1. No category

List of Covered
Drugs for 2015
(Medicaid Formulary)
1-866-549-8289
TDD/TTY: 1-800-750-0750
mmp.BuckeyeHealthPlan.com
H0022_MMP14_022
Formulary: 2015 MMP OH ADD
Date generated: April 1, 2015
List of Abbreviations
B/D: This prescription drug has a Part B versus D administrative prior authorization requirement.
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may need to be submitted describing the use and setting of the drug to make the
determination.
CB: This prescription drug has a capped benefit limit.
DP: Dual Demonstration Plan. This item is covered under your Medicaid benefits. The DP next to
a drug means the drug is not a "Part D drug." The amount you pay when you fill a prescription for
this drug does not count towards your total drug costs (that is, the amount you pay does not help you
qualify for catastrophic coverage). These drugs also have different rules for appeals. An appeal is a
formal way of asking us to review a decision we made about your coverage and to change it if you
think we made a mistake. For example, we might decide that a drug that you want is not covered or
is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision,
you can appeal. If you ever have a question, call Member Services. You can also read the Member
Handbook to learn how to appeal a decision.
EA: Each.
ED: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The
amount you pay when you fill a prescription for this drug does not count towards your total drug
costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition,
if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay
for this drug.
FF: Free First Fill. This prescription drug will be provided at <zero>/<reduced> cost-sharing the
first time you fill it.
GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap.
Please refer to our Evidence of Coverage for more information about this coverage.
HI: Home Infusion. This prescription drug <is>/<may be> covered under our medical benefit. For
more information, call Member Services at <toll-free number>, <days and hours of operation>.
TTY/TDD users should call <toll-free TTY number>
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information consult your Pharmacy Directory or call Member Services at <toll-free number>, <days
and hours of operation>. TTY/TDD users should call <toll-free TTY number>.
MO: Mail Order Drug. This prescription drug is available through a mail-order service.
PA: Prior Authorization. <Plan name> requires you [or your physician] to get prior authorization for
certain drugs. This means that you will need to get approval from <plan name> before you fill your
prescriptions. If you don't get approval, <plan name> may not cover the drug.
Page 1 of 71
QL: Quantity Limit. For certain drugs, <plan name> limits the amount of the drug that <plan name>
will cover. For example, <plan name> provides <number of units> per prescription for <drug
name>. This may be in addition to a standard one month or three month supply.
ST: Step Therapy. In some cases, <plan name> requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if Drug A and
Drug B both treat your medical condition, <plan name> may not cover drug B unless you try Drug
A first. If Drug A does not work for you, <plan name> will then cover Drug B.
Page 2 of 71
Drug Name
Respiratory Tract/Pulmonary Agents
Antihistamines
olopatadine hcl solution 0.6%
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
Respiratory Tract Agents, Other
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
bromfed dm syrup 2mg/5ml; 10mg/5ml; 30mg/5ml
bromfed dm syrup 2mg/5ml; 10mg/5ml; 30mg/5ml
hydrocodone bitartrate/homatropine methylbromide syrup
1.5mg/5ml; 5mg/5ml
hydrocodone bitartrate/homatropine methylbromide tablet
1.5mg; 5mg
hydrocodone bitartrate/homatropine methylbromide tablet
1.5mg; 5mg
hydrocodone polistirex/chlorpheniramine polistirex liquid
extended release 8mg/5ml; 10mg/5ml
hydrocodone polistirex/chlorpheniramine polistirex liquid
extended release 8mg/5ml; 10mg/5ml
hydrocodone polistirex/chlorpheniramine polistirex liquid
extended release 8mg/5ml; 10mg/5ml
hydrocodone/homatropine syrup 1.5mg/5ml; 5mg/5ml
hydromet syrup 1.5mg/5ml; 5mg/5ml
promethazine vc/codeine syrup 10mg/5ml; 5mg/5ml;
6.25mg/5ml
promethazine vc/codeine syrup 10mg/5ml; 5mg/5ml;
6.25mg/5ml
promethazine-dm syrup 15mg/5ml; 6.25mg/5ml
promethazine-dm syrup 15mg/5ml; 6.25mg/5ml
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
Page 3 of 71
Drug Tier Requirements/Limits
1
3
3
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
DP
3
DP
3
DP
3
DP
3
3
3
DP
DP
DP
3
DP
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
Drug Name
promethazine/dextromethorphan syrup 15mg/5ml;
6.25mg/5ml
promethazine/dextromethorphan syrup 15mg/5ml;
6.25mg/5ml
promethazine/dextromethorphan syrup 15mg/5ml;
6.25mg/5ml
TESSALON PERLES CAPSULE 100MG
tussigon tablet 1.5mg; 5mg
TUSSIONEX PENNKINETIC EXTENDED RELEASE
LIQUID EXTENDED RELEASE 8MG/5ML; 10MG/5ML
ZONATUSS CAPSULE 150MG
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Replacement
chromium chloride injection 40mcg/10ml
corvita 150 tablet 120mg; 15mcg; 1.25mg; 150mg; 10mg;
25mg
dexferrum injection 50mg/ml
dexferrum injection 50mg/ml
FERRAPLUS 90 TABLET 120MG; 12MCG; 50MG; 1MG;
90MG
infed injection 50mg/ml
MANGANESE TRACE METAL INJECTION 0.1MG/ML
tl icon capsule 75mg; 15mcg; 110mg; 0.5mg; 240mg
VENOFER INJECTION 20MG/ML
VENOFER INJECTION 20MG/ML
VENOFER INJECTION 20MG/ML
VENOFER INJECTION 20MG/ML
VENOFER INJECTION 20MG/ML
VENOFER INJECTION 20MG/ML
VENOFER INJECTION 20MG/ML
Vitamins
cyanocobalamin injection 1000mcg/ml
cyanocobalamin injection 1000mcg/ml
cyanocobalamin injection 1000mcg/ml
cyanocobalamin injection 1000mcg/ml
FOLIC ACID INJECTION 5MG/ML
FOLIC ACID INJECTION 5MG/ML
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
Page 4 of 71
Drug Tier Requirements/Limits
3
DP
3
DP
3
DP
3
3
3
DP
DP
DP
3
DP
3
3
DP
DP
3
3
3
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
folic acid tablet 1mg
3
folic acid tablet 1mg
3
folic acid tablet 1mg
3
HYDROXOCOBALAMIN INJECTION 1000MCG/ML
3
infuvite pediatric injection 80mg/5ml; 1mcg/5ml;
3
400unit/5ml; 1mcg/5ml; 5mg/5ml; 140mcg/5ml; 17mg/5ml;
1mg/5ml; 1.4mg/5ml; 1.2mg/5ml; 7unit/5ml; 2300unit/5ml;
0.2mg/5ml
infuvite pediatric injection 80mg/5ml; 1mcg/5ml;
3
400unit/5ml; 1mcg/5ml; 5mg/5ml; 140mcg/5ml; 17mg/5ml;
1mg/5ml; 1.4mg/5ml; 1.2mg/5ml; 7unit/5ml; 2300unit/5ml;
0.2mg/5ml
infuvite injection 200mg/10ml; 200unit/10ml; 5mcg/10ml;
3
15mg/10ml; 600mcg/10ml; 40mg/10ml; 6mg/10ml;
3.6mg/10ml; 6mg/10ml; 10unit/10ml; 3300unit/10ml;
150mcg/10ml
M.V.I. ADULT INJECTION 200MG/10ML; 60MCG/10ML; 3
5MCG/10ML; 15MG/10ML; 5MCG/10ML;
600MCG/10ML; 40MG/10ML; 150MCG/10ML;
6MG/10ML; 3.6MG/10ML; 6MG/10ML; 10MG/10ML;
1MG/10ML
M.V.I. PEDIATRIC INJECTION 80MCG; 20MCG; 1MCG; 3
140MCG; 17MG; 5MG; 200MCG; 1MG; 1.4MG; 1.2MG;
0.7MG; 10MCG; 7MG
M.V.I.-12 WITHOUT VITAMIN K INJECTION
3
200MG/10ML; 60MCG/10ML; 5MCG/10ML; 15MG/10ML;
200UNIT/10ML; 600MCG/10ML; 40MG/10ML;
6MG/10ML; 3.6MG/10ML; 6MG/10ML; 10UNIT/10ML;
3300UNIT/10ML
NASCOBAL SOLUTION 500MCG/0.1ML
3
thiamine hcl injection 100mg/ml
3
thiamine hcl injection 100mg/ml
3
vitamin d capsule 50000unit
3
vitamin d capsule 50000unit
3
vitamin d capsule 50000unit
3
vitamin d capsule 50000unit
3
vitamin d capsule 50000unit
3
vitamin d capsule 50000unit
3
VITAMIN K1 INJECTION 10MG/ML
3
vitamin k1 injection 1mg/0.5ml
3
Unclassified
No Classification
BACTERIOSTATIC WATER FOR INJECTION/BENZYL 3
ALCOHOL INJECTION 0.9%; 0
COPPER TRACE METAL INJECTION 0.4MG/ML
3
FERAHEME INJECTION 510MG/17ML
3
FERAHEME INJECTION 510MG/17ML
3
sterile water for injection injection 0
3
sterile water for injection injection 0
3
Page 5 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
sterile water for injection injection 0
sterile water for injection injection 0
sterile water for injection injection 0
sterile water for injection injection 0
sterile water for injection injection 0
sterile water for injection injection 0
sterile water for injection injection 0
sterile water for injection injection 0
sterile water for injection injection 0
sterile water for injection injection 0
sterile water for injection injection 0
ZINC TRACE METAL INJECTION 1MG/ML
Page 6 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
OTC products
Drug Name
Analgesics
Analgesics
acephen suppository 120mg
acephen suppository 120mg
acephen suppository 120mg
acephen suppository 325mg
acephen suppository 325mg
acephen suppository 325mg
acephen suppository 650mg
acephen suppository 650mg
acephen suppository 650mg
acetaminophen suppository 120mg
acetaminophen suppository 120mg
acetaminophen suppository 650mg
acetaminophen suppository 650mg
acetaminophen suppository 650mg
feverall suppository 120mg
feverall suppository 120mg
feverall suppository 325mg
feverall suppository 325mg
feverall suppository 650mg
Nonsteroidal Anti-inflammatory Drugs
aspir-81 tablet delayed release 81mg
aspir-81 tablet delayed release 81mg
aspir-low tablet delayed release 81mg
aspir-low tablet delayed release 81mg
aspirin adult low strength tablet chewable 81mg
aspirin adult low strength tablet chewable 81mg
aspirin childrens tablet chewable 81mg
aspirin ec lo-dose tablet delayed release 81mg
aspirin ec lo-dose tablet delayed release 81mg
aspirin ec low dose tablet delayed release 81mg
aspirin ec low dose tablet delayed release 81mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
Page 7 of 71
Drug Tier
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
aspirin ec tablet delayed release 81mg
3
aspirin ec tablet delayed release 81mg
3
aspirin ec tablet delayed release 81mg
3
aspirin ec tablet delayed release 81mg
3
aspirin ec tablet delayed release 81mg
3
aspirin ec tablet delayed release 81mg
3
aspirin ec tablet delayed release 81mg
3
aspirin ec tablet delayed release 81mg
3
aspirin ec tablet delayed release 81mg
3
aspirin ec tablet delayed release 81mg
3
aspirin enteric coated adult low strength tablet delayed 3
release 81mg
aspirin low dose tablet chewable 81mg
3
aspirin low dose tablet chewable 81mg
3
aspirin low dose tablet chewable 81mg
3
aspirin low strength tablet chewable 81mg
3
aspirin low strength tablet chewable 81mg
3
aspirin tablet chewable 81mg
3
aspirin tablet chewable 81mg
3
aspirin tablet chewable 81mg
3
aspirin tablet chewable 81mg
3
aspirin tablet chewable 81mg
3
aspirin tablet chewable 81mg
3
aspirin tablet delayed release 325mg
3
aspirin tablet delayed release 325mg
3
aspirin tablet delayed release 325mg
3
aspirin tablet delayed release 325mg
3
aspirin tablet delayed release 325mg
3
aspirin tablet delayed release 325mg
3
aspirin tablet delayed release 325mg
3
aspirin tablet delayed release 81mg
3
aspirin tablet delayed release 81mg
3
childrens aspirin low strength tablet chewable 81mg
3
childrens aspirin tablet chewable 81mg
3
childrens aspirin tablet chewable 81mg
3
childrens aspirin tablet chewable 81mg
3
childrens aspirin tablet chewable 81mg
3
childrens aspirin tablet chewable 81mg
3
childrens aspirin tablet chewable 81mg
3
ecpirin tablet delayed release 325mg
3
ecpirin tablet delayed release 325mg
3
enteric coated aspirin tablet delayed release 325mg
3
enteric coated aspirin tablet delayed release 325mg
3
gnp adult aspirin low strength tablet chewable 81mg
3
gnp adult aspirin low strength tablet chewable 81mg
3
gnp adult aspirin low strength tablet chewable 81mg
3
gnp adult aspirin low strength tablet delayed release 81mg3
gnp aspirin low dose tablet delayed release 81mg
3
gnp aspirin low dose tablet delayed release 81mg
3
Page 8 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
gnp aspirin low dose tablet delayed release 81mg
gnp aspirin tablet delayed release 325mg
gnp aspirin tablet delayed release 325mg
hm aspirin ec tablet delayed release 325mg
hm aspirin tablet chewable 81mg
hm aspirin tablet 325mg
miniprin low dose tablet delayed release 81mg
miniprin low dose tablet delayed release 81mg
qc aspirin low dose tablet delayed release 81mg
qc aspirin low dose tablet delayed release 81mg
qc aspirin tablet delayed release 325mg
qc aspirin tablet 325mg
qc childrens aspirin tablet chewable 81mg
sb aspirin tablet delayed release 81mg
sm aspirin adult low strength tablet chewable 81mg
sm aspirin adult low strength tablet delayed release 81mg
sm aspirin adult low strength tablet delayed release 81mg
sm aspirin enteric coated tablet delayed release 325mg
sm aspirin enteric coated tablet delayed release 325mg
sm aspirin enteric coated tablet delayed release 325mg
sm aspirin low dose tablet delayed release 81mg
sm childrens aspirin tablet chewable 81mg
sm childrens aspirin tablet chewable 81mg
Anesthetics
Local Anesthetics
lidocream cream 4%
LMX 4 PLUS KIT 4%
lmx 4 cream 4%
lmx 4 cream 4%
lmx 4 cream 4%
qc azo tablet 95mg
Anti-Addiction/Substance Abuse Treatment Agents
Smoking Cessation Agents
gnp nicotine polacrilex gum 2mg
gnp nicotine polacrilex gum 2mg
gnp nicotine polacrilex gum 2mg
gnp nicotine polacrilex gum 4mg
gnp nicotine polacrilex gum 4mg
gnp nicotine polacrilex gum 4mg
gnp nicotine polacrilex lozenge 2mg
gnp nicotine polacrilex lozenge 4mg
nicoderm cq patch 24 hour 14mg/24hr
nicoderm cq patch 24 hour 14mg/24hr
nicoderm cq patch 24 hour 21mg/24hr
nicoderm cq patch 24 hour 21mg/24hr
nicoderm cq patch 24 hour 21mg/24hr
nicoderm cq patch 24 hour 21mg/24hr
nicoderm cq patch 24 hour 7mg/24hr
nicorelief gum 2mg
Page 9 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
nicorelief gum 2mg
nicorelief gum 2mg
nicorelief gum 2mg
nicorelief gum 4mg
nicorelief gum 4mg
nicorelief gum 4mg
nicorelief gum 4mg
nicorette mini lozenge 2mg
nicorette mini lozenge 2mg
nicorette mini lozenge 4mg
nicorette mini lozenge 4mg
nicorette starter kit gum 2mg
nicorette starter kit gum 2mg
nicorette starter kit gum 4mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 2mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette gum 4mg
nicorette lozenge 2mg
nicorette lozenge 2mg
nicorette lozenge 2mg
nicorette lozenge 2mg
nicorette lozenge 2mg
nicorette lozenge 2mg
nicorette lozenge 4mg
nicorette lozenge 4mg
nicorette lozenge 4mg
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Page 10 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
nicorette lozenge 4mg
nicorette lozenge 4mg
nicorette lozenge 4mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex lozenge 2mg
nicotine polacrilex lozenge 2mg
nicotine polacrilex lozenge 4mg
nicotine polacrilex lozenge 4mg
nicotine transdermal system patch 24 hour 14mg/24hr
Page 11 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
nicotine transdermal system patch 24 hour 14mg/24hr
nicotine transdermal system patch 24 hour 21mg/24hr
nicotine transdermal system patch 24 hour 21mg/24hr
nicotine transdermal system patch 24 hour 7mg/24hr
nicotine transdermal system patch 24 hour 7mg/24hr
nicotine patch 24 hour 14mg/24hr
nicotine patch 24 hour 14mg/24hr
nicotine patch 24 hour 21mg/24hr
nicotine patch 24 hour 21mg/24hr
nicotine patch 24 hour 7mg/24hr
nicotine patch 24 hour 7mg/24hr
sm nicotine polacrilex gum 2mg
sm nicotine polacrilex gum 2mg
sm nicotine polacrilex gum 2mg
sm nicotine polacrilex gum 2mg
sm nicotine polacrilex gum 2mg
sm nicotine polacrilex gum 4mg
sm nicotine polacrilex gum 4mg
sm nicotine polacrilex lozenge 4mg
sm nicotine gum 4mg
sm nicotine gum 4mg
sm nicotine gum 4mg
sm nicotine lozenge 2mg
sm nicotine patch 24 hour 7mg/24hr
Antibacterials
Antibacterials, Other
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin/neomycin/polymyxin ointment 400unit/gm;
5mg/gm; 5000unit/gm
bacitracin/neomycin/polymyxin ointment 400unit/gm;
5mg/gm; 5000unit/gm
bacitracin ointment 500unit/gm
bacitracin ointment 500unit/gm
bacitracin ointment 500unit/gm
betadine surgical scrub solution 7.5%
betadine surgical scrub solution 7.5%
betadine surgical scrub solution 7.5%
betadine surgical scrub solution 7.5%
betadine surgical scrub solution 7.5%
double antibiotic ointment 500unit/gm; 10000unit/gm
double antibiotic ointment 500unit/gm; 10000unit/gm
gnp bacitracin zinc ointment 500unit/gm
Page 12 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
gnp povidone-iodine solution 10%
3
gnp triple antibiotic plus ointment 500unit/gm; 3.5mg/gm; 3
10000unit/gm; 10mg/gm
gnp triple antibiotic ointment 400unit/gm; 3.5mg/gm;
3
5000unit/gm
gnp triple antibiotic ointment 400unit/gm; 3.5mg/gm;
3
5000unit/gm
3
hm bacitracin ointment 500unit/gm
hm double antibiotic ointment 500unit/gm; 100000unit/gm 3
hm povidone-iodine solution 10%
3
povidone-iodine ointment 10%
3
povidone-iodine ointment 10%
3
povidone-iodine solution 10%
3
povidone-iodine solution 10%
3
qc bacitracin ointment 500unit/gm
3
sm double antibiotic ointment 500unit/gm; 100000unit/gm 3
sm triple antibiotic ointment 400unit/gm; 3.5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 3.5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 3.5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 3.5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 3.5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 3.5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm;
3
5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm;
3
5000unit/gm
Antiemetics
Antiemetics, Other
dimenhydrinate tablet 50mg
3
Antifungals
Antifungals
anti-fungal powder powder 1%
3
antifungal cream 1%
3
Page 13 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
antifungal cream 1%
antifungal cream 2%
antifungal cream 2%
antifungal cream 2%
athletes foot af cream cream 1%
baza antifungal cream 2%
baza antifungal cream 2%
baza antifungal cream 2%
carrington antifungal cream 2%
clotrimazole 3 day cream 2%
clotrimazole cream 1%
clotrimazole cream 1%
clotrimazole cream 1%
desenex shake powder powder 2%
desenex shake powder powder 2%
fungoid tincture solution 2%
gnp clotrimazole 3 cream 2%
gnp miconazole 1 kit 0
gnp miconazole 3 kit 0
gnp terbinafine hydrochloride cream 1%
gnp terbinafine hydrochloride cream 1%
gnp terbinafine hydrochloride cream 1%
gnp tioconazole 1 ointment 6.5%
gnp tolnaftate cream 1%
jock itch spray aerosol powder 1%
LAMISIL ADVANCED GEL 1%
lamisil af defense aerosol powder 1%
lamisil af defense powder 1%
lamisil at jock itch cream 1%
lamisil at spray solution 1%
lamisil at spray solution 1%
lamisil at cream 1%
lamisil at cream 1%
lamisil at cream 1%
lamisil at cream 1%
lamisil at cream 1%
lotrimin ultra cream 1%
miconazole 1 kit 0
miconazole 3 combo pack kit 0
miconazole 3 combo pack kit 0
miconazole 7 cream 2%
miconazole 7 cream 2%
miconazole 7 cream 2%
miconazole 7 cream 2%
miconazole 7 cream 2%
miconazole 7 cream 2%
miconazole 7 suppository 100mg
miconazole nitrate cream 2%
miconazole nitrate cream 2%
Page 14 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
miconazole nitrate cream 2%
miconazole nitrate cream 2%
miconazole nitrate cream 2%
miconazole nitrate cream 2%
miconazole nitrate cream 2%
miconazole nitrate suppository 100mg
miconazole cream 2%
micro guard powder 2%
mitrazol powder 2%
qc tolnaftate cream 1%
remedy antifungal cream 2%
remedy antifungal powder 2%
sm 3-day vaginal cream 2%
sm antifungal miconazole cream 2%
sm antifungal tolnaftate cream 1%
sm athletes foot cream 1%
sm athletes foot cream 1%
sm clotrimazole vaginal cream 1%
sm miconazole 7 cream 2%
sm miconazole 7 cream 2%
sm miconazole 7 suppository 100mg
sm tioconazole-1 ointment 6.5%
soothe & cool inzo antifungal cream cream 2%
soothe & cool inzo antifungal cream cream 2%
terbinafine hcl cream 1%
terbinafine hcl cream 1%
tioconazole-1 ointment 6.5%
tolnaftate cream 1%
tolnaftate cream 1%
tolnaftate powder 1%
tolnaftate solution 1%
VAGISTAT-1 OINTMENT 6.5%
vagistat-3 kit 0
Antiparasitics
Anthelmintics
reeses pinworm medicine suspension 144mg/ml
Pediculicides/Scabicides
complete lice treatment kit kit 0.5%; 4%; 0.33%
gnp lice solution kit kit 0.5%; 4%; 0.33%
hm lice killing maximum strength shampoo 4%; 0.33%
lice killing maximum strength shampoo 4%; 0.33%
lice killing maximum strength shampoo 4%; 0.33%
lice solution kit kit 0.5%; 4%; 0.33%
lice treatment creme rinse liquid 4%; 0.33%
permethrin lotion 1%
permethrin lotion 1%
sm lice killing maximum strength shampoo 4%; 0.33%
sm lice killing maximum strength shampoo 4%; 0.33%
sm lice treatment lotion 1%
Page 15 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
sm lice treatment lotion 1%
Blood Glucose Regulators
Glycemic Agents
glucose tablet chewable 4gm
glutose 15 gel 40%
glutose 15 gel 40%
SM GLUCOSE TABLET CHEWABLE 4GM
sm glucose tablet chewable 6mg; 4gm
sm glucose tablet chewable 6mg; 4gm
sm glucose tablet chewable 6mg; 4gm
sm glucose tablet chewable 6mg; 4gm
sm glucose tablet chewable 6mg; 4gm
Dermatological Agents
Dermatological Agents
aloe vesta protective ointment 43%
aluminum acetate astringent packet 1191mg; 839mg
aluminum acetate astringent packet 1191mg; 839mg
AMLACTIN ULTRA CREAM
AQUABASE OINTMENT 0
ATRAC-TAIN CREAM 10%
baza protect cream 0; 0
baza protect cream 0; 0
baza protect cream 0; 0
BENZOIN COMPOUND TINCTURE TINCTURE 0
beta care betatar gel shampoo 2.5%
carmol 10 lotion 10%
dermaphor ointment 0; 0; 0
gnp hemorrhoidal ointment 14%; 71.9%; 0.25%; 3%
gnp hemorrhoidal suppository 85.5%; 0.25%; 3%
hem-prep suppository 85.5%; 0.25%; 3%
hemorrhoidal suppositories suppository 85.5%; 0.25%;
3%
hemorrhoidal suppositories suppository 85.5%; 0.25%;
3%
hemorrhoidal ointment 14%; 71.9%; 0.25%; 3%
hemorrhoidal ointment 14%; 71.9%; 0.25%; 3%
hemorrhoidal suppository 85.5%; 0.25%; 3%
hemorrhoid suppository 85.5%; 0.25%; 3%
HYDROUS EMULSIFIED BASE CREAM 0; 0; 0; 0; 0;
0; 0; 0; 0
ionil-t shampoo 1%
itch relief extra strength cream 2%; 0.1%
minerin cream 0; 0; 0; 0; 0; 0; 0
NAIL SCRUB LIQUID 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0
nutraplus cream 10%
nutraplus lotion 10%
nutraplus lotion 10%
pedi-boro soak paks packet 839mg; 1191mg
pedi-boro soak paks packet 839mg; 1191mg
Page 16 of 71
Drug Tier
3
Requirements/Limits
DP
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
3
3
3
3
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
peleverus clear ointment 0.9%
3
peleverus gold ointment 0
3
peleverus liquid 0.25%
3
peleverus ointment 0
3
PENTRAVAN CREAM 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0 3
periguard ointment 0
3
periguard ointment 0
3
preparation h ointment 14%; 71.9%; 0.25%; 3%
3
PREPARATION H OINTMENT 14%; 71.9%; 0.25%; 3% 3
PREPARATION H SUPPOSITORY 85.5%; 0.25%; 3% 3
preparation h suppository 85.5%; 0.25%; 3%
3
preparation h suppository 85.5%; 0.25%; 3%
3
qc hemorrhoidal ointment 14%; 71.9%; 0.25%; 3%
3
qc hemorrhoidal suppository 85.5%; 0.25%; 3%
3
remedy nutrashield cream 1%
3
remedy nutrashield cream 1%
3
remedy nutrashield cream 1%
3
remedy skin repair cream 1.5%
3
remedy skin repair cream 1.5%
3
remedy skin repair cream 1.5%
3
remedy skin repair cream 1.5%
3
salactic film solution 17%
3
SEBULEX SHAMPOO 2%; 2%
3
SENSI-CARE PROTECTIVE BARRIER OINTMENT 3
49%; 15%
sm hemorrhoidal ointment 14%; 71.9%; 0.25%; 3%
3
SOOTHE & COOL FREE MOISTURE BARRIER
3
OINTMENT 98.3%
SOOTHE & COOL FREE MOISTURE BARRIER
3
OINTMENT 98.3%
soothe & cool protect moisture barrier ointment 98.3%
3
trixaicin hp cream 0.075%
3
ureacin-10 lotion 10%
3
ZIKS ARTHRITIS PAIN RELIEF CREAM 0.025%; 1%; 3
12%
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
icaps capsule 226mg; 14320unit; 0.8mg; 200mg; 34.8mg 3
LACTRASE CAPSULE 250MG
3
Gastrointestinal Agents
Gastrointestinal Agents, Other
acid gone suspension 95mg/15ml; 358mg/15ml
3
ACIDOPHILUS/CITRUS PECTIN TABLET 0; 100MG 3
acidophilus/l-sporogenes extra strength tablet 0; 0
3
almacone double strength suspension 400mg/5ml;
3
400mg/5ml; 40mg/5ml
aluminum hydroxide suspension 320mg/5ml
3
antacid anti-gas maximum strength suspension
3
400mg/5ml; 400mg/5ml; 40mg/5ml
Page 17 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
antacid suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
antacid suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
antacid suspension 400mg/5ml; 400mg/5ml; 40mg/5ml
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl suppository 10mg
bisacodyl suppository 10mg
bisacodyl suppository 10mg
biscolax suppository 10mg
bismatrol maximum strength suspension 525mg/15ml
bismatrol suspension 262mg/15ml
calcium carbonate tablet 648mg
diocto liquid 50mg/5ml
docqlace capsule 100mg
docu liquid 50mg/5ml
docusate calcium capsule 240mg
docusate calcium capsule 240mg
docusate calcium capsule 240mg
docusate calcium capsule 240mg
docusate calcium capsule 240mg
docusate calcium capsule 240mg
docusate sodium capsule 100mg
docusate sodium capsule 100mg
docusate sodium capsule 100mg
docusate sodium capsule 100mg
docusate sodium capsule 100mg
docusate sodium capsule 100mg
docusate sodium capsule 100mg
docusate sodium capsule 100mg
docusate sodium capsule 100mg
docusate sodium capsule 250mg
docusate sodium capsule 250mg
docusate sodium capsule 250mg
Page 18 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
docusate sodium capsule 250mg
3
docusil capsule 100mg
3
docusil capsule 100mg
3
docusol mini enema 283mg
3
dok capsule 100mg
3
dok capsule 100mg
3
dok capsule 100mg
3
dok capsule 100mg
3
dok capsule 250mg
3
dok tablet 100mg
3
ducodyl tablet delayed release 5mg
3
ducodyl tablet delayed release 5mg
3
enema ready-to-use enema 7gm/118ml; 19gm/118ml
3
enemeez mini enema 283mg
3
enemeez plus enema 20mg; 283mg
3
fiber laxative tablet 625mg
3
fiber tabs tablet 625mg
3
fiber therapy powder 58.6%
3
fiber-lax tablet 625mg
3
fiber-lax tablet 625mg
3
fiber-lax tablet 625mg
3
fleet bisacodyl enema 10mg/30ml
3
fleet enema enema 7gm/118ml; 19gm/118ml
3
fleet enema enema 7gm/118ml; 19gm/118ml
3
fleet laxative tablet delayed release 5mg
3
FLEET OIL ENEMA 0
3
fleet pediatric enema 3.5gm/59ml; 9.5gm/59ml
3
formulation r cream 12%; 18%; 0.25%; 3%
3
gas relief suspension 20mg/0.3ml
3
gas relief suspension 20mg/0.3ml
3
gas-x extra strength tablet chewable 125mg
3
gas-x extra strength tablet chewable 125mg
3
GAS-X EXTRA STRENGTH TABLET CHEWABLE
3
125MG
GAVISCON SUSPENSION 95MG/15ML; 358MG/15ML 3
gnp bisa-lax tablet delayed release 5mg
3
gnp foaming antacid tablet chewable 80mg; 20mg
3
gnp gas relief extra strength tablet chewable 125mg
3
gnp gas relief maximum strength tablet chewable 125mg 3
gnp gas relief tablet chewable 80mg
3
gnp infants gas relief suspension 20mg/0.3ml
3
gnp k-pec suspension 262mg/15ml
3
gnp laxative suppository 10mg
3
gnp laxative tablet delayed release 5mg
3
gnp natural fiber powder 28.3%
3
gnp natural fiber powder 48.57%
3
gnp stomach relief maximum strength suspension
3
525mg/15ml
gnp stomach relief suspension 262mg/15ml
3
Page 19 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
gnp stomach relief suspension 262mg/15ml
gnp stool softener extra strength capsule 250mg
gnp stool softener capsule 100mg
gnp stool softener capsule 100mg
gnp stool softener liquid 50mg/5ml
gnp stool softener syrup 60mg/15ml
hm fiber powder 28.3%
hm fiber powder 30.9%
hm fiber powder 48.57%
hm fiber powder 58.6%
hm gas relief infants drops suspension 20mg/0.3ml
hm gas relief tablet chewable 80mg
hm laxative tablet delayed release 5mg
hm senna tablet 8.6mg
hm stomach relief suspension 262mg/15ml
hm stool softener maximum strength capsule 250mg
hm stool softener capsule 100mg
hm stool softener capsule 100mg
infants gas relief suspension 20mg/0.3ml
infants gas relief suspension 40mg/0.6ml
infants simethicone suspension 20mg/0.3ml
kao-tin capsule 240mg
kao-tin suspension 262mg/15ml
kao-tin suspension 262mg/15ml
konsyl capsule 520mg
KONSYL PACKET 60.3%
konsyl powder 30.9%
KONSYL POWDER 60.3%
KONSYL POWDER 71.67%
laxative suppository 10mg
laxative suppository 10mg
laxative tablet delayed release 5mg
maalox advanced suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
magnesium citrate solution 1.745gm/30ml
magnesium oxide tablet 241.3mg
magnesium oxide tablet 241.3mg
magnesium oxide tablet 241.3mg
magnesium oxide tablet 241.3mg
magnesium oxide tablet 400mg
magnesium oxide tablet 400mg
magnesium oxide tablet 400mg
mi-acid gas relief tablet chewable 80mg
mi-acid maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
mi-acid suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
milantex extra strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
milantex suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
Page 20 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
DP
DP
3
DP
Drug Name
milk of magnesia concentrate suspension 2400mg/10ml
milk of magnesia concentrate suspension 2400mg/10ml
milk of magnesia suspension 400mg/5ml
milk of magnesia suspension 400mg/5ml
milk of magnesia suspension 400mg/5ml
milk of magnesia suspension 7.75%
milk of magnesia suspension 7.75%
milk of magnesia suspension 7.75%
milk of magnesia suspension 7.75%
milk of magnesia suspension 7.75%
mintox maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
mintox suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
mytab gas max str tablet chewable 125mg
mytab gas tablet chewable 80mg
natural fiber laxative powder 30.9%
natural fiber therapy powder 30.9%
natural fiber therapy powder 30.9%
natural fiber therapy powder 48.57%
natural fiber therapy powder 48.57%
pedia-lax liquid 50mg/15ml
peptic relief suspension 262mg/15ml
pepto-bismol suspension 524mg/30ml
pepto-bismol suspension 524mg/30ml
pepto-bismol suspension 524mg/30ml
pepto-bismol suspension 524mg/30ml
pink bismuth maximum strength suspension 525mg/15ml
pink bismuth regular strength suspension 527mg/30ml
qc gas relief extra strength tablet chewable 125mg
qc gas relief tablet chewable 80mg
qc gentle laxative suppository 10mg
qc gentle laxative tablet delayed release 5mg
qc natural vegetable powder 95%
qc natural vegetable powder 95%
qc natural vegetable powder 95%
qc pink bismuth suspension 262mg/15ml
qc pink bismuth suspension 262mg/15ml
qc pink bismuth suspension 262mg/15ml
qc senna tablet 8.6mg
qc stool softener capsule 100mg
qc stool softener capsule 100mg
reguloid capsule 0.52gm
reguloid powder 28.3%
reguloid powder 28.3%
reguloid powder 48.57%
reguloid powder 58.6%
reguloid powder 58.6%
reguloid powder 58.6%
reguloid powder 58.6%
Page 21 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
rulox suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
sb bismuth suspension 262mg/15ml
senexon tablet 8.6mg
senexon tablet 8.6mg
senna-tabs tablet 8.6mg
senna-time tablet 8.6mg
senna-time tablet 8.6mg
senna syrup 8.8mg/5ml
senna tablet 8.6mg
senna tablet 8.6mg
senno tablet 8.6mg
silace liquid 150mg/15ml
silace syrup 60mg/15ml
simethicone suspension 40mg/0.6ml
simethicone suspension 40mg/0.6ml
simethicone tablet chewable 125mg
simethicone tablet chewable 80mg
simethicone tablet chewable 80mg
simethicone tablet chewable 80mg
simethicone tablet chewable 80mg
simethicone tablet chewable 80mg
simethicone tablet chewable 80mg
simethicone tablet chewable 80mg
simethicone tablet chewable 80mg
sm fiber powder 28.3%
sm fiber powder 28.3%
sm fiber powder 48.57%
sm fiber powder 58.6%
sm foaming antacid tablet chewable 80mg; 20mg
sm gas relief infants drops suspension 40mg/0.6ml
sm gas relief tablet chewable 80mg
sm gentle laxative tablet delayed release 5mg
sm stomach relief suspension 262mg/15ml
sm stomach relief suspension 527mg/30ml
sm stomach relief suspension 527mg/30ml
sm stool softener capsule 100mg
sm stool softener capsule 100mg
sm stool softener capsule 100mg
sm stool softener capsule 100mg
sm stool softener capsule 250mg
sm womans laxative tablet delayed release 5mg
sodium bicarbonate tablet 325mg
sodium bicarbonate tablet 650mg
sodium bicarbonate tablet 650mg
stimulant laxative tablet delayed release 5mg
stimulant laxative tablet delayed release 5mg
stomach relief maximum strength suspension 525mg/15ml
stomach relief maximum strength suspension 525mg/15ml
stomach relief suspension 262mg/15ml
Page 22 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
stomach relief suspension 262mg/15ml
3
stomach relief suspension 262mg/15ml
3
stomach relief suspension 262mg/15ml
3
stool softener extra strength capsule 250mg
3
stool softener extra strength capsule 250mg
3
stool softener laxative dc capsule 240mg
3
stool softener laxative dc capsule 240mg
3
stool softener laxative dc capsule 240mg
3
stool softener capsule 100mg
3
stool softener capsule 100mg
3
stool softener capsule 100mg
3
stool softener capsule 100mg
3
stool softener capsule 100mg
3
womans laxative tablet delayed release 5mg
3
Laxatives
doc-q-lax tablet 50mg; 8.6mg
3
doc-q-lax tablet 50mg; 8.6mg
3
docqlace capsule 100mg
3
docusate sodium & senna stimulant laxative/stool softener 3
tablet 50mg; 8.6mg
docusate sodium capsule 100mg
3
dok plus tablet 50mg; 8.6mg
3
fleet enema six pack enema 7gm/118ml; 19gm/118ml
3
fleet enema enema 7gm/118ml; 19gm/118ml
3
gnp docusate calcium capsule 240mg
3
gnp enema enema 7gm/118ml; 19gm/118ml
3
gnp enema enema 7gm/118ml; 19gm/118ml
3
gnp fiber therapy tablet 500mg
3
gnp magnesium citrate solution 1.745gm/30ml
3
gnp milk of magnesia suspension 1200mg/15ml
3
gnp milk of magnesia suspension 1200mg/15ml
3
gnp milk of magnesia suspension 1200mg/15ml
3
gnp senna plus tablet 50mg; 8.6mg
3
gnp stool softener/stimulant laxative tablet 50mg; 8.6mg 3
gnp stool softener/stimulant laxative tablet 50mg; 8.6mg 3
hm enema enema 7gm/118ml; 19gm/118ml
3
hm milk of magnesia suspension 1200mg/15ml
3
hm milk of magnesia suspension 1200mg/15ml
3
hm senna-s tablet 50mg; 8.6mg
3
hm stool softener/laxative tablet 50mg; 8.6mg
3
milk of magnesia suspension 1200mg/15ml
3
milk of magnesia suspension 1200mg/15ml
3
milk of magnesia suspension 1200mg/15ml
3
milk of magnesia suspension 400mg/5ml
3
qc docusate calcium capsule 240mg
3
qc enema enema 16gm/133ml; 6gm/133ml
3
qc enema enema 16gm/133ml; 6gm/133ml
3
qc magnesium citrate solution 1.745gm/30ml
3
qc magnesium citrate solution 1.745gm/30ml; 0
3
Page 23 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
qc milk of magnesia suspension 400mg/5ml
qc milk of magnesia suspension 400mg/5ml
qc milk of magnesia suspension 400mg/5ml
qc senna-s tablet 50mg; 8.6mg
qc stool softener plus laxative tablet 50mg; 8.6mg
senexon-s tablet 50mg; 8.6mg
senna-s tablet 50mg; 8.6mg
sennalax-s tablet 50mg; 8.6mg
sennalax-s tablet 50mg; 8.6mg
senokot to go tablet 8.6mg
sm docusate calcium capsule 240mg
sm enema enema 9.5gm/59ml; 3.5gm/59ml
sm fiber laxative tablet 500mg
sm milk of magnesia suspension 1200mg/15ml
sm milk of magnesia suspension 400mg/5ml
sm natural laxative plus stool softener tablet 50mg; 8.6mg
sm oral saline laxative solution 0.9gm/5ml; 2.4gm/5ml
sm oral saline laxative solution 2.7gm/5ml; 7.2gm/5ml
sm stool softener plus laxative tablet 50mg; 8.6mg
sm stool softener plus laxative tablet 50mg; 8.6mg
stool softener laxative tablet 50mg; 8.6mg
Genitourinary Agents
Phosphate Binders
MAGNEBIND 300 TABLET 250MG; 300MG
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying
(Adrenal)
sm hydrocortisone cream 1%
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ALPHA LIPOIC ACID CAPSULE 300MG
arginine tablet 500mg
chew q tablet chewable 100mg
CO Q-10 PLUS CAPSULE 100MG; 20MG
co q-10 capsule 200mg
co-enzyme q-10 capsule 30mg
DIASTIX STRIP 0
fish oil ultra capsule 200mg; 300mg; 1000mg
fish oil capsule delayed release 0; 0; 1000mg; 300mg
fish oil capsule 0; 0; 1000mg; 300mg
fish oil capsule 0; 0; 1000mg; 300mg
fish oil capsule 0; 0; 1000mg; 300mg
fish oil capsule 1000mg
fish oil capsule 1000mg
fish oil capsule 120mg; 180mg; 1000mg; 340mg; 1unit
fish oil capsule 120mg; 180mg; 1000mg; 340mg; 1unit
gnp fish oil capsule delayed release 0; 0; 1200mg
gnp fish oil capsule 175mg; 260mg; 435mg
KETO-DIASTIX STRIP 0
Page 24 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
LACTOSE POWDER 0
natural coenzyme q10 capsule 100mg
ORA-BLEND SF SUSPENSION 0; 0; 0; 0; 0
ORA-BLEND SUSPENSION 0; 0; 0; 0; 0; 0
ORA-PLUS LIQUID 0; 0; 0; 0
ORA-SWEET SF SYRUP 9%; 10%
ORA-SWEET SYRUP 5%; 4%; 54%
PREMIUM CONDOMS LUBRICATED
MISCELLANEOUS
q-gel mega capsule 100mg
sea-omega 30 capsule 0; 0; 1200mg; 2unit
sea-omega 50 capsule 200mg; 300mg; 1000mg; 1unit
Ophthalmic Agents
Ophthalmic Agents, Other
akwa tears ointment 2%; 15%; 83%
artificial tears ointment 0; 0; 0
artificial tears ointment 15%; 83%
artificial tears solution 1.4%
artificial tears solution 1.4%
bion tears solution 0.1%; 0.3%
FRESHKOTE SOLUTION 2.7%; 2%
genteal mild to moderate solution 0.3%
genteal mild to moderate solution 0.3%
genteal mild solution 0.2%
genteal mild solution 0.2%
genteal pm ointment 15%; 85%
GENTEAL SEVERE GEL 0.3%
gnp lubricant eye drops solution 0.4%; 0.3%
isopto tears solution 0.5%
muro 128 ointment 5%
muro 128 ointment 5%
muro 128 solution 5%
muro 128 solution 5%
puralube ointment 15%; 85%
puralube ointment 15%; 85%
refresh celluvisc solution 1%
refresh p.m. ointment 42.5%; 57.3%
refresh plus solution 0.5%
refresh plus solution 0.5%
refresh plus solution 0.5%
REFRESH PLUS SOLUTION 0.5%
refresh plus solution 0.5%
sm artificial tears solution 0.01%; 0; 0.05%; 0.3%
sodium chloride ointment 5%
sodium chloride solution 5%
sterilube ointment 15%; 85%
systane balance restorative formula solution 0.6%
SYSTANE BALANCE RESTORATIVE FORMULA
SOLUTION 0.6%
Page 25 of 71
Drug Tier
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
systane gel gel 0.4%; 0.3%
3
systane nighttime ointment 3%; 94%
3
systane ultra home & away pack solution 0.4%; 0.3%
3
systane ultra solution 0.4%; 0.3%
3
systane ultra solution 0.4%; 0.3%
3
systane ultra solution 0.4%; 0.3%
3
systane solution 0.4%; 0.3%
3
systane solution 0.4%; 0.3%
3
systane solution 0.4%; 0.3%
3
systane solution 0.4%; 0.3%
3
tears naturale forte solution 0.1%; 0.2%; 0.3%
3
tears naturale forte solution 0.1%; 0.2%; 0.3%
3
tears naturale forte solution 0.1%; 0.2%; 0.3%
3
tears naturale forte solution 0.1%; 0.2%; 0.3%
3
tears naturale ii solution 0.01%; 0; 0.05%; 0.3%
3
tears naturale ii solution 0.01%; 0; 0.05%; 0.3%
3
tears naturale solution 0.1%; 0.3%
3
tears naturale solution 0.1%; 0.3%
3
tears pure solution 0.1%; 0.3%
3
Ophthalmic Anti-inflammatories
alaway childrens allergy eye itch relief solution 0.025% 3
alaway solution 0.025%
3
eye itch relief solution 0.025%
3
gnp eye itch relief solution 0.025%
3
gnp itchy eye solution 0.025%
3
ketotifen fumarate solution 0.025%
3
sm eye itch relief solution 0.025%
3
ZADITOR SOLUTION 0.025%
3
zaditor solution 0.025%
3
Otic Agents
Otic Agents
ear drops solution 6.5%
3
ear wax removal drops solution 6.5%
3
ear wax removal kit solution 6.5%
3
ear wax removal system solution 6.5%
3
ear wax remover solution 6.5%
3
earwax treatment drops solution 6.5%
3
gnp ear drops solution 6.5%
3
gnp ear systems solution 6.5%
3
hm earwax removal aid solution 6.5%
3
hm earwax removal kit solution 6.5%
3
qc ear wax removal drops solution 6.5%
3
Respiratory Tract/Pulmonary Agents
Antihistamines
alavert allergy/sinus tablet extended release 12 hour 5mg; 3
120mg
alavert allergy/sinus tablet extended release 12 hour 5mg; 3
120mg
alavert tablet dispersible 10mg
3
Page 26 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
alavert tablet dispersible 10mg
alavert tablet dispersible 10mg
all day allergy childrens tablet chewable 10mg
all day allergy childrens tablet chewable 5mg
all day allergy d-12 tablet extended release 12 hour 5mg;
120mg
all day allergy d tablet extended release 12 hour 5mg;
120mg
all day allergy-d tablet extended release 12 hour 5mg;
120mg
all day allergy-d tablet extended release 12 hour 5mg;
120mg
all day allergy-d tablet extended release 12 hour 5mg;
120mg
all day allergy tablet 10mg
all day allergy tablet 10mg
all day allergy tablet 10mg
all day allergy tablet 10mg
all day allergy tablet 10mg
all day allergy tablet 10mg
all day allergy tablet 10mg
all day allergy tablet 10mg
all day allergy tablet 10mg
all day allergy tablet 10mg
all day allergy tablet 10mg
aller-chlor syrup 2mg/5ml
aller-chlor tablet 4mg
aller-chlor tablet 4mg
aller-chlor tablet 4mg
aller-ease tablet 180mg
aller-ease tablet 180mg
allergy relief child syrup 5mg/5ml
allergy relief d-24 tablet extended release 24 hour 10mg;
240mg
allergy relief d-24 tablet extended release 24 hour 10mg;
240mg
allergy relief/nasal decongestant tablet extended release
24 hour 10mg; 240mg
allergy relief/nasal decongestant tablet extended release
24 hour 10mg; 240mg
allergy relief tablet dispersible 10mg
allergy relief tablet 10mg
allergy relief tablet 10mg
allergy relief tablet 10mg
allergy relief tablet 10mg
allergy relief tablet 10mg
allergy relief tablet 10mg
allergy relief tablet 10mg
allergy relief tablet 10mg
Page 27 of 71
Drug Tier
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
3
DP
3
DP
3
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
DP
3
DP
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
allergy relief tablet 10mg
allergy relief tablet 10mg
allergy relief tablet 10mg
allergy relief tablet 10mg
allergy relief tablet 25mg
allergy tablets tablet 4mg
allergy tablets tablet 4mg
allergy tablets tablet 4mg
allergy tablets tablet 4mg
allergy tablets tablet 4mg
allergy/congestion relief tablet extended release 24 hour
10mg; 240mg
allergy tablet dispersible 10mg
allergy tablet 10mg
allergy tablet 10mg
allergy tablet 10mg
allergy tablet 10mg
allergy tablet 10mg
allergy tablet 10mg
allergy tablet 25mg
allergy tablet 25mg
allergy tablet 25mg
allergy tablet 25mg
allergy tablet 4mg
allergy tablet 4mg
allergy tablet 4mg
allergy tablet 4mg
allergy tablet 4mg
allergy tablet 4mg
allergy tablet 4mg
allergy tablet 4mg
allerhist-1 tablet 1.34mg
banophen capsule 25mg
banophen liquid 12.5mg/5ml
banophen liquid 12.5mg/5ml
banophen tablet 25mg
banophen tablet 25mg
brotapp liquid 1mg/5ml; 15mg/5ml
brotapp liquid 1mg/5ml; 15mg/5ml
brotapp liquid 1mg/5ml; 15mg/5ml
brovex peb liquid 4mg/5ml; 10mg/5ml
brovex psb liquid 4mg/5ml; 20mg/5ml
cardec liquid 1mg/ml; 3.5mg/ml
cetirizine hcl/pseudoephedrine hcl er tablet extended
release 12 hour 5mg; 120mg
cetirizine hcl tablet chewable 10mg
cetirizine hcl tablet chewable 10mg
cetirizine hcl tablet chewable 5mg
cetirizine hcl tablet chewable 5mg
Page 28 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
DP
DP
DP
DP
Drug Name
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 10mg
cetirizine hcl tablet 5mg
cetirizine hcl tablet 5mg
cetirizine hcl tablet 5mg
cetirizine hcl tablet 5mg
childrens cold & allergy elixir 1mg/5ml; 2.5mg/5ml
childrens cold & allergy elixir 1mg/5ml; 2.5mg/5ml
childrens cold & allergy elixir 1mg/5ml; 2.5mg/5ml
childrens loratadine solution 5mg/5ml
childrens loratadine syrup 5mg/5ml
childrens loratadine syrup 5mg/5ml
chlorpheniramine maleate tablet extended release 12mg
chlorpheniramine maleate tablet extended release 12mg
chlorpheniramine maleate tablet 4mg
chlorpheniramine maleate tablet 4mg
claritin reditabs tablet dispersible 10mg
claritin reditabs tablet dispersible 10mg
claritin reditabs tablet dispersible 10mg
claritin reditabs tablet dispersible 5mg
claritin reditabs tablet dispersible 5mg
claritin-d 12 hour tablet extended release 12 hour 5mg;
120mg
claritin-d 12 hour tablet extended release 12 hour 5mg;
120mg
claritin-d 12 hour tablet extended release 12 hour 5mg;
120mg
claritin-d 24 hour tablet extended release 24 hour 10mg;
240mg
claritin-d 24 hour tablet extended release 24 hour 10mg;
240mg
claritin capsule 10mg
Page 29 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
DP
3
DP
3
DP
3
DP
Drug Name
claritin syrup 5mg/5ml
claritin syrup 5mg/5ml
claritin syrup 5mg/5ml
claritin tablet chewable 5mg
claritin tablet chewable 5mg
claritin tablet 10mg
claritin tablet 10mg
claritin tablet 10mg
claritin tablet 10mg
claritin tablet 10mg
claritin tablet 10mg
claritin tablet 10mg
claritin tablet 10mg
claritin tablet 10mg
clemastine fumarate tablet 1.34mg
cold/allergy childrens elixir 1mg/5ml; 2.5mg/5ml
complete allergy medicine capsule 25mg
complete allergy medicine capsule 25mg
complete allergy capsule 25mg
complete allergy capsule 25mg
complete allergy tablet 25mg
dayhist allergy 12 hour relief tablet 1.34mg
dimaphen childrens elixir 1mg/5ml; 2.5mg/5ml
dimaphen childrens elixir 1mg/5ml; 2.5mg/5ml
DIMETAPP COLD & ALLERGY ELIXIR 1MG/5ML;
2.5MG/5ML
dimetapp cold & allergy elixir 1mg/5ml; 2.5mg/5ml
diphenhist capsule 25mg
diphenhist liquid 12.5mg/5ml
diphenhist liquid 12.5mg/5ml
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl capsule 25mg
diphenhydramine hcl tablet 25mg
ed a-hist pse tablet 60mg; 2.5mg
ed a-hist liquid 4mg/5ml; 10mg/5ml
ed chlorped d liquid 2mg/ml; 5mg/ml
ed chlorped jr syrup 2mg/5ml
ed chlorped jr syrup 2mg/5ml
Page 30 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
ed chlorped liquid 2mg/ml
3
ed-chlortan tablet 4mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 180mg
3
fexofenadine hcl tablet 60mg
3
fexofenadine hcl tablet 60mg
3
fexofenadine hcl tablet 60mg
3
fexofenadine hcl tablet 60mg
3
fexofenadine hcl tablet 60mg
3
gnp all day allergy-d tablet extended release 12 hour 5mg; 3
120mg
gnp all day allergy-d tablet extended release 12 hour 5mg; 3
120mg
gnp all day allergy tablet 10mg
3
gnp all day allergy tablet 10mg
3
gnp all day allergy tablet 10mg
3
gnp allergy relief for kids tablet dispersible 10mg
3
gnp allergy relief tablet 180mg
3
gnp allergy relief tablet 180mg
3
gnp allergy relief tablet 180mg
3
gnp allergy relief tablet 180mg
3
gnp allergy capsule 25mg
3
gnp allergy tablet 25mg
3
gnp allergy tablet 25mg
3
gnp allergy tablet 4mg
3
gnp allergy tablet 4mg
3
gnp cold & allergy childrens elixir 1mg/5ml; 2.5mg/5ml 3
gnp cold & allergy childrens elixir 1mg/5ml; 2.5mg/5ml 3
gnp dayhist allergy tablet 1.34mg
3
gnp loratadine-d 12hr tablet extended release 12 hour
3
5mg; 120mg
gnp loratadine-d 24 hour tablet extended release 24 hour 3
10mg; 240mg
gnp loratadine-d 24 hour tablet extended release 24 hour 3
10mg; 240mg
gnp loratadine syrup 5mg/5ml
3
gnp loratadine syrup 5mg/5ml
3
gnp loratadine tablet 10mg
3
gnp loratadine tablet 10mg
3
gnp loratadine tablet 10mg
3
Page 31 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
gnp loratadine tablet 10mg
gnp loratadine tablet 10mg
goodsense all day allergy tablet 10mg
goodsense all day allergy tablet 10mg
hm all day allergy tablet 10mg
hm all day allergy tablet 10mg
hm allergy & congestion tablet extended release 12 hour
5mg; 120mg
hm allergy complete-d tablet extended release 12 hour
5mg; 120mg
hm allergy relief & nasaldecongestant tablet extended
release 24 hour 10mg; 240mg
hm allergy relief tablet dispersible 10mg
hm allergy relief tablet 10mg
hm allergy relief tablet 10mg
hm allergy relief tablet 10mg
hm allergy relief tablet 4mg
hm allergy tablet 25mg
hm allergy tablet 25mg
hm allgery multi symptom capsule 25mg
hm allgery multi symptom capsule 25mg
hm fexofenadine hcl tablet 180mg
hm fexofenadine hcl tablet 180mg
hm loratadine childrens syrup 5mg/5ml
j-tan d pd liquid 1mg/ml; 7.5mg/ml
lohist-d liquid 2mg/5ml; 30mg/5ml
lohist-peb liquid 4mg/5ml; 10mg/5ml
loratadine childrens solution 5mg/5ml
loratadine childrens syrup 5mg/5ml
loratadine hives relief solution 5mg/5ml
loratadine-d 12hr tablet extended release 12 hour 5mg;
120mg
loratadine-d 12hr tablet extended release 12 hour 5mg;
120mg
loratadine-d 12hr tablet extended release 12 hour 5mg;
120mg
loratadine-d 24hr tablet extended release 24 hour 10mg;
240mg
loratadine-d 24hr tablet extended release 24 hour 10mg;
240mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
Page 32 of 71
Drug Tier
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
3
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
DP
3
DP
3
DP
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
multi-symptom allergy capsule 25mg
multi-symptom allergy capsule 25mg
multi-symptom allergy capsule 25mg
nohist-lq liquid 4mg/5ml; 10mg/5ml
pharbedryl capsule 25mg
pharbedryl capsule 25mg
q-dryl capsule 25mg
q-tapp elixir 1mg/5ml; 15mg/5ml
qc all day allergy tablet 10mg
qc all day allergy tablet 10mg
qc all day allergy tablet 10mg
qc allergy relief tablet dispersible 10mg
qc chlor-pheniramine tablet 4mg
qc chlor-pheniramine tablet 4mg
qc complete allergy medicine tablet 25mg
qc complete allergy medicine tablet 25mg
qc loratadine allergy relief tablet 10mg
qc loratadine allergy relief tablet 10mg
qc loratadine allergy relief tablet 10mg
qc loratadine-d tablet extended release 24 hour 10mg;
240mg
robitussin mucus+chest congestion liquid 100mg/5ml
rynex pe elixir 1mg/5ml; 2.5mg/5ml
rynex pse liquid 1mg/5ml; 15mg/5ml
sb loratadine tablet 10mg
siladryl allergy liquid 12.5mg/5ml
siladryl allergy liquid 12.5mg/5ml
siladryl allergy liquid 12.5mg/5ml
sm all day allergy-d tablet extended release 12 hour 5mg;
120mg
sm all day allergy tablet 10mg
sm all day allergy tablet 10mg
sm all day allergy tablet 10mg
sm all day allergy tablet 10mg
sm all day allergy tablet 10mg
sm all day allergy tablet 10mg
sm all day allergy tablet 10mg
sm allergy 4 hour tablet 4mg
Page 33 of 71
Drug Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
sm allergy 4 hour tablet 4mg
3
sm allergy relief loratadine tablet 10mg
3
sm allergy relief loratadine tablet 10mg
3
sm allergy relief loratadine tablet 10mg
3
sm allergy relief loratadine tablet 10mg
3
sm allergy relief capsule 25mg
3
sm allergy relief capsule 25mg
3
sm allergy relief tablet dispersible 10mg
3
sm allergy relief tablet 1.34mg
3
sm allergy relief tablet 25mg
3
sm allergy relief tablet 25mg
3
sm allergy relief tablet 25mg
3
sm childrens loratadine syrup 5mg/5ml
3
sm cold & allergy childrens elixir 1mg/5ml; 2.5mg/5ml
3
sm cold & allergy childrens elixir 1mg/5ml; 2.5mg/5ml
3
sm fexofenadine hcl tablet 180mg
3
sm fexofenadine hcl tablet 180mg
3
sm lorata-dine d tablet extended release 24 hour 10mg; 3
240mg
sm lorata-dine d tablet extended release 24 hour 10mg; 3
240mg
sm loratadine allergy relief tablet dispersible 10mg
3
sm loratadine allergy relief tablet dispersible 10mg
3
sm loratadine d 12hr tablet extended release 12 hour 5mg; 3
120mg
sm loratadine syrup 5mg/5ml
3
sudogest sinus & allergy tablet 4mg; 60mg
3
sudogest sinus & allergy tablet 4mg; 60mg
3
tavist allergy tablet 1.34mg
3
tavist allergy tablet 1.34mg
3
triaminic night time cold & cough syrup 6.25mg/5ml;
3
2.5mg/5ml
virdec liquid 1mg/ml; 3.5mg/ml
3
Bronchodilators, Sympathomimetic
EPHEDRINE SULFATE CAPSULE 25MG
3
Mast Cell Stabilizers
cromolyn sodium aerosol solution 5.2mg/act
3
cromolyn sodium aerosol solution 5.2mg/act
3
Respiratory Tract Agents, Other
12 hour nasal spray solution 0.05%
3
AFRIN MENTHOL SOLUTION 0; 0.05%
3
allergy multi-symptom tablet 325mg; 2mg; 5mg
3
aprodine tablet 60mg; 2.5mg
3
aprodine tablet 60mg; 2.5mg
3
brotapp dm liquid 1mg/5ml; 5mg/5ml; 15mg/5ml
3
brotapp dm liquid 1mg/5ml; 5mg/5ml; 15mg/5ml
3
CAPCOF SYRUP 2MG/5ML; 10MG/5ML; 5MG/5ML 3
CAPMIST DM TABLET 15MG; 400MG; 60MG
3
capmist dm tablet 30mg; 400mg; 30mg
3
Page 34 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
CAPMIST DM TABLET 30MG; 400MG; 30MG
3
CAPRON DM LIQUID 7.5MG/5ML; 7.5MG/5ML
3
cheratussin ac syrup 10mg/5ml; 100mg/5ml
3
cheratussin ac syrup 10mg/5ml; 100mg/5ml
3
cheratussin ac syrup 10mg/5ml; 100mg/5ml
3
cheratussin dac solution 10mg/5ml; 100mg/5ml;
3
30mg/5ml
chest congestion relief tablet 400mg
3
childrens mucus relief cough liquid 5mg/5ml; 100mg/5ml 3
childrens mucus relief expectorant liquid 100mg/5ml
3
childrens pain relief plus multi-symptom cold suspension 3
160mg/5ml; 1mg/5ml; 5mg/5ml; 2.5mg/5ml
CODITUSS DM SYRUP 10MG/5ML; 5MG/5ML;
3
8.33MG/5ML
cold head congestion daytime tablet 325mg; 10mg; 5mg 3
cold head congestion nighttime multi-symptom tablet
3
325mg; 2mg; 10mg; 5mg
cold head congestion nighttime tablet 325mg; 2mg; 10mg; 3
5mg
cold head congestion severe daytime tablet 325mg; 10mg; 3
200mg; 5mg
cold multi-symptom daytime tablet 325mg; 10mg; 5mg
3
cold multi-symptom nighttime tablet 325mg; 2mg; 10mg; 3
5mg
cold multi-symptom severe daytime tablet 325mg; 10mg; 3
200mg; 5mg
cold/cough childrens elixir 1mg/5ml; 5mg/5ml; 2.5mg/5ml 3
cold/cough childrens elixir 1mg/5ml; 5mg/5ml; 2.5mg/5ml 3
cold/cough dm childrens elixir 1mg/5ml; 5mg/5ml;
3
2.5mg/5ml
cold/cough dm childrens elixir 1mg/5ml; 5mg/5ml;
3
2.5mg/5ml
COMTREX COLD & COUGH NIGHTTIME
3
MAXIMUM STRENGTH TABLET 325MG; 2MG;
10MG; 5MG
CONEX COLD/ALLERGY TABLET 2MG; 60MG
3
corfen-dm liquid 4mg/5ml; 15mg/5ml; 10mg/5ml
3
coricidin hbp nighttime multi-symptom cold liquid
3
325mg/15ml; 15mg/15ml; 6.25mg/15ml
cough dm liquid extended release 30mg/5ml
3
cough syrup syrup 100mg/5ml
3
cough syrup syrup 100mg/5ml
3
coughtab tablet 200mg
3
day time cold/flu relief liquid 325mg/15ml; 10mg/15ml; 3
5mg/15ml
day time cold/flu relief liquid 325mg/15ml; 10mg/15ml; 3
5mg/15ml
day time cough liquid 15mg/15ml
3
Page 35 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
decongestant 12hour maximum strength tablet extended 3
release 12 hour 120mg
deep sea nasal spray solution 0.65%
3
delsym night time cough/cold childrens liquid 6.25mg/5ml; 3
2.5mg/5ml
delsym night time cough/cold liquid 6.25mg/5ml;
3
2.5mg/5ml
delsym night time multi-symptom liquid 325mg/15ml;
3
15mg/15ml; 6.25mg/15ml
delsym liquid extended release 30mg/5ml
3
delsym liquid extended release 30mg/5ml
3
delsym liquid extended release 30mg/5ml
3
delsym liquid extended release 30mg/5ml
3
delsym liquid extended release 30mg/5ml
3
delsym liquid extended release 30mg/5ml
3
delsym liquid extended release 30mg/5ml
3
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML 3
delsym liquid extended release 30mg/5ml
3
dextromethorphan polistirex liquid extended release
3
30mg/5ml
dextromethorphan/guaifenesin solution 10mg/5ml;
3
100mg/5ml
dextromethorphan/guaifenesin solution 20mg/10ml;
3
200mg/10ml
dextromethorphan/guaifenesin solution 20mg/10ml;
3
200mg/10ml
diabetic siltussin das-na liquid 100mg/5ml
3
diabetic siltussin-dm maximum strength liquid 10mg/5ml; 3
200mg/5ml
diabetic siltussin-dm liquid 10mg/5ml; 100mg/5ml
3
diabetic tussin dm liquid 10mg/5ml; 100mg/5ml
3
diabetic tussin maximum strength liquid 10mg/5ml;
3
200mg/5ml
diabetic tussin maximum strength liquid 10mg/5ml;
3
200mg/5ml
diabetic tussin liquid 100mg/5ml
3
dimaphen dm cold/cough childrens elixir 1mg/5ml;
3
5mg/5ml; 2.5mg/5ml
dimetapp dm cold & cough liquid 1mg/5ml; 5mg/5ml;
3
2.5mg/5ml
DIMETAPP DM COLD & COUGH LIQUID 1MG/5ML; 3
5MG/5ML; 2.5MG/5ML
DIMETAPP LONG ACTING COUGH PLUS COLD
3
SYRUP 1MG/5ML; 7.5MG/5ML
dimetapp multi-symptom cold & flu liquid 160mg/5ml;
3
1mg/5ml; 5mg/5ml; 2.5mg/5ml
dimetapp nighttime cold &congestion liquid 6.25mg/5ml; 3
2.5mg/5ml
dristan cold tablet 325mg; 2mg; 5mg
3
Page 36 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
ed a-hist dm liquid 4mg/5ml; 15mg/5ml; 10mg/5ml
3
ed bron gp liquid 100mg/5ml; 5mg/5ml
3
endacof-dm liquid 1mg/5ml; 5mg/5ml; 2.5mg/5ml
3
excedrin sinus headache tablet 325mg; 5mg
3
exefen dmx tablet 20mg; 400mg; 60mg
3
extra action cough syrup 10mg/5ml; 100mg/5ml
3
extra action cough syrup 10mg/5ml; 100mg/5ml
3
gnp allergy plus severe sinus headache maximum strength 3
tablet 325mg; 25mg; 5mg
gnp childrens pain relief plus cold suspension 160mg/5ml; 3
1mg/5ml; 5mg/5ml; 2.5mg/5ml
gnp childrens plus multi-symptom cold suspension
3
160mg/5ml; 1mg/5ml; 5mg/5ml; 2.5mg/5ml
gnp cold & cough childrens elixir 1mg/5ml; 5mg/5ml;
3
2.5mg/5ml
gnp cold head congestion night time tablet 325mg; 2mg; 3
10mg; 5mg
gnp cold multi-symptom daytime tablet 325mg; 10mg;
3
5mg
gnp cold multi-symptom nighttime tablet 325mg; 2mg;
3
10mg; 5mg
gnp cold relief multi-symptom daytime tablet 325mg;
3
10mg; 5mg
gnp cough relief liquid 15mg/5ml
3
gnp cough relief liquid 15mg/5ml
3
gnp day time mucus reliefdm liquid 10mg/15ml;
3
200mg/15ml
gnp flu relief therapy seere cold daytime liquid
3
325mg/15ml; 10mg/15ml; 5mg/15ml
gnp flu relief therapy severe cold nighttime liquid
3
325mg/15ml; 12.5mg/15ml; 5mg/15ml
gnp mucus relief cough childrens liquid 5mg/5ml;
3
100mg/5ml
gnp mucus relief dm tablet 20mg; 400mg
3
gnp mucus relief tablet 400mg
3
gnp night time cold/flu relief liquid 500mg/15ml;
3
15mg/15ml; 6.25mg/15ml
gnp night time cold/flu relief liquid 500mg/15ml;
3
15mg/15ml; 6.25mg/15ml
gnp night time cold/flu relief liquid 500mg/15ml;
3
15mg/15ml; 6.25mg/15ml
gnp night time cold/flu relief liquid 500mg/15ml;
3
15mg/15ml; 6.25mg/15ml
gnp night time cough liquid 15mg/15ml; 6.25mg/15ml
3
gnp night time cough liquid 15mg/15ml; 6.25mg/15ml
3
gnp night time sinus capsule 325mg; 6.25mg; 5mg
3
gnp nose drops extra strength solution 1%
3
gnp triacting night time cold & cough childrens liquid
3
6.25mg/5ml; 2.5mg/5ml
Page 37 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
gnp tussin cf cough & cold syrup 10mg/5ml; 100mg/5ml; 3
5mg/5ml
gnp tussin cf cough & cold syrup 10mg/5ml; 100mg/5ml; 3
5mg/5ml
gnp tussin cough long acting syrup 15mg/5ml
3
gnp tussin dm cough liquid 10mg/5ml; 100mg/5ml
3
gnp tussin dm max liquid 10mg/5ml; 200mg/5ml
3
gnp tussin dm max liquid 10mg/5ml; 200mg/5ml
3
gnp tussin dm liquid 10mg/5ml; 100mg/5ml
3
gnp tussin dm liquid 10mg/5ml; 100mg/5ml
3
gnp tussin syrup 100mg/5ml
3
gnp tussin syrup 100mg/5ml
3
guaiatussin ac syrup 10mg/5ml; 100mg/5ml
3
guaifenesin ac syrup 10mg/5ml; 100mg/5ml
3
guaifenesin dac solution 10mg/5ml; 100mg/5ml;
3
30mg/5ml
guaifenesin er tablet extended release 12 hour 600mg
3
guaifenesin-dm syrup 10mg/5ml; 100mg/5ml
3
guaifenesin-dm syrup 10mg/5ml; 100mg/5ml
3
guaifenesin/codeine solution 10mg/5ml; 100mg/5ml
3
guaifenesin/codeine solution 10mg/5ml; 100mg/5ml
3
guaifenesin solution 100mg/5ml
3
guaifenesin solution 100mg/5ml
3
guaifenesin solution 100mg/5ml
3
guaifenesin solution 100mg/5ml
3
guaifenesin solution 200mg/10ml
3
guaifenesin solution 300mg/15ml
3
guaifenesin tablet 200mg
3
intense cough reliever extra strength liquid 20mg/5ml;
3
300mg/5ml
iophen c-nr liquid 10mg/5ml; 100mg/5ml
3
iophen dm-nr liquid 10mg/5ml; 100mg/5ml
3
iophen-nr liquid 100mg/5ml
3
kidkare cough/cold liquid 1mg/5ml; 5mg/5ml; 15mg/5ml 3
liquituss gg liquid 200mg/5ml
3
liquituss gg liquid 200mg/5ml
3
lohist-dm syrup 2mg/5ml; 10mg/5ml; 5mg/5ml
3
m-clear wc solution 6.3mg/5ml; 100mg/5ml
3
m-end dm liquid 2mg/5ml; 15mg/5ml; 15mg/5ml
3
M-END PE LIQUID 1.33MG/5ML; 6.33MG/5ML;
3
3.33MG/5ML
m-end wc liquid 1.33mg/5ml; 6.33mg/5ml; 10mg/5ml
3
mapap sinus maximum strength congestion and pain tablet 3
325mg; 5mg
mucinex chest congestion childrens liquid 100mg/5ml
3
mucinex childrens cold cough & sore throat liquid
3
325mg/10ml; 10mg/10ml; 200mg/10ml; 5mg/10ml
mucinex childrens multi-symptom cold & fever liquid
3
325mg/10ml; 10mg/10ml; 200mg/10ml; 5mg/10ml
Page 38 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
mucinex childrens multi-symptom cold liquid 5mg/5ml;
3
100mg/5ml; 2.5mg/5ml
mucinex cold for kids liquid 100mg/5ml; 2.5mg/5ml
3
mucinex cough childrens liquid 5mg/5ml; 100mg/5ml
3
mucinex cough for kids liquid 5mg/5ml; 100mg/5ml
3
mucinex dm maximum strength tablet extended release 12 3
hour 60mg; 1200mg
mucinex dm maximum strength tablet extended release 12 3
hour 60mg; 1200mg
mucinex dm tablet extended release 12 hour 30mg; 600mg 3
mucinex dm tablet extended release 12 hour 30mg; 600mg 3
mucinex d tablet extended release 12 hour 1200mg;
3
120mg
mucinex d tablet extended release 12 hour 1200mg;
3
120mg
mucinex d tablet extended release 12 hour 600mg; 60mg 3
mucinex d tablet extended release 12 hour 600mg; 60mg 3
mucinex fast-max cold & sinus liquid 650mg/20ml;
3
400mg/20ml; 10mg/20ml
mucinex fast-max cold & sinus tablet 325mg; 200mg; 5mg 3
mucinex fast-max cold & sinus tablet 325mg; 200mg; 5mg 3
mucinex fast-max cold flu& sore throat liquid
3
650mg/20ml; 20mg/20ml; 400mg/20ml; 10mg/20ml
mucinex fast-max cold flu& sore throat tablet 325mg;
3
10mg; 200mg; 5mg
mucinex fast-max cold flu& sore throat tablet 325mg;
3
10mg; 200mg; 5mg
mucinex fast-max dm max liquid 20mg/20ml; 400mg/20ml 3
mucinex fast-max severe congestion & cold tablet 325mg; 3
10mg; 200mg; 5mg
mucinex fast-max severe congestion & cough liquid
3
20mg/20ml; 400mg/20ml; 10mg/20ml
mucinex for kids liquid 100mg/5ml
3
mucinex for kids packet 100mg
3
mucinex for kids packet 50mg
3
mucinex maximum strength tablet extended release 12
3
hour 1200mg
mucinex maximum strength tablet extended release 12
3
hour 1200mg
mucinex maximum strength tablet extended release 12
3
hour 1200mg
mucinex nasal spray full force solution 0.05%
3
mucinex nasal spray moisture smart solution 0.05%
3
mucinex tablet extended release 12 hour 600mg
3
mucinex tablet extended release 12 hour 600mg
3
mucinex tablet extended release 12 hour 600mg
3
mucinex tablet extended release 12 hour 600mg
3
mucinex tablet extended release 12 hour 600mg
3
mucus relief childrens liquid 100mg/5ml
3
Page 39 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
mucus relief cough childrens liquid 5mg/5ml; 100mg/5ml 3
mucus relief cough childrens liquid 5mg/5ml; 100mg/5ml 3
mucus relief tablet 400mg
3
mytussin dac solution 10mg/5ml; 100mg/5ml; 30mg/5ml 3
mytussin dac solution 10mg/5ml; 100mg/5ml; 30mg/5ml 3
nasal decongestant pe maximum strength tablet 10mg
3
nasal decongestant pe maximum strength tablet 10mg
3
nasal decongestant pe maximum strength tablet 10mg
3
nasal decongestant spray solution 0.05%
3
nasal decongestant spray solution 0.05%
3
nasal decongestant spray solution 0.05%
3
nasal decongestant spray solution 0.05%
3
nasal decongestant liquid 30mg/5ml
3
nasal decongestant solution 1%
3
nasal decongestant syrup 30mg/5ml
3
nasohist dm liquid 1mg/ml; 3mg/ml; 2mg/ml
3
nite time cough liquid 15mg/15ml; 6.25mg/15ml
3
nite time multi-symptom cold/flu relief liquid 500mg/15ml; 3
15mg/15ml; 6.25mg/15ml
nite time multi-symptom cold/flu relief liquid 500mg/15ml; 3
15mg/15ml; 6.25mg/15ml
nite time multi-symptom cold/flu relief liquid 500mg/15ml; 3
15mg/15ml; 6.25mg/15ml
nite-time multi-symptom cold/flu relief liquid 500mg/15ml; 3
15mg/15ml; 6.25mg/15ml
nite-time multi-symptom cold/flu relief liquid 500mg/15ml; 3
15mg/15ml; 6.25mg/15ml
nite-time multi-symptom cold/flu relief liquid 500mg/15ml; 3
15mg/15ml; 6.25mg/15ml
nohist-dm liquid 4mg/5ml; 15mg/5ml; 10mg/5ml
3
nrs nasal relief solution 0.05%
3
ocean nasal spray solution 0.65%
3
ocean nasal spray solution 0.65%
3
organ-i nr tablet 200mg
3
pedia relief cough/cold liquid 1mg/5ml; 5mg/5ml;
3
15mg/5ml
pediatric cough/cold liquid 1mg/5ml; 5mg/5ml; 15mg/5ml 3
PHENYLHISTINE DH LIQUID 2MG/5ML; 10MG/5ML; 3
30MG/5ML
phenylhistine dh liquid 2mg/5ml; 10mg/5ml; 30mg/5ml
3
pseudoephedrine hcl tablet 30mg
3
q-tapp dm elixir 1mg/5ml; 5mg/5ml; 15mg/5ml
3
q-tussin dm syrup 10mg/5ml; 100mg/5ml
3
q-tussin dm syrup 10mg/5ml; 100mg/5ml
3
q-tussin dm syrup 10mg/5ml; 100mg/5ml
3
q-tussin syrup 100mg/5ml
3
q-tussin syrup 100mg/5ml
3
q-tussin syrup 100mg/5ml
3
Page 40 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
qc cold relief plus multi-symptom childrens suspension
160mg/5ml; 1mg/5ml; 5mg/5ml; 2.5mg/5ml
qc cough relief liquid 15mg/5ml
qc cough relief liquid 15mg/5ml
qc cough/sore throat nighttime liquid 1000mg/30ml;
30mg/30ml; 12.5mg/30ml
qc nighttime cold/flu relief liquid 500mg/15ml;
15mg/15ml; 6.25mg/15ml
qc nighttime cold/flu relief liquid 500mg/15ml;
15mg/15ml; 6.25mg/15ml
qc nighttime cold/flu relief liquid 500mg/15ml;
15mg/15ml; 6.25mg/15ml
qc nighttime cold/flu relief liquid 500mg/15ml;
15mg/15ml; 6.25mg/15ml
qc nighttime cough liquid 15mg/15ml; 6.25mg/15ml
qc nighttime cough liquid 15mg/15ml; 6.25mg/15ml
qc tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml
qc tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml
relcof c solution 6.3mg/5ml; 100mg/5ml
rescon dm syrup 2mg/5ml; 10mg/5ml; 30mg/5ml
rescon dm syrup 2mg/5ml; 10mg/5ml; 30mg/5ml
rescon-gg liquid 100mg/5ml; 5mg/5ml
rescon-gg liquid 100mg/5ml; 5mg/5ml
RESPAIRE-30 CAPSULE 150MG; 30MG
robafen dm cough clear syrup 10mg/5ml; 100mg/5ml
robafen dm syrup 10mg/5ml; 100mg/5ml
robafen dm syrup 10mg/5ml; 100mg/5ml
robafen dm syrup 10mg/5ml; 100mg/5ml
robafen syrup 100mg/5ml
robafen syrup 100mg/5ml
robitussin childrens cough & cold cf liquid 5mg/5ml;
50mg/5ml; 2.5mg/5ml
robitussin childrens cough long-acting syrup 7.5mg/5ml
robitussin childrens cough/cold long-acting liquid
1mg/5ml; 7.5mg/5ml
robitussin cold+flu daytime capsule 325mg; 10mg; 5mg
robitussin cold+flu nighttime capsule 325mg; 15mg;
6.25mg
robitussin lingering coldlong-acting cough liquid
15mg/5ml
robitussin peak cold cough+ chest congestion dm max
strength liquid 10mg/5ml; 200mg/5ml
robitussin peak cold cough+ chest congestion dm liquid
10mg/5ml; 100mg/5ml
robitussin peak cold cough+ chest congestion dm liquid
10mg/5ml; 100mg/5ml
robitussin peak cold cough+ chest congestion dm liquid
10mg/5ml; 100mg/5ml
robitussin peak cold dm syrup 10mg/5ml; 100mg/5ml
Page 41 of 71
Drug Tier
3
Requirements/Limits
DP
3
3
3
DP
DP
DP
3
DP
3
DP
3
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
DP
DP
3
3
DP
DP
3
DP
3
DP
3
DP
3
DP
3
DP
3
DP
Drug Name
Drug Tier
robitussin peak cold multi-symptom cold maximum
3
strength liquid 10mg/5ml; 200mg/5ml; 5mg/5ml
robitussin peak cold multi-symptom cold liquid 10mg/5ml; 3
100mg/5ml; 5mg/5ml
robitussin peak cold multi-symptom cold liquid 10mg/5ml; 3
100mg/5ml; 5mg/5ml
robitussin peak cold nasal relief tablet 325mg; 5mg
3
robitussin peak cold nighttime multi-symptom cold liquid 3
160mg/5ml; 6.25mg/5ml; 2.5mg/5ml
robitussin peak cold nighttime nasal relief tablet 325mg; 3
2mg; 5mg
RYDEX LIQUID 1.33MG/5ML; 6.33MG/5ML;
3
10MG/5ML
rynex dm liquid 1mg/5ml; 5mg/5ml; 2.5mg/5ml
3
saline mist solution 0.65%
3
saline nasal mist solution 0.65%
3
sea soft nasal mist solution 0.65%
3
siltussin sa syrup 100mg/5ml
3
siltussin sa syrup 100mg/5ml
3
siltussin sa syrup 100mg/5ml
3
siltussin-dm syrup 10mg/5ml; 100mg/5ml
3
siltussin-dm syrup 10mg/5ml; 100mg/5ml
3
siltussin-dm syrup 10mg/5ml; 100mg/5ml
3
sinus congestion & pain daytime tablet 325mg; 5mg
3
sinus nasal spray solution 0.05%
3
sm childrens pain relief plus multi-symptom cold
3
suspension 160mg/5ml; 1mg/5ml; 5mg/5ml; 2.5mg/5ml
sm cold & cough dm childrens elixir 1mg/5ml; 5mg/5ml; 3
2.5mg/5ml
sm cough relief syrup 15mg/5ml
3
sm day time cold & flu relief liquid 325mg/15ml;
3
10mg/15ml; 5mg/15ml
sm flu relief therapy severe cold nighttime liquid
3
325mg/15ml; 12.5mg/15ml; 5mg/15ml
sm mucus er tablet extended release 12 hour 600mg
3
sm mucus er tablet extended release 12 hour 600mg
3
sm mucus relief cough childrens liquid 5mg/5ml;
3
100mg/5ml
sm nasal spray saline solution 0.65%
3
sm nasal spray saline solution 0.65%
3
sm nite time cold & flu relief liquid 500mg/15ml;
3
15mg/15ml; 6.25mg/15ml
sm nite time cold & flu relief liquid 500mg/15ml;
3
15mg/15ml; 6.25mg/15ml
sm nite time cough liquid 15mg/15ml; 6.25mg/15ml
3
sm nose drops nasal decongestant extra strength solution 3
1%
sm tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml
3
sm tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml
3
Page 42 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
sm tussin dm cough/chest congestion syrup 10mg/5ml;
3
100mg/5ml
sm tussin dm cough/chest congestion syrup 10mg/5ml;
3
100mg/5ml
sm tussin dm syrup 10mg/5ml; 100mg/5ml
3
sm tussin dm syrup 10mg/5ml; 100mg/5ml
3
sm tussin dm syrup 10mg/5ml; 100mg/5ml
3
sm tussin syrup 100mg/5ml
3
sm tussin syrup 100mg/5ml
3
sudogest 12 hour tablet extended release 12 hour 120mg 3
sudogest pe tablet 10mg
3
sudogest pe tablet 10mg
3
sudogest tablet 30mg
3
sudogest tablet 30mg
3
sudogest tablet 60mg
3
triacting nightime cold& cough childrens liquid
3
6.25mg/5ml; 2.5mg/5ml
triaminic cold & cough day time childrens syrup 5mg/5ml; 3
2.5mg/5ml
TRIAMINIC MULTI-SYMPTOM FEVER SYRUP
3
160MG/5ML; 1MG/5ML; 7.5MG/5ML
tusnel diabetic liquid 10mg/5ml; 100mg/5ml
3
tusnel pediatric liquid 5mg/5ml; 50mg/5ml; 15mg/5ml
3
tusnel liquid 15mg/5ml; 200mg/5ml; 30mg/5ml
3
tusnel liquid 15mg/5ml; 200mg/5ml; 30mg/5ml
3
tussin cf cough & cold liquid 10mg/5ml; 100mg/5ml;
3
5mg/5ml
tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml
3
tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml
3
tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml
3
tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml
3
tussin chest congestion syrup 100mg/5ml
3
tussin cough syrup 15mg/5ml
3
tussin dm max liquid 10mg/5ml; 200mg/5ml
3
tussin dm max liquid 10mg/5ml; 200mg/5ml
3
tussin dm liquid 10mg/5ml; 100mg/5ml
3
tussin dm liquid 10mg/5ml; 100mg/5ml
3
tussin dm liquid 10mg/5ml; 100mg/5ml
3
tussin dm liquid 10mg/5ml; 100mg/5ml
3
tussin dm liquid 10mg/5ml; 100mg/5ml
3
tussin dm syrup 10mg/5ml; 100mg/5ml
3
tussin dm syrup 10mg/5ml; 100mg/5ml
3
tussin dm syrup 10mg/5ml; 100mg/5ml
3
tussin dm syrup 10mg/5ml; 100mg/5ml
3
tussin mucus + chest congestion syrup 100mg/5ml
3
tussin mucus + chest congestion syrup 100mg/5ml
3
tussin syrup 100mg/5ml
3
tussin syrup 100mg/5ml
3
Therapeutic Nutrients/Minerals/Electrolytes
Page 43 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Electrolyte/Mineral Modifiers
mykidz iron 10 suspension 15mg/1.5ml
Electrolyte/Mineral Replacement
calci-chew tablet chewable 1250mg
CALCI-MIX CAPSULE 1250MG
calcium carbonate suspension 1250mg/5ml
calcium carbonate suspension 1250mg/5ml
calcium carbonate suspension 1250mg/5ml
calcium carbonate tablet 1250mg
calcium carbonate tablet 1250mg
calcium high potency + vitamin d tablet 600mg; 200unit
calcium high potency + vitamin d tablet 600mg; 200unit
CALCIUM LACTATE TABLET 648MG
calcium lactate tablet 648mg
calcium oyster shell tablet 1250mg
calcium oyster shell tablet 1250mg
calcium oyster shell tablet 1250mg
calcium oyster shell tablet 1250mg
calcium oyster shell tablet 1250mg
calcium oyster shell tablet 1250mg
calcium plus vitamin d3 capsule 600mg; 500unit
calcium/vitamin d tablet 600mg; 200unit
calcium/vitamin d tablet 600mg; 400unit
caltrate 600+d plus minerals tablet chewable 600mg;
800unit; 1mg; 50mg; 0; 0; 1.8mg; 250mcg; 7.5mg
CALTRATE 600+D PLUS MINERALS TABLET
CHEWABLE 600MG; 800UNIT; 1MG; 50MG; 0; 0;
1.8MG; 250MCG; 7.5MG
citrus calcium/vitamin d tablet 200mg; 250unit
duofer tablet 6mg; 22mg
fer-iron solution 15mg/ml
ferrex 150 capsule 150mg
ferrex 150 capsule 150mg
ferrous drops solution 15mg/ml
ferrous gluconate tablet 324mg
ferrous sulfate elixir 220mg/5ml
ferrous sulfate elixir 220mg/5ml
ferrous sulfate elixir 220mg/5ml
ferrous sulfate liquid 220mg/5ml
ferrous sulfate tablet extended release 140mg
ferrous sulfate tablet extended release 140mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
gnp calcium 500/d tablet 500mg; 200unit
gnp calcium 500/d tablet 500mg; 200unit
gnp calcium 600 +d tablet 600mg; 400unit
gnp calcium 600 +d tablet 600mg; 400unit
Page 44 of 71
Drug Tier
Requirements/Limits
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
gnp calcuim/vitamin d/minerals tablet chewable 600mg; 3
400unit; 1mg; 40mg; 1.8mg; 250mcg; 7.5mg
gnp slow release iron tablet extended release 47.5mg
3
iferex 150 capsule 150mg
3
iron tablet 27mg
3
mag-delay tablet extended release 64mg
3
mag-g tablet 500mg
3
MAG-TAB SR TABLET EXTENDED RELEASE 84MG 3
mag-tab sr tablet extended release 84mg
3
mag-tab sr tablet extended release 84mg
3
MAGONATE LIQUID 1000MG/5ML
3
magonate tablet 500mg
3
novaferrum 125 liquid 100unit/5ml; 125mg/5ml
3
novaferrum pediatric drops liquid 15mg/ml
3
oysco 500+d tablet chewable 500mg; 600unit
3
oyster shell calcium/vitamin d tablet 200unit; 500mg
3
oyster shell calcium/vitamin d tablet 250mg; 125unit; 0 3
oyster shell calcium/vitamin d tablet 250mg; 125unit; 0 3
oyster shell calcium/vitamin d tablet 250mg; 125unit; 0 3
oyster shell calcium/vitamin d tablet 500mg; 400unit
3
PHOS-NAK POWDER CONCENTRATE PACKET
3
250MG; 280MG; 160MG
poly-iron 150 capsule 150mg
3
profe capsule 180mg
3
qc ferrous sulfate tablet 325mg
3
sm calcium citrate w/vitamin d3 tablet 315mg; 250unit
3
sm iron tablet 325mg
3
zinc sulfate capsule 220mg
3
Vitamins
ADEKS TABLET CHEWABLE 60MG; 3MG; 50MCG; 3
400UNIT; 12MCG; 0.2MG; 10MG; 10MG; 150MCG;
1500MCG; 1300MCG; 1200MCG; 4000UNIT; 150UNIT;
7.5MG
aquadeks capsule 10mg; 100mcg; 12mg; 800unit; 10mg; 3
12mcg; 200mcg; 10mg; 700mcg; 1.9mg; 1.7mg; 75mcg;
75mg; 1.5mg; 150unit; 18167unit; 80mg; 10mg
aquadeks liquid 45mg/ml; 3mg/ml; 15mcg/ml; 3mg/ml;
3
400unit/ml; 2mg/ml; 6mg/ml; 400mcg/ml; 0.6mg/ml;
0.6mg/ml; 10mcg/ml; 0.6mg/ml; 50unit/ml; 5751unit/ml;
15mg/ml; 5mg/ml
AQUADEKS TABLET CHEWABLE 0; 50MCG; 6MG; 3
400UNIT; 5MG; 6MCG; 100MCG; 5MG; 350MCG;
0.95MG; 0.85MG; 37.5MCG; 5MG; 35MG; 0.75MG;
50UNIT; 9083.5UNIT; 15MG; 5MG
aqueous vitamin d infants liquid 400unit/ml
3
aqueous vitamin e solution 15unit/0.3ml
3
calciferol solution 8000unit/ml
3
Page 45 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
centamin liquid 60mg/15ml; 300mcg/15ml; 25mcg/15ml; 3
6mcg/15ml; 9mg/15ml; 2mg/15ml; 20mg/15ml; 10mg/15ml; 150mcg/15ml; 2mg/15ml; 1.7mg/15ml; 25mcg/15ml; 1.5mg/15ml; 30unit/15ml; 2500unit/15ml; 400unit/15ml; 3mg/15ml
centavite a-z complete multivitamin/minerals tablet 90mg; 3
1250unit; 35mcg; 40mg; 7.5mg; 15mcg; 2mg; 9mcg; 0.4mg; 150mcg; 27mg; 100mg; 5mg; 15mcg; 30mg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg; 10mcg; 3mg; 5000unit; 400unit; 30unit; 15mg
centavite a-z complete multivitamin/minerals tablet 90mg; 3
1250unit; 35mcg; 40mg; 7.5mg; 15mcg; 2mg; 9mcg; 0.4mg; 150mcg; 27mg; 100mg; 5mg; 15mcg; 30mg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg; 10mcg; 3mg; 5000unit; 400unit; 30unit; 15mg
centavite a-z complete multivitamin/minerals tablet 90mg; 3
1250unit; 35mcg; 40mg; 7.5mg; 15mcg; 2mg; 9mcg; 0.4mg; 150mcg; 27mg; 100mg; 5mg; 15mcg; 30mg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg; 10mcg; 3mg; 5000unit; 400unit; 30unit; 15mg
centavite a-z complete multivitamin/minerals tablet 90mg; 3
1250unit; 35mcg; 40mg; 7.5mg; 15mcg; 2mg; 9mcg; 0.4mg; 150mcg; 27mg; 100mg; 5mg; 15mcg; 30mg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg; 10mcg; 3mg; 5000unit; 400unit; 30unit; 15mg
centavite a-z complete multivitamin/minerals tablet 90mg; 3
1250unit; 35mcg; 40mg; 7.5mg; 15mcg; 2mg; 9mcg; 0.4mg; 150mcg; 27mg; 100mg; 5mg; 15mcg; 30mg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg; 10mcg; 3mg; 5000unit; 400unit; 30unit; 15mg
3
CENTRUM ADULTS TABLET 60MG; 0; 30MCG;
75MCG; 200MG; 10MG; 72MG; 400UNIT; 35MCG;
0.5MG; 6MCG; 18MG; 400MCG; 50MG; 2.3MG; 20MG;
5MCG; 20MG; 25MCG; 80MG; 150MCG; 2MG; 1.7MG;
2MG; 10MCG; 45MCG; 55MCG; 10MCG; 1.5MG;
30UNIT; 3500UNIT; 11MG
3
CENTRUM LIQUID 60MG/15ML; 300MCG/15ML;
25MCG/15ML; 6MCG/15ML; 150MCG/15ML;
9MG/15ML; 2.5MG/15ML; 25MCG/15ML;
20MG/15ML; 10MG/15ML; 2MG/15ML; 1.7MG/15ML; 1.5MG/15ML; 2500UNIT/15ML; 400UNIT/15ML;
30UNIT/15ML; 3MG/15ML
3
cerovite advanced formula liquid 60mg/15ml;
300mcg/15ml; 10mg/15ml; 25mcg/15ml; 6mcg/15ml; 9mg/15ml; 2mg/15ml; 20mg/15ml; 150mcg/15ml; 2mg/15ml; 1.7mg/15ml; 25mcg/15ml; 1.5mg/15ml; 30unit/15ml; 3mg/15ml
Page 46 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
cerovite advanced formula tablet 60mg; 0; 0; 30mcg;
3
75mcg; 200mg; 10mg; 72mg; 400unit; 35mcg; 0.5mg;
6mcg; 18mg; 400mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg;
25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 0; 10mcg;
45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg
cerovite jr tablet chewable 60mg; 0; 45mcg; 108mg;
3
10mg; 400unit; 20mcg; 2mg; 6mcg; 18mg; 400mcg;
40mg; 1mg; 20mg; 50mg; 10mcg; 150mcg; 2mg; 1.7mg;
0; 20mcg; 1.5mg; 30unit; 3500unit; 15mg
certa plus tablet 60mg; 0; 30mcg; 162mg; 10mg; 72mg; 3
400unit; 120mg; 2mg; 6mcg; 18mg; 400mcg; 250mcg;
100mg; 2mg; 20mg; 5mcg; 109mg; 25mcg; 80mg;
150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 75mcg;
20mcg; 10mcg; 1.5mg; 30unit; 5000unit; 15mg
certavite/antioxidants tablet 60mg; 0; 30mcg; 75mcg;
3
200mg; 10mg; 72mg; 400unit; 35mcg; 0.5mg; 6mcg;
18mg; 400mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg;
25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 10mcg;
45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg
certavite/antioxidants tablet 60mg; 0; 30mcg; 75mcg;
3
200mg; 10mg; 72mg; 400unit; 35mcg; 0.5mg; 6mcg;
18mg; 400mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg;
25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 10mcg;
45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg
chewable vite childrens tablet chewable 60mg; 400unit; 3
4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 1.05mg;
2500unit; 15unit
chewable vite with iron/childrens tablet chewable 0;
3
400unit; 4.5mcg; 15mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg;
9mg; 60mg; 1.05mg; 15unit; 1250unit
childrens chewable vitamins/iron tablet chewable 400unit; 3
4.5mcg; 15mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg;
1.05mg; 15unit; 2500unit
childrens chewable vitamins/iron tablet chewable 400unit; 3
4.5mcg; 15mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg;
1.05mg; 15unit; 2500unit
childrens chewable vitamins tablet chewable 400unit;
3
4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg;
15unit; 2500unit
childrens chewable vitamins tablet chewable 400unit;
3
4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg;
15unit; 2500unit
childrens chewable vitamins tablet chewable 60mg;
3
4.5mcg; 0.3mg; 13.5mg; 0; 1.2mg; 0; 2500unit; 400unit;
15unit
childrens chewable vitamins tablet chewable 60mg;
3
4.5mcg; 0.3mg; 13.5mg; 0; 1.2mg; 0; 2500unit; 400unit;
15unit
Page 47 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
childrens chewable vitamins tablet chewable 60mg;
3
4.5mcg; 0.3mg; 13.5mg; 0; 1.2mg; 0; 2500unit; 400unit;
15unit
childrens chewable vitamins tablet chewable 60mg;
3
4.5mcg; 0.3mg; 13.5mg; 0; 1.2mg; 0; 2500unit; 400unit;
15unit
complete tablet 60mg; 0; 30mcg; 150mcg; 162mg; 72mg; 3
65mcg; 2mg; 6mcg; 400mcg; 150mcg; 18mg; 100mg;
3.5mg; 160mg; 20mg; 5mcg; 10mg; 109mg; 80mg; 2mg;
1.7mg; 20mcg; 2mg; 1.5mg; 10mcg; 10mcg; 5000unit;
400unit; 30unit; 25mcg; 15mg
D-VI-SOL LIQUID 400UNIT/ML
3
d-vita liquid 400unit/ml
3
d3 high potency capsule 1000unit
3
d3 super strength capsule 2000unit
3
d3-50 capsule 50000unit
3
daily multiple vitamins tablet 50mg; 7mg; 1mcg; 400unit; 3
20mg; 1mg; 2.5mg; 2mg; 5000unit
daily multiple vitamins tablet 50mg; 7mg; 1mcg; 400unit; 3
20mg; 1mg; 2.5mg; 2mg; 5000unit
daily vitamin formula+iron tablet 60mg; 0; 10mg;
3
400unit; 6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg;
1.5mg; 30unit; 5000unit
daily vitamin formula+minerals tablet 50mg; 11.6mg;
3
1mg; 5mcg; 1mcg; 4.5mg; 10mg; 1mg; 20mg; 9mg;
150mcg; 1mg; 2.5mg; 5mcg; 2mg; 5000unit; 400unit;
3.75mg
daily vitamin formula tablet 60mg; 400unit; 6mcg; 20mg; 3
2mg; 1.7mg; 1.5mg; 5000unit
daily vitamin formula tablet 60mg; 400unit; 6mcg; 20mg; 3
2mg; 1.7mg; 1.5mg; 5000unit
daily vite tablet 60mg; 0; 23mg; 10mg; 400unit; 6mcg;
3
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit
daily vite tablet 60mg; 0; 23mg; 10mg; 400unit; 6mcg;
3
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit
daily-vite/iron/beta-carotene tablet 60mg; 0; 10mg;
3
400unit; 6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg;
1.5mg; 30unit; 5000unit
daily-vite/iron/beta-carotene tablet 60mg; 0; 10mg;
3
400unit; 6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg;
1.5mg; 30unit; 5000unit
dialyvite 800 tablet 60mg; 0.3mg; 0.006mg; 0.8mg; 20mg; 3
10mg; 10mg; 1.7mg; 1.5mg
DIALYVITE VITAMIN D3 MAX TABLET 50000UNIT 3
drisdol solution 8000unit/ml
3
ergocalciferol solution 8000unit/ml
3
EZFE FORTE CAPSULE 45MG; 150MCG; 10MG;
3
1000MCG; 1000MCG; 20MG; 155MG; 25MG; 1.7MG;
1.5MG
Page 48 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
folic acid tablet 800mcg
3
FOSFREE TABLET 50MG; 300MG; 2MG; 14.5MG;
3
10MG; 1MG; 3MG; 2MG; 5MG; 1500UNIT; 200UNIT
fosfree tablet 50mg; 300mg; 2mg; 14.5mg; 10mg; 1mg; 3
3mg; 2mg; 5mg; 1500unit; 200unit
geri-tonic liquid 100mg/30ml; 1mcg/30ml; 100mcg/30ml; 3
15mg/30ml; 2mg/30ml; 2mg/30ml; 50mg/30ml; 10mg/30ml; 1mg/30ml; 2.5mg/30ml; 5mg/30ml; 2mg/30ml
geriaton liquid 100mg/30ml; 1mcg/30ml; 15mg/30ml; 3
2mg/30ml; 2mg/30ml; 50mg/30ml; 10mg/30ml; 100mcg/30ml; 1mg/30ml; 2.5mg/30ml; 5mg/30ml; 2mg/30ml
gnp century adults 50+ senior tablet 60mg; 0; 30mcg; 3
220mg; 10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg
gnp century ultimate womens senior formula tablet
3
100mg; 0; 30mcg; 500mg; 5mg; 20mg; 72mg; 800unit; 50mcg; 0.5mg; 50mcg; 8mg; 400mcg; 300mcg; 50mg; 2.3mg; 14mg; 5mcg; 50mcg; 80mg; 150mcg; 5mg; 1.1mg; 2mg; 150mcg; 10mcg; 50mcg; 55mcg; 1.1mg; 35unit; 3500unit; 15mg
gnp niacin tr tablet extended release 250mg
3
gnp one daily maximum tablet 60mg; 0; 30mcg; 150mcg; 3
162mg; 10mg; 109mg; 72mg; 400unit; 65mcg; 2mg; 6mcg; 18mg; 400mcg; 100mg; 3.5mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 10mcg; 160mcg; 20mcg; 10mcg; 1.5mg; 30unit; 2500unit; 15mg
3
golden age vitamin/minerals liquid 60mg/15ml; 300mcg/15ml; 25mcg/15ml; 6mcg/15ml; 150mcg/15ml; 9mg/15ml; 2.5mg/15ml; 25mcg/15ml; 20mg/15ml; 10mg/15ml; 2mg/15ml; 1.7mg/15ml; 1.5mg/15ml; 2500unit/15ml; 400unit/15ml; 30unit/15ml; 3mg/15ml
healthy eyes tablet 60mg; 2mg; 6mg; 30unit; 15mg
3
i-vite tablet 200mg; 1000unit; 2mg; 2mg; 55mcg; 60unit; 3
40mg
icaps capsule 226mg; 14320unit; 0.8mg; 200mg; 34.8mg
3
maximum d3 capsule 10000unit
3
meribin capsule 5mg
3
MULTI-DELYN/IRON LIQUID 60MG/5ML;
3
4.5MCG/5ML; 10MG/5ML; 13.5MG/5ML;
1.05MG/5ML; 1.2MG/5ML; 1.05MG/5ML;
15UNIT/5ML; 2500UNIT/5ML; 400UNIT/5ML
multi-delyn/iron liquid 60mg/5ml; 4.5mcg/5ml; 10mg/5ml; 3
13.5mg/5ml; 1.05mg/5ml; 1.2mg/5ml; 1.05mg/5ml;
15unit/5ml; 2500unit/5ml; 400unit/5ml
Page 49 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
multi-delyn liquid 54mg/5ml; 4.05mcg/5ml; 12.2mg/5ml; 3
0.945mg/5ml; 1.08mg/5ml; 0.842mg/5ml; 13.5unit/5ml; 2250unit/5ml; 360unit/5ml
multi-delyn liquid 54mg/5ml; 4.05mcg/5ml; 12.2mg/5ml; 3
0.945mg/5ml; 1.08mg/5ml; 0.842mg/5ml; 13.5unit/5ml; 2250unit/5ml; 360unit/5ml
multi-vitamins tablet 37.5mg; 1mg; 28.5mg; 400unit;
3
20mg; 0.1mg; 2mg; 1.5mg; 5000unit
multilex-t&m tablet 150mg; 10mg; 400unit; 1mg; 7.5mcg; 3
15mg; 5mg; 1mg; 100mg; 0.15mg; 2mg; 10mg; 15mg; 5.5unit; 10000unit; 1.5mg
multilex tablet 100mg; 10mg; 400unit; 1mg; 3mcg; 15mg; 3
5mg; 1mg; 30mg; 0.15mg; 1.7mg; 5mg; 10mg; 5.5unit; 10000unit; 1.5mg
MYKIDZ IRON SUSPENSION 35MG/2ML;
3
400UNIT/2ML; 10MG/2ML; 1500UNIT/2ML
nephro-vite tablet 60mg; 300mcg; 6mcg; 800mcg; 20mg; 3
10mg; 10mg; 1.7mg; 1.5mg
niacin er capsule extended release 250mg
3
niacin er capsule extended release 500mg
3
niacin sr capsule extended release 250mg
3
niacin sr capsule extended release 500mg
3
niacin tr tablet extended release 500mg
3
niacin tr tablet extended release 750mg
3
OCUVITE ADULT 50+ CAPSULE 150MG; 1MG;
3
90MG; 160MG; 5MG; 250MG; 30UNIT; 1MG; 9MG
once daily/iron tablet 50mg; 1mcg; 18mg; 20mg; 1mg; 3
1mg; 2.5mg; 2mg; 5000unit; 400unit
once daily/iron tablet 50mg; 1mcg; 18mg; 20mg; 1mg; 3
1mg; 2.5mg; 2mg; 5000unit; 400unit
once daily tablet 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg; 3
2mg; 5000unit; 400unit
once daily tablet 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg; 3
2mg; 5000unit; 400unit
poly vitamin tablet chewable 60mg; 400unit; 4.5mcg;
3
0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg; 15unit;
2500unit
poly-vitamin drops solution 35mg/ml; 50mcg/ml;
3
2mcg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml
polyvitamin/iron solution 35mg/ml; 400unit/ml; 10mg/ml; 3
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml
polyvitamin/iron tablet chewable 60mg; 400unit; 0.8mg; 3
4.5mcg; 12mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg; 15unit; 2500unit; 8mg
polyvitamin solution 35mg/ml; 400unit/ml; 2mcg/ml;
3
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
Page 50 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
PRESERVISION AREDS 2 CAPSULE 113MG; 0.4MG; 3
87.5MG; 162.5MG; 2.5MG; 250MG; 100UNIT; 0.5MG;
17.4MG
qc childrens chewable vitamins/extra c tablet chewable
3
250mg; 0; 400unit; 4.5mcg; 300mcg; 13.5mg; 1.05mg;
1.2mg; 1.05mg; 15unit; 2500unit
qc childrens chewable vitamins/iron tablet chewable
3
60mg; 0; 400unit; 4.5mcg; 15mg; 300mcg; 13.5mg;
1.05mg; 1.2mg; 1.05mg; 2500unit; 15unit
qc daily multivitamins/iron tablet 60mg; 10mg; 400unit; 3
6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit;
5000unit
qc maximum daily multivitamin/multimineral tablet 50mg; 3
0; 30mcg; 162mg; 10mg; 109mg; 72mg; 400unit; 65mcg;
2mg; 6mcg; 18mg; 400mcg; 100mg; 3.5mg; 20mg; 5mcg;
25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg;
10mcg; 160mcg; 20mcg; 10mcg; 1.5mg; 30unit; 2500unit;
15mg
qc multi-vite 50 & over tablet 60mg; 0; 30mcg; 150mcg; 3
220mg; 10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg;
25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg;
5mcg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 10mcg;
45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg
qc multi-vite tablet 60mg; 0unit; 30mcg; 75mcg; 200mg; 3
10mg; 20mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg; 18mg;
400mcg; 50mg; 2.3mg; 20mg; 5mcg; 25mcg; 80mg;
150mcg; 2mg; 1.7mg; 2mg; 10mcg; 45mcg; 55mcg;
10mcg; 1.5mg; 30unit; 3500unit; 11mg
qc therin-m tablet 90mg; 0; 30mcg; 40mg; 10mg; 7.5mg; 3
400unit; 50mcg; 2mg; 12mcg; 9mg; 400mcg; 100mg;
2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg; 150mcg; 6mg;
3.4mg; 2mg; 150mcg; 10mcg; 75mcg; 70mcg; 10mcg;
3mg; 60unit; 5000unit; 15mg
qc womens daily multivitamin tablet 60mg; 0; 30mcg;
3
450mg; 5mg; 500unit; 120mcg; 2mg; 5mcg; 15mg;
400mcg; 50mg; 2mg; 10mg; 25mcg; 2mg; 1.7mg; 20mcg;
5mg; 30unit; 2500unit; 15mg
rena-vite tablet 60mg; 300mcg; 6mcg; 800mcg; 20mg;
3
10mg; 10mg; 1.7mg; 1.5mg
slo-niacin tablet extended release 250mg
3
slo-niacin tablet extended release 500mg
3
slo-niacin tablet extended release 750mg
3
sm complete senior formula tablet 60mg; 0; 30mcg;
3
220mg; 10mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg;
400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg;
20mg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg;
150mcg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit;
11mg
Page 51 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
stress formula w/iron tablet 600mg; 12mcg; 81mg; 0.4mg; 3
100mg; 20mg; 25mg; 15mg; 15mg; 30unit
stress formula/iron tablet 600mg; 12mcg; 81mg; 0.4mg; 3
100mg; 20mg; 0; 15mg; 0; 30unit
stress formula/zinc tablet 600mg; 45mg; 3mg; 12mcg;
3
400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit; 23.9mg
stress formula tablet 500mg; 45mcg; 12mcg; 400mcg;
3
100mg; 20mg; 3mg; 10mg; 10mg; 30unit
STRESS-600/ZINC TABLET 600MG; 45MCG; 3MG;
3
12MCG; 400MCG; 100MG; 20MG; 5MG; 10MG; 20MG;
30UNIT; 23.9MG
thera-m tablet 120mg; 15mcg; 40mg; 10mg; 7.5mg;
3
400unit; 15mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 5mg; 30mg; 31mg; 7.5mg; 150mcg; 3mg; 3.4mg; 15mcg; 10mcg; 3mg; 30unit; 5500unit; 15mg
thera-m tablet 120mg; 15mcg; 40mg; 10mg; 7.5mg;
3
400unit; 15mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 5mg; 30mg; 31mg; 7.5mg; 150mcg; 3mg; 3.4mg; 15mcg; 10mcg; 3mg; 30unit; 5500unit; 15mg
thera-m tablet 90mg; 0; 30mcg; 150mcg; 40mg; 7.5mg; 3
26mcg; 2mg; 9mcg; 400mcg; 150mcg; 18mg; 100mg; 3.5mg; 32mcg; 20mg; 5mcg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg; 21mcg; 2mg; 3mg; 10mcg; 10mcg; 5000unit; 400unit; 30unit; 28mcg; 15mg
thera-m tablet 90mg; 0; 30mcg; 150mcg; 40mg; 7.5mg; 3
26mcg; 2mg; 9mcg; 400mcg; 150mcg; 18mg; 100mg; 3.5mg; 32mcg; 20mg; 5mcg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg; 21mcg; 2mg; 3mg; 10mcg; 10mcg; 5000unit; 400unit; 30unit; 28mcg; 15mg
THERA-M TABLET 90MG; 0; 30MCG; 30MG; 10MG; 3
50MCG; 2MG; 12MCG; 400UNIT; 9MG; 400MCG;
100MG; 2MG; 20MG; 5MCG; 23MG; 28MCG; 7.5MG; 7MG; 150MCG; 6MG; 3.4MG; 6MG; 150MCG; 10MCG;
75MCG; 70MCG; 10MCG; 3MG; 60UNIT; 5000UNIT; 15MG
3
thera-m tablet 90mg; 0; 30mcg; 30mg; 10mg; 50mcg;
2mg; 12mcg; 400unit; 9mg; 400mcg; 100mg; 2mg; 20mg; 5mcg; 23mg; 28mcg; 7.5mg; 7mg; 150mcg; 6mg; 3.4mg; 6mg; 150mcg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg; 60unit; 5000unit; 15mg
thera-plus liquid 200mg/5ml; 5mcg/5ml; 100mg/5ml;
3
21.4mg/5ml; 4.1mg/5ml; 10mg/5ml; 10mg/5ml; 5000unit/5ml; 400unit/5ml
therapeutic formula/hematinics tablet 11.7mg; 0.67mg; 3
50mcg; 66.7mg; 0.33mg; 41.7mg; 33.3mg; 3.3mg; 3.3mg; 100mg; 3.3mg; 5unit; 1400unit; 140unit
Page 52 of 71
Requirements/Limits
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DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
therapeutic formula/hematinics tablet 11.7mg; 0.67mg; 3
50mcg; 66.7mg; 0.33mg; 41.7mg; 33.3mg; 3.3mg; 3.3mg;
100mg; 3.3mg; 5unit; 1400unit; 140unit
thera tablet 90mg; 30mcg; 9mcg; 400mcg; 20mg; 10mg; 3
3mg; 3.4mg; 3mg; 5000unit; 400unit; 30unit
thera tablet 90mg; 30mcg; 9mcg; 400mcg; 20mg; 10mg; 3
3mg; 3.4mg; 3mg; 5000unit; 400unit; 30unit
therems-h tablet 130mg; 11.7mg; 140unit; 0.67mg;
3
50mcg; 27mg; 0.33mg; 41.7mg; 33.3mg; 3.3mg; 3.3mg;
12mg; 100mg; 3.3mg; 5unit; 1400unit
therems-m tablet 90mg; 0; 0; 30mcg; 40mg; 10mg; 2mg; 3
7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg; 400mcg;
100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg;
150mcg; 6mg; 3.4mg; 0; 150mcg; 10mcg; 75mcg; 70mcg;
10mcg; 3mg; 60unit; 5000unit; 15mg
therems-m tablet 90mg; 0; 0; 30mcg; 40mg; 10mg; 2mg; 3
7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg; 400mcg;
100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg;
150mcg; 6mg; 3.4mg; 0; 150mcg; 10mcg; 75mcg; 70mcg;
10mcg; 3mg; 60unit; 5000unit; 15mg
therems tablet 90mg; 30mcg; 10mg; 45mg; 400unit;
3
9mcg; 400mcg; 20mg; 10mg; 3mg; 3.4mg; 3mg; 30unit;
5000unit
therems tablet 90mg; 30mcg; 10mg; 45mg; 400unit;
3
9mcg; 400mcg; 20mg; 10mg; 3mg; 3.4mg; 3mg; 30unit;
5000unit
tri-vitamin solution 35mg/ml; 400unit/ml; 1500unit/ml
3
unicomplex-m tablet 60mg; 60mg; 10mg; 400unit; 2mg; 3
6mcg; 18mg; 400mcg; 1mg; 20mg; 0; 45mg; 150mcg;
5mg; 2mg; 1.7mg; 0; 1.5mg; 30unit; 5000unit; 15mg
vita-bee/c tablet 300mg; 300mcg; 10mg; 400mcg; 50mg; 3
5mg; 10.2mg; 15mg
vitamin b complex-c capsule 300mg; 10mg; 50mg; 5mg; 3
10.2mg; 15mg
vitamin b complex-c capsule 300mg; 10mg; 50mg; 5mg; 3
10.2mg; 15mg
vitamin b complex-c capsule 300mg; 10mg; 50mg; 5mg; 3
10.2mg; 15mg
vitamin b complex-c capsule 300mg; 10mg; 50mg; 5mg; 3
10.2mg; 15mg
vitamin c tablet 500mg
3
vitamin c tablet 500mg
3
vitamin c tablet 500mg
3
vitamin c tablet 500mg
3
vitamin c tablet 500mg
3
vitamin c tablet 500mg
3
vitamin c tablet 500mg
3
vitamin d3 super strength tablet 2000unit
3
vitamin d3 capsule 10000unit
3
Page 53 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
vitamin d3 capsule 5000unit
3
vitamin d3 liquid 400unit/ml
3
vitamin d3 liquid 400unit/ml
3
vitamin d3 tablet 1000unit
3
vitamin d3 tablet 1000unit
3
vitamin d3 tablet 1000unit
3
vitamin d3 tablet 5000unit
3
vitamin d capsule 1000unit
3
vitamin d capsule 1000unit
3
vitamin d capsule 2000unit
3
vitamin d capsule 2000unit
3
vitamin d liquid 400unit/ml
3
zoo friends complete tablet chewable 30mg; 0; 20mcg;
3
50mg; 5mg; 200unit; 1mg; 3mcg; 9mg; 200mcg; 10mg;
10mg; 50mg; 75mcg; 1mg; 0.85mg; 5mg; 0.75mg; 15unit;
2500unit; 7.5mg
zoo friends plus extra c tablet chewable 250mg; 0;
3
400unit; 5mcg; 300mcg; 13.5mg; 1.05mg; 1.2mg; 0;
1.05mg; 15unit; 2500unit
zoo friends plus iron tablet chewable 60mg; 0; 400unit; 3
4.5mcg; 15mg; 300mcg; 13.5mg; 1.05mg; 1.2mg; 1.05mg;
15unit; 2500unit
zoo friends tablet chewable 60mg; 0; 400unit; 4.5mcg;
3
300mcg; 10mg; 1.05mg; 1.2mg; 1.05mg; 15unit; 1998unit
Unclassified
No Classification
12 hour decongestant tablet extended release 12 hour
3
120mg
12 hour decongestant tablet extended release 12 hour
3
120mg
12 hour decongestant tablet extended release 12 hour
3
120mg
12 hour decongestant tablet extended release 12 hour
3
120mg
allergy eye drops solution 0.025%
3
allergy multi-symptom tablet 325mg; 2mg; 5mg
3
allergy multi-symptom tablet 325mg; 2mg; 5mg
3
allergy multi-symptom tablet 325mg; 2mg; 5mg
3
antacid fast relief suspension 200mg/5ml; 200mg/5ml;
3
20mg/5ml
antacid maximum strength suspension 400mg/5ml;
3
400mg/5ml; 40mg/5ml
antacid maximum strength suspension 400mg/5ml;
3
400mg/5ml; 40mg/5ml
antacid plus anti-gas fast acting suspension 200mg/5ml; 3
200mg/5ml; 20mg/5ml
aqua-e liquid 30mg/ml; 2mg/ml
3
AQUA-E LIQUID 30MG/ML; 2MG/ML
3
Page 54 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
b-complex plus vitamin c tablet 300mg; 150mg; 10mg;
50mg; 5mg; 10.2mg; 15mg
CALCET PETITES TABLET 200MG; 250UNIT
CALCIONATE SYRUP 1.8GM/5ML
calcitrate tablet 950mg
calvite p&d tablet 105mg; 120unit; 81mg
CLINITEST TABLET 0
cold head congestion severe daytime tablet 325mg; 10mg;
200mg; 5mg
cold multi-symptom severe daytime tablet 325mg; 10mg;
200mg; 5mg
cough & sore throat day time liquid 500mg/15ml;
15mg/15ml
cough dm liquid extended release 30mg/5ml
CVS KETONE CARE STRIP 0
CYTO-Q MAX LIQUID 100MG/ML
de-chlor dm liquid 2mg/5ml; 15mg/5ml; 10mg/5ml
dermamed ointment 0
exefen-ir tablet 400mg; 60mg
eye drops allergy relief solution 0.05%; 0.25%
fast acting antacid plus anti-gas maximum strength
suspension 400mg/5ml; 400mg/5ml; 40mg/5ml
fiber laxative tablet 625mg
fiber laxative tablet 625mg
fiber laxative tablet 625mg
FRUCTOSE GRANULES 0
GLYCERIN LIQUID 99.5%
gnp 12 hour nasal spray solution 0.05%
gnp allergy multi-symptom tablet 325mg; 2mg; 5mg
gnp antacid anti-gas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
gnp antacid maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
gnp artificial tears solution 0.5%; 0.6%
gnp calcium 500 +d3 tablet 500mg; 600unit; 0
gnp calcium 500 +d3 tablet 500mg; 600unit; 0
gnp calcium plus 600 +d tablet 600mg; 200unit; 1mg;
40mg; 1.8mg; 250mcg; 7.5mg
gnp capsaicin cream 0.1%
gnp castor oil oil 100%
gnp century ultimate mens complete tablet 90mg; 0;
40mcg; 210mg; 15mg; 20mg; 72mg; 600unit; 35mcg;
0.9mg; 6mcg; 8mg; 200mcg; 600mcg; 100mg; 2.3mg;
16mg; 5mcg; 60mcg; 80mg; 150mcg; 2mg; 1.3mg; 2mg;
150mcg; 10mcg; 50mcg; 100mcg; 10mcg; 1.2mg; 45unit;
3500unit; 11mg
Page 55 of 71
Drug Tier
3
Requirements/Limits
DP
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
3
DP
3
DP
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
3
3
3
DP
DP
DP
DP
3
3
3
DP
DP
DP
Drug Name
Drug Tier
gnp century ultimate mens senior formula tablet 120mg; 0;3
30mcg; 250mg; 10mg; 20mg; 72mg; 600unit; 60mcg;
0.7mg; 100mcg; 300mcg; 300mcg; 600mcg; 50mg; 4mg;
20mg; 5mcg; 60mcg; 80mg; 150mcg; 6mg; 1.7mg; 2mg;
150mcg; 10mcg; 50mcg; 100mcg; 1.5mg; 60unit;
3500unit; 15mg
gnp childrens chewables/extra c tablet chewable 250mg; 3
0; 400unit; 4.5mcg; 300mcg; 13.5mg; 1.05mg; 1.2mg; 0;
1.05mg; 15unit; 2500unit
gnp childrens chewables/iron tablet chewable 60mg; 0; 3
400unit; 4.5mcg; 15mg; 300mcg; 13.5mg; 1.05mg; 1.2mg;
1.05mg; 15unit; 2500unit
gnp childrens plus cough & sore throat liquid 160mg/5ml; 3
5mg/5ml
gnp cold & allergy maximum strength tablet 4mg; 10mg 3
gnp cold head congestion severe daytime tablet 325mg; 3
10mg; 200mg; 5mg
gnp cold relief head congestion severe daytime tablet
3
325mg; 10mg; 200mg; 5mg
gnp cold relief multi-symptom severe daytime tablet
3
325mg; 10mg; 200mg; 5mg
gnp cold severe congestion/daytime tablet 325mg; 10mg; 3
200mg; 5mg
gnp cough dm er liquid extended release 30mg/5ml
3
gnp day time sinus capsule 325mg; 5mg
3
gnp fiber-caps tablet 625mg
3
gnp foaming antacid suspension 95mg/15ml; 358mg/15ml 3
gnp iron tablet extended release 45mg
3
gnp little ones childrens tablet chewable 60mg; 0;
3
400unit; 4.5mcg; 300mcg; 10mg; 1.05mg; 1.2mg; 1.05mg;
15unit; 1998unit
gnp masanti maximum strength suspension 400mg/5ml; 3
400mg/5ml; 40mg/5ml
gnp masanti regular strength suspension 200mg/5ml;
3
200mg/5ml; 20mg/5ml
gnp miconazorb af powder 2%
3
gnp multi-symptom cold nighttime liquid 325mg/15ml;
3
10mg/15ml; 6.25mg/15ml; 5mg/15ml
gnp nasal decongestant pemaximum strength tablet 10mg 3
gnp nasal decongestant pemaximum strength tablet 10mg 3
gnp nasal decongestant tablet 30mg
3
gnp nasal decongestant tablet 30mg
3
gnp nasal spray extra moisturizing solution 0.05%
3
gnp night time cold & flu multisymptom capsule 325mg; 3
15mg; 6.25mg
gnp no drip nasal spray solution 0.05%
3
gnp pseudoephedrine hcl 12 hour tablet extended release 3
12 hour 120mg
Page 56 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
Drug Tier
gnp pseudoephedrine hcl 12 hour tablet extended release 3
12 hour 120mg
gnp sinus congestion & pain daytime tablet 325mg; 5mg 3
gnp sinus congestion/pain nighttime tablet 325mg; 2mg; 3
5mg
gnp sinus relief congestion & pain daytime/nighttime
3
miscellaneous 325mg; 2mg; 5mg
gnp sinus relief congestion & pain nighttime tablet 325mg;3
2mg; 5mg
gnp suphedrin liquid 15mg/5ml
3
gnp tab tussin dm tablet 20mg; 400mg
3
gnp tab tussin tablet 400mg
3
hm advanced antacid maximum strength suspension
3
400mg/5ml; 400mg/5ml; 40mg/5ml
hm antacid anti-gas extrastrength suspension 400mg/5ml; 3
400mg/5ml; 40mg/5ml
hm antacid/antigas suspension 200mg/5ml; 200mg/5ml; 3
20mg/5ml
hm antacid/antigas suspension 200mg/5ml; 200mg/5ml; 3
20mg/5ml
hm artificial tears solution 0.5%; 0.6%
3
hm chest congestion relief dm tablet 20mg; 400mg
3
hm chest congestion relief tablet 400mg
3
hm cold & allergy childrens elixir 1mg/5ml; 2.5mg/5ml 3
hm cold & cough childrens elixir 1mg/5ml; 5mg/5ml;
3
2.5mg/5ml
hm cold & sinus relief tablet 200mg; 30mg
3
hm cough relief liquid 15mg/5ml
3
hm enema mineral oil enema 100%
3
hm eye itch relief solution 0.025%
3
hm fexofenadine hcl tablet 60mg
3
hm fiber capsule 0.52gm
3
hm fiber tablet 500mg
3
hm fish oil capsule delayed release 0; 0; 1000mg; 300mg 3
hm nasal decongestant 12 hour tablet extended release 12 3
hour 120mg
hm nasal decongestant pe tablet 10mg
3
hm nasal decongestant tablet 30mg
3
hm nasal decongestant tablet 30mg
3
hm nasal spray solution 0.05%
3
hm nose drops extra strength solution 1%
3
hm saline nasal spray solution 0.65%
3
hm sinus nasal spray solution 0.05%
3
hm stomach relief maximumstrength suspension
3
525mg/15ml
hm triple antibiotic ointment 400unit/gm; 3.5mg/gm;
3
5000unit/gm
hm tussin adult cough & chest congestion dm liquid
3
10mg/5ml; 100mg/5ml
Page 57 of 71
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
hm tussin adult cough & chest congestion dm liquid
10mg/5ml; 100mg/5ml
hm tussin adult cough & chest congestion dm liquid
10mg/5ml; 100mg/5ml
hm tussin adult multi-symptom cold liquid 10mg/5ml;
100mg/5ml; 5mg/5ml
hm tussin adult liquid 100mg/5ml
L-CITRULLINE POWDER 0
L-GLUTATHIONE CRYSTALS 0
L-ISOLEUCINE POWDER 0
LIQ-10 SYRUP 50MG/5ML; 15UNIT/5ML
LOLLIBASE POWDER 0
long acting nasal spray solution 0.05%
lubricant eye drops dry eye therapy solution 0.4%; 0.3%
metamucil smooth texture powder 58.6%
miconazorb af powder 2%
MULTISTIX 10 SG STRIP 0
nasal decongestant pe tablet 10mg
nasal decongestant pe tablet 10mg
nasal decongestant pe tablet 10mg
nasal decongestant pe tablet 10mg
nasal decongestant pe tablet 10mg
nasal decongestant pe tablet 10mg
nasal decongestant tablet 30mg
nasal decongestant tablet 30mg
nasal spray 12 hour solution 0.05%
nasal spray 12 hour solution 0.05%
nasal spray 12 hour solution 0.05%
nasal spray x-moist solution 0.05%
neutrahist solution 0.8mg/ml; 9mg/ml
nighttime sinus congestion & pain tablet 325mg; 2mg;
5mg
OYSTER SHELL CALCIUM TABLET 250MG
pain relief cold severe congestion tablet 325mg; 10mg;
200mg; 5mg
pain relief sinus pe daytime tablet 325mg; 5mg
PRO-CLEAR AC SYRUP 9MG/5ML; 8.33MG/5ML
PRO-RED AC SYRUP 9MG/5ML; 1MG/5ML;
5MG/5ML
pseudoephedrine hcl tablet 30mg
qc 3 day vaginal cream cream 4%
qc allergy relief multi-symptom daytime tablet 325mg;
2mg; 5mg
qc antacid/anti-gas maximum strength suspension
400mg/5ml; 400mg/5ml; 40mg/5ml
qc antacid/anti-gas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
qc antacid suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
qc athletes foot cream 1%
Page 58 of 71
Drug Tier
3
Requirements/Limits
DP
3
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
DP
DP
3
3
3
DP
DP
DP
3
3
3
DP
DP
DP
3
DP
3
DP
3
3
DP
DP
Drug Name
qc fiber laxative capsule 0.52gm
qc medifin mucus relief childrens liquid 100mg/5ml
qc no drip nasal relief solution 0.05%
qc sinus pain relief tablet 325mg; 5mg
qc suphedrine maximum strength tablet extended release
12 hour 120mg
qc suphedrine pe tablet 10mg
qc suphedrine pe tablet 10mg
qc suphedrine tablet 30mg
qc suphedrine tablet 30mg
rhinaris gel 0.2%
sentry tablet 90mg; 0; 30mcg; 150mcg; 200mg; 10mg;
109mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg; 18mg;
500mcg; 250mcg; 300mcg; 100mg; 2.3mg; 20mg; 5mcg;
25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 10mcg;
45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg
sinus congestion & pain daytime tablet 325mg; 5mg
slow-mag tablet delayed release 119mg; 71.5mg
sm 12 hour sinus decongestant tablet extended release 12
hour 120mg
sm 12-hour no drip solution 0.05%
sm allergy multi-symptom tablet 325mg; 2mg; 5mg
sm antacid anti-gas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
sm antacid maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
sm antacid/antigas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
sm cold head congestion severe day time tablet 325mg;
10mg; 200mg; 5mg
sm eye itch relief solution 0.025%
sm fexofenadine hcl tablet 60mg
sm fiber laxative capsule 0.52gm
sm fiber laxative tablet 625mg
sm nasal decongestant maximum strength tablet 30mg
sm nasal decongestant maximum strength tablet 30mg
sm nasal decongestant maximum strength tablet 30mg
sm nasal decongestant pe tablet 10mg
sm nasal decongestant pe tablet 10mg
sm nasal spray moisturizing solution 0.05%
sm nasal spray sinus solution 0.05%
sm stomach relief maximumstrength suspension
525mg/15ml
TRIXAICIN CREAM 0.025%
VANAHIST PD LIQUID 0.625MG/ML
z-tuss e liquid 9mg/5ml; 200mg/5ml; 30mg/5ml
Page 59 of 71
Drug Tier
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
3
3
3
DP
DP
DP
3
3
3
DP
DP
DP
3
DP
3
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
DP
DP
DP
Index
Drug Name Page #
12 hour decongestant
54
12 hour nasal spray
34
acephen
7
acetaminophen
7
acid gone
17
ACIDOPHILUS/CITRUS PECTIN
17
acidophilus/l-sporogenes extra strength
17
ADEKS
45
AFRIN MENTHOL
34
akwa tears
25
alavert
26
alavert allergy/sinus
26
alaway
26
alaway childrens allergy eye itch relief
26
all day allergy
27
all day allergy childrens
27
all day allergy d
27
all day allergy d-12
27
all day allergy-d
27
aller-chlor
27
aller-ease
27
allergy
28
allergy eye drops
54
allergy multi-symptom
54
allergy multi-symptom
34
allergy relief
27
allergy relief child
27
allergy relief d-24
27
allergy relief/nasal decongestant
27
allergy tablets
28
allergy/congestion relief
28
allerhist-1
28
almacone double strength
17
aloe vesta protective
16
ALPHA LIPOIC ACID
24
aluminum acetate astringent
16
aluminum hydroxide
17
AMLACTIN ULTRA
16
antacid
18
antacid anti-gas maximum strength
17
antacid fast relief
54
antacid maximum strength
54
antacid plus anti-gas fast acting
54
antifungal
13
anti-fungal powder
13
Page 60 of 71
Drug Name Page #
aprodine
34
AQUABASE
16
aquadeks
45
aqua-e
54
aqueous vitamin d infants
45
aqueous vitamin e
45
arginine
24
artificial tears
25
aspir-81
7
aspirin
8
aspirin adult low strength
7
aspirin childrens
7
aspirin ec
7
aspirin ec lo-dose
7
aspirin ec low dose
7
aspirin enteric coated adult low strength
8
aspirin low dose
8
aspirin low strength
8
aspir-low
7
athletes foot af cream
14
ATRAC-TAIN
16
bacitracin
12
bacitracin zinc
12
bacitracin/neomycin/polymyxin
12
BACTERIOSTATIC WATER FOR
5
INJECTION/BENZYL ALCOHOL
banophen
28
baza antifungal
14
baza protect
16
b-complex plus vitamin c
55
BENZOIN COMPOUND TINCTURE
16
benzonatate
3
beta care betatar gel
16
betadine surgical scrub
12
bion tears
25
bisac-evac
18
bisacodyl
18
bisacodyl ec
18
biscolax
18
bismatrol
18
bismatrol maximum strength
18
bromfed dm
3
brotapp
28
brotapp dm
34
brovex peb
28
brovex psb
28
CALCET PETITES
55
calci-chew
44
calciferol
45
Drug Name Page #
44
CALCI-MIX
CALCIONATE
55
calcitrate
55
calcium carbonate
18
calcium carbonate
44
calcium high potency + vitamin d
44
CALCIUM LACTATE
44
calcium oyster shell
44
calcium plus vitamin d3
44
calcium/vitamin d
44
caltrate 600+d plus minerals
44
calvite p&d
55
CAPCOF
34
CAPMIST DM
34
CAPRON DM
35
cardec
28
carmol 10
16
carrington antifungal
14
centamin
46
centavite a-z complete
46
multivitamin/minerals
CENTRUM
46
CENTRUM ADULTS
46
cerovite advanced formula
46
cerovite jr
47
certa plus
47
certavite/antioxidants
47
cetirizine hcl
28
cetirizine hcl/pseudoephedrine hcl er
28
cheratussin ac
35
cheratussin dac
35
chest congestion relief
35
chew q
24
chewable vite childrens
47
chewable vite with iron/childrens
47
childrens aspirin
8
childrens aspirin low strength
8
childrens chewable vitamins
47
childrens chewable vitamins/iron
47
childrens cold & allergy
29
childrens loratadine
29
childrens mucus relief cough
35
childrens mucus relief expectorant
35
childrens pain relief plus multi35
symptom cold
chlorpheniramine maleate
29
chromium chloride
4
citrus calcium/vitamin d
44
claritin
29
Page 61 of 71
Drug Name Page #
29
claritin reditabs
claritin-d 12 hour
29
claritin-d 24 hour
29
clemastine fumarate
30
CLINITEST
55
clotrimazole
14
clotrimazole 3 day
14
co q-10
24
CO Q-10 PLUS
24
CODITUSS DM
35
co-enzyme q-10
24
cold head congestion daytime
35
cold head congestion nighttime
35
cold head congestion nighttime multi35
symptom
cold head congestion severe daytime
55
cold head congestion severe daytime
35
cold multi-symptom daytime
35
cold multi-symptom nighttime
35
cold multi-symptom severe daytime
55
cold multi-symptom severe daytime
35
cold/allergy childrens
30
cold/cough childrens
35
cold/cough dm childrens
35
complete
48
complete allergy
30
complete allergy medicine
30
complete lice treatment kit
15
35
COMTREX COLD & COUGH
NIGHTTIME MAXIMUM
STRENGTH
CONEX COLD/ALLERGY
35
COPPER TRACE METAL
5
corfen-dm
35
coricidin hbp nighttime multi-symptom
35
cold
corvita 150
4
cough & sore throat day time
55
cough dm
55
cough dm
35
cough syrup
35
coughtab
35
cromolyn sodium
34
CVS KETONE CARE
55
cyanocobalamin
4
CYTO-Q MAX
55
d3 high potency
48
d3 super strength
48
d3-50
48
Drug Name Page #
daily multiple vitamins
48
daily vitamin formula
48
daily vitamin formula+iron
48
daily vitamin formula+minerals
48
daily vite
48
daily-vite/iron/beta-carotene
48
day time cold/flu relief
35
day time cough
35
dayhist allergy 12 hour relief
30
de-chlor dm
55
decongestant 12hour maximum
36
strength
deep sea nasal spray
36
delsym
36
delsym night time cough/cold
36
delsym night time cough/cold childrens
36
delsym night time multi-symptom
36
dermamed
55
dermaphor
16
desenex shake powder
14
dexferrum
4
dextromethorphan polistirex
36
dextromethorphan/guaifenesin
36
diabetic siltussin das-na
36
diabetic siltussin-dm
36
diabetic siltussin-dm maximum strength
36
diabetic tussin
36
diabetic tussin dm
36
diabetic tussin maximum strength
36
dialyvite 800
48
DIALYVITE VITAMIN D3 MAX
48
DIASTIX
24
dimaphen childrens
30
dimaphen dm cold/cough childrens
36
dimenhydrinate
13
DIMETAPP COLD & ALLERGY
30
dimetapp dm cold & cough
36
DIMETAPP LONG ACTING COUGH
36
PLUS COLD
dimetapp multi-symptom cold & flu
36
dimetapp nighttime cold &congestion
36
diocto
18
diphenhist
30
diphenhydramine hcl
30
docqlace
18
docqlace
23
doc-q-lax
23
docu
18
docusate calcium
18
Page 62 of 71
Drug Name Page #
docusate sodium
18
docusate sodium
23
docusate sodium & senna stimulant
23
laxative/stool softener
docusil
19
docusol mini
19
dok
19
dok plus
23
double antibiotic
12
drisdol
48
dristan cold
36
ducodyl
19
duofer
44
D-VI-SOL
48
d-vita
48
ear drops
26
ear wax removal drops
26
ear wax removal kit
26
ear wax removal system
26
ear wax remover
26
earwax treatment drops
26
ecpirin
8
ed a-hist
30
ed a-hist dm
37
ed a-hist pse
30
ed bron gp
37
ed chlorped
31
ed chlorped d
30
ed chlorped jr
30
ed-chlortan
31
endacof-dm
37
enema ready-to-use
19
enemeez mini
19
enemeez plus
19
enteric coated aspirin
8
EPHEDRINE SULFATE
34
ergocalciferol
48
excedrin sinus headache
37
exefen dmx
37
exefen-ir
55
extra action cough
37
eye drops allergy relief
55
eye itch relief
26
EZFE FORTE
48
fast acting antacid plus anti-gas
55
maximum strength
FERAHEME
5
fer-iron
44
FERRAPLUS 90
4
Drug Name Page #
ferrex 150
44
ferrous drops
44
ferrous gluconate
44
ferrous sulfate
44
feverall
7
fexofenadine hcl
31
fiber laxative
55
fiber laxative
19
fiber tabs
19
fiber therapy
19
fiber-lax
19
fish oil
24
fish oil ultra
24
fleet bisacodyl
19
fleet enema
19
fleet enema
23
fleet enema six pack
23
fleet laxative
19
FLEET OIL
19
fleet pediatric
19
FOLIC ACID
4
folic acid
49
formulation r
19
FOSFREE
49
FRESHKOTE
25
FRUCTOSE
55
fungoid tincture
14
gas relief
19
gas-x extra strength
19
GAVISCON
19
genteal mild
25
genteal mild to moderate
25
genteal pm
25
GENTEAL SEVERE
25
geriaton
49
geri-tonic
49
glucose
16
glutose 15
16
GLYCERIN
55
gnp 12 hour nasal spray
55
gnp adult aspirin low strength
8
gnp all day allergy
31
gnp all day allergy-d
31
gnp allergy
31
gnp allergy multi-symptom
55
gnp allergy plus severe sinus headache
37
maximum strength
gnp allergy relief
31
gnp allergy relief for kids
31
Page 63 of 71
Drug Name Page #
gnp antacid anti-gas
55
gnp antacid maximum strength
55
gnp artificial tears
55
gnp aspirin
9
gnp aspirin low dose
8
gnp bacitracin zinc
12
gnp bisa-lax
19
gnp calcium 500 +d3
55
gnp calcium 500/d
44
gnp calcium 600 +d
44
gnp calcium plus 600 +d
55
gnp calcuim/vitamin d/minerals
45
gnp capsaicin
55
gnp castor oil
55
gnp century adults 50+ senior
49
gnp century ultimate mens complete
55
gnp century ultimate mens senior
56
formula
gnp century ultimate womens senior
49
formula
gnp childrens chewables/extra c
56
gnp childrens chewables/iron
56
gnp childrens pain relief plus cold
37
gnp childrens plus cough & sore throat
56
gnp childrens plus multi-symptom cold
37
gnp clotrimazole 3
14
gnp cold & allergy childrens
31
gnp cold & allergy maximum strength
56
gnp cold & cough childrens
37
gnp cold head congestion night time
37
gnp cold head congestion severe
56
daytime
gnp cold multi-symptom daytime
37
gnp cold multi-symptom nighttime
37
gnp cold relief head congestion severe
56
daytime
gnp cold relief multi-symptom daytime
37
gnp cold relief multi-symptom severe
56
daytime
gnp cold severe congestion/daytime
56
gnp cough dm er
56
gnp cough relief
37
gnp day time mucus reliefdm
37
gnp day time sinus
56
gnp dayhist allergy
31
gnp docusate calcium
23
gnp ear drops
26
gnp ear systems
26
gnp enema
23
Drug Name Page #
gnp eye itch relief
26
gnp fiber therapy
23
gnp fiber-caps
56
gnp fish oil
24
gnp flu relief therapy seere cold
37
daytime
gnp flu relief therapy severe cold
37
nighttime
gnp foaming antacid
56
gnp foaming antacid
19
gnp gas relief
19
gnp gas relief extra strength
19
gnp gas relief maximum strength
19
gnp hemorrhoidal
16
gnp infants gas relief
19
gnp iron
56
gnp itchy eye
26
gnp k-pec
19
gnp laxative
19
gnp lice solution kit
15
gnp little ones childrens
56
gnp loratadine
31
gnp loratadine-d 12hr
31
gnp loratadine-d 24 hour
31
gnp lubricant eye drops
25
gnp magnesium citrate
23
gnp masanti maximum strength
56
gnp masanti regular strength
56
gnp miconazole 1
14
gnp miconazole 3
14
gnp miconazorb af
56
gnp milk of magnesia
23
gnp mucus relief
37
gnp mucus relief cough childrens
37
gnp mucus relief dm
37
gnp multi-symptom cold nighttime
56
gnp nasal decongestant
56
gnp nasal decongestant pemaximum
56
strength
gnp nasal spray extra moisturizing
56
gnp natural fiber
19
gnp niacin tr
49
gnp nicotine polacrilex
9
gnp night time cold & flu multisymptom
56
gnp night time cold/flu relief
37
gnp night time cough
37
gnp night time sinus
37
gnp no drip nasal spray
56
gnp nose drops extra strength
37
Page 64 of 71
Drug Name Page #
gnp one daily maximum
49
gnp povidone-iodine
13
gnp pseudoephedrine hcl 12 hour
56
gnp senna plus
23
gnp sinus congestion & pain daytime
57
gnp sinus congestion/pain nighttime
57
gnp sinus relief congestion & pain
57
daytime/nighttime
gnp sinus relief congestion & pain
57
nighttime
gnp slow release iron
45
gnp stomach relief
19
gnp stomach relief maximum strength
19
gnp stool softener
20
gnp stool softener extra strength
20
gnp stool softener/stimulant laxative
23
gnp suphedrin
57
gnp tab tussin
57
gnp tab tussin dm
57
gnp terbinafine hydrochloride
14
gnp tioconazole 1
14
gnp tolnaftate
14
gnp triacting night time cold & cough
37
childrens
gnp triple antibiotic
13
gnp triple antibiotic plus
13
gnp tussin
38
gnp tussin cf cough & cold
38
gnp tussin cough long acting
38
gnp tussin dm
38
gnp tussin dm cough
38
gnp tussin dm max
38
golden age vitamin/minerals
49
goodsense all day allergy
32
guaiatussin ac
38
guaifenesin
38
guaifenesin ac
38
guaifenesin dac
38
guaifenesin er
38
guaifenesin/codeine
38
guaifenesin-dm
38
healthy eyes
49
hemorrhoid
16
hemorrhoidal
16
hemorrhoidal suppositories
16
hem-prep
16
hm advanced antacid maximum
57
strength
hm all day allergy
32
Drug Name Page #
hm allergy
32
hm allergy & congestion
32
hm allergy complete-d
32
hm allergy relief
32
hm allergy relief & nasaldecongestant
32
hm allgery multi symptom
32
hm antacid anti-gas extrastrength
57
hm antacid/antigas
57
hm artificial tears
57
hm aspirin
9
hm aspirin ec
9
hm bacitracin
13
hm chest congestion relief
57
hm chest congestion relief dm
57
hm cold & allergy childrens
57
hm cold & cough childrens
57
hm cold & sinus relief
57
hm cough relief
57
hm double antibiotic
13
hm earwax removal aid
26
hm earwax removal kit
26
hm enema
23
hm enema mineral oil
57
hm eye itch relief
57
hm fexofenadine hcl
57
hm fexofenadine hcl
32
hm fiber
57
hm fiber
20
hm fish oil
57
hm gas relief
20
hm gas relief infants drops
20
hm laxative
20
hm lice killing maximum strength
15
hm loratadine childrens
32
hm milk of magnesia
23
hm nasal decongestant
57
hm nasal decongestant 12 hour
57
hm nasal decongestant pe
57
hm nasal spray
57
hm nose drops extra strength
57
hm povidone-iodine
13
hm saline nasal spray
57
hm senna
20
hm senna-s
23
hm sinus nasal spray
57
hm stomach relief
20
hm stomach relief maximumstrength
57
hm stool softener
20
hm stool softener maximum strength
20
Page 65 of 71
Drug Name Page #
hm stool softener/laxative
23
hm triple antibiotic
57
hm tussin adult
58
hm tussin adult cough & chest
57
congestion dm
hm tussin adult multi-symptom cold
58
hydrocodone bitartrate/homatropine
3
methylbromide
hydrocodone
3
polistirex/chlorpheniramine polistirex
hydrocodone/homatropine
3
hydromet
3
HYDROUS EMULSIFIED BASE
16
HYDROXOCOBALAMIN
5
icaps
17
icaps
49
iferex 150
45
infants gas relief
20
infants simethicone
20
infed
4
infuvite
5
infuvite pediatric
5
intense cough reliever extra strength
38
ionil-t
16
iophen c-nr
38
iophen dm-nr
38
iophen-nr
38
iron
45
isopto tears
25
itch relief extra strength
16
i-vite
49
jock itch spray
14
j-tan d pd
32
kao-tin
20
KETO-DIASTIX
24
ketotifen fumarate
26
kidkare cough/cold
38
konsyl
20
LACTOSE
25
LACTRASE
17
LAMISIL ADVANCED
14
lamisil af defense
14
lamisil at
14
lamisil at jock itch
14
lamisil at spray
14
laxative
20
L-CITRULLINE
58
L-GLUTATHIONE
58
lice killing maximum strength
15
Drug Name Page #
lice solution kit
15
lice treatment creme rinse
15
lidocream
9
LIQ-10
58
liquituss gg
38
L-ISOLEUCINE
58
lmx 4
9
LMX 4 PLUS
9
lohist-d
32
lohist-dm
38
lohist-peb
32
LOLLIBASE
58
long acting nasal spray
58
loratadine
32
loratadine childrens
32
loratadine hives relief
32
loratadine-d 12hr
32
loratadine-d 24hr
32
lotrimin ultra
14
lubricant eye drops dry eye therapy
58
M.V.I. ADULT
5
M.V.I. PEDIATRIC
5
M.V.I.-12 WITHOUT VITAMIN K
5
maalox advanced
20
mag-delay
45
mag-g
45
MAGNEBIND 300
24
magnesium citrate
20
magnesium oxide
20
MAGONATE
45
MAG-TAB SR
45
MANGANESE TRACE METAL
4
mapap sinus maximum strength
38
congestion and pain
maximum d3
49
m-clear wc
38
m-end dm
38
M-END PE
38
m-end wc
38
meribin
49
metamucil smooth texture
58
mi-acid
20
mi-acid gas relief
20
mi-acid maximum strength
20
miconazole
15
miconazole 1
14
miconazole 3 combo pack
14
miconazole 7
14
miconazole nitrate
14
Page 66 of 71
Drug Name Page #
miconazorb af
58
micro guard
15
milantex
20
milantex extra strength
20
milk of magnesia
21
milk of magnesia
23
milk of magnesia concentrate
21
minerin
16
miniprin low dose
9
mintox
21
mintox maximum strength
21
mitrazol
15
mucinex
39
mucinex chest congestion childrens
38
mucinex childrens cold cough & sore
38
throat
mucinex childrens multi-symptom cold
39
mucinex childrens multi-symptom cold
38
& fever
mucinex cold for kids
39
mucinex cough childrens
39
mucinex cough for kids
39
mucinex d
39
mucinex dm
39
mucinex dm maximum strength
39
mucinex fast-max cold & sinus
39
mucinex fast-max cold flu& sore throat
39
mucinex fast-max dm max
39
mucinex fast-max severe congestion &
39
cold
mucinex fast-max severe congestion &
39
cough
mucinex for kids
39
mucinex maximum strength
39
mucinex nasal spray full force
39
mucinex nasal spray moisture smart
39
mucus relief
40
mucus relief childrens
39
mucus relief cough childrens
40
multi-delyn
50
MULTI-DELYN/IRON
49
multilex
50
multilex-t&m
50
MULTISTIX 10 SG
58
multi-symptom allergy
33
multi-vitamins
50
muro 128
25
MYKIDZ IRON
50
mykidz iron 10
44
Drug Name Page #
mytab gas
21
mytab gas max str
21
mytussin dac
40
NAIL SCRUB
16
nasal decongestant
58
nasal decongestant
40
nasal decongestant pe
58
nasal decongestant pe maximum
40
strength
nasal decongestant spray
40
nasal spray 12 hour
58
nasal spray x-moist
58
NASCOBAL
5
nasohist dm
40
natural coenzyme q10
25
natural fiber laxative
21
natural fiber therapy
21
nephro-vite
50
neutrahist
58
niacin er
50
niacin sr
50
niacin tr
50
nicoderm cq
9
nicorelief
9
nicorette
10
nicorette mini
10
nicorette starter kit
10
nicotine
12
nicotine polacrilex
11
nicotine transdermal system
11
nighttime sinus congestion & pain
58
nite time cough
40
nite time multi-symptom cold/flu relief
40
nite-time multi-symptom cold/flu relief
40
nohist-dm
40
nohist-lq
33
novaferrum 125
45
novaferrum pediatric drops
45
nrs nasal relief
40
nutraplus
16
ocean nasal spray
40
OCUVITE ADULT 50+
50
olopatadine hcl
3
once daily
50
once daily/iron
50
ORA-BLEND
25
ORA-BLEND SF
25
ORA-PLUS
25
ORA-SWEET
25
Page 67 of 71
Drug Name Page #
ORA-SWEET SF
25
organ-i nr
40
oysco 500+d
45
OYSTER SHELL CALCIUM
58
oyster shell calcium/vitamin d
45
pain relief cold severe congestion
58
pain relief sinus pe daytime
58
pedia relief cough/cold
40
pedia-lax
21
pediatric cough/cold
40
pedi-boro soak paks
16
peleverus
17
peleverus clear
17
peleverus gold
17
PENTRAVAN
17
peptic relief
21
pepto-bismol
21
periguard
17
permethrin
15
pharbedryl
33
PHENYLHISTINE DH
40
PHOS-NAK POWDER
45
CONCENTRATE
pink bismuth maximum strength
21
pink bismuth regular strength
21
poly vitamin
50
poly-iron 150
45
polyvitamin
50
poly-vitamin drops
50
polyvitamin/iron
50
povidone-iodine
13
PREMIUM CONDOMS
25
LUBRICATED
preparation h
17
PRESERVISION AREDS 2
51
PRO-CLEAR AC
58
profe
45
promethazine vc/codeine
3
promethazine/codeine
3
promethazine/codeine
3
promethazine/dextromethorphan
4
promethazine-dm
3
PRO-RED AC
58
pseudoephedrine hcl
58
pseudoephedrine hcl
40
puralube
25
qc 3 day vaginal cream
58
qc all day allergy
33
qc allergy relief
33
Drug Name Page #
qc allergy relief multi-symptom daytime
58
qc antacid
58
qc antacid/anti-gas
58
qc antacid/anti-gas maximum strength
58
qc aspirin
9
qc aspirin low dose
9
qc athletes foot
58
qc azo
9
qc bacitracin
13
qc childrens aspirin
9
qc childrens chewable vitamins/extra c
51
qc childrens chewable vitamins/iron
51
qc chlor-pheniramine
33
qc cold relief plus multi-symptom
41
childrens
qc complete allergy medicine
33
qc cough relief
41
qc cough/sore throat nighttime
41
qc daily multivitamins/iron
51
qc docusate calcium
23
qc ear wax removal drops
26
qc enema
23
qc ferrous sulfate
45
qc fiber laxative
59
qc gas relief
21
qc gas relief extra strength
21
qc gentle laxative
21
qc hemorrhoidal
17
qc loratadine allergy relief
33
qc loratadine-d
33
qc magnesium citrate
23
qc maximum daily
51
multivitamin/multimineral
qc medifin mucus relief childrens
59
qc milk of magnesia
24
qc multi-vite
51
qc multi-vite 50 & over
51
qc natural vegetable
21
qc nighttime cold/flu relief
41
qc nighttime cough
41
qc no drip nasal relief
59
qc pink bismuth
21
qc senna
21
qc senna-s
24
qc sinus pain relief
59
qc stool softener
21
qc stool softener plus laxative
24
qc suphedrine
59
qc suphedrine maximum strength
59
Page 68 of 71
Drug Name Page #
qc suphedrine pe
59
qc therin-m
51
qc tolnaftate
15
qc tussin cf
41
qc womens daily multivitamin
51
q-dryl
33
q-gel mega
25
q-tapp
33
q-tapp dm
40
q-tussin
40
q-tussin dm
40
reeses pinworm medicine
15
refresh celluvisc
25
refresh p.m.
25
refresh plus
25
reguloid
21
relcof c
41
remedy antifungal
15
remedy nutrashield
17
remedy skin repair
17
rena-vite
51
rescon dm
41
rescon-gg
41
RESPAIRE-30
41
rhinaris
59
robafen
41
robafen dm
41
robafen dm cough clear
41
robitussin childrens cough & cold cf
41
robitussin childrens cough long-acting
41
robitussin childrens cough/cold long41
acting
robitussin cold+flu daytime
41
robitussin cold+flu nighttime
41
robitussin lingering coldlong-acting
41
cough
robitussin mucus+chest congestion
33
robitussin peak cold cough+ chest
41
congestion dm
robitussin peak cold cough+ chest
41
congestion dm max strength
robitussin peak cold dm
41
robitussin peak cold multi-symptom
42
cold
robitussin peak cold multi-symptom
42
cold maximum strength
robitussin peak cold nasal relief
42
robitussin peak cold nighttime multi42
symptom cold
Drug Name Page #
robitussin peak cold nighttime nasal
42
relief
rulox
22
RYDEX
42
rynex dm
42
rynex pe
33
rynex pse
33
salactic film
17
saline mist
42
saline nasal mist
42
sb aspirin
9
sb bismuth
22
sb loratadine
33
sea soft nasal mist
42
sea-omega 30
25
sea-omega 50
25
SEBULEX
17
senexon
22
senexon-s
24
senna
22
sennalax-s
24
senna-s
24
senna-tabs
22
senna-time
22
senno
22
senokot to go
24
SENSI-CARE PROTECTIVE
17
BARRIER
sentry
59
silace
22
siladryl allergy
33
siltussin sa
42
siltussin-dm
42
simethicone
22
sinus congestion & pain daytime
59
sinus congestion & pain daytime
42
sinus nasal spray
42
slo-niacin
51
slow-mag
59
sm 12 hour sinus decongestant
59
sm 12-hour no drip
59
sm 3-day vaginal
15
sm all day allergy
33
sm all day allergy-d
33
sm allergy 4 hour
33
sm allergy multi-symptom
59
sm allergy relief
34
sm allergy relief loratadine
34
sm antacid anti-gas
59
Page 69 of 71
Drug Name Page #
sm antacid maximum strength
59
sm antacid/antigas
59
sm antifungal miconazole
15
sm antifungal tolnaftate
15
sm artificial tears
25
sm aspirin adult low strength
9
sm aspirin enteric coated
9
sm aspirin low dose
9
sm athletes foot
15
sm calcium citrate w/vitamin d3
45
sm childrens aspirin
9
sm childrens loratadine
34
sm childrens pain relief plus multi42
symptom cold
sm clotrimazole vaginal
15
sm cold & allergy childrens
34
sm cold & cough dm childrens
42
sm cold head congestion severe day
59
time
sm complete senior formula
51
sm cough relief
42
sm day time cold & flu relief
42
sm docusate calcium
24
sm double antibiotic
13
sm enema
24
sm eye itch relief
59
sm eye itch relief
26
sm fexofenadine hcl
59
sm fexofenadine hcl
34
sm fiber
22
sm fiber laxative
59
sm fiber laxative
24
sm flu relief therapy severe cold
42
nighttime
sm foaming antacid
22
sm gas relief
22
sm gas relief infants drops
22
sm gentle laxative
22
SM GLUCOSE
16
sm hemorrhoidal
17
sm hydrocortisone
24
sm iron
45
sm lice killing maximum strength
15
sm lice treatment
15
sm loratadine
34
sm loratadine allergy relief
34
sm lorata-dine d
34
sm loratadine d 12hr
34
sm miconazole 7
15
Drug Name Page #
sm milk of magnesia
24
sm mucus er
42
sm mucus relief cough childrens
42
sm nasal decongestant maximum
59
strength
sm nasal decongestant pe
59
sm nasal spray moisturizing
59
sm nasal spray saline
42
sm nasal spray sinus
59
sm natural laxative plus stool softener
24
sm nicotine
12
sm nicotine polacrilex
12
sm nite time cold & flu relief
42
sm nite time cough
42
sm nose drops nasal decongestant extra
42
strength
sm oral saline laxative
24
sm stomach relief
22
sm stomach relief maximumstrength
59
sm stool softener
22
sm stool softener plus laxative
24
sm tioconazole-1
15
sm triple antibiotic
13
sm tussin
43
sm tussin cf
42
sm tussin dm
43
sm tussin dm cough/chest congestion
43
sm womans laxative
22
sodium bicarbonate
22
sodium chloride
25
17
SOOTHE & COOL FREE MOISTURE
BARRIER
soothe & cool inzo antifungal cream
15
soothe & cool protect moisture barrier
17
sterile water for injection
5
sterilube
25
stimulant laxative
22
stomach relief
22
stomach relief maximum strength
22
stool softener
23
stool softener extra strength
23
stool softener laxative
24
stool softener laxative dc
23
stress formula
52
stress formula w/iron
52
stress formula/iron
52
stress formula/zinc
52
STRESS-600/ZINC
52
sudogest
43
Page 70 of 71
Drug Name Page #
sudogest 12 hour
43
sudogest pe
43
sudogest sinus & allergy
34
systane
26
systane balance restorative formula
25
systane gel
26
systane nighttime
26
systane ultra
26
systane ultra home & away pack
26
tavist allergy
34
tears naturale
26
tears naturale forte
26
tears naturale ii
26
tears pure
26
terbinafine hcl
15
TESSALON PERLES
4
thera
53
thera-m
52
therapeutic formula/hematinics
52
thera-plus
52
therems
53
therems-h
53
therems-m
53
thiamine hcl
5
tioconazole-1
15
tl icon
4
tolnaftate
15
triacting nightime cold& cough
43
childrens
triaminic cold & cough day time
43
childrens
TRIAMINIC MULTI-SYMPTOM
43
FEVER
triaminic night time cold & cough
34
triple antibiotic
13
tri-vitamin
53
TRIXAICIN
59
trixaicin hp
17
tusnel
43
tusnel diabetic
43
tusnel pediatric
43
tussigon
4
tussin
43
tussin cf
43
tussin cf cough & cold
43
tussin chest congestion
43
tussin cough
43
tussin dm
43
tussin dm max
43
Drug Name Page #
tussin mucus + chest congestion
43
TUSSIONEX PENNKINETIC
4
EXTENDED RELEASE
unicomplex-m
53
ureacin-10
17
VAGISTAT-1
15
vagistat-3
15
VANAHIST PD
59
VENOFER
4
virdec
34
vita-bee/c
53
vitamin b complex-c
53
vitamin c
53
vitamin d
5
vitamin d
54
vitamin d3
53
vitamin d3 super strength
53
VITAMIN K1
5
womans laxative
23
ZADITOR
26
ZIKS ARTHRITIS PAIN RELIEF
17
zinc sulfate
45
ZINC TRACE METAL
6
ZONATUSS
4
zoo friends
54
zoo friends complete
54
zoo friends plus extra c
54
zoo friends plus iron
54
z-tuss e
59
Page 71 of 71
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