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Comprehensive

PREFERRED DRUG LIST

This Formulary is up to date through its date of publication. Please notify IlliniCare Health at

[email protected] or (866) 329-4701 with any mistakes in the formulary.

mailto:[email protected]

Pharmacy Program

IlliniCare Health is committed to providing the right drug coverage to our members. We work with

providers and pharmacists to make sure we cover drugs used to treat many conditions and diseases.

IlliniCare Health covers prescription and certain over-the-counter (OTC) medications when ordered by a

network provider. The pharmacy program does not cover all medications. Some medications require

prior authorization (PA) or have limitations on age, dosage, and maximum quantities.

The Illinicare Health pharmacy program covers members in the HealthChoice Illinois plan.

Filling a Prescription

You can have your prescriptions filled at a network pharmacy. At the pharmacy, you will need to give the

pharmacist your prescription and your ID card. You can find a pharmacy that is in the IlliniCare Health

network by using the Find a Provider tool on www.illinicare.com. If you need help finding a pharmacy

near you, call us at 866-329-4701 (toll-free)/ TTY: 771. There is no cost for covered drugs.

If your medication is not on the preferred drug list or is on the preferred drug list but has limitations, you can:

1. Speak with your doctor about switching to a similar medication that is on the preferred drug list.

2. Request a prior authorization, or speak to your doctor about submitting a prior authorization for you. You or your doctor may do this by submitting the medication prior authorization form, found on www.illinicare.com.

Generic Drugs

Generic drugs have the same active ingredient and work the same as brand name drugs. When generic

drugs are available, the brand name drug will not be covered without prior authorization.

Specialty Drugs

Specialty drugs are usually not available at retail pharmacies, and require additional review and

monitoring. These drugs are only covered when supplied by an IlliniCare Health network specialty

pharmacy. We work with Envolve Pharmacy Solutions and AcariaHealth to help oversee these drugs.

Prior authorization request forms for specialty drugs are located on the IlliniCare Health website at

www.illinicare.com.

http://www.illinicare.com/

http://www.illinicare.com/

Pharmacy Benefit Exclusions

The following drug categories are not part of the IlliniCare Health pharmacy benefit:

- Fertility enhancing drugs

- Anorexia, weight loss, or weight gain drugs

- Durable Medical Equipment (DME) products and medical supplies (unless listed on the PDL)

- Drugs and other agents used for cosmetic purposes or for hair growth

- Erectile dysfunction drugs prescribed to treat impotence

- Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are

classified as ineffective

- OTC products (unless listed on the PDL)

- Drugs not included in the Medicaid Drug Rebate Program, drug product data file (unless listed

on the PDL)

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating Disorders

Amphetamines ADDERALL TABS (Use Amphetamine-Dextroamphetamine)

NF QL(2 ea daily);AL; At least 3 yrs old

ADDERALL XR CP24 (Use Amphetamine-Dextroamphetamine)


amphetamine-dextroamphetamine cp245mg-5mg-5mg-5mg,2.5mg-2.5mg-2.5mg-2.5mg, 7.5mg-7.5mg-7.5mg-7.5mg, 1.25mg-1.25mg-1.25mg-1.25mg,3.75mg-3.75mg-3.75mg-3.75mg, 6.25mg-6.25mg-6.25mg-6.25mg

F

QL(1 ea daily);AL; At least 6 yrs old

amphetamine-dextroamphetamine tabs5mg-5mg-5mg-5mg,2.5mg-2.5mg-2.5mg-2.5mg, 7.5mg-7.5mg-7.5mg-7.5mg, 1.25mg-1.25mg-1.25mg-1.25mg,3.75mg-3.75mg-3.75mg-3.75mg, 1.875mg-1.875mg-1.875mg-1.875mg, 3.125mg-3.125mg-3.125mg-3.125mg

F


DEXEDRINE CP24 10 MG, 15 MG (Use DextroamphetamineSulfate)

NF


DEXEDRINE CP24 5 MG (Use DextroamphetamineSulfate)


dextroamphetamine sulfatecp24 10 mg, 15 mg F


dextroamphetamine sulfatecp24 5 mg F


dextroamphetamine sulfatetabs 5 mg, 10 mg F


Drug Name DrugTier

Requirements/Limits

VYVANSE CAPS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

F ST; QL(1 eadaily)

Analeptics

caffeine citrate soln or 20 mg/ml, 60 mg/3ml F

QL(45 ml perfill retail); AL;Up to 18 yrs old

Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps F ST; AL; At least 6 yrs old

clonidine hcl (adhd) tb12 F

guanfacine hcl (adhd) tb24 F QL(1 ea daily);AL; At least 6 yrs old

INTUNIV TB24 (Use Guanfacine HCl (ADHD)) NF


KAPVAY TB12 (Use Clonidine HCl (ADHD)) NF

STRATTERA CAPS (Use Atomoxetine HCl) NF ST; AL; At least

6 yrs old

Stimulants - Misc. CONCERTA TBCR 18 MG, 27 MG, 54 MG (Use Methylphenidate HCl)


CONCERTA TBCR 36 MG (Use Methylphenidate HCl) NF


dexmethylphenidate hcltabs 5 mg, 10 mg, 2.5 mg F


FOCALIN TABS (Use Dexmethylphenidate HCl) NF


METADATE CD CPCR (Use Methylphenidate HCl) NF


methylphenidate hcl cpcr10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg

F QL(1 ea daily);AL; At least 6 yrs old

METHYLPHENIDATE HCL ER TB24 18 MG, 27 MG, 54 MG


Updated August 1, 2018F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior AuthorizationQL-Quantity limit, SP-Specialty drug, ST-Step Therapy, RX/OTC - both Rx and OTC NDCs, MP-Maintenance Products.

1

Drug Name DrugTier

Requirements/Limits

METHYLPHENIDATE HCL ER TB24 36 MG F


METHYLPHENIDATE HCL ER TBCR 18 MG F


methylphenidate hcl tabs10 mg, 20 mg F


methylphenidate hcl tabs 5 mg F


methylphenidate hcl tbcr 10mg, 36 mg F


methylphenidate hcl tbcr 18mg, 20 mg, 27 mg, 54 mg F


RITALIN TABS 10 MG, 20 MG (Use MethylphenidateHCl)


RITALIN TABS 5 MG (Use Methylphenidate HCl) NF


AMINOGLYCOSIDES - Drugs to Treat BacterialInfections

Aminoglycosides

KITABIS PAK NEBU F PA; SP

neomycin sulfate tabs F

TOBI NEBU (Use Tobramycin) NF PA; SP

tobramycin nebu F PA; SP

TOBRAMYCIN NEBU F PA; SP

TOBRAMYCIN SULFATE SOLN 10 MG/ML, 40MG/ML

F

tobramycin sulfate soln 40mg/ml, 80 mg/2ml, 1.2gm/30ml

F

tobramycin sulfate solr 1.2 gm F

Drug Name DrugTier

Requirements/Limits

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditions

Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

F PA; SP

HUMIRA PEN PNKT F PA; SP

HUMIRA PEN-CROHNS DISEASESTARTER PNKT F PA; SP

HUMIRA PEN-PSORIASIS STARTER PNKT F PA; SP

HUMIRA PSKT 20 MG/0.4ML, 40 MG/0.8ML F PA; SP

Antirheumatic Antimetabolites

RHEUMATREX TABS F

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL TABS (Use Ibuprofen) NF MP

ALEVE ARTHRITIS TABS (Use Naproxen Sodium) NF QL(2 ea daily);

MP ALEVE TABS (Use Naproxen Sodium) NF QL(2 ea daily);

MP ANAPROX DS TABS (Use Naproxen Sodium) NF MP

CELEBREX CAPS (Use Celecoxib) NF PA; QL(2 ea

daily)

celecoxib caps F PA; QL(2 eadaily)

CHILDRENS ADVIL SUSP (Use Ibuprofen) NF RX/OTC; MP

CHILDRENS MOTRIN SUSP (Use Ibuprofen) NF RX/OTC; MP

DAYPRO TABS (Use Oxaprozin) NF MP

diclofenac potassium tabs F MP

diclofenac sodium tb24 or 100 mg F MP

diclofenac sodium tbec or 25 mg, 50 mg, 75 mg F MP

EC-NAPROSYN TBEC (Use Naproxen) NF QL(2 ea daily);

MP


2

Drug Name DrugTier

Requirements/Limits

etodolac caps F MP

etodolac tabs F MP

etodolac tb24 F MP

FELDENE CAPS (Use Piroxicam) NF MP

flurbiprofen tabs F MP

ibuprofen chew 100 mg F MP

ibuprofen susp 100 mg/5ml F RX/OTC; MP

ibuprofen susp 40 mg/ml,50 mg/1.25ml F MP

ibuprofen tabs 200 mg, 400mg, 600 mg, 800 mg F MP

indomethacin caps F MP

indomethacin cpcr F MP

INFANTS ADVIL SUSP (Use Ibuprofen) NF MP

ketoprofen caps 50 mg, 75 mg F MP

KETOPROFEN CAPS 50 MG, 75 MG F MP

KETOPROFEN ER CP24 F

ketorolac tromethamine tabs or 10 mg F AL; At least 17

yrs old LODINE TABS (Use Etodolac) NF MP

meloxicam tabs F MP

MOBIC TABS (Use Meloxicam) NF MP

MOTRIN INFANTS DROPS SUSP (Use Ibuprofen)

NF MP

nabumetone tabs F MP

NAPROSYN SUSP (Use Naproxen) NF MP

NAPROSYN TABS (Use Naproxen) NF MP

Drug Name DrugTier

Requirements/Limits

naproxen sodium tabs 220 mg F QL(2 ea daily);

MP naproxen sodium tabs 275mg, 550 mg F MP

naproxen susp 125 mg/5ml F MP

naproxen tabs 250 mg, 375mg, 500 mg F MP

naproxen tbec 375 mg, 500 mg F QL(2 ea daily);

MP

oxaprozin tabs F MP

piroxicam caps F MP

sulindac tabs F MP

TOLMETIN SODIUM CAPS 400 MG F MP

tolmetin sodium caps 400 mg F MP

TOLMETIN SODIUM TABS 200 MG F MP

TOLMETIN SODIUM TABS 600 MG F

Pyrimidine Synthesis Inhibitors ARAVA TABS (Use Leflunomide) NF QL(1 ea daily);

MP

leflunomide tabs F QL(1 ea daily);MP

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL MINI SOCT F PA

ENBREL SOLR F PA; SP

ENBREL SOSY F PA; SP

ENBREL SURECLICK SOAJ F PA; SP

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions

Analgesic Combinations butalbital-acetaminophentabs 325mg-50mg F

butalbital-acetaminophen-caffeine caps 325mg-50mg-40mg

F QL(4 ea daily)


3

Drug Name DrugTier

Requirements/Limits

butalbital-acetaminophen-caffeine tabs 325mg-50mg-40mg

F QL(4 ea daily)

butalbital-aspirin-caffeine caps F QL(4 ea daily)

ESGIC TABS (Use Butalbital-Acetaminophen-Caffeine)

NF QL(4 ea daily)

FIORINAL CAPS (Use Butalbital-Aspirin-Caffeine) NF QL(4 ea daily)

TENCON TABS F

Analgesics Other acetaminophen chew or 80 mg F

acetaminophen liqd or 160mg/5ml F

acetaminophen soln or 160mg/5ml, 650 mg/20.3ml,325 mg/10.15ml

F

acetaminophen supp re120 mg, 325 mg, 650 mg F

acetaminophen susp or160 mg/5ml, 80 mg/0.8ml,80 mg/2.5ml

F

acetaminophen tabs or 325mg, 500 mg F

NORTEMP INFANTS SUSP F

TYLENOL CHILDRENS SUSP (Use Acetaminophen)

NF

TYLENOL EXTRA STRENGTH TABS (Use Acetaminophen)

NF

TYLENOL INFANTS PAIN+FEVER SUSP (Use Acetaminophen)

NF

TYLENOL INFANTS SUSP (Use Acetaminophen) NF

TYLENOL TABS (Use Acetaminophen) NF

Salicylates aspirin buffered (cal carb-mag carb-mag oxide) tabs F

Drug Name DrugTier

Requirements/Limits

aspirin chew or 81 mg F

ASPIRIN SUPP RE 300 MG, 600 MG F

aspirin supp re 300 mg,600 mg F

aspirin tabs or 325 mg F

aspirin tbec or 81 mg, 324mg, 325 mg F

BUFFERIN TABS (Use Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide))

NF

choline & mag salicylateliqd F

diflunisal tabs F MP

DISALCID TABS (Use Salsalate) NF

ECOTRIN REGULAR STRENGTH TBEC (Use Aspirin)

NF

salsalate tabs F

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint Conditions

Opioid Agonists

codeine sulfate tabs 15 mg,30 mg, 60 mg F


CODEINE SULFATE TABS 15 MG, 30 MG, 60 MG (Use Codeine Sulfate)


DEMEROL TABS OR 100 MG (Use Meperidine HCl) NF

DILAUDID TABS OR 2 MG, 4 MG, 8 MG (Use Hydromorphone HCl)

NF

DOLOPHINE TABS 10 MG (Use Methadone HCl) NF QL(10 ea daily)

DOLOPHINE TABS 5 MG (Use Methadone HCl) NF QL(4 ea daily)

DURAGESIC PT72 (Use Fentanyl) NF QL(0.34 ea

daily) fentanyl pt72 12 mcg/hr, 25mcg/hr, 50 mcg/hr, 75mcg/hr, 100 mcg/hr

F QL(0.34 eadaily)


4

Drug Name DrugTier

Requirements/Limits

HYDROMORPHONE HCL SUPP RE 3 MG F QL(12 ea per

fill retail) hydromorphone hcl tabs or2 mg, 4 mg, 8 mg F

KADIAN CP24 10 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG, 100 MG (Use Morphine Sulfate)

NF

KADIAN CP24 200 MG F

MEPERIDINE HCL SOLN OR 50 MG/5ML F QL(500 ml per

fill retail) meperidine hcl tabs or 50mg, 100 mg F

methadone hcl tabs or 10 mg F QL(10 ea daily)

methadone hcl tabs or 5 mg F QL(4 ea daily)

morphine sulfate cp24 or10 mg, 20 mg, 30 mg, 50mg, 60 mg, 80 mg, 100 mg

F

morphine sulfate soln or 10mg/5ml, 20 mg/5ml F

morphine sulfate soln or 20mg/ml, 100 mg/5ml F QL(240 ml per

fill retail) MORPHINE SULFATE SUPP RE 5 MG, 10 MG, 20 MG, 30 MG

F QL(24 ea perfill retail)

MORPHINE SULFATE TABS OR 15 MG, 30 MG F

morphine sulfate tbcr or 15mg, 30 mg, 60 mg, 100 mg,200 mg

F QL(3 ea daily)

MS CONTIN TBCR (Use Morphine Sulfate) NF QL(3 ea daily)

oxycodone hcl caps 5 mg F

oxycodone hcl conc 100mg/5ml F QL(6 ml daily)

oxycodone hcl soln 5mg/5ml F

oxycodone hcl t12a 10 mg,15 mg, 20 mg, 30 mg, 40mg, 60 mg, 80 mg

F QL(2 ea daily)

oxycodone hcl tabs 5 mg,10 mg, 15 mg, 20 mg, 30 mg

F

Drug Name DrugTier

Requirements/Limits

oxymorphone hcl tb12 5mg, 10 mg, 15 mg, 20 mg,30 mg, 40 mg, 7.5 mg

F

OXYMORPHONE HYDROCHLORIDE ER TB12

F

ROXICODONE TABS (Use Oxycodone HCl) NF

tramadol hcl tabs 50 mg F QL(8 ea daily);AL; At least 18 yrs old

ULTRAM TABS (Use Tramadol HCl) NF


Opioid Combinations

acetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml F

QL(30 mldaily); AL; Atleast 12 yrs old

acetaminophen w/ codeinetabs 300mg-15mg, 300mg-30mg, 300mg-60mg

F

QL(180 ea per27 days retail);AL; At least 12 yrs old

butalbital-acetaminophen-caffeine w/ codeine caps325mg-50mg-40mg-30mg


butalbital-aspirin-caffeinew/cod caps F


FIORINAL/CODEINE #3CAPS (Use Butalbital-Aspirin-Caffeine w/Cod)


hydrocodone-acetaminophen soln2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml

F

QL(180 mldaily)

hydrocodone-acetaminophen tabs 5mg-325mg, 10mg-325mg,7.5mg-325mg

F

NORCO TABS (Use Hydrocodone-Acetaminophen)

NF

oxycodone w/acetaminophen tabs 5mg-325mg, 10mg-325mg,7.5mg-325mg

F


5

Drug Name DrugTier

Requirements/Limits

oxycodone-aspirin tabs F QL(6 ea daily)

OXYCODONE/ACETAMINOPHEN SOLN F QL(30 ml daily)

PERCOCET TABS 5MG-325MG, 10MG-325MG, 7.5MG-325MG (Use Oxycodone w/Acetaminophen)

NF

tramadol-acetaminophentabs F


TYLENOL/CODEINE #3TABS (Use Acetaminophenw/ Codeine)

NF


TYLENOL/CODEINE #4TABS (Use Acetaminophenw/ Codeine)

NF


ULTRACET TABS (Use Tramadol-Acetaminophen) NF


Opioid Partial Agonists

BUNAVAIL FILM F

buprenorphine hcl subl sl 2mg, 8 mg F

buprenorphine hcl-naloxone hcl dihydrate film F

buprenorphine hcl-naloxone hcl dihydrate subl F

SUBLOCADE SOSY F

SUBOXONE FILM F

ZUBSOLV SUBL F

ANDROGENS-ANABOLIC - Drugs to RegulateHormones

Androgens

ANDRODERM PT24 F QL(1 ea daily)

ANDROXY TABS F

Drug Name DrugTier

Requirements/Limits

DEPO-TESTOSTERONE SOLN 200 MG/ML (Use Testosterone Cypionate)

NF

METHITEST TABS F

testosterone cypionate soln200 mg/ml F

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and Itching

Intrarectal Steroids CORTENEMA ENEM (Use Hydrocortisone(Intrarectal))

NF QL(420 ml perfill retail)

hydrocortisone (intrarectal) enem F QL(420 ml per

fill retail) Rectal Combinations ANALPRAM-HC LOTN 1%-2.5% F QL(60 ml per

fill retail) phenylephrine-cocoa buttersupp 88.44%-0.25% F

phenylephrine-shark liveroil-cocoa butter supp F

phenylephrine-shark liveroil-mineral oil-petrolatumoint

F

Rectal Local Anesthetics

pramoxine hcl (rectal) foam F QL(15 gm perfill retail)

PROCTOFOAM FOAM (Use Pramoxine HCl (Rectal))

NF QL(15 gm perfill retail)

Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) NF QL(30 gm per

fill retail) hydrocortisone (rectal) crea2.5 % F QL(30 gm per

fill retail)

ANTACIDS

Antacid Combinations alum & mag hydrox-simethicone liqd200mg/5ml-20mg/5ml-200mg/5ml

F


6

Drug Name DrugTier

Requirements/Limits

alum & mag hydrox-simethicone susp200mg/5ml-20mg/5ml-200mg/5ml, 200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml

F

Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR F

Antacids - Bicarbonate sodium bicarbonate (antacid) tabs F

Antacids - Calcium Salts calcium carbonate (antacid) chew 500 mg F

calcium carbonate (antacid) susp 1250mg/5ml

F

TUMS CHEW (Use Calcium Carbonate (Antacid))

NF

TUMS LASTING EFFECTS CHEW (Use Calcium Carbonate (Antacid))

NF

Antacids - Magnesium Salts magnesium oxide tabs 400 mg F

ANTHELMINTICS - Drugs to Treat WormInfections

Anthelmintics

EMVERM CHEW F

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial Infections

Anti-infective Agents - Misc. FIRVANQ SOLR F

FLAGYL TABS 250 MG, 500 MG (Use Metronidazole)

NF

metronidazole tabs or 250 mg, 500 mg F

trimethoprim tabs F

Drug Name DrugTier

Requirements/Limits

VANCOCIN HCL CAPS 125 MG (Use VancomycinHCl)

NF QL(4 ea daily)

VANCOCIN HCL CAPS 250 MG (Use VancomycinHCl)

NF QL(8 ea daily)

vancomycin hcl caps or125 mg F QL(4 ea daily)

vancomycin hcl caps or250 mg F QL(8 ea daily)

vancomycin hcl solr iv 1000 mg F QL(14 ea per

fill retail) vancomycin hcl solr iv 500 mg F

Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Sulfamethoxazole-Trimethoprim)

NF

BACTRIM TABS (Use Sulfamethoxazole-Trimethoprim)

NF

sulfamethoxazole-trimethoprim susp or40mg/5ml-200mg/5ml

F

sulfamethoxazole-trimethoprim tabs or 80mg-400mg, 160mg-800mg

F

Leprostatics

dapsone tabs F

Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG (Use Clindamycin HCl)

NF

CLEOCIN PEDIATRIC GRANULES SOLR (Use Clindamycin PalmitateHydrochloride)

NF

QL(300 ml perfill retail)

clindamycin hcl caps 150mg, 300 mg F

clindamycin palmitatehydrochloride solr F QL(300 ml per

fill retail) Oxazolidinones

SIVEXTRO TABS OR F PA; QL(6 eaper fill retail)


7

Drug Name DrugTier

Requirements/Limits

ANTIANGINAL AGENTS - Drugs to Treat ChestPain

Nitrates ISORDIL TITRADOSE TABS 5 MG (Use Isosorbide Dinitrate)

NF MP

ISOSORBIDE DINITRATE ER TBCR F MP

isosorbide dinitrate tabs F MP

isosorbide mononitrate tabs 10 mg, 20 mg F QL(2 ea daily);

MP isosorbide mononitrate tb24 30 mg, 60 mg, 120 mg F QL(1 ea daily);

MP

NITRO-BID OINT F

NITRO-DUR PT24 0.1 MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.6 MG/HR (Use Nitroglycerin)

NF

MP

nitroglycerin cpcr or 2.5mg, 6.5 mg F

nitroglycerin cpcr or 9 mg F MP

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

F MP

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg F MP

NITROSTAT SUBL (Use Nitroglycerin) NF MP

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

buspirone hcl tabs 15 mg F QL(4 ea daily);MP

buspirone hcl tabs 30 mg,7.5 mg F QL(3 ea daily);

MP buspirone hcl tabs 5 mg,10 mg F QL(6 ea daily);

MP hydroxyzine hcl syrp or 10mg/5ml F

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg F MP

HYDROXYZINE PAMOATE CAPS 100 MG F

Drug Name DrugTier

Requirements/Limits

hydroxyzine pamoate caps25 mg F

hydroxyzine pamoate caps50 mg F MP

meprobamate tabs F

VISTARIL CAPS 25 MG (Use HydroxyzinePamoate)

NF

VISTARIL CAPS 50 MG (Use HydroxyzinePamoate)

NF MP

Benzodiazepines alprazolam tabs 0.25 mg,0.5 mg, 1 mg, 2 mg F QL(4 ea daily)

ATIVAN SOLN IJ 2 MG/ML(Use Lorazepam) NF QL(3 ml daily)

ATIVAN TABS OR 0.5 MG, 2 MG (Use Lorazepam) NF QL(3 ea daily)

ATIVAN TABS OR 1 MG (Use Lorazepam) NF QL(4 ea daily)

chlordiazepoxide hcl caps F QL(4 ea daily)

clorazepate dipotassiumtabs F QL(3 ea daily)

DIAZEPAM SOLN OR 1 MG/ML F QL(500 ml per

fill retail) diazepam tabs or 2 mg, 5mg, 10 mg F QL(4 ea daily)

lorazepam soln ij 2 mg/ml,20 mg/10ml F QL(3 ml daily)

lorazepam tabs or 0.5 mg,2 mg F QL(3 ea daily)

lorazepam tabs or 1 mg F QL(4 ea daily)

oxazepam caps 10 mg, 15mg, 30 mg F QL(4 ea daily)

OXAZEPAM CAPS 30 MG F QL(4 ea daily)

TRANXENE T TABS (Use Clorazepate Dipotassium) NF QL(3 ea daily)

VALIUM TABS (Use Diazepam) NF QL(4 ea daily)

XANAX TABS (Use Alprazolam) NF QL(4 ea daily)


8

Drug Name DrugTier

Requirements/Limits

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms

Antiarrhythmics Type I-A disopyramide phosphate caps F MP

NORPACE CAPS (Use Disopyramide Phosphate) F MP

NORPACE CR CP12 150 MG F

quinidine gluconate tbcr or324 mg F

QUINIDINE SULFATE TABS F

Antiarrhythmics Type I-B

mexiletine hcl caps F MP

Antiarrhythmics Type I-C

flecainide acetate tabs F MP

propafenone hcl cp12 F MP

propafenone hcl tabs F MP

RYTHMOL SR CP12 (Use Propafenone HCl) NF MP

RYTHMOL TABS (Use Propafenone HCl) NF MP

Antiarrhythmics Type III amiodarone hcl tabs or 200 mg F MP

dofetilide caps F

TIKOSYN CAPS (Use Dofetilide) NF

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Anti-Inflammatory Agents

cromolyn sodium nebu F

Bronchodilators - Anticholinergics

ATROVENT HFA AERS F

INCRUSE ELLIPTA AEPB F QL(30 ea perfill retail)

Drug Name DrugTier

Requirements/Limits

ipratropium bromide soln F

TUDORZA PRESSAIR AEPB F

Leukotriene Modulators montelukast sodium chew 4 mg, 5 mg F QL(1 ea daily);

MP montelukast sodium pack 4 mg F QL(1 ea daily)

montelukast sodium tabs 10 mg F QL(1 ea daily);

MP SINGULAIR CHEW 4 MG, 5 MG (Use Montelukast Sodium)

NF QL(1 ea daily);MP

SINGULAIR PACK 4 MG (Use Montelukast Sodium) NF QL(1 ea daily)

SINGULAIR TABS 10 MG (Use Montelukast Sodium) NF QL(1 ea daily);

MP

Steroid Inhalants

AEROSPAN AERS F QL(0.3 gmdaily,8.9 gmper fill retail)

budesonide (inhalation) susp F

AL; At least 1 yrs old - Up to8 yrs old

FLOVENT DISKUS AEPB 100 MCG/BLIST, 250MCG/BLIST

F QL(2 ea daily)

FLOVENT DISKUS AEPB 50 MCG/BLIST F QL(60 ea per

fill retail) FLOVENT HFA AERO 110 MCG/ACT, 220 MCG/ACT F QL(12 gm per

fill retail) FLOVENT HFA AERO 44 MCG/ACT F QL(11 gm per

fill retail) PULMICORT FLEXHALER AEPB F

PULMICORT SUSP (Use Budesonide (Inhalation)) NF

AL; At least 1 yrs old - Up to8 yrs old

Sympathomimetics ALBUTEROL SULFATE ER TB12 F

albuterol sulfate nebu in 0.5 % F QL(2 ml daily)


9

Drug Name DrugTier

Requirements/Limits

albuterol sulfate nebu in 0.63 mg/3ml, 0.083 %, 1.25mg/3ml

F

albuterol sulfate syrp or 2mg/5ml F

albuterol sulfate tabs or 2 mg, 4 mg F

albuterol sulfate tb12 or 4 mg, 8 mg F

BREO ELLIPTA AEPB F

COMBIVENT RESPIMAT AERS F

DULERA AERO F QL(13 gm perfill retail)

ipratropium-albuterol soln F QL(12 ml daily)

METAPROTERENOL SULFATE SYRP 10 MG/5ML

F QL(30 ml daily)

METAPROTERENOL SULFATE TABS 10 MG, 20 MG

F

SEREVENT DISKUS AEPB F QL(2 ea daily)

SYMBICORT AERO F QL(11 gm perfill retail)

terbutaline sulfate tabs or 5 mg, 2.5 mg F MP

VENTOLIN HFA AERS F

QL(36 gm perfill retail,36 gmper 30 daysretail)

VENTOLIN HFA AERS F


VOSPIRE ER TB12 (Use Albuterol Sulfate) NF

Xanthines

ELIXOPHYLLIN ELIX F

THEO-24 CP24 F

theophylline soln 80mg/15ml F QL(475 ml per

fill retail); MP

Drug Name DrugTier

Requirements/Limits

theophylline tb12 100 mg,200 mg, 300 mg F MP

theophylline tb12 450 mg F

theophylline tb24 400 mg,600 mg F MP

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants COUMADIN TABS (Use Warfarin Sodium) F MP

warfarin sodium tabs F MP

Direct Factor Xa Inhibitors

BEVYXXA CAPS F QL(42 ea per42 days retail)

ELIQUIS STARTER PACK TABS F QL(4 ea daily)

ELIQUIS TABS F QL(4 ea daily)

XARELTO TABS 10 MG F QL(1 eadaily,35 ea per180 days retail)

XARELTO TABS 15 MG F QL(2 ea daily)

XARELTO TABS 20 MG F QL(1 ea daily)

Heparins And Heparinoid-Like Agents

enoxaparin sodium soln ij300 mg/3ml F

QL(42 ml perfill retail,42 ml per 7 daysretail); SP

enoxaparin sodium soln sc100 mg/ml, 150 mg/ml F


enoxaparin sodium soln sc30 mg/0.3ml F

QL(5 ml per fillretail,5 ml per 7days retail); SP






10

Drug Name DrugTier

Requirements/Limits

enoxaparin sodium soln sc80 mg/0.8ml, 120 mg/0.8ml F


heparin sodium (porcine)soln F

LOVENOX SOLN IJ 300 MG/3ML (Use EnoxaparinSodium)

NF


LOVENOX SOLN SC 100 MG/ML, 150 MG/ML (Use Enoxaparin Sodium)

NF


LOVENOX SOLN SC 30 MG/0.3ML (Use Enoxaparin Sodium)

NF QL(5 ml per fillretail,5 ml per 7days retail); SP





LOVENOX SOLN SC 80 MG/0.8ML, 120 MG/0.8ML(Use Enoxaparin Sodium)

NF


ANTICONVULSANTS - Drugs to Treat Seizures

Anticonvulsants - Benzodiazepines clonazepam tabs 0.5 mg, 1mg, 2 mg F QL(4 ea daily)

diazepam (anticonvulsant)gel F

QL(1 ea per fillretail); AL; Atleast 2 yrs old

KLONOPIN TABS (Use Clonazepam) NF QL(4 ea daily)

Anticonvulsants - Misc. carbamazepine chew F MP

carbamazepine cp12 F MP

carbamazepine susp F MP

carbamazepine tabs F MP

Drug Name DrugTier

Requirements/Limits

carbamazepine tb12 F MP

CARBATROL CP12 (Use Carbamazepine) F MP

gabapentin caps 100 mg,300 mg, 400 mg F QL(9 ea daily);

MP gabapentin soln 250mg/5ml, 300 mg/6ml F MP

gabapentin tabs 600 mg F QL(6 ea daily);MP

gabapentin tabs 800 mg F QL(4 ea daily);MP

KEPPRA SOLN OR 100 MG/ML (Use Levetiracetam)

NF QL(30 mldaily); MP

KEPPRA TABS OR 1000 MG (Use Levetiracetam) NF

KEPPRA TABS OR 250 MG, 750 MG (Use Levetiracetam)


KEPPRA TABS OR 500 MG (Use Levetiracetam) NF QL(6 ea daily);

MP KEPPRA XR TB24 (Use Levetiracetam) NF ST

LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use Lamotrigine)

NF MP

LAMICTAL TABS (Use Lamotrigine) NF MP

LAMICTAL XR TB24 25 MG, 50 MG, 100 MG, 200 MG, 250 MG, 300 MG (Use Lamotrigine)

NF

ST

lamotrigine chew 5 mg, 25 mg F MP

lamotrigine tabs 25 mg,100 mg, 150 mg, 200 mg F MP

lamotrigine tb24 25 mg, 50mg, 100 mg, 200 mg, 250mg, 300 mg

F ST

levetiracetam soln or 100 mg/ml, 500 mg/5ml F QL(30 ml

daily); MP levetiracetam tabs or 1000 mg F

levetiracetam tabs or 250 mg, 750 mg F QL(4 ea daily);

MP


11

Drug Name DrugTier

Requirements/Limits

levetiracetam tabs or 500 mg F QL(6 ea daily);

MP levetiracetam tb24 or 500 mg, 750 mg F ST

MYSOLINE TABS (Use Primidone) NF MP

NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use Gabapentin)


NEURONTIN SOLN 250 MG/5ML (Use Gabapentin) NF MP

NEURONTIN TABS 600 MG (Use Gabapentin) NF QL(6 ea daily);

MP NEURONTIN TABS 800 MG (Use Gabapentin) NF QL(4 ea daily);

MP

oxcarbazepine susp F MP

oxcarbazepine tabs F MP

primidone tabs F MP

TEGRETOL SUSP (Use Carbamazepine) F MP

TEGRETOL TABS (Use Carbamazepine) F MP

TEGRETOL-XR TB12 (Use Carbamazepine) F MP

TOPAMAX SPRINKLE CPSP 15 MG (Use Topiramate)


TOPAMAX SPRINKLE CPSP 25 MG (Use Topiramate)


TOPAMAX TABS 100 MG (Use Topiramate) NF QL(4 ea daily);

MP TOPAMAX TABS 200 MG (Use Topiramate) NF QL(2 ea daily);

MP TOPAMAX TABS 25 MG, 50 MG (Use Topiramate) NF QL(6 ea daily);

MP

topiramate cpsp 15 mg F QL(6 ea daily);MP

topiramate cpsp 25 mg F QL(8 ea daily);MP

topiramate tabs 100 mg F QL(4 ea daily);MP

topiramate tabs 200 mg F QL(2 ea daily);MP

Drug Name DrugTier

Requirements/Limits

topiramate tabs 25 mg, 50 mg F QL(6 ea daily);

MP TRILEPTAL SUSP (Use Oxcarbazepine) NF MP

TRILEPTAL TABS (Use Oxcarbazepine) NF MP

ZONEGRAN CAPS (Use Zonisamide) NF MP

zonisamide caps F MP

Carbamates

felbamate susp F

felbamate tabs F

FELBATOL SUSP (Use Felbamate) NF

FELBATOL TABS (Use Felbamate) NF

GABA Modulators GABITRIL TABS 12 MG, 16 MG (Use TiagabineHCl)

NF

GABITRIL TABS 2 MG, 4 MG (Use Tiagabine HCl) NF MP

tiagabine hcl tabs 12 mg,16 mg F

tiagabine hcl tabs 2 mg, 4 mg F MP

Hydantoins CEREBYX SOLN (Use Fosphenytoin Sodium) NF

DILANTIN CAPS 100 MG (Use Phenytoin SodiumExtended)

F MP

DILANTIN CAPS 30 MG F

DILANTIN INFATABS CHEW (Use Phenytoin) F MP

DILANTIN-125 SUSP (Use Phenytoin) F MP

fosphenytoin sodium soln F

PHENYTEK CAPS (Use Phenytoin SodiumExtended)

F MP


12

Drug Name DrugTier

Requirements/Limits

phenytoin chew F MP

phenytoin sodium extended caps F MP

phenytoin susp F MP

Succinimides

ethosuximide caps F MP

ethosuximide soln F MP

ZARONTIN CAPS (Use Ethosuximide) F MP

ZARONTIN SOLN (Use Ethosuximide) F MP

Valproic Acid DEPACON SOLN (Use Valproate Sodium) NF

DEPAKENE CAPS 250 MG (Use Valproic Acid) F MP

DEPAKENE SOLN 250 MG/5ML (Use ValproateSodium)

F

DEPAKOTE ER TB24 (Use Divalproex Sodium) NF MP

DEPAKOTE SPRINKLES CSDR (Use DivalproexSodium)

NF MP

DEPAKOTE TBEC (Use Divalproex Sodium) NF MP

divalproex sodium csdr or125 mg F MP

divalproex sodium tb24 or250 mg, 500 mg F MP

divalproex sodium tbec or125 mg, 250 mg, 500 mg F MP

valproate sodium soln F

valproic acid caps F MP

ANTIDEPRESSANTS - Drugs to TreatDepression

Alpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs 15 mg F QL(3 ea daily);MP

Drug Name DrugTier

Requirements/Limits

mirtazapine tabs 30 mg F QL(1.5 eadaily); MP

mirtazapine tabs 45 mg F QL(1 ea daily);MP

mirtazapine tabs 7.5 mg F QL(1 ea daily)

mirtazapine tbdp 15 mg F QL(3 ea daily)

mirtazapine tbdp 30 mg F QL(1.5 eadaily)

mirtazapine tbdp 45 mg F QL(1 ea daily)

REMERON SOLTAB TBDP 15 MG (Use Mirtazapine) NF QL(3 ea daily)

REMERON SOLTAB TBDP 30 MG (Use Mirtazapine) NF QL(1.5 ea

daily) REMERON SOLTAB TBDP 45 MG (Use Mirtazapine) NF QL(1 ea daily)

REMERON TABS 15 MG (Use Mirtazapine) NF QL(3 ea daily);

MP REMERON TABS 30 MG (Use Mirtazapine) NF QL(1.5 ea

daily); MP REMERON TABS 45 MG (Use Mirtazapine) NF QL(1 ea daily);

MP

Antidepressants - Misc. bupropion hcl tabs 75 mg,100 mg F QL(3 ea daily);

MP

bupropion hcl tb12 100 mg F QL(4 ea daily);MP





MAPROTILINE HCL TABS F

WELLBUTRIN SR TB12 100 MG (Use BupropionHCl)





13

Drug Name DrugTier

Requirements/Limits



WELLBUTRIN XL TB24 150 MG (Use BupropionHCl)


WELLBUTRIN XL TB24 300 MG (Use BupropionHCl)


Monoamine Oxidase Inhibitors (MAOIs) NARDIL TABS (Use Phenelzine Sulfate) NF

PARNATE TABS (Use Tranylcypromine Sulfate) NF

phenelzine sulfate tabs F

tranylcypromine sulfatetabs F

Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 10 MG (Use CitalopramHydrobromide)


CELEXA TABS 20 MG (Use CitalopramHydrobromide)


CELEXA TABS 40 MG (Use CitalopramHydrobromide)


citalopram hydrobromidesoln 10 mg/5ml F

citalopram hydrobromidetabs 10 mg F QL(4 ea daily);

MP citalopram hydrobromidetabs 20 mg F QL(2 ea daily);

MP citalopram hydrobromidetabs 40 mg F QL(1 ea daily);

MP escitalopram oxalate tabs10 mg F QL(2 ea daily);

MP escitalopram oxalate tabs20 mg F QL(1 ea daily);

MP escitalopram oxalate tabs 5 mg F QL(4 ea daily);

MP fluoxetine hcl caps 10 mg,20 mg F QL(4 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

fluoxetine hcl caps 40 mg F QL(4 ea daily);AL; At least 7 yrs old; MP

fluoxetine hcl soln 20 mg/5ml F

QL(600 ml per30 daysretail,360 ml per 90 daysmail); AL; Atleast 7 yrs old

fluoxetine hcl tabs 10 mg F QL(1 ea daily);AL; At least 7 yrs old; MP

fluoxetine hcl tabs 20 mg F QL(4 ea daily)

fluvoxamine maleate tabs 100 mg F QL(3 ea daily)

fluvoxamine maleate tabs 25 mg, 50 mg F QL(2 ea daily)

LEXAPRO TABS 10 MG (Use Escitalopram Oxalate) NF QL(2 ea daily);

MP LEXAPRO TABS 20 MG (Use Escitalopram Oxalate) NF QL(1 ea daily);

MP LEXAPRO TABS 5 MG (Use Escitalopram Oxalate) NF QL(4 ea daily);

MP

paroxetine hcl tabs 10 mg F QL(6 ea daily);MP

paroxetine hcl tabs 20 mg F QL(3 ea daily);MP

paroxetine hcl tabs 30 mg,40 mg F QL(2 ea daily);

MP paroxetine hcl tb24 25 mg,12.5 mg, 37.5 mg F

PAXIL CR TB24 (Use Paroxetine HCl) NF

PAXIL SUSP 10 MG/5ML F QL(40 ml daily)

PAXIL TABS 10 MG (Use Paroxetine HCl) NF QL(6 ea daily);

MP PAXIL TABS 20 MG (Use Paroxetine HCl) NF QL(3 ea daily);

MP PAXIL TABS 30 MG, 40 MG (Use Paroxetine HCl) NF QL(2 ea daily);

MP PROZAC CAPS 10 MG, 20 MG (Use Fluoxetine HCl) NF QL(4 ea daily);

MP

PROZAC CAPS 40 MG (Use Fluoxetine HCl) NF

QL(4 ea daily);AL; At least 7 yrs old; MP


14

Drug Name DrugTier

Requirements/Limits

sertraline hcl conc 20 mg/ml F QL(10 ml daily)

sertraline hcl tabs 100 mg F QL(2 ea daily);MP

sertraline hcl tabs 25 mg,50 mg F QL(4 ea daily);

MP ZOLOFT CONC 20 MG/ML(Use Sertraline HCl) NF QL(10 ml daily)

ZOLOFT TABS 100 MG (Use Sertraline HCl) NF QL(2 ea daily);

MP ZOLOFT TABS 25 MG, 50 MG (Use Sertraline HCl) NF QL(4 ea daily);

MP

Serotonin Modulators NEFAZODONE HCL TABS 100 MG, 150 MG, 200 MG F

nefazodone hcl tabs 50 mg, 250 mg F

trazodone hcl tabs 300 mg F QL(2 ea daily)

trazodone hcl tabs 50 mg,100 mg, 150 mg F MP

TRINTELLIX TABS F QL(1 ea daily);AL; At least 18 yrs old

VIIBRYD TABS F PA; QL(1 eadaily)

Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use Duloxetine HCl) NF QL(1 ea daily);

MP desvenlafaxine succinate tb24 100 mg F ST; QL(4 ea

daily) desvenlafaxine succinate tb24 25 mg, 50 mg F ST; QL(1 ea

daily) duloxetine hcl cpep 20 mg,30 mg, 60 mg F QL(1 ea daily);

MP EFFEXOR XR CP24 150 MG (Use Venlafaxine HCl) NF QL(2 ea daily);

MP EFFEXOR XR CP24 37.5 MG (Use Venlafaxine HCl) NF QL(4 ea daily);

MP EFFEXOR XR CP24 75 MG (Use Venlafaxine HCl) NF QL(5 ea daily);

MP PRISTIQ TB24 100 MG (Use Desvenlafaxine Succinate)

NF ST; QL(4 eadaily)

Drug Name DrugTier

Requirements/Limits

PRISTIQ TB24 25 MG, 50 MG (Use Desvenlafaxine Succinate)

NF ST; QL(1 eadaily)

venlafaxine hcl cp24 150 mg F QL(2 ea daily);

MP venlafaxine hcl cp24 37.5 mg F QL(4 ea daily);

MP

venlafaxine hcl cp24 75 mg F QL(5 ea daily);MP

VENLAFAXINE HCL ER TB24 150 MG (Use Venlafaxine HCl)

NF QL(2 ea daily)

VENLAFAXINE HCL ER TB24 225 MG F QL(1 ea daily)

VENLAFAXINE HCL ER TB24 37.5 MG (Use Venlafaxine HCl)

NF QL(1 ea daily)

VENLAFAXINE HCL ER TB24 75 MG (Use Venlafaxine HCl)

NF

venlafaxine hcl tabs 25 mg,50 mg, 100 mg F

venlafaxine hcl tabs 75 mg,37.5 mg F MP

venlafaxine hcl tb24 150 mg F QL(2 ea daily)

venlafaxine hcl tb24 225 mg, 37.5 mg F QL(1 ea daily)

venlafaxine hcl tb24 75 mg F

Tricyclic Agents

amitriptyline hcl tabs F

AMOXAPINE TABS F

ANAFRANIL CAPS 50 MG, 75 MG (Use ClomipramineHCl)

NF

clomipramine hcl caps 50mg, 75 mg F

desipramine hcl tabs 10mg, 50 mg, 75 mg, 100 mg,150 mg

F

desipramine hcl tabs 25 mg F QL(2 ea daily)

doxepin hcl caps F


15

Drug Name DrugTier

Requirements/Limits

doxepin hcl conc F

ELAVIL TABS (Use Amitriptyline HCl) NF

imipramine hcl tabs F

NORPRAMIN TABS 10 MG (Use Desipramine HCl) NF

NORPRAMIN TABS 25 MG (Use Desipramine HCl) NF QL(2 ea daily)

nortriptyline hcl caps 10mg, 25 mg, 50 mg, 75 mg F

nortriptyline hcl soln 10mg/5ml F QL(20 ml daily)

PAMELOR CAPS (Use Nortriptyline HCl) NF

TOFRANIL TABS (Use Imipramine HCl) NF

ANTIDIABETICS - Drugs to Regulate BloodSugar Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN F PA

SYMLINPEN 60 SOPN F PA

Antidiabetic Combinations ACTOPLUS MET TABS (Use Pioglitazone HCl-Metformin HCl)


alogliptin-metformin hcltabs F PA; QL(2 ea

daily); MP

alogliptin-pioglitazone tabs F PA; QL(1 eadaily); MP

glipizide-metformin hcl tabs F MP

GLUCOVANCE TABS (Use Glyburide-Metformin) NF MP

glyburide-metformin tabs F MP

JENTADUETO TABS F

PA; QL(2 eadaily); AL; Atleast 18 yrs old;MP

pioglitazone hcl-metforminhcl tabs F QL(2 ea daily);

MP

Biguanides

Drug Name DrugTier

Requirements/Limits

GLUCOPHAGE TABS 1000 MG (Use Metformin HCl)


GLUCOPHAGE TABS 500 MG (Use Metformin HCl) NF QL(5 ea daily);

MP GLUCOPHAGE TABS 850 MG (Use Metformin HCl) NF QL(3 ea daily);

MP GLUCOPHAGE XR TB24 500 MG (Use Metformin HCl)


GLUCOPHAGE XR TB24 750 MG (Use Metformin HCl)


metformin hcl tabs 1000 mg F QL(2 ea daily);

MP

metformin hcl tabs 500 mg F QL(5 ea daily);MP

metformin hcl tabs 850 mg F QL(3 ea daily);MP

metformin hcl tb24 500 mg F QL(4 ea daily);MP

metformin hcl tb24 750 mg F QL(2 ea daily);MP

Diabetic Other BD GLUCOSE CHEW F

CVS GLUCOSE CHEW 4 GM F

DEX4 QUICK DISSOLVE GLUCOSE CHEW F

GLUCAGEN HYPOKIT SOLR F

GLUCAGON EMERGENCY KIT KIT F QL(1 ea per fill

retail)

GLUCOSE CHEW 4 GM F

GNP GLUCOSE CHEW 4 GM F

GNP QUICK DISSOLVE GLUCOSE CHEW F

LEADER QUICK DISSOLVE GLUCOSE CHEW

F

SM GLUCOSE CHEW 4 GM F


16

Drug Name DrugTier

Requirements/Limits

WALGREENS GLUCOSE CHEW 4 GM F

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

alogliptin benzoate tabs F PA; QL(1 eadaily); MP

TRADJENTA TABS F

PA; QL(1 eadaily); AL; Atleast 18 yrs old;MP

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON BCISE AUIJ F PA; QL(3.4 mlper 28 daysretail)

BYDUREON PEN PEN F PA; AL; At least 18 yrs old

BYDUREON SRER F PA; AL; At least 18 yrs old

BYETTA SOPN F PA; AL; At least 18 yrs old

VICTOZA SOPN F PA; QL(0.3 mldaily)

Insulin Sensitizing Agents ACTOS TABS (Use Pioglitazone HCl) NF QL(1 ea daily);

MP

AVANDIA TABS F QL(1 ea daily);MP

pioglitazone hcl tabs F QL(1 ea daily);MP

Insulin

ADMELOG SOLN F AGE QL(Age40 to 30, 120 ml daily, 90 ml)

ADMELOG SOLOSTAR SOPN F QL(30 ml per

30 days retail) ADMELOG SOLOSTAR SOPN F

BASAGLAR KWIKPEN SOPN F

HUMALOG JUNIOR KWIKPEN SOPN F

HUMALOG KWIKPEN SOPN 100 UNIT/ML F

HUMALOG MIX 50/50KWIKPEN SUPN F

Drug Name DrugTier

Requirements/Limits

HUMALOG MIX 50/50SUSP F

HUMALOG MIX 75/25KWIKPEN SUPN F

HUMALOG MIX 75/25SUSP F

HUMALOG SOLN F

HUMULIN 70/30 KWIKPENSUPN F

HUMULIN 70/30 SUSP F

HUMULIN N KWIKPEN SUPN F

HUMULIN N SUSP F

HUMULIN R SOLN F

NOVOLIN 70/30 RELIONSUSP F

NOVOLIN 70/30 SUSP F

NOVOLIN N RELION SUSP F

NOVOLIN N SUSP F

NOVOLIN R RELION SOLN F

NOVOLIN R SOLN F

NOVOLOG MIX 70/30PREFILLED FLEXPEN SUPN

F

NOVOLOG MIX 70/30SUSP F

Meglitinide Analogues

nateglinide tabs F QL(3 ea daily);MP

STARLIX TABS (Use Nateglinide) NF QL(3 ea daily);

MP

Sodium-Glucose Co-Transporter 2 (SGLT2)

JARDIANCE TABS F PA; QL(1 eadaily)

Sulfonylureas AMARYL TABS 1 MG, 2 MG (Use Glimepiride) NF QL(4 ea daily);

MP


17

Drug Name DrugTier

Requirements/Limits

AMARYL TABS 4 MG (Use Glimepiride) NF QL(2 ea daily);

MP glimepiride tabs 1 mg, 2 mg F QL(4 ea daily);

MP

glimepiride tabs 4 mg F QL(2 ea daily);MP

glipizide tabs F MP

glipizide tb24 F MP

GLUCOTROL TABS (Use Glipizide) NF MP

GLUCOTROL XL TB24 (Use Glipizide) NF MP

glyburide micronized tabs F MP

glyburide tabs F MP

GLYNASE TABS (Use Glyburide Micronized) NF MP

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat Diarrhea

Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chew262 mg F

bismuth subsalicylate susp525 mg/15ml F

PEPTO-BISMOL CHEW 262 MG (Use Bismuth Subsalicylate)

NF

PEPTO-BISMOL INSTACOOL CHEW (Use Bismuth Subsalicylate)

NF

PEPTO-BISMOL MAX STRENGTH SUSP (Use Bismuth Subsalicylate)

NF

PEPTO-BISMOL TO-GO CHEW (Use Bismuth Subsalicylate)

NF

Antiperistaltic Agents diphenoxylate w/ atropinetabs F

DIPHENOXYLATE/ATROPINE LIQD F

IMODIUM A-D CAPS 2 MG (Use Loperamide HCl) NF QL(8 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

IMODIUM A-D TABS 2 MG (Use Loperamide HCl) NF QL(8 ea daily)

LOMOTIL TABS (Use Diphenoxylate w/ Atropine) NF

loperamide hcl caps 2 mg F QL(8 ea daily);RX/OTC

loperamide hcl liqd 1mg/5ml F QL(40 ml daily)

loperamide hcl tabs 2 mg F QL(8 ea daily)

PAREGORIC TINC F

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

CHEMET CAPS F

JADENU TABS F PA; SP

Antidotes and Specific Antagonists

VISTOGARD PACK F

Opioid Antagonists EVZIO SOAJ 0.4 MG/0.4ML F

naloxone hcl soln 0.4 mg/ml, 4 mg/10ml F

NALOXONE HCL SOSY 2 MG/2ML F

naltrexone hcl tabs F

NARCAN LIQD F

VIVITROL SUSR F

ANTIEMETICS - Drugs to Treat Nausea andVomiting

5-HT3 Receptor Antagonists ondansetron hcl soln or 4 mg/5ml F QL(50 ml per

fill retail)

ondansetron hcl tabs or 4 mg, 8 mg F

QL(2 eadaily,20 ea perfill retail)30 rtllmt day(s),


18

Drug Name DrugTier

Requirements/Limits

ondansetron tbdp F


ZOFRAN ODT TBDP (Use Ondansetron) NF


ZOFRAN SOLN 4 MG/5ML(Use Ondansetron HCl) NF QL(50 ml per

fill retail)

ZOFRAN TABS 4 MG, 8 MG (Use Ondansetron HCl)

NF


Antiemetics - Anticholinergic dimenhydrinate tabs or 50 mg F QL(24 ea per

fill retail) DRAMAMINE TABS (Use Dimenhydrinate) NF QL(24 ea per

fill retail)

meclizine hcl chew 25 mg F

meclizine hcl tabs 25 mg,12.5 mg F RX/OTC

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungals GRIS-PEG TABS (Use Griseofulvin Ultramicrosize) NF

griseofulvin microsize susp F

griseofulvin microsize tabs F

griseofulvin ultramicrosizetabs F

LAMISIL TABS 250 MG (Use Terbinafine HCl) NF

QL(1 eadaily,90 ea per120 days retail)

nystatin tabs F QL(6 ea daily)

terbinafine hcl tabs F QL(1 eadaily,90 ea per120 days retail)

Imidazole-Related Antifungals DIFLUCAN SUSR 10 MG/ML, 40 MG/ML (Use Fluconazole)


Drug Name DrugTier

Requirements/Limits

DIFLUCAN TABS 100 MG (Use Fluconazole) NF QL(1 ea daily)

DIFLUCAN TABS 150 MG (Use Fluconazole) NF QL(2 ea per fill

retail) DIFLUCAN TABS 200 MG (Use Fluconazole) NF QL(2 ea daily)

DIFLUCAN TABS 50 MG (Use Fluconazole) NF QL(7 ea per fill

retail) fluconazole susr 10 mg/ml,40 mg/ml F QL(70 ml per

fill retail)

fluconazole tabs 100 mg F QL(1 ea daily)

fluconazole tabs 150 mg F QL(2 ea per fillretail)

fluconazole tabs 200 mg F QL(2 ea daily)

fluconazole tabs 50 mg F QL(7 ea per fillretail)

itraconazole caps F PA; QL(1 eadaily)

SPORANOX CAPS 100 MG (Use Itraconazole) NF PA; QL(1 ea

daily) SPORANOX PULSEPAK CAPS (Use Itraconazole) NF PA; QL(1 ea

daily)

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines CHLOR-TRIMETON SYRP 2 MG/5ML (Use Chlorpheniramine Maleate)

NF QL(60 ml daily)

CHLOR-TRIMETON TABS 4 MG (Use Chlorpheniramine Maleate)

NF QL(120 ea perfill retail)

chlorpheniramine maleatesyrp 2 mg/5ml F QL(60 ml daily)

chlorpheniramine maleatetabs 4 mg F QL(120 ea per

fill retail) Antihistamines - Ethanolamines BENADRYL ALLERGY CAPS (Use Diphenhydramine HCl)

NF QL(4 ea daily)

BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML (Use Diphenhydramine HCl)

NF



19

Drug Name DrugTier

Requirements/Limits

BENADRYL ALLERGY TABS (Use Diphenhydramine HCl)

NF QL(4 ea daily)

clemastine fumarate tabs 1.34 mg F QL(2 ea daily)

diphenhydramine hcl capsor 25 mg F QL(4 ea daily)

diphenhydramine hcl capsor 50 mg F QL(4 ea daily);

RX/OTC

diphenhydramine hcl elix or12.5 mg/5ml F

QL(240 ml perfill retail);RX/OTC

diphenhydramine hcl liqd or25 mg/10ml, 50 mg/20ml,12.5 mg/5ml

F QL(240 ml perfill retail)

diphenhydramine hcl syrpor 12.5 mg/5ml F QL(240 ml per

fill retail) diphenhydramine hcl tabsor 25 mg F QL(4 ea daily)

SILPHEN COUGH SYRP F QL(240 ml perfill retail)

TAVIST ALLERGY TABS (Use Clemastine Fumarate)

NF QL(2 ea daily)

Antihistamines - Non-Sedating ALLEGRA ALLERGY TABS 180 MG (Use Fexofenadine HCl)

NF QL(1 ea daily)

ALLEGRA ALLERGY TABS 60 MG (Use Fexofenadine HCl)

NF QL(2 ea daily)

cetirizine hcl chew 5 mg,10 mg F QL(1 ea daily)

cetirizine hcl soln 1 mg/ml,5 mg/5ml F


cetirizine hcl syrp 1 mg/ml,5 mg/5ml F


cetirizine hcl tabs 5 mg, 10 mg F QL(1 ea daily)

CLARITIN ALLERGY CHILDRENS SYRP (Use Loratadine)


CLARITIN REDITABS TBDP 10 MG (Use Loratadine)

NF

Drug Name DrugTier

Requirements/Limits

CLARITIN SYRP 5 MG/5ML (Use Loratadine) NF QL(240 ml per

fill retail) CLARITIN TABS 10 MG (Use Loratadine) NF

fexofenadine hcl tabs 180 mg F QL(1 ea daily)

fexofenadine hcl tabs 60 mg F QL(2 ea daily)

levocetirizine dihydrochloride tabs 5 mg F QL(1 ea daily);

RX/OTC

loratadine soln 5 mg/5ml F QL(240 ml perfill retail)

loratadine syrp 5 mg/5ml F QL(240 ml perfill retail)

loratadine tabs 10 mg F

loratadine tbdp 10 mg F

XYZAL ALLERGY 24HR TABS (Use Levocetirizine Dihydrochloride)

NF QL(1 ea daily);RX/OTC

XYZAL TABS 5 MG (Use Levocetirizine Dihydrochloride)


ZYRTEC ALLERGY TABS (Use Cetirizine HCl) NF QL(1 ea daily)

ZYRTEC CHILDRENS ALLERGY SOLN (Use Cetirizine HCl)

NF QL(480 ml perfill retail);RX/OTC

Antihistamines - Phenothiazines

promethazine hcl soln or6.25 mg/5ml F

QL(240 ml perfill retail); AL; Atleast 2 yrs old

promethazine hcl supp re25 mg, 50 mg, 12.5 mg F

QL(12 ea perfill retail); AL; Atleast 2 yrs old

promethazine hcl syrp or6.25 mg/5ml F


promethazine hcl tabs or25 mg, 50 mg, 12.5 mg F AL; At least 2

yrs old

Antihistamines - Piperidines

cyproheptadine hcl syrp F

cyproheptadine hcl tabs F


20

Drug Name DrugTier

Requirements/Limits

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Bile Acid Sequestrants

cholestyramine light pack F MP

cholestyramine light powd F MP

cholestyramine pack F MP

cholestyramine powd F MP

COLESTID FLAVORED GRAN 5 GM (Use Colestipol HCl)

NF MP

COLESTID GRAN 5 GM (Use Colestipol HCl) NF MP

COLESTID TABS 1 GM (Use Colestipol HCl) NF MP

colestipol hcl gran 5 gm F MP

colestipol hcl tabs 1 gm F MP

QUESTRAN LIGHT POWD (Use Cholestyramine Light) NF MP

QUESTRAN PACK (Use Cholestyramine) NF MP

QUESTRAN POWD (Use Cholestyramine) NF MP

Fibric Acid Derivatives fenofibrate micronized caps134 mg, 200 mg F QL(1 ea daily);

MP fenofibrate micronized caps67 mg F QL(2 ea daily);

MP

fenofibrate tabs 160 mg F QL(1 ea daily);MP

fenofibrate tabs 54 mg F QL(3 ea daily);MP

gemfibrozil tabs F QL(2 ea daily);MP

LOFIBRA CAPS 134 MG, 200 MG (Use Fenofibrate Micronized)


LOFIBRA CAPS 67 MG (Use Fenofibrate Micronized)


Drug Name DrugTier

Requirements/Limits

LOFIBRA TABS 160 MG (Use Fenofibrate) NF QL(1 ea daily);

MP LOFIBRA TABS 54 MG (Use Fenofibrate) NF QL(3 ea daily);

MP LOPID TABS (Use Gemfibrozil) NF QL(2 ea daily);

MP

TRIGLIDE TABS F QL(1 ea daily);MP

HMG CoA Reductase Inhibitors

atorvastatin calcium tabs F QL(1 ea daily);MP

CRESTOR TABS (Use Rosuvastatin Calcium) NF ST; QL(1 ea

daily); MP LIPITOR TABS (Use Atorvastatin Calcium) NF QL(1 ea daily);

MP lovastatin tabs 10 mg, 20 mg F QL(1 ea daily);

MP

lovastatin tabs 40 mg F QL(2 ea daily);MP

MEVACOR TABS (Use Lovastatin) NF QL(2 ea daily);

MP PRAVACHOL TABS (Use Pravastatin Sodium) NF QL(1 ea daily);

MP

pravastatin sodium tabs F QL(1 ea daily);MP

rosuvastatin calcium tabs F ST; QL(1 eadaily); MP

simvastatin tabs 5 mg, 10mg, 20 mg, 40 mg F QL(1 ea daily);

MP

simvastatin tabs 80 mg F PA; QL(1 eadaily)

ZOCOR TABS 5 MG, 10 MG, 20 MG, 40 MG (Use Simvastatin)


ZOCOR TABS 80 MG (Use Simvastatin) NF PA; QL(1 ea

daily) Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr F

NIACOR TABS F MP

NIASPAN TBCR (Use Niacin (Antihyperlipidemic)) NF

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure


21

Drug Name DrugTier

Requirements/Limits

ACE Inhibitors ACCUPRIL TABS (Use Quinapril HCl) NF QL(1 ea daily);

MP ALTACE CAPS (Use Ramipril) NF QL(2 ea daily);

MP

benazepril hcl tabs 40 mg F QL(2 ea daily);MP

benazepril hcl tabs 5 mg,10 mg, 20 mg F QL(1 ea daily);

MP

captopril tabs F QL(3 ea daily);MP

enalapril maleate tabs F QL(2 ea daily);MP

EPANED SOLR F

fosinopril sodium tabs F QL(1 ea daily);MP

lisinopril tabs F MP

LOTENSIN TABS 10 MG, 20 MG (Use BenazeprilHCl)


LOTENSIN TABS 40 MG (Use Benazepril HCl) NF QL(2 ea daily);

MP MAVIK TABS (Use Trandolapril) NF QL(1 ea daily);

MP PRINIVIL TABS (Use Lisinopril) NF MP

quinapril hcl tabs F QL(1 ea daily);MP

ramipril caps F QL(2 ea daily);MP

trandolapril tabs 1 mg, 2 mg F QL(1 ea daily);

MP

trandolapril tabs 4 mg F QL(2 ea daily);MP

VASOTEC TABS (Use Enalapril Maleate) NF QL(2 ea daily);

MP ZESTRIL TABS (Use Lisinopril) NF MP

Angiotensin II Receptor Antagonists ATACAND TABS (Use Candesartan Cilexetil) NF

AVAPRO TABS (Use Irbesartan) NF QL(1 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

BENICAR TABS (Use Olmesartan Medoxomil) NF ST

candesartan cilexetil tabs F

COZAAR TABS (Use Losartan Potassium) NF QL(1 ea daily);

MP DIOVAN TABS (Use Valsartan) NF QL(1 ea daily);

MP

irbesartan tabs F QL(1 ea daily);MP

losartan potassium tabs F QL(1 ea daily);MP

MICARDIS TABS (Use Telmisartan) NF QL(1 ea daily)

olmesartan medoxomil tabs or 5 mg, 20 mg, 40 mg F ST

telmisartan tabs F QL(1 ea daily)

valsartan tabs F QL(1 ea daily);MP

Antiadrenergic Antihypertensives CARDURA TABS (Use Doxazosin Mesylate) NF MP

CATAPRES TABS (Use Clonidine HCl) NF MP

clonidine hcl tabs or 0.1 mg, 0.2 mg, 0.3 mg F MP

doxazosin mesylate tabs F MP

guanfacine hcl tabs F MP

methyldopa tabs F MP

MINIPRESS CAPS (Use Prazosin HCl) NF MP

prazosin hcl caps F MP

TENEX TABS (Use Guanfacine HCl) NF MP

terazosin hcl caps F MP

Antihypertensive Combinations ACCURETIC TABS 10MG-12.5MG (Use Quinapril-Hydrochlorothiazide)

NF QL(3 ea daily)


22

Drug Name DrugTier

Requirements/Limits

ACCURETIC TABS 20MG-12.5MG (Use Quinapril-Hydrochlorothiazide)

NF QL(4 ea daily)

ACCURETIC TABS 20MG-25MG (Use Quinapril-Hydrochlorothiazide)

NF QL(2 ea daily)

amlodipine besylate-benazepril hcl caps F QL(1 ea daily);

MP amlodipine besylate-olmesartan medoxomil tabs F ST

amlodipine besylate-valsartan tabs F ST

amlodipine-valsartan-hydrochlorothiazide tabs F ST

ATACAND HCT TABS (Use Candesartan Cilexetil-Hydrochlorothiazide)

NF

atenolol & chlorthalidone tabs F QL(1 ea daily);

MP AVALIDE TABS (Use Irbesartan-Hydrochlorothiazide)


AZOR TABS (Use Amlodipine Besylate-Olmesartan Medoxomil)

NF ST

benazepril &hydrochlorothiazide tabs F QL(1 ea daily);

MP BENICAR HCT TABS (Use Olmesartan Medoxomil-Hydrochlorothiazide)

NF ST

bisoprolol &hydrochlorothiazide tabs F QL(1 ea daily);

MP candesartan cilexetil-hydrochlorothiazide tabs F

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS F QL(2 ea daily);

MP DIOVAN HCT TABS (Use Valsartan-Hydrochlorothiazide)


enalapril maleate &hydrochlorothiazide tabs F QL(2 ea daily);

MP EXFORGE HCT TABS (Use Amlodipine-Valsartan-Hydrochlorothiazide)

NF ST

EXFORGE TABS (Use Amlodipine Besylate-Valsartan)

NF ST

Drug Name DrugTier

Requirements/Limits

fosinopril sodium &hydrochlorothiazide tabs F QL(1 ea daily);

MP HYZAAR TABS (Use Losartan Potassium & Hydrochlorothiazide)


irbesartan-hydrochlorothiazide tabs F QL(1 ea daily);

MP lisinopril &hydrochlorothiazide tabs F MP

LOPRESSOR HCT TABS (Use Metoprolol &Hydrochlorothiazide)


losartan potassium &hydrochlorothiazide tabs F QL(1 ea daily);

MP LOTENSIN HCT TABS (Use Benazepril &Hydrochlorothiazide)


LOTREL CAPS (Use Amlodipine Besylate-Benazepril HCl)


metoprolol &hydrochlorothiazide tabs50mg-25mg, 100mg-25mg,100mg-50mg

F

QL(2 ea daily);MP

metoprolol &hydrochlorothiazide tb2450mg-12.5mg, 100mg-12.5mg

F

QL(1 ea daily)

METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE TB24

F

QL(1 ea daily);MP

METOPROLOL/HYDROCHLOROTHIAZIDE TABS F QL(2 ea daily);

MP MICARDIS HCT TABS (Use Telmisartan-Hydrochlorothiazide)

NF QL(1 ea daily)

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

F ST

olmesartan medoxomil-hydrochlorothiazide tabs F ST

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS F QL(2 ea daily);

MP quinapril-hydrochlorothiazide tabs10mg-12.5mg

F QL(3 ea daily)


23

Drug Name DrugTier

Requirements/Limits

quinapril-hydrochlorothiazide tabs20mg-12.5mg

F QL(4 ea daily)

quinapril-hydrochlorothiazide tabs20mg-25mg

F QL(2 ea daily)

TARKA TBCR (Use Trandolapril-VerapamilHCl)

NF

telmisartan-amlodipine tabs F

telmisartan-hydrochlorothiazide tabs F QL(1 ea daily)

TENORETIC 100 TABS (Use Atenolol & Chlorthalidone)


TENORETIC 50 TABS (Use Atenolol & Chlorthalidone)


trandolapril-verapamil hcltbcr F

TRANDOLAPRIL/VERAPAMIL HCL ER TBCR F

TRIBENZOR TABS (Use Olmesartan Medoxomil-Amlodipine-Hydrochlorothiazide)

NF

ST

TWYNSTA TABS (Use Telmisartan-Amlodipine) NF

valsartan-hydrochlorothiazide tabs F QL(1 ea daily);

MP VASERETIC TABS (Use Enalapril Maleate &Hydrochlorothiazide)


ZESTORETIC TABS (Use Lisinopril &Hydrochlorothiazide)

NF MP

ZIAC TABS (Use Bisoprolol& Hydrochlorothiazide) NF QL(1 ea daily);

MP

Vasodilators hydralazine hcl tabs or 10mg, 25 mg, 50 mg, 100 mg F MP

minoxidil tabs F MP

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)

Drug Name DrugTier

Requirements/Limits

Antimalarial Combinations

COARTEM TABS F QL(24 ea perfill retail)

Antimalarials CHLOROQUINE PHOSPHATE TABS 250 MG

F QL(2 ea daily)

chloroquine phosphate tabs500 mg F

hydroxychloroquine sulfatetabs F MP

mefloquine hcl tabs F

MEFLOQUINE HCL TABS F

PLAQUENIL TABS (Use HydroxychloroquineSulfate)

NF MP

PRIMAQUINE PHOSPHATE TABS F

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents MESTINON TABS 60 MG (Use PyridostigmineBromide)

NF

MESTINON TIMESPAN TBCR (Use PyridostigmineBromide)

NF

pyridostigmine bromidetabs F

pyridostigmine bromide tbcr F

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Antimycobacterial Agents

ethambutol hcl tabs F MP

ISONIAZID SYRP OR 50 MG/5ML F MP

isoniazid tabs or 100 mg,300 mg F MP

MYAMBUTOL TABS (Use Ethambutol HCl) NF MP

pyrazinamide tabs F


24

Drug Name DrugTier

Requirements/Limits

RIFADIN CAPS OR 150 MG, 300 MG (Use Rifampin)

NF

rifampin caps or 150 mg,300 mg F

TRECATOR TABS F

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN TABS OR 2 MG (Use Melphalan) NF

LEUKERAN TABS F

melphalan tabs F

MYLERAN TABS F

TEMODAR CAPS OR 180 MG, 250 MG (Use Temozolomide)

NF PA; QL(2 eadaily); SP

temozolomide caps 180mg, 250 mg F PA; QL(2 ea

daily); SP

Antimetabolites

mercaptopurine tabs F

methotrexate sodium soln ij1 gm/40ml, 50 mg/2ml, 200mg/8ml, 250 mg/10ml

F

METHOTREXATE SODIUM SOLN IJ 250 MG/10ML

F

methotrexate sodium tabs or 2.5 mg F

PURIXAN SUSP F

TREXALL TABS F

Antineoplastic - Hormonal and Related Agents

anastrozole tabs F

ARIMIDEX TABS (Use Anastrozole) NF

AROMASIN TABS (Use Exemestane) NF SP

Drug Name DrugTier

Requirements/Limits

bicalutamide tabs F QL(1 ea daily)

CASODEX TABS (Use Bicalutamide) NF QL(1 ea daily)

exemestane tabs F SP

FARESTON TABS F PA

FEMARA TABS (Use Letrozole) NF

flutamide caps F

letrozole tabs F

MEGACE ORAL SUSP (Use Megestrol Acetate) NF

megestrol acetate susp F

megestrol acetate tabs F

tamoxifen citrate tabs F MP

Antineoplastic Enzyme Inhibitors

COTELLIC TABS F PA; SP

NINLARO CAPS F PA; SP

Antineoplastics Misc. HYDREA CAPS (Use Hydroxyurea) NF

hydroxyurea caps F

Chemotherapy Rescue/Antidote Agents LEUCOVORIN CALCIUM TABS OR 10 MG, 15 MG F

leucovorin calcium tabs or 5 mg, 25 mg F

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease

Antiparkinson Adjuvants

carbidopa tabs F

LODOSYN TABS (Use Carbidopa) NF

Antiparkinson Anticholinergics


25

Drug Name DrugTier

Requirements/Limits

benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg F MP

trihexyphenidyl hcl elix F MP

trihexyphenidyl hcl tabs F MP

Antiparkinson Dopaminergics amantadine hcl caps 100 mg F MP

amantadine hcl syrp 50mg/5ml F MP

bromocriptine mesylate caps F

bromocriptine mesylatetabs F

carbidopa-levodopa tabs10mg-100mg, 25mg-100mg, 25mg-250mg

F MP

carbidopa-levodopa tbcr25mg-100mg, 50mg-200mg

F MP

MIRAPEX TABS (Use PramipexoleDihydrochloride)


PARLODEL CAPS (Use Bromocriptine Mesylate) NF

PARLODEL TABS (Use Bromocriptine Mesylate) NF

pramipexoledihydrochloride tabs 0.125mg, 0.25 mg, 0.75 mg, 0.5mg, 1 mg, 1.5 mg

F


REQUIP TABS 0.25 MG (Use RopiniroleHydrochloride)


REQUIP TABS 0.5 MG, 1 MG, 2 MG (Use RopiniroleHydrochloride)


REQUIP TABS 3 MG, 4 MG (Use RopiniroleHydrochloride)

NF QL(6 ea daily)

REQUIP TABS 5 MG (Use Ropinirole Hydrochloride) NF QL(3 ea daily)

ropinirole hydrochloridetabs 0.25 mg F QL(6 ea daily);

MP ropinirole hydrochloridetabs 0.5 mg, 1 mg, 2 mg F QL(3 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

ropinirole hydrochloridetabs 3 mg, 4 mg F QL(6 ea daily)

ropinirole hydrochloridetabs 5 mg F QL(3 ea daily)

SINEMET CR TBCR (Use Carbidopa-Levodopa) NF MP

SINEMET TABS (Use Carbidopa-Levodopa) NF MP

Antiparkinson Monoamine Oxidase Inhibitors ELDEPRYL CAPS (Use Selegiline HCl) NF MP

selegiline hcl caps F MP

selegiline hcl tabs F MP

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents lithium carbonate caps 150mg, 300 mg, 600 mg F

LITHIUM CARBONATE CAPS 150 MG, 600 MG (Use Lithium Carbonate)

F

lithium carbonate tabs 300 mg F

lithium carbonate tbcr 300 mg, 450 mg F

LITHIUM SOLN F

LITHOBID TBCR (Use Lithium Carbonate) F

Antipsychotics - Misc. GEODON CAPS OR 20 MG, 40 MG, 60 MG, 80 MG (Use Ziprasidone HCl)


NUPLAZID TABS 17 MG F PA; QL(2 eadaily)

ziprasidone hcl caps F QL(2 ea daily);AL; At least 18 yrs old

Benzisoxazoles

RISPERDAL M-TAB TBDP (Use Risperidone) NF



26

Drug Name DrugTier

Requirements/Limits

RISPERDAL SOLN 1 MG/ML (Use Risperidone) NF

QL(4 ml daily);AL; At least 5 yrs old

RISPERDAL TABS 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG (Use Risperidone)

NF


RISPERIDONE ODT TBDP F QL(2 ea daily);AL; At least 5 yrs old

risperidone soln 1 mg/ml F QL(4 ml daily);AL; At least 5 yrs old

risperidone tabs 0.25 mg,0.5 mg, 1 mg, 2 mg, 3 mg,4 mg


risperidone tbdp 0.25 mg,0.5 mg, 1 mg, 2 mg, 3 mg,4 mg


Butyrophenones HALDOL DECANOATE 100 SOLN (Use Haloperidol Decanoate)

NF

HALDOL DECANOATE 50 SOLN (Use HaloperidolDecanoate)

NF

HALDOL SOLN (Use Haloperidol Lactate) NF QL(6 ml daily)

haloperidol decanoate soln F

haloperidol lactate conc or2 mg/ml F

haloperidol lactate soln ij 5mg/ml F QL(6 ml daily)

haloperidol tabs 0.5 mg, 1mg, 10 mg F QL(3 ea daily)

haloperidol tabs 2 mg, 5mg, 20 mg F

Dibenzapines

clozapine tabs 100 mg F QL(9 ea daily);AL; At least 18 yrs old

clozapine tabs 25 mg, 50mg, 200 mg F


Drug Name DrugTier

Requirements/Limits

CLOZARIL TABS 100 MG (Use Clozapine) NF


CLOZARIL TABS 25 MG (Use Clozapine) NF


loxapine succinate caps F QL(4 ea daily)

olanzapine tabs or 10 mg,7.5 mg F


olanzapine tabs or 15 mg,20 mg F


olanzapine tabs or 5 mg,2.5 mg F


quetiapine fumarate tabs25 mg, 50 mg, 100 mg, 200 mg


quetiapine fumarate tabs300 mg, 400 mg F


SEROQUEL TABS 25 MG, 50 MG, 100 MG, 200 MG (Use Quetiapine Fumarate)


SEROQUEL TABS 300 MG, 400 MG (Use Quetiapine Fumarate)


ZYPREXA TABS OR 10 MG, 7.5 MG (Use Olanzapine)


ZYPREXA TABS OR 15 MG, 20 MG (Use Olanzapine)


ZYPREXA TABS OR 5 MG, 2.5 MG (Use Olanzapine)


Dihydroindolones MOLINDONE HYDROCHLORIDE TABS F QL(4 ea daily)

Phenothiazines CHLORPROMAZINE HCL SOLN IJ 25 MG/ML, 50MG/2ML

F QL(12 ml daily)

chlorpromazine hcl tabs or10 mg F QL(10 ea daily)


27

Drug Name DrugTier

Requirements/Limits

chlorpromazine hcl tabs or25 mg, 50 mg, 100 mg, 200 mg

F QL(3 ea daily)

fluphenazine decanoatesoln F

fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg F

perphenazine tabs F QL(4 ea daily)

prochlorperazine maleatetabs F

prochlorperazine supp F

thioridazine hcl tabs F QL(3 ea daily)

trifluoperazine hcl tabs F QL(3 ea daily)

Quinolinone Derivatives

ABILIFY TABS (Use Aripiprazole) NF


aripiprazole soln 1 mg/ml F PA; AL; At least 6 yrs old

aripiprazole tabs 2 mg, 5mg, 10 mg, 15 mg, 20 mg,30 mg


aripiprazole tbdp 10 mg, 15 mg F

PA; QL(1 eadaily); AL; Atleast 6 yrs old

Thioxanthenes

thiothixene caps F QL(3 ea daily)

ANTISEPTICS & DISINFECTANTS

Antiseptics & Disinfectants formaldehyde soln 10%, 10% F QL(90 ml per

fill retail) Chlorine Antiseptics chlorhexidine gluconateliqd ex 4 % F

HIBICLENS LIQD (Use Chlorhexidine Gluconate) NF

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals

Drug Name DrugTier

Requirements/Limits

abacavir sulfate soln 20 mg/ml F QL(30 ml daily)

abacavir sulfate tabs 300 mg F QL(2 ea daily)

abacavir sulfate-lamivudine tabs F QL(1 ea daily)

abacavir sulfate-lamivudine-zidovudine tabs F QL(2 ea daily)

APTIVUS CAPS 250 MG F QL(4 ea daily)

APTIVUS SOLN 100 MG/ML F QL(10 ml daily)

atazanavir sulfate caps F QL(2 ea daily)

ATRIPLA TABS F QL(1 ea daily)

COMBIVIR TABS (Use Lamivudine-Zidovudine) NF QL(2 ea daily)

COMPLERA TABS F ST; QL(1 eadaily)

CRIXIVAN CAPS 200 MG F QL(9 ea daily)

CRIXIVAN CAPS 400 MG F QL(6 ea daily)

DESCOVY TABS F QL(1 ea daily)

didanosine cpdr F QL(1 ea daily)

EDURANT TABS F QL(1 ea daily)

efavirenz caps 200 mg F QL(1 ea daily)

efavirenz caps 50 mg F QL(2 ea daily)

efavirenz tabs 600 mg F QL(1 ea daily)

EMTRIVA CAPS 200 MG F QL(1 ea daily)

EMTRIVA SOLN 10 MG/ML F QL(24 ml daily)

EPIVIR SOLN 10 MG/ML(Use Lamivudine) NF QL(30 ml daily)

EPIVIR TABS 150 MG (Use Lamivudine) NF QL(2 ea daily)

EPIVIR TABS 300 MG (Use Lamivudine) NF QL(1 ea daily)


28

Drug Name DrugTier

Requirements/Limits

EPZICOM TABS (Use Abacavir Sulfate-Lamivudine)

NF QL(1 ea daily)

EVOTAZ TABS F QL(1 ea daily)

fosamprenavir calcium tabs F QL(4 ea daily)

GENVOYA TABS F QL(1 ea daily)

INTELENCE TABS 200 MG F QL(2 ea daily)

INTELENCE TABS 25 MG, 100 MG F QL(4 ea daily)

INVIRASE CAPS 200 MG F QL(10 ea daily)

INVIRASE TABS 500 MG F QL(4 ea daily)

ISENTRESS CHEW 100 MG F QL(6 ea daily)

ISENTRESS CHEW 25 MG F QL(12 ea daily)

ISENTRESS PACK 100 MG F QL(2 ea daily)

ISENTRESS TABS 400 MG F QL(2 ea daily)

KALETRA SOLN 400MG/5ML-100MG/5ML(Use Lopinavir-Ritonavir)

NF QL(10.67 mldaily)

KALETRA TABS 100MG-25MG F QL(4 ea daily)

KALETRA TABS 200MG-50MG F QL(6 ea daily)

lamivudine soln 10 mg/ml F QL(30 ml daily)

lamivudine tabs 150 mg F QL(2 ea daily)

lamivudine tabs 300 mg F QL(1 ea daily)

lamivudine-zidovudine tabs F QL(2 ea daily)

LEXIVA SUSP 50 MG/ML F QL(56 ml daily)

LEXIVA TABS 700 MG (Use FosamprenavirCalcium)

NF QL(4 ea daily)

lopinavir-ritonavir soln F QL(10.67 mldaily)

Drug Name DrugTier

Requirements/Limits

nevirapine tabs 200 mg F QL(2 ea daily)

nevirapine tb24 100 mg F QL(3 ea daily)

nevirapine tb24 400 mg F QL(1 ea daily)

NORVIR CAPS 100 MG F QL(12 ea daily)

NORVIR SOLN 80 MG/ML F QL(15 ml daily)

NORVIR TABS 100 MG (Use Ritonavir) NF QL(12 ea daily)

ODEFSEY TABS F

PREZCOBIX TABS F QL(1 ea daily)

PREZISTA SUSP 100 MG/ML F QL(12 ml daily)

PREZISTA TABS 150 MG F QL(3 ea daily)

PREZISTA TABS 75 MG, 600 MG F QL(2 ea daily)

PREZISTA TABS 800 MG F QL(1 ea daily)

RESCRIPTOR TABS 100 MG F QL(12 ea daily)

RESCRIPTOR TABS 200 MG F QL(6 ea daily)

RETROVIR CAPS 100 MG (Use Zidovudine) NF QL(6 ea daily)

RETROVIR SYRP 50 MG/5ML (Use Zidovudine) NF QL(60 ml daily)

REYATAZ CAPS 150 MG, 200 MG, 300 MG (Use Atazanavir Sulfate)

NF QL(2 ea daily)

REYATAZ PACK 50 MG F QL(6 ea daily)

ritonavir tabs F QL(12 ea daily)

SELZENTRY TABS 25 MG, 75 MG, 150 MG F QL(2 ea daily)

SELZENTRY TABS 300 MG F QL(4 ea daily)

stavudine caps F QL(2 ea daily)

STRIBILD TABS F ST; QL(1 eadaily)


29

Drug Name DrugTier

Requirements/Limits

SUSTIVA CAPS 200 MG (Use Efavirenz) NF QL(1 ea daily)

SUSTIVA CAPS 50 MG (Use Efavirenz) NF QL(2 ea daily)

SUSTIVA TABS 600 MG (Use Efavirenz) NF QL(1 ea daily)

tenofovir disoproxilfumarate tabs F QL(1 ea daily)

TIVICAY TABS F

TRIUMEQ TABS F

TRIZIVIR TABS (Use Abacavir Sulfate-Lamivudine-Zidovudine)

NF QL(2 ea daily)

TRUVADA TABS 300MG-200MG F QL(1 ea daily)

TYBOST TABS F QL(1 ea daily)

VIDEX EC CPDR 125 MG F QL(1 ea daily)

VIDEX EC CPDR 200 MG, 250 MG, 400 MG (Use Didanosine)

NF QL(1 ea daily)

VIDEXPEDIATRIC SOLR F QL(20 ml daily)

VIRACEPT TABS 250 MG F QL(9 ea daily)

VIRACEPT TABS 625 MG F QL(4 ea daily)

VIRAMUNE TABS (Use Nevirapine) NF QL(2 ea daily)

VIRAMUNE XR TB24 100 MG (Use Nevirapine) NF QL(3 ea daily)

VIRAMUNE XR TB24 400 MG (Use Nevirapine) NF QL(1 ea daily)

VIREAD POWD 40 MG/GM F QL(8 gm daily)

VIREAD TABS 150 MG, 200 MG, 250 MG F QL(1 ea daily)

VIREAD TABS 300 MG (Use Tenofovir DisoproxilFumarate)

NF QL(1 ea daily)

ZERIT CAPS 15 MG, 20 MG, 30 MG, 40 MG (Use Stavudine)

NF QL(2 ea daily)

ZERIT SOLR 1 MG/ML F QL(80 ml daily)

Drug Name DrugTier

Requirements/Limits

ZIAGEN SOLN 20 MG/ML(Use Abacavir Sulfate) NF QL(30 ml daily)

ZIAGEN TABS 300 MG (Use Abacavir Sulfate) NF QL(2 ea daily)

zidovudine caps 100 mg F QL(6 ea daily)

zidovudine syrp 50 mg/5ml F QL(60 ml daily)

zidovudine tabs 300 mg F QL(2 ea daily)

CMV Agents VALCYTE TABS 450 MG (Use Valganciclovir HCl) NF QL(2 ea daily)

valganciclovir hcl tabs 450 mg F QL(2 ea daily)

Hepatitis Agents

MAVYRET TABS F PA; QL(3 eadaily); SP

SOVALDI TABS F PA; SP

Herpes Agents

acyclovir caps 200 mg F

acyclovir susp 200 mg/5ml F

acyclovir tabs 400 mg F QL(3 ea daily)

acyclovir tabs 800 mg F

famciclovir tabs F

FAMVIR TABS (Use Famciclovir) NF

valacyclovir hcl tabs 1 gm,1000 mg F QL(42 ea per

21 days retail) valacyclovir hcl tabs 500 mg F QL(2 ea daily)

VALTREX TABS 1 GM (Use Valacyclovir HCl) NF QL(42 ea per

21 days retail) VALTREX TABS 500 MG (Use Valacyclovir HCl) NF QL(2 ea daily)

ZOVIRAX CAPS OR 200 MG (Use Acyclovir) NF

ZOVIRAX SUSP OR 200 MG/5ML (Use Acyclovir) NF


30

Drug Name DrugTier

Requirements/Limits

ZOVIRAX TABS OR 400 MG (Use Acyclovir) NF QL(3 ea daily)

ZOVIRAX TABS OR 800 MG (Use Acyclovir) NF

Influenza Agents oseltamivir phosphate caps30 mg, 45 mg F

oseltamivir phosphate caps75 mg F

QL(10 ea per30 days retail)1rtl MAX fill,180 rtl day(s)supply,

oseltamivir phosphate susr6 mg/ml F

RELENZA DISKHALER AEPB F

QL(20 ea perfill retail); AL; Atleast 5 yrs old

TAMIFLU CAPS 30 MG, 45 MG (Use Oseltamivir Phosphate)

NF

TAMIFLU CAPS 75 MG (Use Oseltamivir Phosphate)

NF

QL(10 ea per30 days retail)1rtl MAX fill,180 rtl day(s)supply,

TAMIFLU SUSR 6 MG/ML(Use Oseltamivir Phosphate)

NF

BETA BLOCKERS - Drugs to Treat High BloodPressure

Alpha-Beta Blockers

carvedilol phosphate cp24 F QL(1 ea daily)

carvedilol tabs 12.5 mg,6.25 mg, 3.125 mg F QL(3 ea daily);

MP

carvedilol tabs 25 mg F QL(4 ea daily);MP

COREG CR CP24 (Use Carvedilol Phosphate) NF QL(1 ea daily)

COREG TABS 12.5 MG, 6.25 MG, 3.125 MG (Use Carvedilol)


COREG TABS 25 MG (Use Carvedilol) NF QL(4 ea daily);

MP

labetalol hcl tabs or 100 mg F QL(3 ea daily);MP

Drug Name DrugTier

Requirements/Limits



Beta Blockers Cardio-Selective

acebutolol hcl caps F MP

atenolol tabs F QL(2 ea daily);MP

bisoprolol fumarate tabs F QL(1 ea daily);MP

LOPRESSOR TABS 100 MG (Use MetoprololTartrate)

NF QL(4.5 eadaily); MP

LOPRESSOR TABS 50 MG (Use MetoprololTartrate)


metoprolol succinate tb24200 mg F QL(2 ea daily);

MP metoprolol succinate tb2425 mg, 50 mg, 100 mg F QL(4 ea daily);

MP metoprolol tartrate tabs or100 mg F QL(4.5 ea

daily); MP metoprolol tartrate tabs or25 mg, 50 mg F QL(4 ea daily);

MP SECTRAL CAPS (Use Acebutolol HCl) NF MP

TENORMIN TABS (Use Atenolol) NF QL(2 ea daily);

MP TOPROL XL TB24 200 MG (Use Metoprolol Succinate) NF QL(2 ea daily);

MP TOPROL XL TB24 25 MG, 50 MG, 100 MG (Use Metoprolol Succinate)


ZEBETA TABS (Use Bisoprolol Fumarate) NF QL(1 ea daily);

MP

Beta Blockers Non-Selective BETAPACE AF TABS (Use Sotalol HCl (AFIB/AFL)) NF QL(2 ea daily);

MP BETAPACE TABS (Use Sotalol HCl) NF QL(2 ea daily);

MP CORGARD TABS (Use Nadolol) NF QL(2 ea daily);

MP

HEMANGEOL SOLN F PA


31

Drug Name DrugTier

Requirements/Limits

INDERAL LA CP24 (Use Propranolol HCl) NF QL(2 ea daily);

MP

nadolol tabs F QL(2 ea daily);MP

pindolol tabs F MP

propranolol hcl cp24 or 60mg, 80 mg, 120 mg, 160 mg

F QL(2 ea daily);MP

PROPRANOLOL HCL SOLN OR 20 MG/5ML, 40MG/5ML

F MP

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

F MP

sotalol hcl (afib/afl) tabs F QL(2 ea daily);MP

sotalol hcl tabs 240 mg F MP

sotalol hcl tabs 80 mg, 120mg, 160 mg F QL(2 ea daily);

MP

TIMOLOL MALEATE TABS F MP

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure

Calcium Channel Blockers ADALAT CC TB24 30 MG, 90 MG (Use Nifedipine) NF QL(1 ea daily);

MP ADALAT CC TB24 60 MG (Use Nifedipine) NF QL(2 ea daily);

MP

amlodipine besylate tabs F QL(1 ea daily);MP

CALAN SR TBCR (Use Verapamil HCl) NF QL(2 ea daily);

MP CALAN TABS (Use Verapamil HCl) NF QL(3 ea daily);

MP CARDIZEM CD CP24 120 MG, 180 MG (Use Diltiazem HCl Coated Beads)

NF

QL(1 ea daily);MP

CARDIZEM CD CP24 240 MG (Use Diltiazem HCl Coated Beads)


CARDIZEM TABS (Use Diltiazem HCl) NF QL(3 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

diltiazem hcl coated beads cp24 120 mg, 180 mg, 300 mg

F QL(1 ea daily);MP

diltiazem hcl coated beads cp24 240 mg F QL(2 ea daily);

MP diltiazem hcl cp12 or 60mg, 90 mg, 120 mg F QL(2 ea daily);

MP diltiazem hcl cp24 or 120mg, 180 mg F QL(1 ea daily);

MP diltiazem hcl cp24 or 240 mg F QL(2 ea daily);

MP diltiazem hcl extended release beads cp24 F QL(1 ea daily);

MP diltiazem hcl tabs or 30 mg,60 mg, 90 mg, 120 mg F QL(3 ea daily);

MP

felodipine tb24 F QL(1 ea daily);MP

nicardipine hcl caps or 20mg, 30 mg F

nifedipine caps 10 mg, 20 mg F QL(4 ea daily);

MP nifedipine tb24 30 mg, 90 mg F QL(1 ea daily);

MP

nifedipine tb24 60 mg F QL(2 ea daily);MP

NORVASC TABS (Use Amlodipine Besylate) NF QL(1 ea daily);

MP PROCARDIA CAPS (Use Nifedipine) NF QL(4 ea daily);

MP PROCARDIA XL TB24 30 MG, 90 MG (Use Nifedipine)


PROCARDIA XL TB24 60 MG (Use Nifedipine) NF QL(2 ea daily);

MP TIAZAC CP24 (Use Diltiazem HCl Extended Release Beads)


verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 240 mg

F QL(2 ea daily);MP

verapamil hcl cp24 or 300 mg F QL(1 ea daily);

MP VERAPAMIL HCL SR CP24 F QL(1 ea daily);

MP verapamil hcl tabs or 40mg, 80 mg, 120 mg F QL(3 ea daily);

MP


32

Drug Name DrugTier

Requirements/Limits

verapamil hcl tbcr or 120mg, 180 mg, 240 mg F QL(2 ea daily);

MP VERELAN CP24 120 MG, 180 MG, 240 MG (Use Verapamil HCl)


VERELAN CP24 360 MG F QL(1 ea daily);MP

VERELAN PM CP24 100 MG, 200 MG (Use Verapamil HCl)


VERELAN PM CP24 300 MG (Use Verapamil HCl) NF QL(1 ea daily);

MP

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Cardiac Glycosides DIGOXIN SOLN OR 0.05 MG/ML F MP

digoxin tabs or 0.125 mg,0.25 mg, 125 mcg, 250 mcg

F MP

LANOXIN TABS OR 125 MCG, 250 MCG (Use Digoxin)

F MP

CEPHALOSPORINS - Drugs to Treat BacterialInfections

Cephalosporins - 1st Generation

cefadroxil caps F

cefadroxil susr F

cefadroxil tabs F

cephalexin caps 250 mg,500 mg F

cephalexin susr 125mg/5ml, 250 mg/5ml F

KEFLEX CAPS 250 MG, 500 MG (Use Cephalexin) NF

Cephalosporins - 2nd Generation cefaclor caps 250 mg, 500 mg F

CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML,375 MG/5ML

F

Drug Name DrugTier

Requirements/Limits

cefprozil susr 125 mg/5ml F QL(200 ml perfill retail); AL;Up to 12 yrs old

cefprozil susr 250 mg/5ml F QL(100 ml perfill retail); AL;Up to 12 yrs old

cefprozil tabs 250 mg, 500 mg F QL(20 ea per

fill retail)

CEFTIN SUSR 125 MG/5ML, 250 MG/5ML F


CEFTIN TABS 500 MG (Use Cefuroxime Axetil) NF QL(20 ea per

fill retail)

cefuroxime axetil tabs F QL(20 ea perfill retail)

Cephalosporins - 3rd Generation

cefdinir caps 300 mg F QL(20 ea perfill retail)

cefdinir susr 125 mg/5ml,250 mg/5ml F QL(100 ml per

fill retail) ceftriaxone sodium solr ij 1gm, 250 mg, 500 mg F QL(3 ea per fill

retail) CONTRACEPTIVES - Drugs to PreventPregnancy

Combination Contraceptives - Oral BREVICON-28 TABS (Use Norethindrone & Eth Estradiol)

NF QL(1 ea daily)

CYCLESSA TABS (Use Desogestrel-EthinylEstradiol (Triphasic))

NF QL(1 ea daily)

DESOGEN TABS (Use Desogestrel & EthinylEstradiol)

NF QL(1 ea daily)

desogestrel & ethinylestradiol tabs F QL(1 ea daily)

desogestrel-ethinylestradiol (biphasic) tabs F QL(1 ea daily)

desogestrel-ethinylestradiol (triphasic) tabs F QL(1 ea daily)

drospirenone-ethinylestradiol tabs F QL(1 ea daily)

ESTROSTEP FE TABS (Use Norethindrone Acetate-Ethinyl Estradiol-Fe)

NF


33

Drug Name DrugTier

Requirements/Limits

ethynodiol diacet & ethestrad tabs 1mg-35mcg F QL(1 ea daily)

ethynodiol diacet & ethestrad tabs 1mg-50mcg F

FEMCON FE CHEW (Use Norethindrone & EthinylEstradiol-Fe)

NF

GENERESS FE CHEW (Use Norethindrone & Ethinyl Estradiol-Fe)

NF

levonorgestrel & ethestradiol tabs F QL(1 ea daily)

levonorgestrel-eth estradiol(triphasic) tabs F QL(1 ea daily)

levonorgestrel-ethinylestradiol (91-day) tabs F QL(1 ea daily)

LOESTRIN 1.5/30-21TABS (Use Norethindrone Acet & Eth Estra)

NF QL(1 ea daily)

LOESTRIN 1/20-21 TABS(Use Norethindrone Acet & Eth Estra)

NF QL(1 ea daily)

LOESTRIN FE 1.5/30TABS (Use Norethin Acet & Estrad-Fe)

NF QL(1 ea daily)

LOESTRIN FE 1/20 TABS(Use Norethin Acet & Estrad-Fe)

NF QL(1 ea daily)

MIRCETTE TABS (Use Desogestrel-EthinylEstradiol (Biphasic))

NF QL(1 ea daily)

MODICON TABS (Use Norethindrone & Eth Estradiol)

NF QL(1 ea daily)

NECON 1/50-28 TABS F QL(1 ea daily)

NECON 10/11-28 TABS F QL(1 ea daily)

norethin acet & estrad-fe tabs 75mg-20mcg-1mg,75mg-30mcg-1.5mg

F QL(1 ea daily)

norethindrone & eth estradiol tabs F QL(1 ea daily)

norethindrone & ethinylestradiol-fe chew F

norethindrone acet & eth estra tabs F QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

norethindrone acetate-ethinyl estradiol-fe tabs F

norethindrone-eth estradiol (triphasic) tabs F QL(1 ea daily)

norgestimate-ethinylestradiol (triphasic) tabs F

norgestimate-ethinylestradiol (triphasic) tabs F QL(1 ea daily)

norgestimate-ethinylestradiol tabs F QL(1 ea daily)

norgestrel & ethinylestradiol tabs F QL(2 ea daily)

NORINYL 1+35 TABS (Use Norethindrone & Eth Estradiol)

NF QL(1 ea daily)

OGESTREL TABS F QL(1 ea daily)

ORTHO TRI-CYCLEN LO TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

NF

ORTHO TRI-CYCLEN TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

NF

QL(1 ea daily)

ORTHO-CYCLEN TABS (Use Norgestimate-EthinylEstradiol)

NF QL(1 ea daily)

ORTHO-NOVUM 1/35TABS (Use Norethindrone & Eth Estradiol)

NF QL(1 ea daily)

ORTHO-NOVUM 7/7/7TABS (Use Norethindrone-Eth Estradiol (Triphasic))

NF QL(1 ea daily)

OVCON-35 TABS (Use Norethindrone & Eth Estradiol)

NF QL(1 ea daily)

SEASONIQUE TABS (Use Levonorgestrel-EthinylEstradiol (91-Day))

NF QL(1 ea daily)

TRI-NORINYL 28 TABS (Use Norethindrone-Eth Estradiol (Triphasic))

NF QL(1 ea daily)

YASMIN 28 TABS (Use Drospirenone-EthinylEstradiol)

NF QL(1 ea daily)


34

Drug Name DrugTier

Requirements/Limits

YAZ TABS (Use Drospirenone-EthinylEstradiol)

NF QL(1 ea daily)

Combination Contraceptives - Transdermal XULANE PTWK F

Combination Contraceptives - Vaginal NUVARING RING F

Emergency Contraceptives

ELLA TABS F

levonorgestrel (emergencyoc) tabs F

PLAN B ONE-STEP TABS (Use Levonorgestrel(Emergency OC))

NF

Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSP (Use MedroxyprogesteroneAcetate (Contraceptive))

NF

QL(1 ml per fillretail)

DEPO-PROVERA CONTRACEPTIVE SUSY (Use MedroxyprogesteroneAcetate (Contraceptive))

NF

DEPO-SUBQ PROVERA 104 SUSY F

medroxyprogesteroneacetate (contraceptive) susp

F QL(1 ml per fillretail)

medroxyprogesteroneacetate (contraceptive) susy

F

Progestin Contraceptives - Oral NOR-QD TABS (Use Norethindrone (Contraceptive))

NF QL(1 ea daily)

norethindrone (contraceptive) tabs F QL(1 ea daily)

ORTHO MICRONOR TABS (Use Norethindrone (Contraceptive))

NF QL(1 ea daily)

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions

Drug Name DrugTier

Requirements/Limits

Glucocorticosteroids CORTEF TABS (Use Hydrocortisone) NF

CORTISONE ACETATE TABS F

dexamethasone elix 0.5 mg/5ml F

DEXAMETHASONE INTENSOL CONC F

dexamethasone sodium phosphate soln ij 4 mg/ml,20 mg/5ml, 120 mg/30ml

F

DEXAMETHASONE SOLN 0.5 MG/5ML F

dexamethasone tabs 0.75 mg, 0.5 mg, 4 mg, 6 mg,1.5 mg

F

DEXAMETHASONE TABS 1 MG, 2 MG F

hydrocortisone tabs F

MEDROL DOSEPAK TBPK (Use Methylprednisolone) NF

MEDROL TABS 4 MG, 8 MG (Use Methylprednisolone)

NF

methylprednisolone tabs or4 mg, 8 mg F

methylprednisolone tbpk or4 mg F

MILLIPRED TABS 5 MG F

PEDIAPRED SOLN (Use Prednisolone Sodium Phosphate)

NF

prednisolone sodiumphosphate soln or 15mg/5ml


prednisolone sodiumphosphate soln or 20mg/5ml


prednisolone sodiumphosphate soln or 5mg/5ml, 6.7 mg/5ml

F

prednisolone soln F


35

Drug Name DrugTier

Requirements/Limits

PREDNISOLONE SOLN F

prednisolone syrp F

PREDNISONE INTENSOL CONC F

PREDNISONE SOLN 5 MG/5ML F

prednisone tabs 1 mg, 5mg, 10 mg, 20 mg, 2.5 mg F

PREDNISONE TABS 50 MG F

PREDNISONE TBPK 5 MG, 10 MG F

VERIPRED 20 SOLN (Use Prednisolone Sodium Phosphate)


Mineralocorticoids fludrocortisone acetate tabs F

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy Symptoms

Antitussives benzonatate caps 100 mg,200 mg F AL; At least 10

yrs old DELSYM COUGH CHILDRENS SUER (Use DextromethorphanPolistirex)

NF

DELSYM SUER (Use DextromethorphanPolistirex)

NF

dextromethorphanpolistirex suer F

hydrocodone w/homatropine syrp 5mg/5ml-1.5mg/5ml

F AL; At least 18 yrs old

TESSALON PERLES CAPS (Use Benzonatate) NF AL; At least 10

yrs old

Cough/Cold/Allergy Combinations ADVIL COLD & SINUS TABS (Use Pseudoephedrine-Ibuprofen)

NF

Drug Name DrugTier

Requirements/Limits

brompheniramine &phenyleph elix 1mg/5ml-2.5mg/5ml, 1mg/5ml-1mg/5ml-2.5mg/5ml-2.5mg/5ml

F


brompheniramine &pseudoeph elix F QL(120 ml per

fill retail) brompheniramine &pseudoeph liqd F QL(120 ml per

fill retail)

BROTAPP DM LIQD F QL(240 ml perfill retail)

cetirizine-pseudoephedrinetb12 F QL(2 ea daily)

CHERACOL PLUS LIQD (Use Dextromethorphan-Guaifenesin)


CHERACOL-D COUGH LIQD (Use Dextromethorphan-Guaifenesin)

NF


CLARITIN-D 12 HOUR TB12 (Use Loratadine & Pseudoephedrine)

NF QL(2 ea daily)

CLARITIN-D 24 HOUR TB24 (Use Loratadine & Pseudoephedrine)

NF QL(1 ea daily)

CLEAR COUGH PM MULTI-SYMPTOM LIQD (Use Dextromethorphan-Doxylamine-Acetaminophen)

NF

DAY TIME MULTI-SYMPTOM COLD/FLURELIEF CAPS (Use Dextromethorphan-Phenylephrine-Acetaminophen)

NF

dextromethorphan-doxylamine-acetaminophenliqd 6.25mg/15ml-15mg/15ml-500mg/15ml,12.5mg/30ml-30mg/30ml-1000mg/30ml,6.25mg/15ml-6.25mg/15ml-15mg/15ml-15mg/15ml-500mg/15ml-500mg/15ml-10%

F


36

Drug Name DrugTier

Requirements/Limits

dextromethorphan-guaifenesin liqd 5mg/5ml-100mg/5ml, 10mg/5ml-100mg/5ml, 10mg/5ml-200mg/5ml, 20mg/10ml-200mg/10ml, 20mg/10ml-400mg/10ml, 20mg/20ml-400mg/20ml, 15mg/7.5ml-150mg/7.5ml, 10mg/5ml-10mg/5ml-100mg/5ml-100mg/5ml

F


dextromethorphan-guaifenesin soln 10mg/5ml-100mg/5ml, 20mg/10ml-200mg/10ml

F


dextromethorphan-guaifenesin syrp10mg/5ml-100mg/5ml,10mg/5ml-10mg/5ml-100mg/5ml-100mg/5ml

F


dextromethorphan-phenylephrine-acetaminophen caps10mg-325mg-5mg, 10mg-10mg-325mg-325mg-5mg-5mg

F

DIMETAPP COLD & ALLERGY ELIX 1MG/5ML-2.5MG/5ML (Use Brompheniramine &Phenyleph)

NF


DIMETAPP LONG ACTING COUGH PLUS COLD SYRP


ED BRON GP LIQD F

guaifenesin-codeine liqd100mg/5ml-10mg/5ml F

guaifenesin-codeine soln100mg/5ml-10mg/5ml F

guaifenesin-codeine syrp100mg/5ml-10mg/5ml F

LOHIST-D LIQD F QL(240 ml perfill retail)

loratadine & pseudoephedrine tb125mg-120mg

F QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

loratadine & pseudoephedrine tb2410mg-240mg, 10mg-10mg-240mg-240mg

F

QL(1 ea daily)

phenylephrine-dm liqd F QL(240 ml perfill retail)

phenylephrine-dm soln F QL(240 ml perfill retail)

promethazine &phenylephrine soln F

promethazine &phenylephrine syrp F

promethazine w/codeinesoln F


promethazine w/codeine syrp F


promethazine-dm syrp F QL(240 ml perfill retail)

promethazine-phenylephrine-codeine syrp F


PROMETHAZINE/PHENYLEPHRINE SYRP F

pseudoephed-bromphen-dm elix F QL(240 ml per

fill retail) pseudoephed-bromphen-dm syrp F QL(240 ml per

fill retail) pseudoephedrine w/codeine-gg soln F QL(240 ml per

fill retail) pseudoephedrine-chlorphen-dm liqd F QL(240 ml per

fill retail) pseudoephedrine-ibuprofentabs F

ROBITUSSIN DM SYRP (Use Dextromethorphan-Guaifenesin)


ROBITUSSIN PEAK COLD COUGH+ CHEST CONGESTION DM MAX STRENGTH LIQD (Use Dextromethorphan-Guaifenesin)

NF



37

Drug Name DrugTier

Requirements/Limits

ROBITUSSIN PEAK COLD DM SYRP (Use Dextromethorphan-Guaifenesin)

NF


TRIAMINIC COLD & COUGH DAY TIME CHILDRENS SOLN


TRIAMINIC COLD & COUGH DAY TIME CHILDRENS SYRP


ZYRTEC-D ALLERGY/CONGESTIONTB12 (Use Cetirizine-Pseudoephedrine)

NF

QL(2 ea daily)

Expectorants guaifenesin liqd 100mg/5ml, 200 mg/10ml, 400mg/20ml


guaifenesin soln 100mg/5ml, 200 mg/10ml, 300mg/15ml


guaifenesin syrp 100mg/5ml, 200 mg/10ml F QL(240 ml per

fill retail)

guaifenesin tb12 600 mg F QL(40 ea perfill retail)

MUCINEX TB12 (Use Guaifenesin) NF QL(40 ea per

fill retail) Misc. Respiratory Inhalants sodium chloride (inhalant)nebu 0.9 % F

Mucolytics

acetylcysteine soln F

DERMATOLOGICALS - Drugs to Treat SkinConditions

Acne Products

ABSORICA CAPS 10 MG, 20 MG, 40 MG F


ACNE MEDICATION 10 LOTN F

ACNE MEDICATION 5 LOTN F

BENZAC AC WASH LIQD (Use Benzoyl Peroxide) NF RX/OTC

Drug Name DrugTier

Requirements/Limits

benzoyl peroxide bar 10 % F

BENZOYL PEROXIDE CLEANSER LOTN 6 % F

benzoyl peroxide gel 10 % F RX/OTC

BENZOYL PEROXIDE GEL 2.5 % F

benzoyl peroxide gel 5 % F

benzoyl peroxide liqd 4 % F

benzoyl peroxide liqd 5 %,10 % F RX/OTC

benzoyl peroxide lotn 6 % F

CLEAN & CLEAR ADVANTAGE 3-IN-1 EXFOLIATING CLEANSER LOTN

F

CLEOCIN-T GEL (Use Clindamycin Phosphate(Topical))


CLEOCIN-T LOTN (Use Clindamycin Phosphate(Topical))


CLEOCIN-T SOLN (Use Clindamycin Phosphate(Topical))

NF

CLINDAGEL GEL F QL(75 ml perfill retail)

clindamycin phosphate(topical) gel F QL(75 ml per

fill retail) clindamycin phosphate(topical) lotn F QL(60 ml per

fill retail) clindamycin phosphate(topical) soln F

CLINDAMYCIN PHOSPHATE GEL EX 1 % F QL(75 ml per

fill retail) DESQUAM-X WASH LIQD (Use Benzoyl Peroxide) NF RX/OTC

ERYGEL GEL (Use Erythromycin (Acne Aid)) NF QL(60 gm per

fill retail)

erythromycin (acne aid) gel F QL(60 gm perfill retail)

erythromycin (acne aid)soln F


38

Drug Name DrugTier

Requirements/Limits

isotretinoin caps 10 mg, 20mg, 40 mg F


KLARON LOTN (Use Sulfacetamide Sodium (Acne))


PANOXYL-4 CREAMY WASH LIQD (Use BenzoylPeroxide)

NF

RETIN-A CREA 0.025 % (Use Tretinoin) NF

QL(20 gm perfill retail); AL;Up to 35 yrs old

RETIN-A CREA 0.05 %, 0.1 % (Use Tretinoin) NF AL; Up to 35

yrs old

RETIN-A GEL 0.025 %, 0.01 % (Use Tretinoin) NF


sulfacetamide sodium (acne) lotn F QL(120 ml per

fill retail)

tretinoin crea 0.025 % F QL(20 gm perfill retail); AL;Up to 35 yrs old

tretinoin crea 0.05 %, 0.1% F AL; Up to 35

yrs old

tretinoin gel 0.025 %, 0.01% F


Anti-inflammatory Agents - Topical diclofenac sodium (topical)gel 1 % F QL(6.68 gm

daily) VOLTAREN GEL (Use Diclofenac Sodium (Topical))

NF QL(6.68 gmdaily)

Antibiotics - Topical BACIGUENT OINT (Use Bacitracin (Topical)) NF QL(30 gm per

fill retail)

bacitracin (topical) oint F QL(30 gm perfill retail)

bacitracin zinc oint F QL(30 gm perfill retail)

BACTROBAN CREA (Use Mupirocin Calcium(Topical))


CENTANY OINT F QL(2160 gmper fill retail)

Drug Name DrugTier

Requirements/Limits

gentamicin sulfate (topical) crea F QL(30 gm per

fill retail) gentamicin sulfate (topical)oint F QL(30 gm per

fill retail) mupirocin calcium (topical) crea F QL(30 gm per

fill retail)

mupirocin oint F QL(2160 gmper fill retail)

neomycin-bacitracin-polymyxin oint F QL(454 gm per

fill retail) neomycin-polymyxin w/pramoxine crea F QL(28.3 gm per

fill retail) NEOSPORIN ORIGINAL OINT (Use Neomycin-Bacitracin-Polymyxin)


NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH CREA (Use Neomycin-Polymyxin w/Pramoxine)

NF

QL(28.3 gm perfill retail)

Antifungals - Topical

clotrimazole (topical) crea F QL(113 gm perfill retail);RX/OTC

clotrimazole (topical) soln F QL(60 ml perfill retail);RX/OTC

clotrimazole w/betamethasone crea F QL(45 gm per

fill retail) clotrimazole w/betamethasone lotn F QL(30 ml per

fill retail)

econazole nitrate crea F QL(30 gm perfill retail)

ketoconazole (topical) crea F QL(60 gm perfill retail)

ketoconazole (topical)sham F QL(120 ml per

fill retail) LAMISIL AT CREA (Use Terbinafine HCl (Topical)) NF QL(42 gm per

fill retail) LAMISIL AT JOCK ITCH CREA (Use Terbinafine HCl (Topical))


LOTRIMIN AF CREA 1 % (Use Clotrimazole (Topical))

NF QL(113 gm perfill retail);RX/OTC


39

Drug Name DrugTier

Requirements/Limits

LOTRIMIN AF FOR HER CREA (Use Clotrimazole (Topical))


LOTRIMIN AF JOCK ITCH CREA (Use Clotrimazole (Topical))


LOTRISONE CREA (Use Clotrimazole w/Betamethasone)


MICATIN CREA (Use Miconazole Nitrate (Topical))


miconazole nitrate (topical) crea F QL(60 ml per

fill retail) NIZORAL SHAM (Use Ketoconazole (Topical)) NF QL(120 ml per

fill retail)

nystatin (topical) crea F QL(30 gm perfill retail)

nystatin (topical) oint F QL(30 gm perfill retail)

nystatin (topical) powd F QL(60 gm perfill retail)

nystatin-triamcinolone crea F QL(60 gm perfill retail)

nystatin-triamcinolone oint F QL(60 gm perfill retail)

terbinafine hcl (topical) crea F QL(42 gm per

fill retail) TINACTIN CREA (Use Tolnaftate) NF QL(30 gm per

fill retail) TINACTIN JOCK ITCH CREA (Use Tolnaftate) NF QL(30 gm per

fill retail)

tolnaftate crea F QL(30 gm perfill retail)

Antineoplastic or Premalignant Lesion Agents -EFUDEX CREA (Use Fluorouracil (Topical)) NF QL(40 gm per

fill retail) fluorouracil (topical) crea0.5 % F QL(30 gm per

fill retail) fluorouracil (topical) crea 5% F QL(40 gm per

fill retail) FLUOROURACIL SOLN EX 2 %, 5 % F QL(10 ml per

fill retail) Antipruritics - Topical camphor & menthol lotn0.5%-0.5% F QL(222 ml per

fill retail)

Drug Name DrugTier

Requirements/Limits

SARNA LOTN (Use Camphor & Menthol) NF QL(222 ml per

fill retail) Antipsoriatics

calcipotriene crea F QL(60 gm perfill retail)

calcipotriene soln F QL(60 ml perfill retail)

DOVONEX CREA (Use Calcipotriene) NF QL(60 gm per

fill retail)

tazarotene crea F QL(60 gm perfill retail)

TAZORAC CREA 0.05 % F QL(100 gm perfill retail)

TAZORAC CREA 0.1 % (Use Tazarotene) NF QL(60 gm per

fill retail) TAZORAC GEL 0.05 %, 0.1 % F QL(100 gm per

fill retail) Antiseborrheic Products OVACE PLUS WASH LIQD (Use Sulfacetamide Sodium)


OVACE WASH LIQD (Use Sulfacetamide Sodium) NF QL(480 ml per

fill retail)

selenium sulfide lotn 1 % F QL(240 ml perfill retail)

selenium sulfide lotn 2.5 % F QL(120 ml perfill retail)

selenium sulfide sham 1 % F QL(240 ml perfill retail)

SELSUN BLUE DAILY LOTN (Use Selenium Sulfide)


SELSUN BLUE LOTN (Use Selenium Sulfide) NF QL(240 ml per

fill retail) SELSUN BLUE MEDICATED LOTN (Use Selenium Sulfide)


SELSUN BLUE MOISTURIZING LOTN (Use Selenium Sulfide)


sulfacetamide sodium liqd ex F QL(480 ml per

fill retail) Antivirals - Topical acyclovir topical oint F


40

Drug Name DrugTier

Requirements/Limits

ZOVIRAX CREA EX 5 % F QL(5 gm per fillretail)

ZOVIRAX OINT EX 5 % (Use Acyclovir Topical) NF

Burn Products SILVADENE CREA (Use Silver Sulfadiazine) NF QL(1000 gm

per fill retail)

silver sulfadiazine crea F QL(1000 gmper fill retail)

Corticosteroids - Topical

APEXICON E CREA F QL(60 gm perfill retail)

betamethasone dipropionate (topical) crea F 1 rtl pack lmt

per fill, betamethasone dipropionate augmented crea

F QL(45 gm perfill retail)

betamethasone valerate crea 0.1 % F QL(45 gm per

fill retail) betamethasone valerate lotn 0.1 % F QL(60 ml per

fill retail) betamethasone valerate oint 0.1 % F QL(45 gm per

fill retail)

clobetasol propionate crea F QL(60 gm perfill retail)

clobetasol propionateemollient base crea F QL(60 gm per

fill retail)

clobetasol propionate gel F QL(60 gm perfill retail)

clobetasol propionate oint F QL(60 gm perfill retail)

clobetasol propionate soln F QL(50 ml perfill retail)

DERMATOP CREA (Use Prednicarbate) NF QL(60 gm per

fill retail)

desonide crea F 1 rtl pack lmtper fill,

desonide oint F 1 rtl pack lmtper fill,

DESOWEN CREA (Use Desonide) NF 1 rtl pack lmt

per fill, desoximetasone crea 0.05 % F QL(300 gm per

fill retail) DIFLORASONE DIACETATE CREA F QL(60 gm per

fill retail)

Drug Name DrugTier

Requirements/Limits

DIFLORASONE DIACETATE OINT F QL(100 gm per

fill retail) DIPROLENE AF CREA (Use Betamethasone Dipropionate Augmented)


ELOCON CREA (Use Mometasone Furoate) NF QL(50 gm per

fill retail) ELOCON OINT (Use Mometasone Furoate) NF QL(45 gm per

fill retail)

EPIFOAM FOAM F

fluocinonide crea 0.05 % F QL(60 gm perfill retail)

fluocinonide emulsified base crea F QL(60 gm per

fill retail)

fluocinonide gel 0.05 % F QL(60 gm perfill retail)

fluocinonide oint 0.05 % F QL(60 gm perfill retail)

fluocinonide soln 0.05 % F QL(60 ml perfill retail)

fluticasone propionate crea0.05 % F QL(60 gm per

fill retail) fluticasone propionate oint0.005 % F QL(60 gm per

fill retail) hydrocortisone (topical)crea 0.5 % F

hydrocortisone (topical)crea 1%, 1 % F

QL(454 gm perfill retail);RX/OTC

hydrocortisone (topical)crea 2.5 % F QL(454 gm per

fill retail) hydrocortisone (topical) lotn1 % F QL(120 ml per

fill retail) hydrocortisone (topical) lotn2.5 % F QL(118 ml per

fill retail)

hydrocortisone (topical) oint1 % F


hydrocortisone (topical) oint2.5 % F QL(454 gm per

fill retail) hydrocortisone butyratesoln F QL(60 ml per

fill retail) hydrocortisone-aloe veracrea 1% F QL(30 gm per

fill retail)


41

Drug Name DrugTier

Requirements/Limits

LOCOID SOLN (Use Hydrocortisone Butyrate) NF QL(60 ml per

fill retail)

mometasone furoate crea F QL(50 gm perfill retail)

mometasone furoate oint F QL(45 gm perfill retail)

mometasone furoate soln F QL(60 ml perfill retail)

MONISTAT SOOTHING CARE ITCH RELIEF CREA (Use Hydrocortisone(Topical))

NF


prednicarbate crea F QL(60 gm perfill retail)

PREDNICARBATE CREA F QL(60 gm perfill retail)

PREDNICARBATE OINT F QL(60 gm perfill retail)

PSORCON CREA F QL(60 gm perfill retail)

TEMOVATE CREA (Use Clobetasol Propionate) NF QL(60 gm per

fill retail) TEMOVATE E CREA (Use Clobetasol PropionateEmollient Base)


TEMOVATE OINT (Use Clobetasol Propionate) NF QL(60 gm per

fill retail) TOPICORT CREA 0.05 % (Use Desoximetasone) NF QL(300 gm per

fill retail) triamcinolone acetonide (topical) crea 0.025 % F QL(908 gm per



fill retail) triamcinolone acetonide (topical) lotn 0.025 %, 0.1%


triamcinolone acetonide (topical) oint 0.025 % F QL(454 gm per

fill retail) triamcinolone acetonide (topical) oint 0.1 % F QL(60 gm per

fill retail) triamcinolone acetonide (topical) oint 0.5 % F QL(15 gm per

fill retail) TRIDESILON CREA (Use Desonide) NF 1 rtl pack lmt

per fill,

Drug Name DrugTier

Requirements/Limits

Emollient/Keratolytic Agents

urea crea 40 % F QL(200 gm perfill retail);RX/OTC

urea lotn 40 % F QL(325 ml perfill retail)

Emollients LAC-HYDRIN CREA (Use Lactic Acid (AmmoniumLactate))


LAC-HYDRIN LOTN (Use Lactic Acid (AmmoniumLactate))


LAC-HYDRIN TWELVE LOTN (Use Lactic Acid (Ammonium Lactate))


lactic acid (ammoniumlactate) crea 12 % F


lactic acid (ammoniumlactate) lotn 12 % F


Immunomodulating Agents - Topical ALDARA CREA (Use Imiquimod) NF

imiquimod crea F

Immunosuppressive Agents - Topical

ELIDEL CREA F PA; AL; At least 2 yrs old

PROTOPIC OINT 0.03 % (Use Tacrolimus (Topical)) NF PA; AL; At least

2 yrs old PROTOPIC OINT 0.1 % (Use Tacrolimus (Topical)) NF PA; AL; At least

16 yrs old tacrolimus (topical) oint0.03 % F PA; AL; At least

2 yrs old tacrolimus (topical) oint 0.1% F PA; AL; At least

16 yrs old

Keratolytic/Antimitotic Agents CONDYLOX SOLN (Use Podofilox) NF QL(4 ml per fill

retail)

podofilox soln F QL(4 ml per fillretail)

Local Anesthetics - Topical


42

Drug Name DrugTier

Requirements/Limits

ARTHRITIS PAIN RELIEVING CREA F QL(60 gm per

fill retail)

capsaicin crea 0.025 % F

capsaicin crea 0.075 % F QL(60 gm perfill retail)

capsaicin crea 0.1 % F QL(43 gm perfill retail)

CAPZASIN-HP CREA (Use Capsaicin) NF QL(43 gm per

fill retail)

dibucaine oint F QL(30 gm perfill retail)

lidocaine crea 4 % F QL(1 gm daily)

lidocaine hcl crea ex 3 % F RX/OTC

lidocaine hcl crea ex 4 % F QL(1 ml daily)

lidocaine hcl gel ex 2 % F QL(30 ml perfill retail);RX/OTC

lidocaine-prilocaine crea F QL(30 gm perfill retail)

LMX 4 CREA (Use Lidocaine) NF QL(1 gm daily)

PREDATOR CREA (Use Lidocaine HCl) NF QL(1 ml daily)

Misc. Topical

DRYSOL SOLN F QL(60 ml perfill retail)

OFF DEEP WOODS AERO F


OFF DEEP WOODS DRY AERO F


ULTRATHON INSECT REPELLENT 8 AERO F


ULTRATHON INSECT REPELLENT LOTN F


Drug Name DrugTier

Requirements/Limits

zinc oxide (topical) oint 20% F QL(500 gm per

fill retail) Pigmenting-Depigmenting Agents

hydroquinone crea F QL(56.8 ml perfill retail)

Rosacea Agents METROCREAM CREA (Use Metronidazole (Topical))


METROLOTION LOTN (Use Metronidazole (Topical))

NF

metronidazole (topical)crea 0.75 % F QL(45 gm per

fill retail) metronidazole (topical) gel0.75 % F QL(45 gm per

fill retail) metronidazole (topical) lotn0.75 % F

Scabicides & Pediculicides ELIMITE CREA (Use Permethrin) NF QL(60 gm per

fill retail)

EURAX CREA F QL(60 gm perfill retail)

EURAX LOTN F QL(454 gm perfill retail)

malathion lotn F QL(59 ml perfill retail)

NIX CREME RINSE LIQD (Use Permethrin) NF

OVIDE LOTN (Use Malathion) NF QL(59 ml per

fill retail)

permethrin crea ex 5 % F QL(60 gm perfill retail)

permethrin liqd ex 1 % F

permethrin lotn ex 1 % F QL(120 ml perfill retail)

pyrethrins-piperonylbutoxide liqd 0.33%-4% F QL(240 ml per

fill retail) pyrethrins-piperonylbutoxide sham 0.3%-0.33%-4%, 0.33%-4%

F

pyrethrins-piperonylbutoxide sham 0.33%-4% F QL(240 ml per

fill retail)


43

Drug Name DrugTier

Requirements/Limits

pyrethrins-piperonylbutoxide-permethrin-nitremover kit

F

RID COMPLETE LICE ELIMINATION KIT (Use Pyrethrins-PiperonylButoxide-Permethrin-Nit Remover)

NF

RID LIQD EX 0.33%-4% (Use Pyrethrins-PiperonylButoxide)


spinosad susp F

Tar Products

coal tar extract sham 0.5 % F

DHS TAR GEL SHAM (Use Coal Tar Extract) NF

DHS TAR SHAM (Use Coal Tar Extract) NF

NEUTROGENA T/GELSHAM (Use Coal Tar Extract)

NF

NEUTROGENA T/GELSTUBBORN ITCH CONTROL SHAM (Use Coal Tar Extract)

NF

DIAGNOSTIC PRODUCTS

Diagnostic Tests CHEK-STIX COMBO PAK URINALYSIS CONTROL STRP

F

CHEK-STIX CONTROL STRP F

CHEMSTRIP-K STRP F

KETOCARE STRP F

KETONE TEST STRIPS STRP F

KETOSTIX STRP F

NOVA MAX PLUS KETONE TESTSTRIPS STRP

F

Drug Name DrugTier

Requirements/Limits

PRECISION XTRA STRP VI F

PTS PANELS KETONE TEST STRP F

RELION KETONE STRP F

RELION KETONE TEST STRIPS STRP F

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

F

INSULIN USERS LIMITED TO 150 PER 30 DAYS, NON-INSULIN USERS LIMITED TO 100 PER 90 DAYS;RX/OTC

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP

F


TRUETEST BLOOD GLUCOSE TEST STRIPS STRP

F


TRUETEST BLOOD GLUCOSE TEST STRP F



44

Drug Name DrugTier

Requirements/Limits

TRUETEST STRIPS STRP F


TRUETRACK BLOOD GLUCOSE TEST STRP F


TRUETRACK TEST STRP F


DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

Digestive Enzymes

CREON CPEP F

PANCREAZE CPEP 14200UNIT-4200UNIT-24600UNIT, 35500UNIT-10500UNIT-61500UNIT, 54700UNIT-21000UNIT-83900UNIT, 56800UNIT-16800UNIT-98400UNIT

F

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood Pressure

Carbonic Anhydrase Inhibitors

acetazolamide cp12 F MP

acetazolamide tabs F MP

Drug Name DrugTier

Requirements/Limits

DIAMOX CP12 (Use Acetazolamide) NF MP

methazolamide tabs F

NEPTAZANE TABS (Use Methazolamide) NF

Diuretic Combinations ALDACTAZIDE TABS 25MG-25MG (Use Spironolactone &Hydrochlorothiazide)

NF

MP

amiloride & hydrochlorothiazide tabs F QL(1 ea daily)

DYAZIDE CAPS (Use Triamterene & Hydrochlorothiazide)


MAXZIDE TABS (Use Triamterene & Hydrochlorothiazide)


MAXZIDE-25 TABS (Use Triamterene & Hydrochlorothiazide)


spironolactone &hydrochlorothiazide tabs F MP

triamterene & hydrochlorothiazide caps F QL(1 ea daily);

MP triamterene & hydrochlorothiazide tabs F QL(1 ea daily);

MP TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS F QL(1 ea daily);

MP

Loop Diuretics bumetanide tabs or 0.5 mg,1 mg, 2 mg F MP

BUMEX TABS (Use Bumetanide) NF MP

DEMADEX TABS 20 MG (Use Torsemide) NF MP

DEMADEX TABS 5 MG, 10 MG (Use Torsemide) NF QL(1 ea daily);

MP furosemide soln or 10 mg/ml F MP

FUROSEMIDE SOLN OR 8 MG/ML F MP

furosemide tabs or 20 mg,40 mg, 80 mg F MP


45

Drug Name DrugTier

Requirements/Limits

LASIX TABS (Use Furosemide) NF MP

torsemide tabs 20 mg F MP

torsemide tabs 5 mg, 10mg, 100 mg F QL(1 ea daily);

MP

Potassium Sparing Diuretics ALDACTONE TABS (Use Spironolactone) NF MP

amiloride hcl tabs F QL(4 ea daily)

spironolactone tabs F MP

Thiazides and Thiazide-Like Diuretics CHLOROTHIAZIDE TABS 250 MG F QL(2 ea daily);

MP

chlorothiazide tabs 500 mg F QL(4 ea daily);MP

chlorthalidone tabs F MP

hydrochlorothiazide caps F MP

hydrochlorothiazide tabs F MP

indapamide tabs F MP

metolazone tabs F MP

MICROZIDE CAPS (Use Hydrochlorothiazide) NF MP

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate Hormones

Bone Density Regulators ACTONEL TABS 35 MG (Use Risedronate Sodium) NF PA

ACTONEL TABS 5 MG, 30 MG (Use Risedronate Sodium)

NF PA; QL(1 eadaily)

ALENDRONATE SODIUM SOLN 70 MG/75ML F QL(10.8 ml

daily); MP alendronate sodium tabs 35 mg, 70 mg F QL(0.15 ea

daily); MP ALENDRONATE SODIUM TABS 40 MG F QL(1 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

alendronate sodium tabs 5 mg, 10 mg F QL(1 ea daily);

MP

calcitonin (salmon) soln F

FORTICAL SOLN F

FOSAMAX TABS (Use Alendronate Sodium) NF QL(0.15 ea

daily); MP MIACALCIN SOLN IJ 200 UNIT/ML F

MIACALCIN SOLN NA 200 UNIT/ACT (Use Calcitonin (Salmon))

NF

risedronate sodium tabs 35 mg F PA

risedronate sodium tabs 5 mg, 30 mg F PA; QL(1 ea

daily) Growth Hormones NORDITROPIN FLEXPRO SOLN F PA; SP

OMNITROPE SOLN 5 MG/1.5ML, 10 MG/1.5ML F PA; SP

Hormone Receptor Modulators EVISTA TABS (Use Raloxifene HCl) NF QL(1 ea daily)

raloxifene hcl tabs F QL(1 ea daily)

Metabolic Modifiers calcitriol caps or 0.25 mcg,0.5 mcg F

CARNITOR SF SOLN (Use Levocarnitine (MetabolicModifiers))

NF QL(30 ml daily)

CARNITOR SOLN OR 1 GM/10ML (Use Levocarnitine (MetabolicModifiers))

NF

QL(30 ml daily)

CARNITOR TABS OR 330 MG (Use Levocarnitine (Metabolic Modifiers))


levocarnitine (metabolicmodifiers) soln 1 gm/10ml F QL(30 ml daily)

levocarnitine (metabolicmodifiers) tabs 330 mg F QL(3 ea daily);

RX/OTC


46

Drug Name DrugTier

Requirements/Limits

ROCALTROL CAPS 0.25 MCG, 0.5 MCG (Use Calcitriol)

NF

Posterior Pituitary Hormones

DDAVP SOLN NA 0.01 % F QL(5 ml per fillretail)

DDAVP SOLN NA 0.01 % (Use DesmopressinAcetate Spray)

NF QL(1 ml daily,5ml per fill retail)

DDAVP TABS OR 0.1 MG, 0.2 MG (Use Desmopressin Acetate)

NF QL(6 ea daily)

desmopressin acetatespray refrigerated soln F QL(1 ml daily,5

ml per fill retail) desmopressin acetatespray soln F QL(1 ml daily,5

ml per fill retail) desmopressin acetate tabsor 0.1 mg, 0.2 mg F QL(6 ea daily)

ESTROGENS - Hormone Replacement/ModifyingDrugs

Estrogen Combinations ACTIVELLA TABS (Use Estradiol & Norethindrone Acetate)

NF QL(1 ea daily)

COMBIPATCH PTTW F QL(0.286 eadaily)

estradiol & norethindrone acetate tabs F QL(1 ea daily)

FEMHRT LOW DOSE TABS (Use Norethindrone Acetate-Ethinyl Estradiol)

NF

norethindrone acetate-ethinyl estradiol tabs F

PREMPHASE TABS F QL(1 ea daily)

PREMPRO TABS F QL(1 ea daily)

Estrogens

ALORA PTTW F QL(0.29 eadaily); MP

CLIMARA PTWK 0.025 MG/24HR (Use Estradiol) NF MP

Drug Name DrugTier

Requirements/Limits

CLIMARA PTWK 0.075 MG/24HR, 0.05 MG/24HR,0.06 MG/24HR, 0.1MG/24HR, 37.5MCG/24HR (Use Estradiol)

NF

Limit 4 permonth;QL(0.134 ea daily,90day(s) limit);MP

ESTRACE TABS OR 0.5 MG, 1 MG, 2 MG (Use Estradiol)

NF MP

estradiol pttw td 0.0375mg/24hr, 0.025 mg/24hr,0.075 mg/24hr, 0.05mg/24hr, 0.1 mg/24hr

F

QL(0.29 eadaily); MP

estradiol ptwk td 0.025mg/24hr F MP

estradiol ptwk td 0.075mg/24hr, 0.05 mg/24hr,0.06 mg/24hr, 0.1 mg/24hr,37.5 mcg/24hr

F

Limit 4 permonth;QL(0.134 ea daily,90day(s) limit);MP

estradiol tabs or 0.5 mg, 1mg, 2 mg F MP

ESTROPIPATE TABS 0.75 MG, 1.5 MG F QL(1 ea daily);

MP ESTROPIPATE TABS 3 MG F QL(2 ea daily);

MP

MINIVELLE PTTW F QL(0.29 eadaily); MP

PREMARIN TABS OR 0.625 MG, 0.45 MG, 0.3 MG, 0.9 MG, 1.25 MG

F QL(1 ea daily)

VIVELLE-DOT PTTW (Use Estradiol) NF QL(0.29 ea

daily); MP

FLUOROQUINOLONES - Drugs to Treat BacterialInfections

Fluoroquinolones CIPRO TABS 250 MG, 500 MG (Use CiprofloxacinHCl)

NF

CIPROFLOXACIN HCL TABS 100 MG F QL(6 ea per fill

retail) ciprofloxacin hcl tabs 250mg, 500 mg, 750 mg F

LEVAQUIN TABS (Use Levofloxacin) NF

QL(1 eadaily,14 ea perfill retail)


47

Drug Name DrugTier

Requirements/Limits

levofloxacin tabs or 250 mg, 500 mg, 750 mg F

QL(1 eadaily,14 ea perfill retail)

ofloxacin tabs 400 mg F QL(56 ea perfill retail)

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal Drugs

Antiflatulents GAS-X CHEW (Use Simethicone) NF

MYLICON INFANTS GAS RELIEF SUSP (Use Simethicone)

NF

MYLICON SUSP (Use Simethicone) NF

simethicone chew 80 mg F

simethicone liqd 20mg/0.3ml, 40 mg/0.6ml F

simethicone susp 20mg/0.3ml, 40 mg/0.6ml F

Bile Acid Synthesis Disorder Agents

CHOLBAM CAPS F PA; QL(5 eadaily); SP

Gallstone Solubilizing Agents ACTIGALL CAPS (Use Ursodiol) NF QL(3 ea daily);

MP URSO 250 TABS (Use Ursodiol) NF QL(7 ea daily);

MP

ursodiol caps 300 mg F QL(3 ea daily);MP

ursodiol tabs 250 mg F QL(7 ea daily);MP

Gastrointestinal Stimulants metoclopramide hcl soln or5 mg/5ml, 10 mg/10ml F

metoclopramide hcl tabs or5 mg, 10 mg F

REGLAN TABS (Use Metoclopramide HCl) NF

Inflammatory Bowel Agents AZULFIDINE EN-TABS TBEC (Use Sulfasalazine) NF MP

Drug Name DrugTier

Requirements/Limits

AZULFIDINE TABS (Use Sulfasalazine) NF MP

balsalazide disodium caps F QL(9 ea daily)

COLAZAL CAPS (Use Balsalazide Disodium) NF QL(9 ea daily)

DELZICOL CPDR F QL(6 ea daily)

mesalamine enem re 4 gm F QL(60 ml daily)

mesalamine tbec or 800 mg F QL(3 ea daily)

SFROWASA ENEM F

sulfasalazine tabs F MP

sulfasalazine tbec F MP

Intestinal Acidifiers lactulose (encephalopathy)soln F

Phosphate Binder Agents calcium acetate (phosphatebinder) caps F

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System

Alkalinizers potassium citrate(alkalinizer) tbcr 540 mg,1080 mg

F

potassium citrate-citric acidpack 3300mg-1002mg F

sodium citrate & citric acid soln F

QL(500 ml per30 days retail);RX/OTC

UROCIT-K 10 TBCR (Use Potassium Citrate (Alkalinizer))

NF

UROCIT-K 5 TBCR (Use Potassium Citrate (Alkalinizer))

NF

Genitourinary Irrigants sodium chloride (guirrigant) soln F


48

Drug Name DrugTier

Requirements/Limits

Interstitial Cystitis Agents

ELMIRON CAPS F QL(3 ea daily)

Prostatic Hypertrophy Agents

finasteride tabs F QL(1 ea daily);MP

FLOMAX CAPS (Use Tamsulosin HCl) NF QL(2 ea daily);

MP PROSCAR TABS (Use Finasteride) NF QL(1 ea daily);

MP

tamsulosin hcl caps F QL(2 ea daily);MP

Urinary Analgesics phenazopyridine hcl tabs100 mg, 200 mg F

PYRIDIUM TABS (Use Phenazopyridine HCl) NF

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations colchicine w/ probenecidtabs F

Gout Agents

allopurinol tabs F MP

colchicine tabs F QL(6 ea per fillretail)

ZYLOPRIM TABS (Use Allopurinol) NF MP

Uricosurics

probenecid tabs F

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood Disorders

Hematorheologic Agents

pentoxifylline tbcr F MP

Platelet Aggregation Inhibitors

BRILINTA TABS F QL(2 ea daily)

cilostazol tabs F QL(2 ea daily);MP

clopidogrel bisulfate tabs or75 mg F QL(1 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

dipyridamole tabs F MP

EFFIENT TABS (Use Prasugrel HCl) NF QL(1 ea daily)

PLAVIX TABS 75 MG (Use Clopidogrel Bisulfate) NF QL(1 ea daily);

MP

prasugrel hcl tabs F QL(1 ea daily)

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Agents for Sickle Cell Anemia

DROXIA CAPS F

Cobalamins

cyanocobalamin soln F

Folic Acid/Folates

folic acid tabs 1 mg F RX/OTC; MP

folic acid tabs 400 mcg,800 mcg F QL(1 ea daily)

Hematopoietic Growth Factors

ZARXIO SOSY F PA; SP

Iron

FERRETTS TABS F QL(2 ea daily)

ferrous fumarate tabs F QL(2 ea daily)

ferrous sulfate elix 220 mg/5ml F QL(16 ml daily)

ferrous sulfate tabs 65 mg,325 mg F MP

HEMOCYTE TABS (Use Ferrous Fumarate) NF QL(2 ea daily)

polysaccharide ironcomplex caps F QL(1 ea daily)

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood Disorders

Hemostatics - Systemic

AMICAR TABS 500 MG F QL(24 ea perfill retail); SP

LYSTEDA TABS (Use Tranexamic Acid) NF AL; At least 12

yrs old


49

Drug Name DrugTier

Requirements/Limits

tranexamic acid tabs or 650 mg F AL; At least 12

yrs old

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS

Antihistamine Hypnotics diphenhydramine hcl(sleep) caps 50 mg F

diphenhydramine hcl(sleep) tabs 25 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) tabs 50 mg F

doxylamine succinate(sleep) tabs F

NYTOL MAXIMUM STRENGTH TABS (Use Diphenhydramine HCl(Sleep))

NF

UNISOM SLEEPGELS CAPS (Use Diphenhydramine HCl(Sleep))

NF

UNISOM TABS (Use Doxylamine Succinate(Sleep))

NF

Barbiturate Hypnotics phenobarbital elix 20mg/5ml F

phenobarbital soln 20mg/5ml F

PHENOBARBITAL TABS 15 MG, 30 MG, 60 MG, 100 MG

F

phenobarbital tabs 16.2mg, 32.4 mg, 64.8 mg, 97.2 mg

F

Non-Barbiturate Hypnotics AMBIEN TABS (Use Zolpidem Tartrate) NF QL(1 ea daily)

FLURAZEPAM HCL CAPS F QL(1 ea daily)

HALCION TABS (Use Triazolam) NF QL(1 ea daily)

midazolam hcl soln F

Drug Name DrugTier

Requirements/Limits

RESTORIL CAPS 15 MG, 30 MG (Use Temazepam) NF


SONATA CAPS (Use Zaleplon) NF


temazepam caps 15 mg,30 mg F


TRIAZOLAM TABS 0.125 MG F QL(1 ea daily)

triazolam tabs 0.25 mg F QL(1 ea daily)

zaleplon caps F QL(1 ea daily);AL; At least 18 yrs old

zolpidem tartrate tabs or 5mg, 10 mg F QL(1 ea daily)

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil tabs F QL(10 ea daily)

FIBERCON TABS (Use Calcium Polycarbophil) NF QL(10 ea daily)

METAMUCIL CAPS 0.52 GM (Use Psyllium) NF

METAMUCIL ORIGINAL TEXTURE POWD (Use Psyllium)

NF

METAMUCIL POWD 48.57 % (Use Psyllium) NF

psyllium caps 0.52 gm, 520 mg F

psyllium powd 28.3 %, 30.9%, 58.6 %, 48.57 % F

Laxative Combinations COLYTE-FLAVOR PACKS SOLR (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

NF


GOLYTELY SOLR 236GM-22.74GM-5.86GM-2.97GM-6.74GM (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

NF



50

Drug Name DrugTier

Requirements/Limits

NULYTELY/FLAVORPACKS SOLR (Use PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride)

NF


peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr


peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr


sennosides-docusate sodium tabs F QL(4 ea daily)

SENOKOT S TABS (Use Sennosides-Docusate Sodium)

NF QL(4 ea daily)

Laxatives - Miscellaneous glycerin (laxative) supp 2 gm F

GLYCERIN ADULT SUPP (Use Glycerin (Laxative)) NF

lactulose soln F

MIRALAX PACK (Use Polyethylene Glycol 3350) NF RX/OTC

MIRALAX POWD (Use Polyethylene Glycol 3350) NF QL(34 gm

daily); RX/OTC polyethylene glycol 3350pack F RX/OTC

polyethylene glycol 3350powd F QL(34 gm

daily); RX/OTC

Saline Laxatives FLEET ENEMA ENEM (Use Sodium Phosphates) NF

FLEET ENEMA SIX PACK ENEM (Use Sodium Phosphates)

NF

FLEET PEDIATRIC ENEM (Use Sodium Phosphates) NF

magnesium citrate soln1.745gm/30ml, 1.745gm/30ml,

F

magnesium hydroxide susp F

Drug Name DrugTier

Requirements/Limits

sodium phosphates enemre 16gm/133ml-6gm/133ml,19gm/118ml-7gm/118ml,9.5gm/59ml-3.5gm/59ml,19gm/118ml-19gm/118ml-7gm/118ml-7gm/118ml

F

Stimulant Laxatives

bisacodyl supp re 10 mg F QL(12 ea perfill retail)

bisacodyl tbec or 5 mg F QL(1 ea daily)

DULCOLAX SUPP RE 10 MG (Use Bisacodyl) NF QL(12 ea per

fill retail) DULCOLAX TBEC OR 5 MG (Use Bisacodyl) NF QL(1 ea daily)

sennosides tabs 8.6 mg F

SENOKOT TABS (Use Sennosides) NF

Surfactant Laxatives COLACE CAPS (Use Docusate Sodium) NF QL(3 ea daily)

docusate sodium caps or100 mg, 250 mg F QL(3 ea daily)

docusate sodium liqd or 50mg/5ml, 150 mg/15ml F

docusate sodium syrp or 60mg/15ml F

docusate sodium tabs or 100 mg F QL(3 ea daily)

MACROLIDES - Drugs to Treat BacterialInfections

Azithromycin

azithromycin pack or 1 gm F QL(2 ea per fillretail)

azithromycin susr or 100mg/5ml F QL(15 ml per

fill retail) azithromycin susr or 200mg/5ml F QL(60 ml per

fill retail) azithromycin tabs or 250 mg F QL(6 ea per fill

retail) azithromycin tabs or 500 mg F QL(4 ea daily)

azithromycin tabs or 600 mg F


51

Drug Name DrugTier

Requirements/Limits

ZITHROMAX SUSR OR 100 MG/5ML (Use Azithromycin)


ZITHROMAX SUSR OR 200 MG/5ML (Use Azithromycin)


ZITHROMAX TABS OR 250 MG (Use Azithromycin)

NF QL(6 ea per fillretail)


NF QL(4 ea daily)


NF

ZITHROMAX TRI-PAK TABS (Use Azithromycin) NF QL(4 ea daily)

ZITHROMAX Z-PAK TABS (Use Azithromycin) NF QL(6 ea per fill

retail) Clarithromycin BIAXIN SUSR 250 MG/5ML (Use Clarithromycin)


BIAXIN TABS 250 MG, 500 MG (Use Clarithromycin) NF QL(28 ea per

fill retail) CLARITHROMYCIN SUSR 125 MG/5ML F QL(100 ml per

fill retail) clarithromycin susr 125mg/5ml F QL(100 ml per

fill retail) clarithromycin susr 250mg/5ml F QL(200 ml per

fill retail) CLARITHROMYCIN SUSR 250 MG/5ML F QL(200 ml per

fill retail) clarithromycin tabs 250 mg,500 mg F QL(28 ea per

fill retail)

clarithromycin tb24 500 mg F QL(14 ea perfill retail)

Erythromycins

E.E.S. 400 TABS F

E.E.S. GRANULES SUSR (Use ErythromycinEthylsuccinate)

NF

ERY-TAB TBEC F

Drug Name DrugTier

Requirements/Limits

ERYPED 200 SUSR (Use ErythromycinEthylsuccinate)

NF

ERYPED 400 SUSR F

ERYTHROCIN STEARATE TABS F

erythromycin base cpep250 mg F

erythromycin base tabs 500 mg F

erythromycinethylsuccinate susr 200mg/5ml

F

ERYTHROMYCIN ETHYLSUCCINATE TABS 400 MG

F

PCE TBEC F

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-Tape ALLEVYN PLUS CAVITY PADS XX F RX/OTC

ALLEVYN THIN PADS F RX/OTC

AMD FOAM DRESSING 4"X4" PADS F RX/OTC

AMD FOAM DRESSING/TOPSHEET4"X4" PADS

F RX/OTC

BAND-AID GAUZE PADS LARGE4" X 4" PADS F RX/OTC

BAND-AID GAUZE PADS MEDIUM 3" X 3" PADS F

BAND-AID GAUZE PADS SMALL2" X 2" PADS F RX/OTC

BAND-AID MIRASORB GAUZE SPONGES LARGE 4" X 4" PADS

F RX/OTC

BIATAIN ADHESIVE FOAM DRESSING 4"X4" PADS

F RX/OTC

BIATAIN FOAM DRESSING 4"X4" PADS F RX/OTC


52

Drug Name DrugTier

Requirements/Limits

BIOGUARD GAUZE SPONGE 2"X2" 8 PLY PADS

F RX/OTC

BIOGUARD GAUZE SPONGES 4"X4" 12 PLY PADS

F RX/OTC

BORDERED GAUZE PADS F RX/OTC

CARRASMART FOAM PADS F RX/OTC

CARRASMART PADS XX F RX/OTC

COPA ISLAND BORDERED FOAM DRESSING 4"X4" PADS

F RX/OTC

COPA PLUS HYDROPHILIC FOAM DRESSING 4"X4" PADS

F RX/OTC

COVRSITE COVER DRESSING PADS F RX/OTC

COVRSITE PLUS COMPOSITE DRESSING PADS

F RX/OTC

CUREX ALL-PURPOSE SPONGES 4"X4" 4 PLY PADS

F RX/OTC

CURITY ALL PURPOSE SPONGES 2"X2" 4PLY PADS

F RX/OTC

CURITY ALL PURPOSE SPONGES 2"X2" PADS F RX/OTC


F

CURITY ALL PURPOSE SPONGES 4 PLY PADS F RX/OTC


F RX/OTC

CURITY ALL PURPOSE SPONGES 4"X4" 4PLY/SOFT POUCH PADS

F RX/OTC

CURITY ALL PURPOSE SPONGES 4"X4" PADS F RX/OTC

Drug Name DrugTier

Requirements/Limits

CURITY AMD ANTIMICROBIALGAUZE SPONGES 2"X2" 8 PLY PADS

F

RX/OTC

CURITY AMD ANTIMICROBIALGAUZE SPONGES 4"X4" 12 PLY PADS

F

RX/OTC

CURITY COVER SPONGE 4"X4" PADS F RX/OTC

CURITY COVER SPONGES 3"X3" PADS F

CURITY COVER SPONGES 4"X4" PADS F RX/OTC

CURITY DRESSING SPONGES 4"X4" 6 PLY PADS

F RX/OTC

CURITY GAUZE PADS 2"X2" 12 PLY PADS F RX/OTC

CURITY GAUZE PADS 2"X2" PADS F RX/OTC

CURITY GAUZE PADS 3"X3" PADS F

CURITY GAUZE PADS 4"X4" 12 PLY PADS F RX/OTC

CURITY GAUZE SPONGE 2"X2" 8 PLY PADS F RX/OTC

CURITY GAUZE SPONGE 2"X2"12 PLY PADS F RX/OTC

CURITY GAUZE SPONGE 3"X3" 12 PLY PADS F




CURITY GAUZE SPONGE 4"X4"16 PLY PADS F RX/OTC

CURITY GAUZE SPONGES 4"X4" 12 PLY PADS

F RX/OTC

CURITY GAUZE SPONGES 4"X4" 8 PLY PADS

F RX/OTC

CURITY NON-ADHERENT STRIPS 3"X3" PADS F


53

Drug Name DrugTier

Requirements/Limits

CURITY SPONGES/CELLULOSEFILLED/2"X2" PADS

F RX/OTC

CURITY SPONGES/CELLULOSEFILLED/4"X4" PADS

F RX/OTC

CVS GAUZE PAD 3"X3" PADS F

CVS GAUZE PADS 2"X2" 12-PLY PADS F RX/OTC

CVS GAUZE PADS 4"X4" 12-PLY PADS F RX/OTC

CVS GAUZE PADS STERILE 4"X4" 12-PLY PADS

F RX/OTC

DERMACEA DRAIN SPONGES 4"X4" PADS F RX/OTC

DERMACEA GAUZE SPONGE 2"X2" 12 PLY PADS

F RX/OTC


F RX/OTC


F


F


F RX/OTC


F RX/OTC


F RX/OTC

DERMACEA I.V. DRAIN SPONGES 2"X2" PADS F RX/OTC

DERMACEA I.V. DRAIN SPONGES 4"X4" PADS F RX/OTC

DERMACEA I.V. SPONGES 2"X2" PADS F RX/OTC

DERMACEA NON-WOVEN SPONGES 2"X2" 4 PLY PADS

F RX/OTC

Drug Name DrugTier

Requirements/Limits


F


F RX/OTC


F RX/OTC

DERMACEA TYPE VII GAUZE 2"X2" 12 PLY PADS

F RX/OTC

DERMACEA TYPE VII GAUZE 2"X2" 8 PLY PADS F RX/OTC


F

DERMACEA TYPE VII GAUZE 3"X3" 12PLY PADS

F


F RX/OTC


F RX/OTC

DERMACEA TYPE VII GAUZE 4"X4" 8 PLY PADS F RX/OTC

DERMACEA X-RAY SPONGES 4"X4" 16 PLY PADS

F RX/OTC

DERMALEVIN ADHESIVE FOAMDRESSING 4"X4" PADS

F RX/OTC

DRYMAX EXTRA PADS F RX/OTC

EQL GAUZE PADS 2"X2"/SMALL PADS F RX/OTC

EQL GAUZE PADS 4"X4"/LARGE PADS F RX/OTC

EQL GAUZE STERILE PADS 3"X3" PADS F

EXCILON AMD ANTIMICROBIALDRAIN SPONGES 4"X4" 6 PLY PADS

F

RX/OTC


54

Drug Name DrugTier

Requirements/Limits

EXCILON AMD ANTIMICROBIALNON-WOVEN SPONGES 4"X4" 6 PLY PADS

F

RX/OTC

EXCILON DRAIN SPONGE 4"X4" PADS F RX/OTC

EXCILON DRAIN SPONGES 4"X4" 6 PLY PADS

F RX/OTC

EXCILON I.V. SPONGES 2"X2" 6 PLY PADS F RX/OTC

FLEXZAN 4 X 4 PADS F RX/OTC

GAUZE DRESSING 4"X4" PADS F RX/OTC

GAUZE PADS 2"X2" PADS F RX/OTC

GAUZE PADS 3"X3" PADS F

GAUZE PADS 4"X4" 12 PLY PADS F RX/OTC

GAUZE PADS 4"X4" PADS F RX/OTC

GAUZE SPONGE TYPE VII MEDI-PAK 2"X2" 8PLY PADS

F RX/OTC

GAUZE SPONGES 4"X4" 12 PLY PADS F RX/OTC

GNP STERILE PADS 3"X3" PADS F

HM STERILE PADS 2"X2" PADS F RX/OTC

HM STERILE PADS PADS F RX/OTC

HYDROCELL ADHESIVE DRESSING 4"X4" PADS F RX/OTC

HYDROCELL DRESSING 4"X4" PADS F RX/OTC

J & J GAUZE 2"X2" 8 PLY PADS F RX/OTC



J & J GAUZE SPONGES 12-PLY 4" X 4" MISC F RX/OTC

Drug Name DrugTier

Requirements/Limits

J & J GAUZE SPONGES 16-PLY 4" X 4" MISC F RX/OTC

J & J GAUZE SPONGES 8-PLY4" X 4" MISC F RX/OTC

KENDALL HYDROPHILIC FOAMDRESSING 2"X2" PADS

F RX/OTC


F


F RX/OTC

KENDALL HYDROPHILIC FOAMPLUS DRESSING 2"X2" PADS

F RX/OTC

KENDALL HYDROPHILIC FOAMPLUS DRESSING 3"X3" PADS

F

KERLIX SPONGES 4" X 4" 12 PLY PADS F RX/OTC

KERLIX SPONGES 4" X 4" 16 PLY PADS F RX/OTC

MIRASORB SPONGES 2" X 2" MISC F RX/OTC

MIRASORB SPONGES 4" X 4" MISC F RX/OTC

NU GAUZE 4PLY 4"X4" PADS F RX/OTC

NU GAUZE GENERAL-USE SPONGES 4"X4" 4 PLY MISC

F RX/OTC

OPTIFOAM PADS F RX/OTC

POLYMEM DRESSING/3"X 3" PADS F

POLYMEM DRESSING/4"X 4" PADS F RX/OTC

QC ALL PURPOSE DRESSINGS4"X4" PADS F RX/OTC

QC BORDER ISLAND GAUZE PAD 2"X2" PADS F RX/OTC

QC STERILE PADS PADS F

QC STERILE PADS PADS F RX/OTC


55

Drug Name DrugTier

Requirements/Limits

RA ALL PURPOSE DRESSINGS4"X4" PADS F RX/OTC

RA DRESSING SPONGES 4"X4" PADS F RX/OTC

RA GAUZE SPONGES 4"X4" PADS F RX/OTC

RA STERILE PADS 2"X2" PADS F RX/OTC

RA STERILE PADS 3"X3" PADS F

RA STERILE PADS 4"X4" PADS F RX/OTC

RAY-TEC X-RAY DETECTABLESPONGES 4" X 4" 16 PLY MISC

F RX/OTC

RESTORE CONTACT LAYER/NON-ADHERENT2"X2" PADS

F RX/OTC

RESTORE FOAM DRESSING BORDERED 4"X4" PADS

F RX/OTC

RESTORE FOAM DRESSING NON-BORDERED 4"X4" PADS

F RX/OTC

RESTORE ODOR ABSORBING DRESSING 4"X4" PADS

F RX/OTC

RESTORE TRIO ABSORBENT DRESSING 3"X3" PADS

F

SM GAUZE PADS 2"X2" PADS F RX/OTC

SM GAUZE PADS 3"X3" PADS F

SM GAUZE PADS 4"X4" PADS F RX/OTC

SM STERILE PADS 2"X2" PADS F RX/OTC

SM STERILE PADS PADS F RX/OTC

SOF-WICK 4"X4" PADS F RX/OTC

STERILE GAUZE PADS 2"X2" PADS F RX/OTC

STERILE GAUZE PADS 3"X3" PADS F

Drug Name DrugTier

Requirements/Limits

STERILE PADS 2"X2" PADS F RX/OTC

STERILE PADS 3"X3" PADS F

STERILE PADS 4"X4" PADS F RX/OTC

SURGICAL GAUZE SPONGE PADS F RX/OTC

TEGADERM FOAM DRESSING 2"X2" PADS F RX/OTC

TEGADERM FOAM DRESSING 4"X4" PADS F RX/OTC

THERAGAUZE PADS F RX/OTC

TOPPER DRESSING SPONGES 4"X4" MISC F RX/OTC

VERSIVA XC 3" X 3" FOAM DRESSING/HYDROFIBERTECHNOLOGY PADS

F

VERSIVA XC 4" X 4" FOAM DRESSING/HYDROFIBERTECHNOLOGY PADS

F

RX/OTC

VISTEC X-RAY DETECTABLE SPONGES 4"X4" 16 PLY PADS

F RX/OTC

Contraceptives AIMSCO LUBRICATED MISC F QL(36 ea per

fill retail) ATLAS COLORED CONDOM/SPERMICIDEDEVI


ATLAS COLORED LUBRICATEDCONDOM DEVI


ATLAS LUBRICATED CONDOM DEVI F QL(36 ea per

fill retail) ATLAS LUBRICATED CONDOM/SPERMICIDEDEVI


CLASS ACT LUBRICATED MISC F QL(36 ea per

fill retail) DUREX EXTRA SENSITIVE DEVI F QL(36 ea per

fill retail) ELEXA NATURAL FEEL MISC F QL(36 ea per

fill retail) Updated August 1, 2018F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior AuthorizationQL-Quantity limit, SP-Specialty drug, ST-Step Therapy, RX/OTC - both Rx and OTC NDCs, MP-Maintenance Products.

56

Drug Name DrugTier

Requirements/Limits

ELEXA STIMULATING MISC F QL(36 ea per

fill retail) ELEXA ULTRA SENSITIVE MISC F QL(36 ea per

fill retail) EXTRA SENSITIVE SPERMICIDAL DEVI F QL(36 ea per

fill retail) FANTASY LUBRICATED MISC F QL(36 ea per

fill retail) FANTASY LUBRICATED/SPERMICIDE MISC


HIGH SENSATION SPERMICIDAL DEVI F QL(36 ea per

fill retail) INTENSE SENSATION DEVI F QL(36 ea per

fill retail) KAMELEON LUBRICATED MISC F QL(36 ea per

fill retail)

KIMONO COLORS DEVI F QL(36 ea perfill retail)

KIMONO LUBRICATED MISC F QL(36 ea per

fill retail) KIMONO MICRO THIN MISC F QL(36 ea per

fill retail) KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED MISC


KIMONO PLUS SPERMICIDE LUBRICATED MISC


KIMONO PLUS SPERMICIDE/LUBRICATED MISC


KIMONO PS LUBRICATED MISC F QL(36 ea per

fill retail) KIMONO PS PLUS SPERMICIDE/LUBRICATED MISC


KIMONO SENSATION LUBRICATED MISC F QL(36 ea per

fill retail) KIMONO SENSATION PLUS SPERMICIDE LUBRICATED MISC


KIMONO SPECIAL DEVI F QL(36 ea perfill retail)

MAXX LUBRICATED MISC F QL(36 ea perfill retail)

Drug Name DrugTier

Requirements/Limits

MAXX PLUS SPERMICIDE LUBRICATED MISC F QL(36 ea per

fill retail) PREMIUM CONDOMS LUBRICATED MISC F QL(36 ea per

fill retail) REALITY LATEX CONDOMS/LUBRICATEDMISC


REALITY LATEX/ULTRATEXTURED DEVI F QL(36 ea per

fill retail) REALITY LATEX/ULTRATHIN DEVI F QL(36 ea per

fill retail) TROJAN ASSORTMENT PACK MISC F QL(36 ea per

fill retail) TROJAN EXTENDED PLEASURE/LUBRICATEDDEVI


TROJAN EXTRA STRENGTH MISC F QL(36 ea per

fill retail)

TROJAN MAGNUM MISC F QL(36 ea perfill retail)

TROJAN MAGNUM WARM SENSATIONS DEVI F QL(36 ea per

fill retail) TROJAN MAGNUM XL LUBRICATED DEVI F QL(36 ea per

fill retail)

TROJAN MISC F QL(36 ea perfill retail)

TROJAN PLEASURE MESH/SPERMICIDALDEVI


TROJAN PLUS MISC F QL(36 ea perfill retail)

TROJAN REGULAR MISC F QL(36 ea perfill retail)

TROJAN RIBBED MISC F QL(36 ea perfill retail)

TROJAN RIBBED W/SPERMICIDAL MISC F QL(36 ea per

fill retail) TROJAN SHARED SENSATION/LUBRICATED DEVI


TROJAN SUPRAS SPERMICIDAL DEVI F QL(36 ea per

fill retail) TROJAN TWISTED PLEASURE DEVI F QL(36 ea per

fill retail)


57

Drug Name DrugTier

Requirements/Limits

TROJAN ULTRA PLEASURE/LUBRICATEDDEVI


TROJAN VERY SENSITIVE LUBRICATED MISC


TROJAN VERY SENSITIVE SPERMICIDAL LUBRICANT MISC


TROJAN VERY THIN LUBRICATED MISC F QL(36 ea per

fill retail) TROJAN VERY THIN SPERMICIDAL LUBRICANT MISC


TROJAN-ENZ LUBRICANT MISC F QL(36 ea per

fill retail) TROJAN-ENZ LUBRICATED MISC F QL(36 ea per

fill retail) TROJAN-ENZ W/SPERMICIDAL MISC F QL(36 ea per

fill retail) TRUSTEX COLOR CONDOMS + LUBE MISC F QL(36 ea per

fill retail) TRUSTEX LUBRICATED EXTRALARGE MISC F QL(36 ea per

fill retail) TRUSTEX LUBRICATED EXTRASTRENGTH MISC F QL(36 ea per

fill retail) TRUSTEX LUBRICATED MISC F QL(36 ea per

fill retail) TRUSTEX LUBRICATED/RIBBED/STUDDED MISC


TRUSTEX LUBRICATED/SPERMICIDE EXTRA LARGE MISC


TRUSTEX LUBRICATED/SPERMICIDE EXTRA STRENGTH MISC

F

QL(36 ea perfill retail)

TRUSTEX LUBRICATED/SPERMICIDE MISC


TRUSTEX NATURAL CONDOMS +LUBE/LUBRICATEDMISC

F


TRUSTEX NON-LUBRICATED MISC F QL(36 ea per

fill retail)

Drug Name DrugTier

Requirements/Limits

TRUSTEX WITH NONOXYNOL-9/RIBBED/STUDDEDMISC

F


TRUSTEX/RIALUBRICATED MISC F QL(36 ea per

fill retail) TRUSTEX/RIALUBRICATED SPERMICIDE MISC


TRUSTEX/RIALUBRICATED/SPERMICIDE MISC


TRUSTEX/RIA NON-LUBRICATED MISC F QL(36 ea per

fill retail)

ULTIMATE FEELING DEVI F QL(36 ea perfill retail)

Diabetic Supplies 1ST CHOICE LANCETS SUPERTHIN MISC F

1ST CHOICE LANCETS THIN MISC F

1ST CHOICE LANCETS ULTRATHIN MISC F

1ST TIER UNILET COMFORTOUCH LANCETS 28G MISC

F

1ST TIER UNILET COMFORTOUCH LANCETS 30G MISC

F

ADJUSTABLE LANCING DEVICE MISC F

ADVANCED MOBILE LANCET 30G MISC F

ADVOCATE LANCING DEVICE MISC F

ADVOCATE RAPID-SAFE LANCING DEVICE MISC F

AGAMATRIX ULTRA-THIN LANCETS 33G MISC F

ALTERNATE SITE LANCING DEVICE MISC F

AQUA LANCE ADJUSTABLE LANCING DEVICE DEVI

F

AURORA LANCET SUPER THIN30G MISC F


58

Drug Name DrugTier

Requirements/Limits

AURORA LANCET THIN 23G MISC F

AUTO-LANCET MINI MISC F

AUTO-LANCET MISC F

AUTOLET IMPRESSION LANCING DEVICE MISC F

AUTOLET LANCING DEVICE MISC F

AUTOLET MINI MISC F

AUTOLET PLUS MISC F

BAYER MICROLET 2 LANCING DEVICE MISC F

BD LANCET DEVICE MISC F

BD LANCET ULTRAFINE 30G MISC F

CARDIOCOM LANCING DEVICE MISC F

CAREONE ADVANCED LANCINGDEVICE MISC F

CAREONE LANCET THIN MISC F

CAREONE LANCET ULTRA THIN MISC F

CARETOUCH LANCING DEVICEWITH EJECTOR MISC

F

CLEANLET LANCETS 28G MISC F

CLOSERCARE MISC F

COMFORT ASSURED LANCETS MICRO THIN 33G MISC

F

COMFORT ASSURED LANCETS SUPER THIN 28G MISC

F

COMFORT LANCETS MISC F

CVS LANCETS 21G MISC F

CVS LANCETS MICRO THIN 33G MISC F

Drug Name DrugTier

Requirements/Limits

CVS LANCETS MICRO-THIN 33G MISC F

CVS LANCETS ORIGINAL MISC F

CVS LANCETS THIN 26G MISC F

CVS LANCETS ULTRA THIN 30G MISC F

CVS LANCETS ULTRA-THIN 30G MISC F

CVS LANCING DEVICE MISC F

CVS ULTRA THIN LANCETS MISC F

DROPLET LANCETS ULTRA THIN 30G MISC F

DROPLET LANCING DEVICE MISC F

DRUG MART ADJUSTABLE LANCING DEVICE MISC

F

DRUG MART LANCETS THIN MISC F

DRUG MART UNILET LANCETSSUPER THIN 30G MISC

F

DRUG MART UNILET LANCETSULTRA THIN 28G MISC

F

DRUG MART UNILET MICRO THIN LANCETS 33G MISC

F

DUANE READE LANCET ALTERNATE SITE 26G MISC

F

DUANE READE LANCET SUPERTHIN 30G MISC F

DUANE READE LANCET ULTRATHIN 28G MISC F

E-Z JECT LANCETS 21G MISC F

E-Z JECT LANCETS COLOR MISC F

E-Z JECT LANCETS MISC F


59

Drug Name DrugTier

Requirements/Limits

E-Z JECT LANCETS SUPER THIN 30G MISC F

E-Z JECT LANCETS THIN 26G MISC F

E-ZJECT LANCETS MICRO-THIN 33G MISC F

EASY MINI EJECT LANCING DEVICE MISC F

EASY MINI LANCING DEVICE MISC F

EASY TOUCH LANCETS 26G/PULL-TOP MISC F

EASY TOUCH LANCETS 26G/TWIST MISC F








EASY TOUCH LANCING DEVICE/EJECTOR MISC F

EASYTEST II LANCETS MISC F

EASYTEST LANCETS MISC F

EQL COLOR LANCETS 21G MISC F

EQL COLOR LANCETS MICRO THIN 33G MISC F

EQL SUPER THIN LANCETS 30G MISC F

EQL THIN LANCETS 26G MISC F

EZ SMART BLOOD GLUCOSE LANCETS MISC

F

Drug Name DrugTier

Requirements/Limits

EZ-LETS LANCETS 23G MISC F

EZ-LETS LANCETS 26G SUPER-SOFT MISC F

EZ-LETS LANCETS 28G ULTRA-SOFT MISC F

EZ-LETS LANCETS 30G MISC F

FIFTY50 LANCING DEVICE MISC F

FIFTY50 UNILET LANCETS 33G MISC F

FORA LANCETS MISC F

FORA LANCING DEVICE MISC F

FORA LANCING DEVICE/CLEARCAP MISC F

FREDS PHARMACY AUTOLET LANCING DEVICE MISC

F

FREDS PHARMACY UNILET LANCETS SUPER THIN 30G MISC

F

FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G MISC

F

GENTEEL LANCING DEVICE/BUFF BLACKMISC

F

GENTEEL LANCING DEVICE/BUTTERFLYBLUE MISC

F

GENTEEL LANCING DEVICE/GLORIOUSGOLD MISC

F

GENTEEL LANCING DEVICE/PLAYFULPURPLE MISC

F

GENTEEL LANCING DEVICE/PRECIOUSPLATINUM MISC

F

GENTEEL LANCING DEVICE/PRINCESS PINKMISC

F


60

Drug Name DrugTier

Requirements/Limits

GENTEEL LANCING DEVICE/STATELY SILVERMISC

F

GENTEEL LANCING DEVICE/WILLOWY WHITEMISC

F

GENTLE-LET GP LANCETS MISC F

GENTLE-LET LANCETS GENERAL PURPOSE STYLE/FINE POINT MISC

F

GENTLE-LET LANCETS GENERAL PURPOSE STYLE/MEDIUM POINTMISC

F

GENTLE-LET LANCETS SAFETY STYLE/FINEPOINT MISC

F

GENTLE-LET LANCETS SAFETY STYLE/MEDIUMPOINT MISC

F

GLOBAL LANCING DEVICE MISC F

GLUCOCOM LANCETS 28G MISC F

GLUCOCOM LANCETS 30G MISC F

GLUCOSOURCE LANCET DEVICE MISC F

GLUCOSOURCE LANCETS MISC F

GNP LANCETS 21G MISC F

GNP LANCETS MICRO THIN 33G MISC F

GNP LANCETS MISC F

GNP LANCETS SUPER THIN 30G MISC F

GNP LANCETS THIN 26G MISC F

GNP LANCETS THIN MISC F

GNP MICRO THIN LANCETS 33G MISC F

GNP SUPER THIN LANCETS/30G MISC F

Drug Name DrugTier

Requirements/Limits

GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL MISC

F

GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL MISC

F

GOODSENSE LANCING DEVICE MISC F

H-E-B INCONTROL ADVANCEDLANCING DEVICE MISC

F

H-E-B INCONTROL LANCETS MICRO THIN 33G MISC

F

H-E-B INCONTROL LANCETS SUPER THIN 30G MISC

F

H-E-B INCONTROL LANCETS ULTRA THIN 28G MISC

F

HEALTH CARE LANCING DEVICE MISC F

HEALTHWISE LANCING PEN MISC F

HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE MISC

F

HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G MISC

F

HY-VEE LANCETS MISC F

HY-VEE THIN LANCETS MISC F

IN TOUCH LANCING DEVICE MISC F

KINNEY LANCETS MISC F

KINNEY THIN LANCETS MISC F

KROGER LANCETS 21G MISC F

KROGER LANCETS MICRO THIN33G MISC F

KROGER LANCETS MISC F


61

Drug Name DrugTier

Requirements/Limits

KROGER LANCETS SUPER THIN MISC F

KROGER LANCETS THIN 26G MISC F

KROGER LANCETS THIN MISC F

KROGER LANCETS ULTRATHIN30G MISC F

KROGER LANCING DEVICE MISC F

LANCET DEVICE ADJUSTABLE MISC F

LANCET DEVICE WITH EJECTOR MISC F

LANCETS 26G TWIST TOP MISC F

LANCETS 28G MISC F

LANCETS 30G MISC F

LANCETS MISC F

LANCETS SAFETY SEAL 21G MISC F



LANCETS THIN MISC F

LANCETS ULTRA THIN MISC F

LANCING DEVICE ADJUSTABLE MISC F

LANCING DEVICE MISC F

LANZO MISC F

LEADER ADVANCED LANCING DEVICE MISC F

LIBERTY MINI LANCING DEVICE MISC F

LITE TOUCH LANCING PEN MISC F

LIVE BETTER ADVANCED LANCING DEVICE MISC F

Drug Name DrugTier

Requirements/Limits

LIVE BETTER LANCET SUPERTHIN 30G MISC F

LIVE BETTER LANCET ULTRATHIN 28G MISC F

LONGS LANCETS STANDARD MISC F

LONGS LANCETS THIN MISC F

MEDISENSE THIN LANCETS MISC F

MEIJER COLOR LANCETS UNIVERSAL 33G MISC

F

MEIJER LANCETS MISC F

MEIJER LANCETS THIN MISC F

MEIJER LANCETS UNIVERSAL21G MISC F



MEIJER SUPER THIN LANCETS MISC F

MICROLET NEXT MISC F

MINI LANCING DEVICE MISC F

MM LANCING DEVICE MISC F

MONOLET LANCETS MISC F

MONOLET OPD LANCETS MISC F

MULTI-LANCET DEVICE MISC F

NOVA SUREFLEX LANCETS MISC F

NOVA SUREFLEX LANCING DEVICE MISC F

ON CALL LANCING DEVICE MISC F

ON CALL PLUS LANCING DEVICE MISC F


62

Drug Name DrugTier

Requirements/Limits

ONETOUCH DELICA LANCING DEVICE MISC F

PC LANCETS SUPER THIN 30G MISC F

PERFECT LANCETS 30G MISC F

PHARMACY COUNTER LANCETS MISC F

PRECISION THIN LANCETS MISC F

PRECISION THINS GP LANCET MISC F

PRECISION ULTRA LANCET MISC F

PREFERRED PLUS LANCETS COLORED 21G MISC

F

PREFERRED PLUS LANCETS SUPER THIN 30G MISC

F

PREFERRED PLUS LANCETS THIN 26G MISC F

PRODIGY LANCING DEVICE MISC F

PRODIGY TWIST TOP LANCETS MISC F

PSS SELECT GP LANCETS MISC F

PSS SELECT SAFETY LANCETS MISC F

PX ADVANCED LANCING DEVICE MISC F

PX LANCET AUTO INJECTOR MISC F

PX LANCETS ULTRA THIN MISC F

QC ADVANCED LANCING DEVICE MISC F

QC LANCETS SUPER THIN MISC F

QC LANCETS ULTRA THIN MISC F

QC UNILET LANCETS 33G/MICRO THIN MISC F

Drug Name DrugTier

Requirements/Limits

RA E-ZJECT COLOR LANCETSMICRO-THIN 33G MISC

F

RA E-ZJECT LANCETS 28G MISC F

RA E-ZJECT LANCETS THIN 26G MISC F

RA E-ZJECT LANCETS THIN 28G MISC F

RA E-ZJECT LANCETS ULTRATHIN 30G MISC F

RA LANCING DEVICE MISC F

REALITY LANCETS MISC F

RELION 2-IN-1 LANCING DEVICE 25G MISC F

RELION 2-IN-1 LANCING DEVICE 30G MISC F

RELION LANCETS MICRO-THIN33G MISC F

RELION LANCETS STANDARD 21G MISC F

RELION LANCETS THIN 26G MISC F

RELION LANCETS ULTRA-THIN30G MISC F

RELION LANCING DEVICE MISC F

RELION ULTRA THIN LANCETS30G MISC F

RELION ULTRA THIN PLUS LANCETS 32G MISC

F

RELION ULTRA THIN PLUS LANCETS 33G MISC

F

REXALL LANCETS ULTRA THIN MISC F

RIGHTEST GD500 LANCING DEVICE MISC F

RIGHTEST GL300 LANCETS MISC F

SAFETY SEAL LANCETS 28G MISC F


63

Drug Name DrugTier

Requirements/Limits

SAFETY SEAL LANCETS 30G MISC F

SB LANCETS THIN MISC F

SB LANCETS ULTRA THIN MISC F

SELECT-LITE LANCING DEVICE MISC F

SHOPKO AUTOLET LANCING DEVICE MISC F

SHOPKO UNILET LANCETS SUPER THIN 30G MISC

F

SHOPKO UNILET LANCETS ULTRA THIN 28G MISC

F

SIDE BUTTON SAFETY LANCET21G MISC F

SIMPLE DIAGNOSTICS LANCING DEVICE MISC F

SM MICRO THIN LANCETS 33G MISC F

SM TRUEDRAW LANCING DEVICE MISC F

SMART DIABETES VANTAGE LANCING DEVICE MISC

F

SMART SENSE COLOR LANCETS UNIVERSAL 33G MISC

F

SMART SENSE STANDARD LANCETS UNIVERSAL 21G MISC

F

SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G MISC

F

SMART SENSE THIN LANCETSUNIVERSAL 26G MISC

F

SOLUS V2 LANCING DEVICE MISC F

STERILANCE TL MISC F

SUPER THIN LANCETS MISC F

SURE COMFORT LANCING PEN MISC F

Drug Name DrugTier

Requirements/Limits

SURE-PEN MISC F

SURELITE LANCETS MISC F

TECHLITE AST LANCETS MISC F

TECHLITE LANCETS 30G MISC F

TECHLITE LANCETS MISC F

TGT ADVANCED LANCING DEVICE MISC F

TGT LANCET ALTERNATE SITE MISC F

TGT LANCET MICRO THIN 33G MISC F

TGT LANCET SUPER THIN 30G MISC F

TGT LANCET THIN 23G MISC F

TGT LANCET THIN 26G MISC F

TGT LANCET ULTRA THIN 28G MISC F

TGT LANCET ULTRA THIN 30G MISC F

TGT LANCING DEVICE MISC F

THINLETS GP LANCETS MISC F

THINLETS LANCET MISC F

TODAYS HEALTH ADVANCED LANCING DEVICE MISC

F

TODAYS HEALTH SUPER THINLANCETS 30G MISC F

TODAYS HEALTH ULTRA THINLANCETS 28G MISC F

TRUE METRIX CONTROL SOLUTION LEVEL 1 SOLN

F


F


64

Drug Name DrugTier

Requirements/Limits


F

TRUECONTROL GLUCOSE CONTROL LEVEL 0 LIQD

F

TRUECONTROL GLUCOSE CONTROL LEVEL 1 LIQD

F

TRUEDRAW LANCING DEVICE MISC F

TRUEPLUS LANCETS 26G MISC F


TRUEPLUS LANCETS 28G SUPER THIN MISC F


TRUEPLUS LANCETS 30G ULTRA THIN MISC F


TRUETEST GLUCOSE CONTROLLEVEL 1 LIQD F



ULTI-LANCE AUTOMATIC/CLEAR TIP MISC F

ULTILET CLASSIC LANCETS MISC F

ULTRA THIN LANCETS 28G MISC F

UNILET COMFORTOUCH LANCET MISC F

UNILET EXCELITE II MISC F

UNILET EXCELITE MISC F

UNILET G.P. LANCET MISC F

UNILET G.P. SUPERLITE LANCET MISC F

Drug Name DrugTier

Requirements/Limits

UNILET GP 28 ULTRA THIN MISC F

UNILET LANCET MISC F

UNILET LANCETS MICRO-THIN33G MISC F

UNILET LANCETS SUPER-THIN30G MISC F

UNILET LANCETS ULTRA-THIN 28G MISC F

UNILET SUPERLITE LANCET MISC F

UNISTIK TOUCH SAFETY LANCETS 21G MISC F




UNIVERSAL 1 LANCETS THIN26G MISC F

UNIVERSAL 1 LANCETS ULTRA THIN 30G MISC F

VALUE PLUS LANCETS STANDARD 21G MISC F

VALUE PLUS LANCETS SUPERTHIN 30G MISC F

VALUE PLUS LANCETS THIN 26G MISC F

VALUE PLUS LANCING DEVICE MISC F

VALUMARK LANCET SUPER THIN 30G MISC F

VALUMARK LANCET ULTRA THIN 28G MISC F

VIDA MIA AUTOLET LANCINGDEVICE MISC F

VIDA MIA UNILET LANCETS SUPER THIN 30G MISC

F

VIDA MIA UNILET LANCETS ULTRA THIN 28G MISC

F

W&F LANCETS 26G MISC F


65

Drug Name DrugTier

Requirements/Limits

W&F LANCETS COLORED 21G MISC F

WALGREENS COMFORT ASSUREDLANCETS MICRO THIN/33G MISC

F

WALGREENS COMFORT ASSUREDLANCETS SUPER THIN/28G MISC

F

WALGREENS THIN LANCETS MISC F

Misc. Devices ALCOHOL PREP PADS PADS F RX/OTC

ALCOHOL PREPS PADS F RX/OTC

ALCOHOL SWABS PADS F RX/OTC

ALCOHOL WIPES PADS F RX/OTC

BD SWABS SINGLE USE BUTTERFLY PADS F RX/OTC

BD SWABS SINGLE USE PADS F RX/OTC

CURITY ALCOHOL PREPS/MEDIUM 2 PLYPADS

F RX/OTC

CURITY ALCOHOL SWABS PADS F RX/OTC

CVS ALCOHOL PREP SWABS PADS F RX/OTC

CVS PREP PADS PADS F RX/OTC

EASY TOUCH ALCOHOL PREP PADS/MEDIUMPADS

F RX/OTC

EQL ALCOHOL SWABS PADS F RX/OTC

FIFTY50 ALCOHOL PREP PADS PADS F RX/OTC

GNP ALCOHOL SWABS PADS F RX/OTC

H-E-B INCONTROL ALCOHOL PADS PADS F RX/OTC

MEIJER ALCOHOL SWABS EXTRA-THICK PADS

F RX/OTC

Drug Name DrugTier

Requirements/Limits

QC ALCOHOL SWABS PADS F RX/OTC

RA ALCOHOL SWABS PADS F RX/OTC

REALITY SWABS PADS F RX/OTC

RELION ALCOHOL SWABS PADS F RX/OTC

SB ALCOHOL PREP PADS PADS F RX/OTC

SHOPKO ALCOHOL SWABS PADS F RX/OTC

SM ALCOHOL PREP PADS PADS F RX/OTC

TGT ALCOHOL SWABS PADS F RX/OTC

ULTICARE ALCOHOL SWABS PADS F RX/OTC

ULTILET ALCOHOL SWABS PADS F RX/OTC

WEBCOL ALCOHOL PREP LARGE 1 PLY PADS

F RX/OTC

WEBCOL ALCOHOL PREP LARGE 2 PLY PADS

F RX/OTC

WEBCOL ALCOHOL PREP MEDIUM 2 PLY PADS

F RX/OTC

Parenteral Therapy Supplies 1ST TIER UNIFINE PENTIPS29GX12MM MISC

F QL(5 ea daily);RX/OTC

1ST TIER UNIFINE PENTIPSPLUS/ORIGINAL/29GX12MM MISC


ADVOCATE INSULIN SYRINGE/U-100/0.3ML/29GX1/2" MISC


ADVOCATE INSULIN SYRINGE/U-100/0.3ML/30GX5/16"MISC

F

QL(5 ea daily);RX/OTC


F

QL(5 ea daily)


66

Drug Name DrugTier

Requirements/Limits

ADVOCATE INSULIN SYRINGE/U-100/0.5ML/29GX1/2" MISC



F



F

QL(5 ea daily)

ADVOCATE INSULIN SYRINGE/U-100/1ML/29GX1/2" MISC





F QL(5 ea daily)

ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


ANTI-STICK INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


ASSURE ID INSULIN SAFETYSYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


ASSURE ID INSULIN SAFETYSYRINGE/U-100/1ML/29G X 1/2" MISC


ASSURE ID SAFETY PEN NEEDLES 30G X 5/16"MISC


AURORA PEN NEEDLES 29GX12MM MISC F QL(5 ea daily);

RX/OTC B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31GX 5/16" MISC

F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

B-D INSULIN SYRINGE ULTRAFINE II/0.5ML/31GX 5/16" MISC

F QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE II/1ML/31G X5/16" MISC

F QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE/0.3ML/30G X1/2" MISC

F QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X1/2" MISC

F QL(5 ea daily)

BD LO-DOSE INSULIN SYRINGE MICROFINE IV/0.5ML/28G X 1/2" MISC


BD AUTOSHIELD 29G X 5/16" MISC F QL(5 ea daily)

BD INSULIN SYRINGE LUER-LOK/U-100/1MLMISC


BD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X 1/2"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE MICROFINE IV/U-100/0.5ML/28G X 1/2"MISC

F


BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/27G X 5/8" MISC

F QL(5 ea daily)

BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/28G X 1/2" MISC


BD INSULIN SYRINGE MICROFINE/U-100/0.3ML/28G X 1/2"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE MICROFINE/U-100/0.5ML/28G X 1/2"MISC

F


BD INSULIN SYRINGE MICROFINE/U-100/1ML/27G X 5/8" MISC

F QL(5 ea daily)

BD INSULIN SYRINGE MICROFINE/U-100/1ML/28G X 1/2" MISC



67

Drug Name DrugTier

Requirements/Limits

BD INSULIN SYRINGE SAFETYGLIDE/0.5ML/29GX 1/2" MISC


BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X1/2" MISC


BD INSULIN SYRINGE SAFETYGLIDE/U-100/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE SAFETYGLIDE/U-100/1ML/31G X 15/64"MISC

F

BD INSULIN SYRINGE SLIP TIP/U-100/1ML MISC F QL(5 ea daily);

RX/OTC BD INSULIN SYRINGE U-100/0.3ML/29G X 1/2"MISC


BD INSULIN SYRINGE U-100/1ML/29G X 1/2" MISC F QL(5 ea daily);

RX/OTC BD INSULIN SYRINGE ULTRAFINE HALF-UNIT/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE II/SHORT/0.5ML/31G X5/16" MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE II/SHORT/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/0.3ML/30G X1/2" MISC

F QL(5 ea daily)


F QL(5 ea daily)


F QL(5 ea daily)


F QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/1ML/30G X1/2" MISC

F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

BD INSULIN SYRINGE ULTRAFINE/1ML/31G X5/16" MISC

F QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F

QL(5 ea daily)


F



F

QL(5 ea daily)


F

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/29G X 1/2" MISC


BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/30G X 1/2" MISC

F QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X 15/64"MISC

F

BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/25GX 1" MISC

F

QL(5 ea daily)


68

Drug Name DrugTier

Requirements/Limits

BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/25GX 5/8" MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/26GX 1/2" MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC

F QL(5 ea daily)

BD INSULIN SYRINGE/U-100/1ML/27G X 1/2" MISC F QL(5 ea daily);

RX/OTC BD INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC F QL(5 ea daily);

RX/OTC BD INSULIN SYRINGE/U-100/2ML/27.5G X 5/8"MISC

F QL(5 ea daily)

BD INTEGRA INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


BD INTEGRA SYRINGE/RETRACTINGNEEDLE/1ML/25G X 1"MISC

F

QL(5 ea daily)

BD SAFETY-GLIDE INSULIN SYRINGE/0.5ML/29G X1/2" MISC

F


BD SAFETY-LOK INSULIN SYRINGE/PERMNEEDLE/UF/1ML/29G X1/2" MISC

F


BD SAFETYGLIDE INSULIN SYSYRINGE/0.5ML/30G X5/16" MISC

F


BD VEO INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X 15/64"MISC

F

CAREFINE PEN NEEDLES 29GX1/2" MISC F QL(5 ea daily);

RX/OTC CAREFINE PEN NEEDLES 30GX5/16"MISC


Drug Name DrugTier

Requirements/Limits

CAREFINE PEN NEEDLES 32GX5MM MISC


CAREONE INSULIN SYRINGES/0.3ML/30G X1/2" MISC

F QL(5 ea daily)


F QL(5 ea daily)


F QL(5 ea daily)


F QL(5 ea daily)

CAREONE INSULIN SYRINGES/1ML/30G X1/2" MISC

F QL(5 ea daily)

CAREONE INSULIN SYRINGES/1ML/31GX5/16" MISC

F QL(5 ea daily)

CAREONE UNIFINE PENTIPS 29GX12MM MISC


CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 29GX12MM MISC

F


CARETOUCH PEN NEEDLES 32GX 5MM MISC


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/29G X1/2" MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)


69

Drug Name DrugTier

Requirements/Limits


F



F



F

QL(5 ea daily)


F



F

QL(5 ea daily)


F

QL(5 ea daily)

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/28G X 1/2"MISC

F


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/29G X 1/2"MISC

F


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/30G X5/16" MISC

F


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/U-100/1ML/31GX5/16" MISC

F

QL(5 ea daily)

CLEVER CHOICE COMFORT EZPEN NEEDLES 29GX12MM MISC

F


CLEVER CHOICE COMFORT EZPEN NEEDLES 32GX5MM MISC

F


Drug Name DrugTier

Requirements/Limits

COMFORT ASSIST INSULIN SYRINGE 0.3ML/29G X 1/2" MISC


COMFORT ASSIST INSULIN SYRINGE/0.3ML/30G X5/16" MISC

F



F

QL(5 ea daily)


F



F



F

QL(5 ea daily)

COMFORT ASSIST INSULIN SYRINGE/1ML/29G X 1/2"MISC

F


COMFORT ASSIST INSULIN SYRINGE/1ML/30G X5/16" MISC

F


COMFORT ASSIST INSULIN SYRINGE/1ML/31G X5/16" MISC

F

QL(5 ea daily)

DROPLET PEN NEEDLES 29GX12MM MISC F QL(5 ea daily);

RX/OTC DROPLET PEN NEEDLES 32G X 3/16" MISC F QL(5 ea daily);

RX/OTC DROPLET PEN NEEDLES 32GX5MM MISC F QL(5 ea daily);

RX/OTC DRUG MART UNIFINE PENTIPS29G X 12MM MISC


DUANE READE UNIFINE PENTIPS 29G X 12MM MISC



70

Drug Name DrugTier

Requirements/Limits

EASY COMFORT INSULIN SYRINGE/0.5ML/30G X5/16" MISC


EASY COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" MISC

F QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC


EASY COMFORT INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC

F

QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

F QL(5 ea daily)

EASY TOUCH 32GX5MM MISC F QL(5 ea daily);

RX/OTC EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2"MISC

F


EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/30GX1/2"MISC

F

QL(5 ea daily)


F



F

QL(5 ea daily)

EASY TOUCH INSULIN SYRINGE/0.3ML/30G X5/16" MISC



F QL(5 ea daily)



Drug Name DrugTier

Requirements/Limits



EASY TOUCH INSULIN SYRINGE/1ML/30G X5/16" MISC


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X 1/2"MISC

F


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/30G X 5/16"MISC

F


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/29G X 1/2" MISC


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/30G X 1/2" MISC

F QL(5 ea daily)

EASY TOUCH INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

F

QL(5 ea daily)


F

QL(5 ea daily)


F



F

QL(5 ea daily)


F

QL(5 ea daily)

EASY TOUCH INSULIN SYRINGE/U-100/1ML/27GX 1/2" MISC





71

Drug Name DrugTier

Requirements/Limits




F QL(5 ea daily)


F QL(5 ea daily)

EASY TOUCH PEN NEEDLE 30G X 5/16"MISC


EASY TOUCH PEN NEEDLES 29GX1/2" MISC F QL(5 ea daily);

RX/OTC EASY TOUCH PEN NEEDLES 32GX3/16"MISC


EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2" MISC

F



F



F

QL(5 ea daily)

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML/30GX1/2"MISC

F

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGE/0.3ML/31G X5/16" MISC

F QL(5 ea daily)





ELITE-THIN INSULIN SYRINGE/1ML/29G X5/16" MISC

F QL(5 ea daily)

ELITE-THIN INSULIN SYRINGE/1ML/30G X5/16" MISC


Drug Name DrugTier

Requirements/Limits

ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F



F

QL(5 ea daily)


F

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC



F QL(5 ea daily)




F QL(5 ea daily)

EQL INSULIN SYRINGE/0.3ML/29G X1/2" MISC





F QL(5 ea daily)






F QL(5 ea daily)

EQL INSULIN SYRINGE/1ML/29G X 1/2"MISC


EQL INSULIN SYRINGE/1ML/30G X5/16" MISC



72

Drug Name DrugTier

Requirements/Limits

EQL INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

EXEL COMFORT POINT INSULIN PEN NEEDLES 29G X 12MM MISC


EXEL COMFORT POINT INSULIN SYRINGE/0.3ML/29G X1/2" MISC

F



F



F



F



F


EXEL COMFORT POINT INSULIN SYRINGE/1ML/28G X 1/2"MISC

F


EXEL COMFORT POINT INSULIN SYRINGE/1ML/29G X 1/2"MISC

F


EXEL COMFORT POINT INSULIN SYRINGE/1ML/30G X5/16" MISC

F


FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.3ML/31G X5/16" MISC

F

QL(5 ea daily)

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.5ML/31G X5/16" MISC

F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/1ML/31G X5/16" MISC

F

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC

F


FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGES/U-100/1ML/30G X 5/16"MISC

F


GLOBAL EASE INJECT PEN NEEDLES 29GX12MM MISC


GLOBAL EASY GLIDE INSULINSYRINGE/U-100/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)


F



73

Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC





F QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

GLOBAL INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

F

QL(5 ea daily)

GLOBAL INSULIN SYRINGES/U-100/0.3ML/30GX5/16"MISC

F


GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)


F

QL(5 ea daily)


F



F

QL(5 ea daily)

GLUCOPRO INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

F QL(5 ea daily)




F QL(5 ea daily)

GNP INSULIN SYRINGE/0.3ML/29G X1/2" MISC





F QL(5 ea daily)








74

Drug Name DrugTier

Requirements/Limits


F QL(5 ea daily)

GNP INSULIN SYRINGE/1ML/28G X 1/2"MISC


GNP INSULIN SYRINGE/1ML/29G X 1/2"MISC


GNP INSULIN SYRINGE/1ML/30G X5/16" MISC


GNP INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X1/2" MISC

F


GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" SHORT MISC

F



F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)

GNP ULTRA COMFORT INSULIN SYRINGE/1ML/28G X 1/2"MISC

F


Drug Name DrugTier

Requirements/Limits

GNP ULTRA COMFORT INSULIN SYRINGE/1ML/29G X 1/2"MISC

F


GNP ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" SHORT MISC

F


GNP ULTRA COMFORT INSULIN SYRINGE/1ML/31G X5/16" SHORT MISC

F

QL(5 ea daily)

H-E-B INCONTROL PEN NEEDLES 29GX12MM MISC


HEALTHWISE PEN NEEDLES 29GX12MM MISC


HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 29GX12MM MISC

F


INSULIN SYRINGE/0.3ML/29G X 1"MISC

F QL(5 ea daily)

INSULIN SYRINGE/0.3ML/29G X1/2" MISC





F QL(5 ea daily)


F QL(5 ea daily)




F QL(5 ea daily)




75

Drug Name DrugTier

Requirements/Limits


F QL(5 ea daily)

INSULIN SYRINGE/1ML/28G X 1/2"MISC


INSULIN SYRINGE/1ML/29G X 1/2"MISC


INSULIN SYRINGE/1ML/30G X5/16" MISC


INSULIN SYRINGE/NEEDLE0.3ML/30G X 5/16" MISC



F QL(5 ea daily)






F QL(5 ea daily)

INSULIN SYRINGE/NEEDLE1ML/29G X 1/2" MISC





F QL(5 ea daily)

INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC






INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC F QL(5 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC F QL(5 ea daily);

RX/OTC INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC


INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F QL(5 ea daily)

INSULIN SYRINGES/0.5ML/27GX1/2" MISC

F QL(5 ea daily)








F QL(5 ea daily)


F QL(5 ea daily)

INSULIN SYRINGES/1ML/27GX/1/2"MISC


INSULIN SYRINGES/1ML/27GX1/2"MISC







F QL(5 ea daily)

INSULIN SYRINGES/1ML/31GX5/16" MISC

F QL(5 ea daily)

INSUPEN 29G X 12MM MISC F QL(5 ea daily);

RX/OTC


76

Drug Name DrugTier

Requirements/Limits

INSUPEN ULTRAFIN 29GX12MM MISC F QL(5 ea daily);

RX/OTC INSUPEN ULTRAFIN 30GX8MM MISC F QL(5 ea daily);

RX/OTC KINRAY INSULIN SYRINGE PREFERRED PLUS/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

KINRAY INSULIN SYRINGE PREFERRED PLUS/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

KINRAY INSULIN SYRINGE PREFERRED PLUS/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

KINRAY INSULIN SYRINGE/0.5ML/29G X1/2" MISC


KMART VALU PLUS INSULIN SYRINGE/1ML/29G MISC


KMART VALU PLUS INSULIN SYRINGE/1ML/30G MISC


KROGER INSULIN SYRINGE/0.3ML/29G X1/2" MISC





F QL(5 ea daily)






F QL(5 ea daily)

KROGER INSULIN SYRINGE/1ML/29G X 1/2"MISC


Drug Name DrugTier

Requirements/Limits

KROGER INSULIN SYRINGE/1ML/30G X5/16" MISC


KROGER INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

KROGER PEN NEEDLES 29G X12MM MISC F QL(5 ea daily);

RX/OTC LEADER INSULIN SYRINGE/0.3ML/29G X1/2" MISC


LEADER INSULIN SYRINGE/0.3ML/30G X5/16" MISC



F QL(5 ea daily)








F QL(5 ea daily)

LEADER INSULIN SYRINGE/1ML/28G X 1/2"MISC


LEADER INSULIN SYRINGE/1ML/29G X 1/2"MISC


LEADER INSULIN SYRINGE/1ML/30G X5/16" MISC


LEADER INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

LITETOUCH INSULIN SYRINGE/0.3ML/29G X1/2" MISC





77

Drug Name DrugTier

Requirements/Limits


F QL(5 ea daily)




F QL(5 ea daily)

LITETOUCH INSULIN SYRINGE/1ML/30G X5/16" MISC


LITETOUCH INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


LITETOUCH INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


LITETOUCH INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC





F QL(5 ea daily)

LIVE BETTER PEN NEEDLES 29G X 12MM MISC


LONGS INSULIN SYRINGE/0.5ML/31G X5/16" MISC

F QL(5 ea daily)

MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F


Drug Name DrugTier

Requirements/Limits


F


MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X 1/2" MISC


MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/30G X 5/16"MISC

F


MARATHON MEDICAL PENTIPS29GX12MM MISC


MAXI-COMFORT INSULIN SYRINGE/U-100/0.5ML/28GX1/2" MISC


MAXI-COMFORT INSULIN SYRINGE/U-100/1ML/28GX1/2" MISC


MEDIC INSULIN SYRINGE/0.3ML/30G X5/16" MISC


MEDIC INSULIN SYRINGE/0.5ML/30G X5/16" MISC


MEDICINE SHOPPE PEN NEEDLES 29G X 12MM MISC


MEIJER PEN NEEDLES 29G X12MM MISC F QL(5 ea daily);

RX/OTC MM INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC


MM INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC

F QL(5 ea daily)

MM INSULIN SYRINGE/U-100/1/2ML/30G X 5/16"MISC


MM INSULIN SYRINGE/U-100/1/2ML/31G X 5/16"MISC

F QL(5 ea daily)

MM INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC



78

Drug Name DrugTier

Requirements/Limits

MM INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F QL(5 ea daily)

MONOJECT INSULIN SYRINGE/1ML MISC F QL(5 ea daily);

RX/OTC MONOJECT INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/25G X 5/8"MISC

F

QL(5 ea daily)

MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/27G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/PERMNEEDLE/1ML/28G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/PERMNEEDLE/U-100/0.5ML/28GX 1/2" MISC

F


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29GX1/2"MISC

F


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/SOFTPACK/1ML/27G X 1/2" MISC


MONOJECT INSULIN SYRINGE/SOFTPACK/U-100/0.5ML/28G X 1/2"MISC

F


Drug Name DrugTier

Requirements/Limits

MONOJECT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC

F



F



F


MONOJECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC


MONOJECT INSULIN SYRINGE/U-100/1ML/30GX 5/16" MISC


MONOJECT INSULIN SYRINGEREGULAR LUER TIP/SOFTPACK/1ML MISC


MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X1/2" MISC

F



F



F

QL(5 ea daily)


F



F



F



79

Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)

MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/28G X 1/2"MISC

F


MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/29G X 1/2"MISC

F


MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC

F


MOORE MED MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


MOORE MED MONOJECT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


MOORE MED MONOJECT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


MOORE MED MONOJECT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC


MS INSULIN SYRINGE/0.3ML/31G X5/16" MISC

F QL(5 ea daily)

MS INSULIN SYRINGE/0.5ML/31G X5/16" MISC

F QL(5 ea daily)

MS INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

NOVOFINE 30GX8MM MISC F QL(5 ea daily);

RX/OTC NOVOFINE AUTOCOVER 30GX8MM MISC F QL(5 ea daily);

RX/OTC NOVOTWIST 30GX8MM MISC F QL(5 ea daily);

RX/OTC NOVOTWIST 32GX5MM MISC F QL(5 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

PC UNIFINE PENTIPS 29G X1/2" MISC F QL(5 ea daily);

RX/OTC PEN NEEDLES 29G X 12MM MISC F QL(5 ea daily);

RX/OTC PEN NEEDLES 29GX1/2"MISC F QL(5 ea daily);

RX/OTC PEN NEEDLES 30GX5/16"MISC F QL(5 ea daily);

RX/OTC PEN NEEDLES 30GX8MM MISC F QL(5 ea daily);

RX/OTC PEN NEEDLES 32G X 5MM MISC F QL(5 ea daily);

RX/OTC PENTIPS 29G X 12MM MISC F QL(5 ea daily);

RX/OTC PENTIPS 29GX12MM MISC F QL(5 ea daily);

RX/OTC PRECISION SURE-DOSE INSULIN SYRINGE/0.3ML/30G X5/16" MISC

F


PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/28G X1/2" MISC

F



F



F

QL(5 ea daily)

PRECISION SURE-DOSE INSULIN SYRINGE/1ML/28G X 1/2"MISC

F


PRECISION SURE-DOSE PLUSINSULIN SYRINGE/0.3ML/29G X1/2" MISC

F


PRECISION SURE-DOSE PLUSINSULIN SYRINGE/1ML/29G X 1/2"MISC

F


PREFERRED PLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



80

Drug Name DrugTier

Requirements/Limits


F



F



F



F


PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC


PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


PREFERRED PLUS UNIFINE PENTIPS 29G X 12MM MISC


PRO COMFORT INSULIN SYRINGES/0.5ML/30G X1/2" MISC

F QL(5 ea daily)




F QL(5 ea daily)

PRO COMFORT INSULIN SYRINGES/1ML/30G X1/2" MISC

F QL(5 ea daily)




F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

PRO COMFORT PEN NEEDLES/32G X 5MMMISC


PRODIGY INSULIN SYRING/U-100/0.3ML/31GX 5/16" MISC

F QL(5 ea daily)

PRODIGY INSULIN SYRINGE/1/2ML/31G X5/16" MISC

F QL(5 ea daily)

PRODIGY INSULIN SYRINGE/1ML/28G X 1/2"MISC


PX INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

F QL(5 ea daily)


F QL(5 ea daily)


F QL(5 ea daily)


F QL(5 ea daily)

PX INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC F QL(5 ea daily)

PX INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F QL(5 ea daily)

PX PEN NEEDLE 29GX12MM MISC F QL(5 ea daily);

RX/OTC QC PEN NEEDLES 29G X 12MM MISC F QL(5 ea daily);

RX/OTC RA INSULIN SYRINGE/0.5ML/29G X1/2" MISC


RA INSULIN SYRINGE/1ML/29G X 1/2"MISC


RA INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC


RA INSULIN SYRINGE/U-100/1 ML/30G X 5/16"MISC



81

Drug Name DrugTier

Requirements/Limits

REALITY INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


REALITY INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


REALITY INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC


REALITY INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


RELION INSULIN SYRINGE 1ML/31GX15/64" MISC

F

RELION INSULIN SYRINGE/U-00/1ML/29GX 1/2" MISC


RELION INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F

QL(5 ea daily)


F



F



F

QL(5 ea daily)



Drug Name DrugTier

Requirements/Limits


F


F QL(5 ea daily)

RELION PEN NEEDLES 29GX12MM MISC F QL(5 ea daily);

RX/OTC SAFESNAP INSULIN SYRINGE/0.3ML/30G X5/16" MISC


SAFESNAP INSULIN SYRINGE/0.5ML/29G X1/2" MISC


SAFESNAP INSULIN SYRINGE/0.5ML/30G X5/16" MISC


SAFESNAP INSULIN SYRINGE/1ML/28G X 1/2"MISC


SAFESNAP INSULIN SYRINGE/1ML/29G X 1/2"MISC


SAFETY INSULIN SYRINGES 0.5ML/29GX1/2" MISC


SAFETY INSULIN SYRINGES 0.5ML/30GX5/16" MISC


SAFETY INSULIN SYRINGES 1ML/27GX1/2"MISC





F QL(5 ea daily)

SAFETY-GLIDE INSULIN SYRINGE/0.3ML/29G X1/2" MISC


SB INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC


SB INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC



82

Drug Name DrugTier

Requirements/Limits

SB INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC F QL(5 ea daily);

RX/OTC SB INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC


SB INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F QL(5 ea daily)

SCHNUCKS INSULIN SYRINGEULTI-FINE/U-100/0.5ML/29G X 1/2"MISC

F


SCHNUCKS INSULIN SYRINGEULTI-FINE/U-100/0.5ML/30G X 5/16"MISC

F


SHOPKO UNIFINE PENTIPS PEN NEEDLES/ORIGINAL/29GX12MM MISC

F


SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/REMOVER/29GX12MM MISC

F


SM INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F


SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16MISC

F

QL(5 ea daily)


F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


F



F



F

QL(5 ea daily)


F


SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X 5/16MISC

F

QL(5 ea daily)

SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC





F QL(5 ea daily)

SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

SURE COMFORT PEN NEEDLES30GX5/16"SHORT MISC


SURE-JECT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



83

Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)

SURE-JECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC







F QL(5 ea daily)

TECHLITE INSULIN SYRINGEU-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

TECHLITE INSULIN SYRINGEU-100/1ML/29GX 1/2" MISC



F QL(5 ea daily)




F


F QL(5 ea daily)

TECHLITE PEN NEEDLES 29GX 12 MM MISC F QL(5 ea daily);

RX/OTC TODAYS HEALTH ORIGINAL PEN NEEDLES 29G X 1/2" MISC


TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" MISC

F



F

QL(5 ea daily)


F



84

Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC

F


TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/31G X5/16" MISC

F

QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F


TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC

F


TOPCO INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F


TOPCO INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC


TOPCO INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F


Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)

TRUEPLUS INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC







F QL(5 ea daily)

TRUEPLUS PEN NEEDLES 29GX12MM MISC


ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X1/2" MISC

F


ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2"MISC

F



85

Drug Name DrugTier

Requirements/Limits

ULTICARE INSULIN SYRINGE/0.3ML/29G X1/2" MISC



F QL(5 ea daily)








F QL(5 ea daily)



ULTICARE INSULIN SYRINGE/1ML/28G X 1/2"MISC





F QL(5 ea daily)

ULTICARE INSULIN SYRINGE/1ML/30G X5/16" MISC


ULTICARE INSULIN SYRINGE/SHORT/0.3ML/30G X 5/16" MISC



F QL(5 ea daily)




F QL(5 ea daily)

ULTICARE INSULIN SYRINGE/SHORT/1ML/30G X 5/16" MISC


Drug Name DrugTier

Requirements/Limits

ULTICARE INSULIN SYRINGE/SHORT/1ML/31G X 5/16" MISC

F QL(5 ea daily)

ULTICARE INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)


F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

ULTICARE INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC



F QL(5 ea daily)




F QL(5 ea daily)


86

Drug Name DrugTier

Requirements/Limits

ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTICARE ORIGINAL PEN NEEDLES ULTI-FINE MISC


ULTILET INSULIN SYRINGE/0.3ML/30G X8MM MISC



F QL(5 ea daily)



ULTILET INSULIN SYRINGE/1ML/30G X8MM MISC


ULTILET INSULIN SYRINGE/1ML/31G X8MM MISC

F QL(5 ea daily)

ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X 12.7MM MISC

F QL(5 ea daily)

ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X 5/16" MISC



F QL(5 ea daily)




F QL(5 ea daily)

ULTILET INSULIN SYRINGE/SHORT/1ML/30G X 5/16" MISC


Drug Name DrugTier

Requirements/Limits

ULTILET INSULIN SYRINGE/SHORT/1ML/31G X 5/16" MISC

F QL(5 ea daily)

ULTILET INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC

F

QL(5 ea daily)

ULTILET INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

F QL(5 ea daily)

ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC

F


ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)

ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC



87

Drug Name DrugTier

Requirements/Limits

ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.3ML/30GX5/16"MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/30GX5/16" MISC


ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/31GX5/16" MISC

F QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE/U-100/0.3ML/29GX1/2" MISC


ULTRA-THIN II INSULIN SYRINGE/U-100/0.5ML/29GX1/2" MISC


ULTRA-THIN II INSULIN SYRINGE/U-100/1ML/29GX1/2" MISC


UNIFINE PENTIPS 29GX12MM MISC F QL(5 ea daily);

RX/OTC UNIFINE PENTIPS PLUS 29GX12MM MISC F QL(5 ea daily);

RX/OTC V-R MONOJECT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F


Drug Name DrugTier

Requirements/Limits

V-R MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


V-R MONOJECT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


V-R MONOJECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC


V-R MONOJECT INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


VALUE HEALTH INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


VALUE HEALTH INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


VALUMARK PEN NEEDLES 29GX12MM MISC


VANISHPOINT INSULIN SYRINGE/0.5ML/30G X1/2" MISC

F QL(5 ea daily)

VANISHPOINT INSULIN SYRINGE/0.5ML/30G X5/16" MISC


VANISHPOINT INSULIN SYRINGE/1ML/29G X 1/2"MISC


VANISHPOINT INSULIN SYRINGE/1ML/29G X5/16" MISC

F QL(5 ea daily)

VANISHPOINT INSULIN SYRINGE/1ML/30G X5/16" MISC


VIDA MIA UNIFINE PENTIPSORIGINAL 29GX12MM MISC


VP INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC


Respiratory Therapy Supplies


88

Drug Name DrugTier

Requirements/Limits

ACE AEROSOL CLOUD ENHANCER MISC F RX/OTC

ACTIVITY POUCH MISC F RX/OTC

ADAPTER PED DISPOSABLE MOUTHPIECE MISC

F RX/OTC

ADULT AEROSOL MASK MISC F RX/OTC

ADULT DISPOSABLE MOUTHPIECE MISC F RX/OTC

ADULT MASK LARGE MISC F RX/OTC

ADULT MASK MISC F RX/OTC

AEROCHAMBER MINI AEROSOLCHAMBER DEVI

F RX/OTC

AEROCHAMBER MV MISC F RX/OTC

AEROCHAMBER PLUS FLOW VU MISC F RX/OTC

AEROCHAMBER PLUS FLOW-VU MISC F RX/OTC

AEROCHAMBER PLUS FLOW-VU/LARGE MASKMISC

F RX/OTC

AEROCHAMBER PLUS FLOW-VU/MASK MISC F RX/OTC

AEROCHAMBER PLUS FLOW-VU/MEDIUM MASKMISC

F RX/OTC

AEROCHAMBER PLUS FLOW-VU/SMALL MASKMISC

F RX/OTC

AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VUMISC

F

RX/OTC

AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL MISC F RX/OTC

AEROCHAMBER Z-STAT PLUS/LARGE MASK MISC F RX/OTC

AEROCHAMBER Z-STAT PLUS/MEDIUM MASKMISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

AEROCHAMBER Z-STAT PLUS/SMALL MASK MISC F RX/OTC

AEROCHAMBER/FLOWSIGNAL MISC F RX/OTC

AEROTRACH PLUS MISC F RX/OTC

AEROVENT PLUS HOLDING CHAMBER/COLLAPSIBLEDEVI

F

RX/OTC

AIRS PEDIATRIC AEROSOL MASK MISC F RX/OTC

ALL FLOW 1000 PULMONARY FUNCTION FILTER MISC

F RX/OTC

ARIAL CHAMBER DEVI F RX/OTC

BREATHERITE COLLAPSIBLEADULT SPACER W/MASK MISC

F RX/OTC

BREATHERITE COLLAPSIBLECHILD SPACER W/MASK MISC

F RX/OTC

BREATHERITE COLLAPSIBLEINFANT SPACER W/MASK MISC

F RX/OTC

BREATHERITE COLLAPSIBLESMALL CHILD SPACER W/MASKMISC

F

RX/OTC

BREATHERITE COLLAPSIBLESPACER W/ NEONATE MASK MISC

F RX/OTC

BREATHERITE MISC F RX/OTC

BREATHERITE RIGID SPACERW/MASK MISC F RX/OTC

BREATHERITE W/LARGEMASK MISC F RX/OTC

BREATHERITE W/MEDIUM MASK MISC F RX/OTC

BREATHERITE W/SMALLMASK MISC F RX/OTC

BUBBLES THE FISH II PEDIATRIC MASK/PVCMISC

F RX/OTC


89

Drug Name DrugTier

Requirements/Limits

CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/ADULT LARGEDEVI

F

RX/OTC

CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM DEVI

F

RX/OTC

CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/SMALL DEVI

F

RX/OTC

CO MONITOR REPLACEMENT TPIECES MISC

F RX/OTC

COMPACT SPACE CHAMBER/ANTI-STATICDEVI

F RX/OTC

COMPACT SPACE CHAMBER/ANTI-STATIC/LARGE MASKDEVI

F

RX/OTC

COMPACT SPACE CHAMBER/ANTI-STATIC/MEDIUM MASKDEVI

F

RX/OTC

COMPACT SPACE CHAMBER/ANTI-STATIC/SMALL MASKDEVI

F

RX/OTC

DISPOSABLE MOUTHPIECE FULL RANGE MISC

F RX/OTC

DISPOSABLE MOUTHPIECE LOWRANGE/PEDIATRICMISC

F

RX/OTC

DISPOSABLE MOUTHPIECE/LOWRANGE MISC

F RX/OTC

DISPOSABLE MOUTHPIECE/UNIVERSAL RANGE MISC

F RX/OTC

DISPOSABLE PAPER MOUTHPIECE MISC F RX/OTC

E-Z SPACER DEVI F RX/OTC

Drug Name DrugTier

Requirements/Limits

E-Z SPACER THE BODY GUARDS PACK DEVI F RX/OTC

EASIVENT MISC F RX/OTC

EASIVENT/MASK-LARGEMISC F RX/OTC

EASIVENT/MASK-MEDIUM MISC F RX/OTC

EASIVENT/MASK-SMALLMISC F RX/OTC

EBASE CONTROLLER KIT MISC F RX/OTC

EFLOW SCF AEROSOL HEAD MISC F RX/OTC

ELITE DC AUTO ADAPTER MISC F RX/OTC

EXPIRATORY MOUTHPIECE MISC F RX/OTC

FILTER AIR PP MISC F RX/OTC

FLEXICHAMBER DEVI F RX/OTC

FULL KIT NEBULIZER SET MISC F RX/OTC

HEALTHY LIVING REPLACEMENT FILTERS MISC

F RX/OTC

HEALTHY LIVING REPLACEMENT KIT FOR NEBULIZER MISC

F RX/OTC

HEALTHY LIVING REPLACEMENT MASKS MISC

F RX/OTC

HUDSON RCI SEE-THRU AEROSOL MASK ELONGATED/ADULTMISC

F

RX/OTC

INNOSPIRE REPLACEMENT FILTER MISC

F RX/OTC

INSPIRACHAMBER/ANTI-STATIC VALVED/MOUTHPIECEDEVI

F

RX/OTC

INSPIRACHAMBER/LARGE DEVI F RX/OTC


90

Drug Name DrugTier

Requirements/Limits

INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM DEVI

F RX/OTC

INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL DEVI

F RX/OTC

INSPIREASE DRUG DELIVERYSYSTEM MISC F RX/OTC

INSPIREASE RESERVOIR BAGS MISC F

KOKO PEAK PRO REPLACEMENTPLASTIC MOUTHPIECE MISC

F RX/OTC

LITEAIRE DEVI F RX/OTC

LITETOUCH MASK LARGE MISC F RX/OTC

LITETOUCH MASK MEDIUM MISC F RX/OTC

LITETOUCH MASK SMALL MISC F RX/OTC

MICROCHAMBER MISC F RX/OTC

MICROELITE FILTER REPLACEMENTS MISC F RX/OTC

MICROELITE RECHARGEABLE BATTERY MISC

F RX/OTC

MICROSPACER MISC F RX/OTC

MINIELITE FILTER REPLACEMENTS MISC F RX/OTC

MINIELITE RECHARGEABLE BATTERY MISC

F RX/OTC

NEBULIZER AIR TUBE/PLUGS MISC F RX/OTC

NEBULIZER PEDIATRIC MASK MISC F RX/OTC

NOSE CLIP MISC F RX/OTC

ONE FLOW TESTER TUBE MOUTHPIECE MISC

F RX/OTC

ONE-WAY VALVED EXPIRATORYMOUTHPIE CE/DISPOSABLE MISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

ONE-WAY VALVED INSPIRATORY MOUTHPIECE/DISPOSABLE MISC

F

RX/OTC

OPTICHAMBER ADVANTAGE/LARGEMASK MISC

F RX/OTC

OPTICHAMBER ADVANTAGE/MEDIUMFACE MASK MISC

F RX/OTC

OPTICHAMBER ADVANTAGE/SMALLFACE MASK MISC

F RX/OTC

OPTICHAMBER DIAMOND MISC F RX/OTC

OPTICHAMBER DIAMOND/LARGEFACEMASK DEVI

F RX/OTC

OPTICHAMBER DIAMOND/MEDIUM FACEMASK MISC

F RX/OTC

OPTICHAMBER DIAMOND/SMALLFACEMASK MISC

F RX/OTC

OPTICHAMBER FACE MASK/LARGE MISC F RX/OTC

OPTICHAMBER FACE MASK/MEDIUM MISC F RX/OTC

OPTICHAMBER FACE MASK/SMALL MISC F RX/OTC

OPTIHALER MDI DRUG DELIVERY SYSTEM DEVI F RX/OTC

OPTIHALER MISC F RX/OTC

PARI ALTERA NEBULIZER HANDSET MISC

F RX/OTC

PARI BABY CONVERSION KITSIZE 1 MISC F RX/OTC



PARI ERAPID NEBULIZER HANDSET MISC F RX/OTC

PARI EXPIRATORY FILTER VALVE SET DEVI F RX/OTC


91

Drug Name DrugTier

Requirements/Limits

PARI MASK SET MISC F RX/OTC

PARI SOFT PLASTIC ADULT MASK MISC F RX/OTC

PARI SOFT PLASTIC PEDIATRIC MASK MISC F RX/OTC

PEDIATRIC AEROSOL MASK MISC F RX/OTC

PEDIATRIC DISPOSABLE MOUTPIECE MISC F RX/OTC

PEDIATRIC MOUTHPIECE/DISPOSABLE MISC

F RX/OTC

PFLEX MISC F RX/OTC

PILLOW MASK/ADULTMISC F RX/OTC

PILLOW MASK/CHILDMISC F RX/OTC

PILLOW MASK/PEDIATRIC MISC F RX/OTC

POCKET CHAMBER DEVI F RX/OTC

POCKET SPACER DEVI F RX/OTC

REPLACEMENT AIR FILTER MISC F RX/OTC

REPLACEMENT FILTERS MISC F RX/OTC

RITEFLO DEVI F RX/OTC

SAMI THE SEAL REPLACEMENTFILTERS MISC

F RX/OTC

SIDESTREAM ADULT FACE MASK MISC F RX/OTC

SIDESTREAM PEDIATRIC FACEMASK MISC F RX/OTC

SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL MISC

F RX/OTC

SIDESTREAM PEDIATRIC FACEMASK/TUCKER THETURTLE MISC

F RX/OTC

SIDESTREAM PLUS ADULT FACE MASK MISC F RX/OTC

Drug Name DrugTier

Requirements/Limits

SILICONE MASK FOR BREATHERITE CHAMBER/ADULT MISC

F RX/OTC

SILICONE MASK FOR BREATHERITE CHAMBER/INFANT MISC

F RX/OTC

SILICONE MASK FOR BREATHERITE CHAMBER/PEDIATRICMISC

F

RX/OTC

SILICONE MASK FOR BREATHRITE CHAMBER/ADULT MISC

F RX/OTC

SOOTHENEB NBL 100 CHILD MASK MISC F RX/OTC

SOOTHENEB NBL 100 MEDICATION CUP MISC F RX/OTC

SOOTHENEB NBL 100 MESH CAP MISC F RX/OTC

SOOTHENEB NBL100 ADULT MASK MISC F RX/OTC

THRESHOLD IMT MISC F RX/OTC

TUBING/WING TIP MISC F RX/OTC

VALVED HOLDING CHAMBER DEVI F RX/OTC

VORTEX VALVED HOLDING CHAMBER DEVI

F RX/OTC

WATCHHALER DEVI F RX/OTC

WINDMILL TRAINER MISC F RX/OTC

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Migraine Combinations CAFERGOT TABS (Use Ergotamine w/ Caffeine) NF

ergotamine w/ caffeine tabs F

Migraine Products D.H.E. 45 SOLN (Use DihydroergotamineMesylate)

NF


92

Drug Name DrugTier

Requirements/Limits

dihydroergotaminemesylate soln F

Serotonin Agonists AMERGE TABS (Use Naratriptan HCl) NF AL; At least 18

yrs old eletriptan hydrobromidetabs F

IMITREX SOLN NA 5 MG/ACT, 20 MG/ACT (Use Sumatriptan)

NF AL; At least 12 yrs old

IMITREX SOLN SC 6 MG/0.5ML (Use Sumatriptan Succinate)

NF

1 rtl pack lmtamt,30 rtl packlmt day(s),; AL;At least 12 yrsold

IMITREX STATDOSE REFILL SOCT 6 MG/0.5ML(Use SumatriptanSuccinate)

NF

AL; At least 12 yrs old

IMITREX STATDOSE SYSTEM SOAJ 6 MG/0.5ML (Use Sumatriptan Succinate)

NF

AL; At least 12 yrs old

IMITREX TABS OR 25 MG, 50 MG, 100 MG (Use Sumatriptan Succinate)

NF AL; At least 12 yrs old

MAXALT TABS (Use Rizatriptan Benzoate) NF AL; At least 6

yrs old MAXALT-MLT TBDP (Use Rizatriptan Benzoate) NF QL(0.4 ea

daily)

naratriptan hcl tabs F AL; At least 18 yrs old

RELPAX TABS (Use Eletriptan Hydrobromide) NF

rizatriptan benzoate tabs 5mg, 10 mg F AL; At least 6

yrs old rizatriptan benzoate tbdp 5mg, 10 mg F QL(0.4 ea

daily)

sumatriptan soln F AL; At least 12 yrs old

sumatriptan succinate soajsc 6 mg/0.5ml F AL; At least 12

yrs old sumatriptan succinate soctsc 6 mg/0.5ml F AL; At least 12

yrs old

Drug Name DrugTier

Requirements/Limits

sumatriptan succinate solnsc 6 mg/0.5ml F

1 rtl pack lmtamt,30 rtl packlmt day(s),; AL;At least 12 yrsold

SUMATRIPTAN SUCCINATE SOSY SC 6 MG/0.5ML


sumatriptan succinate tabsor 25 mg, 50 mg, 100 mg F AL; At least 12

yrs old

zolmitriptan tabs F

zolmitriptan tbdp F

ZOMIG SOLN NA 5 MG F AL; At least 12 yrs old

ZOMIG TABS OR 5 MG, 2.5 MG (Use Zolmitriptan) NF

ZOMIG ZMT TBDP (Use Zolmitriptan) NF

MINERALS & ELECTROLYTES

Electrolyte Mixtures

CERASPORT EX1 SOLN F

CERASPORT SOLN 4MEQ/L-18MEQ/L-20MEQ/L-6MEQ/L

F

ENFAMIL ENFALYTE SOLN F

HYDRALYTE FREEZER POPS SOLN F

HYDRALYTE SOLN 270MG/250ML-210MG/250ML, 45MEQ/L-45MEQ/L-20MEQ/L-90MEQ/L-16GM/L

F

oral electrolytes soln F

PEDIALYTE FREEZER POPS SOLN (Use Oral Electrolytes)

NF


93

Drug Name DrugTier

Requirements/Limits

PEDIALYTE SOLN 20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L,20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L (Use Oral Electrolytes)

NF

Fluoride LURIDE SOLN (Use Sodium Fluoride) NF

sodium fluoride chew 0.25 mg, 0.5 mg, 1 mg, 1.1 mg,2.2 mg

F

sodium fluoride soln 0.125 mg/drop, 0.5 mg/ml F

Magnesium magnesium oxide (mgsupplement) tabs 241.3 mg F

MAGOX 400 TABS (Use Magnesium Oxide (MgSupplement))

NF

Phosphate K-PHOS NEUTRAL TABS (Use Pot PhosphateMonobasic w/ SodPhosphate Dibasic &Monobasic)

NF

QL(8 ea daily)

pot phosphate monobasicw/ sod phosphate dibasic &monobasic tabs

F QL(8 ea daily)

Potassium K-TAB TBCR 10 MEQ (Use Potassium Chloride) NF MP

K-TAB TBCR 8 MEQ F MP

KLOR-CON M15 TBCR F

KLOR-CON/25 PACK F

MICRO-K CPCR 10 MEQ (Use Potassium Chloride) NF MP

MICRO-K CPCR 8 MEQ (Use Potassium Chloride) NF QL(1 ea daily);

MP

potassium bicarbonate tbef F

Drug Name DrugTier

Requirements/Limits

potassium chloride cpcr or10 meq F MP

potassium chloride cpcr or8 meq F QL(1 ea daily);

MP POTASSIUM CHLORIDE ER TBCR 8 MEQ F MP

potassium chloridemicroencapsulated crystalser tbcr

F MP

potassium chloride pack or20 meq F

potassium chloride soln or10 %, 20 % F MP

POTASSIUM CHLORIDE SOLN OR 20 % F MP

potassium chloride tbcr or 8meq, 10 meq F MP

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents

DEPEN TITRATABS TABS F

Immunosuppressive Agents

AZASAN TABS F QL(3 ea daily)

azathioprine tabs or 50 mg F

CELLCEPT CAPS 250 MG (Use MycophenolateMofetil)

NF QL(2 ea daily);SP

CELLCEPT SUSR 200 MG/ML (Use Mycophenolate Mofetil)

NF QL(15 mldaily); SP

CELLCEPT TABS 500 MG (Use MycophenolateMofetil)


cyclosporine caps or 25mg, 100 mg F SP

cyclosporine modified (formicroemulsion) caps 25mg, 50 mg, 100 mg

F QL(4 ea daily);SP

cyclosporine modified (formicroemulsion) soln 100mg/ml

F QL(8 ml daily);SP

CYCLOSPORINE MODIFIED CAPS F QL(4 ea daily);

SP


94

Drug Name DrugTier

Requirements/Limits

CYCLOSPORINE MODIFIED CAPS (Use Cyclosporine Modified (ForMicroemulsion))

NF

QL(4 ea daily);SP

IMURAN TABS (Use Azathioprine) NF

mycophenolate mofetilcaps 250 mg F QL(2 ea daily);

SP mycophenolate mofetil susr200 mg/ml F QL(15 ml

daily); SP mycophenolate mofetil tabs500 mg F QL(4 ea daily);

SP mycophenolate sodiumtbec 180 mg F QL(2 ea daily);

SP mycophenolate sodiumtbec 360 mg F QL(4 ea daily);

SP MYFORTIC TBEC 180 MG (Use MycophenolateSodium)


MYFORTIC TBEC 360 MG (Use MycophenolateSodium)


NEORAL CAPS 25 MG, 100 MG (Use CyclosporineModified (ForMicroemulsion))

NF

QL(4 ea daily);SP

NEORAL SOLN 100 MG/ML (Use CyclosporineModified (ForMicroemulsion))

NF

QL(8 ml daily);SP

PROGRAF CAPS OR 0.5 MG, 1 MG, 5 MG (Use Tacrolimus)


RAPAMUNE SOLN 1 MG/ML F SP

RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (Use Sirolimus)

NF SP

SANDIMMUNE CAPS OR 25 MG, 100 MG (Use Cyclosporine)

NF SP

SANDIMMUNE SOLN OR 100 MG/ML F SP

sirolimus tabs F SP

tacrolimus caps F QL(3 ea daily);SP

Drug Name DrugTier

Requirements/Limits

Potassium Removing Agents KAYEXALATE POWD (Use Sodium PolystyreneSulfonate)


sodium polystyrenesulfonate powd or F QL(454 gm per

fill retail) sodium polystyrenesulfonate susp or 15gm/60ml

F

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln F QL(100 ml per

fill retail) Anti-infectives - Throat nystatin (mouth-throat) susp F QL(120 ml per

fill retail) Antiseptics - Mouth/Throat chlorhexidine gluconate(mouth-throat) soln F

PERIDEX SOLN (Use Chlorhexidine Gluconate (Mouth-Throat))

NF

Dental Products GEL-KAM ORAL CARE RINSE CONC (Use Stannous Fluoride)

NF RX/OTC

PREVIDENT 5000 DRY MOUTH GEL (Use Sodium Fluoride (Dental))


PREVIDENT 5000 PLUS CREA (Use Sodium Fluoride (Dental))


PREVIDENT FLUORIDE GEL (Use Sodium Fluoride (Dental))


sodium fluoride (dental)crea dt 1.1 % F QL(102 gm per

fill retail) sodium fluoride (dental) geldt 1.1 % F QL(672 ml per

fill retail) sodium fluoride (dental)soln mt 0.2 % F

stannous fluoride conc mt 0.63 % F RX/OTC


95

Drug Name DrugTier

Requirements/Limits

THERA-FLUR-N GEL (Use Sodium Fluoride (Dental)) NF QL(672 ml per

fill retail) Steroids - Mouth/Throat triamcinolone acetonide (mouth) pste F QL(5 gm per fill

retail) Throat Products - Misc. pilocarpine hcl (oral) tabs 5 mg F QL(6 ea daily)

SALAGEN TABS 5 MG (Use Pilocarpine HCl(Oral))

NF QL(6 ea daily)

MULTIVITAMINS

B-Complex w/ Folic Acid b-complex w/ c & folic acidcaps 1.5mg-5mg-20mg-1.7mg-6mcg-1mg-150mcg-10mg-100mg, 5mg-1.7mg-6mcg-20mg-1.5mg-1mg-150mcg-10mg-100mg

F


b-complex w/ c & folic acidtabs 1.5mg-10mg-20mg-1.7mg-6mcg-1mg-300mcg-10mg-60mg, 6mcg-1.5mg-10mg-20mg-1.7mg-1mg-300mcg-10mg-100mg,1.5mg-1.7mg-10mg-0.01mcg-20mg-1mg-300mcg-10mg-60mg,20mg-1.7mg-10mg-0.006mg-1.5mg-1mg-0.3mg-10mg-100mg

F

QL(1 ea daily)

NEPHRO-VITE RX TABS 1.5MG-10MG-20MG-1.7MG-6MCG-1MG-300MCG-10MG-60MG (Use B-Complex w/ C &Folic Acid)

NF

QL(1 ea daily)

NEPHROCAPS CAPS (Use B-Complex w/ C &Folic Acid)


Multiple Vitamins w/ Minerals ADVANCED DIABETIC MULTIVITAMIN FORMULA TABS


ALIVE ENERGY 50+ TABS F QL(1 ea daily);RX/OTC

Drug Name DrugTier

Requirements/Limits

ALIVE MENS ENERGY TABS F QL(1 ea daily);

RX/OTC ALIVE ONCE DAILY WOMENS 50+ ULTRA POTENCY TABS


ALIVE ONCE DAILY WOMENS ULTRA POTENCY TABS


ALIVE WOMENS 50+ TABS F QL(1 ea daily);

RX/OTC ALIVE WOMENS ENERGY TABS F QL(1 ea daily);

RX/OTC ANTIOXIDANT FORTE TABS F QL(1 ea daily);

RX/OTC

AP-ZEL TABS F QL(1 ea daily);RX/OTC

BACMIN TABS F QL(1 ea daily);RX/OTC

BASIC AM TABS F QL(1 ea daily);RX/OTC

BASIC PM TABS F QL(1 ea daily);RX/OTC

CAL-DAY 1000 TABS F QL(1 ea daily);RX/OTC

CENTRAVITES 50 PLUS TABS F QL(1 ea daily);

RX/OTC CENTRAVITES ADULTS TABS F QL(1 ea daily);

RX/OTC CENTRUM ADULTS TABS (Use Multiple Vitamins w/Minerals)


CENTRUM CARDIO TABS F QL(1 ea daily);RX/OTC

CENTRUM MEN TABS F QL(1 ea daily);RX/OTC

CENTRUM SILVER ULTRA MENS TABS F QL(1 ea daily);

RX/OTC CENTRUM SILVER ULTRA WOMENS TABS F QL(1 ea daily);

RX/OTC CENTRUM SPECIALIST HEART TABS F QL(1 ea daily);

RX/OTC CENTRUM SPECIALIST IMMUNE SUPPORT TABS F QL(1 ea daily);

RX/OTC CENTRUM SPECIALIST VISION TABS F QL(1 ea daily);

RX/OTC


96

Drug Name DrugTier

Requirements/Limits

CENTRUM ULTRA WOMENS TABS F QL(1 ea daily);

RX/OTC CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS TABS


CLINICAL NUTRIENTS 45-PLUS WOMEN TABS F QL(1 ea daily);

RX/OTC CLINICAL NUTRIENTS 50-PLUS MEN TABS F QL(1 ea daily);

RX/OTC CLINICAL NUTRIENTS FOR FEMALE TEENS TABS


CLINICAL NUTRIENTS FOR MALE TEENS TABS F QL(1 ea daily);

RX/OTC CLINICAL NUTRIENTS FOR MEN TABS F QL(1 ea daily);

RX/OTC CLINICAL NUTRIENTS FOR WOMEN TABS F QL(1 ea daily);

RX/OTC CVS ONE DAILY MENS 50+ ADVANCED TABS F QL(1 ea daily);

RX/OTC CVS SPECTRAVITE ADULT 50+ TABS F QL(1 ea daily);

RX/OTC CVS SPECTRAVITE ULTRA MEN50+ TABS F QL(1 ea daily);

RX/OTC CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR TABS


CVS SPECTRAVITE ULTRA MENS HEALTH TABS


CVS SPECTRAVITE ULTRA WOMEN TABS F QL(1 ea daily);

RX/OTC CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR TABS


CVS SPECTRAVITE ULTRA WOMENS HEALTH TABS


DERMAVITE TABS F QL(1 ea daily);RX/OTC

EQ COMPLETE MULTIVITAMINADULTS UNDER 50 TABS


EQ ONE DAILY MENS 50+ TABS F QL(1 ea daily);

RX/OTC EQ ONE DAILY MENS HEALTH TABS F QL(1 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

EQ ONE DAILY WOMENS 50+ TABS F QL(1 ea daily);

RX/OTC EQ ONE DAILY WOMENS HEALTH TABS F QL(1 ea daily);

RX/OTC EQL CENTURY MATURE ADULTS50+ TABS F QL(1 ea daily);

RX/OTC EQL CENTURY MENS TABS F QL(1 ea daily);

RX/OTC EQL CENTURY WOMENS TABS F QL(1 ea daily);

RX/OTC EQL ONE DAILY MENS TABS F QL(1 ea daily);

RX/OTC FITNESS TABS FOR MEN AM/PM/LYCOPENE TABS F QL(1 ea daily);

RX/OTC FITNESS TABS FOR WOMEN AM/PM/LYCOPENE TABS


FREEDAVITE TABS F QL(1 ea daily);RX/OTC

GERI-FREEDA SENIOR FORMULA TABS F QL(1 ea daily);

RX/OTC

HAIR-VITES TABS F QL(1 ea daily);RX/OTC

HM COMPLETE 50+ MENS ULTIMATE TABS F QL(1 ea daily);

RX/OTC HM COMPLETE 50+ WOMENS ULTIMATE TABS


HM COMPLETE TABS F QL(1 ea daily);RX/OTC

HM HAIR/SKIN/NAILSTABS F QL(1 ea daily);

RX/OTC HM ONE DAILY MENS TABS F QL(1 ea daily);

RX/OTC HM ONE DAILY WOMENS TABS F QL(1 ea daily);

RX/OTC

HYALEX TABS F QL(1 ea daily);RX/OTC

ICAPS AREDS FORMULA TABS F QL(1 ea daily);

RX/OTC

ICAPS PLUS TABS F QL(1 ea daily);RX/OTC

K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH TABS

F



97

Drug Name DrugTier

Requirements/Limits

MACULAR VITAMIN BENEFIT TABS F QL(1 ea daily);

RX/OTC MEGA MULTI FOR WOMEN TABS F QL(1 ea daily);

RX/OTC MEGA MULTIVITAMIN FOR MEN TABS F QL(1 ea daily);

RX/OTC MEGA MULTIVITAMIN FOR WOMEN TABS F QL(1 ea daily);

RX/OTC MEGAVITE FRUITS & VEGGIES TABS F QL(1 ea daily);

RX/OTC MEGAVITE GOLDEN YEARS 55+ TABS F QL(1 ea daily);

RX/OTC MENS 50+ MULTI VITAMIN &MINERAL FORMULA TABS


MENS MULTI VITAMIN & MINERAL FORMULA TABS


MULTI-BETIC DIABETES TABS F QL(1 ea daily);

RX/OTC MULTI-VITAMIN MONOCAPS TABS F QL(1 ea daily);

RX/OTC multiple vitamins w/minerals tabs F QL(1 ea daily);

RX/OTC MULTIVITAMIN ADULTS TABS F QL(1 ea daily);

RX/OTC MULTIVITAMIN MEN TABS F QL(1 ea daily);

RX/OTC NAT-RUL THERAVITE-M/HIGHPOTENCY TABS F QL(1 ea daily);

RX/OTC

NATRUL-MEGA-75 TABS F QL(1 ea daily);RX/OTC

NATRUL-VITES TABS F QL(1 ea daily);RX/OTC

NICADAN TABS F QL(1 ea daily);RX/OTC

NICADAN ZX TABS F QL(1 ea daily);RX/OTC

NICAZEL FORTE TABS F QL(1 ea daily);RX/OTC

NICAZEL TABS F QL(1 ea daily);RX/OTC

NO IRON MULTIPLE VITAMIN/MINERALSTABS


Drug Name DrugTier

Requirements/Limits

NUTRICAP TABS F QL(1 ea daily);RX/OTC

OCULAR VITAMINS TABS F QL(1 ea daily);RX/OTC

ONCOVITE TABS F QL(1 ea daily);RX/OTC

ONE DAILY MENS FORMULA W/O IRONTABS


ONE DAILY PLUS IRON TABS F QL(1 ea daily);

RX/OTC ONE DAILY WOMENS TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY ENERGY TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY MENOPAUSE FORMULA TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY MENS 50+ ADVANTAGE TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY MENS HEALTH FORMULA TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY MENS PRO EDGE TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY PROACTIVE 65+ TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY TEEN ADVANTAGEFOR HIM TABS


OPTI-WOMAN TABS F QL(1 ea daily);RX/OTC

OPURITY TABS F QL(1 ea daily);RX/OTC

PARVLEX TABS F QL(1 ea daily);RX/OTC

PHYTOMULTI TABS F QL(1 ea daily);RX/OTC

PRESERVISION AREDS TABS F QL(1 ea daily);

RX/OTC

PRO-CAL TABS F QL(1 ea daily);RX/OTC

PROCERV HP TABS F QL(1 ea daily);RX/OTC

PRORENAL+D TABS F QL(1 ea daily);RX/OTC

PROVIT TABS F QL(1 ea daily);RX/OTC


98

Drug Name DrugTier

Requirements/Limits

QUENCH TABS F QL(1 ea daily);RX/OTC

QUIN B STRONG TABS F QL(1 ea daily);RX/OTC

QUINTABS-M TABS F QL(1 ea daily);RX/OTC

RA CENTRAL-VITE TABS F QL(1 ea daily);RX/OTC

RA CENTRAL-VITE UNDER 50MENS TABS F QL(1 ea daily);

RX/OTC RA CENTRAL-VITE UNDER 50WOMENS TABS


RENAPLEX-D TABS F QL(1 ea daily);RX/OTC

REQ 49+ TABS F QL(1 ea daily);RX/OTC

SENTRY SENIOR TABS F QL(1 ea daily);RX/OTC

SENTRY SENIOR/LUTEINTABS F QL(1 ea daily);

RX/OTC

SENTRY TABS F QL(1 ea daily);RX/OTC

SIDEROL TABS F QL(1 ea daily);RX/OTC

SM ONE DAILY MENS TABS F QL(1 ea daily);

RX/OTC SM ONE DAILY WOMENS TABS F QL(1 ea daily);

RX/OTC

SOLO TABS F QL(1 ea daily);RX/OTC

STROVITE ONE TABS F QL(1 ea daily);RX/OTC

SUPERB NAILS TABS F QL(1 ea daily);RX/OTC

T-VITES TABS F QL(1 ea daily);RX/OTC

THERA M PLUS TABS F QL(1 ea daily);RX/OTC

THERA-M TABS F QL(1 ea daily);RX/OTC

THERA-TABS M TABS F QL(1 ea daily);RX/OTC

THERABETIC MULTI-VITAMIN TABS F QL(1 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

THERAGRAN-M ADVANCED 50 PLUS TABS


THERAGRAN-M ADVANCED TABS F QL(1 ea daily);

RX/OTC THERAGRAN-M PREMIER 50 PLUS TABS F QL(1 ea daily);

RX/OTC THERAGRAN-M PREMIER TABS F QL(1 ea daily);

RX/OTC

THERAGRAN-M TABS F QL(1 ea daily);RX/OTC

THEREMS-H TABS F QL(1 ea daily);RX/OTC

THEREMS-M TABS F QL(1 ea daily);RX/OTC

UNICOMPLEX-M TABS F QL(1 ea daily);RX/OTC

VITALINE TOTAL FORMULA 2 TABS F QL(1 ea daily);

RX/OTC VITALINE TOTAL FORMULA 3 TABS F QL(1 ea daily);

RX/OTC VITAMIN D3 COMPLETE TABS F QL(1 ea daily);

RX/OTC

VITASANA TABS F QL(1 ea daily);RX/OTC

VITATRUM TABS F QL(1 ea daily);RX/OTC

VITRUM 50+ SENIOR MULTI TABS F QL(1 ea daily);

RX/OTC

VP-ZEL TABS F QL(1 ea daily);RX/OTC

WHOLE FOOD MULTIVITAMIN TABS F QL(1 ea daily);

RX/OTC WOMENS 50+ MULTI VITAMIN& MINERAL FORMULA TABS


WOMENS BIOMULTIPLE TABS F QL(1 ea daily);

RX/OTC WOMENS MULTI VITAMIN & MINERAL FORMULA TABS


YELETS TEENAGE FORMULA TABS F QL(1 ea daily);

RX/OTC

Ped MV w/ Fluoride


99

Drug Name DrugTier

Requirements/Limits

FLORIVA PLUS SOLN F QL(50 ml perfill retail); AL;Up to 13 yrs old

MULTIVITAMIN/FLUORIDE CHEW F

QL(1 ea daily);AL; Up to 13yrs old

pediatric multivitamins w/flchew 0.25mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg,0.25mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg, 0.5mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 0.5mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg,0.5mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-15unit-1.05mg-60mg, 15unit-1mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg, 1mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 1mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg, 15unit-0.5mg-1.05mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 15unit-0.5mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg,15unit-0.25mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg

F


Drug Name DrugTier

Requirements/Limits

pediatric multivitamins w/flsoln 0.25mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-5unit/ml-0.4mg/ml-35mg/ml,0.25mg/ml-5unit/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml,0.25mg/ml-5unit/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml,0.5mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-5unit/ml-0.4mg/ml-35mg/ml,0.5mg/ml-5unit/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml,0.5mg/ml-5unit/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.5mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.5mg/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.25mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml

F


pediatric vitamins acd w/fluoride soln F



100

Drug Name DrugTier

Requirements/Limits

QUFLORA PEDIATRIC CHEW 108MCG-1MG-15UNIT-1MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG, 108MCG-1MG-15UNIT-0.5MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG, 108MCG-1MG-15UNIT-0.25MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG

F


QUFLORA PEDIATRIC SOLN 150MCG/ML-1MG/ML-0.5MG/ML-12MG/ML-1100UNIT/ML-2MG/ML-1MG/ML-3MCG/ML-400UNIT/ML-1MG/ML-81MCG/ML-12UNIT/ML-1MG/ML-45MG/ML, 65MCG/ML-1MG/ML-0.25MG/ML-10MG/ML-1000UNIT/ML-0.8MG/ML-0.6MG/ML-2MCG/ML-400UNIT/ML-0.5MG/ML-35MCG/ML-5UNIT/ML-0.4MG/ML-35MG/ML

F


TRI-VITAMIN/FLUORIDESOLN F


Ped MV w/ Iron

pediatric multiple vitaminsw/ iron soln F


Ped Multi Vitamins w/Fl & FE

ped multivitamins w/fl &iron soln F


TRI-VIT/FLUORIDE/IRONSOLN F


Pediatric Multiple Vitamins

Drug Name DrugTier

Requirements/Limits

pediatric multiple vitamin w/c & fa chew F


pediatric multiple vitamin w/c soln F


Pediatric Vitamins

pediatric vitamins adc soln F QL(50 ml perfill retail); AL;Up to 13 yrs old

Prenatal Vitamins CLASSIC PRENATAL TABS F MP

CO-NATAL FA TABS F

COMPLETENATE CHEW F

CVS PRENATAL TABS F MP

EQL PRENATAL FORMULA TABS F MP

GNP PRENATAL TABS F MP

GOODSENSE PRENATAL VITAMINS TABS F MP

HM PRENATAL TABS F MP

INATAL GT TABS F QL(1 ea daily)

KP PRENATAL MULTIVITAMINS TABS F MP

KPN PRENATAL TABS F

M-VIT TABS F RX/OTC; MP

MULTI PRENATAL TABS F MP

MYNATAL ADVANCE TABS F QL(1 ea daily)

MYNATAL CAPS F QL(1 ea daily)

MYNATAL PLUS TABS F QL(1 ea daily)

MYNATAL ULTRACAPLET TABS F QL(1 ea daily)

MYNATAL-Z TABS F QL(1 ea daily)


101

Drug Name DrugTier

Requirements/Limits

MYNATE 90 PLUS TBCR F QL(1 ea daily)

NAT-RUL PRENATAL VITAMINS TABS F MP

NATALVIT TABS F

NIVA-PLUS TABS F RX/OTC; MP

NUTRICION PORVIDA TABS F QL(1 ea daily)

O-CAL FA TABS F RX/OTC; MP

O-CAL PRENATAL TABS F

OB COMPLETE ADVANCED CAPS F

PERRY PRENATAL CAPS F

PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID TABS

F QL(1 ea daily)

PNV FOLIC ACID + IRON MULTIVITAMIN TABS F RX/OTC; MP

PNV PRENATAL PLUS MULTIVITAMIN TABS F RX/OTC; MP

PNV TABS 29-1 TABS F QL(1 ea daily);MP

PRE-NATAL FORMULA TABS F

PRENATABS FA TABS F

PRENATABS RX TABS F QL(1 ea daily);MP

PRENATAL + DHA THPK F QL(1 ea daily)

PRENATAL 19 CHEW 30UNIT-1000UNIT-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG, 1000UNIT-400UNIT-20MG-25MG-3MG-200MG-29MG-7MG-6MG-3MG-12MCG-1MG-30UNIT-20MG-100MG

F

Drug Name DrugTier

Requirements/Limits

PRENATAL 19 TABS 1000UNIT-30UNIT-20MG-25MG-3MG-200MG-29MG-15MG-3MG-7MG-12MCG-400UNIT-20MG-1MG-100MG, 30UNIT-1000UNIT-20MG-25MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG

F

QL(1 ea daily)

PRENATAL AND IRON TABS F

PRENATAL FORTE TABS F

PRENATAL LOW IRON TABS F MP

PRENATAL MULTIVITAMIN TABS F MP

PRENATAL ONE DAILY TABS F MP

PRENATAL PLUS IRON TABS F QL(1 ea daily);

MP

PRENATAL PLUS TABS F RX/OTC; MP


102

Drug Name DrugTier

Requirements/Limits

PRENATAL TABS 11UNIT- MP 263MG-25MG-1.5MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-0.8MG-2.6MG-120MG, 30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-4000UNIT-8MCG-400UNIT-800MCG-2.6MG-120MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT- F

800MCG-2.6MG-120MG, 4000UNIT-30UNIT-200MG-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 4000UNIT-30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 160MG-11UNIT-200MG-25MG-1.84MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-800MCG-2.6MG-100MG PRENATAL TABS 22MG- RX/OTC; MP2MG-25MG-1.84MG-200MG-27MG-4000UNIT-20MG-3MG-12MCG- F

400UNIT-1MG-10MG-120MG PRENATAL TABS 4000UNIT-200MG-11UNIT-27MG-25MG-1.84MG-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG

F

PRENATAL VITAMIN & MINERAL TABS F MP

PRENATAL VITAMIN TABS F MP

PRENATAL VITAMIN/IRON TABS F MP

Drug Name DrugTier

Requirements/Limits

PRENATAL VITAMINS PLUS LOW IRON TABS F RX/OTC; MP

PRENATAL VITAMINS TABS F MP

PREPLUS TABS F RX/OTC; MP

PRETAB TABS F

PX PRENATAL MULTIVITAMINS TABS F MP

QC PRENATAL TABS F MP

RA PRENATAL FORMULA/FOLICACIDTABS

F MP

RA PRENATAL TABS F MP

RIGHT STEP PRENATAL TABS F MP

SE-NATAL 19 CHEW 30UNIT-1000UNIT-100MG-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG

F

SE-NATAL 19 TABS 30UNIT-1000UNIT-20MG-25MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-3MG-20MG-1MG-100MG

F

QL(1 ea daily)

SM PRENATAL VITAMINS TABS F MP

THERANATAL CORE NUTRITION TABS F RX/OTC; MP

THRIVITE 19 TABS F QL(1 ea daily)

THRIVITE RX TABS F QL(1 ea daily);MP

TRIADVANCE TABS F QL(1 ea daily)

TRICARE TABS F RX/OTC; MP

TRINATAL GT TABS F QL(1 ea daily)

TRINATAL RX 1 TABS F QL(1 ea daily)

VIL-RX TABS F QL(1 ea daily);MP


103

Drug Name DrugTier

Requirements/Limits

VINATE M TABS F QL(1 ea daily)

VINATE ONE TABS F QL(1 ea daily)

VIRT-ADVANCE TABS F QL(1 ea daily)

VIRT-VITE GT TABS F QL(1 ea daily)

VITAFOL-OB TABS F QL(1 ea daily)

VOL-PLUS TABS F RX/OTC; MP

VOL-TAB RX TABS F QL(1 ea daily);MP

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms

Central Muscle Relaxants baclofen tabs or 10 mg, 20 mg F MP

CHLORZOXAZONE TABS 500 MG F

cyclobenzaprine hcl tabs 5mg, 10 mg F QL(3 ea daily)

methocarbamol tabs or 500 mg, 750 mg F

orphenadrine citrate tb12or 100 mg F

ROBAXIN TABS OR 500 MG (Use Methocarbamol) NF

ROBAXIN-750 TABS (Use Methocarbamol) NF

tizanidine hcl tabs 2 mg, 4 mg F

ZANAFLEX TABS 4 MG (Use Tizanidine HCl) NF

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus

Nasal Agents - Misc. OCEAN NASAL SPRAY SOLN (Use Saline) NF QL(480 ml per

fill retail) saline soln na 0.65%-0.002%, 0.65 %, 0.65% F QL(480 ml per

fill retail) Nasal Anti-infectives BACTROBAN NASAL OINT F

Drug Name DrugTier

Requirements/Limits

Nasal Antiallergy ASTEPRO SOLN (Use Azelastine HCl) NF

azelastine hcl soln 0.1 %,137 mcg/spray F QL(1 ml daily)

azelastine hcl soln 0.15 % F

cromolyn sodium (nasal) aers F QL(26 ml per

fill retail) NASALCROM AERS (Use Cromolyn Sodium (Nasal)) NF QL(26 ml per

fill retail) Nasal Anticholinergics ipratropium bromide (nasal)soln 0.03 % F QL(30 ml per

fill retail) ipratropium bromide (nasal)soln 0.06 % F QL(25 ml per

fill retail) Nasal Steroids FLONASE ALLERGY RELIEF CHILDRENS SUSP (Use Fluticasone Propionate (Nasal))

NF


FLONASE ALLERGY RELIEF SUSP (Use Fluticasone Propionate(Nasal))

NF


FLUNISOLIDE SOLN F QL(25 ml perfill retail)

fluticasone propionate(nasal) susp F


Sympathomimetic Decongestants NASAL DECONGESTANT LIQD F

NASAL DECONGESTANT SYRP F

phenylephrine hcl (oral)tabs F QL(24 ea per

fill retail) pseudoephedrine hcl liqd15 mg/5ml F

pseudoephedrine hcl tabs30 mg, 60 mg F

pseudoephedrine hcl tb12120 mg F QL(2 ea daily)


104

Drug Name DrugTier

Requirements/Limits

SUDAFED CHILDRENS LIQD (Use Pseudoephedrine HCl)

NF

SUDAFED CONGESTION TABS (Use Pseudoephedrine HCl)

NF

SUDAFED NASAL DECONGESTANT MAXIMUM STRENGTH TABS (Use Pseudoephedrine HCl)

NF

SUDAFED PE CONGESTION TABS (Use Phenylephrine HCl (Oral))


NUTRIENTS

Carbohydrates

POLYCOSE LIQD F QL(124 ml perfill retail)

POLYCOSE POWD F QL(350 gm perfill retail)

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

artificial tear ointment oint F QL(4 gm per fillretail)

HYPOTEARS SOLN F QL(30 ml perfill retail)

polyvinyl alcohol soln F QL(15 ml perfill retail)

TEARS NATURALE PM OINT (Use White Petrolatum-Mineral Oil)


white petrolatum-mineral oiloint F QL(42 gm per

fill retail) Beta-blockers - Ophthalmic BETAGAN SOLN (Use Levobunolol HCl) NF QL(15 ml per

fill retail)

betaxolol hcl (ophth) soln F QL(15 ml perfill retail)

BETOPTIC-S SUSP F QL(15 ml perfill retail)

carteolol hcl (ophth) soln F

CARTEOLOL HCL SOLN F

Drug Name DrugTier

Requirements/Limits

COSOPT SOLN (Use Dorzolamide HCl-Timolol Maleate)


dorzolamide hcl-timolol maleate soln F QL(10 ml per

fill retail) DORZOLAMIDE HCL/TIMOLOL MALEATESOLN


levobunolol hcl soln F QL(15 ml perfill retail)

METIPRANOLOL SOLN F

timolol maleate (ophth) solg0.5 % F QL(5 ml per fill

retail) timolol maleate (ophth) soln0.25 %, 0.5 % F QL(15 ml per

fill retail) TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG 0.5 %


TIMOPTIC OCUDOSE SOLN F QL(60 ea per

fill retail) TIMOPTIC SOLN (Use Timolol Maleate (Ophth)) NF QL(15 ml per

fill retail) TIMOPTIC-XE SOLG 0.5 % F QL(5 ml per fill

retail) Cycloplegic Mydriatics ATROPINE SULFATE OINT OP 1 % F QL(4 gm per fill

retail) ATROPINE SULFATE SOLN OP 1 % F QL(15 ml per

fill retail) CYCLOGYL SOLN 1 %, 2 % (Use CyclopentolateHCl)


cyclopentolate hcl soln 1%, 2 % F QL(15 ml per

fill retail)

ISOPTO ATROPINE SOLN F QL(15 ml perfill retail)

MYDRIACYL SOLN (Use Tropicamide) NF QL(15 ml per

fill retail)

tropicamide soln F QL(15 ml perfill retail)

Miotics ISOPTO CARPINE SOLN (Use Pilocarpine HCl) NF

pilocarpine hcl soln F


105

Drug Name DrugTier

Requirements/Limits

Ophthalmic Adrenergic Agents

apraclonidine hcl soln F

brimonidine tartrate soln 0.2 % F QL(15 ml per

fill retail) IOPIDINE SOLN 0.5 % (Use Apraclonidine HCl) NF

IOPIDINE SOLN 1 % F

Ophthalmic Anti-infectives BACITRACIN OINT OP 500 UNIT/GM F QL(4 gm per fill

retail) bacitracin-polymyxin b(ophth) oint F QL(4 gm per fill

retail) BLEPH-10 SOLN (Use Sulfacetamide Sodium (Ophth))


CILOXAN OINT F QL(4 gm per fillretail)

CILOXAN SOLN (Use Ciprofloxacin HCl (Ophth)) NF QL(10 ml per

fill retail) ciprofloxacin hcl (ophth)soln F QL(10 ml per

fill retail)

erythromycin (ophth) oint F QL(4 gm per fillretail)

GENTAK OINT F QL(4 gm per fillretail)

gentamicin sulfate (ophth)oint F QL(4 gm per fill

retail) gentamicin sulfate (ophth)soln F QL(15 ml per

fill retail) moxifloxacin hcl (ophth)soln F QL(3 ml per fill

retail) neomycin-bacitracin zn-polymyxin oint F QL(4 gm per fill

retail) neomycin-polymyxin-gramicidin soln F QL(10 ml per

fill retail) NEOSPORIN SOLN (Use Neomycin-Polymyxin-Gramicidin)


OCUFLOX SOLN (Use Ofloxacin (Ophth)) NF QL(10 ml per

fill retail)

ofloxacin (ophth) soln F QL(10 ml perfill retail)

polymyxin b-trimethoprimsoln F QL(10 ml per

fill retail)

Drug Name DrugTier

Requirements/Limits

POLYTRIM SOLN (Use Polymyxin B-Trimethoprim) NF QL(10 ml per

fill retail) sulfacetamide sodium (ophth) soln F QL(15 ml per

fill retail) SULFACETAMIDE SODIUM OINT OP F QL(4 gm per fill

retail)

tobramycin (ophth) soln F QL(5 ml per fillretail)

TOBREX OINT F QL(4 gm per fillretail)

TOBREX SOLN (Use Tobramycin (Ophth)) NF QL(5 ml per fill

retail)

trifluridine soln F QL(8 ml per fillretail)

VIGAMOX SOLN (Use Moxifloxacin HCl (Ophth)) NF QL(3 ml per fill

retail) VIROPTIC SOLN (Use Trifluridine) NF QL(8 ml per fill

retail) Ophthalmic Decongestants phenylephrine hcl (ophth)soln 2.5 % F QL(30 ml per

fill retail) tetrahydrozoline hcl (ophth)soln F QL(1 ml daily)

VISINE EXTRA SOLN (Use Tetrahydrozoline HCl(Ophth))

NF QL(1 ml daily)

VISINE SOLN (Use Tetrahydrozoline HCl(Ophth))

NF QL(1 ml daily)

Ophthalmic Local Anesthetics

tetracaine hcl (ophth) soln F

Ophthalmic Steroids BLEPHAMIDE S.O.P. OINT F QL(4 gm per fill

retail)

BLEPHAMIDE SUSP F QL(10 ml perfill retail)

DEXAMETHASONE SODIUM PHOSPHATE SOLN OP 0.1 %


fluorometholone (ophth) susp F QL(15 ml per

fill retail) FML LIQUIFILM SUSP (Use Fluorometholone (Ophth))



106

Drug Name DrugTier

Requirements/Limits

FML OINT F QL(4 gm per fillretail)

MAXITROL OINT 10000UNIT/GM-3.5MG/GM-0.1% (Use Neomycin-Polymy-Dexameth)

NF

QL(4 gm per fillretail)

MAXITROL SUSP 10000UNIT/ML-3.5MG/ML-0.1% (Use Neomycin-Polymy-Dexameth)

NF


neomycin-polymy-dexameth oint 10000unit/gm-3.5mg/gm-0.1%

F

QL(4 gm per fillretail)

neomycin-polymy-dexameth susp10000unit/ml-3.5mg/ml-0.1%

F


NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP


OMNIPRED SUSP (Use Prednisolone Acetate (Ophth))


PRED FORTE SUSP (Use Prednisolone Acetate (Ophth))


PRED MILD SUSP F QL(10 ml perfill retail)

PRED-G SUSP F QL(0.167 mldaily,5 ml perfill retail)

prednisolone acetate(ophth) susp F QL(15 ml per

fill retail) PREDNISOLONE ACETATE P-F SUSP F QL(15 ml per

fill retail) PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 %


sulfacetamide sod-prednisolone soln F QL(10 ml per

fill retail)

TOBRADEX OINT F QL(4 gm per fillretail)

TOBRADEX SUSP (Use Tobramycin-Dexamethasone)


Drug Name DrugTier

Requirements/Limits

tobramycin-dexamethasone susp F QL(10 ml per

fill retail)

VEXOL SUSP F QL(10 ml perfill retail)

Ophthalmics - Misc. ACULAR LS SOLN (Use Ketorolac Tromethamine (Ophth))

NF

ACULAR SOLN (Use Ketorolac Tromethamine (Ophth))


ALOCRIL SOLN F QL(5 ml per fillretail)

ALOMIDE SOLN F QL(10 ml perfill retail)

azelastine hcl (ophth) soln F QL(6 ml per fillretail)

AZOPT SUSP F QL(15 ml perfill retail)

cromolyn sodium (ophth)soln F QL(10 ml per

fill retail) diclofenac sodium (ophth)soln F QL(5 ml per fill

retail) DORZOLAMIDE HCL SOLN F QL(10 ml per

fill retail)

dorzolamide hcl soln F QL(10 ml perfill retail)

flurbiprofen sodium soln F QL(3 ml per fillretail)

ketorolac tromethamine (ophth) soln 0.4 % F

ketorolac tromethamine (ophth) soln 0.5 % F QL(10 ml per

fill retail) ketotifen fumarate (ophth)soln F QL(240 ml per

fill retail) OCUFEN SOLN (Use Flurbiprofen Sodium) NF QL(3 ml per fill

retail) TRUSOPT SOLN (Use Dorzolamide HCl) NF QL(10 ml per

fill retail) ZADITOR SOLN (Use Ketotifen Fumarate (Ophth))


Prostaglandins - Ophthalmic

latanoprost soln F QL(3 ml per fillretail)


107

Drug Name DrugTier

Requirements/Limits

LATANOPROST SOLN F QL(3 ml per fillretail)

XALATAN SOLN (Use Latanoprost) NF QL(3 ml per fill

retail)

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln F QL(15 ml perfill retail)

carbamide peroxide (otic)soln F QL(15 ml per

fill retail) DEBROX SOLN (Use Carbamide Peroxide (Otic)) NF QL(15 ml per

fill retail) Otic Anti-infectives FLOXIN OTIC SOLN (Use Ofloxacin (Otic)) NF QL(10 ml per

fill retail)

ofloxacin (otic) soln F QL(10 ml perfill retail)

Otic Combinations neomycin-polymyxin-hc(otic) soln F QL(10 ml per

fill retail) neomycin-polymyxin-hc(otic) susp F QL(10 ml per

fill retail) Otic Steroids DERMOTIC OIL (Use Fluocinolone Acetonide (Otic))


fluocinolone acetonide (otic) oil F QL(20 ml per

fill retail) hydrocortisone w/aceticacid soln F QL(10 ml per

fill retail) OXYTOCICS - Drugs to Prevent/Control UterineBleeding

Oxytocics methylergonovine maleatetabs or 0.2 mg F

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem

Immune Serums

HYPERRHO S/D SOSY F SP

RHOGAM ULTRA-FILTERED PLUS SOSY F SP

Drug Name DrugTier

Requirements/Limits

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins amoxicillin caps 250 mg,500 mg F

AMOXICILLIN CHEW 125 MG, 250 MG F

amoxicillin susr 125 mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

F

amoxicillin tabs 875 mg F

ampicillin caps 250 mg,500 mg F

AMPICILLIN CAPS 500 MG F

AMPICILLIN SUSR 125 MG/5ML, 250 MG/5ML F

Natural Penicillins PENICILLIN V POTASSIUM SOLR 125 MG/5ML, 250 MG/5ML

F

penicillin v potassium solr125 mg/5ml, 250 mg/5ml F

penicillin v potassium tabs250 mg, 500 mg F

Penicillin Combinations amoxicillin & potclavulanate susr 200mg/5ml-28.5mg/5ml


amoxicillin & potclavulanate susr 250mg/5ml-62.5mg/5ml


amoxicillin & potclavulanate susr 400mg/5ml-57mg/5ml


amoxicillin & potclavulanate susr 600mg/5ml-42.9mg/5ml


amoxicillin & potclavulanate tabs 250mg-125mg


amoxicillin & potclavulanate tabs 500mg-125mg, 875mg-125mg



108

Drug Name DrugTier

Requirements/Limits

amoxicillin & potclavulanate tb12 1000mg-62.5mg

F

AMOXICILLIN/CLAVULANATE POTASSIUM CHEW F QL(20 ea per

fill retail) AUGMENTIN ES-600 SUSR (Use Amoxicillin & Pot Clavulanate)


AUGMENTIN SUSR 250MG/5ML-62.5MG/5ML(Use Amoxicillin & Pot Clavulanate)

NF


AUGMENTIN TABS 500MG-125MG, 875MG-125MG (Use Amoxicillin & Pot Clavulanate)

NF


AUGMENTIN XR TB12 (Use Amoxicillin & Pot Clavulanate)

NF

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps F

PROGESTINS - Hormone Replacement/ModifyingDrugs

Progestins AYGESTIN TABS (Use Norethindrone Acetate) NF

MAKENA SOAJ SC 275 MG/1.1ML F

medroxyprogesteroneacetate tabs F MP

norethindrone acetate tabs F

progesterone micronizedcaps 100 mg F QL(1 ea daily)

progesterone micronizedcaps 200 mg F

PROMETRIUM CAPS 100 MG (Use ProgesteroneMicronized)

NF QL(1 ea daily)

PROMETRIUM CAPS 200 MG (Use ProgesteroneMicronized)

NF

PROVERA TABS (Use MedroxyprogesteroneAcetate)

NF MP

Drug Name DrugTier

Requirements/Limits

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency

acamprosate calcium tbec F

ANTABUSE TABS (Use Disulfiram) NF

disulfiram tabs F

Antidementia Agents ARICEPT TABS 5 MG, 10 MG (Use DonepezilHydrochloride)

NF QL(1 ea daily)

donepezil hydrochloridetabs 5 mg, 10 mg F QL(1 ea daily)

EXELON CAPS OR 3 MG, 6 MG, 1.5 MG, 4.5 MG (Use Rivastigmine Tartrate)


EXELON PT24 TD 4.6 MG/24HR, 9.5 MG/24HR(Use Rivastigmine)


galantamine hydrobromidecp24 8 mg, 16 mg, 24 mg F QL(1 ea daily)

GALANTAMINE HYDROBROMIDE SOLN 4 MG/ML

F QL(6 ml daily)

galantamine hydrobromidetabs 4 mg, 8 mg, 12 mg F QL(2 ea daily)

memantine hcl tabs F QL(49 ea perfill retail)

memantine hcl tabs 5 mg,10 mg F QL(2 ea daily)

NAMENDA TABS 5 MG, 10 MG (Use Memantine HCl) NF QL(2 ea daily)

NAMENDA TITRATION PAK TABS (Use Memantine HCl)


RAZADYNE ER CP24 (Use Galantamine Hydrobromide)

NF QL(1 ea daily)

RAZADYNE TABS (Use Galantamine Hydrobromide)

NF QL(2 ea daily)

rivastigmine pt24 4.6mg/24hr, 9.5 mg/24hr F PA; QL(1 ea

daily)


109

Drug Name DrugTier

Requirements/Limits

rivastigmine tartrate caps F PA; QL(2 eadaily)

Combination Psychotherapeutics PERPHENAZINE/AMITRIPTYLINE TABS F QL(4 ea daily)

Fibromyalgia Agents

SAVELLA TABS F PA; QL(2 eadaily)

SAVELLA TITRATION PACK MISC F PA

Multiple Sclerosis Agents

AVONEX KIT F PA; SP

AVONEX PEN AJKT F PA; SP

AVONEX PSKT F PA; SP

COPAXONE SOSY (Use Glatiramer Acetate) NF PA; SP

GILENYA CAPS F PA; SP

glatiramer acetate sosy F PA; SP

PLEGRIDY SOPN F PA; SP

PLEGRIDY SOSY F PA; SP

PLEGRIDY STARTER PACK SOPN F PA; SP

PLEGRIDY STARTER PACK SOSY F PA; SP

TECFIDERA CPDR F PA; SP

TECFIDERA STARTER PACK MISC F PA; SP

Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATES TABS F

Smoking Deterrents bupropion hcl (smokingdeterrent) tb12 F QL(2 ea daily)

CHANTIX CONTINUING MONTHPAK TABS F QL(2 ea daily)

CHANTIX STARTING MONTH PAK TABS F QL(53 ea per

fill retail)

Drug Name DrugTier

Requirements/Limits

CHANTIX TABS F QL(2 ea daily)

NICODERM CQ PT24 14 MG/24HR, 21 MG/24HR(Use Nicotine)

NF QL(1 ea daily)

NICODERM CQ PT24 7 MG/24HR (Use Nicotine) NF

NICORETTE GUM 2 MG, 4 MG (Use Nicotine Polacrilex)

NF QL(24 ea daily)

NICORETTE LOZG 2 MG, 4 MG (Use Nicotine Polacrilex)

NF QL(20 ea daily)

NICORETTE MINI LOZG (Use Nicotine Polacrilex) NF QL(20 ea daily)

NICORETTE STARTER KIT GUM (Use Nicotine Polacrilex)

NF QL(24 ea daily)

nicotine polacrilex gum 2mg, 4 mg F QL(24 ea daily)

nicotine polacrilex lozg 2mg, 4 mg F QL(20 ea daily)

nicotine pt24 14 mg/24hr,21 mg/24hr F QL(1 ea daily)

nicotine pt24 7 mg/24hr F

NICOTINE TRANSDERMAL SYSTEM KIT


NICOTROL INHALER INHA F

QL(504 ea perfill retail,504 ea per 30 daysretail)

NICOTROL NS SOLN F

QL(120 ml perfill retail,120 ml per 30 daysretail)

ZYBAN TB12 (Use Bupropion HCl (SmokingDeterrent))

NF QL(2 ea daily)

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung Conditions

Cystic Fibrosis Agents

KALYDECO PACK F PA; SP

KALYDECO TABS F PA; SP


110

Drug Name DrugTier

Requirements/Limits

ORKAMBI TABS 200MG-125MG F PA; SP

TETRACYCLINES - Drugs to Treat BacterialInfections

Tetracyclines ADOXA PAK 1/100 TABS(Use Doxycycline(Monohydrate))

NF

ADOXA PAK 2/100 TABS(Use Doxycycline(Monohydrate))

NF

ADOXA TABS 50 MG, 100 MG (Use Doxycycline(Monohydrate))

NF

doxycycline (monohydrate)caps 50 mg, 100 mg F

doxycycline (monohydrate)tabs 50 mg, 100 mg F

doxycycline hyclate caps or50 mg, 100 mg F

doxycycline hyclate tabs or100 mg F

MINOCIN CAPS OR 50 MG, 75 MG, 100 MG (Use Minocycline HCl)

NF

minocycline hcl caps 50mg, 75 mg, 100 mg F

MONODOX CAPS 100 MG (Use Doxycycline(Monohydrate))

NF

VIBRAMYCIN CAPS 100 MG (Use DoxycyclineHyclate)

NF

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Antithyroid Agents

methimazole tabs F MP

propylthiouracil tabs F MP

TAPAZOLE TABS (Use Methimazole) NF MP

Thyroid Hormones

Drug Name DrugTier

Requirements/Limits

ARMOUR THYROID TABS 15 MG, 30 MG, 60 MG, 90 MG, 120 MG (Use Thyroid)

F

ARMOUR THYROID TABS 180 MG, 240 MG, 300 MG F

CYTOMEL TABS (Use Liothyronine Sodium) NF MP

levothyroxine sodium tabsor 25 mcg, 50 mcg, 75mcg, 88 mcg, 100 mcg,112 mcg, 125 mcg, 137mcg, 150 mcg, 175 mcg,200 mcg, 300 mcg

F

MP

liothyronine sodium tabs or5 mcg, 25 mcg, 50 mcg F MP

SYNTHROID TABS (Use Levothyroxine Sodium) F MP

thyroid tabs F

THYROLAR-1 TABS F

THYROLAR-1/2 TABS F

THYROLAR-1/4 TABS F

THYROLAR-2 TABS F

THYROLAR-3 TABS F

TOXOIDS

Toxoid Combinations

ADACEL SUSP F AL; At least 19 yrs old

BOOSTRIX SUSP F AL; At least 19 yrs old

DIPHTHERIA/TETANUSTOXOIDS ADSORBED PEDIATRIC SUSP


INFANRIX SUSP F AL; At least 19 yrs old

TENIVAC INJ F AL; At least 19 yrs old

TETANUS/DIPHTHERIATOXOIDS-ADSORBED SUSP



111

Drug Name DrugTier

Requirements/Limits

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach Conditions

Antispasmodics ANASPAZ TBDP (Use Hyoscyamine Sulfate) NF

BENTYL CAPS OR 10 MG (Use Dicyclomine HCl) NF

BENTYL TABS OR 20 MG (Use Dicyclomine HCl) NF

dicyclomine hcl caps or 10 mg F

dicyclomine hcl soln or 10mg/5ml F QL(40 ml daily)

dicyclomine hcl tabs or 20 mg F

glycopyrrolate tabs or 1mg, 2 mg F QL(4 ea daily)

hyoscyamine sulfate elix or0.125 mg/5ml F

hyoscyamine sulfate solnor 0.125 mg/ml F

hyoscyamine sulfate subl sl0.125 mg F

hyoscyamine sulfate tabsor 0.125 mg F

hyoscyamine sulfate tb12or 0.375 mg F QL(4 ea daily)

hyoscyamine sulfate tbdpor 0.125 mg F

LEVBID TB12 (Use Hyoscyamine Sulfate) NF QL(4 ea daily)

LEVSIN TABS OR 0.125 MG (Use HyoscyamineSulfate)

NF

LEVSIN/SL SUBL (Use Hyoscyamine Sulfate) NF

ROBINUL FORTE TABS (Use Glycopyrrolate) NF QL(4 ea daily)

ROBINUL TABS OR 1 MG (Use Glycopyrrolate) NF QL(4 ea daily)

H-2 Antagonists

CIMETIDINE HCL SOLN F QL(27 ml daily)

cimetidine tabs 200 mg F RX/OTC

Drug Name DrugTier

Requirements/Limits

cimetidine tabs 300 mg,400 mg, 800 mg F

famotidine susr or 40 mg/5ml F

famotidine tabs or 10 mg,40 mg F

famotidine tabs or 20 mg F RX/OTC

PEPCID AC MAXIMUM STRENGTH TABS (Use Famotidine)

NF RX/OTC

PEPCID AC TABS (Use Famotidine) NF

PEPCID SUSR 40 MG/5ML(Use Famotidine) NF

PEPCID TABS 20 MG (Use Famotidine) NF RX/OTC

PEPCID TABS 40 MG (Use Famotidine) NF

ranitidine hcl caps or 150 mg F QL(2 ea daily)

ranitidine hcl caps or 300 mg F QL(1 ea daily)

ranitidine hcl syrp or 15mg/ml, 75 mg/5ml, 150mg/10ml

F QL(40 ml daily)

ranitidine hcl tabs or 150 mg F QL(2 ea daily);

RX/OTC ranitidine hcl tabs or 75 mg,300 mg F QL(2 ea daily)

TAGAMET HB TABS (Use Cimetidine) NF RX/OTC

ZANTAC 150 MAXIMUM STRENGTH TABS (Use Ranitidine HCl)


ZANTAC 75 TABS (Use Ranitidine HCl) NF QL(2 ea daily)

ZANTAC TABS OR 150 MG (Use Ranitidine HCl) NF QL(2 ea daily);

RX/OTC ZANTAC TABS OR 300 MG (Use Ranitidine HCl) NF QL(2 ea daily)

Misc. Anti-Ulcer CARAFATE SUSP 1 GM/10ML F QL(420 ml per

fill retail) CARAFATE TABS 1 GM (Use Sucralfate) NF QL(4 ea daily)


112

Drug Name DrugTier

Requirements/Limits

sucralfate tabs F QL(4 ea daily)

Proton Pump Inhibitors

DEXILANT CPDR F ST

esomeprazole magnesiumcpdr 20 mg F QL(2 ea daily);

RX/OTC

lansoprazole cpdr 15 mg F QL(2 ea daily);RX/OTC

lansoprazole cpdr 30 mg F QL(2 ea daily)

NEXIUM 24HR CLEAR MINIS CPDR (Use Esomeprazole Magnesium)


NEXIUM 24HR CPDR (Use Esomeprazole Magnesium) NF QL(2 ea daily);

RX/OTC NEXIUM CPDR 20 MG (Use EsomeprazoleMagnesium)


omeprazole cpdr 10 mg, 40 mg F QL(2 ea daily)

omeprazole cpdr 20 mg F QL(2 ea daily);RX/OTC

pantoprazole sodium tbecor 20 mg F QL(1 ea daily)

pantoprazole sodium tbecor 40 mg F QL(2 ea daily)

PREVACID 24HR CPDR (Use Lansoprazole) NF QL(2 ea daily);

RX/OTC PREVACID CPDR 15 MG (Use Lansoprazole) NF QL(2 ea daily);

RX/OTC PREVACID CPDR 30 MG (Use Lansoprazole) NF QL(2 ea daily)

PRILOSEC CPDR 10 MG, 40 MG (Use Omeprazole) NF QL(2 ea daily)

PRILOSEC CPDR 20 MG (Use Omeprazole) NF QL(2 ea daily);

RX/OTC

PRILOSEC OTC TBEC F QL(1 ea daily)

PROTONIX TBEC OR 20 MG (Use PantoprazoleSodium)

NF QL(1 ea daily)

PROTONIX TBEC OR 40 MG (Use PantoprazoleSodium)

NF QL(2 ea daily)

Ulcer Drugs - Prostaglandins

Drug Name DrugTier

Requirements/Limits

CYTOTEC TABS (Use Misoprostol) NF

misoprostol tabs F

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney Infections

Urinary Anti-infective Combinations methenamine-hyosc-methylene blue-sod phos-phenyl sal tabs 40.8mg-0.12mg-36.2mg-81.6mg-10.8mg, 40.8mg-36.2mg-0.12mg-81.6mg-10.8mg

F

Urinary Anti-infectives FURADANTIN SUSP (Use Nitrofurantoin) NF QL(40 ml daily)

MACROBID CAPS (Use Nitrofurantoin MonohydMacro)

NF

MACRODANTIN CAPS 50 MG, 100 MG (Use Nitrofurantoin Macrocrystal)

NF

METHENAMINE MANDELATE TABS 0.5 GM

F

methenamine mandelate tabs 1 gm F

nitrofurantoin macrocrystalcaps 50 mg, 100 mg F

nitrofurantoin monohyd macro caps F

nitrofurantoin susp F QL(40 ml daily)

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodic - Antimuscarinics DETROL LA CP24 (Use Tolterodine Tartrate) NF QL(1 ea daily)

DETROL TABS (Use Tolterodine Tartrate) NF QL(2 ea daily)

DITROPAN XL TB24 (Use Oxybutynin Chloride) NF QL(2 ea daily);

MP

oxybutynin chloride syrp 5mg/5ml F

QL(16 mldaily,90 day(s)limit); MP


113

Drug Name DrugTier

Requirements/Limits

oxybutynin chloride tabs 5 mg F QL(3 ea daily);

MP oxybutynin chloride tb24 5mg, 10 mg, 15 mg F QL(2 ea daily);

MP tolterodine tartrate cp24 2mg, 4 mg F QL(1 ea daily)

tolterodine tartrate tabs 1 mg, 2 mg F QL(2 ea daily)

trospium chloride tabs 20 mg F QL(2 ea daily)

Urinary Antispasmodics - Cholinergic Agonists

bethanechol chloride tabs F MP

URECHOLINE TABS (Use Bethanechol Chloride) NF MP

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl tabs F

VACCINES

Bacterial Vaccines

BEXSERO SUSY F AL; At least 19 yrs old

MENACTRA INJ F AL; At least 19 yrs old

MENOMUNE-A/C/Y/W-135INJ F AL; At least 19

yrs old

MENVEO SOLR F AL; At least 19 yrs old

PNEUMOVAX 23 INJ F AL; At least 19 yrs old

PNEUMOVAX 23/1 DOSEINJ F AL; At least 19

yrs old

PREVNAR 13 SUSP F AL; At least 19 yrs old

TRUMENBA SUSY F AL; At least 19 yrs old

Viral Vaccines

AFLURIA PF 2016-2017 SUSY F

Limit 1 every 6months;1 rtl pack lmtamt,180 rtl pack lmtday(s),; AL; Atleast 13 yrs old

Drug Name DrugTier

Requirements/Limits





AFLURIA QUADRIVALENT 2016-2017 SUSY F

limit 0.5 per180 days;1 rtlpack lmtamt,180 rtl pack lmtday(s),; AL; Atleast 13 yrs old

AFLURIA QUADRIVALENT 2017-2018 SUSP F AL; At least 13

yrs old



AFLURIA QUADRIVALENT 2018-2019 SUSP F AL; At least 13

yrs old



CERVARIX SUSP F AL; At least 19 yrs old

ENGERIX-B INJ F AL; At least 19 yrs old

ENGERIX-B SUSP F AL; At least 19 yrs old


114

Drug Name DrugTier

Requirements/Limits

FLUARIX QUADRIVALENT 2016-2017 SUSY F






FLUBLOK 2015-2016 SOLN F AL; At least 13

yrs old FLUBLOK 2016-2017 SOLN F AL; At least 13

yrs old FLUBLOK 2017-2018 SOLN F AL; At least 13

yrs old

FLUCELVAX 2015-2016 SUSY F


FLUCELVAX QUADRIVALENT 2017-2018 SUSP


FLULAVAL QUADRIVALENT 2014-2015 SUSY

F


FLULAVAL QUADRIVALENT 2016-2017 SUSP


Drug Name DrugTier

Requirements/Limits


F





F





F


FLUMIST QUADRIVALENT SUSP F AL; At least 13

yrs old FLUVIRIN 2015-2016 SUSP F AL; At least 13

yrs old

FLUVIRIN 2015-2016 SUSY F


FLUVIRIN 2016-2017 SUSP F AL; At least 13

yrs old



FLUVIRIN 2017-2018 SUSP F AL; At least 13

yrs old


115

Drug Name DrugTier

Requirements/Limits



FLUZONE HIGH-DOSE PF 2016-2017 SUSY F






FLUZONE INTRADERMAL QUADRIVALENT 2016-2017 SUPN


FLUZONE INTRADERMAL QUADRIVALENT 2017-2018 SUPN


FLUZONE QUADRIVALENT 2016-2017 SUSP

F




Drug Name DrugTier

Requirements/Limits

FLUZONE QUADRIVALENT 2016-2017 SUSY

F

Limit 0.25 per180 days;1 rtlpack lmtamt,180 rtl pack lmtday(s),; AL; Atleast 13 yrs old


F





F



F



F





F



116

Drug Name DrugTier

Requirements/Limits


F



F


GARDASIL 9 SUSP F AL; At least 19 yrs old

GARDASIL 9 SUSY F AL; At least 19 yrs old

GARDASIL SUSP F AL; At least 19 yrs old

HAVRIX SUSP F AL; At least 19 yrs old

M-M-R II INJ F AL; At least 19 yrs old

MEDICAL PROVIDER EZ FLU SHOT 2015-2016 PSKT

F


MEDICAL PROVIDER EZ FLU SHOT PF 2014-2015 PSKT

F


MEDICAL PROVIDER SINGLE USE EZ FLU SHOT PSKT

F


Drug Name DrugTier

Requirements/Limits

MEDICAL PROVIDER SINGLE USE EZ FLU SHOT PSKT

F


RECOMBIVAX HB SUSP F AL; At least 19 yrs old

VAQTA SUSP F AL; At least 19 yrs old

VARIVAX INJ F AL; At least 19 yrs old

ZOSTAVAX SUSR F AL; At least 19 yrs old

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low Hormones

Vaginal Anti-infectives CLEOCIN CREA VA 2 % (Use ClindamycinPhosphate Vaginal)


clindamycin phosphatevaginal crea F QL(40 gm per

fill retail) clotrimazole vaginal crea 1% F QL(45 gm per

fill retail) clotrimazole vaginal crea 2% F QL(30 gm per

fill retail)

GYNAZOLE-1 CREA F

GYNE-LOTRIMIN 3 CREA (Use Clotrimazole Vaginal) NF QL(30 gm per

fill retail) GYNE-LOTRIMIN CREA (Use Clotrimazole Vaginal) NF QL(45 gm per

fill retail) METROGEL-VAGINAL GEL (Use Metronidazole Vaginal)


metronidazole vaginal gel F QL(70 gm perfill retail)

MICONAZOLE 3 SUPP F QL(3 ea per fillretail)

miconazole nitrate vaginalcrea 2 %, 4 % F QL(45 gm per

fill retail) miconazole nitrate vaginalkit F QL(24 gm per

fill retail) miconazole nitrate vaginalsupp 100 mg F QL(7 ea per fill

retail)


117

Drug Name DrugTier

Requirements/Limits

MONISTAT 3 COMBINATION PACK KIT (Use Miconazole Nitrate Vaginal)

NF

QL(24 gm perfill retail)

MONISTAT 3 CREA (Use Miconazole Nitrate Vaginal) NF QL(45 gm per

fill retail) MONISTAT 7 SIMPLY CURE CREA (Use Miconazole Nitrate Vaginal)


TERAZOL 3 CREA (Use Terconazole Vaginal) NF QL(20 gm per

fill retail) TERAZOL 7 CREA (Use Terconazole Vaginal) NF QL(45 gm per

fill retail)

TERCONAZOLE CREA F QL(20 gm perfill retail)

terconazole vaginal crea0.4 % F QL(45 gm per

fill retail) terconazole vaginal crea0.8 % F QL(20 gm per

fill retail) terconazole vaginal supp80 mg F QL(3 ea per fill

retail)

tioconazole vaginal oint F QL(5 gm per fillretail)

VAGISTAT-1 OINT (Use Tioconazole Vaginal) NF QL(5 gm per fill

retail) Vaginal Estrogens ESTRACE CREA VA 0.1 MG/GM (Use Estradiol Vaginal)

NF

estradiol vaginal crea 0.1mg/gm F

PREMARIN CREA VA 0.625 MG/GM F

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions

Anaphylaxis Therapy Agents

ADRENACLICK SOAJ F

epinephrine (anaphylaxis)soaj F

Vasopressors

midodrine hcl tabs F

VITAMINS

Drug Name DrugTier

Requirements/Limits

Oil Soluble Vitamins DRISDOL CAPS (Use Ergocalciferol) NF

ergocalciferol caps F

MEPHYTON TABS (Use Phytonadione) NF

phytonadione tabs F

Water Soluble Vitamins

niacin cpcr F


118

Index 1ST CHOICE LANCETS SUPERTHIN 58 1ST CHOICE LANCETS THIN

58 1ST CHOICE LANCETS ULTRATHIN 58 1ST TIER UNIFINE PENTIPS29GX12MM 66 1ST TIER UNIFINE PENTIPSPLUS/ORIGINAL/29GX12MM 66 1ST TIER UNILET COMFORTOUCH LANCETS 28G 58 1ST TIER UNILET COMFORTOUCH LANCETS 30G 58 abacavir sulfate 28 abacavir sulfate-lamivudine 28 abacavir sulfate-lamivudine-zidovudine 28 ABILIFY 28 ABSORICA 38 acamprosate calcium 109 ACCUPRIL 22 ACCURETIC 22,23 ACE AEROSOL CLOUD ENHANCER 89 acebutolol hcl 31 acetaminophen 4 acetaminophen w/ codeine 5 acetazolamide 45 acetic acid (otic) 108 acetylcysteine 38 ACNE MEDICATION 10 38 ACNE MEDICATION 5 38 ACTIGALL 48 ACTIVELLA 47 ACTIVITY POUCH 89 ACTONEL 46 ACTOPLUS MET 16 ACTOS 17 ACULAR 107 ACULAR LS 107 acyclovir 30 acyclovir topical 40 ADACEL 111 ADALAT CC 32 ADAPTER PED DISPOSABLE MOUTHPIECE 89 ADDERALL 1

ADDERALL XR 1 ADJUSTABLE LANCING DEVICE 58 ADMELOG 17 ADMELOG SOLOSTAR 17 ADOXA 111 ADOXA PAK 1/100 111 ADOXA PAK 2/100 111 ADRENACLICK 118 ADULT AEROSOL MASK 89 ADULT DISPOSABLE MOUTHPIECE 89 ADULT MASK 89 ADULT MASK LARGE 89 ADVANCED DIABETIC MULTIVITAMIN FORMULA 96 ADVANCED MOBILE LANCET 30G 58 ADVIL 2 ADVIL COLD & SINUS 36 ADVOCATE INSULIN SYRINGE/U-100/0.3ML/29GX1/2" 66 ADVOCATE INSULIN SYRINGE/U-100/0.3ML/30GX5/16" 66 ADVOCATE INSULIN SYRINGE/U-100/0.3ML/31GX5/16" 66 ADVOCATE INSULIN SYRINGE/U-100/0.5ML/29GX1/2" 67 ADVOCATE INSULIN SYRINGE/U-100/0.5ML/30GX5/16" 67 ADVOCATE INSULIN SYRINGE/U-100/0.5ML/31GX5/16" 67 ADVOCATE INSULIN SYRINGE/U-100/1ML/29GX1/2" 67 ADVOCATE INSULIN SYRINGE/U-100/1ML/30GX5/16" 67 ADVOCATE INSULIN SYRINGE/U-100/1ML/31GX5/16" 67 ADVOCATE LANCING DEVICE 58 ADVOCATE RAPID-SAFE LANCING DEVICE 58 AEROCHAMBER MINI AEROSOLCHAMBER 89 AEROCHAMBER MV 89

AEROCHAMBER PLUS FLOW VU 89 AEROCHAMBER PLUS FLOW-VU 89 AEROCHAMBER PLUS FLOW-VU/LARGE MASK 89 AEROCHAMBER PLUS FLOW-VU/MASK 89 AEROCHAMBER PLUS FLOW-VU/MEDIUM MASK 89 AEROCHAMBER PLUS FLOW-VU/SMALL MASK 89 AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VU 89 AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL 89 AEROCHAMBER Z-STAT PLUS/LARGE MASK 89 AEROCHAMBER Z-STAT PLUS/MEDIUM MASK 89 AEROCHAMBER Z-STAT PLUS/SMALL MASK 89 AEROCHAMBER/FLOWSIGNAL

89 AEROSPAN 9 AEROTRACH PLUS 89 AEROVENT PLUS HOLDING CHAMBER/COLLAPSIBLE 89 AFLURIA PF 2016-2017 114 AFLURIA PF 2017-2018 114 AFLURIA PF 2018-2019 114 AFLURIA QUADRIVALENT 2016-2017 114 AFLURIA QUADRIVALENT 2017-2018 114 AFLURIA QUADRIVALENT 2018-2019 114 AGAMATRIX ULTRA-THIN LANCETS 33G 58 AIMSCO LUBRICATED 56 AIRS PEDIATRIC AEROSOL MASK 89 albuterol sulfate 9,10 ALBUTEROL SULFATE ER 9 ALCOHOL PREP PADS 66 ALCOHOL PREPS 66 ALCOHOL SWABS 66 ALCOHOL WIPES 66 ALDACTAZIDE 45 ALDACTONE 46 ALDARA 42 ALENDRONATE SODIUM 46 alendronate sodium 46

Index 1

ALENDRONATE SODIUM 46 amlodipine besylate-olmesartan artificial tear ointment 105 medoxomil 23alendronate sodium 46 aspirin 4amlodipine besylate-

ALEVE 2 ASPIRIN 4valsartan 23 ALEVE ARTHRITIS 2 ALIVE ENERGY 50+ 96 ALIVE MENS ENERGY 96 ALIVE ONCE DAILY WOMENS 50+ ULTRA POTENCY 96 ALIVE ONCE DAILY WOMENS ULTRA POTENCY 96 ALIVE WOMENS 50+ 96 ALIVE WOMENS ENERGY 96 ALKERAN 25 ALL FLOW 1000 PULMONARY FUNCTION FILTER 89 ALLEGRA ALLERGY 20 ALLEVYN PLUS CAVITY 52 ALLEVYN THIN 52 allopurinol 49 ALOCRIL 107 alogliptin benzoate 17 alogliptin-metformin hcl 16 alogliptin-pioglitazone 16 ALOMIDE 107 ALORA 47 alprazolam 8 ALTACE 22 ALTERNATE SITE LANCING DEVICE 58 alum & mag hydrox-simethicone 6,7

amlodipine-valsartan-hydrochlorothiazide 23 AMOXAPINE 15 amoxicillin 108 AMOXICILLIN 108 amoxicillin 108 amoxicillin & potclavulanate 108,109 AMOXICILLIN/CLAVULANATEPOTASSIUM 109 amphetamine-dextroamphetamine 1 ampicillin 108 AMPICILLIN 108 ANAFRANIL 15 ANALPRAM-HC 6 ANAPROX DS 2 ANASPAZ 112 anastrozole 25 ANDRODERM 6 ANDROXY 6 ANTABUSE 109 ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 67 ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 67 ANTI-STICK INSULIN

aspirin 4 aspirin buffered (cal carb-magcarb-mag oxide) 4 ASSURE ID INSULIN SAFETYSYRINGE/U-100/0.5ML/29G X 1/2" 67 ASSURE ID INSULIN SAFETYSYRINGE/U-100/1ML/29G X 1/2" 67 ASSURE ID SAFETY PEN NEEDLES 30G X 5/16" 67 ASTEPRO 104 ATACAND 22 ATACAND HCT 23 atazanavir sulfate 28 atenolol 31 atenolol & chlorthalidone 23 ATIVAN 8 ATLAS COLORED CONDOM/SPERMICIDE 56 ATLAS COLORED LUBRICATEDCONDOM 56 ATLAS LUBRICATED CONDOM 56 ATLAS LUBRICATED CONDOM/SPERMICIDE 56 atomoxetine hcl 1 atorvastatin calcium 21 ATRIPLA 28 ATROPINE SULFATE 105

ALUMINUM HYDROXIDE 7 amantadine hcl 26 AMARYL 17,18 AMBIEN 50 AMD FOAM DRESSING 4"X4" 52 AMD FOAM DRESSING/TOPSHEET4"X4" 52 AMERGE 93 AMICAR 49 amiloride & hydrochlorothiazide 45 amiloride hcl 46 amiodarone hcl 9

SYRINGE/U-100/1ML/29G X1/2" 67 ANTIOXIDANT FORTE 96 ANUSOL-HC 6 AP-ZEL 96 APEXICON E 41 apraclonidine hcl 106 APTIVUS 28 AQUA LANCE ADJUSTABLE LANCING DEVICE 58 ARAVA 3 ARIAL CHAMBER 89 ARICEPT 109 ARIMIDEX 25

ATROVENT HFA 9 AUGMENTIN 109 AUGMENTIN ES-600 109 AUGMENTIN XR 109 AURORA LANCET SUPER THIN30G 58 AURORA LANCET THIN 23G 59 AURORA PEN NEEDLES 29GX12MM 67 AUTO-LANCET 59 AUTO-LANCET MINI 59 AUTOLET IMPRESSION LANCING DEVICE 59 AUTOLET LANCING

amitriptyline hcl 15 amlodipine besylate 32 amlodipine besylate-benazeprilhcl 23

aripiprazole ARMOUR THYROID AROMASIN ARTHRITIS PAIN

28 111

25

DEVICE AUTOLET MINI AUTOLET PLUS AVALIDE

59 59 59 23

RELIEVING 43

Index 2

AVANDIA 17 BASAGLAR KWIKPEN 17 BD INSULIN SYRINGE ULTRAFINEAVAPRO 22 BASIC AM 96 II/SHORT/0.5ML/31G XAVONEX 110 BASIC PM 96 5/16" 68

AVONEX PEN 110 BAYER MICROLET 2 BD INSULIN SYRINGE AYGESTIN 109 LANCING DEVICE 59 ULTRAFINE II/SHORT/1ML/31G

BD LO-DOSE INSULIN X 5/16" 68AZASAN 94 SYRINGE MICROFINE BD INSULIN SYRINGE azathioprine 94 IV/0.5ML/28G X 1/2" 67 ULTRAFINE/0.3ML/30G Xazelastine hcl 104 BD AUTOSHIELD 29G X 1/2" 68

5/16" 67 BD INSULIN SYRINGEazelastine hcl (ophth) 107 BD GLUCOSE 16 ULTRAFINE/0.3ML/31G Xazithromycin 51 BD INSULIN SYRINGE LUER- 5/16" 68 AZOPT 107 LOK/U-100/1ML 67 BD INSULIN SYRINGE AZOR 23 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X

MICROFINE IV/U- 1/2" 68AZULFIDINE 48 100/0.3ML/28G X 1/2" 67 BD INSULIN SYRINGEAZULFIDINE EN-TABS 48 BD INSULIN SYRINGE ULTRAFINE/0.5ML/31G Xb-complex w/ c & folic acid 96 MICROFINE IV/U- 5/16" 68 B-D INSULIN SYRINGE 100/0.5ML/28G X 1/2" 67 BD INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X BD INSULIN SYRINGE ULTRAFINE/1ML/30G X5/16" 67 MICROFINE IV/U- 1/2" 68 B-D INSULIN SYRINGE 100/1ML/27G X 5/8" 67 BD INSULIN SYRINGE ULTRAFINE II/0.5ML/31G X BD INSULIN SYRINGE ULTRAFINE/1ML/31G X5/16" 67 MICROFINE IV/U- 5/16" 68 B-D INSULIN SYRINGE 100/1ML/28G X 1/2" 67 BD INSULIN SYRINGE ULTRAFINE II/1ML/31G X BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/29G X5/16" 67 MICROFINE/U-100/0.3ML/28G 1/2" 68 B-D INSULIN SYRINGE X 1/2" 67 BD INSULIN SYRINGE ULTRAFINE/0.3ML/30G X BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/30G X1/2" 67 MICROFINE/U-100/0.5ML/28G 1/2" 68 B-D INSULIN SYRINGE X 1/2" 67 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/31G X1/2" 67 MICROFINE/U-100/1ML/27G X 5/16" 68 BACIGUENT 39 5/8" 67 BD INSULIN SYRINGE

BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/29G XBACITRACIN 106 MICROFINE/U-100/1ML/28G X 1/2" 68bacitracin (topical) 39 1/2" 67 BD INSULIN SYRINGE bacitracin zinc 39 BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/30G Xbacitracin-polymyxin b SAFETYGLIDE/0.5ML/29G X 1/2" 68 (ophth) 106 1/2" 68 BD INSULIN SYRINGE

BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/31G Xbaclofen 104 SAFETYGLIDE/1ML/29G X 5/16" 68BACMIN 96 1/2" 68 BD INSULIN SYRINGE BACTRIM 7 BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/29G XBACTRIM DS 7 SAFETYGLIDE/U- 1/2" 68

100/0.3ML/31G X 5/16" 68 BD INSULIN SYRINGEBACTROBAN 39 BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/30G XBACTROBAN NASAL 104 SAFETYGLIDE/U- 1/2" 68 balsalazide disodium 48 100/1ML/31G X 15/64" 68 BD INSULIN SYRINGE BAND-AID GAUZE PADS BD INSULIN SYRINGE SLIP ULTRAFINE/U-100/1ML/31G XLARGE4" X 4" 52 TIP/U-100/1ML 68 15/64" 68 BAND-AID GAUZE PADS BD INSULIN SYRINGE U- BD INSULIN SYRINGE MEDIUM 3" X 3" 52 100/0.3ML/29G X 1/2" 68 ULTRAFINE/U-100/1ML/31G XBAND-AID GAUZE PADS BD INSULIN SYRINGE U- 5/16" 68 SMALL2" X 2" 52 100/1ML/29G X 1/2" 68 BD INSULIN BAND-AID MIRASORB GAUZE BD INSULIN SYRINGE SYRINGE/DETACHABLESPONGES LARGE 4" X 4" 52 ULTRAFINE HALF- NEEDLE/U-100/1ML/25G X

UNIT/0.3ML/31G X 5/16" 68 1" 68

Index 3

BD INSULIN benztropine mesylate 26 BREATHERITE W/LARGESYRINGE/DETACHABLE MASK 89BETAGAN 105NEEDLE/U-100/1ML/25G X BREATHERITE W/MEDIUMbetamethasone dipropionate5/8" 69 MASK 89(topical) 41BD INSULIN BREATHERITE W/SMALLbetamethasone dipropionateSYRINGE/DETACHABLE MASK 89augmented 41NEEDLE/U-100/1ML/26G X BREO ELLIPTA 10betamethasone valerate 411/2" 69 BREVICON-28 33BD INSULIN SYRINGE/U- BETAPACE 31

BRILINTA 49100/0.5ML/30G X 1/2" 69 BETAPACE AF 31 BD INSULIN SYRINGE/U- brimonidine tartrate 106betaxolol hcl (ophth) 105100/1ML/27G X 1/2" 69 bromocriptine mesylate 26 BD INSULIN SYRINGE/U- bethanechol chloride 114 brompheniramine &100/1ML/28G X 1/2" 69 BETOPTIC-S 105 phenyleph 36BD INSULIN SYRINGE/U- BEVYXXA 10 brompheniramine &100/2ML/27.5G X 5/8" 69 pseudoeph 36BEXSERO 114BD INTEGRA INSULIN BROTAPP DM 36SYRINGE/U-100/1ML/29G X BIATAIN ADHESIVE FOAM 1/2" 69 DRESSING 4"X4" 52 BUBBLES THE FISH II

BIATAIN FOAM DRESSING PEDIATRIC MASK/PVC 89BD INTEGRA 4"X4" 52 budesonide (inhalation) 9SYRINGE/RETRACTING

NEEDLE/1ML/25G X 1" 69 BIAXIN 52 BUFFERIN 4 BD LANCET DEVICE 59 bicalutamide 25 bumetanide 45 BD LANCET ULTRAFINE BIOGUARD GAUZE SPONGE BUMEX 4530G 59 2"X2" 8 PLY 53 BUNAVAIL 6BD SAFETY-GLIDE INSULIN BIOGUARD GAUZE SYRINGE/0.5ML/29G X 1/2" 69 SPONGES 4"X4" 12 PLY 53 buprenorphine hcl 6 BD SAFETY-LOK INSULIN bisacodyl 51 buprenorphine hcl-naloxone hclSYRINGE/PERM dihydrate 6bismuth subsalicylate 18NEEDLE/UF/1ML/29G X bupropion hcl 13bisoprolol &1/2" 69 bupropion hcl (smokinghydrochlorothiazide 23BD SAFETYGLIDE INSULIN deterrent) 110bisoprolol fumarate 31SYSYRINGE/0.5ML/30G X buspirone hcl 85/16" 69 BLEPH-10 106

butalbital-acetaminophen 3BD SWABS SINGLE USE 66 BLEPHAMIDE 106 butalbital-acetaminophen-BD SWABS SINGLE USE BLEPHAMIDE S.O.P. 106 caffeine 3BUTTERFLY 66 BOOSTRIX 111 butalbital-acetaminophen-BD VEO INSULIN SYRINGE caffeine w/ codeine 5ULTRAFINE/U-100/1ML/31G X BORDERED GAUZE 53 butalbital-aspirin-caffeine 415/64" 69 BREATHERITE 89 butalbital-aspirin-caffeineBENADRYL ALLERGY 19 BREATHERITE w/cod 5BENADRYL ALLERGY COLLAPSIBLEADULT BYDUREON 17CHILDRENS 19 SPACER W/MASK 89

benazepril & BREATHERITE BYDUREON BCISE 17 hydrochlorothiazide 23 COLLAPSIBLECHILD SPACER BYDUREON PEN 17 benazepril hcl 22 W/MASK 89 BYETTA 17BREATHERITEBENICAR 22 CAFERGOT 92COLLAPSIBLEINFANTBENICAR HCT 23 SPACER W/MASK 89 caffeine citrate 1 BENTYL 112 BREATHERITE CAL-DAY 1000 96COLLAPSIBLESMALL CHILDBENZAC AC WASH 38 CALAN 32SPACER W/MASK 89benzonatate 36 BREATHERITE CALAN SR 32 benzoyl peroxide 38 COLLAPSIBLESPACER W/ calcipotriene 40 BENZOYL PEROXIDE 38 NEONATE MASK 89 calcitonin (salmon) 46BREATHERITE RIGIDbenzoyl peroxide 38 calcitriol 46SPACERW/MASK 89BENZOYL PEROXIDE CLEANSER 38

Index 4

calcium acetate (phosphatebinder) calcium carbonate (antacid) calcium polycarbophil camphor & menthol candesartan cilexetil

48 7

50 40 22

CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 29GX12MM 69 CARETOUCH LANCING DEVICEWITH EJECTOR 59 CARETOUCH PEN NEEDLES 32GX 5MM 69

CEREBYX CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS CERVARIX cetirizine hcl

12

97 114

20 candesartan cilexetil-hydrochlorothiazide 23 capsaicin 43 captopril 22 CAPTOPRIL/HYDROCHLOROTHIAZIDE 23 CAPZASIN-HP 43 CARAFATE 112 carbamazepine 11 carbamide peroxide (otic) 108 CARBATROL 11 carbidopa 25 carbidopa-levodopa 26 CARDIOCOM LANCING DEVICE 59 CARDIZEM 32 CARDIZEM CD 32 CARDURA 22 CAREFINE PEN NEEDLES 29GX1/2" 69 CAREFINE PEN NEEDLES 30GX5/16" 69 CAREFINE PEN NEEDLES 32GX5MM 69 CAREONE ADVANCED LANCINGDEVICE 59 CAREONE INSULIN SYRINGES/0.3ML/30G X1/2" 69 CAREONE INSULIN SYRINGES/0.3ML/31G X5/16" 69 CAREONE INSULIN SYRINGES/0.5ML/30G X1/2" 69 CAREONE INSULIN SYRINGES/0.5ML/31G X5/16" 69 CAREONE INSULIN SYRINGES/1ML/30G X 1/2" 69 CAREONE INSULIN SYRINGES/1ML/31GX5/16" 69 CAREONE LANCET THIN 59

CARNITOR 46 CARNITOR SF 46 CARRASMART 53 CARRASMART FOAM 53 CARTEOLOL HCL 105 carteolol hcl (ophth) 105 carvedilol 31 carvedilol phosphate 31 CASODEX 25 CATAPRES 22 cefaclor 33 CEFACLOR 33 cefadroxil 33 cefdinir 33 cefprozil 33 CEFTIN 33 ceftriaxone sodium 33 cefuroxime axetil 33 CELEBREX 2 celecoxib 2 CELEXA 14 CELLCEPT 94 CENTANY 39 CENTRAVITES 50 PLUS 96 CENTRAVITES ADULTS 96 CENTRUM ADULTS 96 CENTRUM CARDIO 96 CENTRUM MEN 96 CENTRUM SILVER ULTRA MENS 96 CENTRUM SILVER ULTRA WOMENS 96 CENTRUM SPECIALIST HEART 96 CENTRUM SPECIALIST IMMUNE SUPPORT 96 CENTRUM SPECIALIST VISION 96 CENTRUM ULTRA

cetirizine-pseudoephedrine 36 CHANTIX 110 CHANTIX CONTINUING MONTHPAK 110 CHANTIX STARTING MONTH PAK 110 CHEK-STIX COMBO PAK URINALYSIS CONTROL 44 CHEK-STIX CONTROL 44 CHEMET 18 CHEMSTRIP-K 44 CHERACOL PLUS 36 CHERACOL-D COUGH 36 CHILDRENS ADVIL 2 CHILDRENS MOTRIN 2 CHLOR-TRIMETON 19 chlordiazepoxide hcl 8 chlorhexidine gluconate 28 chlorhexidine gluconate (mouth-throat) 95 CHLOROQUINE PHOSPHATE 24 chloroquine phosphate 24 CHLOROTHIAZIDE 46 chlorothiazide 46 chlorpheniramine maleate 19 CHLORPROMAZINE HCL 27 chlorpromazine hcl 27,28 chlorthalidone 46 CHLORZOXAZONE 104 CHOLBAM 48 cholestyramine 21 cholestyramine light 21 choline & mag salicylate 4 cilostazol 49 CILOXAN 106 cimetidine 112 CIMETIDINE HCL 112 CIPRO 47

CAREONE LANCET ULTRA WOMENS 97 CIPROFLOXACIN HCL 47THIN 59 cephalexin 33 ciprofloxacin hcl 47CAREONE UNIFINE PENTIPS CERASPORT 9329GX12MM 69 ciprofloxacin hcl (ophth) 106 CERASPORT EX1 93 citalopram hydrobromide 14

Index 5

CLARITHROMYCIN 52 CLEVER CHOICE COMFORT clonazepam 11 EZINSULINclarithromycin 52 clonidine hcl 22SYRINGE/0.5ML/30G XCLARITHROMYCIN 52 clonidine hcl (adhd) 15/16" 70

clarithromycin 52 CLEVER CHOICE COMFORT clopidogrel bisulfate 49 CLARITIN 20 EZINSULIN clorazepate dipotassium 8

SYRINGE/0.5ML/31G XCLARITIN ALLERGY CLOSERCARE 595/16" 70CHILDRENS 20 CLEVER CHOICE COMFORT clotrimazole (topical) 39CLARITIN REDITABS 20 EZINSULIN clotrimazole vaginal 117CLARITIN-D 12 HOUR 36 SYRINGE/1.0ML/30G X clotrimazole w/CLARITIN-D 24 HOUR 36 1/2" 70 betamethasone 39

CLEVER CHOICE COMFORTCLASS ACT LUBRICATED 56 clozapine 27EZINSULINCLASSIC PRENATAL 101 CLOZARIL 27SYRINGE/1ML/28G X 1/2" 70CLEAN & CLEAR ADVANTAGE CO MONITOR REPLACEMENTCLEVER CHOICE COMFORT

3-IN-1 EXFOLIATING TPIECES 90EZINSULINCLEANSER 38 SYRINGE/1ML/29G X 1/2" 70 CO-NATAL FA 101 CLEANLET LANCETS 28G 59 CLEVER CHOICE COMFORT coal tar extract 44 CLEAR COUGH PM MULTI- EZINSULIN COARTEM 24SYMPTOM 36 SYRINGE/1ML/30G X codeine sulfate 4clemastine fumarate 20 5/16" 70

CLEVER CHOICE COMFORT CODEINE SULFATE 4CLEOCIN 7,117 EZINSULIN SYRINGE/U- COLACE 51CLEOCIN PEDIATRIC 100/1ML/31GX5/16" 70GRANULES 7 COLAZAL 48CLEVER CHOICE COMFORTCLEOCIN-T 38 colchicine 49EZPEN NEEDLESCLEVER CHOICE ANTI- 29GX12MM 70 colchicine w/ probenecid 49STATICVALVED HOLDING CLEVER CHOICE COMFORT COLESTID 21CHAMBER/ADULT LARGE 90 EZPEN NEEDLESCLEVER CHOICE ANTI- COLESTID FLAVORED 2132GX5MM 70STATICVALVED HOLDING colestipol hcl 21CLIMARA 47CHAMBER/MEDIUM 90 COLYTE-FLAVOR PACKS 50CLINDAGEL 38CLEVER CHOICE ANTI- COMBIPATCHSTATICVALVED HOLDING clindamycin hcl 7 47 CHAMBER/SMALL 90 clindamycin palmitate COMBIVENT RESPIMAT 10 CLEVER CHOICE COMFORT hydrochloride 7 COMBIVIR 28 EZINSULIN CLINDAMYCIN COMFORT ASSIST INSULINSYRINGE/0.3ML/29G X 1/2" 69 PHOSPHATE 38 SYRINGE 0.3ML/29G X 1/2" 70CLEVER CHOICE COMFORT clindamycin phosphate COMFORT ASSIST INSULINEZINSULIN (topical) 38 SYRINGE/0.3ML/30G XSYRINGE/0.3ML/30G X 1/2" 69 clindamycin phosphate 5/16" 70CLEVER CHOICE COMFORT vaginal 117 COMFORT ASSIST INSULINEZINSULIN CLINICAL NUTRIENTS 45- SYRINGE/0.3ML/31G XSYRINGE/0.3ML/30G X PLUS WOMEN 97 5/16" 705/16" 69 CLINICAL NUTRIENTS 50- COMFORT ASSIST INSULINCLEVER CHOICE COMFORT PLUS MEN 97 SYRINGE/0.5ML/29G X 1/2" 70EZINSULIN CLINICAL NUTRIENTS FOR COMFORT ASSIST INSULINSYRINGE/0.3ML/31G X FEMALE TEENS 97 SYRINGE/0.5ML/30G X5/16" 69 CLINICAL NUTRIENTS FOR 5/16" 70CLEVER CHOICE COMFORT MALE TEENS 97 COMFORT ASSIST INSULINEZINSULIN CLINICAL NUTRIENTS FOR SYRINGE/0.5ML/31G XSYRINGE/0.5ML/28G X 1/2" 70 MEN 97 5/16" 70CLEVER CHOICE COMFORT CLINICAL NUTRIENTS FOR COMFORT ASSIST INSULINWOMEN 97EZINSULIN SYRINGE/1ML/29G X 1/2" 70SYRINGE/0.5ML/29G X 1/2" 70 clobetasol propionate 41 COMFORT ASSIST INSULINCLEVER CHOICE COMFORT clobetasol propionate emollient SYRINGE/1ML/30G X 5/16" 70EZINSULIN base 41 COMFORT ASSIST INSULIN SYRINGE/0.5ML/30G X 1/2" 70 clomipramine hcl 15 SYRINGE/1ML/31G X 5/16" 70

Index 6

COMFORT ASSURED LANCETS MICRO THIN 33G 59 COMFORT ASSURED LANCETS SUPER THIN 28G 59 COMFORT LANCETS 59 COMPACT SPACE CHAMBER/ANTI-STATIC 90 COMPACT SPACE CHAMBER/ANTI-STATIC/LARGE MASK 90 COMPACT SPACE CHAMBER/ANTI-STATIC/MEDIUM MASK 90 COMPACT SPACE CHAMBER/ANTI-STATIC/SMALLMASK 90 COMPLERA 28 COMPLETENATE 101 CONCERTA 1 CONDYLOX 42 COPA ISLAND BORDERED FOAM DRESSING 4"X4" 53 COPA PLUS HYDROPHILIC FOAM DRESSING 4"X4" 53 COPAXONE 110 COREG 31 COREG CR 31 CORGARD 31 CORTEF 35 CORTENEMA 6 CORTISONE ACETATE 35 COSOPT 105 COTELLIC 25 COUMADIN 10 COVRSITE COVER DRESSING 53 COVRSITE PLUS COMPOSITE DRESSING 53 COZAAR 22 CREON 45 CRESTOR 21 CRIXIVAN 28 cromolyn sodium 9 cromolyn sodium (nasal) 104 cromolyn sodium (ophth) 107 CUREX ALL-PURPOSE SPONGES 4"X4" 4 PLY 53 CURITY ALCOHOL PREPS/MEDIUM 2 PLY 66 CURITY ALCOHOL SWABS 66

CURITY ALL PURPOSE SPONGES 2"X2" 53 CURITY ALL PURPOSE SPONGES 2"X2" 4PLY 53 CURITY ALL PURPOSE SPONGES 3"X3" 4PLY 53 CURITY ALL PURPOSE SPONGES 4 PLY 53 CURITY ALL PURPOSE SPONGES 4"X4" 53 CURITY ALL PURPOSE SPONGES 4"X4" 4PLY 53 CURITY ALL PURPOSE SPONGES 4"X4" 4PLY/SOFTPOUCH 53 CURITY AMD ANTIMICROBIALGAUZE SPONGES 2"X2" 8 PLY 53 CURITY AMD ANTIMICROBIALGAUZE SPONGES 4"X4" 12 PLY 53 CURITY COVER SPONGE 4"X4" 53 CURITY COVER SPONGES 3"X3" 53 CURITY COVER SPONGES 4"X4" 53 CURITY DRESSING SPONGES 4"X4" 6 PLY 53 CURITY GAUZE PADS 2"X2" 53 CURITY GAUZE PADS 2"X2" 12 PLY 53 CURITY GAUZE PADS 3"X3" 53 CURITY GAUZE PADS 4"X4" 12 PLY 53 CURITY GAUZE SPONGE 2"X2" 8 PLY 53 CURITY GAUZE SPONGE 2"X2"12 PLY 53 CURITY GAUZE SPONGE 3"X3" 12 PLY 53 CURITY GAUZE SPONGE 4"X4" 12 PLY 53 CURITY GAUZE SPONGE 4"X4" 16 PLY 53 CURITY GAUZE SPONGE 4"X4" 8 PLY 53 CURITY GAUZE SPONGE 4"X4"16 PLY 53 CURITY GAUZE SPONGES 4"X4" 12 PLY 53 CURITY GAUZE SPONGES 4"X4" 8 PLY 53 CURITY NON-ADHERENT STRIPS 3"X3" 53

CURITY SPONGES/CELLULOSEFILLED/2"X2" 54 CURITY SPONGES/CELLULOSEFILLED/4"X4" 54 CVS ALCOHOL PREP SWABS 66 CVS GAUZE PAD 3"X3" 54 CVS GAUZE PADS 2"X2" 12-PLY 54 CVS GAUZE PADS 4"X4" 12-PLY 54 CVS GAUZE PADS STERILE 4"X4" 12-PLY 54 CVS GLUCOSE 16 CVS LANCETS 21G 59 CVS LANCETS MICRO THIN 33G 59 CVS LANCETS MICRO-THIN 33G 59 CVS LANCETS ORIGINAL 59 CVS LANCETS THIN 26G 59 CVS LANCETS ULTRA THIN 30G 59 CVS LANCETS ULTRA-THIN 30G 59 CVS LANCING DEVICE 59 CVS ONE DAILY MENS 50+ ADVANCED 97 CVS PRENATAL 101 CVS PREP PADS 66 CVS SPECTRAVITE ADULT 50+ 97 CVS SPECTRAVITE ULTRA MEN50+ 97 CVS SPECTRAVITE ULTRA MENS HEALTH 97 CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR 97 CVS SPECTRAVITE ULTRA WOMEN 97 CVS SPECTRAVITE ULTRA WOMENS HEALTH 97 CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR 97 CVS ULTRA THIN LANCETS 59 cyanocobalamin 49 CYCLESSA 33 cyclobenzaprine hcl 104 CYCLOGYL 105 cyclopentolate hcl 105 cyclosporine 94

Index 7

CYCLOSPORINE DERMACEA NON-WOVEN DEXAMETHASONE 35 MODIFIED 94 SPONGES 2"X2" 4 PLY 54 DEXAMETHASONEcyclosporine modified (for DERMACEA NON-WOVEN INTENSOL 35microemulsion) 94 SPONGES 3"X3" 4 PLY 54 dexamethasone sodium CYMBALTA 15 DERMACEA NON-WOVEN phosphate 35

SPONGES 4"X4" 4 PLY 54cyproheptadine hcl 20 DEXAMETHASONE SODIUMDERMACEA NON-WOVEN PHOSPHATE 106CYTOMEL 111 SPONGES 4"X4" 6 PLY 54 DEXEDRINE 1CYTOTEC 113 DERMACEA TYPE VII GAUZE

DEXILANT 1132"X2" 12 PLY 54D.H.E. 45 92 DERMACEA TYPE VII GAUZE dexmethylphenidate hcl 1dapsone 7 2"X2" 8 PLY 54 dextroamphetamine sulfate 1DAY TIME MULTI-SYMPTOM DERMACEA TYPE VII GAUZECOLD/FLU RELIEF 36 3"X3" 12 PLY 54 dextromethorphan polistirex 36 DAYPRO 2 DERMACEA TYPE VII GAUZE dextromethorphan-doxylamine-

3"X3" 12PLY 54 acetaminophen 36DDAVP 47 DERMACEA TYPE VII GAUZE dextromethorphan-guaifenesin

DEBROX 108 374"X4" 12 PLY 54DELSYM 36 DERMACEA TYPE VII GAUZE dextromethorphan-DELSYM COUGH 4"X4" 16 PLY 54 phenylephrine-acetaminophenCHILDRENS 36 DERMACEA TYPE VII GAUZE 37 DELZICOL 48 4"X4" 8 PLY 54 DHS TAR 44 DEMADEX 45 DERMACEA X-RAY DHS TAR GEL 44

SPONGES 4"X4" 16 PLY 54DEMEROL 4 DIAMOX 45DERMALEVIN ADHESIVE DIAZEPAM 8DEPACON 13 FOAMDRESSING 4"X4" 54

DEPAKENE 13 DERMATOP 41 diazepam 8 DEPAKOTE 13 DERMAVITE 97 diazepam (anticonvulsant) 11 DEPAKOTE ER 13 DERMOTIC 108 dibucaine 43 DEPAKOTE SPRINKLES 13 DESCOVY 28 diclofenac potassium 2 DEPEN TITRATABS 94 desipramine hcl 15 diclofenac sodium 2 DEPO-PROVERA desmopressin acetate 47 diclofenac sodium (ophth) 107 CONTRACEPTIVE 35 desmopressin acetate diclofenac sodium (topical) 39DEPO-SUBQ PROVERA spray 47 dicloxacillin sodium 109104 35 desmopressin acetate sprayDEPO-TESTOSTERONE 6 refrigerated 47 dicyclomine hcl 112 DERMACEA DRAIN SPONGES DESOGEN 33 didanosine 28 4"X4" 54 desogestrel & ethinyl DIFLORASONE DERMACEA GAUZE SPONGE estradiol 33 DIACETATE 41 2"X2" 12 PLY 54 desogestrel-ethinyl estradiol DIFLUCAN 19 DERMACEA GAUZE SPONGE (biphasic) 33 diflunisal 42"X2" 8 PLY 54 desogestrel-ethinyl estradiol DIGOXIN 33DERMACEA GAUZE SPONGE (triphasic) 333"X3" 12 PLY 54 digoxin 33desonide 41DERMACEA GAUZE SPONGE dihydroergotamine mesylate 93DESOWEN 413"X3" 8 PLY 54 DILANTIN 12DERMACEA GAUZE SPONGE desoximetasone 41 4"X4" 12 PLY 54 DILANTIN INFATABS 12DESQUAM-X WASH 38DERMACEA GAUZE SPONGE DILANTIN-125 12desvenlafaxine succinate 154"X4" 16 PLY 54 DILAUDID 4DERMACEA GAUZE SPONGE DETROL 113 4"X4" 8 PLY 54 DETROL LA 113 diltiazem hcl 32 DERMACEA I.V. DRAIN DEX4 QUICK DISSOLVE diltiazem hcl coated beads 32 SPONGES 2"X2" 54 GLUCOSE 16 diltiazem hcl extended releaseDERMACEA I.V. DRAIN dexamethasone 35 beads 32SPONGES 4"X4" 54 dimenhydrinate 19DEXAMETHASONE 35DERMACEA I.V. SPONGES 2"X2" 54 dexamethasone 35

Index 8

DIMETAPP COLD & DROPLET LANCETS ULTRA E-ZJECT LANCETS MICRO-ALLERGY 37 THIN 30G 59 THIN 33G 60 DIMETAPP LONG ACTING DROPLET LANCING E.E.S. 400 52 COUGH PLUS COLD 37 DEVICE 59 E.E.S. GRANULES 52DIOVAN 22 DROPLET PEN NEEDLES

EASIVENT 9029GX12MM 70DIOVAN HCT 23 DROPLET PEN NEEDLES 32G EASIVENT/MASK-LARGE 90diphenhydramine hcl 20 X 3/16" 70 EASIVENT/MASK-MEDIUM 90diphenhydramine hcl (sleep) 50 DROPLET PEN NEEDLES EASIVENT/MASK-SMALL 9032GX5MM 70diphenoxylate w/ atropine 18 drospirenone-ethinyl EASY COMFORT INSULINDIPHENOXYLATE/ATROPINE estradiol 33 SYRINGE/0.5ML/30G X

18 5/16" 71DIPHTHERIA/TETANUS DROXIA 49 EASY COMFORT INSULINTOXOIDS ADSORBED DRUG MART ADJUSTABLE SYRINGE/0.5ML/31G XPEDIATRIC 111 LANCING DEVICE 59 5/16" 71DRUG MART LANCETSDIPROLENE AF 41 EASY COMFORT INSULINTHIN 59dipyridamole 49 SYRINGE/1ML/30G X 5/16" 71DRUG MART UNIFINE EASY COMFORT INSULINDISALCID 4 PENTIPS29G X 12MM 70 SYRINGE/1ML/31G X 5/16" 71disopyramide phosphate 9 DRUG MART UNILET EASY COMFORT INSULINLANCETSSUPER THINDISPOSABLE MOUTHPIECE SYRINGE/U-100/0.5ML/30G X30G 59FULL RANGE 90 1/2" 71DRUG MART UNILETDISPOSABLE MOUTHPIECE EASY COMFORT INSULINLANCETSULTRA THINLOWRANGE/PEDIATRIC 90 SYRINGE/U-100/1ML/30G XDISPOSABLE 28G 59 1/2" 71DRUG MART UNILET MICROMOUTHPIECE/LOW EASY MINI EJECT LANCINGTHIN LANCETS 33G 59RANGE 90 DEVICE 60DISPOSABLE DRYMAX EXTRA 54 EASY MINI LANCING MOUTHPIECE/UNIVERSAL DRYSOL 43 DEVICE 60 RANGE 90 DUANE READE LANCET EASY TOUCH 32GX5MM 71DISPOSABLE PAPER ALTERNATE SITE 26G 59 EASY TOUCH ALCOHOL PREPMOUTHPIECE 90 DUANE READE LANCET PADS/MEDIUM 66disulfiram 109 59SUPERTHIN 30G EASY TOUCH FLIPLOCK

DUANE READE LANCETDITROPAN XL 113 SAFETY INSULIN SYRINGEULTRATHIN 28G 59divalproex sodium 13 1ML/29GX1/2" 71DUANE READE UNIFINE EASY TOUCH FLIPLOCKdocusate sodium 51 PENTIPS 29G X 12MM 70 SAFETY INSULIN SYRINGE

dofetilide 9 DULCOLAX 51 1ML/30GX1/2" 71 DOLOPHINE 4 DULERA 10 EASY TOUCH FLIPLOCK

SAFETY INSULIN SYRINGEdonepezil hydrochloride 109 duloxetine hcl 15 1ML/30GX5/16" 71DORZOLAMIDE HCL 107 DURAGESIC 4 EASY TOUCH FLIPLOCK dorzolamide hcl 107 DUREX EXTRA SAFETY INSULIN SYRINGE dorzolamide hcl-timolol SENSITIVE 56 1ML/31GX5/16" 71 maleate 105 DYAZIDE 45 EASY TOUCH INSULIN DORZOLAMIDE HCL/TIMOLOL E-Z JECT LANCETS 59 SYRINGE/0.3ML/30G XMALEATE 105 5/16" 71E-Z JECT LANCETS 21G 59DOVONEX 40 EASY TOUCH INSULINE-Z JECT LANCETS SYRINGE/0.3ML/31G Xdoxazosin mesylate 22 COLOR 59 5/16" 71doxepin hcl 15 E-Z JECT LANCETS SUPER EASY TOUCH INSULINTHIN 30G 60doxycycline (monohydrate) 111 SYRINGE/0.5ML/29G X 1/2" 71E-Z JECT LANCETS THINdoxycycline hyclate 111 EASY TOUCH INSULIN26G 60 SYRINGE/0.5ML/30G Xdoxylamine succinate E-Z SPACER 90 5/16" 71(sleep) 50 E-Z SPACER THE BODY EASY TOUCH INSULINDRAMAMINE 19 GUARDS PACK 90 SYRINGE/1ML/30G X 5/16" 71DRISDOL 118

Index 9

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X 1/2"EASY TOUCH INSULIN

71

SYRINGE/SAFETY/U-100/0.5ML/30G X 5/16"EASY TOUCH INSULIN

71

SYRINGE/SAFETY/U-100/1ML/29G X 1/2"EASY TOUCH INSULIN

71

SYRINGE/SAFETY/U-100/1ML/30G X 1/2"EASY TOUCH INSULIN

71

SYRINGE/U-100/0.3ML/30G X1/2" 71 EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/27G X1/2" 71 EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 71 EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 71 EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 71 EASY TOUCH INSULIN SYRINGE/U-100/1ML/27G X1/2" 71 EASY TOUCH INSULIN SYRINGE/U-100/1ML/28G X1/2" 71 EASY TOUCH INSULIN SYRINGE/U-100/1ML/29G X1/2" 72 EASY TOUCH INSULIN SYRINGE/U-100/1ML/30G X1/2" 72 EASY TOUCH INSULIN SYRINGE/U-100/1ML/31G X5/16" 72 EASY TOUCH LANCETS 26G/PULL-TOP 60 EASY TOUCH LANCETS 26G/TWIST 60 EASY TOUCH LANCETS 28G/PULL-TOP 60 EASY TOUCH LANCETS 28G/TWIST 60 EASY TOUCH LANCETS 30G/PULL-TOP 60 EASY TOUCH LANCETS 30G/TWIST 60 EASY TOUCH LANCETS

EASY TOUCH LANCETS 33G/TWIST 60 EASY TOUCH LANCING DEVICE/EJECTOR 60 EASY TOUCH PEN NEEDLE 30G X 5/16" 72 EASY TOUCH PEN NEEDLES 29GX1/2" 72 EASY TOUCH PEN NEEDLES 32GX3/16" 72 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2" 72 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/30GX5/16" 72 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/31GX5/16" 72 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML/30GX1/2" 72 EASYTEST II LANCETS 60 EASYTEST LANCETS 60 EBASE CONTROLLER KIT 90 EC-NAPROSYN 2 econazole nitrate 39 ECOTRIN REGULAR STRENGTH 4 ED BRON GP 37 EDURANT 28 efavirenz 28 EFFEXOR XR 15 EFFIENT 49 EFLOW SCF AEROSOL HEAD 90 EFUDEX 40 ELAVIL 16 ELDEPRYL 26 eletriptan hydrobromide 93 ELEXA NATURAL FEEL 56 ELEXA STIMULATING 57 ELEXA ULTRA SENSITIVE 57 ELIDEL 42 ELIMITE 43 ELIQUIS 10 ELIQUIS STARTER PACK 10 ELITE DC AUTO

ELITE-THIN INSULIN SYRINGE/0.5ML/29G X 1/2" 72 ELITE-THIN INSULIN SYRINGE/0.5ML/30G X5/16" 72 ELITE-THIN INSULIN SYRINGE/1ML/29G X 5/16" 72 ELITE-THIN INSULIN SYRINGE/1ML/30G X 5/16" 72 ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 72 ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/29G X5/16" 72 ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 72 ELITE-THIN INSULIN SYRINGE/U-100/1ML/28G X1/2" 72 ELITE-THIN INSULIN SYRINGE/U-100/1ML/28G X5/16" 72 ELITE-THIN INSULIN SYRINGE/U-100/1ML/29G X1/2" 72 ELITE-THIN INSULIN SYRINGE/U-100/1ML/31G X5/16" 72 ELIXOPHYLLIN 10 ELLA 35 ELMIRON 49 ELOCON 41 EMTRIVA 28 EMVERM 7 enalapril maleate 22 enalapril maleate &hydrochlorothiazide 23 ENBREL 3 ENBREL MINI 3 ENBREL SURECLICK 3 ENFAMIL ENFALYTE 93 ENGERIX-B 114 enoxaparin sodium 10,11 EPANED 22 EPIFOAM 41 epinephrine (anaphylaxis) 118 EPIVIR 28 EPZICOM 29

32G/PULL-TOPEASY TOUCH LANCETS

60 ADAPTER ELITE-THIN INSULIN

90 EQ COMPLETE MULTIVITAMINADULTS UNDER

32G/TWIST 60 SYRINGE/0.3ML/31G X5/16" 72

50 EQ ONE DAILY MENS 50+

97 97

Index 10

EQ ONE DAILY MENS ERYTHROCIN EXEL COMFORT POINT HEALTH 97 STEARATE 52 INSULIN SYRINGE/0.5ML/29G XEQ ONE DAILY WOMENS erythromycin (acne aid) 38 1/2" 73 50+ 97 EXEL COMFORT POINTerythromycin (ophth) 106EQ ONE DAILY WOMENS INSULIN SYRINGE/0.5ML/30G XHEALTH 97 erythromycin base 52 5/16" 73 EQL ALCOHOL SWABS 66 erythromycin EXEL COMFORT POINT EQL CENTURY MATURE ethylsuccinate 52 INSULIN SYRINGE/1ML/28G X

ERYTHROMYCINADULTS50+ 97 1/2" 73ETHYLSUCCINATE 52 EXEL COMFORT POINTEQL CENTURY MENS 97 escitalopram oxalate 14 INSULIN SYRINGE/1ML/29G XEQL CENTURY WOMENS 97 ESGIC 4 1/2" 73

EQL COLOR LANCETS 21G60 EXEL COMFORT POINTesomeprazoleEQL COLOR LANCETS MICRO INSULIN SYRINGE/1ML/30G Xmagnesium 113THIN 33G 60 5/16" 73ESTRACE 47,118EQL GAUZE PADS EXELON 109estradiol 472"X2"/SMALL 54 exemestane 25EQL GAUZE PADS estradiol & norethindrone 4"X4"/LARGE 54 acetate 47 EXFORGE 23 EQL GAUZE STERILE PADS estradiol vaginal 118 EXFORGE HCT 23 3"X3" 54 ESTROPIPATE 47 EXPIRATORY EQL INSULIN MOUTHPIECE 90ESTROSTEP FE 33SYRINGE/0.3ML/29G X 1/2" 72 EXTRA SENSITIVE

ethambutol hcl 24EQL INSULIN SPERMICIDAL 57 SYRINGE/0.3ML/30G X ethosuximide 13 EZ SMART BLOOD GLUCOSE 5/16" 72 ethynodiol diacet & eth LANCETS 60 EQL INSULIN estrad 34 EZ-LETS LANCETS 23G 60SYRINGE/0.3ML/31G X etodolac 3 EZ-LETS LANCETS 26G5/16" 72 SUPER-SOFT 60EURAX 43EQL INSULIN EZ-LETS LANCETS 28GSYRINGE/0.5ML/29G X 1/2" 72 EVISTA 46 ULTRA-SOFT 60EQL INSULIN EVOTAZ 29 EZ-LETS LANCETS 30G 60SYRINGE/0.5ML/30G X EVZIO 185/16" 72 famciclovir 30

EXCILON AMDEQL INSULIN famotidine 112ANTIMICROBIALDRAINSYRINGE/0.5ML/31G X FAMVIR 30SPONGES 4"X4" 6 PLY 545/16" 72 EXCILON AMD FANTASY LUBRICATED 57EQL INSULIN ANTIMICROBIALNON-WOVEN FANTASYSYRINGE/1ML/29G X 1/2" 72

EQL INSULIN SPONGES 4"X4" 6 PLY 55 LUBRICATED/SPERMICIDEEXCILON DRAIN SPONGESYRINGE/1ML/30G X 5/16" 72 57 4"X4" 55EQL INSULIN FARESTON 25EXCILON DRAIN SPONGESSYRINGE/1ML/31G X 5/16" 73 felbamate 124"X4" 6 PLY 55EQL ONE DAILY MENS 97 EXCILON I.V. SPONGES 2"X2" FELBATOL 12

EQL PRENATAL 6 PLY 55 FELDENE 3FORMULA 101 EXEL COMFORT POINTEQL SUPER THIN LANCETS felodipine 32INSULIN PEN NEEDLES 29G30G 60 FEMARA 25X 12MM 73EQL THIN LANCETS 26G 60 EXEL COMFORT POINT FEMCON FE 34 ergocalciferol 118 INSULIN SYRINGE/0.3ML/29G FEMHRT LOW DOSE 47 ERGOLOID MESYLATES 110 X 1/2" 73 fenofibrate 21EXEL COMFORT POINTergotamine w/ caffeine 92 fenofibrate micronized 21INSULIN SYRINGE/0.3ML/30GERY-TAB 52 X 5/16" 73 fentanyl 4 ERYGEL 38 EXEL COMFORT POINT FERRETTS 49INSULIN SYRINGE/0.5ML/28GERYPED 200 52 ferrous fumarate 49X 1/2" 73ERYPED 400 52 ferrous sulfate 49

Index 11

fexofenadine hcl 20 FIBERCON 50 FIFTY50 ALCOHOL PREP PADS 66 FIFTY50 LANCING DEVICE 60 FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.3ML/31G X5/16" 73 FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.5ML/31G X5/16" 73 FIFTY50 SUPERIOR COMFORTINSULIN

FLUBLOK 2017-2018 115 FLUCELVAX 2015-2016 115 FLUCELVAX QUADRIVALENT 2017-2018 115 fluconazole 19 fludrocortisone acetate 36 FLULAVAL QUADRIVALENT 2014-2015 115 FLULAVAL QUADRIVALENT 2016-2017 115 FLULAVAL QUADRIVALENT 2017-2018 115 FLULAVAL QUADRIVALENT 2018-2019 115 FLUMIST

FLUZONE QUADRIVALENT 2017-2018 116 FLUZONE QUADRIVALENT 2018-2019 116 FML 107 FML LIQUIFILM 106 FOCALIN 1 folic acid 49 FORA LANCETS 60 FORA LANCING DEVICE 60 FORA LANCING DEVICE/CLEARCAP 60 formaldehyde 28 FORTICAL 46

SYRINGE/1ML/31G X 5/16" 73 FIFTY50 UNILET LANCETS 33G 60 FILTER AIR PP 90 finasteride 49 FIORINAL 4 FIORINAL/CODEINE #3 5 FIRVANQ 7 FITNESS TABS FOR MEN

QUADRIVALENT FLUNISOLIDE fluocinolone acetonide (otic) fluocinonide fluocinonide emulsified base fluorometholone (ophth) FLUOROURACIL

115 104

108 41

41 106

40

FOSAMAX 46 fosamprenavir calcium 29 fosinopril sodium 22 fosinopril sodium &hydrochlorothiazide 23 fosphenytoin sodium 12 FREDS PHARMACY AUTOLET LANCING DEVICE 60 FREDS PHARMACY UNILET

AM/PM/LYCOPENE 97 FITNESS TABS FOR WOMEN AM/PM/LYCOPENE 97 FLAGYL 7 flavoxate hcl 114 flecainide acetate 9 FLEET ENEMA 51 FLEET ENEMA SIX PACK 51 FLEET PEDIATRIC 51 FLEXICHAMBER 90 FLEXZAN 4 X 4 55 FLOMAX 49 FLONASE ALLERGY RELIEF 104 FLONASE ALLERGY RELIEF CHILDRENS 104 FLORIVA PLUS 100

fluorouracil (topical) 40 fluoxetine hcl 14 fluphenazine decanoate 28 fluphenazine hcl 28 FLURAZEPAM HCL 50 flurbiprofen 3 flurbiprofen sodium 107 flutamide 25 fluticasone propionate 41 fluticasone propionate(nasal) 104 FLUVIRIN 2015-2016 115 FLUVIRIN 2016-2017 115 FLUVIRIN 2017-2018 115 fluvoxamine maleate 14 FLUZONE HIGH-DOSE PF

LANCETS SUPER THIN 30G 60 FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G 60 FREEDAVITE 97 FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 73 FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 73 FREESTYLE PRECISION INSULIN SYRINGE/U-100/1ML/31G X 5/16" 73 FREESTYLE PRECISION INSULIN SYRINGES/U-100/1ML/30G X 5/16" 73 FULL KIT NEBULIZER SET 90

FLOVENT DISKUS FLOVENT HFA

9 9

2016-2017 116 FLUZONE HIGH-DOSE PF 2017-2018 116

FURADANTIN furosemide

113 45

FLOXIN OTIC 108 FLUZONE HIGH-DOSE PF FUROSEMIDE 45 FLUARIX QUADRIVALENT 2016-2017 115 FLUARIX QUADRIVALENT 2017-2018 115 FLUARIX QUADRIVALENT 2018-2019 115 FLUBLOK 2015-2016 115 FLUBLOK 2016-2017 115

2018-2019 116 FLUZONE INTRADERMAL QUADRIVALENT 2016-2017 116 FLUZONE INTRADERMAL QUADRIVALENT 2017-2018 116 FLUZONE QUADRIVALENT 2016-2017 116

furosemide 45 gabapentin 11 GABITRIL 12 galantamine hydrobromide 109 GALANTAMINE HYDROBROMIDE 109 galantamine hydrobromide 109 GARDASIL 117

Index 12

GARDASIL 9 117 GAS-X 48 GAUZE DRESSING 4"X4" 55 GAUZE PADS 2"X2" 55 GAUZE PADS 3"X3" 55 GAUZE PADS 4"X4" 55 GAUZE PADS 4"X4" 12 PLY 55 GAUZE SPONGE TYPE VII MEDI-PAK 2"X2" 8PLY 55 GAUZE SPONGES 4"X4" 12 PLY 55 GEL-KAM ORAL CARE RINSE 95 gemfibrozil 21 GENERESS FE 34 GENTAK 106 gentamicin sulfate (ophth) 106 gentamicin sulfate (topical) 39 GENTEEL LANCING DEVICE/BUFF BLACK 60 GENTEEL LANCING DEVICE/BUTTERFLY BLUE 60 GENTEEL LANCING DEVICE/GLORIOUS GOLD 60 GENTEEL LANCING DEVICE/PLAYFUL PURPLE 60 GENTEEL LANCING DEVICE/PRECIOUSPLATINUM 60 GENTEEL LANCING DEVICE/PRINCESS PINK 60 GENTEEL LANCING DEVICE/STATELY SILVER 61 GENTEEL LANCING DEVICE/WILLOWY WHITE 61 GENTLE-LET GP LANCETS 61 GENTLE-LET LANCETS GENERAL PURPOSE STYLE/FINE POINT 61 GENTLE-LET LANCETS GENERAL PURPOSE STYLE/MEDIUM POINT 61 GENTLE-LET LANCETS SAFETY STYLE/FINEPOINT 61 GENTLE-LET LANCETS SAFETY STYLE/MEDIUMPOINT 61 GENVOYA 29 GEODON 26 GERI-FREEDA SENIOR FORMULA 97 GILENYA 110 glatiramer acetate 110

glimepiride 18 glipizide 18 glipizide-metformin hcl 16 GLOBAL EASE INJECT PEN NEEDLES 29GX12MM 73 GLOBAL EASY GLIDE INSULINSYRINGE/U-100/0.3ML/31G X 5/16" 73 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 73 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" 73 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 73 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 73 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 73 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 74 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" 74 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 74 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 74 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/28G X 1/2" 74 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/29G X 1/2" 74 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X 1/2" 74 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X 5/16" 74 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/31G X 5/16" 74 GLOBAL INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 74 GLOBAL INSULIN SYRINGES/U-100/0.3ML/30GX5/16" 74 GLOBAL LANCING DEVICE 61

GLUCAGEN HYPOKIT 16 GLUCAGON EMERGENCY KIT 16 GLUCOCOM LANCETS 28G 61 GLUCOCOM LANCETS 30G 61 GLUCOPHAGE 16 GLUCOPHAGE XR 16 GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 74 GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 74 GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 74 GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 74 GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 74 GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 74 GLUCOPRO INSULIN SYRINGE/U-100/1ML/30G X1/2" 74 GLUCOPRO INSULIN SYRINGE/U-100/1ML/30G X5/16" 74 GLUCOPRO INSULIN SYRINGE/U-100/1ML/31G X5/16" 74 GLUCOSE 16 GLUCOSOURCE LANCET DEVICE 61 GLUCOSOURCE LANCETS 61 GLUCOTROL 18 GLUCOTROL XL 18 GLUCOVANCE 16 glyburide 18 glyburide micronized 18 glyburide-metformin 16 glycerin (laxative) 51 GLYCERIN ADULT 51 glycopyrrolate 112 GLYNASE 18 GNP ALCOHOL SWABS 66 GNP GLUCOSE 16 GNP INSULIN SYRINGE/0.3ML/29G X 1/2" 74

Index 13

GNP INSULIN GNP ULTRA COMFORT HALDOL DECANOATE 100 27 SYRINGE/0.3ML/30G X INSULIN SYRINGE/0.5ML/30G HALDOL DECANOATE 50 275/16" 74 X 5/16" SHORT 75 haloperidol 27GNP INSULIN GNP ULTRA COMFORT SYRINGE/0.3ML/31G X INSULIN SYRINGE/0.5ML/31G haloperidol decanoate 27 5/16" 74 X 5/16" SHORT 75 haloperidol lactate 27GNP INSULIN GNP ULTRA COMFORT HAVRIX 117SYRINGE/0.5ML/28G X 1/2" 74 INSULIN SYRINGE/1ML/28G X HEALTH CARE LANCINGGNP INSULIN 1/2" 75 DEVICE 61SYRINGE/0.5ML/29G X 1/2" 74 GNP ULTRA COMFORT HEALTHWISE LANCINGGNP INSULIN INSULIN SYRINGE/1ML/29G XSYRINGE/0.5ML/30G X 1/2" 75 PEN 61

HEALTHWISE PEN NEEDLES5/16" 74 GNP ULTRA COMFORT 29GX12MM 75GNP INSULIN INSULIN SYRINGE/1ML/30G X HEALTHY ACCENTS AUTOLETSYRINGE/0.5ML/31G X 5/16" SHORT 75 IMPRESSION LANCING5/16" 75 GNP ULTRA COMFORT DEVICE 61GNP INSULIN INSULIN SYRINGE/1ML/31G X HEALTHY ACCENTS UNIFINESYRINGE/1ML/28G X 1/2" 75 5/16" SHORT 75 PENTIPS PEN NEEDLESGNP INSULIN GOLYTELY 50 29GX12MM 75SYRINGE/1ML/29G X 1/2" 75 GOODSENSE LANCETS HEALTHY ACCENTS UNILETGNP INSULIN MICRO-THIN 33G LANCETS SUPER THINSYRINGE/1ML/30G X 5/16" 75 UNIVERSAL 61 30G 61GNP INSULIN GOODSENSE LANCETS HEALTHY LIVINGSYRINGE/1ML/31G X 5/16" 75 ULTRA-THIN 26G REPLACEMENT FILTERS 90GNP LANCETS 61 UNIVERSAL 61 HEALTHY LIVINGGNP LANCETS 21G 61 GOODSENSE LANCING REPLACEMENT KIT FOR GNP LANCETS MICRO THIN DEVICE 61 NEBULIZER 90 33G 61 GOODSENSE PRENATAL HEALTHY LIVING GNP LANCETS SUPER THIN VITAMINS 101 REPLACEMENT MASKS 90 30G 61 GRIS-PEG 19 HEMANGEOL 31 GNP LANCETS THIN 61 griseofulvin microsize 19 HEMOCYTE 49 GNP LANCETS THIN 26G 61 griseofulvin ultramicrosize 19 heparin sodium (porcine) 11GNP MICRO THIN LANCETS guaifenesin 38 HIBICLENS 2833G 61 guaifenesin-codeine 37 HIGH SENSATIONGNP PRENATAL 101

guanfacine hcl 22 SPERMICIDAL 57GNP QUICK DISSOLVE GLUCOSE 16 guanfacine hcl (adhd) 1 HM COMPLETE 97

HM COMPLETE 50+ MENSGNP STERILE PADS 3"X3" 55 GYNAZOLE-1 117 ULTIMATE 97GNP SUPER THIN GYNE-LOTRIMIN 117 HM COMPLETE 50+ WOMENSLANCETS/30G 61 GYNE-LOTRIMIN 3 117 ULTIMATE 97GNP ULTRA COMFORT H-E-B INCONTROL HM HAIR/SKIN/NAILS 97INSULIN SYRINGE/0.3ML/29G X ADVANCEDLANCING1/2" 75 HM ONE DAILY MENS 97DEVICE 61GNP ULTRA COMFORT HM ONE DAILY WOMENS 97H-E-B INCONTROL ALCOHOLINSULIN SYRINGE/0.3ML/30G X PADS 66 HM PRENATAL 1015/16" SHORT 75 H-E-B INCONTROL LANCETS HM STERILE PADS 55GNP ULTRA COMFORT MICRO THIN 33G 61INSULIN SYRINGE/0.3ML/31G X HM STERILE PADS 2"X2" 55H-E-B INCONTROL LANCETS5/16" SHORT 75 HUDSON RCI SEE-THRUSUPER THIN 30G 61GNP ULTRA COMFORT AEROSOL MASKH-E-B INCONTROL LANCETSINSULIN SYRINGE/0.5ML/28G X ELONGATED/ADULT 90ULTRA THIN 28G 611/2" 75 HUMALOG 17H-E-B INCONTROL PENGNP ULTRA COMFORT NEEDLES 29GX12MM 75 HUMALOG JUNIORINSULIN SYRINGE/0.5ML/29G X KWIKPEN 17HAIR-VITES 971/2" 75 HUMALOG KWIKPEN 17HALCION 50

HUMALOG MIX 50/50 17HALDOL 27

Index 14

HUMALOG MIX 50/50 hyoscyamine sulfate 112 INSULIN SYRINGE/0.5ML/30G XKWIKPEN 17 1/2" 75HYPERRHO S/D 108HUMALOG MIX 75/25 17 INSULIN SYRINGE/0.5ML/30G X

HYPOTEARS 105HUMALOG MIX 75/25 5/16" 75 HYZAAR 23 INSULIN SYRINGE/0.5ML/31G XKWIKPEN 17

5/16" 76HUMIRA 2 ibuprofen 3 INSULIN SYRINGE/1ML/28G XHUMIRA PEDIATRIC CROHNS ICAPS AREDS FORMULA 97 1/2" 76DISEASE STARTER PACK 2 ICAPS PLUS 97 INSULIN SYRINGE/1ML/29G XHUMIRA PEN 2 imipramine hcl 16 1/2" 76 HUMIRA PEN-CROHNS INSULIN SYRINGE/1ML/30G Ximiquimod 42DISEASESTARTER 2 5/16" 76 HUMIRA PEN-PSORIASIS IMITREX 93 INSULIN SYRINGE/NEEDLESTARTER 2 IMITREX STATDOSE 0.3ML/30G X 5/16" 76 HUMULIN 70/30 17 REFILL 93 INSULIN SYRINGE/NEEDLEHUMULIN 70/30 KWIKPEN 17 IMITREX STATDOSE 0.3ML/31G X 5/16" 76

SYSTEM 93 INSULIN SYRINGE/NEEDLEHUMULIN N 17 IMODIUM A-D 18 0.5ML/29G X 1/2" 76 HUMULIN N KWIKPEN 17 INSULIN SYRINGE/NEEDLEIMURAN 95 HUMULIN R 17 0.5ML/30G X 5/16" 76IN TOUCH LANCING INSULIN SYRINGE/NEEDLEHY-VEE LANCETS 61 DEVICE 61 0.5ML/31G X 5/16" 76HY-VEE THIN LANCETS 61 INATAL GT 101 INSULIN SYRINGE/NEEDLEHYALEX 97 INCRUSE ELLIPTA 9 1ML/29G X 1/2" 76

indapamide INSULIN SYRINGE/NEEDLEhydralazine hcl 24 46 1ML/30G X 5/16" 76HYDRALYTE 93 INDERAL LA 32 INSULIN SYRINGE/NEEDLE

HYDRALYTE FREEZER indomethacin 3 1ML/31G X 5/16" 76POPS 93 INFANRIX 111 INSULIN SYRINGE/U-HYDREA 25 100/0.3ML/29G X 1/2" 76INFANTS ADVIL 3HYDROCELL ADHESIVE INSULIN SYRINGE/U-INNOSPIRE REPLACEMENTDRESSING 4"X4" 55 100/0.5ML/28G X 1/2" 76FILTER 90HYDROCELL DRESSING INSULIN SYRINGE/U-INSPIRACHAMBER/ANTI-4"X4" 55 100/0.5ML/29G X 1/2" 76STATIChydrochlorothiazide 46 INSULIN SYRINGE/U-VALVED/MOUTHPIECE 90 100/1ML/28G X 1/2" 76hydrocodone w/ INSPIRACHAMBER/LARGE INSULIN SYRINGE/U-homatropine 36 90 100/1ML/29G X 1/2" 76hydrocodone-acetaminophen 5 INSPIRACHAMBER/SOOTHE INSULIN SYRINGE/U-hydrocortisone 35 RMASK/INSPIRAMASK/MEDIU 100/1ML/30G X 5/16" 76 hydrocortisone (intrarectal) 6 M 91 INSULIN SYRINGE/U-INSPIRACHAMBER/SOOTHE 100/1ML/31G X 5/16" 76hydrocortisone (rectal) 6 RMASK/INSPIRAMASK/SMAL INSULINhydrocortisone (topical) 41 L 91 SYRINGES/0.5ML/27GX1/2"INSPIREASE DRUGhydrocortisone butyrate 41 76DELIVERYSYSTEM 91hydrocortisone w/acetic INSULININSPIREASE RESERVOIRacid 108 SYRINGES/0.5ML/28GX1/2"BAGS 91hydrocortisone-aloe vera 41 76INSULIN SYRINGE/0.3ML/29G INSULINHYDROMORPHONE HCL 5 X 1" 75 SYRINGES/0.5ML/29GX1/2"hydromorphone hcl 5 INSULIN SYRINGE/0.3ML/29G

X 1/2" 75 76 hydroquinone 43 INSULININSULIN SYRINGE/0.3ML/30Ghydroxychloroquine sulfate 24 X 5/16" 75 SYRINGES/0.5ML/30GX5/16"hydroxyurea 25 INSULIN SYRINGE/0.3ML/31G 76

INSULINX 5/16" 75hydroxyzine hcl 8 SYRINGES/0.5ML/31GXINSULIN SYRINGE/0.5ML/27GHYDROXYZINE PAMOATE 8 5/16" 76X 1/2" 75 hydroxyzine pamoate 8 INSULIN SYRINGE/0.5ML/28G

X 1/2" 75

Index 15

INSULIN SYRINGES/0.5ML/31GX5/16"

76 INSULIN SYRINGES/1ML/27GX/1/2" 76 INSULIN SYRINGES/1ML/27GX1/2" 76 INSULIN SYRINGES/1ML/28GX1/2" 76 INSULIN SYRINGES/1ML/29GX1/2" 76 INSULIN SYRINGES/1ML/30GX1/2" 76 INSULIN SYRINGES/1ML/31GX5/16" 76 INSUPEN 29G X 12MM 76 INSUPEN ULTRAFIN 29GX12MM 77 INSUPEN ULTRAFIN 30GX8MM 77 INTELENCE 29 INTENSE SENSATION 57 INTUNIV 1 INVIRASE 29 IOPIDINE 106 ipratropium bromide 9 ipratropium bromide (nasal)104 ipratropium-albuterol 10 irbesartan 22 irbesartan-hydrochlorothiazide

23 ISENTRESS 29 ISONIAZID 24 isoniazid 24 ISOPTO ATROPINE 105 ISOPTO CARPINE 105 ISORDIL TITRADOSE 8 isosorbide dinitrate 8 ISOSORBIDE DINITRATE ER8 isosorbide mononitrate 8 isotretinoin 39 itraconazole 19 J & J GAUZE 2"X2" 8 PLY 55 J & J GAUZE 4"X4" 12 PLY 55 J & J GAUZE 4"X4" 8 PLY 55 J & J GAUZE SPONGES 12-PLY 4" X 4" 55 J & J GAUZE SPONGES 16-PLY 4" X 4" 55 J & J GAUZE SPONGES 8-PLY4" X 4" 55 JADENU 18

JARDIANCE 17 JENTADUETO 16 K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH 97 K-PHOS NEUTRAL 94 K-TAB 94 KADIAN 5 KALETRA 29 KALYDECO 110 KAMELEON LUBRICATED 57 KAPVAY 1 KAYEXALATE 95 KEFLEX 33 KENDALL HYDROPHILIC FOAMDRESSING 2"X2" 55 KENDALL HYDROPHILIC FOAMDRESSING 3"X3" 55 KENDALL HYDROPHILIC FOAMDRESSING 4"X4" 55 KENDALL HYDROPHILIC FOAMPLUS DRESSING 2"X2" 55 KENDALL HYDROPHILIC FOAMPLUS DRESSING 3"X3" 55 KEPPRA 11 KEPPRA XR 11 KERLIX SPONGES 4" X 4" 12 PLY 55 KERLIX SPONGES 4" X 4" 16 PLY 55 KETOCARE 44 ketoconazole (topical) 39 KETONE TEST STRIPS 44 ketoprofen 3 KETOPROFEN 3 KETOPROFEN ER 3 ketorolac tromethamine 3 ketorolac tromethamine (ophth) 107 KETOSTIX 44 ketotifen fumarate (ophth)107 KIMONO COLORS 57 KIMONO LUBRICATED 57 KIMONO MICRO THIN 57 KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED 57 KIMONO PLUS SPERMICIDE LUBRICATED 57

KIMONO PLUS SPERMICIDE/LUBRICATED

57 KIMONO PS LUBRICATED 57 KIMONO PS PLUS SPERMICIDE/LUBRICATED

57 KIMONO SENSATION LUBRICATED 57 KIMONO SENSATION PLUS SPERMICIDE LUBRICATED57 KIMONO SPECIAL 57 KINNEY LANCETS 61 KINNEY THIN LANCETS 61 KINRAY INSULIN SYRINGE PREFERRED PLUS/0.3ML/31GX 5/16" 77 KINRAY INSULIN SYRINGE PREFERRED PLUS/0.5ML/31GX 5/16" 77 KINRAY INSULIN SYRINGE PREFERRED PLUS/1ML/31G X5/16" 77 KINRAY INSULIN SYRINGE/0.5ML/29G X 1/2" 77 KITABIS PAK 2 KLARON 39 KLONOPIN 11 KLOR-CON M15 94 KLOR-CON/25 94 KMART VALU PLUS INSULIN SYRINGE/1ML/29G 77 KMART VALU PLUS INSULIN SYRINGE/1ML/30G 77 KOKO PEAK PRO REPLACEMENTPLASTIC MOUTHPIECE 91 KP PRENATAL MULTIVITAMINS 101 KPN PRENATAL 101 KROGER INSULIN SYRINGE/0.3ML/29G X 1/2" 77 KROGER INSULIN SYRINGE/0.3ML/30G X5/16" 77 KROGER INSULIN SYRINGE/0.3ML/31G X5/16" 77 KROGER INSULIN SYRINGE/0.5ML/29G X 1/2" 77 KROGER INSULIN SYRINGE/0.5ML/30G X5/16" 77 KROGER INSULIN SYRINGE/0.5ML/31G X5/16" 77

Index 16

KROGER INSULIN SYRINGE/1ML/29G X 1/2" 77 KROGER INSULIN SYRINGE/1ML/30G X 5/16" 77 KROGER INSULIN SYRINGE/1ML/31G X 5/16" 77 KROGER LANCETS 61 KROGER LANCETS 21G 61 KROGER LANCETS MICRO THIN33G 61 KROGER LANCETS SUPER THIN 62 KROGER LANCETS THIN 62 KROGER LANCETS THIN 26G 62 KROGER LANCETS ULTRATHIN30G 62 KROGER LANCING DEVICE 62 KROGER PEN NEEDLES 29G X12MM 77 labetalol hcl 31 LAC-HYDRIN 42 LAC-HYDRIN TWELVE 42 lactic acid (ammoniumlactate) 42 lactulose 51 lactulose (encephalopathy) 48 LAMICTAL 11 LAMICTAL CHEWABLE DISPERSIBLE 11 LAMICTAL XR 11 LAMISIL 19 LAMISIL AT 39 LAMISIL AT JOCK ITCH 39 lamivudine 29 lamivudine-zidovudine 29 lamotrigine 11 LANCET DEVICE ADJUSTABLE 62 LANCET DEVICE WITH EJECTOR 62 LANCETS 62 LANCETS 26G TWIST TOP 62 LANCETS 28G 62

LANCETS ULTRA THIN 62 LANCING DEVICE 62 LANCING DEVICE ADJUSTABLE 62 LANOXIN 33 lansoprazole 113 LANZO 62 LASIX 46 latanoprost 107 LATANOPROST 108 LEADER ADVANCED LANCING DEVICE 62 LEADER INSULIN SYRINGE/0.3ML/29G X1/2" 77 LEADER INSULIN SYRINGE/0.3ML/30G X5/16" 77 LEADER INSULIN SYRINGE/0.3ML/31G X5/16" 77 LEADER INSULIN SYRINGE/0.5ML/28G X1/2" 77 LEADER INSULIN SYRINGE/0.5ML/29G X1/2" 77 LEADER INSULIN SYRINGE/0.5ML/30G X5/16" 77 LEADER INSULIN SYRINGE/0.5ML/31G X5/16" 77 LEADER INSULIN SYRINGE/1ML/28G X 1/2" 77 LEADER INSULIN SYRINGE/1ML/29G X 1/2" 77 LEADER INSULIN SYRINGE/1ML/30G X5/16" 77 LEADER INSULIN SYRINGE/1ML/31G X5/16" 77 LEADER QUICK DISSOLVE GLUCOSE 16 leflunomide 3 letrozole 25

levocarnitine (metabolicmodifiers) 46 levocetirizine dihydrochloride20 levofloxacin 48 levonorgestrel & ethestradiol 34 levonorgestrel (emergencyoc) 35 levonorgestrel-eth estradiol(triphasic) 34 levonorgestrel-ethinyl estradiol(91-day) 34 levothyroxine sodium 111 LEVSIN 112 LEVSIN/SL 112 LEXAPRO 14 LEXIVA 29 LIBERTY MINI LANCING DEVICE 62 lidocaine 43 lidocaine hcl 43 lidocaine hcl (mouth-throat) 95 lidocaine-prilocaine 43 liothyronine sodium 111 LIPITOR 21 lisinopril 22 lisinopril &hydrochlorothiazide 23 LITE TOUCH LANCING PEN 62 LITEAIRE 91 LITETOUCH INSULIN SYRINGE/0.3ML/29G X 1/2" 77 LITETOUCH INSULIN SYRINGE/0.3ML/30G X5/16" 77 LITETOUCH INSULIN SYRINGE/0.3ML/31G X5/16" 78 LITETOUCH INSULIN SYRINGE/0.5ML/30G X5/16" 78 LITETOUCH INSULIN SYRINGE/0.5ML/31G X5/16" 78 LITETOUCH INSULIN

LANCETS 30G LANCETS SAFETY SEAL 21G LANCETS SAFETY SEAL 26G LANCETS SAFETY SEAL 28G

62

62

62

62

LEUCOVORIN CALCIUM 25 leucovorin calcium 25 LEUKERAN 25 LEVAQUIN 47 LEVBID 112 levetiracetam 11,12

SYRINGE/1ML/30G X 5/16" 78 LITETOUCH INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 78 LITETOUCH INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 78

LANCETS THIN 62 levobunolol hcl 105

Index 17

LITETOUCH INSULIN SYRINGE/U-100/1ML/28G X1/2" 78 LITETOUCH INSULIN SYRINGE/U-100/1ML/29G X1/2" 78 LITETOUCH INSULIN SYRINGE/U-100/1ML/31G X5/16" 78 LITETOUCH MASK LARGE 91 LITETOUCH MASK MEDIUM 91 LITETOUCH MASK SMALL 91 LITHIUM 26 lithium carbonate 26 LITHIUM CARBONATE 26 lithium carbonate 26 LITHOBID 26 LIVE BETTER ADVANCED LANCING DEVICE 62 LIVE BETTER LANCET SUPERTHIN 30G 62 LIVE BETTER LANCET ULTRATHIN 28G 62 LIVE BETTER PEN NEEDLES 29G X 12MM 78 LMX 4 43 LOCOID 42 LODINE 3 LODOSYN 25 LOESTRIN 1.5/30-21 34 LOESTRIN 1/20-21 34 LOESTRIN FE 1.5/30 34 LOESTRIN FE 1/20 34 LOFIBRA 21 LOHIST-D 37 LOMOTIL 18 LONGS INSULIN SYRINGE/0.5ML/31G X5/16" 78 LONGS LANCETS STANDARD 62 LONGS LANCETS THIN 62 loperamide hcl 18 LOPID 21 lopinavir-ritonavir 29 LOPRESSOR 31 LOPRESSOR HCT 23 loratadine 20 loratadine & pseudoephedrine 37 lorazepam 8

losartan potassium 22 losartan potassium &hydrochlorothiazide 23 LOTENSIN 22 LOTENSIN HCT 23 LOTREL 23 LOTRIMIN AF 39 LOTRIMIN AF FOR HER 40 LOTRIMIN AF JOCK ITCH 40 LOTRISONE 40 lovastatin 21 LOVENOX 11 loxapine succinate 27 LURIDE 94 LYSTEDA 49 M-M-R II 117 M-VIT 101 MACROBID 113 MACRODANTIN 113 MACULAR VITAMIN BENEFIT 98 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/29G X1/2" 78 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/30G X5/16" 78 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/29G X1/2" 78 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/30G X5/16" 78 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X1/2" 78 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/30G X5/16" 78 magnesium citrate 51 magnesium hydroxide 51 magnesium oxide 7 magnesium oxide (mgsupplement) 94 MAGOX 400 94 MAKENA 109 malathion 43 MAPROTILINE HCL 13 MARATHON MEDICAL PENTIPS29GX12MM 78 MAVIK 22 MAVYRET 30

MAXALT 93 MAXALT-MLT 93 MAXI-COMFORT INSULIN SYRINGE/U-100/0.5ML/28GX1/2" 78 MAXI-COMFORT INSULIN SYRINGE/U-100/1ML/28GX1/2"

78 MAXITROL 107

MEDICAL PROVIDER EZ FLU

MAXX LUBRICATED 57 MAXX PLUS SPERMICIDE LUBRICATED 57 MAXZIDE 45 MAXZIDE-25 45 meclizine hcl 19 MEDIC INSULIN SYRINGE/0.3ML/30G X5/16"MEDIC INSULIN

78

SYRINGE/0.5ML/30G X5/16" 78

SHOT 2015-2016 117 MEDICAL PROVIDER EZ FLU SHOT PF 2014-2015 117 MEDICAL PROVIDER SINGLE USE EZ FLU SHOT 117 MEDICINE SHOPPE PEN NEEDLES 29G X 12MM 78 MEDISENSE THIN LANCETS 62 MEDROL 35 MEDROL DOSEPAK 35 medroxyprogesterone acetate 109 medroxyprogesterone acetate(contraceptive) 35 mefloquine hcl 24 MEFLOQUINE HCL 24 MEGA MULTI FOR WOMEN98 MEGA MULTIVITAMIN FOR MEN 98 MEGA MULTIVITAMIN FOR WOMEN 98 MEGACE ORAL 25 MEGAVITE FRUITS & VEGGIES 98 MEGAVITE GOLDEN YEARS 55+ 98 megestrol acetate 25 MEIJER ALCOHOL SWABS EXTRA-THICK 66 MEIJER COLOR LANCETS UNIVERSAL 33G 62 MEIJER LANCETS 62

Index 18

MEIJER LANCETS THIN 62 methylergonovine MINIELITE RECHARGEABLE maleate 108 BATTERY 91MEIJER LANCETS

UNIVERSAL21G 62 methylphenidate hcl 1,2 MINIPRESS 22 MEIJER LANCETS METHYLPHENIDATE HCL MINIVELLE 47 UNIVERSAL30G 62 ER 1,2 MINOCIN 111MEIJER LANCETS methylprednisolone 35 minocycline hcl 111UNIVERSAL33G 62 METIPRANOLOL 105MEIJER PEN NEEDLES 29G minoxidil 24

metoclopramide hcl 48X12MM 78 MIRALAX 51MEIJER SUPER THIN metolazone 46 MIRAPEX 26LANCETS 62 metoprolol & MIRASORB SPONGES 2" Xmeloxicam 3 hydrochlorothiazide 23 2" 55melphalan 25 metoprolol succinate 31 MIRASORB SPONGES 4" XMETOPROLOL SUCCINATEmemantine hcl 109 4" 55ER/HYDROCHLOROTHIAZIDEMENACTRA 114 MIRCETTE 34

MENOMUNE-A/C/Y/W-135 23 mirtazapine 13metoprolol tartrate 31114 METOPROLOL/HYDROCHLO misoprostol 113MENS 50+ MULTI VITAMIN ROTHIAZIDE 23 MM INSULIN SYRINGE/U-&MINERAL FORMULA 98 100/0.3ML/30G X 5/16" 78METROCREAM 43MENS MULTI VITAMIN & MM INSULIN SYRINGE/U-MINERAL FORMULA 98 METROGEL-VAGINAL 117 100/0.3ML/31G X 5/16" 78MENVEO 114 METROLOTION 43 MM INSULIN SYRINGE/U-

MEPERIDINE HCL 5 metronidazole 7 100/1/2ML/30G X 5/16" 78 MM INSULIN SYRINGE/U-meperidine hcl 5 metronidazole (topical) 43 100/1/2ML/31G X 5/16" 78MEPHYTON 118 metronidazole vaginal 117 MM INSULIN SYRINGE/U-

meprobamate 8 MEVACOR 21 100/1ML/30G X 5/16" 78 mercaptopurine 25 MM INSULIN SYRINGE/U-mexiletine hcl 9 100/1ML/31G X 5/16" 79mesalamine 48 MIACALCIN 46 MM LANCING DEVICE 62MESTINON 24 MICARDIS 22 MOBIC 3MESTINON TIMESPAN 24 MICARDIS HCT 23 MODICON 34METADATE CD 1 MICATIN 40 MOLINDONEMETAMUCIL 50 MICONAZOLE 3 117 HYDROCHLORIDE 27 METAMUCIL ORIGINAL miconazole nitrate (topical)40 mometasone furoate 42TEXTURE 50 miconazole nitrate MONISTAT 3 118METAPROTERENOL vaginal 117 MONISTAT 3 COMBINATIONSULFATE 10 MICRO-K 94 PACK 118metformin hcl 16 MONISTAT 7 SIMPLYMICROCHAMBER 91methadone hcl 5 CURE 118MICROELITE FILTERmethazolamide 45 MONISTAT SOOTHING CAREREPLACEMENTS 91METHENAMINE MICROELITE ITCH RELIEF 42 MANDELATE 113 RECHARGEABLE MONODOX 111 methenamine mandelate 113 BATTERY 91 MONOJECT INSULIN methenamine-hyosc-methylene MICROLET NEXT 62 SYRINGE/1ML 79 blue-sod phos-phenyl sal 113 MONOJECT INSULINMICROSPACER 91 SYRINGE/1ML/31G X 5/16" 79methimazole 111 MICROZIDE 46 MONOJECT INSULINMETHITEST 6 midazolam hcl 50 SYRINGE/DETACHmethocarbamol 104 NEEDLE/1ML/25G X 5/8" 79midodrine hcl 118methotrexate sodium 25 MONOJECT INSULINMILLIPRED 35 SYRINGE/DETACHMETHOTREXATE SODIUM 25 MINI LANCING DEVICE 62 NEEDLE/1ML/27G X 1/2" 79methotrexate sodium 25 MINIELITE FILTER MONOJECT INSULIN methyldopa 22 REPLACEMENTS 91 SYRINGE/PERM

NEEDLE/1ML/28G X 1/2" 79

Index 19

MONOJECT INSULIN MONOJECT ULTRA MULTIVITAMIN/FLUORIDESYRINGE/PERM NEEDLE/U- COMFORT INSULIN 100 100/0.5ML/28G X 1/2" 79 SYRINGE/0.5ML/31G X mupirocin 39 MONOJECT INSULIN 5/16" 80 mupirocin calcium (topical) 39SYRINGE/SAFETY/PERM MONOJECT ULTRA NEEDLE/0.3ML/29G X 1/2" 79 COMFORT INSULIN MYAMBUTOL 24 MONOJECT INSULIN SYRINGE/1ML/28G X 1/2" 80 mycophenolate mofetil 95 SYRINGE/SAFETY/PERM MONOJECT ULTRA mycophenolate sodium 95 NEEDLE/0.3ML/29GX1/2" 79 COMFORT INSULIN MYDRIACYL 105MONOJECT INSULIN SYRINGE/1ML/29G X 1/2" 80 SYRINGE/SAFETY/PERM MONOJECT ULTRA MYFORTIC 95 NEEDLE/0.5ML/29G X 1/2" 79 COMFORT INSULIN MYLERAN 25 MONOJECT INSULIN SYRINGE/1ML/30G X MYLICON 48SYRINGE/SAFETY/PERM 5/16" 80 MYLICON INFANTS GASNEEDLE/1ML/29G X 1/2" 79 MONOLET LANCETS 62 RELIEF 48MONOJECT INSULIN MONOLET OPD MYNATAL 101SYRINGE/SOFTPACK/1ML/27G LANCETS 62X 1/2" 79 MYNATAL ADVANCE 101montelukast sodium 9MONOJECT INSULIN MYNATAL PLUS 101MOORE MED MONOJECTSYRINGE/SOFTPACK/U- INSULIN SYRINGE/U- MYNATAL ULTRACAPLET 101100/0.5ML/28G X 1/2" 79 100/0.5ML/28G X 1/2" 80 MYNATAL-Z 101MONOJECT INSULIN MOORE MED MONOJECTSYRINGE/U-100/0.3ML/30G X MYNATE 90 PLUS 102INSULIN SYRINGE/U-5/16" 79 MYSOLINE 12100/0.5ML/29G X 1/2" 80MONOJECT INSULIN MOORE MED MONOJECT nabumetone 3SYRINGE/U-100/0.5ML/28G X1/2" 79 INSULIN SYRINGE/U- nadolol 32

100/1ML/28G X 1/2" 80MONOJECT INSULIN naloxone hcl 18MOORE MED MONOJECTSYRINGE/U-100/0.5ML/30G X INSULIN SYRINGE/U- NALOXONE HCL 185/16" 79 100/1ML/29G X 1/2" 80 naltrexone hcl 18MONOJECT INSULIN SYRINGE/U-100/1ML/28G X morphine sulfate 5 NAMENDA 109 1/2" 79 MORPHINE SULFATE 5 NAMENDA TITRATION MONOJECT INSULIN morphine sulfate 5 PAK 109 SYRINGE/U-100/1ML/30G X NAPROSYN 3MOTRIN INFANTS DROPS 35/16" 79 naproxen 3MONOJECT INSULIN moxifloxacin hcl (ophth) 106

naproxen sodium 3SYRINGEREGULAR LUER MS CONTIN 5 TIP/SOFTPACK/1ML 79 MS INSULIN naratriptan hcl 93 MONOJECT ULTRA COMFORT SYRINGE/0.3ML/31G X NARCAN 18INSULIN SYRINGE/0.3ML/29G X 5/16" 80 NARDIL 141/2" 79 MS INSULINMONOJECT ULTRA COMFORT SYRINGE/0.5ML/31G X NASAL DECONGESTANT 104 INSULIN SYRINGE/0.3ML/30G X 5/16" 80 NASALCROM 104 5/16" 79 MS INSULIN NAT-RUL PRENATALMONOJECT ULTRA COMFORT SYRINGE/1ML/31G X VITAMINS 102INSULIN SYRINGE/0.3ML/31G X 5/16" 80 NAT-RUL THERAVITE-5/16" 79 MUCINEX 38 M/HIGHPOTENCY 98MONOJECT ULTRA COMFORT NATALVIT 102MULTI PRENATALINSULIN SYRINGE/0.5ML/28G X 101

nateglinide 171/2" 79 MULTI-BETIC DIABETES 98 MONOJECT ULTRA COMFORT NATRUL-MEGA-75 98MULTI-LANCET DEVICE 62 INSULIN SYRINGE/0.5ML/29G X NATRUL-VITES 98MULTI-VITAMIN1/2" 79 MONOCAPS 98 NEBULIZER AIRMONOJECT ULTRA COMFORT multiple vitamins w/ TUBE/PLUGS 91INSULIN SYRINGE/0.5ML/30G X 98 NEBULIZER PEDIATRICminerals5/16" 79 MASK 91MULTIVITAMIN ADULTS 98

NECON 1/50-28 34MULTIVITAMIN MEN 98

Index 20

NECON 10/11-28 34 nicotine 110 nortriptyline hcl 16 NEFAZODONE HCL 15 nicotine polacrilex 110 NORVASC 32 nefazodone hcl 15 NICOTINE TRANSDERMAL NORVIR 29 neomycin sulfate 2 neomycin-bacitracin zn-polymyxin 106 neomycin-bacitracin-polymyxin

39 neomycin-polymy-dexameth 107

SYSTEM NICOTROL INHALER NICOTROL NS nifedipine NINLARO NITRO-BID

110 110 110

32 25

8

NOSE CLIP 91 NOVA MAX PLUS KETONE TESTSTRIPS 44 NOVA SUREFLEX LANCETS 62 NOVA SUREFLEX LANCING DEVICE 62

neomycin-polymyxin w/pramoxine 39 neomycin-polymyxin-gramicidin

106 neomycin-polymyxin-hc(otic) 108 NEOMYCIN/POLYMYXIN/HYDROCORTISONE 107 NEORAL 95 NEOSPORIN 106 NEOSPORIN ORIGINAL 39 NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH 39 NEPHRO-VITE RX 96 NEPHROCAPS 96 NEPTAZANE 45 NEURONTIN 12 NEUTROGENA T/GEL 44 NEUTROGENA T/GELSTUBBORN ITCH CONTROL 44 nevirapine 29 NEXIUM 113

NITRO-DUR 8 nitrofurantoin 113 nitrofurantoin macrocrystal 113 nitrofurantoin monohyd macro 113 nitroglycerin 8 NITROSTAT 8 NIVA-PLUS 102 NIX CREME RINSE 43 NIZORAL 40 NO IRON MULTIPLE VITAMIN/MINERALS 98 NOR-QD 35 NORCO 5 NORDITROPIN FLEXPRO 46 norethin acet & estrad-fe 34 norethindrone & eth estradiol 34 norethindrone & ethinylestradiol-fe 34 norethindrone (contraceptive) 35 norethindrone acet & eth

NOVOFINE 30GX8MM 80 NOVOFINE AUTOCOVER 30GX8MM 80 NOVOLIN 70/30 17 NOVOLIN 70/30 RELION 17 NOVOLIN N 17 NOVOLIN N RELION 17 NOVOLIN R 17 NOVOLIN R RELION 17 NOVOLOG MIX 70/30 17 NOVOLOG MIX 70/30PREFILLED FLEXPEN 17 NOVOTWIST 30GX8MM 80 NOVOTWIST 32GX5MM 80 NU GAUZE 4PLY 4"X4" 55 NU GAUZE GENERAL-USE SPONGES 4"X4" 4 PLY 55 NULYTELY/FLAVORPACKS 51 NUPLAZID 26 NUTRICAP 98 NUTRICION PORVIDA 102 NUVARING 35

NEXIUM 24HR NEXIUM 24HR CLEAR MINIS niacin

113

113 118

estra 34 norethindrone acetate 109 norethindrone acetate-ethinylestradiol 47

nystatin nystatin (mouth-throat) nystatin (topical)

19 95 40

niacin (antihyperlipidemic) NIACOR NIASPAN NICADAN NICADAN ZX nicardipine hcl NICAZEL NICAZEL FORTE NICODERM CQ NICORETTE NICORETTE MINI NICORETTE STARTER

21 21 21 98 98 32 98 98

110 110 110

norethindrone acetate-ethinylestradiol-fe 34 norethindrone-eth estradiol (triphasic) 34 norgestimate-ethinylestradiol 34 norgestimate-ethinyl estradiol(triphasic) 34 norgestrel & ethinylestradiol 34 NORINYL 1+35 34 NORPACE 9 NORPACE CR 9 NORPRAMIN 16

nystatin-triamcinolone NYTOL MAXIMUM STRENGTH O-CAL FA O-CAL PRENATAL OB COMPLETE ADVANCED OCEAN NASAL SPRAY OCUFEN OCUFLOX OCULAR VITAMINS ODEFSEY OFF DEEP WOODS

40

50 102 102

102 104 107 106

98 29 43

KIT 110 NORTEMP INFANTS 4 OFF DEEP WOODS DRY 43

Index 21

ofloxacin 48 ofloxacin (ophth) 106 ofloxacin (otic) 108 OGESTREL 34 olanzapine 27 olmesartan medoxomil 22 olmesartan medoxomil-amlodipine-hydrochlorothiazide

23 olmesartan medoxomil-hydrochlorothiazide 23 omeprazole 113 OMNIPRED 107 OMNITROPE 46 ON CALL LANCING DEVICE 62 ON CALL PLUS LANCING DEVICE 62 ONCOVITE 98 ondansetron 19 ondansetron hcl 18 ONE DAILY MENS FORMULA W/O IRON 98 ONE DAILY PLUS IRON 98 ONE DAILY WOMENS 98 ONE FLOW TESTER TUBE MOUTHPIECE 91 ONE-A-DAY ENERGY 98 ONE-A-DAY MENOPAUSE FORMULA 98 ONE-A-DAY MENS 50+ ADVANTAGE 98 ONE-A-DAY MENS HEALTH FORMULA 98 ONE-A-DAY MENS PRO EDGE 98 ONE-A-DAY PROACTIVE 65+ 98 ONE-A-DAY TEEN ADVANTAGEFOR HIM 98 ONE-WAY VALVED EXPIRATORYMOUTHPIECE/DISPOSABLE 91 ONE-WAY VALVED INSPIRATORY MOUTHPIECE/DISPOSABLE

91 ONETOUCH DELICA LANCING DEVICE 63 OPTI-WOMAN 98 OPTICHAMBER ADVANTAGE/LARGEMASK 91

OPTICHAMBER ADVANTAGE/MEDIUM FACEMASK 91 OPTICHAMBER ADVANTAGE/SMALL FACEMASK 91 OPTICHAMBER DIAMOND 91 OPTICHAMBER DIAMOND/LARGEFACEMASK 91 OPTICHAMBER DIAMOND/MEDIUM FACEMASK 91 OPTICHAMBER DIAMOND/SMALLFACEMASK 91 OPTICHAMBER FACE MASK/LARGE 91 OPTICHAMBER FACE MASK/MEDIUM 91 OPTICHAMBER FACE MASK/SMALL 91 OPTIFOAM 55 OPTIHALER 91 OPTIHALER MDI DRUG DELIVERY SYSTEM 91 OPURITY 98 oral electrolytes 93 ORKAMBI 111 orphenadrine citrate 104 ORTHO MICRONOR 35 ORTHO TRI-CYCLEN 34 ORTHO TRI-CYCLEN LO 34 ORTHO-CYCLEN 34 ORTHO-NOVUM 1/35 34 ORTHO-NOVUM 7/7/7 34 oseltamivir phosphate 31 OVACE PLUS WASH 40 OVACE WASH 40 OVCON-35 34 OVIDE 43 oxaprozin 3 oxazepam 8 OXAZEPAM 8 oxcarbazepine 12 oxybutynin chloride 113,114 oxycodone hcl 5 oxycodone w/acetaminophen 5 oxycodone-aspirin 6

OXYCODONE/ACETAMINOPHEN 6 oxymorphone hcl OXYMORPHONE

5

HYDROCHLORIDE ER 5 PAMELOR 16 PANCREAZE 45 PANOXYL-4 CREAMY WASH 39 pantoprazole sodium 113 PAREGORIC 18 PARI ALTERA NEBULIZER HANDSET 91 PARI BABY CONVERSION KITSIZE 1 91 PARI BABY CONVERSION KITSIZE 2 91 PARI BABY CONVERSION KITSIZE 3 91 PARI ERAPID NEBULIZER HANDSET 91 PARI EXPIRATORY FILTER VALVE SET 91 PARI MASK SET 92 PARI SOFT PLASTIC ADULT MASK 92 PARI SOFT PLASTIC PEDIATRIC MASK 92 PARLODEL 26 PARNATE 14 paroxetine hcl 14 PARVLEX 98 PAXIL 14 PAXIL CR 14 PC LANCETS SUPER THIN 30G 63 PC UNIFINE PENTIPS 29G X1/2" 80 PCE 52 ped multivitamins w/fl &iron 101 PEDIALYTE 94 PEDIALYTE FREEZER POPS 93 PEDIAPRED 35 PEDIATRIC AEROSOL MASK 92 PEDIATRIC DISPOSABLE MOUTPIECE 92 PEDIATRIC MOUTHPIECE/DISPOSABLE

92 pediatric multiple vitamin w/ c 101

Index 22

pediatric multiple vitamin w/ c &fa 101 pediatric multiple vitamins w/iron 101 pediatric multivitamins w/fl 100 pediatric vitamins acd w/fluoride 100 pediatric vitamins adc 101 peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 51 peg 3350-potassium chloride-sodbicarbonate-sod chloride 51 PEN NEEDLES 29G X 12MM 80 PEN NEEDLES 29GX1/2" 80 PEN NEEDLES 30GX5/16" 80 PEN NEEDLES 30GX8MM 80 PEN NEEDLES 32G X 5MM 80 PENICILLIN V POTASSIUM 108 penicillin v potassium 108 PENTIPS 29G X 12MM 80 PENTIPS 29GX12MM 80 pentoxifylline 49 PEPCID 112

phenylephrine hcl (oral) 104 phenylephrine-cocoa butter 6 phenylephrine-dm 37 phenylephrine-shark liver oil-cocoa butter 6 phenylephrine-shark liver oil-mineral oil-petrolatum 6 PHENYTEK 12 phenytoin 13 phenytoin sodiumextended 13 PHYTOMULTI 98 phytonadione 118 PILLOW MASK/ADULT 92 PILLOW MASK/CHILD 92 PILLOW MASK/PEDIATRIC 92 pilocarpine hcl 105 pilocarpine hcl (oral) 96 pindolol 32 pioglitazone hcl 17 pioglitazone hcl-metforminhcl 16 piroxicam 3

polysaccharide iron complex 49 POLYTRIM 106 polyvinyl alcohol 105 pot phosphate monobasic w/ sodphosphate dibasic &monobasic 94 potassium bicarbonate 94 potassium chloride 94 POTASSIUM CHLORIDE 94 potassium chloride 94 POTASSIUM CHLORIDE ER 94 potassium chloridemicroencapsulated crystals er 94 potassium citrate(alkalinizer) 48 potassium citrate-citric acid 48 pramipexole dihydrochloride 26 pramoxine hcl (rectal) 6 prasugrel hcl 49 PRAVACHOL 21 pravastatin sodium 21 prazosin hcl 22

PEPCID AC 112 PLAN B ONE-STEP 35 PRE-NATAL FORMULA 102 PEPCID AC MAXIMUM STRENGTH PEPTO-BISMOL PEPTO-BISMOL INSTACOOL PEPTO-BISMOL MAX STRENGTH PEPTO-BISMOL TO-GO PERCOCET

112 18

18

18 18

6

PLAQUENIL PLAVIX PLEGRIDY PLEGRIDY STARTER PACK PNEUMOVAX 23 PNEUMOVAX 23/1DOSE PNV FERROUS

24 49

110

110 114

114

PRECISION SURE-DOSE INSULIN SYRINGE/0.3ML/30G X5/16" 80 PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/28G X1/2" 80 PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/29G X1/2" 80 PRECISION SURE-DOSE

PERFECT LANCETS 30G 63 PERIDEX 95 permethrin 43 perphenazine 28 PERPHENAZINE/AMITRIPTYLINE 110

FUMARATE/DOCUSATE/FOLIC ACID 102 PNV FOLIC ACID + IRON MULTIVITAMIN 102 PNV PRENATAL PLUS MULTIVITAMIN 102 PNV TABS 29-1 102

INSULIN SYRINGE/0.5ML/30G X3/8" 80 PRECISION SURE-DOSE INSULIN SYRINGE/1ML/28G X1/2" 80 PRECISION SURE-DOSE PLUSINSULIN

PERRY PRENATAL PFLEX PHARMACY COUNTER LANCETS phenazopyridine hcl phenelzine sulfate phenobarbital PHENOBARBITAL phenobarbital phenylephrine hcl (ophth)

102 92

63 49 14 50 50 50

106

POCKET CHAMBER 92 POCKET SPACER 92 podofilox 42 POLYCOSE 105 polyethylene glycol 3350 51 POLYMEM DRESSING/3" X3" 55 POLYMEM DRESSING/4" X4" 55 polymyxin b-trimethoprim 106

SYRINGE/0.3ML/29G X 1/2" 80 PRECISION SURE-DOSE PLUSINSULIN SYRINGE/1ML/29G X 1/2" 80 PRECISION THIN LANCETS 63 PRECISION THINS GP LANCET 63 PRECISION ULTRA LANCET 63 PRECISION XTRA 44 PRED FORTE 107

Index 23

PRED MILD 107 PRED-G 107 PREDATOR 43 prednicarbate 42 PREDNICARBATE 42 prednisolone 35 PREDNISOLONE 36 prednisolone acetate(ophth) 107 PREDNISOLONE ACETATE P-F 107 prednisolone sodiumphosphate 35 PREDNISOLONE SODIUM PHOSPHATE 107 PREDNISONE 36 prednisone 36 PREDNISONE 36 PREDNISONE INTENSOL 36 PREFERRED PLUS INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 80 PREFERRED PLUS INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 81 PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 81 PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 81 PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 81 PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/28G X1/2" 81 PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/29G X1/2" 81 PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/30G X5/16" 81 PREFERRED PLUS LANCETS COLORED 21G 63 PREFERRED PLUS LANCETS SUPER THIN 30G 63 PREFERRED PLUS LANCETS THIN 26G 63 PREFERRED PLUS UNIFINE PENTIPS 29G X 12MM 81 PREMARIN 47,118 PREMIUM CONDOMS LUBRICATED 57 PREMPHASE 47

PREMPRO 47 PRENATABS FA 102 PRENATABS RX 102 PRENATAL 103 PRENATAL + DHA 102 PRENATAL 19 102 PRENATAL AND IRON 102 PRENATAL FORTE 102 PRENATAL LOW IRON 102 PRENATAL MULTIVITAMIN 102 PRENATAL ONE DAILY 102 PRENATAL PLUS 102 PRENATAL PLUS IRON 102 PRENATAL VITAMIN 103 PRENATAL VITAMIN & MINERAL 103 PRENATAL VITAMIN/IRON 103 PRENATAL VITAMINS 103 PRENATAL VITAMINS PLUS LOW IRON 103 PREPLUS 103 PRESERVISION AREDS 98 PRETAB 103 PREVACID 113 PREVACID 24HR 113 PREVIDENT 5000 DRY MOUTH 95 PREVIDENT 5000 PLUS 95 PREVIDENT FLUORIDE 95 PREVNAR 13 114 PREZCOBIX 29 PREZISTA 29 PRILOSEC 113 PRILOSEC OTC 113 PRIMAQUINE PHOSPHATE 24 primidone 12 PRINIVIL 22 PRISTIQ 15 PRO COMFORT INSULIN SYRINGES/0.5ML/30G X1/2" 81 PRO COMFORT INSULIN SYRINGES/0.5ML/30G X5/16" 81 PRO COMFORT INSULIN SYRINGES/0.5ML/31G X5/16" 81

PRO COMFORT INSULIN SYRINGES/1ML/30G X 1/2" 81 PRO COMFORT INSULIN SYRINGES/1ML/30G X5/16" 81 PRO COMFORT INSULIN SYRINGES/1ML/31G X5/16" 81 PRO COMFORT PEN NEEDLES/32G X 5MM 81 PRO-CAL 98 probenecid 49 PROCARDIA 32 PROCARDIA XL 32 PROCERV HP 98 prochlorperazine 28 prochlorperazine maleate 28 PROCTOFOAM 6 PRODIGY INSULIN SYRING/U-100/0.3ML/31G X 5/16" 81 PRODIGY INSULIN SYRINGE/1/2ML/31G X5/16" 81 PRODIGY INSULIN SYRINGE/1ML/28G X 1/2" 81 PRODIGY LANCING DEVICE 63 PRODIGY TWIST TOP LANCETS 63 progesterone micronized 109 PROGRAF 95 promethazine &phenylephrine 37 promethazine hcl 20 promethazine w/codeine 37 promethazine-dm 37 promethazine-phenylephrine-codeine 37 PROMETHAZINE/PHENYLEPHRINE 37 PROMETRIUM 109 propafenone hcl 9 propranolol hcl 32 PROPRANOLOL HCL 32 propranolol hcl 32 PROPRANOLOL/HYDROCHLOROTHIAZIDE 23 propylthiouracil 111 PRORENAL+D 98 PROSCAR 49 PROTONIX 113 PROTOPIC 42

Index 24

PROVERA 109 QC LANCETS SUPER RA PRENATAL 103 THIN 63PROVIT 98 RA PRENATALQC LANCETS ULTRA FORMULA/FOLICACID 103PROZAC 14 THIN 63 RA STERILE PADS 2"X2" 56pseudoephed-bromphen-dm 37 QC PEN NEEDLES 29G X

RA STERILE PADS 3"X3" 5612MM 81pseudoephedrine hcl 104 QC PRENATAL 103 RA STERILE PADS 4"X4" 56pseudoephedrine w/ codeine-

gg 37 QC STERILE PADS 55 raloxifene hcl 46 pseudoephedrine-chlorphen-dm QC UNILET LANCETS ramipril 22

37 33G/MICRO THIN 63 ranitidine hcl 112pseudoephedrine-ibuprofen 37 QUENCH 99 RAPAMUNE 95PSORCON 42 QUESTRAN 21 RAY-TEC X-RAY PSS SELECT GP LANCETS 63 QUESTRAN LIGHT 21 DETECTABLESPONGES 4" X 4" PSS SELECT SAFETY quetiapine fumarate 27 16 PLY 56 LANCETS 63 RAZADYNE 109QUFLORA PEDIATRIC 101psyllium 50 RAZADYNE ER 109QUIN B STRONG 99PTS PANELS KETONE REALITY INSULIN SYRINGE/U-TEST 44 quinapril hcl 22 100/0.5ML/28G X 1/2" 82 PULMICORT 9 quinapril-hydrochlorothiazide REALITY INSULIN SYRINGE/U-

23,24PULMICORT FLEXHALER 9 100/0.5ML/29G X 1/2" 82 quinidine gluconate 9 REALITY INSULIN SYRINGE/U-PURIXAN 25 QUINIDINE SULFATE 9 100/1ML/28G X 1/2" 82PX ADVANCED LANCING REALITY INSULIN SYRINGE/U-DEVICE 63 QUINTABS-M 99 100/1ML/29G X 1/2" 82PX INSULIN SYRINGE/U- RA ALCOHOL SWABS 66 REALITY LANCETS 63100/0.3ML/30G X 1/2" 81 RA ALL PURPOSE

PX INSULIN SYRINGE/U- REALITY LATEXDRESSINGS4"X4" 56100/0.3ML/31G X 5/16" 81 CONDOMS/LUBRICATED 57RA CENTRAL-VITE 99PX INSULIN SYRINGE/U- REALITY LATEX/ULTRA

RA CENTRAL-VITE UNDER TEXTURED100/0.5ML/30G X 1/2" 81 57 PX INSULIN SYRINGE/U- 50MENS 99 REALITY LATEX/ULTRA

RA CENTRAL-VITE UNDER THIN 57100/0.5ML/31G X 5/16" 81 50WOMENS 99PX INSULIN SYRINGE/U- REALITY SWABS 66RA DRESSING SPONGES100/1ML/30G X 1/2" 81 RECOMBIVAX HB 1174"X4" 56PX INSULIN SYRINGE/U- RA E-ZJECT COLOR REGLAN 48100/1ML/31G X 5/16" 81 LANCETSMICRO-THIN RELENZA DISKHALER 31PX LANCET AUTO 33G 63INJECTOR 63 RELION 2-IN-1 LANCINGRA E-ZJECT LANCETS DEVICE 25G 63PX LANCETS ULTRA THIN 63 28G 63 RELION 2-IN-1 LANCINGPX PEN NEEDLE RA E-ZJECT LANCETS THIN DEVICE 30G 6329GX12MM 81 26G 63 RELION ALCOHOL SWABS 66PX PRENATAL RA E-ZJECT LANCETS THIN

MULTIVITAMINS 103 RELION INSULIN SYRINGE28G 63 pyrazinamide 24 1ML/31GX15/64" 82RA E-ZJECT LANCETS RELION INSULIN SYRINGE/U-pyrethrins-piperonyl butoxide43 ULTRATHIN 30G 63 00/1ML/29G X 1/2" 82pyrethrins-piperonyl butoxide- RA GAUZE SPONGES RELION INSULIN SYRINGE/U-permethrin-nit remover 44 4"X4" 56 100/0.3ML/29G X 1/2" 82RA INSULINPYRIDIUM 49 RELION INSULIN SYRINGE/U-SYRINGE/0.5ML/29G Xpyridostigmine bromide 24 100/0.3ML/30G X 5/16" 821/2" 81QC ADVANCED LANCING RELION INSULIN SYRINGE/U-RA INSULIN 100/0.3ML/31G X 5/16" 82DEVICE 63 SYRINGE/1ML/29G X 1/2" 81 RELION INSULIN SYRINGE/U-QC ALCOHOL SWABS 66 RA INSULIN SYRINGE/U- 100/0.5ML/29G X 1/2" 82QC ALL PURPOSE 100/0.5ML/30G X 5/16" 81 RELION INSULIN SYRINGE/U-DRESSINGS4"X4" 55 RA INSULIN SYRINGE/U- 100/0.5ML/30G X 5/16" 82QC BORDER ISLAND GAUZE 100/1 ML/30G X 5/16" 81 RELION INSULIN SYRINGE/U-PAD 2"X2" 55 RA LANCING DEVICE 63 100/0.5ML/31G X 5/16" 82

Index 25

RELION INSULIN SYRINGE/U- RHOGAM ULTRA-FILTERED SAFESNAP INSULIN 100/1ML/30G X 5/16" 82 PLUS 108 SYRINGE/1ML/29G X 1/2" 82 RELION INSULIN SYRINGE/U- RID 44 SAFETY INSULIN SYRINGES 100/1ML/31G X 15/64" 82 RID COMPLETE LICE 0.5ML/29GX1/2" 82 RELION INSULIN SYRINGE/U- SAFETY INSULIN SYRINGESELIMINATION 44100/1ML/31G X 5/16" 82 0.5ML/30GX5/16" 82RIFADIN 25RELION KETONE 44 SAFETY INSULIN SYRINGES

rifampin 25RELION KETONE TEST 1ML/27GX1/2" 82 RIGHT STEP SAFETY INSULIN SYRINGESSTRIPS 44 PRENATAL 103RELION LANCETS MICRO- 1ML/29GX1/2" 82 RIGHTEST GD500 LANCING SAFETY INSULIN SYRINGESTHIN33G 63

RELION LANCETS STANDARD DEVICE 63 1ML/30GX1/2" 82 RIGHTEST GL300 SAFETY SEAL LANCETS21G 63 LANCETS 63 28G 63RELION LANCETS THIN risedronate sodium 46 SAFETY SEAL LANCETS26G 63

30G 64RELION LANCETS ULTRA- RISPERDAL 27 SAFETY-GLIDE INSULINTHIN30G 63 RISPERDAL M-TAB 26 SYRINGE/0.3ML/29G X 1/2" 82RELION LANCING DEVICE 63 risperidone 27 SALAGEN 96RELION PEN NEEDLES RISPERIDONE ODT 2729GX12MM 82 saline 104 RELION ULTRA THIN RITALIN 2 salsalate 4 LANCETS30G 63 92RITEFLO SAMI THE SEALRELION ULTRA THIN PLUS ritonavir 29 REPLACEMENTFILTERS 92LANCETS 32G 63 SANDIMMUNE 95RELION ULTRA THIN PLUS rivastigmine 109 LANCETS 33G 63 rivastigmine tartrate 110 SARNA 40 RELPAX 93 rizatriptan benzoate 93 SAVELLA 110

SAVELLA TITRATIONREMERON 13 ROBAXIN 104 PACK 110REMERON SOLTAB 13 ROBAXIN-750 104 SB ALCOHOL PREP PADS 66RENAPLEX-D 99 ROBINUL 112 SB INSULIN SYRINGE/U-REPLACEMENT AIR ROBINUL FORTE 112 100/0.5ML/29G X 1/2" 82FILTER 92 ROBITUSSIN DM 37 SB INSULIN SYRINGE/U-REPLACEMENT FILTERS 92 100/0.5ML/30G X 5/16" 82ROBITUSSIN PEAK COLDREQ 49+ 99 SB INSULIN SYRINGE/U-COUGH+ CHEST 100/1ML/29G X 1/2" 83REQUIP 26 CONGESTION DM MAX SB INSULIN SYRINGE/U-RESCRIPTOR 29 STRENGTH 37 100/1ML/30G X 5/16" 83ROBITUSSIN PEAK COLDRESTORE CONTACT SB INSULIN SYRINGE/U-DM 38LAYER/NON-ADHERENT 100/1ML/31G X 5/16" 83ROCALTROL 472"X2" 56 SB LANCETS THIN 64RESTORE FOAM DRESSING ropinirole hydrochloride 26 SB LANCETS ULTRA THIN 64BORDERED 4"X4" 56 rosuvastatin calcium 21 SCHNUCKS INSULINRESTORE FOAM DRESSING ROXICODONE 5 SYRINGEULTI-FINE/U-NON-BORDERED 4"X4" 56 RESTORE ODOR ABSORBING RYTHMOL 9 100/0.5ML/29G X 1/2" 83

SCHNUCKS INSULINDRESSING 4"X4" 56 RYTHMOL SR 9RESTORE TRIO ABSORBENT SYRINGEULTI-FINE/U-SAFESNAP INSULINDRESSING 3"X3" 56 100/0.5ML/30G X 5/16" 83SYRINGE/0.3ML/30G XRESTORIL 50 5/16" 82 SE-NATAL 19 103

RETIN-A 39 SAFESNAP INSULIN SEASONIQUE 34 SYRINGE/0.5ML/29G X SECTRAL 31RETROVIR 29

REXALL LANCETS ULTRA 1/2" 82 SELECT-LITE LANCING SAFESNAP INSULIN DEVICE 64THIN 63 SYRINGE/0.5ML/30G XREYATAZ 29 selegiline hcl 265/16" 82 selenium sulfide 40RHEUMATREX 2 SAFESNAP INSULIN SYRINGE/1ML/28G X 1/2" 82 SELSUN BLUE 40

Index 26

SELSUN BLUE DAILY SELSUN BLUE MEDICATED SELSUN BLUE MOISTURIZING SELZENTRY sennosides sennosides-docusate sodium

40

40

40 29 51

51

SILICONE MASK FOR BREATHERITE CHAMBER/PEDIATRICSILICONE MASK FOR BREATHRITE CHAMBER/ADULT SILPHEN COUGH SILVADENE silver sulfadiazine

92

92 20 41 41

sodium chloride (gu irrigant) 48 sodium chloride (inhalant) 38 sodium citrate & citric acid 48 sodium fluoride 94 sodium fluoride (dental) 95 sodium phosphates 51 sodium polystyrenesulfonate 95

SENOKOT 51 simethicone 48 SOF-WICK 4"X4" 56 SENOKOT S 51 SIMPLE DIAGNOSTICS SOLO 99 SENTRY 99 SENTRY SENIOR 99 SENTRY SENIOR/LUTEIN 99 SEREVENT DISKUS 10 SEROQUEL 27 sertraline hcl 15 SFROWASA 48 SHOPKO ALCOHOL SWABS 66 SHOPKO AUTOLET LANCING DEVICE 64 SHOPKO UNIFINE PENTIPS PEN NEEDLES/ORIGINAL/29GX12MM 83 SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/REMOVER/29GX12MM 83 SHOPKO UNILET LANCETS

LANCING DEVICE 64 simvastatin 21 SINEMET 26 SINEMET CR 26 SINGULAIR 9 sirolimus 95 SIVEXTRO 7 SM ALCOHOL PREP PADS 66 SM GAUZE PADS 2"X2" 56 SM GAUZE PADS 3"X3" 56 SM GAUZE PADS 4"X4" 56 SM GLUCOSE 16 SM INSULIN SYRINGE/1ML/31G X5/16" 83 SM MICRO THIN LANCETS 33G 64 SM ONE DAILY MENS 99

SOLUS V2 LANCING DEVICE 64 SONATA 50 SOOTHENEB NBL 100 CHILD MASK 92 SOOTHENEB NBL 100 MEDICATION CUP 92 SOOTHENEB NBL 100 MESH CAP 92 SOOTHENEB NBL100 ADULT MASK 92 sotalol hcl 32 sotalol hcl (afib/afl) 32 SOVALDI 30 spinosad 44 spironolactone 46 spironolactone &hydrochlorothiazide 45 SPORANOX 19 SPORANOX PULSEPAK 19

SUPER THIN 30G 64 SHOPKO UNILET LANCETS ULTRA THIN 28G 64 SIDE BUTTON SAFETY LANCET21G 64 SIDEROL 99 SIDESTREAM ADULT FACE MASK 92 SIDESTREAM PEDIATRIC FACEMASK 92 SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL 92 SIDESTREAM PEDIATRIC FACEMASK/TUCKER THETURTLE 92 SIDESTREAM PLUS ADULT FACE MASK 92 SILICONE MASK FOR BREATHERITE CHAMBER/ADULT 92 SILICONE MASK FOR BREATHERITE CHAMBER/INFANT 92

SM ONE DAILY WOMENS99 SM PRENATAL VITAMINS 103 SM STERILE PADS 56 SM STERILE PADS 2"X2" 56 SM TRUEDRAW LANCING DEVICE 64 SMART DIABETES VANTAGE LANCING DEVICE 64 SMART SENSE COLOR LANCETS UNIVERSAL 33G 64 SMART SENSE STANDARD LANCETS UNIVERSAL 21G 64 SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G 64 SMART SENSE THIN LANCETSUNIVERSAL 26G 64 sodium bicarbonate (antacid) 7

stannous fluoride 95 STARLIX 17 stavudine 29 STERILANCE TL 64 STERILE GAUZE PADS 2"X2" 56 STERILE GAUZE PADS 3"X3" 56 STERILE PADS 2"X2" 56 STERILE PADS 3"X3" 56 STERILE PADS 4"X4" 56 STRATTERA 1 STRIBILD 29 STROVITE ONE 99 SUBLOCADE 6 SUBOXONE 6 sucralfate 113 SUDAFED CHILDRENS 105 SUDAFED CONGESTION 105

Index 27

SUDAFED NASAL SURE COMFORT INSULIN SYMBICORT 10 DECONGESTANT MAXIMUM STRENGTH 105 SUDAFED PE

SYRINGE/U-100/1ML/28G X1/2" 83 SURE COMFORT INSULIN

SYMLINPEN 120 SYMLINPEN 60

16 16

CONGESTION 105 sulfacetamide sod-prednisolone 107 sulfacetamide sodium 40 SULFACETAMIDE SODIUM 106 sulfacetamide sodium (acne)39 sulfacetamide sodium (ophth) 106 sulfamethoxazole-trimethoprim 7 sulfasalazine 48 sulindac 3

SYRINGE/U-100/1ML/29G X1/2" 83 SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X1/2" 83 SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X5/16" 83 SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X5/16" 83 SURE COMFORT LANCING PEN 64 SURE COMFORT PEN

SYNTHROID T-VITES tacrolimus tacrolimus (topical) TAGAMET HB TAMIFLU tamoxifen citrate tamsulosin hcl TAPAZOLE TARKA TAVIST ALLERGY

111 99 95 42

112 31 25 49

111 24 20

sumatriptan sumatriptan succinate SUMATRIPTAN SUCCINATE sumatriptan succinate

93 93

93 93

NEEDLES30GX5/16"SHORT 83 SURE-JECT INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 83 SURE-JECT INSULIN

tazarotene TAZORAC TEARS NATURALE PM TECFIDERA TECFIDERA STARTER

40 40

105 110

SUPER THIN LANCETS 64 SUPERB NAILS 99 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 83 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 83 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 83 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X5/16 83 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 83 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 83 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 83 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 83 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 83 SURE COMFORT INSULIN

SYRINGE/U-100/0.3ML/30G X5/16" 83 SURE-JECT INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 84 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 84 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 84 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 84 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 84 SURE-JECT INSULIN SYRINGE/U-100/1ML/28G X1/2" 84 SURE-JECT INSULIN SYRINGE/U-100/1ML/29G X1/2" 84 SURE-JECT INSULIN SYRINGE/U-100/1ML/30G X5/16" 84 SURE-JECT INSULIN SYRINGE/U-100/1ML/31G X5/16" 84 SURE-PEN 64

PACK 110 TECHLITE AST LANCETS 64 TECHLITE INSULIN SYRINGEU-100/0.3ML/29G X 1/2" 84 TECHLITE INSULIN SYRINGEU-100/0.3ML/30G X 1/2" 84 TECHLITE INSULIN SYRINGEU-100/0.3ML/30G X 5/16" 84 TECHLITE INSULIN SYRINGEU-100/0.3ML/31G X 5/16" 84 TECHLITE INSULIN SYRINGEU-100/0.5ML/29G X 1/2" 84 TECHLITE INSULIN SYRINGEU-100/0.5ML/30G X 1/2" 84 TECHLITE INSULIN SYRINGEU-100/0.5ML/30G X 5/16" 84 TECHLITE INSULIN SYRINGEU-100/0.5ML/31G X 5/16" 84 TECHLITE INSULIN SYRINGEU-100/1ML/29G X 1/2" 84 TECHLITE INSULIN SYRINGEU-100/1ML/30G X 1/2" 84 TECHLITE INSULIN SYRINGEU-100/1ML/30G X 5/16" 84 TECHLITE INSULIN SYRINGEU-100/1ML/31G X 15/64" 84 TECHLITE INSULIN SYRINGEU-100/1ML/31G X 5/16" 84 TECHLITE LANCETS 64 TECHLITE LANCETS 30G 64

SYRINGE/U-100/0.5ML/31G X5/16 83

SURELITE LANCETS SURGICAL GAUZE SPONGE

64

56

TECHLITE PEN NEEDLES 29GX 12 MM 84 TEGADERM FOAM DRESSING

SUSTIVA 30 2"X2" 56

Index 28

TEGADERM FOAM DRESSING THEO-24 10 TIVICAY 30 4"X4" 56 TEGRETOL 12 TEGRETOL-XR 12 telmisartan 22 telmisartan-amlodipine 24 telmisartan-hydrochlorothiazide

24 temazepam 50 TEMODAR 25 TEMOVATE 42 TEMOVATE E 42 temozolomide 25 TENCON 4 TENEX 22 TENIVAC 111 tenofovir disoproxil fumarate 30 TENORETIC 100 24 TENORETIC 50 24 TENORMIN 31 TERAZOL 3 118 TERAZOL 7 118 terazosin hcl 22 terbinafine hcl 19 terbinafine hcl (topical) 40 terbutaline sulfate 10 TERCONAZOLE 118 terconazole vaginal 118 TESSALON PERLES 36 testosterone cypionate 6 TETANUS/DIPHTHERIATOXOIDS-ADSORBED 111 tetracaine hcl (ophth) 106 tetrahydrozoline hcl (ophth) 106 TGT ADVANCED LANCING DEVICE 64 TGT ALCOHOL SWABS 66 TGT LANCET ALTERNATE SITE 64 TGT LANCET MICRO THIN 33G 64 TGT LANCET SUPER THIN 30G 64 TGT LANCET THIN 23G 64

theophylline 10 THERA M PLUS 99 THERA-FLUR-N 96 THERA-M 99 THERA-TABS M 99 THERABETIC MULTI-VITAMIN 99 THERAGAUZE 56 THERAGRAN-M 99 THERAGRAN-M ADVANCED 99 THERAGRAN-M ADVANCED 50 PLUS 99 THERAGRAN-M PREMIER 99 THERAGRAN-M PREMIER 50 PLUS 99 THERANATAL CORE NUTRITION 103 THEREMS-H 99 THEREMS-M 99 THINLETS GP LANCETS 64 THINLETS LANCET 64 thioridazine hcl 28 thiothixene 28 THRESHOLD IMT 92 THRIVITE 19 103 THRIVITE RX 103 thyroid 111 THYROLAR-1 111 THYROLAR-1/2 111 THYROLAR-1/4 111 THYROLAR-2 111 THYROLAR-3 111 tiagabine hcl 12 TIAZAC 32 TIKOSYN 9 TIMOLOL MALEATE 32 timolol maleate (ophth) 105 TIMOLOL MALEATE OPHTHALMIC GEL FORMING 105 TIMOPTIC 105

tizanidine hcl 104 TOBI 2 TOBRADEX 107 tobramycin 2 TOBRAMYCIN 2 tobramycin (ophth) 106 TOBRAMYCIN SULFATE 2 tobramycin sulfate 2 tobramycin-dexamethasone 107 TOBREX 106 TODAYS HEALTH ADVANCED LANCING DEVICE 64 TODAYS HEALTH ORIGINAL PEN NEEDLES 29G X 1/2" 84 TODAYS HEALTH SUPER THINLANCETS 30G 64 TODAYS HEALTH ULTRA THINLANCETS 28G 64 TOFRANIL 16 TOLMETIN SODIUM 3 tolmetin sodium 3 TOLMETIN SODIUM 3 tolnaftate 40 tolterodine tartrate 114 TOPAMAX 12 TOPAMAX SPRINKLE 12 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" 84 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X5/16" 84 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X5/16" 84 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" 85 TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" 85 TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/31G X5/16" 85 TOPCARE ULTRA COMFORT

TGT LANCET THIN 26G TGT LANCET ULTRA THIN 28G TGT LANCET ULTRA THIN 30G TGT LANCING DEVICE

64

64

64 64

TIMOPTIC OCUDOSE TIMOPTIC-XE TINACTIN TINACTIN JOCK ITCH tioconazole vaginal

105 105

40 40

118

INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 85 TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 85

Index 29

TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" 85 TOPCO INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 85 TOPCO INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 85 TOPCO INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 85 TOPCO INSULIN SYRINGE/U-100/1ML/28G X 1/2" 85 TOPCO INSULIN SYRINGE/U-100/1ML/29G X 1/2" 85 TOPICORT 42 topiramate 12 TOPPER DRESSING SPONGES 4"X4" 56 TOPROL XL 31 torsemide 46 TRADJENTA 17 tramadol hcl 5 tramadol-acetaminophen 6 trandolapril 22 trandolapril-verapamil hcl 24 TRANDOLAPRIL/VERAPAMILHCL ER 24 tranexamic acid 50 TRANXENE T 8 tranylcypromine sulfate 14 trazodone hcl 15 TRECATOR 25 tretinoin 39 TREXALL 25 TRI-NORINYL 28 34 TRI-VIT/FLUORIDE/IRON 101 TRI-VITAMIN/FLUORIDE 101 TRIADVANCE 103 triamcinolone acetonide (mouth) 96 triamcinolone acetonide (topical) 42 TRIAMINIC COLD & COUGH DAY TIME CHILDRENS 38 triamterene & hydrochlorothiazide 45 TRIAMTERENE/HYDROCHLOROTHIAZIDE 45 TRIAZOLAM 50 triazolam 50 TRIBENZOR 24 TRICARE 103 TRIDESILON 42

trifluoperazine hcl 28 trifluridine 106 TRIGLIDE 21 trihexyphenidyl hcl 26 TRILEPTAL 12 trimethoprim 7 TRINATAL GT 103 TRINATAL RX 1 103 TRINTELLIX 15 TRIUMEQ 30 TRIZIVIR 30 TROJAN 57 TROJAN ASSORTMENT PACK 57 TROJAN EXTENDED PLEASURE/LUBRICATED

57 TROJAN EXTRA STRENGTH 57 TROJAN MAGNUM 57 TROJAN MAGNUM WARM SENSATIONS 57 TROJAN MAGNUM XL LUBRICATED 57 TROJAN PLEASURE MESH/SPERMICIDAL 57 TROJAN PLUS 57 TROJAN REGULAR 57 TROJAN RIBBED 57 TROJAN RIBBED W/SPERMICIDAL 57 TROJAN SHARED SENSATION/LUBRICATED

57 TROJAN SUPRAS SPERMICIDAL 57 TROJAN TWISTED PLEASURE 57 TROJAN ULTRA PLEASURE/LUBRICATED

58 TROJAN VERY SENSITIVE LUBRICATED 58 TROJAN VERY SENSITIVE SPERMICIDAL LUBRICANT 58 TROJAN VERY THIN LUBRICATED 58 TROJAN VERY THIN SPERMICIDAL LUBRICANT 58 TROJAN-ENZ LUBRICANT 58 TROJAN-ENZ LUBRICATED 58

TROJAN-ENZ W/SPERMICIDAL 58 tropicamide 105 trospium chloride 114 TRUE METRIX BLOOD GLUCOSETEST STRIPS 44 TRUE METRIX CONTROL SOLUTION LEVEL 1 64 TRUE METRIX CONTROL SOLUTION LEVEL 2 64 TRUE METRIX CONTROL SOLUTION LEVEL 3 65 TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS 44 TRUECONTROL GLUCOSE CONTROL LEVEL 0 65 TRUECONTROL GLUCOSE CONTROL LEVEL 1 65 TRUEDRAW LANCING DEVICE 65 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 85 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 85 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 85 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 85 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 85 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 85 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 85 TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X1/2" 85 TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X1/2" 85 TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X5/16" 85 TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X5/16" 85 TRUEPLUS LANCETS 26G 65 TRUEPLUS LANCETS 28G 65 TRUEPLUS LANCETS 28G SUPER THIN 65

Index 30

TRUEPLUS LANCETS 30G 65 TRUVADA 30 ULTICARE INSULIN TRUEPLUS LANCETS 30G ULTRA THIN 65 TRUEPLUS LANCETS 33G 65 TRUEPLUS PEN NEEDLES 29GX12MM 85 TRUETEST BLOOD GLUCOSE TEST 44 TRUETEST BLOOD GLUCOSE TEST STRIPS 44 TRUETEST GLUCOSE CONTROLLEVEL 1 65 TRUETEST GLUCOSE CONTROLLEVEL 2 65 TRUETEST GLUCOSE CONTROLLEVEL 3 65 TRUETEST STRIPS 45 TRUETRACK BLOOD GLUCOSE TEST 45 TRUETRACK TEST 45 TRUMENBA 114 TRUSOPT 107 TRUSTEX COLOR CONDOMS + LUBE 58 TRUSTEX LUBRICATED 58 TRUSTEX LUBRICATED EXTRALARGE 58 TRUSTEX LUBRICATED EXTRASTRENGTH 58 TRUSTEX LUBRICATED/RIBBED/STUDDED 58 TRUSTEX LUBRICATED/SPERMICIDE

58 TRUSTEX LUBRICATED/SPERMICIDEEXTRA LARGE 58 TRUSTEX LUBRICATED/SPERMICIDEEXTRA STRENGTH 58 TRUSTEX NATURAL CONDOMS +LUBE/LUBRICATED 58 TRUSTEX NON-LUBRICATED 58 TRUSTEX WITH NONOXYNOL-9/RIBBED/STUDDED 58 TRUSTEX/RIALUBRICATED 58 TRUSTEX/RIA LUBRICATEDSPERMICIDE 58 TRUSTEX/RIALUBRICATED/SPERMICIDE

58 TRUSTEX/RIA NON-LUBRICATED 58

TUBING/WING TIP 92 TUDORZA PRESSAIR 9 TUMS 7 TUMS LASTING EFFECTS 7 TWYNSTA 24 TYBOST 30 TYLENOL 4 TYLENOL CHILDRENS 4 TYLENOL EXTRA STRENGTH 4 TYLENOL INFANTS 4 TYLENOL INFANTS PAIN+FEVER 4 TYLENOL/CODEINE #3 6 TYLENOL/CODEINE #4 6 ULTI-LANCE AUTOMATIC/CLEAR TIP 65 ULTICARE ALCOHOL SWABS 66 ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X1/2" 85 ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2" 85 ULTICARE INSULIN SYRINGE/0.3ML/29G X1/2" 86 ULTICARE INSULIN SYRINGE/0.3ML/30G X1/2" 86 ULTICARE INSULIN SYRINGE/0.3ML/30G X5/16" 86 ULTICARE INSULIN SYRINGE/0.5ML/28G X1/2" 86 ULTICARE INSULIN SYRINGE/0.5ML/29G X1/2" 86 ULTICARE INSULIN SYRINGE/0.5ML/30G X1/2" 86 ULTICARE INSULIN SYRINGE/0.5ML/30G X5/16" 86 ULTICARE INSULIN SYRINGE/1ML/28G X 1/2" 86 ULTICARE INSULIN SYRINGE/1ML/29G X 1/2" 86 ULTICARE INSULIN SYRINGE/1ML/30G X 1/2" 86 ULTICARE INSULIN SYRINGE/1ML/30G X5/16" 86

SYRINGE/SHORT/0.3ML/30G X5/16" 86 ULTICARE INSULIN SYRINGE/SHORT/0.3ML/31G X5/16" 86 ULTICARE INSULIN SYRINGE/SHORT/0.5ML/30G X5/16" 86 ULTICARE INSULIN SYRINGE/SHORT/0.5ML/31G X5/16" 86 ULTICARE INSULIN SYRINGE/SHORT/1ML/30G X5/16" 86 ULTICARE INSULIN SYRINGE/SHORT/1ML/31G X5/16" 86 ULTICARE INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 86 ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 86 ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 86 ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 86 ULTICARE INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 86 ULTICARE INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 86 ULTICARE INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 86 ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 86 ULTICARE INSULIN SYRINGE/U-100/1ML/29G X1/2" 86 ULTICARE INSULIN SYRINGE/U-100/1ML/30G X1/2" 86 ULTICARE INSULIN SYRINGE/U-100/1ML/30G X5/16" 86 ULTICARE INSULIN SYRINGE/U-100/1ML/31G X5/16" 86 ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.3ML/31G X 5/16" 87

Index 31

ULTICARE INSULIN ULTRA-COMFORT INSULIN ULTRAM 5 SYRINGEULTRAFINE U- SYRINGE/U-100/0.3ML/30G X ULTRATHON INSECT100/0.5ML/31G X 5/16" 87 5/16" 87 REPELLENT 43ULTICARE INSULIN ULTRA-COMFORT INSULIN ULTRATHON INSECTSYRINGEULTRAFINE U- SYRINGE/U-100/0.3ML/31G X REPELLENT 8 43100/1ML/31G X 5/16" 87 5/16" 87 UNICOMPLEX-M 99ULTICARE ORIGINAL PEN ULTRA-COMFORT INSULIN UNIFINE PENTIPSNEEDLES ULTI-FINE 87 SYRINGE/U-100/0.5ML/28G X 29GX12MM 88ULTILET ALCOHOL 1/2" 87 UNIFINE PENTIPS PLUSSWABS 66 ULTRA-COMFORT INSULIN 29GX12MM 88ULTILET CLASSIC SYRINGE/U-100/0.5ML/29G X UNILET COMFORTOUCHLANCETS 65 1/2" 87 LANCET 65ULTILET INSULIN ULTRA-COMFORT INSULIN UNILET EXCELITE 65SYRINGE/0.3ML/30G X SYRINGE/U-100/0.5ML/30G X8MM 87 5/16" 87 UNILET EXCELITE II 65 ULTILET INSULIN ULTRA-COMFORT INSULIN UNILET G.P. LANCET 65 SYRINGE/0.3ML/31G X SYRINGE/U-100/0.5ML/31G X UNILET G.P. SUPERLITE8MM 87 5/16" 87 LANCET 65ULTILET INSULIN ULTRA-COMFORT INSULIN UNILET GP 28 ULTRA THIN65SYRINGE/0.5ML/30G X SYRINGE/U-100/1ML/28G X UNILET LANCET 658MM 87 1/2" 87 ULTILET INSULIN ULTRA-COMFORT INSULIN UNILET LANCETS MICRO-SYRINGE/1ML/30G X 8MM 87 SYRINGE/U-100/1ML/29G X THIN33G 65 ULTILET INSULIN 1/2" 87 UNILET LANCETS SUPER-SYRINGE/1ML/31G X 8MM 87 ULTRA-COMFORT INSULIN THIN30G 65 ULTILET INSULIN SYRINGE/U-100/1ML/30G X UNILET LANCETS ULTRA-THIN SYRINGE/SHORT/0.3ML/30G X 5/16" 88 28G 65 12.7MM 87 UNILET SUPERLITEULTRA-COMFORT INSULIN ULTILET INSULIN SYRINGE/U-100/1ML/31G X LANCET 65 SYRINGE/SHORT/0.3ML/30G X 5/16" 88 UNISOM 50 5/16" 87 ULTRA-THIN II INSULIN UNISOM SLEEPGELS 50ULTILET INSULIN SYRINGE SHORT/U- UNISTIK TOUCH SAFETYSYRINGE/SHORT/0.3ML/31G X 100/0.3ML/30GX5/16" 88 LANCETS 21G 655/16" 87 ULTRA-THIN II INSULIN UNISTIK TOUCH SAFETYULTILET INSULIN SYRINGE SHORT/U- LANCETS 23G 65SYRINGE/SHORT/0.5ML/30G X 100/0.3ML/31GX5/16" 88 UNISTIK TOUCH SAFETY5/16" 87 ULTRA-THIN II INSULIN LANCETS 28G 65ULTILET INSULIN SYRINGE SHORT/U- UNISTIK TOUCH SAFETYSYRINGE/SHORT/0.5ML/31G X 100/0.5ML/30GX5/16" 88 LANCETS 30G 655/16" 87 ULTRA-THIN II INSULIN UNIVERSAL 1 LANCETSULTILET INSULIN SYRINGE SHORT/U- THIN26G 65SYRINGE/SHORT/1ML/30G X 100/0.5ML/31GX5/16" 88 UNIVERSAL 1 LANCETS ULTRA5/16" 87 ULTRA-THIN II INSULIN THIN 30G 65ULTILET INSULIN SYRINGE SHORT/U- urea 42SYRINGE/SHORT/1ML/31G X 100/1ML/30GX5/16" 88 URECHOLINE5/16" 87 ULTRA-THIN II INSULIN 114 ULTILET INSULIN SYRINGE/U- SYRINGE SHORT/U- UROCIT-K 10 48 100/0.5ML/30G X 1/2" 87 100/1ML/31GX5/16" 88 UROCIT-K 5 48ULTILET INSULIN SYRINGE/U- ULTRA-THIN II INSULIN URSO 250 48100/1ML/30G X 1/2" 87 SYRINGE/U-ULTIMATE FEELING 58 100/0.3ML/29GX1/2" 88 ursodiol 48 ULTRA COMFORT INSULIN ULTRA-THIN II INSULIN V-R MONOJECT INSULIN

SYRINGE/U-100/0.3ML/29G XSYRINGE/U-100/0.3ML/30G X SYRINGE/U-5/16" 87 100/0.5ML/29GX1/2" 88 1/2" 88 ULTRA THIN LANCETS ULTRA-THIN II INSULIN V-R MONOJECT INSULIN 28G 65 SYRINGE/U- SYRINGE/U-100/0.5ML/28G XULTRA-COMFORT INSULIN 100/1ML/29GX1/2" 88 1/2" 88 SYRINGE/U-100/0.3ML/29G X ULTRACET 6 1/2" 87

Index 32

V-R MONOJECT INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 88 V-R MONOJECT INSULIN SYRINGE/U-100/1ML/28G X1/2" 88 V-R MONOJECT INSULIN SYRINGE/U-100/1ML/29G X1/2" 88 VAGISTAT-1 118 valacyclovir hcl 30 VALCYTE 30 valganciclovir hcl 30 VALIUM 8 valproate sodium 13 valproic acid 13 valsartan 22 valsartan-hydrochlorothiazide

24 VALTREX 30 VALUE HEALTH INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 88 VALUE HEALTH INSULIN SYRINGE/U-100/1ML/29G X1/2" 88 VALUE PLUS LANCETS STANDARD 21G 65 VALUE PLUS LANCETS SUPERTHIN 30G 65 VALUE PLUS LANCETS THIN 26G 65 VALUE PLUS LANCING DEVICE 65 VALUMARK LANCET SUPER THIN 30G 65 VALUMARK LANCET ULTRA THIN 28G 65 VALUMARK PEN NEEDLES 29GX12MM 88 VALVED HOLDING CHAMBER 92 VANCOCIN HCL 7 vancomycin hcl 7 VANISHPOINT INSULIN SYRINGE/0.5ML/30G X 1/2" 88 VANISHPOINT INSULIN SYRINGE/0.5ML/30G X5/16" 88 VANISHPOINT INSULIN SYRINGE/1ML/29G X 1/2" 88 VANISHPOINT INSULIN SYRINGE/1ML/29G X 5/16" 88 VANISHPOINT INSULIN SYRINGE/1ML/30G X 5/16" 88 VAQTA 117

VARIVAX 117 VASERETIC 24 VASOTEC 22 venlafaxine hcl 15 VENLAFAXINE HCL ER 15 VENTOLIN HFA 10 verapamil hcl 32,33 VERAPAMIL HCL SR 32 VERELAN 33 VERELAN PM 33 VERIPRED 20 36 VERSIVA XC 3" X 3" FOAM DRESSING/HYDROFIBERTECHNOLOGY 56 VERSIVA XC 4" X 4" FOAM DRESSING/HYDROFIBERTECHNOLOGY 56 VEXOL 107 VIBRAMYCIN 111 VICTOZA 17 VIDA MIA AUTOLET LANCINGDEVICE 65 VIDA MIA UNIFINE PENTIPSORIGINAL 29GX12MM 88 VIDA MIA UNILET LANCETS SUPER THIN 30G 65 VIDA MIA UNILET LANCETS ULTRA THIN 28G 65 VIDEX EC 30 VIDEXPEDIATRIC 30 VIGAMOX 106 VIIBRYD 15 VIL-RX 103 VINATE M 104 VINATE ONE 104 VIRACEPT 30 VIRAMUNE 30 VIRAMUNE XR 30 VIREAD 30 VIROPTIC 106 VIRT-ADVANCE 104 VIRT-VITE GT 104 VISINE 106 VISINE EXTRA 106 VISTARIL 8 VISTEC X-RAY DETECTABLE SPONGES 4"X4" 16 PLY 56 VISTOGARD 18 VITAFOL-OB 104

VITALINE TOTAL FORMULA 2 99 VITALINE TOTAL FORMULA 3 99 VITAMIN D3 COMPLETE 99 VITASANA 99 VITATRUM 99 VITRUM 50+ SENIOR MULTI 99 VIVELLE-DOT 47 VIVITROL 18 VOL-PLUS 104 VOL-TAB RX 104 VOLTAREN 39 VORTEX VALVED HOLDING CHAMBER 92 VOSPIRE ER 10 VP INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 88 VP-ZEL 99 VYVANSE 1 W&F LANCETS 26G 65 W&F LANCETS COLORED 21G 66 WALGREENS COMFORT ASSUREDLANCETS MICRO THIN/33G 66 WALGREENS COMFORT ASSUREDLANCETS SUPER THIN/28G 66 WALGREENS GLUCOSE 17 WALGREENS THIN LANCETS 66 warfarin sodium 10 WATCHHALER 92 WEBCOL ALCOHOL PREP LARGE 1 PLY 66 WEBCOL ALCOHOL PREP LARGE 2 PLY 66 WEBCOL ALCOHOL PREP MEDIUM 2 PLY 66 WELLBUTRIN SR 13,14 WELLBUTRIN XL 14 white petrolatum-mineral oil 105 WHOLE FOOD MULTIVITAMIN 99 WINDMILL TRAINER 92 WOMENS 50+ MULTI VITAMIN& MINERAL FORMULA 99 WOMENS BIOMULTIPLE 99 WOMENS MULTI VITAMIN & MINERAL FORMULA 99 XALATAN 108

Index 33

XANAX 8 XARELTO 10

YELETS TEENAGE

ZANTAC 150 MAXIMUM

ZOVIRAX 31,41

XULANE 35 XYZAL 20 XYZAL ALLERGY 24HR 20 YASMIN 28 34 YAZ 35

FORMULA 99 ZADITOR 107 zaleplon 50 ZANAFLEX 104 ZANTAC 112

STRENGTH 112 ZANTAC 75 112 ZARONTIN 13 ZARXIO 49 ZEBETA 31 ZERIT 30 ZESTORETIC 24 ZESTRIL 22 ZIAC 24 ZIAGEN 30 zidovudine 30 zinc oxide (topical) 43 ziprasidone hcl 26 ZITHROMAX 52 ZITHROMAX TRI-PAK 52 ZITHROMAX Z-PAK 52 ZOCOR 21 ZOFRAN 19 ZOFRAN ODT 19 zolmitriptan 93 ZOLOFT 15 zolpidem tartrate 50 ZOMIG 93 ZOMIG ZMT 93 ZONEGRAN 12 zonisamide 12 ZOSTAVAX 117

ZUBSOLV 6 ZYBAN 110 ZYLOPRIM 49 ZYPREXA 27 ZYRTEC ALLERGY 20

ZYRTEC CHILDRENS ALLERGY 20 ZYRTEC-D ALLERGY/CONGESTION 38

Index 34

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