aetna better health pennsylvania supplemental formulary ...€¦ · prior approval (pa): this means...

AETNA BETTER HEALTH® Supplemental Formulary Guide – 2020

Aetna Better Health Pennsylvania

Supplemental Formulary Guide

July 2020


What is the Aetna Better Health of Pennsylvania Supplemental Formulary?

This is a drug list created by Aetna Better Health in Pennsylvania (“plan”). The plan will cover drugs on this list in addition to the drugs covered on the Statewide Preferred Drug List (PDL). This list is for drugs and products outside the scope of the Statewide PDL. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a the plan’s network pharmacy. This list is for drugs covered under you prescription benefit. Drugs may not be listed here if they are covered under your medical benefit. Drugs covered under your medical benefit are usually those a health care professional gives to you, like an IV infusion or other injection, and not typically a medication you would take on your own.

www.aetnabetterhealth.com/pennsylvania 2 PA‐10‐03‐03A

http://www.aetnabetterhealth.com/pennsylvania


Are there any exclusions from the formulary?

Yes, some drugs are excluded from coverage by direction of the department of Health Services (DHS). Examples include:

• Drugs and devices classified as experimental by the FDA or whose use is classified as experimental by the FDA

• Drugs and devices not approved by the FDA or whose use is not approved by the FDA • Drugs and other items prescribed for obesity or appetite control • Drugs marketed by a drug company who does not participate in the Medicaid Drug Rebate

Program. • Drugs designated as a DESI (Drug Efficacy Study Implementation). A DESI drug is one that was

approved by the FDA solely on the basis of their safety prior to 1962. Subsequent to 1962, Congress required drugs to be shown to be effective as well. As a result, the FDA initiated a DESI to evaluate the effectiveness of medications previously approved based on safety alone. DESI drugs may continue to be marketed until proceedings evaluating efficacy have been concluded, at which point continued marketing would only be permitted if a New Drug Application is submitted for those drugs.

• Durable Medical Equipment (DME) items (with the exception of preferred diabetic supplies, syringes, lancets, alcohol wipes and condoms)

• Items prescribed or ordered by a physician who has been barred or suspended from participating in the Medical Assistance Program

• Pharmaceutical services provided to a hospitalized person • Placebos

Can the Plan’s Drug List change?

The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review at least 30 days before the change is made. Utilizing members will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website.

How do I use the Plan’s Formulary?

• Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug).

• Column #2: lists the brand name of the drug when a generic is covered • Column #3: shows coverage rules for the drug

Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed




under the section, “Otic.” If you know what your drug is used for; please look for that section name on the drug list. Then look under that section for your drug.

What are generic drugs?

Generic drugs are copies of brand‐name drugs. They are the same as those brand name drugs in dosage form, safety, strength, route of administration, quality, and intended use.

When a drug is available as a generic, you will be required to use the generic version for your prescription. If your provider feels it is medically necessary that you take only the brand, then your provider must request a prior authorization from the plan before the brand will be covered.

Are Over‐The‐Counter (OTC) drugs covered?

The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan.

How much will I pay for covered drugs?

No Copays There are no copays for: • Pregnant women • Children under 21 years of age • Members in a nursing home or other facility (Intermediate Care Facility for Mental Retardation) • Family planning drugs • Emergency situation (condition in which emergency medical care is needed to prevent death or

serious injury of a member) • Certain drug groups listed below do not have copays. For those drug groups that will not

require a copay the drug group will be marked with a “no copay” on the formulary.

o Anti‐glaucoma drugs o Anti‐Parkinson drugs o Antipsychotic drugs (except for those anti‐anxiety drugs that are controlled

substances, like alprazolam or diazepam) o Cancer drugs o Diabetes drugs o Drugs used only to treat HIV/AIDS o Epilepsy drugs o Heart disease drugs




o High blood pressure drugs o Naloxone injection/nasal spray for drug overdose o Preventative vaccines

Copays Members 21 years of age and older: generic drugs on formulary are $1; brand drugs on formulary are $3 per prescription. Services cannot be denied if the member cannot afford the copay.

What are some types of coverage rules?

• Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug.

• Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Your doctor will need to get approval from the plan first before the drug can be filled for more than the plans limits.

• Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you or you cannot take Drug A, then Drug B will be covered.

What if my drug is not on the plan’s Formulary?

• Check whether the drug is on the Statewide PDL – it may be preferred and covered. • If not already covered on the Statewide PDL, ask your doctor for a similar drug that is on the

Statewide PDL or Supplemental Formulary or • Your doctor can ask the plan to cover your drug through the prior approval process.

Where can I fill my prescriptions?

You can fill your prescriptions at any network pharmacy. You can find the location of an in‐network pharmacy by visiting the CVS Caremark pharmacy locator. http://www.aetnabetterhealth.com/pennsylvania/providers/pharmacy This allows you to search for a pharmacy by zip code so you can find a location close to you.


http://www.aetnabetterhealth.com/pennsylvania/providers/pharmacy



Definition of Symbols F Formulary

AL

Age Restriction: We require that the appropriate dose of medication based on age (e.g., pediatric and elderly populations) and indication AND Dosage requested must be based on national established/ recognized guidelines pertaining to the treatment and management of the diagnosis and age for which

the medication is being used to treat. OR FDA-approved age limitations. Click this symbol on the online search tool for more information.

Names in

Italics

Generic Drug - The plan covers both brand and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

PA This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug.

QLL This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs.

ST

This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. For a complete list of all drugs requiring step therapy; click on the following -https://www.aetnabetterhealth.com/pennsylvania/assets/pdf/pharmacy/Pennsylvania_Step_Therapy.pdf


https://www.aetnabetterhealth.com/pennsylvania/assets/pdf/pharmacy/Pennsylvania_Step_Therapy.pdf


Aetna Better Health Pennsylvania Supplemental Formulary

Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................................3 *ALTERNATIVE MEDICINES*............................................................................................................................. 3 *ANALGESICS - ANTI-INFLAMMATORY*........................................................................................................ 3 *ANALGESICS - NONNARCOTIC*.......................................................................................................................3 *ANORECTAL AGENTS*.......................................................................................................................................4 *ANTACIDS*............................................................................................................................................................4 *ANTHELMINTICS*............................................................................................................................................... 5 *ANTIARRHYTHMICS*......................................................................................................................................... 5 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*.............................................................................. 5 *ANTIDIABETICS*................................................................................................................................................. 5 *ANTIDIARRHEALS*.............................................................................................................................................6 *ANTIHISTAMINES*.............................................................................................................................................. 6 *ANTIHYPERTENSIVES*...................................................................................................................................... 6 *ANTI-INFECTIVE AGENTS - MISC.*................................................................................................................. 7 *ANTIMYASTHENIC AGENTS*........................................................................................................................... 7 *ANTIMYCOBACTERIAL AGENTS*................................................................................................................... 7 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*..................................................................................7 *ANTIPSYCHOTICS/ANTIMANIC AGENTS*..................................................................................................... 8 *ASSORTED CLASSES*......................................................................................................................................... 8 *CARDIOTONICS*.................................................................................................................................................. 8 *CHEMICALS*.........................................................................................................................................................8 *CONTRACEPTIVES*.............................................................................................................................................9 *COUGH/COLD/ALLERGY*..................................................................................................................................9 *DERMATOLOGICALS*...................................................................................................................................... 10 *DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS*................................................................10 *DIURETICS*.........................................................................................................................................................11 *ENDOCRINE AND METABOLIC AGENTS - MISC.*......................................................................................11 *GASTROINTESTINAL AGENTS - MISC.*........................................................................................................12 *GENITOURINARY AGENTS - MISCELLANEOUS*....................................................................................... 12 *HEMATOLOGICAL AGENTS - MISC.*............................................................................................................ 13 *HEMATOPOIETIC AGENTS*.............................................................................................................................13 *HEMOSTATICS*..................................................................................................................................................13 *HYPNOTICS*....................................................................................................................................................... 13 *LAXATIVES*....................................................................................................................................................... 13 *MEDICAL DEVICES*..........................................................................................................................................15 *MINERALS & ELECTROLYTES*......................................................................................................................17 *MOUTH/THROAT/DENTAL AGENTS*............................................................................................................18 *MULTIVITAMINS*..............................................................................................................................................19 *NASAL AGENTS - SYSTEMIC AND TOPICAL*............................................................................................. 20 *NEUROMUSCULAR AGENTS*......................................................................................................................... 20 *NUTRIENTS*........................................................................................................................................................20 *OPHTHALMIC AGENTS*...................................................................................................................................20 *OTIC AGENTS*....................................................................................................................................................21 *OXYTOCICS*.......................................................................................................................................................21 *PASSIVE IMMUNIZING AGENTS*...................................................................................................................21 *PHARMACEUTICAL ADJUVANTS*................................................................................................................ 22 *RESPIRATORY AGENTS - MISC.*....................................................................................................................22

1

*SINUS NODE INHIBITORS**.............................................................................................................................22 *SULFONAMIDES*...............................................................................................................................................22 *THYROID AGENTS*........................................................................................................................................... 23 *ULCER DRUGS*.................................................................................................................................................. 23 *URINARY ANTISPASMODICS*........................................................................................................................23 *VAGINAL PRODUCTS*......................................................................................................................................23 *VASOPRESSORS*............................................................................................................................................... 23 *VITAMINS*.......................................................................................................................................................... 23

2

Drug Name Reference Restrictions *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* *Analeptics*** caffeine citrate oral solution 20 mg/ml caffeine citrated powder

*ALTERNATIVE MEDICINES* *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 mg OTC melatonin oral tablet 3 mg OTC

*ANALGESICS - ANTI-INFLAMMATORY* *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg Arava

*ANALGESICS - NONNARCOTIC* *Analgesics Other*** acetaminophen childrens oral suspension 160 mg/5ml Panadol Childrens OTC

acetaminophen childrens oral tablet chewable 160 mg Mapap Childrens OTC

acetaminophen er oral tablet extended release 650 mg Midol OTC

acetaminophen extra strength oral tablet 500 mg

Healthy Mama Shake That Ache OTC

acetaminophen oral liquid 160 mg/5ml Little Remedies for Fever OTC acetaminophen oral solution 160 mg/5ml OTC acetaminophen oral tablet 325 mg Pharbetol OTC acetaminophen rectal suppository 120 mg FeverAll Childrens OTC acetaminophen rectal suppository 650 mg FeverAll Adults OTC childrens pain reliever oral tablet chewable 80 mg Childrens Medi-Tabs OTC

FEVERALL JUNIOR STRENGTH RECTAL SUPPOSITORY 325 MG OTC

MAPAP ACETAMINOPHEN EXTRA STR ORAL LIQUID 500 MG/15ML Pain Reliever OTC

*Salicylates***

aspirin adult oral tablet 325 mg Bayer Advanced Aspirin Reg St OTC

aspirin ec oral tablet delayed release 325 mg Bayer Aspirin OTC

3

Drug Name Reference Restrictions aspirin low dose oral tablet chewable 81 mg Bayer Low Dose OTC ASPIR-LOW ORAL TABLET DELAYED RELEASE 81 MG

EQ Adult Aspirin Low Strength OTC

*ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema 100 mg/60ml Colocort

*Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % QLL (30 GM per 30 days)

*ANTACIDS* *Antacid & Simethicone*** antacid anti-gas max strength oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

antacid oral suspension 200-200-20 mg/5ml Almacone OTC MINTOX PLUS ORAL TABLET CHEWABLE 200-200-25 MG OTC

*Antacid Combinations*** antacid extra strength oral tablet chewable 160-105 mg Acid Gone OTC

ACID GONE ORAL SUSPENSION 95-358 MG/15ML GNP Foaming Antacid OTC

*Antacids - Bicarbonate*** sodium bicarbonate oral powder sodium bicarbonate oral tablet 325 mg, 650 mg OTC

*Antacids - Calcium Salts*** calcium antacid extra strength oral tablet chewable 750 mg Tums Extra Strength 750 OTC

calcium antacid oral tablet chewable 500 mg Tums OTC calcium antacid ultra max st oral tablet chewable 1000 mg Tums Ultra 1000 OTC

calcium carbonate antacid oral suspension 1250 mg/5ml OTC

TUMS EXTRA STRENGTH 750 ORAL TABLET CHEWABLE 750 MG SB Antacid Extra Strength OTC

TUMS ORAL TABLET CHEWABLE 500 MG Antacid OTC

TUMS ULTRA 1000 ORAL TABLET CHEWABLE 1000 MG CVS Antacid Ultra Strength OTC

*Antacids - Magnesium Salts*** magnesium oxide oral tablet 400 mg OTC

4

Drug Name Reference Restrictions magnesium oxide oral tablet 420 mg Maox OTC

*ANTHELMINTICS* *Anthelmintics*** albendazole oral tablet 200 mg Albenza PA ivermectin oral tablet 3 mg Stromectol praziquantel oral tablet 600 mg Biltricide PA reeses pinworm medicine oral suspension 144 (50 base) mg/ml OTC

*ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 150 mg Norpace No Copay

*Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150 mg, 200 mg No Copay

*Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg No Copay

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg Rythmol SR No Copay

propafenone hcl oral tablet 150 mg No Copay

*Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg Pacerone No Copay

MULTAQ ORAL TABLET 400 MG PA; No Copay; QLL (2 EA per 1 day)

*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Xanthines*** theophylline er oral tablet extended release 12 hour 300 mg, 450 mg theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

*ANTIDIABETICS* *Diabetic Other - Combinations*** sm glucose oral tablet chewable 4-6 gm-mg Dex4 No Copay; OTC

*Diabetic Other*** glucose oral tablet chewable 4 gm Dex4 Quick Dissolve Glucose No Copay; OTC sm glucose oral tablet chewable 4 gm Dex4 Quick Dissolve Glucose No Copay; OTC GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG No Copay

5

Drug Name Reference Restrictions GLUCAGON EMERGENCY INJECTION KIT 1 MG No Copay

*ANTIDIARRHEALS* *Antidiarrheal Agents - Misc.*** bismuth subsalicylate oral tablet chewable 262 mg Pepto-Bismol OTC

gnp pink bismuth oral tablet 262 mg Kaopectate OTC pink bismuth maximum strength oral suspension 525 mg/15ml Kaopectate Extra Strength OTC

pink bismuth oral suspension 262 mg/15ml Kaopectate OTC

*Antiperistaltic Agents*** diphenoxylate-atropine oral tablet 2.5-0.025 mg Lomotil

loperamide hcl oral capsule 2 mg Imodium A-D loperamide hcl oral liquid 1 mg/5ml OTC loperamide hcl oral liquid 1 mg/7.5ml Imodium A-D OTC loperamide hcl oral tablet 2 mg Imodium A-D OTC

*ANTIHISTAMINES* *Antihistamines - Alkylamines*** chlorpheniramine maleate oral tablet 4 mg Chlor-Trimeton OTC sm allergy 4 hour oral tablet 4 mg Chlor-Trimeton OTC

*Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet 4 mg clemastine fumarate oral tablet 2.68 mg diphenhydramine hcl oral capsule 25 mg, 50 mg Banophen

diphenhydramine hcl oral elixir 12.5 mg/5ml diphenhydramine hcl oral liquid 12.5 mg/5ml Banophen OTC diphenhydramine hcl oral liquid 6.25 mg/ml PediaClear Cough Childrens OTC diphenhydramine hcl oral tablet 25 mg Alka-Seltzer Plus Allergy OTC

*Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 mg/5ml cyproheptadine hcl oral tablet 4 mg

*ANTIHYPERTENSIVES* *Vasodilators*** hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg No Copay

minoxidil oral tablet 10 mg, 2.5 mg No Copay

6

Drug Name Reference Restrictions *ANTI-INFECTIVE AGENTS -MISC.* *Anti-Infective Misc. -Combinations*** sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml Sulfatrim Pediatric

sulfamethoxazole-trimethoprim oral tablet 400-80 mg Bactrim

sulfamethoxazole-trimethoprim oral tablet 800-160 mg Bactrim DS

*Leprostatics*** dapsone oral tablet 100 mg, 25 mg

*Lincosamides*** clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg Cleocin

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml Cleocin

*ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 mg Mestinon

*ANTIMYCOBACTERIAL AGENTS* *Antimycobacterial Agents*** ethambutol hcl oral tablet 400 mg Myambutol isoniazid oral tablet 100 mg, 300 mg pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg Mycobutin rifampin oral capsule 150 mg, 300 mg Rifadin PRIFTIN ORAL TABLET 150 MG

*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Antineoplastics Misc.*** hydroxyurea oral capsule 500 mg Hydrea No Copay

*Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg No Copay

*Mitotic Inhibitors*** etoposide oral capsule 50 mg PA; No Copay

7

Drug Name Reference Restrictions *Retinoids*** tretinoin oral capsule 10 mg PA; No Copay

*Selective Retinoid X Receptor Agonists*** bexarotene oral capsule 75 mg Targretin PA; No Copay

*ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300 mg Lithobid No Copay; QLL (8 EA per 1

day) lithium carbonate er oral tablet extended release 450 mg

No Copay; QLL (6 EA per 1 day)

lithium carbonate oral capsule 150 mg No Copay; QLL (16 EA per 1 day)



lithium carbonate oral tablet 300 mg No Copay; QLL (8 EA per 1 day)

lithium oral solution 8 meq/5ml No Copay; QLL (40 ML per 1 day)

*ASSORTED CLASSES* *Irrigation Solutions*** sterile water for irrigation irrigation solution Argyle Sterile Water

*CARDIOTONICS* *Cardiac Glycosides*** digoxin oral solution 0.05 mg/ml No Copay digoxin oral tablet 125 mcg, 250 mcg Digitek No Copay DIGITEK ORAL TABLET 125 MCG, 250 MCG Digoxin No Copay

*CHEMICALS* *Bulk Chemicals - Hy's*** hydroxyprogesterone caproate powder

*Bulk Chemicals - St's*** stevia extract powder steviol glycosides powder 95 %

*Liquids*** glycerin liquid

8

Drug Name Reference Restrictions *CONTRACEPTIVES* *Emergency Contraceptives*** levonorgestrel oral tablet 1.5 mg Aftera No Copay; OTC AFTERA ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC ECONTRA EZ ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC ECONTRA ONE-STEP ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC

ELLA ORAL TABLET 30 MG No Copay MY CHOICE ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC MY WAY ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC NEW DAY ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC OPCICON ONE-STEP ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC

OPTION 2 ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC REACT ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC TAKE ACTION ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC

*COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic***

benzonatate oral capsule 100 mg Tessalon Perles QLL (6 EA per 1 day); AL (Min 10 Years)

benzonatate oral capsule 200 mg QLL (3 EA per 1 day); AL (Min 10 Years)

*Expectorants*** guaifenesin er oral tablet extended release 12 hour 600 mg EQ Mucus ER

guaifenesin oral solution 100 mg/5ml, 200 mg/10ml, 300 mg/15ml Buckleys Chest Congestion OTC

guaifenesin oral syrup 100 mg/5ml Diabetic Tussin EX OTC

*Misc. Respiratory Inhalants*** sodium chloride inhalation nebulization solution 0.9 %, 10 % sodium chloride inhalation nebulization solution 3 % Nebusal

sodium chloride inhalation nebulization solution 7 % HyperSal

HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %

*Mucolytics*** acetylcysteine inhalation solution 10 %, 20 %

9

Drug Name Reference Restrictions *DERMATOLOGICALS* *Antineoplastic Antimetabolites -Topical*** fluorouracil external cream 5 % Efudex fluorouracil external solution 5 %

*Astringents*** zinc oxide external ointment 20 % OTC zinc oxide external ointment 40 % Boudreauxs Butt Paste OTC

*Burn Products*** SSD EXTERNAL CREAM 1 % Silver Sulfadiazine

*Diaper Rash Products*** A+D PREVENT EXTERNAL OINTMENT CVS Pediatric Ointment OTC

*Emollient Combinations*** mineral oil-hydrophil petrolat external ointment OTC

*Emollients*** ammonium lactate external cream 12 % Geri-Hydrolac 12 ammonium lactate external lotion 12 % AL12 thera-derm external lotion A + D Personal Care Lotion OTC HYDROLATUM EXTERNAL OINTMENT Hydrophor OTC

SOOTHE & COOL SKIN EXTERNAL CREAM Beta Care OTC

*Enzymes - Topical*** SANTYL EXTERNAL OINTMENT 250 UNIT/GM

*Misc. Topical*** DRYSOL EXTERNAL SOLUTION 20 %

*Skin Cleansers*** alcohol wipes external 70 % OTC

*Tar Products*** therapeutic external shampoo 0.5 % DHS Tar OTC

*DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* *Nutritional Supplements*** BOOST HIGH PROTEIN ORAL LIQUID Nutritional Supplement OTC

10

Drug Name Reference Restrictions *DIURETICS* *Carbonic Anhydrase Inhibitors*** acetazolamide er oral capsule extended release 12 hour 500 mg No Copay

acetazolamide oral tablet 125 mg, 250 mg No Copay methazolamide oral tablet 50 mg No Copay

*Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5-50 mg No Copay

spironolactone-hctz oral tablet 25-25 mg Aldactazide No Copay triamterene-hctz oral capsule 37.5-25 mg Dyazide No Copay triamterene-hctz oral tablet 37.5-25 mg Maxzide-25 No Copay triamterene-hctz oral tablet 75-50 mg Maxzide No Copay

*Loop Diuretics*** bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Bumex No Copay furosemide oral solution 10 mg/ml No Copay furosemide oral tablet 20 mg, 40 mg, 80 mg Lasix No Copay torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg No Copay

*Potassium Sparing Diuretics*** amiloride hcl oral tablet 5 mg No Copay spironolactone oral tablet 100 mg, 25 mg, 50 mg Aldactone No Copay

*Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250 mg, 500 mg No Copay chlorthalidone oral tablet 25 mg, 50 mg No Copay hydrochlorothiazide oral capsule 12.5 mg No Copay hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg No Copay

indapamide oral tablet 1.25 mg, 2.5 mg No Copay metolazone oral tablet 10 mg, 2.5 mg, 5 mg No Copay

*ENDOCRINE AND METABOLIC AGENTS - MISC.* *Dopamine Receptor Agonists*** cabergoline oral tablet 0.5 mg

*Somatostatic Agents*** octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml SandoSTATIN PA

11

Drug Name Reference Restrictions SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

PA

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML

PA

*Vasopressin*** desmopressin ace spray refrig nasal solution 0.01 % QLL (5 ML per 12 days)

desmopressin acetate oral tablet 0.1 mg, 0.2 mg DDAVP QLL (3 EA per 1 day)

desmopressin acetate spray nasal solution 0.01 % DDAVP QLL (5 ML per 12 days)

*GASTROINTESTINAL AGENTS -MISC.* *Antiflatulents*** gas relief extra strength oral capsule 125 mg Gas-X Extra Strength OTC gas relief ultra strength oral capsule 180 mg Gas-X Ultra Strength OTC simethicone oral suspension 40 mg/0.6ml Little Remedies for Tummys OTC simethicone oral tablet chewable 125 mg Gas-X Extra Strength OTC simethicone oral tablet chewable 80 mg Gas-X OTC

*Intestinal Acidifiers*** lactulose encephalopathy oral solution 10 gm/15ml

*GENITOURINARY AGENTS -MISCELLANEOUS* *Citrates*** cytra k crystals oral packet 3300-1002 mg Taron-Crystals potassium citrate er oral tablet extended release 10 meq (1080 mg) Urocit-K 10

potassium citrate er oral tablet extended release 15 meq (1620 mg) Urocit-K 15

potassium citrate er oral tablet extended release 5 meq (540 mg) Urocit-K 5

potassium citrate-citric acid oral solution 1100-334 mg/5ml sod citrate-citric acid oral solution 500-334 mg/5ml TARON-CRYSTALS ORAL PACKET 3300-1002 MG Cytra K Crystals

12

Drug Name Reference Restrictions *Genitourinary Irrigants*** sodium chloride irrigation solution 0.9 % Argyle Sterile Saline

*Interstitial Cystitis Agents*** ELMIRON ORAL CAPSULE 100 MG PA

*Phosphates*** K-PHOS NO 2 ORAL TABLET 305-700 MG

*Urinary Analgesics*** phenazopyridine hcl oral tablet 100 mg Pyridium phenazopyridine hcl oral tablet 200 mg Phenazo

*HEMATOLOGICAL AGENTS -MISC.* *Hematorheologic Agents*** pentoxifylline er oral tablet extended release 400 mg No Copay

*HEMATOPOIETIC AGENTS* *Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml

*Cytotoxic Agents*** DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

*Folic Acid/Folates*** folic acid oral tablet 1 mg

*HEMOSTATICS* *Hemostatics - Systemic*** aminocaproic acid oral tablet 500 mg Amicar

*HYPNOTICS* *Antihistamine Hypnotics*** sleep aid (diphenhydramine) oral tablet 25 mg Nytol OTC sleep aid oral tablet 25 mg Unisom SleepTabs OTC

*LAXATIVES* *Bowel Evacuant Combinations*** peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm GaviLyte-N with Flavor Pack

peg-3350/electrolytes oral solution reconstituted 236 gm GaviLyte-G

13

Drug Name Reference Restrictions GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM

PEG 3350-KCl-Na Bicarb-NaCl

TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM

PEG 3350-KCl-Na Bicarb-NaCl

*Bulk Laxatives*** konsyl daily fiber oral powder 28.3 % Metamucil OTC natural fiber laxative oral powder 58.6 % Metamucil Smooth Texture OTC natural fiber therapy oral powder 48.57 % Metamucil OTC qc fiber laxative oral capsule 0.52 gm Medi-Mucil OTC qc natural vegetable oral powder 95 % Hydrocil OTC

*Laxatives - Miscellaneous*** glycerin (adult) rectal suppository 2.1 gm OTC glycerin (pediatric) rectal suppository 1.2 gm OTC lactulose oral solution 10 gm/15ml polyethylene glycol 3350 oral packet 17 gm CVS Purelax QLL (17 GM per 1 day) polyethylene glycol 3350 oral powder 17 gm/scoop ClearLax QLL (17 GM per 1 day)

*Laxatives & Dss*** senna-docusate sodium oral tablet 8.6-50 mg Colace 2-IN-1 OTC

*Lubricant Laxatives*** mineral oil rectal enema Fleet Oil OTC

*Saline Laxative Mixtures*** enema rectal enema 7-19 gm/118ml Fleet Enema OTC FLEET PEDIATRIC RECTAL ENEMA 3.5-9.5 GM/59ML Enema Pediatric OTC

*Saline Laxatives*** milk of magnesia oral suspension 400 mg/5ml Dulcolax Milk of Magnesia OTC

*Stimulant Laxatives*** bisacodyl ec oral tablet delayed release 5 mg Alophen OTC bisacodyl rectal suppository 10 mg Dulcolax OTC chocolated laxative oral tablet chewable 15 mg OTC

laxative regular strength oral tablet 15 mg Medi-Lax OTC senna oral syrup 176 mg/5ml, 8.8 mg/5ml OTC senna oral tablet 8.6 mg Dr Edwards Olive Laxative OTC

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Drug Name Reference Restrictions FLEET BISACODYL RECTAL ENEMA 10 MG/30ML OTC

SENOKOT EXTRA STRENGTH ORAL TABLET 17.2 MG CVS Senna-Extra OTC

*Surfactant Laxatives*** docusate calcium oral capsule 240 mg Kao-Tin OTC docusate sodium oral capsule 100 mg Colace OTC docusate sodium oral capsule 250 mg OTC docusate sodium oral liquid 150 mg/15ml OTC docusate sodium oral syrup 60 mg/15ml OTC docusate sodium oral tablet 100 mg DOK OTC COLACE CLEAR ORAL CAPSULE 50 MG RA Col-Rite OTC

PEDIA-LAX ORAL LIQUID 50 MG/15ML OTC

*MEDICAL DEVICES* *Applicators,Cotton Balls,Etc*** alcohol pads pad 70 % Alcoh-Glove Contoured Wipe OTC

*Condoms - Female*** FC FEMALE CONDOM No Copay; OTC

*Condoms - Male*** premium condoms lubricated Durex Extra Sensitive No Copay; OTC

*Glucose Monitoring Test Supplies*** lancet device with ejector Advocate Lancing Device OTC ACCU-CHEK FASTCLIX LANCET KIT Select-Lite Device/Lancets OTC

ACCU-CHEK SOFTCLIX LANCETS Global Inject Ease Lancets 28G OTC

BD LANCET ULTRAFINE 30G Global Inject Ease Lancets 28G OTC

*Hearing Aid Supplies-Batteries*** hearing aid batteries Duracell Hearing Aid Batteries OTC

*Incontinence Supplies*** A + D PERSONAL CARE WIPES Ultra-Soft Plus Briefs XXL OTC

*Needles & Syringes*** ADVOCATE INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

ADVOCATE INSULIN SYRINGE 30G X 5/16" 1 ML Ultra-Comfort Insulin Syringe OTC

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Drug Name Reference Restrictions BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.3 ML Elite-Thin Insulin Syringe OTC

BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML OTC

BD INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Leader Insulin Syringe OTC

BD INSULIN SYRINGE 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML OTC

BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

BD INSULIN SYRINGE MICROFINE 28G X 1/2" 1 ML Leader Insulin Syringe OTC

BD INSULIN SYRINGE U/F 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML Global Inject Ease Insulin Syr OTC

BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.3 ML Global Inject Ease Insulin Syr OTC

BD LUER-LOK SYRINGE 20G X 1" 1 ML OTC BD LUER-LOK SYRINGE 25G X 5/8" 1 ML Safety Syringe/Needle OTC

BD PEN NEEDLE MICRO U/F 32G X 6 MM Sure Comfort Pen Needles OTC

BD PEN NEEDLE MINI U/F 31G X 5 MM Sure Comfort Pen Needles OTC BD PEN NEEDLE NANO U/F 32G X 4 MM QC Unifine Pentips

BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM Sure Comfort Pen Needles OTC

BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 ML Elite-Thin Insulin Syringe OTC

BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 ML TechLITE Insulin Syringe

BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML TechLITE Insulin Syringe OTC

EASY TOUCH FLIPLOCK SAFETY SYR 25G X 1" 1 ML OTC

*Peak Flow Meters*** PEAK AIR PEAK FLOW METER DEVICE

Lung Perform Peak Flow Meter OTC; QLL (1 EA per 365 days)

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Drug Name Reference Restrictions *Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER MV Valved Holding Chamber QLL (2 EA per 365 days)

*MINERALS & ELECTROLYTES* *Bicarbonates*** sodium bicarbonate intravenous solution 8.4 %

*Calcium Combinations*** calcium + d3 oral tablet 600-200 mg-unit OTC calcium 500/d oral tablet chewable 500-400 mg-unit OTC

calcium 600+d oral tablet 600-400 mg-unit OTC calcium 600-d oral tablet 600-400 mg-unit OTC calcium citrate + d oral tablet 315-250 mg-unit Calcitrate OTC

calcium high potency/vitamin d oral tablet 600-200 mg-unit OTC

citrus calcium/vitamin d oral tablet 200-250 mg-unit Citracal Petites/Vitamin D OTC

oyster calcium + d oral tablet 500-125 mg-unit OTC

oyster shell calcium/d oral tablet 500-200 mg-unit RA Hi Cal OTC

oyster shell calcium/d oral tablet 500-400 mg-unit OTC

oyster shell calcium/vitamin d oral tablet 250-125 mg-unit OTC

sm calcium citrate-vit d oral tablet 315-200 mg-unit OTC

sm oyster shell calcium/vit d3 oral tablet 500-400 mg-unit Oystercal-D OTC

OYSCO 500+D ORAL TABLET 500-200 MG-UNIT Oyster Shell Calcium + D OTC

*Calcium*** calcium 600 oral tablet 600 mg High Potency Calcium OTC calcium carbonate powder CALCITRATE ORAL TABLET 950 MG OTC

*Electrolytes Oral*** REHYDRALYTE ORAL SOLUTION HM Pediatric Electrolyte OTC

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Drug Name Reference Restrictions *Fluoride*** sodium fluoride oral solution 1.1 (0.5 f) mg/ml AL (Max 13 Years) sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg Ludent

*Magnesium*** magnesium oral tablet 250 mg OTC magnesium oxide oral tablet 400 (240 mg) mg, 500 mg OTC

magnesium oxide oral tablet 400 (241.3 mg) mg MAGnesium-Oxide OTC

*Phosphate*** K-PHOS ORAL TABLET 500 MG PHOSPHA 250 NEUTRAL ORAL TABLET 155-852-130 MG Av-Phos 250 Neutral

*Potassium*** potassium chloride crys er oral tablet extended release 10 meq Klor-Con M10

potassium chloride crys er oral tablet extended release 20 meq Klor-Con M20

potassium chloride er oral capsule extended release 10 meq, 8 meq Klor-Con Sprinkle

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq K-Tab

KLOR-CON/EF ORAL TABLET EFFERVESCENT 25 MEQ Potassium Bicarbonate

*MOUTH/THROAT/DENTAL AGENTS* *Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat solution 0.12 % Paroex

sore throat spray mouth/throat liquid 1.4 % Cheracol Sore Throat OTC

*Fluoride Dental Products*** sodium fluoride 5000 plus dental cream 1.1 % Denta 5000 Plus sodium fluoride dental gel 1.1 % Cavarest

*Saliva Stimulants*** pilocarpine hcl oral tablet 5 mg, 7.5 mg Salagen

*Steroids - Mouth/Throat*** triamcinolone acetonide mouth/throat paste 0.1 % Oralone

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Drug Name Reference Restrictions *MULTIVITAMINS* *Multiple Vitamins W/ Iron*** daily-vite/iron/beta-carotene oral tablet OTC

*Multiple Vitamins W/ Minerals*** dekas plus oral capsule ActivNutrients OTC therapeutic-m oral tablet Centrum OTC AQUADEKS ORAL TABLET CHEWABLE RA One Daily Gummy Vites OTC

CENTRUM ORAL TABLET Multi Complete/Iron OTC ICAPS MV ORAL TABLET Multi Complete/Iron OTC

*Multivitamins*** multi-vitamins oral tablet EstroFactors OTC

*Ped Multi Vitamins W/Fl & Fe*** multivitamin/fluoride/iron oral solution 0.25-10 mg/ml AL (Max 16 Years)

*Ped Multiple Vitamins W/ Minerals & C*** AQUADEKS ORAL LIQUID OTC CENTRUM KIDS ORAL TABLET CHEWABLE GNP ZooChews Gummies OTC

MVW COMPLETE FORMULATION ORAL SOLUTION 45 MG/0.5ML OTC

*Ped Multiple Vitamins W/ Minerals*** dekas plus oral liquid OTC

*Ped Mv W/ Fluoride*** multivitamin/fluoride oral solution 0.25 mg/ml Floriva Plus AL (Max 16 Years) multivitamin/fluoride oral solution 0.5 mg/ml Quflora Pediatric AL (Max 16 Years) multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg MVC-Fluoride

*Ped Mv W/ Iron*** POLY-VI-SOL/IRON ORAL SOLUTION Poly-Vitamin/Iron OTC

*Ped Vitamins Acd W/ Fluoride*** tri-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml AL (Max 16 Years)

*Pediatric Multiple Vitamins W/ C & Fa*** chewable vite childrens oral tablet chewable Animal Shapes OTC

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Drug Name Reference Restrictions *NASAL AGENTS - SYSTEMIC AND TOPICAL* *Nasal Agents - Misc.*** deep sea nasal spray nasal solution 0.65 % Afrin Saline Nasal Mist OTC saline mist spray nasal solution 0.65 % Afrin Saline Nasal Mist OTC AFRIN SALINE NASAL MIST NASAL SOLUTION 0.65 % Altamist Spray OTC

AYR NASAL SOLUTION 0.65 % Altamist Spray OTC BABY AYR SALINE NASAL SOLUTION 0.65 % Altamist Spray OTC

*Systemic Decongestants*** pseudoephedrine hcl oral tablet 60 mg SudoGest

*Topical Decongestants*** 12 hour nasal decongestant nasal solution 0.05 % Afrin 12 Hour OTC

12 hour nasal spray nasal solution 0.05 % Afrin 12 Hour OTC nasal decongestant spray nasal solution 0.05 % Afrin 12 Hour OTC

*NEUROMUSCULAR AGENTS* *Benzathiazoles*** riluzole oral tablet 50 mg Rilutek

*NUTRIENTS* *Misc. Nutritional Substances*** SEA-OMEGA ORAL CAPSULE 1000 MG Omega-3 CF OTC

*OPHTHALMIC AGENTS* *Artificial Tear And Lubricant Combinations*** artificial tears ophthalmic solution 0.1-0.3 % GenTeal Tears OTC GENTEAL TEARS MODERATE PF OPHTHALMIC SOLUTION 0.1-0.3 % RA Lubricant Eye OTC

SYSTANE OPHTHALMIC GEL 0.4-0.3 % OTC

*Artificial Tear Solutions*** SYSTANE CONTACTS OPHTHALMIC SOLUTION Just Tears Eye Drops OTC

*Artificial Tears And Lubricants*** artificial tears ophthalmic solution 1.4 % OTC lubricating plus eye drops ophthalmic solution 0.5 % Biolle Tears OTC

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Drug Name Reference Restrictions REFRESH CELLUVISC OPHTHALMIC GEL 1 % OTC

REFRESH LIQUIGEL OPHTHALMIC GEL 1 % CVS Lubricant Drops OTC

REFRESH TEARS OPHTHALMIC SOLUTION 0.5 % Lubricant Eye Drops OTC

*Cycloplegic Mydriatics*** atropine sulfate ophthalmic ointment 1 % atropine sulfate ophthalmic solution 1 % Isopto Atropine cyclopentolate hcl ophthalmic solution 1 %, 2 % Cyclogyl

*OTIC AGENTS* *Otic Agents - Miscellaneous*** acetic acid otic solution 2 % ear drops earwax aid otic solution 6.5 % Clearcanal Earwax Softener OTC

*Otic Steroids*** hydrocortisone-acetic acid otic solution 1-2 % Acetasol HC

*OXYTOCICS* *Oxytocics*** methylergonovine maleate oral tablet 0.2 mg Methergine

*PASSIVE IMMUNIZING AGENTS* *Immune Serums*** FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 5 GM/50ML

PA

GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

PA

GAMMAKED INJECTION SOLUTION 10 GM/100ML, 20 GM/200ML, 5 GM/50ML

PA

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

PA

HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT

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Drug Name Reference Restrictions RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT

*PHARMACEUTICAL ADJUVANTS* *Antimicrobial Agents*** benzyl alcohol liquid

*Oral Vehicles*** cherry oral syrup oral suspending compound plus oral suspension Flavor Blend OTC

simple syrup oral syrup sorbitol solution 70 % ORA-PLUS ORAL LIQUID Flavor Plus ORA-SWEET SF ORAL SYRUP Flavor Sweet SYRSPEND SF ALKA ORAL SUSPENSION RECONSTITUTED OTC

SYRSPEND SF ORAL SUSPENSION RECONSTITUTED OTC

SYRSPEND SF PH4 ORAL SUSPENSION RECONSTITUTED

*Parenteral Vehicles*** sterile water for injection injection solution sterile water for injection intravenous solution

*Pharmaceutical Excipients*** lactose monohydrate powder

*RESPIRATORY AGENTS -MISC.* *Hydrolytic Enzymes*** PULMOZYME INHALATION SOLUTION 1 MG/ML

PA; QLL (5 ML per 1 day); AL (Min 5 Years)

*SINUS NODE INHIBITORS** *Sinus Node Inhibitors** CORLANOR ORAL TABLET 5 MG, 7.5 MG

PA; No Copay; QLL (2 EA per 1 day)

*SULFONAMIDES* *Sulfonamides*** sulfadiazine oral tablet 500 mg

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Drug Name Reference Restrictions *THYROID AGENTS* *Antithyroid Agents*** methimazole oral tablet 10 mg, 5 mg Tapazole propylthiouracil oral tablet 50 mg

*ULCER DRUGS* *Antispasmodics*** dicyclomine hcl oral capsule 10 mg dicyclomine hcl oral solution 10 mg/5ml AL (Max 10 Years) dicyclomine hcl oral tablet 20 mg

*Misc. Anti-Ulcer*** sucralfate oral suspension 1 gm/10ml Carafate AL (Max 10 Years) sucralfate oral tablet 1 gm Carafate CARAFATE ORAL SUSPENSION 1 GM/10ML Sucralfate AL (Max 10 Years)

*Quaternary Anticholinergics*** glycopyrrolate injection solution 4 mg/20ml glycopyrrolate oral tablet 1 mg, 2 mg propantheline bromide oral tablet 15 mg

*Ulcer Drugs - Prostaglandins*** misoprostol oral tablet 100 mcg, 200 mcg Cytotec

*URINARY ANTISPASMODICS* *Urinary Antispasmodics -Cholinergic Agonists*** (New) bethanechol chloride oral tablet 10 mg, 5 mg bethanechol chloride oral tablet 25 mg, 50 mg Urecholine

*VAGINAL PRODUCTS* *Vaginal Estrogens*** estradiol vaginal cream 0.1 mg/gm Estrace estradiol vaginal tablet 10 mcg Vagifem ESTRING VAGINAL RING 2 MG

*VASOPRESSORS* *Vasopressors*** midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg No Copay

*VITAMINS* *Vitamin D*** d 400 oral tablet chewable 10 mcg (400 unit) Healthy Kids Vitamin D3 OTC d 5000 oral tablet 125 mcg (5000 ut) Radiance Platinum Vitamin D3 OTC

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Drug Name Reference Restrictions vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) Drisdol

vitamin d oral liquid 10 mcg/ml BProtected Pedia D-Vite OTC vitamin d oral tablet 25 mcg (1000 ut) Vitamin D-1000 Max St OTC vitamin d oral tablet 50 mcg (2000 ut) Thera-D 2000 OTC vitamin d3 oral capsule 125 mcg (5000 ut) Dialyvite Vitamin D 5000 OTC vitamin d3 oral capsule 50 mcg (2000 ut) OTC vitamin d3 oral tablet 10 mcg (400 unit) OTC vitamin d3 oral tablet chewable 25 mcg (1000 ut)

Kids First Vitamin D3 Gummies OTC

CALCIFEROL ORAL SOLUTION 200 MCG/ML Ergocalciferol OTC

*Vitamin K*** phytonadione oral tablet 5 mg Mephyton

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Index Header 12 hour nasal decongestant 20 12 hour nasal spray 20 A + D PERSONAL CARE WIPES 15 A+D PREVENT 10 ACCU-CHEK FASTCLIX LANCET 15 ACCU-CHEK SOFTCLIX LANCETS 15 acetaminophen 3 acetaminophen childrens 3 acetaminophen er 3 acetaminophen extra strength 3 acetazolamide 11 acetazolamide er 11 acetic acid 21 acetylcysteine 9 ACID GONE 4 ADVOCATE INSULIN SYRINGE 15 AEROCHAMBER MV 17 AFRIN SALINE NASAL MIST 20 AFTERA 9 albendazole 5 alcohol pads 15 alcohol wipes 10 amiloride hcl 11 amiloride-hydrochlorothiazide 11 aminocaproic acid 13 amiodarone hcl 5 ammonium lactate 10 antacid 4 antacid anti-gas max strength 4 antacid extra strength 4 AQUADEKS 19 artificial tears 20 aspirin adult 3 aspirin ec 3 aspirin low dose 4 ASPIR-LOW 4 atropine sulfate 21 AYR 20 BABY AYR SALINE 20 BD INSULIN SYR ULTRAFINE II 16 BD INSULIN SYRINGE 16 BD INSULIN SYRINGE MICROFINE 16 BD INSULIN SYRINGE U/F 16

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BD INSULIN SYRINGE ULTRAFINE 16 BD LANCET ULTRAFINE 30G 15 BD LUER-LOK SYRINGE 16 BD PEN NEEDLE MICRO U/F 16 BD PEN NEEDLE MINI U/F 16 BD PEN NEEDLE NANO U/F 16 BD PEN NEEDLE ORIGINAL U/F 16 BD SAFETYGLIDE INSULIN SYRINGE 16 benzonatate 9 benzyl alcohol 22 bethanechol chloride 23 bexarotene 8 bisacodyl 14 bisacodyl ec 14 bismuth subsalicylate 6 BOOST HIGH PROTEIN 10 bumetanide 11 cabergoline 11 caffeine citrate 3 caffeine citrated 3 CALCIFEROL 24 CALCITRATE 17 calcium + d3 17 calcium 500/d 17 calcium 600 17 calcium 600+d 17 calcium 600-d 17 calcium antacid 4 calcium antacid extra strength 4 calcium antacid ultra max st 4 calcium carbonate 17 calcium carbonate antacid 4 calcium citrate + d 17 calcium high potency/vitamin d 17 CARAFATE 23 carbinoxamine maleate 6 CENTRUM 19 CENTRUM KIDS 19 cherry 22 chewable vite childrens 19 childrens pain reliever 3 chlorhexidine gluconate 18 chlorothiazide 11 chlorpheniramine maleate 6 chlorthalidone 11

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chocolated laxative 14 citrus calcium/vitamin d 17 clemastine fumarate 6 clindamycin hcl 7 clindamycin palmitate hcl 7 COLACE CLEAR 15 CORLANOR 22 cyanocobalamin 13 cyclopentolate hcl 21 cyproheptadine hcl 6 cytra k crystals 12 d 400 23 d 5000 23 daily-vite/iron/beta-carotene 19 dapsone 7 deep sea nasal spray 20 dekas plus 19 desmopressin ace spray refrig 12 desmopressin acetate 12 desmopressin acetate spray 12 dicyclomine hcl 23 DIGITEK 8 digoxin 8 diphenhydramine hcl 6 diphenoxylate-atropine 6 disopyramide phosphate 5 docusate calcium 15 docusate sodium 15 DROXIA 13 DRYSOL 10 ear drops earwax aid 21 EASY TOUCH FLIPLOCK SAFETY SYR 16 ECONTRA EZ 9 ECONTRA ONE-STEP 9 ELLA 9 ELMIRON 13 enema 14 estradiol 23 ESTRING 23 ethambutol hcl 7 etoposide 7 FC FEMALE CONDOM 15 FEVERALL JUNIOR STRENGTH 3 FLEBOGAMMA DIF 21 flecainide acetate 5 FLEET BISACODYL 15 FLEET PEDIATRIC 14 fluorouracil 10 folic acid 13

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furosemide 11 GAMMAGARD 21 GAMMAKED 21 GAMUNEX-C 21 gas relief extra strength 12 gas relief ultra strength 12 GAVILYTE-C 14 GAVILYTE-N WITH FLAVOR PACK 14 GENTEAL TEARS MODERATE PF 20 GLUCAGEN HYPOKIT 5 GLUCAGON EMERGENCY 6 glucose 5 glycerin 8 glycerin (adult) 14 glycerin (pediatric) 14 glycopyrrolate 23 gnp pink bismuth 6 guaifenesin 9 guaifenesin er 9 hearing aid batteries 15 hydralazine hcl 6 hydrochlorothiazide 11 hydrocortisone 4 hydrocortisone-acetic acid 21 HYDROLATUM 10 hydroxyprogesterone caproate 8 hydroxyurea 7 HYPERRHO S/D 21 HYPERSAL 9 ICAPS MV 19 indapamide 11 isoniazid 7 ivermectin 5 KLOR-CON/EF 18 konsyl daily fiber 14 K-PHOS 18 K-PHOS NO 2 13 lactose monohydrate 22 lactulose 14 lactulose encephalopathy 12 lancet device with ejector 15 laxative regular strength 14 leflunomide 3 leucovorin calcium 7 levonorgestrel 9 lithium 8 lithium carbonate 8 lithium carbonate er 8 loperamide hcl 6 lubricating plus eye drops 20

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magnesium 18 magnesium oxide 4, 5, 18 MAPAP ACETAMINOPHEN EXTRA STR 3 melatonin 3 melatonin maximum strength 3 methazolamide 11 methimazole 23 methylergonovine maleate 21 metolazone 11 mexiletine hcl 5 midodrine hcl 23 milk of magnesia 14 mineral oil 14 mineral oil-hydrophil petrolat 10 minoxidil 6 MINTOX PLUS 4 misoprostol 23 MULTAQ 5 multivitamin/fluoride 19 multivitamin/fluoride/iron 19 multi-vitamins 19 MVW COMPLETE FORMULATION 19 MY CHOICE 9 MY WAY 9 nasal decongestant spray 20 natural fiber laxative 14 natural fiber therapy 14 NEW DAY 9 octreotide acetate 11 OPCICON ONE-STEP 9 OPTION 2 9 oral suspending compound plus 22 ORA-PLUS 22 ORA-SWEET SF 22 OYSCO 500+D 17 oyster calcium + d 17 oyster shell calcium/d 17 oyster shell calcium/vitamin d 17 PEAK AIR PEAK FLOW METER 16 PEDIA-LAX 15 peg 3350-kcl-na bicarb-nacl 13 peg-3350/electrolytes 13 pentoxifylline er 13 phenazopyridine hcl 13 PHOSPHA 250 NEUTRAL 18 phytonadione 24 pilocarpine hcl 18 pink bismuth 6 pink bismuth maximum strength 6

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polyethylene glycol 3350 14 POLY-VI-SOL/IRON 19 potassium chloride crys er 18 potassium chloride er 18 potassium citrate er 12 potassium citrate-citric acid 12 praziquantel 5 premium condoms lubricated 15 PRIFTIN 7 propafenone hcl 5 propafenone hcl er 5 propantheline bromide 23 propylthiouracil 23 pseudoephedrine hcl 20 PULMOZYME 22 pyrazinamide 7 pyridostigmine bromide 7 qc fiber laxative 14 qc natural vegetable 14 REACT 9 RECTIV 4 reeses pinworm medicine 5 REFRESH CELLUVISC 21 REFRESH LIQUIGEL 21 REFRESH TEARS 21 REHYDRALYTE 17 RHOGAM ULTRA-FILTERED PLUS 22 rifabutin 7 rifampin 7 riluzole 20 saline mist spray 20 SANDOSTATIN LAR DEPOT 12 SANTYL 10 SEA-OMEGA 20 senna 14 senna-docusate sodium 14 SENOKOT EXTRA STRENGTH 15 simethicone 12 simple syrup 22 sleep aid 13 sleep aid (diphenhydramine) 13 sm allergy 4 hour 6 sm calcium citrate-vit d 17 sm glucose 5 sm oyster shell calcium/vit d3 17 sod citrate-citric acid 12 sodium bicarbonate 4, 17 sodium chloride 9, 13 sodium fluoride 18

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sodium fluoride 5000 plus 18 SOMATULINE DEPOT 12 SOOTHE & COOL SKIN 10 sorbitol 22 sore throat spray 18 spironolactone 11 spironolactone-hctz 11 SSD 10 sterile water for injection 22 sterile water for irrigation 8 stevia extract 8 steviol glycosides 8 sucralfate 23 sulfadiazine 22 sulfamethoxazole-trimethoprim 7 SYRSPEND SF 22 SYRSPEND SF ALKA 22 SYRSPEND SF PH4 22 SYSTANE 20 SYSTANE CONTACTS 20 TAKE ACTION 9 TARON-CRYSTALS 12 theophylline er 5 thera-derm 10 therapeutic 10 therapeutic-m 19 torsemide 11 tretinoin 8 triamcinolone acetonide 18 triamterene-hctz 11 TRILYTE 14 tri-vitamin/fluoride 19 TUMS 4 TUMS EXTRA STRENGTH 750 4 TUMS ULTRA 1000 4 vitamin d 24 vitamin d (ergocalciferol) 24 vitamin d3 24 zinc oxide 10

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aetna better health pennsylvania supplemental formulary ...€¦ · prior approval (pa): this means...

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