COMMERCIAL FORMULARY
Effective February 2016
Provided by EnvisionRx
Introduction
The Total Health Care (THC) Commercial Formulary was developed to serve as a guide for physicians,
pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total
Health Care recognizes that drug therapy is an integral part of effective health management.
Total Health Care continually reviews new and existing medications to ensure the Formulary remains
responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for
the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison
of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential
duplications.
Notice
The information contained in this formulary is provided by THC, solely for the convenience of medical
providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be
comprehensive in nature.
This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical
provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or
omissions of any medical provider based upon reliance, in whole or in part, on the information contained
herein. The medical provider should consult the drug manufacturer’s product literature or standard references
for more detailed information.
How to Read the Formulary
Drug Name
All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in
uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be
accessed by using the index, using the covered generic name or the covered brand name of the drug. The
brand names listed are for reference use only, and do not denote coverage, unless specifically noted. Any drug
not found in this Formulary listing shall be considered a non-formulary drug.
i
Co-Pay Structure
Generic Drug
Generic Co-Pay Applies
Brand Drug
Brand Co-Pay Applies
Requirements/Limits
This field includes potential limitations to the formulary drug. It also may contain additional information
about the coverage of the drug such as applicable quantity limits (QL). For certain agents within the
Commercial Formulary, a recommended prescribing guideline may apply.
Prescribing Guidelines
Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by
benefit design but may include:
Prior Authorization
Required (PA)
Drug requires prior authorization through a specific physician request
process.
Over the Counter Drugs
(OTC)
Drug coverage is available for drugs that are available OTC with an
authorized prescription from your provider.
Specialty Drugs (SP)
Drug requires processing through THC’s contracted specialty pharmacy,
Diplomat Specialty Pharmacy.
Quantity Limit (QL)
Drug coverage may be limited to specific quantities per prescription and/or
time period.
Age Limit (AL)
Drug coverage may depend on patient age.
Gender Restriction (GR)
Drug coverage may depend on patient gender.
Step Therapy Required
(ST)
Drug coverage requires that an alternative or trial of another drug be used
before the medication is covered.
Custom (C)
Drug coverage has unique restrictions.
Benefit Coverage and Limitations
This formulary does not define benefit coverage and limitations. Members may have specific benefit
inclusions, exclusions, copayments, or a lack of coverage, which are not reflected in the Total Health Care
Commercial Formulary. Members should contact Total Health Care at 1-800-826-2862 if they have
questions regarding their coverage. Please note that the formulary process is evolutionary and changes can
occur throughout the year.
ii
Prior Authorization (PA)
Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior
Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also
request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should
be faxed to 1-866-414-3453. Prior Authorization review of prescribing guidelines will be evaluated utilizing
the established drug review criteria approved by Total Health Care. If the request does not meet the approved
criteria, the request will not be approved and alternative therapy may be recommended along with the proper
course of alternative action. The requesting provider will be provided written notification of Total Health
Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy
Department to ask for an exception request.
Non-Formulary Agents
A Drug not located on the Total Health Care Commercial Formulary, or any updates published by Total
Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may
be requested by the health professional depending on specific coverage parameters. Review for nonformulary drug requests will require a Prior Authorization request with documentation of medical necessity.
Generally, the following basic medical necessity guidelines are used in conducting a review:



The patient has failed an appropriate trial of formulary or preferred agents.
The use of preferred or formulary agent is contraindicated in the patient.
The formulary drug or preferred agents are not suited for the present patient care need, and the drug
selected is required for patient safety.
If the request does not meet the established guidelines request, it will not be approved and alternative therapy
may be recommended along with the proper course of alternative action.
Common Drug Exclusions
The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for
drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not
limited to:







OTC medications or their equivalents unless otherwise specified in the Formulary listing.
Drug products used for cosmetic purposes.
Drug products for erectile dysfunction.
Drug products for infertility treatment.
Drug products for weight loss.
Experimental drug products or any drug product used in an experimental manner.
Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).
Mandated Generic Substitution
Total Health Care advocates the use of cost-effective generic drugs where FDA-approved generic equivalent
drugs are available. Generic products are listed in the Formulary and noted in lowercase lettering wherever
an FDA-approved generic drug product is available. If a member or physician requests a brand-name product
in lieu of an approved generic, the member, based upon their coverage, will typically be required to pay the
difference in cost between the brand and the generic drug.
iii
Total Health Care Pharmacy and Therapeutics (P&T) Committee
Total Health Care’s Pharmacy & Therapeutics Committee meets quarterly to review and recommend
medications for formulary consideration. The Committee considers clinical information on drugs that are new
to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the
formulary remains responsive to patient and physician needs. The Committee is composed of physicians,
pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy
Benefits Manager's Pharmacy and Therapeutics Advisory Panel.
Product Selection Criteria
The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary
based upon an objective analysis of the safety, efficacy, approved indications, adverse effects,
contraindications, patient administration/compliance considerations and cost effectiveness of available drugs.
When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including
those currently in the THC Commercial Formulary. Physicians may request a copy of THC’s drug criteria by
calling the Pharmacy Department at 1-800-826-2862.
Diabetic Testing Supplies
Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members.
Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and
SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD
Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are
to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program,
please contact J&B Medical Supply at 1-844-236-7933.
Specialty Bio-Pharmaceutical Pharmacy Program
Total Health Care works with Diplomat Specialty Pharmacy to provide Specialty Bio-Pharmaceutical
Pharmacy products to our members. These medications are to be filled exclusively through Diplomat
Specialty Pharmacy.
A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRx at 1-866414-3453 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug
Prior Authorization Request form found on the Total Health Care website at www.THCmi.com.
Once the order is received, EnvisionRx obtains authorization from Total Health Care. If the specialty prior
authorization is approved, Total Health Care notifies Diplomat Specialty Pharmacy. Then, the Diplomat
Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All
packages are individually marked for each patient and refrigerated items are shipped in insulated containers.
Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions
about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRx at 1-844-222-5584 or
Diplomat Specialty Pharmacy at 1-877-977-9118.
Contact Information
The Total Health Care Commercial Formulary is designed to assist physicians, members and other health care
professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback
on how we can assist in improving this document and the formulary management process. You may contact
THC at 1-800-826-2862.
iv
Medication Limitations
Quantity Limitations
Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation.
These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation
on the duration of therapy.
Age Limitations
Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation.
Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age,
and/or the combination of a minimum and maximum age edit.
Gender Restrictions
Gender restrictions are indicated with a “GR” on the formulary and require the member to be a specific
gender for coverage.
Step Therapy Criteria
Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line
medication be tried and failed before the requested medication can be covered. The online claims adjudication
system will automatically allow for the requested medication to be filled based on electronic claims history
indicating that the first line medication was filled.
Step Therapy Criteria
Therapy Class
First Line
Second Line
Third Line
Step Therapy Criteria
Attention
Deficit/Hyperactivity
Amphetamine
ImmediateRelease
Amphetamine
ExtendedRelease
Vyvanse
Antimigraine
Sumatriptan
(Imitrex)
Rizatriptan
(Maxalt)
Second Line: Prior use
of Amphetamine
Immediate-Release for
60 days within the last
90 days.
Third Line: Prior use of
Amphetamine ExtendedRelease for 60 days
within the last 90 days.
Prior use of Sumatriptan
in the last 90 days.
Antipsychotic
Agents
Risperidone
Quetiapine
ImmediateRelease
Ziprasidone
Second Line: Prior use
of Quetiapine within the
last 90 days.
Third Line: Prior use of
Ziprasidone in the last
90 days.
v
Osteoporosis
Alendronate
(Fosamax)
Actonel
Urinary
Antispasmodics
Oxybutynin,
OxybutyninER,
Oxybutynin
Syrup,
Oxytrol OTC
Tolterodine,
Tolterodine
ExtendedRelease,
Trospium
Prior use of alendronate
within the last 90 days.
Enablex,
Trospium
ExtendedRelease,
Vesicare
Second Line: Prior use
of Oxytrol OTC or
Oxybutynin,
oxybutynin-ER or
Oxybutynin Syrup in the
last 90 days.
Third Line: Prior use of
Tolterodine, Tolterodine
Extended-Release or
Trospium in the last 90
days.
*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths.
The benefit design determines what is covered and the applicable co-payment. The medications listed on this
formulary are subject to change pursuant to the formulary management activities of EnvisionRx. The presence
of a medication on this formulary list does not guarantee coverage.
vi
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
ANALGESICS (PAIN, INFLAMMATION, MUSCLE, JOINT CONDITIONS DRUGS)
Nonsteroidal Anti-inflammatory Drugs (PAIN, ANTI-INFLAMMATORY DRUGS)
diclofenac potassium
diclofenac sodium (tab delayed release 25 mg, tab delayed release 50 mg,
tab delayed release 75 mg, tab sr 24hr 100 mg)
diflunisal tab 500 mg
etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500 mg, tab sr 24hr
600 mg, tab sr 24hr 400 mg, tab sr 24hr 500 mg)
FENOPROFEN CALCIUM TAB 600 MG
flurbiprofen (tab 50 mg, tab 100 mg)
ibuprofen (tab 200 mg, tab 600 mg, tab 800 mg)
ibuprofen susp 100 mg/5ml
QL
120 / 7 days
ibuprofen tab 400 mg
QL
6 / 1 days
ketoprofen cap 50 mg
QL
360 / 30 days
ketoprofen cap 75 mg
QL
120 / 30 days
QL
20 / 5 days
indomethacin (cap 25 mg, cap 50 mg)
ketorolac tromethamine tab 10 mg
C
Max of 5 day supply
MECLOFENAMATE SODIUM CAP 50 MG
meloxicam (tab 7.5 mg, tab 15 mg)
nabumetone tab 500 mg
QL
120 / 30 days
nabumetone tab 750 mg
QL
60 / 30 days
naproxen (susp 125 mg/5ml, suspension 125 mg/5ml, tab 250 mg, tab 375
mg, tab 500 mg, tab ec 375 mg)
naproxen sodium tab 220 mg
oxaprozin
piroxicam (cap 10 mg, cap 20 mg)
sulindac (tab 150 mg, tab 200 mg)
PAGE 7
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
Opioid Analgesics, Long-acting (NARCOTIC PAIN RELIEVERS)
fentanyl (patch 72hr 25, patch 72hr 100, patch 72hr 12, patch 72hr 75,
patch 72hr 50)
QL
10 / 30 days
PA
methadone hcl (soln 5 mg/5ml, soln 10 mg/5ml, solution 5 mg/5ml, solution
10 mg/5ml, tab 5 mg)
methadone hcl tab 10 mg
QL
240 / 30 days
MORPHINE SULFATE (TAB 15 MG, TAB 30 MG)
QL
180 / 30 days
morphine sulfate (tab 15 mg, tab 30 mg, tab 60 mg, tab 100 mg)
QL
90 / 30 days
QL
390 / 30 days
hydrocodone-acetaminophen (tab 7.5-325 mg, tab 10-325 mg)
QL
180 / 30 days
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
QL
900 / 90 days
hydrocodone-acetaminophen tab 5-325 mg
QL
360 / 30 days
hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg)
QL
240 / 30 days
oxycodone hcl (tab 5 mg, tab 15 mg, tab 30 mg)
QL
180 / 30 days
oxycodone w/ acetaminophen (tab 7.5-325 mg, tab 10-325 mg)
QL
180 / 30 days
oxycodone w/ acetaminophen tab 5-325 mg
QL
360 / 30 days
tramadol hcl tab 50 mg
QL
240 / 30 days
ZAMICET
QL
900 / 90 days
QL
6.6 / 30 days
Opioid Analgesics, Short-Acting ( NARCOTIC PAIN RELIEVERS)
acetaminophen w/ codeine (tab 300-60 mg, tab 300-30 mg, tab 300-15 mg)
acetaminophen w/ codeine soln 120-12 mg/5ml
butalbital-aspirin-caffeine w/cod
CODEINE SULFATE (TAB 30 MG, TAB 60 MG)
morphine sulfate ((concentrate) soln 20 mg/ml, soln 10 mg/5ml, soln 20
mg/5ml, soln 100 mg/5ml (20 mg/ml))
oxycodone hcl (soln 5, solution 5)
oxycodone-aspirin
ANTIFUNGALS (FUNGUS INFECTION DRUGS)
ciclopirox solution 8%
clotrimazole soln 1%
PAGE 8
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
clotrimazole troche 10 mg
econazole nitrate cream 1%
fluconazole (susp 10 mg/ml, susp 40 mg/ml)
fluconazole (tab 50 mg, tab 100 mg, tab 200 mg)
QL
30 / 30 days
fluconazole tab 150 mg
QL
4 / 30 days
griseofulvin microsize (susp 125 mg/5ml, tab 500 mg)
griseofulvin ultramicrosize (tab 125 mg, tab 250 mg)
ketoconazole (topical) (cream, shampoo)
ketoconazole tab 200 mg
MICONAZOLE 3
miconazole nitrate vaginal suppos 100 mg
nystatin (mouth-throat)
nystatin (powder, tab 500000 unit)
nystatin (topical) (*nystatin topical powder**, nystatin cream 100000
unit/gm, nystatin oint 100000 unit/gm)
nystatin-triamcinolone (cream, oint)
terbinafine hcl tab 250 mg
terconazole vaginal (cream 0.4%, cream 0.8%, suppos 80 mg)
ANTINEOPLASTICS (CANCER DRUGS)
ALKYLATING AGENTS (CHEMOTHERAPY DRUGS)
HEXALEN CAP 50 MG
PA
LEUKERAN
PA
LOMUSTINE (CAP 10 MG, CAP 40 MG, CAP 100 MG)
PA
MATULANE
PA
ANTIMETABOLITES (CHEMOTHERAPY DRUGS)
hydroxyurea cap 500 mg
mercaptopurine tab 50 mg
TABLOID
PA
Antiandrogens (CANCER DRUGS)
bicalutamide
PAGE 9
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
flutamide
LIMITS & RESTRICTIONS
PA
Antiestrogens/Modifiers (CANCER DRUGS)
GL
Female
AL1
At least 35 yrs old
leucovorin calcium tab 5 mg
QL
3 / 1 days
MENEST (TAB 0.3 MG, TAB 0.625 MG, TAB 1.25 MG, TAB 2.5 MG)
GL
Female
GL
Female
QL
30 / 30 days
AL1
At least 18 yrs old
tamoxifen citrate (tab 10 mg, tab 20 mg)
Antineoplastics, Other (CANCER DRUGS)
CYCLOPHOSPHAMIDE (CAP 25 MG, CAP 50 MG)
LEUCOVORIN CALCIUM (TAB 15 MG, TAB 25 MG)
Aromatase Inhibitors, 3rd Generation (HORMONAL CHEMOTHERAPY DRUGS)
anastrozole tab 1 mg
letrozole tab 2.5 mg
Retinoids (CANCER DRUGS)
tretinoin (chemotherapy)
PA
ANTIPARASITICS (INFECTION FIGHTING DRUGS)
Antiprotozoals (MALARIA DRUGS)
atovaquone susp 750 mg/5ml
QL
chloroquine phosphate tab 250 mg
PA
DARAPRIM
PA
210 / 18 days
hydroxychloroquine sulfate tab 200 mg
mefloquine hcl
QL
5 / 30 days
PRIMAQUINE PHOSPHATE TAB 26.3 MG
QL
14 / 30 days
QL
120 / 365 days
quinine sulfate cap 324 mg
Pediculicides/Scabicides (SCABIES DRUGS)
EURAX (CREAM 10 %, LOTION 10 %)
lindane (lotion, shampoo)
malathion lotion 0.5%
PAGE 10
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
OVIDE
permethrin cream 5%
QL
120 / 30 days
QL
85 / 30 days
QL
30 / 30 days
Anesthetics
LOCAL ANESTHETICS (LOCAL NUMBING DRUGS)
lidocaine hcl (gel 2%, soln 4%)
lidocaine hcl (mouth-throat) (laryngotracheal soln 4%, viscous soln 2%)
lidocaine hcl cream 3%
lidocaine hcl local inj 4%
lidocaine-prilocaine cream 2.5-2.5%
Anti-Addiction/Substance Abuse Treatment Agents (NERVE CONDITIONS DRUGS)
ALCOHOL DETERRENTS/ANTI-CRAVING (MISCELLANEOUS MENTAL HEALTH DRUGS)
disulfiram (tab 250 mg, tab 500 mg)
Opioid Dependence Treatments (MISCELLANEOUS MENTAL HEALTH DRUGS)
naltrexone hcl tab 50 mg
QL
40 / 30 days
QL
2 / 90 days
QL
180 / 365 days
QL
60 / 30 days
Opioid Reversal Agents (MISCELLANEOUS MENTAL HEALTH DRUGS)
naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml, solution 0.4 mg/ml, solution 1
mg/ml)
Smoking Cessation Agents (DEPRESSION DRUGS)
bupropion hcl (smoking deterrent)
CHANTIX (TAB 0.5 MG, TAB 1 MG)
C
QL
CHANTIX CONTINUING MONTH PAK
C
QL
CHANTIX STARTING MONTH PAK
NICOTROL NS
PAGE 11
90 days of coverage
per year
60 / 30 days
90 days of coverage
per year
60 / 30 days
C
90 days of coverage
per year
C
90 days of coverage
per year
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
Antibacterials (INFECTION FIGHTING DRUGS)
Aminoglycosides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))
GENTAMICIN SULFATE (CREAM 0.1 %, OINTMENT 0.1 %)
gentamicin sulfate (ophth) (oint, soln)
gentamicin sulfate (topical) (cream, oint)
neomycin sulfate tab 500 mg
tobramycin (ophth)
Antibacterials, Other (MISCELLANEOUS INFECTION FIGHTING DRUGS)
BACITRACIN OINTMENT 500 UNIT/GM
bacitracin-poly-neomycin-hc
bacitracin-polymyxin b (ophth)
CLEOCIN SUPPOS 100 MG
clindamycin hcl (cap 75 mg, cap 150 mg, cap 300 mg)
clindamycin palmitate hydrochloride
clindamycin phosphate vaginal
CURITY ALCOHOL PREPS
MACRODANTIN CAP 25 MG
methenamine hippurate
METHENAMINE MANDELATE (TAB 0.5 GM, TAB 1 GM)
metronidazole (tab 250 mg, tab 500 mg)
metronidazole (topical) (cream, gel, lotion)
metronidazole vaginal
mupirocin calcium (topical)
mupirocin oint 2%
neomycin-bacitracin zn-polymyxin
neomycin-polymyxin-gramicidin
NEOMYCIN-POLYMYXIN-HC
nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg)
QL
60 / 30 days
nitrofurantoin monohyd macro
QL
60 / 30 days
polymyxin b-trimethoprim
silver sulfadiazine cream 1%
PAGE 12
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
trimethoprim tab 100 mg
LIMITS & RESTRICTIONS
QL
60 / 30 days
cefadroxil cap 500 mg
QL
40 / 10 days
cefadroxil tab 1 gm
QL
20 / 10 days
cefdinir (susp 125, susp 250)
AL1
Up to 11 yrs old
ceftriaxone sodium (inj 1 gm, inj 500 mg)
QL
10 / 30 days
ceftriaxone sodium for inj 250 mg
QL
180 / 30 days
QL
42 / 14 days
QL
28 / 14 days
vancomycin hcl (for inj 10 gm, for inj 500 mg, for inj 1000 mg, for inj 5000
mg, recon soln 750 mg)
Beta-lactam, Cephalosporins (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))
cefaclor (cap 250 mg, cap 500 mg, recon susp 125 mg/5ml, recon susp
250 mg/5ml, recon susp 375 mg/5ml)
cefadroxil (susp 250, susp 500)
cefdinir cap 300 mg
cefpodoxime proxetil (for susp 50 mg/5ml, for susp 100 mg/5ml, tab 100
mg, tab 200 mg)
cefprozil (for susp 125 mg/5ml, for susp 250 mg/5ml, tab 250 mg, tab 500
mg)
ceftriaxone sodium for iv soln 1 gm
cefuroxime axetil (tab 250 mg, tab 500 mg)
cephalexin (cap 250 mg, cap 500 mg, for susp 125 mg/5ml, for susp 250
mg/5ml)
Beta-lactam, Other (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))
DORIBAX (RECON SOLN 250 MG, RECON SOLN 500 MG)
Beta-lactam, Penicillins (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))
amoxicillin & k clavulanate tab 250-125 mg
amoxicillin & pot clavulanate (chew tab 200-28.5 mg, chew tab 400-57 mg,
for susp 200-28.5 mg/5ml, for susp 400-57 mg/5ml, for susp 600-42.9
mg/5ml)
amoxicillin & pot clavulanate (tab 500-125 mg, tab 875-125 mg)
PAGE 13
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
AMOXICILLIN ((TRIHYDRATE) CAP 250 MG, (TRIHYDRATE) CAP 500
MG, (TRIHYDRATE) CHEW TAB 250 MG, (TRIHYDRATE) FOR SUSP
125 MG/5ML, (TRIHYDRATE) FOR SUSP 200 MG/5ML, (TRIHYDRATE)
FOR SUSP 250 MG/5ML, (TRIHYDRATE) FOR SUSP 400 MG/5ML,
(TRIHYDRATE) TAB 500 MG, (TRIHYDRATE) TAB 875 MG, CHEW TAB
125 MG, CHEW TAB 250 MG)
AMOXICILLIN-POT CLAVULANATE (CHEW TAB 200-28.5 MG, CHEW
TAB 400-57 MG)
ampicillin (cap 250 mg, cap 500 mg)
BICILLIN C-R
QL
4 / 28 days
BICILLIN C-R 900/300
QL
4 / 28 days
azithromycin tab 250 mg
QL
12 / 30 days
azithromycin tab 500 mg
QL
6 / 30 days
QL
14 / 14 days
dicloxacillin sodium (cap 250 mg, cap 500 mg)
penicillin v potassium (for soln 125 mg/5ml, for soln 250 mg/5ml, tab 250
mg, tab 500 mg)
Macrolides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))
azithromycin (for susp 100 mg/5ml, for susp 200 mg/5ml, tab 600 mg)
clarithromycin (for susp 125 mg/5ml, for susp 250 mg/5ml, tab 250 mg, tab
500 mg, tab sr 24hr 500 mg)
erythromycin (acne aid) (gel, soln)
erythromycin (ophth)
Quinolones (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))
ciprofloxacin hcl (ophth)
ciprofloxacin hcl (tab 250 mg, tab 500 mg, tab 750 mg)
levofloxacin (tab 250 mg, tab 500 mg, tab 750 mg)
ofloxacin (ophth)
ofloxacin (otic)
OFLOXACIN TAB 400 MG
Sulfonamides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))
BLEPHAMIDE S.O.P.
sulfacetamide sod-prednisolone
sulfacetamide sodium (ophth)
PAGE 14
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
SULFADIAZINE TAB 500 MG
sulfamethoxazole-trimethoprim (susp 200-40 mg/5ml, tab 400-80 mg, tab
800-160 mg)
Tetracyclines (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))
doxycycline hyclate (cap 50 mg, cap 100 mg, tab 100 mg)
doxycycline monohydrate for susp 25 mg/5ml
minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg)
Anticonvulsants (NERVE CONDITIONS DRUGS)
Anticonvulsants, Other (SEIZURE CONTROL DRUGS)
levetiracetam oral soln 100 mg/ml
levetiracetam tab 1000 mg
QL
90 / 30 days
levetiracetam tab 250 mg
QL
360 / 30 days
levetiracetam tab 500 mg
QL
3 / 1 days
levetiracetam tab 750 mg
QL
4 / 1 days
zonisamide (cap 25 mg, cap 50 mg)
QL
30 / 30 days
zonisamide cap 100 mg
QL
180 / 30 days
PHENOBARBITAL (ELIXIR 20 MG/5ML, TAB 15 MG, TAB 16.2 MG, TAB
30 MG, TAB 32.4 MG, TAB 60 MG, TAB 64.8 MG, TAB 97.2 MG, TAB 100
MG)
Calcium Channel Modifying Agents (SEIZURES CONTROL DRUGS)
ethosuximide (cap 250 mg, soln 250 mg/5ml)
Gamma-aminobutyric Acid (GABA) Augmenting Agents (SEIZURES CONTROL DRUGS)
clonazepam (tab 0.5 mg, tab 1 mg, tab 2 mg)
DIAZEPAM GEL 2.5 MG
QL
2 / 30 days
divalproex sodium (cap sprinkle 125 mg, tab delayed release 125 mg, tab
delayed release 250 mg, tab delayed release 500 mg, tab sr 24 hr 500 mg,
tab sr 24 hr 250 mg)
gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, oral soln 250 mg/5ml,
tab 600 mg, tab 800 mg)
primidone (tab 50 mg, tab 250 mg)
valproate sodium syrup 250 mg/5ml (base equiv)
PAGE 15
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
Glutamate Reducing Agents (SEIZURES CONTROL DRUGS)
lamotrigine (tab 100 mg, tab 150 mg, tab 200 mg)
QL
3 / 1 days
QL
750 / 30 days
lamotrigine (tab 25 mg, tab chewable dispersible 5 mg, tab chewable
dispersible 25 mg)
topiramate (sprinkle cap 15 mg, sprinkle cap 25 mg, tab 25 mg, tab 50 mg,
tab 100 mg, tab 200 mg)
Sodium Channel Agents (SEIZURES CONTROL DRUGS)
carbamazepine (cap sr 12hr 300 mg, chew tab 100 mg, susp 100 mg/5ml,
tab 200 mg, tab sr 12hr 200 mg, tab sr 12hr 400 mg)
DILANTIN CAP 100 MG
fosphenytoin sodium (inj 100 mg/2ml, inj 500 mg/10ml)
oxcarbazepine (tab 150 mg, tab 300 mg, tab 600 mg)
phenytoin chew tab 50 mg
phenytoin sodium extended cap 100 mg
phenytoin susp 125 mg/5ml
Antidementia Agents (NERVE CONDITIONS DRUGS)
'Cholinesterase Inhibitors (ALZEIMER'S AND DEMENTIA DRUGS)'
donepezil hydrochloride (tab 5 mg, tab 10 mg)
galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg)
Antidepressants (NERVE CONDITIONS DRUGS)
Antidepressants, Other (DEPRESSION DRUGS)
bupropion hcl (tab 75 mg, tab 100 mg, tab sr 12hr 150 mg, tab sr 12hr 100
mg, tab sr 12hr 200 mg, tab sr 24hr 150 mg, tab sr 24hr 300 mg)
mirtazapine (tab 15 mg, tab 30 mg, tab 45 mg)
trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab 300 mg)
Monoamine Oxidase Inhibitors (DEPRESSION DRUGS)
phenelzine sulfate tab 15 mg
tranylcypromine sulfate
PA
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor
(DEPRESSION)
citalopram hydrobromide (tab 10 mg, tab 20 mg)
QL
51 / 30 days
citalopram hydrobromide tab 40 mg (base equiv)
PAGE 16
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
duloxetine hcl (cap 20 mg, cap 30 mg, cap 60 mg)
QL
30 / 30 days
escitalopram oxalate (tab 5 mg, tab 10 mg)
QL
45 / 30 days
escitalopram oxalate tab 20 mg (base equiv)
QL
30 / 30 days
fluoxetine hcl (cap 10 mg, cap 20 mg, cap 40 mg, solution 20 mg/5ml, tab
10 mg, tab 20 mg)
fluvoxamine maleate (tab 25 mg, tab 50 mg, tab 100 mg)
paroxetine hcl (tab 10 mg, tab 20 mg, tab 30 mg, tab 40 mg)
sertraline hcl (tab 25 mg, tab 50 mg, tab 100 mg)
venlafaxine hcl (cap sr 24hr 150 mg (base equivalent), cap sr 24hr 37.5 mg
(base equivalent), cap sr 24hr 75 mg (base equivalent), tab 25 mg, tab 37.5
mg, tab 50 mg, tab 75 mg, tab 100 mg)
Tricyclics (DEPRESSION DRUGS)
amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75 mg, tab 100 mg,
tab 150 mg)
PA
C
PA for members over
age 65
PA
AMOXAPINE (TAB 25 MG, TAB 50 MG, TAB 100 MG, TAB 150 MG)
C
PA for members over
age 65
clomipramine hcl cap 75 mg
PA
imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg)
C
PA for members over
age 65
nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg, soln 10
mg/5ml, solution 10 mg/5ml)
Antiemetics (BOWEL, INSTESTINE, AND STOMACH CONDITIONS DRUGS)
ANTIEMETICS, Other (NAUSEA AND VOMITING DRUGS)
meclizine hcl (tab 12.5 mg, tab 25 mg)
promethazine hcl (suppos 12.5 mg, suppos 25 mg, suppos 50 mg)
QL
28 / 14 days
promethazine hcl (syrup 6.25 mg/5ml, tab 12.5 mg, tab 25 mg, tab 50 mg)
trimethobenzamide hcl cap 300 mg
Emetogenic Therapy Adjuncts (NAUSEA AND VOMITING DRUGS)
dronabinol (cap 2.5 mg, cap 5 mg, cap 10 mg)
PA
ondansetron (tab 4 mg, tab 8 mg)
PAGE 17
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
ondansetron hcl (tab 4 mg, tab 8 mg)
ondansetron hcl oral soln 4 mg/5ml
QL
50 / 30 days
QL
20 / 30 days
QL
9 / 30 days
Antigout Agents (GOUT DRUGS)
allopurinol (tab 100 mg, tab 300 mg)
COLCHICINE TAB 0.6 MG
colchicine w/ probenecid
probenecid tab 500 mg
Antimigraine Agents (NERVE CONDITIONS DRUGS)
Prophylactic (MIGRAINE DRUGS)
TIMOLOL MALEATE (TAB 5 MG, TAB 10 MG, TAB 20 MG)
valproic acid cap 250 mg
Serotonin (5-HT) 1b/1d Receptor Agonists (MIGRAINE DRUGS)
rizatriptan benzoate (tab 5 mg, tab 10 mg)
ST
sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg)
QL
9 / 30 days
Antimycobacterials (INFECTION FIGHTING DRUGS)
Antimycobacterials, Other (MISCELLANEOUS INFECTION FIGHTING DRUGS)
DAPSONE (TAB 25 MG, TAB 100 MG)
Antituberculars
ethambutol hcl (tab 100 mg, tab 400 mg)
isoniazid (tab 100 mg, tab 300 mg)
pyrazinamide tab 500 mg
rifampin (cap 150 mg, cap 300 mg)
RIFATER
TRECATOR
Antiparkinson Agents (NERVE CONDITIONS DRUGS)
'Anticholinergics (PARKINSON'S DISEASE DRUGS)'
benztropine mesylate (tab 0.5 mg, tab 1 mg, tab 2 mg)
trihexyphenidyl hcl (tab 2 mg, tab 5 mg)
PAGE 18
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
'Dopamine Agonists (PARKINSON'S DISEASE DRUGS)'
bromocriptine mesylate (cap 5 mg, tab 2.5 mg)
pramipexole dihydrochloride (tab 0.125 mg, tab 0.25 mg, tab 0.5 mg, tab 1
mg, tab 1.5 mg)
ropinirole hydrochloride (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3
mg, tab 4 mg, tab 5 mg)
'Monoamine Oxidase B (MAO-B) Inhibitors (PARKINSON'S DISEASE DRUGS)'
selegiline hcl cap 5 mg
Antiparkinson Agents, Other
entacapone
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa tab 25 mg
carbidopa-levodopa (tab 10-100 mg, tab 25-100 mg, tab 25-250 mg, tab cr
25-100 mg, tab cr 50-200 mg)
Antipsychotics (NERVE CONDITIONS DRUGS)
1st Generation/Typical (MOOD DISORDER DRUGS)
chlorpromazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100 mg, tab 200
mg)
fluphenazine hcl (conc 5 mg/ml, elixir 2.5 mg/5ml, solution 2.5 mg/ml, tab 1
mg, tab 2.5 mg, tab 5 mg, tab 10 mg)
haloperidol (tab 0.5 mg, tab 1 mg, tab 2 mg, tab 5 mg, tab 10 mg, tab 20
mg)
haloperidol decanoate im soln 100 mg/ml
loxapine succinate (cap 5 mg, cap 10 mg, cap 25 mg, cap 50 mg)
perphenazine (tab 2 mg, tab 4 mg, tab 8 mg, tab 16 mg)
prochlorperazine
QL
60 / 30 days
prochlorperazine maleate (tab 5 mg, tab 10 mg)
thiothixene (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10 mg)
2nd Generation/Atypical (MOOD DISORDER DRUGS)
quetiapine fumarate (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg, tab
300 mg, tab 400 mg)
ST
risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4
mg)
PAGE 19
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
ziprasidone hcl (cap 20 mg, cap 40 mg, cap 60 mg, cap 80 mg)
LIMITS & RESTRICTIONS
ST
Treatment-Resistant (MOOD DISORDER DRUGS)
clozapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg)
Antispasticity Agents (MUSCLE AND JOINT DRUGS)
baclofen (tab 10 mg, tab 20 mg)
tizanidine hcl (tab 2 mg (base equivalent), tab 2 mg, tab 4 mg (base
equivalent), tab 4 mg)
QL
90 / 30 days
Antivirals (INFECTION FIGHTING DRUGS)
Anti-HIV Agents, Integrase Inhibitors (INSTI) (RETROVIRUS INFECTION FIGHTING DRUGS)
ATRIPLA
QL
30 / 30 days
ISENTRESS TAB 400 MG
QL
60 / 30 days
EDURANT
QL
30 / 30 days
INTELENCE TAB 100 MG
QL
120 / 30 days
INTELENCE TAB 200 MG
QL
60 / 30 days
NEVIRAPINE SUSPENSION 50 MG/5ML
QL
1200 / 30 days
nevirapine tab 200 mg
QL
60 / 30 days
nevirapine tab sr 24hr 400 mg
QL
30 / 30 days
RESCRIPTOR TAB 100 MG
QL
360 / 30 days
RESCRIPTOR TAB 200 MG
QL
180 / 30 days
STRIBILD
QL
30 / 30 days
SUSTIVA CAP 200 MG
QL
90 / 30 days
SUSTIVA CAP 50 MG
QL
360 / 30 days
SUSTIVA TAB 600 MG
QL
30 / 30 days
VIRAMUNE SUSPENSION 50 MG/5ML
QL
1200 / 30 days
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) (RETROVIRUS
INFECTION DRUGS)
abacavir sulfate
PAGE 20
QL
60 / 30 days
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
abacavir sulfate-lamivudine-zidovudine
QL
60 / 30 days
didanosine (capsule 125 mg, capsule 200 mg)
QL
60 / 30 days
didanosine (capsule 250 mg, capsule 400 mg)
QL
30 / 30 days
EMTRIVA CAP 200 MG
QL
30 / 30 days
EMTRIVA SOLUTION 10 MG/ML
QL
600 / 30 days
EPIVIR HBV SOLUTION 5 MG/ML
QL
1800 / 30 days
EPIVIR SOLUTION 10 MG/ML
QL
900 / 30 days
EPZICOM
QL
30 / 30 days
lamivudine (hbv)
QL
90 / 30 days
lamivudine tab 150 mg
QL
60 / 30 days
lamivudine tab 300 mg
QL
30 / 30 days
lamivudine-zidovudine
QL
60 / 30 days
stavudine (cap 15 mg, cap 20 mg, cap 40 mg)
QL
60 / 30 days
stavudine cap 30 mg
QL
30 / 30 days
stavudine for oral soln 1 mg/ml
QL
1200 / 30 days
TRUVADA
QL
30 / 30 days
VIDEX (RECON SOLN 2 GM, RECON SOLN 4 GM)
QL
603 / 30 days
VIREAD TAB 300 MG
QL
30 / 30 days
ZIAGEN SOLUTION 20 MG/ML
QL
900 / 30 days
zidovudine cap 100 mg
QL
180 / 30 days
zidovudine syrup 10 mg/ml
QL
1800 / 30 days
zidovudine tab 300 mg
QL
60 / 30 days
QL
120 / 30 days
QL
120 / 30 days
Anti-HIV Agents, Other (RETROVIRUS INFECTION DRUGS)
SELZENTRY (TAB 150 MG, TAB 300 MG)
Anti-HIV Agents, Protease Inhibitors (RETROVIRUS INFECTION DRUGS)
APTIVUS CAP 250 MG
PAGE 21
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
APTIVUS SOLUTION 100 MG/ML
QL
300 / 30 days
CRIXIVAN CAP 200 MG
QL
360 / 30 days
CRIXIVAN CAP 400 MG
QL
180 / 30 days
INVIRASE CAP 200 MG
QL
300 / 30 days
INVIRASE TAB 500 MG
QL
120 / 30 days
KALETRA SOLUTION 400-100 MG/5ML
QL
450 / 30 days
KALETRA TAB 100-25 MG
QL
360 / 30 days
KALETRA TAB 200-50 MG
QL
180 / 30 days
LEXIVA SUSPENSION 50 MG/ML
QL
360 / 60 days
LEXIVA TAB 700 MG
QL
120 / 30 days
NORVIR (CAP 100 MG, TAB 100 MG)
QL
360 / 30 days
NORVIR SOLUTION 80 MG/ML
QL
450 / 30 days
PREZISTA TAB 150 MG
QL
240 / 30 days
PREZISTA TAB 600 MG
QL
60 / 30 days
PREZISTA TAB 75 MG
QL
480 / 30 days
PREZISTA TAB 800 MG
QL
30 / 30 days
REYATAZ (CAP 150 MG, CAP 200 MG)
QL
60 / 30 days
REYATAZ CAP 300 MG
QL
30 / 30 days
VIRACEPT TAB 250 MG
QL
300 / 30 days
VIRACEPT TAB 625 MG
QL
120 / 30 days
Anti-hepatitis B (HBV) Agents (VIRUS INFECTION DRUGS)
INTRON A (RECON SOLN 10000000 UNIT, RECON SOLN 18000000
UNIT, RECON SOLN 50000000 UNIT, SOLUTION 6000000 UNIT/ML,
SOLUTION 10000000 UNIT/ML)
PA
Anti-hepatitis C (HCV) Agents (VIRUS INFECTION DRUGS)
PEG-INTRON (KIT 50, KIT 80, KIT 120, KIT 150)
PA
PEG-INTRON REDIPEN (KIT 50, KIT 80, KIT 120, KIT 150)
PA
PEG-INTRON REDIPEN PAK 4 (4 KIT 80, 4 KIT 120, 4 KIT 150, 4 KIT 50)
PA
PAGE 22
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
PEGINTRON (KIT 50, KIT 80, KIT 120, KIT 150)
PA
ribavirin cap 200 mg
PA
Anti-influenza Agents (VIRUS INFECTION DRUGS)
amantadine hcl (cap 100 mg, syrup 50 mg/5ml)
RELENZA DISKHALER
QL
20 / 5 days
QL
10 / 5 days
AL1
Up to 12 yrs old
rimantadine hydrochloride
TAMIFLU (CAP 30 MG, CAP 45 MG, CAP 75 MG)
Antiherpetic Agents
acyclovir (cap 200 mg, tab 400 mg, tab 800 mg)
acyclovir susp 200 mg/5ml
trifluridine ophth soln 1%
valacyclovir hcl (tab 1 gm, tab 500 mg)
Anxiolytics (NERVE CONDITIONS DRUGS)
Anxiolytics, Other (ANXIETY DRUGS)
buspirone hcl (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg, tab 30 mg)
doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg, cap 100 mg,
cap 150 mg, conc 10 mg/ml)
PA
C
PA for members over
age 65
Benzodiazepines (ANXIETY DRUGS)
alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg)
alprazolam (tab 24hr 2 mg, tab 24hr 1 mg, tab 24hr 3 mg, tab 24hr 0.5 mg)
PA
clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg, tab 15 mg)
diazepam (solution 1 mg/ml, solution 5 mg/ml, tab 2 mg, tab 5 mg, tab 10
mg)
PA
C
PA for members over
age 65
lorazepam (tab 0.5 mg, tab 1 mg, tab 2 mg)
oxazepam (cap 10 mg, cap 15 mg, cap 30 mg)
PA
temazepam (cap 15 mg, cap 30 mg)
C
PAGE 23
PA for members over
age 65
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
Bipolar Agents (NERVE CONDITIONS DRUGS)
Mood Stabilizers (MISCELLANEOUS NERVE CONDITIONS DRUGS)
lithium carbonate (cap 150 mg, cap 300 mg, cap 600 mg, tab 300 mg, tab
cr 300 mg, tab cr 450 mg)
Blood Glucose Regulators (HORMONE AND DIABETIC DRUGS)
ANTIDIABETIC AGENTS (BLOOD SUGAR PRODUCTS)
acarbose (tab 25 mg, tab 50 mg, tab 100 mg)
glimepiride (tab 1 mg, tab 2 mg, tab 4 mg)
glipizide (tab 24hr 2.5 mg, tab 24hr 5 mg, tab 24hr 10 mg)
QL
60 / 30 days
JANUMET (TAB 50-500 MG, TAB 50-1000 MG)
QL
60 / 30 days
JANUMET XR (TAB ER 24H 50-1000 MG, TAB ER 24H 100-1000 MG,
TAB ER 24H 50-500 MG)
QL
30 / 30 days
JANUVIA (TAB 25 MG, TAB 50 MG, TAB 100 MG)
QL
30 / 30 days
nateglinide (tab 60 mg, tab 120 mg)
QL
90 / 30 days
pioglitazone hcl (tab 15 mg, tab 30 mg, tab 45 mg)
QL
30 / 30 days
pioglitazone hcl-metformin hcl (-metformin tab 15-500 mg, -metformin tab
15-850 mg)
QL
60 / 30 days
QL
2 / 365 days
glipizide (tab 5 mg, tab 10 mg)
glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg)
glyburide micronized (tab 1.5 mg, tab 3 mg, tab 6 mg)
glyburide-metformin (tab 1.25-250 mg, tab 2.5-500 mg, tab 5-500 mg)
metformin hcl (tab 500 mg, tab 850 mg, tab 1000 mg, tab sr 24hr 500 mg,
tab sr 24hr 750 mg)
GLYCEMIC AGENTS (LOW BLOOD GLUCOSE DRUGS)
GLUCAGON EMERGENCY
Insulins (INJECTABLE DIABETES, BLOOD SUGAR DRUGS)
APIDRA
APIDRA SOLOSTAR
LANTUS
LANTUS SOLOSTAR
NOVOLIN 70/30
PAGE 24
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
NOVOLIN 70/30 RELION
NOVOLIN N
NOVOLIN N RELION
NOVOLIN R
NOVOLIN R RELION
NOVOLOG MIX 70/30
TOUJEO SOLOSTAR
Blood Products/Modifiers/Volume Expanders (BLOOD DISORDER DRUGS)
ANTICOAGULANTS (BLOOD THINNERS)
enoxaparin sodium (inj 30 mg/0.3ml, inj 40 mg/0.4ml, inj 60 mg/0.6ml, inj
80 mg/0.8ml, inj 100 mg/ml, inj 120 mg/0.8ml, inj 150 mg/ml, inj 300
mg/3ml)
PA
GL
Female
QL
35 / 35 days
heparin sodium (porcine) (inj 1000 unit/ml, inj 5000 unit/ml, inj 10000
unit/ml, inj 20000 unit/ml, pf inj 5000 unit/0.5ml)
warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5 mg, tab 3 mg, tab 4 mg, tab 5
mg, tab 6 mg, tab 7.5 mg, tab 10 mg)
XARELTO TAB 10 MG
PA
Blood Formation Modifiers (BLOOD FORMATION DRUGS)
anagrelide hcl (cap 0.5 mg, cap 1 mg)
EPOGEN (SOLUTION 2000, SOLUTION 3000, SOLUTION 4000,
SOLUTION 10000)
PA
NEUPOGEN (SOLN PRSYR 300 MCG/0.5ML, SOLN PRSYR 480
MCG/0.8ML, SOLUTION 300 MCG/ML, SOLUTION 480 MCG/1.6ML)
PA
PROCRIT (SOLUTION 2000, SOLUTION 3000, SOLUTION 4000,
SOLUTION 10000, SOLUTION 40000)
PA
Platelet Modifying Agents (BLOOD THINNERS)
cilostazol (tab 50 mg, tab 100 mg)
clopidogrel bisulfate tab 300 mg (base equiv)
QL
5 / 90 days
clopidogrel bisulfate tab 75 mg (base equiv)
QL
30 / 30 days
dipyridamole (tab 25 mg, tab 50 mg, tab 75 mg)
EFFIENT (TAB 5 MG, TAB 10 MG)
PA
ticlopidine hcl
PAGE 25
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
CENTRAL NERVOUS SYSTEM AGENTS (NERVE CONDITIONS DRUGS)
Attention Deficit Hyperactivity Disorder Agents, Amphetamines (ADHD DRUGS)
QL
amphetamine-dextroamphetamine (cap 24hr 30 mg, cap 24hr 15 mg, cap
24hr 20 mg, cap 24hr 5 mg, cap 24hr 25 mg, cap 24hr 10 mg)
30 / 30 days
ST
AL1
6 to 17 yrs old
amphetamine-dextroamphetamine (tab 5 mg, tab 7.5 mg, tab 10 mg, tab
12.5 mg, tab 15 mg, tab 20 mg, tab 30 mg)
AL1
6 to 17 yrs old
dextroamphetamine sulfate (cap sr 24hr 15 mg, cap sr 24hr 10 mg, cap sr
24hr 5 mg, tab 5 mg, tab 10 mg)
AL1
6 to 17 yrs old
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines (ADHD DRUGS)
dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
AL1
6 to 17 yrs old
methylphenidate hcl (cap 10 mg, cap 20 mg, cap 30 mg, cap 40 mg, cap 50
mg, cap 60 mg, tab 10 mg)
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
90 / 30 days
AL1
6 to 17 yrs old
QL
180 / 30 days
AL1
6 to 17 yrs old
methylphenidate hcl (tab 5 mg, tab 20 mg, tab cr 20 mg)
methylphenidate hcl tab 10 mg
Central Nervous System, Other (MISCELLANEOUS NERVE CONDITIONS DRUGS)
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg
MULTIPLE SCLEROSIS AGENTS (MULTIPLE SCLEROSIS DRUGS)
AVONEX
PA
BETASERON
PA
EXTAVIA
PA
glatiramer acetate
PA
Cardiovascular Agents (HEART AND CIRCULATION CONDITIONS DRUGS)
ANGIOTENSIN II RECEPTOR ANTAGONISTS (BLOOD PRESSURE DRUGS)
irbesartan (tab 75 mg, tab 150 mg, tab 300 mg)
QL
30 / 30 days
irbesartan-hydrochlorothiazide (tab 150-12.5 mg, tab 300-12.5 mg)
QL
30 / 30 days
losartan potassium & hydrochlorothiazide (tab 50-12.5 mg, tab 100-25 mg,
tab 100-12.5 mg)
QL
30 / 30 days
PAGE 26
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
losartan potassium (tab 25 mg, tab 50 mg, tab 100 mg)
LIMITS & RESTRICTIONS
QL
30 / 30 days
NORPACE CR CAP ER 12H 100 MG
QL
60 / 30 days
NORPACE CR CAP ER 12H 150 MG
QL
120 / 30 days
midodrine hcl (tab 2.5 mg, tab 5 mg)
QL
30 / 30 days
midodrine hcl tab 10 mg
QL
120 / 30 days
QL
90 / 30 days
QL
30 / 30 days
ANTIARRHYTHMICS (HEART REGULATION DRUGS)
amiodarone hcl tab 200 mg
disopyramide phosphate (cap 100 mg, cap 150 mg)
flecainide acetate (tab 50 mg, tab 100 mg, tab 150 mg)
propafenone hcl (tab 150 mg, tab 225 mg, tab 300 mg)
quinidine gluconate tab cr 324 mg
QUINIDINE SULFATE (TAB 200 MG, TAB 300 MG)
sotalol hcl (afib/afl) (tab 80 mg, tab 120 mg, tab 160 mg)
sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg, tab 240 mg)
Alpha-adrenergic Agonists (HEART AND CIRCULATION CONDITIONS DRUGS)
clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg)
guanfacine hcl (tab 1 mg, tab 2 mg)
methyldopa (tab 250 mg, tab 500 mg)
Alpha-adrenergic Blocking Agents (BLOOD PRESSURE DRUGS)
prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg)
Angiotensin-converting Enzyme (ACE) Inhibitors (BLOOD PRESSURE DRUGS)
benazepril & hydrochlorothiazide (tab 5-6.25 mg, tab 10-12.5 mg, tab 2012.5 mg, tab 20-25 mg)
benazepril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
captopril (tab 12.5 mg, tab 25 mg, tab 50 mg)
captopril tab 100 mg
CAPTOPRIL-HYDROCHLOROTHIAZIDE (TAB 25-15 MG, TAB 25-25 MG,
TAB 50-15 MG, TAB 50-25 MG)
enalapril maleate & hydrochlorothiazide (tab 5-12.5 mg, tab 10-25 mg)
enalapril maleate (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg)
fosinopril sodium (tab 10 mg, tab 20 mg, tab 40 mg)
PAGE 27
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
lisinopril & hydrochlorothiazide (tab 10-12.5 mg, tab 20-25 mg, tab 20-12.5
mg)
lisinopril (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg)
QL
2 / 1 days
lisinopril tab 30 mg
QL
1 / 1 days
QL
30 / 30 days
lisinopril tab 40 mg
moexipril hcl (tab 7.5 mg, tab 15 mg)
quinapril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
quinapril-hydrochlorothiazide (tab 10-12.5 mg, tab 20-25 mg, tab 20-12.5
mg)
ramipril (cap 1.25 mg, cap 2.5 mg, cap 5 mg, cap 10 mg)
trandolapril (tab 1 mg, tab 2 mg, tab 4 mg)
Beta-adrenergic Blocking Agents (BLOOD PRESSURE DRUGS)
acebutolol hcl (cap 200 mg, cap 400 mg)
atenolol & chlorthalidone (tab 50-25 mg, tab 100-25 mg)
atenolol (tab 25 mg, tab 50 mg, tab 100 mg)
bisoprolol & hydrochlorothiazide (tab 2.5-6.25 mg, tab 5-6.25 mg, tab 106.25 mg)
bisoprolol fumarate (tab 5 mg, tab 10 mg)
BYSTOLIC (TAB 2.5 MG, TAB 5 MG, TAB 10 MG, TAB 20 MG)
PA
carvedilol (tab 3.125 mg, tab 6.25 mg, tab 12.5 mg, tab 25 mg)
labetalol hcl (tab 100 mg, tab 200 mg, tab 300 mg)
metoprolol & hydrochlorothiazide (tab 50-25 mg, tab 100-25 mg, tab 100-50
mg)
metoprolol succinate (tab 24hr 100 mg, tab 24hr 200 mg, tab 24hr 50 mg,
tab 24hr 25 mg)
QL
30 / 30 days
QL
30 / 30 days
metoprolol tartrate (tab 25 mg, tab 50 mg, tab 100 mg)
nadolol (tab 20 mg, tab 40 mg, tab 80 mg)
pindolol (tab 5 mg, tab 10 mg)
propranolol hcl (cap sr 24hr 80 mg, cap sr 24hr 60 mg, cap sr 24hr 120 mg,
cap sr 24hr 160 mg, tab 10 mg, tab 20 mg, tab 40 mg, tab 60 mg, tab 80
mg)
PROPRANOLOL-HCTZ (TAB 40-25 MG, TAB 80-25 MG)
PAGE 28
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
Calcium Channel Blocking Agents (BLOOD PRESSURE DRUGS)
amlodipine besylate (tab 2.5 mg, tab 5 mg, tab 10 mg)
QL
30 / 30 days
QL
30 / 30 days
amlodipine besylate-benazepril hcl (cap 2.5-10 mg, cap 5-10 mg, cap 5-40
mg, cap 5-20 mg, cap 10-40 mg, cap 10-20 mg)
AZOR (TAB 5-20 MG, TAB 5-40 MG, TAB 10-40 MG, TAB 10-20 MG)
PA
diltiazem hcl (cap 24hr 240 mg, cap 24hr 120 mg, cap 24hr 180 mg)
QL
30 / 30 days
diltiazem hcl (cap 60 mg, cap 90 mg, cap 120 mg)
QL
60 / 30 days
diltiazem hcl coated beads (beads cap 24hr 300 mg, beads cap 24hr 180
mg, beads cap 24hr 240 mg, beads cap 24hr 120 mg)
QL
30 / 30 days
diltiazem hcl extended release beads (beads cap 24hr 360 mg, beads cap
24hr 180 mg, beads cap 24hr 300 mg, beads cap 24hr 240 mg, beads cap
24hr 120 mg, beads cap 24hr 420 mg)
QL
30 / 30 days
felodipine (tab 24hr 10 mg, tab 24hr 5 mg, tab 24hr 2.5 mg)
QL
30 / 30 days
nifedipine (tab 24hr 60 mg, tab 24hr osmotic 60 mg, tab 24hr osmotic 30
mg, tab 24hr osmotic 90 mg, tab 24hr 30 mg, tab 24hr 90 mg)
QL
30 / 30 days
nimodipine cap 30 mg
PA
verapamil hcl (cap sr 24hr 120 mg, cap sr 24hr 100 mg, cap sr 24hr 180
mg, cap sr 24hr 360 mg, cap sr 24hr 200 mg, cap sr 24hr 240 mg, cap sr
24hr 300 mg, tab cr 120 mg, tab cr 180 mg, tab cr 240 mg)
QL
diltiazem hcl (tab 30 mg, tab 60 mg, tab 90 mg, tab 120 mg)
nicardipine hcl (cap 20 mg, cap 30 mg)
nifedipine (cap 10 mg, cap 20 mg)
30 / 30 days
verapamil hcl (tab 40 mg, tab 80 mg, tab 120 mg)
Cardiovascular Agents, Other (MISCELLANEOUS HEART AND CIRCULATION DRUGS)
digoxin (tab 125 mcg (0.125, tab 250 mcg (0.25)
pentoxifylline tab cr 400 mg
QL
90 / 30 days
DIURETICS, LOOP (BLOOD PRESSURE DRUGS (WATER PILLS))
bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg)
furosemide (inj 10 mg/ml, oral soln 10 mg/ml, tab 20 mg, tab 40 mg, tab 80
mg)
torsemide (tab 5 mg, tab 10 mg, tab 20 mg, tab 100 mg)
PAGE 29
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
DIURETICS, THIAZIDE (BLOOD PRESSURE DRUGS (WATER PILLS))
chlorothiazide (tab 250 mg, tab 500 mg)
CHLORTHALIDONE (TAB 25 MG, TAB 50 MG)
hydrochlorothiazide (cap 12.5 mg, tab 25 mg, tab 50 mg)
indapamide (tab 1.25 mg, tab 2.5 mg)
METHYCLOTHIAZIDE TAB 5 MG
metolazone (tab 2.5 mg, tab 5 mg, tab 10 mg)
Diuretics, Carbonic Anhydrase Inhibitors (BLOOD PRESSURE DRUGS (WATER PILLS))
acetazolamide (tab 125 mg, tab 250 mg)
methazolamide (tab 25 mg, tab 50 mg)
Diuretics, Potassium-sparing (BLOOD PRESSURE DRUGS (WATER PILLS))
amiloride & hydrochlorothiazide
amiloride hcl tab 5 mg
spironolactone & hydrochlorothiazide
spironolactone (tab 25 mg, tab 50 mg, tab 100 mg)
triamterene & hydrochlorothiazide (cap 37.5-25 mg, tab 37.5-25 mg, tab
75-50 mg)
Dyslipidemics, Fibric Acid Derivatives (CHOLESTEROL DRUGS)
fenofibrate (tab 54 mg, tab 160 mg)
QL
30 / 30 days
QL
30 / 30 days
QL
30 / 30 days
fenofibrate micronized (cap 67 mg, cap 134 mg, cap 200 mg)
gemfibrozil tab 600 mg
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab 80 mg)
lovastatin (tab 10 mg, tab 20 mg, tab 40 mg)
pravastatin sodium (tab 10 mg, tab 20 mg, tab 40 mg, tab 80 mg)
simvastatin (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
Dyslipidemics, Other (CHOLESTEROL DRUGS)
cholestyramine light powder 4 gm/dose
cholestyramine powder 4 gm/dose
colestipol hcl (granules 5 gm, tab 1 gm)
NIACOR
PAGE 30
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
Vasodilators, Direct-acting Arterial (MISCELLANEOUS HEART AND CIRCULATION DRUGS)
hydralazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100 mg)
minoxidil (tab 2.5 mg, tab 10 mg)
Vasodilators, Direct-acting Arterial/Venous (CHEST PAIN DRUGS)
isosorbide dinitrate (tab 5 mg, tab 10 mg, tab 20 mg, tab 30 mg, tab cr 40
mg)
ISOSORBIDE DINITRATE ER
isosorbide mononitrate (tab 20 mg, tab sr 24hr 120 mg, tab sr 24hr 30 mg,
tab sr 24hr 60 mg)
NITRO-BID
nitroglycerin (patch 24hr 0.4, patch 24hr 0.1, patch 24hr 0.2, patch 24hr
0.6)
NITROSTAT (SL TAB 0.3 MG, SL TAB 0.4 MG, SL TAB 0.6 MG)
Dental and Oral Agents (DRUGS FOR THE MOUTH)
chlorhexidine gluconate (mouth-throat)
pilocarpine hcl tab 5 mg
triamcinolone acetonide (mouth)
Dermatological Agents
alclometasone dipropionate (cream, oint)
betamethasone dipropionate (topical) (cream, oint)
QL
90 / 30 days
betamethasone dipropionate augmented cream 0.05%
QL
100 / 30 days
betamethasone dipropionate lotion 0.05%
QL
120 / 30 days
betamethasone valerate (cream, oint)
QL
90 / 30 days
betamethasone valerate lotion 0.1%
QL
120 / 30 days
clobetasol propionate soln 0.05%
QL
100 / 30 days
DERMA-SMOOTHE/FS BODY
QL
120 / 30 days
DERMA-SMOOTHE/FS SCALP
QL
120 / 30 days
desonide oint 0.05%
QL
120 / 30 days
fluocinolone acetonide (cream 0.01%, cream 0.025%, oint 0.025%)
QL
120 / 30 days
clindamycin phosphate (topical) (lotion, soln, swab)
PAGE 31
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
fluocinonide (cream, gel, oint, soln)
QL
120 / 30 days
fluocinonide emulsified base
QL
120 / 30 days
QL
120 / 30 days
halobetasol propionate (cream, oint)
QL
100 / 30 days
hydrocortisone (topical) (cream 0.5%, oint 0.5%, oint 1%)
QL
60 / 30 days
hydrocortisone (topical) (cream 1%, lotion 2.5%)
QL
120 / 30 days
hydrocortisone (topical) (cream, oint)
QL
90 / 30 days
hydrocortisone lotion 1%
QL
240 / 30 days
QL
120 / 30 days
lactic acid (ammonium lactate) lotion 5%
QL
226 / 30 days
mometasone furoate (cream, oint, solution (lotion))
QL
60 / 30 days
prednicarbate oint 0.1%
QL
60 / 30 days
SANTYL OINTMENT 250 UNIT/GM
QL
60 / 30 days
QL
45 / 30 days
AL1
Up to 29 yrs old
triamcinolone acetonide (topical) (cream 0.025%, cream 0.1%, oint
0.025%, oint 0.1%)
QL
160 / 30 days
triamcinolone acetonide (topical) (lotion 0.025%, lotion 0.1%)
QL
120 / 30 days
triamcinolone acetonide cream 0.5%
QL
60 / 30 days
TRIAMCINOLONE ACETONIDE OINTMENT 0.5 %
QL
60 / 30 days
fluorouracil (topical) (cream 5%, soln 2%, soln 5%)
fluticasone propionate (cream 0.05%, oint 0.005%)
GAUZE SPONGE
hydrocortisone rectal cream 2.5%
hydrocortisone valerate (cream, oint)
lactic acid (ammonium lactate) (cream 12%, lotion 10%, lotion 12%)
podofilox soln 0.5%
selenium sulfide lotion 2.5%
sulfacetamide sodium (acne)
SURGICAL DRESSING PAD 5"X9"
tretinoin (cream 0.025%, cream 0.05%, cream 0.1%, gel 0.01%, gel
0.025%)
PAGE 32
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
Enzyme Replacement/Modifiers (ENZYME DEFICIENCY DRUGS)
CREON (CP DR PART 3000-9500, CP DR PART 6000, CP DR PART
12000, CP DR PART 24000, CP DR PART 36000)
PANCREAZE (CP DR PART 4200, CP DR PART 10500, CP DR PART
16800, CP DR PART 21000)
PANCRELIPASE (LIP-PROT-AMYL)
PERTZYE (CP DR PART 8000, CP DR PART 16000)
ULTRESA (CP DR PART 13800, CP DR PART 20700, CP DR PART
23000)
VIOKACE (TAB 10440, TAB 20880)
ZENPEP (CP DR PART 3000-10000, CP DR PART 5000, CP DR PART
10000, CP DR PART 15000, CP DR PART 20000, CP DR PART 25000)
GASTROINTESTINAL Agents (BOWEL, INSTESTINE, AND STOMACH CONDITIONS DRUGS)
ANTISPASMODICS, GASTROINTESTINAL (BOWEL TREATMENT DRUGS)
dicyclomine hcl (cap 10 mg, tab 20 mg)
glycopyrrolate (tab 1 mg, tab 2 mg)
Gastrointestinal Agents, Other (MISCELLANEOUS DIGESTIVE SYSTEM DRUGS)
diphenoxylate w/ atropine
DIPHENOXYLATE-ATROPINE
loperamide hcl (cap 2 mg, tab 2 mg)
metoclopramide hcl (soln 5 mg/5ml (10 mg/10ml), tab 5 mg, tab 10 mg)
ursodiol cap 300 mg
Histamine2 (H2) Receptor Antagonists (ULCER AND STOMACH ACID DRUGS)
cimetidine (tab 200 mg, tab 300 mg, tab 400 mg, tab 800 mg)
cimetidine hcl
famotidine (inj 20 mg/2ml, inj 40 mg/4ml, inj 200 mg/20ml, solution 500
mg/50ml, tab 10 mg, tab 20 mg, tab 40 mg)
ranitidine hcl (syrup 15 mg/ml (75 mg/5ml), tab 150 mg, tab 300 mg)
LAXATIVES (CONSTIPATION DRUGS)
QL
4000 / 365 days
AL1
50 to 75 yrs old
QL
4000 / 365 days
AL1
50 to 75 yrs old
COLYTE WITH FLAVOR PACKS (RECON SOLN 240 GM, 240 GM)
GOLYTELY RECON SOLN 236 GM
PAGE 33
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
lactulose (encephalopathy)
lactulose solution 10 gm/15ml
QL
4000 / 365 days
AL1
50 to 75 yrs old
QL
4000 / 365 days
AL1
50 to 75 yrs old
QL
4000 / 365 days
AL1
50 to 75 yrs old
lansoprazole cap delayed release 15 mg
QL
60 / 30 days
lansoprazole cap delayed release 30 mg
QL
30 / 30 days
omeprazole (cap 10 mg, cap 40 mg)
QL
30 / 30 days
omeprazole cap delayed release 20 mg
QL
60 / 30 days
pantoprazole sodium ec tab 20 mg (base equiv)
QL
30 / 30 days
pantoprazole sodium ec tab 40 mg (base equiv)
QL
60 / 30 days
NULYTELY WITH FLAVOR PACKS
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (soln236gm, soln240gm)
peg 3350-potassium chloride-sod bicarbonate-sod chloride
polyethylene glycol 3350 (3350 powder, 3350 packet)
PROTECTANTS (MISCELLANEOUS DIGESTIVE SYSTEM DRUGS)
misoprostol (tab 100 mcg, tab 200 mcg)
sucralfate tab 1 gm
PROTON PUMP INHIBITORS (ULCER AND STOMACH ACID DRUGS)
Genitourinary Agents (BLADDER, GENITAL, AND KIDNEY CONDITIONS DRUGS)
Antispasmodics, Urinary (BLADDER MUSCLE RELAXANTS)
ENABLEX (TAB ER 24H 7.5 MG, TAB ER 24H 15 MG)
ST
oxybutynin chloride (syrup 5 mg/5ml, tab 5 mg, tab sr 24hr 15 mg, tab sr
24hr 10 mg, tab sr 24hr 5 mg)
OXYTROL
OXYTROL FOR WOMEN
tolterodine tartrate (cap sr 24hr 4 mg, cap sr 24hr 2 mg, tab 1 mg, tab 2
mg)
ST
TOVIAZ (TAB ER 24H 8 MG, TAB ER 24H 4 MG)
ST
trospium chloride (cap sr 24hr 60 mg, tab 20 mg)
ST
PAGE 34
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
VESICARE (TAB 5 MG, TAB 10 MG)
LIMITS & RESTRICTIONS
ST
BENIGN PROSTATIC HYPERTROPHY AGENTS (PROSTATE DRUGS)
alfuzosin hcl
doxazosin mesylate (tab 1 mg, tab 2 mg, tab 4 mg, tab 8 mg)
finasteride tab 5 mg
tamsulosin hcl
QL
60 / 30 days
terazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
Genitourinary Agents, Other (MISCELLANEOUS BLADDER, GENITAL, AND KIDNEY CONDITIONS DRUGS)
bethanechol chloride (tab 5 mg, tab 10 mg, tab 25 mg, tab 50 mg)
PHOSPHATE BINDERS (PHOSPHATE REMOVING DRUGS)
calcium acetate (phosphate binder) (cap 667 mg (169 mg ca), tab 667 mg)
ELIPHOS
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
clotrimazole w/ betamethasone cream 1-0.05%
QL
90 / 24 days
clotrimazole w/ betamethasone lotion 1-0.05%
QL
60 / 24 days
QL
120 / 30 days
CORTISONE ACETATE TAB 25 MG
dexamethasone (elixir 0.5 mg/5ml, tab 0.5 mg, tab 0.75 mg, tab 1.5 mg, tab
2 mg, tab 4 mg, tab 6 mg)
DEXAMETHASONE INTENSOL
fludrocortisone acetate tab 0.1 mg
hydrocortisone (tab 5 mg, tab 10 mg, tab 20 mg)
hydrocortisone rectal cream 1%
methylprednisolone (tab 4 mg, tab 4 mg dose pack, tab 8 mg)
prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)
prednisolone syrup 15 mg/5ml (usp solution equivalent)
PREDNISONE (PAK) (TAB 5 MG, TAB 10 MG)
prednisone (solution 5 mg/5ml, tab 1 mg, tab 2.5 mg, tab 5 mg, tab 5 mg
dose pack, tab 10 mg, tab 10 mg dose pack, tab 20 mg, tab 50 mg)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acetate (tab 0.1 mg, tab 0.2 mg)
desmopressin acetate spray
PAGE 35
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
desmopressin acetate spray refrigerated
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
ANDROGENS (MALE HORMONE DRUGS)
testosterone cypionate (j oil 100 mg/ml, j oil 200 mg/ml)
PA
ESTROGENS (HORMONE REPLACEMENT/MODIFYING DRUGS)
QL
37.5 / 28 days
GL
Female
QL
37.5 / 28 days
GL
Female
QL
28 / 23 days
GL
Female
QL
4 / 21 days
GL
Female
estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr, patch 0.05 mg/24hr,
patch 0.075 mg/24hr, patch 0.1 mg/24hr)
QL
8 / 28 days
GL
Female
estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg)
GL
Female
QL
21 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
37.5 / 28 days
GL
Female
QL
91 / 91 days
GL
Female
QL
28 / 28 days
GL
Female
QL
37.5 / 28 days
QL
37.5 / 28 days
GL
Female
desogestrel & ethinyl estradiol
desogestrel-ethinyl estradiol (triphasic)
ESTRACE CREAM 0.1 MG/GM
estradiol & norethindrone acetate (tab 0.5-0.1 mg, tab 1-0.5 mg)
estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr (37.5 mcg/24hr),
patch 0.05 mg/24hr, patch 0.06 mg/24hr, patch 0.075 mg/24hr, patch 0.1
mg/24hr)
estropipate (tab 0.75 mg, tab 1.5 mg, tab 3 mg)
ethynodiol diacet & eth estrad
levonorgestrel & eth estradiol (tab 0.1 mg-20 mcg, tab 0.15 mg-30 mcg)
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg
levonorgestrel-eth estradiol (triphasic)
NECON 10/11 (28)
norethin acet & estrad-fe (tab 1 mg-20 mcg, tab 1.5 mg-30 mcg)
PAGE 36
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
QL
37.5 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
21 / 28 days
GL
Female
QL
37.5 / 28 days
GL
Female
QL
37.5 / 28 days
GL
Female
QL
37.5 / 28 days
GL
Female
QL
37.5 / 28 days
GL
Female
QL
30 / 30 days
GL
Female
QL
30 / 30 days
GL
Female
PREMPRO (TAB 0.3-1.5 MG, TAB 0.45-1.5 MG, TAB 0.625-5 MG, TAB
0.625-2.5 MG)
QL
30 / 30 days
GL
Female
ZOVIA 1/50E (28)
QL
37.5 / 28 days
QL
1 / 90 days
GL
Female
norethindrone & eth estradiol (tab 0.5 mcg, tab 1 mcg)
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)
norethindrone acet & eth estra (tab 1 mg-20 mcg, tab 1.5 mg-30 mcg)
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg
norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg
norgestimate-ethinyl estradiol
norgestrel & ethinyl estradiol
PREMARIN (TAB 0.3 MG, TAB 0.45 MG, TAB 0.625 MG, TAB 0.9 MG,
TAB 1.25 MG)
PREMPHASE
PROGESTINS (HORMONE REPLACEMENT/MODIFYING DRUGS)
DEPO-PROVERA SUSPENSION 150 MG/ML
fluorometholone (ophth)
MAGNESIUM SULFATE (INJ 50%, SOLUTION 2 GM/50ML, SOLUTION 4
GM/50ML, SOLUTION 4 GM/100ML, SOLUTION 20 GM/500ML,
SOLUTION 40 GM/1000ML)
PAGE 37
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
QL
1 / 90 days
GL
Female
QL
30 / 30 days
GL
Female
QL
28 / 28 days
GL
Female
QL
120 / 30 days
GL
Female
QL
37.5 / 28 days
GL
Female
QL
60 / 30 days
GL
Female
medroxyprogesterone acetate (contraceptive)
medroxyprogesterone acetate tab 10 mg
medroxyprogesterone acetate tab 2.5 mg
medroxyprogesterone acetate tab 5 mg
megestrol acetate (susp 40 mg/ml, tab 20 mg, tab 40 mg)
norethindrone (contraceptive)
norethindrone acetate tab 5 mg
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium (tab 25 mcg, tab 50 mcg, tab 75 mcg, tab 88 mcg, tab
100 mcg, tab 112 mcg, tab 125 mcg, tab 137 mcg, tab 150 mcg, tab 175
mcg, tab 200 mcg, tab 300 mcg)
SYNTHROID (TAB 25 MCG, TAB 50 MCG, TAB 75 MCG, TAB 88 MCG,
TAB 100 MCG, TAB 112 MCG, TAB 125 MCG, TAB 137 MCG, TAB 150
MCG, TAB 175 MCG, TAB 200 MCG, TAB 300 MCG)
Hormonal Agents, Suppressant (Parathyroid) (DRUGS TO TREAT HIGH CALCIUM)
SENSIPAR (TAB 30 MG, TAB 60 MG)
PA
Hormonal Agents, Suppressant (Pituitary) (HORMONE AND DIABETIC DRUGS)
ELIGARD (KIT 7.5 MG, KIT 22.5 MG, KIT 30 MG, KIT 45 MG)
PA
LUPRON DEPOT (KIT 3.75 MG, KIT 7.5 MG, KIT 11.25 MG, KIT 22.5 MG,
KIT 30 MG)
PA
LUPRON DEPOT-PED (KIT 7.5 MG, KIT 11.25 MG, KIT 15 MG)
PA
Hormonal Agents, Suppressant (Thyroid) (HORMONE AND DIABETIC DRUGS)
Antithyroid Agents (THYROID DRUGS)
methimazole (tab 5 mg, tab 10 mg)
propylthiouracil tab 50 mg
PAGE 38
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
Immunological Agents (DRUGS AFFECTING THE IMMUNE SYSTEM)
Immune Suppressants (IMMUNE SYSTEM DRUGS)
azathioprine tab 50 mg
CELLCEPT RECON SUSP 200 MG/ML
cyclosporine (cap 25 mg, cap 100 mg)
CYCLOSPORINE MODIFIED
cyclosporine modified (for microemulsion) (cap 25 mg, cap 100 mg, oral
soln 100 mg/ml)
ENBREL (KIT 25 MG, SOLN PRSYR 25 MG/0.5ML, SOLN PRSYR 50
MG/ML)
PA
ENBREL SURECLICK
PA
HUMIRA (PREF SY KT 10 MG/0.2ML, PREF SY KT 20 MG/0.4ML, PREF
SY KT 40 MG/0.8ML)
PA
HUMIRA PEDIATRIC CROHNS START
PA
HUMIRA PEN
PA
HUMIRA PEN-CROHNS STARTER
PA
HUMIRA PEN-PSORIASIS STARTER
PA
methotrexate sodium tab 2.5 mg (base equiv)
mycophenolate mofetil (cap 250 mg, tab 500 mg)
mycophenolate mofetil for oral susp 200 mg/ml
PA
tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg)
Immunomodulators (IMMUNE SYSTEM DRUGS)
leflunomide (tab 10 mg, tab 20 mg)
SYNAGIS (SOLUTION 50 MG/0.5ML, SOLUTION 100 MG/ML)
PA
VACCINES (VACCINES)
ZOSTAVAX
AL1
At least 60 yrs old
Inflammatory Bowel Disease Agents (BOWEL, INSTESTINE, AND STOMACH CONDITIONS DRUGS)
Aminosalicylates (BOWEL TREATMENT DRUGS)
APRISO
QL
120 / 30 days
balsalazide disodium
PAGE 39
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
mesalamine enema 4 gm
QL
240 / 30 days
SFROWASA
QL
240 / 30 days
QL
5 / 30 days
Glucocorticoids (BOWEL TREATMENT DRUGS)
hydrocortisone (intrarectal)
Sulfonamides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))
sulfasalazine (tab 500 mg, tab delayed release 500 mg)
Metabolic Bone Disease Agents (HORMONE AND BONE DRUGS)
ACTONEL TAB 35 MG
ST
ALENDRONATE SODIUM (TAB 5 MG, TAB 10 MG, TAB 35 MG, TAB 40
MG)
alendronate sodium tab 70 mg
QL
4 / 28 days
1ST TIER UNIFINE PENTIPS (MISC 29G 12MM, MISC 31G 5 MM, MISC
31G 8 MM, MISC 31G 6 MM, MISC 32G 4 MM)
QL
200 / 30 days
1ST TIER UNIFINE PENTIPS PLUS (MISC 29G 12MM, MISC 31G 5 MM,
MISC 31G 6 MM, MISC 31G 8 MM, MISC 32G 4 MM)
QL
200 / 30 days
ADVOCATE INSULIN PEN NEEDLES (PEN MISC 5, PEN MISC 8)
QL
200 / 30 days
ADVOCATE INSULIN SYRINGE (MISC 29G 1/2" 0.3 ML, MISC 29G 1/2"
0.5 ML, MISC 29G 1/2" 1 ML, MISC 30G 5/16" 1 ML, MISC 30G 5/16" 0.5
ML, MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 1
ML, MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
ANTI-STICK INSULIN SYRINGE
QL
200 / 30 days
ASSURE ID INSULIN SAFETY SYR (MISC 0.5 ML, MISC 1 ML)
QL
200 / 30 days
AURORA PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC 31G 6 MM,
PEN MISC 31G 8 MM)
QL
200 / 30 days
AURORA UNIFINE PENTIPS (MISC 31G 5, MISC 32G 4)
QL
200 / 30 days
BD AUTOSHIELD (MISC 5MM, MISC 8MM, MISC 12MM)
QL
200 / 30 days
BD AUTOSHIELD DUO
QL
200 / 30 days
BD INSULIN SYR ULTRAFINE II (MISC 0.5 ML, MISC 1 ML)
QL
200 / 30 days
calcitonin (salmon)
calcitriol (cap 0.25 mcg, cap 0.5 mcg)
Miscellaneous Therapeutic Agents (Miscellaneous Drug Products)
PAGE 40
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
BD INSULIN SYRINGE (MISC 25G X 1" 1 ML, MISC 25G X 5/8" 1 ML,
MISC 26G X 1/2" 1 ML, MISC 27G X 1/2" 1 ML, MISC 28G X 1/2" 1 ML,
MISC 29G X 1/2" 0.5 ML, MISC 29G X 1/2" 1 ML, MISC 30G X 1/2" 0.5
ML, MISC 31G X 5/16" 0.3 ML, MISC U-100 1 ML)
QL
200 / 30 days
BD INSULIN SYRINGE HALF-UNIT
QL
200 / 30 days
BD INSULIN SYRINGE MICROFINE (MISC 27G 5/8" 1 ML, MISC 28G 1/2"
1 ML, MISC 28G 1/2" 0.3 ML, MISC 28G 1/2" 0.5 ML)
QL
200 / 30 days
BD INSULIN SYRINGE U-40
QL
200 / 30 days
BD INSULIN SYRINGE ULTRAFINE (MISC 29G 1/2" 0.5 ML, MISC 29G
1/2" 0.3 ML, MISC 29G 1/2" 1 ML, MISC 30G 1/2" 1 ML, MISC 30G 1/2"
0.3 ML, MISC 30G 1/2" 0.5 ML, MISC 31G 15/64" 0.5 ML, MISC 31G
15/64" 1 ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.5 ML, MISC 31G
15/64" 0.3 ML, MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
BD INTEGRA INSULIN SYRINGE
QL
200 / 30 days
BD INTEGRA SYRINGE MISC 25G X 1" 1 ML
QL
200 / 30 days
BD PEN NEEDLE MINI U/F
QL
200 / 30 days
BD PEN NEEDLE NANO U/F
QL
200 / 30 days
BD PEN NEEDLE SHORT U/F
QL
200 / 30 days
BD PEN NEEDLE ULTRAFINE
QL
200 / 30 days
BD SAFETY-LOK INSULIN SYRINGE
QL
200 / 30 days
BD SAFETYGLIDE INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML
QL
200 / 30 days
CAREFINE PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC 30G 8
MM, PEN MISC 31G 8 MM, PEN MISC 31G 6 MM, PEN MISC 32G 5 MM,
PEN MISC 32G 4 MM, PEN MISC 32G 6 MM)
QL
200 / 30 days
CAREONE INSULIN SYRINGE (MISC 30G 1/2" 0.3 ML, MISC 30G 1/2"
0.5 ML, MISC 30G 1/2" 1 ML, MISC 31G 5/16" 0.3 ML, MISC 31G 5/16" 1
ML, MISC 31G 5/16" 0.5 ML)
QL
200 / 30 days
CAREONE UNIFINE PENTIPS (MISC 29G 12MM, MISC 31G 5 MM, MISC
31G 8 MM, MISC 31G 6 MM, MISC 32G 4 MM)
QL
200 / 30 days
CAREONE UNIFINE PENTIPS PLUS (MISC 29G 12MM, MISC 31G 6 MM,
MISC 31G 5 MM, MISC 31G 8 MM, MISC 32G 4 MM)
QL
200 / 30 days
CLICKFINE PEN NEEDLES (PEN MISC 31G 8, PEN MISC 31G 6, PEN
MISC 32G 4)
QL
200 / 30 days
PAGE 41
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
COMFORT EZ INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G 1/2"
0.5 ML, MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 1
ML, MISC 30G 1/2" 0.5 ML, MISC 30G 5/16" 0.3 ML, MISC 30G 5/16" 1
ML, MISC 30G 1/2" 0.3 ML, MISC 30G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML,
MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
QL
200 / 30 days
COMFORT EZ PEN NEEDLES (PEN MISC 31G 5, PEN MISC 31G 6, PEN
MISC 31G 8, PEN MISC 32G 4)
QL
200 / 30 days
DRUG MART UNIFINE PENTIPS (MISC 29G 12MM, MISC 31G 8 MM,
MISC 31G 5 MM, MISC 31G 6 MM, MISC 32G 4 MM)
QL
200 / 30 days
DRUG MART UNIFINE PENTIPS PLUS
QL
200 / 30 days
DUANE READE UNIFINE PENTIPS (MISC 29G 12MM, MISC 31G 8 MM,
MISC 31G 6 MM)
QL
200 / 30 days
EASY COMFORT INSULIN SYRINGE (MISC 1/2" 0.5 ML, MISC 1/2" 1 ML,
MISC 5/16" 0.3 ML, MISC 5/16" 1 ML, MISC 5/16" 0.5 ML)
QL
200 / 30 days
EASY COMFORT PEN NEEDLES (PEN MISC 31G 5, PEN MISC 31G 8,
PEN MISC 32G 4)
QL
200 / 30 days
EASY TOUCH INSULIN SAFETY SYR (MISC 29G 1/2" 1 ML, MISC 29G
1/2" 0.5 ML, MISC 30G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
QL
200 / 30 days
EASY TOUCH INSULIN SYRINGE (MISC 27G 1/2" 1 ML, MISC 27G 1/2"
0.5 ML, MISC 28G 1/2" 0.5 ML, MISC 28G 1/2" 1 ML, MISC 29G 1/2" 1 ML,
MISC 29G 1/2" 0.5 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 1/2" 0.3 ML,
MISC 30G 1/2" 0.5 ML, MISC 30G 5/16" 1 ML, MISC 30G 5/16" 0.3 ML,
MISC 30G 1/2" 1 ML, MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 0.3 ML,
MISC 31G 5/16" 1 ML)
QL
200 / 30 days
EASY TOUCH PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC 31G 5
MM, PEN MISC 31G 8 MM, PEN MISC 31G 6 MM, PEN MISC 32G 5 MM,
PEN MISC 32G 6 MM, PEN MISC 32G 4 MM)
QL
200 / 30 days
EQL INSULIN SYRINGE (MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 0.5 ML,
MISC 29G 1/2" 1 ML, MISC 30G 5/16" 1 ML, MISC 30G 5/16" 0.3 ML,
MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML,
MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
EQL SHORT PEN NEEDLE
QL
200 / 30 days
EQL ULTRA COMFORT INSULIN SYR MISC 31G X 5/16" 0.3 ML
QL
200 / 30 days
EQL ULTRA SHORT PEN NEEDLE
QL
200 / 30 days
EXCEL COMFORT POINT PEN NEEDLE (PEN MISC 29G 12MM, PEN
MISC 31G 6 MM, PEN MISC 31G 8 MM)
QL
200 / 30 days
PAGE 42
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
EXEL COMFORT POINT INSULIN SYR (EEL MISC 28G 1/2" 1 ML, EEL
MISC 28G 1/2" 0.5 ML, EEL MISC 29G 1/2" 1 ML, EEL MISC 29G 1/2" 0.5
ML, EEL MISC 29G 1/2" 0.3 ML, EEL MISC 30G 5/16" 0.3 ML, EEL MISC
30G 5/16" 1 ML, EEL MISC 30G 5/16" 0.5 ML)
QL
200 / 30 days
FIFTY50 PEN NEEDLES (PEN MISC 5, PEN MISC 8)
QL
200 / 30 days
FIFTY50 SUPERIOR COMFORT SYR (MISC 0.3 ML, MISC 0.5 ML, MISC
1 ML)
QL
200 / 30 days
FREDS PHARMACY UNIFINE PENTIP+ (MISC 5, MISC 8)
QL
200 / 30 days
FREDS PHARMACY UNIFINE PENTIPS
QL
200 / 30 days
FREESTYLE PRECISION INS SYR (MISC 30G 1 ML, MISC 30G 0.5 ML,
MISC 31G 0.5 ML, MISC 31G 1 ML)
QL
200 / 30 days
GLOBAL EASE INJECT PEN NEEDLES (PEN MISC 29G 12MM, PEN
MISC 31G 5 MM, PEN MISC 31G 8 MM, PEN MISC 32G 4 MM)
QL
200 / 30 days
GLOBAL INJECT EASE INSULIN SYR (MISC 28G 1/2" 1 ML, MISC 28G
1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 0.5 ML, MISC 29G
1/2" 1 ML, MISC 30G 5/16" 1 ML, MISC 30G 5/16" 0.3 ML, MISC 30G 1/2"
1 ML, MISC 30G 1/2" 0.3 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 1/2" 0.5
ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 0.3
ML)
QL
200 / 30 days
GLUCOPRO INSULIN SYRINGE (MISC 30G 5/16" 0.3 ML, MISC 30G 1/2"
1 ML, MISC 30G 1/2" 0.3 ML, MISC 30G 5/16" 1 ML, MISC 30G 1/2" 0.5
ML, MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 1
ML, MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
GNP CLICKFINE PEN NEEDLES (PEN MISC 6, PEN MISC 8)
QL
200 / 30 days
GNP INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G 1/2" 0.5 ML,
MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 0.5 ML, MISC
30G 5/16" 0.3 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 1 ML, MISC
31G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
GNP ULTRA COM INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G
1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 0.5 ML, MISC 29G
1/2" 1 ML, MISC 30G 5/16" 1 ML, MISC 30G 5/16" 0.3 ML, MISC 30G
5/16" 0.5 ML, MISC 31G 5/16" 0.3 ML, MISC 31G 5/16" 0.5 ML, MISC 31G
5/16" 1 ML)
QL
200 / 30 days
H-E-B INCONTROL PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC
31G 8 MM, PEN MISC 31G 5 MM, PEN MISC 31G 6 MM, PEN MISC 32G
4 MM)
QL
200 / 30 days
HEALTHWISE MINI PEN NEEDLES
QL
200 / 30 days
HEALTHWISE PEN NEEDLES
QL
200 / 30 days
HEALTHWISE SHORT PEN NEEDLES
QL
200 / 30 days
PAGE 43
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
HEALTHWISE UNIFINE PENTIPS
QL
200 / 30 days
HEALTHY ACCENTS UNIFINE PENTIP (MISC 29G 12MM, MISC 31G 5
MM, MISC 31G 6 MM, MISC 31G 8 MM, MISC 32G 4 MM)
QL
200 / 30 days
INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML, MISC 28G 1/2" 1 ML, MISC
29G 1/2" 1 ML, MISC 29G 1" 0.3 ML, MISC 29G 1/2" 0.5 ML, MISC 29G
1/2" 0.3 ML, MISC 30G 1/2" 0.5 ML, MISC 30G 5/16" 0.5 ML, MISC 30G
5/16" 1 ML, MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 0.3 ML, MISC 31G
5/16" 1 ML)
QL
200 / 30 days
INSULIN SYRINGE/NEEDLE (MISC 27G 0.5 ML, MISC 28G 1 ML, MISC
28G 0.5 ML)
QL
200 / 30 days
INSUPEN PEN NEEDLES MISC 32G X 4 MM
QL
200 / 30 days
INSUPEN SENSITIVE (MISC 6, MISC 8)
QL
200 / 30 days
INSUPEN ULTRAFIN (MISC 29G 12MM, MISC 30G 8 MM, MISC 31G 8
MM, MISC 31G 6 MM)
QL
200 / 30 days
KINRAY INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC 31G 5/16" 0.5
ML, MISC 31G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
QL
200 / 30 days
KMART VALU INSULIN SYRINGE 29G (MISC 0.5 ML, MISC 1 ML)
QL
200 / 30 days
KMART VALU INSULIN SYRINGE 30G (MISC 0.3 ML, MISC 0.5 ML,
MISC 1 ML)
QL
200 / 30 days
KROGER INSULIN SYRINGE (MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.5
ML, MISC 29G 1/2" 0.3 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 1
ML, MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.5
ML, MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
KROGER PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC 31G 8 MM,
PEN MISC 31G 6 MM)
QL
200 / 30 days
LEADER INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G 1/2" 0.5
ML, MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 1 ML,
MISC 30G 5/16" 1 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 0.3 ML,
MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
LEADER UNIFINE PENTIPS (MISC 31G 5, MISC 32G 4)
QL
200 / 30 days
LEADER UNIFINE PENTIPS PLUS (MISC 31G 5, MISC 31G 8, MISC 32G
4)
QL
200 / 30 days
LITE TOUCH PEN NEEDLES
QL
200 / 30 days
PAGE 44
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
LITETOUCH INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML, MISC 28G 1/2" 1
ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 0.3 ML, MISC 30G 5/16" 1 ML,
MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
QL
200 / 30 days
LITETOUCH PEN NEEDLES (PEN MISC 29G 12.7MM, PEN MISC 31G 6
MM, PEN MISC 31G 8 MM)
QL
200 / 30 days
LIVE BETTER PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC 31G 8
MM, PEN MISC 31G 6 MM)
QL
200 / 30 days
LONGS INSULIN SYRINGE
QL
200 / 30 days
MAGELLAN INSULIN SAFETY SYR (MISC 29G 1/2" 0.3 ML, MISC 29G
1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML, MISC 30G
5/16" 1 ML, MISC 30G 5/16" 0.3 ML)
QL
200 / 30 days
MEDIC INSULIN SYRINGE (MISC 0.3 ML, MISC 0.5 ML)
QL
200 / 30 days
MEDICINE SHOPPE PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC
31G 8 MM, PEN MISC 31G 6 MM)
QL
200 / 30 days
MEIJER PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC 31G 6 MM,
PEN MISC 31G 8 MM)
QL
200 / 30 days
methylergonovine maleate tab 0.2 mg
QL
28 / 365 days
MONOJECT INSULIN SYRINGE (MISC 25G X 5/8" 1 ML, MISC 27G X
1/2" 1 ML, MISC 28G X 1/2" 0.5 ML, MISC 28G X 1/2" 1 ML, MISC 29G X
1/2" 1 ML, MISC 29G X 1/2" 0.3 ML, MISC 29G X 1/2" 0.5 ML, MISC 30G
X 5/16" 0.3 ML, MISC 30G X 5/16" 0.5 ML, MISC 30G X 5/16" 1 ML, MISC
31G X 5/16" 1 ML, MISC U-100 1 ML)
QL
200 / 30 days
MONOJECT ULTRA COMFORT SYRINGE (MISC 28G 1/2" 0.5 ML, MISC
28G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 0.5 ML, MISC 29G
1/2" 1 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 0.3 ML, MISC 31G
5/16" 0.3 ML, MISC 31G 5/16" 0.5 ML)
QL
200 / 30 days
MOORE MONO INSULIN SYRINGE (MISC 28G 1 ML, MISC 28G 0.5 ML,
MISC 29G 0.5 ML, MISC 29G 1 ML)
QL
200 / 30 days
MS INSULIN SYRINGE (MISC 0.3 ML, MISC 0.5 ML, MISC 1 ML)
QL
200 / 30 days
NOVOFINE (MISC 30G 8, MISC 32G 6)
QL
200 / 30 days
NOVOFINE AUTOCOVER
QL
200 / 30 days
NOVOFINE PLUS
QL
200 / 30 days
NOVOTWIST (MISC 30G 8, MISC 32G 5)
QL
200 / 30 days
PC UNIFINE PENTIPS (MISC 29G 12MM, MISC 31G 5 MM, MISC 31G 8
MM, MISC 31G 6 MM)
QL
200 / 30 days
PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC 31G 6 MM)
QL
200 / 30 days
PAGE 45
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
PEN NEEDLES 1/2"
QL
200 / 30 days
PEN NEEDLES 3/16"
QL
200 / 30 days
PEN NEEDLES 5/16" (PEN MISC 30G 8, PEN MISC 31G 8)
QL
200 / 30 days
PRECISION SURE-DOSE SYRINGE (MISC 28G 1/2" 0.5 ML, MISC 28G
1/2" 1 ML, MISC 29G 1/2" 0.5 ML, MISC 30G 3/8" 0.5 ML)
QL
200 / 30 days
PRECISION SUREDOSE PLUS SYR (MISC 0.3 ML, MISC 1 ML)
QL
200 / 30 days
PREFERRED PLUS INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G
1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2"
0.5 ML, MISC 30G 5/16" 0.3 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 5/16"
1 ML)
QL
200 / 30 days
PREFERRED PLUS UNIFINE PENTIPS (MISC 29G 12MM, MISC 31G 5
MM, MISC 31G 6 MM, MISC 31G 8 MM, MISC 32G 4 MM)
QL
200 / 30 days
PRODIGY INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 31G 5/16" 0.5
ML, MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
PX EXTRA SHORT PEN NEEDLES
QL
200 / 30 days
PX INSULIN SYRINGE (MISC 30G 1/2" 0.5 ML, MISC 30G 1/2" 1 ML,
MISC 30G 1/2" 0.3 ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.5 ML,
MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
PX MINI PEN NEEDLES
QL
200 / 30 days
PX PEN NEEDLE (PEN MISC 29G 12MM, PEN MISC 31G 8 MM)
QL
200 / 30 days
QC PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC 31G 8 MM, PEN
MISC 31G 6 MM)
QL
200 / 30 days
QC UNIFINE PENTIPS
QL
200 / 30 days
RA INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 1 ML,
MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 1 ML)
QL
200 / 30 days
RA PEN NEEDLES (PEN MISC 5, PEN MISC 8)
QL
200 / 30 days
RELI-ON INSULIN SYRINGE (MISC 0.3 ML, MISC 0.5 ML, MISC X 1/2" 1
ML)
QL
200 / 30 days
RELION INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 0.3
ML, MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 0.3
ML, MISC 30G 5/16" 1 ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.3 ML,
MISC 31G 5/16" 0.5 ML)
QL
200 / 30 days
RELION MINI PEN NEEDLES
QL
200 / 30 days
RELION PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC 31G 8 MM,
PEN MISC 32G 4 MM)
QL
200 / 30 days
PAGE 46
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
RELION SHORT PEN NEEDLES
QL
200 / 30 days
SAFESNAP INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 29G 1/2" 1
ML, MISC 29G 1/2" 0.5 ML, MISC 30G 5/16" 0.3 ML, MISC 30G 5/16" 0.5
ML)
QL
200 / 30 days
SAFETY-GLIDE SYRINGE
QL
200 / 30 days
SB INSULIN SYRINGE (MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 1 ML, MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML)
QL
200 / 30 days
SCHNUCKS INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC 30G 5/16"
0.5 ML)
QL
200 / 30 days
SHOPKO UNIFINE PENTIPS (MISC 29G 12MM, MISC 31G 8 MM, MISC
31G 5 MM, MISC 32G 4 MM)
QL
200 / 30 days
SM INSULIN SYRINGE MISC 31G X 5/16" 1 ML
QL
200 / 30 days
SURE COMFORT INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G
1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2"
0.5 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 1/2" 0.5 ML, MISC 30G 1/2" 1
ML, MISC 30G 1/2" 0.3 ML, MISC 30G 5/16" 1 ML, MISC 31G 5/16" 0.5
ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
SURE COMFORT PEN NEEDLES (PEN MISC 30G 8, PEN MISC 31G 8,
PEN MISC 31G 5, PEN MISC 32G 4)
QL
200 / 30 days
SURE-FINE PEN NEEDLES (PEN MISC 29G 12.7MM, PEN MISC 31G 8
MM, PEN MISC 31G 5 MM)
QL
200 / 30 days
SURE-JECT INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G 1/2" 0.5
ML, MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML,
MISC 30G 5/16" 1 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 0.3 ML,
MISC 31G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.5 ML)
QL
200 / 30 days
TERUMO INSULIN SYRINGE (MISC 27G 1/2" 0.5 ML, MISC 27G 1/2" 1
ML, MISC 28G 1/2" 0.5 ML, MISC 28G 1/2" 1 ML, MISC 29G 1/2" 0.5 ML,
MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 1 ML, MISC 30G 3/8" 0.5 ML, MISC
30G 3/8" 1 ML)
QL
200 / 30 days
TERUMO SURGUARD INSULIN SYR (MISC 28G 0.5 ML, MISC 28G 1
ML, MISC 29G 0.5 ML, MISC 29G 1 ML, MISC 29G 0.3 ML)
QL
200 / 30 days
THINPRO INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML, MISC 28G 1/2" 1
ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 0.5 ML,
MISC 30G 3/8" 0.5 ML, MISC 30G 3/8" 1 ML, MISC 31G 3/8" 0.3 ML, MISC
31G 3/8" 0.5 ML, MISC 31G 3/8" 1 ML)
QL
200 / 30 days
TODAYS HEALTH MINI PEN NEEDLES
QL
200 / 30 days
TODAYS HEALTH PEN NEEDLES
QL
200 / 30 days
TODAYS HEALTH SHORT PEN NEEDLE
QL
200 / 30 days
sodium chloride irrigation soln 0.9%
PAGE 47
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
TOPCARE CLICKFINE PEN NEEDLES (PEN MISC 6, PEN MISC 8)
QL
200 / 30 days
TOPCARE ULTRA COMFORT INS SYR (MISC 29G 1/2" 0.3 ML, MISC
29G 1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML, MISC 30G
5/16" 1 ML, MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 0.5 ML, MISC 31G
5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
QL
200 / 30 days
TRUEPLUS INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML, MISC 28G 1/2" 1
ML, MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML,
MISC 30G 5/16" 0.3 ML, MISC 30G 5/16" 1 ML, MISC 30G 5/16" 0.5 ML,
MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
ULTICARE INSULIN SAFETY SYR (MISC 0.5 ML, MISC 1 ML)
QL
200 / 30 days
ULTICARE INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G 1/2" 0.5
ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 0.5 ML,
MISC 30G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 1 ML,
MISC 30G 1/2" 0.5 ML, MISC 30G 5/16" 0.3 ML, MISC 30G 1/2" 0.3 ML,
MISC 31G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML, MISC 31G 5/16" 0.3 ML)
QL
200 / 30 days
ULTICARE MICRO PEN NEEDLES
QL
200 / 30 days
ULTICARE MINI PEN NEEDLES
QL
200 / 30 days
ULTICARE PEN NEEDLES (PEN MISC 12MM, PEN MISC 12.7MM)
QL
200 / 30 days
ULTICARE SHORT PEN NEEDLES
QL
200 / 30 days
ULTILET INSULIN SYRINGE SHORT (MISC 30G 0.3 ML, MISC 30G 1 ML,
MISC 30G 0.5 ML, MISC 31G 0.5 ML, MISC 31G 0.3 ML, MISC 31G 1 ML)
QL
200 / 30 days
ULTILET PEN NEEDLE
QL
200 / 30 days
ULTRA COMFORT INSULIN SYRINGE
QL
200 / 30 days
ULTRA-COMFORT INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G
1/2" 0.5 ML, MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC 29G
1/2" 1 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 1 ML, MISC 30G
5/16" 0.3 ML, MISC 31G 5/16" 0.3 ML, MISC 31G 5/16" 0.5 ML, MISC 31G
5/16" 1 ML)
QL
200 / 30 days
ULTRA-THIN II INS SYR SHORT MISC 31G X 5/16" 1 ML
QL
200 / 30 days
UNIFINE PENTIPS (MISC 29G 12MM, MISC 31G 8 MM, MISC 31G 5 MM,
MISC 31G 6 MM, MISC 32G 4 MM)
QL
200 / 30 days
UNIFINE PENTIPS PLUS (MISC 29G 12MM, MISC 31G 5 MM, MISC 31G
6 MM, MISC 31G 8 MM, MISC 32G 4 MM)
QL
200 / 30 days
V-R MONO INSULIN SYRINGE (MISC 28G 1 ML, MISC 28G 0.5 ML,
MISC 29G 1 ML, MISC 29G 0.5 ML, MISC 29G 0.3 ML)
QL
200 / 30 days
VALUE HEALTH INSULIN SYRINGE (MISC 0.5 ML, MISC 1 ML)
QL
200 / 30 days
VALUMARK PEN NEEDLES (PEN MISC 29G 12MM, PEN MISC 31G 6
MM, PEN MISC 31G 8 MM)
QL
200 / 30 days
PAGE 48
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
VANISHPOINT INSULIN SYRINGE (MISC 29G 1 ML, MISC 30G 0.5 ML)
QL
200 / 30 days
VIDA MIA UNIFINE PENTIPS (MISC 29G 12MM, MISC 31G 6 MM, MISC
31G 8 MM, MISC 32G 4 MM)
QL
200 / 30 days
VP INSULIN SYRINGE
QL
200 / 30 days
QL
200 / 30 days
QL
5 / 18 days
QL
5 / 10 days
water for irrigation, sterile
WEGMANS UNIFINE PENTIPS PLUS (MISC 31G 6, MISC 31G 5, MISC
31G 8, MISC 32G 4)
OPHTHALMIC AGENTS (EYE MEDICATIONS)
Ophthalmic Agents, Other (MISCELLANEOUS EYE MEDICATIONS)
artificial tear ointment
artificial tear solution
neomycin-polymy-dexameth (oint, susp)
proparacaine hcl ophth soln 0.5%
Ophthalmic Anti-allergy Agents (ALLERGY EYE MEDICATIONS)
azelastine hcl (ophth)
cromolyn sodium (ophth)
epinastine hcl (ophth)
Ophthalmic Anti-inflammatories (INFLAMMATION EYE MEDICATIONS)
dexamethasone sodium phosphate (ophth)
DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 0.1 %
diclofenac sodium (ophth)
FLAREX
flurbiprofen sodium
FML
ketorolac tromethamine ophth soln 0.4%
ketorolac tromethamine ophth soln 0.5%
prednisolone acetate (ophth)
PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1 %
tobramycin-dexamethasone
PAGE 49
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
Ophthalmic Antiglaucoma Agents (GLAUCOMA MEDICATIONS)
acetazolamide cap sr 12hr 500 mg
atropine sulfate (ophthalmic)
betaxolol hcl (ophth)
brimonidine tartrate ophth soln 0.2%
carteolol hcl (ophth)
dorzolamide hcl
dorzolamide hcl-timolol maleate
levobunolol hcl ophth soln 0.5%
QL
5 / 18 days
QL
5 / 30 days
METIPRANOLOL
timolol maleate (ophth) (soln 0.25%, soln 0.5%)
Ophthalmic Prostaglandin and Prostamide Analogs (GLAUCOMA MEDICATIONS)
BIMATOPROST SOLUTION 0.03 %
ST
latanoprost ophth soln 0.005%
QL
5 / 30 days
QL
5 / 30 days
TRAVOPROST
ST
OTIC AGENTS (EAR DRUGS)
acetic acid (otic)
hydrocortisone w/acetic acid
neomycin-polymyxin-hc (otic) (soln 1%, susp 3.5 mg/ml-10000 unit/ml-1%)
Respiratory Tract/Pulmonary Agents (ALLERGIES, COUGH, COLD AND LUNG CONDITION DRUGS)
ANTIHISTAMINES (ALLERGY DRUGS)
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)
cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg)
hydroxyzine hcl (syrup 10 mg/5ml, tab 10 mg, tab 25 mg, tab 50 mg)
HYDROXYZINE PAMOATE (CAP 25 MG, CAP 50 MG, CAP 100 MG)
levocetirizine dihydrochloride tab 5 mg
QL
30 / 30 days
QL
60 / 30 days
AL1
Up to 11 yrs old
Anti-inflammatories, Inhaled Corticosteroids (ASTHMA/LUNG DRUGS)
ADVAIR DISKUS AER POW BA 100-50 MCG/DOSE
PAGE 50
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
BREO ELLIPTA (AER POW BA 100-25, AER POW BA 200-25)
QL
60 / 30 days
budesonide (inhalation) (susp 0.25, susp 0.5)
AL1
Up to 6 yrs old
DULERA (AEROSOL 100-5, AEROSOL 200-5)
QL
13 / 30 days
QL
60 / 30 days
AL1
4 to 11 yrs old
QL
10.6 / 30 days
AL1
4 to 11 yrs old
flunisolide (nasal)
QL
50 / 30 days
fluticasone propionate (nasal)
QL
16 / 30 days
QL
10.2 / 30 days
QL
12.9 / 30 days
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
QL
30 / 30 days
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
QL
15 / 30 days
TUDORZA PRESSAIR
QL
1 / 30 days
QL
2 / 30 days
QL
60 / 30 days
FLOVENT DISKUS (AER POW BA 50, AER POW BA 100)
FLOVENT HFA AEROSOL 44 MCG/ACT
NASACORT ALLERGY 24HR AEROSOL 55 MCG/ACT
SYMBICORT (AEROSOL 80-4.5, AEROSOL 160-4.5)
Antileukotrienes (ASTHMA/LUNG DRUGS)
montelukast sodium (chew tab 4 mg, chew tab 5 mg, tab 10 mg)
Bronchodilators, Anticholinergic (ASTHMA/LUNG DRUGS)
ATROVENT HFA
ipratropium bromide inhal soln 0.02%
Bronchodilators, Sympathomimetic (ASTHMA/LUNG DRUGS)
ADRENACLICK SOLN A-INJ 0.3 MG/0.3ML
albuterol sulfate (soln nebu 0.083% (2.5 mg/3ml), soln nebu 0.5% (5
mg/ml), syrup 2 mg/5ml)
ANORO ELLIPTA
PA
EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML
QL
2 / 30 days
EPIPEN 2-PAK
QL
2 / 30 days
QL
60 / 30 days
EPIPEN JR 2-PAK
FORADIL AEROLIZER
PAGE 51
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
METAPROTERENOL SULFATE SYRUP 10 MG/5ML
SEREVENT DISKUS
QL
120 / 30 days
QL
18 / 25 days
terbutaline sulfate (tab 2.5 mg, tab 5 mg)
VENTOLIN HFA
Cystic Fibrosis Agents (ALLERGIES, COUGH, COLD AND LUNG CONDITION DRUGS)
PULMOZYME
PA
Phosphodiesterase Inhibitors, Airways Disease (ALLERGIES, COUGH, COLD AND LUNG CONDITION DRUGS)
LUFYLLIN (TAB 200 MG, TAB 400 MG)
theophylline (soln 80 mg/15ml, tab sr 12hr 200 mg, tab sr 12hr 450 mg, tab
sr 12hr 300 mg, tab sr 12hr 100 mg)
Respiratory Tract Agents, Other (MISCELLANEOUS RESPIRATORY DRUGS)
acetylcysteine (soln 10%, soln 20%)
promethazine & phenylephrine
Skeletal Muscle Relaxants (MUSCLE AND JOINT DRUGS)
chlorzoxazone tab 500 mg
cyclobenzaprine hcl (tab 5 mg, tab 10 mg)
methocarbamol (tab 500 mg, tab 750 mg)
Sleep Disorder Agents (SLEEP CONDITIONS DRUGS)
GABA Receptor Modulators (SEDATION AND SLEEP DRUGS)
zaleplon (cap 5 mg, cap 10 mg)
zolpidem tartrate (tab 5 mg, tab 10 mg)
QL
30 / 30 days
Therapeutic Nutrients/Minerals/Electrolytes (MULTIVITAMINS AND REPLACEMENT SOLUTIONS)
ELECTROLYTE/MINERAL MODIFIERS (ANTIDOTES/PROTECTANTS)
*sodium polystyrene sulfonate powder**
ELECTROLYTE/MINERAL REPLACEMENT (ELECTROLYTES REPLACEMENTS)
potassium chloride (cap cr 8 meq, cap cr 10 meq, oral liq 10% (20
meq/15ml), oral soln 10% (20 meq/15ml), tab cr 8 meq (600 mg), tab cr 10
meq)
POTASSIUM CHLORIDE ER TAB ER 8 MEQ
potassium chloride microencapsulated crystals cr (mioencapsulated ys tab
10, mioencapsulated ys tab 20)
PAGE 52
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
sodium chloride (inj, iv soln)
sodium chloride flush
Uncategorized
Unclassified
*b-complex w/ c tab**
*multiple vitamin tab**
*nystatin oral powder*
ABREVA
ACCU-CHEK TENDER 1 INFUSION
QL
200 / 30 days
QL
200 / 30 days
QL
30 / 30 days
AL1
40 to 79 yrs old
AEROSPAN
QL
8.9 / 30 days
AFLURIA
QL
0.5 / 365 days
ACEROLA C 500
acetaminophen (cap 500 mg, chew tab 80 mg, elixir 160 mg/5ml, liquid 160
mg/5ml, soln 100 mg/ml, suppos 120 mg, suppos 325 mg, susp 80
mg/0.8ml, tab 325 mg, tab 500 mg, tab cr 650 mg)
acetaminophen w/ dm (160-5 mg/5ml, 1000-30 mg/30ml)
acetaminophen-guaifenesin
ACETIC ACID-ALUMINUM ACETATE SOLUTION 2 %
ACETONE SOLUTION
ACIDOPHILUS PLUS PECTIN
ACIDOPHILUS/CITRUS PECTIN
ACNE MEDICATION
ACTIPHYTE OF LEMONGRASS
ADMINISTRATION SET
ADULT ACNOMEL
ADULT ASPIRIN LOW STRENGTH
ADVIL ALLERGY & CONGESTION
ADVIL ALLERGY SINUS
ADVIL COLD & SINUS LIQUI-GELS
AFLURIA PRESERVATIVE FREE
PAGE 53
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
AGORAL MAXIMUM STRENGTH
AIR ELIMINATING TPN IV SET
QL
200 / 30 days
ALA-HIST PE
ALCOHOL (RUBBING)
ALCOHOL DENATURED
ALCOHOL SOLUTION 95 %
PA
ALER-DRYL
C
covered up to age 65,
then PA required
ALKA-SELTZER HEARTBURN
ALKA-SELTZER PLUS COLD & COUGH (CAP 5-2-10-325 MG, EFFER
TAB 7.8-2-10-325 MG)
ALKA-SELTZER PLUS COLD & FLU EFFER TAB 5-2-10-250 MG
ALKA-SELTZER PLUS DAY/NIGHT
ALKA-SELTZER PLUS NIGHT COLD
ALKA-SELTZER PLUS SINUS
alum & mag hydrox-simethicone (chew tab 200-200-25 mg, susp 200-20020 mg/5ml, susp 400-400-40 mg/5ml)
aluminum hydroxide-mag carb (chew tab 160-105 mg, susp 95-358
mg/15ml)
aluminum hydroxide-mag trisil
AMMONIUM LACTATE
AMPICILLIN (RECON SUSP 125, RECON SUSP 250)
ANESTHESIA EXTENSION TUBING
QL
200 / 30 days
QL
200 / 30 days
ANTACID (CHEW TAB 350-150 MG, CHEW TAB 1177 MG)
antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%)
APATATE FORTE
ARGYLE EXTENSION TUBE 20"
ARMOUR THYROID (TAB 15 MG, TAB 30 MG, TAB 60 MG, TAB 120 MG,
TAB 180 MG, TAB 240 MG, TAB 300 MG)
PAGE 54
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
ascorbic acid (cap cr 500 mg, chew tab 100 mg, chew tab 250 mg, chew
tab 500 mg, inj 500 mg/ml, liquid 500 mg/5ml, lozenge 60 mg, syrup 500
mg/5ml, tab 100 mg, tab 250 mg, tab 500 mg, tab 1000 mg, tab cr 500 mg,
tab cr 1000 mg, tab cr 1500 mg)
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
AUTOJECT 2
QL
200 / 30 days
AUTOPEN
QL
200 / 30 days
BD ANGIOCATH AUTOGUARD
QL
200 / 30 days
BD ECLIPSE SYRINGE MISC 25G X 5/8" 1 ML
QL
200 / 30 days
BD FIRST MIDCATH 18G/4FRX20CM (KIT, MISC)
QL
200 / 30 days
aspirin (chew tab 81 mg, tab 81 mg, tab delayed release 81 mg)
aspirin (suppos 300 mg, suppos 600 mg, tab 500 mg)
aspirin (tab 325 mg, tab delayed release 325 mg)
aspirin buffered
aspirin buffered (cal carb-mag carb-mag oxide)
aspirin-acetaminophen-caffeine
ASSURE DOSE CONTROL
ATABEX
ATABEX EC
ATROPINE SULFATE OINTMENT 1 %
AZOLEN TINCTURE
b-complex w/ c & calcium
b-complex w/ c & e + zn
b-complex w/ c & folic acid (ap 1 mg***, tab***)
B-NATAL (LOZ HANDLE 25 MG, LOZENGE 25 MG)
B1 NATURAL
bacitracin (topical)
bacitracin zinc oint 500 unit/gm
PAGE 55
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
BD FIRST MIDCATH 20G/3FRX20CM (KIT, MISC)
QL
200 / 30 days
BD FIRST PICC 16G/5FRX65CM (KIT, MISC)
QL
200 / 30 days
BD FIRST PICC 18G/4FRX65CM (KIT, MISC)
QL
200 / 30 days
BD FIRST PICC 20G/3FRX65CM (KIT, MISC)
QL
200 / 30 days
BD FIRST PICC 22G/2.8FRX50CM
QL
200 / 30 days
BD FIRST PICC 26G/1.9FRX50CM (KIT, MISC)
QL
200 / 30 days
BD INTEGRA SYRINGE MISC 25G X 5/8" 1 ML
QL
200 / 30 days
BD L-CATH 16G/5FR
QL
200 / 30 days
BD L-CATH 16G/5FRX60CM
QL
200 / 30 days
BD L-CATH 18G/3.5FR
QL
200 / 30 days
BD L-CATH 18G/3.5FRX60CM
QL
200 / 30 days
BD L-CATH 20G/2.6FR
QL
200 / 30 days
BD L-CATH 20G/2.6FRX60CM
QL
200 / 30 days
BD L-CATH 20G/3FR
QL
200 / 30 days
BD L-CATH 20G/3FRX60CM
QL
200 / 30 days
BD L-CATH 28G/1.2FRX25CM
QL
200 / 30 days
BD L-CATH MIDLINE 18G/3.5FRX20 (KIT, MISC)
QL
200 / 30 days
BD L-CATH MIDLINE 20G/3FRX20CM
QL
200 / 30 days
BD LUER-LOK SYRINGE (MISC 20G 1" 1 ML, MISC 25G 5/8" 1 ML)
QL
200 / 30 days
BD NEXIVA 18GX1.25"
QL
200 / 30 days
BD NEXIVA 18GX1.75"
QL
200 / 30 days
BD NEXIVA 20GX1"
QL
200 / 30 days
BD NEXIVA 20GX1.25"
QL
200 / 30 days
BD NEXIVA 20GX1.75"
QL
200 / 30 days
BD NEXIVA 22GX1"
QL
200 / 30 days
BD NEXIVA 24GX0.56"
QL
200 / 30 days
PAGE 56
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
BD NEXIVA 24GX0.75"
QL
200 / 30 days
BD SAF-T E-Z SET
QL
200 / 30 days
BD SAF-T-INTIMA 18G X 1"
QL
200 / 30 days
BD SAF-T-INTIMA 20GX1"
QL
200 / 30 days
BD SAF-T-INTIMA 22G X 0.75"
QL
200 / 30 days
BD SAF-T-INTIMA 22GX3/4"
QL
200 / 30 days
BD SAF-T-INTIMA 24G X 0.75"
QL
200 / 30 days
BD SAF-T-INTIMA 24GX3/4"
QL
200 / 30 days
BD SAFETY-LOK SET
QL
200 / 30 days
BD SAFETY-LOK VACUTAINER SET
QL
200 / 30 days
BD SYRINGE/NEEDLE MISC 25G X 5/8" 1 ML
QL
200 / 30 days
BD SYRINGE/NEEDLE SLIP TIP
QL
200 / 30 days
BD VACUTAINER SET
QL
200 / 30 days
BENFOTIAMINE CAP 150 MG
BENFOTIAMINE-V
benzocaine (dental) (gel 7.5%, gel 20%, liquid 20%, paste 20%, soln 20%,
swab 20%)
benzocaine-docusate sodium
benzonatate (cap 100 mg, cap 200 mg)
benzoyl peroxide (cleanser 3.5%, cream 2.5%, cream 10%, gel 2.5 %, gel
5%, gel 10%, liq 2.5%, liq 5%, liq 10%, lotion 6%)
BENZYL ALCOHOL
BENZYL BENZOATE
BICARSIM
BICARSIM FORTE
BIOBRON SF
BIODESP DM
BIONATUSS DXP
BIONEL
BIONEL PEDIATRIC
PAGE 57
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
BIOSPEC DMX
BIOSUPP
BIOTECT PLUS
biotin (cap 2.5 mg, cap 5 mg, tab 2.5 mg, tab 5 mg, tab 10 mg, tab 300
mcg, tab 800 mcg, tab 1000 mcg, tab 7500 mcg)
BIOTIN ULTRA STRENGTH
BIOVOL
bisacodyl (suppos 10 mg, tab delayed release 5 mg)
bismuth subsalicylate (chew tab 262 mg, susp 262 mg/15ml, susp 525
mg/15ml, tab 262 mg)
BLACK DRAUGHT
BLINK TEARS (GEL 0.25 %, SOLUTION 0.25 %)
BP CLEANSING WASH
BPO GEL 4 %
BRAINSTRONG PRENATAL
BRASIVOL
BROHIST D
brompheniramine & phenyleph (elixir 1-2.5, susp 6-10)
brompheniramine & pseudoeph
BRONCOTRON PED DROPS
BRONCOTRON-S
BRONKAID
BRONKIDS (LIQUID 1.5-0.6-2.75 MG/ML, LIQUID 10-4-10 MG/5ML)
BUFFERED VITAMIN C
QL
30 / 30 days
AL1
40 to 79 yrs old
BUFFERIN
BURIED TREASURE ACTIVE 55 PLUS
butalbital-acetaminophen
butalbital-acetaminophen-caffeine tab 50-325-40 mg
butalbital-aspirin-caffeine
cal carb & mag hydrox-simeth
CAL-MAG CHELA-MAX
PAGE 58
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
CAL-QUICK
CAL/MAG
CALCET CREAMY BITES CHEW TAB 500-400 MG-UNIT
calcium carbonate (antacid) (chew tab 400 mg, chew tab 420 mg, chew tab
500 mg, chew tab 750 mg, chew tab 1000 mg, tab 648 mg)
calcium carbonate (susp 1250, tab 1250 mg mg)
CALCIUM CARBONATE ANTACID
calcium carbonate-cholecalciferol (chew tab 500 mg-100, tab 500 mg-125,
tab 500 mg-600, tab 500 mg-200, tab 500 mg-400, tab 600 mg-800, tab
600 mg-400, tab 600 mg-200)
calcium carbonate-mag hydrox (chew tab 550-110 mg, chew tab 675-135
mg, chew tab 700-300 mg, susp 400-135 mg/5ml)
calcium carbonate-simethicone
calcium carbonate-vitamin d (cap 600 mg-200, tab 250 mg-125, tab 500
mg-125, tab 500 mg-200, tab 500 mg-400, tab 600 mg-400, tab 600 mg125, tab 600 mg-200)
CALCIUM CHEW TAB 600-400 MG-UNIT
CALCIUM CITRATE (GRANULES 760 MG/3.5GM, TAB 200 MG, TAB 950
MG (200 MG ELEMENTAL CA))
CALCIUM CITRATE MALATE-VIT D
CALCIUM CITRATE-VITAMIN D (TAB 250-50 MG-UNIT, TAB 250 MG-200
UNIT (ELEMENTAL CA), TAB 315 MG-200 UNIT (ELEMENTAL CA))
CALCIUM CITRATE-VITAMIN D3
CALCIUM PANTOTHENATE TAB 100 MG
CALCIUM PLUS VITAMIN D
calcium polycarbophil tab 625 mg
calcium w/ magnesium tab 250-125 mg
calcium w/ vitamin d (tab 500 mg-125, tab 600 mg-200)
CALCIUM-MAGNESIUM TAB 750-465 MG
CALCIUM-VITAMIN D3
CALCIUM/VITAMIN D3 GUMMIES
camphor (inhalant)
CAMPHOR SPIRIT
CAPCOF
capecitabine (tab 150 mg, tab 500 mg)
PAGE 59
PA
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
CAPMIST DM
CAPRON DM
capsaicin (cream 0.025%, cream 0.075%, cream 0.1%)
CAPZASIN
carbamide peroxide (otic)
CARBAPHEN CH
CARBAPHEN PED CH
carboxymethylcellulose sodium (ophth) (gel 1%, soln 0.5%)
carboxymethylcellulose-glycerin
CCP CAFFEINE FREE
CEFTIN RECON SUSP 250 MG/5ML
AL1
Up to 11 yrs old
cefuroxime axetil for susp 125 mg/5ml
AL1
Up to 11 yrs old
CENTRUM SPECIALIST PRENATAL
CERALYTE 70 SOLUTION
CERASPORT SOLUTION
CERTUSS-D
cetirizine hcl (tab 5 mg, tab 10 mg)
cetirizine-pseudoephedrine
CHERRY
CHERRY CONCENTRATE
CHLO TUSS
CHLO TUSS EX
CHLOPHED
PA
chlordiazepoxide hcl (cap 5 mg, cap 10 mg, cap 25 mg)
C
PA for members over
age 65
chlordiazepoxide hcl-clidinium bromide
CHLORHEXIDINE GLUCONATE SOLUTION
CHLOROFORM
chlorpheniramine & phenylephrine (liquid 1-3.5 mg/ml, liquid 4-10 mg/5ml,
tab 4-10 mg)
chlorpheniramine & pseudoeph (syrup 1-15 mg/5ml, tab 4-60 mg)
PAGE 60
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
chlorpheniramine maleate (powder, syrup 2 mg/5ml, tab 4 mg, tab cr 12
mg)
chlorpheniramine w/ codeine
chlorpheniramine-acetaminophen
chlorpheniramine-dm (liquid 1-5 mg/5ml, liquid 2-15 mg/5ml, tab 4-30 mg)
chlorpheniramine-phenylephrine-acetaminophen (chlorphen-pe-apap tab 25-325 mg & pe-apap tab 5-325 mg pack, chlorphen-phenylephrine w/ apap
effer tab 2-5-250 mg, chlorphen-phenylephrine w/ apap susp 1-2.5-160
mg/5ml, chlorphen-phenylephrine w/ apap tab 2-5-325 mg, chlorphenphenylephrine w/ apap tab 4-10-650 mg)
chlorpheniramine-phenylephrine-asa
chlorpheniramine-pseudoephedrine-acetaminophen (cap 2-30-325 mg,
liquid 1-15-160 mg/5ml)
CHLORPROPAMIDE (TAB 100 MG, TAB 250 MG)
cholecalciferol (tab 1000, tab 5000)
cholecalciferol cap 400 unit
AL1
At least 65 yrs old
QL
60 / 30 days
AL1
At least 65 yrs old
AL1
Up to 9 yrs old
cholecalciferol tab 400 unit
choline & magnesium salicylates liq 500 mg/5ml
CIPROFLOXACIN HCL SOLUTION 0.2 %
CITROCARBONATE
CLASSIC PRENATAL
CLEARCANAL EAR WAX REMOVAL
clemastine fumarate (syrup 0.67 mg/5ml (0.5 mg/5ml base eq), syrup 0.67
mg/5ml, tab 1.34 mg (1 mg base equiv), tab 2.68 mg)
CLINICAL NUTRIENTS PRENATAL
clotrimazole cream 1%
clotrimazole vaginal (cream 1%, cream 2%)
CODAR AR
CODAR D
CODITUSS DM
COMPLETE FORMULATION PEDIATRIC
COMPLETE NATAL DHA
COMPLETE NUTRITIONAL DRINK
PAGE 61
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
COMPLETE PRENATAL/DHA
COMPLETE SINUS RELIEF
COMPLETENATE
CONCEPTIONXR MOTILITY SUPPORT
CONEX COLD/ALLERGY (SOLUTION 1-30 MG/5ML, TAB 2-60 MG)
CONTAC COLD+FLU MAX ST
CONTAC COLD/FLU DAY & NIGHT
COOL MIST HUMIDIFIER
CORICIDIN HBP DAY/NIGHT COLD
CORICIDIN NIGHTTIME COLD-COUGH
CORNWALL METAL PIPETTING
QL
200 / 30 days
CORRECTOL HERBAL TEA
COTTONSEED OIL
cromolyn sodium (nasal)
CRYOSERV
CULTURELLE
CULTURELLE DIGESTIVE HEALTH (CAP, CHEW TAB)
CULTURELLE HEALTH & WELLNESS
CULTURELLE IMMUNITY SUPPORT
CVS DIABETES HEALTH SUPPORT
CVS EAR WAX CLEANSING SYSTEM
CVS ETHYL ALCOHOL
CVS ISOPROPYL ALCOHOL (SOLUTION 70 %, SOLUTION 91 %)
CVS ISOPROPYL RUBBING ALCOHOL
CVS NATURAL FIBER SUPPLEMENT
CVS PRENATAL
CVS PRENATAL GUMMY
CVS VITAMIN C
CVS WOMENS PRENATAL+DHA
cyanocobalamin (inj 1000 mcg/ml, tab 1000 mcg)
cyclopentolate hcl ophth soln 1%
PAGE 62
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
CYTRA-3
DAILY ENERGY ENFUSION
DAILY HEART HEALTH SUPPORT
DAILY PAK MAXIMUM MULTIVITAMIN
DALLERGY (LIQUID 1-2.5 MG/ML, TAB 1-5 MG)
DAYTIME COLD MEDICINE
DELTUSS DP
DELZICOL
QL
180 / 30 days
DENTURE ADHESIVE
DESGEN DM
DESPEC-DM
DEWEES CARMINATIVE
DEXAMETHASONE SOLUTION 0.5 MG/5ML
DEXCHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML
DEXPAK 10 DAY
DEXPAK 13 DAY
DEXPAK 6 DAY
dextromethorphan hbr syrup 15 mg/5ml
dextromethorphan-acetaminophen-chlorpheniramine (susp 5-160-1
mg/5ml, tab 15-500-2 mg)
dextromethorphan-doxylamine-acetaminophen (cap 15-6.25-325 mg, liquid
15-6.25-325 mg/15ml, liquid 30-12.5-1000 mg/30ml)
dextromethorphan-guaifenesin (cap 10-200 mg, liquid 5-100 mg/5ml, liquid
10-200 mg/15ml, liquid 10-200 mg/5ml, liquid 10-100 mg/5ml, liquid 20-300
mg/5ml, liquid 30-200 mg/5ml, syrup 10-100 mg/5ml, tab 20-400 mg, tab sr
12hr 60-1200 mg, tab sr 12hr 30-600 mg)
dextromethorphan-phenylephrine-acetaminophen (cap 10-5-325 mg, liqd
10-5-325 mg/15ml, powd pack 20-10-650 mg, tab 10-5-325 mg)
DIABETES HEALTH
DIABETES SUPPORT MISC
DIABETIC TUSSIN COLD & FLU
DIABETIC TUSSIN NIGHT COLD/FLU
DIALYVITE SUPREME D
dimenhydrinate (solution 50 mg/ml, tab 50 mg)
PAGE 63
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
DIMETAPP LONG ACT COUGH/COLD
DIMETHYL SULFOXIDE (SOLUTION, SOLUTION 100 %)
DINO-LIFE W/IRON-ZINC
AL1
diphenhydramine hcl (cap 25 mg, cap 50 mg, chew tab 12.5 mg, elixir 12.5
mg/5ml, liquid 12.5 mg/5ml, syrup 12.5 mg/5ml, tab 25 mg, tab disp 12.5
mg)
PA
diphenhydramine hcl (sleep) (cap 25 mg, cap 50 mg, liquid 50 mg/30ml, tab
25 mg, tab 50 mg, tab disp 25 mg)
C
Up to 9 yrs old
covered up to age 65,
then PA required
PA
C
PA for members over
age 65
diphenhydramine-acetaminophen (tab 12.5-325 mg, tab 12.5-500 mg, tab
25-500 mg)
diphenhydramine-acetaminophen tab 25-500 mg (sleep)
diphenhydramine-phenylephrine (liq 6.25-2.5 mg/5ml, soln 12.5-5 mg/5ml,
tab 25-10 mg)
diphenhydramine-phenylephrine-acetaminophen (liq 6.25-2.5-160 mg/5ml,
liq 12.5-5-325 mg/10ml, liq 12.5-5-325 mg/15ml, packet 25-10-650 mg,
susp 12.5-2.5-160 mg/5ml, tab 12.5-5-325 mg, tab 25-10-650 mg, tab 25-5325 mg)
diphenhydramine-pse w/ apap tab 12.5-30-500 mg
QL
600 / 30 days
AL1
Up to 12 yrs old
DIURIL
docusate calcium
docusate sodium (cap 50 mg, cap 100 mg, cap 250 mg, enema 283 mg,
liquid 150 mg/15ml, syrup 60 mg/15ml, tab 100 mg)
DOCUSOL KIDS
DOLOGEN TAB 2-650 MG
DOMETUSS-DA/CHILDREN
DOMETUSS-DMX
doxylamine-dm (& dm 15 liqd ther pack, liquid)
doxylamine-phenylephrine-acetaminophen (*pe-apap cap & doxylaminepe-apap cap therapy pack***, doxylamine-phenylephrine-apap cap 6.25-5325 mg)
DRAMAMINE CHEW TAB 50 MG
DURAVENT PE
E-Z-GAS II
PAGE 64
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
EAR WAX CLEANSING
EASIVENT
QL
2 / 365 days
EASIVENT MASK LARGE
QL
2 / 365 days
EASIVENT MASK MEDIUM
QL
2 / 365 days
EASIVENT MASK SMALL
QL
2 / 365 days
EASY TOUCH FLURINGE (MISC 1" 1 ML, MISC 5/8" 1 ML)
QL
200 / 30 days
EASY TOUCH SAFETY SYRINGE (MISC 1" 1 ML, MISC 5/8" 1 ML)
QL
200 / 30 days
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
4 / 28 days
ECOTRIN
ED CHLORPED
ED CHLORPED D
EFFACLAR DUO
ELDERTONIC
ELITE IRON
ENDACON
ENERGY BOOSTER
ENFAMIL ENFALYTE
ENFAMIL EXPECTA
ENTEX LQ
ENTEX T
ephedrine-guaifenesin
EQL CALCIUM/VITAMIN D
EQL ETHYL ALCOHOL (RUBBING)
EQL ISOPROPYL ALCOHOL
EQL PRENATAL FORMULA
EQL SUPER ENERGY BOOSTER
EQL VITAMIN D-3 HIGH POTENCY
EQUALACTIN
ergocalciferol cap 50000 unit
estazolam (tab 1 mg, tab 2 mg)
PAGE 65
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
QL
21 / 28 days
GL
Female
AL1
Up to 12 yrs old
AL1
Up to 12 yrs old
FIRST-LANSOPRAZOLE
QL
150 / 30 days
FIRST-OMEPRAZOLE
QL
150 / 30 days
esterified estrogens & methyltestosterone (tab 0.625-1.25 mg, tab 1.25-2.5
mg)
ETHER SOLUTION
ETHYL ALCOHOL (RUBBING)
ETHYL ALCOHOL SOLUTION 95 %
EUGENOL SOLUTION
EVAC-U-GEN
EZFE FORTE
FAMOTIDINE PREMIXED
fe fumarate-vitamin c-vitamin b12-folic acid
FENESIN DM IR
FER-IN-SOL
FERRETTS IPS
FERRIMIN 150
FERROUS FUMARATE (TAB 29 MG, TAB 325 MG (106 MG ELEMENTAL
FE))
ferrous fumarate w/ b12-vit c-fa-ifc
ferrous gluconate (tab 225 (27 fe) mg, tab 240 mg (27 mg elemental fe),
tab 324 mg (37.5 mg elemental iron), tab 325 mg (36 mg elemental fe))
ferrous sulfate (elixir 220 (44 elemental, soln 75 mg/ml (15 mg/ml
elemental, syrup 300 (60)
ferrous sulfate (granules, tab 27 mg (elemental fe), tab 134 mg (27 mg
elemental fe), tab 325 mg (65 mg elemental fe), tab cr 47.5 mg (elemental
fe), tab cr 142 mg (45 mg fe equivalent), tab ec 325 mg (65 mg fe
equivalent))
ferrous sulfate dried (tab 200 mg (65 mg elemental fe), tab cr 45 mg (fe
equivalent), tab cr 160 mg (50 mg fe equivalent))
fexofenadine hcl (susp 30 mg/5ml (6 mg/ml), tab 180 mg)
FIRST-PROGESTERONE VGS 100
FIRST-PROGESTERONE VGS 200
FIRST-PROGESTERONE VGS 25
PAGE 66
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
FIRST-PROGESTERONE VGS 400
FIRST-PROGESTERONE VGS 50
FIRST-VANCOMYCIN 25
QL
300 / 15 days
FIRST-VANCOMYCIN 50
QL
150 / 15 days
FLUARIX QUADRIVALENT
QL
0.5 / 365 days
FLUCELVAX
QL
0.5 / 365 days
FLUID ADMINISTRATION SET
QL
200 / 30 days
FLULAVAL
QL
0.5 / 365 days
FLULAVAL QUADRIVALENT SUSP PRSYR 0.5 ML
QL
0.5 / 365 days
FLAVOR BLEND
FLAVOR PLUS
FLAVOR SWEET
FLAVOR SWEET-SF
FLEET BISACODYL
FLU & SORE THROAT
FLUARIX
PA
FLURAZEPAM HCL (CAP 15 MG, CAP 30 MG)
C
PA for members over
age 65
flurazepam hcl (cap 15 mg, cap 30 mg)
FLUVIRIN PRESERVATIVE FREE
QL
0.5 / 365 days
QL
0.5 / 365 days
FLUZONE QUADRIVALENT (SUSP PRSYR 0.5 ML, SUSPENSION 0.5
ML)
QL
0.5 / 365 days
FLUZONE SUSP PEN 9 MCG/STRAIN
QL
0.1 / 365 days
FLUZONE SUSPENSION
QL
0.5 / 365 days
FLUVIRIN SUSP PRSYR 0.5 ML
FLUVIRIN SUSPENSION
FLUZONE PEDIATRIC PF
FLUZONE PRESERVATIVE FREE (SUSP PRSYR 0.5 ML, SUSPENSION)
PAGE 67
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
folic acid (tab 400 mcg, tab 800 mcg)
LIMITS & RESTRICTIONS
QL
30 / 30 days
GL
Female
AL1
14 to 50 yrs old
folic acid tab 1 mg
FORTAVIT LIQUID
FREESTYLE CONTROL SOLUTION
FUNGOID TINCTURE SOLUTION 2 %
G-DOLOGEN
G-P-TUSS DXP
G-TRON PEDIATRIC DROPS
G-TUSICOF
G-ZYNCOF
GAS-X EXTRA STRENGTH STRIP 62.5 MG
GAVISCON CHEW TAB 80-14.2 MG
GAVISCON EXTRA RELIEF FORMULA
GENTEAL
GENTEAL SEVERE
GLUCOCARD EXPRESSION CONTROL
GLUCOCARD EXPRESSION TEST
GLUCOCARD VITAL TEST
glycerin (laxative) (suppos 1 gm, suppos 1.2 gm, suppos 2 gm, suppos 2.1
gm, suppos 80.7%)
GLYCERIN (LIQUID, SOLUTION)
glycerin (topical)
glycerin-hypromellose-polyethylene glycol 400
GLYCERINE
GLYCEROL FORMAL
GLYCINE SOYA EXTRACT
GLYCINE SOYA PROTEIN
GNP ALCOHOL DENATURED
GNP CAPSAICIN
GNP DAILY PRENATAL
PAGE 68
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
GNP ETHYL ALCOHOL
GNP ETHYL RUBBING ALCOHOL
GNP ISOPROPYL ALCOHOL (SOLUTION 70 %, SOLUTION 91 %)
GNP PEPPERMINT SPIRIT
GNP PRENATAL
GNP SODIUM SILICATE
GOODSENSE PRENATAL VITAMINS
GRAPE SYRUP
GUAIACOL
guaifenesin (liquid 100 mg/5ml, liquid 200 mg/5ml, powder, syrup 100
mg/5ml, tab 200 mg, tab 400 mg, tab sr 12hr 600 mg)
guaifenesin-codeine (liquid 225-7.5, soln 100-10, soln 100-6.3)
GYNAZOLE-1
H 468L TUBING
QL
200 / 30 days
HONEY BEARS W/IRON-ZINC
AL1
Up to 9 yrs old
HUBER INFUSION SET
QL
200 / 30 days
HUMAPEN LUXURA HD
QL
200 / 30 days
HUMATROPEN FOR 12MG
QL
200 / 30 days
HUMATROPEN FOR 24MG
QL
200 / 30 days
HUMATROPEN FOR 6MG
QL
200 / 30 days
HC DERMAPAX
HEALTHY MAMA BE WELL ROUNDED
HERBAL EXPEC
HIGH POTENCY IRON
HISTEX-DM
HISTEX-PE
HM ETHYL RUBBING ALCOHOL
HM ISOPROPYL ALCOHOL (SOLUTION 70 %, SOLUTION 91 %)
HM ONE DAILY PRENATAL
HM PRENATAL
homatropine hbr
PAGE 69
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
HYDROCIL PACKET 95 %
hydrocodone polistirex-chlorpheniramine polistirex
hydrocodone w/ homatropine (syrup mg/5ml, tab mg)
hydrocortisone acetate (rectal) (suppos 25 mg, suppos 30 mg)
QL
28 / 14 days
hydrocortisone acetate cream 1%
QL
60 / 30 days
hydrocortisone gel 1%
QL
60 / 30 days
hydrocortisone soln 1%
QL
90 / 30 days
hydrocortisone-aloe vera (cream 0.5%, cream 1%)
QL
90 / 30 days
INCRUSE ELLIPTA
QL
30 / 30 days
INFUSION SET
QL
200 / 30 days
INFUSION SET 23" COMFORT
QL
200 / 30 days
INJECT-EASE
QL
200 / 30 days
INJECT-EASE AUTOMATIC INJECTOR
QL
200 / 30 days
INSUFLON
QL
200 / 30 days
INSYTE AUTOGUARD 14GX1.75"
QL
200 / 30 days
INSYTE AUTOGUARD 18GX1.16"
QL
200 / 30 days
INSYTE AUTOGUARD 20GX1"
QL
200 / 30 days
HYDROXYPROGESTERONE CAPROATE
hyoscyamine sulfate (elixir 0.125 mg/5ml, soln 0.125 mg/ml, tab 0.125 mg,
tab disp 0.125 mg, tab sl 0.125 mg, tab sr 12hr 0.375 mg)
HYPERRHO S/D SOLN PRSYR 1500 UNIT
hypromellose (gonioscopic)
hypromellose (ophth) (soln 0.3%, soln 0.4%)
ibuprofen cap 200 mg
ibuprofen-diphenhydramine citrate
IMMUNE SUPPORT VITAMIN C
IMODIUM A-D CHEW TAB 2 MG
INATAL ADVANCE
INATAL ULTRA
PAGE 70
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
INSYTE AUTOGUARD 20GX1.16"
QL
200 / 30 days
INSYTE AUTOGUARD 22GX1"
QL
200 / 30 days
INSYTE AUTOGUARD 24GX3/4"
QL
200 / 30 days
INTERLINK INJECT SITE/LUER LOC
QL
200 / 30 days
INVOKANA (TAB 100 MG, TAB 300 MG)
PA
IRON (FERROUS GLUCONATE)
iron combinations
iron polysaccharide complex-vit b12-folic acid
IRON UP
ISONIAZID SYRUP 50 MG/5ML
ISOPROPANOL
ISOPROPYL ALCOHOL (SOLUTION, SOLUTION 50 %, SOLUTION 70 %,
SOLUTION 91 %)
ISOPROPYL ALCOHOL WIPES
ISOPROPYL PALMITATE
ISOPTO TEARS
K-PHOS
K-PHOS NO 2
KALA
KANGAROO BURETTE SET
QL
200 / 30 days
QL
5 / 30 days
L606 TUBING
QL
200 / 30 days
L609 TUBING
QL
200 / 30 days
KETOSTIX
ketotifen fumarate (ophth)
KNEE STABILIZER/ELASTIC/SM/MED
KONSYL (PACKET 28.3 %, PACKET 60.3 %, PACKET 100 %, POWDER
60.3 %, POWDER 71.67 %)
KONSYL-D POWDER 52.3 %
KP PRENATAL MULTIVITAMINS
KPN PRENATAL
PAGE 71
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
lactic acid w/ vitamin e
lactobacillus acidophilus-pectin
QL
2 / 30 days
GL
Female
QL
2 / 30 days
GL
Female
LTXF PRIM CNV PIN MICRODRIP
QL
200 / 30 days
LTXF PRIM IV SET/CNVT PIN
QL
200 / 30 days
LTXF SECONDARY/CNV PIN/32INC
QL
200 / 30 days
LEVONORGESTREL
levonorgestrel (emergency oc) (tab 0.75 mg, tab 1.5 mg)
LICIDE TREATMENT
LIFE PACK MENS
LIQUIMAT
LITTLE REMEDIES FOR COLDS LIQUID 2.5-1.25-80 MG/ML
LODRANE D
LOHIST-D
loperamide hcl (1 mg/5ml (0.2 mg/ml), 1 mg/7.5ml)
loratadine & pseudoephedrine (tab 12hr 5-120 mg, tab 24hr 10-240 mg)
loratadine (rapidly-disintegrating tab 10 mg, syrup 5 mg/5ml, tab 10 mg)
LORTUSS DM
LORTUSS LQ
M-END DMX
M-END MAX D
M-END PE
M-VIT
M2 POTASSIUM
MAG-AL
MAG-TAB SR
MAGINEX
MAGINEX DS
MAGNESIUM (CAP 300 MG, TAB 30 MG, TAB 100 MG, TAB 200 MG,
TAB 250 MG, TAB 400 MG)
PAGE 72
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
MAGNESIUM CARBONATE HEAVY POWDER
MAGNESIUM CARBONATE POWDER
magnesium chloride (crystals, powder, tab cr 535 mg (64 mg elemental
mg))
MAGNESIUM CITRATE (SOLN, TAB 100 MG)
magnesium gluconate (tab 30 mg, tab 500 mg (27 mg elemental mg), tab
550 mg)
magnesium oxide (cap 400 mg, powder, tab 250 mg, tab 400 mg, tab 420
mg)
magnesium oxide (mg supplement) (tab 250 mg (mg supplement), tab 400
mg (240 mg elemental mg), tab 400 mg (241.3 mg elemental mg))
MAGONATE
MAR-COF BP
MAXIMIN PACK
MECLIZINE HCL (CHEW TAB 25 MG, POWDER)
MEDSAVER SYRINGE MISC 25G X 5/8" 1 ML
QL
200 / 30 days
QL
200 / 30 days
MEGA BIOTIN
MEGA MULTIVITAMIN
meperidine hcl (tab 50 mg, tab 100 mg)
METAMUCIL SMOOTH TEXTURE
METAMUCIL WAFER
METAPROTERENOL SULFATE (TAB 10 MG, TAB 20 MG)
methadone hcl (conc 10 mg/ml, tab for oral susp 40 mg)
METHADOSE
METHADOSE SUGAR-FREE
METHANOL (SOLUTION, SOLUTION 99 %)
METHYL ALCOHOL
methylcellulose powder laxative
MH MACULAR HEALTH
miconazole nitrate (topical) (aerosol, aerosol pow, cream, ointment,
powder)
miconazole nitrate vaginal (cream, supp 200 mg & cream 9 gm kit)
MONOJECT LIFESHIELD SYRINGE MISC 18G X 1" 1 ML
PAGE 73
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
MONOJECT MAGELLAN SYRINGE (MISC 23G 1" 1 ML, MISC 25G 5/8" 1
ML, MISC 25G 1" 1 ML)
LIMITS & RESTRICTIONS
QL
200 / 30 days
MUCINEX CHILD MS DAY-NIGHT CLD
MUCINEX COUGH FOR KIDS
MUCINEX D (TAB ER 12H 120-1200 MG, TAB ER 12H 60-600 MG)
MUCINEX FAST-MAX CONGEST COUGH TAB 5-10-200 MG
MUCINEX FAST-MAX DAY/NIGHT MISC
MUCINEX FOR KIDS
MUCINEX MAXIMUM STRENGTH
MUCINEX SINUS-MAX DAY/NIGHT MISC
MULTI FOR HER
MULTI PRENATAL
multiple vitamins w/ iron
multiple vitamins w/ minerals (cap**, chew tab**, tab cr**, tab**)
MYKIDZ IRON 10
MYLERAN
PA
MYNATAL (CAP, TAB 90-1 MG)
MYNATAL ADVANCE
MYNATAL PLUS
MYNATAL-Z
MYNATE 90 PLUS
NANOVM T/F LIQUID
AL1
Up to 9 yrs old
NAPHAZOLINE HCL SOLUTION 0.1 %
naphazoline w/ pheniramine (soln 0.025-0.3%, soln 0.027-0.315%)
naphazoline-glycerin (soln 0.012-0.25%, soln 0.012-0.2%, soln 0.03-0.5%)
naphazoline-hypromellose
naphazoline-polyethylene glycol 300
NAPRELAN (TAB ER 24H 500 MG, TAB ER 24H 375 MG, TAB ER 24H
750 MG)
naproxen sodium (cap 220 mg, powder)
NASAL DECONGESTANT (LIQUID 30, SYRUP 30)
NASOPEN
PAGE 74
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
NASOPEN PE
NAT-RUL PRENATAL VITAMINS
NATALVIT
NATRUL-100
NATURAL SENNA LAXATIVE
NATURE-THROID (TAB 32.5 MG, TAB 48.75 MG, TAB 65 MG, TAB 97.5
MG, TAB 130 MG, TAB 195 MG, TAB 260 MG, TAB 325 MG)
QL
37.5 / 28 days
GL
Female
NERIA 29G INFUSION SET 10MM
QL
200 / 30 days
NERIA 29G INFUSION SET 6MM
QL
200 / 30 days
NERIA 29G INFUSION SET 8MM
QL
200 / 30 days
NERIA MULTI 27G 2X10MM
QL
200 / 30 days
NERIA MULTI 27G 3X10MM
QL
200 / 30 days
NERIA MULTI 27G 4X12MM
QL
200 / 30 days
NERIA SOFT 25G INFUSION 13MM
QL
200 / 30 days
NERIA SOFT 25G INFUSION 17MM
QL
200 / 30 days
NEXIUM 24HR
QL
60 / 30 days
NEXIUM CAP DR 20 MG
QL
60 / 30 days
NECON 1/50 (28)
neomycin-bacitracin-polymyxin
neomycin-bacitracin-polymyxin w/ lidocaine
NEOSPORIN ESSENTIALS TRIAL PK
NEOTUSS PLUS
NEOTUSS-D
NEUTROGENA CLEAR PORE
niacin (cap cr 250 mg, cap cr 500 mg, tab 50 mg, tab 100 mg, tab 250 mg,
tab 500 mg, tab cr 250 mg, tab cr 500 mg, tab cr 750 mg)
NIACIN ER
NIACINAMIDE (TAB 100 MG, TAB 500 MG, TAB ER 500 MG)
NICODERM CQ (PATCH 24HR 7 MG/24HR, PATCH 24HR 21 MG/24HR,
PATCH 24HR 14 MG/24HR)
PAGE 75
C
90 days of coverage
per year
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
NICORETTE (GUM 2 MG, GUM 4 MG, LOZENGE 2 MG, LOZENGE 4
MG)
LIMITS & RESTRICTIONS
QL
C
QL
NICORETTE MINI (LOZENGE 2 MG, LOZENGE 4 MG)
C
QL
NICORETTE REFILL (GUM 2 MG, GUM 4 MG)
C
QL
NICORETTE STARTER KIT (KIT GUM 2 MG, KIT GUM 4 MG)
NICOTINE (KIT 21-14-7 MG/24HR, TD PATCH 24HR 7 MG/24HR, TD
PATCH 24HR 21 MG/24HR, TD PATCH 24HR 14 MG/24HR)
90 days of coverage
per year
270 / 30 days
90 days of coverage
per year
270 / 30 days
90 days of coverage
per year
270 / 30 days
C
90 days of coverage
per year
C
90 days of coverage
per year
QL
NICOTINE MINI
C
QL
nicotine polacrilex (gum 2 mg, gum 4 mg, lozenge 2 mg, lozenge 4 mg)
NICOTROL
270 / 30 days
270 / 30 days
90 days of coverage
per year
270 / 30 days
C
90 days of coverage
per year
C
90 days of coverage
per year
nit remover
NITE-TIME COLD/FLU RELIEF
nitroglycerin (cap 2.5 mg, cap 6.5 mg, cap 9 mg)
NORDIPEN 5 INJECTION DEVICE
QL
200 / 30 days
NORDIPEN DELIVERY SYSTEM
QL
200 / 30 days
QL
200 / 30 days
NOREL AD
NOVAFERRUM PEDIATRIC DROPS
NOVOPEN ECHO
O-CAL FA
O-CAL PRENATAL
OBSTETRIX DHA
OBSTETRIX EC
OBTREX
PAGE 76
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
OBTREX DHA
OC8 GEL 7 %
OMEPRAZOLE+SYRSPEND SF ALKA
QL
150 / 30 days
omeprazole-sodium bicarbonate cap 20-1100 mg
QL
60 / 30 days
QL
1 / 365 days
GL
Female
OMNITROPE PEN 10 INJ DEVICE
QL
200 / 30 days
OMNITROPE PEN 5 INJ DEVICE
QL
200 / 30 days
QL
1 / 365 days
GL
Female
QL
1 / 365 days
GL
Female
OMNIFLEX DIAPHRAGM
ONE-A-DAY WOMENS PRENATAL
ONETOUCH ULTRA CONTROL
ORA-BLEND
ORA-BLEND SF
ORA-FILM
ORA-PLUS
ORA-SWEET
ORA-SWEET SF
ORACIT
ORAL MIX
ORAL MIX SF
ORAL SUSPEND
ORAL SYRUP
ORAL SYRUP SF
ORAZINC
ORTHO DIAPHRAGM ALL-FLEX (DIAPHRAGM DIAPHRAGM 65,
DIAPHRAGM DIAPHRAGM 70, DIAPHRAGM DIAPHRAGM 75,
DIAPHRAGM DIAPHRAGM 80)
ORTHO DIAPHRAGM COIL (DIAPHRAGM KIT 50, DIAPHRAGM KIT 100,
DIAPHRAGM KIT 105)
PAGE 77
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
ORTHO DIAPHRAGM FLAT (DIAPHRAGM KIT 55, DIAPHRAGM KIT 60,
DIAPHRAGM KIT 65, DIAPHRAGM KIT 70, DIAPHRAGM KIT 75,
DIAPHRAGM KIT 80, DIAPHRAGM KIT 85, DIAPHRAGM KIT 90,
DIAPHRAGM KIT 95)
LIMITS & RESTRICTIONS
QL
1 / 365 days
GL
Female
pediatric multiple vitamin w/ c
AL1
Up to 9 yrs old
pediatric multiple vitamin w/ c & fa
AL1
Up to 9 yrs old
pediatric multiple vitamin w/ extra c & fa
AL1
Up to 9 yrs old
pediatric multiple vitamin w/ minerals & c (drops 45 mg/ml**, hew tab 30
mg**, hew tab 60 mg**, hew tab**)
AL1
Up to 9 yrs old
pediatric multiple vitamins
AL1
Up to 9 yrs old
pediatric multiple vitamins w/ iron (chew tab 15 mg**, drops 10 mg/ml**)
AL1
Up to 9 yrs old
pediatric vitamins acd w/ fluoride (soln 0.25, soln 0.5)
AL1
Up to 9 yrs old
OSTEO-PORETICAL
oxycodone hcl (conc 100, conc 100 (20 mg/ml))
oxymetazoline hcl nasal soln 0.05%
OYSTER SHELL CALCIUM/D
PA PRENATAL FORMULA
PABA
PARVA-CAL (TAB 250-100, TAB 500-200)
PCCA SWEET-SF
PCCA SYRUP VEHICLE
PCCA-PLUS
PECGEN DMX LIQUID 15-125 MG/5ML
PEDIA-LAX (LIQUID 50 MG/15ML, SUPPOS 2.8 GM)
PEPCID AC MAXIMUM STRENGTH CHEW TAB 20 MG
PEPPERMINT SPIRIT
PERFECT IRON
permethrin & pyrethrins-piperonyl butoxide
permethrin (aerosol 0.5%, creme rinse 1%, lotion 1%)
PERRY PRENATAL
phenazopyridine hcl (tab 95 mg, tab 100 mg, tab 200 mg)
phenyleph-promethazine w/ cod
PAGE 78
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
phenylephrine w/ acetaminophen (cap 5-325 mg, powd pack 10-650 mg,
tab 5-325 mg, tab 5-500 mg)
phenylephrine w/ dm-gg (liqd 2.5-7.5-88 mg/ml, liqd 2.5-5-75 mg/5ml, liqd
2.5-5-100 mg/5ml, liqd 2.5-5-50 mg/ml, liqd 5-10-200 mg/5ml, liqd 5-10-100
mg/5ml, liqd 10-30-200 mg/5ml, liqd 10-15-300 mg/5ml, liqd 10-28-388
mg/5ml, liquid 10-15-350 mg/5ml, syrup 5-10-100 mg/5ml, tab 10-15-380
mg, tab 10-20-400 mg)
phenylephrine-acetaminophen-guaifenesin (liqd 10-650-400 mg/20ml, tab
5-325-200 mg, tab 10-650-400 mg)
phenylephrine-brompheniramine-dm (elixir 2.5-1-5, liquid 2.5-1-5, liquid
7.5-4-15, liquid 10-4-20, syrup 5-2-10)
phenylephrine-chlorphen-dm (liquid 3.5-1-3 mg/ml, liquid 10-4-15 mg/5ml)
phenylephrine-chlorpheniramine-dm w/ apap (pe-dm-apap & pe-cpm-dmapap tab day/night therapy pack, phenyleph-chlorphen-dm w/apap susp
2.5-1-5-160 mg/5ml, phenyleph-chlorphen-dm w/apap tab 5-2-10-325 mg)
phenylephrine-diphenhydramine-dm-guaifenesin-apap
phenylephrine-dm
phenylephrine-dm-gg w/ apap (liq 5-10-200-325 mg/10ml, liq 5-10-200-325
mg/15ml, tab 5-15-200-325 mg, tab 5-10-100-325 mg, tab 5-10-200-325
mg)
phenylephrine-doxylamine-dextromethorphan-acetaminophen (pe-dm-apap
cap & doxylamine-dm-apap cap day/night ther pack, pe-dm-apap liq &
doxylamine-dm-apap liq day/night ther pack, phenylephrine-doxyl-dmacetaminophen cap 5-6.25-10-325 mg, phenylephrine-doxylamine-dmapap liq 5-6.25-10-325 mg/15ml)
phenylephrine-guaifenesin (liqd 5-100 mg/5ml, tab 5-200 mg, tab 10-400
mg, tab 10-380 mg)
PHENYLHISTINE DH
PHLEXY-VITS
phytonadione tab 100 mcg
PINE TAR LIQUID
QL
2 / 30 days
GL
Female
QL
2 / 30 days
GL
Female
QL
200 / 30 days
PLAN B
PLAN B ONE-STEP
PLASTIC ADAPTER (MISC, MISC 1 ML)
PNV FE FUM/DOCUSATE/FOLIC ACID
PAGE 79
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
PNV FOLIC ACID + IRON
PNV PRENATAL PLUS MULTIVITAMIN
PNV TABS 29-1
PNV-VP-U
POLY HIST FORTE TAB 7.5-10 MG
POLY-HIST DM
POLY-HIST PD
POLY-TUSSIN
POLY-TUSSIN AC LIQUID 10-4-10 MG/5ML
POLY-TUSSIN D
POLY-VENT DM
POLY-VENT IR
POLYETHYLENE GLYCOL 3350 POWDER
polyethylene glycol-propylene glycol (ophth)
POLYSORBATE 20
POLYSORBATE 40
POLYSORBATE 60
POLYSORBATE 80
polyvinyl alcohol-povidone (ophth)
pot phosphate monobasic w/ sod phosphate dibasic & monobasic
POTABA
potassium bicarb & chloride
potassium bicarbonate effer tab 25 meq
potassium chloride powder packet 20 meq
potassium citrate-citric acid (powder pack 3300-1002 mg, soln 1100-334
mg/5ml)
povidone-iodine (pad 10 %, soln 10%)
povidone-iodine douche soln 10%
PR NATAL 400
PR NATAL 430
pramoxine-calamine
pramoxine-phenylephrine-glycerin-petrolatum
PAGE 80
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
PRE-NATAL FORMULA
PRECISION XTRA KETONE
PREMIUM PACKETS
PRENAPLUS
PRENATA
PRENATABS FA
PRENATABS RX
PRENATAL (TAB 6.75-0.2 MG, TAB 27-1 MG, TAB 27-0.8 MG, TAB 280.8 MG)
PRENATAL 19 (19 CHEW TAB, 19 CHEW TAB 29-1 MG, 19 TAB 29-1
MG, 19 TAB)
PRENATAL COMPLETE
PRENATAL FORMULA (CAP 28-0.8-235 MG, TAB 28-0.8 MG)
PRENATAL FORMULA A-FREE
PRENATAL LOW IRON (TAB 27-0.8 MG, TAB 27-1 MG)
PRENATAL MULTI +DHA CAP 27-0.8-228 MG
PRENATAL MULTIVITAMIN + DHA
PRENATAL ONE DAILY
PRENATAL PLUS
PRENATAL PLUS IRON
PRENATAL VITAMINS (TAB 0.8 MG, TAB 28-0.8 MG)
PRENATAL+DHA
PRENATAL-U
PRENATAL/IRON
PRENATAL/OMEGA-3/FA/IRON
PREPLUS
PRESCRIPTIVE FORMULAS MENS
PRESCRIPTIVE FORMULAS WOMENS
PRETAB
PRETZ SOLUTION 10 %
PRILOSEC OTC
QL
60 / 30 days
PRIMSOL
QL
600 / 30 days
PAGE 81
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
PRO-CHLO
PRO-CLEAR AC
PRO-RED AC
PROFE FORTE
PROFERRIN ES
promethazine w/codeine
promethazine-dm
PROPANTHELINE BROMIDE TAB 15 MG
PROPRANOLOL HCL (SOLUTION 20, SOLUTION 40)
propylene glycol-glycerin
PROTECT PLUS NF
pseudoeph-cpm-dm w/apap (cap 30-2-10-325 mg, pack 60-4-30-1000 mg,
tab 30-2-15-500 mg, tab 30-2-15-325 mg)
pseudoephed-bromphen-dm (elixir 15-1-5, syrup 30-2-10)
pseudoephed-doxyl-dm w/apap (w/ apap cap 30-6.25-15-325 mg, w/apap
liq 60-12.5-30-1000 mg/30ml)
pseudoephedrine hcl (liq 15 mg/5ml, tab 30 mg, tab 60 mg, tab abuse deter
30 mg, tab sr 12hr 120 mg)
pseudoephedrine w/ acetaminophen tab 30-500 mg
pseudoephedrine w/ codeine-gg (soln, syrup)
pseudoephedrine w/ dm-gg (cap 30-10-200 mg, liquid 30-10-100 mg/5ml,
liquid 30-15-175 mg/5ml)
pseudoephedrine-acetaminophen-dextromethorphan (cap 30-325-15 mg,
liq 30-325-15 mg/15ml, tab 30-500-15 mg)
pseudoephedrine-brompheniramine-codeine
pseudoephedrine-chlophedianol-guaifenesin
pseudoephedrine-chlorphen-dm (15-1-5, 15-1-7.5)
pseudoephedrine-dexchlorpheniramine-chlophedianol (liq 15-0.5-6.25
mg/ml, liqd 30-1-12.5 mg/5ml, liqd 60-2-25 mg/5ml)
pseudoephedrine-dexchlorpheniramine-dextromethorphan
pseudoephedrine-dm-gg w/ apap tab 30-15-200-325 mg
pseudoephedrine-guaifenesin (cap 30-200 mg, tab 40-400 mg, tab 60-400
mg)
pseudoephedrine-ibuprofen (susp 15-100 mg/5ml, tab 30-200 mg)
PAGE 82
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
pseudoephedrine-naproxen sodium
psyllium (cap 0.52 gm, powder 28.3%, powder 30.9%, powder 48.57%,
powder 58.6%, powder 68%, powder 95%, powder 100%)
PUREFE OB PLUS
pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv)
pyrethrins-piperonyl butoxide (liq, shampoo)
pyrethrins-piperonyl butoxide-permethrin-nit remover
pyridoxine hcl (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg, tab 250 mg,
tab 500 mg, tab cr 200 mg)
pyrilamine maleate-phenylephrine hcl tannate
pyrilamine-phenylephrine
QC ISOPROPYL RUBBING ALCOHOL
RA ACNE MAXIMUM
RA CALCIUM-BORON
RA EAR WAX CLEANSING SYSTEM
RA ESSENCE-C
RA ETHYL ALCOHOL
RA ONE DAILY
RA PRENATAL
RA PRENATAL FORMULA
REFRESH OPTIVE ADVANCED
RENAGEL (TAB 400 MG, TAB 800 MG)
PA
RESCON DM
RESPAIRE-30
RETAINE MGD
REZAMID
RHOGAM ULTRA-FILTERED PLUS
riboflavin (cap 50 mg, cap 100 mg, tab 25 mg, tab 50 mg, tab 400 mg)
RID ESSENTIAL LICE ELIMINATION
RIGHT STEP PRENATAL
ROBITUSSIN CHILD COUGH/COLD CF
ROBITUSSIN CHILD COUGH/COLD LA
PAGE 83
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
ROBITUSSIN DAY/NIGHT VALUE PAK
ROBITUSSIN NIGHTTIME COUGH DM
ROBITUSSIN PK COLD DAY/NGHT DM
ROBITUSSIN PK COLD DAY/NGHT MS
RU-HIST D
RYMED
SAFE TUSSIN PM
SAFELET IV CATHETER
QL
200 / 30 days
QL
90 / 30 days
QL
200 / 30 days
salicylic acid & sulfur
salicylic acid pad 40%
saline nasal spray 0.65%
salsalate (tab 500 mg, tab 750 mg)
SCALP VEIN SET
SCHOOLTIME SHAMPOO
SCOT-TUSSIN SENIOR
SE-NATAL 19 (19 TAB MG, 19 CHEW TAB MG)
SENNA LEAVES
SENNA SYRUP 176 MG/5ML
sennosides (cap 8.6 mg, chew tab 15 mg, syrup 8.8 mg/5ml, tab 8.6 mg,
tab 15 mg, tab 17.2 mg, tab 25 mg)
sennosides-docusate sodium
simethicone (cap 125 mg, cap 180 mg, chew tab 80 mg, chew tab 125 mg,
liquid 40 mg/0.6ml, susp 40 mg/0.6ml)
SIMILAC PRENATAL EARLY SHIELD
SINADRIN PE COMPLETE SINUS REL
SKIN BEAUTY & WELLNESS
SM CAMPHOR SPIRIT
SM ETHYL ALCOHOL (RUBBING)
SM ISOPROPYL ALCOHOL (SOLUTION 50 %, SOLUTION 70 %,
SOLUTION 91 %)
SM ONE DAILY PRENATAL
SM PRENATAL VITAMINS
PAGE 84
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
SODIUM ASCORBATE GRANULES
sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg)
SODIUM BICARBONATE POWDER
sodium chloride (inhalant) (aero soln, soln nebu)
sodium chloride hypertonic (oint, soln)
sodium chloride tab 1 gm
sodium citrate & citric acid
QL
30 / 30 days
AL1
Up to 10 yrs old
SOLUTION ADMINISTRATION SET
QL
200 / 30 days
SOLUTION TRANSFER DEVICE
QL
200 / 30 days
SPATONE PUR-ABSORB IRON
AL1
Up to 12 yrs old
QL
4 / 30 days
sodium fluoride (chew tab 0.5 mg f 1.1 mg, chew tab 1 mg f 2.2 mg, soln
0.5 mg/ml f 1.1 mg/ml)
sodium fluoride cream 1.1%
SODIUM SILICATE SOLUTION 40 %
soft lens products
STAHIST AD (LIQUID MG/5ML, TAB MG)
stannous fluoride (conc 0.63%, gel 0.4%)
starch (topical)
STEP 2
STERILE LUBRICANT
STRIVERDI RESPIMAT
STUART ONE
SUDAFED PE DAY & NIGHT
sulfacetamide sodium w/ sulfur (cleanser 9.8-4.8%, cleanser 10-2%,
emulsion 10-5%, susp 8-4%, wash 9-4.5%, wash 9-4%)
sulfacetamide sodium-sulfur in urea vehicle
sulfur bar 5%
SUPERVITE EC
SUPPORT
SUPRESS A PEDIATRIC
SUPRESS DM PEDIATRIC
PAGE 85
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
SUPRESS-PE PEDIATRIC
SURE-T INFUSION SET 18"
QL
200 / 30 days
SURE-T INFUSION SET 23"
QL
200 / 30 days
SURE-T INFUSION SET 32"
QL
200 / 30 days
QL
200 / 30 days
QL
120 / 10 days
AL1
Up to 12 yrs old
SYNATEK
SYRINGE LUER SLIP (MISC 25G 5/8" 1 ML, MISC 26G 3/8" 1 ML)
SYRPALTA (RED) SYRUP
SYRPALTA SYRUP
SYRSPEND SF LIQUID
SYSTANE BALANCE
SYSTANE OVERNIGHT THERAPY
TAMIFLU RECON SUSP 6 MG/ML
TANZEUM (PEN 30 MG, PEN 50 MG)
PA
TARON-BC
terbinafine hcl (topical)
TERPIN HYDRATE
TERUMO SURGUARD2 SYRINGE (MISC 25G 5/8" 1 ML, MISC 26G 3/8"
1 ML)
QL
200 / 30 days
tetrahydrozoline hcl (ophth)
tetrahydrozoline w/ polyethylene glycol
tetrahydrozoline w/ zinc sulfate
TGQ 15DM/5PEH/2CPM
TGQ 30PSE/150GFN/15DM
TH PRENATAL VITAMINS
THEO-24 (CAP ER 24H 100 MG, CAP ER 24H 200 MG, CAP ER 24H 300
MG)
THERAFLU COLD & SORE THROAT
THERAFLU FLU & SORE THROAT
THERAFLU MAX-D COLD & FLU
THERAFLU SEVERE COLD & COUGH
PAGE 86
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
THERAFLU SEVERE COLD DAYTIME
THERAFLU SINUS & COLD
THERANATAL COMPLETE
THERANATAL CORE NUTRITION
THERANATAL LACTATION SUPPORT
THERANATAL PLUS
THERAPEUTIC LIQUID
thiamine hcl (tab 50 mg, tab 100 mg)
thyroid (tab 30 mg (1/2, tab 90 mg (1 1/2)
TL G-FOL OS
QL
30 / 30 days
GL
Female
AL1
14 to 50 yrs old
TREXBROM
TRIACTIN CHEST CONGESTION
TRIADVANCE
TRIAMINIC CHEST/NASAL CONGEST
TRIAMINIC COLD/ALLERGY CHILD
TRIAMINIC COLD/COUGH
TRIAMINIC COLD/COUGH DAY TIME (SOLUTION, SYRUP)
TRIAMINIC COUGH & SORE THROAT SYRUP 160-5 MG/5ML
PA
TRIAMINIC COUGH/RUNNY NOSE
C
covered up to age 65,
then PA required
TRIAMINIC COUGH/SORE THROAT
TRIAMINIC NIGHT TIME COLD/CGH
PA
triazolam (tab 0.125 mg, tab 0.25 mg)
C
PA for members over
age 65
TRICARE
TRICODE AR
TRICODE GF
trihexyphenidyl hcl elixir 0.4 mg/ml
TRINATAL GT
PAGE 87
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
TRINATAL RX 1
triprolidine & pseudoephedrine (liquid 0.938-10 mg/ml, tab 2.5-60 mg)
TRISPEC DMX
TRIVEEN-DUO DHA
tropicamide (soln 0.5%, soln 1%)
trypsin w/ castor oil & peruvian balsam
QL
60 / 30 days
QL
200 / 30 days
QL
200 / 30 days
VANISHPOINT 18GX1-1/4" FEP
QL
200 / 30 days
VANISHPOINT 18GX1-1/4" PUR
QL
200 / 30 days
VANISHPOINT 20GX1-1/4" FEP
QL
200 / 30 days
TURPENTINE LIQUID
TUSICOF
TUSNEL (CAP 2-15-200 MG, LIQUID 30-15-200 MG/5ML)
TUSNEL PEDIATRIC LIQUID 15-5-50 MG/5ML
TUSSAFEX-A
TYLENOL CHILDRENS COLD/STUFFY
TYLENOL CHILDRENS PLUS CLD/CGH
ULTICARE SYRINGE MISC 22G X 1-1/2" 1 ML
ULTRA MENS PACK
ULTRA WOMENS PACK
UNDECYLENIC ACID LIQUID
UPCAL D (PACKET MG-UNIT, POWER MG-UNT/5GM)
urea cream 40%
URO-MAG
VACUTAINER TUBING
VANACOF APE
VANACOF DM
VANACOF G
VANACOF GPE
VANACOF-8
VANATAB DX
PAGE 88
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
VANISHPOINT 20GX1-1/4" PUR
QL
200 / 30 days
VANISHPOINT 22GX1" FEP
QL
200 / 30 days
VANISHPOINT 22GX1" PUR
QL
200 / 30 days
VANISHPOINT 24GX3/4" FEP
QL
200 / 30 days
VANISHPOINT 24GX3/4" PUR
QL
200 / 30 days
VANISHPOINT SYRINGE
QL
200 / 30 days
VENATAL-FA
VERSAFREE
VERSAPLUS
VIBRAMYCIN SYRUP 50 MG/5ML
VICKS NATURE FUSION COLD & FLU
VICKS NATURE FUSION CONGEST
VICKS NYQUIL CHILDRENS CLD/CGH
VICKS NYQUIL COLD & FLU NIGHT LIQUID 30-650-4 MG/30ML
VINATE II
VINATE M
VINATE ONE
VIRT-ADVANCE
VIRT-VITE GT
VITAFOL-OB
VITALINE BUFFERED ZINC-220
VITAMENT
VITAMIN C (CALCIUM ASCORBATE)
VITAMIN C SYRUP 500 MG/5ML
VITAMIN C-ELECTROLYTES
vitamin e cap 400 unit
VITAMINS TO GO MAXIMUM
VITAMINS TO GO MEN
VITAMINS TO GO WOMEN
VOL-PLUS
PAGE 89
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
VOL-TAB RX
QL
VYVANSE (CAP 20 MG, CAP 30 MG, CAP 40 MG, CAP 50 MG, CAP 60
MG, CAP 70 MG)
30 / 30 days
ST
AL1
6 to 17 yrs old
QL
1 / 365 days
GL
Female
QL
1 / 365 days
GL
Female
QL
1 / 365 days
GL
Female
QL
1 / 365 days
GL
Female
QL
1 / 365 days
GL
Female
QL
1 / 365 days
GL
Female
QL
1 / 365 days
GL
Female
QL
1 / 365 days
GL
Female
WARM MIST VAPORIZER
WEGMANS COMPLETE PRENATAL+DHA
WESTHROID (TAB 32.5 MG, TAB 48.75 MG, TAB 65 MG, TAB 97.5 MG,
TAB 130 MG, TAB 195 MG)
white petrolatum-mineral oil
WIDE-SEAL DIAPHRAGM 60
WIDE-SEAL DIAPHRAGM 65
WIDE-SEAL DIAPHRAGM 70
WIDE-SEAL DIAPHRAGM 75
WIDE-SEAL DIAPHRAGM 80
WIDE-SEAL DIAPHRAGM 85
WIDE-SEAL DIAPHRAGM 90
WIDE-SEAL DIAPHRAGM 95
WP THYROID (TAB 32.5 MG, TAB 48.75 MG, TAB 65 MG, TAB 97.5 MG,
TAB 130 MG)
YOUR LIFE MULTI PRENATAL
Z-TUSS AC
ZINC 15
ZINC SULFATE (GRANULES, SOLUTION 1 MG/ML, SOLUTION 5
MG/ML)
PAGE 90
LAST UPDATED 01/2016
PRODUCT DESCRIPTION
LIMITS & RESTRICTIONS
ZODRYL AC 25
ZODRYL AC 30
ZODRYL AC 35
ZODRYL AC 40
ZODRYL DAC 25
ZODRYL DAC 30
ZODRYL DAC 35
ZODRYL DAC 40
ZODRYL DEC 25
ZODRYL DEC 30
ZODRYL DEC 35
ZODRYL DEC 40
ZYNCOF
PAGE 91
LAST UPDATED 01/2016
Index of covered drugs
1
AGORAL MAXIMUM STRENGTH
54
AIR ELIMINATING TPN IV SET
54
1ST TIER UNIFINE PENTIPS
40
ALA-HIST PE
54
1ST TIER UNIFINE PENTIPS PLUS
40
albuterol sulfate
51
alclometasone dipropionate
31
ALCOHOL
54
A
abacavir sulfate
20
ALCOHOL (RUBBING)
54
abacavir sulfate-lamivudine-zidovudine
21
ALCOHOL DENATURED
54
ABREVA
53
ALENDRONATE SODIUM
40
acarbose
24
alendronate sodium
40
ACCU-CHEK TENDER 1 INFUSION
53
ALER-DRYL
54
acebutolol hcl
28
alfuzosin hcl
35
ACEROLA C 500
53
ALKA-SELTZER HEARTBURN
54
acetaminophen
53
ALKA-SELTZER PLUS COLD & COUGH
54
8
ALKA-SELTZER PLUS COLD & FLU
54
acetaminophen w/ dm
53
ALKA-SELTZER PLUS DAY/NIGHT
54
acetaminophen-guaifenesin
53
ALKA-SELTZER PLUS NIGHT COLD
54
ALKA-SELTZER PLUS SINUS
54
acetaminophen w/ codeine
acetazolamide
30,50
acetic acid (otic)
50
allopurinol
18
ACETIC ACID-ALUMINUM ACETATE
53
alprazolam
23
ACETONE
53
alum & mag hydrox-simethicone
54
acetylcysteine
52
aluminum hydroxide-mag carb
54
ACIDOPHILUS PLUS PECTIN
53
aluminum hydroxide-mag trisil
54
ACIDOPHILUS/CITRUS PECTIN
53
amantadine hcl
23
ACNE MEDICATION
53
amiloride & hydrochlorothiazide
30
ACTIPHYTE OF LEMONGRASS
53
amiloride hcl
30
ACTONEL
40
amiodarone hcl
27
acyclovir
23
amitriptyline hcl
17
ADMINISTRATION SET
53
amlodipine besylate
29
ADRENACLICK
51
amlodipine besylate-benazepril hcl
29
ADULT ACNOMEL
53
AMMONIUM LACTATE
54
ADULT ASPIRIN LOW STRENGTH
53
AMOXAPINE
17
ADVAIR DISKUS
50
AMOXICILLIN
14
ADVIL ALLERGY & CONGESTION
53
amoxicillin & pot clavulanate
13
ADVIL ALLERGY SINUS
53
AMOXICILLIN-POT CLAVULANATE
14
ADVIL COLD & SINUS LIQUI-GELS
53
amphetamine-dextroamphetamine
26
ADVOCATE INSULIN PEN NEEDLES
40
ampicillin
14
ADVOCATE INSULIN SYRINGE
40
AMPICILLIN
54
AEROSPAN
53
anagrelide hcl
25
AFLURIA
53
anastrozole
10
AFLURIA PRESERVATIVE FREE
53
ANESTHESIA EXTENSION TUBING
54
PAGE 92
LAST UPDATED 01/2016
ANORO ELLIPTA
51
ANTACID
54
B
ANTI-STICK INSULIN SYRINGE
40
b complex w/ c
53
antipyrine-benzocaine
54
b-complex w/ c & calcium
55
APATATE FORTE
54
b-complex w/ c & e + zn
55
APIDRA
24
b-complex w/ c & folic acid
55
APIDRA SOLOSTAR
24
B-NATAL
55
APRISO
39
B1 NATURAL
55
21,22
BACITRACIN
12
APTIVUS
ARGYLE EXTENSION TUBE 20"
54
bacitracin (topical)
55
ARMOUR THYROID
54
bacitracin zinc
55
artificial tear ointment
49
bacitracin-poly-neomycin-hc
12
artificial tear solution
49
bacitracin-polymyxin b (ophth)
12
ascorbic acid
55
baclofen
20
aspirin
55
balsalazide disodium
39
aspirin buffered
55
BD ANGIOCATH AUTOGUARD
55
aspirin buffered (cal carb-mag carb-mag oxide)
55
BD AUTOSHIELD
40
aspirin-acetaminophen-caffeine
55
BD AUTOSHIELD DUO
40
ASSURE DOSE CONTROL
55
BD ECLIPSE SYRINGE
55
ASSURE ID INSULIN SAFETY SYR
40
BD FIRST MIDCATH 18G/4FRX20CM
55
ATABEX
55
BD FIRST MIDCATH 20G/3FRX20CM
56
ATABEX EC
55
BD FIRST PICC 16G/5FRX65CM
56
atenolol
28
BD FIRST PICC 18G/4FRX65CM
56
atenolol & chlorthalidone
28
BD FIRST PICC 20G/3FRX65CM
56
atorvastatin calcium
30
BD FIRST PICC 22G/2.8FRX50CM
56
atovaquone
10
BD FIRST PICC 26G/1.9FRX50CM
56
ATRIPLA
20
BD INSULIN SYR ULTRAFINE II
40
ATROPINE SULFATE
55
BD INSULIN SYRINGE
41
atropine sulfate (ophthalmic)
50
BD INSULIN SYRINGE HALF-UNIT
41
ATROVENT HFA
51
BD INSULIN SYRINGE MICROFINE
41
AURORA PEN NEEDLES
40
BD INSULIN SYRINGE U-40
41
AURORA UNIFINE PENTIPS
40
BD INSULIN SYRINGE ULTRAFINE
41
AUTOJECT 2
55
BD INTEGRA INSULIN SYRINGE
41
AUTOPEN
55
BD INTEGRA SYRINGE
AVONEX
26
BD L-CATH 16G/5FR
56
azathioprine
39
BD L-CATH 16G/5FRX60CM
56
azelastine hcl (ophth)
49
BD L-CATH 18G/3.5FR
56
azithromycin
14
BD L-CATH 18G/3.5FRX60CM
56
AZOLEN TINCTURE
55
BD L-CATH 20G/2.6FR
56
AZOR
29
BD L-CATH 20G/2.6FRX60CM
56
BD L-CATH 20G/3FR
56
PAGE 93
41,56
LAST UPDATED 01/2016
BD L-CATH 20G/3FRX60CM
56
BENZYL BENZOATE
57
BD L-CATH 28G/1.2FRX25CM
56
betamethasone dipropionate (topical)
31
BD L-CATH MIDLINE 18G/3.5FRX20
56
betamethasone dipropionate augmented
31
BD L-CATH MIDLINE 20G/3FRX20CM
56
betamethasone valerate
31
BD LUER-LOK SYRINGE
56
BETASERON
26
BD NEXIVA 18GX1.25"
56
betaxolol hcl (ophth)
50
BD NEXIVA 18GX1.75"
56
bethanechol chloride
35
BD NEXIVA 20GX1"
56
bicalutamide
BD NEXIVA 20GX1.25"
56
BICARSIM
57
BD NEXIVA 20GX1.75"
56
BICARSIM FORTE
57
BD NEXIVA 22GX1"
56
BICILLIN C-R
14
BD NEXIVA 24GX0.56"
56
BICILLIN C-R 900/300
14
BD NEXIVA 24GX0.75"
57
BIMATOPROST
50
BD PEN NEEDLE MINI U/F
41
BIOBRON SF
57
BD PEN NEEDLE NANO U/F
41
BIODESP DM
57
BD PEN NEEDLE SHORT U/F
41
BIONATUSS DXP
57
BD PEN NEEDLE ULTRAFINE
41
BIONEL
57
BD SAF-T E-Z SET
57
BIONEL PEDIATRIC
57
BD SAF-T-INTIMA 18G X 1"
57
BIOSPEC DMX
58
BD SAF-T-INTIMA 20GX1"
57
BIOSUPP
58
BD SAF-T-INTIMA 22G X 0.75"
57
BIOTECT PLUS
58
BD SAF-T-INTIMA 22GX3/4"
57
biotin
58
BD SAF-T-INTIMA 24G X 0.75"
57
BIOTIN ULTRA STRENGTH
58
BD SAF-T-INTIMA 24GX3/4"
57
BIOVOL
58
BD SAFETY-LOK INSULIN SYRINGE
41
bisacodyl
58
BD SAFETY-LOK SET
57
bismuth subsalicylate
58
BD SAFETY-LOK VACUTAINER SET
57
bisoprolol & hydrochlorothiazide
28
BD SAFETYGLIDE INSULIN SYRINGE
41
bisoprolol fumarate
28
BD SYRINGE/NEEDLE
57
BLACK DRAUGHT
58
BD SYRINGE/NEEDLE SLIP TIP
57
BLEPHAMIDE S.O.P.
14
BD VACUTAINER SET
57
BLINK TEARS
58
benazepril & hydrochlorothiazide
27
BP CLEANSING WASH
58
benazepril hcl
27
BPO
58
BENFOTIAMINE
57
BRAINSTRONG PRENATAL
58
BENFOTIAMINE-V
57
BRASIVOL
58
benzocaine (dental)
57
BREO ELLIPTA
51
benzocaine-docusate sodium
57
brimonidine tartrate
50
benzonatate
57
BROHIST D
58
benzoyl peroxide
57
bromocriptine mesylate
19
benztropine mesylate
18
brompheniramine & phenyleph
58
BENZYL ALCOHOL
57
brompheniramine & pseudoeph
58
PAGE 94
9
LAST UPDATED 01/2016
BRONCOTRON PED DROPS
58
CALCIUM PLUS VITAMIN D
59
BRONCOTRON-S
58
calcium polycarbophil
59
BRONKAID
58
calcium w/ magnesium
59
BRONKIDS
58
calcium w/ vitamin d
59
budesonide (inhalation)
51
CALCIUM-MAGNESIUM
59
BUFFERED VITAMIN C
58
CALCIUM-VITAMIN D3
59
BUFFERIN
58
CALCIUM/VITAMIN D3 GUMMIES
59
bumetanide
29
camphor (inhalant)
59
bupropion hcl
16
CAMPHOR SPIRIT
59
bupropion hcl (smoking deterrent)
11
CAPCOF
59
BURIED TREASURE ACTIVE 55 PLUS
58
capecitabine
59
buspirone hcl
23
CAPMIST DM
60
butalbital-acetaminophen
58
CAPRON DM
60
butalbital-acetaminophen-caffeine
58
capsaicin
60
butalbital-acetaminophen-caffeine w/ codeine
26
captopril
27
butalbital-aspirin-caffeine
58
CAPTOPRIL-HYDROCHLOROTHIAZIDE
27
CAPZASIN
60
carbamazepine
16
carbamide peroxide (otic)
60
CARBAPHEN CH
60
butalbital-aspirin-caffeine w/cod
BYSTOLIC
8
28
C
cal carb & mag hydrox-simeth
58
CARBAPHEN PED CH
60
CAL-MAG CHELA-MAX
58
carbidopa
19
CAL-QUICK
59
carbidopa-levodopa
19
CAL/MAG
59
carboxymethylcellulose sodium (ophth)
60
CALCET CREAMY BITES
59
carboxymethylcellulose-glycerin
60
calcitonin (salmon)
40
CAREFINE PEN NEEDLES
41
calcitriol
40
CAREONE INSULIN SYRINGE
41
CALCIUM
59
CAREONE UNIFINE PENTIPS
41
calcium acetate (phosphate binder)
35
CAREONE UNIFINE PENTIPS PLUS
41
calcium carbonate
59
carteolol hcl (ophth)
50
calcium carbonate (antacid)
59
carvedilol
28
CALCIUM CARBONATE ANTACID
59
CCP CAFFEINE FREE
60
calcium carbonate-cholecalciferol
59
cefaclor
13
calcium carbonate-mag hydrox
59
cefadroxil
13
calcium carbonate-simethicone
59
cefdinir
13
calcium carbonate-vitamin d
59
cefpodoxime proxetil
13
CALCIUM CITRATE
59
cefprozil
13
CALCIUM CITRATE MALATE-VIT D
59
CEFTIN
60
CALCIUM CITRATE-VITAMIN D
59
ceftriaxone sodium
13
CALCIUM CITRATE-VITAMIN D3
59
cefuroxime axetil
CALCIUM PANTOTHENATE
59
CELLCEPT
PAGE 95
13,60
39
LAST UPDATED 01/2016
CENTRUM SPECIALIST PRENATAL
60
cimetidine
33
cephalexin
13
cimetidine hcl
33
CERALYTE 70
60
ciprofloxacin hcl
14
CERASPORT
60
CIPROFLOXACIN HCL
61
CERTUSS-D
60
ciprofloxacin hcl (ophth)
14
citalopram hydrobromide
16
cetirizine hcl
50,60
cetirizine-pseudoephedrine
60
CITROCARBONATE
61
CHANTIX
11
clarithromycin
14
CHANTIX CONTINUING MONTH PAK
11
CLASSIC PRENATAL
61
CHANTIX STARTING MONTH PAK
11
CLEARCANAL EAR WAX REMOVAL
61
CHERRY
60
clemastine fumarate
61
CHERRY CONCENTRATE
60
CLEOCIN
12
CHLO TUSS
60
CLICKFINE PEN NEEDLES
41
CHLO TUSS EX
60
clindamycin hcl
12
CHLOPHED
60
clindamycin palmitate hydrochloride
12
chlordiazepoxide hcl
60
clindamycin phosphate (topical)
31
chlordiazepoxide hcl-clidinium bromide
60
clindamycin phosphate vaginal
12
CHLORHEXIDINE GLUCONATE
60
CLINICAL NUTRIENTS PRENATAL
61
chlorhexidine gluconate (mouth-throat)
31
clobetasol propionate
31
CHLOROFORM
60
clomipramine hcl
17
chloroquine phosphate
10
clonazepam
15
chlorothiazide
30
clonidine hcl
27
chlorpheniramine & phenylephrine
60
clopidogrel bisulfate
25
chlorpheniramine & pseudoeph
60
clorazepate dipotassium
23
chlorpheniramine maleate
61
clotrimazole
chlorpheniramine w/ codeine
61
clotrimazole (topical)
chlorpheniramine-acetaminophen
61
clotrimazole vaginal
61
chlorpheniramine-dm
61
clotrimazole w/ betamethasone
35
chlorpheniramine-phenylephrine-acetaminophen
61
clozapine
20
chlorpheniramine-phenylephrine-asa
61
CODAR AR
61
chlorpheniramine-pseudoephedrine-acetaminophen 61
CODAR D
61
chlorpromazine hcl
19
CODEINE SULFATE
CHLORPROPAMIDE
61
CODITUSS DM
61
CHLORTHALIDONE
30
COLCHICINE
18
chlorzoxazone
52
colchicine w/ probenecid
18
cholecalciferol
61
colestipol hcl
30
cholestyramine
30
COLYTE WITH FLAVOR PACKS
33
cholestyramine light
30
COMFORT EZ INSULIN SYRINGE
42
choline & mag salicylate
61
COMFORT EZ PEN NEEDLES
42
COMPLETE FORMULATION PEDIATRIC
61
COMPLETE NATAL DHA
61
ciclopirox
8
cilostazol
25
PAGE 96
9
8,61
8
LAST UPDATED 01/2016
COMPLETE NUTRITIONAL DRINK
61
cyclosporine modified (for microemulsion)
39
COMPLETE PRENATAL/DHA
62
cyproheptadine hcl
50
COMPLETE SINUS RELIEF
62
CYTRA-3
63
COMPLETENATE
62
CONCEPTIONXR MOTILITY SUPPORT
62
D
CONEX COLD/ALLERGY
62
DAILY ENERGY ENFUSION
63
CONTAC COLD+FLU MAX ST
62
DAILY HEART HEALTH SUPPORT
63
CONTAC COLD/FLU DAY & NIGHT
62
DAILY PAK MAXIMUM MULTIVITAMIN
63
COOL MIST HUMIDIFIER
62
DALLERGY
63
CORICIDIN HBP DAY/NIGHT COLD
62
DAPSONE
18
CORICIDIN NIGHTTIME COLD-COUGH
62
DARAPRIM
10
CORNWALL METAL PIPETTING
62
DAYTIME COLD MEDICINE
63
CORRECTOL HERBAL TEA
62
DELTUSS DP
63
CORTISONE ACETATE
35
DELZICOL
63
COTTONSEED OIL
62
DENTURE ADHESIVE
63
CREON
33
DEPO-PROVERA
37
CRIXIVAN
22
DERMA-SMOOTHE/FS BODY
31
cromolyn sodium (nasal)
62
DERMA-SMOOTHE/FS SCALP
31
cromolyn sodium (ophth)
49
DESGEN DM
63
CRYOSERV
62
desmopressin acetate
35
CULTURELLE
62
desmopressin acetate spray
35
CULTURELLE DIGESTIVE HEALTH
62
desmopressin acetate spray refrigerated
36
CULTURELLE HEALTH & WELLNESS
62
desogestrel & ethinyl estradiol
36
CULTURELLE IMMUNITY SUPPORT
62
desogestrel-ethinyl estradiol (triphasic)
36
CURITY ALCOHOL PREPS
12
desonide
31
CVS DIABETES HEALTH SUPPORT
62
DESPEC-DM
63
CVS EAR WAX CLEANSING SYSTEM
62
DEWEES CARMINATIVE
63
CVS ETHYL ALCOHOL
62
dexamethasone
35
CVS ISOPROPYL ALCOHOL
62
DEXAMETHASONE
63
CVS ISOPROPYL RUBBING ALCOHOL
62
DEXAMETHASONE INTENSOL
35
CVS NATURAL FIBER SUPPLEMENT
62
DEXAMETHASONE SODIUM PHOSPHATE
49
CVS PRENATAL
62
dexamethasone sodium phosphate (ophth)
49
CVS PRENATAL GUMMY
62
DEXCHLORPHENIRAMINE MALEATE
63
CVS VITAMIN C
62
dexmethylphenidate hcl
26
CVS WOMENS PRENATAL+DHA
62
DEXPAK 10 DAY
63
cyanocobalamin
62
DEXPAK 13 DAY
63
cyclobenzaprine hcl
52
DEXPAK 6 DAY
63
cyclopentolate hcl
62
dextroamphetamine sulfate
26
CYCLOPHOSPHAMIDE
10
dextromethorphan hbr
63
cyclosporine
39
dextromethorphan-acetaminophen-chlorpheniramine 63
CYCLOSPORINE MODIFIED
39
dextromethorphan-doxylamine-acetaminophen
PAGE 97
63
LAST UPDATED 01/2016
dextromethorphan-guaifenesin
63
DOCUSOL KIDS
64
dextromethorphan-phenylephrine-acetaminophen
63
DOLOGEN
64
DIABETES HEALTH
63
DOMETUSS-DA/CHILDREN
64
DIABETES SUPPORT
63
DOMETUSS-DMX
64
DIABETIC TUSSIN COLD & FLU
63
donepezil hydrochloride
16
DIABETIC TUSSIN NIGHT COLD/FLU
63
DORIBAX
13
DIALYVITE SUPREME D
63
dorzolamide hcl
50
DIAZEPAM
15
dorzolamide hcl-timolol maleate
50
diazepam
23
doxazosin mesylate
35
diclofenac potassium
7
doxepin hcl
23
diclofenac sodium
7
doxycycline (monohydrate)
15
diclofenac sodium (ophth)
49
doxycycline hyclate
15
dicloxacillin sodium
14
doxylamine-dm
64
dicyclomine hcl
33
doxylamine-phenylephrine-acetaminophen
64
didanosine
21
DRAMAMINE
64
dronabinol
17
diflunisal
7
digoxin
29
DRUG MART UNIFINE PENTIPS
42
DILANTIN
16
DRUG MART UNIFINE PENTIPS PLUS
42
diltiazem hcl
29
DUANE READE UNIFINE PENTIPS
42
diltiazem hcl coated beads
29
DULERA
51
diltiazem hcl extended release beads
29
duloxetine hcl
17
dimenhydrinate
63
DURAVENT PE
64
DIMETAPP LONG ACT COUGH/COLD
64
DIMETHYL SULFOXIDE
64
E
DINO-LIFE W/IRON-ZINC
64
E-Z-GAS II
64
diphenhydramine hcl
64
EAR WAX CLEANSING
65
diphenhydramine hcl (sleep)
64
EASIVENT
65
diphenhydramine-acetaminophen
64
EASIVENT MASK LARGE
65
diphenhydramine-acetaminophen (sleep)
64
EASIVENT MASK MEDIUM
65
diphenhydramine-phenylephrine
64
EASIVENT MASK SMALL
65
diphenhydramine-phenylephrine-acetaminophen
64
EASY COMFORT INSULIN SYRINGE
42
diphenhydramine-pseudoephedrine-acetaminophen 64
EASY COMFORT PEN NEEDLES
42
diphenoxylate w/ atropine
33
EASY TOUCH FLURINGE
65
DIPHENOXYLATE-ATROPINE
33
EASY TOUCH INSULIN SAFETY SYR
42
dipyridamole
25
EASY TOUCH INSULIN SYRINGE
42
disopyramide phosphate
27
EASY TOUCH PEN NEEDLES
42
disulfiram
11
EASY TOUCH SAFETY SYRINGE
65
DIURIL
64
econazole nitrate
divalproex sodium
15
ECOTRIN
65
docusate calcium
64
ED CHLORPED
65
docusate sodium
64
ED CHLORPED D
65
PAGE 98
9
LAST UPDATED 01/2016
EDURANT
20
ergocalciferol
65
EFFACLAR DUO
65
erythromycin (acne aid)
14
EFFIENT
25
erythromycin (ophth)
14
ELDERTONIC
65
escitalopram oxalate
17
ELIGARD
38
estazolam
65
ELIPHOS
35
esterified estrogens & methyltestosterone
66
ELITE IRON
65
ESTRACE
36
EMTRIVA
21
estradiol
36
ENABLEX
34
estradiol & norethindrone acetate
36
enalapril maleate
27
estropipate
36
enalapril maleate & hydrochlorothiazide
27
ethambutol hcl
18
ENBREL
39
ETHER
66
ENBREL SURECLICK
39
ethosuximide
15
ENDACON
65
ETHYL ALCOHOL
66
ENERGY BOOSTER
65
ETHYL ALCOHOL (RUBBING)
66
ENFAMIL ENFALYTE
65
ethynodiol diacet & eth estrad
36
ENFAMIL EXPECTA
65
etodolac
enoxaparin sodium
25
EUGENOL
66
entacapone
19
EURAX
10
ENTEX LQ
65
EVAC-U-GEN
66
ENTEX T
65
EXCEL COMFORT POINT PEN NEEDLE
42
ephedrine-guaifenesin
65
EXEL COMFORT POINT INSULIN SYR
43
epinastine hcl (ophth)
49
EXTAVIA
26
EPINEPHRINE
51
EZFE FORTE
66
EPIPEN 2-PAK
51
EPIPEN JR 2-PAK
51
F
EPIVIR
21
famotidine
33
EPIVIR HBV
21
FAMOTIDINE PREMIXED
66
EPOGEN
25
fe fumarate-vitamin c-vitamin b12-folic acid
66
EPZICOM
21
felodipine
29
EQL CALCIUM/VITAMIN D
65
FENESIN DM IR
66
EQL ETHYL ALCOHOL (RUBBING)
65
fenofibrate
30
EQL INSULIN SYRINGE
42
fenofibrate micronized
30
EQL ISOPROPYL ALCOHOL
65
FENOPROFEN CALCIUM
7
EQL PRENATAL FORMULA
65
fentanyl
8
EQL SHORT PEN NEEDLE
42
FER-IN-SOL
66
EQL SUPER ENERGY BOOSTER
65
FERRETTS IPS
66
EQL ULTRA COMFORT INSULIN SYR
42
FERRIMIN 150
66
EQL ULTRA SHORT PEN NEEDLE
42
FERROUS FUMARATE
66
EQL VITAMIN D-3 HIGH POTENCY
65
ferrous fumarate w/ b12-vit c-fa-ifc
66
EQUALACTIN
65
ferrous gluconate
66
PAGE 99
7
LAST UPDATED 01/2016
ferrous sulfate
66
FLURAZEPAM HCL
67
ferrous sulfate dried
66
flurazepam hcl
67
fexofenadine hcl
66
flurbiprofen
FIFTY50 PEN NEEDLES
43
flurbiprofen sodium
49
FIFTY50 SUPERIOR COMFORT SYR
43
flutamide
10
finasteride
35
fluticasone propionate
32
FIRST-LANSOPRAZOLE
66
fluticasone propionate (nasal)
51
FIRST-OMEPRAZOLE
66
FLUVIRIN
67
FIRST-PROGESTERONE VGS 100
66
FLUVIRIN PRESERVATIVE FREE
67
FIRST-PROGESTERONE VGS 200
66
fluvoxamine maleate
17
FIRST-PROGESTERONE VGS 25
66
FLUZONE
67
FIRST-PROGESTERONE VGS 400
67
FLUZONE PEDIATRIC PF
67
FIRST-PROGESTERONE VGS 50
67
FLUZONE PRESERVATIVE FREE
67
FIRST-VANCOMYCIN 25
67
FLUZONE QUADRIVALENT
67
FIRST-VANCOMYCIN 50
67
FML
49
FLAREX
49
FOLGARD OS
68
FLAVOR BLEND
67
folic acid
68
FLAVOR PLUS
67
FORADIL AEROLIZER
51
FLAVOR SWEET
67
FORTAVIT
68
FLAVOR SWEET-SF
67
fosinopril sodium
27
flecainide acetate
27
fosphenytoin sodium
16
FLEET BISACODYL
67
FREDS PHARMACY UNIFINE PENTIP+
43
FLOVENT DISKUS
51
FREDS PHARMACY UNIFINE PENTIPS
43
FLOVENT HFA
51
FREESTYLE CONTROL SOLUTION
68
FLU & SORE THROAT
67
FREESTYLE PRECISION INS SYR
43
FLUARIX
67
FUNGOID TINCTURE
68
FLUARIX QUADRIVALENT
67
furosemide
29
FLUCELVAX
67
fluconazole
9
7
G
fludrocortisone acetate
35
G-DOLOGEN
68
FLUID ADMINISTRATION SET
67
G-P-TUSS DXP
68
FLULAVAL
67
G-TRON PEDIATRIC DROPS
68
FLULAVAL QUADRIVALENT
67
G-TUSICOF
68
flunisolide (nasal)
51
G-ZYNCOF
68
fluocinolone acetonide
31
gabapentin
15
fluocinonide
32
galantamine hydrobromide
16
fluocinonide emulsified base
32
GAS-X EXTRA STRENGTH
68
fluorometholone (ophth)
37
GAUZE SPONGE
32
fluorouracil (topical)
32
GAVISCON
68
fluoxetine hcl
17
GAVISCON EXTRA RELIEF FORMULA
68
fluphenazine hcl
19
gemfibrozil
30
PAGE 100
LAST UPDATED 01/2016
GENTAMICIN SULFATE
12
GRAPE SYRUP
gentamicin sulfate (ophth)
12
griseofulvin microsize
9
gentamicin sulfate (topical)
12
griseofulvin ultramicrosize
9
GENTEAL
68
GUAIACOL
69
GENTEAL SEVERE
68
guaifenesin
69
glatiramer acetate
26
guaifenesin-codeine
69
glimepiride
24
guanfacine hcl
27
glipizide
24
GYNAZOLE-1
69
GLOBAL EASE INJECT PEN NEEDLES
43
GLOBAL INJECT EASE INSULIN SYR
43
H
GLUCAGON EMERGENCY
24
H 468L TUBING
69
GLUCOCARD EXPRESSION CONTROL
68
H-E-B INCONTROL PEN NEEDLES
43
GLUCOCARD EXPRESSION TEST
68
halobetasol propionate
32
GLUCOCARD VITAL TEST
68
haloperidol
19
GLUCOPRO INSULIN SYRINGE
43
haloperidol decanoate
19
glyburide
24
HC DERMAPAX
69
glyburide micronized
24
HEALTHWISE MINI PEN NEEDLES
43
glyburide-metformin
24
HEALTHWISE PEN NEEDLES
43
GLYCERIN
68
HEALTHWISE SHORT PEN NEEDLES
43
glycerin (laxative)
68
HEALTHWISE UNIFINE PENTIPS
44
glycerin (topical)
68
HEALTHY ACCENTS UNIFINE PENTIP
44
glycerin-hypromellose-polyethylene glycol 400
68
HEALTHY MAMA BE WELL ROUNDED
69
GLYCERINE
68
heparin sodium (porcine)
25
GLYCEROL FORMAL
68
HERBAL EXPEC
69
GLYCINE SOYA EXTRACT
68
HEXALEN
GLYCINE SOYA PROTEIN
68
HIGH POTENCY IRON
69
glycopyrrolate
33
HISTEX-DM
69
GNP ALCOHOL DENATURED
68
HISTEX-PE
69
GNP CAPSAICIN
68
HM ETHYL RUBBING ALCOHOL
69
GNP CLICKFINE PEN NEEDLES
43
HM ISOPROPYL ALCOHOL
69
GNP DAILY PRENATAL
68
HM ONE DAILY PRENATAL
69
GNP ETHYL ALCOHOL
69
HM PRENATAL
69
GNP ETHYL RUBBING ALCOHOL
69
homatropine hbr
69
GNP INSULIN SYRINGE
43
HONEY BEARS W/IRON-ZINC
69
GNP ISOPROPYL ALCOHOL
69
HUBER INFUSION SET
69
GNP PEPPERMINT SPIRIT
69
HUMAPEN LUXURA HD
69
GNP PRENATAL
69
HUMATROPEN FOR 12MG
69
GNP SODIUM SILICATE
69
HUMATROPEN FOR 24MG
69
GNP ULTRA COM INSULIN SYRINGE
43
HUMATROPEN FOR 6MG
69
GOLYTELY
33
HUMIRA
39
GOODSENSE PRENATAL VITAMINS
69
HUMIRA PEDIATRIC CROHNS START
39
PAGE 101
69
9
LAST UPDATED 01/2016
HUMIRA PEN
39
INFUSION SET 23" COMFORT
70
HUMIRA PEN-CROHNS STARTER
39
INJECT-EASE
70
HUMIRA PEN-PSORIASIS STARTER
39
INJECT-EASE AUTOMATIC INJECTOR
70
hydralazine hcl
31
INSUFLON
70
hydrochlorothiazide
30
INSULIN SYRINGE
44
HYDROCIL
70
INSULIN SYRINGE/NEEDLE
44
hydrocodone polistirex-chlorpheniramine polistirex
70
INSUPEN PEN NEEDLES
44
hydrocodone w/ homatropine
70
INSUPEN SENSITIVE
44
hydrocodone-acetaminophen
8
INSUPEN ULTRAFIN
44
hydrocortisone
35
INSYTE AUTOGUARD 14GX1.75"
70
hydrocortisone (intrarectal)
40
INSYTE AUTOGUARD 18GX1.16"
70
hydrocortisone (rectal)
32,35
INSYTE AUTOGUARD 20GX1"
70
hydrocortisone (topical)
32,70
INSYTE AUTOGUARD 20GX1.16"
71
hydrocortisone acetate (rectal)
70
INSYTE AUTOGUARD 22GX1"
71
hydrocortisone acetate (topical)
70
INSYTE AUTOGUARD 24GX3/4"
71
hydrocortisone valerate
32
INTELENCE
20
hydrocortisone w/acetic acid
50
INTERLINK INJECT SITE/LUER LOC
71
hydrocortisone-aloe vera
70
INTRON A
22
8
INVIRASE
22
hydroxychloroquine sulfate
10
INVOKANA
71
HYDROXYPROGESTERONE CAPROATE
70
ipratropium bromide
51
ipratropium bromide (nasal)
51
hydromorphone hcl
hydroxyurea
9
hydroxyzine hcl
50
irbesartan
26
HYDROXYZINE PAMOATE
50
irbesartan-hydrochlorothiazide
26
hyoscyamine sulfate
70
IRON (FERROUS GLUCONATE)
71
HYPERRHO S/D
70
iron combinations
71
hypromellose (gonioscopic)
70
iron polysaccharide complex-vit b12-folic acid
71
hypromellose (ophth)
70
IRON UP
71
ISENTRESS
20
isoniazid
18
ISONIAZID
71
I
ibuprofen
7,70
ibuprofen-diphenhydramine citrate
70
ISOPROPANOL
71
imipramine hcl
17
ISOPROPYL ALCOHOL
71
IMMUNE SUPPORT VITAMIN C
70
ISOPROPYL ALCOHOL WIPES
71
IMODIUM A-D
70
ISOPROPYL PALMITATE
71
INATAL ADVANCE
70
ISOPTO TEARS
71
INATAL ULTRA
70
isosorbide dinitrate
31
INCRUSE ELLIPTA
70
ISOSORBIDE DINITRATE ER
31
indapamide
30
isosorbide mononitrate
31
indomethacin
INFUSION SET
PAGE 102
7
70
LAST UPDATED 01/2016
J
lamivudine-zidovudine
21
lamotrigine
16
JANUMET
24
lansoprazole
34
JANUMET XR
24
LANTUS
24
JANUVIA
24
LANTUS SOLOSTAR
24
latanoprost
50
LEADER INSULIN SYRINGE
44
K
K-PHOS
71
LEADER UNIFINE PENTIPS
44
K-PHOS NO 2
71
LEADER UNIFINE PENTIPS PLUS
44
KALA
71
leflunomide
39
KALETRA
22
letrozole
10
KANGAROO BURETTE SET
71
LEUCOVORIN CALCIUM
10
10
ketoconazole
9
leucovorin calcium
ketoconazole (topical)
9
LEUKERAN
9
ketoprofen
7
levetiracetam
15
ketorolac tromethamine
7
levobunolol hcl
50
ketorolac tromethamine (ophth)
49
levocetirizine dihydrochloride
50
KETOSTIX
71
levofloxacin
14
ketotifen fumarate (ophth)
71
LEVONORGESTREL
72
KINRAY INSULIN SYRINGE
44
levonorgestrel & eth estradiol
36
KMART VALU INSULIN SYRINGE 29G
44
levonorgestrel (emergency oc)
72
KMART VALU INSULIN SYRINGE 30G
44
levonorgestrel-eth estradiol (triphasic)
36
KNEE STABILIZER/ELASTIC/SM/MED
71
levonorgestrel-ethinyl estradiol (91-day)
36
KONSYL
71
levothyroxine sodium
38
KONSYL-D
71
LEXIVA
22
KP PRENATAL MULTIVITAMINS
71
LICIDE TREATMENT
72
KPN PRENATAL
71
lidocaine hcl
11
KROGER INSULIN SYRINGE
44
lidocaine hcl (local anesth.)
11
KROGER PEN NEEDLES
44
lidocaine hcl (mouth-throat)
11
lidocaine-prilocaine
11
LIFE PACK MENS
72
L
L606 TUBING
71
lindane
10
L609 TUBING
71
LIQUIMAT
72
labetalol hcl
28
lisinopril
28
lactic acid (ammonium lactate)
32
lisinopril & hydrochlorothiazide
28
lactic acid w/ vitamin e
72
LITE TOUCH PEN NEEDLES
44
lactobacillus acidophilus-pectin
72
LITETOUCH INSULIN SYRINGE
45
lactulose
34
LITETOUCH PEN NEEDLES
45
lactulose (encephalopathy)
34
lithium carbonate
24
lamivudine
21
LITTLE REMEDIES FOR COLDS
72
lamivudine (hbv)
21
LIVE BETTER PEN NEEDLES
45
PAGE 103
LAST UPDATED 01/2016
LODRANE D
72
MAGNESIUM SULFATE
37
LOHIST-D
72
MAGONATE
73
malathion
10
MAR-COF BP
73
LOMUSTINE
LONGS INSULIN SYRINGE
loperamide hcl
9
45
33,72
MATULANE
9
loratadine
72
MAXIMIN PACK
73
loratadine & pseudoephedrine
72
meclizine hcl
17
lorazepam
23
MECLIZINE HCL
73
LORTUSS DM
72
MECLOFENAMATE SODIUM
LORTUSS LQ
72
MEDIC INSULIN SYRINGE
45
losartan potassium
27
MEDICINE SHOPPE PEN NEEDLES
45
losartan potassium & hydrochlorothiazide
26
medroxyprogesterone acetate
38
lovastatin
30
medroxyprogesterone acetate (contraceptive)
38
loxapine succinate
19
MEDSAVER SYRINGE
73
LTXF PRIM CNV PIN MICRODRIP
72
mefloquine hcl
10
LTXF PRIM IV SET/CNVT PIN
72
MEGA BIOTIN
73
LTXF SECONDARY/CNV PIN/32INC
72
MEGA MULTIVITAMIN
73
LUFYLLIN
52
megestrol acetate
38
LUPRON DEPOT
38
MEIJER PEN NEEDLES
45
LUPRON DEPOT-PED
38
meloxicam
M
7
7
MENEST
10
meperidine hcl
73
9
M-END DMX
72
mercaptopurine
M-END MAX D
72
mesalamine
40
M-END PE
72
METAMUCIL
73
M-VIT
72
METAMUCIL SMOOTH TEXTURE
73
M2 POTASSIUM
72
METAPROTERENOL SULFATE
MACRODANTIN
12
metformin hcl
MAG-AL
72
methadone hcl
8,73
MAG-TAB SR
72
METHADOSE
73
MAGELLAN INSULIN SAFETY SYR
45
METHADOSE SUGAR-FREE
73
MAGINEX
72
METHANOL
73
MAGINEX DS
72
methazolamide
30
MAGNESIUM
72
methenamine hippurate
12
MAGNESIUM CARBONATE
73
METHENAMINE MANDELATE
12
MAGNESIUM CARBONATE HEAVY
73
methimazole
38
magnesium chloride
73
methocarbamol
52
MAGNESIUM CITRATE
73
methotrexate sodium
39
magnesium gluconate
73
METHYCLOTHIAZIDE
30
magnesium oxide
73
METHYL ALCOHOL
73
magnesium oxide (mg supplement)
73
methylcellulose (laxative)
73
PAGE 104
52,73
24
LAST UPDATED 01/2016
methyldopa
27
MULTI FOR HER
74
methylergonovine maleate
45
MULTI PRENATAL
74
methylphenidate hcl
26
multiple vitamin
53
methylprednisolone
35
multiple vitamins w/ iron
74
METIPRANOLOL
50
multiple vitamins w/ minerals
74
metoclopramide hcl
33
mupirocin
12
metolazone
30
mupirocin calcium (topical)
12
metoprolol & hydrochlorothiazide
28
mycophenolate mofetil
39
metoprolol succinate
28
MYKIDZ IRON 10
74
metoprolol tartrate
28
MYLERAN
74
metronidazole
12
MYNATAL
74
metronidazole (topical)
12
MYNATAL ADVANCE
74
metronidazole vaginal
12
MYNATAL PLUS
74
MH MACULAR HEALTH
73
MYNATAL-Z
74
MYNATE 90 PLUS
74
MICONAZOLE 3
miconazole nitrate (topical)
miconazole nitrate vaginal
9
73
9,73
N
midodrine hcl
27
nabumetone
7
minocycline hcl
15
nadolol
28
minoxidil
31
naloxone hcl
11
mirtazapine
16
naltrexone hcl
11
misoprostol
34
NANOVM T/F
74
moexipril hcl
28
NAPHAZOLINE HCL
74
mometasone furoate
32
naphazoline w/ pheniramine
74
MONOJECT INSULIN SYRINGE
45
naphazoline-glycerin
74
MONOJECT LIFESHIELD SYRINGE
73
naphazoline-hypromellose
74
MONOJECT MAGELLAN SYRINGE
74
naphazoline-polyethylene glycol 300
74
MONOJECT ULTRA COMFORT SYRINGE
45
NAPRELAN
74
montelukast sodium
51
naproxen
MOORE MONO INSULIN SYRINGE
45
naproxen sodium
7
7,74
MORPHINE SULFATE
8
NASACORT ALLERGY 24HR
51
morphine sulfate
8
NASAL DECONGESTANT
74
MS INSULIN SYRINGE
45
NASOPEN
74
MUCINEX CHILD MS DAY-NIGHT CLD
74
NASOPEN PE
75
MUCINEX COUGH FOR KIDS
74
NAT-RUL PRENATAL VITAMINS
75
MUCINEX D
74
NATALVIT
75
MUCINEX FAST-MAX CONGEST COUGH
74
nateglinide
24
MUCINEX FAST-MAX DAY/NIGHT
74
NATRUL-100
75
MUCINEX FOR KIDS
74
NATURAL SENNA LAXATIVE
75
MUCINEX MAXIMUM STRENGTH
74
NATURE-THROID
75
MUCINEX SINUS-MAX DAY/NIGHT
74
NECON 1/50 (28)
75
PAGE 105
LAST UPDATED 01/2016
NECON 10/11 (28)
36
nifedipine
29
neomycin sulfate
12
nimodipine
29
neomycin-bacitracin zn-polymyxin
12
nit remover
76
neomycin-bacitracin-polymyxin
75
NITE-TIME COLD/FLU RELIEF
76
neomycin-bacitracin-polymyxin w/ lidocaine
75
NITRO-BID
31
neomycin-polymy-dexameth
49
nitrofurantoin macrocrystal
12
neomycin-polymyxin-gramicidin
12
nitrofurantoin monohyd macro
12
NEOMYCIN-POLYMYXIN-HC
12
nitroglycerin
31,76
neomycin-polymyxin-hc (otic)
50
NITROSTAT
31
NEOSPORIN ESSENTIALS TRIAL PK
75
NORDIPEN 5 INJECTION DEVICE
76
NEOTUSS PLUS
75
NORDIPEN DELIVERY SYSTEM
76
NEOTUSS-D
75
NOREL AD
76
NERIA 29G INFUSION SET 10MM
75
norethin acet & estrad-fe
NERIA 29G INFUSION SET 6MM
75
norethindrone & eth estradiol
37
NERIA 29G INFUSION SET 8MM
75
norethindrone (contraceptive)
38
NERIA MULTI 27G 2X10MM
75
norethindrone acet & eth estra
37
NERIA MULTI 27G 3X10MM
75
norethindrone acetate
38
NERIA MULTI 27G 4X12MM
75
norethindrone acetate-ethinyl estradiol
37
NERIA SOFT 25G INFUSION 13MM
75
norethindrone-eth estradiol (triphasic)
37
NERIA SOFT 25G INFUSION 17MM
75
norgestimate-ethinyl estradiol
37
NEUPOGEN
25
norgestimate-ethinyl estradiol (triphasic)
37
NEUTROGENA CLEAR PORE
75
norgestrel & ethinyl estradiol
37
NEVIRAPINE
20
NORPACE CR
27
nevirapine
20
nortriptyline hcl
17
NEXIUM
75
NORVIR
22
NEXIUM 24HR
75
NOVAFERRUM PEDIATRIC DROPS
76
niacin
75
NOVOFINE
45
NIACIN ER
75
NOVOFINE AUTOCOVER
45
NIACINAMIDE
75
NOVOFINE PLUS
45
NIACOR
30
NOVOLIN 70/30
24
nicardipine hcl
29
NOVOLIN 70/30 RELION
25
NICODERM CQ
75
NOVOLIN N
25
NICORETTE
76
NOVOLIN N RELION
25
NICORETTE MINI
76
NOVOLIN R
25
NICORETTE REFILL
76
NOVOLIN R RELION
25
NICORETTE STARTER KIT
76
NOVOLOG MIX 70/30
25
NICOTINE
76
NOVOPEN ECHO
76
NICOTINE MINI
76
NOVOTWIST
45
nicotine polacrilex
76
NULYTELY WITH FLAVOR PACKS
34
NICOTROL
76
nystatin
NICOTROL NS
11
nystatin (mouth-throat)
PAGE 106
36,37
9,53
9
LAST UPDATED 01/2016
nystatin (topical)
9
OVIDE
nystatin-triamcinolone
9
oxaprozin
7
oxazepam
23
oxcarbazepine
16
34
O
11
O-CAL FA
76
oxybutynin chloride
O-CAL PRENATAL
76
oxycodone hcl
OBSTETRIX DHA
76
oxycodone w/ acetaminophen
8
OBSTETRIX EC
76
oxycodone-aspirin
8
OBTREX
76
oxymetazoline hcl
78
OBTREX DHA
77
OXYTROL
34
OC8
77
OXYTROL FOR WOMEN
34
OFLOXACIN
14
OYSTER SHELL CALCIUM/D
78
ofloxacin (ophth)
14
ofloxacin (otic)
14
P
omeprazole
34
PA PRENATAL FORMULA
78
OMEPRAZOLE+SYRSPEND SF ALKA
77
PABA
78
omeprazole-sodium bicarbonate
77
PANCREAZE
33
OMNIFLEX DIAPHRAGM
77
PANCRELIPASE (LIP-PROT-AMYL)
33
OMNITROPE PEN 10 INJ DEVICE
77
pantoprazole sodium
34
OMNITROPE PEN 5 INJ DEVICE
77
paroxetine hcl
17
ondansetron
17
PARVA-CAL
78
ondansetron hcl
18
PC UNIFINE PENTIPS
45
ONE-A-DAY WOMENS PRENATAL
77
PCCA SWEET-SF
78
ONETOUCH ULTRA CONTROL
77
PCCA SYRUP VEHICLE
78
ORA-BLEND
77
PCCA-PLUS
78
ORA-BLEND SF
77
PECGEN DMX
78
ORA-FILM
77
PEDIA-LAX
78
ORA-PLUS
77
pediatric multiple vitamin w/ c
78
ORA-SWEET
77
pediatric multiple vitamin w/ c & fa
78
ORA-SWEET SF
77
pediatric multiple vitamin w/ extra c & fa
78
ORACIT
77
pediatric multiple vitamin w/ minerals & c
78
ORAL MIX
77
pediatric multiple vitamins
78
ORAL MIX SF
77
pediatric multiple vitamins w/ iron
78
ORAL SUSPEND
77
pediatric vitamins acd w/ fluoride
78
ORAL SYRUP
77
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
34
ORAL SYRUP SF
77
peg 3350-potassium chloride-sod bicarbonate-sod
ORAZINC
77
chloride
34
ORTHO DIAPHRAGM ALL-FLEX
77
PEG-INTRON
22
ORTHO DIAPHRAGM COIL
77
PEG-INTRON REDIPEN
22
ORTHO DIAPHRAGM FLAT
78
PEG-INTRON REDIPEN PAK 4
22
OSTEO-PORETICAL
78
PEGINTRON
23
PAGE 107
8,78
LAST UPDATED 01/2016
PEN NEEDLES
45
piroxicam
PEN NEEDLES 1/2"
46
PLAN B
79
PEN NEEDLES 3/16"
46
PLAN B ONE-STEP
79
PEN NEEDLES 5/16"
46
PLASTIC ADAPTER
79
penicillin v potassium
14
PNV FE FUM/DOCUSATE/FOLIC ACID
79
pentoxifylline
29
PNV FOLIC ACID + IRON
80
PEPCID AC MAXIMUM STRENGTH
78
PNV PRENATAL PLUS MULTIVITAMIN
80
PEPPERMINT SPIRIT
78
PNV TABS 29-1
80
PERFECT IRON
78
PNV-VP-U
80
podofilox
32
permethrin
11,78
7
permethrin & pyrethrins-piperonyl butoxide
78
POLY HIST FORTE
80
perphenazine
19
POLY-HIST DM
80
PERRY PRENATAL
78
POLY-HIST PD
80
PERTZYE
33
POLY-TUSSIN
80
phenazopyridine hcl
78
POLY-TUSSIN AC
80
phenelzine sulfate
16
POLY-TUSSIN D
80
PHENOBARBITAL
15
POLY-VENT DM
80
phenyleph-promethazine w/ cod
78
POLY-VENT IR
80
phenylephrine w/ acetaminophen
79
polyethylene glycol 3350
34
phenylephrine w/ dm-gg
79
POLYETHYLENE GLYCOL 3350
80
phenylephrine-acetaminophen-guaifenesin
79
polyethylene glycol-propylene glycol (ophth)
80
phenylephrine-brompheniramine-dm
79
polymyxin b-trimethoprim
12
phenylephrine-chlorphen-dm
79
POLYSORBATE 20
80
phenylephrine-chlorpheniramine-dm w/ apap
79
POLYSORBATE 40
80
POLYSORBATE 60
80
phenylephrine-diphenhydramine-dm-guaifenesinapap
79
POLYSORBATE 80
80
phenylephrine-dm
79
polyvinyl alcohol-povidone (ophth)
80
phenylephrine-dm-gg w/ apap
79
pot phosphate monobasic w/ sod phosphate dibasic &
phenylephrine-doxylamine-dextromethorphan-
monobasic
80
acetaminophen
79
POTABA
80
phenylephrine-guaifenesin
79
potassium bicarb & chloride
80
PHENYLHISTINE DH
79
potassium bicarbonate
80
phenytoin
16
potassium chloride
phenytoin sodium extended
16
POTASSIUM CHLORIDE ER
52
PHLEXY-VITS
79
potassium chloride microencapsulated crystals cr
52
phytonadione
79
potassium citrate-citric acid
80
pilocarpine hcl (oral)
31
povidone-iodine
80
pindolol
28
povidone-iodine vaginal
80
PINE TAR
79
PR NATAL 400
80
pioglitazone hcl
24
PR NATAL 430
80
pioglitazone hcl-metformin hcl
24
pramipexole dihydrochloride
19
PAGE 108
52,80
LAST UPDATED 01/2016
pramoxine-calamine
80
PREPLUS
81
pramoxine-phenylephrine-glycerin-petrolatum
80
PRESCRIPTIVE FORMULAS MENS
81
pravastatin sodium
30
PRESCRIPTIVE FORMULAS WOMENS
81
prazosin hcl
27
PRETAB
81
PRE-NATAL FORMULA
81
PRETZ
81
PRECISION SURE-DOSE SYRINGE
46
PREZISTA
22
PRECISION SUREDOSE PLUS SYR
46
PRILOSEC OTC
81
PRECISION XTRA KETONE
81
PRIMAQUINE PHOSPHATE
10
prednicarbate
32
primidone
15
prednisolone
35
PRIMSOL
81
prednisolone acetate (ophth)
49
PRO-CHLO
82
prednisolone sodium phosphate
35
PRO-CLEAR AC
82
PREDNISOLONE SODIUM PHOSPHATE
49
PRO-RED AC
82
prednisone
35
probenecid
18
PREDNISONE (PAK)
35
prochlorperazine
19
PREFERRED PLUS INSULIN SYRINGE
46
prochlorperazine maleate
19
PREFERRED PLUS UNIFINE PENTIPS
46
PROCRIT
25
PREMARIN
37
PRODIGY INSULIN SYRINGE
46
PREMIUM PACKETS
81
PROFE FORTE
82
PREMPHASE
37
PROFERRIN ES
82
PREMPRO
37
promethazine & phenylephrine
52
PRENAPLUS
81
promethazine hcl
17
PRENATA
81
promethazine w/codeine
82
PRENATABS FA
81
promethazine-dm
82
PRENATABS RX
81
propafenone hcl
27
PRENATAL
81
PROPANTHELINE BROMIDE
82
PRENATAL 19
81
proparacaine hcl
49
PRENATAL COMPLETE
81
propranolol hcl
28
PRENATAL FORMULA
81
PROPRANOLOL HCL
82
PRENATAL FORMULA A-FREE
81
PROPRANOLOL-HCTZ
28
PRENATAL LOW IRON
81
propylene glycol-glycerin
82
PRENATAL MULTI +DHA
81
propylthiouracil
38
PRENATAL MULTIVITAMIN + DHA
81
PROTECT PLUS NF
82
PRENATAL ONE DAILY
81
pseudoeph-cpm-dm w/apap
82
PRENATAL PLUS
81
pseudoephed-bromphen-dm
82
PRENATAL PLUS IRON
81
pseudoephed-doxyl-dm w/apap
82
PRENATAL VITAMINS
81
pseudoephedrine hcl
82
PRENATAL+DHA
81
pseudoephedrine w/ codeine-gg
82
PRENATAL-U
81
pseudoephedrine w/ dm-gg
82
PRENATAL/IRON
81
pseudoephedrine-acetaminophen
82
PRENATAL/OMEGA-3/FA/IRON
81
pseudoephedrine-acetaminophen-dextromethorphan82
PAGE 109
LAST UPDATED 01/2016
pseudoephedrine-brompheniramine-codeine
82
RA ESSENCE-C
83
pseudoephedrine-chlophedianol-guaifenesin
82
RA ETHYL ALCOHOL
83
pseudoephedrine-chlorphen-dm
82
RA INSULIN SYRINGE
46
RA ONE DAILY
83
RA PEN NEEDLES
46
RA PRENATAL
83
pseudoephedrine-dexchlorpheniraminechlophedianol
82
pseudoephedrine-dexchlorpheniraminedextromethorphan
82
RA PRENATAL FORMULA
83
pseudoephedrine-dm-gg w/ apap
82
ramipril
28
pseudoephedrine-guaifenesin
82
ranitidine hcl
33
pseudoephedrine-ibuprofen
82
REFRESH OPTIVE ADVANCED
83
pseudoephedrine-naproxen sodium
83
RELENZA DISKHALER
23
psyllium
83
RELI-ON INSULIN SYRINGE
46
PULMOZYME
52
RELION INSULIN SYRINGE
46
PUREFE OB PLUS
83
RELION MINI PEN NEEDLES
46
PX EXTRA SHORT PEN NEEDLES
46
RELION PEN NEEDLES
46
PX INSULIN SYRINGE
46
RELION SHORT PEN NEEDLES
47
PX MINI PEN NEEDLES
46
RENAGEL
83
PX PEN NEEDLE
46
RESCON DM
83
pyrantel pamoate
83
RESCRIPTOR
20
pyrazinamide
18
RESPAIRE-30
83
pyrethrins-piperonyl butoxide
83
RETAINE MGD
83
pyrethrins-piperonyl butoxide-permethrin-nit remover 83
REYATAZ
22
pyridoxine hcl
83
REZAMID
83
pyrilamine maleate-phenylephrine hcl tannate
83
RHOGAM ULTRA-FILTERED PLUS
83
pyrilamine-phenylephrine
83
ribavirin (hepatitis c)
23
riboflavin
83
RID ESSENTIAL LICE ELIMINATION
83
Q
QC ISOPROPYL RUBBING ALCOHOL
83
rifampin
18
QC PEN NEEDLES
46
RIFATER
18
QC UNIFINE PENTIPS
46
RIGHT STEP PRENATAL
83
quetiapine fumarate
19
rimantadine hydrochloride
23
quinapril hcl
28
risperidone
19
quinapril-hydrochlorothiazide
28
rizatriptan benzoate
18
quinidine gluconate
27
ROBITUSSIN CHILD COUGH/COLD CF
83
QUINIDINE SULFATE
27
ROBITUSSIN CHILD COUGH/COLD LA
83
quinine sulfate
10
ROBITUSSIN DAY/NIGHT VALUE PAK
84
ROBITUSSIN NIGHTTIME COUGH DM
84
ROBITUSSIN PK COLD DAY/NGHT DM
84
R
RA ACNE MAXIMUM
83
ROBITUSSIN PK COLD DAY/NGHT MS
84
RA CALCIUM-BORON
83
ropinirole hydrochloride
19
RA EAR WAX CLEANSING SYSTEM
83
RU-HIST D
84
PAGE 110
LAST UPDATED 01/2016
RYMED
84
S
SM PRENATAL VITAMINS
84
SODIUM ASCORBATE
85
SODIUM BICARBONATE
85
85
SAFE TUSSIN PM
84
sodium bicarbonate (antacid)
SAFELET IV CATHETER
84
sodium chloride
SAFESNAP INSULIN SYRINGE
47
sodium chloride (gu irrigant)
47
SAFETY-GLIDE SYRINGE
47
sodium chloride (inhalant)
85
salicylic acid
84
sodium chloride flush
53
salicylic acid & sulfur
84
sodium chloride hypertonic
85
saline
84
sodium citrate & citric acid
85
salsalate
84
sodium fluoride
85
SANTYL
32
sodium fluoride (dental)
85
SB INSULIN SYRINGE
47
sodium polystyrene sulfonate
52
SCALP VEIN SET
84
SODIUM SILICATE
85
SCHNUCKS INSULIN SYRINGE
47
soft lens products
85
SCHOOLTIME SHAMPOO
84
SOLUTION ADMINISTRATION SET
85
SCOT-TUSSIN SENIOR
84
SOLUTION TRANSFER DEVICE
85
SE-NATAL 19
84
sotalol hcl
27
selegiline hcl
19
sotalol hcl (afib/afl)
27
selenium sulfide
32
SPATONE PUR-ABSORB IRON
85
SELZENTRY
21
spironolactone
30
SENNA
84
spironolactone & hydrochlorothiazide
30
SENNA LEAVES
84
STAHIST AD
85
sennosides
84
stannous fluoride
85
sennosides-docusate sodium
84
starch (topical)
85
SENSIPAR
38
stavudine
21
SEREVENT DISKUS
52
STEP 2
85
sertraline hcl
17
STERILE LUBRICANT
85
SFROWASA
40
STRIBILD
20
SHOPKO UNIFINE PENTIPS
47
STRIVERDI RESPIMAT
85
silver sulfadiazine
12
STUART ONE
85
simethicone
84
sucralfate
34
SIMILAC PRENATAL EARLY SHIELD
84
SUDAFED PE DAY & NIGHT
85
simvastatin
30
sulfacetamide sod-prednisolone
14
SINADRIN PE COMPLETE SINUS REL
84
sulfacetamide sodium (acne)
32
SKIN BEAUTY & WELLNESS
84
sulfacetamide sodium (ophth)
14
SM CAMPHOR SPIRIT
84
sulfacetamide sodium w/ sulfur
85
SM ETHYL ALCOHOL (RUBBING)
84
sulfacetamide sodium-sulfur in urea vehicle
85
SM INSULIN SYRINGE
47
SULFADIAZINE
15
SM ISOPROPYL ALCOHOL
84
sulfamethoxazole-trimethoprim
15
SM ONE DAILY PRENATAL
84
sulfasalazine
40
PAGE 111
53,85
LAST UPDATED 01/2016
sulfur
sulindac
85
terconazole vaginal
9
7
TERPIN HYDRATE
86
sumatriptan succinate
18
TERUMO INSULIN SYRINGE
47
SUPERVITE EC
85
TERUMO SURGUARD INSULIN SYR
47
SUPPORT
85
TERUMO SURGUARD2 SYRINGE
86
SUPRESS A PEDIATRIC
85
testosterone cypionate
36
SUPRESS DM PEDIATRIC
85
tetrahydrozoline hcl (ophth)
86
SUPRESS-PE PEDIATRIC
86
tetrahydrozoline w/ polyethylene glycol
86
SURE COMFORT INSULIN SYRINGE
47
tetrahydrozoline w/ zinc sulfate
86
SURE COMFORT PEN NEEDLES
47
TGQ 15DM/5PEH/2CPM
86
SURE-FINE PEN NEEDLES
47
TGQ 30PSE/150GFN/15DM
86
SURE-JECT INSULIN SYRINGE
47
TH PRENATAL VITAMINS
86
SURE-T INFUSION SET 18"
86
THEO-24
86
SURE-T INFUSION SET 23"
86
theophylline
52
SURE-T INFUSION SET 32"
86
THERAFLU COLD & SORE THROAT
86
SURGICAL DRESSING
32
THERAFLU FLU & SORE THROAT
86
SUSTIVA
20
THERAFLU MAX-D COLD & FLU
86
SYMBICORT
51
THERAFLU SEVERE COLD & COUGH
86
SYNAGIS
39
THERAFLU SEVERE COLD DAYTIME
87
SYNATEK
86
THERAFLU SINUS & COLD
87
SYNTHROID
38
THERANATAL COMPLETE
87
SYRINGE LUER SLIP
86
THERANATAL CORE NUTRITION
87
SYRPALTA
86
THERANATAL LACTATION SUPPORT
87
SYRPALTA (RED)
86
THERANATAL PLUS
87
SYRSPEND SF
86
THERAPEUTIC LIQUID
87
SYSTANE BALANCE
86
thiamine hcl
87
SYSTANE OVERNIGHT THERAPY
86
THINPRO INSULIN SYRINGE
47
thiothixene
19
thyroid
87
ticlopidine hcl
25
TIMOLOL MALEATE
18
timolol maleate (ophth)
50
T
TABLOID
9
tacrolimus
39
TAMIFLU
23,86
tamoxifen citrate
10
tizanidine hcl
20
tamsulosin hcl
35
TL G-FOL OS
87
TANZEUM
86
tobramycin (ophth)
12
TARON-BC
86
tobramycin-dexamethasone
49
temazepam
23
TODAYS HEALTH MINI PEN NEEDLES
47
terazosin hcl
35
TODAYS HEALTH PEN NEEDLES
47
TODAYS HEALTH SHORT PEN NEEDLE
47
terbinafine hcl
9
terbinafine hcl (topical)
86
tolterodine tartrate
34
terbutaline sulfate
52
TOPCARE CLICKFINE PEN NEEDLES
48
PAGE 112
LAST UPDATED 01/2016
TOPCARE ULTRA COMFORT INS SYR
48
TRIVEEN-DUO DHA
88
topiramate
16
tropicamide
88
torsemide
29
trospium chloride
34
TOUJEO SOLOSTAR
25
TRUEPLUS INSULIN SYRINGE
48
TOVIAZ
34
TRUVADA
21
trypsin w/ castor oil & peruvian balsam
88
tramadol hcl
8
trandolapril
28
TUDORZA PRESSAIR
51
tranylcypromine sulfate
16
TURPENTINE
88
TRAVOPROST
50
TUSICOF
88
trazodone hcl
16
TUSNEL
88
TRECATOR
18
TUSNEL PEDIATRIC
88
tretinoin
32
TUSSAFEX-A
88
tretinoin (chemotherapy)
10
TYLENOL CHILDRENS COLD/STUFFY
88
TREXBROM
87
TYLENOL CHILDRENS PLUS CLD/CGH
88
TRIACTIN CHEST CONGESTION
87
TRIADVANCE
87
U
TRIAMCINOLONE ACETONIDE
32
ULTICARE INSULIN SAFETY SYR
48
triamcinolone acetonide (mouth)
31
ULTICARE INSULIN SYRINGE
48
triamcinolone acetonide (topical)
32
ULTICARE MICRO PEN NEEDLES
48
TRIAMINIC CHEST/NASAL CONGEST
87
ULTICARE MINI PEN NEEDLES
48
TRIAMINIC COLD/ALLERGY CHILD
87
ULTICARE PEN NEEDLES
48
TRIAMINIC COLD/COUGH
87
ULTICARE SHORT PEN NEEDLES
48
TRIAMINIC COLD/COUGH DAY TIME
87
ULTICARE SYRINGE
88
TRIAMINIC COUGH & SORE THROAT
87
ULTILET INSULIN SYRINGE SHORT
48
TRIAMINIC COUGH/RUNNY NOSE
87
ULTILET PEN NEEDLE
48
TRIAMINIC COUGH/SORE THROAT
87
ULTRA COMFORT INSULIN SYRINGE
48
TRIAMINIC NIGHT TIME COLD/CGH
87
ULTRA MENS PACK
88
triamterene & hydrochlorothiazide
30
ULTRA WOMENS PACK
88
triazolam
87
ULTRA-COMFORT INSULIN SYRINGE
48
TRICARE
87
ULTRA-THIN II INS SYR SHORT
48
TRICODE AR
87
ULTRESA
33
TRICODE GF
87
UNDECYLENIC ACID
88
trifluoperazine hcl
19
UNIFINE PENTIPS
48
trifluridine
23
UNIFINE PENTIPS PLUS
48
UPCAL D
88
trihexyphenidyl hcl
18,87
trimethobenzamide hcl
17
urea
88
trimethoprim
13
URO-MAG
88
TRINATAL GT
87
ursodiol
33
TRINATAL RX 1
88
triprolidine & pseudoephedrine
88
V
TRISPEC DMX
88
V-R MONO INSULIN SYRINGE
PAGE 113
48
LAST UPDATED 01/2016
VACUTAINER TUBING
88
VIRACEPT
22
valacyclovir hcl
23
VIRAMUNE
20
valproate sodium
15
VIREAD
21
valproic acid
18
VIRT-ADVANCE
89
VALUE HEALTH INSULIN SYRINGE
48
VIRT-VITE GT
89
VALUMARK PEN NEEDLES
48
VITAFOL-OB
89
VANACOF APE
88
VITALINE BUFFERED ZINC-220
89
VANACOF DM
88
VITAMENT
89
VANACOF G
88
VITAMIN C
89
VANACOF GPE
88
VITAMIN C (CALCIUM ASCORBATE)
89
VANACOF-8
88
VITAMIN C-ELECTROLYTES
89
VANATAB DX
88
vitamin e
89
vancomycin hcl
13
VITAMINS TO GO MAXIMUM
89
VANISHPOINT 18GX1-1/4" FEP
88
VITAMINS TO GO MEN
89
VANISHPOINT 18GX1-1/4" PUR
88
VITAMINS TO GO WOMEN
89
VANISHPOINT 20GX1-1/4" FEP
88
VOL-PLUS
89
VANISHPOINT 20GX1-1/4" PUR
89
VOL-TAB RX
90
VANISHPOINT 22GX1" FEP
89
VP INSULIN SYRINGE
49
VANISHPOINT 22GX1" PUR
89
VYVANSE
90
VANISHPOINT 24GX3/4" FEP
89
VANISHPOINT 24GX3/4" PUR
89
W
VANISHPOINT INSULIN SYRINGE
49
warfarin sodium
25
VANISHPOINT SYRINGE
89
WARM MIST VAPORIZER
90
VENATAL-FA
89
water for irrigation, sterile
49
venlafaxine hcl
17
WEGMANS COMPLETE PRENATAL+DHA
90
VENTOLIN HFA
52
WEGMANS UNIFINE PENTIPS PLUS
49
verapamil hcl
29
WESTHROID
90
VERSAFREE
89
white petrolatum-mineral oil
90
VERSAPLUS
89
WIDE-SEAL DIAPHRAGM 60
90
VESICARE
35
WIDE-SEAL DIAPHRAGM 65
90
VIBRAMYCIN
89
WIDE-SEAL DIAPHRAGM 70
90
VICKS NATURE FUSION COLD & FLU
89
WIDE-SEAL DIAPHRAGM 75
90
VICKS NATURE FUSION CONGEST
89
WIDE-SEAL DIAPHRAGM 80
90
VICKS NYQUIL CHILDRENS CLD/CGH
89
WIDE-SEAL DIAPHRAGM 85
90
VICKS NYQUIL COLD & FLU NIGHT
89
WIDE-SEAL DIAPHRAGM 90
90
VIDA MIA UNIFINE PENTIPS
49
WIDE-SEAL DIAPHRAGM 95
90
VIDEX
21
WP THYROID
90
VINATE II
89
VINATE M
89
X
VINATE ONE
89
XARELTO
VIOKACE
33
PAGE 114
25
LAST UPDATED 01/2016
Y
YOUR LIFE MULTI PRENATAL
90
Z
Z-TUSS AC
90
zaleplon
52
ZAMICET
8
ZENPEP
33
ZIAGEN
21
zidovudine
21
ZINC 15
90
ZINC SULFATE
90
ziprasidone hcl
20
ZODRYL AC 25
91
ZODRYL AC 30
91
ZODRYL AC 35
91
ZODRYL AC 40
91
ZODRYL DAC 25
91
ZODRYL DAC 30
91
ZODRYL DAC 35
91
ZODRYL DAC 40
91
ZODRYL DEC 25
91
ZODRYL DEC 30
91
ZODRYL DEC 35
91
ZODRYL DEC 40
91
zolpidem tartrate
52
zonisamide
15
ZOSTAVAX
39
ZOVIA 1/50E (28)
37
ZYNCOF
91
PAGE 115
LAST UPDATED 01/2016