List of Covered Drugs for 2015 - Medicare Medicaid Program from
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 DP 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 4349 Easton Way, Suite 200 Columbus, OH 43219 1-866-549-8289 TTY: 1-800-750-0750 mmp.BuckeyeHealthPlan.com © 2015 Buckeye Health Plan
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