Provided by Elixir Introduction - Total Health CareProvided by Elixir Introduction The Total Health...

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COMMERCIAL FORMULARY Effective January 2021

Provided by Elixir

Introduction

The Total Health Care (THC) Commercial Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management. Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications.

Notice

The information contained in this formulary is provided by THC, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information.

How to Read the Formulary

Drug Name

All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. The brand names listed are for reference use only, and do not denote coverage, unless specifically noted. Any drug not found in this Formulary listing shall be considered a non-formulary drug.

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Co-Pay Structure

Requirements/Limits

This field includes potential limitations to the formulary drug. It also may contain additional information about the coverage of the drug such as applicable quantity limits (QL). For certain agents within the Commercial Formulary, a recommended prescribing guideline may apply.

Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Required (PA)

Drug requires prior authorization through a specific physician request process.

Over the Counter Drugs (OTC)

Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider.

Specialty Drugs (SP)

Drug requires processing through THC’s contracted specialty pharmacy, Elixir Specialty Pharmacy.

Quantity Limit (QL) Drug coverage may be limited to specific quantities per prescription and/or time period.

Age Limit (AL) Drug coverage may depend on patient age.

Gender Restriction (GR) Drug coverage may depend on patient gender.

Step Therapy Required (ST)

Drug coverage requires that an alternative or trial of another drug be used before the medication is covered.

Custom (C) Drug coverage has unique restrictions.

Benefit Coverage and Limitations

This formulary does not define benefit coverage and limitations. Members may have specific benefit inclusions, exclusions, copayments, or a lack of coverage, which are not reflected in the Total Health Care Commercial Formulary. Members should contact Total Health Care at 1-800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year.

Generic Drug Generic Co-Pay Applies

Brand Drug Brand Co-Pay Applies

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Prior Authorization (PA) Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-866-422-9119. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy Department to ask for an exception request.

Non-Formulary Agents

A Drug not located on the Total Health Care Commercial Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non-formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review:

The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. The formulary drug or preferred agents are not suited for the present patient care need, and the drug

selected is required for patient safety.

If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to:

OTC medications or their equivalents unless otherwise specified in the Formulary listing. Drug products used for cosmetic purposes. Drug products for sexual dysfunction. Drug products for infertility treatment. Drug products for weight loss. Experimental drug products or any drug product used in an experimental manner. Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).

Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA-approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted in lowercase lettering wherever an FDA-approved generic drug product is available. If a member or physician requests a brand-name product in lieu of an approved generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic drug.

http://www.thcmi.com/

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Total Health Care Pharmacy and Therapeutics (P&T) Committee

Total Health Care’s Pharmacy & Therapeutics Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel.

Product Selection Criteria

The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Commercial Formulary. Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862.

Diabetic Testing Supplies

Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844-236-7933.

Specialty Bio-Pharmaceutical Pharmacy Program

Total Health Care works with Elixir Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Elixir Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to Elixir at 1-866-422-9119 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at www.THCmi.com. Once the order is received, Elixir obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Elixir Specialty Pharmacy. Then, the Elixir Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact Elixir at 1-844-222-5584 or Elixir Specialty Pharmacy at 1-877-437-9012.

Contact Information

The Total Health Care Commercial Formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at 1-800-826-2862.

http://www.thcmi.com/

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Medication Limitations

Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit. Gender Restrictions Gender restrictions are indicated with a “GR” on the formulary and require the member to be a specific gender for coverage. Step Therapy Criteria Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled.

Step Therapy Criteria

Therapy Class First Line Second Line Third Line Step Therapy Criteria

Antimigraine sumatriptan, rizatriptan

naratriptan, zolmitriptan, zolmitriptan odt

Prior use of sumatriptan AND rizatriptan in the last 90 days.

Antipsychotic Agents

risperidone, quetiapine immediate-release, olanzapine

quetiapine ER Prior use for 30 days of quetiapine IR, olanzapine, risperidone, or ziprasidone

Anticonvulsants lamotrigine IR

lamotrigine ER

Prior use for 30 days of lamotrigine IR

Urinary Antispasmodics

oxybutynin, oxybutynin ER, oxybutynin syrup, OXYTROL OTC

tolterodine, tolterodine ER, trospium

darifenacin ER, trospium ER, solifenacin

Second Line: Prior use of OXYTROL OTC, oxybutynin, oxybutynin ER, or oxybutynin syrup in the last 90 days. Third Line: Prior use of tolterodine, tolterodine ER, or trospium in the last 90 days.

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*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of Elixir. The presence of a medication on this formulary list does not guarantee coverage.

CURRENT AS OF 1/1/2021

lowercase italics = Generic drugsUPPERCASE BOLD = Brand name drugs

StatusT1 = Covered

Notes = Preferred = PDL Non-PreferredAL = Age LimitGR-F = Female OnlyGR-M = Male OnlyPA = Prior AuthorizationQL = Quantity LimitST = Step Therapy

Drug Status Notes

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

T1QL (30 EA per 30 days); AL (Min 6 Years)

amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg


amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg


amphetamine-dextroamphetamine oral tablet 20 mg, 5 mg, 7.5 mg


amphetamine-dextroamphetamine oral tablet 30 mg


armodafinil oral tablet 150 mg, 200 mg T1 QL (30 EA per 30 days)

atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg

T1 QL (60 EA per 30 days)

dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg


dexmethylphenidate hcl oral tablet 10 mg, 5 mg T1QL (150 EA per 30 days); AL (Min 4 Years)

dexmethylphenidate hcl oral tablet 2.5 mg T1QL (90 EA per 30 days); AL (Min 4 Years)

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

T1

dextroamphetamine sulfate oral tablet 10 mg T1 QL (180 EA per 30 days)

dextroamphetamine sulfate oral tablet 5 mg T1 QL (360 EA per 30 days)

guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg


methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg


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Drug Status Notesmethylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

T1QL (30 EA per 30 days); AL (Min 4 Years and Max 10 Years)

methylphenidate hcl er oral tablet extended release 10 mg


methylphenidate hcl er oral tablet extended release 18 mg, 27 mg


methylphenidate hcl er oral tablet extended release 20 mg


methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg


methylphenidate hcl er oral tablet extended release 24 hour 36 mg, 54 mg


methylphenidate hcl er oral tablet extended release 36 mg, 54 mg


methylphenidate hcl oral solution 5 mg/5ml T1QL (600 ML per 30 days); AL (Min 4 Years and Max 10 Years)

methylphenidate hcl oral tablet 10 mg T1QL (300 EA per 30 days); AL (Min 4 Years)



methylphenidate hcl oral tablet chewable 10 mg T1QL (300 EA per 30 days); AL (Min 4 Years and Max 10 Years)

methylphenidate hcl oral tablet chewable 2.5 mg T1QL (1200 EA per 30 days); AL (Min 4 Years and Max 10 Years)

methylphenidate hcl oral tablet chewable 5 mg T1QL (600 EA per 30 days); AL (Min 4 Years and Max 10 Years)

modafinil oral tablet 100 mg, 200 mg T1 PA

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG T1

ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)

*Aminoglycosides*neomycin sulfate oral tablet 500 mg T1

*Analgesics - Anti-Inflammatory*celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg


diclofenac potassium oral tablet 50 mg T1

diclofenac sodium er oral tablet extended release 24 hour 100 mg

T1

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

T1

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Drug Status NotesENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

T1 PA

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG T1 PA

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML T1 PA

fenoprofen calcium oral tablet 600 mg T1

flurbiprofen oral tablet 100 mg, 50 mg T1

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

T1 PA

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML T1 PA

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

T1 PA

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

T1 PA

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML

T1 PA

ibuprofen oral capsule 200 mg T1

ibuprofen oral suspension 100 mg/5ml T1

ibuprofen oral tablet 200 mg, 400 mg, 600 mg, 800 mg

T1

INDOCIN ORAL SUSPENSION 25 MG/5ML T1

indomethacin oral capsule 25 mg, 50 mg T1

ketoprofen oral capsule 50 mg T1 QL (360 EA per 30 days)

ketoprofen oral capsule 75 mg T1 QL (120 EA per 30 days)

ketorolac tromethamine oral tablet 10 mg T1Max of 5 day supply; QL (20 EA per 5 days)

leflunomide oral tablet 10 mg, 20 mg T1

meloxicam oral tablet 15 mg, 7.5 mg T1

nabumetone oral tablet 500 mg T1 QL (120 EA per 30 days)

nabumetone oral tablet 750 mg T1 QL (60 EA per 30 days)

NAPROXEN COMFORT PAC COMBINATION KIT 500 MG T1

naproxen dr oral tablet delayed release 375 mg T1

naproxen oral tablet 250 mg, 375 mg, 500 mg T1

naproxen powder T1

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Drug Status Notesnaproxen sodium oral capsule 220 mg T1

naproxen sodium oral tablet 220 mg T1

oxaprozin oral tablet 600 mg T1

piroxicam oral capsule 10 mg, 20 mg T1

sulindac oral tablet 150 mg, 200 mg T1

*Analgesics - Nonnarcotic*ACEPHEN RECTAL SUPPOSITORY 325 MG T1

acetaminophen er oral tablet extended release650 mg

T1

acetaminophen oral capsule 500 mg T1

acetaminophen oral elixir 160 mg/5ml T1

acetaminophen oral suspension 160 mg/5ml T1

acetaminophen oral tablet 325 mg, 500 mg T1

acetaminophen rectal suppository 120 mg T1

adult aspirin low strength oral tablet dispersible81 mg


apap oral tablet chewable 80 mg T1

ASCRIPTIN ORAL TABLET 325 MG T1

aspirin adult low strength oral tablet delayed release 81 mg


aspirin low dose oral tablet chewable 81 mg T1QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years)

aspirin oral tablet 325 mg T1QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

aspirin oral tablet 81 mg T1QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years)

aspirin oral tablet delayed release 325 mg T1QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

aspirin rectal suppository 300 mg, 600 mg T1

aspirtab maximum strength oral tablet 500 mg T1

buffasal oral tablet 324 mg T1QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

buffered aspirin oral tablet 325 mg T1QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

butalbital-acetaminophen oral tablet 50-325 mg T1

butalbital-apap-caffeine oral tablet 50-325-40 mg T1

butalbital-aspirin-caffeine oral capsule 50-325-40 mg

T1

choline & mag trisalicylate oral tablet 1000 mg T1

choline-mag trisalicylate oral liquid 500 mg/5ml T1

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Drug Status Notesdiflunisal oral tablet 500 mg T1

infants pain relief oral suspension 80 mg/0.8ml T1

migraine relief oral tablet 250-250-65 mg T1

q-pap infants oral solution 80 mg/0.8ml T1

q-pap oral liquid 160 mg/5ml T1

salsalate oral tablet 500 mg, 750 mg T1

*Analgesics - Opioid*acetaminophen-codeine #2 oral tablet 300-15 mg T1 QL (390 EA per 30 days)

acetaminophen-codeine #3 oral tablet 300-30 mg T1 QL (390 EA per 30 days)

acetaminophen-codeine #4 oral tablet 300-60 mg T1 QL (390 EA per 30 days)

acetaminophen-codeine oral solution 120-12 mg/5ml

T1

butalbital-apap-caff-cod oral capsule 50-325-40-30 mg

T1

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg

T1

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg T1

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 7.5-325 mg/15ml

T1 QL (900 ML per 90 days)

hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg


hydrocodone-acetaminophen oral tablet 5-325 mg T1 QL (360 EA per 30 days)

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg T1 QL (240 EA per 30 days)

LORTAB ORAL ELIXIR 10-300 MG/15ML T1 QL (900 ML per 90 days)

meperidine hcl oral tablet 100 mg, 50 mg T1

methadone hcl oral concentrate 10 mg/ml T1

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml T1

methadone hcl oral tablet 10 mg T1 QL (240 EA per 30 days)

methadone hcl oral tablet 5 mg T1 QL (120 EA per 30 days)

methadone hcl oral tablet soluble 40 mg T1

morphine sulfate (concentrate) oral solution 100 mg/5ml

T1

morphine sulfate er oral tablet extended release100 mg, 15 mg, 30 mg, 60 mg


morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml

T1

morphine sulfate oral tablet 15 mg, 30 mg T1 QL (180 EA per 30 days)

oxycodone hcl oral concentrate 100 mg/5ml T1

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Drug Status Notesoxycodone hcl oral solution 5 mg/5ml T1

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg


oxycodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg


oxycodone-acetaminophen oral tablet 5-325 mg T1 QL (360 EA per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg T1

tramadol hcl oral tablet 50 mg T1 QL (240 EA per 30 days)

*Androgens-Anabolic*testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

T1 GR-M

testosterone enanthate intramuscular solution200 mg/ml

T1 GR-M

*Anorectal And Related Products*FLEET NATURALS CLEANSING ENEMA RECTAL ENEMA T1

hydrocortisone rectal enema 100 mg/60ml T1

*Antacids*ALKA-SELTZER HEARTBURN ORAL TABLET EFFERVESCENT 1940-1000 MG T1

ALMACONE ORAL TABLET CHEWABLE200-200-25 MG T1

antacid & antigas oral suspension 200-200-20 mg/5ml, 400-400-40 mg/5ml

T1

antacid extra strength oral tablet chewable 675-135 mg

T1

antacid multi-symptom oral tablet chewable 675-135-60 mg

T1

antacid oral tablet chewable 1177 mg, 350-150 mg, 420 mg, 550-110 mg

T1

calcium antacid ultra oral tablet chewable 1000 mg

T1

calcium carbonate antacid oral tablet 648 mg T1

calcium carbonate antacid oral tablet chewable500 mg, 750 mg

T1

CHILDRENS SOOTHE ORAL TABLET CHEWABLE 400 MG T1

CITROCARBONATE ORAL GRANULES EFFERVESCENT 0.78-1.82 GM/DOSE T1

cvs antacid & anti-gas oral tablet chewable 1000-60 mg

T1

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Drug Status Notescvs antacid supreme oral suspension 400-135 mg/5ml

T1

cvs heartburn relief ex st oral suspension 254-237.5 mg/5ml

T1

DEWEES CARMINATIVE ORAL LIQUID 6-250 T1

E-Z-GAS II ORAL PACKET 2.21-1.53-0.04 GM T1

GAVISCON ORAL TABLET CHEWABLE80-14.2 MG T1

gnp foaming antacid oral suspension 95-358 mg/15ml

T1

gnp foaming antacid oral tablet chewable 80-20 mg

T1

heartburn antacid ex st oral tablet chewable 160-105 mg

T1

mag-al oral liquid 200-200 mg/5ml T1

magnesium oxide oral capsule 400 mg T1

magnesium oxide oral tablet 250 mg, 400 mg T1

magnesium oxide powder T1

MAOX ORAL TABLET 420 MG T1

MI-ACID ORAL TABLET CHEWABLE 700-300 MG T1

sodium bicarbonate oral powder T1

sodium bicarbonate oral tablet 325 mg, 650 mg T1

URO-MAG ORAL CAPSULE 140 MG T1

*Anthelmintics*ivermectin oral tablet 3 mg T1 QL (20 EA per 90 days)

PIN-X ORAL SUSPENSION 50 MG/ML T1

PIN-X ORAL TABLET CHEWABLE 720.5 MG T1

reeses pinworm medicine oral suspension 144 (50 base) mg/ml

T1

*Antianginal Agents*isosorbide dinitrate er oral tablet extended release 40 mg

T1

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

T1

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

T1

isosorbide mononitrate oral tablet 20 mg T1

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Drug Status NotesNITRO-BID TRANSDERMAL OINTMENT 2 % T1

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

T1

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

T1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

T1

*Antianxiety Agents*alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

T1 AL (Max 64 Years)

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg

T1

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


clorazepate dipotassium oral tablet 15 mg, 3.75 mg

T1

clorazepate dipotassium oral tablet 7.5 mg T1 AL (Max 64 Years)

diazepam injection solution 5 mg/ml T1

diazepam oral solution 1 mg/ml T1 AL (Max 64 Years)

diazepam oral tablet 10 mg, 2 mg, 5 mg T1 AL (Max 64 Years)

hydroxyzine hcl oral syrup 10 mg/5ml T1 AL (Max 64 Years)

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg T1 AL (Max 64 Years)

hydroxyzine pamoate oral capsule 100 mg T1

hydroxyzine pamoate oral capsule 25 mg, 50 mg T1 AL (Max 64 Years)

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg T1

oxazepam oral capsule 10 mg, 15 mg, 30 mg T1

*Antiarrhythmics*amiodarone hcl oral tablet 200 mg T1

disopyramide phosphate oral capsule 100 mg, 150 mg

T1

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

T1

MULTAQ ORAL TABLET 400 MG T1 QL (60 EA per 30 days)

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG T1 QL (60 EA per 30 days)

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 150 MG T1 QL (120 EA per 30 days)

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

T1

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Drug Status Notesquinidine gluconate er oral tablet extended release 324 mg

T1

quinidine sulfate oral tablet 200 mg, 300 mg T1

*Antiasthmatic And Bronchodilator Agents*ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE

T1QL (60 EA per 30 days); AL (Max 11 Years)

AEROSPAN INHALATION AEROSOL SOLUTION 80 MCG/ACT T1 QL (8.9 GM per 30 days)

albuterol sulfate inhalation nebulization solution(2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%

T1

albuterol sulfate oral syrup 2 mg/5ml T1

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

T1 PA; QL (60 EA per 30 days)

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT T1 QL (12.9 GM per 30 days)

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH


budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml

T1 AL (Max 6 Years)

budesonide-formoterol fumarate aerosol 160-4.5 mcg/act inhalation 160-4.5 mcg/act

T1 QL (10.2 GM per 30 days)

budesonide-formoterol fumarate aerosol 80-4.5 mcg/act inhalation 80-4.5 mcg/act


DIFIL-G FORTE ORAL LIQUID 100-100 MG/5ML T1

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT T1 QL (13 GM per 30 days)

FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30 MG/ML T1 PA

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL44 MCG/ACT T1

QL (10.6 GM per 30 days); AL (Min 4 Years and Max 11 Years)

fluticasone-salmeterol aerosol powder breath activated 113-14 mcg/act inhalation 113-14 mcg/act


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Drug Status Notesfluticasone-salmeterol aerosol powder breath activated 232-14 mcg/act inhalation 232-14 mcg/act


fluticasone-salmeterol aerosol powder breath activated 55-14 mcg/act inhalation 55-14 mcg/act


FORADIL AEROLIZER INHALATION CAPSULE 12 MCG T1 QL (60 EA per 30 days)

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH


ipratropium bromide inhalation solution 0.02 % T1

LUFYLLIN ORAL TABLET 200 MG, 400 MG T1

metaproterenol sulfate oral syrup 10 mg/5ml T1

metaproterenol sulfate oral tablet 10 mg, 20 mg T1

montelukast sodium oral tablet 10 mg T1

montelukast sodium oral tablet chewable 4 mg, 5 mg

T1

QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT T1 QL (8.7 GM per 30 days)

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT


SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE


STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT T1 QL (4 GM per 30 days)

terbutaline sulfate oral tablet 2.5 mg, 5 mg T1

THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

T1

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 200 MG T1

theophylline er oral tablet extended release 12 hour 100 mg, 300 mg, 450 mg

T1

theophylline er oral tablet extended release 24 hour 400 mg

T1

theophylline oral solution 80 mg/15ml T1

TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT


10

Drug Status NotesVENTOLIN HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT

T1 QL (36 GM per 28 days)

*Anticoagulants*enoxaparin sodium injection solution 300 mg/3ml T1 PA; 7 day supply then PA

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

T1 PA; 7 day supply then PA

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

T1

heparin sodium (porcine) intravenous solution2000 unit/ml

T1

heparin sodium (porcine) pf injection solution5000 unit/0.5ml

T1

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

T1

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

T1

XARELTO ORAL TABLET 10 MG T1 QL (30 EA per 30 days)

XARELTO ORAL TABLET 15 MG, 2.5 MG, 20 MG T1 QL (60 EA per 30 days)

*Anticonvulsants*carbamazepine er oral capsule extended release 12 hour 300 mg

T1

carbamazepine er oral tablet extended release 12 hour 200 mg, 400 mg

T1

carbamazepine oral suspension 100 mg/5ml T1

carbamazepine oral tablet 200 mg T1

carbamazepine oral tablet chewable 100 mg T1

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg T1

DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG T1 QL (2 EA per 30 days)

diazepam rectal gel 10 mg, 2.5 mg, 20 mg T1 QL (2 EA per 30 days)

DILANTIN ORAL CAPSULE 100 MG, 30 MG T1

divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg

T1

divalproex sodium oral capsule delayed release sprinkle 125 mg

T1

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

T1

11

Drug Status NotesEPITOL ORAL TABLET 200 MG T1

ethosuximide oral capsule 250 mg T1

ethosuximide oral solution 250 mg/5ml T1

fosphenytoin sodium injection solution 100 mg pe/2ml, 500 mg pe/10ml

T1

gabapentin oral capsule 100 mg, 300 mg, 400 mg T1

gabapentin oral solution 250 mg/5ml T1

gabapentin oral tablet 600 mg, 800 mg T1

lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

T1 ST; QL (30 EA per 30 days)

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

T1

lamotrigine oral tablet chewable 25 mg, 5 mg T1

levetiracetam oral solution 100 mg/ml T1

levetiracetam oral tablet 1000 mg T1 QL (90 EA per 30 days)




oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

T1

phenytoin oral suspension 125 mg/5ml T1 QL (750 ML per 30 days)

phenytoin oral tablet chewable 50 mg T1

phenytoin sodium extended oral capsule 100 mg T1

phenytoin sodium injection solution 50 mg/ml T1

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg


primidone oral tablet 250 mg, 50 mg T1

topiramate oral capsule sprinkle 15 mg, 25 mg T1

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

T1

valproic acid oral capsule 250 mg T1

valproic acid oral solution 250 mg/5ml T1

zonisamide oral capsule 100 mg T1 QL (180 EA per 30 days)

zonisamide oral capsule 25 mg, 50 mg T1 QL (360 EA per 30 days)

*Antidepressants*amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg


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


12

Drug Status Notesbupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg

T1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

T1

bupropion hcl oral tablet 100 mg, 75 mg T1

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

T1

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg


doxepin hcl oral concentrate 10 mg/ml T1 AL (Max 64 Years)

duloxetine hcl oral capsule delayed release particles 20 mg


duloxetine hcl oral capsule delayed release particles 30 mg, 60 mg


escitalopram oxalate oral solution 5 mg/5ml T1

escitalopram oxalate oral tablet 10 mg, 5 mg T1 QL (45 EA per 30 days)

escitalopram oxalate oral tablet 20 mg T1 QL (30 EA per 30 days)

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg T1

fluoxetine hcl oral solution 20 mg/5ml T1

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg

T1

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg T1 AL (Max 64 Years)

mirtazapine oral tablet 15 mg, 30 mg, 45 mg T1 AL (Max 64 Years)

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

T1

nortriptyline hcl oral solution 10 mg/5ml T1

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

T1

phenelzine sulfate oral tablet 15 mg T1

sertraline hcl oral concentrate 20 mg/ml T1

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg T1

tranylcypromine sulfate oral tablet 10 mg T1 PA

trazodone hcl oral tablet 100 mg, 150 mg, 50 mg T1

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

T1

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

T1

*Antidiabetics*acarbose oral tablet 100 mg, 25 mg, 50 mg T1

alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg


13

Drug Status Notesalogliptin-metformin hcl oral tablet 12.5-1000 mg T1 QL (60 EA per 30 days)

alogliptin-metformin hcl oral tablet 12.5-500 mg T1 QL (30 EA per 30 days)

alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg


chlorpropamide oral tablet 100 mg, 250 mg T1

FIASP FLEXTOUCH SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML

T1

FIASP PENFILL SOLUTION CARTRIDGE 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML

T1

FIASP SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T1

glimepiride oral tablet 1 mg, 2 mg, 4 mg T1

glipizide oral tablet 10 mg, 5 mg T1

glipizide xl oral tablet extended release 24 hour10 mg, 2.5 mg, 5 mg


glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

T1

glucagon emergency injection kit 1 mg T1 QL (2 EA per 365 days)

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

T1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg T1

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

T1

INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG T1 QL (60 EA per 30 days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG


INVOKANA ORAL TABLET 100 MG, 300 MG T1 QL (30 EA per 30 days)

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG T1 QL (60 EA per 30 days)

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG T1 QL (30 EA per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG T1 QL (30 EA per 30 days)

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1

14

Drug Status NotesLANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML T1

LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1

LEVEMIR SUBCUTANEOUS SOLUTION100 UNIT/ML T1

metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg

T1

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

T1

nateglinide oral tablet 120 mg, 60 mg T1 QL (90 EA per 30 days)

NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

T1

NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

T1

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T1

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T1

NOVOLIN N FLEXPEN SUSPENSION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML

T1

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML T1

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML T1

NOVOLIN R FLEXPEN SOLUTION PEN-INJECTOR 100 UNIT/ML INJECTION 100 UNIT/ML

T1

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML T1

NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML T1

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T1

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

T1

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML T1

NOVOLOG SUBCUTANEOUS SOLUTION100 UNIT/ML T1

15

Drug Status NotesOZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

T1 QL (1.5 ML per 30 days)

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML T1 QL (3 ML per 30 days)

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg T1 QL (30 EA per 30 days)

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg


RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG T1 QL (30 EA per 30 days)

SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG T1 QL (60 EA per 30 days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG


TANZEUM SUBCUTANEOUS PEN-INJECTOR 30 MG, 50 MG T1 PA

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML T1

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

T1

TRESIBA SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T1

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML T1 QL (9 ML per 30 days)

*Antidiarrheal/Probiotic Agents*acidophilus/citrus pectin oral tablet T1

acidophilus/pectin oral capsule T1

bismuth oral tablet chewable 262 mg T1

CULTURELLE DIGESTIVE HEALTH ORAL CAPSULE T1

CULTURELLE DIGESTIVE HEALTH ORAL TABLET CHEWABLE T1

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml

T1

diphenoxylate-atropine oral tablet 2.5-0.025 mg T1

loperamide hcl oral capsule 2 mg T1

loperamide hcl oral liquid 1 mg/5ml T1

loperamide hcl oral suspension 1 mg/7.5ml T1

loperamide hcl oral tablet 2 mg T1

16

Drug Status Notespink bismuth maximum strength oral suspension525 mg/15ml

T1

pink bismuth oral suspension 262 mg/15ml T1

probiotic-prebiotic oral capsule 1-250 billion-mg T1

ra pink bismuth oral tablet 262 mg T1

ra probiotic digestive care oral capsule T1

*Antidotes And Specific Antagonists*CHEMET ORAL CAPSULE 100 MG T1

naloxone hcl injection solution 0.4 mg/ml T1 QL (2 ML per 90 days)

naloxone hcl injection solution cartridge 0.4 mg/ml


naltrexone hcl oral tablet 50 mg T1

NARCAN NASAL LIQUID 4 MG/0.1ML T1

*Antiemetics*dimenhydrinate injection solution 50 mg/ml T1

dimenhydrinate oral tablet 50 mg T1

DRAMAMINE ORAL TABLET CHEWABLE50 MG T1

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg T1 PA

granisetron hcl oral tablet 1 mg T1 QL (10 EA per 30 days)

meclizine hcl oral tablet 12.5 mg, 25 mg T1

meclizine hcl oral tablet chewable 25 mg T1

meclizine hcl powder T1

ondansetron hcl oral solution 4 mg/5ml T1 QL (50 ML per 30 days)

ondansetron hcl oral tablet 4 mg, 8 mg T1

ondansetron oral tablet dispersible 4 mg, 8 mg T1

trimethobenzamide hcl oral capsule 300 mg T1

*Antifungals*fluconazole oral suspension reconstituted 10 mg/ml

T1

fluconazole oral suspension reconstituted 40 mg/ml


fluconazole oral tablet 100 mg, 50 mg T1

fluconazole oral tablet 150 mg T1 QL (4 EA per 30 days)

fluconazole oral tablet 200 mg T1 QL (30 EA per 30 days)

griseofulvin microsize oral suspension 125 mg/5ml

T1

griseofulvin microsize oral tablet 500 mg T1

17

Drug Status Notesgriseofulvin ultramicrosize oral tablet 125 mg, 250 mg

T1

itraconazole oral capsule 100 mg T1

ketoconazole oral tablet 200 mg T1

nystatin oral powder T1

nystatin oral tablet 500000 unit T1

terbinafine hcl oral tablet 250 mg T1

*Antihistamines*

aler-dryl oral tablet 50 mg T1PA; covered up to age 65, then PA required

aller-chlor oral syrup 2 mg/5ml T1

cetirizine hcl oral syrup 5 mg/5ml T1

cetirizine hcl oral tablet 10 mg, 5 mg T1

chlorpheniramine maleate er oral tablet extended release 12 mg

T1

chlorpheniramine maleate oral tablet 4 mg T1

chlorpheniramine maleate powder T1

CLARITIN CHILDRENS ORAL TABLET CHEWABLE 5 MG T1

clemastine fumarate oral syrup 0.67 mg/5ml T1

clemastine fumarate oral tablet 1.34 mg, 2.68 mg T1

cvs allergy childrens oral tablet chewable 12.5 mg

T1PA; covered up to age 65, then PA required

cyproheptadine hcl oral syrup 2 mg/5ml T1

cyproheptadine hcl oral tablet 4 mg T1

dexchlorpheniramine maleate oral syrup 2 mg/5ml

T1

diphenhist oral liquid 12.5 mg/5ml T1PA; covered up to age 65, then PA required

diphenhydramine hcl oral capsule 25 mg, 50 mg T1PA; covered up to age 65, then PA required

diphenhydramine hcl oral elixir 12.5 mg/5ml T1PA; covered up to age 65, then PA required

diphenhydramine hcl oral tablet 25 mg T1PA; covered up to age 65, then PA required

ED CHLORPED ORAL LIQUID 2 MG/ML T1

fexofenadine hcl childrens oral suspension 30 mg/5ml

T1

fexofenadine hcl oral tablet 180 mg T1

levocetirizine dihydrochloride oral tablet 5 mg T1 QL (30 EA per 30 days)

18

Drug Status Notesloratadine allergy relief oral tablet dispersible 10 mg

T1

loratadine childrens oral solution 5 mg/5ml T1

loratadine oral tablet 10 mg T1

promethazine hcl oral solution 6.25 mg/5ml T1

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

T1

promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg


ra allergy relief childrens oral tablet dispersible12.5 mg

T1PA; covered up to age 65, then PA required

silphen cough oral syrup 12.5 mg/5ml T1PA; covered up to age 65, then PA required

TRIAMINIC COUGH/RUNNY NOSE ORAL STRIP 12.5 MG T1

*Antihyperlipidemics*atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg


cholestyramine light oral powder 4 gm/dose T1

cholestyramine oral powder 4 gm/dose T1

colestipol hcl oral granules 5 gm T1

colestipol hcl oral tablet 1 gm T1

ezetimibe oral tablet 10 mg T1 QL (30 EA per 30 days)

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

T1

fenofibrate oral tablet 145 mg, 48 mg T1

fenofibrate oral tablet 160 mg, 54 mg T1 QL (30 EA per 30 days)

gemfibrozil oral tablet 600 mg T1

lovastatin oral tablet 10 mg, 20 mg, 40 mg T1

NIACOR ORAL TABLET 500 MG T1

PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML, 75 MG/ML T1 PA; QL (2 ML per 28 days)

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

T1

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE420 MG/3.5ML

T1 PA; QL (3.5 ML per 30 days)

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML T1 PA; QL (2 ML per 28 days)

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML T1 PA; QL (2 ML per 28 days)

19

Drug Status Notesrosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg

T1

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg T1

simvastatin oral tablet 80 mg T1 QL (30 EA per 30 days)

*Antihypertensives*amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

T1

amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg


amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg


atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

T1

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

T1

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

T1

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

T1

captopril oral tablet 100 mg T1

captopril oral tablet 12.5 mg, 25 mg, 50 mg T1 QL (90 EA per 30 days)

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

T1

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg T1

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

T1

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

T1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

T1

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg T1

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

T1

guanfacine hcl oral tablet 1 mg, 2 mg T1

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

T1

irbesartan oral tablet 150 mg, 300 mg, 75 mg T1 QL (30 EA per 30 days)

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg


lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

T1

20

Drug Status Noteslisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

T1

losartan potassium oral tablet 100 mg, 25 mg, 50 mg

T1

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

T1

methyldopa oral tablet 250 mg, 500 mg T1

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

T1

minoxidil oral tablet 10 mg, 2.5 mg T1

moexipril hcl oral tablet 15 mg, 7.5 mg T1

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg

T1

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg T1

propranolol-hctz oral tablet 40-25 mg, 80-25 mg T1 QL (60 EA per 30 days)

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

T1

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg


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

T1

telmisartan oral tablet 20 mg, 40 mg, 80 mg T1

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

T1

trandolapril oral tablet 1 mg, 2 mg, 4 mg T1

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

T1

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

T1

*Anti-Infective Agents - Misc.*atovaquone oral suspension 750 mg/5ml T1 QL (210 ML per 18 days)

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

T1

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

T1

dapsone oral tablet 100 mg, 25 mg T1

DORIBAX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG T1

FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML T1

21

Drug Status NotesFIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML T1

FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 MG/ML T1

linezolid oral tablet 600 mg T1 QL (28 EA per 14 days)

methenamine hippurate oral tablet 1 gm T1

methenamine mandelate oral tablet 0.5 gm, 1 gm T1

metronidazole oral tablet 250 mg, 500 mg T1

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg


nitrofurantoin macrocrystal oral capsule 25 mg T1

nitrofurantoin monohyd macro oral capsule 100 mg


nitrofurantoin oral suspension 25 mg/5ml T1 AL (Max 12 Years)

PRIMSOL ORAL SOLUTION 50 MG/5ML T1 QL (600 ML per 30 days)

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

T1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

T1

tinidazole oral tablet 500 mg T1

trimethoprim oral tablet 100 mg T1 QL (60 EA per 30 days)

vancomycin hcl intravenous solution reconstituted10 gm, 1000 mg, 500 mg, 5000 mg, 750 mg

T1

*Antimalarials*chloroquine phosphate oral tablet 250 mg T1 PA

hydroxychloroquine sulfate oral tablet 200 mg T1

mefloquine hcl oral tablet 250 mg T1 QL (5 EA per 30 days)

primaquine phosphate oral tablet 26.3 mg T1 QL (14 EA per 30 days)

quinine sulfate oral capsule 324 mg T1

*Antimycobacterial Agents*ethambutol hcl oral tablet 100 mg, 400 mg T1

isoniazid oral syrup 50 mg/5ml T1

isoniazid oral tablet 100 mg, 300 mg T1

pyrazinamide oral tablet 500 mg T1

rifampin oral capsule 150 mg, 300 mg T1

RIFATER ORAL TABLET 50-120-300 MG T1

TRECATOR ORAL TABLET 250 MG T1

*Antineoplastics And Adjunctive Therapies*anastrozole oral tablet 1 mg T1 GR-F

22

Drug Status Notesbicalutamide oral tablet 50 mg T1

capecitabine oral tablet 150 mg, 500 mg T1 PA

cyclophosphamide oral capsule 25 mg, 50 mg T1

cyclophosphamide oral tablet 25 mg, 50 mg T1

ELIGARD SUBCUTANEOUS KIT 22.5 MG, 45 MG T1 PA

ELIGARD SUBCUTANEOUS KIT 30 MG, 7.5 MG T1

ERLEADA ORAL TABLET 60 MG T1 PA

flutamide oral capsule 125 mg T1 PA

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG T1 PA

HEXALEN ORAL CAPSULE 50 MG T1 PA

hydroxyurea oral capsule 500 mg T1

imatinib mesylate oral tablet 100 mg, 400 mg T1 PA

INTRON A INJECTION SOLUTION10000000 UNIT/ML, 6000000 UNIT/ML T1 PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

T1 PA

letrozole oral tablet 2.5 mg T1 QL (30 EA per 30 days)

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

T1

LEUKERAN ORAL TABLET 2 MG T1

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG T1 PA

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 MG T1 PA

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG T1 PA

MATULANE ORAL CAPSULE 50 MG T1 PA

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

T1

megestrol acetate oral tablet 20 mg, 40 mg T1

mercaptopurine oral tablet 50 mg T1

methotrexate oral tablet 2.5 mg T1

methotrexate sodium (pf) injection solution 50 mg/2ml

T1

methotrexate sodium injection solution 50 mg/2ml T1

MYLERAN ORAL TABLET 2 MG T1

TABLOID ORAL TABLET 40 MG T1

23

Drug Status Notestamoxifen citrate oral tablet 10 mg, 20 mg T1 GR-F; AL (Min 35 Years)

tretinoin oral capsule 10 mg T1 PA

*Antiparkinson And Related Therapy Agents*amantadine hcl oral capsule 100 mg T1

amantadine hcl oral syrup 50 mg/5ml T1

amantadine hcl oral tablet 100 mg T1

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

T1

bromocriptine mesylate oral capsule 5 mg T1

bromocriptine mesylate oral tablet 2.5 mg T1

carbidopa oral tablet 25 mg T1

carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

T1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

T1

entacapone oral tablet 200 mg T1

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

T1

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

T1

selegiline hcl oral capsule 5 mg T1

trihexyphenidyl hcl oral tablet 2 mg, 5 mg T1

*Antipsychotics/Antimanic Agents*aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg


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

T1

fluphenazine hcl injection solution 2.5 mg/ml T1

fluphenazine hcl oral concentrate 5 mg/ml T1

fluphenazine hcl oral elixir 2.5 mg/5ml T1

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

T1

haloperidol decanoate intramuscular solution100 mg/ml

T1

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

T1

lithium carbonate er oral tablet extended release300 mg, 450 mg

T1

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

T1

24

Drug Status Noteslithium carbonate oral tablet 300 mg T1

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

T1

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

T1

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


perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg T1

prochlorperazine maleate oral tablet 10 mg, 5 mg T1

prochlorperazine rectal suppository 25 mg T1 QL (60 EA per 30 days)

quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 50 mg


quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg


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

T1

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

T1

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg T1

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

T1

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

T1

*Antiseptics & Disinfectants*povidone-iodine external pad 10 % T1

povidone-iodine external solution 10 % T1

*Antivirals*abacavir sulfate oral solution 20 mg/ml T1 QL (900 ML per 30 days)

abacavir sulfate oral tablet 300 mg T1 QL (60 EA per 30 days)

abacavir sulfate-lamivudine oral tablet 600-300 mg


abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg


acyclovir oral capsule 200 mg T1

acyclovir oral suspension 200 mg/5ml T1 AL (Max 12 Years)

acyclovir oral tablet 400 mg, 800 mg T1

APTIVUS ORAL CAPSULE 250 MG T1 QL (120 EA per 30 days)

APTIVUS ORAL SOLUTION 100 MG/ML T1 QL (300 ML per 30 days)

atazanavir sulfate oral capsule 150 mg, 200 mg T1 QL (60 EA per 30 days)

atazanavir sulfate oral capsule 300 mg T1 QL (30 EA per 30 days)

BIKTARVY ORAL TABLET 50-200-25 MG T1 QL (30 EA per 30 days)

25

Drug Status NotesCOMPLERA ORAL TABLET 200-25-300 MG T1 QL (30 EA per 30 days)

CRIXIVAN ORAL CAPSULE 200 MG T1 QL (360 EA per 30 days)

CRIXIVAN ORAL CAPSULE 400 MG T1 QL (180 EA per 30 days)

DESCOVY ORAL TABLET 200-25 MG T1 QL (30 EA per 30 lifetimes)

didanosine oral capsule delayed release 125 mg, 200 mg


didanosine oral capsule delayed release 250 mg, 400 mg


EDURANT ORAL TABLET 25 MG T1 QL (30 EA per 30 days)

efavirenz oral capsule 200 mg T1 QL (90 EA per 30 days)

efavirenz oral capsule 50 mg T1 QL (360 EA per 30 days)

efavirenz oral tablet 600 mg T1 QL (30 EA per 30 days)

efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg


efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600-300-300 mg


emtricitabine oral capsule 200 mg T1 QL (30 EA per 30 days)

emtricitabine-tenofovir df oral tablet 200-300 mg T1 QL (30 EA per 30 days)

EMTRIVA ORAL SOLUTION 10 MG/ML T1 QL (600 ML per 30 days)

EPIVIR HBV ORAL SOLUTION 5 MG/ML T1 QL (1800 ML per 30 days)

famciclovir oral tablet 125 mg, 250 mg, 500 mg T1 QL (90 EA per 30 days)

fosamprenavir calcium oral tablet 700 mg T1 QL (120 EA per 30 days)

GENVOYA ORAL TABLET 150-150-200-10 MG T1 QL (30 EA per 30 days)

INTELENCE ORAL TABLET 100 MG T1 QL (120 EA per 30 days)

INTELENCE ORAL TABLET 200 MG T1 QL (60 EA per 30 days)

INTELENCE ORAL TABLET 25 MG T1

INVIRASE ORAL CAPSULE 200 MG T1 QL (300 EA per 30 days)

INVIRASE ORAL TABLET 500 MG T1 QL (120 EA per 30 days)

ISENTRESS ORAL TABLET 400 MG T1 QL (60 EA per 30 days)

ISENTRESS ORAL TABLET CHEWABLE100 MG, 25 MG T1

KALETRA ORAL TABLET 100-25 MG T1 QL (360 EA per 30 days)

KALETRA ORAL TABLET 200-50 MG T1 QL (180 EA per 30 days)

lamivudine oral solution 10 mg/ml T1 QL (900 ML per 30 days)

lamivudine oral tablet 100 mg T1

lamivudine oral tablet 150 mg T1 QL (60 EA per 30 days)

lamivudine oral tablet 300 mg T1 QL (30 EA per 30 days)

lamivudine-zidovudine oral tablet 150-300 mg T1 QL (60 EA per 30 days)

26

Drug Status NotesLEXIVA ORAL SUSPENSION 50 MG/ML T1 QL (360 ML per 60 days)

lopinavir-ritonavir oral solution 400-100 mg/5ml T1 QL (450 ML per 30 days)

MAVYRET ORAL TABLET 100-40 MG T1 PA

nevirapine er oral tablet extended release 24 hour400 mg


nevirapine oral suspension 50 mg/5ml T1 QL (1200 ML per 30 days)

nevirapine oral tablet 200 mg T1 QL (60 EA per 30 days)

NORVIR ORAL CAPSULE 100 MG T1 QL (360 EA per 30 days)

NORVIR ORAL SOLUTION 80 MG/ML T1 QL (450 ML per 30 days)

oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg


oseltamivir phosphate oral suspension reconstituted 6 mg/ml

T1QL (120 ML per 10 days); AL (Max 12 Years)

PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML

T1 PA

PEG-INTRON REDIPEN SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML

T1 PA

PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML

T1 PA

PEG-INTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML

T1 PA

PREZISTA ORAL TABLET 150 MG T1 QL (240 EA per 30 days)




RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER


RESCRIPTOR ORAL TABLET 100 MG T1 QL (360 EA per 30 days)

RESCRIPTOR ORAL TABLET 200 MG T1

RIBASPHERE ORAL CAPSULE 200 MG T1 PA

ribavirin oral capsule 200 mg T1 PA

rimantadine hcl oral tablet 100 mg T1

ritonavir oral tablet 100 mg T1 QL (360 EA per 30 days)

SELZENTRY ORAL TABLET 150 MG T1 QL (120 EA per 30 days)

SELZENTRY ORAL TABLET 300 MG T1

27

Drug Status Notessofosbuvir-velpatasvir tablet 400-100 mg oral400-100 mg


stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg


stavudine oral solution reconstituted 1 mg/ml T1 QL (1200 EA per 30 days)

STRIBILD ORAL TABLET 150-150-200-300 MG T1 QL (30 EA per 30 days)

tenofovir disoproxil fumarate oral tablet 300 mg T1 QL (30 EA per 30 days)

TIVICAY ORAL TABLET 50 MG T1 QL (30 EA per 30 days)

TRIUMEQ ORAL TABLET 600-50-300 MG T1 QL (30 EA per 30 days)

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG T1 QL (30 EA per 30 days)

valacyclovir hcl oral tablet 1 gm, 500 mg T1

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM T1 QL (603 ML per 30 days)

VIRACEPT ORAL TABLET 250 MG T1 QL (300 EA per 30 days)

VIRACEPT ORAL TABLET 625 MG T1 QL (120 EA per 30 days)

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG T1 QL (30 EA per 30 days)

zidovudine oral capsule 100 mg T1 QL (180 EA per 30 days)

zidovudine oral syrup 50 mg/5ml T1 QL (1800 ML per 30 days)

zidovudine oral tablet 300 mg T1 QL (60 EA per 30 days)

*Beta Blockers*acebutolol hcl oral capsule 200 mg, 400 mg T1

atenolol oral tablet 100 mg, 25 mg, 50 mg T1

bisoprolol fumarate oral tablet 10 mg, 5 mg T1

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG T1 QL (30 EA per 30 days)

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

T1

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg T1

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


metoprolol succinate er oral tablet extended release 24 hour 200 mg


metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

T1

nadolol oral tablet 20 mg, 40 mg, 80 mg T1

pindolol oral tablet 10 mg, 5 mg T1

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

T1

28

Drug Status Notespropranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

T1

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

T1

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg T1

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

T1

timolol maleate oral tablet 10 mg, 20 mg, 5 mg T1

*Calcium Channel Blockers*amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg


CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG


diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg


diltiazem hcl er beads oral capsule extended release 24 hour 420 mg


diltiazem hcl er coated beads oral capsule extended release 24 hour 300 mg


diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg


diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg


diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

T1

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg


felodipine er oral tablet extended release 24 hour10 mg, 2.5 mg, 5 mg


isradipine oral capsule 2.5 mg, 5 mg T1

nicardipine hcl oral capsule 20 mg, 30 mg T1

nifedipine er oral tablet extended release 24 hour30 mg, 60 mg


nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg


nifedipine oral capsule 10 mg, 20 mg T1

nimodipine oral capsule 30 mg T1 PA

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


verapamil hcl er oral capsule extended release 24 hour 200 mg, 300 mg


29

Drug Status Notesverapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg


verapamil hcl oral tablet 120 mg, 40 mg, 80 mg T1

*Cardiotonics*digoxin oral tablet 125 mcg, 250 mcg T1

*Cardiovascular Agents - Misc.*sildenafil citrate oral tablet 20 mg T1 PA

*Cephalosporins*cefaclor oral capsule 250 mg, 500 mg T1

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml


cefadroxil oral capsule 500 mg T1 QL (40 EA per 10 days)

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

T1

cefadroxil oral tablet 1 gm T1 QL (20 EA per 10 days)

cefdinir oral capsule 300 mg T1

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

T1

cefpodoxime proxetil oral tablet 100 mg, 200 mg T1

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

cefprozil oral tablet 250 mg, 500 mg T1

CEFTIN ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML


ceftriaxone sodium injection solution reconstituted 1 gm, 500 mg


ceftriaxone sodium injection solution reconstituted 250 mg


ceftriaxone sodium intravenous solution reconstituted 1 gm

T1

cefuroxime axetil oral suspension reconstituted125 mg/5ml


cefuroxime axetil oral tablet 250 mg, 500 mg T1

cephalexin oral capsule 250 mg, 500 mg T1

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

*Chemicals*acetone solution T1

30

Drug Status NotesACTIPHYTE OF LEMONGRASS LIQUID T1

ammonium lactate solution 70 % T1

benzyl benzoate liquid T1

camphor spirit spirit T1

chlorhexidine gluconate solution T1

chloroform solution T1

cottonseed oil oil T1

CRYOSERV SOLUTION T1

dimethyl sulfoxide solution , 100 % T1

ether solution T1

ethyl alcohol (rubbing) solution 70 % T1

ethyl alcohol external solution 95 % T1

ethyl alcohol solution 95 % T1

eugenol solution T1

glycerin liquid T1

glycerin solution T1

glycerine liquid T1

glycerol formal liquid T1

glycine soya extract solution T1

glycine soya protein solution T1

gnp alcohol denatured solution T1

gnp peppermint spirit spirit T1

gnp sodium silicate solution T1

guaiacol solution T1

hydroxyprogesterone caproate powder T1

isopropyl alcohol (rubbing) solution 70 % T1

isopropyl alcohol solution , 50 %, 70 %, 91 %, 99 %

T1

isopropyl palmitate liquid T1

methanol solution , 99 % T1

methyl alcohol solution T1

peppermint spirit spirit T1

pine tar liquid T1

polysorbate 20 solution T1

polysorbate 40 solution T1

polysorbate 60 liquid T1

polysorbate 80 oral liquid T1

PRETZ SOLUTION 10 % T1

31

Drug Status Notesra ethyl alcohol solution 70 % T1

sm camphor spirit spirit T1

sodium bicarbonate powder T1

sodium silicate solution 40 % T1

turpentine liquid T1

undecylenic acid liquid T1

*Contraceptives*ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG T1 QL (28 EA per 28 days)

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

T1 GR-F; QL (28 EA per 21 days)

drospirenone-ethinyl estradiol tablet 3-0.02 mg oral 3-0.02 mg



T1



ELLA ORAL TABLET 30 MG T1 GR-F; QL (1 EA per 30 days)

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG T1 GR-F; QL (28 EA per 21 days)

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg


levonorgestrel oral tablet 0.75 mg T1 GR-F; QL (2 EA per 30 days)

levonorgestrel oral tablet 1.5 mg T1 GR-F; QL (1 EA per 30 days)

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg


levonorgestrel-ethinyl estrad oral tablet 90-20 mcg


LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG T1 GR-F; QL (28 EA per 21 days)

medroxyprogesterone acetate intramuscular suspension 150 mg/ml

T1 GR-F; QL (1 ML per 90 days)

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG T1 GR-F; QL (21 EA per 21 days)

MICROGESTIN FE 1.5/30 ORAL TABLET1.5-30 MG-MCG T1 GR-F; QL (28 EA per 21 days)

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG T1 GR-F; QL (28 EA per 21 days)

NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG T1 GR-F; QL (28 EA per 21 days)

NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG T1 GR-F; QL (28 EA per 21 days)

32

Drug Status NotesNECON 10/11 (28) ORAL TABLET 35 MCG T1 GR-F; QL (28 EA per 21 days)

NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG T1 GR-F; QL (28 EA per 21 days)

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1-20 mg-mcg(24)


norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg


norethindrone oral tablet 0.35 mg T1 GR-F; QL (28 EA per 21 days)

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg


OCELLA ORAL TABLET 3-0.03 MG T1 PA; QL (28 EA per 21 days)

OGESTREL ORAL TABLET 0.5-50 MG-MCG T1 QL (28 EA per 21 days)

SYEDA TABLET 3-0.03 MG ORAL 3-0.03 MG T1 PA; QL (28 EA per 21 days)

TRINESSA (28) ORAL TABLET0.18/0.215/0.25 MG-35 MCG T1 GR-F; QL (28 EA per 21 days)

TRINESSA LO ORAL TABLET0.18/0.215/0.25 MG-25 MCG T1 GR-F; QL (28 EA per 21 days)

TRIVORA (28) ORAL TABLET 50-30/75-40/ 125-30 MCG T1 GR-F; QL (28 EA per 21 days)

TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG/24HR T1 PA; QL (3 EA per 28 days)

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG T1 GR-F; QL (28 EA per 21 days)

ZARAH TABLET 3-0.03 MG ORAL 3-0.03 MG T1 PA; QL (28 EA per 21 days)

ZENCHENT ORAL TABLET 0.4-35 MG-MCG T1 GR-F; QL (28 EA per 21 days)

ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG T1 GR-F; QL (28 EA per 21 days)

ZUMANDIMINE ORAL TABLET 3-0.03 MG T1 PA; QL (28 EA per 21 days)

*Corticosteroids*cortisone acetate oral tablet 25 mg T1

DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML T1

dexamethasone oral elixir 0.5 mg/5ml T1

dexamethasone oral solution 0.5 mg/5ml T1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

T1

dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg (35), 1.5 mg (51)

T1

33

Drug Status Notesfludrocortisone acetate oral tablet 0.1 mg T1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg T1

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

T1

methylprednisolone oral tablet therapy pack 4 mg T1

prednisolone oral solution 15 mg/5ml T1

prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 base) mg/5ml

T1

prednisone oral solution 5 mg/5ml T1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

T1

prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48)

T1

*Cough/Cold/Allergy*ACETA-GESIC ORAL TABLET 12.5-325 MG T1

acetylcysteine inhalation solution 10 %, 20 % T1

ADVIL ALLERGY & CONGESTION ORAL TABLET 4-10-200 MG T1

ADVIL ALLERGY SINUS ORAL TABLET 2-30-200 MG T1

ADVIL COLD & SINUS LIQUI-GELS ORAL CAPSULE 30-200 MG T1

ALA-HIST PE ORAL TABLET 2-10 MG T1

ALKA-SELTZER PLS ALLERGY & CGH ORAL CAPSULE 5-6.25-10-325 MG T1

ALKA-SELTZER PLUS COLD & COUGH ORAL CAPSULE 5-2-10-325 MG T1

ALKA-SELTZER PLUS COLD & COUGH ORAL TABLET EFFERVESCENT 7.8-2-10-325 MG

T1

ALKA-SELTZER PLUS COLD & FLU ORAL TABLET EFFERVESCENT 5-2-10-250 MG

T1

ALKA-SELTZER PLUS DAY/NIGHT ORAL T1

ALKA-SELTZER PLUS NIGHT COLD ORAL TABLET EFFERVESCENT 7.8-6.25-10-500 MG

T1

ALKA-SELTZER PLUS SINUS ORAL TABLET EFFERVESCENT 7.8-325 MG T1

all day pain relf sinus/cold d oral tablet extended release 12 hour 120-220 mg

T1

34

Drug Status Notesallergy multi-symptom day/nght oral T1

aller-time oral tablet 2.5-60 mg T1

ambi 12.5cpd/100gfn/30pse oral liquid 30-12.5-100 mg/5ml

T1

ambi 12.5cpd/1dcpm/30pse oral liquid 30-1-12.5 mg/5ml

T1

ap-hist dm oral liquid 7.5-4-15 mg/5ml T1

benzonatate oral capsule 100 mg, 200 mg T1

biobron sf oral syrup 10-15-350 mg/5ml T1

biodesp dm oral syrup 5-15-100 mg/5ml T1

biogtuss oral liquid 10-15-300 mg/5ml T1

bionatuss dxp oral liquid 10-2-20 mg/5ml T1

bionel oral liquid 30-15-200 mg/5ml T1

bionel pediatric oral liquid 15-5-50 mg/5ml T1

biospec dmx oral liquid 15-25 mg/5ml T1

bpm-dm-phen oral syrup 5-2-10 mg/5ml T1

bronchial asthma relief oral tablet 12.5-200 mg T1

BRONCOTRON PED DROPS ORAL LIQUID 2.5-5-100 MG/ML T1

BRONCOTRON PED ORAL LIQUID 10-15-350 MG/5ML T1

BRONCOTRON-S ORAL LIQUID 20-400 MG/5ML T1

BRONKAID ORAL TABLET 25-400 MG T1

bronkids oral liquid 1.5-0.6-2.75 mg/ml, 10-4-10 mg/5ml

T1

brotapp dm oral liquid 15-1-5 mg/5ml T1

capcof oral syrup 5-2-10 mg/5ml T1 QL (240 ML per 30 days)

capmist dm oral tablet 60-15-400 mg T1

capron dm oral liquid 7.5-7.5 mg/5ml T1

CARBAPHEN CH ORAL SUSPENSION 10-4-24 MG/5ML T1

CARBAPHEN PED CH ORAL SUSPENSION2.5-1.25-8 MG/ML T1

CCP CAFFEINE FREE ORAL TABLET 325-200-10 MG T1

CERTUSS-D ORAL TABLET 60-25-400 MG T1

cetirizine-pseudoephedrine er oral tablet extended release 12 hour 5-120 mg

T1

cheratussin ac oral syrup 100-10 mg/5ml T1

cheratussin dac oral solution 30-10-100 mg/5ml T1

35

Drug Status Noteschest congestion daytime oral tablet 325-200 mg T1

chest congestion relief pe oral tablet 10-400 mg T1

chest congestion/pain & sinus oral tablet 10-650-400 mg

T1

childrens cough oral liquid 5-100 mg/5ml T1

childrens cough/runny nose oral suspension 5-160-1 mg/5ml

T1

childrens plus cold & allergy oral suspension12.5-2.5-160 mg/5ml

T1

childrens plus cold oral suspension 1-2.5-160 mg/5ml

T1

childrens plus flu oral suspension 2.5-1-5-160 mg/5ml

T1

chlo tuss ex oral liquid 12.5-100 mg/5ml T1

CHLO TUSS ORAL LIQUID 30-1-12.5 MG/5ML T1

chlophed oral liquid 5-12.5-100 mg/5ml T1

codituss dm oral syrup 5-8.33-10 mg/5ml T1

cold & cough childrens oral elixir 2.5-1-5 mg/5ml T1

cold & cough day/night child oral 2.5-5 &2.5-6.25 mg/5ml

T1

cold & cough daytime oral liquid 1000-30 mg/30ml

T1

cold & flu nighttime/daytime oral (liquid) T1

cold & flu relief nighttime d oral liquid 60-12.5-30-1000 mg/30ml

T1

cold & flu severe daytime oral tablet 5-10-200-325 mg

T1

cold control pe cold/flu med oral tablet 25-10-650 mg

T1

cold head congestion daytime oral tablet 10-5-325 mg

T1

cold head congestion nighttime oral tablet 5-2-10-325 mg

T1

cold multi-symptom day/night oral 5-2-10-325 mg T1

cold multi-symptom warm night oral liquid 5-6.25-10-325 mg/15ml

T1

cold relief plus oral tablet effervescent 2-7.8-325 mg

T1

cold/flu relief day/night oral T1

cold/flu relief nighttime oral liquid 15-6.25-325 mg/15ml

T1

36

Drug Status Notescold/flu relief oral liquid 10-5-325 mg/15ml T1

complete sinus relief oral tablet 2-10-500 mg T1

CONEX COLD/ALLERGY ORAL SOLUTION 1-30 MG/5ML T1

CONEX COLD/ALLERGY ORAL TABLET2-60 MG T1

CONTAC COLD+FLU MAX ST ORAL TABLET 2-5-500 MG T1

CORICIDIN HBP CONGESTION/COUGH ORAL CAPSULE 10-200 MG T1

CORICIDIN HBP DAY/NIGHT COLD ORAL 10-20 &15-200-2 MG T1

CORICIDIN NIGHTTIME COLD-COUGH ORAL LIQUID 12.5-325 MG/15ML T1

cough & cold oral tablet 4-30 mg T1

cough & sore throat nighttime oral liquid 30-12.5-1000 mg/30ml

T1

cough daytime/nighttime oral liquid therapy pack6.25-15 & 15 mg/15ml

T1

cvs cough & sore throat child oral liquid 160-5 mg/5ml

T1

cvs non-drying sinus pe oral tablet 5-200 mg T1

DALLERGY ORAL LIQUID 1-2.5 MG/ML T1

DALLERGY ORAL TABLET 1-5 MG T1

day time pe cold/flu relief oral capsule 10-5-325 mg

T1

daytime cold & cough childrens oral solution 2.5-5 mg/5ml

T1

DAYTIME COLD MEDICINE ORAL LIQUID 325-15 MG/15ML T1

DELSYM CGH/CLD NIGHTTIME CHILD ORAL LIQUID 12.5-5-325 MG/10ML T1

DELTUSS DMX ORAL LIQUID 30-1-15 MG/5ML T1

DELTUSS DP ORAL LIQUID 1-30 MG/5ML T1

DESGEN DM ORAL SYRUP 5-15-100 MG/5ML T1

DESGEN PEDIATRIC ORAL LIQUID 2.5-5-50 MG/ML T1

despec dm oral syrup 5-10-100 mg/5ml T1

despec-dm oral tablet 40-30-400 mg T1

37

Drug Status Notesdextromethorphan-guaifenesin oral solution 10-100 mg/5ml

T1

DIABETIC TUSSIN COLD & FLU ORAL LIQUID 10-12.5-325 MG/5ML T1

DIABETIC TUSSIN NIGHT COLD/FLU ORAL LIQUID 10-12.5-325 MG/5ML T1

DIMETAPP LONG ACT COUGH/COLD ORAL SYRUP 1-7.5 MG/5ML T1

DOLOGEN ORAL TABLET 2-650 MG T1

dometuss-da/children oral liquid 1-2.5 mg/5ml T1

dometuss-dmx oral liquid 10-30-200 mg/5ml T1

doxylamine-phenylephrine oral tablet 7.5-10 mg T1

dr manzanilla pe oral liquid 2.5-10 mg/5ml T1

DURAVENT PE ORAL TABLET 10-395 MG T1

ed bron gp oral liquid 5-100 mg/5ml T1

ED CHLORPED D ORAL LIQUID 2-5 MG/ML T1

ed-a-hist dm oral liquid 10-4-15 mg/5ml T1

ENDACOF-DM ORAL LIQUID 2.5-1-5 MG/5ML T1

ENDACON ORAL SYRUP 10-20-100 MG/5ML T1

ENTEX LQ ORAL LIQUID 10-100 MG/5ML T1

ENTEX T ORAL TABLET 60-375 MG T1

entre-cough oral liquid 30-15-175 mg/5ml T1

eq allergy/sinus headache oral tablet 12.5-30-500 mg

T1

eq childrens cold oral liquid 1-15-160 mg/5ml T1

eq cold plus oral capsule 2-30-325 mg T1

eq cold relief complete oral tablet 30-2-15-325 mg

T1

eq cold/cough plus oral capsule 30-2-10-325 mg T1

eq daytime cold/flu relief oral capsule 30-325-15 mg

T1

eq daytime cold/flu relief oral liquid 30-325-15 mg/15ml

T1

eq flu & severe cold & cough oral packet 25-10-650 mg

T1

eq flu relief oral tablet 30-500-15 mg T1

eq flu/severe cold/congestion oral packet 60-4-30-1000 mg

T1

38

Drug Status Noteseq night time cold & cough oral liquid 6.25-2.5 mg/5ml

T1

eq nite time cold/flu relief oral capsule 30-6.25-15-325 mg

T1

eq nitetime cold/flu ms relief oral capsule 15-6.25-325 mg

T1

eq non-drying sinus oral capsule 30-200 mg T1

eq sinus congestion & pain oral tablet 5-325-200 mg

T1

eq triacting cold/allergy oral syrup 1-15 mg/5ml T1

eql congestion relief oral tablet 10-200 mg T1

FENESIN DM IR ORAL TABLET 15-400 MG T1

flu & sore throat oral packet 20-10-650 mg T1

flu/severe cold & cough day oral packet 20-10-650 mg

T1

GENCONTUSS ORAL LIQUID 5-2-10 MG/5ML T1

G-P-TUSS DXP ORAL LIQUID 10-2-20 MG/5ML T1

G-TRON PEDIATRIC DROPS ORAL LIQUID 2.5-5-100 MG/ML T1

guaifenesin dm oral tablet 400-20 mg T1

guaifenesin er oral tablet extended release 12 hour 1200 mg, 600 mg

T1

guaifenesin oral solution 100 mg/5ml T1

guaifenesin oral tablet 200 mg, 400 mg T1

guaifenesin powder T1

guaifenesin-dm oral syrup 100-10 mg/5ml T1

G-ZYNCOF ORAL SYRUP 20-400 MG/5ML T1

HERBAL EXPEC ORAL LIQUID 150 MG/15ML T1

HISTEX-DM ORAL SYRUP 10-2.5-20 MG/5ML T1

hist-pse oral liquid 0.938-10 mg/ml T1

hydrocod polst-cpm polst er oral suspension extended release 10-8 mg/5ml


hydrocodone-homatropine oral syrup 5-1.5 mg/5ml


hydrocodone-homatropine oral tablet 5-1.5 mg T1

ibu-profen cold/sinus oral tablet 30-200 mg T1

intense cough reliever oral liquid 20-300 mg/5ml, 30-200 mg/5ml

T1

39

Drug Status Noteslexuss 210 oral liquid 2-10 mg/5ml T1 QL (240 ML per 30 days)

liquituss gg oral liquid 200 mg/5ml T1

LITTLE REMEDIES FOR COLDS ORAL LIQUID 2.5-1.25-80 MG/ML T1

LODRANE D ORAL CAPSULE 4-60 MG T1

LOHIST-D ORAL LIQUID 2-30 MG/5ML T1

loratadine-d 12hr oral tablet extended release 12 hour 5-120 mg

T1

loratadine-d 24hr oral tablet extended release 24 hour 10-240 mg

T1

LORTUSS DM ORAL LIQUID 30-6.25-15 MG/5ML T1

LORTUSS LQ ORAL LIQUID 6.25-30 MG/5ML T1

MAR-COF BP ORAL LIQUID 30-2-7.5 MG/5ML T1 QL (240 ML per 30 days)

maxi-tuss pe oral liquid 2-5 mg/5ml T1

m-end dmx oral liquid 20-0.667-10 mg/5ml T1

M-END PE ORAL LIQUID 3.33-1.33-6.33 MG/5ML T1 QL (240 ML per 30 days)

MUCINEX CHILD MS DAY-NIGHT CLD ORAL T1

MUCINEX COUGH FOR KIDS ORAL PACKET 5-100 MG T1

MUCINEX FAST-MAX CONGEST COUGH ORAL TABLET 5-10-200 MG T1

MUCINEX FOR KIDS ORAL PACKET 100 MG T1

MUCINEX SINUS-MAX DAY/NIGHT ORALT1

mucus d oral tablet extended release 12 hour 120-1200 mg

T1

mucus relief cold flu throat oral liquid 5-10-200-325 mg/10ml

T1

mucus relief cold/sinus max st oral liquid 10-650-400 mg/20ml

T1

mucus relief d oral tablet 40-400 mg T1

mucus relief severe congst/cgh oral liquid 10-20-400 mg/20ml

T1

mucus-dm max oral tablet extended release 12 hour 60-1200 mg

T1

mucus-dm oral tablet extended release 12 hour30-600 mg

T1

40

Drug Status Notesnasal mist inhalation aerosol solution 0.9 % T1

NASOPEN ORAL LIQUID 9.375-30 MG/5ML T1

NASOPEN PE ORAL LIQUID 50-10 MG/15ML T1

NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML T1

NEOTUSS-D ORAL LIQUID 7.5-30-200 MG/5ML T1

nighttime cough oral liquid 6.25-15 mg/15ml T1

nighttime pain plus sleep oral liquid 25-500 mg/15ml

T1

nite-time cold/flu relief oral liquid 5-6.25-15-500 mg/15ml

T1

NIVANEX DMX ORAL TABLET 10-15-380 MG T1

nohist-lq oral liquid 4-10 mg/5ml T1

non-pseudo cold relief oral tablet 5-15-200-325 mg

T1

NOREL AD ORAL TABLET 4-10-325 MG T1

nortuss-ex oral liquid 20-200 mg/5ml T1

PANATUSS PED DROPS ORAL LIQUID 15-0.5-6.25 MG/ML T1

PANATUSS PED ORAL LIQUID 60-2-25 MG/5ML T1

PECGEN DMX ORAL LIQUID 15-125 MG/5ML T1

PEDIACARE CHILD ALLERGY/COLD ORAL LIQUID 12.5-5 MG/5ML T1

pediatric cough/cold oral liquid 15-1-5 mg/5ml T1

phenylephrine-chlorphen-dm oral liquid 1.75-0.75-2.75 mg/ml

T1

phenylephrine-dm-gg oral liquid 10-18-200 mg/15ml

T1

phenylhistine dh oral liquid 30-2-10 mg/5ml T1 QL (240 ML per 30 days)

poly-hist dm oral liquid 5-25-10 mg/5ml T1

poly-hist pd oral liquid 6.25-6.25 mg/ml T1

poly-tussin ac oral liquid 10-4-10 mg/5ml T1 QL (240 ML per 30 days)

POLY-VENT DM ORAL TABLET 60-20-380 MG T1

POLY-VENT IR ORAL TABLET 60-380 MG T1

pres gen pediatric oral liquid 2.5-5-75 mg/5ml T1

pro-chlo oral liquid 5-12.5-12.5 mg/5ml T1

41

Drug Status NotesPRO-CLEAR AC ORAL SYRUP 9-8.33 MG/5ML T1 QL (240 ML per 30 days)

promethazine vc plain oral syrup 6.25-5 mg/5ml T1

promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml


promethazine-codeine oral syrup 6.25-10 mg/5ml T1 QL (240 ML per 30 days)

promethazine-dm oral syrup 6.25-15 mg/5ml T1

PRO-RED AC ORAL SYRUP 5-1-9 MG/5ML T1 QL (240 ML per 30 days)

pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml

T1

pseudoephedrine-guaifenesin er oral tablet extended release 12 hour 60-600 mg

T1

pyrilamine-phenylephrine oral suspension 5-16 mg/5ml

T1

pyrilamine-phenylephrine oral tablet 25-10 mg T1

qc cold relief oral tablet 12.5-500 mg T1

qc cold relief plus oral tablet effervescent 2-5-250 mg

T1

qc flu relief therapy night oral liquid 12.5-5-325 mg/15ml

T1

qc medifin cp oral tablet 650-400 mg T1

Q-TAPP ORAL ELIXIR 1-15 MG/5ML T1

ra allergy multi-symptom night oral tablet 25-5-325 mg

T1

ra allergy multi-symptom oral tablet 2-5-325 mg T1

ra allergy plus sinus oral tablet 25-10 mg T1

ra childrens cold & allergy oral elixir 1-2.5 mg/5ml

T1

ra cold & flu oral tablet 2-325 mg T1

ra cold/cough sinus relief pe oral tablet 5-10-100-325 mg

T1

ra flu maximum strength oral tablet 15-500-2 mg T1

ra severe cold/night cold&flu oral T1

ra severe cold/sinus relief pe oral tablet 12.5-5-325 mg

T1

ra sinus congst/pain day/night oral 2-5-325 & 5-325 mg

T1

ra suphedrine day/night combo oral T1

ra suphedrine pe oral tablet 4-10 mg, 5-325 mg T1

ra tussin nighttime cough dm oral liquid 12.5-30 mg/10ml

T1

42

Drug Status NotesREFENESEN CHEST CONG/PAIN RLF ORAL TABLET 650-400 MG T1

refenesen plus oral tablet 60-400 mg T1

relcof c oral solution 100-6.3 mg/5ml T1

RESCON DM ORAL SYRUP 30-2-10 MG/5ML T1

RESPAIRE-30 ORAL CAPSULE 30-150 MG T1

ROBITUSSIN CHILD COUGH/COLD CF ORAL LIQUID 2.5-5-50 MG/5ML T1

ROBITUSSIN CHILD COUGH/COLD LA ORAL LIQUID 1-7.5 MG/5ML T1

ROBITUSSIN DAY/NIGHT VALUE PAK ORAL T1

ROBITUSSIN PEAK COLD MULTI-SYM ORAL LIQUID 6.25-2.5-160 MG/5ML T1

ROBITUSSIN PK COLD DAY/NGHT DM ORAL T1

ROBITUSSIN PK COLD DAY/NGHT MS ORAL T1

ru-hist d oral tablet 4-10 mg T1

rymed oral tablet 2-10 mg T1

SAFE TUSSIN PM ORAL LIQUID 3.125-7.5 MG/5ML T1

sb daytime sinus oral capsule 5-325 mg T1

sb nighttime sinus multi-sympt oral capsule 6.25-5-325 mg

T1

sb severe cold congestion oral tablet 30-15-200-325 mg

T1

SCOT-TUSSIN DM ORAL LIQUID 2-15 MG/5ML T1

SCOT-TUSSIN SENIOR ORAL LIQUID 15-200 MG/5ML T1

SINADRIN PE COMPLETE SINUS REL ORAL TABLET 2-10-650 MG T1

sinus daytime/nighttime oral T1

sinus maximum strength oral tablet 30-500 mg T1

sm cough/runny nose childrens oral liquid 1-5 mg/5ml

T1

sm ibuprofren cold childrens oral suspension 15-100 mg/5ml

T1

sm pain reliever sinus pe oral tablet 5-500 mg T1

sm tussin cf oral liquid 30-10-100 mg/5ml T1

43

Drug Status Notessodium chloride inhalation nebulization solution0.9 %

T1

sonahist dm oral liquid† 2-1-3 mg/ml T1

stahist ad oral liquid 25-60 mg/5ml T1

stahist ad oral tablet 25-60 mg T1

SUDAFED PE DAY & NIGHT ORAL 25-10 & 10 MG T1

SUDOGEST SINUS/ALLERGY ORAL TABLET 4-60 MG T1

super strength sinadrin oral tablet 4-10-650 mg T1

supress a pediatric oral liquid 5-1-10 mg/ml T1

supress dm pediatric oral liquid 5-50 mg/ml T1

SUPRESS-PE PEDIATRIC ORAL LIQUID2.5-50 MG/ML T1

terpin hydrate powder T1

tg 10peh/380gfn oral tablet 10-380 mg T1

tgq 15dm/5peh/2cpm oral syrup 15-5-2 mg/5ml T1

tgq 30pse/150gfn/15dm oral syrup 30-150-15 mg/5ml

T1

tgq 30pse/3brm/15dm oral syrup 30-3-15 mg/5ml T1

theracaps cough/cold reliever oral tablet 30-2-15-500 mg

T1

THERAFLU MAX-D COLD & FLU ORAL PACKET 60-30-400-1000 MG T1

THERAFLU SEVERE COLD & COUGH ORAL PACKET T1

THERAFLU SEVERE COLD DAYTIME ORAL TABLET 15-5-325 MG T1

TREXBROM ORAL LIQUID 10-4-25 MG/5ML T1

triactin chest congestion oral solution 50 mg/5ml T1

TRIAMINIC CHEST/NASAL CONGEST ORAL SYRUP 2.5-50 MG/5ML T1

TRIAMINIC COLD/ALLERGY CHILD ORAL SYRUP 1-2.5 MG/5ML T1

TRIAMINIC COLD/COUGH DAY TIME ORAL SOLUTION 2.5-5 MG/5ML T1

TRIAMINIC COUGH & SORE THROAT ORAL SYRUP 160-5 MG/5ML T1

TRIAMINIC COUGH/SORE THROAT ORAL TABLET CHEWABLE 160-5 MG T1

44

Drug Status NotesTRIAMINIC NIGHT TIME COLD/CGH ORAL SYRUP 6.25-2.5 MG/5ML T1

trigofen dm oral liquid 2-1-3 mg/ml T1

TRISPEC DMX ORAL LIQUID 10-187 MG/5ML T1

TRISPEC PSE PEDIATRIC ORAL LIQUID30-10-187 MG/5ML T1

trymine cg oral liquid 225-7.5 mg/5ml T1

TUSICOF ORAL LIQUID 10-20-400 MG/5ML T1

TUSICOF ORAL TABLET 10-20-400 MG T1

TUSNEL C ORAL SYRUP 30-10-100 MG/5ML T1

TUSNEL ORAL CAPSULE 2-15-200 MG T1

TUSNEL ORAL LIQUID 30-15-200 MG/5ML T1

TUSNEL PEDIATRIC ORAL LIQUID 15-5-50 MG/5ML T1

tussafex ex oral liquid 10-30-200 mg/5ml T1

tussafex-a oral liquid 6-2-15 mg/5ml T1

tussin cf cough & cold oral liquid 5-10-100 mg/5ml

T1

tussin cf max multi-symptom oral liquid 5-10-200 mg/5ml

T1

tussin chest congestion oral syrup 100 mg/5ml T1

tussin cold/congestion oral capsule 30-10-200 mg T1

tussin cough oral syrup 15 mg/5ml T1

tussin dm max oral liquid 10-200 mg/5ml T1

tussi-pres b oral liquid 10-4-20 mg/5ml T1

TUSSLIN ORAL LIQUID 10-28-388 MG/5ML T1

TUSSLIN PEDIATRIC ORAL LIQUID 2.5-7.5-88 MG/ML T1

TYLENOL CHILDRENS COLD/STUFFY ORAL SUSPENSION 2.5-160 MG/5ML T1

TYLENOL CHILDRENS PLUS CLD/CGH ORAL SUSPENSION 5-2.5-160 MG/5ML T1

VANACOF APE ORAL LIQUID 10-50-25 MG/15ML T1

VANACOF G ORAL LIQUID 25-200 MG/5ML T1

VANACOF GPE ORAL LIQUID 10-25-200 MG/15ML T1

45

Drug Status NotesVANACOF-8 ORAL LIQUID 25-50 MG/15ML T1

VANATAB DX ORAL TABLET 30-12.5-200 MG T1

vaporizing steam inhalation liquid 6.2 % T1

VAZOBID-PD ORAL SUSPENSION 6-10 MG/5ML T1

VICKS DAYQUIL MUCUS CONTROL DM ORAL LIQUID 10-200 MG/15ML T1

VICKS DAYQUIL SEVERE COLD/FLU ORAL LIQUID 5-10-200-325 MG/15ML T1

VICKS NATURE FUSION COLD & FLU ORAL LIQUID 30-7.5-650 MG/30ML T1

VICKS NATURE FUSION CONGEST ORAL LIQUID 20-200 MG/30ML T1

VICKS NYQUIL CHILDRENS CLD/CGH ORAL LIQUID 2-15 MG/15ML T1

VICKS NYQUIL COLD & FLU NIGHT ORAL LIQUID 30-650-4 MG/30ML T1

virdec dm oral liquid 3.5-1-3 mg/ml T1

virdec oral liquid 1-3.5 mg/ml T1

WAL-FLU COLD & SORE THROAT ORAL PACKET 20-10-325 MG T1

WAL-FLU SEVERE COLD DAYTIME ORAL PACKET 10-650 MG T1

ZODRYL DEC 25 ORAL SUSPENSION 5-1-20 MG/ML T1

ZODRYL DEC 30 ORAL SUSPENSION4.286-1-20 MG/ML T1

ZODRYL DEC 35 ORAL SUSPENSION 3.75-1-20 MG/ML T1

ZODRYL DEC 40 ORAL SUSPENSION3.333-1-20 MG/ML T1

Z-TUSS AC ORAL LIQUID 2-9 MG/5ML T1 QL (240 ML per 30 days)

ZYNCOF ORAL SYRUP 20-400 MG/5ML T1

*Dermatologicals*acne medication 10 external lotion 10 % T1

acne medication 5 external lotion 5 % T1

adapalene external gel 0.1 % T1 QL (45 GM per 30 days)

ADULT ACNOMEL EXTERNAL CREAM 2-8 % T1

46

Drug Status Notesalclometasone dipropionate external cream 0.05 %

T1

alclometasone dipropionate external ointment0.05 %

T1

alevazol external ointment 1 % T1

ammonium lactate external cream 12 % T1 QL (385 GM per 30 days)

ammonium lactate external lotion 12 % T1 QL (385 GM per 30 days)

ANECREAM EXTERNAL CREAM 4 % T1

ASPERCREME LIDOCAINE PATCH 4 % EXTERNAL 4 % T1 QL (30 EA per 30 days)

ASPERCREME W/LIDOCAINE EXTERNAL CREAM 4 % T1

bacitracin external ointment 500 unit/gm T1

bacitracin zinc external ointment 500 unit/gm T1

bacitracin-neomycin-polymyxin external ointment400-5-5000

T1

BASIS OVERNIGHT EXTERNAL CREAM T1

benzoyl peroxide cleanser external lotion 6 % T1

benzoyl peroxide external gel 10 %, 2.5 %, 5 % T1

benzoyl peroxide wash external liquid 10 %, 5 % T1

benzoyl peroxide-erythromycin external gel 5-3 % T1 QL (46.6 GM per 30 days)

betamethasone dipropionate aug external cream0.05 %


betamethasone dipropionate external cream 0.05 %


betamethasone dipropionate external lotion 0.05 %

T1

betamethasone dipropionate external ointment0.05 %


betamethasone valerate external cream 0.1 % T1 QL (90 GM per 30 days)

betamethasone valerate external lotion 0.1 % T1 QL (120 ML per 30 days)

betamethasone valerate external ointment 0.1 % T1 QL (90 GM per 30 days)

bp cleansing external lotion 4 % T1

bp cleansing wash external emulsion 10-4 % T1

BRASIVOL EXTERNAL PASTE T1

CALAGESIC EXTERNAL LOTION 1-8 % T1

capsaicin external cream 0.025 %, 0.1 % T1

CAPZASIN EXTERNAL LIQUID 0.15 % T1

CASTIVA WARMING EXTERNAL LOTION0.035 % T1

ciclopirox external solution 8 % T1 QL (6.6 ML per 30 days)

47

Drug Status NotesCLEAN & CLEAR ACNE CONTROL EXTERNAL KIT 0.5 & 2 & 10 % T1

clindamycin phosphate external solution 1 % T1

clindamycin phosphate external swab 1 % T1 QL (60 EA per 30 days)

clobetasol propionate external cream 0.05 % T1

clobetasol propionate external solution 0.05 % T1 QL (100 ML per 30 days)

clotrimazole external cream 1 % T1

clotrimazole external solution 1 % T1

clotrimazole-betamethasone external cream 1-0.05 %


clotrimazole-betamethasone external lotion 1-0.05 %


CORTISPORIN EXTERNAL OINTMENT 1 % T1

CORTIZONE-10/ALOE EXTERNAL LIQUID 1 % T1 QL (36 ML per 30 days)

cvs cortisone cooling relief external gel 1 % T1 QL (60 GM per 30 days)

cvs hydrocortisone acetate external cream 0.5 % T1 QL (120 GM per 30 days)

cvs targeted acne spot external cream 2.5 % T1

DENOREX DUAL FORCE EXTERNAL SHAMPOO 1 & 3 % T1

desonide external ointment 0.05 % T1 QL (120 GM per 30 days)

diclofenac sodium transdermal gel 1 % T1 QL (200 GM per 30 days)

DIFFERIN EXTERNAL GEL 0.1 % T1 QL (45 GM per 30 days)

diflorasone diacetate external ointment 0.05 % T1

docosanol external cream 10 % T1

DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 MG/2ML T1 PA

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML T1 PA

econazole nitrate external cream 1 % T1

effaclar duo external solution 5.5 % T1

erythromycin external gel 2 % T1

erythromycin external solution 2 % T1

ethyl chloride external aerosol T1

EUCERIN EXTERNAL CREAM T1

EXODERM EXTERNAL BAR 10-3 % T1

first aid antibiotic external ointment 4 % T1

fluocinolone acetonide body external oil 0.01 % T1 QL (120 ML per 30 days)

48

Drug Status Notesfluocinolone acetonide external cream 0.01 %, 0.025 %


fluocinolone acetonide external ointment 0.025 % T1 QL (120 GM per 30 days)

fluocinolone acetonide scalp external oil 0.01 % T1 QL (120 ML per 30 days)

fluocinonide external cream 0.05 % T1 QL (120 GM per 30 days)

fluocinonide external gel 0.05 % T1 QL (120 GM per 30 days)

fluocinonide external ointment 0.05 % T1 QL (120 GM per 30 days)

fluocinonide external solution 0.05 % T1 QL (120 ML per 30 days)

fluocinonide-e external cream 0.05 % T1 QL (120 GM per 30 days)

fluorouracil external cream 5 % T1

fluorouracil external solution 2 %, 5 % T1

fluticasone propionate external cream 0.05 % T1 QL (120 GM per 30 days)

fluticasone propionate external ointment 0.005 % T1

FUNGOID TINCTURE EXTERNAL SOLUTION 2 % T1

gentamicin sulfate external cream 0.1 % T1

gentamicin sulfate external ointment 0.1 % T1

glycerin external liquid T1

GRANDPAS THYLOX SOAP EXTERNAL BAR 3 % T1

granulderm external aerosol, solution 650-72.5-0.1 mg/0.82ml


halobetasol propionate external cream 0.05 % T1

halobetasol propionate external ointment 0.05 % T1 QL (100 GM per 30 days)

HC DERMAPAX EXTERNAL LIQUID 0.5-0.5 % T1

hydrocortisone external cream 0.5 % T1 QL (60 GM per 30 days)

hydrocortisone external cream 2.5 % T1 QL (90 GM per 30 days)

hydrocortisone external lotion 1 % T1 QL (240 GM per 30 days)

hydrocortisone external lotion 2.5 % T1 QL (120 ML per 30 days)

hydrocortisone external ointment 0.5 %, 1 % T1 QL (60 GM per 30 days)

hydrocortisone external ointment 2.5 % T1 QL (90 GM per 30 days)

hydrocortisone max st external cream 1 % T1 QL (120 GM per 30 days)

hydrocortisone valerate external cream 0.2 % T1

hydrocortisone valerate external ointment 0.2 % T1 QL (120 GM per 30 days)

hydrocortisone-aloe external cream 0.5 %, 1 % T1 QL (90 GM per 30 days)

isopropyl alcohol wipes external 70 % T1

ketoconazole external cream 2 % T1

ketoconazole external shampoo 2 % T1

49

Drug Status NotesLAC-HYDRIN FIVE EXTERNAL LOTION 5 % T1

lactic acid e external cream 10-3500 %-unt/30gm T1

lactic acid external lotion 10 % T1

lc-4 lidocaine external cream 4 % T1

lice killing maximum strength external shampoo0.33-4 %

T1

lice solution combination kit 0.33-4-0.5 % T1

lice treatment external liquid 0.33-4 %, 1 % T1

LICEMD EXTERNAL GEL 0.33-4 % T1

LICIDE TREATMENT COMBINATION KITT1

lidocaine external cream 4 % T1 QL (90 GM per 30 days)

lidocaine hcl external gel 2 % T1

lidocaine hcl external solution 4 % T1

lidocaine-prilocaine external cream 2.5-2.5 % T1 QL (30 GM per 30 days)

lindane external lotion 1 % T1

lindane external shampoo 1 % T1

LIQUIMAT EXTERNAL LOTION 5 % T1

LMX 4 EXTERNAL CREAM 4 % T1

LOTRIMIN AF EXTERNAL AEROSOL 2 % T1

malathion external lotion 0.5 % T1

medi-first hydrocortisone external cream 1 % T1 QL (60 EA per 30 days)

metronidazole external cream 0.75 % T1

metronidazole external gel 0.75 % T1

metronidazole external lotion 0.75 % T1

miconazole nitrate external aerosol powder 2 % T1

miconazole nitrate external cream 2 % T1

miconazorb af external powder 2 % T1

mometasone furoate external cream 0.1 % T1 QL (60 GM per 30 days)

mometasone furoate external ointment 0.1 % T1 QL (60 GM per 30 days)

mometasone furoate external solution 0.1 % T1 QL (60 ML per 30 days)

mupirocin external ointment 2 % T1

NEOSPORIN ESSENTIALS TRIAL PK EXTERNAL KIT 1 & 1 % T1

NEUTROGENA CLEAR PORE EXTERNAL LIQUID 3.5 % T1

NOBLE MYSTIQUE EMU-LAC EXTERNAL CREAM 10 % T1

NUOX EXTERNAL GEL 6-3 % T1

50

Drug Status Notesnystatin external cream 100000 unit/gm T1

nystatin external ointment 100000 unit/gm T1

nystatin external powder 100000 unit/gm T1

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

T1

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

T1

OC8 EXTERNAL GEL 7 % T1

PANOXYL-8 CREAMY WASH EXTERNAL LIQUID 8 % T1

permethrin external cream 5 % T1 QL (120 GM per 30 days)

permethrin external lotion 1 % T1

podofilox external solution 0.5 % T1

PRAMOSONE EXTERNAL CREAM 1-1 % T1 QL (30 GM per 30 days)

prednicarbate external ointment 0.1 % T1 QL (60 GM per 30 days)

PRO:12 MOUSSE AL12 EXTERNAL FOAM12 % T1

PRONTO AEROSOL 0.4 % T1

pyrethins-piperonyl butoxide external liquid 0.2-2 %

T1

ra acne maximum external pad 2 % T1

ra acne treatment external cream 10 % T1

ra first aid anti-itch spray external solution 1 % T1 QL (90 GM per 30 days)

ra lice bedding aerosol 0.5 % T1

ra lice egg remover external gel T1

ra lice solution combination kit 0.5-0.33-4 % T1

ra wart remover external pad 40 % T1

resorcinol-sulfur external lotion 2-5 % T1

RID ESSENTIAL LICE ELIMINATION EXTERNAL KIT 0.33-4 % T1

SANTYL EXTERNAL OINTMENT 250 UNIT/GM T1 QL (60 GM per 30 days)

SCHOOLTIME SHAMPOO EXTERNAL SHAMPOO T1

sebex external shampoo 2-2 % T1

selenium sulfide external lotion 2.5 % T1

silver sulfadiazine external cream 1 % T1

STEP 2 EXTERNAL SOLUTION 8 % T1

sulfacetamide sodium (acne) external lotion 10 % T1

51

Drug Status Notessulfacetamide sodium-sulfur external emulsion10-5 %

T1

sulfacetamide sodium-sulfur external liquid 9-4.5 %

T1

sulfurated lime external solution T1

tbc external aerosol solution 650-72.5-0.1 mg/0.82ml


terbinafine hcl external cream 1 % T1

triamcinolone acetonide external cream 0.025 %, 0.1 %


triamcinolone acetonide external cream 0.5 % T1 QL (60 GM per 30 days)

triamcinolone acetonide external lotion 0.025 %, 0.1 %


triamcinolone acetonide external ointment 0.025 %, 0.1 %


triamcinolone acetonide external ointment 0.5 % T1 QL (60 GM per 30 days)

triple paste af external ointment 2 % T1

trixaicin hp external cream 0.075 % T1

urea external cream 40 % T1

VASOLEX EXTERNAL OINTMENT T1 QL (60 GM per 30 days)

ZEASORB-AF EXTERNAL LOTION 2 % T1

*Diagnostic Products*GLUCOCARD EXPRESSION TEST IN VITRO STRIP T1

GLUCOCARD VITAL TEST IN VITRO STRIP T1

KETOSTIX IN VITRO STRIP T1

ONETOUCH VERIO STRIP IN VITRO T1QL 100/90 for members not on insulin and QL 300/90 for members on insulin

PRECISION XTRA KETONE IN VITRO STRIP T1

*Dietary Products/Dietary Management Products*complete protein/vitamin shake oral powder T1

*Digestive Aids*CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

T1

52

Drug Status NotesPANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT

T1

pancrelipase (lip-prot-amyl) oral capsule delayed release particles 5000 unit

T1

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 8000 UNIT

T1

ULTRESA ORAL CAPSULE DELAYED RELEASE PARTICLES 13800 UNIT, 20700 UNIT, 23000 UNIT

T1

VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT T1

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000-51000 UNIT, 20000-68000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000-136000 UNIT, 5000 UNIT

T1

*Diuretics*acetazolamide er oral capsule extended release 12 hour 500 mg


acetazolamide oral tablet 125 mg, 250 mg T1

amiloride hcl oral tablet 5 mg T1

amiloride-hydrochlorothiazide oral tablet 5-50 mg

T1

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg T1

CAROSPIR ORAL SUSPENSION 25 MG/5ML T1 AL (Max 12 Years)

chlorothiazide oral tablet 250 mg, 500 mg T1

chlorthalidone oral tablet 100 mg, 25 mg, 50 mg T1

DIURIL ORAL SUSPENSION 250 MG/5ML T1QL (600 ML per 30 days); AL (Max 12 Years)

furosemide injection solution 10 mg/ml T1

furosemide oral solution 10 mg/ml T1

furosemide oral tablet 20 mg, 40 mg, 80 mg T1

hydrochlorothiazide oral capsule 12.5 mg T1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

T1

indapamide oral tablet 1.25 mg, 2.5 mg T1

methazolamide oral tablet 25 mg T1

methyclothiazide oral tablet 5 mg T1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg T1

53

Drug Status Notesspironolactone oral tablet 100 mg, 25 mg, 50 mg T1

spironolactone-hctz oral tablet 25-25 mg T1

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg T1

triamterene-hctz oral capsule 37.5-25 mg T1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg T1

*Endocrine And Metabolic Agents - Misc.*alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg

T1

calcitonin (salmon) nasal solution 200 unit/act T1

calcitriol oral capsule 0.25 mcg, 0.5 mcg T1

desmopressin ace spray refrig nasal solution 0.01 %

T1

desmopressin acetate oral tablet 0.1 mg, 0.2 mg T1

desmopressin acetate spray nasal solution 0.01 % T1

GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG

T1 PA

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 12 MG, 5 MG

T1 PA

ibandronate sodium oral tablet 150 mg T1 QL (1 EA per 28 days)

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG

T1 PA

NORDITROPIN FLEXPRO SOLUTION PEN-INJECTOR 10 MG/1.5ML SUBCUTANEOUS 10 MG/1.5ML

T1 PA


T1 PA

NORDITROPIN FLEXPRO SOLUTION PEN-INJECTOR 30 MG/3ML SUBCUTANEOUS 30 MG/3ML

T1 PA


T1 PA

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

T1 PA

54

Drug Status Notesraloxifene hcl oral tablet 60 mg T1

risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg

T1

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG T1 PA

*Estrogens*estradiol oral tablet 0.5 mg, 1 mg, 2 mg T1 GR-F

estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr


estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr


estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg


estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg T1 GR-F; QL (21 EA per 28 days)

JINTELI ORAL TABLET 1-5 MG-MCG T1 GR-F; QL (21 EA per 28 days)

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG T1 GR-F

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg


PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG T1 GR-F; QL (30 EA per 30 days)

PREMPHASE ORAL TABLET 0.625-5 MG T1 GR-F; QL (30 EA per 30 days)

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG T1 GR-F; QL (30 EA per 30 days)

*Fluoroquinolones*CIPRO ORAL SUSPENSION RECONSTITUTED 500 MG/5ML (10%) T1

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

T1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg T1

ofloxacin oral tablet 400 mg T1

*Gastrointestinal Agents - Misc.*APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM T1 QL (120 EA per 30 days)

balsalazide disodium oral capsule 750 mg T1

BICARSIM FORTE ORAL TABLET 125 MG T1

BICARSIM ORAL TABLET 80 MG T1

calcium acetate (phos binder) oral capsule 667 mg

T1

55

Drug Status Notescalcium acetate (phos binder) oral tablet 667 mg T1

cvs gas relief drops ex st oral liquid 40 mg/0.6ml T1

GAS-X EXTRA STRENGTH ORAL STRIP62.5 MG T1

lactulose encephalopathy oral solution 10 gm/15ml

T1

mesalamine oral capsule delayed release 400 mg T1 QL (180 EA per 30 days)

mesalamine oral tablet delayed release 1.2 gm T1 QL (60 EA per 30 days)

mesalamine rectal enema 4 gm T1 QL (240 ML per 30 days)

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

T1

metoclopramide hcl oral tablet 10 mg, 5 mg T1

RENAGEL ORAL TABLET 400 MG T1 PA

sevelamer hcl oral tablet 800 mg T1 PA

SFROWASA RECTAL ENEMA 4 GM/60ML T1 QL (240 ML per 30 days)

simethicone oral capsule 125 mg, 180 mg T1

simethicone oral suspension 20 mg/0.3ml T1

simethicone oral tablet chewable 125 mg, 80 mg T1

sulfasalazine oral tablet 500 mg T1

sulfasalazine oral tablet delayed release 500 mg T1

ursodiol oral capsule 300 mg T1

ursodiol oral tablet 250 mg, 500 mg T1

*Genitourinary Agents - Miscellaneous*alfuzosin hcl er oral tablet extended release 24 hour 10 mg

T1

citric acid-sodium citrate oral solution 334-500 mg/5ml

T1

cytra k crystals oral packet 3300-1002 mg T1

cytra-2 oral solution 500-334 mg/5ml T1

CYTRA-3 ORAL SYRUP 550-500-334 MG/5ML T1

cytra-k oral solution 1100-334 mg/5ml T1

finasteride oral tablet 5 mg T1

K-PHOS NO 2 ORAL TABLET 305-700 MG T1

ORACIT ORAL SOLUTION 490-640 MG/5ML T1

phenazopyridine hcl oral tablet 100 mg, 200 mg, 95 mg

T1

potassium citrate-citric acid oral packet 3300-1002 mg

T1

56

Drug Status Notespotassium citrate-citric acid oral solution 1100-334 mg/5ml

T1

sodium chloride irrigation solution 0.9 % T1

tamsulosin hcl oral capsule 0.4 mg T1

*Gout Agents*allopurinol oral tablet 100 mg, 300 mg T1

colchicine oral capsule 0.6 mg T1 QL (60 EA per 30 days)

colchicine oral tablet 0.6 mg T1 QL (60 EA per 30 days)

colchicine-probenecid oral tablet 0.5-500 mg T1

probenecid oral tablet 500 mg T1

*Hematological Agents - Misc.*anagrelide hcl oral capsule 0.5 mg, 1 mg T1

BRILINTA ORAL TABLET 60 MG, 90 MG T1 QL (60 EA per 30 days)

cilostazol oral tablet 100 mg, 50 mg T1

clopidogrel bisulfate oral tablet 300 mg T1

clopidogrel bisulfate oral tablet 75 mg T1 QL (30 EA per 30 days)

dipyridamole oral tablet 25 mg, 50 mg, 75 mg T1

pentoxifylline er oral tablet extended release 400 mg


prasugrel hcl oral tablet 10 mg, 5 mg T1 PA

ticlopidine hcl oral tablet 250 mg T1

*Hematopoietic Agents*cyanocobalamin injection solution 1000 mcg/ml T1

ELITE IRON ORAL TABLET 15 MG T1

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

T1 PA

EZFE 200 ORAL CAPSULE 434.8 (200 FE) MG T1

FEMIRON ORAL TABLET 63 (20 FE) MG T1

ferretts chewable iron oral tablet chewable 18 mg T1

ferretts ips oral solution 40 mg/15ml T1

ferretts oral tablet 325 (106 fe) mg T1

FERRIMIN 150 ORAL TABLET 150 MG T1

ferrous aspartate oral tablet 112 (18 fe) mg T1

ferrous fumarate oral tablet 29 mg, 324 (106 fe) mg

T1

ferrous gluconate oral tablet 225 (27 fe) mg, 240 (27 fe) mg, 324 (37.5 fe) mg, 324 (38 fe) mg, 325 (36 fe) mg

T1

57

Drug Status Notesferrous sulfate er oral tablet extended release 140 (45 fe) mg, 50 mg

T1

ferrous sulfate granules T1

ferrous sulfate oral elixir 220 (44 fe) mg/5ml T1 AL (Max 12 Years)

ferrous sulfate oral solution 75 (15 fe) mg/ml T1 AL (Max 12 Years)

ferrous sulfate oral syrup 300 (60 fe) mg/5ml T1 AL (Max 12 Years)

ferrous sulfate oral tablet 27 mg, 325 (65 fe) mg T1

ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg

T1

folic acid oral tablet 1 mg T1

folic acid oral tablet 400 mcg, 800 mcg T1GR-F; QL (30 EA per 30 days); AL (Min 14 Years and Max 50 Years)

FOLITAB 500 ORAL TABLET EXTENDED RELEASE 105-500-0.8 MG T1

HEMATOGEN FORTE ORAL CAPSULE460-60-0.01-1 MG T1

high potency iron oral capsule 86 (27 fe) mg T1

high potency iron oral tablet 134 mg T1

hm iron oral tablet 200 (65 fe) mg T1

IFEREX 150 ORAL CAPSULE 150 MG T1

iron (ferrous gluconate) oral tablet 256 (28 fe) mg

T1

iron chews pediatric oral tablet chewable 15 mg T1

iron complex oral capsule T1

iron oral tablet 90 (18 fe) mg T1

iron oral tablet extended release 18 mg T1

IRON UP ORAL LIQUID 15 MG/0.5ML T1

MYKIDZ IRON 10 ORAL SUSPENSION 15 MG/1.5ML T1

NOVAFERRUM 50 ORAL CAPSULE 50 MG T1

NOVAFERRUM PEDIATRIC DROPS ORAL LIQUID 15 MG/ML T1

PERFECT IRON ORAL TABLET 25 MG T1

poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg

T1

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

T1 PA

PROFE ORAL CAPSULE 391.3 (180 FE) MG T1

58

Drug Status NotesPROFERRIN ES ORAL TABLET 12 MG T1

RETACRIT INJECTION SOLUTION 20000 UNIT/ML T1 PA

slow iron oral tablet extended release 160 (50 fe) mg

T1

slow release iron oral tablet extended release 45 mg, 47.5 mg

T1

sm slow release iron oral tablet extended release142 (45 fe) mg, 143 (45 fe) mg

T1

SPATONE PUR-ABSORB IRON ORAL LIQUID 5 MG/20ML T1 AL (Max 12 Years)

tl icon oral capsule T1

vitamin b-12 oral tablet 1000 mcg T1

wee care oral suspension 15 mg/1.25ml T1

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

T1 PA

*Hypnotics/Sedatives/Sleep Disorder Agents*ACETADRYL ORAL TABLET 25-500 MG T1

diphenhydramine hcl (sleep) oral tablet 50 mg T1 PA; PA for members over age 65

diphenhydramine-apap (sleep) oral tablet 25-500 mg

T1

estazolam oral tablet 1 mg, 2 mg T1

eszopiclone oral tablet 1 mg, 2 mg, 3 mg T1QL (30 EA per 30 days); AL (Max 64 Years)

flurazepam hcl oral capsule 15 mg, 30 mg T1

ibuprofen pm oral tablet 200-38 mg T1

phenobarbital oral solution 20 mg/5ml T1

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

T1

ra sleep aid (diphenhydramine) oral tablet 25 mg T1 PA; PA for members over age 65

ra sleep aid oral capsule 50 mg T1 PA; PA for members over age 65

ra sleep aid oral liquid 50 mg/30ml T1 PA; PA for members over age 65

ra sleep-aid nighttime oral capsule 25 mg T1 PA; PA for members over age 65

temazepam oral capsule 15 mg, 30 mg T1QL (30 EA per 30 days); AL (Max 64 Years)

triazolam oral tablet 0.125 mg, 0.25 mg T1 AL (Max 64 Years)

wal-som oral tablet dispersible 25 mg T1 PA; PA for members over age 65

zaleplon oral capsule 10 mg, 5 mg T1

59

Drug Status Noteszolpidem tartrate er oral tablet extended release12.5 mg, 6.25 mg


zolpidem tartrate oral tablet 10 mg, 5 mg T1QL (30 EA per 30 days); AL (Max 64 Years)

*Laxatives*AGORAL MAXIMUM STRENGTH ORAL LIQUID 25 MG/15ML T1

bisacodyl ec oral tablet delayed release 5 mg T1

bisacodyl rectal suppository 10 mg T1

CORRECTOL HERBAL TEA ORAL 30 MG T1

cvs mini enema kids rectal enema 100 mg/5ml T1

cvs natural fiber supplement oral packet 58.6 % T1

diocto oral syrup 60 mg/15ml T1

docusate calcium oral capsule 240 mg T1

docusate sodium oral capsule 100 mg, 250 mg T1

docusate sodium oral liquid 50 mg/5ml T1

docusate sodium oral tablet 100 mg T1

DOCUSOL MINI RECTAL ENEMA 283 MG/5ML T1

DOCUSOL PLUS MINI-ENEMA RECTAL ENEMA 20-283 MG T1

EQUALACTIN ORAL TABLET CHEWABLE 625 MG T1

EVAC-U-GEN ORAL TABLET CHEWABLE10 MG T1

fiber laxative oral capsule 0.52 gm T1

fiber laxative oral tablet 625 mg T1

fiber therapy oral powder 58.6 % T1

FLEET BISACODYL RECTAL ENEMA 10 MG/30ML T1

GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM T1

QL (4000 ML per 365 days); AL (Min 50 Years and Max 75 Years)

GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM T1


geri-mucil oral powder 68 % T1

glycerin (adult) rectal suppository 2.1 gm T1

glycerin (infants & children) rectal suppository 1 gm, 1.2 gm

T1

glycerin adult rectal suppository 2 gm T1

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM T1 QL (1 EA per 365 days)

60

Drug Status NotesHYDROCIL ORAL PACKET 95 % T1

konsyl daily fiber oral packet 100 % T1

KONSYL ORAL PACKET 28.3 %, 60.3 % T1

KONSYL ORAL POWDER 60.3 %, 71.67 % T1

KONSYL-D ORAL POWDER 52.3 % T1

lactulose oral solution 10 gm/15ml T1

laxative pills oral tablet 15 mg T1

magnesium citrate oral solution 1.745 gm/30ml T1

METAMUCIL MULTIHEALTH FIBER ORAL POWDER 55.46 % T1

METAMUCIL ORAL WAFER T1

METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 % T1

natural fiber laxative oral powder 28.3 %, 48.57 %

T1

natural psyllium seed oral powder 100 % T1

natural senna laxative oral tablet 64.8-324 mg T1

PEDIA-LAX ORAL LIQUID 50 MG/15ML T1

PEDIA-LAX RECTAL SUPPOSITORY 2.8 GM T1

peg 3350 oral packet 17 gm T1

peg 3350/electrolytes oral solution reconstituted240 gm

T1QL (4000 ML per 365 days); AL (Min 50 Years and Max 75 Years)

polyethylene glycol 3350 oral powder 17 gm/scoop

T1

qc natural vegetable oral powder 95 % T1

ra col-rite oral capsule 50 mg T1

ra glycerin child rectal suppository 80.7 % T1

ra laxative extra strength oral tablet 17.2 mg T1

ra laxative oral tablet chewable 15 mg T1

sb natural fiber laxative oral powder 49 % T1

senna laxative oral tablet 25 mg T1

senna leaves oral leaves T1

senna oral capsule 8.6 mg T1

senna oral syrup 176 mg/5ml, 8.8 mg/5ml T1

senna oral tablet 8.6 mg T1

senna-docusate sodium oral tablet 8.6-50 mg T1

SOLUBLE FIBER THERAPY ORAL POWDER T1

61

Drug Status NotesTRILYTE ORAL SOLUTION RECONSTITUTED 420 GM T1


*Local Anesthetics-Parenteral*lidocaine hcl (pf) injection solution 4 % T1

*Macrolides*azithromycin oral packet 1 gm T1 QL (2 EA per 30 days)

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

T1

azithromycin oral tablet 250 mg T1 QL (12 EA per 30 days)

azithromycin oral tablet 500 mg T1 QL (5 EA per 30 days)

azithromycin oral tablet 600 mg T1

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

clarithromycin oral tablet 250 mg, 500 mg T1

*Medical Devices And Supplies*1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm


1st tier unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm


ACCU-CHEK TENDER 1 INFUSION KIT T1 QL (200 EA per 30 days)

ADVOCATE INSULIN PEN NEEDLES 31G X 5 MM , 31G X 8 MM T1 QL (200 EA per 30 days)

ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


anesthesia extension tubing T1 QL (200 EA per 30 days)

anti-stick insulin syringe 29g x 1/2" 1 ml T1 QL (200 EA per 30 days)

ARGYLE EXTENSION TUBE 20" T1 QL (200 EA per 30 days)

ASSURE DOSE CONTROL IN VITRO SOLUTION NORMAL T1

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML T1 QL (200 EA per 30 days)

aurora pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm


aurora unifine pentips 31g x 5 mm , 32g x 4 mm T1 QL (200 EA per 30 days)

AUTOJECT 2 T1 QL (200 EA per 30 days)

autopen device T1 QL (200 EA per 30 days)

BD ANGIOCATH AUTOGUARD T1 QL (200 EA per 30 days)

BD AUTOSHIELD 29G X 5MM , 29G X 8MM T1 QL (200 EA per 30 days)

62

Drug Status NotesBD AUTOSHIELD DUO 30G X 5 MM T1 QL (200 EA per 30 days)

BD ECLIPSE SYRINGE 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

BD FIRST MIDCATH 18G/4FRX20CM T1 QL (200 EA per 30 days)

BD FIRST MIDCATH 18G/4FRX20CM KIT T1 QL (200 EA per 30 days)

BD FIRST MIDCATH 20G/3FRX20CM T1 QL (200 EA per 30 days)

BD FIRST MIDCATH 20G/3FRX20CM KIT T1 QL (200 EA per 30 days)

BD FIRST PICC 16G/5FRX65CM T1 QL (200 EA per 30 days)

BD FIRST PICC 16G/5FRX65CM KIT T1 QL (200 EA per 30 days)





BD FIRST PICC 22G/2.8FRX50CM T1 QL (200 EA per 30 days)

BD FIRST PICC 26G/1.9FRX50CM T1 QL (200 EA per 30 days)

BD FIRST PICC 26G/1.9FRX50CM KIT T1 QL (200 EA per 30 days)

BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, U-100 1 ML


BD INSULIN SYRINGE HALF-UNIT 31G X 5/16" 0.3 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.3 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML


BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML, 31G X 5/16" 0.3 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE U-40 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 31G X 5/16" 0.5 ML


BD INTEGRA INSULIN SYRINGE 29G X 1/2" 1 ML T1 QL (200 EA per 30 days)

BD INTEGRA SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

BD L-CATH 16G/5FR KIT T1 QL (200 EA per 30 days)

BD L-CATH 16G/5FRX60CM T1 QL (200 EA per 30 days)

BD L-CATH 18G/3.5FR KIT T1 QL (200 EA per 30 days)

BD L-CATH 18G/3.5FRX60CM T1 QL (200 EA per 30 days)

63

Drug Status NotesBD L-CATH 20G/2.6FR KIT T1 QL (200 EA per 30 days)

BD L-CATH 20G/2.6FRX60CM T1 QL (200 EA per 30 days)

BD L-CATH 20G/3FR KIT T1 QL (200 EA per 30 days)

BD L-CATH 20G/3FRX60CM T1 QL (200 EA per 30 days)

BD L-CATH 28G/1.2FRX25CM KIT T1 QL (200 EA per 30 days)

BD L-CATH MIDLINE 18G/3.5FRX20 T1 QL (200 EA per 30 days)

BD L-CATH MIDLINE 18G/3.5FRX20 KIT T1 QL (200 EA per 30 days)

BD L-CATH MIDLINE 20G/3FRX20CM T1 QL (200 EA per 30 days)

BD LUER-LOK SYRINGE 20G X 1" 1 ML, 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

BD NEXIVA 18GX1.25" T1 QL (200 EA per 30 days)


BD NEXIVA 20GX1" T1 QL (200 EA per 30 days)



BD NEXIVA 22GX1" T1 QL (200 EA per 30 days)



BD PEN NEEDLE MINI U/F 31G X 5 MM T1 QL (200 EA per 30 days)

BD PEN NEEDLE NANO U/F 32G X 4 MM T1 QL (200 EA per 30 days)

BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM T1 QL (200 EA per 30 days)

BD PEN NEEDLE SHORT U/F 31G X 8 MM T1 QL (200 EA per 30 days)

BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML T1 QL (200 EA per 30 days)

BD SAFETY-LOK INSULIN SYRINGE 29G X 1/2" 1 ML T1 QL (200 EA per 30 days)

BD SAFETY-LOK SET T1 QL (200 EA per 30 days)

BD SAFETY-LOK VACUTAINER SET T1 QL (200 EA per 30 days)

BD SAF-T E-Z SET T1 QL (200 EA per 30 days)

BD SAF-T-INTIMA 18G X 1" KIT T1 QL (200 EA per 30 days)

BD SAF-T-INTIMA 20GX1" T1 QL (200 EA per 30 days)

BD SAF-T-INTIMA 22G X 0.75" KIT T1 QL (200 EA per 30 days)

BD SAF-T-INTIMA 22GX3/4" T1 QL (200 EA per 30 days)

BD SAF-T-INTIMA 24G X 0.75" KIT T1 QL (200 EA per 30 days)

BD SAF-T-INTIMA 24GX3/4" T1 QL (200 EA per 30 days)

BD SYRINGE/NEEDLE 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

BD SYRINGE/NEEDLE SLIP TIP 26G X 5/8" 1 ML T1 QL (200 EA per 30 days)

64

Drug Status NotesBD VACUTAINER SET T1 QL (200 EA per 30 days)

CAREFINE PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM


careone insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


careone unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm


careone unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm


clickfine pen needles 31g x 6 mm , 31g x 8 mm , 32g x 4 mm


COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM T1 QL (200 EA per 30 days)

cool mist humidifier T1

CORNWALL METAL PIPETTING T1 QL (200 EA per 30 days)

CURITY ALCOHOL PREPS PAD 70 % T1

denture adhesive cream T1

drug mart unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm


drug mart unifine pentips plus 32g x 4 mm T1 QL (200 EA per 30 days)

EASIVENT T1 QL (2 EA per 365 days)

EASIVENT MASK LARGE T1 QL (2 EA per 365 days)

EASIVENT MASK MEDIUM T1 QL (2 EA per 365 days)

EASIVENT MASK SMALL T1 QL (2 EA per 365 days)

easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml


easy comfort pen needles 31g x 5 mm , 31g x 8 mm , 32g x 4 mm


EASY TOUCH FLURINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML


65

Drug Status NotesEASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


EASY TOUCH PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM


EASY TOUCH SAFETY SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

elite-thin insulin syringe 28g x 5/16" 0.5 ml T1 QL (100 EA per 30 days)

eql insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


EXEL COMFORT POINT INSULIN SYR28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML


FIFTY50 PEN NEEDLES 31G X 5 MM , 31G X 8 MM T1 QL (200 EA per 30 days)

FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


fluid administration set T1 QL (200 EA per 30 days)

freds pharmacy unifine pentip+ 31g x 5 mm , 31g x 8 mm


freds pharmacy unifine pentips 32g x 4 mm T1 QL (200 EA per 30 days)

FREESTYLE CONTROL SOLUTION IN VITRO LIQUID T1

FREESTYLE PRECISION INS SYR 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


gauze sponge pad 4"x4" T1

global ease inject pen needles 29g x 12mm , 31g x 5 mm , 31g x 8 mm , 32g x 4 mm


global inject ease insulin syr 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


66

Drug Status NotesGLUCOCARD EXPRESSION CONTROL IN VITRO SOLUTION T1

GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


gnp clickfine pen needles 31g x 6 mm , 31g x 8 mm


gnp insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


H 468L TUBING T1 QL (200 EA per 30 days)

healthwise mini pen needles 31g x 6 mm T1 QL (200 EA per 30 days)

healthwise pen needles 29g x 12mm T1 QL (200 EA per 30 days)

healthwise short pen needles 31g x 8 mm T1 QL (200 EA per 30 days)

healthwise unifine pentips 32g x 4 mm T1 QL (200 EA per 30 days)

healthy accents unifine pentip 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm


h-e-b incontrol pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm


HM ULTICARE INSULIN SYRINGE 31G X 5/16" 0.3 ML T1 QL (200 EA per 30 days)

HUBER INFUSION SET T1 QL (200 EA per 30 days)

HUMAPEN LUXURA HD DEVICE T1 QL (200 EA per 30 days)

HUMATROPEN FOR 12MG DEVICE T1 QL (200 EA per 30 days)



infusion set T1 QL (200 EA per 30 days)

infusion set 23" comfort T1 QL (200 EA per 30 days)

inject-ease T1 QL (200 EA per 30 days)

INJECT-EASE AUTOMATIC INJECTOR T1 QL (200 EA per 30 days)

INSUFLON 25G X 0.71" T1 QL (200 EA per 30 days)

insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 5/16" 1 ml


67

Drug Status Notesinsulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

T1

insulin syringe/needle 27g x 1/2" 0.5 ml, 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml


insupen pen needles 32g x 4 mm T1 QL (200 EA per 30 days)

INSUPEN SENSITIVE 32G X 6 MM , 32G X 8 MM T1 QL (200 EA per 30 days)

INSUPEN ULTRAFIN 29G X 12MM , 30G X 8 MM , 31G X 6 MM , 31G X 8 MM T1 QL (200 EA per 30 days)

INSYTE AUTOGUARD 14GX1.75" T1 QL (200 EA per 30 days)


INSYTE AUTOGUARD 20GX1" T1 QL (200 EA per 30 days)


INSYTE AUTOGUARD 22GX1" T1 QL (200 EA per 30 days)

INSYTE AUTOGUARD 24GX3/4" T1 QL (200 EA per 30 days)

KANGAROO BURETTE SET T1 QL (200 EA per 30 days)

kinray insulin syringe 29g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


kmart valu insulin syringe 29g u-100 0.5 ml, u-100 1 ml


kmart valu insulin syringe 30g u-100 0.3 ml, u-100 0.5 ml, u-100 1 ml


kroger insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


kroger pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm


L606 TUBING T1 QL (200 EA per 30 days)

L609 TUBING T1 QL (200 EA per 30 days)

leader insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


LEADER UNIFINE PENTIPS 31G X 5 MM , 32G X 4 MM T1 QL (200 EA per 30 days)

LEADER UNIFINE PENTIPS PLUS 31G X 5 MM , 31G X 8 MM , 32G X 4 MM T1 QL (200 EA per 30 days)

68

Drug Status NotesLITETOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


LITETOUCH PEN NEEDLES 29G X 12.7MM , 31G X 6 MM , 31G X 8 MM T1 QL (200 EA per 30 days)

longs insulin syringe 31g x 5/16" 0.5 ml T1 QL (200 EA per 30 days)

LTXF PRIM CNV PIN MICRODRIP T1 QL (200 EA per 30 days)

LTXF PRIM IV SET/CNVT PIN T1 QL (200 EA per 30 days)

LTXF SECONDARY/CNV PIN/32INC T1 QL (200 EA per 30 days)

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML


medic insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml


medicine shoppe pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm


MEDSAVER SYRINGE 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

meijer pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm


MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML, U-100 1 ML


MONOJECT LIFESHIELD SYRINGE 18G X 1" 1 ML T1 QL (200 EA per 30 days)

MONOJECT MAGELLAN SYRINGE 23G X 1" 1 ML, 25G X 1" 1 ML, 25G X 5/8" 1 ML T1 QL (200 EA per 30 days)

MONOJECT ULTRA COMFORT SYRINGE28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML


MOORE MONO INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML


ms insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


NERIA 29G INFUSION SET 10MM T1 QL (200 EA per 30 days)

NERIA 29G INFUSION SET 6MM T1 QL (200 EA per 30 days)

69

Drug Status NotesNERIA 29G INFUSION SET 8MM T1 QL (200 EA per 30 days)

NERIA MULTI 27G 2X10MM T1 QL (200 EA per 30 days)



NERIA SOFT 25G INFUSION 13MM T1 QL (200 EA per 30 days)

NERIA SOFT 25G INFUSION 17MM T1 QL (200 EA per 30 days)

NORDIPEN 5 INJECTION DEVICE T1 QL (200 EA per 30 days)

NORDIPEN DELIVERY SYSTEM T1 QL (200 EA per 30 days)

NOVOFINE 30G X 8 MM , 32G X 6 MM T1 QL (200 EA per 30 days)

NOVOFINE AUTOCOVER 30G X 8 MM T1 QL (200 EA per 30 days)

NOVOFINE PLUS 32G X 4 MM T1 QL (200 EA per 30 days)

NOVOPEN ECHO DEVICE T1 QL (200 EA per 30 days)

NOVOTWIST 32G X 5 MM T1 QL (200 EA per 30 days)

OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM T1 GR-F; QL (1 EA per 365 days)

OMNITROPE PEN 10 INJ DEVICE T1 QL (200 EA per 30 days)

OMNITROPE PEN 5 INJ DEVICE T1 QL (200 EA per 30 days)

ONETOUCH DELICA LANCETS 30G T1QL 100/90 for members not on insulin and QL 300/90 for members on insulin

ONETOUCH DELICA LANCETS 33G T1QL 100/90 for members not on insulin and QL 300/90 for members on insulin

ONETOUCH ULTRA CONTROL IN VITRO SOLUTION T1

ONETOUCH VERIO SOLUTION IN VITRO T1 QL (1 EA per 365 days)

pc unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm


pen needles 1/2" 29g x 12mm T1 QL (200 EA per 30 days)

pen needles 29g x 12mm , 31g x 6 mm T1 QL (200 EA per 30 days)

pen needles 3/16" 31g x 5 mm T1 QL (200 EA per 30 days)

pen needles 5/16" 30g x 8 mm , 31g x 8 mm T1 QL (200 EA per 30 days)

plastic adapter , 1 ml T1 QL (200 EA per 30 days)

PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML T1 QL (200 EA per 30 days)

PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 30G X 3/8" 0.5 ML


70

Drug Status Notespreferred plus insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml


preferred plus unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm


PRODIGY INSULIN SYRINGE 28G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML T1 QL (200 EA per 30 days)

px extra short pen needles 31g x 6 mm T1 QL (200 EA per 30 days)

px insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


px mini pen needles 31g x 5 mm T1 QL (200 EA per 30 days)

px pen needle 29g x 12mm , 31g x 8 mm T1 QL (200 EA per 30 days)

qc pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm


qc unifine pentips 32g x 4 mm T1 QL (200 EA per 30 days)

ra insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml


ra pen needles 31g x 5 mm , 31g x 8 mm T1 QL (200 EA per 30 days)

RELI-ON INSULIN SYRINGE 29G 0.3 ML, 29G 0.5 ML, 29G X 1/2" 1 ML T1 QL (200 EA per 30 days)

RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML


RELI-ON INSULIN SYRINGE 30G 1 ML T1 QL (100 EA per 30 days)

RELION INSULIN SYRINGE 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

T1

RELION MINI PEN NEEDLES 31G X 6 MM T1 QL (200 EA per 30 days)

RELION PEN NEEDLES 29G X 12MM , 31G X 8 MM , 32G X 4 MM T1 QL (200 EA per 30 days)

RELION SHORT PEN NEEDLES 31G X 8 MM T1 QL (200 EA per 30 days)

SAFELET IV CATHETER T1 QL (200 EA per 30 days)

SAFESNAP INSULIN SYRINGE 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML


sb insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 1 ml


scalp vein set T1 QL (200 EA per 30 days)

71

Drug Status Notesschnucks insulin syringe 29g x 1/2" 0.5 ml, 30g x 5/16" 0.5 ml


SHOPKO UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM T1 QL (200 EA per 30 days)

sm insulin syringe 31g x 5/16" 1 ml T1 QL (200 EA per 30 days)

solution transfer device T1 QL (200 EA per 30 days)

sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


sure comfort pen needles 30g x 8 mm , 31g x 5 mm , 31g x 8 mm , 32g x 4 mm


SURE-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM T1 QL (200 EA per 30 days)

SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


SURE-T INFUSION SET 18" T1 QL (200 EA per 30 days)



surgical dressing pad 5"x9" T1

syringe luer slip 25g x 5/8" 1 ml, 26g x 3/8" 1 ml T1 QL (200 EA per 30 days)

todays health mini pen needles 31g x 6 mm T1 QL (200 EA per 30 days)

todays health pen needles 29g x 12mm T1 QL (200 EA per 30 days)

todays health short pen needle 31g x 8 mm T1 QL (200 EA per 30 days)

topcare clickfine pen needles 31g x 6 mm , 31g x 8 mm


topcare ultra comfort ins syr 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


72

Drug Status NotesULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML T1 QL (200 EA per 30 days)

ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


ULTICARE MICRO PEN NEEDLES 32G X 4 MM T1 QL (200 EA per 30 days)

ULTICARE MINI PEN NEEDLES 31G X 6 MM T1 QL (200 EA per 30 days)

ULTICARE PEN NEEDLES 29G X 12.7MM T1 QL (200 EA per 30 days)

ULTICARE SHORT PEN NEEDLES 31G X 8 MM T1 QL (200 EA per 30 days)

ULTICARE SYRINGE 22G X 1-1/2" 1 ML T1 QL (200 EA per 30 days)

ULTILET INSULIN SYRINGE SHORT 30G X 5/16" 0.3 ML, 30G X 5/16" 1 ML T1

ULTILET INSULIN SYRINGE SHORT 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML


ULTILET PEN NEEDLE 31G X 8 MM T1 QL (200 EA per 30 days)

ultra comfort insulin syringe 30g x 5/16" 0.3 ml T1 QL (200 EA per 30 days)

ultra-comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


ULTRA-THIN II INS SYR SHORT 31G X 5/16" 1 ML T1 QL (200 EA per 30 days)

UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM


UNIFINE PENTIPS PLUS 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM


VACUTAINER TUBING T1 QL (200 EA per 30 days)

value health insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml


valumark pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm


VANISHPOINT 18GX1-1/4" FEP T1 QL (200 EA per 30 days)

VANISHPOINT 18GX1-1/4" PUR T1 QL (200 EA per 30 days)

73

Drug Status NotesVANISHPOINT 20GX1-1/4" FEP T1 QL (200 EA per 30 days)

VANISHPOINT 20GX1-1/4" PUR T1 QL (200 EA per 30 days)

VANISHPOINT 22GX1" FEP T1 QL (200 EA per 30 days)

VANISHPOINT 22GX1" PUR T1 QL (200 EA per 30 days)

VANISHPOINT 24GX3/4" FEP T1 QL (200 EA per 30 days)

VANISHPOINT 24GX3/4" PUR T1 QL (200 EA per 30 days)

VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML T1 QL (200 EA per 30 days)

VANISHPOINT SYRINGE 25G X 1" 1 ML T1 QL (200 EA per 30 days)

VIDA MIA UNIFINE PENTIPS 29G X 12MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM T1 QL (200 EA per 30 days)

vp insulin syringe 29g x 1/2" 0.3 ml T1 QL (200 EA per 30 days)

V-R MONO INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML


warm mist vaporizer T1

wegmans unifine pentips plus 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm


WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % T1 GR-F; QL (1 EA per 365 days)








*Migraine Products*naratriptan hcl oral tablet 1 mg, 2.5 mg T1 ST; QL (9 EA per 30 days)

rizatriptan benzoate oral tablet 10 mg, 5 mg T1 QL (12 EA per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg


sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg


zolmitriptan oral tablet 2.5 mg, 5 mg T1 ST

74

Drug Status Noteszolmitriptan oral tablet dispersible 2.5 mg, 5 mg T1 ST

*Minerals & Electrolytes*cal/mag oral tablet 200-100 mg T1

CALCET CREAMY BITES ORAL TABLET CHEWABLE 500-400 MG-UNIT T1

cal-citrate plus vitamin d oral tablet 250-100 mg-unit

T1

calcium + d3 oral tablet 600-200 mg-unit T1

calcium 1000 + d oral tablet 1000-800 mg-unit T1

calcium 500 + d oral tablet 500-125 mg-unit T1

calcium 500/d oral tablet 500-200 mg-unit T1

calcium 500/d oral tablet chewable 500-400 mg-unit

T1

calcium 500+d high potency oral tablet 500-400 mg-unit

T1

calcium 500+d oral tablet 500-200 mg-unit, 500-400 mg-unit

T1

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

T1

calcium 600+d oral tablet 600-200 mg-unit, 600-400 mg-unit

T1

calcium 600+d3 oral tablet 600-400 mg-unit, 600-800 mg-unit

T1

calcium carbonate oral suspension 1250 (500 ca) mg/5ml

T1

calcium carbonate oral tablet 1250 (500 ca) mg T1

calcium carbonate-vitamin d oral capsule 600-200 mg-unit

T1

calcium citrate + d oral tablet 315-200 mg-unit T1

calcium citrate + d3 oral tablet 250-200 mg-unit, 315-250 mg-unit

T1

calcium citrate malate-vit d oral tablet 250-100 mg-unit

T1

calcium citrate oral granules 760 mg/3.5gm T1

calcium citrate oral tablet 200 mg, 250 mg, 950 (200 ca) mg

T1

calcium citrate+d3 petites oral tablet 200-250 mg-unit

T1

calcium citrate-vitamin d oral tablet 250-50 mg-unit

T1

calcium citrate-vitamin d3 oral liquid 1000-400 T1

calcium magnesium 750 oral tablet 300-300 mg T1

75

Drug Status Notescalcium oral tablet chewable 500-100 mg-unit, 600-400 mg-unit

T1

calcium plus vitamin d oral capsule 300-100 mg-unit, 500-50 mg-unit

T1

calcium/vitamin d3 gummies oral tablet chewable200-200 mg-unit

T1

calcium-carb 600 + d oral tablet 600-125 mg-unit T1

calcium-magnesium oral tablet 250-125 mg, 250-155 mg, 500-250 mg

T1

calcium-vitamin d oral tablet 600-200 mg-unit T1

calcium-vitamin d3 oral capsule 600-400 mg-unit, 600-500 mg-unit

T1

calcium-vitamin d3 oral tablet 250-125 mg-unit T1

cal-mag aspartate oral tablet 333.33-167 mg T1

CAL-MAG CHELA-MAX ORAL CAPSULE70-83 MG T1

calmag thins oral tablet 200-50 mg T1

CAL-QUICK ORAL LIQUID 500-400 MG-UNT/5ML T1

chelated magnesium oral tablet 100 mg T1

cvs calcium oral tablet chewable 250-400 mg-unit T1

cvs oyster shell calcium+vit d oral tablet 500-125 mg-unit

T1

elite ca/mg oral tablet 100-50 mg T1

eql calcium/vitamin d oral capsule 600-100 mg-unit

T1

eql vitamin d-3 high potency oral tablet 115-2000 mg-unit

T1

gnp calcium 500 +d3 oral tablet 500-600 mg-unit T1

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ T1

K-PHOS ORAL TABLET 500 MG T1

liquid calcium with d3 oral capsule 600-1000 mg-unit

T1

m2 magnesium oral capsule 100 mg T1

MAG64 ORAL TABLET DELAYED RELEASE 64 MG T1

mag-g oral tablet 500 (27 mg) mg T1

MAGINEX DS ORAL PACKET 1230 MG T1

MAGINEX ORAL TABLET DELAYED RELEASE 615 MG T1

magnesium aspartate oral tablet 65 mg T1

76

Drug Status Notesmagnesium carbonate oral powder 250 mg/gm T1

magnesium carbonate powder T1

magnesium chloride crystals T1

magnesium chloride powder T1

magnesium citrate oral tablet 100 mg T1

magnesium gluconate oral tablet 27.5 mg, 30 mg, 500 mg, 550 mg

T1

magnesium lactate oral tablet extended release 84 mg (7meq)

T1

magnesium oral capsule 300 mg, 500 mg T1

magnesium oral tablet 200 mg, 250 mg, 30 mg, 400 mg

T1

magnesium oxide -mg supplement oral capsule400 mg

T1

magnesium oxide -mg supplement oral tablet 250 mg

T1

magnesium oxide oral powder T1

magnesium oxide oral tablet 400 (240 mg) mg, 400 (241.3 mg) mg, 500 mg

T1

magnesium sulfate in d5w intravenous solution 1-5 gm/100ml-%

T1

magnesium sulfate injection solution 50 % T1

magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml

T1

magnesium sulfate oral capsule 70 mg T1

MAGONATE ORAL LIQUID 54 (MAG EQUIV) MG/5ML T1

ORAZINC ORAL TABLET 110 MG T1

OSTEO-PORETICAL ORAL TABLET 600-1000 MG-UNIT T1

OSTIGEN ORAL 350 MG T1

OYSCO 500+D ORAL TABLET CHEWABLE 500-600 MG-UNIT T1

oyster shell calcium plus d oral tablet 333-133 mg-unit

T1

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

T1

parva-cal oral tablet 250-100 mg-unit, 500-200 mg-unit

T1

PEDIALYTE ORAL SOLUTION T1

77

Drug Status NotesPHOSPHA 250 NEUTRAL ORAL TABLET155-852-130 MG T1

phosphorus supplement oral packet 280-160-250 mg

T1

pot bicarb-pot chloride oral tablet effervescent 25 meq

T1

potassium bicarbonate oral tablet effervescent 25 meq

T1

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

T1

potassium chloride er oral capsule extended release 10 meq, 8 meq

T1

potassium chloride er oral tablet extended release10 meq, 20 meq, 8 meq

T1

potassium chloride oral packet 20 meq T1

potassium chloride oral solution 20 meq/15ml (10%)

T1

ra calcium hi-cal/vitamin d oral tablet 500-125 mg-unit

T1

ra calcium-boron oral tablet 500-1.5 mg T1

sodium chloride flush intravenous solution 0.9 % T1

sodium chloride injection solution 0.9 % T1

sodium chloride intravenous solution 0.9 % T1

sodium chloride oral tablet 1 gm T1

sodium fluoride oral solution 1.1 (0.5 f) mg/ml T1QL (30 ML per 30 days); AL (Max 10 Years)

sodium fluoride oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg

T1QL (30 EA per 30 days); AL (Max 10 Years)

UPCAL D ORAL PACKET 500-500 MG-UNIT T1

UPCAL D ORAL POWDER 500-500 MG-UNT/5GM T1

VITALINE BUFFERED ZINC-220 ORAL TABLET EXTENDED RELEASE 220 (50 ZN) MG

T1

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

T1

ZINC 15 ORAL TABLET 66 MG T1

zinc sulfate granules T1

zinc sulfate intravenous solution 1 mg/ml, 5 mg/ml

T1

zinc sulfate oral capsule 220 (50 zn) mg T1

78

Drug Status Noteszinc sulfate oral tablet 140 (50 zn) mg, 220 (50 zn) mg

T1

zinc sulfate powder T1

*Miscellaneous Therapeutic Classes*ARGYLE STERILE WATER IRRIGATION SOLUTION T1

azathioprine oral tablet 50 mg T1

CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML T1 PA

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

T1

cyclosporine modified oral solution 100 mg/ml T1

cyclosporine oral capsule 100 mg, 25 mg T1

GENGRAF ORAL CAPSULE 100 MG, 25 MG T1

GENGRAF ORAL SOLUTION 100 MG/ML T1

KIONEX ORAL POWDER T1

mycophenolate mofetil oral capsule 250 mg T1

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

T1 PA

mycophenolate mofetil oral tablet 500 mg T1

sodium polystyrene sulfonate oral powder T1

sterile water for irrigation irrigation solution T1

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg T1

*Mouth/Throat/Dental Agents*ANBESOL MOUTH/THROAT LIQUID 10 % T1

BENZ-O-STHETIC MOUTH/THROAT SOLUTION 20 % T1

BENZ-O-STHETIC MOUTH/THROAT SWAB 20 % T1

chlorhexidine gluconate mouth/throat solution0.12 %

T1

clotrimazole mouth/throat lozenge 10 mg T1

DENTS TOOTHACHE MOUTH/THROAT GUM 20 % T1

GEL-TIN DENTAL GEL 0.4 % T1

lidocaine hcl mouth/throat solution 4 % T1

lidocaine viscous mouth/throat solution 2 % T1

LITTLE TEETHERS PAIN RELIEF MOUTH/THROAT SWAB 7.5 % T1

nystatin mouth/throat suspension 100000 unit/ml T1

79

Drug Status NotesORA-FILM MOUTH/THROAT STRIP 6 % T1

oral analgesic max st mouth/throat gel 20 % T1

oral analgesic max st mouth/throat liquid 20 % T1

oral anesthetic mouth/throat paste 20 % T1

ORAMAGIC PLUS MOUTH/THROAT SUSPENSION RECONSTITUTED 10 % T1

PERIOMED MOUTH/THROAT CONCENTRATE 0.63 % T1

pilocarpine hcl oral tablet 5 mg T1

ra baby care oral pain relief mouth/throat gel 7.5 %

T1

sf 5000 plus dental cream 1.1 % T1

triamcinolone acetonide mouth/throat paste 0.1 % T1

*Multivitamins*adult gummy oral tablet chewable T1

antioxidant formula sg oral capsule extended release

T1

ATABEX EC ORAL TABLET DELAYED RELEASE 29-1 MG T1 GR-F

ATABEX ORAL TABLET CHEWABLE 18-0.8 MG T1 GR-F

b-complex balanced oral tablet T1

b-complex/vitamin c oral tablet T1

biovol oral syrup T1

BRAINSTRONG PRENATAL ORAL 33-0.8 & 350 MG T1 GR-F

CENTRUM SPECIALIST PRENATAL ORAL 27-0.8 & 200 MG T1 GR-F

child chewable vitamins/iron oral tablet chewableT1 AL (Max 9 Years)

childrens gummies oral tablet chewable T1 AL (Max 9 Years)

childrens multivitamin oral tablet chewable 60 mg

T1 AL (Max 9 Years)

CLINICAL NUTRIENTS PRENATAL ORAL TABLET 7.5-0.2 MG T1 GR-F

COMPLETE FORMULATION PEDIATRIC ORAL SOLUTION 45 MG/0.5ML T1 AL (Max 9 Years)

complete natal dha oral 29-1-200 & 250 mg T1 GR-F

complete prenatal/dha oral 30-0.975 & 300 mg T1 GR-F

CORVITA ORAL TABLET 1.25 MG T1

80

Drug Status Notescvs prenatal gummy oral tablet chewable 0.4-113.5 mg

T1 GR-F

daily multiple vitamins/min oral tablet T1

DAILY PAK MAXIMUM MULTIVITAMIN ORAL T1

daily vitamin plus oral capsule T1

daily-vitamin oral tablet T1

DIALYVITE SUPREME D ORAL TABLET 3 MG T1

ELDERTONIC ORAL ELIXIR T1

eql childrens multivitamins oral tablet chewable T1

eql gummies childrens oral tablet chewable 30 mg

T1 AL (Max 9 Years)

FLINTSTONES TODDLER ORAL TABLET CHEWABLE 40 MG T1

FOLGARD OS ORAL TABLET 500-1.1 MG T1GR-F; QL (30 EA per 30 days); AL (Min 14 Years and Max 50 Years)

HEALTHY MAMA BE WELL ROUNDED ORAL THERAPY PACK 28-0.8 & 450 MG T1 GR-F

HONEY BEARS W/IRON-ZINC ORAL TABLET CHEWABLE 30-200-3 T1 AL (Max 9 Years)

kpn prenatal oral tablet 0.1 mg T1 GR-F

MEGA MULTIVITAMIN ORAL POWDER T1

multi-delyn oral liquid T1 AL (Max 9 Years)

multi-delyn/iron oral liquid T1

multivitamins oral tablet chewable T1

multivitamins pediatric oral solution T1 AL (Max 9 Years)

MYKIDZ IRON ORAL SUSPENSION 10 MG/2ML T1

MYNATAL ORAL CAPSULE T1 GR-F

mynatal plus oral tablet T1 GR-F

mynate 90 plus oral tablet extended release T1 GR-F

NANOVM T/F ORAL LIQUID T1 AL (Max 9 Years)

NANOVM T/F ORAL POWDER T1

NATALVIT ORAL TABLET T1 GR-F

OBSTETRIX DHA ORAL 29-1 & 387 MG T1 GR-F

OBSTETRIX EC ORAL TABLET 29-1 MG T1 GR-F

O-CAL PRENATAL ORAL TABLET T1 GR-F

ONE-A-DAY WOMENS PRENATAL ORAL28-0.8 & 223 MG T1 GR-F

81

Drug Status Notespa prenatal formula oral tablet 9-0.5 mg T1 GR-F

PERRY PRENATAL ORAL CAPSULE 13.5-0.4 MG T1 GR-F

poly vitamin oral tablet chewable T1 AL (Max 9 Years)

polyvitamin oral solution 35 mg/ml T1 AL (Max 9 Years)

polyvitamin/iron oral solution 10 mg/ml T1 AL (Max 9 Years)

PR NATAL 400 ORAL 29-1-200 & 400 MG T1 GR-F

PR NATAL 430 ORAL 29-1-200 & 430 MG T1 GR-F

PRENATA ORAL TABLET CHEWABLE 29-1 MG T1 GR-F

prenatabs fa oral tablet T1 GR-F

prenatal 19 oral tablet 29-1 mg T1 GR-F

prenatal 19 oral tablet chewable 29-1 mg T1 GR-F

prenatal complete oral tablet 14-0.4 mg T1 GR-F

prenatal formula a-free oral tablet 9-0.267 mg T1 GR-F

prenatal formula oral capsule 28-0.8-235 mg T1 GR-F

prenatal multi +dha oral capsule 27-0.8-228 mg T1 GR-F

PRENATAL MULTIVITAMIN + DHA ORAL28-0.8 & 200 MG T1 GR-F

prenatal oral tablet 27-0.8 mg, 28-0.8 mg, 6.75-0.2 mg

T1 GR-F

prenatal plus iron oral tablet 29-1 mg T1 GR-F

prenatal plus oral tablet 27-1 mg T1 GR-F

prenatal vitamins oral tablet 0.8 mg T1 GR-F

prenatal/omega-3/fa/iron oral capsule 28-0.8-530 mg

T1 GR-F

prenatal+dha oral 28-0.975 & 200 mg T1 GR-F

PRENATAL-U ORAL CAPSULE 106.5-1 MG T1 GR-F

profe forte oral capsule 155-1 mg T1 GR-F

purefe ob plus oral capsule 162-115.2-1 mg T1 GR-F

qc childrens vitamins/extra c oral tablet chewableT1 AL (Max 9 Years)

ra one daily oral 28-0.8 & 440 mg T1 GR-F

RENAL ORAL CAPSULE 1 MG T1

SCOOBY-DOO ONE A DAY ORAL TABLET CHEWABLE T1

stress formula/iron oral tablet T1

stress formula/zinc oral tablet T1

STUART ONE ORAL CAPSULE 27-0.8-200 MG T1 GR-F

82

Drug Status Notessuper b complex/vitamin c oral tablet T1

SUPERVITE EC ORAL TABLET DELAYED RELEASE 1 MG T1

SYNATEK ORAL CAPSULE 1.25 MG T1

TARON-BC ORAL 20-1 MG & 2 X 25 MG T1 GR-F

THERANATAL COMPLETE ORAL 27-1 & 300 MG T1 GR-F

therapeutic liquid oral solution T1

trinatal rx 1 oral tablet 60-1 mg T1 GR-F

tri-vit/fluoride oral solution 0.25 mg/ml T1 AL (Max 9 Years)

tri-vitamin/fluoride oral solution 0.5 mg/ml T1 AL (Max 9 Years)

UDAMIN SP ORAL TABLET 1 MG T1

ultra-mega oral tablet extended release T1

VINATE II ORAL TABLET 29-1 MG T1 GR-F

VINATE M ORAL TABLET 27-1 MG T1 GR-F

virt-vite gt oral tablet 90-1 mg T1 GR-F

vitamin c-electrolytes oral packet T1

zinc oral lozenge T1

*Musculoskeletal Therapy Agents*baclofen oral tablet 10 mg, 20 mg T1

chlorzoxazone oral tablet 500 mg T1

cyclobenzaprine hcl oral tablet 10 mg, 5 mg T1

methocarbamol oral tablet 500 mg, 750 mg T1

tizanidine hcl oral tablet 2 mg, 4 mg T1 QL (90 EA per 30 days)

*Nasal Agents - Systemic And Topical*allergy spray 24 hour aerosol 55 mcg/act nasal55 mcg/act


anefrin spray nasal solution 0.05 % T1

childrens silfedrine oral liquid 15 mg/5ml T1

cromolyn sodium nasal aerosol solution 5.2 mg/act

T1

cvs nasal allergy spray aerosol 55 mcg/act nasal55 mcg/act


eq nasal allergy aerosol 55 mcg/act nasal 55 mcg/act


fluticasone propionate nasal suspension 50 mcg/act


gnp 24 hour nasal allergy aerosol 55 mcg/act nasal 55 mcg/act


83

Drug Status Notesgoodsense nasal allergy spray aerosol 55 mcg/act nasal 55 mcg/act


ipratropium bromide nasal solution 0.03 % T1 QL (30 ML per 30 days)

ipratropium bromide nasal solution 0.06 % T1 QL (15 ML per 30 days)

NASACORT ALLERGY 24HR NASAL AEROSOL 55 MCG/ACT T1

nasal allergy 24 hour aerosol 55 mcg/act nasal55 mcg/act


nasal decongestant oral liquid 30 mg/5ml T1

nasal decongestant oral syrup 30 mg/5ml T1

NEXAFED ORAL TABLET ABUSE-DETERRENT 30 MG T1

pseudoephedrine hcl er oral tablet extended release 12 hour 120 mg

T1

pseudoephedrine hcl oral tablet 30 mg, 60 mg T1

ra nasal allergy aerosol 55 mcg/act nasal 55 mcg/act


RHINOCORT ALLERGY NASAL SUSPENSION 32 MCG/ACT T1

saline nasal spray nasal solution 0.65 % T1 QL (90 ML per 30 days)

triamcinolone acetonide aerosol 55 mcg/act nasal (otc) 55 mcg/act


*Neuromuscular Agents*riluzole oral tablet 50 mg T1 QL (60 EA per 30 days)

*Ophthalmic Agents*advanced lubricant ophthalmic solution 0.05-1 % T1

artificial tears ophthalmic ointment 83-15 % T1

artificial tears ophthalmic solution 0.1-0.3 %, 0.2-0.2-1 %, 0.4 %, 1-0.3 %, 1.4 %, 5-6 mg/ml

T1

atropine sulfate ophthalmic ointment 1 % T1

atropine sulfate ophthalmic solution 1 % T1

azelastine hcl ophthalmic solution 0.05 % T1

bacitracin ophthalmic ointment 500 unit/gm T1

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

T1

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

T1

betaxolol hcl ophthalmic solution 0.5 % T1

bimatoprost ophthalmic solution 0.03 % T1 ST; QL (5 ML per 30 days)

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % T1

84

Drug Status NotesBLINK TEARS OPHTHALMIC GEL 0.25 % T1

BLINK TEARS OPHTHALMIC SOLUTION0.25 % T1

brimonidine tartrate ophthalmic solution 0.2 % T1

carteolol hcl ophthalmic solution 1 % T1

CILOXAN OPHTHALMIC OINTMENT 0.3 % T1

ciprofloxacin hcl ophthalmic solution 0.3 % T1

cromolyn sodium ophthalmic solution 4 % T1

cvs lubricant drops ophthalmic gel 0.25-0.3 %, 1 %

T1

CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % T1

cyclopentolate hcl ophthalmic solution 1 % T1

dexamethasone sodium phosphate ophthalmic solution 0.1 %

T1

diclofenac sodium ophthalmic solution 0.1 % T1

dorzolamide hcl ophthalmic solution 2 % T1

dorzolamide hcl-timolol mal ophthalmic solution22.3-6.8 mg/ml

T1

epinastine hcl ophthalmic solution 0.05 % T1

EQ GENTLE LUBRICANT OPHTHALMIC SOLUTION 0.3 % T1

eq lubricating eye drops ophthalmic solution 0.5-0.9 %

T1

erythromycin ophthalmic ointment 5 mg/gm T1

eye allergy relief ophthalmic solution 0.025-0.3 %, 0.027-0.315 %

T1

eye drops allergy relief ophthalmic solution 0.05-0.25 %

T1

eye drops ophthalmic solution 0.012-0.2 % T1

eye lubricant ophthalmic ointment T1

FLAREX OPHTHALMIC SUSPENSION 0.1 % T1

fluorometholone ophthalmic suspension 0.1 % T1

flurbiprofen sodium ophthalmic solution 0.03 % T1

FML OPHTHALMIC OINTMENT 0.1 % T1

GENTAK OPHTHALMIC OINTMENT 0.3 % T1

gentamicin sulfate ophthalmic solution 0.3 % T1

85

Drug Status NotesGENTEAL MILD OPHTHALMIC SOLUTION 0.2 % T1

GONIOTAIRE OPHTHALMIC SOLUTION2.5 % T1

HOMATROPAIRE OPHTHALMIC SOLUTION 5 % T1

HYPOTEARS OPHTHALMIC SOLUTION 1-1 % T1

ISOPTO CARBACHOL OPHTHALMIC SOLUTION 3 % T1

ISOPTO HOMATROPINE OPHTHALMIC SOLUTION 2 % T1

ISOPTO TEARS OPHTHALMIC SOLUTION 0.5 % T1

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

T1

ketotifen fumarate ophthalmic solution 0.025 % T1 QL (5 ML per 30 days)

latanoprost ophthalmic solution 0.005 % T1 QL (5 ML per 30 days)

levobunolol hcl ophthalmic solution 0.25 % T1

levobunolol hcl ophthalmic solution 0.5 % T1 QL (5 ML per 18 days)

lubricant eye drops ophthalmic solution 0.4-0.3 %, 0.5 %, 0.6 %

T1

metipranolol ophthalmic solution 0.3 % T1

multi-purpose solution solution T1

MURO 128 OPHTHALMIC SOLUTION 2 % T1

naphazoline hcl ophthalmic solution 0.1 % T1

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

T1

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

T1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

T1

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

T1

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

T1

NEO-POLYCIN HC OPHTHALMIC OINTMENT 1 % T1

NUTRATEAR OPHTHALMIC SOLUTION0.6 % T1

ofloxacin ophthalmic solution 0.3 % T1

86

Drug Status NotesPHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 % T1

polymyxin b-trimethoprim ophthalmic solution10000-0.1 unit/ml-%

T1

PRED MILD OPHTHALMIC SUSPENSION0.12 % T1

prednisolone acetate ophthalmic suspension 1 % T1

prednisolone sodium phosphate ophthalmic solution 1 %

T1

proparacaine hcl ophthalmic solution 0.5 % T1

ra sterile eye drops ophthalmic solution 0.03-0.5 %

T1

redness relief max strength ophthalmic solution0.03-0.5 %

T1

REDNESS RELIEF OPHTHALMIC SOLUTION 0.012-0.25 % T1

redness reliever eye drops ophthalmic solution0.05 %

T1

REFRESH CELLUVISC OPHTHALMIC GEL 1 % T1

REFRESH LIQUIGEL OPHTHALMIC SOLUTION 1 % T1

REFRESH OPTIVE ADVANCED PF OPHTHALMIC SOLUTION 0.5-1-0.5 % T1

REFRESH OPTIVE SENSITIVE OPHTHALMIC SOLUTION 0.5-0.9 % T1

RETAINE MGD OPHTHALMIC EMULSION 0.5-0.5 % T1

sm redness relief ophthalmic solution 0.012-0.2 % T1

sodium chloride (hypertonic) ophthalmic ointment5 %

T1

sodium chloride (hypertonic) ophthalmic solution5 %

T1

SOOTHE OPHTHALMIC SOLUTION 0.6-0.6 % T1

STERILE LUBRICANT OPHTHALMIC LIQUID 0.7 % T1

sulfacetamide sodium ophthalmic ointment 10 % T1

sulfacetamide sodium ophthalmic solution 10 % T1

sulfacetamide-prednisolone ophthalmic solution10-0.23 %

T1

SYSTANE OPHTHALMIC GEL 0.4-0.3 % T1

87

Drug Status NotesSYSTANE OVERNIGHT THERAPY OPHTHALMIC GEL 0.3 % T1

tgt lubricant eye drops ophthalmic solution 0.95 %

T1

THERATEARS PF OPHTHALMIC SOLUTION 0.25 % T1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

T1

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 %, 0.5 % T1

TOBRADEX OPHTHALMIC OINTMENT0.3-0.1 % T1

tobramycin ophthalmic solution 0.3 % T1

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %


TOBREX OPHTHALMIC OINTMENT 0.3 % T1

travoprost ophthalmic solution 0.004 % T1 ST; QL (5 ML per 30 days)

trifluridine ophthalmic solution 1 % T1

tropicamide ophthalmic solution 0.5 %, 1 % T1

VASOCLEAR-A OPHTHALMIC SOLUTION 0.02-0.25 % T1

VISINE TEARS OPHTHALMIC SOLUTION0.2-0.36-1 % T1

*Otic Agents*acetic acid otic solution 2 % T1

acetic acid-aluminum acetate otic solution 2 % T1

antipyrine-benzocaine otic solution 5.4-1.4 % T1

ciprofloxacin hcl otic solution 0.2 % T1

ear drops otic solution 6.5 % T1

ear wax cleansing otic kit 6.5 % T1

hydrocortisone-acetic acid otic solution 1-2 % T1

neomycin-polymyxin-hc otic solution 1 % T1

neomycin-polymyxin-hc otic suspension 3.5-10000-1

T1

ofloxacin otic solution 0.3 % T1

pinnacaine otic otic solution 20 % T1

*Oxytocics*methylergonovine maleate oral tablet 0.2 mg T1

88

Drug Status Notes

*Passive Immunizing And Treatment Agents*RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT

T1 GR-F

SYNAGIS INTRAMUSCULAR SOLUTION100 MG/ML, 50 MG/0.5ML T1 PA

*Penicillins*amoxicillin oral capsule 250 mg, 500 mg T1

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

T1

amoxicillin oral tablet 500 mg, 875 mg T1

amoxicillin oral tablet chewable 125 mg, 250 mg T1

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

T1

amoxicillin-pot clavulanate oral tablet 250-125 mg


amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg


amoxicillin-pot clavulanate oral tablet chewable200-28.5 mg, 400-57 mg


ampicillin oral capsule 250 mg, 500 mg T1

ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

T1

BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION 900000-300000 UNIT/2ML T1 QL (4 ML per 28 days)

BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML T1 QL (4 ML per 28 days)

dicloxacillin sodium oral capsule 250 mg, 500 mg T1

penicillin v potassium oral solution reconstituted125 mg/5ml, 250 mg/5ml

T1

penicillin v potassium oral tablet 250 mg, 500 mg T1

*Pharmaceutical Adjuvants*benzyl alcohol liquid T1

cherry concentrate oral syrup T1

cherry oral syrup T1

FLAVOR BLEND ORAL SUSPENSION T1

flavor plus oral liquid T1

flavor sweet oral syrup T1

flavor sweet-sf oral liquid† T1

89

Drug Status Notesgrape syrup oral syrup T1

ORA-BLEND ORAL SUSPENSION T1

ORA-BLEND SF ORAL SUSPENSION T1

ORAL MIX ORAL LIQUID T1

ORAL MIX SF ORAL LIQUID T1

oral suspend oral liquid T1

oral syrup oral liquid T1

oral syrup sf oral liquid T1

ORA-PLUS ORAL LIQUID T1

ORA-SWEET ORAL SYRUP T1

ORA-SWEET SF ORAL SYRUP T1

PCCA SWEET-SF ORAL SYRUP T1

PCCA SYRUP VEHICLE ORAL SYRUP T1

PCCA-PLUS ORAL SUSPENSION T1

polyethylene glycol 3350 powder T1

simple syrup oral syrup T1

SYRPALTA (RED) ORAL SYRUP T1

syrpalta oral syrup T1

SYRSPEND SF ORAL LIQUID T1

VERSAFREE ORAL SYRUP T1

VERSAPLUS ORAL SYRUP T1

*Progestins*medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg


norethindrone acetate oral tablet 5 mg T1 GR-F; QL (60 EA per 30 days)

*Psychotherapeutic And Neurological Agents - Misc.*acamprosate calcium oral tablet delayed release333 mg

T1

AVONEX INTRAMUSCULAR KIT 30 MCG T1 PA

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML T1 PA

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML T1 PA

BETASERON SUBCUTANEOUS KIT 0.3 MG T1 PA

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg


CHANTIX ORAL TABLET 0.5 MG, 1 MG T1 QL (60 EA per 30 days)

90

Drug Status NotesCHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 T1 QL (60 EA per 30 days)

dimethyl fumarate oral capsule delayed release120 mg, 240 mg


disulfiram oral tablet 250 mg, 500 mg T1

donepezil hcl oral tablet 10 mg, 5 mg T1

EXTAVIA SUBCUTANEOUS KIT 0.3 MG T1 PA

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg

T1

glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml

T1 PA

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML T1 PA

MAYZENT ORAL TABLET 0.25 MG, 2 MG T1 PA

memantine hcl oral tablet 10 mg, 5 mg T1 QL (60 EA per 30 days)

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg T1 QL (49 EA per 365 days)

nicotine mini mouth/throat lozenge 2 mg T190 days of coverage per year; QL (270 EA per 30 days)

nicotine polacrilex mouth/throat gum 2 mg, 4 mg T190 days of coverage per year; QL (270 EA per 30 days)

nicotine polacrilex mouth/throat lozenge 4 mg T190 days of coverage per year; QL (270 EA per 30 days)

nicotine transdermal kit 21-14-7 mg/24hr T1 90 days of coverage per year

nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr

T1 90 days of coverage per year

NICOTROL INHALATION INHALER 10 MG T1 QL (168 EA per 30 days)

*Respiratory Agents - Misc.*PULMOZYME INHALATION SOLUTION 1 MG/ML T1 PA

*Sulfonamides*sulfadiazine oral tablet 500 mg T1

*Tetracyclines*doxycycline hyclate oral capsule 100 mg, 50 mg T1

doxycycline hyclate oral tablet 100 mg T1

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

T1

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg

T1

VIBRAMYCIN ORAL SYRUP 50 MG/5ML T1

91

Drug Status Notes

*Thyroid Agents*ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

T1

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

T1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

T1

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

T1

methimazole oral tablet 10 mg, 5 mg T1

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

T1

np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

T1

propylthiouracil oral tablet 50 mg T1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

T1

thyroid oral tablet 65 mg T1

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

T1

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG T1

WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

T1

*Ulcer Drugs/Antispasmodics/Anticholinergics*cimetidine hcl oral solution 300 mg/5ml T1 AL (Max 12 Years)

cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg

T1

dicyclomine hcl oral capsule 10 mg T1

dicyclomine hcl oral solution 10 mg/5ml T1

dicyclomine hcl oral tablet 20 mg T1

92

Drug Status Notesfamotidine intravenous solution 20 mg/2ml, 200 mg/20ml, 40 mg/4ml

T1

famotidine oral suspension reconstituted 40 mg/5ml


famotidine oral tablet 10 mg, 20 mg, 40 mg T1

famotidine premixed intravenous solution 20-0.9 mg/50ml-%

T1

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML T1 QL (150 ML per 30 days)

FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML T1 QL (150 ML per 30 days)

glycopyrrolate oral tablet 1 mg, 2 mg T1

hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg

T1

hyoscyamine sulfate oral elixir 0.125 mg/5ml T1

hyoscyamine sulfate oral solution 0.125 mg/ml T1

hyoscyamine sulfate oral tablet 0.125 mg T1

hyoscyamine sulfate oral tablet dispersible 0.125 mg

T1

hyoscyamine sulfate sublingual tablet sublingual0.125 mg

T1

lansoprazole oral capsule delayed release 15 mg T1 QL (60 EA per 30 days)

lansoprazole oral capsule delayed release 30 mg T1 QL (30 EA per 30 days)

misoprostol oral tablet 100 mcg, 200 mcg T1

omeprazole oral capsule delayed release 10 mg, 40 mg


omeprazole oral capsule delayed release 20 mg T1 QL (60 EA per 30 days)

pantoprazole sodium oral tablet delayed release20 mg


pantoprazole sodium oral tablet delayed release40 mg


PEPCID AC MAXIMUM STRENGTH ORAL TABLET CHEWABLE 20 MG T1

phenobarbital-belladonna alk oral elixir 16.2 mg/5ml

T1

propantheline bromide oral tablet 15 mg T1

ra omeprazole-sodium bicarb capsule 20-1100 mg oral 20-1100 mg


sucralfate oral tablet 1 gm T1

*Urinary Antispasmodics*bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

T1

93

Drug Status Notesoxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

T1

oxybutynin chloride oral syrup 5 mg/5ml T1

oxybutynin chloride oral tablet 5 mg T1

OXYTROL FOR WOMEN TRANSDERMAL PATCH TWICE WEEKLY 3.9 MG/24HR T1

OXYTROL TRANSDERMAL PATCH TWICE WEEKLY 3.9 MG/24HR T1

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

T1 ST

tolterodine tartrate oral tablet 1 mg, 2 mg T1 ST

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG T1 ST

trospium chloride er oral capsule extended release 24 hour 60 mg

T1 ST

trospium chloride oral tablet 20 mg T1 ST

VESICARE ORAL TABLET 10 MG, 5 MG T1 ST

*Vaccines*AFLURIA INTRAMUSCULAR SUSPENSION T1

QL (0.5 ML per 365 days); AL (Min 5 Years)

AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

T1QL (0.5 ML per 365 days); AL (Min 5 Years)

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION T1

QL (0.5 ML per 365 days); AL (Min 6 Months)

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML

T1QL (0.25 ML per 365 days); AL (Min 6 Months and Max 35 Months)

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


AFLURIA QUADRIVALENT SUSPENSION PREFILLED SYRINGE 0.5 ML INTRAMUSCULAR 0.5 ML


AFLURIA QUADRIVALENT SUSPENSION PREFILLED SYRINGE 0.5 ML INTRAMUSCULAR 0.5 ML


FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML T1


FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE0.5 ML


94

Drug Status NotesFLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

T1QL (0.5 ML per 365 days); AL (Min 6 Months)

FLUCELVAX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION T1


FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


FLUVIRIN INTRAMUSCULAR SUSPENSION T1


FLUVIRIN INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


FLUVIRIN PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


FLUZONE HIGH-DOSE SUSPENSION PREFILLED SYRINGE 0.5 ML INTRAMUSCULAR 0.5 ML


FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION T1


FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 0.5 ML T1


FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML

T1QL (0.25 ML per 365 days); AL (Min 6 Months and Max 35 Months)

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML


SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

T1QL (2 EA per 2 lifetimes); AL (Min 50 Years)

ZOSTAVAX SUBCUTANEOUS SOLUTION RECONSTITUTED 19400 UNT/0.65ML T1 AL (Min 60 Years)

*Vaginal And Related Products*CLEOCIN VAGINAL SUPPOSITORY 100 MG T1 GR-F

clindamycin phosphate vaginal cream 2 % T1 GR-F

95

Drug Status Notesclotrimazole 3 vaginal cream 2 % T1 GR-F

clotrimazole-7 vaginal cream 1 % T1 GR-F

estradiol vaginal cream 0.1 mg/gm T1 GR-F

estradiol vaginal tablet 10 mcg T1

GYNAZOLE-1 VAGINAL CREAM 2 % T1 GR-F

metronidazole vaginal gel 0.75 % T1 GR-F

miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm)

T1 GR-F

miconazole 3 vaginal suppository 200 mg T1 GR-F

miconazole 7 vaginal cream 2 % T1 GR-F

miconazole 7 vaginal suppository 100 mg T1 GR-F

terconazole vaginal cream 0.4 %, 0.8 % T1 GR-F

terconazole vaginal suppository 80 mg T1 GR-F

*Vasopressors*epinephrine solution auto-injector 0.15 mg/0.15ml injection 0.15 mg/0.15ml


epinephrine solution auto-injector 0.15 mg/0.3ml injection 0.15 mg/0.3ml


epinephrine solution auto-injector 0.3 mg/0.3ml injection 0.3 mg/0.3ml


midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg T1 QL (90 EA per 30 days)

SYMJEPI SOLUTION PREFILLED SYRINGE 0.15 MG/0.3ML INJECTION 0.15 MG/0.3ML


*Vitamins*ACEROLA C 500 ORAL WAFER 500 MG T1

ascocid-iso-ph oral powder effervescent T1

ascorbic acid injection solution 500 mg/ml T1

b1 natural oral tablet 250 mg T1

b-1 oral tablet 500 mg T1

B-2-400 ORAL CAPSULE 400 MG T1

benfotiamine oral capsule 150 mg T1

biotin 5000 oral capsule 5 mg T1

biotin forte oral tablet 3 mg T1

biotin oral capsule 1 mg, 2500 mcg T1

biotin oral tablet 10 mg, 1000 mcg, 300 mcg, 5 mg, 7500 mcg, 800 mcg

T1

B-NATAL MOUTH/THROAT LOZENGE 25 MG T1

96

Drug Status NotesB-NATAL MOUTH/THROAT LOZENGE ON A HANDLE 25 MG T1

BPROTECTED VITAMIN C ORAL LIQUID500 MG/5ML T1

buffered vitamin c oral capsule 1000 mg T1

calcium ascorbate oral tablet 500 mg T1

calcium pantothenate oral tablet 100 mg, 200 mg, 500 mg

T1

cvs biotin oral capsule 10 mg T1

cvs vitamin c oral tablet chewable 1000 mg T1

CYTO B2 ORAL POWDER 343 MG/GM T1

d 1000 oral tablet 25 mcg (1000 ut) T1

d 5000 oral tablet 125 mcg (5000 ut) T1

fruit c oral tablet chewable 100 mg T1

LEXINAL ORAL TABLET 2.5 MG T1

LIQUID C 500 ORAL LIQUID 500 MG/15ML T1

M2 POTASSIUM ORAL CAPSULE 60 MG T1

NEURO-K-250 T.D. ORAL CAPSULE 250 MG T1

niacin er oral capsule extended release 250 mg, 500 mg

T1

niacin er oral tablet extended release 1000 mg, 250 mg, 500 mg, 750 mg

T1

niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg T1

niacinamide oral tablet 100 mg, 500 mg T1

niacinamide oral tablet extended release 500 mg T1

paba oral tablet 100 mg T1

panto-250 oral capsule 250 mg T1

pantothenic acid oral tablet 500 mg T1

phytonadione oral tablet 5 mg T1

POTABA ORAL CAPSULE 500 MG T1

PROTEXIN ORAL SYRUP 500 MG/15ML T1

ra vitamin c oral tablet chewable 300 mg T1

riboflavin oral capsule 100 mg, 50 mg T1

riboflavin oral tablet 400 mg T1

sodium ascorbate granules T1

thiamine oral capsule 50 mg T1

vita-c oral crystals T1

vitamin b1 oral tablet 100 mg T1

vitamin b-1 oral tablet 100 mg, 250 mg, 50 mg T1

97

Drug Status Notesvitamin b-2 oral tablet 100 mg, 25 mg, 50 mg T1

vitamin b-6 er oral tablet extended release 200 mg

T1

vitamin b-6 oral tablet 100 mg, 25 mg, 250 mg, 50 mg, 500 mg

T1

vitamin b6 oral tablet 200 mg T1

vitamin c (calcium ascorbate) oral solution reconstituted

T1

vitamin c drops mouth/throat lozenge 60 mg T1

vitamin c er oral capsule extended release 500 mg T1

vitamin c er oral tablet extended release 1500 mg, 500 mg

T1

vitamin c gummie oral tablet chewable 120 mg T1

vitamin c oral capsule 500 mg T1

vitamin c oral syrup 500 mg/5ml T1

vitamin c oral tablet 100 mg, 1000 mg, 250 mg, 500 mg

T1

vitamin c oral tablet chewable 250 mg, 500 mg T1

vitamin c-rose hips er oral tablet extended release1000 mg

T1

vitamin d (cholecalciferol) oral capsule 10 mcg (400 unit)

T1 AL (Min 65 Years)

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)


vitamin d3 oral tablet 10 mcg (400 unit) T1QL (60 EA per 30 days); AL (Min 65 Years)

vitamin e oral capsule 400 unit T1

vitamin k (phytonadione) oral tablet 100 mcg T1

98

Index1st tier unifine pentips ................ 621st tier unifine pentips plus .........62abacavir sulfate .......................... 25abacavir sulfate-lamivudine ....... 25abacavir-lamivudine-zidovudine 25acamprosate calcium .................. 90acarbose ......................................13ACCU-CHEK TENDER 1 INFUSION .................................62acebutolol hcl ..............................28ACEPHEN ...................................4ACEROLA C 500 ..................... 96ACETADRYL ........................... 59ACETA-GESIC .........................34acetaminophen ..............................4acetaminophen er ..........................4acetaminophen-codeine ................ 5acetaminophen-codeine #2 ........... 5acetaminophen-codeine #3 ........... 5acetaminophen-codeine #4 ........... 5acetazolamide ............................. 53acetazolamide er .........................53acetic acid ...................................88acetic acid-aluminum acetate ..... 88acetone ........................................30acetylcysteine .............................. 34acidophilus/citrus pectin .............16acidophilus/pectin .......................16acne medication 10 ..................... 46acne medication 5 ....................... 46ACTIPHYTE OF LEMONGRASS ........................31acyclovir ......................................25adapalene ....................................46ADULT ACNOMEL ................ 46adult aspirin low strength .............4adult gummy ................................80ADVAIR DISKUS ...................... 9advanced lubricant ..................... 84ADVIL ALLERGY & CONGESTION ......................... 34ADVIL ALLERGY SINUS ......34ADVIL COLD & SINUS LIQUI-GELS .............................34ADVOCATE INSULIN PEN NEEDLES ..................................62ADVOCATE INSULIN SYRINGE .................................. 62AEROSPAN ................................ 9AFLURIA .................................. 94

AFLURIA PRESERVATIVE FREE ..........................................94AFLURIA QUADRIVALENT 94AGORAL MAXIMUM STRENGTH .............................. 60ALA-HIST PE ...........................34albuterol sulfate ............................ 9alclometasone dipropionate ........47alendronate sodium .................... 54aler-dryl ...................................... 18alevazol ....................................... 47alfuzosin hcl er ............................56ALKA-SELTZER HEARTBURN .............................6ALKA-SELTZER PLS ALLERGY & CGH .................. 34ALKA-SELTZER PLUS COLD & COUGH .................... 34ALKA-SELTZER PLUS COLD & FLU ........................... 34ALKA-SELTZER PLUS DAY/NIGHT ............................. 34ALKA-SELTZER PLUS NIGHT COLD .......................... 34ALKA-SELTZER PLUS SINUS .........................................34all day pain relf sinus/cold d ...... 34aller-chlor ................................... 18allergy multi-symptom day/nght . 35allergy spray 24 hour ..................83aller-time .....................................35allopurinol .................................. 57ALMACONE ...............................6alogliptin benzoate ......................13alogliptin-metformin hcl ............. 14alogliptin-pioglitazone ................14alprazolam .................................... 8amantadine hcl ............................24ambi 12.5cpd/100gfn/30pse ........35ambi 12.5cpd/1dcpm/30pse ........ 35amiloride hcl ...............................53amiloride-hydrochlorothiazide ... 53amiodarone hcl ............................. 8amitriptyline hcl ..........................12amlodipine besy-benazepril hcl .. 20amlodipine besylate .................... 29amlodipine besylate-valsartan ....20amlodipine-olmesartan ............... 20ammonium lactate .................31, 47amoxapine ...................................12amoxicillin .................................. 89

amoxicillin-pot clavulanate ........ 89amphetamine-dextroamphet er ..... 1amphetamine-dextroamphetamine .......................1ampicillin .................................... 89anagrelide hcl ............................. 57anastrozole ..................................22ANBESOL ................................. 79ANECREAM .............................47anefrin spray ...............................83anesthesia extension tubing ........ 62ANORO ELLIPTA .....................9antacid .......................................... 6antacid & antigas ......................... 6antacid extra strength ................... 6antacid multi-symptom ..................6antioxidant formula sg ................80antipyrine-benzocaine .................88anti-stick insulin syringe .............62apap .............................................. 4ap-hist dm ................................... 35APRISO ..................................... 55APTIVUS ...................................25ARANELLE .............................. 32ARGYLE EXTENSION TUBE 20" .................................. 62ARGYLE STERILE WATER .79aripiprazole .................................24armodafinil ................................... 1ARMOUR THYROID ..............92artificial tears ............................. 84ascocid-iso-ph .............................96ascorbic acid ...............................96ASCRIPTIN ................................ 4ASPERCREME LIDOCAINE 47ASPERCREME W/LIDOCAINE ........................ 47aspirin ........................................... 4aspirin adult low strength .............4aspirin low dose ............................4aspirtab maximum strength .......... 4ASSURE DOSE CONTROL ... 62ASSURE ID INSULIN SAFETY SYR ............................62ATABEX ....................................80ATABEX EC ............................. 80atazanavir sulfate ........................25atenolol ....................................... 28atenolol-chlorthalidone .............. 20atomoxetine hcl .............................1atorvastatin calcium ................... 19

99

atovaquone ..................................21atropine sulfate ........................... 84ATROVENT HFA ...................... 9aurora pen needles ......................62aurora unifine pentips .................62AUTOJECT 2 ............................62autopen ....................................... 62AVONEX ................................... 90AVONEX PEN .......................... 90AVONEX PREFILLED ........... 90azathioprine ................................ 79azelastine hcl .............................. 84azithromycin ............................... 62b-1 ............................................... 96b1 natural ....................................96B-2-400 ....................................... 96bacitracin ..............................47, 84bacitracin zinc ............................ 47bacitracin-neomycin-polymyxin ..47bacitracin-polymyxin b ............... 84bacitra-neomycin-polymyxin-hc . 84baclofen .......................................83balsalazide disodium .................. 55BASIS OVERNIGHT ...............47b-complex balanced .................... 80b-complex/vitamin c ....................80BD ANGIOCATH AUTOGUARD .......................... 62BD AUTOSHIELD ................... 62BD AUTOSHIELD DUO ......... 63BD ECLIPSE SYRINGE ......... 63BD FIRST MIDCATH 18G/4FRX20CM ....................... 63BD FIRST MIDCATH 20G/3FRX20CM ....................... 63BD FIRST PICC 16G/5FRX65CM ....................... 63BD FIRST PICC 18G/4FRX65CM ....................... 63BD FIRST PICC 20G/3FRX65CM ....................... 63BD FIRST PICC 22G/2.8FRX50CM .................... 63BD FIRST PICC 26G/1.9FRX50CM .................... 63BD INSULIN SYR ULTRAFINE II .........................63BD INSULIN SYRINGE ..........63BD INSULIN SYRINGE HALF-UNIT ..............................63BD INSULIN SYRINGE MICROFINE .............................63

BD INSULIN SYRINGE U/F .. 63BD INSULIN SYRINGE U-40 .63BD INSULIN SYRINGE ULTRAFINE .............................63BD INTEGRA INSULIN SYRINGE .................................. 63BD INTEGRA SYRINGE ........63BD L-CATH 16G/5FR ..............63BD L-CATH 16G/5FRX60CM 63BD L-CATH 18G/3.5FR ...........63BD L-CATH 18G/3.5FRX60CM .................... 63BD L-CATH 20G/2.6FR ...........64BD L-CATH 20G/2.6FRX60CM .................... 64BD L-CATH 20G/3FR ..............64BD L-CATH 20G/3FRX60CM 64BD L-CATH 28G/1.2FRX25CM .................... 64BD L-CATH MIDLINE 18G/3.5FRX20 ...........................64BD L-CATH MIDLINE 20G/3FRX20CM ....................... 64BD LUER-LOK SYRINGE ..... 64BD NEXIVA 18GX1.25" ..........64BD NEXIVA 18GX1.75" ..........64BD NEXIVA 20GX1" ...............64BD NEXIVA 20GX1.25" ..........64BD NEXIVA 20GX1.75" ..........64BD NEXIVA 22GX1" ...............64BD NEXIVA 24GX0.56" ..........64BD NEXIVA 24GX0.75" ..........64BD PEN NEEDLE MINI U/F .. 64BD PEN NEEDLE NANO U/F ..............................................64BD PEN NEEDLE ORIGINAL U/F ........................ 64BD PEN NEEDLE SHORT U/F ..............................................64BD SAFETYGLIDE INSULIN SYRINGE ................ 64BD SAFETY-LOK INSULIN SYRINGE .................................. 64BD SAFETY-LOK SET ........... 64BD SAFETY-LOK VACUTAINER SET .................64BD SAF-T E-Z SET .................. 64BD SAF-T-INTIMA 18G X 1" 64BD SAF-T-INTIMA 20GX1" .. 64BD SAF-T-INTIMA 22G X 0.75" ........................................... 64

BD SAF-T-INTIMA 22GX3/4" ................................... 64BD SAF-T-INTIMA 24G X 0.75" ........................................... 64BD SAF-T-INTIMA 24GX3/4" ................................... 64BD SYRINGE/NEEDLE .......... 64BD SYRINGE/NEEDLE SLIP TIP ....................................64BD VACUTAINER SET .......... 65benazepril hcl ..............................20benazepril-hydrochlorothiazide ..20benfotiamine ............................... 96benzonatate ................................. 35BENZ-O-STHETIC ..................79benzoyl peroxide ......................... 47benzoyl peroxide cleanser ...........47benzoyl peroxide wash ................47benzoyl peroxide-erythromycin ...47benztropine mesylate ...................24benzyl alcohol ............................. 89benzyl benzoate ...........................31betamethasone dipropionate .......47betamethasone dipropionate aug .............................................. 47betamethasone valerate .............. 47BETASERON ............................90betaxolol hcl ................................84bethanechol chloride ...................93bicalutamide ............................... 23BICARSIM ................................55BICARSIM FORTE ................. 55BICILLIN C-R ..........................89BICILLIN C-R 900/300 ............89BIKTARVY ...............................25bimatoprost ................................. 84biobron sf .................................... 35biodesp dm .................................. 35biogtuss ....................................... 35bionatuss dxp .............................. 35bionel .......................................... 35bionel pediatric ...........................35biospec dmx .................................35biotin ........................................... 96biotin 5000 .................................. 96biotin forte .................................. 96biovol .......................................... 80bisacodyl ..................................... 60bisacodyl ec .................................60bismuth ........................................16bisoprolol fumarate .................... 28bisoprolol-hydrochlorothiazide .. 20

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BLEPHAMIDE S.O.P. ............. 84BLINK TEARS ......................... 85B-NATAL ............................ 96, 97bp cleansing ................................ 47bp cleansing wash .......................47bpm-dm-phen .............................. 35BPROTECTED VITAMIN C ..97BRAINSTRONG PRENATAL .............................. 80BRASIVOL ............................... 47BREO ELLIPTA ........................ 9BRILINTA .................................57brimonidine tartrate ....................85bromocriptine mesylate ...............24bronchial asthma relief ...............35BRONCOTRON PED .............. 35BRONCOTRON PED DROPS .......................................35BRONCOTRON-S ....................35BRONKAID .............................. 35bronkids ...................................... 35brotapp dm ..................................35budesonide .................................... 9budesonide-formoterol fumarate .. 9buffasal ......................................... 4buffered aspirin .............................4buffered vitamin c ....................... 97bumetanide ..................................53bupropion hcl ..............................13bupropion hcl er (smoking det) ...90bupropion hcl er (sr) ...................13bupropion hcl er (xl) ...................13buspirone hcl ................................ 8butalbital-acetaminophen ............. 4butalbital-apap-caff-cod ............... 5butalbital-apap-caffeine ............... 4butalbital-asa-caff-codeine ...........5butalbital-aspirin-caffeine ............ 4BYSTOLIC ................................28cal/mag ....................................... 75CALAGESIC .............................47CALCET CREAMY BITES ....75calcitonin (salmon) ..................... 54cal-citrate plus vitamin d ............ 75calcitriol ......................................54calcium ........................................76calcium + d3 ............................... 75calcium 1000 + d ........................ 75calcium 500 + d .......................... 75calcium 500/d ..............................75calcium 500+d ............................ 75calcium 500+d high potency ...... 75

calcium 600/vitamin d .................75calcium 600+d ............................ 75calcium 600+d3 .......................... 75calcium acetate (phos binder)...............................................55, 56calcium antacid ultra ....................6calcium ascorbate .......................97calcium carbonate .......................75calcium carbonate antacid ............6calcium carbonate-vitamin d ...... 75calcium citrate ............................ 75calcium citrate + d ......................75calcium citrate + d3 ....................75calcium citrate malate-vit d ........ 75calcium citrate+d3 petites .......... 75calcium citrate-vitamin d ............75calcium citrate-vitamin d3 ..........75calcium magnesium 750 ..............75calcium pantothenate ..................97calcium plus vitamin d ................ 76calcium/vitamin d3 gummies ...... 76calcium-carb 600 + d ................. 76calcium-magnesium .................... 76calcium-vitamin d ....................... 76calcium-vitamin d3 ..................... 76cal-mag aspartate ....................... 76CAL-MAG CHELA-MAX .......76calmag thins ................................76CAL-QUICK ............................. 76camphor spirit .............................31capcof ..........................................35capecitabine ................................23capmist dm .................................. 35capron dm ................................... 35capsaicin ..................................... 47captopril ......................................20captopril-hydrochlorothiazide ....20CAPZASIN ................................47carbamazepine ............................11carbamazepine er ........................11CARBAPHEN CH .................... 35CARBAPHEN PED CH ........... 35carbidopa ....................................24carbidopa-levodopa ....................24carbidopa-levodopa er ................24CAREFINE PEN NEEDLES ...65careone insulin syringe ...............65careone unifine pentips ...............65careone unifine pentips plus ....... 65CAROSPIR ............................... 53carteolol hcl ................................ 85CARTIA XT .............................. 29

carvedilol .................................... 28CASTIVA WARMING ............ 47CCP CAFFEINE FREE ........... 35cefaclor ....................................... 30cefadroxil .................................... 30cefdinir ........................................30cefpodoxime proxetil ...................30cefprozil ...................................... 30CEFTIN ..................................... 30ceftriaxone sodium ......................30cefuroxime axetil .........................30celecoxib ....................................... 2CELLCEPT ...............................79CENTRUM SPECIALIST PRENATAL .............................. 80cephalexin ................................... 30CERTUSS-D ..............................35cetirizine hcl ................................18cetirizine-pseudoephedrine er .....35CHANTIX ................................. 90CHANTIX STARTING MONTH PAK ........................... 91chelated magnesium ....................76CHEMET ...................................17cheratussin ac ............................. 35cheratussin dac ........................... 35cherry ..........................................89cherry concentrate ...................... 89chest congestion daytime ............ 36chest congestion relief pe ............36chest congestion/pain & sinus .... 36child chewable vitamins/iron ......80childrens cough ...........................36childrens cough/runny nose ........36childrens gummies ...................... 80childrens multivitamin ................ 80childrens plus cold ......................36childrens plus cold & allergy ..... 36childrens plus flu .........................36childrens silfedrine ..................... 83CHILDRENS SOOTHE .............6CHLO TUSS ..............................36chlo tuss ex ..................................36chlophed ......................................36chlordiazepoxide hcl .....................8chlorhexidine gluconate ........31, 79chloroform .................................. 31chloroquine phosphate ................22chlorothiazide ............................. 53chlorpheniramine maleate .......... 18chlorpheniramine maleate er ......18chlorpropamide ...........................14

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chlorthalidone .............................53chlorzoxazone ............................. 83cholestyramine ............................19cholestyramine light ....................19choline & mag trisalicylate .......... 4choline-mag trisalicylate .............. 4ciclopirox .................................... 47cilostazol ..................................... 57CILOXAN ................................. 85cimetidine ....................................92cimetidine hcl ..............................92CIPRO ....................................... 55ciprofloxacin hcl ............. 55, 85, 88citalopram hydrobromide ........... 13citric acid-sodium citrate ............56CITROCARBONATE ................6clarithromycin .............................62CLARITIN CHILDRENS ........18CLEAN & CLEAR ACNE CONTROL ................................ 48clemastine fumarate ....................18CLEOCIN ..................................95clickfine pen needles ................... 65clindamycin hcl ...........................21clindamycin palmitate hcl ...........21clindamycin phosphate ......... 48, 95CLINICAL NUTRIENTS PRENATAL .............................. 80clobetasol propionate ................. 48clonazepam ................................. 11clonidine hcl ................................20clopidogrel bisulfate ................... 57clorazepate dipotassium ............... 8clotrimazole .......................... 48, 79clotrimazole 3 ............................. 96clotrimazole-7 ............................. 96clotrimazole-betamethasone ....... 48clozapine ..................................... 24codeine sulfate .............................. 5codituss dm ................................. 36colchicine ....................................57colchicine-probenecid .................57cold & cough childrens ...............36cold & cough day/night child ..... 36cold & cough daytime .................36cold & flu nighttime/daytime ...... 36cold & flu relief nighttime d ........36cold & flu severe daytime ........... 36cold control pe cold/flu med ....... 36cold head congestion daytime .....36cold head congestion nighttime .. 36cold multi-symptom day/night .....36

cold multi-symptom warm night . 36cold relief plus ............................ 36cold/flu relief ...............................37cold/flu relief day/night ...............36cold/flu relief nighttime ...............36colestipol hcl ...............................19COMFORT EZ INSULIN SYRINGE .................................. 65COMFORT EZ PEN NEEDLES ..................................65COMPLERA ............................. 26COMPLETE FORMULATION PEDIATRIC ..............................80complete natal dha ......................80complete prenatal/dha ................ 80complete protein/vitamin shake .. 52complete sinus relief ................... 37CONEX COLD/ALLERGY .... 37CONTAC COLD+FLU MAX ST ............................................... 37cool mist humidifier .................... 65CORICIDIN HBP CONGESTION/COUGH ......... 37CORICIDIN HBP DAY/NIGHT COLD .................37CORICIDIN NIGHTTIME COLD-COUGH ........................ 37CORNWALL METAL PIPETTING .............................. 65CORRECTOL HERBAL TEA ............................................ 60cortisone acetate .........................33CORTISPORIN ........................ 48CORTIZONE-10/ALOE .......... 48CORVITA ................................. 80cottonseed oil .............................. 31cough & cold ...............................37cough & sore throat nighttime ....37cough daytime/nighttime .............37CREON ......................................52CRIXIVAN ................................26cromolyn sodium ...................83, 85CRYOSERV ..............................31CULTURELLE DIGESTIVE HEALTH ................................... 16CURITY ALCOHOL PREPS . 65cvs allergy childrens ................... 18cvs antacid & anti-gas .................. 6cvs antacid supreme ......................7cvs biotin .....................................97cvs calcium ..................................76

cvs cortisone cooling relief .........48cvs cough & sore throat child .....37cvs gas relief drops ex st .............56cvs heartburn relief ex st ...............7cvs hydrocortisone acetate ..........48cvs lubricant drops ..................... 85cvs mini enema kids .................... 60cvs nasal allergy spray ............... 83cvs natural fiber supplement .......60cvs non-drying sinus pe ...............37cvs oyster shell calcium+vit d .....76cvs prenatal gummy .................... 81cvs targeted acne spot .................48cvs vitamin c ................................97cyanocobalamin ..........................57cyclobenzaprine hcl .................... 83CYCLOMYDRIL ..................... 85cyclopentolate hcl ....................... 85cyclophosphamide .......................23cyclosporine ................................79cyclosporine modified .................79cyproheptadine hcl ......................18CYTO B2 ................................... 97cytra k crystals ............................56cytra-2 .........................................56CYTRA-3 ...................................56cytra-k ......................................... 56d 1000 ......................................... 97d 5000 ......................................... 97daily multiple vitamins/min .........81DAILY PAK MAXIMUM MULTIVITAMIN .....................81daily vitamin plus ........................81daily-vitamin ............................... 81DALLERGY ..............................37dapsone ....................................... 21day time pe cold/flu relief ........... 37daytime cold & cough childrens . 37DAYTIME COLD MEDICINE ............................... 37DELSYM CGH/CLD NIGHTTIME CHILD .............. 37DELTUSS DMX ........................37DELTUSS DP ............................37DENOREX DUAL FORCE ..... 48DENTS TOOTHACHE ............79denture adhesive ......................... 65DESCOVY .................................26DESGEN DM ............................ 37DESGEN PEDIATRIC ............ 37desmopressin ace spray refrig .... 54desmopressin acetate .................. 54

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desmopressin acetate spray ........ 54desogestrel-ethinyl estradiol .......32desonide ...................................... 48despec dm ....................................37despec-dm ................................... 37DEWEES CARMINATIVE .......7dexamethasone ............................33DEXAMETHASONE INTENSOL ................................33dexamethasone sodium phosphate ....................................85dexchlorpheniramine maleate .....18dexmethylphenidate hcl .................1dexmethylphenidate hcl er ............ 1dextroamphetamine sulfate ...........1dextroamphetamine sulfate er .......1dextromethorphan-guaifenesin ... 38DIABETIC TUSSIN COLD & FLU ............................................ 38DIABETIC TUSSIN NIGHT COLD/FLU ................................38DIALYVITE SUPREME D ..... 81DIASTAT ACUDIAL ...............11diazepam ................................. 8, 11diclofenac potassium .................... 2diclofenac sodium ............. 2, 48, 85diclofenac sodium er .....................2dicloxacillin sodium ....................89dicyclomine hcl ........................... 92didanosine ...................................26DIFFERIN ................................. 48DIFIL-G FORTE ........................ 9diflorasone diacetate .................. 48diflunisal ....................................... 5digoxin ........................................ 30DILANTIN ................................ 11diltiazem cd .................................29diltiazem hcl ................................29diltiazem hcl er ........................... 29diltiazem hcl er beads ................. 29diltiazem hcl er coated beads ......29dilt-xr .......................................... 29dimenhydrinate ........................... 17DIMETAPP LONG ACT COUGH/COLD .........................38dimethyl fumarate ....................... 91dimethyl sulfoxide ....................... 31diocto .......................................... 60diphenhist ....................................18diphenhydramine hcl ...................18diphenhydramine hcl (sleep) .......59diphenhydramine-apap (sleep) ... 59

diphenoxylate-atropine ............... 16dipyridamole ............................... 57disopyramide phosphate ............... 8disulfiram ....................................91DIURIL ......................................53divalproex sodium .......................11divalproex sodium er .................. 11docosanol ....................................48docusate calcium .........................60docusate sodium ..........................60DOCUSOL MINI ......................60DOCUSOL PLUS MINI-ENEMA ..................................... 60DOLOGEN ................................38dometuss-da/children ..................38dometuss-dmx ..............................38donepezil hcl ............................... 91DORIBAX ................................. 21dorzolamide hcl .......................... 85dorzolamide hcl-timolol mal .......85doxazosin mesylate ..................... 20doxepin hcl ..................................13doxycycline hyclate ..................... 91doxycycline monohydrate ........... 91doxylamine-phenylephrine ..........38dr manzanilla pe ......................... 38DRAMAMINE .......................... 17dronabinol ...................................17drospirenone-ethinyl estradiol ....32drug mart unifine pentips ............65drug mart unifine pentips plus ....65DULERA ..................................... 9duloxetine hcl ..............................13DUPIXENT ............................... 48DURAVENT PE ........................38ear drops .....................................88ear wax cleansing ....................... 88EASIVENT ................................65EASIVENT MASK LARGE ....65EASIVENT MASK MEDIUM 65EASIVENT MASK SMALL ....65easy comfort insulin syringe ....... 65easy comfort pen needles ............ 65EASY TOUCH FLURINGE ....65EASY TOUCH INSULIN SAFETY SYR ............................65EASY TOUCH INSULIN SYRINGE .................................. 66EASY TOUCH PEN NEEDLES ..................................66EASY TOUCH SAFETY SYRINGE .................................. 66

econazole nitrate .........................48ed bron gp ................................... 38ED CHLORPED ....................... 18ED CHLORPED D ................... 38ed-a-hist dm ................................ 38EDURANT .................................26efavirenz ......................................26efavirenz-emtricitab-tenofovir .... 26efavirenz-lamivudine-tenofovir ...26effaclar duo .................................48ELDERTONIC ......................... 81ELIGARD ..................................23elite ca/mg ...................................76ELITE IRON .............................57elite-thin insulin syringe ............. 66ELLA ......................................... 32emtricitabine ............................... 26emtricitabine-tenofovir df ........... 26EMTRIVA ................................. 26enalapril maleate ........................ 20enalapril-hydrochlorothiazide ....20ENBREL ......................................3ENBREL SURECLICK ............. 3ENDACOF-DM .........................38ENDACON ................................ 38enoxaparin sodium ......................11entacapone ..................................24ENTEX LQ ................................38ENTEX T ...................................38entre-cough ................................. 38epinastine hcl .............................. 85epinephrine ................................. 96EPITOL ..................................... 12EPIVIR HBV .............................26EPOGEN ................................... 57eq allergy/sinus headache ...........38eq childrens cold .........................38eq cold plus ................................. 38eq cold relief complete ................38eq cold/cough plus ...................... 38eq daytime cold/flu relief ............ 38eq flu & severe cold & cough ..... 38eq flu relief ..................................38eq flu/severe cold/congestion ......38EQ GENTLE LUBRICANT ....85eq lubricating eye drops ............. 85eq nasal allergy ...........................83eq night time cold & cough .........39eq nite time cold/flu relief ........... 39eq nitetime cold/flu ms relief .......39eq non-drying sinus .....................39eq sinus congestion & pain .........39

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eq triacting cold/allergy ............. 39eql calcium/vitamin d ..................76eql childrens multivitamins .........81eql congestion relief ....................39eql gummies childrens ................ 81eql insulin syringe .......................66eql vitamin d-3 high potency .......76EQUALACTIN ......................... 60ERLEADA .................................23erythromycin ......................... 48, 85escitalopram oxalate ...................13estazolam .................................... 59estradiol ................................ 55, 96estradiol-norethindrone acet ...... 55estropipate .................................. 55eszopiclone ..................................59ethambutol hcl ............................ 22ether ............................................ 31ethosuximide ............................... 12ethyl alcohol ................................31ethyl alcohol (rubbing) ............... 31ethyl chloride .............................. 48EUCERIN ..................................48eugenol ........................................31EVAC-U-GEN ...........................60EXEL COMFORT POINT INSULIN SYR ...........................66EXODERM ............................... 48EXTAVIA ..................................91eye allergy relief ......................... 85eye drops .....................................85eye drops allergy relief ............... 85eye lubricant ............................... 85ezetimibe ..................................... 19EZFE 200 ...................................57E-Z-GAS II .................................. 7famciclovir .................................. 26famotidine ................................... 93famotidine premixed ................... 93FASENRA ................................... 9felodipine er ................................ 29FEMIRON ................................. 57FENESIN DM IR ......................39fenofibrate ...................................19fenofibrate micronized ................ 19fenoprofen calcium ....................... 3fentanyl ......................................... 5ferretts .........................................57ferretts chewable iron ................. 57ferretts ips ................................... 57FERRIMIN 150 .........................57ferrous aspartate .........................57

ferrous fumarate ......................... 57ferrous gluconate ........................ 57ferrous sulfate ............................. 58ferrous sulfate er .........................58fexofenadine hcl .......................... 18fexofenadine hcl childrens .......... 18FIASP .........................................14FIASP FLEXTOUCH .............. 14FIASP PENFILL ...................... 14fiber laxative ............................... 60fiber therapy ................................60FIFTY50 PEN NEEDLES ........66FIFTY50 SUPERIOR COMFORT SYR ...................... 66finasteride ................................... 56first aid antibiotic ....................... 48FIRST-LANSOPRAZOLE ...... 93FIRST-OMEPRAZOLE .......... 93FIRST-VANCOMYCIN 25 ......21FIRST-VANCOMYCIN 50 ......22FIRVANQ ..................................22FLAREX ....................................85FLAVOR BLEND .....................89flavor plus ................................... 89flavor sweet .................................89flavor sweet-sf .............................89flecainide acetate .......................... 8FLEET BISACODYL .............. 60FLEET NATURALS CLEANSING ENEMA ...............6FLINTSTONES TODDLER ....81FLOVENT DISKUS ................... 9FLOVENT HFA ..........................9flu & sore throat ......................... 39flu/severe cold & cough day ....... 39FLUAD .......................................94FLUAD QUADRIVALENT .....94FLUARIX QUADRIVALENT 95FLUCELVAX ........................... 95fluconazole ..................................17fludrocortisone acetate ............... 34fluid administration set ............... 66FLULAVAL QUADRIVALENT ................... 95fluocinolone acetonide ................49fluocinolone acetonide body ....... 48fluocinolone acetonide scalp ...... 49fluocinonide ................................ 49fluocinonide-e ............................. 49fluorometholone ..........................85fluorouracil ................................. 49fluoxetine hcl ...............................13

fluphenazine hcl .......................... 24flurazepam hcl ............................ 59flurbiprofen ................................... 3flurbiprofen sodium .................... 85flutamide ..................................... 23fluticasone propionate .......... 49, 83fluticasone-salmeterol .............9, 10FLUVIRIN .................................95FLUVIRIN PRESERVATIVE FREE ..........................................95fluvoxamine maleate ................... 13FLUZONE HIGH-DOSE .........95FLUZONE QUADRIVALENT ................... 95FML ........................................... 85FOLGARD OS .......................... 81folic acid ..................................... 58FOLITAB 500 ........................... 58FORADIL AEROLIZER .........10fosamprenavir calcium ............... 26fosinopril sodium ........................ 20fosinopril sodium-hctz ................ 20fosphenytoin sodium ................... 12freds pharmacy unifine pentip+ ..66freds pharmacy unifine pentips ...66FREESTYLE CONTROL SOLUTION ............................... 66FREESTYLE PRECISION INS SYR .....................................66fruit c ...........................................97FUNGOID TINCTURE ........... 49furosemide ...................................53gabapentin .................................. 12galantamine hydrobromide .........91GAS-X EXTRA STRENGTH ..56gauze sponge ...............................66GAVILYTE-C ...........................60GAVILYTE-G ...........................60GAVISCON .................................7GEL-TIN ................................... 79gemfibrozil .................................. 19GENCONTUSS .........................39GENGRAF ................................ 79GENOTROPIN ......................... 54GENOTROPIN MINIQUICK .54GENTAK ................................... 85gentamicin sulfate .................49, 85GENTEAL MILD .....................86GENVOYA ................................26geri-mucil ....................................60glatiramer acetate .......................91GLATOPA .................................91

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GLEOSTINE .............................23glimepiride ..................................14glipizide .......................................14glipizide xl ...................................14glipizide-metformin hcl ...............14global ease inject pen needles .... 66global inject ease insulin syr ...... 66glucagon emergency ................... 14GLUCOCARD EXPRESSION CONTROL ......67GLUCOCARD EXPRESSION TEST ................52GLUCOCARD VITAL TEST . 52GLUCOPRO INSULIN SYRINGE .................................. 67glyburide ..................................... 14glyburide micronized .................. 14glyburide-metformin ................... 14glycerin ................................. 31, 49glycerin (adult) ........................... 60glycerin (infants & children) ...... 60glycerin adult .............................. 60glycerine ......................................31glycerol formal ............................31glycine soya extract .................... 31glycine soya protein ....................31glycopyrrolate .............................93gnp 24 hour nasal allergy ...........83gnp alcohol denatured ................ 31gnp calcium 500 +d3 .................. 76gnp clickfine pen needles ............ 67gnp foaming antacid ..................... 7gnp insulin syringe ......................67gnp peppermint spirit ..................31gnp sodium silicate ..................... 31gnp ultra com insulin syringe ..... 67GOLYTELY ..............................60GONIOTAIRE ..........................86goodsense nasal allergy spray ....84G-P-TUSS DXP .........................39GRANDPAS THYLOX SOAP ..........................................49granisetron hcl ............................17granulderm ................................. 49grape syrup ................................. 90griseofulvin microsize .................17griseofulvin ultramicrosize ......... 18G-TRON PEDIATRIC DROPS .......................................39guaiacol ...................................... 31guaifenesin ..................................39guaifenesin dm ............................ 39

guaifenesin er ..............................39guaifenesin-dm ............................39guanfacine hcl .............................20guanfacine hcl er .......................... 1GYNAZOLE-1 .......................... 96G-ZYNCOF ............................... 39H 468L TUBING .......................67halobetasol propionate ............... 49haloperidol ..................................24haloperidol decanoate ................ 24HC DERMAPAX ...................... 49healthwise mini pen needles ....... 67healthwise pen needles ................67healthwise short pen needles ...... 67healthwise unifine pentips ...........67healthy accents unifine pentip .....67HEALTHY MAMA BE WELL ROUNDED ................... 81heartburn antacid ex st ................. 7h-e-b incontrol pen needles .........67HEMATOGEN FORTE ...........58heparin sodium (porcine) ............11heparin sodium (porcine) pf ....... 11HERBAL EXPEC .....................39HEXALEN .................................23high potency iron ........................ 58HISTEX-DM ............................. 39hist-pse ........................................39hm iron ........................................58HM ULTICARE INSULIN SYRINGE .................................. 67HOMATROPAIRE .................. 86HONEY BEARS W/IRON-ZINC .......................................... 81HUBER INFUSION SET ......... 67HUMAPEN LUXURA HD .......67HUMATROPEN FOR 12MG ..67HUMATROPEN FOR 24MG ..67HUMATROPEN FOR 6MG ....67HUMIRA ..................................... 3HUMIRA PEDIATRIC CROHNS START .......................3HUMIRA PEN ............................ 3HUMIRA PEN-CD/UC/HS STARTER ................................... 3HUMIRA PEN-PS/UV/ADOL HS START ...................................3hydralazine hcl ............................20hydrochlorothiazide ....................53HYDROCIL .............................. 61hydrocod polst-cpm polst er ....... 39hydrocodone-acetaminophen ........5

hydrocodone-homatropine ..........39hydrocortisone .................. 6, 34, 49hydrocortisone max st .................49hydrocortisone valerate .............. 49hydrocortisone-acetic acid ......... 88hydrocortisone-aloe ....................49hydromorphone hcl .......................5hydroxychloroquine sulfate .........22hydroxyprogesterone caproate ... 31hydroxyurea ................................ 23hydroxyzine hcl ............................. 8hydroxyzine pamoate .................... 8hyoscyamine sulfate .................... 93hyoscyamine sulfate er ................93HYPOTEARS ........................... 86ibandronate sodium .................... 54ibuprofen .......................................3ibu-profen cold/sinus .................. 39ibuprofen pm ...............................59IFEREX 150 .............................. 58imatinib mesylate ........................ 23imipramine hcl ............................ 13INCRUSE ELLIPTA ................10indapamide ................................. 53INDOCIN .....................................3indomethacin .................................3infants pain relief ..........................5infusion set .................................. 67infusion set 23" comfort ..............67inject-ease ................................... 67INJECT-EASE AUTOMATIC INJECTOR ..... 67INSUFLON ................................67insulin syringe .......................67, 68insulin syringe/needle ................. 68insupen pen needles .................... 68INSUPEN SENSITIVE ............ 68INSUPEN ULTRAFIN .............68INSYTE AUTOGUARD 14GX1.75" ................................. 68INSYTE AUTOGUARD 18GX1.16" ................................. 68INSYTE AUTOGUARD 20GX1" ...................................... 68INSYTE AUTOGUARD 20GX1.16" ................................. 68INSYTE AUTOGUARD 22GX1" ...................................... 68INSYTE AUTOGUARD 24GX3/4" ................................... 68INTELENCE .............................26intense cough reliever .................39

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INTRON A ................................ 23INVIRASE .................................26INVOKAMET ...........................14INVOKAMET XR .................... 14INVOKANA .............................. 14ipratropium bromide .............10, 84irbesartan ....................................20irbesartan-hydrochlorothiazide ..20iron ..............................................58iron (ferrous gluconate) ..............58iron chews pediatric ................... 58iron complex ............................... 58IRON UP ....................................58ISENTRESS .............................. 26isoniazid ......................................22isopropyl alcohol ........................ 31isopropyl alcohol (rubbing) ........31isopropyl alcohol wipes .............. 49isopropyl palmitate ..................... 31ISOPTO CARBACHOL .......... 86ISOPTO HOMATROPINE ..... 86ISOPTO TEARS .......................86isosorbide dinitrate .......................7isosorbide dinitrate er ...................7isosorbide mononitrate ................. 7isosorbide mononitrate er .............7isradipine .................................... 29itraconazole ................................ 18ivermectin ......................................7JANTOVEN .............................. 11JANUMET .................................14JANUMET XR ..........................14JANUVIA .................................. 14JARDIANCE .............................14JINTELI .................................... 55KALETRA .................................26KANGAROO BURETTE SET .............................................68KELNOR 1/35 ...........................32ketoconazole ..........................18, 49ketoprofen ..................................... 3ketorolac tromethamine .......... 3, 86KETOSTIX ............................... 52ketotifen fumarate ....................... 86kinray insulin syringe ................. 68KIONEX .................................... 79KLOR-CON M15 ......................76kmart valu insulin syringe 29g ... 68kmart valu insulin syringe 30g ... 68KONSYL ................................... 61konsyl daily fiber .........................61KONSYL-D ............................... 61

K-PHOS ..................................... 76K-PHOS NO 2 ........................... 56kpn prenatal ................................ 81kroger insulin syringe ................. 68kroger pen needles ...................... 68L606 TUBING ...........................68L609 TUBING ...........................68labetalol hcl ................................ 28LAC-HYDRIN FIVE ................50lactic acid ....................................50lactic acid e .................................50lactulose ......................................61lactulose encephalopathy ............56lamivudine ...................................26lamivudine-zidovudine ................26lamotrigine ..................................12lamotrigine er ............................. 12lansoprazole ................................93LANTUS .................................... 15LANTUS SOLOSTAR ............. 14latanoprost ..................................86laxative pills ................................61lc-4 lidocaine .............................. 50leader insulin syringe ................. 68LEADER UNIFINE PENTIPS ................................... 68LEADER UNIFINE PENTIPS PLUS ........................ 68leflunomide ................................... 3letrozole ...................................... 23leucovorin calcium ......................23LEUKERAN ..............................23LEVEMIR ................................. 15LEVEMIR FLEXTOUCH .......15levetiracetam ...............................12levobunolol hcl ............................86levocetirizine dihydrochloride .... 18levofloxacin .................................55levonorgest-eth estrad 91-day .... 32levonorgestrel ............................. 32levonorgestrel-ethinyl estrad ...... 32levothyroxine sodium .................. 92LEVOXYL .................................92LEXINAL .................................. 97LEXIVA .....................................27lexuss 210 ....................................40lice killing maximum strength .....50lice solution .................................50lice treatment .............................. 50LICEMD ....................................50LICIDE TREATMENT ........... 50lidocaine ..................................... 50

lidocaine hcl ..........................50, 79lidocaine hcl (pf) .........................62lidocaine viscous .........................79lidocaine-prilocaine ....................50lindane ........................................ 50linezolid .......................................22liothyronine sodium .................... 92LIQUID C 500 ...........................97liquid calcium with d3 ................ 76LIQUIMAT ............................... 50liquituss gg ..................................40lisinopril ......................................20lisinopril-hydrochlorothiazide ....21LITETOUCH INSULIN SYRINGE .................................. 69LITETOUCH PEN NEEDLES ..................................69lithium carbonate ..................24, 25lithium carbonate er ................... 24LITTLE REMEDIES FOR COLDS .......................................40LITTLE TEETHERS PAIN RELIEF ..................................... 79LMX 4 ........................................ 50LODRANE D ............................ 40LOHIST-D .................................40longs insulin syringe ................... 69loperamide hcl ............................ 16lopinavir-ritonavir ...................... 27loratadine ....................................19loratadine allergy relief ..............19loratadine childrens ....................19loratadine-d 12hr ........................40loratadine-d 24hr ........................40lorazepam ..................................... 8LORTAB ..................................... 5LORTUSS DM .......................... 40LORTUSS LQ ...........................40losartan potassium ......................21losartan potassium-hctz .............. 21LOTRIMIN AF .........................50lovastatin .....................................19LOW-OGESTREL ................... 32loxapine succinate .......................25LTXF PRIM CNV PIN MICRODRIP ............................ 69LTXF PRIM IV SET/CNVT PIN ............................................. 69LTXF SECONDARY/CNV PIN/32INC ................................. 69lubricant eye drops ..................... 86LUFYLLIN ................................10

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LUPRON DEPOT (1-MONTH) ................................... 23LUPRON DEPOT (3-MONTH) ................................... 23LUPRON DEPOT (4-MONTH) ................................... 23LUPRON DEPOT-PED (1-MONTH) ................................... 54m2 magnesium ............................ 76M2 POTASSIUM ......................97MAG64 .......................................76mag-al ........................................... 7MAGELLAN INSULIN SAFETY SYR ............................69mag-g .......................................... 76MAGINEX .................................76MAGINEX DS .......................... 76magnesium .................................. 77magnesium aspartate .................. 76magnesium carbonate .................77magnesium chloride ....................77magnesium citrate .................61, 77magnesium gluconate ................. 77magnesium lactate ...................... 77magnesium oxide .....................7, 77magnesium oxide -mg supplement .................................. 77magnesium sulfate ...................... 77magnesium sulfate in d5w ...........77MAGONATE ............................ 77malathion .................................... 50MAOX ..........................................7MAR-COF BP ...........................40MATULANE ............................. 23MAVYRET ................................27maxi-tuss pe ................................ 40MAYZENT ................................91meclizine hcl ............................... 17medic insulin syringe .................. 69medicine shoppe pen needles ......69medi-first hydrocortisone ............50medroxyprogesterone acetate...............................................32, 90MEDSAVER SYRINGE .......... 69mefloquine hcl .............................22MEGA MULTIVITAMIN ....... 81megestrol acetate ........................ 23meijer pen needles ...................... 69meloxicam ..................................... 3memantine hcl .............................91m-end dmx ...................................40M-END PE .................................40

MENEST ................................... 55meperidine hcl ...............................5mercaptopurine ...........................23mesalamine ................................. 56METAMUCIL ...........................61METAMUCIL MULTIHEALTH FIBER ........ 61METAMUCIL SMOOTH TEXTURE ................................. 61metaproterenol sulfate ................ 10metformin hcl .............................. 15metformin hcl er ..........................15methadone hcl ...............................5methanol ..................................... 31methazolamide ............................ 53methenamine hippurate ...............22methenamine mandelate ............. 22methimazole ................................ 92methocarbamol ........................... 83methotrexate ................................23methotrexate sodium ...................23methotrexate sodium (pf) ............ 23methyclothiazide ......................... 53methyl alcohol .............................31methyldopa ..................................21methylergonovine maleate .......... 88methylphenidate hcl ...................... 2methylphenidate hcl er ..................2methylphenidate hcl er (cd) .......... 1methylphenidate hcl er (la) ........... 2methylprednisolone .....................34metipranolol ................................86metoclopramide hcl .....................56metolazone .................................. 53metoprolol succinate er .............. 28metoprolol tartrate ......................28metoprolol-hydrochlorothiazide . 21metronidazole ................. 22, 50, 96MI-ACID ......................................7miconazole 3 ............................... 96miconazole 3 combo pack ........... 96miconazole 7 ............................... 96miconazole nitrate ...................... 50miconazorb af ............................. 50MICROGESTIN 1.5/30 ............32MICROGESTIN FE 1.5/30 ......32midodrine hcl .............................. 96migraine relief .............................. 5minocycline hcl ........................... 91minoxidil ..................................... 21mirtazapine ................................. 13misoprostol ................................. 93

modafinil ....................................... 2moexipril hcl ............................... 21mometasone furoate ....................50MONOJECT INSULIN SYRINGE .................................. 69MONOJECT LIFESHIELD SYRINGE .................................. 69MONOJECT MAGELLAN SYRINGE .................................. 69MONOJECT ULTRA COMFORT SYRINGE ............ 69montelukast sodium .................... 10MOORE MONO INSULIN SYRINGE .................................. 69morphine sulfate ........................... 5morphine sulfate (concentrate) .....5morphine sulfate er ....................... 5ms insulin syringe ....................... 69MUCINEX CHILD MS DAY-NIGHT CLD ..............................40MUCINEX COUGH FOR KIDS ...........................................40MUCINEX FAST-MAX CONGEST COUGH .................40MUCINEX FOR KIDS .............40MUCINEX SINUS-MAX DAY/NIGHT ............................. 40mucus d ....................................... 40mucus relief cold flu throat .........40mucus relief cold/sinus max st .... 40mucus relief d ..............................40mucus relief severe congst/cgh ... 40mucus-dm ....................................40mucus-dm max ............................ 40MULTAQ .................................... 8multi-delyn .................................. 81multi-delyn/iron .......................... 81multi-purpose solution ................ 86multivitamins ...............................81multivitamins pediatric ............... 81mupirocin ....................................50MURO 128 .................................86mycophenolate mofetil ................ 79MYKIDZ IRON ........................ 81MYKIDZ IRON 10 ................... 58MYLERAN ................................23MYNATAL ................................81mynatal plus ................................81mynate 90 plus ............................ 81nabumetone ...................................3nadolol ........................................ 28naloxone hcl ................................17

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naltrexone hcl ............................. 17NANOVM T/F ...........................81naphazoline hcl ...........................86naproxen ....................................... 3NAPROXEN COMFORT PAC .............................................. 3naproxen dr ...................................3naproxen sodium ...........................4naratriptan hcl ............................ 74NARCAN ................................... 17NASACORT ALLERGY 24HR .......................................... 84nasal allergy 24 hour ..................84nasal decongestant ......................84nasal mist .................................... 41NASOPEN ................................. 41NASOPEN PE ........................... 41NATALVIT ............................... 81nateglinide .................................. 15natural fiber laxative .................. 61natural psyllium seed ..................61natural senna laxative .................61NATURE-THROID ..................92NECON 0.5/35 (28) ................... 32NECON 1/35 (28) ...................... 32NECON 1/50 (28) ...................... 32NECON 10/11 (28) .................... 33NECON 7/7/7 .............................33neomycin sulfate ........................... 2neomycin-bacitracin zn-polymyx ....................................... 86neomycin-polymyxin-dexameth ...86neomycin-polymyxin-gramicidin 86neomycin-polymyxin-hc ........ 86, 88NEO-POLYCIN HC .................86NEOSPORIN ESSENTIALS TRIAL PK ................................. 50NEOTUSS PLUS ...................... 41NEOTUSS-D ............................. 41NERIA 29G INFUSION SET 10MM .........................................69NERIA 29G INFUSION SET 6MM ...........................................69NERIA 29G INFUSION SET 8MM ...........................................70NERIA MULTI 27G 2X10MM ....................................70NERIA MULTI 27G 3X10MM ....................................70NERIA MULTI 27G 4X12MM ....................................70

NERIA SOFT 25G INFUSION 13MM .................... 70NERIA SOFT 25G INFUSION 17MM .................... 70NEURO-K-250 T.D. ..................97NEUTROGENA CLEAR PORE ......................................... 50nevirapine ................................... 27nevirapine er ...............................27NEXAFED ................................. 84niacin .......................................... 97niacin er ...................................... 97niacinamide .................................97NIACOR .................................... 19nicardipine hcl ............................ 29nicotine ....................................... 91nicotine mini ............................... 91nicotine polacrilex ...................... 91NICOTROL ...............................91nifedipine .................................... 29nifedipine er ................................ 29nifedipine er osmotic release ...... 29nighttime cough .......................... 41nighttime pain plus sleep ............ 41nimodipine .................................. 29nite-time cold/flu relief ............... 41NITRO-BID .................................8nitrofurantoin ..............................22nitrofurantoin macrocrystal ........22nitrofurantoin monohyd macro ...22nitroglycerin ................................. 8nitroglycerin er ............................. 8NIVANEX DMX ....................... 41NOBLE MYSTIQUE EMU-LAC ............................................50nohist-lq ...................................... 41non-pseudo cold relief ................ 41NORDIPEN 5 INJECTION DEVICE .....................................70NORDIPEN DELIVERY SYSTEM ....................................70NORDITROPIN FLEXPRO ... 54NOREL AD ............................... 41norethin ace-eth estrad-fe ...........33norethindrone ............................. 33norethindrone acetate .................90norethindrone acet-ethinyl est .... 33norethindrone-eth estradiol ........ 55norgestimate-eth estradiol .......... 33NORPACE CR ............................8nortriptyline hcl .......................... 13nortuss-ex ....................................41

NORVIR .................................... 27NOVAFERRUM 50 .................. 58NOVAFERRUM PEDIATRIC DROPS ............... 58NOVOFINE ...............................70NOVOFINE AUTOCOVER ....70NOVOFINE PLUS ....................70NOVOLIN 70/30 ....................... 15NOVOLIN 70/30 FLEXPEN ... 15NOVOLIN 70/30 FLEXPEN RELION .....................................15NOVOLIN 70/30 RELION ...... 15NOVOLIN N ............................. 15NOVOLIN N FLEXPEN ..........15NOVOLIN N RELION .............15NOVOLIN R ............................. 15NOVOLIN R FLEXPEN ..........15NOVOLIN R RELION .............15NOVOLOG ............................... 15NOVOLOG FLEXPEN ............15NOVOLOG MIX 70/30 ............ 15NOVOLOG MIX 70/30 FLEXPEN ..................................15NOVOPEN ECHO ....................70NOVOTWIST ........................... 70np thyroid ....................................92NUOX .........................................50NUTRATEAR ........................... 86nystatin ............................18, 51, 79nystatin-triamcinolone ................51OBSTETRIX DHA ................... 81OBSTETRIX EC ...................... 81OC8 ............................................ 51O-CAL PRENATAL ................ 81OCELLA ................................... 33ofloxacin ......................... 55, 86, 88OGESTREL .............................. 33olanzapine ...................................25olmesartan medoxomil ................21omeprazole ..................................93OMNIFLEX DIAPHRAGM ....70OMNITROPE PEN 10 INJ DEVICE .....................................70OMNITROPE PEN 5 INJ DEVICE .....................................70ondansetron ................................ 17ondansetron hcl .......................... 17ONE-A-DAY WOMENS PRENATAL .............................. 81ONETOUCH DELICA LANCETS 30G ......................... 70

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ONETOUCH DELICA LANCETS 33G ......................... 70ONETOUCH ULTRA CONTROL ................................ 70ONETOUCH VERIO .........52, 70ORA-BLEND ............................ 90ORA-BLEND SF .......................90ORACIT .................................... 56ORA-FILM ................................80oral analgesic max st .................. 80oral anesthetic ............................ 80ORAL MIX ................................90ORAL MIX SF ..........................90oral suspend ................................90oral syrup ....................................90oral syrup sf ................................ 90ORAMAGIC PLUS .................. 80ORA-PLUS ................................90ORA-SWEET ............................90ORA-SWEET SF ...................... 90ORAZINC ................................. 77oseltamivir phosphate .................27OSTEO-PORETICAL ............. 77OSTIGEN .................................. 77oxaprozin ...................................... 4oxazepam ...................................... 8oxcarbazepine ............................. 12oxybutynin chloride .....................94oxybutynin chloride er ................ 94oxycodone hcl ........................... 5, 6oxycodone-acetaminophen ............6oxycodone-aspirin .........................6OXYTROL ................................ 94OXYTROL FOR WOMEN ..... 94OYSCO 500+D .......................... 77oyster shell calcium plus d ..........77oyster shell calcium/d ................. 77OZEMPIC (0.25 OR 0.5 MG/DOSE) ................................ 16OZEMPIC (1 MG/DOSE) ........16pa prenatal formula .................... 82paba ............................................ 97PANATUSS PED ...................... 41PANATUSS PED DROPS ........41PANCREAZE ........................... 53pancrelipase (lip-prot-amyl) .......53PANOXYL-8 CREAMY WASH ........................................ 51panto-250 ....................................97pantoprazole sodium ...................93pantothenic acid ..........................97paroxetine hcl ............................. 13

parva-cal .....................................77pc unifine pentips ........................70PCCA SWEET-SF .................... 90PCCA SYRUP VEHICLE ....... 90PCCA-PLUS ..............................90PECGEN DMX ......................... 41PEDIACARE CHILD ALLERGY/COLD ....................41PEDIA-LAX .............................. 61PEDIALYTE ............................. 77pediatric cough/cold ................... 41peg 3350 ......................................61peg 3350/electrolytes .................. 61PEGINTRON ............................ 27PEG-INTRON ...........................27PEG-INTRON REDIPEN ........27PEG-INTRON REDIPEN PAK 4 .........................................27pen needles ..................................70pen needles 1/2" ..........................70pen needles 3/16" ........................70pen needles 5/16" ........................70penicillin v potassium ................. 89pentoxifylline er .......................... 57PEPCID AC MAXIMUM STRENGTH .............................. 93peppermint spirit .........................31PERFECT IRON ...................... 58PERIOMED .............................. 80permethrin ...................................51perphenazine ...............................25PERRY PRENATAL ................82PERTZYE ................................. 53phenazopyridine hcl ....................56phenelzine sulfate ........................13phenobarbital ..............................59phenobarbital-belladonna alk .... 93phenylephrine-chlorphen-dm ......41phenylephrine-dm-gg .................. 41phenylhistine dh .......................... 41phenytoin .....................................12phenytoin sodium ........................ 12phenytoin sodium extended .........12PHOSPHA 250 NEUTRAL ..... 78PHOSPHOLINE IODIDE ....... 87phosphorus supplement .............. 78phytonadione ...............................97pilocarpine hcl ............................ 80pindolol ....................................... 28pine tar ........................................31pink bismuth ................................17pink bismuth maximum strength . 17

pinnacaine otic ............................88PIN-X ........................................... 7pioglitazone hcl ...........................16pioglitazone hcl-metformin hcl ... 16piroxicam ...................................... 4plastic adapter ............................ 70podofilox ..................................... 51poly vitamin ................................ 82polyethylene glycol 3350 ...... 61, 90poly-hist dm ................................ 41poly-hist pd ................................. 41poly-iron 150 forte ......................58polymyxin b-trimethoprim ...........87polysorbate 20 ............................ 31polysorbate 40 ............................ 31polysorbate 60 ............................ 31polysorbate 80 ............................ 31poly-tussin ac .............................. 41POLY-VENT DM ..................... 41POLY-VENT IR ....................... 41polyvitamin ................................. 82polyvitamin/iron ..........................82pot bicarb-pot chloride ............... 78POTABA ....................................97potassium bicarbonate ................78potassium chloride ......................78potassium chloride crys er ..........78potassium chloride er ................. 78potassium citrate-citric acid . 56, 57povidone-iodine .......................... 25PR NATAL 400 ......................... 82PR NATAL 430 ......................... 82PRALUENT .............................. 19pramipexole dihydrochloride ......24PRAMOSONE .......................... 51prasugrel hcl ...............................57pravastatin sodium ......................19prazosin hcl .................................21PRECISION SUREDOSE PLUS SYR ................................. 70PRECISION SURE-DOSE SYRINGE .................................. 70PRECISION XTRA KETONE ................................... 52PRED MILD ..............................87prednicarbate ..............................51prednisolone ............................... 34prednisolone acetate ...................87prednisolone sodium phosphate...............................................34, 87prednisone ...................................34preferred plus insulin syringe .....71

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preferred plus unifine pentips .....71pregabalin ...................................12PREMARIN .............................. 55PREMPHASE ........................... 55PREMPRO ................................ 55PRENATA ................................. 82prenatabs fa ................................ 82prenatal .......................................82prenatal 19 ..................................82prenatal complete ....................... 82prenatal formula ......................... 82prenatal formula a-free ...............82prenatal multi +dha ....................82PRENATAL MULTIVITAMIN + DHA ....... 82prenatal plus ............................... 82prenatal plus iron ....................... 82prenatal vitamins ........................ 82prenatal/omega-3/fa/iron ............82prenatal+dha .............................. 82PRENATAL-U .......................... 82pres gen pediatric ....................... 41PRETZ ....................................... 31PREZISTA ................................ 27primaquine phosphate ................ 22primidone ....................................12PRIMSOL ..................................22PRO:12 MOUSSE AL12 .......... 51probenecid .................................. 57probiotic-prebiotic ......................17pro-chlo .......................................41prochlorperazine .........................25prochlorperazine maleate ...........25PRO-CLEAR AC ......................42PROCRIT ..................................58PRODIGY INSULIN SYRINGE .................................. 71PROFE .......................................58profe forte ................................... 82PROFERRIN ES .......................59promethazine hcl .........................19promethazine vc plain .................42promethazine vc/codeine .............42promethazine-codeine .................42promethazine-dm ........................ 42PRONTO ................................... 51propafenone hcl ............................ 8propantheline bromide ................93proparacaine hcl .........................87propranolol hcl ........................... 29propranolol hcl er .......................28propranolol-hctz ......................... 21

propylthiouracil .......................... 92PRO-RED AC ........................... 42PROTEXIN ............................... 97pseudoeph-bromphen-dm ............42pseudoephedrine hcl ................... 84pseudoephedrine hcl er ...............84pseudoephedrine-guaifenesin er . 42PULMOZYME ......................... 91purefe ob plus ............................. 82px extra short pen needles .......... 71px insulin syringe ........................71px mini pen needles .....................71px pen needle .............................. 71pyrazinamide ...............................22pyrethins-piperonyl butoxide ...... 51pyrilamine-phenylephrine ...........42qc childrens vitamins/extra c ...... 82qc cold relief ............................... 42qc cold relief plus ........................42qc flu relief therapy night ........... 42qc medifin cp ...............................42qc natural vegetable ....................61qc pen needles .............................71qc unifine pentips ........................71q-pap ............................................. 5q-pap infants ................................. 5Q-TAPP ..................................... 42quetiapine fumarate .................... 25quetiapine fumarate er ................25quinapril hcl ................................21quinapril-hydrochlorothiazide ....21quinidine gluconate er .................. 9quinidine sulfate ............................9quinine sulfate .............................22QVAR .........................................10QVAR REDIHALER ............... 10ra acne maximum ........................51ra acne treatment ........................51ra allergy multi-symptom ............42ra allergy multi-symptom night .. 42ra allergy plus sinus ....................42ra allergy relief childrens ........... 19ra baby care oral pain relief .......80ra calcium hi-cal/vitamin d .........78ra calcium-boron ........................ 78ra childrens cold & allergy .........42ra cold & flu ................................42ra cold/cough sinus relief pe .......42ra col-rite .................................... 61ra ethyl alcohol ........................... 32ra first aid anti-itch spray ...........51ra flu maximum strength .............42

ra glycerin child ..........................61ra insulin syringe ........................ 71ra laxative ................................... 61ra laxative extra strength ............61ra lice bedding ............................ 51ra lice egg remover .....................51ra lice solution ............................ 51ra nasal allergy ...........................84ra omeprazole-sodium bicarb .....93ra one daily ................................. 82ra pen needles ............................. 71ra pink bismuth ........................... 17ra probiotic digestive care ..........17ra severe cold/night cold&flu ..... 42ra severe cold/sinus relief pe ...... 42ra sinus congst/pain day/night ....42ra sleep aid ................................. 59ra sleep aid (diphenhydramine) ..59ra sleep-aid nighttime ................. 59ra sterile eye drops ..................... 87ra suphedrine day/night combo .. 42ra suphedrine pe ......................... 42ra tussin nighttime cough dm ......42ra vitamin c ................................. 97ra wart remover .......................... 51raloxifene hcl .............................. 55ramipril ....................................... 21REDNESS RELIEF .................. 87redness relief max strength .........87redness reliever eye drops .......... 87reeses pinworm medicine ..............7REFENESEN CHEST CONG/PAIN RLF .................... 43refenesen plus ............................. 43REFRESH CELLUVISC ......... 87REFRESH LIQUIGEL ............ 87REFRESH OPTIVE ADVANCED PF ........................87REFRESH OPTIVE SENSITIVE ............................... 87relcof c ........................................ 43RELENZA DISKHALER ........ 27RELION INSULIN SYRINGE .................................. 71RELI-ON INSULIN SYRINGE .................................. 71RELION MINI PEN NEEDLES ..................................71RELION PEN NEEDLES ........71RELION SHORT PEN NEEDLES ..................................71RENAGEL .................................56

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RENAL ...................................... 82REPATHA .................................19REPATHA PUSHTRONEX SYSTEM ....................................19REPATHA SURECLICK ........ 19RESCON DM ............................ 43RESCRIPTOR .......................... 27resorcinol-sulfur ......................... 51RESPAIRE-30 ...........................43RETACRIT ............................... 59RETAINE MGD ....................... 87RHINOCORT ALLERGY ...... 84RHOGAM ULTRA-FILTERED PLUS .....................89RIBASPHERE .......................... 27ribavirin ...................................... 27riboflavin .....................................97RID ESSENTIAL LICE ELIMINATION ........................ 51rifampin .......................................22RIFATER .................................. 22riluzole ........................................ 84rimantadine hcl ...........................27risedronate sodium ..................... 55risperidone ..................................25ritonavir ...................................... 27rizatriptan benzoate .................... 74ROBITUSSIN CHILD COUGH/COLD CF .................. 43ROBITUSSIN CHILD COUGH/COLD LA .................. 43ROBITUSSIN DAY/NIGHT VALUE PAK .............................43ROBITUSSIN PEAK COLD MULTI-SYM .............................43ROBITUSSIN PK COLD DAY/NGHT DM ....................... 43ROBITUSSIN PK COLD DAY/NGHT MS ........................43ropinirole hcl .............................. 24rosuvastatin calcium ...................20ru-hist d .......................................43RYBELSUS ............................... 16rymed .......................................... 43SAFE TUSSIN PM ................... 43SAFELET IV CATHETER ..... 71SAFESNAP INSULIN SYRINGE .................................. 71saline nasal spray ....................... 84salsalate ........................................ 5SANTYL .................................... 51sb daytime sinus ..........................43

sb insulin syringe ........................ 71sb natural fiber laxative ..............61sb nighttime sinus multi-sympt ....43sb severe cold congestion ........... 43scalp vein set ...............................71schnucks insulin syringe ............. 72SCHOOLTIME SHAMPOO ...51SCOOBY-DOO ONE A DAY ..82SCOT-TUSSIN DM .................. 43SCOT-TUSSIN SENIOR ......... 43sebex ............................................51selegiline hcl ............................... 24selenium sulfide .......................... 51SELZENTRY ............................ 27senna ........................................... 61senna laxative ............................. 61senna leaves ................................ 61senna-docusate sodium ...............61SENSIPAR .................................55SEREVENT DISKUS ...............10sertraline hcl ...............................13sevelamer hcl .............................. 56sf 5000 plus ................................. 80SFROWASA ..............................56SHINGRIX ................................ 95SHOPKO UNIFINE PENTIPS ................................... 72sildenafil citrate .......................... 30silphen cough .............................. 19silver sulfadiazine ....................... 51simethicone ................................. 56simple syrup ................................ 90simvastatin .................................. 20SINADRIN PE COMPLETE SINUS REL ............................... 43sinus daytime/nighttime .............. 43sinus maximum strength ............. 43slow iron ..................................... 59slow release iron .........................59sm camphor spirit ....................... 32sm cough/runny nose childrens ...43sm ibuprofren cold childrens ...... 43sm insulin syringe ....................... 72sm pain reliever sinus pe ............ 43sm redness relief ......................... 87sm slow release iron ................... 59sm tussin cf ..................................43sodium ascorbate ........................ 97sodium bicarbonate ................ 7, 32sodium chloride .............. 44, 57, 78sodium chloride (hypertonic) ......87sodium chloride flush ..................78

sodium fluoride ........................... 78sodium polystyrene sulfonate ......79sodium silicate ............................ 32sofosbuvir-velpatasvir .................28SOLUBLE FIBER THERAPY .................................61solution transfer device ...............72sonahist dm ................................. 44SOOTHE ................................... 87sotalol hcl ....................................29sotalol hcl (af) .............................29SPATONE PUR-ABSORB IRON ..........................................59spironolactone ............................ 54spironolactone-hctz .....................54stahist ad .....................................44stavudine ..................................... 28STEP 2 ....................................... 51STERILE LUBRICANT .......... 87sterile water for irrigation .......... 79stress formula/iron ......................82stress formula/zinc ...................... 82STRIBILD ................................. 28STRIVERDI RESPIMAT ........ 10STUART ONE .......................... 82sucralfate .................................... 93SUDAFED PE DAY & NIGHT ....................................... 44SUDOGEST SINUS/ALLERGY ....................44sulfacetamide sodium ..................87sulfacetamide sodium (acne) ...... 51sulfacetamide sodium-sulfur .......52sulfacetamide-prednisolone ........87sulfadiazine ................................. 91sulfamethoxazole-trimethoprim .. 22sulfasalazine ............................... 56sulfurated lime ............................ 52sulindac .........................................4sumatriptan succinate .................74super b complex/vitamin c .......... 83super strength sinadrin ............... 44SUPERVITE EC .......................83supress a pediatric ......................44supress dm pediatric ................... 44SUPRESS-PE PEDIATRIC .....44sure comfort insulin syringe ....... 72sure comfort pen needles ............ 72SURE-FINE PEN NEEDLES .. 72SURE-JECT INSULIN SYRINGE .................................. 72SURE-T INFUSION SET 18" . 72

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SURE-T INFUSION SET 23" . 72SURE-T INFUSION SET 32" . 72surgical dressing .........................72SYEDA .......................................33SYMJEPI ...................................96SYNAGIS ...................................89SYNATEK ................................. 83SYNJARDY ...............................16SYNJARDY XR ........................ 16SYNTHROID ............................ 92syringe luer slip .......................... 72syrpalta ....................................... 90SYRPALTA (RED) ...................90SYRSPEND SF ..........................90SYSTANE ..................................87SYSTANE OVERNIGHT THERAPY .................................88TABLOID ..................................23tacrolimus ................................... 79tamoxifen citrate ......................... 24tamsulosin hcl ............................. 57TANZEUM ................................16TARON-BC ............................... 83TAZTIA XT .............................. 29tbc ............................................... 52telmisartan .................................. 21temazepam .................................. 59tenofovir disoproxil fumarate ..... 28terazosin hcl ................................21terbinafine hcl .......................18, 52terbutaline sulfate ....................... 10terconazole ..................................96terpin hydrate ..............................44testosterone cypionate ...................6testosterone enanthate .................. 6tg 10peh/380gfn .......................... 44tgq 15dm/5peh/2cpm ...................44tgq 30pse/150gfn/15dm ...............44tgq 30pse/3brm/15dm ................. 44tgt lubricant eye drops ................ 88THEO-24 ................................... 10THEOCHRON ..........................10theophylline .................................10theophylline er ............................ 10theracaps cough/cold reliever .... 44THERAFLU MAX-D COLD & FLU ........................................ 44THERAFLU SEVERE COLD & COUGH .................................44THERAFLU SEVERE COLD DAYTIME ................................. 44THERANATAL COMPLETE 83

therapeutic liquid ........................83THERATEARS PF ...................88thiamine ...................................... 97thiothixene ...................................25thyroid .........................................92ticlopidine hcl ............................. 57timolol maleate ..................... 29, 88TIMOPTIC OCUDOSE ...........88tinidazole .....................................22TIVICAY ................................... 28tizanidine hcl ...............................83tl icon .......................................... 59TOBRADEX ..............................88tobramycin .................................. 88tobramycin-dexamethasone ........ 88TOBREX ................................... 88todays health mini pen needles ... 72todays health pen needles ........... 72todays health short pen needle ....72tolterodine tartrate ......................94tolterodine tartrate er ................. 94topcare clickfine pen needles ......72topcare ultra comfort ins syr ...... 72topiramate ...................................12torsemide .....................................54TOUJEO SOLOSTAR ............. 16TOVIAZ .....................................94tramadol hcl ..................................6trandolapril .................................21tranylcypromine sulfate .............. 13travoprost ....................................88trazodone hcl .............................. 13TRECATOR ..............................22TRESIBA ...................................16TRESIBA FLEXTOUCH ........ 16tretinoin .......................................24TREXBROM .............................44triactin chest congestion ............. 44triamcinolone acetonide . 52, 80, 84TRIAMINIC CHEST/NASAL CONGEST .................................44TRIAMINIC COLD/ALLERGY CHILD ......44TRIAMINIC COLD/COUGH DAY TIME ................................ 44TRIAMINIC COUGH & SORE THROAT ....................... 44TRIAMINIC COUGH/RUNNY NOSE ..........19TRIAMINIC COUGH/SORE THROAT ................................... 44

TRIAMINIC NIGHT TIME COLD/CGH ...............................45triamterene-hctz ..........................54triazolam ..................................... 59trifluoperazine hcl .......................25trifluridine ...................................88trigofen dm ..................................45trihexyphenidyl hcl ......................24TRILYTE .................................. 62trimethobenzamide hcl ................17trimethoprim ............................... 22trinatal rx 1 ................................. 83TRINESSA (28) .........................33TRINESSA LO ..........................33triple paste af .............................. 52TRISPEC DMX ........................ 45TRISPEC PSE PEDIATRIC ... 45TRIUMEQ .................................28tri-vit/fluoride ............................. 83tri-vitamin/fluoride ..................... 83TRIVORA (28) ..........................33trixaicin hp ..................................52tropicamide ................................. 88trospium chloride ........................94trospium chloride er ................... 94TRUEPLUS INSULIN SYRINGE .................................. 72TRUVADA ................................ 28trymine cg ................................... 45TUDORZA PRESSAIR ............10turpentine ....................................32TUSICOF ...................................45TUSNEL .................................... 45TUSNEL C ................................ 45TUSNEL PEDIATRIC .............45tussafex ex ...................................45tussafex-a .................................... 45tussin cf cough & cold ................ 45tussin cf max multi-symptom .......45tussin chest congestion ............... 45tussin cold/congestion .................45tussin cough ................................ 45tussin dm max ............................. 45tussi-pres b ..................................45TUSSLIN ................................... 45TUSSLIN PEDIATRIC ............45TWIRLA ....................................33TYLENOL CHILDRENS COLD/STUFFY ........................ 45TYLENOL CHILDRENS PLUS CLD/CGH ...................... 45UDAMIN SP ..............................83

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ULTICARE INSULIN SAFETY SYR ............................73ULTICARE INSULIN SYRINGE .................................. 73ULTICARE MICRO PEN NEEDLES ..................................73ULTICARE MINI PEN NEEDLES ..................................73ULTICARE PEN NEEDLES ...73ULTICARE SHORT PEN NEEDLES ..................................73ULTICARE SYRINGE ............ 73ULTILET INSULIN SYRINGE SHORT ................... 73ULTILET PEN NEEDLE ........ 73ultra comfort insulin syringe ...... 73ultra-comfort insulin syringe ...... 73ultra-mega ...................................83ULTRA-THIN II INS SYR SHORT ...................................... 73ULTRESA ................................. 53undecylenic acid ......................... 32UNIFINE PENTIPS ..................73UNIFINE PENTIPS PLUS ...... 73UNITHROID .............................92UPCAL D ...................................78urea ............................................. 52URO-MAG .................................. 7ursodiol ....................................... 56VACUTAINER TUBING ........ 73valacyclovir hcl ...........................28valproic acid ............................... 12valsartan ..................................... 21valsartan-hydrochlorothiazide ... 21value health insulin syringe ........ 73valumark pen needles ..................73VANACOF APE ....................... 45VANACOF G ............................ 45VANACOF GPE ....................... 45VANACOF-8 ............................. 46VANATAB DX ..........................46vancomycin hcl ........................... 22VANISHPOINT 18GX1-1/4" FEP .............................................73VANISHPOINT 18GX1-1/4" PUR ............................................ 73VANISHPOINT 20GX1-1/4" FEP .............................................74VANISHPOINT 20GX1-1/4" PUR ............................................ 74VANISHPOINT 22GX1" FEP 74

VANISHPOINT 22GX1" PUR ............................................ 74VANISHPOINT 24GX3/4" FEP .............................................74VANISHPOINT 24GX3/4" PUR ............................................ 74VANISHPOINT INSULIN SYRINGE .................................. 74VANISHPOINT SYRINGE .....74vaporizing steam .........................46VASOCLEAR-A ....................... 88VASOLEX ................................. 52VAZOBID-PD ........................... 46VELIVET .................................. 33venlafaxine hcl ............................ 13venlafaxine hcl er ........................13VENTOLIN HFA ......................11verapamil hcl .............................. 30verapamil hcl er ....................29, 30VERSAFREE ............................ 90VERSAPLUS .............................90VESICARE ................................94VIBRAMYCIN ..........................91VICKS DAYQUIL MUCUS CONTROL DM ........................ 46VICKS DAYQUIL SEVERE COLD/FLU ................................46VICKS NATURE FUSION COLD & FLU ........................... 46VICKS NATURE FUSION CONGEST .................................46VICKS NYQUIL CHILDRENS CLD/CGH .........46VICKS NYQUIL COLD & FLU NIGHT .............................. 46VICTOZA ..................................16VIDA MIA UNIFINE PENTIPS ................................... 74VIDEX ....................................... 28VINATE II .................................83VINATE M ................................ 83VIOKACE ................................. 53VIRACEPT ............................... 28virdec .......................................... 46virdec dm .....................................46VIREAD .....................................28virt-vite gt ....................................83VISINE TEARS ........................ 88vita-c ........................................... 97VITALINE BUFFERED ZINC-220 ................................... 78vitamin b1 ................................... 97

vitamin b-1 .................................. 97vitamin b-12 ................................ 59vitamin b-2 .................................. 98vitamin b6 ................................... 98vitamin b-6 .................................. 98vitamin b-6 er ..............................98vitamin c ......................................98vitamin c (calcium ascorbate) .....98vitamin c drops ........................... 98vitamin c er ................................. 98vitamin c gummie ........................98vitamin c-electrolytes ..................83vitamin c-rose hips er ................. 98vitamin d (cholecalciferol) ..........98vitamin d (ergocalciferol) ........... 98vitamin d3 ................................... 98vitamin e ......................................98vitamin k (phytonadione) ............ 98vp insulin syringe ........................74V-R MONO INSULIN SYRINGE .................................. 74VYVANSE ................................... 2WAL-FLU COLD & SORE THROAT ................................... 46WAL-FLU SEVERE COLD DAYTIME ................................. 46wal-som .......................................59warfarin sodium ..........................11warm mist vaporizer ................... 74wee care ...................................... 59wegmans unifine pentips plus ..... 74WESTHROID ........................... 92WIDE-SEAL DIAPHRAGM 60 ................................................ 74WIDE-SEAL DIAPHRAGM 65 ................................................ 74WIDE-SEAL DIAPHRAGM 70 ................................................ 74WIDE-SEAL DIAPHRAGM 75 ................................................ 74WIDE-SEAL DIAPHRAGM 80 ................................................ 74WIDE-SEAL DIAPHRAGM 85 ................................................ 74WIDE-SEAL DIAPHRAGM 90 ................................................ 74WIDE-SEAL DIAPHRAGM 95 ................................................ 74WP THYROID ..........................92XARELTO .................................11yl oyster shell calcium/d ............. 78zaleplon .......................................59

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ZARAH ......................................33ZARXIO .................................... 59ZEASORB-AF ...........................52ZENCHENT ..............................33ZENPEP .....................................53zidovudine ................................... 28zinc ..............................................83ZINC 15 ..................................... 78zinc sulfate ............................ 78, 79ziprasidone hcl ............................25ZODRYL DEC 25 .....................46ZODRYL DEC 30 .....................46ZODRYL DEC 35 .....................46ZODRYL DEC 40 .....................46zolmitriptan ...........................74, 75zolpidem tartrate .........................60zolpidem tartrate er .................... 60zonisamide .................................. 12ZOSTAVAX .............................. 95ZOVIA 1/50E (28) .....................33Z-TUSS AC ................................46ZUMANDIMINE ......................33ZYNCOF ................................... 46

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