea per 28

days retail) ZITHROMAX PACK OR 1 GM NP

ZITHROMAX SUSR OR 100 MG/5ML (Use azithromycin)



95

Drug Name DrugTier

Requirements/Limits

ZITHROMAX SUSR OR 200 MG/5ML (Use azithromycin)


ZITHROMAX TABS OR 250 MG (Use azithromycin) NP QL(6 ea per fill

retail) ZITHROMAX TABS OR 500 MG (Use azithromycin) NP QL(4 ea daily)

ZITHROMAX TABS OR 600 MG (Use azithromycin) NP QL(8 ea per 28

days retail) ZITHROMAX TRI-PAK TABS (Use azithromycin) NP QL(4 ea daily)

ZITHROMAX Z-PAK TABS (Use azithromycin) NP QL(6 ea per fill

retail) Clarithromycin CLARITHROMYCIN SUSR OR 125 MG/5ML, 250MG/5ML


clarithromycin tabs or 250mg, 500 mg 1 QL(28 ea per

fill retail) clarithromycin tb24 or 500 mg 1 QL(14 ea per

fill retail) Erythromycins

E.E.S. 400 TABS 2

E.E.S. GRANULES SUSR (Use erythromycinethylsuccinate)

2

ERYPED 200 SUSR (Use erythromycinethylsuccinate)

2

ERYPED 400 SUSR (Use erythromycinethylsuccinate)

NP

ERYTHROCIN STEARATE TABS NP

erythromycin base cpep250 mg 1

erythromycin base tabs250 mg, 500 mg 1

erythromycin base tbec250 mg, 333 mg, 500 mg NP

ERYTHROMYCIN CPEP OR 2

erythromycinethylsuccinate susr or 200mg/5ml, 400 mg/5ml

1

Drug Name DrugTier

Requirements/Limits

ERYTHROMYCIN ETHYLSUCCINATE TABS OR 400 MG

2

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-Tape ALCOHOL PREP PADS-MISC 2 OTC

Contraceptives

CONDOMS-MISC 2 QL(36 ea perfill retail)

Diabetic Supplies 1ST TIER UNILET COMFORTOUCH LANCETS 28G MISC

2 200 /month;QL(6.67ea daily)

1ST TIER UNILET COMFORTOUCH LANCETS 30G MISC


ACCU-CHEK AVIVA CONNECT KIT NP Limit 1 every 2

years;RX/OTC ACCU-CHEK AVIVA DEVI XX NP Limit 1 every 2

years ACCU-CHEK AVIVA PLUS KIT XX NP Limit 1 every 2

years;RX/OTC ACCU-CHEK COMPACT PLUS CARE KIT KIT NP Limit 1 every 2

years

ACCU-CHEK FASTCLIX LANCETS MISC NP

200 /month;QL(6.67ea daily)

ACCU-CHEK GUIDE KIT XX NP Limit 1 every 2

years;RX/OTC ACCU-CHEK GUIDE ME KIT NP Limit 1 every 2

years;RX/OTC

ACCU-CHEK MULTICLIX LANCETS MISC NP


ACCU-CHEK NANO SMARTVIEW KIT NP Limit 1 every 2

years;RX/OTC

ACCU-CHEK SAFE-T-PRO LANCETS MISC NP


ACCU-CHEK SAFE-T-PRO PLUSLANCETS MISC NP



96

Drug Name DrugTier

Requirements/Limits

ACCU-CHEK SOFTCLIX LANCETS MISC NP


ACCU-CHEK SOFTCLIX LANCETS MISC NP

ACCUTREND PLUS DEVI 2

ACTI-LANCE LANCETS 28G MISC NP


ACTI-LANCE LITE SAFETY LANCETS 28G MISC

NP 200 /month;QL(6.67ea daily)

ACTI-LANCE SPECIAL SAFETY LANCETS 17G MISC


ACTI-LANCE SPECIAL SAFETYLANCETS 17G MISC


ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G MISC


ACTIVE 1ST BLOOD LANCETS30G/EASYTWIST CAP MISC


ADVANCE INTUITION BLOOD GLUCOSE METER DEVI

NP Limit 1 every 2 years

ADVANCE INTUITION BLOOD GLUCOSE MONITORING SYSTEM KIT

NP

Limit 1 every 2years;RX/OTC

ADVANCE MICRO-DRAW METER DEVI NP Limit 1 every 2

years

ADVANCED MOBILE LANCET 30G MISC 2


ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM DEVI


ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM KIT

NP Limit 1 every 2years;RX/OTC

ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM/TALKING KIT


ADVOCATE DUO/TALKING DEVI NP

Drug Name DrugTier

Requirements/Limits

ADVOCATE DUO/TALKING KIT NP

ADVOCATE LANCETS 30G MISC NP


ADVOCATE LANCETS MISC NP


ADVOCATE REDI-CODE DEVI XX NP Limit 1 every 2

years ADVOCATE REDI-CODE+ BLOOD GLUCOSE SYSTEM/SPEAKING DEVI


ADVOCATE REDI-CODE+ BLOODGLUCOSE MONITORING SYSTEM DEVI

NP

Limit 1 every 2 years

ADVOCATE REDI-CODE+/TALKING KIT NP Limit 1 every 2

years;RX/OTC ADVOCATE REDI-CODE/TALKING KIT NP Limit 1 every 2

years;RX/OTC

ADVOCATE SAFETY LANCETS 26G MISC NP


ADVOCATE SAFETY LANCETS MISC NP


AGAMATRIX AMP NO CODE ADVANCED BLOOD GLUCOSE MONITORING SYST DEVI

NP


AGAMATRIX JAZZ WIRELESS 2 KIT NP Limit 1 every 2

years;RX/OTC

AGAMATRIX PRESTO KIT NP Limit 1 every 2years;RX/OTC

AGAMATRIX PRESTO PRO METER DEVI NP Limit 1 every 2

years

AGAMATRIX ULTRA-THIN LANCETS 33G MISC 2


AIMSCO TWIST LANCETS 32G MISC 2


AIMSCO TWIST LANCETS 33G MISC 2



97

Drug Name DrugTier

Requirements/Limits

AQUALANCE LANCETS ULTRA THIN 30G MISC NP


ASSURE 3 METER KIT NP Limit 1 every 2 years

ASSURE 4 BLOOD GLUCOSE METER DEVI NP Limit 1 every 2

years ASSURE COMFORT LANCETS ULTRA THIN 28G MISC


ASSURE HAEMOLANCE PLUS HIGH FLOW 18G MISC


ASSURE HAEMOLANCE PLUS LOW FLOW 25G MISC


ASSURE HAEMOLANCE PLUS MICRO FLOW 28G MISC


ASSURE HAEMOLANCE PLUS NORMAL FLOW 21G MISC


ASSURE HAEMOLANCE PLUS PEDIATRIC BLADE MISC


ASSURE LANCE LANCETS 21G MISC NP


ASSURE LANCE LANCETS MISC NP


ASSURE LANCE PLUS SAFETYLANCETS 25G MISC


ASSURE LANCE PLUS SAFETYLANCETS 30G MISC


ASSURE LANCE SAFETY LANCET 28G MISC NP

ASSURE LANCETS MISC NP 200 /month;QL(6.67ea daily)

ASSURE PLATINUM BLOOD GLUCOSE METER DEVI


Drug Name DrugTier

Requirements/Limits

ASSURE PRISM MULTI BLOODGLUCOSE MONITORING SYSTEM DEVI

NP


ASSURE PRO BLOOD GLUCOSE METER DEVI NP Limit 1 every 2

years

AURORA LANCET SUPER THIN30G MISC 2


AURORA LANCET THIN 23G MISC 2


BAYER CONTOUR LINK 2.4 BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


BD LANCET ULTRAFINE 30G MISC 2


BD LANCET ULTRAFINE 30G MISC NP


BD LANCET ULTRAFINE 33G MISC NP


BD LATITUDE DIABETES MANAGEMENT SYSTEM KIT


BD LOGIC BLOOD GLUCOSE MONITOR KIT NP Limit 1 every 2

years;RX/OTC

BD MICROTAINER LANCETS MISC NP


BIOTEL CARE CONNECTED BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


BLOOD GLUCOSE MONITORINGSYSTEM KIT


BLOOD GLUCOSE MONITORINGSYSTEM PREMIUM KIT


BLOOD GLUCOSE SYSTEM PAK KIT NP Limit 1 every 2

years;RX/OTC

BULLSEYE MINI SAFETY LANCETS MISC NP



98

Drug Name DrugTier

Requirements/Limits

BULLSEYE SAFETY LANCETS MISC NP


CAREONE BLOOD GLUCOSE MONITORING SYSTEM/PREMIUM KIT


CAREONE BLOOD GLUCOSE MONITORING SYSTEM/VALUE KIT


CAREONE LANCET THIN MISC 2


CAREONE LANCET ULTRA THIN MISC 2


CARESENS LANCETS MISC 2 QL(6.67 ea

daily) CARESENS N GLUCOSE MONITORING SYSTEM DEVI


CARESENS N VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


CARETOUCH BLOOD GLUCOSE MONITORING SYSTEM KIT


CARETOUCH SAFETY LANCETS/26G MISC NP



CARETOUCH TWIST LANCETS 30G MISC NP

CHOICE DM DIABETES RISK IN-HOME TEST KIT KIT


CLEANLET LANCETS 28G MISC 2


CLEVER CHEK AUTO CODE VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


Drug Name DrugTier

Requirements/Limits

CLEVER CHEK AUTO-CODE BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


CLEVER CHEK AUTO-CODE DEVI NP

CLEVER CHEK AUTO-CODE VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


CLEVER CHEK BLOOD GLUCOSE MONITORING SYSTEM KIT


CLEVER CHEK LANCETS ULTRATHIN 30G MISC NP


CLEVER CHEK LANCETS ULTRATHIN MISC NP


CLEVER CHOICE AUTO-CODE PRO BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


CLEVER CHOICE MICRO BLOODGLUCOSE MONITORING SYSTEM KIT

NP


CLEVER CHOICE MINI BLOODGLUCOSE MONITORING SYSTEM DEVI

NP


CLEVER CHOICE TALK BLOODGLUCOSE MONITORING SYSTEM DEVI

NP


COAGUCHEK LANCETS MISC NP


COMFORT ASSURED LANCETS MICRO THIN 33G MISC


COMFORT ASSURED LANCETS SUPER THIN 28G MISC


COMFORT ASSURED LANCETS SUPER THIN 28G MISC



99

Drug Name DrugTier

Requirements/Limits

COMFORT LANCETS MISC 2


CONTOUR BLOOD GLUCOSE MONITORING SYSTEM DEVI


CONTOUR BLOOD GLUCOSE MONITORING SYSTEM KIT


CONTOUR NEXT BLOOD GLUCOSE MONITORING SYSTEM KIT


CONTOUR NEXT BLOOD GLUCOSE MONITORING SYSTEM KIT

NP RX/OTC

CONTOUR NEXT EZ BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


CONTOUR NEXT LINK BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


CONTOUR NEXT LINK WIRELESS BLOOD GLUCOSE MONITORING SY KIT

NP


CONTOUR NEXT ONE BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


COOL BLOOD GLUCOSE MONITORING KIT KIT NP Limit 1 every 2

years;RX/OTC COOL BLOOD GLUCOSE MONITORING SYSTEM DEVI


CVS ADVANCED GLUCOSE METER KIT NP Limit 1 every 2

years;RX/OTC

CVS LANCETS 21G MISC 2 200 /month;QL(6.67ea daily)

CVS LANCETS MICRO THIN 33G MISC 2


CVS LANCETS MICRO-THIN 33G MISC 2


Drug Name DrugTier

Requirements/Limits

CVS LANCETS ORIGINAL MISC 2


CVS LANCETS THIN 26G MISC 2


CVS LANCETS ULTRA THIN 30G MISC 2


CVS LANCETS ULTRA-THIN 30G MISC 2


CVS ULTRA THIN LANCETS MISC 2


D-CARE GLUCOMETER KIT/GLUCOSE TESTSTRIPS KIT


DIATHRIVE BLOOD GLUCOSE METER DEVI NP Limit 1 every 2

years DIATHRIVE LANCETS MISC 2 QL(6.67 ea

daily) DIATHRIVE LANCETS ULTRA THIN 30G MISC 2 QL(6.67 ea

daily)

DIATHRIVE LANCETS ULTRA THIN 30G MISC 2


DIATRUE PLUS BLOOD GLUCOSE MONITORING SYSTEM DEVI


DROPLET LANCETS ULTRA THIN 30G MISC 2


DRUG MART LANCETS THIN MISC 2


DRUG MART ON-THE-GO LANCETS GENTLE 30G MISC


DRUG MART UNILET LANCETSSUPER THIN 30G MISC


DRUG MART UNILET LANCETSULTRA THIN 28G MISC



100

Drug Name DrugTier

Requirements/Limits

DRUG MART UNILET MICRO THIN LANCETS 33G MISC


DUO-CARE DEVI NP

E-Z JECT LANCETS 21G MISC 2


E-Z JECT LANCETS COLOR MISC 2


E-Z JECT LANCETS MISC 2 200 /month;QL(6.67ea daily)

E-Z JECT LANCETS SUPER THIN 30G MISC 2


E-Z JECT LANCETS THIN 26G MISC 2


E-ZJECT LANCETS MICRO-THIN 33G MISC 2


EASY COMFORT LANCETS 30G/PULL TOPMISC


EASY COMFORT LANCETS 30G/THIN TOPMISC


EASY COMFORT LANCETS MISC NP


EASY COMFORT LANCETS TWIST TOP MISC

NP

EASY PLUS BLOOD GLUCOSE MONITOR DEVI


EASY PLUS BLOOD GLUCOSE MONITORING SYSTEM KIT


EASY PLUS II BLOOD GLUCOSE MONITORING SYSTEM DEVI


EASY STEP BLOOD GLUCOSE MONITOR DEVI


Drug Name DrugTier

Requirements/Limits

EASY STEP BLOOD GLUCOSE MONITOR STARTER KIT KIT


EASY TALK BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI


EASY TALK BLOOD GLUCOSE MONITORING SYSTEM/TALKING KIT


EASY TOUCH GLUCOSE MONITORING SYSTEM KIT


EASY TOUCH LANCETS 21G/PRESSUREACTIVATED MISC






EASY TOUCH LANCETS 26G/PULL-TOP MISC 2






EASY TOUCH LANCETS 28G/TWIST MISC 2


EASY TOUCH LANCETS 30G/BUTTON-ACTIVATEDMISC











101

Drug Name DrugTier

Requirements/Limits







EASY TOUCH SAFETY LANCETS21G/PRESSUREACTIVATED MISC




EASY TOUCH SAFETY LANCETS26G/BUTTONACTIVATED MISC




EASY TOUCH SAFETY LANCETS28G/BUTTONACTIVATED MISC




EASY TRAK II CONTROL SOLUTION/NORMAL LIQD NP

EASY TRAK BLOOD GLUCOSE MONITORING SYSTEM DEVI


EASY TRAK BLOOD GLUCOSE MONITORING SYSTEM KIT


EASY TRAK II BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP

EASY TWIST & CAP LANCETS MISC NP


EASYGLUCO KIT XX NP Limit 1 every 2 years

EASYGLUCO STARTER KIT KIT NP Limit 1 every 2

years EASYMAX L BLOOD GLUCOSE SYSTEM DEVI NP Limit 1 every 2

years

Drug Name DrugTier

Requirements/Limits

EASYMAX L BLOOD GLUCOSE SYSTEM KIT NP Limit 1 every 2

years;RX/OTC EASYMAX N BLOOD GLUCOSE SYSTEM DEVI NP Limit 1 every 2

years EASYMAX N BLOOD GLUCOSE SYSTEM KIT NP Limit 1 every 2

years;RX/OTC EASYMAX NG SELF-MONITORING BLOOD GLUCOSE SYSTEM DEVI


EASYMAX NG SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT


EASYMAX V BLOOD GLUCOSE SYSTEM DEVI NP Limit 1 every 2

years EASYMAX V BLOOD GLUCOSE SYSTEM/TALKING KIT


EASYMAX V2 SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING DEVI

NP


EASYMAX V2 SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING KIT

NP


EASYPLUS R13N SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT


EASYPLUS V SELF-MONITORING BLOOD GLUCOSE SYSTEM/SPEAKING KIT

NP


EASYPRO BLOOD GLUCOSE MONITORING SYSTEM KIT


EASYPRO PLUS KIT XX NP Limit 1 every 2years;RX/OTC

ELEMENT AUTOCODE SYSTEM KIT NP Limit 1 every 2

years;RX/OTC ELEMENT COMPACT BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


ELEMENT COMPACT V BLOODGLUCOSE MONITORING SYSTEM DEVI

NP



102

Drug Name DrugTier

Requirements/Limits

ELEMENT PLUS BLOOD GLUCOSE METER DEVI NP Limit 1 every 2

years EMBRACE BLOOD GLUCOSE MONITORING SYSTEM DEVI


EMBRACE BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI


EMBRACE EVO BLOOD GLUCOSE MONITORING KIT KIT


EMBRACE LANCETS ULTRA THIN 30G MISC NP


EMBRACE PRO BLOOD GLUCOSE METER DEVI NP Limit 1 every 2

years EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI


EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT


EMBRACE TALK GLUCOSE CONTROL SOLUTION HIGH SOLN

NP

EMBRACE TALK GLUCOSE CONTROL SOLUTION LOW SOLN

NP

EQL COLOR LANCETS 21G MISC 2


EQL COLOR LANCETS MICRO THIN 33G MISC 2


EQL SUPER THIN LANCETS 30G MISC 2


EQL THIN LANCETS 26G MISC 2


EVENCARE BLOOD GLUCOSE MONITORING SYSTEM KIT


EVENCARE G2 BLOOD GLUCOSEMONITORING SYSTEM DEVI


Drug Name DrugTier

Requirements/Limits

EVENCARE G3 BLOOD GLUCOSEMONITORING SYSTEM DEVI


EVENCARE MINI BLOOD GLUCOSE MONITORING SYSTEM DEVI


EVOLUTION AUTOCODE DEVI XX NP Limit 1 every 2

years EZ SMART BLOOD GLUCOSE LANCETS MISC


EZ SMART DIABETES MONITORING SYSTEM DEVI


EZ SMART PLUS DIABETES MONITORING SYSTEM DEVI


EZ-LETS LANCETS 21G MISC NP


EZ-LETS LANCETS 26G SUPER-SOFT MISC 2


EZ-LETS LANCETS 28G ULTRA-SOFT MISC 2


EZ-LETS LANCETS 30G MISC 2


FIFTY50 GLUCOSE METER 2.0 KIT NP Limit 1 every 2

years;RX/OTC

FIFTY50 SAFETY SEAL LANCETS 30G MISC NP


FIFTY50 SAFETY SEAL LANCETS 32G MISC NP


FIFTY50 UNILET LANCETS 33G MISC NP


FINE 30 MISC NP 200 /month;QL(6.67ea daily)

FINGERSTIX LANCETS MISC NP



103

Drug Name DrugTier

Requirements/Limits

FORA D10 2-IN-1 BLOOD GLUCOSE AND PRESSURE MONITOR DEVI

NP

FORA D15G 2-IN-1 BLOOD GLUCOSE AND PRESSURE MONITOR DEVI

NP

FORA D20 2-IN-1 BLOOD GLUCOSE AND PRESSURE MONITOR DEVI

NP

FORA D40 BLOOD GLUCOSE PLUS BLOOD PRESSURE MONITORING SYSTEM DEVI

NP

FORA D40G BLOOD GLUCOSE PLUS BLOOD PRESSURE MONITORING SYSTE DEVI

NP

FORA G20 BLOOD GLUCOSE MONITORING SYSTEM KIT


FORA G30A BLOOD GLUCOSE MONITORING SYSTEM DEVI


FORA GD20 BLOOD GLUCOSE MONITORING SYSTEM DEVI


FORA GD50 BLOOD GLUCOSE MONITORING SYSTEM DEVI


FORA GTEL BLOOD GLUCOSE MONITORING SYSTEM/MULTI-FUNCTIONAL DEVI

NP


FORA LANCETS MISC 2 200 /month;QL(6.67ea daily)

FORA LANCETS MISC NP 200 /month;QL(6.67ea daily)

FORA PREMIUM V10 BLE BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


Drug Name DrugTier

Requirements/Limits

FORA TEST N' GO VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


FORA TN'G VOICE BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


FORA V10 BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI


FORA V10/V12/D10/D20BLOOD GLUCOSE TEST STRIPS/LANCETS 30GKIT

NP


FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/NO-CODINGDEVI

NP


FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI


FORA V20 BLOOD GLUCOSE MONITORING SYSTEM DEVI


FORA V30A BLOOD GLUCOSE MONITORING SYSTEM DEVI


FORA V30A BLOOD GLUCOSE MONITORING SYSTEM KIT


FORACARE GD40 BLOOD GLUCOSE MONITORING SYSTEM DEVI


FORACARE PREMIUM V10 BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


FORACARE TEST N GO BLOODGLUCOSE MONITORING SYSTEM DEVI

NP


FORTISCARE SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT


FREDS PHARMACY UNILET LANCETS SUPER THIN 30G MISC



104

Drug Name DrugTier

Requirements/Limits

FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G MISC


FREESTYLE FLASH SYSTEM KIT NP Limit 1 every 2

years FREESTYLE FREEDOM KIT NP Limit 1 every 2

years;RX/OTC FREESTYLE FREEDOM LITE KIT NP Limit 1 every 2

years;RX/OTC FREESTYLE INSULINX BLOODGLUCOSE MONITORING SYSTEM KIT

NP


FREESTYLE LANCETS MISC NP


FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM DEVI


FREESTYLE PRECISION NEO BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


FREESTYLE SIDEKICK II VALUEPACK KIT NP Limit 1 every 2

years;RX/OTC FREESTYLE SYSTEM KIT KIT NP Limit 1 every 2

years

FREESTYLE UNISTICK II LANCETS MISC NP


GAUZE SPONGES 2 RX/OTC

GE100 BLOOD GLUCOSE MONITORING SYSTEM DEVI


GE100 BLOOD GLUCOSE MONITORING SYSTEM KIT


GENTEEL BUTTERFLY TOUCH LANCETS MISC NP

GENTLE-LET GP LANCETS MISC 2


GENTLE-LET LANCETS GENERAL PURPOSE STYLE/FINE POINT MISC


Drug Name DrugTier

Requirements/Limits

GENTLE-LET LANCETS GENERAL PURPOSE STYLE/MEDIUM POINTMISC

2


GENTLE-LET LANCETS SAFETY STYLE/FINEPOINT MISC


GENTLE-LET LANCETS SAFETY STYLE/MEDIUMPOINT MISC


GHT BLOOD GLUCOSE MONITORING SYSTEM KIT


GLOBAL INJECT EASE LANCETS 28G MISC NP


GLOBAL INJECT EASE LANCETS 30G MISC NP


GLUCO PERFECT 3 BLOOD GLUCOSE METER DEVI


GLUCO PERFECT 3 BLOOD GLUCOSE MONITORING SYSTEM/VOICE DEVI

NP


GLUCOCARD 01 BLOOD GLUCOSE METER DEVI NP Limit 1 every 2

years GLUCOCARD 01 BLOOD GLUCOSE MONITORING SYSTEM KIT


GLUCOCARD 01-MINI BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


GLUCOCARD EXPRESSION AUDIO-ENABLED BLOOD GLUCOSE MONITORING KIT

NP


GLUCOCARD SHINE CONNEX BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


GLUCOCARD SHINE DEVI NP Limit 1 every 2

years


105

Drug Name DrugTier

Requirements/Limits

GLUCOCARD SHINE EXPRESS BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


GLUCOCARD SHINE KIT NP Limit 1 every 2years;RX/OTC

GLUCOCARD SHINE XL DEVI NP Limit 1 every 2

years GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM BLACK KIT

NP


GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM BLUE KIT

NP


GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM PINK KIT

NP


GLUCOCARD X-METER KIT NP Limit 1 every 2

years;RX/OTC GLUCOCOM BLOOD GLUCOSE MONITOR DEVI


GLUCOCOM BLOOD GLUCOSE MONITORING SYSTEM KIT


GLUCOCOM BLOOD GLUCOSE MONITORING SYSTEM VALUE KIT KIT


GLUCOCOM LANCETS 28G MISC NP






GLUCONAVII BLOOD GLUCOSEMONITORING SYSTEM KIT


Drug Name DrugTier

Requirements/Limits

GNP EASY TOUCH GLUCOSE MONITORING SYSTEM/NO CODINGDEVI

NP


GNP LANCETS 21G MISC 2 200 /month;QL(6.67ea daily)

GNP LANCETS MICRO THIN 33G MISC 2


GNP LANCETS MISC 2 200 /month;QL(6.67ea daily)

GNP LANCETS SUPER THIN 30G MISC 2


GNP LANCETS THIN 26G MISC 2


GNP LANCETS THIN MISC 2


GNP MICRO THIN LANCETS 33G MISC 2


GNP SUPER THIN LANCETS/30G MISC 2


GOJJI CONTROL SOLUTION NORMAL SOLN

NP

GOJJI STERILE LANCETS 30G MISC 2 QL(6.67 ea

daily) GOODSENSE COLOR LANCETS MICRO-THIN 33G UNIVERSAL MISC

2 QL(6.67 eadaily)

GOODSENSE LANCETS MICRO-THIN 33G MISC NP

GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL MISC

2 QL(6.67 eadaily)

GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL MISC


GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL MISC



106

Drug Name DrugTier

Requirements/Limits

GOODSENSE LANCETS ULTRA-THIN 30G MISC NP

GOODSENSE LANCETS ULTRA-THIN 30G UNIVERSAL MISC

2 QL(6.67 eadaily)

GOODSENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM KIT

NP


H-E-B INCONTROL LANCETS MICRO THIN 33G MISC


H-E-B INCONTROL LANCETS SUPER THIN 30G MISC


H-E-B INCONTROL LANCETS ULTRA THIN 28G MISC


HAEMOLANCE LOW FLOW LANCETS MISC NP


HAEMOLANCE MISC NP 200 /month;QL(6.67ea daily)

HAEMOLANCE PLUS HIGH FLOW MISC NP


HAEMOLANCE PLUS LOW FLOW MISC NP


HAEMOLANCE PLUS MAX FLOW MISC NP


HAEMOLANCE PLUS MISC NP


HAEMOLANCE PLUS PEDIATRIC FLOW MISC NP


HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G MISC


HW EMBRACE PRO BLOOD GLUCOSE METER DEVI


HW EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI


Drug Name DrugTier

Requirements/Limits

HW EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


HY-VEE LANCETS MISC 2 200 /month;QL(6.67ea daily)

HY-VEE THIN LANCETS MISC 2


IBG STAR BLOOD GLUCOSE MONITORING SYSTEM KIT


IGLUCOSE BLOOD GLUCOSE MOITORING SYSTEM KIT


IN TOUCH DEVI NP Limit 1 every 2 years

IN TOUCH STERILE LANCETS30G MISC NP


INFINITY BLOOD GLUCOSE MONITORING SYSTEM KIT


INFINITY BLOOD GLUCOSE MONITORING SYSTEM/STARTER KITKIT

NP


INFINITY VOICE KIT XX NP Limit 1 every 2years;RX/OTC

KINNEY LANCETS MISC 2 200 /month;QL(6.67ea daily)

KINNEY THIN LANCETS MISC 2


KROGER BLOOD GLUCOSE MONITORING KIT KIT


KROGER HEALTHPRO BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


KROGER HEALTHPRO TWIST LANCETS/26GMISC



107

Drug Name DrugTier

Requirements/Limits

KROGER LANCETS 21G MISC 2


KROGER LANCETS MICRO THIN33G MISC 2


KROGER LANCETS MISC 2 200 /month;QL(6.67ea daily)

KROGER LANCETS SUPER THIN MISC 2


KROGER LANCETS THIN 26G MISC 2


KROGER LANCETS THIN MISC 2


KROGER LANCETS ULTRATHIN30G MISC 2


KROGER PREMIUM BLOOD GLUCOSE MONITORING KIT KIT


LANCETS 26G TWIST TOP MISC 2


LANCETS 28G MISC 2 200 /month;QL(6.67ea daily)

LANCETS 30G MISC 2 200 /month;QL(6.67ea daily)

LANCETS 30G MISC NP 200 /month;QL(6.67ea daily)

LANCETS 30G TWIST TOP MISC NP



LANCETS 30G/TWISTTOP MISC NP




Drug Name DrugTier

Requirements/Limits

LANCETS 33G UNIVERSAL DESIGN MISC


LANCETS MICRO THIN 33G MISC NP


LANCETS MISC 2 200 /month;QL(6.67ea daily)

LANCETS MISC NP 200 /month;QL(6.67ea daily)

LANCETS SAFETY SEAL 21G MISC 2






LANCETS SAFETY SEAL 30G MISC NP


LANCETS SUPER THIN 28G MISC 2


LANCETS SUPER THIN 28G MISC NP


LANCETS THIN MISC 2 200 /month;QL(6.67ea daily)

LANCETS TWIST TOP MISC NP


LANCETS ULTRA FINE MISC NP


LANCETS ULTRA THIN 30G MISC NP


LANCETS ULTRA THIN MISC 2


LANCETSBULLSEYE SAFETY MISC NP



108

Drug Name DrugTier

Requirements/Limits

LDR BLOOD GLUCOSE TRUETEST KIT KIT NP Limit 1 every 2

years;RX/OTC LIBERTY BLOOD GLUCOSE METER DEVI NP Limit 1 every 2

years

LIBERTY MEDICAL LANCETS 30G MISC NP


LIBERTY NEXT GENERATION BLOOD GLUCOSE MONITOR DEVI

NP


LIFESCAN UNISTIK 2 DEEP PENETRATION MISC


LIFESCAN UNISTIK II LANCETS MISC NP


LITE TOUCH LANCETS MISC NP


LITETOUCH LANCETS MICRO THIN 33G MISC NP


LIVE BETTER LANCET SUPERTHIN 30G MISC 2


LIVE BETTER LANCET ULTRATHIN 28G MISC 2


LONGS LANCETS STANDARD MISC 2


LONGS LANCETS THIN MISC 2


LONGS LANCETS ULTRA THIN MISC NP


MEDICHOICE PRE-SET SAFETY LANCET DUAL USE MISC


MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW MISC


MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW MISC


Drug Name DrugTier

Requirements/Limits

MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW MISC


MEDICHOICE SAFETY LANCETEXTRA MISC NP


MEDICHOICE SAFETY LANCETNORMAL MISC NP


MEDISENSE THIN LANCETS MISC 2


MEDLANCE PLUS EXTRA LANCETS 21G MISC NP


MEDLANCE PLUS LANCETS LITE 25G MISC NP


MEDLANCE PLUS LANCETS MISC NP


MEDLANCE PLUS LITE LANCETS 25G MISC NP


MEDLANCE PLUS SPECIAL LANCETS 0.8MM MISC


MEDLANCE PLUS SUPERLITE 30G MISC NP


MEDLANCE PLUS SUPERLITE 30G/COMFORT MAXMISC

NP


MEDLANCE PLUS UNIVERSAL LANCETS 21G MISC


MEDLANCE PLUS/LITE25G MISC NP


MEDLANCE/EXTRA MISC NP 200 /month;QL(6.67ea daily)

MEDLANCE/LITE MISC NP 200 /month;QL(6.67ea daily)


109

Drug Name DrugTier

Requirements/Limits

MEDLANCE/UNIVERSALMISC NP


MEIJER BLOOD GLUCOSE MONITORING KIT KIT


MEIJER COLOR LANCETS UNIVERSAL 33G MISC


MEIJER ESSENTIAL BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


MEIJER LANCETS MISC 2 200 /month;QL(6.67ea daily)

MEIJER LANCETS THIN MISC 2


MEIJER LANCETS UNIVERSAL21G MISC 2






MEIJER PREMIUM BLOOD GLUCOSE MONITORING KIT KIT


MEIJER SUPER THIN LANCETS MISC 2


MEIJER TRUE2GO BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


MEIJER TRUERESULT BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


MEIJER TRUETRACK BLOOD GLUCOSE MONITORING KIT KIT


MICRODOT BLOOD GLUCOSE MONITORING SYSTEM KIT


Drug Name DrugTier

Requirements/Limits

MICROLET LANCETS MISC NP


MICROTAINER SAFETY FLOW LANCET/STERILE/SINGLE-USE MISC

NP


MM EASY TOUCH BLOOD GLUCOSE METER KIT NP Limit 1 every 2

years;RX/OTC

MONOLET LANCETS MISC 2


MONOLET LANCETS MISC NP


MONOLET OPD LANCETS MISC 2


MONOLETTOR SAFETY LANCETS MISC NP


MPD SAFETY LANCET 21G/1.8MM MISC NP



MPD SAFETY LANCETS 23G/1.8MM MISC NP

MYGLUCOHEALTH BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G MISC


NEUTEK 2TEK BLOOD GLUCOSE AND WRIST BLOOD PRESSURE MONITOR DEVI

NP

NOVA MAX BLOOD GLUCOSE MONITORING SYSTEM DEVI


NOVA MAX BLOOD GLUCOSE MONITORING SYSTEM KIT



110

Drug Name DrugTier

Requirements/Limits

NOVA SAFETY LANCETS 23G MISC NP


NOVA SAFETY LANCETS 28G MISC NP


NOVA SUREFLEX LANCETS MISC 2


NOVA SUREFLEX LANCETS MISC NP


ON CALL EXPRESS BLOOD GLUCOSE METER DEVI


ON CALL EXPRESS BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


ON CALL LANCETS MISC NP 200 /month;QL(6.67ea daily)

ON CALL PLUS BLOOD GLUCOSE METER DEVI NP Limit 1 every 2

years ON CALL PLUS BLOOD GLUCOSE METER KIT NP Limit 1 every 2

years;RX/OTC ON CALL PLUS BLOOD GLUCOSE MONITORING SYSTEM KIT


ON CALL PLUS LANCETS MISC NP


ON CALL VIVID BLOOD GLUCOSE METER DEVI NP Limit 1 every 2

years ON CALL VIVID BLOOD GLUCOSE METER KIT NP Limit 1 every 2

years;RX/OTC ON CALL VIVID BLOOD GLUCOSE MONITORING SYSTEM KIT


ON CALL VIVID PAL BLOOD GLUCOSE METER DEVI


ON CALL VIVID PAL BLOOD GLUCOSE METER KIT


Drug Name DrugTier

Requirements/Limits

ONE DROP BLOOD GLUCOSE MONITORING SYSTEM KIT


ONETOUCH CLUB LANCETS FINE POINT MISC


ONETOUCH DELICA LANCETS EXTRA FINE 33G MISC


ONETOUCH DELICA LANCETS FINE 30G MISC NP


ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G MISC


ONETOUCH DELICA PLUS LANCETS FINE 30G MISC


ONETOUCH FINEPOINT LANCETS MISC NP


ONETOUCH ULTRA 2 KIT NP Limit 1 every 2years;RX/OTC

ONETOUCH ULTRA MINI KIT NP Limit 1 every 2

years;RX/OTC ONETOUCH ULTRALINK SYSTEM (DEC) KIT NP Limit 1 every 2

years;RX/OTC ONETOUCH ULTRALINK SYSTEM (HEX) KIT NP Limit 1 every 2

years;RX/OTC

ONETOUCH ULTRASOFT LANCETS MISC NP


ONETOUCH VERIO FLEX BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


ONETOUCH VERIO IQ BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


ONETOUCH VERIO KIT NP Limit 1 every 2years;RX/OTC

ONETOUCH VERIO REFLECT KIT NP RX/OTC


111

Drug Name DrugTier

Requirements/Limits

ONETOUCH VERIO SYNC BLOODGLUCOSE MONITORING SYSTEM KIT

NP


OPTIUM BLOOD GLUCOSE MONITORING SYSTEM DEVI


OPTIUM BLOOD GLUCOSE MONITORING SYSTEM KIT


OPTUMRX BLOOD GLUCOSE METER KIT NP Limit 1 every 2

years;RX/OTC OPTUMRX BLOOD GLUCOSE MONITORING SYSTEM KIT


PARADIGM LINK BLOOD GLUCOSE MONITOR KIT NP Limit 1 every 2

years;RX/OTC

PC LANCETS SUPER THIN 30G MISC 2


PERFECT LANCETS 30G MISC 2


PERFECT PRESSURE ACTIVATED SAFETY LANCETS 28G MISC


PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


PHARMACIST CHOICE MINI BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


PHARMACIST CHOICE ULTRA THIN LANCETS 28G MISC








Drug Name DrugTier

Requirements/Limits

PHARMACIST CHOICE ULTRA THIN LANCETS MISC


PHARMACY COUNTER LANCETS MISC 2


PIP LANCETS/28G MISC NP

PIP LANCETS/30G MISC NP

POCKETCHEM EZ BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


PRECISION LINK KIT NP Limit 1 every 2years;RX/OTC

PRECISION QID MONITOR DEVI NP Limit 1 every 2

years PRECISION SOF-TACT MONITOR DEVI NP Limit 1 every 2

years

PRECISION THINS GP LANCET MISC 2


PRECISION XTRA DEVI XX NP Limit 1 every 2

years

PRECISION XTRA KIT XX NP Limit 1 every 2 years

PRECISION XTRA KIT XX NP Limit 1 every 2years;RX/OTC

PRECISION XTRA MONITOR DEVI NP Limit 1 every 2

years PREFERRED PLUS LANCETS COLORED 21G MISC


PREFERRED PLUS LANCETS SUPER THIN 30G MISC


PREFERRED PLUS LANCETS THIN 26G MISC 2


PRESSURE ACTIVATED SAFETYLANCET 21G MISC


PRO COMFORT LANCETS 30G MISC NP



112

Drug Name DrugTier

Requirements/Limits

PRO COMFORT LANCETS 31G MISC NP

PRO VOICE V8 BLOOD GLUCOSE MONITORING SYSTEM DEVI


PRO VOICE V9 BLOOD GLUCOSE MONITORING SYSTEM DEVI


PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING/TALKINGKIT

NP


PRODIGY NO CODING BLOOD GLUCOSE KIT NP RX/OTC

PRODIGY POCKET BLOOD GLUCOSE METER KIT KIT


PRODIGY PRESSURE ACTIVATED SAFETY LANCETS MISC


PRODIGY SAFETY LANCETS MISC NP


PRODIGY TWIST TOP LANCETS MISC NP


PRODIGY TWIST TOP LANCETS MISC 2


PRODIGY VOICE BLOOD GLUCOSE METER KIT KIT


PSS SELECT GP LANCETS MISC 2


PSS SELECT SAFETY LANCETS MISC 2


Drug Name DrugTier

Requirements/Limits

PUSH BUTTON SAFETY LANCETS 21G MISC NP





PX LANCETS ULTRA THIN MISC 2


QC LANCETS SUPER THIN MISC 2


QC LANCETS ULTRA THIN MISC 2


QC UNILET LANCETS 28G/ULTRA THIN MISC 2


QC UNILET LANCETS 33G/MICRO THIN MISC 2


QUICKTEK KIT NP Limit 1 every 2 years

QUICKTEK KIT NP Limit 1 every 2years;RX/OTC

QUINTET AC BLOOD GLUCOSEMONITORING SYSTEM DEVI


QUINTET BLOOD GLUCOSE MONITORING SYSTEM DEVI


RA BLOOD GLUCOSE MONITOR DEVI NP Limit 1 every 2

years RA E-ZJECT COLOR LANCETSMICRO-THIN 33G MISC


RA E-ZJECT LANCETS 28G MISC 2


RA E-ZJECT LANCETS THIN 26G MISC 2


RA E-ZJECT LANCETS THIN 28G MISC 2



113

Drug Name DrugTier

Requirements/Limits

RA E-ZJECT LANCETS ULTRATHIN 30G MISC 2


RA TRUE2GO BLOOD GLUCOSEMONITORING SYSTEM KIT


RA TRUERESULT BLOOD GLUCOSE MONITOR KIT NP Limit 1 every 2

years;RX/OTC READYLANCE SAFETY LANCETS/30G/1.6MMMISC

NP

REALITY LANCETS MISC 2 200 /month;QL(6.67ea daily)

REALITY TRIGGER LANCETS MISC NP


REFUAH PLUS BLOOD GLUCOSEMONITORING SYSTEM KIT


RELION CONFIRM BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


RELION LANCETS MICRO-THIN33G MISC 2


RELION LANCETS STANDARD 21G MISC 2


RELION LANCETS THIN 26G MISC 2


RELION LANCETS ULTRA-THIN30G MISC 2


RELION MICRO BLOOD GLUCOSE MONITORING SYSTEM KIT


RELION PREMIER BLU BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


RELION PREMIER CLASSIC BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP

Drug Name DrugTier

Requirements/Limits

RELION PREMIER COMPACT BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


RELION PREMIER VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


RELION PRIME BLOOD GLUCOSE MONITORING SYSTEM DEVI


RELION ULTIMA BLOOD GLUCOSE MONITORING SYSTEM KIT


RELION ULTRA THIN LANCETS/30G MISC 2 QL(6.67 ea

daily)

RELION ULTRA THIN LANCETS30G MISC 2


RELION ULTRA THIN PLUS LANCETS 32G MISC


RELION ULTRA THIN PLUS LANCETS 33G MISC


REVEAL BLOOD GLUCOSE MONITOR KIT NP Limit 1 every 2

years;RX/OTC REXALL BLOOD GLUCOSE MONITORING SYSTEM KIT


REXALL LANCETS ULTRA THIN MISC 2


RIGHTEST GL300 LANCETS MISC 2


RIGHTEST GM100 BLOOD GLUCOSE MONITORING SYSTEM KIT

NP



NP



NP



114

Drug Name DrugTier

Requirements/Limits

SAFE-T-LANCE LOW FLOW 25G MISC NP


SAFE-T-LANCE NORMAL FLOW21G MISC NP


SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW MISC


SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW MISC


SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW MISC


SAFETY LANCET 21G/PRESSUREACTIVATED MISC



NP




NP

SAFETY LANCETS 21G MISC NP





SAFETY LANCETS MISC NP 200 /month;QL(6.67ea daily)

SAFETY LET LANCETS MISC NP


SAFETY SEAL LANCETS 28G MISC 2


SAFETY SEAL LANCETS 30G MISC 2


Drug Name DrugTier

Requirements/Limits

SAPS HEALTH CARE TWIST TOP LANCETS MISC

NP

SAPSCARE TWIST TOP LANCETS 30G MISC NP


SB LANCETS THIN MISC 2 200 /month;QL(6.67ea daily)

SB LANCETS ULTRA THIN MISC 2


SHOPKO ON-THE-GO COMFORTLANCETS 30G MISC


SHOPKO UNILET LANCETS SUPER THIN 30G MISC


SHOPKO UNILET LANCETS ULTRA THIN 28G MISC


SIDE BUTTON SAFETY LANCET21G MISC NP


SINGLE-LET MISC NP 200 /month;QL(6.67ea daily)

SM MICRO THIN LANCETS 33G MISC 2


SMART SENSE COLOR LANCETS UNIVERSAL 33G MISC


SMART SENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM KIT

NP


SMART SENSE STANDARD LANCETS UNIVERSAL 21G MISC


SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G MISC


SMART SENSE THIN LANCETSUNIVERSAL 26G MISC



115

Drug Name DrugTier

Requirements/Limits

SMART SENSE VALUE BLOODGLUCOSE MONITORING SYSTEM KIT

NP


SMARTEST EJECT BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


SMARTEST EJECT STARTER KIT KIT NP Limit 1 every 2

years;RX/OTC

SMARTEST LANCETS 28G MISC NP


SMARTEST PERSONA STARTERKIT KIT NP Limit 1 every 2

years;RX/OTC SMARTEST PRONTO STARTERKIT KIT NP Limit 1 every 2

years;RX/OTC SMARTEST PROTEGE BLOOD GLUCOSE MONITORING SYSTEM DEVI

NP


SMARTEST PROTEGE STARTERKIT KIT NP Limit 1 every 2

years;RX/OTC SOLUS V2 AUDIBLE BLOOD GLUCOSE MANAGEMENT SYSTEM DEVI

NP


SOLUS V2 AUDIBLE BLOOD GLUCOSE MANAGEMENT SYSTEM KIT

NP


SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G MISC


SOLUS V2 TWIST LANCETS 30G MISC NP


STERILANCE TL MISC 2 200 /month;QL(6.67ea daily)

SUPER THIN LANCETS MISC 2


SURE COMFORT LANCETS 28G MISC NP


Drug Name DrugTier

Requirements/Limits

SURE COMFORT LANCETS 30G MISC NP


SURE EDGE BLOOD GLUCOSE MONITORING SYSTEM DEVI


SURE-LANCE FLAT LANCETS MISC NP


SURE-LANCE LANCETS 26G MISC NP


SURE-LANCE THIN LANCETS 28G MISC NP


SURE-LANCE ULTRA THIN LANCETS MISC NP


SURE-TEST EASYPLUS MINI SELF MONITORING BLOOD GLUCOSE METER DEVI

NP


SURE-TOUCH LANCETS UNIVERSAL MISC NP


SURECHEK BLOOD GLUCOSE MONITORING SYSTEM DEVI


SURECHEK BLOOD GLUCOSE MONITORING SYSTEM STARTER KIT KIT

NP


SURELITE LANCETS MISC 2


TECHLITE AST LANCETS MISC 2


TECHLITE LANCETS 30G MISC 2


TECHLITE LANCETS MISC 2


TELCARE BLOOD GLUCOSE MONITORING SYSTEM KIT



116

Drug Name DrugTier

Requirements/Limits

TGT BLOOD GLUCOSE METER MONITORING SYSTEM KIT


TGT BLOOD GLUCOSE MONITORING SYSTEM KIT


TGT BLOOD GLUCOSE MONITORING SYSTEM PREMIUM KIT


TGT LANCET MICRO THIN 33G MISC 2


TGT LANCET THIN 26G MISC 2


TGT LANCET ULTRA THIN 30G MISC 2


THINLETS GP LANCETS MISC 2


TODAYS HEALTH SUPER THINLANCETS 30G MISC 2


TODAYS HEALTH ULTRA THINLANCETS 28G MISC 2


TOPCARE LANCETS MICRO-THIN 33G MISC NP

TRAVEL LANCETS 30G MISC NP


TRAVEL LANCETS ADVANCED 28G MISC NP

TRUE COMFORT TWIST TOP LANCETS 30G MISC NP

TRUE FOCUS BLOOD GLUCOSESELF MONITORING METER DEVI

NP


TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTHDEVI

NP


TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTHSMART KIT

NP


Drug Name DrugTier

Requirements/Limits

TRUE METRIX AIR W/BLUETOOTH SMARTKIT


TRUE METRIX BLOOD GLUCOSEMETER KIT NP Limit 1 every 2

years;RX/OTC TRUE METRIX CONTROL SOLUTION LEVEL 1 SOLN

2

TRUE METRIX CONTROL SOLUTION LEVEL 2 SOLN

2

TRUE METRIX CONTROL SOLUTION LEVEL 3 SOLN

2

TRUE METRIX DEVI NP Limit 1 every 2 years

TRUE METRIX GO BLOOD GLUCOSE METER KIT


TRUEPLUS LANCETS 26G MISC 2




TRUEPLUS LANCETS 28G SUPER THIN MISC NP


TRUEPLUS LANCETS 28G SUPER THIN MISC 2




TRUEPLUS LANCETS 30G ULTRA THIN MISC NP


TRUEPLUS LANCETS 30G ULTRA THIN MISC 2


TRUEPLUS LANCETS 33G MICRO THIN MISC NP





117

Drug Name DrugTier

Requirements/Limits

TRUEPLUS SAFETY LANCETS 28G MISC NP


TRUEPLUS SAFETY LANCETS 28G MISC NP

TRUERESULT BLOOD GLUCOSEMONITORING SYSTEM/NO CODING KIT


TRUETRACK BLOOD GLUCOSE MONITORING SYSTEM DEVI


TRUETRACK BLOOD GLUCOSE MONITORING SYSTEM KIT


TRUETRACK SMART SYSTEM KIT NP Limit 1 every 2

years;RX/OTC

ULTILET CLASSIC LANCETS MISC NP


ULTILET CLASSIC LANCETS MISC 2


ULTILET LANCETS 33G MISC NP


ULTILET LANCETS MISC NP 200 /month;QL(6.67ea daily)

ULTILET SAFETY LANCETS 23G MISC NP


ULTIMA KIT NP Limit 1 every 2 years

ULTRA THIN LANCETS 31G MISC NP

ULTRA TRAK PRO BLOOD GLUCOSE MONITORING SYSTEM KIT

NP


ULTRA-CARE LANCETS 30G MISC NP

ULTRA-THIN II AUTO LANCET MISC NP


ULTRA-THIN II LANCETS 28G MISC NP


Drug Name DrugTier

Requirements/Limits

ULTRA-THIN II LANCETS 30G MISC NP


ULTRATRAK ACTIVE DEVI NP Limit 1 every 2

years

ULTRATRAK PRO DEVI NP Limit 1 every 2 years

ULTRATRAK ULTIMATE MONITOR DEVI NP Limit 1 every 2

years

UNILET COMFORTOUCH LANCET MISC 2


UNILET EXCELITE II MISC 2 200 /month;QL(6.67ea daily)

UNILET EXCELITE MISC 2 200 /month;QL(6.67ea daily)

UNILET G.P. LANCET MISC 2


UNILET G.P. SUPERLITE LANCET MISC 2


UNILET GP 28 ULTRA THIN MISC 2


UNILET LANCET MISC 2 200 /month;QL(6.67ea daily)

UNILET LANCETS MICRO-THIN33G MISC NP

UNILET LANCETS MICRO-THIN33G MISC 2


UNILET LANCETS SUPER-THIN30G MISC 2


UNILET LANCETS SUPER-THIN30G MISC NP

UNILET LANCETS ULTRA-THIN 28G MISC NP

UNILET LANCETS ULTRA-THIN 28G MISC 2



118

Drug Name DrugTier

Requirements/Limits

UNILET SUPERLITE LANCET MISC 2


UNISTIK 3 GENTLE MISC NP 200 /month;QL(6.67ea daily)

UNISTIK PRO SAFETY LANCET 21G MISC NP



UNISTIK SAFETY LANCETS 28G MISC NP


UNISTIK SAFETY LANCETS 30G MISC NP


UNISTIK TOUCH SAFETY LANCETS 21G MISC NP








UNIVERSAL 1 LANCETS THIN26G MISC 2


UNIVERSAL 1 LANCETS ULTRA THIN 30G MISC 2


UNIVERSAL 1 LANCETS/33G/MICRO-THIN MISC


VALUE PLUS LANCETS STANDARD 21G MISC 2


VALUE PLUS LANCETS SUPERTHIN 30G MISC 2


Drug Name DrugTier

Requirements/Limits

VALUE PLUS LANCETS THIN 26G MISC 2


VALUMARK LANCET SUPER THIN 30G MISC 2


VALUMARK LANCET ULTRA THIN 28G MISC 2


VERASENS BLOOD GLUCOSE MONITORING SYSTEM KIT


VERASENS BLOOD GLUCOSE MONITORING SYSTEM METER KIT DEVI

NP


VICTORY BLOOD GLUCOSE MONITORING SYSTEM DEVI


VIDA MIA UNILET LANCETS SUPER THIN 30G MISC


VIDA MIA UNILET LANCETS ULTRA THIN 28G MISC


VITALET PRO LANCETS MISC NP


VITALET PRO PLUS LANCETS MISC NP


VIVAGUARD LANCETS MISC NP

VOCAL POINT BLOOD GLUCOSE MONITORING SYSTEM DEVI


WALGREENS ADVANCED TRAVELLANCETS 28G MISC


WALGREENS COMFORT ASSUREDLANCETS MICRO THIN/33G MISC


WALGREENS COMFORT ASSUREDLANCETS SUPER THIN/28G MISC


WALGREENS LANCETS MISC NP



119

Drug Name DrugTier

Requirements/Limits

WALGREENS THIN LANCETS MISC NP


WALGREENS THIN LANCETS MISC 2


WALGREENS ULTRA THIN LANCETS MISC NP


WAVESENSE AMP KIT NP Limit 1 every 2years;RX/OTC

WAVESENSE KEYNOTE KIT NP Limit 1 every 2

years;RX/OTC WAVESENSE KEYNOTE PRO METER DEVI NP Limit 1 every 2

years

Misc. Devices 14-COUNT WARMER MISC 2 RX/OTC

2-WAY FOLEY STABILIZATIONDEVICE MISC

2 RX/OTC

3-IN-1 BEDSIDE TOILET MISC 2 RX/OTC

3-IN-1 COMMODE MISC 2 RX/OTC

ACU-LIFE PILL CRUSHER/CONTAINERMISC

2 RX/OTC

ADAPTER CAP BLUE A 18MM MISC 2 RX/OTC

ADAPTER CAP BLUE B 20MM MISC 2 RX/OTC

ADAPTER CAP BLUE C 22MM MISC 2 RX/OTC

ADAPTER CAP BLUE D 24MM MISC 2 RX/OTC

ADAPTER CAP BLUE E 28MM/SHORT NECKMISC

2 RX/OTC

ADAPTER CAP BLUE F 28MM/LONG NECK MISC 2 RX/OTC

ADAPTER CAP BLUE K 28MM/MEDIUM NECKMISC

2 RX/OTC

ADAPTER CAP BLUE M 24MM MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

ADAPTER CAP GREEN A 18MM MISC 2 RX/OTC

ADAPTER CAP GREEN B 20MM MISC 2 RX/OTC

ADAPTER CAP GREEN C 22MM MISC 2 RX/OTC

ADAPTER CAP GREEN D 24MM MISC 2 RX/OTC

ADAPTER CAP GREEN E 28MM/SHORT NECKMISC

2 RX/OTC

ADAPTER CAP GREEN F 28MM/LONG NECK MISC 2 RX/OTC

ADAPTER CAP GREEN K 28MM/MEDIUM NECKMISC

2 RX/OTC

ADAPTER CAP GREEN M 24MM MISC 2 RX/OTC

ADAPTER CAP RED A 18MM MISC 2 RX/OTC

ADAPTER CAP RED B 20MM MISC 2 RX/OTC

ADAPTER CAP RED C 22MM MISC 2 RX/OTC

ADAPTER CAP RED D 24MM MISC 2 RX/OTC

ADAPTER CAP RED E 28MM/SHORT NECKMISC

2 RX/OTC

ADAPTER CAP RED F 28MM/LONG NECK MISC 2 RX/OTC

ADAPTER CAP RED K 28MM/MEDIUM NECKMISC

2 RX/OTC

ADAPTER CAP RED M 24MM MISC 2 RX/OTC

ADAPTER CAP WHITE B 20MM MISC 2 RX/OTC

ADAPTER CAP WHITE C 22MM MISC 2 RX/OTC

ADD-VANTAGE ADDAPTOR CONNECTOR MISC

2 RX/OTC

ADJUST ALUMINUM CANE/ROUNDHANDLE/5/8" MISC

2 RX/OTC


120

Drug Name DrugTier

Requirements/Limits

ADJUST ALUMINUM CANE/ROUNDHANDLE/7/8" MISC

2 RX/OTC

ADJUST ALUMINUM OFFSET CANE/CUSHHANDLE/WRISTSTRAP/3/4" MISC

2

RX/OTC

ADJUST FOLD CANE/BLACKFIN/WALNUT PISTOLGRIP DERBY HANDLE MISC

2

RX/OTC

ADJUSTABLE BATH/SHOWER SEATMISC

2 RX/OTC

ADJUSTABLE BATH/SHOWERSEAT/BACK MISC

2 RX/OTC

ADJUSTABLE COMMODE 3-IN-1 MISC 2 RX/OTC

ADJUSTABLE FOLDING CANE/YORK HANDLEMISC

2 RX/OTC

ADULT PUSH BUTTON ALUMINUM CRUTCH MISC

2 RX/OTC

ADULT-LOCK SAFETY TABLETCUTTER MISC 2 RX/OTC

ALCOH-GLOVE CONTOURED WIPE PADS NP RX/OTC

ALCOHOL PADS PADS NP RX/OTC

ALCOHOL PREP PADS PADS NP RX/OTC

ALCOHOL PREP PADS PADS 2 RX/OTC

ALCOHOL SWABS PADS 2 RX/OTC

ALCOHOL SWABS PADS NP RX/OTC

ALCOHOL SWABSTICK PADS 2 RX/OTC

ALCOHOL WIPES PADS XX 2 RX/OTC

ALEVE DIRECT THERAPY TENSDEVICE REFILL GEL PADS MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

ALHPAMOP FOAM REPLACEMENTPADS MISC

2 RX/OTC

ALL-BODY MASSAGE MISC 2 RX/OTC

ALUMINUM BLANKET SUPPORT2 HEIGHTS MISC

2 RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/13MM/RED MISC

2 RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/13MM/ROYAL BLUEMISC

2

RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/13MM/YELLOWMISC

2

RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/BLACK MISC

2 RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/BLUE MISC

2 RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/GREEN MISC

2 RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/LIGHT GREENMISC

2

RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/MIST GRAYMISC

2

RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/NATURALMISC

2

RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/ROYAL BLUEMISC

2

RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/WHITE MISC

2 RX/OTC


121

Drug Name DrugTier

Requirements/Limits

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/WILLOWGREEN MISC

2

RX/OTC

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/YELLOWMISC

2

RX/OTC

AMBER GLASS BOTTLE MISC 2 RX/OTC

AMBER GLASS VIALS 2ML MISC 2 RX/OTC

AMBER GLASS VIALS 2ML/13MM MISC 2 RX/OTC

AMBER GLASS VIALS 30ML/20MM MISC 2 RX/OTC

AMEDA ADAPTER CAP MISC 2 RX/OTC

AMEDA BREAST FLANGE INSERT/22.5MM/SMALLMISC

2 RX/OTC

AMEDA CUSTOMFIT BREAST FLANGE/25MM/STANDARD MISC

2

RX/OTC

AMEDA CUSTOMFIT BREAST FLANGE/28.5MM/MEDIUMMISC

2

RX/OTC

AMEDA CUSTOMFIT BREAST FLANGE/30.5MM/LARGEMISC

2

RX/OTC

AMEDA DIAPHRAGMS MISC 2 RX/OTC

AMEDA DUAL HYGIENIKIT MILK COLLECTION SYSTEM MISC

2

RX/OTC

AMEDA DUAL HYGIENIKIT MILK COLLECTION SYSTEM/PUMP ADAPTERMISC

2

RX/OTC

Drug Name DrugTier

Requirements/Limits

AMEDA DUAL HYGIENIKIT SYSTEM/CUSTOMFITFLANGES/PUMPADAPTER MISC

2

RX/OTC

AMEDA ELITE BREAST PUMP MISC 2 RX/OTC

AMEDA FINESSE DOUBLE ELECTRIC BREAST PUMP MISC

2 RX/OTC

AMEDA FINESSE DOUBLE ELECTRIC BREAST PUMP/DOTTIETOTE MISC

2

RX/OTC

AMEDA FINESSE DOUBLE ELECTRIC BREAST PUMP/MINNIETOTE MISC

2

RX/OTC

AMEDA FINESSE DOUBLE ELECTRIC BREAST PUMP/SHOULDER BAGMISC

2

RX/OTC

AMEDA FLEXISHIELD MISC 2 RX/OTC

AMEDA MYA JOY DOUBLE ELECTRIC BREAST PUMP MISC

2 RX/OTC

AMEDA MYA JOY DOUBLE ELECTRIC BREAST PUMP/LARGETOTE MISC

2

RX/OTC

AMEDA ONE-HAND BREAST PUMP/TOTEMISC

2 RX/OTC

AMEDA ONE-HAND MANUAL BREAST PUMP MISC

2 RX/OTC

AMEDA PLATINUM MULTI-USER ELECTRIC BREAST PUMP MISC

2 RX/OTC

AMEDA PURELY YOURS BREASTPUMP/HYGIENIKIT MISC

2 RX/OTC

AMEDA PURELY YOURS DOUBLE ELECTRIC BREAST PUMP/CARRYALL MISC

2

RX/OTC


122

Drug Name DrugTier

Requirements/Limits

AMEDA PURELY YOURS ELECTRIC BREAST PUMP/HYGIENIKIT MISC

2 RX/OTC

AMEDA SILICONE TUBING MISC 2 RX/OTC

AMEDA TUBING ADAPTER MISC 2 RX/OTC

AMEDA VALVES MISC 2 RX/OTC

AMIELLE RESTORE VAGINAL EXERCISERS MISC

2 RX/OTC

AMIELLE VAGINAL TRAINER MISC 2 RX/OTC

ANGEL WING BLOOD COLLECTION SET/HOLDER/23GX3/4"MISC

2

RX/OTC

ANGEL WING BLOOD COLLECTION SET/HOLDER/25GX3/4"MISC

2

RX/OTC

ANGEL WING LUER ADAPTER/TUBE HOLDERSET/FEMALE MISC

2 RX/OTC

ANGEL WING TRANSFER DEVICE/FEMALEADAPTER MISC

2 RX/OTC

ANGEL WING TUBE HOLDER/FEMALE LUERMISC

2 RX/OTC

APLICARE ALCOHOL SWABSTICK PADS 2 RX/OTC

APNEASTRIP MISC 2 RX/OTC

APPLICATOR ACCESSORIES/TAP-N-CLICK SILICONE PAD MULTI-PURPOS MISC

2

RX/OTC

ARGYLE SARATOGA SUMP DRAIN/20FR/20"MISC

2 RX/OTC


2 RX/OTC


2 RX/OTC

Drug Name DrugTier

Requirements/Limits

ARGYLE TRACHEOSTOMY TUBEHOLDER MISC

2 RX/OTC

AUTOCLAVE ACCESSORIES PRINTER PAPER MISC

2 RX/OTC

AUTOCLAVE AIR FILTER MISC 2 RX/OTC

AUTOCLAVE PAPER 36" X 36" MISC 2 RX/OTC

AUTOCLAVE POUCH 7.5" X 13"/SELF-SEALINGMISC

2 RX/OTC

AVOSTARTGRIP MISC 2 RX/OTC

BABY FRIDGE MISC 2 RX/OTC

BAMBOO CANE MISC 2 RX/OTC

BANDAGE SCISSORS MISC 2 RX/OTC

BARIATRIC ALUMINUM CANE/OFFSET MISC 2 RX/OTC

BARIATRIC CANE/OFFSETHANDLE/29"-38"/500LBCAPACITY MISC

2

RX/OTC

BARIATRIC QUAD CANE/29"-38"/500LBCAPACITY MISC

2 RX/OTC

BARIATRIC ROLLATOR/EXTRAWIDE/400LB CAPACITY/HEAVYDUTY MISC

2

RX/OTC

BATH BENCH WITH BACK MISC 2 RX/OTC

BATH/SHOWER SEATWITH BACK/ADJUSTABLEMISC

2 RX/OTC

BATH/SHOWERSEAT/ADJUSTABLE MISC 2 RX/OTC

BATHTUB SAFETY RAIL MISC 2 RX/OTC

BD PHASEAL DRUG VIAL PROTECTOR/20MMNECK MISC

2 RX/OTC


123

Drug Name DrugTier

Requirements/Limits

BD PHASEAL DRUG VIAL PROTECTOR/28MMNECK MISC

2 RX/OTC

BD PHASEAL INFUSION ADAPTER/CONNECTORMISC

2 RX/OTC

BD PHASEAL INJECTOR LUERLOCK TRANSFER DEVICE MISC

2 RX/OTC

BD PHASEAL LUER LOCK CONNECTOR/NEEDLEFREE PORTS MISC

2 RX/OTC

BD PHASEAL SYRINGE TRAY M15 MISC 2 RX/OTC

BD PHASEAL Y-SITE CONNECTOR MISC 2 RX/OTC

BD SAFE CLIP NEEDLE CLIPPER MISC 2 RX/OTC

BD SAFE-CLIP BY MAIL MISC 2 RX/OTC

BD SWABS SINGLE USE BUTTERFLY PADS 2 RX/OTC

BD SWABS SINGLE USE PADS 2 RX/OTC

BED WEDGE/10" MISC 2 RX/OTC



BEDSIDE COMMODE MISC 2 RX/OTC

BELT CLIP MISC 2 RX/OTC

BEUTLICH PH TEST ROLL MISC 2 RX/OTC

BI-FOCAL MAGNIFIER MISC 2 RX/OTC

BLISTER PACK ADHESIVE LABEL MISC 2 RX/OTC

BLISTER PACK/AMBER12 CAVITY MISC 2 RX/OTC

BLOOD COLLECTION TUBE HOLDER/WITHNEEDLE MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

BLOOD COLLECTION TUBE HOLDER/WITHOUTNEEDLE MISC

2 RX/OTC

BLOW MOLDED BATHTUB TRANSFER BENCH MISC

2 RX/OTC

BLOW MOLDED BATHTUB TRANSFER BENCH/COMMODESEAT/PAIL MISC

2

RX/OTC

BOTTLE ADAPTERS/24MM/PRESS-IN MISC

2 RX/OTC

BOTTLE AMBER 16OZ/GRADUATED/OVALPET/28-400/CAP MISC

2 RX/OTC

BOTTLE AMBER 8OZ/GRADUATED/OVALPET/24-400/CAP MISC

2 RX/OTC

BOTTLE AMBER GLASS 33OZ/BOSTONROUND/33/430NECK/RIBBED CAP MISC

2

RX/OTC

BOTTLE/6OZ/WHITE/HDPE/WITH TWIST TOPSIFTER CAP MISC

2 RX/OTC

BOTTLE/BOSTONROUND NATURAL MISC 2 RX/OTC

BOTTLE/THIN WALL MISC 2 RX/OTC

BOTTLETOP DISPENSER 0.25-2.0ML MISC 2 RX/OTC

BOTTLETOP DISPENSER ADAPTER/38MM MISC 2 RX/OTC

BOULES QUIES EAR PLUGS MISC 2 RX/OTC

BREAST PUMP MISC 2 RX/OTC

BREAST SELF EXAM PROGRAM MISC 2 RX/OTC

BSS & BSS PLUS ADMIN SET MISC 2 RX/OTC

BUBBLE POINT TESTER KIT/WIZARD MISC 2 RX/OTC

CANE HOLDER MISC 2 RX/OTC

CANE TIPS 3/4" MISC 2 RX/OTC


124

Drug Name DrugTier

Requirements/Limits

CANE TIPS 7/8" MISC 2 RX/OTC

CANE TIPS FOR ALUM/3/4" MISC 2 RX/OTC

CANE TIPS FOR WOOD 1" MISC 2 RX/OTC

CANE TIPS FOR WOOD 5/8" MISC 2 RX/OTC

CANE TIPS FOR WOOD/3/4" MISC 2 RX/OTC

CANE TIPS FOR WOOD/7/8" MISC 2 RX/OTC

CANE TIPS/1" MISC 2 RX/OTC

CANE TIPS/3/4" MISC 2 RX/OTC

CANE TIPS/3/4" QUADNON-SUCTION MISC 2 RX/OTC

CANE TIPS/5/8" QUADSUCTION TYPE MISC 2 RX/OTC

CANE TIPS/7/8"-1" MISC 2 RX/OTC

CANE TIPS/BLACK/3/4"MISC 2 RX/OTC

CANE TIPS/BLACK/7/8"-1"MISC 2 RX/OTC

CANE TIPS/GREY/3/4"MISC 2 RX/OTC

CANE TIPS/GREY/7/8"-1"MISC 2 RX/OTC

CANE TIPS/ICE GRIP TIPMISC 2 RX/OTC

CANE WITH STRAP/BLACK MISC 2 RX/OTC

CANE WRIST STRAP MISC 2 RX/OTC

CANE/ADJUSTABLE/ALUMINUM/ROUND HANDLE5/8" MISC

2 RX/OTC

CANE/ADJUSTABLE/ALUMINUM/ROUND HANDLEMISC

2 RX/OTC

CANE/ADJUSTABLE/PAISLEY MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

CANE/ALUMINUM/ADJUSTABLE/BRONZETONE/STANDARDHANDLE MISC

2

RX/OTC

CANE/ALUMINUM/ADJUSTABLE/DEVON HANDLEMISC

2 RX/OTC

CANE/ALUMINUM/ADJUSTABLE/LADIES HANDLEMISC

2 RX/OTC

CANE/ALUMINUM/ADJUSTABLE/MENS HANDLEMISC

2 RX/OTC

CANE/ALUMINUM/ADJUSTABLE/OFFSETHANDLE/7/8" MISC

2 RX/OTC

CANE/ALUMINUM/ADJUSTABLE/OFFSETHANDLE/AUTUMNBRONZE MISC

2

RX/OTC

CANE/ALUMINUM/ADJUSTABLE/OFFSETHANDLE/BLACK MISC

2 RX/OTC

CANE/ALUMINUM/ADJUSTABLE/OFFSETHANDLE/BLUE ICE MISC

2 RX/OTC

CANE/ALUMINUM/ADJUSTABLE/OFFSETHANDLE/VIOLET MISC

2 RX/OTC

CANE/ALUMINUM/BLACK/DEVONHANDLE/7/8"MISC

2 RX/OTC

CANE/ALUMINUM/BRONZE-TONE MISC 2 RX/OTC

CANE/ALUMINUM/BRONZE/FOLDING/ORTHOHANDLE/3/4" MISC

2 RX/OTC

CANE/ALUMINUM/BRONZE/OFFSETHANDLE/CUSHGRIP/WRIST STRAP/3/4MISC

2

RX/OTC

CANE/ALUMINUM/BRONZE/ORTHO HANDLE/3/4"MISC

2 RX/OTC

CANE/ALUMINUM/BRONZE/YORKHANDLE/7/8"MISC

2 RX/OTC


125

Drug Name DrugTier

Requirements/Limits

CANE/ALUMINUM/FOLDING/36"BLACK MISC 2 RX/OTC

CANE/ALUMINUM/FOLDING/ADJUSTABLE/BLACKMISC

2 RX/OTC

CANE/ALUMINUM/FOLDING/ADJUSTABLE/BRONZE-TONE MISC

2 RX/OTC

CANE/ALUMINUM/FOLDING/ADJUSTABLE/BRONZE/ORTHO HANDLE MISC

2 RX/OTC

CANE/ALUMINUM/FOLDING/BLIND MISC 2 RX/OTC

CANE/ALUMINUM/MEDPEWTERBLUE/ORTHOHANDLE/3/4" MISC

2 RX/OTC

CANE/ALUMINUM/OFFSET CUSHIONED HANDLE/WRISTSTRAP/3/4" MISC

2

RX/OTC

CANE/ALUMINUM/OFFSET HANDLE/NO SAFETYLOCKNUT/3/4" MISC

2 RX/OTC

CANE/ALUMINUM/OFFSET ORTHO GRIP/BLACKMISC

2 RX/OTC

CANE/ALUMINUM/OFFSET ORTHO HANDLE/WRISTSTRAP/3/4" MISC

2

RX/OTC

CANE/ALUMINUM/OFFSET ORTHO MISC 2 RX/OTC

CANE/ALUMINUM/ORTHO/BRONZE MISC 2 RX/OTC

CANE/ALUMINUM/ROUND HANDLE/5/8" MISC 2 RX/OTC

CANE/ALUMINUM/ROUND HANDLE/7/8" MISC 2 RX/OTC

CANE/ALUMINUM/TELESCOPIC/BRONZE/MEDIUMHANDLE/7/8" MISC

2 RX/OTC

CANE/ALUMINUM/TELESCOPIC/LARGEHANDLE/3/4" MISC

2 RX/OTC

CANE/ALUMINUM/TELESCOPIC/MEDIUMHANDLE/7/8" MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

CANE/DESIGNEROFFSET HANDLE MISC 2 RX/OTC

CANE/LADY/BRONZEMISC 2 RX/OTC

CANE/MENS MISC 2 RX/OTC

CANE/OFFSETHANDLE/ALUMINUM/29"-38" MISC

2 RX/OTC

CANE/OFFSETHANDLE/ALUMINUM/29"-38"/CAMOUFLAGE MISC

2 RX/OTC

CANE/OFFSETHANDLE/ALUMINUM/29-38" MISC

2 RX/OTC

CANE/OFFSETHANDLE/ALUMINUM/ADJUSTABLE MISC

2 RX/OTC

CANE/ROSEWOOD/1"MISC 2 RX/OTC

CANE/STANDARD/BLACKHANDLE MISC 2 RX/OTC

CANE/STANDARD/BRONZE HANDLE MISC 2 RX/OTC

CANE/T-HANDLE/ALUMINUM/29"-38" MISC

2 RX/OTC

CANE/T-HANDLE/ALUMINUM/29"-38"/FLORAL PATTERNMISC

2

RX/OTC

CANE/T-HANDLE/BLACK& BLUE MISC 2 RX/OTC

CANE/WOOD/BLACK/ROUND HANDLE/1" MISC 2 RX/OTC

CANE/WOOD/BLACK/ROUND HANDLE/7/8" MISC 2 RX/OTC

CANE/WOOD/LADIESSTANDARDHANDLE/EBONY FINISH/13/16" MISC

2 RX/OTC

CANE/WOOD/LADIESSTANDARDHANDLE/ROSEWOOD FINISH/13/16"MISC

2

RX/OTC


126

Drug Name DrugTier

Requirements/Limits

CANE/WOOD/LADIESSTANDARDHANDLE/STAINED WALNUT FINISH MISC

2

RX/OTC

CANE/WOOD/LADIES/T-HANDLEBLACK WOOD MISC

2 RX/OTC

CANE/WOOD/LADIES/T-HANDLEWALNUT/3/4"MISC

2 RX/OTC

CANE/WOOD/MENSROUND HANDLE/ROSEWOODFINISH MISC

2

RX/OTC

CANE/WOOD/MENSSTANDARD HANDLE/EBONYFINISH/1" MISC

2

RX/OTC

CANE/WOOD/MENSSTANDARD HANDLE/ROSEWOODFINISH/1" MISC

2

RX/OTC

CANE/WOOD/MENSSTANDARD HANDLE/STAINEDWALNUT WOOD MISC

2

RX/OTC

CANE/WOOD/MENS T-HANDLE/BLACK WOODMISC

2 RX/OTC

CANE/WOOD/NATURALASH/ROUND HANDLE/1"MISC

2 RX/OTC

CANE/WOOD/NATURALASH/ROUNDHANDLE/7/8" MISC

2 RX/OTC

CANE/WOOD/ROSEWOOD/1" MISC 2 RX/OTC

CANE/WOOD/STANDARD/BLACKFINISH/1" MISC 2 RX/OTC

CANE/WOOD/STANDARD/BLACKFINISH/7/8" MISC 2 RX/OTC

CANE/WOOD/STANDARD/NATURAL FINISH/1"MISC

2 RX/OTC

CANE/WOOD/STANDARD/NATURAL FINISH/7/8"MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

CANE/WOOD/STANDARD/WALNUT42"LONG MISC 2 RX/OTC

CANE/WOOD/STANDARD/WALNUTFINISH/7/8"MISC

2 RX/OTC

CANE/WOOD/T-HANDLE/WALNUT3/4"MISC

2 RX/OTC

CANE/WOOD/T-HANDLE/WALNUTFINISH/1" MISC

2 RX/OTC

CANE/WOOD/T-HANDLE/WALNUTFINISH/13/16" MISC

2 RX/OTC

CANE/WOOD/WALNUT/7/8" MISC 2 RX/OTC

CANE/WOOD/WALNUT/PISTOL GRIP DERBY HANDLE/7/8" MISC

2 RX/OTC

CANE/WOOD/WALNUT/ROUND HANDLE/7/8" MISC 2 RX/OTC

CARETOUCH ALCOHOL PREP PADS PADS NP RX/OTC

CAREX COCCYX CUSHION MISC 2 RX/OTC

CAREX ULTRA GRABBER 32" MISC 2 RX/OTC

CAREX WHEELCHAIR MISC 2 RX/OTC

CATHETER INTRODUCER MISC 2 RX/OTC

CERVICAL PILLOW MISC 2 RX/OTC

CERVICAL PILLOW/BREATHE EASYMISC

2 RX/OTC

CERVICAL PILLOW/COVER MISC 2 RX/OTC

CERVICAL PILLOW/ORTHOPEDICMISC

2 RX/OTC

CERVICAL ROLL PILLOW/CONTOUR MISC 2 RX/OTC

CHEMO TRANSFER PIN MISC 2 RX/OTC

CINIS PREEMIE HALO LARGE MISC 2 RX/OTC


127

Drug Name DrugTier

Requirements/Limits

CINIS PREEMIE HALO MEDIUM MISC 2 RX/OTC

CINIS PREEMIE HALO SMALL MISC 2 RX/OTC

CLASSICS ROLLING WALKER MISC 2 RX/OTC

CLEANROOM TACKY MAT 18" X36"/60 LAYERMISC

2 RX/OTC

CLEAR GLASS VIALS 10ML MISC 2 RX/OTC

CLEAR GLASS VIALS 2ML MISC 2 RX/OTC

CLEVER CHOICE DIGITAL BMI SCALE MISC 2 RX/OTC

CLEVER CHOICE ELECTRIC BREAST PUMP MISC

2 RX/OTC

CLEVER CHOICE PULSE OXIMETER MISC 2 RX/OTC

CLIP & STOR MISC 2 RX/OTC

COMAR PRESS-IN BOTTLE ADAPTERS 24MM MISC

2 RX/OTC

COMFORT CURVE MASSAGE CUSHION MISC

2 RX/OTC

COMFORT FIT FLANGES LARGE MISC 2 RX/OTC

COMFORT MASSAGER/CORDLESSMISC

2 RX/OTC

COMFORT PERSONAL CLEANSING CART MISC 2 RX/OTC

COMFORT PERSONAL CLEANSING MICROWAVE MISC

2 RX/OTC

COMFORT PERSONAL CLEANSING SHAMPOO CAP MISC

2 RX/OTC

COMFORT PERSONAL CLEANSING WARMER/14-COUNTMISC

2

RX/OTC

Drug Name DrugTier

Requirements/Limits

COMFORT PERSONAL CLEANSING WARMER/28-COUNTMISC

2

RX/OTC

COMMODE 3-IN-1 MISC 2 RX/OTC

COMMODE BEDSIDE MISC 2 RX/OTC

COMMODE BEDSIDE/BACK MISC 2 RX/OTC

COMMODE PAIL WITH HANDLE/LID/12QT MISC 2 RX/OTC

COMMODE SPLASH GUARD MISC 2 RX/OTC

COMPOSITE TRANSFER BENCH MISC 2 RX/OTC

CONTOUR BACK CUSHION MISC 2 RX/OTC

CONTOUR FITTED SHEETS MISC 2 RX/OTC

CONTOUR MATTRESS COVER MISC 2 RX/OTC

COVERALL BOOTS/DISPOSABLE/UNIVERSAL MISC

2 RX/OTC

COVERALL W/HOOD/SMALL/DISPOSABLE MISC

2 RX/OTC

COVERALL W/HOOD/3XL/DISPOSABLE MISC

2 RX/OTC

COVERALL W/HOOD/XL/DISPOSABLE MISC

2 RX/OTC

COVERALL W/HOOD/XXL/DISPOSABLE MISC

2 RX/OTC

COVERALLS MEDIUM/ELASTICBACK/WRIST/ANKLES MISC

2 RX/OTC

CRUTCH ACCESSORY KIT MISC 2 RX/OTC

CRUTCH ACCESSORY KIT/ARMPADS/HANDGRIPS/TIPS MISC

2 RX/OTC

CRUTCH ARMPADS MISC 2 RX/OTC


128

Drug Name DrugTier

Requirements/Limits

CRUTCH HANDGRIPS MISC 2 RX/OTC

CRUTCH HANDGRIPS PREMIUM MISC 2 RX/OTC

CRUTCH HANDGRIPS/SOLID MISC 2 RX/OTC

CRUTCH HANDGRIPS/SPLIT MISC 2 RX/OTC

CRUTCH PILLOWS/ARMAND HAND MISC 2 RX/OTC

CRUTCH SET/ALUMINUM/LARGEMISC

2 RX/OTC

CRUTCH SET/WOOD/ADULT MISC 2 RX/OTC

CRUTCH SET/WOOD/MEDIUMMISC

2 RX/OTC

CRUTCH SET/WOOD/YOUTH MISC 2 RX/OTC

CRUTCH TIPS/EXTRA-LARGE/7/8" MISC 2 RX/OTC

CRUTCH TIPS/JUMBO/GREY MISC 2 RX/OTC

CRUTCH TIPS/REGULARMISC 2 RX/OTC

CRUTCH TIPS/SUPERGRIP/BROWN MISC 2 RX/OTC

CRUTCH TIPS/SUPERMISC 2 RX/OTC

CRUTCH UNDERARM PADS MISC 2 RX/OTC

CRUTCH UNDERARM PADS PREMIUM MISC 2 RX/OTC

CRUTCH-MATE/ADULTARM MISC 2 RX/OTC

CRUTCH-MATE/ADULTFOREARM MISC 2 RX/OTC

CRUTCH-MATE/ADULTHAND GRIPS LARGE MISC

2 RX/OTC

CRUTCH-MATE/ADULTHAND GRIPS MISC 2 RX/OTC

CRUTCH/ALUMINUM/ADULT MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

CRUTCH/ALUMINUM/ADULT/5'2"-5'10" MISC 2 RX/OTC

CRUTCH/ALUMINUM/ADULT/ARMPADS/TIPS/GRIPSMISC

2 RX/OTC

CRUTCH/ALUMINUM/ADULT/PUSH BUTTON MISC 2 RX/OTC

CRUTCH/ALUMINUM/ADULT/PUSH-BUTTON ADJMISC

2 RX/OTC

CRUTCH/ALUMINUM/MEDIUM MISC 2 RX/OTC

CRUTCH/ALUMINUM/TALL ADULT/PUSH BUTTONMISC

2 RX/OTC

CRUTCH/ALUMINUM/TALL/PUSHBUTTON ADJMISC

2 RX/OTC

CRUTCH/ALUMINUM/TALL/PUSHBUTTON MISC 2 RX/OTC

CRUTCH/ALUMINUM/YOUTH MISC 2 RX/OTC

CRUTCH/ALUMINUM/YOUTH/ARMPADS/TIPS/GRIPS MISC

2 RX/OTC

CRUTCH/ALUMINUM/YOUTH/PUSH BUTTON MISC 2 RX/OTC

CRUTCH/ALUMINUM/YOUTH/PUSH-BUTTON ADJMISC

2 RX/OTC

CRUTCH/FOREARM/ADULT MISC 2 RX/OTC

CRUTCH/FOREARM/YOUTH MISC 2 RX/OTC

CRUTCH/STANDARDFOREARM/ADULT MISC 2 RX/OTC

CRUTCH/WOOD/ADULT/48"-60" MISC 2 RX/OTC

CRUTCH/WOOD/ADULT/ARMPADS/TIPS/GRIPSMISC

2 RX/OTC

CRUTCH/WOOD/YOUTH/34"-42" MISC 2 RX/OTC

CRUTCH/WOOD/YOUTH/ARMPADS/TIPS/GRIPSMISC

2 RX/OTC


129

Drug Name DrugTier

Requirements/Limits

CRUTCHES/ALUMINUM/ADULT MISC 2 RX/OTC

CRUTCHES/ALUMINUM/ADULT/TALL MISC 2 RX/OTC

CUBE PESSARY MISC 2 RX/OTC

CUBE PESSARY/DRAINSMISC 2 RX/OTC

CUFF ACCESSORIES DISPOSABLE BULB & VALVE MISC

2 RX/OTC

CUFF ACCESSORIES DISPOSABLE SINGE HEAD STETHOSCOPE MISC

2

RX/OTC

CURITY ALCOHOL PREPS/MEDIUM 2 PLYPADS

2 RX/OTC

CURITY ALCOHOL SWABS PADS 2 RX/OTC

CUSTOM-FLEX MISC 2 RX/OTC

CVS ALCOHOL PREP PADS PADS NP RX/OTC

CVS ALKALINE BATTERIES/SIZE AAMISC

2 RX/OTC

CVS CANE MISC 2 RX/OTC

CVS CRUTCHES UNIVERSAL MISC 2 RX/OTC

CVS EAR PLUGS MISC 2 RX/OTC

CVS FOLDING CANE GEL GRIP MISC 2 RX/OTC

CVS NEEDLE COLLECTION & DISPOSAL MISC

2 RX/OTC

CVS PILL SPLITTER MISC 2 RX/OTC

CVS PORTABLE DIABETIC ORGANIZER MISC

2 RX/OTC

CVS PREP PADS PADS 2 RX/OTC

CVS PREP PADS PADS NP RX/OTC

Drug Name DrugTier

Requirements/Limits

CVS PULSE OXIMETER MISC 2 RX/OTC

CVS PULSE OXIMETER/PORTABLEMISC

2 RX/OTC

CVS QUAD CANE MISC 2 RX/OTC

CVS READY SET GO DELUXE ALIMINUM BATH BENCH MISC

2 RX/OTC

CVS REUSABLE SHEET PROTECTOR MISC 2 RX/OTC

CVS RUBBER CUSHION/INFLATABLEMISC

2 RX/OTC

DDS 100 CERVICAL TRACTIONCOLLAR MISC 2 RX/OTC

DDS 300 LUMBAR TRACTION BELT/26"-28"MISC

2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


130

Drug Name DrugTier

Requirements/Limits

DDS 500 LUMBAR TRACTION BELT/PANELS/26"-28"MISC

2

RX/OTC


2

RX/OTC


2

RX/OTC


2

RX/OTC


2

RX/OTC


2

RX/OTC


2

RX/OTC


2

RX/OTC


2

RX/OTC


2

RX/OTC

DEEP-TISSUE MISC 2 RX/OTC

DELUXE SAFETY TABLET CUTTER MISC 2 RX/OTC

DELUXE TABLET CUTTER MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

DELUXE VINYL PADDED BATHTUB TRANSFER BENCH/FULL SEAT MISC

2 RX/OTC

DENTAL GUARD MISC 2 RX/OTC

DEODORANT PLASTIC TUBES2.65OZ/CAPSMISC

2 RX/OTC

DIAL-A-DOSE SYRINGE 15ML/TIPS MISC 2 RX/OTC



DIFFUSER ULTRA SONIC/LAVENDER OILMISC

2 RX/OTC

DIGITAL GLASS SCALE MISC 2 RX/OTC

DINAMAP MONITOR PROBE COVERS MISC 2 RX/OTC

DISH PESSARY MISC 2 RX/OTC

DISH PESSARY/SUPPORTMISC

2 RX/OTC

DISPENSER BOTTLES 50ML/FOAMER PUMPSMISC

2 RX/OTC

DISPENSER MD JAR 50ML/AIRLESS/VIEWWINDOW MISC

2 RX/OTC

DISPENSER MD PEN 6.5ML/AIRLESS/CLICKMISC

2 RX/OTC

DISPENSER MD PEN 6.5ML/AIRLESS/VIEWWINDOW MISC

2 RX/OTC

DISPENSER MD PUMP 0.5ML/ACTUATOR A MISC 2 RX/OTC

DISPENSER MD PUMP 0.5ML/ACTUATORA/BLUE MISC

2 RX/OTC

DISPENSER MD PUMP 0.5ML/ACTUATORA/GREEN MISC

2 RX/OTC


131

Drug Name DrugTier

Requirements/Limits

DISPENSER MD PUMP 0.5ML/ACTUATOR A/PINKMISC

2 RX/OTC

DISPENSER MD PUMP 1.0ML/ACTUATOR B MISC 2 RX/OTC

DISPENSER MD PUMP 1.0ML/ACTUATORB/BLUE MISC

2 RX/OTC

DISPENSER MD PUMP 1.0ML/ACTUATORB/GREEN MISC

2 RX/OTC

DISPENSER MD PUMP 1.0ML/ACTUATOR B/PINKMISC

2 RX/OTC

DISPENSER MD PUMP 1.5ML/ACTUATOR CMISC

2 RX/OTC

DISPENSER MD PUMP 1.5ML/ACTUATORC/BLUE MISC

2 RX/OTC

DISPENSER MD PUMP 1.5ML/ACTUATORC/GREEN MISC

2 RX/OTC

DISPENSER MD PUMP 1.5ML/ACTUATOR C/PINKMISC

2 RX/OTC

DISPENSER MD PUMP BOTTLE100ML/VIEWWINDOW/AIRLESS MISC

2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC

Drug Name DrugTier

Requirements/Limits


2 RX/OTC

DISPENSER MD SYRINGE 10ML/VIEWWINDOW/AIRLESS MISC

2 RX/OTC

DISPENSER MD SYRINGE 5ML/VIEWWINDOW/AIRLESS MISC

2 RX/OTC

DISPENSER MEGAPUMP/AIRLESS/OVAL/30ML/0.3ML/T-FILL/CAP MISC

2

RX/OTC

DISPENSER MEGAPUMP/AIRLESS/ROUND/100ML/1.5ML/B-FILLWITH CAP MISC

2

RX/OTC

DISPENSER MEGAPUMP/AIRLESS/ROUND/150ML/1.5ML/B-FILLWITH CAP MISC

2

RX/OTC

DISPENSER MEGAPUMP/AIRLESS/ROUND/150ML/1ML/B-FILLWITH CAP MISC

2

RX/OTC

DISPENSER MEGAPUMP/AIRLESS/ROUND/15ML/0.3ML/T-FILLWITH CAP MISC

2

RX/OTC

DISPENSER MEGAPUMP/MEZZOROUND/30ML/0.5ML/T-FILLWITH CAP MISC

2

RX/OTC


2

RX/OTC

DISPENSER MEGAPUMP/MEZZOROUND/50ML/0.5ML/T-FILL/CAP MISC

2

RX/OTC


2

RX/OTC

DISPENSER TIP CAP/PRECISEDOSE/SELF-RIGHTING MISC

2 RX/OTC


132

Drug Name DrugTier

Requirements/Limits

DISPENSER/MD FOAMERWITHACTUATOR 0.5ML/50ML MISC

2 RX/OTC

DISPENSER/MD FOAMERWITHACTUATOR 0.7ML/110ML MISC

2 RX/OTC

DIVERTER VALVE/BATHACCESSORY MISC 2 RX/OTC

DONUT PESSARY MISC 2 RX/OTC

DOVER COMMODE SPECIMEN COLLECTOR MISC

2 RX/OTC

DOVER MIDSTREAM SPECIMENCATCH KIT MISC

2 RX/OTC

DROPPER & SCREW CAP 4OZ MISC 2 RX/OTC

DROPPING BOTTLE 30ML MISC 2 RX/OTC

DROPTAINER TIP CAPS MISC 2 RX/OTC

DROPTAINERS 10ML MISC 2 RX/OTC

DROPTAINERS 15ML/OPHTHALMIC MISC 2 RX/OTC



DUAL HEAD STETHOSCOPE BLACK MISC

2 RX/OTC

DUAL HEAD STETHOSCOPE NAVY MISC

2 RX/OTC

DUAL PADDLE FOLDING WALKER/ADULT MISC 2 RX/OTC

DUAL-HEAD STETHOSCOPE MISC 2 RX/OTC

DUNLAP FOAM RING CUSHION/LARGE MISC 2 RX/OTC

DUNLAP FOAM RING CUSHION/MEDIUM MISC 2 RX/OTC

DUNLAP INFLATABLE VINYL RING CUSHION 16" MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

E-Z LOCK RAISED TOILET SEAT MISC 2 RX/OTC

E-Z LOCK RAISED TOILET SEAT/ARMSMISC

2 RX/OTC

EAR SYRINGE MISC 2 RX/OTC

EAR SYRINGE/INFANTMISC 2 RX/OTC

EAR WAX REMOVAL KIT/TRI-STREAM TIPMISC

2 RX/OTC

EARPLUGS MISC 2 RX/OTC

EARPOPPER MIDDLE EAR INFLATION DEVICE DEVI

2 RX/OTC

EASY COMFORT ALCOHOL PADS PADS NP RX/OTC

EASY FEED DOUBLE ELECTRIC BREAST FEEDING PUMP MISC

2 RX/OTC

EASY TOUCH ALCOHOL PREP PADS/MEDIUMPADS

2 RX/OTC

ECO-SMARTFUNNEL 186ML/DISPOSABLEMISC

2 RX/OTC

EGG CRATE BED PAD/2"CALKING SIZE MISC 2 RX/OTC

EGG CRATE BED PAD/2"DUALKING SIZE MISC 2 RX/OTC

EGG CRATE BED PAD/2"FULLSIZE MISC 2 RX/OTC

EGG CRATE BED PAD/2"QUEEN SIZE MISC 2 RX/OTC

EGG CRATE BED PAD/2"TWINSIZE MISC 2 RX/OTC

ELECTRODES 2"X2"/REUSABLE MISC 2 RX/OTC

ELECTROTHERAPY PAIN RELIEF MISC 2 RX/OTC

ELECTROTHERAPY PAIN RELIEF/LONG LIFEPADS/2.5" X 4" MISC

2 RX/OTC


133

Drug Name DrugTier

Requirements/Limits

ELON PROFESSIONAL NAIL CARE SYSTEM MISC

2 RX/OTC

ELONGATED TOILET SEAT ELEVATOR MISC 2 RX/OTC

EMPTY VIAL 3ML MISC 2 RX/OTC

ENDOSCOPIC DELIVERY SYSTEM MISC 2 RX/OTC

ENDURANCE FOUR LEG SEAT CANE MISC 2 RX/OTC

ENDURANCE HD HEAVY DUTY COMMODE MISC 2 RX/OTC

ENTERALITE INFINITY ENTERAL PUMP UNIVERSAL POLE CLAMP MISC

2

RX/OTC

EQ BATH & SHOWER SEAT/BACK MISC 2 RX/OTC

EQ FOLDING WALKER MISC 2 RX/OTC

EQL ALCOHOL SWABS PADS NP RX/OTC

EQL EAR PLUGS/SILICONE MISC 2 RX/OTC

EQL MUSTACHE/BEARDSCISSORS/COMB MISC 2 RX/OTC

EQL SKIN CARE TOOL MISC 2 RX/OTC

EVERYDAY PICK MISC 2 RX/OTC

EXTENDABLE BEDSIDE RAIL MISC 2 RX/OTC

EXTRA-WIDE COMMODE MISC 2 RX/OTC

EYE/EAR DROPPERMISC 2 RX/OTC

EZY DOSE CUT N CRUSH ULTRA FINE MISC 2 RX/OTC

EZY DOSE MEDICINE CUPS MISC 2 RX/OTC

EZY DOSE MEMORY PAC SYSTEM COLD SEAL CARD/31-DAY MISC

2 RX/OTC

EZY DOSE ORIGINAL TABLETCUTTER/DAILYDOSE MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

EZY DOSE TABLET CUTTER ORIGINAL MISC 2 RX/OTC

FASHION CANE/T-HANDLE/BLACK/250LBCAPACITY MISC

2 RX/OTC

FASHION CANE/T-HANDLE/FLORALPRINT/250LB CAPACITYMISC

2

RX/OTC

FASHION CANE/T-HANDLE/LEOPARDPRINT/250LB CAPACITYMISC

2

RX/OTC

FASHION CANE/T-HANDLE/MAPLEPRINT/250LB CAPACITYMISC

2

RX/OTC

FIFTY50 ALCOHOL PREP PADS PADS 2 RX/OTC

FILTER 0.2 MICRON/25MM MISC 2 RX/OTC

FILTER 0.2 MICRON/25MM/DOUBLELUER LOCK MISC

2 RX/OTC



FILTER 0.20 MICRON/1000ML MISC 2 RX/OTC

FILTER 0.22 MICRON/73MM/1000MLMISC

2 RX/OTC

FILTER ATTACHMENT MISC 2 RX/OTC

FILTER FLUORODYNE/0.22MICRON MISC

2 RX/OTC

FILTER, POSIDYNE ELD/0.2UM/LUER LOCKCONNECTORS/NYLONMEMBRA MISC

2

RX/OTC

FILTER/MILLEX-GP/50MM/CLEAR MISC 2 RX/OTC

FINGERTIP PULSE OXIMETER MISC 2 RX/OTC


134

Drug Name DrugTier

Requirements/Limits

FLA ADJUSTABLE AIR ANKLEWALKER/LOW/SMALL MISC

2 RX/OTC

FLAORTHO WALKER/LOW/BLACK/SMALL MISC

2 RX/OTC

FLENTS EAR STOPPLES MISC 2 RX/OTC

FLEX & GO FOLDING CANE MISC 2 RX/OTC

FLEX SHIELD WITH EAR LOOPS MISC 2 RX/OTC

FLEX SHIELD WITH TIE STRINGS MISC 2 RX/OTC

FLEX THERAPY MISC 2 RX/OTC

FLIGHT EAR PLUGS MISC 2 RX/OTC

FOAM CHAIR CUSHION MISC 2 RX/OTC

FOAM CRUTCH PAD MISC 2 RX/OTC

FOAM CUSHION MISC 2 RX/OTC

FOAM CUSHION THERAPEUTICRING MISC

2 RX/OTC

FOAM EAR PLUGS MISC 2 RX/OTC

FOAM INVALID CUSHION MISC 2 RX/OTC

FOAM RING 2" MISC 2 RX/OTC

FOIL WRAPPER 3" X 3" MISC 2 RX/OTC

FOLDING CANE MISC 2 RX/OTC

FOLDING COMMODE MISC 2 RX/OTC

FOLDING PADDLE WALKER/5"WHEELSMISC

2 RX/OTC

FOLDING REACHER MISC 2 RX/OTC

FOLDING SEAT CANE/3/4"TIP MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

FOLDING WALKER/5"WHEELS/ADULT MISC 2 RX/OTC

FOLDING WALKER/5"WHEELS/PINK MISC 2 RX/OTC

FOLDING WALKING CANE MISC 2 RX/OTC

FOOT MASSAGER/HEAT/AERATION MISC

2 RX/OTC

FORA GATEWAY MISC 2 RX/OTC

FORA GW9014 TELEHEALTH GATEWAY MISC

2 RX/OTC

FORA TN'G SCALE 550 MISC 2 RX/OTC

FREE SPIRIT KNEE AND LEGWALKER MISC 2 RX/OTC

FREESTYLE DOUBLE ELECTRICBREASTPUMP MISC

2 RX/OTC

GEHRUNG PESSARY/SUPPORTMISC

2 RX/OTC

GEL-FOAM CUSHION MISC 2 RX/OTC

GELLHORN PESSARY MISC 2 RX/OTC

GETGO ROLLING WALKER MISC 2 RX/OTC

GLASS BOTTLE 15ML MISC 2 RX/OTC


GLASS BOTTLE 30ML/BLACK PHENOLICBRUSH CAP MISC

2 RX/OTC

GLASS BOTTLE 30ML/BLACK PHENOLICPOLYSEAL CAP MISC

2 RX/OTC


GLASS BOTTLE/30ML/BLUNTEND APPLICATOR MISC

2 RX/OTC


135

Drug Name DrugTier

Requirements/Limits

GLASS SERUM BOTTLES/20ML/TYPE 1MISC

2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC

GLASS VIAL 2ML MISC 2 RX/OTC

GLASS VIAL AMBER 3ML/13MM/TYPE 1 MISC 2 RX/OTC

GLOBAL ALCOHOL PREP EASEPADS PADS NP RX/OTC

GNP ALCOHOL SWABS PADS 2 RX/OTC

GRADUATED BOTTLE 2OZ W/CAP MISC 2 RX/OTC

GRADUATED BOTTLE 4OZ W/CAP MISC 2 RX/OTC

GROOVE ROLLING WALKER MISC 2 RX/OTC

H-E-B INCONTROL ALCOHOL PADS PADS NP RX/OTC

HAND HELD SHOWER SPRAY MISC 2 RX/OTC

HARMONY BREASTPUMP MISC 2 RX/OTC

HEAD COVERS 24"/BOUFFONCAP/IRRADIATED MISC

2 RX/OTC

HEAD HALTER OVER DOOR TRACTION SET MISC

2 RX/OTC

HEAD HALTER REPLACEMENT FOR TRACTION KIT MISC

2 RX/OTC

HEAD LICE COMB MISC 2 RX/OTC

HEART RATE MONITOR MISC 2 RX/OTC

HEART RATE MONITOR STRAPLESS MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

HEAT THERAPY MISC 2 RX/OTC

HEELBOOT LARGE MISC 2 RX/OTC

HEELBOOT LAUNDRY BAG MISC 2 RX/OTC

HEELBOOT LINER LARGE MISC 2 RX/OTC

HEELBOOT LINER REGULAR MISC 2 RX/OTC

HEELBOOT REGULAR MISC 2 RX/OTC

HEELBOOT WALK PAD MISC 2 RX/OTC

HIBICLENS DISPENSER NOZZLE MISC 2 RX/OTC

HIBICLENS FOOT PEDAL MISC 2 RX/OTC

HIBICLENS HAND PUMP/16OZ MISC 2 RX/OTC

HIBICLENS HAND PUMP/32OZ MISC 2 RX/OTC

HIBICLENS HAND PUMP/GALLON MISC 2 RX/OTC

HIBICLENS HAND PUMP/NONFOAMING/16OZ MISC

2 RX/OTC

HIBICLENS PUMP ASSEMBLY MISC 2 RX/OTC

HIBICLENS WALL DISPENSER/FOOT MISC 2 RX/OTC

HIBICLENS WALL DISPENSER/HAND MISC 2 RX/OTC

HIP/FRACTURE RAISEDTOILET SEAT/LEFT MISC 2 RX/OTC

HIP/FRACTURE RAISEDTOILET SEAT/RIGHTMISC

2 RX/OTC

HM COMFORT FOAM EAR PLUGS MISC 2 RX/OTC

HM STERILE ALCOHOL PREP PADS PADS 2 RX/OTC

HODGE PESSARY MISC 2 RX/OTC

HODGE PESSARY/SUPPORTMISC

2 RX/OTC


136

Drug Name DrugTier

Requirements/Limits

HOME STYLE BED RAILS MISC 2 RX/OTC

HOT-COLD THERAPY MISC 2 RX/OTC

HURRICAINE DISPENSING CAP MISC 2 RX/OTC

HURRICAINE LIQUID DISPENSER MISC 2 RX/OTC

HURRICAINE SPRAY EXTENSION TUBES MISC 2 RX/OTC

HURRIPAK PERIODONTAL ANESTHETIC REFILL KIT MISC

2

RX/OTC

HURRIPAK PERIODONTAL IRRIGATION TIPS MISC

2 RX/OTC

HURRYCANE FREEDOM EDITIONCANE/BLACKMISC

2 RX/OTC

ICY DIAMOND TOTE CANVAS MISC 2 RX/OTC

ICY DIAMOND TOTE NON GENUINE LEATHER MISC 2 RX/OTC

ICY HOT SMART RELIEF TENS THERAPY REFILL PADS MISC

2 RX/OTC

ILLUSIONS AA WEIGHTED OFFTHE SHELF BREAST PROSTHESIS FORM MISC

2

RX/OTC

ILLUSIONS C WEIGHTED OFFTHE SHELF BREAST PROSTHESIS FORM MISC

2

RX/OTC

INDICATOR/BIOLOGICALTEST KIT/SPORVIEWSTEAM KIT

2 RX/OTC

INFLATABLE CUSHION/VINYL MISC 2 RX/OTC

INFLATABLE NECK REST MISC 2 RX/OTC

INHALATION VIAL CAP/BLUE MISC 2 RX/OTC

INHALATION VIAL CAP/GREEN MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

INHALATION VIAL CAP/ORANGE MISC 2 RX/OTC

INHALATION VIAL CAP/RED MISC 2 RX/OTC

INHALATION VIAL CAP/WHITE MISC 2 RX/OTC

INHALATION VIAL CAP/YELLOW MISC 2 RX/OTC

INHALATION VIAL W/CAP/BLUE/3.5MLSTOCKWELL MISC

2 RX/OTC

INHALATION VIAL W/CAP/GREEN/3.5MLSTOCKWELL MISC

2 RX/OTC

INHALATION VIAL W/CAP/ORANGE/3.5MLSTOCKWELL MISC

2 RX/OTC

INHALATION VIAL W/CAP/RED/3.5MLSTOCKWELL MISC

2 RX/OTC

INHALATION VIAL W/CAP/WHITE/3.5MLSTOCKWELL MISC

2 RX/OTC

INHALATION VIAL W/CAP/YELLOW/3.5MLSTOCKWELL MISC

2 RX/OTC

INHALATION VIAL W/OCAP/AMBER/3.5MLSTOCKWELL MISC

2 RX/OTC

IR ADAPTER MISC 2 RX/OTC

J & J TOURNIQUET 36"X3/4" MISC 2 RX/OTC

JAR/8OZ/WHITE LID MISC 2 RX/OTC

JOHNSON & JOHNSON ANTISEPTIC WIPES MISC 2 RX/OTC

JOHNSON & JOHNSON INSTANTCOLD PACK MISC

2 RX/OTC

JOURNEY SERIES ROLLING WALKER/4205BL-R/BLUEMISC

2

RX/OTC


137

Drug Name DrugTier

Requirements/Limits

JOURNEY SERIES ROLLING WALKER/4205RD/REDMISC

2

RX/OTC

JUG AMBER GLASS 4L/POLYSEAL CAP/LONGMISC

2 RX/OTC

KANESON BREAST PUMP/NURSER MISC 2 RX/OTC

KANGAROO RIGID CONTAINERPUMP SET 1200ML MISC

2 RX/OTC

KEGEL BALL TRAINER MISC 2 RX/OTC

L.O.S. YANKAUER HOLDER MISC 2 RX/OTC

LAB COAT/DISPOSABLEMISC 2 RX/OTC

LAB COAT/DISPOSABLE/LARGE MISC

2 RX/OTC

LAB COAT/DISPOSABLE/MEDIUM MISC

2 RX/OTC

LAB COAT/DISPOSABLE/SMALL MISC

2 RX/OTC

LAB COAT/DISPOSABLE/X-LARGE MISC

2 RX/OTC

LAB COAT/DISPOSABLE/XX-LARGE MISC

2 RX/OTC

LADYCARE MENOPAUSE MISC 2 RX/OTC

LANSINOH BREASTFEEDING PILLOW MISC

2 RX/OTC

LANSINOH BREASTMILK COLLECTOR MISC 2 RX/OTC

LANSINOH EXTRA PUMPING SET MISC 2 RX/OTC

LANSINOH MANUAL BREAST PUMP MISC 2 RX/OTC

LANSINOH PUMP ADAPTERS MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

LANSINOH SMART PUMP TOTEBAGS MISC 2 RX/OTC

LANSINOH SMARTPUMP 2.0 MISC 2 RX/OTC

LANSINOH SMARTPUMP DOUBLEELECTRIC BREAST PUMP MISC

2 RX/OTC

LANSINOH SMARTPUMP DOUBLEELECTRIC MISC 2 RX/OTC

LATCH ASSIST NIPPLE EVERTER MISC 2 RX/OTC

LMA MAD NASAL MISC 2 RX/OTC

LUER LOCK ADAPTER MISC 2 RX/OTC

LULLABY DOUBLE ELECTRIC BREAST PUMP MISC

2 RX/OTC

LUMBAR CUSHION MISC 2 RX/OTC

LUMBAR SUPPORT CUSHION MISC 2 RX/OTC

MAD NASAL MISC 2 RX/OTC

MAGNIFIER HANDS-FREE MISC 2 RX/OTC

MAR-LAND PESSARY MISC 2 RX/OTC

MAR-LAND PESSARY/SUPPORTMISC

2 RX/OTC

MASSAGER MULTI-PURPOSE/RECHARGEABLE MISC

2 RX/OTC

MASSAGER/2 SPEEDMISC 2 RX/OTC

MASSAGER/FIVE INONE/HEAT MISC 2 RX/OTC

MASSAGER/SWEDISH/1SPEED MISC 2 RX/OTC

MATTRESS COVER/DELUXE MISC 2 RX/OTC

MATTRESS COVER/ECONOMY MISC 2 RX/OTC

MATTRESS PAD/35"X74"/EGGCRATE2" MISC

2 RX/OTC


138

Drug Name DrugTier

Requirements/Limits


2 RX/OTC


2 RX/OTC

MAZERUSTAR KK-250S/KK-300SSMIXER/DISPOSABLEMIXING CONTAINE MISC

2

RX/OTC

MAZERUSTAR KK-250S/KK-300SSMIXER/STANDARDMIXING CONTAINER MISC

2

RX/OTC

MEDELA ADVANCED PERSONALDOUBLE BREAST PUMP MISC

2 RX/OTC

MEDELA LACTINA DOUBLE PUMPING KIT MISC

2 RX/OTC

MEDELA PUMP IN STYLE ADVANCED STARTER SET MISC

2 RX/OTC

MEDI-COOLER MISC 2 RX/OTC

MEDI-FRIDGE IIX MISC 2 RX/OTC

MEDI-RDT BLISTER PACKS/LABELS &SLEEVE MISC

2 RX/OTC

MEDICINE DROPPER MISC 2 RX/OTC

MEDICINE DROPPER/CALIBRATEDMISC

2 RX/OTC

MEDICINE SPOON MISC 2 RX/OTC

MEGAPUMP MISC 2 RX/OTC

MEIJER ALCOHOL SWABS EXTRA-THICK PADS

2 RX/OTC

METAL REACHER/27"MISC 2 RX/OTC

METAL REACHER/32"MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

METERED NASAL SPRAY PUMP MISC 2 RX/OTC

METERED NASAL SPRAY PUMP15ML/SAFETY CLIPMISC

2 RX/OTC

MICROCLENS WALL MOUNT BRACKET MISC 2 RX/OTC

MINI DIFFUSER/COOLMIST/ESSENTIAL OILMISC

2 RX/OTC

MINI MALLET 3/4"PLASTIC/NON-MARRINGMISC

2 RX/OTC

MINI TRANSFER PIN MISC 2 RX/OTC

MIXER/MAZERUSTAR KK-300SS/STANDARD/MIXING CONTAINER FOR EMP MISC

2

RX/OTC

MIXER/MAZERUSTAR KK-400W/STANDARD/MIXINGCONTAINER MISC

2 RX/OTC

MIXER/MAZERUSTAR/EMP/JARMIXINGADAPTER/100ML MISC

2 RX/OTC

MIXER/MAZERUSTAR/EMP/JARMIXING/ADAPTERSET/15ML-50ML/100MLMISC

2

RX/OTC

MIXER/MAZRUSTAR/MDPUMP MIXING ADAPTER MISC

2 RX/OTC

MIXING/MAZERUSTAR/EMP/JAR MIXINGADAPTER/15ML-50MLMISC

2

RX/OTC

MN8 MISC 2 RX/OTC

MOIST-SURE REPLACEMENT COVER/LARGE/14" X 27"MISC

2

RX/OTC

MOIST-SURE REPLACEMENT COVER/MEDIUM/14" X 14"MISC

2

RX/OTC


139

Drug Name DrugTier

Requirements/Limits

MOIST-SURE REPLACEMENT COVER/PETITE/4" X 17"MISC

2

RX/OTC

MOISTUREPLUS COVER/LARGE/14" X 27"MISC

2 RX/OTC

MOISTUREPLUS COVER/MEDIUM/14" X14" MISC

2 RX/OTC

MOISTUREPLUS COVER/PETITE/4" X 17"MISC

2 RX/OTC

MONOJECT BLOOD COLLECTION TUBE/BLUESTOPPER/4.5ML MISC

2 RX/OTC

MONOJECT BLOOD COLLECTION TUBE/GRAYSTOPPER/10ML MISC

2

RX/OTC

MONOJECT BLOOD COLLECTION TUBE/GRAYSTOPPER/5ML MISC

2

RX/OTC

MONOJECT BLOOD COLLECTION TUBE/GREENSTOPPER/2ML MISC

2

RX/OTC

MONOJECT BLOOD COLLECTION TUBE/GREENSTOPPER/3ML MISC

2

RX/OTC

MONOJECT BLOOD COLLECTION TUBE/LAVENDERSTOPPER/10ML MISC

2

RX/OTC


2

RX/OTC


2

RX/OTC


2

RX/OTC

Drug Name DrugTier

Requirements/Limits


2

RX/OTC


2

RX/OTC

MONOJECT BLOOD COLLECTION TUBE/REDSTOPPER/10ML MISC

2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC

MONOJECT BLOOD COLLECTION TUBE/ROYAL BLUESTOPPER/7ML MISC

2

RX/OTC

MONOJECT BLOOD COLLECTION/INFUSIONSET/FEMALELUER/19GX3/4" MISC

2

RX/OTC


2

RX/OTC


2

RX/OTC


140

Drug Name DrugTier

Requirements/Limits


2

RX/OTC

MONOJECT BLOOD COLLECTION/INFUSIONSET/MULTI-SAMPLE/19GX3/4" MISC

2

RX/OTC


2

RX/OTC


2

RX/OTC


2

RX/OTC

MONOJECT BLOOD TUBE HOLDER MISC 2 RX/OTC

MONOJECT LUER ADAPTER MISC 2 RX/OTC

MONOJECT MULTI-SAMPLE COLLECTION SET/HOLDER/SAFETYCAP/MALE MISC

2

RX/OTC

MONOJECT MULTI-SAMPLE COLLECTION SET/TUBEHOLDER/MALE MISC

2

RX/OTC

MUCOSAL ATOMIZATION NASALDEVICE MISC 2 RX/OTC

MY MDI FINGER PULSE OXIMETER MISC 2 RX/OTC

NAIL POLISH BOTTLE/BRUSH15MLMISC

2 RX/OTC

NASADOCK MISC 2 RX/OTC

NASAL SPRAY BOTTLE 20ML MISC 2 RX/OTC

NASAL SPRAY PUMP 30ML/METERED/0.1MLDOSAGE MISC

2 RX/OTC

NATURAL WOOD CANE MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

NATURAL WOOD WALKING STICK MISC 2 RX/OTC

NATURESPIRIT PULSE OXIMETER MISC 2 RX/OTC

NEXCARE COMFORT FOAM EAR PLUGS MISC 2 RX/OTC

NEXCARE REUSABLE EAR PLUGS MISC 2 RX/OTC

NEXDOSE PRESCRIPTION MEDICATION DIGITAL ASSISTANT MISC

2

RX/OTC

NG SECURE NASOGASTRIC TUBE HOLDER MISC

2 RX/OTC

NOVA BATH SEAT/BACK& ARMS MISC 2 RX/OTC

NOVA CUSHION GEL/FOAM SEATPAD/18X16X3 MISC

2 RX/OTC

NOVA QUAD TIP/FOURPRONGS 3/4" SHAFTCANE MISC

2 RX/OTC

NVZZLER PRO DOUBLE ELECTRIC BREAST PUMP MISC

2 RX/OTC

NVZZLER SINGLE ELECTRIC BREAST PUMP MISC

2 RX/OTC

O-RING CUSHION 16" DIAMETER MISC 2 RX/OTC

OFFSET CANE/BLACK/300LBCAPACITY MISC

2 RX/OTC

OFFSET CANE/BLUEICE/300LB CAPACITYMISC

2 RX/OTC

OFFSET CANE/BRONZE/300LBCAPACITY MISC

2 RX/OTC

OFFSET CANE/BROQUETEAL/300LB CAPACITYMISC

2 RX/OTC

OFFSET CANE/CHROME/300LBCAPACITY MISC

2 RX/OTC


141

Drug Name DrugTier

Requirements/Limits

OFFSET CANE/GREENICE/300LB CAPACITYMISC

2 RX/OTC

OFFSET CANE/HOUNDSTOOTH/300LB CAPACITY MISC

2 RX/OTC

OFFSET CANE/METALLICBLACK/300LB CAPACITYMISC

2 RX/OTC

OFFSET CANE/MOBILITY/250LBCAPACITY MISC

2 RX/OTC

OFFSET CANE/ROSEPRINT/300LB CAPACITYMISC

2 RX/OTC

OFFSET CANE/STRAPMISC 2 RX/OTC

OINTMENT JAR 2OZ MISC 2 RX/OTC

OINTMENT TUBE OPHTHALMICTIP 1/8OZ/METAL MISC

2 RX/OTC

OINTMENT TUBE/METAL/1OZ MISC 2 RX/OTC



OINTMENT TUBE/PLASTICW/SCREW CAP/8OZ MISC

2 RX/OTC

OINTMENT TUBE/PLASTIC/1OZ MISC 2 RX/OTC




ONE OUNCE MEDICINE CUPS MISC 2 RX/OTC

ONE STEP AT A TIME FILTERS MISC 2 RX/OTC

ONE-DAY-AT-A-TIME PLANNER/BLISTERCARD/MEDIUM MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

ORAL DOSE SYRINGE MISC 2 RX/OTC

ORAL ENDOTRACHEAL TUBE ATTACHMENT DEVICE MISC

2 RX/OTC

ORAL MEDICINE DROPPER MISC 2 RX/OTC

ORAL SYRINGE/BRUSHMISC 2 RX/OTC

ORIGINAL MCKENZIE CERVICAL ROLL MISC 2 RX/OTC

OVAL PESSARY/SUPPORTMISC

2 RX/OTC

PADDLE WALKER/FOLDING/5"WHEELS/ADJUSTABLE MISC

2 RX/OTC

PCCA ACCUPEN-15 MISC 2 RX/OTC

PEDAL EXERCISER MISC 2 RX/OTC

PELVIC MUSCLE TRAINER MISC 2 RX/OTC

PERSONAL BLOOD PRESSURE SMART CARD MISC

2 RX/OTC

PH ACCESSORIES STORAGE SOLUTION 230ML MISC

2 RX/OTC

PHARMACIST CHOICE ALCOHOL PRED PADS PADS

NP RX/OTC

PHARMACIST CHOICE ALCOHOLPREP PADS PADS

NP RX/OTC

PILL BOX 7 DAY MISC 2 RX/OTC

PILL CRUSHER MISC 2 RX/OTC

PILL CRUSHER/BUILT INSTORAGE MISC 2 RX/OTC

PILL POUCH MISC 2 RX/OTC

PILL SPLITTER MISC 2 RX/OTC

PILLGUARD DISPENSER MISC 2 RX/OTC


142

Drug Name DrugTier

Requirements/Limits

PILLGUARD REFILL CARTRIDGE MISC 2 RX/OTC

PLASTIC BED PAN MISC 2 RX/OTC

PLASTIC BOTTLES/30ML/TWISTTOP SIFTER CAPS MISC

2 RX/OTC

PLASTIC BOTTLES/90ML/TWISTTOP SIFTER CAPS MISC

2 RX/OTC

PLASTIC ENEMA BOTTLE/2OZ/20/410OPENING MISC

2 RX/OTC

PLASTIC JAR 6OZ MISC 2 RX/OTC

PLASTIC SCOOP 1ML/4"HANDLE MISC 2 RX/OTC

PLATFORM WALKER ATTACHMENT MISC 2 RX/OTC

PLATINUM REACHER 31" MISC 2 RX/OTC

POCKET MAGNIFIER MISC 2 RX/OTC

POCKET PRO+ REPLACEMENT SENSOR/TESTER MISC

2 RX/OTC

POLYPROPYLENE CAP/LINER MISC 2 RX/OTC

POSTURE SEAT MISC 2 RX/OTC

POWDER INSUFFLATOR MISC 2 RX/OTC

PRECISION CATHETER URINESPECIMEN SYSTEM KIT KIT

2 RX/OTC

PRECISION MIDSTREAM PRESERVATIVE KIT KIT 2 RX/OTC

PRECISION SCALE COMPACT MISC 2 RX/OTC

PRECISION SPECIMEN CONTAINER/5OZ MISC 2 RX/OTC

PRECISION SPECIMEN CONTAINER/POSITIVESEAL INDICATOR MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

PRECISION SPECIMEN CONTAINER/POSITIVESEAL INDICATOR/118MLMISC

2

RX/OTC

PRECISION SPUTUM COLLECTOR KIT WITH TUBE MISC

2 RX/OTC

PRECISION SPUTUM COLLECTOR KIT/TUBEMISC

2 RX/OTC

PRECISION STOOL COLLECTOR MISC 2 RX/OTC

PRECISION TISSUE GRINDER MISC 2 RX/OTC

PRECISION TISSUE GRINDER/15ML MISC 2 RX/OTC

PRECISION TISSUE GRINDER/50ML MISC 2 RX/OTC

PRECISION URINE SPECIMENSYSTEM WITH PRESERVATIVE KIT

2 RX/OTC

PRECISION URINE SPECIMENSYSTEM WITH PRESERVATIVE MISC

2 RX/OTC

PREMIUM PILL CRUSHER MISC 2 RX/OTC

PRESCRIPTION BOTTLE MAGNIFIER MISC 2 RX/OTC

PRO COMFORT ALCOHOL PADS PADS 2 RX/OTC

PRO COMFORT FOOT BATH MISC 2 RX/OTC

PROFIT PRECISION SCALE MISC 2 RX/OTC

PULSE OXIMETER DELUXE MISC 2 RX/OTC

PULSE OXIMETER FOR FINGER MISC 2 RX/OTC

PULSE OXIMETER MISC 2 RX/OTC

PUMP IN STYLE ADVANCED DOUBLE BREASTPUMP MISC

2 RX/OTC

PUMP IN STYLE ADVANCED DOUBLE BREASTPUMP/BACKPACK MISC

2

RX/OTC


143

Drug Name DrugTier

Requirements/Limits

PURE COMFORT ALCOHOL PREPPADS PADS

NP RX/OTC

QC ALCOHOL SWABS PADS 2 RX/OTC

QUAD CANE TIPS 1/2"MISC 2 RX/OTC

QUAD CANE TIPS 5/8"MISC 2 RX/OTC

QUAD CANE TIPS/BLACK/5/8" MISC 2 RX/OTC

QUAD CANE TIPS/GREY/5/8" MISC 2 RX/OTC

QUAD CANE/BRONZEHANDLE/SMALL BASEMISC

2 RX/OTC

QUAD CANE/LARGEBASE/BRONZEALUMINUM MISC

2 RX/OTC

QUAD CANE/LARGEBASE/CUSHIONEDHANDLE/5/8" MISC

2 RX/OTC

QUAD CANE/LARGEBASE/ORTHOHANDLE/5/8" MISC

2 RX/OTC

QUAD CANE/LARGEBASE/SELECTAGRIPHANDLE/5/8" MISC

2 RX/OTC

QUAD CANE/LARGEBASE/SHOVEL HANDLEMISC

2 RX/OTC

QUAD CANE/LARGE LOWBASE MISC 2 RX/OTC

QUAD CANE/LARGE LOWBASE/DEVON HANDLEMISC

2 RX/OTC

QUAD CANE/ORTHOGRIP MISC 2 RX/OTC

QUAD CANE/SMALLBASE MISC 2 RX/OTC

QUAD CANE/SMALLBASE. MISC 2 RX/OTC

QUAD CANE/SMALLBASE/BRONZEALUMINUM MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

QUAD CANE/SMALLBASE/BRONZE/CUSHIONED HANDLE/1/2" MISC

2 RX/OTC

QUAD CANE/SMALLBASE/CUSHIONEDHANDLE/1/2" MISC

2 RX/OTC

QUAD CANE/SMALLBASE/OFFSET HANDLEMISC

2 RX/OTC

QUAD CANE/SMALLBASE/ORTHOHANDLE/1/2" MISC

2 RX/OTC

QUAD CANE/SMALLBASE/SHOVEL HANDLEMISC

2 RX/OTC

QUAD CANE/SMALL LOWBASE/DEVON HANDLEMISC

2 RX/OTC

QUAD CANE/SMALL LOWBASE/ORTHO GRIP MISC 2 RX/OTC

QUICK-FIT CRUTCHES MISC 2 RX/OTC

QUIET PLEASE FOAM EAR PLUGS MISC 2 RX/OTC

RA ALCOHOL SWABS PADS 2 RX/OTC

RA BANDAGE SCISSORS MISC 2 RX/OTC

RA COMFORT-FOAM EAR PLUGS MISC 2 RX/OTC

RA DELUXE CUT N CRUSH MISC 2 RX/OTC

RA EXTRA COMFORT NIGHT PROTECTOR ORAL CARE MISC

2 RX/OTC

RA FOAM EAR PLUGS MISC 2 RX/OTC

RA FOLDING SYRINGE MISC 2 RX/OTC

RA GLASS DROPPERS MISC 2 RX/OTC

RA MEDICINE DROPPER/SPOON MISC 2 RX/OTC

RA QUIET PLEASE FOAM EARPLUGS MISC 2 RX/OTC

RA RENEWAL HAIR STYLING SHEARS MISC 2 RX/OTC


144

Drug Name DrugTier

Requirements/Limits

RA REST ASSURED NITE PROTECTOR MISC 2 RX/OTC

RA SITZ BATH MISC 2 RX/OTC

RA TABLET CUTTER MISC 2 RX/OTC

RAISED TOILET SEAT MISC 2 RX/OTC

RAISED TOILET SEAT/LOCK &ARMS MISC 2 RX/OTC

RAISED TOILET SEAT/LOCK MISC 2 RX/OTC

REALITY SWABS PADS 2 RX/OTC

RECONSTITUBE MISC 2 RX/OTC

REFLECTIONS AA LIGHTWEIGHT OFF SHELF BREAST PROSTHESIS FORM MISC

2

RX/OTC

REFLECTIONS C LIGHTWEIGHTOFF SHELF BREAST PROSTHESIS FORM MISC

2

RX/OTC

RELION ALCOHOL SWABS PADS 2 RX/OTC

RELION PULSE OXIMETER MISC 2 RX/OTC

REMOVABLE BACK ALUMINUM COMMODE/PADDEDARMRESTS MISC

2

RX/OTC

REPLACEMENT NECKBAND STRAPS FOR TUBE ATTACHMENT DEVICE MISC

2

RX/OTC

RIDVANTAGE LICE COMB MISC 2 RX/OTC

RING CUSHION 14" MISC 2 RX/OTC



RING PESSARY MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

RING PESSARY/SUPPORTMISC

2 RX/OTC

RINOFLOW MICRONIZER CHAMBER TUBING MISC 2 RX/OTC

RINOFLOW NASAL SYSTEM MISC 2 RX/OTC

ROLLATOR ULTRA-LIGHT MISC 2 RX/OTC

ROLLER WALKER MISC 2 RX/OTC

ROLLING WALKER/BURGUNDYMISC

2 RX/OTC

ROUND SHOWER STOOL MISC 2 RX/OTC

RUBBER BATH MAT MISC 2 RX/OTC

RUBBER INFLATABLE CUSHION MISC 2 RX/OTC

RX LOCKING CAP MISC 2 RX/OTC

RX TIMER CAP 13/16DRAM TOPS PHARMACY MISC

2 RX/OTC

RX TIMER CAP 30/40/60DRAM TOPS PHARMACY MISC

2 RX/OTC

SAFE-SENSE BEARD NET MISC 2 RX/OTC

SAFE-SENSE HEAD COVER/BOUFFANT CAP21" MISC

2 RX/OTC

SAFE-SENSE HEAD COVER/BOUFFANTCAP/CIRCULAR/ 21" MISC

2 RX/OTC

SAFE-SENSE SHOE COVER/NON-SKID MISC 2 RX/OTC

SAFETY-LOK COLLECTION SET23GX3/4"/12" TUBINGMISC

2

RX/OTC

SAFETY-SHIELD TABLET CUTTER MISC 2 RX/OTC

SAPS CARE ALCOHOL PREP PADS PADS NP RX/OTC


145

Drug Name DrugTier

Requirements/Limits

SAPS HEALTH ALCOHOL PREPPADS PADS NP RX/OTC

SAPS HEALTH CARE ALCOHOLPREP PADS PADS

NP RX/OTC

SB ALCOHOL PREP PADS PADS 2 RX/OTC

SCD SOFT SLEEVES/KNEE LENGTH21" MISC

2 RX/OTC

SCD SOFT SLEEVES/THIGH LENGTHMEDIUM MISC

2 RX/OTC

SEAL-RITE SILICONE EAR PLUGS MISC 2 RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/ADULTFOOT/ANKLE MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/ADULTHAND MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/ADULTLONG ARM MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/ADULTLONG LEG MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/ADULTSHORT ARM MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/ADULTSHORT LEG MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/ADULTWIDE SHORT ARM MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/ADULTWIDE SHORT LEG MISC

2

RX/OTC

Drug Name DrugTier

Requirements/Limits

SEAL-TIGHT CAST/BANDAGEPROTECTOR/PED LARGEARM MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/PED LARGELEG MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/PEDMEDIUM ARM MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/PEDMEDIUM LEG MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/PED SMALLARM MISC

2

RX/OTC

SEAL-TIGHT CAST/BANDAGEPROTECTOR/PED SMALLLEG MISC

2

RX/OTC

SEAL-TIGHT MID-ARM PROTECTOR MISC 2 RX/OTC

SEALS/ALUMINUM/FLIPOFF/13MM/BLANK TOPMISC

2 RX/OTC

SEATING CANE/8-1/2"SEATDIAMETER MISC 2 RX/OTC

SERUM BOTTLE STOPPER 20MM MISC 2 RX/OTC

SERUM BOTTLE/100MLMISC 2 RX/OTC

SERUM BOTTLE/250MLMISC 2 RX/OTC

SERUM BOTTLES/AMBERGLASS/20ML/20MM MISC 2 RX/OTC

SERUM BOTTLES/AMBERGLASS/30ML/20MM MISC 2 RX/OTC

SETTLING PLATE SDA/29ML/100X15MMMISC

2 RX/OTC

SETTLING PLATE TSA/25ML/100X15MMMISC

2 RX/OTC


146

Drug Name DrugTier

Requirements/Limits

SHAATZ PESSARY MISC 2 RX/OTC

SHAPERS ADJUSTABLE LAYERED BREAST SHAPER/AFRICANAMERICAN MISC

2

RX/OTC

SHAPERS ADJUSTABLE LAYERED BREAST SHAPER/CAUCASIANMISC

2

RX/OTC

SHOPKO ALCOHOL SWABS PADS 2 RX/OTC

SHOWER-PAK MISC 2 RX/OTC

SIGNATURE PRO DOUBLE ELECTRIC BREAST PUMP MISC

2 RX/OTC

SIGNATURE PRO HEALTHCAREDOUBLE ELECTRIC BREAST PUMP MISC

2

RX/OTC

SILICONE EAR PLUGS FOR KIDS MISC 2 RX/OTC

SILICONE EAR PLUGS KID SIZE MISC 2 RX/OTC

SILICONE EAR PLUGS MISC 2 RX/OTC

SILICONE EARPLUGS CHILDRENS MISC 2 RX/OTC

SIMPLE WISHES PUMPING BRALARGE-PLUS HANDS-FREE/ADJUSTABLE MISC

2

RX/OTC

SIMPLE WISHES PUMPING BRAXS-L HANDS-FREE/ADJUSTABLE MISC

2

RX/OTC

SIMPLYGO BREAST PUMP/DUAL MISC 2 RX/OTC

SIMPLYGO BREAST PUMP/SINGLE MISC 2 RX/OTC

SINGLE HEAD STETHOSCOPE MISC 2 RX/OTC

SITZ BATH MISC 2 RX/OTC

SLEEPRIGHT DENTAL GUARD DURA-COMFORT MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

SLEEPRIGHT DENTAL GUARD MISC 2 RX/OTC

SLEEPRIGHT DENTAL GUARD SLIM-COMFORT MISC

2 RX/OTC

SLEEPRIGHT INTRA-NASAL BREATHE AID MISC

2 RX/OTC

SLEEPRIGHT INTRA-NASAL VAPOR INHALER MISC

2 RX/OTC

SLEEPRIGHT SPORT INTRA-NASAL BREATHE AID MISC

2 RX/OTC

SM ALCOHOL PREP PADS PADS 2 RX/OTC

SM FOAM EAR PLUGS MISC 2 RX/OTC

SM WALKER/YOUTH/FOLDING/DUAL WHEELS MISC

2 RX/OTC

SNAP-ON CHLOROBUTYL STOPPER/13MM/GREYMISC

2

RX/OTC

SOFT HANDS COTTON GLOVE/EXTRA LARGEMISC

2 RX/OTC

SOFT HANDS COTTON GLOVE/LARGE MISC 2 RX/OTC

SOFT HANDS COTTON GLOVE/SMALL-MEDIUMMISC

2 RX/OTC

SOOTHIES COOLING GEL PADS MISC 2 RX/OTC

SOOTHIES GEL PADS/REUSABLE MISC 2 RX/OTC

SPENCO SILICORE BED PAD MISC 2 RX/OTC

SPENCO SILICORE CHAIR PAD MISC 2 RX/OTC

SPENCO SILICORE FOOT PILLOWS/ONE SIZE MISC 2 RX/OTC

SPENCO SILICORE FOOT POSITIONER MISC 2 RX/OTC

SPENCO SILICORE WHEELCHAIR PAD MISC 2 RX/OTC


147

Drug Name DrugTier

Requirements/Limits

SPLASH SHIELD/FULLFACE MISC 2 RX/OTC

SPLASH SHIELD/SHORTFACE MISC 2 RX/OTC

SPLIT HANDGRIPS MISC 2 RX/OTC

SPRAGUE RAPPAPORT STETHOSCOPE/BLACKMISC

2 RX/OTC

SPRAGUE RAPPAPORT STETHOSCOPE/NAVYMISC

2 RX/OTC

SPRAGUE RAPPAPORT STETHOSCOPE/PURPLEMISC

2 RX/OTC

SPRAY APPLICATOR KIT MISC 2 RX/OTC

SPRAY BOTTLE 120ML/PLASTIC MISC 2 RX/OTC

STANDARD CRUTCH TIP MISC 2 RX/OTC

STEEL COMMODE/BEDSIDE/FOLDING/SPLASH GUARDMISC

2

RX/OTC

STEEL ROLLING WALKER MISC 2 RX/OTC

STEP COUNTER MISC 2 RX/OTC

STEP N' REST II WALKER MISC 2 RX/OTC

STEP N' REST MISC 2 RX/OTC

STEP N' REST WALKER MISC 2 RX/OTC

STEP N' REST WALKER/5" SWIVELWHEELS/GLIDE WHEELSMISC

2

RX/OTC

STETHOSCOPE DUAL HEAD MISC 2 RX/OTC

STETHOSCOPE MISC 2 RX/OTC

STETHOSCOPE SINGLE HEAD MISC 2 RX/OTC

STETHOSCOPE-LIGHTWEIGHT MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

STETHOSCOPE-SINGLE HEAD MISC 2 RX/OTC

STETHOSCOPE/NURSESBLUE MISC 2 RX/OTC

STETHOSCOPE/SPRAGUE RAPPAPORT STYLE MISC

2 RX/OTC

STIRRING ROD/GLASS12X1/4" MISC 2 RX/OTC

STOCKING APPLICATOR/PETITEMISC

2 RX/OTC

STOCKING APPLICATOR/REGULARMISC

2 RX/OTC

STOP LICE EGG & NIT REMOVAL SYSTEM MISC 2 RX/OTC

STRAINER/STAINLESSSTEELWITH PLASTIC HANDLE/2-1/2" MISC

2 RX/OTC

SUCTION GRAB BAR MISC 2 RX/OTC

SUCTION TIPS FOR TRANSFERBENCHES MISC

2 RX/OTC

SUNBEAM KING COVER MISC 2 RX/OTC

SUNBEAM STANDARD COVER MISC 2 RX/OTC

SUPPOSISTRIP MOLD 1.4GM MISC 2 RX/OTC

SUPPOSISTRIP MOLD 1.9GM MISC 2 RX/OTC

SUPPOSITORY MOLD 2GM MISC 2 RX/OTC

SUPPOSITORY MOLD 60 CAVITY MISC 2 RX/OTC

SUPPOSITORY MOLD/ALUMINUM2GM/100 CAVITY MISC

2 RX/OTC

SUPPOSITORY MOLDS 1.3ML/PEEL-AWAY MISC 2 RX/OTC

SUPPOSITORY MOLDS 2.25ML/PEEL-AWAY MISC 2 RX/OTC

SUPPOSITORY MOLDS 2CC/V-NOTCH MISC 2 RX/OTC


148

Drug Name DrugTier

Requirements/Limits

SUPPOSITORY MOLDS 2GM MISC 2 RX/OTC

SUPPOSITORY MOLDS 2ML/PEEL-AWAY MISC 2 RX/OTC

SUPPOSITORY MOLDS 3ML/PEEL-AWAY MISC 2 RX/OTC

SUPPOSITORY SHELL 2.0ML MISC 2 RX/OTC

SUPPOSITORY SHELL MEDIUM2.25GM MISC 2 RX/OTC

SUPPOSITORY SHELL RACK MISC 2 RX/OTC

SUPPOSITORY SHELL SMALL 1.46GM MISC 2 RX/OTC

SUPPOSITORY SHELLS 2.4ML MISC 2 RX/OTC

SURE COMFORT ALCOHOL PREP PADS PADS

NP RX/OTC

SURE-PREP ALCOHOL PREP PADS PADS NP RX/OTC

SURELIFE CLEARWAVE II PULSE OXIMETER MISC 2 RX/OTC

SURELIFE CLEARWAVE PULSEOXIMETER MISC 2 RX/OTC

SWIM EARPLUGS MISC 2 RX/OTC

SYMPHONY DOUBLE PUMPING SYSTEM MISC 2 RX/OTC

SYRINGE ACCESSORIES/LEURTIPCAP TRAY MISC

2 RX/OTC

SYRINGE DIAL-A-DOSE MISC 2 RX/OTC

SYRINGE TIP-RECTAL/VAGINAL LUERAPPLICATOR MISC

2 RX/OTC

TABLET CRUSHER/CONTAINERMISC

2 RX/OTC

TABLET CUTTER MISC 2 RX/OTC

TABLET CUTTER/CRUSHER MISC 2 RX/OTC

TABLET CUTTER/DELUXESAFETY MISC

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

TABLET CUTTER/SAFETYSHIELD MISC 2 RX/OTC

TABLET CUTTER/SAFETY-SHIELDMISC

2 RX/OTC

TAKEAWAY ENVIRONMENTAL RETURN SYSTEM ENVELOPE MISC

2

RX/OTC

TAKEAWAY ENVIRONMENTAL RETURN SYSTEM MISC

2 RX/OTC

TEXTURE WALL GRAB BAR/12" MISC 2 RX/OTC





TGT ALCOHOL SWABS PADS 2 RX/OTC

THE DOCTORS NIGHTGUARD ADVANCED COMFORT MISC

2

RX/OTC

THE SIDE RESTER CUSHION IMPERMEABLE COVER MISC

2 RX/OTC

THE SIDE RESTER CUSHION REGULAR COVER MISC

2 RX/OTC

THERA-BAND EXERCISE BANDS MISC 2 RX/OTC

TIP CAPS MISC 2 RX/OTC

TIP RECTAL/VAGINALW/PERFORATIONS MISC 2 RX/OTC

TOILET SAFETY FRAME MISC 2 RX/OTC

TOILET SEAT ELEVATOR MISC 2 RX/OTC

TONGUE CLEANER/COMFORTCURVE MISC

2 RX/OTC


149

Drug Name DrugTier

Requirements/Limits

TONGUE DEPRESSORS MISC 2 RX/OTC

TOOTHETTE BITE BLOCK MISC 2 RX/OTC

TOPI-CLICK 140/BLACKMISC 2 RX/OTC

TOPI-CLICK 140/BLUEMISC 2 RX/OTC

TOPI-CLICK 140/GOLDMISC 2 RX/OTC

TOPI-CLICK 140/GREENMISC 2 RX/OTC

TOPI-CLICK 140/PINKMISC 2 RX/OTC

TOPI-CLICK 140/PURPLEMISC 2 RX/OTC

TOPI-CLICK 140/REDMISC 2 RX/OTC

TOPI-CLICK 140/SILVERMISC 2 RX/OTC

TOPI-CLICK 140/WHITEMISC 2 RX/OTC

TOPI-CLICK 35 DOSE CHECK MISC 2 RX/OTC

TOPI-CLICK 35 USP671 UV BLOCKING/ORANGEBODY/CAP/BASE MISC

2 RX/OTC

TOPI-CLICK 35 USP671 UV BLOCKING/ORANGEBODY/WHITE CAP/BASEMISC

2

RX/OTC

TOPI-CLICK 35 VAGINAL APPLICATOR DOSE LOADER MISC

2 RX/OTC

TOPI-CLICK 35 VAGINAL DOSE APPLICATOR MISC 2 RX/OTC

TOPI-CLICK 35 VAGINAL DOSING SYSTEM/APPLICATORMISC

2

RX/OTC

TOPI-CLICK APPLICATOR/140MLMISC

2 RX/OTC

TOPI-CLICK APPLICATOR/35ML MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

TOPI-CLICK APPLICATOR/MICRO/PINPOINT/9ML/0.05ML/BLUEMISC

2

RX/OTC

TOPI-CLICK APPLICATOR/MICRO/ROUNDED/9ML/0.05ML/BLUEMISC

2

RX/OTC

TOPI-CLICK APPLICATOR/MICRO/SOFT ANGLED/9ML/0.05ML/BLUE MISC

2

RX/OTC

TOPI-CLICK MICRO/PINPOINT APPLICATOR/BLUE MISC

2 RX/OTC

TOPI-CLICK MICRO/ROUNDEDAPPLICATOR/BLUE MISC

2 RX/OTC

TOPI-CLICK MICRO/SOFTANGLED APPLICATOR/BLUE MISC

2 RX/OTC

TOPI-CLICK NOZZLE MISC 2 RX/OTC

TOPI-CLICK PERL VAGINAL APPLICATOR DOSE LOADER/35MLMISC

2

RX/OTC

TOPI-CLICK PERL VAGINAL DOSE APPLICATOR/4ML MISC

2 RX/OTC

TOPI-CLICK PERL VAGINAL DOSING SYSTEM/VAGINALAPPLICATOR 35 MISC

2

RX/OTC

TOPI-CLICK/35ML/1PORT/BLACK MISC 2 RX/OTC

TOPI-CLICK/35ML/1PORT/BLUE MISC 2 RX/OTC

TOPI-CLICK/35ML/1PORT/GOLD MISC 2 RX/OTC

TOPI-CLICK/35ML/1PORT/GREEN MISC 2 RX/OTC

TOPI-CLICK/35ML/1PORT/ORANGE MISC 2 RX/OTC

TOPI-CLICK/35ML/1PORT/PINK MISC 2 RX/OTC


150

Drug Name DrugTier

Requirements/Limits

TOPI-CLICK/35ML/1PORT/PURPLE MISC 2 RX/OTC

TOPI-CLICK/35ML/1PORT/RED MISC 2 RX/OTC

TOPI-CLICK/35ML/1PORT/SILVER MISC 2 RX/OTC

TOPI-CLICK/35ML/1PORT/WHITE MISC 2 RX/OTC

TOPI-CLICK/35ML/3PORT/BLACK MISC 2 RX/OTC

TOPI-CLICK/35ML/3PORT/BLUE MISC 2 RX/OTC

TOPI-CLICK/35ML/3PORT/GOLD MISC 2 RX/OTC

TOPI-CLICK/35ML/3PORT/GREEN MISC 2 RX/OTC

TOPI-CLICK/35ML/3PORT/PINK MISC 2 RX/OTC

TOPI-CLICK/35ML/3PORT/PURPLE MISC 2 RX/OTC

TOPI-CLICK/35ML/3PORT/RED MISC 2 RX/OTC

TOPI-CLICK/35ML/3PORT/SILVER MISC 2 RX/OTC

TOPI-CLICK/35ML/3PORT/WHITE MISC 2 RX/OTC

TOTAL COMFORT WHEELCHAIRBACK CUSHION MISC

2 RX/OTC

TOTAL COMFORT WHEELCHAIRSEAT CUSHION MISC

2 RX/OTC

TRACTION FLOOR STAND/ECONOMYMODEL MISC

2 RX/OTC

TRACTION HEAD HALTER ROPE10' MISC 2 RX/OTC

TRACTION PELVIC BELT MISC 2 RX/OTC

TRACTION WEIGHT BAG/20LB MISC 2 RX/OTC

TRAINER FOR EPINEPHRINE MISC 2 RX/OTC

TRANSFER BENCH MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

TRANSFER BENCH W/BACK MISC 2 RX/OTC

TRANSFER BOARD/28"X8-1/4" MISC 2 RX/OTC

TRANSFER PIN MISC 2 RX/OTC

TRANSPORT CHAIR ULTRA LIGHT MISC 2 RX/OTC

TRAVEL BOTTLES MISC 2 RX/OTC

TRAVEL POUCH MISC 2 RX/OTC

TRAVELER 3 WHEEL ROLLINGWALKER MISC 2 RX/OTC

TRI-GRIP BATHTUB RAIL MISC 2 RX/OTC

TRIGGER RELEASE JUNIOR WALKER/WHEELS MISC

2 RX/OTC

TRIO ROLLING WALKER MISC 2 RX/OTC

TROCHE MOLD 30 CAVITY MISC 2 RX/OTC

TRU FIT MAGNETIX ANKLE/2SMALL DISKSMISC

2 RX/OTC

TRU FIT MAGNETIX BACK MISC 2 RX/OTC

TRU FIT MAGNETIX ELBOW/2SMALL DISKSMISC

2 RX/OTC

TRU FIT MAGNETIX OPEN KNEE/2 LARGEDISKS MISC

2 RX/OTC

TRU FIT MAGNETIX SELF-ADHESIVE MAGNETS MISC

2 RX/OTC

TRU FIT MAGNETIX WRIST/2SMALL DISKSMISC

2 RX/OTC

TRUE COMFORT ALCOHOL PREP PADS PADS

NP RX/OTC

TUB TRANSFER BOARD MISC 2 RX/OTC

TWIN MEDICINE SPOON MISC 2 RX/OTC


151

Drug Name DrugTier

Requirements/Limits

TYVEK PROTECTIVE SLEEVES/DISPOSABLEMISC

2 RX/OTC

ULTICARE ALCOHOL SWABS PADS NP RX/OTC

ULTRA PILL CRUSHER MISC 2 RX/OTC

ULTRA-CARE ALCOHOL PREP PADS PADS NP RX/OTC

UNGUATOR 100/200/57MM/DISPOSABLE BLADES MISC

2 RX/OTC

UNGUATOR 15/20/30/36MM/DISPOSABLE BLADES MISC

2 RX/OTC

UNGUATOR 50/43MM/DISPOSABLEBLADES MISC

2 RX/OTC

UNGUATOR ACCESSORIES EXACTDOSE 0.5ML MISC

2 RX/OTC

UNGUATOR APPLICATOR 1"/SHORT/CAP MISC

2 RX/OTC

UNGUATOR APPLICATOR 2.5"/LONGMISC

2 RX/OTC

UNGUATOR JAR 100/140BLUELID MISC 2 RX/OTC

UNGUATOR JAR 100/140REDLID MISC 2 RX/OTC

UNGUATOR JAR 15/20BLUE LID MISC 2 RX/OTC

UNGUATOR JAR 15/20GREENLID MISC 2 RX/OTC

UNGUATOR JAR 15/20RED LID MISC 2 RX/OTC


UNGUATOR JAR 20/33BLUE MISC 2 RX/OTC


UNGUATOR JAR 20/33WHITE/BLUE LID MISC 2 RX/OTC

UNGUATOR JAR 200/280BLUELID MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

UNGUATOR JAR 200/280GREEN LID MISC 2 RX/OTC

UNGUATOR JAR 200/280REDLID MISC 2 RX/OTC

UNGUATOR JAR 200/280WHITE MISC 2 RX/OTC


UNGUATOR JAR 30/42BLUE/BLUE LID MISC 2 RX/OTC



UNGUATOR JAR 30/42TURQUOISE/TURQUOISELID MISC

2 RX/OTC

UNGUATOR JAR 30/42WHITELID MISC 2 RX/OTC

UNGUATOR JAR 30/42YELLOW MISC 2 RX/OTC


UNGUATOR JAR 50/70BLUE/BLUE LID MISC 2 RX/OTC


UNGUATOR JAR 50/70PINK/PINK LID MISC 2 RX/OTC


UNGUATOR JAR 50/70TURQUOISE MISC 2 RX/OTC

UNGUATOR JAR 50/70WHITELID MISC 2 RX/OTC

UNGUATOR JAR 50/70YELLOW MISC 2 RX/OTC

UNGUATOR JAR FOR AIRDYNAMIK 1000/1250MISC

2 RX/OTC

UNGUATOR JAR FOR AIRDYNAMIK 300/390MISC

2 RX/OTC

UNGUATOR JAR FOR AIRDYNAMIK 500/600WHITE MISC

2 RX/OTC


152

Drug Name DrugTier

Requirements/Limits

UNGUATOR JAR W/SPINDLE 300/390 MISC 2 RX/OTC

UNGUATOR JAR W/SPINDLE 500/600 MISC 2 RX/OTC

UNGUATOR LID 1000ML MISC 2 RX/OTC

UNGUATOR LID 500ML MISC 2 RX/OTC

UNGUATOR VARIONOZZLE 1MM MISC

2 RX/OTC

UNGUATOR VARIONOZZLE 4MM MISC

2 RX/OTC

UNIVERSAL QUICK ADJUST CRUTCH MISC 2 RX/OTC

UNIVERSAL SLEEVE COVERS MISC 2 RX/OTC

UNIVERSAL TIPS/1" MISC 2 RX/OTC

UNIVERSAL WALKER ORGANIZER MISC 2 RX/OTC

VAGINAL CREAM APPLICATOR MISC 2 RX/OTC

VAGINAL SUPPOSITORY APPLICATOR MISC 2 RX/OTC

VANISHPOINT BLOOD COLLECTION SET 21G X 3/4" X 12" MISC

2 RX/OTC


2 RX/OTC


2 RX/OTC

VANISHPOINT BLOOD COLLECTION TUBE HOLDER MISC

2 RX/OTC

VARITHENA ADMINISTRATIONPACK MISC

2 RX/OTC

VERSAJET EXACT HYDROSURGERY SYSTEM HANDPIECE 14MM MISC

2

RX/OTC

Drug Name DrugTier

Requirements/Limits

VERSAJET EXACT HYDROSURGERY SYSTEM HANDPIECE 8MM MISC

2

RX/OTC

VERSAJET II EXACT HYDROSURGERY SYSTEM HANDPIECE 14MM MISC

2

RX/OTC

VERSAJET II EXACT HYDROSURGERY SYSTEM HANDPIECE 8MM MISC

2

RX/OTC

VERSAJET II PLUS HYDROSURGERY SYSTEM HANDPIECE 14MM MISC

2

RX/OTC

VERSAJET II PLUS HYDROSURGERY SYSTEM HANDPIECE 8MM MISC

2

RX/OTC

VERSAJET PLUS HYDROSURGERY SYSTEM HANDPIECE 14MM MISC

2

RX/OTC

VERSAJET PLUS HYDROSURGERY SYSTEM HANDPIECE 8MM MISC

2

RX/OTC

VIAL ACCESSORIES/INHALATION WORK STATION/50HOLES MISC

2

RX/OTC

VIAL/2ML/SCREW TOPMISC 2 RX/OTC

VIBE 6 MISC 2 RX/OTC

VIBRATING FOOT BATH/HEAT MISC 2 RX/OTC

VINYL INFLATABLE CUSHION MISC 2 RX/OTC

VINYL PADDED BATHTUB TRANSFER BENCH/COMMODESEAT/PAIL MISC

2

RX/OTC

VIRAGE CUSTOM BREAST PROSTHESIS EXTRA WEIGHTED THICKNESS MISC

2

RX/OTC


153

Drug Name DrugTier

Requirements/Limits

VIRAGE CUSTOM BREAST PROSTHESIS LIGHTWEIGHT THICKNESS MISC

2

RX/OTC

VIRAGE CUSTOM BREAST PROSTHESIS LIGHTWEIGHT THICKNESS/MAGNETMISC

2

RX/OTC

VIRAGE CUSTOM BREAST PROSTHESIS WEIGHTED THICKNESS MISC

2

RX/OTC

VIRAGE CUSTOM BREAST PROSTHESIS WEIGHTED THICKNESS/MAGNETSMISC

2

RX/OTC

WALKER AUTO GLIDES/5ADJUSTMENT HOLES/1-1/8" MISC

2 RX/OTC

WALKER AUTO GLIDES/8ADJUSTMENT HOLES/1-1/8" MISC

2 RX/OTC

WALKER BASKET MISC 2 RX/OTC

WALKER GLIDE WHEELS/5 ADJUSTMENTHOLES/1-1/8" MISC

2 RX/OTC

WALKER GLIDE WHEELS/8 ADJUSTMENTHOLES/1-1/8" MISC

2 RX/OTC

WALKER SKI GLIDES/1"MISC 2 RX/OTC

WALKER SKI GLIDES/1-1/8" MISC 2 RX/OTC

WALKER SWIVEL WHEELS/5 ADJUSTMENTHOLES/3" MISC

2 RX/OTC

WALKER SWIVEL WHEELS/5 ADJUSTMENTHOLES/5" MISC

2 RX/OTC

WALKER TALL EXTENSION LEGS MISC 2 RX/OTC

WALKER TIPS/1-1/8"MISC 2 RX/OTC

WALKER TIPS/BLACK/1-1/8" MISC 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

WALKER WHEELS/FIXEDWITH5 ADJUSTMENT HOLES/3" MISC

2 RX/OTC


2 RX/OTC


2 RX/OTC


2 RX/OTC

WALKER/ADULT/FOLDING MISC 2 RX/OTC

WALKER/EXTENDEDFRAME MISC 2 RX/OTC

WALKER/FOLDING HEMIMISC 2 RX/OTC

WALKER/TWO-BUTTONFOLDING/32"-39"/NOWHEELS MISC

2 RX/OTC

WALKER/TWO-BUTTONFOLDING/TITANIUM MISC 2 RX/OTC

WALKER/YOUTH/FOLDING MISC 2 RX/OTC

WASH GLOVES PRE-MOISTENED MISC 2 RX/OTC

WATERPROOF SHEETING/36" X54" MISC 2 RX/OTC

WATERPROOF SHEETING/36" X66" MISC 2 RX/OTC

WEBCOL ALCOHOL PREP LARGE 1 PLY PADS

2 RX/OTC

WEBCOL ALCOHOL PREP LARGE 2 PLY PADS

2 RX/OTC

WEBCOL ALCOHOL PREP MEDIUM 2 PLY PADS

2 RX/OTC

WEIGH BOAT/PLASTIC/ANTI-STATIC MISC

2 RX/OTC

WET-STOP 3 MISC 2 RX/OTC

WHEEL CHAIR K1 BASIC DESKARM MISC 2 RX/OTC


154

Drug Name DrugTier

Requirements/Limits

WHEELCHAIR CUSHION MISC 2 RX/OTC

WHEELCHAIR INVALID RING MISC 2 RX/OTC

WHEELCHAIR MISC 2 RX/OTC

WHITE WALL GRAB BAR/12" MISC 2 RX/OTC




WOODEN CANE/ROUNDHANDLE/7/8" MISC 2 RX/OTC

WOODEN CANE/WALNUTFINISH/PISTOLGRIP/DERBYHANDLE/7/8" MISC

2

RX/OTC

WOODEN CANE/WALNUTFINISH/ROUNDHANDLE/7/8" MISC

2 RX/OTC

WORK BELT MISC 2 RX/OTC

WRIST BRACE MISC 2 RX/OTC

WRIST SLEEP SUPPORT MISC 2 RX/OTC

YOUTH PUSH BUTTON ALUMINUM CRUTCH MISC

2 RX/OTC

ZEWA ELECTRODES MISC 2 RX/OTC

ZIPPERED MATTRESS COVER MISC 2 RX/OTC

ZOOM 20 ROLLING WALKER MISC 2 RX/OTC

Parenteral Therapy Supplies 1ST TIER UNIFINE PENTIPS31GX8MM MISC 2 QL(5 ea daily);

RX/OTC 1ST TIER UNIFINE PENTIPSPLUS 31GX8MM MISC

2 QL(5 ea daily);RX/OTC

ABOUTTIME PEN NEEDLES 31G X 5/16"MISC

NP RX/OTC

Drug Name DrugTier

Requirements/Limits

ADVOCATE INSULIN PEN NEEDLES 31GX8MM MISC


AURORA PEN NEEDLES 31G X8MM MISC 2 QL(5 ea daily);

RX/OTC BD PEN NEEDLE/SHORT/ULTRA-FINE/31G X 8MM MISC


CAREFINE PEN NEEDLES 31GX8MM MISC


CAREONE UNIFINE PENTIPS 31GX8MM MISC 2 QL(5 ea daily);

RX/OTC CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX8MM MISC

2

QL(5 ea daily);RX/OTC

CARETOUCH PEN NEEDLES 31GX 8MM MISC


CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES 31GX8MM MISC

2


CLEVER CHOICE COMFORT EZPEN NEEDLES 31GX8MM MISC

2


CLICKFINE PEN NEEDLE UNIVERSAL/31GX5/16"MISC


CLICKFINE PEN NEEDLES 31G X 5/16"MISC


CLICKFINE PEN NEEDLES 31G X 8MM MISC

NP RX/OTC

CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16"MISC


COMFORT EZ SHORT/31G X 8MM MISC NP RX/OTC

DROPLET PEN NEEDLES 31GX8MM MISC 2 QL(5 ea daily);

RX/OTC DROPLET PEN NEEDLES 31GX8MM MISC NP RX/OTC


155

Drug Name DrugTier

Requirements/Limits

DROPSAFE SAFETY PEN NEEDLES/31G X 5/16"MISC

NP RX/OTC

DRUG MART UNIFINE PENTIPS31GX8MM MISC 2 QL(5 ea daily);

RX/OTC EASY COMFORT PEN NEEDLES31GX5/16"MISC


EASY TOUCH PEN NEEDLES 31GX5/16"MISC


EXEL COMFORT POINT INSULIN PEN NEEDLES 31G X 8MM MISC


FIFTY50 PEN NEEDLES 31G X5/16" (8MM) MISC 2 QL(5 ea daily);

RX/OTC FIFTY50 PEN NEEDLES/31GX8MMMISC


FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX8MM MISC


GLOBAL EASE INJECT PEN NEEDLES 31GX8MM MISC


GNP CLICKFINE PEN NEEDLEUNIVERSAL/31GX5/16" MISC


GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16"MISC

2


GOODSENSE PEN NEEDLE/PENFINECLASSIC/31G X 5/16"MISC

NP

RX/OTC

H-E-B IN CONTROL PEN NEEDLES 31GX8MM MISC


HEALTHWISE SHORT PEN NEEDLES 31GX8MM MISC


HEALTHWISE SHORT PEN NEEDLES/31G X5/16" MISC

NP RX/OTC

Drug Name DrugTier

Requirements/Limits

HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 31GX8MM MISC

2


HM ULTICARE SHORT PEN NEEDLES 31GX8MM MISC

NP RX/OTC

INSULIN SYRINGES 2 QL (5 ea daily);RX/OTC

INSUPEN 31G X 8MM MISC 2 QL(5 ea daily);

RX/OTC INSUPEN ULTRAFIN 31GX8MM MISC 2 QL(5 ea daily);

RX/OTC KROGER PEN NEEDLES 31G X8MM MISC 2 QL(5 ea daily);

RX/OTC KROGER PEN NEEDLES/31G X5/16"MISC

NP RX/OTC

LEADER UNIFINE PENTIPS PLUS/SHORT/31GX5/16"MISC

2


LITETOUCH PEN NEEDLES 31GX8MM SHORT MISC


LITETOUCH PEN NEEDLES/31G X8MM/SHORT MISC

NP RX/OTC

MARATHON MEDICAL PENTIPS31GX8MM MISC 2 QL(5 ea daily);

RX/OTC MEDICINE SHOPPE PEN NEEDLES 31G X 8MM MISC


MEIJER PEN NEEDLES 31G X8MM MISC 2 QL(5 ea daily);

RX/OTC MM PEN NEEDLES 31G X 5/16" MISC NP RX/OTC

PC UNIFINE PENTIPS 31G X8MM SHORT MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES 31G X 8MM MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES 31GX5/16"MISC NP RX/OTC

PEN NEEDLES 31GX5/16"MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES 31GX8MM (5/16") MISC 2 QL(5 ea daily);

RX/OTC


156

Drug Name DrugTier

Requirements/Limits

PEN NEEDLES 31GX8MM MISC 2 QL(5 ea daily);

RX/OTC

PEN NEEDLES-MISC 2 QL (5 ea daily);RX/OTC

PEN NEEDLES/31G X5/16" MISC NP RX/OTC

PENTIPS 31G X 8MM MISC 2 QL(5 ea daily);

RX/OTC

PENTIPS 31GX8MM MISC 2 QL(5 ea daily);RX/OTC

PREFERRED PLUS UNIFINE PENTIPS 31G X 8MM SHORT MISC


PREVENT SAFETY PEN NEEDLES 31GX5/16"MISC

NP RX/OTC

PRO COMFORT PEN NEEDLES/31G X 8MMMISC


PX PEN NEEDLE 31GX8MM MISC 2 QL(5 ea daily);

RX/OTC PX SHORTLENGTH PEN NEEDLES/31GX8MMMISC


QC PEN NEEDLES 31G X 8MM MISC 2 QL(5 ea daily);

RX/OTC RA PEN NEEDLES 31G X 8MM5/16" MISC 2 QL(5 ea daily);

RX/OTC RELION PEN NEEDLES 31GX8MM MISC 2 QL(5 ea daily);

RX/OTC RELION PEN NEEDLES 31GX8MM MISC NP RX/OTC

RELION SHORT PEN NEEDLES31GX8MM MISC 2 QL(5 ea daily);

RX/OTC SHOPKO UNIFINE PENTIPS PEN NEEDLES/SHORT/31GX8MM MISC

2


SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/SHORT/REMOVR/31GX8MM MISC

2


SURE COMFORT PEN NEEDLES31GX5/16"(8MM) MISC


Drug Name DrugTier

Requirements/Limits

SURE-FINE PEN NEEDLES 31GX5/16" 8MMMISC


TECHLITE PEN NEEDLES/31GX 8MMMISC


TODAYS HEALTH SHORT PEN NEEDLES 31G X 5/16" MISC


TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX5/16" MISC


TRUEPLUS 5-BEVEL PEN NEEDLES 31GX8MM MISC

NP RX/OTC

TRUEPLUS PEN NEEDLES 31GX8MM MISC


ULTICARE MICRO PEN NEEDLES 31G X 8MM MISC


ULTICARE MICRO PEN NEEDLES/31G X 5/16"MISC

NP RX/OTC

ULTICARE SHORT PEN NEEDLES 31GX8MM MISC


ULTICARE SHORT PEN NEEDLES ULTI-FINE IV MISC


ULTICARE SHORT PEN NEEDLES/31G X 8MMMISC

NP RX/OTC

ULTICARE SHORT PEN NEEDLES/31G X 8MMMISC


ULTIGUARD SAFEPACK/SHORTPENNEEDLE/31G X5/16"/SHARPS CONTAMISC

NP

RX/OTC

ULTILET SHORT PEN NEEDLES 31GX5/16"MISC


ULTRA-THIN II PEN NEEDLES/SHORT/31GX5/16" MISC



157

Drug Name DrugTier

Requirements/Limits

ULTRACARE PEN NEEDLES/31G X 5/16"MISC

NP RX/OTC

UNIFINE PENTIPS 31GX8MM MISC 2 QL(5 ea daily);

RX/OTC UNIFINE PENTIPS PLUS 31GX8MM MISC 2 QL(5 ea daily);

RX/OTC VALUMARK PEN NEEDLES 31GX 8MM MISC


VIDA MIA UNIPFINE PENTIPSSHORT 31GX8MM MISC


WEGMANS UNIFINE PENTIPS PLUS/SHORT/31GX8MMMISC

2


Respiratory Therapy Supplies

ACE AEROSOL CLOUD ENHANCER MISC 2

QL(1 ml per360 daysretail); RX/OTC

ACTIVITY POUCH MISC 2 QL(1 ml per360 daysretail); RX/OTC

ADULT AEROSOL MASK MISC 2


ADULT MASK LARGE MISC 2


ADULT MASK MISC 2 QL(1 ml per360 daysretail); RX/OTC

AEROCHAMBER MINI AEROSOLCHAMBER DEVI

2 QL(2 ea per360 daysretail); RX/OTC

AEROCHAMBER MV MISC 2

QL(2 ea per360 daysretail); RX/OTC

AEROCHAMBER PLUS FLOW VU MISC 2


AEROCHAMBER PLUS FLOW-VU MISC 2


Drug Name DrugTier

Requirements/Limits

AEROCHAMBER PLUS FLOW-VU/LARGE MASKMISC


AEROCHAMBER PLUS FLOW-VU/MASK MISC 2


AEROCHAMBER PLUS FLOW-VU/MEDIUM MASKMISC


AEROCHAMBER PLUS FLOW-VU/SMALL MASKMISC


AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VUMISC

2


AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL MISC 2


AEROCHAMBER Z-STAT PLUS/LARGE MASK MISC 2


AEROCHAMBER Z-STAT PLUS/MEDIUM MASKMISC


AEROCHAMBER Z-STAT PLUS/SMALL MASK MISC 2


AEROCHAMBER/FLOWSIGNAL MISC 2


AEROTRACH PLUS MISC 2 QL(1 ml per360 daysretail); RX/OTC

AEROVENT PLUS HOLDING CHAMBER/COLLAPSIBLEDEVI

2


AIRS PEDIATRIC AEROSOL MASK MISC 2


ALL FLOW 1000 PULMONARY FUNCTION FILTER MISC

2 QL(1 ml per360 daysretail); RX/OTC

ARIAL CHAMBER DEVI 2 QL(2 ea per360 daysretail); RX/OTC


158

Drug Name DrugTier

Requirements/Limits

BREATHE EASE NEBULIZER MASK/CHILDMISC


BREATHE EASE NEBULIZER MASK/INFANT MISC


BREATHE EASE/LARGEMASK DEVI 2


BREATHE EASE/MEDIUMMASK DEVI 2


BREATHE EASE/SMALLMASK DEVI 2


BREATHERITE COLLAPSIBLEADULT SPACER W/MASK MISC


BREATHERITE COLLAPSIBLECHILD SPACER W/MASK MISC


BREATHERITE COLLAPSIBLEINFANT SPACER W/MASK MISC


BREATHERITE COLLAPSIBLESMALL CHILD SPACER W/MASKMISC

2


BREATHERITE COLLAPSIBLESPACER W/ NEONATE MASK MISC


BREATHERITE MISC 2 QL(2 ea per360 daysretail); RX/OTC

BREATHERITE RIGID SPACERW/MASK MISC 2


BREATHERITE W/LARGEMASK MISC 2


BREATHERITE W/MEDIUM MASK MISC 2


BREATHERITE W/SMALLMASK MISC 2


Drug Name DrugTier

Requirements/Limits

BUBBLES THE FISH II PEDIATRIC MASK/PVCMISC


CARETOUCH 2 CPAP HOSE HANGER MISC 2


CARETOUCH CPAP & BIPAP HOSE/6FT MISC 2


CARETOUCH CPAP MASK WIPES MISC 2


CARETOUCH CPAP NEUTRALIZING PRE-WASH MISC


CARETOUCH CPAP TUBE CLEANING BRUSH MISC 2


CARETOUCH UNIVERSAL CPAPFILTERS MISC 2


CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/ADULT LARGEDEVI

2


CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM DEVI

2


CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM/3YEA DEVI

2


CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/SMALL DEVI

2


CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/SMALLINFANT DEVI

2


CO MONITOR REPLACEMENT TPIECES MISC



159

Drug Name DrugTier

Requirements/Limits

COMPACT SPACE CHAMBER/ANTI-STATICDEVI


COMPACT SPACE CHAMBER/ANTI-STATIC/LARGE MASKDEVI

2


COMPACT SPACE CHAMBER/ANTI-STATIC/MEDIUM MASKDEVI

2


COMPACT SPACE CHAMBER/ANTI-STATIC/SMALL MASKDEVI

2


EASIVENT MISC 2 QL(2 ea per360 daysretail); RX/OTC

EASIVENT/MASK-LARGEMISC 2


EASIVENT/MASK-MEDIUM MISC 2


EASIVENT/MASK-SMALLMISC 2


EBASE CONTROLLER KIT MISC 2


EFLOW SCF AEROSOL HEAD MISC 2


ELITE DC AUTO ADAPTER MISC 2


FILTER AIR PP MISC 2 QL(1 ml per360 daysretail); RX/OTC

FLEXICHAMBER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

FLYP HYPERSONIQ CARTRIDGE MISC 2


FULL KIT NEBULIZER SET MISC 2


Drug Name DrugTier

Requirements/Limits

HUDSON RCI SEE-THRU AEROSOL MASK ELONGATED/ADULTMISC

2


INNOSPIRE REPLACEMENT FILTER MISC


INSPIRACHAMBER/ANTI-STATIC VALVED/MOUTHPIECEDEVI

2


INSPIRACHAMBER/LARGE DEVI 2


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM DEVI


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL DEVI


INSPIREASE DRUG DELIVERYSYSTEM MISC 2


INSPIREASE RESERVOIR BAGS MISC 2 QL(3 ea per

180 days retail)

LITEAIRE DEVI 2 QL(2 ea per360 daysretail); RX/OTC

LITETOUCH MASK LARGE MISC 2


LITETOUCH MASK MEDIUM MISC 2


LITETOUCH MASK SMALL MISC 2


MICROCHAMBER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

MICROCHAMBER MISC 2 QL(2 ea per360 daysretail); RX/OTC

MICROELITE FILTER REPLACEMENTS MISC 2



160

Drug Name DrugTier

Requirements/Limits

MICROELITE RECHARGEABLE BATTERY MISC


MICROSPACER MISC 2 QL(2 ea per360 daysretail); RX/OTC

MINIELITE FILTER REPLACEMENTS MISC 2


MINIELITE RECHARGEABLE BATTERY MISC


NEBULIZER AIR TUBE/PLUGS MISC 2


NEBULIZER PEDIATRIC MASK MISC 2


NOSE CLIP MISC 2 QL(1 ml per360 daysretail); RX/OTC

OPTICHAMBER ADVANTAGE/LARGEMASK MISC


OPTICHAMBER ADVANTAGE/MEDIUMFACE MASK MISC


OPTICHAMBER ADVANTAGE/SMALLFACE MASK MISC


OPTICHAMBER DIAMOND MISC 2


OPTICHAMBER DIAMOND/LARGEFACEMASK DEVI


OPTICHAMBER DIAMOND/MEDIUM FACEMASK MISC


OPTICHAMBER DIAMOND/SMALLFACEMASK MISC


OPTICHAMBER FACE MASK/LARGE MISC 2


OPTICHAMBER FACE MASK/MEDIUM MISC 2


Drug Name DrugTier

Requirements/Limits

OPTICHAMBER FACE MASK/SMALL MISC 2


OPTIHALER MDI DRUG DELIVERY SYSTEM DEVI 2


OPTIHALER MISC 2 QL(2 ea per360 daysretail); RX/OTC

PARI ALTERA NEBULIZER HANDSET MISC


PARI BABY CONVERSION KITSIZE 1 MISC 2






PARI ERAPID NEBULIZER HANDSET MISC 2


PARI EXPIRATORY FILTER VALVE SET DEVI 2


PARI MASK SET MISC 2 QL(1 ml per360 daysretail); RX/OTC

PARI SOFT PLASTIC ADULT MASK MISC 2


PARI SOFT PLASTIC PEDIATRIC MASK MISC 2


PARI VORTEX ADULT MASK MISC 2


PEDIATRIC MOUTHPIECE/DISPOSABLE MISC


PFLEX MISC 2 QL(1 ml per360 daysretail); RX/OTC

PILLOW MASK/ADULTMISC 2



161

Drug Name DrugTier

Requirements/Limits

PILLOW MASK/CHILDMISC 2


PILLOW MASK/PEDIATRIC MISC 2


POCKET CHAMBER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

POCKET SPACER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

PRO COMFORT INHALER SPACER CHAMBER ADULT MISC


PRO COMFORT INHALER SPACER CHAMBER CHILD MISC


PRO COMFORT INHALER SPACER CHAMBER INFANT DEVI


PROCARE SPACER CHAMBER W/ADULTMASK DEVI


PROCARE SPACER CHAMBER W/CHILDMASK DEVI


PRONEB ULTRA FILTER SET MISC 2


REPLACEMENT AIR FILTER MISC 2


REPLACEMENT FILTERS MISC 2


RITEFLO DEVI 2 QL(2 ea per360 daysretail); RX/OTC

SAMI THE SEAL REPLACEMENTFILTERS MISC


SIDESTREAM ADULT FACE MASK MISC 2


SIDESTREAM PEDIATRIC FACEMASK MISC 2


Drug Name DrugTier

Requirements/Limits

SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL MISC


SIDESTREAM PEDIATRIC FACEMASK/TUCKER THETURTLE MISC


SIDESTREAM PLUS ADULT FACE MASK MISC 2


SILICONE MASK FOR BREATHERITE CHAMBER/ADULT MISC


SILICONE MASK FOR BREATHERITE CHAMBER/INFANT MISC


SILICONE MASK FOR BREATHERITE CHAMBER/PEDIATRICMISC

2


SILICONE MASK FOR BREATHRITE CHAMBER/ADULT MISC


SOOTHENEB NBL 100 CHILD MASK MISC 2


SOOTHENEB NBL 100 MEDICATION CUP MISC 2


SOOTHENEB NBL 100 MESH CAP MISC 2


SOOTHENEB NBL100 ADULT MASK MISC 2


THRESHOLD IMT MISC 2 QL(1 ml per360 daysretail); RX/OTC

TUBING/WING TIP MISC 2 QL(1 ml per360 daysretail); RX/OTC

VALVED HOLDING CHAMBER DEVI 2


VORTEX VALVED HOLDING CHAMBER DEVI



162

Drug Name DrugTier

Requirements/Limits

WATCHHALER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

WINDMILL TRAINER MISC 2


MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Calcitonin Gene-Related Peptide (CGRP) AIMOVIG SOAJ NP SP

AJOVY SOSY NP SP

EMGALITY SOAJ 2 PA; SP

EMGALITY SOSY 2 PA; SP

Migraine Combinations CAFERGOT TABS (Use ergotamine w/ caffeine) NP

ergotamine w/ caffeine tabs 1

MIGRANOW THPK NP

sumatriptan-naproxensodium tabs 1

TREXIMET TABS 10 MG-60 MG NP

TREXIMET TABS 85 MG-500 MG (Use sumatriptan-naproxen sodium)

NP

Migraine Products D.H.E. 45 SOLN (Use dihydroergotaminemesylate)

NP

dihydroergotaminemesylate soln ij 1 mg/ml 1

dihydroergotaminemesylate soln na 4 mg/ml NP

dihydroergotaminemesylate soln na 4 mg/ml 2

MIGRANAL SOLN (Use dihydroergotaminemesylate)

2

Serotonin Agonists

Drug Name DrugTier

Requirements/Limits

almotriptan malate tabs 1

AMERGE TABS (Use naratriptan hcl) NP


AXERT TABS (Use almotriptan malate) NP

eletriptan hydrobromidetabs 1 QL(0.2 ea

daily) FROVA TABS (Use frovatriptan succinate) NP

frovatriptan succinate tabs 1

IMITREX SOLN NA 5 MG/ACT, 20 MG/ACT (Use sumatriptan)

NP QL(6 ea per 30days retail)

IMITREX SOLN SC 6 MG/0.5ML (Use sumatriptan succinate)

NP

QL(2.5 ml per30 days retail);AL(At least 12yrs old)

IMITREX STATDOSE REFILL SOCT 4 MG/0.5ML(Use sumatriptansuccinate)

NP

IMITREX STATDOSE REFILL SOCT 6 MG/0.5ML(Use sumatriptansuccinate)

NP

QL(0.67 mldaily)

IMITREX STATDOSE SYSTEM SOAJ 4 MG/0.5ML (Use sumatriptan succinate)

NP

IMITREX STATDOSE SYSTEM SOAJ 6 MG/0.5ML (Use sumatriptan succinate)

NP

QL(0.67 mldaily)

IMITREX TABS OR 25 MG, 50 MG, 100 MG (Use sumatriptan succinate)


MAXALT TABS (Use rizatriptan benzoate) NP

QL(12 ea per30 days retail);AL(At least 6yrs old)

MAXALT-MLT TBDP (Use rizatriptan benzoate) NP


163

Drug Name DrugTier

Requirements/Limits

naratriptan hcl tabs 1


ONZETRA XSAIL EXHP NP

RELPAX TABS (Use eletriptan hydrobromide) NP QL(0.2 ea

daily)

rizatriptan benzoate tabs 5mg, 10 mg 1

QL(12 ea per30 days retail);AL(At least 6yrs old)

rizatriptan benzoate tbdp 5mg, 10 mg 1

sumatriptan soln na 5mg/act, 20 mg/act 1 QL(6 ea per 30

days retail) sumatriptan succinate soajsc 4 mg/0.5ml 1

sumatriptan succinate soajsc 6 mg/0.5ml 1 QL(0.67 ml

daily) sumatriptan succinate soctsc 4 mg/0.5ml 1

sumatriptan succinate soctsc 6 mg/0.5ml 1 QL(0.67 ml

daily)

sumatriptan succinate solnsc 6 mg/0.5ml 1

QL(2.5 ml per30 days retail);AL(At least 12yrs old)

SUMATRIPTAN SUCCINATE SOSY SC 6 MG/0.5ML

2 QL(0.67 mldaily)

sumatriptan succinate tabsor 25 mg, 50 mg, 100 mg 1 QL(9 ea per 30

days retail) ZEMBRACE SYMTOUCH SOAJ NP

zolmitriptan tabs or 5 mg,2.5 mg 1 QL(6 ea per 30

days retail) zolmitriptan tbdp or 5 mg,2.5 mg 1 QL(6 ea per 30

days retail)

ZOMIG SOLN NA 2.5 MG NP

ZOMIG SOLN NA 5 MG NP QL(6 ea per 30days retail)

ZOMIG TABS OR 5 MG, 2.5 MG (Use zolmitriptan) NP QL(6 ea per 30

days retail) ZOMIG ZMT TBDP (Use zolmitriptan) NP QL(6 ea per 30

days retail)

Drug Name DrugTier

Requirements/Limits

MINERALS & ELECTROLYTES

Calcium CALCIUM ACETATE TABS OR 2

calcium carbonate-cholecalciferol tabs 500 mg-5 mcg, 500 mg-200 unit

1

calcium carbonate-vitamin d tabs 125 unit-250 mg,125 unit-500 mg, 200 unit-500 mg, 250 mg-125 unit,500 mg-125 unit, 500 mg-200 unit, 500 mg-500 mg-200 unit-200 unit

1

calcium carbonate-vitamin d tabs 200 unit-600 mg,400 unit-600 mg, 600 mg-200 unit, 600 mg-400 unit

1

QL(2 ea daily)

oyster shell tabs 1

RA OYSTER SHELL CALCIUM/VITAMIN DTABS 500 MG-200 UNIT

2

Electrolyte Mixtures CERALYTE 70 SOLN 60 MEQ/L-70 MEQ/L-20MEQ/L-30 MEQ/L

2

CERASPORT EX1 SOLN 2

CERASPORT SOLN 4 MEQ/L-18 MEQ/L-20MEQ/L-6 MEQ/L

2

ENFAMIL ENFALYTE SOLN 2

EQUALYTE SOLN (Use oral electrolytes) NP

HYDRALYTE FREEZER POPS SOLN 2

HYDRALYTE SOLN 270 MG/250ML-210MG/250ML, 45 MEQ/L-45MEQ/L-20 MEQ/L-90MEQ/L-16 GM/L

2

oral electrolytes soln 1


164

Drug Name DrugTier

Requirements/Limits

PEDIALYTE ADVANCED CARE SOLN (Use oral electrolytes)

NP

PEDIALYTE FREEZER POPS SOLN (Use oral electrolytes)

NP

PEDIALYTE SINGLES SOLN (Use oral electrolytes)

NP

PEDIALYTE SOLN 20 MEQ/L-45 MEQ/L-35MEQ/L-5 GM/L-20 GM/L,4.7 MEQ/237ML-10.6MEQ/237ML-8.3MEQ/237ML, 20 MEQ/L-45MEQ/L-35 MEQ/L-30MEQ/L-25 GM/L, 35MEQ/L-45 MEQ/L-7.8MG/L-20 MEQ/L-25 GM/L,2.1 MEQ/59ML-2.7MEQ/59ML-0.5 MG/59ML-1.2 MEQ/59ML-1.5GM/59ML (Use oral electrolytes)

NP

Fluoride

FLURA-DROPS SOLN 2

sodium fluoride chew or 0.25 mg, 0.5 mg, 1 mg, 2.2 mg

1

sodium fluoride soln or 0.125 mg/drop, 0.5 mg/ml 1

Magnesium

MAGNEBIND 400 TABS NP

Phosphate K-PHOS NEUTRAL TABS (Use pot phosphatemonobasic w/ sodphosphate dibasic &monobasic)

NP

QL(8 ea daily)

pot phosphate monobasicw/ sod phosphate dibasic &monobasic tabs

1 QL(8 ea daily)

Potassium K-TAB TBCR 10 MEQ (Use potassium chloride) NP

Drug Name DrugTier

Requirements/Limits

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 2

potassium bicarbonate tbefor 25 meq, 2.5 gm-2 gm 1

potassium chloride cpcr or10 meq 1

potassium chloride cpcr or8 meq 1 QL(1 ea daily)

POTASSIUM CHLORIDE ER TBCR 2

potassium chloridemicroencapsulated crystalser tbcr

1

potassium chloride pack or20 meq 1

potassium chloride soln or10 %, 20 % 1

potassium chloride tbcr or 8meq, 10 meq 1

Zinc

zinc sulfate caps or 220 mg 1

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents DEPEN TITRATABS TABS (Use penicillamine) NP

penicillamine tabs or 1

SYPRINE CAPS (Use trientine hcl) NP PA; SP

trientine hcl caps 1 PA; SP

Enzymes

XIAFLEX SOLR 2 PA; SP

Fecal Incontinence Bulking Agents

SOLESTA GEL 2 PA; SP

Immunomodulators

REVLIMID CAPS 2 PA; SP

THALOMID CAPS 2 PA; SP


165

Drug Name DrugTier

Requirements/Limits

Immunosuppressive Agents

ASTAGRAF XL CP24 2 PA; SP

ATGAM INJ 2 PA; SP

AZASAN TABS 2

azathioprine tabs or 50 mg 1

CELLCEPT CAPS (Use mycophenolate mofetil) NP PA; SP

CELLCEPT INTRAVENOUS SOLR (Use mycophenolatemofetil hcl)

NP

PA; SP

CELLCEPT SUSR (Use mycophenolate mofetil) NP PA; SP

CELLCEPT TABS (Use mycophenolate mofetil) NP PA; SP

cyclosporine caps or 25mg, 100 mg 1 PA; SP

cyclosporine modified (formicroemulsion) caps 1 PA; SP

cyclosporine modified (formicroemulsion) soln 1 PA; SP

cyclosporine soln iv 50mg/ml 1 PA; SP

everolimus (immunosuppressant) tabs 1 PA; SP

GAMIFANT SOLN 2 PA; SP

IMURAN TABS (Use azathioprine) NP

mycophenolate mofetil caps 1 PA; SP

mycophenolate mofetil hclsolr 1 PA; SP

mycophenolate mofetil susr 1 PA; SP

mycophenolate mofetil tabs 1 PA; SP

mycophenolate sodiumtbec 1 PA; SP

MYFORTIC TBEC (Use mycophenolate sodium) NP PA; SP

Drug Name DrugTier

Requirements/Limits

NEORAL CAPS (Use cyclosporine modified (formicroemulsion))

NP PA; SP

NEORAL SOLN (Use cyclosporine modified (formicroemulsion))

NP PA; SP

NULOJIX SOLR 2 PA; SP

PROGRAF CAPS OR 0.5 MG, 1 MG, 5 MG (Use tacrolimus)

NP PA; SP

PROGRAF PACK OR 0.2 MG, 1 MG 2 PA; SP

PROGRAF SOLN IV 5 MG/ML 2 PA; SP

RAPAMUNE SOLN (Use sirolimus) NP PA; SP

RAPAMUNE TABS (Use sirolimus) NP PA; SP

SANDIMMUNE CAPS OR 25 MG, 100 MG (Use cyclosporine)

2 PA; SP

SANDIMMUNE SOLN IV 50 MG/ML (Use cyclosporine)

NP PA; SP

SANDIMMUNE SOLN OR 100 MG/ML 2 PA; SP

sirolimus soln or 1 mg/ml 1 PA; SP

sirolimus tabs or 0.5 mg, 1mg, 2 mg 1 PA; SP

tacrolimus caps or 0.5 mg,1 mg, 5 mg 1 PA; SP

THYMOGLOBULIN SOLR 2 PA; SP

ZORTRESS TABS 0.25 MG, 0.75 MG, 0.5 MG (Use everolimus (immunosuppressant))

NP

PA; SP

ZORTRESS TABS 1 MG 2 PA

Lymphatic Agents

SYLVANT SOLR 2 PA; SP

Potassium Removing Agents sodium polystyrenesulfonate powd or 1 QL(454 gm per

fill retail)


166

Drug Name DrugTier

Requirements/Limits

sodium polystyrenesulfonate susp or 15gm/60ml

1

Systemic Lupus Erythematosus Agents

BENLYSTA SOLR 2 PA; SP

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln 1 QL(100 ml per

fill retail) Anti-infectives - Throat nystatin (mouth-throat) susp 1 QL(100 ml per

fill retail) Antiseptics - Mouth/Throat chlorhexidine gluconate(mouth-throat) soln 1

PERIDEX SOLN (Use chlorhexidine gluconate(mouth-throat))

NP

Dental Products PREVIDENT 5000 DRY MOUTH GEL (Use sodium fluoride (dental))


PREVIDENT 5000 PLUS CREA (Use sodium fluoride (dental))


PREVIDENT FLUORIDE GEL (Use sodium fluoride (dental))


PREVIDENT RINSE SOLN (Use sodium fluoride (dental))

NP

sodium fluoride (dental)crea dt 1.1 % 1 QL(57 gm per

fill retail) sodium fluoride (dental) geldt 1.1 % 1 QL(60 ml per

fill retail) sodium fluoride (dental)soln mt 0.2 % 1

stannous fluoride conc mt 0.63 % 1 RX/OTC

Periodontal Products

ARESTIN MISC 2 PA; SP

Steroids - Mouth/Throat/Dental

Drug Name DrugTier

Requirements/Limits

triamcinolone acetonide (mouth) pste 1 QL(5 gm per fill

retail) Throat Products - Misc.

AQUORAL SOLN 2 QL(900 ml perfill retail);RX/OTC

BIOTENE DRY MOUTH MOISTURIZING SPRAY SOLN

2 QL(900 ml perfill retail);RX/OTC

CAPHOSOL SOLN 2 QL(900 ml perfill retail);RX/OTC

CVS DRY MOUTH SPRAY SOLN 2


EQL DRY MOUTH ORAL RINSE SOLN 2


MOI-STIR SOLN 2 QL(900 ml perfill retail);RX/OTC

MOUTH KOTE REMINT SOLN 2


MOUTH KOTE SOLN 2 QL(900 ml perfill retail);RX/OTC

NUMOISYN LIQD 2 QL(900 ml perfill retail);RX/OTC

ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT SOLN

2 QL(900 ml perfill retail);RX/OTC

pilocarpine hcl (oral) tabs 5 mg 1 QL(6 ea daily)

RA DRY MOUTH SOLN 2 QL(900 ml perfill retail);RX/OTC

SALAGEN TABS 5 MG (Use pilocarpine hcl (oral)) NP QL(6 ea daily)

XEROSTOMIA RELIEF SPRAY SOLN 2


MULTIVITAMINS

B-Complex Vitamins


167

Drug Name DrugTier

Requirements/Limits

b-complex vitamins caps or70 mg-100 mg-1 mg-10mg-2 mg-1.5 mg-100 mcg,

QL(1 ea daily)

60 mg-60 mg-3 mg-5 mg-20 mg-3 mg-1 mcg-0.5 mg,60 mg-60 mg-5 mg-20 mg-3 mg-1 mcg-3 mg-0.5 mg

1

b-complex vitamins tabs or0.1 mg-20 mg-2 mg-5 mcg-3 mg-1 mg, 10 mg-10 mg-2mg-1.5 mg-0.2 mg, 10 mg-14 mg-25 mcg-7 mg-4.5mg, 15 mg-2 mg-5 mg-2mcg-2 mg-2 mg, 3 mg-10mg-20 mg-3 mg-6 mcg-2mg, 3 mg-20 mg-3 mg-10

QL(1 ea daily)

mg-6 mcg-2 mg, 83 mg-3mg-20 mg-2 mg-5 mcg-1mg, 100 mg-50 mg-40 mg-10 mg-20 mg-5 mg-4.6 mg-1 mcg-5 mg-1 mg, 3 mg-3mg-20 mg-20 mg-3 mg-3mg-10 mg-10 mg-6 mcg-6mcg-2 mg-2 mg, 30 mg-50mg-50 mg-50 mg-50 mg-50mg-50 mcg-50 mg-100mcg-50 mcg-50 mg

1

B-Complex w/ C b complex w/ c caps 10 QL(1 ea daily)mg-50 mg-10 mg-15 mg-5mg-300 mg, 10 mg-50 mg-10.2 mg-15 mg-5 mg-300 1

mg, 10.2 mg-10 mg-15 mg-50 mg-5 mg-300 mg

B-Complex w/ Folic Acid b-complex w/ c & folic acidcaps 1.5 mg-5 mg-20 mg-1.7 mg-6 mcg-1 mg-150mcg-10 mg-100 mg, 5 mg-1.7 mg-6 mcg-20 mg-1.5mg-1 mg-150 mcg-10 mg-100 mg

1


Drug Name DrugTier

Requirements/Limits

b-complex w/ c & folic acidtabs 1.5 mg-10 mg-20 mg-1.7 mg-6 mcg-1 mg-300mcg-10 mg-60 mg, 30 mcg-1.5 mg-20 mg-1.7 mg-1mg-1 mg-300 mcg-8 mg-200 mg, 10 mg-20 mg-1.7mg-6 mcg-1.5 mg-1 mg-300 mcg-10 mg-100 mg, 6mcg-1.5 mg-10 mg-20 mg-1.7 mg-1 mg-300 mcg-10mg-100 mg, 1.5 mg-1.7mg-10 mg-0.01 mcg-20mg-1 mg-300 mcg-10 mg-60 mg, 20 mg-1.7 mg-10mg-0.006 mg-1.5 mg-1 mg-0.3 mg-10 mg-100 mg, 1.5mg-5 mg-20 mg-1.7 mg-6mcg-1000 mcg-150 mcg-10mg-100 mg, 6 mcg-1.5 mg-10 mg-20 mg-1.7 mg-1000mcg-300 mcg-10 mg-100mg, 6 mcg-6 mcg-1.5 mg-1.5 mg-10 mg-10 mg-20mg-20 mg-1.7 mg-1.7 mg-1mg-1 mg-300 mcg-300mcg-10 mg-10 mg-100 mg-100 mg

1


NEPHRO-VITE RX TABS (Use b-complex w/ c & folicacid)


NEPHROCAPS CAPS (Use b-complex w/ c & folicacid)


Multiple Vitamins w/ Iron multiple vitamins w/ irontabs 1 QL(1 ea daily)

Multiple Vitamins w/ Minerals multiple vitamins w/minerals tabs-assorted brand

2 RX/OTC

multiple vitamins w/minerals tabs-assorted generic

1 RX/OTC

Multivitamins multiple vitamins tabs-assorted brand 2 QL(1 ea daily)


168

Drug Name DrugTier

Requirements/Limits

multiple vitamins tabs-assorted generic 1 QL(1 ea daily)

Ped MV w/ Fluoride

pediatric multivitamins w/flchew-assorted brand 2

QL(1 ea daily);AL(Up to 13 yrsold)

pediatric multivitamins w/flchew-assorted generic 1

QL(1 ea daily);AL(Up to 13 yrsold)

pediatric multivitamins w/flsoln-assorted brand 2

QL(50ml per fillretail); AL(Up to13 yrs old)

pediatric multivitamins w/flsoln-assorted generic 1

QL(50ml per fillretail); AL(Up to13 yrs old)

pediatric vitamins acd w/fluoride soln 1


Ped MV w/ Iron pediatric multiple vitaminsw/ iron soln 0.6 mg/ml-10mg/ml-5 unit/ml-8 mg/ml-1500 unit/ml-400 unit/ml-0.5 mg/ml-0.4 mg/ml-35mg/ml, 10 mg/ml-8 mg/ml-0.6 mg/ml-750 unit/ml-2mcg/ml-400 unit/ml-0.5mg/ml-5 unit/ml-0.4 mg/ml

1


POLY-VI-SOL/IRON SOLN(Use pediatric multiplevitamins w/ iron)


Ped Multi Vitamins w/Fl & FE

ped multivitamins w/fl &iron soln 1


TRI-VIT/FLUORIDE/IRONSOLN 2


Ped Multiple Vitamins w/ Minerals

Drug Name DrugTier

Requirements/Limits

pediatric multiple vitamin w/minerals & c liqd 0.6mg/ml-5751 unit/ml-3mg/ml-5 mg/ml-10 mcg/ml-15 mg/ml-2 mg/ml-3 mg/ml-6 mg/ml-400 mcg/ml-400unit/ml-0.6 mg/ml-50unit/ml-15 mcg/ml-0.6mg/ml-45 mg/ml

1

RX/OTC

pediatric multiple vitamin w/minerals & c soln 0.6 mg/ml-300 mcg/ml-7.5mg/ml-50 unit/ml-3 mg/ml-6mg/ml-3170 unit/ml-4mcg/ml-400 unit/ml-0.5mg/ml-15 mcg/ml-0.6mg/ml-45 mg/ml, 50unit/ml-5 mg/ml-3 mg/ml-45mg/ml-6 mg/ml-400mcg/ml-0.6 mg/ml-4627unit/ml-4 mcg/ml-500unit/ml-0.5 mg/ml-15mcg/ml-0.6 mg/ml

1

RX/OTC

Pediatric Multiple Vitamins ONE-A-DAY VITACRAVES GUMMIES+OMEGA-3 DHA CHEW (Use pediatricmultiple vitamin w/ c & fa)

NP

QL(1 ea daily)

pediatric multiple vitamin w/c & fa chew 1 QL(1 ea daily)

pediatric multiple vitamin w/c soln 1 QL(50 ml per

fill retail) POLY-VI-SOL SOLN (Use pediatric multiple vitamin w/ c)


Prenatal Vitamins

prenatal vitamins-assortedbrand 2

QL(30 ea per30 days retail);RX/OTC

prenatal vitamins-assortedgeneric 1

QL(30 ea per30 days retail);RX/OTC

Vitamin Mixtures


169

Drug Name DrugTier

Requirements/Limits

cod liver oil caps 10 minim,1250 unit-130 unit, 1250unit-133 unit, 1250 unit-135unit, 200 unit-4000 unit,1250 unit-133.33 unit, 530mg-1250 unit-130 unit, 34mg-1250 unit-415 mg-32mg-135 unit, 37 mg-415mg-36 mg-1250 unit-135unit, 52 mg-2500 unit-600mg-52 mg-270 unit, 110mg-2664 unit-1000 mg-100mg-200 unit, 20 mg-35 mg-1250 unit-45 mg-133.333unit, 90 mg-37 mg-415 mg-36 mg-1250 unit-135 unit,50 mg-110 mg-250 unit-110 mg-100 unit-10 unit,

1

Vitamins w/ Lipotropics vitamins w/ lipotropics caps50 mg-50 mg-50 mg-50mg-50 mcg-50 mcg-50mcg-50 mg, 86 mg-2 mg-10 mg-83 mg-240 mg-3mg-2 mcg-3 mg-110 mg-1.65 mg, 50 mg-50 mg-50mg-50 mg-50 mg-50 mg-50mg-50 mcg-100 mcg-50mcg-50 mg, 10000 unit-3mg-0.5 mg-2 mg-75 mg-58mg-30 mg-2 unit-0.5 mg-4mg-40 mg-15 mg-31.4 mg-2.5 mg-2 mcg-5 mg-1 mg-75 mg-400 unit

1

QL(1 ea daily)

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms

Articular Cartilage Repair Therapy

MACI SHEE 2 PA; SP

Central Muscle Relaxants AMRIX CP24 (Use cyclobenzaprine hcl) NP

baclofen soln it 40 mg/20ml, 500 mcg/ml,20000 mcg/20ml

1 PA; SP

baclofen tabs or 10 mg, 20 mg 1

Drug Name DrugTier

Requirements/Limits

BACLOFEN TABS OR 5 MG 2 PA

carisoprodol tabs or 250 mg 1 PA

carisoprodol tabs or 350 mg 1 PA;

CHLORZOXAZONE TABS 250 MG 2

chlorzoxazone tabs 375 mg, 750 mg NP

chlorzoxazone tabs 375 mg, 750 mg 2

chlorzoxazone tabs 500 mg 1

cyclobenzaprine hcl cp24or 15 mg, 30 mg 1

cyclobenzaprine hcl tabs or5 mg, 10 mg 1 QL(3 ea daily)

cyclobenzaprine hcl tabs or7.5 mg 1 QL(4 ea daily)

FEXMID TABS (Use cyclobenzaprine hcl) NP QL(4 ea daily)

GABLOFEN SOLN 10000 MCG/20ML, 40000MCG/20ML

2 PA; SP

GABLOFEN SOLN 20000 MCG/20ML (Use baclofen) NP PA; SP

LIORESAL INTRATHECAL SOLN 0.05 MG/ML, 10MG/5ML

2 PA; SP

LIORESAL INTRATHECAL SOLN 10 MG/20ML, 40MG/20ML (Use baclofen)

NP PA; SP

METAXALONE TABS 400 MG 2

metaxalone tabs 800 mg 1

methocarbamol tabs or 500 mg, 750 mg 1

orphenadrine citrate tb12 or100 mg 1

ROBAXIN TABS OR 500 MG (Use methocarbamol) NP

ROBAXIN-750 TABS (Use methocarbamol) NP


170

Drug Name DrugTier

Requirements/Limits

SKELAXIN TABS (Use metaxalone) NP

SOMA TABS 250 MG (Use carisoprodol) NP PA

SOMA TABS 350 MG (Use carisoprodol) NP PA;

tizanidine hcl caps or 2 mg,4 mg, 6 mg 1

tizanidine hcl tabs or 2 mg,4 mg 1

ZANAFLEX CAPS (Use tizanidine hcl) NP

ZANAFLEX TABS (Use tizanidine hcl) NP

Direct Muscle Relaxants DANTRIUM CAPS (Use dantrolene sodium) NP

dantrolene sodium caps or25 mg, 50 mg, 100 mg 1

Muscle Relaxant Combinations

carisoprodol w/ aspirin tabs 1

CARISOPRODOL/ASPIRIN TABS 2

Viscosupplements

EUFLEXXA SOSY 2 PA; SP

GEL-ONE PRSY 2 PA; SP

GELSYN-3 SOSY 2 PA; SP

GENVISC 850 SOSY 2 PA; SP

HYALGAN SOLN 2 PA; SP

HYALGAN SOSY 2 PA; SP

HYMOVIS SOSY 2 PA; SP

MONOVISC SOSY 2 PA; SP

ORTHOVISC SOSY 2 PA; SP

SODIUM HYALURONATE SOSY IX 20 MG/2ML 2 PA; SP

SUPARTZ FX SOSY 2 PA; SP

Drug Name DrugTier

Requirements/Limits

SYNVISC ONE SOSY 2 PA; SP

SYNVISC SOSY 2 PA; SP

TRILURON SOSY 2 PA; SP

TRIVISC SOSY 2 PA; SP

VISCO-3 SOSY 2 PA; SP

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus

Nasal Agent Combinations azelastine hcl-fluticasone propionate susp NP

DYMISTA SUSP (Use azelastine hcl-fluticasone propionate)

NP

Nasal Agents - Misc. DERMACINRX TICANASE PAK THPK 2

OCEAN NASAL SPRAY SOLN (Use saline) NP QL(90 ml per

fill retail) saline soln na 0.65 %-0.002 %, 0.65 % 1 QL(90 ml per

fill retail)

TICASPRAY THPK 2

Nasal Anti-infectives BACTROBAN NASAL OINT NP

Nasal Antiallergy ASTEPRO SOLN (Use azelastine hcl) 2 QL(30 ml per

fill retail) azelastine hcl soln na 0.15 %, 0.1 %, 137 mcg/spray 1 QL(30 ml per

fill retail) cromolyn sodium (nasal) aers 1 QL(26 ml per

fill retail) NASALCROM AERS (Use cromolyn sodium (nasal)) NP QL(26 ml per

fill retail)

olopatadine hcl (nasal) soln 1

PATANASE SOLN (Use olopatadine hcl (nasal)) 2

Nasal Anticholinergics


171

Drug Name DrugTier

Requirements/Limits

ipratropium bromide (nasal)soln 0.03 % 1 QL(30 ml per

30 days retail) ipratropium bromide (nasal)soln 0.06 % 1 QL(15 ml per

30 days retail) Nasal Steroids

BECONASE AQ SUSP NP

budesonide (nasal) susp 1

FLONASE ALLERGY RELIEF CHILDRENS SUSP (Use fluticasone propionate (nasal))

NP


FLONASE ALLERGY RELIEF SUSP (Use fluticasone propionate(nasal))

NP


FLUNISOLIDE SOLN 2 QL(25 ml perfill retail)

fluticasone propionate(nasal) susp 1


mometasone furoate (nasal) susp 1

QL(17 gm perfill retail); AL(Atleast 2 yrs old)

NASONEX SUSP (Use mometasone furoate (nasal))

NP QL(17 gm perfill retail); AL(Atleast 2 yrs old)

OMNARIS SUSP NP

QNASL AERS NP

QNASL CHILDRENS AERS NP

ZETONNA AERS NP

Sympathomimetic Decongestants ADRENALIN SOLN NA 0.1 % 2

NASAL DECONGESTANT LIQD 2

NASAL DECONGESTANT SYRP 2

phenylephrine hcl (oral)tabs 1 QL(24 ea per

fill retail) pseudoephedrine hcl liqdor 15 mg/5ml 1

Drug Name DrugTier

Requirements/Limits

pseudoephedrine hcl tabsor 30 mg, 60 mg 1

pseudoephedrine hcl tb12or 120 mg 1 QL(2 ea daily)

SUDAFED CHILDRENS LIQD (Use pseudoephedrine hcl)

NP

SUDAFED CONGESTION TABS (Use pseudoephedrine hcl)

NP

SUDAFED PE CHILDRENS NASAL DECONGESTANT SOLN


SUDAFED PE SINUS CONGESTION TABS (Use phenylephrine hcl (oral))

NP QL(24 ea perfill retail)

SUDAFED SINUS CONGESTION TABS (Use pseudoephedrine hcl)

NP

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze Muscles

ALS Agents RILUTEK TABS (Use riluzole) NP PA

riluzole tabs 1 PA

TIGLUTIK SUSP 2 PA; SP

Muscular Dystrophy Agents

EXONDYS 51 SOLN 2 PA; SP

Neuromuscular Blocking Agent - Neurotoxins

BOTOX SOLR 2 PA; SP

DYSPORT SOLR 2 PA; SP

MYOBLOC SOLN 2 PA; SP

XEOMIN SOLR 2 PA; SP

Spinal Muscular Atrophy Agents (SMA) SPINRAZA SOLN 2 PA; SP

ZOLGENSMA 10.1-10.5 KG KIT 2 PA; SP


172

Drug Name DrugTier

Requirements/Limits






















NUTRIENTS

Carbohydrates

Drug Name DrugTier

Requirements/Limits

POLYCOSE LIQD 2 QL(124 ml perfill retail)

POLYCOSE POWD 2 QL(350 gm perfill retail)

Misc. Nutritional Substances

ALGAL-900 DHA CAPS 2

CARDIO OMEGA BENEFITS/VITAMIN D-3CAPS

2

COROMEGA OMEGA 3 KIDS EMUL 2

COROMEGA OMEGA 3 SQUEEZE EMUL 2

docosahexaenoic acid caps 1

DRY EYE OMEGA BENEFITS/VITAMIN D-3CAPS

2

FISH OIL + VITAMIN D3 CAPS 2

FISH OIL CAPS 950 MG-1360 MG 2

FISH OIL CHEW 135 MG-875 MG-90 MG 2

FISH OIL PEARLS CAPS 2

FISH OIL TRIPLE STRENGTH CAPS 2

FISH OIL ULTRA CAPS 2

FLEX OMEGA BENEFITS/VITAMIN D-3CAPS

2

GNP FISH OIL CPDR 2

HM FISH OIL CAPS 2

MOMS OMEGA ADVANTAGE/VITAMIN D-3 CAPS

2

OMEGA ESSENTIALS/VITAMIND-3CAPS

2

OMEGA POWER CAPS 2


173

Drug Name DrugTier

Requirements/Limits

OMEGA-3 2100 CAPS 2

OMEGA-3 CAPS 2

OMEGA-3 CPDR 2

Drug Name DrugTier

Requirements/Limits

omega-3 fatty acids caps1000 mg, 1200 mg, 180mg-120 mg, 1200 mg-2unit, 300 mg-1000 mg, 350mg-1000 mg, 360 mg-1200mg, 600 mg-1000 mg, 600mg-1200 mg, 180 mg-120mg-5 unit, 300 mg-180 mg-120 mg, 1000 mg-180 mg-120 mg, 160 mg-1000 mg-100 mg, 180 mg-1000 mg-120 mg, 180 mg-1200 mg-144 mg, 216 mg-1200 mg-144 mg, 270 mg-1000 mg-180 mg, 300 mg-1 unit-1000 mg, 300 mg-1000mg-1 unit, 300 mg-1000mg-200 mg, 336 mg-1200mg-276 mg, 350 mg-1000mg-250 mg, 400 mg-1000mg-300 mg, 500 mg-1000mg-250 mg, 180 mg-120mg-1.8 unit, 300 mg-180mg-1 gm-120 mg, 1000mg-180 mg-120 mg-1 mg,210 mg-1000 mg-75 mg-90mg, 360 mg-360 mg-12mg-1200 mg, 60 mg-180mg-1200 mg-120 mg, 60mg-360 mg-1200 mg-300mg, 1000 mg-180 mg-120mg-1 unit, 180 mg-1 unit-1000 mg-120 mg, 180 mg-1000 mg-120 mg-1 unit,300 mg-1000 mg-200 mg-1unit, 300 mg-180 mg-1000mg-120 mg, 360 mg-216mg-1200 mg-144 mg, 600mg-324 mg-1200 mg-216mg, 900 mg-455 mg-1000mg-360 mg, 100 mg-1000mg-500 mg-10 unit, 216mg-1200 mg-144 mg-15unit, 300 mg-1000 mg-1000mg-1 unit, 340 mg-180 mg-1 unit-1000 mg-120 mg

1

QL(6 ea daily)


174

Drug Name DrugTier

Requirements/Limits

omega-3 fatty acids caps300 mg, 500 mg, 180 mg-120 mg, 300 mg-200 mg,300 mg-500 mg, 90 mg-500 mg-60 mg, 180 mg-500 mg-120 mg, 435 mg-260 mg-175 mg, 500 mg-270 mg-135 mg, 500 mg-320 mg-130 mg, 300 mg-1000 mg-200 mg, 150 mg-90 mg-500 mg-60 mg, 27 1

mg-244 mg-500 mg-89 mg,300 mg-772.5 mg-90 mg-180 mg, 300 mg-500 mg-200 mg-2.5 unit, 300 mg-160 mg-1000 mg-100 mg-5unit, 500 mg-300 mg-1000mg-200 mg-1 unit, 435 mg-435 mg-260 mg-260 mg-175 mg-175 mg omega-3 fatty acids chew 5mg-113.5 mg-25 mg, 35mg-5 mg-113.5 mg-25 mg, 1 28.5 mg-4.75 mg-113.5mg-23.75 mg omega-3 fatty acids cpdr1200 mg, 300 mg-1000mg, 360 mg-1200 mg, 684mg-1200 mg, 600 mg-400mg-200 mg, 160 mg-1000mg-100 mg, 180 mg-1000 1 mg-120 mg, 300 mg-162mg-600 mg-108 mg, 300mg-180 mg-1000 mg-120mg, 360 mg-216 mg-1200mg-144 mg omega-3 fatty acids liqd 4.6gm/5ml, 1024 mg/15ml-712mg/15ml, 1400 mg/5ml-740mg/5ml-460 mg/5ml, 300mg/5ml-800 mg/5ml-500mg/5ml-10 unit/5ml, 1600 1

mg/5ml-800 mg/5ml-500mg/5ml-10 unit/5ml, 800mg/2.5ml-400 mg/2.5ml-250 mg/2.5ml-5 unit/2.5ml OMEGA-3 FISH OIL EXTRA STRENGTH CAPS 2

OMEGAPURE 780 EC CPDR 2

Drug Name DrugTier

Requirements/Limits

PA FISH OIL/VITAMIN D-3TRIPLE STRENGTH CPDR

2

PRENATAL OMEGA BABY EMUL 2

RA FISH OIL CPDR 2

RA TRIPLE STRENGTH FISH OIL CAPS 2

SM FISH OIL CAPS 2

SUPER TWIN EPA/DHACAPS 2

ULTRA OMEGA-3 FISH OIL BURP-LESS CAPS 2

ULTRA STRENGTH OMEGA-3 +VITAMIN D3 LIQD

2

UPSPRING BABY VITAMIN D + BRAIN LIQD 2

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

artificial tear ointment oint 1 QL(4 gm per fillretail)

HYPOTEARS SOLN 2 QL(30 ml perfill retail)

polyvinyl alcohol soln op 1 QL(15 ml perfill retail)

TEARS NATURALE PM OINT (Use white petrolatum-mineral oil)

NP QL(5 gm per fillretail)

white petrolatum-mineral oiloint 1 QL(5 gm per fill

retail) Beta-blockers - Ophthalmic BETAGAN SOLN (Use levobunolol hcl) NP QL(5 ml per fill

retail)

betaxolol hcl (ophth) soln 1 QL(5 ml per fillretail)

BETIMOL SOLN NP

BETOPTIC-S SUSP NP QL(15 ml perfill retail)

CARTEOLOL HCL SOLN 2


175

Drug Name DrugTier

Requirements/Limits

COMBIGAN SOLN 2

COSOPT PF SOLN (Use dorzolamide hcl-timolol maleate)

NP

COSOPT SOLN (Use dorzolamide hcl-timolol maleate)


dorzolamide hcl-timolol maleate soln 2 %-0.5 % 1

dorzolamide hcl-timolol maleate soln 20 mg/ml-5mg/ml, 22.3 mg/ml-6.8mg/ml

1


DORZOLAMIDE HCL/TIMOLOL MALEATESOLN


ISTALOL SOLN (Use timolol maleate (ophth)) NP

levobunolol hcl soln 1 QL(5 ml per fillretail)

LEVOBUNOLOL HCL SOLN 2 QL(5 ml per fill

retail)

METIPRANOLOL SOLN 2

timolol maleate (ophth)soln 0.25 %, 0.5 % 1 QL(5 ml per fill

retail) timolol maleate (ophth)soln 0.5 % 1

TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG 0.25 %

2

TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG 0.5 %

2 QL(5 ml per fillretail)

TIMOLOL/BRIMONIDE/DORZOLAMIDE SOLN 2

TIMOPTIC OCUDOSE SOLN NP QL(60 ea per

fill retail) TIMOPTIC SOLN (Use timolol maleate (ophth)) NP QL(5 ml per fill

retail) TIMOPTIC-XE SOLG 0.25 % NP

TIMOPTIC-XE SOLG 0.5 % NP QL(5 ml per fill

retail) Cycloplegic Mydriatics

Drug Name DrugTier

Requirements/Limits

ATROPINE SULFATE OINT OP 1 % 2 QL(4 gm per fill

retail) ATROPINE SULFATE SOLN OP 1 % 2 QL(5 ml per fill

retail) CYCLOGYL SOLN 0.5 % (Use cyclopentolate hcl) NP QL(15 ml per

fill retail) CYCLOGYL SOLN 1 % (Use cyclopentolate hcl) NP QL(5 ml per fill

retail) cyclopentolate hcl soln op0.5 % 1 QL(15 ml per

fill retail) cyclopentolate hcl soln op 1% 1 QL(5 ml per fill

retail)

ISOPTO ATROPINE SOLN 2 QL(5 ml per fillretail)

MYDRIACYL SOLN (Use tropicamide) NP QL(3 ml per fill

retail) phenylephrine hcl(mydriatic) soln 2.5 % 1 QL(5 ml per fill

retail)

tropicamide soln op 0.5 % 1 QL(15 ml perfill retail)

tropicamide soln op 1 % 1 QL(3 ml per fillretail)

Miotics ISOPTO CARPINE SOLN (Use pilocarpine hcl) NP

pilocarpine hcl soln op 1 %,2 %, 4 % 1

Ophthalmic - Angiogenesis Inhibitors

BEVACIZUMAB SOSY 2 PA; SP

EYLEA SOLN 2 PA; SP

LUCENTIS SOLN 2 PA; SP

LUCENTIS SOSY 2 PA; SP

MACUGEN SOLN 2 PA; SP

Ophthalmic Adrenergic Agents

ALPHAGAN P SOLN 0.1 % 2

ALPHAGAN P SOLN 0.15 % (Use brimonidine tartrate)

2

apraclonidine hcl soln 1


176

Drug Name DrugTier

Requirements/Limits

brimonidine tartrate soln op0.15 % 1

brimonidine tartrate soln op0.2 % 1 QL(5 ml per fill

retail) IOPIDINE SOLN 0.5 % (Use apraclonidine hcl) NP

IOPIDINE SOLN 1 % NP

SIMBRINZA SUSP 2

Ophthalmic Anti-infectives

AZASITE SOLN NP

bacitracin-polymyxin b(ophth) oint 1 QL(4 gm per fill

retail)

BESIVANCE SUSP NP

BLEPH-10 SOLN (Use sulfacetamide sodium (ophth))


CILOXAN OINT NP QL(4 gm per fillretail)

CILOXAN SOLN (Use ciprofloxacin hcl (ophth)) NP QL(5 ml per fill

retail) ciprofloxacin hcl (ophth)soln 1 QL(5 ml per fill

retail)

erythromycin (ophth) oint 1 QL(4 gm per fillretail)

gatifloxacin (ophth) soln NP

GENTAK OINT 2 QL(4 gm per fillretail)

gentamicin sulfate (ophth)soln 1 QL(5 ml per fill

retail)

KLARITY-A SOLN NP

levofloxacin (ophth) soln 1

MOXEZA SOLN (Use moxifloxacin hcl (ophth)) NP

moxifloxacin hcl (ophth)soln 1 QL(3 ml per fill

retail) moxifloxacin hcl (ophth)soln 1

neomycin-bacitracin zn-polymyxin oint 1 QL(4 gm per fill

retail)

Drug Name DrugTier

Requirements/Limits

NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN 2 QL(10 ml per

fill retail)

NEOSPORIN SOLN NP QL(10 ml perfill retail)

OCUFLOX SOLN (Use ofloxacin (ophth)) NP QL(5 ml per fill

retail)

ofloxacin (ophth) soln 1 QL(5 ml per fillretail)

polymyxin b-trimethoprimsoln 1 QL(10 ml per

fill retail) POLYTRIM SOLN (Use polymyxin b-trimethoprim) NP QL(10 ml per

fill retail) sulfacetamide sodium (ophth) soln 1 QL(15 ml per

fill retail)

tobramycin (ophth) soln 1 QL(5 ml per fillretail)

TOBREX OINT 2 QL(4 gm per fillretail)

TOBREX SOLN (Use tobramycin (ophth)) NP QL(5 ml per fill

retail)

TRIFLURIDINE SOLN OP 2 QL(8 ml per fillretail)

VIGAMOX SOLN (Use moxifloxacin hcl (ophth)) 2 QL(3 ml per fill

retail)

VIROPTIC SOLN NP QL(8 ml per fillretail)

ZYMAXID SOLN (Use gatifloxacin (ophth)) NP

Ophthalmic Decongestants naphazoline w/pheniramine soln 0.025 %-0.3 %

1

naphazoline w/pheniramine soln 0.027 %-0.315 %

1 QL(0.5 mldaily)

NAPHCON-A SOLN (Use naphazoline w/pheniramine)

NP

OPCON-A SOLN (Use naphazoline w/pheniramine)

NP QL(0.5 mldaily)

tetrahydrozoline hcl (ophth)soln 1 QL(30 ml per

fill retail)


177

Drug Name DrugTier

Requirements/Limits

VISINE RED EYE COMFORT SOLN (Use tetrahydrozoline hcl(ophth))

NP


VISINE SOLN (Use tetrahydrozoline hcl(ophth))


Ophthalmic Local Anesthetics

tetracaine hcl (ophth) soln 1

Ophthalmic Nerve Growth Factors

OXERVATE SOLN 2 PA; SP

Ophthalmic Photodynamic Therapy Agents

VISUDYNE SOLR 2 PA; SP

Ophthalmic Steroids

ALREX SUSP NP

BLEPHAMIDE S.O.P. OINT 2 QL(4 gm per fill

retail)

BLEPHAMIDE SUSP 2 QL(5 ml per fillretail)

DEXAMETHASONE SODIUM PHOSPHATE SOLN OP 0.1 %


DEXTENZA INST 2 PA; SP

fluorometholone (ophth) susp 1 QL(5 ml per fill

retail) FML LIQUIFILM SUSP (Use fluorometholone (ophth))


FML OINT 2 QL(4 gm per fillretail)

ILUVIEN IMPL 2 PA; SP

MAXITROL OINT 10000 UNIT/GM-3.5 MG/GM-0.1% (Use neomycin-polymy-dexameth)

NP

QL(4 gm per fillretail)

MAXITROL SUSP 10000 UNIT/ML-3.5 MG/ML-0.1 %(Use neomycin-polymy-dexameth)

NP

QL(5 ml per fillretail)

Drug Name DrugTier

Requirements/Limits

neomycin-polymy-dexameth oint 10000 unit/gm-3.5 mg/gm-0.1 %

1 QL(4 gm per fillretail)

neomycin-polymy-dexameth susp 10000unit/ml-3.5 mg/ml-0.1 %


NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP


OMNIPRED SUSP NP QL(5 ml per fillretail)

OZURDEX IMPL 2 PA; SP

PRED FORTE SUSP 2 QL(5 ml per fillretail)

PRED MILD SUSP 2 QL(10 ml perfill retail)

PRED-G SUSP 2 QL(5 ml per fillretail)

PREDNISOLONE ACETATE P-F SUSP 2 QL(5 ml per fill

retail) PREDNISOLONE ACETATE SUSP OP 2 QL(5 ml per fill

retail) PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 %


RETISERT IMPL 2 PA; SP

sulfacetamide sod-prednisolone soln 1 QL(5 ml per fill

retail) SULFACETAMIDE SODIUM/PREDNISOLONESODIUM PHOSPHATE SOLN

2

QL(5 ml per fillretail)

TOBRADEX OINT 2 QL(4 gm per fillretail)

TOBRADEX SUSP (Use tobramycin-dexamethasone)


tobramycin-dexamethasone susp 1 QL(5 ml per fill

retail)

YUTIQ IMPL 2 SP

Ophthalmics - Misc. ACULAR LS SOLN (Use ketorolac tromethamine (ophth))

NP


178

Drug Name DrugTier

Requirements/Limits

ACULAR SOLN (Use ketorolac tromethamine (ophth))


ACUVAIL SOLN NP

ALOCRIL SOLN NP

ALOMIDE SOLN NP

azelastine hcl (ophth) soln 1 QL(6 ml per fillretail)

AZOPT SUSP NP QL(15 ml perfill retail)

BEPREVE SOLN NP

bromfenac sodium (ophth)soln 1

BROMSITE SOLN NP

cromolyn sodium (ophth)soln 1 QL(10 ml per

fill retail)

CYSTARAN SOLN 2 PA; SP

diclofenac sodium (ophth)soln 1 QL(5 ml per fill

retail)

dorzolamide hcl soln 1 QL(10 ml perfill retail)

DORZOLAMIDE HCL SOLN 2 QL(10 ml per

fill retail) ELESTAT SOLN (Use epinastine hcl (ophth)) NP

EMADINE SOLN NP

epinastine hcl (ophth) soln 1

flurbiprofen sodium soln 1 QL(3 ml per fillretail)

FLURBIPROFEN SODIUM SOLN 2 QL(3 ml per fill

retail)

ILEVRO SUSP 2

ketorolac tromethamine (ophth) soln 0.4 % 1

ketorolac tromethamine (ophth) soln 0.5 % 1 QL(5 ml per fill

retail) ketotifen fumarate (ophth)soln 1 QL(5 ml per fill

retail)

Drug Name DrugTier

Requirements/Limits

LASTACAFT SOLN NP

NEVANAC SUSP NP QL(3 ml per fillretail)

olopatadine hcl soln 1 RX/OTC

PATADAY SOLN 0.1 % (Use olopatadine hcl) NP RX/OTC

PATADAY SOLN 0.2 % (Use olopatadine hcl) 2 RX/OTC

PATANOL SOLN (Use olopatadine hcl) NP RX/OTC

PAZEO SOLN 2

PROLENSA SOLN NP

TRUSOPT SOLN (Use dorzolamide hcl) NP QL(10 ml per

fill retail) ZADITOR SOLN (Use ketotifen fumarate (ophth)) NP QL(5 ml per fill

retail) Prostaglandins - Ophthalmic

bimatoprost soln op 1

LATANOPROST SOLN OP 2 QL(3 ml per fillretail)

latanoprost soln op 1 QL(3 ml per fillretail)

LUMIGAN SOLN NP

RESCULA SOLN NP

TRAVATAN Z SOLN (Use travoprost) NP

travoprost soln 1

XALATAN SOLN (Use latanoprost) NP QL(3 ml per fill

retail)

ZIOPTAN SOLN NP

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln 1 QL(15 ml perfill retail)

carbamide peroxide (otic)soln 1 QL(0.5 ml

daily)


179

Drug Name DrugTier

Requirements/Limits

DEBROX SOLN (Use carbamide peroxide (otic)) NP QL(0.5 ml

daily) Otic Anti-infectives

CETRAXAL SOLN NP

CIPROFLOXACIN SOLN OT 0.2 % 2

FLOXIN OTIC SOLN (Use ofloxacin (otic)) 2 QL(5 ml per fill

retail)

ofloxacin (otic) soln 1 QL(5 ml per fillretail)

Otic Combinations

CIPRO HC SUSP NP

CIPRODEX SUSP 2

QL(7.5 ml perfill retail)1 rtlMAX fill,30 rtl day(s) supply,

CORTANE-B-OTIC SOLN (Use pramoxine-hc-chloroxylenol)


neomycin-polymyxin-hc(otic) soln 1 QL(10 ml per

fill retail) neomycin-polymyxin-hc(otic) susp 1 QL(10 ml per

fill retail) OTICIN HC NR SOLN (Use pramoxine-hc-chloroxylenol)


pramoxine-hc-chloroxylenolsoln 1 QL(15 ml per

fill retail) Otic Steroids DERMOTIC OIL (Use fluocinolone acetonide (otic))


fluocinolone acetonide (otic) oil 1 QL(20 ml per

fill retail) hydrocortisone w/aceticacid soln 1 QL(10 ml per

fill retail) OXYTOCICS - Drugs to Prevent/Control UterineBleeding

Oxytocics methylergonovine maleatetabs or 0.2 mg 1

Drug Name DrugTier

Requirements/Limits

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem

Immune Serums

BIVIGAM SOLN 2 PA; SP

CARIMUNE NANOFILTERED SOLR 2 PA; SP

CUVITRU SOLN 2 PA; SP

CYTOGAM INJ 2 PA; SP

FLEBOGAMMA DIF SOLN 2 PA; SP

GAMASTAN INJ 2 PA; SP

GAMASTAN S/D INJ 2 PA; SP

GAMMAGARD LIQUID SOLN 2 PA; SP

GAMMAGARD S/D IGALESS THAN 1MCG/MLSOLR

2 PA; SP

GAMMAKED SOLN 2 PA; SP

GAMMAPLEX SOLN 2 PA; SP

GAMUNEX-C SOLN 2 PA; SP

HEPAGAM B SOLN 2 PA; SP

HIZENTRA SOLN 1 GM/5ML, 2 GM/10ML, 4GM/20ML, 10 GM/50ML

2 PA; SP

HYPERHEP B S/D SOLN 2 PA; SP

HYPERRHO S/D MINI-DOSE SOSY 2 PA; SP

HYPERRHO S/D SOSY 2 PA; SP

MICRHOGAM ULTRA-FILTEREDPLUS SOSY 2 PA; SP

NABI-HB SOLN 2 PA; SP


180

Drug Name DrugTier

Requirements/Limits

OCTAGAM SOLN 1 GM/20ML, 2 GM/20ML, 5GM/50ML, 5 GM/100ML,10 GM/100ML, 10GM/200ML, 2.5 GM/50ML,20 GM/200ML, 25GM/500ML

2

PA; SP

OCTAGAM SOLN 30 GM/300ML 2 PA

PANZYGA SOLN 2 PA; SP

PRIVIGEN SOLN 2 PA; SP

RHOGAM ULTRA-FILTERED PLUS SOSY 2 PA; SP

RHOPHYLAC SOSY 2 PA; SP

WINRHO SDF SOLN 2 PA; SP

Monoclonal Antibodies

SYNAGIS SOLN 2 PA; SP

ZINPLAVA SOLN 2 PA; SP

Passive Immunizing Agents - Combinations

HYQVIA KIT 2 PA; SP

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins amoxicillin caps 250 mg,500 mg 1

AMOXICILLIN CHEW 125 MG, 250 MG 2

amoxicillin susr 125 mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

1

amoxicillin tabs 875 mg 1

AMPICILLIN CAPS 2

Natural Penicillins PENICILLIN V POTASSIUM SOLR 125 MG/5ML, 250 MG/5ML

2

penicillin v potassium tabs250 mg, 500 mg 1

Drug Name DrugTier

Requirements/Limits

Penicillin Combinations amoxicillin & potclavulanate susr 200 mg/5ml-28.5 mg/5ml, 250mg/5ml-62.5 mg/5ml

1


amoxicillin & potclavulanate susr 400 mg/5ml-57 mg/5ml


amoxicillin & potclavulanate susr 600 mg/5ml-42.9 mg/5ml


amoxicillin & potclavulanate tabs 250 mg-125 mg


amoxicillin & potclavulanate tabs 500 mg-125 mg, 875 mg-125 mg


amoxicillin & potclavulanate tb12 1000 mg-62.5 mg

1 QL(1.34 eadaily)

AMOXICILLIN/CLAVULANATE POTASSIUM CHEW 2 QL(20 ea per

fill retail) AMOXICILLIN/CLAVULANATE POTASSIUM ER TB12

2 QL(1.34 eadaily)

AUGMENTIN ES-600 SUSR (Use amoxicillin & pot clavulanate)


AUGMENTIN SUSR 250 MG/5ML-62.5 MG/5ML(Use amoxicillin & potclavulanate)

NP


AUGMENTIN TABS 500 MG-125 MG, 875 MG-125 MG (Use amoxicillin & potclavulanate)

NP

QL(20 ea perfill retail)

AUGMENTIN XR TB12 (Use amoxicillin & potclavulanate)

NP QL(1.34 eadaily)

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps 1

PHARMACEUTICAL ADJUVANTS

Internal Vehicle Ingredients/Agents


181

Drug Name DrugTier

Requirements/Limits

SIMPLYTHICK EASY MIX GEL 2


SIMPLYTHICK EASYMIX GEL 2


SIMPLYTHICK GEL 2 QL(1816 ml perfill retail); AL(Atleast 2 yrs old)

Liquid Vehicles

glycine diluent soln 1 PA; SP

PH 12 STERILE DILUENT FORFLOLAN SOLN (Use glycine diluent)

NP PA; SP

STERILE DILUENT FOR FLOLAN SOLN (Use glycine diluent)

NP PA; SP

STERILE DILUENT FOR TREPROSTINIL INJECTION SOLN

2 PA; SP

Semi Solid Vehicles

lanolin oint ex 1 RX/OTC

lanolin oint xx 1 RX/OTC

PROGESTINS - Hormone Replacement/ModifyingDrugs

Progestins AYGESTIN TABS (Use norethindrone acetate) NP

hydroxyprogesteronecaproate oil im 250 mg/ml 1 PA; SP

MAKENA OIL IM 250 MG/ML (Use hydroxyprogesterone caproate)

NP

PA; SP

MAKENA SOAJ SC 275 MG/1.1ML 2 PA; SP

medroxyprogesteroneacetate tabs or 5 mg, 10mg, 2.5 mg

1

norethindrone acetate tabs or 1

progesterone micronizedcaps or 100 mg 1 QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

progesterone micronizedcaps or 200 mg 1 QL(20 ea per

30 days retail) PROMETRIUM CAPS 100 MG (Use progesteronemicronized)

NP QL(1 ea daily)

PROMETRIUM CAPS 200 MG (Use progesteronemicronized)

NP QL(20 ea per30 days retail)

PROVERA TABS (Use medroxyprogesterone acetate)

NP

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency ANTABUSE TABS 250 MG (Use disulfiram) NP

disulfiram tabs or 250 mg 1

LUCEMYRA TABS NP

Anti-Cataplectic Agents

XYREM SOLN 2 PA; SP

Antidementia Agents ARICEPT TABS 23 MG (Use donepezilhydrochloride)

NP

ARICEPT TABS 5 MG, 10 MG (Use donepezilhydrochloride)

NP QL(1 ea daily)

donepezil hydrochloridetabs 23 mg 1

donepezil hydrochloridetabs 5 mg, 10 mg 1 QL(1 ea daily)

donepezil hydrochloridetbdp 5 mg, 10 mg 1

EXELON PT24 13.3 MG/24HR (Use rivastigmine)

2

EXELON PT24 4.6 MG/24HR, 9.5 MG/24HR(Use rivastigmine)

2 QL(1 ea daily)

galantamine hydrobromidecp24 8 mg, 16 mg, 24 mg 1 QL(1 ea daily)


182

Drug Name DrugTier

Requirements/Limits

GALANTAMINE HYDROBROMIDE SOLN 4 MG/ML

2 QL(6 ml daily)

galantamine hydrobromidetabs 4 mg, 8 mg, 12 mg 1 QL(2 ea daily)

memantine hcl cp24 7 mg,14 mg, 21 mg, 28 mg 1

memantine hcl soln 2 mg/ml, 10 mg/5ml 1 QL(10 ml daily)

memantine hcl tabs 1 QL(1 ea per 28days retail)

memantine hcl tabs 5 mg,10 mg 1 QL(2 ea daily)

NAMENDA TABS (Use memantine hcl) NP QL(2 ea daily)

NAMENDA TITRATION PAK TABS (Use memantine hcl)


NAMENDA XR CP24 (Use memantine hcl) NP

NAMENDA XR TITRATION PACK CP24 NP

NAMZARIC C4PK NP

NAMZARIC CP24 NP

RAZADYNE ER CP24 (Use galantamine hydrobromide) NP QL(1 ea daily)

RAZADYNE TABS (Use galantamine hydrobromide) NP QL(2 ea daily)

rivastigmine pt24 13.3mg/24hr 1

rivastigmine pt24 4.6mg/24hr, 9.5 mg/24hr 1 QL(1 ea daily)

rivastigmine tartrate caps 1 QL(2 ea daily)

Combination Psychotherapeutics PERPHENAZINE/AMITRIPTYLINE TABS 2 QL(4 ea daily)

Fibromyalgia Agents

SAVELLA TABS 2 PA; QL(2 eadaily)

SAVELLA TITRATION PACK MISC 2

PA; QL(55 eaper 365 daysretail)

Movement Disorder Drug Therapy

Drug Name DrugTier

Requirements/Limits

INGREZZA CAPS 2 PA; SP

INGREZZA CPPK 2 PA; SP

tetrabenazine tabs 1 PA; SP

XENAZINE TABS (Use tetrabenazine) NP PA; SP

Multiple Sclerosis Agents AMPYRA TB12 (Use dalfampridine) NP PA; SP

AUBAGIO TABS NP SP

AVONEX KIT 2 PA; SP

AVONEX PEN AJKT 2 PA; SP

AVONEX PSKT 2 PA; SP

BETASERON KIT 2 PA; SP

COPAXONE SOSY (Use glatiramer acetate) 2 PA; SP

dalfampridine tb12 or 1 PA; SP

EXTAVIA KIT NP SP

GILENYA CAPS 2 PA; SP

glatiramer acetate sosy 1 PA; SP

LEMTRADA SOLN NP SP

MAYZENT STARTER PACK TBPK 2 PA; SP

MAYZENT TABS 2 PA; SP

PLEGRIDY SOPN NP SP

PLEGRIDY SOSY NP SP

PLEGRIDY STARTER PACK SOPN NP SP

PLEGRIDY STARTER PACK SOSY NP SP

REBIF REBIDOSE SOAJ 2 PA; SP


183

Drug Name DrugTier

Requirements/Limits

REBIF REBIDOSE TITRATIONPACK SOAJ 2 PA; SP

REBIF SOSY 2 PA; SP

REBIF TITRATION PACK SOSY 2 PA; SP

TECFIDERA CPDR 2 PA; SP

TECFIDERA STARTER PACK MISC 2 PA; SP

TYSABRI CONC 2 PA; SP

Premenstrual Dysphoric Disorder (PMDD) Agents

FLUOXETINE CAPS 2

fluoxetine hcl (pmdd) tabs 1

SARAFEM TABS (Use fluoxetine hcl (pmdd)) NP

Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATES TABS OR 2

Smoking Deterrents bupropion hcl (smokingdeterrent) tb12 0 AL(At least 18

yrs old)

CHANTIX CONTINUING MONTHPAK TABS 0


CHANTIX STARTING MONTH PAK TABS 0 AL(At least 18

yrs old)

CHANTIX TABS 0 QL(2 ea daily);AL(At least 18yrs old)

NICODERM CQ PT24 (Use nicotine) NP AL(At least 18

yrs old) NICORETTE GUM (Use nicotine polacrilex) NP AL(At least 18

yrs old) NICORETTE LOZG (Use nicotine polacrilex) NP AL(At least 18

yrs old) NICORETTE MINI LOZG (Use nicotine polacrilex) NP AL(At least 18

yrs old) NICORETTE STARTER KIT GUM (Use nicotine polacrilex)

NP AL(At least 18yrs old)

nicotine polacrilex gum mt2 mg, 4 mg 0 AL(At least 18

yrs old)

Drug Name DrugTier

Requirements/Limits

nicotine polacrilex lozg mt 2mg, 4 mg 0 AL(At least 18

yrs old)

nicotine pt24 0 AL(At least 18yrs old)

NICOTINE TRANSDERMAL SYSTEM KIT


NICOTROL INHALER INHA 0 PA; AL(At least

18 yrs old)

NICOTROL NS SOLN 0 PA; AL(At least18 yrs old)

ZYBAN TB12 (Use bupropion hcl (smokingdeterrent))

NP AL(At least 18yrs old)

Transthyretin Amyloidosis Agents

ONPATTRO SOLN 2 PA; SP

TEGSEDI SOSY 2 PA; SP

Vasomotor Symptom Agents BRISDELLE CAPS (Use paroxetine mesylate(vasomotor))

NP

paroxetine mesylate(vasomotor) caps 1

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung Conditions

Alpha-Proteinase Inhibitor (Human) ARALAST NP SOLR 2 PA; SP

GLASSIA SOLN 2 PA; SP

PROLASTIN-C SOLR 2 PA; SP

ZEMAIRA SOLR 2 PA; SP

Cystic Fibrosis Agents KALYDECO PACK 50 MG, 75 MG 2 PA; SP

KALYDECO TABS 150 MG 2 PA; SP

ORKAMBI PACK 2 PA; SP

ORKAMBI TABS 2 PA; SP


184

Drug Name DrugTier

Requirements/Limits

PULMOZYME SOLN 2 PA; SP

SYMDEKO TBPK 2 PA; SP

TRIKAFTA TBPK 2 PA; QL(3 eadaily); SP

Pulmonary Fibrosis Agents

ESBRIET CAPS 2 PA; SP

OFEV CAPS 2 PA; SP

TETRACYCLINES - Drugs to Treat BacterialInfections

Tetracyclines doxycycline (monohydrate)caps 50 mg, 100 mg 1

doxycycline (monohydrate)tabs 50 mg, 100 mg 1

doxycycline hyclate caps or50 mg, 100 mg 1

doxycycline hyclate tabs or100 mg 1

MINOCIN CAPS OR 50 MG, 100 MG (Use minocycline hcl)

NP

minocycline hcl caps or 50mg, 75 mg, 100 mg 1

VIBRAMYCIN CAPS 100 MG (Use doxycyclinehyclate)

NP

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Antithyroid Agents methimazole tabs or 5 mg,10 mg 1

propylthiouracil tabs or 1

TAPAZOLE TABS (Use methimazole) NP

Thyroid Hormones ARMOUR THYROID TABS 15 MG, 30 MG, 60 MG, 90 MG, 120 MG (Use thyroid)

2

ARMOUR THYROID TABS 180 MG, 240 MG, 300 MG 2

Drug Name DrugTier

Requirements/Limits

CYTOMEL TABS (Use liothyronine sodium) NP

levothyroxine sodium tabsor 25 mcg, 50 mcg, 75mcg, 88 mcg, 100 mcg,112 mcg, 125 mcg, 137mcg, 150 mcg, 175 mcg,200 mcg, 300 mcg

1

liothyronine sodium tabs or5 mcg, 25 mcg, 50 mcg 1

NATURE-THROID TABS 65 MG, 130 MG 2

SYNTHROID TABS (Use levothyroxine sodium) 2

thyroid tabs or 15 mg, 30mg, 60 mg, 90 mg, 120 mg 1

THYROLAR-1 TABS 2

THYROLAR-1/2 TABS 2

THYROLAR-1/4 TABS 2

THYROLAR-2 TABS 2

THYROLAR-3 TABS 2

TIROSINT CAPS 13 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG, 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG

2

WESTHROID TABS 65 MG, 130 MG 2

WP THYROID TABS 65 MG, 130 MG 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

QL(1 ml per999 daysretail); AL(Atleast 18 yrsold)

BOOSTRIX SUSP 0



185

Drug Name DrugTier

Requirements/Limits

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach Conditions

Antispasmodics ANASPAZ TBDP (Use hyoscyamine sulfate) NP

BENTYL CAPS OR 10 MG (Use dicyclomine hcl) NP

dicyclomine hcl caps or 10 mg 1

dicyclomine hcl soln or 10mg/5ml 1 QL(40 ml daily)

dicyclomine hcl tabs or 20 mg 1

glycopyrrolate tabs or 1mg, 2 mg 1 QL(4 ea daily)

hyoscyamine sulfate elix or0.125 mg/5ml 1

hyoscyamine sulfate elix or0.125 mg/5ml NP

hyoscyamine sulfate solnor 0.125 mg/ml NP

hyoscyamine sulfate solnor 0.125 mg/ml 1

hyoscyamine sulfate subl sl0.125 mg NP

hyoscyamine sulfate subl sl0.125 mg 1

hyoscyamine sulfate tabsor 0.125 mg 1

hyoscyamine sulfate tabsor 0.125 mg NP

hyoscyamine sulfate tb12or 0.375 mg 1

hyoscyamine sulfate tbdpor 0.125 mg 1

hyoscyamine sulfate tbdpor 0.125 mg NP

LEVBID TB12 (Use hyoscyamine sulfate) NP

LEVSIN TABS OR 0.125 MG (Use hyoscyaminesulfate)

NP

LEVSIN/SL SUBL (Use hyoscyamine sulfate) NP

Drug Name DrugTier

Requirements/Limits

ROBINUL FORTE TABS (Use glycopyrrolate) NP QL(4 ea daily)

ROBINUL TABS OR 1 MG (Use glycopyrrolate) NP QL(4 ea daily)

SYMAX DUOTAB TBCR 2

H-2 Antagonists

CIMETIDINE HCL SOLN 2 QL(27 ml daily)

cimetidine tabs or 200 mg 1 RX/OTC

cimetidine tabs or 300 mg,400 mg 1

cimetidine tabs or 800 mg 1 QL(500 ea perfill retail)

famotidine tabs or 10 mg,40 mg 1

famotidine tabs or 20 mg 1 RX/OTC

PEPCID AC MAXIMUM STRENGTH TABS (Use famotidine)

NP RX/OTC

PEPCID AC TABS (Use famotidine) NP

PEPCID TABS 20 MG (Use famotidine) NP RX/OTC

PEPCID TABS 40 MG (Use famotidine) NP

ranitidine hcl caps or 150 mg 1 QL(2 ea daily)

ranitidine hcl caps or 300 mg 1 QL(1 ea daily)

ranitidine hcl syrp or 15mg/ml, 75 mg/5ml, 150mg/10ml

1 QL(40 ml daily)

ranitidine hcl tabs or 150 mg 1 QL(2 ea daily);

RX/OTC ranitidine hcl tabs or 75 mg,300 mg 1 QL(2 ea daily)

TAGAMET HB TABS (Use cimetidine) NP RX/OTC

ZANTAC 150 MAXIMUM STRENGTH TABS (Use ranitidine hcl)


ZANTAC 75 TABS (Use ranitidine hcl) NP QL(2 ea daily)


186

Drug Name DrugTier

Requirements/Limits

ZANTAC TABS OR 300 MG (Use ranitidine hcl) NP QL(2 ea daily)

Misc. Anti-Ulcer CARAFATE SUSP 1 GM/10ML (Use sucralfate) NP QL(420 ml per

fill retail) CARAFATE TABS 1 GM (Use sucralfate) NP QL(4 ea daily)

sucralfate susp or 1gm/10ml 1 QL(420 ml per

fill retail)

sucralfate tabs or 1 gm 1 QL(4 ea daily)

Proton Pump Inhibitors ACIPHEX SPRINKLE CPSP 5 MG, 10 MG NP

ACIPHEX TBEC (Use rabeprazole sodium) NP

DEXILANT CPDR NP

esomeprazole magnesiumcpdr 20 mg NP RX/OTC

esomeprazole magnesiumcpdr 20 mg 1 QL(2 ea daily);

RX/OTC esomeprazole magnesiumpack 10 mg, 20 mg, 40 mg 1

ESOMEPRAZOLE STRONTIUM CPDR 2

lansoprazole cpdr or 15 mg 1 RX/OTC

lansoprazole cpdr or 30 mg 1

lansoprazole tbdd or 15 mg 1 PA; RX/OTC

lansoprazole tbdd or 30 mg 1 PA

NEXIUM 24HR CPDR (Use esomeprazole magnesium) NP QL(2 ea daily);

RX/OTC

NEXIUM 24HR TBEC NP

NEXIUM CPDR 20 MG (Use esomeprazolemagnesium)


NEXIUM PACK 10 MG, 20 MG, 40 MG (Use esomeprazole magnesium)

NP

NEXIUM PACK 5 MG, 2.5 MG 2

Drug Name DrugTier

Requirements/Limits

omeprazole cpdr or 10 mg,40 mg 1 QL(2 ea daily)

omeprazole cpdr or 20 mg 1 QL(2 ea daily);RX/OTC

omeprazole magnesiumcpdr 20 mg, 20.6 mg 1

omeprazole magnesiumtbec 20 mg 1 QL(1 ea daily)

omeprazole tbdd or 20 mg 1

OMEPRAZOLE TBEC OR 20 MG 2 QL(1 ea daily)

omeprazole tbec or 20 mg 1 QL(1 ea daily)

pantoprazole sodium tbecor 20 mg 1 QL(1 ea daily)

pantoprazole sodium tbecor 40 mg 1 QL(2 ea daily)

PREVACID 24HR CPDR (Use lansoprazole) NP RX/OTC

PREVACID CPDR 15 MG (Use lansoprazole) NP RX/OTC

PREVACID CPDR 30 MG (Use lansoprazole) NP

PREVACID SOLUTAB TBDD 15 MG (Use lansoprazole)

NP PA; RX/OTC

PREVACID SOLUTAB TBDD 30 MG (Use lansoprazole)

NP PA

PRILOSEC OTC TBEC (Use omeprazolemagnesium)

NP QL(1 ea daily)

PRILOSEC PACK NP

PROTONIX PACK OR 40 MG 2

PROTONIX TBEC OR 20 MG (Use pantoprazolesodium)

NP QL(1 ea daily)

PROTONIX TBEC OR 40 MG (Use pantoprazolesodium)

NP QL(2 ea daily)

RABEPRAZOLE SODIUM DR SPRINKLE CPSP NP

rabeprazole sodium tbec 1


187

Drug Name DrugTier

Requirements/Limits

Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use misoprostol) NP

misoprostol tabs or 100mcg, 200 mcg 1

Ulcer Therapy Combinations omeprazole-sodiumbicarbonate caps 20 mg-1100 mg

1 RX/OTC

omeprazole-sodiumbicarbonate caps 40 mg-1100 mg

1

omeprazole-sodiumbicarbonate pack 20 mg-1680 mg, 40 mg-1680 mg

1

ZEGERID CAPS 20 MG-1100 MG (Use omeprazole-sodiumbicarbonate)

NP

RX/OTC

ZEGERID CAPS 40 MG-1100 MG (Use omeprazole-sodiumbicarbonate)

NP

ZEGERID OTC CAPS (Use omeprazole-sodiumbicarbonate)

NP RX/OTC

ZEGERID PACK 20 MG-1680 MG, 40 MG-1680 MG (Use omeprazole-sodiumbicarbonate)

NP

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney Infections

Urinary Anti-infective Combinations methenamine-hyosc-methylene blue-sod phos-phenyl sal tabs 40.8 mg-0.12 mg-36.2 mg-81.6 mg-10.8 mg, 40.8 mg-36.2 mg-0.12 mg-81.6 mg-10.8 mg

1

Urinary Anti-infectives FURADANTIN SUSP (Use nitrofurantoin) NP QL(40 ml daily)

MACROBID CAPS (Use nitrofurantoin monohyd macro)

NP

Drug Name DrugTier

Requirements/Limits

MACRODANTIN CAPS 50 MG, 100 MG (Use nitrofurantoin macrocrystal)

NP

methenamine mandelate tabs or 0.5 gm, 1 gm, 500 mg

1

nitrofurantoin macrocrystalcaps or 50 mg, 100 mg 1

nitrofurantoin monohyd macro caps 1

nitrofurantoin susp or 1 QL(40 ml daily)

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodic - Antimuscarinics darifenacin hydrobromidetb24 1

DETROL LA CP24 (Use tolterodine tartrate) NP QL(1 ea daily)

DETROL TABS (Use tolterodine tartrate) NP QL(2 ea daily)

DITROPAN XL TB24 (Use oxybutynin chloride) NP QL(2 ea daily)

ENABLEX TB24 (Use darifenacin hydrobromide) NP

GELNIQUE GEL NP

GELNIQUE PUMP GEL NP

oxybutynin chloride syrp or5 mg/5ml 1 QL(16 ml daily)

oxybutynin chloride tabs or5 mg 1 QL(3 ea daily)

oxybutynin chloride tb24 or5 mg, 10 mg, 15 mg 1 QL(2 ea daily)

OXYTROL FOR WOMEN PTTW NP RX/OTC

OXYTROL PTTW NP RX/OTC

solifenacin succinate tabs 1

tolterodine tartrate cp24 2mg, 4 mg 1 QL(1 ea daily)

tolterodine tartrate tabs 1 mg, 2 mg 1 QL(2 ea daily)


188

Drug Name DrugTier

Requirements/Limits

TOVIAZ TB24 2

trospium chloride cp24 60 mg 1

trospium chloride tabs 20 mg 1 QL(2 ea daily)

VESICARE TABS (Use solifenacin succinate) 2

Urinary Antispasmodics - Beta-3 Adrenergic

MYRBETRIQ TB24 NP

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs or 5 mg, 10 mg, 25 mg, 50 mg

1

URECHOLINE TABS (Use bethanechol chloride) NP

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl tabs 1

VACCINES

Bacterial Vaccines

BEXSERO SUSY 0


MENACTRA INJ 0


MENVEO SOLR 0

QL(1 ea per999 daysretail); AL(Atleast 18 yrsold)

PNEUMOVAX 23 INJ 0

2 rtl pack lmtamt,999 rtl pack lmtday(s),; AL(Atleast 19 yrsold)

Drug Name DrugTier

Requirements/Limits

PNEUMOVAX 23/1 DOSEINJ 0

2 rtl pack lmtamt,999 rtl pack lmtday(s),; AL(Atleast 19 yrsold)

PREVNAR 13 SUSP 0 AL(At least 19yrs old)

TRUMENBA SUSY 0


Viral Vaccines

ENGERIX-B INJ 0


ENGERIX-B SUSP 0


FLUMIST QUADRIVALENT SUSP 0

limit 0.5 per180 days;1 rtlpack lmtamt,180 rtl pack lmtday(s),; AL(Atleast 7 yrs old)

HAVRIX SUSP 0


M-M-R II SOLR 0 AL(At least 18yrs old)

RECOMBIVAX HB SUSP 0


Seasonal Influenza Vaccine 0

QL (1 ea per180 daysretail); AL: Atleast 7 yrs old


189

Drug Name DrugTier

Requirements/Limits

Seasonal Influenza Vaccine-High Dose 0

QL (1 ea per180 daysretail); AL: Atleast 65 yrs old

VAQTA SUSP 0


ZOSTAVAX SUSR 0

QL(1 ea per999 daysretail); AL(Atleast 60 yrsold)

VAGINAL AND RELATED PRODUCTS

Spermicides

ENCARE SUPP 2 QL(12 ea perfill retail)

nonoxynol-9 gel 1

OPTIONS CONCEPTROL VAGINAL CONTRACEPTIVE GEL (Use nonoxynol-9)

NP

OPTIONS GYNOL II VAGINALCONTRACEPTIV E GEL


SHUR-SEAL GEL 2 QL(24 gm perfill retail)

VCF VAGINAL CONTRACEPTIVE FILM FILM

2 QL(9 ea per fillretail)

Vaginal Anti-infectives CLEOCIN CREA VA 2 % (Use clindamycinphosphate vaginal)


clindamycin phosphatevaginal crea 1 QL(40 gm per

fill retail) clotrimazole vaginal crea 1% 1 QL(45 gm per

fill retail) clotrimazole vaginal crea 2% 1 QL(21 gm per

fill retail)

GYNAZOLE-1 CREA 2

GYNE-LOTRIMIN 3 CREA (Use clotrimazole vaginal) NP QL(21 gm per

fill retail)

Drug Name DrugTier

Requirements/Limits

GYNE-LOTRIMIN CREA (Use clotrimazole vaginal) NP QL(45 gm per

fill retail) METROGEL-VAGINAL GEL (Use metronidazole vaginal)


metronidazole vaginal gel 1 QL(70 gm perfill retail)

MICONAZOLE 3 SUPP 2 QL(3 ea per fillretail)

miconazole nitrate vaginalcrea 2 % 1 QL(45 gm per

fill retail) miconazole nitrate vaginalcrea 4 % 1 QL(15 gm

daily) miconazole nitrate vaginalkit 1 QL(24 gm per

fill retail) miconazole nitrate vaginalsupp 100 mg 1 QL(7 ea per fill

retail) MONISTAT 3 COMBINATION PACK KIT (Use miconazole nitrate vaginal)

NP

QL(24 gm perfill retail)

MONISTAT 3 CREA (Use miconazole nitrate vaginal) NP QL(15 gm

daily) MONISTAT 7 SIMPLY CURE CREA (Use miconazole nitrate vaginal)


TERAZOL 7 CREA (Use terconazole vaginal) NP QL(45 gm per

fill retail)

TERCONAZOLE CREA 2 QL(20 gm perfill retail)

terconazole vaginal crea0.4 % 1 QL(45 gm per

fill retail) terconazole vaginal supp80 mg 1 QL(3 ea per fill

retail)

tioconazole vaginal oint 1 QL(5 gm per fillretail)

Vaginal Estrogens ESTRACE CREA VA 0.1 MG/GM (Use estradiol vaginal)

NP QL(43 gm per30 days retail)

estradiol vaginal crea 0.1mg/gm 1 QL(43 gm per

30 days retail) estradiol vaginal tabs 10 mcg 1

PREMARIN CREA VA 0.625 MG/GM 2 QL(43 gm per

30 days retail)


190

Drug Name DrugTier

Requirements/Limits

VAGIFEM TABS (Use estradiol vaginal) NP

Vaginal Progestins

CRINONE GEL 2 AL(At least 15yrs old)

FIRST-PROGESTERONE VGS 100 COMPOUNDING KIT SUPP


FIRST-PROGESTERONE VGS 200 COMPOUNDING KIT SUPP

2

AL(At least 15yrs old)

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions

Anaphylaxis Therapy Agents AUVI-Q SOAJ 0.1 MG/0.1ML NP

AUVI-Q SOAJ 0.3 MG/0.3ML NP QL(4 ea per

365 days retail)

epinephrine (anaphylaxis)soaj 0.15 mg/0.15ml 2

2/30DAYS;QL(2 eaper 30 daysretail)

epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml NP

epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml, 0.3mg/0.3ml

2 QL(4 ea per365 days retail)

epinephrine (anaphylaxis)soaj 0.3 mg/0.3ml 1

QL(2 ea per fillretail,4 ea per365 days retail)

epinephrine (anaphylaxis)soaj 0.3 mg/0.3ml 1 QL(4 ea per

365 days retail) epinephrine (anaphylaxis)soaj 0.3 mg/0.3ml 1

EPIPEN 2-PAK SOAJ (Use epinephrine (anaphylaxis)) NP QL(4 ea per

365 days retail) EPIPEN-JR 2-PAK SOAJ (Use epinephrine(anaphylaxis))

NP QL(4 ea per365 days retail)

SYMJEPI SOSY 0.15 MG/0.3ML NP PA

SYMJEPI SOSY 0.3 MG/0.3ML NP

Neurogenic Orthostatic Hypotension (NOH) -

Drug Name DrugTier

Requirements/Limits

NORTHERA CAPS 2 PA; SP

Vasopressors

midodrine hcl tabs 1

VITAMINS

Oil Soluble Vitamins BABY DDROPS LIQD 400 UT/0.028ML (Use cholecalciferol)

NP

cholecalciferol caps or 1.25mg, 50000 unit 1 QL(0.267 ea

daily) cholecalciferol caps or 125mcg, 5000 unit 1 QL(2 ea daily)

cholecalciferol caps or 25mcg, 50 mcg, 1000 unit,2000 unit

1

cholecalciferol liqd or 400unit/ml, 5000 unit/ml, 400ut/0.028ml

1

D-VI-SOL LIQD (Use cholecalciferol) NP

DRISDOL CAPS (Use ergocalciferol) NP

ergocalciferol caps or 1.25mg, 50000 unit 1

ergocalciferol soln or 8000unit/ml NP

KEY-E CHEW OR 2 QL(2 ea daily)

MEPHYTON TABS (Use phytonadione) NP

phytonadione tabs or 5 mg 1

vitamin e caps or 100 unit,200 unit, 400 unit 1 QL(2 ea daily)

VITAMIN E CHEW OR 400 UNIT 2 QL(2 ea daily)

Water Soluble Vitamins ascorbic acid tabs or 250 mg, 500 mg, 1000 mg, 10mg-500 mg, 37 mg-500mg, 37 mg-1000 mg, 14mg-25 mg-500 mg, 25 mg-35 mg-500 mg

1



191

Drug Name DrugTier

Requirements/Limits

B-1 TABS 2 QL(2.94 eadaily)

niacin cpcr or 250 mg, 500 mg 1

niacin tabs or 500 mg 1

niacin tbcr or 250 mg, 500mg, 750 mg 1

NIACIN TR TBCR 2

pyridoxine hcl tabs or 25mg, 50 mg, 100 mg 1

riboflavin tabs or 25 mg, 50mg, 100 mg 1 QL(2.94 ea

daily) SLO-NIACIN TBCR (Use niacin) NP

thiamine hcl tabs or 50 mg,100 mg, 250 mg 1 QL(2.94 ea

daily)

thiamine mononitrate tabs 1 QL(2.94 eadaily)


192

Index 14-COUNT WARMER 120 ACCU-CHEK SOFTCLIX ACU-LIFE PILL 1ST TIER UNIFINE PENTIPS31GX8MM 155

LANCETS ACCUPRIL

97 32

CRUSHER/CONTAINER ACULAR

120 179

1ST TIER UNIFINE ACCURETIC 34 ACULAR LS 178 PENTIPSPLUS 31GX8MM 155 1ST TIER UNILET COMFORTOUCH LANCETS 28G 96 1ST TIER UNILET COMFORTOUCH LANCETS 30G 96 2-WAY FOLEY STABILIZATIONDEVICE 120 3-IN-1 BEDSIDE TOILET 120 3-IN-1 COMMODE 120 A + D PERSONAL CARE LOTION 68

ACCUTREND GLUCOSE 74 ACCUTREND PLUS 97 ACE AEROSOL CLOUD ENHANCER 158 acebutolol hcl 49 acetaminophen 6 acetaminophen w/ codeine 8 acetazolamide 82 acetic acid (otic) 179 acetylcysteine 59 ACIDOPHILUS 25

ACUVAIL 179 acyclovir 48 acyclovir topical 64 ADACEL 185 ADAGEN 2 ADALAT CC 50 adapalene 59 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADAPTER CAP BLUE A 18MM 120

abacavir sulfate 45 ACIDOPHILUS HIGH- ADAPTER CAP BLUE B abacavir sulfate-lamivudine 45 abacavir sulfate-lamivudine-zidovudine 45 ABILIFY 45 ABILIFY MAINTENA 44 ABILIFY MYCITE 45 abiraterone acetate 38 ABOUTTIME PEN NEEDLES 31G X 5/16" 155 ABRAXANE 41

POTENCY 25 ACIDOPHILUS PEARLS 25 ACIDOPHILUS PROBIOTIC BLEND 25 ACIDOPHILUS SUPER PROBIOTIC 25 ACIDOPHILUS/GOATMILK 25 ACIPHEX 187 ACIPHEX SPRINKLE 187 ACNE MEDICATION 10 59

20MM ADAPTER CAP BLUE C 22MM ADAPTER CAP BLUE D 24MM ADAPTER CAP BLUE E 28MM/SHORT NECKADAPTER CAP BLUE F 28MM/LONG NECKADAPTER CAP BLUE K 28MM/MEDIUM NECKADAPTER CAP BLUE M

120

120

120

120

120

120

ABSORICA 59 ACANYA 59 acarbose 22 ACCOLATE 14 ACCU-CHEK AVIVA 96 ACCU-CHEK AVIVA CONNECT 96 ACCU-CHEK AVIVA PLUS 74 ACCU-CHEK COMPACT PLUS 74 ACCU-CHEK COMPACT PLUS CARE KIT 96 ACCU-CHEK FASTCLIX LANCETS 96 ACCU-CHEK GUIDE 74 ACCU-CHEK GUIDE ME 96

ACNE MEDICATION 5 59 ACTEMRA 4 ACTEMRA ACTPEN 4 ACTHAR 83 ACTI-LANCE LANCETS 28G 97 ACTI-LANCE LITE SAFETY LANCETS 28G 97 ACTI-LANCE SPECIAL SAFETY LANCETS 17G 97 ACTI-LANCE SPECIAL SAFETYLANCETS 17G 97 ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G 97 ACTIGALL 87 ACTIMMUNE 40

24MM 120 ADAPTER CAP GREEN A 18MM 120 ADAPTER CAP GREEN B 20MM 120 ADAPTER CAP GREEN C 22MM 120 ADAPTER CAP GREEN D 24MM 120 ADAPTER CAP GREEN E 28MM/SHORT NECK 120 ADAPTER CAP GREEN F 28MM/LONG NECK 120 ADAPTER CAP GREEN K 28MM/MEDIUM NECK 120 ADAPTER CAP GREEN M 24MM 120 ADAPTER CAP RED A

ACCU-CHEK MULTICLIX LANCETS ACCU-CHEK NANO

96 ACTIVE 1ST BLOOD LANCETS30G/EASY TWISTCAP 97

18MM ADAPTER CAP RED B 20MM

120

120 SMARTVIEW 96 ACTIVELLA 86 ADAPTER CAP RED C ACCU-CHEK SAFE-T-PRO LANCETS ACCU-CHEK SAFE-T-PRO

96 ACTIVITY POUCH ACTONEL

158 82,83

22MM ADAPTER CAP RED D 24MM

120

120 PLUSLANCETS 96 ACTOPLUS MET 22 ADAPTER CAP RED E ACCU-CHEK SMARTVIEW STRIPS 74

ACTOPLUS MET XR ACTOS

22 23

28MM/SHORT NECK 120

Index 1

ADAPTER CAP RED F 28MM/LONG NECK 120 ADAPTER CAP RED K 28MM/MEDIUM NECK 120 ADAPTER CAP RED M 24MM 120 ADAPTER CAP WHITE B 20MM 120 ADAPTER CAP WHITE C 22MM 120 ADASUVE 44 ADCETRIS 37 ADCIRCA 51 ADD-VANTAGE ADDAPTOR CONNECTOR 120 ADDERALL 1 ADDERALL XR 1 ADEMPAS 52 ADJUST ALUMINUM CANE/ROUNDHANDLE/5/8" 120 ADJUST ALUMINUM CANE/ROUNDHANDLE/7/8" 121 ADJUST ALUMINUM OFFSET CANE/CUSH HANDLE/WRISTSTRAP/3/4" 121 ADJUST FOLD CANE/BLACKFIN/WALNUT PISTOL GRIPDERBY HANDLE 121 ADJUSTABLE BATH/SHOWERSEAT 121 ADJUSTABLE BATH/SHOWERSEAT/BACK 121 ADJUSTABLE COMMODE 3-IN-1 121 ADJUSTABLE FOLDING CANE/YORK HANDLE 121 ADLYXIN 23 ADLYXIN STARTER PACK 23 ADMELOG 23 ADMELOG SOLOSTAR 23 ADRENALIN 172 ADULT AEROSOL MASK 158 ADULT MASK 158 ADULT MASK LARGE 158 ADULT OMEGA PLUS DHA 3 ADULT PUSH BUTTON ALUMINUM CRUTCH 121 ADULT-LOCK SAFETY TABLETCUTTER 121 ADVAIR DISKUS 14 ADVAIR HFA 14

ADVANCE INTUITION BLOOD GLUCOSE METER 97 ADVANCE INTUITION BLOOD GLUCOSE MONITORING SYSTEM 97 ADVANCE INTUITION TEST STRIPS 74 ADVANCE MICRO-DRAW METER 97 ADVANCE MICRO-DRAW TEST STRIPS 74 ADVANCED MOBILE LANCET 30G 97 ADVANCED PROBIOTIC 25 ADVANCED PROBIOTIC 10 25 ADVANCED PROBIOTIC-14 25 ADVATE 89 ADVIL 4 ADVIL COLD & SINUS 58 ADVIL PM 92 ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM 97 ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM/TALKING 97 ADVOCATE DUO/TALKING 97 ADVOCATE INSULIN PEN NEEDLES 31GX8MM 155 ADVOCATE LANCETS 97 ADVOCATE LANCETS 30G 97 ADVOCATE REDI-CODE 74 ADVOCATE REDI-CODE+ BLOOD GLUCOSE SYSTEM/SPEAKING 97 ADVOCATE REDI-CODE+ BLOODGLUCOSE MONITORING SYSTEM 97 ADVOCATE REDI-CODE+ TESTSTRIPS 74 ADVOCATE REDI-CODE+/TALKING 97 ADVOCATE REDI-CODE/TALKING 97 ADVOCATE SAFETY LANCETS 97 ADVOCATE SAFETY LANCETS 26G 97 ADVOCATE TEST STRIPS 74 ADYNOVATE 89 ADZENYS ER 1

ADZENYS XR-ODT 1 AEROCHAMBER MINI AEROSOLCHAMBER 158 AEROCHAMBER MV 158 AEROCHAMBER PLUS FLOW VU 158 AEROCHAMBER PLUS FLOW-VU 158 AEROCHAMBER PLUS FLOW-VU/LARGE MASK 158 AEROCHAMBER PLUS FLOW-VU/MASK 158 AEROCHAMBER PLUS FLOW-VU/MEDIUM MASK 158 AEROCHAMBER PLUS FLOW-VU/SMALL MASK 158 AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VU 158 AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL 158 AEROCHAMBER Z-STAT PLUS/LARGE MASK 158 AEROCHAMBER Z-STAT PLUS/MEDIUM MASK 158 AEROCHAMBER Z-STAT PLUS/SMALL MASK 158 AEROCHAMBER/FLOWSIGNAL

158 AEROTRACH PLUS 158 AEROVENT PLUS HOLDING CHAMBER/COLLAPSIBLE 158 AFINITOR 39 AFINITOR DISPERZ 39 AFREZZA 24 AFSTYLA 89 AGAMATRIX AMP NO CODE ADVANCED BLOOD GLUCOSE MONITORING SYST 97 AGAMATRIX AMP NO CODE TEST STRIPS 74 AGAMATRIX JAZZ TEST STRIPS 74 AGAMATRIX JAZZ WIRELESS 2 97 AGAMATRIX KEYNOTE TEST STRIPS 74 AGAMATRIX PRESTO 97 AGAMATRIX PRESTO PRO METER 97 AGAMATRIX PRESTO TEST STRIPS 74 AGAMATRIX ULTRA-THIN LANCETS 33G 97 AGGRENOX 90 AIMOVIG 163

Index 2

AIMSCO TWIST LANCETS ALLEGRA-D 12 HOUR 32G 97 ALLERGY & AIMSCO TWIST LANCETS CONGESTION 58 33G 97 ALLEGRA-D 24 HOUR AIRS PEDIATRIC AEROSOL ALLERGY & MASK 158 CONGESTION 58 AJOVY 163 allopurinol 89 AKYNZEO 29 almotriptan malate 163 albuterol sulfate 14 ALOCRIL 179

ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/LIGHTGREEN 121 ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/MISTGRAY 121 ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/NATURAL 121 ALUMINUM FLIP OFF SEALS

ALBUTEROL SULFATE ER 14 alclometasone dipropionate 64 ALCOH-GLOVE CONTOURED WIPE 121 ALCOHOL PADS 121 ALCOHOL PREP PADS 121 ALCOHOL PREP PADS-MISC 96

ALOE 10000 & PROBIOTICS ALOE AFTERSUN LOTION alogliptin benzoate alogliptin-metformin hcl alogliptin-pioglitazone ALOMIDE

25

68 23 22 22

179

BLANK TOP/20MM/ROYALBLUE 121 ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/WHITE 121 ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/WILLOWGREEN 122 ALUMINUM FLIP OFF SEALS BLANK

ALCOHOL SWABS ALCOHOL SWABSTICK

121 121

ALORA ALPHAGAN P

86 176

TOP/20MM/YELLOW ALUMINUM HYDROXIDE

122 11

ALCOHOL WIPES 121 ALDACTAZIDE 82 ALDACTONE 82 ALDARA 71 ALDURAZYME 84 ALECENSA 39 ALENDRONATE SODIUM 83 alendronate sodium 83 ALENDRONATE SODIUM 83 ALER-DRYL 30 ALEVE 4 ALEVE ARTHRITIS 4 ALEVE DIRECT THERAPY TENSDEVICE REFILL GEL PADS 121 ALEVE PM 92 ALFERON N 40 alfuzosin hcl 88 ALGAL-900 DHA 173 ALHPAMOP FOAM REPLACEMENTPADS 121 ALIGN 25 ALIGN EXTRA STRENGTH 25 ALIMTA 36 ALKERAN 36

ALPHANATE/VONWILLEBRANDFACTOR COMPLEX/HUMAN 89 ALPHANINE SD 89 alprazolam 12 ALPRAZOLAM INTENSOL12 ALPROLIX 89 ALREX 178 ALTABAX 61 ALTACE 33 ALTOPREV 32 ALTRENO 60 alum & mag hydrox-simethicone 10 ALUMINUM BLANKET SUPPORT2 HEIGHTS 121 ALUMINUM FLIP OFF SEALS BLANK TOP/13MM/RED 121 ALUMINUM FLIP OFF SEALS BLANK TOP/13MM/ROYALBLUE 121 ALUMINUM FLIP OFF SEALS BLANK TOP/13MM/YELLOW 121 ALUMINUM FLIP OFF SEALS BLANK TOP/20MM/BLACK 121 ALUMINUM FLIP OFF SEALS

ALVESCO 14 amantadine hcl 42 AMARYL 25 AMBER GLASS BOTTLE 122 AMBER GLASS VIALS 2ML 122 AMBER GLASS VIALS 2ML/13MM 122 AMBER GLASS VIALS 30ML/20MM 122 AMBIEN 93 AMBIEN CR 93 ambrisentan 51 AMCINONIDE 64 AMEDA ADAPTER CAP 122 AMEDA BREAST FLANGE INSERT/22.5MM/SMALL 122 AMEDA CUSTOMFIT BREAST FLANGE/25MM/STANDARD

122 AMEDA CUSTOMFIT BREAST FLANGE/28.5MM/MEDIUM

122 AMEDA CUSTOMFIT BREAST FLANGE/30.5MM/LARGE 122 AMEDA DIAPHRAGMS 122 AMEDA DUAL HYGIENIKIT MILK COLLECTION

ALL FLOW 1000 PULMONARY BLANK SYSTEM 122 FUNCTION FILTER ALL-BODY MASSAGE

158 121

TOP/20MM/BLUE 121 ALUMINUM FLIP OFF SEALS

AMEDA DUAL HYGIENIKIT MILK COLLECTION

ALLEGRA ALLERGY ALLEGRA ALLERGY

30 BLANK TOP/20MM/GREEN 121

SYSTEM/PUMP ADAPTER122

CHILDRENS 30

Index 3

AMEDA DUAL HYGIENIKIT amiodarone hcl 13 ANTABUSE 182 SYSTEM/CUSTOMFIT amitriptyline hcl 21 ANTARA 31FLANGES/PUMP amlodipine besylate 50 ANTI-INFLAMMATORYADAPTER 122 AMEDA ELITE BREAST amlodipine besylate- ENZYMEFORMULA 81 PUMP 122 atorvastatin calcium 51 ANTIOXIDANT FORMULA 81 AMEDA FINESSE DOUBLE amlodipine besylate-benazepril ANUSOL-HC 10 ELECTRIC BREAST hcl 34 ANZEMET 28 PUMP 122 amlodipine besylate-olmesartan

APEXICON E 64AMEDA FINESSE DOUBLE medoxomil 34 ELECTRIC BREAST amlodipine besylate- APLENZIN 19 PUMP/DOTTIE TOTE 122 valsartan 34 APLICARE ALCOHOL AMEDA FINESSE DOUBLE amlodipine-valsartan- SWABSTICK 123 ELECTRIC BREAST hydrochlorothiazide 34 APLIGRAF 74 PUMP/MINNIE TOTE 122 AMOXAPINE 21 APNEASTRIP 123AMEDA FINESSE DOUBLE amoxicillin 181 APOKYN 42ELECTRIC BREAST AMOXICILLIN 181 APPLICATORPUMP/SHOULDER BAG 122 amoxicillin 181 ACCESSORIES/TAP-N-CLICKAMEDA FLEXISHIELD 122 amoxicillin & pot SILICONE PAD MULTI-AMEDA MYA JOY DOUBLE clavulanate 181 PURPOS 123ELECTRIC BREAST AMOXICILLIN/CLAVULANATE apraclonidine hcl 176PUMP 122 POTASSIUM 181AMEDA MYA JOY DOUBLE aprepitant 29AMOXICILLIN/CLAVULANATEELECTRIC BREAST APTENSIO XR 2POTASSIUM ER 181PUMP/LARGE TOTE 122 AMPHETAMINE ER 1 APTIOM 17AMEDA ONE-HAND BREAST PUMP/TOTE 122 amphetamine sulfate 1 APTIVUS 45 AMEDA ONE-HAND MANUAL amphetamine- AQUA GLYCOLIC HAND & BREAST PUMP 122 dextroamphetamine 1 BODYLOTION 68 AMEDA PLATINUM MULTI- AMPICILLIN 181 AQUA LACTEN 68 USER ELECTRIC BREAST AQUADERMAMPYRA 183PUMP 122 TREATMENT/MOISTURIZERAMRIX 170AMEDA PURELY YOURS 68 BREASTPUMP/HYGIENIKIT ANAFRANIL 21 AQUALANCE LANCETS ULTRA

122 ANAPROX DS 4 THIN 30G 98 AMEDA PURELY YOURS AQUAMED 68ANASPAZ 186DOUBLE ELECTRIC BREAST AQUORAL 167PUMP/CARRY ALL 122 anastrozole 38 AMEDA PURELY YOURS ANDEXXA 28 ARALAST NP 184 ELECTRIC BREAST ARANESP ALBUMIN FREE 91ANDRODERM 9PUMP/HYGIENIKIT 123 ARAVA 5ANDROGEL 10AMEDA SILICONE ARCALYST 4TUBING 123 ANDROGEL PUMP 10 AMEDA TUBING ANGEL WING BLOOD ARCAPTA NEOHALER 14 ADAPTER 123 COLLECTION ARESTIN 167 AMEDA VALVES 123 SET/HOLDER/23GX3/4" 123 ARGYLE SARATOGA SUMP AMERGE 163 ANGEL WING BLOOD DRAIN/20FR/20" 123

COLLECTION ARGYLE SARATOGA SUMPAMICAR 92 SET/HOLDER/25GX3/4" 123 DRAIN/24FR/20" 123AMIELLE RESTORE VAGINAL ANGEL WING LUER ARGYLE SARATOGA SUMPEXERCISERS 123 ADAPTER/TUBE HOLDER DRAIN/28FR/20" 123AMIELLE VAGINAL SET/FEMALE 123 ARGYLE TRACHEOSTOMYTRAINER 123 ANGEL WING TRANSFER TUBEHOLDER 123amiloride & DEVICE/FEMALE ARIAL CHAMBER 158hydrochlorothiazide 82 ADAPTER 123 ARICEPT 182amiloride hcl 82 ANGEL WING TUBE AMINO PM RMS 81 HOLDER/FEMALE LUER 123 ARIKAYCE 3

aminocaproic acid 92 ANORO ELLIPTA 14 ARIMIDEX 38

Index 4

aripiprazole 45 ASSURE II TEST STRIPS 74 AURORA PEN NEEDLES 31G X8MM 155ARISTADA 45 ASSURE LANCE

LANCETS 98 AURYXIA 88ARISTADA INITIO 45 ASSURE LANCE LANCETS AUTOCLAVE ACCESSORIESARIXTRA 16 21G 98 PRINTER PAPER 123 ARMOUR THYROID 185 ASSURE LANCE PLUS AUTOCLAVE AIR FILTER 123

SAFETYLANCETS 25G 98ARNUITY ELLIPTA 14 AUTOCLAVE PAPER 36" XASSURE LANCE PLUS 36" 123AROMASIN 38 SAFETYLANCETS 30G 98 AUTOCLAVE POUCH 7.5" Xarsenic trioxide 40 ASSURE LANCE SAFETY 13"/SELF-SEALING 123

ARTHRITIS PAIN LANCET 28G 98 AUVI-Q 191RELIEVING 71 ASSURE LANCETS 98 AVALIDE 34artificial tear ointment 175 ASSURE PLATINUM BLOOD AVANDIA 23ARYMO ER 7 GLUCOSE METER 98

ASSURE PLATINUM TEST AVAPRO 33ARZERRA 37 STRIPS 74 AVASTIN 37ascorbic acid 191 ASSURE PRISM MULTI AVEED 10ASMANEX HFA 14 BLOODGLUCOSE AVEENO ACTIVE NATURALSASMANEX TWISTHALER 120 MONITORING SYSTEM 98 DAILY MOISTURIZING BODYMETERED DOSES 14 ASSURE PRISM MULTI TEST YOGURT 68ASMANEX TWISTHALER 14 STRIPS 74 AVEENO ACTIVE NATURALSMETERED DOSES 14 ASSURE PRO BLOOD DAILY MOISTURIZING BODYASMANEX TWISTHALER 30 GLUCOSE METER 98 YOGURT/APRICO 68METERED DOSES 14 ASSURE PRO TEST AVEENO DAILYASMANEX TWISTHALER 60 STRIPS 74 MOISTURIZINGSPF 15 68METERED DOSES 14 ASTAGRAF XL 166 AVEENO POSITIVELYASMANEX TWISTHALER 7 ASTEPRO 171 AGELESSFIRMING BODY 68METERED DOSES 14 ATACAND 33 AVEENO POSITIVELYaspirin 6 RADIANT 68ATACAND HCT 34ASPIRIN 6 AVEENO STRESS RELIEFatazanavir sulfate 45aspirin 6 MOISTURIZING 68

ATELVIA 83aspirin buffered (cal carb-mag AVELOX 86 carb-mag oxide) 6 atenolol 49 AVODART 88 aspirin-dipyridamole 90 atenolol & chlorthalidone 34 AVONEX 183 ASPIRIN/OMEPRAZOLE 90 ATGAM 166 AVONEX PEN 183 ASPIRIN/OMEPRAZOLE ER90 ATIVAN 12 AVOSTARTGRIP 123 ASSURE 3 METER 98 atomoxetine hcl 1 AXERT 163 ASSURE 3 TEST STRIPS 74 atorvastatin calcium 32 AYGESTIN 182 ASSURE 4 BLOOD GLUCOSE ATRALIN 60 azacitidine 36METER 98 ATRIPLA 45 AZASAN 166ASSURE 4 TEST STRIPS 74 ATROPINE SULFATE 176 AZASITE 177ASSURE COMFORT LANCETS ULTRA THIN 28G 98 ATROVENT HFA 13 azathioprine 166 ASSURE HAEMOLANCE PLUS AUBAGIO 183 AZEDRA DOSIMETRIC 40HIGH FLOW 18G 98 AUGMENTED AZEDRA THERAPEUTIC 40ASSURE HAEMOLANCE PLUS BETAMETHASONE LOW FLOW 25G 98 azelastine hcl 171DIPROPIONATE 64ASSURE HAEMOLANCE PLUS AUGMENTIN 181 azelastine hcl (ophth) 179 MICRO FLOW 28G 98 azelastine hcl-fluticasoneAUGMENTIN ES-600 181ASSURE HAEMOLANCE PLUS propionate 171NORMAL FLOW 21G 98 AUGMENTIN XR 181 AZITHROMYCIN 95ASSURE HAEMOLANCE PLUS AURORA LANCET SUPER PEDIATRIC BLADE 98 THIN30G 98 azithromycin 95 ASSURE II 74 AURORA LANCET THIN AZOPT 179

23G 98ASSURE II CHECK STRIP 74 AZOR 34

Index 5

AZULFIDINE 87 BD LOGIC BLOOD GLUCOSE BENICAR HCT 34 MONITOR 98AZULFIDINE EN-TABS 87 BENLYSTA 167BD MICROTAINER

b complex w/ c 168 BENTYL 186LANCETS 98 B-1 192 BD PEN BENZAC AC WASH 60

NEEDLE/SHORT/ULTRA-b-complex vitamins 168 BENZACLIN 60FINE/31G X 8MM 155b-complex w/ c & folic acid 168 BENZACLIN WITH PUMP 60BD PHASEAL DRUG VIAL

BABY DDROPS 191 PROTECTOR/20MM BENZNIDAZOLE 11 BABY FRIDGE 123 NECK 123 benzonatate 58

BD PHASEAL DRUG VIALBACID 25 BENZOYL PEROXIDE 60PROTECTOR/28MMBACIGUENT 61 benzoyl peroxide 60NECK 124 bacitracin (topical) 61 BD PHASEAL INFUSION benztropine mesylate 42 bacitracin zinc 61 ADAPTER/CONNECTOR124 BEPREVE 179

BD PHASEAL INJECTORbacitracin-polymyxin b BERINERT 90LUERLOCK TRANSFER(ophth) 177 BESIVANCE 177DEVICE 124baclofen 170 BD PHASEAL LUER LOCK BETA CARE 68BACLOFEN 170 CONNECTOR/NEEDLE FREE BETAGAN 175BACTRIM 11 PORTS 124 betamethasone dipropionateBD PHASEAL SYRINGE TRAYBACTRIM DS 11 (topical) 64M15 124BACTROBAN 61 betamethasone dipropionateBD PHASEAL Y-SITE augmented 64BACTROBAN NASAL 171 CONNECTOR 124 betamethasone valerate 64BD SAFE CLIP NEEDLEbalsalazide disodium 87

CLIPPER 124 BETAPACE 49BAMBOO CANE 123 BD SAFE-CLIP BY MAIL 124 BETAPACE AF 49BANDAGE SCISSORS 123 BD SWABS SINGLE BETASERON 183BANZEL 17 USE 124 betaxolol hcl 49BARIATRIC ALUMINUM BD SWABS SINGLE USE CANE/OFFSET 123 BUTTERFLY 124 betaxolol hcl (ophth) 175 BARIATRIC CANE/OFFSET BEBULIN 89 bethanechol chloride 189 HANDLE/29"-38"/500LB BECONASE AQ 172 BETHKIS 3CAPACITY 123 BARIATRIC QUAD CANE/29"- BED WEDGE/10" 124 BETIMOL 175 38"/500LB CAPACITY 123 BED WEDGE/12" 124 BETOPTIC-S 175 BARIATRIC BED WEDGE/7" 124 BEUTLICH PH TEST ROLL124ROLLATOR/EXTRAWIDE/400LB BEDSIDE COMMODE 124 BEVACIZUMAB 176CAPACITY/HEAVY DUTY 123

BELBUCA 9 BEVESPI AEROSPHERE 15BASAGLAR KWIKPEN 24 39 40BATH BENCH WITH BACK123 BELEODAQ bexarotene

BATH/SHOWER SEAT WITH BELRAPZO 36 BEXSERO 189 BACK/ADJUSTABLE 123 BELSOMRA 94 BEYAZ 52 BATH/SHOWER BELT CLIP 124 BI-FOCAL MAGNIFIER 124SEAT/ADJUSTABLE 123

BENADRYL ALLERGY 30 bicalutamide 38BATHTUB SAFETY RAIL 123 BENADRYL ALLERGY BIKTARVY 45BAYER CONTOUR LINK 2.4 CHILDRENS 30BLOOD GLUCOSE bimatoprost 179benazepril &MONITORING SYSTEM 98 BINOSTO 83hydrochlorothiazide 34BD GLUCOSE 23 benazepril hcl 33 BIO-IMMUNEX 81

BD LANCET ULTRAFINE BENDAMUSTINE BIO-KULT 2530G 98 HYDROCHLORIDE 36 BIOHM PROBIOTICBD LANCET ULTRAFINE BENDEKA 36 SUPPLEMENT 2533G 98 BIOHM PROBIOTICBD LATITUDE DIABETES BENEFIX 89 SUPPLEMENT/VITAMIN C 25MANAGEMENT SYSTEM 98 BENICAR 33

Index 6

BIOSCANNER GLUCOSE TEST BOTTLE AMBER BRIDION 28 STRIPS 75 8OZ/GRADUATED/OVAL BRILINTA 90BIOTEL CARE CONNECTED PET/24-400/CAP 124 brimonidine tartrate 177BLOOD GLUCOSE BOTTLE AMBER GLASS MONITORING SYSTEM 98 33OZ/BOSTON BRISDELLE 184 BIOTENE DRY MOUTH ROUND/33/430 NECK/RIBBED BRIVIACT 17MOISTURIZING SPRAY 167 CAP 124 BROMASE 81bisacodyl 95 BOTTLE/6OZ/WHITE/HDPE/WI

TH TWIST TOP SIFTER bromfenac sodium (ophth) 179bismuth subsalicylate 25 CAP 124 bromocriptine mesylate 42bisoprolol & BOTTLE/BOSTON ROUND brompheniramine &hydrochlorothiazide 34 NATURAL 124 phenyleph 58bisoprolol fumarate 49 BOTTLE/THIN WALL 124 brompheniramine &BIVIGAM 180 BOTTLETOP DISPENSER pseudoeph 58 BLEPH-10 177 0.25-2.0ML 124 BROMSITE 179 BLEPHAMIDE 178 BOTTLETOP DISPENSER BROVANA 15ADAPTER/38MM 124BLEPHAMIDE S.O.P. 178 BSS & BSS PLUS ADMINBOULES QUIES EAR SET 124BLINCYTO 37 PLUGS 124 BUBBLE POINT TESTERBLISTER PACK ADHESIVE BRAFTOVI 39 KIT/WIZARD 124LABEL 124 BREAST PUMP 124 BUBBLES THE FISH IIBLISTER PACK/AMBER 12 BREAST SELF EXAM PEDIATRIC MASK/PVC 159CAVITY 124 PROGRAM 124 budesonide 57BLOOD COLLECTION TUBE BREATHE EASE NEBULIZERHOLDER/WITH NEEDLE 124 budesonide (inhalation) 14MASK/CHILD 159BLOOD COLLECTION TUBE budesonide (nasal) 172BREATHE EASE NEBULIZERHOLDER/WITHOUT MASK/INFANT 159 BUDESONIDE/FORMOTEROLNEEDLE 124 BREATHE EASE/LARGE FUMARATE DIHYDRATE 15BLOOD GLUCOSE MASK 159 BUFFERIN 7MONITORINGSYSTEM 98 BREATHE EASE/MEDIUM BULLSEYE MINI SAFETYBLOOD GLUCOSE MASK 159 LANCETS 98MONITORINGSYSTEM BREATHE EASE/SMALL BULLSEYE SAFETYPREMIUM 98 MASK 159 LANCETS 99BLOOD GLUCOSE SYSTEM

BREATHERITE 159 bumetanide 82PAK 98 BLOOD GLUCOSE TEST BREATHERITE BUMEX 82 STRIPS 75 COLLAPSIBLEADULT BUNAVAIL 9BLOOD GLUCOSE TEST SPACER W/MASK 159

BUPHENYL 84STRIPS PREMIUM 75 BREATHERITE BLOW MOLDED BATHTUB COLLAPSIBLECHILD SPACER buprenorphine 9 TRANSFER BENCH 124 W/MASK 159 buprenorphine hcl 9BLOW MOLDED BATHTUB BREATHERITE buprenorphine hcl-naloxone hclTRANSFER BENCH/COMMODE COLLAPSIBLEINFANT dihydrate 9SEAT/PAIL 124 SPACER W/MASK 159 bupropion hcl 19BREATHERITEBONIVA 83 bupropion hcl (smokingCOLLAPSIBLESMALL CHILDBOOSTRIX 185 SPACER W/MASK 159 deterrent) 184 BORTEZOMIB 39 BUPROPIONBREATHERITE

HYDROCHLORIDE ER (XL) 19bosentan 51 COLLAPSIBLESPACER W/NEONATE MASK 159 buspirone hcl 12BOSULIF 39 BREATHERITE RIGID butalbital-acetaminophen 6BOTOX 172 SPACERW/MASK 159 butalbital-acetaminophen-BOTTLE BREATHERITE W/LARGE caffeine 6ADAPTERS/24MM/PRESS-IN MASK 159 butalbital-acetaminophen-124 BREATHERITE W/MEDIUM caffeine w/ codeine 8BOTTLE AMBER MASK 159 butalbital-aspirin-caffeine 616OZ/GRADUATED/OVAL BREATHERITE W/SMALL butalbital-aspirin-caffeinePET/28-400/CAP 124 MASK 159 w/cod 8BREO ELLIPTA 15

Index 7

BUTALBITAL/ASPIRIN/CAFFEIN CANE TIPS/3/4" 125 CANE/ALUMINUM/BRONZE/OFE 6 CANE TIPS/3/4" QUAD NON- FSET HANDLE/CUSHBUTRANS 9 SUCTION 125 GRIP/WRIST STRAP/3/4 125

CANE TIPS/5/8" QUAD CANE/ALUMINUM/BRONZE/ORBYDUREON 23 SUCTION TYPE 125 THO HANDLE/3/4" 125BYDUREON PEN 23 CANE/ALUMINUM/BRONZE/YOCANE TIPS/7/8"-1" 125BYETTA 23 RKHANDLE/7/8" 125CANE TIPS/BLACK/3/4" 125 CANE/ALUMINUM/FOLDING/36"BYSTOLIC 49 CANE TIPS/BLACK/7/8"- BLACK 126BYVALSON 34 1" 125 CANE/ALUMINUM/FOLDING/AD

CABOMETYX 39 CANE TIPS/GREY/3/4" 125 JUSTABLE/BLACK 126 CADUET 51 CANE TIPS/GREY/7/8"- CANE/ALUMINUM/FOLDING/AD

1" 125 JUSTABLE/BRONZE-TONECAFERGOT 163 CANE TIPS/ICE GRIP 126caffeine citrate 1 TIP 125 CANE/ALUMINUM/FOLDING/ADCALAN 50 CANE WITH JUSTABLE/BRONZE/ORTHOCALAN SR 50 STRAP/BLACK 125 HANDLE 126

CANE WRIST STRAP 125 CANE/ALUMINUM/FOLDING/BLIcalcipotriene 63 ND 126CANE/ADJUSTABLE/ALUMINCALCIPOTRIENE 63 CANE/ALUMINUM/MEDUM/ROUND HANDLE 125calcipotriene-betamethasone PEWTERBLUE/ORTHOCANE/ADJUSTABLE/ALUMINdipropionate 64 HANDLE/3/4" 126UM/ROUND HANDLEcalcitonin (salmon) 83 5/8" 125 CANE/ALUMINUM/OFFSET

CUSHIONED HANDLE/WRISTCALCITRIOL 63 CANE/ADJUSTABLE/PAISLEYSTRAP/3/4" 126calcitriol 84 125 CANE/ALUMINUM/OFFSETCANE/ALUMINUM/ADJUSTABCALCIUM ACETATE 164 HANDLE/NO SAFETYLE/BRONZE

calcium acetate (phosphate LOCKNUT/3/4" 126TONE/STANDARDbinder) 88 CANE/ALUMINUM/OFFSETHANDLE 125 calcium carbonate (antacid) 11 CANE/ALUMINUM/ADJUSTAB ORTHO 126

CANE/ALUMINUM/OFFSETcalcium carbonate- LE/DEVON HANDLE 125 cholecalciferol 164 CANE/ALUMINUM/ADJUSTAB ORTHO GRIP/BLACK 126

CANE/ALUMINUM/OFFSETcalcium carbonate-vitamin LE/LADIES HANDLE 125 ORTHO HANDLE/WRISTd 164 CANE/ALUMINUM/ADJUSTABSTRAP/3/4" 126calcium polycarbophil 94 LE/MENS HANDLE 125 CANE/ALUMINUM/ORTHO/BROCANE/ALUMINUM/ADJUSTABCAM 68 NZE 126LE/OFFSETcamphor & menthol 63 CANE/ALUMINUM/ROUNDHANDLE/7/8" 125

CAMPTOSAR 41 CANE/ALUMINUM/ADJUSTAB HANDLE/5/8" 126 CANE/ALUMINUM/ROUNDCANASA 87 LE/OFFSET HANDLE/7/8" 126HANDLE/AUTUMNcandesartan cilexetil 33 CANE/ALUMINUM/TELESCOPICBRONZE 125candesartan cilexetil- /BRONZE/MEDIUMCANE/ALUMINUM/ADJUSTABhydrochlorothiazide 34 HANDLE/7/8" 126LE/OFFSET

CANE HOLDER 124 CANE/ALUMINUM/TELESCOPICHANDLE/BLACK 125 /LARGE HANDLE/3/4" 126CANE TIPS 3/4" 124 CANE/ALUMINUM/ADJUSTAB CANE/ALUMINUM/TELESCOPICCANE TIPS 7/8" 125 LE/OFFSET HANDLE/BLUE /MEDIUM HANDLE/7/8" 126ICE 125CANE TIPS FOR CANE/DESIGNER OFFSETCANE/ALUMINUM/ADJUSTABALUM/3/4" 125 HANDLE 126LE/OFFSETCANE TIPS FOR WOOD CANE/LADY/BRONZE 126HANDLE/VIOLET 1251" 125 CANE/ALUMINUM/BLACK/DE CANE/MENS 126CANE TIPS FOR WOOD VONHANDLE/7/8" 125 CANE/OFFSET5/8" 125 CANE TIPS FOR CANE/ALUMINUM/BRONZE- HANDLE/ALUMINUM/29"-38"

TONE 125WOOD/3/4" 125 126 CANE/ALUMINUM/BRONZE/FCANE TIPS FOR CANE/OFFSET

WOOD/7/8" 125 OLDING/ORTHO HANDLE/ALUMINUM/29"-HANDLE/3/4" 125 38"/CAMOUFLAGE 126CANE TIPS/1" 125

Index 8

CANE/OFFSETHANDLE/ALUMINUM/29-38"

126 CANE/OFFSETHANDLE/ALUMINUM/ADJUSTABLE 126 CANE/ROSEWOOD/1" 126 CANE/STANDARD/BLACKHANDLE 126 CANE/STANDARD/BRONZEHANDLE 126 CANE/T-HANDLE/ALUMINUM/29"-38"

126 CANE/T-HANDLE/ALUMINUM/29"-38"/FLORAL PATTERN 126 CANE/T-HANDLE/BLACK &BLUE 126 CANE/WOOD/BLACK/ROUNDHANDLE/1" 126 CANE/WOOD/BLACK/ROUNDHANDLE/7/8" 126 CANE/WOOD/LADIESSTANDARDHANDLE/EBONYFINISH/13/16" 126 CANE/WOOD/LADIESSTANDARDHANDLE/ROSEWOOD FINISH/13/16" 126 CANE/WOOD/LADIESSTANDARDHANDLE/STAINEDWALNUT FINISH 127 CANE/WOOD/LADIES/T-HANDLEBLACK WOOD 127 CANE/WOOD/LADIES/T-HANDLEWALNUT/3/4" 127 CANE/WOOD/MENS ROUNDHANDLE/ROSEWOODFINISH 127 CANE/WOOD/MENSSTANDARD HANDLE/EBONYFINISH/1" 127 CANE/WOOD/MENSSTANDARD HANDLE/ROSEWOODFINISH/1" 127 CANE/WOOD/MENSSTANDARD HANDLE/STAINEDWALNUT WOOD 127 CANE/WOOD/MENS T-HANDLE/BLACK WOOD 127 CANE/WOOD/NATURALASH/ROUND HANDLE/1" 127 CANE/WOOD/NATURALASH/ROUNDHANDLE/7/8" 127 CANE/WOOD/ROSEWOOD/1"

127

CANE/WOOD/STANDARD/BLACKFINISH/1" 127 CANE/WOOD/STANDARD/BLACKFINISH/7/8" 127 CANE/WOOD/STANDARD/NATURAL FINISH/1" 127 CANE/WOOD/STANDARD/NATURAL FINISH/7/8" 127 CANE/WOOD/STANDARD/WALNUT42"LONG 127 CANE/WOOD/STANDARD/WALNUTFINISH/7/8" 127 CANE/WOOD/T-HANDLE/WALNUT3/4" 127 CANE/WOOD/T-HANDLE/WALNUTFINISH/1"

127 CANE/WOOD/T-HANDLE/WALNUTFINISH/13/16" 127 CANE/WOOD/WALNUT/7/8"

127 CANE/WOOD/WALNUT/PISTOL GRIP DERBY HANDLE/7/8" 127 CANE/WOOD/WALNUT/ROUND HANDLE/7/8" 127 capecitabine 36 CAPEX 64 CAPHOSOL 167 CAPRELSA 39 capsaicin 71,72 captopril 33 CAPTOPRIL/HYDROCHLOROTHIAZIDE 34 CAPZASIN-HP 72 CAPZASIN-P 72 CARAC 63 CARAFATE 187 CARBAGLU 84 carbamazepine 17 carbamide peroxide (otic) 179 CARBATROL 17 carbidopa 42 carbidopa-levodopa 42 carboplatin 36 CARDIO COMPLETE 81 CARDIO OMEGA BENEFITS/VITAMIN D-3 173 CARDIOSTEROL 3 CARDIZEM 50 CARDIZEM CD 50 CARDIZEM LA 50

CARDURA 33 CAREFINE PEN NEEDLES 31GX8MM 155 CAREONE BLOOD GLUCOSE MONITORING SYSTEM/PREMIUM 99 CAREONE BLOOD GLUCOSE MONITORING SYSTEM/VALUE 99 CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM 75 CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE 75 CAREONE LANCET THIN 99 CAREONE LANCET ULTRA THIN 99 CAREONE UNIFINE PENTIPS 31GX8MM 155 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX8MM 155 CARESENS LANCETS 99 CARESENS N BLOOD GLUCOSETEST STRIPS 75 CARESENS N GLUCOSE MONITORING SYSTEM 99 CARESENS N VOICE BLOOD GLUCOSE MONITORING SYSTEM 99 CARETOUCH 2 CPAP HOSE HANGER 159 CARETOUCH ALCOHOL PREP PADS 127 CARETOUCH BLOOD GLUCOSE MONITORING SYSTEM 99 CARETOUCH BLOOD GLUCOSE TEST STRIPS 75 CARETOUCH CPAP & BIPAP HOSE/6FT 159 CARETOUCH CPAP MASK WIPES 159 CARETOUCH CPAP NEUTRALIZING PRE-WASH 159 CARETOUCH CPAP TUBE CLEANING BRUSH 159 CARETOUCH PEN NEEDLES 31GX 8MM 155 CARETOUCH SAFETY LANCETS/26G 99 CARETOUCH SAFETY LANCETS/28G 99 CARETOUCH SAFETY LANCETS/30G 99 CARETOUCH TWIST LANCETS 30G 99

Index 9

CARETOUCH UNIVERSAL CERAVE AM SPF 30 68 chlorothiazide 82 CPAPFILTERS 159 CERAVE PM 68 chlorpheniramine maleate 30CAREX COCCYX

CERAVE SA RENEWING 68 chlorpromazine hcl 44CUSHION 127 CAREX ULTRA GRABBER CERDELGA 91 chlorthalidone 82 32" 127 CEREZYME 91 CHLORZOXAZONE 170 CAREX WHEELCHAIR 127 CERVICAL PILLOW 127 chlorzoxazone 170CARIMUNE CERVICAL PILLOW/BREATHE CHOICE DM DIABETES RISKNANOFILTERED 180 EASY 127 IN-HOME TEST KIT 99carisoprodol 170 CERVICAL CHOLBAM 87 carisoprodol w/ aspirin 171 PILLOW/COVER 127 cholecalciferol 191CARISOPRODOL/ASPIRIN CERVICAL

cholestyramine 31171 PILLOW/ORTHOPEDIC 127 CARNITOR 84,85 CERVICAL ROLL cholestyramine light 31

PILLOW/CONTOUR 127CARNITOR SF 84 choline & mag salicylate 7CETAPHIL DAILY ADVANCE CHOLINE MAGNESIUMCARTEOLOL HCL 175 ULTRA HYDRATING 68 TRISALICYLATE 7carvedilol 48,49 CETAPHIL DAILY FACIAL CHORIONICMOISTURIZER 68carvedilol phosphate 48 GONADOTROPIN 83CETAPHIL DERMACONTROLCASODEX 38 CHRONOVISION 81MOISTURIZER/SPF 30 68 CASTIVA WARMING 72 CETAPHIL CICLODAN CREAM KIT 62 CATAPRES 33 MOISTURIZING 68 CICLODAN SOLUTION KIT 62

CETAPHILCATHETER INTRODUCER127 ciclopirox 62RESTORADERM 69 CAYSTON 12 ciclopirox olamine 62cetirizine hcl 30 cefaclor 52 cetirizine-pseudoephedrine CICLOPIROX TREATMENT 62 CEFACLOR 52 58 cilostazol 91

CETRAXAL 180 CILOXANCEFACLOR ER 52 177 CETROTIDE 84 cimetidinecefadroxil 52 186

cefdinir 52 CHANTIX 184 CIMETIDINE HCL 186 CHANTIX CONTINUINGCEFDITOREN PIVOXIL 52 CIMZIA 87MONTHPAK 184

cefixime 52 CIMZIA STARTER KIT 87CHANTIX STARTING MONTH cefpodoxime proxetil 52 PAK 184 cinacalcet hcl 85 cefprozil 52 CHEMET 28 CINIS PREEMIE HALO

LARGE 127ceftriaxone sodium 52 CHEMO TRANSFER PIN 127 CINIS PREEMIE HALO cefuroxime axetil 52 CHEMSTRIP-K 75 MEDIUM 128 CELEBREX 4 CHENODAL 87 CINIS PREEMIE HALO

celecoxib 4 CHERACOL PLUS 58 SMALL 128 CINQAIR 13CELEXA 20 CHERACOL-D COUGH 58 CINRYZE 90CELLCEPT 166 CHILDRENS ADVIL 4 CIPRO 86CELLCEPT CHILDRENS MOTRIN 4

INTRAVENOUS 166 CHILDRENS PROBIOTIC CIPRO HC 180 CELONTIN 19 PEARLS 25 CIPRODEX 180 CENTANY 61 CHLOR-TRIMETON 29 ciprofloxacin 86 CENTANY AT 61 chlordiazepoxide hcl 12 CIPROFLOXACIN 180

chlorhexidine gluconatecephalexin 52 CIPROFLOXACIN ER 86(mouth-throat) 167CEPROTIN 90 CIPROFLOXACIN HCL 86chloroquine phosphate 35CERALYTE 70 164 ciprofloxacin hcl 86CHLOROQUINECERASPORT 164 PHOSPHATE 35 ciprofloxacin hcl (ophth) 177 CERASPORT EX1 164 chloroquine phosphate 35 CISPLATIN 36 CERAVE 68 CHLOROTHIAZIDE 82 cisplatin 36

Index 10

CISPLATIN citalopram hydrobromide cladribine CLARINEX CLARINEX-D 12 HOUR CLARITHROMYCIN clarithromycin CLARITIN CLARITIN ALLERGY

36 20 36 30 58 96 96 30

CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM 159 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM/3YEA 159 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/SMALL 159 CLEVER CHOICE ANTI-

clindamycin phosphate(topical) 60 clindamycin phosphatevaginal 190 clindamycin phosphate-benzoylperoxide 60 clindamycin phosphate-benzoylperoxide (refrigerate) 60 clindamycin phosphate-tretinoin 60 CLIP & STOR 128

CHILDRENS 30 STATICVALVED HOLDING CLN FACIAL MOISTURIZER CLARITIN CHILDRENS 30 CLARITIN REDITABS 30 CLARITIN-D 12 HOUR 58 CLARITIN-D 24 HOUR 58 CLASSICS ROLLING WALKER 128 CLEANLET LANCETS 28G 99 CLEANROOM TACKY MAT 18" X36"/60 LAYER 128 CLEAR GLASS VIALS 10ML 128 CLEAR GLASS VIALS 2ML128

CHAMBER/SMALLINFANT 159 CLEVER CHOICE AUTO-CODE PRO BLOOD GLUCOSE MONITORING SYSTEM 99 CLEVER CHOICE AUTO-CODE PRO TEST STRIPS75 CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES 31GX8MM 155 CLEVER CHOICE COMFORT EZPEN NEEDLES 31GX8MM 155

NOURISHING 69 clobazam 16 clobetasol propionate 64 clobetasol propionate emollientbase 64 clobetasol propionateemulsion 64 CLOBEX 65 CLOCORTOLONE PIVALATE 65 CLOCORTOLONE PIVALATE PUMP 65 CLODERM 65

clemastine fumarate 30 CLEOCIN 11,190 CLEOCIN PEDIATRIC GRANULES 11 CLEOCIN-T 60 CLEVER CHEK AUTO CODE VOICE BLOOD GLUCOSE MONITORING SYSTEM 99 CLEVER CHEK AUTO-CODE 99 CLEVER CHEK AUTO-CODE BLOOD GLUCOSE MONITORING SYSTEM 99 CLEVER CHEK AUTO-CODE TEST STRIPS 75 CLEVER CHEK AUTO-CODE VOICE BLOOD GLUCOSE MONITORING SYSTEM 99 CLEVER CHEK AUTO-CODE VOICE TEST STRIPS 75 CLEVER CHEK BLOOD GLUCOSE MONITORING SYSTEM 99 CLEVER CHEK LANCETS ULTRATHIN 99 CLEVER CHEK LANCETS ULTRATHIN 30G 99 CLEVER CHEK TEST STRIPS 75 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/ADULT LARGE 159

CLEVER CHOICE DIGITAL BMI SCALE 128 CLEVER CHOICE ELECTRIC BREAST PUMP 128 CLEVER CHOICE MICRO BLOODGLUCOSE MONITORING SYSTEM 99 CLEVER CHOICE MICRO TESTSTRIPS 75 CLEVER CHOICE MINI BLOODGLUCOSE MONITORING SYSTEM 99 CLEVER CHOICE PULSE OXIMETER 128 CLEVER CHOICE TALK BLOODGLUCOSE MONITORING SYSTEM 99 CLICKFINE PEN NEEDLE UNIVERSAL/31GX5/16" 155 CLICKFINE PEN NEEDLES 31G X 5/16" 155 CLICKFINE PEN NEEDLES 31G X 8MM 155 CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16" 155 CLIMARA 86 CLINDAGEL 60 clindamycin hcl 11 clindamycin palmitatehydrochloride 12 CLINDAMYCIN PHOSPHATE 60

CLODERM PUMP 65 clomipramine hcl 21 clonazepam 16 clonidine hcl 33 clonidine hcl (adhd) 1 clopidogrel bisulfate 91 clorazepate dipotassium 12 clotrimazole (topical) 62 clotrimazole vaginal 190 clotrimazole w/betamethasone 62 clozapine 44 CLOZAPINE ODT 44 CLOZARIL 44 CO MONITOR REPLACEMENT TPIECES 159 COAGADEX 89 COAGUCHEK LANCETS 99 coal tar extract 74 COARTEM 35 COCOA BUTTER 69 COCOA BUTTER HAND & BODYLOTION 69 cod liver oil 170 CODEINE SULFATE 7 codeine sulfate 7 COLACE 95

Index 11

COLACE CLEAR 95 COMMODE CORDARONE 13 BEDSIDE/BACK 128COLAZAL 87 CORDRAN 65COMMODE PAIL WITH

colchicine 89 COREG 49HANDLE/LID/12QT 128 colchicine w/ probenecid 89 COMMODE SPLASH COREG CR 49

GUARD 128COLCRYS 89 CORGARD 49COMPACT SPACECOLEMAN 100 MAX INSECT CORIFACT 89CHAMBER/ANTI-STATICREPELLENT/CONTINUOUS 160 COROMEGA OMEGA 3SPRAY 72 KIDS 173COMPACT SPACECOLEMAN INSECT COROMEGA OMEGA 3CHAMBER/ANTI-REPELLENT/HIGH & DRY 72 SQUEEZE 173STATIC/LARGE MASK 160COLEMAN INSECT COMPACT SPACE CORTANE-B-OTIC 180REPELLENT/SPORTSMEN 72 CHAMBER/ANTI- CORTEF 57COLESTID 31 STATIC/MEDIUM MASK 160 CORTENEMA 10COLESTID FLAVORED 31 COMPACT SPACE CORTISONE ACETATE 57colestipol hcl 31 CHAMBER/ANTI-

STATIC/SMALL MASK 160 CORTROSYN 74COLYTE-FLAVOR PACKS 94 COMPLERA 45 CORZIDE 34COMAR PRESS-IN BOTTLE COMPOSITE TRANSFERADAPTERS 24MM 128 COSENTYX 63 BENCH 128COMBIGAN 176 COSENTYX SENSOREADY CONCERTA 2 PEN 63COMBIPATCH 86 CONDOMS-MISC 96 COSOPT 176COMBIVENT RESPIMAT 15 CONTOUR BACK COSOPT PF 176COMBIVIR 45 CUSHION 128 cosyntropin 74COMETRIQ 39 CONTOUR BLOOD GLUCOSE

COTELLIC 39COMFORT ASSURED MONITORING SYSTEM 100 LANCETS MICRO THIN CONTOUR BLOOD GLUCOSE COUMADIN 15 33G 99 TEST STRIPS 75 COVERALL COMFORT ASSURED CONTOUR FITTED BOOTS/DISPOSABLE/UNIVERSLANCETS SUPER THIN SHEETS 128 AL 128 28G 99 CONTOUR MATTRESS COVERALL W/COMFORT CURVE MASSAGE COVER 128 HOOD/SMALL/DISPOSABLECUSHION 128 CONTOUR NEXT BLOOD 128 COMFORT EZ SHORT/31G X GLUCOSE MONITORING COVERALL 8MM 155 SYSTEM 100 W/HOOD/3XL/DISPOSABLECOMFORT FIT FLANGES CONTOUR NEXT BLOOD 128 LARGE 128 GLUCOSE TEST 75 COVERALL COMFORT LANCETS 100 CONTOUR NEXT EZ BLOOD W/HOOD/XL/DISPOSABLE

GLUCOSE MONITORINGCOMFORT 128SYSTEM 100MASSAGER/CORDLESS 128 COVERALLCONTOUR NEXT LINKCOMFORT PERSONAL W/HOOD/XXL/DISPOSABLEBLOOD GLUCOSECLEANSING CART 128 128MONITORING SYSTEM 100COMFORT PERSONAL COVERALLSCONTOUR NEXT LINKCLEANSING MICROWAVE128 MEDIUM/ELASTICBACK/WRIST/WIRELESS BLOOD GLUCOSECOMFORT PERSONAL ANKLES 128MONITORING SY 100CLEANSING SHAMPOO COZAAR 33CONTOUR NEXT ONECAP 128 CREON 81BLOOD GLUCOSECOMFORT PERSONAL MONITORING SYSTEM 100 CRESTOR 32CLEANSING WARMER/14-

COUNT 128 CONZIP 7 CRINONE 191 COMFORT PERSONAL COOL BLOOD GLUCOSE CRIXIVAN 45 CLEANSING WARMER/28- MONITORING KIT 100 CROMOLYN SODIUM 13COUNT 128 COOL BLOOD GLUCOSE

MONITORING SYSTEM 100 cromolyn sodium 13COMMODE 3-IN-1 128 COOL BLOOD GLUCOSE cromolyn sodium (nasal) 171COMMODE BEDSIDE 128 TEST STRIPS 75 cromolyn sodium (ophth) 179COPAXONE 183

Index 12

CROTAN 73 CRUTCH/ALUMINUM/TALL/PU CURITY ALCOHOL SHBUTTON 129 SWABS 130CRUTCH ACCESSORY CRUTCH/ALUMINUM/TALL/PU CUSTOM-FLEXKIT 128 130 SHBUTTON ADJ 129CRUTCH ACCESSORY CUTIVATE 65CRUTCH/ALUMINUM/YOUTHKIT/ARMPADS/HAND CUTTER 72GRIPS/TIPS 128 129 CRUTCH/ALUMINUM/YOUTH/ CUTTER ALL FAMILY 72CRUTCH ARMPADS 128 ARMPADS/TIPS/GRIPS 129 CUTTER BACKWOODS 72CRUTCH HANDGRIPS 129 CRUTCH/ALUMINUM/YOUTH/ CUTTER BACKWOODSCRUTCH HANDGRIPS PUSH BUTTON 129 DRY 72PREMIUM 129 CRUTCH/ALUMINUM/YOUTH/ CUTTER DRY 72CRUTCH PUSH-BUTTON ADJ 129

HANDGRIPS/SOLID 129 CRUTCH/FOREARM/ADULT CUTTER SKINSATIONS 72 CRUTCH 129 CUTTER SPORT 72HANDGRIPS/SPLIT 129 CRUTCH/FOREARM/YOUTH CUVITRU 180CRUTCH PILLOWS/ARM AND 129 CVS ADULT 50+HAND 129 CRUTCH/STANDARD PROBIOTIC 26CRUTCH FOREARM/ADULT 129 SET/ALUMINUM/LARGE 129 CRUTCH/WOOD/ADULT/48"- CVS ADULT PROBIOTIC 26 CRUTCH 60" 129 CVS ADVANCED GLUCOSE SET/WOOD/ADULT 129 CRUTCH/WOOD/ADULT/ARM METER 100 CRUTCH PADS/TIPS/GRIPS 129 CVS ADVANCED GLUCOSE SET/WOOD/MEDIUM 129 CRUTCH/WOOD/YOUTH/34"- METER TEST STRIPS 75 CRUTCH 42" 129 CVS ALCOHOL PREP SET/WOOD/YOUTH 129 CRUTCH/WOOD/YOUTH/ARM PADS 130 CRUTCH TIPS/EXTRA- PADS/TIPS/GRIPS 129 CVS ALKALINE LARGE/7/8" 129 CRUTCHES/ALUMINUM/ADUL BATTERIES/SIZE AA 130 CRUTCH T 130 CVS BEAUTY 360 DRY TIPS/JUMBO/GREY 129 CRUTCHES/ALUMINUM/ADUL SKIN 69 CRUTCH TIPS/REGULAR 129 T/TALL 130 CVS CANE 130 CRUTCH TIPS/SUPER 129 CRYSVITA 85 CVS CRUTCHES CRUTCH TIPS/SUPER CUBE PESSARY 130 UNIVERSAL 130

CVS DAILY ULTRAGRIP/BROWN 129 CUBE MOISTURELOTIONCRUTCH UNDERARM PESSARY/DRAINS 130 69 CVS DIGESTIVEPADS 129 CUFF ACCESSORIES PROBIOTIC 26CRUTCH UNDERARM PADS DISPOSABLE BULB &

PREMIUM 129 VALVE 130 CVS DRY MOUTH SPRAY 167 CRUTCH-MATE/ADULT CUFF ACCESSORIES CVS EAR PLUGS 130 ARM 129 DISPOSABLE SINGE HEAD CVS FOLDING CANE GELCRUTCH-MATE/ADULT STETHOSCOPE 130 GRIP 130FOREARM 129 CULTURELLE ADULT CVS GLUCOSE 23CRUTCH-MATE/ADULT HAND ULTIMATEBALANCE 27 CVS GLUCOSE METER TESTGRIPS 129 CULTURELLE ADVANCED STRIPS 75CRUTCH-MATE/ADULT HAND IMMUNE DEFENSE 25 CVS INSECT REPELLENT 72GRIPS LARGE 129 CULTURELLE DIGESTIVE CRUTCH/ALUMINUM/ADULT HEALTH 27 CVS LANCETS 21G 100

129 CULTURELLE DIGESTIVE CVS LANCETS MICRO THIN CRUTCH/ALUMINUM/ADULT/5'2 HEALTH PROBIOTIC 27 33G 100 "-5'10" 129 CULTURELLE HEALTH & CVS LANCETS MICRO-THIN CRUTCH/ALUMINUM/ADULT/A WELLNESS 27 33G 100 RMPADS/TIPS/GRIPS 129 CULTURELLE KIDS 25 CVS LANCETS ORIGINAL 100CRUTCH/ALUMINUM/ADULT/P CULTURELLE KIDS CVS LANCETS THIN 26G 100USH BUTTON 129 REGULARITY 25CRUTCH/ALUMINUM/ADULT/P CVS LANCETS ULTRA THIN

CULTURELLE PRO-WELL25 30G 100USH-BUTTON ADJ 129 CRUTCH/ALUMINUM/MEDIUM CULTURELLE PROBIOTICS CVS LANCETS ULTRA-THIN

KIDS 26 30G 100 CRUTCH/ALUMINUM/TALL

129 CURITY ALCOHOL CVS MOOD SUPPORT

ADULT/PUSH BUTTON 129 PREPS/MEDIUM 2 PLY 130 PROBIOTIC 26

Index 13

CVS NEEDLE COLLECTION & DISPOSAL 130 CVS PILL SPLITTER 130 CVS PORTABLE DIABETIC ORGANIZER 130 CVS PREP PADS 130 CVS PROBIOTIC 26 CVS PROBIOTIC MAXIMUM

DACOGEN 37 DAILY MOISTURIZING 69 DAILY PROBIOTIC 26 DAKLINZA 47 dalfampridine 183 DALIRESP 14 DANTRIUM 171

DDS 500 LUMBAR TRACTION BELT/PANELS/49"-51" 131 DDS 500 LUMBAR TRACTION BELT/PANELS/52"-55" 131 DDS 500 LUMBAR TRACTION BELT/PANELS/56"-59" 131 DEBROX 180 decitabine 37

STRENGTH 26 CVS PROBIOTIC PEARLS EXTRA STRENGTH 26 CVS PULSE OXIMETER 130 CVS PULSE OXIMETER/PORTABLE 130 CVS QUAD CANE 130 CVS READY SET GO DELUXE ALIMINUM BATH BENCH 130 CVS REUSABLE SHEET PROTECTOR 130 CVS RUBBER CUSHION/INFLATABLE 130 CVS SENIOR PROBIOTIC 26

dantrolene sodium 171 dapsone 11 DARAPRIM 35 darifenacin hydrobromide 188 DARZALEX 37 daunorubicin hcl 38 DAUNORUBICIN HYDROCHLORIDE 38,39 DAURISMO 38 DAYPRO 4 DAYTRANA 2 DDAVP 85

DECON-A 58 DEEP-TISSUE 131 deferasirox 28 deferoxamine mesylate 28 DEFITELIO 15 DEFLUX 89 DELSTRIGO 45 DELUXE SAFETY TABLET CUTTER 131 DELUXE TABLET CUTTER 131 DELUXE VINYL PADDED BATHTUB TRANSFER

CVS SOFT GLUCOSE 23 CVS TOTAL HOME INSECT

DDS 100 CERVICAL TRACTIONCOLLAR 130

BENCH/FULL SEAT DEMADEX

131 82

REPELLENT 72 DDS 300 LUMBAR TRACTION DEMSER 33 CVS ULTRA THIN LANCETS cyanocobalamin cyclobenzaprine hcl CYCLOGYL

100 91

170 176

BELT/26"-28" 130 DDS 300 LUMBAR TRACTION BELT/29"-32" 130 DDS 300 LUMBAR TRACTION BELT/33"-35" 130 DDS 300 LUMBAR TRACTION

DENAVIR DENTAL GUARD DEODORANT PLASTIC TUBES2.65OZ/CAPS DEPAKENE

64 131

131 19

cyclopentolate hcl cyclosporine cyclosporine modified (formicroemulsion) CYMBALTA cyproheptadine hcl CYRAMZA CYSTADANE CYSTAGON CYSTARAN cytarabine CYTARABINEAQUEOUS CYTOGAM

176 166

166 21 31 37 85 88

179 37 37

180

BELT/36"-38" 130 DDS 300 LUMBAR TRACTION BELT/39"-41" 130 DDS 300 LUMBAR TRACTION BELT/42"-44" 130 DDS 300 LUMBAR TRACTION BELT/45"-48" 130 DDS 300 LUMBAR TRACTION BELT/49"-51" 130 DDS 300 LUMBAR TRACTION BELT/52"-55" 130 DDS 300 LUMBAR TRACTION BELT/56"-59" 130 DDS 500 LUMBAR TRACTION BELT/PANELS/26"-28" 131 DDS 500 LUMBAR TRACTION

DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES DEPEN TITRATABS DEPO-PROVERA CONTRACEPTIVE DEPO-SUBQ PROVERA 104 DEPO-TESTOSTERONE DERMA-SMOOTHE/FSBODY DERMA-SMOOTHE/FSSCALP DERMACINRX SILAPAK

19 19 19

165

57

57 10

65

65 65

CYTOMEL 185 CYTOTEC 188 D-CARE BLOOD GLUCOSE 75 D-CARE DM2 22 D-CARE GLUCOMETER KIT/GLUCOSE TESTSTRIPS 100 D-VI-SOL 191 D.H.E. 45 163

BELT/PANELS/29"-32" 131 DDS 500 LUMBAR TRACTION BELT/PANELS/33"-35" 131 DDS 500 LUMBAR TRACTION BELT/PANELS/36"-38" 131 DDS 500 LUMBAR TRACTION BELT/PANELS/39"-41" 131 DDS 500 LUMBAR TRACTION BELT/PANELS/42"-44" 131 DDS 500 LUMBAR TRACTION BELT/PANELS/45"-48" 131

DERMACINRX TICANASE PAK 171 DERMAGRAFT 74 DERMAL THERAPY EXTRA STRENGTH BODY LOTION 69 DERMAL THERAPY FACE CAREMOISTURIZING LOTION 69 DERMAL THERAPY FOOT MASSAGE 69

Index 14

DERMAL THERAPY HAND dexrazoxane hcl 41 diflunisal 7 ELBOW & KNEE CREAM 69 DERMAL THERAPY HEEL CARE 69 DERMAZONE 65 DERMOTIC 180 DESCOVY 45 DESFERAL 28 desipramine hcl 21 DESLORATADINE ODT 30 desmopressin acetate 85 desmopressin acetate spray 85 desmopressin acetate sprayrefrigerated 85 DESOGEN 53 desogestrel & ethinylestradiol 53 desogestrel-ethinyl estradiol(biphasic) 53 desogestrel-ethinyl estradiol(triphasic) 53 DESONATE 65

DEXTENZA 178 dextroamphetamine sulfate 1 dextromethorphan-guaifenesin

59 DHS TAR 74 DHS TAR GEL 74 DIABETIDERM 69 DIABETIDERM HAND & BODY 69 DIACOMIT 17 DIAL-A-DOSE SYRINGE 15ML/TIPS 131 DIAL-A-DOSE SYRINGE 30ML/TIPS 131 DIAL-A-DOSE SYRINGE 60ML/TIPS 131 DIASTAT ACUDIAL 16 DIASTAT PEDIATRIC 16 DIATHRIVE BLOOD GLUCOSE METER 100 DIATHRIVE BLOOD

DIGESTIVE ADVANTAGE 26 DIGESTIVE ADVANTAGE LACTOSE DEFENSE FORMULA 26 DIGITAL GLASS SCALE 131 digoxin 51 DIGOXIN 51 digoxin 51 dihydroergotaminemesylate 163 DILANTIN 19 DILANTIN INFATABS 19 DILANTIN-125 19 DILAUDID 7 DILT-XR 50 diltiazem hcl 50 diltiazem hcl coated beads 50 diltiazem hcl extended release beads 50 DIMETAPP COLD &

desonide DESOWEN DESOXIMETASONE

65 65 65

GLUCOSE TEST STRIPS 75 DIATHRIVE LANCETS 100 DIATHRIVE LANCETS ULTRA THIN 30G 100

ALLERGY 59 DINAMAP MONITOR PROBE COVERS 131 DIOVAN 33

desoximetasone DESOXYN DESVENLAFAXINE ER desvenlafaxine succinate DETROL DETROL LA DEX4 QUICK DISSOLVE GLUCOSE dexamethasone DEXAMETHASONE dexamethasone DEXAMETHASONE DEXAMETHASONE INTENSOL

65 1

21 21

188 188

23 57 57 57 57

57

DIATRUE PLUS BLOOD GLUCOSE MONITORING SYSTEM 100 DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS 75 diazepam 12 DIAZEPAM 12 diazepam 13 DIAZEPAM RECTAL GEL 16 dibucaine 72 DICLEGIS 29 diclofenac potassium 4 diclofenac sodium 4 diclofenac sodium (ophth)179

DIOVAN HCT 34 DIPENTUM 87 diphenhydramine hcl 30 diphenhydramine hcl (sleep) 92 diphenhydramine-acetaminophen(sleep) 93 diphenoxylate w/ atropine 28 DIPHENOXYLATE/ATROPINE

28 DIPROLENE 65 DIPROLENE AF 65 dipyridamole 91 DISH PESSARY 131 DISH

dexamethasone sodium phosphate 57 DEXAMETHASONE SODIUM PHOSPHATE 178 DEXCHLORPHENIRAMINE MALEATE 30 DEXEDRINE 1

diclofenac sodium (topical) 61 dicloxacillin sodium 181 dicyclomine hcl 186 DIDANOSINE 45 DIFF-STAT 26 DIFFERIN 60

PESSARY/SUPPORT disopyramide phosphate DISPENSER BOTTLES 50ML/FOAMER PUMPSDISPENSER MD JAR 50ML/AIRLESS/VIEWWINDOW

131 13

131

131 DEXILANT 187 dexmedetomidine hcl 93 dexmedetomidine hcl in sodium chloride 93 dexmethylphenidate hcl 2

DIFFUSER ULTRA SONIC/LAVENDER OILDIFLORASONE DIACETATE diflorasone diacetate DIFLUCAN

131

65 65 29

DISPENSER MD PEN 6.5ML/AIRLESS/CLICKDISPENSER MD PEN 6.5ML/AIRLESS/VIEWWINDOW

131

131

Index 15

DISPENSER MD PUMP DISPENSER MD SYRINGE docusate sodium 95 0.5ML/ACTUATOR A 131 5ML/VIEW dofetilide 13DISPENSER MD PUMP WINDOW/AIRLESS 132 DOLOPHINE 70.5ML/ACTUATOR DISPENSER A/BLUE 131 MEGAPUMP/AIRLESS/OVAL/3 donepezil hydrochloride 182 DISPENSER MD PUMP 0ML/0.3ML/T-FILL/CAP 132 DONUT PESSARY 1330.5ML/ACTUATOR DISPENSER DOPTELET 91A/GREEN 131 MEGAPUMP/AIRLESS/ROUNDISPENSER MD PUMP D/100ML/1.5ML/B-FILL WITH DORAL 93 0.5ML/ACTUATOR A/PINK 132 CAP 132 dorzolamide hcl 179 DISPENSER MD PUMP DISPENSER DORZOLAMIDE HCL 1791.0ML/ACTUATOR B 132 MEGAPUMP/AIRLESS/ROUN dorzolamide hcl-timololDISPENSER MD PUMP D/150ML/1.5ML/B-FILL WITH maleate 1761.0ML/ACTUATOR CAP 132 DORZOLAMIDE HCL/TIMOLOLB/BLUE 132 DISPENSER MALEATE 176DISPENSER MD PUMP MEGAPUMP/AIRLESS/ROUN DOVATO 451.0ML/ACTUATOR D/150ML/1ML/B-FILL WITHB/GREEN 132 DOVER COMMODE SPECIMENCAP 132 DISPENSER MD PUMP DISPENSER COLLECTOR 133 1.0ML/ACTUATOR B/PINK 132 MEGAPUMP/AIRLESS/ROUN DOVER MIDSTREAM

SPECIMENCATCH KIT 133DISPENSER MD PUMP D/15ML/0.3ML/T-FILL WITH1.5ML/ACTUATOR C 132 CAP 132 DOVONEX 63 DISPENSER MD PUMP DISPENSER doxazosin mesylate 33 1.5ML/ACTUATOR MEGAPUMP/MEZZOROUND/3 doxepin hcl 21C/BLUE 132 0ML/0.5ML/T-FILL WITH DOXEPIN HCL 21DISPENSER MD PUMP CAP 1321.5ML/ACTUATOR DISPENSER doxepin hcl 21 C/GREEN 132 MEGAPUMP/MEZZOROUND/5 doxepin hcl (sleep) 93DISPENSER MD PUMP 0ML/0.5ML/T-FILL WITH doxycycline (monohydrate) 1851.5ML/ACTUATOR C/PINK 132 CAP 132DISPENSER MD PUMP doxycycline hyclate 185DISPENSERBOTTLE100ML/VIEW MEGAPUMP/MEZZOROUND/5 doxylamine succinateWINDOW/AIRLESS 132 0ML/0.5ML/T-FILL/CAP 132 (sleep) 93 DISPENSER MD PUMP DISPENSER doxylamine-pyridoxine 29 BOTTLE150ML/VIEW MEGAPUMP/MEZZOROUND/7 DRISDOL 191WINDOW/AIRLESS 132 5ML/0.5ML/T-FILL WITH droperidol 12DISPENSER MD PUMP CAP 132BOTTLE15ML/VIEW DISPENSER TIP DROPLET LANCETS ULTRA

THIN 30G 100WINDOW/AIRLESS 132 CAP/PRECISEDOSE/SELF-DISPENSER MD PUMP DROPLET PEN NEEDLESRIGHTING 132BOTTLE200ML/VIEW DISPENSER/MD FOAMER 31GX8MM 155 WINDOW/AIRLESS 132 DROPPER & SCREW CAPWITHACTUATOR 4OZ 133DISPENSER MD PUMP 0.5ML/50ML 133 DROPPING BOTTLE 30ML133BOTTLE240ML/VIEW DISPENSER/MD FOAMERWINDOW/AIRLESS 132 WITHACTUATOR DROPSAFE SAFETY PEN DISPENSER MD PUMP 0.7ML/110ML 133 NEEDLES/31G X 5/16" 156 BOTTLE30ML/VIEW DROPTAINER TIP CAPS 133disulfiram 182WINDOW/AIRLESS 132 DROPTAINERS 10ML 133DITROPAN XL 188DISPENSER MD PUMP DROPTAINERSBOTTLE50ML/VIEW divalproex sodium 19 15ML/OPHTHALMIC 133WINDOW/AIRLESS 132 DIVERTER VALVE/BATH DROPTAINERSDISPENSER MD PUMP ACCESSORY 133 3ML/OPHTHALMIC 133BOTTLE80ML/VIEW DOCETAXEL 41 DROPTAINERSWINDOW/AIRLESS 132 docetaxel 41 7ML/OPHTHALMIC 133DISPENSER MD SYRINGE drospirenone-ethinyl10ML/VIEW DOCETAXEL 41

estradiol 53WINDOW/AIRLESS 132 DOCETAXEL (NON-ALCOHOL drospirenone-ethinyl estradiol-FORMULA) 41 levomefolate calcium 53docosahexaenoic acid 173

Index 16

DROXIA 91 E-Z JECT LANCETS SUPER EASY STEP TEST STRIPS 75 THIN 30G 101DRUG MART LANCETS EASY TALK BLOOD GLUCOSEE-Z JECT LANCETS THINTHIN 100 MONITORING

DRUG MART ON-THE-GO 26G 101 SYSTEM/TALKING 101E-Z LOCK RAISED TOILETLANCETS GENTLE 30G 100 EASY TALK BLOOD GLUCOSESEAT 133DRUG MART UNIFINE TEST STRIPS 75E-Z LOCK RAISED TOILETPENTIPS31GX8MM 156 EASY TOUCH ALCOHOL PREP

DRUG MART UNILET SEAT/ARMS 133 PADS/MEDIUM 133E-ZJECT LANCETS MICRO-LANCETSSUPER THIN EASY TOUCH GLUCOSETHIN 33G 10130G 100 MONITORING SYSTEM 101

DRUG MART UNILET E.E.S. 400 96 EASY TOUCH GLUCOSE TEST LANCETSULTRA THIN E.E.S. GRANULES 96 STRIPS 75 28G 100 EASY TOUCH LANCETSEAR SYRINGE 133DRUG MART UNILET MICRO 21G/PRESSUREEAR SYRINGE/INFANT 133THIN LANCETS 33G 101 ACTIVATED 101 DRY EYE OMEGA EAR WAX REMOVAL KIT/TRI- EASY TOUCH LANCETS BENEFITS/VITAMIN D-3 173 STREAM TIP 133 23G/PRESSUREDRYSOL 72 EARPLUGS 133 ACTIVATED 101

EARPOPPER MIDDLE EAR EASY TOUCH LANCETSDUAC 60 INFLATION DEVICE 133 26G/PRESSUREDUAL HEAD STETHOSCOPE EASIVENT 160 ACTIVATED 101BLACK 133 EASY TOUCH LANCETSDUAL HEAD STETHOSCOPE EASIVENT/MASK-LARGE26G/PULL-TOP 101NAVY 133 160 EASY TOUCH LANCETSDUAL PADDLE FOLDING EASIVENT/MASK-MEDIUM28G/PRESSUREWALKER/ADULT 133 160

DUAL-HEAD EASIVENT/MASK-SMALL ACTIVATED 101 EASY TOUCH LANCETSSTETHOSCOPE 133 160

EASY COMFORT ALCOHOL 28G/PULL-TOP 101DUETACT 22 EASY TOUCH LANCETSPADS 133DULCOLAX 95 EASY COMFORT 28G/TWIST 101 EASY TOUCH LANCETSDULERA 15 LANCETS 101

duloxetine hcl 21 EASY COMFORT LANCETS 30G/BUTTON-ACTIVATED

DUNLAP FOAM RING 30G/PULL TOP 101 101 EASY TOUCH LANCETSEASY COMFORT LANCETSCUSHION/LARGE 133 30G/THIN TOP 101 30G/PRESSUREDUNLAP FOAM RING EASY COMFORT LANCETS ACTIVATED 101CUSHION/MEDIUM 133 EASY TOUCH LANCETSTWIST TOP 101DUNLAP INFLATABLE VINYL EASY COMFORT PEN 30G/PULL-TOP 101RING CUSHION 16" 133 NEEDLES31GX5/16" 156 EASY TOUCH LANCETS

DUO-CARE 101 EASY FEED DOUBLE 30G/TWIST 101 DUO-CARE TEST STRIPS 75 EASY TOUCH LANCETSELECTRIC BREAST FEEDING

32G/PRESSUREDUPIXENT 68 PUMP 133 EASY PLUS BLOOD ACTIVATED 101DURAGESIC 7 EASY TOUCH LANCETSGLUCOSE MONITOR 101DURLAZA 91 EASY PLUS BLOOD 32G/PULL-TOP 102

dutasteride 88 EASY TOUCH LANCETSGLUCOSE MONITORING 32G/TWIST 102dutasteride-tamsulosin hcl 88 SYSTEM 101 EASY TOUCH LANCETSEASY PLUS BLOODDUTOPROL 34 GLUCOSE TEST STRIPS 75 33G/TWIST 102

DYANAVEL XR 1 EASY TOUCH PEN NEEDLESEASY PLUS II BLOOD DYAZIDE 82 GLUCOSE MONITORING 31GX5/16" 156

EASY TOUCH SAFETYSYSTEM 101DYMISTA 171 EASY PLUS II BLOOD LANCETS21G/PRESSUREDYSPORT 172 ACTIVATED 102GLUCOSE TEST 75 E-Z JECT LANCETS 101 EASY STEP BLOOD EASY TOUCH SAFETY

LANCETS23G/PRESSUREE-Z JECT LANCETS 21G 101 GLUCOSE MONITOR 101 EASY STEP BLOOD ACTIVATED 102E-Z JECT LANCETS GLUCOSE MONITORCOLOR 101 STARTER KIT 101

Index 17

EASY TOUCH SAFETY EASYPRO BLOOD GLUCOSE ELEMENT PLUS BLOOD LANCETS26G/BUTTON TEST STRIPS 75 GLUCOSE METER 103 ACTIVATED 102 EASYPRO PLUS 76 ELEMENT TEST STRIPS 76 EASY TOUCH SAFETY EBASE CONTROLLER ELESTAT 179LANCETS26G/PRESSURE KIT 160 eletriptan hydrobromide 163ACTIVATED 102 EC-NAPROSYN 5EASY TOUCH SAFETY ELIDEL 71 LANCETS28G/BUTTON EC-NAPROXEN 5 ELIGARD 38ECO-SMARTFUNNELACTIVATED 102 ELIMITE 73EASY TOUCH SAFETY 186ML/DISPOSABLE 133 LANCETS28G/PRESSURE econazole nitrate 62 ELIQUIS 15 ACTIVATED 102 ECOTRIN MAXIMUM ELIQUIS STARTER PACK 15 EASY TRAK II CONTROL STRENGTH 7 ELITE DC AUTO SOLUTION/NORMAL 102 ECOTRIN REGULAR ADAPTER 160EASY TRAK BLOOD GLUCOSE STRENGTH 7 ELIXOPHYLLIN 15MONITORING SYSTEM 102 EDARBI 33 ELLA 56EASY TRAK BLOOD GLUCOSE EDARBYCLOR 34TEST STRIPS 75 ELLENCE 39

EDLUAR 93EASY TRAK II BLOOD ELMIRON 88 GLUCOSE MONITORING EDURANT 45 ELOCON 65SYSTEM 102 efavirenz 45 ELOCTATE 89EASY TRAK II BLOOD EFFEXOR XR 21GLUCOSE TEST STRIPS 75 ELON PROFESSIONAL NAIL EASY TWIST & CAP EFFIENT 91 CARE SYSTEM 134 LANCETS 102 EFLOW SCF AEROSOL ELONGATED TOILET SEAT EASYGLUCO 75 HEAD 160 ELEVATOR 134

EFUDEX 63 EMADINE 179EASYGLUCO PLUS 75 EASYGLUCO STARTER EGG CRATE BED PAD/2" EMBEDA 7 KIT 102 CALKING SIZE 133 EMBRACE BLOOD GLUCOSE EASYMAX 15 TEST EGG CRATE BED PAD/2" MONITORING SYSTEM 103 STRIPS 75 DUALKING SIZE 133 EMBRACE BLOOD GLUCOSE EASYMAX L BLOOD GLUCOSE EGG CRATE BED PAD/2" MONITORING SYSTEM 102 FULLSIZE 133 SYSTEM/TALKING 103 EASYMAX N BLOOD GLUCOSE EGG CRATE BED PAD/2" EMBRACE BLOOD GLUCOSE SYSTEM 102 QUEEN SIZE 133 TEST STRIPS 76 EASYMAX NG SELF- EGG CRATE BED PAD/2" EMBRACE EVO BLOOD MONITORING BLOOD TWINSIZE 133 GLUCOSE MONITORING GLUCOSE SYSTEM 102 EGRIFTA 84 KIT 103

EMBRACE EVO BLOODEASYMAX TEST STRIPS 75 ELAPRASE 85 GLUCOSETEST STRIPS 76EASYMAX V BLOOD GLUCOSE ELDEPRYL 42 EMBRACE LANCETS ULTRASYSTEM 102 ELECTRODES THIN 30G 103EASYMAX V BLOOD GLUCOSE 2"X2"/REUSABLE 133 EMBRACE PRO BLOODSYSTEM/TALKING 102 ELECTROTHERAPY PAIN GLUCOSE METER 103EASYMAX V2 SELF- RELIEF 133 EMBRACE PRO BLOODMONITORING BLOOD ELECTROTHERAPY PAIN GLUCOSETEST STRIPS 76GLUCOSE RELIEF/LONG LIFE PADS/2.5" EMBRACE TALK BLOODSYSTEM/SPEAKING 102 X 4" 133 GLUCOSE MONITOR 103EASYPLUS BLOOD GLUCOSE ELELYSO 91 EMBRACE TALK BLOODTEST STRIP 75 ELEMENT AUTOCODE GLUCOSE MONITORINGEASYPLUS R13N SELF- SYSTEM 102 SYSTEM 103MONITORING BLOOD ELEMENT COMPACT BLOOD EMBRACE TALK BLOODGLUCOSE SYSTEM 102 GLUCOSE MONITORING GLUCOSE TEST STRIPS 76EASYPLUS V SELF- SYSTEM 102 EMBRACE TALK GLUCOSEMONITORING BLOOD ELEMENT COMPACT TEST CONTROL SOLUTIONGLUCOSE STRIPS 76 HIGH 103SYSTEM/SPEAKING 102 ELEMENT COMPACT V EMBRACE TALK GLUCOSEEASYPRO BLOOD GLUCOSE BLOODGLUCOSE CONTROL SOLUTIONMONITORING SYSTEM 102 MONITORING SYSTEM 102 LOW 103

Index 18

EMCYT 38 EMEND 29 EMEND TRIPACK 29 EMFLAZA 57 EMGALITY 163 EMOLLIA-LOTION 69 emollient 69 EMPLICITI 37 EMPTY VIAL 3ML 134 EMSAM 20 EMTRIVA 45 EMVERM 11 ENABLEX 188 enalapril maleate 33 enalapril maleate &hydrochlorothiazide 34 ENBREL 6 ENBREL MINI 6 ENBREL SURECLICK 6 ENCARE 190 ENDOSCOPIC DELIVERY SYSTEM 134 ENDURANCE FOUR LEG SEAT CANE 134 ENDURANCE HD HEAVY DUTY COMMODE 134 ENFAMIL ENFALYTE 164 ENGERIX-B 189 ENLYTE 80 enoxaparin sodium 16 ENSTILAR 66 ENTERALITE INFINITY ENTERAL PUMP UNIVERSAL POLE CLAMP 134 ENTRESTO 51 ENTYVIO 87 EPANED 33 EPCLUSA 47 EPIDIOLEX 17 EPIDUO 60 EPIDUO FORTE 60 EPIFOAM 66 EPILYT 69 epinastine hcl (ophth) 179 epinephrine (anaphylaxis) 191 EPIPEN 2-PAK 191 EPIPEN-JR 2-PAK 191 epirubicin hcl 39

EPIVIR 45 EPOGEN 91 epoprostenol sodium 51 EPROSARTAN MESYLATE 33 EPZICOM 45 EQ BATH & SHOWER SEAT/BACK 134 EQ BLOOD GLUCOSE TEST STRIPS 76 EQ FOLDING WALKER 134 EQ PROBIOTIC DIGESTIVE SYSTEM SUPPORT 26 EQL ADVANCED RECOVERY SKIN CARE 69 EQL ALCOHOL SWABS 134 EQL COLOR LANCETS 21G 103 EQL COLOR LANCETS MICRO THIN 33G 103 EQL DAILY PROBIOTIC 26 EQL DRY MOUTH ORAL RINSE 167 EQL EAR PLUGS/SILICONE 134 EQL MUSTACHE/BEARDSCISSORS/COMB 134 EQL PROBIOTIC COLON SUPPORT 26 EQL SKIN CARE TOOL 134 EQL SUPER THIN LANCETS 30G 103 EQL THIN LANCETS 26G 103 EQL ULTRA MOISTURIZING DAILY LOTION 69 EQUALYTE 164 EQUETRO 43 ERBITUX 37 ergocalciferol 191 ERGOLOID MESYLATES 184 ergotamine w/ caffeine 163 ERIVEDGE 38 ERLEADA 38 erlotinib hcl 39 ertapenem sodium 11 ERWINAZE 40 ERYGEL 60 ERYPED 200 96 ERYPED 400 96 ERYTHROCIN STEARATE 96

ERYTHROMYCIN 96 erythromycin (acne aid) 60 erythromycin (ophth) 177 erythromycin base 96 erythromycin ethylsuccinate 96 ERYTHROMYCIN ETHYLSUCCINATE 96 ESBRIET 185 escitalopram oxalate 20 ESGIC 6 esomeprazole magnesium 187 ESOMEPRAZOLE STRONTIUM 187 estazolam 93 ESTRACE 86,190 estradiol 86 estradiol & norethindrone acetate 86 estradiol vaginal 190 ESTROPIPATE 86 ESTROSTEP FE 53 ESTROVEN WEIGHT MANAGEMENT 81 eszopiclone 93 ethambutol hcl 36 ethosuximide 19 ethynodiol diacet & ethestrad 53 ETIDRONATE DISODIUM 83 etodolac 5 etonogestrel-ethinyl estradiol56 ETOPOSIDE 41 etoposide 41 EUCERIN 69 EUCERIN BABY 69 EUCERIN DAILY PROTECTION/SPF 30 69 EUCERIN INTENSIVE REPAIR 69 EUCERIN ORIGINAL HEALINGSOOTHING REPAIR 69 EUCERIN PLUS 69 EUCERIN PROFESSIONAL REPAIR RICH FEEL 69 EUCERIN SMOOTHING REPAIRADVANCED FORMULA 69 EUCRISA 73 EUFLEXXA 171 EURAX 73

Index 19

EVAC 94 EYLEA 176 FEIBA 89 EVEKEO 1 EZ SMART BLOOD GLUCOSE felbamate 18

LANCETS 103EVENCARE + BLOOD FELBATOL 18EZ SMART BLOOD GLUCOSEGLUCOSETEST STRIP 76 FELDENE 5TEST STRIPS 76EVENCARE BLOOD GLUCOSE EZ SMART DIABETES felodipine 50MONITORING SYSTEM 103 MONITORING SYSTEM 103EVENCARE BLOOD GLUCOSE FEMARA 38EZ SMART PLUS BLOODTEST STRIP 76 FEMHRT LOW DOSE 86GLUCOSE TEST STRIPS 76EVENCARE G2 BLOOD EZ SMART PLUS DIABETES FENOFIBRATE 31,32GLUCOSEMONITORING

SYSTEM 103 MONITORING SYSTEM 103 fenofibrate 32 EVENCARE G2 TEST EZ-LETS LANCETS 21G 103 31fenofibrate micronized STRIPS 76 EZ-LETS LANCETS 26G FENOFIBRIC ACID 32EVENCARE G3 BLOOD SUPER-SOFT 103

FENOGLIDE 32GLUCOSEMONITORING EZ-LETS LANCETS 28G SYSTEM 103 ULTRA-SOFT 103 FENSOLVI 38 EVENCARE G3 TEST EZ-LETS LANCETS 30G 103 fentanyl 7STRIPS 76 ezetimibe 32 FER-IN-SOL 92EVENCARE MINI BLOOD ezetimibe-simvastatin 31 FERRETTS 92GLUCOSE MONITORING

EZY DOSE CUT N CRUSHSYSTEM 103 FERRIPROX 28 EVENCARE MINI BLOOD ULTRA FINE 134 ferrous fumarate 92EZY DOSE MEDICINEGLUCOSE TEST STRIPS 76 ferrous fumarate-fa-b complex-c-EVENCARE PROVIEW BLOOD CUPS 134

EZY DOSE MEMORY PAC zn-mg-mn-cu 92GLUCOSE TEST STRIPS 76 SYSTEM COLD SEAL ferrous gluconate 92EVENITY 83 CARD/31-DAY 134 FERROUS GLUCONATE 92everolimus 39 EZY DOSE ORIGINAL ferrous sulfate 92everolimus TABLETCUTTER/DAILY

(immunosuppressant) 166 DOSE 134 FERROUS SULFATE 92 EVERYDAY PICK 134 EZY DOSE TABLET CUTTER ferrous sulfate 92

ORIGINAL 134EVISTA 84 ferrous sulfate dried 92 FABIOR 60EVOLUTION AUTOCODE 76 FETZIMA 21 FABRAZYME 85EVOMELA 36 FETZIMA TITRATION PACK21 FALESSA 53EVOTAZ 45 FEVERALL JUNIOR

EXACTECH R-S-G TEST famciclovir 48 STRENGTH 6 STRIPS 76 famotidine 186 FEXMID 170 EXACTECH TEST STRIPS 76 fexofenadine hcl 30FANAPT 43 EXALGO 7 FANAPT TITRATION fexofenadine-pseudoephedrineEXCEDRIN PM 93 PACK 43 59

38 94EXEL COMFORT POINT FARESTON FIBERCON INSULIN PEN NEEDLES 31G X FARXIGA 25 FIBRICOR 32 8MM 156 FARYDAK 39 FIBRYGA 89 EXELON 182 FASHION CANE/T- FIFTY50 ALCOHOL PREP exemestane 38 HANDLE/BLACK/250LB PADS 134

CAPACITY 134 FIFTY50 GLUCOSE METEREXFORGE 34 FASHION CANE/T- 2.0 103EXFORGE HCT 34 HANDLE/FLORAL FIFTY50 GLUCOSE TEST

EXJADE 28 PRINT/250LB CAPACITY134 STRIP 2.0 76 EXONDYS 51 172 FASHION CANE/T- FIFTY50 PEN NEEDLES 31G

HANDLE/LEOPARD X5/16" (8MM) 156EXTAVIA 183 PRINT/250LB CAPACITY134 FIFTY50 PENEXTENDABLE BEDSIDE FASHION CANE/T- NEEDLES/31GX8MM 156RAIL 134 HANDLE/MAPLE PRINT/250LB FIFTY50 SAFETY SEAL

EXTRA-WIDE COMMODE 134 LANCETS 30G 103CAPACITY 134 EYE/EAR DROPPER 134 FAZACLO 44

Index 20

FIFTY50 SAFETY SEAL LANCETS 32G 103 FIFTY50 UNILET LANCETS 33G 103 FILTER 0.2 MICRON/25MM 134 FILTER 0.2 MICRON/25MM/DOUBLE LUERLOCK 134 FILTER 0.2

FLAORTHO WALKER/LOW/BLACK/SMALL

135 flavoxate hcl 189 FLAX + DHA 3 flaxseed oil-fish oil-borageoil 3 FLEBOGAMMA DIF 180 flecainide acetate 13

fluorometholone (ophth) FLUOROURACIL fluorouracil (topical) FLUOXETINE FLUOXETINE DR fluoxetine hcl fluoxetine hcl (pmdd) FLUOXETINE

178 63 63

184 20 20

184

MICRON/32MMFILTER 0.2 MICRON/47MMFILTER 0.20 MICRON/1000MLFILTER 0.22

134

134

134

FLEET ENEMA 95 FLEET ENEMA SIX PACK 95 FLEET PEDIATRIC 95 FLENTS EAR STOPPLES 135

HYDROCHLORIDE fluphenazine decanoate FLUPHENAZINE HCL fluphenazine hcl FLURA-DROPS

20 44 44 44

165 MICRON/73MM/1000ML 134 FILTER AIR PP 160 FILTER ATTACHMENT 134 FILTER FLUORODYNE/0.22MICRON 134 FILTER, POSIDYNE ELD/0.2UM/LUER LOCKCONNECTORS/NYLONMEMBRA 134 FILTER/MILLEX-GP/50MM/CLEAR 134 finasteride 88 FINE 30 103 FINGERSTIX LANCETS 103 FINGERTIP PULSE OXIMETER 134 FIORINAL 6 FIORINAL/CODEINE #3 8 FIRAZYR 90 FIRDAPSE 36 FIRMAGON 38 FIRST-PROGESTERONE VGS 100 COMPOUNDING KIT 191 FIRST-PROGESTERONE VGS 200 COMPOUNDING KIT 191 FIRVANQ 11 FISH OIL 173 FISH OIL + VITAMIN D3 173 FISH OIL PEARLS 173 FISH OIL TRIPLE STRENGTH 173 FISH OIL ULTRA 173 fish oil-cholecalciferol 3 fish oil-krill oil 3 FLA ADJUSTABLE AIR ANKLEWALKER/LOW/SMALL

135 FLAGYL 11

FLEX & GO FOLDING CANE 135 FLEX OMEGA BENEFITS/VITAMIN D-3 173 FLEX SHIELD WITH EAR LOOPS 135 FLEX SHIELD WITH TIE STRINGS 135 FLEX THERAPY 135 FLEXICHAMBER 160 FLIGHT EAR PLUGS 135 FLOLAN 51 FLOMAX 88 FLONASE ALLERGY RELIEF 172 FLONASE ALLERGY RELIEF CHILDRENS 172 FLORA VANCE 26 FLORAJEN3 26 FLORAJEN4KIDS 26 FLORASTOR PLUS 26 FLORASTOR PRE 26 FLOVENT DISKUS 14 FLOVENT HFA 14 FLOXIN OTIC 180 fluconazole 29 fludarabine phosphate 37 fludrocortisone acetate 58 FLUMADINE 48 FLUMIST QUADRIVALENT 189 FLUNISOLIDE 172 fluocinolone acetonide 66 fluocinolone acetonide (otic) 180 fluocinonide 66 fluocinonide emulsified base 66

flurandrenolide 66 FLURAZEPAM HCL 93 flurbiprofen 5 flurbiprofen sodium 179 FLURBIPROFEN SODIUM 179 flutamide 38 fluticasone propionate 66 fluticasone propionate(nasal) 172 fluticasone-salmeterol 15 fluvastatin sodium 32 fluvoxamine maleate 20 FLYP HYPERSONIQ CARTRIDGE 160 FML 178 FML LIQUIFILM 178 FOAM CHAIR CUSHION 135 FOAM CRUTCH PAD 135 FOAM CUSHION 135 FOAM CUSHION THERAPEUTICRING 135 FOAM EAR PLUGS 135 FOAM INVALID CUSHION 135 FOAM RING 2" 135 FOCALIN 2 FOCALIN XR 2 FOIL WRAPPER 3" X 3" 135 FOLDING CANE 135 FOLDING COMMODE 135 FOLDING PADDLE WALKER/5"WHEELS 135 FOLDING REACHER 135 FOLDING SEAT CANE/3/4"TIP 135 FOLDING WALKER/5"WHEELS/ADULT 135

Index 21

FOLDING WALKER/5"WHEELS/PINKFOLDING WALKING

135

CANE 135 folic acid 91 FOLOTYN 37 fondaparinux sodium FOOT

16

MASSAGER/HEAT/AERATION135

FORA BLOOD GLUCOSE TEST STRIPS 76 FORA D10 2-IN-1 BLOOD GLUCOSE AND PRESSURE MONITOR 104 FORA D15G 2-IN-1 BLOOD GLUCOSE AND PRESSURE MONITOR 104 FORA D15G BLOOD GLUCOSE TEST STRIPS 76 FORA D20 2-IN-1 BLOOD GLUCOSE AND PRESSURE MONITOR 104 FORA D20 BLOOD GLUCOSE TEST STRIPS 76 FORA D40 BLOOD GLUCOSE PLUS BLOOD PRESSURE MONITORING SYSTEM 104 FORA D40/G31 BLOODGLUCOSE TEST STRIPS 76 FORA D40G BLOOD GLUCOSE PLUS BLOOD PRESSURE MONITORING SYSTE 104 FORA G20 BLOOD GLUCOSE MONITORING SYSTEM 104 FORA G20 BLOOD GLUCOSE TEST STRIPS 76 FORA G30/PREMIUM V10BLOOD GLUCOSE TEST STRIPS 76 FORA G30A BLOOD GLUCOSE MONITORING SYSTEM 104 FORA GATEWAY 135 FORA GD20 BLOOD GLUCOSE MONITORING SYSTEM 104 FORA GD20 TEST STRIPS 76 FORA GD50 BLOOD GLUCOSE MONITORING SYSTEM 104 FORA GD50 BLOOD GLUCOSE TEST STRIPS 76 FORA GTEL BLOOD GLUCOSE MONITORING SYSTEM/MULTI-FUNCTIONAL 104 FORA GTEL BLOOD GLUCOSE TEST STRIPS 76 FORA GW9014 TELEHEALTH GATEWAY 135

FORA LANCETS 104 FORA PREMIUM V10 BLE BLOOD GLUCOSE MONITORING SYSTEM 104 FORA TEST N' GO VOICE BLOOD GLUCOSE MONITORING SYSTEM 104 FORA TN'G SCALE 550 135 FORA TN'G VOICE BLOOD GLUCOSE MONITORING SYSTEM 104 FORA TN'G/TN'G VOICEBLOOD GLUCOSE TEST STRIPS 76 FORA V10 BLOOD GLUCOSE MONITORING SYSTEM/TALKING 104 FORA V10 BLOOD GLUCOSE TEST STRIPS 76 FORA V10/V12/D10/D20BLOOD GLUCOSE TEST STRIPS/LANCETS 30G 104 FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/NO-CODING 104 FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/TALKING 104 FORA V12 BLOOD GLUCOSE TEST STRIPS 76 FORA V20 BLOOD GLUCOSE MONITORING SYSTEM 104 FORA V20 BLOOD GLUCOSE TEST STRIPS 76 FORA V30A BLOOD GLUCOSE MONITORING SYSTEM 104 FORA V30A BLOOD GLUCOSE TEST STRIPS 76 FORACARE GD40 76 FORACARE GD40 BLOOD GLUCOSE MONITORING SYSTEM 104 FORACARE PREMIUM V10 BLOOD GLUCOSE MONITORING SYSTEM 104 FORACARE PREMIUM V10 TESTSTRIPS 77 FORACARE TEST N GO BLOODGLUCOSE MONITORING SYSTEM 104 FORACARE TEST N GO TEST STRIPS 77 FORFIVO XL 19 FORMALDEHYDE 45 formaldehyde 45 FORTAMET 22

FORTEO 83 FORTESTA 10 FORTIFY DAILY PROBIOTIC 26 FORTISCARE BLOOD GLUCOSETEST STRIP 77 FORTISCARE SELF-MONITORING BLOOD GLUCOSE SYSTEM 104 FOSAMAX 83 FOSAMAX PLUS D 83 fosamprenavir calcium 45 fosinopril sodium 33 fosinopril sodium &hydrochlorothiazide 34 FOSRENOL 88 FOSTEUM PLUS 80 FOVEX 80 FRAGMIN 16 FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX8MM 156 FREDS PHARMACY UNILET LANCETS SUPER THIN 30G 104 FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G 105 FREE SPIRIT KNEE AND LEGWALKER 135 FREESTYLE DOUBLE ELECTRICBREASTPUMP 135 FREESTYLE FLASH SYSTEM 105 FREESTYLE FREEDOM 105 FREESTYLE FREEDOM LITE 105 FREESTYLE INSULINX BLOODGLUCOSE MONITORING SYSTEM 105 FREESTYLE INSULINX BLOODGLUCOSE TEST 77 FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS 77 FREESTYLE LANCETS 105 FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM 105 FREESTYLE LITE TEST STRIPS 77 FREESTYLE PRECISION NEO BLOOD GLUCOSE MONITORING SYSTEM 105 FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS 77

Index 22

FREESTYLE SIDEKICK II VALUEPACK 105 FREESTYLE SYSTEM KIT 105 FREESTYLE TEST STRIPS 77 FREESTYLE UNISTICK II LANCETS 105 FROVA 163 frovatriptan succinate 163 FULL KIT NEBULIZER SET 160 FULPHILA 91 FURADANTIN 188 furosemide 82 FUROSEMIDE 82 furosemide 82 FUSILEV 41 FUZEON 45 FYCOMPA 16 GABADONE 80 gabapentin 17 GABITRIL 18 GABLOFEN 170 GALAFOLD 85 galantamine hydrobromide 182 GALANTAMINE HYDROBROMIDE 183

GEL-FOAM CUSHION 135 GEL-ONE 171 GELLHORN PESSARY 135 GELNIQUE 188 GELNIQUE PUMP 188 GELSYN-3 171 gemfibrozil 32 GENERESS FE 53 GENOTROPIN 84 GENOTROPIN MINIQUICK 84 GENTAK 177 gentamicin sulfate(ophth) 177 gentamicin sulfate (topical) 61 GENTEEL BUTTERFLY TOUCH LANCETS 105 GENTLE-LET GP LANCETS 105 GENTLE-LET LANCETS GENERAL PURPOSE STYLE/FINE POINT 105 GENTLE-LET LANCETS GENERAL PURPOSE STYLE/MEDIUM POINT 105 GENTLE-LET LANCETS SAFETY STYLE/FINEPOINT 105

GLASS BOTTLE/30ML/BLUNTEND APPLICATOR 135 GLASS SERUM BOTTLES/20ML/TYPE 1 136 GLASS SERUM BOTTLES/2ML/TYPE 1 136 GLASS SERUM BOTTLES/30ML/TYPE 1 136 GLASS SERUM BOTTLES/5ML/TYPE 1 136 GLASS VIAL 2ML 136 GLASS VIAL AMBER 3ML/13MM/TYPE 1 136 GLASSIA 184 glatiramer acetate 183 GLEEVEC 39 glimepiride 25 glipizide 25 glipizide-metformin hcl 22 GLOBAL ALCOHOL PREP EASEPADS 136 GLOBAL EASE INJECT PEN NEEDLES 31GX8MM 156 GLOBAL INJECT EASE LANCETS 28G 105 GLOBAL INJECT EASE LANCETS 30G 105 GLUCAGEN HYPOKIT 23 GLUCAGON EMERGENCY

galantamine hydrobromide 183 GAMASTAN 180 GAMASTAN S/D 180

GENTLE-LET LANCETS SAFETY STYLE/MEDIUMPOINT 105 GENULTIMATE TEST

KIT 23 GLUCO PERFECT 3 BLOOD GLUCOSE METER 105 GLUCO PERFECT 3 BLOOD

GAMIFANT 166 STRIPS 77 GLUCOSE MONITORING GAMMAGARD LIQUID 180 GAMMAGARD S/D IGA LESSTHAN 1MCG/ML 180 GAMMAKED 180 GAMMAPLEX 180 GAMUNEX-C 180 ganirelix acetate 84 GANIRELIX ACETATE 84 GAS-X 87 gatifloxacin (ophth) 177 GATTEX 88 GAUZE SPONGES 105 GAVILYTE-C 94 GAZYVA 37 GE100 BLOOD GLUCOSE MONITORING SYSTEM 105 GE100 BLOOD GLUCOSE TESTSTRIPS 77 GEHRUNG PESSARY/SUPPORT 135

GENVISC 850 171 GENVOYA 46 GEODON 43 GETGO ROLLING WALKER 135 GHT BLOOD GLUCOSE MONITORING SYSTEM 105 GHT TEST STRIPS 77 GIAZO 87 GILENYA 183 GILOTRIF 39 ginger (zingiber officinalis) 2 GLASS BOTTLE 15ML 135 GLASS BOTTLE 30ML 135 GLASS BOTTLE 30ML/BLACKPHENOLIC BRUSH CAP 135 GLASS BOTTLE 30ML/BLACKPHENOLIC POLYSEAL CAP 135 GLASS BOTTLE 60ML 135

SYSTEM/VOICE 105 GLUCO PERFECT 3 TEST STRIPS 77 GLUCOCARD 01 BLOOD GLUCOSE METER 105 GLUCOCARD 01 BLOOD GLUCOSE MONITORING SYSTEM 105 GLUCOCARD 01 SENSOR PLUS 77 GLUCOCARD 01 SENSOR PLUSTEST STRIPS 77 GLUCOCARD 01-MINI BLOOD GLUCOSE MONITORING SYSTEM 105 GLUCOCARD EXPRESSION AUDIO-ENABLED BLOOD GLUCOSE MONITORING 105 GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS 77 GLUCOCARD SHINE 105

Index 23

GLUCOCARD SHINE CONNEX glyburide-metformin 22 GOJJI STERILE LANCETS BLOOD GLUCOSE 30G 106glycerin (laxative) 95MONITORING SYSTEM 105 GOLD BOND MEDICATED

GLYCERIN ADULT 95GLUCOCARD SHINE EXPRESS BODYLOTION 69 BLOOD GLUCOSE glycine diluent 182 GOLD BOND MEDICATED MONITORING SYSTEM 106 glycopyrrolate 186 BODYLOTION EXTRA GLUCOCARD SHINE TEST STRENGTH 69GLYNASE 25STRIPS 77 GOLD BOND ULTIMATE 69

GLYSET 22GLUCOCARD SHINE XL 106 GOLD BOND ULTIMATE GLUCOCARD VITAL BLOOD GLYXAMBI 22 DIABETICS DRY SKIN GLUCOSE MONITORING GNP ACIDOPHILUS HIGH RELIEF 69 SYSTEM 106 POTENCY 26 GOLD BOND ULTIMATE GLUCOCARD VITAL BLOOD GNP ADVANCED DIABETICS' DRY RELIEF 69 GLUCOSE MONITORING RECOVERY 69 GOLD BOND ULTIMATE SYSTEM BLACK 106 GNP ALCOHOL SWABS 136 HEALING 69 GLUCOCARD VITAL BLOOD GNP CLICKFINE PEN GOLD BOND ULTIMATE GLUCOSE MONITORING NEEDLEUNIVERSAL/31GX5/1 OVERNIGHT 69 SYSTEM BLUE 106 GOLD BOND ULTIMATE6" 156GLUCOCARD VITAL BLOOD GNP CLICKFINE UNIVERSAL PROTECTION 69 GLUCOSE MONITORING PEN NEEDLES GOLD BOND ULTIMATE SYSTEM PINK 106 31GX5/16" 156 RESTORING 69

GOLD BOND ULTIMATEGLUCOCARD VITAL TEST GNP EASY TOUCH GLUCOSE STRIPS 77 SHEERRIBBONSMONITORING SYSTEM/NO

PEARLRADIANCE 69GLUCOCARD X-METER 106 CODING 106 GOLD BOND ULTIMATEGNP EASY TOUCH GLUCOSEGLUCOCARD X-SENSOR 77 SHEERRIBBONSTEST STRIPS 77GLUCOCOM BLOOD GLUCOSE SILKSOFTNESS 69GNP FISH OIL 173MONITOR 106 GOLD BOND ULTIMATEGLUCOCOM BLOOD GLUCOSE GNP GLUCOSE 23 SOFTENING 70MONITORING SYSTEM 106 GNP LANCETS 106 GOLD BOND ULTIMATEGLUCOCOM BLOOD GLUCOSE SOOTHING 70GNP LANCETS 21G 106MONITORING SYSTEM VALUE GOLYTELY 94GNP LANCETS MICRO THINKIT 106 GOODSENSE COLORGLUCOCOM LANCETS 33G 106 GNP LANCETS SUPER THIN LANCETS MICRO-THIN 33G28G 106 30G 106 UNIVERSAL 106GLUCOCOM LANCETS GOODSENSE LANCETS30G 106 GNP LANCETS THIN 106

MICRO-THIN 33G 106GLUCOCOM LANCETS GNP LANCETS THIN GOODSENSE LANCETS33G 106 26G 106 MICRO-THIN 33GGLUCOCOM TEST STRIPS 77 GNP MICRO THIN LANCETS UNIVERSAL 106GLUCONAVII BLOOD 33G 106 GOODSENSE LANCETSGNP PROBIOTIC COLONGLUCOSEMONITORING ULTRA-THIN 26GSUPPORT 26SYSTEM 106 UNIVERSAL 106GNP PROBIOTIC DIGESTIVEGLUCONAVII BLOOD GOODSENSE LANCETSSUPPORT 26GLUCOSETEST STRIPS 77 ULTRA-THIN 30G 107GNP QUICK DISSOLVEGLUCOPHAGE 22 GOODSENSE LANCETSGLUCOSE 23GLUCOPHAGE XR 22 ULTRA-THIN 30GGNP SUPER THIN UNIVERSAL 107GLUCOSE 23 LANCETS/30G 106 GOODSENSE PENGLUCOSE METER TEST GNP TRIPLE OMEGA NEEDLE/PENFINESTRIPS ADVANCED 77 COMPLEX 3

GOJJI BLOOD GLUCOSE CLASSIC/31G X 5/16" 156GLUCOTROL 25 GOODSENSE PREMIUMTESTSTRIPS 77GLUCOTROL XL 25 BLOODGLUCOSEGOJJI BLOOD GLUCOSE GLUCOVANCE 22 TESTSTRIPS/GOJJI STERILE MONITORING SYSTEM 107

GRADUATED BOTTLE 2OZGLUMETZA 22 LANCETS 30G 77 GOJJI CONTROL SOLUTION W/CAP 136glyburide 25 GRADUATED BOTTLE 4OZNORMAL 106glyburide micronized 25 W/CAP 136

Index 24

granisetron hcl 28 HARMONY BLOOD GLUCOSE HIBICLENS HAND TEST STRIPS 77 PUMP/16OZ 136GRANIX 91 HARMONY HIBICLENS HAND

GRIS-PEG 29 BREASTPUMP 136 PUMP/32OZ 136 griseofulvin microsize 29 HARVONI 47 HIBICLENS HAND

PUMP/GALLON 136griseofulvin ultramicrosize 29 HAVRIX 189 HIBICLENS HAND PUMP/NONGROOVE ROLLING HCG 83 FOAMING/16OZ 136WALKER 136 HEAD COVERS HIBICLENS PUMPGRX VITAMIN E 70 24"/BOUFFON ASSEMBLY 136 guaifenesin-codeine 59 CAP/IRRADIATED 136 HIBICLENS WALL guanfacine hcl 33 HEAD HALTER OVER DOOR DISPENSER/FOOT 136

TRACTION SET 136 HIBICLENS WALLguanfacine hcl (adhd) 1 HEAD HALTER DISPENSER/HAND 136GYNAZOLE-1 190 REPLACEMENT FOR HIGH POTENCY GYNE-LOTRIMIN 190 TRACTION KIT 136 PROBIOTIC 26

HEAD LICE COMB 136 HIP/FRACTURE RAISEDGYNE-LOTRIMIN 3 190 H-E-B IN CONTROL PEN HEALTHWISE SHORT PEN TOILET SEAT/LEFT 136

NEEDLES 31GX8MM 156 HIP/FRACTURE RAISEDNEEDLES 31GX8MM 156 HEALTHWISE SHORT PEN TOILET SEAT/RIGHT 136H-E-B INCONTROL ALCOHOL

PADS 136 NEEDLES/31G X 5/16" 156 HIZENTRA 180 HEALTHY ACCENTS UNIFINEH-E-B INCONTROL LANCETS HM ACIDOPHILUS 26 PENTIPS PEN NEEDLESMICRO THIN 33G 107 HM COMFORT FOAM EAR

H-E-B INCONTROL LANCETS 31GX8MM 156 PLUGS 136HEALTHY ACCENTS UNILETSUPER THIN 30G 107 HM FISH OIL 173H-E-B INCONTROL LANCETS LANCETS SUPER THIN HM OMEGA-3-6-9 FATTYULTRA THIN 28G 107 30G 107 ACIDS 3HAEMOLANCE 107 HEART RATE MONITOR 136 HM STERILE ALCOHOL PREP HAEMOLANCE LOW FLOW HEART RATE MONITOR PADS 136 LANCETS 107 STRAPLESS 136 HM ULTICARE SHORT PEN HAEMOLANCE PLUS 107 HEAT THERAPY 136 NEEDLES 31GX8MM 156 HAEMOLANCE PLUS HIGH HEELBOOT LARGE 136 HODGE PESSARY 136 FLOW 107 HEELBOOT LAUNDRY HODGE HAEMOLANCE PLUS LOW BAG 136 PESSARY/SUPPORT 136 FLOW 107 HEELBOOT LINER HOME STYLE BED RAILS 137HAEMOLANCE PLUS MAX LARGE 136 HOMOCYSTEINEFLOW 107 HEELBOOT LINER SUPPORT 81HAEMOLANCE PLUS REGULAR 136 HOT-COLD THERAPY 137PEDIATRIC FLOW 107 HEELBOOT REGULAR 136 HUDSON RCI SEE-THRUHALAC 66 HEELBOOT WALK PAD 136 AEROSOL MASKHALAVEN 41 HELIXATE FS 89 ELONGATED/ADULT 160 halcinonide 66 HUMALOG JUNIORHEMANGEOL 49 KWIKPEN 24HALCION 93 HEMLIBRA 89 HUMALOG KWIKPEN 24HALDOL 43 HEMOCYTE 92 HUMALOG MIX 50/50 24HALDOL DECANOATE 100 43 HEMOFIL M 89 HUMALOG MIX 50/50HALDOL DECANOATE 50 43 HEPAGAM B 180 KWIKPEN 24 halobetasol propionate 66 heparin sodium (porcine) 16 HUMALOG MIX 75/25 24 HALOBETASOL HERCEPTIN 37 HUMALOG MIX 75/25PROPIONATE 66 KWIKPEN 24HERCEPTIN HYLECTA 39HALOG 66 HUMATE-P 89

HETLIOZ 94haloperidol 44 HUMATROPE 84HIBICLENS DISPENSERhaloperidol decanoate 43 HUMATROPE COMBONOZZLE 136haloperidol lactate 43 HIBICLENS FOOT PACK 84 HAND HELD SHOWER PEDAL 136 HUMIRA 4 SPRAY 136

Index 25

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 4 HUMIRA PEN 4 HUMIRA PEN-CD/UC/HSSTARTER 4 HUMIRA PEN-PS/UVSTARTER 4 HUMULIN 70/30 24 HUMULIN 70/30 KWIKPEN 24 HUMULIN N 24 HUMULIN N KWIKPEN 24 HUMULIN R 24 HUMULIN R U-500 (CONCENTRATED) 24 HURRICAINE DISPENSING CAP 137 HURRICAINE LIQUID DISPENSER 137 HURRICAINE SPRAY EXTENSION TUBES 137 HURRIPAK PERIODONTAL ANESTHETIC REFILL KIT 137 HURRIPAK PERIODONTAL IRRIGATION TIPS 137 HURRYCANE FREEDOM EDITIONCANE/BLACK 137 HW EMBRACE PRO BLOOD GLUCOSE METER 107 HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS 77 HW EMBRACE TALK BLOOD

hydrocortisone (rectal) 10 hydrocortisone (topical) 66 hydrocortisone butyrate 66 hydrocortisone butyratehydrophilic lipo base 66 hydrocortisone valerate 66 hydrocortisone w/aceticacid 180 hydrocortisone-aloe vera 66 HYDROMORPHONE HCL 7 hydromorphone hcl 7 hydroxychloroquine sulfate 35 HYDROXYPROGESTERONE CAPROATE 38 hydroxyprogesterone caproate 182 hydroxyurea 40 HYDROXYZINE HCL 12 hydroxyzine hcl 12 HYDROXYZINE HYDROCHLORIDE 12 HYDROXYZINE PAMOATE 12 hydroxyzine pamoate 12 HYMOVIS 171 hyoscyamine sulfate 186 HYPER-SAL 59 HYPERHEP B S/D 180

ICY DIAMOND TOTE NON GENUINE LEATHER 137 ICY HOT SMART RELIEF TENS THERAPY REFILL PADS 137 IDELVION 89 IGLUCOSE BLOOD GLUCOSE MOITORING SYSTEM 107 ILARIS 4 ILEVRO 179 ILLUSIONS AA WEIGHTED OFFTHE SHELF BREAST PROSTHESIS FORM 137 ILLUSIONS C WEIGHTED OFFTHE SHELF BREAST PROSTHESIS FORM 137 ILUMYA 63 ILUVIEN 178 imatinib mesylate 39 IMBRUVICA 39 imipramine hcl 21 imipramine pamoate 21 imiquimod 71 IMITREX 163 IMITREX STATDOSE REFILL 163 IMITREX STATDOSE SYSTEM 163 IMLYGIC 41 IMODIUM A-D 28

GLUCOSE MONITOR 107 HW EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM 107 HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS 77 HY-VEE LANCETS 107 HY-VEE THIN LANCETS 107 HYALGAN 171 HYCAMTIN 42 hydralazine hcl 35 HYDRALYTE 164 HYDRALYTE FREEZER POPS 164 HYDRAZONE LOTION 70 HYDREA 40 hydrochlorothiazide 82 hydrocodone bitartrate 7 hydrocodone w/homatropine 58 hydrocodone-acetaminophen 8 hydrocortisone 57 hydrocortisone (intrarectal) 10

HYPERRHO S/D 180 HYPERRHO S/D MINI-DOSE 180 HYPERSAL 59 HYPERTENSA 80 HYPOTEARS 175 HYQVIA 181 HYSINGLA ER 7 HYZAAR 34 ibandronate sodium 83 IBG STAR BLOOD GLUCOSE MONITORING SYSTEM 107 IBRANCE 39 ibuprofen 5 ibuprofen-diphenhydraminecitrate 93 ibuprofen-diphenhydraminehcl 93 icatibant acetate 90 ICLUSIG 39 ICY DIAMOND TOTE CANVAS 137

IMURAN 166 IN TOUCH 107 IN TOUCH BLOOD GLUCOSE TEST STRIPS 77 IN TOUCH STERILE LANCETS30G 107 INCRELEX 84 INCRUSE ELLIPTA 13 indapamide 82 INDERAL LA 49 INDERAL XL 49 INDICATOR/BIOLOGICAL TESTKIT/SPORVIEW STEAM 137 indomethacin 5 INFANTS ADVIL 5 INFINITY BLOOD GLUCOSE MONITORING SYSTEM 107 INFINITY BLOOD GLUCOSE MONITORING SYSTEM/STARTER KIT 107 INFINITY BLOOD GLUCOSE TEST STRIPS 77 INFINITY VOICE 77

Index 26

12 INFLATABLE INSPIREASE RESERVOIR ISORDIL TITRADOSE CUSHION/VINYL 137 BAGS 160 isosorbide dinitrate 12INFLATABLE NECK REST 137 INSULIN ASPART ISOSORBIDE DINITRATEPROTAMINE/INSULININFLECTRA 87 ER 12ASPART 24INGREZZA 183 isosorbide mononitrate 12INSULIN ASPART INHALATION VIAL PROTAMINE/INSULIN isotretinoin 60 CAP/BLUE 137 ASPART FLEXPEN 24 isradipine 50INHALATION VIAL INSULIN LISPRO 24 ISTALOL 176CAP/GREEN 137 INSULIN LISPRO JUNIORINHALATION VIAL ISTODAX (OVERFILL) 39KWIKPEN 24CAP/ORANGE 137 INSULIN LISPRO ITCH RELIEF 63INHALATION VIAL KWIKPEN 24 itraconazole 29CAP/RED 137 INSULIN LISPROINHALATION VIAL IXEMPRA KIT 41PROTAMINE/INSULIN LISPROCAP/WHITE 137 IXINITY 89KWIKPEN 24INHALATION VIAL J & J TOURNIQUETINSULIN SYRINGES 156CAP/YELLOW 137 36"X3/4" 137INHALATION VIAL INSUPEN 31G X 8MM 156 JADENU 28W/CAP/BLUE/3.5ML INSUPEN ULTRAFIN JADENU SPRINKLE 28STOCKWELL 137 31GX8MM 156 INHALATION VIAL JAKAFI 39INTELENCE 46 W/CAP/GREEN/3.5ML INTERMEZZO 93 JALYN 89STOCKWELL 137 INHALATION VIAL INTRON A 40 JANUMET 22 W/CAP/ORANGE/3.5ML INTUNIV 1 JANUMET XR 22 STOCKWELL 137 23INVANZ 11 JANUVIA INHALATION VIAL INVEGA 43 JAR/8OZ/WHITE LID 137W/CAP/RED/3.5MLSTOCKWELL 137 INVEGA SUSTENNA 43 JARDIANCE 25 INHALATION VIAL INVEGA TRINZA 43 JENTADUETO 22 W/CAP/WHITE/3.5ML JENTADUETO XR 22INVIRASE 46STOCKWELL 137 INVOKAMET 22 JEVTANA 41INHALATION VIAL JOHNSON & JOHNSONW/CAP/YELLOW/3.5ML INVOKAMET XR 22 ANTISEPTIC WIPES 137STOCKWELL 137 INVOKANA 25 JOHNSON & JOHNSONINHALATION VIAL W/O IOPIDINE 177 INSTANTCOLD PACK 137CAP/AMBER/3.5MLSTOCKWELL 137 ipratropium bromide 13 JOURNEY SERIES ROLLING

WALKER/4205BL-R/BLUE 137INLYTA 39 ipratropium bromide JOURNEY SERIES ROLLING(nasal) 172INNOPRAN XL 49 WALKER/4205RD/RED 138ipratropium-albuterol 15INNOSPIRE REPLACEMENT JUBLIA 62IR ADAPTER 137FILTER 160 JUG AMBER GLASS INREBIC 39 irbesartan 33 4L/POLYSEAL CAP/LONG 138 INSPIRACHAMBER/ANTI- irbesartan-hydrochlorothiazide JUXTAPID 32 STATIC 34 JYNARQUE 86VALVED/MOUTHPIECE 160 IRESSA 39 INSPIRACHAMBER/LARGE IRINOTECAN 42

K-PHOS NEUTRAL 165 160 K-TAB 165irinotecan hcl 42INSPIRACHAMBER/SOOTHER KADCYLA 37

MASK/INSPIRAMASK/MEDIUM IRON CHEWS KADIAN 7PEDIATRIC 92160

INSPIRACHAMBER/SOOTHER ISENTRESS 46 KALBITOR 90 MASK/INSPIRAMASK/SMALL ISONIAZID 36 KALETRA 46

160 isoniazid 36 KALYDECO 184INSPIREASE DRUG KANESON BREASTISOPTO ATROPINE 176DELIVERYSYSTEM 160 PUMP/NURSER 138ISOPTO CARPINE 176

Index 27

KANGAROO RIGID KINNEY THIN LANCETS 107 KROGER PREMIUM BLOOD CONTAINERPUMP SET GLUCOSE MONITORINGKITABIS PAK 31200ML 138 KIT 108KLARITY-A 177KANJINTI 37 KROGER PREMIUM BLOOD

KLARON 60 GLUCOSE TEST STRIPS 78KANUMA 85 KLONOPIN 16 KROGER TEST STRIPS 78KAPSPARGO SPRINKLE 49 KLOR-CON M15 165 KRYSTEXXA 89KAPVAY 1 KOATE 90 KUVAN 85KAZANO 22 KOATE-DVI 90 KYLEENA 56KCENTRA 89 KOGENATE FS 90 KYNAMRO 31KEFLEX 52 KOGENATE FS BIO-SET 90 KYPROLIS 39KEGEL BALL TRAINER 138 L.O.S. YANKAUER KOMBIGLYZE XR 22KENALOG 67 HOLDER 138KONSYL DAILY FIBER 94KEPIVANCE 41 LAB COAT/DISPOSABLE 138KONSYL ORIGINALKEPPRA 17 LABFORMULADAILY FIBER 94 COAT/DISPOSABLE/LARGEKEPPRA XR 17 KORLYM 23 138KERALYT 71 KOVALTRY 90 LAB

KERI ADVANCED MOISTURE KRILL OIL 2 COAT/DISPOSABLE/MEDIUMTHERAPY 70 138krill oil 3KERI BASIC ESSENTIALS 70 LAB KERI NOURISHING SHEA KRILL OIL OMEGA-3 3 COAT/DISPOSABLE/SMALLBUTTER 70 KRILL OIL TRIPLE 138 KERI ORIGINAL 70 STRENGTH RED 3 LAB COAT/DISPOSABLE/X-

KRILL OIL ULTRA LARGE 138KERI OVERNIGHT 70 STRENGTH 3 LAB COAT/DISPOSABLE/XX-KERI RENEWAL MILK KRILL OIL WITH LARGE 138BODY 70 ASTAXANTHIN TRIPLE labetalol hcl 49KERI RENEWAL SKIN STRENGTH 3FIRMING 70 LAC-HYDRIN 70KRINTAFEL 35KERI RENEWAL STRETCH LAC-HYDRIN TWELVE 70KROGER BLOOD GLUCOSEMARK MINIMIZER 70 MONITORING KIT 107 lactic acid (ammoniumKERI SENSITIVE SKIN 70 KROGER BLOOD GLUCOSE lactate) 70 KERYDIN 62 TESTSTRIPS 77 LACTO-PECTIN 26 ketoconazole (topical) 62 KROGER HEALTHPRO lactulose 95

BLOOD GLUCOSEKETONE 77 lactulose (encephalopathy) 88MONITORING SYSTEM 107KETONE TEST STRIPS 77 LADYCARE MENOPAUSE 138KROGER HEALTHPRO KETOPROFEN 5 GLUCOSETEST STRIPS 77 LAMICTAL 17

KROGER HEALTHPRO TWIST LAMICTAL CHEWABLEKETOPROFEN ER 5 LANCETS/26G 107 DISPERSIBLE 17ketorolac tromethamine 5 KROGER LANCETS 108 LAMICTAL ODT 17ketorolac tromethamine

(ophth) 179 KROGER LANCETS 21G 108 LAMICTAL STARTER/NOTKROGER LANCETS MICRO TAKING CARBAMAZEPINE 17KETOSTIX 77 THIN33G 108 LAMICTAL STARTER/TAKINGketotifen fumarate (ophth) 179 KROGER LANCETS SUPER CARBAMAZEPINE/NOT TAKING

KEVZARA 4 THIN 108 VALPROATE 17 KEY-E 191 KROGER LANCETS LAMICTAL STARTER/TAKING

THIN 108 VALPROATE 17KEYTRUDA 37 KROGER LANCETS THIN LAMICTAL XR 17KHAPZORY 41 26G 108 LAMISIL AT 62KHEDEZLA 21 KROGER LANCETS LAMISIL AT JOCK ITCH 62ULTRATHIN30G 108KIDNEY 81 KROGER PEN NEEDLES 31G lamivudine 46KINERET 4 X8MM 156 lamivudine-zidovudine 46KINNEY LANCETS 107 KROGER PEN NEEDLES/31G lamotrigine 17X5/16" 156

Index 28

LANCETS 108 lanthanum carbonate 88 LEVEMIR 24 LANCETS 26G TWIST LANTUS SOLOSTAR 24 LEVEMIR FLEXTOUCH 24 TOP LANCETS 28G LANCETS 30G LANCETS 30G TWIST TOP LANCETS 30G/TWISTTOP

108 108 108

108

108

LARTRUVO LASIX LASTACAFT LATANOPROST latanoprost LATCH ASSIST NIPPLE

37 82

179 179 179

levetiracetam 17,18 levobunolol hcl 176 LEVOBUNOLOL HCL 176 levocarnitine (metabolicmodifiers) 85 levocetirizine dihydrochloride30

LANCETS 31G TWIST EVERTER 138 levofloxacin 87 TOP 108 LANCETS 33G UNIVERSAL DESIGN 108 LANCETS MICRO THIN 33G 108 LANCETS SAFETY SEAL 21G 108 LANCETS SAFETY SEAL 26G 108 LANCETS SAFETY SEAL 28G 108 LANCETS SAFETY SEAL 30G 108 LANCETS SUPER THIN 28G 108 LANCETS THIN 108 LANCETS TWIST TOP 108 LANCETS ULTRA FINE 108

LATUDA 43 LDR BLOOD GLUCOSE TRUETEST KIT 109 LEADER QUICK DISSOLVE GLUCOSE 23 LEADER UNIFINE PENTIPS PLUS/SHORT/31GX5/16"

156 LEDIPASVIR/SOFOSBUVIR

47 leflunomide 5 LEMTRADA 183 LENVIMA 10 MG DAILY DOSE 39 LENVIMA 12MG DAILY DOSE 39 LENVIMA 14 MG DAILY DOSE 39

levofloxacin (ophth) 177 LEVOLEUCOVORIN 41 levoleucovorin calcium 41 levonorgestrel & ethestradiol 53 levonorgestrel (emergencyoc) 56 levonorgestrel-eth estradiol(triphasic) 53 levonorgestrel-ethinyl estradiol(91-day) 53 levonorgestrel-ethinyl estradiol(continuous) 54 levothyroxine sodium 185 LEVSIN 186 LEVSIN/SL 186 LEVULAN KERASTICK 63

LANCETS ULTRA THIN LANCETS ULTRA THIN 30G LANCETSBULLSEYE

108

108

LENVIMA 18 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE

39

39

LEXAPRO LEXAZIN LEXETTE

20 80 67

SAFETY 108 LENVIMA 24 MG DAILY LEXIVA 46 lanolin 182 lanolin (topical) 72 LANOXIN 51 LANSINOH BREASTFEEDING PILLOW 138 LANSINOH BREASTMILK COLLECTOR 138 LANSINOH EXTRA PUMPING SET 138 LANSINOH MANUAL BREAST PUMP 138 LANSINOH PUMP

DOSE LENVIMA 4 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LESCOL XL LETAIRIS letrozole LEUCOVORIN CALCIUM leucovorin calcium LEUKERAN

39

39

39 32 51 38 41 41 36

LIALDA 87 LIBERTY BLOOD GLUCOSE METER 109 LIBERTY MEDICAL LANCETS 30G 109 LIBERTY NEXT GENERATION BLOOD GLUCOSE MONITOR 109 LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS 78 LIBERTY TEST STRIPS 78

ADAPTERS 138 LEUKINE 91 LIBTAYO 37 LANSINOH SMART PUMP TOTEBAGS 138 LANSINOH SMARTPUMP 2.0 138 LANSINOH SMARTPUMP DOUBLEELECTRIC 138 LANSINOH SMARTPUMP DOUBLEELECTRIC BREAST PUMP 138

leuprolide acetate 38 LEUPROLIDE ACETATE/BUPIVACAINEHYDROCHLORIDE 38 levalbuterol hcl 15 LEVALBUTEROL TARTRATE HFA 15 LEVAQUIN 87

LICEMD 73 LICIDE TREATMENT KIT 73 LIDOCAINE 72 lidocaine 72 lidocaine hcl 72 lidocaine hcl (mouth-throat) 167 LIDOCAINE HCL JELLY 72

lansoprazole 187 LEVBID 186 lidocaine-prilocaine 72

Index 29

LIFESCAN UNISTIK 2 DEEP PENETRATION 109 LIFESCAN UNISTIK II LANCETS 109 LILETTA 56 LINDANE 73 LINZESS 88 LIORESAL INTRATHECAL 170 liothyronine sodium 185

LOESTRIN FE 1/20 54 LOMOTIL 28 LONGS LANCETS STANDARD 109 LONGS LANCETS THIN 109 LONGS LANCETS ULTRA THIN 109 LONSURF 39 loperamide hcl 28

LUBRIDERM SKIN NOURISHINGWITH SHEA AND COCOA BUTTERS 70 LUBRISOFT 70 LUCEMYRA 182 LUCENTIS 176 LUER LOCK ADAPTER 138 LULICONAZOLE 62 LULLABY DOUBLE ELECTRIC

LIPICHOL 540 80 LOPID 32 BREAST PUMP 138 LIPITOR 32 LIPOFEN 32 lisinopril 33 lisinopril &hydrochlorothiazide 34 LISTER-V 80 LITE TOUCH LANCETS 109 LITEAIRE 160 LITETOUCH LANCETS MICRO THIN 33G 109 LITETOUCH MASK LARGE 160 LITETOUCH MASK MEDIUM 160 LITETOUCH MASK SMALL160 LITETOUCH PEN NEEDLES 31GX8MM SHORT 156 LITETOUCH PEN NEEDLES/31G X8MM/SHORT 156 LITHATE 81 LITHIUM 43 lithium carbonate 43 LITHIUM CARBONATE 43 lithium carbonate 43 LITHOBID 43 LIVALO 32 LIVE BETTER LANCET SUPERTHIN 30G 109 LIVE BETTER LANCET ULTRATHIN 28G 109 LMA MAD NASAL 138 LMX 4 72 LO LOESTRIN FE 54 LOCOID 67 LOCOID LIPOCREAM 67 LODINE 5 LODOSYN 42 LOESTRIN 1.5/30-21 54 LOESTRIN 1/20-21 54 LOESTRIN FE 1.5/30 54

lopinavir-ritonavir 46 LOPRESSOR 49 LOPRESSOR HCT 34 LOPROX 62 LOPROX SHAMPOO 62 loratadine 30 loratadine & pseudoephedrine 59 lorazepam 13 LORBRENA 40 LORMATE 80 losartan potassium 33 losartan potassium &hydrochlorothiazide 34 LOSEASONIQUE 54 LOTENSIN 33 LOTENSIN HCT 34 LOTREL 34 LOTRIMIN AF 62 LOTRIMIN AF JOCK ITCH 62 LOTRISONE 62 lovastatin 32 LOVAZA 31 LOVENOX 16 loxapine succinate 44 LUBRIDERM 70 LUBRIDERM ADVANCED THERAPY 70 LUBRIDERM DAILY MOISTURE/NORMAL TO DRYSKIN 70 LUBRIDERM DAILY MOISTURESHEA + CALMING LAVENDER JASMINE 70 LUBRIDERM INTENSE SKIN REPAIR 70 LUBRIDERM MENS 3-IN-1 70 LUBRIDERM SERIOUSLY SENSITIVE 70

LUMBAR CUSHION 138 LUMBAR SUPPORT CUSHION 138 LUMIGAN 179 LUMIZYME 85 LUMOXITI 37 LUNESTA 93 LUPANETA PACK 84 LUPRON DEPOT (1-MONTH) 38 LUPRON DEPOT (3-MONTH) 38 LUPRON DEPOT (4-MONTH) 38 LUPRON DEPOT (6-MONTH) 38 LUPRON DEPOT-PED (1-MONTH) 84 LUPRON DEPOT-PED (3-MONTH) 84 LUTATHERA 40 LUXIQ 67 LUZU 62 LYNPARZA 40 LYRICA 18 LYSODREN 38 LYSTEDA 92 M-M-R II 189 MACI 170 MACROBID 188 MACRODANTIN 188 MACUGEN 176 MACUZIN 80 MAD NASAL 138 MAGNEBIND 400 165 magnesium citrate 95 magnesium hydroxide 95 magnesium oxide 11 MAGNIFIER HANDS-FREE138 MAKENA 182

Index 30

malathion 73 MEDELA PUMP IN STYLE MEDROL 57 ADVANCED STARTERMALE SUPPORT 81 MEDROL DOSEPAK 57SET 139MAPROTILINE HCL 19 medroxyprogesteroneMEDERMA AG HAND & BODY acetate 182MAR-LAND PESSARY 138 LOTION 70 medroxyprogesterone acetateMAR-LAND MEDI-COOLER 139 (contraceptive) 57PESSARY/SUPPORT 138 MEDI-FRIDGE IIX 139 MEFLOQUINE HCL 35MARATHON MEDICAL MEDI-RDT BLISTERPENTIPS31GX8MM 156 MEGA PROBIOTIC 26PACKS/LABELS &MARQIBO 41 MEGAPUMP 139SLEEVE 139

MASSAGER MULTI- MEDICHOICE PRE-SET megestrol acetate 38 PURPOSE/RECHARGEABLE SAFETY LANCET DUAL MEIJER ALCOHOL SWABS

138 USE 109 EXTRA-THICK 139 MASSAGER/2 SPEED 138 MEDICHOICE PRE-SET MEIJER BLOOD GLUCOSE MASSAGER/FIVE IN SAFETY LANCET LOW MONITORING KIT 110 ONE/HEAT 138 FLOW 109 MEIJER BLOOD GLUCOSE MASSAGER/SWEDISH/1 MEDICHOICE PRE-SET TESTSTRIPS 78 SPEED 138 SAFETY LANCET MEDIUM MEIJER COLOR LANCETS MATTRESS FLOW 109 UNIVERSAL 33G 110 COVER/DELUXE 138 MEDICHOICE PRE-SET MEIJER ESSENTIAL BLOOD MATTRESS SAFETY LANCET MODERATE GLUCOSE MONITORING COVER/ECONOMY 138 FLOW 109 SYSTEM 110 MATTRESS MEDICHOICE SAFETY MEIJER ESSENTIAL BLOOD PAD/35"X74"/EGGCRATE LANCETEXTRA 109 GLUCOSE TEST STRIPS 78 2" 138 MEDICHOICE SAFETY MEIJER LANCETS 110 MATTRESS LANCETNORMAL 109 MEIJER LANCETS THIN 110PAD/35"X74"/EGGCRATE MEDICINE DROPPER 139 MEIJER LANCETS3" 139 MEDICINE UNIVERSAL21G 110MATTRESS DROPPER/CALIBRATED139 MEIJER LANCETSPAD/35"X74"/EGGCRATE MEDICINE SHOPPE PEN UNIVERSAL30G 1104" 139 NEEDLES 31G X 8MM 156 MEIJER LANCETSMATULANE 40 MEDICINE SPOON 139 UNIVERSAL33G 110 MAVYRET 47 MEDISENSE THIN MEIJER PEN NEEDLES 31G

LANCETS 109 X8MM 156MAXALT 163 MEDLANCE PLUS EXTRA MEIJER PREMIUM BLOODMAXALT-MLT 163 LANCETS 21G 109 GLUCOSE MONITORING

MAXAM 70 MEDLANCE PLUS KIT 110 MAXITROL 178 LANCETS 109 MEIJER PREMIUM BLOOD

MEDLANCE PLUS LANCETS GLUCOSE TEST STRIPS 78MAXZIDE 82 LITE 25G 109 MEIJER SUPER THINMAXZIDE-25 82 MEDLANCE PLUS LITE LANCETS 110 MAYZENT 183 LANCETS 25G 109 MEIJER TRUE2GO BLOOD MAYZENT STARTER MEDLANCE PLUS SPECIAL GLUCOSE MONITORING PACK 183 LANCETS 0.8MM 109 SYSTEM 110 MAZERUSTAR KK-250S/KK- MEDLANCE PLUS MEIJER TRUERESULT BLOOD 300SS MIXER/DISPOSABLE SUPERLITE 30G 109 GLUCOSE MONITORING MIXING CONTAINE 139 MEDLANCE PLUS SYSTEM 110 MAZERUSTAR KK-250S/KK- SUPERLITE 30G/COMFORT MEIJER TRUETEST BLOOD 300SS MIXER/STANDARD MAX 109 GLUCOSE TEST STRIPS 78 MIXING CONTAINER 139 MEDLANCE PLUS MEIJER TRUETRACK BLOOD meclizine hcl 29 UNIVERSAL LANCETS GLUCOSE MONITORING

21G 109 KIT 110MEDELA ADVANCED MEDLANCE PLUS/LITE MEIJER TRUETRACK BLOODPERSONALDOUBLE BREAST 25G 109 GLUCOSE TEST STRIPS 78PUMP 139 MEDELA LACTINA DOUBLE MEDLANCE/EXTRA 109 MEKINIST 40 PUMPING KIT 139 MEDLANCE/LITE 109 MEKTOVI 40

MEDLANCE/UNIVERSAL110 melatonin 3

Index 31

meloxicam 5 methyldopa 33 MICROELITE FILTER

melphalan 36 methylergonovine REPLACEMENTS 160 MICROELITE RECHARGEABLEmaleate 180melphalan hcl 36 BATTERY 161METHYLIN 2memantine hcl 183 MICROLET LANCETS 110METHYLPEHNIDATE

MENACTRA 189 2 161HYDROCHLORIDE ER MICROSPACER MENVEO 189 methylphenidate hcl 2 MICROTAINER SAFETY FLOW

METHYLPHENIDATE LANCET/STERILE/SINGLE-USEMEPERIDINE HCL 7 HYDROCHLORIDE ER 2meperidine hcl 7 110 methylprednisolone 58 MICROZIDE 82

MEPHYTON 191 MIDAZOLAM HCL 93METIPRANOLOL 176meprobamate 12 metoclopramide hcl 87 midazolam hcl 94

mercaptopurine 37 midodrine hcl 191metolazone 82mesalamine 87 metoprolol & miglitol 22mesalamine w/ cleanser 87 hydrochlorothiazide 34 miglustat 91 mesna 41 metoprolol succinate 49 MIGRANAL 163MESNEX 41 METOPROLOL SUCCINATE MIGRANOW 163MESTINON 36 ER/HYDROCHLOROTHIAZIDE

MINASTRIN 24 FE 5434MESTINON TIMESPAN 36 MINI DIFFUSER/COOLmetoprolol tartrate 49META BIOTIC/BIO-ACTIVE MIST/ESSENTIAL OIL 139METOPROLOL/HYDROCHLO12 26 MINI MALLET 3/4"ROTHIAZIDE 34METAL REACHER/27" 139 PLASTIC/NON-MARRING 139METROCREAM 73METAL REACHER/32" 139 MINI TRANSFER PIN 139METROGEL-VAGINAL 190METAMUCIL 94 MINIELITE FILTER METROLOTION 73 REPLACEMENTS 161METAMUCIL ORIGINAL

TEXTURE 94 metronidazole 11 MINIELITE RECHARGEABLE BATTERY 161METAPROTERENOL metronidazole (topical) 73

SULFATE 15 MINIPRESS 33metronidazole vaginal 190METAXALONE 170 MINIVELLE 86MEXILETINE HCL 13metaxalone 170 MINOCIN 185mexiletine hcl 13METERED NASAL SPRAY minocycline hcl 185MIACALCIN 83PUMP 139 minoxidil 35METERED NASAL SPRAY MICARDIS 33 PUMP15ML/SAFETY CLIP 139 MICARDIS HCT 34 MIRALAX 95 metformin hcl 23 MIRAPEX 42MICATIN 62 methadone hcl 7 MIRAPEX ER 42MICONAZOLE 3 190 methamphetamine hcl 1 MIRCERA 91miconazole nitrate (topical)62 METHAVER 80 MIRCETTE 54miconazole nitrate METHAZEL 80 vaginal 190 MIRENA 56 methazolamide 82 MICORT-HC 67 mirtazapine 19 methenamine mandelate 188 MICRHOGAM ULTRA- misoprostol 188

FILTEREDPLUS 180methenamine-hyosc-methylene mitoxantrone hcl 39 blue-sod phos-phenyl sal 188 MICROCHAMBER 160 MIXER/MAZERUSTAR KK-

MICROCLENS WALL MOUNTmethimazole 185 300SS/STANDARD/MIXINGBRACKET 139 CONTAINER FOR EMP 139METHIONINE-200 81 MICRODOT BLOOD MIXER/MAZERUSTAR KK-METHITEST 10 GLUCOSE MONITORING 400W/STANDARD/MIXING

methocarbamol 170 SYSTEM 110 CONTAINER 139MICRODOT TESTMETHOTREXATE 4 MIXER/MAZERUSTAR/EMP/JARSTRIPS 78 MIXING ADAPTER/100ML 139methotrexate sodium 37 MICRODOT XTRA TEST MIXER/MAZERUSTAR/EMP/JARMETHOTREXATE SODIUM 37 STRIPS 78 MIXING/ADAPTER SET/15ML-

methotrexate sodium 37 50ML/100ML 139

Index 32

MIXER/MAZRUSTAR/MD PUMPMIXING ADAPTER 139 MIXING/MAZERUSTAR/EMP/JAR MIXING ADAPTER/15ML-50ML 139 MM EASY TOUCH BLOOD GLUCOSE METER 110 MM PEN NEEDLES 31G X 5/16" 156 MN8 139 MOBIC 5 MODERIBA 1200 DOSE PACK 47 moexipril hcl 33 moexipril-hydrochlorothiazide

35 MOI-STIR 167 MOIST-SURE REPLACEMENT COVER/LARGE/14" X 27" 139 MOIST-SURE REPLACEMENT COVER/MEDIUM/14" X 14"139 MOIST-SURE REPLACEMENT COVER/PETITE/4" X 17" 140 MOISTUREPLUS COVER/LARGE/14" X 27" 140 MOISTUREPLUS COVER/MEDIUM/14" X 14"140 MOISTUREPLUS COVER/PETITE/4" X 17" 140 MOLINDONE HYDROCHLORIDE 44 mometasone furoate 67 mometasone furoate

MONOJECT BLOOD COLLECTION TUBE/GREENSTOPPER/2ML 140 MONOJECT BLOOD COLLECTION TUBE/GREENSTOPPER/3ML 140 MONOJECT BLOOD COLLECTION TUBE/LAVENDERSTOPPER/10ML 140 MONOJECT BLOOD COLLECTION TUBE/LAVENDERSTOPPER/2ML 140 MONOJECT BLOOD COLLECTION TUBE/LAVENDERSTOPPER/3ML 140 MONOJECT BLOOD COLLECTION TUBE/LAVENDERSTOPPER/4ML 140 MONOJECT BLOOD COLLECTION TUBE/LAVENDERSTOPPER/5ML 140 MONOJECT BLOOD COLLECTION TUBE/LAVENDERSTOPPER/7ML 140 MONOJECT BLOOD COLLECTION TUBE/REDSTOPPER/10ML 140 MONOJECT BLOOD

MONOJECT BLOOD COLLECTION/INFUSIONSET/FEMALELUER/21GX3/4" 140 MONOJECT BLOOD COLLECTION/INFUSIONSET/FEMALELUER/23GX3/4" 140 MONOJECT BLOOD COLLECTION/INFUSIONSET/FEMALELUER/25GX3/4" 141 MONOJECT BLOOD COLLECTION/INFUSIONSET/MULTI-SAMPLE/19GX3/4"

141 MONOJECT BLOOD COLLECTION/INFUSIONSET/MULTI-SAMPLE/21GX3/4"



141 MONOJECT BLOOD TUBE HOLDER 141 MONOJECT LUER ADAPTER 141 MONOJECT MULTI-SAMPLE COLLECTION

(nasal)MOMMYS BLISS PROBIOTIC

172

26

COLLECTION TUBE/REDSTOPPER/15ML 140 MONOJECT BLOOD

SET/HOLDER/SAFETYCAP/MALE 141 MONOJECT MULTI-SAMPLE

MOMS OMEGA ADVANTAGE/VITAMIN D-3 173

COLLECTION TUBE/REDSTOPPER/2ML 140 MONOJECT BLOOD

COLLECTION SET/TUBEHOLDER/MALE MONOLET LANCETS

141 110

MONISTAT 3 190 MONISTAT 3 COMBINATION PACK 190 MONISTAT 7 SIMPLY CURE 190 MONISTAT SOOTHING CARE ITCH RELIEF 67 MONOCLATE-P 90 MONOJECT BLOOD COLLECTION TUBE/BLUESTOPPER/4.5ML 140 MONOJECT BLOOD COLLECTION TUBE/GRAYSTOPPER/10ML 140 MONOJECT BLOOD COLLECTION TUBE/GRAYSTOPPER/5ML 140

COLLECTION TUBE/REDSTOPPER/3ML 140 MONOJECT BLOOD COLLECTION TUBE/REDSTOPPER/4ML 140 MONOJECT BLOOD COLLECTION TUBE/REDSTOPPER/5ML 140 MONOJECT BLOOD COLLECTION TUBE/REDSTOPPER/7ML 140 MONOJECT BLOOD COLLECTION TUBE/ROYALBLUE STOPPER/7ML 140 MONOJECT BLOOD COLLECTION/INFUSIONSET/FEMALELUER/19GX3/4" 140

MONOLET OPD LANCETS110 MONOLETTOR SAFETY LANCETS 110 MONONINE 90 MONOVISC 171 montelukast sodium 14 morphine sulfate 7 MORPHINE SULFATE 8 morphine sulfate 8 MORPHINE SULFATE 8 morphine sulfate 8 MORPHINE SULFATE ER 7 MOTHERS FRIEND 70 MOTRIN CHILDRENS 5 MOTRIN INFANTS DROPS 5

Index 33

MOUTH KOTE 167 MYLICON INFANTS GAS NATRUL PROBIOTIC 26 RELIEF DYE FREE 87MOUTH KOTE REMINT 167 NATURAL WOOD CANE 141MYOBLOC 172MOXEZA 177 NATURAL WOOD WALKING MYRBETRIQ 189 STICK 141moxifloxacin hcl 87 MYSOLINE 18 NATURE-THROID 185moxifloxacin hcl (ophth) 177 NABI-HB 180 NATURESPIRIT PULSE

MOZOBIL 92 OXIMETER 141nabumetone 5MPD SAFETY LANCET NEBULIZER AIR 21G/1.8MM 110 nadolol 49 TUBE/PLUGS 161 MPD SAFETY LANCET NADOLOL/BENDROFLUMETH NEBULIZER PEDIATRIC 28G/1.8MM 110 IAZIDE 35 MASK 161 MPD SAFETY LANCET NAGLAZYME NEFAZODONE HCL85 2130G/1.8MM 110 NAIL POLISH nefazodone hcl 21MPD SAFETY LANCETS BOTTLE/BRUSH15ML 141 NEFAZODONE23G/1.8MM 110 NALOXONE HCL 28 HYDROCHLORIDE 21MS CONTIN 8 naloxone hcl 28 neomycin sulfate 3MSM SKIN LOTION 70 NALTREXONE 28 neomycin-bacitracin zn-MUCOSAL ATOMIZATION polymyxin 177naltrexone hcl 28NASALDEVICE 141 neomycin-bacitracin-polymyxinMULPLETA 91 NAMENDA 183 multiple vitamins tabs-assorted NAMENDA TITRATION neomycin-polymy-

61

PAK 183brand 168 dexameth 178 multiple vitamins tabs-assorted NAMENDA XR 183 neomycin-polymyxin w/generic 169 NAMENDA XR TITRATION pramoxine 61 multiple vitamins w/ iron 168 PACK 183 neomycin-polymyxin-hcmultiple vitamins w/ minerals NAMZARIC 183 (otic) 180 tabs-assorted brand 168 naphazoline w/ NEOMYCIN/POLYMYXIN/GRAMmultiple vitamins w/ minerals pheniramine 177 ICIDIN 177 tabs-assorted generic 168 NAPHCON-A 177 NEOMYCIN/POLYMYXIN/HYDR

OCORTISONE 178mupirocin 61 NAPROSYN 5 NEORAL 166mupirocin calcium (topical) 61 naproxen 5 NEOSPORIN 177MUSTARGEN 36 naproxen sodium 5 NEOSPORIN ORIGINAL 61MVASI 37 naproxen sodium- NEOSPORIN PLUS PAINMY MDI FINGER PULSE diphenhydramine hcl 93 RELIEF MAXIMUMOXIMETER 141 naproxen-esomeprazole STRENGTH 62MYALEPT 85 magnesium 5 NEPHRO-VITE RX 168MYAMBUTOL 36 naratriptan hcl 164

NEPHROCAPS 168mycophenolate mofetil 166 NARCAN 28

NEPTAZANE 82mycophenolate mofetil hcl 166 NARDIL 20

NESINA 23mycophenolate sodium 166 NASADOCK 141

NEULASTA 91NASALMYDRIACYL 176 DECONGESTANT 172 NEULASTA ONPRO KIT 91

MYFORTIC 166 NASAL SPRAY BOTTLE NEUPOGEN 91MYGLUCOHEALTH BLOOD 20ML 141 NEUPRO 42GLUCOSE MONITORING NASAL SPRAY PUMPSYSTEM 110 30ML/METERED/0.1ML NEUREPA 80 MYGLUCOHEALTH BLOOD DOSAGE 141 NEURONTIN 18GLUCOSE TEST 78 NASALCROM 171 NEUTEK 2TEK BLOODMYGLUCOHEALTH MGH GLUCOSE AND WRIST BLOODNASONEX 172SOFTLANCE LANCETS PRESSURE MONITOR 11030G 110 NATAZIA 54 NEUTEK 2TEK TESTMYLERAN 36 nateglinide 24 STRIPS 78 MYLICON INFANTS GAS NATPARA 83 NEUTROGENA BODY LIGHT RELIEF 87 SESAME FORMULA 70NATROBA 73

Index 34

NEUTROGENA HEALTHY SKIN NITRO-TIME 12 NORTRIPTYLINE HCL 21 FACE SPF 15 70 nitrofurantoin 188 nortriptyline hcl 21NEUTROGENA MOISTURE nitrofurantoin NORVASC 50SENSITIVE SKIN 70 macrocrystal 188NEUTROGENA T/GEL 74 NORVIR 46nitrofurantoin monohydNEUTROGENA T/GEL NOSE CLIP 161macro 188STUBBORN ITCH nitroglycerin 12 NOVA BATH SEAT/BACK &CONTROL 74 ARMS 141NITROSTAT 12NEVANAC 179 NOVA CUSHION GEL/FOAMnevirapine 46 NIVEA 70 SEAT PAD/18X16X3 141

NIVEA EXTRA NOVA MAX BLOOD GLUCOSENEVIRAPINE ER 46 ENRICHED 70 MONITORING SYSTEM 110 NEXAVAR 40 NIVEA EXTRA ENRICHED NOVA MAX GLUCOSE TEST NEXCARE COMFORT FOAM LOTION 70 STRIPS 78 EAR PLUGS 141 NIVEA GENTLE BODY NOVA QUAD TIP/FOURNEXCARE REUSABLE EAR EXFOLIATOR 70 PRONGS 3/4" SHAFTPLUGS 141 NIVEA LIGHT 70 CANE 141 NEXDOSE PRESCRIPTION NOVA SAFETY LANCETSNIVEA ORIGINAL 70MEDICATION DIGITAL 23G 111NIVEA ORIGINALASSISTANT 141 NOVA SAFETY LANCETSMOISTURE 70NEXIUM 187 28G 111NIVEA VISAGE 71 NOVA SUREFLEXNEXIUM 24HR 187 NIVESTYM 91 LANCETS 111NEXPLANON 57 NIX CREME RINSE 73 NOVAREL 83NG SECURE NASOGASTRIC NIZORAL 62 NOVOEIGHT 90TUBE HOLDER 141

nonoxynol-9 190 NOVOLIN 70/30 24NIACIN 32 NORCO 8 NOVOLIN 70/30 FLEXPEN 24niacin 192

NOVOLIN 70/30 FLEXPENniacin (antihyperlipidemic) 32 NORDITROPIN FLEXPRO 84 RELION 24

NIACIN TR 192 norethin acet & estrad-fe 54 NOVOLIN 70/30 RELION 24norethindrone & ethNIACOR 32 NOVOLIN N 24estradiol 54NIASPAN 32 norethindrone & ethinyl NOVOLIN N FLEXPEN 24 nicardipine hcl 50 estradiol-fe 54 NOVOLIN N FLEXPEN NICODERM CQ 184 norethindrone RELION 24

(contraceptive) 57NICORETTE 184 NOVOLIN N RELION 24norethindrone acet & eth NICORETTE MINI 184 NOVOLIN R 24estra 55 NICORETTE STARTER NOVOLIN R RELION 24norethindrone acetate 182 KIT 184 norethindrone acetate-ethinyl NOVOLOG MIX 70/30 24 nicotine 184 estradiol 86 NOVOLOG MIX 70/30nicotine polacrilex 184 norethindrone acetate-ethinyl PREFILLED FLEXPEN 24 NICOTINE TRANSDERMAL estradiol-fe 55 NOVOSEVEN RT 90

norethindrone-eth estradiolSYSTEM 184 NPLATE 91(triphasic) 55NICOTROL INHALER 184 norgestimate-ethinyl NUCALA 13 NICOTROL NS 184 estradiol 55 NUCYNTA 8 nifedipine 50 norgestimate-ethinyl estradiol NUCYNTA ER 8 nimodipine 50 (triphasic) 55 NULOJIX 166norgestrel & ethinylNINLARO 40 estradiol 55 NULYTELY/FLAVORnisoldipine 50 PACKS 94NORPACE 13 NISOLDIPINE ER 50 NUMOISYN 167NORPRAMIN 21 nitisinone 85 NUPLAZID 43NORTEMP INFANTS 6 NITRO-BID 12 NUTRADERM 71NORTHERA 191 NUTRADERM ADVANCEDNITRO-DUR 12 nortriptyline hcl 21 FORMULA 71

Index 35

nutritional supplements 81 OFFSET CANE/GREEN OMEGA ICE/300LB CAPACITY 142 ESSENTIALS/VITAMIND-3NUTROPIN AQ NUSPIN 10 84 OFFSET 173NUTROPIN AQ NUSPIN 20 84 CANE/HOUNDSTOOTH/300LB OMEGA POWER 173

NUTROPIN AQ NUSPIN 5 84 CAPACITY 142 OMEGA-3 174OFFSET CANE/METALLICNUVARING 56 BLACK/300LB OMEGA-3 + D 3

NUWIQ 90 CAPACITY 142 OMEGA-3 2100 174NVZZLER PRO DOUBLE OFFSET OMEGA-3 EXTRA STRENGTHELECTRIC BREAST CANE/MOBILITY/250LB +VITAMIN D3 3PUMP 141 CAPACITY 142 omega-3 fatty acids 174,175NVZZLER SINGLE ELECTRIC OFFSET CANE/ROSE OMEGA-3 FISH OIL EXTRABREAST PUMP 141 PRINT/300LB CAPACITY142 STRENGTH 175NYMALIZE 50 OFFSET CANE/STRAP 142 OMEGA-3 GUMMIES 3nystatin 29 OFLOXACIN 87 OMEGA-3 KRILL OIL 3nystatin (mouth-throat) 167 ofloxacin 87 OMEGA-3-6-9 3nystatin (topical) 62 ofloxacin (ophth) 177 omega-3-acid ethyl esters 31nystatin-triamcinolone 62 ofloxacin (otic) 180 OMEGAPURE 780 EC 175NYTOL MAXIMUM OGESTREL 55STRENGTH 93 omeprazole 187 O-RING CUSHION 16" OINTMENT JAR 2OZ 142 OMEPRAZOLE 187 DIAMETER 141 OINTMENT TUBE omeprazole magnesium 187OPHTHALMICTIPOBIZUR 90 omeprazole-sodium1/8OZ/METAL 142OCALIVA 87 bicarbonate 188OINTMENTOCEAN NASAL SPRAY 171 TUBE/METAL/1OZ 142 OMNARIS 172 OCTAGAM 181 OINTMENT OMNIPRED 178

TUBE/METAL/2OZ 142OCTREOTIDE ACETATE 85 OMNIQUIN 81OINTMENToctreotide acetate 86 OMNITROPE 84TUBE/METAL/4OZ 142 OCUFLOX 177 OINTMENT TUBE/PLASTIC ON CALL EXPRESS BLOOD

ODEFSEY 46 W/SCREW CAP/8OZ 142 GLUCOSE METER 111 OINTMENT ON CALL EXPRESS BLOOD

ODOMZO 38 TUBE/PLASTIC/1OZ 142 GLUCOSE MONITORING OFEV 185 OINTMENT SYSTEM 111 OFF ACTIVE 72 TUBE/PLASTIC/2OZ 142 ON CALL EXPRESS BLOOD

OINTMENT GLUCOSE TEST STRIPS 78OFF DEEP WOODS 72 TUBE/PLASTIC/4OZ 142 ON CALL LANCETS 111OFF DEEP WOODS DRY 72 OINTMENT ON CALL PLUS BLOODOFF DEEP WOODS TUBE/PLASTIC/6OZ 142 GLUCOSE METER 111SPORTSMEN 72 olanzapine 44 ON CALL PLUS BLOODOFF FAMILYCARE SMOOTH & GLUCOSE MONITORINGolmesartan medoxomil 33DRY 72 SYSTEM 111olmesartan medoxomil-OFF SMOOTH & DRY 72 ON CALL PLUS BLOODamlodipine-hydrochlorothiazideOFFSET GLUCOSE TEST 78 CANE/BLACK/300LBCAPACITY olmesartan medoxomil-

35 ON CALL PLUS LANCETS 111 141 hydrochlorothiazide 35 ON CALL VIVID BLOOD

OFFSET CANE/BLUE ICE/300LB GLUCOSE METER 111olopatadine hcl 179CAPACITY 141 ON CALL VIVID BLOODOFFSET olopatadine hcl (nasal) 171 GLUCOSE MONITORINGCANE/BRONZE/300LBCAPACIT OLUMIANT 4 SYSTEM 111Y 141 OLUX 67 ON CALL VIVID BLOODOFFSET CANE/BROQUE GLUCOSE TEST 78TEAL/300LB CAPACITY 141 OLUX-E 67 ON CALL VIVID BLOODOFFSET OLYSIO 47 GLUCOSE TEST STRIPS 78CANE/CHROME/300LBCAPACIT OMEGA 3-6-9 COMPLEX 3 ON CALL VIVID PAL BLOODY 141 GLUCOSE METER 111OMEGA DHA 3

ONCASPAR 40

Index 36

ondansetron 28 ONGLYZA 23 ORAL MEDICINE DROPPER 142ondansetron hcl 28 ONMEL 29 ORAL RELIEF SPRAY FOR

ONDANSETRON HCL 28 ONPATTRO 184 DRYMOUTH & ondansetron hcl 28 ONZETRA XSAIL 164 DISCOMFORT 167 ONE DROP BLOOD GLUCOSE OPCON-A 177 ORAL SYRINGE/BRUSH 142 MONITORING SYSTEM 111 OPDIVO 37 ORALAIR 2ONE DROP BLOOD GLUCOSE ORALAIR ADULT SAMPLEOPSUMIT 51TEST STRIPS 78 KIT 2ONE OUNCE MEDICINE OPTICHAMBER ORALAIR ADULT STARTERCUPS 142 ADVANTAGE/LARGE PACK 2ONE STEP AT A TIME MASK 161 ORENCIA 6FILTERS 142 OPTICHAMBER ONE-A-DAY VITACRAVES ADVANTAGE/MEDIUM FACE ORENCIA CLICKJECT 5 GUMMIES+OMEGA-3 MASK 161 ORENITRAM 51 DHA 169 OPTICHAMBER ORFADIN 85ONE-DAY-AT-A-TIME ADVANTAGE/SMALL FACE ORIGINAL MCKENZIEPLANNER/BLISTER MASK 161 CERVICAL ROLL 142CARD/MEDIUM 142 OPTICHAMBER

ORILISSA 84ONETOUCH CLUB LANCETS DIAMOND 161 FINE POINT 111 OPTICHAMBER ORKAMBI 184 ONETOUCH DELICA LANCETS DIAMOND/LARGEFACE orphenadrine citrate 170EXTRA FINE 33G 111 MASK 161 ORTHO MICRONOR 57ONETOUCH DELICA LANCETS OPTICHAMBER FINE 30G 111 DIAMOND/MEDIUM FACE ORTHO TRI-CYCLEN 55 ONETOUCH DELICA PLUS MASK 161 ORTHO TRI-CYCLEN LO 55 LANCETS EXTRA FINE OPTICHAMBER ORTHO-CYCLEN 5533G 111 DIAMOND/SMALLFACE

ORTHO-NOVUM 1/35 55ONETOUCH DELICA PLUS MASK 161 LANCETS FINE 30G 111 OPTICHAMBER FACE ORTHO-NOVUM 7/7/7 55 ONETOUCH FINEPOINT MASK/LARGE 161 ORTHOVISC 171LANCETS 111 OPTICHAMBER FACE oseltamivir phosphate 48ONETOUCH ULTRA 78 MASK/MEDIUM 161

OPTICHAMBER FACE OSENI 22ONETOUCH ULTRA 2 111 MASK/SMALL 161 OTEZLA 5ONETOUCH ULTRA MINI 111 OPTIHALER 161 OTICIN HC NR 180ONETOUCH ULTRALINK OPTIHALER MDI DRUGSYSTEM (DEC) 111 OTREXUP 4DELIVERY SYSTEM 161ONETOUCH ULTRALINK OVACE PLUS WASH 63OPTIONS CONCEPTROLSYSTEM (HEX) 111 VAGINAL OVACE WASH 63ONETOUCH ULTRASOFT CONTRACEPTIVE 190 OVALLANCETS 111 OPTIONS GYNOL II PESSARY/SUPPORT 142ONETOUCH VERIO 111 VAGINALCONTRACEPTIVE OVARY 81ONETOUCH VERIO FLEX 190 OVIDE 73BLOOD GLUCOSE OPTIUM BLOOD GLUCOSE MONITORING SYSTEM 111 MONITORING SYSTEM 112 oxaprozin 5 ONETOUCH VERIO IQ BLOOD OPTIUM TEST STRIPS 78 oxazepam 13GLUCOSE MONITORING OPTIUMEZ TEST STRIPS 78 OXAZEPAM 13SYSTEM 111 OPTUMRX BLOOD GLUCOSE oxcarbazepine 18ONETOUCH VERIO

METER 112REFLECT 111 OXERVATE 178OPTUMRX BLOOD GLUCOSEONETOUCH VERIO SYNC oxiconazole nitrate 62MONITORING SYSTEM 112BLOODGLUCOSE OPTUMRX BLOOD GLUCOSE OXISTAT 62MONITORING SYSTEM 112 TEST 78ONETOUCH VERIO TEST OXTELLAR XR 18 ORAL DOSE SYRINGE 142STRIPS 78 oxybutynin chloride 188

ONEXTON 60 oral electrolytes 164 oxycodone hcl 8ORAL ENDOTRACHEAL TUBEONFI 16 OXYCODONE HCL ER 8ATTACHMENT DEVICE 142

Index 37

OXYCODONE HYDROCHLORIDE ER 8 oxycodone w/ acetaminophen 9 oxycodone-aspirin 9 OXYCODONE/ACETAMINOPHEN 9 OXYCODONE/ASPIRIN 9 OXYCONTIN 8 OXYMORPHONE

PARI BABY CONVERSION KITSIZE 1 161 PARI BABY CONVERSION KITSIZE 2 161 PARI BABY CONVERSION KITSIZE 3 161 PARI ERAPID NEBULIZER HANDSET 161 PARI EXPIRATORY FILTER VALVE SET 161

pediatric multiple vitamin w/minerals & c 169 pediatric multiple vitamins w/iron 169 pediatric multivitamins w/fl chew-assorted brand 169 pediatric multivitamins w/fl chew-assorted generic 169 pediatric multivitamins w/fl soln-assorted brand 169

HYDROCHLORIDE ER 8 PARI MASK SET 161 pediatric multivitamins w/fl soln-OXYMORPHONE PARI SOFT PLASTIC ADULT assorted generic 169 HYDROCHLORIDEER 8 pediatric vitamins acd w/MASK 161

fluoride 169OXYTROL 188 PARI SOFT PLASTIC peg 3350-kcl-sod bicarb-sodPEDIATRIC MASK 161OXYTROL FOR WOMEN 188 chloride-sod sulfate 94PARI VORTEX ADULToyster shell 164 peg 3350-potassium chloride-sodMASK 161 bicarbonate-sod chloride 95OZURDEX 178 paricalcitol 85

PA FISH PEGANONE 19PARLODEL 42OIL/PHYTOSTEROLSTRIPLE PEGASYS 48PARNATE 20STRENGTH 3 PEGASYS PROCLICK 48PA FISH OIL/VITAMIN D-3 paroxetine hcl 20 PEGINTRON 48TRIPLE STRENGTH 175 paroxetine mesylate

PADDLE (vasomotor) 184 PELVIC MUSCLE WALKER/FOLDING/5"WHEELS/ PARSABIV 85 TRAINER 142

PEN NEEDLES 31G XADJUSTABLE 142 PATADAY 179PAIN RELIEF DAY & NIGHT 8MM 156 EXTRA STRENGTH 93 PATANASE 171 PEN NEEDLES 31GX5/16" 156 paliperidone 43 PATANOL 179 PEN NEEDLES 31GX8MM 157 PALMERS COCOA BUTTER PAXIL 20 PEN NEEDLES 31GX8MM FORMULA LOTION 71 (5/16") 156PAXIL CR 20PALMERS COCOA BUTTER PEN NEEDLES-MISC 157PAZEO 179FORMULA LOTION PEN NEEDLES/31G XPC LANCETS SUPER THINFRAGRANCE FREE 71 5/16" 157PALMERS COCOA BUTTER 30G 112 penicillamine 165PC UNIFINE PENTIPS 31GFORMULA MASSAGE LOTION/STRETCH MARKS 71 X8MM SHORT 156 PENICILLIN V

POTASSIUM 181PALMERS COCONUT OIL PCCA ACCUPEN-15 142 penicillin v potassium 181FORMULA BODY LOTION 71 PEARLS IC 26

PALYNZIQ 85 ped multivitamins w/fl & PENLAC NAIL LACQUER 63 PAMELOR 21 iron 169 PENTIPS 31G X 8MM 157 pamidronate disodium 83 PEDAL EXERCISER 142 PENTIPS 31GX8MM 157 PAMIDRONATE DISODIUM 83 PEDIALYTE 165 pentoxifylline 90

PEDIALYTE ADVANCEDPANCREAZE 81 PEPCID 186CARE 165PANDEL 67 PEPCID AC 186PEDIALYTE FREEZER

PEPCID AC MAXIMUMpantoprazole sodium 187 POPS 165 STRENGTH 186PANZYGA 181 PEDIALYTE SINGLES 165 PEPTO-BISMOL 26PARADIGM LINK BLOOD PEDIAPRED 58 PEPTO-BISMOL MAXGLUCOSE MONITOR 112 PEDIATRIC STRENGTH 26PARAGARD INTRAUTERINE MOUTHPIECE/DISPOSABLE PEPTO-BISMOL TO-GO 26COPPER CONTRACEPTIVE 161

T380A 56 pediatric multiple vitamin w/ PERCOCET 9 PAREGORIC 28 c 169 PERCURA 81 PARI ALTERA NEBULIZER pediatric multiple vitamin w/ c & PERFECT LANCETS 30G 112HANDSET 161 fa 169

Index 38

PERFECT PRESSURE ACTIVATED SAFETY LANCETS 28G 112

phenylephrine-dm 59 phenylephrine-shark liver oil-cocoa butter 10

PLASTIC ENEMA BOTTLE/2OZ/20/410OPENING 143

PERFOROMIST 15 PERIDEX 167 perindopril erbumine 33 PERJETA 37 permethrin 73 perphenazine 44 PERPHENAZINE/AMITRIPTYLINE 183 PERSERIS 43 PERSONAL BLOOD PRESSURE SMART CARD 142 PERTZYE 81 PEXEVA 20 PFLEX 161 PH 12 STERILE DILUENT FORFLOLAN 182 PH ACCESSORIES STORAGE SOLUTION 230ML 142

phenylephrine-shark liver oil-mineral oil-petrolatum 10 PHENYTEK 19 phenytoin 19 phenytoin sodiumextended 19 PHILLIPS COLON HEALTH 26 PHOSLYRA 88 PHOTOFRIN 41 phytonadione 191 PIFELTRO 46 PILL BOX 7 DAY 142 PILL CRUSHER 142 PILL CRUSHER/BUILT INSTORAGE 142 PILL POUCH 142 PILL SPLITTER 142

PLASTIC JAR 6OZ 143 PLASTIC SCOOP 1ML/4"HANDLE 143 PLATFORM WALKER ATTACHMENT 143 PLATINUM REACHER 31" 143 PLAVIX 91 PLEGRIDY 183 PLEGRIDY STARTER PACK 183 PLIXDA 60 PNEUMOVAX 23 189 PNEUMOVAX 23/1 DOSE 189 POCKET CHAMBER 162 POCKET MAGNIFIER 143 POCKET PRO+ REPLACEMENT SENSOR/TESTER 143 POCKET SPACER 162

PHARMACIST CHOICE ALCOHOL PRED PADS 142 PHARMACIST CHOICE ALCOHOLPREP PADS 142 PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM 112 PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS 78 PHARMACIST CHOICE MINI BLOOD GLUCOSE MONITORING SYSTEM 112 PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS 78 PHARMACIST CHOICE ULTRA THIN LANCETS 112 PHARMACIST CHOICE ULTRA THIN LANCETS 28G 112 PHARMACIST CHOICE ULTRA THIN LANCETS 30G 112 PHARMACIST CHOICE ULTRA THIN LANCETS 31G 112 PHARMACIST CHOICE ULTRA THIN LANCETS 33G 112 PHARMACY COUNTER

PILLGUARD DISPENSER 142 PILLGUARD REFILL CARTRIDGE 143 PILLOW MASK/ADULT 161 PILLOW MASK/CHILD 162 PILLOW MASK/PEDIATRIC 162 pilocarpine hcl 176 pilocarpine hcl (oral) 167 pimecrolimus 71 pindolol 49 pioglitazone hcl 23 pioglitazone hcl-glimepiride 22 pioglitazone hcl-metforminhcl 22 PIP LANCETS/28G 112 PIP LANCETS/30G 112 piroxicam 5 PLAN B ONE-STEP 56 PLAQUENIL 35 PLASTIC BED PAN 143

POCKETCHEM EZ BLOOD GLUCOSE MONITORING SYSTEM 112 POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS 78 podofilox 71 POLIVY 37 POLY-VI-SOL 169 POLY-VI-SOL/IRON 169 POLYCOSE 173 polyethylene glycol 3350 95 polymyxin b-trimethoprim 177 POLYPROPYLENE CAP/LINER 143 polysaccharide iron complex 92 POLYTRIM 177 polyvinyl alcohol 175 POMALYST 38 PORTRAZZA 37 POSTURE SEAT 143 pot phosphate monobasic w/ sodphosphate dibasic &monobasic 165

LANCETS phenazopyridine hcl phenelzine sulfate phenobarbital phenylephrine hcl(mydriatic) phenylephrine hcl (oral)

112 89 20 93

176 172

PLASTIC BOTTLES/30ML/TWIST TOPSIFTER CAPS 143 PLASTIC BOTTLES/90ML/TWIST TOPSIFTER CAPS 143

potassium bicarbonate 165 potassium chloride 165 POTASSIUM CHLORIDE ER 165 potassium chloridemicroencapsulated crystals er 165

Index 39

potassium citrate PRECISION TISSUE prenatal vitamins-assorted(alkalinizer) 88 GRINDER 143 generic 169 potassium citrate-citric acid 88 PRECISION TISSUE PREORBOTIC 26 POTELIGEO 37 GRINDER/15ML 143 PRESCRIPTION BOTTLE

PRECISION TISSUE MAGNIFIER 143POWDER INSUFFLATOR 143 GRINDER/50ML 143 PRESSURE ACTIVATEDPRADAXA 16 PRECISION URINE SAFETYLANCET 21G 112

SPECIMENSYSTEM WITHPRALUENT 32 PRESTALIA 35PRESERVATIVE 143pramipexole dihydrochloride 42 PREVACID 187PRECISION XTRA 112pramoxine hcl (rectal) 10 PREVACID 24HR 187PRECISION XTRA BLOODpramoxine-hc-chloroxylenol GLUCOSE TEST STRIPS 78 PREVACID SOLUTAB 187

180 PRECISION XTRA PREVENT SAFETY PENPRANDIN 24 MONITOR 112 NEEDLES 31GX5/16" 157 prasugrel hcl 91 PRECOSE 22 PREVIDENT 5000 DRY

MOUTH 167PRAVACHOL 32 PRED FORTE 178 PREVIDENT 5000 PLUS 167pravastatin sodium 32 PRED MILD 178 PREVIDENT FLUORIDE 167prazosin hcl 33 PRED-G 178 PREVIDENT RINSE 167PRECEDEX 94 PREDATOR 72 PREVNAR 13 189PRECISION CATHETER PREDNICARBATE 67

URINESPECIMEN SYSTEM PREVYMIS 47PREDNISOLONE 58KIT 143 PREZCOBIX 46PREDNISOLONEPRECISION LINK 112 ACETATE 178 PREZISTA 46PRECISION MIDSTREAM PREDNISOLONE ACETATE P- PRIALT 6PRESERVATIVE KIT 143 F 178 PRILOSEC 187PRECISION PCX 78 prednisolone sodiumPRECISION PCX PLUS TEST phosphate 58 PRILOSEC OTC 187 STRIPS 78 PREDNISOLONE SODIUM primidone 18 PRECISION POINT OF CARE PHOSPHATE 178 PRINIVIL 33TEST STRIPS 78 PREDNISONE 58 PRISTIQ 21PRECISION QID prednisone 58MONITOR 112 PRIVIGEN 181

PREDNISONE INTENSOL 58PRECISION QID TEST PRO COMFORT ALCOHOL STRIPS 78 PREFERRED PLUS LANCETS PADS 143

COLORED 21G 112PRECISION SCALE PRO COMFORT FOOT COMPACT 143 PREFERRED PLUS LANCETS BATH 143 PRECISION SOF-TACT SUPER THIN 30G 112 PRO COMFORT INHALER MONITOR 112 PREFERRED PLUS LANCETS SPACER CHAMBER PRECISION SOF-TACT TEST THIN 26G 112 ADULT 162PREFERRED PLUS UNIFINESTRIPS 78 PRO COMFORT INHALER PRECISION SPECIMEN PENTIPS 31G X 8MM SPACER CHAMBER CONTAINER/5OZ 143 SHORT 157 CHILD 162PRECISION SPECIMEN pregabalin 18 PRO COMFORT INHALER CONTAINER/POSITIVE SEAL PREGNYL W/DILUENT SPACER CHAMBER INDICATOR 143 BENZYLALCOHOL/NACL 84 INFANT 162PRECISION SPECIMEN PREMARIN 86,190 PRO COMFORT LANCETS CONTAINER/POSITIVE SEAL 30G 112PREMIUM BLOOD GLUCOSEINDICATOR/118ML 143 PRO COMFORT LANCETSTEST STRIPS 78PRECISION SPUTUM PREMIUM PILL 31G 113 COLLECTOR KIT WITH PRO COMFORT PENCRUSHER 143TUBE 143 NEEDLES/31G X 8MM 157PREMPHASE 86PRECISION SPUTUM PRO VOICE V8 BLOOD COLLECTOR KIT/TUBE 143 PREMPRO 86 GLUCOSE MONITORING PRECISION STOOL PRENATAL OMEGA SYSTEM 113 COLLECTOR 143 BABY 175 PRO VOICE V8/V9 BLOODPRECISION THINS GP prenatal vitamins-assorted GLUCOSE TEST STRIPS 79 LANCET 112 brand 169

Index 40

PRO VOICE V9 BLOOD GLUCOSE MONITORING

PRODIGY AUTOCODE BLOOD GLUCOSE

PROPRANOLOL/HYDROCHLOROTHIAZIDE 35

SYSTEM PRO-BIOTIC BLEND PRO-FLORA IMMUNE PROAIR HFA

113 26 26 15

MONITORING SYSTEM 113 PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING/TALKING 113 PRODIGY NO CODING

propylthiouracil PROS-TECH PLUS PROSCAR PROSTATE 2.4

185 81 89 81

PROAIR RESPICLICK 15 probenecid 89 PROBIOMAX DAILY DF 26 PROBIOTIC 27 PROBIOTIC & ACIDOPHILUS FORMULA EXTRA STRENGTH 26

BLOOD GLUCOSE 113 PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS 79 PRODIGY POCKET BLOOD GLUCOSE METER KIT 113 PRODIGY PRESSURE ACTIVATED SAFETY

PROTEOLIN PROTONIX PROTOPIC protriptyline hcl PROVAD PROVENGE

81 187

71 21 27 38

PROBIOTIC + OMEGA-3 27 LANCETS 113 PROVENTIL HFA 15 PROBIOTIC ACIDOPHILUS 27 PROBIOTIC ACIDOPHILUS BEADS 27 PROBIOTIC ADVANCED ULTRAPOTENCY 27 PROBIOTIC COLON SUPPORT 27 PROBIOTIC

PRODIGY SAFETY LANCETS 113 PRODIGY TWIST TOP LANCETS 113 PRODIGY VOICE BLOOD GLUCOSE METER KIT 113 PROFILNINE 90 PROFILNINE SD 90

PROVERA 182 PROZAC 20 pseudoephedrine hcl 172 pseudoephedrine w/ codeine-gg 59 pseudoephedrine-ibuprofen 59 PSORCON 67

COMPLEX/ACIDOPHILUS PROBIOTIC DAILY PROBIOTIC DIGESTIVE SUPPORT EXTRA STRENGTH PROBIOTIC MATURE ADULT

27 27

28

27

PROFIT PRECISION SCALE 143 progesterone micronized 182 PROGRAF 166 PROLASTIN-C 184 PROLENSA 179

PSS SELECT GP LANCETS PSS SELECT SAFETY LANCETS psyllium PTS PANELS GLUCOSE TEST

113

113 94

79 PROBIOTIC PEARLS 27 PROLEUKIN 41 PULMICORT 14 PROBIOTIC PEARLS PROLIA 83 PULMICORT FLEXHALER 14 ADVANTAGE 27 PROBIOTIC+TURMERIC EXTRACT 27 PROBIOTIC-10 ULTIMATE 27 PROBIOTIC/PREBIOTIC/CRANBERRY 27 PROBUPHINE IMPLANT KIT 9 PROCARDIA 50 PROCARDIA XL 50

PROMACTA 91 PROMELLA IN PREBIOTIC 27 promethazine &phenylephrine 59 promethazine hcl 31 promethazine w/codeine 59 promethazine-phenylephrine-codeine 59

PULMONA 81 PULMOZYME 185 PULSE OXIMETER 143 PULSE OXIMETER DELUXE 143 PULSE OXIMETER FOR FINGER 143 PUMP IN STYLE ADVANCED DOUBLE BREASTPUMP 143

PROCARE SPACER CHAMBER W/ADULT MASK 162 PROCARE SPACER CHAMBER W/CHILD MASK 162 prochlorperazine 44 prochlorperazine edisylate 44 prochlorperazine maleate 44 PROCRIT 91 PROCTOCORT 10 PROCTOFOAM 10 PROCYSBI 88 PRODIGEN 27

PROMETHAZINE/PHENYLEPHRINE 59 PROMETHAZINE/PHENYLEPHRINE/CODEINE 59 PROMETHEGAN 31 PROMETRIUM 182 PRONEB ULTRA FILTER SET 162 propafenone hcl 13 propranolol hcl 49 PROPRANOLOL HCL 49 propranolol hcl 49

PUMP IN STYLE ADVANCED DOUBLE BREASTPUMP/BACKPACK

143 PURE COMFORT ALCOHOL PREPPADS 144 PURIXAN 37 PUSH BUTTON SAFETY LANCETS 21G 113 PUSH BUTTON SAFETY LANCETS 28G 113 PX LANCETS ULTRA THIN 113 PX PEN NEEDLE 31GX8MM 157

Index 41

PX SHORTLENGTH PEN QUAD CANE/SMALL RA BLOOD GLUCOSE NEEDLES/31GX8MM 157 BASE. 144 MONITOR 113 pyrantel pamoate 11 QUAD CANE/SMALL RA COMFORT-FOAM EAR

BASE/BRONZE PLUGS 144pyrazinamide 36 ALUMINUM 144 RA DAYLOGIC HEALING DRYpyrethrins-piperonyl butoxide73 QUAD CANE/SMALL SKIN THERAPY 71 pyrethrins-piperonyl butoxide- BASE/BRONZE/CUSHIONED RA DELUXE CUT N permethrin-nit remover 73 HANDLE/1/2" 144 CRUSH 144 PYRIDIUM 89 QUAD CANE/SMALL RA DRY MOUTH 167 pyridostigmine bromide 36 BASE/CUSHIONED RA E-ZJECT COLOR

HANDLE/1/2" 144 LANCETSMICRO-THINpyridoxine hcl 192 QUAD CANE/SMALL 33G 113pyrimethamine 35 BASE/OFFSET HANDLE 144 RA E-ZJECT LANCETS QBRELIS 33 QUAD CANE/SMALL 28G 113 QC ALCOHOL SWABS 144 BASE/ORTHO RA E-ZJECT LANCETS THIN

HANDLE/1/2" 144QC LANCETS SUPER 26G 113QUAD CANE/SMALL RA E-ZJECT LANCETS THINTHIN 113 BASE/SHOVEL HANDLE 144 28G 113QC LANCETS ULTRA QUAD CANE/SMALL LOW RA E-ZJECT LANCETSTHIN 113 BASE/DEVON HANDLE 144 ULTRATHIN 30G 114QC PEN NEEDLES 31G X QUAD CANE/SMALL LOW RA EXTRA COMFORT NIGHT8MM 157 BASE/ORTHO GRIP 144 PROTECTOR ORAL CARE144QC UNILET LANCETS

28G/ULTRA THIN 113 QUAD-PROBIOTIC 27 RA FISH OIL 175 QC UNILET LANCETS QUARTETTE 55 RA FOAM EAR PLUGS 144 33G/MICRO THIN 113 QUAZEPAM 94 RA FOLDING SYRINGE 144QNASL 172 QUDEXY XR 18 RA GLASS DROPPERS 144QNASL CHILDRENS 172 QUESTRAN 31 RA KRILL OIL 3QUAD CANE TIPS 1/2" 144 QUESTRAN LIGHT 31 RA LICE SOLUTION KIT 73QUAD CANE TIPS 5/8" 144 quetiapine fumarate 44 RA MEDICINEQUAD CANE QUICK-FIT CRUTCHES 144 DROPPER/SPOON 144TIPS/BLACK/5/8" 144 RA OMEGA 3-6-9 3QUAD CANE QUICKTEK 113

RA OYSTER SHELLTIPS/GREY/5/8" 144 QUICKTEK TEST STRIPS 79 CALCIUM/VITAMIN D 164QUAD CANE/BRONZE QUIET PLEASE FOAM EAR RA PEN NEEDLES 31G XHANDLE/SMALL BASE 144 PLUGS 144 8MM5/16" 157QUAD CANE/LARGE QUILLICHEW ER 2 RA PROBIOTIC COLONBASE/BRONZE QUILLIVANT XR 2 CARE 27ALUMINUM 144 QUAD CANE/LARGE quinapril hcl 33 RA PROBIOTIC COMPLEX 27 BASE/CUSHIONED quinapril-hydrochlorothiazide RA PROBIOTIC DIGESTIVE HANDLE/5/8" 144 35 SUPPORT 27 QUAD CANE/LARGE RA PROBIOTIC MAXIMUMquinidine gluconate 13 BASE/ORTHO STRENGTH 27QUINIDINE SULFATE 13HANDLE/5/8" 144 RA QUIET PLEASE FOAM

QUINTET AC BLOOD EARPLUGS 144QUAD CANE/LARGEBASE/SELECTAGRIP GLUCOSEMONITORING RA RENEWAL DRY SKIN

113 71HANDLE/5/8" 144 SYSTEM THERAPY QUAD CANE/LARGE QUINTET AC BLOOD RA RENEWAL HAIR STYLING

GLUCOSETEST STRIPS 79 SHEARS 144BASE/SHOVEL HANDLE 144 QUINTET BLOOD GLUCOSE RA REST ASSURED NITEQUAD CANE/LARGE LOW MONITORING SYSTEM 113 PROTECTOR 145BASE 144 QUINTET BLOOD GLUCOSEQUAD CANE/LARGE LOW RA SITZ BATH 145TEST STRIPS 79BASE/DEVON HANDLE 144 RA TABLET CUTTER 145

QUAD CANE/ORTHO QVAR REDIHALER 14 RA TRIPLE STRENGTH FISHGRIP 144 RA ALCOHOL SWABS 144 OIL 175QUAD CANE/SMALL RA BANDAGE BASE 144 SCISSORS 144

Index 42

RA TRUE2GO BLOOD REFUAH PLUS BLOOD RELION ULTIMA BLOOD GLUCOSEMONITORING GLUCOSEMONITORING GLUCOSE TEST STRIPS 79 SYSTEM 114 SYSTEM 114 RELION ULTIMA TEST RA TRUERESULT BLOOD REFUAH PLUS BLOOD STRIPS 79 GLUCOSE MONITOR 114 GLUCOSETEST STRIPS 79 RELION ULTRA THIN RA TRUETEST STRIPS 79 rabeprazole sodium 187 RABEPRAZOLE SODIUM DR SPRINKLE 187 RADIAGUARD ADVANCED 71 RAISED TOILET SEAT 145 RAISED TOILET SEAT/LOCK 145 RAISED TOILET SEAT/LOCK&ARMS 145 raloxifene hcl 84 ramelteon 94 ramipril 33 ranitidine hcl 186 RAPAFLO 89

REGLAN 87 RELENZA DISKHALER 48 RELION ALCOHOL SWABS 145 RELION BLOOD GLUCOSE TESTSTRIPS 79 RELION CONFIRM BLOOD GLUCOSE MONITORING SYSTEM 114 RELION CONFIRM/MICROTEST STRIPS 79 RELION KETONE 79 RELION KETONE TEST STRIPS 79 RELION LANCETS MICRO-THIN33G 114 RELION LANCETS

LANCETS/30G 114 RELION ULTRA THIN LANCETS30G 114 RELION ULTRA THIN PLUS LANCETS 32G 114 RELION ULTRA THIN PLUS LANCETS 33G 114 RELPAX 164 REMERON 19 REMERON SOLTAB 19 REMICADE 87 REMODULIN 51 REMOVABLE BACK ALUMINUM COMMODE/PADDEDARMRESTS 145 RENAGEL 88

RAPAMUNE 166 STANDARD 21G 114 RENVELA 88 RASUVO RAVICTI RAZADYNE RAZADYNE ER

4 85

183 183

RELION LANCETS THIN 26G 114 RELION LANCETS ULTRA-THIN30G 114 RELION MICRO BLOOD

repaglinide 24 REPAGLINIDE/METFORMINHYDROCHLORIDE 22 REPATHA 32

READYLANCE SAFETY GLUCOSE MONITORING REPATHA SURECLICK 32 LANCETS/30G/1.6MM REALITY LANCETS REALITY SWABS REALITY TRIGGER LANCETS

114 114 145

114

SYSTEM 114 RELION PEN NEEDLES 31GX8MM 157 RELION PREMIER BLOOD GLUCOSE TEST STRIPS 79 RELION PREMIER BLU

REPEL FAMILY REPEL FAMILY DRY REPEL HUNTERS FORMULA REPEL SPORTSMEN

72 72

72 73

REBETOL 48 BLOOD GLUCOSE REPEL SPORTSMEN DRY 73 REBIF 184 REBIF REBIDOSE 183 REBIF REBIDOSE TITRATIONPACK 184 REBIF TITRATION PACK 184 REBINYN 90 RECLAST 83 RECOMBINATE 90 RECOMBIVAX HB 189 RECONSTITUBE 145 REFLECTIONS AA LIGHTWEIGHT OFF SHELF

MONITORING SYSTEM 114 RELION PREMIER CLASSIC BLOOD GLUCOSE MONITORING SYSTEM 114 RELION PREMIER COMPACT BLOOD GLUCOSE MONITORING SYSTEM 114 RELION PREMIER VOICE BLOOD GLUCOSE MONITORING SYSTEM 114 RELION PRIME BLOOD GLUCOSE MONITORING SYSTEM 114 RELION PRIME BLOOD

REPEL SPORTSMEN MAX 73 REPLACEMENT AIR FILTER 162 REPLACEMENT FILTERS 162 REPLACEMENT NECKBAND STRAPS FOR TUBE ATTACHMENT DEVICE 145 REQUIP 42 REQUIP XL 42 RESCRIPTOR 46 RESCULA 179 RESTA LITE 71

BREAST PROSTHESIS FORM 145 REFLECTIONS C LIGHTWEIGHTOFF SHELF BREAST PROSTHESIS FORM 145

GLUCOSE TEST STRIPS 79 RELION PULSE OXIMETER 145 RELION SHORT PEN NEEDLES31GX8MM 157 RELION ULTIMA BLOOD GLUCOSE MONITORING SYSTEM 114

RESTORA RESTORIL RETACRIT RETIN-A RETIN-A MICRO RETIN-A MICRO PUMP

27 94 92

60,61 61 61

Index 43

RETISERT 178 RILUTEK 172 ROUND SHOWER STOOL 145 RETROVIR 46 riluzole 172 ROWASA 88 RETROVIR IV INFUSION 46 RIMANTADINE ROXICET 9 REVATIO 51 REVCOVI 85 REVEAL BLOOD GLUCOSE MONITOR 114 REVEAL BLOOD GLUCOSE TEST 79 REVLIMID 165 REXALL BLOOD GLUCOSE MONITORING SYSTEM 114

HYDROCHLORIDE 48 RING CUSHION 14" 145 RING CUSHION 16" 145 RING CUSHION 18" 145 RING PESSARY 145 RING PESSARY/SUPPORT 145 RINOFLOW MICRONIZER CHAMBER TUBING 145

ROXICODONE ROZEREM ROZLYTREK RUBBER BATH MAT RUBBER INFLATABLE CUSHION RUBRACA RUCONEST

8 94 40

145

145 40 90

REXALL BLOOD GLUCOSE RINOFLOW NASAL RUZURGI 36 TEST STRIPS 79 REXALL LANCETS ULTRA THIN 114 REXULTI 45 REYATAZ 46 RHEUMATE 81 RHOGAM ULTRA-FILTERED PLUS 181 RHOPHYLAC 181

SYSTEM RINVOQ RIOMET RISAQUAD RISAQUAD-2 risedronate sodium RISPERDAL RISPERDAL CONSTA

145 4

23 27 27 83 43 43

RX LOCKING CAP 145 RX TIMER CAP 13/16 DRAMTOPS PHARMACY 145 RX TIMER CAP 30/40/60 DRAMTOPS PHARMACY 145 RYCLORA 30 SABRIL 18 SAFE-SENSE BEARD NET145 SAFE-SENSE HEAD

RIASTAP RIBASPHERE RIBASPHERE RIBAPAK ribavirin (hepatitis c) riboflavin

90 48 48 48

192

RISPERDAL M-TAB risperidone RISPERIDONE ODT RITALIN RITALIN LA

43 43 43

2 2

COVER/BOUFFANT CAP21" SAFE-SENSE HEAD COVER/BOUFFANTCAP/CIRCULAR/ 21"SAFE-SENSE SHOE

145

145

RIBOZEL RID RID COMPLETE LICE

81 73,74

RITEFLO ritonavir RITUXAN

162 46 37

COVER/NON-SKID 145 SAFE-T-LANCE LOW FLOW 25G 115 SAFE-T-LANCE NORMAL

ELIMINATION 73 RID ESSENTIAL LICE ELIMINATION KIT 73 RIDVANTAGE LICE COMB145

rivastigmine rivastigmine tartrate RIXUBIS

183 183

90

FLOW21G SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW

115

115 RIFADIN 36 rifampin 36 RIGHTEST GL300 LANCETS 114 RIGHTEST GM100 BLOOD GLUCOSE MONITORING SYSTEM 114 RIGHTEST GM300 BLOOD GLUCOSE MONITORING SYSTEM 114 RIGHTEST GM550 BLOOD GLUCOSE MONITORING SYSTEM 114 RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS 79 RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS 79 RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS 79

rizatriptan benzoate ROBAXIN ROBAXIN-750 ROBINUL ROBINUL FORTE ROC DEEP WRINKLE SERUM ROCALTROL ROLLATOR ULTRA-LIGHT ROLLER WALKER ROLLING WALKER/BURGUNDY ROMIDEPSIN ropinirole hydrochloride ROSE MILK rosuvastatin calcium

164 170 170 186 186

71 85

145 145

145 40 42 71 32

SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW 115 SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW 115 SAFETY LANCET 21G/PRESSUREACTIVATED 115 SAFETY LANCET 23G/PRESSUREACTIVATED 115 SAFETY LANCET 28G/PRESSUREACTIVATED 115 SAFETY LANCET 30G/PRESSUREACTIVATED 115 SAFETY LANCETS 115 SAFETY LANCETS 21G 115

Index 44

SAFETY LANCETS 28G 115 SCD SOFT SLEEVES/KNEE SEASONIQUE 55 LENGTH 21" 146SAFETY LET LANCETS 115 SEATING CANE/8-1/2"SCD SOFT SLEEVES/THIGH SEATDIAMETER 146SAFETY SEAL LANCETS LENGTH MEDIUM 14628G 115 SEEBRI NEOHALER 13SCHOOLTIME SHAMPOO74SAFETY SEAL LANCETS SEGLUROMET 22SD PROBIOTIC-1030G 115 selegiline hcl 42COMPLEXULTRA 27SAFETY-LOK COLLECTION

SET23GX3/4"/12" TUBING 145 SEAL-RITE SILICONE EAR SELEGILINE HCL 43 PLUGS 146SAFETY-SHIELD TABLET selenium sulfide 63,64SEAL-TIGHT CAST/BANDAGECUTTER 145 SELSUN BLUE 64PROTECTOR/ADULTSAFYRAL 55 FOOT/ANKLE 146 SELSUN BLUE DAILY 64

SAIZEN 84 SEAL-TIGHT CAST/BANDAGE SELSUN BLUE SAIZEN CLICK.EASY 84 PROTECTOR/ADULT MEDICATED 64 SAIZENPREP HAND 146 SELSUN BLUE RECONSTITUTIONKIT 84 SEAL-TIGHT CAST/BANDAGE MOISTURIZING 64 SALAGEN 167 PROTECTOR/ADULT LONG SELZENTRY 46

ARM 146salicylic acid 71 sennosides 95SEAL-TIGHT CAST/BANDAGE sennosides-docusatesaline 171 PROTECTOR/ADULT LONG sodium 95SALMON OIL 81 LEG 146 SENOKOT 95SEAL-TIGHT CAST/BANDAGEsalsalate 7 PROTECTOR/ADULT SHORT SENOKOT S 95SAMI THE SEAL ARM 146 SENSIPAR 85REPLACEMENTFILTERS 162 SEAL-TIGHT CAST/BANDAGESAMSCA 86 SENTRA AM 81PROTECTOR/ADULT SHORTSANCUSO 28 LEG 146 SENTRA PM 81 SANDIMMUNE 166 SEAL-TIGHT CAST/BANDAGE SEREVENT DISKUS 15

PROTECTOR/ADULT WIDESANDOSTATIN 86 SERNIVO 67SHORT ARM 146SANDOSTATIN LAR SEROQUELSEAL-TIGHT CAST/BANDAGE 44

DEPOT 86 PROTECTOR/ADULT WIDE SEROQUEL XR 44 SAPHRIS 44 SHORT LEG 146 SEROSTIM 84SAPS CARE ALCOHOL PREP SEAL-TIGHT CAST/BANDAGE sertraline hcl 20PADS 145 PROTECTOR/PED LARGE SERUM BOTTLE STOPPERSAPS HEALTH ALCOHOL ARM 146 20MM 146PREPPADS 146 SEAL-TIGHT CAST/BANDAGESAPS HEALTH CARE SERUM BOTTLE/100ML 146PROTECTOR/PED LARGEALCOHOLPREP PADS 146 LEG 146 SERUM BOTTLE/250ML 146 SAPS HEALTH CARE TWIST SEAL-TIGHT CAST/BANDAGE SERUM BOTTLES/AMBERTOP LANCETS 115 PROTECTOR/PED MEDIUM GLASS/20ML/20MM 146SAPSCARE TWIST TOP ARM 146 SERUM BOTTLES/AMBERLANCETS 30G 115 SEAL-TIGHT CAST/BANDAGE GLASS/30ML/20MM 146 SARAFEM 184 PROTECTOR/PED MEDIUM SETTLING PLATE SARNA 63 LEG 146 SDA/29ML/100X15MM 146

SEAL-TIGHT CAST/BANDAGE SETTLING PLATESAVAYSA 16 PROTECTOR/PED SMALL TSA/25ML/100X15MM 146SAVELLA 183 ARM 146 sevelamer carbonate 88SAVELLA TITRATION SEAL-TIGHT CAST/BANDAGE sevelamer hcl 88PACK 183 PROTECTOR/PED SMALL SEVELAMERSAWYER INSECT LEG 146 HYDROCHLORIDE 88REPELLENT 73 SEAL-TIGHT MID-ARMSAWYER INSECT REPELLENT SFROWASA 88PROTECTOR 146CONTROLLED RELEASE 73 SEALS/ALUMINUM/FLIP SHAATZ PESSARY 147 SB ALCOHOL PREP OFF/13MM/BLANK TOP 146 SHAPERS ADJUSTABLEPADS 146 Seasonal Influenza LAYERED BREAST SB LANCETS THIN 115 Vaccine 189 SHAPER/AFRICANSB LANCETS ULTRA Seasonal Influenza Vaccine- AMERICAN 147 THIN 115 High Dose 190

Index 45

SHAPERS ADJUSTABLE SILICONE EAR PLUGS KID SLEEPRIGHT DENTAL LAYERED BREAST SIZE 147 GUARD 147 SHAPER/CAUCASIANSHOPKO ALCOHOL

147 SILICONE EARPLUGS CHILDRENS 147

SLEEPRIGHT DENTAL GUARD DURA-COMFORT 147

SWABS 147 SILICONE MASK FOR SLEEPRIGHT DENTAL GUARD SHOPKO ON-THE-GO BREATHERITE SLIM-COMFORT 147 COMFORTLANCETS 30G 115 SHOPKO UNIFINE PENTIPS

CHAMBER/ADULTSILICONE MASK FOR

162 SLEEPRIGHT INTRA-NASAL BREATHE AID 147

PEN BREATHERITE SLEEPRIGHT INTRA-NASAL NEEDLES/SHORT/31GX8MM

157 CHAMBER/INFANTSILICONE MASK FOR

162 VAPOR INHALER 147 SLEEPRIGHT SPORT INTRA-

SHOPKO UNIFINE PENTIPS BREATHERITE NASAL BREATHE AID 147 PLUS PEN NEEDLES/SHORT/REMOVR/31GX8MM 157 SHOPKO UNILET LANCETS SUPER THIN 30G 115 SHOPKO UNILET LANCETS ULTRA THIN 28G 115 SHOWER-PAK 147 SHUR-SEAL 190 SIDE BUTTON SAFETY

CHAMBER/PEDIATRICSILICONE MASK FOR BREATHRITE CHAMBER/ADULT silodosin SILVADENE silver sulfadiazine SIMBRINZA simethicone

162

162 89 64 64

177 87

SLO-NIACIN 192 SM ACIDOPHILUS PEARLS 27 SM ALCOHOL PREP PADS 147 SM FISH OIL 175 SM FOAM EAR PLUGS 147 SM GLUCOSE 23 SM IPECAC SYRUP 28 SM MICRO THIN LANCETS

LANCET21G 115 SIMPLE WISHES PUMPING 33G 115 SIDESTREAM ADULT FACE MASK 162 SIDESTREAM PEDIATRIC FACEMASK 162 SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL 162 SIDESTREAM PEDIATRIC FACEMASK/TUCKER THETURTLE 162 SIDESTREAM PLUS ADULT FACE MASK 162 SIGNATURE PRO DOUBLE ELECTRIC BREAST PUMP 147 SIGNATURE PRO HEALTHCAREDOUBLE ELECTRIC BREAST PUMP 147 SIGNIFOR 86 SIGNIFOR LAR 86 SIKLOS 91 SILALITE PAK 67

BRALARGE-PLUS HANDS-FREE/ADJUSTABLE 147 SIMPLE WISHES PUMPING BRAXS-L HANDS-FREE/ADJUSTABLE 147 SIMPLYGO BREAST PUMP/DUAL 147 SIMPLYGO BREAST PUMP/SINGLE 147 SIMPLYTHICK 182 SIMPLYTHICK EASY MIX 182 SIMPLYTHICK EASYMIX 182 SIMPONI 4 SIMPONI ARIA 4 simvastatin 32 SINEMET 42 SINEMET CR 42 SINGLE HEAD STETHOSCOPE 147 SINGLE-LET 115 SINGULAIR 14

SM OMEGA-3 3 SM OMEGA-3-6-9 FATTY ACIDS 3 SM WALKER/YOUTH/FOLDING/DUAL WHEELS 147 SMART SENSE COLOR LANCETS UNIVERSAL 33G 115 SMART SENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM 115 SMART SENSE PREMIUM BLOODGLUCOSE STRIPS 79 SMART SENSE STANDARD LANCETS UNIVERSAL 21G 115 SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G 115 SMART SENSE THIN LANCETSUNIVERSAL 26G 115 SMART SENSE VALUE BLOOD

SILAZONE PHARMAPAK 67 SILAZONE-II 67 sildenafil citrate (pulmonaryhypertension) 51,52 SILENOR 93 SILICA 81 SILICONE EAR PLUGS 147 SILICONE EAR PLUGS FOR KIDS 147

sirolimus SITAVIG SITZ BATH SIVEXTRO SKELAXIN SKIN REPAIR SKLICE SKYLA SKYRIZI

166 48

147 12

171 71 74 56 63

GLUCOSE STRIPS 79 SMART SENSE VALUE BLOODGLUCOSE MONITORING SYSTEM 116 SMARTEST BLOOD GLUCOSE TEST STRIPS 79 SMARTEST EJECT BLOOD GLUCOSE MONITORING SYSTEM 116 SMARTEST EJECT STARTER KIT 116

Index 46

SMARTEST LANCETS 28G 116 SMARTEST PERSONA STARTERKIT 116 SMARTEST PRONTO STARTERKIT 116 SMARTEST PROTEGE BLOOD GLUCOSE MONITORING SYSTEM 116

SOOTHE & COOL MOISTURIZING BODY LOTION WITH ALOE 71 SOOTHENEB NBL 100 CHILD MASK 162 SOOTHENEB NBL 100 MEDICATION CUP 162 SOOTHENEB NBL 100 MESH CAP 162

SPRAVATO 84MG DOSE 20 SPRAY APPLICATOR KIT 148 SPRAY BOTTLE 120ML/PLASTIC 148 SPRITAM 18 SPRYCEL 40 ST IVES SWISS FORMULA 24HOUR MOISTURE 71

SMARTEST PROTEGE SOOTHENEB NBL100 ADULT ST JOSEPH ADULT 7STARTERKIT 116 MASK 162 ST JOSEPH ADULTSNAP-ON CHLOROBUTYL SOOTHIES COOLING GEL ANALGESICLOW DOSE BITESTOPPER/13MM/GREY 147 PADS 147 SIZE 7SODIUM BENZOATE 81 SOOTHIES GEL STANDARD CRUTCH TIP 148sodium bicarbonate PADS/REUSABLE 147

stannous fluoride 167(antacid) 11 SORBITOL 95 sodium chloride (gu irrigant) 88 SORILUX 63 STARLIX 25

sodium chloride (inhalant) 59 sotalol hcl 49 stavudine 47 STEELsodium citrate & citric acid 88 sotalol hcl (afib/afl) 49 COMMODE/BEDSIDE/FOLDING/sodium fluoride 165 SOTYLIZE 49 SPLASH GUARD 148

sodium fluoride (dental) 167 SOVALDI 48 STEEL ROLLING WALKER148 SODIUM HYALURONATE 171 SPECTRACEF 52 STEGLATRO 25 sodium phenylbutyrate 85 SPENCO SILICORE BED STELARA 63PAD 147sodium phosphates 95 STEP COUNTER 148SPENCO SILICORE CHAIRsodium polystyrene PAD 147 STEP N' REST 148sulfonate 166,167 SPENCO SILICORE FOOT STEP N' REST II WALKER 148SODIUM PILLOWS/ONE SIZE 147SULFACETAMIDE/SULFUR STEP N' REST WALKER 148SPENCO SILICORE FOOT

61 STEP N' REST WALKER/5"POSITIONER 147SOFOSBUVIR/VELPATASVIR SWIVEL WHEELS/GLIDESPENCO SILICORE48 WHEELS 148WHEELCHAIR PAD 147SOFT HANDS COTTON STERILANCE TL 116SPINOSAD 74GLOVE/EXTRA LARGE 147 STERILE DILUENT FORSOFT HANDS COTTON SPINRAZA 172 FLOLAN 182GLOVE/LARGE 147 SPIRIVA HANDIHALER 13 STERILE DILUENT FORSOFT HANDS COTTON SPIRIVA RESPIMAT 13 TREPROSTINILGLOVE/SMALL-MEDIUM 147 INJECTION 182spironolactone 82SOLESTA 165 STETHOSCOPE 148spironolactone &solifenacin succinate 188 hydrochlorothiazide 82 STETHOSCOPE DUAL

SOLIQUA 100/33 22 SPLASH SHIELD/FULL HEAD 148 STETHOSCOPE SINGLESOLIRIS 90 FACE 148

SPLASH SHIELD/SHORT HEAD 148SOLUS V2 AUDIBLE BLOOD FACE 148 STETHOSCOPE-LIGHTWEIGHTGLUCOSE MANAGEMENT 148SPLIT HANDGRIPS 148SYSTEM 116 STETHOSCOPE-SINGLESOLUS V2 AUDIBLE TEST 79 SPORANOX 29 HEAD 148

SOLUS V2 PRESSURE SPORANOX PULSEPAK 29 STETHOSCOPE/NURSESACTIVATED SAFETY LANCETS SPRAGUE RAPPAPORT BLUE 148 28G 116 STETHOSCOPE/BLACK 148 STETHOSCOPE/SPRAGUESOLUS V2 TWIST LANCETS SPRAGUE RAPPAPORT RAPPAPORT STYLE 148 30G 116 STETHOSCOPE/NAVY 148 STIMATE 85 SOMA 171 SPRAGUE RAPPAPORT STIOLTO RESPIMAT 15 SOMATULINE DEPOT 86 STETHOSCOPE/PURPLE 14 STIRRING ROD/GLASSSOMAVERT 84 8 12X1/4" 148SPRAVATO 56MG DOSE 20SONATA 94 STIVARGA 40

Index 47

STOCKING APPLICATOR/PETITE 148 STOCKING APPLICATOR/REGULAR 148 STOP LICE EGG & NIT REMOVAL SYSTEM 148 STRAINER/STAINLESSSTEELWITH PLASTIC

SUNBEAM STANDARD COVER 148 SUPARTZ FX 171 SUPER OMEGA-3 3 SUPER PROBIOTIC 27 SUPER PROBIOTIC DIGESTIVE SUPPORT 27

SURE EDGE BLOOD GLUCOSE TEST STRIPS 79 SURE-FINE PEN NEEDLES 31GX5/16" 8MM 157 SURE-LANCE FLAT LANCETS 116 SURE-LANCE LANCETS 26G 116

HANDLE/2-1/2" 148 STRATTERA 1 STRENSIQ 85 STRIBILD 47 STRIVERDI RESPIMAT 15 STUDIO 35 EXTRA MOISTURIZING LOTION 71 SUBLOCADE 9 SUBOXONE 9 SUCRAID 81 sucralfate 187 SUCTION GRAB BAR 148 SUCTION TIPS FOR TRANSFERBENCHES 148 SUDAFED CHILDRENS 172 SUDAFED CONGESTION 172 SUDAFED PE CHILDRENS NASAL DECONGESTANT 172 SUDAFED PE SINUS CONGESTION 172 SUDAFED SINUS CONGESTION 172 SULAR 50

SUPER THIN LANCETS 116 SUPER TWIN EPA/DHA 175 SUPPOSISTRIP MOLD 1.4GM 148 SUPPOSISTRIP MOLD 1.9GM 148 SUPPOSITORY MOLD 2GM 148 SUPPOSITORY MOLD 60 CAVITY 148 SUPPOSITORY MOLD/ALUMINUM2GM/100CAVITY 148 SUPPOSITORY MOLDS 1.3ML/PEEL-AWAY 148 SUPPOSITORY MOLDS 2.25ML/PEEL-AWAY 148 SUPPOSITORY MOLDS 2CC/V-NOTCH 148 SUPPOSITORY MOLDS 2GM 149 SUPPOSITORY MOLDS 2ML/PEEL-AWAY 149 SUPPOSITORY MOLDS 3ML/PEEL-AWAY 149 SUPPOSITORY SHELL

SURE-LANCE THIN LANCETS 28G 116 SURE-LANCE ULTRA THIN LANCETS 116 SURE-PREP ALCOHOL PREP PADS 149 SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS 79 SURE-TEST EASYPLUS MINI SELF MONITORING BLOOD GLUCOSE METER 116 SURE-TOUCH LANCETS UNIVERSAL 116 SURECHEK BLOOD GLUCOSE MONITORING SYSTEM 116 SURECHEK BLOOD GLUCOSE MONITORING SYSTEM STARTER KIT 116 SURECHEK BLOOD GLUCOSE TEST STRIPS 79 SURELIFE CLEARWAVE II PULSE OXIMETER 149 SURELIFE CLEARWAVE PULSEOXIMETER 149 SURELITE LANCETS 116

sulfacetamide sod- 2.0ML 149 SURMONTIL 22 prednisolone 178 sulfacetamide sodium 64 sulfacetamide sodium (acne)61 sulfacetamide sodium (ophth) 177 SULFACETAMIDE SODIUM/PREDNISOLONESODIUM PHOSPHATE 178 sulfamethoxazole-trimethoprim

11

SUPPOSITORY SHELL MEDIUM2.25GM 149 SUPPOSITORY SHELL RACK 149 SUPPOSITORY SHELL SMALL 1.46GM 149 SUPPOSITORY SHELLS 2.4ML 149 SUPPRELIN LA 84 SUPRAX 52

SUSTIVA SUTENT SWIM EARPLUGS SYLATRON SYLVANT SYMAX DUOTAB SYMBICORT SYMDEKO

47 40

149 41

166 186

15 185

sulfasalazine 88 SUPREME TEST STRIPS 79 SYMFI 47 SULFZIX sulindac sumatriptan

81 5

164

SURE COMFORT ALCOHOL PREP PADS 149 SURE COMFORT LANCETS 28G 116

SYMFI LO SYMJEPI SYMLINPEN 120

47 191

22 sumatriptan succinate SUMATRIPTAN SUCCINATE sumatriptan succinate sumatriptan-naproxensodium SUNBEAM KING COVER

164

164 164

163 148

SURE COMFORT LANCETS 30G 116 SURE COMFORT PEN NEEDLES31GX5/16"(8MM) 157 SURE EDGE BLOOD GLUCOSE MONITORING SYSTEM 116

SYMLINPEN 60 SYMPHONY DOUBLE PUMPING SYSTEM SYMTUZA SYNAGIS SYNALAR SYNALAR CREAM KIT

22

149 47

181 67 67

Index 48

SYNALAR OINTMENT KIT 67 TARCEVA 40 TERCONAZOLE 190 SYNALAR TS 67 TARGRETIN 41,63 terconazole vaginal 190 SYNAREL 84 TARKA 35 TESSALON PERLES 58 SYNJARDY 22 TASIGNA 40 TESTIM 10 SYNRIBO 41 TAVALISSE 90 TESTOPEL 10 SYNTHROID 185 TAXOTERE 41 testosterone 10 SYNVISC 171 TAYTULLA 55 TESTOSTERONE 10 SYNVISC ONE 171 tazarotene 63 testosterone 10 SYPRINE SYRINGE

165 TAZORAC TEARS NATURALE PM

63 175

testosterone cypionate TESTOSTERONE PUMP

10 10

ACCESSORIES/LEURTIP CAPTRAY 149 SYRINGE DIAL-A-DOSE 149 SYRINGE TIP-RECTAL/VAGINAL LUERAPPLICATOR 149 SYTRINOL 81 T-SUPPORT MAX 81 TABLET CRUSHER/CONTAINER 149 TABLET CUTTER 149 TABLET CUTTER/CRUSHER 149 TABLET CUTTER/DELUXESAFETY 149 TABLET CUTTER/SAFETYSHIELD 149 TABLET CUTTER/SAFETY-SHIELD 149 TABLOID 37 TACLONEX 67

TECENTRIQ 37 TECFIDERA 184 TECFIDERA STARTER PACK 184 TECHLITE AST LANCETS 116 TECHLITE LANCETS 116 TECHLITE LANCETS 30G 116 TECHLITE PEN NEEDLES/31GX 8MM 157 TECHNIVIE 48 TEGRETOL 18 TEGRETOL-XR 18 TEGSEDI 184 TELCARE BLOOD GLUCOSE MONITORING SYSTEM 116 TELCARE BLOOD GLUCOSE TEST STRIPS 79 telmisartan 33

tetrabenazine 183 tetracaine hcl (ophth) 178 tetrahydrozoline hcl (ophth) 177 TEXACORT 67 TEXTURE WALL GRAB BAR/12" 149 TEXTURE WALL GRAB BAR/16" 149 TEXTURE WALL GRAB BAR/18" 149 TEXTURE WALL GRAB BAR/24" 149 TEXTURE WALL GRAB BAR/32" 149 TGT ALCOHOL SWABS 149 TGT BLOOD GLUCOSE METER MONITORING SYSTEM 117 TGT BLOOD GLUCOSE MONITORING SYSTEM 117 TGT BLOOD GLUCOSE MONITORING SYSTEM

tacrolimus tacrolimus (topical) tadalafil (pulmonaryhypertension) TAFINLAR

166 71

52 40

telmisartan-amlodipine 35 telmisartan-hydrochlorothiazide

35 temazepam 94 TEMODAR 36

PREMIUM 117 TGT BLOOD GLUCOSE TEST STRIPS 79 TGT BLOOD GLUCOSE TEST STRIPS PREMIUM 79 TGT LANCET MICRO THIN

TAGAMET HB 186 TEMOVATE 67 33G 117 TAGRISSO 40 temozolomide 36 TGT LANCET THIN 26G 117 TAKEAWAY ENVIRONMENTAL temsirolimus 40 TGT LANCET ULTRA THIN RETURN SYSTEM 149 TAKEAWAY ENVIRONMENTAL RETURN SYSTEM ENVELOPE 149 TAKHZYRO 90 TALTZ 63 TALZENNA 40 TAMIFLU 48 tamoxifen citrate 38 tamsulosin hcl 89 TANZEUM 23 TAPAZOLE 185

TENCON tenofovir disoproxilfumarate TENORETIC 100 TENORETIC 50 TENORMIN TEPADINA TERAZOL 7 terazosin hcl terbinafine hcl terbinafine hcl (topical) terbutaline sulfate

6

47 35 35 49 36

190 33 29 63 15

30G 117 THALOMID 165 THE DOCTORS NIGHTGUARD ADVANCED COMFORT 149 THE SIDE RESTER CUSHION IMPERMEABLE COVER 149 THE SIDE RESTER CUSHION REGULAR COVER 149 THEO-24 15 theophylline 15 THEOPHYLLINE ER 15 THERA-BAND EXERCISE BANDS 149

Index 49

THERABETIC SKIN CARE 71 TL-ICARE 81 TOPI-CLICK 35 DOSE

THERAMINE THERAPLEX HYDROLOTION thiamine hcl thiamine mononitrate THINLETS GP LANCETS THIOLA thioridazine hcl thiotepa thiothixene THRESHOLD IMT

81

71 192 192 117

89 44 36 45

162

TOBAKIENT 81 TOBI 3 TOBI PODHALER 3 TOBRADEX 178 TOBRAMYCIN 4 tobramycin 4 tobramycin (ophth) 177 TOBRAMYCIN SULFATE 4 tobramycin sulfate 4 tobramycin-dexamethasone 178

CHECK 150 TOPI-CLICK 35 USP671 UV BLOCKING/ORANGEBODY/CAP/BASE 150 TOPI-CLICK 35 USP671 UV BLOCKING/ORANGEBODY/WHITE CAP/BASE 150 TOPI-CLICK 35 VAGINAL APPLICATOR DOSE LOADER 150 TOPI-CLICK 35 VAGINAL DOSE APPLICATOR 150 TOPI-CLICK 35 VAGINAL DOSING

THROMBATE III THROMBATE III W/10 MLSTERILE WATER THROMBATE III W/20 MLSTERILE WATER THYMOGLOBULIN THYROGEN thyroid THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3

90

90

90 166

74 185 185 185 185 185 185

TOBREX 177 TODAYS HEALTH SHORT PEN NEEDLES 31G X 5/16" 157 TODAYS HEALTH SUPER THINLANCETS 30G 117 TODAYS HEALTH ULTRA THINLANCETS 28G 117 TOFRANIL 22 TOILET SAFETY FRAME149 TOILET SEAT ELEVATOR 149 TOLMETIN SODIUM 5 tolnaftate 63

SYSTEM/APPLICATOR 150 TOPI-CLICK APPLICATOR/140ML 150 TOPI-CLICK APPLICATOR/35ML 150 TOPI-CLICK APPLICATOR/MICRO/PINPOINT/9ML/0.05ML/BLUE 150 TOPI-CLICK APPLICATOR/MICRO/ROUNDED/9ML/0.05ML/BLUE 150 TOPI-CLICK APPLICATOR/MICRO/SOFTANGLED/9ML/0.05ML/BLUE

150 tiagabine hcl TIAZAC TIBSOVO TICASPRAY TIGLUTIK TIKOSYN timolol maleate

18 50 40

171 172

13 49

tolterodine tartrate 188 tolvaptan 86 TONGUE CLEANER/COMFORTCURVE 149 TONGUE DEPRESSORS150 TOOTHETTE BITE BLOCK 150

TOPI-CLICK MICRO/PIN POINTAPPLICATOR/BLUE 150 TOPI-CLICK MICRO/ROUNDEDAPPLICATOR/BLUE 150 TOPI-CLICK MICRO/SOFTANGLED APPLICATOR/BLUE 150 TOPI-CLICK NOZZLE 150

timolol maleate (ophth) TIMOLOL MALEATE

176 TOPAMAX TOPAMAX SPRINKLE

18 18

TOPI-CLICK PERL VAGINAL APPLICATOR DOSE

OPHTHALMIC GEL FORMING 176 TIMOLOL/BRIMONIDE/DORZOLAMIDE 176 TIMOPTIC 176 TIMOPTIC OCUDOSE 176 TIMOPTIC-XE 176 TINACTIN 63 tioconazole vaginal 190 TIP CAPS 149 TIP RECTAL/VAGINALW/PERFORATIONS 149 TIROSINT 185 TIVICAY 47 tizanidine hcl 171

TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX5/16" 157 TOPCARE LANCETS MICRO-THIN 33G 117 TOPI-CLICK 140/BLACK 150 TOPI-CLICK 140/BLUE 150 TOPI-CLICK 140/GOLD 150 TOPI-CLICK 140/GREEN 150 TOPI-CLICK 140/PINK 150 TOPI-CLICK 140/PURPLE 150 TOPI-CLICK 140/RED 150 TOPI-CLICK 140/SILVER 150 TOPI-CLICK 140/WHITE 150

LOADER/35ML 150 TOPI-CLICK PERL VAGINAL DOSE APPLICATOR/4ML 150 TOPI-CLICK PERL VAGINAL DOSING SYSTEM/VAGINALAPPLICATOR 35 150 TOPI-CLICK/35ML/1PORT/BLACK 150 TOPI-CLICK/35ML/1PORT/BLUE 150 TOPI-CLICK/35ML/1PORT/GOLD 150 TOPI-CLICK/35ML/1PORT/GREEN 150 TOPI-CLICK/35ML/1PORT/ORANGE 150 TOPI-CLICK/35ML/1PORT/PINK 150

Index 50

TOPI-CLICK/35ML/1PORT/PURPLETOPI-CLICK/35ML/1PORT/REDTOPI-CLICK/35ML/1PORT/SILVERTOPI-CLICK/35ML/1PORT/WHITETOPI-CLICK/35ML/3PORT/BLACKTOPI-CLICK/35ML/3PORT/BLUETOPI-CLICK/35ML/3PORT/GOLDTOPI-CLICK/35ML/3PORT/GREENTOPI-CLICK/35ML/3PORT/PINKTOPI-CLICK/35ML/3PORT/PURPLETOPI-CLICK/35ML/3PORT/REDTOPI-CLICK/35ML/3PORT/SILVERTOPI-CLICK/35ML/3PORT/WHITE TOPICORT topiramate TOPIRAMATE ER TOPOTECAN HCL topotecan hcl TOPROL XL toremifene citrate TORISEL torsemide TOTAL COMFORT WHEELCHAIRBACK CUSHION TOTAL COMFORT WHEELCHAIRSEAT CUSHION TOTECT

151

151

151

151

151

151

151

151

151

151

151

151

151 67 18 18 42 42 49 38 40 82

151

151 41

TRAINER FOR EPINEPHRINE 151 tramadol hcl 8 TRAMADOL HCL ER 8 tramadol-acetaminophen 9 trandolapril 33 trandolapril-verapamil hcl 35 TRANDOLAPRIL/VERAPAMILHCL ER 35 tranexamic acid 92 TRANSFER BENCH 151 TRANSFER BENCH W/BACK 151 TRANSFER BOARD/28"X8-1/4" 151 TRANSFER PIN 151 TRANSPORT CHAIR ULTRA LIGHT 151 TRANXENE T 13 tranylcypromine sulfate 20 TRAVATAN Z 179 TRAVEL BOTTLES 151 TRAVEL LANCETS 30G 117 TRAVEL LANCETS ADVANCED 28G 117 TRAVEL POUCH 151 TRAVELER 3 WHEEL ROLLINGWALKER 151 travoprost 179 trazodone hcl 21 TREANDA 36 TRECATOR 36 TRELEGY ELLIPTA 15 TRELSTAR MIXJECT 38 TREMFYA 63 TREPADONE 81 treprostinil 51 TRESIBA 24

triamcinolone acetonide (mouth) 167 triamcinolone acetonide (topical) 67,68 triamcinolone acetonide-dimethicone-silicone 68 triamterene & hydrochlorothiazide 82 TRIANEX 68 triazolam 94 TRIBENZOR 35 TRIDESILON 68 trientine hcl 165 trifluoperazine hcl 44 TRIFLURIDINE 177 TRIGGER RELEASE JUNIOR WALKER/WHEELS 151 TRIGLIDE 32 trihexyphenidyl hcl 42 TRIKAFTA 185 TRILEPTAL 18 TRILURON 171 trimethoprim 11 trimipramine maleate 22 TRINTELLIX 21 TRIO ROLLING WALKER 151 TRIPLE OMEGA COMPLEX 3 TRIPLE OMEGA-3-6-9 3 TRISENOX 41 TRIUMEQ 47 TRIVISC 171 TRIZIVIR 47 TROCHE MOLD 30 CAVITY 151 TROKENDI XR 18 tropicamide 176 trospium chloride 189 TRU FIT MAGNETIX

TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR

24 24

TRESIBA FLEXTOUCH tretinoin

24 61

ANKLE/2SMALL DISKS 151 TRU FIT MAGNETIX BACK151

TOVIAZ 189 TRACLEER 51 TRACTION FLOOR STAND/ECONOMYMODEL 151 TRACTION HEAD HALTER ROPE10' 151 TRACTION PELVIC BELT 151 TRACTION WEIGHT BAG/20LB 151 TRADJENTA 23

tretinoin (chemotherapy) 41 tretinoin microsphere 61 TRETTEN 90 TREXALL 37 TREXIMET 163 TRI-GRIP BATHTUB RAIL 151 TRI-NORINYL 28 56 TRI-VIT/FLUORIDE/IRON

169

TRU FIT MAGNETIX ELBOW/2SMALL DISKS 151 TRU FIT MAGNETIX OPEN KNEE/2 LARGE DISKS 151 TRU FIT MAGNETIX SELF-ADHESIVE MAGNETS 151 TRU FIT MAGNETIX WRIST/2SMALL DISKS 151 TRUBIOTICS 27 TRUE COMFORT ALCOHOL PREP PADS 151

Index 51

TRUE COMFORT TWIST TOP TRUETRACK BLOOD ULTICARE MICRO PEN LANCETS 30G TRUE FOCUS BLOOD

117 GLUCOSE MONITORING SYSTEM 118

NEEDLES/31G X 5/16"ULTICARE SHORT PEN

157

GLUCOSESELF MONITORING TRUETRACK BLOOD NEEDLES 31GX8MM 157 METER 117 GLUCOSE TEST 80 ULTICARE SHORT PEN TRUE FOCUS SELF TRUETRACK SMART NEEDLES ULTI-FINE IV 157 MONITORING BLOOD SYSTEM 118 ULTICARE SHORT PEN GLUCOSE TEST STRIPS 79 TRUE METRIX 117 TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTH 117 TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTHSMART 117 TRUE METRIX AIR W/BLUETOOTH SMART 117 TRUE METRIX BLOOD

TRUETRACK TEST 80 TRULICITY 23 TRUMENBA 189 TRUNATURE DIGESTIVE PROBIOTIC 27 TRUSOPT 179 TRUVADA 47 TUB TRANSFER BOARD151 TUBING/WING TIP 162 TUDORZA PRESSAIR 13

NEEDLES/31G X 8MM 157 ULTIGUARD SAFEPACK/SHORTPENNEEDLE/31G X 5/16"/SHARPSCONTA 157 ULTILET CLASSIC LANCETS 118 ULTILET LANCETS 118 ULTILET LANCETS 33G 118 ULTILET SAFETY LANCETS 23G 118 ULTILET SHORT PEN

GLUCOSEMETER 117 TRUE METRIX BLOOD GLUCOSETEST STRIPS 79 TRUE METRIX CONTROL SOLUTION LEVEL 1 117 TRUE METRIX CONTROL SOLUTION LEVEL 2 117 TRUE METRIX CONTROL SOLUTION LEVEL 3 117 TRUE METRIX GO BLOOD GLUCOSE METER 117 TRUE METRIX PRO GLUCOSE TEST STRIPS 80 TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS 80 TRUEPLUS 5-BEVEL PEN NEEDLES 31GX8MM 157 TRUEPLUS LANCETS 26G 117 TRUEPLUS LANCETS 28G 117 TRUEPLUS LANCETS 28G SUPER THIN 117 TRUEPLUS LANCETS 30G 117 TRUEPLUS LANCETS 30G ULTRA THIN 117 TRUEPLUS LANCETS 33G 117 TRUEPLUS LANCETS 33G MICRO THIN 117 TRUEPLUS PEN NEEDLES 31GX8MM 157 TRUEPLUS SAFETY LANCETS 28G 118 TRUERESULT BLOOD GLUCOSEMONITORING SYSTEM/NO CODING 118 TRUETEST STRIPS 80

TUMS 11 TUMS LASTING EFFECTS 11 TWIN MEDICINE SPOON 151 TWYNSTA 35 TYBOST 47 TYKERB 40 TYLENOL 6 TYLENOL CHILDRENS 6 TYLENOL CHILDRENS CHEWABLES/PAIN +FEVER 6 TYLENOL EXTRA STRENGTH 6 TYLENOL INFANTS 6 TYLENOL INFANTS PAIN+FEVER 6 TYLENOL PM EXTRA STRENGTH 93 TYLENOL/CODEINE #3 9 TYLENOL/CODEINE #4 9 TYSABRI 184 TYVASO 51 TYVASO REFILL 51 TYVASO STARTER 51 TYVEK PROTECTIVE SLEEVES/DISPOSABLE 152 UCERIS 10,58 UDENYCA 92 ULESFIA 74 ULTICARE ALCOHOL SWABS 152 ULTICARE MICRO PEN NEEDLES 31G X 8MM 157

NEEDLES 31GX5/16" 157 ULTIMA 118 ULTIMA TEST STRIPS 80 ULTOMIRIS 90 ULTRA OMEGA-3 FISH OIL BURP-LESS 175 ULTRA PILL CRUSHER 152 ULTRA STRENGTH OMEGA-3 +VITAMIN D3 175 ULTRA THIN LANCETS 31G 118 ULTRA TRAK PRO BLOOD GLUCOSE MONITORING SYSTEM 118 ULTRA-CARE ALCOHOL PREP PADS 152 ULTRA-CARE LANCETS 30G 118 ULTRA-THIN II AUTO LANCET 118 ULTRA-THIN II LANCETS 28G 118 ULTRA-THIN II LANCETS 30G 118 ULTRA-THIN II PEN NEEDLES/SHORT/31GX5/16"

157 ULTRACARE PEN NEEDLES/31G X 5/16" 158 ULTRACET 9 ULTRAFLORA IMMUNE HEALTH 27 ULTRAM 8 ULTRATHON INSECT REPELLENT 73 ULTRATHON INSECT REPELLENT 8 73 ULTRATRAK ACTIVE 118

Index 52

ULTRATRAK PRO 118 ULTRATRAK PRO TEST STRIPS 80 ULTRATRAK ULTIMATE MONITOR 118 ULTRATRAK ULTIMATE TEST STRIPS 80 ULTRAVATE 68 UNGUATOR 100/200/57MM/DISPOSABLEBLADES 152 UNGUATOR 15/20/30/36MM/DISPOSABLEBLADES 152 UNGUATOR 50/43MM/DISPOSABLEBLADES 152 UNGUATOR ACCESSORIES EXACTDOSE 0.5ML 152 UNGUATOR APPLICATOR 1"/SHORT/CAP 152 UNGUATOR APPLICATOR 2.5"/LONG 152 UNGUATOR JAR 100/140BLUELID 152 UNGUATOR JAR 100/140REDLID 152 UNGUATOR JAR 15/20 BLUELID 152 UNGUATOR JAR 15/20GREENLID 152 UNGUATOR JAR 15/20 REDLID 152 UNGUATOR JAR 15/28 BLUELID 152 UNGUATOR JAR 20/33BLUE 152 UNGUATOR JAR 20/33 REDLID 152

UNGUATOR JAR 30/42TURQUOISE/TURQUOISELID 152 UNGUATOR JAR 30/42WHITELID 152 UNGUATOR JAR 30/42YELLOW 152 UNGUATOR JAR 50/70 BLUELID 152 UNGUATOR JAR 50/70BLUE/BLUE LID 152 UNGUATOR JAR 50/70GREENLID 152 UNGUATOR JAR 50/70PINK/PINK LID 152 UNGUATOR JAR 50/70 REDLID 152 UNGUATOR JAR 50/70TURQUOISE 152 UNGUATOR JAR 50/70WHITELID 152 UNGUATOR JAR 50/70YELLOW 152 UNGUATOR JAR FOR AIRDYNAMIK 1000/1250 152 UNGUATOR JAR FOR AIRDYNAMIK 300/390 152 UNGUATOR JAR FOR AIRDYNAMIK 500/600WHITE 152 UNGUATOR JAR W/SPINDLE300/390 153 UNGUATOR JAR W/SPINDLE500/600 153 UNGUATOR LID 1000ML153 UNGUATOR LID 500ML 153 UNGUATOR VARIONOZZLE 1MM 153 UNGUATOR VARIONOZZLE

UNILET LANCETS ULTRA-THIN 28G 118 UNILET SUPERLITE LANCET 119 UNISOM SLEEPGELS 93 UNISOM SLEEPMELTS 93 UNISOM SLEEPTABS 93 UNISTIK 3 GENTLE 119 UNISTIK PRO SAFETY LANCET 21G 119 UNISTIK PRO SAFETY LANCET 25G 119 UNISTIK PRO SAFETY LANCET 28G 119 UNISTIK SAFETY LANCETS 28G 119 UNISTIK SAFETY LANCETS 30G 119 UNISTIK TOUCH SAFETY LANCETS 21G 119 UNISTIK TOUCH SAFETY LANCETS 23G 119 UNISTIK TOUCH SAFETY LANCETS 28G 119 UNISTIK TOUCH SAFETY LANCETS 30G 119 UNISTRIP1 GENERIC 80 UNITUXIN 37 UNIVERSAL 1 LANCETS THIN26G 119 UNIVERSAL 1 LANCETS ULTRA THIN 30G 119 UNIVERSAL 1 LANCETS/33G/MICRO-THIN

119 UNIVERSAL QUICK ADJUST CRUTCH 153 UNIVERSAL SLEEVE

UNGUATOR JAR 20/33WHITE/BLUE LIDUNGUATOR JAR 200/280BLUELID UNGUATOR JAR 200/280GREEN LID UNGUATOR JAR 200/280REDLID

152

152

152

152

4MM 153 UNIFINE PENTIPS 31GX8MM 158 UNIFINE PENTIPS PLUS 31GX8MM 158 UNILET COMFORTOUCH LANCET 118 UNILET EXCELITE 118

COVERS 153 UNIVERSAL TIPS/1" 153 UNIVERSAL WALKER ORGANIZER 153 UP4 PROBIOTICS ADULT 27 UP4 PROBIOTICS ULTRA 27 UP4 PROBIOTICS

UNGUATOR JAR 200/280WHITE 152 UNGUATOR JAR 30/42 BLUELID 152 UNGUATOR JAR 30/42BLUE/BLUE LID 152 UNGUATOR JAR 30/42GREENLID 152

UNILET EXCELITE II 118 UNILET G.P. LANCET 118 UNILET G.P. SUPERLITE LANCET 118 UNILET GP 28 ULTRA THIN 118 UNILET LANCET 118

WOMENS 27 UPSPRING BABY VITAMIN D + BRAIN 175 UPTRAVI 52 urea 68 URECHOLINE 189 UROCIT-K 10 88

UNGUATOR JAR 30/42 REDLID 152

UNILET LANCETS MICRO-THIN33G 118 UNILET LANCETS SUPER-THIN30G 118

UROCIT-K 5 UROXATRAL URSO 250

88 89 87

Index 53

ursodiol 87 VARUBI 29 VERSAJET II PLUS

UTIBRON NEOHALER 15 VAGIFEM 191 VAGINAL CREAM APPLICATOR 153 VAGINAL SUPPOSITORY APPLICATOR 153 valacyclovir hcl 48 VALCYTE 47 valganciclovir hcl 47 VALIUM 13 valproate sodium 19 valproic acid 19 valrubicin 39 valsartan 33 valsartan-hydrochlorothiazide

35 VALSTAR 39 VALTREX 48 VALUE PLUS LANCETS STANDARD 21G 119 VALUE PLUS LANCETS SUPERTHIN 30G 119 VALUE PLUS LANCETS THIN 26G 119 VALUMARK LANCET SUPER THIN 30G 119 VALUMARK LANCET ULTRA THIN 28G 119 VALUMARK PEN NEEDLES 31GX 8MM 158 VALVED HOLDING CHAMBER 162 VANCOCIN 11 VANCOCIN HCL 11

VASCEPA 31 VASERETIC 35 VASOTEC 33 VAYARIN PLUS 81 VAYAROL 81 VCF VAGINAL CONTRACEPTIVE FILM 190 VECAMYL 35 VECTIBIX 37 VECTICAL 63 VELCADE 40 VELETRI 51 VELPHORO 88 VELTIN 61 VEMLIDY 48 VENCLEXTA 38 VENCLEXTA STARTING PACK 37 venlafaxine hcl 21 VENTAVIS 51 VENTOLIN HFA 15 verapamil hcl 50,51 VERAPAMIL HCL ER 50 VERAPAMIL HCL SR 50 VERAPAMIL HYDROCHLORIDE ER 51 VERASENS BLOOD GLUCOSE MONITORING SYSTEM 119 VERASENS BLOOD GLUCOSE MONITORING SYSTEM METER KIT 119

HYDROSURGERY SYSTEM HANDPIECE 14MM 153 VERSAJET II PLUS HYDROSURGERY SYSTEM HANDPIECE 8MM 153 VERSAJET PLUS HYDROSURGERY SYSTEM HANDPIECE 14MM 153 VERSAJET PLUS HYDROSURGERY SYSTEM HANDPIECE 8MM 153 VESICARE 189 VIACTIV DIGESTIVE HEALTH 28 VIAL ACCESSORIES/INHALATIONWORK STATION/50HOLES 153 VIAL/2ML/SCREW TOP 153 VIBE 6 153 VIBRAMYCIN 185 VIBRATING FOOT BATH/HEAT 153 VICTORY AGM-4000 TEST STRIPS 80 VICTORY BLOOD GLUCOSE MONITORING SYSTEM 119 VICTOZA 23 VIDA MIA UNILET LANCETS SUPER THIN 30G 119 VIDA MIA UNILET LANCETS ULTRA THIN 28G 119 VIDA MIA UNIPFINE PENTIPSSHORT 31GX8MM 158 VIDAZA 37

vancomycin hcl VANICREAM LITE

11 71

VERDESO VERELAN

68 51

VIDEX EC VIDEXPEDIATRIC

47 47

VANISHPOINT BLOOD VERELAN PM 51 VIEKIRA PAK 48 COLLECTION SET 21G X 3/4" X12" 153 VANISHPOINT BLOOD COLLECTION SET 23G X 3/4" X12" 153 VANISHPOINT BLOOD COLLECTION SET 25G X 3/4" X12" 153 VANISHPOINT BLOOD COLLECTION TUBE HOLDER 153 VANOS 68 VANTAS 38 VAQTA 190 VARITHENA ADMINISTRATIONPACK 153

VERIPRED 20 58 VERSACLOZ 44 VERSAJET EXACT HYDROSURGERY SYSTEM HANDPIECE 14MM 153 VERSAJET EXACT HYDROSURGERY SYSTEM HANDPIECE 8MM 153 VERSAJET II EXACT HYDROSURGERY SYSTEM HANDPIECE 14MM 153 VERSAJET II EXACT HYDROSURGERY SYSTEM HANDPIECE 8MM 153

vigabatrin 19 VIGAMOX 177 VIIBRYD 21 VIIBRYD STARTER PACK 21 VIMIZIM 85 VIMOVO 5 VIMPAT 18 vincristine sulfate 41 VINCRISTINE SULFATE 41 VINYL INFLATABLE CUSHION 153 VINYL PADDED BATHTUB TRANSFER BENCH/COMMODESEAT/PAIL 153

Index 54

VIOKACE 81 VIRACEPT 47 VIRAGE CUSTOM BREAST PROSTHESIS EXTRA WEIGHTED THICKNESS 153 VIRAGE CUSTOM BREAST PROSTHESIS LIGHTWEIGHT THICKNESS 154 VIRAGE CUSTOM BREAST PROSTHESIS LIGHTWEIGHT THICKNESS/MAGNET 154 VIRAGE CUSTOM BREAST PROSTHESIS WEIGHTED THICKNESS 154 VIRAGE CUSTOM BREAST PROSTHESIS WEIGHTED THICKNESS/MAGNETS 154 VIRAMUNE 47 VIRAMUNE XR 47 VIREAD 47 VIROPTIC 177 VISBIOME PROBIOTIC HIGH POTENCY 27 VISCO-3 171 VISINE 178 VISINE RED EYE COMFORT 178 VISTARIL 12 VISTOGARD 28 VISUDYNE 178 VITALET PRO LANCETS 119 VITALET PRO PLUS LANCETS 119

VONVENDI 90 VORAXAZE 41 VORTEX VALVED HOLDING CHAMBER 162 VOTRIENT 40 VPRIV 91 VRAYLAR 43 VSL#3 27 VYNDAMAX 52 VYNDAQEL 52 VYTORIN 31 VYVANSE 1 WALGREENS ADVANCED TRAVELLANCETS 28G 119 WALGREENS COMFORT ASSUREDLANCETS MICRO THIN/33G 119 WALGREENS COMFORT ASSUREDLANCETS SUPER THIN/28G 119 WALGREENS GLUCOSE 23 WALGREENS LANCETS 119 WALGREENS THIN LANCETS 120 WALGREENS ULTRA THIN LANCETS 120 WALKER AUTO GLIDES/5ADJUSTMENT HOLES/1-1/8" 154 WALKER AUTO GLIDES/8ADJUSTMENT HOLES/1-1/8" 154 WALKER BASKET 154

WALKER WHEELS/FIXEDWITH5 ADJUSTMENT HOLES/3" 154 WALKER WHEELS/FIXEDWITH5 ADJUSTMENT HOLES/5" 154 WALKER WHEELS/FIXEDWITH8 ADJUSTMENT HOLES/3" 154 WALKER WHEELS/FIXEDWITH8 ADJUSTMENT HOLES/5" 154 WALKER/ADULT/FOLDING

154 WALKER/EXTENDEDFRAME 154 WALKER/FOLDING HEMI 154 WALKER/TWO-BUTTONFOLDING/32"-39"/NOWHEELS 154 WALKER/TWO-BUTTONFOLDING/TITANIUM 154 WALKER/YOUTH/FOLDING

154 warfarin sodium 15 WASH GLOVES PRE-MOISTENED 154 WATCHHALER 163 WATERPROOF SHEETING/36"X54" 154 WATERPROOF SHEETING/36"X66" 154 WAVESENSE AMP 120 WAVESENSE KEYNOTE 120 WAVESENSE KEYNOTE PRO

vitamin e VITAMIN E vitamins w/ lipotropics VITRAKVI VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS VIVAGUARD LANCETS VIVELLE-DOT VIVITROL VIVLODEX VIZIMPRO VOCAL POINT BLOOD GLUCOSE MONITORING SYSTEM

191 191 170

40

80 119

86 28

5 40

119

WALKER GLIDE WHEELS/5ADJUSTMENT HOLES/1-1/8" 154 WALKER GLIDE WHEELS/8ADJUSTMENT HOLES/1-1/8" 154 WALKER SKI GLIDES/1" 154 WALKER SKI GLIDES/1-1/8" 154 WALKER SWIVEL WHEELS/5ADJUSTMENT HOLES/3" 154 WALKER SWIVEL WHEELS/5ADJUSTMENT HOLES/5" 154 WALKER TALL EXTENSION

METER 120 WAVESENSE PRESTO TEST STRIPS 80 WEBCOL ALCOHOL PREP LARGE 1 PLY 154 WEBCOL ALCOHOL PREP LARGE 2 PLY 154 WEBCOL ALCOHOL PREP MEDIUM 2 PLY 154 WEGMANS UNIFINE PENTIPS PLUS/SHORT/31GX8MM 158 WEIGH BOAT/PLASTIC/ANTI-STATIC 154 WELLBUTRIN SR 20 WELLBUTRIN XL 20 WESTHROID 185

VOCAL POINT BLOOD GLUCOSE TEST STRIPS VOGELXO VOGELXO PUMP

80 10 10

LEGS 154 WALKER TIPS/1-1/8" 154 WALKER TIPS/BLACK/1-1/8" 154

WET-STOP 3 154 WHEEL CHAIR K1 BASIC DESKARM 154 WHEELCHAIR 155

VOLTAREN 61 WHEELCHAIR CUSHION 155

Index 55

WHEELCHAIR INVALID XTAMPZA ER 8 ZEWA ELECTRODES 155 RING 155 white petrolatum-mineral oil 175 WHITE WALL GRAB BAR/12" 155 WHITE WALL GRAB

XTANDI XULANE XULTOPHY 100/3.6 XYNTHA

38 56 22 90

ZIAC ZIAGEN ZIANA zidovudine

35 47 61 47

BAR/16"WHITE WALL GRAB BAR/18"WHITE WALL GRAB BAR/24" WIBI WILATE WINDMILL TRAINER WINRHO SDF

155

155

155 71 90

163 181

XYNTHA SOLOFUSE XYREM XYZAL ALLERGY 24HR CHILDRENS YASMIN 28 YAZ YERVOY YONDELIS

90 182

31 56 56 37 36

zileuton ZILRETTA zinc oxide (topical) zinc sulfate ZINECARD ZINPLAVA ZIOPTAN ZIPPERED MATTRESS

14 58 73

165 41

181 179

WOODEN CANE/ROUNDHANDLE/7/8" 155 WOODEN CANE/WALNUTFINISH/PISTOL GRIP/DERBYHANDLE/7/8" 155 WOODEN CANE/WALNUTFINISH/ROUNDHANDLE/7/8" 155 WORK BELT 155 WP THYROID 185 WRIST BRACE 155 WRIST SLEEP SUPPORT 155 XALATAN 179 XALKORI 40 XANAX 13 XANAX XR 13 XARELTO 16 XARELTO STARTER PACK 16 XELJANZ 4 XELJANZ XR 4 XELODA 37 XENAZINE 183 XEOMIN 172 XERESE 64 XEROSTOMIA RELIEF SPRAY 167 XGEVA 83 XIAFLEX 165 XIGDUO XR 22 XOFLUZA 48 XOLAIR 13 XOPENEX 15 XOPENEX CONCENTRATE 15 XOPENEX HFA 15 XOSPATA 40

YOSPRALA YOUTH PUSH BUTTON ALUMINUM CRUTCH YUPELRI YUTIQ ZADITOR zafirlukast zaleplon ZALTRAP ZANAFLEX ZANTAC ZANTAC 150 MAXIMUM STRENGTH ZANTAC 75 ZARONTIN ZARXIO ZAVESCA ZAVITROL ZEGERID ZEGERID OTC ZELAC ZELBORAF ZEMAIRA ZEMBRACE SYMTOUCH ZEMPLAR ZENPEP ZENZEDI ZEPATIER ZERIT ZESTORETIC ZESTRIL ZETIA ZETONNA ZEVALIN Y-90

91

155 13

178 179

14 94 37

171 187

186 186

19 92 91 81

188 188

27 40

184

164 85 82

1 48 47 35 33 32

172 37

COVER 155 ziprasidone hcl 43 ziprasidone mesylate 43 ZITHROMAX 95,96 ZITHROMAX TRI-PAK 96 ZITHROMAX Z-PAK 96 ZOCOR 32 ZOFRAN 29 ZOFRAN ODT 29 ZOHYDRO ER 8 ZOLADEX 38 zoledronic acid 83 ZOLEDRONIC ACID 83 zoledronic acid 83 ZOLEDRONIC ACID 83 ZOLGENSMA 10.1-10.5 KG 172 ZOLGENSMA 10.6-11.0 KG 173 ZOLGENSMA 11.1-11.5 KG 173 ZOLGENSMA 11.6-12.0 KG 173 ZOLGENSMA 12.1-12.5 KG 173 ZOLGENSMA 12.6-13.0 KG 173 ZOLGENSMA 13.1-13.5 KG 173 ZOLGENSMA 2.6-3.0 KG 173 ZOLGENSMA 3.1-3.5 KG 173 ZOLGENSMA 3.6-4.0 KG 173 ZOLGENSMA 4.1-4.5 KG 173 ZOLGENSMA 4.6-5.0 KG 173 ZOLGENSMA 5.1-5.5 KG 173 ZOLGENSMA 5.6-6.0 KG 173 ZOLGENSMA 6.1-6.5 KG 173

Index 56

ZOLGENSMA 6.6-7.0 KG 173

ZOOM 20 ROLLING

ZOVIRAX 48,64

ZYRTEC CHILDRENS

ZYRTEC-D

ZOLGENSMA 7.1-7.5 KG 173 ZOLGENSMA 7.6-8.0 KG 173 ZOLGENSMA 8.1-8.5 KG 173 ZOLGENSMA 8.6-9.0 KG 173 ZOLGENSMA 9.1-9.5 KG 173 ZOLGENSMA 9.6-10.0 KG 173 ZOLINZA 40 zolmitriptan 164 ZOLOFT 20 zolpidem tartrate 94 ZOLPIMIST 94 ZOMACTON 84 ZOMETA 83 ZOMIG 164 ZOMIG ZMT 164 ZONEGRAN 18 zonisamide 18 ZONTIVITY 91

WALKER 155 ZORBTIVE 84 ZORTRESS 166 ZOSTAVAX 190

ZUBSOLV 9 ZULRESSO 20 ZUPLENZ 29 ZYBAN 184 ZYDELIG 40 ZYFLO 14 ZYFLO CR 14 ZYKADIA 40 ZYLOPRIM 89 ZYMAXID 177 ZYPREXA 44 ZYPREXA RELPREVV 44 ZYPREXA ZYDIS 44 ZYRTEC ALLERGY 31

ALLERGY 31

ALLERGY/CONGESTION 59 ZYTIGA 38 ZZZQUIL 93

Index 57

Pharmacy Program Preferred Drug List › content › dam › centene › ... · 2020-05-21 ·...

Documents

Transcript of Pharmacy Program Preferred Drug List › content › dam › centene › ... · 2020-05-21 ·...