amerihealth caritas pennsylvania supplemental …...fe-caps capsule extended release* 250 mg oral t3...

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AmeriHealth Caritas Pennsylvania Supplemental Formulary May 13, 2020

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Page 1: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

AmeriHealth Caritas Pennsylvania

Supplemental Formulary

May 13, 2020

Page 2: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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)

Page 3: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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)

Page 4: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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

Page 5: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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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)

Page 6: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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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)

Page 7: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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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

Page 8: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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

Page 9: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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)

Page 10: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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

Page 11: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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)

Page 12: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg

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

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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)

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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)

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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

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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)

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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

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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)

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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

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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)

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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)

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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)

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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)

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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)

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

Page 269: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg
Page 270: AmeriHealth Caritas Pennsylvania Supplemental …...fe-caps capsule extended release* 250 mg oral T3 ferra capsule extended release* 250 mg oral T3 ferro-bob tablet 325 (65 fe) mg