amerihealth caritas pennsylvania supplemental …...fe-caps capsule extended release* 250 mg oral t3...
TRANSCRIPT
AmeriHealth Caritas Pennsylvania
Supplemental Formulary
May 13, 2020
1
lowercase italics = Generic drugs
UPPERCASE = Brand name drugs
Tier T3 = Supplemental Formulary Drug
T4 = Supplemental Specialty
Requirements/Limits AL = Age Restriction
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
Drug Tier Requirements/Limits
a thru z select tablet chewable oral T3
abc plus tablet oral T3
a-caro-25 capsule 25000 unit oral T3
ADVANCE MICRO-DRAW CONTROL
LIQUID IN VITRO T3 QL (1 EA per 90 days)
advanced mobile lancet T3 QL (100 EA per 25 days)
ADVOCATE MEMORY BP MONITOR T3 QL (1 EA per 365 days)
ADVOCATE WRIST BP MONITOR T3 QL (1 EA per 365 days)
af lancets super thin T3 QL (100 EA per 25 days)
AFRIN SALINE NASAL MIST SOLUTION
0.65 % NASAL T3
aimsco twist lancets 32g T3 QL (100 EA per 25 days)
AIMSCO TWIST LANCETS 33G T3 QL (100 EA per 25 days)
ALCOHOL SWABSTICK PAD T3 QL (150 EA per 34 days)
ALCOHOL SWABSTICK PAD 70 % T3 QL (150 EA per 34 days)
alcohol wipes 70 % external T3 QL (150 EA per 34 days)
alph-e capsule 400 unit oral T3
alph-e-mixed 1000 capsule 1000 unit oral T3
alph-e-mixed capsule 200 unit oral T3
alph-e-mixed capsule 400 unit oral T3
ANEMAGEN FORTE TABLET 50-101-1 MG
ORAL T3
ANEMAGEN TABLET 70 MG ORAL T3
anti-oxidant tablet oral T3
anti-stick tuberculin syringe 25g x 5/8" 1 ml T3 QL (200 EA per 34 days)
APLICARE ALCOHOL SWABSTICK PAD 70
% T3 QL (150 EA per 34 days)
ARIAL CHAMBER DEVICE T3 QL (2 EA per 365 days)
asco-tabs-1000 tablet 1000 mg oral T3
ASSURE II CONTROL LEVEL 1 & 2 LIQUID
IN VITRO T3 QL (1 EA per 90 days)
ASSURE II CONTROL LIQUID IN VITRO T3 QL (1 EA per 90 days)
AT LAST CONTROL SOLUTION IN VITRO T3 QL (1 EA per 90 days)
AT LAST LANCETS T3 QL (100 EA per 25 days)
2
Drug Tier Requirements/Limits
ATLAS COLOR CONDOM/SPERMICIDE
DEVICE T3 QL (48 EA per 34 days)
ATLAS COLOR LUBRICATED CONDOM
DEVICE T3 QL (48 EA per 34 days)
ATLAS LUB CONDOM/SPERMICIDE
DEVICE T3 QL (48 EA per 34 days)
ATLAS LUBRICATED CONDOM DEVICE T3 QL (48 EA per 34 days)
AUTO-LANCET T3 QL (1 EA per 365 days)
auto-lancets T3 QL (1 EA per 365 days)
b complex vitamins plus tablet oral T3
b complex-vitamin b12 tablet oral T3
B-50 FORMULA TABLET ORAL T3
b-50 tablet oral T3
b-caro-t capsule 15 mg oral T3
BD ASSURE BPM/AUTO ARM CUFF T3 QL (1 EA per 365 days)
BD ASSURE BPM/AUTO WRIST CUFF T3 QL (1 EA per 365 days)
BD ASSURE BPM/DELUXE ARM CUFF T3 QL (1 EA per 365 days)
BD ASSURE BPM/MANUAL ARM CUFF T3 QL (1 EA per 365 days)
BD ASSURE BPM/PORT WRISTWATCH T3 QL (1 EA per 365 days)
BD GENIE T3 QL (100 EA per 25 days)
BD GENIE LANCETS T3 QL (100 EA per 25 days)
BD KLATSKIN BIOPSY NEEDLE 16G X 4" T3 QL (200 EA per 34 days)
BD LUER-LOCK SYRINGE 18G X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
BD OSGOOD BIOPSY NEEDLE 16G X 1-5/16" T3 QL (200 EA per 34 days)
BD PLASTIPAK SYRINGES ALLERGY 28G X
1/2" 1 ML T3 QL (200 EA per 34 days)
BD ROSENTHAL BIOPSY NEEDLE 16G X 1-
5/16" T3 QL (200 EA per 34 days)
BD SWABS SINGLE USE BUTTERFLY PAD T3 QL (150 EA per 34 days)
BD ULTRA-FINE LANCETS T3 QL (100 EA per 25 days)
BD YALE REUSABLE TB SYRINGE 1 ML T3 QL (200 EA per 34 days)
bec/zinc tablet oral T3
BIG 100 TABLET ORAL T3
BIOTECT PLUS CAPSULE ORAL T3
biotin forte tablet 5 mg oral T3
bl glucose tablet chewable 4 gm oral T3
bl lancets T3 QL (100 EA per 25 days)
bl lancets super thin T3 QL (100 EA per 25 days)
3
Drug Tier Requirements/Limits
bl lancets thin T3 QL (100 EA per 25 days)
blood pressure kit T3 QL (1 EA per 365 days)
blood pressure kit device T3 QL (1 EA per 365 days)
blood pressure monitor deluxe kit T3 QL (1 EA per 365 days)
blood pressure monitor/prm arm device T3 QL (1 EA per 365 days)
blood pressure monitor/wrist kit T3 QL (1 EA per 365 days)
bp monitor-stethoscope kit T3 QL (1 EA per 365 days)
breathe ease humidifier T3 QL (1 EA per 365 days)
breathe ease large device T3 QL (2 EA per 365 days)
breathe ease medium device T3 QL (2 EA per 365 days)
breathe ease small device T3 QL (2 EA per 365 days)
BRONCHO SALINE AEROSOL SOLUTION
0.9 % INHALATION T3
BULLSEYE SAFETY LANCETS T3 QL (100 EA per 25 days)
calcium tablet 500 mg oral T3
calcium-vitamin d tablet 250-125 mg-unit oral T3
CARDENZ TABLET ORAL T3
CARDIOCOM LANCING DEVICE T3 QL (1 EA per 365 days)
CAREONE GLUCOSE TABLET CHEWABLE
4 GM ORAL T3
CAREONE LANCET 26G T3 QL (100 EA per 25 days)
CAREONE LANCET 30G T3 QL (100 EA per 25 days)
CAREONE LANCET ULTRA THIN T3 QL (100 EA per 25 days)
CARESENS LANCETS T3 QL (100 EA per 25 days)
caroguard capsule 15 mg oral T3
CAROMEGA TABLET ORAL T3
caution condoms device T3 QL (48 EA per 34 days)
caution condoms/spermicide device T3 QL (48 EA per 34 days)
centavite liquid oral T3
CERALYTE 50 SOLUTION 1.3-1.1-2.9 GM/L
ORAL T3
cerovite silver tablet oral T3
CERTA-VITE LIQUID ORAL T3
chew-c tablet chewable 500 mg oral T3
childrens acetaminophen suspension 325
mg/10.15ml oral T3
CHOOZ TABLET CHEWABLE 500 MG ORAL T3
4
Drug Tier Requirements/Limits
CLASS ACT LUBRICATED T3 QL (48 EA per 34 days)
CLEANLET LANCETS 28G T3 QL (100 EA per 25 days)
CLEVER CHOICE HUMIDIFIER T3 QL (1 EA per 365 days)
CLEVER CHOICE LANCETS 21G T3 QL (100 EA per 25 days)
CLOSERCARE T3 QL (1 EA per 365 days)
cobal-1000 solution 1000 mcg/ml injection T3
condoms T3 QL (48 EA per 34 days)
cool mist humidifier 2 gallon T3 QL (1 EA per 365 days)
CORNWALL DISPENSING SYRINGE 10 ML T3 QL (200 EA per 34 days)
crono syringe 19g x 1-1/2" 10 ml T3 QL (200 EA per 34 days)
CURITY ALCOHOL SWABS PAD T3 QL (150 EA per 34 days)
cvs auto pressure monitor kit T3 QL (1 EA per 365 days)
cvs semi-auto pressure monitor kit T3 QL (1 EA per 365 days)
cvs series 800 blood pressure device T3 QL (1 EA per 365 days)
cvs vitamin a capsule 3 mg (10000 ut) oral T3
daily multi vitamin/minerals tablet oral T3
daily vitamins for women tablet oral T3
dd glucose tablet chewable 4 gm oral T3
dd lancets T3 QL (100 EA per 25 days)
dd thin lancets T3 QL (100 EA per 25 days)
de glucose tablet chewable 4 gm oral T3
DE LANCETS T3 QL (100 EA per 25 days)
DE THIN LANCETS T3 QL (100 EA per 25 days)
DIABEVITE TABLET ORAL T3
DIASENSE MULTIVITAMIN TABLET ORAL T3
DIASTAR EASY TEST II LANCETS T3 QL (100 EA per 25 days)
DIASTAR EASY TEST LANCETS T3 QL (100 EA per 25 days)
diathrive glucose control soln liquid in vitro T3 QL (1 EA per 90 days)
diathrive lancet ultra thin 30 T3 QL (100 EA per 25 days)
diathrive lancets T3 QL (100 EA per 25 days)
diathrive lancing device T3 QL (1 EA per 365 days)
diphenhydramine hcl childrens liquid 12.5
mg/5ml oral T3
dr glucose tablet chewable 4 gm oral T3
dr lancets T3 QL (100 EA per 25 days)
dr thin lancets T3 QL (100 EA per 25 days)
dual ultrasonic humidifier T3 QL (1 EA per 365 days)
5
Drug Tier Requirements/Limits
DUO-CARE CONTROL SOLUTION LIQUID
IN VITRO T3 QL (1 EA per 90 days)
DURAVITE TABLET ORAL T3
DUREX EXTRA SENSITIVE DEVICE T3 QL (48 EA per 34 days)
e-400-clear capsule 400 unit oral T3
e-400-mixed capsule 400 unit oral T3
easy plus control solution high in vitro T3 QL (1 EA per 90 days)
easy plus control solution low in vitro T3 QL (1 EA per 90 days)
easy plus control solution normal in vitro T3 QL (1 EA per 90 days)
easy talk control solution normal in vitro T3 QL (1 EA per 90 days)
easy trak control solution normal in vitro T3 QL (1 EA per 90 days)
EASYGLUCO CONTROL SOLUTION HIGH
IN VITRO T3 QL (1 EA per 90 days)
EASYGLUCO CONTROL SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
EASYGLUCO CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
EASYMAX 15 LEVEL 1-2 CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
EASYMAX CONTROL NORMAL/LOW
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
EASYTEST II LANCETS T3 QL (100 EA per 25 days)
EASYTEST LANCETS T3 QL (100 EA per 25 days)
eck glucose tablet chewable 4 gm oral T3
ELEXA NATURAL FEEL T3 QL (48 EA per 34 days)
ELEXA STIMULATING T3 QL (48 EA per 34 days)
ELEXA ULTRA SENSITIVE T3 QL (48 EA per 34 days)
e-max-1000 capsule 1000 unit oral T3
ENVIRO-STRESS TABLET ORAL T3
epidural needle 18g x 2" T3 QL (200 EA per 34 days)
epidural needle 18g x 3-1/2" T3 QL (200 EA per 34 days)
epidural needle 18g x 4" T3 QL (200 EA per 34 days)
epidural needle tw 18g x 3-1/2" T3 QL (200 EA per 34 days)
EPILOR SYRINGE 10 ML T3 QL (200 EA per 34 days)
EPILOR SYRINGE 5 ML T3 QL (200 EA per 34 days)
eq antacid tablet chewable 500 mg oral T3
eq laxative tablet chewable 15 mg oral T3
eql alcohol swabs pad 70 % T3 QL (150 EA per 34 days)
6
Drug Tier Requirements/Limits
EQUALYTE SOLUTION ORAL T3
essentra wipes 9x9" 70 % external T3 QL (150 EA per 34 days)
EVENCARE MINI CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
EXTRA SENSITIVE SPERMICIDAL DEVICE T3 QL (48 EA per 34 days)
EZ-LETS LANCETS T3 QL (100 EA per 25 days)
EZ-LETS LANCETS 21G T3 QL (100 EA per 25 days)
EZ-LETS LANCETS 23G T3 QL (100 EA per 25 days)
EZ-LETS LANCETS 28G T3 QL (100 EA per 25 days)
EZ-LETS LANCETS 30G T3 QL (100 EA per 25 days)
FA-8 TABLET 800 MCG ORAL T3
fe tabs tablet delayed release 325 (65 fe) mg oral T3
fe-caps capsule extended release* 250 mg oral T3
ferra capsule extended release* 250 mg oral T3
ferro-bob tablet 325 (65 fe) mg oral T3
ferrotabs tablet 240 mg oral T3
ferrous gluconate tablet 216 mg oral T3
ferrous gluconate tablet 239 (27 fe) mg oral T3
ferrous sulfate er tablet extended release 50 mg
oral T3
ferrous sulfate tablet 134 mg oral T3
ferrous sulfate tablet 27 mg oral T3
formula b tablet oral T3
formula twenty-one tablet oral T3
fp lancets super thin T3 QL (100 EA per 25 days)
genesupp-500 capsule oral T3
genetect plus capsule oral T3
genetect plus liquid† oral (otc) T3
genetical capsule oral T3
GENTEEL BUTTERFLY TOUCH LANCET T3 QL (100 EA per 25 days)
GENTEEL LANCING DEVICE (BLACK) T3 QL (1 EA per 365 days)
GENTEEL LANCING DEVICE (GOLD) T3 QL (1 EA per 365 days)
GENTEEL LANCING DEVICE(PLATNM) T3 QL (1 EA per 365 days)
GENTEEL LANCING DEVICE(SILVER) T3 QL (1 EA per 365 days)
GENTLE-LET GP LANCETS T3 QL (100 EA per 25 days)
GENTLE-LET LANCETS T3 QL (100 EA per 25 days)
gerivite complete tablet oral T3
7
Drug Tier Requirements/Limits
giant eagle glucose tablet chewable 4 gm oral T3
giant eagle lancets T3 QL (100 EA per 25 days)
giant eagle lancets colored T3 QL (100 EA per 25 days)
gnp acetaminophen tablet chewable 160 mg oral T3
gnp blood pressure monitor device T3 QL (1 EA per 365 days)
gnp calcium 500 tablet 500 mg oral T3
gnp iron tablet 325 (65 fe) mg oral T3
GNP MENS MULTIPLUS TABLET ORAL T3
gnp mucus d 12 hr tablet extended release 12
hour 60-600 mg oral T3
gnp mucus relief childrens liquid 100 mg/5ml oral T3
gnp vitamin a capsule 2400 mcg (8000 ut) oral T3
goodsense antacid tablet chewable 500 mg oral T3
goodsense laxative pills tablet 25 mg oral T3
goodsense mucus-d tablet extended release 12
hour 60-600 mg oral T3
GREENE POINT SPINAL NEEDLE 22G X 3-
1/2" T3 QL (200 EA per 34 days)
HANKSCRAFT HUMIDIFIER T3 QL (1 EA per 365 days)
HANKSCRAFT VAPORIZER T3 QL (1 EA per 365 days)
HEALTHSMART BP MONITOR/WRIST
DEVICE T3 QL (1 EA per 365 days)
healthwise alcohol prep pad 70 % T3 QL (150 EA per 34 days)
healthwise lancets 30g T3 QL (100 EA per 25 days)
healthwise lancing pen T3 QL (1 EA per 365 days)
h-e-b incontrol deluxe auto bp device T3 QL (1 EA per 365 days)
h-e-b incontrol premium bp device T3 QL (1 EA per 365 days)
high potency iron tablet 134 mg oral T3
HIGH SENSATION SPERMICIDAL DEVICE T3 QL (48 EA per 34 days)
HI-POTENCY SOFT MULTIPLE CAPSULE
ORAL T3
hipotest tablet oral T3
hm anti-diarrheal capsule 2 mg oral T3 QL (240 EA per 30 days)
hm arthritis creme cream 10 % external T3
hm gas relief tablet chewable 125 mg oral T3
hm pain relief tablet extended release 650 mg
oral T3
8
Drug Tier Requirements/Limits
hm slow release iron tablet extended release 45
mg oral T3
hm stomach relief ultra suspension 525 mg/15ml
oral T3
huber needle 19g x 1-1/4" T3 QL (200 EA per 34 days)
huber needle 19g x 3/4" T3 QL (200 EA per 34 days)
huber needle 20g x 1-1/4" T3 QL (200 EA per 34 days)
HUMIST SOLUTION 0.65 % NASAL T3
HYALEX TABLET ORAL T3
HY-VEE LANCETS T3 QL (100 EA per 25 days)
hy-vee thin lancets T3 QL (100 EA per 25 days)
IN TOUCH GLUCOSE CONTROL SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
IN TOUCH LANCING DEVICE T3 QL (1 EA per 365 days)
IN TOUCH STERILE LANCETS 30G T3 QL (100 EA per 25 days)
INTENSE SENSATION DEVICE T3 QL (48 EA per 34 days)
iron (ferrous sulfate) tablet extended release 142
(45 fe) mg oral T3
iron high-potency tablet extended release 142 (45
fe) mg oral T3
iron slow release tablet extended release 142 (45
fe) mg oral T3
iron slow release tablet extended release 143 (45
fe) mg oral T3
iron supplement elixir 220 (44 fe) mg/5ml oral T3
iron tablet extended release 142 (45 fe) mg oral T3
isopropyl alcohol 70 % external T3 QL (150 EA per 34 days)
J & J EYE PADS OVAL SMALL PAD T3 QL (40 EA per 34 days)
J & J OVAL EYE PADS PAD T3 QL (40 EA per 34 days)
J & J STERILE EYE PADS PAD T3 QL (40 EA per 34 days)
JOHNSONS STERILE EYE PADS PAD T3 QL (40 EA per 34 days)
KAMELEON LUBRICATED T3 QL (48 EA per 34 days)
kaz humidifier evaporativ 3000 T3 QL (1 EA per 365 days)
kaz humidifier evaporativ 3300 T3 QL (1 EA per 365 days)
kaz humidifier evaporativ 3400 T3 QL (1 EA per 365 days)
KAZ ULTRASONIC HUMIDIFIER T3 QL (1 EA per 365 days)
KIMONO COLORS DEVICE T3 QL (48 EA per 34 days)
kimono plus T3 QL (48 EA per 34 days)
9
Drug Tier Requirements/Limits
kimono ps T3 QL (48 EA per 34 days)
kimono ps plus T3 QL (48 EA per 34 days)
KIMONO SPECIAL DEVICE T3 QL (48 EA per 34 days)
kinney glucose tablet chewable 4 gm oral T3
kroger lancets T3 QL (100 EA per 25 days)
kroger lancets super thin T3 QL (100 EA per 25 days)
kroger lancets thin T3 QL (100 EA per 25 days)
LIBERTY MEDICAL LANCETS T3 QL (100 EA per 25 days)
LIFESCAN UNISTIK 2 T3 QL (100 EA per 25 days)
LIFESCAN UNISTIK II LANCETS T3 QL (100 EA per 25 days)
LIFESTYLES ASSORTED COLORS T3 QL (48 EA per 34 days)
LIFESTYLES EXTRA STRENGTH T3 QL (48 EA per 34 days)
LIFESTYLES FORM FITTING T3 QL (48 EA per 34 days)
LIFESTYLES LUBRICATED T3 QL (48 EA per 34 days)
LIFESTYLES RIBBED T3 QL (48 EA per 34 days)
LIFESTYLES SKYN ORIGINAL T3 QL (48 EA per 34 days)
LIFESTYLES SPERMICIDAL LUBE T3 QL (48 EA per 34 days)
LIFESTYLES STUDDED T3 QL (48 EA per 34 days)
LIFESTYLES ULTRA SENSITIVE T3 QL (48 EA per 34 days)
LIFESTYLES VIBRA-RIBBED T3 QL (48 EA per 34 days)
LIFESTYLES XTRA PLEASURE T3 QL (48 EA per 34 days)
local anesthesia needle 20g x 4" T3 QL (200 EA per 34 days)
local anesthesia needle 22 x 4" T3 QL (200 EA per 34 days)
local anesthesia needle 22g x 3" T3 QL (200 EA per 34 days)
long lasting antacid tablet chewable 500 mg oral T3
longs glucose tablet chewable 4 gm oral T3
lung perform peak flow meter device T3 QL (1 EA per 365 days)
MAXIMUM BLUE LABEL TABLET ORAL T3
MAXIMUM GREEN LABEL TABLET ORAL T3
MAXIMUM RED LABEL TABLET ORAL T3
maxx plus T3 QL (48 EA per 34 days)
medichoice safety lancet T3 QL (100 EA per 25 days)
medichoice safety lancet extra T3 QL (100 EA per 25 days)
medichoice safety lancet norm T3 QL (100 EA per 25 days)
MEDIPLEX PLUS TABLET ORAL T3
mega vm-80 tablet oral T3
10
Drug Tier Requirements/Limits
meijer alcohol swabs pad 70 % T3 QL (150 EA per 34 days)
meijer ferrous sulfate tablet 325 (65 fe) mg oral T3
meijer glucose tablet chewable 4 gm oral T3
MEIJER LANCETS UNIVERSAL 21G T3 QL (100 EA per 25 days)
MEIJER LANCETS UNIVERSAL 30G T3 QL (100 EA per 25 days)
meijer saline nasal spray solution 0.65 % nasal T3
mi-basic t tablet oral T3
MICROLET VACULANCE DEVICE T3 QL (1 EA per 365 days)
MICROLIFE BPM1 BP MONITOR KIT T3 QL (1 EA per 365 days)
MICROLIFE BPM2 BP MONITOR KIT T3 QL (1 EA per 365 days)
MICROLIFE BPM3 DELUXE MONITOR KIT T3 QL (1 EA per 365 days)
microlife deluxe bp monitor kit T3 QL (1 EA per 365 days)
MICROTAINER SAFETY FLOW LANCET T3 QL (100 EA per 25 days)
MILCO-B-FORTE TABLET ORAL T3
MONOJECT BLUNTIP SYR/CANNULA 12
ML T3 QL (200 EA per 34 days)
MONOJECT BLUNTIP SYR/CANNULA 6 ML T3 QL (200 EA per 34 days)
MONOJECT CONTROL SYRINGE 20 ML T3 QL (200 EA per 34 days)
MONOJECT EPIDURAL NEEDLE 18G X 3-
1/2" T3 QL (200 EA per 34 days)
MONOJECT LIFESHIELD SYRINGE 18G X 1"
12 ML T3 QL (200 EA per 34 days)
MONOJECT MAGELLAN SYRINGE 18G X 1"
12 ML T3 QL (200 EA per 34 days)
MONOJECT MAGELLAN SYRINGE 18G X 1"
6 ML T3 QL (200 EA per 34 days)
MONOJECT MAGELLAN SYRINGE 20G X 1-
1/2" 12 ML T3 QL (200 EA per 34 days)
MONOJECT MAGELLAN SYRINGE 20G X 1-
1/2" 6 ML T3 QL (200 EA per 34 days)
MONOJECT MAGELLAN SYRINGE 21G X 1"
12 ML T3 QL (200 EA per 34 days)
MONOJECT MAGELLAN SYRINGE 21G X 1"
6 ML T3 QL (200 EA per 34 days)
MONOJECT MAGELLAN SYRINGE 21G X 1-
1/2" 12 ML T3 QL (200 EA per 34 days)
MONOJECT MAGELLAN SYRINGE 21G X 1-
1/2" 6 ML T3 QL (200 EA per 34 days)
11
Drug Tier Requirements/Limits
MONOJECT MAGELLAN SYRINGE 22G X 1-
1/2" 12 ML T3 QL (200 EA per 34 days)
MONOJECT MAGELLAN SYRINGE 22G X 1-
1/2" 6 ML T3 QL (200 EA per 34 days)
MONOJECT SPINAL NEEDLE 18G X 3-1/2" T3 QL (200 EA per 34 days)
MONOJECT SPINAL NEEDLE 19G X 3-1/2" T3 QL (200 EA per 34 days)
MONOJECT SPINAL NEEDLE 20G X 3-1/2" T3 QL (200 EA per 34 days)
MONOJECT SPINAL NEEDLE 22G X 1-1/2" T3 QL (200 EA per 34 days)
MONOJECT SPINAL NEEDLE 22G X 3-1/2" T3 QL (200 EA per 34 days)
MONOJECT SPINAL NEEDLE 25G X 3-1/2" T3 QL (200 EA per 34 days)
MONOJECT SPINAL NEEDLE 26G X 3-1/2" T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 22G X 1-1/2" 12 ML
(OTC) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 22G X 1-1/2" 12 ML
(RX) T3 QL (200 EA per 34 days)
MONOLET OPD LANCETS T3 QL (100 EA per 25 days)
MONOLETTOR SAFETY LANCETS T3 QL (100 EA per 25 days)
mpd safety lancet 21g T3 QL (100 EA per 25 days)
mpd safety lancet 23g T3 QL (100 EA per 25 days)
mpd safety lancet 28g T3 QL (100 EA per 25 days)
mpd safety lancet 30g T3 QL (100 EA per 25 days)
mucus relief multi symptom liquid 2.5-5-100
mg/5ml oral T3
mucus-er max tablet extended release 12 hour
1200 mg oral T3
multi vitamin tablet oral T3
multi vitamin w/d-3 tablet oral T3
multi-b-plus tablet oral T3
multi-day tablet oral T3
multi-day vitamins tablet oral T3
multi-day/calcium/extra iron tablet oral T3
MULTIFIT REUSABLE SYRINGE 10 ML T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE SYRINGE 20 ML T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE SYRINGE 3 ML T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE TB SYRINGE 2 ML T3 QL (200 EA per 34 days)
multiple vitamin tablet oral T3
MULTIPLEX-2 CAPSULE ORAL T3
multivitamin/iron tablet oral T3
12
Drug Tier Requirements/Limits
multi-vitamin/iron tablet oral T3
myamulti tablet oral T3
nasal moisturizer solution 0.65 % nasal T3
nasal solution 0.65 % nasal T3
nat-rul iron tablet 325 mg oral T3
natural mixed tocopherols capsule 100 unit oral T3
NATURALYTE SOLUTION ORAL T3
na-zone solution 0.65 % nasal T3
NETGROUP LANCETS T3 QL (100 EA per 25 days)
neuro-k-250 vitamin b6 tablet 250 mg oral T3
neuro-k-50 tablet 50 mg oral T3
neuro-k-500 tablet 500 mg oral T3
NEXGEN CONTROL LIQUID NORMAL IN
VITRO T3 QL (1 EA per 90 days)
NUTRAVANCE TABLET ORAL T3
NUTRIFAC ZX TABLET ORAL T3
OCUSOFT VMS TABLET ORAL T3
OCUVITE ADULT FORMULA CAPSULE
ORAL T3
ONE-A-DAY 50 PLUS TABLET ORAL T3
ONE-A-DAY BONE STRENGTH TABLET
500-28-100 MG-MG-UNIT ORAL T3
ONE-A-DAY COLD SEASON TABLET 500-
50-7.5 MG ORAL T3
ONE-A-DAY EXTRAS ANTIOXIDANT
CAPSULE ORAL T3
ONETOUCH CLUB LANCETS FINE PT T3 QL (100 EA per 25 days)
ONETOUCH COMBO PACK T3 QL (100 EA per 25 days)
optic-vites tablet oral T3
OPTIHALER DEVICE T3 QL (2 EA per 365 days)
optimum pms tablet oral T3
OPTI-VITAMINS TABLET ORAL T3
OPTIVITE P.M.T. TABLET ORAL T3
oyster calcium + d tablet 250-125 mg-unit oral T3
OYSTERCAL TABLET 500 MG ORAL T3
PATIENT SAFE SYRINGE 10 ML T3 QL (200 EA per 34 days)
PATIENT SAFE SYRINGE 20 ML T3 QL (200 EA per 34 days)
PATIENT SAFE SYRINGE 30 ML T3 QL (200 EA per 34 days)
13
Drug Tier Requirements/Limits
PATIENT SAFE SYRINGE 5 ML T3 QL (200 EA per 34 days)
PATIENT SAFE SYRINGE 60 ML T3 QL (200 EA per 34 days)
peak a-i-r flow meter device T3 QL (1 EA per 365 days)
peak flow meter device T3 QL (1 EA per 365 days)
peak flow meter universal rang device T3 QL (1 EA per 365 days)
PERFECT LANCETS 28G T3 QL (100 EA per 25 days)
PERFECT LANCETS 30G T3 QL (100 EA per 25 days)
PHARMACY COUNTER LANCETS T3 QL (100 EA per 25 days)
PMS-WOMENS FORMULA TABLET ORAL T3
POCKET SPACER DEVICE T3 QL (2 EA per 365 days)
POCKETPEAK PEAK FLOW METER DEVICE T3 QL (1 EA per 365 days)
PRECISION GLUCOSE CONTROL LIQUID IN
VITRO T3 QL (1 EA per 90 days)
PRECISION GLUCOSE CONTROL SOLN
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
PRECISION GLUCOSE/KETONE CONTR
LIQUID IN VITRO T3 QL (1 EA per 90 days)
PRECISION THIN LANCETS T3 QL (100 EA per 25 days)
PRECISION THINS GP LANCETS T3 QL (100 EA per 25 days)
PRECISION ULTRA LANCET T3 QL (100 EA per 25 days)
premium automatic bp monitor device T3 QL (1 EA per 365 days)
pressure activat safety lancet T3 QL (100 EA per 25 days)
PROTEGRA CAPSULE ORAL T3
PSS SELECT GP LANCETS T3 QL (100 EA per 25 days)
PSS SELECT SAFETY LANCETS T3 QL (100 EA per 25 days)
push button safety lancets T3 QL (100 EA per 25 days)
px lancet auto injector T3 QL (1 EA per 365 days)
px vitamin a capsule 2400 mcg (8000 ut) oral T3
qc lancets T3 QL (100 EA per 25 days)
qc lancets thin T3 QL (100 EA per 25 days)
qc nasal spray solution 0.05 % nasal T3
ra bp wrist monitor automatic device T3 QL (1 EA per 365 days)
ra calcium/iron/vitamin d tablet 600-18-125 mg-
mg-unit oral T3
RA E-ZJECT COLOR LANCETS 33G T3 QL (100 EA per 25 days)
RA HI-CAL TABLET 500 MG ORAL T3
ra lancing device T3 QL (1 EA per 365 days)
14
Drug Tier Requirements/Limits
ra laxative tablet chewable 15 mg oral T3
ra oyster shell calcium tablet 500 mg oral T3
ra senna capsule 8.6 mg oral T3
ra vitamin c tablet chewable 250 mg oral T3
RAGUS TABLET ORAL T3
reality lancets T3 QL (100 EA per 25 days)
REALITY LATEX/ULTRA TEXTURED
DEVICE T3 QL (48 EA per 34 days)
REALITY LATEX/ULTRA THIN DEVICE T3 QL (48 EA per 34 days)
reality swabs pad T3 QL (150 EA per 34 days)
reality trigger lancets T3 QL (100 EA per 25 days)
REHYDRALYTE SOLUTION ORAL T3
RELION ALCOHOL SWABS PAD T3 QL (150 EA per 34 days)
RELION THIN LANCETS T3 QL (100 EA per 25 days)
RENAL MULTIVITAMIN/ZINC TABLET
ORAL T3
RENAL TABLET ORAL T3
replace capsule oral T3
revital freezer pops solution oral T3
revital jell cups solution oral T3
revital liquid squeezers solution oral T3
SAFE-LUV CONDOMS T3 QL (48 EA per 34 days)
SAFE-T-LANCE T3 QL (100 EA per 25 days)
SAFE-T-LANCE PLUS T3 QL (100 EA per 25 days)
safety syringe/needle 27g x 1/2" 1 ml T3 QL (200 EA per 34 days)
safety syringes/needle 20g x 1-1/2" 10 ml T3 QL (200 EA per 34 days)
safety syringes/needle 20g x 1-1/2" 5 ml T3 QL (200 EA per 34 days)
safety syringes/needle 21g x 1-1/2" 5 ml T3 QL (200 EA per 34 days)
safety syringes/needle 22g x 1-1/2" 10 ml T3 QL (200 EA per 34 days)
safety syringes/needle 22g x 1-1/2" 5 ml T3 QL (200 EA per 34 days)
safety syringes/needle 27g x 1-1/2" 10 ml T3 QL (200 EA per 34 days)
SANA-LOK CONTROL SYRINGE 10 ML T3 QL (200 EA per 34 days)
SANA-LOK CONTROL SYRINGE 20 ML T3 QL (200 EA per 34 days)
SANA-LOK CONTROL SYRINGE 5 ML T3 QL (200 EA per 34 days)
sb alcohol prep pad 70 % T3 QL (150 EA per 34 days)
SCLEREX TABLET ORAL T3
15
Drug Tier Requirements/Limits
SECURESAFE SYRINGE/NEEDLE 21G X 1-
1/2" 10 ML T3 QL (200 EA per 34 days)
SECURESAFE SYRINGE/NEEDLE 21G X 1-
1/2" 5 ML T3 QL (200 EA per 34 days)
SECURESAFE SYRINGE/NEEDLE 27G X 1/2"
1 ML T3 QL (200 EA per 34 days)
SECURESAFE TUBERCULIN SYRINGE 25G
X 5/8" 1 ML T3 QL (200 EA per 34 days)
SECURESAFE TUBERCULIN SYRINGE 26G
X 3/8" 1 ML T3 QL (200 EA per 34 days)
SENETONIC LIQUID† ORAL T3
senna maximum strength tablet 25 mg oral T3
senna tablet 15 mg oral T3
sennazon syrup 8.8 mg/5ml oral T3
sennosides tablet 8.6 mg oral T3
sg saline nasal solution 0.65 % nasal T3
SHOPKO ALCOHOL SWABS PAD 70 % T3 QL (150 EA per 34 days)
side button safety lancet T3 QL (100 EA per 25 days)
SIGTAB TABLET ORAL T3
SINGLE-LET T3 QL (100 EA per 25 days)
sm enema enema rectal T3
sm humidifier/cool mist T3 QL (1 EA per 365 days)
sm iron tablet 134 mg oral T3
SM TRUEDRAW LANCING DEVICE T3 QL (1 EA per 365 days)
sodium chloride solution 0.65 % nasal T3
SOLARTEK GLUCOSE CONTROL LIQUID IN
VITRO T3 QL (1 EA per 90 days)
sphygmomanometer T3 QL (1 EA per 365 days)
spinal needle 18g x 3" T3 QL (200 EA per 34 days)
spinal needle 18g x 3-1/2" T3 QL (200 EA per 34 days)
spinal needle 18g x 6" T3 QL (200 EA per 34 days)
spinal needle 20g x 1-1/2" T3 QL (200 EA per 34 days)
spinal needle 20g x 3-1/2" T3 QL (200 EA per 34 days)
spinal needle 22g x 1-1/2" T3 QL (200 EA per 34 days)
spinal needle 22g x 2-1/2" T3 QL (200 EA per 34 days)
spinal needle 22g x 3" T3 QL (200 EA per 34 days)
spinal needle 22g x 3-1/2" T3 QL (200 EA per 34 days)
spinal needle 22g x 5" T3 QL (200 EA per 34 days)
16
Drug Tier Requirements/Limits
spinal needle 22g x 7" T3 QL (200 EA per 34 days)
spinal needle 23g x 3-1/2" T3 QL (200 EA per 34 days)
spinal needle 25g x 1" T3 QL (200 EA per 34 days)
spinal needle 25g x 2" T3 QL (200 EA per 34 days)
spinal needle 25g x 3" T3 QL (200 EA per 34 days)
spinal needle 25g x 3-1/2" T3 QL (200 EA per 34 days)
spinal needle 25g x 4-11/16" T3 QL (200 EA per 34 days)
spinal needle 26g x 3-1/2" T3 QL (200 EA per 34 days)
spinal needle 27g x 3-1/2" T3 QL (200 EA per 34 days)
spinal needle 27g x 4-11/16" T3 QL (200 EA per 34 days)
spinal needle 29g x 3-1/2" T3 QL (200 EA per 34 days)
spinal needle 29g x 4-11/16" T3 QL (200 EA per 34 days)
spinal needle tw 18g x 3-1/2" T3 QL (200 EA per 34 days)
spinal needle/stylet tw 14g x 2" T3 QL (200 EA per 34 days)
spinal needle/stylet tw 18g x 1-1/2" T3 QL (200 EA per 34 days)
spinal needle/stylet tw 18g x 2-1/2" T3 QL (200 EA per 34 days)
spinal needle/stylet tw 18g x 6" T3 QL (200 EA per 34 days)
STIMEX INSULATED NEEDLE 22G X 2-1/8" T3 QL (200 EA per 34 days)
STIMEX INSULATED NEEDLE 22G X 4-1/4" T3 QL (200 EA per 34 days)
stress formula 500/biotin tablet oral T3
stress formula 500/zinc tablet oral T3
stress formula/iron/biotin tablet oral T3
stress/iron tablet oral T3
STRESSTABS ADVANCED TABLET ORAL T3
STRESSTABS ENERGY TABLET ORAL T3
SUNBEAM COOL SPRAY HUMIDIFIER T3 QL (1 EA per 365 days)
SUNBEAM EVAP HUMIDIFIER T3 QL (1 EA per 365 days)
SUNBEAM HUMIDIFIER T3 QL (1 EA per 365 days)
SUNBEAM PORTABLE VAPORIZER T3 QL (1 EA per 365 days)
SUNBEAM ULTRA-SONIC HUMIDIFIER T3 QL (1 EA per 365 days)
SUNBEAM VAPORIZER T3 QL (1 EA per 365 days)
super aytinal 50 plus tablet oral T3
super aytinal tablet oral T3
super vita-mins tablet oral T3
supreme ii high/low control liquid in vitro T3 QL (1 EA per 90 days)
SURBEX W/ZINC TABLET ORAL T3
17
Drug Tier Requirements/Limits
SURECHEK CONTROL SOLUTION LIQUID
LOW IN VITRO T3 QL (1 EA per 90 days)
SURECHEK CONTROL SOLUTION LIQUID
NORMAL IN VITRO T3 QL (1 EA per 90 days)
SURE-LANCE LANCETS 26G T3 QL (100 EA per 25 days)
SURELITE LANCETS T3 QL (100 EA per 25 days)
SURE-PEN T3 QL (1 EA per 365 days)
sympathetic nerve needle 18g x 6" T3 QL (200 EA per 34 days)
sympathetic nerve needle 19g x 5" T3 QL (200 EA per 34 days)
sympathetic nerve needle 20g x 5" T3 QL (200 EA per 34 days)
syringe 20g x 1" 12 ml T3 QL (200 EA per 34 days)
syringe 20g x 1" 6 ml T3 QL (200 EA per 34 days)
syringe 20g x 1-1/2" 12 ml T3 QL (200 EA per 34 days)
syringe 20g x 1-1/2" 6 ml T3 QL (200 EA per 34 days)
syringe 21g x 1" 12 ml T3 QL (200 EA per 34 days)
syringe 21g x 1" 6 ml T3 QL (200 EA per 34 days)
syringe 21g x 1-1/2" 12 ml T3 QL (200 EA per 34 days)
syringe 21g x 1-1/2" 6 ml T3 QL (200 EA per 34 days)
syringe 21g x 1-1/4" 6 ml T3 QL (200 EA per 34 days)
syringe 22g x 1" 12 ml T3 QL (200 EA per 34 days)
syringe 22g x 1" 6 ml T3 QL (200 EA per 34 days)
syringe 22g x 1-1/2" 12 ml T3 QL (200 EA per 34 days)
syringe 22g x 1-1/2" 6 ml T3 QL (200 EA per 34 days)
syringe 22g x 1-1/4" 6 ml T3 QL (200 EA per 34 days)
syringe luer lock 10 ml T3 QL (200 EA per 34 days)
syringe luer lock 20 ml T3 QL (200 EA per 34 days)
syringe luer lock 20g x 1" 10 ml T3 QL (200 EA per 34 days)
syringe luer lock 20g x 1" 5 ml T3 QL (200 EA per 34 days)
syringe luer lock 20g x 1-1/2" 10 ml T3 QL (200 EA per 34 days)
syringe luer lock 20g x 1-1/2" 5 ml T3 QL (200 EA per 34 days)
syringe luer lock 21g x 1" 10 ml T3 QL (200 EA per 34 days)
syringe luer lock 21g x 1" 5 ml T3 QL (200 EA per 34 days)
syringe luer lock 21g x 1-1/2" 10 ml T3 QL (200 EA per 34 days)
syringe luer lock 21g x 1-1/2" 5 ml T3 QL (200 EA per 34 days)
syringe luer lock 22g x 1" 10 ml T3 QL (200 EA per 34 days)
syringe luer lock 22g x 1" 5 ml T3 QL (200 EA per 34 days)
syringe luer lock 22g x 1-1/2" 10 ml T3 QL (200 EA per 34 days)
18
Drug Tier Requirements/Limits
syringe luer lock 22g x 1-1/2" 5 ml T3 QL (200 EA per 34 days)
syringe luer lock 35 ml T3 QL (200 EA per 34 days)
syringe luer lock 5 ml T3 QL (200 EA per 34 days)
syringe luer lock 60 ml T3 QL (200 EA per 34 days)
syringe luer slip 10 ml T3 QL (200 EA per 34 days)
syringe luer slip 20 ml T3 QL (200 EA per 34 days)
syringe luer slip 27g x 1/2" 1 ml T3 QL (200 EA per 34 days)
syringe luer slip 35 ml T3 QL (200 EA per 34 days)
syringe luer slip 5 ml T3 QL (200 EA per 34 days)
syringe luer slip 60 ml T3 QL (200 EA per 34 days)
syringe/cannula 5 ml T3 QL (200 EA per 34 days)
syringe/hypodermic safety 18g x 1" 12 ml T3 QL (200 EA per 34 days)
T.E.D. BELOW KNEE/L X-LGTH T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/LARGE T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/L-REGULAR T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/M X-LGTH T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/MEDIUM T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/M-REGULAR T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/S X-LGTH T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/SMALL T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/S-REGULAR T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/XL T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/XL X-LGTH T3 QL (2 EA per 180 days)
T.E.D. BELOW KNEE/X-LARGE T3 QL (2 EA per 180 days)
talking blood pressure monitor kit T3 QL (1 EA per 365 days)
th slow release iron tablet extended release 50 mg
oral T3
thera vital m tablet oral T3
therabasic-m tablet oral T3
thera-m multiple vitamins tablet oral T3
therapeutic multivit/mineral tablet oral T3
theravim-m tablet oral T3
thevimine-t tablet oral T3
THINLETS GP LANCETS T3 QL (100 EA per 25 days)
THINLETS LANCET T3 QL (100 EA per 25 days)
TOTAL FORMULA 2 TABLET ORAL T3
TOTAL FORMULA 3 TABLET ORAL T3
19
Drug Tier Requirements/Limits
TOTAL FORMULA TABLET ORAL T3
TROJAN T3 QL (48 EA per 34 days)
TROJAN ASSORTMENT PACK T3 QL (48 EA per 34 days)
TROJAN EXTENDED PLEASURE/LUBE
DEVICE T3 QL (48 EA per 34 days)
TROJAN EXTRA STRENGTH T3 QL (48 EA per 34 days)
TROJAN MAGNUM T3 QL (48 EA per 34 days)
TROJAN MAGNUM WARM SENSATIONS
DEVICE T3 QL (48 EA per 34 days)
TROJAN MAGNUM XL LUBRICATED
DEVICE T3 QL (48 EA per 34 days)
TROJAN NATURALAMB T3 QL (48 EA per 34 days)
TROJAN NATURALAMB/SPERMICIDE T3 QL (48 EA per 34 days)
TROJAN PLEASURE MESH/SPERMICID
DEVICE T3 QL (48 EA per 34 days)
TROJAN PLUS T3 QL (48 EA per 34 days)
TROJAN REGULAR T3 QL (48 EA per 34 days)
TROJAN RIBBED T3 QL (48 EA per 34 days)
TROJAN RIBBED/SPERMICIDAL T3 QL (48 EA per 34 days)
TROJAN SHARED SENSATION/LUBE
DEVICE T3 QL (48 EA per 34 days)
TROJAN SUPRAS SPERMICIDAL DEVICE T3 QL (48 EA per 34 days)
TROJAN TWISTED PLEASURE DEVICE T3 QL (48 EA per 34 days)
TROJAN ULTRA PLEASURE LUBRICAT
DEVICE T3 QL (48 EA per 34 days)
TROJAN VERY SENSITIVE LUBRICAT T3 QL (48 EA per 34 days)
TROJAN VERY SENSITIVE SPERMICI T3 QL (48 EA per 34 days)
TROJAN VERY THIN LUBRICATED T3 QL (48 EA per 34 days)
TROJAN VERY THIN SPERMICIDE T3 QL (48 EA per 34 days)
TROJAN-ENZ LUBRICATED T3 QL (48 EA per 34 days)
TROJAN-ENZ/SPERMICIDAL T3 QL (48 EA per 34 days)
TRUSTEX COLOR CONDOMS + LUBE T3 QL (48 EA per 34 days)
TRUSTEX NATURAL CONDOMS + LUBE T3 QL (48 EA per 34 days)
TUMS LASTING EFFECTS TABLET
CHEWABLE 500 MG ORAL T3
tuohy epidural needle tw 14g x 3" T3 QL (200 EA per 34 days)
tuohy epidural needle tw 16g x 3" T3 QL (200 EA per 34 days)
tuohy epidural needle tw 17g x 3" T3 QL (200 EA per 34 days)
20
Drug Tier Requirements/Limits
tuohy epidural needle tw 17g x 3-1/2" T3 QL (200 EA per 34 days)
tuohy epidural needle tw 17g x 7" T3 QL (200 EA per 34 days)
tuohy epidural needle tw 18g x 2" T3 QL (200 EA per 34 days)
tuohy epidural needle tw 18g x 3" T3 QL (200 EA per 34 days)
tuohy epidural needle tw 18g x 3-1/2" T3 QL (200 EA per 34 days)
tuohy epidural needle tw 20g x 3-1/2" T3 QL (200 EA per 34 days)
TWINRIX SUSPENSION 720-20 ELU-
MCG/ML INTRAMUSCULAR T3 QL (30 ML per 30 days); AL
ULTI-LANCE MINI ADJUSTABLE T3 QL (1 EA per 365 days)
ULTILET OPERATING DEVICE T3 QL (1 EA per 365 days)
ULTILET SAFETY LANCETS T3 QL (100 EA per 25 days)
ULTILET ULTI-LANCE ADJ DEVICE T3 QL (1 EA per 365 days)
ULTIMATE FEELING DEVICE T3 QL (48 EA per 34 days)
ULTRACHOICE ADV FORMULA MATURE
TABLET ORAL T3
ULTRACHOICE ADVANCED FORMULA
TABLET ORAL T3
ultrasonic humidifier T3 QL (1 EA per 365 days)
uni-daily/iron tablet oral T3
uni-thera m advanced tablet oral T3
UNIVERSAL 1 LANCETS THIN 33G T3 QL (100 EA per 25 days)
VANISHPOINT SAFETY SYRINGE 20G X 1"
10 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 20G X 1"
5 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 20G X 1-
1/2" 10 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 20G X 1-
1/2" 5 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 21G X 1"
10 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 22G X 1"
10 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 22G X 1"
5 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 22G X 1-
1/2" 10 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 25G X 1-
1/2" 10 ML T3 QL (200 EA per 34 days)
21
Drug Tier Requirements/Limits
VANISHPOINT SAFETY SYRINGE 25G X 1-
1/2" 5 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 27G X 1-
1/2" 10 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 27G X 1-
1/2" 5 ML T3 QL (200 EA per 34 days)
varidin capsule oral T3
VICKS GERMFREE HUMIDIFIER T3 QL (1 EA per 365 days)
VICKS PUREMIST HUMIDIFIER T3 QL (1 EA per 365 days)
VICKS ULTRASONIC HUMIDIFIER T3 QL (1 EA per 365 days)
VICKS VAPORIZER T3 QL (1 EA per 365 days)
VICKS WARM MIST HUMIDIFIER T3 QL (1 EA per 365 days)
VICKS WATERLESS VAPORIZER T3 QL (1 EA per 365 days)
vita hair tablet oral T3
vitabasic complete tablet oral T3
vitabasic senior tablet oral T3
VITA-BOB CAPSULE ORAL T3
VITALET PRO LANCETS T3 QL (100 EA per 25 days)
VITALET PRO PLUS LANCETS T3 QL (100 EA per 25 days)
VITAMAX TABLET CHEWABLE ORAL T3 AL
vitamin c-acerola tablet 500 mg oral T3
vitamin c-rose hips er tablet extended release
1500 mg oral T3
vitamin c-rose hips tablet 250 mg oral T3 AL
vitamin c-rose hips tablet chewable 500 mg oral T3
vitamin d3 tablet 1.25 mg (50000 ut) oral T3
vitamin d3 ultra potency tablet 1.25 mg (50000
ut) oral T3
vitamin e complex capsule 1000 unit oral T3
vitamin e complex capsule 400 unit oral T3
vitamins for the hair tablet oral T3
vitaplex plus tablet oral T3
vita-plus e capsule 400 unit oral T3
VITAROCA PLUS TABLET ORAL T3
VITASANA TABLET ORAL T3
VOCAL POINT CONTROL SOLUTION HIGH
IN VITRO T3 QL (1 EA per 90 days)
22
Drug Tier Requirements/Limits
VOCAL POINT CONTROL SOLUTION LOW
IN VITRO T3 QL (1 EA per 90 days)
warm mist vaporizer T3 QL (1 EA per 365 days)
wd glucose tablet chewable 4 gm oral T3
WD LANCETS T3 QL (100 EA per 25 days)
WD LANCETS THIN T3 QL (100 EA per 25 days)
WEISS EPIDURAL NEEDLE 17G X 3" T3 QL (200 EA per 34 days)
WEISS EPIDURAL NEEDLE 20G X 2" T3 QL (200 EA per 34 days)
WEISS EPIDURAL NEEDLE TW 17G X 3-1/2" T3 QL (200 EA per 34 days)
WEISS EPIDURAL NEEDLE TW 17G X 5" T3 QL (200 EA per 34 days)
WEISS EPIDURAL NEEDLE TW 17G X 8 CM T3 QL (200 EA per 34 days)
WEISS EPIDURAL NEEDLE TW 18G X 2" T3 QL (200 EA per 34 days)
WEISS EPIDURAL NEEDLE TW 18G X 3-1/2" T3 QL (200 EA per 34 days)
WEISS EPIDURAL NEEDLE TW 18G X 5" T3 QL (200 EA per 34 days)
WEISS EPIDURAL NEEDLE TW 18G X 8 CM T3 QL (200 EA per 34 days)
WEISS EPIDURAL NEEDLE TW 20G X 3-1/2" T3 QL (200 EA per 34 days)
WHITACRE SPINAL NEEDLE 22G X 1-1/2" T3 QL (200 EA per 34 days)
WHITACRE SPINAL NEEDLE 25G X 1-1/2" T3 QL (200 EA per 34 days)
WHITACRE SPINAL NEEDLE 25G X 3-1/2" T3 QL (200 EA per 34 days)
WHITACRE SPINAL NEEDLE 25G X 4-11/16" T3 QL (200 EA per 34 days)
WHITACRE SPINAL NEEDLE 27G X 1-1/2" T3 QL (200 EA per 34 days)
WHITACRE SPINAL NEEDLE 27G X 3-1/2" T3 QL (200 EA per 34 days)
WHITACRE SPINAL NEEDLE 27G X 4-11/16" T3 QL (200 EA per 34 days)
womens bone health tablet oral T3
YALE REUSABLE TB SYRINGE 1/2 ML T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 17G X 3-1/2" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 18G X 3" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 18G X 3-1/2" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 19G X 3" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 19G X 3-1/2" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 20G X 2" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 20G X 3" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 20G X 3-1/2" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 20G X 4" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 22G X 1-1/2" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 22G X 2" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 22G X 3" T3 QL (200 EA per 34 days)
23
Drug Tier Requirements/Limits
YALE SPINAL NEEDLE 22G X 3-1/2" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 24G X 3-1/2" T3 QL (200 EA per 34 days)
YALE SPINAL NEEDLE 26G X 3-1/2" T3 QL (200 EA per 34 days)
yl beta carotene capsule 25000 unit oral T3
yl folic acid tablet 400 mcg oral T3
yl vitamin b-6 tablet 100 mg oral T3
yl vitamin c tablet 1000 mg oral T3
yl vitamin c-rose hips tablet 1000 mg oral T3
yl vitamin c-rose hips tablet 500 mg oral T3
yl vitamin e capsule 400 unit oral T3
z-basic tablet oral T3
Z-BEC TABLET ORAL T3
Antihistamine Drugs
Ethanolamine Derivatives
allergy childrens liquid 12.5 mg/5ml oral T3
allergy relief capsule 25 mg oral T3
allergy relief childrens liquid 12.5 mg/5ml oral T3
allergy relief tablet 25 mg oral T3
allergy tablet 25 mg oral T3
BANOPHEN CAPSULE 25 MG ORAL T3
BANOPHEN CAPSULE 50 MG ORAL T3
BANOPHEN LIQUID 12.5 MG/5ML ORAL T3
BANOPHEN TABLET 25 MG ORAL T3
complete allergy medicine capsule 25 mg oral T3
diphenhist capsule 25 mg oral T3
diphenhist liquid 12.5 mg/5ml oral T3
diphenhist tablet 25 mg oral T3
diphenhydramine hcl capsule 25 mg oral (otc) T3
diphenhydramine hcl capsule 50 mg oral (otc) T3
diphenhydramine hcl elixir 12.5 mg/5ml oral (rx) T3
diphenhydramine hcl liquid 12.5 mg/5ml oral T3
diphenhydramine hcl solution 50 mg/ml injection T3
diphenhydramine hcl tablet 25 mg oral T3
dye-free allergy relief liquid 12.5 mg/5ml oral T3
eql vitamin e capsule 400 unit oral T3
gnp allergy antihistamine liquid 12.5 mg/5ml oral T3
24
Drug Tier Requirements/Limits
gnp allergy capsule 25 mg oral T3
gnp allergy relief capsule 25 mg oral T3
gnp allergy relief tablet chewable 12.5 mg oral T3
gnp allergy tablet 25 mg oral T3
gnp childrens allergy liquid 12.5 mg/5ml oral T3
gnp sleep aid tablet 25 mg oral T3
hm allergy multi symptom capsule 25 mg oral T3
hm allergy relief capsule 25 mg oral T3
hm allergy relief childrens liquid 12.5 mg/5ml
oral T3
hm allergy relief tablet 25 mg oral T3
hm allergy tablet 25 mg oral T3
hm sleep aid tablet 25 mg oral T3
multi-symptom allergy capsule 25 mg oral T3
pharbedryl capsule 25 mg oral T3
pharbedryl capsule 50 mg oral T3
qc complete allergy medicine capsule 25 mg oral T3
siladryl allergy liquid 12.5 mg/5ml oral T3
sleep aid tablet 25 mg oral T3
sm allergy relief capsule 25 mg oral T3
sm allergy relief liquid 12.5 mg/5ml oral T3
sm allergy relief tablet 25 mg oral T3
sm sleep aid tablet 25 mg oral T3
First Gen. Antihist. Derivatives, Misc.
cyproheptadine hcl syrup 2 mg/5ml oral T3
cyproheptadine hcl tablet 4 mg oral T3
First Generation Antihistamines
aller-chlor syrup 2 mg/5ml oral T3
aller-chlor tablet 4 mg oral T3
allergy childrens liquid 12.5 mg/5ml oral T3
allergy relief capsule 25 mg oral T3
allergy relief childrens liquid 12.5 mg/5ml oral T3
allergy relief tablet 25 mg oral T3
allergy relief tablet 4 mg oral T3
allergy tablet 25 mg oral T3
allergy tablet 4 mg oral T3
25
Drug Tier Requirements/Limits
allergy-time tablet 4 mg oral T3
BANOPHEN CAPSULE 25 MG ORAL T3
BANOPHEN CAPSULE 50 MG ORAL T3
BANOPHEN LIQUID 12.5 MG/5ML ORAL T3
BANOPHEN TABLET 25 MG ORAL T3
complete allergy medicine capsule 25 mg oral T3
cyproheptadine hcl syrup 2 mg/5ml oral T3
cyproheptadine hcl tablet 4 mg oral T3
diphenhist capsule 25 mg oral T3
diphenhist liquid 12.5 mg/5ml oral T3
diphenhist tablet 25 mg oral T3
diphenhydramine hcl capsule 25 mg oral (otc) T3
diphenhydramine hcl capsule 50 mg oral (otc) T3
diphenhydramine hcl elixir 12.5 mg/5ml oral (rx) T3
diphenhydramine hcl liquid 12.5 mg/5ml oral T3
diphenhydramine hcl solution 50 mg/ml injection T3
diphenhydramine hcl tablet 25 mg oral T3
dye-free allergy relief liquid 12.5 mg/5ml oral T3
ed chlorped jr syrup 2 mg/5ml oral T3
gnp allergy antihistamine liquid 12.5 mg/5ml oral T3
gnp allergy capsule 25 mg oral T3
gnp allergy relief capsule 25 mg oral T3
gnp allergy relief tablet chewable 12.5 mg oral T3
gnp allergy tablet 25 mg oral T3
gnp allergy tablet 4 mg oral T3
gnp childrens allergy liquid 12.5 mg/5ml oral T3
gnp sleep aid tablet 25 mg oral T3
hm allergy multi symptom capsule 25 mg oral T3
hm allergy relief capsule 25 mg oral T3
hm allergy relief childrens liquid 12.5 mg/5ml
oral T3
hm allergy relief tablet 25 mg oral T3
hm allergy relief tablet 4 mg oral T3
hm allergy tablet 25 mg oral T3
hm sleep aid tablet 25 mg oral T3
multi-symptom allergy capsule 25 mg oral T3
pharbedryl capsule 25 mg oral T3
26
Drug Tier Requirements/Limits
pharbedryl capsule 50 mg oral T3
qc complete allergy medicine capsule 25 mg oral T3
siladryl allergy liquid 12.5 mg/5ml oral T3
sleep aid tablet 25 mg oral T3
sm allergy 4 hour tablet 4 mg oral T3
sm allergy relief capsule 25 mg oral T3
sm allergy relief liquid 12.5 mg/5ml oral T3
sm allergy relief tablet 25 mg oral T3
sm sleep aid tablet 25 mg oral T3
Phenothiazine Derivatives
promethazine vc plain solution 6.25-5 mg/5ml
oral T3 QL (900 ML per 30 days)
promethazine vc/codeine syrup 6.25-5-10 mg/5ml
oral T3 QL (120 ML per 30 days); AL
promethazine-dm solution 6.25-15 mg/5ml oral T3
promethazine-dm syrup 6.25-15 mg/5ml oral T3
promethazine-phenyleph-codeine syrup 6.25-5-10
mg/5ml oral T3 QL (120 ML per 30 days); AL
promethazine-phenylephrine syrup 6.25-5 mg/5ml
oral T3 QL (900 ML per 30 days)
Propylamine Derivatives
aller-chlor syrup 2 mg/5ml oral T3
aller-chlor tablet 4 mg oral T3
allergy relief tablet 4 mg oral T3
allergy tablet 4 mg oral T3
allergy-time tablet 4 mg oral T3
ed chlorped jr syrup 2 mg/5ml oral T3
gnp allergy tablet 4 mg oral T3
hm allergy relief tablet 4 mg oral T3
m-end dmx liquid 20-0.667-10 mg/5ml oral T3
sm allergy 4 hour tablet 4 mg oral T3
SUDOGEST SINUS/ALLERGY TABLET 4-60
MG ORAL T3
Anti-Infective Agents
Aminoglycoside Antibiotics
ZEMDRI SOLUTION 500 MG/10ML
INTRAVENOUS T4 PA
27
Drug Tier Requirements/Limits
Anthelmintics
albendazole tablet 200 mg oral T3 QL (120 EA per 30 days)
ALBENZA TABLET 200 MG ORAL T3 QL (120 EA per 30 days)
BILTRICIDE TABLET 600 MG ORAL T3
EMVERM TABLET CHEWABLE 100 MG
ORAL T3 QL (60 EA per 30 days)
ivermectin tablet 3 mg oral T3
praziquantel tablet 600 mg oral T3
STROMECTOL TABLET 3 MG ORAL T3
Antifungals, Miscellaneous
SSKI SOLUTION 1 GM/ML ORAL T3
Antimalarials
DARAPRIM TABLET 25 MG ORAL T4 PA; QL (90 EA per 30 days)
quinidine gluconate er tablet extended release
324 mg oral T3
Antimycobacterials, Miscellaneous
dapsone tablet 100 mg oral T3
dapsone tablet 25 mg oral T3
Antiprotozoals, Miscellaneous
atovaquone suspension 750 mg/5ml oral T3 PA; QL (600 ML per 30 days)
dapsone tablet 100 mg oral T3
dapsone tablet 25 mg oral T3
MEPRON SUSPENSION 750 MG/5ML ORAL T3 PA; QL (600 ML per 30 days)
NEBUPENT SOLUTION RECONSTITUTED
300 MG INHALATION T4 PA
Antituberculosis Agents
ethambutol hcl tablet 100 mg oral T3
ethambutol hcl tablet 400 mg oral T3
isoniazid syrup 50 mg/5ml oral T3
isoniazid tablet 100 mg oral T3
isoniazid tablet 300 mg oral T3
MYAMBUTOL TABLET 400 MG ORAL T3
MYCOBUTIN CAPSULE 150 MG ORAL T3
pretomanid T4 PA
pyrazinamide tablet 500 mg oral T3
rifabutin capsule 150 mg oral T3
28
Drug Tier Requirements/Limits
RIFADIN CAPSULE 150 MG ORAL T3
RIFADIN CAPSULE 300 MG ORAL T3
RIFADIN SOLUTION RECONSTITUTED 600
MG INTRAVENOUS T4 PA
rifampin capsule 150 mg oral T3
rifampin capsule 300 mg oral T3
rifampin solution reconstituted 600 mg
intravenous T4 PA
Antivirals, Miscellaneous
PREVYMIS SOLUTION 240 MG/12ML
INTRAVENOUS T4 PA; QL (360 ML per 30 days)
PREVYMIS SOLUTION 480 MG/24ML
INTRAVENOUS T4 PA; QL (720 ML per 30 days)
Azole Antifungals
CRESEMBA SOLUTION RECONSTITUTED
372 MG INTRAVENOUS T4 PA
Carbapenem Antibiotics
ertapenem sodium solution reconstituted 1 gm
injection T4 PA; QL (30 EA per 30 days)
INVANZ SOLUTION RECONSTITUTED 1 GM
INJECTION T4 PA; QL (30 EA per 30 days)
Chloramphenicol Antibiotics
chloramphenicol sod succinate solution
reconstituted 1 gm intravenous T3
Cyclic Lipopeptide Antibiotics
CUBICIN RF SOLUTION RECONSTITUTED
500 MG INTRAVENOUS T4 PA
CUBICIN SOLUTION RECONSTITUTED 500
MG INTRAVENOUS T4 PA
daptomycin solution reconstituted 350 mg
intravenous T4 PA
daptomycin solution reconstituted 500 mg
intravenous T4 PA
Glycopeptide Antibiotics
DALVANCE SOLUTION RECONSTITUTED
500 MG INTRAVENOUS T4 PA
Glycylcycline Antibiotics
tigecycline solution reconstituted 50 mg
intravenous T4 PA
29
Drug Tier Requirements/Limits
TYGACIL SOLUTION RECONSTITUTED 50
MG INTRAVENOUS T4 PA
Interferon Antivirals
INTRON A SOLUTION 10000000 UNIT/ML
INJECTION T4 PA
INTRON A SOLUTION RECONSTITUTED
18000000 UNIT INJECTION T4 PA
SYLATRON KIT 200 MCG SUBCUTANEOUS T4 PA
SYLATRON KIT 300 MCG SUBCUTANEOUS T4 PA
SYLATRON KIT 600 MCG SUBCUTANEOUS T4 PA
Lincomycin Antibiotics
CLEOCIN CAPSULE 150 MG ORAL T3
CLEOCIN CAPSULE 300 MG ORAL T3
CLEOCIN CAPSULE 75 MG ORAL T3
CLEOCIN SOLUTION RECONSTITUTED 75
MG/5ML ORAL T3
clindamycin hcl capsule 150 mg oral T3
clindamycin hcl capsule 300 mg oral T3
clindamycin hcl capsule 75 mg oral T3
clindamycin palmitate hcl solution reconstituted
75 mg/5ml oral T3
Monoclonal Antibody Antivirals
SYNAGIS SOLUTION 100 MG/ML
INTRAMUSCULAR T4 PA
SYNAGIS SOLUTION 50 MG/0.5ML
INTRAMUSCULAR T4 PA
Nucleoside And Nucleotide Antivirals
cidofovir solution 75 mg/ml intravenous T4 PA
CYTOVENE SOLUTION RECONSTITUTED
500 MG INTRAVENOUS T4 PA
ganciclovir sodium solution reconstituted 500 mg
intravenous T4 PA
PREVYMIS SOLUTION 240 MG/12ML
INTRAVENOUS T4 PA; QL (360 ML per 30 days)
PREVYMIS SOLUTION 480 MG/24ML
INTRAVENOUS T4 PA; QL (720 ML per 30 days)
ribavirin solution reconstituted 6 gm inhalation T4 PA
VIRAZOLE SOLUTION RECONSTITUTED 6
GM INHALATION T4 PA
30
Drug Tier Requirements/Limits
Oxazolidinone Antibiotics
SIVEXTRO TABLET 200 MG ORAL T4 PA; QL (30 EA per 30 days)
Polymyxin Antibiotics
colistimethate sodium (cba) solution reconstituted
150 mg injection T4 PA
COLY-MYCIN M SOLUTION
RECONSTITUTED 150 MG INJECTION T4 PA
Rifamycin Antibiotics
MYCOBUTIN CAPSULE 150 MG ORAL T3
rifabutin capsule 150 mg oral T3
RIFADIN CAPSULE 150 MG ORAL T3
RIFADIN CAPSULE 300 MG ORAL T3
RIFADIN SOLUTION RECONSTITUTED 600
MG INTRAVENOUS T4 PA
rifampin capsule 150 mg oral T3
rifampin capsule 300 mg oral T3
rifampin solution reconstituted 600 mg
intravenous T4 PA
Sulfonamide Antibiotics (Systemic)
BACTRIM DS TABLET 800-160 MG ORAL T3
BACTRIM TABLET 400-80 MG ORAL T3
sulfadiazine tablet 500 mg oral T3
sulfamethoxazole-trimethoprim suspension 200-
40 mg/5ml oral T3
sulfamethoxazole-trimethoprim tablet 400-80 mg
oral T3
sulfamethoxazole-trimethoprim tablet 800-160 mg
oral T3
SULFATRIM PEDIATRIC SUSPENSION 200-
40 MG/5ML ORAL T3
Antineoplastic Agents
Antineoplastic Agents
ABRAXANE SUSPENSION
RECONSTITUTED 100 MG INTRAVENOUS T4 PA
ADCETRIS SOLUTION RECONSTITUTED 50
MG INTRAVENOUS T4 PA
ADRIAMYCIN SOLUTION 2 MG/ML
INTRAVENOUS T4 PA
31
Drug Tier Requirements/Limits
adriamycin solution reconstituted 10 mg
intravenous T4 PA
ADRIAMYCIN SOLUTION RECONSTITUTED
50 MG INTRAVENOUS T4 PA
ADRUCIL SOLUTION 2.5 GM/50ML
INTRAVENOUS T4 PA
ADRUCIL SOLUTION 5 GM/100ML
INTRAVENOUS T4 PA
ADRUCIL SOLUTION 500 MG/10ML
INTRAVENOUS T4 PA
ALIMTA SOLUTION RECONSTITUTED 100
MG INTRAVENOUS T4 PA
ALIMTA SOLUTION RECONSTITUTED 500
MG INTRAVENOUS T4 PA
ALIQOPA SOLUTION RECONSTITUTED 60
MG INTRAVENOUS T4 PA
ALKERAN SOLUTION RECONSTITUTED 50
MG INTRAVENOUS T4 PA
arsenic trioxide solution 10 mg/10ml intravenous T4 PA
ARZERRA CONCENTRATE 100 MG/5ML
INTRAVENOUS T4 PA
ARZERRA CONCENTRATE 1000 MG/50ML
INTRAVENOUS T4 PA
ASPARLAS T4 PA
AVASTIN SOLUTION 100 MG/4ML
INTRAVENOUS T4 PA; QL (195 ML per 30 days)
AVASTIN SOLUTION 400 MG/16ML
INTRAVENOUS T4 PA; QL (195 ML per 30 days)
azacitidine suspension reconstituted 100 mg
injection T4 PA
AZEDRA DOSIMETRIC SOLUTION 15
MCI/ML INTRAVENOUS T4 PA
AZEDRA THERAPEUTIC SOLUTION 15
MCI/ML INTRAVENOUS T4 PA
BAVENCIO SOLUTION 200 MG/10ML
INTRAVENOUS T4 PA
BELEODAQ SOLUTION RECONSTITUTED
500 MG INTRAVENOUS T4 PA
BELRAPZO SOLUTION 100 MG/4ML
INTRAVENOUS T4 PA
32
Drug Tier Requirements/Limits
bendamustine hcl solution 100 mg/4ml
intravenous T4 PA
BENDEKA SOLUTION 100 MG/4ML
INTRAVENOUS T4 PA
BESPONSA SOLUTION RECONSTITUTED
0.9 MG INTRAVENOUS T4 PA
BICNU SOLUTION RECONSTITUTED 100
MG INTRAVENOUS T4 PA
bleomycin sulfate solution reconstituted 15 unit
injection T4 PA
bleomycin sulfate solution reconstituted 30 unit
injection T4 PA
BLINCYTO SOLUTION RECONSTITUTED 35
MCG INTRAVENOUS T4 PA
bortezomib solution reconstituted 3.5 mg
intravenous T4 PA
busulfan solution 6 mg/ml intravenous T4 PA
BUSULFEX SOLUTION 6 MG/ML
INTRAVENOUS T4 PA
CAMPTOSAR SOLUTION 100 MG/5ML
INTRAVENOUS T4 PA
CAMPTOSAR SOLUTION 300 MG/15ML
INTRAVENOUS T4 PA
CAMPTOSAR SOLUTION 40 MG/2ML
INTRAVENOUS T4 PA
carmustine solution reconstituted 100 mg
intravenous T4 PA
cisplatin solution 200 mg/200ml intravenous T4 PA
cisplatin solution 50 mg/50ml intravenous T4 PA
COSMEGEN SOLUTION RECONSTITUTED
0.5 MG INTRAVENOUS T4 PA
cyclophosphamide capsule 50 mg oral T3
cyclophosphamide solution reconstituted 1 gm
injection T4 PA
cyclophosphamide solution reconstituted 2 gm
injection T4 PA
cyclophosphamide solution reconstituted 500 mg
injection T4 PA
CYRAMZA SOLUTION 100 MG/10ML
INTRAVENOUS T4 PA
cytarabine (pf) solution 100 mg/ml injection T4 PA
33
Drug Tier Requirements/Limits
cytarabine (pf) solution 20 mg/ml injection T4 PA
cytarabine solution 20 mg/ml injection T4 PA
dacarbazine solution reconstituted 100 mg
intravenous T4 PA
dacarbazine solution reconstituted 200 mg
intravenous T4 PA
DACOGEN SOLUTION RECONSTITUTED 50
MG INTRAVENOUS T4 PA
dactinomycin solution reconstituted 0.5 mg
intravenous T4 PA
DARZALEX SOLUTION 100 MG/5ML
INTRAVENOUS T4 PA
daunorubicin hcl solution 20 mg/4ml intravenous T4 PA
daunorubicin hcl solution 50 mg/10ml
intravenous T4 PA
decitabine solution reconstituted 50 mg
intravenous T4 PA
DOCEFREZ SOLUTION RECONSTITUTED 20
MG INTRAVENOUS T4 PA
docetaxel (non-alcohol) solution 20 mg/ml
intravenous T4 PA
docetaxel concentrate 160 mg/8ml intravenous T4 PA
docetaxel concentrate 20 mg/ml intravenous T4 PA
docetaxel concentrate 200 mg/10ml intravenous T4 PA
docetaxel concentrate 80 mg/4ml intravenous T4 PA
docetaxel solution 160 mg/16ml intravenous T4 PA
docetaxel solution 20 mg/2ml intravenous T4 PA
docetaxel solution 80 mg/8ml intravenous T4 PA
DOXIL INJECTABLE 2 MG/ML
INTRAVENOUS T4 PA
doxorubicin hcl liposomal injectable 2 mg/ml
intravenous T4 PA
doxorubicin hcl solution 2 mg/ml intravenous T4 PA
doxorubicin hcl solution reconstituted 10 mg
intravenous T4 PA
doxorubicin hcl solution reconstituted 50 mg
intravenous T4 PA
DROXIA CAPSULE 200 MG ORAL T3
DROXIA CAPSULE 300 MG ORAL T3
DROXIA CAPSULE 400 MG ORAL T3
34
Drug Tier Requirements/Limits
ELLENCE SOLUTION 200 MG/100ML
INTRAVENOUS T4 PA
ELLENCE SOLUTION 50 MG/25ML
INTRAVENOUS T4 PA
ELZONRIS SOLUTION 1000 MCG/ML
INTRAVENOUS T4 PA
EMPLICITI SOLUTION RECONSTITUTED
300 MG INTRAVENOUS T4 PA
EMPLICITI SOLUTION RECONSTITUTED
400 MG INTRAVENOUS T4 PA
ENHERTU T4 PA
epirubicin hcl solution 200 mg/100ml intravenous T4 PA
epirubicin hcl solution 50 mg/25ml intravenous T4 PA
ERBITUX SOLUTION 100 MG/50ML
INTRAVENOUS T4 PA
ERBITUX SOLUTION 200 MG/100ML
INTRAVENOUS T4 PA
ERWINAZE SOLUTION RECONSTITUTED
10000 UNIT INJECTION T4 PA
ETOPOPHOS SOLUTION RECONSTITUTED
100 MG INTRAVENOUS T4 PA
etoposide solution 1 gm/50ml intravenous T4 PA
EVOMELA SOLUTION RECONSTITUTED 50
MG INTRAVENOUS T4 PA
FASLODEX SOLUTION 250 MG/5ML
INTRAMUSCULAR T4 PA
FIRMAGON (240 MG DOSE) SOLUTION
RECONSTITUTED 120 MG/VIAL
SUBCUTANEOUS
T4 PA
FIRMAGON SOLUTION RECONSTITUTED
80 MG SUBCUTANEOUS T4 PA
floxuridine solution reconstituted 0.5 gm injection T4 PA
fludarabine phosphate solution 50 mg/2ml
intravenous T4 PA
fludarabine phosphate solution reconstituted 50
mg intravenous T4 PA
fluorouracil solution 1 gm/20ml intravenous T4 PA
fluorouracil solution 2.5 gm/50ml intravenous T4 PA
fluorouracil solution 5 gm/100ml intravenous T4 PA
fluorouracil solution 500 mg/10ml intravenous T4 PA
35
Drug Tier Requirements/Limits
FOLOTYN SOLUTION 20 MG/ML
INTRAVENOUS T4 PA
FOLOTYN SOLUTION 40 MG/2ML
INTRAVENOUS T4 PA
fulvestrant solution 250 mg/5ml intramuscular T4 PA
GAZYVA SOLUTION 1000 MG/40ML
INTRAVENOUS T4 PA
gemcitabine hcl solution 1 gm/10ml intravenous T4 PA
gemcitabine hcl solution 1 gm/26.3ml intravenous T4 PA
gemcitabine hcl solution 2 gm/52.6ml intravenous T4 PA
gemcitabine hcl solution 200 mg/2ml intravenous T4 PA
gemcitabine hcl solution 200 mg/5.26ml
intravenous T4 PA
gemcitabine hcl solution reconstituted 1 gm
intravenous T4 PA
gemcitabine hcl solution reconstituted 2 gm
intravenous T4 PA
gemcitabine hcl solution reconstituted 200 mg
intravenous T4 PA
GEMZAR SOLUTION RECONSTITUTED 1
GM INTRAVENOUS T4 PA
GEMZAR SOLUTION RECONSTITUTED 200
MG INTRAVENOUS T4 PA
HALAVEN SOLUTION 1 MG/2ML
INTRAVENOUS T4 PA
HERCEPTIN SOLUTION RECONSTITUTED
150 MG INTRAVENOUS T4 PA
HERCEPTIN SOLUTION RECONSTITUTED
440 MG INTRAVENOUS T4 PA
HYCAMTIN SOLUTION RECONSTITUTED 4
MG INTRAVENOUS T4 PA
hydroxyurea capsule 500 mg oral T3
IDAMYCIN PFS SOLUTION 5 MG/5ML
INTRAVENOUS T4 PA
idarubicin hcl solution 5 mg/5ml intravenous T4 PA
IFEX SOLUTION RECONSTITUTED 1 GM
INTRAVENOUS T4 PA
IFEX SOLUTION RECONSTITUTED 3 GM
INTRAVENOUS T4 PA
ifosfamide solution 1 gm/20ml intravenous T4 PA
36
Drug Tier Requirements/Limits
ifosfamide solution 3 gm/60ml intravenous T4 PA
ifosfamide solution reconstituted 1 gm
intravenous T4 PA
ifosfamide solution reconstituted 3 gm
intravenous T4 PA
IMFINZI SOLUTION 120 MG/2.4ML
INTRAVENOUS T4 PA
IMLYGIC SUSPENSION 1000000 UNIT/ML
INTRALESIONAL T4 PA
IMLYGIC SUSPENSION 100000000 UNIT/ML
INTRALESIONAL T4 PA
INTRON A SOLUTION 10000000 UNIT/ML
INJECTION T4 PA
INTRON A SOLUTION RECONSTITUTED
18000000 UNIT INJECTION T4 PA
irinotecan hcl solution 100 mg/5ml intravenous T4 PA
irinotecan hcl solution 40 mg/2ml intravenous T4 PA
irinotecan hcl solution 500 mg/25ml intravenous T4 PA
ISTODAX (OVERFILL) SOLUTION
RECONSTITUTED 10 MG INTRAVENOUS T4 PA
ISTODAX SOLUTION RECONSTITUTED 10
MG INTRAVENOUS T4 PA
IXEMPRA KIT SOLUTION RECONSTITUTED
15 MG INTRAVENOUS T4 PA
IXEMPRA KIT SOLUTION RECONSTITUTED
45 MG INTRAVENOUS T4 PA
JEVTANA SOLUTION 60 MG/1.5ML
INTRAVENOUS T4 PA
KADCYLA SOLUTION RECONSTITUTED
100 MG INTRAVENOUS T4 PA
KADCYLA SOLUTION RECONSTITUTED
160 MG INTRAVENOUS T4 PA
KANJINTI T4 PA
KEYTRUDA SOLUTION 100 MG/4ML
INTRAVENOUS T4 PA
KEYTRUDA SOLUTION RECONSTITUTED
50 MG INTRAVENOUS T4 PA
KYMRIAH SUSPENSION INTRAVENOUS T4 PA
KYPROLIS SOLUTION RECONSTITUTED 10
MG INTRAVENOUS T4 PA
37
Drug Tier Requirements/Limits
KYPROLIS SOLUTION RECONSTITUTED 30
MG INTRAVENOUS T4 PA
KYPROLIS SOLUTION RECONSTITUTED 60
MG INTRAVENOUS T4 PA
LARTRUVO SOLUTION 190 MG/19ML
INTRAVENOUS T4 PA
LARTRUVO SOLUTION 500 MG/50ML
INTRAVENOUS T4 PA
LIBTAYO SOLUTION 350 MG/7ML
INTRAVENOUS T4 PA
LUMOXITI SOLUTION RECONSTITUTED 1
MG INTRAVENOUS T4 PA
MARQIBO SUSPENSION 5 MG/31ML
INTRAVENOUS T4 PA
melphalan hcl solution reconstituted 50 mg
intravenous T4 PA
mercaptopurine tablet 50 mg oral T3
mitomycin solution reconstituted 20 mg
intravenous T4 PA
mitomycin solution reconstituted 40 mg
intravenous T4 PA
mitomycin solution reconstituted 5 mg
intravenous T4 PA
MUSTARGEN SOLUTION RECONSTITUTED
10 MG INJECTION T4 PA
MUTAMYCIN SOLUTION RECONSTITUTED
20 MG INTRAVENOUS T4 PA
MUTAMYCIN SOLUTION RECONSTITUTED
40 MG INTRAVENOUS T4 PA
MUTAMYCIN SOLUTION RECONSTITUTED
5 MG INTRAVENOUS T4 PA
MYLOTARG SOLUTION RECONSTITUTED
4.5 MG INTRAVENOUS T4 PA
NAVELBINE SOLUTION 10 MG/ML
INTRAVENOUS T4 PA
NAVELBINE SOLUTION 50 MG/5ML
INTRAVENOUS T4 PA
NIPENT SOLUTION RECONSTITUTED 10
MG INTRAVENOUS T4 PA
OGIVRI T4 PA
38
Drug Tier Requirements/Limits
ONCASPAR SOLUTION 750 UNIT/ML
INJECTION T4 PA
ONIVYDE INJECTABLE 43 MG/10ML
INTRAVENOUS T4 PA
OPDIVO SOLUTION 100 MG/10ML
INTRAVENOUS T4 PA
OPDIVO SOLUTION 240 MG/24ML
INTRAVENOUS T4 PA
OPDIVO SOLUTION 40 MG/4ML
INTRAVENOUS T4 PA
oxaliplatin solution 100 mg/20ml intravenous T4 PA
oxaliplatin solution 50 mg/10ml intravenous T4 PA
oxaliplatin solution reconstituted 100 mg
intravenous T4 PA
oxaliplatin solution reconstituted 50 mg
intravenous T4 PA
paclitaxel concentrate 100 mg/16.7ml intravenous T4 PA
paclitaxel concentrate 150 mg/25ml intravenous T4 PA
PADCEV INTRAVENOUS SOLUTION
RECONSTITUTED 20 MG T4 PA
PERJETA SOLUTION 420 MG/14ML
INTRAVENOUS T4 PA
PORTRAZZA SOLUTION 800 MG/50ML
INTRAVENOUS T4 PA
POTELIGEO SOLUTION 20 MG/5ML
INTRAVENOUS T4 PA
PROLEUKIN SOLUTION RECONSTITUTED
22000000 UNIT INTRAVENOUS T4 PA
RITUXAN HYCELA SOLUTION 1400-23400
MG -UT/11.7ML SUBCUTANEOUS T4 PA
RITUXAN HYCELA SOLUTION 1600-26800
MG -UT/13.4ML SUBCUTANEOUS T4 PA
RITUXAN SOLUTION 100 MG/10ML
INTRAVENOUS T4 PA
RITUXAN SOLUTION 500 MG/50ML
INTRAVENOUS T4 PA
romidepsin solution reconstituted 10 mg
intravenous T4 PA
SYLATRON KIT 200 MCG SUBCUTANEOUS T4 PA
SYLATRON KIT 300 MCG SUBCUTANEOUS T4 PA
SYLATRON KIT 600 MCG SUBCUTANEOUS T4 PA
39
Drug Tier Requirements/Limits
SYLVANT SOLUTION RECONSTITUTED 100
MG INTRAVENOUS T4 PA
SYLVANT SOLUTION RECONSTITUTED 400
MG INTRAVENOUS T4 PA
SYNRIBO SOLUTION RECONSTITUTED 3.5
MG SUBCUTANEOUS T4 PA
TARGRETIN GEL 1 % EXTERNAL T4 PA
TAXOTERE CONCENTRATE 20 MG/ML
INTRAVENOUS T4 PA
TAXOTERE CONCENTRATE 80 MG/4ML
INTRAVENOUS T4 PA
TECENTRIQ SOLUTION 1200 MG/20ML
INTRAVENOUS T4 PA
TECENTRIQ SOLUTION 840 MG/14ML
INTRAVENOUS T4 PA
TEMODAR SOLUTION RECONSTITUTED
100 MG INTRAVENOUS T4 PA
teniposide solution 10 mg/ml intravenous T4 PA
TEPADINA SOLUTION RECONSTITUTED
100 MG INJECTION T4 PA
TEPADINA SOLUTION RECONSTITUTED 15
MG INJECTION T4 PA
thiotepa solution reconstituted 15 mg injection T4 PA
TICE BCG SUSPENSION RECONSTITUTED
50 MG INTRAVESICAL T4 PA
TOPOSAR SOLUTION 1 GM/50ML
INTRAVENOUS T4 PA
topotecan hcl solution 4 mg/4ml intravenous T4 PA
topotecan hcl solution reconstituted 4 mg
intravenous T4 PA
TREANDA SOLUTION RECONSTITUTED
100 MG INTRAVENOUS T4 PA
TREANDA SOLUTION RECONSTITUTED 25
MG INTRAVENOUS T4 PA
TRISENOX SOLUTION 10 MG/10ML
INTRAVENOUS T4 PA
TRISENOX SOLUTION 12 MG/6ML
INTRAVENOUS T4 PA
UNITUXIN SOLUTION 17.5 MG/5ML
INTRAVENOUS T4 PA
valrubicin solution 40 mg/ml intravesical T4 PA
40
Drug Tier Requirements/Limits
VALSTAR SOLUTION 40 MG/ML
INTRAVESICAL T4 PA
VECTIBIX SOLUTION 100 MG/5ML
INTRAVENOUS T4 PA
VECTIBIX SOLUTION 400 MG/20ML
INTRAVENOUS T4 PA
VELCADE SOLUTION RECONSTITUTED 3.5
MG INJECTION T4 PA
VIDAZA SUSPENSION RECONSTITUTED
100 MG INJECTION T4 PA
vinblastine sulfate solution 1 mg/ml intravenous T4 PA
VINCASAR PFS SOLUTION 1 MG/ML
INTRAVENOUS T4 PA
vincristine sulfate solution 1 mg/ml intravenous T4 PA
vinorelbine tartrate solution 10 mg/ml
intravenous T4 PA
vinorelbine tartrate solution 50 mg/5ml
intravenous T4 PA
VYXEOS SUSPENSION RECONSTITUTED
44-100 MG INTRAVENOUS T4 PA
YERVOY SOLUTION 200 MG/40ML
INTRAVENOUS T4 PA
YERVOY SOLUTION 50 MG/10ML
INTRAVENOUS T4 PA
YESCARTA SUSPENSION INTRAVENOUS T4 PA
YONDELIS SOLUTION RECONSTITUTED 1
MG INTRAVENOUS T4 PA
ZALTRAP SOLUTION 100 MG/4ML
INTRAVENOUS T4 PA
ZALTRAP SOLUTION 200 MG/8ML
INTRAVENOUS T4 PA
ZEVALIN Y-90 KIT 3.2 MG/2ML
INTRAVENOUS T4 PA
Antitoxins,Immune
Glob,Toxoids,Vaccines
Allergenic Extracts (Therapeutic)
ORALAIR TABLET SUBLINGUAL 300 IR
SUBLINGUAL T4 PA
Antitoxins And Immune Globulins
ASCENIV T4 PA
41
Drug Tier Requirements/Limits
BIVIGAM SOLUTION 10 GM/100ML
INTRAVENOUS T4 PA
BIVIGAM SOLUTION 5 GM/50ML
INTRAVENOUS T4 PA
CARIMUNE NF SOLUTION
RECONSTITUTED 12 GM INTRAVENOUS T4 PA
CARIMUNE NF SOLUTION
RECONSTITUTED 6 GM INTRAVENOUS T4 PA
CUVITRU SOLUTION 1 GM/5ML
SUBCUTANEOUS T4 PA
CUVITRU SOLUTION 2 GM/10ML
SUBCUTANEOUS T4 PA
CUVITRU SOLUTION 4 GM/20ML
SUBCUTANEOUS T4 PA
CYTOGAM INJECTABLE 50 MG/ML
INTRAVENOUS T4 PA
FLEBOGAMMA DIF SOLUTION 10
GM/100ML INTRAVENOUS T4 PA
FLEBOGAMMA DIF SOLUTION 10
GM/200ML INTRAVENOUS T4 PA
FLEBOGAMMA DIF SOLUTION 20
GM/200ML INTRAVENOUS T4 PA
FLEBOGAMMA DIF SOLUTION 20
GM/400ML INTRAVENOUS T4 PA
FLEBOGAMMA DIF SOLUTION 5 GM/100ML
INTRAVENOUS T4 PA
FLEBOGAMMA DIF SOLUTION 5 GM/50ML
INTRAVENOUS T4 PA
GAMASTAN INJECTABLE
INTRAMUSCULAR T4 PA
GAMASTAN S/D INJECTABLE
INTRAMUSCULAR T4 PA
GAMMAGARD S/D LESS IGA SOLUTION
RECONSTITUTED 10 GM INTRAVENOUS T4 PA
GAMMAGARD S/D LESS IGA SOLUTION
RECONSTITUTED 5 GM INTRAVENOUS T4 PA
GAMMAGARD SOLUTION 1 GM/10ML
INJECTION T4 PA
GAMMAGARD SOLUTION 10 GM/100ML
INJECTION T4 PA
GAMMAGARD SOLUTION 2.5 GM/25ML
INJECTION T4 PA
42
Drug Tier Requirements/Limits
GAMMAGARD SOLUTION 20 GM/200ML
INJECTION T4 PA
GAMMAGARD SOLUTION 5 GM/50ML
INJECTION T4 PA
GAMMAKED SOLUTION 1 GM/10ML
INJECTION T4 PA
GAMMAKED SOLUTION 10 GM/100ML
INJECTION T4 PA
GAMMAKED SOLUTION 2.5 GM/25ML
INJECTION T4 PA
GAMMAKED SOLUTION 20 GM/200ML
INJECTION T4 PA
GAMMAKED SOLUTION 5 GM/50ML
INJECTION T4 PA
GAMMAPLEX SOLUTION 10 GM/100ML
INTRAVENOUS T4 PA
GAMMAPLEX SOLUTION 10 GM/200ML
INTRAVENOUS T4 PA
GAMMAPLEX SOLUTION 20 GM/200ML
INTRAVENOUS T4 PA
GAMMAPLEX SOLUTION 20 GM/400ML
INTRAVENOUS T4 PA
GAMMAPLEX SOLUTION 5 GM/100ML
INTRAVENOUS T4 PA
GAMMAPLEX SOLUTION 5 GM/50ML
INTRAVENOUS T4 PA
GAMUNEX-C SOLUTION 1 GM/10ML
INJECTION T4 PA
GAMUNEX-C SOLUTION 10 GM/100ML
INJECTION T4 PA
GAMUNEX-C SOLUTION 2.5 GM/25ML
INJECTION T4 PA
GAMUNEX-C SOLUTION 20 GM/200ML
INJECTION T4 PA
GAMUNEX-C SOLUTION 5 GM/50ML
INJECTION T4 PA
HEPAGAM B SOLUTION INJECTION T4 PA
HIZENTRA SOLUTION 1 GM/5ML
SUBCUTANEOUS T4 PA
HIZENTRA SOLUTION 10 GM/50ML
SUBCUTANEOUS T4 PA
43
Drug Tier Requirements/Limits
HIZENTRA SOLUTION 2 GM/10ML
SUBCUTANEOUS T4 PA
HIZENTRA SOLUTION 4 GM/20ML
SUBCUTANEOUS T4 PA
HYPERHEP B S/D SOLUTION
INTRAMUSCULAR T4 PA
HYPERRAB S/D SOLUTION 1500 UNIT/10ML
INJECTION T4 PA
HYPERRAB S/D SOLUTION 300 UNIT/2ML
INJECTION T4 PA
HYPERRHO S/D SOLUTION PREFILLED
SYRINGE 1500 UNIT INTRAMUSCULAR T4 PA
HYPERRHO S/D SOLUTION PREFILLED
SYRINGE 250 UNIT INTRAMUSCULAR T4 PA
HYPERTET S/D INJECTABLE 250 UNIT/ML
INTRAMUSCULAR T4 PA
HYQVIA KIT 10 GM/100ML
SUBCUTANEOUS T4 PA
HYQVIA KIT 2.5 GM/25ML
SUBCUTANEOUS T4 PA
HYQVIA KIT 20 GM/200ML
SUBCUTANEOUS T4 PA
HYQVIA KIT 30 GM/300ML
SUBCUTANEOUS T4 PA
HYQVIA KIT 5 GM/50ML SUBCUTANEOUS T4 PA
kedrab solution 1500 unit/10ml injection T4 PA
kedrab solution 300 unit/2ml injection T4 PA
MICRHOGAM ULTRA-FILTERED PLUS
SOLUTION PREFILLED SYRINGE 250 UNIT
INTRAMUSCULAR
T4 PA
NABI-HB SOLUTION INTRAMUSCULAR T4 PA
OCTAGAM SOLUTION 1 GM/20ML
INTRAVENOUS T4 PA
OCTAGAM SOLUTION 10 GM/100ML
INTRAVENOUS T4 PA
OCTAGAM SOLUTION 10 GM/200ML
INTRAVENOUS T4 PA
OCTAGAM SOLUTION 20 GM/200ML
INTRAVENOUS T4 PA
OCTAGAM SOLUTION 5 GM/100ML
INTRAVENOUS T4 PA
44
Drug Tier Requirements/Limits
OCTAGAM SOLUTION 5 GM/50ML
INTRAVENOUS T4 PA
PANZYGA SOLUTION 2.5 GM/25ML
INTRAVENOUS T4 PA
PRIVIGEN SOLUTION 10 GM/100ML
INTRAVENOUS T4 PA
PRIVIGEN SOLUTION 20 GM/200ML
INTRAVENOUS T4 PA
PRIVIGEN SOLUTION 40 GM/400ML
INTRAVENOUS T4 PA
PRIVIGEN SOLUTION 5 GM/50ML
INTRAVENOUS T4 PA
RHOGAM ULTRA-FILTERED PLUS
SOLUTION PREFILLED SYRINGE 1500 UNIT
INTRAMUSCULAR
T4 PA
RHOPHYLAC SOLUTION PREFILLED
SYRINGE 1500 UNIT/2ML INJECTION T4 PA
VARIZIG SOLUTION 125 UNIT/1.2ML
INTRAMUSCULAR T4 PA
WINRHO SDF SOLUTION 1500 UNIT/1.3ML
INJECTION T4 PA
WINRHO SDF SOLUTION 15000 UNIT/13ML
INJECTION T4 PA
WINRHO SDF SOLUTION 2500 UNIT/2.2ML
INJECTION T4 PA
WINRHO SDF SOLUTION 5000 UNIT/4.4ML
INJECTION T4 PA
XEMBIFY T4 PA
Toxoids
ADACEL SUSPENSION 5-2-15.5 LF-MCG/0.5
INTRAMUSCULAR T3 QL (15 ML per 30 days); AL
BOOSTRIX SUSPENSION 5-2.5-18.5
INTRAMUSCULAR T3 QL (15 ML per 30 days); AL
BOOSTRIX SUSPENSION 5-2.5-18.5 LF-
MCG/0.5 INTRAMUSCULAR T3 QL (15 ML per 30 days); AL
Vaccines
AFLURIA QUADRIVALENT SUSPENSION
INTRAMUSCULAR T3 QL (0.5 ML per 180 days); AL
AFLURIA QUADRIVALENT SUSPENSION
PREFILLED SYRINGE 0.5 ML
INTRAMUSCULAR
T3 QL (0.5 ML per 180 days); AL
45
Drug Tier Requirements/Limits
ENGERIX-B SUSPENSION 10 MCG/0.5ML
INJECTION T3 QL (15 ML per 30 days)
ENGERIX-B SUSPENSION 20 MCG/ML
INJECTION T3 QL (30 ML per 30 days)
FLUAD SUSPENSION PREFILLED SYRINGE
0.5 ML INTRAMUSCULAR T3 QL (0.5 ML per 180 days); AL
FLUARIX QUADRIVALENT SUSPENSION
PREFILLED SYRINGE 0.5 ML
INTRAMUSCULAR
T3 QL (0.5 ML per 180 days); AL
FLUCELVAX QUADRIVALENT
SUSPENSION INTRAMUSCULAR T3 QL (0.5 ML per 180 days); AL
FLUCELVAX QUADRIVALENT
SUSPENSION PREFILLED SYRINGE 0.5 ML
INTRAMUSCULAR
T3 QL (0.5 ML per 180 days); AL
FLULAVAL QUADRIVALENT SUSPENSION
INTRAMUSCULAR T3 QL (0.5 ML per 180 days); AL
FLULAVAL QUADRIVALENT SUSPENSION
PREFILLED SYRINGE 0.5 ML
INTRAMUSCULAR
T3 QL (0.5 ML per 180 days); AL
FLUMIST QUADRIVALENT SUSPENSION
NASAL T3 QL (1 EA per 180 days); AL
FLUZONE HIGH-DOSE SUSPENSION
PREFILLED SYRINGE 0.5 ML
INTRAMUSCULAR
T3 QL (0.5 ML per 180 days); AL
FLUZONE QUADRIVALENT SUSPENSION
0.5 ML INTRAMUSCULAR T3 QL (0.5 ML per 180 days); AL
FLUZONE QUADRIVALENT SUSPENSION
INTRAMUSCULAR T3 QL (0.5 ML per 180 days); AL
FLUZONE QUADRIVALENT SUSPENSION
PREFILLED SYRINGE 0.5 ML
INTRAMUSCULAR
T3 QL (0.5 ML per 180 days); AL
HAVRIX SUSPENSION 1440 EL U/ML
INTRAMUSCULAR T3 QL (30 ML per 30 days); AL
HAVRIX SUSPENSION 720 EL U/0.5ML
INTRAMUSCULAR T3 QL (15 ML per 30 days)
PNEUMOVAX 23 INJECTABLE 25
MCG/0.5ML INJECTION T3 QL (15 ML per 30 days); AL
PREVNAR 13 SUSPENSION
INTRAMUSCULAR T3 QL (15 ML per 30 days); AL
RECOMBIVAX HB SUSPENSION 10
MCG/ML INJECTION T3 QL (30 ML per 30 days); AL
46
Drug Tier Requirements/Limits
RECOMBIVAX HB SUSPENSION 40
MCG/ML INJECTION T3 QL (30 ML per 30 days); AL
RECOMBIVAX HB SUSPENSION 5
MCG/0.5ML INJECTION T3 QL (15 ML per 30 days)
SHINGRIX SUSPENSION RECONSTITUTED
50 MCG/0.5ML INTRAMUSCULAR T3 AL
TICE BCG SUSPENSION RECONSTITUTED
50 MG INTRAVESICAL T4 PA
TWINRIX SUSPENSION 720-20
INTRAMUSCULAR T3 QL (30 ML per 30 days); AL
TWINRIX SUSPENSION PREFILLED
SYRINGE 720-20 ELU-MCG/ML
INTRAMUSCULAR
T3 QL (30 ML per 30 days)
VAQTA SUSPENSION 25 UNIT/0.5ML
INTRAMUSCULAR T3 QL (15 ML per 30 days)
VAQTA SUSPENSION 50 UNIT/ML
INTRAMUSCULAR T3 QL (30 ML per 30 days); AL
ZOSTAVAX SUSPENSION RECONSTITUTED
19400 UNT/0.65ML SUBCUTANEOUS T3 QL (30 EA per 30 days)
Autonomic Drugs
Alpha- And Beta-Adrenergic Agonists
BROMFED DM SYRUP 30-2-10 MG/5ML
ORAL T3
brotapp dm liquid 15-1-5 mg/5ml oral T3
CONGESTAC TABLET 60-400 MG ORAL T3
gnp nasal decongestant tablet 30 mg oral T3
guaifenesin dac solution 30-10-100 mg/5ml oral T3 QL (1200 ML per 30 days)
hm mucus relief d tablet extended release 12 hour
60-600 mg oral T3
hm nasal decongestant tablet 30 mg oral T3
m-end dmx liquid 20-0.667-10 mg/5ml oral T3
MUCINEX D MAX STRENGTH TABLET
EXTENDED RELEASE 12 HOUR 120-1200
MG ORAL
T3
MUCINEX D TABLET EXTENDED RELEASE
12 HOUR 60-600 MG ORAL (OTC) T3
mucus d tablet extended release 12 hour 60-600
mg oral T3
mucus relief d tablet extended release 12 hour 60-
600 mg oral T3
47
Drug Tier Requirements/Limits
nasal decongestant max st tablet 30 mg oral T3
nasal decongestant tablet 30 mg oral T3
pseudoeph-bromphen-dm syrup 30-2-10 mg/5ml
oral (rx) T3
pseudoephedrine hcl tablet 30 mg oral (otc) T3
pseudoephedrine-guaifenesin er tablet extended
release 12 hour 60-600 mg oral T3
sm mucus relief d tablet extended release 12 hour
60-600 mg oral T3
sm nasal decongestant max st tablet 30 mg oral T3
SUDOGEST MAXIMUM STRENGTH
TABLET 30 MG ORAL T3
SUDOGEST SINUS/ALLERGY TABLET 4-60
MG ORAL T3
SUDOGEST TABLET 30 MG ORAL T3
SUDOGEST TABLET 60 MG ORAL T3
TUSNEL C SYRUP 30-10-100 MG/5ML ORAL T3
virtussin dac solution 30-10-100 mg/5ml oral T3 QL (1200 ML per 30 days)
Alpha-Adrenergic Agonists
ed bron gp liquid 5-100 mg/5ml oral T3
eql vitamin e capsule 400 unit oral T3
goodsense mucus relief child liquid 2.5-5-100
mg/5ml oral T3
goodsense tussin cf liquid 5-10-100 mg/5ml oral T3
hm tussin adult multi-symptom liquid 5-10-100
mg/5ml oral T3
MUCINEX COLD CHILDRENS LIQUID 2.5-5-
100 MG/5ML ORAL T3
MUCINEX CONGEST & COUGH CHILD
LIQUID 2.5-5-100 MG/5ML ORAL T3
MUCINEX FAST-MAX CONGEST COUGH
LIQUID 10-20-400 MG/20ML ORAL T3
MUCINEX FAST-MAX CONGEST COUGH
LIQUID 2.5-5-100 MG/5ML ORAL T3
MUCINEX STUFFY NOSE/COLD CHILD
LIQUID 2.5-100 MG/5ML ORAL T3
mucus relief childrens liquid 2.5-5-100 mg/5ml
oral T3
promethazine vc plain solution 6.25-5 mg/5ml
oral T3 QL (900 ML per 30 days)
48
Drug Tier Requirements/Limits
promethazine vc/codeine syrup 6.25-5-10 mg/5ml
oral T3 QL (120 ML per 30 days); AL
promethazine-phenyleph-codeine syrup 6.25-5-10
mg/5ml oral T3 QL (120 ML per 30 days); AL
promethazine-phenylephrine syrup 6.25-5 mg/5ml
oral T3 QL (900 ML per 30 days)
qc tussin cf liquid 5-10-100 mg/5ml oral T3
RESCON-GG LIQUID 5-100 MG/5ML ORAL T3
robafen cf multi-symptom cold liquid 5-10-100
mg/5ml oral T3
sm tussin cf liquid 5-10-100 mg/5ml oral T3
tussin cf cough & cold liquid 5-10-100 mg/5ml
oral T3
tussin cf liquid 5-10-100 mg/5ml oral T3
tussin multi-symptom cold cf liquid 5-10-100
mg/5ml oral T3
Antimuscarinics/Antispasmodics
dicyclomine hcl capsule 10 mg oral T3
dicyclomine hcl solution 10 mg/5ml oral T3
dicyclomine hcl tablet 20 mg oral T3
diphenoxylate-atropine tablet 2.5-0.025 mg oral T3
glycopyrrolate tablet 1 mg oral T3
glycopyrrolate tablet 2 mg oral T3
LOMOTIL TABLET 2.5-0.025 MG ORAL T3
propantheline bromide tablet 15 mg oral T3
Gaba-Derivative Skeletal Muscle
Relaxant
baclofen solution 10 mg/20ml intrathecal T4 PA
baclofen solution 20000 mcg/20ml intrathecal T4 PA
baclofen solution 40 mg/20ml intrathecal T4 PA
GABLOFEN SOLUTION 10000 MCG/20ML
INTRATHECAL T4 PA
GABLOFEN SOLUTION 20000 MCG/20ML
INTRATHECAL T4 PA
GABLOFEN SOLUTION 40000 MCG/20ML
INTRATHECAL T4 PA
GABLOFEN SOLUTION PREFILLED
SYRINGE 10000 MCG/20ML INTRATHECAL T4 PA
49
Drug Tier Requirements/Limits
GABLOFEN SOLUTION PREFILLED
SYRINGE 20000 MCG/20ML INTRATHECAL T4 PA
GABLOFEN SOLUTION PREFILLED
SYRINGE 40000 MCG/20ML INTRATHECAL T4 PA
GABLOFEN SOLUTION PREFILLED
SYRINGE 50 MCG/ML INTRATHECAL T4 PA
LIORESAL SOLUTION 0.05 MG/ML
INTRATHECAL T4 PA
LIORESAL SOLUTION 10 MG/20ML
INTRATHECAL T4 PA
LIORESAL SOLUTION 10 MG/5ML
INTRATHECAL T4 PA
LIORESAL SOLUTION 40 MG/20ML
INTRATHECAL T4 PA
Non-Sel.Alpha-1-Adrenergic Blocking
Agts
MINIPRESS CAPSULE 1 MG ORAL T3
MINIPRESS CAPSULE 2 MG ORAL T3
MINIPRESS CAPSULE 5 MG ORAL T3
prazosin hcl capsule 1 mg oral T3
prazosin hcl capsule 2 mg oral T3
prazosin hcl capsule 5 mg oral T3
Non-Sel.Alpha-Adrenergic Blocking
Agents
DIBENZYLINE CAPSULE 10 MG ORAL T3 PA
phenoxybenzamine hcl capsule 10 mg oral T3 PA
Parasympathomimetic (Cholinergic
Agents)
bethanechol chloride tablet 10 mg oral T3
bethanechol chloride tablet 25 mg oral T3
bethanechol chloride tablet 5 mg oral T3
bethanechol chloride tablet 50 mg oral T3
MESTINON SOLUTION 60 MG/5ML ORAL T3
MESTINON TABLET 60 MG ORAL T3 AL
MESTINON TABLET EXTENDED RELEASE
180 MG ORAL T3 AL
pyridostigmine bromide er tablet extended release
180 mg oral T3 AL
pyridostigmine bromide solution 60 mg/5ml oral T3
50
Drug Tier Requirements/Limits
pyridostigmine bromide tablet 60 mg oral T3 AL
URECHOLINE TABLET 10 MG ORAL T3
URECHOLINE TABLET 25 MG ORAL T3
URECHOLINE TABLET 5 MG ORAL T3
URECHOLINE TABLET 50 MG ORAL T3
Blood Formation, Coagulation,
Thrombosis
Antianemia Drugs
REBLOZYL T4 PA
Antihemorrhagic Agents, Miscellaneous
ANDEXXA SOLUTION RECONSTITUTED
100 MG INTRAVENOUS T4 PA
ANDEXXA SOLUTION RECONSTITUTED
200 MG INTRAVENOUS T4 PA
Antithrombotic Agents, Miscellaneous
CABLIVI KIT 11 MG INJECTION T4 PA
Blood Form.,Coag,Thrombosis Agents
Misc.
ADAKVEO T4 PA
OXBRYTA T4 PA
Hematopoietic Agents
MOZOBIL SOLUTION 24 MG/1.2ML
SUBCUTANEOUS T4 PA; QL (72 ML per 30 days)
REBLOZYL T4 PA
Hemorrheologic Agents
pentoxifylline er tablet extended release 400 mg
oral T3
Hemostatics
AMICAR SOLUTION 0.25 GM/ML ORAL T3
AMICAR TABLET 500 MG ORAL T3 PA
aminocaproic acid tablet 500 mg oral T3 PA
DDAVP RHINAL TUBE SOLUTION 0.01 %
NASAL T3 PA
DDAVP TABLET 0.1 MG ORAL T3 AL
DDAVP TABLET 0.2 MG ORAL T3 AL
desmopressin ace spray refrig solution 0.01 %
nasal T3 PA
51
Drug Tier Requirements/Limits
desmopressin acetate tablet 0.1 mg oral T3 AL
desmopressin acetate tablet 0.2 mg oral T3 AL
STIMATE SOLUTION 1.5 MG/ML NASAL T3 PA
Heparins
heparin sodium (porcine) solution 10000 unit/ml
injection T3
heparin sodium (porcine) solution 5000 unit/ml
injection T3
Iron Preparations
a thru z advanced tablet oral T3
a thru z advantage tablet oral T3
a thru z select ultimate women tablet oral T3
a thru z ultimate mens tablet oral T3
ADVANCED MULTI EA TABLET
CHEWABLE ORAL T3
ALIVE WOMENS ENERGY TABLET ORAL T3
BACMIN TABLET ORAL T3
bariatric multivitamins/iron capsule oral T3
BIO-35 GLUTEN-FREE CAPSULE ORAL T3
BIOTECT PLUS LIQUID ORAL T3
b-plex plus tablet oral T3
BPROTECTED MULTI-VITE LIQUID ORAL T3
CALCET PLUS TABLET ORAL T3
centamin liquid oral T3
centavite a-z complete-mineral tablet oral T3
central-vite tablet oral T3
centravites adults tablet oral T3
centravites tablet oral T3
CENTRUM ADULTS TABLET ORAL T3
CENTRUM LIQUID ORAL T3
CENTRUM MEN TABLET ORAL T3
CENTRUM PERFORMANCE TABLET ORAL T3
CENTRUM SILVER 50+WOMEN TABLET
ORAL T3
CENTRUM SILVER ULTRA WOMENS
TABLET ORAL T3
CENTRUM SPECIALIST ENERGY TABLET
ORAL T3
52
Drug Tier Requirements/Limits
CENTRUM TABLET CHEWABLE ORAL T3
CENTRUM TABLET ORAL T3
CENTRUM ULTRA MENS TABLET ORAL T3
CENTRUM ULTRA WOMENS TABLET
ORAL T3
century tablet oral T3
CEROVITE ADVANCED FORMULA LIQUID
ORAL T3
CEROVITE ADVANCED FORMULA TABLET
ORAL T3
certa plus tablet oral T3
certagen liquid† oral T3
certagen tablet oral T3
CERTAVITE/ANTIOXIDANTS LIQUID ORAL T3
CERTAVITE/ANTIOXIDANTS TABLET
ORAL T3
CHROMAGEN FA TABLET 70-150-2-1 MG
ORAL T3
CHROMAGEN FORTE TABLET 50-101-1 MG
ORAL T3
CHROMAGEN TABLET 70 MG ORAL T3
COMPETE TABLET ORAL T3
complete multivitamin/mineral liquid oral T3
complete tablet oral T3
cvs daily multiple fe/ca/zn tablet oral T3
cvs daily multiple for women tablet oral T3
cvs daily multiple plus iron tablet oral T3
cvs daily teen tablet oral T3
cvs one daily womens formula tablet oral T3
cvs slow release iron tablet extended release 143
(45 fe) mg oral T3
cvs slow release iron tablet extended release 45
mg oral T3
cvs spectravite advanced liquid oral T3
cvs spectravite advanced tablet oral T3
cvs spectravite energy tablet oral T3
cvs spectravite naturalized tablet oral T3
cvs spectravite performance tablet oral T3
53
Drug Tier Requirements/Limits
cvs spectravite plus tablet oral T3
cvs spectravite probiotic tablet oral T3
cvs spectravite tablet oral T3
cvs spectravite ultra mens tablet oral T3
cvs spectravite ultra women tablet oral T3
cvs spectravite womens senior tablet oral T3
cvs womens active daily tablet oral T3
daily combo multi vitamins tablet oral T3
daily combo multivits/calcium tablet oral T3
daily multi tablet oral T3
daily multiple vitamins/iron tablet oral T3
daily multiple weight loss tablet oral T3
daily vitamin formula+iron tablet oral T3
daily vite multivitamin/iron tablet oral T3
daily vites/iron tablet oral T3
daily-vite/iron/beta-carotene tablet oral T3
dekas bariatric tablet chewable oral T3
eq complete multivitamin-adult tablet oral T3
eq one daily womens health tablet oral T3
eq slow-release iron tablet extended release 45
mg oral T3
EQL CENTRAL-VITE PERFORMANCE
TABLET ORAL T3
EQL CENTRAL-VITE SELECT TABLET
ORAL T3
eql century mens tablet oral T3
eql iron supplement therapy tablet 325 mg oral T3
eql one daily diet support tablet oral T3
eql one daily dieters support tablet oral T3
eql one daily maximum tablet oral T3
eql one daily womens tablet oral T3
eql slow release iron tablet extended release 160
(50 fe) mg oral T3
eql ultimate womens century tablet oral T3
ESSENTIA TABLET ORAL T3
essential balance tablet oral T3
feasp-fefum -suc-c-thre-b12-fa tablet 50-101-1 mg
oral T3
54
Drug Tier Requirements/Limits
fer-gen-sol solution 75 (15 fe) mg/0.6ml oral T3
fer-iron solution 75 (15 fe) mg/ml oral T3
ferrous gluconate tablet 225 (27 fe) mg oral T3
ferrous gluconate tablet 324 (37.5 fe) mg oral T3
ferrous gluconate tablet 325 mg oral T3
ferrous sulfate cr tablet extendedrelease* 160 (50
fe) mg oral T3
ferrous sulfate er tablet extended release 140 (45
fe) mg oral T3
ferrous sulfate powder (otc) T3
ferrous sulfate powder (rx) T3
ferrous sulfate solution 75 (15 fe) mg/0.6ml oral T3
ferrous sulfate syrup 300 (60 fe) mg/5ml oral T3
ferrous sulfate tablet 83 mg oral T3
ferrovite fa tablet 70-150-2-1 mg oral T3
FERROVITE FORTE TABLET 50-101-1 MG
ORAL T3
FERROVITE TABLET 70 MG ORAL T3
fe-succ-c-thre-b12-des stomach tablet 70 mg oral T3
formula b plus tablet oral T3
FORTAVIT CAPSULE ORAL T3
freedavite tablet oral T3
generix t tablet oral T3
gnp century active performance tablet oral T3
gnp century energy metabolism tablet oral T3
gnp century tablet oral T3
gnp century ultimate mens tablet oral T3
gnp century ultimate womens tablet oral T3
gnp hair/skin/nails tablet oral T3
gnp maximum one daily tablet oral T3
gnp mega multi for women tablet oral T3
gnp one daily maximum tablet oral T3
gnp one daily plus iron tablet oral T3
gnp one daily womens health tablet oral T3
gnp slow release iron tablet extended release 47.5
mg oral T3
gnp therapeutic m complete tablet oral T3
55
Drug Tier Requirements/Limits
gnp therapeutic-m tablet oral T3
gnp womens one daily tablet oral T3
golden age vitamin/minerals liquid oral T3
hair formula extra strength tablet oral T3
hair vitamins tablet oral T3
hair/skin/nails tablet oral T3
hair/skin/nails/biotin tablet oral T3
hm complete 50+ women ultimate tablet oral T3
hm complete men tablet oral T3
hm complete tablet oral T3
hm complete women tablet oral T3
hm iron slow release tablet extended release 142
(45 fe) mg oral T3
hm one daily womens tablet oral T3
hm one daily/iron tablet oral T3
iron (ferrous gluconate) tablet 256 (28 fe) mg
oral T3
iron slow release tablet extended release 140 (45
fe) mg oral T3
iron supplement tablet 325 (65 fe) mg oral T3
iron tablet 240 (27 fe) mg oral T3
iron tablet 28 mg oral T3
iron tablet 90 (18 fe) mg oral T3
iron tablet extended release 18 mg oral T3
iron tablet extendedrelease* 160 (50 fe) mg oral T3
kp adults daily formula tablet oral T3
kp ferrous gluconate tablet 324 (37.5 fe) mg oral T3
kp womens daily formula tablet oral T3
K-PAX IMMUNE PROFESSIONAL ST
TABLET ORAL T3
mega multivitamin for women tablet oral T3
MEGAVITE RX TABLET ORAL T3
meijer advanced formula tablet oral T3
multi complete/iron tablet oral T3
multi for her capsule oral T3
multi for her tablet oral T3
multi max tablet oral T3
56
Drug Tier Requirements/Limits
multi vitamin/minerals tablet oral T3
multi-day plus iron tablet oral T3
multi-day plus minerals tablet oral T3
multi-delyn/iron liquid oral T3
MULTIGEN FOLIC TABLET 70-150-2-1 MG
ORAL T3
MULTIGEN PLUS TABLET 50-101-1 MG
ORAL T3
MULTIGEN TABLET 70 MG ORAL T3
multilex tablet oral T3
multilex-t&m tablet oral T3
multiple vitamins/iron tablet oral T3
multiple vitamins/womens tablet oral T3
multi-vit/fluoride/iron solution 0.25-10 mg/ml
oral T3
multi-vit/iron/fluoride solution 0.25-10 mg/ml
oral T3
multivital performance tablet oral T3
multivitamin & mineral liquid oral T3
multivitamin adult tablet oral T3
multivitamin adults tablet oral T3
multivitamin liquid oral T3
multi-vitamin monocaps tablet oral T3
multivitamin women 50+ tablet oral T3
multivitamin women tablet oral T3
multivitamin/fluoride/iron solution 0.25-10 mg/ml
oral T3
multi-vitamin/fluoride/iron solution 0.25-10
mg/ml oral T3
multivitamins/minerals adult liquid oral T3
multi-vite liquid oral T3
NUTRICAP TABLET ORAL T3
NUTRIVIT LIQUID ORAL T3
OCUVITE EXTRA TABLET ORAL T3
once daily/iron tablet oral T3
one daily calcium/iron tablet oral T3
one daily complete tablet oral T3
one daily for women tablet oral T3
57
Drug Tier Requirements/Limits
one daily healthy weight adv tablet oral T3
one daily maximum tablet oral T3
one daily multivitamin/iron tablet oral T3
ONE DAILY PLUS IRON TABLET ORAL T3
one daily plus minerals tablet oral T3
one daily/iron tablet oral T3
ONE-A-DAY ENERGY TABLET ORAL T3
ONE-A-DAY TEEN ADVANTAGE/HER
TABLET ORAL T3
ONE-A-DAY TEEN ADVANTAGE/HIM
TABLET ORAL T3
ONE-A-DAY WEIGHT SMART ADVANCE
TABLET ORAL T3
ONE-A-DAY WOMENS FORMULA TABLET
ORAL T3
ONE-A-DAY WOMENS HEALTHY SKIN
TABLET ORAL T3
ONE-A-DAY WOMENS MIND & BODY
TABLET ORAL T3
ONE-A-DAY WOMENS PETITES TABLET
ORAL T3
one-daily/iron tablet oral T3
one-tablet-daily/iron tablet oral T3
OPTISOURCE POST BARIATRIC SURG
TABLET CHEWABLE ORAL T3
OPTISOURCE TABLET CHEWABLE ORAL T3
OPURITY BYPASS OPTIMIZED TABLET
CHEWABLE ORAL T3
parvlex tablet oral T3
polyvitamin/iron tablet chewable 18 mg oral T3 AL
PROCERV HP TABLET ORAL T3
PRORENAL + D TABLET ORAL T3
PRORENAL + D W/ OMEGA-3 CAPSULE
ORAL T3
PROTECT PLUS CAPSULE ORAL T3
PROTECT PLUS LIQUID ORAL T3
PROTECT PLUS NF LIQUID ORAL T3
px iron tablet 200 (65 fe) mg oral T3
px iron tablet 27 mg oral T3
58
Drug Tier Requirements/Limits
qc daily multivit/multimineral tablet oral T3
qc daily multivitamins/iron tablet oral T3
qc ferrous sulfate tablet 325 (65 fe) mg oral T3
qc multi-vite tablet oral T3
qc therin-m tablet oral T3
qc womens daily multivitamin tablet oral T3
quintabs-m tablet oral T3
ra central-vite energy tablet oral T3
ra central-vite performance tablet oral T3
RA CENTRAL-VITE SELECT TABLET ORAL T3
RA CENTRAL-VITE TABLET ORAL T3
ra central-vite under 50 mens tablet oral T3
ra central-vite under 50 women tablet oral T3
ra central-vite womens mature tablet oral T3
ra high potency iron tablet 27 mg oral T3
ra iron tablet 27 mg oral T3
ra one daily maximum tablet oral T3
ra one daily multi-vit plus fe tablet oral T3
ra one daily womens tablet oral T3
ra slow release iron tablet extended release 45
mg oral T3
ra slow release iron tablet extended release 47.5
mg oral T3
ra therapeutic m plus beta car tablet oral T3
sentry tablet oral T3
SIDEROL LIQUID† ORAL T3
SIDEROL TABLET ORAL T3
slow iron tablet extended release 160 (50 fe) mg
oral T3
slow release iron tablet extended release 160 (50
fe) mg oral T3
slow release iron tablet extended release 47.5 mg
oral T3
slow release iron tablet extended release 50 mg
oral T3
sm complete 50+ ultimate women tablet oral T3
sm complete advanced formula tablet oral T3
sm complete tablet oral T3
59
Drug Tier Requirements/Limits
sm iron slow release tablet extended release 160
(50 fe) mg oral T3
sm multiple vitamins/iron tablet oral T3
sm one daily womens tablet oral T3
sm slow release iron tablet extended release 142
(45 fe) mg oral T3
sm slow release iron tablet extended release 143
(45 fe) mg oral T3
sm therapeutic-m tablet oral T3
stress formula/iron tablet oral T3
STROVITE FORTE TABLET ORAL T3
STROVITE PLUS TABLET ORAL T3
TAB-A-VITE TABLET ORAL T3
TAB-A-VITE WOMENS TABLET ORAL T3
tab-a-vite/iron tablet oral T3
TAB-A-VITE/WEIGHTSLIM TABLET ORAL T3
th b complex/iron/c/e tablet oral T3
th daily multiple vitamin/iron tablet oral T3
th premium daily multiple tablet oral T3
th theradex-m tablet oral T3
th womens daily tablet oral T3
THERA M PLUS TABLET ORAL T3
THERAGRAN-M ADVANCED TABLET
ORAL T3
THERAGRAN-M PREMIER TABLET ORAL T3
THERAGRAN-M TABLET ORAL T3
thera-m tablet oral T3
therapeutic formula/hematinics tablet oral T3
therapeutic m tablet oral T3
therapeutic-m tablet oral T3
therapeutic-m/lutein tablet oral T3
thera-tabs m tablet oral T3
THERATRUM COMPLETE TABLET ORAL T3
therems m tablet oral T3
THEREMS-H TABLET ORAL T3
THEREMS-M TABLET ORAL T3
therobec plus tablet oral T3
60
Drug Tier Requirements/Limits
trimagen fa tablet 70-150-2-1 mg oral T3
trimagen forte tablet 50-101-1 mg oral T3
trimagen tablet 70 mg oral T3
tri-vit/fluoride/iron solution 0.25-10 mg/ml oral T3
ultimate teen tablet oral T3
ultra freeda/iron tablet oral T3
unicomplex-m tablet oral T3
VITA S FORTE TABLET ORAL T3
vitagen advance tablet 70 mg oral T3
vitagen forte tablet 50-101-1 mg oral T3
vitamin-mineral supplement liquid oral T3
vitamins for hair tablet oral T3
VITATRUM COMPLETE TABLET ORAL T3
vitatrum tablet chewable oral T3
womens daily form/fa/ca/fe tablet oral T3
womens daily formula tablet oral T3
womens multi capsule oral T3
womens one daily tablet oral T3
YELETS TEENAGE FORMULA TABLET
ORAL T3
Platelet-Aggregation Inhibitors
adult aspirin regimen tablet delayed release 81
mg oral T3
aspirin 81 tablet delayed release 81 mg oral T3
aspirin adult low dose tablet delayed release 81
mg oral T3
aspirin adult low strength tablet chewable 81 mg
oral T3
aspirin adult tablet 325 mg oral T3 QL (360 EA per 30 days)
aspirin ec low dose tablet delayed release 81 mg
oral T3
aspirin ec low strength tablet delayed release 81
mg oral T3
aspirin ec tablet delayed release 325 mg oral T3
aspirin ec tablet delayed release 81 mg oral T3
aspirin low dose adult tablet chewable 81 mg oral T3
aspirin low dose tablet chewable 81 mg oral T3
61
Drug Tier Requirements/Limits
aspirin low dose tablet delayed release 81 mg
oral T3
aspirin low strength tablet chewable 81 mg oral T3
aspirin regimen low dose adult tablet delayed
release 81 mg oral T3
aspirin suppository 300 mg rectal T3 QL (180 EA per 30 days)
aspirin suppository 600 mg rectal T3 QL (180 EA per 30 days)
aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
aspirin tablet chewable 81 mg oral T3
aspirin tablet delayed release 81 mg oral T3
ASPIR-LOW TABLET DELAYED RELEASE
81 MG ORAL T3
childrens aspirin low strength tablet chewable 81
mg oral T3
cilostazol tablet 100 mg oral T3 QL (60 EA per 30 days)
cilostazol tablet 50 mg oral T3 QL (60 EA per 30 days)
ECPIRIN TABLET DELAYED RELEASE 325
MG ORAL T3
eq aspirin tablet delayed release 325 mg oral T3
gnp adult aspirin low strength tablet chewable 81
mg oral T3
gnp aspirin low dose tablet delayed release 81 mg
oral T3
gnp aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
gnp aspirin tablet delayed release 325 mg oral T3
gnp aspirin tablet delayed release 81 mg oral T3
goodsense aspirin adult low st tablet chewable 81
mg oral T3
goodsense aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
goodsense aspirin tablet chewable 81 mg oral T3
hm aspirin ec low dose tablet delayed release 81
mg oral T3
hm aspirin ec tablet delayed release 325 mg oral T3
hm aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
hm aspirin tablet chewable 81 mg oral T3
qc aspirin low dose tablet chewable 81 mg oral T3
qc aspirin low dose tablet delayed release 81 mg
oral T3
qc aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
62
Drug Tier Requirements/Limits
qc enteric aspirin tablet delayed release 325 mg
oral T3
sb aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
sm aspirin adult low strength tablet chewable 81
mg oral T3
sm aspirin adult low strength tablet delayed
release 81 mg oral T3
sm aspirin ec tablet delayed release 325 mg oral T3
sm aspirin low dose tablet chewable 81 mg oral T3
sm aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
sm childrens aspirin tablet chewable 81 mg oral T3
ST JOSEPH LOW DOSE TABLET
CHEWABLE 81 MG ORAL T3
ST JOSEPH LOW DOSE TABLET DELAYED
RELEASE 81 MG ORAL T3
ticlopidine hcl tablet 250 mg oral T3 QL (60 EA per 30 days)
Thrombolytic Agents
ACTIVASE SOLUTION RECONSTITUTED
100 MG INTRAVENOUS T4 PA
ACTIVASE SOLUTION RECONSTITUTED 50
MG INTRAVENOUS T4 PA
adult aspirin regimen tablet delayed release 81
mg oral T3
aspirin 81 tablet delayed release 81 mg oral T3
aspirin adult low dose tablet delayed release 81
mg oral T3
aspirin adult low strength tablet chewable 81 mg
oral T3
aspirin adult tablet 325 mg oral T3 QL (360 EA per 30 days)
aspirin ec low dose tablet delayed release 81 mg
oral T3
aspirin ec low strength tablet delayed release 81
mg oral T3
aspirin ec tablet delayed release 325 mg oral T3
aspirin ec tablet delayed release 81 mg oral T3
aspirin low dose adult tablet chewable 81 mg oral T3
aspirin low dose tablet chewable 81 mg oral T3
aspirin low dose tablet delayed release 81 mg
oral T3
63
Drug Tier Requirements/Limits
aspirin low strength tablet chewable 81 mg oral T3
aspirin regimen low dose adult tablet delayed
release 81 mg oral T3
aspirin suppository 300 mg rectal T3 QL (180 EA per 30 days)
aspirin suppository 600 mg rectal T3 QL (180 EA per 30 days)
aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
aspirin tablet chewable 81 mg oral T3
aspirin tablet delayed release 81 mg oral T3
ASPIR-LOW TABLET DELAYED RELEASE
81 MG ORAL T3
CATHFLO ACTIVASE SOLUTION
RECONSTITUTED 2 MG INJECTION T4 PA
childrens aspirin low strength tablet chewable 81
mg oral T3
ECPIRIN TABLET DELAYED RELEASE 325
MG ORAL T3
eq aspirin tablet delayed release 325 mg oral T3
gnp adult aspirin low strength tablet chewable 81
mg oral T3
gnp aspirin low dose tablet delayed release 81 mg
oral T3
gnp aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
gnp aspirin tablet delayed release 325 mg oral T3
gnp aspirin tablet delayed release 81 mg oral T3
goodsense aspirin adult low st tablet chewable 81
mg oral T3
goodsense aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
goodsense aspirin tablet chewable 81 mg oral T3
hm aspirin ec low dose tablet delayed release 81
mg oral T3
hm aspirin ec tablet delayed release 325 mg oral T3
hm aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
hm aspirin tablet chewable 81 mg oral T3
qc aspirin low dose tablet chewable 81 mg oral T3
qc aspirin low dose tablet delayed release 81 mg
oral T3
qc aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
qc enteric aspirin tablet delayed release 325 mg
oral T3
64
Drug Tier Requirements/Limits
sb aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
sm aspirin adult low strength tablet chewable 81
mg oral T3
sm aspirin adult low strength tablet delayed
release 81 mg oral T3
sm aspirin ec tablet delayed release 325 mg oral T3
sm aspirin low dose tablet chewable 81 mg oral T3
sm aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
sm childrens aspirin tablet chewable 81 mg oral T3
ST JOSEPH LOW DOSE TABLET
CHEWABLE 81 MG ORAL T3
ST JOSEPH LOW DOSE TABLET DELAYED
RELEASE 81 MG ORAL T3
Cardiovascular Drugs
Alpha-Adrenergic Blocking Agents
MINIPRESS CAPSULE 1 MG ORAL T3
MINIPRESS CAPSULE 2 MG ORAL T3
MINIPRESS CAPSULE 5 MG ORAL T3
prazosin hcl capsule 1 mg oral T3
prazosin hcl capsule 2 mg oral T3
prazosin hcl capsule 5 mg oral T3
Alpha-Adrenergic Blocking
Agt.(Hypoten)
MINIPRESS CAPSULE 1 MG ORAL T3
MINIPRESS CAPSULE 2 MG ORAL T3
MINIPRESS CAPSULE 5 MG ORAL T3
prazosin hcl capsule 1 mg oral T3
prazosin hcl capsule 2 mg oral T3
prazosin hcl capsule 5 mg oral T3
Antiarrhythmics, Miscellaneous
DIGITEK TABLET 125 MCG ORAL T3
DIGITEK TABLET 250 MCG ORAL T3
DIGOX TABLET 125 MCG ORAL T3
DIGOX TABLET 250 MCG ORAL T3
digoxin solution 0.05 mg/ml oral T3
digoxin tablet 125 mcg oral T3
digoxin tablet 250 mcg oral T3
65
Drug Tier Requirements/Limits
LANOXIN TABLET 125 MCG ORAL T3
LANOXIN TABLET 250 MCG ORAL T3
Carbonic Anhydrase
Inhibitors(Hypoten)
acetazolamide er capsule extended release 12
hour 500 mg oral T3
acetazolamide tablet 125 mg oral T3
acetazolamide tablet 250 mg oral T3
DIAMOX SEQUELS CAPSULE EXTENDED
RELEASE 12 HOUR 500 MG ORAL T3
Cardiac Drugs, Miscellaneous
VYNDAMAX T4 PA
VYNDAQEL T4 PA
Cardiotonic Agents
DIGITEK TABLET 125 MCG ORAL T3
DIGITEK TABLET 250 MCG ORAL T3
DIGOX TABLET 125 MCG ORAL T3
DIGOX TABLET 250 MCG ORAL T3
digoxin solution 0.05 mg/ml oral T3
digoxin tablet 125 mcg oral T3
digoxin tablet 250 mcg oral T3
LANOXIN TABLET 125 MCG ORAL T3
LANOXIN TABLET 250 MCG ORAL T3
milrinone lactate solution 10 mg/10ml
intravenous T4 PA
Class Ia Antiarrhythmics
disopyramide phosphate capsule 100 mg oral T3
disopyramide phosphate capsule 150 mg oral T3
NORPACE CAPSULE 100 MG ORAL T3
NORPACE CAPSULE 150 MG ORAL T3
NORPACE CR CAPSULE EXTENDED
RELEASE 12 HOUR 100 MG ORAL T3
NORPACE CR CAPSULE EXTENDED
RELEASE 12 HOUR 150 MG ORAL T3
quinidine gluconate er tablet extended release
324 mg oral T3
Class Ib Antiarrhythmics
66
Drug Tier Requirements/Limits
mexiletine hcl capsule 150 mg oral T3
mexiletine hcl capsule 200 mg oral T3
mexiletine hcl capsule 250 mg oral T3
Class Ic Antiarrhythmics
flecainide acetate tablet 100 mg oral T3
flecainide acetate tablet 150 mg oral T3
flecainide acetate tablet 50 mg oral T3
propafenone hcl tablet 150 mg oral T3
propafenone hcl tablet 225 mg oral T3
propafenone hcl tablet 300 mg oral T3
Class Iii Antiarrhythmics
amiodarone hcl tablet 100 mg oral T3
amiodarone hcl tablet 200 mg oral T3
MULTAQ TABLET 400 MG ORAL T3 PA; QL (60 EA per 30 days)
PACERONE TABLET 100 MG ORAL T3
PACERONE TABLET 200 MG ORAL T3
Direct Vasodilators
hydralazine hcl tablet 10 mg oral T3
hydralazine hcl tablet 100 mg oral T3
hydralazine hcl tablet 25 mg oral T3
hydralazine hcl tablet 50 mg oral T3
minoxidil tablet 10 mg oral T3
minoxidil tablet 2.5 mg oral T3
Diuretics, Miscellaneous (Hypotensive)
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 100 MG ORAL T3
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 200 MG ORAL T3
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 400 MG ORAL T3
theophylline er tablet extended release 12 hour
200 mg oral T3
theophylline er tablet extended release 12 hour
300 mg oral T3
theophylline er tablet extended release 24 hour
400 mg oral T3
theophylline er tablet extended release 24 hour
600 mg oral T3
67
Drug Tier Requirements/Limits
Hypotensive Agents, Miscellaneous
DIBENZYLINE CAPSULE 10 MG ORAL T3 PA
phenoxybenzamine hcl capsule 10 mg oral T3 PA
Loop Diuretics (Hypotensive Agents)
bumetanide tablet 0.5 mg oral T3
bumetanide tablet 1 mg oral T3
bumetanide tablet 2 mg oral T3
DEMADEX TABLET 10 MG ORAL T3
DEMADEX TABLET 20 MG ORAL T3
furosemide solution 10 mg/ml oral T3
furosemide solution 8 mg/ml oral T3
furosemide tablet 20 mg oral T3
furosemide tablet 40 mg oral T3
furosemide tablet 80 mg oral T3
LASIX TABLET 20 MG ORAL T3
LASIX TABLET 40 MG ORAL T3
LASIX TABLET 80 MG ORAL T3
torsemide tablet 10 mg oral T3
torsemide tablet 100 mg oral T3
torsemide tablet 20 mg oral T3
torsemide tablet 5 mg oral T3
Mineralocorticoid (Aldosterone)
Antagnts
ALDACTAZIDE TABLET 25-25 MG ORAL T3
ALDACTONE TABLET 100 MG ORAL T3
ALDACTONE TABLET 25 MG ORAL T3
ALDACTONE TABLET 50 MG ORAL T3
spironolactone tablet 100 mg oral T3
spironolactone tablet 25 mg oral T3
spironolactone tablet 50 mg oral T3
spironolactone-hctz tablet 25-25 mg oral T3
Mineralocorticoid(Aldoster.)Antag(Hyp
ot)
ALDACTAZIDE TABLET 25-25 MG ORAL T3
ALDACTONE TABLET 100 MG ORAL T3
ALDACTONE TABLET 25 MG ORAL T3
68
Drug Tier Requirements/Limits
ALDACTONE TABLET 50 MG ORAL T3
spironolactone tablet 100 mg oral T3
spironolactone tablet 25 mg oral T3
spironolactone tablet 50 mg oral T3
spironolactone-hctz tablet 25-25 mg oral T3
Phosphodiesterase Type 5 Inhibitors
cilostazol tablet 100 mg oral T3 QL (60 EA per 30 days)
cilostazol tablet 50 mg oral T3 QL (60 EA per 30 days)
Potassium-Sparing Diuretics (Hypoten)
ALDACTAZIDE TABLET 25-25 MG ORAL T3
ALDACTONE TABLET 100 MG ORAL T3
ALDACTONE TABLET 25 MG ORAL T3
ALDACTONE TABLET 50 MG ORAL T3
amiloride hcl tablet 5 mg oral T3
amiloride-hydrochlorothiazide tablet 5-50 mg
oral T3
DYAZIDE CAPSULE 37.5-25 MG ORAL T3
MAXZIDE TABLET 75-50 MG ORAL T3
MAXZIDE-25 TABLET 37.5-25 MG ORAL T3
spironolactone tablet 100 mg oral T3
spironolactone tablet 25 mg oral T3
spironolactone tablet 50 mg oral T3
spironolactone-hctz tablet 25-25 mg oral T3
triamterene-hctz capsule 37.5-25 mg oral T3
triamterene-hctz tablet 37.5-25 mg oral T3
triamterene-hctz tablet 75-50 mg oral T3
Thiazide Diuretics(Hypotensive Agents)
ALDACTAZIDE TABLET 25-25 MG ORAL T3
amiloride-hydrochlorothiazide tablet 5-50 mg
oral T3
chlorothiazide tablet 250 mg oral T3
chlorothiazide tablet 500 mg oral T3
DIURIL SUSPENSION 250 MG/5ML ORAL T3
DYAZIDE CAPSULE 37.5-25 MG ORAL T3
hydrochlorothiazide capsule 12.5 mg oral T3
hydrochlorothiazide tablet 12.5 mg oral T3
hydrochlorothiazide tablet 25 mg oral T3
69
Drug Tier Requirements/Limits
hydrochlorothiazide tablet 50 mg oral T3
MAXZIDE TABLET 75-50 MG ORAL T3
MAXZIDE-25 TABLET 37.5-25 MG ORAL T3
MICROZIDE CAPSULE 12.5 MG ORAL T3
spironolactone-hctz tablet 25-25 mg oral T3
triamterene-hctz capsule 37.5-25 mg oral T3
triamterene-hctz tablet 37.5-25 mg oral T3
triamterene-hctz tablet 75-50 mg oral T3
Thiazide-Like Diuretics(Hypotensive
Agt)
chlorthalidone tablet 25 mg oral T3
chlorthalidone tablet 50 mg oral T3
indapamide tablet 1.25 mg oral T3
indapamide tablet 2.5 mg oral T3
metolazone tablet 10 mg oral T3
metolazone tablet 2.5 mg oral T3
metolazone tablet 5 mg oral T3
Vasodilating Agents, Miscellaneous
epoprostenol sodium solution reconstituted 0.5
mg intravenous T4 PA
epoprostenol sodium solution reconstituted 1.5
mg intravenous T4 PA
FLOLAN SOLUTION RECONSTITUTED 0.5
MG INTRAVENOUS T4 PA
FLOLAN SOLUTION RECONSTITUTED 1.5
MG INTRAVENOUS T4 PA
REMODULIN SOLUTION 100 MG/20ML
INJECTION T4 PA
REMODULIN SOLUTION 20 MG/20ML
INJECTION T4 PA
REMODULIN SOLUTION 200 MG/20ML
INJECTION T4 PA
REMODULIN SOLUTION 50 MG/20ML
INJECTION T4 PA
treprostinil solution 100 mg/20ml injection T4 PA
treprostinil solution 20 mg/20ml injection T4 PA
treprostinil solution 200 mg/20ml injection T4 PA
treprostinil solution 50 mg/20ml injection T4 PA
70
Drug Tier Requirements/Limits
VELETRI SOLUTION RECONSTITUTED 0.5
MG INTRAVENOUS T4 PA
VELETRI SOLUTION RECONSTITUTED 1.5
MG INTRAVENOUS T4 PA
Cellular And Gene Therapy
Cellular And Gene Therapy
PROVENGE SUSPENSION INTRAVENOUS T4 PA; QL (810 ML per 30 days)
Cellular Therapy
PROVENGE SUSPENSION INTRAVENOUS T4 PA; QL (810 ML per 30 days)
Gene Therapy
KYMRIAH SUSPENSION INTRAVENOUS T4 PA
LUXTURNA SUSPENSION 5000000000000
VG/ML INTRAOCULAR T4 PA
YESCARTA SUSPENSION INTRAVENOUS T4 PA
Central Nervous System Agents
Analgesics And Antipyretics, Misc.
8 hour arthritis pain reliever tablet extended
release 650 mg oral T3
8 hour pain relief tablet extended release 650 mg
oral T3
8hr muscle aches & pain tablet extended release
650 mg oral T3
ACEPHEN SUPPOSITORY 120 MG RECTAL T3
ACEPHEN SUPPOSITORY 325 MG RECTAL T3
ACEPHEN SUPPOSITORY 650 MG RECTAL T3
acetaminophen childrens suspension 160 mg/5ml
oral T3
acetaminophen childrens tablet chewable 160 mg
oral T3
acetaminophen er tablet extended release 650 mg
oral T3
acetaminophen extra strength tablet 500 mg oral T3
acetaminophen infants suspension 160 mg/5ml
oral T3
acetaminophen liquid 160 mg/5ml oral T3
acetaminophen solution 160 mg/5ml oral T3
acetaminophen solution 325 mg/10.15ml oral T3
acetaminophen solution 650 mg/20.3ml oral T3
71
Drug Tier Requirements/Limits
acetaminophen suppository 120 mg rectal T3
acetaminophen suppository 650 mg rectal T3
acetaminophen tablet 325 mg oral T3
acetaminophen tablet 500 mg oral T3
acetaminophen tablet chewable 160 mg oral T3
arthritis pain relief tablet extended release 650
mg oral T3
childrens acetaminophen suspension 160 mg/5ml
oral T3
childrens silapap liquid 160 mg/5ml oral T3
ed-apap liquid 160 mg/5ml oral T3
eql vitamin e capsule 400 unit oral T3
extra strength pain relief tablet 500 mg oral T3
FEVERALL ADULTS SUPPOSITORY 650 MG
RECTAL T3
FEVERALL CHILDRENS SUPPOSITORY 120
MG RECTAL T3
FEVERALL INFANTS SUPPOSITORY 80 MG
RECTAL T3
FEVERALL JUNIOR STRENGTH
SUPPOSITORY 325 MG RECTAL T3
gnp 8 hour pain reliever tablet extended release
650 mg oral T3
gnp acetaminophen tablet 325 mg oral T3
gnp arthritis pain relief tablet extended release
650 mg oral T3
gnp childrens pain relief suspension 160 mg/5ml
oral T3
gnp infants pain relief suspension 160 mg/5ml
oral T3
gnp infants pain/fever suspension 160 mg/5ml
oral T3
gnp pain & fever childrens suspension 160
mg/5ml oral T3
gnp pain relief extra strength tablet 500 mg oral T3
gnp pain relief tablet 325 mg oral T3
goodsense arthritis pain tablet extended release
650 mg oral T3
goodsense pain & fever child suspension 160
mg/5ml oral T3
72
Drug Tier Requirements/Limits
goodsense pain & fever infants suspension 160
mg/5ml oral T3
goodsense pain relief extra st tablet 500 mg oral T3
goodsense pain relief tablet extended release 650
mg oral T3
hm acetaminophen childrens tablet chewable 160
mg oral T3
hm arthritis pain relief tablet extended release
650 mg oral T3
hm pain & fever childrens suspension 160 mg/5ml
oral T3
hm pain & fever infants suspension 160 mg/5ml
oral T3
hm pain relief extra strength tablet 500 mg oral T3
hm pain reliever tablet 325 mg oral T3
infants pain relief suspension 80 mg/0.8ml oral T3
mapap arthritis pain tablet extended release 650
mg oral T3
MAPAP CHILDRENS SUSPENSION 160
MG/5ML ORAL T3
MAPAP CHILDRENS TABLET CHEWABLE
160 MG ORAL T3
MAPAP EXTRA STRENGTH TABLET 500
MG ORAL T3
mapap liquid 160 mg/5ml oral T3
mapap tablet 325 mg oral T3
mapap tablet 500 mg oral T3
non-aspirin childrens suspension 160 mg/5ml
oral T3
pain & fever childrens solution 160 mg/5ml oral T3
pain & fever childrens suspension 160 mg/5ml
oral T3
pain & fever extra strength tablet 500 mg oral T3
pain & fever infants suspension 160 mg/5ml oral T3
pain & fever tablet 325 mg oral T3
pain relief childrens suspension 160 mg/5ml oral T3
pain relief extra strength tablet 500 mg oral T3
pain relief tablet 325 mg oral T3
pain relief tablet 500 mg oral T3
73
Drug Tier Requirements/Limits
pain reliever extra strength tablet 500 mg oral T3
PHARBETOL EXTRA STRENGTH TABLET
500 MG ORAL T3
PHARBETOL TABLET 325 MG ORAL T3
qc acetaminophen 8 hours tablet extended release
650 mg oral T3
qc arthritis pain relief tablet extended release 650
mg oral T3
qc non-aspirin childrens suspension 160 mg/5ml
oral T3
qc non-aspirin extra strength tablet 500 mg oral T3
qc pain relief childrens suspension 160 mg/5ml
oral T3
qc pain relief extra strength tablet 500 mg oral T3
qc pain relief infants suspension 160 mg/5ml oral T3
qc pain relief tablet 325 mg oral T3
sm 8 hour pain relief tablet extended release 650
mg oral T3
sm arthritis pain relief tablet extended release
650 mg oral T3
sm arthritis pain reliever tablet extended release
650 mg oral T3
sm pain & fever childrens suspension 160 mg/5ml
oral T3
sm pain & fever infants suspension 160 mg/5ml
oral T3
sm pain reliever ex st tablet 500 mg oral T3
sm pain reliever ex st tablet extended release 650
mg oral T3
sm pain reliever tablet 325 mg oral T3
tactinal extra strength tablet 500 mg oral T3
tactinal tablet 325 mg oral T3
Antimanic Agents
lithium carbonate capsule 150 mg oral T3
lithium carbonate capsule 300 mg oral T3
lithium carbonate capsule 600 mg oral T3
lithium carbonate er tablet extended release 300
mg oral T3
74
Drug Tier Requirements/Limits
lithium carbonate er tablet extended release 450
mg oral T3
lithium carbonate tablet 300 mg oral T3
lithium solution 8 meq/5ml oral T3
Antimigraine Agents, Miscellaneous
adult aspirin regimen tablet delayed release 81
mg oral T3
aspirin 81 tablet delayed release 81 mg oral T3
aspirin adult low dose tablet delayed release 81
mg oral T3
aspirin adult low strength tablet chewable 81 mg
oral T3
aspirin adult tablet 325 mg oral T3 QL (360 EA per 30 days)
aspirin ec low dose tablet delayed release 81 mg
oral T3
aspirin ec low strength tablet delayed release 81
mg oral T3
aspirin ec tablet delayed release 325 mg oral T3
aspirin ec tablet delayed release 81 mg oral T3
aspirin low dose adult tablet chewable 81 mg oral T3
aspirin low dose tablet chewable 81 mg oral T3
aspirin low dose tablet delayed release 81 mg
oral T3
aspirin low strength tablet chewable 81 mg oral T3
aspirin regimen low dose adult tablet delayed
release 81 mg oral T3
aspirin suppository 300 mg rectal T3 QL (180 EA per 30 days)
aspirin suppository 600 mg rectal T3 QL (180 EA per 30 days)
aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
aspirin tablet chewable 81 mg oral T3
aspirin tablet delayed release 81 mg oral T3
ASPIR-LOW TABLET DELAYED RELEASE
81 MG ORAL T3
childrens aspirin low strength tablet chewable 81
mg oral T3
ECPIRIN TABLET DELAYED RELEASE 325
MG ORAL T3
eq aspirin tablet delayed release 325 mg oral T3
75
Drug Tier Requirements/Limits
gnp adult aspirin low strength tablet chewable 81
mg oral T3
gnp aspirin low dose tablet delayed release 81 mg
oral T3
gnp aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
gnp aspirin tablet delayed release 325 mg oral T3
gnp aspirin tablet delayed release 81 mg oral T3
goodsense aspirin adult low st tablet chewable 81
mg oral T3
goodsense aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
goodsense aspirin tablet chewable 81 mg oral T3
hm aspirin ec low dose tablet delayed release 81
mg oral T3
hm aspirin ec tablet delayed release 325 mg oral T3
hm aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
hm aspirin tablet chewable 81 mg oral T3
qc aspirin low dose tablet chewable 81 mg oral T3
qc aspirin low dose tablet delayed release 81 mg
oral T3
qc aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
qc enteric aspirin tablet delayed release 325 mg
oral T3
sb aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
sm aspirin adult low strength tablet chewable 81
mg oral T3
sm aspirin adult low strength tablet delayed
release 81 mg oral T3
sm aspirin ec tablet delayed release 325 mg oral T3
sm aspirin low dose tablet chewable 81 mg oral T3
sm aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
sm childrens aspirin tablet chewable 81 mg oral T3
ST JOSEPH LOW DOSE TABLET
CHEWABLE 81 MG ORAL T3
ST JOSEPH LOW DOSE TABLET DELAYED
RELEASE 81 MG ORAL T3
Anxiolytics,Sedatives,And
Hypnotics,Misc
droperidol solution 2.5 mg/ml injection T3
gnp sleep aid tablet 25 mg oral T3
76
Drug Tier Requirements/Limits
hm sleep aid tablet 25 mg oral T3
sleep aid tablet 25 mg oral T3
sm sleep aid tablet 25 mg oral T3
Central Nervous System Agents, Misc.
RADICAVA SOLUTION 30 MG/100ML
INTRAVENOUS T4 PA; QL (3000 ML per 30 days)
RILUTEK TABLET 50 MG ORAL T4 PA; QL (60 EA per 30 days)
riluzole tablet 50 mg oral T4 QL (60 EA per 30 days)
TIGLUTIK SUSPENSION 50 MG/10ML ORAL T4 PA
XYREM SOLUTION 500 MG/ML ORAL T4 PA; QL (540 ML per 30 days)
Ergot-Deriv. Dopamine Receptor
Agonists
cabergoline tablet 0.5 mg oral T3 ST
Nonergot-Deriv.Dopamine Receptor
Agonist
APOKYN SOLUTION CARTRIDGE 30
MG/3ML SUBCUTANEOUS T4 PA
Opiate Agonists
cheratussin ac syrup 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
guaiatussin ac syrup 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
guaifenesin ac syrup 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
guaifenesin dac solution 30-10-100 mg/5ml oral T3 QL (1200 ML per 30 days)
guaifenesin-codeine solution 100-10 mg/5ml oral
(otc) T3 QL (120 ML per 30 days); AL
promethazine vc/codeine syrup 6.25-5-10 mg/5ml
oral T3 QL (120 ML per 30 days); AL
promethazine-codeine solution 6.25-10 mg/5ml
oral T3 QL (120 ML per 30 days); AL
promethazine-codeine syrup 6.25-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
promethazine-phenyleph-codeine syrup 6.25-5-10
mg/5ml oral T3 QL (120 ML per 30 days); AL
robafen ac solution 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
TUSNEL C SYRUP 30-10-100 MG/5ML ORAL T3
virtussin a/c solution 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
virtussin dac solution 30-10-100 mg/5ml oral T3 QL (1200 ML per 30 days)
Respiratory And Cns Stimulants
caffeine citrate solution 20 mg/ml oral T3
77
Drug Tier Requirements/Limits
caffeine citrate solution 60 mg/3ml oral T3
Salicylates
adult aspirin regimen tablet delayed release 81
mg oral T3
aspirin 81 tablet delayed release 81 mg oral T3
aspirin adult low dose tablet delayed release 81
mg oral T3
aspirin adult low strength tablet chewable 81 mg
oral T3
aspirin adult tablet 325 mg oral T3 QL (360 EA per 30 days)
aspirin ec low dose tablet delayed release 81 mg
oral T3
aspirin ec low strength tablet delayed release 81
mg oral T3
aspirin ec tablet delayed release 325 mg oral T3
aspirin ec tablet delayed release 81 mg oral T3
aspirin low dose adult tablet chewable 81 mg oral T3
aspirin low dose tablet chewable 81 mg oral T3
aspirin low dose tablet delayed release 81 mg
oral T3
aspirin low strength tablet chewable 81 mg oral T3
aspirin regimen low dose adult tablet delayed
release 81 mg oral T3
aspirin suppository 300 mg rectal T3 QL (180 EA per 30 days)
aspirin suppository 600 mg rectal T3 QL (180 EA per 30 days)
aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
aspirin tablet chewable 81 mg oral T3
aspirin tablet delayed release 81 mg oral T3
ASPIR-LOW TABLET DELAYED RELEASE
81 MG ORAL T3
childrens aspirin low strength tablet chewable 81
mg oral T3
choline-mag trisalicylate liquid 500 mg/5ml oral T3 QL (1350 ML per 30 days)
ECPIRIN TABLET DELAYED RELEASE 325
MG ORAL T3
eq aspirin tablet delayed release 325 mg oral T3
gnp adult aspirin low strength tablet chewable 81
mg oral T3
gnp arthricream cream 10 % external T3
78
Drug Tier Requirements/Limits
gnp aspirin low dose tablet delayed release 81 mg
oral T3
gnp aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
gnp aspirin tablet delayed release 325 mg oral T3
gnp aspirin tablet delayed release 81 mg oral T3
goodsense aspirin adult low st tablet chewable 81
mg oral T3
goodsense aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
goodsense aspirin tablet chewable 81 mg oral T3
hm aspirin ec low dose tablet delayed release 81
mg oral T3
hm aspirin ec tablet delayed release 325 mg oral T3
hm aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
hm aspirin tablet chewable 81 mg oral T3
MOBISYL CREAM 10 % EXTERNAL T3
pain relieving cream 10 % external T3
qc aspirin low dose tablet chewable 81 mg oral T3
qc aspirin low dose tablet delayed release 81 mg
oral T3
qc aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
qc enteric aspirin tablet delayed release 325 mg
oral T3
salsalate tablet 500 mg oral T3 QL (120 EA per 30 days)
salsalate tablet 750 mg oral T3 QL (120 EA per 30 days)
sb aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
sm arthricream rub cream 10 % external T3
sm aspirin adult low strength tablet chewable 81
mg oral T3
sm aspirin adult low strength tablet delayed
release 81 mg oral T3
sm aspirin ec tablet delayed release 325 mg oral T3
sm aspirin low dose tablet chewable 81 mg oral T3
sm aspirin tablet 325 mg oral T3 QL (360 EA per 30 days)
sm childrens aspirin tablet chewable 81 mg oral T3
ST JOSEPH LOW DOSE TABLET
CHEWABLE 81 MG ORAL T3
ST JOSEPH LOW DOSE TABLET DELAYED
RELEASE 81 MG ORAL T3
trolamine salicylate cream 10 % external T3
79
Drug Tier Requirements/Limits
Contraceptives (E.G. Foams, Devices)
Contraceptives (E.G. Foams, Devices)
aimsco lubricated T3 QL (48 EA per 34 days)
DUREX REALFEEL DEVICE T3 QL (48 EA per 34 days)
FANTASY LUBRICATED T3 QL (48 EA per 34 days)
FANTASY LUBRICATED/SPERMICIDE T3 QL (48 EA per 34 days)
FC FEMALE CONDOM T3 QL (48 EA per 34 days)
FC2 FEMALE CONDOM T3 QL (48 EA per 34 days)
kimono T3 QL (48 EA per 34 days)
kimono micro thin T3 QL (48 EA per 34 days)
kimono micro thin plus T3 QL (48 EA per 34 days)
kimono sensation T3 QL (48 EA per 34 days)
kimono sensation plus T3 QL (48 EA per 34 days)
maxx T3 QL (48 EA per 34 days)
premium condoms lubricated T3 QL (48 EA per 34 days)
REALITY LATEX CONDOMS T3 QL (48 EA per 34 days)
TRUSTEX LUB/RIBBED/STUDDED T3 QL (48 EA per 34 days)
TRUSTEX LUB/SPERMICIDE EX ST T3 QL (48 EA per 34 days)
TRUSTEX LUB/SPERMICIDE XL T3 QL (48 EA per 34 days)
TRUSTEX LUBRICATED T3 QL (48 EA per 34 days)
TRUSTEX LUBRICATED EX LARGE T3 QL (48 EA per 34 days)
TRUSTEX LUBRICATED EXTRA ST T3 QL (48 EA per 34 days)
TRUSTEX LUBRICATED/SPERMICIDE T3 QL (48 EA per 34 days)
TRUSTEX NON-LUBRICATED T3 QL (48 EA per 34 days)
TRUSTEX RIA LUB/SPERMICIDE T3 QL (48 EA per 34 days)
TRUSTEX RIA LUBRICATED T3 QL (48 EA per 34 days)
TRUSTEX RIA NON-LUBRICATED T3 QL (48 EA per 34 days)
TRUSTEX-NONOXYNOL-9/RIB/STUD T3 QL (48 EA per 34 days)
Devices
Devices
10 SERIES BP MONITOR/UPPER ARM
DEVICE T3 QL (1 EA per 365 days)
10 SERIES+ BP MONITR/UPPER ARM
DEVICE T3 QL (1 EA per 365 days)
1st choice lancets super thin T3 QL (100 EA per 25 days)
1st choice lancets thin T3 QL (100 EA per 25 days)
80
Drug Tier Requirements/Limits
1st choice lancets ultra thin T3 QL (100 EA per 25 days)
1st tier unilet comfortouch T3 QL (100 EA per 25 days)
3 SERIES BP MONITOR/UPPER ARM
DEVICE T3 QL (1 EA per 365 days)
3 SERIES BP MONITOR/WRIST DEVICE T3 QL (1 EA per 365 days)
5 SERIES BP MONITOR DEVICE T3 QL (1 EA per 365 days)
5 SERIES BP MONITOR/UPPER ARM
DEVICE T3 QL (1 EA per 365 days)
7 SERIES BP MONITOR/UPPER ARM
DEVICE T3 QL (1 EA per 365 days)
7 SERIES BP MONITOR/WRIST DEVICE T3 QL (1 EA per 365 days)
ACCU-CHEK ACTIVE GLUCOSE CONT
LIQUID IN VITRO T3 QL (1 EA per 90 days)
ACCU-CHEK AVIVA SOLUTION IN VITRO T3 QL (1 EA per 90 days)
ACCU-CHEK COMFORT CURVE LINEAR
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
ACCU-CHEK COMFORT CURVE SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
ACCU-CHEK COMPACT BLUE CONTROL
LIQUID IN VITRO T3 QL (1 EA per 90 days)
ACCU-CHEK COMPACT GLUCOSE CONT
LIQUID† IN VITRO T3 QL (1 EA per 90 days)
ACCU-CHEK COMPACT PLUS CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
ACCU-CHEK FASTCLIX LANCETS T3 QL (102 EA per 25 days)
ACCU-CHEK GUIDE CONTROL LIQUID IN
VITRO T3 QL (1 EA per 90 days)
ACCU-CHEK INSTANT CONTROL LIQUID
IN VITRO T3 QL (1 EA per 90 days)
ACCU-CHEK MULTICLIX LANCETS T3 QL (100 EA per 25 days)
ACCU-CHEK MULTICLIX LANCETS T3 QL (102 EA per 25 days)
ACCU-CHEK SAFE-T PRO LANCETS T3 QL (100 EA per 25 days)
ACCU-CHEK SMARTVIEW CONTROL
LIQUID IN VITRO T3 QL (1 EA per 90 days)
ACCU-CHEK SOFT TOUCH DEVICE T3 QL (1 EA per 365 days)
ACCU-CHEK SOFT TOUCH LANCETS T3 QL (100 EA per 25 days)
ACCU-CHEK SOFTCLIX LANCET DEV T3 QL (1 EA per 365 days)
ACCU-CHEK SOFTCLIX LANCETS T3 QL (100 EA per 25 days)
ACCUTREND GLUCOSE CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
81
Drug Tier Requirements/Limits
acti-lance 28g T3 QL (100 EA per 25 days)
acti-lance lite lancets 28g T3 QL (100 EA per 25 days)
acti-lance special lancets 17g T3 QL (100 EA per 25 days)
acti-lance universal 23g T3 QL (100 EA per 25 days)
ACTIVE 1ST BLOOD LANCETS 30G T3 QL (100 EA per 25 days)
ACURA CONTROL SOLUTION HIGH IN
VITRO T3 QL (1 EA per 90 days)
ACURA CONTROL SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
ACURA CONTROL SOLUTION NORMAL IN
VITRO T3 QL (1 EA per 90 days)
adjustable lancing device T3 QL (1 EA per 365 days)
ADVANCE INTUITION CONTROL LIQUID
NORMAL IN VITRO T3 QL (1 EA per 90 days)
ADVANCE MICRO-DRAW NORMAL LIQUID
IN VITRO T3 QL (1 EA per 90 days)
ADVOCATE ARM BPM DEVICE T3 QL (1 EA per 365 days)
ADVOCATE CONTROL SOLUTION LIQUID
HIGH IN VITRO T3 QL (1 EA per 90 days)
ADVOCATE CONTROL SOLUTION LIQUID
LOW IN VITRO T3 QL (1 EA per 90 days)
ADVOCATE LANCETS T3 QL (100 EA per 25 days)
ADVOCATE LANCETS 30G T3 QL (100 EA per 25 days)
ADVOCATE LANCING DEVICE T3 QL (1 EA per 365 days)
ADVOCATE RAPID-SAFE LANCING T3 QL (1 EA per 365 days)
ADVOCATE REDI-CODE+ CONTROL
SOLUTION HIGH IN VITRO T3 QL (1 EA per 90 days)
ADVOCATE REDI-CODE+ CONTROL
SOLUTION LOW IN VITRO T3 QL (1 EA per 90 days)
ADVOCATE SAFETY LANCETS T3 QL (100 EA per 25 days)
ADVOCATE SAFETY LANCETS 26G T3 QL (100 EA per 25 days)
AEROCHAMBER MINI CHAMBER DEVICE T3 QL (2 EA per 365 days)
AEROCHAMBER MV T3 QL (2 EA per 365 days)
AEROCHAMBER PLUS T3 QL (2 EA per 365 days)
AEROCHAMBER PLUS FLO-VU T3 QL (2 EA per 365 days)
AEROCHAMBER PLUS FLO-VU LARGE T3 QL (2 EA per 365 days)
AEROCHAMBER PLUS FLO-VU MEDIUM T3 QL (2 EA per 365 days)
AEROCHAMBER PLUS FLO-VU SMALL T3 QL (2 EA per 365 days)
AEROCHAMBER PLUS FLO-VU W/MASK T3 QL (2 EA per 365 days)
82
Drug Tier Requirements/Limits
AEROCHAMBER PLUS FLOW VU T3 QL (2 EA per 365 days)
AEROCHAMBER PLUS W/MASK T3 QL (2 EA per 365 days)
AEROCHAMBER PLUS W/MASK SMALL T3 QL (2 EA per 365 days)
AEROCHAMBER W/FLOWSIGNAL T3 QL (2 EA per 365 days)
AEROCHAMBER Z-STAT PLUS T3 QL (2 EA per 365 days)
AEROCHAMBER Z-STAT PLUS CHAMBR T3 QL (2 EA per 365 days)
AEROCHAMBER Z-STAT PLUS/LARGE T3 QL (2 EA per 365 days)
AEROCHAMBER Z-STAT PLUS/MEDIUM T3 QL (2 EA per 365 days)
AEROCHAMBER Z-STAT PLUS/SMALL T3 QL (2 EA per 365 days)
AEROVENT PLUS DEVICE T3 QL (2 EA per 365 days)
AGAMATRIX CONTROL SOLUTION HIGH
IN VITRO T3 QL (1 EA per 90 days)
AGAMATRIX CONTROL SOLUTION IN
VITRO T3 QL (1 EA per 90 days)
AGAMATRIX CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
AGAMATRIX ULTRA-THIN LANCETS T3 QL (100 EA per 25 days)
AIRZONE PEAK FLOW METER DEVICE T3 QL (1 EA per 365 days)
ALCOH-GLOVE CONTOURED WIPE PAD T3 QL (150 EA per 34 days)
alcoh-wipe sheet T3 QL (150 EA per 34 days)
allergy syringe 28g x 1/2" 1 ml T3 QL (200 EA per 34 days)
alternate site lancing device T3 QL (1 EA per 365 days)
aqua lance adjustable lancing device T3 QL (1 EA per 365 days)
AQUALANCE LANCETS 30G T3 QL (100 EA per 25 days)
ASCENSIA AUTODISC CONTROL LIQUID
NORMAL IN VITRO T3 QL (1 EA per 90 days)
ASCENSIA AUTODISC CONTROLS LIQUID
IN VITRO T3 QL (1 EA per 90 days)
ASCENSIA ELITE CONTROL LIQUID†
NORMAL IN VITRO T3 QL (1 EA per 90 days)
ASCENSIA ELITE CONTROLS LIQUID† IN
VITRO T3 QL (1 EA per 90 days)
ASSESS FULL RANGE PEAK METER
DEVICE T3 QL (1 EA per 365 days)
ASSESS LOW RANGE PEAK METER
DEVICE T3 QL (1 EA per 365 days)
ASSESS PEAK FLOW METER DEVICE T3 QL (1 EA per 365 days)
ASSURE 3 CONTROL LIQUID IN VITRO T3 QL (1 EA per 90 days)
83
Drug Tier Requirements/Limits
ASSURE 4 CONTROL LEVEL 1 & 2 LIQUID
IN VITRO T3 QL (1 EA per 90 days)
assure comfort lancets 28g T3 QL (100 EA per 25 days)
ASSURE DOSE CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
ASSURE DOSE NORM/HIGH CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
ASSURE HAEMOLANCE PLUS HIGH T3 QL (100 EA per 25 days)
ASSURE HAEMOLANCE PLUS LOW T3 QL (100 EA per 25 days)
ASSURE HAEMOLANCE PLUS MICRO T3 QL (100 EA per 25 days)
ASSURE HAEMOLANCE PLUS NORMAL T3 QL (100 EA per 25 days)
ASSURE HAEMOLANCE PLUS PED T3 QL (100 EA per 25 days)
ASSURE LANCE LANCETS T3 QL (100 EA per 25 days)
ASSURE LANCE LANCETS 21G T3 QL (100 EA per 25 days)
ASSURE LANCE PLUS SAFETY 25G T3 QL (100 EA per 25 days)
ASSURE LANCE PLUS SAFETY 30G T3 QL (100 EA per 25 days)
ASSURE LANCE SAFETY LANCET 28G T3 QL (100 EA per 25 days)
ASSURE LANCETS T3 QL (100 EA per 25 days)
ASSURE PRISM CONTROL LEVEL 1&2
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
ASSURE PRO CONTROL LEVEL 1 & 2
LIQUID IN VITRO T3 QL (1 EA per 90 days)
ASTHMA CHECK METER-ZONE SYSTEM
DEVICE T3 QL (1 EA per 365 days)
ASTHMAMENTOR DEVICE T3 QL (1 EA per 365 days)
AURORA HEALTHCARE LANCETS T3 QL (100 EA per 25 days)
aurora lancet super thin 30g T3 QL (100 EA per 25 days)
aurora lancet thin 23g T3 QL (100 EA per 25 days)
AUTO-LANCET MINI T3 QL (1 EA per 365 days)
AUTOLET LANCING DEVICE T3 QL (1 EA per 365 days)
AUTOLET MINI T3 QL (1 EA per 365 days)
AUTOLET PLUS T3 QL (1 EA per 365 days)
BARDIA BULB IRRIGATION SYRINGE 60
ML T3 QL (200 EA per 34 days)
BARDIA PISTON IRRIGATION SYR 60 ML T3 QL (200 EA per 34 days)
BAYER BREEZE 2 CONTROL LIQUID HIGH
IN VITRO T3 QL (1 EA per 90 days)
BAYER BREEZE 2 CONTROL LIQUID LOW
IN VITRO T3 QL (1 EA per 90 days)
84
Drug Tier Requirements/Limits
BAYER BREEZE 2 CONTROL LIQUID
NORMAL IN VITRO T3 QL (1 EA per 90 days)
BAYER MICROLET 2 LANCING DEVIC T3 QL (1 EA per 365 days)
BAYER MICROLET LANCETS T3 QL (100 EA per 25 days)
BD ALLERGY SYRINGE 28G X 1/2" 1 ML T3 QL (200 EA per 34 days)
BD AUTOSHIELD DUO 30G X 5 MM T3 QL (200 EA per 34 days)
BD ECLIPSE SYRINGE 27G X 1/2" 1 ML T3 QL (200 EA per 34 days)
BD HYPODERMIC NEEDLE 26G X 3/8" T3 QL (200 EA per 34 days)
BD INSULIN SYRINGE U/F 1/2UNIT 31G X
5/16" 0.3 ML T3 QL (200 EA per 34 days)
BD INSULIN SYRINGE U/F 30G X 1/2" 0.3 ML T3 QL (200 EA per 34 days)
BD INSULIN SYRINGE U/F 30G X 1/2" 0.5 ML T3 QL (200 EA per 34 days)
BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML T3 QL (200 EA per 34 days)
BD INSULIN SYRINGE U/F 31G X 5/16" 0.3
ML T3 QL (200 EA per 34 days)
BD INSULIN SYRINGE U/F 31G X 5/16" 0.5
ML T3 QL (200 EA per 34 days)
BD INSULIN SYRINGE U/F 31G X 5/16" 1 ML T3 QL (200 EA per 34 days)
BD INSULIN SYRINGE U-500 31G X 6MM 0.5
ML T3 QL (200 EA per 34 days)
BD LANCET DEVICE T3 QL (1 EA per 365 days)
BD LANCET ULTRAFINE 30G T3 QL (100 EA per 25 days)
BD LANCET ULTRAFINE 33G T3 QL (100 EA per 25 days)
BD LUER-LOK SYRINGE 20G X 1" 10 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 20G X 1" 5 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 20G X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 20G X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 21G X 1" 10 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 21G X 1" 5 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 21G X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 21G X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 22G X 1" 10 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 22G X 1" 5 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 22G X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 22G X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 23G X 1" 5 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 23G X 1-1/4" 10 ML T3 QL (200 EA per 34 days)
BD LUER-LOK SYRINGE 23G X 1-1/4" 5 ML T3 QL (200 EA per 34 days)
85
Drug Tier Requirements/Limits
BD MICROTAINER LANCETS T3 QL (100 EA per 25 days)
BD MULTIFIT REUSABLE SYRINGE 3 ML T3 QL (200 EA per 34 days)
BD PEN NEEDLE MICRO U/F 32G X 6 MM T3 QL (200 EA per 34 days)
BD PEN NEEDLE MINI U/F 31G X 5 MM T3 QL (200 EA per 34 days)
BD PEN NEEDLE NANO 2ND GEN 32G X 4
MM T3 QL (200 EA per 34 days)
BD PEN NEEDLE NANO U/F 32G X 4 MM
(OTC) T3 QL (200 EA per 34 days)
BD PEN NEEDLE ORIGINAL U/F 29G X
12.7MM T3 QL (200 EA per 34 days)
BD PEN NEEDLE SHORT U/F 31G X 8 MM T3 QL (200 EA per 34 days)
BD SAFETYGLIDE ALLERGY SYRINGE 26G
X 3/8" 1 ML T3 QL (200 EA per 34 days)
BD SAFETYGLIDE NEEDLE 18G X 1-1/2" T3 QL (200 EA per 34 days)
BD SAFETYGLIDE SHIELDED NEEDLE 22G
X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
BD SAFETYGLIDE SHIELDED NEEDLE 22G
X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
BD SAFETYGLIDE SYRINGE/NEEDLE 27G X
5/8" 1 ML T3 QL (200 EA per 34 days)
BD SYRINGE 20 ML T3 QL (200 EA per 34 days)
BD SYRINGE 30 ML T3 QL (200 EA per 34 days)
BD SYRINGE 50-60 ML 60 ML T3 QL (200 EA per 34 days)
BD SYRINGE 60 ML T3 QL (200 EA per 34 days)
BD SYRINGE BLUNT CANNULA 17G 10 ML T3 QL (200 EA per 34 days)
BD SYRINGE BLUNT CANNULA 17G 5 ML T3 QL (200 EA per 34 days)
BD SYRINGE CATH TIP 60 ML T3 QL (200 EA per 34 days)
BD SYRINGE DUAL CANNULA 10 ML T3 QL (200 EA per 34 days)
BD SYRINGE LUER SLIP TIP 20 ML T3 QL (200 EA per 34 days)
BD SYRINGE LUER SLIP TIP 5 ML T3 QL (200 EA per 34 days)
BD SYRINGE LUER-LOK 1 ML T3 QL (200 EA per 34 days)
BD SYRINGE LUER-LOK 10 ML T3 QL (200 EA per 34 days)
BD SYRINGE LUER-LOK 20 ML T3 QL (200 EA per 34 days)
BD SYRINGE LUER-LOK 3 ML (OTC) T3 QL (200 EA per 34 days)
BD SYRINGE LUER-LOK 30 ML (OTC) T3 QL (200 EA per 34 days)
BD SYRINGE LUER-LOK 30 ML (RX) T3 QL (200 EA per 34 days)
BD SYRINGE LUER-LOK 5 ML (OTC) T3 QL (200 EA per 34 days)
BD SYRINGE LUER-LOK 5 ML (RX) T3 QL (200 EA per 34 days)
86
Drug Tier Requirements/Limits
BD SYRINGE LUER-LOK 60 ML T3 QL (200 EA per 34 days)
BD SYRINGE SLIP TIP 1 ML T3 QL (200 EA per 34 days)
BD SYRINGE SLIP TIP 10 ML T3 QL (200 EA per 34 days)
BD SYRINGE SLIP TIP 20 ML (OTC) T3 QL (200 EA per 34 days)
BD SYRINGE SLIP TIP 20 ML (RX) T3 QL (200 EA per 34 days)
BD SYRINGE SLIP TIP 30 ML T3 QL (200 EA per 34 days)
BD SYRINGE SLIP TIP 5 ML T3 QL (200 EA per 34 days)
BD SYRINGE SLIP TIP 60 ML T3 QL (200 EA per 34 days)
BD TB SYRINGE 21G X 1" 1 ML T3 QL (200 EA per 34 days)
BD TB SYRINGE 22G X 1" 1 ML T3 QL (200 EA per 34 days)
BD TB SYRINGE 25G X 5/8" 1 ML T3 QL (200 EA per 34 days)
BD TB SYRINGE 26G X 3/8" 1 ML T3 QL (200 EA per 34 days)
BD TB SYRINGE 27G X 1/2" 0.5 ML T3 QL (200 EA per 34 days)
BD TUBERCULIN SYRINGE 1 ML T3 QL (200 EA per 34 days)
BD VEO INSULIN SYR U/F 1/2UNIT 31G X
15/64" 0.3 ML T3 QL (200 EA per 34 days)
BD VEO INSULIN SYRINGE U/F 31G X
15/64" 0.3 ML T3 QL (200 EA per 34 days)
BD VEO INSULIN SYRINGE U/F 31G X
15/64" 0.5 ML T3 QL (200 EA per 34 days)
BD VEO INSULIN SYRINGE U/F 31G X
15/64" 1 ML T3 QL (200 EA per 34 days)
blood press monitor/m-l cuff T3 QL (1 EA per 365 days)
blood pressure kit kit T3 QL (1 EA per 365 days)
blood pressure monitor T3 QL (1 EA per 365 days)
BLOOD PRESSURE MONITOR 3 DEVICE T3 QL (1 EA per 365 days)
BLOOD PRESSURE MONITOR 7 DEVICE T3 QL (1 EA per 365 days)
blood pressure monitor automat device T3 QL (1 EA per 365 days)
blood pressure monitor device T3 QL (1 EA per 365 days)
blood pressure monitor kit T3 QL (1 EA per 365 days)
blood pressure monitor/arm device T3 QL (1 EA per 365 days)
blood pressure monitor/l cuff T3 QL (1 EA per 365 days)
blood pressure monitor/m cuff T3 QL (1 EA per 365 days)
blood pressure monitor/s cuff T3 QL (1 EA per 365 days)
blood pressure monitor/wrist device T3 QL (1 EA per 365 days)
blood pressure unit T3 QL (1 EA per 365 days)
BREATHERITE T3 QL (2 EA per 365 days)
87
Drug Tier Requirements/Limits
BREATHERITE COLL SPACER ADULT T3 QL (2 EA per 365 days)
BREATHERITE COLL SPACER CHILD T3 QL (2 EA per 365 days)
BREATHERITE COLL SPACER INFANT T3 QL (2 EA per 365 days)
BREATHERITE RIGID SPACER/MASK T3 QL (2 EA per 365 days)
BREATHERITE SPACER NEONATE T3 QL (2 EA per 365 days)
BREATHERITE SPACER SMALL CHILD T3 QL (2 EA per 365 days)
BREATHERITE/LARGE MASK T3 QL (2 EA per 365 days)
BREATHERITE/MEDIUM MASK T3 QL (2 EA per 365 days)
BREATHERITE/SMALL MASK T3 QL (2 EA per 365 days)
bullseye mini safety lancets T3 QL (100 EA per 25 days)
careone advanced lancing dev T3 QL (1 EA per 365 days)
careone lancet thin 23g T3 QL (100 EA per 25 days)
careone lancet ultra thin 28g T3 QL (100 EA per 25 days)
CARESENS CONTROL A SOLUTION IN
VITRO T3 QL (1 EA per 90 days)
CARETOUCH BP ARM MONITOR DEVICE T3 QL (1 EA per 365 days)
CARETOUCH BP WRIST MONITOR DEVICE T3 QL (1 EA per 365 days)
CARETOUCH LANCING/EJECTOR T3 QL (1 EA per 365 days)
CARETOUCH SAFETY LANCETS T3 QL (100 EA per 25 days)
CARETOUCH SAFETY LANCETS 26G T3 QL (100 EA per 25 days)
CARETOUCH TWIST LANCETS 28G T3 QL (100 EA per 25 days)
CARETOUCH TWIST LANCETS 30G T3 QL (100 EA per 25 days)
CARETOUCH TWIST LANCETS 33G T3 QL (100 EA per 25 days)
CLEVER CHEK LANCETS T3 QL (100 EA per 25 days)
CLEVER CHOICE BP MONITOR/ARM
DEVICE T3 QL (1 EA per 365 days)
CLEVER CHOICE BP MONITOR/WRIST
DEVICE T3 QL (1 EA per 365 days)
CLEVER CHOICE GLUCOSE CONTROL
LIQUID HIGH IN VITRO T3 QL (1 EA per 90 days)
CLEVER CHOICE GLUCOSE CONTROL
LIQUID LOW IN VITRO T3 QL (1 EA per 90 days)
CLEVER CHOICE HOLDING CHAMBER
DEVICE (RX) T3 QL (2 EA per 365 days)
CLEVER CHOICE LANCETS 23G T3 QL (100 EA per 25 days)
CLEVER CHOICE LANCETS 28G T3 QL (100 EA per 25 days)
CLEVER CHOICE PEAK FLOW METER
DEVICE T3 QL (1 EA per 365 days)
88
Drug Tier Requirements/Limits
COAGUCHEK LANCETS T3 QL (100 EA per 25 days)
comfort assured lancets 28g T3 QL (100 EA per 25 days)
comfort assured lancets 33g T3 QL (100 EA per 25 days)
comfort lancets T3 QL (100 EA per 25 days)
COMPACT SPACE CHAMBER DEVICE T3 QL (2 EA per 365 days)
COMPACT SPACE CHAMBER/LG MASK
DEVICE T3 QL (2 EA per 365 days)
COMPACT SPACE CHAMBER/MED MASK
DEVICE T3 QL (2 EA per 365 days)
COMPACT SPACE CHAMBER/SM MASK
DEVICE T3 QL (2 EA per 365 days)
CONTOUR CONTROL LIQUID HIGH IN
VITRO T3 QL (1 EA per 90 days)
CONTOUR CONTROL LIQUID LOW IN
VITRO T3 QL (1 EA per 90 days)
CONTOUR CONTROL LIQUID NORMAL IN
VITRO T3 QL (1 EA per 90 days)
CONTOUR NEXT CONTROL SOLUTION
LOW IN VITRO T3 QL (1 EA per 90 days)
CONTOUR NEXT CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
control solution normal in vitro T3 QL (1 EA per 90 days)
control syringe disposable 10 ml T3 QL (200 EA per 34 days)
COOL CONTROL A SOLUTION IN VITRO T3 QL (1 EA per 90 days)
COOL CONTROL B SOLUTION IN VITRO T3 QL (1 EA per 90 days)
cool mist humidifier T3 QL (1 EA per 365 days)
cool mist humidifier 0.8 gal T3 QL (1 EA per 365 days)
cool mist humidifier 1 gallon T3 QL (1 EA per 365 days)
cool mist humidifier 1.2 gal T3 QL (1 EA per 365 days)
cool mist humidifier 1.3 gal T3 QL (1 EA per 365 days)
CORNWALL CONTROL SYRINGE 10 ML T3 QL (200 EA per 34 days)
CORNWALL CONTROL SYRINGE 2 ML T3 QL (200 EA per 34 days)
CORNWALL CONTROL SYRINGE 5 ML T3 QL (200 EA per 34 days)
cvs advanced automatic bp device T3 QL (1 EA per 365 days)
cvs advanced bp monitor device T3 QL (1 EA per 365 days)
cvs blood pressure monitor T3 QL (1 EA per 365 days)
cvs blood pressure monitor kit T3 QL (1 EA per 365 days)
cvs cool mist humidifer T3 QL (1 EA per 365 days)
89
Drug Tier Requirements/Limits
cvs eye pad T3 QL (40 EA per 34 days)
cvs lancets 21g T3 QL (100 EA per 25 days)
cvs lancets micro thin 33g T3 QL (100 EA per 25 days)
cvs lancets original T3 QL (100 EA per 25 days)
cvs lancets thin T3 QL (100 EA per 25 days)
cvs lancets thin 26g T3 QL (100 EA per 25 days)
cvs lancets ultra thin 30g T3 QL (100 EA per 25 days)
cvs lancets ultra-thin 30g T3 QL (100 EA per 25 days)
cvs lancing device T3 QL (1 EA per 365 days)
cvs manual blood pressure kit T3 QL (1 EA per 365 days)
cvs series 100 blood pressure device T3 QL (1 EA per 365 days)
cvs series 400 blood pressure device T3 QL (1 EA per 365 days)
cvs series 400w blood pressure device T3 QL (1 EA per 365 days)
cvs series 600 blood pressure device T3 QL (1 EA per 365 days)
cvs ultra thin lancets T3 QL (100 EA per 25 days)
cvs vaporizer warm steam T3 QL (1 EA per 365 days)
diatrue control level 1 solution low in vitro T3 QL (1 EA per 90 days)
diatrue control level 2 solution normal in vitro T3 QL (1 EA per 90 days)
diatrue control level 3 solution high in vitro T3 QL (1 EA per 90 days)
DROPLET LANCETS ULTRA THIN 30G T3 QL (100 EA per 25 days)
DROPLET LANCING DEVICE T3 QL (1 EA per 365 days)
drug mart lancets thin 26g T3 QL (100 EA per 25 days)
drug mart lancets ultra thin T3 QL (100 EA per 25 days)
DRUG MART LANCING DEVICE T3 QL (1 EA per 365 days)
DRUG MART ON-THE-GO LANCET 30G T3 QL (100 EA per 25 days)
DRUG MART UNILET LANCETS 28G T3 QL (100 EA per 25 days)
DRUG MART UNILET LANCETS 30G T3 QL (100 EA per 25 days)
DRUG MART UNILET LANCETS 33G T3 QL (100 EA per 25 days)
duane reade lancet altern site T3 QL (100 EA per 25 days)
duane reade lancet super thin T3 QL (100 EA per 25 days)
duane reade lancet ultra thin T3 QL (100 EA per 25 days)
EASIVENT T3 QL (2 EA per 365 days)
EASIVENT MASK LARGE T3 QL (2 EA per 365 days)
EASIVENT MASK MEDIUM T3 QL (2 EA per 365 days)
EASIVENT MASK SMALL T3 QL (2 EA per 365 days)
easy check control solution high in vitro T3 QL (1 EA per 90 days)
90
Drug Tier Requirements/Limits
easy check control solution normal in vitro T3 QL (1 EA per 90 days)
easy comfort lancets T3 QL (100 EA per 25 days)
easy comfort lancets twist top T3 QL (100 EA per 25 days)
EASY GLIDE LUER LOCK SYRINGE 1 ML T3 QL (200 EA per 34 days)
easy mini eject lancing device T3 QL (1 EA per 365 days)
easy mini lancing device T3 QL (1 EA per 365 days)
easy plus ii control solution high in vitro T3 QL (1 EA per 90 days)
easy plus ii control solution low in vitro T3 QL (1 EA per 90 days)
EASY STEP CONTROL SOLUTION HIGH IN
VITRO T3 QL (1 EA per 90 days)
EASY STEP CONTROL SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
EASY STEP CONTROL SOLUTION NORMAL
IN VITRO T3 QL (1 EA per 90 days)
easy talk control solution high in vitro T3 QL (1 EA per 90 days)
easy talk control solution low in vitro T3 QL (1 EA per 90 days)
EASY TOUCH ALLERGY SYRINGE 26G X
3/8" 1 ML T3 QL (200 EA per 34 days)
EASY TOUCH CONTROL HIGH & LOW
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
EASY TOUCH FLIPLOCK SAFETY SYR 18G
X 1" 10 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 18G
X 1" 5 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 18G
X 1.5" 10 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 20G
X 1" 10 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 20G
X 1" 5 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 20G
X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 20G
X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 21G
X 1" 10 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 21G
X 1" 5 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 21G
X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
91
Drug Tier Requirements/Limits
EASY TOUCH FLIPLOCK SAFETY SYR 21G
X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 22G
X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 22G
X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 25G
X 1" 10 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 25G
X 1" 5 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 25G
X 5/8" 5 ML T3 QL (200 EA per 34 days)
EASY TOUCH FLIPLOCK SAFETY SYR 27G
X 1/2" 1 ML T3 QL (200 EA per 34 days)
EASY TOUCH LANCETS 21G T3 QL (100 EA per 25 days)
EASY TOUCH LANCETS 23G T3 QL (100 EA per 25 days)
EASY TOUCH LANCETS 26G T3 QL (100 EA per 25 days)
EASY TOUCH LANCETS 28G T3 QL (100 EA per 25 days)
EASY TOUCH LANCETS 28G/TWIST T3 QL (100 EA per 25 days)
EASY TOUCH LANCETS 30G T3 QL (100 EA per 25 days)
EASY TOUCH LANCETS 32G T3 QL (100 EA per 25 days)
EASY TOUCH LANCETS 32G/TWIST T3 QL (100 EA per 25 days)
EASY TOUCH LANCING DEVICE T3 QL (1 EA per 365 days)
EASY TOUCH SAFETY LANCETS 21G T3 QL (100 EA per 25 days)
EASY TOUCH SAFETY LANCETS 23G T3 QL (100 EA per 25 days)
EASY TOUCH SAFETY LANCETS 26G T3 QL (100 EA per 25 days)
EASY TOUCH SAFETY LANCETS 28G T3 QL (100 EA per 25 days)
EASY TOUCH SHEATHLOCK SYRINGE 21G
X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
EASY TOUCH SHEATHLOCK SYRINGE 21G
X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
EASY TOUCH SHEATHLOCK SYRINGE 22G
X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
EASY TOUCH SHEATHLOCK SYRINGE 22G
X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
EASY TOUCH SHEATHLOCK SYRINGE 25G
X 1" 10 ML T3 QL (200 EA per 34 days)
EASY TOUCH SHEATHLOCK SYRINGE 25G
X 1" 5 ML T3 QL (200 EA per 34 days)
92
Drug Tier Requirements/Limits
EASY TOUCH TB FLIPLOCK SYRINGE 26G
X 5/8" 1 ML T3 QL (200 EA per 34 days)
EASY TOUCH TB FLIPLOCK SYRINGE 28G
X 1/2" 1 ML T3 QL (200 EA per 34 days)
EASY TOUCH TB SHEATHLOCK SYR 25G X
5/8" 1 ML T3 QL (200 EA per 34 days)
EASY TOUCH TB SHEATHLOCK SYR 28G X
1/2" 1 ML T3 QL (200 EA per 34 days)
easy trak control solution high in vitro T3 QL (1 EA per 90 days)
easy trak control solution low in vitro T3 QL (1 EA per 90 days)
EASY TWIST & CAP LANCETS T3 QL (100 EA per 25 days)
EASYGLUCO PLUS LEVEL 1 SOLUTION IN
VITRO T3 QL (1 EA per 90 days)
EASYMAX 15 LEVEL 1 CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
EASYMAX 15 LEVEL 2 CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
EASYMAX CONTROL SOLUTION HIGH IN
VITRO T3 QL (1 EA per 90 days)
EASYMAX CONTROL SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
EASYMAX CONTROL SOLUTION NORMAL
IN VITRO T3 QL (1 EA per 90 days)
ECLIPSE CONTROL LIQUID HIGH IN VITRO T3 QL (1 EA per 90 days)
ECLIPSE CONTROL LIQUID LOW IN VITRO T3 QL (1 EA per 90 days)
ECLIPSE CONTROL SOLUTION NORMAL IN
VITRO T3 QL (1 EA per 90 days)
element compact control 2 solution in vitro T3 QL (1 EA per 90 days)
element compact control 3 solution in vitro T3 QL (1 EA per 90 days)
ELEMENT CONTROL LIQUID HIGH IN
VITRO T3 QL (1 EA per 90 days)
ELEMENT CONTROL LIQUID LOW IN
VITRO T3 QL (1 EA per 90 days)
ELEMENT CONTROL LIQUID NORMAL IN
VITRO T3 QL (1 EA per 90 days)
ELEMENT PLUS CONTROL SOLUTION
HIGH IN VITRO T3 QL (1 EA per 90 days)
ELEMENT PLUS CONTROL SOLUTION LOW
IN VITRO T3 QL (1 EA per 90 days)
ELEMENT PLUS CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
93
Drug Tier Requirements/Limits
EMBRACE CONTROL SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
EMBRACE EVO CONTROL LEVEL 1 LIQUID
LOW IN VITRO T3 QL (1 EA per 90 days)
EMBRACE EVO CONTROL LEVEL 2 LIQUID
NORMAL IN VITRO T3 QL (1 EA per 90 days)
EMBRACE GLUCOSE CONTROL LIQUID
HIGH IN VITRO T3 QL (1 EA per 90 days)
EMBRACE LANCETS ULTRA THIN 30G T3 QL (100 EA per 25 days)
EMBRACE PRO GLUCOSE CONTROL
LIQUID IN VITRO T3 QL (1 EA per 90 days)
EMBRACE TALK GLUCOSE CONTROL
SOLUTION HIGH IN VITRO T3 QL (1 EA per 90 days)
EMBRACE TALK GLUCOSE CONTROL
SOLUTION LOW IN VITRO T3 QL (1 EA per 90 days)
ENVISION CONTROL SOLUTION HIGH IN
VITRO T3 QL (1 EA per 90 days)
ENVISION CONTROL SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
ENVISION CONTROL SOLUTION NORMAL
IN VITRO T3 QL (1 EA per 90 days)
eql blood pressure monitor device T3 QL (1 EA per 365 days)
eql color lancets 21g T3 QL (100 EA per 25 days)
eql color lancets micro 33g T3 QL (100 EA per 25 days)
eql super thin lancets 30g T3 QL (100 EA per 25 days)
eql thin lancets 26g T3 QL (100 EA per 25 days)
EVENCARE CONTROL LOW/HIGH LIQUID
IN VITRO T3 QL (1 EA per 90 days)
EVENCARE G2 LOW/HIGH CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
EVENCARE G3 LOW/HIGH CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
EVOLUTION CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
E-Z JECT LANCET MICRO-THIN 33G T3 QL (100 EA per 25 days)
E-Z JECT LANCET SUPER THIN 30G T3 QL (100 EA per 25 days)
E-Z JECT LANCETS T3 QL (100 EA per 25 days)
E-Z JECT LANCETS 21G T3 QL (100 EA per 25 days)
E-Z JECT LANCETS THIN 26G T3 QL (100 EA per 25 days)
EZ SMART BLOOD GLUCOSE LANCETS T3 QL (100 EA per 25 days)
94
Drug Tier Requirements/Limits
E-Z SPACER DEVICE T3 QL (2 EA per 365 days)
E-Z SPACER THE BODY GUARDS PK
DEVICE T3 QL (2 EA per 365 days)
EZ-LETS LANCETS 26G T3 QL (100 EA per 25 days)
FIFTY50 CONTROL 2.0 SOLUTION IN VITRO T3 QL (1 EA per 90 days)
FIFTY50 LANCING DEVICE T3 QL (1 EA per 365 days)
FIFTY50 SAFETY SEAL LANCETS T3 QL (100 EA per 25 days)
FIFTY50 UNILET LANCETS 33G T3 QL (100 EA per 25 days)
FINE 30 T3 QL (100 EA per 25 days)
FINGERSTIX LANCETS T3 QL (100 EA per 25 days)
FIRST CHOICE LANCETS COLORED T3 QL (100 EA per 25 days)
FIRST CHOICE LANCETS THIN T3 QL (100 EA per 25 days)
FLEXICHAMBER DEVICE T3 QL (2 EA per 365 days)
FORA CONTROL SOLUTION HIGH IN
VITRO T3 QL (1 EA per 90 days)
FORA CONTROL SOLUTION LOW IN VITRO T3 QL (1 EA per 90 days)
FORA CONTROL SOLUTION NORMAL IN
VITRO T3 QL (1 EA per 90 days)
FORA LANCETS T3 QL (100 EA per 25 days)
FORA LANCING DEVICE T3 QL (1 EA per 365 days)
FORA P20 BP MONITOR SYSTEM DEVICE T3 QL (1 EA per 365 days)
FORA TEST N' GO BP DEVICE T3 QL (1 EA per 365 days)
FORACARE GDH CONTROL SOLUTION
HIGH IN VITRO T3 QL (1 EA per 90 days)
FORACARE GDH CONTROL SOLUTION
LOW IN VITRO T3 QL (1 EA per 90 days)
FORACARE GDH CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
FORTISCARE CONTROL SOLUTION HIGH
IN VITRO T3 QL (1 EA per 90 days)
FORTISCARE CONTROL SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
FORTISCARE CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
fp lancets T3 QL (100 EA per 25 days)
fp lancets thin T3 QL (100 EA per 25 days)
freds pharmacy autolet lancing T3 QL (1 EA per 365 days)
freds pharmacy unilet lanc 28g T3 QL (100 EA per 25 days)
freds pharmacy unilet lanc 30g T3 QL (100 EA per 25 days)
95
Drug Tier Requirements/Limits
FREESTYLE CONTROL SOLUTION LIQUID
IN VITRO T3 QL (1 EA per 90 days)
FREESTYLE LANCETS T3 QL (100 EA per 25 days)
FREESTYLE UNISTICK II LANCETS T3 QL (100 EA per 25 days)
ge100 control solution normal in vitro T3 QL (1 EA per 90 days)
GENTEEL LANCING DEVICE (BLUE) T3 QL (1 EA per 365 days)
GENTEEL LANCING DEVICE (PINK) T3 QL (1 EA per 365 days)
GENTEEL LANCING DEVICE (WHITE) T3 QL (1 EA per 365 days)
GENTEEL LANCING DEVICE(PURPLE) T3 QL (1 EA per 365 days)
GLASPAK DISP SYRINGE 10 ML T3 QL (200 EA per 34 days)
GLASPAK DISP SYRINGE 5 ML T3 QL (200 EA per 34 days)
GLASPAK TB SYRINGE 1 ML T3 QL (200 EA per 34 days)
global inject ease lancets 28g T3 QL (100 EA per 25 days)
global inject ease lancets 30g T3 QL (100 EA per 25 days)
global lancing device T3 QL (1 EA per 365 days)
GLUCOCARD 01 CONTROL LIQUID IN
VITRO T3 QL (1 EA per 90 days)
GLUCOCARD 01 CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
GLUCOCARD EXPRESSION CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
GLUCOCARD SHINE CONTROL SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
GLUCOCARD X-SENSOR CONTROL
SOLUTION NORMAL IN VITRO T3 QL (1 EA per 90 days)
GLUCOCOM CONTROL LIQUID HIGH IN
VITRO T3 QL (1 EA per 90 days)
GLUCOCOM CONTROL LIQUID NORMAL
IN VITRO T3 QL (1 EA per 90 days)
GLUCOCOM LANCETS 28G T3 QL (100 EA per 25 days)
GLUCOCOM LANCETS 30G T3 QL (100 EA per 25 days)
GLUCOCOM LANCETS 33G T3 QL (100 EA per 25 days)
GLUCOLAB CONTROL LIQUID HIGH IN
VITRO T3 QL (1 EA per 90 days)
GLUCOLAB CONTROL LIQUID LOW IN
VITRO T3 QL (1 EA per 90 days)
GLUCOLAB CONTROL LIQUID NORMAL IN
VITRO T3 QL (1 EA per 90 days)
GLUCOLET 2 AUTOMATIC LANCING T3 QL (1 EA per 365 days)
96
Drug Tier Requirements/Limits
glucose control solution in vitro T3 QL (1 EA per 90 days)
glucose control solution normal in vitro T3 QL (1 EA per 90 days)
GLUCOSOURCE LANCET DEVICE T3 QL (1 EA per 365 days)
GLUCOSOURCE LANCETS T3 QL (100 EA per 25 days)
GMATE CONTROL LEVEL 2 SOLUTION IN
VITRO T3 QL (1 EA per 90 days)
GMATE LANCETS 30G T3 QL (100 EA per 25 days)
GMATE LANCING DEVICE T3 QL (1 EA per 365 days)
gnp blood pressure monitor T3 QL (1 EA per 365 days)
GNP EASY TOUCH CONT HIGH/LOW
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
gnp lancets T3 QL (100 EA per 25 days)
gnp lancets 21g T3 QL (100 EA per 25 days)
gnp lancets micro thin 33g T3 QL (100 EA per 25 days)
gnp lancets super thin 30g T3 QL (100 EA per 25 days)
gnp lancets thin T3 QL (100 EA per 25 days)
gnp lancets thin 26g T3 QL (100 EA per 25 days)
GNP LANCING SYSTEM DEVICE T3 QL (1 EA per 365 days)
gnp micro thin lancets 33g T3 QL (100 EA per 25 days)
gnp super thin lancets 30g T3 QL (100 EA per 25 days)
GOJJI CONTROL SOLUTION NORMAL IN
VITRO T3 QL (1 EA per 90 days)
GOJJI LANCING DEVICE/CLEAR CAP T3 QL (1 EA per 365 days)
GOJJI STERILE LANCETS T3 QL (100 EA per 25 days)
goodsense color lancets 33g T3 QL (100 EA per 25 days)
goodsense lancets 26g univ T3 QL (100 EA per 25 days)
goodsense lancets 30g T3 QL (100 EA per 25 days)
goodsense lancets 30g univ T3 QL (100 EA per 25 days)
goodsense lancets 33g T3 QL (100 EA per 25 days)
goodsense lancets 33g univ T3 QL (100 EA per 25 days)
goodsense lancing device T3 QL (1 EA per 365 days)
H&H THINLET LANCETS 26G T3 QL (100 EA per 25 days)
H&H THINLET LANCETS 30G T3 QL (100 EA per 25 days)
HAEMOLANCE T3 QL (100 EA per 25 days)
HAEMOLANCE LOW FLOW LANCETS T3 QL (100 EA per 25 days)
HAEMOLANCE PLUS T3 QL (100 EA per 25 days)
HAEMOLANCE PLUS HIGH FLOW T3 QL (100 EA per 25 days)
97
Drug Tier Requirements/Limits
HAEMOLANCE PLUS LOW FLOW T3 QL (100 EA per 25 days)
HAEMOLANCE PLUS MAX FLOW T3 QL (100 EA per 25 days)
HAEMOLANCE PLUS PEDIATRIC FLOW T3 QL (100 EA per 25 days)
HEALTH CARE LANCING DEVICE T3 QL (1 EA per 365 days)
health sense bp monitor device T3 QL (1 EA per 365 days)
healthy accents lancing device T3 QL (1 EA per 365 days)
healthy accents unilet lancets T3 QL (100 EA per 25 days)
h-e-b incontrol adv lancing T3 QL (1 EA per 365 days)
H-E-B INCONTROL BP MONITOR T3 QL (1 EA per 365 days)
h-e-b incontrol lancets 28g T3 QL (100 EA per 25 days)
h-e-b incontrol lancets 30g T3 QL (100 EA per 25 days)
h-e-b incontrol lancets 33g T3 QL (100 EA per 25 days)
hm blood pressure monitor device T3 QL (1 EA per 365 days)
hm lancets micro thin 33g T3 QL (100 EA per 25 days)
hm lancets ultra thin 30g T3 QL (100 EA per 25 days)
humidifier T3 QL (1 EA per 365 days)
HYPERSAL NEBULIZATION SOLUTION 7 %
INHALATION T3
INFINITY CONTROL SOLUTION HIGH IN
VITRO T3 QL (1 EA per 90 days)
INFINITY CONTROL SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
INFINITY CONTROL SOLUTION NORMAL
IN VITRO T3 QL (1 EA per 90 days)
INFINITY VOICE LIQUID NORMAL IN
VITRO T3 QL (1 EA per 90 days)
INSPIRACHAMBER/LARGE DEVICE T3 QL (2 EA per 365 days)
INSPIRACHAMBER/MEDIUM DEVICE T3 QL (2 EA per 365 days)
INSPIRACHAMBER/MOUTHPIECE DEVICE T3 QL (2 EA per 365 days)
INSPIRACHAMBER/SMALL DEVICE T3 QL (2 EA per 365 days)
INSPIREASE T3 QL (2 EA per 365 days)
KAZ HEALTHMIST HUMIDIFIER T3 QL (1 EA per 365 days)
KAZ VAPORIZER T3 QL (1 EA per 365 days)
KAZ VICKS VAPORIZER V150 T3 QL (1 EA per 365 days)
kinney lancets T3 QL (100 EA per 25 days)
kinney thin lancets T3 QL (100 EA per 25 days)
KROGER AUTOLET LANCING DEVICE T3 QL (1 EA per 365 days)
kroger blood pressure monitor device T3 QL (1 EA per 365 days)
98
Drug Tier Requirements/Limits
KROGER HEALTHPRO CONTROL HI/LO
LIQUID IN VITRO T3 QL (1 EA per 90 days)
KROGER HEALTHPRO LANCET 26G T3 QL (100 EA per 25 days)
KROGER HEALTHPRO LANCET 30G T3 QL (100 EA per 25 days)
KROGER HEALTHPRO LANCET 33G T3 QL (100 EA per 25 days)
kroger lancets 21g T3 QL (100 EA per 25 days)
kroger lancets micro thin 33g T3 QL (100 EA per 25 days)
kroger lancets thin 26g T3 QL (100 EA per 25 days)
kroger lancets ultrathin 30g T3 QL (100 EA per 25 days)
kroger lancing device T3 QL (1 EA per 365 days)
lady lite lancets T3 QL (100 EA per 25 days)
lancet device T3 QL (1 EA per 365 days)
lancet device with ejector T3 QL (1 EA per 365 days)
lancets T3 QL (100 EA per 25 days)
lancets 28g T3 QL (100 EA per 25 days)
lancets 30g T3 QL (100 EA per 25 days)
lancets micro thin 33g T3 QL (100 EA per 25 days)
lancets super thin 28g T3 QL (100 EA per 25 days)
lancets thin T3 QL (100 EA per 25 days)
LANCETS ULTRA FINE T3 QL (100 EA per 25 days)
LANCETS ULTRA THIN T3 QL (100 EA per 25 days)
lancets ultra thin 30g T3 QL (100 EA per 25 days)
lancing device T3 QL (1 EA per 365 days)
LANZO T3 QL (1 EA per 365 days)
leader advanced lancing device T3 QL (1 EA per 365 days)
LIBERTY GLUCOSE CONTROL LIQUID
NORMAL IN VITRO T3 QL (1 EA per 90 days)
LIBERTY GLUCOSE CONTROL MID
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
LIBERTY GLUCOSE CONTROL SOLUTION
HIGH IN VITRO T3 QL (1 EA per 90 days)
LIBERTY GLUCOSE CONTROL SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
LIBERTY GLUCOSE CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
LIBERTY MINI LANCING DEVICE T3 QL (1 EA per 365 days)
lifestylecomfort vaporizer T3 QL (1 EA per 365 days)
lite touch lancets T3 QL (100 EA per 25 days)
99
Drug Tier Requirements/Limits
LITE TOUCH LANCING DEVICE T3 QL (1 EA per 365 days)
LITE TOUCH LANCING PEN T3 QL (1 EA per 365 days)
LITEAIRE DEVICE T3 QL (2 EA per 365 days)
LITETOUCH LANCETS T3 QL (100 EA per 25 days)
live better adv lancing device T3 QL (1 EA per 365 days)
live better lancet super thin T3 QL (100 EA per 25 days)
live better lancet ultra thin T3 QL (100 EA per 25 days)
local anesthesia needle 22g x 2" T3 QL (200 EA per 34 days)
longs lancets standard T3 QL (100 EA per 25 days)
longs lancets thin T3 QL (100 EA per 25 days)
longs lancets ultra thin T3 QL (100 EA per 25 days)
MAGELLAN TUBERCULIN SYRINGE 28G X
1/2" 1 ML T3 QL (200 EA per 34 days)
major comfort lancets T3 QL (100 EA per 25 days)
MAXIMA CONTROL SOLUTION IN VITRO T3 QL (1 EA per 90 days)
MAXIMA CONTROL SOLUTION NORMAL
IN VITRO T3 QL (1 EA per 90 days)
medicine shoppe lancets T3 QL (100 EA per 25 days)
medicine shoppe lancets thin T3 QL (100 EA per 25 days)
medi-lance lancets T3 QL (100 EA per 25 days)
MEDISENSE GLUCOSE KETONE CONTR
LIQUID IN VITRO T3 QL (1 EA per 90 days)
MEDISENSE HI/MID/LOW CONTROL
LIQUID IN VITRO T3 QL (1 EA per 90 days)
MEDISENSE HIGH/LOW CONTROL LIQUID
IN VITRO T3 QL (1 EA per 90 days)
MEDISENSE MID CONTROL LIQUID IN
VITRO T3 QL (1 EA per 90 days)
MEDISENSE THIN LANCETS T3 QL (100 EA per 25 days)
MEDLANCE EXTRA 21G T3 QL (100 EA per 25 days)
MEDLANCE LITE 25G T3 QL (100 EA per 25 days)
MEDLANCE PLUS EXTRA 21G T3 QL (100 EA per 25 days)
MEDLANCE PLUS LANCETS T3 QL (100 EA per 25 days)
MEDLANCE PLUS LITE 25G T3 QL (100 EA per 25 days)
MEDLANCE PLUS SPECIAL 0.8MM T3 QL (100 EA per 25 days)
MEDLANCE PLUS SUPERLITE 30G T3 QL (100 EA per 25 days)
MEDLANCE PLUS UNIVERSAL 21G T3 QL (100 EA per 25 days)
MEDLANCE UNIVERSAL 21G T3 QL (100 EA per 25 days)
100
Drug Tier Requirements/Limits
MEIJER LANCETS T3 QL (100 EA per 25 days)
MEIJER LANCETS THIN T3 QL (100 EA per 25 days)
MEIJER LANCETS UNIVERSAL 33G T3 QL (100 EA per 25 days)
MEIJER SUPER THIN LANCETS T3 QL (100 EA per 25 days)
MICROCHAMBER T3 QL (2 EA per 365 days)
MICROCHAMBER DEVICE T3 QL (2 EA per 365 days)
MICRODOT CONTROL HIGH/LOW
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
MICRODOT CONTROL SOLUTION NORMAL
IN VITRO T3 QL (1 EA per 90 days)
MICROLET LANCETS T3 QL (100 EA per 25 days)
MICROLET NEXT LANCING DEVICE T3 QL (1 EA per 365 days)
microlife bp monitor device T3 QL (1 EA per 365 days)
MICROLIFE BPM6 PREMIUM MONITOR
DEVICE T3 QL (1 EA per 365 days)
microlife deluxe bp monitor device T3 QL (1 EA per 365 days)
MICROLIFE DIGITAL PEAK FLOW DEVICE T3 QL (1 EA per 365 days)
microlife wrist bp monitor device T3 QL (1 EA per 365 days)
MICROSPACER T3 QL (2 EA per 365 days)
mini lancing device T3 QL (1 EA per 365 days)
MINI WRIGHT PEAK FLOW METER DEVICE T3 QL (1 EA per 365 days)
MM LANCING DEVICE T3 QL (1 EA per 365 days)
MM TWIST LANCETS T3 QL (100 EA per 25 days)
MONOJECT BLOOD COLLECTION NDL 20G
X 1" T3 QL (200 EA per 34 days)
MONOJECT BLOOD COLLECTION NDL 20G
X 1-1/2" T3 QL (200 EA per 34 days)
MONOJECT BLOOD COLLECTION NDL 21G
X 1" T3 QL (200 EA per 34 days)
MONOJECT BLOOD COLLECTION NDL 22G
X 1" T3 QL (200 EA per 34 days)
MONOJECT CONTROL SYRINGE 12 ML T3 QL (200 EA per 34 days)
MONOJECT HYPODERMIC NEEDLE 19G X
1-1/4" T3 QL (200 EA per 34 days)
MONOJECT LIFESHIELD SYRINGE 18G X 1"
6 ML T3 QL (200 EA per 34 days)
MONOJECT PHARMACY TRAY 1 ML T3 QL (200 EA per 34 days)
MONOJECT PHARMACY TRAY 12 ML T3 QL (200 EA per 34 days)
MONOJECT PHARMACY TRAY 20 ML T3 QL (200 EA per 34 days)
101
Drug Tier Requirements/Limits
MONOJECT PHARMACY TRAY 35 ML T3 QL (200 EA per 34 days)
MONOJECT PHARMACY TRAY 6 ML T3 QL (200 EA per 34 days)
MONOJECT PHARMACY TRAY 60 ML T3 QL (200 EA per 34 days)
MONOJECT SAFETY SYRINGE/SHIELD 12
ML T3 QL (200 EA per 34 days)
MONOJECT SAFETY SYRINGE/SHIELD 20G
X 1-1/2" 12 ML T3 QL (200 EA per 34 days)
MONOJECT SAFETY SYRINGE/SHIELD 20G
X 1-1/2" 6 ML T3 QL (200 EA per 34 days)
MONOJECT SAFETY SYRINGE/SHIELD 21G
X 1-1/2" 12 ML T3 QL (200 EA per 34 days)
MONOJECT SAFETY SYRINGE/SHIELD 21G
X 1-1/2" 6 ML T3 QL (200 EA per 34 days)
MONOJECT SAFETY SYRINGE/SHIELD 6
ML T3 QL (200 EA per 34 days)
MONOJECT SOFTPACK/CATHTIP 35 ML T3 QL (200 EA per 34 days)
MONOJECT SOFTPACK/CATHTIP 60 ML T3 QL (200 EA per 34 days)
MONOJECT SOFTPACK/LLOCK 20 ML T3 QL (200 EA per 34 days)
MONOJECT SOFTPACK/LLOCK 35 ML T3 QL (200 EA per 34 days)
MONOJECT SOFTPACK/LLOCK 60 ML T3 QL (200 EA per 34 days)
MONOJECT SOFTPACK/LTIP 20 ML T3 QL (200 EA per 34 days)
MONOJECT SOFTPACK/RG LOCK 35 ML T3 QL (200 EA per 34 days)
MONOJECT SOFTPACK/RG LUER 60 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 12 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 18G X 1" 12 ML (OTC) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 18G X 1" 12 ML (RX) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 20G X 1-1/2" 12 ML
(OTC) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 20G X 1-1/2" 12 ML
(RX) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 20G X 1-1/2" 6 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 21G X 1" 12 ML (OTC) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 21G X 1" 12 ML (RX) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 21G X 1" 6 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 21G X 1-1/2" 12 ML
(OTC) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 21G X 1-1/2" 12 ML
(RX) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 21G X 1-1/2" 6 ML T3 QL (200 EA per 34 days)
102
Drug Tier Requirements/Limits
MONOJECT SYRINGE 22G X 1-1/2" 6 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE 6 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE CATH TIP 35 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE CATH TIP 60 ML
(OTC) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE CATH TIP 60 ML (RX) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE ECC LUER 20 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE ECC LUER 35 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE ECCENTRIC TIP 12
ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE ECCENTRIC TIP 60
ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE LUER LOCK 20 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE LUER LOCK 35 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE LUER LOCK 6 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE LUER LOCK 60 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE LUER-LOCK TIP 60
ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE PHARMACY TRAY 1
ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE REG LUER 12 ML
(OTC) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE REG LUER 12 ML
(RX) T3 QL (200 EA per 34 days)
MONOJECT SYRINGE REG LUER 20 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE REG LUER 35 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE REG LUER 6 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE REGULAR TIP 20 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE REGULAR TIP 6 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE REGULAR TIP 60 ML T3 QL (200 EA per 34 days)
MONOJECT SYRINGE TOOMEY TYPE 60
ML T3 QL (200 EA per 34 days)
MONOJECT TB SAFETY SYRINGE 25G X
5/8" 1 ML T3 QL (200 EA per 34 days)
MONOJECT TB SAFETY SYRINGE 28G X
1/2" 1 ML T3 QL (200 EA per 34 days)
MONOJECT TB SYRINGE 1 ML (OTC) T3 QL (200 EA per 34 days)
MONOJECT TB SYRINGE 1 ML (RX) T3 QL (200 EA per 34 days)
103
Drug Tier Requirements/Limits
MONOJECT TB SYRINGE 25G X 5/8" 1 ML
(OTC) T3 QL (200 EA per 34 days)
MONOJECT TB SYRINGE 25G X 5/8" 1 ML
(RX) T3 QL (200 EA per 34 days)
MONOJECT TB SYRINGE 26G X 3/8" 1 ML
(OTC) T3 QL (200 EA per 34 days)
MONOJECT TB SYRINGE 26G X 3/8" 1 ML
(RX) T3 QL (200 EA per 34 days)
MONOJECT TB SYRINGE 28G X 1/2" 0.5 ML T3 QL (200 EA per 34 days)
MONOJECT TB SYRINGE 28G X 1/2" 1 ML
(OTC) T3 QL (200 EA per 34 days)
MONOJECT TB SYRINGE 28G X 1/2" 1 ML
(RX) T3 QL (200 EA per 34 days)
MONOLET LANCETS T3 QL (100 EA per 25 days)
MONOLET THIN LANCETS T3 QL (100 EA per 25 days)
multi-draw needle 20g x 1" T3 QL (200 EA per 34 days)
multi-draw needle 21g x 1" T3 QL (200 EA per 34 days)
multi-draw needle 22g x 1" T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE SYRINGE 2 ML T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE SYRINGE 30 ML T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE SYRINGE 5 ML T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE SYRINGE 50 ML T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE TB SYRINGE 10 ML T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE TB SYRINGE 20 ML T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE TB SYRINGE 3 ML T3 QL (200 EA per 34 days)
MULTIFIT REUSABLE TB SYRINGE 5 ML T3 QL (200 EA per 34 days)
multi-lancet device T3 QL (1 EA per 365 days)
MULTI-USER BLOOD PRESSURE KIT T3 QL (1 EA per 365 days)
MYGLUCOHEALTH CONTROL SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
MYGLUCOHEALTH LANCETS 30G T3 QL (100 EA per 25 days)
NEBUSAL NEBULIZATION SOLUTION 3 %
INHALATION T3
NESSI SPACER WITH MASK LARGE
DEVICE T3 QL (2 EA per 365 days)
NESSI SPACER WITH MASK SM/MED
DEVICE T3 QL (2 EA per 365 days)
NESSI SPACER WITH MOUTHPIECE
DEVICE T3 QL (2 EA per 365 days)
104
Drug Tier Requirements/Limits
NEUTEK 2TEK CONTROL SOLUTION IN
VITRO T3 QL (1 EA per 90 days)
NORM-JECT LUER LOCK SYRINGE 10 ML T3 QL (200 EA per 34 days)
NORM-JECT LUER LOCK SYRINGE 20 ML T3 QL (200 EA per 34 days)
NORM-JECT LUER SLIP SYRINGE 1 ML T3 QL (200 EA per 34 days)
NOVA MAX CONTROL LIQUID† NORMAL
IN VITRO T3 QL (1 EA per 90 days)
NOVA MAX PLUS GLU/KET CONTROL
LIQUID IN VITRO T3 QL (1 EA per 90 days)
NOVA MAX PLUS KETONE TEST STRIP IN
VITRO T3
NOVA SAFETY LANCETS 23G T3 QL (100 EA per 25 days)
NOVA SAFETY LANCETS 28G T3 QL (100 EA per 25 days)
NOVA SUREFLEX LANCETS T3 QL (100 EA per 25 days)
NOVA SUREFLEX LANCING DEVICE T3 QL (1 EA per 365 days)
NOVOFINE AUTOCOVER 30G X 8 MM T3 QL (200 EA per 34 days)
OMRON 10 SERIES BP MONITOR DEVICE T3 QL (1 EA per 365 days)
OMRON 3 SERIES BP MONITOR DEVICE T3 QL (1 EA per 365 days)
OMRON 5 SERIES BP MONITOR DEVICE T3 QL (1 EA per 365 days)
OMRON 7 SERIES BP MONITOR DEVICE T3 QL (1 EA per 365 days)
ON CALL EXPRESS GLUCOSE CONTR
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
ON CALL LANCETS T3 QL (100 EA per 25 days)
ON CALL LANCING DEVICE T3 QL (1 EA per 365 days)
ON CALL PLUS GLUCOSE CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
ON CALL PLUS LANCETS T3 QL (100 EA per 25 days)
ON CALL PLUS LANCING DEVICE T3 QL (1 EA per 365 days)
ON CALL VIVID GLUCOSE CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
ONETOUCH DELICA LANCETS 30G T3 QL (100 EA per 25 days)
ONETOUCH DELICA LANCETS 33G T3 QL (100 EA per 25 days)
ONETOUCH DELICA LANCING DEV T3 QL (1 EA per 365 days)
ONETOUCH DELICA PLUS LANCET30G T3 QL (100 EA per 25 days)
ONETOUCH DELICA PLUS LANCET33G T3 QL (100 EA per 25 days)
ONETOUCH DELICA PLUS LANCING T3 QL (1 EA per 365 days)
ONETOUCH FINEPOINT LANCETS T3 QL (100 EA per 25 days)
ONETOUCH LANCETS T3 QL (100 EA per 25 days)
105
Drug Tier Requirements/Limits
ONETOUCH ULTRA CONTROL SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
ONETOUCH ULTRASOFT LANCETS T3 QL (100 EA per 25 days)
ONETOUCH VERIO SOLUTION HIGH IN
VITRO T3 QL (1 EA per 90 days)
ONETOUCH VERIO SOLUTION IN VITRO T3 QL (1 EA per 90 days)
OPTICHAMBER ADVANTAGE T3 QL (2 EA per 365 days)
OPTICHAMBER ADVANTAGE-LG MASK T3 QL (2 EA per 365 days)
OPTICHAMBER ADVANTAGE-MED MASK T3 QL (2 EA per 365 days)
OPTICHAMBER ADVANTAGE-SM MASK T3 QL (2 EA per 365 days)
OPTICHAMBER DIAMOND T3 QL (2 EA per 365 days)
OPTICHAMBER DIAMOND DEVICE T3 QL (2 EA per 365 days)
OPTICHAMBER DIAMOND-LG MASK
DEVICE T3 QL (2 EA per 365 days)
OPTICHAMBER DIAMOND-MD MASK T3 QL (2 EA per 365 days)
OPTICHAMBER DIAMOND-SM MASK T3 QL (2 EA per 365 days)
OPTICHAMBER FACE MASK-LARGE T3 QL (2 EA per 365 days)
OPTICHAMBER FACE MASK-MEDIUM T3 QL (2 EA per 365 days)
OPTICHAMBER FACE MASK-SMALL T3 QL (2 EA per 365 days)
OPTIHALER T3 QL (2 EA per 365 days)
OPTUMRX GLUCOSE CONTROL SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
pc lancets super thin 30g T3 QL (100 EA per 25 days)
PEAK AIR PEAK FLOW METER DEVICE T3 QL (1 EA per 365 days)
PEDIACARE GENTLE VAPORS T3 QL (1 EA per 365 days)
PERSONAL BEST FULL RANGE DEVICE T3 QL (1 EA per 365 days)
PERSONAL BEST LOW RANGE DEVICE T3 QL (1 EA per 365 days)
personal ultrasonic humidifier T3 QL (1 EA per 365 days)
PHARMACIST CHOICE LANCETS T3 QL (100 EA per 25 days)
PIKO 1 DEVICE T3 QL (1 EA per 365 days)
pip lancets 28g T3 QL (100 EA per 25 days)
pip lancets 30g T3 QL (100 EA per 25 days)
POCKET CHAMBER DEVICE T3 QL (2 EA per 365 days)
POCKET PEAK FLOW METER DEVICE T3 QL (1 EA per 365 days)
POCKETCHEM EZ CONTROL SOLUTION IN
VITRO T3 QL (1 EA per 90 days)
PRECISION GLUCOSE KETONE CONTR
LIQUID IN VITRO T3 QL (1 EA per 90 days)
106
Drug Tier Requirements/Limits
PRECISION XTRA KETONE STRIP IN VITRO T3
preferred plus lancets colored T3 QL (100 EA per 25 days)
preferred plus lancets thin T3 QL (100 EA per 25 days)
PRESTIGE GLUCOSE CONTROL LIQUID†
HIGH IN VITRO T3 QL (1 EA per 90 days)
PRESTIGE GLUCOSE CONTROL LIQUID†
LOW IN VITRO T3 QL (1 EA per 90 days)
pro comfort lancets 30g T3 QL (100 EA per 25 days)
pro comfort lancets 31g T3 QL (100 EA per 25 days)
pro comfort spacer adult T3 QL (2 EA per 365 days)
pro comfort spacer child T3 QL (2 EA per 365 days)
procare humidifier T3 QL (1 EA per 365 days)
procare spacer/adult mask device T3 QL (2 EA per 365 days)
procare spacer/child mask device T3 QL (2 EA per 365 days)
PROCARE UPPER ARM BP MONITOR
DEVICE T3 QL (1 EA per 365 days)
PROCARE WRIST BP MONITOR DEVICE T3 QL (1 EA per 365 days)
PRODIGY CONTROL SOLUTION SOLUTION
HIGH IN VITRO T3 QL (1 EA per 90 days)
PRODIGY CONTROL SOLUTION SOLUTION
LOW IN VITRO T3 QL (1 EA per 90 days)
PRODIGY LANCETS 21G T3 QL (100 EA per 25 days)
PRODIGY LANCETS 26G T3 QL (100 EA per 25 days)
PRODIGY LANCETS 28G T3 QL (100 EA per 25 days)
PRODIGY LANCING DEVICE T3 QL (1 EA per 365 days)
PRODIGY SAFETY LANCETS 26G T3 QL (100 EA per 25 days)
PRODIGY TWIST TOP LANCETS 28G T3 QL (100 EA per 25 days)
PULMOSAL NEBULIZATION SOLUTION 7 %
INHALATION T3
pure comfort humidifier T3 QL (1 EA per 365 days)
push button safety lancets 28g T3 QL (100 EA per 25 days)
px advanced lancing device T3 QL (1 EA per 365 days)
px lancets T3 QL (100 EA per 25 days)
px lancets ultra thin T3 QL (100 EA per 25 days)
px lancets ultra thin 28g T3 QL (100 EA per 25 days)
qc advanced lancing device T3 QL (1 EA per 365 days)
qc blood pressure monitor T3 QL (1 EA per 365 days)
qc lancets super thin 30g T3 QL (100 EA per 25 days)
107
Drug Tier Requirements/Limits
qc lancets ultra thin T3 QL (100 EA per 25 days)
qc unilet lancets 28g T3 QL (100 EA per 25 days)
qc unilet lancets micro thin T3 QL (100 EA per 25 days)
QUICKTEK CONTROL SOLUTION LIQUID
IN VITRO T3 QL (1 EA per 90 days)
QUINTET CONTROL HIGH/NORMAL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
ra blood pressure cuff monitor T3 QL (1 EA per 365 days)
ra blood pressure cuff monitor device T3 QL (1 EA per 365 days)
RA E-ZJECT LANCETS 28G T3 QL (100 EA per 25 days)
RA E-ZJECT LANCETS THIN 26G T3 QL (100 EA per 25 days)
RA E-ZJECT LANCETS THIN 28G T3 QL (100 EA per 25 days)
RA E-ZJECT LANCETS ULTRA THIN T3 QL (100 EA per 25 days)
ra lancets alternate site T3 QL (100 EA per 25 days)
ra lancets thin T3 QL (100 EA per 25 days)
ra lancets ultra thin T3 QL (100 EA per 25 days)
READYLANCE SAFETY LANCETS T3 QL (100 EA per 25 days)
REFUAH PLUS GLUCOSE CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
RELION BLOOD PRESSURE MONITOR
DEVICE T3 QL (1 EA per 365 days)
RELION BLOOD PRESSURE MONITOR KIT T3 QL (1 EA per 365 days)
RELION LANCET DEVICES 30G T3 QL (1 EA per 365 days)
RELION LANCETS T3 QL (100 EA per 25 days)
RELION LANCETS MICRO-THIN 33G T3 QL (100 EA per 25 days)
RELION LANCETS STANDARD 21G T3 QL (100 EA per 25 days)
RELION LANCETS THIN 26G T3 QL (100 EA per 25 days)
RELION LANCETS ULTRA-THIN 30G T3 QL (100 EA per 25 days)
RELION LANCING DEVICE T3 QL (1 EA per 365 days)
RELION PREMIUM MONITOR DEVICE T3 QL (1 EA per 365 days)
RELION ULTRA THIN LANCETS 30G T3 QL (100 EA per 25 days)
RELION ULTRA THIN PLUS LANCETS T3 QL (100 EA per 25 days)
RENEW ADV CARTRIDGE REFILLS T3 QL (100 EA per 25 days)
RENEW ADVANCED LANCING DEVICE T3 QL (1 EA per 365 days)
REXALL LANCETS ULTRA THIN 30G T3 QL (100 EA per 25 days)
RIGHTEST GC300 CONTROL LIQUID HIGH
IN VITRO T3 QL (1 EA per 90 days)
108
Drug Tier Requirements/Limits
RIGHTEST GC300 CONTROL LIQUID
NORMAL IN VITRO T3 QL (1 EA per 90 days)
RIGHTEST GD500 LANCING DEVICE T3 QL (1 EA per 365 days)
RIGHTEST GL300 LANCETS T3 QL (100 EA per 25 days)
RITEFLO DEVICE T3 QL (2 EA per 365 days)
SAFESNAP SYRINGE 10 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 20G X 1" 10 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 20G X 1" 5 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 20G X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 20G X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 21G X 1" 10 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 21G X 1" 5 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 21G X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 21G X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 22G X 1" 10 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 22G X 1" 5 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 22G X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 22G X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
SAFESNAP SYRINGE 5 ML T3 QL (200 EA per 34 days)
SAFESNAP TUBERCULIN SYRINGE 25G X
5/8" 1 ML T3 QL (200 EA per 34 days)
safety lancet 21g/pressure act T3 QL (100 EA per 25 days)
safety lancet 28g/pressure act T3 QL (100 EA per 25 days)
SAFETY LANCET 2MM T3 QL (100 EA per 25 days)
SAFETY LANCETS T3 QL (100 EA per 25 days)
SAFETY LANCETS 21G T3 QL (100 EA per 25 days)
safety lancets 28g T3 QL (100 EA per 25 days)
SAFETY LET LANCETS T3 QL (100 EA per 25 days)
SAFETY SEAL LANCETS T3 QL (100 EA per 25 days)
SAFETY-LOK SYRINGE 10 ML T3 QL (200 EA per 34 days)
SAFETY-LOK SYRINGE 21G X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
SAFETY-LOK SYRINGE 21G X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
SAFETY-LOK SYRINGE 5 ML T3 QL (200 EA per 34 days)
SAFETY-LOK TB SYRINGE 25G X 5/8" 1 ML T3 QL (200 EA per 34 days)
saps health twist top lancets T3 QL (100 EA per 25 days)
saps twist top lancets T3 QL (100 EA per 25 days)
sapscare twist top lancets T3 QL (100 EA per 25 days)
109
Drug Tier Requirements/Limits
sb lancets thin T3 QL (100 EA per 25 days)
sb lancets ultra thin T3 QL (100 EA per 25 days)
select-lite lancing device T3 QL (1 EA per 365 days)
self-taking blood pressure T3 QL (1 EA per 365 days)
self-taking blood pressure kit T3 QL (1 EA per 365 days)
SHOPKO AUTOLET LANCING DEVICE T3 QL (1 EA per 365 days)
SHOPKO ON-THE-GO LANCETS 30G T3 QL (100 EA per 25 days)
SHOPKO UNILET LANCETS 28G T3 QL (100 EA per 25 days)
SHOPKO UNILET LANCETS 30G T3 QL (100 EA per 25 days)
SIMPLE DIAGNOSTICS LANCING DEV T3 QL (1 EA per 365 days)
slip tip syringe 10 ml T3 QL (200 EA per 34 days)
sm blood pressure monitor T3 QL (1 EA per 365 days)
sm blood pressure monitor device T3 QL (1 EA per 365 days)
sm lancets 21g T3 QL (100 EA per 25 days)
sm lancets 33g T3 QL (100 EA per 25 days)
sm super thin lancets 30g T3 QL (100 EA per 25 days)
sm thin lancets 26g T3 QL (100 EA per 25 days)
sm wrist cuff bp monitor T3 QL (1 EA per 365 days)
SMART DIABETES VANTAGE LANCETS T3 QL (100 EA per 25 days)
SMART DIABETES VANTAGE LANCING T3 QL (1 EA per 365 days)
SMART SENSE COLOR LANCETS 33G T3 QL (100 EA per 25 days)
SMART SENSE STANDARD LANCETS T3 QL (100 EA per 25 days)
SMART SENSE SUPER THIN LANCETS T3 QL (100 EA per 25 days)
SMART SENSE THIN LANCETS 26G T3 QL (100 EA per 25 days)
SMARTEST CONTROL MEDIUM SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
SMARTEST LANCETS 28G T3 QL (100 EA per 25 days)
sodium chloride nebulization solution 3 %
inhalation T3
sodium chloride nebulization solution 7 %
inhalation T3
SOLUS V2 CONTROL SOLUTION HIGH IN
VITRO T3 QL (1 EA per 90 days)
SOLUS V2 CONTROL SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
SOLUS V2 LANCETS 28G T3 QL (100 EA per 25 days)
SOLUS V2 LANCING DEVICE T3 QL (1 EA per 365 days)
SOLUS V2 TWIST LANCETS 30G T3 QL (100 EA per 25 days)
110
Drug Tier Requirements/Limits
spinal needle 19g x 3" T3 QL (200 EA per 34 days)
spinal needle 19g x 3-1/2" T3 QL (200 EA per 34 days)
spinal needle 20g x 2-1/2" T3 QL (200 EA per 34 days)
spinal needle 20g x 3" T3 QL (200 EA per 34 days)
spinal needle tw 18g x 2-1/2" T3 QL (200 EA per 34 days)
STERILANCE TL T3 QL (100 EA per 25 days)
SUDACARE ADVANCED VAPOR-PLUG T3 QL (1 EA per 365 days)
super thin lancets T3 QL (100 EA per 25 days)
sure comfort lancets 18g T3 QL (100 EA per 25 days)
sure comfort lancets 21g T3 QL (100 EA per 25 days)
sure comfort lancets 23g T3 QL (100 EA per 25 days)
sure comfort lancets 28g T3 QL (100 EA per 25 days)
sure comfort lancets 30g T3 QL (100 EA per 25 days)
sure comfort lancing pen T3 QL (1 EA per 365 days)
SURE EDGE GLUCOSE CONTROL
SOLUTION HIGH IN VITRO T3 QL (1 EA per 90 days)
SURE EDGE GLUCOSE CONTROL
SOLUTION LOW IN VITRO T3 QL (1 EA per 90 days)
SURE EDGE GLUCOSE CONTROL
SOLUTION NORMAL IN VITRO T3 QL (1 EA per 90 days)
SURECHEK CONTROL SOLUTION LIQUID
HIGH IN VITRO T3 QL (1 EA per 90 days)
SURE-LANCE FLAT LANCETS T3 QL (100 EA per 25 days)
SURE-LANCE THIN LANCETS 28G T3 QL (100 EA per 25 days)
SURE-LANCE ULTRA THIN LANCETS T3 QL (100 EA per 25 days)
SURELIFE BP MONITOR/ARM DEVICE T3 QL (1 EA per 365 days)
SURELIFE BP MONITOR/WRIST DEVICE T3 QL (1 EA per 365 days)
SURESTEP GLUCOSE CONTROL SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
SURESTEP PRO HIGH GLUCOSE LIQUID IN
VITRO T3 QL (1 EA per 90 days)
SURESTEP PRO LOW GLUCOSE LIQUID IN
VITRO T3 QL (1 EA per 90 days)
SURESTEP PRO NORMAL GLUCOSE
LIQUID IN VITRO T3 QL (1 EA per 90 days)
SURE-TEST EASYPLUS CONTROL
SOLUTION NORMAL IN VITRO T3 QL (1 EA per 90 days)
SURE-TOUCH LANCETS UNIVERSAL T3 QL (100 EA per 25 days)
syringe 10-12 ml 12 ml T3 QL (200 EA per 34 days)
111
Drug Tier Requirements/Limits
syringe 20-25 ml 25 ml T3 QL (200 EA per 34 days)
syringe 30 ml T3 QL (200 EA per 34 days)
syringe 30-35 ml 35 ml T3 QL (200 EA per 34 days)
syringe 50-60 ml 60 ml T3 QL (200 EA per 34 days)
syringe 5-6 ml 6 ml T3 QL (200 EA per 34 days)
syringe disposable 10 ml T3 QL (200 EA per 34 days)
syringe disposable 20 ml T3 QL (200 EA per 34 days)
syringe disposable 30 ml T3 QL (200 EA per 34 days)
syringe disposable 5 ml T3 QL (200 EA per 34 days)
syringe disposable 50-60ml 60 ml T3 QL (200 EA per 34 days)
syringe disposable 60 ml T3 QL (200 EA per 34 days)
syringe eccentric tip 10 ml T3 QL (200 EA per 34 days)
syringe luer lock 30 ml (otc) T3 QL (200 EA per 34 days)
syringe luer lock 30 ml (rx) T3 QL (200 EA per 34 days)
syringe luer slip 1 ml (otc) T3 QL (200 EA per 34 days)
syringe luer slip 1 ml (rx) T3 QL (200 EA per 34 days)
syringe/cannula 10 ml T3 QL (200 EA per 34 days)
T.E.D. BELTED THIGH/L-LONG T3 QL (2 EA per 180 days)
T.E.D. BELTED THIGH/M-REGULAR T3 QL (2 EA per 180 days)
T.E.D. BELTED THIGH/S-LONG T3 QL (2 EA per 180 days)
T.E.D. BELTED THIGH/XL-LONG T3 QL (2 EA per 180 days)
T.E.D. BELTED THIGH/XL-REGULAR (OTC) T3 QL (2 EA per 180 days)
T.E.D. BELTED THIGH/XL-REGULAR (RX) T3 QL (2 EA per 180 days)
T.E.D. BELTED THIGH/XS-LONG (OTC) T3 QL (2 EA per 180 days)
T.E.D. BELTED THIGH/XS-LONG (RX) T3 QL (2 EA per 180 days)
T.E.D. BELTED THIGH/XS-REGULAR (OTC) T3 QL (2 EA per 180 days)
T.E.D. BELTED THIGH/XS-REGULAR (RX) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/L-LONG (OTC) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/L-LONG (RX) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/L-REGULAR (OTC) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/L-REGULAR (RX) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/M-LONG (OTC) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/M-LONG (RX) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/M-REGULAR (OTC) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/M-REGULAR (RX) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/S-LONG (OTC) T3 QL (2 EA per 180 days)
112
Drug Tier Requirements/Limits
T.E.D. KNEE LENGTH/S-LONG (RX) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/S-REGULAR (OTC) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/S-REGULAR (RX) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/XL-LONG (OTC) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/XL-LONG (RX) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/XL-REGULAR (OTC) T3 QL (2 EA per 180 days)
T.E.D. KNEE LENGTH/XL-REGULAR (RX) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/L-LONG (OTC) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/L-LONG (RX) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/L-REGULAR (OTC) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/L-REGULAR (RX) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/L-SHORT (OTC) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/L-SHORT (RX) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/M-LONG (OTC) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/M-LONG (RX) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/M-REGULAR (OTC) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/M-REGULAR (RX) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/M-SHORT (OTC) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/M-SHORT (RX) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/S-LONG (OTC) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/S-LONG (RX) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/S-REGULAR (OTC) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/S-REGULAR (RX) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/S-SHORT (OTC) T3 QL (2 EA per 180 days)
T.E.D. THIGH LENGTH/S-SHORT (RX) T3 QL (2 EA per 180 days)
TAI DOC CONTROL SOLUTION NORMAL IN
VITRO T3 QL (1 EA per 90 days)
talking sense bp monitor device T3 QL (1 EA per 365 days)
TECHLITE AST LANCETS T3 QL (100 EA per 25 days)
TECHLITE LANCETS T3 QL (100 EA per 25 days)
TECHLITE LANCETS 30G T3 QL (100 EA per 25 days)
TELCARE GLUCOSE CONTROL SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
TERUMO SURGUARD2 SYRINGE 20G X 1"
10 ML T3 QL (200 EA per 34 days)
TERUMO SURGUARD2 SYRINGE 20G X 1" 5
ML T3 QL (200 EA per 34 days)
113
Drug Tier Requirements/Limits
TERUMO SURGUARD2 SYRINGE 20G X 1-
1/2" 10 ML T3 QL (200 EA per 34 days)
TERUMO SURGUARD2 SYRINGE 20G X 1-
1/2" 5 ML T3 QL (200 EA per 34 days)
TERUMO SURGUARD2 SYRINGE 21G X 1"
10 ML T3 QL (200 EA per 34 days)
TERUMO SURGUARD2 SYRINGE 21G X 1-
1/2" 10 ML T3 QL (200 EA per 34 days)
TERUMO SURGUARD2 SYRINGE 21G X 1-
1/2" 5 ML T3 QL (200 EA per 34 days)
TERUMO SURGUARD2 SYRINGE 27G X 1/2"
1 ML T3 QL (200 EA per 34 days)
TERUMO SYRINGE 30 ML T3 QL (200 EA per 34 days)
TERUMO SYRINGE/NEEDLE 20G X 1" 5 ML T3 QL (200 EA per 34 days)
TERUMO SYRINGE/NEEDLE 20G X 1-1/2" 5
ML T3 QL (200 EA per 34 days)
TERUMO SYRINGE/NEEDLE 21G X 1" 5 ML T3 QL (200 EA per 34 days)
TERUMO SYRINGE/NEEDLE 21G X 1-1/2" 5
ML T3 QL (200 EA per 34 days)
TERUMO SYRINGE/NEEDLE 22G X 1" 5 ML T3 QL (200 EA per 34 days)
TERUMO SYRINGE/NEEDLE 22G X 1-1/2" 5
ML T3 QL (200 EA per 34 days)
tgt advanced lancing device T3 QL (1 EA per 365 days)
tgt blood pressure monitor device T3 QL (1 EA per 365 days)
tgt lancet alternate site T3 QL (100 EA per 25 days)
tgt lancet micro thin 33g T3 QL (100 EA per 25 days)
tgt lancet super thin 30g T3 QL (100 EA per 25 days)
tgt lancet thin 23g T3 QL (100 EA per 25 days)
tgt lancet thin 26g T3 QL (100 EA per 25 days)
tgt lancet ultra thin 28g T3 QL (100 EA per 25 days)
tgt lancet ultra thin 30g T3 QL (100 EA per 25 days)
tgt lancing device T3 QL (1 EA per 365 days)
todays health lancing device T3 QL (1 EA per 365 days)
todays health thin lancets 28g T3 QL (100 EA per 25 days)
todays health thin lancets 30g T3 QL (100 EA per 25 days)
toomey syringe 70 ml T3 QL (200 EA per 34 days)
topcare lancets micro-thin 33g T3 QL (100 EA per 25 days)
travel lancets T3 QL (100 EA per 25 days)
TRAVEL LANCETS ADVANCED 28G T3 QL (100 EA per 25 days)
114
Drug Tier Requirements/Limits
true comfort twist top lancets T3 QL (100 EA per 25 days)
TRUE METRIX LEVEL 1 SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
TRUE METRIX LEVEL 2 SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
TRUE METRIX LEVEL 3 SOLUTION HIGH IN
VITRO T3 QL (1 EA per 90 days)
TRUECONTROL GLUCOSE CONT LEV 0
LIQUID IN VITRO T3 QL (1 EA per 90 days)
TRUECONTROL GLUCOSE CONT LEV 1
LIQUID IN VITRO T3 QL (1 EA per 90 days)
TRUEDRAW LANCING DEVICE T3 QL (1 EA per 365 days)
TRUEPLUS LANCETS 26G T3 QL (100 EA per 25 days)
TRUEPLUS LANCETS 28G T3 QL (100 EA per 25 days)
TRUEPLUS LANCETS 30G T3 QL (100 EA per 25 days)
TRUEPLUS LANCETS 33G T3 QL (100 EA per 25 days)
TRUEPLUS SAFETY LANCETS 28G T3 QL (100 EA per 25 days)
TRUETEST CONTROL LEVEL 1 LIQUID IN
VITRO T3 QL (1 EA per 90 days)
TRUETEST CONTROL LEVEL 2 LIQUID IN
VITRO T3 QL (1 EA per 90 days)
TRUETEST CONTROL LEVEL 3 LIQUID IN
VITRO T3 QL (1 EA per 90 days)
TRUETRACK GLUCOSE CONTROL LIQUID†
HIGH IN VITRO T3 QL (1 EA per 90 days)
TRUETRACK GLUCOSE CONTROL LIQUID†
IN VITRO T3 QL (1 EA per 90 days)
TRUETRACK GLUCOSE CONTROL LIQUID†
LOW IN VITRO T3 QL (1 EA per 90 days)
TRUZONE PEAK FLOW METER DEVICE T3 QL (1 EA per 365 days)
tuberculin syringe 1 ml T3 QL (200 EA per 34 days)
tuberculin syringe 25g x 5/8" 1 ml T3 QL (200 EA per 34 days)
tuberculin syringe 26g x 3/8" 1 ml T3 QL (200 EA per 34 days)
tuberculin syringe 26g x 5/8" 1 ml T3 QL (200 EA per 34 days)
two party blood pressure kit T3 QL (1 EA per 365 days)
ULTICARE THIN LANCETS 28G T3 QL (100 EA per 25 days)
ULTICARE THIN LANCETS 30G T3 QL (100 EA per 25 days)
ULTICARE TUBERCULIN SAFETY SYR 25G
X 1" 1 ML T3 QL (200 EA per 34 days)
115
Drug Tier Requirements/Limits
ULTICARE TUBERCULIN SAFETY SYR 25G
X 5/8" 1 ML T3 QL (200 EA per 34 days)
ULTICARE TUBERCULIN SAFETY SYR 27G
X 1/2" 1 ML T3 QL (200 EA per 34 days)
ULTICARE TUBERCULIN SAFETY SYR 27G
X 5/8" 1 ML T3 QL (200 EA per 34 days)
ULTICARE TUBERCULIN SAFETY SYR 28G
X 1/2" 1 ML T3 QL (200 EA per 34 days)
ULTI-LANCE AUTO-ADJUST DEVICE T3 QL (1 EA per 365 days)
ULTI-LANCE AUTOMATIC T3 QL (1 EA per 365 days)
ULTILET BASIC LANCETS 30G T3 QL (100 EA per 25 days)
ULTILET CLASSIC LANCETS T3 QL (100 EA per 25 days)
ULTILET LANCETS T3 QL (100 EA per 25 days)
ULTILET SAFETY LANCETS 23G T3 QL (100 EA per 25 days)
ultra thin lancets 28g T3 QL (100 EA per 25 days)
ultra thin lancets 30g T3 QL (100 EA per 25 days)
ultra thin lancets 31g T3 QL (100 EA per 25 days)
ultra-care lancets 30g T3 QL (100 EA per 25 days)
ULTRA-THIN II AUTO LANCET T3 QL (100 EA per 25 days)
ULTRA-THIN II LANCETS T3 QL (100 EA per 25 days)
ULTRATRAK PRO CONTROL SOLUTION IN
VITRO T3 QL (1 EA per 90 days)
ULTRATRAK PRO CONTROL SOLUTION
NORMAL IN VITRO T3 QL (1 EA per 90 days)
ULTRATRAK ULTIMATE CONTROL
SOLUTION IN VITRO T3 QL (1 EA per 90 days)
UNILET COMFORTOUCH LANCET T3 QL (100 EA per 25 days)
UNILET EXCELITE T3 QL (100 EA per 25 days)
UNILET EXCELITE II T3 QL (100 EA per 25 days)
UNILET G.P. LANCET T3 QL (100 EA per 25 days)
UNILET G.P. SUPERLITE LANCET T3 QL (100 EA per 25 days)
UNILET GP 28 ULTRA THIN T3 QL (100 EA per 25 days)
UNILET LANCET T3 QL (100 EA per 25 days)
UNILET MICRO-THIN 33G T3 QL (100 EA per 25 days)
UNILET SUPERLITE LANCET T3 QL (100 EA per 25 days)
UNILET SUPER-THIN 30G T3 QL (100 EA per 25 days)
UNILET ULTRA-THIN 28G T3 QL (100 EA per 25 days)
UNISTIK 3 GENTLE T3 QL (100 EA per 25 days)
116
Drug Tier Requirements/Limits
UNISTIK PRO SAFETY LANCET T3 QL (100 EA per 25 days)
UNISTIK SAFETY LANCETS 28G T3 QL (100 EA per 25 days)
UNISTIK SAFETY LANCETS 30G T3 QL (100 EA per 25 days)
UNISTIK TOUCH SAFETY LANC 21G T3 QL (100 EA per 25 days)
UNISTIK TOUCH SAFETY LANC 23G T3 QL (100 EA per 25 days)
UNISTIK TOUCH SAFETY LANC 28G T3 QL (100 EA per 25 days)
UNISTIK TOUCH SAFETY LANC 30G T3 QL (100 EA per 25 days)
UNISTRIP CONTROL SOLUTION HIGH IN
VITRO T3 QL (1 EA per 90 days)
UNISTRIP CONTROL SOLUTION LOW IN
VITRO T3 QL (1 EA per 90 days)
UNIVERSAL 1 LANCETS THIN 26G T3 QL (100 EA per 25 days)
UNIVERSAL 1 LANCETS ULTRA THIN T3 QL (100 EA per 25 days)
value plus lancet standard 21g T3 QL (100 EA per 25 days)
value plus lancets super thin T3 QL (100 EA per 25 days)
value plus lancets thin 26g T3 QL (100 EA per 25 days)
value plus lancing device T3 QL (1 EA per 365 days)
valumark lancet super thin 30g T3 QL (100 EA per 25 days)
valumark lancet ultra thin 28g T3 QL (100 EA per 25 days)
valved holding chamber device T3 QL (2 EA per 365 days)
VANISHPOINT SAFETY SYRINGE 21G X 1"
5 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 21G X 1-
1/2" 10 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 21G X 1-
1/2" 5 ML T3 QL (200 EA per 34 days)
VANISHPOINT SAFETY SYRINGE 22G X 1-
1/2" 5 ML T3 QL (200 EA per 34 days)
VANISHPOINT SYRINGE 21G X 1-1/2" 10 ML T3 QL (200 EA per 34 days)
VANISHPOINT SYRINGE 21G X 1-1/2" 5 ML T3 QL (200 EA per 34 days)
VANISHPOINT TUBERCULIN SYRINGE 25G
X 1" 1 ML T3 QL (200 EA per 34 days)
VANISHPOINT TUBERCULIN SYRINGE 25G
X 5/8" 1 ML T3 QL (200 EA per 34 days)
vaporizer T3 QL (1 EA per 365 days)
verasens glucose control liquid in vitro T3 QL (1 EA per 90 days)
VICKS COOL MIST HUMIDIFIER T3 QL (1 EA per 365 days)
VICKS HUMIDIFIER T3 QL (1 EA per 365 days)
117
Drug Tier Requirements/Limits
VICKS MINI COOLMIST HUMIDIFIER T3 QL (1 EA per 365 days)
VICKS NURSERY VAPORIZER T3 QL (1 EA per 365 days)
VICTORY CONTROL LEVEL 1/2 SOLUTION
IN VITRO T3 QL (1 EA per 90 days)
VIDA MIA AUTOLET LANCING DEV T3 QL (1 EA per 365 days)
VIDA MIA UNILET LANCETS 28G T3 QL (100 EA per 25 days)
VIDA MIA UNILET LANCETS 30G T3 QL (100 EA per 25 days)
VIVAGUARD INO CONTROL SOLUTION
LIQUID IN VITRO T3 QL (1 EA per 90 days)
VIVAGUARD LANCETS T3 QL (100 EA per 25 days)
VIVAGUARD LANCING DEVICE T3 QL (1 EA per 365 days)
VORTEX VALVED HOLDING CHAMBER
DEVICE T3 QL (2 EA per 365 days)
W&F LANCETS 26G T3 QL (100 EA per 25 days)
W&F LANCETS COLORED 21G T3 QL (100 EA per 25 days)
walgreens adv travel lancets T3 QL (100 EA per 25 days)
WALGREENS LANCETS T3 QL (100 EA per 25 days)
walgreens lancets micro thin T3 QL (100 EA per 25 days)
walgreens lancets super thin T3 QL (100 EA per 25 days)
WALGREENS LANCING DEVICE T3 QL (1 EA per 365 days)
WALGREENS THIN LANCETS T3 QL (100 EA per 25 days)
WALGREENS ULTRA THIN LANCETS T3 QL (100 EA per 25 days)
WATCHHALER DEVICE T3 QL (2 EA per 365 days)
WHITACRE SPINAL NEEDLE 22G X 3-1/2" T3 QL (200 EA per 34 days)
womens adv bp monitor/uppr arm T3 QL (1 EA per 365 days)
wrist blood pressure monitor T3 QL (1 EA per 365 days)
XPRES CONTROL SOLUTION NORMAL IN
VITRO T3 QL (1 EA per 90 days)
YALE REUSABLE SYRINGE 10 ML T3 QL (200 EA per 34 days)
YALE REUSABLE SYRINGE 2 ML T3 QL (200 EA per 34 days)
YALE REUSABLE SYRINGE 20 ML T3 QL (200 EA per 34 days)
YALE REUSABLE SYRINGE 3 ML T3 QL (200 EA per 34 days)
YALE REUSABLE SYRINGE 30 ML T3 QL (200 EA per 34 days)
YALE REUSABLE SYRINGE 5 ML T3 QL (200 EA per 34 days)
YALE REUSABLE SYRINGE 50 ML T3 QL (200 EA per 34 days)
YALE REUSABLE TB SYRINGE 1 ML T3 QL (200 EA per 34 days)
YALE REUSABLE TB SYRINGE 1/4 ML T3 QL (200 EA per 34 days)
118
Drug Tier Requirements/Limits
YALE REUSABLE TB SYRINGE 2 ML T3 QL (200 EA per 34 days)
ZOEY ASTHMAMENTOR DEVICE T3 QL (1 EA per 365 days)
ZOEY OPTICHAMBER ADVANTAGE T3 QL (2 EA per 365 days)
ZOEY PERSONAL BEST PEAK METER
DEVICE T3 QL (1 EA per 365 days)
Diagnostic Agents
Adrenocortical Insufficiency
ACTHAR GEL 80 UNIT/ML INJECTION T4 PA
Diabetes Mellitus
ADVOCATE ARM BPM DEVICE T3 QL (1 EA per 365 days)
Ketones
CHEMSTRIP K STRIP IN VITRO T3
CVS KETONE CARE STRIP IN VITRO T3
ketone test strip in vitro T3
KETOSTIX STRIP IN VITRO T3
RELION KETONE STRIP IN VITRO T3
RELION KETONE TEST STRIP IN VITRO T3
Protein
ALBUSTIX STRIP IN VITRO T3
Roentgenography And Other Imaging
Agents
AZEDRA DOSIMETRIC SOLUTION 15
MCI/ML INTRAVENOUS T4 PA
AZEDRA THERAPEUTIC SOLUTION 15
MCI/ML INTRAVENOUS T4 PA
Sugar
DIASTIX STRIP IN VITRO T3
Thyroid Function
THYROGEN SOLUTION RECONSTITUTED
1.1 MG INTRAMUSCULAR T4 PA
Urine And Feces Contents
CHEMSTRIP 10/SG STRIP IN VITRO T3
CHEMSTRIP UGK STRIP IN VITRO T3
KETO-DIASTIX STRIP IN VITRO T3
MULTISTIX 10 SG STRIP IN VITRO T3
119
Drug Tier Requirements/Limits
Electrolytic, Caloric, And Water
Balance
Alkalinizing Agents
cytra-2 solution 500-334 mg/5ml oral T3
potassium citrate er tablet extended release 10
meq (1080 mg) oral T3
potassium citrate er tablet extended release 5 meq
(540 mg) oral T3
sod citrate-citric acid solution 500-334 mg/5ml
oral T3
UROCIT-K 10 TABLET EXTENDED
RELEASE 10 MEQ (1080 MG) ORAL T3
UROCIT-K 5 TABLET EXTENDED RELEASE
5 MEQ (540 MG) ORAL T3
Ammonia Detoxicants
CARBAGLU TABLET 200 MG ORAL T4 PA
constulose solution 10 gm/15ml oral T3
lactulose solution 10 gm/15ml oral T3
lactulose solution 20 gm/30ml oral T3
Caloric Agents
cvs glucose tablet chewable 4 gm oral T3
cvs soft glucose tablet chewable 4 gm oral T3
DEX4 QUICK DISSOLVE GLUCOSE TABLET
CHEWABLE 4 GM ORAL T3
first choice glucose tablet chewable 4 gm oral T3
fp glucose tablet chewable 4 gm oral T3
glucose tablet chewable 4 gm oral T3
gnp glucose tablet chewable 4 gm oral T3
gnp quick dissolve glucose tablet chewable 4 gm
oral T3
leader quick dissolve glucose tablet chewable 4
gm oral T3
ms quick dissolve glucose tablet chewable 4 gm
oral T3
sm glucose tablet chewable 4 gm oral T3
TRUEPLUS GLUCOSE ON THE GO TABLET
CHEWABLE ORAL T3
TRUEPLUS GLUCOSE TABLET CHEWABLE
ORAL T3
120
Drug Tier Requirements/Limits
ultilet glucose tablet chewable 4 gm oral T3
walgreens glucose tablet chewable 4 gm oral T3
Carbonic Anhydrase Inhibitors
acetazolamide er capsule extended release 12
hour 500 mg oral T3
acetazolamide tablet 125 mg oral T3
acetazolamide tablet 250 mg oral T3
DIAMOX SEQUELS CAPSULE EXTENDED
RELEASE 12 HOUR 500 MG ORAL T3
Diuretics, Miscellaneous
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 100 MG ORAL T3
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 200 MG ORAL T3
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 400 MG ORAL T3
theophylline er tablet extended release 12 hour
200 mg oral T3
theophylline er tablet extended release 12 hour
300 mg oral T3
theophylline er tablet extended release 24 hour
400 mg oral T3
theophylline er tablet extended release 24 hour
600 mg oral T3
Electrolytic,Caloric,Water Balance
Misc,
CRYSVITA SOLUTION 10 MG/ML
SUBCUTANEOUS T4 PA
CRYSVITA SOLUTION 20 MG/ML
SUBCUTANEOUS T4 PA
CRYSVITA SOLUTION 30 MG/ML
SUBCUTANEOUS T4 PA
Irrigating Solutions
sterile water for irrigation solution irrigation T3
Loop Diuretics
bumetanide tablet 0.5 mg oral T3
bumetanide tablet 1 mg oral T3
bumetanide tablet 2 mg oral T3
DEMADEX TABLET 10 MG ORAL T3
121
Drug Tier Requirements/Limits
DEMADEX TABLET 20 MG ORAL T3
furosemide solution 10 mg/ml oral T3
furosemide solution 8 mg/ml oral T3
furosemide tablet 20 mg oral T3
furosemide tablet 40 mg oral T3
furosemide tablet 80 mg oral T3
LASIX TABLET 20 MG ORAL T3
LASIX TABLET 40 MG ORAL T3
LASIX TABLET 80 MG ORAL T3
torsemide tablet 10 mg oral T3
torsemide tablet 100 mg oral T3
torsemide tablet 20 mg oral T3
torsemide tablet 5 mg oral T3
Potassium-Removing Agents
KIONEX SUSPENSION 15 GM/60ML ORAL T3
sodium polystyrene sulfonate suspension 15
gm/60ml oral T3
SPS SUSPENSION 15 GM/60ML ORAL T3
Potassium-Sparing Diuretics
ALDACTAZIDE TABLET 25-25 MG ORAL T3
ALDACTONE TABLET 100 MG ORAL T3
ALDACTONE TABLET 25 MG ORAL T3
ALDACTONE TABLET 50 MG ORAL T3
amiloride hcl tablet 5 mg oral T3
amiloride-hydrochlorothiazide tablet 5-50 mg
oral T3
DYAZIDE CAPSULE 37.5-25 MG ORAL T3
MAXZIDE TABLET 75-50 MG ORAL T3
MAXZIDE-25 TABLET 37.5-25 MG ORAL T3
spironolactone tablet 100 mg oral T3
spironolactone tablet 25 mg oral T3
spironolactone tablet 50 mg oral T3
spironolactone-hctz tablet 25-25 mg oral T3
triamterene-hctz capsule 37.5-25 mg oral T3
triamterene-hctz tablet 37.5-25 mg oral T3
triamterene-hctz tablet 75-50 mg oral T3
Replacement Preparations
122
Drug Tier Requirements/Limits
actical capsule oral T3
ADVANTAGE CARE ELECTROLYTE PED
SOLUTION ORAL T3
ALIVE WOMENS ENERGY TABLET ORAL T3
antacid calcium extra strength tablet chewable
750 mg oral T3
antacid calcium tablet chewable 500 mg oral T3
antacid extra strength tablet chewable 750 mg
oral T3
antacid regular strength tablet chewable 500 mg
oral T3
antacid tablet chewable 500 mg oral T3
antacid ultra strength tablet chewable 1000 mg
oral T3
baby darlings ped electrolyte solution oral T3
BIO-35 GLUTEN-FREE CAPSULE ORAL T3
biocal capsule oral T3
calcarb 600 tablet 1500 (600 ca) mg oral T3
CALCITRATE TABLET 315-250 MG-UNIT
ORAL T3
CALCITRATE TABLET 950 MG ORAL T3
calcium + d tablet 250-125 mg-unit oral T3
calcium + d tablet 315-200 mg-unit oral T3
calcium + d3 tablet 600-200 mg-unit oral T3
calcium 500 + d3 tablet 500-600 mg-unit oral T3
calcium 500 +d tablet 500-400 mg-unit oral T3
calcium 500+d tablet 500-400 mg-unit oral T3
calcium 500+d3 tablet 500-400 mg-unit oral T3
calcium 600 tablet 1500 (600 ca) mg oral T3
calcium 600/vitamin d tablet 600-400 mg-unit
oral T3
calcium 600+d plus minerals tablet 600-400 mg-
unit oral T3
calcium 600+d3 tablet 600-200 mg-unit oral T3
calcium 600-d tablet 600-400 mg-unit oral T3
calcium antacid extra strength tablet chewable
750 mg oral T3
calcium antacid tablet chewable 500 mg oral T3
123
Drug Tier Requirements/Limits
calcium antacid ultra max st tablet chewable
1000 mg oral T3
calcium antacid ultra strength tablet chewable
1000 mg oral T3
calcium antacid ultra tablet chewable 1000 mg
oral T3
calcium carbonate antacid suspension 1250
mg/5ml oral T3
calcium carbonate antacid tablet chewable 500
mg oral T3
calcium carbonate tablet 1500 (600 ca) mg oral T3
calcium carbonate tablet chewable 500 mg oral T3
calcium carbonate-vitamin d tablet 500-400 mg-
unit oral T3
calcium carbonate-vitamin d tablet 600-400 mg-
unit oral T3
calcium citrate + d tablet 315-200 mg-unit oral T3
calcium citrate + d tablet 315-250 mg-unit oral T3
calcium citrate + d3 maximum tablet 315-250
mg-unit oral T3
calcium citrate + d3 tablet 200-250 mg-unit oral T3
calcium citrate + tablet 315-200 mg-unit oral T3
calcium citrate +d tablet 315-250 mg-unit oral T3
calcium citrate maximum/vit d tablet 315-250 mg-
unit oral T3
calcium citrate petite/vit d tablet 200-250 mg-unit
oral T3
calcium citrate tablet 200 mg oral T3
calcium citrate tablet 250 mg oral T3
calcium citrate tablet 950 mg oral T3
calcium citrate+d3 petites tablet 200-250 mg-unit
oral T3
calcium citrate+d3 tablet 315-250 mg-unit oral T3
calcium citrate-vitamin d tablet 200-125 mg-unit
oral T3
calcium citrate-vitamin d tablet 315-200 mg-unit
oral T3
calcium citrate-vitamin d tablet 315-250 mg-unit
oral T3
124
Drug Tier Requirements/Limits
calcium citrate-vitamin d3 tablet 315-250 mg-unit
oral T3
calcium extra d3 tablet 500-600 mg-unit oral T3
calcium gluconate tablet 500 mg oral T3
calcium lactate tablet 648 mg oral T3
calcium tablet 1500 mg oral T3
calcium-vitamin d tablet 500-400 mg-unit oral T3
calcium-vitamin d tablet 600-200 mg-unit oral T3
calcium-vitamin d3 tablet 500-400 mg-unit oral T3
CAL-GEST ANTACID TABLET CHEWABLE
500 MG ORAL T3
CALTRATE 600 TABLET 1500 (600 CA) MG
ORAL T3
CERALYTE 70 SOLUTION ORAL T3
CERASPORT EX1 SOLUTION ORAL T3
CERASPORT SOLUTION ORAL T3
CITRACAL CALCIUM GUMMIES TABLET
CHEWABLE 250-115-250 MG-MG-UNIT
ORAL
T3
CITRACAL MAXIMUM PLUS TABLET
ORAL T3
CITRACAL MAXIMUM TABLET 315-250
MG-UNIT ORAL T3
CITRACAL PETITES/VITAMIN D TABLET
200-250 MG-UNIT ORAL T3
citrus calcium +d tablet 315-250 mg-unit oral T3
citrus calcium/vitamin d tablet 200-250 mg-unit
oral T3
cvs antacid tablet chewable 500 mg oral T3
cvs calcium 600 + d/minerals tablet 600-400 mg-
unit oral T3
cvs calcium citrate +d tablet 315-250 mg-unit
oral T3
cvs calcium citrate +d3 mini tablet 200-250 mg-
unit oral T3
cvs calcium tablet 1500 (600 ca) mg oral T3
cvs daily multiple for women tablet oral T3
cvs daily multiple women 50+ tablet oral T3
cvs electrolyte solution solution oral T3
125
Drug Tier Requirements/Limits
cvs oyster shell calcium tablet 500 mg oral T3
cvs ped electrolyte freeze pop solution oral T3
cvs pediatric electrolyte solution oral T3
cvs spectravite probiotic tablet oral T3
cvs womens active daily tablet oral T3
ENFALYTE SOLUTION ORAL T3
ENFAMIL ENFALYTE SOLUTION ORAL T3
EPIKLOR PACKET 20 MEQ ORAL T3
eq calcium citrate+d tablet 315-250 mg-unit oral T3
eq one daily womens health tablet oral T3
eql antacid tablet chewable 500 mg oral T3
eql calcium citrate/vitamin d tablet 315-250 mg-
unit oral T3
eql calcium citrate/vitamin d3 tablet 315-250 mg-
unit oral T3
eql century mens tablet oral T3
eql one daily diet support tablet oral T3
eql one daily womens 50+ adv tablet oral T3
eql pediatric electrolyte solution oral T3
FOSFREE TABLET ORAL T3
GAVISCON ACID BRKTHRGH FORMULA
TABLET CHEWABLE 500 MG ORAL T3
gnp antacid extra strength tablet chewable 750
mg oral T3
gnp antacid tablet chewable 500 mg oral T3
gnp calcium 500 +d3 tablet 500-600 mg-unit oral T3
gnp calcium citrate +d3 tablet 315-250 mg-unit
oral T3
gnp calcium citrate+d maximum tablet 315-250
mg-unit oral T3
gnp mega multi for women tablet oral T3
gnp one daily womens health tablet oral T3
gnp pediatric electrolyte solution oral T3
gnp therapeutic-m tablet oral T3
hair/skin/nails/biotin tablet oral T3
HEALTHY MAMA TAME THE FLAME
TABLET CHEWABLE 500 MG ORAL T3
h-e-b oral electrolyte solution oral T3
126
Drug Tier Requirements/Limits
hm calcium antacid ex st tablet chewable 750 mg
oral T3
hm calcium antacid tablet chewable 500 mg oral T3
hm calcium antacid tablet chewable 750 mg oral T3
hm calcium antacid ultra st tablet chewable 1000
mg oral T3
hm calcium citrate+d3 petite tablet 200-250 mg-
unit oral T3
hm calcium citrate+vitamin d tablet 315-250 mg-
unit oral T3
hm calcium-vitamin d-minerals tablet 600-400
mg-unit oral T3
hm magnesium tablet 250 mg oral T3
hm one daily womens tablet oral T3
hm pediatric electrolyte solution oral T3
hm womens 50+ advanced daily tablet oral T3
HYPERSAL NEBULIZATION SOLUTION 7 %
INHALATION T3
KLOR-CON 10 TABLET EXTENDED
RELEASE 10 MEQ ORAL T3
KLOR-CON M10 TABLET EXTENDED
RELEASE 10 MEQ ORAL T3
KLOR-CON M20 TABLET EXTENDED
RELEASE 20 MEQ ORAL T3
KLOR-CON PACKET 20 MEQ ORAL T3
KLOR-CON SPRINKLE CAPSULE
EXTENDED RELEASE 10 MEQ ORAL T3
KLOR-CON TABLET EXTENDED RELEASE
8 MEQ ORAL T3
kls antacid tablet chewable 500 mg oral T3
kp calcium citrate+d tablet 315-250 mg-unit oral T3
kp vitamin b-12 tablet 1000 mcg oral T3
kp womens 50+ daily formula tablet oral T3
kp womens daily formula tablet oral T3
K-TAB TABLET EXTENDED RELEASE 10
MEQ ORAL T3
K-TAB TABLET EXTENDED RELEASE 8
MEQ ORAL T3
MAG64 TABLET DELAYED RELEASE 64 MG
ORAL T3
127
Drug Tier Requirements/Limits
MAGDELAY TABLET DELAYED RELEASE
64 MG ORAL T3
magnesium chloride tablet delayed release 64 mg
oral T3
mega multivitamin for women tablet oral T3
MG PLUS PROTEIN TABLET 133 MG ORAL T3
MG-PLUS PROTEIN TABLET 133 MG ORAL T3
multi for her tablet oral T3
multivitamin women tablet oral T3
NEBUSAL NEBULIZATION SOLUTION 3 %
INHALATION T3
ONE-A-DAY ENERGY TABLET ORAL T3
ONE-A-DAY MENOPAUSE FORMULA
TABLET ORAL T3
ONE-A-DAY PROACTIVE 65+ TABLET
ORAL T3
ONE-A-DAY TEEN ADVANTAGE/HIM
TABLET ORAL T3
ONE-A-DAY WOMENS 50 PLUS TABLET
ORAL T3
ONE-A-DAY WOMENS 50+ ADVANTAGE
TABLET ORAL T3
ONE-A-DAY WOMENS FORMULA TABLET
ORAL T3
ONE-A-DAY WOMENS HEALTHY SKIN
TABLET ORAL T3
ONE-A-DAY WOMENS MIND & BODY
TABLET ORAL T3
ONE-A-DAY WOMENS PETITES TABLET
ORAL T3
OPTISOURCE POST BARIATRIC SURG
TABLET CHEWABLE ORAL T3
oral electrolytes solution oral T3
ORALYTE FREEZER POPS SOLUTION ORAL T3
ORALYTE SOLUTION ORAL T3
ORTHOVITE TABLET ORAL T3
OS-CAL EXTRA D3 TABLET 500-600 MG-
UNIT ORAL T3
OYSCO 500 TABLET 500 MG ORAL T3
128
Drug Tier Requirements/Limits
OYSCO 500+D TABLET 500-200 MG-UNIT
ORAL T3
oyst-cal d tablet 250-125 mg-unit oral T3
oyst-cal tablet 500 mg oral T3
oyster calcium tablet 500 mg oral T3
oyster shell calcium + d tablet 500-400 mg-unit
oral T3
oyster shell calcium + d3 tablet 500-400 mg-unit
oral T3
oyster shell calcium 500 + d tablet 500-200 mg-
unit oral T3
oyster shell calcium tablet 500 mg oral T3
oyster shell calcium tablet 500-400 mg-unit oral T3
oyster shell calcium/d tablet 250-125 mg-unit oral T3
oyster shell calcium/d tablet 500-200 mg-unit oral T3
oyster shell calcium/d3 tablet 500-400 mg-unit
oral T3
oyster shell calcium/vitamin d tablet 250-125 mg-
unit oral T3
OYSTERCAL-D TABLET 500-400 MG-UNIT
ORAL T3
pc pediatric electrolyte solution oral T3
ped electrolyte freeze pops solution oral T3
ped electrolyte freezer pops solution oral T3
PEDIA VANCE SOLUTION ORAL T3
PEDIALYTE ADVANCED CARE SOLUTION
ORAL T3
PEDIALYTE FREEZER POPS SOLUTION
ORAL T3
PEDIALYTE SINGLES SOLUTION ORAL T3
PEDIALYTE SOLUTION ORAL T3
pediatric electrolyte solution oral T3
pediatric electrolyte-zinc solution oral T3
potassium chloride crys er tablet extended release
10 meq oral T3
potassium chloride crys er tablet extended release
20 meq oral T3
potassium chloride er capsule extended release
10 meq oral T3
129
Drug Tier Requirements/Limits
potassium chloride er tablet extended release 10
meq oral T3
potassium chloride er tablet extended release 8
meq oral T3
potassium chloride packet 20 meq oral T3
potassium chloride solution 20 meq/15ml (10%)
oral T3
potassium chloride solution 40 meq/15ml (20%)
oral T3
PRO-CAL TABLET ORAL T3
PULMOSAL NEBULIZATION SOLUTION 7 %
INHALATION T3
px calcium antacid tablet chewable 500 mg oral T3
qc antacid tablet chewable 500 mg oral T3
qc calcium/minerals/vitamin d tablet 600-400 mg-
unit oral T3
qc pediatric electrolyte solution oral T3
quintabs-m tablet oral T3
ra antacid tablet chewable 500 mg oral T3
ra calcium cit plus vit d-3 tablet 315-250 mg-unit
oral T3
ra calcium citrate plus vit d tablet 315-200 mg-
unit oral T3
ra calcium cit-vit d-3 petites tablet 200-250 mg-
unit oral T3
ra calcium/minerals/vitamin d tablet 600-400 mg-
unit oral T3
ra central-vite under 50 women tablet oral T3
ra one daily womens tablet oral T3
ra oyster shell calcium/d tablet 250-125 mg-unit
oral T3
ra ped electrolyte freezer pop solution oral T3
ra pediatric electrolyte solution oral T3
sb antacid tablet chewable 500 mg oral T3
sb oyster shell calcium tablet 500 mg oral T3
sb pediatric electrolyte solution oral T3
sm calcium 600 tablet 1500 mg oral T3
sm calcium antacid ex st tablet chewable 750 mg
oral T3
130
Drug Tier Requirements/Limits
sm calcium antacid tablet chewable 500 mg oral T3
sm calcium antacid ultra st tablet chewable 1000
mg oral T3
sm calcium citrate w/vit d3 tablet 315-250 mg-
unit oral T3
sm calcium citrate+/vit d3 tablet 315-250 mg-unit
oral T3
sm calcium citrate+d3 petite tablet 200-250 mg-
unit oral T3
sm calcium citrate-vit d tablet 315-200 mg-unit
oral T3
sm calcium tablet 500 mg oral T3
sm calcium/vitamin d/minerals tablet 600-400
mg-unit oral T3
SM CORAL CALCIUM TABLET 1000 (390
CA) MG ORAL T3
sm one daily womens tablet oral T3
sm oyster shell calcium/vit d3 tablet 500-400 mg-
unit oral T3
sm pediatric electrolyte solution oral T3
sodium chloride nebulization solution 3 %
inhalation T3
sodium chloride nebulization solution 7 %
inhalation T3
super calcium tablet 1500 mg oral T3
th antacid regular strength tablet chewable 500
mg oral T3
th calcium citrate-vitamin d tablet 315-200 mg-
unit oral T3
th theradex-m tablet oral T3
th womens daily tablet oral T3
THERA M PLUS TABLET ORAL T3
thera-m tablet oral T3
therapeutic-m tablet oral T3
therapeutic-m/lutein tablet oral T3
thera-tabs m tablet oral T3
TUMS CHEWY BITES TABLET CHEWABLE
750 MG ORAL T3
TUMS E-X 750 TABLET CHEWABLE 750 MG
ORAL T3
131
Drug Tier Requirements/Limits
TUMS EXTRA STRENGTH 750 TABLET
CHEWABLE 750 MG ORAL T3
TUMS FRESHERS TABLET CHEWABLE 500
MG ORAL T3
TUMS KIDS TABLET CHEWABLE 750 MG
ORAL T3
TUMS SMOOTHIES TABLET CHEWABLE
750 MG ORAL T3
TUMS TABLET CHEWABLE 500 MG ORAL T3
TUMS ULTRA 1000 TABLET CHEWABLE
1000 MG ORAL T3
ultra freeda tablet oral T3
ultra freeda/iron tablet oral T3
womens daily formula tablet oral T3
Thiazide Diuretics
ALDACTAZIDE TABLET 25-25 MG ORAL T3
amiloride-hydrochlorothiazide tablet 5-50 mg
oral T3
chlorothiazide tablet 250 mg oral T3
chlorothiazide tablet 500 mg oral T3
DIURIL SUSPENSION 250 MG/5ML ORAL T3
DYAZIDE CAPSULE 37.5-25 MG ORAL T3
hydrochlorothiazide capsule 12.5 mg oral T3
hydrochlorothiazide tablet 12.5 mg oral T3
hydrochlorothiazide tablet 25 mg oral T3
hydrochlorothiazide tablet 50 mg oral T3
MAXZIDE TABLET 75-50 MG ORAL T3
MAXZIDE-25 TABLET 37.5-25 MG ORAL T3
MICROZIDE CAPSULE 12.5 MG ORAL T3
spironolactone-hctz tablet 25-25 mg oral T3
triamterene-hctz capsule 37.5-25 mg oral T3
triamterene-hctz tablet 37.5-25 mg oral T3
triamterene-hctz tablet 75-50 mg oral T3
Thiazide-Like Diuretics
chlorthalidone tablet 25 mg oral T3
chlorthalidone tablet 50 mg oral T3
indapamide tablet 1.25 mg oral T3
indapamide tablet 2.5 mg oral T3
132
Drug Tier Requirements/Limits
metolazone tablet 10 mg oral T3
metolazone tablet 2.5 mg oral T3
metolazone tablet 5 mg oral T3
Vasopressin Antagonists
JYNARQUE TABLET 15 MG ORAL T4 PA; QL (30 EA per 30 days)
JYNARQUE TABLET 30 MG ORAL T4 PA; QL (60 EA per 30 days)
JYNARQUE TABLET THERAPY PACK 45 &
15 MG ORAL T4 PA
JYNARQUE TABLET THERAPY PACK 60 &
30 MG ORAL T4 PA
JYNARQUE TABLET THERAPY PACK 90 &
30 MG ORAL T4 PA
SAMSCA TABLET 15 MG ORAL T4 PA; QL (30 EA per 30 days)
SAMSCA TABLET 30 MG ORAL T4 PA; QL (60 EA per 30 days)
Enzymes
Enzymes
ACTIVASE SOLUTION RECONSTITUTED
100 MG INTRAVENOUS T4 PA
ACTIVASE SOLUTION RECONSTITUTED 50
MG INTRAVENOUS T4 PA
ADAGEN SOLUTION 250 UNIT/ML
INTRAMUSCULAR T4 PA
ALDURAZYME SOLUTION 2.9 MG/5ML
INTRAVENOUS T4 PA
BRINEURA KIT 2 X 150 MG/5ML T4 PA
CATHFLO ACTIVASE SOLUTION
RECONSTITUTED 2 MG INJECTION T4 PA
ELAPRASE SOLUTION 6 MG/3ML
INTRAVENOUS T4 PA
ELITEK SOLUTION RECONSTITUTED 1.5
MG INTRAVENOUS T4 PA
ELITEK SOLUTION RECONSTITUTED 7.5
MG INTRAVENOUS T4 PA
FABRAZYME SOLUTION RECONSTITUTED
35 MG INTRAVENOUS T4 PA
FABRAZYME SOLUTION RECONSTITUTED
5 MG INTRAVENOUS T4 PA
KANUMA SOLUTION 20 MG/10ML
INTRAVENOUS T4 PA
133
Drug Tier Requirements/Limits
LUMIZYME SOLUTION RECONSTITUTED
50 MG INTRAVENOUS T4 PA
MEPSEVII SOLUTION 10 MG/5ML
INTRAVENOUS T4 PA
NAGLAZYME SOLUTION 1 MG/ML
INTRAVENOUS T4 PA
PALYNZIQ SOLUTION PREFILLED
SYRINGE 10 MG/0.5ML SUBCUTANEOUS T4 PA; QL (15 ML per 30 days)
PALYNZIQ SOLUTION PREFILLED
SYRINGE 2.5 MG/0.5ML SUBCUTANEOUS T4 PA; QL (4.5 ML per 30 days)
PALYNZIQ SOLUTION PREFILLED
SYRINGE 20 MG/ML SUBCUTANEOUS T4 PA; QL (60 ML per 30 days)
PULMOZYME SOLUTION 1 MG/ML
INHALATION T4 PA; QL (150 ML per 30 days)
REVCOVI SOLUTION 2.4 MG/1.5ML
INTRAMUSCULAR T4 PA
STRENSIQ SOLUTION 40 MG/ML
SUBCUTANEOUS T4 PA
STRENSIQ SOLUTION 80 MG/0.8ML
SUBCUTANEOUS T4 PA
VIMIZIM SOLUTION 5 MG/5ML
INTRAVENOUS T4 PA
XIAFLEX SOLUTION RECONSTITUTED 0.9
MG INJECTION T4 PA; QL (4.5 EA per 30 days)
Eye, Ear, Nose And Throat (Eent)
Preps.
Antivirals (Eent)
trifluridine solution 1 % ophthalmic T3 QL (8 ML per 25 days)
VIROPTIC SOLUTION 1 % OPHTHALMIC T3 QL (8 ML per 25 days)
Carbonic Anhydrase Inhibitors (Eent)
acetazolamide er capsule extended release 12
hour 500 mg oral T3
acetazolamide tablet 125 mg oral T3
acetazolamide tablet 250 mg oral T3
DIAMOX SEQUELS CAPSULE EXTENDED
RELEASE 12 HOUR 500 MG ORAL T3
Eent Anti-Infectives, Miscellaneous
chlorhexidine gluconate solution 0.12 %
mouth/throat T3
ear drops earwax aid solution 6.5 % otic T3
134
Drug Tier Requirements/Limits
ear drops solution 6.5 % otic T3
earwax removal kit solution 6.5 % otic T3
earwax treatment drops solution 6.5 % otic T3
gnp ear systems solution 6.5 % otic T3
hm earwax removal aid solution 6.5 % otic T3
hm earwax removal kit solution 6.5 % otic T3
sm ear drops solution 6.5 % otic T3
Eent Drugs, Miscellaneous
AKWA TEARS OINTMENT 2-15-83 %
OPHTHALMIC T3
altamist spray solution 0.65 % nasal T3
artificial tears solution 1.4 % ophthalmic T3
AYR SOLUTION 0.65 % NASAL T3
BABY AYR SALINE SOLUTION 0.65 %
NASAL T3
BION TEARS PF SOLUTION 0.1-0.3 %
OPHTHALMIC T3
cvs child saline spray/drops solution 0.65 % nasal T3
cvs saline nasal spray solution 0.65 % nasal T3
cvs saline nose spray solution 0.65 % nasal T3
CYSTARAN SOLUTION 0.44 %
OPHTHALMIC T4 PA
deep sea nasal spray solution 0.65 % nasal T3
eq saline nasal spray solution 0.65 % nasal T3
eql saline nasal spray solution 0.65 % nasal T3
GENTEAL TEARS MODERATE PF
SOLUTION 0.1-0.3 % OPHTHALMIC T3
GENTEAL TEARS PF SOLUTION 0.1-0.3 %
OPHTHALMIC T3
GENTEAL TEARS SOLUTION 0.1-0.2-0.3 %
OPHTHALMIC T3
GENTEAL TEARS SOLUTION 0.1-0.3 %
OPHTHALMIC T3
gnp eye drops solution 0.5 % ophthalmic T3
gnp lubricating plus eye drops solution 0.5 %
ophthalmic T3
gnp nasal moisturizing solution 0.65 % nasal T3
goodsense lubricating eye drop solution 0.5 %
ophthalmic T3
135
Drug Tier Requirements/Limits
hm lubricating plus solution 0.5 % ophthalmic T3
hm saline nasal spray solution 0.65 % nasal T3
ISOPTO TEARS SOLUTION 0.5 %
OPHTHALMIC T3
JETREA SOLUTION 0.375 MG/0.3ML
INTRAVITREAL T4 PA; QL (2.4 ML per 30 days)
liquitears solution 1.4 % ophthalmic T3
LITTLE NOSES SALINE SOLUTION 0.65 %
NASAL T3
LITTLE NOSES STUFFY NOSE KIT
SOLUTION 0.65 % NASAL T3
LITTLE REMEDIES SALINE MIST AEROSOL
SOLUTION NASAL T3
lubricating plus eye drops solution 0.5 %
ophthalmic T3
MURO 128 OINTMENT 5 % OPHTHALMIC T3
MURO 128 SOLUTION 5 % OPHTHALMIC T3
nasal mist aerosol solution 0.9 % inhalation T3
NASAL MOIST SOLUTION 0.65 % NASAL T3
nasal moisturizing spray solution 0.65 % nasal T3
nasal spray solution 0.65 % nasal T3
natural balance tears solution 0.1-0.3 %
ophthalmic T3
natures tears solution 0.1-0.3 % ophthalmic T3
OCEAN FOR KIDS SOLUTION 0.65 % NASAL T3
OCEAN NASAL SPRAY SOLUTION 0.65 %
NASAL T3
OXERVATE SOLUTION 0.002 %
OPHTHALMIC T4 PA
px saline nasal spray solution 0.65 % nasal T3
ra saline nasal spray solution 0.65 % nasal T3
REFRESH OPTIVE SOLUTION 0.5-0.9 %
OPHTHALMIC T3
REFRESH PLUS SOLUTION 0.5 %
OPHTHALMIC T3
REFRESH REPAIR SOLUTION 0.5-0.9 %
OPHTHALMIC T3
REFRESH SOLUTION 1.4-0.6 %
OPHTHALMIC T3
136
Drug Tier Requirements/Limits
REFRESH TEARS SOLUTION 0.5 %
OPHTHALMIC T3
saline mist spray solution 0.65 % nasal T3
saline nasal spray solution 0.65 % nasal T3
sb saline nose solution 0.65 % nasal T3
sea soft nasal mist solution 0.65 % nasal T3
sm lubricating plus solution 0.5 % ophthalmic T3
sm nasal spray saline solution 0.65 % nasal T3
sodium chloride (hypertonic) ointment 5 %
ophthalmic T3
sodium chloride (hypertonic) solution 5 %
ophthalmic T3
tgt nasal spray solution 0.65 % nasal T3
tgt saline nasal spray solution 0.65 % nasal T3
Mydriatics
atropine sulfate solution 1 % ophthalmic T3
CYCLOGYL SOLUTION 2 % OPHTHALMIC T3
cyclopentolate hcl solution 2 % ophthalmic T3
ISOPTO ATROPINE SOLUTION 1 %
OPHTHALMIC T3
Vasoconstrictors
12 hour nasal decongestant solution 0.05 % nasal T3
12 hour nasal spray solution 0.05 % nasal T3
gnp 12 hour nasal spray solution 0.05 % nasal T3
gnp nasal spray extra moist solution 0.05 % nasal T3
gnp nasal spray solution 0.05 % nasal T3
gnp no drip nasal spray solution 0.05 % nasal T3
hm nasal spray solution 0.05 % nasal T3
hm sinus nasal spray solution 0.05 % nasal T3
MUCINEX SINUS-MAX CLEAR & COOL
SOLUTION 0.05 % NASAL T3
MUCINEX SINUS-MAX FULL FORCE
SOLUTION 0.05 % NASAL T3
MUCINEX SINUS-MAX MOIST SMART
SOLUTION 0.05 % NASAL T3
nasal decongestant spray solution 0.05 % nasal T3
nasal relief solution 0.05 % nasal T3
nasal spray 12 hour solution 0.05 % nasal T3
137
Drug Tier Requirements/Limits
nasal spray extra moisturizing solution 0.05 %
nasal T3
no drip nasal spray solution 0.05 % nasal T3
phenylephrine hcl solution 10 % ophthalmic T3
phenylephrine hcl solution 2.5 % ophthalmic T3
sinus nasal spray solution 0.05 % nasal T3
sinus relief nasal spray solution 0.05 % nasal T3
sm nasal spray 12 hour solution 0.05 % nasal T3
sm nasal spray moisturizing solution 0.05 %
nasal T3
sm nasal spray sinus solution 0.05 % nasal T3
sm nasal spray solution 0.05 % nasal T3
Gastrointestinal Drugs
Antacids And Adsorbents
ACID GONE SUSPENSION 95-358 MG/15ML
ORAL T3
ALMACONE DOUBLE STRENGTH
SUSPENSION 400-400-40 MG/5ML ORAL T3
ALMACONE SUSPENSION 200-200-20
MG/5ML ORAL T3
aluminum hydroxide gel suspension 320 mg/5ml
oral T3
antacid anti-gas max strength suspension 400-
400-40 mg/5ml oral T3
antacid calcium extra strength tablet chewable
750 mg oral T3
antacid calcium tablet chewable 500 mg oral T3
antacid extra strength tablet chewable 750 mg
oral T3
antacid fast acting suspension 200-200-20
mg/5ml oral T3
antacid fast relief suspension 200-200-20 mg/5ml
oral T3
antacid maximum strength suspension 400-400-
40 mg/5ml oral T3
antacid plus anti-gas fast act suspension 200-200-
20 mg/5ml oral T3
antacid plus anti-gas relief suspension 200-200-
20 mg/5ml oral T3
138
Drug Tier Requirements/Limits
antacid plus anti-gas relief suspension 400-400-
40 mg/5ml oral T3
antacid regular strength tablet chewable 500 mg
oral T3
antacid suspension 200-200-20 mg/5ml oral T3
antacid tablet chewable 500 mg oral T3
antacid ultra strength tablet chewable 1000 mg
oral T3
bismatrol maximum strength suspension 525
mg/15ml oral T3
bismatrol suspension 262 mg/15ml oral T3
bismatrol tablet chewable 262 mg oral T3
calcium antacid extra strength tablet chewable
750 mg oral T3
calcium antacid tablet chewable 500 mg oral T3
calcium antacid ultra max st tablet chewable
1000 mg oral T3
calcium antacid ultra strength tablet chewable
1000 mg oral T3
calcium antacid ultra tablet chewable 1000 mg
oral T3
calcium carbonate antacid tablet chewable 500
mg oral T3
CAL-GEST ANTACID TABLET CHEWABLE
500 MG ORAL T3
cvs antacid tablet chewable 500 mg oral T3
cvs magnesium oxide tablet 500 mg oral T3
eql antacid tablet chewable 500 mg oral T3
eql magnesium tablet 250 mg oral T3
fast acting antacid/anti-gas suspension 400-400-
40 mg/5ml oral T3
GAVISCON ACID BRKTHRGH FORMULA
TABLET CHEWABLE 500 MG ORAL T3
GAVISCON SUSPENSION 95-358 MG/15ML
ORAL T3
gnp antacid & anti-gas suspension 200-200-20
mg/5ml oral T3
gnp antacid & anti-gas suspension 400-400-40
mg/5ml oral T3
139
Drug Tier Requirements/Limits
gnp antacid anti-gas suspension 200-200-20
mg/5ml oral T3
gnp antacid extra strength tablet chewable 750
mg oral T3
gnp antacid maximum strength suspension 400-
400-40 mg/5ml oral T3
gnp antacid regular strength suspension 200-200-
20 mg/5ml oral T3
gnp antacid tablet chewable 500 mg oral T3
gnp magnesium oxide tablet 250 mg oral T3
GNP MASANTI MAXIMUM STRENGTH
SUSPENSION 400-400-40 MG/5ML ORAL T3
GNP MASANTI REGULAR STRENGTH
SUSPENSION 200-200-20 MG/5ML ORAL T3
gnp pink bismuth tablet chewable 262 mg oral T3
gnp stomach relief max st suspension 525
mg/15ml oral T3
gnp stomach relief suspension 262 mg/15ml oral T3
goodsense stomach relief tablet chewable 262 mg
oral T3
HEALTHY MAMA TAME THE FLAME
TABLET CHEWABLE 500 MG ORAL T3
hm advanced antacid max st suspension 400-400-
40 mg/5ml oral T3
hm antacid anti-gas ex st suspension 400-400-40
mg/5ml oral T3
hm antacid suspension 200-200-20 mg/5ml oral T3
hm antacid/antigas suspension 200-200-20
mg/5ml oral T3
hm calcium antacid ex st tablet chewable 750 mg
oral T3
hm calcium antacid tablet chewable 500 mg oral T3
hm calcium antacid tablet chewable 750 mg oral T3
hm calcium antacid ultra st tablet chewable 1000
mg oral T3
hm magnesium tablet 400 mg oral T3
hm stomach relief max strength suspension 525
mg/15ml oral T3
hm stomach relief suspension 525 mg/30ml oral T3
hm stomach relief tablet chewable 262 mg oral T3
140
Drug Tier Requirements/Limits
KAO-TIN SUSPENSION 262 MG/15ML ORAL T3
kls antacid tablet chewable 500 mg oral T3
mag-al plus liquid 200-200-20 mg/5ml oral T3
mag-al plus xs liquid 400-400-40 mg/5ml oral T3
magnesium capsule 500 mg oral T3
magnesium oxide capsule 500 mg oral T3
magnesium oxide tablet 250 mg oral T3
magnesium oxide tablet 400 (240 mg) mg oral T3
magnesium oxide tablet 400 (241.3 mg) mg oral T3
magnesium oxide tablet 400 mg oral T3
magnesium oxide tablet 420 mg oral T3
magnesium oxide tablet 500 mg oral T3
MAGNESIUM-OXIDE TABLET 400 (241.3
MG) MG ORAL T3
MAGOX 400 TABLET 400 (241.3 MG) MG
ORAL T3
MAG-OX 400 TABLET 400 MG ORAL T3
MAOX TABLET 420 MG ORAL T3
mi-acid maximum strength suspension 400-400-
40 mg/5ml oral T3
MI-ACID SUSPENSION 200-200-20 MG/5ML
ORAL T3
mintox maximum strength suspension 400-400-40
mg/5ml oral T3
MINTOX REGULAR STRENGTH
SUSPENSION 200-200-20 MG/5ML ORAL T3
MINTOX SUSPENSION 200-200-20 MG/5ML
ORAL T3
peptic relief suspension 262 mg/15ml oral T3
peptic relief tablet chewable 262 mg oral T3
pink bismuth tablet chewable 262 mg oral T3
px calcium antacid tablet chewable 500 mg oral T3
qc antacid suspension 200-200-20 mg/5ml oral T3
qc antacid tablet chewable 500 mg oral T3
qc antacid/anti-gas suspension 200-200-20
mg/5ml oral T3
qc antacid/anti-gas suspension 400-400-40
mg/5ml oral T3
ra antacid tablet chewable 500 mg oral T3
141
Drug Tier Requirements/Limits
ra magnesium capsule 500 mg oral T3
rulox suspension 200-200-20 mg/5ml oral T3
sb antacid tablet chewable 500 mg oral T3
sm antacid advanced max st suspension 400-400-
40 mg/5ml oral T3
sm antacid advanced suspension 200-200-20
mg/5ml oral T3
sm antacid/antigas suspension 200-200-20
mg/5ml oral T3
sm calcium antacid ex st tablet chewable 750 mg
oral T3
sm calcium antacid tablet chewable 500 mg oral T3
sm calcium antacid ultra st tablet chewable 1000
mg oral T3
sm stomach relief suspension 262 mg/15ml oral T3
sm stomach relief suspension 525 mg/30ml oral T3
sm stomach relief tablet chewable 262 mg oral T3
sodium bicarbonate tablet 325 mg oral T3
sodium bicarbonate tablet 650 mg oral T3
stomach relief max st suspension 525 mg/15ml
oral T3
stomach relief suspension 262 mg/15ml oral T3
stomach relief tablet chewable 262 mg oral T3
TUMS CHEWY BITES TABLET CHEWABLE
750 MG ORAL T3
TUMS E-X 750 TABLET CHEWABLE 750 MG
ORAL T3
TUMS EXTRA STRENGTH 750 TABLET
CHEWABLE 750 MG ORAL T3
TUMS FRESHERS TABLET CHEWABLE 500
MG ORAL T3
TUMS KIDS TABLET CHEWABLE 750 MG
ORAL T3
TUMS SMOOTHIES TABLET CHEWABLE
750 MG ORAL T3
TUMS TABLET CHEWABLE 500 MG ORAL T3
TUMS ULTRA 1000 TABLET CHEWABLE
1000 MG ORAL T3
URO-MAG CAPSULE 140 MG ORAL T3
142
Drug Tier Requirements/Limits
Antidiarrhea Agents
anti-diarrheal capsule 2 mg oral T3 QL (240 EA per 30 days)
anti-diarrheal tablet 2 mg oral T3
bismatrol maximum strength suspension 525
mg/15ml oral T3
bismatrol suspension 262 mg/15ml oral T3
bismatrol tablet chewable 262 mg oral T3
diphenoxylate-atropine tablet 2.5-0.025 mg oral T3
gnp anti-diarrheal capsule 2 mg oral T3 QL (240 EA per 30 days)
gnp anti-diarrheal tablet 2 mg oral T3
gnp pink bismuth tablet chewable 262 mg oral T3
gnp stomach relief max st suspension 525
mg/15ml oral T3
gnp stomach relief suspension 262 mg/15ml oral T3
goodsense stomach relief tablet chewable 262 mg
oral T3
hm anti-diarrheal tablet 2 mg oral T3
hm loperamide hcl capsule 2 mg oral T3 QL (240 EA per 30 days)
hm stomach relief max strength suspension 525
mg/15ml oral T3
hm stomach relief suspension 525 mg/30ml oral T3
hm stomach relief tablet chewable 262 mg oral T3
KAO-TIN SUSPENSION 262 MG/15ML ORAL T3
LOMOTIL TABLET 2.5-0.025 MG ORAL T3
loperamide hcl capsule 2 mg oral T3 QL (240 EA per 30 days)
loperamide hcl tablet 2 mg oral T3
peptic relief suspension 262 mg/15ml oral T3
peptic relief tablet chewable 262 mg oral T3
pink bismuth tablet chewable 262 mg oral T3
qc anti-diarrheal capsule 2 mg oral T3 QL (240 EA per 30 days)
qc anti-diarrheal tablet 2 mg oral T3
sm anti-diarrheal capsule 2 mg oral T3 QL (240 EA per 30 days)
sm anti-diarrheal tablet 2 mg oral T3
sm stomach relief suspension 262 mg/15ml oral T3
sm stomach relief suspension 525 mg/30ml oral T3
sm stomach relief tablet chewable 262 mg oral T3
stomach relief max st suspension 525 mg/15ml
oral T3
143
Drug Tier Requirements/Limits
stomach relief suspension 262 mg/15ml oral T3
stomach relief tablet chewable 262 mg oral T3
XERMELO TABLET 250 MG ORAL T4 PA; QL (90 EA per 30 days)
Antiflatulents
ALMACONE DOUBLE STRENGTH
SUSPENSION 400-400-40 MG/5ML ORAL T3
ALMACONE SUSPENSION 200-200-20
MG/5ML ORAL T3
antacid anti-gas max strength suspension 400-
400-40 mg/5ml oral T3
antacid fast acting suspension 200-200-20
mg/5ml oral T3
antacid fast relief suspension 200-200-20 mg/5ml
oral T3
antacid maximum strength suspension 400-400-
40 mg/5ml oral T3
antacid plus anti-gas fast act suspension 200-200-
20 mg/5ml oral T3
antacid plus anti-gas relief suspension 200-200-
20 mg/5ml oral T3
antacid plus anti-gas relief suspension 400-400-
40 mg/5ml oral T3
antacid suspension 200-200-20 mg/5ml oral T3
fast acting antacid/anti-gas suspension 400-400-
40 mg/5ml oral T3
gas relief extra strength capsule 125 mg oral T3
gas relief maximum strength tablet chewable 125
mg oral T3
gas relief tablet chewable 80 mg oral T3
GAS-X EXTRA STRENGTH CAPSULE 125
MG ORAL T3
GAS-X EXTRA STRENGTH TABLET
CHEWABLE 125 MG ORAL T3
GAS-X TABLET CHEWABLE 80 MG ORAL T3
gnp antacid & anti-gas suspension 200-200-20
mg/5ml oral T3
gnp antacid & anti-gas suspension 400-400-40
mg/5ml oral T3
gnp antacid anti-gas suspension 200-200-20
mg/5ml oral T3
144
Drug Tier Requirements/Limits
gnp antacid maximum strength suspension 400-
400-40 mg/5ml oral T3
gnp antacid regular strength suspension 200-200-
20 mg/5ml oral T3
gnp gas relief extra strength capsule 125 mg oral T3
gnp gas relief extra strength tablet chewable 125
mg oral T3
gnp gas relief tablet chewable 80 mg oral T3
GNP MASANTI MAXIMUM STRENGTH
SUSPENSION 400-400-40 MG/5ML ORAL T3
GNP MASANTI REGULAR STRENGTH
SUSPENSION 200-200-20 MG/5ML ORAL T3
hm advanced antacid max st suspension 400-400-
40 mg/5ml oral T3
hm antacid anti-gas ex st suspension 400-400-40
mg/5ml oral T3
hm antacid suspension 200-200-20 mg/5ml oral T3
hm antacid/antigas suspension 200-200-20
mg/5ml oral T3
hm gas relief extra strength capsule 125 mg oral T3
hm gas relief tablet chewable 80 mg oral T3
mag-al plus liquid 200-200-20 mg/5ml oral T3
mag-al plus xs liquid 400-400-40 mg/5ml oral T3
mi-acid gas relief tablet chewable 80 mg oral T3
mi-acid maximum strength suspension 400-400-
40 mg/5ml oral T3
MI-ACID SUSPENSION 200-200-20 MG/5ML
ORAL T3
mintox maximum strength suspension 400-400-40
mg/5ml oral T3
MINTOX REGULAR STRENGTH
SUSPENSION 200-200-20 MG/5ML ORAL T3
MINTOX SUSPENSION 200-200-20 MG/5ML
ORAL T3
mytab gas maximum strength tablet chewable 125
mg oral T3
mytab gas tablet chewable 80 mg oral T3
qc antacid suspension 200-200-20 mg/5ml oral T3
qc antacid/anti-gas suspension 200-200-20
mg/5ml oral T3
145
Drug Tier Requirements/Limits
qc antacid/anti-gas suspension 400-400-40
mg/5ml oral T3
rulox suspension 200-200-20 mg/5ml oral T3
simethicone tablet chewable 80 mg oral T3
sm antacid advanced max st suspension 400-400-
40 mg/5ml oral T3
sm antacid advanced suspension 200-200-20
mg/5ml oral T3
sm antacid/antigas suspension 200-200-20
mg/5ml oral T3
sm gas relief extra strength capsule 125 mg oral T3
sm gas relief tablet chewable 125 mg oral T3
sm gas relief tablet chewable 80 mg oral T3
Cathartics And Laxatives
BISAC-EVAC SUPPOSITORY 10 MG
RECTAL T3
bisacodyl ec tablet delayed release 5 mg oral T3
bisacodyl suppository 10 mg rectal T3
biscolax suppository 10 mg rectal T3
chocolated laxative tablet chewable 15 mg oral T3
CLEARLAX POWDER 17 GM/SCOOP ORAL T3
COLACE 2-IN-1 TABLET 8.6-50 MG ORAL T3
COLACE CAPSULE 100 MG ORAL T3
COLACE CLEAR CAPSULE 50 MG ORAL T3
COLYTE WITH FLAVOR PACKS SOLUTION
RECONSTITUTED 240 GM ORAL T3
cvs chocolate laxative pieces tablet chewable 15
mg oral T3
cvs laxative pills tablet 25 mg oral T3
cvs senna tablet 8.6 mg oral T3
cvs senna-c tablet 8.6 mg oral T3
cvs senna-extra tablet 17.2 mg oral T3
diocto liquid 50 mg/5ml oral T3
diocto syrup 60 mg/15ml oral T3
docqlace capsule 100 mg oral T3
docu liquid 50 mg/5ml oral T3
docusate sodium capsule 100 mg oral T3
docusate sodium liquid 50 mg/5ml oral T3
146
Drug Tier Requirements/Limits
DOCUSIL CAPSULE 100 MG ORAL T3
DOCUSOL MINI ENEMA 283 MG/5ML
RECTAL T3
DOK CAPSULE 100 MG ORAL T3
DOK CAPSULE 250 MG ORAL T3
DOK PLUS TABLET 50-8.6 MG ORAL T3
ducodyl tablet delayed release 5 mg oral T3
enema enema 7-19 gm/118ml rectal T3
enema mineral oil enema rectal T3
enema ready-to-use enema 7-19 gm/118ml rectal T3
ENEMEEZ MINI ENEMA 283 MG/5ML
RECTAL T3
eq laxative maximum strength tablet 25 mg oral T3
eq natural laxative tablet 8.6 mg oral T3
eq natural vegetable laxative tablet 8.6 mg oral T3
eq vegetable laxative tablet 8.6 mg oral T3
eql laxative maximum strength tablet 25 mg oral T3
eql laxative tablet 25 mg oral T3
eql laxative tablet chewable 15 mg oral T3
eql senna laxative tablet 8.6 mg oral T3
EX-LAX TABLET CHEWABLE 15 MG ORAL T3
fiber laxative tablet 625 mg oral T3
fiber tablet 625 mg oral T3
fiber-lax tablet 625 mg oral T3
FLEET BISACODYL ENEMA 10 MG/30ML
RECTAL T3
FLEET ENEMA ENEMA 7-19 GM/118ML
RECTAL T3
FLEET OIL ENEMA RECTAL T3
gavilax powder 17 gm/scoop oral T3
GAVILYTE-C SOLUTION RECONSTITUTED
240 GM ORAL T3
GAVILYTE-G SOLUTION RECONSTITUTED
236 GM ORAL T3
GAVILYTE-N WITH FLAVOR PACK
SOLUTION RECONSTITUTED 420 GM ORAL T3
gentle laxative tablet delayed release 5 mg oral T3
geri-kot tablet 8.6 mg oral T3
147
Drug Tier Requirements/Limits
glycerin (pediatric) suppository 1.2 gm rectal T3
GLYCOLAX POWDER 17 GM/SCOOP ORAL T3
GNP BISA-LAX TABLET DELAYED
RELEASE 5 MG ORAL T3
GNP CLEARLAX POWDER 17 GM/SCOOP
ORAL T3
gnp docusate calcium capsule 240 mg oral T3
gnp enema enema 7-19 gm/118ml rectal T3
gnp enema enema rectal T3
gnp fiber-caps tablet 625 mg oral T3
gnp gentle laxative suppository 10 mg rectal T3
gnp laxative pills tablet 25 mg oral T3
gnp laxative tablet delayed release 5 mg oral T3
gnp magnesium citrate solution 1.745 gm/30ml
oral T3
gnp milk of magnesia suspension 1200 mg/15ml
oral T3
gnp mineral oil enema rectal T3
gnp mineral oil heavy oil oral T3
gnp mineral oil oil oral T3
gnp natural fiber powder 48.57 % oral T3
gnp senna lax tablet 8.6 mg oral T3
gnp senna plus tablet 8.6-50 mg oral T3
gnp senna-lax tablet 8.6 mg oral T3
gnp stool softener capsule 100 mg oral T3
gnp stool softener capsule 250 mg oral T3
gnp stool softener ex st capsule 250 mg oral T3
gnp stool softener liquid 50 mg/5ml oral T3
gnp stool softener syrup 60 mg/15ml oral T3
gnp stool softener/laxative tablet 8.6-50 mg oral T3
gnp womens gentle laxative tablet delayed release
5 mg oral T3
gnp womens laxative tablet delayed release 5 mg
oral T3
GOLYTELY SOLUTION RECONSTITUTED
236 GM ORAL T3
GOODSENSE CLEARLAX POWDER 17
GM/SCOOP ORAL T3
148
Drug Tier Requirements/Limits
goodsense senna laxative tablet 8.6 mg oral T3
HM CLEARLAX POWDER ORAL T3
hm enema enema 7-19 gm/118ml rectal T3
hm enema mineral oil enema rectal T3
hm fiber powder 28.3 % oral T3
hm fiber powder 48.57 % oral T3
hm laxative tablet delayed release 5 mg oral T3
hm magnesium citrate solution 1.745 gm/30ml
oral T3
hm milk of magnesia suspension 1200 mg/15ml
oral T3
hm senna tablet 8.6 mg oral T3
hm senna-s tablet 8.6-50 mg oral T3
hm stool softener capsule 100 mg oral T3
hm stool softener capsule 250 mg oral T3
hm stool softener/laxative tablet 8.6-50 mg oral T3
KAO-TIN CAPSULE 240 MG ORAL T3
konsyl daily fiber powder 28.3 % oral T3
KONSYL FIBER TABLET 625 MG ORAL T3
kp senna tablet 8.6 mg oral T3
laxative feminine tablet delayed release 5 mg oral T3
laxative max str tablet 25 mg oral T3
laxative pills tablet 15 mg oral T3
laxative pills tablet 25 mg oral T3
laxative regular strength tablet 15 mg oral T3
laxative suppository 10 mg rectal T3
laxative tablet 25 mg oral T3
laxative tablet delayed release 5 mg oral T3
magnesium citrate solution 1.745 gm/30ml oral T3
medi-natural tablet 8.6 mg oral T3
milk of magnesia suspension 1200 mg/15ml oral T3
milk of magnesia suspension 400 mg/5ml oral T3
milk of magnesia suspension 7.75 % oral T3
mineral oil oil oral T3
natural fiber laxative powder 48.57 % oral T3
natural fiber powder 28.3 % oral T3
natural fiber therapy powder 28.3 % oral T3
149
Drug Tier Requirements/Limits
natural fiber therapy powder 48.57 % oral T3
natural senna laxative tablet 8.6 mg oral T3
NULYTELY WITH FLAVOR PACKS
SOLUTION RECONSTITUTED 420 GM ORAL T3
PEDIA-LAX SUPPOSITORY 2.8 GM RECTAL T3
peg 3350 powder 17 gm/scoop oral T3
peg 3350/electrolytes solution reconstituted 240
gm oral T3
peg 3350-kcl-na bicarb-nacl solution
reconstituted 420 gm oral T3
peg-3350/electrolytes solution reconstituted 236
gm oral T3
PERI-COLACE TABLET 8.6-50 MG ORAL T3
polyethylene glycol 3350 powder 17 gm/scoop
oral (otc) T3
polyethylene glycol 3350 powder 17 gm/scoop
oral (rx) T3
px vegetable laxative tablet 8.6 mg oral T3
qc enema enema 16-6 gm/133ml rectal T3
qc gentle laxative suppository 10 mg rectal T3
qc laxative tablet 25 mg oral T3
qc magnesium citrate solution 1.745 gm/30ml
oral T3
qc milk of magnesia suspension 400 mg/5ml oral T3
qc mineral oil heavy oil oral T3
qc natural vegetable laxative tablet 8.6 mg oral T3
qc natura-lax powder oral T3
qc senna tablet 8.6 mg oral T3
qc stool softener capsule 100 mg oral T3
qc stool softener pls laxative tablet 8.6-50 mg
oral T3
ra laxative extra strength tablet 17.2 mg oral T3
ra laxative maximum strength tablet 25 mg oral T3
ra laxative tablet 25 mg oral T3
ra senna tablet 8.6 mg oral T3
REGULOID POWDER 28.3 % ORAL T3
REGULOID POWDER 48.57 % ORAL T3
REGULOID POWDER 58.6 % ORAL T3
150
Drug Tier Requirements/Limits
SANI-SUPP PEDIATRIC SUPPOSITORY 1.2
GM RECTAL T3
sb senna-lax tablet 8.6 mg oral T3
senexon liquid 8.8 mg/5ml oral T3
senexon tablet 8.6 mg oral T3
SENEXON-S TABLET 8.6-50 MG ORAL T3
senna capsule 8.6 mg oral T3
senna concentrate tablet 8.6 mg oral T3
senna lax tablet 8.6 mg oral T3
senna laxative tablet 25 mg oral T3
senna laxative tablet 8.6 mg oral T3
senna leaves leaves oral T3
senna liquid 8.8 mg/5ml oral T3
senna plus tablet 8.6-50 mg oral T3
senna syrup 176 mg/5ml oral T3
senna syrup 8.8 mg/5ml oral T3
senna tablet 8.6 mg oral T3
senna-docusate sodium tablet 8.6-50 mg oral T3
senna-gen tablet 8.6 mg oral T3
senna-grx syrup 8.8 mg/5ml oral T3
senna-lax tablet 8.6 mg oral T3
senna-s tablet 8.6-50 mg oral T3
senna-tabs tablet 8.6 mg oral T3
senna-time s tablet 8.6-50 mg oral T3
senna-time tablet 8.6 mg oral T3
SENNO TABLET 8.6 MG ORAL T3
sennosides-docusate sodium tablet 8.6-50 mg oral T3
SENOKOT S TABLET 8.6-50 MG ORAL T3
SENOKOT TABLET 8.6 MG ORAL T3
sen-o-tabs tablet 187 mg oral T3
silace liquid 150 mg/15ml oral T3
silace syrup 60 mg/15ml oral T3
SM CLEARLAX POWDER ORAL T3
sm enema enema 7-19 gm/118ml rectal T3
sm fiber powder 28.3 % oral T3
sm fiber powder 48.57 % oral T3
sm fiber tablet 625 mg oral T3
151
Drug Tier Requirements/Limits
sm gentle laxative tablet delayed release 5 mg
oral T3
sm laxative maximum strength tablet 25 mg oral T3
sm magnesium citrate solution 1.745 gm/30ml
oral T3
sm milk of magnesia suspension 1200 mg/15ml
oral T3
sm mineral oil enema rectal T3
sm senna laxative max st tablet 25 mg oral T3
sm senna laxative tablet 8.6 mg oral T3
sm senna-s tablet 8.6-50 mg oral T3
sm stool softener capsule 100 mg oral T3
sm stool softener capsule 240 mg oral T3
sm stool softener tablet 8.6-50 mg oral T3
sm stool softener/laxative tablet 8.6-50 mg oral T3
stimulant laxative tablet delayed release 5 mg
oral T3
stool softener capsule 100 mg oral T3
stool softener capsule 240 mg oral T3
stool softener capsule 250 mg oral T3
stool softener laxative capsule 100 mg oral T3
stool softener laxative capsule 250 mg oral T3
stool softener plus laxative tablet 8.6-50 mg oral T3
tgt laxative pills max st tablet 25 mg oral T3
tgt natural laxative pills tablet 25 mg oral T3
tgt senna laxative tablet 8.6 mg oral T3
tgt senna tablet 8.6 mg oral T3
TRILYTE SOLUTION RECONSTITUTED 420
GM ORAL T3
vegetable lax+stool softener tablet 8.6-50 mg oral T3
womans laxative tablet delayed release 5 mg oral T3
Gi Drugs, Miscellaneous
ENDARI PACKET 5 GM ORAL T4 PA
GATTEX KIT 5 MG SUBCUTANEOUS T4 PA
Lipotropic Agents
LIPOTRIAD TABLET ORAL T3
Prostaglandins
152
Drug Tier Requirements/Limits
CYTOTEC TABLET 100 MCG ORAL T3
CYTOTEC TABLET 200 MCG ORAL T3
misoprostol tablet 100 mcg oral T3
misoprostol tablet 200 mcg oral T3
Protectants
CARAFATE SUSPENSION 1 GM/10ML ORAL T3
CARAFATE TABLET 1 GM ORAL T3
sucralfate suspension 1 gm/10ml oral T3
sucralfate tablet 1 gm oral T3
Heavy Metal Antagonists
Heavy Metal Antagonists
CHEMET CAPSULE 100 MG ORAL T3
CUPRIMINE CAPSULE 250 MG ORAL T4 PA
DEPEN TITRATABS TABLET 250 MG ORAL T4 PA
GALZIN CAPSULE 25 MG ORAL T4 PA
GALZIN CAPSULE 50 MG ORAL T4 PA
penicillamine capsule 250 mg oral T4 PA
SYPRINE CAPSULE 250 MG ORAL T4 PA
trientine hcl capsule 250 mg oral T4 PA
Hormones And Synthetic Substitutes
Adrenals
dexamethasone sod phosphate pf solution 10
mg/ml injection T3
dexamethasone sodium phosphate solution 10
mg/ml injection T3
dexamethasone sodium phosphate solution 100
mg/10ml injection T3
dexamethasone sodium phosphate solution 120
mg/30ml injection T3
dexamethasone sodium phosphate solution 20
mg/5ml injection T3
dexamethasone sodium phosphate solution 4
mg/ml injection T3
Androgens
danazol capsule 100 mg oral T3 PA
danazol capsule 200 mg oral T3 PA
danazol capsule 50 mg oral T3 PA
153
Drug Tier Requirements/Limits
Antigonadtropins
FIRMAGON (240 MG DOSE) SOLUTION
RECONSTITUTED 120 MG/VIAL
SUBCUTANEOUS
T4 PA
FIRMAGON SOLUTION RECONSTITUTED
80 MG SUBCUTANEOUS T4 PA
ganirelix acetate solution prefilled syringe 250
mcg/0.5ml subcutaneous T4 PA
Antiparathyroid Agents
PARSABIV SOLUTION 10 MG/2ML
INTRAVENOUS T4 PA
PARSABIV SOLUTION 2.5 MG/0.5ML
INTRAVENOUS T4 PA
Antithyroid Agents
methimazole tablet 10 mg oral T3
methimazole tablet 5 mg oral T3
propylthiouracil tablet 50 mg oral T3
SSKI SOLUTION 1 GM/ML ORAL T3
TAPAZOLE TABLET 10 MG ORAL T3
TAPAZOLE TABLET 5 MG ORAL T3
Contraceptives
AFTERA TABLET 1.5 MG ORAL T3
ECONTRA EZ TABLET 1.5 MG ORAL T3
ECONTRA ONE-STEP TABLET 1.5 MG ORAL T3
FALLBACK SOLO TABLET 1.5 MG ORAL T3
levonorgestrel tablet 1.5 mg oral (otc) T3
MY CHOICE TABLET 1.5 MG ORAL T3
MY WAY TABLET 1.5 MG ORAL (OTC) T3
NEW DAY TABLET 1.5 MG ORAL T3
OPCICON ONE-STEP TABLET 1.5 MG ORAL T3
OPTION 2 TABLET 1.5 MG ORAL T3
PLAN B ONE-STEP TABLET 1.5 MG ORAL
(OTC) T3
PLAN B ONE-STEP TABLET 1.5 MG ORAL
(RX) T3
TAKE ACTION TABLET 1.5 MG ORAL T3
Estrogens
estradiol cream 0.1 mg/gm vaginal T3
154
Drug Tier Requirements/Limits
estradiol tablet 10 mcg vaginal T3
YUVAFEM TABLET 10 MCG VAGINAL T3
Glycogenolytic Agents
BAQSIMI ONE PACK T3 QL (2 EA per 30 days); AL
BAQSIMI TWO PACK T3 QL (2 EA per 30 days); AL
GLUCAGEN HYPOKIT SOLUTION
RECONSTITUTED 1 MG INJECTION T3
GLUCAGON EMERGENCY KIT 1 MG
INJECTION T3
Gonadotropins
BRAVELLE SOLUTION RECONSTITUTED 75
UNIT INJECTION T4 PA
chorionic gonadotropin solution reconstituted
10000 unit intramuscular T4 PA
FOLLISTIM AQ SOLUTION 300 UNT/0.36ML
SUBCUTANEOUS T4 PA
FOLLISTIM AQ SOLUTION 600 UNT/0.72ML
SUBCUTANEOUS T4 PA
FOLLISTIM AQ SOLUTION 900 UNT/1.08ML
SUBCUTANEOUS T4 PA
GONAL-F RFF REDIJECT SOLUTION 300
UNIT/0.5ML SUBCUTANEOUS T4 PA
GONAL-F RFF REDIJECT SOLUTION 450
UNT/0.75ML SUBCUTANEOUS T4 PA
GONAL-F RFF REDIJECT SOLUTION 900
UNIT/1.5ML SUBCUTANEOUS T4 PA
GONAL-F RFF SOLUTION RECONSTITUTED
75 UNIT SUBCUTANEOUS T4 PA
GONAL-F SOLUTION RECONSTITUTED
1050 UNIT INJECTION T4 PA
GONAL-F SOLUTION RECONSTITUTED 450
UNIT INJECTION T4 PA
MENOPUR SOLUTION RECONSTITUTED 75
UNIT SUBCUTANEOUS T4 PA
NOVAREL SOLUTION RECONSTITUTED
10000 UNIT INTRAMUSCULAR T4 PA
NOVAREL SOLUTION RECONSTITUTED
5000 UNIT INTRAMUSCULAR T4 PA
OVIDREL INJECTABLE 250 MCG/0.5ML
SUBCUTANEOUS T4 PA
155
Drug Tier Requirements/Limits
PREGNYL SOLUTION RECONSTITUTED
10000 UNIT INTRAMUSCULAR T4 PA
Gonadotropins And Antigonadotropins
BRAVELLE SOLUTION RECONSTITUTED 75
UNIT INJECTION T4 PA
chorionic gonadotropin solution reconstituted
10000 unit intramuscular T4 PA
FOLLISTIM AQ SOLUTION 300 UNT/0.36ML
SUBCUTANEOUS T4 PA
FOLLISTIM AQ SOLUTION 600 UNT/0.72ML
SUBCUTANEOUS T4 PA
FOLLISTIM AQ SOLUTION 900 UNT/1.08ML
SUBCUTANEOUS T4 PA
GONAL-F RFF REDIJECT SOLUTION 300
UNIT/0.5ML SUBCUTANEOUS T4 PA
GONAL-F RFF REDIJECT SOLUTION 450
UNT/0.75ML SUBCUTANEOUS T4 PA
GONAL-F RFF REDIJECT SOLUTION 900
UNIT/1.5ML SUBCUTANEOUS T4 PA
GONAL-F RFF SOLUTION RECONSTITUTED
75 UNIT SUBCUTANEOUS T4 PA
GONAL-F SOLUTION RECONSTITUTED
1050 UNIT INJECTION T4 PA
GONAL-F SOLUTION RECONSTITUTED 450
UNIT INJECTION T4 PA
MENOPUR SOLUTION RECONSTITUTED 75
UNIT SUBCUTANEOUS T4 PA
NOVAREL SOLUTION RECONSTITUTED
10000 UNIT INTRAMUSCULAR T4 PA
NOVAREL SOLUTION RECONSTITUTED
5000 UNIT INTRAMUSCULAR T4 PA
OVIDREL INJECTABLE 250 MCG/0.5ML
SUBCUTANEOUS T4 PA
PREGNYL SOLUTION RECONSTITUTED
10000 UNIT INTRAMUSCULAR T4 PA
Leptins
MYALEPT SOLUTION RECONSTITUTED
11.3 MG SUBCUTANEOUS T4 PA; QL (30 EA per 30 days)
Pituitary
ACTHAR GEL 80 UNIT/ML INJECTION T4 PA
156
Drug Tier Requirements/Limits
DDAVP RHINAL TUBE SOLUTION 0.01 %
NASAL T3 PA
DDAVP TABLET 0.1 MG ORAL T3 AL
DDAVP TABLET 0.2 MG ORAL T3 AL
desmopressin ace spray refrig solution 0.01 %
nasal T3 PA
desmopressin acetate tablet 0.1 mg oral T3 AL
desmopressin acetate tablet 0.2 mg oral T3 AL
STIMATE SOLUTION 1.5 MG/ML NASAL T3 PA
Somatostatin Agonists
octreotide acetate solution 100 mcg/ml injection T4 PA
octreotide acetate solution 1000 mcg/ml injection T4 PA
octreotide acetate solution 200 mcg/ml injection T4 PA
octreotide acetate solution 50 mcg/ml injection T4 PA
octreotide acetate solution 500 mcg/ml injection T4 PA
SANDOSTATIN LAR DEPOT KIT 10 MG
INTRAMUSCULAR T4 PA; QL (1.2 EA per 30 days)
SANDOSTATIN LAR DEPOT KIT 20 MG
INTRAMUSCULAR T4 PA; QL (2.4 EA per 30 days)
SANDOSTATIN LAR DEPOT KIT 30 MG
INTRAMUSCULAR T4 PA; QL (1.2 EA per 30 days)
SANDOSTATIN SOLUTION 100 MCG/ML
INJECTION T4 PA
SANDOSTATIN SOLUTION 1000 MCG/ML
INJECTION T4 PA
SANDOSTATIN SOLUTION 200 MCG/ML
INJECTION T4 PA
SANDOSTATIN SOLUTION 50 MCG/ML
INJECTION T4 PA
SANDOSTATIN SOLUTION 500 MCG/ML
INJECTION T4 PA
SIGNIFOR LAR SUSPENSION
RECONSTITUTED ER 10 MG
INTRAMUSCULAR
T4 PA
SIGNIFOR LAR SUSPENSION
RECONSTITUTED ER 20 MG
INTRAMUSCULAR
T4 PA; QL (1.2 EA per 30 days)
SIGNIFOR LAR SUSPENSION
RECONSTITUTED ER 30 MG
INTRAMUSCULAR
T4 PA
157
Drug Tier Requirements/Limits
SIGNIFOR LAR SUSPENSION
RECONSTITUTED ER 40 MG
INTRAMUSCULAR
T4 PA; QL (1.2 EA per 30 days)
SIGNIFOR LAR SUSPENSION
RECONSTITUTED ER 60 MG
INTRAMUSCULAR
T4 PA; QL (1.2 EA per 30 days)
SIGNIFOR SOLUTION 0.3 MG/ML
SUBCUTANEOUS T4 PA; QL (60 ML per 30 days)
SIGNIFOR SOLUTION 0.6 MG/ML
SUBCUTANEOUS T4 PA; QL (60 ML per 30 days)
SIGNIFOR SOLUTION 0.9 MG/ML
SUBCUTANEOUS T4 PA; QL (60 ML per 30 days)
SOMATULINE DEPOT SOLUTION 120
MG/0.5ML SUBCUTANEOUS T4 PA; QL (0.6 ML per 30 days)
SOMATULINE DEPOT SOLUTION 60
MG/0.2ML SUBCUTANEOUS T4 PA; QL (0.3 ML per 30 days)
SOMATULINE DEPOT SOLUTION 90
MG/0.3ML SUBCUTANEOUS T4 PA; QL (0.6 ML per 30 days)
Somatotropin Agonists
EGRIFTA SOLUTION RECONSTITUTED 1
MG SUBCUTANEOUS T4 PA
EGRIFTA SV T4 PA
INCRELEX SOLUTION 40 MG/4ML
SUBCUTANEOUS T4 PA
Somatotropin Antagonists
SOMAVERT SOLUTION RECONSTITUTED
10 MG SUBCUTANEOUS T4 PA; QL (30 EA per 30 days)
SOMAVERT SOLUTION RECONSTITUTED
15 MG SUBCUTANEOUS T4 PA; QL (30 EA per 30 days)
SOMAVERT SOLUTION RECONSTITUTED
20 MG SUBCUTANEOUS T4 PA; QL (60 EA per 30 days)
SOMAVERT SOLUTION RECONSTITUTED
25 MG SUBCUTANEOUS T4 PA; QL (30 EA per 30 days)
SOMAVERT SOLUTION RECONSTITUTED
30 MG SUBCUTANEOUS T4 PA; QL (30 EA per 30 days)
Miscellaneous Therapeutic Agents
Alcohol Deterrents
ANTABUSE TABLET 250 MG ORAL T3
ANTABUSE TABLET 500 MG ORAL T3
disulfiram tablet 250 mg oral T3
158
Drug Tier Requirements/Limits
disulfiram tablet 500 mg oral T3
Antidotes
BAQSIMI ONE PACK T3 QL (2 EA per 30 days); AL
BAQSIMI TWO PACK T3 QL (2 EA per 30 days); AL
CHEMET CAPSULE 100 MG ORAL T3
FUSILEV SOLUTION RECONSTITUTED 50
MG INTRAVENOUS T4 PA
GLUCAGEN HYPOKIT SOLUTION
RECONSTITUTED 1 MG INJECTION T3
GLUCAGON EMERGENCY KIT 1 MG
INJECTION T3
KHAPZORY SOLUTION RECONSTITUTED
175 MG INTRAVENOUS T4 PA
KHAPZORY SOLUTION RECONSTITUTED
300 MG INTRAVENOUS T4 PA
KIONEX SUSPENSION 15 GM/60ML ORAL T3
leucovorin calcium solution reconstituted 100 mg
injection T4 PA
leucovorin calcium solution reconstituted 200 mg
injection T4 PA
leucovorin calcium solution reconstituted 350 mg
injection T4 PA
leucovorin calcium solution reconstituted 50 mg
injection T4 PA
leucovorin calcium solution reconstituted 500 mg
injection T4 PA
leucovorin calcium tablet 10 mg oral T4 PA
leucovorin calcium tablet 15 mg oral T4 PA
leucovorin calcium tablet 25 mg oral T4 PA
leucovorin calcium tablet 5 mg oral T4 PA
levoleucovorin calcium solution reconstituted 50
mg intravenous T4 PA
MEPHYTON TABLET 5 MG ORAL T3
phytonadione tablet 5 mg oral T3
sodium polystyrene sulfonate suspension 15
gm/60ml oral T3
SPS SUSPENSION 15 GM/60ML ORAL T3
SSKI SOLUTION 1 GM/ML ORAL T3
Antisense Oligonucleotides
159
Drug Tier Requirements/Limits
EXONDYS 51 SOLUTION 100 MG/2ML
INTRAVENOUS T4 PA
SPINRAZA SOLUTION 12 MG/5ML
INTRATHECAL T4 PA
TEGSEDI SOLUTION PREFILLED SYRINGE
284 MG/1.5ML SUBCUTANEOUS T4 PA
VYONDYS 53 T4 PA
Cariostatic Agents
DENTA 5000 PLUS CREAM 1.1 % DENTAL T3 AL
DENTAGEL GEL 1.1 % DENTAL T3 AL
EPIFLUR TABLET CHEWABLE 0.55 (0.25 F)
MG ORAL T3 AL
EPIFLUR TABLET CHEWABLE 1.1 (0.5 F)
MG ORAL T3 AL
EPIFLUR TABLET CHEWABLE 2.2 (1 F) MG
ORAL T3 AL
FLORIVA PLUS SOLUTION 0.25 MG/ML
ORAL T3
FLUOR-A-DAY SOLUTION 0.275 (0.125 F)
MG/DROP ORAL T3 AL
LUDENT TABLET CHEWABLE 0.55 (0.25 F)
MG ORAL T3 AL
LUDENT TABLET CHEWABLE 1.1 (0.5 F)
MG ORAL T3 AL
LUDENT TABLET CHEWABLE 2.2 (1 F) MG
ORAL T3 AL
multi vitamin/fluoride tablet chewable 1 mg oral T3
multi-vit/fluoride solution 0.25 mg/ml oral T3
multi-vit/fluoride solution 0.5 mg/ml oral T3
multi-vit/fluoride/iron solution 0.25-10 mg/ml
oral T3
multi-vit/iron/fluoride solution 0.25-10 mg/ml
oral T3
multivitamin/fluoride solution 0.25 mg/ml oral T3
multi-vitamin/fluoride solution 0.25 mg/ml oral T3
multivitamin/fluoride solution 0.5 mg/ml oral T3
multi-vitamin/fluoride solution 0.5 mg/ml oral T3
multivitamin/fluoride tablet chewable 0.25 mg
oral T3
multivitamin/fluoride tablet chewable 0.5 mg oral T3
160
Drug Tier Requirements/Limits
multivitamin/fluoride tablet chewable 1 mg oral T3
multivitamin/fluoride/iron solution 0.25-10 mg/ml
oral T3
multi-vitamin/fluoride/iron solution 0.25-10
mg/ml oral T3
MVC-FLUORIDE TABLET CHEWABLE 0.25
MG ORAL T3
MVC-FLUORIDE TABLET CHEWABLE 0.5
MG ORAL T3
MVC-FLUORIDE TABLET CHEWABLE 1 MG
ORAL T3
neutral sodium fluoride solution 0.2 %
mouth/throat (rx) T3 AL
QUFLORA PEDIATRIC SOLUTION 0.25
MG/ML ORAL T3
QUFLORA PEDIATRIC SOLUTION 0.5
MG/ML ORAL T3
QUFLORA PEDIATRIC TABLET CHEWABLE
0.25 MG ORAL T3
QUFLORA PEDIATRIC TABLET CHEWABLE
0.5 MG ORAL T3
QUFLORA PEDIATRIC TABLET CHEWABLE
1 MG ORAL T3
sf 5000 plus cream 1.1 % dental T3 AL
sf gel 1.1 % dental T3 AL
sodium fluoride solution 1.1 (0.5 f) mg/ml oral T3 AL
sodium fluoride tablet chewable 0.55 (0.25 f) mg
oral T3 AL
sodium fluoride tablet chewable 1.1 (0.5 f) mg
oral T3 AL
sodium fluoride tablet chewable 2.2 (1 f) mg oral T3 AL
tri-vit/fluoride solution 0.25 mg/ml oral T3
tri-vit/fluoride/iron solution 0.25-10 mg/ml oral T3
tri-vitamin/fluoride solution 0.25 mg/ml oral T3
tri-vite/fluoride solution 0.25 mg/ml oral T3
vitamins acd-fluoride solution 0.25 mg/ml oral T3
Complement Inhibitors
SOLIRIS SOLUTION 300 MG/30ML
INTRAVENOUS T4 PA; QL (385.8 ML per 30 days)
161
Drug Tier Requirements/Limits
ULTOMIRIS SOLUTION 300 MG/30ML
INTRAVENOUS T4 PA; QL (642.9 ML per 30 days)
Disease-Modifying Antirheumatic
Agents
ARAVA TABLET 10 MG ORAL T3
ARAVA TABLET 20 MG ORAL T3
CUPRIMINE CAPSULE 250 MG ORAL T4 PA
DEPEN TITRATABS TABLET 250 MG ORAL T4 PA
leflunomide tablet 10 mg oral T3
leflunomide tablet 20 mg oral T3
penicillamine capsule 250 mg oral T4 PA
Gonadotropin-Releasing Hormone
Antagnts
FIRMAGON (240 MG DOSE) SOLUTION
RECONSTITUTED 120 MG/VIAL
SUBCUTANEOUS
T4 PA
FIRMAGON SOLUTION RECONSTITUTED
80 MG SUBCUTANEOUS T4 PA
ganirelix acetate solution prefilled syringe 250
mcg/0.5ml subcutaneous T4 PA
Immunomodulatory Agents
ACTIMMUNE SOLUTION 2000000
UNIT/0.5ML SUBCUTANEOUS T4 PA
ARAVA TABLET 10 MG ORAL T3
ARAVA TABLET 20 MG ORAL T3
INTRON A SOLUTION 10000000 UNIT/ML
INJECTION T4 PA
INTRON A SOLUTION RECONSTITUTED
18000000 UNIT INJECTION T4 PA
leflunomide tablet 10 mg oral T3
leflunomide tablet 20 mg oral T3
PROLEUKIN SOLUTION RECONSTITUTED
22000000 UNIT INTRAVENOUS T4 PA
Immunosuppressive Agents
ATGAM INJECTABLE 50 MG/ML
INTRAVENOUS T4 PA
BENLYSTA SOLUTION AUTO-INJECTOR
200 MG/ML SUBCUTANEOUS T4 PA
162
Drug Tier Requirements/Limits
BENLYSTA SOLUTION PREFILLED
SYRINGE 200 MG/ML SUBCUTANEOUS T4 PA
BENLYSTA SOLUTION RECONSTITUTED
120 MG INTRAVENOUS T4 PA
BENLYSTA SOLUTION RECONSTITUTED
400 MG INTRAVENOUS T4 PA
CELLCEPT INTRAVENOUS SOLUTION
RECONSTITUTED 500 MG INTRAVENOUS T4 PA
cyclophosphamide capsule 50 mg oral T3
cyclophosphamide solution reconstituted 1 gm
injection T4 PA
cyclophosphamide solution reconstituted 2 gm
injection T4 PA
cyclophosphamide solution reconstituted 500 mg
injection T4 PA
GAMIFANT SOLUTION 10 MG/2ML
INTRAVENOUS T4 PA
mercaptopurine tablet 50 mg oral T3
mycophenolate mofetil hcl solution reconstituted
500 mg intravenous T4 PA
NULOJIX SOLUTION RECONSTITUTED 250
MG INTRAVENOUS T4 PA
PROGRAF SOLUTION 5 MG/ML
INTRAVENOUS T4 PA
SIMULECT SOLUTION RECONSTITUTED 10
MG INTRAVENOUS T4 PA; QL (30 EA per 30 days)
SIMULECT SOLUTION RECONSTITUTED 20
MG INTRAVENOUS T4 PA; QL (30 EA per 30 days)
THYMOGLOBULIN SOLUTION
RECONSTITUTED 25 MG INTRAVENOUS T4 PA
Other Miscellaneous Therapeutic
Agents
acetylcysteine solution 10 % inhalation T3
acetylcysteine solution 20 % inhalation T3
antioxidant formula tablet oral T3
CARNITOR SF SOLUTION 1 GM/10ML ORAL T4 PA
CARNITOR SOLUTION 1 GM/10ML ORAL T4 PA
CARNITOR TABLET 330 MG ORAL T3
cvs melatonin gummies oral tablet chewable 5 mg T3
cvs melatonin oral capsule 10 mg T3
163
Drug Tier Requirements/Limits
cvs melatonin oral tablet 3 mg T3
CYSTADANE POWDER ORAL T4 PA
DEMSER CAPSULE 250 MG ORAL T4 PA; QL (480 EA per 30 days)
ELON MATRIX 5000 COMPLETE TABLET
ORAL T3
ENDARI PACKET 5 GM ORAL T4 PA
EXONDYS 51 SOLUTION 100 MG/2ML
INTRAVENOUS T4 PA
eye vitamins & minerals tablet oral T3
eyeprotect tablet oral T3
FIRDAPSE TABLET 10 MG ORAL T4 PA
GALAFOLD CAPSULE 123 MG ORAL T4 PA; QL (15 EA per 30 days)
GIVLAARI T4 PA
gnp healthy eyes supervision capsule oral T3
gnp melatonin oral T3
hair/skin/nails capsule oral T3
hair/skin/nails tablet oral T3
ICAPS AREDS FORMULA TABLET ORAL T3
ICAPS CAPSULE ORAL T3
i-vite protect tablet oral T3
KUVAN PACKET 100 MG ORAL T4 PA
KUVAN PACKET 500 MG ORAL T4 PA
KUVAN TABLET SOLUBLE 100 MG ORAL T4 PA
levocarnitine solution 1 gm/10ml oral (rx) T4 PA
levocarnitine tablet 330 mg oral (rx) T3
LIPOTRIAD TABLET ORAL T3
MACUVITE/LUTEIN TABLET ORAL T3
melatonin er oral tablet extended release 10 mg,
3 mg T3
melatonin gummies T3
melatonin oral liquid 1 mg/ml, 2.5 mg/10ml T3
melatonin oral tablet 1 mg, 3 mg, 5 mg T3
melatonin oral tablet dispersible 5 mg T3
melatonin sublingual tablet sublingual 3 mg T3
NITYR TABLET 10 MG ORAL T4 PA
NITYR TABLET 2 MG ORAL T4 PA
NITYR TABLET 5 MG ORAL T4 PA
164
Drug Tier Requirements/Limits
octreotide acetate solution 100 mcg/ml injection T4 PA
octreotide acetate solution 1000 mcg/ml injection T4 PA
octreotide acetate solution 200 mcg/ml injection T4 PA
octreotide acetate solution 50 mcg/ml injection T4 PA
octreotide acetate solution 500 mcg/ml injection T4 PA
OCUVITE ADULT 50+ CAPSULE ORAL T3
OCUVITE EYE HEATLH GUMMIES TABLET
CHEWABLE ORAL T3
OCUVITE PRESERVISION TABLET ORAL T3
OCUVITE-LUTEIN CAPSULE ORAL T3
ONPATTRO SOLUTION 10 MG/5ML
INTRAVENOUS T4 PA
ORALAIR TABLET SUBLINGUAL 300 IR
SUBLINGUAL T4 PA
ORFADIN CAPSULE 10 MG ORAL T4 PA
ORFADIN CAPSULE 2 MG ORAL T4 PA
ORFADIN CAPSULE 20 MG ORAL T4 PA
ORFADIN CAPSULE 5 MG ORAL T4 PA
ORFADIN SUSPENSION 4 MG/ML ORAL T4 PA
PANHEMATIN SOLUTION
RECONSTITUTED 350 MG INTRAVENOUS T4 PA
PARSABIV SOLUTION 10 MG/2ML
INTRAVENOUS T4 PA
PARSABIV SOLUTION 2.5 MG/0.5ML
INTRAVENOUS T4 PA
PRESERVISION AREDS 2 CAPSULE ORAL T3
PRESERVISION AREDS CAPSULE ORAL T3
PRESERVISION AREDS TABLET ORAL T3
PRESERVISION/LUTEIN CAPSULE ORAL T3
PROCYSBI CAPSULE DELAYED RELEASE
25 MG ORAL T4 PA
PROCYSBI CAPSULE DELAYED RELEASE
75 MG ORAL T4 PA
ra melatonin oral tablet 3 mg, 5 mg T3
RUZURGI T4 PA
SANDOSTATIN LAR DEPOT KIT 10 MG
INTRAMUSCULAR T4 PA; QL (1.2 EA per 30 days)
SANDOSTATIN LAR DEPOT KIT 20 MG
INTRAMUSCULAR T4 PA; QL (2.4 EA per 30 days)
165
Drug Tier Requirements/Limits
SANDOSTATIN LAR DEPOT KIT 30 MG
INTRAMUSCULAR T4 PA; QL (1.2 EA per 30 days)
SANDOSTATIN SOLUTION 100 MCG/ML
INJECTION T4 PA
SANDOSTATIN SOLUTION 1000 MCG/ML
INJECTION T4 PA
SANDOSTATIN SOLUTION 200 MCG/ML
INJECTION T4 PA
SANDOSTATIN SOLUTION 50 MCG/ML
INJECTION T4 PA
SANDOSTATIN SOLUTION 500 MCG/ML
INJECTION T4 PA
sm stool softener tablet 8.6-50 mg oral T3
SPINRAZA SOLUTION 12 MG/5ML
INTRATHECAL T4 PA
THIOLA TABLET 100 MG ORAL T4 PA
vision formula 2 capsule oral T3
vision formula eye health capsule oral T3
VITAJOY GUMMIES T3
vp-zel tablet oral T3
Protective Agents
amifostine solution reconstituted 500 mg
intravenous T4 PA
dexrazoxane hcl solution reconstituted 250 mg
intravenous T4 PA
dexrazoxane hcl solution reconstituted 500 mg
intravenous T4 PA
ELMIRON CAPSULE 100 MG ORAL T3 QL (90 EA per 30 days)
ETHYOL SOLUTION RECONSTITUTED 500
MG INTRAVENOUS T4 PA
MESNEX TABLET 400 MG ORAL T4 PA
TOTECT SOLUTION RECONSTITUTED 500
MG INTRAVENOUS T4 PA
ZINECARD SOLUTION RECONSTITUTED
250 MG INTRAVENOUS T4 PA
ZINECARD SOLUTION RECONSTITUTED
500 MG INTRAVENOUS T4 PA
Oxytocics
Oxytocics
166
Drug Tier Requirements/Limits
METHERGINE TABLET 0.2 MG ORAL T3
methylergonovine maleate tablet 0.2 mg oral T3
Pharmaceutical Aids
Pharmaceutical Aids
propylene glycol liquid (rx) T3 QL (1 ML per 90 days)
STERILE DILUENT FOR FLOLAN
SOLUTION INTRAVENOUS T4 PA
sterile diluent/epoprostenol solution intravenous T4 PA
Radioactive Agents
Radioactive Agents
AZEDRA DOSIMETRIC SOLUTION 15
MCI/ML INTRAVENOUS T4 PA
AZEDRA THERAPEUTIC SOLUTION 15
MCI/ML INTRAVENOUS T4 PA
XOFIGO SOLUTION 30 MCCI/ML
INTRAVENOUS T4 PA
Respiratory Tract Agents
Alpha And Beta Adrenergic
Agonist(Respr)
BROMFED DM SYRUP 30-2-10 MG/5ML
ORAL T3
brotapp dm liquid 15-1-5 mg/5ml oral T3
CONGESTAC TABLET 60-400 MG ORAL T3
gnp nasal decongestant tablet 30 mg oral T3
guaifenesin dac solution 30-10-100 mg/5ml oral T3 QL (1200 ML per 30 days)
hm mucus relief d tablet extended release 12 hour
60-600 mg oral T3
hm nasal decongestant tablet 30 mg oral T3
m-end dmx liquid 20-0.667-10 mg/5ml oral T3
MUCINEX D MAX STRENGTH TABLET
EXTENDED RELEASE 12 HOUR 120-1200
MG ORAL
T3
MUCINEX D TABLET EXTENDED RELEASE
12 HOUR 60-600 MG ORAL (OTC) T3
mucus d tablet extended release 12 hour 60-600
mg oral T3
mucus relief d tablet extended release 12 hour 60-
600 mg oral T3
167
Drug Tier Requirements/Limits
nasal decongestant max st tablet 30 mg oral T3
nasal decongestant tablet 30 mg oral T3
pseudoeph-bromphen-dm syrup 30-2-10 mg/5ml
oral (rx) T3
pseudoephedrine hcl tablet 30 mg oral (otc) T3
pseudoephedrine-guaifenesin er tablet extended
release 12 hour 60-600 mg oral T3
sm mucus relief d tablet extended release 12 hour
60-600 mg oral T3
sm nasal decongestant max st tablet 30 mg oral T3
SUDOGEST MAXIMUM STRENGTH
TABLET 30 MG ORAL T3
SUDOGEST SINUS/ALLERGY TABLET 4-60
MG ORAL T3
SUDOGEST TABLET 30 MG ORAL T3
SUDOGEST TABLET 60 MG ORAL T3
TUSNEL C SYRUP 30-10-100 MG/5ML ORAL T3
virtussin dac solution 30-10-100 mg/5ml oral T3 QL (1200 ML per 30 days)
Anticholinergic Agents (Respir.Tract)
diphenoxylate-atropine tablet 2.5-0.025 mg oral T3
LOMOTIL TABLET 2.5-0.025 MG ORAL T3
Antitussives
benzonatate capsule 100 mg oral T3
benzonatate capsule 200 mg oral T3
BROMFED DM SYRUP 30-2-10 MG/5ML
ORAL T3
brotapp dm liquid 15-1-5 mg/5ml oral T3
cheratussin ac syrup 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
cough/chest congestion dm syrup 10-100 mg/5ml
oral T3
dextromethorphan-guaifenesin solution 10-100
mg/5ml oral T3
dextromethorphan-guaifenesin syrup 10-100
mg/5ml oral T3
diabetic siltussin-dm liquid 100-10 mg/5ml oral T3
eql vitamin e capsule 400 unit oral T3
extra action cough syrup 100-10 mg/5ml oral T3
extra action cough syrup 10-100 mg/5ml oral T3
168
Drug Tier Requirements/Limits
gnp tussin dm cough liquid 100-10 mg/5ml oral T3
gnp tussin dm liquid 100-10 mg/5ml oral T3
goodsense mucus relief child liquid 2.5-5-100
mg/5ml oral T3
goodsense tussin cf liquid 5-10-100 mg/5ml oral T3
guaiatussin ac syrup 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
guaifenesin ac syrup 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
guaifenesin dac solution 30-10-100 mg/5ml oral T3 QL (1200 ML per 30 days)
guaifenesin-codeine solution 100-10 mg/5ml oral
(otc) T3 QL (120 ML per 30 days); AL
guaifenesin-dm syrup 100-10 mg/5ml oral T3
hm tussin adult dm liquid 100-10 mg/5ml oral T3
hm tussin adult multi-symptom liquid 5-10-100
mg/5ml oral T3
m-end dmx liquid 20-0.667-10 mg/5ml oral T3
MUCINEX COLD CHILDRENS LIQUID 2.5-5-
100 MG/5ML ORAL T3
MUCINEX CONGEST & COUGH CHILD
LIQUID 2.5-5-100 MG/5ML ORAL T3
MUCINEX DM TABLET EXTENDED
RELEASE 12 HOUR 30-600 MG ORAL (OTC) T3
MUCINEX FAST-MAX CONGEST COUGH
LIQUID 10-20-400 MG/20ML ORAL T3
MUCINEX FAST-MAX CONGEST COUGH
LIQUID 2.5-5-100 MG/5ML ORAL T3
mucus relief childrens liquid 2.5-5-100 mg/5ml
oral T3
mucus relief dm tablet extended release 12 hour
30-600 mg oral T3
promethazine vc/codeine syrup 6.25-5-10 mg/5ml
oral T3 QL (120 ML per 30 days); AL
promethazine-codeine solution 6.25-10 mg/5ml
oral T3 QL (120 ML per 30 days); AL
promethazine-codeine syrup 6.25-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
promethazine-dm solution 6.25-15 mg/5ml oral T3
promethazine-dm syrup 6.25-15 mg/5ml oral T3
promethazine-phenyleph-codeine syrup 6.25-5-10
mg/5ml oral T3 QL (120 ML per 30 days); AL
pseudoeph-bromphen-dm syrup 30-2-10 mg/5ml
oral (rx) T3
169
Drug Tier Requirements/Limits
qc tussin cf liquid 5-10-100 mg/5ml oral T3
qc tussin dm cough/congestion liquid 10-100
mg/5ml oral T3
robafen ac solution 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
robafen cf multi-symptom cold liquid 5-10-100
mg/5ml oral T3
ROBAFEN DM CGH/CHEST CONGEST
LIQUID 10-100 MG/5ML ORAL T3
ROBAFEN DM COUGH CLEAR SYRUP 100-
10 MG/5ML ORAL T3
ROBAFEN DM COUGH LIQUID 10-100
MG/5ML ORAL T3
robafen dm syrup 100-10 mg/5ml oral T3
siltussin dm das liquid 100-10 mg/5ml oral T3
siltussin-dm alcohol free syrup 100-10 mg/5ml
oral T3
sm tussin cf liquid 5-10-100 mg/5ml oral T3
sm tussin cough/chest congest syrup 100-10
mg/5ml oral T3
sm tussin dm syrup 100-10 mg/5ml oral T3
TESSALON PERLES CAPSULE 100 MG
ORAL T3
TUSNEL C SYRUP 30-10-100 MG/5ML ORAL T3
tusnel diabetic liquid 10-100 mg/5ml oral T3
tussin cf cough & cold liquid 5-10-100 mg/5ml
oral T3
tussin cf liquid 5-10-100 mg/5ml oral T3
tussin dm clear liquid 100-10 mg/5ml oral T3
tussin dm cough + chest liquid 10-100 mg/5ml
oral T3
tussin dm liquid 100-10 mg/5ml oral T3
tussin dm liquid 20-200 mg/10ml oral T3
tussin dm syrup 100-10 mg/5ml oral T3
tussin multi-symptom cold cf liquid 5-10-100
mg/5ml oral T3
virtussin a/c solution 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
virtussin dac solution 30-10-100 mg/5ml oral T3 QL (1200 ML per 30 days)
Cystic Fibrosis (Cftr) Correctors
ORKAMBI PACKET 100-125 MG ORAL T4 PA; QL (60 EA per 30 days)
170
Drug Tier Requirements/Limits
ORKAMBI PACKET 150-188 MG ORAL T4 PA; QL (60 EA per 30 days)
ORKAMBI TABLET 100-125 MG ORAL T4 PA; QL (120 EA per 30 days)
ORKAMBI TABLET 200-125 MG ORAL T4 PA; QL (120 EA per 30 days)
SYMDEKO TABLET THERAPY PACK 100-
150 & 150 MG ORAL T4 PA; QL (60 EA per 30 days)
TRIKAFTA TABLET THERAPY PACK 100-
50-75 & 150 MG ORAL T4 PA; QL (90 EA per 30 days)
Cystic Fibrosis (Cftr) Potentiators
KALYDECO PACKET 50 MG ORAL T4 PA; QL (60 EA per 30 days)
KALYDECO PACKET 75 MG ORAL T4 PA; QL (60 EA per 30 days)
KALYDECO TABLET 150 MG ORAL T4 PA; QL (60 EA per 30 days)
ORKAMBI PACKET 100-125 MG ORAL T4 PA; QL (60 EA per 30 days)
ORKAMBI PACKET 150-188 MG ORAL T4 PA; QL (60 EA per 30 days)
ORKAMBI TABLET 100-125 MG ORAL T4 PA; QL (120 EA per 30 days)
ORKAMBI TABLET 200-125 MG ORAL T4 PA; QL (120 EA per 30 days)
SYMDEKO TABLET THERAPY PACK 100-
150 & 150 MG ORAL T4 PA; QL (60 EA per 30 days)
TRIKAFTA TABLET THERAPY PACK 100-
50-75 & 150 MG ORAL T4 PA; QL (90 EA per 30 days)
Expectorants
cheratussin ac syrup 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
childrens mucus relief expect liquid 100 mg/5ml
oral T3
CONGESTAC TABLET 60-400 MG ORAL T3
cough/chest congestion dm syrup 10-100 mg/5ml
oral T3
dextromethorphan-guaifenesin solution 10-100
mg/5ml oral T3
dextromethorphan-guaifenesin syrup 10-100
mg/5ml oral T3
diabetic siltussin das-na liquid 100 mg/5ml oral T3
diabetic siltussin-dm liquid 100-10 mg/5ml oral T3
ed bron gp liquid 5-100 mg/5ml oral T3
extra action cough syrup 100-10 mg/5ml oral T3
extra action cough syrup 10-100 mg/5ml oral T3
gnp mucus er tablet extended release 12 hour
1200 mg oral T3
gnp tussin dm cough liquid 100-10 mg/5ml oral T3
171
Drug Tier Requirements/Limits
gnp tussin dm liquid 100-10 mg/5ml oral T3
gnp tussin mucus & chest cong liquid 100 mg/5ml
oral T3
goodsense mucus relief child liquid 2.5-5-100
mg/5ml oral T3
goodsense tussin cf liquid 5-10-100 mg/5ml oral T3
guaiatussin ac syrup 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
guaifenesin ac syrup 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
guaifenesin dac solution 30-10-100 mg/5ml oral T3 QL (1200 ML per 30 days)
guaifenesin er tablet extended release 12 hour
1200 mg oral T3
guaifenesin liquid 100 mg/5ml oral T3
guaifenesin solution 100 mg/5ml oral T3
guaifenesin solution 200 mg/10ml oral T3
guaifenesin solution 300 mg/15ml oral T3
guaifenesin-codeine solution 100-10 mg/5ml oral
(otc) T3 QL (120 ML per 30 days); AL
guaifenesin-dm syrup 100-10 mg/5ml oral T3
hm mucus relief d tablet extended release 12 hour
60-600 mg oral T3
hm tussin adult dm liquid 100-10 mg/5ml oral T3
hm tussin adult liquid 100 mg/5ml oral T3
hm tussin adult multi-symptom liquid 5-10-100
mg/5ml oral T3
MUCINEX CHEST CONGESTION CHILD
LIQUID 100 MG/5ML ORAL T3
MUCINEX COLD CHILDRENS LIQUID 2.5-5-
100 MG/5ML ORAL T3
MUCINEX CONGEST & COUGH CHILD
LIQUID 2.5-5-100 MG/5ML ORAL T3
MUCINEX D MAX STRENGTH TABLET
EXTENDED RELEASE 12 HOUR 120-1200
MG ORAL
T3
MUCINEX D TABLET EXTENDED RELEASE
12 HOUR 60-600 MG ORAL (OTC) T3
MUCINEX DM TABLET EXTENDED
RELEASE 12 HOUR 30-600 MG ORAL (OTC) T3
MUCINEX FAST-MAX CONGEST COUGH
LIQUID 10-20-400 MG/20ML ORAL T3
172
Drug Tier Requirements/Limits
MUCINEX FAST-MAX CONGEST COUGH
LIQUID 2.5-5-100 MG/5ML ORAL T3
MUCINEX MAXIMUM STRENGTH TABLET
EXTENDED RELEASE 12 HOUR 1200 MG
ORAL
T3
MUCINEX STUFFY NOSE/COLD CHILD
LIQUID 2.5-100 MG/5ML ORAL T3
mucus & chest congestion liquid 100 mg/5ml oral T3
mucus d tablet extended release 12 hour 60-600
mg oral T3
mucus relief childrens liquid 100 mg/5ml oral T3
mucus relief childrens liquid 2.5-5-100 mg/5ml
oral T3
mucus relief d tablet extended release 12 hour 60-
600 mg oral T3
mucus relief dm tablet extended release 12 hour
30-600 mg oral T3
mucus relief max st tablet extended release 12
hour 1200 mg oral T3
pseudoephedrine-guaifenesin er tablet extended
release 12 hour 60-600 mg oral T3
qc mucus relief er tablet extended release 12 hour
1200 mg oral T3
qc tussin cf liquid 5-10-100 mg/5ml oral T3
qc tussin dm cough/congestion liquid 10-100
mg/5ml oral T3
qc tussin mucus/congestion liquid 100 mg/5ml
oral T3
RESCON-GG LIQUID 5-100 MG/5ML ORAL T3
robafen ac solution 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
robafen cf multi-symptom cold liquid 5-10-100
mg/5ml oral T3
ROBAFEN DM CGH/CHEST CONGEST
LIQUID 10-100 MG/5ML ORAL T3
ROBAFEN DM COUGH CLEAR SYRUP 100-
10 MG/5ML ORAL T3
ROBAFEN DM COUGH LIQUID 10-100
MG/5ML ORAL T3
robafen dm syrup 100-10 mg/5ml oral T3
ROBAFEN MUCUS/CHEST CONGESTION
LIQUID 200 MG/10ML ORAL T3
173
Drug Tier Requirements/Limits
siltussin dm das liquid 100-10 mg/5ml oral T3
siltussin-dm alcohol free syrup 100-10 mg/5ml
oral T3
sm mucus relief d tablet extended release 12 hour
60-600 mg oral T3
sm mucus relief max strength tablet extended
release 12 hour 1200 mg oral T3
sm tussin cf liquid 5-10-100 mg/5ml oral T3
sm tussin cough/chest congest syrup 100-10
mg/5ml oral T3
sm tussin dm syrup 100-10 mg/5ml oral T3
sm tussin mucus+chest congest liquid 100 mg/5ml
oral T3
SSKI SOLUTION 1 GM/ML ORAL T3
TUSNEL C SYRUP 30-10-100 MG/5ML ORAL T3
tusnel diabetic liquid 10-100 mg/5ml oral T3
tussin cf cough & cold liquid 5-10-100 mg/5ml
oral T3
tussin cf liquid 5-10-100 mg/5ml oral T3
tussin dm clear liquid 100-10 mg/5ml oral T3
tussin dm cough + chest liquid 10-100 mg/5ml
oral T3
tussin dm liquid 100-10 mg/5ml oral T3
tussin dm liquid 20-200 mg/10ml oral T3
tussin dm syrup 100-10 mg/5ml oral T3
tussin mucus & chest congest liquid 100 mg/5ml
oral T3
tussin mucus+chest congestion liquid 100 mg/5ml
oral T3
tussin multi-symptom cold cf liquid 5-10-100
mg/5ml oral T3
virtussin a/c solution 100-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
virtussin dac solution 30-10-100 mg/5ml oral T3 QL (1200 ML per 30 days)
First Generation Antihist.(Respir Tract)
aller-chlor syrup 2 mg/5ml oral T3
aller-chlor tablet 4 mg oral T3
allergy childrens liquid 12.5 mg/5ml oral T3
allergy relief capsule 25 mg oral T3
allergy relief childrens liquid 12.5 mg/5ml oral T3
174
Drug Tier Requirements/Limits
allergy relief tablet 25 mg oral T3
allergy relief tablet 4 mg oral T3
allergy tablet 25 mg oral T3
allergy tablet 4 mg oral T3
allergy-time tablet 4 mg oral T3
BANOPHEN CAPSULE 25 MG ORAL T3
BANOPHEN CAPSULE 50 MG ORAL T3
BANOPHEN LIQUID 12.5 MG/5ML ORAL T3
BANOPHEN TABLET 25 MG ORAL T3
BROMFED DM SYRUP 30-2-10 MG/5ML
ORAL T3
brotapp dm liquid 15-1-5 mg/5ml oral T3
complete allergy medicine capsule 25 mg oral T3
cyproheptadine hcl syrup 2 mg/5ml oral T3
cyproheptadine hcl tablet 4 mg oral T3
diphenhist capsule 25 mg oral T3
diphenhist liquid 12.5 mg/5ml oral T3
diphenhist tablet 25 mg oral T3
diphenhydramine hcl capsule 25 mg oral (otc) T3
diphenhydramine hcl capsule 50 mg oral (otc) T3
diphenhydramine hcl elixir 12.5 mg/5ml oral (rx) T3
diphenhydramine hcl liquid 12.5 mg/5ml oral T3
diphenhydramine hcl solution 50 mg/ml injection T3
diphenhydramine hcl tablet 25 mg oral T3
dye-free allergy relief liquid 12.5 mg/5ml oral T3
ed chlorped jr syrup 2 mg/5ml oral T3
eql vitamin e capsule 400 unit oral T3
gnp allergy antihistamine liquid 12.5 mg/5ml oral T3
gnp allergy capsule 25 mg oral T3
gnp allergy relief capsule 25 mg oral T3
gnp allergy relief tablet chewable 12.5 mg oral T3
gnp allergy tablet 25 mg oral T3
gnp allergy tablet 4 mg oral T3
gnp childrens allergy liquid 12.5 mg/5ml oral T3
gnp sleep aid tablet 25 mg oral T3
hm allergy multi symptom capsule 25 mg oral T3
hm allergy relief capsule 25 mg oral T3
175
Drug Tier Requirements/Limits
hm allergy relief childrens liquid 12.5 mg/5ml
oral T3
hm allergy relief tablet 25 mg oral T3
hm allergy relief tablet 4 mg oral T3
hm allergy tablet 25 mg oral T3
hm sleep aid tablet 25 mg oral T3
m-end dmx liquid 20-0.667-10 mg/5ml oral T3
multi-symptom allergy capsule 25 mg oral T3
pharbedryl capsule 25 mg oral T3
pharbedryl capsule 50 mg oral T3
promethazine vc plain solution 6.25-5 mg/5ml
oral T3 QL (900 ML per 30 days)
promethazine vc/codeine syrup 6.25-5-10 mg/5ml
oral T3 QL (120 ML per 30 days); AL
promethazine-codeine solution 6.25-10 mg/5ml
oral T3 QL (120 ML per 30 days); AL
promethazine-codeine syrup 6.25-10 mg/5ml oral T3 QL (120 ML per 30 days); AL
promethazine-dm solution 6.25-15 mg/5ml oral T3
promethazine-dm syrup 6.25-15 mg/5ml oral T3
promethazine-phenyleph-codeine syrup 6.25-5-10
mg/5ml oral T3 QL (120 ML per 30 days); AL
promethazine-phenylephrine syrup 6.25-5 mg/5ml
oral T3 QL (900 ML per 30 days)
pseudoeph-bromphen-dm syrup 30-2-10 mg/5ml
oral (rx) T3
qc complete allergy medicine capsule 25 mg oral T3
siladryl allergy liquid 12.5 mg/5ml oral T3
sleep aid tablet 25 mg oral T3
sm allergy 4 hour tablet 4 mg oral T3
sm allergy relief capsule 25 mg oral T3
sm allergy relief liquid 12.5 mg/5ml oral T3
sm allergy relief tablet 25 mg oral T3
sm sleep aid tablet 25 mg oral T3
SUDOGEST SINUS/ALLERGY TABLET 4-60
MG ORAL T3
Mucolytic Agents
acetylcysteine solution 10 % inhalation T3
acetylcysteine solution 20 % inhalation T3
176
Drug Tier Requirements/Limits
PULMOZYME SOLUTION 1 MG/ML
INHALATION T4 PA; QL (150 ML per 30 days)
Respiratory Tract Agents,
Miscellaneous
ARALAST NP SOLUTION RECONSTITUTED
1000 MG INTRAVENOUS T4 PA
ARALAST NP SOLUTION RECONSTITUTED
500 MG INTRAVENOUS T4 PA
GLASSIA SOLUTION 1000 MG/50ML
INTRAVENOUS T4 PA
PROLASTIN-C SOLUTION RECONSTITUTED
1000 MG INTRAVENOUS T4 PA
ZEMAIRA SOLUTION RECONSTITUTED
1000 MG INTRAVENOUS T4 PA
Vasodilating Agents (Respiratory Tract)
epoprostenol sodium solution reconstituted 0.5
mg intravenous T4 PA
epoprostenol sodium solution reconstituted 1.5
mg intravenous T4 PA
FLOLAN SOLUTION RECONSTITUTED 0.5
MG INTRAVENOUS T4 PA
FLOLAN SOLUTION RECONSTITUTED 1.5
MG INTRAVENOUS T4 PA
REMODULIN SOLUTION 100 MG/20ML
INJECTION T4 PA
REMODULIN SOLUTION 20 MG/20ML
INJECTION T4 PA
REMODULIN SOLUTION 200 MG/20ML
INJECTION T4 PA
REMODULIN SOLUTION 50 MG/20ML
INJECTION T4 PA
treprostinil solution 100 mg/20ml injection T4 PA
treprostinil solution 20 mg/20ml injection T4 PA
treprostinil solution 200 mg/20ml injection T4 PA
treprostinil solution 50 mg/20ml injection T4 PA
VELETRI SOLUTION RECONSTITUTED 0.5
MG INTRAVENOUS T4 PA
VELETRI SOLUTION RECONSTITUTED 1.5
MG INTRAVENOUS T4 PA
Xanthine Derivatives
177
Drug Tier Requirements/Limits
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 100 MG ORAL T3
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 200 MG ORAL T3
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 400 MG ORAL T3
theophylline er tablet extended release 12 hour
200 mg oral T3
theophylline er tablet extended release 12 hour
300 mg oral T3
theophylline er tablet extended release 24 hour
400 mg oral T3
theophylline er tablet extended release 24 hour
600 mg oral T3
Skin And Mucous Membrane Agents
Anti-Inflammatory Agents (Skin,
Mucous)
PROCTOFOAM HC FOAM 1-1 % EXTERNAL T3
Antipruritics And Local Anesthetics
dibucaine (perianal) ointment 1 % external T3
phenazopyridine hcl tablet 100 mg oral T3
phenazopyridine hcl tablet 200 mg oral T3
PROCTOFOAM HC FOAM 1-1 % EXTERNAL T3
PYRIDIUM TABLET 100 MG ORAL T3
PYRIDIUM TABLET 200 MG ORAL T3
SARNA SENSITIVE LOTION 1 % EXTERNAL T3
Astringents
alum sulfate-ca acetate packet external T3
PEDI-BORO SOAK PACKET EXTERNAL T3
Basic Lotions And Liniments
ammonium lactate lotion 12 % external (otc) T3
ammonium lactate lotion 12 % external (rx) T3
Basic Oils And Other Solvents
gnp mineral oil heavy oil oral T3
Basic Ointments And Protectants
ammonium lactate cream 12 % external (otc) T3
ammonium lactate cream 12 % external (rx) T3
178
Drug Tier Requirements/Limits
Cell Stimulants And Proliferants
KEPIVANCE SOLUTION RECONSTITUTED
6.25 MG INTRAVENOUS T4 PA
Corticosteroids (Skin, Mucous
Membrane)
PROCTOFOAM HC FOAM 1-1 % EXTERNAL T3
Keratolytic Agents
corn & callus remover liquid 17 % external T3
DHS SAL SHAMPOO 3 % EXTERNAL T3
gnp wart remover liquid 17 % external T3
SALACTIC FILM SOLUTION 17 %
EXTERNAL T3
SAL-PLANT GEL 17 % EXTERNAL T3
urea cream 40 % external T3
wart remover maximum strength liquid 17 %
external T3
Local Anti-Infectives, Miscellaneous
alcohol pads pad 70 % T3 QL (150 EA per 34 days)
alcohol prep pad T3 QL (150 EA per 34 days)
alcohol prep pad 70 % T3 QL (150 EA per 34 days)
alcohol prep pad pad 70 % T3 QL (150 EA per 34 days)
alcohol preps pad T3 QL (150 EA per 34 days)
alcohol swabs pad T3 QL (150 EA per 34 days)
alcohol swabs pad 70 % T3 QL (150 EA per 34 days)
alcohol wipes pad 70 % T3 QL (150 EA per 34 days)
anti-dandruff shampoo 1 % external T3
BD SWAB SINGLE USE REGULAR PAD T3 QL (150 EA per 34 days)
CARETOUCH ALCOHOL PREP PAD 70 % T3 QL (150 EA per 34 days)
CURITY ALCOHOL PREPS PAD 70 % T3 QL (150 EA per 34 days)
cvs alcohol prep pads pad 70 % T3 QL (150 EA per 34 days)
cvs alcohol prep swabs pad 70 % T3 QL (150 EA per 34 days)
cvs alcohol swabs pad T3 QL (150 EA per 34 days)
cvs isopropyl alcohol wipes 70 % external T3 QL (150 EA per 34 days)
cvs prep pad 70 % T3 QL (150 EA per 34 days)
easy comfort alcohol pads pad T3 QL (150 EA per 34 days)
EASY TOUCH ALCOHOL PREP MEDIUM
PAD 70 % T3 QL (150 EA per 34 days)
179
Drug Tier Requirements/Limits
FIFTY50 ALCOHOL PREP PAD 70 % T3 QL (150 EA per 34 days)
global alcohol prep ease pad 70 % T3 QL (150 EA per 34 days)
gnp alcohol swabs pad T3 QL (150 EA per 34 days)
gnp alcohol swabs pad 70 % T3 QL (150 EA per 34 days)
gnp isopropyl alcohol wipes 70 % external T3 QL (150 EA per 34 days)
h-e-b incontrol alcohol pad T3 QL (150 EA per 34 days)
hm sterile alcohol prep pad T3 QL (150 EA per 34 days)
isopropyl alcohol wipes 70 % external T3 QL (150 EA per 34 days)
PHARMACIST CHOICE ALCOHOL PAD T3 QL (150 EA per 34 days)
pro comfort alcohol pad 70 % T3 QL (150 EA per 34 days)
qc alcohol swabs pad 70 % T3 QL (150 EA per 34 days)
ra alcohol swabs pad 70 % T3 QL (150 EA per 34 days)
ra isopropyl alcohol wipes 70 % external T3 QL (150 EA per 34 days)
RELION ALCOHOL SWABS PAD 70 % T3 QL (150 EA per 34 days)
saps care alcohol prep pad 70 % T3 QL (150 EA per 34 days)
saps health alcohol prep pad 70 % T3 QL (150 EA per 34 days)
saps health care alcohol prep pad 70 % T3 QL (150 EA per 34 days)
selenium sulfide lotion 2.5 % external T3
SILVADENE CREAM 1 % EXTERNAL T3
silver sulfadiazine cream 1 % external T3
sm alcohol prep pad T3 QL (150 EA per 34 days)
sm alcohol prep pad 70 % T3 QL (150 EA per 34 days)
SSD CREAM 1 % EXTERNAL T3
sure comfort alcohol prep pad 70 % T3 QL (150 EA per 34 days)
SURE-PREP ALCOHOL PREP PAD 70 % T3 QL (150 EA per 34 days)
tgt alcohol swabs pad 70 % T3 QL (150 EA per 34 days)
true comfort alcohol prep pads pad 70 % T3 QL (150 EA per 34 days)
ULTICARE ALCOHOL SWABS PAD T3 QL (150 EA per 34 days)
ULTICARE ALCOHOL SWABS PAD 70 % T3 QL (150 EA per 34 days)
ultilet alcohol swab pad T3 QL (150 EA per 34 days)
ultilet alcohol swabs pad T3 QL (150 EA per 34 days)
ultra-care alcohol prep pads pad 70 % T3 QL (150 EA per 34 days)
WEBCOL ALCOHOL PREP LARGE PAD 70 % T3 QL (150 EA per 34 days)
WEBCOL ALCOHOL PREP MEDIUM PAD 70
% T3 QL (150 EA per 34 days)
Scabicides And Pediculicides
180
Drug Tier Requirements/Limits
COLEMAN INSECT REPEL HIGH&DRY
AEROSOL 25 % EXTERNAL T3 QL (900 GM per 30 days)
COLEMAN INSECT REPEL SPORTSMEN
AEROSOL 40 % EXTERNAL T3 QL (900 GM per 30 days)
CUTTER BACKWOODS AEROSOL
EXTERNAL T3 QL (900 GM per 30 days)
CUTTER BACKWOODS DRY AEROSOL
EXTERNAL T3 QL (900 GM per 30 days)
CUTTER SKINSATIONS LIQUID 7 %
EXTERNAL T3 QL (900 ML per 30 days)
cvs insect repellent aerosol 15 % external T3 QL (900 GM per 30 days)
OFF ACTIVE AEROSOL 15 % EXTERNAL T3 QL (900 GM per 30 days)
OFF DEEP WOODS AEROSOL EXTERNAL T3 QL (900 GM per 30 days)
OFF DEEP WOODS DRY AEROSOL
EXTERNAL T3 QL (900 GM per 30 days)
OFF FAMILYCARE UNSCENTED LIQUID 7
% EXTERNAL T3 QL (900 ML per 30 days)
OFF SMOOTH & DRY AEROSOL 15 %
EXTERNAL T3 QL (900 GM per 30 days)
REPEL FAMILY AEROSOL 15 % EXTERNAL T3 QL (900 GM per 30 days)
REPEL HUNTERS FORMULA AEROSOL
EXTERNAL T3 QL (900 GM per 30 days)
REPEL SPORTSMEN AEROSOL EXTERNAL T3 QL (900 GM per 30 days)
REPEL SPORTSMEN DRY AEROSOL
EXTERNAL T3 QL (900 GM per 30 days)
REPEL SPORTSMEN MAX AEROSOL 40 %
EXTERNAL T3 QL (900 GM per 30 days)
ULTRATHON INSECT REPELLENT 8
AEROSOL 25 % EXTERNAL T3 QL (900 GM per 30 days)
Skin And Mucous Membrane Agents,
Misc.
COLEMAN 100 MAX CONTINUOUS SPR
AEROSOL 98.11 % EXTERNAL T3 QL (900 GM per 30 days)
COLEMAN 100 MAX INSECT REPEL LIQUID
98.11 % EXTERNAL T3 QL (900 ML per 30 days)
COLEMAN INSECT REPEL HIGH&DRY
AEROSOL 25 % EXTERNAL T3 QL (900 GM per 30 days)
COLEMAN INSECT REPEL SPORTSMEN
AEROSOL 40 % EXTERNAL T3 QL (900 GM per 30 days)
CUTTER BACKWOODS AEROSOL
EXTERNAL T3 QL (900 GM per 30 days)
181
Drug Tier Requirements/Limits
CUTTER BACKWOODS DRY AEROSOL
EXTERNAL T3 QL (900 GM per 30 days)
CUTTER BACKWOODS LIQUID EXTERNAL T3 QL (900 ML per 30 days)
CUTTER SKINSATIONS LIQUID 7 %
EXTERNAL T3 QL (900 ML per 30 days)
cvs insect repellent aerosol 15 % external T3 QL (900 GM per 30 days)
cvs total home insect repel aerosol 30 % external T3 QL (900 ML per 30 days)
NATRAPEL 12-HOUR TICK/INSECT
AEROSOL 20 % EXTERNAL T3
OFF ACTIVE AEROSOL 15 % EXTERNAL T3 QL (900 GM per 30 days)
OFF DEEP WOODS AEROSOL EXTERNAL T3 QL (900 GM per 30 days)
OFF DEEP WOODS DRY AEROSOL
EXTERNAL T3 QL (900 GM per 30 days)
OFF DEEP WOODS LIQUID EXTERNAL T3 QL (900 ML per 30 days)
OFF DEEP WOODS SPORTSMEN AEROSOL
30 % EXTERNAL T3 QL (900 GM per 30 days)
OFF DEEP WOODS SPORTSMEN LIQUID
98.25 % EXTERNAL T3 QL (900 ML per 30 days)
OFF DEEP WOODS SPORTSMEN LIQUID
EXTERNAL T3 QL (900 ML per 30 days)
OFF FAMILYCARE CLEAN FEEL LIQUID 5
% EXTERNAL T3 QL (900 ML per 30 days)
OFF FAMILYCARE TROPICAL FRESH
LIQUID 5 % EXTERNAL T3 QL (900 ML per 30 days)
OFF FAMILYCARE UNSCENTED LIQUID 7
% EXTERNAL T3 QL (900 ML per 30 days)
OFF SMOOTH & DRY AEROSOL 15 %
EXTERNAL T3 QL (900 GM per 30 days)
podofilox solution 0.5 % external T3
RANGER READY REPELLENT LIQUID 20 %
EXTERNAL T3 QL (900 ML per 30 days)
REPEL 100 LIQUID 98.11 % EXTERNAL T3 QL (900 ML per 30 days)
REPEL FAMILY AEROSOL 15 % EXTERNAL T3 QL (900 GM per 30 days)
REPEL FAMILY DRY AEROSOL 10 %
EXTERNAL T3 QL (900 GM per 30 days)
REPEL HUNTERS FORMULA AEROSOL
EXTERNAL T3 QL (900 GM per 30 days)
REPEL SPORTSMEN AEROSOL EXTERNAL T3 QL (900 GM per 30 days)
REPEL SPORTSMEN DRY AEROSOL
EXTERNAL T3 QL (900 GM per 30 days)
182
Drug Tier Requirements/Limits
REPEL SPORTSMEN MAX AEROSOL 40 %
EXTERNAL T3 QL (900 GM per 30 days)
REPEL SPORTSMEN MAX LIQUID 40 %
EXTERNAL T3 QL (900 ML per 30 days)
REPEL TICK DEFENSE AEROSOL 15 %
EXTERNAL T3
SANTYL OINTMENT 250 UNIT/GM
EXTERNAL T3
SAWYER INSECT REPELLENT LIQUID 20 %
EXTERNAL T3 QL (900 ML per 30 days)
TARGRETIN GEL 1 % EXTERNAL T4 PA
ULTRATHON INSECT REPELLENT 8
AEROSOL 25 % EXTERNAL T3 QL (900 GM per 30 days)
Smooth Muscle Relaxants
Respiratory Smooth Muscle Relaxants
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 100 MG ORAL T3
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 200 MG ORAL T3
THEO-24 CAPSULE EXTENDED RELEASE 24
HOUR 400 MG ORAL T3
theophylline er tablet extended release 12 hour
200 mg oral T3
theophylline er tablet extended release 12 hour
300 mg oral T3
theophylline er tablet extended release 24 hour
400 mg oral T3
theophylline er tablet extended release 24 hour
600 mg oral T3
Vitamins
Multivitamin Preparations
50+ adult eye health capsule oral T3
a thru z advanced tablet oral T3
a thru z advantage tablet oral T3
a thru z high potency tablet oral T3
a thru z select 50+ advanced tablet oral T3
a thru z select 50+ mens tablet oral T3
a thru z select advanced tablet oral T3
a thru z select tablet oral T3
183
Drug Tier Requirements/Limits
a thru z select ultimate women tablet oral T3
a thru z ultimate mens tablet oral T3
ABC PLUS SENIOR ADULTS 50+ TABLET
ORAL T3
abdek capsule oral T3
ADEKS TABLET CHEWABLE ORAL T3
adult one daily gummies tablet chewable oral T3
ADVANCED MULTI EA TABLET
CHEWABLE ORAL T3
advanced stress formula/zinc tablet oral T3
ALIVE ONCE DAILY WOMENS 50+ TABLET
ORAL T3
ALIVE WOMENS ENERGY TABLET ORAL T3
ALIVE WOMENS GUMMY TABLET
CHEWABLE ORAL T3
antioxidant a/c/e/selenium tablet oral T3
antioxidant capsule oral T3
antioxidant formula capsule oral T3
antioxidant tablet oral T3
antioxidant vitamins tablet oral T3
APATATE FORTE LIQUID ORAL T3
AQUADEKS CAPSULE ORAL T3
AQUADEKS LIQUID ORAL T3
AQUADEKS TABLET CHEWABLE ORAL T3
BACMIN TABLET ORAL T3
bariatric multivitamins/iron capsule oral T3
bee zee tablet oral T3
BIO-35 GLUTEN-FREE CAPSULE ORAL T3
biocel tablet oral T3
biosupp liquid oral T3
BIOTECT PLUS LIQUID ORAL T3
biotin plus/calcium/vit d3 tablet oral T3
body/hair/skin/nails capsule oral T3
b-plex plus tablet oral T3
BPROTECTED MULTI-VITE LIQUID ORAL T3
CALCET PLUS TABLET ORAL T3
CARRAVITE TABLET ORAL T3
184
Drug Tier Requirements/Limits
centamin liquid oral T3
centavite a-z complete-mineral tablet oral T3
central-vite tablet oral T3
centravites 50 plus tablet oral T3
centravites adults tablet oral T3
centravites tablet oral T3
CENTRUM ADULTS TABLET ORAL T3
CENTRUM CARDIO TABLET ORAL T3
CENTRUM FLAVOR BURST ADULT
TABLET CHEWABLE ORAL T3
CENTRUM FLAVOR BURST KIDS TABLET
CHEWABLE ORAL T3
CENTRUM LIQUID ORAL T3
CENTRUM MEN TABLET ORAL T3
CENTRUM MULTIGUMMIES TABLET
CHEWABLE ORAL T3
CENTRUM PERFORMANCE TABLET ORAL T3
CENTRUM SILVER 50+MEN TABLET ORAL T3
CENTRUM SILVER 50+WOMEN TABLET
ORAL T3
CENTRUM SILVER ADULT 50+ TABLET
ORAL T3
CENTRUM SILVER TABLET CHEWABLE
ORAL T3
CENTRUM SILVER TABLET ORAL T3
CENTRUM SILVER ULTRA WOMENS
TABLET ORAL T3
CENTRUM SPECIALIST ENERGY TABLET
ORAL T3
CENTRUM SPECIALIST HEART TABLET
ORAL T3
CENTRUM SPECIALIST VISION TABLET
ORAL T3
CENTRUM TABLET CHEWABLE ORAL T3
CENTRUM TABLET ORAL T3
CENTRUM ULTRA MENS TABLET ORAL T3
CENTRUM ULTRA WOMENS TABLET
ORAL T3
century mature tablet oral T3
185
Drug Tier Requirements/Limits
CENTURY SENIOR TABLET ORAL T3
century tablet oral T3
CEROVITE ADVANCED FORMULA LIQUID
ORAL T3
CEROVITE ADVANCED FORMULA TABLET
ORAL T3
CEROVITE SENIOR TABLET ORAL T3
certa plus senior tablet oral T3
certa plus tablet oral T3
certagen liquid† oral T3
certagen tablet oral T3
CERTAVITE SENIOR/ANTIOXIDANT
TABLET ORAL T3
CERTAVITE/ANTIOXIDANTS LIQUID ORAL T3
CERTAVITE/ANTIOXIDANTS TABLET
ORAL T3
chewable vite childrens tablet chewable oral T3
choice-tabs tablet oral T3
COMPANION MULTI MEN TABLET ORAL T3
companion tablet oral T3
COMPETE TABLET ORAL T3
complete multivitamin/mineral liquid oral T3
complete senior tablet oral T3
complete tablet oral T3
CORVITE FREE TABLET ORAL T3
cvs daily energy tablet oral T3
cvs daily gummies tablet chewable oral T3
cvs daily multiple fe/ca/zn tablet oral T3
cvs daily multiple for men 50+ tablet oral T3
cvs daily multiple for men tablet oral T3
cvs daily multiple for women tablet oral T3
cvs daily multiple plus iron tablet oral T3
cvs daily multiple plus min tablet oral T3
cvs daily multiple tablet oral T3
cvs daily multiple women 50+ tablet oral T3
cvs daily teen tablet oral T3
cvs eye health & lutein tablet oral T3
186
Drug Tier Requirements/Limits
cvs hair/skin/nails tablet oral T3
cvs mega multi tablet oral T3
cvs mens daily gummies tablet chewable oral T3
cvs one daily essential tablet oral T3
cvs one daily mens 50+ adv tablet oral T3
cvs one daily womens formula tablet oral T3
cvs spectravite adult 50+ tablet chewable oral T3
cvs spectravite adult 50+ tablet oral T3
cvs spectravite adult gummies tablet chewable
oral T3
cvs spectravite advanced liquid oral T3
cvs spectravite advanced tablet oral T3
cvs spectravite cardio health tablet oral T3
cvs spectravite energy tablet oral T3
cvs spectravite naturalized tablet oral T3
cvs spectravite performance tablet oral T3
cvs spectravite plus tablet oral T3
cvs spectravite probiotic tablet oral T3
cvs spectravite senior tablet oral T3
cvs spectravite tablet oral T3
cvs spectravite ultra men 50+ tablet oral T3
cvs spectravite ultra mens tablet oral T3
cvs spectravite ultra women tablet oral T3
cvs spectravite womens senior tablet oral T3
cvs stress formula tablet oral T3
cvs stress formula/zinc tablet oral T3
cvs vision formula tablet oral T3
cvs womens active daily tablet oral T3
cvs womens daily gummies tablet chewable oral T3
daily combo multi vitamins tablet oral T3
daily combo multivits/calcium tablet oral T3
daily diet support tablet oral T3
daily multi tablet oral T3
daily multiple vitamins tablet oral T3
daily multiple vitamins/iron tablet oral T3
daily multiple vitamins/min tablet oral T3
daily multiple weight loss tablet oral T3
187
Drug Tier Requirements/Limits
daily multivitamin capsule oral T3
daily value multivitamin tablet oral T3
daily vitamin formula tablet oral T3
daily vitamin formula+iron tablet oral T3
daily vitamin formula+minerals tablet oral T3
daily vitamin tablet oral T3
daily vitamins tablet oral T3
daily vite multivitamin/iron tablet oral T3
daily vite tablet oral T3
daily vites tablet oral T3
daily vites/iron tablet oral T3
daily-vite tablet oral T3
daily-vite/iron/beta-carotene tablet oral T3
DECUBI-VITE CAPSULE ORAL T3
dekas bariatric tablet chewable oral T3
dekas essential capsule oral T3
dekas essential liquid oral T3
dekas plus capsule oral T3
dekas plus liquid oral T3
dekas plus tablet chewable oral T3
diabetes health formula tablet oral T3
ELON MATRIX 5000 COMPLETE TABLET
ORAL T3
ELON MATRIX COMPLETE TABLET ORAL T3
EMERGEN-C VITAMIN C TABLET
CHEWABLE ORAL T3
eq complete multivit adult 50+ tablet oral T3
eq complete multivitamin-adult tablet oral T3
eq one daily mens 50+ tablet oral T3
eq one daily mens health tablet oral T3
eq one daily womens health tablet oral T3
EQL CENTRAL-VITE PERFORMANCE
TABLET ORAL T3
EQL CENTRAL-VITE SELECT TABLET
ORAL T3
EQL CENTRAL-VITE TABLET ORAL T3
eql century cardio health tablet oral T3
188
Drug Tier Requirements/Limits
eql century mature adults 50+ tablet oral T3
eql century mature tablet oral T3
eql century mens tablet oral T3
eql century tablet oral T3
eql one daily 50 plus tablet oral T3
eql one daily diet support tablet oral T3
eql one daily dieters support tablet oral T3
eql one daily essential tablet oral T3
eql one daily maximum tablet oral T3
eql one daily mens 50+ advance tablet oral T3
eql one daily mens health tablet oral T3
eql one daily womens 50+ adv tablet oral T3
eql one daily womens tablet oral T3
eql ultimate womens century tablet oral T3
eql vision formula tablet oral T3
ESSENTIA TABLET ORAL T3
essential balance tablet oral T3
essential one daily multivit tablet oral T3
eye-vite extra plus lutein tablet oral T3
FEMTABS TABLET ORAL T3
FLORIVA PLUS SOLUTION 0.25 MG/ML
ORAL T3
formula b plus tablet oral T3
FORTAVIT CAPSULE ORAL T3
freedavite tablet oral T3
generix t tablet oral T3
geravim liquid oral T3
geriaton liquid oral T3
geritabs tablet oral T3
geri-tonic liquid oral T3
geri-vite liquid† oral T3
gnp century active performance tablet oral T3
gnp century adults 50+ senior tablet oral T3
gnp century cardio health tablet oral T3
gnp century energy metabolism tablet oral T3
gnp century mature tablet oral T3
gnp century tablet oral T3
189
Drug Tier Requirements/Limits
gnp century ultimate mens tablet oral T3
gnp century ultimate womens tablet oral T3
gnp essential one daily tablet oral T3
gnp hair/skin/nails tablet oral T3
gnp healthy eyes tablet oral T3
gnp maximum one daily tablet oral T3
gnp mega multi for men tablet oral T3
gnp mega multi for women tablet oral T3
gnp one daily maximum tablet oral T3
gnp one daily mens 50+advanced tablet oral T3
gnp one daily mens health 50+ tablet oral T3
gnp one daily mens/lycopene tablet oral T3
gnp one daily plus iron tablet oral T3
gnp one daily womens 50+ tablet oral T3
gnp one daily womens health tablet oral T3
gnp opti-vitamins tablet oral T3
gnp therapeutic m complete tablet oral T3
gnp therapeutic-m tablet oral T3
gnp womens one daily tablet oral T3
golden age vitamin/minerals liquid oral T3
hair formula extra strength tablet oral T3
hair vitamins tablet oral T3
hair/skin/nails capsule oral T3
hair/skin/nails tablet oral T3
hair/skin/nails/biotin tablet oral T3
healthy eyes tablet oral T3
healthy eyes/lutein tablet oral T3
healthy hair/skin/nails tablet oral T3
high potency multivit/min/iron tablet oral T3
hm antioxidant vitamins tablet oral T3
hm complete 50+ mens ultimate tablet oral T3
hm complete 50+ tablet oral T3
hm complete 50+ women ultimate tablet oral T3
hm complete men tablet oral T3
hm complete tablet oral T3
hm complete women tablet oral T3
190
Drug Tier Requirements/Limits
hm hair/skin/nails tablet oral T3
hm mens 50+ advanced one daily tablet oral T3
hm one daily essential tablet oral T3
hm one daily mens tablet oral T3
hm one daily womens tablet oral T3
hm one daily/iron tablet oral T3
hm womens 50+ advanced daily tablet oral T3
ICAPS AREDS FORMULA TABLET ORAL T3
ICAPS LUTEIN & OMEGA-3 CAPSULE ORAL T3
ICAPS MV TABLET ORAL T3
ICAPS PLUS TABLET ORAL T3
i-vite tablet oral T3
kp adults 50+ daily formula tablet oral T3
kp adults daily formula tablet oral T3
kp mens 50+ daily formula tablet oral T3
kp mens daily formula tablet oral T3
KP VISION FORMULA TABLET ORAL T3
KP VISION FORMULA/LUTEIN TABLET
ORAL T3
kp womens 50+ daily formula tablet oral T3
kp womens daily formula tablet oral T3
K-PAX DOUBLE STRENGTH CAPSULE
ORAL T3
K-PAX IMMUNE PROFESSIONAL ST
TABLET ORAL T3
K-PAX SINGLE STRENGTH CAPSULE ORAL T3
LIPOTRIAD TABLET ORAL T3
MACULAR HEALTH FORMULA CAPSULE
ORAL T3
macular vitamin benefit tablet oral T3
MACUVITE EYE CARE TABLET ORAL T3
MACUVITE TABLET ORAL T3
MEGA MULTI MEN TABLET ORAL T3
mega multiple/chelated mineral tablet oral T3
mega multivitamin for men tablet oral T3
mega multivitamin for women tablet oral T3
MEGAVITE RX TABLET ORAL T3
191
Drug Tier Requirements/Limits
meijer advanced formula tablet oral T3
mens 50+ advanced capsule oral T3
mens daily formula/lycopene capsule oral T3
mens multi vitamin & mineral tablet oral T3
MILLTRIUM SENIOR TABLET ORAL T3
multi + omega-3 adult gummies tablet chewable
oral T3
multi adult gummies tablet chewable oral T3
multi complete/iron tablet oral T3
multi for her 50+ capsule oral T3
multi for her 50+ tablet oral T3
multi for her capsule oral T3
multi for her tablet oral T3
multi for him 50+ tablet oral T3
MULTI FOR HIM TABLET ORAL T3
multi max tablet oral T3
multi vitamin daily tablet oral T3
multi vitamin mens tablet oral T3
multi vitamin/fluoride tablet chewable 1 mg oral T3
multi vitamin/minerals tablet oral T3
MULTI-BETIC TABLET ORAL T3
multi-day plus iron tablet oral T3
multi-day plus minerals tablet oral T3
multi-delyn liquid oral T3
multi-delyn/iron liquid oral T3
multilex tablet oral T3
multilex-t&m tablet oral T3
multiple vit/minerals/no iron tablet oral T3
multiple vitamins essential tablet oral T3
multiple vitamins tablet oral T3
multiple vitamins/iron tablet oral T3
multiple vitamins/womens tablet oral T3
multi-vit/fluoride solution 0.25 mg/ml oral T3
multi-vit/fluoride solution 0.5 mg/ml oral T3
multi-vit/fluoride/iron solution 0.25-10 mg/ml
oral T3
192
Drug Tier Requirements/Limits
multi-vit/iron/fluoride solution 0.25-10 mg/ml
oral T3
multivital performance tablet oral T3
multivital platinum silver tablet chewable oral T3
multivital platinum tablet oral T3
multivital tablet oral T3
multivitamin & mineral liquid oral T3
multivitamin adult extra c tablet chewable oral T3
multivitamin adult tablet chewable oral T3
multivitamin adult tablet oral T3
multivitamin adults 50+ tablet oral T3
multivitamin adults tablet oral T3
multi-vitamin daily tablet oral T3
multivitamin gummies adult tablet chewable oral T3
multivitamin gummies mens tablet chewable oral T3
multi-vitamin gummies tablet chewable oral T3
multivitamin gummies womens tablet chewable
oral T3
multivitamin liquid oral T3
multivitamin men 50+ tablet oral T3
multivitamin men tablet oral T3
multi-vitamin monocaps tablet oral T3
multi-vitamin tablet oral T3
multivitamin women 50+ tablet oral T3
multivitamin women tablet oral T3
multivitamin/extra vitamin d3 tablet chewable
oral T3
multivitamin/fluoride solution 0.25 mg/ml oral T3
multi-vitamin/fluoride solution 0.25 mg/ml oral T3
multivitamin/fluoride solution 0.5 mg/ml oral T3
multi-vitamin/fluoride solution 0.5 mg/ml oral T3
multivitamin/fluoride tablet chewable 0.25 mg
oral T3
multivitamin/fluoride tablet chewable 0.5 mg oral T3
multivitamin/fluoride tablet chewable 1 mg oral T3
multivitamin/fluoride/iron solution 0.25-10 mg/ml
oral T3
193
Drug Tier Requirements/Limits
multi-vitamin/fluoride/iron solution 0.25-10
mg/ml oral T3
multi-vitamin/minerals tablet oral T3
multivitamins plus zinc capsule oral T3
multi-vitamins tablet oral T3
multivitamins/minerals adult liquid oral T3
multi-vite liquid oral T3
MVC-FLUORIDE TABLET CHEWABLE 0.25
MG ORAL T3
MVC-FLUORIDE TABLET CHEWABLE 0.5
MG ORAL T3
MVC-FLUORIDE TABLET CHEWABLE 1 MG
ORAL T3
MVW COMPLETE FORMULATION
CAPSULE ORAL T3
MVW COMPLETE FORMULATION D3000
CAPSULE ORAL T3
MVW COMPLETE FORMULATION D3000
TABLET CHEWABLE ORAL T3 AL
MVW COMPLETE FORMULATION D5000
CAPSULE ORAL T3
MVW COMPLETE FORMULATION D5000
TABLET CHEWABLE ORAL T3 AL
MVW COMPLETE FORMULATION MINIS
CAPSULE ORAL T3
MVW COMPLETE FORMULATION
SOLUTION 45 MG/0.5ML ORAL T3
MVW COMPLETE FORMULATION TABLET
CHEWABLE ORAL T3 AL
MVW COMPLETE FORMULATION TABLET
CHEWABLE ORAL T3
my-vitalife capsule oral T3
neovite tablet oral T3
no iron mult vitamin-minerals tablet oral T3
NUTRICAP TABLET ORAL T3
NUTRIVIT LIQUID ORAL T3
ocular vitamins tablet oral T3
ocutabs tablet oral T3
ocutabs-lutein tablet oral T3
OCUVITE ADULT 50+ CAPSULE ORAL T3
194
Drug Tier Requirements/Limits
OCUVITE EXTRA TABLET ORAL T3
OCUVITE EYE + MULTI TABLET ORAL T3
OCUVITE TABLET ORAL T3
OCUVITE-LUTEIN TABLET ORAL T3
omnicap tablet oral T3
once daily tablet oral T3
once daily/iron tablet oral T3
ONCOVITE TABLET ORAL T3
ONE A DAY MENS VITACRAVES TABLET
CHEWABLE ORAL T3
one daily adults 50+ tablet oral T3
one daily calcium/iron tablet oral T3
one daily complete tablet oral T3
one daily for men 50+ advanced tablet oral T3
one daily for men/lycopene tablet oral T3
one daily for women 50+ adv tablet oral T3
one daily for women tablet oral T3
one daily healthy weight adv tablet oral T3
one daily maximum tablet oral T3
one daily mens 50+ multivit tablet oral T3
one daily mens health tablet oral T3
one daily mens tablet oral T3
one daily multivitamin adult tablet oral T3
one daily multivitamin/iron tablet oral T3
ONE DAILY PLUS IRON TABLET ORAL T3
one daily plus minerals tablet oral T3
one daily tablet oral T3
one daily womens 50 plus tablet oral T3
one daily womens 50+ tablet oral T3
one daily/iron tablet oral T3
one daily/minerals tablet oral T3
ONE-A-DAY CHOLESTEROL PLUS TABLET
ORAL T3
ONE-A-DAY ENERGY TABLET ORAL T3
ONE-A-DAY ESSENTIAL TABLET ORAL T3
ONE-A-DAY MAXIMUM FORMULA
TABLET ORAL T3
195
Drug Tier Requirements/Limits
ONE-A-DAY MENOPAUSE FORMULA
TABLET ORAL T3
ONE-A-DAY MENS 50+ ADVANTAGE
TABLET ORAL T3
ONE-A-DAY MENS HEALTH FORMULA
TABLET ORAL T3
ONE-A-DAY MENS TABLET ORAL T3
ONE-A-DAY MENS VITACRAVES TABLET
CHEWABLE ORAL T3
ONE-A-DAY PROACTIVE 65+ TABLET
ORAL T3
ONE-A-DAY TEEN ADVANTAGE/HER
TABLET ORAL T3
ONE-A-DAY TEEN ADVANTAGE/HIM
TABLET ORAL T3
ONE-A-DAY VITACRAVES ADULT TABLET
CHEWABLE ORAL T3
ONE-A-DAY VITACRAVES IMMUNITY
TABLET CHEWABLE ORAL T3
ONE-A-DAY VITACRAVES SOUR TABLET
CHEWABLE ORAL T3
ONE-A-DAY VITACRAVES TABLET
CHEWABLE ORAL T3
ONE-A-DAY VITACRAVES+OMEGA-3
TABLET CHEWABLE ORAL T3
ONE-A-DAY WEIGHT SMART ADVANCE
TABLET ORAL T3
ONE-A-DAY WOMENS 50 PLUS TABLET
ORAL T3
ONE-A-DAY WOMENS 50+ ADVANTAGE
TABLET ORAL T3
ONE-A-DAY WOMENS FORMULA TABLET
ORAL T3
ONE-A-DAY WOMENS HEALTHY SKIN
TABLET ORAL T3
ONE-A-DAY WOMENS MIND & BODY
TABLET ORAL T3
ONE-A-DAY WOMENS PETITES TABLET
ORAL T3
ONE-A-DAY WOMENS VITACRAVES
TABLET CHEWABLE ORAL T3
196
Drug Tier Requirements/Limits
one-daily multi vitamins tablet oral T3
one-daily multi-vitamin tablet oral T3
one-daily/iron tablet oral T3
one-tablet-daily tablet oral T3
one-tablet-daily with minerals tablet oral T3
one-tablet-daily/iron tablet oral T3
OPTISOURCE POST BARIATRIC SURG
TABLET CHEWABLE ORAL T3
OPTISOURCE TABLET CHEWABLE ORAL T3
OPURITY BYPASS OPTIMIZED TABLET
CHEWABLE ORAL T3
polyvitamin/iron tablet chewable 18 mg oral T3 AL
PROCERV HP TABLET ORAL T3
PRORENAL + D W/ OMEGA-3 CAPSULE
ORAL T3
PROSIGHT TABLET ORAL T3
PROTECT CARDIO AF CAPSULE ORAL T3
PROTECT PLUS AF CAPSULE ORAL T3
PROTECT PLUS CAPSULE ORAL T3
PROTECT PLUS LIQUID ORAL T3
PROTECT PLUS NF LIQUID ORAL T3
PROTECT PLUS NR CAPSULE ORAL T3
PROTECT PLUS SO CAPSULE ORAL T3
px advanced formula multivits tablet oral T3
px complete senior multivits tablet oral T3
px mens multivitamins tablet oral T3
qc daily multivit/multimineral tablet oral T3
qc daily multivitamins/iron tablet oral T3
qc mens daily multivitamin tablet oral T3
qc multivitamin cholesterol tablet oral T3
qc multi-vite 50 & over tablet oral T3
qc multi-vite tablet oral T3
qc therin-m tablet oral T3
qc womens daily multivitamin tablet oral T3
QUFLORA PEDIATRIC SOLUTION 0.25
MG/ML ORAL T3
QUFLORA PEDIATRIC SOLUTION 0.5
MG/ML ORAL T3
197
Drug Tier Requirements/Limits
QUFLORA PEDIATRIC TABLET CHEWABLE
0.25 MG ORAL T3
QUFLORA PEDIATRIC TABLET CHEWABLE
0.5 MG ORAL T3
QUFLORA PEDIATRIC TABLET CHEWABLE
1 MG ORAL T3
quintabs tablet oral T3
quintabs-m tablet oral T3
ra central-vite cardio tablet oral T3
ra central-vite energy tablet oral T3
ra central-vite performance tablet oral T3
RA CENTRAL-VITE SELECT TABLET ORAL T3
ra central-vite senior tablet oral T3
RA CENTRAL-VITE TABLET ORAL T3
ra central-vite under 50 mens tablet oral T3
ra central-vite under 50 women tablet oral T3
ra central-vite womens mature tablet oral T3
RA CENTRAL-VITE/ANTIOXIDANTS
TABLET ORAL T3
ra hair/skin/nails tablet oral T3
ra one daily energy formula tablet oral T3
ra one daily essential tablet oral T3
ra one daily gummy vites tablet chewable oral T3
ra one daily maximum tablet oral T3
ra one daily mens 50+ w/vit d3 tablet oral T3
ra one daily mens/vit d-3 tablet oral T3
ra one daily multi-vit plus fe tablet oral T3
ra one daily multi-vitamin tablet oral T3
ra one daily womens tablet oral T3
ra stress formula advanced tablet oral T3
ra stress formula energy tablet oral T3
ra therapeutic m plus beta car tablet oral T3
ra vision vite plus zinc tablet oral T3
RA WHOLE SOURCE DIETARY MATURE
TABLET ORAL T3
RA WHOLE SOURCE DIETARY MEN
TABLET ORAL T3
198
Drug Tier Requirements/Limits
RA WHOLE SOURCE DIETARY TABLET
ORAL T3
RA WHOLE SOURCE FOR MEN TABLET
ORAL T3
REQ 49+ TABLET ORAL T3
SAVISION TABLET ORAL T3
senior tabs tablet oral T3
sentry adult tablet oral T3
sentry senior tablet oral T3
sentry tablet oral T3
sm antioxidant vitamins tablet oral T3
sm complete 50+ tablet oral T3
sm complete 50+ ultimate mens tablet oral T3
sm complete 50+ ultimate women tablet oral T3
sm complete advanced formula tablet oral T3
sm complete senior formula tablet oral T3
sm complete tablet oral T3
sm hair/skin/nails tablet oral T3
sm multiple vitamins essential tablet oral T3
sm multiple vitamins/iron tablet oral T3
sm one daily essential tablet oral T3
sm one daily mens tablet oral T3
sm one daily womens tablet oral T3
sm opti-vitamins tablet oral T3
sm therapeutic-m tablet oral T3
solo tablet oral T3
SOURCECF CAPSULE ORAL T3
stress 500 b-complex tablet oral T3
stress 500 b-complex/zinc tablet oral T3
stress b/zinc tablet oral T3
stress formula tablet oral T3
stress formula/zinc tablet oral T3
stress tab nf tablet oral T3
stress/zinc tablet oral T3
STROVITE ADVANCE TABLET ORAL T3
STROVITE FORTE TABLET ORAL T3
STROVITE ONE TABLET ORAL T3
199
Drug Tier Requirements/Limits
STROVITE PLUS TABLET ORAL T3
SUNVITE ADVANCED TABLET ORAL T3
super antioxidant capsule oral T3
super ginseng multivitamin capsule oral T3
super mega vite 75/beta caro tablet oral T3
super multiple capsule oral T3
super multiple tablet oral T3
SUPER NU-THERA LIQUID ORAL T3
SUPER NU-THERA TABLET ORAL T3
super thera vite m tablet oral T3
super vikaps tablet oral T3
support liquid oral (otc) T3
support liquid oral (rx) T3
SYNDION CAPSULE ORAL T3
SYNDION LIQUID ORAL T3
SYNDION-SF LIQUID ORAL T3
SYSTANE ICAPS AREDS2 CAPSULE ORAL T3
SYSTANE ICAPS AREDS2 TABLET
CHEWABLE ORAL T3
SYSTANE ICAPS AREDS2 TABLET ORAL T3
TAB-A-VITE MAXIMUM TABLET ORAL T3
TAB-A-VITE TABLET ORAL T3
TAB-A-VITE WOMENS TABLET ORAL T3
TAB-A-VITE/BETA CAROTENE TABLET
ORAL T3
tab-a-vite/iron tablet oral T3
TAB-A-VITE/WEIGHTSLIM TABLET ORAL T3
th complete multi 50+ tablet oral T3
th complete multi tablet oral T3
th daily multiple vitamin/iron tablet oral T3
th daily multiple vitamins tablet oral T3
th premium daily multiple tablet oral T3
th theradex-m tablet oral T3
th vision vitamins tablet oral T3
th womens daily tablet oral T3
THERA M PLUS TABLET ORAL T3
THERA TABLET ORAL T3
200
Drug Tier Requirements/Limits
THERAGRAN-M ADVANCED 50 PLUS
TABLET ORAL T3
THERAGRAN-M ADVANCED TABLET
ORAL T3
THERAGRAN-M PREMIER 50 PLUS TABLET
ORAL T3
THERAGRAN-M PREMIER TABLET ORAL T3
THERAGRAN-M TABLET ORAL T3
thera-m tablet oral T3
THERAMILL FORTE CAPSULE ORAL T3
therapeutic formula/hematinics tablet oral T3
therapeutic liquid solution oral T3
therapeutic m tablet oral T3
therapeutic tablet oral T3
therapeutic-m tablet oral T3
therapeutic-m/lutein tablet oral T3
thera-tabs m tablet oral T3
thera-tabs tablet oral T3
THERATRUM COMPLETE 50 PLUS TABLET
ORAL T3
THERATRUM COMPLETE TABLET ORAL T3
therems m tablet oral T3
THEREMS TABLET ORAL T3
THEREMS-H TABLET ORAL T3
THEREMS-M TABLET ORAL T3
therobec plus tablet oral T3
tri-vit/fluoride solution 0.25 mg/ml oral T3
tri-vit/fluoride/iron solution 0.25-10 mg/ml oral T3
tri-vitamin/fluoride solution 0.25 mg/ml oral T3
tri-vite/fluoride solution 0.25 mg/ml oral T3
TRUEPLUS DIABETIC MULTIVITAMIN
TABLET ORAL T3
UDAMIN SP TABLET 1 MG ORAL T3
ultimate teen tablet oral T3
ultra antioxidant formula tablet oral T3
ultra freeda tablet oral T3
ultra freeda/iron tablet oral T3
unicomplex-m tablet oral T3
201
Drug Tier Requirements/Limits
urosex tablet oral T3
v-c forte capsule oral T3
vica forte capsule oral T3
vicap forte capsule oral T3
VIC-FORTE CAPSULE ORAL T3
vigomar forte tablet oral T3
vigortol liquid† oral T3
VISION FORMULA TABLET ORAL T3
vision formula/lutein tablet oral T3
vision vitamins tablet oral T3
vit e-vit c-beta carotene tablet 200-250-5000 oral T3
VITA S FORTE TABLET ORAL T3
vitabex plus capsule oral T3
VITACEL TABLET ORAL T3
vitalee tablet oral T3
vitamin forte capsule oral T3
vitamin-mineral supplement liquid oral T3
vitamins acd-fluoride solution 0.25 mg/ml oral T3
vitamins a-d-e/selenium tablet oral T3
vitamins for hair tablet oral T3
vitamins/minerals tablet oral T3
VITATRUM COMPLETE TABLET ORAL T3
vitatrum tablet chewable oral T3
vitatrum tablet oral T3
vitrum 50+ senior multi tablet oral T3
VITRUM SENIOR TABLET ORAL T3
womens 50+ advanced capsule oral T3
womens biomultiple tablet oral T3
womens daily form/fa/ca/fe tablet oral T3
womens daily formula tablet oral T3
womens hair, skin & nails tablet oral T3
womens multi capsule oral T3
womens one daily tablet oral T3
YELETS TEENAGE FORMULA TABLET
ORAL T3
YOUR LIFE MULTI ADULT GUMMIES
TABLET CHEWABLE ORAL T3
202
Drug Tier Requirements/Limits
Vitamin A
a-10000 capsule 3 mg (10000 ut) oral T3
beta carotene capsule 25000 unit oral T3
cvs b-carotene capsule 25000 unit oral T3
cvs beta carotene capsule 15 mg oral T3
cvs beta carotene capsule 25000 unit oral T3
cvs vitamin a capsule 2400 mcg (8000 ut) oral T3
dekas essential capsule oral T3
dekas essential liquid oral T3
eql beta carotene capsule 25000 unit oral T3
gnp vitamin a capsule 3 mg (10000 ut) oral T3
KP VISION FORMULA TABLET ORAL T3
LIPOTRIAD TABLET ORAL T3
MACUVITE EYE CARE TABLET ORAL T3
MACUVITE TABLET ORAL T3
ocular vitamins tablet oral T3
prevent capsule oral T3
PROSIGHT TABLET ORAL T3
ra beta carotene capsule 15 mg oral T3
ra vitamin a capsule 3 mg (10000 ut) oral T3
tri-vit/fluoride solution 0.25 mg/ml oral T3
tri-vitamin/fluoride solution 0.25 mg/ml oral T3
tri-vite/fluoride solution 0.25 mg/ml oral T3
vitamin a capsule 10000 unit oral T3
vitamin a capsule 2400 mcg (8000 ut) oral T3
vitamin a capsule 3 mg (10000 ut) oral T3
vitamin a palmitate capsule 10000 unit oral T3
vitamin a-beta carotene capsule 25000 unit oral T3
vitamins acd-fluoride solution 0.25 mg/ml oral T3
vitamins a-d-e/selenium tablet oral T3
Vitamin B Complex
a thru z advanced tablet oral T3
a thru z advantage tablet oral T3
a thru z select 50+ advanced tablet oral T3
a thru z select 50+ mens tablet oral T3
a thru z select advanced tablet oral T3
203
Drug Tier Requirements/Limits
a thru z select tablet oral T3
a thru z ultimate mens tablet oral T3
ABC PLUS SENIOR ADULTS 50+ TABLET
ORAL T3
adult one daily gummies tablet chewable oral T3
ADVANCED MULTI EA TABLET
CHEWABLE ORAL T3
ALIVE ONCE DAILY WOMENS 50+ TABLET
ORAL T3
ALIVE WOMENS ENERGY TABLET ORAL T3
ALIVE WOMENS GUMMY TABLET
CHEWABLE ORAL T3
AQUADEKS CAPSULE ORAL T3
AQUADEKS TABLET CHEWABLE ORAL T3
b complex capsule oral T3
b complex formula 1 tablet oral T3
b complex tablet oral T3
b complex vitamins capsule oral T3
b complex-c-folic acid tablet oral T3
b-1 tablet 250 mg oral T3
b-100 complex tablet oral T3
b-100 tablet oral T3
b-12 tablet 100 mcg oral T3
b-12 tablet 1000 mcg oral T3
b-12 tablet 250 mcg oral T3
b-12 tablet 50 mcg oral T3
b-12 tablet 500 mcg oral T3
b-12 tablet extended release 1000 mcg oral T3
b-12 tablet sublingual 2500 mcg sublingual T3 AL
b-12 tr tablet extended release 1000 mcg oral T3
b2 tablet 100 mg oral T3
b-2 tablet 100 mg oral T3
b-2 tablet 50 mg oral T3 AL
b-50 complex tablet oral T3
b6 natural tablet 100 mg oral T3
b-6 tablet 100 mg oral T3
b-6 tablet 250 mg oral T3
204
Drug Tier Requirements/Limits
b-6 tablet 50 mg oral T3
BACMIN TABLET ORAL T3
balance b-100 tablet oral T3
balance b-50 tablet oral T3
balanced b-100 tablet oral T3
balanced b-50 complex tablet oral T3
balanced b-50 tablet oral T3
bariatric multivitamins/iron capsule oral T3
b-complex balanced tablet oral T3
b-complex tablet oral T3
b-complex/folic acid/vitamin c tablet extended
release oral T3
b-complex/vitamin c tablet oral T3
b-complex-c tablet oral T3
BIO-35 GLUTEN-FREE CAPSULE ORAL T3
biocal capsule oral T3
biocel tablet oral T3
biotin 5000 capsule 5 mg oral T3
biotin capsule 5 mg oral T3
biotin capsule 5000 mcg oral T3
biotin maximum strength capsule 5000 mcg oral T3
biotin tablet 1000 mcg oral T3
biotin tablet 300 mcg oral T3
biotin tablet 5 mg oral T3
biotin tablet 5000 mcg oral T3
b-plex tablet oral T3
calcium pantothenate tablet 500 mg oral T3
centravites 50 plus tablet oral T3
centravites adults tablet oral T3
CENTRUM ADULTS TABLET ORAL T3
CENTRUM FLAVOR BURST ADULT
TABLET CHEWABLE ORAL T3
CENTRUM MEN TABLET ORAL T3
CENTRUM MULTIGUMMIES TABLET
CHEWABLE ORAL T3
CENTRUM PERFORMANCE TABLET ORAL T3
CENTRUM SILVER 50+MEN TABLET ORAL T3
205
Drug Tier Requirements/Limits
CENTRUM SILVER 50+WOMEN TABLET
ORAL T3
CENTRUM SILVER ADULT 50+ TABLET
ORAL T3
CENTRUM SILVER TABLET CHEWABLE
ORAL T3
CENTRUM SILVER TABLET ORAL T3
CENTRUM SILVER ULTRA WOMENS
TABLET ORAL T3
CENTRUM SPECIALIST ENERGY TABLET
ORAL T3
CENTRUM SPECIALIST VISION TABLET
ORAL T3
CENTRUM TABLET CHEWABLE ORAL T3
CENTRUM TABLET ORAL T3
CENTRUM ULTRA MENS TABLET ORAL T3
CENTRUM ULTRA WOMENS TABLET
ORAL T3
CEROVITE ADVANCED FORMULA TABLET
ORAL T3
certa plus tablet oral T3
certagen tablet oral T3
CERTAVITE SENIOR/ANTIOXIDANT
TABLET ORAL T3
CERTAVITE/ANTIOXIDANTS TABLET
ORAL T3
choice-tabs tablet oral T3
COMPANION MULTI MEN TABLET ORAL T3
companion tablet oral T3
CORVITE FREE TABLET ORAL T3
cvs b-12 tablet 500 mcg oral T3
cvs b-12 tablet extended release 1000 mcg oral T3
cvs b6 tablet 100 mg oral T3
cvs b-6 tablet 100 mg oral T3
CVS BALANCED B-100 TABLET ORAL T3
CVS BALANCED B50 TABLET ORAL T3
cvs biotin capsule 5000 mcg oral T3
cvs biotin high potency tablet 1000 mcg oral T3
cvs daily gummies tablet chewable oral T3
206
Drug Tier Requirements/Limits
cvs daily multiple for men 50+ tablet oral T3
cvs daily multiple for men tablet oral T3
cvs daily multiple for women tablet oral T3
cvs daily multiple women 50+ tablet oral T3
cvs daily teen tablet oral T3
cvs folic acid tablet 400 mcg oral T3
cvs folic acid tablet 800 mcg oral T3
cvs mens daily gummies tablet chewable oral T3
cvs one daily essential tablet oral T3
cvs one daily mens 50+ adv tablet oral T3
cvs one daily womens formula tablet oral T3
cvs spectravite adult 50+ tablet chewable oral T3
cvs spectravite adult 50+ tablet oral T3
cvs spectravite adult gummies tablet chewable
oral T3
cvs spectravite advanced tablet oral T3
cvs spectravite energy tablet oral T3
cvs spectravite probiotic tablet oral T3
cvs spectravite senior tablet oral T3
cvs spectravite ultra men 50+ tablet oral T3
cvs spectravite ultra mens tablet oral T3
cvs spectravite ultra women tablet oral T3
cvs spectravite womens senior tablet oral T3
cvs vitamin b/c tablet oral T3
cvs vitamin b-12 tablet 100 mcg oral T3
cvs vitamin b12 tablet 1000 mcg oral T3
cvs vitamin b-12 tablet 1000 mcg oral T3
cvs vitamin b-12 tablet 250 mcg oral T3
cvs vitamin b-12 tablet 500 mcg oral T3
cvs vitamin b12 tablet extended release 1000 mcg
oral T3
cvs vitamin b-2 tablet 100 mg oral T3
cvs vitamin b-6 tablet 100 mg oral T3
cvs vitamin b-6 tablet 50 mg oral T3
cvs womens active daily tablet oral T3
cvs womens daily gummies tablet chewable oral T3
cyanocobalamin solution 1000 mcg/ml injection T3
207
Drug Tier Requirements/Limits
cyanocobalamin tablet sublingual 2500 mcg
sublingual T3 AL
daily multi tablet oral T3
daily multiple vitamins/iron tablet oral T3
daily multivitamin capsule oral T3
daily vitamin formula+iron tablet oral T3
DECUBI-VITE CAPSULE ORAL T3
dekas bariatric tablet chewable oral T3
dekas plus capsule oral T3
dekas plus tablet chewable oral T3
diabetes health formula tablet oral T3
dialyvite 800/ultra d tablet oral T3
ELDERTONIC LIQUID ORAL T3
ELON MATRIX 5000 COMPLETE TABLET
ORAL T3
ELON MATRIX COMPLETE TABLET ORAL T3
eq complete multivit adult 50+ tablet oral T3
eq complete multivitamin-adult tablet oral T3
eq one daily mens 50+ tablet oral T3
eq one daily mens health tablet oral T3
eq one daily womens health tablet oral T3
eql b complex tablet oral T3
eql b-12 tablet extended release 1000 mcg oral T3
eql b-6 tablet 100 mg oral T3
EQL CENTRAL-VITE TABLET ORAL T3
eql century mature adults 50+ tablet oral T3
eql century mature tablet oral T3
eql century mens tablet oral T3
eql century tablet oral T3
eql folic acid tablet 400 mcg oral T3
eql one daily diet support tablet oral T3
eql one daily mens 50+ advance tablet oral T3
eql one daily womens 50+ adv tablet oral T3
eql stress b-complex c/zinc tablet oral T3
eql super b complex/vitamin c tablet oral T3
eql ultimate womens century tablet oral T3
eql vitamin b-12 tablet 500 mcg oral T3
208
Drug Tier Requirements/Limits
eql vitamin b-12 tr tablet extended release 1000
mcg oral T3
ESSENTIA TABLET ORAL T3
essential one daily multivit tablet oral T3
feasp-fefum -suc-c-thre-b12-fa tablet 50-101-1 mg
oral T3
FEMTABS TABLET ORAL T3
folate tablet 400 mcg oral T3
folic acid tablet 1 mg oral (otc) T3
folic acid tablet 1 mg oral (rx) T3
folic acid tablet 400 mcg oral T3
folic acid tablet 800 mcg oral T3
freedavite tablet oral T3
GLUTOFAC TABLET ORAL T3
gnp b-12 tablet sublingual 2500 mcg sublingual T3 AL
gnp biotin capsule 5000 mcg oral T3
gnp century active performance tablet oral T3
gnp century adults 50+ senior tablet oral T3
gnp century energy metabolism tablet oral T3
gnp century mature tablet oral T3
gnp century tablet oral T3
gnp century ultimate mens tablet oral T3
gnp century ultimate womens tablet oral T3
gnp essential one daily tablet oral T3
gnp folic acid tablet 400 mcg oral T3
gnp hair/skin/nails tablet oral T3
gnp maximum one daily tablet oral T3
gnp mega multi for men tablet oral T3
gnp mega multi for women tablet oral T3
gnp one daily maximum tablet oral T3
gnp one daily mens health 50+ tablet oral T3
gnp one daily mens/lycopene tablet oral T3
gnp one daily plus iron tablet oral T3
gnp one daily womens 50+ tablet oral T3
gnp one daily womens health tablet oral T3
gnp therapeutic-m tablet oral T3
gnp vitamin b1 tablet 100 mg oral T3 AL
209
Drug Tier Requirements/Limits
gnp vitamin b-12 tablet 500 mcg oral T3
gnp vitamin b-12 tablet extended release 1000
mcg oral T3
gnp vitamin b-12 tr tablet extended release 1000
mcg oral T3
gnp vitamin b-6 tablet 100 mg oral T3
hair formula extra strength tablet oral T3
hair/skin/nails tablet oral T3
hair/skin/nails/biotin tablet oral T3
hairvite tablet oral T3
healthy hair/skin/nails tablet oral T3
hm biotin capsule 5000 mcg oral T3
hm complete 50+ mens ultimate tablet oral T3
hm complete 50+ tablet oral T3
hm complete 50+ women ultimate tablet oral T3
hm complete men tablet oral T3
hm complete tablet oral T3
hm complete women tablet oral T3
hm folic acid tablet 400 mcg oral T3
hm hair/skin/nails tablet oral T3
hm mens 50+ advanced one daily tablet oral T3
hm one daily essential tablet oral T3
hm one daily mens tablet oral T3
hm one daily womens tablet oral T3
hm one daily/iron tablet oral T3
hm super vitamin b complex/c tablet oral T3
hm vitamin b complex/vitamin c tablet oral T3
hm vitamin b1 tablet 100 mg oral T3 AL
hm vitamin b-12 tablet 500 mcg oral T3
hm vitamin b12 tablet 500 mcg oral T3
hm vitamin b12 tablet extended release 1000 mcg
oral T3
hm vitamin b6 tablet 100 mg oral T3
hm womens 50+ advanced daily tablet oral T3
hylavite tablet oral T3
ICAPS MV TABLET ORAL T3
kobee tablet oral T3
210
Drug Tier Requirements/Limits
kp adults 50+ daily formula tablet oral T3
kp adults daily formula tablet oral T3
kp b complex-c tablet oral T3
kp folic acid tablet 1 mg oral T3
kp folic acid tablet 800 mcg oral T3
kp mens 50+ daily formula tablet oral T3
kp mens daily formula tablet oral T3
kp vitamin b-12 tablet 1000 mcg oral T3
kp vitamin b-6 tablet 100 mg oral T3
kp womens 50+ daily formula tablet oral T3
kp womens daily formula tablet oral T3
K-PAX IMMUNE PROFESSIONAL ST
TABLET ORAL T3
LIPOTRIAD TABLET ORAL T3
l-methylfolate-b6-b12 tablet 3-35-2 mg oral T3
macular vitamin benefit tablet oral T3
MEGA MULTI MEN TABLET ORAL T3
mega multivitamin for men tablet oral T3
mega multivitamin for women tablet oral T3
MEGAVITE RX TABLET ORAL T3
mens 50+ advanced capsule oral T3
mens daily formula/lycopene capsule oral T3
mens multi vitamin & mineral tablet oral T3
MERIBIN CAPSULE 5 MG ORAL T3
multi + omega-3 adult gummies tablet chewable
oral T3
multi adult gummies tablet chewable oral T3
multi complete/iron tablet oral T3
multi for her 50+ capsule oral T3
multi for her 50+ tablet oral T3
multi for her capsule oral T3
multi for her tablet oral T3
multi for him 50+ tablet oral T3
MULTI FOR HIM TABLET ORAL T3
multi vitamin/minerals tablet oral T3
MULTI-BETIC TABLET ORAL T3
multi-day plus iron tablet oral T3
211
Drug Tier Requirements/Limits
multi-day plus minerals tablet oral T3
MULTIGEN FOLIC TABLET 70-150-2-1 MG
ORAL T3
MULTIGEN PLUS TABLET 50-101-1 MG
ORAL T3
multivital platinum silver tablet chewable oral T3
multivital platinum tablet oral T3
multivitamin adult extra c tablet chewable oral T3
multivitamin adult tablet chewable oral T3
multivitamin adult tablet oral T3
multivitamin adults 50+ tablet oral T3
multivitamin adults tablet oral T3
multivitamin gummies adult tablet chewable oral T3
multivitamin gummies mens tablet chewable oral T3
multi-vitamin gummies tablet chewable oral T3
multivitamin gummies womens tablet chewable
oral T3
multivitamin men 50+ tablet oral T3
multivitamin men tablet oral T3
multi-vitamin monocaps tablet oral T3
multivitamin women 50+ tablet oral T3
multivitamin women tablet oral T3
multivitamin/extra vitamin d3 tablet chewable
oral T3
neovite tablet oral T3
nervidox-6 nr tablet oral T3
NICOMIDE TABLET 750-25-1.5-0.5 MG ORAL T3
NUTRICAP TABLET ORAL T3
NUTRIVIT LIQUID ORAL T3
OCUVITE EYE + MULTI TABLET ORAL T3
omnicap tablet oral T3
ONE A DAY MENS VITACRAVES TABLET
CHEWABLE ORAL T3
one daily adults 50+ tablet oral T3
one daily complete tablet oral T3
one daily for men 50+ advanced tablet oral T3
one daily for men/lycopene tablet oral T3
one daily for women 50+ adv tablet oral T3
212
Drug Tier Requirements/Limits
one daily for women tablet oral T3
one daily healthy weight adv tablet oral T3
one daily maximum tablet oral T3
one daily mens 50+ multivit tablet oral T3
one daily mens health tablet oral T3
one daily multivitamin adult tablet oral T3
one daily multivitamin/iron tablet oral T3
ONE DAILY PLUS IRON TABLET ORAL T3
one daily womens 50 plus tablet oral T3
one daily womens 50+ tablet oral T3
ONE-A-DAY CHOLESTEROL PLUS TABLET
ORAL T3
ONE-A-DAY ENERGY TABLET ORAL T3
ONE-A-DAY MENOPAUSE FORMULA
TABLET ORAL T3
ONE-A-DAY MENS 50+ ADVANTAGE
TABLET ORAL T3
ONE-A-DAY MENS HEALTH FORMULA
TABLET ORAL T3
ONE-A-DAY MENS TABLET ORAL T3
ONE-A-DAY MENS VITACRAVES TABLET
CHEWABLE ORAL T3
ONE-A-DAY PROACTIVE 65+ TABLET
ORAL T3
ONE-A-DAY TEEN ADVANTAGE/HER
TABLET ORAL T3
ONE-A-DAY TEEN ADVANTAGE/HIM
TABLET ORAL T3
ONE-A-DAY VITACRAVES ADULT TABLET
CHEWABLE ORAL T3
ONE-A-DAY VITACRAVES IMMUNITY
TABLET CHEWABLE ORAL T3
ONE-A-DAY VITACRAVES SOUR TABLET
CHEWABLE ORAL T3
ONE-A-DAY VITACRAVES TABLET
CHEWABLE ORAL T3
ONE-A-DAY VITACRAVES+OMEGA-3
TABLET CHEWABLE ORAL T3
ONE-A-DAY WEIGHT SMART ADVANCE
TABLET ORAL T3
213
Drug Tier Requirements/Limits
ONE-A-DAY WOMENS 50 PLUS TABLET
ORAL T3
ONE-A-DAY WOMENS 50+ ADVANTAGE
TABLET ORAL T3
ONE-A-DAY WOMENS FORMULA TABLET
ORAL T3
ONE-A-DAY WOMENS HEALTHY SKIN
TABLET ORAL T3
ONE-A-DAY WOMENS MIND & BODY
TABLET ORAL T3
ONE-A-DAY WOMENS PETITES TABLET
ORAL T3
ONE-A-DAY WOMENS VITACRAVES
TABLET CHEWABLE ORAL T3
OPTISOURCE POST BARIATRIC SURG
TABLET CHEWABLE ORAL T3
OPTISOURCE TABLET CHEWABLE ORAL T3
OPURITY BYPASS OPTIMIZED TABLET
CHEWABLE ORAL T3
ORTHOVITE TABLET ORAL T3
pa biotin capsule 5000 mcg oral T3
pantothenic acid tablet 500 mg oral T3
parvlex tablet oral T3
polyvitamin/iron tablet chewable 18 mg oral T3 AL
PROCERV HP TABLET ORAL T3
PRORENAL + D TABLET ORAL T3
PRORENAL + D W/ OMEGA-3 CAPSULE
ORAL T3
PROTECT CARDIO AF CAPSULE ORAL T3
PROTECT PLUS AF CAPSULE ORAL T3
PROTECT PLUS NF LIQUID ORAL T3
PROTECT PLUS SO CAPSULE ORAL T3
px b complex/vitamin c tablet oral T3
PX B-50 TABLET ORAL T3
px folic acid tablet 400 mcg oral T3
px mens multivitamins tablet oral T3
pyri 500 tablet 500 mg oral T3
pyridoxine hcl tablet 100 mg oral T3
pyridoxine hcl tablet 25 mg oral T3
214
Drug Tier Requirements/Limits
pyridoxine hcl tablet 50 mg oral T3
qc daily multivitamins/iron tablet oral T3
qc mens daily multivitamin tablet oral T3
qc multivitamin cholesterol tablet oral T3
qc multi-vite tablet oral T3
qc therin-m tablet oral T3
quin b strong tablet oral T3
quintabs tablet oral T3
quintabs-m tablet oral T3
ra central-vite energy tablet oral T3
ra central-vite senior tablet oral T3
RA CENTRAL-VITE TABLET ORAL T3
ra central-vite under 50 mens tablet oral T3
ra central-vite under 50 women tablet oral T3
ra central-vite womens mature tablet oral T3
RA CENTRAL-VITE/ANTIOXIDANTS
TABLET ORAL T3
ra folic acid tablet 400 mcg oral T3
ra folic acid tablet 800 mcg oral T3
ra one daily essential tablet oral T3
ra one daily gummy vites tablet chewable oral T3
ra one daily maximum tablet oral T3
ra one daily mens 50+ w/vit d3 tablet oral T3
ra one daily mens/vit d-3 tablet oral T3
ra one daily womens tablet oral T3
ra stress formula advanced tablet oral T3
ra stress formula energy tablet oral T3
ra vitamin b-1 tablet 100 mg oral T3 AL
ra vitamin b-12 tablet 100 mcg oral T3
ra vitamin b-12 tablet extended release 1000 mcg
oral T3
ra vitamin b-12 tr tablet extended release 1000
mcg oral T3
ra vitamin b-6 cr tablet extended release 200 mg
oral T3
ra vitamin b-6 tablet 100 mg oral T3
ra vitamin b-6 tablet 50 mg oral T3
215
Drug Tier Requirements/Limits
rabano yodado liquid oral T3
RENAPLEX TABLET ORAL T3
RENAPLEX-D TABLET ORAL T3
senior tabs tablet oral T3
sentry senior tablet oral T3
sentry tablet oral T3
SIDEROL LIQUID† ORAL T3
SIDEROL TABLET ORAL T3
sm b super vitamin complex tablet oral T3
sm balanced b-100 tablet oral T3
sm balanced b-50 tablet oral T3
sm b-complex/vitamin c tablet oral T3
sm biotin capsule 5000 mcg oral T3
sm biotin tablet 5000 mcg oral T3
sm complete 50+ tablet oral T3
sm complete 50+ ultimate mens tablet oral T3
sm complete 50+ ultimate women tablet oral T3
sm complete advanced formula tablet oral T3
sm complete senior formula tablet oral T3
sm complete tablet oral T3
sm folic acid tablet 400 mcg oral T3
sm one daily essential tablet oral T3
sm one daily mens tablet oral T3
sm one daily womens tablet oral T3
sm stress formula b-complex/zn tablet oral T3
sm therapeutic-m tablet oral T3
sm vitamin b1 tablet 100 mg oral T3 AL
sm vitamin b-1 tablet 100 mg oral T3 AL
sm vitamin b-12 tablet 100 mcg oral T3
sm vitamin b-12 tablet 500 mcg oral T3
sm vitamin b12 tr tablet extended release 1000
mcg oral T3
sm vitamin b-12 tr tablet extendedrelease* 1000
mcg oral T3
sm vitamin b6 tablet 100 mg oral T3
sm vitamin b-6 tablet 100 mg oral T3
solo tablet oral T3
216
Drug Tier Requirements/Limits
SOURCECF CAPSULE ORAL T3
stress b complex/zinc tablet oral T3
stress b-complex/vit c/zinc tablet oral T3
stress formula/iron tablet oral T3
STROVITE ADVANCE TABLET ORAL T3
STROVITE FORTE TABLET ORAL T3
STROVITE ONE TABLET ORAL T3
STROVITE PLUS TABLET ORAL T3
STROVITE TABLET ORAL T3
SUNVITE ADVANCED TABLET ORAL T3
super b complex maxi tablet oral T3
super b complex/fa/vit c tablet oral T3
super b-50 complex tablet oral T3
super b-complex/vit c/fa tablet oral T3
super biotin capsule 5000 mcg oral T3
super biotin tablet 5000 mcg oral T3
super multiple capsule oral T3
super multiple tablet oral T3
SYNDION CAPSULE ORAL T3
SYNDION LIQUID ORAL T3
SYNDION-SF LIQUID ORAL T3
TAB-A-VITE TABLET ORAL T3
TAB-A-VITE/WEIGHTSLIM TABLET ORAL T3
th b 100 complex tablet oral T3
th b complex/iron/c/e tablet oral T3
th complete multi 50+ tablet oral T3
th daily multiple vitamin/iron tablet oral T3
th premium daily multiple tablet oral T3
th theradex-m tablet oral T3
th vitamin b12 er tablet extended release 1000
mcg oral T3
th vitamin b12 tablet 100 mcg oral T3
th vitamin b-12 tablet 500 mcg oral T3
th vitamin b-6 tablet 100 mg oral T3
th womens daily tablet oral T3
THERA M PLUS TABLET ORAL T3
217
Drug Tier Requirements/Limits
THERAGRAN-M ADVANCED 50 PLUS
TABLET ORAL T3
THERAGRAN-M ADVANCED TABLET
ORAL T3
THERAGRAN-M PREMIER 50 PLUS TABLET
ORAL T3
THERAGRAN-M PREMIER TABLET ORAL T3
THERAGRAN-M TABLET ORAL T3
thera-m tablet oral T3
THERAMILL FORTE CAPSULE ORAL T3
therapeutic m tablet oral T3
therapeutic-m tablet oral T3
therapeutic-m/lutein tablet oral T3
thera-tabs m tablet oral T3
THERATRUM COMPLETE 50 PLUS TABLET
ORAL T3
THEREMS TABLET ORAL T3
therobec tablet oral T3
trimagen fa tablet 70-150-2-1 mg oral T3
trimagen forte tablet 50-101-1 mg oral T3
TRUEPLUS DIABETIC MULTIVITAMIN
TABLET ORAL T3
UDAMIN SP TABLET 1 MG ORAL T3
ultra b-100 complex tablet oral T3
ultra freeda tablet oral T3
ultra freeda/iron tablet oral T3
urosex tablet oral T3
v-c forte capsule oral T3
vica forte capsule oral T3
vicap forte capsule oral T3
VIC-FORTE CAPSULE ORAL T3
VITA S FORTE TABLET ORAL T3
vita-bee/c tablet oral T3
vitabex plus capsule oral T3
VITACEL TABLET ORAL T3
vitalee tablet oral T3
vitamin b 12 tablet 500 mcg oral T3
vitamin b complex tablet oral T3
218
Drug Tier Requirements/Limits
vitamin b-1 tablet 100 mg oral T3 AL
vitamin b1 tablet 100 mg oral T3 AL
vitamin b-1 tablet 250 mg oral T3
vitamin b1 tablet 50 mg oral T3
vitamin b-1 tablet 50 mg oral T3
vitamin b-12 er tablet extended release 1000 mcg
oral T3
vitamin b12 tablet 100 mcg oral T3
vitamin b-12 tablet 100 mcg oral T3
vitamin b-12 tablet 1000 mcg oral T3
vitamin b-12 tablet 250 mcg oral T3
vitamin b-12 tablet 50 mcg oral T3
vitamin b12 tablet 500 mcg oral T3
vitamin b-12 tablet 500 mcg oral T3
vitamin b-12 tablet sublingual 2500 mcg
sublingual T3 AL
vitamin b12 tr tablet extended release 1000 mcg
oral T3
vitamin b-2 tablet 100 mg oral T3
vitamin b-2 tablet 25 mg oral T3
vitamin b-2 tablet 50 mg oral T3 AL
vitamin b-6 er tablet extended release 200 mg
oral T3
vitamin b-6 tablet 100 mg oral T3
vitamin b-6 tablet 25 mg oral T3
vitamin b6 tablet 250 mg oral T3
vitamin b-6 tablet 250 mg oral T3
vitamin b6 tablet 50 mg oral T3
vitamin b-6 tablet 50 mg oral T3
vitamin forte capsule oral T3
vitamins for hair tablet oral T3
VITATRUM COMPLETE TABLET ORAL T3
vitatrum tablet chewable oral T3
vitrum 50+ senior multi tablet oral T3
vp-zel tablet oral T3
womens 50+ advanced capsule oral T3
womens daily formula tablet oral T3
219
Drug Tier Requirements/Limits
womens multi capsule oral T3
YELETS TEENAGE FORMULA TABLET
ORAL T3
YOUR LIFE MULTI ADULT GUMMIES
TABLET CHEWABLE ORAL T3
Vitamin C
acerola c-500 tablet chewable 500 mg oral T3
ascorbic acid tablet 250 mg oral T3 AL
ascorbic acid tablet 500 mg oral T3
b complex-c-folic acid tablet oral T3
b-complex/folic acid/vitamin c tablet extended
release oral T3
b-complex/vitamin c tablet oral T3
b-complex-c tablet oral T3
b-plex tablet oral T3
c 1000 tablet 1000 mg oral T3
c 250 tablet 250 mg oral T3 AL
c 250 tablet chewable 250 mg oral T3
c 500 tablet 500 mg oral T3
c 500 tablet chewable 500 mg oral T3
c 500/rose hips tablet 500 mg oral T3
c-1000 tablet 1000 mg oral T3
c-1000/rose hips tablet 1000 mg oral T3
c-250 tablet 250 mg oral T3 AL
c-250 tablet chewable 250 mg oral T3
c-500 tablet 500 mg oral T3
c-500 tablet chewable 500 mg oral T3
c-500 tablet extended release 500 mg oral T3 AL
c-500/rose hips tablet 500 mg oral T3
c-chewable tablet chewable 500 mg oral T3
CEMILL TABLET EXTENDED RELEASE 500
MG ORAL T3 AL
chewable vitamin c tablet chewable 250 mg oral T3
cvs vitamin b/c tablet oral T3
cvs vitamin c tablet 1000 mg oral T3
cvs vitamin c tablet 250 mg oral T3 AL
cvs vitamin c tablet 500 mg oral T3
220
Drug Tier Requirements/Limits
cvs vitamin c tablet chewable 500 mg oral T3
cvs vitamin c-acerola tablet chewable 500 mg
oral T3
cvs vitamin c-rose hips tablet 1000 mg oral T3
cvs vitamin c-rose hips tablet 500 mg oral T3
DECUBI-VITE CAPSULE ORAL T3
dialyvite 800/ultra d tablet oral T3
EMERGEN-C VITAMIN C TABLET
CHEWABLE ORAL T3
ENDUR-C TABLET EXTENDED RELEASE
500 MG ORAL T3 AL
eql b complex tablet oral T3
eql stress b-complex c/zinc tablet oral T3
eql super b complex/vitamin c tablet oral T3
eql vitamin c tablet 1000 mg oral T3
eql vitamin c tablet 500 mg oral T3
eql vitamin c tablet chewable 500 mg oral T3
eql vitamin c/rose hips tablet 1000 mg oral T3
eql vitamin c/rose hips tablet 500 mg oral T3
feasp-fefum -suc-c-thre-b12-fa tablet 50-101-1 mg
oral T3
fruit c 200 tablet chewable oral T3
fruit c 500 tablet chewable 500 mg oral T3
fruity c tablet chewable 250 mg oral T3
GLUTOFAC TABLET ORAL T3
gnp vitamin c cr tablet extended release 500 mg
oral T3 AL
gnp vitamin c tablet 1000 mg oral T3
gnp vitamin c tablet 250 mg oral T3 AL
gnp vitamin c tablet 500 mg oral T3
gnp vitamin c tablet chewable 500 mg oral T3
gnp vitamin c tablet extended release 500 mg oral T3 AL
gnp vitamin c w/rose hips tablet 500 mg oral T3
gnp vitamin c w/rose hips tablet 500-37 mg oral T3
gnp vitamin c/rose hips tablet 1000 mg oral T3
hm super vitamin b complex/c tablet oral T3
hm vitamin b complex/vitamin c tablet oral T3
hm vitamin c tablet 1000 mg oral T3
221
Drug Tier Requirements/Limits
hm vitamin c tablet 500 mg oral T3
hm vitamin c tablet chewable 500 mg oral T3
hm vitamin c tr tablet extended release 500 mg
oral T3 AL
hm vitamin c/rose hips tablet 1000 mg oral T3
hm vitamin c/rose hips tablet 500 mg oral T3
hylavite tablet oral T3
kp b complex-c tablet oral T3
KP VISION FORMULA TABLET ORAL T3
LIPOTRIAD TABLET ORAL T3
MACUVITE EYE CARE TABLET ORAL T3
MACUVITE TABLET ORAL T3
meijer c tablet 500 mg oral T3
MULTIGEN FOLIC TABLET 70-150-2-1 MG
ORAL T3
MULTIGEN PLUS TABLET 50-101-1 MG
ORAL T3
natural c/rose hips tablet 1000 mg oral T3
ocular vitamins tablet oral T3
ORTHOVITE TABLET ORAL T3
parvlex tablet oral T3
prevent capsule oral T3
PRORENAL + D TABLET ORAL T3
PROSIGHT TABLET ORAL T3
PUREWAY-C TABLET 500 MG ORAL T3
px b complex/vitamin c tablet oral T3
px vitamin c tablet 500 mg oral T3
quin b strong tablet oral T3
ra stress formula energy tablet oral T3
ra vitamin c cr tablet extended release 500 mg
oral T3 AL
ra vitamin c tablet 250 mg oral T3 AL
ra vitamin c tablet 500 mg oral T3
ra vitamin c tablet chewable 500 mg oral T3
ra vitamin c/acerola tablet chewable 500 mg oral T3
ra vitamin c/rose hips cr tablet extended release
500 mg oral T3 AL
ra vitamin c/rose hips tablet 1000 mg oral T3
222
Drug Tier Requirements/Limits
ra vitamin c/rose hips tablet 500 mg oral T3
RENAPLEX TABLET ORAL T3
RENAPLEX-D TABLET ORAL T3
sb vitamin c tablet 500 mg oral T3
SIDEROL LIQUID† ORAL T3
SIDEROL TABLET ORAL T3
sm b super vitamin complex tablet oral T3
sm b-complex/vitamin c tablet oral T3
sm chewable c tablet chewable 500 mg oral T3
sm chewable vitamin c tablet chewable 500 mg
oral T3
sm vit c/rose hips tablet 1000 mg oral T3
sm vitamin c cr tablet extended release 500 mg
oral T3 AL
sm vitamin c tablet 1000 mg oral T3
sm vitamin c tablet 250 mg oral T3 AL
sm vitamin c tablet 500 mg oral T3
sm vitamin c tablet chewable 500 mg oral T3
sm vitamin c/rose hips tablet 500 mg oral T3
stress b complex/zinc tablet oral T3
stress b-complex/vit c/zinc tablet oral T3
stress formula/iron tablet oral T3
STROVITE TABLET ORAL T3
super b complex/fa/vit c tablet oral T3
super b-complex/vit c/fa tablet oral T3
SYSTANE ICAPS AREDS2 CAPSULE ORAL T3
SYSTANE ICAPS AREDS2 TABLET
CHEWABLE ORAL T3
SYSTANE ICAPS AREDS2 TABLET ORAL T3
th b complex/iron/c/e tablet oral T3
th vitamin c tablet 1000 mg oral T3
th vitamin c tablet 250 mg oral T3 AL
th vitamin c tablet 500 mg oral T3
th vitamin c tablet chewable 500 mg oral T3
therobec tablet oral T3
trimagen fa tablet 70-150-2-1 mg oral T3
trimagen forte tablet 50-101-1 mg oral T3
223
Drug Tier Requirements/Limits
tri-vit/fluoride solution 0.25 mg/ml oral T3
tri-vitamin/fluoride solution 0.25 mg/ml oral T3
tri-vite/fluoride solution 0.25 mg/ml oral T3
vita-bee/c tablet oral T3
vitamin b complex tablet oral T3
vitamin c er tablet extended release 1500 mg oral T3
vitamin c er tablet extended release 500 mg oral T3 AL
vitamin c immune health tablet chewable 500 mg
oral T3
vitamin c liquid 500 mg/5ml oral T3
vitamin c plus wild rose hips tablet chewable 500
mg oral T3
vitamin c tablet 1000 mg oral T3
vitamin c tablet 250 mg oral T3 AL
vitamin c tablet 500 mg oral T3
vitamin c tablet chewable 250 mg oral T3
vitamin c tablet chewable 500 mg oral T3
vitamin c tablet chewable oral T3
vitamin c/rose hips tablet 500 mg oral T3
vitamin c-rose hips er tablet extended release 500
mg oral T3 AL
vitamin c-rose hips tablet 1000 mg oral T3
vitamin c-rose hips tablet 500 mg oral T3
vitamin c-rose hips tr tablet extended release 500
mg oral T3 AL
vitamins acd-fluoride solution 0.25 mg/ml oral T3
Vitamin D
abdek capsule oral T3
actical capsule oral T3
aqueous vitamin d liquid 10 mcg/ml oral T3
biocal capsule oral T3
CALCITRATE TABLET 315-250 MG-UNIT
ORAL T3
calcium + d tablet 250-125 mg-unit oral T3
calcium + d tablet 315-200 mg-unit oral T3
calcium + d3 tablet 600-200 mg-unit oral T3
calcium 500 + d3 tablet 500-600 mg-unit oral T3
calcium 500 +d tablet 500-400 mg-unit oral T3
224
Drug Tier Requirements/Limits
calcium 500+d tablet 500-400 mg-unit oral T3
calcium 500+d3 tablet 500-400 mg-unit oral T3
calcium 600/vitamin d tablet 600-400 mg-unit
oral T3
calcium 600+d plus minerals tablet 600-400 mg-
unit oral T3
calcium 600+d3 tablet 600-200 mg-unit oral T3
calcium 600-d tablet 600-400 mg-unit oral T3
calcium carbonate antacid tablet chewable 500
mg oral T3
calcium carbonate-vitamin d tablet 500-400 mg-
unit oral T3
calcium carbonate-vitamin d tablet 600-400 mg-
unit oral T3
calcium citrate + d tablet 315-200 mg-unit oral T3
calcium citrate + d tablet 315-250 mg-unit oral T3
calcium citrate + d3 maximum tablet 315-250
mg-unit oral T3
calcium citrate + d3 tablet 200-250 mg-unit oral T3
calcium citrate + tablet 315-200 mg-unit oral T3
calcium citrate +d tablet 315-250 mg-unit oral T3
calcium citrate maximum/vit d tablet 315-250 mg-
unit oral T3
calcium citrate petite/vit d tablet 200-250 mg-unit
oral T3
calcium citrate tablet 950 mg oral T3
calcium citrate+d3 petites tablet 200-250 mg-unit
oral T3
calcium citrate+d3 tablet 315-250 mg-unit oral T3
calcium citrate-vitamin d tablet 200-125 mg-unit
oral T3
calcium citrate-vitamin d tablet 315-200 mg-unit
oral T3
calcium citrate-vitamin d tablet 315-250 mg-unit
oral T3
calcium citrate-vitamin d3 tablet 315-250 mg-unit
oral T3
calcium extra d3 tablet 500-600 mg-unit oral T3
calcium-vitamin d tablet 500-400 mg-unit oral T3
calcium-vitamin d tablet 600-200 mg-unit oral T3
225
Drug Tier Requirements/Limits
calcium-vitamin d3 tablet 500-400 mg-unit oral T3
choice-tabs tablet oral T3
CITRACAL CALCIUM GUMMIES TABLET
CHEWABLE 250-115-250 MG-MG-UNIT
ORAL
T3
CITRACAL MAXIMUM PLUS TABLET
ORAL T3
CITRACAL MAXIMUM TABLET 315-250
MG-UNIT ORAL T3
CITRACAL PETITES/VITAMIN D TABLET
200-250 MG-UNIT ORAL T3
citrus calcium +d tablet 315-250 mg-unit oral T3
citrus calcium/vitamin d tablet 200-250 mg-unit
oral T3
cvs calcium 600 + d/minerals tablet 600-400 mg-
unit oral T3
cvs calcium citrate +d tablet 315-250 mg-unit
oral T3
cvs calcium citrate +d3 mini tablet 200-250 mg-
unit oral T3
cvs d3 capsule 125 mcg (5000 ut) oral T3
cvs d3 capsule 25 mcg (1000 ut) oral T3
cvs d3 capsule 50 mcg (2000 ut) oral T3
cvs vitamin d3 capsule 1000 unit oral T3
cvs vitamin d3 tablet chewable 25 mcg (1000 ut)
oral T3
d 1000 capsule 25 mcg (1000 ut) oral T3
d 10000 capsule 250 mcg (10000 ut) oral T3
d2000 ultra strength capsule 50 mcg (2000 ut)
oral T3
d3 high potency capsule 25 mcg (1000 ut) oral T3
d3-1000 capsule 25 mcg (1000 ut) oral T3
d3-1000 tablet 25 mcg (1000 ut) oral T3
d-5000 tablet 125 mcg (5000 ut) oral T3
DECARA CAPSULE 625 MCG (25000 UT)
ORAL T3
dekas essential capsule oral T3
dekas essential liquid oral T3
dialyvite 800/ultra d tablet oral T3
226
Drug Tier Requirements/Limits
D-VI-SOL LIQUID 10 MCG/ML ORAL T3
eq calcium citrate+d tablet 315-250 mg-unit oral T3
eql calcium citrate/vitamin d tablet 315-250 mg-
unit oral T3
eql calcium citrate/vitamin d3 tablet 315-250 mg-
unit oral T3
eql vitamin d3 capsule 25 mcg (1000 ut) oral T3
ergocalciferol capsule 1.25 mg (50000 ut) oral T3
gnp calcium 500 +d3 tablet 500-600 mg-unit oral T3
gnp calcium citrate +d3 tablet 315-250 mg-unit
oral T3
gnp calcium citrate+d maximum tablet 315-250
mg-unit oral T3
gnp d 1000 capsule 25 mcg (1000 ut) oral T3
gnp vitamin d3 extra strength tablet 25 mcg (1000
ut) oral T3
hm calcium citrate+d3 petite tablet 200-250 mg-
unit oral T3
hm calcium citrate+vitamin d tablet 315-250 mg-
unit oral T3
hm calcium-vitamin d-minerals tablet 600-400
mg-unit oral T3
kp calcium citrate+d tablet 315-250 mg-unit oral T3
kp vitamin b-12 tablet 1000 mcg oral T3
kp vitamin d capsule 25 mcg (1000 ut) oral T3
kp vitamin d3 capsule 25 mcg (1000 ut) oral T3
multi + omega-3 adult gummies tablet chewable
oral T3
multivitamins plus zinc capsule oral T3
MVW COMPLETE FORMULATION
CAPSULE ORAL T3
MVW COMPLETE FORMULATION D3000
CAPSULE ORAL T3
MVW COMPLETE FORMULATION D3000
TABLET CHEWABLE ORAL T3 AL
MVW COMPLETE FORMULATION D5000
CAPSULE ORAL T3
MVW COMPLETE FORMULATION D5000
TABLET CHEWABLE ORAL T3 AL
227
Drug Tier Requirements/Limits
MVW COMPLETE FORMULATION MINIS
CAPSULE ORAL T3
MVW COMPLETE FORMULATION
SOLUTION 45 MG/0.5ML ORAL T3
MVW COMPLETE FORMULATION TABLET
CHEWABLE ORAL T3 AL
MVW COMPLETE FORMULATION TABLET
CHEWABLE ORAL T3
ORTHOVITE TABLET ORAL T3
OS-CAL EXTRA D3 TABLET 500-600 MG-
UNIT ORAL T3
OYSCO 500+D TABLET 500-200 MG-UNIT
ORAL T3
oyst-cal d tablet 250-125 mg-unit oral T3
oyster shell calcium + d tablet 500-400 mg-unit
oral T3
oyster shell calcium + d3 tablet 500-400 mg-unit
oral T3
oyster shell calcium 500 + d tablet 500-200 mg-
unit oral T3
oyster shell calcium tablet 500-400 mg-unit oral T3
oyster shell calcium/d tablet 250-125 mg-unit oral T3
oyster shell calcium/d tablet 500-200 mg-unit oral T3
oyster shell calcium/d3 tablet 500-400 mg-unit
oral T3
oyster shell calcium/vitamin d tablet 250-125 mg-
unit oral T3
OYSTERCAL-D TABLET 500-400 MG-UNIT
ORAL T3
PRORENAL + D TABLET ORAL T3
PRORENAL + D W/ OMEGA-3 CAPSULE
ORAL T3
qc calcium/minerals/vitamin d tablet 600-400 mg-
unit oral T3
ra calcium cit plus vit d-3 tablet 315-250 mg-unit
oral T3
ra calcium citrate plus vit d tablet 315-200 mg-
unit oral T3
ra calcium cit-vit d-3 petites tablet 200-250 mg-
unit oral T3
228
Drug Tier Requirements/Limits
ra calcium/minerals/vitamin d tablet 600-400 mg-
unit oral T3
ra oyster shell calcium/d tablet 250-125 mg-unit
oral T3
ra vitamin d-3 capsule 50 mcg (2000 ut) oral T3
RENAPLEX-D TABLET ORAL T3
sm calcium citrate w/vit d3 tablet 315-250 mg-
unit oral T3
sm calcium citrate+/vit d3 tablet 315-250 mg-unit
oral T3
sm calcium citrate+d3 petite tablet 200-250 mg-
unit oral T3
sm calcium citrate-vit d tablet 315-200 mg-unit
oral T3
sm calcium/vitamin d/minerals tablet 600-400
mg-unit oral T3
sm oyster shell calcium/vit d3 tablet 500-400 mg-
unit oral T3
sm vitamin d3 tablet 25 mcg (1000 ut) oral T3
STROVITE ONE TABLET ORAL T3
th calcium citrate-vitamin d tablet 315-200 mg-
unit oral T3
th vitamin d3 capsule 1000 unit oral T3
tri-vit/fluoride solution 0.25 mg/ml oral T3
tri-vitamin/fluoride solution 0.25 mg/ml oral T3
tri-vite/fluoride solution 0.25 mg/ml oral T3
TRUEPLUS GLUCOSE ON THE GO TABLET
CHEWABLE ORAL T3
TRUEPLUS GLUCOSE TABLET CHEWABLE
ORAL T3
vitamin d (cholecalciferol) capsule 25 mcg (1000
ut) oral T3
vitamin d (ergocalciferol) capsule 1.25 mg
(50000 ut) oral T3
vitamin d capsule 1000 unit oral T3
vitamin d high potency capsule 25 mcg (1000 ut)
oral T3
vitamin d liquid 10 mcg/ml oral T3
vitamin d tablet 25 mcg (1000 ut) oral T3
vitamin d tablet 400 unit oral T3
229
Drug Tier Requirements/Limits
vitamin d tablet 50 mcg (2000 ut) oral T3
vitamin d3 adult gummies tablet chewable 25 mcg
(1000 ut) oral T3
vitamin d3 capsule 1.25 mg (50000 ut) oral T3
vitamin d3 capsule 125 mcg (5000 ut) oral T3
vitamin d3 capsule 25 mcg (1000 ut) oral T3
vitamin d-3 capsule 25 mcg (1000 ut) oral T3
vitamin d3 capsule 50 mcg (2000 ut) oral T3
vitamin d3 tablet 10 mcg (400 unit) oral T3
vitamin d3 tablet 25 mcg (1000 ut) oral T3
vitamin d3 tablet 50 mcg (2000 ut) oral T3
vitamins acd-fluoride solution 0.25 mg/ml oral T3
vitamins a-d-e/selenium tablet oral T3
Vitamin E
cvs e capsule 200 unit oral T3
cvs e oil oil 100 unt/0.25ml oral T3
cvs vitamin e capsule 1000 unit oral T3
cvs vitamin e capsule 200 unit oral T3
cvs vitamin e capsule 400 unit oral T3
dekas essential capsule oral T3
dekas essential liquid oral T3
e 1000 capsule 1000 unit oral T3
e 400 blended capsule 400 unit oral T3
e1000 capsule 1000 unit oral T3
e-200 capsule 200 unit oral T3
e200 capsule 200 unit oral T3
e400 capsule 400 unit oral T3
e-400 capsule 400 unit oral T3
e400 mixed capsule 400 unit oral T3
e-oil oil 100 unt/0.25ml oral T3
eql stress b-complex c/zinc tablet oral T3
eql vitamin e capsule 1000 unit oral T3
eql vitamin e capsule 400 unit oral T3
ESTER-E CAPSULE 400 UNIT ORAL T3
FORMULA E 400 CAPSULE 400 UNIT ORAL T3
gnp vitamin e capsule 1000 unit oral T3
gnp vitamin e capsule 200 unit oral T3
230
Drug Tier Requirements/Limits
gnp vitamin e capsule 400 unit oral T3
hm e vitamin capsule 400 unit oral T3
hm vitamin e capsule 1000 unit oral T3
hm vitamin e capsule 200 unit oral T3
hm vitamin e capsule 400 unit oral T3
KP VISION FORMULA TABLET ORAL T3
kp vitamin e capsule 100 unit oral T3
LIPOTRIAD TABLET ORAL T3
MACUVITE EYE CARE TABLET ORAL T3
MACUVITE TABLET ORAL T3
natural mixed tocopherols capsule 1000 unit oral T3
natural mixed tocopherols capsule 400 unit oral T3
natural vitamin e capsule 1000 unit oral T3
natural vitamin e capsule 400 unit oral T3
ocular vitamins tablet oral T3
pa vitamin e capsule 400 unit oral T3
prevent capsule oral T3
PROSIGHT TABLET ORAL T3
px vitamin e capsule 400 unit oral T3
ra natural vitamin e capsule 400 unit oral T3
ra vitamin e blend capsule 400 unit oral T3
ra vitamin e capsule 1000 unit oral T3
ra vitamin e capsule 200 unit oral T3
ra vitamin e capsule 400 unit oral T3
RENAPLEX-D TABLET ORAL T3
sm vitamin e capsule 1000 unit oral T3
sm vitamin e capsule 200 unit oral T3
sm vitamin e capsule 400 unit oral T3
stress formula/iron tablet oral T3
SYSTANE ICAPS AREDS2 CAPSULE ORAL T3
SYSTANE ICAPS AREDS2 TABLET
CHEWABLE ORAL T3
SYSTANE ICAPS AREDS2 TABLET ORAL T3
th b complex/iron/c/e tablet oral T3
th vitamin e capsule 1000 unit oral T3
th vitamin e capsule 200 unit oral T3
th vitamin e capsule 400 unit oral T3
231
Drug Tier Requirements/Limits
vita zinc tablet oral T3
vitamin e blend capsule 400 unit oral T3
vitamin e capsule 100 unit oral T3
vitamin e capsule 1000 unit oral T3
vitamin e capsule 200 unit oral T3
vitamin e capsule 400 unit oral T3
vitamin e high potency capsule 400 unit oral T3
vitamin e mtc capsule 1000 unit oral T3
vitamin e natural capsule 400 unit oral T3
vitamin e oil 100 unt/0.25ml oral T3
vitamin e water soluble capsule 1000 unit oral T3
vitamin e water soluble capsule 400 unit oral T3
vitamin e/d-alpha capsule 200 unit oral T3
vitamin e/d-alpha natural capsule 200 unit oral T3
vitamin e/d-alpha natural capsule 400 unit oral T3
vitamin e-200 capsule 200 unit oral T3
vitamin e-400 capsule 400 unit oral T3
vitamins a-d-e/selenium tablet oral T3
z-gen tablet oral T3
Vitamin K Activity
abdek capsule oral T3
ADVANCED MULTI EA TABLET
CHEWABLE ORAL T3
ALIVE ONCE DAILY WOMENS 50+ TABLET
ORAL T3
ALIVE WOMENS ENERGY TABLET ORAL T3
AQUADEKS LIQUID ORAL T3
bariatric multivitamins/iron capsule oral T3
biocal capsule oral T3
centravites adults tablet oral T3
CENTRUM SPECIALIST ENERGY TABLET
ORAL T3
CENTRUM TABLET CHEWABLE ORAL T3
cvs daily multiple for men tablet oral T3
cvs daily multiple women 50+ tablet oral T3
cvs one daily mens 50+ adv tablet oral T3
cvs one daily womens formula tablet oral T3
232
Drug Tier Requirements/Limits
daily multivitamin capsule oral T3
dekas bariatric tablet chewable oral T3
dekas essential capsule oral T3
dekas essential liquid oral T3
dekas plus capsule oral T3
dekas plus tablet chewable oral T3
eq one daily mens 50+ tablet oral T3
eq one daily mens health tablet oral T3
eql century mature adults 50+ tablet oral T3
eql century mature tablet oral T3
eql century mens tablet oral T3
eql one daily mens 50+ advance tablet oral T3
eql one daily womens 50+ adv tablet oral T3
hm mens 50+ advanced one daily tablet oral T3
hm one daily mens tablet oral T3
hm womens 50+ advanced daily tablet oral T3
kp adults daily formula tablet oral T3
kp mens 50+ daily formula tablet oral T3
kp mens daily formula tablet oral T3
kp womens 50+ daily formula tablet oral T3
kp womens daily formula tablet oral T3
MEPHYTON TABLET 5 MG ORAL T3
multi for her 50+ capsule oral T3
multi for her capsule oral T3
multi for her tablet oral T3
multi-day plus minerals tablet oral T3
multivitamin adult tablet oral T3
multivitamin adults tablet oral T3
multivitamin men tablet oral T3
multivitamin women tablet oral T3
multivitamins plus zinc capsule oral T3
MVW COMPLETE FORMULATION
CAPSULE ORAL T3
MVW COMPLETE FORMULATION D3000
CAPSULE ORAL T3
MVW COMPLETE FORMULATION D3000
TABLET CHEWABLE ORAL T3 AL
233
Drug Tier Requirements/Limits
MVW COMPLETE FORMULATION D5000
CAPSULE ORAL T3
MVW COMPLETE FORMULATION D5000
TABLET CHEWABLE ORAL T3 AL
MVW COMPLETE FORMULATION MINIS
CAPSULE ORAL T3
MVW COMPLETE FORMULATION
SOLUTION 45 MG/0.5ML ORAL T3
MVW COMPLETE FORMULATION TABLET
CHEWABLE ORAL T3 AL
MVW COMPLETE FORMULATION TABLET
CHEWABLE ORAL T3
OCUVITE EYE + MULTI TABLET ORAL T3
one daily mens 50+ multivit tablet oral T3
ONE-A-DAY MENS 50+ ADVANTAGE
TABLET ORAL T3
ONE-A-DAY MENS HEALTH FORMULA
TABLET ORAL T3
ONE-A-DAY MENS TABLET ORAL T3
ONE-A-DAY WOMENS 50 PLUS TABLET
ORAL T3
ONE-A-DAY WOMENS 50+ ADVANTAGE
TABLET ORAL T3
ONE-A-DAY WOMENS FORMULA TABLET
ORAL T3
OPTISOURCE POST BARIATRIC SURG
TABLET CHEWABLE ORAL T3
ORTHOVITE TABLET ORAL T3
phytonadione tablet 5 mg oral T3
polyvitamin/iron tablet chewable 18 mg oral T3 AL
PROCERV HP TABLET ORAL T3
RA CENTRAL-VITE TABLET ORAL T3
ra one daily mens 50+ w/vit d3 tablet oral T3
ra one daily mens/vit d-3 tablet oral T3
sm one daily mens tablet oral T3
solo tablet oral T3
TRUEPLUS DIABETIC MULTIVITAMIN
TABLET ORAL T3
234
Index
1 10 SERIES BP
MONITOR/UPPER ARM . 79
10 SERIES+ BP
MONITR/UPPER ARM .... 79
12 hour nasal decongestant .. 136
12 hour nasal spray ............... 136
1st choice lancets super thin ... 79
1st choice lancets thin ............ 79
1st choice lancets ultra thin .... 80
1st tier unilet comfortouch ..... 80
3 3 SERIES BP
MONITOR/UPPER ARM . 80
3 SERIES BP
MONITOR/WRIST ............ 80
5 5 SERIES BP MONITOR ...... 80
5 SERIES BP
MONITOR/UPPER ARM . 80
50+ adult eye health ............. 182
7 7 SERIES BP
MONITOR/UPPER ARM . 80
7 SERIES BP
MONITOR/WRIST ............ 80
8 8 hour arthritis pain reliever ... 70
8 hour pain relief .................... 70
8hr muscle aches & pain ........ 70
A a thru z advanced .... 51, 182, 202
a thru z advantage ... 51, 182, 202
a thru z high potency ............ 182
a thru z select ............ 1, 182, 203
a thru z select 50+ advanced 182,
202
a thru z select 50+ mens182, 202
a thru z select advanced 182, 202
a thru z select ultimate women
.................................... 51, 183
a thru z ultimate mens ... 51, 183,
203
a-10000 ................................. 202
abc plus ..................................... 1
ABC PLUS SENIOR ADULTS
50+ ............................ 183, 203
abdek .................... 183, 223, 231
ABRAXANE .......................... 30
a-caro-25 ................................... 1
ACCU-CHEK ACTIVE
GLUCOSE CONT .............. 80
ACCU-CHEK AVIVA ........... 80
ACCU-CHEK COMFORT
CURVE .............................. 80
ACCU-CHEK COMFORT
CURVE LINEAR ............... 80
ACCU-CHEK COMPACT
BLUE CONTROL .............. 80
ACCU-CHEK COMPACT
GLUCOSE CONT .............. 80
ACCU-CHEK COMPACT
PLUS CONTROL .............. 80
ACCU-CHEK FASTCLIX
LANCETS .......................... 80
ACCU-CHEK GUIDE
CONTROL ......................... 80
ACCU-CHEK INSTANT
CONTROL ......................... 80
ACCU-CHEK MULTICLIX
LANCETS .......................... 80
ACCU-CHEK SAFE-T PRO
LANCETS .......................... 80
ACCU-CHEK SMARTVIEW
CONTROL ......................... 80
ACCU-CHEK SOFT TOUCH
DEVICE ............................. 80
ACCU-CHEK SOFT TOUCH
LANCETS .......................... 80
ACCU-CHEK SOFTCLIX
LANCET DEV ................... 80
ACCU-CHEK SOFTCLIX
LANCETS .......................... 80
ACCUTREND GLUCOSE
CONTROL ......................... 80
ACEPHEN.............................. 70
acerola c-500 ........................ 219
acetaminophen .................. 70, 71
acetaminophen childrens ........ 70
acetaminophen er .................... 70
acetaminophen extra strength . 70
acetaminophen infants ............ 70
acetazolamide ......... 65, 120, 133
acetazolamide er ..... 65, 120, 133
acetylcysteine ............... 162, 175
ACID GONE ........................ 137
ACTHAR ...................... 118, 155
actical ............................ 122, 223
acti-lance 28g.......................... 81
acti-lance lite lancets 28g ....... 81
acti-lance special lancets 17g . 81
acti-lance universal 23g .......... 81
ACTIMMUNE ..................... 161
ACTIVASE .................... 62, 132
ACTIVE 1ST BLOOD
LANCETS 30G .................. 81
ACURA CONTROL .............. 81
ADACEL ................................ 44
ADAGEN ............................. 132
ADAKVEO ............................ 50
ADCETRIS............................. 30
ADEKS ................................. 183
adjustable lancing device ........ 81
adriamycin .............................. 31
ADRIAMYCIN ................ 30, 31
ADRUCIL .............................. 31
adult aspirin regimen . 60, 62, 74,
77
adult one daily gummies ...... 183,
203
ADVANCE INTUITION
CONTROL ......................... 81
ADVANCE MICRO-DRAW
CONTROL ........................... 1
ADVANCE MICRO-DRAW
NORMAL ........................... 81
advanced mobile lancet ............ 1
ADVANCED MULTI EA ..... 51,
183, 203, 231
advanced stress formula/zinc 183
ADVANTAGE CARE
ELECTROLYTE PED ..... 122
ADVOCATE ARM BPM...... 81,
118
ADVOCATE CONTROL
SOLUTION ........................ 81
ADVOCATE LANCETS ....... 81
ADVOCATE LANCETS 30G
............................................ 81
ADVOCATE LANCING
DEVICE ............................. 81
ADVOCATE MEMORY BP
MONITOR ........................... 1
235
ADVOCATE RAPID-SAFE
LANCING .......................... 81
ADVOCATE REDI-CODE+
CONTROL ......................... 81
ADVOCATE SAFETY
LANCETS .......................... 81
ADVOCATE SAFETY
LANCETS 26G .................. 81
ADVOCATE WRIST BP
MONITOR ........................... 1
AEROCHAMBER MINI
CHAMBER ........................ 81
AEROCHAMBER MV .......... 81
AEROCHAMBER PLUS ...... 81
AEROCHAMBER PLUS FLO-
VU ...................................... 81
AEROCHAMBER PLUS FLO-
VU LARGE ........................ 81
AEROCHAMBER PLUS FLO-
VU MEDIUM .................... 81
AEROCHAMBER PLUS FLO-
VU SMALL........................ 81
AEROCHAMBER PLUS FLO-
VU W/MASK ..................... 81
AEROCHAMBER PLUS
FLOW VU .......................... 82
AEROCHAMBER PLUS
W/MASK ........................... 82
AEROCHAMBER PLUS
W/MASK SMALL ............. 82
AEROCHAMBER
W/FLOWSIGNAL ............. 82
AEROCHAMBER Z-STAT
PLUS .................................. 82
AEROCHAMBER Z-STAT
PLUS CHAMBR ................ 82
AEROCHAMBER Z-STAT
PLUS/LARGE .................... 82
AEROCHAMBER Z-STAT
PLUS/MEDIUM ................ 82
AEROCHAMBER Z-STAT
PLUS/SMALL ................... 82
AEROVENT PLUS................ 82
af lancets super thin .................. 1
AFLURIA QUADRIVALENT
............................................ 44
AFRIN SALINE NASAL MIST
.............................................. 1
AFTERA .............................. 153
AGAMATRIX CONTROL.... 82
AGAMATRIX ULTRA-THIN
LANCETS .......................... 82
aimsco lubricated .................... 79
aimsco twist lancets 32g ........... 1
AIMSCO TWIST LANCETS
33G ....................................... 1
AIRZONE PEAK FLOW
METER .............................. 82
AKWA TEARS .................... 134
albendazole ............................. 27
ALBENZA ............................. 27
ALBUSTIX .......................... 118
ALCOH-GLOVE
CONTOURED WIPE......... 82
alcohol pads .......................... 178
alcohol prep .......................... 178
alcohol prep pad ................... 178
alcohol preps......................... 178
alcohol swabs ....................... 178
ALCOHOL SWABSTICK ....... 1
alcohol wipes .................... 1, 178
alcoh-wipe .............................. 82
ALDACTAZIDE ..... 67, 68, 121,
131
ALDACTONE.......... 67, 68, 121
ALDURAZYME .................. 132
ALIMTA ................................ 31
ALIQOPA .............................. 31
ALIVE ONCE DAILY
WOMENS 50+ . 183, 203, 231
ALIVE WOMENS ENERGY
............ 51, 122, 183, 203, 231
ALIVE WOMENS GUMMY
.................................. 183, 203
ALKERAN ............................. 31
aller-chlor ................. 24, 26, 173
allergy ................. 23, 24, 26, 174
allergy childrens ....... 23, 24, 173
allergy relief 23, 24, 26, 173, 174
allergy relief childrens ..... 23, 24,
173
allergy syringe ........................ 82
allergy-time .............. 25, 26, 174
ALMACONE ............... 137, 143
ALMACONE DOUBLE
STRENGTH ............. 137, 143
alph-e ........................................ 1
alph-e-mixed ............................. 1
alph-e-mixed 1000 .................... 1
altamist spray ........................ 134
alternate site lancing device.... 82
alum sulfate-ca acetate ......... 177
aluminum hydroxide gel ....... 137
AMICAR ................................ 50
amifostine ............................. 165
amiloride hcl ................... 68, 121
amiloride-hydrochlorothiazide
............................ 68, 121, 131
aminocaproic acid ................... 50
amiodarone hcl ....................... 66
ammonium lactate ................ 177
ANDEXXA ............................ 50
ANEMAGEN ........................... 1
ANEMAGEN FORTE.............. 1
ANTABUSE ......................... 157
antacid................... 122, 138, 143
antacid anti-gas max strength
.................................. 137, 143
antacid calcium ............. 122, 137
antacid calcium extra strength
.................................. 122, 137
antacid extra strength .... 122, 137
antacid fast acting ......... 137, 143
antacid fast relief .......... 137, 143
antacid maximum strength .. 137,
143
antacid plus anti-gas fast act 137,
143
antacid plus anti-gas relief ... 137,
138, 143
antacid regular strength 122, 138
antacid ultra strength .... 122, 138
anti-dandruff ......................... 178
anti-diarrheal......................... 142
antioxidant ............................ 183
anti-oxidant ............................... 1
antioxidant a/c/e/selenium .... 183
antioxidant formula ...... 162, 183
antioxidant vitamins ............. 183
anti-stick tuberculin syringe ..... 1
APATATE FORTE .............. 183
APLICARE ALCOHOL
SWABSTICK ....................... 1
APOKYN ............................... 76
aqua lance adjustable lancing . 82
AQUADEKS ........ 183, 203, 231
AQUALANCE LANCETS 30G
............................................ 82
aqueous vitamin d ................. 223
ARALAST NP...................... 176
236
ARAVA ................................ 161
ARIAL CHAMBER ................. 1
arsenic trioxide ....................... 31
arthritis pain relief .................. 71
artificial tears ........................ 134
ARZERRA ............................. 31
ASCENIV............................... 40
ASCENSIA AUTODISC
CONTROL ......................... 82
ASCENSIA AUTODISC
CONTROLS ....................... 82
ASCENSIA ELITE CONTROL
............................................ 82
ASCENSIA ELITE
CONTROLS ....................... 82
ascorbic acid ......................... 219
asco-tabs-1000 .......................... 1
ASPARLAS ........................... 31
aspirin ................... 61, 63, 74, 77
aspirin 81 .............. 60, 62, 74, 77
aspirin adult .......... 60, 62, 74, 77
aspirin adult low dose 60, 62, 74,
77
aspirin adult low strength 60, 62,
74, 77
aspirin ec .............. 60, 62, 74, 77
aspirin ec low dose60, 62, 74, 77
aspirin ec low strength..... 60, 62,
74, 77
aspirin low dose ... 60, 61, 62, 74,
77
aspirin low dose adult 60, 62, 74,
77
aspirin low strength ... 61, 63, 74,
77
aspirin regimen low dose adult
.......................... 61, 63, 74, 77
ASPIR-LOW ........ 61, 63, 74, 77
ASSESS FULL RANGE PEAK
METER .............................. 82
ASSESS LOW RANGE PEAK
METER .............................. 82
ASSESS PEAK FLOW METER
............................................ 82
ASSURE 3 CONTROL .......... 82
ASSURE 4 CONTROL LEVEL
1 & 2 ................................... 83
assure comfort lancets 28g ..... 83
ASSURE DOSE CONTROL . 83
ASSURE DOSE NORM/HIGH
CONTROL ......................... 83
ASSURE HAEMOLANCE
PLUS HIGH ....................... 83
ASSURE HAEMOLANCE
PLUS LOW ........................ 83
ASSURE HAEMOLANCE
PLUS MICRO .................... 83
ASSURE HAEMOLANCE
PLUS NORMAL ................ 83
ASSURE HAEMOLANCE
PLUS PED .......................... 83
ASSURE II CONTROL ........... 1
ASSURE II CONTROL LEVEL
1 & 2 ..................................... 1
ASSURE LANCE LANCETS 83
ASSURE LANCE LANCETS
21G ..................................... 83
ASSURE LANCE PLUS
SAFETY 25G ..................... 83
ASSURE LANCE PLUS
SAFETY 30G ..................... 83
ASSURE LANCE SAFETY
LANCET 28G .................... 83
ASSURE LANCETS .............. 83
ASSURE PRISM CONTROL
LEVEL 1&2 ....................... 83
ASSURE PRO CONTROL
LEVEL 1 & 2 ..................... 83
ASTHMA CHECK METER-
ZONE SYSTEM................. 83
ASTHMAMENTOR .............. 83
AT LAST CONTROL .............. 1
AT LAST LANCETS ............... 1
ATGAM ............................... 161
ATLAS COLOR
CONDOM/SPERMICIDE ... 2
ATLAS COLOR
LUBRICATED CONDOM .. 2
ATLAS LUB
CONDOM/SPERMICIDE ... 2
ATLAS LUBRICATED
CONDOM ............................ 2
atovaquone.............................. 27
atropine sulfate ..................... 136
AURORA HEALTHCARE
LANCETS .......................... 83
aurora lancet super thin 30g ... 83
aurora lancet thin 23g ............. 83
AUTO-LANCET ...................... 2
AUTO-LANCET MINI .......... 83
auto-lancets ............................... 2
AUTOLET LANCING
DEVICE ............................. 83
AUTOLET MINI.................... 83
AUTOLET PLUS ................... 83
AVASTIN............................... 31
AYR ...................................... 134
azacitidine ............................... 31
AZEDRA DOSIMETRIC ..... 31,
118, 166
AZEDRA THERAPEUTIC... 31,
118, 166
B b complex ............................. 203
b complex formula 1 ............. 203
b complex vitamins............... 203
b complex vitamins plus ........... 2
b complex-c-folic acid .. 203, 219
b complex-vitamin b12 ............. 2
b-1 ......................................... 203
b-100 ..................................... 203
b-100 complex ...................... 203
b-12 ....................................... 203
b-12 tr ................................... 203
b2 .......................................... 203
b-2 ......................................... 203
b-2 ......................................... 203
b-50 ........................................... 2
b-50 complex ........................ 203
B-50 FORMULA...................... 2
b-6 ................................. 203, 204
b6 natural .............................. 203
BABY AYR SALINE .......... 134
baby darlings ped electrolyte 122
baclofen .................................. 48
BACMIN ................ 51, 183, 204
BACTRIM .............................. 30
BACTRIM DS ........................ 30
balance b-100........................ 204
balance b-50.......................... 204
balanced b-100...................... 204
balanced b-50........................ 204
balanced b-50 complex ......... 204
BANOPHEN ............ 23, 25, 174
BAQSIMI ONE PACK 154, 158
BAQSIMI TWO PACK 154, 158
BARDIA BULB IRRIGATION
SYRINGE ........................... 83
237
BARDIA PISTON
IRRIGATION SYR ............ 83
bariatric multivitamins/iron ... 51,
183, 204, 231
BAVENCIO ........................... 31
BAYER BREEZE 2 CONTROL
...................................... 83, 84
BAYER MICROLET 2
LANCING DEVIC ............. 84
BAYER MICROLET
LANCETS .......................... 84
b-caro-t ..................................... 2
b-complex ............................. 204
b-complex balanced.............. 204
b-complex/folic acid/vitamin c
.................................. 204, 219
b-complex/vitamin c ..... 204, 219
b-complex-c .................. 204, 219
BD ALLERGY SYRINGE .... 84
BD ASSURE BPM/AUTO
ARM CUFF .......................... 2
BD ASSURE BPM/AUTO
WRIST CUFF ...................... 2
BD ASSURE BPM/DELUXE
ARM CUFF .......................... 2
BD ASSURE BPM/MANUAL
ARM CUFF .......................... 2
BD ASSURE BPM/PORT
WRISTWATCH ................... 2
BD AUTOSHIELD DUO ...... 84
BD ECLIPSE SYRINGE ....... 84
BD GENIE ............................... 2
BD GENIE LANCETS ............ 2
BD HYPODERMIC NEEDLE
............................................ 84
BD INSULIN SYRINGE U/F 84
BD INSULIN SYRINGE U/F
1/2UNIT ............................. 84
BD INSULIN SYRINGE U-500
............................................ 84
BD KLATSKIN BIOPSY
NEEDLE .............................. 2
BD LANCET DEVICE .......... 84
BD LANCET ULTRAFINE
30G ..................................... 84
BD LANCET ULTRAFINE
33G ..................................... 84
BD LUER-LOCK SYRINGE .. 2
BD LUER-LOK SYRINGE ... 84
BD MICROTAINER
LANCETS .......................... 85
BD MULTIFIT REUSABLE
SYRINGE ........................... 85
BD OSGOOD BIOPSY
NEEDLE .............................. 2
BD PEN NEEDLE MICRO U/F
............................................ 85
BD PEN NEEDLE MINI U/F 85
BD PEN NEEDLE NANO 2ND
GEN .................................... 85
BD PEN NEEDLE NANO U/F
............................................ 85
BD PEN NEEDLE ORIGINAL
U/F ...................................... 85
BD PEN NEEDLE SHORT U/F
............................................ 85
BD PLASTIPAK SYRINGES
ALLERGY ........................... 2
BD ROSENTHAL BIOPSY
NEEDLE .............................. 2
BD SAFETYGLIDE
ALLERGY SYRINGE ....... 85
BD SAFETYGLIDE NEEDLE
............................................ 85
BD SAFETYGLIDE
SHIELDED NEEDLE ........ 85
BD SAFETYGLIDE
SYRINGE/NEEDLE .......... 85
BD SWAB SINGLE USE
REGULAR ....................... 178
BD SWABS SINGLE USE
BUTTERFLY ....................... 2
BD SYRINGE ........................ 85
BD SYRINGE 50-60 ML ....... 85
BD SYRINGE BLUNT
CANNULA 17G................. 85
BD SYRINGE CATH TIP ..... 85
BD SYRINGE DUAL
CANNULA ........................ 85
BD SYRINGE LUER SLIP TIP
............................................ 85
BD SYRINGE LUER-LOK .. 85,
86
BD SYRINGE SLIP TIP ........ 86
BD TB SYRINGE .................. 86
BD TUBERCULIN SYRINGE
............................................ 86
BD ULTRA-FINE LANCETS . 2
BD VEO INSULIN SYR U/F
1/2UNIT ............................. 86
BD VEO INSULIN SYRINGE
U/F ...................................... 86
BD YALE REUSABLE TB
SYRINGE ............................. 2
bec/zinc ..................................... 2
bee zee .................................. 183
BELEODAQ........................... 31
BELRAPZO ........................... 31
bendamustine hcl .................... 32
BENDEKA ............................. 32
BENLYSTA ................. 161, 162
benzonatate ........................... 167
BESPONSA ............................ 32
beta carotene ......................... 202
bethanechol chloride ............... 49
BICNU .................................... 32
BIG 100 .................................... 2
BILTRICIDE .......................... 27
BIO-35 GLUTEN-FREE ....... 51,
122, 183, 204
biocal ............ 122, 204, 223, 231
biocel ............................ 183, 204
BION TEARS PF ................. 134
biosupp ................................. 183
BIOTECT PLUS ........ 2, 51, 183
biotin ..................................... 204
biotin 5000 ............................ 204
biotin forte ................................ 2
biotin maximum strength ...... 204
biotin plus/calcium/vit d3 ..... 183
BISAC-EVAC ...................... 145
bisacodyl ............................... 145
bisacodyl ec .......................... 145
biscolax ................................. 145
bismatrol ....................... 138, 142
bismatrol maximum strength
.................................. 138, 142
BIVIGAM............................... 41
bl glucose .................................. 2
bl lancets ................................... 2
bl lancets super thin .................. 2
bl lancets thin ............................ 3
bleomycin sulfate.................... 32
BLINCYTO ............................ 32
blood press monitor/m-l cuff .. 86
blood pressure ........................... 3
blood pressure kit ............... 3, 86
blood pressure monitor ........... 86
238
BLOOD PRESSURE
MONITOR 3 ...................... 86
BLOOD PRESSURE
MONITOR 7 ...................... 86
blood pressure monitor automat
............................................ 86
blood pressure monitor deluxe . 3
blood pressure monitor/arm ... 86
blood pressure monitor/l cuff . 86
blood pressure monitor/m cuff86
blood pressure monitor/prm arm
.............................................. 3
blood pressure monitor/s cuff . 86
blood pressure monitor/wrist ... 3,
86
blood pressure unit ................. 86
body/hair/skin/nails .............. 183
BOOSTRIX ............................ 44
bortezomib .............................. 32
bp monitor-stethoscope ............ 3
b-plex ............................ 204, 219
b-plex plus ...................... 51, 183
BPROTECTED MULTI-VITE
.................................... 51, 183
BRAVELLE ................. 154, 155
breathe ease humidifier ............ 3
breathe ease large ..................... 3
breathe ease medium ................ 3
breathe ease small..................... 3
BREATHERITE..................... 86
BREATHERITE COLL
SPACER ADULT .............. 87
BREATHERITE COLL
SPACER CHILD ............... 87
BREATHERITE COLL
SPACER INFANT ............. 87
BREATHERITE RIGID
SPACER/MASK ................ 87
BREATHERITE SPACER
NEONATE ......................... 87
BREATHERITE SPACER
SMALL CHILD ................. 87
BREATHERITE/LARGE
MASK ................................ 87
BREATHERITE/MEDIUM
MASK ................................ 87
BREATHERITE/SMALL
MASK ................................ 87
BRINEURA ......................... 132
BROMFED DM .... 46, 166, 167,
174
BRONCHO SALINE ............... 3
brotapp dm ...... 46, 166, 167, 174
bullseye mini safety lancets .... 87
BULLSEYE SAFETY
LANCETS ............................ 3
bumetanide ..................... 67, 120
busulfan .................................. 32
BUSULFEX ........................... 32
C c 1000 ................................... 219
c 250 ..................................... 219
c 500 ..................................... 219
c 500/rose hips ...................... 219
c-1000 ................................... 219
c-1000/rose hips ................... 219
c-250 ..................................... 219
c-500 ..................................... 219
c-500/rose hips ..................... 219
cabergoline ............................. 76
CABLIVI ................................ 50
caffeine citrate .................. 76, 77
calcarb 600 ........................... 122
CALCET PLUS .............. 51, 183
CALCITRATE ............. 122, 223
calcium ............................. 3, 124
calcium + d ................... 122, 223
calcium + d3 ................. 122, 223
calcium 500 + d3 .......... 122, 223
calcium 500 +d ............. 122, 223
calcium 500+d .............. 122, 224
calcium 500+d3 ............ 122, 224
calcium 600 .......................... 122
calcium 600/vitamin d .. 122, 224
calcium 600+d plus minerals
.................................. 122, 224
calcium 600+d3 ............ 122, 224
calcium 600-d ............... 122, 224
calcium antacid ............. 122, 138
calcium antacid extra strength
.................................. 122, 138
calcium antacid ultra .... 123, 138
calcium antacid ultra max st 123,
138
calcium antacid ultra strength
.................................. 123, 138
calcium carbonate ................. 123
calcium carbonate antacid ... 123,
138, 224
calcium carbonate-vitamin d123,
224
calcium citrate .............. 123, 224
calcium citrate + ........... 123, 224
calcium citrate + d ........ 123, 224
calcium citrate + d3 ...... 123, 224
calcium citrate + d3 maximum
.................................. 123, 224
calcium citrate +d ......... 123, 224
calcium citrate maximum/vit d
.................................. 123, 224
calcium citrate petite/vit d ... 123,
224
calcium citrate+d3 ........ 123, 224
calcium citrate+d3 petites .... 123,
224
calcium citrate-vitamin d ..... 123,
224
calcium citrate-vitamin d3 ... 124,
224
calcium extra d3 ........... 124, 224
calcium gluconate ................. 124
calcium lactate ...................... 124
calcium pantothenate ............ 204
calcium-vitamin d ..... 3, 124, 224
calcium-vitamin d3 ....... 124, 225
CAL-GEST ANTACID 124, 138
CALTRATE 600 .................. 124
CAMPTOSAR ........................ 32
CARAFATE ......................... 152
CARBAGLU ........................ 119
CARDENZ ............................... 3
CARDIOCOM LANCING
DEVICE ............................... 3
careone advanced lancing dev 87
CAREONE GLUCOSE ............ 3
CAREONE LANCET 26G....... 3
CAREONE LANCET 30G....... 3
careone lancet thin 23g ........... 87
CAREONE LANCET ULTRA
THIN..................................... 3
careone lancet ultra thin 28g ... 87
CARESENS CONTROL A .... 87
CARESENS LANCETS ........... 3
CARETOUCH ALCOHOL
PREP................................. 178
CARETOUCH BP ARM
MONITOR ......................... 87
CARETOUCH BP WRIST
MONITOR ......................... 87
239
CARETOUCH
LANCING/EJECTOR ........ 87
CARETOUCH SAFETY
LANCETS .......................... 87
CARETOUCH SAFETY
LANCETS 26G .................. 87
CARETOUCH TWIST
LANCETS 28G .................. 87
CARETOUCH TWIST
LANCETS 30G .................. 87
CARETOUCH TWIST
LANCETS 33G .................. 87
CARIMUNE NF .................... 41
carmustine .............................. 32
CARNITOR ......................... 162
CARNITOR SF .................... 162
caroguard .................................. 3
CAROMEGA ........................... 3
CARRAVITE ....................... 183
CATHFLO ACTIVASE . 63, 132
caution condoms ....................... 3
caution condoms/spermicide .... 3
c-chewable ............................ 219
CELLCEPT INTRAVENOUS
.......................................... 162
CEMILL ............................... 219
centamin ......................... 51, 184
centavite ................................... 3
centavite a-z complete-mineral
.................................... 51, 184
central-vite ...................... 51, 184
centravites....................... 51, 184
centravites 50 plus ........ 184, 204
centravites adults ... 51, 184, 204,
231
CENTRUM ..... 51, 52, 184, 205,
231
CENTRUM ADULTS... 51, 184,
204
CENTRUM CARDIO .......... 184
CENTRUM FLAVOR BURST
ADULT .................... 184, 204
CENTRUM FLAVOR BURST
KIDS................................. 184
CENTRUM MEN .. 51, 184, 204
CENTRUM MULTIGUMMIES
.................................. 184, 204
CENTRUM PERFORMANCE
............................ 51, 184, 204
CENTRUM SILVER ... 184, 205
CENTRUM SILVER 50+MEN
.................................. 184, 204
CENTRUM SILVER
50+WOMEN ...... 51, 184, 205
CENTRUM SILVER ADULT
50+ ............................ 184, 205
CENTRUM SILVER ULTRA
WOMENS .......... 51, 184, 205
CENTRUM SPECIALIST
ENERGY .... 51, 184, 205, 231
CENTRUM SPECIALIST
HEART ............................. 184
CENTRUM SPECIALIST
VISION .................... 184, 205
CENTRUM ULTRA MENS . 52,
184, 205
CENTRUM ULTRA WOMENS
............................ 52, 184, 205
century ............................ 52, 185
century mature ...................... 184
CENTURY SENIOR ............ 185
CERALYTE 50 ........................ 3
CERALYTE 70 .................... 124
CERASPORT ....................... 124
CERASPORT EX1............... 124
CEROVITE ADVANCED
FORMULA ........ 52, 185, 205
CEROVITE SENIOR ........... 185
cerovite silver ........................... 3
certa plus................. 52, 185, 205
certa plus senior .................... 185
certagen .................. 52, 185, 205
CERTA-VITE .......................... 3
CERTAVITE
SENIOR/ANTIOXIDANT
.................................. 185, 205
CERTAVITE/ANTIOXIDANT
S .......................... 52, 185, 205
CHEMET...................... 152, 158
CHEMSTRIP 10/SG ............ 118
CHEMSTRIP K .................... 118
CHEMSTRIP UGK .............. 118
cheratussin ac ......... 76, 167, 170
chewable vitamin c ............... 219
chewable vite childrens ........ 185
chew-c ...................................... 3
childrens acetaminophen .... 3, 71
childrens aspirin low strength 61,
63, 74, 77
childrens mucus relief expect
.......................................... 170
childrens silapap ..................... 71
chloramphenicol sod succinate
............................................ 28
chlorhexidine gluconate........ 133
chlorothiazide ................. 68, 131
chlorthalidone ................. 69, 131
chocolated laxative ............... 145
choice-tabs ............ 185, 205, 225
choline-mag trisalicylate ........ 77
CHOOZ .................................... 3
chorionic gonadotropin . 154, 155
CHROMAGEN ...................... 52
CHROMAGEN FA ................ 52
CHROMAGEN FORTE ......... 52
cidofovir ................................. 29
cilostazol ........................... 61, 68
cisplatin................................... 32
CITRACAL CALCIUM
GUMMIES ............... 124, 225
CITRACAL MAXIMUM ... 124,
225
CITRACAL MAXIMUM PLUS
.................................. 124, 225
CITRACAL
PETITES/VITAMIN D ... 124,
225
citrus calcium +d .......... 124, 225
citrus calcium/vitamin d124, 225
CLASS ACT LUBRICATED .. 4
CLEANLET LANCETS 28G... 4
CLEARLAX ......................... 145
CLEOCIN ............................... 29
CLEVER CHEK LANCETS .. 87
CLEVER CHOICE BP
MONITOR/ARM ............... 87
CLEVER CHOICE BP
MONITOR/WRIST ............ 87
CLEVER CHOICE GLUCOSE
CONTROL ......................... 87
CLEVER CHOICE HOLDING
CHAMBER ........................ 87
CLEVER CHOICE
HUMIDIFIER....................... 4
CLEVER CHOICE LANCETS
21G ....................................... 4
CLEVER CHOICE LANCETS
23G ..................................... 87
240
CLEVER CHOICE LANCETS
28G ..................................... 87
CLEVER CHOICE PEAK
FLOW METER .................. 87
clindamycin hcl ...................... 29
clindamycin palmitate hcl ...... 29
CLOSERCARE ........................ 4
COAGUCHEK LANCETS .... 88
cobal-1000 ................................ 4
COLACE .............................. 145
COLACE 2-IN-1 .................. 145
COLACE CLEAR ................ 145
COLEMAN 100 MAX
CONTINUOUS SPR ........ 180
COLEMAN 100 MAX INSECT
REPEL .............................. 180
COLEMAN INSECT REPEL
HIGH&DRY .................... 180
COLEMAN INSECT REPEL
SPORTSMEN .................. 180
colistimethate sodium (cba) ... 30
COLY-MYCIN M .................. 30
COLYTE WITH FLAVOR
PACKS ............................. 145
comfort assured lancets 28g ... 88
comfort assured lancets 33g ... 88
comfort lancets ....................... 88
COMPACT SPACE
CHAMBER ........................ 88
COMPACT SPACE
CHAMBER/LG MASK ..... 88
COMPACT SPACE
CHAMBER/MED MASK.. 88
COMPACT SPACE
CHAMBER/SM MASK ..... 88
companion .................... 185, 205
COMPANION MULTI MEN
.................................. 185, 205
COMPETE ..................... 52, 185
complete ......................... 52, 185
complete allergy medicine .... 23,
25, 174
complete multivitamin/mineral
.................................... 52, 185
complete senior .................... 185
condoms ................................... 4
CONGESTAC ........ 46, 166, 170
constulose ............................. 119
CONTOUR CONTROL ......... 88
CONTOUR NEXT CONTROL
............................................ 88
control ..................................... 88
control syringe disposable ...... 88
COOL CONTROL A ............. 88
COOL CONTROL B.............. 88
cool mist humidifier ............... 88
cool mist humidifier 0.8 gal ... 88
cool mist humidifier 1 gallon . 88
cool mist humidifier 1.2 gal ... 88
cool mist humidifier 1.3 gal ... 88
cool mist humidifier 2 gallon ... 4
corn & callus remover .......... 178
CORNWALL CONTROL
SYRINGE ........................... 88
CORNWALL DISPENSING
SYRINGE ............................. 4
CORVITE FREE .......... 185, 205
COSMEGEN .......................... 32
cough/chest congestion dm . 167,
170
CRESEMBA .......................... 28
crono syringe ............................ 4
CRYSVITA .......................... 120
CUBICIN................................ 28
CUBICIN RF .......................... 28
CUPRIMINE ................ 152, 161
CURITY ALCOHOL PREPS
.......................................... 178
CURITY ALCOHOL SWABS 4
CUTTER BACKWOODS ... 180,
181
CUTTER BACKWOODS DRY
.................................. 180, 181
CUTTER SKINSATIONS .. 180,
181
CUVITRU .............................. 41
cvs advanced automatic bp ..... 88
cvs advanced bp monitor ........ 88
cvs alcohol prep pads ........... 178
cvs alcohol prep swabs ......... 178
cvs alcohol swabs ................. 178
cvs antacid .................... 124, 138
cvs auto pressure monitor ......... 4
cvs b-12 ................................ 205
cvs b6 .................................... 205
cvs b-6 .................................. 205
CVS BALANCED B-100 .... 205
CVS BALANCED B50 ........ 205
cvs b-carotene ....................... 202
cvs beta carotene................... 202
cvs biotin .............................. 205
cvs biotin high potency ......... 205
cvs blood pressure monitor ..... 88
cvs calcium ........................... 124
cvs calcium 600 + d/minerals
.................................. 124, 225
cvs calcium citrate +d ... 124, 225
cvs calcium citrate +d3 mini 124,
225
cvs child saline spray/drops .. 134
cvs chocolate laxative pieces 145
cvs cool mist humidifer .......... 88
cvs d3 .................................... 225
cvs daily energy .................... 185
cvs daily gummies ........ 185, 205
cvs daily multiple ................. 185
cvs daily multiple fe/ca/zn ..... 52,
185
cvs daily multiple for men ... 185,
206, 231
cvs daily multiple for men 50+
.................................. 185, 206
cvs daily multiple for women 52,
124, 185, 206
cvs daily multiple plus iron ... 52,
185
cvs daily multiple plus min... 185
cvs daily multiple women 50+
.................. 124, 185, 206, 231
cvs daily teen .......... 52, 185, 206
cvs e ...................................... 229
cvs e oil ................................. 229
cvs electrolyte solution ......... 124
cvs eye .................................... 89
cvs eye health & lutein ......... 185
cvs folic acid ......................... 206
cvs glucose............................ 119
cvs hair/skin/nails ................. 186
cvs insect repellent ....... 180, 181
cvs isopropyl alcohol wipes .. 178
CVS KETONE CARE .......... 118
cvs lancets 21g ........................ 89
cvs lancets micro thin 33g ...... 89
cvs lancets original ................. 89
cvs lancets thin ....................... 89
cvs lancets thin 26g ................ 89
cvs lancets ultra thin 30g ........ 89
cvs lancets ultra-thin 30g ........ 89
cvs lancing device................... 89
241
cvs laxative pills ................... 145
cvs magnesium oxide ........... 138
cvs manual blood pressure ..... 89
cvs mega multi ..................... 186
cvs melatonin................ 162, 163
cvs melatonin gummies ........ 162
cvs mens daily gummies ..... 186,
206
cvs one daily essential .. 186, 206
cvs one daily mens 50+ adv 186,
206, 231
cvs one daily womens formula
.................... 52, 186, 206, 231
cvs oyster shell calcium........ 125
cvs ped electrolyte freeze pop
.......................................... 125
cvs pediatric electrolyte ........ 125
cvs prep ................................ 178
cvs saline nasal spray ........... 134
cvs saline nose spray ............ 134
cvs semi-auto pressure monitor 4
cvs senna .............................. 145
cvs senna-c ........................... 145
cvs senna-extra ..................... 145
cvs series 100 blood pressure . 89
cvs series 400 blood pressure . 89
cvs series 400w blood pressure
............................................ 89
cvs series 600 blood pressure . 89
cvs series 800 blood pressure ... 4
cvs slow release iron .............. 52
cvs soft glucose .................... 119
cvs spectravite ................ 53, 186
cvs spectravite adult 50+ ..... 186,
206
cvs spectravite adult gummies
.................................. 186, 206
cvs spectravite advanced52, 186,
206
cvs spectravite cardio health 186
cvs spectravite energy ... 52, 186,
206
cvs spectravite naturalized .... 52,
186
cvs spectravite performance .. 52,
186
cvs spectravite plus......... 53, 186
cvs spectravite probiotic 53, 125,
186, 206
cvs spectravite senior ... 186, 206
cvs spectravite ultra men 50+
.................................. 186, 206
cvs spectravite ultra mens...... 53,
186, 206
cvs spectravite ultra women .. 53,
186, 206
cvs spectravite womens senior
............................ 53, 186, 206
cvs stress formula ................. 186
cvs stress formula/zinc ......... 186
cvs total home insect repel ... 181
cvs ultra thin lancets ............... 89
cvs vaporizer warm steam ...... 89
cvs vision formula ................ 186
cvs vitamin a ..................... 4, 202
cvs vitamin b/c.............. 206, 219
cvs vitamin b12 .................... 206
cvs vitamin b-12 ................... 206
cvs vitamin b-12 ................... 206
cvs vitamin b-12 ................... 206
cvs vitamin b-12 ................... 206
cvs vitamin b-2 ..................... 206
cvs vitamin b-6 ..................... 206
cvs vitamin c ................. 219, 220
cvs vitamin c-acerola ............ 220
cvs vitamin c-rose hips ......... 220
cvs vitamin d3 ...................... 225
cvs vitamin e ......................... 229
cvs womens active daily 53, 125,
186, 206
cvs womens daily gummies . 186,
206
cyanocobalamin ............ 206, 207
CYCLOGYL ........................ 136
cyclopentolate hcl ................. 136
cyclophosphamide .......... 32, 162
cyproheptadine hcl ... 24, 25, 174
CYRAMZA ............................ 32
CYSTADANE ...................... 163
CYSTARAN ........................ 134
cytarabine ............................... 33
cytarabine (pf) .................. 32, 33
CYTOGAM ............................ 41
CYTOTEC............................ 152
CYTOVENE .......................... 29
cytra-2 ................................... 119
D d 1000 ................................... 225
d 10000 ................................. 225
d2000 ultra strength .............. 225
d3 high potency .................... 225
d3-1000 ................................. 225
d-5000 ................................... 225
dacarbazine ............................. 33
DACOGEN............................. 33
dactinomycin .......................... 33
daily combo multi vitamins ... 53,
186
daily combo multivits/calcium
.................................... 53, 186
daily diet support .................. 186
daily multi ............... 53, 186, 207
daily multi vitamin/minerals ..... 4
daily multiple vitamins ......... 186
daily multiple vitamins/iron .. 53,
186, 207
daily multiple vitamins/min .. 186
daily multiple weight loss ...... 53,
186
daily multivitamin 187, 207, 232
daily value multivitamin ....... 187
daily vitamin ......................... 187
daily vitamin formula ........... 187
daily vitamin formula+iron ... 53,
187, 207
daily vitamin formula+minerals
.......................................... 187
daily vitamins ....................... 187
daily vitamins for women ......... 4
daily vite ............................... 187
daily vite multivitamin/iron ... 53,
187
daily vites.............................. 187
daily vites/iron ................ 53, 187
daily-vite ............................... 187
daily-vite/iron/beta-carotene.. 53,
187
DALVANCE .......................... 28
danazol .................................. 152
dapsone ................................... 27
daptomycin ............................. 28
DARAPRIM ........................... 27
DARZALEX........................... 33
daunorubicin hcl ..................... 33
dd glucose ................................. 4
dd lancets .................................. 4
dd thin lancets ........................... 4
DDAVP .......................... 50, 156
DDAVP RHINAL TUBE ...... 50,
156
242
de glucose ................................. 4
DE LANCETS.......................... 4
DE THIN LANCETS ............... 4
DECARA ............................. 225
decitabine ............................... 33
DECUBI-VITE..... 187, 207, 220
deep sea nasal spray ............. 134
dekas bariatric 53, 187, 207, 232
dekas essential ..... 187, 202, 225,
229, 232
dekas plus ............. 187, 207, 232
DEMADEX ............ 67, 120, 121
DEMSER .............................. 163
DENTA 5000 PLUS............. 159
DENTAGEL......................... 159
DEPEN TITRATABS .. 152, 161
desmopressin ace spray refrig 50,
156
desmopressin acetate ...... 51, 156
DEX4 QUICK DISSOLVE
GLUCOSE ....................... 119
dexamethasone sod phosphate pf
.......................................... 152
dexamethasone sodium
phosphate .......................... 152
dexrazoxane hcl .................... 165
dextromethorphan-guaifenesin
.................................. 167, 170
DHS SAL ............................. 178
diabetes health formula 187, 207
diabetic siltussin das-na ........ 170
diabetic siltussin-dm ..... 167, 170
DIABEVITE............................. 4
dialyvite 800/ultra d .... 207, 220,
225
DIAMOX SEQUELS .... 65, 120,
133
DIASENSE MULTIVITAMIN 4
DIASTAR EASY TEST II
LANCETS ............................ 4
DIASTAR EASY TEST
LANCETS ............................ 4
DIASTIX .............................. 118
diathrive glucose control soln .. 4
diathrive lancet ultra thin 30..... 4
diathrive lancets........................ 4
diathrive lancing device ........... 4
diatrue control level 1 ............. 89
diatrue control level 2 ............. 89
diatrue control level 3 ............. 89
DIBENZYLINE ............... 49, 67
dibucaine (perianal) .............. 177
dicyclomine hcl ...................... 48
DIGITEK .......................... 64, 65
DIGOX ............................. 64, 65
digoxin .............................. 64, 65
diocto .................................... 145
diphenhist ................. 23, 25, 174
diphenhydramine hcl 23, 25, 174
diphenhydramine hcl childrens 4
diphenoxylate-atropine .. 48, 142,
167
disopyramide phosphate ......... 65
disulfiram...................... 157, 158
DIURIL .......................... 68, 131
DOCEFREZ ........................... 33
docetaxel ................................. 33
docetaxel (non-alcohol) .......... 33
docqlace ................................ 145
docu ...................................... 145
docusate sodium ................... 145
DOCUSIL ............................. 146
DOCUSOL MINI ................. 146
DOK ..................................... 146
DOK PLUS........................... 146
DOXIL.................................... 33
doxorubicin hcl ....................... 33
doxorubicin hcl liposomal ...... 33
dr glucose ................................. 4
dr lancets................................... 4
dr thin lancets ........................... 4
droperidol ............................... 75
DROPLET LANCETS ULTRA
THIN 30G........................... 89
DROPLET LANCING DEVICE
............................................ 89
DROXIA ................................ 33
drug mart lancets thin 26g ...... 89
drug mart lancets ultra thin ..... 89
DRUG MART LANCING
DEVICE ............................. 89
DRUG MART ON-THE-GO
LANCET 30G .................... 89
DRUG MART UNILET
LANCETS 28G .................. 89
DRUG MART UNILET
LANCETS 30G .................. 89
DRUG MART UNILET
LANCETS 33G .................. 89
dual ultrasonic humidifier ........ 4
duane reade lancet altern site .. 89
duane reade lancet super thin . 89
duane reade lancet ultra thin ... 89
ducodyl ................................. 146
DUO-CARE CONTROL
SOLUTION .......................... 5
DURAVITE .............................. 5
DUREX EXTRA SENSITIVE . 5
DUREX REALFEEL ............. 79
D-VI-SOL ............................. 226
DYAZIDE .............. 68, 121, 131
dye-free allergy relief23, 25, 174
E e 1000 ................................... 229
e 400 blended ........................ 229
e1000 .................................... 229
e200 ...................................... 229
e-200 ..................................... 229
e400 ...................................... 229
e-400 ..................................... 229
e400 mixed ........................... 229
e-400-clear ................................ 5
e-400-mixed .............................. 5
ear drops ............................... 134
ear drops earwax aid ............. 133
earwax removal kit ............... 134
earwax treatment drops......... 134
EASIVENT............................. 89
EASIVENT MASK LARGE .. 89
EASIVENT MASK MEDIUM
............................................ 89
EASIVENT MASK SMALL . 89
easy check control ............ 89, 90
easy comfort alcohol pads .... 178
easy comfort lancets ............... 90
easy comfort lancets twist top 90
EASY GLIDE LUER LOCK
SYRINGE ........................... 90
easy mini eject lancing device 90
easy mini lancing device ........ 90
easy plus control ....................... 5
easy plus ii control .................. 90
EASY STEP CONTROL ....... 90
easy talk control .................. 5, 90
EASY TOUCH ALCOHOL
PREP MEDIUM ............... 178
EASY TOUCH ALLERGY
SYRINGE ........................... 90
EASY TOUCH CONTROL
HIGH & LOW .................... 90
243
EASY TOUCH FLIPLOCK
SAFETY SYR .............. 90, 91
EASY TOUCH LANCETS 21G
............................................ 91
EASY TOUCH LANCETS 23G
............................................ 91
EASY TOUCH LANCETS 26G
............................................ 91
EASY TOUCH LANCETS 28G
............................................ 91
EASY TOUCH LANCETS
28G/TWIST ........................ 91
EASY TOUCH LANCETS 30G
............................................ 91
EASY TOUCH LANCETS 32G
............................................ 91
EASY TOUCH LANCETS
32G/TWIST ........................ 91
EASY TOUCH LANCING
DEVICE ............................. 91
EASY TOUCH SAFETY
LANCETS 21G .................. 91
EASY TOUCH SAFETY
LANCETS 23G .................. 91
EASY TOUCH SAFETY
LANCETS 26G .................. 91
EASY TOUCH SAFETY
LANCETS 28G .................. 91
EASY TOUCH
SHEATHLOCK SYRINGE
............................................ 91
EASY TOUCH TB FLIPLOCK
SYRINGE........................... 92
EASY TOUCH TB
SHEATHLOCK SYR ........ 92
easy trak control ................. 5, 92
EASY TWIST & CAP
LANCETS .......................... 92
EASYGLUCO CONTROL ...... 5
EASYGLUCO PLUS LEVEL 1
............................................ 92
EASYMAX 15 LEVEL 1
CONTROL ......................... 92
EASYMAX 15 LEVEL 1-2
CONTROL ........................... 5
EASYMAX 15 LEVEL 2
CONTROL ......................... 92
EASYMAX CONTROL ........ 92
EASYMAX CONTROL
NORMAL/LOW .................. 5
EASYTEST II LANCETS ....... 5
EASYTEST LANCETS ........... 5
eck glucose ............................... 5
ECLIPSE CONTROL ............ 92
ECONTRA EZ ..................... 153
ECONTRA ONE-STEP ....... 153
ECPIRIN .............. 61, 63, 74, 77
ed bron gp ....................... 47, 170
ed chlorped jr ............ 25, 26, 174
ed-apap ................................... 71
EGRIFTA ............................. 157
EGRIFTA SV ....................... 157
ELAPRASE .......................... 132
ELDERTONIC ..................... 207
element compact control 2 ..... 92
element compact control 3 ..... 92
ELEMENT CONTROL ......... 92
ELEMENT PLUS CONTROL
............................................ 92
ELEXA NATURAL FEEL ...... 5
ELEXA STIMULATING......... 5
ELEXA ULTRA SENSITIVE . 5
ELITEK ................................ 132
ELLENCE .............................. 34
ELMIRON ............................ 165
ELON MATRIX 5000
COMPLETE ..... 163, 187, 207
ELON MATRIX COMPLETE
.................................. 187, 207
ELZONRIS ............................. 34
e-max-1000 ............................... 5
EMBRACE CONTROL ......... 93
EMBRACE EVO CONTROL
LEVEL 1 ............................ 93
EMBRACE EVO CONTROL
LEVEL 2 ............................ 93
EMBRACE GLUCOSE
CONTROL ......................... 93
EMBRACE LANCETS ULTRA
THIN 30G........................... 93
EMBRACE PRO GLUCOSE
CONTROL ......................... 93
EMBRACE TALK GLUCOSE
CONTROL ......................... 93
EMERGEN-C VITAMIN C 187,
220
EMPLICITI ............................ 34
EMVERM .............................. 27
ENDARI ....................... 151, 163
ENDUR-C ............................ 220
enema .................................... 146
enema mineral oil ................. 146
enema ready-to-use ............... 146
ENEMEEZ MINI ................. 146
ENFALYTE ......................... 125
ENFAMIL ENFALYTE ....... 125
ENGERIX-B........................... 45
ENHERTU ............................. 34
ENVIRO-STRESS ................... 5
ENVISION CONTROL ......... 93
e-oil ....................................... 229
epidural needle.......................... 5
epidural needle tw..................... 5
EPIFLUR .............................. 159
EPIKLOR ............................. 125
EPILOR SYRINGE .................. 5
epirubicin hcl .......................... 34
epoprostenol sodium ....... 69, 176
eq antacid .................................. 5
eq aspirin .............. 61, 63, 74, 77
eq calcium citrate+d ..... 125, 226
eq complete multivit adult 50+
.................................. 187, 207
eq complete multivitamin-adult
............................ 53, 187, 207
eq laxative ................................. 5
eq laxative maximum strength
.......................................... 146
eq natural laxative................. 146
eq natural vegetable laxative 146
eq one daily mens 50+ . 187, 207,
232
eq one daily mens health ..... 187,
207, 232
eq one daily womens health .. 53,
125, 187, 207
eq saline nasal spray ............. 134
eq slow-release iron ................ 53
eq vegetable laxative ............ 146
eql alcohol swabs ...................... 5
eql antacid ..................... 125, 138
eql b complex ............... 207, 220
eql b-12 ................................. 207
eql b-6 ................................... 207
eql beta carotene ................... 202
eql blood pressure monitor ..... 93
eql calcium citrate/vitamin d125,
226
eql calcium citrate/vitamin d3
.................................. 125, 226
244
EQL CENTRAL-VITE 187, 207
EQL CENTRAL-VITE
PERFORMANCE ...... 53, 187
EQL CENTRAL-VITE
SELECT ..................... 53, 187
eql century .................... 188, 207
eql century cardio health ...... 187
eql century mature 188, 207, 232
eql century mature adults 50+
.......................... 188, 207, 232
eql century mens.... 53, 125, 188,
207, 232
eql color lancets 21g ............... 93
eql color lancets micro 33g .... 93
eql folic acid ......................... 207
eql iron supplement therapy ... 53
eql laxative ........................... 146
eql laxative maximum strength
.......................................... 146
eql magnesium...................... 138
eql one daily 50 plus............. 188
eql one daily diet support ...... 53,
125, 188, 207
eql one daily dieters support.. 53,
188
eql one daily essential .......... 188
eql one daily maximum .. 53, 188
eql one daily mens 50+ advance
.......................... 188, 207, 232
eql one daily mens health ..... 188
eql one daily womens ..... 53, 188
eql one daily womens 50+ adv
.................. 125, 188, 207, 232
eql pediatric electrolyte ........ 125
eql saline nasal spray ............ 134
eql senna laxative ................. 146
eql slow release iron ............... 53
eql stress b-complex c/zinc . 207,
220, 229
eql super b complex/vitamin c
.................................. 207, 220
eql super thin lancets 30g ....... 93
eql thin lancets 26g ................. 93
eql ultimate womens century. 53,
188, 207
eql vision formula................. 188
eql vitamin b-12 ................... 207
eql vitamin b-12 tr ................ 208
eql vitamin c ......................... 220
eql vitamin c/rose hips.......... 220
eql vitamin d3 ....................... 226
eql vitamin e ...... 23, 47, 71, 167,
174, 229
EQUALYTE ............................. 6
ERBITUX ............................... 34
ergocalciferol ........................ 226
ertapenem sodium................... 28
ERWINAZE ........................... 34
ESSENTIA ............. 53, 188, 208
essential balance ............. 53, 188
essential one daily multivit .. 188,
208
essentra wipes 9x9 .................... 6
ESTER-E .............................. 229
estradiol ........................ 153, 154
ethambutol hcl ........................ 27
ETHYOL .............................. 165
ETOPOPHOS ......................... 34
etoposide ................................. 34
EVENCARE CONTROL
LOW/HIGH ........................ 93
EVENCARE G2 LOW/HIGH
CONTROL ......................... 93
EVENCARE G3 LOW/HIGH
CONTROL ......................... 93
EVENCARE MINI CONTROL
.............................................. 6
EVOLUTION CONTROL ..... 93
EVOMELA ............................ 34
EX-LAX ............................... 146
EXONDYS 51 .............. 159, 163
extra action cough ........ 167, 170
EXTRA SENSITIVE
SPERMICIDAL ................... 6
extra strength pain relief ......... 71
eye vitamins & minerals ....... 163
eyeprotect ............................. 163
eye-vite extra plus lutein ...... 188
E-Z JECT LANCET MICRO-
THIN 33G........................... 93
E-Z JECT LANCET SUPER
THIN 30G........................... 93
E-Z JECT LANCETS ............. 93
E-Z JECT LANCETS 21G ..... 93
E-Z JECT LANCETS THIN
26G ..................................... 93
EZ SMART BLOOD
GLUCOSE LANCETS....... 93
E-Z SPACER .......................... 94
E-Z SPACER THE BODY
GUARDS PK...................... 94
EZ-LETS LANCETS ............... 6
EZ-LETS LANCETS 21G ....... 6
EZ-LETS LANCETS 23G ....... 6
EZ-LETS LANCETS 26G ..... 94
EZ-LETS LANCETS 28G ....... 6
EZ-LETS LANCETS 30G ....... 6
F FA-8 .......................................... 6
FABRAZYME ..................... 132
FALLBACK SOLO.............. 153
FANTASY LUBRICATED ... 79
FANTASY
LUBRICATED/SPERMICID
E .......................................... 79
FASLODEX ........................... 34
fast acting antacid/anti-gas .. 138,
143
FC FEMALE CONDOM ....... 79
FC2 FEMALE CONDOM ..... 79
fe tabs........................................ 6
feasp-fefum -suc-c-thre-b12-fa
............................ 53, 208, 220
fe-caps....................................... 6
FEMTABS .................... 188, 208
fer-gen-sol............................... 54
fer-iron .................................... 54
ferra........................................... 6
ferro-bob ................................... 6
ferrotabs .................................... 6
ferrous gluconate ................ 6, 54
ferrous sulfate ..................... 6, 54
ferrous sulfate cr ..................... 54
ferrous sulfate er ................. 6, 54
FERROVITE .......................... 54
ferrovite fa .............................. 54
FERROVITE FORTE ............ 54
fe-succ-c-thre-b12-des stomach
............................................ 54
FEVERALL ADULTS ........... 71
FEVERALL CHILDRENS .... 71
FEVERALL INFANTS .......... 71
FEVERALL JUNIOR
STRENGTH ....................... 71
fiber....................................... 146
fiber laxative ......................... 146
fiber-lax ................................ 146
FIFTY50 ALCOHOL PREP 179
FIFTY50 CONTROL 2.0 ....... 94
245
FIFTY50 LANCING DEVICE
............................................ 94
FIFTY50 SAFETY SEAL
LANCETS .......................... 94
FIFTY50 UNILET LANCETS
33G ..................................... 94
FINE 30 .................................. 94
FINGERSTIX LANCETS ..... 94
FIRDAPSE ........................... 163
FIRMAGON........... 34, 153, 161
FIRMAGON (240 MG DOSE)
............................ 34, 153, 161
first choice glucose ............... 119
FIRST CHOICE LANCETS
COLORED ......................... 94
FIRST CHOICE LANCETS
THIN .................................. 94
FLEBOGAMMA DIF ............ 41
flecainide acetate .................... 66
FLEET BISACODYL .......... 146
FLEET ENEMA ................... 146
FLEET OIL .......................... 146
FLEXICHAMBER ................. 94
FLOLAN ........................ 69, 176
FLORIVA PLUS .......... 159, 188
floxuridine .............................. 34
FLUAD................................... 45
FLUARIX QUADRIVALENT
............................................ 45
FLUCELVAX
QUADRIVALENT ............ 45
fludarabine phosphate ............ 34
FLULAVAL
QUADRIVALENT ............ 45
FLUMIST QUADRIVALENT
............................................ 45
FLUOR-A-DAY................... 159
fluorouracil ............................. 34
FLUZONE HIGH-DOSE ....... 45
FLUZONE QUADRIVALENT
............................................ 45
folate ..................................... 208
folic acid ............................... 208
FOLLISTIM AQ .......... 154, 155
FOLOTYN ............................. 35
FORA CONTROL ................. 94
FORA LANCETS .................. 94
FORA LANCING DEVICE .. 94
FORA P20 BP MONITOR
SYSTEM ............................ 94
FORA TEST N' GO BP ......... 94
FORACARE GDH CONTROL
............................................ 94
formula b .................................. 6
formula b plus ................. 54, 188
FORMULA E 400 ................ 229
formula twenty-one .................. 6
FORTAVIT .................... 54, 188
FORTISCARE CONTROL .... 94
FOSFREE ............................. 125
fp glucose ............................. 119
fp lancets................................. 94
fp lancets super thin .................. 6
fp lancets thin ......................... 94
freds pharmacy autolet lancing
............................................ 94
freds pharmacy unilet lanc 28g
............................................ 94
freds pharmacy unilet lanc 30g
............................................ 94
freedavite ................ 54, 188, 208
FREESTYLE CONTROL
SOLUTION ........................ 95
FREESTYLE LANCETS ....... 95
FREESTYLE UNISTICK II
LANCETS .......................... 95
fruit c 200 ............................. 220
fruit c 500 ............................. 220
fruity c .................................. 220
fulvestrant ............................... 35
furosemide ...................... 67, 121
FUSILEV.............................. 158
G GABLOFEN ..................... 48, 49
GALAFOLD ........................ 163
GALZIN ............................... 152
GAMASTAN ......................... 41
GAMASTAN S/D .................. 41
GAMIFANT ......................... 162
GAMMAGARD ............... 41, 42
GAMMAGARD S/D LESS IGA
............................................ 41
GAMMAKED ........................ 42
GAMMAPLEX ...................... 42
GAMUNEX-C........................ 42
ganciclovir sodium ................. 29
ganirelix acetate ............ 153, 161
gas relief ............................... 143
gas relief extra strength ........ 143
gas relief maximum strength 143
GAS-X .................................. 143
GAS-X EXTRA STRENGTH
.......................................... 143
GATTEX .............................. 151
gavilax .................................. 146
GAVILYTE-C ...................... 146
GAVILYTE-G ...................... 146
GAVILYTE-N WITH FLAVOR
PACK ............................... 146
GAVISCON ......................... 138
GAVISCON ACID
BRKTHRGH FORMULA
.................................. 125, 138
GAZYVA ............................... 35
ge100 control .......................... 95
gemcitabine hcl ....................... 35
GEMZAR ............................... 35
generix t .......................... 54, 188
genesupp-500 ............................ 6
genetect plus ............................. 6
genetical .................................... 6
GENTEAL TEARS .............. 134
GENTEAL TEARS
MODERATE PF .............. 134
GENTEAL TEARS PF......... 134
GENTEEL BUTTERFLY
TOUCH LANCET................ 6
GENTEEL LANCING DEVICE
(BLACK) .............................. 6
GENTEEL LANCING DEVICE
(BLUE) ............................... 95
GENTEEL LANCING DEVICE
(GOLD) ................................ 6
GENTEEL LANCING DEVICE
(PINK) ................................ 95
GENTEEL LANCING DEVICE
(WHITE)............................. 95
GENTEEL LANCING
DEVICE(PLATNM) ............ 6
GENTEEL LANCING
DEVICE(PURPLE) ............ 95
GENTEEL LANCING
DEVICE(SILVER) ............... 6
gentle laxative ....................... 146
GENTLE-LET GP LANCETS . 6
GENTLE-LET LANCETS ....... 6
geravim ................................. 188
geriaton ................................. 188
geri-kot ................................. 146
geritabs ................................. 188
246
geri-tonic .............................. 188
geri-vite ................................ 188
gerivite complete ...................... 6
giant eagle glucose ................... 7
giant eagle lancets .................... 7
giant eagle lancets colored ....... 7
GIVLAARI........................... 163
GLASPAK DISP SYRINGE . 95
GLASPAK TB SYRINGE ..... 95
GLASSIA ............................. 176
global alcohol prep ease ....... 179
global inject ease lancets 28g . 95
global inject ease lancets 30g . 95
global lancing device .............. 95
GLUCAGEN HYPOKIT .... 154,
158
GLUCAGON EMERGENCY
.................................. 154, 158
GLUCOCARD 01 CONTROL
............................................ 95
GLUCOCARD EXPRESSION
CONTROL ......................... 95
GLUCOCARD SHINE
CONTROL ......................... 95
GLUCOCARD X-SENSOR
CONTROL ......................... 95
GLUCOCOM CONTROL ..... 95
GLUCOCOM LANCETS 28G
............................................ 95
GLUCOCOM LANCETS 30G
............................................ 95
GLUCOCOM LANCETS 33G
............................................ 95
GLUCOLAB CONTROL ...... 95
GLUCOLET 2 AUTOMATIC
LANCING .......................... 95
glucose .................................. 119
glucose control ....................... 96
GLUCOSOURCE LANCET
DEVICE ............................. 96
GLUCOSOURCE LANCETS 96
GLUTOFAC................. 208, 220
glycerin (pediatric) ............... 147
GLYCOLAX ........................ 147
glycopyrrolate......................... 48
GMATE CONTROL LEVEL 2
............................................ 96
GMATE LANCETS 30G ....... 96
GMATE LANCING DEVICE96
gnp 12 hour nasal spray ........ 136
gnp 8 hour pain reliever.......... 71
gnp acetaminophen ............. 7, 71
gnp adult aspirin low strength61,
63, 75, 77
gnp alcohol swabs ................ 179
gnp allergy .......... 24, 25, 26, 174
gnp allergy antihistamine 23, 25,
174
gnp allergy relief ...... 24, 25, 174
gnp antacid ................... 125, 139
gnp antacid & anti-gas .. 138, 143
gnp antacid anti-gas ...... 139, 143
gnp antacid extra strength.... 125,
139
gnp antacid maximum strength
.................................. 139, 144
gnp antacid regular strength 139,
144
gnp anti-diarrheal ................. 142
gnp arthricream....................... 77
gnp arthritis pain relief ........... 71
gnp aspirin ............ 61, 63, 75, 78
gnp aspirin low dose .. 61, 63, 75,
78
gnp b-12 ................................ 208
gnp biotin .............................. 208
GNP BISA-LAX .................. 147
gnp blood pressure monitor 7, 96
gnp calcium 500 ....................... 7
gnp calcium 500 +d3 .... 125, 226
gnp calcium citrate +d3 125, 226
gnp calcium citrate+d maximum
.................................. 125, 226
gnp century ............. 54, 188, 208
gnp century active performance
............................ 54, 188, 208
gnp century adults 50+ senior
.................................. 188, 208
gnp century cardio health ..... 188
gnp century energy metabolism
............................ 54, 188, 208
gnp century mature ....... 188, 208
gnp century ultimate mens .... 54,
189, 208
gnp century ultimate womens 54,
189, 208
gnp childrens allergy 24, 25, 174
gnp childrens pain relief ......... 71
GNP CLEARLAX ................ 147
gnp d 1000 ............................ 226
gnp docusate calcium ........... 147
gnp ear systems..................... 134
GNP EASY TOUCH CONT
HIGH/LOW ........................ 96
gnp enema ............................. 147
gnp essential one daily.. 189, 208
gnp eye drops ........................ 134
gnp fiber-caps ....................... 147
gnp folic acid ........................ 208
gnp gas relief ........................ 144
gnp gas relief extra strength . 144
gnp gentle laxative ................ 147
gnp glucose ........................... 119
gnp hair/skin/nails .. 54, 189, 208
gnp healthy eyes ................... 189
gnp healthy eyes supervision 163
gnp infants pain relief ............. 71
gnp infants pain/fever ............. 71
gnp iron ..................................... 7
gnp isopropyl alcohol wipes . 179
gnp lancets .............................. 96
gnp lancets 21g ....................... 96
gnp lancets micro thin 33g ..... 96
gnp lancets super thin 30g ...... 96
gnp lancets thin ....................... 96
gnp lancets thin 26g ................ 96
GNP LANCING SYSTEM
DEVICE ............................. 96
gnp laxative .......................... 147
gnp laxative pills................... 147
gnp lubricating plus eye drops
.......................................... 134
gnp magnesium citrate .......... 147
gnp magnesium oxide ........... 139
GNP MASANTI MAXIMUM
STRENGTH ............. 139, 144
GNP MASANTI REGULAR
STRENGTH ............. 139, 144
gnp maximum one daily 54, 189,
208
gnp mega multi for men 189, 208
gnp mega multi for women .... 54,
125, 189, 208
gnp melatonin ....................... 163
GNP MENS MULTIPLUS....... 7
gnp micro thin lancets 33g ..... 96
gnp milk of magnesia ........... 147
gnp mineral oil ...................... 147
gnp mineral oil heavy ... 147, 177
gnp mucus d 12 hr .................... 7
247
gnp mucus er ........................ 170
gnp mucus relief childrens ....... 7
gnp nasal decongestant ... 46, 166
gnp nasal moisturizing ......... 134
gnp nasal spray ..................... 136
gnp nasal spray extra moist .. 136
gnp natural fiber ................... 147
gnp no drip nasal spray......... 136
gnp one daily maximum 54, 189,
208
gnp one daily mens
50+advanced .................... 189
gnp one daily mens health 50+
.................................. 189, 208
gnp one daily mens/lycopene
.................................. 189, 208
gnp one daily plus iron .. 54, 189,
208
gnp one daily womens 50+ . 189,
208
gnp one daily womens health 54,
125, 189, 208
gnp opti-vitamins.................. 189
gnp pain & fever childrens ..... 71
gnp pain relief......................... 71
gnp pain relief extra strength .. 71
gnp pediatric electrolyte ....... 125
gnp pink bismuth .......... 139, 142
gnp quick dissolve glucose ... 119
gnp senna lax ........................ 147
gnp senna plus ...................... 147
gnp senna-lax........................ 147
gnp sleep aid ....... 24, 25, 75, 174
gnp slow release iron .............. 54
gnp stomach relief ........ 139, 142
gnp stomach relief max st.... 139,
142
gnp stool softener ................. 147
gnp stool softener ex st ......... 147
gnp stool softener/laxative ... 147
gnp super thin lancets 30g ...... 96
gnp therapeutic m complete .. 54,
189
gnp therapeutic-m .. 55, 125, 189,
208
gnp tussin dm ............... 168, 171
gnp tussin dm cough ..... 168, 170
gnp tussin mucus & chest cong
.......................................... 171
gnp vitamin a .................... 7, 202
gnp vitamin b1 ...................... 208
gnp vitamin b-12 .................. 209
gnp vitamin b-12 tr ............... 209
gnp vitamin b-6 .................... 209
gnp vitamin c ........................ 220
gnp vitamin c cr .................... 220
gnp vitamin c w/rose hips ..... 220
gnp vitamin c/rose hips......... 220
gnp vitamin d3 extra strength
.......................................... 226
gnp vitamin e ................ 229, 230
gnp wart remover.................. 178
gnp womens gentle laxative . 147
gnp womens laxative ............ 147
gnp womens one daily .... 55, 189
GOJJI CONTROL .................. 96
GOJJI LANCING
DEVICE/CLEAR CAP ...... 96
GOJJI STERILE LANCETS .. 96
golden age vitamin/minerals . 55,
189
GOLYTELY ......................... 147
GONAL-F .................... 154, 155
GONAL-F RFF ............ 154, 155
GONAL-F RFF REDIJECT 154,
155
goodsense antacid ..................... 7
goodsense arthritis pain .......... 71
goodsense aspirin . 61, 63, 75, 78
goodsense aspirin adult low st
.......................... 61, 63, 75, 78
GOODSENSE CLEARLAX 147
goodsense color lancets 33g ... 96
goodsense lancets 26g univ .... 96
goodsense lancets 30g ............ 96
goodsense lancets 30g univ .... 96
goodsense lancets 33g ............ 96
goodsense lancets 33g univ .... 96
goodsense lancing device ....... 96
goodsense laxative pills ............ 7
goodsense lubricating eye drop
.......................................... 134
goodsense mucus relief child 47,
168, 171
goodsense mucus-d................... 7
goodsense pain & fever child . 71
goodsense pain & fever infants
............................................ 72
goodsense pain relief .............. 72
goodsense pain relief extra st . 72
goodsense senna laxative ...... 148
goodsense stomach relief ..... 139,
142
goodsense tussin cf . 47, 168, 171
GREENE POINT SPINAL
NEEDLE............................... 7
guaiatussin ac.......... 76, 168, 171
guaifenesin ............................ 171
guaifenesin ac ......... 76, 168, 171
guaifenesin dac 46, 76, 166, 168,
171
guaifenesin er........................ 171
guaifenesin-codeine 76, 168, 171
guaifenesin-dm ............. 168, 171
H H&H THINLET LANCETS
26G ..................................... 96
H&H THINLET LANCETS
30G ..................................... 96
HAEMOLANCE .................... 96
HAEMOLANCE LOW FLOW
LANCETS .......................... 96
HAEMOLANCE PLUS ......... 96
HAEMOLANCE PLUS HIGH
FLOW ................................. 96
HAEMOLANCE PLUS LOW
FLOW ................................. 97
HAEMOLANCE PLUS MAX
FLOW ................................. 97
HAEMOLANCE PLUS
PEDIATRIC FLOW ........... 97
hair formula extra strength .... 55,
189, 209
hair vitamins ................... 55, 189
hair/skin/nails . 55, 163, 189, 209
hair/skin/nails/biotin ...... 55, 125,
189, 209
hairvite .................................. 209
HALAVEN ............................. 35
HANKSCRAFT HUMIDIFIER
.............................................. 7
HANKSCRAFT VAPORIZER 7
HAVRIX................................. 45
HEALTH CARE LANCING
DEVICE ............................. 97
health sense bp monitor .......... 97
HEALTHSMART BP
MONITOR/WRIST .............. 7
healthwise alcohol prep ............ 7
healthwise lancets 30g .............. 7
248
healthwise lancing pen ............. 7
healthy accents lancing device97
healthy accents unilet lancets . 97
healthy eyes .......................... 189
healthy eyes/lutein ................ 189
healthy hair/skin/nails .. 189, 209
HEALTHY MAMA TAME
THE FLAME............ 125, 139
h-e-b incontrol adv lancing .... 97
h-e-b incontrol alcohol ......... 179
H-E-B INCONTROL BP
MONITOR ......................... 97
h-e-b incontrol deluxe auto bp . 7
h-e-b incontrol lancets 28g ..... 97
h-e-b incontrol lancets 30g ..... 97
h-e-b incontrol lancets 33g ..... 97
h-e-b incontrol premium bp...... 7
h-e-b oral electrolyte ............ 125
HEPAGAM B ........................ 42
heparin sodium (porcine) ....... 51
HERCEPTIN .......................... 35
high potency iron ...................... 7
high potency multivit/min/iron
.......................................... 189
HIGH SENSATION
SPERMICIDAL ................... 7
HI-POTENCY SOFT
MULTIPLE .......................... 7
hipotest ..................................... 7
HIZENTRA ...................... 42, 43
hm acetaminophen childrens .. 72
hm advanced antacid max st 139,
144
hm allergy ................. 24, 25, 175
hm allergy multi symptom .... 24,
25, 174
hm allergy relief 24, 25, 26, 174,
175
hm allergy relief childrens..... 24,
25, 175
hm antacid .................... 139, 144
hm antacid anti-gas ex st ..... 139,
144
hm antacid/antigas ........ 139, 144
hm anti-diarrheal .............. 7, 142
hm antioxidant vitamins ....... 189
hm arthritis creme..................... 7
hm arthritis pain relief ............ 72
hm aspirin ............. 61, 63, 75, 78
hm aspirin ec ........ 61, 63, 75, 78
hm aspirin ec low dose .... 61, 63,
75, 78
hm biotin............................... 209
hm blood pressure monitor ..... 97
hm calcium antacid ....... 126, 139
hm calcium antacid ex st ..... 126,
139
hm calcium antacid ultra st .. 126,
139
hm calcium citrate+d3 petite
.................................. 126, 226
hm calcium citrate+vitamin d
.................................. 126, 226
hm calcium-vitamin d-minerals
.................................. 126, 226
HM CLEARLAX ................. 148
hm complete ........... 55, 189, 209
hm complete 50+ .......... 189, 209
hm complete 50+ mens ultimate
.................................. 189, 209
hm complete 50+ women
ultimate ............... 55, 189, 209
hm complete men ... 55, 189, 209
hm complete women ..... 55, 189,
209
hm e vitamin ......................... 230
hm earwax removal aid ........ 134
hm earwax removal kit ......... 134
hm enema ............................. 148
hm enema mineral oil ........... 148
hm fiber ................................ 148
hm folic acid ......................... 209
hm gas relief ..................... 7, 144
hm gas relief extra strength .. 144
hm hair/skin/nails ......... 190, 209
hm iron slow release ............... 55
hm lancets micro thin 33g ...... 97
hm lancets ultra thin 30g ........ 97
hm laxative ........................... 148
hm loperamide hcl ................ 142
hm lubricating plus ............... 135
hm magnesium ............. 126, 139
hm magnesium citrate .......... 148
hm mens 50+ advanced one
daily .................. 190, 209, 232
hm milk of magnesia ............ 148
hm mucus relief d ... 46, 166, 171
hm nasal decongestant .... 46, 166
hm nasal spray ...................... 136
hm one daily essential .. 190, 209
hm one daily mens 190, 209, 232
hm one daily womens .... 55, 126,
190, 209
hm one daily/iron .... 55, 190, 209
hm pain & fever childrens ...... 72
hm pain & fever infants .......... 72
hm pain relief ............................ 7
hm pain relief extra strength ... 72
hm pain reliever ...................... 72
hm pediatric electrolyte ........ 126
hm saline nasal spray ............ 135
hm senna ............................... 148
hm senna-s ............................ 148
hm sinus nasal spray ............. 136
hm sleep aid ........ 24, 25, 76, 175
hm slow release iron ................. 8
hm sterile alcohol prep ......... 179
hm stomach relief ......... 139, 142
hm stomach relief max strength
.................................. 139, 142
hm stomach relief ultra ............. 8
hm stool softener .................. 148
hm stool softener/laxative ..... 148
hm super vitamin b complex/c
.................................. 209, 220
hm tussin adult ...................... 171
hm tussin adult dm........ 168, 171
hm tussin adult multi-symptom
............................ 47, 168, 171
hm vitamin b complex/vitamin c
.................................. 209, 220
hm vitamin b1 ....................... 209
hm vitamin b12 ..................... 209
hm vitamin b-12 ................... 209
hm vitamin b6 ....................... 209
hm vitamin c ................. 220, 221
hm vitamin c tr...................... 221
hm vitamin c/rose hips.......... 221
hm vitamin e ......................... 230
hm womens 50+ advanced daily
.................. 126, 190, 209, 232
huber needle.............................. 8
humidifier ............................... 97
HUMIST ................................... 8
HYALEX .................................. 8
HYCAMTIN........................... 35
hydralazine hcl........................ 66
hydrochlorothiazide .. 68, 69, 131
hydroxyurea ............................ 35
hylavite ......................... 209, 221
249
HYPERHEP B S/D ................ 43
HYPERRAB S/D ................... 43
HYPERRHO S/D ................... 43
HYPERSAL ................... 97, 126
HYPERTET S/D .................... 43
HYQVIA ................................ 43
HY-VEE LANCETS ................ 8
hy-vee thin lancets .................... 8
I ICAPS................................... 163
ICAPS AREDS FORMULA
.................................. 163, 190
ICAPS LUTEIN & OMEGA-3
.......................................... 190
ICAPS MV ................... 190, 209
ICAPS PLUS ........................ 190
IDAMYCIN PFS .................... 35
idarubicin hcl .......................... 35
IFEX ....................................... 35
ifosfamide ......................... 35, 36
IMFINZI ................................. 36
IMLYGIC ............................... 36
IN TOUCH GLUCOSE
CONTROL ........................... 8
IN TOUCH LANCING
DEVICE ............................... 8
IN TOUCH STERILE
LANCETS 30G .................... 8
INCRELEX .......................... 157
indapamide ..................... 69, 131
infants pain relief .................... 72
INFINITY CONTROL ........... 97
INFINITY VOICE ................. 97
INSPIRACHAMBER/LARGE
............................................ 97
INSPIRACHAMBER/MEDIU
M ........................................ 97
INSPIRACHAMBER/MOUTH
PIECE ................................. 97
INSPIRACHAMBER/SMALL
............................................ 97
INSPIREASE ......................... 97
INTENSE SENSATION .......... 8
INTRON A ............... 29, 36, 161
INVANZ................................. 28
irinotecan hcl .......................... 36
iron ..................................... 8, 55
iron (ferrous gluconate) .......... 55
iron (ferrous sulfate) ................. 8
iron high-potency ..................... 8
iron slow release ................. 8, 55
iron supplement .................. 8, 55
isoniazid.................................. 27
isopropyl alcohol ...................... 8
isopropyl alcohol wipes ........ 179
ISOPTO ATROPINE ........... 136
ISOPTO TEARS .................. 135
ISTODAX .............................. 36
ISTODAX (OVERFILL) ....... 36
ivermectin ............................... 27
i-vite...................................... 190
i-vite protect ......................... 163
IXEMPRA KIT ...................... 36
J J & J EYE PADS OVAL
SMALL ................................ 8
J & J OVAL EYE PADS .......... 8
J & J STERILE EYE PADS ..... 8
JETREA................................ 135
JEVTANA .............................. 36
JOHNSONS STERILE EYE
PADS .................................... 8
JYNARQUE ......................... 132
K KADCYLA ............................ 36
KALYDECO ........................ 170
KAMELEON LUBRICATED . 8
KANJINTI .............................. 36
KANUMA ............................ 132
KAO-TIN ............. 140, 142, 148
KAZ HEALTHMIST
HUMIDIFIER .................... 97
kaz humidifier evaporativ 3000 8
kaz humidifier evaporativ 3300 8
kaz humidifier evaporativ 3400 8
KAZ ULTRASONIC
HUMIDIFIER ...................... 8
KAZ VAPORIZER ................ 97
KAZ VICKS VAPORIZER
V150 ................................... 97
kedrab ..................................... 43
KEPIVANCE ....................... 178
KETO-DIASTIX .................. 118
ketone test ............................. 118
KETOSTIX .......................... 118
KEYTRUDA .......................... 36
KHAPZORY ........................ 158
kimono .................................... 79
KIMONO COLORS ................. 8
kimono micro thin .................. 79
kimono micro thin plus ........... 79
kimono plus .............................. 8
kimono ps ................................. 9
kimono ps plus .......................... 9
kimono sensation .................... 79
kimono sensation plus ............ 79
KIMONO SPECIAL ................ 9
kinney glucose .......................... 9
kinney lancets ......................... 97
kinney thin lancets .................. 97
KIONEX ....................... 121, 158
KLOR-CON ......................... 126
KLOR-CON 10 .................... 126
KLOR-CON M10 ................. 126
KLOR-CON M20 ................. 126
KLOR-CON SPRINKLE ..... 126
kls antacid ..................... 126, 140
kobee..................................... 209
konsyl daily fiber .................. 148
KONSYL FIBER.................. 148
kp adults 50+ daily formula . 190,
210
kp adults daily formula .. 55, 190,
210, 232
kp b complex-c ............. 210, 221
kp calcium citrate+d ..... 126, 226
kp ferrous gluconate ............... 55
kp folic acid .......................... 210
kp mens 50+ daily formula .. 190,
210, 232
kp mens daily formula . 190, 210,
232
kp senna ................................ 148
KP VISION FORMULA ..... 190,
202, 221, 230
KP VISION
FORMULA/LUTEIN ....... 190
kp vitamin b-12..... 126, 210, 226
kp vitamin b-6....................... 210
kp vitamin d .......................... 226
kp vitamin d3 ........................ 226
kp vitamin e .......................... 230
kp womens 50+ daily formula
.................. 126, 190, 210, 232
kp womens daily formula ...... 55,
126, 190, 210, 232
K-PAX DOUBLE STRENGTH
.......................................... 190
250
K-PAX IMMUNE
PROFESSIONAL ST 55, 190,
210
K-PAX SINGLE STRENGTH
.......................................... 190
KROGER AUTOLET
LANCING DEVICE .......... 97
kroger blood pressure monitor 97
KROGER HEALTHPRO
CONTROL HI/LO ............. 98
KROGER HEALTHPRO
LANCET 26G .................... 98
KROGER HEALTHPRO
LANCET 30G .................... 98
KROGER HEALTHPRO
LANCET 33G .................... 98
kroger lancets ........................... 9
kroger lancets 21g .................. 98
kroger lancets micro thin 33g . 98
kroger lancets super thin .......... 9
kroger lancets thin .................... 9
kroger lancets thin 26g ........... 98
kroger lancets ultrathin 30g .... 98
kroger lancing device ............. 98
K-TAB .................................. 126
KUVAN ............................... 163
KYMRIAH ....................... 36, 70
KYPROLIS ...................... 36, 37
L lactulose ................................ 119
lady lite lancets ....................... 98
lancet device ........................... 98
lancet device with ejector ....... 98
lancets ..................................... 98
lancets 28g .............................. 98
lancets 30g .............................. 98
lancets micro thin 33g ............ 98
lancets super thin 28g ............. 98
lancets thin.............................. 98
LANCETS ULTRA FINE ...... 98
LANCETS ULTRA THIN ..... 98
lancets ultra thin 30g .............. 98
lancing device ......................... 98
LANOXIN .............................. 65
LANZO .................................. 98
LARTRUVO .......................... 37
LASIX ............................ 67, 121
laxative ................................. 148
laxative feminine .................. 148
laxative max str .................... 148
laxative pills ......................... 148
laxative regular strength ....... 148
leader advanced lancing device
............................................ 98
leader quick dissolve glucose
.......................................... 119
leflunomide ........................... 161
leucovorin calcium ............... 158
levocarnitine ......................... 163
levoleucovorin calcium ........ 158
levonorgestrel ....................... 153
LIBERTY GLUCOSE
CONTROL ......................... 98
LIBERTY GLUCOSE
CONTROL MID ................ 98
LIBERTY MEDICAL
LANCETS ............................ 9
LIBERTY MINI LANCING
DEVICE ............................. 98
LIBTAYO .............................. 37
LIFESCAN UNISTIK 2 ........... 9
LIFESCAN UNISTIK II
LANCETS ............................ 9
lifestylecomfort vaporizer ...... 98
LIFESTYLES ASSORTED
COLORS .............................. 9
LIFESTYLES EXTRA
STRENGTH ......................... 9
LIFESTYLES FORM FITTING
.............................................. 9
LIFESTYLES LUBRICATED 9
LIFESTYLES RIBBED ........... 9
LIFESTYLES SKYN
ORIGINAL ........................... 9
LIFESTYLES SPERMICIDAL
LUBE.................................... 9
LIFESTYLES STUDDED ....... 9
LIFESTYLES ULTRA
SENSITIVE .......................... 9
LIFESTYLES VIBRA-RIBBED
.............................................. 9
LIFESTYLES XTRA
PLEASURE .......................... 9
LIORESAL ............................. 49
LIPOTRIAD 151, 163, 190, 202,
210, 221, 230
liquitears ............................... 135
lite touch lancets ..................... 98
LITE TOUCH LANCING
DEVICE ............................. 99
LITE TOUCH LANCING PEN
............................................ 99
LITEAIRE .............................. 99
LITETOUCH LANCETS ....... 99
lithium..................................... 74
lithium carbonate .............. 73, 74
lithium carbonate er .......... 73, 74
LITTLE NOSES SALINE .... 135
LITTLE NOSES STUFFY
NOSE KIT ........................ 135
LITTLE REMEDIES SALINE
MIST................................. 135
live better adv lancing device . 99
live better lancet super thin..... 99
live better lancet ultra thin ...... 99
l-methylfolate-b6-b12 ........... 210
local anesthesia needle ....... 9, 99
LOMOTIL .............. 48, 142, 167
long lasting antacid ................... 9
longs glucose ............................ 9
longs lancets standard ............. 99
longs lancets thin .................... 99
longs lancets ultra thin ............ 99
loperamide hcl ...................... 142
lubricating plus eye drops ..... 135
LUDENT .............................. 159
LUMIZYME......................... 133
LUMOXITI ............................ 37
lung perform peak flow meter .. 9
LUXTURNA .......................... 70
M MACULAR HEALTH
FORMULA....................... 190
macular vitamin benefit 190, 210
MACUVITE . 190, 202, 221, 230
MACUVITE EYE CARE.... 190,
202, 221, 230
MACUVITE/LUTEIN ......... 163
MAG64 ................................. 126
mag-al plus ................... 140, 144
mag-al plus xs ............... 140, 144
MAGDELAY ....................... 127
MAGELLAN TUBERCULIN
SYRINGE ........................... 99
magnesium ............................ 140
magnesium chloride.............. 127
magnesium citrate ................. 148
magnesium oxide .................. 140
MAGNESIUM-OXIDE ........ 140
MAGOX 400 ........................ 140
251
MAG-OX 400 ...................... 140
major comfort lancets ............. 99
MAOX .................................. 140
mapap ..................................... 72
mapap arthritis pain ................ 72
MAPAP CHILDRENS ........... 72
MAPAP EXTRA STRENGTH
............................................ 72
MARQIBO ............................. 37
MAXIMA CONTROL ........... 99
MAXIMUM BLUE LABEL .... 9
MAXIMUM GREEN LABEL . 9
MAXIMUM RED LABEL ...... 9
maxx ....................................... 79
maxx plus ................................. 9
MAXZIDE ....... 68, 69, 121, 131
MAXZIDE-25 .. 68, 69, 121, 131
medichoice safety lancet .......... 9
medichoice safety lancet extra . 9
medichoice safety lancet norm . 9
medicine shoppe lancets ......... 99
medicine shoppe lancets thin . 99
medi-lance lancets .................. 99
medi-natural ......................... 148
MEDIPLEX PLUS ................... 9
MEDISENSE GLUCOSE
KETONE CONTR ............. 99
MEDISENSE HI/MID/LOW
CONTROL ......................... 99
MEDISENSE HIGH/LOW
CONTROL ......................... 99
MEDISENSE MID CONTROL
............................................ 99
MEDISENSE THIN LANCETS
............................................ 99
MEDLANCE EXTRA 21G ... 99
MEDLANCE LITE 25G ........ 99
MEDLANCE PLUS EXTRA
21G ..................................... 99
MEDLANCE PLUS LANCETS
............................................ 99
MEDLANCE PLUS LITE 25G
............................................ 99
MEDLANCE PLUS SPECIAL
0.8MM ................................ 99
MEDLANCE PLUS
SUPERLITE 30G ............... 99
MEDLANCE PLUS
UNIVERSAL 21G ............. 99
MEDLANCE UNIVERSAL
21G ..................................... 99
MEGA MULTI MEN ... 190, 210
mega multiple/chelated mineral
.......................................... 190
mega multivitamin for men . 190,
210
mega multivitamin for women
.................... 55, 127, 190, 210
mega vm-80 .............................. 9
MEGAVITE RX..... 55, 190, 210
meijer advanced formula 55, 191
meijer alcohol swabs .............. 10
meijer c ................................. 221
meijer ferrous sulfate .............. 10
meijer glucose......................... 10
MEIJER LANCETS ............. 100
MEIJER LANCETS THIN .. 100
MEIJER LANCETS
UNIVERSAL 21G ............. 10
MEIJER LANCETS
UNIVERSAL 30G ............. 10
MEIJER LANCETS
UNIVERSAL 33G ........... 100
meijer saline nasal spray......... 10
MEIJER SUPER THIN
LANCETS ........................ 100
melatonin .............................. 163
melatonin er .......................... 163
melatonin gummies .............. 163
melphalan hcl ......................... 37
m-end dmx 26, 46, 166, 168, 175
MENOPUR .................. 154, 155
mens 50+ advanced ...... 191, 210
mens daily formula/lycopene
.................................. 191, 210
mens multi vitamin & mineral
.................................. 191, 210
MEPHYTON ................ 158, 232
MEPRON ............................... 27
MEPSEVII............................ 133
mercaptopurine ............... 37, 162
MERIBIN ............................. 210
MESNEX.............................. 165
MESTINON ........................... 49
METHERGINE .................... 166
methimazole ......................... 153
methylergonovine maleate ... 166
metolazone...................... 69, 132
mexiletine hcl ......................... 66
MG PLUS PROTEIN ........... 127
MG-PLUS PROTEIN ........... 127
MI-ACID ...................... 140, 144
mi-acid gas relief .................. 144
mi-acid maximum strength .. 140,
144
mi-basic t ................................ 10
MICRHOGAM ULTRA-
FILTERED PLUS .............. 43
MICROCHAMBER ............. 100
MICRODOT CONTROL ..... 100
MICRODOT CONTROL
HIGH/LOW ...................... 100
MICROLET LANCETS ....... 100
MICROLET NEXT LANCING
DEVICE ........................... 100
MICROLET VACULANCE
DEVICE ............................. 10
microlife bp monitor ............. 100
MICROLIFE BPM1 BP
MONITOR ......................... 10
MICROLIFE BPM2 BP
MONITOR ......................... 10
MICROLIFE BPM3 DELUXE
MONITOR ......................... 10
MICROLIFE BPM6 PREMIUM
MONITOR ....................... 100
microlife deluxe bp monitor .. 10,
100
MICROLIFE DIGITAL PEAK
FLOW ............................... 100
microlife wrist bp monitor .... 100
MICROSPACER .................. 100
MICROTAINER SAFETY
FLOW LANCET ................ 10
MICROZIDE .................. 69, 131
MILCO-B-FORTE ................. 10
milk of magnesia .................. 148
MILLTRIUM SENIOR ........ 191
milrinone lactate ..................... 65
mineral oil ............................. 148
mini lancing device............... 100
MINI WRIGHT PEAK FLOW
METER............................. 100
MINIPRESS ..................... 49, 64
minoxidil................................. 66
MINTOX ...................... 140, 144
mintox maximum strength ... 140,
144
252
MINTOX REGULAR
STRENGTH ............. 140, 144
misoprostol ........................... 152
mitomycin............................... 37
MM LANCING DEVICE .... 100
MM TWIST LANCETS....... 100
MOBISYL .............................. 78
MONOJECT BLOOD
COLLECTION NDL........ 100
MONOJECT BLUNTIP
SYR/CANNULA ............... 10
MONOJECT CONTROL
SYRINGE................... 10, 100
MONOJECT EPIDURAL
NEEDLE ............................ 10
MONOJECT HYPODERMIC
NEEDLE .......................... 100
MONOJECT LIFESHIELD
SYRINGE................... 10, 100
MONOJECT MAGELLAN
SYRINGE..................... 10, 11
MONOJECT PHARMACY
TRAY ....................... 100, 101
MONOJECT SAFETY
SYRINGE/SHIELD ......... 101
MONOJECT
SOFTPACK/CATHTIP ... 101
MONOJECT
SOFTPACK/LLOCK ....... 101
MONOJECT SOFTPACK/LTIP
.......................................... 101
MONOJECT SOFTPACK/RG
LOCK ............................... 101
MONOJECT SOFTPACK/RG
LUER ............................... 101
MONOJECT SPINAL
NEEDLE ............................ 11
MONOJECT SYRINGE 11, 101,
102
MONOJECT SYRINGE CATH
TIP .................................... 102
MONOJECT SYRINGE ECC
LUER ............................... 102
MONOJECT SYRINGE
ECCENTRIC TIP ............. 102
MONOJECT SYRINGE LUER
LOCK ............................... 102
MONOJECT SYRINGE LUER-
LOCK TIP ........................ 102
MONOJECT SYRINGE
PHARMACY TRAY ....... 102
MONOJECT SYRINGE REG
LUER................................ 102
MONOJECT SYRINGE
REGULAR TIP ................ 102
MONOJECT SYRINGE
TOOMEY TYPE .............. 102
MONOJECT TB SAFETY
SYRINGE ......................... 102
MONOJECT TB SYRINGE102,
103
MONOLET LANCETS ....... 103
MONOLET OPD LANCETS 11
MONOLET THIN LANCETS
.......................................... 103
MONOLETTOR SAFETY
LANCETS .......................... 11
MOZOBIL .............................. 50
mpd safety lancet 21g ............. 11
mpd safety lancet 23g ............. 11
mpd safety lancet 28g ............. 11
mpd safety lancet 30g ............. 11
ms quick dissolve glucose .... 119
MUCINEX CHEST
CONGESTION CHILD ... 171
MUCINEX COLD
CHILDRENS...... 47, 168, 171
MUCINEX CONGEST &
COUGH CHILD. 47, 168, 171
MUCINEX D ......... 46, 166, 171
MUCINEX D MAX
STRENGTH ....... 46, 166, 171
MUCINEX DM ............ 168, 171
MUCINEX FAST-MAX
CONGEST COUGH . 47, 168,
171, 172
MUCINEX MAXIMUM
STRENGTH ..................... 172
MUCINEX SINUS-MAX
CLEAR & COOL ............. 136
MUCINEX SINUS-MAX
FULL FORCE .................. 136
MUCINEX SINUS-MAX
MOIST SMART ............... 136
MUCINEX STUFFY
NOSE/COLD CHILD 47, 172
mucus & chest congestion .... 172
mucus d................... 46, 166, 172
mucus relief childrens.... 47, 168,
172
mucus relief d ......... 46, 166, 172
mucus relief dm ............ 168, 172
mucus relief max st ............... 172
mucus relief multi symptom ... 11
mucus-er max ......................... 11
MULTAQ ............................... 66
multi + omega-3 adult gummies
.......................... 191, 210, 226
multi adult gummies ..... 191, 210
multi complete/iron 55, 191, 210
multi for her ... 55, 127, 191, 210,
232
multi for her 50+ ... 191, 210, 232
MULTI FOR HIM ........ 191, 210
multi for him 50+ ......... 191, 210
multi max ........................ 55, 191
multi vitamin .......................... 11
multi vitamin daily ............... 191
multi vitamin mens ............... 191
multi vitamin w/d-3 ................ 11
multi vitamin/fluoride ... 159, 191
multi vitamin/minerals... 56, 191,
210
MULTI-BETIC............. 191, 210
multi-b-plus ............................ 11
multi-day................................. 11
multi-day plus iron . 56, 191, 210
multi-day plus minerals . 56, 191,
211, 232
multi-day vitamins .................. 11
multi-day/calcium/extra iron .. 11
multi-delyn ........................... 191
multi-delyn/iron .............. 56, 191
multi-draw needle ................. 103
MULTIFIT REUSABLE
SYRINGE ................... 11, 103
MULTIFIT REUSABLE TB
SYRINGE ................... 11, 103
MULTIGEN ........................... 56
MULTIGEN FOLIC ...... 56, 211,
221
MULTIGEN PLUS 56, 211, 221
multi-lancet device ............... 103
multilex ........................... 56, 191
multilex-t&m .................. 56, 191
multiple vit/minerals/no iron 191
multiple vitamin...................... 11
multiple vitamins .................. 191
253
multiple vitamins essential ... 191
multiple vitamins/iron .... 56, 191
multiple vitamins/womens .... 56,
191
MULTIPLEX-2 ...................... 11
MULTISTIX 10 SG ............. 118
multi-symptom allergy .... 24, 25,
175
MULTI-USER BLOOD
PRESSURE ...................... 103
multi-vit/fluoride .......... 159, 191
multi-vit/fluoride/iron.... 56, 159,
191
multi-vit/iron/fluoride.... 56, 159,
192
multivital .............................. 192
multivital performance ... 56, 192
multivital platinum ....... 192, 211
multivital platinum silver .... 192,
211
multivitamin ................... 56, 192
multi-vitamin ........................ 192
multivitamin & mineral .. 56, 192
multivitamin adult . 56, 192, 211,
232
multivitamin adult extra c ... 192,
211
multivitamin adults 56, 192, 211,
232
multivitamin adults 50+ 192, 211
multi-vitamin daily ............... 192
multi-vitamin gummies 192, 211
multivitamin gummies adult 192,
211
multivitamin gummies mens192,
211
multivitamin gummies womens
.................................. 192, 211
multivitamin men . 192, 211, 232
multivitamin men 50+ .. 192, 211
multi-vitamin monocaps 56, 192,
211
multivitamin women ..... 56, 127,
192, 211, 232
multivitamin women 50+ ...... 56,
192, 211
multivitamin/extra vitamin d3
.................................. 192, 211
multivitamin/fluoride .. 159, 160,
192
multi-vitamin/fluoride .......... 159
multi-vitamin/fluoride .......... 159
multi-vitamin/fluoride .......... 192
multi-vitamin/fluoride .......... 192
multivitamin/fluoride/iron ..... 56,
160, 192
multi-vitamin/fluoride/iron ..... 56
multi-vitamin/fluoride/iron ... 160
multi-vitamin/fluoride/iron ... 193
multivitamin/iron .................... 11
multi-vitamin/iron .................. 12
multi-vitamin/minerals ......... 193
multi-vitamins ...................... 193
multivitamins plus zinc 193, 226,
232
multivitamins/minerals adult . 56,
193
multi-vite ........................ 56, 193
MURO 128 ........................... 135
MUSTARGEN ....................... 37
MUTAMYCIN ....................... 37
MVC-FLUORIDE ........ 160, 193
MVW COMPLETE
FORMULATION .... 193, 226,
227, 232, 233
MVW COMPLETE
FORMULATION D3000 193,
226, 232
MVW COMPLETE
FORMULATION D5000 193,
226, 233
MVW COMPLETE
FORMULATION MINIS 193,
227, 233
MY CHOICE ........................ 153
MY WAY ............................. 153
MYALEPT ........................... 155
MYAMBUTOL ...................... 27
myamulti ................................. 12
MYCOBUTIN .................. 27, 30
mycophenolate mofetil hcl ... 162
MYGLUCOHEALTH
CONTROL ....................... 103
MYGLUCOHEALTH
LANCETS 30G ................ 103
MYLOTARG ......................... 37
mytab gas .............................. 144
mytab gas maximum strength
.......................................... 144
my-vitalife ............................ 193
N NABI-HB ............................... 43
NAGLAZYME ..................... 133
nasal ........................................ 12
nasal decongestant .......... 47, 167
nasal decongestant max st ..... 47,
167
nasal decongestant spray ...... 136
nasal mist .............................. 135
NASAL MOIST ................... 135
nasal moisturizer ..................... 12
nasal moisturizing spray ....... 135
nasal relief ............................ 136
nasal spray ............................ 135
nasal spray 12 hour ............... 136
nasal spray extra moisturizing
.......................................... 137
NATRAPEL 12-HOUR
TICK/INSECT .................. 181
nat-rul iron .............................. 12
natural balance tears ............. 135
natural c/rose hips ................. 221
natural fiber .......................... 148
natural fiber laxative ............. 148
natural fiber therapy ..... 148, 149
natural mixed tocopherols ..... 12,
230
natural senna laxative ........... 149
natural vitamin e ................... 230
NATURALYTE ..................... 12
natures tears .......................... 135
NAVELBINE ......................... 37
na-zone ................................... 12
NEBUPENT ........................... 27
NEBUSAL .................... 103, 127
neovite .......................... 193, 211
nervidox-6 nr ........................ 211
NESSI SPACER WITH MASK
LARGE ............................. 103
NESSI SPACER WITH MASK
SM/MED .......................... 103
NESSI SPACER WITH
MOUTHPIECE ................ 103
NETGROUP LANCETS ........ 12
neuro-k-250 vitamin b6 .......... 12
neuro-k-50 .............................. 12
neuro-k-500 ............................ 12
NEUTEK 2TEK CONTROL 104
neutral sodium fluoride......... 160
NEW DAY ........................... 153
254
NEXGEN CONTROL............ 12
NICOMIDE .......................... 211
NIPENT .................................. 37
NITYR .................................. 163
no drip nasal spray................ 137
no iron mult vitamin-minerals
.......................................... 193
non-aspirin childrens .............. 72
NORM-JECT LUER LOCK
SYRINGE......................... 104
NORM-JECT LUER SLIP
SYRINGE......................... 104
NORPACE ............................. 65
NORPACE CR ....................... 65
NOVA MAX CONTROL .... 104
NOVA MAX PLUS GLU/KET
CONTROL ....................... 104
NOVA MAX PLUS KETONE
TEST ................................ 104
NOVA SAFETY LANCETS
23G ................................... 104
NOVA SAFETY LANCETS
28G ................................... 104
NOVA SUREFLEX LANCETS
.......................................... 104
NOVA SUREFLEX LANCING
DEVICE ........................... 104
NOVAREL ................... 154, 155
NOVOFINE AUTOCOVER 104
NULOJIX ............................. 162
NULYTELY WITH FLAVOR
PACKS ............................. 149
NUTRAVANCE .................... 12
NUTRICAP ............ 56, 193, 211
NUTRIFAC ZX...................... 12
NUTRIVIT ............. 56, 193, 211
O OCEAN FOR KIDS ............. 135
OCEAN NASAL SPRAY .... 135
OCTAGAM ...................... 43, 44
octreotide acetate .......... 156, 164
ocular vitamins .... 193, 202, 221,
230
OCUSOFT VMS .................... 12
ocutabs .................................. 193
ocutabs-lutein ....................... 193
OCUVITE ............................ 194
OCUVITE ADULT 50+ ..... 164,
193
OCUVITE ADULT FORMULA
............................................ 12
OCUVITE EXTRA ........ 56, 194
OCUVITE EYE + MULTI .. 194,
211, 233
OCUVITE EYE HEATLH
GUMMIES ....................... 164
OCUVITE PRESERVISION164
OCUVITE-LUTEIN ..... 164, 194
OFF ACTIVE ............... 180, 181
OFF DEEP WOODS .... 180, 181
OFF DEEP WOODS DRY.. 180,
181
OFF DEEP WOODS
SPORTSMEN .................. 181
OFF FAMILYCARE CLEAN
FEEL ................................ 181
OFF FAMILYCARE
TROPICAL FRESH ......... 181
OFF FAMILYCARE
UNSCENTED .......... 180, 181
OFF SMOOTH & DRY180, 181
OGIVRI .................................. 37
omnicap ........................ 194, 211
OMRON 10 SERIES BP
MONITOR ....................... 104
OMRON 3 SERIES BP
MONITOR ....................... 104
OMRON 5 SERIES BP
MONITOR ....................... 104
OMRON 7 SERIES BP
MONITOR ....................... 104
ON CALL EXPRESS
GLUCOSE CONTR ......... 104
ON CALL LANCETS .......... 104
ON CALL LANCING DEVICE
.......................................... 104
ON CALL PLUS GLUCOSE
CONTROL ....................... 104
ON CALL PLUS LANCETS
.......................................... 104
ON CALL PLUS LANCING
DEVICE ........................... 104
ON CALL VIVID GLUCOSE
CONTROL ....................... 104
ONCASPAR ........................... 38
once daily ............................. 194
once daily/iron ................ 56, 194
ONCOVITE.......................... 194
ONE A DAY MENS
VITACRAVES ......... 194, 211
one daily ............................... 194
one daily adults 50+ ..... 194, 211
one daily calcium/iron .... 56, 194
one daily complete .. 56, 194, 211
one daily for men 50+ advanced
.................................. 194, 211
one daily for men/lycopene . 194,
211
one daily for women ...... 56, 194,
212
one daily for women 50+ adv
.................................. 194, 211
one daily healthy weight adv . 57,
194, 212
one daily maximum 57, 194, 212
one daily mens ...................... 194
one daily mens 50+ multivit 194,
212, 233
one daily mens health ... 194, 212
one daily multivitamin adult 194,
212
one daily multivitamin/iron ... 57,
194, 212
ONE DAILY PLUS IRON .... 57,
194, 212
one daily plus minerals ... 57, 194
one daily womens 50 plus ... 194,
212
one daily womens 50+ .. 194, 212
one daily/iron .................. 57, 194
one daily/minerals ................ 194
ONE-A-DAY 50 PLUS .......... 12
ONE-A-DAY BONE
STRENGTH ....................... 12
ONE-A-DAY CHOLESTEROL
PLUS ........................ 194, 212
ONE-A-DAY COLD SEASON
............................................ 12
ONE-A-DAY ENERGY 57, 127,
194, 212
ONE-A-DAY ESSENTIAL . 194
ONE-A-DAY EXTRAS
ANTIOXIDANT ................ 12
ONE-A-DAY MAXIMUM
FORMULA....................... 194
ONE-A-DAY MENOPAUSE
FORMULA....... 127, 195, 212
255
ONE-A-DAY MENS .. 195, 212,
233
ONE-A-DAY MENS 50+
ADVANTAGE . 195, 212, 233
ONE-A-DAY MENS HEALTH
FORMULA ...... 195, 212, 233
ONE-A-DAY MENS
VITACRAVES......... 195, 212
ONE-A-DAY PROACTIVE
65+ .................... 127, 195, 212
ONE-A-DAY TEEN
ADVANTAGE/HER . 57, 195,
212
ONE-A-DAY TEEN
ADVANTAGE/HIM . 57, 127,
195, 212
ONE-A-DAY VITACRAVES
.................................. 195, 212
ONE-A-DAY VITACRAVES
ADULT .................... 195, 212
ONE-A-DAY VITACRAVES
IMMUNITY ............. 195, 212
ONE-A-DAY VITACRAVES
SOUR ....................... 195, 212
ONE-A-DAY
VITACRAVES+OMEGA-3
.................................. 195, 212
ONE-A-DAY WEIGHT
SMART ADVANCE. 57, 195,
212
ONE-A-DAY WOMENS 50
PLUS ........ 127, 195, 213, 233
ONE-A-DAY WOMENS 50+
ADVANTAGE 127, 195, 213,
233
ONE-A-DAY WOMENS
FORMULA 57, 127, 195, 213,
233
ONE-A-DAY WOMENS
HEALTHY SKIN ...... 57, 127,
195, 213
ONE-A-DAY WOMENS MIND
& BODY .... 57, 127, 195, 213
ONE-A-DAY WOMENS
PETITES .... 57, 127, 195, 213
ONE-A-DAY WOMENS
VITACRAVES......... 195, 213
one-daily multi vitamins....... 196
one-daily multi-vitamin ........ 196
one-daily/iron ................. 57, 196
one-tablet-daily ..................... 196
one-tablet-daily with minerals
.......................................... 196
one-tablet-daily/iron ....... 57, 196
ONETOUCH CLUB LANCETS
FINE PT ............................. 12
ONETOUCH COMBO PACK
............................................ 12
ONETOUCH DELICA
LANCETS 30G ................ 104
ONETOUCH DELICA
LANCETS 33G ................ 104
ONETOUCH DELICA
LANCING DEV ............... 104
ONETOUCH DELICA PLUS
LANCET30G ................... 104
ONETOUCH DELICA PLUS
LANCET33G ................... 104
ONETOUCH DELICA PLUS
LANCING ........................ 104
ONETOUCH FINEPOINT
LANCETS ........................ 104
ONETOUCH LANCETS ..... 104
ONETOUCH ULTRA
CONTROL ....................... 105
ONETOUCH ULTRASOFT
LANCETS ........................ 105
ONETOUCH VERIO ........... 105
ONIVYDE .............................. 38
ONPATTRO ......................... 164
OPCICON ONE-STEP......... 153
OPDIVO ................................. 38
OPTICHAMBER
ADVANTAGE ................. 105
OPTICHAMBER
ADVANTAGE-LG MASK
.......................................... 105
OPTICHAMBER
ADVANTAGE-MED MASK
.......................................... 105
OPTICHAMBER
ADVANTAGE-SM MASK
.......................................... 105
OPTICHAMBER DIAMOND
.......................................... 105
OPTICHAMBER DIAMOND-
LG MASK ........................ 105
OPTICHAMBER DIAMOND-
MD MASK ....................... 105
OPTICHAMBER DIAMOND-
SM MASK ........................ 105
OPTICHAMBER FACE
MASK-LARGE ................ 105
OPTICHAMBER FACE
MASK-MEDIUM............. 105
OPTICHAMBER FACE
MASK-SMALL ................ 105
optic-vites ............................... 12
OPTIHALER .................. 12, 105
optimum pms .......................... 12
OPTION 2 ............................ 153
OPTISOURCE ....... 57, 196, 213
OPTISOURCE POST
BARIATRIC SURG .. 57, 127,
196, 213, 233
OPTI-VITAMINS .................. 12
OPTIVITE P.M.T. .................. 12
OPTUMRX GLUCOSE
CONTROL ....................... 105
OPURITY BYPASS
OPTIMIZED....... 57, 196, 213
oral electrolytes .................... 127
ORALAIR ...................... 40, 164
ORALYTE ........................... 127
ORALYTE FREEZER POPS
.......................................... 127
ORFADIN ............................ 164
ORKAMBI ................... 169, 170
ORTHOVITE ...... 127, 213, 221,
227, 233
OS-CAL EXTRA D3 ... 127, 227
OVIDREL..................... 154, 155
oxaliplatin ............................... 38
OXBRYTA ............................. 50
OXERVATE......................... 135
OYSCO 500.......................... 127
OYSCO 500+D ............ 128, 227
oyst-cal ................................. 128
oyst-cal d ...................... 128, 227
oyster calcium ....................... 128
oyster calcium + d .................. 12
oyster shell calcium ...... 128, 227
oyster shell calcium + d 128, 227
oyster shell calcium + d3 ..... 128,
227
oyster shell calcium 500 + d 128,
227
oyster shell calcium/d ... 128, 227
oyster shell calcium/d3 . 128, 227
256
oyster shell calcium/vitamin d
.................................. 128, 227
OYSTERCAL ........................ 12
OYSTERCAL-D .......... 128, 227
P pa biotin ................................ 213
pa vitamin e .......................... 230
PACERONE ........................... 66
paclitaxel ................................ 38
PADCEV ................................ 38
pain & fever ............................ 72
pain & fever childrens ............ 72
pain & fever extra strength ..... 72
pain & fever infants ................ 72
pain relief................................ 72
pain relief childrens ................ 72
pain relief extra strength ......... 72
pain reliever extra strength ..... 73
pain relieving .......................... 78
PALYNZIQ .......................... 133
PANHEMATIN ................... 164
pantothenic acid.................... 213
PANZYGA ............................. 44
PARSABIV .................. 153, 164
parvlex .................... 57, 213, 221
PATIENT SAFE SYRINGE . 12,
13
pc lancets super thin 30g ...... 105
pc pediatric electrolyte ......... 128
peak a-i-r flow meter .............. 13
PEAK AIR PEAK FLOW
METER ............................ 105
peak flow meter ...................... 13
peak flow meter universal rang
............................................ 13
ped electrolyte freeze pops ... 128
ped electrolyte freezer pops.. 128
PEDIA VANCE ................... 128
PEDIACARE GENTLE
VAPORS .......................... 105
PEDIA-LAX......................... 149
PEDIALYTE ........................ 128
PEDIALYTE ADVANCED
CARE ............................... 128
PEDIALYTE FREEZER POPS
.......................................... 128
PEDIALYTE SINGLES ...... 128
pediatric electrolyte .............. 128
pediatric electrolyte-zinc ...... 128
PEDI-BORO SOAK ............. 177
peg 3350 ............................... 149
peg 3350/electrolytes ............ 149
peg 3350-kcl-na bicarb-nacl . 149
peg-3350/electrolytes ........... 149
penicillamine ................ 152, 161
pentoxifylline er ..................... 50
peptic relief ................... 140, 142
PERFECT LANCETS 28G .... 13
PERFECT LANCETS 30G .... 13
PERI-COLACE .................... 149
PERJETA ............................... 38
PERSONAL BEST FULL
RANGE ............................ 105
PERSONAL BEST LOW
RANGE ............................ 105
personal ultrasonic humidifier
.......................................... 105
pharbedryl ........... 24, 25, 26, 175
PHARBETOL ........................ 73
PHARBETOL EXTRA
STRENGTH ....................... 73
PHARMACIST CHOICE
ALCOHOL ....................... 179
PHARMACIST CHOICE
LANCETS ........................ 105
PHARMACY COUNTER
LANCETS .......................... 13
phenazopyridine hcl ............. 177
phenoxybenzamine hcl ..... 49, 67
phenylephrine hcl ................. 137
phytonadione ................ 158, 233
PIKO 1 .................................. 105
pink bismuth ................. 140, 142
pip lancets 28g ...................... 105
pip lancets 30g ...................... 105
PLAN B ONE-STEP ............ 153
PMS-WOMENS FORMULA 13
PNEUMOVAX 23 ................. 45
POCKET CHAMBER .......... 105
POCKET PEAK FLOW
METER ............................ 105
POCKET SPACER ................ 13
POCKETCHEM EZ
CONTROL ....................... 105
POCKETPEAK PEAK FLOW
METER .............................. 13
podofilox .............................. 181
polyethylene glycol 3350 ..... 149
polyvitamin/iron .... 57, 196, 213,
233
PORTRAZZA......................... 38
potassium chloride ................ 129
potassium chloride crys er .... 128
potassium chloride er .... 128, 129
potassium citrate er ............... 119
POTELIGEO .......................... 38
praziquantel ............................ 27
prazosin hcl ....................... 49, 64
PRECISION GLUCOSE
CONTROL ......................... 13
PRECISION GLUCOSE
CONTROL SOLN .............. 13
PRECISION GLUCOSE
KETONE CONTR............ 105
PRECISION
GLUCOSE/KETONE
CONTR............................... 13
PRECISION THIN LANCETS
............................................ 13
PRECISION THINS GP
LANCETS .......................... 13
PRECISION ULTRA LANCET
............................................ 13
PRECISION XTRA KETONE
.......................................... 106
preferred plus lancets colored
.......................................... 106
preferred plus lancets thin .... 106
PREGNYL ............................ 155
premium automatic bp monitor
............................................ 13
premium condoms lubricated . 79
PRESERVISION AREDS .... 164
PRESERVISION AREDS 2 . 164
PRESERVISION/LUTEIN .. 164
pressure activat safety lancet .. 13
PRESTIGE GLUCOSE
CONTROL ....................... 106
pretomanid .............................. 27
prevent .................. 202, 221, 230
PREVNAR 13 ........................ 45
PREVYMIS ...................... 28, 29
PRIVIGEN ............................. 44
pro comfort alcohol .............. 179
pro comfort lancets 30g ........ 106
pro comfort lancets 31g ........ 106
pro comfort spacer adult ....... 106
pro comfort spacer child ....... 106
PRO-CAL ............................. 129
procare humidifier ................ 106
257
procare spacer/adult mask .... 106
procare spacer/child mask .... 106
PROCARE UPPER ARM BP
MONITOR ....................... 106
PROCARE WRIST BP
MONITOR ....................... 106
PROCERV HP 57, 196, 213, 233
PROCTOFOAM HC .... 177, 178
PROCYSBI .......................... 164
PRODIGY CONTROL
SOLUTION ...................... 106
PRODIGY LANCETS 21G . 106
PRODIGY LANCETS 26G . 106
PRODIGY LANCETS 28G . 106
PRODIGY LANCING DEVICE
.......................................... 106
PRODIGY SAFETY
LANCETS 26G ................ 106
PRODIGY TWIST TOP
LANCETS 28G ................ 106
PROGRAF ........................... 162
PROLASTIN-C .................... 176
PROLEUKIN ................. 38, 161
promethazine vc plain ..... 26, 47,
175
promethazine vc/codeine . 26, 48,
76, 168, 175
promethazine-codeine ... 76, 168,
175
promethazine-dm .... 26, 168, 175
promethazine-phenyleph-
codeine ... 26, 48, 76, 168, 175
promethazine-phenylephrine . 26,
48, 175
propafenone hcl ...................... 66
propantheline bromide............ 48
propylene glycol ................... 166
propylthiouracil .................... 153
PRORENAL + D ... 57, 213, 221,
227
PRORENAL + D W/ OMEGA-
3 .................. 57, 196, 213, 227
PROSIGHT .. 196, 202, 221, 230
PROTECT CARDIO AF ..... 196,
213
PROTECT PLUS ........... 57, 196
PROTECT PLUS AF ... 196, 213
PROTECT PLUS NF .... 57, 196,
213
PROTECT PLUS NR ........... 196
PROTECT PLUS SO ... 196, 213
PROTEGRA ........................... 13
PROVENGE ........................... 70
pseudoeph-bromphen-dm ...... 47,
167, 168, 175
pseudoephedrine hcl ....... 47, 167
pseudoephedrine-guaifenesin er
............................ 47, 167, 172
PSS SELECT GP LANCETS 13
PSS SELECT SAFETY
LANCETS .......................... 13
PULMOSAL ................ 106, 129
PULMOZYME ............. 133, 176
pure comfort humidifier ....... 106
PUREWAY-C ...................... 221
push button safety lancets....... 13
push button safety lancets 28g
.......................................... 106
px advanced formula multivits
.......................................... 196
px advanced lancing device .. 106
px b complex/vitamin c 213, 221
PX B-50 ................................ 213
px calcium antacid ........ 129, 140
px complete senior multivits 196
px folic acid .......................... 213
px iron..................................... 57
px lancet auto injector ............ 13
px lancets .............................. 106
px lancets ultra thin .............. 106
px lancets ultra thin 28g ....... 106
px mens multivitamins . 196, 213
px saline nasal spray ............. 135
px vegetable laxative ............ 149
px vitamin a ............................ 13
px vitamin c .......................... 221
px vitamin e .......................... 230
pyrazinamide .......................... 27
pyri 500................................. 213
PYRIDIUM .......................... 177
pyridostigmine bromide ... 49, 50
pyridostigmine bromide er ..... 49
pyridoxine hcl ............... 213, 214
Q qc acetaminophen 8 hours ...... 73
qc advanced lancing device .. 106
qc alcohol swabs ................... 179
qc antacid .............. 129, 140, 144
qc antacid/anti-gas 140, 144, 145
qc anti-diarrheal .................... 142
qc arthritis pain relief.............. 73
qc aspirin .............. 61, 63, 75, 78
qc aspirin low dose .... 61, 63, 75,
78
qc blood pressure monitor .... 106
qc calcium/minerals/vitamin d
.................................. 129, 227
qc complete allergy medicine 24,
26, 175
qc daily multivit/multimineral
.................................... 58, 196
qc daily multivitamins/iron.... 58,
196, 214
qc enema ............................... 149
qc enteric aspirin... 62, 63, 75, 78
qc ferrous sulfate .................... 58
qc gentle laxative .................. 149
qc lancets ................................ 13
qc lancets super thin 30g ...... 106
qc lancets thin ......................... 13
qc lancets ultra thin ............... 107
qc laxative ............................. 149
qc magnesium citrate ............ 149
qc mens daily multivitamin . 196,
214
qc milk of magnesia.............. 149
qc mineral oil heavy ............. 149
qc mucus relief er ................. 172
qc multivitamin cholesterol . 196,
214
qc multi-vite............ 58, 196, 214
qc multi-vite 50 & over ........ 196
qc nasal spray ......................... 13
qc natural vegetable laxative 149
qc natura-lax ......................... 149
qc non-aspirin childrens ......... 73
qc non-aspirin extra strength .. 73
qc pain relief ........................... 73
qc pain relief childrens ........... 73
qc pain relief extra strength .... 73
qc pain relief infants ............... 73
qc pediatric electrolyte ......... 129
qc senna ................................ 149
qc stool softener .................... 149
qc stool softener pls laxative 149
qc therin-m.............. 58, 196, 214
qc tussin cf .............. 48, 169, 172
qc tussin dm cough/congestion
.................................. 169, 172
qc tussin mucus/congestion .. 172
258
qc unilet lancets 28g ............. 107
qc unilet lancets micro thin .. 107
qc womens daily multivitamin
.................................... 58, 196
QUFLORA PEDIATRIC .... 160,
196, 197
QUICKTEK CONTROL
SOLUTION ...................... 107
quin b strong ................. 214, 221
quinidine gluconate er ...... 27, 65
quintabs ........................ 197, 214
quintabs-m ...... 58, 129, 197, 214
QUINTET CONTROL
HIGH/NORMAL ............. 107
R ra alcohol swabs ................... 179
ra antacid ...................... 129, 140
ra beta carotene..................... 202
ra blood pressure cuff monitor
.......................................... 107
ra bp wrist monitor automatic 13
ra calcium cit plus vit d-3 .... 129,
227
ra calcium citrate plus vit d . 129,
227
ra calcium cit-vit d-3 petites 129,
227
ra calcium/iron/vitamin d ....... 13
ra calcium/minerals/vitamin d
.................................. 129, 228
RA CENTRAL-VITE ... 58, 197,
214, 233
ra central-vite cardio............. 197
ra central-vite energy ..... 58, 197,
214
ra central-vite performance ... 58,
197
RA CENTRAL-VITE SELECT
.................................... 58, 197
ra central-vite senior ..... 197, 214
ra central-vite under 50 mens 58,
197, 214
ra central-vite under 50 women
.................... 58, 129, 197, 214
ra central-vite womens mature
............................ 58, 197, 214
RA CENTRAL-
VITE/ANTIOXIDANTS . 197,
214
RA E-ZJECT COLOR
LANCETS 33G .................. 13
RA E-ZJECT LANCETS 28G
.......................................... 107
RA E-ZJECT LANCETS THIN
26G ................................... 107
RA E-ZJECT LANCETS THIN
28G ................................... 107
RA E-ZJECT LANCETS
ULTRA THIN .................. 107
ra folic acid ........................... 214
ra hair/skin/nails ................... 197
RA HI-CAL ............................ 13
ra high potency iron ................ 58
ra iron ..................................... 58
ra isopropyl alcohol wipes .... 179
ra lancets alternate site ......... 107
ra lancets thin........................ 107
ra lancets ultra thin ............... 107
ra lancing device ..................... 13
ra laxative ....................... 14, 149
ra laxative extra strength ...... 149
ra laxative maximum strength
.......................................... 149
ra magnesium ....................... 141
ra melatonin .......................... 164
ra natural vitamin e ............... 230
ra one daily energy formula.. 197
ra one daily essential .... 197, 214
ra one daily gummy vites .... 197,
214
ra one daily maximum ... 58, 197,
214
ra one daily mens 50+ w/vit d3
.......................... 197, 214, 233
ra one daily mens/vit d-3 ..... 197,
214, 233
ra one daily multi-vit plus fe . 58,
197
ra one daily multi-vitamin .... 197
ra one daily womens ...... 58, 129,
197, 214
ra oyster shell calcium ............ 14
ra oyster shell calcium/d ...... 129,
228
ra ped electrolyte freezer pop129
ra pediatric electrolyte .......... 129
ra saline nasal spray .............. 135
ra senna ........................... 14, 149
ra slow release iron ................. 58
ra stress formula advanced .. 197,
214
ra stress formula energy....... 197,
214, 221
ra therapeutic m plus beta car 58,
197
ra vision vite plus zinc .......... 197
ra vitamin a ........................... 202
ra vitamin b-1 ....................... 214
ra vitamin b-12 ..................... 214
ra vitamin b-12 tr .................. 214
ra vitamin b-6 ....................... 214
ra vitamin b-6 cr ................... 214
ra vitamin c ..................... 14, 221
ra vitamin c cr ....................... 221
ra vitamin c/acerola .............. 221
ra vitamin c/rose hips.... 221, 222
ra vitamin c/rose hips cr ....... 221
ra vitamin d-3 ....................... 228
ra vitamin e ........................... 230
ra vitamin e blend ................. 230
RA WHOLE SOURCE
DIETARY......................... 198
RA WHOLE SOURCE
DIETARY MATURE ....... 197
RA WHOLE SOURCE
DIETARY MEN ............... 197
RA WHOLE SOURCE FOR
MEN ................................. 198
rabano yodado ...................... 215
RADICAVA ........................... 76
RAGUS................................... 14
RANGER READY
REPELLENT .................... 181
READYLANCE SAFETY
LANCETS ........................ 107
reality lancets .......................... 14
REALITY LATEX CONDOMS
............................................ 79
REALITY LATEX/ULTRA
TEXTURED ....................... 14
REALITY LATEX/ULTRA
THIN................................... 14
reality swabs ........................... 14
reality trigger lancets .............. 14
REBLOZYL ........................... 50
RECOMBIVAX HB ......... 45, 46
REFRESH............................. 135
REFRESH OPTIVE ............. 135
REFRESH PLUS .................. 135
259
REFRESH REPAIR ............. 135
REFRESH TEARS ............... 136
REFUAH PLUS GLUCOSE
CONTROL ....................... 107
REGULOID ......................... 149
REHYDRALYTE .................. 14
RELION ALCOHOL SWABS
.................................... 14, 179
RELION BLOOD PRESSURE
MONITOR ....................... 107
RELION KETONE .............. 118
RELION KETONE TEST .... 118
RELION LANCET DEVICES
30G ................................... 107
RELION LANCETS ............ 107
RELION LANCETS MICRO-
THIN 33G ........................ 107
RELION LANCETS
STANDARD 21G ............ 107
RELION LANCETS THIN 26G
.......................................... 107
RELION LANCETS ULTRA-
THIN 30G ........................ 107
RELION LANCING DEVICE
.......................................... 107
RELION PREMIUM
MONITOR ....................... 107
RELION THIN LANCETS .... 14
RELION ULTRA THIN
LANCETS 30G ................ 107
RELION ULTRA THIN PLUS
LANCETS ........................ 107
REMODULIN ................ 69, 176
RENAL................................... 14
RENAL
MULTIVITAMIN/ZINC ... 14
RENAPLEX ................. 215, 222
RENAPLEX-D .... 215, 222, 228,
230
RENEW ADV CARTRIDGE
REFILLS .......................... 107
RENEW ADVANCED
LANCING DEVICE ........ 107
REPEL 100 ........................... 181
REPEL FAMILY ......... 180, 181
REPEL FAMILY DRY ........ 181
REPEL HUNTERS FORMULA
.................................. 180, 181
REPEL SPORTSMEN . 180, 181
REPEL SPORTSMEN DRY
.................................. 180, 181
REPEL SPORTSMEN MAX
.................................. 180, 182
REPEL TICK DEFENSE ..... 182
replace .................................... 14
REQ 49+ ............................... 198
RESCON-GG ................. 48, 172
REVCOVI ............................ 133
revital freezer pops ................. 14
revital jell cups ....................... 14
revital liquid squeezers ........... 14
REXALL LANCETS ULTRA
THIN 30G......................... 107
RHOGAM ULTRA-FILTERED
PLUS .................................. 44
RHOPHYLAC........................ 44
ribavirin .................................. 29
rifabutin ............................ 27, 30
RIFADIN .......................... 28, 30
rifampin ............................ 28, 30
RIGHTEST GC300 CONTROL
.................................. 107, 108
RIGHTEST GD500 LANCING
DEVICE ........................... 108
RIGHTEST GL300 LANCETS
.......................................... 108
RILUTEK ............................... 76
riluzole .................................... 76
RITEFLO.............................. 108
RITUXAN .............................. 38
RITUXAN HYCELA ............. 38
robafen ac ............... 76, 169, 172
robafen cf multi-symptom cold
............................ 48, 169, 172
robafen dm .................... 169, 172
ROBAFEN DM CGH/CHEST
CONGEST................ 169, 172
ROBAFEN DM COUGH .... 169,
172
ROBAFEN DM COUGH
CLEAR ..................... 169, 172
ROBAFEN MUCUS/CHEST
CONGESTION ................ 172
romidepsin .............................. 38
rulox.............................. 141, 145
RUZURGI ............................ 164
S SAFE-LUV CONDOMS ........ 14
SAFESNAP SYRINGE ........ 108
SAFESNAP TUBERCULIN
SYRINGE ......................... 108
SAFE-T-LANCE .................... 14
SAFE-T-LANCE PLUS ......... 14
safety lancet 21g/pressure act
.......................................... 108
safety lancet 28g/pressure act
.......................................... 108
SAFETY LANCET 2MM .... 108
SAFETY LANCETS ............ 108
SAFETY LANCETS 21G .... 108
safety lancets 28g ................. 108
SAFETY LET LANCETS .... 108
SAFETY SEAL LANCETS . 108
safety syringe/needle .............. 14
safety syringes/needle ............. 14
SAFETY-LOK SYRINGE ... 108
SAFETY-LOK TB SYRINGE
.......................................... 108
SALACTIC FILM ................ 178
saline mist spray ................... 136
saline nasal spray .................. 136
SAL-PLANT ........................ 178
salsalate................................... 78
SAMSCA .............................. 132
SANA-LOK CONTROL
SYRINGE ........................... 14
SANDOSTATIN .......... 156, 165
SANDOSTATIN LAR DEPOT
.......................... 156, 164, 165
SANI-SUPP PEDIATRIC .... 150
SANTYL .............................. 182
saps care alcohol prep ........... 179
saps health alcohol prep........ 179
saps health care alcohol prep 179
saps health twist top lancets . 108
saps twist top lancets ............ 108
sapscare twist top lancets...... 108
SARNA SENSITIVE ........... 177
SAVISION ........................... 198
SAWYER INSECT
REPELLENT .................... 182
sb alcohol prep ........................ 14
sb antacid ...................... 129, 141
sb aspirin ............... 62, 64, 75, 78
sb lancets thin ....................... 109
sb lancets ultra thin ............... 109
sb oyster shell calcium.......... 129
sb pediatric electrolyte .......... 129
sb saline nose ........................ 136
260
sb senna-lax .......................... 150
sb vitamin c .......................... 222
SCLEREX .............................. 14
sea soft nasal mist ................. 136
SECURESAFE
SYRINGE/NEEDLE .......... 15
SECURESAFE TUBERCULIN
SYRINGE........................... 15
select-lite lancing device ...... 109
selenium sulfide.................... 179
self-taking blood pressure .... 109
SENETONIC .......................... 15
senexon ................................. 150
SENEXON-S ........................ 150
senior tabs ..................... 198, 215
senna ............................... 15, 150
senna concentrate ................. 150
senna lax ............................... 150
senna laxative ....................... 150
senna leaves .......................... 150
senna maximum strength ........ 15
senna plus ............................. 150
senna-docusate sodium ......... 150
senna-gen .............................. 150
senna-grx .............................. 150
senna-lax............................... 150
senna-s .................................. 150
senna-tabs ............................. 150
senna-time ............................ 150
senna-time s .......................... 150
sennazon ................................. 15
SENNO................................. 150
sennosides............................... 15
sennosides-docusate sodium 150
SENOKOT ........................... 150
SENOKOT S ........................ 150
sen-o-tabs ............................. 150
sentry ...................... 58, 198, 215
sentry adult ........................... 198
sentry senior ................. 198, 215
sf 160
sf 5000 plus .......................... 160
sg saline nasal ......................... 15
SHINGRIX ............................. 46
SHOPKO ALCOHOL SWABS
............................................ 15
SHOPKO AUTOLET
LANCING DEVICE ........ 109
SHOPKO ON-THE-GO
LANCETS 30G ................ 109
SHOPKO UNILET LANCETS
28G ................................... 109
SHOPKO UNILET LANCETS
30G ................................... 109
side button safety lancet ......... 15
SIDEROL ............... 58, 215, 222
SIGNIFOR............................ 157
SIGNIFOR LAR........... 156, 157
SIGTAB.................................. 15
silace ..................................... 150
siladryl allergy .......... 24, 26, 175
siltussin dm das ............ 169, 173
siltussin-dm alcohol free ..... 169,
173
SILVADENE........................ 179
silver sulfadiazine ................. 179
simethicone ........................... 145
SIMPLE DIAGNOSTICS
LANCING DEV ............... 109
SIMULECT .......................... 162
SINGLE-LET ......................... 15
sinus nasal spray ................... 137
sinus relief nasal spray ......... 137
SIVEXTRO ............................ 30
sleep aid .............. 24, 26, 76, 175
slip tip syringe ...................... 109
slow iron ................................. 58
slow release iron ..................... 58
sm 8 hour pain relief ............... 73
sm alcohol prep .................... 179
sm allergy 4 hour ............ 26, 175
sm allergy relief ........ 24, 26, 175
sm antacid advanced ..... 141, 145
sm antacid advanced max st 141,
145
sm antacid/antigas ........ 141, 145
sm anti-diarrheal ................... 142
sm antioxidant vitamins........ 198
sm arthricream rub.................. 78
sm arthritis pain relief............. 73
sm arthritis pain reliever ......... 73
sm aspirin ............. 62, 64, 75, 78
sm aspirin adult low strength. 62,
64, 75, 78
sm aspirin ec ......... 62, 64, 75, 78
sm aspirin low dose ... 62, 64, 75,
78
sm b super vitamin complex 215,
222
sm balanced b-100 ................ 215
sm balanced b-50 .................. 215
sm b-complex/vitamin c215, 222
sm biotin ............................... 215
sm blood pressure monitor ... 109
sm calcium ............................ 130
sm calcium 600 ..................... 129
sm calcium antacid ....... 130, 141
sm calcium antacid ex st ...... 129,
141
sm calcium antacid ultra st .. 130,
141
sm calcium citrate w/vit d3.. 130,
228
sm calcium citrate+/vit d3 ... 130,
228
sm calcium citrate+d3 petite 130,
228
sm calcium citrate-vit d 130, 228
sm calcium/vitamin d/minerals
.................................. 130, 228
sm chewable c....................... 222
sm chewable vitamin c ......... 222
sm childrens aspirin ... 62, 64, 75,
78
SM CLEARLAX .................. 150
sm complete ............ 58, 198, 215
sm complete 50+ .......... 198, 215
sm complete 50+ ultimate mens
.................................. 198, 215
sm complete 50+ ultimate
women ................ 58, 198, 215
sm complete advanced formula
............................ 58, 198, 215
sm complete senior formula 198,
215
SM CORAL CALCIUM ...... 130
sm ear drops .......................... 134
sm enema ........................ 15, 150
sm fiber ................................. 150
sm folic acid ......................... 215
sm gas relief .......................... 145
sm gas relief extra strength ... 145
sm gentle laxative ................. 151
sm glucose ............................ 119
sm hair/skin/nails .................. 198
sm humidifier/cool mist .......... 15
sm iron .................................... 15
sm iron slow release ............... 59
sm lancets 21g ...................... 109
sm lancets 33g ...................... 109
261
sm laxative maximum strength
.......................................... 151
sm lubricating plus ............... 136
sm magnesium citrate ........... 151
sm milk of magnesia ............ 151
sm mineral oil ....................... 151
sm mucus relief d ... 47, 167, 173
sm mucus relief max strength
.......................................... 173
sm multiple vitamins essential
.......................................... 198
sm multiple vitamins/iron...... 59,
198
sm nasal decongestant max st 47,
167
sm nasal spray ...................... 137
sm nasal spray 12 hour ......... 137
sm nasal spray moisturizing . 137
sm nasal spray saline ............ 136
sm nasal spray sinus ............. 137
sm one daily essential ... 198, 215
sm one daily mens 198, 215, 233
sm one daily womens .... 59, 130,
198, 215
sm opti-vitamins ................... 198
sm oyster shell calcium/vit d3
.................................. 130, 228
sm pain & fever childrens ...... 73
sm pain & fever infants .......... 73
sm pain reliever ...................... 73
sm pain reliever ex st .............. 73
sm pediatric electrolyte ........ 130
sm senna laxative ................. 151
sm senna laxative max st ...... 151
sm senna-s ............................ 151
sm sleep aid ........ 24, 26, 76, 175
sm slow release iron ............... 59
sm stomach relief ......... 141, 142
sm stool softener........... 151, 165
sm stool softener/laxative ..... 151
sm stress formula b-complex/zn
.......................................... 215
sm super thin lancets 30g ..... 109
sm therapeutic-m .... 59, 198, 215
sm thin lancets 26g ............... 109
SM TRUEDRAW LANCING
DEVICE ............................. 15
sm tussin cf ............. 48, 169, 173
sm tussin cough/chest congest
.................................. 169, 173
sm tussin dm ................. 169, 173
sm tussin mucus+chest congest
.......................................... 173
sm vit c/rose hips .................. 222
sm vitamin b1 ....................... 215
sm vitamin b-1 ...................... 215
sm vitamin b-12 .................... 215
sm vitamin b12 tr .................. 215
sm vitamin b-12 tr ................ 215
sm vitamin b6 ....................... 215
sm vitamin b-6 ...................... 215
sm vitamin c ......................... 222
sm vitamin c cr ..................... 222
sm vitamin c/rose hips .......... 222
sm vitamin d3 ....................... 228
sm vitamin e ......................... 230
sm wrist cuff bp monitor ...... 109
SMART DIABETES
VANTAGE LANCETS .... 109
SMART DIABETES
VANTAGE LANCING .... 109
SMART SENSE COLOR
LANCETS 33G ................ 109
SMART SENSE STANDARD
LANCETS ........................ 109
SMART SENSE SUPER THIN
LANCETS ........................ 109
SMART SENSE THIN
LANCETS 26G ................ 109
SMARTEST CONTROL
MEDIUM ......................... 109
SMARTEST LANCETS 28G
.......................................... 109
sod citrate-citric acid ............ 119
sodium bicarbonate............... 141
sodium chloride ...... 15, 109, 130
sodium chloride (hypertonic) 136
sodium fluoride..................... 160
sodium polystyrene sulfonate
.................................. 121, 158
SOLARTEK GLUCOSE
CONTROL ......................... 15
SOLIRIS ............................... 160
solo ....................... 198, 215, 233
SOLUS V2 CONTROL........ 109
SOLUS V2 LANCETS 28G. 109
SOLUS V2 LANCING
DEVICE ........................... 109
SOLUS V2 TWIST LANCETS
30G ................................... 109
SOMATULINE DEPOT ...... 157
SOMAVERT ........................ 157
SOURCECF ................. 198, 216
sphygmomanometer ............... 15
spinal needle ............. 15, 16, 110
spinal needle tw .............. 16, 110
spinal needle/stylet tw ............ 16
SPINRAZA................... 159, 165
spironolactone........... 67, 68, 121
spironolactone-hctz.... 67, 68, 69,
121, 131
SPS ............................... 121, 158
SSD ....................................... 179
SSKI ............... 27, 153, 158, 173
ST JOSEPH LOW DOSE 62, 64,
75, 78
STERILANCE TL ................ 110
STERILE DILUENT FOR
FLOLAN .......................... 166
sterile diluent/epoprostenol .. 166
sterile water for irrigation ..... 120
STIMATE ....................... 51, 156
STIMEX INSULATED
NEEDLE............................. 16
stimulant laxative.................. 151
stomach relief ............... 141, 143
stomach relief max st .... 141, 142
stool softener ........................ 151
stool softener laxative ........... 151
stool softener plus laxative ... 151
STRENSIQ ........................... 133
stress 500 b-complex ............ 198
stress 500 b-complex/zinc .... 198
stress b complex/zinc .... 216, 222
stress b/zinc .......................... 198
stress b-complex/vit c/zinc .. 216,
222
stress formula........................ 198
stress formula 500/biotin ........ 16
stress formula 500/zinc ........... 16
stress formula/iron . 59, 216, 222,
230
stress formula/iron/biotin........ 16
stress formula/zinc ................ 198
stress tab nf ........................... 198
stress/iron ................................ 16
stress/zinc ............................. 198
STRESSTABS ADVANCED 16
STRESSTABS ENERGY ...... 16
STROMECTOL ..................... 27
262
STROVITE................... 216, 222
STROVITE ADVANCE ..... 198,
216
STROVITE FORTE ...... 59, 198,
216
STROVITE ONE . 198, 216, 228
STROVITE PLUS .. 59, 199, 216
sucralfate .............................. 152
SUDACARE ADVANCED
VAPOR-PLUG................. 110
SUDOGEST ................... 47, 167
SUDOGEST MAXIMUM
STRENGTH ............... 47, 167
SUDOGEST
SINUS/ALLERGY...... 26, 47,
167, 175
sulfadiazine............................. 30
sulfamethoxazole-trimethoprim
............................................ 30
SULFATRIM PEDIATRIC ... 30
SUNBEAM COOL SPRAY
HUMIDIFIER .................... 16
SUNBEAM EVAP
HUMIDIFIER .................... 16
SUNBEAM HUMIDIFIER .... 16
SUNBEAM PORTABLE
VAPORIZER ..................... 16
SUNBEAM ULTRA-SONIC
HUMIDIFIER .................... 16
SUNBEAM VAPORIZER ..... 16
SUNVITE ADVANCED .... 199,
216
super antioxidant .................. 199
super aytinal ........................... 16
super aytinal 50 plus ............... 16
super b complex maxi .......... 216
super b complex/fa/vit c216, 222
super b-50 complex .............. 216
super b-complex/vit c/fa ...... 216,
222
super biotin ........................... 216
super calcium........................ 130
super ginseng multivitamin .. 199
super mega vite 75/beta caro 199
super multiple ............... 199, 216
SUPER NU-THERA ............ 199
super thera vite m ................. 199
super thin lancets .................. 110
super vikaps .......................... 199
super vita-mins ....................... 16
support .................................. 199
supreme ii high/low control .... 16
SURBEX W/ZINC ................. 16
sure comfort alcohol prep ..... 179
sure comfort lancets 18g....... 110
sure comfort lancets 21g....... 110
sure comfort lancets 23g....... 110
sure comfort lancets 28g....... 110
sure comfort lancets 30g....... 110
sure comfort lancing pen ...... 110
SURE EDGE GLUCOSE
CONTROL ....................... 110
SURECHEK CONTROL
SOLUTION ................ 17, 110
SURE-LANCE FLAT
LANCETS ........................ 110
SURE-LANCE LANCETS 26G
............................................ 17
SURE-LANCE THIN
LANCETS 28G ................ 110
SURE-LANCE ULTRA THIN
LANCETS ........................ 110
SURELIFE BP
MONITOR/ARM ............. 110
SURELIFE BP
MONITOR/WRIST .......... 110
SURELITE LANCETS .......... 17
SURE-PEN ............................. 17
SURE-PREP ALCOHOL PREP
.......................................... 179
SURESTEP GLUCOSE
CONTROL ....................... 110
SURESTEP PRO HIGH
GLUCOSE........................ 110
SURESTEP PRO LOW
GLUCOSE........................ 110
SURESTEP PRO NORMAL
GLUCOSE........................ 110
SURE-TEST EASYPLUS
CONTROL ....................... 110
SURE-TOUCH LANCETS
UNIVERSAL ................... 110
SYLATRON ..................... 29, 38
SYLVANT ............................. 39
SYMDEKO .......................... 170
sympathetic nerve needle ....... 17
SYNAGIS ............................... 29
SYNDION .................... 199, 216
SYNDION-SF .............. 199, 216
SYNRIBO .............................. 39
SYPRINE ............................. 152
syringe ............................ 17, 111
syringe 10-12 ml ................... 110
syringe 20-25 ml ................... 111
syringe 30-35 ml ................... 111
syringe 50-60 ml ................... 111
syringe 5-6 ml ....................... 111
syringe disposable ................ 111
syringe disposable 50-60ml .. 111
syringe eccentric tip .............. 111
syringe luer lock ....... 17, 18, 111
syringe luer slip .............. 18, 111
syringe/cannula ............... 18, 111
syringe/hypodermic safety...... 18
SYSTANE ICAPS AREDS2
.......................... 199, 222, 230
T T.E.D. BELOW KNEE/L X-
LGTH ................................. 18
T.E.D. BELOW KNEE/LARGE
............................................ 18
T.E.D. BELOW KNEE/L-
REGULAR ......................... 18
T.E.D. BELOW KNEE/M X-
LGTH ................................. 18
T.E.D. BELOW
KNEE/MEDIUM ................ 18
T.E.D. BELOW KNEE/M-
REGULAR ......................... 18
T.E.D. BELOW KNEE/S X-
LGTH ................................. 18
T.E.D. BELOW KNEE/SMALL
............................................ 18
T.E.D. BELOW KNEE/S-
REGULAR ......................... 18
T.E.D. BELOW KNEE/XL .... 18
T.E.D. BELOW KNEE/XL X-
LGTH ................................. 18
T.E.D. BELOW KNEE/X-
LARGE ............................... 18
T.E.D. BELTED THIGH/L-
LONG ............................... 111
T.E.D. BELTED THIGH/M-
REGULAR ....................... 111
T.E.D. BELTED THIGH/S-
LONG ............................... 111
T.E.D. BELTED THIGH/XL-
LONG ............................... 111
T.E.D. BELTED THIGH/XL-
REGULAR ....................... 111
263
T.E.D. BELTED THIGH/XS-
LONG ............................... 111
T.E.D. BELTED THIGH/XS-
REGULAR ....................... 111
T.E.D. KNEE LENGTH/L-
LONG ............................... 111
T.E.D. KNEE LENGTH/L-
REGULAR ....................... 111
T.E.D. KNEE LENGTH/M-
LONG ............................... 111
T.E.D. KNEE LENGTH/M-
REGULAR ....................... 111
T.E.D. KNEE LENGTH/S-
LONG ....................... 111, 112
T.E.D. KNEE LENGTH/S-
REGULAR ....................... 112
T.E.D. KNEE LENGTH/XL-
LONG ............................... 112
T.E.D. KNEE LENGTH/XL-
REGULAR ....................... 112
T.E.D. THIGH LENGTH/L-
LONG ............................... 112
T.E.D. THIGH LENGTH/L-
REGULAR ....................... 112
T.E.D. THIGH LENGTH/L-
SHORT ............................. 112
T.E.D. THIGH LENGTH/M-
LONG ............................... 112
T.E.D. THIGH LENGTH/M-
REGULAR ....................... 112
T.E.D. THIGH LENGTH/M-
SHORT ............................. 112
T.E.D. THIGH LENGTH/S-
LONG ............................... 112
T.E.D. THIGH LENGTH/S-
REGULAR ....................... 112
T.E.D. THIGH LENGTH/S-
SHORT ............................. 112
TAB-A-VITE ......... 59, 199, 216
TAB-A-VITE MAXIMUM.. 199
TAB-A-VITE WOMENS ..... 59,
199
TAB-A-VITE/BETA
CAROTENE..................... 199
tab-a-vite/iron ................. 59, 199
TAB-A-VITE/WEIGHTSLIM
............................ 59, 199, 216
tactinal .................................... 73
tactinal extra strength ............. 73
TAI DOC CONTROL .......... 112
TAKE ACTION ................... 153
talking blood pressure monitor
............................................ 18
talking sense bp monitor....... 112
TAPAZOLE ......................... 153
TARGRETIN ................. 39, 182
TAXOTERE ........................... 39
TECENTRIQ .......................... 39
TECHLITE AST LANCETS 112
TECHLITE LANCETS ........ 112
TECHLITE LANCETS 30G 112
TEGSEDI ............................. 159
TELCARE GLUCOSE
CONTROL ....................... 112
TEMODAR ............................ 39
teniposide................................ 39
TEPADINA ............................ 39
TERUMO SURGUARD2
SYRINGE ................. 112, 113
TERUMO SYRINGE ........... 113
TERUMO SYRINGE/NEEDLE
.......................................... 113
TESSALON PERLES .......... 169
tgt advanced lancing device . 113
tgt alcohol swabs .................. 179
tgt blood pressure monitor .... 113
tgt lancet alternate site .......... 113
tgt lancet micro thin 33g ....... 113
tgt lancet super thin 30g ....... 113
tgt lancet thin 23g ................. 113
tgt lancet thin 26g ................. 113
tgt lancet ultra thin 28g ......... 113
tgt lancet ultra thin 30g ......... 113
tgt lancing device.................. 113
tgt laxative pills max st ......... 151
tgt nasal spray ....................... 136
tgt natural laxative pills ........ 151
tgt saline nasal spray............. 136
tgt senna ................................ 151
tgt senna laxative .................. 151
th antacid regular strength .... 130
th b 100 complex .................. 216
th b complex/iron/c/e ..... 59, 216,
222, 230
th calcium citrate-vitamin d . 130,
228
th complete multi .................. 199
th complete multi 50+ .. 199, 216
th daily multiple vitamin/iron 59,
199, 216
th daily multiple vitamins ..... 199
th premium daily multiple ..... 59,
199, 216
th slow release iron ................. 18
th theradex-m .. 59, 130, 199, 216
th vision vitamins ................. 199
th vitamin b12 ....................... 216
th vitamin b-12 ..................... 216
th vitamin b12 er ................... 216
th vitamin b-6 ....................... 216
th vitamin c ........................... 222
th vitamin d3 ......................... 228
th vitamin e ........................... 230
th womens daily ..... 59, 130, 199,
216
THEO-24 ........ 66, 120, 177, 182
theophylline er 66, 120, 177, 182
THERA ................................. 199
THERA M PLUS .. 59, 130, 199,
216
thera vital m ............................ 18
therabasic-m ........................... 18
THERAGRAN-M... 59, 200, 217
THERAGRAN-M
ADVANCED ...... 59, 200, 217
THERAGRAN-M
ADVANCED 50 PLUS ... 200,
217
THERAGRAN-M PREMIER
............................ 59, 200, 217
THERAGRAN-M PREMIER
50 PLUS ................... 200, 217
thera-m ............ 59, 130, 200, 217
thera-m multiple vitamins....... 18
THERAMILL FORTE . 200, 217
therapeutic ............................ 200
therapeutic formula/hematinics
.................................... 59, 200
therapeutic liquid .................. 200
therapeutic m .......... 59, 200, 217
therapeutic multivit/mineral ... 18
therapeutic-m .. 59, 130, 200, 217
therapeutic-m/lutein ....... 59, 130,
200, 217
thera-tabs .............................. 200
thera-tabs m .... 59, 130, 200, 217
THERATRUM COMPLETE 59,
200
THERATRUM COMPLETE 50
PLUS ........................ 200, 217
264
theravim-m ............................. 18
THEREMS ................... 200, 217
therems m ....................... 59, 200
THEREMS-H ................. 59, 200
THEREMS-M ................ 59, 200
therobec ........................ 217, 222
therobec plus .................. 59, 200
thevimine-t ............................. 18
THINLETS GP LANCETS .... 18
THINLETS LANCET ............ 18
THIOLA ............................... 165
thiotepa ................................... 39
THYMOGLOBULIN ........... 162
THYROGEN ........................ 118
TICE BCG ........................ 39, 46
ticlopidine hcl ......................... 62
tigecycline .............................. 28
TIGLUTIK ............................. 76
todays health lancing device 113
todays health thin lancets 28g
.......................................... 113
todays health thin lancets 30g
.......................................... 113
toomey syringe ..................... 113
topcare lancets micro-thin 33g
.......................................... 113
TOPOSAR .............................. 39
topotecan hcl .......................... 39
torsemide ........................ 67, 121
TOTAL FORMULA .............. 19
TOTAL FORMULA 2 ........... 18
TOTAL FORMULA 3 ........... 18
TOTECT............................... 165
travel lancets ......................... 113
TRAVEL LANCETS
ADVANCED 28G............ 113
TREANDA ............................. 39
treprostinil ...................... 69, 176
triamterene-hctz 68, 69, 121, 131
trientine hcl ........................... 152
trifluridine............................. 133
TRIKAFTA .......................... 170
TRILYTE ............................. 151
trimagen .................................. 60
trimagen fa.............. 60, 217, 222
trimagen forte ......... 60, 217, 222
TRISENOX ............................ 39
tri-vit/fluoride ...... 160, 200, 202,
223, 228
tri-vit/fluoride/iron . 60, 160, 200
tri-vitamin/fluoride ...... 160, 200,
202, 223, 228
tri-vite/fluoride .... 160, 200, 202,
223, 228
TROJAN ................................. 19
TROJAN ASSORTMENT
PACK ................................. 19
TROJAN EXTENDED
PLEASURE/LUBE ............ 19
TROJAN EXTRA STRENGTH
............................................ 19
TROJAN MAGNUM ............. 19
TROJAN MAGNUM WARM
SENSATIONS.................... 19
TROJAN MAGNUM XL
LUBRICATED ................... 19
TROJAN NATURALAMB ... 19
TROJAN
NATURALAMB/SPERMICI
DE ....................................... 19
TROJAN PLEASURE
MESH/SPERMICID .......... 19
TROJAN PLUS ...................... 19
TROJAN REGULAR ............. 19
TROJAN RIBBED ................. 19
TROJAN
RIBBED/SPERMICIDAL.. 19
TROJAN SHARED
SENSATION/LUBE .......... 19
TROJAN SUPRAS
SPERMICIDAL ................. 19
TROJAN TWISTED
PLEASURE ........................ 19
TROJAN ULTRA PLEASURE
LUBRICAT ........................ 19
TROJAN VERY SENSITIVE
LUBRICAT ........................ 19
TROJAN VERY SENSITIVE
SPERMICI.......................... 19
TROJAN VERY THIN
LUBRICATED ................... 19
TROJAN VERY THIN
SPERMICIDE .................... 19
TROJAN-ENZ LUBRICATED
............................................ 19
TROJAN-ENZ/SPERMICIDAL
............................................ 19
trolamine salicylate................. 78
true comfort alcohol prep pads
.......................................... 179
true comfort twist top lancets114
TRUE METRIX LEVEL 1 ... 114
TRUE METRIX LEVEL 2 ... 114
TRUE METRIX LEVEL 3 ... 114
TRUECONTROL GLUCOSE
CONT LEV 0 ................... 114
TRUECONTROL GLUCOSE
CONT LEV 1 ................... 114
TRUEDRAW LANCING
DEVICE ........................... 114
TRUEPLUS DIABETIC
MULTIVITAMIN ... 200, 217,
233
TRUEPLUS GLUCOSE ..... 119,
228
TRUEPLUS GLUCOSE ON
THE GO.................... 119, 228
TRUEPLUS LANCETS 26G
.......................................... 114
TRUEPLUS LANCETS 28G
.......................................... 114
TRUEPLUS LANCETS 30G
.......................................... 114
TRUEPLUS LANCETS 33G
.......................................... 114
TRUEPLUS SAFETY
LANCETS 28G ................ 114
TRUETEST CONTROL
LEVEL 1 .......................... 114
TRUETEST CONTROL
LEVEL 2 .......................... 114
TRUETEST CONTROL
LEVEL 3 .......................... 114
TRUETRACK GLUCOSE
CONTROL ....................... 114
TRUSTEX COLOR
CONDOMS + LUBE ......... 19
TRUSTEX
LUB/RIBBED/STUDDED. 79
TRUSTEX LUB/SPERMICIDE
EX ST ................................. 79
TRUSTEX LUB/SPERMICIDE
XL ....................................... 79
TRUSTEX LUBRICATED .... 79
TRUSTEX LUBRICATED EX
LARGE ............................... 79
TRUSTEX LUBRICATED
EXTRA ST ......................... 79
265
TRUSTEX
LUBRICATED/SPERMICID
E ......................................... 79
TRUSTEX NATURAL
CONDOMS + LUBE ......... 19
TRUSTEX NON-
LUBRICATED................... 79
TRUSTEX RIA
LUB/SPERMICIDE ........... 79
TRUSTEX RIA LUBRICATED
............................................ 79
TRUSTEX RIA NON-
LUBRICATED................... 79
TRUSTEX-NONOXYNOL-
9/RIB/STUD....................... 79
TRUZONE PEAK FLOW
METER ............................ 114
tuberculin syringe ................. 114
TUMS ........................... 131, 141
TUMS CHEWY BITES ...... 130,
141
TUMS E-X 750 ............ 130, 141
TUMS EXTRA STRENGTH
750 ............................ 131, 141
TUMS FRESHERS ...... 131, 141
TUMS KIDS ................ 131, 141
TUMS LASTING EFFECTS . 19
TUMS SMOOTHIES ... 131, 141
TUMS ULTRA 1000 ... 131, 141
tuohy epidural needle tw .. 19, 20
TUSNEL C ...... 47, 76, 167, 169,
173
tusnel diabetic ............... 169, 173
tussin cf .................. 48, 169, 173
tussin cf cough & cold ... 48, 169,
173
tussin dm ...................... 169, 173
tussin dm clear .............. 169, 173
tussin dm cough + chest169, 173
tussin mucus & chest congest
.......................................... 173
tussin mucus+chest congestion
.......................................... 173
tussin multi-symptom cold cf 48,
169, 173
TWINRIX......................... 20, 46
two party blood pressure ...... 114
TYGACIL .............................. 29
U UDAMIN SP ................ 200, 217
ULTICARE ALCOHOL
SWABS ............................ 179
ULTICARE THIN LANCETS
28G ................................... 114
ULTICARE THIN LANCETS
30G ................................... 114
ULTICARE TUBERCULIN
SAFETY SYR .......... 114, 115
ULTI-LANCE AUTO-ADJUST
DEVICE ........................... 115
ULTI-LANCE AUTOMATIC
.......................................... 115
ULTI-LANCE MINI
ADJUSTABLE ................... 20
ultilet alcohol swab ............... 179
ultilet alcohol swabs ............. 179
ULTILET BASIC LANCETS
30G ................................... 115
ULTILET CLASSIC
LANCETS ........................ 115
ultilet glucose ....................... 120
ULTILET LANCETS........... 115
ULTILET OPERATING
DEVICE ............................. 20
ULTILET SAFETY LANCETS
............................................ 20
ULTILET SAFETY LANCETS
23G ................................... 115
ULTILET ULTI-LANCE ADJ
DEVICE ............................. 20
ULTIMATE FEELING .......... 20
ultimate teen ................... 60, 200
ULTOMIRIS ........................ 161
ultra antioxidant formula ...... 200
ultra b-100 complex.............. 217
ultra freeda ............ 131, 200, 217
ultra freeda/iron ..... 60, 131, 200,
217
ultra thin lancets 28g ............ 115
ultra thin lancets 30g ............ 115
ultra thin lancets 31g ............ 115
ultra-care alcohol prep pads . 179
ultra-care lancets 30g............ 115
ULTRACHOICE ADV
FORMULA MATURE....... 20
ULTRACHOICE ADVANCED
FORMULA ........................ 20
ultrasonic humidifier .............. 20
ULTRA-THIN II AUTO
LANCET .......................... 115
ULTRA-THIN II LANCETS115
ULTRATHON INSECT
REPELLENT 8 ......... 180, 182
ULTRATRAK PRO
CONTROL ....................... 115
ULTRATRAK ULTIMATE
CONTROL ....................... 115
unicomplex-m ................. 60, 200
uni-daily/iron .......................... 20
UNILET COMFORTOUCH
LANCET .......................... 115
UNILET EXCELITE............ 115
UNILET EXCELITE II ........ 115
UNILET G.P. LANCET ....... 115
UNILET G.P. SUPERLITE
LANCET .......................... 115
UNILET GP 28 ULTRA THIN
.......................................... 115
UNILET LANCET ............... 115
UNILET MICRO-THIN 33G
.......................................... 115
UNILET SUPERLITE
LANCET .......................... 115
UNILET SUPER-THIN 30G 115
UNILET ULTRA-THIN 28G
.......................................... 115
UNISTIK 3 GENTLE........... 115
UNISTIK PRO SAFETY
LANCET .......................... 116
UNISTIK SAFETY LANCETS
28G ................................... 116
UNISTIK SAFETY LANCETS
30G ................................... 116
UNISTIK TOUCH SAFETY
LANC 21G ....................... 116
UNISTIK TOUCH SAFETY
LANC 23G ....................... 116
UNISTIK TOUCH SAFETY
LANC 28G ....................... 116
UNISTIK TOUCH SAFETY
LANC 30G ....................... 116
UNISTRIP CONTROL ........ 116
uni-thera m advanced ............. 20
UNITUXIN............................. 39
UNIVERSAL 1 LANCETS
THIN 26G ......................... 116
UNIVERSAL 1 LANCETS
THIN 33G ........................... 20
UNIVERSAL 1 LANCETS
ULTRA THIN .................. 116
266
urea ....................................... 178
URECHOLINE ...................... 50
UROCIT-K 10 ...................... 119
UROCIT-K 5 ........................ 119
URO-MAG ........................... 141
urosex ........................... 201, 217
V valrubicin ................................ 39
VALSTAR ............................. 40
value plus lancet standard 21g
.......................................... 116
value plus lancets super thin. 116
value plus lancets thin 26g ... 116
value plus lancing device ..... 116
valumark lancet super thin 30g
.......................................... 116
valumark lancet ultra thin 28g
.......................................... 116
valved holding chamber ....... 116
VANISHPOINT SAFETY
SYRINGE............. 20, 21, 116
VANISHPOINT SYRINGE . 116
VANISHPOINT
TUBERCULIN SYRINGE
.......................................... 116
vaporizer ............................... 116
VAQTA .................................. 46
varidin..................................... 21
VARIZIG ............................... 44
v-c forte ........................ 201, 217
VECTIBIX ............................. 40
vegetable lax+stool softener . 151
VELCADE ............................. 40
VELETRI ....................... 70, 176
verasens glucose control....... 116
vica forte ....................... 201, 217
vicap forte ..................... 201, 217
VIC-FORTE ................. 201, 217
VICKS COOL MIST
HUMIDIFIER .................. 116
VICKS GERMFREE
HUMIDIFIER .................... 21
VICKS HUMIDIFIER ......... 116
VICKS MINI COOLMIST
HUMIDIFIER .................. 117
VICKS NURSERY
VAPORIZER ................... 117
VICKS PUREMIST
HUMIDIFIER .................... 21
VICKS ULTRASONIC
HUMIDIFIER .................... 21
VICKS VAPORIZER............. 21
VICKS WARM MIST
HUMIDIFIER .................... 21
VICKS WATERLESS
VAPORIZER...................... 21
VICTORY CONTROL LEVEL
1/2 ..................................... 117
VIDA MIA AUTOLET
LANCING DEV ............... 117
VIDA MIA UNILET
LANCETS 28G ................ 117
VIDA MIA UNILET
LANCETS 30G ................ 117
VIDAZA ................................. 40
vigomar forte ........................ 201
vigortol ................................. 201
VIMIZIM.............................. 133
vinblastine sulfate ................... 40
VINCASAR PFS .................... 40
vincristine sulfate ................... 40
vinorelbine tartrate ................. 40
VIRAZOLE ............................ 29
VIROPTIC............................ 133
virtussin a/c............. 76, 169, 173
virtussin dac ..... 47, 76, 167, 169,
173
VISION FORMULA ............ 201
vision formula 2.................... 165
vision formula eye health ..... 165
vision formula/lutein ............ 201
vision vitamins ..................... 201
vit e-vit c-beta carotene ........ 201
vita hair ................................... 21
VITA S FORTE...... 60, 201, 217
vita zinc ................................ 231
vitabasic complete .................. 21
vitabasic senior ....................... 21
vita-bee/c ...................... 217, 223
vitabex plus................... 201, 217
VITA-BOB ............................. 21
VITACEL ..................... 201, 217
vitagen advance ...................... 60
vitagen forte ............................ 60
VITAJOY GUMMIES ......... 165
vitalee ........................... 201, 217
VITALET PRO LANCETS ... 21
VITALET PRO PLUS
LANCETS .......................... 21
VITAMAX ............................. 21
vitamin a ............................... 202
vitamin a palmitate ............... 202
vitamin a-beta carotene ......... 202
vitamin b 12 .......................... 217
vitamin b complex ........ 217, 223
vitamin b1 ............................. 218
vitamin b-1............................ 218
vitamin b-1............................ 218
vitamin b-1............................ 218
vitamin b12 ........................... 218
vitamin b-12.......................... 218
vitamin b-12.......................... 218
vitamin b-12.......................... 218
vitamin b-12.......................... 218
vitamin b-12.......................... 218
vitamin b-12.......................... 218
vitamin b-12 er ..................... 218
vitamin b12 tr ....................... 218
vitamin b-2............................ 218
vitamin b6 ............................. 218
vitamin b-6............................ 218
vitamin b-6............................ 218
vitamin b-6............................ 218
vitamin b-6 er ....................... 218
vitamin c ............................... 223
vitamin c er ........................... 223
vitamin c immune health ...... 223
vitamin c plus wild rose hips 223
vitamin c/rose hips ................ 223
vitamin c-acerola .................... 21
vitamin c-rose hips ......... 21, 223
vitamin c-rose hips er ..... 21, 223
vitamin c-rose hips tr ............ 223
vitamin d ....................... 228, 229
vitamin d (cholecalciferol) ... 228
vitamin d (ergocalciferol) ..... 228
vitamin d high potency ......... 228
vitamin d3 ....................... 21, 229
vitamin d-3............................ 229
vitamin d3 adult gummies .... 229
vitamin d3 ultra potency ......... 21
vitamin e ............................... 231
vitamin e blend ..................... 231
vitamin e complex .................. 21
vitamin e high potency ......... 231
vitamin e mtc ........................ 231
vitamin e natural ................... 231
vitamin e water soluble ......... 231
vitamin e/d-alpha .................. 231
267
vitamin e/d-alpha natural ...... 231
vitamin e-200........................ 231
vitamin e-400........................ 231
vitamin forte ................. 201, 218
vitamin-mineral supplement .. 60,
201
vitamins acd-fluoride... 160, 201,
202, 223, 229
vitamins a-d-e/selenium ...... 201,
202, 229, 231
vitamins for hair ..... 60, 201, 218
vitamins for the hair ............... 21
vitamins/minerals ................. 201
vitaplex plus ........................... 21
vita-plus e ............................... 21
VITAROCA PLUS ................ 21
VITASANA ........................... 21
vitatrum .................. 60, 201, 218
VITATRUM COMPLETE .... 60,
201, 218
vitrum 50+ senior multi 201, 218
VITRUM SENIOR ............... 201
VIVAGUARD INO CONTROL
SOLUTION ...................... 117
VIVAGUARD LANCETS ... 117
VIVAGUARD LANCING
DEVICE ........................... 117
VOCAL POINT CONTROL 21,
22
VORTEX VALVED HOLDING
CHAMBER ...................... 117
vp-zel ............................ 165, 218
VYNDAMAX ........................ 65
VYNDAQEL .......................... 65
VYONDYS 53 ..................... 159
VYXEOS ................................ 40
W W&F LANCETS 26G .......... 117
W&F LANCETS COLORED
21G ................................... 117
walgreens adv travel lancets . 117
walgreens glucose ................ 120
WALGREENS LANCETS .. 117
walgreens lancets micro thin 117
walgreens lancets super thin . 117
WALGREENS LANCING
DEVICE ........................... 117
WALGREENS THIN
LANCETS ........................ 117
WALGREENS ULTRA THIN
LANCETS ........................ 117
warm mist vaporizer ............... 22
wart remover maximum strength
.......................................... 178
WATCHHALER .................. 117
wd glucose .............................. 22
WD LANCETS ...................... 22
WD LANCETS THIN ............ 22
WEBCOL ALCOHOL PREP
LARGE ............................. 179
WEBCOL ALCOHOL PREP
MEDIUM ......................... 179
WEISS EPIDURAL NEEDLE
............................................ 22
WEISS EPIDURAL NEEDLE
TW ...................................... 22
WHITACRE SPINAL NEEDLE
.................................... 22, 117
WINRHO SDF ....................... 44
womans laxative ................... 151
womens 50+ advanced . 201, 218
womens adv bp monitor/uppr
arm .................................... 117
womens biomultiple ............. 201
womens bone health ............... 22
womens daily form/fa/ca/fe ... 60,
201
womens daily formula ... 60, 131,
201, 218
womens hair, skin & nails .... 201
womens multi ......... 60, 201, 219
womens one daily ........... 60, 201
wrist blood pressure monitor 117
X XEMBIFY .............................. 44
XERMELO ........................... 143
XIAFLEX ............................. 133
XOFIGO ............................... 166
XPRES CONTROL .............. 117
XYREM .................................. 76
Y YALE REUSABLE SYRINGE
.......................................... 117
YALE REUSABLE TB
SYRINGE ........... 22, 117, 118
YALE SPINAL NEEDLE 22, 23
YELETS TEENAGE
FORMULA......... 60, 201, 219
YERVOY ............................... 40
YESCARTA ..................... 40, 70
yl beta carotene ....................... 23
yl folic acid ............................. 23
yl vitamin b-6 ......................... 23
yl vitamin c ............................. 23
yl vitamin c-rose hips ............. 23
yl vitamin e ............................. 23
YONDELIS ............................ 40
YOUR LIFE MULTI ADULT
GUMMIES ............... 201, 219
YUVAFEM .......................... 154
Z ZALTRAP .............................. 40
z-basic ..................................... 23
Z-BEC..................................... 23
ZEMAIRA ............................ 176
ZEMDRI ................................. 26
ZEVALIN Y-90...................... 40
z-gen ..................................... 231
ZINECARD .......................... 165
ZOEY ASTHMAMENTOR . 118
ZOEY OPTICHAMBER
ADVANTAGE ................. 118
ZOEY PERSONAL BEST
PEAK METER ................. 118
ZOSTAVAX........................... 46