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HEALTHY MICHIGAN FORMULARY
Effective December 2014
Provided by EnvisionRxOptions
Introduction
The Total Health Care (THC) Healthy Michigan Formulary was developed to serve as a guide for physicians,
pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health
Care recognizes that drug therapy is an integral part of effective health management.
Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to
the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary
includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant
benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications.
Notice
The information contained in this formulary is provided by THC, solely for the convenience of medical providers
and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive
in nature.
This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical
provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or
omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The
medical provider should consult the drug manufacturer’s product literature or standard references for more detailed
information.
How to Read the Formulary
Drug Name
All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase).
Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the
index, using the covered generic name or the covered brand name of the drug. The brand names listed are for
reference use only, and do not denote coverage, unless specifically noted. Any drug not found in this Formulary
listing shall be considered a non-formulary drug.
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Requirements/Limits
This field includes potential limitations to the formulary drug. It also may contain additional information about the
coverage of the drug such as applicable quantity limits (QL). For certain agents within the Healthy Michigan
Formulary, a recommended prescribing guideline may apply.
Prescribing Guidelines
Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit
design but may include:
Prior Authorization
Required (PA)
Drug requires prior authorization through a specific physician request
process.
Over the Counter Drugs
(OTC)
Drug coverage is available for drugs that are available OTC with an
authorized prescription from your provider.
Specialty Drugs (SP)
Drug requires processing through THC’s contracted specialty
pharmacy, Diplomat Specialty Pharmacy.
Quantity Limit (QL)
Drug coverage may be limited to specific quantities per prescription
and/or time period.
Age Limit (AL)
Drug coverage may depend on patient age.
Gender Restriction (GR) Drug coverage may depend on patient gender.
Step Therapy Required
(ST)
Drug coverage requires that an alternative or trial of another drug be
used before the medication is covered.
Benefit Coverage and Limitations
This formulary does not define benefit coverage and limitations. Members should contact Total Health Care at 1800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is
evolutionary and changes can occur throughout the year.
Prior Authorization (PA)
Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior
Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also request a
form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-877503-7231. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review
criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be
approved and alternative therapy may be recommended along with the proper course of alternative action. The
requesting provider will be provided written notification of Total Health Care review decisions. THC’s website has a
contact link where members can contact THC’s Pharmacy Department to ask for an exception request.
Non-Formulary Agents
Drugs not found on the Total Health Care Healthy Michigan Formulary, or any updates published by Total Health
Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by
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the health professional depending on specific coverage parameters. Review for non-formulary drug requests will
require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical
necessity guidelines are used in conducting a review:



The patient has failed an appropriate trial of formulary or preferred agents.
The use of preferred or formulary agent is contraindicated in the patient.
The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected
is required for patient safety.
If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be
recommended along with the proper course of alternative action.
Common Drug Exclusions
The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs
that are specifically excluded by benefit design. Common excluded coverage may include, but are not limited to:





Drug products used for cosmetic purposes
Drug products for erectile dysfunction
Drug products for infertility treatment
Experimental drug products, or any drug product used in an experimental manner
Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA)
Healthy Michigan Carve Out List
The State of Michigan has a carve-out list for the Healthy Michigan formulary. The carve-out drugs include mental
health, HIV/AIDS, Oncology, Hemophilia and other miscellaneous drugs that have been added to the State's 100%
carve-out list. These drugs must be billed directly by the pharmacies at point-of-sale to the Michigan Department of
Community Health's contracted Pharmacy Benefits Manager (PBM). A list of the carve-out drugs can be found at
https://michigan.fhsc.com/Providers/DrugInfo.asp.
Mandated Generic Substitution
Total Health Care advocates the use of cost-effective generic drugs where FDA- approved generic equivalent drugs are
available. Generic products are listed in the Formulary and noted as “generic” wherever an FDA-approved generic
drug product is available. The brand names listed in the formulary are for reference only.
Total Health Care Pharmacy and Therapeutics (P&T) Committee
Total Health Care’s Pharmacy &Therapeutic Committee meets quarterly to review and recommend medications for
formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs
that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to
patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals.
The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics
Advisory Panel.
Product Selection Criteria
The primary goal of the THC Pharmacy & Therapeutic Committee is to maintain and update the formulary based upon
an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient
administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for
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formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary.
Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862.
Diabetic Testing Supplies
Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered
diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor
GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test
strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical
Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844236-7933.
Specialty Bio-Pharmaceutical Pharmacy Program
Total Health Care works with Diplomat Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy
products to our members. These medications are to be filled exclusively through Diplomat Specialty Pharmacy.
A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRxOptions at 1-877-5037231 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior
Authorization Request form found on the Total Health Care website at www.THCmi.com.
Once the order is received, EnvisionRxOptions obtains authorization from Total Health Care. If the specialty prior
authorization is approved, Total Health Care notifies Diplomat Specialty Pharmacy. Then the Diplomat Specialty
Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All packages are
individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate,
each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty BioPharmaceutical Pharmacy program, please contact EnvisionRxOptions at 1-844-222-5584 or Diplomat Specialty
Pharmacy at 1-877-977-9118.
Contact Information
The Total Health Care Healthy Michigan formulary is designed to assist physicians, members and other health care
professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how
we can assist in improving this document and the formulary management process.
You may contact THC at 1-800-826-2862.
Medication Limitations
Quantity Limitations
Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are
medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation on the duration of
therapy.
Age Limitations
Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a
medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a
minimum and maximum age edit.
Gender Restrictions
Gender restrictions are indicated with a “GR” on the formulary and require the member to be a specific gender for
coverage.
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Step Therapy Criteria
Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line
medication be tried and failed before the requested medication can be covered. The online claims adjudication
system will automatically allow for the requested medication to be filled based on electronic claims history
indicating that the first line medication was filled.
Step-Therapy Criteria
Therapy Class
First Line
Second Line
Step Therapy Criteria
Acetylcholinesterase
Inhibitors
Aricept ImmediateRelease
Galantamine
Immediate-Release
Prior use of Aricept ImmediateRelease in the last 60 days
Antibiotics
Cefadroxil,
Cefaclor,
Cefprozil
Prior use of Amoxicillin,
Ampicillin, Amoxicillin &
Clavulanate, Cefpodoxime,
Cefdinir, Cefuroxime,
Cephalexin, Ciprofloxacin,
Clindamycin, Dicloxacillin,
Doxycycline, Erythromycin,
Penicillin, SulfamethoxazoleTrimethoprim or Tetracycline
in the last 30 days
Antidiabetic Agents
Amoxicillin, Ampicillin,
Amoxicillin &
Clavulanate,
Cefpodoxime, Cefdinir,
Cefuroxime, Cephalexin,
Ciprofloxacin,
Clindamycin,
Dicloxacillin,
Doxycycline,
Erythromycin,
Penicillin,
SulfamethoxazoleTrimethoprim,
Tetracycline
Metformin
Januvia,
Janumet,
PioglitazoneGlimepiride
Prior use of Metformin in the
last 90 days
Glucocorticoid Inhaler
Qvar
Prior use of Qvar within the
last 90 days.
Pediculicides
Lice-B-Gone Kit,
Lice-B-Gone Shampoo,
Pyrethrins-Piperonyl
Butoxide Liquid,
Permethrin Spray &
Pyrethins-Piperonyl
Butoxide Shampoo Kit
Dulera,
Symbicort,
Advair Diskus
100/50
Malathion Lotion,
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Prior use of Lice-B-Gone Kit,
Lice-B-Gone Shampoo,
Pyrethrins-Piperonyl Butoxide
Liquid, Permethrin Spray &
Pyrethins-Piperonyl Butoxide
Shampoo Kit in the last 30 days
Urinary Antispasmodics
Oxybutynin,
Oxybutynin Syrup,
Oxytrol OTC
Oxybutynin
Extended-Release,
Tolterodine,
Tolterodine
Extended-Release
Prior use of Oxytrol OTC or
Oxybutynin/Oxybutynin Syrup
in the last 90 days.
*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The
benefit design determines what is covered. The medications listed on this formulary are subject to change pursuant
to the formulary management activities of EnvisionRxOptions. The presence of a medication on this formulary list
does not guarantee coverage.
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Drug Name
Requirements/ Limits
ANALGESICS
Analgesics
acetamin sup 650mg
acetaminophen cap 500 mg
acetaminophen chew tab 80 mg
acetaminophen elixir 160 mg/5
acetaminophen liquid 160 mg/5
acetaminophen soln 100 mg/ml
acetaminophen suppos 120 mg
acetaminophen suppos 325 mg
acetaminophen susp 80 mg/0.8m
acetaminophen tab 325 mg
acetaminophen tab 500 mg
acetaminophen tab cr 650 mg
acetaminophen-caffeine-py
aspirin-acetaminophen-caffein
butalbital-acetaminophen tab
butalbital-acetaminophen-caff
butalbital-acetaminophen-caff
butalbital-acetaminophen-caff
butalbital-aspirin-caff w/ co
butalbital-aspirin-caffeine c
BUTALBITAL-ASPIRIN-CAFFEINE T
eql acetamin tab 160mg
eql acetamin tab 80mg
non-aspirin chw 160mg jr
pain & fever sol 160/5ml
Opioid Analgesics, Long-acting
fentanyl td patch 72hr 100 mc
PA
fentanyl td patch 72hr 12 mcg
PA
fentanyl td patch 72hr 25 mcg
PA
fentanyl td patch 72hr 50 mcg
PA
fentanyl td patch 72hr 75 mcg
PA
hydromorphone hcl tab 2 mg
hydromorphone hcl tab 4 mg
hydromorphone hcl tab 8 mg
meperidine hcl tab 100 mg
meperidine hcl tab 50 mg
methadone hcl conc 10 mg/ml
methadone hcl soln 10 mg/5ml
methadone hcl soln 5 mg/5ml
methadone hcl tab 10 mg
methadone hcl tab 5 mg
methadone hcl tab for oral su
morphine sulfate (concentrate
morphine sulfate oral soln 10
morphine sulfate oral soln 20
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
1
Formulary last updated date (11/01/2014)
Drug Name
morphine sulfate tab 15 mg
morphine sulfate tab 30 mg
morphine sulfate tab cr 100 m
morphine sulfate tab cr 15 mg
morphine sulfate tab cr 30 mg
morphine sulfate tab cr 60 mg
oxycodone hcl cap 5 mg
oxycodone hcl conc 100 mg/5ml
oxycodone hcl soln 5 mg/5ml
oxycodone hcl tab 15 mg
oxycodone hcl tab 30 mg
oxycodone hcl tab 5 mg
Opioid Analgesics, Short-acting
acetaminophen w/ codeine soln
acetaminophen w/ codeine tab
acetaminophen w/ codeine tab
acetaminophen w/ codeine tab
codeine sulf tab 15mg
codeine sulf tab 60mg
codeine sulfate tab 30 mg
hydrocodone-acetaminophen sol
hydrocodone-acetaminophen sol
hydrocodone-acetaminophen sol
hydrocodone-acetaminophen tab
hydrocodone-acetaminophen tab
hydrocodone-acetaminophen tab
hydrocodone-acetaminophen tab
hydrocodone-acetaminophen tab
hydrocodone-acetaminophen tab
hydrocodone-acetaminophen tab
hydrocodone-acetaminophen tab
hydrocodone-acetaminophen tab
hydrocodone-acetaminophen tab
hydrocodone-acetaminophen tab
oxycodone w/ acetaminophen ca
oxycodone w/ acetaminophen ta
oxycodone w/ acetaminophen ta
oxycodone w/ acetaminophen ta
oxycodone w/ acetaminophen ta
oxycodone w/ acetaminophen ta
oxycodone w/ acetaminophen ta
oxycodone-aspirin tab 4.8355tramadol hcl tab 50 mg
Requirements/ Limits
QL 900/90
QL 900/90
QL 900/90
QL 240/30
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
Smoking Cessation Agents
bupropion hcl (smoking deterr
QL 180/365
CHANTIX PAK 0.5& 1MG
QL 60/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
2
Formulary last updated date (11/01/2014)
Drug Name
CHANTIX PAK 1MG
CHANTIX TAB 0.5MG
nicotine inhaler system 1
nicotine polacrilex gum 2 mg
nicotine polacrilex gum 4 mg
nicotine polacrilex lozenge 2
nicotine polacrilex lozenge 4
NICOTINE SYS KIT TRANSDER
nicotine td patch 24hr 14 mg/
nicotine td patch 24hr 21 mg/
nicotine td patch 24hr 7 mg/2
NICOTROL NS SPR 10MG/ML
Requirements/ Limits
QL 60/30
QL 60/30
QL 360/30
QL 270/30
QL 270/30
QL 270/30
QL 270/30
QL
QL
QL
QL
ANTI-INFLAMMATORY AGENTS
Nonsteroidal Anti-inflammatory Drugs
ascriptin tab
aspirin buffered (ca carb-mg
QL 30/30 AL
aspirin buffered tab 325 mg
QL 30/30 AL
aspirin chew tab 81 mg
AL
aspirin suppos 300 mg
aspirin suppos 600 mg
aspirin tab 325 mg
AL
aspirin tab 500 mg
aspirin tab 650mg ec
aspirin tab 81 mg
AL
aspirin tab delayed release 3
AL
aspirin tab delayed release 5
aspirin tab delayed release 8
AL
choline & magnesium salicylat
choline & magnesium salicylat
choline & magnesium salicylat
choline & magnesium salicylat
diclofenac potassium tab 50 m
diclofenac sodium tab delayed
diclofenac sodium tab delayed
diclofenac sodium tab delayed
diclofenac sodium tab sr 24hr
diflunisal tab 500 mg
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab 400 mg
etodolac tab 500 mg
etodolac tab sr 24hr 400 mg
etodolac tab sr 24hr 500 mg
etodolac tab sr 24hr 600 mg
fenoprofen calcium tab 600 mg
flurbiprofen tab 100 mg
flurbiprofen tab 50 mg
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
3
Formulary last updated date (11/01/2014)
Drug Name
goodys tab ex st
halfprin tab 162mg ec
ibuprofen jr chw 100mg
ibuprofen susp 100 mg/5ml
ibuprofen susp 40 mg/ml
ibuprofen tab 200 mg
ibuprofen tab 400 mg
ibuprofen tab 600 mg
ibuprofen tab 800 mg
indocin sus 25mg/5ml
indomethacin cap 25 mg
indomethacin cap 50 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
ketorolac tromethamine tab 10
meclofenamate sodium cap 50 m
meloxicam tab 15 mg
meloxicam tab 7.5 mg
nabumetone tab 500 mg
nabumetone tab 750 mg
NAPRELAN TAB 375MG CR
NAPRELAN TAB 500MG CR
NAPRELAN TAB 750MG CR
naproxen kit comfort
naproxen pow
NAPROXEN POW SODIUM
naproxen sodium cap 220 mg
naproxen sodium tab 220 mg
naproxen sodium tab 275 mg
naproxen sodium tab 550 mg
naproxen susp 125 mg/5ml
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
naproxen tab ec 375 mg
oxaprozin tab 600 mg
piroxicam cap 10 mg
piroxicam cap 20 mg
salsalate tab 500 mg
salsalate tab 750 mg
sm ibuprofen tab 100mg jr
sulindac tab 150 mg
sulindac tab 200 mg
Requirements/ Limits
QL 360/30
QL 120/30
QL 20/5
QL 120/30
QL 60/30
ANTIBACTERIALS
Aminoglycosides
neomycin sulfate tab 500 mg
Antibacterials, Other
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
4
Formulary last updated date (11/01/2014)
Drug Name
clindamycin hcl cap 150 mg
clindamycin hcl cap 300 mg
clindamycin hcl cap 75 mg
clindamycin sol 75mg/5ml
dapsone tab 100 mg
dapsone tab 25 mg
DORIBAX INJ 250MG
DORIBAX INJ 500MG
erythromycin-sulfisoxazole fo
MACRODANTIN CAP 25MG
METHENAM MAN TAB 500MG
methenamine hippurate tab 1 g
methenamine mandelate tab 1 g
metronidazole tab 250 mg
metronidazole tab 500 mg
nitrofurantoin macrocrystalli
nitrofurantoin macrocrystalli
nitrofurantoin monohydrate ma
PRIMSOL SOL 50MG/5ML
sulfamethoxazole-trimethoprim
sulfamethoxazole-trimethoprim
sulfamethoxazole-trimethoprim
trimethoprim tab 100 mg
vancomycin hcl for inj 10 gm
vancomycin hcl for inj 1000 m
vancomycin hcl for inj 500 mg
vancomycin hcl for inj 5000 m
VANCOMYCIN INJ 750MG
VANCOMYCN 25 SOL 25MG/ML
VANCOMYCN 50 SOL 50MG/ML
Beta-lactam, Cephalosporins
cefaclor cap 250 mg
cefaclor cap 500 mg
CEFACLOR SUS 125/5ML
CEFACLOR SUS 250/5ML
CEFACLOR SUS 375/5ML
cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5m
cefadroxil for susp 500 mg/5m
cefadroxil tab 1 gm
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
cefpodoxime proxetil for susp
cefpodoxime proxetil for susp
cefpodoxime proxetil tab 100
cefpodoxime proxetil tab 200
Requirements/ Limits
QL 60/30
QL 60/30
QL 60/30
QL 600/30
QL 60/30
PA
PA
PA
PA
PA
QL 20/14
QL 10/14
ST
ST
ST
ST
ST
QL 40/10 ST
ST
ST
QL 20/10 ST
AL
AL
QL 60/30
QL 60/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
5
Formulary last updated date (11/01/2014)
Drug Name
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
CEFTIN SUS 250/5ML
ceftriaxone sodium for inj 1
ceftriaxone sodium for inj 25
ceftriaxone sodium for inj 50
cefuroxime axetil for susp 12
cefuroxime axetil tab 250 mg
cefuroxime axetil tab 500 mg
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin for susp 125 mg/5m
cephalexin for susp 250 mg/5m
Beta-lactam, Penicillins
amoxicillin & k clavulanate c
amoxicillin & k clavulanate c
amoxicillin & k clavulanate f
amoxicillin & k clavulanate f
amoxicillin & k clavulanate f
amoxicillin & k clavulanate t
amoxicillin & k clavulanate t
amoxicillin & k clavulanate t
amoxicillin (trihydrate) cap
amoxicillin (trihydrate) cap
amoxicillin (trihydrate) chew
amoxicillin (trihydrate) chew
amoxicillin (trihydrate) for
amoxicillin (trihydrate) for
amoxicillin (trihydrate) for
amoxicillin (trihydrate) for
amoxicillin (trihydrate) tab
amoxicillin (trihydrate) tab
ampicillin cap 250 mg
ampicillin cap 500 mg
ampicillin for susp 125 mg/5m
ampicillin for susp 250 mg/5m
BICILLIN C-R INJ 1200000
BICILLIN C-R INJ 900/300
dicloxacillin sodium cap 250
dicloxacillin sodium cap 500
penicillin v potassium for so
penicillin v potassium for so
penicillin v potassium tab 25
penicillin v potassium tab 50
Macrolides
Requirements/ Limits
ST
ST
QL 60/30 ST
QL 60/30 ST
AL
QL 10/30
QL 10/30
QL 10/30
AL
QL 28/14
QL 28/14
QL 4/28
QL 4/28
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
6
Formulary last updated date (11/01/2014)
Drug Name
azithromycin for susp 100 mg/
azithromycin for susp 200 mg/
azithromycin tab 250 mg
azithromycin tab 500 mg
azithromycin tab 600 mg
clarithromycin for susp 125 m
clarithromycin for susp 250 m
clarithromycin tab 250 mg
clarithromycin tab 500 mg
clarithromycin tab sr 24hr 50
ERY-TAB TAB 250MG EC
ERY-TAB TAB 333MG EC
ERYPED SUS 200/5ML
ERYPED SUS 400/5ML
erythromycin ethylsuccinate t
erythromycin stearate tab 250
erythromycin tab 250 mg
erythromycin tab 500 mg
erythromycin tab delayed rele
erythromycin w/ delayed relea
PCE TAB 333MG EC
PCE TAB 500MG EC
Quinolones
ciprofloxacin hcl tab 100 mg
ciprofloxacin hcl tab 250 mg
ciprofloxacin hcl tab 500 mg
ciprofloxacin hcl tab 750 mg
levofloxacin tab 250 mg
levofloxacin tab 500 mg
levofloxacin tab 750 mg
ofloxacin tab 200 mg
ofloxacin tab 300 mg
ofloxacin tab 400 mg
Sulfonamides
sulfadiazine tab 500 mg
Tetracyclines
doxycycline hyclate cap 100 m
doxycycline hyclate cap 50 mg
doxycycline hyclate tab 100 m
doxycycline monohydrate for s
minocycline hcl cap 100 mg
minocycline hcl cap 50 mg
minocycline hcl cap 75 mg
TETRACYCLINE CAP 500MG
tetracycline hcl cap 250 mg
VIBRAMYCIN SYP 50MG/5ML
Requirements/ Limits
QL 12/30
QL 12/30
QL 60/30
QL 14/14
QL 14/14
QL 14/14
QL 60/30
QL 60/30
QL 60/30
ANTIDEMENTIA AGENTS
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
7
Formulary last updated date (11/01/2014)
Drug Name
Cholinesterase Inhibitors
donepezil hydrochloride tab 1
donepezil hydrochloride tab 5
galantamine hydrobromide tab
galantamine hydrobromide tab
galantamine hydrobromide tab
Requirements/ Limits
ST
ST
ST
ANTIEMETICS
Emetogenic Therapy Adjuncts
DIMENHYDRIN INJ 50MG/ML
dimenhydrinate tab 50 mg
DRAMAMINE CHW 50MG
dronabinol cap 10 mg
dronabinol cap 2.5 mg
dronabinol cap 5 mg
meclizine hcl chew tab 25 mg
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
meclizine hcl tab 32 mg
MECLIZINE POW HCL
ondansetron hcl oral soln 4 m
ondansetron hcl tab 4 mg
ondansetron hcl tab 8 mg
ondansetron orally disintegra
ondansetron orally disintegra
trimethobenzamide hcl cap 300
PA
PA
PA
QL 50/30
ANTIFUNGALS
Antifungals
fluconazole for susp 10 mg/ml
fluconazole for susp 40 mg/ml
fluconazole tab 100 mg
fluconazole tab 150 mg
fluconazole tab 200 mg
fluconazole tab 50 mg
griseofulvin microsize susp 1
griseofulvin microsize tab 50
griseofulvin ultramicrosize t
griseofulvin ultramicrosize t
ketoconazole tab 200 mg
nystatin tab 500000 unit
terbinafine hcl tab 250 mg
QL 30/30
QL 4/30
QL 30/30
QL 30/30
ANTIGOUT AGENTS
Antigout Agents
allopurinol tab 100 mg
allopurinol tab 300 mg
colchicine w/ probenecid tab
COLCRYS TAB 0.6MG
QL 20/30
probenecid tab 500 mg
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
8
Formulary last updated date (11/01/2014)
Drug Name
Requirements/ Limits
ANTIMIGRAINE AGENTS
Serotonin (5-HT) 1b/1d Receptor Agonists
sumatriptan succinate tab 100
sumatriptan succinate tab 25
sumatriptan succinate tab 50
QL 9/30
QL 9/30
QL 9/30
ANTIMYASTHENIC AGENTS
Parasympathomimetics
pyridostigmine bromide sy
pyridostigmine bromide ta
pyridostigmine bromide ta
ANTIMYCOBACTERIALS
Antituberculars
cycloserine cap 250 mg
ethambutol hcl tab 100 mg
ethambutol hcl tab 400 mg
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
pyrazinamide tab 500 mg
rifabutin cap 150 mg
rifampin cap 150 mg
rifampin cap 300 mg
RIFATER TAB
TRECATOR TAB 250MG
ANTINEOPLASTICS
Antineoplastics
anastrozole tab 1 mg
GR
bicalutamide tab 50 mg
capecitabine tab 150 mg
PA
capecitabine tab 500 mg
PA
cyclophosphamide tab 25 mg
cyclophosphamide tab 50 mg
ELIGARD INJ 22.5MG
PA
ELIGARD INJ 30MG
PA
ELIGARD INJ 45MG
PA
ELIGARD INJ 7.5MG
PA
flutamide cap 125 mg
PA
HEXALEN CAP 50MG
PA
hydroxyurea cap 500 mg
INTRON-A INJ 10MU
PA
INTRON-A INJ 18MU
PA
INTRON-A INJ 18MU
PA
INTRON-A INJ 25MU
PA
INTRON-A INJ 50MU
PA
letrozole tab 2.5 mg
QL 30/30 AL
leucovorin calcium tab 15 mg
leucovorin calcium tab 25 mg
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
9
Formulary last updated date (11/01/2014)
Drug Name
leucovorin calcium tab 5 mg
LEUKERAN TAB 2MG
lomustine cap 10 mg
lomustine cap 100 mg
lomustine cap 40 mg
LUPRON DEPOT INJ 11.25MG
LUPRON DEPOT INJ 22.5MG
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ 30MG
LUPRON DEPOT INJ 7.5MG
MATULANE CAP 50MG
megestrol acetate susp 40 mg/
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
mercaptopurine tab 50 mg
methotrexate sodium tab 2.5 m
MYLERAN TAB 2MG
TABLOID TAB 40MG
tamoxifen citrate tab 10 mg (
tamoxifen citrate tab 20 mg (
tretinoin cap 10 mg
Requirements/ Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
ANTIPARASITICS
Anthelmintics
STROMECTOL TAB 3MG
Antibacterials, Other
atovaquone susp 750 mg/5ml
Antiprotozoals
chloroquine phosphate tab 250
DARAPRIM TAB 25MG
hydroxychloroquine sulfate ta
mefloquine hcl tab 250 mg
PRIMAQUINE TAB 26.3MG
quinine sulfate cap 324 mg
QL 20/90
QL 210/18
PA
QL 6/30
QL 5/30
QL 14/30
ANTIPARKINSON AGENTS
Antiparkinson Agents, Other
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5m
bromocriptine mesylate cap 5
bromocriptine mesylate tab 2.
carbidopa tab 25 mg
selegiline hcl cap 5 mg
Dopamine Agonists
carbidopa & levodopa tab 10-1
carbidopa & levodopa tab 25-1
carbidopa & levodopa tab 25-2
carbidopa & levodopa tab cr 2
carbidopa & levodopa tab cr 5
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
10
Formulary last updated date (11/01/2014)
Drug Name
pramipexole dihydrochloride t
pramipexole dihydrochloride t
pramipexole dihydrochloride t
pramipexole dihydrochloride t
pramipexole dihydrochloride t
ropinirole hydrochloride tab
ropinirole hydrochloride tab
ropinirole hydrochloride tab
ropinirole hydrochloride tab
ropinirole hydrochloride tab
ropinirole hydrochloride tab
ropinirole hydrochloride tab
Requirements/ Limits
ANTIPSYCHOTICS
1st Generation/Typical
prochlorperazine maleate tab
prochlorperazine maleate tab
prochlorperazine suppos 25 mg
QL 60/30
ANTIVIRALS
Anti-HIV Agents, Other
EPIVIR HBV SOL 5MG/ML
lamivudine tab 100 mg
Anti-influenza Agents
RELENZA MIS DISKHALE
rimantadine hydrochloride tab
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
Antihepatitis Agents
INFERGEN INJ 15MCG
INFERGEN INJ 9MCG
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 150MCG
PEG-INTRON KIT 50MCG RP
PEG-INTRON KIT 80MCG
ribavirin cap 200 mg
Antiherpetic Agents
acyclovir cap 200 mg
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
QL 1800/30
QL 90/30
QL 20/5
QL 10/5
QL 10/5
QL 10/5
QL 120/10 AL
PA
PA
PA
PA
PA
PA
PA
AL
ANXIOLYTICS
Anxiolytics, Other
hydroxyzine hcl syrup 10 mg/5
hydroxyzine hcl tab 10 mg
hydroxyzine hcl tab 25 mg
hydroxyzine hcl tab 50 mg
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
11
Formulary last updated date (11/01/2014)
Drug Name
hydroxyzine pamoate cap 100 m
hydroxyzine pamoate cap 25 mg
hydroxyzine pamoate cap 50 mg
Requirements/ Limits
BLOOD GLUCOSE REGULATORS
Antidiabetic Agents
acarbose tab 100 mg
acarbose tab 25 mg
acarbose tab 50 mg
BYDUREON INJ
chlorpropamide tab 100 mg
chlorpropamide tab 250 mg
glimepiride tab 1 mg
glimepiride tab 2 mg
glimepiride tab 4 mg
glipizide tab 10 mg
glipizide tab 5 mg
glipizide tab sr 24hr 10 mg
QL 60/30
glipizide tab sr 24hr 2.5 mg
QL 60/30
glipizide tab sr 24hr 5 mg
QL 60/30
glyburide micronized tab 1.5
glyburide micronized tab 3 mg
glyburide micronized tab 6 mg
glyburide tab 1.25 mg
glyburide tab 2.5 mg
glyburide tab 5 mg
glyburide-metformin tab 1.25glyburide-metformin tab 2.5-5
glyburide-metformin tab 5-500
INVOKANA TAB 100MG
PA
INVOKANA TAB 300MG
PA
JANUMET TAB 50-1000
QL 60/30 ST
JANUMET TAB 50-500MG
QL 60/30 ST
JANUVIA TAB 100MG
QL 30/30 ST
JANUVIA TAB 25MG
QL 30/30 ST
JANUVIA TAB 50MG
QL 30/30 ST
metformin hcl tab 1000 mg
metformin hcl tab 500 mg
metformin hcl tab 850 mg
metformin hcl tab sr 24hr 500
metformin hcl tab sr 24hr 750
nateglinide tab 120 mg
QL 90/30
nateglinide tab 60 mg
QL 90/30
pioglitazone hcl tab 15 mg (b
QL 30/30
pioglitazone hcl tab 30 mg (b
QL 30/30
pioglitazone hcl tab 45 mg (b
QL 30/30
pioglitazone hcl-metformin hc
QL 60/30
pioglitazone hcl-metformin hc
QL 60/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
12
Formulary last updated date (11/01/2014)
Drug Name
Glycemic Agents
GLUCAGON KIT 1MG
glucose gel 40%
Insulins
APIDRA INJ U-100
HUMULIN N PN INJ U-100
HUMULIN PEN INJ 70/30
LANTUS INJ 100/ML
LEVEMIR INJ
NOVOLIN INJ 70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ U-100
NOVOLOG MIX INJ 70/30
Requirements/ Limits
QL 2/365
BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS
Anticoagulants
enoxaparin sodium inj 100 mg/
PA QL AL GR
enoxaparin sodium inj 120 mg/
PA QL AL GR
enoxaparin sodium inj 150 mg/
PA QL AL GR
enoxaparin sodium inj 30 mg/0
PA QL AL GR
enoxaparin sodium inj 300 mg/
PA QL AL GR
enoxaparin sodium inj 40 mg/0
PA QL AL GR
enoxaparin sodium inj 60 mg/0
PA QL AL GR
enoxaparin sodium inj 80 mg/0
PA QL AL GR
heparin sodium (porcine) inj
heparin sodium (porcine) inj
heparin sodium (porcine) inj
heparin sodium (porcine) inj
heparin sodium (porcine) inj
heparin sodium (porcine) pf i
warfarin sodium tab 1 mg
warfarin sodium tab 10 mg
warfarin sodium tab 2 mg
warfarin sodium tab 2.5 mg
warfarin sodium tab 3 mg
warfarin sodium tab 4 mg
warfarin sodium tab 5 mg
warfarin sodium tab 6 mg
warfarin sodium tab 7.5 mg
xarelto tab 10mg
PA QL 35/35
Blood Formation Modifiers
EPOGEN INJ 10000/ML
PA
EPOGEN INJ 2000/ML
PA
EPOGEN INJ 20000/ML
PA
EPOGEN INJ 3000/ML
PA
EPOGEN INJ 4000/ML
PA
NEUPOGEN INJ 300/0.5
PA
NEUPOGEN INJ 300MCG
PA
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
13
Formulary last updated date (11/01/2014)
Drug Name
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
PROCRIT INJ 40000/ML
Platelet Modifying Agents
anagrelide hcl cap 0.5 mg
anagrelide hcl cap 1 mg
cilostazol tab 100 mg
cilostazol tab 50 mg
clopidogrel bisulfate tab 300
clopidogrel bisulfate tab 75
dipyridamole tab 25 mg
dipyridamole tab 50 mg
dipyridamole tab 75 mg
EFFIENT TAB 10MG
EFFIENT TAB 5MG
ticlopidine hcl tab 250 mg
Requirements/ Limits
PA
PA
PA
QL 5/90
QL 30/30
PA
PA
CARDIOVASCULAR AGENTS
Alpha-adrenergic Agonists
midodrine hcl tab 10 mg
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
Angiotensin II Receptor Antagonists
losartan potassium tab 100 mg
QL 30/30
losartan potassium tab 25 mg
QL 30/30
losartan potassium tab 50 mg
QL 30/30
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl tab 10 mg
QL 30/30
benazepril hcl tab 20 mg
QL 30/30
benazepril hcl tab 40 mg
benazepril hcl tab 5 mg
QL 30/30
captopril tab 100 mg
captopril tab 12.5 mg
QL 30/30
captopril tab 25 mg
QL 30/30
captopril tab 50 mg
QL 30/30
enalapril maleate tab 10 mg
QL 30/30
enalapril maleate tab 2.5 mg
QL 30/30
enalapril maleate tab 20 mg
enalapril maleate tab 5 mg
QL 30/30
fosinopril sodium tab 10 mg
QL 30/30
fosinopril sodium tab 20 mg
QL 30/30
fosinopril sodium tab 40 mg
lisinopril tab 10 mg
QL 30/30
lisinopril tab 2.5 mg
QL 30/30
lisinopril tab 20 mg
QL 30/30
lisinopril tab 30 mg
QL 30/30
lisinopril tab 40 mg
lisinopril tab 5 mg
QL 30/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
14
Formulary last updated date (11/01/2014)
Drug Name
moexipril hcl tab 15 mg
moexipril hcl tab 7.5 mg
quinapril hcl tab 10 mg
quinapril hcl tab 20 mg
quinapril hcl tab 40 mg
quinapril hcl tab 5 mg
ramipril cap 1.25 mg
ramipril cap 10 mg
ramipril cap 2.5 mg
ramipril cap 5 mg
trandolapril tab 1 mg
trandolapril tab 2 mg
trandolapril tab 4 mg
Antiarrhythmics
amiodarone hcl tab 200 mg
disopyramide phosphate cap 10
disopyramide phosphate cap 15
flecainide acetate tab 100 mg
flecainide acetate tab 150 mg
flecainide acetate tab 50 mg
NORPACE CAP 100MG CR
NORPACE CAP 150MG CR
propafenone hcl tab 150 mg
propafenone hcl tab 225 mg
propafenone hcl tab 300 mg
quinidine gluconate tab cr 32
quinidine sulfate tab 200 mg
quinidine sulfate tab 300 mg
Antihypertensive Combinations
amlodipine besylate-benazepri
amlodipine besylate-benazepri
amlodipine besylate-benazepri
amlodipine besylate-benazepri
amlodipine besylate-benazepri
amlodipine besylate-benazepri
atenolol & chlorthalidone tab
atenolol & chlorthalidone tab
AZOR TAB 10-20MG
AZOR TAB 10-40MG
AZOR TAB 5-20MG
AZOR TAB 5-40MG
benazepril & hydrochlorothiaz
benazepril & hydrochlorothiaz
benazepril & hydrochlorothiaz
benazepril & hydrochlorothiaz
bisoprolol & hydrochlorothiaz
bisoprolol & hydrochlorothiaz
Requirements/ Limits
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 60/30
QL 120/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
PA QL 30/30
PA QL 30/30
PA QL 30/30
PA QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
15
Formulary last updated date (11/01/2014)
Drug Name
bisoprolol & hydrochlorothiaz
captopril & hydrochlorothiazi
captopril & hydrochlorothiazi
captopril & hydrochlorothiazi
captopril & hydrochlorothiazi
enalapril maleate & hydrochlo
enalapril maleate & hydrochlo
lisinopril & hydrochlorothiaz
lisinopril & hydrochlorothiaz
lisinopril & hydrochlorothiaz
losartan potassium & hydrochl
losartan potassium & hydrochl
losartan potassium & hydrochl
metoprolol & hydrochlorothiaz
metoprolol & hydrochlorothiaz
metoprolol & hydrochlorothiaz
propranolol & hydrochlorothia
propranolol & hydrochlorothia
quinapril-hydrochlorothiazide
quinapril-hydrochlorothiazide
quinapril-hydrochlorothiazide
Beta-adrenergic Blocking Agents
acebutolol hcl cap 200 mg
acebutolol hcl cap 400 mg
atenolol tab 100 mg
atenolol tab 25 mg
atenolol tab 50 mg
bisoprolol fumarate tab 10 mg
bisoprolol fumarate tab 5 mg
BYSTOLIC TAB 10MG
BYSTOLIC TAB 2.5MG
BYSTOLIC TAB 20MG
BYSTOLIC TAB 5MG
carvedilol tab 12.5 mg
carvedilol tab 25 mg
carvedilol tab 3.125 mg
carvedilol tab 6.25 mg
diltiazem hcl cap sr 24hr 120
labetalol hcl tab 100 mg
labetalol hcl tab 200 mg
labetalol hcl tab 300 mg
metoprolol succinate tab sr 2
metoprolol succinate tab sr 2
metoprolol succinate tab sr 2
metoprolol succinate tab sr 2
metoprolol tartrate tab 100 m
metoprolol tartrate tab 25 mg
Requirements/ Limits
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
PA
PA
PA
PA
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
16
Formulary last updated date (11/01/2014)
Drug Name
metoprolol tartrate tab 50 mg
nadolol tab 20 mg
nadolol tab 40 mg
nadolol tab 80 mg
pindolol tab 10 mg
pindolol tab 5 mg
propranolol hcl cap sr 24hr 1
propranolol hcl cap sr 24hr 1
propranolol hcl cap sr 24hr 6
propranolol hcl cap sr 24hr 8
propranolol hcl oral soln 20
propranolol hcl oral soln 40
propranolol hcl tab 10 mg
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
propranolol hcl tab 60 mg
propranolol hcl tab 80 mg
sotalol hcl (afib/afl) tab 12
sotalol hcl (afib/afl) tab 16
sotalol hcl (afib/afl) tab 80
sotalol hcl tab 120 mg
sotalol hcl tab 160 mg
sotalol hcl tab 240 mg
sotalol hcl tab 80 mg
timolol maleate tab 10 mg
timolol maleate tab 20 mg
timolol maleate tab 5 mg
Calcium Channel Blocking Agents
amlodipine besylate tab 10 mg
amlodipine besylate tab 2.5 m
amlodipine besylate tab 5 mg
diltiazem hcl cap sr 12hr 120
diltiazem hcl cap sr 12hr 60
diltiazem hcl cap sr 12hr 90
diltiazem hcl cap sr 24hr 180
diltiazem hcl cap sr 24hr 240
diltiazem hcl coated beads ca
diltiazem hcl coated beads ca
diltiazem hcl coated beads ca
diltiazem hcl coated beads ca
diltiazem hcl coated beads ca
diltiazem hcl coated beads ta
diltiazem hcl coated beads ta
diltiazem hcl coated beads ta
diltiazem hcl coated beads ta
diltiazem hcl coated beads ta
diltiazem hcl extended releas
Requirements/ Limits
QL 30/30
QL 30/30
QL 30/30
QL 60/30
QL 60/30
QL 60/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
17
Formulary last updated date (11/01/2014)
Drug Name
diltiazem hcl tab 120 mg
diltiazem hcl tab 30 mg
diltiazem hcl tab 60 mg
diltiazem hcl tab 90 mg
felodipine tab sr 24hr 10 mg
felodipine tab sr 24hr 2.5 mg
felodipine tab sr 24hr 5 mg
nicardipine hcl cap 20 mg
nicardipine hcl cap 30 mg
nifedipine cap 10 mg
nifedipine cap 20 mg
nifedipine tab sr 24hr 30 mg
nifedipine tab sr 24hr 60 mg
nifedipine tab sr 24hr 90 mg
nifedipine tab sr 24hr osmoti
nifedipine tab sr 24hr osmoti
nifedipine tab sr 24hr osmoti
verapamil hcl cap sr 24hr 100
verapamil hcl cap sr 24hr 120
verapamil hcl cap sr 24hr 180
verapamil hcl cap sr 24hr 200
verapamil hcl cap sr 24hr 240
verapamil hcl cap sr 24hr 300
verapamil hcl cap sr 24hr 360
verapamil hcl tab 120 mg
verapamil hcl tab 40 mg
verapamil hcl tab 80 mg
verapamil hcl tab cr 120 mg
verapamil hcl tab cr 180 mg
verapamil hcl tab cr 240 mg
Cardiovascular Agents, Other
clonidine hcl tab 0.1 mg
clonidine hcl tab 0.2 mg
clonidine hcl tab 0.3 mg
digoxin tab 125 mcg (0.125 mg
digoxin tab 250 mcg (0.25 mg)
doxazosin mesylate tab 1 mg
doxazosin mesylate tab 2 mg
doxazosin mesylate tab 4 mg
doxazosin mesylate tab 8 mg
guanfacine hcl tab 1 mg
guanfacine hcl tab 2 mg
hydralazine hcl tab 10 mg
hydralazine hcl tab 100 mg
hydralazine hcl tab 25 mg
hydralazine hcl tab 50 mg
isosorbide dinitrate sl tab 2
Requirements/ Limits
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
18
Formulary last updated date (11/01/2014)
Drug Name
isosorbide dinitrate tab 10 m
isosorbide dinitrate tab 20 m
isosorbide dinitrate tab 30 m
isosorbide dinitrate tab 5 mg
isosorbide dinitrate tab cr 4
isosorbide mononitrate tab 20
isosorbide mononitrate tab sr
isosorbide mononitrate tab sr
isosorbide mononitrate tab sr
methyldopa tab 250 mg
methyldopa tab 500 mg
minoxidil tab 10 mg
minoxidil tab 2.5 mg
NITRO-BID OIN 2%
nitroglycerin cap cr 2.5 mg
nitroglycerin cap cr 6.5 mg
nitroglycerin cap cr 9 mg
nitroglycerin td patch 24hr 0
nitroglycerin td patch 24hr 0
nitroglycerin td patch 24hr 0
nitroglycerin td patch 24hr 0
NITROSTAT SUB 0.3MG
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG
pentoxifylline tab cr 400 mg
prazosin hcl cap 1 mg
prazosin hcl cap 2 mg
prazosin hcl cap 5 mg
terazosin hcl cap 1 mg
terazosin hcl cap 10 mg
terazosin hcl cap 2 mg
terazosin hcl cap 5 mg
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide cap sr 12hr 500
acetazolamide tab 125 mg
acetazolamide tab 250 mg
methazolamide tab 25 mg
methazolamide tab 50 mg
Diuretics, Loop
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
furosemide oral soln 10 mg/ml
furosemide tab 20 mg
furosemide tab 40 mg
furosemide tab 80 mg
torsemide tab 10 mg
Requirements/ Limits
QL 90/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
19
Formulary last updated date (11/01/2014)
Drug Name
torsemide tab 100 mg
torsemide tab 20 mg
torsemide tab 5 mg
Diuretics, Potassium-sparing
amiloride hcl tab 5 mg
spironolactone tab 100 mg
spironolactone tab 25 mg
spironolactone tab 50 mg
Diuretics, Thiazide
amiloride & hydrochlorothiazi
chlorothiazide tab 250 mg
chlorothiazide tab 500 mg
chlorthalidone tab 100 mg
chlorthalidone tab 25 mg
chlorthalidone tab 50 mg
DIURIL SUS 250/5ML
hydrochlorothiazide cap 12.5
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
methyclothiazide tab 5 mg
metolazone tab 10 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
spironolactone & hydrochlorot
triamterene & hydrochlorothia
triamterene & hydrochlorothia
triamterene & hydrochlorothia
triamterene & hydrochlorothia
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized cap 13
fenofibrate micronized cap 20
fenofibrate micronized cap 67
gemfibrozil tab 600 mg
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium tab 10 m
atorvastatin calcium tab 20 m
atorvastatin calcium tab 40 m
atorvastatin calcium tab 80 m
lovastatin tab 10 mg
lovastatin tab 20 mg
lovastatin tab 40 mg
pravastatin sodium tab 10 mg
pravastatin sodium tab 20 mg
pravastatin sodium tab 40 mg
pravastatin sodium tab 80 mg
Requirements/ Limits
QL 600/30 AL
QL 30/30
QL 30/30
QL 30/30
QL 30/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
20
Formulary last updated date (11/01/2014)
Drug Name
simvastatin tab 10 mg
simvastatin tab 20 mg
simvastatin tab 40 mg
simvastatin tab 5 mg
Dyslipidemics, Other
cholestyramine powder 4 gm/do
cholestyramine powder packets
colestipol hcl granule packet
colestipol hcl granules 5 gm
colestipol hcl tab 1 gm
fenofibrate tab 160mg
fenofibrate tab 54mg
NIACOR TAB 500MG
Requirements/ Limits
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
QL 30/30
CENTRAL NERVOUS SYSTEM AGENTS
Multiple Sclerosis Agents
AVONEX KIT 30MCG
avonex prefl kit 30mcg
COPAXONE KIT 20MG/ML
EXTAVIA INJ 0.3MG
PA
PA
PA
PA
DENTAL AND ORAL AGENTS
Dental and Oral Agents
anbesol liq 10%
BABY ORAJEL LIQ 7.5%
benzocaine dental cream 20%
benzocaine dental gel 10%
benzocaine dental gel 20%
benzocaine dental gel 7.5%
benzocaine dental liquid 20%
benzocaine dental paste 20%
benzocaine dental soln 20%
benzocaine dental swab 20%
benzodent oin 20%
chlorhexidine gluconate soln
clotrimazole troche 10 mg
lidocaine hcl laryngotracheal
lidocaine hcl viscous soln 2%
little teeth mis pain rel
nystatin susp 100000 unit/ml
ORA-FILM MIS 6%
oramagic pls sus 10%
pilocarpine hcl tab 5 mg
sodium fluoride cream 1.1%
stannous fluoride conc 0.63%
stannous fluoride gel 0.4%
toothache gum
triamcinolone acetonide denta
DERMATOLOGICAL AGENTS
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
21
Formulary last updated date (11/01/2014)
Drug Name
Dermatological Agents
ALneomycin-bacitracin-polymyxi
ALneomycin-bacitracin-polymyxi
ALnit remover - gelALALAL
ALnystatin topical powderALAL
A-200 GEL 0.33-4%
abreva cre 10%
ACETONE SOL
ACNE MEDICAT LOT 10%
acne medicat lot 5%
ACNOTEX LOT
ACTIPHYTE OF LIQ LEMONGRA
alclometasone dipropionate cr
alclometasone dipropionate oi
ALCOHOL ISOP SOL 50% WINT
alevazol oin 1%
AMMONIUM LAC SOL 70%
ANISE OIL
bacitracin oint 500 unit/gm
bacitracin zinc oint 500 unit
BARC LIQ
BENSULFOID CRE
BENZOYL PER GEL 2.5%
benzoyl peroxide cleanser 3.5
benzoyl peroxide cream 10%
benzoyl peroxide cream 2.5%
benzoyl peroxide creamy wash
benzoyl peroxide creamy wash
benzoyl peroxide gel 10%
benzoyl peroxide gel 4%
benzoyl peroxide gel 5%
benzoyl peroxide liq 10%
benzoyl peroxide liq 2.5%
benzoyl peroxide liq 5%
benzoyl peroxide lotion 6%
BENZOYL PEROXIDE LOTION 8%
BENZYL BENZO LIQ
betamethasone dipropionate au
betamethasone dipropionate cr
betamethasone dipropionate lo
betamethasone dipropionate oi
betamethasone valerate cream
betamethasone valerate lotion
betamethasone valerate oint 0
BP CLEANSING LOT 4%
BRASIVOL PST
CAMPHOR SOL SPIRITS
Requirements/ Limits
QL 100/30
QL 90/30
QL 120/30
QL 90/30
QL 90/30
QL 120/30
QL 90/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
22
Formulary last updated date (11/01/2014)
Drug Name
CAPSAGEL GEL 0.025%
CAPSAGEL MS GEL 0.075%
CAPSAGEL XS GEL 0.05%
capsaicin cream 0.025%
capsaicin cream 0.075%
capsaicin cream 0.1%
CAPZASIN LIQ 0.15%
castiva lot
CASTOR OIL
CEDAR LEAF OIL
CELERY SEED OIL
CHLORHEXIDIN SOL GLUCONAT
CHLOROFORM SOL
ciclopirox solution 8%
CINNAMON OIL ARTIFIC
CITRONELLA OIL
clean&clear kit acne
clindamycin phosphate lotion
clindamycin phosphate soln 1%
clindamycin phosphate swab 1%
clobetasol propionate cream 0
clobetasol propionate oint 0.
clobetasol propionate soln 0.
clotrimazole cream 1%
clotrimazole soln 1%
clotrimazole w/ betamethasone
clotrimazole w/ betamethasone
CLOVE OIL
cortisporin oin 1%
cortizone-10 liq /aloe 1%
COTTONSEED OIL
DENATURED SOL ALCOHOL
denorex dual sha 1%-3%
DERMA-SMOOTH OIL /FS BODY
DERMA-SMOOTH OIL /FS SCLP
desonide oint 0.05%
DIFLORASONE DIACETATE OINT 0.
DIMETHYL SOL SULFOXID
econazole nitrate cream 1%
EFFACLAR DUO SOL 5.5%
erythromycin gel 2%
erythromycin soln 2%
ETHER SOL
ETHYL ALCOHO SOL 70%
ETHYL ALCOHO SOL 95%
ethyl chlor aer mist
EUCALYPTUS OIL
Requirements/ Limits
QL 6.6/30
QL 120/30
QL 120/30
QL 100/30
QL 90/24
QL 60/24
QL 36/30
QL 120/30
QL 120/30
QL 120/30
QL 120/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
23
Formulary last updated date (11/01/2014)
Drug Name
EUGENOL SOL
EURAX CRE 10%
EURAX LOT 10%
exoderm bar
fleet naturl ene cleansng
fluocinolone acetonide cream
fluocinolone acetonide cream
fluocinolone acetonide oint 0
fluocinonide cream 0.05%
fluocinonide emulsified base
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
fluorouracil cream 5%
fluorouracil soln 2%
fluorouracil soln 5%
fluticasone propionate cream
fluticasone propionate oint 0
gentamicin sulfate cream 0.1%
gentamicin sulfate oint 0.1%
GLYCERIN LIQ
GLYCERIN SOL SYNTHETC
GLYCINE SOYA SOL EXTRACT
GLYCINE SOYA SOL PROTEIN
GNP ALCOHOL SOL DENATURE
grandpas bar thylox
GUAIACOL SOL
halobetasol propionate cream
halobetasol propionate oint 0
HC DERMAPAX SPR 0.5-0.5%
hc-1% hemorr oin 1%
hydrocort ac cre 0.5%
hydrocortisone acetate cream
hydrocortisone acetate suppos
hydrocortisone acetate suppos
hydrocortisone cream 0.5%
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone enema 100 mg/6
hydrocortisone gel 1%
hydrocortisone lotion 1%
hydrocortisone lotion 2.5%
hydrocortisone oint 0.5%
hydrocortisone oint 1%
hydrocortisone oint 2.5%
hydrocortisone rectal cream 1
hydrocortisone rectal cream 2
Requirements/ Limits
QL 120/365
QL 120/365
QL 120/30
QL 120/30
QL 120/30
QL 120/30
QL 120/30
QL 120/30
QL 120/30
QL 120/30
QL 120/30
QL 120/30
QL 100/30
QL 100/30
QL 60/30
QL 120/30
QL 60/30
QL 28/14
QL 28/14
QL 60/30
QL 120/30
QL 90/30
QL 60/30
QL 240/30
QL 120/30
QL 60/30
QL 60/30
QL 90/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
24
Formulary last updated date (11/01/2014)
Drug Name
hydrocortisone soln 1%
hydrocortisone valerate cream
hydrocortisone valerate oint
hydrocortisone-aloe vera crea
hydrocortisone-aloe vera crea
IONIL SHA
IPECAC SYP
ISOP ALCOHOL SOL 50%
ISOP ALCOHOL SOL 70% WG
ISOP ALCOHOL SOL 91%
isop alcohol sol 99%
ISOPROPYL ALCOHOL, RUBBING 70
ISOPROPYL LIQ PALMITAT
JUNIPER TAR OIL
ketoconazole cream 2%
ketoconazole shampoo 2%
lactic acid (ammonium lactate
lactic acid (ammonium lactate
lactic acid (ammonium lactate
lactic acid (ammonium lactate
lactic acid w/ vitamin e crea
LAVENDER OIL
LEMON OIL
LICE B GONE KIT
LICE B GONE SHA
lidocaine hcl gel 2%
lidocaine hcl soln 4%
lidocaine oint 5%
lidocaine-prilocaine cream 2.
LIME OIL
lindane lotion 1%
lindane shampoo 1%
LINSEED OIL RAW
LIQUIMAT LOT 5%
MACADAMIA OIL NUT OIL
malathion lotion 0.5%
METHANOL SOL 99%
metronidazole cream 0.75%
metronidazole gel 0.75%
metronidazole lotion 0.75%
miconazole nitrate aerosol 2%
miconazole nitrate aerosol po
miconazole nitrate cream 2%
miconazole nitrate ointment 2
miconazole nitrate powder 2%
MIRANEL AF SOL 2%
mometasone furoate cream 0.1%
Requirements/ Limits
QL 90/30
QL 120/30
QL 120/30
QL 90/30
QL 90/30
QL 107/30
QL 30/30
ST
QL 60/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
25
Formulary last updated date (11/01/2014)
Drug Name
mometasone furoate oint 0.1%
mometasone furoate solution 0
mupirocin calcium cream 2%
mupirocin oint 2%
NEOSPORIN KIT TRIAL
NIAOULI OIL
noble mystiq cre emu-lac
nuox gel 6-3%
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
nystatin-triamcinolone cream
nystatin-triamcinolone oint 1
OC8 GEL 7%
OIL-ALMOND OIL SWEET
OIL-COCONUT OIL
OLIVE OIL
ORANGE OIL
panoxyl-4 liq crem wsh
panoxyl-8 liq crem wsh
PEANUT OIL
PEPPERMINT OIL
PEPPERMINT SOL SPIRIT
permethrin aerosol 0.5%
permethrin cream 5%
permethrin creme rinse 1%
permethrin lotion 1%
permethrin spray & pyrethinsphisohex liq 3%
pin-x sus 50
PINE OIL
PINE TAR LIQ
plexion liq 9.8-4.8%
podofilox soln 0.5%
POLYSORBATE LIQ 60
POLYSORBATE LIQ 80
POLYSORBATE SOL 20
POLYSORBATE SOL 40
povidone-iodine soln 10%
pramosone cre 1%
prednicarbate oint 0.1%
PRETZ SOL
pro:12 aer mousse
pronto aer 0.4%
pyre/piperon liq
pyreth-piperonyl butox sham-p
pyrethrins-piperonyl butoxide
pyrethrins-piperonyl butoxide
Requirements/ Limits
QL 60/30
QL 60/30
ST
QL 30/30
QL 60/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
26
Formulary last updated date (11/01/2014)
Drug Name
pyrethrins-piperonyl butoxide
pyrethrins-piperonyl butoxide
RA ACNE MAX PAD 2%
RA LOT
REZAMID LOT
ROSE OIL
ROSEMARY OIL
RUB ALCOHOL SOL 70% ETHY
SAFFLOWER OIL
salicylic acid & sulfur shamp
SANTYL
OIN 250U/GM
SASSAFRAS OIL
SASTID BAR 3-5%
SCHOOLTIME SHA
SEBASORB LOT
selenium sulfide lotion 2.5%
SESAME OIL
silver sulfadiazine cream 1%
SOD SILICATE SOL
SOD SILICATE SOL 40%
SOYBEAN OIL
SPEARMINT OIL
starch suppositories 51%
STEP 2 SOL 8%
sulf lime sol
sulfacetamide sodium lotion 1
sulfacetamide sodium w/ sulfu
sulfacetamide sodium w/ sulfu
sulfacetamide sodium w/ sulfu
sulfacetamide sodium w/ sulfu
sulfacetamide sodium w/ sulfu
sulfacetamide sodium-sulfur i
SULFOAM SHA 2%
SULFUR BAR 10%
sulfur bar 5%
TANGERINE OIL
TEGRIN-LT KIT
terbinafine hcl cream 1%
tretinoin cream 0.025%
tretinoin cream 0.05%
tretinoin cream 0.1%
tretinoin gel 0.01%
tretinoin gel 0.025%
triamcinolone acetonide cream
triamcinolone acetonide cream
triamcinolone acetonide cream
triamcinolone acetonide lotio
Requirements/ Limits
QL 45/30 AL
QL 45/30 AL
QL 45/30 AL
QL 45/30 AL
QL 45/30 AL
QL 160/30
QL 160/30
QL 60/30
QL 120/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
27
Formulary last updated date (11/01/2014)
Drug Name
triamcinolone acetonide lotio
triamcinolone acetonide oint
triamcinolone acetonide oint
triamcinolone acetonide oint
trypsin w/ castor oil & peruv
trypsin w/ castor oil & peruv
TURPENTINE LIQ SPIRITS
TURPENTINE OIL
UNDECYLENIC LIQ ACID
urea cream 40%
zeasorb-af lot 2%
ZOSTRIX-HP MIS 0.075%
Requirements/ Limits
QL 120/30
QL 160/30
QL 160/30
QL 60/30
QL 60/30
QL 60/30
GASTROINTESTINAL AGENTS
Antispasmodics, Gastrointestinal
belladonna alkaloids-phenobar
clidinium & chlordiazepoxide
dicyclomine hcl cap 10 mg
dicyclomine hcl tab 20 mg
glycopyrrolate tab 1 mg
glycopyrrolate tab 2 mg
hyoscyamine sulfate elixir 0.
hyoscyamine sulfate soln 0.12
hyoscyamine sulfate tab 0.125
hyoscyamine sulfate tab disp
hyoscyamine sulfate tab sl 0.
hyoscyamine sulfate tab sr 12
propantheline bromide tab 15
Digestive Enzymes
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 3000UNIT
CREON CAP 36000UNT
CREON CAP 6000UNIT
PANCREAZE CAP 10500UNT
PANCREAZE CAP 16800UNT
PANCREAZE CAP 21000UNT
PANCREAZE CAP 4200UNIT
PANCRELIPASE CAP 5000UNIT
PERTZYE CAP
PERTZYE CAP
ULTRESA CAP 13800UNT
ULTRESA CAP 20700UNT
ULTRESA CAP 23000UNT
VIOKACE TAB
VIOKACE TAB
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
28
Formulary last updated date (11/01/2014)
Drug Name
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 3000UNIT
Gastrointestinal Agents, Other
ALlactobacillus acidophilus-pe
ACIDOPHILUS/ TAB CIT PECT
AGORAL LIQ MAX ST
ALAMAG CHW 300-150
ALKA SELTZER TAB HEARTBRN
alum & mag hydroxide-simethic
alum & mag hydroxide-simethic
alum & mag hydroxide-simethic
aluminum hydroxide-magnesium
aluminum hydroxide-magnesium
aluminum hydroxide-magnesium
ANTACID CHW
benzocaine-docusate sodium re
BICARSIM TAB 125MG
BICARSIM TAB 80MG
bisacodyl suppos 10 mg
bisacodyl tab delayed release
bismuth subsalicylate chew ta
bismuth subsalicylate susp 26
bismuth subsalicylate susp 52
bismuth subsalicylate tab 262
cal carb & mag hydrox-simethi
CALCIUM CARB TAB 648MG
calcium carbonate (antacid) c
calcium carbonate (antacid) c
calcium carbonate (antacid) c
calcium carbonate (antacid) c
calcium carbonate (antacid) c
calcium carbonate (antacid) c
calcium carbonate-mag hydroxi
calcium carbonate-mag hydroxi
calcium carbonate-mag hydroxi
calcium carbonate-mag hydroxi
calcium carbonate-simethicone
calcium polycarbophil tab 625
CITROCARBONA GRA
clearlax pow
clearlax pow
clearlax pow
CLEARLAX POW
CORRECTOL MIS HERBAL
CULTURELLE CAP
CULTURELLE CHW DI
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
29
Formulary last updated date (11/01/2014)
Drug Name
cvs purelax pow
cvs purelax pow
DEWEES CARMI LIQ
DI-GEL CHW
DI-GEL SUS
diphenoxylate w/ atropine liq
diphenoxylate w/ atropine tab
docusate calcium cap 240 mg
docusate sodium cap 100 mg
docusate sodium cap 250 mg
docusate sodium cap 50 mg
docusate sodium enema 283 mg
docusate sodium liquid 150 mg
docusate sodium syrup 60 mg/1
docusate sodium tab 100 mg
DOCUSOL KIDS ENE 100MG/5M
DULCOLAX KIT BOWEL
dulcolax pow balance
E-Z-GAS II GRA
eq clearlax pow
eql clearlax pow
EQL NATURAL POW FIBER
EQUALACTIN CHW 625MG
EVAC-U-GEN CHW 10MG
FLEET BISACO ENE 10/30ML
GAS-X CHILD MIS 40MG
GAS-X EX-STR MIS 62.5MG
GAS-X/MAALOX CHW EXTRA ST
gavilax pow
gentlelax pow
glycerin suppos 1 gm
glycerin suppos 1.2 gm
glycerin suppos 1.5 gm
glycerin suppos 2 gm
glycerin suppos 2.1 gm
glycerin suppos 80.7%
glycolax pow 3350 nf
gnp clearlax pow
hm clearlax pow
HYDROCIL INS POW 95%
IMODIUM A-D CHW 2MG
KONSYL POW 100%
KONSYL POW 28.3%
KONSYL POW 60.3%
KONSYL POW 60.3%
KONSYL POW 71.67%
KONSYL-D POW 52.3%
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
30
Formulary last updated date (11/01/2014)
Drug Name
lactulose solution 10 gm/15ml
laxaclear pow
LITTLE TUMMY DRO LAXATIVE
loperamide hcl cap 2 mg
loperamide hcl liq 1 mg/5ml (
loperamide hcl liq 1 mg/7.5ml
loperamide hcl tab 2 mg
MAALOX JR CHW /ANTIGAS
MAALOX TC SUS
MAG OXIDE CAP 400MG
MAG-AL LIQ
MAGN OXIDE POW HEAVY
magnesium citrate soln
magnesium oxide tab 250 mg
magnesium oxide tab 400 mg
magnesium oxide tab 420 mg
METAMUCIL POW 28%
METAMUCIL POW 63%
METAMUCIL WAF
methylcellulose powder laxati
metoclopramide hcl soln 5 mg/
metoclopramide hcl tab 10 mg
metoclopramide hcl tab 5 mg
MYLANTA SUS ULTIMATE
MYLANTA TAB
NAT FIBER POW 58.6%
NAT SENNA TAB LAXATIVE
natura-lax pow 3350 nf
OPIUM TINCT TIN 2MG/5ML
PEDIA-LAX LIQ 50MG
PEDIA-LAX SUP 2.8GM
peg 3350 pow
peg 3350-kcl-na bicarb-nacl-n
peg 3350-kcl-na bicarb-nacl-n
polyeth glyc pow 3350 nf
polyeth glyc pow 3350 nf
polyeth glyc pow 3350 nf
polyeth glyc pow 3350 nf
polyeth glyc pow 3350 nf
polyeth glyc pow 3350 nf
POLYETH GLYC POW 3350 NF
polyeth glyc pow 3350-grx
powderlax pow
PROBIOTIC W/ CAP PREBIOTI
psyllium cap 0.52 gm
psyllium powder 100%
psyllium powder 28.3%
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
31
Formulary last updated date (11/01/2014)
Drug Name
psyllium powder 30%
psyllium powder 30.9%
psyllium powder 33%
psyllium powder 48.57%
psyllium powder 55.46%
psyllium powder 58.6%
psyllium powder 68%
psyllium powder 95%
ra laxative pow
RA LAXATIVE POW
RI-MAG PLUS SUS
ROLAIDS CHW EX ST
SB NAT FIBER POW 49%
SENNA LEAVES MIS
SENNA SYP
SENNA TAB 187MG
sennosides cap 8.6 mg
sennosides chew tab 15 mg
sennosides syrup 8.8 mg/5ml
sennosides tab 15 mg
sennosides tab 17.2 mg
sennosides tab 25 mg
sennosides tab 8.6 mg
sennosides-docusate sodium ta
simethicone cap 125 mg
simethicone cap 180 mg
simethicone chew tab 125 mg
simethicone chew tab 80 mg
simethicone liquid 40 mg/0.6m
simethicone susp 40 mg/0.6ml
sm clearlax pow
smooth lax pow
sodium bicarbonate tab 325 mg
sodium bicarbonate tab 650 mg
SODIUM POW BICARBON
sucralfate tab 1 gm
sw clearlax pow
TITRALAC CHW PLUS
URO-MAG CAP 140MG
ursodiol cap 300 mg
Histamine2 (H2) Receptor Antagonists
cimetidine hcl soln 300 mg/5m
cimetidine tab 200 mg
cimetidine tab 300 mg
cimetidine tab 400 mg
cimetidine tab 800 mg
famotidine inj 20 mg/2ml
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
32
Formulary last updated date (11/01/2014)
Drug Name
famotidine inj 200 mg/20ml
FAMOTIDINE INJ 20MG/50M
famotidine inj 40 mg/4ml
famotidine inj 500 mg/50ml
famotidine tab 10 mg
famotidine tab 20 mg
famotidine tab 40 mg
misoprostol tab 100 mcg
misoprostol tab 200 mcg
PEPCID AC CHW 10MG
PEPCID AC CHW MAX ST
ranitidine hcl syrup 15 mg/ml
ranitidine tab 150mg
ranitidine tab 300mg
Proton Pump Inhibitors
heartburn tr cap 15mg
hrtbrn rel cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
lansoprazole cap 15mg dr
LANSOPRAZOLE SUS 3MG/ML
NEXIUM 24HR CAP 20MG
omepra/bicar cap 20-1100
omepra/bicar cap 20-1100
omepra/bicar cap 20-1100
omepra/bicar cap 20-1100
omepra/bicar cap 20-1100
omepra/bicar cap 20-1100
omepra/bicar cap 20-1100
omepra/bicar cap 20-1100
omeprazole cap delayed releas
omeprazole cap delayed releas
pantoprazole sodium ec tab 20
pantoprazole sodium ec tab 40
PRILOSEC OTC TAB 20MG
Requirements/ Limits
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 150/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 60/30
QL 30/30
QL 30/30
QL 60/30
QL 60/30
GENITOURINARY AGENTS
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
33
Formulary last updated date (11/01/2014)
Drug Name
Antispasmodics, Urinary
bethanechol chloride tab 10 m
bethanechol chloride tab 25 m
bethanechol chloride tab 5 mg
bethanechol chloride tab 50 m
ENABLEX TAB 15MG
ENABLEX TAB 7.5MG
oxybutynin chloride syrup 5 m
oxybutynin chloride tab 5 mg
oxybutynin chloride tab sr 24
oxybutynin chloride tab sr 24
oxybutynin chloride tab sr 24
OXYTROL/WOMN DIS 3.9MG/24
tolterodine tartrate cap sr 2
tolterodine tartrate cap sr 2
tolterodine tartrate tab 1 mg
tolterodine tartrate tab 2 mg
trospium chloride tab 20 mg
VESICARE TAB 10MG
VESICARE TAB 5MG
Benign Prostatic Hypertrophy Agents
finasteride tab 5 mg
tamsulosin hcl cap 0.4 mg
Genitourinary Agents, Other
methylergonovine maleate tab
Phosphate Binders
calcium acetate (phosphate bi
calcium acetate (phosphate bi
RENAGEL TAB 400MG
RENAGEL TAB 800MG
sevelamer carbonate tab 800 m
Vaginal Products
CLEOCIN SUP 100MG
clindamycin phosphate vaginal
clotrimazole vaginal cream 1%
clotrimazole vaginal cream 2%
ESTRACE VAG CRE 0.1MG/GM
GYNAZOLE-1 CRE 2%
metronidazole vaginal gel 0.7
miconazole nitrate vaginal cr
miconazole nitrate vaginal su
miconazole nitrate vaginal su
miconazole nitrate vaginal su
NONOXYNOL-9 GEL 2%
NONOXYNOL-9 GEL 3%
nystatin vaginal tab 100000 u
PROGESTERONE SUP VGS 100
Requirements/ Limits
ST
ST
ST
ST
ST
QL 8/30
ST
ST
ST
ST
ST
ST
ST
QL 60/30
QL 28/365
PA
PA
PA
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
34
Formulary last updated date (11/01/2014)
Drug Name
PROGESTERONE SUP VGS 200
PROGESTERONE SUP VGS 25
PROGESTERONE SUP VGS 400
PROGESTERONE SUP VGS 50
terconazole vaginal cream 0.4
terconazole vaginal cream 0.8
terconazole vaginal suppos 80
Requirements/ Limits
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)
Glucocorticoids/Mineralocorticoids
cortisone acetate tab 25 mg
dexamethasone conc 1 mg/ml
dexamethasone elixir 0.5 mg/5
dexamethasone soln 0.5 mg/5ml
dexamethasone tab 0.5 mg
dexamethasone tab 0.75 mg
dexamethasone tab 1.5 mg
dexamethasone tab 2 mg
dexamethasone tab 4 mg
dexamethasone tab 6 mg
DEXPAK PAK 10 DAY
fludrocortisone acetate tab 0
hydrocortisone tab 10 mg
hydrocortisone tab 20 mg
hydrocortisone tab 5 mg
methylprednisolone tab 4 mg
methylprednisolone tab 4 mg d
methylprednisolone tab 8 mg
prednisolone sod phosphate or
prednisolone syrup 15 mg/5ml
prednisone oral soln 5 mg/5ml
prednisone tab 1 mg
prednisone tab 10 mg
prednisone tab 10 mg dose pac
prednisone tab 2.5 mg
prednisone tab 20 mg
prednisone tab 5 mg
prednisone tab 5 mg dose pack
prednisone tab 50 mg
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/
MODIFIERS)
Androgens
PA GR
testosterone cypionate im in
testosterone cypionate im in
PA GR
Contraceptives
ALORA DIS 0.025MG
QL 8/28 GR
ALORA DIS 0.05MG
QL 8/28 GR
ALORA DIS 0.075MG
QL 8/28 GR
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
35
Formulary last updated date (11/01/2014)
Drug Name
ALORA DIS 0.1MG
altavera
altavera
altavera
alyacen 1/35
apri
aubra
aubra
aviane
camila
caziant
cesia
chateal
chateal
chateal
CYCLAFEM 1/35
CYCLAFEM 1/35
cyclafem 7/7/7
cyclafem 7/7/7
dasetta 1/35
dasetta 1/35
dasetta 7/7/7
delyla
desogestrel/ethinyl estradiol
emoquette
emoquette
enpresse-28
enpresse-28
enpresse-28
enskyce
enskyce
errin
estradiol & norethindrone ace
estradiol & norethindrone ace
falmina
falmina
falmina
gildess 1.5/30
gildess 1.5/30
gildess 1.5/30
gildess 1/20
gildess 1/20
gildess 1/20
gildess fe 1.5/30
gildess fe 1/20
heather
introvale
Requirements/ Limits
QL 8/28 GR
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 28/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 28/23 GR
QL 28/23 GR
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 21/28
QL 21/28
QL 21/28
QL 21/28
QL 21/28
QL 21/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 91/91
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
36
Formulary last updated date (11/01/2014)
Drug Name
introvale
jencycla
jencycla
jolessa
jolivette
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
kurvelo
kurvelo
larin 1.5/30
larin 1.5/30
larin 1/20
larin 1/20
larin fe 1.5/30
larin fe 1.5/30
larin fe 1/20
larin fe 1/20
lessina
levonest
levonest
levonorgestrel tab 0.75 mg
levonorgestrel tab 1.5 mg
levonorgestrel/ethinyl estrad
levonorgestrel/ethinyl estrad
levonorgestrel/ethinyl estrad
levonorgestrel/ethinyl estrad
levonorgestrel/ethinyl estrad
levonorgestrel/ethinyl estrad
levora 0.15/30-28
lutera
lyza
marlissa
marlissa
medroxyprogesterone acetate i
microgestin tab 1/20
microgestin tab fe 1/20
microgestin 1.5/30
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
myzilra
myzilra
necon 0.5/35-28
necon 1/35
Requirements/ Limits
QL 91/91
QL 37.5/28
QL 37.5/28
QL 91/91
QL 37.5/28
QL 21/28
QL 21/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 21/28
QL 21/28
QL 21/28
QL 21/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 2/30 GR
QL 2/30 GR
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 91/91
QL 91/91
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 1/90 GR
QL 37.5/28
QL 21/28
QL 21/28
QL 21/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
37
Formulary last updated date (11/01/2014)
Drug Name
necon 1/50-28
necon 10/11-28
nora-be
norethindrone
norethindrone
norethindrone
norethindrone
norethindrone
norethindrone
norethindrone
norethindrone
norethindrone
norethindrone acetate/ethinyl
norethindrone acetate/ethinyl
nortrel 0.5/35
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 1/35
nortrel 1/35
nortrel 7/7/7
orsythia
orsythia
pirmella 1/35
pirmella 1/35
portia-28
quasense
solia
sronyx
trivora-28
velivet
velivet
wera
wera
ZOVIA 1/50E
Estrogens
esterified estrogens & methyl
esterified estrogens & methyl
estradiol tab 0.5 mg
estradiol tab 1 mg
estradiol tab 2 mg
estradiol td patch weekly 0.0
estradiol td patch weekly 0.0
estradiol td patch weekly 0.0
estradiol td patch weekly 0.0
estradiol td patch weekly 0.0
estradiol td patch weekly 0.1
estropipate tab 0.75 mg
Requirements/ Limits
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 21/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 21/28
QL 21/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 91/91
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 37.5/28
QL 21/28 GR
QL 21/28 GR
GR
GR
GR
QL 4/21 GR
QL 4/21 GR
QL 4/21 GR
QL 4/21 GR
QL 4/21 GR
QL 4/21 GR
QL 21/28 GR
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
38
Formulary last updated date (11/01/2014)
Drug Name
estropipate tab 1.5 mg
estropipate tab 3 mg
FEMHRT TAB 0.5-2.5
MENEST TAB 0.3MG
MENEST TAB 0.625MG
MENEST TAB 1.25MG
MENEST TAB 2.5MG
norethindrone acetate-ethinyl
PREMARIN TAB 0.3MG
PREMARIN TAB 0.45MG
PREMARIN TAB 0.625MG
PREMARIN TAB 0.9MG
PREMARIN TAB 1.25MG
PREMPHASE TAB
PREMPRO TAB .625-2.5
PREMPRO TAB 0.3-1.5
PREMPRO TAB 0.45-1.5
PREMPRO TAB 0.625-5
Progestins
medroxyprogesterone acetate t
medroxyprogesterone acetate t
medroxyprogesterone acetate t
norethindrone acetate tab 5 m
Requirements/ Limits
QL 21/28 GR
QL 21/28 GR
QL 28/28 GR
GR
GR
GR
GR
QL 21/28 GR
QL 30/30 GR
QL 30/30 GR
QL 30/30 GR
QL 30/30 GR
QL 30/30 GR
QL 30/30 GR
QL 30/30 GR
QL 30/30 GR
QL 30/30 GR
QL 30/30 GR
QL 28/28 GR
QL 120/30 GR
QL 30/30 GR
QL 60/30 GR
HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY)
Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)
desmopressin acetate nasal sp
desmopressin acetate nasal sp
desmopressin acetate tab 0.1
desmopressin acetate tab 0.2
HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID)
Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)
ARMOUR THYRO TAB 120MG
ARMOUR THYRO TAB 15MG
ARMOUR THYRO TAB 180MG
ARMOUR THYRO TAB 240MG
ARMOUR THYRO TAB 300MG
levothyroxin tab 100mcg
levothyroxin tab 100mcg
levothyroxin tab 100mcg
levothyroxin tab 100mcg
levothyroxin tab 112mcg
levothyroxin tab 112mcg
levothyroxin tab 112mcg
levothyroxin tab 112mcg
levothyroxin tab 125mcg
levothyroxin tab 125mcg
levothyroxin tab 125mcg
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
39
Formulary last updated date (11/01/2014)
Drug Name
levothyroxin tab 125mcg
levothyroxin tab 137mcg
levothyroxin tab 137mcg
levothyroxin tab 137mcg
levothyroxin tab 150mcg
levothyroxin tab 150mcg
levothyroxin tab 150mcg
levothyroxin tab 150mcg
levothyroxin tab 175mcg
levothyroxin tab 175mcg
levothyroxin tab 175mcg
levothyroxin tab 200mcg
levothyroxin tab 200mcg
levothyroxin tab 200mcg
levothyroxin tab 25mcg
levothyroxin tab 25mcg
levothyroxin tab 25mcg
levothyroxin tab 25mcg
levothyroxin tab 300mcg
levothyroxin tab 300mcg
levothyroxin tab 300mcg
levothyroxin tab 50mcg
levothyroxin tab 50mcg
levothyroxin tab 50mcg
levothyroxin tab 50mcg
levothyroxin tab 75mcg
levothyroxin tab 75mcg
levothyroxin tab 75mcg
levothyroxin tab 75mcg
levothyroxin tab 88mcg
levothyroxin tab 88mcg
levothyroxin tab 88mcg
levoxyl tab 100mcg
levoxyl tab 112mcg
levoxyl tab 125mcg
levoxyl tab 137mcg
levoxyl tab 150mcg
levoxyl tab 175mcg
levoxyl tab 200mcg
levoxyl tab 25mcg
levoxyl tab 50mcg
levoxyl tab 75mcg
levoxyl tab 88mcg
NATURE-THROI TAB 130MG
NATURE-THROI TAB 195MG
NATURE-THROI TAB 260MG
NATURE-THROI TAB 32.5MG
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
40
Formulary last updated date (11/01/2014)
Drug Name
NATURE-THROI TAB 325MG
NATURE-THROI TAB 48.75MG
NATURE-THROI TAB 65MG
NATURE-THROI TAB 97.5MG
thyroid tab 16.25 mg
thyroid tab 30 mg (1/2 grain)
thyroid tab 60 mg (1 grain)
thyroid tab 90 mg (1 1/2 grai
unithroid tab 100mcg
unithroid tab 100mcg
unithroid tab 112mcg
unithroid tab 112mcg
unithroid tab 125mcg
unithroid tab 125mcg
unithroid tab 137mcg
unithroid tab 150mcg
unithroid tab 150mcg
unithroid tab 175mcg
unithroid tab 175mcg
unithroid tab 200mcg
unithroid tab 200mcg
unithroid tab 25mcg
unithroid tab 25mcg
unithroid tab 300mcg
unithroid tab 300mcg
unithroid tab 50mcg
unithroid tab 50mcg
unithroid tab 75mcg
unithroid tab 75mcg
unithroid tab 88mcg
unithroid tab 88mcg
Requirements/ Limits
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
Hormonal Agents, Suppressant (Pituitary)
LUPR DEP-PED INJ 11.25MG
LUPR DEP-PED INJ 15MG
LUPR DEP-PED INJ 7.5MG
PA
PA
PA
HORMONAL AGENTS, SUPPRESSANT (THYROID)
Antithyroid Agents
methimazole tab 10 mg
methimazole tab 5 mg
propylthiouracil tab 50 mg
IMMUNOLOGICAL AGENTS
Immune Suppressants
azathioprine tab 50 mg
cellcept sus 200mg/ml
PA
cyclosporine cap 100 mg
cyclosporine cap 25 mg
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
41
Formulary last updated date (11/01/2014)
Drug Name
cyclosporine modified cap 100
cyclosporine modified cap 25
cyclosporine modified cap 50
cyclosporine modified oral so
leflunomide tab 10 mg
leflunomide tab 20 mg
mycophenolate mofetil cap 250
mycophenolate mofetil tab 500
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
Immunizing Agents, Passive
RHOGAM PLUS INJ 300MCG
SYNAGIS INJ 100MG/ML
SYNAGIS INJ 50MG
Vaccines
ZOSTAVAX INJ
Requirements/ Limits
PA
PA
AL
INFLAMMATORY BOWEL DISEASE AGENTS
Aminosalicylates
APRISO CAP 0.375GM
balsalazide disodium cap 750
DELZICOL CAP 400MG
mesalamine enema 4 gm
SFROWASA ENE 4GM
Sulfonamides
sulfasalazine tab 500 mg
sulfasalazine tab delayed rel
QL 120/30
QL 180/30
QL 180/30
QL 180/30
METABOLIC BONE DISEASE AGENTS
Metabolic Bone Disease Agents
alendronate sodium tab 10 mg
alendronate sodium tab 35 mg
alendronate sodium tab 40 mg
alendronate sodium tab 5 mg
alendronate sodium tab 70 mg
calcitonin (salmon) nasal sol
QL 4/28
MISCELLANEOUS
Miscellaneous
QL 12/30
ALCONDOMS - MALEALALAL
ALoral vehiclesALALAL
ALsodium polystyrene sulfonate
1 ML SYRIMGE MIS 18GX1"
QL 100/30
1 ML SYRINGE MIS 22X1-1/2
QL 100/30
1ML SYR/NEED MIS 26GX5/8"
QL 100/30
1ML SYRINGE MIS 23GX1"
QL 100/30
1ML SYRINGE MIS 25GX1"
QL 100/30
1ML SYRINGE MIS 25GX5/8"
QL 100/30
1ML SYRINGE MIS 26GX3/8"
QL 100/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
42
Formulary last updated date (11/01/2014)
Drug Name
ADRENACLICK INJ 0.3MG
AKRAY EXPRESSION TEST STRIPS
ARKRAY GLUCOCARD VITAL TEST S
AUTOSHIELD MIS 29X3/16"
AUTOSHIELD MIS 29X5/16"
AUTOSHIELD MIS 30GX3/16
GR SAF-T-INT KIT 24GX0.75
chemet cap 100mg
cherry syp
CONDOMS LATEX LUBRICATED
CONDOMS LATEX NON-LUBRICA
CONDOMS NON-LATEX NON-LUB
CONTOUR NEXT TEST STRIPS, BOX
CONTROL SOLUTION, ARKRAY EXPR
CONTROL SOLUTION, ARKRAY GLUC
CONTROL SOLUTION, FREESTYLE
CONTROL SOLUTION, ONE TOUCH U
CONTROL SOLUTION, SD GLUCONAV
CONTROL SOLUTION, SD GLUCONAV
CURITY PREP PAD ALCOHOL
epinephrine inj 0.3mg
EPINEPHRINE INJ 0.3MG
EPIPEN 2-PAK INJ 0.3MG
EPIPEN-JR INJ 0.15MG
HUMAPEN MIS MEMOIR
HUMATROPEN MIS FOR 6MG
INSUFLON MIS 25GX0.71
INSULIN SYRG MIS 0.3/28G
INSULIN SYRG MIS 0.3/29G
INSULIN SYRG MIS 0.3/29G
INSULIN SYRG MIS 0.3/29G
INSULIN SYRG MIS 0.3/29G
INSULIN SYRG MIS 0.3/30G
INSULIN SYRG MIS 0.3/30G
INSULIN SYRG MIS 0.3/30G
insulin syrg mis 0.3/30g
INSULIN SYRG MIS 0.3/30G
INSULIN SYRG MIS 0.3/31G
INSULIN SYRG MIS 0.3/31G
INSULIN SYRG MIS 0.5/27G
insulin syrg mis 0.5/28g
INSULIN SYRG MIS 0.5/29G
INSULIN SYRG MIS 0.5/29G
INSULIN SYRG MIS 0.5/29G
INSULIN SYRG MIS 0.5/29G
INSULIN SYRG MIS 0.5/29G
INSULIN SYRG MIS 0.5/30G
Requirements/ Limits
QL 2/90
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 12/30
QL 12/30
QL 12/30
QL 2/90
QL 2/90
QL 2/90
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
43
Formulary last updated date (11/01/2014)
Drug Name
INSULIN SYRG MIS 0.5/30G
insulin syrg mis 0.5/30g
INSULIN SYRG MIS 0.5/30G
INSULIN SYRG MIS 0.5/30G
INSULIN SYRG MIS 0.5/31G
INSULIN SYRG MIS 0.5/31G
INSULIN SYRG MIS 1ML
INSULIN SYRG MIS 1ML/25G
INSULIN SYRG MIS 1ML/25G
INSULIN SYRG MIS 1ML/25G
INSULIN SYRG MIS 1ML/26G
INSULIN SYRG MIS 1ML/27G
INSULIN SYRG MIS 1ML/27G
INSULIN SYRG MIS 1ML/28G
INSULIN SYRG MIS 1ML/28G
INSULIN SYRG MIS 1ML/29G
insulin syrg mis 1ml/29g
INSULIN SYRG MIS 1ML/29G
insulin syrg mis 1ml/30g
INSULIN SYRG MIS 1ML/30G
insulin syrg mis 1ml/30g
INSULIN SYRG MIS 1ML/30G
INSULIN SYRG MIS 1ML/31G
INSULIN SYRG MIS 1ML/31G
INSULIN SYRG MIS 2/27.5G
INSULIN SYRG MIS 2ML/29G
INSULIN SYRINGE MIS 0.3/30G
INSULIN SYRINGE MIS 0.3/31G
INSULIN SYRINGE MIS 0.5/29G
INSULIN SYRINGE MIS 0.5/30G
INSULIN SYRINGE MIS 0.5/31 G
INSULIN SYRINGE MIS 1ML/29G
INSULIN SYRINGE MIS 1ML/30G
INSULIN SYRINGE MIS 1ML/31G
insulin syringe/needle u-100
INSULIN SYRINGE/NEEDLE U-100
INSULIN SYRINGE/NEEDLE U-100
INSULIN SYRINGE/NEEDLE U-100
INSULIN SYRINGE/NEEDLE U-100
INSULIN SYRINGE/NEEDLE U-100
INSULIN SYRINGE/NEEDLE U-100
INSUPEN SENS MIS 32GX8MM
INSYTE AUTOG MIS 24GX3/4"
J-TIP KIT KIT ADAPTERS
KETOSTIX TEST STRIPS
LITE TOUCH INSULIN PEN NEEDLE
LITE TOUCH INSULIN PEN NEEDLE
Requirements/ Limits
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
44
Formulary last updated date (11/01/2014)
Drug Name
LTXF PRIM IV MIS SET/MICR
LUER-LOK SYR MIS 1ML/20G
MEDI-JECTOR MIS VISION
NEEDLE-FREE KIT A
NEEDLE-FREE MIS SYRG A
NOVOFINE MIS 30GX8MM
NOVOFINE MIS 32GX6MM
NOVOTWIST MIS 32GX5MM
OMNIFLEX DPR
ORTHO COIL DPR KIT 100
ORTHO COIL DPR KIT 105
ORTHO COIL DPR KIT 50
ORTHO FLAT DPR KIT 55
ORTHO FLAT DPR KIT 60
ORTHO FLAT DPR KIT 65
ORTHO FLAT DPR KIT 70
ORTHO FLAT DPR KIT 75
ORTHO FLAT DPR KIT 80
ORTHO FLAT DPR KIT 85
ORTHO FLAT DPR KIT 90
ORTHO FLAT DPR KIT 95
ORTHO FLEX DPR 65MM
ORTHO FLEX DPR 70MM
ORTHO FLEX DPR 75MM
ORTHO FLEX DPR 80MM
PEN NEEDLES MIS 29GX12.7
PLAS ADAPT MIS 1ML
PRECISN XTRA TES KETONE
PRODIGY MIS 29GX1/2"
ROCHE - FASTCLIIX LANCETS, BO
SD GLUCONAVII TEST STRIPS
SURE-LANCE MIS LANCETS
SURE-T INFUS MIS SET 23"
TENDER 1 KIT 31"
UNIFINE PNTP MIS 29GX12MM
UNIFINE PNTP MIS 31GX5MM
UNIFINE PNTP MIS 31GX6MM
UNIFINE PNTP MIS 31GX8MM
UNIFINE PNTP MIS 32GX4MM
water for irrigation, sterile
WIDE-SEAL DPR KIT 60
WIDE-SEAL DPR KIT 65
WIDE-SEAL DPR KIT 70
WIDE-SEAL DPR KIT 75
WIDE-SEAL DPR KIT 80
WIDE-SEAL DPR KIT 85
WIDE-SEAL DPR KIT 90
Requirements/ Limits
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 100/30
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
QL 1/365
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
45
Formulary last updated date (11/01/2014)
Drug Name
wide-seal dpr kit 95
Requirements/ Limits
QL 1/365
OPHTHALMIC AGENTS
Ophthalmic Agents, Other
ALartificial tear ophth ointme
ALartificial tear ophth soluti
ALwhite petrolatum-mineral oil
BLINK TEARS DRO 0.25% OP
BLINK TEARS DRO 0.25% OP
brimonidine tartrate ophth so
carboxymethylcellulose sodium
carboxymethylcellulose sodium
carboxymethylcellulose-glycer
CLEAR EYES DRO DRY EYES
COMPUTER EYE SOL DROPS
GENTEAL GEL
genteal mild dro 0.2%
glycerin-hypromellose-peg 400
GONIOVISC SOL 2%
hypotears sol 1-1%
hypromellose gonioscopic soln
hypromellose ophth soln 0.3%
hypromellose ophth soln 0.4%
iso carbacho sol 3% op
ISOPTO TEARS SOL 0.5% OP
moisture eye sol p/f
muro 128 sol 2% op
naphazoline hcl ophth soln 0.
naphazoline w/ pheniramine op
naphazoline w/ pheniramine op
naphazoline-glycerin ophth so
naphazoline-glycerin ophth so
naphazoline-glycerin ophth so
naphazoline-hypromellose opht
naphazoline-polyethylene glyc
nutratear sol 0.6%
phospholine sol 0.125%op
polyethylene glycol-propylene
POLYVINYL ALCOHOL OPHTH SOLN
polyvinyl alcohol-povidone op
polyvinyl alcohol-povidone op
proparacaine hcl ophth soln 0
propylene glycol-glycerin oph
refresh cell dro 1% op
REFRESH DRO RELIEF
refresh sol optive
RETAINE MGD EMU 0.5-0.5%
sodium chloride hypertonic op
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
46
Formulary last updated date (11/01/2014)
Drug Name
sodium chloride hypertonic op
soothe dro 0.6-0.6%
STERILE LUBR DRO 0.7%
SYSTANE BAL SOL RESTOR
SYSTANE GEL 0.3%
systane liq dro 0.4-0.3%
TEARS AGAIN GEL NGHT/DAY
tetrahydrozoline hcl ophth so
tetrahydrozoline w/ polyethyl
tetrahydrozoline w/ zinc sulf
theratears sol op
vasoclear a sol op
visine tears dro
VIVA DROPS DRO 1%
Ophthalmic Anti Infectives
bacitracin ophth oint 500 uni
bacitracin-polymyxin b ophth
ciloxan oin 0.3% op
CIPROFLOXACIN 0.2% SOL
ciprofloxacin hcl ophth soln
erythromycin ophth oint 5 mg/
gentamicin sulfate ophth oint
gentamicin sulfate ophth soln
neomycin-bacitrac zn-polymyx
NEOMYCIN-POLYMY-GRAMICID OP S
ofloxacin ophth soln 0.3%
polymyxin b-trimethoprim opht
sulfacet sod oin 10% op
SULFACETAMIDE SODIUM OPHTH SO
tobramycin ophth soln 0.3%
tobrex oin 0.3% op
trifluridine ophth soln 1%
Ophthalmic Anti-allergy Agents
azelastine hcl ophth soln 0.0
cromolyn sodium ophth soln 4%
dorzolamide hcl ophth soln 2%
ketotifen fumarate ophth soln
Ophthalmic Anti-inflammatories
atropine sulfate ophth oint 1
atropine sulfate ophth soln 1
bacitracin-polymyxin-neomycin
BLEPHAMIDE OIN S.O.P.
BLEPHAMIDE SUS OP
BLEPHAMIDE SUS OP
BLEPHAMIDE SUS OP
blephamide sus op
cyclomydril sol op
Requirements/ Limits
QL 5/30
QL 5/30
QL 5/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
47
Formulary last updated date (11/01/2014)
Drug Name
cyclopentolate hcl ophth soln
dexamethasone sodium phosphat
diclofenac sodium ophth soln
FLAREX SUS 0.1% OP
FLUOROMETHOLONE OPHTH SUSP 0.
flurbiprofen sodium ophth sol
FML FORTE SUS 0.25% OP
FML OIN 0.1% OP
homatropine hbr ophth soln 5%
iso homatrop sol 2% op
ketorolac tromethamine ophth
ketorolac tromethamine ophth
latanoprost ophth soln 0.005%
neomycin-polymyxin-dexamethas
neomycin-polymyxin-dexamethas
neomycin-polymyxin-hc ophth s
pred mild sus 0.12% op
prednisolone acetate ophth su
PREDNISOLONE SODIUM PHOSPHATE
sulfacetamide sodium-predniso
tobradex oin 0.3-0.1%
tobramycin-dexamethasone opht
tropicamide ophth soln 0.5%
tropicamide ophth soln 1%
Ophthalmic Antiglaucoma Agents
betaxolol hcl ophth soln 0.5%
carteolol hcl ophth soln 1%
COSOPT
SOL 2-0.5%OP
DORZOLAMIDE HCL-TIMOLOL MALEA
dorzolamide hcl-timolol malea
levobunolol hcl ophth soln 0.
levobunolol sol 0.25% op
metipranolol ophth soln 0.3%
timolol maleate ophth soln 0.
timolol maleate ophth soln 0.
timoptic ocu sol 0.25% op
timoptic ocu sol 0.5% op
Requirements/ Limits
QL 5/30
QL 5/10
OTIC AGENTS
Otic Agents
acetic acid 2% in aluminum ac
acetic acid otic soln 2%
antipyrine-benzocaine otic so
carbamide peroxide 6.5% otic
CLEARCANAL KIT EAR WAX
hydrocortisone w/ acetic acid
neomycin-polymyxin-hc otic so
neomycin-polymyxin-hc otic su
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
48
Formulary last updated date (11/01/2014)
Drug Name
ofloxacin otic soln 0.3%
pinnacaine dro 20% otic
Requirements/ Limits
RESPIRATORY TRACT AGENTS
Anti-inflammatories, Inhaled Corticosteroids
AL
budesonide inhalation susp 0.
budesonide inhalation susp 0.
AL
FLOVENT DISK AER 100MCG
QL 60/30 AL
FLOVENT DISK AER 50MCG
QL 60/30 AL
FLOVENT HFA AER 44MCG
QL 10.6/30 AL
QVAR AER 40MCG
QL 8.7/30
QVAR AER 80MCG
QL 8.7/30
Antihistamines
ALER-DRYL TAB 50MG
AL
cetirizine hcl oral soln 1 mg
cetirizine hcl tab 10 mg
cetirizine hcl tab 5 mg
CHLORPHENIR POW MALEATE
chlorpheniramine maleate syru
chlorpheniramine maleate tab
chlorpheniramine maleate tab
CLARITIN RDT TAB 5MG
clemastine fumarate syrup 0.6
clemastine fumarate tab 1.34
clemastine fumarate tab 2.68
cyproheptadine hcl syrup 2 mg
cyproheptadine hcl tab 4 mg
dexchlorpheniramine maleate s
diphenhydramine hcl cap 25 mg
AL
diphenhydramine hcl chew tab
AL
diphenhydramine hcl elixir 12
AL
diphenhydramine hcl liquid 12
AL
diphenhydramine hcl syrup 12.
AL
diphenhydramine hcl tab disp
AL
ED CHLORPED LIQ 2MG/ML
ED-CHLOR-TAN TAB 8MG
fexofenadine hcl susp 30 mg/5
loratadine rapidly-disintegra
loratadine syrup 5 mg/5ml
loratadine tab 10 mg
promethazine hcl suppos 12.5
QL 28/14
promethazine hcl suppos 25 mg
QL 28/14
promethazine hcl suppos 50 mg
QL 28/14
promethazine hcl syrup 6.25 m
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
Antileukotrienes
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
49
Formulary last updated date (11/01/2014)
Drug Name
montelukast sodium chew tab 4
montelukast sodium chew tab 5
montelukast sodium tab 10 mg
Bronchodilators, Anticholinergic
ATROVENT HFA AER 17MCG
cromolyn sodium soln nebu 20
ipratropium bromide inhal sol
TUDORZA PRES AER 400/ACT
Bronchodilators, Sympathomimetic
ADVAIR DISKU AER 100/50
albuterol sulfate soln nebu 0
albuterol sulfate soln nebu 0
albuterol sulfate syrup 2 mg/
albuterol sulfate tab 2 mg
albuterol sulfate tab 4 mg
ANORO ELLIPT AER 62.5-25
BREO ELLIPTA INH 100-25
DULERA AER 100-5MCG
DULERA AER 200-5MCG
FORADIL CAP AEROLIZE
metaproterenol sulfate syrup
metaproterenol sulfate tab 10
metaproterenol sulfate tab 20
SEREVENT DIS AER 50MCG
SYMBICORT AER 160-4.5
SYMBICORT AER 80-4.5
terbutaline sulfate tab 2.5 m
terbutaline sulfate tab 5 mg
VENTOLIN HFA AER
Nasal Agents
cromolyn sodium nasal aerosol
flunisolide nasal soln 25 mcg
flunisolide nasal soln 29 mcg
fluticasone propionate nasal
ipratropium bromide nasal sol
ipratropium bromide nasal sol
NASACORT ALR SPR 55MCG/AC
oxymetazoline hcl nasal soln
saline nasal spray 0.65%
Respiratory Tract Agents, Other
ALpe-apap cap & doxylamine-peA-S PL SINUS TAB 7.8-325
A-S PLS SINU CAP ALLR/CGH
acetaminophen w/ dm liq 1000acetaminophen w/ dm liq 160-5
acetaminophen-guaifenesin tab
acetaminophen-guaifenesin tab
Requirements/ Limits
QL 12.9/30
QL 1/30
QL 60/30 ST
PA QL 14/30
QL 60/30
QL 13/30 ST
QL 13/30 ST
QL 60/30
QL 120/30
QL 10.2/30 ST
QL 10.2/30 ST
QL 18/25
QL 50/30
QL 50/30
QL 16/30
QL 30/30
QL 15/30
QL 90/30
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
50
Formulary last updated date (11/01/2014)
Drug Name
acetylcysteine inhal soln 10%
acetylcysteine inhal soln 20%
ADVIL ALLERG TAB CONGEST
ADVIL ALLERG TAB SINUS
ADVIL COLD/ CAP SINUS
ADVIL CONGST TAB RELIEF
ALA-HIST PE TAB 2-10MG
ALBATUSSIN LIQ NN
ALKA-SELT PL CAP COLD/CGH
ALKA-SELT PL MIS DAY/NGHT
ALKA-SELT PL TAB CLD/FLU
ALKA-SELT PL TAB COLD/CGH
ALKA-SELT PL TAB NGHT CLD
benzonatate cap 100 mg
benzonatate cap 200 mg
BICLORA LIQ
BICLORA TAB 25-25MG
BICLORA-D LIQ
BICLORA-D TAB
BIOBRON SF SYP
BIONEL LIQ PEDIATRC
BIOSPEC DMX LIQ
BPM-PSE-DM LIQ 4-20-20
BROHIST D TAB 4-10MG
brompheniramine & phenylephri
brompheniramine & phenylephri
brompheniramine & phenylephri
brompheniramine & pseudoephed
BRONCOTRON DRO PED
BRONCOTRON-S LIQ 20-400/5
BRONKAID TAB 25-400MG
BRONKIDS DRO
BRONKIDS LIQ 10-4-10
BRONTUSS DX LIQ
CAPCOF SYP
CAPMIST DM TAB
CAPRON DM LIQ
CARBAPHEN 12 LIQ
CARBAPHEN CH SUS
CARBAPHEN SUS PED CH
CCP CAFFEINE TAB FREE
CERTUSS-D TAB
cetirizine-pseudoephedrine ta
CHEST CONGES GRA CHILDREN
CHEST CONGST GRA CHILDRNS
CHEST CONGST GRA COUGH
CHLO TUSS EX LIQ 12.5-100
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
51
Formulary last updated date (11/01/2014)
Drug Name
CHLO TUSS LIQ
CHLO TUSS LIQ
CHLOPHED LIQ
chlorphen-pe-apap tab & diphe
chlorphen-pe-apap tab 2-5-325
chlorphen-phenylephrine w/ ap
chlorphen-phenylephrine w/ ap
chlorphen-phenylephrine w/ ap
chlorphen-phenylephrine w/ ap
chlorphen-pseudoephedrine w/
chlorphen-pseudoephedrine w/
chlorpheniramine & phenylephr
chlorpheniramine & phenylephr
chlorpheniramine & phenylephr
chlorpheniramine & phenylephr
chlorpheniramine & pseudoephe
chlorpheniramine & pseudoephe
chlorpheniramine & pseudoephe
chlorpheniramine w/ codeine l
chlorpheniramine-acetaminophe
chlorpheniramine-dm liquid 1chlorpheniramine-dm liquid 2chlorpheniramine-dm tab 4-30
chlorpheniramine-phenylephrin
CLOFERA LIQ
CNTC CLD/FLU PAK DAY/NGHT
CNTC CLD/FLU TAB MAX ST
CODAR AR LIQ
CODAR D LIQ
CODAR GF LIQ
CODITUSS DM SYP
COMPLETE SIN TAB RELIEF
CONEX SOL CLD/ALRG
CONEX TAB 2-60MG
CORICIDIN NT LIQ COLD/CGH
CORICIDN HBP MIS MULTI SY
COUGH D SYP
CPB WC LIQ
DALLERGY DRO 1-2.5MG
DALLERGY SYP
DALLERGY TAB 1-5MG
DALLERGY TAB 25-10MG
day/nyquil liq severe
DAYTIME LIQ COLD MED
DECON-A ELX 2-5MG/5M
DECON-A LIQ DROPS
DECON-G DRO 2-1-40MG
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
52
Formulary last updated date (11/01/2014)
Drug Name
DELTUSS DP LIQ 1-30/5ML
DESPEC DM SYP
DESPEC-DM TAB
DEX-TUSS LIQ 300-10/5
DEXATREX D ELX CF-NASAL
dexbrompheniramine & pseudoep
dextromethorphan hbr syrup 15
dextromethorphan-apap-chlorph
dextromethorphan-apap-chlorph
dextromethorphan-doxylamine-a
dextromethorphan-doxylamine-a
dextromethorphan-doxylamine-a
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-phenylephrin
dextromethorphan-phenylephrin
dextromethorphan-phenylephrin
dextromethorphan-phenylephrin
DIABETIC CAP COLD/FLU
DIABETIC TUS LIQ COLD/FLU
DICEL CD LIQ
DIMETAPP CLD CHW /ALLERGY
DIMETAPP SYP CGH/COLD
diphenhydramine-acetaminophen
diphenhydramine-acetaminophen
diphenhydramine-acetaminophen
diphenhydramine-phenylephrine
diphenhydramine-phenylephrine
diphenhydramine-phenylephrine
diphenhydramine-phenylephrine
diphenhydramine-phenylephrine
diphenhydramine-phenylephrine
diphenhydramine-phenylephrine
diphenhydramine-phenylephrine
diphenhydramine-phenylephrine
diphenhydramine-phenylephrine
diphenhydramine-pse w/ apap t
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
53
Formulary last updated date (11/01/2014)
Drug Name
dm-gg-pot cit-citric acid liq
DOLOGEN TAB
DOMETUSS-DA LIQ 1-2.5MG
DONATUSSIN SYP
doxylamine-dm 6.25-15 mg/15ml
doxylamine-dm liquid 6.25-15
doxylamine-phenylephrine-apap
DRIXORAL CAP CGH & ST
DRIXORAL TAB COLD/FLU
DURAVENT PE TAB 10-395MG
dyphylline-guaifenesin liqd 1
dyphylline-guaifenesin tab 20
ED CHLORPED DRO D
ELIXOPHYLLIN ELX 80/15ML
ELIXSURE GEL CONGEST
ENDACON SYP
ENTEX LQ LIQ
ENTEX T TAB 60-375MG
ENTRE-COUGH SUS TANNATE
ephedrine-guaifenesin tab 12.
EQL INFANT DRO DCON/CGH
FATHER JOHNS SOL PLUS
FENESIN DM TAB 15-400MG
GILTUSS LIQ PED-C
GILTUSS TR CAP 7-14-288
guaifenesin liquid 100 mg/5ml
guaifenesin liquid 200 mg/5ml
GUAIFENESIN POW
guaifenesin syrup 100 mg/5ml
guaifenesin tab 200 mg
guaifenesin tab 400 mg
guaifenesin tab sr 12hr 600 m
guaifenesin-codeine liquid 22
guaifenesin-codeine soln 100guaifenesin-codeine soln 100HERBAL EXPEC LIQ 150/15ML
HISTEX-DM SYP
HISTEX-PE SYP 2.5-10/5
hydrocod polst-chlorphen pols
hydrocodone w/ homatropine sy
hydrocodone w/ homatropine ta
LITTLE REMED LIQ COLDS
LODRANE D CAP 4-60MG
LOHIST-PSB LIQ 4-20/5ML
loratadine & pseudoephedrine
loratadine & pseudoephedrine
LORTUSS DM LIQ
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
54
Formulary last updated date (11/01/2014)
Drug Name
LORTUSS EX LIQ
LORTUSS LQ LIQ
LUFYLLIN TAB 200MG
LUFYLLIN TAB 400MG
LUSAIR LIQ
M-END DMX LIQ
M-END MAX D LIQ
M-END PE LIQ
MAR-COF BP LIQ
MAXIFED DMX TAB
MEDI-GRAINE TAB
MUCINEX FAST MIS DAY/NGHT
MUCINEX FAST TAB 5-10-200
MUCINEX TAB 1200MG
NASAL DECON SYP 30MG/5ML
NASOPEN LIQ
NASOPEN PE LIQ
NEO DM SYP
NEOTUSS PLUS LIQ
NEOTUSS-D LIQ
NEOTUSS-D LIQ
NITE-TIME LIQ COLD/FLU
NOREL AD TAB 4-10-325
NOREL CS LIQ
NOTUSS-NX LIQ
NOTUSS-NXD LIQ
ONSET FORTE TAB
PAIN RELIEF TAB COLD PE
PANATUSS DXP LIQ
PANATUSS DXP LIQ PEDIATRI
PANATUSS PED DRO
PANATUSS PED LIQ 60-2-25
pe-dm-apap & pe-cpm-dm-apap t
pe-dm-apap cap & doxylamine-d
pe-dm-apap liq & doxylamine-d
pe-dm-gg-apap tab & pe-diphen
PE-HIST DM SYP 5-2-15MG
PECGEN DMX LIQ 15-125MG
phenyleph-chlorphen-dm w/apap
phenyleph-chlorphen-dm w/apap
phenyleph-chlorphen-dm w/apap
phenylephrine w/ acetaminophe
phenylephrine w/ acetaminophe
phenylephrine w/ acetaminophe
phenylephrine w/ acetaminophe
phenylephrine w/ dm-gg liqd 1
phenylephrine w/ dm-gg liqd 1
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
55
Formulary last updated date (11/01/2014)
Drug Name
phenylephrine w/ dm-gg liqd 1
phenylephrine w/ dm-gg liqd 2
phenylephrine w/ dm-gg liqd 2
phenylephrine w/ dm-gg liqd 2
phenylephrine w/ dm-gg liqd 2
phenylephrine w/ dm-gg liqd 5
phenylephrine w/ dm-gg liqd 5
phenylephrine w/ dm-gg liquid
phenylephrine w/ dm-gg syrup
phenylephrine w/ dm-gg tab 10
phenylephrine w/ dm-gg tab 10
phenylephrine-apap-gg liqd 10
phenylephrine-apap-gg tab 10phenylephrine-apap-gg tab 5-3
phenylephrine-brompheniramine
phenylephrine-brompheniramine
phenylephrine-brompheniramine
phenylephrine-brompheniramine
phenylephrine-brompheniramine
phenylephrine-chlorphen-dm li
phenylephrine-chlorphen-dm li
phenylephrine-chlorphen-dm li
phenylephrine-chlorphen-dm li
phenylephrine-chlorphen-dm li
phenylephrine-dm soln 2.5-5 m
phenylephrine-dm-gg w/ apap l
phenylephrine-dm-gg w/ apap l
phenylephrine-dm-gg w/ apap t
phenylephrine-dm-gg w/ apap t
phenylephrine-dm-gg w/ apap t
phenylephrine-doxylamine-dm-a
phenylephrine-guaifenesin liq
phenylephrine-guaifenesin liq
phenylephrine-guaifenesin syr
phenylephrine-guaifenesin tab
phenylephrine-guaifenesin tab
phenylephrine-guaifenesin tab
phenylephrine-promethazine w/
PHENYLHIST LIQ DH
POLY HIST TAB 7.5-10MG
POLY-HIST DM LIQ 5-25-10
POLY-HIST PD LIQ
POLY-TUSSIN LIQ AC
POLY-VENT DM TAB
POLY-VENT DM TAB
POLY-VENT IR TAB 60-380MG
PRO-CHLO LIQ
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
56
Formulary last updated date (11/01/2014)
Drug Name
PRO-RED AC SYP 5-1-9/5
promethazine & phenylephrine
promethazine w/ codeine syrup
promethazine-dm syrup 6.25-15
pseudoeph-chlorphen-dm w/ apa
pseudoeph-chlorphen-dm w/ apa
pseudoeph-chlorphen-dm w/ apa
pseudoeph-chlorphen-dm w/ apa
pseudoeph-chlorphen-dm w/ apa
pseudoeph-doxylamine-dm w/ ap
pseudoeph-doxylamine-dm w/apa
pseudoephed-bromphen-dm elixi
pseudoephed-bromphen-dm syrup
pseudoephed-bromphen-dm syrup
pseudoephed-chlorphen-dm liq
pseudoephed-chlorphen-dm liq
pseudoephed-chlorphen-dm liq
pseudoephed-dexchlorphen-chlo
pseudoephedrine hcl liq 15 mg
pseudoephedrine hcl tab 30 mg
pseudoephedrine hcl tab 60 mg
pseudoephedrine hcl tab abuse
pseudoephedrine hcl tab sr 12
pseudoephedrine w/ acetaminop
pseudoephedrine w/ apap-dm ca
pseudoephedrine w/ apap-dm li
pseudoephedrine w/ apap-dm ta
pseudoephedrine w/ cod-gg sol
pseudoephedrine w/ cod-gg syr
pseudoephedrine w/ dm-gg cap
pseudoephedrine w/ dm-gg liqu
pseudoephedrine w/ dm-gg liqu
pseudoephedrine w/ dm-gg syru
pseudoephedrine-bromphen-code
pseudoephedrine-chlophedianol
pseudoephedrine-dexchlorpheni
pseudoephedrine-dm liqd 15-7.
pseudoephedrine-dm syrup 30-1
pseudoephedrine-dm-gg w/ apap
pseudoephedrine-guaifenesin c
pseudoephedrine-guaifenesin s
pseudoephedrine-guaifenesin t
pseudoephedrine-guaifenesin t
pseudoephedrine-guaifenesin t
pseudoephedrine-guaifenesin t
pseudoephedrine-ibuprofen sus
pseudoephedrine-ibuprofen tab
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
57
Formulary last updated date (11/01/2014)
Drug Name
pseudoephedrine-naproxen sodi
PULMOZYME SOL 1MG/ML
PYRIL DM SUS
pyrilamine mal-phenylephrine
pyrilamine-phenylephrine tab
RESCON-DM SYP
RESPAIRE-30 CAP
ROBITUS NGHT LIQ 12.5-30
ROBITUSSIN D LIQ CGH/COLD
ROBITUSSIN LIQ CF
ROBITUSSIN LIQ NIGHT TM
ROBITUSSIN MIS DAY/NGHT
ROBITUSSIN MIS DAY/NITE
ROBITUSSIN MIS DAY/NITE
RU-HIST-D LIQ 30-10/5
RU-HIST-D TAB 30-10MG
RYCONTUSS LIQ 5-2-10/5
RYDEX G TAB 38.5-398
RYMED TAB 2-10MG
SAFE TUSSIN LIQ PM
SCOT-TUSSIN LIQ ORIGINAL
SCOT-TUSSIN LIQ SENIOR
SEV SIN CONG TAB DAYTIME
SINADRIN PE TAB 2-10-650
SINUS-MAX MIS DAY/NGHT
sodium chloride aero soln 0.9
sodium chloride soln nebu 0.9
STAHIST AD LIQ
STAHIST AD TAB 25-60MG
STATUSS LIQ GREEN
SUDAFED 24HR TAB 240MG
SUDAFED PE PAK DAY&NGHT
SUPPRESS A DRO 5-1-10
SUPRESS DM DRO 5-50/ML
SUPRESS-PE DRO PEDIATRI
TERPIN HYDR POW MONOHYDR
THEO-24 CAP 100MG CR
THEO-24 CAP 200MG CR
THEO-24 CAP 300MG CR
theophylline tab sr 12hr 100
theophylline tab sr 12hr 200
theophylline tab sr 12hr 300
theophylline tab sr 12hr 450
THERACOF PLS LIQ CGH/COLD
THERAFLU CLD MIS CGH DAY
THERAFLU FLU PAK SORE THR
THERAFLU FLU POW CHST CON
Requirements/ Limits
PA
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
58
Formulary last updated date (11/01/2014)
Drug Name
THERAFLU LIQ WARM RLF
THERAFLU PAK COLD/CGH
THERAFLU POW
THERAFLU POW MAX-D
THERAFLU SEV PAK COLD/CGH
TREXBROM LIQ 10-4-25
TRIACTIN SOL CHST CON
TRIACTING LIQ CGH/RUN
TRIAMIN FLU/ SYP CGH/FVR
TRIAMINIC CHW
TRIAMINIC CHW
TRIAMINIC LIQ
TRIAMINIC LIQ CHST/NAS
TRIAMINIC MIS CGH/COLD
TRIAMINIC MIS COLD/CGH
TRIAMINIC MIS GRAPE
TRIAMINIC NT MIS COLD/CGH
TRIAMINIC SOL COLD/CGH
TRIAMINIC SYP CGH/SORE
triaminic syp child
TRIAMINIC SYP CHST/NSL
TRIAMINIC SYP COLD/ALL
TRIAMINIC SYP COLD/CGH
TRIAMINIC-D SYP
TRICODE AR LIQ
TRICODE GF LIQ
triprolidine & pseudoephedrin
triprolidine & pseudoephedrin
triprolidine & pseudoephedrin
TRISPEC DMX LIQ 10-187/5
TRISPEC PSE LIQ
TRISPEC PSE LIQ
TUSICOF LIQ
TUSNEL CAP
TUSSAFEX-A LIQ 6-2-15/5
TYLENOL CGH PAK SORE THR
TYLENOL CHES LIQ CONGEST
TYLENOL CHLD SUS CLD/CGH
TYLENOL CHLD SUS STUFFY
TYLENOL COLD LIQ RELIEF
TYLENOL SINU MIS DAY/NITE
UNIFED LIQ 30MG/5ML
VANACOF APE LIQ
VANACOF CD LIQ
VANACOF DM LIQ
VANACOF G LIQ
VANACOF GPE LIQ
Requirements/ Limits
AL
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
59
Formulary last updated date (11/01/2014)
Drug Name
VANACOF-8 LIQ 25-50/15
VANATAB DX TAB
VICKS NATURE LIQ COLD/FLU
VICKS NATURE LIQ CONGEST
VICKS NYQUIL LIQ CHILDREN
VICKS NYQUIL LIQ COLD/FLU
WAL-DRYL-D TAB 25-60MG
Z-TUSS AC LIQ 2-9/5ML
Z-TUSS E LIQ
ZODRYL AC 25 SUS
ZODRYL AC 30 SUS
ZODRYL AC 35 SUS
ZODRYL AC 40 SUS
ZODRYL DAC SUS 25
ZODRYL DAC SUS 30
ZODRYL DAC SUS 35
ZODRYL DAC SUS 40
ZODRYL DEC25 SUS
ZODRYL DEC30 SUS
ZODRYL DEC35 SUS
ZODRYL DEC40 SUS
ZYNCOF SYP 20-400/5
Requirements/ Limits
SKELETAL MUSCLE RELAXANTS
Skeletal Muscle Relaxants
baclofen tab 10 mg
baclofen tab 20 mg
chlorzoxazone tab 500 mg
cyclobenzaprine hcl tab 10 mg
cyclobenzaprine hcl tab 5 mg
methocarbamol tab 500 mg
methocarbamol tab 750 mg
tizanidine hcl tab 2 mg
tizanidine hcl tab 4 mg
QL 90/30
QL 90/30
THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES
Electrolyte/Mineral Modifiers
calcitriol cap 0.25 mcg
calcitriol cap 0.5 mcg
SENSIPAR TAB 30MG
PA
SENSIPAR TAB 60MG
PA
Electrolyte/Mineral Replacement
CYTRA-K SOL
K-PHOS TAB NO 2
ORACIT SOL
phenazopyridine hcl tab 100 m
phenazopyridine hcl tab 200 m
pot & sod citrates w/ cit ac
potassium citrate & citric ac
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
60
Formulary last updated date (11/01/2014)
Drug Name
sodium chloride irrigation so
sodium citrate & citric acid
Nutrients
ATABEX CHW PRENATAL
ATABEX EC TAB
ATABEX TAB PRENATAL
BRAINSTRONG MIS PRENATAL
CENTRUM SPEC PAK PRENATAL
CO-NATAL FA TAB 29-1MG
COMP PRNATAL MIS DHA
COMPLETE NAT PAK DHA
COMPLETENATE CHW
CVS PRENATAL CHW GUMMY
ENFAMIL MIS EXPECTA
EZFE FORTE CAP
LACTOCAL-F TAB
MISSION PREN TAB
MISSION PREN TAB /FA
MYNATAL CAP
NATALVIT TAB 75-1MG
NUTRIENTS TAB PRENATAL
O-CAL FA TAB
O-CAL TAB PRENATAL
OBSTETRIX EC TAB
OBSTETRIX PAK DHA
ONE A DAY MIS PRENATAL
PRENAT MULTI CAP +DHA
PRENATA CHW 29-1MG
PRENATAL CAP FORMULA
PRENATAL CAP OMEGA-3
PRENATAL FRM TAB A-FREE
PRENATAL MUL CAP +DHA
PRENATAL TAB FORMULA
PRENATAL TAB PLUS DHA
PRENATAL TAB PLUS FE
PRENATAL+DHA MIS
SE-NATAL 19 TAB
SE-NATAL 90 TAB
SETONET PAK
SM ONE DAILY MIS PRENATAL
STUART ONE CAP
TARON-BC MIS
THERANATAL MIS COMPLETE
TRINATAL RX TAB 1
TRIVEEN-DUO PAK DHA
TRIVEEN-U CAP
ULTRA TABS TAB
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
61
Formulary last updated date (11/01/2014)
Drug Name
VINATE CAL TAB
VINATE IC CAP
VINATE II TAB
VINATE M TAB
VITA-PREN TAB
Vitamins
ALb-complex w/ c & folic acid
ALb-complex w/ c & folic acid
ALiron combination capALALAL
ALmultiple vitamin tabALAL
ALmultiple vitamins w/ iro
ALmultiple vitamins w/ mineral
ALmultiple vitamins w/ mineral
ALmultiple vitamins w/ mineral
ALmultiple vitamins w/ mineral
ALMULTIPLE VITAMINS W/ MINERAL
ALMULTIPLE VITAMINS W/ MINERAL
ALMULTIPLE VITAMINS W/ MINERAL
ALORAL ELECTROLYTE SOLUTIONALALAL
ALoral electrolyte tabALALAL
ALpediatric multiple vitamin l
ALpediatric multiple vitamin w
ALpediatric multiple vitamin w
ALpediatric multiple vitamin w
ALpediatric multiple vitamin w
ALpediatric multiple vitamin w
ALpediatric multiple vitamin w
ALpediatric multiple vitamin w
ALpediatric multiple vitamins
ALpediatric multiple vitamins
ALpediatric vitamins acd w/ fl
ALpediatric vitamins acd w/ fl
ALpediatric vitamins adc d
ACEROLA C WAF 500MG
antioxidant cap
ascocid-iso- pow ph
ascorbic acid cap cr 500 mg
ascorbic acid chew tab 100 mg
ascorbic acid chew tab 250 mg
ascorbic acid chew tab 500 mg
ascorbic acid inj 500 mg/ml
ascorbic acid liquid 500 mg/5
ascorbic acid lozenge 60 mg
ascorbic acid syrup 500 mg/5m
ascorbic acid tab 100 mg
ascorbic acid tab 1000 mg
ascorbic acid tab 250 mg
Requirements/ Limits
AL
AL
AL
AL
AL
AL
AL
AL
AL
AL
AL
AL
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
62
Formulary last updated date (11/01/2014)
Drug Name
ascorbic acid tab 500 mg
ascorbic acid tab cr 1000 mg
ascorbic acid tab cr 1500 mg
ascorbic acid tab cr 500 mg
b-1 tab 500mg
b-2-400 cap
B-NATAL LOZ 25MG
B-NATAL LOZ 25MG
B1 NATURAL TAB 250MG
BE WELL PAK ROUNDED
BENFOTIAMINE CAP 150MG
biotin cap 1mg
biotin cap 2.5 mg
biotin cap 5 mg
biotin forte tab 3mg
biotin tab 1000 mcg
BIOTIN TAB 10MG
biotin tab 2.5 mg
biotin tab 300 mcg
biotin tab 5 mg
BIOTIN TAB 7500MCG
biotin tab 800 mcg
BONE MEAL TAB
BUFFERED VIT CAP C 1000MG
ca citrate tab 250mg
CA HI-CAL/D TAB 250MG
CA HI-CAL/D TAB 500MG
ca hi-cal/d tab 500mg
CA PANTOTHEN TAB 100MG
ca pantothen tab 200mg
CAL CIT MAL/ TAB VITAMIND
CAL-CITRATE CAP 150MG
cal-citrate tab plus d
CAL-CYUM WAF 500MG
CAL-MAG CHEL CAP 70-83MG
CAL-QUICK LIQ 500-400
CAL/MAG TAB CHEW
CALC CITRATE LIQ VIT D3
CALC/VIT D3 CHW 200-200
CALCET BITES CHW 500-400
CALCIUM &MAG TAB
calcium 1000 tab + d
CALCIUM ASCORBATE TAB 500 MG
calcium carbonate tab 1250 mg
CALCIUM CARBONATE-CHOLECALCIF
CALCIUM CARBONATE-CHOLECALCIF
calcium carbonate-cholecalcif
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
63
Formulary last updated date (11/01/2014)
Drug Name
calcium carbonate-cholecalcif
calcium carbonate-cholecalcif
calcium carbonate-cholecalcif
calcium carbonate-cholecalcif
CALCIUM CARBONATE-CHOLECALCIF
CALCIUM CARBONATE-CHOLECALCIF
calcium carbonate-ergocalcife
CALCIUM CARBONATE-VITAMIN D C
calcium carbonate-vitamin d c
calcium carbonate-vitamin d t
calcium carbonate-vitamin d t
calcium carbonate-vitamin d t
calcium carbonate-vitamin d t
calcium carbonate-vitamin d t
calcium carbonate-vitamin d t
calcium carbonate-vitamin d t
CALCIUM CHW 600-400
CALCIUM CIT TAB 1040MG
CALCIUM CIT TAB W/VIT D
calcium citrate tab 950 mg (2
calcium citrate-vitamin d tab
calcium citrate-vitamin d tab
CALCIUM CITRATE-VITAMIN D TAB
CALCIUM CITRATE-VITAMIN D TAB
calcium glubionate syrup
calcium gluconate tab 500
CALCIUM GRA CITRATE
CALCIUM PANTOTHENATE TAB 500
CALCIUM PLUS CAP VIT D
calcium plus cap vit d
calcium tab magnesiu
calcium w/ magnesium tab 250CALCIUM W/ MAGNESIUM TAB 333CALCIUM W/ MAGNESIUM TAB 500CALCIUM W/ VITAMIN D TAB 600
calcium/vitd cap 600-400
calmag thins tab 200-50mg
CALNA TAB
carbonyl iron chew tab 15 mg
CARBONYL IRON SUSP 15 MG/1.25
child-multi chw vitamins
cholecalciferol cap 400 unit
cholecalciferol tab 400 u
CLUSIMAR SYP
COMPLETE DRO PE
cyanocobalamin inj 1000 mcg/m
cyto b2 pow
Requirements/ Limits
AL
QL 60/30
QL 60/30
AL
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
64
Formulary last updated date (11/01/2014)
Drug Name
DIALYVITE TAB SUPREM D
DOLOMITE TAB 10GR
ELDERTONIC ELX
elite ca/mg tab 100-50mg
ELITE IRON TAB 15MG
EQL CALCIUM CAP VIT D
EQL VIT D-3 TAB
ergocalciferol cap 50000 unit
ergocalciferol soln 8000
fe aspartate tab
fe fumarate w/ b12-vit c-fa-i
fe fumarate-vit c-vit b12-fa
femiron tab
feosol tab 45mg
ferate tab 28mg
ferretts fe chw 18mg
FERRETTS IPS SOL
FERRIMIN 150 TAB
FERROUS FUM TAB 29MG
FERROUS FUMA TAB
ferrous fumarate tab 325 mg (
FERROUS GLUC TAB 225MG
ferrous gluc tab 324mg
ferrous gluconate tab 240 mg
ferrous gluconate tab 324 mg
ferrous gluconate tab 325 mg
FERROUS SULF GRA
ferrous sulf syp 300/5ml
ferrous sulf tab 140mg
ferrous sulf tab 324mg ec
ferrous sulfate dried tab 200
ferrous sulfate dried tab cr
ferrous sulfate dried tab cr
ferrous sulfate elixir 220 mg
ferrous sulfate soln 75 mg/ml
ferrous sulfate tab 134 mg (2
ferrous sulfate tab 27 mg (el
ferrous sulfate tab 325 mg (6
ferrous sulfate tab cr 142 mg
ferrous sulfate tab cr 47.5 m
FERROUS SULFATE TAB CR 50 MG
ferrous sulfate tab ec 325 mg
ferrous sulfate-vit c-folic a
flintstones chw toddler
folic acid tab 1 mg
folic acid tab 200mcg
folic acid tab 400 mcg
Requirements/ Limits
QL 4/28
AL
AL
QL 30/30 AL GR
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
65
Formulary last updated date (11/01/2014)
Drug Name
folic acid tab 800 mcg
GUMMY BITES CHW
HONEY BEARS CHW IRON-ZIN
IRON HIGH CAP POTENCY
iron polysacch complex-vit b1
iron tab 18mg
iron tab 18mg cr
IRON UP LIQ
K-PHOS TAB
KP PRENATAL TAB MULTIVIT
KPN PRENATAL TAB
liquid c 500 liq 500/15ml
liquid calci cap with d3
LOZI-FLUR LOZ 1MG F
M2K CAP 60MG
mag carbonat pow 250mg/gm
MAG CARBONAT POW HEAVY
MAG CITRATE TAB 100MG
mag-200 tab
MAG-TAB SR TAB 84MG
MAGIMIN TAB 80MG
MAGINEX DS GRA 1230MG
MAGINEX TAB 615 MG
MAGN CHLORID CRY HEXAHYDR
MAGN CHLORID POW
magn sulfate cap 70mg
MAGNEBIND TAB 200
MAGNESIUM CAP 100 MG
MAGNESIUM CAP 300MG
magnesium cap 400mg
MAGNESIUM CHLORIDE INJ 200 MG
magnesium chloride tab cr 535
magnesium gl tab 550mg
MAGNESIUM GLUCONATE TAB 27.5
MAGNESIUM GLUCONATE TAB 500 M
MAGNESIUM GLUCONATE TAB 500 M
magnesium gluconate tab 500 m
MAGNESIUM OXIDE CAP 500 MG (E
magnesium oxide tab 250 mg (m
magnesium oxide tab 400 mg (2
magnesium oxide tab 400 mg (2
MAGNESIUM OXIDE TAB 500 MG (M
magnesium pow oxide
MAGNESIUM SULFATE 1% IN D5W
magnesium sulfate inj 4%
magnesium sulfate inj 50%
magnesium sulfate inj 8%
Requirements/ Limits
QL 30/30 AL GR
AL
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
66
Formulary last updated date (11/01/2014)
Drug Name
magnesium tab 100 mg
magnesium tab 200 mg
magnesium tab 250 mg
MAGNESIUM TAB 30MG
MAGNESIUM TAB 30MG
MAGNESIUM TAB 500MG
MAGONATE LIQ 1000/5ML
magtrate tab 500mg
mega biotin cap 10mg
mephyton tab 5mg
mg aspartate tab 65mg
MG GLUCONATE TAB 250MG
MG SO4/D5W INJ 20MG/ML
multi-delyn liq /iron
mykidz iron sus 10mg/2ml
MYKIDZ IRON SUS 15/1.5ML
nanovm pow 1-3 yrs
NANOVM T/F LIQ
neuro-k-250 cap t.d.
niacin cap cr 250 mg
niacin cap cr 500 mg
niacin tab 100 mg
niacin tab 250 mg
niacin tab 50 mg
niacin tab 500 mg
niacin tab cr 250 mg
niacin tab cr 500 mg
niacin tab cr 750 mg
NIACIN TR TAB 1000MG
niacinamide tab 100 mg
niacinamide tab 500 mg
NIACINAMIDE TAB 500MG PR
novaferrum cap 50mg
NOVAFERRUM DRO 15MG/ML
NUTRICION TAB PORVIDA
ORAZINC TAB 110MG
OS-CAL CHW
OSTEO-PORETI TAB
ostigen mis 350mg
OYST SHELL/D TAB 250MG
oyster shell calcium tab
oyster shell tab plus d
PABA TAB 100MG
panto-250 cap
PANTOTHENIC ACID TAB 500 MG
PARVA-CAL TAB 250-100
PARVA-CAL TAB 500MG
Requirements/ Limits
AL
AL
AL
AL
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
67
Formulary last updated date (11/01/2014)
Drug Name
PERFECT IRON TAB 25MG
PERRY PRENAT CAP
PHLEXY-VITS POW
phos-nak pow concentr
phytonadione tab 100 mcg
POLYSACCHARIDE IRON COMPLEX C
POLYSACCHARIDE IRON COMPLEX C
POSTURE TAB
pot bicarbonate & chloride ef
pot phos monobasic w/sod phos
POTABA CAP 500MG
POTABA TAB 500MG
potassium bicarbonate effer t
potassium chloride cap cr 10
potassium chloride cap cr 8 m
potassium chloride microencap
potassium chloride microencap
potassium chloride microencap
potassium chloride oral liq 1
potassium chloride powder pac
potassium chloride tab cr 10
potassium chloride tab cr 8 m
PRENATAL TAB
PRENATAL TAB 27-0.8MG
PRENATAL TAB COMPLETE
PRENATAL TAB VITAMINS
profe cap 180mg
PROFERRIN ES TAB 12 MG
protexin syp
pur-absorb liq 5mg/20ml
pyridoxine hcl tab 100 mg
pyridoxine hcl tab 200 mg
pyridoxine hcl tab 25 mg
pyridoxine hcl tab 250 mg
pyridoxine hcl tab 50 mg
pyridoxine hcl tab 500 mg
pyridoxine hcl tab cr 200 mg
RA CA/BORON TAB
RA ESSENCE-C POW LMN-LIME
ra oys shl/d tab 250mg
ra vitamin c chw 300mg
RIBOFLAVIN CAP 100MG
RIBOFLAVIN CAP 50MG
RIBOFLAVIN TAB 100 MG
riboflavin tab 25 mg
RIBOFLAVIN TAB 400MG
riboflavin tab 50 mg
Requirements/ Limits
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
68
Formulary last updated date (11/01/2014)
Drug Name
scooby-doo chw
slow rel fe tab 143mg cr
slow release tab 143mg
sodium chloride tab 1 gm
sodium fluoride chew tab 0.5
sodium fluoride chew tab 1 mg
SODIUM FLUORIDE SOLN 0.5 MG/M
STROVITE FOR SYP
SUPERVITE EC TAB
SYNATEK CAP
thiamine cap 50mg
thiamine hcl tab 100 mg
THIAMINE HCL TAB 250 MG
thiamine hcl tab 50 mg
THIAMINE MONONITRATE TAB 100
tl g-fol os tab
udamin sp tab
UPCAL D POW
UPCAL D POW
vita-c cry
VITA-CALCIUM WAF
vitamin b-12 tab 1000mcg
vitamin c cap 500mg
VITAMIN C CHW 1000MG
vitamin c chw gummie
VITAMIN C SOL
ZINC 15 TAB 66MG
zinc loz
ZINC SULFATE CAP 220 MG (50 M
ZINC SULFATE GRA HEPTAHYR
ZINC SULFATE INJ 1MG/ML
ZINC SULFATE INJ 5MG/ML
zinc sulfate pow
zinc sulfate tab
ZINC SULFATE TAB 220 MG (50 M
ZINC TAB 220MG
Requirements/ Limits
AL
AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required
QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584
69
Formulary last updated date (11/01/2014)
* *artificial tear ophth ointme 46
*artificial tear ophth soluti 46
*b-complex w/ c & folic acid 62
*condoms - male***
42
*iron combination cap*** 62
*lactobacillus acidophilus-pe 29
*multiple vitamin tab**
62
*multiple vitamins w/ iro
62
*multiple vitamins w/ mineral
62
*neomycin-bacitracin-polymyxi
22
*nit remover - gel***
22
*nystatin topical powder** 22
*oral electrolyte solution*** 62
*oral electrolyte tab***
62
*oral vehicles***
42
*pe-apap cap & doxylamine-pe50
*pediatric multiple vitamin l 62
*pediatric multiple vitamin w 62
*pediatric multiple vitamins 62
*pediatric vitamins acd w/ fl 62
*pediatric vitamins adc d
62
*sodium polystyrene sulfonate
42
*white petrolatum-mineral oil46
1 1 ml syrimge mis 18gx1"
42
1 ml syringe mis 22x1-1/2 42
1ml syr/need mis 26gx5/8" 42
1ml syringe mis 23gx1"
42
1ml syringe mis 25gx1"
42
1ml syringe mis 25gx5/8"
42
1ml syringe mis 26gx3/8"
42
A a-200 gel 0.33-4%
22
abreva cre 10%
22
acarbose tab 100 mg
12
acarbose tab 25 mg
12
acarbose tab 50 mg
12
acebutolol hcl cap 200 mg 16
acebutolol hcl cap 400 mg 16
acerola c waf 500mg
62
acetamin sup 650mg
1
acetaminophen cap 500 mg 1
acetaminophen chew tab 80 mg
1
70
acetaminophen elixir 160 mg/51
acetaminophen liquid 160 mg/5
1
acetaminophen soln 100 mg/ml
1
acetaminophen suppos 120 mg 1
acetaminophen suppos 325 mg 1
acetaminophen susp 80
mg/0.8m
1
acetaminophen tab 325 mg
1
acetaminophen tab 500 mg
1
acetaminophen tab cr 650 mg 1
acetaminophen w/ codeine soln
2
acetaminophen w/ codeine tab 2
acetaminophen w/ dm liq 100050
acetaminophen w/ dm liq 160-5
50
acetaminophen-caffeine-py
1
acetaminophen-guaifenesin tab
50
acetazolamide cap sr 12hr 500
19
acetazolamide tab 125 mg 19
acetazolamide tab 250 mg 19
acetic acid 2% in aluminum ac
48
acetic acid otic soln 2%
48
acetone sol
22
acetylcysteine inhal soln 10% 51
acetylcysteine inhal soln 20% 51
acidophilus/ tab cit pect
29
acne medicat lot 10%
22
acne medicat lot 5%
22
acnotex lot
22
actiphyte of liq lemongra
22
acyclovir cap 200 mg
11
acyclovir susp 200 mg/5ml 11
acyclovir tab 400 mg
11
acyclovir tab 800 mg
11
adrenaclick inj 0.3mg
43
advair disku aer 100/50
50
advil allerg tab congest
51
advil allerg tab sinus
51
advil cold/ cap sinus
51
advil congst tab relief
51
agoral liq max st
29
akray expression test strips 43
ala-hist pe tab 2-10mg
51
alamag chw 300-150
29
albatussin liq nn
51
albuterol sulfate soln nebu 0 50
albuterol sulfate syrup 2 mg/ 50
albuterol sulfate tab 2 mg
50
albuterol sulfate tab 4 mg
50
alclometasone dipropionate cr
22
alclometasone dipropionate oi
22
alcohol isop sol 50% wint
22
alendronate sodium tab 10 mg
42
alendronate sodium tab 35 mg
42
alendronate sodium tab 40 mg
42
alendronate sodium tab 5 mg 42
alendronate sodium tab 70 mg
42
aler-dryl tab 50mg
49
alevazol oin 1%
22
alka seltzer tab heartbrn
29
alka-selt pl cap cold/cgh
51
alka-selt pl mis day/nght
51
alka-selt pl tab cld/flu
51
alka-selt pl tab cold/cgh
51
alka-selt pl tab nght cld
51
allopurinol tab 100 mg
8
allopurinol tab 300 mg
8
alora dis 0.025mg
35
alora dis 0.05mg
35
alora dis 0.075mg
35
alora dis 0.1mg
36
altavera
36
alum & mag hydroxidesimethic
29
aluminum hydroxidemagnesium
29
alyacen 1/35
36
amantadine hcl cap 100 mg 10
amantadine hcl syrup 50 mg/5m
10
amiloride & hydrochlorothiazi
20
amiloride hcl tab 5 mg
20
amiodarone hcl tab 200 mg 15
amlodipine besylate tab 10 mg
17
amlodipine besylate tab 2.5 m
17
amlodipine besylate tab 5 mg 17
amlodipine besylate-benazepri
15
ammonium lac sol 70%
22
amoxicillin & k clavulanate c 6
amoxicillin & k clavulanate f 6
amoxicillin & k clavulanate t 6
amoxicillin (trihydrate) cap 6
amoxicillin (trihydrate) chew 6
amoxicillin (trihydrate) for
6
amoxicillin (trihydrate) tab
6
ampicillin cap 250 mg
6
ampicillin cap 500 mg
6
ampicillin for susp 125 mg/5m 6
ampicillin for susp 250 mg/5m 6
anagrelide hcl cap 0.5 mg
14
anagrelide hcl cap 1 mg
14
anastrozole tab 1 mg
9
anbesol liq 10%
21
anise oil
22
anoro ellipt aer 62.5-25
50
antacid chw
29
antioxidant cap
62
antipyrine-benzocaine otic so 48
apidra inj u-100
13
apri
36
apriso cap 0.375gm
42
arkray glucocard vital test s 43
armour thyro tab 120mg
39
armour thyro tab 15mg
39
armour thyro tab 180mg
39
armour thyro tab 240mg
39
armour thyro tab 300mg
39
a-s pl sinus tab 7.8-325
50
a-s pls sinu cap allr/cgh
50
ascocid-iso- pow ph
62
ascorbic acid cap cr 500 mg 62
ascorbic acid chew tab 100 mg
62
ascorbic acid chew tab 250 mg
62
ascorbic acid chew tab 500 mg
62
ascorbic acid inj 500 mg/ml 62
ascorbic acid liquid 500 mg/5 62
ascorbic acid lozenge 60 mg 62
71
ascorbic acid syrup 500 mg/5m
62
ascorbic acid tab 100 mg
62
ascorbic acid tab 1000 mg 62
ascorbic acid tab 250 mg
62
ascorbic acid tab 500 mg
63
ascorbic acid tab cr 1000 mg 63
ascorbic acid tab cr 1500 mg 63
ascorbic acid tab cr 500 mg 63
ascriptin tab
3
aspirin buffered (ca carb-mg 3
aspirin buffered tab 325 mg 3
aspirin chew tab 81 mg
3
aspirin suppos 300 mg
3
aspirin suppos 600 mg
3
aspirin tab 325 mg
3
aspirin tab 500 mg
3
aspirin tab 650mg ec
3
aspirin tab 81 mg
3
aspirin tab delayed release 3 3
aspirin tab delayed release 5 3
aspirin tab delayed release 8 3
aspirin-acetaminophen-caffein 1
atabex chw prenatal
61
atabex ec tab
61
atabex tab prenatal
61
atenolol & chlorthalidone tab 15
atenolol tab 100 mg
16
atenolol tab 25 mg
16
atenolol tab 50 mg
16
atorvastatin calcium tab 10 m 20
atorvastatin calcium tab 20 m 20
atorvastatin calcium tab 40 m 20
atorvastatin calcium tab 80 m 20
atovaquone susp 750 mg/5ml 10
atropine sulfate ophth oint 1 47
atropine sulfate ophth soln 1 47
atrovent hfa aer 17mcg
50
aubra
36
autoshield mis 29x3/16"
43
autoshield mis 29x5/16"
43
autoshield mis 30gx3/16
43
aviane
36
avonex kit 30mcg
21
avonex prefl kit 30mcg
21
azathioprine tab 50 mg
41
azelastine hcl ophth soln 0.0 47
azithromycin for susp 100 mg/ 7
azithromycin for susp 200 mg/ 7
azithromycin tab 250 mg
7
azithromycin tab 500 mg
7
azithromycin tab 600 mg
7
azor tab 10-20mg
15
azor tab 10-40mg
15
azor tab 5-20mg
15
azor tab 5-40mg
15
B b1 natural tab 250mg
63
b-1 tab 500mg
63
b-2-400 cap
63
baby orajel liq 7.5%
21
bacitracin oint 500 unit/gm 22
bacitracin ophth oint 500 uni 47
bacitracin zinc oint 500 unit 22
bacitracin-polymyxin b ophth 47
bacitracin-polymyxin-neomycin
47
baclofen tab 10 mg
60
baclofen tab 20 mg
60
balsalazide disodium cap 750 42
barc liq
22
bd saf-t-int kit 24gx0.75
43
be well pak rounded
63
belladonna alkaloids-phenobar
28
benazepril & hydrochlorothiaz
15
benazepril hcl tab 10 mg
14
benazepril hcl tab 20 mg
14
benazepril hcl tab 40 mg
14
benazepril hcl tab 5 mg
14
benfotiamine cap 150mg
63
bensulfoid cre
22
benzocaine dental cream 20%21
benzocaine dental gel 10% 21
benzocaine dental gel 20% 21
benzocaine dental gel 7.5% 21
benzocaine dental liquid 20% 21
benzocaine dental paste 20% 21
benzocaine dental soln 20% 21
benzocaine dental swab 20% 21
benzocaine-docusate sodium re
29
benzodent oin 20%
21
benzonatate cap 100 mg
51
benzonatate cap 200 mg
51
benzoyl per gel 2.5%
22
benzoyl peroxide cleanser 3.522
benzoyl peroxide cream 10% 22
benzoyl peroxide cream 2.5%22
benzoyl peroxide creamy wash
22
benzoyl peroxide gel 10% 22
benzoyl peroxide gel 4%
22
benzoyl peroxide gel 5%
22
benzoyl peroxide liq 10%
22
benzoyl peroxide liq 2.5% 22
benzoyl peroxide liq 5%
22
benzoyl peroxide lotion 6% 22
benzoyl peroxide lotion 8% 22
benzyl benzo liq
22
betamethasone dipropionate au
22
betamethasone dipropionate cr
22
betamethasone dipropionate lo
22
betamethasone dipropionate oi
22
betamethasone valerate cream
22
betamethasone valerate lotion22
betamethasone valerate oint 0 22
betaxolol hcl ophth soln 0.5%48
bethanechol chloride tab 10 m
34
bethanechol chloride tab 25 m
34
bethanechol chloride tab 5 mg
34
bethanechol chloride tab 50 m
34
bicalutamide tab 50 mg
9
bicarsim tab 125mg
29
bicarsim tab 80mg
29
bicillin c-r inj 1200000
6
bicillin c-r inj 900/300
6
biclora liq
51
biclora tab 25-25mg
51
biclora-d liq
51
biclora-d tab
51
biobron sf syp
51
bionel liq pediatrc
51
biospec dmx liq
51
biotin cap 1mg
63
biotin cap 2.5 mg
63
biotin cap 5 mg
63
biotin forte tab 3mg
63
biotin tab 1000 mcg
63
biotin tab 10mg
63
72
biotin tab 2.5 mg
63
biotin tab 300 mcg
63
biotin tab 5 mg
63
biotin tab 7500mcg
63
biotin tab 800 mcg
63
bisacodyl suppos 10 mg
29
bisacodyl tab delayed release 29
bismuth subsalicylate chew ta29
bismuth subsalicylate susp 26 29
bismuth subsalicylate susp 52 29
bismuth subsalicylate tab 262 29
bisoprolol & hydrochlorothiaz
15, 16
bisoprolol fumarate tab 10 mg
16
bisoprolol fumarate tab 5 mg 16
blephamide oin s.o.p.
47
blephamide sus op
47
blink tears dro 0.25% op
46
b-natal loz 25mg
63
bone meal tab
63
bp cleansing lot 4%
22
bpm-pse-dm liq 4-20-20
51
brainstrong mis prenatal
61
brasivol pst
22
breo ellipta inh 100-25
50
brimonidine tartrate ophth so 46
brohist d tab 4-10mg
51
bromocriptine mesylate cap 5 10
bromocriptine mesylate tab 2.10
brompheniramine &
phenylephri
51
brompheniramine &
pseudoephed
51
broncotron dro ped
51
broncotron-s liq 20-400/5
51
bronkaid tab 25-400mg
51
bronkids dro
51
bronkids liq 10-4-10
51
brontuss dx liq
51
budesonide inhalation susp 0. 49
buffered vit cap c 1000mg 63
bumetanide tab 0.5 mg
19
bumetanide tab 1 mg
19
bumetanide tab 2 mg
19
bupropion hcl (smoking deterr 2
butalbital-acetaminophen tab 1
butalbital-acetaminophen-caff 1
butalbital-aspirin-caff w/ co 1
butalbital-aspirin-caffeine c 1
butalbital-aspirin-caffeine t
1
bydureon inj
12
bystolic tab 10mg
16
bystolic tab 2.5mg
16
bystolic tab 20mg
16
bystolic tab 5mg
16
C ca citrate tab 250mg
63
ca hi-cal/d tab 250mg
63
ca hi-cal/d tab 500mg
63
ca pantothen tab 100mg
63
ca pantothen tab 200mg
63
cal carb & mag hydrox-simethi
29
cal cit mal/ tab vitamind
63
cal/mag tab chew
63
calc citrate liq vit d3
63
calc/vit d3 chw 200-200
63
calcet bites chw 500-400
63
calcitonin (salmon) nasal sol 42
cal-citrate cap 150mg
63
cal-citrate tab plus d
63
calcitriol cap 0.25 mcg
60
calcitriol cap 0.5 mcg
60
calcium &mag tab
63
calcium 1000 tab + d
63
calcium acetate (phosphate bi 34
calcium ascorbate tab 500 mg63
calcium carb tab 648mg
29
calcium carbonate (antacid) c 29
calcium carbonate tab 1250 mg
63
calcium carbonate-cholecalcif
63, 64
calcium carbonate-ergocalcife
64
calcium carbonate-mag hydroxi
29
calcium carbonate-simethicone
29
calcium carbonate-vitamin d c
64
calcium carbonate-vitamin d t64
calcium chw 600-400
64
calcium cit tab 1040mg
64
calcium cit tab w/vit d
64
calcium citrate tab 950 mg (2 64
calcium citrate-vitamin d tab 64
calcium glubionate syrup
64
calcium gluconate tab 500 64
calcium gra citrate
64
calcium pantothenate tab 500 64
calcium plus cap vit d
64
calcium polycarbophil tab 625
29
calcium tab magnesiu
64
calcium w/ magnesium tab 25064
calcium w/ magnesium tab 33364
calcium w/ magnesium tab 50064
calcium w/ vitamin d tab 600 64
calcium/vitd cap 600-400
64
cal-cyum waf 500mg
63
cal-mag chel cap 70-83mg 63
calmag thins tab 200-50mg 64
calna tab
64
cal-quick liq 500-400
63
camila
36
camphor sol spirits
22
capcof syp
51
capecitabine tab 150 mg
9
capecitabine tab 500 mg
9
capmist dm tab
51
capron dm liq
51
capsagel gel 0.025%
23
capsagel ms gel 0.075%
23
capsagel xs gel 0.05%
23
capsaicin cream 0.025%
23
capsaicin cream 0.075%
23
capsaicin cream 0.1%
23
captopril & hydrochlorothiazi16
captopril tab 100 mg
14
captopril tab 12.5 mg
14
captopril tab 25 mg
14
captopril tab 50 mg
14
capzasin liq 0.15%
23
carbamide peroxide 6.5% otic48
carbaphen 12 liq
51
carbaphen ch sus
51
carbaphen sus ped ch
51
carbidopa & levodopa tab 10-1
10
carbidopa & levodopa tab 25-1
10
carbidopa & levodopa tab 25-2
10
carbidopa & levodopa tab cr 2
10
73
carbidopa & levodopa tab cr 5
10
carbidopa tab 25 mg
10
carbonyl iron chew tab 15 mg64
carbonyl iron susp 15 mg/1.25
64
carboxymethylcellulose sodium
46
carboxymethylcellulose-glycer
46
carteolol hcl ophth soln 1% 48
carvedilol tab 12.5 mg
16
carvedilol tab 25 mg
16
carvedilol tab 3.125 mg
16
carvedilol tab 6.25 mg
16
castiva lot
23
castor oil
23
caziant
36
ccp caffeine tab free
51
cedar leaf oil
23
cefaclor cap 250 mg
5
cefaclor cap 500 mg
5
cefaclor sus 125/5ml
5
cefaclor sus 250/5ml
5
cefaclor sus 375/5ml
5
cefadroxil cap 500 mg
5
cefadroxil for susp 250 mg/5m 5
cefadroxil for susp 500 mg/5m 5
cefadroxil tab 1 gm
5
cefdinir cap 300 mg
5
cefdinir for susp 125 mg/5ml 5
cefdinir for susp 250 mg/5ml 5
cefpodoxime proxetil for susp 5
cefpodoxime proxetil tab 100 5
cefpodoxime proxetil tab 200 5
cefprozil for susp 125 mg/5ml 6
cefprozil for susp 250 mg/5ml 6
cefprozil tab 250 mg
6
cefprozil tab 500 mg
6
ceftin sus 250/5ml
6
ceftriaxone sodium for inj 1 6
ceftriaxone sodium for inj 25 6
ceftriaxone sodium for inj 50 6
cefuroxime axetil for susp 12 6
cefuroxime axetil tab 250 mg 6
cefuroxime axetil tab 500 mg 6
celery seed oil
23
cellcept sus 200mg/ml
41
centrum spec pak prenatal 61
cephalexin cap 250 mg
6
cephalexin cap 500 mg
6
cephalexin for susp 125 mg/5m
6
cephalexin for susp 250 mg/5m
6
certuss-d tab
51
cesia
36
cetirizine hcl oral soln 1 mg 49
cetirizine hcl tab 10 mg
49
cetirizine hcl tab 5 mg
49
cetirizine-pseudoephedrine ta 51
chantix pak 0.5& 1mg
2
chantix pak 1mg
3
chantix tab 0.5mg
3
chateal
36
chemet cap 100mg
43
cherry syp
43
chest conges gra children
51
chest congst gra childrns
51
chest congst gra cough
51
child-multi chw vitamins
64
chlo tuss ex liq 12.5-100
51
chlo tuss liq
52
chlophed liq
52
chlorhexidin sol gluconat
23
chlorhexidine gluconate soln 21
chloroform sol
23
chloroquine phosphate tab 250
10
chlorothiazide tab 250 mg 20
chlorothiazide tab 500 mg 20
chlorphenir pow maleate
49
chlorpheniramine & phenylephr
52
chlorpheniramine &
pseudoephe
52
chlorpheniramine maleate syru
49
chlorpheniramine maleate tab 49
chlorpheniramine w/ codeine l
52
chlorpheniramine-acetaminophe
52
chlorpheniramine-dm liquid 152
chlorpheniramine-dm liquid 252
chlorpheniramine-dm tab 4-30
52
chlorpheniramine-phenylephrin
52
chlorphen-pe-apap tab & diphe
52
chlorphen-pe-apap tab 2-5-325
52
chlorphen-phenylephrine w/ ap
52
chlorphen-pseudoephedrine w/
52
chlorpropamide tab 100 mg 12
chlorpropamide tab 250 mg 12
chlorthalidone tab 100 mg 20
chlorthalidone tab 25 mg
20
chlorthalidone tab 50 mg
20
chlorzoxazone tab 500 mg 60
cholecalciferol cap 400 unit 64
cholecalciferol tab 400 u
64
cholestyramine powder 4 gm/do
21
cholestyramine powder packets
21
choline & magnesium salicylat 3
ciclopirox solution 8%
23
cilostazol tab 100 mg
14
cilostazol tab 50 mg
14
ciloxan oin 0.3% op
47
cimetidine hcl soln 300 mg/5m
32
cimetidine tab 200 mg
32
cimetidine tab 300 mg
32
cimetidine tab 400 mg
32
cimetidine tab 800 mg
32
cinnamon oil artific
23
ciprofloxacin 0.2% sol
47
ciprofloxacin hcl ophth soln 47
ciprofloxacin hcl tab 100 mg 7
ciprofloxacin hcl tab 250 mg 7
ciprofloxacin hcl tab 500 mg 7
ciprofloxacin hcl tab 750 mg 7
citrocarbona gra
29
citronella oil
23
clarithromycin for susp 125 m 7
clarithromycin for susp 250 m 7
clarithromycin tab 250 mg
7
clarithromycin tab 500 mg
7
clarithromycin tab sr 24hr 50 7
claritin rdt tab 5mg
49
clean&clear kit acne
23
clear eyes dro dry eyes
46
74
clearcanal kit ear wax
48
clearlax pow
29
clemastine fumarate syrup 0.6
49
clemastine fumarate tab 1.34 49
clemastine fumarate tab 2.68 49
cleocin sup 100mg
34
clidinium & chlordiazepoxide28
clindamycin hcl cap 150 mg 5
clindamycin hcl cap 300 mg 5
clindamycin hcl cap 75 mg
5
clindamycin phosphate lotion 23
clindamycin phosphate soln 1%
23
clindamycin phosphate swab
1%
23
clindamycin phosphate vaginal
34
clindamycin sol 75mg/5ml
5
clobetasol propionate cream 0
23
clobetasol propionate oint 0. 23
clobetasol propionate soln 0. 23
clofera liq
52
clonidine hcl tab 0.1 mg
18
clonidine hcl tab 0.2 mg
18
clonidine hcl tab 0.3 mg
18
clopidogrel bisulfate tab 300 14
clopidogrel bisulfate tab 75 14
clotrimazole cream 1%
23
clotrimazole soln 1%
23
clotrimazole troche 10 mg 21
clotrimazole vaginal cream 1%
34
clotrimazole vaginal cream 2%
34
clotrimazole w/ betamethasone
23
clove oil
23
clusimar syp
64
cntc cld/flu pak day/nght
52
cntc cld/flu tab max st
52
codar ar liq
52
codar d liq
52
codar gf liq
52
codeine sulf tab 15mg
2
codeine sulf tab 60mg
2
codeine sulfate tab 30 mg
2
codituss dm syp
52
colchicine w/ probenecid tab 8
colcrys tab 0.6mg
8
colestipol hcl granule packet 21
colestipol hcl granules 5 gm 21
colestipol hcl tab 1 gm
21
comp prnatal mis dha
61
complete dro pe
64
complete nat pak dha
61
complete sin tab relief
52
completenate chw
61
computer eye sol drops
46
co-natal fa tab 29-1mg
61
condoms latex lubricated
43
condoms latex non-lubrica 43
condoms non-latex non-lub 43
conex sol cld/alrg
52
conex tab 2-60mg
52
contour next test strips, box 43
control solution, arkray expr 43
control solution, arkray gluc 43
control solution, freestyle
43
control solution, one touch u 43
control solution, sd gluconav 43
copaxone kit 20mg/ml
21
coricidin nt liq cold/cgh
52
coricidn hbp mis multi sy
52
correctol mis herbal
29
cortisone acetate tab 25 mg 35
cortisporin oin 1%
23
cortizone-10 liq /aloe 1%
23
cosopt
sol 2-0.5%op
48
cottonseed oil
23
cough d syp
52
cpb wc liq
52
creon cap 12000unt
28
creon cap 24000unt
28
creon cap 3000unit
28
creon cap 36000unt
28
creon cap 6000unit
28
cromolyn sodium nasal aerosol
50
cromolyn sodium ophth soln
4%
47
cromolyn sodium soln nebu 20
50
culturelle cap
29
culturelle chw di
29
curity prep pad alcohol
43
cvs prenatal chw gummy
61
cvs purelax pow
30
cyanocobalamin inj 1000
mcg/m
64
cyclafem 1/35
36
cyclafem 7/7/7
36
cyclobenzaprine hcl tab 10 mg
60
cyclobenzaprine hcl tab 5 mg 60
cyclomydril sol op
47
cyclopentolate hcl ophth soln 48
cyclophosphamide tab 25 mg 9
cyclophosphamide tab 50 mg 9
cycloserine cap 250 mg
9
cyclosporine cap 100 mg
41
cyclosporine cap 25 mg
41
cyclosporine modified cap 100
42
cyclosporine modified cap 25 42
cyclosporine modified cap 50 42
cyclosporine modified oral so 42
cyproheptadine hcl syrup 2 mg
49
cyproheptadine hcl tab 4 mg 49
cyto b2 pow
64
cytra-k sol
60
D dallergy dro 1-2.5mg
52
dallergy syp
52
dallergy tab 1-5mg
52
dallergy tab 25-10mg
52
dapsone tab 100 mg
5
dapsone tab 25 mg
5
daraprim tab 25mg
10
dasetta 1/35
36
dasetta 7/7/7
36
day/nyquil liq severe
52
daytime liq cold med
52
decon-a elx 2-5mg/5m
52
decon-a liq drops
52
decon-g dro 2-1-40mg
52
deltuss dp liq 1-30/5ml
53
delyla
36
delzicol cap 400mg
42
denatured sol alcohol
23
denorex dual sha 1%-3%
23
derma-smooth oil /fs body 23
derma-smooth oil /fs sclp
23
desmopressin acetate nasal sp 39
desmopressin acetate tab 0.1 39
desmopressin acetate tab 0.2 39
desogestrel/ethinyl estradiol 36
75
desonide oint 0.05%
23
despec dm syp
53
despec-dm tab
53
dewees carmi liq
30
dexamethasone conc 1 mg/ml 35
dexamethasone elixir 0.5 mg/5
35
dexamethasone sodium
phosphat
48
dexamethasone soln 0.5 mg/5ml
35
dexamethasone tab 0.5 mg 35
dexamethasone tab 0.75 mg 35
dexamethasone tab 1.5 mg 35
dexamethasone tab 2 mg
35
dexamethasone tab 4 mg
35
dexamethasone tab 6 mg
35
dexatrex d elx cf-nasal
53
dexbrompheniramine &
pseudoep
53
dexchlorpheniramine maleate s
49
dexpak pak 10 day
35
dextromethorphan hbr syrup 15
53
dextromethorphan-apap-chlorph
53
dextromethorphan-doxylaminea
53
dextromethorphan-guaifenesin
53
dextromethorphan-phenylephrin
53
dex-tuss liq 300-10/5
53
diabetic cap cold/flu
53
diabetic tus liq cold/flu
53
dialyvite tab suprem d
65
dicel cd liq
53
diclofenac potassium tab 50 m 3
diclofenac sodium ophth soln 48
diclofenac sodium tab delayed 3
diclofenac sodium tab sr 24hr 3
dicloxacillin sodium cap 250 6
dicloxacillin sodium cap 500 6
dicyclomine hcl cap 10 mg 28
dicyclomine hcl tab 20 mg 28
diflorasone diacetate oint 0. 23
diflunisal tab 500 mg
3
di-gel chw
30
di-gel sus
30
digoxin tab 125 mcg (0.125 mg
18
digoxin tab 250 mcg (0.25 mg)
18
diltiazem hcl cap sr 12hr 120 17
diltiazem hcl cap sr 12hr 60 17
diltiazem hcl cap sr 12hr 90 17
diltiazem hcl cap sr 24hr 120 16
diltiazem hcl cap sr 24hr 180 17
diltiazem hcl cap sr 24hr 240 17
diltiazem hcl coated beads ca 17
diltiazem hcl coated beads ta 17
diltiazem hcl extended releas 17
diltiazem hcl tab 120 mg
18
diltiazem hcl tab 30 mg
18
diltiazem hcl tab 60 mg
18
diltiazem hcl tab 90 mg
18
dimenhydrin inj 50mg/ml
8
dimenhydrinate tab 50 mg
8
dimetapp cld chw /allergy
53
dimetapp syp cgh/cold
53
dimethyl sol sulfoxid
23
diphenhydramine hcl cap 25 mg
49
diphenhydramine hcl chew tab
49
diphenhydramine hcl elixir 12
49
diphenhydramine hcl liquid 12
49
diphenhydramine hcl syrup 12.
49
diphenhydramine hcl tab disp 49
diphenhydramineacetaminophen
53
diphenhydraminephenylephrine
53
diphenhydramine-pse w/ apap t
53
diphenoxylate w/ atropine liq 30
diphenoxylate w/ atropine tab 30
dipyridamole tab 25 mg
14
dipyridamole tab 50 mg
14
dipyridamole tab 75 mg
14
disopyramide phosphate cap 10
15
disopyramide phosphate cap 15
15
diuril sus 250/5ml
20
dm-gg-pot cit-citric acid liq 54
docusate calcium cap 240 mg 30
docusate sodium cap 100 mg 30
docusate sodium cap 250 mg 30
docusate sodium cap 50 mg 30
docusate sodium enema 283 mg
30
docusate sodium liquid 150 mg
30
docusate sodium syrup 60 mg/1
30
docusate sodium tab 100 mg 30
docusol kids ene 100mg/5m 30
dologen tab
54
dolomite tab 10gr
65
dometuss-da liq 1-2.5mg
54
donatussin syp
54
donepezil hydrochloride tab 1 8
donepezil hydrochloride tab 5 8
doribax inj 250mg
5
doribax inj 500mg
5
dorzolamide hcl ophth soln 2%
47
dorzolamide hcl-timolol malea
48
doxazosin mesylate tab 1 mg 18
doxazosin mesylate tab 2 mg 18
doxazosin mesylate tab 4 mg 18
doxazosin mesylate tab 8 mg 18
doxycycline hyclate cap 100 m7
doxycycline hyclate cap 50 mg7
doxycycline hyclate tab 100 m 7
doxycycline monohydrate for s7
doxylamine-dm 6.25-15
mg/15ml
54
doxylamine-dm liquid 6.25-15
54
doxylamine-phenylephrine-apap
54
dramamine chw 50mg
8
drixoral cap cgh & st
54
drixoral tab cold/flu
54
dronabinol cap 10 mg
8
dronabinol cap 2.5 mg
8
dronabinol cap 5 mg
8
dulcolax kit bowel
30
dulcolax pow balance
30
dulera aer 100-5mcg
50
dulera aer 200-5mcg
50
duravent pe tab 10-395mg 54
dyphylline-guaifenesin liqd 1 54
76
dyphylline-guaifenesin tab 2054
E econazole nitrate cream 1% 23
ed chlorped dro d
54
ed chlorped liq 2mg/ml
49
ed-chlor-tan tab 8mg
49
effaclar duo sol 5.5%
23
effient tab 10mg
14
effient tab 5mg
14
eldertonic elx
65
eligard inj 22.5mg
9
eligard inj 30mg
9
eligard inj 45mg
9
eligard inj 7.5mg
9
elite ca/mg tab 100-50mg
65
elite iron tab 15mg
65
elixophyllin elx 80/15ml
54
elixsure gel congest
54
emoquette
36
enablex tab 15mg
34
enablex tab 7.5mg
34
enalapril maleate & hydrochlo
16
enalapril maleate tab 10 mg 14
enalapril maleate tab 2.5 mg 14
enalapril maleate tab 20 mg 14
enalapril maleate tab 5 mg 14
endacon syp
54
enfamil mis expecta
61
enoxaparin sodium inj 100 mg/
13
enoxaparin sodium inj 120 mg/
13
enoxaparin sodium inj 150 mg/
13
enoxaparin sodium inj 30 mg/0
13
enoxaparin sodium inj 300 mg/
13
enoxaparin sodium inj 40 mg/0
13
enoxaparin sodium inj 60 mg/0
13
enoxaparin sodium inj 80 mg/0
13
enpresse-28
36
enskyce
36
entex lq liq
54
entex t tab 60-375mg
54
entre-cough sus tannate
54
ephedrine-guaifenesin tab 12. 54
epinephrine inj 0.3mg
43
epipen 2-pak inj 0.3mg
43
epipen-jr inj 0.15mg
43
epivir hbv sol 5mg/ml
11
epogen inj 10000/ml
13
epogen inj 2000/ml
13
epogen inj 20000/ml
13
epogen inj 3000/ml
13
epogen inj 4000/ml
13
eq clearlax pow
30
eql acetamin tab 160mg
1
eql acetamin tab 80mg
1
eql calcium cap vit d
65
eql clearlax pow
30
eql infant dro dcon/cgh
54
eql natural pow fiber
30
eql vit d-3 tab
65
equalactin chw 625mg
30
ergocalciferol cap 50000 unit 65
ergocalciferol soln 8000
65
errin
36
eryped sus 200/5ml
7
eryped sus 400/5ml
7
ery-tab tab 250mg ec
7
ery-tab tab 333mg ec
7
erythromycin ethylsuccinate t 7
erythromycin gel 2%
23
erythromycin ophth oint 5 mg/
47
erythromycin soln 2%
23
erythromycin stearate tab 250 7
erythromycin tab 250 mg
7
erythromycin tab 500 mg
7
erythromycin tab delayed rele 7
erythromycin w/ delayed relea 7
erythromycin-sulfisoxazole fo 5
esterified estrogens & methyl 38
estrace vag cre 0.1mg/gm
34
estradiol & norethindrone ace 36
estradiol tab 0.5 mg
38
estradiol tab 1 mg
38
estradiol tab 2 mg
38
estradiol td patch weekly 0.0 38
estradiol td patch weekly 0.1 38
estropipate tab 0.75 mg
38
estropipate tab 1.5 mg
39
estropipate tab 3 mg
39
ethambutol hcl tab 100 mg
9
ethambutol hcl tab 400 mg
9
ether sol
23
ethyl alcoho sol 70%
23
ethyl alcoho sol 95%
23
ethyl chlor aer mist
23
etodolac cap 200 mg
3
etodolac cap 300 mg
3
etodolac tab 400 mg
3
etodolac tab 500 mg
3
etodolac tab sr 24hr 400 mg 3
etodolac tab sr 24hr 500 mg 3
etodolac tab sr 24hr 600 mg 3
eucalyptus oil
23
eugenol sol
24
eurax cre 10%
24
eurax lot 10%
24
evac-u-gen chw 10mg
30
exoderm bar
24
extavia inj 0.3mg
21
ezfe forte cap
61
e-z-gas ii gra
30
F falmina
36
famotidine inj 20 mg/2ml
32
famotidine inj 200 mg/20ml 33
famotidine inj 20mg/50m
33
famotidine inj 40 mg/4ml
33
famotidine inj 500 mg/50ml 33
famotidine tab 10 mg
33
famotidine tab 20 mg
33
famotidine tab 40 mg
33
father johns sol plus
54
fe aspartate tab
65
fe fumarate w/ b12-vit c-fa-i 65
fe fumarate-vit c-vit b12-fa 65
felodipine tab sr 24hr 10 mg 18
felodipine tab sr 24hr 2.5 mg 18
felodipine tab sr 24hr 5 mg 18
femhrt tab 0.5-2.5
39
femiron tab
65
fenesin dm tab 15-400mg
54
fenofibrate tab 160mg
21
fenofibrate tab 54mg
21
fenofibrate micronized cap 13
20
fenofibrate micronized cap 20
20
fenofibrate micronized cap 67
20
fenoprofen calcium tab 600 mg
3
77
fentanyl td patch 72hr 100 mc 1
fentanyl td patch 72hr 12 mcg 1
fentanyl td patch 72hr 25 mcg 1
fentanyl td patch 72hr 50 mcg 1
fentanyl td patch 72hr 75 mcg 1
feosol tab 45mg
65
ferate tab 28mg
65
ferretts fe chw 18mg
65
ferretts ips sol
65
ferrimin 150 tab
65
ferrous fum tab 29mg
65
ferrous fuma tab
65
ferrous fumarate tab 325 mg (65
ferrous gluc tab 225mg
65
ferrous gluc tab 324mg
65
ferrous gluconate tab 240 mg 65
ferrous gluconate tab 324 mg 65
ferrous gluconate tab 325 mg 65
ferrous sulf gra
65
ferrous sulf syp 300/5ml
65
ferrous sulf tab 140mg
65
ferrous sulf tab 324mg ec
65
ferrous sulfate dried tab 200 65
ferrous sulfate dried tab cr 65
ferrous sulfate elixir 220 mg 65
ferrous sulfate soln 75 mg/ml 65
ferrous sulfate tab 134 mg (2 65
ferrous sulfate tab 27 mg (el 65
ferrous sulfate tab 325 mg (6 65
ferrous sulfate tab cr 142 mg 65
ferrous sulfate tab cr 47.5 m 65
ferrous sulfate tab cr 50 mg 65
ferrous sulfate tab ec 325 mg 65
ferrous sulfate-vit c-folic a 65
fexofenadine hcl susp 30 mg/5
49
finasteride tab 5 mg
34
flarex sus 0.1% op
48
flecainide acetate tab 100 mg 15
flecainide acetate tab 150 mg 15
flecainide acetate tab 50 mg 15
fleet bisaco ene 10/30ml
30
fleet naturl ene cleansng
24
flintstones chw toddler
65
flovent disk aer 100mcg
49
flovent disk aer 50mcg
49
flovent hfa aer 44mcg
49
fluconazole for susp 10 mg/ml 8
fluconazole for susp 40 mg/ml 8
fluconazole tab 100 mg
8
fluconazole tab 150 mg
8
fluconazole tab 200 mg
8
fluconazole tab 50 mg
8
fludrocortisone acetate tab 0 35
flunisolide nasal soln 25 mcg 50
flunisolide nasal soln 29 mcg 50
fluocinolone acetonide cream 24
fluocinolone acetonide oint 0 24
fluocinonide cream 0.05% 24
fluocinonide emulsified base 24
fluocinonide gel 0.05%
24
fluocinonide oint 0.05%
24
fluocinonide soln 0.05%
24
fluorometholone ophth susp 0.
48
fluorouracil cream 5%
24
fluorouracil soln 2%
24
fluorouracil soln 5%
24
flurbiprofen sodium ophth sol48
flurbiprofen tab 100 mg
3
flurbiprofen tab 50 mg
3
flutamide cap 125 mg
9
fluticasone propionate cream 24
fluticasone propionate nasal 50
fluticasone propionate oint 0 24
fml forte sus 0.25% op
48
fml oin 0.1% op
48
folic acid tab 1 mg
65
folic acid tab 200mcg
65
folic acid tab 400 mcg
65
folic acid tab 800 mcg
66
foradil cap aerolize
50
fosinopril sodium tab 10 mg 14
fosinopril sodium tab 20 mg 14
fosinopril sodium tab 40 mg 14
furosemide oral soln 10 mg/ml
19
furosemide tab 20 mg
19
furosemide tab 40 mg
19
furosemide tab 80 mg
19
G galantamine hydrobromide tab 8
gas-x child mis 40mg
30
gas-x ex-str mis 62.5mg
30
gas-x/maalox chw extra st 30
gavilax pow
30
gemfibrozil tab 600 mg
20
gentamicin sulfate cream 0.1%
24
gentamicin sulfate oint 0.1% 24
gentamicin sulfate ophth oint 47
gentamicin sulfate ophth soln 47
genteal gel
46
genteal mild dro 0.2%
46
gentlelax pow
30
gildess 1.5/30
36
gildess 1/20
36
gildess fe 1.5/30
36
gildess fe 1/20
36
giltuss liq ped-c
54
giltuss tr cap 7-14-288
54
glimepiride tab 1 mg
12
glimepiride tab 2 mg
12
glimepiride tab 4 mg
12
glipizide tab 10 mg
12
glipizide tab 5 mg
12
glipizide tab sr 24hr 10 mg 12
glipizide tab sr 24hr 2.5 mg 12
glipizide tab sr 24hr 5 mg
12
glucagon kit 1mg
13
glucose gel 40%
13
glyburide micronized tab 1.5 12
glyburide micronized tab 3 mg
12
glyburide micronized tab 6 mg
12
glyburide tab 1.25 mg
12
glyburide tab 2.5 mg
12
glyburide tab 5 mg
12
glyburide-metformin tab 1.2512
glyburide-metformin tab 2.5-5
12
glyburide-metformin tab 5-500
12
glycerin liq
24
glycerin sol synthetc
24
glycerin suppos 1 gm
30
glycerin suppos 1.2 gm
30
glycerin suppos 1.5 gm
30
glycerin suppos 2 gm
30
glycerin suppos 2.1 gm
30
glycerin suppos 80.7%
30
glycerin-hypromellose-peg 400
46
glycine soya sol extract
24
glycine soya sol protein
24
glycolax pow 3350 nf
30
glycopyrrolate tab 1 mg
28
glycopyrrolate tab 2 mg
28
78
gnp alcohol sol denature
24
gnp clearlax pow
30
goniovisc sol 2%
46
goodys tab ex st
4
grandpas bar thylox
24
griseofulvin microsize susp 1 8
griseofulvin microsize tab 50 8
griseofulvin ultramicrosize t 8
guaiacol sol
24
guaifenesin liquid 100 mg/5ml
54
guaifenesin liquid 200 mg/5ml
54
guaifenesin pow
54
guaifenesin syrup 100 mg/5ml
54
guaifenesin tab 200 mg
54
guaifenesin tab 400 mg
54
guaifenesin tab sr 12hr 600 m 54
guaifenesin-codeine liquid 22 54
guaifenesin-codeine soln 10054
guanfacine hcl tab 1 mg
18
guanfacine hcl tab 2 mg
18
gummy bites chw
66
gynazole-1 cre 2%
34
H halfprin tab 162mg ec
4
halobetasol propionate cream 24
halobetasol propionate oint 0 24
hc dermapax spr 0.5-0.5% 24
hc-1% hemorr oin 1%
24
heartburn tr cap 15mg
33
heather
36
heparin sodium (porcine) inj 13
heparin sodium (porcine) pf i 13
herbal expec liq 150/15ml 54
hexalen cap 50mg
9
histex-dm syp
54
histex-pe syp 2.5-10/5
54
hm clearlax pow
30
homatropine hbr ophth soln 5%
48
honey bears chw iron-zin
66
hrtbrn rel cap 15mg dr
33
humapen mis memoir
43
humatropen mis for 6mg
43
humulin n pn inj u-100
13
humulin pen inj 70/30
13
hydralazine hcl tab 10 mg
18
hydralazine hcl tab 100 mg 18
hydralazine hcl tab 25 mg
18
hydralazine hcl tab 50 mg
18
hydrochlorothiazide cap 12.5 20
hydrochlorothiazide tab 25 mg
20
hydrochlorothiazide tab 50 mg
20
hydrocil ins pow 95%
30
hydrocod polst-chlorphen pols
54
hydrocodone w/ homatropine sy
54
hydrocodone w/ homatropine ta
54
hydrocodone-acetaminophen
sol
2
hydrocodone-acetaminophen
tab
2
hydrocort ac cre 0.5%
24
hydrocortisone acetate cream 24
hydrocortisone acetate suppos
24
hydrocortisone cream 0.5% 24
hydrocortisone cream 1%
24
hydrocortisone cream 2.5% 24
hydrocortisone enema 100 mg/6
24
hydrocortisone gel 1%
24
hydrocortisone lotion 1%
24
hydrocortisone lotion 2.5% 24
hydrocortisone oint 0.5%
24
hydrocortisone oint 1%
24
hydrocortisone oint 2.5%
24
hydrocortisone rectal cream 1 24
hydrocortisone rectal cream 2 24
hydrocortisone soln 1%
25
hydrocortisone tab 10 mg
35
hydrocortisone tab 20 mg
35
hydrocortisone tab 5 mg
35
hydrocortisone valerate cream
25
hydrocortisone valerate oint 25
hydrocortisone w/ acetic acid 48
hydrocortisone-aloe vera crea 25
hydromorphone hcl tab 2 mg 1
hydromorphone hcl tab 4 mg 1
hydromorphone hcl tab 8 mg 1
hydroxychloroquine sulfate ta10
hydroxyurea cap 500 mg
9
hydroxyzine hcl syrup 10 mg/5
11
hydroxyzine hcl tab 10 mg 11
hydroxyzine hcl tab 25 mg 11
hydroxyzine hcl tab 50 mg 11
hydroxyzine pamoate cap 100
m
12
hydroxyzine pamoate cap 25
mg
12
hydroxyzine pamoate cap 50
mg
12
hyoscyamine sulfate elixir 0. 28
hyoscyamine sulfate soln 0.12
28
hyoscyamine sulfate tab 0.125
28
hyoscyamine sulfate tab disp 28
hyoscyamine sulfate tab sl 0. 28
hyoscyamine sulfate tab sr 12 28
hypotears sol 1-1%
46
hypromellose gonioscopic soln
46
hypromellose ophth soln 0.3%
46
hypromellose ophth soln 0.4%
46
I ibuprofen jr chw 100mg
4
ibuprofen susp 100 mg/5ml 4
ibuprofen susp 40 mg/ml
4
ibuprofen tab 200 mg
4
ibuprofen tab 400 mg
4
ibuprofen tab 600 mg
4
ibuprofen tab 800 mg
4
imodium a-d chw 2mg
30
indapamide tab 1.25 mg
20
indapamide tab 2.5 mg
20
indocin sus 25mg/5ml
4
indomethacin cap 25 mg
4
indomethacin cap 50 mg
4
infergen inj 15mcg
11
infergen inj 9mcg
11
insuflon mis 25gx0.71
43
insulin syrg mis 0.3/28g
43
insulin syrg mis 0.3/29g
43
insulin syrg mis 0.3/30g
43
insulin syrg mis 0.3/31g
43
insulin syrg mis 0.5/27g
43
insulin syrg mis 0.5/28g
43
insulin syrg mis 0.5/29g
43
79
insulin syrg mis 0.5/30g 43, 44
insulin syrg mis 0.5/31g
44
insulin syrg mis 1ml
44
insulin syrg mis 1ml/25g
44
insulin syrg mis 1ml/26g
44
insulin syrg mis 1ml/27g
44
insulin syrg mis 1ml/28g
44
insulin syrg mis 1ml/29g
44
insulin syrg mis 1ml/30g
44
insulin syrg mis 1ml/31g
44
insulin syrg mis 2/27.5g
44
insulin syrg mis 2ml/29g
44
insulin syringe mis 0.3/30g 44
insulin syringe mis 0.3/31g 44
insulin syringe mis 0.5/29g 44
insulin syringe mis 0.5/30g 44
insulin syringe mis 0.5/31 g 44
insulin syringe mis 1ml/29g 44
insulin syringe mis 1ml/30g 44
insulin syringe mis 1ml/31g 44
insulin syringe/needle u-100 44
insupen sens mis 32gx8mm 44
insyte autog mis 24gx3/4" 44
intron-a inj 10mu
9
intron-a inj 18mu
9
intron-a inj 25mu
9
intron-a inj 50mu
9
introvale
36, 37
invokana tab 100mg
12
invokana tab 300mg
12
ionil sha
25
ipecac syp
25
ipratropium bromide inhal sol50
ipratropium bromide nasal sol
50
iron high cap potency
66
iron polysacch complex-vit b1
66
iron tab 18mg
66
iron tab 18mg cr
66
iron up liq
66
iso carbacho sol 3% op
46
iso homatrop sol 2% op
48
isoniazid syrup 50 mg/5ml
9
isoniazid tab 100 mg
9
isoniazid tab 300 mg
9
isop alcohol sol 50%
25
isop alcohol sol 70% wg
25
isop alcohol sol 91%
25
isop alcohol sol 99%
25
isopropyl alcohol, rubbing 70 25
isopropyl liq palmitat
25
isopto tears sol 0.5% op
46
isosorbide dinitrate sl tab 2 18
isosorbide dinitrate tab 10 m 19
isosorbide dinitrate tab 20 m 19
isosorbide dinitrate tab 30 m 19
isosorbide dinitrate tab 5 mg 19
isosorbide dinitrate tab cr 4 19
isosorbide mononitrate tab 20 19
isosorbide mononitrate tab sr 19
J janumet tab 50-1000
12
janumet tab 50-500mg
12
januvia tab 100mg
12
januvia tab 25mg
12
januvia tab 50mg
12
jencycla
37
jolessa
37
jolivette
37
j-tip kit kit adapters
44
junel 1.5/30
37
junel 1/20
37
junel fe 1.5/30
37
junel fe 1/20
37
juniper tar oil
25
K ketoconazole cream 2%
25
ketoconazole shampoo 2% 25
ketoconazole tab 200 mg
8
ketoprofen cap 50 mg
4
ketoprofen cap 75 mg
4
ketorolac tromethamine ophth
48
ketorolac tromethamine tab 10 4
ketostix test strips
44
ketotifen fumarate ophth soln 47
konsyl pow 100%
30
konsyl pow 28.3%
30
konsyl pow 60.3%
30
konsyl pow 71.67%
30
konsyl-d pow 52.3%
30
kp prenatal tab multivit
66
k-phos tab
66
k-phos tab no 2
60
kpn prenatal tab
66
kurvelo
37
L labetalol hcl tab 100 mg
16
labetalol hcl tab 200 mg
16
labetalol hcl tab 300 mg
16
lactic acid (ammonium lactate
25
lactic acid w/ vitamin e crea 25
lactocal-f tab
61
lactulose solution 10 gm/15ml
31
lamivudine tab 100 mg
11
lansoprazole cap 15mg dr
33
lansoprazole sus 3mg/ml
33
lantus inj 100/ml
13
larin 1.5/30
37
larin 1/20
37
larin fe 1.5/30
37
larin fe 1/20
37
latanoprost ophth soln 0.005%
48
lavender oil
25
laxaclear pow
31
leflunomide tab 10 mg
42
leflunomide tab 20 mg
42
lemon oil
25
lessina
37
letrozole tab 2.5 mg
9
leucovorin calcium tab 15 mg 9
leucovorin calcium tab 25 mg 9
leucovorin calcium tab 5 mg 10
leukeran tab 2mg
10
levemir inj
13
levobunolol hcl ophth soln 0. 48
levobunolol sol 0.25% op
48
levofloxacin tab 250 mg
7
levofloxacin tab 500 mg
7
levofloxacin tab 750 mg
7
levonest
37
levonorgestrel tab 0.75 mg 37
levonorgestrel tab 1.5 mg
37
levonorgestrel/ethinyl estrad 37
levora 0.15/30-28
37
levothyroxin tab 100mcg
39
levothyroxin tab 112mcg
39
levothyroxin tab 125mcg 39, 40
levothyroxin tab 137mcg
40
levothyroxin tab 150mcg
40
levothyroxin tab 175mcg
40
levothyroxin tab 200mcg
40
levothyroxin tab 25mcg
40
levothyroxin tab 300mcg
40
levothyroxin tab 50mcg
40
levothyroxin tab 75mcg
40
80
levothyroxin tab 88mcg
40
levoxyl tab 100mcg
40
levoxyl tab 112mcg
40
levoxyl tab 125mcg
40
levoxyl tab 137mcg
40
levoxyl tab 150mcg
40
levoxyl tab 175mcg
40
levoxyl tab 200mcg
40
levoxyl tab 25mcg
40
levoxyl tab 50mcg
40
levoxyl tab 75mcg
40
levoxyl tab 88mcg
40
lice b gone kit
25
lice b gone sha
25
lidocaine hcl gel 2%
25
lidocaine hcl laryngotracheal 21
lidocaine hcl soln 4%
25
lidocaine hcl viscous soln 2% 21
lidocaine oint 5%
25
lidocaine-prilocaine cream 2. 25
lime oil
25
lindane lotion 1%
25
lindane shampoo 1%
25
linseed oil raw
25
liquid c 500 liq 500/15ml
66
liquid calci cap with d3
66
liquimat lot 5%
25
lisinopril & hydrochlorothiaz 16
lisinopril tab 10 mg
14
lisinopril tab 2.5 mg
14
lisinopril tab 20 mg
14
lisinopril tab 30 mg
14
lisinopril tab 40 mg
14
lisinopril tab 5 mg
14
lite touch insulin pen needle 44
little remed liq colds
54
little teeth mis pain rel
21
little tummy dro laxative
31
lodrane d cap 4-60mg
54
lohist-psb liq 4-20/5ml
54
lomustine cap 10 mg
10
lomustine cap 100 mg
10
lomustine cap 40 mg
10
loperamide hcl cap 2 mg
31
loperamide hcl liq 1 mg/5ml (31
loperamide hcl liq 1 mg/7.5ml
31
loperamide hcl tab 2 mg
31
loratadine & pseudoephedrine
54
loratadine rapidly-disintegra 49
loratadine syrup 5 mg/5ml 49
loratadine tab 10 mg
49
lortuss dm liq
54
lortuss ex liq
55
lortuss lq liq
55
losartan potassium & hydrochl
16
losartan potassium tab 100 mg
14
losartan potassium tab 25 mg 14
losartan potassium tab 50 mg 14
lovastatin tab 10 mg
20
lovastatin tab 20 mg
20
lovastatin tab 40 mg
20
lozi-flur loz 1mg f
66
ltxf prim iv mis set/micr
45
luer-lok syr mis 1ml/20g
45
lufyllin tab 200mg
55
lufyllin tab 400mg
55
lupr dep-ped inj 11.25mg
41
lupr dep-ped inj 15mg
41
lupr dep-ped inj 7.5mg
41
lupron depot inj 11.25mg
10
lupron depot inj 22.5mg
10
lupron depot inj 3.75mg
10
lupron depot inj 30mg
10
lupron depot inj 7.5mg
10
lusair liq
55
lutera
37
lyza
37
M m2k cap 60mg
66
maalox jr chw /antigas
31
maalox tc sus
31
macadamia oil nut oil
25
macrodantin cap 25mg
5
mag carbonat pow 250mg/gm66
mag carbonat pow heavy
66
mag citrate tab 100mg
66
mag oxide cap 400mg
31
mag-200 tab
66
mag-al liq
31
magimin tab 80mg
66
maginex ds gra 1230mg
66
maginex tab 615 mg
66
magn chlorid cry hexahydr 66
magn chlorid pow
66
magn oxide pow heavy
31
magn sulfate cap 70mg
66
magnebind tab 200
66
magnesium cap 100 mg
66
magnesium cap 300mg
66
magnesium cap 400mg
66
magnesium chloride inj 200 mg
66
magnesium chloride tab cr 535
66
magnesium citrate soln
31
magnesium gl tab 550mg
66
magnesium gluconate tab 27.5
66
magnesium gluconate tab 500 m
66
magnesium oxide cap 500 mg
(e
66
magnesium oxide tab 250 mg 31
magnesium oxide tab 250 mg
(m
66
magnesium oxide tab 400 mg 31
magnesium oxide tab 400 mg (2
66
magnesium oxide tab 420 mg 31
magnesium oxide tab 500 mg
(m
66
magnesium pow oxide
66
magnesium sulfate 1% in d5w
66
magnesium sulfate inj 4%
66
magnesium sulfate inj 50% 66
magnesium sulfate inj 8%
66
magnesium tab 100 mg
67
magnesium tab 200 mg
67
magnesium tab 250 mg
67
magnesium tab 30mg
67
magnesium tab 500mg
67
magonate liq 1000/5ml
67
mag-tab sr tab 84mg
66
magtrate tab 500mg
67
malathion lotion 0.5%
25
mar-cof bp liq
55
marlissa
37
matulane cap 50mg
10
maxifed dmx tab
55
meclizine hcl chew tab 25 mg 8
meclizine hcl tab 12.5 mg
8
meclizine hcl tab 25 mg
8
meclizine hcl tab 32 mg
8
meclizine pow hcl
8
81
meclofenamate sodium cap 50
m
4
medi-graine tab
55
medi-jector mis vision
45
medroxyprogesterone acetate i
37
medroxyprogesterone acetate t
39
mefloquine hcl tab 250 mg 10
mega biotin cap 10mg
67
megestrol acetate susp 40 mg/
10
megestrol acetate tab 20 mg 10
megestrol acetate tab 40 mg 10
meloxicam tab 15 mg
4
meloxicam tab 7.5 mg
4
m-end dmx liq
55
m-end max d liq
55
m-end pe liq
55
menest tab 0.3mg
39
menest tab 0.625mg
39
menest tab 1.25mg
39
menest tab 2.5mg
39
meperidine hcl tab 100 mg
1
meperidine hcl tab 50 mg
1
mephyton tab 5mg
67
mercaptopurine tab 50 mg 10
mesalamine enema 4 gm
42
metamucil pow 28%
31
metamucil pow 63%
31
metamucil waf
31
metaproterenol sulfate syrup 50
metaproterenol sulfate tab 10 50
metaproterenol sulfate tab 20 50
metformin hcl tab 1000 mg 12
metformin hcl tab 500 mg
12
metformin hcl tab 850 mg
12
metformin hcl tab sr 24hr 50012
metformin hcl tab sr 24hr 75012
methadone hcl conc 10 mg/ml 1
methadone hcl soln 10 mg/5ml 1
methadone hcl soln 5 mg/5ml 1
methadone hcl tab 10 mg
1
methadone hcl tab 5 mg
1
methadone hcl tab for oral su 1
methanol sol 99%
25
methazolamide tab 25 mg
19
methazolamide tab 50 mg
19
methenam man tab 500mg
5
methenamine hippurate tab 1 g 5
methenamine mandelate tab 1 g
5
methimazole tab 10 mg
41
methimazole tab 5 mg
41
methocarbamol tab 500 mg 60
methocarbamol tab 750 mg 60
methotrexate sodium tab 2.5 m
10
methyclothiazide tab 5 mg 20
methylcellulose powder laxati
31
methyldopa tab 250 mg
19
methyldopa tab 500 mg
19
methylergonovine maleate tab
34
methylprednisolone tab 4 mg 35
methylprednisolone tab 4 mg d
35
methylprednisolone tab 8 mg 35
metipranolol ophth soln 0.3% 48
metoclopramide hcl soln 5 mg/
31
metoclopramide hcl tab 10 mg
31
metoclopramide hcl tab 5 mg 31
metolazone tab 10 mg
20
metolazone tab 2.5 mg
20
metolazone tab 5 mg
20
metoprolol & hydrochlorothiaz
16
metoprolol succinate tab sr 2 16
metoprolol tartrate tab 100 m 16
metoprolol tartrate tab 25 mg 16
metoprolol tartrate tab 50 mg 17
metronidazole cream 0.75% 25
metronidazole gel 0.75%
25
metronidazole lotion 0.75% 25
metronidazole tab 250 mg
5
metronidazole tab 500 mg
5
metronidazole vaginal gel 0.7 34
mg aspartate tab 65mg
67
mg gluconate tab 250mg
67
mg so4/d5w inj 20mg/ml
67
miconazole nitrate aerosol 2%
25
miconazole nitrate aerosol po 25
miconazole nitrate cream 2% 25
miconazole nitrate ointment 225
miconazole nitrate powder 2%
25
miconazole nitrate vaginal cr 34
miconazole nitrate vaginal su 34
microgestin tab 1/20
37
microgestin tab fe 1/20
37
microgestin 1.5/30
37
microgestin 1/20
37
microgestin fe
37
microgestin fe 1.5/30
37
midodrine hcl tab 10 mg
14
midodrine hcl tab 2.5 mg
14
midodrine hcl tab 5 mg
14
minocycline hcl cap 100 mg 7
minocycline hcl cap 50 mg
7
minocycline hcl cap 75 mg
7
minoxidil tab 10 mg
19
minoxidil tab 2.5 mg
19
miranel af sol 2%
25
misoprostol tab 100 mcg
33
misoprostol tab 200 mcg
33
mission pren tab
61
mission pren tab /fa
61
moexipril hcl tab 15 mg
15
moexipril hcl tab 7.5 mg
15
moisture eye sol p/f
46
mometasone furoate cream
0.1%
25
mometasone furoate oint 0.1%
26
mometasone furoate solution 0
26
montelukast sodium chew tab 4
50
montelukast sodium chew tab 5
50
montelukast sodium tab 10 mg
50
morphine sulfate (concentrate 1
morphine sulfate oral soln 10 1
morphine sulfate oral soln 20 1
morphine sulfate tab 15 mg 2
morphine sulfate tab 30 mg 2
morphine sulfate tab cr 100 m 2
morphine sulfate tab cr 15 mg 2
morphine sulfate tab cr 30 mg 2
morphine sulfate tab cr 60 mg 2
mucinex fast mis day/nght 55
mucinex fast tab 5-10-200 55
mucinex tab 1200mg
55
multi-delyn liq /iron
67
mupirocin calcium cream 2% 26
82
mupirocin oint 2%
26
muro 128 sol 2% op
46
mycophenolate mofetil cap 250
42
mycophenolate mofetil tab 500
42
mykidz iron sus 10mg/2ml 67
mykidz iron sus 15/1.5ml
67
mylanta sus ultimate
31
mylanta tab
31
myleran tab 2mg
10
mynatal cap
61
myzilra
37
N nabumetone tab 500 mg
4
nabumetone tab 750 mg
4
nadolol tab 20 mg
17
nadolol tab 40 mg
17
nadolol tab 80 mg
17
nanovm pow 1-3 yrs
67
nanovm t/f liq
67
naphazoline hcl ophth soln 0. 46
naphazoline w/ pheniramine op
46
naphazoline-glycerin ophth so
46
naphazoline-hypromellose opht
46
naphazoline-polyethylene glyc
46
naprelan tab 375mg cr
4
naprelan tab 500mg cr
4
naprelan tab 750mg cr
4
naproxen kit comfort
4
naproxen pow
4
naproxen pow sodium
4
naproxen sodium cap 220 mg 4
naproxen sodium tab 220 mg 4
naproxen sodium tab 275 mg 4
naproxen sodium tab 550 mg 4
naproxen susp 125 mg/5ml
4
naproxen tab 250 mg
4
naproxen tab 375 mg
4
naproxen tab 500 mg
4
naproxen tab ec 375 mg
4
nasacort alr spr 55mcg/ac
50
nasal decon syp 30mg/5ml 55
nasopen liq
55
nasopen pe liq
55
nat fiber pow 58.6%
31
nat senna tab laxative
31
natalvit tab 75-1mg
61
nateglinide tab 120 mg
12
nateglinide tab 60 mg
12
natura-lax pow 3350 nf
31
nature-throi tab 130mg
40
nature-throi tab 195mg
40
nature-throi tab 260mg
40
nature-throi tab 32.5mg
40
nature-throi tab 325mg
41
nature-throi tab 48.75mg
41
nature-throi tab 65mg
41
nature-throi tab 97.5mg
41
necon 0.5/35-28
37
necon 1/35
37
necon 1/50-28
38
necon 10/11-28
38
needle-free kit a
45
needle-free mis syrg a
45
neo dm syp
55
neomycin sulfate tab 500 mg 4
neomycin-bacitrac zn-polymyx
47
neomycin-polymy-gramicid op
s
47
neomycin-polymyxindexamethas
48
neomycin-polymyxin-hc ophth
s
48
neomycin-polymyxin-hc otic so
48
neomycin-polymyxin-hc otic su
48
neosporin kit trial
26
neotuss plus liq
55
neotuss-d liq
55
neupogen inj 300/0.5
13
neupogen inj 300mcg
13
neupogen inj 480/0.8
14
neupogen inj 480mcg
14
neuro-k-250 cap t.d.
67
nexium 24hr cap 20mg
33
niacin cap cr 250 mg
67
niacin cap cr 500 mg
67
niacin tab 100 mg
67
niacin tab 250 mg
67
niacin tab 50 mg
67
niacin tab 500 mg
67
niacin tab cr 250 mg
67
niacin tab cr 500 mg
67
niacin tab cr 750 mg
67
niacin tr tab 1000mg
67
niacinamide tab 100 mg
67
niacinamide tab 500 mg
67
niacinamide tab 500mg pr 67
niacor tab 500mg
21
niaouli oil
26
nicardipine hcl cap 20 mg
18
nicardipine hcl cap 30 mg
18
nicotine inhaler system 1
3
nicotine polacrilex gum 2 mg 3
nicotine polacrilex gum 4 mg 3
nicotine polacrilex lozenge 2 3
nicotine polacrilex lozenge 4 3
nicotine sys kit transder
3
nicotine td patch 24hr 14 mg/ 3
nicotine td patch 24hr 21 mg/ 3
nicotine td patch 24hr 7 mg/2 3
nicotrol ns spr 10mg/ml
3
nifedipine cap 10 mg
18
nifedipine cap 20 mg
18
nifedipine tab sr 24hr 30 mg 18
nifedipine tab sr 24hr 60 mg 18
nifedipine tab sr 24hr 90 mg 18
nifedipine tab sr 24hr osmoti 18
nite-time liq cold/flu
55
nitro-bid oin 2%
19
nitrofurantoin macrocrystalli 5
nitrofurantoin monohydrate ma
5
nitroglycerin cap cr 2.5 mg 19
nitroglycerin cap cr 6.5 mg 19
nitroglycerin cap cr 9 mg
19
nitroglycerin td patch 24hr 0 19
nitrostat sub 0.3mg
19
nitrostat sub 0.4mg
19
nitrostat sub 0.6mg
19
noble mystiq cre emu-lac
26
non-aspirin chw 160mg jr
1
nonoxynol-9 gel 2%
34
nonoxynol-9 gel 3%
34
nora-be
38
norel ad tab 4-10-325
55
norel cs liq
55
norethindrone
38
norethindrone acetate tab 5 m 39
norethindrone acetate/ethinyl 38
norethindrone acetate-ethinyl 39
norpace cap 100mg cr
15
norpace cap 150mg cr
15
83
nortrel 0.5/35
38
nortrel 0.5/35 (28)
38
nortrel 1/35
38
nortrel 7/7/7
38
notuss-nx liq
55
notuss-nxd liq
55
novaferrum cap 50mg
67
novaferrum dro 15mg/ml
67
novofine mis 30gx8mm
45
novofine mis 32gx6mm
45
novolin inj 70/30
13
novolin n inj u-100
13
novolin r inj u-100
13
novolog mix inj 70/30
13
novotwist mis 32gx5mm
45
nuox gel 6-3%
26
nutratear sol 0.6%
46
nutricion tab porvida
67
nutrients tab prenatal
61
nystatin cream 100000 unit/gm
26
nystatin oint 100000 unit/gm 26
nystatin susp 100000 unit/ml 21
nystatin tab 500000 unit
8
nystatin vaginal tab 100000 u 34
nystatin-triamcinolone cream 26
nystatin-triamcinolone oint 1 26
O obstetrix ec tab
61
obstetrix pak dha
61
oc8 gel 7%
26
o-cal fa tab
61
o-cal tab prenatal
61
ofloxacin ophth soln 0.3% 47
ofloxacin otic soln 0.3%
49
ofloxacin tab 200 mg
7
ofloxacin tab 300 mg
7
ofloxacin tab 400 mg
7
oil-almond oil sweet
26
oil-coconut oil
26
olive oil
26
omepra/bicar cap 20-1100 33
omeprazole cap delayed releas
33
omniflex dpr
45
ondansetron hcl oral soln 4 m 8
ondansetron hcl tab 4 mg
8
ondansetron hcl tab 8 mg
8
ondansetron orally disintegra 8
one a day mis prenatal
61
onset forte tab
55
opium tinct tin 2mg/5ml
31
oracit sol
60
ora-film mis 6%
21
oramagic pls sus 10%
21
orange oil
26
orazinc tab 110mg
67
orsythia
38
ortho coil dpr kit 100
45
ortho coil dpr kit 105
45
ortho coil dpr kit 50
45
ortho flat dpr kit 55
45
ortho flat dpr kit 60
45
ortho flat dpr kit 65
45
ortho flat dpr kit 70
45
ortho flat dpr kit 75
45
ortho flat dpr kit 80
45
ortho flat dpr kit 85
45
ortho flat dpr kit 90
45
ortho flat dpr kit 95
45
ortho flex dpr 65mm
45
ortho flex dpr 70mm
45
ortho flex dpr 75mm
45
ortho flex dpr 80mm
45
os-cal chw
67
osteo-poreti tab
67
ostigen mis 350mg
67
oxaprozin tab 600 mg
4
oxybutynin chloride syrup 5 m
34
oxybutynin chloride tab 5 mg 34
oxybutynin chloride tab sr 24 34
oxycodone hcl cap 5 mg
2
oxycodone hcl conc 100
mg/5ml
2
oxycodone hcl soln 5 mg/5ml 2
oxycodone hcl tab 15 mg
2
oxycodone hcl tab 30 mg
2
oxycodone hcl tab 5 mg
2
oxycodone w/ acetaminophen
ca
2
oxycodone w/ acetaminophen ta
2
oxycodone-aspirin tab 4.8355- 2
oxymetazoline hcl nasal soln 50
oxytrol/womn dis 3.9mg/24 34
oyst shell/d tab 250mg
67
oyster shell calcium tab
67
oyster shell tab plus d
67
P paba tab 100mg
67
pain & fever sol 160/5ml
1
pain relief tab cold pe
55
panatuss dxp liq
55
panatuss dxp liq pediatri
55
panatuss ped dro
55
panatuss ped liq 60-2-25
55
pancreaze cap 10500unt
28
pancreaze cap 16800unt
28
pancreaze cap 21000unt
28
pancreaze cap 4200unit
28
pancrelipase cap 5000unit
28
panoxyl-4 liq crem wsh
26
panoxyl-8 liq crem wsh
26
panto-250 cap
67
pantoprazole sodium ec tab 20
33
pantoprazole sodium ec tab 40
33
pantothenic acid tab 500 mg 67
parva-cal tab 250-100
67
parva-cal tab 500mg
67
pce tab 333mg ec
7
pce tab 500mg ec
7
peanut oil
26
pecgen dmx liq 15-125mg 55
pedia-lax liq 50mg
31
pedia-lax sup 2.8gm
31
pe-dm-apap & pe-cpm-dm-apap
t
55
pe-dm-apap cap & doxylamined
55
pe-dm-apap liq & doxylamine-d
55
pe-dm-gg-apap tab & pe-diphen
55
peg 3350 pow
31
peg 3350-kcl-na bicarb-nacl-n
31
peg-intron kit 120 rp
11
peg-intron kit 150mcg
11
peg-intron kit 50mcg rp
11
peg-intron kit 80mcg
11
pe-hist dm syp 5-2-15mg
55
pen needles mis 29gx12.7
45
penicillin v potassium for so 6
penicillin v potassium tab 25 6
penicillin v potassium tab 50 6
pentoxifylline tab cr 400 mg 19
84
pepcid ac chw 10mg
33
pepcid ac chw max st
33
peppermint oil
26
peppermint sol spirit
26
perfect iron tab 25mg
68
permethrin aerosol 0.5%
26
permethrin cream 5%
26
permethrin creme rinse 1% 26
permethrin lotion 1%
26
permethrin spray & pyrethins26
perry prenat cap
68
pertzye cap
28
phenazopyridine hcl tab 100 m
60
phenazopyridine hcl tab 200 m
60
phenyleph-chlorphen-dm
w/apap
55
phenylephrine w/ acetaminophe
55
phenylephrine w/ dm-gg liqd 1
55, 56
phenylephrine w/ dm-gg liqd 2
56
phenylephrine w/ dm-gg liqd 5
56
phenylephrine w/ dm-gg liquid
56
phenylephrine w/ dm-gg syrup
56
phenylephrine w/ dm-gg tab 10
56
phenylephrine-apap-gg liqd 10
56
phenylephrine-apap-gg tab 1056
phenylephrine-apap-gg tab 5-3
56
phenylephrinebrompheniramine
56
phenylephrine-chlorphen-dm li
56
phenylephrine-dm soln 2.5-5 m
56
phenylephrine-dm-gg w/ apap l
56
phenylephrine-dm-gg w/ apap t
56
phenylephrine-doxylamine-dma
56
phenylephrine-guaifenesin liq56
phenylephrine-guaifenesin syr
56
phenylephrine-guaifenesin tab
56
phenylephrine-promethazine w/
56
phenylhist liq dh
56
phisohex liq 3%
26
phlexy-vits pow
68
phos-nak pow concentr
68
phospholine sol 0.125%op 46
phytonadione tab 100 mcg 68
pilocarpine hcl tab 5 mg
21
pindolol tab 10 mg
17
pindolol tab 5 mg
17
pine oil
26
pine tar liq
26
pinnacaine dro 20% otic
49
pin-x sus 50
26
pioglitazone hcl tab 15 mg (b 12
pioglitazone hcl tab 30 mg (b 12
pioglitazone hcl tab 45 mg (b 12
pioglitazone hcl-metformin hc
12
pirmella 1/35
38
piroxicam cap 10 mg
4
piroxicam cap 20 mg
4
plas adapt mis 1ml
45
plexion liq 9.8-4.8%
26
podofilox soln 0.5%
26
poly hist tab 7.5-10mg
56
polyeth glyc pow 3350 nf
31
polyeth glyc pow 3350-grx 31
polyethylene glycol-propylene
46
poly-hist dm liq 5-25-10
56
poly-hist pd liq
56
polymyxin b-trimethoprim opht
47
polysaccharide iron complex c
68
polysorbate liq 60
26
polysorbate liq 80
26
polysorbate sol 20
26
polysorbate sol 40
26
poly-tussin liq ac
56
poly-vent dm tab
56
poly-vent ir tab 60-380mg 56
polyvinyl alcohol ophth soln 46
polyvinyl alcohol-povidone op
46
portia-28
38
posture tab
68
pot & sod citrates w/ cit ac 60
pot bicarbonate & chloride ef 68
pot phos monobasic w/sod phos
68
potaba cap 500mg
68
potaba tab 500mg
68
potassium bicarbonate effer t 68
potassium chloride cap cr 10 68
potassium chloride cap cr 8 m
68
potassium chloride microencap
68
potassium chloride oral liq 1 68
potassium chloride powder pac
68
potassium chloride tab cr 10 68
potassium chloride tab cr 8 m 68
potassium citrate & citric ac 60
povidone-iodine soln 10% 26
powderlax pow
31
pramipexole dihydrochloride t
11
pramosone cre 1%
26
pravastatin sodium tab 10 mg 20
pravastatin sodium tab 20 mg 20
pravastatin sodium tab 40 mg 20
pravastatin sodium tab 80 mg 20
prazosin hcl cap 1 mg
19
prazosin hcl cap 2 mg
19
prazosin hcl cap 5 mg
19
precisn xtra tes ketone
45
pred mild sus 0.12% op
48
prednicarbate oint 0.1%
26
prednisolone acetate ophth su 48
prednisolone sod phosphate or
35
prednisolone sodium phosphate
48
prednisolone syrup 15 mg/5ml
35
prednisone oral soln 5 mg/5ml
35
prednisone tab 1 mg
35
prednisone tab 10 mg
35
85
prednisone tab 10 mg dose pac
35
prednisone tab 2.5 mg
35
prednisone tab 20 mg
35
prednisone tab 5 mg
35
prednisone tab 5 mg dose pack
35
prednisone tab 50 mg
35
premarin tab 0.3mg
39
premarin tab 0.45mg
39
premarin tab 0.625mg
39
premarin tab 0.9mg
39
premarin tab 1.25mg
39
premphase tab
39
prempro tab .625-2.5
39
prempro tab 0.3-1.5
39
prempro tab 0.45-1.5
39
prempro tab 0.625-5
39
prenat multi cap +dha
61
prenata chw 29-1mg
61
prenatal cap formula
61
prenatal cap omega-3
61
prenatal frm tab a-free
61
prenatal mul cap +dha
61
prenatal tab
68
prenatal tab 27-0.8mg
68
prenatal tab complete
68
prenatal tab formula
61
prenatal tab plus dha
61
prenatal tab plus fe
61
prenatal tab vitamins
68
prenatal+dha mis
61
pretz sol
26
prilosec otc tab 20mg
33
primaquine tab 26.3mg
10
primsol sol 50mg/5ml
5
pro
12 aer mousse
26
probenecid tab 500 mg
8
probiotic w/ cap prebioti
31
pro-chlo liq
56
prochlorperazine maleate tab 11
prochlorperazine suppos 25 mg
11
procrit inj 40000/ml
14
prodigy mis 29gx1/2"
45
profe cap 180mg
68
proferrin es tab 12 mg
68
progesterone sup vgs 100
34
progesterone sup vgs 200
35
progesterone sup vgs 25
35
progesterone sup vgs 400
35
progesterone sup vgs 50
35
promethazine & phenylephrine
57
promethazine hcl suppos 12.549
promethazine hcl suppos 25 mg
49
promethazine hcl suppos 50 mg
49
promethazine hcl syrup 6.25 m
49
promethazine hcl tab 12.5 mg 49
promethazine hcl tab 25 mg 49
promethazine hcl tab 50 mg 49
promethazine w/ codeine syrup
57
promethazine-dm syrup 6.25-15
57
pronto aer 0.4%
26
propafenone hcl tab 150 mg 15
propafenone hcl tab 225 mg 15
propafenone hcl tab 300 mg 15
propantheline bromide tab 15 28
proparacaine hcl ophth soln 0 46
propranolol & hydrochlorothia
16
propranolol hcl cap sr 24hr 1 17
propranolol hcl cap sr 24hr 6 17
propranolol hcl cap sr 24hr 8 17
propranolol hcl oral soln 20 17
propranolol hcl oral soln 40 17
propranolol hcl tab 10 mg
17
propranolol hcl tab 20 mg
17
propranolol hcl tab 40 mg
17
propranolol hcl tab 60 mg
17
propranolol hcl tab 80 mg
17
propylene glycol-glycerin oph
46
propylthiouracil tab 50 mg 41
pro-red ac syp 5-1-9/5
57
protexin syp
68
pseudoeph-chlorphen-dm w/
apa
57
pseudoeph-doxylamine-dm w/
ap
57
pseudoeph-doxylamine-dm
w/apa
57
pseudoephed-bromphen-dm
elixi
57
pseudoephed-bromphen-dm
syrup
57
pseudoephed-chlorphen-dm liq
57
pseudoephed-dexchlorphenchlo
57
pseudoephedrine hcl liq 15 mg
57
pseudoephedrine hcl tab 30 mg
57
pseudoephedrine hcl tab 60 mg
57
pseudoephedrine hcl tab abuse
57
pseudoephedrine hcl tab sr 1257
pseudoephedrine w/ acetaminop
57
pseudoephedrine w/ apap-dm ca
57
pseudoephedrine w/ apap-dm li
57
pseudoephedrine w/ apap-dm ta
57
pseudoephedrine w/ cod-gg sol
57
pseudoephedrine w/ cod-gg syr
57
pseudoephedrine w/ dm-gg cap
57
pseudoephedrine w/ dm-gg liqu
57
pseudoephedrine w/ dm-gg syru
57
pseudoephedrine-bromphencode
57
pseudoephedrine-chlophedianol
57
pseudoephedrine-dexchlorpheni
57
pseudoephedrine-dm liqd 15-7.
57
pseudoephedrine-dm syrup 30-1
57
pseudoephedrine-dm-gg w/
apap
57
pseudoephedrine-guaifenesin c
57
pseudoephedrine-guaifenesin s
57
86
pseudoephedrine-guaifenesin t
57
pseudoephedrine-ibuprofen sus
57
pseudoephedrine-ibuprofen tab
57
pseudoephedrine-naproxen sodi
58
psyllium cap 0.52 gm
31
psyllium powder 100%
31
psyllium powder 28.3%
31
psyllium powder 30%
32
psyllium powder 30.9%
32
psyllium powder 33%
32
psyllium powder 48.57%
32
psyllium powder 55.46%
32
psyllium powder 58.6%
32
psyllium powder 68%
32
psyllium powder 95%
32
pulmozyme sol 1mg/ml
58
pur-absorb liq 5mg/20ml
68
pyrazinamide tab 500 mg
9
pyre/piperon liq
26
pyreth-piperonyl butox sham-p
26
pyrethrins-piperonyl butoxide
26, 27
pyridostigmine bromide sy
9
pyridostigmine bromide ta
9
pyridoxine hcl tab 100 mg 68
pyridoxine hcl tab 200 mg 68
pyridoxine hcl tab 25 mg
68
pyridoxine hcl tab 250 mg 68
pyridoxine hcl tab 50 mg
68
pyridoxine hcl tab 500 mg 68
pyridoxine hcl tab cr 200 mg 68
pyril dm sus
58
pyrilamine mal-phenylephrine
58
pyrilamine-phenylephrine tab 58
Q quasense
38
quinapril hcl tab 10 mg
15
quinapril hcl tab 20 mg
15
quinapril hcl tab 40 mg
15
quinapril hcl tab 5 mg
15
quinapril-hydrochlorothiazide16
quinidine gluconate tab cr 32 15
quinidine sulfate tab 200 mg 15
quinidine sulfate tab 300 mg 15
quinine sulfate cap 324 mg 10
qvar aer 40mcg
49
qvar aer 80mcg
49
R ra acne max pad 2%
27
ra ca/boron tab
68
ra essence-c pow lmn-lime 68
ra laxative pow
32
ra lot
27
ra oys shl/d tab 250mg
68
ra vitamin c chw 300mg
68
ramipril cap 1.25 mg
15
ramipril cap 10 mg
15
ramipril cap 2.5 mg
15
ramipril cap 5 mg
15
ranitidine hcl syrup 15 mg/ml 33
ranitidine tab 150mg
33
ranitidine tab 300mg
33
refresh cell dro 1% op
46
refresh dro relief
46
refresh sol optive
46
relenza mis diskhale
11
renagel tab 400mg
34
renagel tab 800mg
34
rescon-dm syp
58
respaire-30 cap
58
retaine mgd emu 0.5-0.5% 46
rezamid lot
27
rhogam plus inj 300mcg
42
ribavirin cap 200 mg
11
riboflavin cap 100mg
68
riboflavin cap 50mg
68
riboflavin tab 100 mg
68
riboflavin tab 25 mg
68
riboflavin tab 400mg
68
riboflavin tab 50 mg
68
rifabutin cap 150 mg
9
rifampin cap 150 mg
9
rifampin cap 300 mg
9
rifater tab
9
ri-mag plus sus
32
rimantadine hydrochloride tab
11
robitus nght liq 12.5-30
58
robitussin d liq cgh/cold
58
robitussin liq cf
58
robitussin liq night tm
58
robitussin mis day/nght
58
robitussin mis day/nite
58
roche - fastcliix lancets, bo 45
rolaids chw ex st
32
ropinirole hydrochloride tab 11
rose oil
27
rosemary oil
27
rub alcohol sol 70% ethy
27
ru-hist-d liq 30-10/5
58
ru-hist-d tab 30-10mg
58
rycontuss liq 5-2-10/5
58
rydex g tab 38.5-398
58
rymed tab 2-10mg
58
S safe tussin liq pm
58
safflower oil
27
salicylic acid & sulfur shamp 27
saline nasal spray 0.65%
50
salsalate tab 500 mg
4
salsalate tab 750 mg
4
santyl
oin 250u/gm
27
sassafras oil
27
sastid bar 3-5%
27
sb nat fiber pow 49%
32
schooltime sha
27
scooby-doo chw
69
scot-tussin liq original
58
scot-tussin liq senior
58
sd gluconavii test strips
45
sebasorb lot
27
selegiline hcl cap 5 mg
10
selenium sulfide lotion 2.5% 27
se-natal 19 tab
61
se-natal 90 tab
61
senna leaves mis
32
senna syp
32
senna tab 187mg
32
sennosides cap 8.6 mg
32
sennosides chew tab 15 mg 32
sennosides syrup 8.8 mg/5ml 32
sennosides tab 15 mg
32
sennosides tab 17.2 mg
32
sennosides tab 25 mg
32
sennosides tab 8.6 mg
32
sennosides-docusate sodium ta
32
sensipar tab 30mg
60
sensipar tab 60mg
60
serevent dis aer 50mcg
50
sesame oil
27
setonet pak
61
sev sin cong tab daytime
58
87
sevelamer carbonate tab 800 m
34
sfrowasa ene 4gm
42
silver sulfadiazine cream 1% 27
simethicone cap 125 mg
32
simethicone cap 180 mg
32
simethicone chew tab 125 mg32
simethicone chew tab 80 mg 32
simethicone liquid 40 mg/0.6m
32
simethicone susp 40 mg/0.6ml
32
simvastatin tab 10 mg
21
simvastatin tab 20 mg
21
simvastatin tab 40 mg
21
simvastatin tab 5 mg
21
sinadrin pe tab 2-10-650
58
sinus-max mis day/nght
58
slow rel fe tab 143mg cr
69
slow release tab 143mg
69
sm clearlax pow
32
sm ibuprofen tab 100mg jr
4
sm one daily mis prenatal
61
smooth lax pow
32
sod silicate sol
27
sod silicate sol 40%
27
sodium bicarbonate tab 325 mg
32
sodium bicarbonate tab 650 mg
32
sodium chloride aero soln 0.9 58
sodium chloride hypertonic op
46, 47
sodium chloride irrigation so 61
sodium chloride soln nebu 0.9
58
sodium chloride tab 1 gm
69
sodium citrate & citric acid 61
sodium fluoride chew tab 0.5 69
sodium fluoride chew tab 1 mg
69
sodium fluoride cream 1.1% 21
sodium fluoride soln 0.5 mg/m
69
sodium pow bicarbon
32
solia
38
soothe dro 0.6-0.6%
47
sotalol hcl (afib/afl) tab 12 17
sotalol hcl (afib/afl) tab 16 17
sotalol hcl (afib/afl) tab 80 17
sotalol hcl tab 120 mg
17
sotalol hcl tab 160 mg
17
sotalol hcl tab 240 mg
17
sotalol hcl tab 80 mg
17
soybean oil
27
spearmint oil
27
spironolactone & hydrochlorot
20
spironolactone tab 100 mg 20
spironolactone tab 25 mg
20
spironolactone tab 50 mg
20
sronyx
38
stahist ad liq
58
stahist ad tab 25-60mg
58
stannous fluoride conc 0.63% 21
stannous fluoride gel 0.4% 21
starch suppositories 51%
27
statuss liq green
58
step 2 sol 8%
27
sterile lubr dro 0.7%
47
stromectol tab 3mg
10
strovite for syp
69
stuart one cap
61
sucralfate tab 1 gm
32
sudafed 24hr tab 240mg
58
sudafed pe pak day&nght
58
sulf lime sol
27
sulfacet sod oin 10% op
47
sulfacetamide sodium lotion 1
27
sulfacetamide sodium ophth so
47
sulfacetamide sodium w/ sulfu
27
sulfacetamide sodium-predniso
48
sulfacetamide sodium-sulfur i27
sulfadiazine tab 500 mg
7
sulfamethoxazole-trimethoprim
5
sulfasalazine tab 500 mg
42
sulfasalazine tab delayed rel 42
sulfoam sha 2%
27
sulfur bar 10%
27
sulfur bar 5%
27
sulindac tab 150 mg
4
sulindac tab 200 mg
4
sumatriptan succinate tab 100 9
sumatriptan succinate tab 25 9
sumatriptan succinate tab 50 9
supervite ec tab
69
suppress a dro 5-1-10
58
supress dm dro 5-50/ml
58
supress-pe dro pediatri
58
sure-lance mis lancets
45
sure-t infus mis set 23"
45
sw clearlax pow
32
symbicort aer 160-4.5
50
symbicort aer 80-4.5
50
synagis inj 100mg/ml
42
synagis inj 50mg
42
synatek cap
69
systane bal sol restor
47
systane gel 0.3%
47
systane liq dro 0.4-0.3%
47
T tabloid tab 40mg
10
tacrolimus cap 0.5 mg
42
tacrolimus cap 1 mg
42
tacrolimus cap 5 mg
42
tamiflu cap 30mg
11
tamiflu cap 45mg
11
tamiflu cap 75mg
11
tamiflu sus 6mg/ml
11
tamoxifen citrate tab 10 mg ( 10
tamoxifen citrate tab 20 mg ( 10
tamsulosin hcl cap 0.4 mg 34
tangerine oil
27
taron-bc mis
61
tears again gel nght/day
47
tegrin-lt kit
27
tender 1 kit 31"
45
terazosin hcl cap 1 mg
19
terazosin hcl cap 10 mg
19
terazosin hcl cap 2 mg
19
terazosin hcl cap 5 mg
19
terbinafine hcl cream 1%
27
terbinafine hcl tab 250 mg
8
terbutaline sulfate tab 2.5 m 50
terbutaline sulfate tab 5 mg 50
terconazole vaginal cream 0.435
terconazole vaginal cream 0.835
terconazole vaginal suppos 80
35
terpin hydr pow monohydr 58
testosterone cypionate im in 35
tetracycline cap 500mg
7
tetracycline hcl cap 250 mg 7
tetrahydrozoline hcl ophth so 47
tetrahydrozoline w/ polyethyl 47
88
tetrahydrozoline w/ zinc sulf 47
theo-24 cap 100mg cr
58
theo-24 cap 200mg cr
58
theo-24 cap 300mg cr
58
theophylline tab sr 12hr 100 58
theophylline tab sr 12hr 200 58
theophylline tab sr 12hr 300 58
theophylline tab sr 12hr 450 58
theracof pls liq cgh/cold
58
theraflu cld mis cgh day
58
theraflu flu pak sore thr
58
theraflu flu pow chst con
58
theraflu liq warm rlf
59
theraflu pak cold/cgh
59
theraflu pow
59
theraflu pow max-d
59
theraflu sev pak cold/cgh
59
theranatal mis complete
61
theratears sol op
47
thiamine cap 50mg
69
thiamine hcl tab 100 mg
69
thiamine hcl tab 250 mg
69
thiamine hcl tab 50 mg
69
thiamine mononitrate tab 100 69
thyroid tab 16.25 mg
41
thyroid tab 30 mg (1/2 grain) 41
thyroid tab 60 mg (1 grain) 41
thyroid tab 90 mg (1 1/2 grai 41
ticlopidine hcl tab 250 mg 14
timolol maleate ophth soln 0. 48
timolol maleate tab 10 mg 17
timolol maleate tab 20 mg 17
timolol maleate tab 5 mg
17
timoptic ocu sol 0.25% op 48
timoptic ocu sol 0.5% op
48
titralac chw plus
32
tizanidine hcl tab 2 mg
60
tizanidine hcl tab 4 mg
60
tl g-fol os tab
69
tobradex oin 0.3-0.1%
48
tobramycin ophth soln 0.3% 47
tobramycin-dexamethasone
opht
48
tobrex oin 0.3% op
47
tolterodine tartrate cap sr 2 34
tolterodine tartrate tab 1 mg 34
tolterodine tartrate tab 2 mg 34
toothache gum
21
torsemide tab 10 mg
19
torsemide tab 100 mg
20
torsemide tab 20 mg
20
torsemide tab 5 mg
20
tramadol hcl tab 50 mg
2
trandolapril tab 1 mg
15
trandolapril tab 2 mg
15
trandolapril tab 4 mg
15
trecator tab 250mg
9
tretinoin cap 10 mg
10
tretinoin cream 0.025%
27
tretinoin cream 0.05%
27
tretinoin cream 0.1%
27
tretinoin gel 0.01%
27
tretinoin gel 0.025%
27
trexbrom liq 10-4-25
59
triactin sol chst con
59
triacting liq cgh/run
59
triamcinolone acetonide cream
27
triamcinolone acetonide denta
21
triamcinolone acetonide lotio27,
28
triamcinolone acetonide oint 28
triamin flu/ syp cgh/fvr
59
triaminic chw
59
triaminic liq
59
triaminic liq chst/nas
59
triaminic mis cgh/cold
59
triaminic mis cold/cgh
59
triaminic mis grape
59
triaminic nt mis cold/cgh
59
triaminic sol cold/cgh
59
triaminic syp cgh/sore
59
triaminic syp child
59
triaminic syp chst/nsl
59
triaminic syp cold/all
59
triaminic syp cold/cgh
59
triaminic-d syp
59
triamterene & hydrochlorothia
20
tricode ar liq
59
tricode gf liq
59
trifluridine ophth soln 1%
47
trimethobenzamide hcl cap 300
8
trimethoprim tab 100 mg
5
trinatal rx tab 1
61
triprolidine & pseudoephedrin
59
trispec dmx liq 10-187/5
59
trispec pse liq
triveen-duo pak dha
triveen-u cap
trivora-28
tropicamide ophth soln 0.5%
tropicamide ophth soln 1%
trospium chloride tab 20 mg
trypsin w/ castor oil & peruv
tudorza pres aer 400/act
turpentine liq spirits
turpentine oil
tusicof liq
tusnel cap
tussafex-a liq 6-2-15/5
tylenol cgh pak sore thr
tylenol ches liq congest
tylenol chld sus cld/cgh
tylenol chld sus stuffy
tylenol cold liq relief
tylenol sinu mis day/nite
U udamin sp tab
ultra tabs tab
ultresa cap 13800unt
ultresa cap 20700unt
ultresa cap 23000unt
undecylenic liq acid
unifed liq 30mg/5ml
unifine pntp mis 29gx12mm
unifine pntp mis 31gx5mm
unifine pntp mis 31gx6mm
unifine pntp mis 31gx8mm
unifine pntp mis 32gx4mm
unithroid tab 100mcg
unithroid tab 112mcg
unithroid tab 125mcg
unithroid tab 137mcg
unithroid tab 150mcg
unithroid tab 175mcg
unithroid tab 200mcg
unithroid tab 25mcg
unithroid tab 300mcg
unithroid tab 50mcg
unithroid tab 75mcg
unithroid tab 88mcg
upcal d pow
urea cream 40%
uro-mag cap 140mg
ursodiol cap 300 mg
89
59
61
61
38
48
48
34
28
50
28
28
59
59
59
59
59
59
59
59
59
69
61
28
28
28
28
59
45
45
45
45
45
41
41
41
41
41
41
41
41
41
41
41
41
69
28
32
32
V vanacof ape liq
59
vanacof cd liq
59
vanacof dm liq
59
vanacof g liq
59
vanacof gpe liq
59
vanacof-8 liq 25-50/15
60
vanatab dx tab
60
vancomycin hcl for inj 10 gm 5
vancomycin hcl for inj 1000 m 5
vancomycin hcl for inj 500 mg 5
vancomycin hcl for inj 5000 m 5
vancomycin inj 750mg
5
vancomycn 25 sol 25mg/ml 5
vancomycn 50 sol 50mg/ml 5
vasoclear a sol op
47
velivet
38
ventolin hfa aer
50
verapamil hcl cap sr 24hr 100 18
verapamil hcl cap sr 24hr 120 18
verapamil hcl cap sr 24hr 180 18
verapamil hcl cap sr 24hr 200 18
verapamil hcl cap sr 24hr 240 18
verapamil hcl cap sr 24hr 300 18
verapamil hcl cap sr 24hr 360 18
verapamil hcl tab 120 mg
18
verapamil hcl tab 40 mg
18
verapamil hcl tab 80 mg
18
verapamil hcl tab cr 120 mg 18
verapamil hcl tab cr 180 mg 18
verapamil hcl tab cr 240 mg 18
vesicare tab 10mg
34
vesicare tab 5mg
34
vibramycin syp 50mg/5ml
7
vicks nature liq cold/flu
60
vicks nature liq congest
60
vicks nyquil liq children
60
vicks nyquil liq cold/flu
60
vinate cal tab
62
vinate ic cap
62
vinate ii tab
62
vinate m tab
62
viokace tab
28
visine tears dro
47
vita-c cry
69
vita-calcium waf
69
vitamin b-12 tab 1000mcg 69
vitamin c cap 500mg
69
vitamin c chw 1000mg
69
vitamin c chw gummie
69
vitamin c sol
69
vita-pren tab
62
viva drops dro 1%
47
W wal-dryl-d tab 25-60mg
60
warfarin sodium tab 1 mg
13
warfarin sodium tab 10 mg 13
warfarin sodium tab 2 mg
13
warfarin sodium tab 2.5 mg 13
warfarin sodium tab 3 mg
13
warfarin sodium tab 4 mg
13
warfarin sodium tab 5 mg
13
warfarin sodium tab 6 mg
13
warfarin sodium tab 7.5 mg 13
water for irrigation, sterile 45
wera
38
wide-seal dpr kit 60
45
wide-seal dpr kit 65
45
wide-seal dpr kit 70
45
wide-seal dpr kit 75
45
wide-seal dpr kit 80
45
wide-seal dpr kit 85
45
wide-seal dpr kit 90
45
wide-seal dpr kit 95
46
X xarelto tab 10mg
13
Z zeasorb-af lot 2%
28
zenpep cap 10000unt
28
zenpep cap 15000unt
28
zenpep cap 20000unt
29
zenpep cap 25000unt
29
zenpep cap 3000unit
29
zinc 15 tab 66mg
69
zinc loz
69
zinc sulfate cap 220 mg (50 m
69
zinc sulfate gra heptahyr
69
zinc sulfate inj 1mg/ml
69
zinc sulfate inj 5mg/ml
69
zinc sulfate pow
69
zinc sulfate tab
69
zinc sulfate tab 220 mg (50 m69
zinc tab 220mg
69
zodryl ac 25 sus
60
zodryl ac 30 sus
60
zodryl ac 35 sus
60
zodryl ac 40 sus
60
zodryl dac sus 25
60
zodryl dac sus 30
60
zodryl dac sus 35
zodryl dac sus 40
zodryl dec25 sus
zodryl dec30 sus
90
60
60
60
60
zodryl dec35 sus
zodryl dec40 sus
zostavax inj
zostrix-hp mis 0.075%
60
60
42
28
zovia 1/50e
z-tuss ac liq 2-9/5ml
z-tuss e liq
zyncof syp 20-400/5
38
60
60
60