aetna better health of virginia ccc plus formulary guide ... · if drug a does not work for you,...

AETNA BETTER HEALTH®CCC Plus Formulary Guide

Aetna Better Health of VirginiaCCC Plus Formulary Guide

August 2017

http://www.aetnabetterhealth.com/Virginia

Updated: 08/2017 Page | 1

http://www.aetnabetterhealth.com/Virginia


What is the Aetna Better Health of Virginia Formulary?

This is a drug list created by Aetna Better Health of Virginia. The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy.

Can the Plan’s Drug List change?

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

How do I use the Plan’s Formulary?

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

• Column #2: shows brand drug for the generic; brand drugs are not covered ifgeneric equivalent is available.

• Column #3: tells you if drug has a need for prior authorization or other restrictions

Drugs are also grouped by drug class. If you know what class your drug is in, please look for that class name in the table of contents. Then look under that page for your drug.

What are generic drugs?

The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA).

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

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

Are there Medication Copays?

Refer to member handbook for copay information.

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What are some types of coverage rules?

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

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

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

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

First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then:

• Ask your doctor for a similar drug that is covered. • Your doctor can ask the plan to cover your drug through the prior approval process.

Updated: 08/2017

Aetna Better Health of Virginia CCC Plus

Table of Contents

*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................................3*ALTERNATIVE MEDICINES*............................................................................................................................. 5*AMINOGLYCOSIDES*......................................................................................................................................... 5*ANALGESICS - ANTI-INFLAMMATORY*........................................................................................................ 5*ANALGESICS - NONNARCOTIC*.....................................................................................................................11*ANALGESICS - OPIOID*.................................................................................................................................... 21*ANDROGENS-ANABOLIC*............................................................................................................................... 24*ANORECTAL AGENTS*.....................................................................................................................................25*ANTACIDS*..........................................................................................................................................................26*ANTHELMINTICS*............................................................................................................................................. 29*ANTIANGINAL AGENTS*................................................................................................................................. 29*ANTIANXIETY AGENTS*..................................................................................................................................30*ANTIARRHYTHMICS*....................................................................................................................................... 31*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*............................................................................ 31*ANTICOAGULANTS*......................................................................................................................................... 34*ANTICONVULSANTS*.......................................................................................................................................35*ANTIDEPRESSANTS*.........................................................................................................................................37*ANTIDIABETICS*............................................................................................................................................... 39*ANTIDIARRHEALS*...........................................................................................................................................44*ANTIDOTES*....................................................................................................................................................... 45*ANTIEMETICS*................................................................................................................................................... 45*ANTIFUNGALS*..................................................................................................................................................47*ANTIHISTAMINES*............................................................................................................................................ 48*ANTIHYPERLIPIDEMICS*.................................................................................................................................54*ANTIHYPERTENSIVES*.................................................................................................................................... 55*ANTI-INFECTIVE AGENTS - MISC.*............................................................................................................... 58*ANTIMALARIALS*.............................................................................................................................................59*ANTIMYASTHENIC AGENTS*......................................................................................................................... 59*ANTIMYASTHENIC/CHOLINERGIC AGENTS*............................................................................................. 59*ANTIMYCOBACTERIAL AGENTS*................................................................................................................. 60*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*................................................................................60*ANTI-OBESITY AGENT COMBINATIONS**..................................................................................................62*ANTIPARKINSON AGENTS*.............................................................................................................................62*ANTIPSYCHOTICS/ANTIMANIC AGENTS*................................................................................................... 63*ANTIRETROVIRALS ADJUVANTS***............................................................................................................ 66*ANTISEPTICS & DISINFECTANTS*.................................................................................................................66*ANTIVIRALS*......................................................................................................................................................66*ASSORTED CLASSES*....................................................................................................................................... 70*BETA BLOCKERS*............................................................................................................................................. 71*CALCIUM CHANNEL BLOCKERS*................................................................................................................. 72*CARDIOTONICS*................................................................................................................................................ 74*CARDIOVASCULAR AGENTS - MISC.*.......................................................................................................... 74*CEPHALOSPORINS*...........................................................................................................................................75*CHEMICALS*.......................................................................................................................................................76

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*CONTRACEPTIVES*...........................................................................................................................................77*CORTICOSTEROIDS*......................................................................................................................................... 85*COUGH/COLD/ALLERGY*................................................................................................................................85*DERMATOLOGICALS*...................................................................................................................................... 97*DIAGNOSTIC PRODUCTS*..............................................................................................................................122*DIGESTIVE AIDS*.............................................................................................................................................123*DIRECT-ACTING P2Y12 INHIBITORS***..................................................................................................... 124*DIURETICS*.......................................................................................................................................................124*ENDOCRINE AND METABOLIC AGENTS - MISC.*....................................................................................125*ESTROGENS*.....................................................................................................................................................126*FLUOROQUINOLONES*.................................................................................................................................. 127*GASTROINTESTINAL AGENTS - MISC.*......................................................................................................128*GENITOURINARY AGENTS - MISCELLANEOUS*..................................................................................... 131*GOUT AGENTS*................................................................................................................................................132*HEMATOLOGICAL AGENTS - MISC.*.......................................................................................................... 132*HEMATOPOIETIC AGENTS*...........................................................................................................................133*HEPATITIS C AGENT - COMBINATIONS***............................................................................................... 136*HYPNOTICS*..................................................................................................................................................... 136*LAXATIVES*..................................................................................................................................................... 138*MACROLIDES*..................................................................................................................................................141*MEDICAL DEVICES*........................................................................................................................................142*MIGRAINE PRODUCTS*..................................................................................................................................189*MINERALS & ELECTROLYTES*....................................................................................................................190*MOUTH/THROAT/DENTAL AGENTS*..........................................................................................................197*MULTIVITAMINS*............................................................................................................................................198*MUSCULOSKELETAL THERAPY AGENTS*................................................................................................217*NASAL AGENTS - SYSTEMIC AND TOPICAL*........................................................................................... 218*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***........................................... 219*NEUROMUSCULAR AGENTS*....................................................................................................................... 219*NUTRIENTS*......................................................................................................................................................220*OPHTHALMIC AGENTS*.................................................................................................................................222*OTIC AGENTS*..................................................................................................................................................228*PASSIVE IMMUNIZING AGENTS*.................................................................................................................229*PENICILLINS*....................................................................................................................................................230*PHARMACEUTICAL ADJUVANTS*.............................................................................................................. 231*POTASSIUM REMOVING AGENTS***..........................................................................................................240*PROGESTINS*....................................................................................................................................................240*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*........................................................241*RESPIRATORY AGENTS - MISC.*..................................................................................................................246*SEROTONIN MODULATORS***.................................................................................................................... 246*SULFONAMIDES*.............................................................................................................................................246*TETRACYCLINES*........................................................................................................................................... 246*THYROID AGENTS*......................................................................................................................................... 247*ULCER DRUGS*................................................................................................................................................ 248*URINARY ANTI-INFECTIVES*.......................................................................................................................253*URINARY ANTISPASMODICS*......................................................................................................................254*VAGINAL PRODUCTS*....................................................................................................................................255*VASOPRESSORS*............................................................................................................................................. 256*VITAMINS*........................................................................................................................................................ 256

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Aetna Better Health of Virginia CCC Plus

CURRENT AS OF 8/1/2017

Formulary Drug Name Reference Restrictions *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 MG CloNIDine HCl ER PA; ST; AL (Max 18 Years)

*Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG

Atomoxetine HCl AL (Max 18 Years)

*Amphetamine Mixtures*** amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

Adderall AL (Min 3 Years and Max 18 Years)

ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG

Amphetamine-Dextroamphet ER

ST; AL (Min 6 Years and Max 18 Years)

*Amphetamines*** dextroamphetamine sulfate oral tablet 10 mg, 5 mg Zenzedi AL (Min 6 Years and Max 18

Years) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

AL (Min 6 Years and Max 18 Years)

ZENZEDI ORAL TABLET 10 MG, 5 MG Dextroamphetamine Sulfate

*Analeptics*** caffeine anhydrous powder caffeine citrate oral solution 20 mg/ml, 60 mg/3ml caffeine citrated powder

3

Formulary Drug Name Reference Restrictions *Anorexiant Combinations*** QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG

PA; QLL (1 EA per 1 day); AL (Min 18 Years)

*Anorexiants Non-Amphetamine***

benzphetamine hcl oral tablet 25 mg Regimex PA; QLL (3 EA per 1 day); AL (Min 12 Years)

benzphetamine hcl oral tablet 50 mg Didrex PA; QLL (3 EA per 1 day); AL (Min 12 Years)

diethylpropion hcl er oral tablet extended release 24 hour 75 mg


diethylpropion hcl oral tablet 25 mg PA; QLL (3 EA per 1 day); AL (Min 17 Years)

phendimetrazine tartrate oral tablet 35 mg PA; QLL (3 EA per 1 day); AL (Min 17 Years)

phentermine hcl oral capsule 15 mg PA; QLL (2 EA per 1 day); AL (Min 16 Years)

phentermine hcl oral capsule 30 mg PA; QLL (1 EA per 1 day); AL (Min 16 Years)

phentermine hcl oral capsule 37.5 mg Adipex-P PA; QLL (1 EA per 1 day); AL (Min 16 Years)

phentermine hcl oral tablet 37.5 mg Adipex-P PA; QLL (1 EA per 1 day); AL (Min 16 Years)

*Lipase Inhibitors***

ALLI ORAL CAPSULE 60 MG PA; OTC; QLL (6 EA per 1 day); AL (Min 12 Years)

*Serotonin 2C Receptor Agonists***

BELVIQ ORAL TABLET 10 MG PA; QLL (2 EA per 1 day); AL (Min 18 Years)

*Stimulants - Misc.*** methylphenidate hcl er oral tablet extended release 10 mg


methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg Concerta AL (Min 6 Years and Max 18

Years) methylphenidate hcl er oral tablet extended release 20 mg Metadate ER AL (Min 6 Years and Max 18

Years) methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg


methylphenidate hcl oral tablet 10 mg Ritalin AL (Min 6 Years) methylphenidate hcl oral tablet 20 mg Ritalin AL (Min 18 Years)

methylphenidate hcl oral tablet 5 mg Ritalin AL (Min 3 Years and Max 18 Years)

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Formulary Drug Name Reference Restrictions DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR


FOCALIN ORAL TABLET 2.5 MG, 5 MG Dexmethylphenidate HCl AL (Min 6 Years and Max 18 Years)

FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG

Dexmethylphenidate HCl ER AL (Min 6 Years and Max 18 Years)

QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG


QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED 25 MG/5ML


*ALTERNATIVE MEDICINES* *Alternative Medicine - St's*** stevia oral packet 100 mg OTC

*AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML

QLL (224 ML per 28 days); AL (Min 6 Years)

KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML

Tobramycin

TOBI PODHALER INHALATION CAPSULE 28 MG

ST; QLL (224 EA per 28 days); AL (Min 6 Years)

*ANALGESICS - ANTI-INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

AL (Min 2 Years)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML AL (Min 2 Years)

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

AL (Min 2 Years)

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Formulary Drug Name Reference Restrictions HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

AL (Min 2 Years)

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML

AL (Min 2 Years)

*Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

AL (Min 2 Years)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML AL (Min 2 Years)

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

AL (Min 2 Years)

HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

AL (Min 2 Years)

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML

AL (Min 2 Years)

*Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg CeleBREX

CELEBREX ORAL CAPSULE 400 MG, 50 MG Celecoxib ST

*Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** addaprin oral tablet 200 mg Motrin IB OTC all day pain relief oral tablet 220 mg Aleve OTC all day relief oral tablet 220 mg Aleve OTC childrens ibuprofen 100 oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

childrens ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

childrens ibuprofen oral suspension 40 mg/ml Medi-Profen OTC childs ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC cvs all day pain relief oral tablet 220 mg Aleve OTC

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Formulary Drug Name Reference Restrictions cvs childrens ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

cvs ibuprofen childrens oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

cvs ibuprofen ib oral tablet 200 mg Motrin IB OTC cvs ibuprofen infants oral suspension 50 mg/1.25ml Medi-Profen OTC

cvs ibuprofen oral capsule 200 mg Advil Migraine OTC cvs ibuprofen oral tablet 200 mg Motrin IB OTC cvs naproxen sodium oral capsule 220 mg Aleve OTC cvs naproxen sodium oral tablet 220 mg Aleve OTC diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg dyspel oral tablet 200 mg Motrin IB OTC eq childrens ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

eq ibuprofen infants oral suspension 50 mg/1.25ml Medi-Profen OTC

eq ibuprofen oral capsule 200 mg Advil Migraine OTC eq ibuprofen oral tablet 200 mg Motrin IB OTC eq naproxen sodium oral capsule 220 mg Aleve OTC eq naproxen sodium oral tablet 220 mg Aleve OTC eql childrens ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

eql ibuprofen infants oral suspension 50 mg/1.25ml Medi-Profen OTC

eql ibuprofen oral capsule 200 mg Advil Migraine OTC eql ibuprofen oral tablet 200 mg Motrin IB OTC eql naproxen sodium oral capsule 220 mg Aleve OTC eql naproxen sodium oral tablet 220 mg Aleve OTC etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg Lodine etodolac oral tablet 500 mg fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg genpril oral tablet 200 mg Motrin IB OTC

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Formulary Drug Name Reference Restrictions gnp all day pain relief oral tablet 220 mg Aleve OTC gnp childrens ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

gnp ibuprofen infants oral suspension 50 mg/1.25ml Medi-Profen OTC

gnp ibuprofen oral capsule 200 mg Advil Migraine OTC gnp ibuprofen oral tablet 200 mg Motrin IB OTC gnp naproxen sodium oral capsule 220 mg Aleve OTC gnp naproxen sodium oral tablet 220 mg Aleve OTC goodsense ibuprofen childrens oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

goodsense ibuprofen infants oral suspension 50 mg/1.25ml Medi-Profen OTC

goodsense ibuprofen oral capsule 200 mg Advil Migraine OTC goodsense ibuprofen oral tablet 200 mg Motrin IB OTC goodsense naproxen sodium oral tablet 220 mg Aleve OTC

hm ibuprofen childrens oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

hm ibuprofen ib oral tablet 200 mg Motrin IB OTC hm ibuprofen infants oral suspension 50 mg/1.25ml Medi-Profen OTC

hm ibuprofen oral capsule 200 mg Advil Migraine OTC hm ibuprofen oral tablet 200 mg Motrin IB OTC hm naproxen sodium oral capsule 220 mg Aleve OTC hm naproxen sodium oral tablet 220 mg Aleve OTC hy-vee all day relief oral tablet 220 mg Aleve OTC ibu-200 oral tablet 200 mg Motrin IB OTC ibu-drops oral suspension 40 mg/ml, 50 mg/1.25ml Medi-Profen OTC

ibuprofen childrens oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

ibuprofen oral capsule 200 mg Advil Migraine OTC ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens ibuprofen oral tablet 200 mg Motrin IB OTC ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 25 mg, 50 mg infants ibuprofen oral suspension 50 mg/1.25ml Medi-Profen OTC

8

Formulary Drug Name Reference Restrictions i-prin oral tablet 200 mg Motrin IB OTC ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine oral tablet 10 mg kls ibuprofen oral tablet 200 mg Motrin IB OTC kls naproxen sodium oral tablet 220 mg Aleve OTC ks ibuprofen oral capsule 200 mg Advil Migraine OTC meclofenamate sodium oral capsule 100 mg, 50 mg meijer ibuprofen oral tablet 200 mg Motrin IB OTC meloxicam oral tablet 15 mg, 7.5 mg Mobic nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg EC-Naprosyn

naproxen oral suspension 125 mg/5ml Naprosyn naproxen oral tablet 250 mg, 500 mg Naprosyn naproxen oral tablet 375 mg naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg Naprelan

naproxen sodium oral capsule 220 mg Aleve OTC naproxen sodium oral tablet 220 mg Aleve OTC naproxen sodium oral tablet 275 mg naproxen sodium oral tablet 550 mg Anaprox DS oxaprozin oral tablet 600 mg Daypro piroxicam oral capsule 10 mg, 20 mg Feldene px all day relief oral tablet 220 mg Aleve OTC px childrens profen ib oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

px ibuprofen oral tablet 200 mg Motrin IB OTC px infants profen ib oral suspension 50 mg/1.25ml Medi-Profen OTC

qc childrens ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

qc ibuprofen ib oral tablet 200 mg Motrin IB OTC qc ibuprofen infants oral suspension 50 mg/1.25ml Medi-Profen OTC

qc ibuprofen oral tablet 200 mg Motrin IB OTC qc naproxen sodium oral tablet 220 mg Aleve OTC ra ibuprofen childrens oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

9

Formulary Drug Name Reference Restrictions ra ibuprofen infants oral suspension 50 mg/1.25ml Medi-Profen OTC

ra ibuprofen oral capsule 200 mg Advil Migraine OTC ra ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC ra ibuprofen oral tablet 200 mg Motrin IB OTC ra naproxen sodium oral capsule 220 mg Aleve OTC ra naproxen sodium oral tablet 220 mg Aleve OTC sb childrens ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

sb ibuprofen oral tablet 200 mg Motrin IB OTC sb infants ibuprofen oral suspension 50 mg/1.25ml Medi-Profen OTC

sb naproxen sodium oral tablet 220 mg Aleve OTC sm all day pain relief oral tablet 220 mg Aleve OTC sm childrens ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

sm ibuprofen ib oral tablet 200 mg Motrin IB OTC sm ibuprofen jr oral tablet 100 mg Advil Junior Strength OTC sm ibuprofen oral capsule 200 mg Advil Migraine OTC sm ibuprofen oral tablet 200 mg Motrin IB OTC sm infants ibuprofen oral suspension 50 mg/1.25ml Medi-Profen OTC

sm naproxen sodium oral capsule 220 mg Aleve OTC sm naproxen sodium oral tablet 220 mg Aleve OTC sulindac oral tablet 150 mg, 200 mg tgt childrens ibuprofen oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

tgt ibuprofen childrens oral suspension 100 mg/5ml HyVee Ibuprofen Childrens OTC

tgt ibuprofen oral capsule 200 mg Advil Migraine OTC tgt ibuprofen oral tablet 200 mg Motrin IB OTC tgt infants ibuprofen oral suspension 50 mg/1.25ml Medi-Profen OTC

tgt naproxen sodium oral capsule 220 mg Aleve OTC tgt naproxen sodium oral tablet 220 mg Aleve OTC tolmetin sodium oral capsule 400 mg tolmetin sodium oral tablet 200 mg, 600 mg ADVIL JUNIOR STRENGTH ORAL TABLET 100 MG SM Ibuprofen Jr OTC

CHILDRENS MEDI-PROFEN ORAL SUSPENSION 100 MG/5ML CVS Childrens Ibuprofen OTC

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Formulary Drug Name Reference Restrictions FLANAX PAIN RELIEF ORAL TABLET 220 MG Naproxen Sodium OTC

HYVEE IBUPROFEN CHILDRENS ORAL SUSPENSION 100 MG/5ML CVS Childrens Ibuprofen OTC

MEDI-PROFEN ORAL CAPSULE 200 MG RA Ibuprofen OTC

MEDI-PROFEN ORAL SUSPENSION 40 MG/ML CVS Ibuprofen Infants OTC

MEDI-PROFEN ORAL TABLET 200 MG GoodSense Ibuprofen OTC MEDIPROXEN ORAL TABLET 220 MG Naproxen Sodium OTC MOTRIN IB ORAL TABLET 200 MG GoodSense Ibuprofen OTC PAMPRIN ALL DAY RELIEF MAX ST ORAL TABLET 220 MG Naproxen Sodium OTC

PROVIL ORAL TABLET 200 MG GoodSense Ibuprofen OTC WAL-PROFEN ORAL CAPSULE 200 MG RA Ibuprofen OTC WAL-PROFEN ORAL TABLET 200 MG GoodSense Ibuprofen OTC

*Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg Arava QLL (30 EA per 30 days)

*Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

AL (Min 2 Years)

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG AL (Min 2 Years)

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

AL (Min 2 Years)

*ANALGESICS - NONNARCOTIC* *Analgesics Other*** acetaminophen extra strength oral capsule 500 mg OTC

acetaminophen extra strength oral liquid 500 mg/15ml Chloraseptic Sore Throat OTC

acetaminophen oral liquid 160 mg/5ml Little Remedies for Fever OTC acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650 mg/20.3ml PediaCare Infant Fever/Pain OTC

acetaminophen oral tablet chewable 80 mg Childrens Medi-Tabs OTC acetaminophen rapid tabs child oral tablet dispersible 80 mg Mapap Childrens OTC

acetaminophen rectal suppository 120 mg Acephen OTC

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Formulary Drug Name Reference Restrictions acetaminophen rectal suppository 650 mg FeverAll Adults OTC apap oral tablet chewable 80 mg Childrens Medi-Tabs OTC apra oral elixir 160 mg/5ml Medi-Tabs Childrens OTC betatemp childrens oral suspension 160 mg/5ml PediaCare Children OTC

childrens acetaminophen oral suspension 160 mg/5ml PediaCare Children OTC

childrens acetaminophen oral tablet dispersible 80 mg Mapap Childrens OTC

childrens apap oral tablet chewable 80 mg Childrens Medi-Tabs OTC

childrens aspirin free oral elixir 80 mg/2.5ml Medi-Tabs Childrens OTC; QLL (240 ML per 30 days)

childrens aspirin free oral suspension 160 mg/5ml PediaCare Children OTC

childrens mapap rapid tabs oral tablet dispersible 80 mg Mapap Childrens OTC

childrens non-asa pain relief oral tablet chewable 80 mg Childrens Medi-Tabs OTC

childrens non-aspirin oral suspension 160 mg/5ml PediaCare Children OTC

childrens non-aspirin oral tablet chewable 80 mg Childrens Medi-Tabs OTC

childrens pain reliever oral suspension 160 mg/5ml PediaCare Children OTC

childrens pain reliever oral tablet chewable 80 mg Childrens Medi-Tabs OTC

childrens pain reliever oral tablet dispersible 80 mg Mapap Childrens OTC

childrens silapap oral liquid 160 mg/5ml Little Remedies for Fever OTC childrens tactinal oral tablet chewable 80 mg Childrens Medi-Tabs OTC cvs childs non-aspirin oral tablet chewable 80 mg Childrens Medi-Tabs OTC

cvs fever reducing childrens rectal suppository 120 mg Acephen OTC

cvs infants pain relief drops oral suspension 160 mg/5ml PediaCare Children OTC

cvs non-aspirin childrens oral tablet chewable 80 mg Childrens Medi-Tabs OTC

cvs non-aspirin jr oral tablet chewable 160 mg Medi-Tabs Junior Strength OTC cvs pain & fever childrens oral suspension 160 mg/5ml PediaCare Children OTC

cvs pain & fever infants oral suspension 160 mg/5ml PediaCare Children OTC

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Formulary Drug Name Reference Restrictions cvs pain relief adult oral liquid 500 mg/15ml Chloraseptic Sore Throat OTC cvs pain relief childrens oral suspension 160 mg/5ml PediaCare Children OTC

ed-apap oral liquid 160 mg/5ml Little Remedies for Fever OTC; QLL (240 ML per 30 days)

eq acetaminophen childrens oral suspension 160 mg/5ml PediaCare Children OTC

eq acetaminophen childrens oral tablet dispersible 80 mg Mapap Childrens OTC

eq childrens pain reliever oral suspension 160 mg/5ml PediaCare Children OTC

eq childrens pain reliever oral tablet chewable 80 mg Childrens Medi-Tabs OTC

eq pain & fever childrens oral suspension 160 mg/5ml PediaCare Children OTC

eq pain & fever infants oral suspension 160 mg/5ml PediaCare Children OTC

eq pain relief/rapid burst oral liquid 500 mg/15ml Chloraseptic Sore Throat OTC

eq pain reliever junior oral tablet chewable 160 mg Medi-Tabs Junior Strength OTC

eql acetaminophen childrens oral suspension 160 mg/5ml PediaCare Children OTC

eql acetaminophen infants oral suspension 160 mg/5ml PediaCare Children OTC

eql pain & fever infants oral suspension 160 mg/5ml PediaCare Children OTC

fever reducer childrens rectal suppository 120 mg Acephen OTC

gnp childrens easy-melts oral tablet dispersible 80 mg Mapap Childrens OTC

gnp childrens pain relief oral suspension 160 mg/5ml PediaCare Children OTC

gnp infants pain relief oral suspension 160 mg/5ml PediaCare Children OTC

gnp infants pain/fever oral suspension 160 mg/5ml PediaCare Children OTC

gnp pain & fever childrens oral suspension 160 mg/5ml PediaCare Children OTC

gnp pain relief extra strength oral liquid 500 mg/15ml Chloraseptic Sore Throat OTC

goodsense pain & fever child oral suspension 160 mg/5ml PediaCare Children OTC; QLL (240 ML per 30

days)

13

Formulary Drug Name Reference Restrictions goodsense pain & fever infants oral suspension 160 mg/5ml PediaCare Children OTC

hm acetaminophen childrens oral tablet chewable 160 mg Medi-Tabs Junior Strength OTC

hm pain & fever childrens oral suspension 160 mg/5ml PediaCare Children OTC

hm pain & fever infants oral suspension 160 mg/5ml PediaCare Children OTC

hm pain relief childrens oral suspension 160 mg/5ml PediaCare Children OTC

infants pain & fever oral suspension 160 mg/5ml PediaCare Children OTC

infants pain reliever oral suspension 80 mg/0.8ml OTC

kls pain & fever infants oral suspension 160 mg/5ml PediaCare Children OTC

kls pain relief childrens oral suspension 160 mg/5ml PediaCare Children OTC

liquid pain relief oral liquid 160 mg/5ml Little Remedies for Fever OTC mapap oral capsule 500 mg OTC mapap oral liquid 160 mg/5ml Little Remedies for Fever OTC mapap oral tablet chewable 80 mg Childrens Medi-Tabs OTC meijer jr st aspirin free oral tablet chewable 160 mg Medi-Tabs Junior Strength OTC

non-aspirin childrens oral suspension 160 mg/5ml PediaCare Children OTC

non-aspirin jr strength oral tablet chewable 160 mg Medi-Tabs Junior Strength OTC

nortemp infants oral suspension 80 mg/0.8ml OTC pain & fever childrens oral solution 160 mg/5ml PediaCare Infant Fever/Pain OTC

pain & fever childrens oral suspension 160 mg/5ml PediaCare Children OTC

pain & fever childrens oral tablet chewable 80 mg Childrens Medi-Tabs OTC

pain & fever infants oral suspension 160 mg/5ml PediaCare Children OTC

pain relief childrens oral suspension 160 mg/5ml PediaCare Children OTC

pain relief extra strength oral capsule 500 mg OTC pain reliever oral liquid 500 mg/15ml Chloraseptic Sore Throat OTC pain reliever/fever reducer rectal suppository 120 mg Acephen OTC

14

Formulary Drug Name Reference Restrictions px childrens pain relief oral suspension 160 mg/5ml PediaCare Children OTC

qc non-aspirin childrens oral suspension 160 mg/5ml PediaCare Children OTC

qc pain relief childrens oral suspension 160 mg/5ml PediaCare Children OTC

qc pain relief infants oral suspension 160 mg/5ml PediaCare Children OTC

ra acetaminophen rapid melts oral tablet dispersible 80 mg Mapap Childrens OTC

ra childrens non-aspirin oral suspension 160 mg/5ml PediaCare Children OTC

ra fever reducer/pain reliever oral suspension 160 mg/5ml PediaCare Children OTC

ra pain reliever ex st oral liquid 500 mg/15ml Chloraseptic Sore Throat OTC sb childrens non-aspirin oral tablet dispersible 80 mg Mapap Childrens OTC

sb non-aspirin oral tablet chewable 160 mg Medi-Tabs Junior Strength OTC sb non-aspirin oral tablet chewable 80 mg Childrens Medi-Tabs OTC sb pain reliever childrens oral suspension 160 mg/5ml PediaCare Children OTC

sm infants pain reliever oral suspension 160 mg/5ml PediaCare Children OTC

sm pain & fever childrens oral suspension 160 mg/5ml PediaCare Children OTC

sm pain & fever infants oral suspension 160 mg/5ml PediaCare Children OTC

sm pain reliever childrens oral suspension 160 mg/5ml PediaCare Children OTC

sm pain reliever ex st oral capsule 500 mg OTC sm pain reliever oral capsule 500 mg OTC tgt acetaminophen childrens oral suspension 160 mg/5ml PediaCare Children OTC

tgt acetaminophen infants oral suspension 80 mg/0.8ml OTC

tgt acetaminophen melts child oral tablet dispersible 80 mg Mapap Childrens OTC

tgt childrens acetaminophen oral suspension 160 mg/5ml PediaCare Children OTC

tgt pain/fever acetaminophen oral suspension 160 mg/5ml PediaCare Children OTC

ACEPHEN RECTAL SUPPOSITORY 120 MG Fever Reducer Childrens OTC

15

Formulary Drug Name Reference Restrictions ACEPHEN RECTAL SUPPOSITORY 325 MG OTC

ACEPHEN RECTAL SUPPOSITORY 650 MG Acetaminophen OTC

CHILDRENS MEDI-TABS ORAL TABLET CHEWABLE 80 MG CVS Non-Aspirin Childrens OTC

CHLORASEPTIC SORE THROAT ORAL LIQUID 1000 MG/30ML Acetaminophen Extra Strength OTC

FEVERALL ADULTS RECTAL SUPPOSITORY 650 MG Acetaminophen OTC

FEVERALL CHILDRENS RECTAL SUPPOSITORY 120 MG Fever Reducer Childrens OTC

FEVERALL JUNIOR STRENGTH RECTAL SUPPOSITORY 325 MG OTC

LITTLE REMEDIES FOR FEVER ORAL LIQUID 160 MG/5ML Childrens Silapap OTC

MAPAP ACETAMINOPHEN EXTRA STR ORAL LIQUID 500 MG/15ML Acetaminophen Extra Strength OTC

MAPAP CHILDRENS ORAL SUSPENSION 160 MG/5ML Pain & Fever Infants OTC

MAPAP CHILDRENS ORAL TABLET CHEWABLE 160 MG CVS Non-Aspirin Jr OTC

MAPAP CHILDRENS ORAL TABLET DISPERSIBLE 80 MG SB Childrens Non-Aspirin OTC

MEDI-TABS CHILDRENS ORAL ELIXIR 80 MG/2.5ML Childrens Aspirin Free OTC

MEDI-TABS JUNIOR STRENGTH ORAL TABLET CHEWABLE 160 MG CVS Non-Aspirin Jr OTC

NORTEMP ORAL SUSPENSION 160 MG/5ML Pain & Fever Infants OTC

PEDIACARE CHILDREN ORAL SUSPENSION 160 MG/5ML Pain & Fever Infants OTC

PEDIACARE INFANT FEVER/PAIN ORAL SOLUTION 160 MG/5ML Acetaminophen OTC

PEDIACARE INFANTS ORAL SUSPENSION 160 MG/5ML Pain & Fever Infants OTC

TRIAMINIC FEVER REDUCER ORAL SYRUP 160 MG/5ML

OTC; QLL (240 ML per 30 days)

*Analgesics-Sedatives*** butalbital-acetaminophen oral tablet 50-325 mg Tencon QLL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-300 -40 mg Fioricet QLL (180 EA per 30 days)

16

Formulary Drug Name Reference Restrictions butalbital-apap-caffeine oral capsule 50-325 -40 mg Zebutal

butalbital-apap-caffeine oral tablet 50-325-40 mg Esgic QLL (180 EA per 30 days)

butalbital-asa-caffeine oral capsule 50-325-40 mg Fiorinal

butalbital-aspirin-caffeine oral capsule 50 -325-40 mg Fiorinal QLL (180 EA per 30 days)

marten-tab oral tablet 50-325 mg Tencon CAPACET ORAL CAPSULE 50-325-40 MG Butalbital-APAP-Caffeine

ESGIC ORAL CAPSULE 50-325-40 MG Butalbital-APAP-Caffeine TENCON ORAL TABLET 50-325 MG Marten-Tab ZEBUTAL ORAL CAPSULE 50-325-40 MG Butalbital-APAP-Caffeine

*Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 mg/5ml

*Salicylates*** adult aspirin ec low strength oral tablet delayed release 81 mg Aspir-Low OTC

aspir-81 oral tablet delayed release 81 mg Aspir-Low OTC aspirin adult low dose oral tablet delayed release 81 mg Aspir-Low OTC

aspirin adult low strength oral tablet chewable 81 mg Bayer Low Dose OTC

aspirin adult low strength oral tablet delayed release 81 mg Aspir-Low OTC

aspirin childrens oral tablet chewable 81 mg Bayer Low Dose OTC aspirin ec low dose oral tablet delayed release 81 mg Aspir-Low OTC

aspirin ec low strength oral tablet delayed release 81 mg Aspir-Low OTC

aspirin ec oral tablet delayed release 81 mg Aspir-Low OTC aspirin low dose oral tablet chewable 81 mg Bayer Low Dose OTC aspirin low dose oral tablet delayed release 81 mg Aspir-Low OTC

aspirin low strength oral tablet chewable 81 mg Bayer Low Dose OTC

aspirin oral tablet 325 mg Norwich Aspirin OTC aspirin oral tablet chewable 81 mg Bayer Low Dose OTC aspirin oral tablet delayed release 81 mg Aspir-Low OTC

17

Formulary Drug Name Reference Restrictions aspirin rectal suppository 300 mg, 600 mg OTC aspirtab maximum strength oral tablet 500 mg Bayer Aspirin Extra Strength OTC childrens aspirin low strength oral tablet chewable 81 mg Bayer Low Dose OTC

childrens aspirin oral tablet chewable 81 mg Bayer Low Dose OTC cvs aspirin adult low dose oral tablet chewable 81 mg Bayer Low Dose OTC

cvs aspirin adult low strength oral tablet delayed release 81 mg Aspir-Low OTC

cvs aspirin ec oral tablet delayed release 81 mg Aspir-Low OTC

cvs aspirin low dose oral tablet delayed release 81 mg Aspir-Low OTC

cvs aspirin oral tablet 325 mg Norwich Aspirin OTC cvs aspirin oral tablet delayed release 81 mg Aspir-Low OTC diflunisal oral tablet 500 mg ec-81 aspirin oral tablet delayed release 81 mg Aspir-Low OTC

eq adult aspirin low strength oral tablet delayed release 81 mg Aspir-Low OTC

eq aspirin adult low dose oral tablet delayed release 81 mg Aspir-Low OTC

eq aspirin low dose oral tablet chewable 81 mg Bayer Low Dose OTC

eq aspirin low dose oral tablet delayed release 81 mg Aspir-Low OTC

eq aspirin oral tablet 325 mg Norwich Aspirin OTC eq aspirin oral tablet delayed release 500 mg Ecotrin Maximum Strength OTC eq childrens aspirin oral tablet chewable 81 mg Bayer Low Dose OTC

eql aspirin low dose oral tablet chewable 81 mg Bayer Low Dose OTC

eql aspirin low dose oral tablet delayed release 81 mg Aspir-Low OTC

eql aspirin oral tablet 325 mg Norwich Aspirin OTC gnp adult aspirin low strength oral tablet chewable 81 mg Bayer Low Dose OTC

gnp adult aspirin low strength oral tablet delayed release 81 mg Aspir-Low OTC

gnp aspirin low dose oral tablet delayed release 81 mg Aspir-Low OTC

gnp aspirin oral tablet 325 mg Norwich Aspirin OTC

18

Formulary Drug Name Reference Restrictions gnp aspirin oral tablet delayed release 81 mg Aspir-Low OTC goodsense aspirin adult low st oral tablet chewable 81 mg Bayer Low Dose OTC

goodsense aspirin low dose oral tablet delayed release 81 mg Aspir-Low OTC

goodsense aspirin oral tablet 325 mg Norwich Aspirin OTC goodsense aspirin oral tablet chewable 81 mg Bayer Low Dose OTC h-e-b aspirin oral tablet delayed release 81 mg Aspir-Low OTC

hm aspirin ec low dose oral tablet delayed release 81 mg Aspir-Low OTC

hm aspirin oral tablet 325 mg Norwich Aspirin OTC hm aspirin oral tablet chewable 81 mg Bayer Low Dose OTC kls aspirin low dose oral tablet delayed release 81 mg Aspir-Low OTC

kp aspirin oral tablet delayed release 81 mg Aspir-Low OTC mm aspirin oral tablet 325 mg Norwich Aspirin OTC px aspirin oral tablet 325 mg Norwich Aspirin OTC px aspirin oral tablet chewable 81 mg Bayer Low Dose OTC px enteric aspirin oral tablet delayed release 81 mg Aspir-Low OTC

qc aspirin low dose oral tablet chewable 81 mg Bayer Low Dose OTC

qc aspirin low dose oral tablet delayed release 81 mg Aspir-Low OTC

qc aspirin oral tablet 325 mg Norwich Aspirin OTC qc childrens aspirin oral tablet chewable 81 mg Bayer Low Dose OTC

ra aspirin adult low dose oral tablet chewable 81 mg Bayer Low Dose OTC

ra aspirin adult low strength oral tablet chewable 81 mg Bayer Low Dose OTC

ra aspirin adult low strength oral tablet delayed release 81 mg Aspir-Low OTC

ra aspirin childrens oral tablet chewable 81 mg Bayer Low Dose OTC

ra aspirin ec adult low st oral tablet delayed release 81 mg Aspir-Low OTC

ra aspirin ec oral tablet delayed release 81 mg Aspir-Low OTC ra aspirin oral tablet 325 mg Norwich Aspirin OTC ra aspirin oral tablet 500 mg Bayer Aspirin Extra Strength OTC

19

Formulary Drug Name Reference Restrictions ra childrens aspirin oral tablet chewable 81 mg Bayer Low Dose OTC

salsalate oral tablet 500 mg, 750 mg sb aspirin adult low strength oral tablet delayed release 81 mg Aspir-Low OTC

sb aspirin oral tablet 325 mg Norwich Aspirin OTC sb aspirin oral tablet delayed release 81 mg Aspir-Low OTC sb childrens aspirin oral tablet chewable 81 mg Bayer Low Dose OTC

sb low dose asa ec oral tablet delayed release 81 mg Aspir-Low OTC

sm aspirin adult low strength oral tablet chewable 81 mg Bayer Low Dose OTC

sm aspirin adult low strength oral tablet delayed release 81 mg Aspir-Low OTC

sm aspirin ec low strength oral tablet delayed release 81 mg Aspir-Low OTC

sm aspirin oral tablet 325 mg Norwich Aspirin OTC sm childrens aspirin oral tablet chewable 81 mg Bayer Low Dose OTC

tgt aspirin low dose oral tablet delayed release 81 mg Aspir-Low OTC

tgt aspirin oral tablet 325 mg Norwich Aspirin OTC tgt aspirin oral tablet chewable 81 mg Bayer Low Dose OTC tgt aspirin oral tablet delayed release 81 mg Aspir-Low OTC tgt childrens aspirin oral tablet chewable 81 mg Bayer Low Dose OTC

ASPIR-LOW ORAL TABLET DELAYED RELEASE 81 MG HM Aspirin EC Low Dose OTC

BAYER ADVANCED ASPIRIN EX ST ORAL TABLET 500 MG Aspirtab Maximum Strength OTC

BAYER ADVANCED ASPIRIN REG ST ORAL TABLET 325 MG CVS Aspirin OTC

BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG HM Aspirin EC Low Dose OTC

BAYER ASPIRIN EXTRA STRENGTH ORAL TABLET 500 MG Aspirtab Maximum Strength OTC

BAYER ASPIRIN ORAL TABLET 325 MG CVS Aspirin OTC

BAYER LOW DOSE ORAL TABLET CHEWABLE 81 MG CVS Aspirin Adult Low Dose OTC

BAYER LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG HM Aspirin EC Low Dose OTC

20

Formulary Drug Name Reference Restrictions ECOTRIN LOW STRENGTH ORAL TABLET DELAYED RELEASE 81 MG HM Aspirin EC Low Dose OTC

MINIPRIN LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG HM Aspirin EC Low Dose OTC

NORWICH ASPIRIN ORAL TABLET 325 MG CVS Aspirin OTC

ST JOSEPH ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG HM Aspirin EC Low Dose OTC

ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE 81 MG CVS Aspirin Adult Low Dose OTC

*ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet 300-15 mg QLL (300 EA per 30 days)

acetaminophen-codeine #3 oral tablet 300-30 mg Tylenol with Codeine #3 QLL (300 EA per 30 days)

acetaminophen-codeine #4 oral tablet 300-60 mg Tylenol with Codeine #4 QLL (300 EA per 30 days)

acetaminophen-codeine oral solution 120-12 mg/5ml QLL (4500 ML per 30 days)

acetaminophen-codeine oral tablet 300-15 mg acetaminophen-codeine oral tablet 300-60 mg Tylenol with Codeine #4 butalbital-apap-caff-cod oral capsule 50-300 -40-30 mg Fioricet/Codeine QLL (180 EA per 30 days)

butalbital-apap-caff-cod oral capsule 50-325 -40-30 mg QLL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule 50 -325-40-30 mg Fiorinal/Codeine #3 QLL (180 EA per 30 days)

ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG Butalbital-ASA-Caff-Codeine

*Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml Hycet

hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml Hycet QLL (5400 ML per 30 days)

hydrocodone-acetaminophen oral tablet 10 -300 mg Vicodin HP

hydrocodone-acetaminophen oral tablet 10 -325 mg Norco QLL (270 EA per 30 days)

hydrocodone-acetaminophen oral tablet 2.5 -325 mg Verdrocet QLL (360 EA per 30 days)

21

Formulary Drug Name Reference Restrictions hydrocodone-acetaminophen oral tablet 5-300 mg Xodol

hydrocodone-acetaminophen oral tablet 5-325 mg, 7.5-325 mg Norco QLL (360 EA per 30 days)

hydrocodone-acetaminophen oral tablet 7.5 -300 mg Vicodin ES

hydrocodone-ibuprofen oral tablet 10-200 mg Xylon QLL (150 EA per 30 days) hydrocodone-ibuprofen oral tablet 5-200 mg Ibudone QLL (150 EA per 30 days) hydrocodone-ibuprofen oral tablet 7.5-200 mg QLL (150 EA per 30 days) IBUDONE ORAL TABLET 10-200 MG, 5 -200 MG Hydrocodone-Ibuprofen

LORCET HD ORAL TABLET 10-325 MG Hydrocodone-Acetaminophen LORCET ORAL TABLET 5-325 MG Hydrocodone-Acetaminophen LORCET PLUS ORAL TABLET 7.5-325 MG Hydrocodone-Acetaminophen

VERDROCET ORAL TABLET 2.5-325 MG Hydrocodone-Acetaminophen

VICODIN ES ORAL TABLET 7.5-300 MG Hydrocodone-Acetaminophen QLL (270 EA per 30 days) VICODIN HP ORAL TABLET 10-300 MG Hydrocodone-Acetaminophen QLL (360 EA per 30 days) VICODIN ORAL TABLET 5-300 MG Hydrocodone-Acetaminophen QLL (270 EA per 30 days) XYLON ORAL TABLET 10-200 MG Hydrocodone-Ibuprofen

*Opioid Agonists*** codeine sulfate oral tablet 15 mg QLL (720 EA per 30 days) codeine sulfate oral tablet 30 mg QLL (360 EA per 30 days) codeine sulfate oral tablet 60 mg QLL (180 EA per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr Duragesic-100 PA; QLL (10 EA per 30 days)

fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 PA; QLL (10 EA per 30 days) fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 PA; QLL (10 EA per 30 days) fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 PA; QLL (10 EA per 30 days) fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 PA; QLL (10 EA per 30 days) hydromorphone hcl oral tablet 2 mg Dilaudid QLL (330 EA per 30 days) hydromorphone hcl oral tablet 4 mg Dilaudid QLL (150 EA per 30 days) hydromorphone hcl oral tablet 8 mg Dilaudid QLL (60 EA per 30 days) hydromorphone hcl rectal suppository 3 mg QLL (120 EA per 30 days) methadone hcl oral solution 10 mg/5ml PA; QLL (450 ML per 30 days) methadone hcl oral solution 5 mg/5ml PA; QLL (900 ML per 30 days) methadone hcl oral tablet 10 mg Dolophine PA; QLL (90 EA per 30 days) methadone hcl oral tablet 5 mg Dolophine PA; QLL (180 EA per 30 days)

22

Formulary Drug Name Reference Restrictions morphine sulfate (concentrate) oral solution 100 mg/5ml QLL (120 ML per 30 days)

morphine sulfate (concentrate) oral solution 20 mg/ml morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg Kadian PA; QLL (60 EA per 30 days)

morphine sulfate er oral capsule extended release 24 hour 100 mg, 50 mg, 60 mg, 80 mg Kadian PA; QLL (30 EA per 30 days)

morphine sulfate er oral capsule extended release 24 hour 30 mg Kadian PA; QLL (90 EA per 30 days)

morphine sulfate er oral tablet extended release 100 mg, 200 mg MS Contin PA; QLL (60 EA per 30 days)

morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg MS Contin PA; QLL (90 EA per 30 days)

morphine sulfate oral solution 10 mg/5ml QLL (900 ML per 30 days) morphine sulfate oral solution 20 mg/5ml QLL (660 ML per 30 days) morphine sulfate oral tablet 15 mg QLL (180 EA per 30 days) morphine sulfate oral tablet 30 mg QLL (90 EA per 30 days) morphine sulfate rectal suppository 10 mg, 20 mg, 5 mg morphine sulfate rectal suppository 30 mg oxycodone hcl oral capsule 5 mg QLL (180 EA per 30 days) oxycodone hcl oral concentrate 100 mg/5ml QLL (90 ML per 30 days) oxycodone hcl oral solution 5 mg/5ml QLL (900 ML per 30 days) oxycodone hcl oral tablet 10 mg QLL (180 EA per 30 days) oxycodone hcl oral tablet 15 mg Roxicodone QLL (120 EA per 30 days) oxycodone hcl oral tablet 20 mg QLL (90 EA per 30 days) oxycodone hcl oral tablet 30 mg Roxicodone QLL (60 EA per 30 days) oxycodone hcl oral tablet 5 mg Roxicodone QLL (180 EA per 30 days) oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

PA; QLL (60 EA per 30 days)

oxymorphone hcl oral tablet 10 mg Opana QLL (90 EA per 30 days) oxymorphone hcl oral tablet 5 mg Opana QLL (180 EA per 30 days) tramadol hcl oral tablet 50 mg Ultram QLL (240 EA per 30 days) NUCYNTA ORAL TABLET 100 MG QLL (2 EA per 1 day) NUCYNTA ORAL TABLET 50 MG QLL (4 EA per 1 day) NUCYNTA ORAL TABLET 75 MG QLL (3 EA per 1 day) OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG, 7.5 MG

23

Formulary Drug Name Reference Restrictions *Opioid Combinations*** oxycodone-acetaminophen oral tablet 10-325 mg Endocet QLL (180 EA per 30 days)

oxycodone-acetaminophen oral tablet 2.5-325 mg Percocet QLL (360 EA per 30 days)

oxycodone-acetaminophen oral tablet 5-325 mg Endocet QLL (360 EA per 30 days)

oxycodone-acetaminophen oral tablet 7.5-325 mg Endocet QLL (240 EA per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg QLL (360 EA per 30 days) ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG Oxycodone-Acetaminophen

*Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2 mg


buprenorphine hcl sublingual tablet sublingual 8 mg


butorphanol tartrate nasal solution 10 mg/ml QLL (5 ML per 1 day) pentazocine-naloxone hcl oral tablet 50-0.5 mg QLL (120 EA per 30 days)

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 5 MCG/HR, 7.5 MCG/HR

Buprenorphine PA; QLL (8 EA per 28 days)

BUTRANS TRANSDERMAL PATCH WEEKLY 15 MCG/HR, 20 MCG/HR Buprenorphine PA; QLL (4 EA per 28 days)

SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG


SUBOXONE SUBLINGUAL FILM 2-0.5 MG


SUBOXONE SUBLINGUAL FILM 8-2 MG


*Tramadol Combinations*** tramadol-acetaminophen oral tablet 37.5-325 mg Ultracet QLL (240 EA per 30 days)

*ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100 mg, 200 mg, 50 mg methyltestosterone oral capsule 10 mg Android testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml Depo-Testosterone PA; QLL (10 ML per 90 days)

testosterone enanthate intramuscular solution 200 mg/ml PA; QLL (10 ML per 90 days)

24

Formulary Drug Name Reference Restrictions testosterone transdermal gel 10 mg/act (2%) Fortesta testosterone transdermal gel 12.5 mg/act (1%) Vogelxo Pump testosterone transdermal gel 25 mg/2.5gm (1%) AndroGel

testosterone transdermal gel 50 mg/5gm (1%) Vogelxo ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%) ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%) ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%), 50 MG/5GM (1%) Testosterone

TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) Testosterone

VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%) Testosterone

VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) Testosterone

*ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema 100 mg/60ml Cortenema COLOCORT RECTAL ENEMA 100 MG/60ML Hydrocortisone

CORTIFOAM RECTAL FOAM 10 %

*Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % PA

*Rectal Anesthetic Combinations*** cvs hemorrhoidal rectal cream 1-0.25-14.4-15 % Preparation H OTC

eq hemorrhoidal max st rectal cream 1-0.25 -14.4-15 % Preparation H OTC

eql hemorrhoidal rectal cream 1-0.25-14.4-15 % Preparation H OTC

hemorrhoidal max st/aloe rectal cream 1-0.25 -14.4-15 % Preparation H OTC

hemorrhoidal max str rectal cream 1-0.25 -14.4-15 % Preparation H OTC

hemorrhoidal rectal cream 1-0.25-14.4-15 % Preparation H OTC px hemorrhoidal rectal cream 1-0.25-14.4-15 % Preparation H OTC

ra hemorrhoidal rectal cream 1-0.25-14.4-15 % Preparation H OTC

25

Formulary Drug Name Reference Restrictions sm hemorrhoidal rectal cream 1-0.25-14.4-15 % Preparation H OTC

tgt hemorrhoidal rectal cream 1-0.25-14.4-15 % Preparation H OTC

*Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream 3 -0.5 % lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 % PROCTOFOAM HC RECTAL FOAM 1-1 %

*Rectal Combinations - Misc.*** hemorrhoidal rectal suppository 0.25-3-85.5 % OTC

px hemorrhoidal rectal suppository 0.25-3 -85.5 % OTC

ra hemorrhoidal rectal suppository 0.25-3 -85.5 % OTC

*Rectal Steroids*** hydrocortisone acetate rectal suppository 30 mg Hemmorex-HC

hydrocortisone rectal cream 2.5 % Procto-Med HC ANUSOL-HC RECTAL CREAM 2.5 % Hydrocortisone HEMMOREX-HC RECTAL SUPPOSITORY 30 MG Hydrocortisone Acetate

PROCTOCORT RECTAL CREAM 1 % Hydrocortisone PROCTO-MED HC RECTAL CREAM 2.5 % Hydrocortisone

PROCTOSOL HC RECTAL CREAM 2.5 % Hydrocortisone

PROCTOZONE-HC RECTAL CREAM 2.5 % Hydrocortisone

*ANTACIDS* *Antacid & Simethicone*** antacid & antigas oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

antacid advanced oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

antacid anti-gas max strength oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

antacid extra strength oral suspension 400 -400-40 mg/5ml Almacone Double Strength OTC

26

Formulary Drug Name Reference Restrictions antacid iii oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC antacid maximum strength oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

antacid oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC antacid plus anti-gas relief oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

antacid/simethicone ds oral suspension 400 -400-40 mg/5ml Almacone Double Strength OTC

comfort gel antacid anti-gas oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

cvs antacid plus antigas oral suspension 400 -400-40 mg/5ml Almacone Double Strength OTC

cvs antacid/anti-gas oral suspension 400-400 -40 mg/5ml Almacone Double Strength OTC

eq antacid maximum strength oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

eql antacid advanced max st oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

fast acting antacid/anti-gas oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

gnp antacid maximum strength oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

hm advanced antacid max st oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

hm antacid anti-gas ex st oral suspension 400 -400-40 mg/5ml Almacone Double Strength OTC

mag-al plus xs oral liquid 400-400-40 mg/5ml Almacone Double Strength OTC meijer antacid oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

mi-acid maximum strength oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

milantex extra strength oral suspension 400 -400-40 mg/5ml Almacone Double Strength OTC

mintox maximum strength oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

px antacid maximum strength oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

qc antacid/anti-gas oral suspension 400-400 -40 mg/5ml Almacone Double Strength OTC

ra antacid/anti-gas max st oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

ra antacid/gas relief max st oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

27

Formulary Drug Name Reference Restrictions sm antacid advanced max st oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

sm antacid anti-gas ex st oral suspension 400 -400-40 mg/5ml Almacone Double Strength OTC

sm antacid maximum strength oral suspension 400-400-40 mg/5ml Almacone Double Strength OTC

ALMACONE DOUBLE STRENGTH ORAL SUSPENSION 400-400-40 MG/5ML CVS Antacid/Anti-Gas OTC

GNP MASANTI MAXIMUM STRENGTH ORAL SUSPENSION 400-400-40 MG/5ML CVS Antacid/Anti-Gas OTC

MAALOX ADVANCED MAX ST ORAL SUSPENSION 400-400-40 MG/5ML CVS Antacid/Anti-Gas OTC

MAALOX MAX ORAL SUSPENSION 400-400-40 MG/5ML CVS Antacid/Anti-Gas OTC

MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION 400-400-40 MG/5ML CVS Antacid/Anti-Gas OTC

MYLANTA MAXIMUM STRENGTH ORAL SUSPENSION 400-400-40 MG/5ML CVS Antacid/Anti-Gas OTC

*Antacid Combinations*** gnp foaming antacid oral tablet chewable 80 -20 mg OTC

sm foaming antacid oral tablet chewable 80 -20 mg OTC

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

*Antacids - Calcium Salts*** childrens pepto oral tablet chewable 400 mg Childrens Mylanta OTC ra stomach relief kids oral tablet chewable 400 mg Childrens Mylanta OTC

CHILDRENS SOOTHE ORAL TABLET CHEWABLE 400 MG RA Stomach Relief Kids OTC

MAALOX CHILDRENS ORAL TABLET CHEWABLE 400 MG RA Stomach Relief Kids OTC

TITRALAC ORAL TABLET CHEWABLE 420 MG OTC

*Antacids - Magnesium Salts*** gnp magnesium oxide oral tablet 250 mg OTC hm magnesium oral tablet 250 mg, 400 mg OTC magnesium oxide oral tablet 250 mg, 400 mg OTC magnesium oxide oral tablet 420 mg Maox OTC 28

Formulary Drug Name Reference Restrictions MAOX ORAL TABLET 420 MG Magnesium Oxide OTC

*ANTHELMINTICS* *Anthelmintics*** ivermectin oral tablet 3 mg Stromectol pinworm medicine oral suspension 144 mg/ml OTC reeses pinworm medicine oral suspension 144 mg/ml OTC

reeses pinworm medicine oral tablet 180 mg OTC ALBENZA ORAL TABLET 200 MG ST BILTRICIDE ORAL TABLET 600 MG PA

*ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 mg isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg isosorbide dinitrate oral tablet 5 mg Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120 mg QLL (60 EA per 30 days)

isosorbide mononitrate er oral tablet extended release 24 hour 30 mg, 60 mg QLL (30 EA per 30 days)

isosorbide mononitrate oral tablet 10 mg, 20 mg nitroglycerin er oral capsule extended release 2.5 mg, 6.5 mg, 9 mg Nitro-Time

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg Nitrostat

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.4 mg/hr Nitro-Dur

nitroglycerin transdermal patch 24 hour 0.2 mg/hr, 0.6 mg/hr Minitran

MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

Nitroglycerin

NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG

Nitroglycerin ER

29

Formulary Drug Name Reference Restrictions *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg QLL (6 EA per 1 day) buspirone hcl oral tablet 15 mg QLL (4 EA per 1 day) buspirone hcl oral tablet 5 mg QLL (12 EA per 1 day) buspirone hcl oral tablet 7.5 mg QLL (8 EA per 1 day) hydroxyzine hcl oral syrup 10 mg/5ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg hydroxyzine pamoate oral capsule 25 mg, 50 mg Vistaril

meprobamate oral tablet 200 mg, 400 mg

*Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg Xanax XR QLL (60 EA per 30 days); AL

(Max 18 Years) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg Xanax QLL (102 EA per 34 days); AL

(Max 18 Years) alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

QLL (90 EA per 30 days); AL (Min 18 Years)

alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg Xanax XR QLL (60 EA per 30 days); AL

(Max 18 Years) alprazolam xr oral tablet extended release 24 hour 3 mg Xanax XR

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg


clorazepate dipotassium oral tablet 15 mg, 3.75 mg


clorazepate dipotassium oral tablet 7.5 mg Tranxene-T QLL (136 EA per 34 days); AL (Min 9 Years)

diazepam oral solution 1 mg/ml QLL (340 ML per 34 days) diazepam oral tablet 10 mg, 2 mg, 5 mg Valium QLL (136 EA per 34 days) lorazepam oral concentrate 2 mg/ml LORazepam Intensol QLL (204 ML per 34 days) lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Ativan QLL (102 EA per 34 days)

oxazepam oral capsule 10 mg, 15 mg, 30 mg QLL (136 EA per 34 days); AL (Min 6 Years)

ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML

QLL (204 ML per 34 days); AL (Min 18 Years)

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML LORazepam

30

Formulary Drug Name Reference Restrictions *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100 mg, 150 mg Norpace

quinidine gluconate er oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg

*Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

*Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

*Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg Pacerone

MULTAQ ORAL TABLET 400 MG ST; QLL (60 EA per 30 days) PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG Amiodarone HCl

*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE

AL (Min 4 Years)

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE

AL (Min 12 Years)

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT AL (Min 12 Years)

SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT AL (Min 12 Years)

*Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 mg/2ml

31

Formulary Drug Name Reference Restrictions *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg VoSpire ER

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate oral syrup 2 mg/5ml albuterol sulfate oral tablet 2 mg, 4 mg levalbuterol tartrate inhalation aerosol 45 mcg/act Xopenex HFA ST

metaproterenol sulfate oral syrup 10 mg/5ml metaproterenol sulfate oral tablet 10 mg, 20 mg terbutaline sulfate oral tablet 2.5 mg, 5 mg ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG AL (Min 18 Years)

PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE

AL (Min 4 Years)

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT AL (Min 18 Years)

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

*Bronchodilators -Anticholinergics*** ipratropium bromide inhalation solution 0.02 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG

*Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 mg Singulair montelukast sodium oral tablet 10 mg Singulair

32

Formulary Drug Name Reference Restrictions montelukast sodium oral tablet chewable 4 mg, 5 mg Singulair

zafirlukast oral tablet 10 mg, 20 mg Accolate

*Steroid Inhalants*** budesonide inhalation suspension 1 mg/2ml Pulmicort ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT PULMICORT INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML

Budesonide

QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT

*Xanthines*** theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg Theochron

theophylline er oral tablet extended release 12 hour 450 mg theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

33

Formulary Drug Name Reference Restrictions theophylline oral solution 80 mg/15ml THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

Theophylline ER

*ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1 mg, 2.5 mg, 4 mg Jantoven

warfarin sodium oral tablet 10 mg, 2 mg, 3 mg, 5 mg, 6 mg, 7.5 mg Coumadin

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

Warfarin Sodium

*Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

*Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml

*Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 mg/3ml Lovenox

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

Lovenox

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

*Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

Arixtra

34

Formulary Drug Name Reference Restrictions *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG

*ANTICONVULSANTS* *Anticonvulsants -Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg, 2 mg KlonoPIN clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG

*Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg Carbatrol

carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg TEGretol-XR

carbamazepine oral suspension 100 mg/5ml TEGretol carbamazepine oral tablet 200 mg Epitol carbamazepine oral tablet chewable 100 mg gabapentin oral capsule 100 mg, 300 mg, 400 mg Neurontin

gabapentin oral solution 250 mg/5ml, 300 mg/6ml Neurontin

gabapentin oral tablet 600 mg, 800 mg Neurontin lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

LaMICtal XR

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg LaMICtal

lamotrigine oral tablet chewable 25 mg, 5 mg LaMICtal levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg Keppra XR

levetiracetam oral solution 100 mg/ml Keppra levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg Keppra

oxcarbazepine oral suspension 300 mg/5ml Trileptal oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Trileptal

35

Formulary Drug Name Reference Restrictions primidone oral tablet 250 mg, 50 mg Mysoline topiramate oral capsule sprinkle 15 mg, 25 mg Topamax Sprinkle topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg Topamax

zonisamide oral capsule 100 mg, 25 mg Zonegran zonisamide oral capsule 50 mg EPITOL ORAL TABLET 200 MG CarBAMazepine LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

ST

ROWEEPRA ORAL TABLET 1000 MG, 500 MG, 750 MG LevETIRAcetam

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 400 MG

CarBAMazepine ER

TRILEPTAL ORAL SUSPENSION 300 MG/5ML OXcarbazepine

VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

*Carbamates*** felbamate oral suspension 600 mg/5ml Felbatol felbamate oral tablet 400 mg, 600 mg Felbatol

*Gaba Modulators*** tiagabine hcl oral tablet 2 mg, 4 mg Gabitril GABITRIL ORAL TABLET 12 MG, 16 MG GABITRIL ORAL TABLET 2 MG, 4 MG TiaGABine HCl

*Hydantoins*** phenytoin oral suspension 125 mg/5ml Dilantin phenytoin oral tablet chewable 50 mg Dilantin Infatabs phenytoin sodium extended oral capsule 100 mg Dilantin

phenytoin sodium extended oral capsule 200 mg, 300 mg Phenytek

DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG Phenytoin

DILANTIN ORAL CAPSULE 100 MG Phenytoin Sodium Extended DILANTIN ORAL CAPSULE 30 MG PHENYTEK ORAL CAPSULE 200 MG, 300 MG Phenytoin Sodium Extended

36

Formulary Drug Name Reference Restrictions PHENYTOIN INFATABS ORAL TABLET CHEWABLE 50 MG Phenytoin

*Succinimides*** ethosuximide oral capsule 250 mg Zarontin ethosuximide oral solution 250 mg/5ml Zarontin CELONTIN ORAL CAPSULE 300 MG

*Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg Depakote ER

divalproex sodium oral capsule delayed release sprinkle 125 mg Depakote Sprinkles

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg Depakote

valproate sodium oral solution 250 mg/5ml Depakene valproic acid oral capsule 250 mg Depakene valproic acid oral solution 250 mg/5ml Depakene

*ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 mg, 30 mg, 45 mg Remeron mirtazapine oral tablet 7.5 mg mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg Remeron SolTab

*Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg Wellbutrin SR

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg Wellbutrin XL

bupropion hcl oral tablet 100 mg, 75 mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg

*Modified Cyclics*** trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

*Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 mg Nardil tranylcypromine sulfate oral tablet 10 mg Parnate

37

Formulary Drug Name Reference Restrictions *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg CeleXA

escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg Lexapro

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg PROzac

fluoxetine hcl oral solution 20 mg/5ml fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg Paxil

sertraline hcl oral concentrate 20 mg/ml Zoloft sertraline hcl oral tablet 100 mg, 25 mg, 50 mg Zoloft

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg Cymbalta

duloxetine hcl oral capsule delayed release particles 40 mg venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg Effexor XR

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

*Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 50 mg, 75 mg amitriptyline hcl oral tablet 25 mg Elavil amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg desipramine hcl oral tablet 10 mg, 25 mg Norpramin desipramine hcl oral tablet 100 mg, 150 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml

38

Formulary Drug Name Reference Restrictions imipramine hcl oral tablet 10 mg, 25 mg, 50 mg Tofranil

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg Pamelor

nortriptyline hcl oral solution 10 mg/5ml protriptyline hcl oral tablet 10 mg, 5 mg

*ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 mg Precose miglitol oral tablet 100 mg, 25 mg, 50 mg Glyset

*Biguanides*** metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg Glucophage XR

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg Glucophage

*Diabetic Other - Combinations*** cvs glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC glucose instant energy oral tablet chewable 4 -6 gm-mg, 6-4 mg-gm ReliOn Glucose OTC

glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC gnp glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC goodsense glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC

hm glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC hy-vee glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC

kroger glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC

leader glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC

longs glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC meijer glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC

preferred plus glucose oral tablet chewable 4 -6 gm-mg ReliOn Glucose OTC

px glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC ra glucose oral tablet chewable 4-6 gm-mg, 6 -4 mg-gm ReliOn Glucose OTC

sm glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC tgt glucose oral tablet chewable 4-0.006 gm, 4-6 gm-mg ReliOn Glucose OTC

39

Formulary Drug Name Reference Restrictions up & up glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC

value plus glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC

walgreens glucose oral tablet chewable 4-6 gm-mg ReliOn Glucose OTC

DEX4 GLUCOSE ORAL TABLET CHEWABLE 4-6 GM-MG HM Glucose OTC

DEX4 NATURALS ORAL TABLET CHEWABLE 4-6 GM-MG HM Glucose OTC

DEX4 ORAL TABLET CHEWABLE 4-6 GM-MG HM Glucose OTC

DEX4 POUCH PACK ORAL TABLET CHEWABLE 4-6 GM-MG HM Glucose OTC

RELION GLUCOSE ORAL TABLET CHEWABLE 4-6 GM-MG HM Glucose OTC

SMART SENSE GLUCOSE ORAL TABLET CHEWABLE 4-6 GM-MG HM Glucose OTC

*Diabetic Other*** cvs glucose oral gel 15 gm/38gm, 40 % Glutose 15 OTC cvs glucose oral tablet chewable 4 gm Dex4 Quick Dissolve Glucose OTC cvs glucose shot oral liquid 15 gm/59ml ReliOn Glucose Drink OTC glucose oral gel 40 % Glutose 15 OTC glucose oral liquid 15 gm/59ml ReliOn Glucose Drink OTC glucose oral tablet chewable 4 gm Dex4 Quick Dissolve Glucose OTC gnp glucose oral tablet chewable 4 gm Dex4 Quick Dissolve Glucose OTC gnp quick dissolve glucose oral tablet chewable 4 gm Dex4 Quick Dissolve Glucose OTC

leader quick dissolve glucose oral tablet chewable 4 gm Dex4 Quick Dissolve Glucose OTC

ra glucose oral gel 40 % Glutose 15 OTC sm glucose oral tablet chewable 4 gm Dex4 Quick Dissolve Glucose OTC value plus glucose oral gel 40 % Glutose 15 OTC walgreens glucose oral tablet chewable 4 gm Dex4 Quick Dissolve Glucose OTC BD GLUCOSE ORAL TABLET CHEWABLE 5 GM OTC

DEX4 QUICK DISSOLVE GLUCOSE ORAL TABLET CHEWABLE 4 GM CVS Glucose OTC

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG QLL (1 EA per 1 Fill)

GLUCAGON EMERGENCY INJECTION KIT 1 MG QLL (1 EA per 1 Fill)

40

Formulary Drug Name Reference Restrictions GLUCO BURST ORAL GEL 40 % Value Plus Glucose OTC GLUTOSE 15 ORAL GEL 40 % Value Plus Glucose OTC INSTA-GLUCOSE ORAL GEL 77.4 % OTC RELION GLUCOSE DRINK ORAL LIQUID 15 GM/59ML Glucose OTC

RELION GLUCOSE ORAL GEL 15 GM/38GM Value Plus Glucose OTC

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG TRADJENTA ORAL TABLET 5 MG

*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000 MG, 50-500 MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 -1000 MG, 50-1000 MG, 50-500 MG JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG

*Human Insulin*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

41

Formulary Drug Name Reference Restrictions HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

OTC

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML OTC

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

OTC

HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML OTC

HUMULIN R INJECTION SOLUTION 100 UNIT/ML OTC

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

OTC

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML OTC

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML OTC

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML OTC

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML OTC

NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML OTC

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

42

Formulary Drug Name Reference Restrictions NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MCG/0.04ML BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML

*Meglitinide Analogues*** nateglinide oral tablet 120 mg, 60 mg Starlix repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg, 2 mg Prandin

*Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg

*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors***

FARXIGA ORAL TABLET 10 MG, 5 MG ST; QLL (30 EA per 30 days); AL (Min 18 Years)

INVOKANA ORAL TABLET 100 MG, 300 MG

ST; QLL (1 EA per 1 day); AL (Min 18 Years)

*Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

43

Formulary Drug Name Reference Restrictions glyburide-metformin oral tablet 1.25-250 mg glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg Glucovance

*Sulfonylureas*** chlorpropamide oral tablet 100 mg, 250 mg glimepiride oral tablet 1 mg, 2 mg, 4 mg Amaryl glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg Glucotrol XL

glipizide oral tablet 10 mg, 5 mg Glucotrol glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg Glucotrol XL

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg Glynase

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg tolazamide oral tablet 250 mg, 500 mg tolbutamide oral tablet 500 mg

*Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg Duetact

*Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet 15 -500 mg, 15-850 mg Actoplus Met

*Thiazolidinediones*** pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg Actos

AVANDIA ORAL TABLET 2 MG, 4 MG ST

*ANTIDIARRHEALS* *Antidiarrheal Agents - Misc.*** acidophilus oral capsule Dofus OTC

*Antiperistaltic Agents*** anti-diarrheal oral capsule 2 mg Imodium A-D OTC anti-diarrheal oral liquid 1 mg/5ml OTC cvs anti-diarrheal oral capsule 2 mg Imodium A-D OTC diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml diphenoxylate-atropine oral tablet 2.5-0.025 mg Lomotil

eq anti-diarrheal oral capsule 2 mg Imodium A-D OTC

44

Formulary Drug Name Reference Restrictions eq anti-diarrheal oral liquid 1 mg/5ml OTC gnp anti-diarrheal oral capsule 2 mg Imodium A-D OTC gnp anti-diarrheal oral liquid 1 mg/5ml OTC hm loperamide hcl oral capsule 2 mg Imodium A-D OTC loperamide hcl oral capsule 2 mg Imodium A-D loperamide hcl oral liquid 1 mg/5ml OTC meijer anti-diarrheal oral liquid 1 mg/5ml OTC ra anti-diarrheal oral capsule 2 mg Imodium A-D OTC ra anti-diarrheal oral liquid 1 mg/5ml OTC sm anti-diarrheal oral capsule 2 mg Imodium A-D OTC sm anti-diarrheal oral liquid 1 mg/5ml OTC tgt loperamide hcl oral capsule 2 mg Imodium A-D OTC

*ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG

*Opioid Antagonists*** naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml naloxone hcl injection solution cartridge 0.4 mg/ml naloxone hcl injection solution prefilled syringe 2 mg/2ml naltrexone hcl oral tablet 50 mg NARCAN NASAL LIQUID 4 MG/0.1ML VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG

*ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 mg QLL (10 EA per 1 Rx) ondansetron hcl oral solution 4 mg/5ml Zofran ondansetron hcl oral tablet 24 mg QLL (1 EA per 1 Rx) ondansetron hcl oral tablet 4 mg, 8 mg Zofran QLL (15 EA per 1 Rx) ondansetron oral tablet dispersible 4 mg, 8 mg Zofran ODT QLL (15 EA per 1 Rx)

*Antiemetic Combinations*** anti-nausea oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC anti-nausea/rekematol oral solution 1.87-1.87 -21.5 Little Tummys Nausea Relief OTC

cvs nausea relief oral liquid 1.87-1.87-21.5 Little Tummys Nausea Relief OTC

45

Formulary Drug Name Reference Restrictions eq anti-nausea oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC eql anti-nausea oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC formula em oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC gnp anti-nausea oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC hm anti-nausea oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC nausatrol oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC nausea control oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC ra anti-nausea oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC sb anti-nausea oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC sm anti-nausea oral solution 1.87-1.87-21.5 Little Tummys Nausea Relief OTC LITTLE TUMMYS NAUSEA RELIEF ORAL SOLUTION 1.87-1.87-21.5 GNP Anti-Nausea OTC

*Antiemetics - Anticholinergic*** cvs motion sickness ii oral tablet 25 mg Dramamine Less Drowsy OTC cvs motion sickness oral tablet 50 mg Dramamine OTC cvs motion sickness relief oral tablet chewable 25 mg OTC

dimenhydrinate oral tablet 50 mg Dramamine eq motion sickness oral tablet 50 mg Dramamine OTC eq motion sickness relief oral tablet 25 mg Dramamine Less Drowsy OTC eq motion sickness relief oral tablet 50 mg Dramamine OTC eql motion sickness relief oral tablet 25 mg Dramamine Less Drowsy OTC gnp motion sickness relief oral tablet 25 mg Dramamine Less Drowsy OTC gnp motion sickness relief oral tablet 50 mg Dramamine OTC hm motion relief oral tablet 25 mg Dramamine Less Drowsy OTC hm motion sickness oral tablet 50 mg Dramamine OTC hm motion sickness relief oral tablet 25 mg Dramamine Less Drowsy OTC hm motion sickness relief oral tablet 50 mg Dramamine OTC meclizine hcl oral tablet 12.5 mg meclizine hcl oral tablet 25 mg Dramamine Less Drowsy meclizine hcl oral tablet chewable 25 mg OTC motion sickness oral tablet 50 mg Dramamine OTC motion sickness relief oral tablet 50 mg Dramamine OTC motion sickness relief oral tablet chewable 25 mg OTC

motion-time oral tablet chewable 25 mg OTC ra motion sickness relief oral tablet 25 mg Dramamine Less Drowsy OTC ra motion sickness relief oral tablet 50 mg Dramamine OTC

46

Formulary Drug Name Reference Restrictions ra motion sickness relief oral tablet chewable 25 mg OTC

sb motion sickness oral tablet 50 mg Dramamine OTC sm motion sickness oral tablet 25 mg Dramamine Less Drowsy OTC sm motion sickness oral tablet 50 mg Dramamine OTC sm motion sickness relief oral tablet 50 mg Dramamine OTC travel sickness oral tablet 50 mg Dramamine OTC travel sickness oral tablet chewable 25 mg OTC trav-tabs oral tablet 50 mg Dramamine OTC trimethobenzamide hcl oral capsule 300 mg Tigan DRAMAMINE LESS DROWSY ORAL TABLET 25 MG SM Motion Sickness OTC

DRIMINATE ORAL TABLET 50 MG HM Motion Sickness OTC WAL-DRAM II ORAL TABLET 25 MG SM Motion Sickness OTC WAL-DRAM ORAL TABLET 50 MG HM Motion Sickness OTC

*Antiemetics - Miscellaneous*** dronabinol oral capsule 10 mg, 2.5 mg, 5 mg Marinol PA

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant oral capsule 125 mg Emend QLL (1 EA per 1 Rx) aprepitant oral capsule 40 mg Emend QLL (4 EA per 1 Rx) aprepitant oral capsule 80 & 125 mg Emend Tri-Pack QLL (1 Pack per 1 Rx) aprepitant oral capsule 80 mg Emend QLL (2 EA per 1 Rx)

*ANTIFUNGALS* *Antifungals*** bio-statin oral powder griseofulvin microsize oral suspension 125 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg Gris-PEG

nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 mg LamISIL

*Imidazoles*** ketoconazole oral tablet 200 mg

*Triazoles*** fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml Diflucan

47

Formulary Drug Name Reference Restrictions fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg Diflucan

itraconazole oral capsule 100 mg Sporanox

*ANTIHISTAMINES* *Antihistamines - Alkylamines*** aller-chlor oral syrup 2 mg/5ml Diabetic Tussin Allergy OTC brompheniramine tannate oral tablet chewable 12 mg

ed chlorped jr oral syrup 2 mg/5ml Diabetic Tussin Allergy OTC; QLL (120 ML per 30 days)

DIABETIC TUSSIN ALLERGY ORAL SYRUP 2 MG/5ML Ed Chlorped Jr OTC

*Antihistamines - Ethanolamines*** allergy childrens oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC allergy medication childrens oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC

allergy relief childrens oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC; QLL (120 ML per 30

days) allergy relief childrens oral tablet dispersible 12.5 mg

Wal-Dryl Allergy Rel Childrens OTC

carbinoxamine maleate oral tablet 4 mg childrens allergy oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC clemastine fumarate oral tablet 2.68 mg cvs allergy childrens oral tablet chewable 12.5 mg Benadryl Allergy Childrens OTC

cvs allergy oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC cvs allergy relief adult oral liquid 50 mg/20ml Scot-Tussin Allergy Relief OTC cvs allergy relief oral liquid 25 mg/10ml Scot-Tussin Allergy Relief OTC cvs childrens allergy oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC diphenhist oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC diphenhydramine hcl oral capsule 50 mg Banophen eq allergy relief childrens oral elixir 12.5 mg/5ml OTC

eq allergy relief childrens oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC

eq allergy relief childrens oral tablet dispersible 12.5 mg


eql allergy relief childrens oral tablet dispersible 12.5 mg


eql childrens allergy oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC gnp childrens allergy oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC

48

Formulary Drug Name Reference Restrictions hm allergy childrens oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC hm allergy relief childrens oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC

kp diphenhydramine hcl oral capsule 50 mg Banophen OTC ormir oral capsule 50 mg Banophen OTC pharbedryl oral capsule 50 mg Banophen px allergy oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC q-dryl oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC ra allergy medication oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC ra allergy oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC ra allergy relief childrens oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC

ra allergy relief childrens oral tablet dispersible 12.5 mg


sb allergy medicine oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC siladryl allergy oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC silphen cough oral syrup 12.5 mg/5ml OTC sm allergy relief childrens oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC

sm allergy relief oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC tgt allergy childrens oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC tgt allergy melts childrens oral tablet dispersible 12.5 mg


tgt allergy relief childrens oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief OTC

BANOPHEN ORAL CAPSULE 50 MG DiphenhydrAMINE HCl OTC BANOPHEN ORAL LIQUID 12.5 MG/5ML Q-Dryl OTC

NARAMIN ORAL LIQUID 12.5 MG/5ML Q-Dryl OTC PEDIACARE CHILDRENS ALLERGY ORAL LIQUID 12.5 MG/5ML Q-Dryl OTC

RA DIPHEDRYL ALLERGY ORAL LIQUID 12.5 MG/5ML Q-Dryl OTC

SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID 12.5 MG/5ML Q-Dryl OTC

TOTAL ALLERGY MEDICINE ORAL LIQUID 12.5 MG/5ML Q-Dryl OTC

WAL-DRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 MG/5ML Q-Dryl OTC

WAL-DRYL ALLERGY ORAL LIQUID 12.5 MG/5ML Q-Dryl OTC

49

Formulary Drug Name Reference Restrictions WAL-DRYL ALLERGY REL CHILDRENS ORAL TABLET DISPERSIBLE 12.5 MG

RA Allergy Relief Childrens OTC

*Antihistamines - Non-Sedating*** all day allergy childrens oral solution 1 mg/ml, 5 mg/5ml KLS Aller-Tec Childrens OTC

all day allergy oral tablet 10 mg ZyrTEC Allergy OTC all-day allergy childrens oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC

allergy 24hour indoor/outdoor oral tablet 10 mg ZyrTEC Allergy OTC

allergy childrens oral syrup 5 mg/5ml Claritin OTC allergy oral tablet 10 mg Claritin OTC allergy relief child oral syrup 5 mg/5ml Claritin OTC allergy relief childrens oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC allergy relief childrens oral syrup 5 mg/5ml Claritin OTC allergy relief childrens oral tablet dispersible 10 mg Claritin Reditabs OTC

allergy relief for kids oral syrup 5 mg/5ml Claritin OTC allergy relief oral tablet 10 mg Claritin OTC allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC cetirizine hcl allergy child oral solution 5 mg/5ml KLS Aller-Tec Childrens

cetirizine hcl childrens alrgy oral syrup 1 mg/ml KLS Aller-Tec Childrens OTC

cetirizine hcl childrens oral solution 1 mg/ml, 5 mg/5ml KLS Aller-Tec Childrens OTC

cetirizine hcl hives relief oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC

cetirizine hcl oral solution 1 mg/ml KLS Aller-Tec Childrens cetirizine hcl oral syrup 1 mg/ml KLS Aller-Tec Childrens cetirizine hcl oral tablet 10 mg ZyrTEC Allergy OTC cetirizine hcl oral tablet 5 mg OTC childrens loratadine oral solution 5 mg/5ml Claritin OTC childrens loratadine oral syrup 5 mg/5ml Claritin OTC cvs allergy relief childrens oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC

cvs allergy relief childrens oral syrup 5 mg/5ml Claritin OTC

cvs allergy relief oral tablet 10 mg Claritin OTC cvs allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC

50

Formulary Drug Name Reference Restrictions cvs indoor/outdoor allergy rlf oral tablet 10 mg ZyrTEC Allergy OTC

cvs loratadine oral tablet 10 mg Claritin OTC eq allergy relief (cetirizine) oral solution 1 mg/ml KLS Aller-Tec Childrens OTC

eq allergy relief (cetirizine) oral tablet 10 mg ZyrTEC Allergy OTC eq allergy relief childrens oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC

eq allergy relief childrens oral syrup 5 mg/5ml Claritin OTC eq allergy relief oral tablet 10 mg Claritin OTC eq childrens loratadine oral syrup 5 mg/5ml Claritin OTC eq loratadine oral tablet 10 mg Claritin OTC eql all day allergy childrens oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC

eql all day allergy oral tablet 10 mg ZyrTEC Allergy OTC eql allergy relief oral tablet 10 mg Claritin OTC gnp all day allergy childrens oral solution 1 mg/ml, 5 mg/5ml KLS Aller-Tec Childrens OTC

gnp all day allergy childrens oral syrup 5 mg/5ml KLS Aller-Tec Childrens OTC

gnp all day allergy oral tablet 10 mg ZyrTEC Allergy OTC gnp allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC gnp loratadine childrens oral syrup 5 mg/5ml Claritin OTC gnp loratadine oral syrup 5 mg/5ml Claritin OTC gnp loratadine oral tablet 10 mg Claritin OTC goodsense all day allergy oral tablet 10 mg ZyrTEC Allergy OTC hm all day allergy oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC hm all day allergy oral tablet 10 mg ZyrTEC Allergy OTC hm allergy complete childrens oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC

hm allergy relief oral tablet 10 mg Claritin OTC hm allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC hm cetirizine hcl childrens oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC

hm loratadine childrens oral syrup 5 mg/5ml Claritin OTC hm loratadine oral tablet 10 mg Claritin OTC kp cetirizine hcl oral tablet 10 mg ZyrTEC Allergy OTC kp cetirizine hcl oral tablet 5 mg OTC kp loratadine oral tablet 10 mg Claritin OTC loradamed oral tablet 10 mg Claritin OTC

51

Formulary Drug Name Reference Restrictions loratadine allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC

loratadine childrens oral solution 5 mg/5ml Claritin OTC loratadine childrens oral syrup 5 mg/5ml Claritin OTC loratadine hives relief oral solution 5 mg/5ml Claritin OTC loratadine oral tablet 10 mg Claritin OTC meijer allergy relief oral tablet 10 mg Claritin OTC meijer allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC

meijer loratadine oral syrup 5 mg/5ml Claritin OTC px allergy relief cetirizine oral tablet 10 mg ZyrTEC Allergy OTC px allergy relief loratadine oral tablet 10 mg Claritin OTC px allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC px childrens allergy oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC qc all day allergy oral tablet 10 mg ZyrTEC Allergy OTC qc allergy relief childrens oral syrup 1 mg/ml KLS Aller-Tec Childrens OTC qc allergy relief childrens oral syrup 5 mg/5ml Claritin OTC qc allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC qc loratadine allergy relief oral tablet 10 mg Claritin OTC ra allergy relief childrens oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC

ra allergy relief childrens oral syrup 5 mg/5ml KLS Aller-Tec Childrens OTC ra allergy relief oral tablet 10 mg ZyrTEC Allergy OTC ra allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC ra cetirizine hcl child allrgy oral syrup 5 mg/5ml KLS Aller-Tec Childrens OTC

ra cetirizine oral tablet 10 mg ZyrTEC Allergy OTC ra loratadine childrens oral syrup 5 mg/5ml Claritin OTC ra loratadine oral syrup 5 mg/5ml Claritin OTC ra loratadine oral tablet 10 mg Claritin OTC ra loratadine oral tablet dispersible 10 mg Claritin Reditabs OTC sb allergy oral tablet 10 mg ZyrTEC Allergy OTC sb allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC sb cetirizine hcl childrens oral syrup 1 mg/ml KLS Aller-Tec Childrens OTC sb loratadine allergy relief oral tablet 10 mg Claritin OTC sb loratadine oral syrup 5 mg/5ml Claritin OTC sb loratadine oral tablet 10 mg Claritin OTC sm all day allergy childrens oral solution 1 mg/ml, 5 mg/5ml KLS Aller-Tec Childrens OTC

52

Formulary Drug Name Reference Restrictions sm all day allergy oral tablet 10 mg ZyrTEC Allergy OTC sm allergy relief loratadine oral tablet 10 mg Claritin OTC sm allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC sm childrens loratadine oral syrup 5 mg/5ml Claritin OTC sm loratadine allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC

sm loratadine oral syrup 5 mg/5ml Claritin OTC sm loratadine oral tablet 10 mg Claritin OTC sm loratadine oral tablet dispersible 10 mg Claritin Reditabs OTC sw allergy relief oral tablet 10 mg ZyrTEC Allergy OTC tgt all day allergy childrens oral solution 5 mg/5ml KLS Aller-Tec Childrens OTC

tgt all day allergy childrens oral syrup 5 mg/5ml KLS Aller-Tec Childrens OTC

tgt all day allergy relief oral tablet 10 mg ZyrTEC Allergy OTC tgt allergy relief oral tablet 10 mg Claritin OTC tgt allergy relief oral tablet dispersible 10 mg Claritin Reditabs OTC tgt loratadine childrens oral syrup 5 mg/5ml Claritin OTC ALAVERT ORAL TABLET 10 MG Loratadine OTC ALAVERT ORAL TABLET DISPERSIBLE 10 MG PX Allergy Relief OTC

CLARITIN ALLERGY CHILDRENS ORAL SYRUP 5 MG/5ML Meijer Loratadine OTC

KLS ALLERCLEAR ORAL TABLET 10 MG Loratadine OTC

KLS ALLER-TEC CHILDRENS ORAL SOLUTION 1 MG/ML, 5 MG/5ML RA Allergy Relief Childrens OTC

KLS ALLER-TEC ORAL TABLET 10 MG Cetirizine HCl OTC TRIAMINIC ALLERCHEWS ORAL TABLET DISPERSIBLE 10 MG PX Allergy Relief OTC

WAL-ITIN ALLERGY REDITABS ORAL TABLET DISPERSIBLE 10 MG PX Allergy Relief OTC

WAL-ITIN ALLER-MELTS ORAL TABLET DISPERSIBLE 10 MG PX Allergy Relief OTC

WAL-ITIN CHILDRENS ORAL SOLUTION 5 MG/5ML Meijer Loratadine OTC

WAL-ITIN ORAL SYRUP 5 MG/5ML Meijer Loratadine OTC WAL-ITIN ORAL TABLET 10 MG Loratadine OTC WAL-ITIN ORAL TABLET DISPERSIBLE 10 MG PX Allergy Relief OTC

53

Formulary Drug Name Reference Restrictions WAL-VERT ORAL TABLET DISPERSIBLE 10 MG PX Allergy Relief OTC

WAL-ZYR ALL DAY ALLERGY CHILD ORAL SOLUTION 5 MG/5ML RA Allergy Relief Childrens OTC

WAL-ZYR CHILDRENS ORAL SOLUTION 1 MG/ML, 5 MG/5ML RA Allergy Relief Childrens OTC

WAL-ZYR ORAL TABLET 10 MG Cetirizine HCl OTC

*Antihistamines - Phenothiazines*** promethazine hcl oral solution 6.25 mg/5ml AL (Min 2 Years) promethazine hcl oral syrup 6.25 mg/5ml AL (Min 2 Years) promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg AL (Min 2 Years)

promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg Phenergan

PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG Promethazine HCl AL (Min 2 Years)

PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG Promethazine HCl

PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG Promethazine HCl

PROMETHEGAN RECTAL SUPPOSITORY 50 MG Promethazine HCl AL (Min 2 Years)

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

*ANTIHYPERLIPIDEMICS* *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite cholestyramine light oral powder 4 gm/dose Prevalite cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran colestipol hcl oral granules 5 gm Colestid Flavored colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid PREVALITE ORAL PACKET 4 GM Cholestyramine Light PREVALITE ORAL POWDER 4 GM/DOSE Cholestyramine Light

WELCHOL ORAL TABLET 625 MG

54

Formulary Drug Name Reference Restrictions *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg Lofibra

fenofibrate oral tablet 145 mg, 48 mg Tricor fenofibrate oral tablet 160 mg Triglide fenofibrate oral tablet 54 mg Lofibra fenofibric acid oral capsule delayed release 135 mg, 45 mg Trilipix

gemfibrozil oral tablet 600 mg Lopid

*Hmg Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg Lipitor

fluvastatin sodium er oral tablet extended release 24 hour 80 mg Lescol XL

fluvastatin sodium oral capsule 20 mg Lescol fluvastatin sodium oral capsule 40 mg lovastatin oral tablet 10 mg, 20 mg lovastatin oral tablet 40 mg Mevacor pravastatin sodium oral tablet 10 mg pravastatin sodium oral tablet 20 mg, 40 mg, 80 mg Pravachol

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg Crestor

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg Zocor

*Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 mg Zetia ZETIA ORAL TABLET 10 MG Ezetimibe

*Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg Niaspan

*ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg Lotrel

amlodipine besy-benazepril hcl oral capsule 2.5-10 mg, 5-40 mg

55

Formulary Drug Name Reference Restrictions *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet 10 -12.5 mg, 20-12.5 mg, 20-25 mg Lotensin HCT

benazepril-hydrochlorothiazide oral tablet 5 -6.25 mg captopril-hydrochlorothiazide oral tablet 25 -15 mg, 25-25 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet 10 -25 mg Vaseretic

enalapril-hydrochlorothiazide oral tablet 5 -12.5 mg fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg lisinopril-hydrochlorothiazide oral tablet 10 -12.5 mg, 20-12.5 mg, 20-25 mg Zestoretic

moexipril-hydrochlorothiazide oral tablet 15 -12.5 mg, 15-25 mg, 7.5-12.5 mg quinapril-hydrochlorothiazide oral tablet 10 -12.5 mg, 20-12.5 mg, 20-25 mg Accuretic

*Ace Inhibitors*** benazepril hcl oral tablet 10 mg, 20 mg, 40 mg Lotensin benazepril hcl oral tablet 5 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg Vasotec

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg lisinopril oral tablet 10 mg, 20 mg, 5 mg Prinivil lisinopril oral tablet 2.5 mg, 30 mg, 40 mg Zestril moexipril hcl oral tablet 15 mg, 7.5 mg perindopril erbumine oral tablet 2 mg perindopril erbumine oral tablet 4 mg, 8 mg Aceon quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg Accupril

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg Altace

trandolapril oral tablet 1 mg, 2 mg trandolapril oral tablet 4 mg Mavik

56

Formulary Drug Name Reference Restrictions *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

*Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet 10 -160 mg, 10-320 mg, 5-160 mg, 5-320 mg Exforge

*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg Atacand HCT

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg Avalide

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg Hyzaar

valsartan-hydrochlorothiazide oral tablet 160 -12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

Diovan HCT

*Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg Atacand

irbesartan oral tablet 150 mg, 300 mg, 75 mg Avapro losartan potassium oral tablet 100 mg, 25 mg, 50 mg Cozaar

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Diovan

DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG Valsartan

*Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet 10-160 -12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

Exforge HCT

*Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Catapres

guanfacine hcl oral tablet 1 mg, 2 mg methyldopa oral tablet 250 mg, 500 mg

57

Formulary Drug Name Reference Restrictions CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 MG/24HR CloNIDine HCl

CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY 0.2 MG/24HR CloNIDine HCl

CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY 0.3 MG/24HR CloNIDine HCl

*Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg Cardura QLL (30 EA per 30 days)

doxazosin mesylate oral tablet 8 mg Cardura QLL (60 EA per 30 days) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg Minipress QLL (120 EA per 30 days) terazosin hcl oral capsule 1 mg, 5 mg QLL (30 EA per 30 days) terazosin hcl oral capsule 10 mg, 2 mg QLL (60 EA per 30 days)

*Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet 100-25 mg Tenoretic 100 atenolol-chlorthalidone oral tablet 50-25 mg Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet 10 -6.25 mg, 2.5-6.25 mg, 5-6.25 mg Ziac

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg metoprolol-hydrochlorothiazide oral tablet 50-25 mg Lopressor HCT

nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg Corzide

propranolol-hctz oral tablet 40-25 mg, 80-25 mg

*Vasodilators*** hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg

*ANTI-INFECTIVE AGENTS -MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule 375 mg Flagyl metronidazole oral tablet 250 mg, 500 mg Flagyl trimethoprim oral tablet 100 mg vancomycin hcl intravenous solution reconstituted 10 gm, 1000 mg, 500 mg, 5000 mg

58

Formulary Drug Name Reference Restrictions vancomycin hcl oral capsule 125 mg, 250 mg Vancocin HCl FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML

*Anti-Infective Misc. -Combinations*** sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml Sulfatrim Pediatric

sulfamethoxazole-trimethoprim oral tablet 400-80 mg Bactrim

sulfamethoxazole-trimethoprim oral tablet 800-160 mg Bactrim DS

SULFATRIM PEDIATRIC ORAL SUSPENSION 200-40 MG/5ML

Sulfamethoxazole-Trimethoprim

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

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

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

*ANTIMALARIALS* *Antimalarials*** chloroquine phosphate oral tablet 250 mg, 500 mg hydroxychloroquine sulfate oral tablet 200 mg Plaquenil mefloquine hcl oral tablet 250 mg DARAPRIM ORAL TABLET 25 MG PA

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

*Antimyasthenic/Cholinergic Agents*** pyridostigmine bromide oral tablet 60 mg Mestinon

*ANTIMYASTHENIC/CHOLINER GIC AGENTS* pyridostigmine bromide oral tablet 60 mg Mestinon

59

Formulary Drug Name Reference Restrictions *ANTIMYCOBACTERIAL AGENTS* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100 mg, 400 mg Myambutol isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg Mycobutin rifampin oral capsule 150 mg, 300 mg Rifadin PRIFTIN ORAL TABLET 150 MG

*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** HEXALEN ORAL CAPSULE 50 MG MYLERAN ORAL TABLET 2 MG

*Antiadrenals*** LYSODREN ORAL TABLET 500 MG

*Antiandrogens*** bicalutamide oral tablet 50 mg Casodex QLL (30 EA per 30 days) flutamide oral capsule 125 mg

*Antiestrogens*** tamoxifen citrate oral tablet 10 mg, 20 mg FARESTON ORAL TABLET 60 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML

*Antimetabolites*** capecitabine oral tablet 150 mg Xeloda PA; QLL (140 EA per 21 days) capecitabine oral tablet 500 mg Xeloda PA; QLL (154 EA per 21 days) mercaptopurine oral tablet 50 mg methotrexate oral tablet 2.5 mg methotrexate sodium (pf) injection solution 1 gm/40ml, 100 mg/4ml, 200 mg/8ml, 250 mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml methotrexate sodium injection solution reconstituted 1 gm TABLOID ORAL TABLET 40 MG

60

Formulary Drug Name Reference Restrictions *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG PA; QLL (30 EA per 30 days)

*Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 200 MG PA; QLL (120 EA per 30 days) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG PA; QLL (30 EA per 30 days)

*Antineoplastic - Tyrosine Kinase Inhibitors*** imatinib mesylate oral tablet 100 mg Gleevec PA; QLL (90 EA per 30 days) imatinib mesylate oral tablet 400 mg Gleevec PA; QLL (60 EA per 30 days) CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; QLL (1 EA per 1 day)

IMBRUVICA ORAL CAPSULE 140 MG PA; QLL (120 EA per 30 days) TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG PA; QLL (30 EA per 30 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG PA; QLL (120 EA per 30 days)

TYKERB ORAL TABLET 250 MG PA; QLL (180 EA per 30 days) VOTRIENT ORAL TABLET 200 MG PA; QLL (120 EA per 30 days)

*Antineoplastics Misc.*** hydroxyurea oral capsule 500 mg Hydrea ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML PA

INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

PA

MATULANE ORAL CAPSULE 50 MG

*Aromatase Inhibitors*** anastrozole oral tablet 1 mg Arimidex QLL (30 EA per 30 days) exemestane oral tablet 25 mg Aromasin QLL (30 EA per 30 days) letrozole oral tablet 2.5 mg Femara QLL (30 EA per 30 days)

*Estrogens-Antineoplastic*** EMCYT ORAL CAPSULE 140 MG

61

Formulary Drug Name Reference Restrictions *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

*Imidazotetrazines*** temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg Temodar

*Mitotic Inhibitors*** etoposide oral capsule 50 mg

*Nitrogen Mustards*** ALKERAN ORAL TABLET 2 MG Melphalan LEUKERAN ORAL TABLET 2 MG

*Progestins-Antineoplastic*** megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml megestrol acetate oral tablet 20 mg, 40 mg

*Retinoids*** tretinoin oral capsule 10 mg

*Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG

*ANTI-OBESITY AGENT COMBINATIONS** *Anti-Obesity Agent Combinations** CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR 8-90 MG


*ANTIPARKINSON AGENTS* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg trihexyphenidyl hcl oral elixir 0.4 mg/ml trihexyphenidyl hcl oral tablet 2 mg, 5 mg

*Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 mg amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 100 mg bromocriptine mesylate oral capsule 5 mg Parlodel bromocriptine mesylate oral tablet 2.5 mg Parlodel

62

Formulary Drug Name Reference Restrictions *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 mg Eldepryl selegiline hcl oral tablet 5 mg

*Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg Sinemet CR

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg Sinemet

carbidopa-levodopa oral tablet dispersible 10 -100 mg, 25-100 mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg Stalevo 50 QLL (270 EA per 30 days)

carbidopa-levodopa-entacapone oral tablet 18.75-75-200 mg Stalevo 75 QLL (270 EA per 30 days)

carbidopa-levodopa-entacapone oral tablet 25-100-200 mg Stalevo 100 QLL (270 EA per 30 days)



carbidopa-levodopa-entacapone oral tablet 50-200-200 mg Stalevo 200 QLL (270 EA per 30 days)

*Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg Mirapex

ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg Requip XL

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg Requip

*Peripheral Comt Inhibitors*** entacapone oral tablet 200 mg Comtan QLL (120 EA per 30 days)

*ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300 mg Lithobid

lithium carbonate er oral tablet extended release 450 mg

63

Formulary Drug Name Reference Restrictions lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium oral solution 8 meq/5ml

*Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg Geodon AL (Min 18 Years)

GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG LATUDA ORAL TABLET 120 MG, 20 MG, 60 MG, 80 MG AL (Min 18 Years)

LATUDA ORAL TABLET 40 MG

*Benzisoxazoles*** risperidone oral solution 1 mg/ml RisperDAL AL (Min 18 Years) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg RisperDAL AL (Min 18 Years)

risperidone oral tablet dispersible 0.25 mg AL (Min 18 Years) risperidone oral tablet dispersible 0.5 mg, 3 mg, 4 mg RisperDAL M-TAB AL (Min 18 Years)

risperidone oral tablet dispersible 1 mg, 2 mg RisperiDONE M-TAB AL (Min 18 Years) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML

AL (Min 18 Years)

INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML

AL (Min 18 Years)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG

AL (Min 18 Years)

RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

RisperiDONE

*Butyrophenones*** haloperidol lactate injection solution 5 mg/ml Haldol AL (Min 18 Years) haloperidol lactate oral concentrate 2 mg/ml AL (Min 18 Years) haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg AL (Min 18 Years)

*Dibenzodiazepines*** clozapine oral tablet 100 mg, 25 mg Clozaril AL (Min 18 Years)

64

Formulary Drug Name Reference Restrictions clozapine oral tablet 200 mg AL (Min 18 Years) clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg FazaClo AL (Min 18 Years)

*Dibenzothiazepines*** quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

SEROquel XR AL (Min 18 Years)

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg SEROquel AL (Min 18 Years)

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG

QUEtiapine Fumarate ER AL (Min 18 Years)

*Dibenzoxazepines*** loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg AL (Min 18 Years)

*Phenothiazines*** chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg AL (Min 18 Years)

fluphenazine hcl oral concentrate 5 mg/ml AL (Min 18 Years) fluphenazine hcl oral elixir 2.5 mg/5ml AL (Min 18 Years) fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg AL (Min 18 Years)

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg AL (Min 18 Years)

prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg Compro thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg AL (Min 18 Years)

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg AL (Min 18 Years)

trifluoperazine hcl oral tablet 5 mg AL (Min 19 Years) COMPRO RECTAL SUPPOSITORY 25 MG Prochlorperazine

*Quinolinone Derivatives*** aripiprazole oral solution 1 mg/ml AL (Min 18 Years) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg Abilify AL (Min 18 Years)

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 400 MG

AL (Min 18 Years)

65

Formulary Drug Name Reference Restrictions ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML

AL (Min 18 Years)

*Thienbenzodiazepines*** olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 5 mg, 7.5 mg ZyPREXA AL (Min 18 Years)

olanzapine oral tablet 20 mg ZyPREXA AL (Min 6 Years) olanzapine oral tablet dispersible 10 mg, 15 mg ZyPREXA Zydis AL (Min 18 Years)

olanzapine oral tablet dispersible 20 mg, 5 mg ZyPREXA Zydis AL (Min 6 Years)

*Thioxanthenes*** thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg AL (Min 18 Years)

*ANTIRETROVIRALS ADJUVANTS*** *Antiretrovirals Adjuvants*** TYBOST ORAL TABLET 150 MG QLL (30 EA per 30 days)

*ANTISEPTICS & DISINFECTANTS* *Chlorine Antiseptics*** chlorhexidine gluconate solution 20 %

*ANTIVIRALS* *Antiretroviral Combinations*** abacavir sulfate-lamivudine oral tablet 600 -300 mg Epzicom

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg Trizivir

lamivudine-zidovudine oral tablet 150-300 mg Combivir lopinavir-ritonavir oral solution 400-100 mg/5ml Kaletra

ATRIPLA ORAL TABLET 600-200-300 MG QLL (30 EA per 30 days)

COMPLERA ORAL TABLET 200-25-300 MG DESCOVY ORAL TABLET 200-25 MG QLL (1 EA per 1 day) EVOTAZ ORAL TABLET 300-150 MG GENVOYA ORAL TABLET 150-150-200 -10 MG QLL (1 EA per 1 day)

KALETRA ORAL TABLET 100-25 MG, 200-50 MG

66

Formulary Drug Name Reference Restrictions PREZCOBIX ORAL TABLET 800-150 MG STRIBILD ORAL TABLET 150-150-200 -300 MG QLL (30 EA per 30 days)

TRIUMEQ ORAL TABLET 600-50-300 MG QLL (30 EA per 30 days)

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG QLL (30 EA per 30 days)

*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG

*Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG

*Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG QLL (60 EA per 30 days) ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG QLL (180 EA per 30 days)

TIVICAY ORAL TABLET 10 MG, 25 MG QLL (2 EA per 1 day) TIVICAY ORAL TABLET 50 MG QLL (60 EA per 30 days)

*Antiretrovirals - Protease Inhibitors*** APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML CRIXIVAN ORAL CAPSULE 200 MG, 400 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZISTA ORAL SUSPENSION 100 MG/ML QLL (400 ML per 30 days)

PREZISTA ORAL TABLET 150 MG, 75 MG QLL (60 EA per 30 days)

67

Formulary Drug Name Reference Restrictions PREZISTA ORAL TABLET 600 MG, 800 MG REYATAZ ORAL CAPSULE 150 MG, 300 MG QLL (30 EA per 30 days)

REYATAZ ORAL CAPSULE 200 MG QLL (60 EA per 30 days) REYATAZ ORAL PACKET 50 MG VIRACEPT ORAL TABLET 250 MG, 625 MG

*Antiretrovirals - Rti-Non-Nucleoside Analogues*** nevirapine er oral tablet extended release 24 hour 100 mg Viramune XR QLL (90 EA per 30 days)

nevirapine er oral tablet extended release 24 hour 400 mg Viramune XR

nevirapine oral suspension 50 mg/5ml Viramune nevirapine oral tablet 200 mg Viramune EDURANT ORAL TABLET 25 MG INTELENCE ORAL TABLET 100 MG, 200 MG INTELENCE ORAL TABLET 25 MG QLL (120 EA per 30 days) RESCRIPTOR ORAL TABLET 100 MG, 200 MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG

*Antiretrovirals - Rti-Nucleoside Analogues-Purines*** abacavir sulfate oral tablet 300 mg Ziagen didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg Videx EC

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM ZIAGEN ORAL SOLUTION 20 MG/ML

*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines*** lamivudine oral solution 10 mg/ml Epivir lamivudine oral tablet 150 mg, 300 mg Epivir EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML

68

Formulary Drug Name Reference Restrictions *Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg Zerit

zidovudine oral capsule 100 mg Retrovir zidovudine oral syrup 50 mg/5ml Retrovir zidovudine oral tablet 300 mg RETROVIR INTRAVENOUS SOLUTION 10 MG/ML

*Antiretrovirals - Rti-Nucleotide Analogues*** VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG QLL (30 EA per 30 days)

VIREAD ORAL TABLET 300 MG

*Hepatitis B Agents*** entecavir oral tablet 0.5 mg, 1 mg Baraclude QLL (30 EA per 30 days) lamivudine oral tablet 100 mg Epivir HBV QLL (30 EA per 30 days) BARACLUDE ORAL SOLUTION 0.05 MG/ML EPIVIR HBV ORAL SOLUTION 5 MG/ML QLL (300 ML per 30 days)

*Hepatitis C Agents*** ribavirin oral capsule 200 mg Rebetol ribavirin oral tablet 200 mg Ribasphere COPEGUS ORAL TABLET 200 MG Ribavirin ST PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML PA

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PA

PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML REBETOL ORAL SOLUTION 40 MG/ML ST; QLL (500 ML per 30 days) RIBASPHERE ORAL CAPSULE 200 MG Ribavirin RIBASPHERE ORAL TABLET 200 MG Ribavirin

69

Formulary Drug Name Reference Restrictions *Herpes Agents - Purine Analogues*** acyclovir oral capsule 200 mg Zovirax acyclovir oral suspension 200 mg/5ml Zovirax acyclovir oral tablet 400 mg, 800 mg Zovirax valacyclovir hcl oral tablet 1 gm, 500 mg Valtrex

*Herpes Agents - Thymidine Analogues*** famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg Famvir

*Influenza Agents*** rimantadine hcl oral tablet 100 mg Flumadine

*Neuraminidase Inhibitors*** oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg Tamiflu

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG Oseltamivir Phosphate

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

*ASSORTED CLASSES* *Antileprotics*** THALOMID ORAL CAPSULE 100 MG, 50 MG PA; QLL (30 EA per 30 days)

THALOMID ORAL CAPSULE 150 MG, 200 MG PA; QLL (60 EA per 30 days)

*Chelating Agents*** CUPRIMINE ORAL CAPSULE 250 MG

*Cyclosporine Analogs*** cyclosporine modified oral capsule 100 mg, 25 mg Neoral

cyclosporine modified oral capsule 50 mg Gengraf cyclosporine modified oral solution 100 mg/ml Neoral cyclosporine oral capsule 100 mg, 25 mg SandIMMUNE GENGRAF ORAL CAPSULE 100 MG, 25 MG, 50 MG CycloSPORINE Modified

GENGRAF ORAL SOLUTION 100 MG/ML CycloSPORINE Modified

70

Formulary Drug Name Reference Restrictions *Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG PA; QLL (30 EA per 30 days)

*Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mg CellCept mycophenolate mofetil oral suspension reconstituted 200 mg/ml CellCept

mycophenolate mofetil oral tablet 500 mg CellCept

*Irrigation Solutions*** sterile water for irrigation irrigation solution Argyle Sterile Water ARGYLE STERILE WATER IRRIGATION SOLUTION Sterile Water for Irrigation

*Macrolide Immunosuppressants*** sirolimus oral tablet 0.5 mg, 1 mg, 2 mg Rapamune tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Prograf RAPAMUNE ORAL SOLUTION 1 MG/ML

*Potassium Removing Resins*** sodium polystyrene sulfonate oral powder Kionex sodium polystyrene sulfonate oral suspension 15 gm/60ml Kionex

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml KIONEX ORAL POWDER Sodium Polystyrene Sulfonate KIONEX ORAL SUSPENSION 15 GM/60ML Sodium Polystyrene Sulfonate

SPS ORAL SUSPENSION 15 GM/60ML Sodium Polystyrene Sulfonate

*Purine Analogs*** azathioprine oral tablet 50 mg Imuran

*BETA BLOCKERS* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Coreg

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg

*Beta Blockers Cardio-Selective*** acebutolol hcl oral capsule 200 mg, 400 mg

71

Formulary Drug Name Reference Restrictions atenolol oral tablet 100 mg, 25 mg, 50 mg Tenormin betaxolol hcl oral tablet 10 mg, 20 mg bisoprolol fumarate oral tablet 10 mg, 5 mg metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

Toprol XL

metoprolol tartrate oral tablet 100 mg, 50 mg Lopressor metoprolol tartrate oral tablet 25 mg, 37.5 mg, 75 mg

*Beta Blockers Non-Selective*** nadolol oral tablet 20 mg, 40 mg, 80 mg Corgard pindolol oral tablet 10 mg, 5 mg propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

Inderal LA

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg Betapace AF

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg Sorine

timolol maleate oral tablet 10 mg, 20 mg, 5 mg SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG Sotalol HCl

*CALCIUM CHANNEL BLOCKERS* *Calcium Channel Blockers*** amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg Norvasc

diltiazem cd oral capsule extended release 24 hour 120 mg, 300 mg Cartia XT

diltiazem cd oral capsule extended release 24 hour 180 mg, 240 mg Cardizem CD

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 240 mg, 300 mg Taztia XT

diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 360 mg, 420 mg Tiazac

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 300 mg Cartia XT

72

Formulary Drug Name Reference Restrictions diltiazem hcl er coated beads oral capsule extended release 24 hour 180 mg, 240 mg, 360 mg

Cardizem CD

diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 360 mg Cardizem LA

diltiazem hcl er coated beads oral tablet extended release 24 hour 240 mg, 300 mg, 420 mg

Matzim LA

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg Cardizem diltiazem hcl oral tablet 90 mg dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg nicardipine hcl oral capsule 20 mg, 30 mg nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg Adalat CC

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 90 mg Procardia XL

nifedipine er osmotic release oral tablet extended release 24 hour 60 mg Nifedical XL

nifedipine oral capsule 10 mg Procardia nifedipine oral capsule 20 mg nimodipine oral capsule 30 mg nisoldipine er oral tablet extended release 24 hour 17 mg, 34 mg, 8.5 mg Sular

nisoldipine er oral tablet extended release 24 hour 20 mg, 25.5 mg, 30 mg, 40 mg verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg Verelan

verapamil hcl er oral capsule extended release 24 hour 200 mg, 300 mg Verelan PM

verapamil hcl er oral tablet extended release 120 mg, 180 mg Calan SR

verapamil hcl er oral tablet extended release 240 mg Isoptin SR

verapamil hcl oral tablet 120 mg, 80 mg Calan verapamil hcl oral tablet 40 mg

73

Formulary Drug Name Reference Restrictions AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG

NIFEdipine ER

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG

Diltiazem HCl ER Coated Beads

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG, 300 MG

DilTIAZem HCl ER Coated Beads

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

Diltiazem HCl ER Coated Beads

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG

NIFEdipine ER Osmotic Release

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

Diltiazem HCl ER Beads

*CARDIOTONICS* *Cardiac Glycosides*** digoxin oral solution 0.05 mg/ml digoxin oral tablet 125 mcg Digitek digoxin oral tablet 250 mcg Lanoxin DIGITEK ORAL TABLET 125 MCG, 250 MCG Digoxin

DIGOX ORAL TABLET 125 MCG, 250 MCG Digoxin

LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG

*CARDIOVASCULAR AGENTS -MISC.* *Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

Caduet

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg

*Prostaglandin Vasodilators*** VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML

74

Formulary Drug Name Reference Restrictions *Pulmonary Hypertension -Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG AL (Min 18 Years) TRACLEER ORAL TABLET 125 MG, 62.5 MG AL (Min 18 Years)

*Pulmonary Hypertension -Phosphodiesterase Inhibitors*** sildenafil citrate oral tablet 20 mg Revatio PA; AL (Min 18 Years) ADCIRCA ORAL TABLET 20 MG PA; AL (Min 18 Years)

*CEPHALOSPORINS* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cephalexin oral capsule 250 mg, 500 mg Keflex cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg

*Cephalosporins - 2Nd Generation*** cefaclor er oral tablet extended release 12 hour 500 mg cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg Ceftin CEFTIN ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML

*Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml Suprax

75

Formulary Drug Name Reference Restrictions cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg ceftriaxone sodium injection solution reconstituted 1 gm Rocephin QLL (2 EA per 1 Fill)

ceftriaxone sodium injection solution reconstituted 2 gm, 250 mg, 500 mg QLL (2 EA per 1 Fill)

SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG

*CHEMICALS* *Bulk Chemicals - Et's*** ethyl oleate liquid

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

*Bulk Chemicals - La's*** acidophilus lactobacillus powder , 10 bu/gm

*Bulk Chemicals - Le's*** calcium folinate powder leucovorin calcium powder

*Bulk Chemicals - Ph's*** phytonadione liquid vitamin k1 powder OTC

*Bulk Chemicals - Py's*** pyrimethamine powder

*Bulk Chemicals - St's*** stevia extract powder stevia extract powder 90 % OTC steviol glycosides powder 95 % stevioside fluid extract 15 %

*Fixed Oils*** castor oil oil cottonseed oil oil hm castor oil oil OTC olive oil oil qc castor oil oil OTC qc sweet oil oil OTC

76

Formulary Drug Name Reference Restrictions sesame oil oil sm sweet oil oil OTC sweet oil oil OTC

*Liquids*** benzyl benzoate liquid chlorhexidine gluconate solution glycerin liquid glycerine liquid glycerol formal liquid

*Solids*** sorbitol powder

*CONTRACEPTIVES* *Biphasic Contraceptives - Oral*** desogestrel-ethinyl estradiol oral tablet 0.15 -0.02/0.01 mg (21/5) Pimtrea

viorele oral tablet 0.15-0.02/0.01 mg (21/5) Pimtrea AZURETTE ORAL TABLET 0.15 -0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol

BEKYREE ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol

KIMIDESS ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol

NECON 10/11 (28) ORAL TABLET 35 MCG PIMTREA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol

*Combination Contraceptives -Oral*** alyacen 1/35 oral tablet 1-35 mg-mcg Pirmella 1/35 briellyn oral tablet 0.4-35 mg-mcg Philith desogestrel-ethinyl estradiol oral tablet 0.15 -30 mg-mcg Isibloom

drospirenone-ethinyl estradiol oral tablet 3 -0.02 mg Loryna

drospirenone-ethinyl estradiol oral tablet 3 -0.03 mg Syeda

ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg Zovia 1/50E (28)

77

Formulary Drug Name Reference Restrictions levonorgestrel-ethinyl estrad oral tablet 0.1 -20 mg-mcg Aubra

levonorgestrel-ethinyl estrad oral tablet 0.15 -30 mg-mcg Kurvelo

marlissa oral tablet 0.15-30 mg-mcg Kurvelo norethin ace-eth estrad-fe oral tablet 1-20 mg -mcg Tarina FE 1/20

norethin ace-eth estrad-fe oral tablet 1-20 mg -mcg(24) Larin 24 FE

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg Larin 1/20

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg MonoNessa

ALTAVERA ORAL TABLET 0.15-30 MG -MCG Levonorgestrel-Ethinyl Estrad

APRI ORAL TABLET 0.15-30 MG-MCG Desogestrel-Ethinyl Estradiol AUBRA ORAL TABLET 0.1-20 MG-MCG Levonorgestrel-Ethinyl Estrad AVIANE ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

BALZIVA ORAL TABLET 0.4-35 MG -MCG Briellyn

BLISOVI 24 FE ORAL TABLET 1-20 MG -MCG(24) Norethin Ace-Eth Estrad-FE

BLISOVI FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG BLISOVI FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE

CHATEAL ORAL TABLET 0.15-30 MG -MCG Levonorgestrel-Ethinyl Estrad

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG Alyacen 1/35

CYRED ORAL TABLET 0.15-30 MG -MCG Desogestrel-Ethinyl Estradiol

DASETTA 1/35 ORAL TABLET 1-35 MG -MCG Alyacen 1/35

DELYLA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

ELINEST ORAL TABLET 0.3-30 MG -MCG EMOQUETTE ORAL TABLET 0.15-30 MG-MCG Desogestrel-Ethinyl Estradiol

78

Formulary Drug Name Reference Restrictions ENSKYCE ORAL TABLET 0.15-30 MG -MCG Desogestrel-Ethinyl Estradiol

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol

FALMINA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

FEMYNOR ORAL TABLET 0.25-35 MG -MCG Norgestimate-Eth Estradiol

GIANVI ORAL TABLET 3-0.02 MG Drospirenone-Ethinyl Estradiol GILDAGIA ORAL TABLET 0.4-35 MG -MCG Briellyn

GILDESS FE 1.5/30 ORAL TABLET 1.5 -30 MG-MCG GILDESS FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE

ISIBLOOM ORAL TABLET 0.15-30 MG -MCG Desogestrel-Ethinyl Estradiol

JULEBER ORAL TABLET 0.15-30 MG -MCG Desogestrel-Ethinyl Estradiol

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG -MCG JUNEL 1/20 ORAL TABLET 1-20 MG -MCG

Norethindrone Acet-Ethinyl Est

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG JUNEL FE 1/20 ORAL TABLET 1-20 MG -MCG Norethin Ace-Eth Estrad-FE

JUNEL FE 24 ORAL TABLET 1-20 MG -MCG(24) Norethin Ace-Eth Estrad-FE

KELNOR 1/35 ORAL TABLET 1-35 MG -MCG KURVELO ORAL TABLET 0.15-30 MG -MCG Levonorgestrel-Ethinyl Estrad

LARIN 1.5/30 ORAL TABLET 1.5-30 MG -MCG LARIN 1/20 ORAL TABLET 1-20 MG -MCG


LARIN 24 FE ORAL TABLET 1-20 MG -MCG(24) Norethin Ace-Eth Estrad-FE

LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG LARIN FE 1/20 ORAL TABLET 1-20 MG -MCG Norethin Ace-Eth Estrad-FE

79

Formulary Drug Name Reference Restrictions LARISSIA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

LESSINA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG Levonorgestrel-Ethinyl Estrad

LOMEDIA 24 FE ORAL TABLET 1-20 MG-MCG(24) Norethin Ace-Eth Estrad-FE

LORYNA ORAL TABLET 3-0.02 MG Drospirenone-Ethinyl Estradiol LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG LUTERA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG MICROGESTIN 1/20 ORAL TABLET 1 -20 MG-MCG


MICROGESTIN 24 FE ORAL TABLET 1 -20 MG-MCG Norethin Ace-Eth Estrad-FE

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol

MONONESSA ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG Alyacen 1/35

NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG NIKKI ORAL TABLET 3-0.02 MG Drospirenone-Ethinyl Estradiol NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG Alyacen 1/35

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG Alyacen 1/35

OCELLA ORAL TABLET 3-0.03 MG Drospirenone-Ethinyl Estradiol OGESTREL ORAL TABLET 0.5-50 MG -MCG

80

Formulary Drug Name Reference Restrictions ORSYTHIA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

PHILITH ORAL TABLET 0.4-35 MG -MCG Briellyn

PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG Alyacen 1/35

PORTIA-28 ORAL TABLET 0.15-30 MG -MCG Levonorgestrel-Ethinyl Estrad

PREVIFEM ORAL TABLET 0.25-35 MG -MCG Norgestimate-Eth Estradiol

RECLIPSEN ORAL TABLET 0.15-30 MG -MCG Desogestrel-Ethinyl Estradiol

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol

SRONYX ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

SYEDA ORAL TABLET 3-0.03 MG Drospirenone-Ethinyl Estradiol TARINA FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE

VESTURA ORAL TABLET 3-0.02 MG Drospirenone-Ethinyl Estradiol VIENVA ORAL TABLET 0.1-20 MG -MCG Levonorgestrel-Ethinyl Estrad

VYFEMLA ORAL TABLET 0.4-35 MG -MCG Briellyn

WERA ORAL TABLET 0.5-35 MG-MCG ZARAH ORAL TABLET 3-0.03 MG Drospirenone-Ethinyl Estradiol ZENCHENT ORAL TABLET 0.4-35 MG -MCG Briellyn

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG Ethynodiol Diac-Eth Estradiol

*Combination Contraceptives -Transdermal*** XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR QLL (3 EA per 28 days)

*Combination Contraceptives -Vaginal*** NUVARING VAGINAL RING 0.12-0.015 MG/24HR QLL (1 EA per 30 days)

81

Formulary Drug Name Reference Restrictions *Continuous Contraceptives -Oral*** levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

*Copper Contraceptives - Iud*** PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

QLL (1 EA per 999 days)

*Copper Contraceptives - Iud*** (New) PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE


*Emergency Contraceptives*** levonorgestrel oral tablet 1.5 mg My Way AFTERA ORAL TABLET 1.5 MG Levonorgestrel OTC ECONTRA EZ ORAL TABLET 1.5 MG Levonorgestrel OTC ELLA ORAL TABLET 30 MG FALLBACK SOLO ORAL TABLET 1.5 MG Levonorgestrel OTC

MY WAY ORAL TABLET 1.5 MG Levonorgestrel NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG Levonorgestrel

OPCICON ONE-STEP ORAL TABLET 1.5 MG Levonorgestrel OTC

OPTION 2 ORAL TABLET 1.5 MG Levonorgestrel OTC; QLL (3 EA per 1 Year) REACT ORAL TABLET 1.5 MG Levonorgestrel OTC TAKE ACTION ORAL TABLET 1.5 MG Levonorgestrel OTC

*Extended-Cycle Contraceptives -Oral*** levonorgest-eth estrad 91-day oral tablet 0.15 -0.03 &0.01 mg Camrese

levonorgest-eth estrad 91-day oral tablet 0.15 -0.03 mg Quasense

AMETHIA ORAL TABLET 0.15-0.03 &0.01 MG

Levonorgest-Eth Estrad 91-Day

ASHLYNA ORAL TABLET 0.15-0.03 &0.01 MG


CAMRESE ORAL TABLET 0.15-0.03 &0.01 MG


82

Formulary Drug Name Reference Restrictions DAYSEE ORAL TABLET 0.15-0.03 &0.01 MG


INTROVALE ORAL TABLET 0.15-0.03 MG


JOLESSA ORAL TABLET 0.15-0.03 MG Levonorgest-Eth Estrad 91-Day

QUASENSE ORAL TABLET 0.15-0.03 MG


SETLAKIN ORAL TABLET 0.15-0.03 MG Levonorgest-Eth Estrad 91-Day

*Progestin Contraceptives -Implants*** NEXPLANON SUBCUTANEOUS IMPLANT 68 MG QLL (1 EA per 876 days)

*Progestin Contraceptives -Injectable*** medroxyprogesterone acetate intramuscular suspension 150 mg/ml Depo-Provera QLL (1 ML per 90 days)

medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml Depo-Provera

*Progestin Contraceptives - Iud*** KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MG QLL (1 EA per 999 days)

LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 18.6 MCG/DAY


MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/24HR QLL (1 EA per 999 days)

SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG QLL (1 EA per 999 days)

*Progestin Contraceptives - Oral*** norethindrone oral tablet 0.35 mg Lyza QLL (28 EA per 30 days) CAMILA ORAL TABLET 0.35 MG Norethindrone DEBLITANE ORAL TABLET 0.35 MG Norethindrone ERRIN ORAL TABLET 0.35 MG Norethindrone HEATHER ORAL TABLET 0.35 MG Norethindrone JENCYCLA ORAL TABLET 0.35 MG Norethindrone JOLIVETTE ORAL TABLET 0.35 MG Norethindrone LYZA ORAL TABLET 0.35 MG Norethindrone NORA-BE ORAL TABLET 0.35 MG Norethindrone NORLYDA ORAL TABLET 0.35 MG Norethindrone

83

Formulary Drug Name Reference Restrictions NORLYROC ORAL TABLET 0.35 MG Norethindrone SHAROBEL ORAL TABLET 0.35 MG Norethindrone

*Triphasic Contraceptives - Oral*** alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg -mcg Dasetta 7/7/7

levonorg-eth estrad triphasic oral tablet Myzilra norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg Tri-Estarylla

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7

DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7

ENPRESSE-28 ORAL TABLET Levonorg-Eth Estrad Triphasic LEENA ORAL TABLET 0.5/1/0.5-35 MG -MCG LEVONEST ORAL TABLET Levonorg-Eth Estrad Triphasic MYZILRA ORAL TABLET Levonorg-Eth Estrad Triphasic NECON 7/7/7 ORAL TABLET 0.5/0.75/1 -35 MG-MCG Alyacen 7/7/7

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7

PIRMELLA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7

TILIA FE ORAL TABLET 1-20/1-30/1-35 MG-MCG TRI FEMYNOR ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

Norgestim-Eth Estrad Triphasic

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG


TRI-LEGEST FE ORAL TABLET 1-20/1 -30/1-35 MG-MCG TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG


TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG


TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG


84

Formulary Drug Name Reference Restrictions TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG


TRIVORA (28) ORAL TABLET Levonorg-Eth Estrad Triphasic VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG

*CORTICOSTEROIDS* *Glucocorticosteroids*** budesonide oral capsule delayed release particles 3 mg Entocort EC

cortisone acetate oral tablet 25 mg dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral solution 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Cortef methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg Medrol

methylprednisolone oral tablet therapy pack 4 mg Medrol

prednisolone oral solution 15 mg/5ml prednisolone oral syrup 15 mg/5ml prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml Pediapred

prednisone oral solution 5 mg/5ml prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg, 50 mg prednisone oral tablet 20 mg Deltasone prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48) DELTASONE ORAL TABLET 20 MG PredniSONE

*Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 mg

*COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic*** benzonatate oral capsule 100 mg Tessalon Perles AL (Min 6 Years) benzonatate oral capsule 150 mg, 200 mg AL (Min 6 Years)

cough relief oral liquid 15 mg/5ml Wal-Tussin Cough Long Acting OTC

85

Formulary Drug Name Reference Restrictions cvs tussin cough oral capsule 15 mg Wal-Tussin Cough OTC

cvs tussin long-acting oral liquid 15 mg/5ml Wal-Tussin Cough Long Acting OTC

cvs tussin maximum strength oral syrup 15 mg/5ml Wal-Tussin Cough OTC

eql tussin cough long-acting oral syrup 15 mg/5ml Wal-Tussin Cough OTC

father johns medicine oral syrup 10 mg/5ml OTC

gnp cough relief oral liquid 15 mg/5ml Wal-Tussin Cough Long Acting OTC

gnp tussin cough long acting oral syrup 15 mg/5ml Wal-Tussin Cough OTC

hm cough relief oral liquid 15 mg/5ml Wal-Tussin Cough Long Acting OTC

px tussin max oral syrup 15 mg/5ml Wal-Tussin Cough OTC

qc cough relief oral liquid 15 mg/5ml Wal-Tussin Cough Long Acting OTC

ra tussin cough adult oral capsule 15 mg Wal-Tussin Cough OTC ra tussin cough oral capsule 15 mg Wal-Tussin Cough OTC ra tussin long acting cough oral liquid 15 mg/5ml

Wal-Tussin Cough Long Acting OTC

ra tussin maximum strength oral syrup 15 mg/5ml Wal-Tussin Cough OTC

robafen cough oral capsule 15 mg Wal-Tussin Cough OTC sb cough control oral capsule 15 mg Wal-Tussin Cough OTC silphen dm cough oral syrup 10 mg/5ml OTC sm cough relief oral syrup 15 mg/5ml Wal-Tussin Cough OTC tussin cough long-acting oral syrup 15 mg/5ml Wal-Tussin Cough OTC tussin cough oral capsule 15 mg Wal-Tussin Cough OTC tussin cough oral syrup 15 mg/5ml Wal-Tussin Cough OTC ROBITUSSIN LINGERING LA COUGH ORAL LIQUID 15 MG/5ML Cough Relief OTC; QLL (120 ML per 30

days) WAL-TUSSIN COUGH LONG ACTING ORAL LIQUID 15 MG/5ML Cough Relief OTC

WAL-TUSSIN COUGH LONG ACTING ORAL SYRUP 15 MG/5ML

CVS Tussin Maximum Strength OTC

WAL-TUSSIN COUGH ORAL CAPSULE 15 MG CVS Tussin Cough OTC; AL (Min 6 Years)

WAL-TUSSIN COUGH ORAL SYRUP 15 MG/5ML

CVS Tussin Maximum Strength


86

Formulary Drug Name Reference Restrictions *Antitussive - Opioid*** hydrocodone-homatropine oral syrup 5-1.5 mg/5ml AL (Min 6 Years)

hydrocodone-homatropine oral tablet 5-1.5 mg Tussigon AL (Min 2 Years)

hydromet oral syrup 5-1.5 mg/5ml TUSSIGON ORAL TABLET 5-1.5 MG Hydrocodone-Homatropine

*Antitussive-Decongestant-Analgesic*** day time pe cold/flu relief oral capsule 10-5 -325 mg Vicks DayQuil Cold & Flu OTC

daytime cold/flu relief oral capsule 10-5-325 mg Vicks DayQuil Cold & Flu OTC

day-time pe cold/flu relief oral capsule 10-5 -325 mg Vicks DayQuil Cold & Flu OTC

eq daytime cold/flu ms relief oral capsule 10 -5-325 mg Vicks DayQuil Cold & Flu OTC

eql daytime cold/flu relief oral capsule 10-5 -325 mg Vicks DayQuil Cold & Flu OTC

gnp day time cold/flu oral capsule 10-5-325 mg Vicks DayQuil Cold & Flu OTC

goodsense daytime oral capsule 10-5-325 mg Vicks DayQuil Cold & Flu OTC hm day time oral capsule 10-5-325 mg Vicks DayQuil Cold & Flu OTC px daytime pe oral capsule 10-5-325 mg Vicks DayQuil Cold & Flu OTC qc daytime cold/flu oral capsule 10-5-325 mg Vicks DayQuil Cold & Flu OTC ra cold/flu relief daytime oral capsule 10-5 -325 mg Vicks DayQuil Cold & Flu OTC

ra daytime multi-symp cold/flu oral capsule 10-5-325 mg Vicks DayQuil Cold & Flu OTC

ra daytime multi-symptom cold oral capsule 10-5-325 mg Vicks DayQuil Cold & Flu OTC

sb day time cold/flu relief oral capsule 10-5 -325 mg Vicks DayQuil Cold & Flu OTC

sm day time non drowsy oral capsule 10-5-325 mg Vicks DayQuil Cold & Flu OTC

sm day time pe cold/flu relief oral capsule 10 -5-325 mg Vicks DayQuil Cold & Flu OTC

tgt cold/flu relief day-time oral capsule 10-5 -325 mg Vicks DayQuil Cold & Flu OTC

ALKA-SELTZER PLS SINUS & COUGH ORAL CAPSULE 10-5-325 MG GNP Day Time Cold/Flu OTC

87

Formulary Drug Name Reference Restrictions ALKA-SELTZER PLUS DAY COLD/FLU ORAL CAPSULE 10-5-325 MG GNP Day Time Cold/Flu OTC

MUCINEX FAST-MAX COLD & SINUS ORAL CAPSULE 10-5-325 MG GNP Day Time Cold/Flu OTC

ROBITUSSIN COLD+FLU DAYTIME ORAL CAPSULE 10-5-325 MG GNP Day Time Cold/Flu OTC; QLL (120 EA per 30

days) VICKS DAYQUIL COLD & FLU ORAL CAPSULE 10-5-325 MG GNP Day Time Cold/Flu OTC

*Antitussive-Expectorant -Decongest-Analgesic*** cold multi-symptom severe day oral tablet 5 -10-200-325 mg

Theraflu ExpressMax Sev Cld/Fl OTC

*Antitussive-Expectorant*** altarussin dm oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC biocotron oral liquid 10-100 mg/5ml Tolu-Sed DM OTC cheratussin ac oral syrup 100-10 mg/5ml OTC chest congestion relief dm oral tablet 20-400 mg TabTussin DM OTC

chest congestion/cough relief oral tablet 20 -400 mg TabTussin DM OTC

childrens cough oral liquid 5-100 mg/5ml Robitussin Cough+Chest Cong DM OTC

childrens mucus relief cough oral liquid 5-100 mg/5ml

Robitussin Cough+Chest Cong DM OTC

cvs chest congest/cough child oral liquid 5 -100 mg/5ml


cvs chest congestion relief dm oral tablet 20 -400 mg TabTussin DM OTC

cvs dm maximum adult oral liquid 5-100 mg/5ml


cvs tussin dm cough/chest oral liquid 10-200 mg/5ml Diabetic Tussin Max St OTC

cvs tussin dm oral liquid 100-10 mg/5ml, 200 -20 mg/10ml Tolu-Sed DM OTC

dextromethorphan-guaifenesin oral syrup 10 -100 mg/5ml Wal-Tussin Cough/Chest DM OTC

dextromethorphan-guaifenesin oral tablet 20 -400 mg TabTussin DM OTC

diabetic siltussin-dm max st oral liquid 10-200 mg/5ml Diabetic Tussin Max St OTC

diabetic siltussin-dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC

88

Formulary Drug Name Reference Restrictions

eq cough childrens oral liquid 5-100 mg/5ml Robitussin Cough+Chest Cong DM OTC

eq tussin dm cough/chest oral syrup 10-100 mg/5ml Wal-Tussin Cough/Chest DM OTC

eq tussin dm max oral liquid 10-200 mg/5ml Diabetic Tussin Max St OTC eql tussin cough/chest dm max oral liquid 10 -200 mg/5ml Diabetic Tussin Max St OTC

eql tussin dm cough/chest cong oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC

extra action cough oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC g tussin ac oral solution 100-10 mg/5ml OTC geri-tussin dm oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC g-fen dm oral tablet 20-400 mg TabTussin DM OTC gnp mucus relief cough child oral liquid 5-100 mg/5ml


gnp mucus relief dm max oral liquid 5-100 mg/5ml


gnp mucus relief dm oral tablet 20-400 mg TabTussin DM OTC gnp tab tussin dm oral tablet 20-400 mg TabTussin DM OTC gnp tussin dm cough oral liquid 100-10 mg/5ml Tolu-Sed DM OTC

gnp tussin dm max oral liquid 10-200 mg/5ml Diabetic Tussin Max St OTC gnp tussin dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC guaiasorb dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC guaiatussin ac oral syrup 100-10 mg/5ml OTC guaicon dms oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC guaifenesin ac oral syrup 100-10 mg/5ml OTC guaifenesin dm oral tablet 400-20 mg TabTussin DM OTC guaifenesin-codeine oral solution 100-10 mg/5ml OTC; AL (Min 6 Years)

guaifenesin-dm oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC hm chest congestion relief dm oral tablet 20 -400 mg TabTussin DM OTC

hm tussin adult dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC hm tussin adult dm oral liquid 10-200 mg/5ml Diabetic Tussin Max St OTC intense cough reliever oral liquid 30-200 mg/5ml OTC

m-clear wc oral solution 100-6.3 mg/5ml PA; OTC; AL (Min 6 Years) medi-tussin dm diabetic oral liquid 100-10 mg/5ml Tolu-Sed DM OTC

89

Formulary Drug Name Reference Restrictions medi-tussin dm double strength oral liquid 30 -200 mg/5ml OTC

medi-tussin dm oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC meijer cough syrup dm oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC

mucosa dm oral tablet 20-400 mg TabTussin DM OTC mucus relief cough childrens oral liquid 5-100 mg/5ml


mucus relief dm cough oral tablet 20-400 mg TabTussin DM OTC mucus relief dm max oral liquid 20-400 mg/20ml, 5-100 mg/5ml


mucus relief dm oral tablet 20-400 mg TabTussin DM OTC

neotuss oral liquid 30-200 mg/5ml OTC; QLL (120 ML per 30 days)

pediatric formula cough/congst oral liquid 10 -100 mg/5ml Tolu-Sed DM OTC

px tussin dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC qc medifin dm oral tablet 20-400 mg TabTussin DM OTC q-tussin dm oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC ra tussin cgh/chest congest dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC

ra tussin cough dm sugar free oral syrup 100 -10 mg/5ml Wal-Tussin Cough/Chest DM OTC

ra tussin cough oral liquid 10-100 mg/5ml Tolu-Sed DM OTC ra tussin cough/chest dm max oral liquid 10 -200 mg/5ml Diabetic Tussin Max St OTC

ra tussin dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC

recofen d oral liquid 5-100 mg/5ml Robitussin Cough+Chest Cong DM OTC

refenesen dm oral tablet 400-20 mg TabTussin DM OTC relcof c oral solution 100-6.3 mg/5ml OTC robafen dm oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC sb cough control dm max oral liquid 10-200 mg/5ml Diabetic Tussin Max St OTC

sb cough control dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC

sb mucus relief dm oral tablet 20-400 mg TabTussin DM OTC siltussin dm das oral liquid 100-10 mg/5ml Tolu-Sed DM OTC siltussin-dm alcohol free oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC

sm chest congestion relief dm oral tablet 20 -400 mg TabTussin DM OTC

90

Formulary Drug Name Reference Restrictions sm mucus relief cough children oral liquid 5 -100 mg/5ml


sm tussin cough/chest congest oral syrup 100 -10 mg/5ml Wal-Tussin Cough/Chest DM OTC

sm tussin dm max oral liquid 10-200 mg/5ml Diabetic Tussin Max St OTC sm tussin dm oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC tgt cough formula dm max adult oral liquid 10-200 mg/5ml Diabetic Tussin Max St OTC

tgt cough formula dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC

tgt mucus relief cough child oral liquid 5-100 mg/5ml


tgt mucus/cough relief oral tablet 20-400 mg TabTussin DM OTC tgt tussin dm cough oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC tusnel diabetic oral liquid 10-100 mg/5ml Tolu-Sed DM OTC tussin cough dm oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC tussin dm clear oral liquid 100-10 mg/5ml Tolu-Sed DM OTC tussin dm max adult oral liquid 10-200 mg/5ml Diabetic Tussin Max St OTC; QLL (120 ML per 30

days) tussin dm max oral liquid 10-200 mg/5ml Diabetic Tussin Max St OTC tussin dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC

tussin dm oral syrup 100-10 mg/5ml Wal-Tussin Cough/Chest DM OTC; QLL (120 ML per 30 days)

virtussin a/c oral solution 100-10 mg/5ml OTC wal-tussin dm oral liquid 100-10 mg/5ml Tolu-Sed DM OTC DELSYM CGH/CHEST CONG DM CHILD ORAL LIQUID 5-100 MG/5ML

SM Mucus Relief Cough Children OTC

DELSYM COUGH/CHEST CONGEST DM ORAL LIQUID 5-100 MG/5ML


DIABETIC TUSSIN DM ORAL LIQUID 100-10 MG/5ML Biocotron OTC

DIABETIC TUSSIN FOR CHILDREN ORAL LIQUID 10-100 MG/5ML Biocotron OTC

DIABETIC TUSSIN MAX ST ORAL LIQUID 10-200 MG/5ML Tussin DM Max Adult OTC

FENESIN DM IR ORAL TABLET 20-400 MG

Dextromethorphan-Guaifenesin OTC

G-TRON ORAL LIQUID 10-100 MG/5ML Biocotron OTC MUCINEX COUGH CHILDRENS ORAL LIQUID 5-100 MG/5ML


MUCINEX FAST-MAX DM MAX ORAL LIQUID 20-400 MG/20ML


91

Formulary Drug Name Reference Restrictions PEDIACARE COUGH/CONGESTION ORAL LIQUID 5-100 MG/5ML


ROBAFEN DM CGH/CHEST CONGEST ORAL LIQUID 10-100 MG/5ML Biocotron OTC

ROBAFEN DM COUGH CLEAR ORAL SYRUP 100-10 MG/5ML Tussin DM OTC

ROBITUSSIN COLD COUGH+ CHEST ORAL LIQUID 10-100 MG/5ML Biocotron OTC

ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG/20ML


ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 5-100 MG/5ML

SM Mucus Relief Cough Children


ROBITUSSIN TO GO CGH/CHEST DM ORAL LIQUID 100-10 MG/5ML Biocotron OTC; QLL (120 ML per 30

days) SAFE TUSSIN DM ORAL LIQUID 100-10 MG/5ML Biocotron OTC

SB TAB TUSSIN DM ORAL TABLET 20 -400 MG


SORBUGEN NR ORAL LIQUID 15-150 MG/7.5ML Biocotron OTC

TABTUSSIN DM ORAL TABLET 20-400 MG


TOLU-SED DM ORAL LIQUID 100-10 MG/5ML Biocotron OTC

WAL-TUSSIN COUGH/CHEST DM MAX ORAL LIQUID 10-200 MG/5ML Tussin DM Max Adult OTC

WAL-TUSSIN COUGH/CHEST DM ORAL SYRUP 100-10 MG/5ML Tussin DM OTC

WAL-TUSSIN DM CGH/CHEST CONG ORAL LIQUID 100-10 MG/5ML Biocotron OTC

ZYNCOF ORAL TABLET 20-400 MG Dextromethorphan-Guaifenesin OTC

*Antitussive-Expectorants-Decongestant***

biogtuss oral liquid 10-15-300 mg/5ml OTC; QLL (120 ML per 30 days)

bionel pediatric oral liquid 15-5-50 mg/5ml Tusnel Pediatric OTC; AL (Min 6 Years) biotuss oral liquid 10-15-300 mg/5ml brontuss sf nr oral liquid 10-15-300 mg/5ml OTC ACTINEL PEDIATRIC ORAL LIQUID 15-5-50 MG/5ML Bionel Pediatric OTC

TUSNEL PEDIATRIC ORAL LIQUID 15 -5-50 MG/5ML Bionel Pediatric OTC

92

Formulary Drug Name Reference Restrictions *Decongestant & Antihistamine*** all day allergy d oral tablet extended release 12 hour 5-120 mg

Shopko Allergy Relief-D (Ceti) OTC

all day allergy d-12 oral tablet extended release 12 hour 5-120 mg


all day allergy-d oral tablet extended release 12 hour 5-120 mg


allergy d-12 oral tablet extended release 12 hour 5-120 mg


cetirizine-pseudoephedrine er oral tablet extended release 12 hour 5-120 mg


cvs allergy relief-d oral tablet extended release 12 hour 5-120 mg


entre-b oral suspension 6-10 mg/5ml Vazobid-PD OTC eql all day allergy-d oral tablet extended release 12 hour 5-120 mg


gnp all day allergy-d oral tablet extended release 12 hour 5-120 mg


hm allergy complete-d oral tablet extended release 12 hour 5-120 mg


promethazine vc plain oral solution 6.25-5 mg/5ml AL (Min 6 Years)

promethazine-phenylephrine oral syrup 6.25-5 mg/5ml px allergy relief d oral tablet extended release 12 hour 5-120 mg


ra cetiri-d oral tablet extended release 12 hour 5-120 mg


sm all day allergy-d oral tablet extended release 12 hour 5-120 mg


sw allergy relief-d oral tablet extended release 12 hour 5-120 mg


tgt all day allergy-d oral tablet extended release 12 hour 5-120 mg


tgt allergy+ congestion relief oral tablet extended release 12 hour 5-120 mg


KLS ALLER-TEC D ORAL TABLET EXTENDED RELEASE 12 HOUR 5-120 MG

Cetirizine-Pseudoephedrine ER OTC

SHOPKO ALLERGY RELIEF-D (CETI) ORAL TABLET EXTENDED RELEASE 12 HOUR 5-120 MG


93

Formulary Drug Name Reference Restrictions VAZOBID-PD ORAL SUSPENSION 6-10 MG/5ML Entre-B OTC

WAL-TAP CHILDRENS ORAL ELIXIR 1-2.5 MG/5ML Childrens Cold & Allergy OTC

WAL-ZYR D ORAL TABLET EXTENDED RELEASE 12 HOUR 5-120 MG


*Decongestant W/ Expectorant*** TUSNEL PEDIATRIC ORAL LIQUID 7.5 -50 MG/ML OTC; AL (Min 6 Years)

*Expectorants*** altarussin oral syrup 100 mg/5ml Diabetic Tussin EX OTC chest congestion childrens oral liquid 100 mg/5ml

Mucinex Chest Congestion Child OTC

childrens mucus relief expect oral liquid 100 mg/5ml


cough syrup oral syrup 100 mg/5ml Diabetic Tussin EX OTC cvs chest congestion childrens oral liquid 100 mg/5ml


cvs mucus extended release oral tablet extended release 12 hour 600 mg Mucinex OTC

cvs tussin adult chest congest oral liquid 100 mg/5ml


diabetic siltussin das-na oral liquid 100 mg/5ml


eq tussin oral liquid 100 mg/5ml Mucinex Chest Congestion Child OTC

eql mucus-er oral tablet extended release 12 hour 600 mg Mucinex OTC

eql tussin mucus/chest congest oral liquid 100 mg/5ml


geri-tussin oral syrup 100 mg/5ml Diabetic Tussin EX OTC gnp mucus er oral tablet extended release 12 hour 600 mg Mucinex OTC

gnp mucus relief childrens oral liquid 100 mg/5ml


gnp tussin mucus & chest cong oral liquid 100 mg/5ml


gnp tussin oral syrup 100 mg/5ml Diabetic Tussin EX OTC guaifenesin er oral tablet extended release 12 hour 600 mg Mucinex

guaifenesin oral liquid 100 mg/5ml Mucinex Chest Congestion Child OTC

94

Formulary Drug Name Reference Restrictions guaifenesin oral solution 100 mg/5ml, 200 mg/10ml, 300 mg/15ml


guaifenesin oral syrup 100 mg/5ml Diabetic Tussin EX OTC hm mucus er oral tablet extended release 12 hour 600 mg Mucinex OTC

hm tussin adult oral liquid 100 mg/5ml Mucinex Chest Congestion Child OTC

mucus relief chest congestion oral liquid 400 mg/20ml


mucus relief childrens oral liquid 100 mg/5ml Mucinex Chest Congestion Child OTC

mucus relief er oral tablet extended release 12 hour 600 mg Mucinex OTC

mucus-er oral tablet extended release 12 hour 600 mg Mucinex OTC

pa mucus relief oral tablet extended release 12 hour 600 mg Mucinex OTC

px tussin oral solution 100 mg/5ml Mucinex Chest Congestion Child OTC

qc medifin mucus relief child oral liquid 100 mg/5ml


ra mucus relief oral tablet extended release 12 hour 600 mg Mucinex OTC

ra tussin chest congestion oral liquid 100 mg/5ml


ra tussin chest congestion oral syrup 100 mg/5ml Diabetic Tussin EX OTC

ra tussin oral syrup 100 mg/5ml Diabetic Tussin EX OTC robafen oral syrup 100 mg/5ml Diabetic Tussin EX OTC sb cough control oral syrup 100 mg/5ml Diabetic Tussin EX OTC

scot-tussin expectorant oral liquid 100 mg/5ml Mucinex Chest Congestion Child OTC

siltussin das oral liquid 100 mg/5ml Mucinex Chest Congestion Child OTC

siltussin sa oral syrup 100 mg/5ml Diabetic Tussin EX OTC sm mucus er oral tablet extended release 12 hour 600 mg Mucinex OTC

sm mucus relief childrens oral liquid 100 mg/5ml


sm tussin mucus+chest congest oral liquid 100 mg/5ml


sm tussin oral syrup 100 mg/5ml Diabetic Tussin EX OTC

95

Formulary Drug Name Reference Restrictions tgt mucus relief childrens oral liquid 100 mg/5ml


tussin chest congestion oral syrup 100 mg/5ml Diabetic Tussin EX OTC tussin mucus & chest congest oral liquid 100 mg/5ml


tussin mucus+chest congestion oral liquid 100 mg/5ml


tussin mucus+chest congestion oral syrup 100 mg/5ml Diabetic Tussin EX OTC; QLL (120 ML per 30

days)

tussin oral liquid 100 mg/5ml Mucinex Chest Congestion Child OTC

tussin oral syrup 100 mg/5ml Diabetic Tussin EX OTC wal-tussin oral syrup 100 mg/5ml Diabetic Tussin EX OTC BUCKLEYS CHEST CONGESTION ORAL LIQUID 100 MG/5ML GuaiFENesin OTC

DIABETIC TUSSIN EX ORAL SYRUP 100 MG/5ML SB Cough Control OTC

DIABETIC TUSSIN ORAL LIQUID 100 MG/5ML GuaiFENesin OTC

EQ MUCUS ER ORAL TABLET EXTENDED RELEASE 12 HOUR 600 MG Mucus-ER OTC

MUCINEX CHEST CONGESTION CHILD ORAL LIQUID 100 MG/5ML GuaiFENesin OTC

ROBITUSSIN MUCUS+CHEST CONGEST ORAL LIQUID 100 MG/5ML GuaiFENesin OTC; QLL (120 ML per 30

days) WAL-TUSSIN CHEST CONGESTION ORAL LIQUID 100 MG/5ML GuaiFENesin OTC

*Misc. Respiratory Inhalants*** nasal mist inhalation aerosol solution 0.9 % Simply Saline Baby OTC sodium chloride inhalation nebulization solution 0.9 %, 10 % sodium chloride inhalation nebulization solution 3 % Nebusal

sodium chloride inhalation nebulization solution 7 % HyperSal

BRONCHO SALINE INHALATION AEROSOL SOLUTION 0.9 % Nasal Mist OTC

HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 % NEBUSAL INHALATION NEBULIZATION SOLUTION 3 % Sodium Chloride

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

96

Formulary Drug Name Reference Restrictions PULMOSAL INHALATION NEBULIZATION SOLUTION 7 % Sodium Chloride

SIMPLY SALINE BABY INHALATION AEROSOL SOLUTION 0.9 % Nasal Mist OTC

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

*Non-Narc Antitussive-Antihistamine*** promethazine-dm oral syrup 6.25-15 mg/5ml AL (Min 6 Years)

*Non-Narc Antitussive-Decongestant-Antihistamine*** glenmax peb dm oral liquid 5-2-10 mg/5ml OTC; AL (Min 2 Years) lohist-dm oral syrup 5-2-10 mg/5ml OTC; AL (Min 2 Years) ALAHIST DM ORAL LIQUID 7.5-2-15 MG/5ML OTC; AL (Min 6 Years)

*Opioid Antitussive-Antihistamine*** promethazine-codeine oral syrup 6.25-10 mg/5ml AL (Min 6 Years)

*Opioid Antitussive-Decongestant-Antihistamine*** promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml AL (Min 6 Years)

promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml

*DERMATOLOGICALS* *Acne Antibiotics*** clindamycin phosphate external gel 1 % Cleocin-T AL (Max 18 Years) clindamycin phosphate external lotion 1 % Cleocin-T AL (Max 18 Years) clindamycin phosphate external solution 1 % Cleocin-T AL (Max 18 Years) clindamycin phosphate external swab 1 % Clindacin-P AL (Max 18 Years) ery external pad 2 % AL (Max 18 Years) erythromycin external gel 2 % Erygel AL (Max 18 Years) erythromycin external pad 2 % erythromycin external solution 2 % AL (Max 18 Years) sulfacetamide sodium (acne) external lotion 10 % Klaron

sulfacetamide sodium external suspension 10 % Klaron AL (Max 18 Years)

97

Formulary Drug Name Reference Restrictions CLINDACIN ETZ EXTERNAL SWAB 1 % Clindamycin Phosphate AL (Max 18 Years)

CLINDACIN-P EXTERNAL SWAB 1 % Clindamycin Phosphate AL (Max 18 Years)

*Acne Combinations*** clindamycin phos-benzoyl perox external gel 1.2-5 % Neuac AL (Max 18 Years)

clindamycin phos-benzoyl perox external gel 1-5 % BenzaClin AL (Max 18 Years)

BENZACLIN EXTERNAL GEL 1-5 % Clindamycin Phos-Benzoyl Perox AL (Max 18 Years)

BENZACLIN WITH PUMP EXTERNAL GEL 1-5 %

Clindamycin Phos-Benzoyl Perox

NEUAC EXTERNAL GEL 1.2-5 % Clindamycin Phos-Benzoyl Perox AL (Max 18 Years)

*Acne Products*** acne foaming wash external liquid 10 % Desquam-X Wash OTC

acne medication 10 external gel 10 % Clean & Clear Persa-Gel Max St OTC

acne medication 10 external lotion 10 % OTC; AL (Max 18 Years) acne medication 5 external gel 5 % Clearplex V

acne medication 5 external lotion 5 % Clean & Clear Advantage 3-in-1 OTC; AL (Max 18 Years)

acne treatment external bar 10 % OTC

acne treatment external gel 10 % Clean & Clear Persa-Gel Max St OTC

acne-clear external gel 10 % Clean & Clear Persa-Gel Max St OTC

adapalene external cream 0.1 % Differin AL (Max 18 Years) adapalene external gel 0.1 %, 0.3 % Differin AL (Max 18 Years) benzoyl peroxide cleanser external lotion 3 % OTC; AL (Max 18 Years) benzoyl peroxide cleanser external lotion 6 % Oscion Cleanser

benzoyl peroxide external gel 10 % Clean & Clear Persa-Gel Max St

benzoyl peroxide external gel 2.5 % OTC; AL (Max 18 Years) benzoyl peroxide external gel 5 % Clearplex V benzoyl peroxide wash external liquid 10 % Desquam-X Wash benzoyl peroxide wash external liquid 5 % Desquam-X Wash OTC bp foaming wash external liquid 10 % Desquam-X Wash

bp gel external gel 10 % Clean & Clear Persa-Gel Max St OTC

bp gel external gel 5 % Clearplex V OTC

98

Formulary Drug Name Reference Restrictions bp wash external liquid 10 %, 5 % Desquam-X Wash OTC bp wash external liquid 2.5 % PanOxyl bp wash external liquid 7 % PR Benzoyl Peroxide Wash AL (Max 18 Years) bpo-10 wash external liquid 10 % Desquam-X Wash OTC bpo-5 wash external liquid 5 % Desquam-X Wash OTC cvs acne cleansing external bar 10 % OTC cvs acne foaming face wash external liquid 10 % Desquam-X Wash OTC

cvs acne treatment external gel 10 % Clean & Clear Persa-Gel Max St OTC

cvs advanced 3-in-1 cleanser external liquid 5 % Desquam-X Wash OTC

cvs foaming acne face wash external liquid 10 % Desquam-X Wash OTC

kp benzoyl peroxide external gel 10 % Clean & Clear Persa-Gel Max St OTC; AL (Max 18 Years)

kp benzoyl peroxide external gel 5 % Clearplex V OTC; AL (Max 18 Years) kp benzoyl peroxide wash external liquid 10 % Desquam-X Wash OTC kp benzoyl peroxide wash external liquid 5 % Desquam-X Wash OTC; AL (Max 18 Years) tretinoin external cream 0.025 % Avita tretinoin external cream 0.05 %, 0.1 % Retin-A AL (Max 18 Years) tretinoin external gel 0.01 % Retin-A AL (Max 18 Years) tretinoin external gel 0.025 % Retin-A tretinoin external gel 0.05 % Atralin AL (Min 6 Years) AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG ST; QLL (2 EA per 1 day)

AVITA EXTERNAL CREAM 0.025 % Tretinoin AL (Max 18 Years) AVITA EXTERNAL GEL 0.025 % Tretinoin AL (Max 18 Years) BENZEPRO CREAMY WASH EXTERNAL LIQUID 7 % BP Wash

BENZIQ WASH EXTERNAL LIQUID 5.25 % CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 40 MG CLARAVIS ORAL CAPSULE 30 MG ST; QLL (2 EA per 1 day) CLEAN & CLEAR ADVANTAGE 3-IN-1 EXTERNAL LOTION 5 % Acne Medication 5 OTC

CLEAN & CLEAR PERSA-GEL MAX ST EXTERNAL GEL 10 % Acne-Clear OTC

CLEARPLEX V EXTERNAL GEL 5 % KP Benzoyl Peroxide OTC CLEARPLEX X EXTERNAL GEL 10 % Acne-Clear

99

Formulary Drug Name Reference Restrictions DIFFERIN EXTERNAL CREAM 0.1 % Adapalene DIFFERIN EXTERNAL GEL 0.1 % Adapalene DIFFERIN EXTERNAL GEL 0.3 % Adapalene AL (Max 18 Years) DIFFERIN EXTERNAL LOTION 0.1 % Adapalene AL (Max 18 Years) MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG OSCION CLEANSER EXTERNAL LOTION 6 % Benzoyl Peroxide Cleanser AL (Max 18 Years)

PANOXYL WASH EXTERNAL LIQUID 10 % Benzoyl Peroxide Wash OTC; AL (Max 18 Years)

PANOXYL-4 CREAMY WASH EXTERNAL LIQUID 4 % CVS Creamy Acne Face Wash OTC; AL (Max 18 Years)

PR BENZOYL PEROXIDE WASH EXTERNAL LIQUID 7 % BP Wash

RA RENEWAL ACNE TREATMENT EXTERNAL GEL 10 % Acne-Clear OTC

RETIN-A EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 % Tretinoin AL (Max 18 Years)

RETIN-A EXTERNAL GEL 0.01 %, 0.025 % Tretinoin AL (Max 18 Years)

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

*Antibiotic Mixtures Topical*** antibiotic plus pain relief external cream 3.5 -10000-10 Neosporin Plus Pain Relief MS OTC

cvs antibiotic plus external cream 3.5-10000 -10 Neosporin Plus Pain Relief MS OTC

cvs triple antibiotic max str external ointment 1 %

Neosporin + Pain Relief Max St OTC

double antibiotic + pain rlf external cream 3.5-10000-10 Neosporin Plus Pain Relief MS OTC

eq antibiotic + pain relief external cream 3.5 -10000-10 Neosporin Plus Pain Relief MS OTC

eql antibiotic + pain relief external cream 3.5 -10000-10 Neosporin Plus Pain Relief MS OTC

eql first aid antibiotic external ointment 1 % Neosporin + Pain Relief Max St OTC

gnp antibiotic plus pramoxine external cream 3.5-10000-10 Neosporin Plus Pain Relief MS OTC

gnp triple antibiotic plus external ointment 1 %


hm triple antibiotic max st external ointment 1 %


100

Formulary Drug Name Reference Restrictions multi antibiotic plus external cream 3.5 -10000-10 Neosporin Plus Pain Relief MS OTC

ra antibiotic plus external cream 3.5-10000-10 Neosporin Plus Pain Relief MS OTC

ra antibiotic/pain relief external ointment 1 % Neosporin + Pain Relief Max St OTC

ra triple antibiotic plus external ointment 1 % Neosporin + Pain Relief Max St OTC

sm antibiotic plus pain relief external cream 3.5-10000-10 Neosporin Plus Pain Relief MS OTC

sm triple antibiotic max st external ointment 1 %


tgt first aid antibiotic external cream 3.5 -10000-10 Neosporin Plus Pain Relief MS OTC

tri-biozene external ointment 1 % Neosporin + Pain Relief Max St OTC

triple antibiotic pain relief external ointment 1 %


triple antibiotic plus external ointment 1 % Neosporin + Pain Relief Max St OTC

triple antibiotic plus max st external ointment 1 %


NEOSPORIN + PAIN RELIEF MAX ST EXTERNAL OINTMENT 1 % RA Triple Antibiotic Plus OTC

NEOSPORIN + PAIN/ITCH/SCAR EXTERNAL OINTMENT 1 % RA Triple Antibiotic Plus OTC

*Antibiotics - Topical*** bacitracin external ointment 500 unit/gm Baciguent OTC bacitracin zinc external ointment 500 unit/gm OTC cvs bacitracin external ointment 500 unit/gm OTC cvs bacitracin zinc external ointment 500 unit/gm OTC

eql bacitracin zinc external ointment 500 unit/gm OTC

gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % gentamicin sulfate powder gnp bacitracin zinc external ointment 500 unit/gm OTC

hm bacitracin external ointment 500 unit/gm Baciguent OTC kp bacitracin zinc external ointment 500 unit/gm OTC

mupirocin external ointment 2 % Centany

101

Formulary Drug Name Reference Restrictions qc bacitracin external ointment 500 unit/gm Baciguent OTC ra bacitracin external ointment 500 unit/gm OTC ra bacitracin zinc first aid external ointment 500 unit/gm OTC

sb bacitracin external ointment 500 unit/gm Baciguent OTC sm antibiotic external ointment 500 unit/gm OTC tgt bacitracin external ointment 500 unit/gm Baciguent OTC BACITRAYCIN PLUS EXTERNAL OINTMENT 500 UNIT/GM HM Bacitracin OTC

*Antifungals - Topical Combinations*** clotrimazole-betamethasone external cream 1 -0.05 % Lotrisone

clotrimazole-betamethasone external lotion 1 -0.05 % hydrocortisone-iodoquinol external cream 1-1 % Dermazene

nystatin-triamcinolone external cream 100000-0.1 unit/gm-% nystatin-triamcinolone external ointment 100000-0.1 unit/gm-% DERMAZENE EXTERNAL CREAM 1-1 % Hydrocortisone-Iodoquinol

*Antifungals - Topical*** antifungal external aerosol 1 % Tinactin OTC antifungal external cream 1 % Tinactin OTC anti-fungal external powder 1 % Odor Eaters Antifungal OTC antifungal foot external cream 1 % LamISIL AT OTC athletes foot af external cream 1 % LamISIL AT OTC athletes foot external cream 1 % LamISIL AT OTC athletes foot spray external aerosol 1 % Tinactin OTC ciclopirox external gel 0.77 % ciclopirox external shampoo 1 % Loprox ciclopirox external solution 8 % Ciclodan ciclopirox olamine external cream 0.77 % Ciclodan AL (Min 18 Years) ciclopirox olamine external suspension 0.77 % Loprox cvs af spray powder external aerosol powder 1 % Tinactin OTC

cvs antifungal external cream 1 % Tinactin OTC cvs athletes foot external cream 1 % LamISIL AT OTC

102

Formulary Drug Name Reference Restrictions cvs foot & sneaker external aerosol powder 1 % Tinactin OTC

cvs jock itch external cream 1 % LamISIL AT OTC eq athletes foot (terbinafine) external cream 1 % LamISIL AT OTC

eq athletes foot (tolnaftate) external cream 1 % Tinactin OTC

eq athletes foot external aerosol powder 1 % Tinactin OTC eq tolnaftate external aerosol 1 % Tinactin OTC eql antifungal (tolnaftate) external cream 1 % Tinactin OTC eql athletes foot(terbinafine) external cream 1 % LamISIL AT OTC

fungi-guard external cream 1 % Tinactin OTC gnp terbinafine hydrochloride external cream 1 % LamISIL AT OTC

gnp tolnaftate external cream 1 % Tinactin OTC jock itch spray external aerosol powder 1 % Tinactin OTC jock itch spray powder external aerosol powder 1 % Tinactin OTC

kp terbinafine hydrochloride external cream 1 % LamISIL AT OTC

kp tolnaftate external cream 1 % Tinactin OTC medicated anti-fungal external solution 1 % Blis-To-Sol OTC nystatin external cream 100000 unit/gm nystatin external ointment 100000 unit/gm nystatin external powder 100000 unit/gm Nystop odor control foot & sneaker external aerosol powder 1 % Tinactin OTC

podactin external powder 1 % Odor Eaters Antifungal OTC qc athletes foot external cream 1 % LamISIL AT OTC qc tolnaftate external cream 1 % Tinactin OTC ra antifungal external aerosol 1 % Tinactin OTC ra antifungal foot care external cream 1 % LamISIL AT OTC ra athletes foot (tolnaftate) external cream 1 % Tinactin OTC

ra foot care antifungal external cream 1 % LamISIL AT OTC ra jock itch max st external aerosol powder 1 % Tinactin OTC

sb anti-fungal external cream 1 % Tinactin OTC sm antifungal tolnaftate external cream 1 % Tinactin OTC sm athletes foot external aerosol 1 % Tinactin OTC

103

Formulary Drug Name Reference Restrictions sm athletes foot external aerosol powder 1 % Tinactin OTC sm athletes foot external cream 1 % LamISIL AT OTC terbinafine hcl external cream 1 % LamISIL AT OTC tgt antifungal external aerosol 1 % Tinactin OTC tgt antifungal external cream 1 % Tinactin OTC tgt antifungal spray powder external aerosol powder 1 % Tinactin OTC

tgt athletes foot external cream 1 % LamISIL AT OTC tinaspore external solution 1 % Blis-To-Sol OTC tolnaftate external aerosol powder 1 % Tinactin OTC tolnaftate external cream 1 % Tinactin OTC tolnaftate external powder 1 % Odor Eaters Antifungal OTC tolnaftate external solution 1 % Blis-To-Sol OTC BLIS-TO-SOL EXTERNAL LIQUID 1 % Tolnaftate OTC CICLODAN EXTERNAL CREAM 0.77 % Ciclopirox Olamine CICLODAN EXTERNAL SOLUTION 8 % Ciclopirox DR GS CLEAR NAIL EXTERNAL SOLUTION 1 % Tolnaftate OTC

FUNGOID-D EXTERNAL CREAM 1 % EQ Athletes Foot (tolnaftate) OTC LAMISIL AF DEFENSE EXTERNAL AEROSOL POWDER 1 % SM Athletes Foot OTC

MEDI-FIRST ANTI-FUNGAL EXTERNAL CREAM 1 % EQ Athletes Foot (tolnaftate) OTC

MYCOCIDE CLINICAL NS EXTERNAL SOLUTION 1 % Tolnaftate OTC

NYAMYC EXTERNAL POWDER 100000 UNIT/GM Nystatin

NYATA EXTERNAL POWDER 100000 UNIT/GM Nystatin

NYSTOP EXTERNAL POWDER 100000 UNIT/GM Nystatin

ODOR EATERS ANTIFUNGAL EXTERNAL POWDER 1 % Tolnaftate OTC

ODOR EATERS FOOT/SNEAKER SPRAY EXTERNAL AEROSOL POWDER 1 %

SM Athletes Foot OTC

THE TREATMENT FORMULA 3 EXTERNAL SOLUTION 1 % Tolnaftate OTC

*Anti-Inflammatory Agents -Topical*** diclofenac sodium transdermal gel 1 % Voltaren

104

Formulary Drug Name Reference Restrictions FLECTOR TRANSDERMAL PATCH 1.3 % VOLTAREN TRANSDERMAL GEL 1 % Diclofenac Sodium

*Antineoplastic Antimetabolites -Topical*** fluorouracil external cream 0.5 % Carac fluorouracil external cream 5 % Efudex fluorouracil external solution 2 %, 5 % FLUOROPLEX EXTERNAL CREAM 1 %

*Antipsoriatics - Systemic*** methoxsalen oral capsule 10 mg methoxsalen rapid oral capsule 10 mg Oxsoralen Ultra

*Antipsoriatics*** calcipotriene external cream 0.005 % Dovonex calcipotriene external ointment 0.005 % Calcitrene calcipotriene external solution 0.005 % CALCITRENE EXTERNAL OINTMENT 0.005 % Calcipotriene

*Antiseborrheic Combinations*** selenium sulf-pyrithione-urea external shampoo 2.25 %

*Antiseborrheic Products*** selenium sulfide external lotion 2.5 % sulfacetamide sodium external liquid 10 % Ovace Wash AL (Min 18 Years) SEB-PREV WASH EXTERNAL LIQUID 10 % Sulfacetamide Sodium

*Antivirals - Topical*** acyclovir external ointment 5 % Zovirax ABREVA EXTERNAL CREAM 10 % OTC ZOVIRAX EXTERNAL CREAM 5 %

*Astringents*** cvs diaper rash external ointment 40 % Desitin OTC cvs zinc oxide external ointment 20 % OTC diaper rash external ointment 40 % Desitin OTC eql baby basics diaper rash external ointment 40 % Desitin OTC

gnp zinc oxide external ointment 20 % OTC meijer zinc oxide external ointment 20 % OTC ra diaper rash external ointment 40 % Desitin OTC

105

Formulary Drug Name Reference Restrictions ra zinc oxide external ointment 20 % OTC tippy toes diaper rash external ointment 40 % Desitin OTC zinc oxide external ointment 20 % OTC zinc oxide external ointment 40 % Desitin OTC BOUDREAUXS BUTT PASTE EXTERNAL OINTMENT 40 % Tippy Toes Diaper Rash OTC

COTTONTAILS DIAPER RASH EXTERNAL OINTMENT 40 % Tippy Toes Diaper Rash OTC

*Burn Products*** silver sulfadiazine external cream 1 % Silvadene SSD EXTERNAL CREAM 1 % Silver Sulfadiazine

*Cauterizing Agent Combinations*** ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 %

*Corticosteroids - Topical*** ala-cort external cream 1 % Aveeno Anti-Itch Max St ala-cort external cream 2.5 % alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % amcinonide external cream 0.1 % amcinonide external lotion 0.1 % amcinonide external ointment 0.1 % anti-itch maximum strength external cream 1 % Aveeno Anti-Itch Max St OTC

beta hc external lotion 1 % Cortizone-10 Eczema OTC betamethasone dipropionate aug external cream 0.05 % Diprolene AF

betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % Diprolene

betamethasone dipropionate aug external ointment 0.05 % Diprolene

betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 %

106

Formulary Drug Name Reference Restrictions betamethasone valerate external cream 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % clobetasol propionate e external cream 0.05 % clobetasol propionate external cream 0.05 % Temovate clobetasol propionate external foam 0.05 % Olux clobetasol propionate external gel 0.05 % Temovate clobetasol propionate external lotion 0.05 % Clobex clobetasol propionate external ointment 0.05 % Temovate

clobetasol propionate external shampoo 0.05 % Clodan

clobetasol propionate external solution 0.05 % Cormax Scalp Application cvs anti-itch maximum strength external cream 1 % Aveeno Anti-Itch Max St OTC

cvs cortisone intense healing external cream 1 % Aveeno Anti-Itch Max St OTC

cvs cortisone long-lasting external lotion 1 % Cortizone-10 Eczema OTC cvs cortisone maximum strength external cream 1 % Aveeno Anti-Itch Max St OTC

cvs cortisone maximum strength external ointment 1 % Cortizone-10 OTC

cvs eczema anti-itch external cream 1 % Aveeno Anti-Itch Max St OTC cvs hydrocortisone anti-itch external cream 1 % Aveeno Anti-Itch Max St OTC

cvs hydrocortisone max st external cream 1 % Aveeno Anti-Itch Max St OTC desonide external cream 0.05 % DesOwen desonide external lotion 0.05 % DesOwen desonide external ointment 0.05 % desoximetasone external cream 0.05 %, 0.25 % Topicort

desoximetasone external gel 0.05 % Topicort desoximetasone external ointment 0.05 %, 0.25 % Topicort

diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % eq anti-itch max strength external cream 1 % Aveeno Anti-Itch Max St OTC eq hydrocortisone max st external cream 1 % Aveeno Anti-Itch Max St OTC eq hydrocortisone plus external cream 1 % Aveeno Anti-Itch Max St OTC eql anti-itch intensive heal external cream 1 % Aveeno Anti-Itch Max St OTC

107

Formulary Drug Name Reference Restrictions eql anti-itch maximum strength external cream 1 % Aveeno Anti-Itch Max St OTC

eql anti-itch maximum strength external ointment 1 % Cortizone-10 OTC

fluocinolone acetonide external cream 0.01 % fluocinolone acetonide external cream 0.025 % Synalar

fluocinolone acetonide external ointment 0.025 % Synalar

fluocinolone acetonide external solution 0.01 % Synalar

fluocinolone acetonide powder fluocinonide emulsified base external cream 0.05 % fluocinonide external cream 0.05 % fluocinonide external cream 0.1 % Vanos fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % fluticasone propionate external cream 0.05 % Cutivate fluticasone propionate external ointment 0.005 % gnp hydrocortisone external cream 0.5 % OTC gnp hydrocortisone max st external ointment 1 % Cortizone-10 OTC

gnp hydrocortisone plus external cream 1 % Aveeno Anti-Itch Max St OTC gnp hydro-lotion external lotion 1 % Cortizone-10 Eczema OTC halobetasol propionate external cream 0.05 % Ultravate halobetasol propionate external ointment 0.05 % Ultravate

hydrocortisone acetate external cream 1 % Lanacort 10 OTC hydrocortisone acetate powder hydrocortisone butyr lipo base external cream 0.1 % Locoid Lipocream

hydrocortisone butyrate external cream 0.1 % Locoid hydrocortisone butyrate external ointment 0.1 % Locoid

hydrocortisone butyrate external solution 0.1 % Locoid

hydrocortisone external cream 0.5 % OTC

108

Formulary Drug Name Reference Restrictions hydrocortisone external cream 1 % Aveeno Anti-Itch Max St hydrocortisone external cream 2.5 % hydrocortisone external lotion 1 % Cortizone-10 Eczema OTC hydrocortisone external lotion 2.5 % hydrocortisone external ointment 0.5 % OTC hydrocortisone external ointment 1 % Cortizone-10 hydrocortisone external ointment 2.5 % hydrocortisone intensive heal external cream 1 % Aveeno Anti-Itch Max St OTC

hydrocortisone max st external cream 1 % Aveeno Anti-Itch Max St OTC hydrocortisone max st/12 moist external cream 1 % Aveeno Anti-Itch Max St OTC

hydrocortisone micronized powder hydrocortisone plus external cream 1 % Aveeno Anti-Itch Max St OTC hydrocortisone powder hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % Westcort

instacort 5 external cream 0.5 % OTC kp hydrocortisone external cream 1 % Aveeno Anti-Itch Max St OTC kp hydrocortisone max st external ointment 1 % Cortizone-10 OTC

med-derm hydrocortisone external cream 0.5 % OTC

med-derm hydrocortisone external cream 1 % Aveeno Anti-Itch Max St OTC medi-first hydrocortisone external cream 1 % Lanacort 10 OTC meijer hydrocortisone external cream 1 % Aveeno Anti-Itch Max St OTC mometasone furoate external cream 0.1 % Elocon mometasone furoate external ointment 0.1 % Elocon mometasone furoate external solution 0.1 % prednicarbate external cream 0.1 % Dermatop prednicarbate external ointment 0.1 % Dermatop px hydrocream external cream 1 % Aveeno Anti-Itch Max St OTC qc hydrocortisone external cream 1 % Aveeno Anti-Itch Max St OTC qc hydrocortisone max st external cream 1 % Aveeno Anti-Itch Max St OTC ra anti-itch maximum strength external cream 1 % Aveeno Anti-Itch Max St OTC

ra anti-itch maximum strength external ointment 1 % Cortizone-10 OTC

109

Formulary Drug Name Reference Restrictions ra first aid anti-itch spray external solution 1 % Noble Formula HC OTC

ra hydrocortisone max st external cream 1 % Aveeno Anti-Itch Max St OTC ra hydrocortisone plus 12 external cream 1 % Aveeno Anti-Itch Max St OTC recort plus external cream 1 % Aveeno Anti-Itch Max St OTC rederm external lotion 1 % Cortizone-10 Eczema OTC sb hydrocortisone external cream 1 % Aveeno Anti-Itch Max St OTC sb hydrocortisone max st external ointment 1 % Cortizone-10 OTC

sb hydrocortisone plus external cream 1 % Aveeno Anti-Itch Max St OTC scalacort external lotion 2 % Ala Scalp scalp relief maximum strength external solution 1 % Noble Formula HC OTC

sm hydrocortisone external cream 0.5 % OTC sm hydrocortisone external cream 1 % Aveeno Anti-Itch Max St OTC sm hydrocortisone external ointment 0.5 % OTC sm hydrocortisone max st external ointment 1 % Cortizone-10 OTC

tgt anti-itch maximum strength external cream 1 % Aveeno Anti-Itch Max St OTC

tgt anti-itch maximum strength external ointment 1 % Cortizone-10 OTC

tgt anti-itch plus oatmeal external cream 1 % Aveeno Anti-Itch Max St OTC tgt anti-itch/aloe/vit e external cream 1 % Aveeno Anti-Itch Max St OTC triamcinolone acetonide external cream 0.025 %, 0.5 % triamcinolone acetonide external cream 0.1 % Triderm triamcinolone acetonide external lotion 0.025 %, 0.1 % triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % triamcinolone acetonide powder ANTI-ITCH INTENSIVE HEALING EXTERNAL LOTION 1 % CVS Cortisone Long-Lasting OTC

AQUANIL HC EXTERNAL LOTION 1 % CVS Cortisone Long-Lasting OTC AVEENO ANTI-ITCH MAX ST EXTERNAL CREAM 1 % EQ Hydrocortisone Max St OTC

CLODAN EXTERNAL SHAMPOO 0.05 % Clobetasol Propionate CORMAX SCALP APPLICATION EXTERNAL SOLUTION 0.05 % Clobetasol Propionate

110

Formulary Drug Name Reference Restrictions CORTAID MAXIMUM STRENGTH EXTERNAL CREAM 1 % EQ Hydrocortisone Max St OTC

CORTIZONE-10 DIABETICS SKIN EXTERNAL LOTION 1 % CVS Cortisone Long-Lasting OTC

CORTIZONE-10 ECZEMA EXTERNAL LOTION 1 % CVS Cortisone Long-Lasting OTC

CORTIZONE-10 EXTERNAL OINTMENT 1 % Hydrocortisone OTC

CORTIZONE-10 HYDRATENSIVE EXTERNAL LOTION 1 % CVS Cortisone Long-Lasting OTC

DERMAREST ECZEMA EXTERNAL LOTION 1 % CVS Cortisone Long-Lasting OTC

GYNECORT 10 EXTERNAL CREAM 1 % Hydrocortisone Acetate OTC

HYDROCORTISONE IN ABSORBASE EXTERNAL OINTMENT 1 % Hydrocortisone

HYDROSKIN EXTERNAL CREAM 1 % EQ Hydrocortisone Max St OTC HYDROSKIN EXTERNAL LOTION 1 % CVS Cortisone Long-Lasting OTC KERICORT 10 EXTERNAL CREAM 1 % EQ Hydrocortisone Max St OTC LANACORT 10 EXTERNAL CREAM 1 % Hydrocortisone Acetate OTC NOBLE FORMULA HC EXTERNAL CREAM 1 % EQ Hydrocortisone Max St OTC

NOBLE FORMULA HC EXTERNAL SOLUTION 1 % RA First Aid Anti-Itch Spray OTC

PREPARATION H HYDROCORTISONE EXTERNAL CREAM 1 % EQ Hydrocortisone Max St OTC

SARNOL-HC EXTERNAL LOTION 1 % CVS Cortisone Long-Lasting OTC SCALPICIN MAXIMUM STRENGTH EXTERNAL SOLUTION 1 % RA First Aid Anti-Itch Spray OTC

TRIDERM EXTERNAL CREAM 0.1 % Triamcinolone Acetonide

*Diaper Rash Products*** cvs all-purpose skin protect external ointment Medi-Paste OTC cvs pediatric ointment external ointment Medi-Paste OTC A+D PREVENT EXTERNAL OINTMENT CVS Pediatric Ointment OTC

COTTONTAILS A + D EXTERNAL OINTMENT CVS Pediatric Ointment OTC

DESITIN EXTERNAL OINTMENT CVS Pediatric Ointment OTC MEDI-PASTE EXTERNAL OINTMENT CVS Pediatric Ointment OTC PALADIN EXTERNAL OINTMENT CVS Pediatric Ointment OTC PINXAV EXTERNAL OINTMENT CVS Pediatric Ointment OTC

111

Formulary Drug Name Reference Restrictions *Emollient Combinations*** mineral oil-hydrophil petrolat external ointment OTC

*Emollient/Keratolytic Agents*** AQUAPHILIC/CARBAMIDE EXTERNAL OINTMENT 10 %, 20 % OTC

LANAPHILIC/UREA EXTERNAL OINTMENT 10 %, 20 % OTC

*Emollients*** advanced healing/baby external ointment Aquaphor OTC ammonium lactate external cream 12 % Lac-Hydrin ammonium lactate external lotion 12 % Lac-Hydrin beauty lotion external lotion Aveeno Active Naturals Daily OTC cocoa butter skin external cream Aveeno Positively Radiant OTC collagen external cream Aveeno Positively Radiant OTC complete moisture external lotion Aveeno Active Naturals Daily OTC cvs advanced healing external ointment Aquaphor OTC cvs dry skin care external lotion Aveeno Active Naturals Daily OTC cvs extra moisturizing external lotion Aveeno Active Naturals Daily OTC cvs gentle skin cleanser external lotion Aveeno Active Naturals Daily OTC cvs hydrating skin treatment external lotion 12 % Lac-Hydrin OTC

cvs moisturizing external cream Aveeno Positively Radiant OTC cvs moisturizing external lotion Aveeno Active Naturals Daily OTC cvs moisturizing extra dry external cream Aveeno Positively Radiant OTC cvs pure glycerin external liquid 99.5 % OTC cvs skin treatment external lotion 12 % Lac-Hydrin OTC cvs special care external lotion Aveeno Active Naturals Daily OTC dry skin treatment adv therapy external ointment Aquaphor OTC

dry skin treatment external ointment Aquaphor OTC e-ointment external ointment Aquaphor OTC eql absolute moisture dry skin external lotion Aveeno Active Naturals Daily OTC eql advanced healing external ointment 41 % Aquaphor OTC eql advanced recovery external lotion Aveeno Active Naturals Daily OTC eql advanced skin therapy external lotion Aveeno Active Naturals Daily OTC eql aloe after sun external lotion Aveeno Active Naturals Daily OTC glycerin external liquid OTC gnp glycerin external liquid 99.5 % OTC

112

Formulary Drug Name Reference Restrictions gordomatic external lotion Aveeno Active Naturals Daily OTC hm glycerin external liquid OTC hydrophor external ointment Aquaphor OTC lubricating lotion external lotion Aveeno Active Naturals Daily OTC moisture external lotion Aveeno Active Naturals Daily OTC moisture recovery external lotion Aveeno Active Naturals Daily OTC moisturizing cream external cream Aveeno Positively Radiant OTC moisturizing lotion external lotion Aveeno Active Naturals Daily OTC moisturizing sensitive skin external lotion Aveeno Active Naturals Daily OTC moisturizing vitamin e/aloe external lotion Aveeno Active Naturals Daily OTC qc glycerin external liquid 99.5 % OTC ra advanced recovery external lotion Aveeno Active Naturals Daily OTC ra calming daily moisturizing external cream Aveeno Positively Radiant OTC ra derma external lotion Aveeno Active Naturals Daily OTC ra gentle skin external lotion Aveeno Active Naturals Daily OTC ra glycerin external liquid OTC ra hydrating healing external ointment Aquaphor OTC ra moisturizing oatmeal external lotion Aveeno Active Naturals Daily OTC ra moisturizing therapy external cream Aveeno Positively Radiant OTC ra renewal moisturizing external cream Aveeno Positively Radiant OTC ra total moisture external lotion Aveeno Active Naturals Daily OTC refreshing aloe external lotion Aveeno Active Naturals Daily OTC sm dry skin therapy external lotion Aveeno Active Naturals Daily OTC sm glycerin external liquid 99.5 % OTC thera-derm external lotion Aveeno Active Naturals Daily OTC

AL12 EXTERNAL LOTION 12 % CVS Hydrating Skin Treatment OTC

AMLACTIN EXTERNAL LOTION 12 % CVS Hydrating Skin Treatment OTC

DERMADAILY EXTERNAL LOTION Complete Moisture OTC DERMAPHOR EXTERNAL OINTMENT E-Ointment OTC DERMAVANTAGE EXTERNAL LOTION Complete Moisture OTC

DML EXTERNAL LOTION Complete Moisture OTC FLANDERS BUTTOCKS EXTERNAL OINTMENT E-Ointment OTC

GERI-HYDROLAC 12 EXTERNAL CREAM 12 % Ammonium Lactate OTC

GERI-HYDROLAC 12 EXTERNAL LOTION 12 %

CVS Hydrating Skin Treatment OTC

113

Formulary Drug Name Reference Restrictions HYDROLATUM EXTERNAL OINTMENT E-Ointment OTC

LUBRISILK EXTERNAL LOTION Complete Moisture OTC LUBRISKIN EXTERNAL LOTION Complete Moisture OTC MINERIN EXTERNAL LOTION Complete Moisture OTC RA RENEWAL COCOA BUTTER EXTERNAL LOTION Complete Moisture OTC

SARATOGA EXTERNAL OINTMENT E-Ointment OTC

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

*Imidazole-Related Antifungals -Topical*** anti-fungal external cream 1 % Lotrimin AF Jock Itch OTC antifungal external cream 2 % Micatin OTC athletes foot external powder 2 % Lotrimin AF OTC athletes foot powder spray external aerosol powder 2 % Lotrimin AF Powder OTC

athletes foot spray external aerosol powder 2 % Lotrimin AF Powder OTC

baza antifungal external cream 2 % Micatin OTC clotrimazole af external cream 1 % Lotrimin AF Jock Itch OTC clotrimazole anti-fungal external cream 1 % Lotrimin AF Jock Itch clotrimazole external cream 1 % Lotrimin AF Jock Itch

clotrimazole external solution 1 % FungiCure Intensive/NailGuard

cvs anti-fungal external powder 2 % Lotrimin AF OTC cvs athletes foot spray external aerosol powder 2 % Lotrimin AF Powder OTC

cvs clotrimazole external cream 1 % Lotrimin AF Jock Itch OTC cvs itch relief external cream 1 % Lotrimin AF Jock Itch OTC cvs ringworm external cream 1 % Lotrimin AF Jock Itch OTC eq antifungal external cream 1 % Lotrimin AF Jock Itch OTC eq athletes foot external cream 1 % Lotrimin AF Jock Itch OTC eq athletes foot spray external aerosol powder 2 % Lotrimin AF Powder OTC

eq jock itch external cream 1 % Lotrimin AF Jock Itch OTC eql antifungal external cream 1 % Lotrimin AF Jock Itch OTC eql athletes foot external cream 1 % Lotrimin AF Jock Itch OTC gnp athletes foot external cream 1 % Lotrimin AF Jock Itch OTC

114

Formulary Drug Name Reference Restrictions gnp miconazole nitrate external aerosol powder 2 % Lotrimin AF Powder OTC

gnp miconazorb af external powder 2 % Lotrimin AF OTC jock itch external cream 1 % Lotrimin AF Jock Itch OTC jock itch relief external cream 1 % Lotrimin AF Jock Itch OTC ketoconazole external cream 2 % ketoconazole external shampoo 2 % Nizoral kp clotrimazole external cream 1 % Lotrimin AF Jock Itch OTC kp miconazole nitrate external cream 2 % Micatin OTC micaderm external cream 2 % Micatin OTC miconazole nitrate external aerosol powder 2 % Lotrimin AF Powder OTC

miconazole nitrate external cream 2 % Micatin OTC miconazorb af external powder 2 % Lotrimin AF OTC podactin external cream 2 % Micatin OTC pro-ex antifungal external cream 1 % Lotrimin AF Jock Itch OTC px athletic foot external cream 1 % Lotrimin AF Jock Itch OTC qc clotrimazole external cream 1 % Lotrimin AF Jock Itch OTC ra antifungal external cream 2 % Micatin OTC ra atheletes foot external aerosol powder 2 % Lotrimin AF Powder OTC ra athletes foot external cream 1 % Lotrimin AF Jock Itch OTC ra clotrimazole external cream 1 % Lotrimin AF Jock Itch OTC ra jock itch external cream 1 % Lotrimin AF Jock Itch OTC sb clotrimazole foot external cream 1 % Lotrimin AF Jock Itch OTC sm antifungal clotrimazole external cream 1 % Lotrimin AF Jock Itch OTC sm antifungal miconazole external cream 2 % Micatin OTC tgt clotrimazole external cream 1 % Lotrimin AF Jock Itch OTC triple paste af external ointment 2 % DermaFungal PA; OTC CARRINGTON ANTIFUNGAL EXTERNAL CREAM 2 % RA Antifungal OTC

CLOTRIMAZOLE GRX EXTERNAL CREAM 1 % PX Athletic Foot OTC

CRITIC-AID CLEAR AF EXTERNAL OINTMENT 2 % Triple Paste AF OTC

CRUEX PRESCRIPTION STRENGTH EXTERNAL AEROSOL POWDER 2 % CVS Athletes Foot Spray OTC

DERMAFUNGAL EXTERNAL OINTMENT 2 % Triple Paste AF OTC

DESENEX EXTERNAL CREAM 1 % PX Athletic Foot OTC DESENEX EXTERNAL POWDER 2 % Athletes Foot OTC

115

Formulary Drug Name Reference Restrictions DESENEX JOCK ITCH EXTERNAL AEROSOL POWDER 2 % CVS Athletes Foot Spray OTC

FUNGICURE INTENSIVE/NAILGUARD EXTERNAL SOLUTION 1 % Clotrimazole OTC

LOTRIMIN AF DEODORANT POWDER EXTERNAL AEROSOL POWDER 2 % CVS Athletes Foot Spray OTC

LOTRIMIN AF EXTERNAL AEROSOL 2 % OTC

LOTRIMIN AF EXTERNAL POWDER 2 % Athletes Foot OTC

LOTRIMIN AF JOCK ITCH POWDER EXTERNAL AEROSOL POWDER 2 % CVS Athletes Foot Spray OTC

LOTRIMIN AF POWDER EXTERNAL AEROSOL POWDER 2 % CVS Athletes Foot Spray OTC

MICRO GUARD EXTERNAL POWDER 2 % Athletes Foot OTC

REMEDY ANTIFUNGAL CLEAR EXTERNAL OINTMENT 2 % Triple Paste AF OTC

REMEDY ANTIFUNGAL EXTERNAL CREAM 2 % RA Antifungal OTC

REMEDY ANTIFUNGAL EXTERNAL POWDER 2 % Athletes Foot OTC

REMEDY PHYTOPLEX ANTIFUNGAL EXTERNAL POWDER 2 % Athletes Foot OTC

SECURA ANTIFUNGAL EXTERNAL CREAM 2 % RA Antifungal OTC

SECURA ANTIFUNGAL EXTRA THICK EXTERNAL CREAM 2 % RA Antifungal OTC

SHOPKO ATHLETES FOOT EXTERNAL CREAM 1 % PX Athletic Foot OTC

SOOTHE & COOL INZO ANTIFUNGAL EXTERNAL CREAM 2 % RA Antifungal OTC

TETTERINE EXTERNAL OINTMENT 2 % Triple Paste AF OTC

TINEACIDE EXTERNAL CREAM 2 % RA Antifungal OTC ZEASORB-AF EXTERNAL POWDER 2 % Athletes Foot OTC

*Immunomodulators Imidazoquinolinamines - Topical*** imiquimod external cream 5 % Aldara QLL (12 EA per 30 days)

*Insect Repellents*** OFF DEEP WOODS DRY EXTERNAL AEROSOL CVS Total Home Insect Repel OTC

116

Formulary Drug Name Reference Restrictions OFF DEEP WOODS EXTERNAL AEROSOL CVS Total Home Insect Repel OTC

OFF DEEP WOODS SPORTSMEN EXTERNAL AEROSOL 30 % CVS Total Home Insect Repel OTC

OFF FAMILYCARE CLEAN FEEL EXTERNAL LIQUID 5 % OTC

OFF SMOOTH & DRY EXTERNAL AEROSOL 15 % CVS Total Home Insect Repel OTC

SAWYER INSECT REPELLENT EXTERNAL LIQUID 20 % OTC

ULTRATHON INSECT REPELLENT 8 EXTERNAL AEROSOL 25 % CVS Total Home Insect Repel OTC

*Keratolytic/Antimitotic Agents*** eql scalp relief max strength external liquid 3 % Psoriasin OTC

gnp scalp relief external liquid 3 % Psoriasin OTC podofilox external solution 0.5 % ra scalp itch/dandruff relief external liquid 3 % Psoriasin OTC

salicylic acid external cream 6 % Salacyn salicylic acid external lotion 6 % Salacyn salicylic acid external shampoo 6 % Salex salitech forte external lotion 6 % Salacyn CONDYLOX EXTERNAL GEL 0.5 % PSORIASIN EXTERNAL LIQUID 3 % RA Scalp Itch/Dandruff Relief OTC SALACYN EXTERNAL CREAM 6 % Salicylic Acid SALACYN EXTERNAL LOTION 6 % Salicylic Acid SCALPICIN 2 IN 1 EXTERNAL LIQUID 3 % RA Scalp Itch/Dandruff Relief OTC

SCALPICIN EXTERNAL LIQUID 3 % RA Scalp Itch/Dandruff Relief OTC

*Local Anesthetics - Topical*** capsaicin arthritis relief external liquid 0.15 % Capzasin OTC

capsaicin external cream 0.025 % Zostrix Arthritis Pain Relief OTC cvs capsaicin external liquid 0.15 % Capzasin OTC gnp capsaicin external liquid 0.15 % Capzasin OTC lidocaine external ointment 5 % QLL (90 GM per 30 days) lidocaine external patch 5 % Lidoderm QLL (90 EA per 1 Rx) lidocaine hcl external cream 3 % CidalEaze lidocaine hcl external gel 2 % Glydo

117

Formulary Drug Name Reference Restrictions lidocaine hcl external solution 4 % Xylocaine lidocaine pak external ointment 5 % lidopin external cream 3 % CidalEaze premium lidocaine external ointment 5 % sure result sr relief external cream 0.025 % Zostrix Arthritis Pain Relief OTC CAPZASIN EXTERNAL LIQUID 0.15 % GNP Capsaicin OTC CAPZASIN-HP EXTERNAL CREAM 0.1 % Capsaicin OTC

CAPZASIN-P EXTERNAL CREAM 0.035 % OTC

CIDALEAZE EXTERNAL CREAM 3 % Lidopin GLYDO EXTERNAL GEL 2 % Lidocaine HCl REGENECARE HA EXTERNAL GEL 2 % Lidocaine HCl OTC

*Macrolide Immunosuppressants -Topical*** tacrolimus external ointment 0.03 %, 0.1 % Protopic PA ELIDEL EXTERNAL CREAM 1 % PA; AL (Min 2 Years)

*Powders*** baby cornstarch external powder Johnsons Baby Cornstarch OTC baby powder external powder RA Tugaboos Baby (Talc) OTC cvs baby powder external powder RA Tugaboos Baby (Talc) OTC hm baby cornstarch external powder Johnsons Baby Cornstarch OTC sm baby powder external powder RA Tugaboos Baby (Talc) OTC JOHNSONS BABY CORNSTARCH EXTERNAL POWDER Baby Cornstarch OTC

JOHNSONS BABY POWDER EXTERNAL POWDER Baby Powder OTC

JOHNSONS BABY PURE CORNSTARCH EXTERNAL POWDER Baby Cornstarch OTC

RA TUGABOOS BABY (TALC) EXTERNAL POWDER Baby Powder OTC

RA TUGABOOS BABY EXTERNAL POWDER Baby Cornstarch OTC

SOOTHE & COOL BODY EXTERNAL POWDER Baby Cornstarch OTC

*Rosacea Agents*** metronidazole external cream 0.75 % Rosadan metronidazole external gel 0.75 % Rosadan metronidazole external gel 1 % Metrogel

118

Formulary Drug Name Reference Restrictions metronidazole external lotion 0.75 % MetroLotion ROSADAN EXTERNAL CREAM 0.75 % MetroNIDAZOLE ROSADAN EXTERNAL GEL 0.75 % MetroNIDAZOLE

*Scabicide Combinations*** lice treatment external liquid 0.33-4 % Licide Maximum Strength OTC sm lice killing external shampoo 0.33-4 % Licide Maximum Strength OTC stop lice maximum strength external liquid 0.33-4 % Licide Maximum Strength OTC

LICIDE MAXIMUM STRENGTH EXTERNAL LIQUID 0.33-4 % Lice Treatment OTC

*Scabicides & Pediculicides*** cvs permethrin external lotion 1 % OTC hm lice treatment external lotion 1 % OTC lice treatment external lotion 1 % OTC lindane external shampoo 1 % QLL (60 ML per 30 days) malathion external lotion 0.5 % Ovide QLL (59 ML per 180 days) permethrin external cream 5 % Elimite QLL (60 GM per 180 days) ra lice treatment external lotion 1 % OTC sm lice treatment external lotion 1 % OTC spinosad external suspension 0.9 % Natroba

*Skin Cleansers*** cvs isopropyl alcohol wipes external 70 % Pharmacist Choice Alcohol OTC essentra wipes 9x9" external 70 % Pharmacist Choice Alcohol gnp isopropyl alcohol wipes external 70 % Pharmacist Choice Alcohol OTC isopropyl alcohol external 70 % Pharmacist Choice Alcohol OTC isopropyl alcohol wipes external 70 % Pharmacist Choice Alcohol OTC ra isopropyl alcohol wipes external 70 % Pharmacist Choice Alcohol OTC sure comfort alcohol prep external pad 70 % Pharmacist Choice Alcohol OTC PHARMACIST CHOICE ALCOHOL EXTERNAL PAD 70 % Isopropyl Alcohol OTC

*Soaps*** anti-bacterial hand external lotion DiabetiDerm Cleansing OTC gentle skin cleanser external lotion DiabetiDerm Cleansing OTC sm skin cleanser gentle external lotion DiabetiDerm Cleansing OTC topiclear external lotion DiabetiDerm Cleansing OTC AQUANIL SKIN CLEANSER EXTERNAL LOTION Topiclear OTC

AVEENO POSITIVE RADIANT CLEANS EXTERNAL LOTION Topiclear OTC

119

Formulary Drug Name Reference Restrictions DIABETIDERM CLEANSING EXTERNAL LOTION Topiclear OTC

NIVEA MOISTURIZING BODY WASH EXTERNAL LOTION Topiclear OTC

NIVEA TOUCH OF SMOOTHNESS EXTERNAL LOTION Topiclear OTC

NIVEA VISAGE GENTLE CLEANSING EXTERNAL LOTION Topiclear OTC

OCUSOFT HAND SOAP EXTERNAL LOTION Topiclear OTC

*Steroid-Local Anesthetic Combinations*** CORTANE-B EXTERNAL LOTION 10 -10-1 MG/ML

*Tar Products*** cvs therapeutic external shampoo 0.5 % Tera-Gel Tar OTC eql therapeutic external shampoo 0.5 % Tera-Gel Tar OTC pc-tar external shampoo 1 % Theraplex T OTC ra therapeutic external shampoo 0.5 % Tera-Gel Tar OTC ra therapeutic external shampoo 2.5 % Beta Care Betatar Gel OTC sm anti-dandruff coal tar external shampoo 0.5 % Tera-Gel Tar OTC

therapeutic external shampoo 0.5 % Tera-Gel Tar OTC BETA CARE BETATAR GEL EXTERNAL SHAMPOO 2.5 % RA Therapeutic OTC

IONIL-T EXTERNAL SHAMPOO 1 % PC-Tar OTC MG217 MEDICATED TAR EXTERNAL SHAMPOO 15 % OTC

TERA-GEL TAR EXTERNAL SHAMPOO 0.5 % EQL Therapeutic OTC

THERAPEUTIC T+PLUS EXTERNAL SHAMPOO 0.5 % EQL Therapeutic OTC

X-SEB T PEARL EXTERNAL SHAMPOO 10 % OTC

X-SEB T PLUS EXTERNAL SHAMPOO 10 % OTC

*Topical Anesthetic Combinations*** agoneaze external kit 2.5-2.5 % Priloxx LP anodyne lpt external kit 2.5-2.5 % Priloxx LP lidocaine-prilocaine external cream 2.5-2.5 % QLL (240 GM per 30 days)

120

Formulary Drug Name Reference Restrictions lidocaine-prilocaine external kit 2.5-2.5 % Priloxx LP QLL (2 EA per 1 Rx) lidopril external kit 2.5-2.5 % Priloxx LP lidopril xr external kit 2.5-2.5 % Priloxx LP prilolid external kit 2.5-2.5 % Priloxx LP DERMACINRX EMPRICAINE EXTERNAL KIT 2.5-2.5 % Lidopril XR

DERMACINRX PRIZOPAK EXTERNAL KIT 2.5-2.5 % Lidopril XR

LEVA SET/OCCLUSIVE DRESSING EXTERNAL KIT 2.5-2.5 % Lidopril XR

LIDO BDK EXTERNAL KIT 2.5-2.5 % Lidopril XR LIDO-PRILO CAINE PACK EXTERNAL KIT 2.5-2.5 % Lidopril XR

LIPROZONEPAK EXTERNAL KIT 2.5 -2.5 % Lidopril XR

LIVIXIL PAK EXTERNAL KIT 2.5-2.5 % Lidopril XR LP LITE PAK EXTERNAL KIT 2.5-2.5 % Lidopril XR MEDOLOR PAK EXTERNAL KIT 2.5-2.5 % Lidopril XR

PRILOXX LP EXTERNAL KIT 2.5-2.5 % Lidopril XR RELADOR PAK EXTERNAL KIT 2.5-2.5 % Lidopril XR

RELADOR PAK PLUS EXTERNAL KIT 2.5-2.5 % Lidopril XR

*Topical Selective Retinoid X Receptor Agonists*** TARGRETIN EXTERNAL GEL 1 %

*Topical Steroid Combinations*** gnp hydrocortisone/aloe external cream 1 % Cortizone-10 Plus OTC hm hydrocortisone plus external cream 1 % Cortizone-10 Plus OTC hm hydrocortisone-aloe max st external cream 1 % Cortizone-10 Plus OTC

hydrocortisone-aloe external cream 1 % Cortizone-10 Plus OTC kls hydrocortisone plus external cream 1 % Cortizone-10 Plus OTC ra hydrocortisone plus external cream 1 % Cortizone-10 Plus OTC sm hydrocortisone plus external cream 1 % Cortizone-10 Plus OTC sm hydrocortisone-aloe max st external cream 1 % Cortizone-10 Plus OTC

tgt anti-itch/aloe max st external cream 1 % Cortizone-10 Plus OTC CORTIZONE-10 INTENSIVE HEALING EXTERNAL CREAM 1 % SM Hydrocortisone Plus OTC

121

Formulary Drug Name Reference Restrictions CORTIZONE-10 PLUS EXTERNAL CREAM 1 % SM Hydrocortisone Plus OTC

CORTIZONE-10/ALOE EXTERNAL CREAM 1 % SM Hydrocortisone Plus OTC

*Wound Dressings*** CARRACOLLOID 4"X4" EXTERNAL PAD Triple Helix Collagen 2"x2" OTC

CARRACOLLOID 6"X6" EXTERNAL PAD Triple Helix Collagen 2"x2" OTC

DRS CHOICE BLISTER CARE EXTERNAL PAD Triple Helix Collagen 2"x2" OTC

HYDROCOL EXTERNAL PAD Triple Helix Collagen 2"x2" OTC

*DIAGNOSTIC PRODUCTS* *Diagnostic Tests*** ketone test in vitro strip Chek-Stix Control OTC universal ph in vitro strip Chemstrip 2 OTC ALBUSTIX IN VITRO STRIP OTC CHEK-STIX CONTROL IN VITRO STRIP Ketone Test OTC

CHEMSTRIP 2 IN VITRO STRIP Universal pH OTC CHEMSTRIP K IN VITRO STRIP Ketone Test OTC CHEMSTRIP MICRAL IN VITRO STRIP OTC DIASTIX IN VITRO STRIP OTC KETOCARE IN VITRO STRIP Ketone Test OTC KETOSTIX IN VITRO STRIP Ketone Test OTC NITRATEST PAPER IN VITRO DIAGNOSTIC TEST Universal pH OTC

NOVA MAX PLUS KETONE TEST IN VITRO STRIP OTC

ONETOUCH ULTRA BLUE IN VITRO STRIP Kroger Test OTC; QLL (150 EA per 30

days)

ONETOUCH VERIO IN VITRO STRIP Kroger Test OTC; QLL (150 EA per 30 days)

PRECISION XTRA KETONE IN VITRO STRIP OTC

PTS PANELS KETONE TEST IN VITRO STRIP OTC

RELION KETONE IN VITRO STRIP Ketone Test OTC RELION KETONE TEST IN VITRO STRIP Ketone Test OTC

122

Formulary Drug Name Reference Restrictions *Multiple Urine Tests*** CHEMSTRIP 10 MD IN VITRO STRIP OTC CHEMSTRIP 10/SG IN VITRO STRIP OTC CHEMSTRIP 2 GP IN VITRO STRIP OTC CHEMSTRIP 5 OB IN VITRO STRIP OTC CHEMSTRIP 7 IN VITRO STRIP OTC CHEMSTRIP 9 IN VITRO STRIP OTC CHEMSTRIP UGK IN VITRO STRIP OTC COMBISTIX IN VITRO STRIP OTC CVS KETONE CARE IN VITRO STRIP OTC HEMA-COMBISTIX IN VITRO STRIP OTC KETO-DIASTIX IN VITRO STRIP OTC LABSTIX IN VITRO STRIP OTC MULTISTIX 10 SG IN VITRO STRIP OTC MULTISTIX 5 IN VITRO STRIP OTC MULTISTIX 7 IN VITRO STRIP OTC MULTISTIX 8 IN VITRO STRIP OTC MULTISTIX 9 IN VITRO STRIP OTC MULTISTIX 9 SG IN VITRO STRIP OTC MULTISTIX IN VITRO STRIP OTC URISTIX 4 IN VITRO STRIP OTC URISTIX IN VITRO STRIP OTC

*DIGESTIVE AIDS* *Digestive Enzymes*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

PA

VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000 UNIT

PA

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 5000 UNIT

123

Formulary Drug Name Reference Restrictions *DIRECT-ACTING P2Y12 INHIBITORS*** *Direct-Acting P2y12 Inhibitors*** BRILINTA ORAL TABLET 60 MG, 90 MG

*DIURETICS* *Carbonic Anhydrase Inhibitors*** acetazolamide er oral capsule extended release 12 hour 500 mg Diamox Sequels

acetazolamide oral tablet 125 mg, 250 mg methazolamide oral tablet 25 mg, 50 mg Neptazane

*Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5 -50 mg spironolactone-hctz oral tablet 25-25 mg Aldactazide triamterene-hctz oral capsule 37.5-25 mg Dyazide triamterene-hctz oral capsule 50-25 mg triamterene-hctz oral tablet 37.5-25 mg Maxzide-25 triamterene-hctz oral tablet 75-50 mg Maxzide

*Loop Diuretics*** bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Bumex furosemide oral solution 10 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 mg Lasix torsemide oral tablet 10 mg, 20 mg Demadex torsemide oral tablet 100 mg, 5 mg

*Potassium Sparing Diuretics*** amiloride hcl oral tablet 5 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg Aldactone

*Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250 mg, 500 mg chlorthalidone oral tablet 25 mg, 50 mg hydrochlorothiazide oral capsule 12.5 mg Microzide hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg, 2.5 mg, 5 mg

124

Formulary Drug Name Reference Restrictions *ENDOCRINE AND METABOLIC AGENTS - MISC.* *Bisphosphonates*** alendronate sodium oral solution 70 mg/75ml alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg alendronate sodium oral tablet 70 mg Fosamax etidronate disodium oral tablet 200 mg, 400 mg ibandronate sodium intravenous solution 3 mg/3ml Boniva

ibandronate sodium oral tablet 150 mg Boniva pamidronate disodium intravenous solution 30 mg/10ml, 90 mg/10ml pamidronate disodium intravenous solution 6 mg/ml pamidronate disodium intravenous solution reconstituted 30 mg, 90 mg

*Calcitonins*** calcitonin (salmon) nasal solution 200 unit/act Miacalcin

*Carnitine Replenisher - Agents*** levocarnitine oral solution 1 gm/10ml Carnitor SF levocarnitine oral tablet 330 mg Carnitor MCCARNITINE ORAL TABLET 330 MG LevOCARNitine OTC

*Dopamine Receptor Agonists*** cabergoline oral tablet 0.5 mg QLL (16 EA per 30 days)

*Growth Hormones*** GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG

PA; AL (Max 18 Years)

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 12 MG, 5 MG


NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 10 MG/2ML


NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION 20 MG/2ML

PA

125

Formulary Drug Name Reference Restrictions NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION 5 MG/2ML


ZOMACTON SUBCUTANEOUS SOLUTION RECONSTITUTED 5 MG

*Hyperparathyroid Treatment -Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg Rocaltrol calcitriol oral solution 1 mcg/ml Rocaltrol paricalcitol oral capsule 1 mcg, 2 mcg Zemplar QLL (30 EA per 30 days) paricalcitol oral capsule 4 mcg ST; QLL (30 EA per 30 days)

*Selective Estrogen Receptor Modulators (Serms)*** raloxifene hcl oral tablet 60 mg Evista

*Somatostatic Agents*** octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

SandoSTATIN PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

PA

*Vasopressin*** desmopressin ace rhinal tube nasal solution 0.01 % DDAVP Rhinal Tube QLL (2.5 ML per 30 days)

desmopressin ace spray refrig nasal solution 0.01 % QLL (5 ML per 30 days)

desmopressin acetate oral tablet 0.1 mg, 0.2 mg DDAVP QLL (90 EA per 30 days)

desmopressin acetate spray nasal solution 0.01 % DDAVP QLL (5 ML per 30 days)

*ESTROGENS* *Estrogen & Progestin*** estradiol-norethindrone acet oral tablet 0.5 -0.1 mg Mimvey Lo

estradiol-norethindrone acet oral tablet 1-0.5 mg Mimvey

jevantique lo oral tablet 0.5-2.5 mg-mcg Femhrt Low Dose norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg Femhrt Low Dose

norethindrone-eth estradiol oral tablet 1-5 mg-mcg Jinteli

126

Formulary Drug Name Reference Restrictions AMABELZ ORAL TABLET 0.5-0.1 MG, 1-0.5 MG Estradiol-Norethindrone Acet

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/DAY QLL (4 EA per 30 days)

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY


FYAVOLV ORAL TABLET 0.5-2.5 MG -MCG Jevantique Lo

FYAVOLV ORAL TABLET 1-5 MG-MCG Norethindrone-Eth Estradiol JINTELI ORAL TABLET 1-5 MG-MCG Norethindrone-Eth Estradiol QLL (30 EA per 30 days) LOPREEZA ORAL TABLET 0.5-0.1 MG, 1-0.5 MG Estradiol-Norethindrone Acet

MIMVEY LO ORAL TABLET 0.5-0.1 MG Estradiol-Norethindrone Acet QLL (30 EA per 30 days) MIMVEY ORAL TABLET 1-0.5 MG Estradiol-Norethindrone Acet QLL (30 EA per 30 days) PREFEST ORAL TABLET 1/1-0.09 MG (15/15) QLL (30 EA per 30 days)

PREMPHASE ORAL TABLET 0.625-5 MG QLL (30 EA per 30 days)

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG QLL (30 EA per 30 days)

*Estrogens*** estradiol oral tablet 0.5 mg, 1 mg, 2 mg Estrace QLL (30 EA per 30 days) estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

Minivelle QLL (8 EA per 30 days)

estradiol transdermal patch twice weekly 0.05 mg/24hr Alora QLL (8 EA per 30 days)

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

Climara QLL (4 EA per 30 days)

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg QLL (30 EA per 30 days) MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG QLL (30 EA per 30 days)

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG QLL (30 EA per 30 days)

*FLUOROQUINOLONES* *Fluoroquinolones*** ciprofloxacin hcl oral tablet 100 mg, 750 mg ciprofloxacin hcl oral tablet 250 mg, 500 mg Cipro ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%) Cipro

127

Formulary Drug Name Reference Restrictions ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg, 500 mg Cipro XR

levofloxacin oral solution 25 mg/ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg Levaquin

moxifloxacin hcl oral tablet 400 mg Avelox ofloxacin oral tablet 400 mg

*GASTROINTESTINAL AGENTS -MISC.* *Antiflatulents*** cvs gas relief drops ex st oral liquid 40 mg/0.6ml Gas-X Infant Drops OTC

cvs gas relief infants oral suspension 20 mg/0.3ml Mylicon Infants Gas Relief OTC

cvs gas relief oral capsule 125 mg Gas-X Extra Strength OTC cvs infants gas relief oral suspension 20 mg/0.3ml Mylicon Infants Gas Relief OTC

eq gas relief oral capsule 125 mg Gas-X Extra Strength OTC eq infants gas relief oral suspension 40 mg/0.6ml Mylicon Infants Gas Relief OTC

eql gas relief oral capsule 125 mg Gas-X Extra Strength OTC eql infants gas relief oral suspension 20 mg/0.3ml Mylicon Infants Gas Relief OTC

gas relief extra strength oral capsule 125 mg Gas-X Extra Strength OTC gas relief oral liquid 40 mg/0.6ml Gas-X Infant Drops OTC gas relief oral suspension 20 mg/0.3ml Mylicon Infants Gas Relief OTC gnp gas relief extra strength oral capsule 125 mg Gas-X Extra Strength OTC

gnp infants gas relief oral suspension 20 mg/0.3ml Mylicon Infants Gas Relief OTC

hm gas relief extra strength oral capsule 125 mg Gas-X Extra Strength OTC

hm gas relief infants drops oral suspension 20 mg/0.3ml Mylicon Infants Gas Relief OTC

infants gas relief oral suspension 20 mg/0.3ml, 40 mg/0.6ml Mylicon Infants Gas Relief OTC

infants simethicone oral suspension 20 mg/0.3ml Mylicon Infants Gas Relief OTC

px gas relief extra strength oral capsule 125 mg Gas-X Extra Strength OTC

px gas relief infants oral suspension 20 mg/0.3ml Mylicon Infants Gas Relief OTC

128

Formulary Drug Name Reference Restrictions qc gas relief oral capsule 125 mg Gas-X Extra Strength OTC ra gas relief extra strength oral capsule 125 mg Gas-X Extra Strength OTC

ra gas relief oral capsule 125 mg Gas-X Extra Strength OTC ra gas relief oral suspension 40 mg/0.6ml Mylicon Infants Gas Relief OTC ra gas relief/infants oral suspension 20 mg/0.3ml Mylicon Infants Gas Relief OTC

sb gas relief oral suspension 40 mg/0.6ml Mylicon Infants Gas Relief OTC simeped oral suspension 40 mg/0.6ml Mylicon Infants Gas Relief OTC simethicone extra strength oral capsule 125 mg Gas-X Extra Strength OTC

simethicone oral capsule 125 mg Gas-X Extra Strength OTC simethicone oral suspension 20 mg/0.3ml, 40 mg/0.6ml Mylicon Infants Gas Relief OTC

sm gas relief extra strength oral capsule 125 mg Gas-X Extra Strength OTC

sm gas relief infants drops oral suspension 40 mg/0.6ml Mylicon Infants Gas Relief OTC

sm gas relief infants oral suspension 20 mg/0.3ml Mylicon Infants Gas Relief OTC

tgt gas relief extra strength oral capsule 125 mg Gas-X Extra Strength OTC

tgt gas relief infants oral liquid 20 mg/0.3ml Gas-X Infant Drops OTC GAS-X EXTRA STRENGTH ORAL CAPSULE 125 MG Gas Relief Extra Strength OTC

GAS-X INFANT DROPS ORAL LIQUID 20 MG/0.3ML TGT Gas Relief Infants OTC

LITTLE REMEDIES FOR TUMMYS ORAL SUSPENSION 20 MG/0.3ML CVS Gas Relief Infants OTC

LITTLE TUMMYS GAS RELIEF ORAL SUSPENSION 20 MG/0.3ML CVS Gas Relief Infants OTC

PEDIACARE INFANTS GAS RELIEF ORAL SUSPENSION 20 MG/0.3ML CVS Gas Relief Infants OTC

*Gallstone Solubilizing Agents*** ursodiol oral capsule 300 mg Actigall ursodiol oral tablet 250 mg Urso 250 ursodiol oral tablet 500 mg Urso Forte

*Gastrointestinal Chloride Channel Activators*** AMITIZA ORAL CAPSULE 24 MCG, 8 MCG PA; AL (Min 18 Years)

129

Formulary Drug Name Reference Restrictions *Gastrointestinal Stimulants*** metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml metoclopramide hcl oral tablet 10 mg, 5 mg Reglan

*Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists*** LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG PA; AL (Min 18 Years)

*Inflammatory Bowel Agents*** balsalazide disodium oral capsule 750 mg Colazal mesalamine oral tablet delayed release 800 mg Asacol HD

mesalamine rectal enema 4 gm sulfasalazine oral tablet 500 mg Azulfidine sulfasalazine oral tablet delayed release 500 mg Azulfidine EN-tabs

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM CANASA RECTAL SUPPOSITORY 1000 MG PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG

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

*Peripheral Opioid Receptor Antagonists*** MOVANTIK ORAL TABLET 12.5 MG, 25 MG PA; AL (Min 18 Years)

*Phosphate Binder Agents*** calcium acetate (phos binder) oral capsule 667 mg PhosLo

calcium acetate (phos binder) oral tablet 667 mg Eliphos

calcium acetate oral capsule 667 mg PhosLo AURYXIA ORAL TABLET 1 GM 210 MG(FE) CALPHRON ORAL TABLET 667 MG Calcium Acetate (Phos Binder) OTC

130

Formulary Drug Name Reference Restrictions FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG PHOSLYRA ORAL SOLUTION 667 MG/5ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL TABLET 800 MG Sevelamer Carbonate

*GENITOURINARY AGENTS -MISCELLANEOUS* *5-Alpha Reductase Inhibitors*** finasteride oral tablet 5 mg Proscar

*Alpha 1-Adrenoceptor Antagonists*** alfuzosin hcl er oral tablet extended release 24 hour 10 mg Uroxatral

tamsulosin hcl oral capsule 0.4 mg Flomax

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

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

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

potassium citrate-citric acid oral packet 3300 -1002 mg Taron-Crystals

potassium citrate-citric acid oral solution 1100-334 mg/5ml sod citrate-citric acid oral solution 500-334 mg/5ml Shohls Modified

tricitrates oral solution 550-500-334 mg/5ml virtrate-2 oral solution 500-334 mg/5ml Shohls Modified virtrate-3 oral solution 550-500-334 mg/5ml virtrate-k oral solution 1100-334 mg/5ml TARON-CRYSTALS ORAL PACKET 3300-1002 MG Cytra K Crystals

*Genitourinary Irrigants*** sodium chloride irrigation solution 0.9 % Curity Sterile Saline ARGYLE STERILE SALINE IRRIGATION SOLUTION 0.9 % Sodium Chloride

131

Formulary Drug Name Reference Restrictions CURITY STERILE SALINE IRRIGATION SOLUTION 0.9 % Sodium Chloride

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

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

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

PHENAZO ORAL TABLET 200 MG Phenazopyridine HCl

*GOUT AGENTS* *Gout Agent Combinations*** colchicine-probenecid oral tablet 0.5-500 mg

*Gout Agents*** allopurinol oral tablet 100 mg, 300 mg Zyloprim colchicine oral capsule 0.6 mg Mitigare colchicine oral tablet 0.6 mg Colcrys PA COLCRYS ORAL TABLET 0.6 MG Colchicine ULORIC ORAL TABLET 40 MG, 80 MG ST

*Uricosurics*** probenecid oral tablet 500 mg

*HEMATOLOGICAL AGENTS -MISC.* *C1 Inhibitors*** BERINERT INTRAVENOUS KIT 500 UNIT PA; QLL (8 mL per 34 days)

CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT PA; QLL (20 mL per 34 days)

*Cyclopentyltriazolopyrimidine (Cptp) Derivatives*** BRILINTA ORAL TABLET 60 MG, 90 MG

*Hematorheologic Agents*** pentoxifylline er oral tablet extended release 400 mg

*Phosphodiesterase Iii Inhibitors*** cilostazol oral tablet 100 mg, 50 mg

132

Formulary Drug Name Reference Restrictions *Plasma Kallikrein Inhibitors*** KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML

PA; QLL (6 ML per 34 days); AL (Min 12 Years)

*Platelet Aggregation Inhibitors*** dipyridamole oral tablet 25 mg, 50 mg, 75 mg

*Quinazoline Agents*** anagrelide hcl oral capsule 0.5 mg Agrylin anagrelide hcl oral capsule 1 mg

*Thienopyridine Derivatives*** clopidogrel bisulfate oral tablet 300 mg, 75 mg Plavix

EFFIENT ORAL TABLET 10 MG, 5 MG

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

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

*Erythropoiesis-Stimulating Agents (Esas)*** ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

133

Formulary Drug Name Reference Restrictions *Erythropoietins*** ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

*Folic Acid/Folate Combinations*** fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25 -0.5 mg folplex 2.2 oral tablet 2.2-25-0.5 mg

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

*Granulocyte Colony-Stimulating Factors (G-Csf)*** GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

PA

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

PA

*Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)*** LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG PA

*Iron Combinations*** fe c tab plus oral tablet 100-250-0.025-1 mg Icar-C Plus OTC iron 100 plus oral tablet 100-250-0.025-1 mg Icar-C Plus OTC ICAR-C PLUS ORAL TABLET 100-250 -0.025-1 MG Iron 100 Plus

134

Formulary Drug Name Reference Restrictions *Iron*** cvs iron oral tablet 325 (65 fe) mg OTC eql iron supplement therapy oral tablet 325 mg OTC

fe tabs oral tablet delayed release 325 (65 fe) mg OTC

ferro-bob oral tablet 325 (65 fe) mg OTC ferrous gluconate oral tablet 324 (37.5 fe) mg OTC ferrous gluconate oral tablet 325 (36 fe) mg OTC ferrous sulfate oral elixir 220 (44 fe) mg/5ml FeroSul OTC ferrous sulfate oral tablet 27 mg, 325 (65 fe) mg OTC

ferrous sulfate oral tablet delayed release 325 (65 fe) mg OTC

ferrousul oral tablet 325 (65 fe) mg OTC gnp iron oral tablet 325 (65 fe) mg OTC gnp slow release iron oral tablet extended release 47.5 mg OTC

high potency iron oral tablet 27 mg OTC iron high-potency oral tablet 325 mg OTC iron oral tablet 28 mg OTC iron oral tablet 325 (65 fe) mg OTC kp ferrous gluconate oral tablet 324 (37.5 fe) mg OTC

kp ferrous sulfate oral tablet 325 (65 fe) mg OTC meijer ferrous sulfate oral tablet 325 (65 fe) mg OTC

px iron oral tablet 27 mg OTC qc ferrous sulfate oral tablet 325 (65 fe) mg OTC ra high potency iron oral tablet 27 mg OTC ra iron oral tablet 27 mg, 325 (65 fe) mg OTC ra slow release iron oral tablet extended release 47.5 mg OTC

slow release iron oral tablet extended release 47.5 mg OTC

sm iron oral tablet 325 (65 fe) mg OTC sm slow release iron oral tablet extended release 143 (45 fe) mg OTC

FEROSUL ORAL ELIXIR 220 (44 FE) MG/5ML Ferrous Sulfate OTC

135

Formulary Drug Name Reference Restrictions *Thrombopoietin (Tpo) Receptor Agonists*** PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG PA; QLL (30 EA per 30 days)

*HEPATITIS C AGENT -COMBINATIONS*** *Hepatitis C Agent -Combinations*** EPCLUSA ORAL TABLET 400-100 MG PA; AL (Min 18 Years) HARVONI ORAL TABLET 90-400 MG PA; AL (Min 18 Years) TECHNIVIE ORAL TABLET 12.5-75-50 MG PA; AL (Min 18 Years)

VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 &250 MG PA; AL (Min 18 Years)

VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 200 -8.33-50- 33.33 MG

PA; AL (Min 18 Years)

ZEPATIER ORAL TABLET 50-100 MG PA; AL (Min 18 Years)

*HYPNOTICS* *Antihistamine Hypnotics*** compoz oral capsule 50 mg Unisom Sleepgels OTC compoz oral tablet 50 mg Nytol Maximum Strength OTC cvs sleep aid nighttime oral capsule 50 mg Unisom Sleepgels OTC cvs sleep aid nighttime oral tablet 25 mg Restfully Sleep OTC cvs sleep aid oral capsule 50 mg Unisom Sleepgels OTC cvs sleep aid oral tablet 25 mg Restfully Sleep OTC diphenhydramine hcl (sleep) oral tablet 50 mg Nytol Maximum Strength OTC eq nighttime sleep aid max st oral capsule 50 mg Unisom Sleepgels OTC

eq nighttime sleep aid oral tablet 25 mg Restfully Sleep OTC eql nighttime sleep aid oral tablet 25 mg Restfully Sleep OTC eql sleep aid oral capsule 50 mg Unisom Sleepgels OTC gnp nighttime sleep aid oral tablet 25 mg Restfully Sleep OTC hm nighttime sleep aid oral capsule 50 mg Unisom Sleepgels OTC hm nighttime sleep aid oral tablet 25 mg Restfully Sleep OTC night time sleep aid oral tablet 25 mg Restfully Sleep OTC nighttime sleep aid oral tablet 25 mg Restfully Sleep OTC nighttime sleep oral tablet 25 mg Restfully Sleep OTC qc rest simply oral tablet 25 mg Restfully Sleep OTC

136

Formulary Drug Name Reference Restrictions qc sleep aid max st oral capsule 50 mg Unisom Sleepgels OTC ra nighttime sleep aid oral capsule 50 mg Unisom Sleepgels OTC ra nighttime sleep aid oral tablet 25 mg Restfully Sleep OTC ra sleep aid (diphenhydramine) oral tablet 25 mg Restfully Sleep OTC

ra sleep aid oral capsule 50 mg Unisom Sleepgels OTC sb sleep oral tablet 25 mg Restfully Sleep OTC sleep aid (diphenhydramine) oral tablet 25 mg Restfully Sleep OTC sleep aid oral capsule 50 mg Unisom Sleepgels OTC sleep ii oral tablet 25 mg Restfully Sleep OTC sleep tabs oral tablet 25 mg Restfully Sleep OTC sleep-aid maximum strength oral capsule 50 mg Unisom Sleepgels OTC

sleep-tabs oral tablet 25 mg Restfully Sleep OTC sm nighttime sleep aid oral tablet 25 mg Restfully Sleep OTC sm sleep aid maximum strength oral capsule 50 mg Unisom Sleepgels OTC

sm sleep aid night time oral tablet 25 mg Restfully Sleep OTC tetra-formula nighttime sleep oral tablet 50 mg Nytol Maximum Strength OTC

tgt nighttime sleep aid oral tablet 25 mg Restfully Sleep OTC tgt sleep aid max strength oral capsule 50 mg Unisom Sleepgels OTC wal-som maximum strength oral capsule 50 mg Unisom Sleepgels OTC

NYTOL ORAL TABLET 25 MG SM Nighttime Sleep Aid OTC RESTFULLY SLEEP ORAL TABLET 25 MG SM Nighttime Sleep Aid OTC

SIMPLY SLEEP ORAL TABLET 25 MG SM Nighttime Sleep Aid OTC SOMINEX ORAL TABLET 25 MG SM Nighttime Sleep Aid OTC

*Barbiturate Hypnotics*** phenobarbital oral elixir 20 mg/5ml phenobarbital oral solution 20 mg/5ml phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

*Benzodiazepine Hypnotics***

estazolam oral tablet 1 mg, 2 mg QLL (34 EA per 34 days); AL (Min 18 Years)

flurazepam hcl oral capsule 15 mg, 30 mg QLL (34 EA per 34 days); AL (Min 15 Years)

temazepam oral capsule 15 mg, 30 mg Restoril

137

Formulary Drug Name Reference Restrictions triazolam oral tablet 0.125 mg QLL (34 EA per 34 days) triazolam oral tablet 0.25 mg Halcion QLL (34 EA per 34 days)

*Non-Benzodiazepine - Gaba-Receptor Modulators*** zaleplon oral capsule 10 mg, 5 mg Sonata zolpidem tartrate oral tablet 10 mg, 5 mg Ambien

*Selective Melatonin Receptor Agonists*** ROZEREM ORAL TABLET 8 MG ST

*LAXATIVES* *Bowel Evacuant Combinations*** peg 3350/electrolytes oral solution reconstituted 240 gm Colyte with Flavor Packs

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm Nulytely with Flavor Packs

peg-3350/electrolytes oral solution reconstituted 236 gm Golytely QLL (4000 ML per 30 days)

GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM PEG 3350/Electrolytes QLL (4000 ML per 30 days)

GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM PEG-3350/Electrolytes

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM

PEG 3350-KCl-Na Bicarb-NaCl

TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM

PEG 3350-KCl-Na Bicarb-NaCl

*Bulk Laxatives*** cvs natural daily fiber oral powder 58.6 % Wal-Mucil OTC eq natural fiber laxative oral powder 28.3 % Reguloid OTC eq natural fiber laxative oral powder 58.6 % Wal-Mucil OTC eql fiber therapy oral powder 28.3 % Reguloid OTC eql natural fiber oral powder 28.3 % Reguloid OTC eql natural fiber oral powder 58.6 % Wal-Mucil OTC gnp natural fiber oral powder 28.3 % Reguloid OTC goodsense natural fiber oral powder 28.3 % Reguloid OTC hm fiber oral powder 28.3 % Reguloid OTC hm fiber oral powder 58.6 % Wal-Mucil OTC kls natural psyllium fiber oral powder 58.6 % Wal-Mucil OTC natural fiber laxative oral powder 28.3 % Reguloid OTC natural fiber laxative oral powder 58.6 % Wal-Mucil OTC

138

Formulary Drug Name Reference Restrictions natural fiber oral powder 58.6 % Wal-Mucil OTC ra fiber oral powder 58.6 % Wal-Mucil OTC ra fiber supplement oral powder 28.3 % Reguloid OTC ra multihealth fiber oral powder 58.6 % Wal-Mucil OTC sm fiber oral powder 28.3 % Reguloid OTC sm fiber oral powder 58.6 % Wal-Mucil OTC tgt fiber therapy oral powder 28.3 % Reguloid OTC tgt fiber therapy oral powder 58.6 % Wal-Mucil OTC KONSYL ORAL PACKET 100 % OTC KONSYL ORAL POWDER 28.3 % RA Fiber Supplement OTC METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 % RA Fiber Supplement OTC

METAMUCIL SMOOTH TEXTURE ORAL POWDER 58.6 % RA Multihealth Fiber OTC

REGULOID ORAL POWDER 28.3 % RA Fiber Supplement OTC REGULOID ORAL POWDER 58.6 % RA Multihealth Fiber OTC WAL-MUCIL ORAL POWDER 28.3 % RA Fiber Supplement OTC WAL-MUCIL ORAL POWDER 58.6 % RA Multihealth Fiber OTC

*Laxatives - Miscellaneous*** constulose oral solution 10 gm/15ml cvs glycerin adult rectal suppository 2.1 gm OTC glycerin (adult) rectal suppository 2.1 gm OTC glycerin (child) rectal suppository 1.2 gm Sani-Supp Pediatric OTC glycerin (infants & children) rectal suppository 1.2 gm Sani-Supp Pediatric OTC

glycerin (pediatric) rectal suppository 1.2 gm Sani-Supp Pediatric OTC gnp glycerin (adult) rectal suppository 2.1 gm OTC gnp glycerin (infant) rectal suppository 1.2 gm Sani-Supp Pediatric OTC gnp glycerin child rectal suppository 1.2 gm Sani-Supp Pediatric OTC lactulose oral solution 10 gm/15ml, 20 gm/30ml peg 3350 oral packet CVS Purelax OTC polyethylene glycol 3350 oral packet CVS Purelax px glycerin rectal suppository 2.1 gm OTC ra glycerin adult rectal suppository 80.7 % OTC ra glycerin child rectal suppository 80.7 % OTC ra laxative oral packet CVS Purelax OTC sb glycerin adult rectal suppository 2.1 gm OTC sb glycerin pediatric rectal suppository 1.2 gm Sani-Supp Pediatric OTC

139

Formulary Drug Name Reference Restrictions sm glycerin pediatric rectal suppository 1.2 gm Sani-Supp Pediatric OTC

sm glycerin pediatric rectal suppository 80.7 % OTC

sorbitol rectal solution 70 % OTC CVS PURELAX ORAL PACKET RA Laxative OTC HEALTHYLAX ORAL PACKET RA Laxative OTC SANI-SUPP PEDIATRIC RECTAL SUPPOSITORY 1.2 GM Glycerin (Pediatric) OTC

SMOOTH LAX ORAL PACKET RA Laxative OTC

*Saline Laxatives*** cvs laxative dietary supplemnt oral tablet 500 mg Phillips OTC

milk of magnesia concentrate oral suspension 2400 mg/10ml OTC

*Stimulant Laxatives*** castor oil stimulant laxative oral oil 100 % OTC cvs castor oil oral oil 100 % OTC eql castor oil oral oil 100 % OTC gnp castor oil oral oil 100 % OTC senexon oral liquid 8.8 mg/5ml OTC senna oral syrup 176 mg/5ml OTC senna oral syrup 8.8 mg/5ml OTC senna-grx oral syrup 8.8 mg/5ml OTC sennazon oral syrup 8.8 mg/5ml OTC sm castor oil oral oil 100 % OTC FLEET BISACODYL RECTAL ENEMA 10 MG/30ML OTC

LITTLE TUMMYS LAXATIVE ORAL LIQUID 8.8 MG/ML OTC

*Surfactant Laxatives*** cvs stool softener oral capsule 250 mg DOK OTC diocto oral liquid 50 mg/5ml OTC docu oral liquid 50 mg/5ml OTC docuprene oral tablet 100 mg DOK OTC docusate sodium oral capsule 250 mg DOK OTC docusate sodium oral liquid 50 mg/5ml OTC docusate sodium oral tablet 100 mg DOK OTC dss oral capsule 250 mg DOK OTC

140

Formulary Drug Name Reference Restrictions eq stool softener oral capsule 250 mg DOK OTC gnp stool softener oral capsule 250 mg DOK OTC gnp stool softener oral liquid 50 mg/5ml OTC hm stool softener oral capsule 250 mg DOK OTC hm stool softener oral tablet 100 mg DOK OTC ra col-rite oral capsule 250 mg DOK OTC silace oral liquid 150 mg/15ml OTC sm stool softener oral capsule 250 mg DOK OTC stool softener oral capsule 250 mg DOK OTC stool softener oral tablet 100 mg DOK OTC DOCUSOL PLUS MINI-ENEMA RECTAL ENEMA 20-283 MG OTC

DOK ORAL CAPSULE 250 MG EQ Stool Softener OTC DOK ORAL TABLET 100 MG HM Stool Softener OTC ENEMEEZ PLUS RECTAL ENEMA 20 -283 MG OTC

HEALTHY MAMA MOVE IT ALONG ORAL TABLET 100 MG HM Stool Softener OTC

PEDIA-LAX ORAL LIQUID 50 MG/15ML OTC PROMOLAXIN ORAL TABLET 100 MG HM Stool Softener OTC

*MACROLIDES* *Azithromycin*** azithromycin oral packet 1 gm Zithromax azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml Zithromax

azithromycin oral tablet 250 mg, 500 mg, 600 mg Zithromax

*Clarithromycin*** clarithromycin er oral tablet extended release 24 hour 500 mg Biaxin XL Pac

clarithromycin oral suspension reconstituted 125 mg/5ml clarithromycin oral suspension reconstituted 250 mg/5ml Biaxin

clarithromycin oral tablet 250 mg, 500 mg Biaxin

*Erythromycins*** erythromycin base oral capsule delayed release particles 250 mg erythromycin base oral tablet 250 mg, 500 mg

141

Formulary Drug Name Reference Restrictions erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml E.E.S. Granules

erythromycin ethylsuccinate oral tablet 400 mg E.E.S. 400

E.E.S. 400 ORAL TABLET 400 MG Erythromycin Ethylsuccinate E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML Erythromycin Ethylsuccinate

ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML Erythromycin Ethylsuccinate

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG Erythromycin Stearate

*MEDICAL DEVICES* *Applicators,Cotton Balls,Etc*** alcohol pads pad 70 % BD Swab Single Use Regular OTC alcohol prep pad , 70 % BD Swab Single Use Regular OTC alcohol swabs pad , 70 % BD Swab Single Use Regular OTC alcohol wipes pad BD Swab Single Use Regular alcohol wipes pad 70 % BD Swab Single Use Regular OTC cvs alcohol prep pads pad 70 % BD Swab Single Use Regular OTC cvs prep pad 70 % BD Swab Single Use Regular OTC eql alcohol swabs pad 70 % BD Swab Single Use Regular OTC global alcohol prep ease pad 70 % BD Swab Single Use Regular OTC gnp alcohol swabs pad 70 % BD Swab Single Use Regular OTC healthwise alcohol prep pad 70 % BD Swab Single Use Regular OTC h-e-b incontrol alcohol pad BD Swab Single Use Regular OTC meijer alcohol swabs pad 70 % BD Swab Single Use Regular OTC pro comfort alcohol pad 70 % BD Swab Single Use Regular OTC qc alcohol swabs pad 70 % BD Swab Single Use Regular OTC ra alcohol swabs pad 70 % BD Swab Single Use Regular OTC reality swabs pad BD Swab Single Use Regular OTC saps care alcohol prep pad 70 % BD Swab Single Use Regular OTC saps health alcohol prep pad 70 % BD Swab Single Use Regular OTC sb alcohol prep pad 70 % BD Swab Single Use Regular OTC sm alcohol prep pad , 70 % BD Swab Single Use Regular OTC sure comfort alcohol prep pad 70 % BD Swab Single Use Regular OTC tgt alcohol swabs pad 70 % BD Swab Single Use Regular OTC

142

Formulary Drug Name Reference Restrictions ultilet alcohol swabs pad BD Swab Single Use Regular OTC ALCOH-GLOVE CONTOURED WIPE PAD Ultilet Alcohol Swabs

ALCOHOL SWABSTICK PAD Ultilet Alcohol Swabs OTC BD SWAB SINGLE USE REGULAR PAD Ultilet Alcohol Swabs OTC BD SWABS SINGLE USE BUTTERFLY PAD Ultilet Alcohol Swabs OTC

CARETOUCH ALCOHOL PREP PAD 70 % Ultilet Alcohol Swabs OTC

CURITY ALCOHOL PREPS PAD 70 % Ultilet Alcohol Swabs OTC CURITY ALCOHOL SWABS PAD Ultilet Alcohol Swabs OTC EASY TOUCH ALCOHOL PREP MEDIUM PAD 70 % Ultilet Alcohol Swabs OTC

FIFTY50 ALCOHOL PREP PAD 70 % Ultilet Alcohol Swabs OTC PHARMACIST CHOICE ALCOHOL PAD Ultilet Alcohol Swabs OTC

RELION ALCOHOL SWABS PAD , 70 % Ultilet Alcohol Swabs OTC SHOPKO ALCOHOL SWABS PAD 70 % Ultilet Alcohol Swabs OTC SURE-PREP ALCOHOL PREP PAD 70 % Ultilet Alcohol Swabs OTC ULTICARE ALCOHOL SWABS PAD , 70 % Ultilet Alcohol Swabs OTC

WEBCOL ALCOHOL PREP LARGE PAD 70 % Ultilet Alcohol Swabs OTC

WEBCOL ALCOHOL PREP MEDIUM PAD 70 % Ultilet Alcohol Swabs OTC

*Cervical Caps*** FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM PRENTIF CAVITY-RIM CERV CAP VAGINAL DEVICE 22 MM, 25 MM, 28 MM, 31 MM PRENTIF FITTING SET VAGINAL

*Condoms - Male*** aimsco lubricated Trojan Ribbed/Spermicidal OTC kimono Trojan Ribbed/Spermicidal OTC

kimono micro thin Atlas Color Condom/Spermicide OTC

kimono micro thin plus Trojan Ribbed/Spermicidal OTC kimono plus Trojan Ribbed/Spermicidal OTC kimono ps Trojan Ribbed/Spermicidal OTC kimono ps plus Trojan Ribbed/Spermicidal OTC

143

Formulary Drug Name Reference Restrictions kimono sensation Trojan Ribbed/Spermicidal OTC kimono sensation plus Trojan Ribbed/Spermicidal OTC maxx Trojan Ribbed/Spermicidal OTC maxx plus Trojan Ribbed/Spermicidal OTC premium condoms lubricated Trojan Ribbed/Spermicidal OTC; QLL (12 EA per 30 days) ATLAS COLOR CONDOM/SPERMICIDE DEVICE Kimono Micro Thin OTC

ATLAS COLOR LUBRICATED CONDOM DEVICE Aimsco Lubricated OTC

ATLAS LUB CONDOM/SPERMICIDE DEVICE Aimsco Lubricated OTC

ATLAS LUBRICATED CONDOM DEVICE Aimsco Lubricated OTC

CLASS ACT LUBRICATED Aimsco Lubricated OTC DUREX EXTRA SENSITIVE DEVICE Aimsco Lubricated OTC ELEXA NATURAL FEEL Aimsco Lubricated OTC ELEXA STIMULATING Aimsco Lubricated OTC ELEXA ULTRA SENSITIVE Aimsco Lubricated OTC FANTASY LUBRICATED Aimsco Lubricated OTC FANTASY LUBRICATED/SPERMICIDE Aimsco Lubricated OTC KAMELEON LUBRICATED Aimsco Lubricated OTC KIMONO COLORS DEVICE Aimsco Lubricated OTC KIMONO SPECIAL DEVICE Aimsco Lubricated OTC REALITY LATEX CONDOMS Aimsco Lubricated OTC REALITY LATEX/ULTRA TEXTURED DEVICE Aimsco Lubricated OTC

REALITY LATEX/ULTRA THIN DEVICE Aimsco Lubricated OTC

TROJAN Kimono Micro Thin OTC TROJAN ASSORTMENT PACK Kimono Micro Thin OTC TROJAN EXTENDED PLEASURE/LUBE DEVICE Aimsco Lubricated OTC

TROJAN EXTRA STRENGTH Kimono Micro Thin OTC TROJAN MAGNUM Aimsco Lubricated OTC TROJAN MAGNUM WARM SENSATIONS DEVICE Aimsco Lubricated OTC

TROJAN MAGNUM XL LUBRICATED DEVICE Aimsco Lubricated OTC

TROJAN PLEASURE MESH/SPERMICID DEVICE Aimsco Lubricated OTC

TROJAN PLUS Kimono Micro Thin OTC

144

Formulary Drug Name Reference Restrictions TROJAN REGULAR Kimono Micro Thin OTC TROJAN RIBBED Kimono Micro Thin OTC TROJAN RIBBED/SPERMICIDAL Aimsco Lubricated OTC TROJAN SHARED SENSATION/LUBE DEVICE Aimsco Lubricated OTC

TROJAN SUPRAS SPERMICIDAL DEVICE Aimsco Lubricated OTC

TROJAN TWISTED PLEASURE DEVICE Aimsco Lubricated OTC

TROJAN ULTRA PLEASURE LUBRICAT DEVICE Aimsco Lubricated OTC

TROJAN VERY SENSITIVE LUBRICAT Aimsco Lubricated OTC TROJAN VERY SENSITIVE SPERMICI Aimsco Lubricated OTC TROJAN VERY THIN LUBRICATED Aimsco Lubricated OTC TROJAN VERY THIN SPERMICIDE Aimsco Lubricated OTC TROJAN-ENZ LUBRICATED Aimsco Lubricated OTC TROJAN-ENZ/SPERMICIDAL Aimsco Lubricated OTC TRUSTEX COLOR CONDOMS + LUBE Aimsco Lubricated OTC TRUSTEX LUB/RIBBED/STUDDED Aimsco Lubricated OTC TRUSTEX LUB/SPERMICIDE EX ST Aimsco Lubricated OTC TRUSTEX LUB/SPERMICIDE XL Aimsco Lubricated OTC TRUSTEX LUBRICATED Aimsco Lubricated OTC TRUSTEX LUBRICATED EX LARGE Aimsco Lubricated OTC TRUSTEX LUBRICATED EXTRA ST Aimsco Lubricated OTC TRUSTEX LUBRICATED/SPERMICIDE Aimsco Lubricated OTC TRUSTEX NATURAL CONDOMS + LUBE Aimsco Lubricated OTC

TRUSTEX NON-LUBRICATED Kimono Micro Thin OTC TRUSTEX RIA LUB/SPERMICIDE Aimsco Lubricated OTC TRUSTEX RIA LUBRICATED Aimsco Lubricated OTC TRUSTEX RIA NON-LUBRICATED Kimono Micro Thin OTC; QLL (12 EA per 30 days) TRUSTEX-NONOXYNOL-9/RIB/STUD Aimsco Lubricated OTC

*Diaphragms*** OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 %

145

Formulary Drug Name Reference Restrictions WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 %

*Glucose Monitoring Test Supplies*** 1st tier unilet comfortouch Fingerstix Lancets OTC acti-lance 28g Fingerstix Lancets OTC acti-lance lite lancets 28g Fingerstix Lancets OTC acti-lance special lancets 17g Fingerstix Lancets OTC acti-lance universal 23g Fingerstix Lancets OTC adjustable lancing device Autolet Mini OTC alternate site lancing device Autolet Mini OTC aqua lance adjustable lancing device Autolet Mini OTC assure comfort lancets 28g Fingerstix Lancets OTC assure comfort lancets 30g Fingerstix Lancets OTC aurora lancet super thin 30g Fingerstix Lancets OTC aurora lancet thin 23g Fingerstix Lancets OTC bullseye mini safety lancets Fingerstix Lancets OTC careone advanced lancing dev Autolet Mini OTC careone lancet thin 23g Fingerstix Lancets OTC careone lancet ultra thin 28g Fingerstix Lancets OTC comfort assured lancets 28g Fingerstix Lancets OTC comfort assured lancets 33g Fingerstix Lancets OTC comfort lancets Fingerstix Lancets OTC control in vitro solution normal EasyGluco Control OTC cvs lancets 21g Fingerstix Lancets OTC cvs lancets micro thin 33g Fingerstix Lancets OTC cvs lancets original Fingerstix Lancets OTC cvs lancets thin 26g Fingerstix Lancets OTC cvs lancets ultra thin 30g Fingerstix Lancets OTC cvs lancets ultra-thin 30g Fingerstix Lancets OTC

146

Formulary Drug Name Reference Restrictions cvs lancing device Autolet Mini OTC cvs ultra thin lancets Fingerstix Lancets OTC diatrue control level 1 in vitro solution low Solus V2 Control OTC diatrue control level 2 in vitro solution normal EasyGluco Control OTC diatrue control level 3 in vitro solution high Prodigy Control Solution OTC drug mart lancets thin 26g Fingerstix Lancets OTC easy comfort lancets Fingerstix Lancets OTC easy mini eject lancing device Autolet Mini OTC easy mini lancing device Autolet Mini OTC easy plus ii control in vitro solution high Prodigy Control Solution OTC easy plus ii control in vitro solution low Solus V2 Control OTC easy talk control in vitro solution high Prodigy Control Solution OTC easy talk control in vitro solution low Solus V2 Control OTC easy talk control in vitro solution normal EasyGluco Control OTC easy trak control in vitro solution high Prodigy Control Solution OTC easy trak control in vitro solution low Solus V2 Control OTC easy trak control in vitro solution normal EasyGluco Control OTC element compact control 2 in vitro solution On Call Express Glucose Contr OTC element compact control 3 in vitro solution On Call Express Glucose Contr OTC eql color lancets 21g Fingerstix Lancets OTC eql color lancets micro 33g Fingerstix Lancets OTC eql super thin lancets 30g Fingerstix Lancets OTC eql thin lancets 26g Fingerstix Lancets OTC freds pharmacy autolet lancing Autolet Mini OTC freds pharmacy unilet lanc 28g Fingerstix Lancets OTC freds pharmacy unilet lanc 30g Fingerstix Lancets OTC ge100 control in vitro solution normal EasyGluco Control OTC global inject ease lancets 28g Fingerstix Lancets OTC global inject ease lancets 30g Fingerstix Lancets OTC global lancing device Autolet Mini OTC glucose control in vitro solution On Call Express Glucose Contr OTC glucose control in vitro solution normal EasyGluco Control OTC gnp lancets Fingerstix Lancets OTC gnp lancets 21g Fingerstix Lancets OTC gnp lancets micro thin 33g Fingerstix Lancets OTC gnp lancets super thin 30g Fingerstix Lancets OTC gnp lancets thin Fingerstix Lancets OTC gnp lancets thin 26g Fingerstix Lancets OTC

147

Formulary Drug Name Reference Restrictions gnp micro thin lancets 33g Fingerstix Lancets OTC gnp super thin lancets 30g Fingerstix Lancets OTC goodsense lancets 30g Fingerstix Lancets OTC goodsense lancets 33g Fingerstix Lancets OTC goodsense lancing device Autolet Mini OTC healthwise lancets 30g Fingerstix Lancets OTC healthwise lancing pen Autolet Mini OTC healthy accents lancing device Autolet Mini OTC healthy accents unilet lancets Fingerstix Lancets OTC h-e-b incontrol adv lancing Autolet Mini OTC h-e-b incontrol lancets 28g Fingerstix Lancets OTC h-e-b incontrol lancets 30g Fingerstix Lancets OTC h-e-b incontrol lancets 33g Fingerstix Lancets OTC hy-vee thin lancets Fingerstix Lancets OTC kinney lancets Fingerstix Lancets OTC kinney thin lancets Fingerstix Lancets OTC kroger lancets Fingerstix Lancets OTC kroger lancets 21g Fingerstix Lancets OTC kroger lancets micro thin 33g Fingerstix Lancets OTC kroger lancets super thin Fingerstix Lancets OTC kroger lancets thin Fingerstix Lancets OTC kroger lancets thin 26g Fingerstix Lancets OTC kroger lancets ultrathin 30g Fingerstix Lancets OTC kroger lancing device Autolet Mini OTC lancet device Autolet Mini OTC lancet device with ejector Autolet Mini OTC lancet transporter case Autolet Platforms OTC lancets Fingerstix Lancets OTC lancets 28g Fingerstix Lancets OTC lancets 30g Fingerstix Lancets OTC lancets micro thin 33g Fingerstix Lancets OTC lancets super thin 28g Fingerstix Lancets OTC lancets thin Fingerstix Lancets OTC lancets ultra thin 30g Fingerstix Lancets OTC lancing device Autolet Mini OTC leader advanced lancing device Autolet Mini OTC lite touch lancets Fingerstix Lancets OTC live better adv lancing device Autolet Mini OTC

148

Formulary Drug Name Reference Restrictions live better lancet super thin Fingerstix Lancets OTC live better lancet ultra thin Fingerstix Lancets OTC longs lancets standard Fingerstix Lancets OTC longs lancets thin Fingerstix Lancets OTC longs lancets ultra thin Fingerstix Lancets OTC medichoice safety lancet Fingerstix Lancets OTC medichoice safety lancet extra Fingerstix Lancets OTC medichoice safety lancet norm Fingerstix Lancets OTC mini lancing device Autolet Mini OTC multi-lancet device Autolet Mini OTC pc lancets super thin 30g Fingerstix Lancets OTC preferred plus lancets colored Fingerstix Lancets OTC preferred plus lancets thin Fingerstix Lancets OTC pressure activat safety lancet Fingerstix Lancets OTC pro comfort lancets 30g Fingerstix Lancets OTC pro comfort lancets 31g Fingerstix Lancets OTC push button safety lancets Fingerstix Lancets OTC px advanced lancing device Autolet Mini OTC px lancet auto injector Autolet Mini OTC px lancets ultra thin Fingerstix Lancets OTC qc advanced lancing device Autolet Mini OTC qc lancets super thin 30g Fingerstix Lancets OTC qc lancets ultra thin Fingerstix Lancets OTC qc unilet lancets 28g Fingerstix Lancets OTC qc unilet lancets micro thin Fingerstix Lancets OTC ra lancing device Autolet Mini OTC reality lancets Fingerstix Lancets OTC reality trigger lancets Fingerstix Lancets OTC safety lancet 21g/pressure act Fingerstix Lancets OTC safety lancet 28g/pressure act Fingerstix Lancets OTC safety lancets 28g Fingerstix Lancets OTC saps health twist top lancets Fingerstix Lancets OTC sapscare twist top lancets Fingerstix Lancets OTC sb lancets thin Fingerstix Lancets OTC sb lancets ultra thin Fingerstix Lancets OTC select-lite device/lancets kit Autolet Lite Starter Pack OTC select-lite lancing device Autolet Mini OTC side button safety lancet Fingerstix Lancets OTC

149

Formulary Drug Name Reference Restrictions sm lancets 33g Fingerstix Lancets OTC super thin lancets Fingerstix Lancets OTC supreme ii confidence paddles Chemstrip bG Log Book OTC supreme ii high/low control in vitro liquid On Call Express Glucose Contr OTC sure comfort lancets 18g Fingerstix Lancets OTC sure comfort lancets 21g Fingerstix Lancets OTC sure comfort lancets 23g Fingerstix Lancets OTC sure comfort lancets 28g Fingerstix Lancets OTC sure comfort lancets 30g Fingerstix Lancets OTC sure comfort lancing pen Autolet Mini OTC tgt lancet micro thin 33g Fingerstix Lancets OTC tgt lancet thin 26g Fingerstix Lancets OTC tgt lancet ultra thin 30g Fingerstix Lancets OTC tgt lancing device Autolet Mini OTC todays health lancing device Autolet Mini OTC todays health thin lancets 28g Fingerstix Lancets OTC todays health thin lancets 30g Fingerstix Lancets OTC topcare lancets micro-thin 33g Fingerstix Lancets OTC travel lancets Fingerstix Lancets OTC value plus lancet standard 21g Fingerstix Lancets OTC value plus lancets super thin Fingerstix Lancets OTC value plus lancets thin 26g Fingerstix Lancets OTC value plus lancing device Autolet Mini OTC valumark lancet super thin 30g Fingerstix Lancets OTC valumark lancet ultra thin 28g Fingerstix Lancets OTC walgreens adv travel lancets Fingerstix Lancets OTC walgreens lancets micro thin Fingerstix Lancets OTC walgreens lancets super thin Fingerstix Lancets OTC ACCU-CHEK AVIVA IN VITRO SOLUTION Element Compact Control 2 OTC

ACCU-CHEK COMPACT PLUS CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

ACCU-CHEK FASTCLIX LANCET KIT Select-Lite Device/Lancets OTC

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

ACCU-CHEK GUIDE CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

ACCU-CHEK MULTICLIX LANCET DEV KIT Select-Lite Device/Lancets OTC

150


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

ACCU-CHEK SAFE-T PRO LANCETS Global Inject Ease Lancets 28G OTC

ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

ACCU-CHEK SOFT TOUCH LANCETS Global Inject Ease Lancets 28G OTC

ACCU-CHEK SOFTCLIX LANCET DEV KIT Select-Lite Device/Lancets OTC

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

ACCUTREND GLUCOSE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

ACTIVE 1ST BLOOD LANCETS 30G Global Inject Ease Lancets 28G OTC

ADVANCE INTUITION CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

ADVANCE MICRO-DRAW CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

ADVANCE MICRO-DRAW NORMAL IN VITRO LIQUID Element Compact Control 2 OTC

ADVOCATE CONTROL SOLUTION IN VITRO LIQUID HIGH Easy Trak Control OTC

ADVOCATE CONTROL SOLUTION IN VITRO LIQUID LOW DiaTrue Control Level 1 OTC

ADVOCATE LANCETS Global Inject Ease Lancets 28G OTC

ADVOCATE LANCETS 30G Global Inject Ease Lancets 28G OTC

ADVOCATE LANCING DEVICE H-E-B inControl Adv Lancing OTC ADVOCATE RAPID-SAFE LANCING H-E-B inControl Adv Lancing OTC ADVOCATE REDI-CODE+ CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

ADVOCATE REDI-CODE+ CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

ADVOCATE SAFETY LANCETS Global Inject Ease Lancets 28G OTC

ADVOCATE SAFETY LANCETS 26G Global Inject Ease Lancets 28G OTC

AGAMATRIX CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

151

Formulary Drug Name Reference Restrictions AGAMATRIX CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

AGAMATRIX CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

AGAMATRIX ULTRA-THIN LANCETS Global Inject Ease Lancets 28G OTC

ASSURE 3 CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

ASSURE 4 CONTROL LEVEL 1 & 2 IN VITRO LIQUID Element Compact Control 2 OTC

ASSURE DOSE CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

ASSURE DOSE NORM/HIGH CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

ASSURE HAEMOLANCE PLUS HIGH Global Inject Ease Lancets 28G OTC

ASSURE HAEMOLANCE PLUS LOW Global Inject Ease Lancets 28G OTC

ASSURE HAEMOLANCE PLUS MICRO Global Inject Ease Lancets 28G OTC

ASSURE HAEMOLANCE PLUS NORMAL

Global Inject Ease Lancets 28G OTC

ASSURE HAEMOLANCE PLUS PED Global Inject Ease Lancets 28G OTC

ASSURE II CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

ASSURE II CONTROL LEVEL 1 & 2 IN VITRO LIQUID Element Compact Control 2 OTC

ASSURE LANCE LANCETS Global Inject Ease Lancets 28G OTC

ASSURE LANCE LANCETS 21G Global Inject Ease Lancets 28G OTC

ASSURE LANCE PLUS SAFETY 25G Global Inject Ease Lancets 28G OTC

ASSURE LANCE PLUS SAFETY 30G Global Inject Ease Lancets 28G OTC

ASSURE LANCETS Global Inject Ease Lancets 28G OTC

ASSURE PRISM CONTROL LEVEL 1&2 IN VITRO SOLUTION Element Compact Control 2 OTC

ASSURE PRO CONTROL LEVEL 1 & 2 IN VITRO LIQUID Element Compact Control 2 OTC

AT LAST CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

152


AT LAST LANCETS Global Inject Ease Lancets 28G OTC

AUTO-LANCET H-E-B inControl Adv Lancing OTC AUTO-LANCET MINI H-E-B inControl Adv Lancing OTC AUTOLET II CLINISAFE KIT Select-Lite Device/Lancets OTC AUTOLET LANCING DEVICE H-E-B inControl Adv Lancing OTC AUTOLET LITE CLINISAFE KIT Select-Lite Device/Lancets OTC AUTOLET LITE STARTER PACK KIT Select-Lite Device/Lancets OTC AUTOLET MINI H-E-B inControl Adv Lancing OTC AUTOLET PLATFORMS Lancet Transporter Case OTC AUTOLET PLUS H-E-B inControl Adv Lancing OTC BAYER BREEZE 2 CONTROL IN VITRO LIQUID HIGH Easy Trak Control OTC

BAYER BREEZE 2 CONTROL IN VITRO LIQUID LOW DiaTrue Control Level 1 OTC

BAYER BREEZE 2 CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

BAYER CONTOUR IN VITRO LIQUID HIGH Easy Trak Control OTC

BAYER CONTOUR IN VITRO LIQUID LOW DiaTrue Control Level 1 OTC

BAYER CONTOUR IN VITRO LIQUID NORMAL Easy Talk Control OTC

BAYER CONTOUR NEXT CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

BAYER CONTOUR NEXT CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

BAYER MICROLET 2 LANCING DEVIC H-E-B inControl Adv Lancing OTC

BAYER MICROLET LANCETS Global Inject Ease Lancets 28G OTC

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

BD LANCET ULTRAFINE 33G Global Inject Ease Lancets 28G OTC

BD MICROTAINER LANCETS Global Inject Ease Lancets 28G OTC

BULLSEYE SAFETY LANCETS Global Inject Ease Lancets 28G OTC

CARDIOCOM LANCING DEVICE H-E-B inControl Adv Lancing OTC CARESENS CONTROL A IN VITRO SOLUTION Element Compact Control 2 OTC

CARETOUCH LANCING/EJECTOR H-E-B inControl Adv Lancing OTC

153


CARETOUCH TWIST LANCETS 30G Global Inject Ease Lancets 28G OTC

CHEMSTRIP BG LOG BOOK Supreme II Confidence Paddles OTC

CLEANLET LANCETS 28G Global Inject Ease Lancets 28G OTC

CLEVER CHEK LANCETS Global Inject Ease Lancets 28G OTC

CLEVER CHOICE GLUCOSE CONTROL IN VITRO LIQUID HIGH Easy Trak Control OTC

CLEVER CHOICE GLUCOSE CONTROL IN VITRO LIQUID LOW DiaTrue Control Level 1 OTC

CLOSERCARE H-E-B inControl Adv Lancing OTC

COAGUCHEK LANCETS Global Inject Ease Lancets 28G OTC

COOL CONTROL A IN VITRO SOLUTION Element Compact Control 2 OTC

COOL CONTROL B IN VITRO SOLUTION Element Compact Control 2 OTC

DIASTAR EASY TEST II LANCETS Global Inject Ease Lancets 28G OTC

DIASTAR EASY TEST LANCETS Global Inject Ease Lancets 28G OTC

DROPLET LANCETS ULTRA THIN 30G Global Inject Ease Lancets 28G OTC

DROPLET LANCING DEVICE H-E-B inControl Adv Lancing OTC DRUG MART LANCING DEVICE H-E-B inControl Adv Lancing OTC DRUG MART ON-THE-GO LANCET 30G Global Inject Ease Lancets

28G OTC

DRUG MART UNILET LANCETS 28G Global Inject Ease Lancets 28G OTC

DRUG MART UNILET LANCETS 30G Global Inject Ease Lancets 28G OTC

DUO-CARE CONTROL SOLUTION IN VITRO LIQUID Element Compact Control 2 OTC

EASY STEP CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

EASY STEP CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

EASY STEP CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

EASY TOUCH CONTROL HIGH & LOW IN VITRO SOLUTION Element Compact Control 2 OTC

154

Formulary Drug Name Reference Restrictions EASY TOUCH HEALTHPRO CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

EASY TOUCH LANCETS 21G Global Inject Ease Lancets 28G OTC



EASY TOUCH LANCETS 26G/TWIST Global Inject Ease Lancets 28G OTC








EASY TOUCH LANCING DEVICE H-E-B inControl Adv Lancing OTC

EASY TOUCH SAFETY LANCETS 21G Global Inject Ease Lancets 28G OTC




EASY TWIST & CAP LANCETS Global Inject Ease Lancets 28G OTC

EASYGLUCO CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

EASYGLUCO CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

EASYGLUCO CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

EASYGLUCO PLUS LEVEL 1 IN VITRO SOLUTION Element Compact Control 2 OTC

155

Formulary Drug Name Reference Restrictions EASYMAX 15 LEVEL 1 CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

EASYMAX 15 LEVEL 1-2 CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

EASYMAX 15 LEVEL 2 CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

EASYMAX CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

EASYMAX CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

EASYMAX CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

EASYMAX CONTROL NORMAL/LOW IN VITRO SOLUTION Element Compact Control 2 OTC

EASYTEST II LANCETS Global Inject Ease Lancets 28G OTC

EASYTEST LANCETS Global Inject Ease Lancets 28G OTC

ELEMENT CONTROL IN VITRO LIQUID HIGH Easy Trak Control OTC

ELEMENT CONTROL IN VITRO LIQUID LOW DiaTrue Control Level 1 OTC

ELEMENT CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

EMBRACE CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

EMBRACE EVO CONTROL LEVEL 1 IN VITRO LIQUID LOW DiaTrue Control Level 1 OTC

EMBRACE EVO CONTROL LEVEL 2 IN VITRO LIQUID NORMAL Easy Talk Control OTC

EMBRACE GLUCOSE CONTROL IN VITRO LIQUID HIGH Easy Trak Control OTC

EMBRACE LANCETS ULTRA THIN 30G Global Inject Ease Lancets 28G OTC

EMBRACE PRO GLUCOSE CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

EVENCARE CONTROL LOW/HIGH IN VITRO LIQUID Element Compact Control 2 OTC

EVENCARE G2 LOW/HIGH CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

EVENCARE G3 LOW/HIGH CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

EVENCARE MINI CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

156

Formulary Drug Name Reference Restrictions EVOLUTION CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

E-Z JECT LANCET MICRO-THIN 33G Global Inject Ease Lancets 28G OTC

E-Z JECT LANCET SUPER THIN 30G Global Inject Ease Lancets 28G OTC

E-Z JECT LANCETS Global Inject Ease Lancets 28G OTC

E-Z JECT LANCETS 21G Global Inject Ease Lancets 28G OTC

E-Z JECT LANCETS THIN 26G Global Inject Ease Lancets 28G OTC

EZ SMART BLOOD GLUCOSE LANCETS


EZ-LETS LANCETS 21G Global Inject Ease Lancets 28G OTC





FIFTY50 SAFETY SEAL LANCETS Global Inject Ease Lancets 28G OTC

FIFTY50 UNILET LANCETS 33G Global Inject Ease Lancets 28G OTC

FINE 30 Global Inject Ease Lancets 28G OTC

FINGERSTIX LANCETS Global Inject Ease Lancets 28G OTC

FORA CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

FORA CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

FORA CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

FORA LANCETS Global Inject Ease Lancets 28G OTC

FORA LANCING DEVICE H-E-B inControl Adv Lancing OTC FORACARE GDH CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

157

Formulary Drug Name Reference Restrictions FORACARE GDH CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

FORACARE GDH CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

FORTISCARE CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

FORTISCARE CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

FORTISCARE CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

FREESTYLE CONTROL SOLUTION IN VITRO LIQUID Element Compact Control 2 OTC

FREESTYLE LANCETS Global Inject Ease Lancets 28G OTC

FREESTYLE UNISTICK II LANCETS Global Inject Ease Lancets 28G OTC

GENTLE-LET GP LANCETS Global Inject Ease Lancets 28G OTC

GENTLE-LET LANCETS Global Inject Ease Lancets 28G OTC

GENTLE-LET PLATFORMS Lancet Transporter Case OTC GLUCOCARD 01 CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

GLUCOCARD 01 CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

GLUCOCARD EXPRESSION CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

GLUCOCARD SHINE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

GLUCOCARD X-SENSOR CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

GLUCOCOM AUTOLINK TELEMONITOR

Supreme II Confidence Paddles OTC

GLUCOCOM CONTROL IN VITRO LIQUID HIGH Easy Trak Control OTC

GLUCOCOM CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

GLUCOCOM LANCETS 28G Global Inject Ease Lancets 28G OTC



158

Formulary Drug Name Reference Restrictions GLUCOSOURCE LANCET DEVICE H-E-B inControl Adv Lancing OTC

GLUCOSOURCE LANCETS Global Inject Ease Lancets 28G OTC

GMATE CONTROL LEVEL 2 IN VITRO SOLUTION Element Compact Control 2 OTC

GMATE LANCETS 30G Global Inject Ease Lancets 28G OTC

GMATE LANCING DEVICE H-E-B inControl Adv Lancing OTC GNP EASY TOUCH CONT HIGH/LOW IN VITRO SOLUTION Element Compact Control 2 OTC

HAEMOLANCE Global Inject Ease Lancets 28G OTC

HAEMOLANCE LOW FLOW LANCETS Global Inject Ease Lancets 28G OTC

HAEMOLANCE PLUS Global Inject Ease Lancets 28G OTC

HAEMOLANCE PLUS HIGH FLOW Global Inject Ease Lancets 28G OTC

HAEMOLANCE PLUS LOW FLOW Global Inject Ease Lancets 28G OTC

HAEMOLANCE PLUS MAX FLOW Global Inject Ease Lancets 28G OTC

HAEMOLANCE PLUS PEDIATRIC FLOW


HEALTH CARE LANCING DEVICE H-E-B inControl Adv Lancing OTC HYPOLANCE AST LANCING KIT Select-Lite Device/Lancets OTC

HY-VEE LANCETS Global Inject Ease Lancets 28G OTC

IN TOUCH Supreme II Confidence Paddles OTC

IN TOUCH GLUCOSE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

IN TOUCH LANCING DEVICE H-E-B inControl Adv Lancing OTC

IN TOUCH STERILE LANCETS 30G Global Inject Ease Lancets 28G OTC

INFINITY CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

INFINITY CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

INFINITY CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

LANCETS ULTRA FINE Global Inject Ease Lancets 28G OTC

159


LANCETS ULTRA THIN Global Inject Ease Lancets 28G OTC

LANZO H-E-B inControl Adv Lancing OTC LIBERTY GLUCOSE CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

LIBERTY GLUCOSE CONTROL MID IN VITRO SOLUTION Element Compact Control 2 OTC

LIBERTY MEDICAL LANCETS Global Inject Ease Lancets 28G OTC

LIBERTY MINI LANCING DEVICE H-E-B inControl Adv Lancing OTC

LIFESCAN UNISTIK 2 Global Inject Ease Lancets 28G OTC

LIFESCAN UNISTIK II LANCETS Global Inject Ease Lancets 28G OTC

LITE TOUCH LANCING DEVICE H-E-B inControl Adv Lancing OTC LITE TOUCH LANCING PEN H-E-B inControl Adv Lancing OTC

LITETOUCH LANCETS Global Inject Ease Lancets 28G OTC

MEDISENSE GLUCOSE KETONE CONTR IN VITRO LIQUID Element Compact Control 2 OTC

MEDISENSE HI/MID/LOW CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

MEDISENSE HIGH/LOW CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

MEDISENSE MID CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

MEDISENSE THIN LANCETS Global Inject Ease Lancets 28G OTC

MEDLANCE EXTRA 21G Global Inject Ease Lancets 28G OTC

MEDLANCE LITE 25G Global Inject Ease Lancets 28G OTC

MEDLANCE PLUS EXTRA 21G Global Inject Ease Lancets 28G OTC

MEDLANCE PLUS LANCETS Global Inject Ease Lancets 28G OTC

160


MEDLANCE PLUS LITE 25G Global Inject Ease Lancets 28G OTC

MEDLANCE PLUS SPECIAL 0.8MM Global Inject Ease Lancets 28G OTC

MEDLANCE PLUS SUPERLITE 30G Global Inject Ease Lancets 28G OTC

MEDLANCE PLUS UNIVERSAL 21G Global Inject Ease Lancets 28G OTC

MEDLANCE UNIVERSAL 21G Global Inject Ease Lancets 28G OTC

MEIJER LANCETS Global Inject Ease Lancets 28G OTC

MEIJER LANCETS THIN Global Inject Ease Lancets 28G OTC

MEIJER LANCETS UNIVERSAL 21G Global Inject Ease Lancets 28G OTC



MEIJER SUPER THIN LANCETS Global Inject Ease Lancets 28G OTC

MICRODOT CONTROL HIGH/LOW IN VITRO SOLUTION Element Compact Control 2 OTC

MICROLET LANCETS Global Inject Ease Lancets 28G OTC

MICROLET NEXT LANCING DEVICE H-E-B inControl Adv Lancing OTC MICROTAINER SAFETY FLOW LANCET


MONOJECTOR END CAPS Lancet Transporter Case OTC MONOJECTOR OPD END CAPS Lancet Transporter Case OTC

MONOLET LANCETS Global Inject Ease Lancets 28G OTC

MONOLET OPD LANCETS Global Inject Ease Lancets 28G OTC

MONOLETTOR SAFETY LANCETS Global Inject Ease Lancets 28G OTC

MULTI-LANCET DEVICE 2 KIT Select-Lite Device/Lancets OTC MYGLUCOHEALTH CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

MYGLUCOHEALTH LANCETS 30G Global Inject Ease Lancets 28G OTC

161


NETGROUP LANCETS Global Inject Ease Lancets 28G OTC

NEUTEK 2TEK CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

NEXGEN CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

NOVA MAX PLUS GLU/KET CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

NOVA SAFETY LANCETS 23G Global Inject Ease Lancets 28G OTC

NOVA SAFETY LANCETS 28G Global Inject Ease Lancets 28G OTC

NOVA SUREFLEX LANCETS Global Inject Ease Lancets 28G OTC

NOVA SUREFLEX LANCING DEVICE H-E-B inControl Adv Lancing OTC ON CALL EXPRESS GLUCOSE CONTR IN VITRO SOLUTION Element Compact Control 2 OTC

ON CALL LANCETS Global Inject Ease Lancets 28G OTC

ON CALL LANCING DEVICE H-E-B inControl Adv Lancing OTC ON CALL PLUS GLUCOSE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

ON CALL PLUS LANCETS Global Inject Ease Lancets 28G OTC

ON CALL PLUS LANCING DEVICE H-E-B inControl Adv Lancing OTC ON CALL VIVID GLUCOSE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

ONETOUCH CLUB LANCETS FINE PT Global Inject Ease Lancets 28G OTC

ONETOUCH COMBO PACK Global Inject Ease Lancets 28G OTC

ONETOUCH DELICA LANCETS 33G Global Inject Ease Lancets 28G OTC

ONETOUCH DELICA LANCETS FINE Global Inject Ease Lancets 28G OTC

ONETOUCH DELICA LANCING DEV H-E-B inControl Adv Lancing OTC

ONETOUCH FINEPOINT LANCETS Global Inject Ease Lancets 28G OTC

ONETOUCH LANCETS Global Inject Ease Lancets 28G OTC

ONETOUCH SURESOFT LANCING DEV Lancet Transporter Case OTC

162


ONETOUCH ULTRA 2 KIT W/DEVICE Blood Glucose Monitor System OTC; QLL (1 kit per 365 days)

ONETOUCH ULTRA CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

ONETOUCH ULTRA MINI KIT W/DEVICE

Blood Glucose Monitor System OTC; QLL (1 kit per 365 days)

ONETOUCH ULTRALINK KIT W/DEVICE


ONETOUCH ULTRASOFT LANCETS Global Inject Ease Lancets 28G OTC

ONETOUCH VERIO IN VITRO SOLUTION Element Compact Control 2 OTC

ONETOUCH VERIO IN VITRO SOLUTION HIGH Easy Trak Control OTC

ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE


ONETOUCH VERIO KIT W/DEVICE Blood Glucose Monitor System OTC; QLL (1 kit per 365 days)

OPTUMRX GLUCOSE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

PENLET II BLOOD SAMPLER KIT Select-Lite Device/Lancets OTC PENLET II REPLACEMENT CAP Lancet Transporter Case OTC

PERFECT LANCETS 28G Global Inject Ease Lancets 28G OTC

PERFECT LANCETS 30G Global Inject Ease Lancets 28G OTC

PHARMACIST CHOICE LANCETS Global Inject Ease Lancets 28G OTC

PHARMACY COUNTER LANCETS Global Inject Ease Lancets 28G OTC

POCKETCHEM EZ CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

PRECISION GLUCOSE CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

PRECISION GLUCOSE CONTROL SOLN IN VITRO SOLUTION Element Compact Control 2 OTC

PRECISION GLUCOSE KETONE CONTR IN VITRO LIQUID Element Compact Control 2 OTC

PRECISION GLUCOSE/KETONE CONTR IN VITRO LIQUID Element Compact Control 2 OTC

PRECISION THIN LANCETS Global Inject Ease Lancets 28G OTC

163


PRECISION THINS GP LANCETS Global Inject Ease Lancets 28G OTC

PRECISION ULTRA LANCET Global Inject Ease Lancets 28G OTC

PRODIGY CONTROL SOLUTION IN VITRO SOLUTION HIGH Easy Trak Control OTC

PRODIGY CONTROL SOLUTION IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

PRODIGY LANCETS 28G Global Inject Ease Lancets 28G OTC

PRODIGY LANCING DEVICE H-E-B inControl Adv Lancing OTC

PRODIGY SAFETY LANCETS 26G Global Inject Ease Lancets 28G OTC

PRODIGY TWIST TOP LANCETS 28G Global Inject Ease Lancets 28G OTC

PSS SELECT GP LANCETS Global Inject Ease Lancets 28G OTC

PSS SELECT PLATFORMS Lancet Transporter Case OTC

PSS SELECT SAFETY LANCETS Global Inject Ease Lancets 28G OTC

QUICKTEK CONTROL SOLUTION IN VITRO LIQUID Element Compact Control 2 OTC

QUINTET CONTROL HIGH/NORMAL IN VITRO SOLUTION Element Compact Control 2 OTC

RA E-ZJECT COLOR LANCETS 33G Global Inject Ease Lancets 28G OTC

RA E-ZJECT LANCETS 28G Global Inject Ease Lancets 28G OTC

RA E-ZJECT LANCETS THIN 26G Global Inject Ease Lancets 28G OTC

RA E-ZJECT LANCETS THIN 28G Global Inject Ease Lancets 28G OTC

RA E-ZJECT LANCETS ULTRA THIN Global Inject Ease Lancets 28G OTC

READYLANCE SAFETY LANCETS Global Inject Ease Lancets 28G OTC

REFUAH PLUS GLUCOSE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

RELION LANCETS MICRO-THIN 33G Global Inject Ease Lancets 28G OTC

RELION LANCETS STANDARD 21G Global Inject Ease Lancets 28G OTC

164


RELION LANCETS THIN 26G Global Inject Ease Lancets 28G OTC

RELION LANCETS ULTRA-THIN 30G Global Inject Ease Lancets 28G OTC

RELION LANCING DEVICE H-E-B inControl Adv Lancing OTC RELION LANCING DEVICE KIT Select-Lite Device/Lancets OTC

RELION ULTRA THIN LANCETS 30G Global Inject Ease Lancets 28G OTC

RELION ULTRA THIN PLUS LANCETS Global Inject Ease Lancets 28G OTC

REXALL LANCETS ULTRA THIN 30G Global Inject Ease Lancets 28G OTC

RIGHTEST ALTERNATE SITE ADAPT Lancet Transporter Case OTC RIGHTEST GC300 CONTROL IN VITRO LIQUID HIGH Easy Trak Control OTC

RIGHTEST GC300 CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

RIGHTEST GD500 LANCING DEVICE H-E-B inControl Adv Lancing OTC

RIGHTEST GL300 LANCETS Global Inject Ease Lancets 28G OTC

SAFE-T-LANCE Global Inject Ease Lancets 28G OTC

SAFE-T-LANCE PLUS Global Inject Ease Lancets 28G OTC

SAFETY LANCETS Global Inject Ease Lancets 28G OTC

SAFETY LANCETS 21G Global Inject Ease Lancets 28G OTC

SAFETY LET LANCETS Global Inject Ease Lancets 28G OTC

SAFETY SEAL LANCETS Global Inject Ease Lancets 28G OTC

SHOPKO AUTOLET LANCING DEVICE H-E-B inControl Adv Lancing OTC

SHOPKO ON-THE-GO LANCETS 30G Global Inject Ease Lancets 28G OTC

SHOPKO UNILET LANCETS 28G Global Inject Ease Lancets 28G OTC

SHOPKO UNILET LANCETS 30G Global Inject Ease Lancets 28G OTC

SIMPLE DIAGNOSTICS LANCING DEV H-E-B inControl Adv Lancing OTC

SINGLE-LET Global Inject Ease Lancets 28G OTC

165

Formulary Drug Name Reference Restrictions SMART DIABETES VANTAGE LANCING H-E-B inControl Adv Lancing OTC

SMART SENSE COLOR LANCETS 33G Global Inject Ease Lancets 28G OTC

SMART SENSE STANDARD LANCETS Global Inject Ease Lancets 28G OTC

SMART SENSE SUPER THIN LANCETS Global Inject Ease Lancets 28G OTC

SMART SENSE THIN LANCETS 26G Global Inject Ease Lancets 28G OTC

SMARTEST CONTROL MEDIUM IN VITRO SOLUTION Element Compact Control 2 OTC

SMARTEST LANCETS 28G Global Inject Ease Lancets 28G OTC

SOLARTEK GLUCOSE CONTROL IN VITRO LIQUID Element Compact Control 2 OTC

SOLUS V2 CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

SOLUS V2 CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

SOLUS V2 LANCETS 28G Global Inject Ease Lancets 28G OTC

SOLUS V2 LANCING DEVICE H-E-B inControl Adv Lancing OTC

SOLUS V2 TWIST LANCETS 30G Global Inject Ease Lancets 28G OTC

STERILANCE PA Lancet Transporter Case OTC

STERILANCE TL Global Inject Ease Lancets 28G OTC

SURE-LANCE FLAT LANCETS Global Inject Ease Lancets 28G OTC

SURE-LANCE LANCETS 26G Global Inject Ease Lancets 28G OTC

SURE-LANCE THIN LANCETS 28G Global Inject Ease Lancets 28G OTC

SURE-LANCE ULTRA THIN LANCETS Global Inject Ease Lancets 28G OTC

SURELITE LANCETS Global Inject Ease Lancets 28G OTC

SURE-PEN H-E-B inControl Adv Lancing OTC SURESTEP GLUCOSE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID Easy Trak Control OTC

166


SURESTEP PRO LINEARITY KIT Supreme II Confidence Paddles OTC

SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID DiaTrue Control Level 1 OTC

SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID Easy Talk Control OTC

SURE-TOUCH LANCETS UNIVERSAL Global Inject Ease Lancets 28G OTC

TAI DOC CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

TECHLITE AST LANCETS Global Inject Ease Lancets 28G OTC

TECHLITE LANCETS Global Inject Ease Lancets 28G OTC

TECHLITE LANCETS 30G Global Inject Ease Lancets 28G OTC

TELCARE GLUCOSE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

THINLETS GP LANCETS Global Inject Ease Lancets 28G OTC

THINLETS LANCET Global Inject Ease Lancets 28G OTC

TRACER II 3 VOLT BATTERY Supreme II Confidence Paddles OTC

TRAVEL LANCETS ADVANCED 28G Global Inject Ease Lancets 28G OTC

TRUE METRIX LEVEL 1 IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

TRUE METRIX LEVEL 2 IN VITRO SOLUTION NORMAL Easy Talk Control OTC

TRUE METRIX LEVEL 3 IN VITRO SOLUTION HIGH Easy Trak Control OTC

TRUECONTROL GLUCOSE CONT LEV 0 IN VITRO LIQUID Element Compact Control 2 OTC

TRUECONTROL GLUCOSE CONT LEV 1 IN VITRO LIQUID Element Compact Control 2 OTC

TRUEDRAW LANCING DEVICE H-E-B inControl Adv Lancing OTC

TRUEPLUS LANCETS 26G Global Inject Ease Lancets 28G OTC



167



TRUEPLUS SAFETY LANCETS 28G Global Inject Ease Lancets 28G OTC

TRUETEST CONTROL LEVEL 1 IN VITRO LIQUID Element Compact Control 2 OTC



ULTI-LANCE AUTOMATIC H-E-B inControl Adv Lancing OTC

ULTILET CLASSIC LANCETS Global Inject Ease Lancets 28G OTC

ULTILET LANCETS Global Inject Ease Lancets 28G OTC

ULTILET SAFETY LANCETS Global Inject Ease Lancets 28G OTC

ULTILET SAFETY LANCETS 23G Global Inject Ease Lancets 28G OTC

ULTRALANCE Lancet Transporter Case OTC

ULTRA-THIN II AUTO LANCET Global Inject Ease Lancets 28G OTC

ULTRA-THIN II LANCETS Global Inject Ease Lancets 28G OTC

ULTRATRAK PRO CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

ULTRATRAK PRO CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

ULTRATRAK ULTIMATE CONTROL IN VITRO SOLUTION Element Compact Control 2 OTC

UNILET COMFORTOUCH LANCET Global Inject Ease Lancets 28G OTC

UNILET EXCELITE Global Inject Ease Lancets 28G OTC

UNILET EXCELITE II Global Inject Ease Lancets 28G OTC

UNILET G.P. LANCET Global Inject Ease Lancets 28G OTC

UNILET G.P. SUPERLITE LANCET Global Inject Ease Lancets 28G OTC

UNILET GP 28 ULTRA THIN Global Inject Ease Lancets 28G OTC

168


UNILET LANCET Global Inject Ease Lancets 28G OTC

UNILET MICRO-THIN 33G Global Inject Ease Lancets 28G OTC

UNILET SUPERLITE LANCET Global Inject Ease Lancets 28G OTC

UNILET SUPER-THIN 30G Global Inject Ease Lancets 28G OTC

UNILET ULTRA-THIN 28G Global Inject Ease Lancets 28G OTC

UNISTIK 1 Lancet Transporter Case OTC UNISTIK 2 Lancet Transporter Case OTC UNISTIK 2 COMFORT Lancet Transporter Case OTC UNISTIK 2 EXTRA Lancet Transporter Case OTC UNISTIK 2 NEONATAL Lancet Transporter Case OTC UNISTIK 2 NORMAL Lancet Transporter Case OTC UNISTIK 2 SUPER Lancet Transporter Case OTC UNISTIK 3 Lancet Transporter Case OTC UNISTIK 3 COMFORT Lancet Transporter Case OTC UNISTIK 3 EXTRA Lancet Transporter Case OTC

UNISTIK 3 GENTLE Global Inject Ease Lancets 28G OTC

UNISTIK 3 NEONATAL Lancet Transporter Case OTC UNISTIK 3 NORMAL Lancet Transporter Case OTC UNISTIK CZT COMFORT Lancet Transporter Case OTC UNISTIK CZT NORMAL Lancet Transporter Case OTC

UNISTIK SAFETY LANCETS 28G Global Inject Ease Lancets 28G OTC

UNISTIK SAFETY LANCETS 30G Global Inject Ease Lancets 28G OTC

UNISTIK TOUCH SAFETY LANC 21G Global Inject Ease Lancets 28G OTC




UNISTRIP CONTROL IN VITRO SOLUTION HIGH Easy Trak Control OTC

UNISTRIP CONTROL IN VITRO SOLUTION LOW DiaTrue Control Level 1 OTC

169


UNIVERSAL 1 LANCETS THIN 26G Global Inject Ease Lancets 28G OTC

UNIVERSAL 1 LANCETS THIN 33G Global Inject Ease Lancets 28G OTC

UNIVERSAL 1 LANCETS ULTRA THIN Global Inject Ease Lancets 28G OTC

VICTORY CONTROL LEVEL 1/2 IN VITRO SOLUTION Element Compact Control 2 OTC

VIDA MIA AUTOLET LANCING DEV H-E-B inControl Adv Lancing OTC

VIDA MIA UNILET LANCETS 28G Global Inject Ease Lancets 28G OTC

VIDA MIA UNILET LANCETS 30G Global Inject Ease Lancets 28G OTC

VITALET PRO LANCETS Global Inject Ease Lancets 28G OTC

VITALET PRO PLUS LANCETS Global Inject Ease Lancets 28G OTC

W&F LANCETS 26G Global Inject Ease Lancets 28G OTC

W&F LANCETS COLORED 21G Global Inject Ease Lancets 28G OTC

WALGREENS LANCETS Global Inject Ease Lancets 28G OTC

WALGREENS THIN LANCETS Global Inject Ease Lancets 28G OTC

WALGREENS ULTRA THIN LANCETS Global Inject Ease Lancets 28G OTC

*Misc. Devices***

folding paddle walker Tracho-Foam Discs Extra-Large OTC

mucosal atomization device Tracho-Foam Discs Extra-Large OTC

RINOFLOW CHAMBER TUBING Bariatric Aluminum Cane OTC RINOFLOW NASAL SYSTEM Bariatric Aluminum Cane OTC

*Needles & Syringes*** anti-stick immun syringe 23g x 1" 1 ml Monoject Magellan Syringe OTC anti-stick immun syringe 25g x 5/8" 1 ml BD Syringe/Needle Slip Tip OTC anti-stick insulin syringe 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC anti-stick insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC anti-stick insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC careone insulin syringe 30g x 1/2" 0.3 ml Ultilet Insulin Syringe Short OTC

170

Formulary Drug Name Reference Restrictions careone insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml BD Insulin Syringe Ultrafine OTC

careone insulin syringe 31g x 5/16" 0.3 ml Ultilet Insulin Syringe OTC careone insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

dialysis safety syringe/needle 22g x 1-1/2" 1 ml UltiCare Syringe OTC

easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml BD Insulin Syringe Ultrafine OTC

easy comfort insulin syringe 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml Ultilet Insulin Syringe OTC

easy comfort insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

elite-thin insulin syringe 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC elite-thin insulin syringe 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC elite-thin insulin syringe 28g x 5/16" 0.5 ml, 28g x 5/16" 1 ml, 29g x 5/16" 0.5 ml OTC

elite-thin insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC elite-thin insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC elite-thin insulin syringe 29g x 5/16" 1 ml VanishPoint Insulin Syringe OTC elite-thin insulin syringe 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml Ultilet Insulin Syringe OTC

elite-thin insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

eql insulin syringe 29g x 1/2" 0.3 ml BD Insulin Syringe Ultrafine OTC eql insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC eql insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC eql insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml

Ultilet Insulin Syringe OTC

eql insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

global easy glide insulin syr 31g x 5/16" 0.3 ml Ultilet Insulin Syringe OTC

global inject ease insulin syr 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC global inject ease insulin syr 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC global inject ease insulin syr 29g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml BD Insulin Syringe Ultrafine OTC

global inject ease insulin syr 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC global inject ease insulin syr 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC global inject ease insulin syr 30g x 1/2" 0.3 ml Ultilet Insulin Syringe Short OTC

171

Formulary Drug Name Reference Restrictions global inject ease insulin syr 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml


global inject ease insulin syr 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

global insulin syringes 30g x 1/2" 0.3 ml Ultilet Insulin Syringe Short OTC global insulin syringes 30g x 5/16" 0.3 ml Ultilet Insulin Syringe OTC gnp insulin syringe 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC gnp insulin syringe 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC gnp insulin syringe 29g x 1/2" 0.3 ml BD Insulin Syringe Ultrafine OTC gnp insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC gnp insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC gnp insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml


gnp insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

gnp ultra com insulin syringe 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC

gnp ultra com insulin syringe 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC gnp ultra com insulin syringe 29g x 1/2" 0.3 ml BD Insulin Syringe Ultrafine OTC

gnp ultra com insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC

gnp ultra com insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC gnp ultra com insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml


gnp ultra com insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

insulin syringe 27g x 1/2" 0.5 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

insulin syringe 27g x 1/2" 1 ml, 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC

insulin syringe 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC insulin syringe 29g x 1" 0.3 ml OTC insulin syringe 29g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml BD Insulin Syringe Ultrafine OTC

insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml Ultilet Insulin Syringe OTC

172

Formulary Drug Name Reference Restrictions insulin syringe/needle 27g x 1/2" 0.5 ml Easy Touch Insulin Syringe OTC insulin syringe/needle 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC insulin syringe/needle 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC kinray insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC kinray insulin syringe 31g x 5/16" 0.3 ml Ultilet Insulin Syringe OTC kinray insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

kmart valu insulin syringe 29g u-100 0.5 ml OTC kmart valu insulin syringe 29g u-100 1 ml Monoject Insulin Syringe OTC kmart valu insulin syringe 30g u-100 0.3 ml, u-100 0.5 ml OTC

kmart valu insulin syringe 30g u-100 1 ml Monoject Insulin Syringe OTC kroger insulin syringe 29g x 1/2" 0.3 ml BD Insulin Syringe Ultrafine OTC kroger insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC kroger insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC kroger insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml


kroger insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

leader insulin syringe 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC leader insulin syringe 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC leader insulin syringe 29g x 1/2" 0.3 ml BD Insulin Syringe Ultrafine OTC leader insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC leader insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC leader insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml


leader insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

longs insulin syringe 31g x 5/16" 0.5 ml Easy Touch Insulin Syringe OTC medic insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml Ultilet Insulin Syringe OTC

ms insulin syringe 31g x 5/16" 0.3 ml Ultilet Insulin Syringe OTC ms insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

preferred plus insulin syringe 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC

preferred plus insulin syringe 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC preferred plus insulin syringe 29g x 1/2" 0.3 ml BD Insulin Syringe Ultrafine OTC

173

Formulary Drug Name Reference Restrictions preferred plus insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC

preferred plus insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC preferred plus insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml Ultilet Insulin Syringe OTC

px insulin syringe 30g x 1/2" 0.3 ml Ultilet Insulin Syringe Short OTC px insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml BD Insulin Syringe Ultrafine OTC

px insulin syringe 31g x 5/16" 0.3 ml Ultilet Insulin Syringe OTC px insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

ra insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC ra insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC ra insulin syringe 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml Ultilet Insulin Syringe OTC

reality insulin syringe 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC reality insulin syringe 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC reality insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC reality insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC safety insulin syringes 27g x 1/2" 1 ml Monoject Insulin Syringe OTC safety insulin syringes 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC safety insulin syringes 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC safety insulin syringes 30g x 1/2" 1 ml BD Insulin Syringe Ultrafine OTC safety insulin syringes 30g x 5/16" 0.5 ml Ultilet Insulin Syringe OTC safety syringe/needle 25g x 5/8" 1 ml BD Syringe/Needle Slip Tip OTC safety syringe/needle 27g x 1/2" 1 ml BD Eclipse Syringe OTC sb insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC sb insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC sb insulin syringe 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml Ultilet Insulin Syringe OTC

sb insulin syringe 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC sm insulin syringe 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC sure comfort insulin syringe 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC sure comfort insulin syringe 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC sure comfort insulin syringe 29g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml BD Insulin Syringe Ultrafine OTC

sure comfort insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC sure comfort insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC sure comfort insulin syringe 30g x 1/2" 0.3 ml Ultilet Insulin Syringe Short OTC

174

Formulary Drug Name Reference Restrictions sure comfort insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml


sure comfort insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

syringe 20g x 1" 12 ml, 20g x 1" 6 ml, 21g x 1 -1/4" 6 ml, 22g x 1" 12 ml, 22g x 1" 6 ml, 22g x 1-1/4" 6 ml

OTC

syringe 20g x 1-1/2" 12 ml, 21g x 1" 12 ml, 21g x 1-1/2" 12 ml, 22g x 1-1/2" 12 ml, 22g x 1-1/2" 6 ml

Monoject Magellan Syringe OTC

syringe 21g x 1" 6 ml, 21g x 1-1/2" 6 ml Monoject Syringe OTC syringe luer slip 25g x 5/8" 1 ml BD Syringe/Needle Slip Tip OTC syringe luer slip 27g x 1/2" 1 ml BD Eclipse Syringe OTC syringe/hypodermic safety 18g x 1" 12 ml Monoject Magellan Syringe OTC topcare ultra comfort ins syr 29g x 1/2" 0.3 ml BD Insulin Syringe Ultrafine OTC topcare ultra comfort ins syr 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC topcare ultra comfort ins syr 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC topcare ultra comfort ins syr 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml


topcare ultra comfort ins syr 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

ultra comfort insulin syringe 30g x 5/16" 0.3 ml Ultilet Insulin Syringe OTC

ultra-comfort insulin syringe 28g x 1/2" 0.5 ml Monoject Insulin Syringe OTC ultra-comfort insulin syringe 28g x 1/2" 1 ml Prodigy Insulin Syringe OTC ultra-comfort insulin syringe 29g x 1/2" 0.3 ml BD Insulin Syringe Ultrafine OTC ultra-comfort insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC ultra-comfort insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC ultra-comfort insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml


ultra-comfort insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml Easy Touch Insulin Syringe OTC

value health insulin syringe 29g x 1/2" 0.5 ml UltiCare Insulin Syringe OTC value health insulin syringe 29g x 1/2" 1 ml Sure-Ject Insulin Syringe OTC vp insulin syringe 29g x 1/2" 0.3 ml BD Insulin Syringe Ultrafine OTC ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

175

Formulary Drug Name Reference Restrictions ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML

Elite-Thin Insulin Syringe OTC

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

ADVOCATE INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML Kroger Insulin Syringe

BD ECLIPSE SYRINGE 25G X 5/8" 1 ML Anti-Stick Immun Syringe BD ECLIPSE SYRINGE 27G X 1/2" 1 ML Syringe Luer Slip OTC BD ECLIPSE SYRINGE 30G X 1/2" 1 ML OTC BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

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

BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML

OTC

BD INSULIN SYRINGE 27G X 1/2" 1 ML Safety Insulin Syringes OTC BD INSULIN SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC BD INSULIN SYRINGE 30G X 1/2" 0.5 ML Insulin Syringe OTC

BD INSULIN SYRINGE 31G X 5/16" 0.3 ML Elite-Thin Insulin Syringe OTC

BD INSULIN SYRINGE HALF-UNIT 31G X 5/16" 0.3 ML Elite-Thin Insulin Syringe OTC

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

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

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

BD INSULIN SYRINGE U-100 1 ML Kmart Valu Insulin Syringe 30G OTC

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

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


176

Formulary Drug Name Reference Restrictions BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.3 ML, 30G X 1/2" 1 ML Global Inject Ease Insulin Syr OTC

BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.5 ML Insulin Syringe OTC

BD INSULIN SYRINGE ULTRAFINE 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML

OTC

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

BD LUER-LOK SYRINGE 20G X 1" 1 ML OTC BD LUER-LOK SYRINGE 25G X 5/8" 1 ML Anti-Stick Immun Syringe OTC

BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML Elite-Thin Insulin Syringe OTC

BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 ML BD SAFETYGLIDE SYRINGE/NEEDLE 27G X 5/8" 1 ML OTC

BD SAFETY-LOK INSULIN SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

BD SYRINGE/NEEDLE 25G X 5/8" 1 ML Anti-Stick Immun Syringe OTC BD SYRINGE/NEEDLE SLIP TIP 25G X 5/8" 1 ML Anti-Stick Immun Syringe OTC

BD SYRINGE/NEEDLE SLIP TIP 26G X 5/8" 1 ML OTC

COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


COMFORT ASSIST INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

COMFORT ASSIST INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


COMFORT EZ INSULIN SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe OTC

COMFORT EZ INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

177

Formulary Drug Name Reference Restrictions COMFORT EZ INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G X 1/2" 1 ML Global Inject Ease Insulin Syr OTC

COMFORT EZ INSULIN SYRINGE 30G X 1/2" 0.5 ML Insulin Syringe OTC

COMFORT EZ INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

COMFORT EZ INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

EASY TOUCH FLIPLOCK INSULIN SY 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

EASY TOUCH FLIPLOCK INSULIN SY 30G X 1/2" 1 ML Global Inject Ease Insulin Syr OTC

EASY TOUCH FLIPLOCK INSULIN SY 30G X 5/16" 1 ML, 31G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

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

EASY TOUCH FLIPLOCK SAFETY SYR 27G X 1/2" 1 ML Syringe Luer Slip OTC

EASY TOUCH FLURINGE 25G X 1" 1 ML OTC

EASY TOUCH FLURINGE 25G X 5/8" 1 ML Anti-Stick Immun Syringe OTC

EASY TOUCH FLURINGE FLIPLOCK 25G X 1" 1 ML OTC

EASY TOUCH FLURINGE FLIPLOCK 25G X 5/8" 1 ML Anti-Stick Immun Syringe OTC

EASY TOUCH FLURINGE SHEATHLOCK 25G X 1" 1 ML OTC

EASY TOUCH FLURINGE SHEATHLOCK 25G X 5/8" 1 ML Anti-Stick Immun Syringe OTC

EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML Elite-Thin Insulin Syringe OTC

EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

EASY TOUCH INSULIN SAFETY SYR 30G X 1/2" 1 ML Global Inject Ease Insulin Syr OTC

EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML Insulin Syringe/Needle OTC

EASY TOUCH INSULIN SYRINGE 27G X 1/2" 1 ML Safety Insulin Syringes OTC

EASY TOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


178

Formulary Drug Name Reference Restrictions EASY TOUCH INSULIN SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe OTC

EASY TOUCH INSULIN SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

EASY TOUCH INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G X 1/2" 1 ML Global Inject Ease Insulin Syr OTC

EASY TOUCH INSULIN SYRINGE 30G X 1/2" 0.5 ML Insulin Syringe OTC

EASY TOUCH INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

EASY TOUCH INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

EASY TOUCH SAFETY SYRINGE 25G X 1" 1 ML OTC

EASY TOUCH SAFETY SYRINGE 25G X 5/8" 1 ML Anti-Stick Immun Syringe OTC

EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

EASY TOUCH SHEATHLOCK SYRINGE 30G X 1/2" 1 ML Global Inject Ease Insulin Syr OTC

EASY TOUCH SHEATHLOCK SYRINGE 30G X 5/16" 1 ML, 31G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

EASY TOUCH TB SHEATHLOCK SYR 26G X 5/8" 1 ML OTC

EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML


EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 1 ML Leader Insulin Syringe OTC

EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

EXEL COMFORT POINT INSULIN SYR 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

FREESTYLE PRECISION INS SYR 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML


FREESTYLE PRECISION INS SYR 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

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

179

Formulary Drug Name Reference Restrictions GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.5 ML Insulin Syringe OTC

GLUCOPRO INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

GLUCOPRO INSULIN SYRINGE 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


GLUCOPRO INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

LITETOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


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

LITETOUCH INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

LITETOUCH INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

LITETOUCH INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Elite-Thin Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe

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

MAXI-COMFORT INSULIN SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe OTC

MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML OTC

MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML Safety Insulin Syringes

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML


MONOJECT INSULIN SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe

MONOJECT INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe

180

Formulary Drug Name Reference Restrictions MONOJECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe

MONOJECT INSULIN SYRINGE 31G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

MONOJECT INSULIN SYRINGE U-100 1 ML

Kmart Valu Insulin Syringe 30G

MONOJECT LIFESHIELD SYRINGE 18G X 1" 12 ML Syringe/Hypodermic Safety

MONOJECT MAGELLAN SYRINGE 18G X 1" 12 ML Syringe/Hypodermic Safety

MONOJECT MAGELLAN SYRINGE 20G X 1-1/2" 12 ML, 21G X 1" 12 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 6 ML, 22G X 1-1/2" 12 ML, 22G X 1-1/2" 6 ML

Syringe

MONOJECT MAGELLAN SYRINGE 20G X 1-1/2" 6 ML, 25G X 1" 1 ML MONOJECT MAGELLAN SYRINGE 23G X 1" 1 ML, 25G X 5/8" 1 ML Anti-Stick Immun Syringe

MONOJECT SYRINGE 18G X 1" 12 ML Syringe/Hypodermic Safety MONOJECT SYRINGE 20G X 1-1/2" 12 ML, 21G X 1" 12 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 6 ML, 22G X 1-1/2" 6 ML

Syringe

MONOJECT SYRINGE 20G X 1-1/2" 6 ML MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML


MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML

Kroger Insulin Syringe OTC

MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 0.5 ML, 31G X 5/16" 0.3 ML


MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

181

Formulary Drug Name Reference Restrictions PRECISION SURE-DOSE SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe OTC

PRECISION SURE-DOSE SYRINGE 30G X 3/8" 0.5 ML

OTC; QLL (100 EA per 30 days)

PRECISION SURE-DOSE SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

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

PRODIGY INSULIN SYRINGE 31G X 5/16" 0.3 ML Elite-Thin Insulin Syringe OTC

PRODIGY INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

RELI-ON INSULIN SYRINGE 29G 0.3 ML, 29G 0.5 ML, 30G 0.3 ML, 30G 0.5 ML, 30G 1 ML

OTC

RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

RELION INSULIN SYRINGE 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


RELI-ON INSULIN SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

RELION INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

RELION INSULIN SYRINGE 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML

OTC

RELION INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

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

SAFESNAP INSULIN SYRINGE 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML Elite-Thin Insulin Syringe OTC

SAFESNAP INSULIN SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

SAFESNAP INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

SAFETY-GLIDE SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


182

Formulary Drug Name Reference Restrictions SURE-JECT INSULIN SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe OTC

SURE-JECT INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

SURE-JECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

SURE-JECT INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


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

TRUEPLUS INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

TRUEPLUS INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

TRUEPLUS INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 1 ML Kroger Insulin Syringe

ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


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

ULTICARE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

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

ULTICARE INSULIN SYRINGE 30G X 1/2" 0.5 ML Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

ULTICARE SYRINGE 22G X 1-1/2" 1 ML Dialysis Safety Syringe/Needle OTC ULTILET INSULIN SYRINGE 30G X 1/2" 0.5 ML Insulin Syringe OTC

183

Formulary Drug Name Reference Restrictions ULTILET INSULIN SYRINGE 30G X 1/2" 1 ML Global Inject Ease Insulin Syr OTC

ULTILET INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

ULTILET INSULIN SYRINGE 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


ULTILET INSULIN SYRINGE 31G X 15/64" 0.3 ML ULTILET INSULIN SYRINGE 31G X 15/64" 0.5 ML OTC

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

ULTILET INSULIN SYRINGE SHORT 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

ULTILET INSULIN SYRINGE SHORT 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


ULTILET INSULIN SYRINGE SHORT 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML


ULTRA-THIN II INS SYR SHORT 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

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

VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

VANISHPOINT INSULIN SYRINGE 29G X 5/16" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML


VANISHPOINT INSULIN SYRINGE 30G X 1/2" 0.5 ML Insulin Syringe OTC

VANISHPOINT SYRINGE 25G X 1" 1 ML OTC

*Peak Flow Meters*** peak flow meter device Assess Peak Flow Meter OTC peak flow meter universal rang device Assess Peak Flow Meter OTC

184

Formulary Drug Name Reference Restrictions AIRZONE PEAK FLOW METER DEVICE

Peak Flow Meter Universal Rang OTC

ASSESS FULL RANGE PEAK METER DEVICE


ASSESS LOW RANGE PEAK METER DEVICE


ASSESS PEAK FLOW METER DEVICE Peak Flow Meter Universal Rang OTC

ASTHMA CHECK METER-ZONE SYSTEM DEVICE


ASTHMAMENTOR DEVICE Peak Flow Meter Universal Rang OTC

MICROLIFE DIGITAL PEAK FLOW DEVICE


MINI WRIGHT PEAK FLOW METER DEVICE


PEAK AIR PEAK FLOW METER DEVICE


PERSONAL BEST FULL RANGE DEVICE


PERSONAL BEST LOW RANGE DEVICE


PIKO 1 DEVICE Peak Flow Meter Universal Rang OTC

POCKET PEAK FLOW METER DEVICE Peak Flow Meter Universal Rang OTC

POCKETPEAK PEAK FLOW METER DEVICE


TRUZONE PEAK FLOW METER DEVICE

Peak Flow Meter Universal Rang QLL (2 EA per 1 Year)

*Respiratory Therapy Supplies*** adult mask device Pulmo-Aide Traveler/Filters co monitor device Pulmo-Aide Traveler/Filters nebulizer device Pulmo-Aide Traveler/Filters OTC spiro pd device Pulmo-Aide Traveler/Filters AEROBIKA DEVICE Nebulizer QLL (2 EA per 1 Year) ALL FLOW 1000 PFT FILTER DEVICE Nebulizer ALL FLOW 2000 PFT FILTER DEVICE Nebulizer ALL FLOW 3000 PFT FILTER DEVICE Nebulizer ALL FLOW 4000 PFT FILTER DEVICE Nebulizer ALL FLOW 5000 PFT FILTER DEVICE Nebulizer ALL FLOW 6000 PFT FILTER DEVICE Nebulizer

185

Formulary Drug Name Reference Restrictions ALL FLOW 7000 PFT FILTER DEVICE Nebulizer BREATHERITE VALVED MDI CHAMBER DEVICE Nebulizer

DEVILBISS COMPRESSOR DEVICE Nebulizer OTC IN-CHECK DIAL FLOW TRAINER DEVICE Nebulizer

IN-CHECK INSPIRATORY FLOW MTR DEVICE Nebulizer

MISTASSIST DEVICE Nebulizer ONE FLOW SPIROMETER DEVICE Nebulizer PARI MANUAL INTERRUPTER DEVICE Nebulizer

PARI TREK S COMBO PACK DEVICE Nebulizer PRIMEAIRE HOLDING CHAMBER DEVICE Nebulizer

PULMO-AIDE COMP/PULMO-NEB DISP DEVICE Nebulizer

PULMO-AIDE LT COMPRESS/NEBULIZ DEVICE Nebulizer

PULMO-AIDE TRAVELER/FILTERS DEVICE Nebulizer

PULMONEB LT DEVICE Nebulizer QUAKE DEVICE Nebulizer THRESHOLD PEP DEVICE Nebulizer VORTEX HOLDING CHAMBER/MASK DEVICE Nebulizer

*Spacer/Aerosol-Holding Chambers & Supplies*** valved holding chamber device Pocket Chamber AEROCHAMBER MINI CHAMBER DEVICE Valved Holding Chamber

AEROCHAMBER MV Valved Holding Chamber AEROCHAMBER PLUS FLO-VU Valved Holding Chamber AEROCHAMBER PLUS FLO-VU LARGE Valved Holding Chamber

AEROCHAMBER PLUS FLO-VU MEDIUM Valved Holding Chamber

AEROCHAMBER PLUS FLO-VU SMALL Valved Holding Chamber

AEROCHAMBER PLUS FLO-VU W/MASK Valved Holding Chamber

AEROCHAMBER PLUS FLOW VU Valved Holding Chamber 186

Formulary Drug Name Reference Restrictions AEROCHAMBER W/FLOWSIGNAL Valved Holding Chamber AEROCHAMBER Z-STAT PLUS Valved Holding Chamber AEROCHAMBER Z-STAT PLUS CHAMBR Valved Holding Chamber

AEROCHAMBER Z-STAT PLUS/LARGE Valved Holding Chamber

AEROCHAMBER Z-STAT PLUS/MEDIUM Valved Holding Chamber

AEROCHAMBER Z-STAT PLUS/SMALL Valved Holding Chamber

AEROVENT PLUS DEVICE Valved Holding Chamber ARIAL CHAMBER DEVICE Valved Holding Chamber OTC BREATHERITE Valved Holding Chamber BREATHERITE COLL SPACER ADULT Valved Holding Chamber BREATHERITE COLL SPACER CHILD Valved Holding Chamber BREATHERITE COLL SPACER INFANT Valved Holding Chamber

BREATHERITE RIGID SPACER/MASK Valved Holding Chamber BREATHERITE SPACER NEONATE Valved Holding Chamber BREATHERITE SPACER SMALL CHILD Valved Holding Chamber

BREATHERITE/LARGE MASK Valved Holding Chamber BREATHERITE/MEDIUM MASK Valved Holding Chamber BREATHERITE/SMALL MASK Valved Holding Chamber CLEVER CHOICE HOLDING CHAMBER DEVICE Valved Holding Chamber

COMPACT SPACE CHAMBER DEVICE Valved Holding Chamber COMPACT SPACE CHAMBER/LG MASK DEVICE Valved Holding Chamber

COMPACT SPACE CHAMBER/MED MASK DEVICE Valved Holding Chamber

COMPACT SPACE CHAMBER/SM MASK DEVICE Valved Holding Chamber

EASIVENT Valved Holding Chamber EASIVENT MASK LARGE Valved Holding Chamber EASIVENT MASK MEDIUM Valved Holding Chamber EASIVENT MASK SMALL Valved Holding Chamber E-Z SPACER DEVICE Valved Holding Chamber E-Z SPACER THE BODY GUARDS PK DEVICE Valved Holding Chamber

187

Formulary Drug Name Reference Restrictions FLEXICHAMBER ADULT MASK/SMALL FLEXICHAMBER CHILD MASK/LARGE FLEXICHAMBER CHILD MASK/SMALL FLEXICHAMBER DEVICE Valved Holding Chamber INSPIRACHAMBER/LARGE DEVICE Valved Holding Chamber INSPIRACHAMBER/MEDIUM DEVICE Valved Holding Chamber INSPIRACHAMBER/MOUTHPIECE DEVICE Valved Holding Chamber

INSPIRACHAMBER/SMALL DEVICE Valved Holding Chamber INSPIREASE Valved Holding Chamber QLL (2 EA per 1 Year) LITEAIRE DEVICE Valved Holding Chamber MASK VORTEX OTC MICROCHAMBER Valved Holding Chamber MICROSPACER Valved Holding Chamber OPTICHAMBER ADVANTAGE Valved Holding Chamber OPTICHAMBER ADVANTAGE-LG MASK Valved Holding Chamber

OPTICHAMBER ADVANTAGE-MED MASK Valved Holding Chamber

OPTICHAMBER ADVANTAGE-SM MASK Valved Holding Chamber

OPTICHAMBER DIAMOND Valved Holding Chamber OPTICHAMBER DIAMOND DEVICE Valved Holding Chamber OPTICHAMBER DIAMOND-LG MASK DEVICE Valved Holding Chamber

OPTICHAMBER DIAMOND-MD MASK Valved Holding Chamber OPTICHAMBER DIAMOND-SM MASK Valved Holding Chamber OPTICHAMBER FACE MASK-LARGE Valved Holding Chamber OTC OPTICHAMBER FACE MASK-MEDIUM Valved Holding Chamber OTC

OPTICHAMBER FACE MASK-SMALL Valved Holding Chamber OTC OPTIHALER Valved Holding Chamber OPTIHALER DEVICE Valved Holding Chamber PANDA MASK LARGE OTC PANDA MASK MEDIUM OTC PANDA MASK SMALL OTC PEDIATRIC PANDA MASK OTC; QLL (2 EA per 1 Year)

188

Formulary Drug Name Reference Restrictions POCKET CHAMBER DEVICE Valved Holding Chamber POCKET SPACER DEVICE Valved Holding Chamber RITEFLO DEVICE Valved Holding Chamber VORTEX VALVED HOLDING CHAMBER DEVICE Valved Holding Chamber

WATCHHALER DEVICE Valved Holding Chamber

*MIGRAINE PRODUCTS* *Ergot Combinations*** MIGERGOT RECTAL SUPPOSITORY 2 -100 MG

*Migraine Products*** dihydroergotamine mesylate nasal solution 4 mg/ml Migranal QLL (8 ML per 30 days)

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG

*Selective Serotonin Agonists 5-Ht(1)*** naratriptan hcl oral tablet 1 mg, 2.5 mg Amerge QLL (9 EA per 1 Rx) rizatriptan benzoate oral tablet 10 mg, 5 mg Maxalt QLL (12 EA per 1 Rx) rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg Maxalt-MLT QLL (12 EA per 1 Rx)

sumatriptan nasal solution 20 mg/act, 5 mg/act Imitrex

sumatriptan succinate oral tablet 100 mg Imitrex QLL (9 EA per 1 Rx) sumatriptan succinate oral tablet 25 mg, 50 mg Imitrex QLL (18 EA per 1 Rx)

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml Imitrex STATdose Refill

sumatriptan succinate subcutaneous solution 6 mg/0.5ml Imitrex

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml Imitrex STATdose System

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml zolmitriptan oral tablet 2.5 mg, 5 mg Zomig QLL (8 EA per 1 Rx) zolmitriptan oral tablet dispersible 2.5 mg, 5 mg Zomig ZMT QLL (8 EA per 1 Rx)

RELPAX ORAL TABLET 20 MG, 40 MG Eletriptan Hydrobromide QLL (6 EA per 1 Rx)

189

Formulary Drug Name Reference Restrictions *MINERALS & ELECTROLYTES* *Bicarbonates*** sodium bicarbonate intravenous solution 8.4 %

*Calcium Combinations*** calcium + d3 oral tablet 600-200 mg-unit OTC calcium 500 + d oral tablet 500-125 mg-unit OTC calcium 500 +d oral tablet 500-400 mg-unit Oystercal-D OTC calcium 500/d oral tablet 500-200 mg-unit RA Hi-Cal Plus Vitamin D OTC calcium 500/d oral tablet chewable 500-400 mg-unit OTC

calcium 500/vitamin d oral tablet 500-125 mg-unit OTC

calcium 500+d high potency oral tablet 500 -400 mg-unit OTC

calcium 500+d oral tablet 500-200 mg-unit Oysco 500+D OTC calcium 500+d oral tablet 500-400 mg-unit Oystercal-D OTC calcium 500+d3 oral tablet 500-400 mg-unit Oystercal-D OTC calcium 600 + d oral tablet 600-200 mg-unit OTC calcium 600 + minerals oral tablet 600-200 mg-unit OTC

calcium 600/vitamin d oral tablet 600-400 mg-unit OTC

calcium 600+d high potency oral tablet 600 -400 mg-unit OTC

calcium 600+d oral tablet 600-200 mg-unit, 600-400 mg-unit OTC

calcium 600+d plus minerals oral tablet 600 -400 mg-unit OTC

calcium 600+d plus minerals oral tablet chewable 600-400 mg-unit OTC

calcium 600+d3 oral tablet 600-200 mg-unit, 600-400 mg-unit OTC

calcium 600-d oral tablet 600-400 mg-unit OTC calcium carbonate-vitamin d oral tablet 500 -400 mg-unit, 600-400 mg-unit OTC

calcium carbonate-vitamin d3 oral tablet 600 -400 mg-unit OTC

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

calcium oral tablet 500-125 mg-unit OTC

190

Formulary Drug Name Reference Restrictions calcium-carb 600 + d oral tablet 600-125 mg-unit OTC

calcium-vitamin d oral tablet 500-125 mg- unit, 600-125 mg-unit, 600-200 mg-unit, 600-400 mg-unit

OTC

calcium-vitamin d oral tablet 500-200 mg-unit RA Hi-Cal Plus Vitamin D OTC calcium-vitamin d oral tablet 500-400 mg-unit Oystercal-D OTC calcium-vitamin d3 oral tablet 250-125 mg-unit, 600-125 mg-unit, 600-400 mg-unit OTC

calcium-vitamin d3 oral tablet 500-400 mg-unit Oystercal-D OTC

calcium-vitamin d-minerals oral tablet chewable 600-400 mg-unit OTC

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

eq calcium 500+d oral tablet 500-200 mg-unit Oysco 500+D OTC eql calcium/vitamin d oral tablet 600-400 mg-unit OTC

gnp calcium 500/d oral tablet 500-200 mg-unit RA Hi-Cal Plus Vitamin D OTC gnp calcium 600 plus d/mineral oral tablet 600-400 mg-unit OTC

gnp calcium 600/d oral tablet 600-400 mg-unit OTC gnp calcium plus 600 +d oral tablet 600-200 mg-unit OTC

gnp calcium/vitamin d/minerals oral tablet chewable 600-400 mg-unit OTC

hm calcium-vitamin d oral tablet 500-200 mg-unit Oysco 500+D OTC

hm calcium-vitamin d oral tablet 600-400 mg-unit OTC

hm calcium-vitamin d-minerals oral tablet 600-400 mg-unit OTC

kp calcium 600+d oral tablet 600-400 mg-unit OTC oscal 500/200 d-3 oral tablet 500-200 mg-unit RA Hi-Cal Plus Vitamin D OTC oyst-cal d oral tablet 250-125 mg-unit OTC oyster calcium + d oral tablet 250-125 mg-unit, 500-125 mg-unit OTC

oyster calcium/d3 oral tablet 500-200 mg-unit Oysco 500+D OTC oyster shell calcium + d oral tablet 500-200 mg-unit Oysco 500+D OTC

oyster shell calcium + d oral tablet 500-400 mg-unit Oystercal-D OTC

191

Formulary Drug Name Reference Restrictions oyster shell calcium + d3 oral tablet 500-400 mg-unit Oystercal-D OTC

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

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

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

oyster shell calcium oral tablet 500-400 mg-unit Oystercal-D OTC

oyster shell calcium plus d oral tablet 500-125 mg-unit OTC

oyster shell calcium plus d oral tablet 500-200 mg-unit Oysco 500+D OTC

oyster shell calcium/d oral tablet 250-125 mg-unit, 500-400 mg-unit OTC

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

oyster shell calcium/d3 oral tablet 500-400 mg-unit OTC

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

oyster shell calcium/vitamin d oral tablet 500 -200 mg-unit Oysco 500+D OTC

oyster shell/vitamin d oral tablet 600-125 mg-unit OTC

oyster-cal 250 + d oral tablet 250-125 mg-unit OTC oyster-cal 500 + d oral tablet 500-125 mg-unit OTC pa calcium/vitamin d oral tablet 600-400 mg-unit OTC

pa oyster shell calcium oral tablet 500-200 mg-unit RA Hi-Cal Plus Vitamin D OTC

px calcium&d oral tablet 600-400 mg-unit OTC qc calcium/minerals/vitamin d oral tablet 600 -400 mg-unit OTC

ra calcium 600/vit d/minerals oral tablet 600 -200 mg-unit OTC

ra calcium 600/vit d/minerals oral tablet chewable 600-400 mg-unit OTC

ra calcium 600/vitamin d-3 oral tablet 600 -400 mg-unit OTC

ra calcium hi-cal/vitamin d oral tablet 500 -125 mg-unit OTC

192

Formulary Drug Name Reference Restrictions ra calcium plus vitamin d oral tablet 600-200 mg-unit, 600-400 mg-unit OTC

ra calcium plus vitamin d3 oral tablet 600-400 mg-unit OTC

ra calcium/minerals/vitamin d oral tablet 600 -400 mg-unit OTC

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

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

sb calcium + d oral tablet 600-200 mg-unit OTC sm calcium 500/vitamin d3 oral tablet 500-400 mg-unit OTC

sm calcium 600/vitamin d oral tablet 600-400 mg-unit OTC

sm calcium/vitamin d oral tablet 500-200 mg-unit Oysco 500+D OTC

sm calcium-vitamin d oral tablet 500-200 mg-unit Oysco 500+D OTC

sm calcium-vitamin d oral tablet 600-400 mg-unit OTC

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

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

super calcium 600 + d 400 oral tablet 600 -400 mg-unit OTC

super calcium 600 + d3 oral tablet 600-400 mg-unit OTC

OS-CAL CALCIUM + D3 ORAL TABLET 500-200 MG-UNIT Oyster Shell Calcium + D OTC

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

OYSTERCAL-D ORAL TABLET 500-400 MG-UNIT

SM Oyster Shell Calcium/Vit D3 OTC

RA HI CAL ORAL TABLET 500-200 MG -UNIT Calcium 500/D OTC

RA HI-CAL PLUS VITAMIN D ORAL TABLET 500-200 MG-UNIT Calcium 500/D OTC

*Calcium*** calcium 600 high potency oral tablet 600 mg High Potency Calcium OTC calcium 600 oral tablet 1500 (600 ca) mg Caltrate 600 OTC calcium 600 oral tablet 600 mg High Potency Calcium OTC

193

Formulary Drug Name Reference Restrictions calcium carbonate extra light powder OTC calcium carbonate light powder calcium carbonate oral suspension 1250 (500 ca) mg/5ml OTC

calcium carbonate oral tablet 1250 (500 ca) mg Cal-Carb Forte OTC

calcium carbonate oral tablet 1500 (600 ca) mg Caltrate 600 OTC

calcium carbonate oral tablet 600 mg High Potency Calcium OTC calcium carbonate powder calcium citrate oral tablet 200 mg OTC calcium citrate oral tablet 250 mg OTC calcium citrate oral tablet 950 mg Calcitrate OTC calcium high potency oral tablet 600 mg High Potency Calcium OTC calcium oral tablet 600 mg OTC calcium oyster shell oral tablet 1250 (500 ca) mg Cal-Carb Forte OTC

calcium oyster shell oral tablet 500 mg RA Hi-Cal OTC calcium-carb 600 oral tablet 600 mg High Potency Calcium OTC cvs calcium carbonate oral tablet 1250 (500 ca) mg Cal-Carb Forte OTC

cvs calcium oral tablet 1500 (600 ca) mg Caltrate 600 OTC gnp calcium oral tablet 600 mg High Potency Calcium OTC oyster shell calcium oral tablet 500 mg RA Hi-Cal OTC oyster-cal 500 oral tablet 500 mg OTC qc calcium fast dissolution oral tablet 600 mg High Potency Calcium OTC ra calcium 600 oral tablet 600 mg High Potency Calcium OTC ra calcium hi-cal oral tablet 500 mg OTC ra calcium high potency oral tablet 600 mg OTC ra calcium oral tablet 500 mg OTC ra oyster shell calcium oral tablet 500 mg RA Hi-Cal OTC sb oyster shell calcium oral tablet 500 mg RA Hi-Cal OTC super calcium oral tablet 600 mg High Potency Calcium OTC CAL-CARB FORTE ORAL TABLET 1250 (500 CA) MG CVS Calcium Carbonate OTC

CALCITRATE ORAL TABLET 950 MG Calcium Citrate OTC CALTRATE 600 ORAL TABLET 1500 (600 CA) MG CVS Calcium OTC

HIGH POTENCY CALCIUM ORAL TABLET 600 MG Super Calcium OTC

194

Formulary Drug Name Reference Restrictions OYSCO 500 ORAL TABLET 500 MG RA Oyster Shell Calcium OTC OYSTERCAL ORAL TABLET 500 MG RA Oyster Shell Calcium OTC RA HI-CAL ORAL TABLET 500 MG RA Oyster Shell Calcium OTC

*Fluoride Combinations*** FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79 MG, 1 (F) -236.79 MG

*Fluoride*** fluoritab oral solution 0.275 (0.125 f) mg/drop Flura-Drops fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg Ludent

sodium fluoride oral solution 1.1 (0.5 f) mg/ml sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg Ludent

FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML FLUOR-A-DAY ORAL SOLUTION 0.275 (0.125 F) MG/DROP Fluoritab

FLURA-DROPS ORAL SOLUTION 0.275 (0.125 F) MG/DROP Fluoritab

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP KARIDIUM ORAL SOLUTION 0.275 (0.125 F) MG/DROP Fluoritab

LUDENT ORAL TABLET CHEWABLE 0.55 (0.25 F) MG Sodium Fluoride

LUDENT ORAL TABLET CHEWABLE 1.1 (0.5 F) MG, 2.2 (1 F) MG Fluoritab

NAFRINSE DROPS ORAL SOLUTION 0.275 (0.125 F) MG/DROP Fluoritab

NAFRINSE ORAL TABLET CHEWABLE 2.2 (1 F) MG Fluoritab

*Magnesium*** cvs magnesium oral tablet 250 mg OTC cvs magnesium oxide oral tablet 500 mg OTC essential magnesium oral tablet 250 mg OTC gnp magnesium oral tablet 250 mg OTC magnesium oral capsule 500 mg OTC magnesium oral tablet 200 mg OTC

195

Formulary Drug Name Reference Restrictions magnesium oral tablet 250 mg OTC magnesium oxide -mg supplement oral tablet 250 mg OTC

magnesium oxide oral capsule 500 mg OTC magnesium oxide oral tablet 400 (240 mg) mg, 500 mg OTC

natrul magnesium oral tablet 250 mg OTC ra magnesium oral capsule 500 mg OTC ra natural magnesium oral tablet 250 mg OTC sm magnesium oral tablet 250 mg OTC sm magnesium oxide oral tablet 250 mg OTC

*Phosphate*** av-phos 250 neutral oral tablet 155-852-130 mg K-Phos-Neutral

virt-phos 250 neutral oral tablet 155-852-130 mg K-Phos-Neutral

K-PHOS ORAL TABLET 500 MG PHOSPHA 250 NEUTRAL ORAL TABLET 155-852-130 MG Virt-Phos 250 Neutral

PHOSPHO-TRIN 250 NEUTRAL ORAL TABLET 155-852-130 MG Virt-Phos 250 Neutral

*Potassium Combinations*** effervescent pot chloride oral tablet effervescent 25 meq pot bicarb-pot chloride oral tablet effervescent 25 meq

*Potassium*** k-effervescent oral tablet effervescent 25 meq K-Prime k-vescent oral tablet effervescent 25 meq K-Prime potassium bicarbonate oral tablet effervescent 25 meq K-Prime

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

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

potassium chloride er oral capsule extended release 10 meq, 8 meq Micro-K

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

potassium chloride er oral tablet extended release 8 meq Klor-Con

196

Formulary Drug Name Reference Restrictions EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ Potassium Bicarbonate

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ Potassium Chloride ER

KLOR-CON M10 ORAL TABLET EXTENDED RELEASE 10 MEQ Potassium Chloride Crys ER

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ KLOR-CON M20 ORAL TABLET EXTENDED RELEASE 20 MEQ Potassium Chloride Crys ER

KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ Potassium Chloride ER

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 10 MEQ, 8 MEQ

Potassium Chloride ER

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

K-PRIME ORAL TABLET EFFERVESCENT 25 MEQ Potassium Bicarbonate

*MOUTH/THROAT/DENTAL AGENTS* *Anesthetics Topical Oral*** lidocaine hcl mouth/throat solution 4 % lidocaine viscous mouth/throat solution 2 %

*Anti-Infectives - Throat*** clotrimazole mouth/throat lozenge 10 mg clotrimazole mouth/throat troche 10 mg nystatin mouth/throat suspension 100000 unit/ml

*Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat solution 0.12 % Peridex

PAROEX MOUTH/THROAT SOLUTION 0.12 % Chlorhexidine Gluconate

PERIOGARD MOUTH/THROAT SOLUTION 0.12 % Chlorhexidine Gluconate

*Fluoride Dental Products*** neutral sodium fluoride mouth/throat solution 0.2 % PreviDent

sf 5000 plus dental cream 1.1 % Denta 5000 Plus sf dental gel 1.1 % Karigel

197

Formulary Drug Name Reference Restrictions CAVAREST DENTAL GEL 1.1 % SF DENTA 5000 PLUS DENTAL CREAM 1.1 % SF 5000 Plus

DENTAGEL DENTAL GEL 1.1 % SF FLUORIDEX DAILY RENEWAL MOUTH/THROAT CONCENTRATE 0.63 % KARIGEL DENTAL GEL 1.1 % SF KARIGEL-N DENTAL GEL 1.1 % SF NEUTRAGARD ADVANCED DENTAL GEL 1.1 % SF

PERIOMED MOUTH/THROAT CONCENTRATE 0.63 % OTC

PHOS-FLUR DENTAL GEL 1.1 % SF PREVIDENT MOUTH/THROAT SOLUTION 0.2 % Neutral Sodium Fluoride

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

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

ORALONE MOUTH/THROAT PASTE 0.1 % Triamcinolone Acetonide

*MULTIVITAMINS* *B-Complex W/ C & E + Zn*** advanced stress formula/zinc oral tablet OTC bec/zinc oral tablet OTC bee zee oral tablet OTC cvs stress formula/zinc oral tablet OTC eql stress b-complex c/zinc oral tablet OTC stress b/zinc oral tablet OTC stress b-complex/vit c/zinc oral tablet OTC stress formula/zinc oral tablet OTC stress plus zinc oral tablet OTC zinc-vites oral tablet OTC

*B-Complex W/ C & Folic Acid*** b complex-c-folic acid oral tablet Milco-B-Forte OTC b-complex balanced oral tablet Milco-B-Forte OTC b-complex/vitamin c oral tablet Milco-B-Forte OTC

198

Formulary Drug Name Reference Restrictions b-plex oral tablet Milco-B-Forte eql super b complex/vitamin c oral tablet Milco-B-Forte OTC hm super vitamin b complex/c oral tablet Milco-B-Forte OTC hm vitamin b complex/vitamin c oral tablet Milco-B-Forte OTC kp b complex-c oral tablet Milco-B-Forte OTC px b complex/vitamin c oral tablet Milco-B-Forte OTC sm b super vitamin complex oral tablet Milco-B-Forte OTC stress formula oral tablet Milco-B-Forte OTC super b-complex/vit c/fa oral tablet Milco-B-Forte OTC vita-bee/c oral tablet Milco-B-Forte OTC

*B-Complex W/ C*** b-complex-c oral tablet Allbee/C OTC super b complex/vitamin c oral tablet Allbee/C OTC

*B-Complex W/ Minerals*** geriaton oral liquid OTC rabano yodado oral liquid OTC

*Multiple Vitamins W/ Iron*** daily multiple vitamins/iron oral tablet OTC daily vitamin formula+iron oral tablet OTC daily vite multivitamin/iron oral tablet OTC daily-vitamin/iron oral tablet OTC daily-vite/iron/beta-carotene oral tablet OTC gnp one daily plus iron oral tablet OTC hm one daily/iron oral tablet OTC multi-day plus iron oral tablet OTC multiple vitamins/iron oral tablet OTC multi-vitamin/iron oral tablet OTC once daily/iron oral tablet OTC one daily multivitamin/iron oral tablet OTC one-daily/iron oral tablet OTC qc daily multivitamins/iron oral tablet OTC ra one daily multi-vit plus fe oral tablet OTC sm multiple vitamins/iron oral tablet OTC stress b complex/iron oral tablet OTC stress formula/iron oral tablet OTC tab-a-vite/iron oral tablet OTC

*Multiple Vitamins W/ Minerals*** 50+ adult eye health oral capsule Theramill Forte OTC

199

Formulary Drug Name Reference Restrictions a thru z advanced adult oral tablet One-A-Day Energy OTC a thru z advanced oral tablet One-A-Day Energy OTC a thru z high potency oral tablet One-A-Day Energy OTC a thru z select 50+ advanced oral tablet One-A-Day Energy OTC a thru z select 50+ mens oral tablet One-A-Day Energy OTC a thru z select advanced oral tablet One-A-Day Energy OTC a thru z select oral tablet One-A-Day Energy OTC a thru z select oral tablet chewable Centrum Silver OTC a thru z select ultimate women oral tablet One-A-Day Energy OTC a thru z ultimate mens oral tablet One-A-Day Energy OTC abc plus oral tablet One-A-Day Energy OTC actical oral capsule Theramill Forte OTC adult gummy oral tablet chewable Centrum Silver OTC advanced eye health oral capsule Theramill Forte OTC antioxidant a/c/e/selenium oral tablet One-A-Day Energy OTC anti-oxidant formula oral capsule Theramill Forte OTC antioxidant formula oral tablet One-A-Day Energy OTC antioxidant formula/minerals oral capsule Theramill Forte OTC antioxidant oral capsule Theramill Forte OTC antioxidant protection formula oral tablet One-A-Day Energy OTC antioxidant vitamins oral tablet One-A-Day Energy OTC biocel oral tablet One-A-Day Energy biotin plus/calcium/vit d3 oral tablet One-A-Day Energy OTC body/hair/skin/nails oral capsule Theramill Forte OTC b-plex plus oral tablet One-A-Day Energy b-redi/red hearts/red roosters oral tablet One-A-Day Energy OTC centamin oral liquid Super Nu-Thera OTC centavite a-z complete-mineral oral tablet One-A-Day Energy OTC centavite oral liquid Super Nu-Thera OTC centravites 50 plus oral tablet One-A-Day Energy OTC centravites oral tablet One-A-Day Energy OTC century mature oral tablet One-A-Day Energy OTC century oral tablet One-A-Day Energy OTC certa plus oral tablet One-A-Day Energy OTC certagen oral tablet One-A-Day Energy OTC companion oral tablet One-A-Day Energy OTC complere oral tablet One-A-Day Energy OTC complete daily/lutein oral tablet One-A-Day Energy OTC

200

Formulary Drug Name Reference Restrictions complete energy oral tablet One-A-Day Energy OTC complete multivitamin/mineral oral liquid Super Nu-Thera OTC complete oral tablet One-A-Day Energy OTC complete pms support complex oral capsule Theramill Forte OTC complete senior oral tablet One-A-Day Energy OTC complete womens oral tablet One-A-Day Energy OTC coral calcium plus oral capsule Theramill Forte OTC cvs daily gummies oral tablet chewable Centrum Silver OTC cvs daily multiple fe/ca/zn oral tablet One-A-Day Energy OTC cvs daily multiple for men oral tablet One-A-Day Energy OTC cvs daily multiple for women oral tablet One-A-Day Energy OTC cvs daily multiple women 50+ oral tablet One-A-Day Energy OTC cvs mens daily gummies oral tablet chewable Centrum Silver OTC cvs spectravite advanced oral tablet One-A-Day Energy OTC cvs spectravite senior oral tablet One-A-Day Energy OTC cvs spectravite ultra mens oral tablet One-A-Day Energy OTC cvs spectravite womens senior oral tablet One-A-Day Energy OTC cvs vision formula oral tablet One-A-Day Energy OTC cvs womens active daily oral tablet One-A-Day Energy OTC cvs womens daily gummies oral tablet chewable Centrum Silver OTC

daily betic oral tablet One-A-Day Energy OTC daily combo multi vitamins oral tablet One-A-Day Energy OTC daily mens health formula oral tablet One-A-Day Energy OTC daily multi 50+ oral tablet One-A-Day Energy OTC daily multi oral tablet One-A-Day Energy OTC daily multiple vitamins/min oral tablet One-A-Day Energy OTC daily multivitamin oral capsule Theramill Forte OTC daily vitamin formula+minerals oral tablet One-A-Day Energy OTC daily vitamin plus oral capsule Theramill Forte OTC daily womens health formula oral tablet One-A-Day Energy OTC daily-vitamin maximum formula oral tablet One-A-Day Energy OTC diabetes health formula oral tablet One-A-Day Energy OTC dialyvite 800/ultra d oral tablet One-A-Day Energy OTC ecolovit oral tablet One-A-Day Energy OTC eq complete multivit adult 50+ oral tablet One-A-Day Energy OTC eq one daily womens health oral tablet One-A-Day Energy OTC eq vision formula 50+ oral capsule Theramill Forte OTC

201

Formulary Drug Name Reference Restrictions eql century mature men 50+ oral tablet One-A-Day Energy OTC eql century mature oral tablet One-A-Day Energy OTC eql century mature women 50+ oral tablet One-A-Day Energy OTC eql century oral tablet One-A-Day Energy OTC eql one daily mens 50+ advance oral tablet One-A-Day Energy OTC eql one daily mens health oral tablet One-A-Day Energy OTC eql one daily womens 50+ adv oral tablet One-A-Day Energy OTC eql vision formula oral tablet One-A-Day Energy OTC essential balance oral tablet One-A-Day Energy OTC eye vitamins & minerals oral tablet One-A-Day Energy OTC eyeprotect oral tablet One-A-Day Energy OTC gerivite complete oral tablet One-A-Day Energy OTC glucoten oral capsule Theramill Forte OTC gnp century active performance oral tablet One-A-Day Energy OTC gnp century adult formula oral tablet One-A-Day Energy OTC gnp century adults 50+ senior oral tablet One-A-Day Energy OTC gnp century cardio health oral tablet One-A-Day Energy OTC gnp century mature oral tablet One-A-Day Energy OTC gnp century oral tablet One-A-Day Energy OTC gnp century ultimate mens oral tablet One-A-Day Energy OTC gnp century ultimate womens oral tablet One-A-Day Energy OTC gnp diabetic support formula oral tablet One-A-Day Energy OTC gnp hair/skin/nails oral tablet One-A-Day Energy OTC gnp healthy eyes oral tablet One-A-Day Energy OTC gnp healthy eyes supervision oral capsule Theramill Forte OTC gnp maximum one daily oral tablet One-A-Day Energy OTC gnp mega multi for men oral tablet One-A-Day Energy OTC gnp mega multi for women oral tablet One-A-Day Energy OTC gnp one daily maximum oral tablet One-A-Day Energy OTC gnp one daily mens 50+advanced oral tablet One-A-Day Energy OTC gnp one daily mens health 50+ oral tablet One-A-Day Energy OTC gnp one daily mens/lycopene oral tablet One-A-Day Energy OTC gnp one daily womens 50+ oral tablet One-A-Day Energy OTC gnp one daily womens oral tablet One-A-Day Energy OTC gnp opti-vitamins oral tablet One-A-Day Energy OTC gnp therapeutic-m oral tablet One-A-Day Energy OTC gnp womens one daily oral tablet One-A-Day Energy OTC hair formula extra strength oral tablet One-A-Day Energy OTC

202

Formulary Drug Name Reference Restrictions hair skin and nails formula oral tablet One-A-Day Energy OTC hair skin nails oral capsule Theramill Forte OTC hair vitamins oral tablet One-A-Day Energy OTC hair/skin/nails oral capsule Theramill Forte OTC hair/skin/nails oral tablet One-A-Day Energy OTC hair/skin/nails/biotin oral tablet One-A-Day Energy OTC healthy eyes oral tablet One-A-Day Energy OTC healthy eyes/lutein oral tablet One-A-Day Energy OTC hi-kovite 2-part formula oral tablet One-A-Day Energy OTC hi-potency multi-vitamin oral tablet One-A-Day Energy OTC hm antioxidant vitamins oral tablet One-A-Day Energy OTC hm complete 50+ oral tablet One-A-Day Energy OTC hm complete oral tablet One-A-Day Energy OTC hm complete women oral tablet One-A-Day Energy OTC hm mens 50+ advanced one daily oral tablet One-A-Day Energy OTC hm multivitamin adult gummy oral tablet chewable Centrum Silver OTC

hm womens 50+ advanced daily oral tablet One-A-Day Energy OTC i-vite oral tablet One-A-Day Energy OTC i-vite protect oral tablet One-A-Day Energy OTC kp adults 50+ daily formula oral tablet One-A-Day Energy OTC kp adults daily formula oral tablet One-A-Day Energy OTC kp mens 50+ daily formula oral tablet One-A-Day Energy OTC kp mens daily formula oral tablet One-A-Day Energy OTC kp womens 50+ daily formula oral tablet One-A-Day Energy OTC kp womens daily formula oral tablet One-A-Day Energy OTC magnum-75 oral tablet extended release M2 B-60 OTC maximum daily green oral tablet One-A-Day Energy OTC mega vm-80 oral tablet One-A-Day Energy OTC mega-marathon 100 tr oral tablet extended release M2 B-60 OTC

meijer advanced formula oral tablet One-A-Day Energy OTC mens daily formula/lycopene oral capsule Theramill Forte OTC multi + omega-3 adult gummies oral tablet chewable Centrum Silver OTC

multi adult gummies oral tablet chewable Centrum Silver OTC multi complete/iron oral tablet One-A-Day Energy OTC multi for her 50+ oral capsule Theramill Forte OTC multi for her 50+ oral tablet One-A-Day Energy OTC

203

Formulary Drug Name Reference Restrictions multi for her oral capsule Theramill Forte OTC multi for her oral tablet One-A-Day Energy OTC multi for him 50+ oral tablet One-A-Day Energy OTC multi vitamin/minerals oral tablet One-A-Day Energy OTC multi-day plus minerals oral tablet One-A-Day Energy OTC multilex oral tablet One-A-Day Energy OTC multilex-t&m oral tablet One-A-Day Energy OTC multimineral plus oral tablet One-A-Day Energy OTC multiple vit/minerals/no iron oral tablet One-A-Day Energy OTC multiple vitamins/womens oral tablet One-A-Day Energy OTC multivitamin & mineral oral liquid Super Nu-Thera OTC multivitamin adults 50+ oral tablet One-A-Day Energy OTC multivitamin adults oral tablet One-A-Day Energy OTC multivitamin gummies adult oral tablet chewable Centrum Silver OTC

multivitamin gummies mens oral tablet chewable Centrum Silver OTC

multi-vitamin gummies oral tablet chewable Centrum Silver OTC multivitamin gummies womens oral tablet chewable Centrum Silver OTC

multivitamin men 50+ oral tablet One-A-Day Energy OTC multi-vitamin menopausal oral tablet One-A-Day Energy OTC multivitamin oral liquid Super Nu-Thera OTC multivitamin women 50+ oral tablet One-A-Day Energy OTC multivitamin women oral tablet One-A-Day Energy OTC multivitamin/extra vitamin d3 oral tablet chewable Centrum Silver OTC

multi-vitamin/minerals oral tablet One-A-Day Energy OTC multivitamins/minerals adult oral liquid Super Nu-Thera OTC myamulti oral tablet One-A-Day Energy OTC my-vitalife oral capsule Theramill Forte OTC ocutabs oral tablet One-A-Day Energy OTC ocutabs-lutein oral tablet One-A-Day Energy OTC one daily 50 plus oral tablet One-A-Day Energy OTC one daily adults 50+ oral tablet One-A-Day Energy OTC one daily calcium/iron oral tablet One-A-Day Energy OTC one daily complete for men oral tablet One-A-Day Energy OTC one daily complete oral tablet One-A-Day Energy OTC one daily for men 50+ advanced oral tablet One-A-Day Energy OTC

204

Formulary Drug Name Reference Restrictions one daily for men/lycopene oral tablet One-A-Day Energy OTC one daily for women 50+ adv oral tablet One-A-Day Energy OTC one daily for women oral tablet One-A-Day Energy OTC one daily healthy weight adv oral tablet One-A-Day Energy OTC one daily healthy weight oral tablet One-A-Day Energy OTC one daily maximum oral tablet One-A-Day Energy OTC one daily mens 50+ multivit oral tablet One-A-Day Energy OTC one daily mens 50+/lycopene oral tablet One-A-Day Energy OTC one daily mens health oral tablet One-A-Day Energy OTC one daily mens oral tablet One-A-Day Energy OTC one daily multivit/iron-free oral tablet One-A-Day Energy OTC one daily multivitamin men oral tablet One-A-Day Energy OTC one daily multivitamin women oral tablet One-A-Day Energy OTC one daily plus minerals oral tablet One-A-Day Energy OTC one daily womens 50 plus oral tablet One-A-Day Energy OTC one daily womens 50+ oral tablet One-A-Day Energy OTC one daily womens oral tablet One-A-Day Energy OTC one daily/minerals oral tablet One-A-Day Energy OTC optic-vites oral tablet One-A-Day Energy OTC optic-vites with lutein oral tablet One-A-Day Energy OTC optimum pms oral tablet One-A-Day Energy OTC prevent oral capsule Theramill Forte OTC px advanced formula multivits oral tablet One-A-Day Energy OTC px complete senior multivits oral tablet One-A-Day Energy OTC px mens multivitamins oral tablet One-A-Day Energy OTC qc daily multivit/multimineral oral tablet One-A-Day Energy OTC qc mens daily multivitamin oral tablet One-A-Day Energy OTC qc multi-vite 50 & over oral tablet One-A-Day Energy OTC qc multi-vite oral tablet One-A-Day Energy OTC qc multi-vite plus oral tablet One-A-Day Energy OTC qc therin-m oral tablet One-A-Day Energy OTC qc womens daily multivitamin oral tablet One-A-Day Energy OTC quintabs-m oral tablet One-A-Day Energy OTC ra central-vite energy oral tablet One-A-Day Energy OTC ra central-vite mens mature oral tablet One-A-Day Energy OTC ra central-vite senior oral tablet One-A-Day Energy OTC ra central-vite womens mature oral tablet One-A-Day Energy OTC ra hair/skin/nails oral tablet One-A-Day Energy OTC

205

Formulary Drug Name Reference Restrictions ra mature womens dietary supp oral tablet One-A-Day Energy OTC ra one daily energy formula oral tablet One-A-Day Energy OTC ra one daily gummy vites oral tablet chewable Centrum Silver OTC ra one daily maximum oral tablet One-A-Day Energy OTC ra one daily mens 50+ w/vit d3 oral tablet One-A-Day Energy OTC ra one daily mens multi oral tablet One-A-Day Energy OTC ra one daily mens/vit d-3 oral tablet One-A-Day Energy OTC ra one daily womens oral tablet One-A-Day Energy OTC ra stress formula advanced oral tablet One-A-Day Energy OTC ra stress formula energy oral tablet One-A-Day Energy OTC ra therapeutic m plus beta car oral tablet One-A-Day Energy OTC ra vision vite plus zinc oral tablet One-A-Day Energy OTC senior tabs oral tablet One-A-Day Energy OTC sentry adult oral tablet One-A-Day Energy OTC sentry oral tablet One-A-Day Energy OTC sentry senior oral tablet One-A-Day Energy OTC sm antioxidant vitamins oral tablet One-A-Day Energy OTC sm complete 50+ oral tablet One-A-Day Energy OTC sm complete 50+ ultimate mens oral tablet One-A-Day Energy OTC sm complete 50+ ultimate women oral tablet One-A-Day Energy OTC sm complete advanced formula oral tablet One-A-Day Energy OTC sm complete oral tablet One-A-Day Energy OTC sm complete senior formula oral tablet One-A-Day Energy OTC sm daily diet support oral tablet One-A-Day Energy OTC sm hair/skin/nails oral tablet One-A-Day Energy OTC sm opti-vitamins oral tablet One-A-Day Energy OTC stress b-complex/c/zinc oral tablet One-A-Day Energy OTC super 28 formula oral tablet One-A-Day Energy OTC super antioxidants protector oral capsule Theramill Forte OTC super aytinal 50 plus oral tablet One-A-Day Energy OTC super aytinal oral tablet One-A-Day Energy OTC super multiple oral capsule Theramill Forte OTC super multiple oral tablet One-A-Day Energy OTC super natrul-100 oral tablet extended release M2 B-60 OTC super thera vite m oral tablet One-A-Day Energy OTC super vikaps oral tablet One-A-Day Energy OTC super vita-mins oral tablet One-A-Day Energy OTC superior 35 oral tablet extended release M2 B-60 OTC

206

Formulary Drug Name Reference Restrictions sure guard anti-oxidant plus oral tablet One-A-Day Energy OTC sure guard multi vit/mineral oral tablet One-A-Day Energy OTC tgt multivitamin/multimineral oral tablet One-A-Day Energy OTC thera vital m oral tablet One-A-Day Energy OTC thera vital-m oral tablet One-A-Day Energy OTC therabasic-m oral tablet One-A-Day Energy OTC therapeutic formula/hematinics oral tablet One-A-Day Energy OTC therapeutic m oral tablet One-A-Day Energy OTC therapeutic-m oral tablet One-A-Day Energy OTC therapeutic-m/lutein oral tablet One-A-Day Energy OTC theravim-m oral tablet One-A-Day Energy OTC totalday multiple oral tablet extended release M2 B-60 OTC tropical liquid nutrition oral liquid Super Nu-Thera OTC ultra antioxidant formula oral tablet One-A-Day Energy OTC ultra freeda oral tablet One-A-Day Energy OTC ultra freeda/iron oral tablet One-A-Day Energy OTC ultra multi formula/iron oral capsule Theramill Forte OTC ultra-mega oral tablet extended release M2 B-60 OTC v-c forte oral capsule Theramill Forte vision formula 2 oral tablet One-A-Day Energy OTC vision formula eye health oral capsule Theramill Forte OTC vision formula/lutein oral tablet One-A-Day Energy OTC vision plus oral capsule Theramill Forte OTC vision vitamins oral tablet One-A-Day Energy OTC visivites oral tablet One-A-Day Energy OTC visivites/lutein oral tablet One-A-Day Energy OTC vit b3-azelac-turm-fa-b6-zn-cu oral tablet One-A-Day Energy vita hair oral tablet One-A-Day Energy OTC vitabasic complete oral tablet One-A-Day Energy OTC vitabasic senior oral tablet One-A-Day Energy OTC vita-min oral capsule Theramill Forte vitamins a-d-e/selenium oral tablet One-A-Day Energy OTC vitamins/minerals oral tablet One-A-Day Energy OTC vitatrum oral tablet chewable Centrum Silver OTC womens 50+ advanced oral capsule Theramill Forte OTC womens daily form/fa/ca/fe oral tablet One-A-Day Energy OTC womens daily formula oral tablet One-A-Day Energy OTC womens multi oral capsule Theramill Forte OTC

207

Formulary Drug Name Reference Restrictions womens multivitamin oral tablet One-A-Day Energy OTC womens one daily oral tablet One-A-Day Energy OTC ABC PLUS SENIOR ADULTS 50+ ORAL TABLET KP Adults 50+ Daily Formula OTC

ABC PLUS SENIOR ORAL TABLET KP Adults 50+ Daily Formula OTC ADVANCED MULTI EA ORAL TABLET CHEWABLE

EQ Multivitamins Adult Gummy OTC

AIRBORNE GUMMIES ORAL TABLET CHEWABLE


AIRBORNE ORAL TABLET CHEWABLE


AMORYN MOOD BOOSTER ORAL CAPSULE Daily Multivitamin OTC

ANTIOXIN 4000 ORAL CAPSULE Daily Multivitamin OTC BPROTECTED MULTI-VITE ORAL LIQUID CentaVite OTC

CARRAVITE ORAL TABLET KP Adults 50+ Daily Formula OTC CEROVITE ADVANCED FORMULA ORAL TABLET KP Adults 50+ Daily Formula OTC

CEROVITE SENIOR ORAL TABLET KP Adults 50+ Daily Formula OTC CERTAVITE/ANTIOXIDANTS ORAL LIQUID CentaVite OTC

CERTAVITE/ANTIOXIDANTS ORAL TABLET KP Adults 50+ Daily Formula OTC

COMPETE ORAL TABLET KP Adults 50+ Daily Formula OTC CORVITE FREE ORAL TABLET KP Adults 50+ Daily Formula DOCTORS CHOICE MEN ORAL TABLET KP Adults 50+ Daily Formula OTC

DRY EYE FORMULA ORAL CAPSULE Daily Multivitamin OTC ENVIRO-STRESS ORAL TABLET KP Adults 50+ Daily Formula OTC EQ ONE DAILY WOMENS PRO-ACTIVE ORAL TABLET KP Adults 50+ Daily Formula OTC

ESSENTIA ORAL TABLET KP Adults 50+ Daily Formula OTC EYE VITAMINS ORAL CAPSULE Daily Multivitamin OTC EYE-VITES ORAL TABLET KP Adults 50+ Daily Formula OTC ICAPS AREDS 2 ORAL CAPSULE Daily Multivitamin OTC ICAPS LUTEIN & OMEGA-3 ORAL CAPSULE Daily Multivitamin OTC

ICAPS MV ORAL TABLET KP Adults 50+ Daily Formula OTC ICAPS ORAL CAPSULE Daily Multivitamin OTC KP VISION FORMULA ORAL TABLET KP Adults 50+ Daily Formula OTC

208

Formulary Drug Name Reference Restrictions KP VISION FORMULA/LUTEIN ORAL TABLET KP Adults 50+ Daily Formula OTC

LYSIPLEX PLUS ORAL LIQUID CentaVite OTC LYSIPLEX PLUS ORAL TABLET KP Adults 50+ Daily Formula MACULAR HEALTH FORMULA ORAL CAPSULE Daily Multivitamin OTC

MACUVITE EYE CARE ORAL TABLET KP Adults 50+ Daily Formula OTC MACUVITE ORAL TABLET KP Adults 50+ Daily Formula OTC MACUVITE/LUTEIN ORAL TABLET KP Adults 50+ Daily Formula OTC MAXIMUM BLUE LABEL ORAL TABLET KP Adults 50+ Daily Formula OTC

MAXIMUM GREEN LABEL ORAL TABLET KP Adults 50+ Daily Formula OTC

MAXIMUM RED LABEL ORAL TABLET KP Adults 50+ Daily Formula OTC

MEDIPLEX PLUS ORAL TABLET KP Adults 50+ Daily Formula OTC MENS HAIR FORMULA ULTRA MAN ORAL TABLET KP Adults 50+ Daily Formula OTC

MENS LIFE PACK ORAL TABLET KP Adults 50+ Daily Formula OTC MILLTRIUM ADVANCED FORMULA ORAL TABLET KP Adults 50+ Daily Formula OTC

MILLTRIUM CARDIO ORAL TABLET KP Adults 50+ Daily Formula OTC MILLTRIUM SENIOR ORAL TABLET KP Adults 50+ Daily Formula OTC MULTI COMPLETE ORAL CAPSULE Daily Multivitamin OTC MULTI FOR HIM ORAL CAPSULE Daily Multivitamin OTC MULTI FOR HIM ORAL TABLET KP Adults 50+ Daily Formula OTC MULTI-DAY WEIGHT TRIM ORAL TABLET KP Adults 50+ Daily Formula OTC

MULTI-LEAN ORAL TABLET KP Adults 50+ Daily Formula OTC NUTRIFAC ZX ORAL TABLET KP Adults 50+ Daily Formula OCUVITE EXTRA ORAL TABLET KP Adults 50+ Daily Formula OTC OCUVITE EYE + MULTI ORAL TABLET KP Adults 50+ Daily Formula OTC

OCUVITE EYE HEALTH FORMULA ORAL CAPSULE Daily Multivitamin OTC

OCUVITE EYE HEATLH GUMMIES ORAL TABLET CHEWABLE


OCUVITE-LUTEIN ORAL TABLET KP Adults 50+ Daily Formula OTC ONE DAILY PLUS IRON ORAL TABLET KP Adults 50+ Daily Formula OTC

209

Formulary Drug Name Reference Restrictions ONE-A-DAY TEEN ADVANTAGE/HER ORAL TABLET KP Adults 50+ Daily Formula OTC

ORTHOVITE ORAL TABLET KP Adults 50+ Daily Formula OTC OSTEOPRIME ULTRA ORAL TABLET KP Adults 50+ Daily Formula OTC PROSIGHT ORAL CAPSULE Daily Multivitamin OTC PROSIGHT ORAL TABLET KP Adults 50+ Daily Formula OTC RA CENTRAL-VITE ORAL TABLET KP Adults 50+ Daily Formula OTC RA CENTRAL-VITE SELECT ORAL TABLET KP Adults 50+ Daily Formula OTC

RA CENTRAL-VITE/ANTIOXIDANTS ORAL TABLET KP Adults 50+ Daily Formula OTC

RA WHOLE SOURCE DIETARY MATURE ORAL TABLET KP Adults 50+ Daily Formula OTC

RA WHOLE SOURCE DIETARY MEN ORAL TABLET KP Adults 50+ Daily Formula OTC

RA WHOLE SOURCE DIETARY ORAL TABLET KP Adults 50+ Daily Formula OTC

RA WHOLE SOURCE FOR MEN ORAL TABLET KP Adults 50+ Daily Formula OTC

RA WHOLE SOURCE WOMENS ORAL TABLET KP Adults 50+ Daily Formula OTC

RENAL ORAL TABLET KP Adults 50+ Daily Formula OTC RENAPLEX ORAL TABLET KP Adults 50+ Daily Formula OTC SAVISION ORAL TABLET KP Adults 50+ Daily Formula OTC SCLEREX ORAL TABLET KP Adults 50+ Daily Formula OTC STRESSTABS ADVANCED ORAL TABLET KP Adults 50+ Daily Formula OTC

SUNVITE ACTIVE ADULT 50+ ORAL TABLET KP Adults 50+ Daily Formula OTC

SUNVITE ADVANCED ORAL TABLET KP Adults 50+ Daily Formula OTC SUPER NU-THERA ORAL LIQUID CentaVite OTC SUPER NU-THERA ORAL TABLET KP Adults 50+ Daily Formula OTC TAB-A-VITE MAXIMUM ORAL TABLET KP Adults 50+ Daily Formula OTC

THERADEX M ORAL TABLET KP Adults 50+ Daily Formula OTC THERADEX M/BETA CAROTENE ORAL TABLET KP Adults 50+ Daily Formula OTC

THERA-MILL M ORAL TABLET KP Adults 50+ Daily Formula OTC THERAMILL PLUS ORAL CAPSULE Daily Multivitamin OTC THERATRUM COMPLETE 50 PLUS ORAL TABLET KP Adults 50+ Daily Formula OTC

210

Formulary Drug Name Reference Restrictions THERATRUM COMPLETE ORAL TABLET KP Adults 50+ Daily Formula OTC

THRIVE FOR LIFE WOMENS ORAL TABLET KP Adults 50+ Daily Formula OTC

TOTAL FORMULA 2 ORAL TABLET KP Adults 50+ Daily Formula OTC TOTAL FORMULA 3 ORAL TABLET KP Adults 50+ Daily Formula OTC TOTAL FORMULA ORAL TABLET KP Adults 50+ Daily Formula OTC TRUEPLUS DIABETIC MULTIVITAMIN ORAL TABLET KP Adults 50+ Daily Formula OTC

ULTRA VITA-TIME ORAL TABLET KP Adults 50+ Daily Formula OTC ULTRACHOICE ADV FORMULA MATURE ORAL TABLET KP Adults 50+ Daily Formula OTC

ULTRACHOICE ADVANCED FORMULA ORAL TABLET KP Adults 50+ Daily Formula OTC

VIC-FORTE ORAL CAPSULE Daily Multivitamin VITA S FORTE ORAL TABLET KP Adults 50+ Daily Formula VITACEL ORAL TABLET KP Adults 50+ Daily Formula VITATRUM COMPLETE ORAL TABLET KP Adults 50+ Daily Formula OTC

VITEYES AREDS ADVANCED ORAL CAPSULE Daily Multivitamin OTC

VITEYES AREDS FORMULA ORAL CAPSULE Daily Multivitamin OTC

VITEYES AREDS FORMULA/LUTEIN ORAL CAPSULE Daily Multivitamin OTC

VITEYES COMPANION/LYCOPENE ORAL TABLET KP Adults 50+ Daily Formula OTC

VITEYES COMPLETE ORAL CAPSULE Daily Multivitamin OTC VITEYES SMOKERS ADVANCED ORAL CAPSULE Daily Multivitamin OTC

VITEYES SMOKERS FORMULA/LUTEIN ORAL CAPSULE Daily Multivitamin OTC

VITRUM SENIOR ORAL TABLET KP Adults 50+ Daily Formula OTC WOMENS LIFE PACK ORAL TABLET KP Adults 50+ Daily Formula OTC YOUR LIFE MULTI MENS 50+ ORAL TABLET KP Adults 50+ Daily Formula OTC

YOUR LIFE MULTI WOMENS 50+ ORAL TABLET KP Adults 50+ Daily Formula OTC

*Multivitamins*** antioxidant formula oral capsule 250-10000 -200 Ze-Plus OTC

multivitamins oral capsule Ze-Plus OTC

211

Formulary Drug Name Reference Restrictions mv-one oral capsule Ze-Plus OTC vitamin e/folic acid/b-6/b-12 oral capsule Ze-Plus OTC

*Ped Multi Vitamins W/Fl & Fe*** multi-vit/fluoride/iron oral solution 0.25-10 mg/ml multi-vit/iron/fluoride oral solution 0.25-10 mg/ml multi-vitamin/fluoride/iron oral solution 0.25 -10 mg/ml

*Ped Multiple Vitamins W/ Minerals & C*** childrens animal shapes oral tablet chewable 60 mg Flintstones Complete OTC

childrens multivitamin oral tablet chewable 60 mg Flintstones Complete OTC

cvs childrens complete oral tablet chewable 60 mg Flintstones Complete OTC

eq complete multivitamin child oral tablet chewable 60 mg Flintstones Complete OTC

eql child multivit/minerals oral tablet chewable 60 mg Flintstones Complete OTC

hm animal shapes oral tablet chewable 60 mg Flintstones Complete OTC polyvitamin/iron oral tablet chewable Flintstones Complete OTC qc childrens complete oral tablet chewable 60 mg Flintstones Complete OTC

ra vitamins complete childrens oral tablet chewable 60 mg Flintstones Complete OTC

sm animal shapes complete oral tablet chewable 60 mg Flintstones Complete OTC

zoo friends gummies oral tablet chewable Ultra Choice Multivitamin Kids OTC

zoo friends oral tablet chewable 60 mg Flintstones Complete OTC ALIVE MULTI-VITAMIN CHILDRENS ORAL TABLET CHEWABLE 60 MG HM Animal Shapes OTC

CENTRUM KIDS COMPLETE ORAL TABLET CHEWABLE 60 MG HM Animal Shapes OTC

CEROVITE JR ORAL TABLET CHEWABLE 60 MG HM Animal Shapes OTC

FLINTSTONES COMPLETE ORAL TABLET CHEWABLE 60 MG HM Animal Shapes OTC

FLINTSTONES GUMMIES BONE BUILD ORAL TABLET CHEWABLE 60 MG HM Animal Shapes OTC

212

Formulary Drug Name Reference Restrictions PX CHILDRENS VITAMIN ORAL TABLET CHEWABLE HM Animal Shapes OTC

SEA BUDDIES DAILY MULTIPLE ORAL TABLET CHEWABLE 60 MG HM Animal Shapes OTC

*Ped Mv W/ Fluoride*** multi-vit/fluoride oral solution 0.25 mg/ml Floriva Plus multi-vit/fluoride oral solution 0.5 mg/ml Quflora Pediatric multivitamin/fluoride oral solution 0.25 mg/ml Floriva Plus multi-vitamin/fluoride oral solution 0.25 mg/ml Floriva Plus

multivitamin/fluoride oral solution 0.5 mg/ml Quflora Pediatric multi-vitamin/fluoride oral solution 0.5 mg/ml Quflora Pediatric multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg MVC-Fluoride

multivitamins/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg MVC-Fluoride

MVC-FLUORIDE ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG Multivitamins/Fluoride

*Ped Mv W/ Iron*** animal shapes plus iron oral tablet chewable 15 mg Flintstones Plus Iron OTC

bite-a-mins/iron oral tablet chewable 15 mg Flintstones Plus Iron OTC chewable vite/iron childrens oral tablet chewable 15 mg Flintstones Plus Iron OTC

child chewable vitamins/iron oral tablet chewable Flintstones Plus Iron OTC

childrens multivitamin/iron oral tablet chewable 15 mg Flintstones Plus Iron OTC

childrens vitamins/iron oral tablet chewable 15 mg Flintstones Plus Iron OTC

cvs children multivitamin/iron oral tablet chewable 15 mg Flintstones Plus Iron OTC

fruity chews/iron oral tablet chewable Flintstones Plus Iron OTC gnp animal shapes plus iron oral tablet chewable 15 mg Flintstones Plus Iron OTC

gnp childrens chewables/iron oral tablet chewable 15 mg Flintstones Plus Iron OTC

little animals plus iron oral tablet chewable 15 mg Flintstones Plus Iron OTC

poly-vita/iron oral solution 10 mg/ml BProtected Pedia Poly-Vite/Fe OTC polyvitamin/iron oral solution 10 mg/ml BProtected Pedia Poly-Vite/Fe OTC

213

Formulary Drug Name Reference Restrictions qc childrens vitamins/iron oral tablet chewable 15 mg Flintstones Plus Iron OTC

ra childrens chewable vit/iron oral tablet chewable 15 mg Flintstones Plus Iron OTC

zoo friends plus iron oral tablet chewable 15 mg Flintstones Plus Iron OTC

BPROTECTED PEDIA POLY-VITE/FE ORAL SOLUTION 10 MG/ML Poly-Vita/Iron OTC

FLINTSTONES PLUS IRON ORAL TABLET CHEWABLE Fruity Chews/Iron OTC

LAND BEFORE TIME MULTIVITAMIN ORAL TABLET CHEWABLE 15 MG Fruity Chews/Iron OTC

*Ped Vitamins Acd Fluoride & Iron*** tri-vit/fluoride/iron oral solution 0.25-10 mg/ml

*Ped Vitamins Acd W/ Fluoride*** tri-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml tri-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml vitamins acd-fluoride oral solution 0.25 mg/ml

*Pediatric Multiple Vitamins W/ C & Fa*** animal chews oral tablet chewable Flintstones Plus Calcium OTC bite-a-mins oral tablet chewable Flintstones Plus Calcium OTC chewable vite childrens oral tablet chewable Flintstones Plus Calcium OTC childrens chewable multi vits oral tablet chewable Flintstones Plus Calcium OTC

childrens chewable vitamins oral tablet chewable Flintstones Plus Calcium OTC

childrens multivitamin oral tablet chewable Flintstones Plus Calcium OTC fruity chews oral tablet chewable Flintstones Plus Calcium OTC gnp animal shapes oral tablet chewable Flintstones Plus Calcium OTC gnp little ones childrens oral tablet chewable Flintstones Plus Calcium OTC little animals oral tablet chewable Flintstones Plus Calcium OTC multivitamin childrens oral tablet chewable Flintstones Plus Calcium OTC poly vitamin oral tablet chewable Flintstones Plus Calcium OTC sm animal shapes kids first oral tablet chewable Flintstones Plus Calcium OTC

214

Formulary Drug Name Reference Restrictions ANIMAL SHAPES ORAL TABLET CHEWABLE WITH C & FA SM Animal Shapes Kids First OTC

BOUNTY BEARS/C ORAL TABLET CHEWABLE SM Animal Shapes Kids First OTC

DINO-LIFE ORAL TABLET CHEWABLE SM Animal Shapes Kids First OTC

FLINSTONES GUMMIES OMEGA-3 DHA ORAL TABLET CHEWABLE SM Animal Shapes Kids First OTC

FLINTSTONES PLUS CALCIUM ORAL TABLET CHEWABLE SM Animal Shapes Kids First OTC

FLINTSTONES/MY FIRST ORAL TABLET CHEWABLE WITH C & FA SM Animal Shapes Kids First OTC

*Pediatric Multiple Vitamins W/ C*** poly-vita oral solution 35 mg/ml BProtected Pedia Poly-Vite OTC polyvitamin oral solution 35 mg/ml BProtected Pedia Poly-Vite OTC BPROTECTED PEDIA POLY-VITE ORAL SOLUTION 35 MG/ML Poly-Vita OTC

*Pediatric Multiple Vitamins W/ Extra C & Fa*** gnp animal shapes plus extra c oral tablet chewable Flintstones/Extra C OTC

gnp childrens chewables/ex c oral tablet chewable Flintstones/Extra C OTC

qc childrens vitamins/extra c oral tablet chewable Flintstones/Extra C OTC

zoo friends plus extra c oral tablet chewable Flintstones/Extra C OTC DINO-LIFE W/EXTRA C ORAL TABLET CHEWABLE

GNP Childrens Chewables/Ex C OTC

FLINTSTONES/EXTRA C ORAL TABLET CHEWABLE


LAND BEFORE TIME MULTIVITAMIN ORAL TABLET CHEWABLE W/EXTRA C & FA


ZOO FRIENDS/EXTRA C ORAL TABLET CHEWABLE


*Pediatric Multiple Vitamins*** multi-delyn oral liquid PediaVit OTC PEDIAVIT ORAL LIQUID Multi-Delyn OTC

*Prenatal Mv & Min W/Fe-Fa*** bp multinatal plus oral tablet 30-1 mg QLL (100 EA per 90 days)

215

Formulary Drug Name Reference Restrictions bp multinatal plus oral tablet chewable 40-1 mg QLL (100 EA per 90 days)

dothelle dha oral capsule 53.5-38-1 mg Taron-C DHA mynatal plus oral tablet Vitafol-OB mynatal-z oral tablet Vitafol-OB pnv folic acid + iron oral tablet 27-1 mg TheraNatal Core Nutrition pnv prenatal plus multivitamin oral tablet 27 -1 mg TheraNatal Core Nutrition

pnv-select oral tablet 27-0.6-0.4 mg QLL (100 EA per 90 days) pnv-vp-u oral capsule 106.5-1 mg Prenatal-U prenatal 19 oral tablet QLL (100 EA per 1 day) prenatal 19 oral tablet chewable QLL (100 EA per 90 days) prenatal oral tablet 27-1 mg TheraNatal Core Nutrition prenatal plus oral tablet 27-1 mg TheraNatal Core Nutrition prenatal vitamin plus low iron oral tablet 27-1 mg TheraNatal Core Nutrition

preplus oral tablet 27-1 mg TheraNatal Core Nutrition triadvance oral tablet 90-1 mg Inatal GT QLL (100 EA per 90 days) trinatal rx 1 oral tablet 60-1 mg Vinate One QLL (100 EA per 90 days) virt-c dha oral capsule 53.5-38-1 mg Taron-C DHA vol-plus oral tablet 27-1 mg TheraNatal Core Nutrition CONCEPT DHA ORAL CAPSULE 53.5 -38-1 MG Virt-C DHA

INATAL ADVANCE ORAL TABLET TriAdvance INATAL GT ORAL TABLET TriAdvance INATAL ULTRA ORAL TABLET TriAdvance M-VIT ORAL TABLET Prenatal Plus/Iron NIVA-PLUS ORAL TABLET 27-1 MG Prenatal Plus/Iron O-CAL FA ORAL TABLET 27-1 MG Prenatal Plus/Iron QLL (100 EA per 90 days) PRENATABS RX ORAL TABLET 29-1 MG Vol-Tab Rx QLL (100 EA per 90 days)

PRENATAL-U ORAL CAPSULE 106.5-1 MG PNV-VP-U QLL (100 EA per 90 days)

SELECT-OB ORAL TABLET CHEWABLE 29-1 MG QLL (100 EA per 90 days)

TARON-C DHA ORAL CAPSULE 53.5 -38-1 MG Virt-C DHA QLL (100 EA per 90 days)

THERANATAL CORE NUTRITION ORAL TABLET 27-1 MG Prenatal Plus/Iron OTC

TRICARE ORAL TABLET Prenatal Plus/Iron

216

Formulary Drug Name Reference Restrictions TRINATE ORAL TABLET Vol-Nate QLL (100 EA per 90 days) VINATE II ORAL TABLET 29-1 MG QLL (100 EA per 90 days) VINATE M ORAL TABLET 27-1 MG QLL (100 EA per 90 days) VINATE ONE ORAL TABLET 60-1 MG Trinatal Rx 1 VITAFOL-OB ORAL TABLET Mynatal-Z QLL (100 EA per 90 days)

*Prenatal Mv & Min W/Fe-Fa-Dha*** folcal dha oral capsule 27-1.25-300 mg VemaVite-PRx 2 pnv-dha oral capsule 27-0.6-0.4-300 mg Zatean-Pn DHA QLL (100 EA per 90 days) pnv-dha+docusate oral capsule 27-1.25-300 mg VemaVite-PRx 2

SELECT-OB+DHA ORAL 29-1 & 250 MG QLL (100 EA per 90 days) VEMAVITE-PRX 2 ORAL CAPSULE 27 -1.25-300 MG Folcal DHA QLL (100 EA per 90 days)

*Prenatal Vitamins*** bp folinatal plus b oral tablet 1 mg QLL (100 EA per 90 days)

*Specialty Vitamins Products*** a thru z advantage oral tablet Brain OTC cvs hair/skin/nails oral tablet Brain OTC cvs menopause support oral tablet Brain OTC ra central-vite cardio oral tablet Brain OTC ra central-vite performance oral tablet Brain OTC ra menopause support oral tablet Brain OTC ultimate fat burner oral tablet Brain OTC urosex oral tablet Brain varisan vitality oral tablet Brain OTC vitamins for hair oral tablet Brain OTC weight loss daily multi oral tablet Brain OTC MILLTRIUM STAMINA PLUS ORAL TABLET Thymus OTC

*MUSCULOSKELETAL THERAPY AGENTS* *Central Muscle Relaxants*** baclofen oral tablet 10 mg, 20 mg

carisoprodol oral tablet 350 mg Soma QLL (4 EA per 1 day); AL (Min 16 Years)

chlorzoxazone oral tablet 500 mg Parafon Forte DSC cyclobenzaprine hcl oral tablet 10 mg, 5 mg cyclobenzaprine hcl oral tablet 7.5 mg Fexmid

217

Formulary Drug Name Reference Restrictions methocarbamol oral tablet 500 mg Robaxin methocarbamol oral tablet 750 mg Robaxin-750 orphenadrine citrate er oral tablet extended release 12 hour 100 mg tizanidine hcl oral tablet 2 mg tizanidine hcl oral tablet 4 mg Zanaflex

*Direct Muscle Relaxants*** dantrolene sodium oral capsule 100 mg dantrolene sodium oral capsule 25 mg, 50 mg Dantrium

*Muscle Relaxant Combinations***

carisoprodol-aspirin oral tablet 200-325 mg QLL (4 EA per 1 day); AL (Min 16 Years)

carisoprodol-aspirin-codeine oral tablet 200 -325-16 mg QLL (120 EA per 30 days)

*NASAL AGENTS - SYSTEMIC AND TOPICAL* *Nasal Anticholinergics*** ipratropium bromide nasal solution 0.03 % QLL (30 ML per 30 days) ipratropium bromide nasal solution 0.06 % QLL (15 ML per 30 days)

*Nasal Antihistamines*** azelastine hcl nasal solution 0.1 % olopatadine hcl nasal solution 0.6 % Patanase

*Nasal Steroids*** allergy relief nasal suspension 50 mcg/act Flonase OTC allergy spray 24 hour nasal aerosol 55 mcg/act Nasacort Allergy 24HR OTC

allergy spray 24 hour nasal suspension 50 mcg/act Flonase OTC

budesonide nasal suspension 32 mcg/act Rhinocort Aqua cvs fluticasone propionate nasal suspension 50 mcg/act Flonase OTC

cvs nasal allergy spray nasal aerosol 55 mcg/act Nasacort Allergy 24HR OTC

eq allergy relief nasal suspension 50 mcg/act Flonase OTC eq nasal allergy nasal aerosol 55 mcg/act Nasacort Allergy 24HR OTC eql fluticasone childrens nasal suspension 50 mcg/act Flonase OTC

eql fluticasone propionate nasal suspension 50 mcg/act Flonase OTC

flunisolide nasal solution 25 mcg/act (0.025%) ST

218

Formulary Drug Name Reference Restrictions fluticasone propionate nasal suspension 50 mcg/act Flonase

gnp 24 hour nasal allergy nasal aerosol 55 mcg/act Nasacort Allergy 24HR OTC

gnp fluticasone propionate nasal suspension 50 mcg/act Flonase OTC

goodsense nasoflow nasal suspension 50 mcg/act Flonase OTC

hm allergy relief nasal suspension 50 mcg/act Flonase OTC kp fluticasone propionate nasal suspension 50 mcg/act Flonase OTC

mometasone furoate nasal suspension 50 mcg/act Nasonex

nasal allergy 24 hour nasal aerosol 55 mcg/act Nasacort Allergy 24HR OTC

ra budesonide nasal suspension 32 mcg/act Rhinocort Aqua OTC sm allergy relief nasal suspension 50 mcg/act Flonase OTC triamcinolone acetonide nasal aerosol 55 mcg/act Nasacort Allergy 24HR

CLARISPRAY NASAL SUSPENSION 50 MCG/ACT Fluticasone Propionate OTC

KLS ALLER-FLO NASAL SUSPENSION 50 MCG/ACT Fluticasone Propionate OTC

RHINOCORT ALLERGY NASAL SUSPENSION 32 MCG/ACT RA Budesonide OTC

*Systemic Decongestants*** kp pseudoephedrine hcl oral tablet 60 mg SudoGest OTC pseudoephedrine hcl oral tablet 60 mg SudoGest SUDOGEST ORAL TABLET 60 MG KP Pseudoephedrine HCl OTC

*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb***

ENTRESTO ORAL TABLET 24-26 MG PA; QLL (60 EA per 30 days); AL (Min 18 Years)

ENTRESTO ORAL TABLET 49-51 MG, 97-103 MG


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

219

Formulary Drug Name Reference Restrictions *NUTRIENTS* *Misc. Nutritional Substances*** cvs fish oil oral capsule 1000 mg Ultra Omega 3 OTC cvs fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC cvs fish oil oral capsule delayed release 1200 mg OTC

cvs natural fish oil oral capsule 1000 mg Ultra Omega 3 OTC cvs natural fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC epa oral capsule 1000 mg Ultra Omega 3 OTC eql fish oil oral capsule 1000 mg Ultra Omega 3 OTC eql omega 3 fish oil oral capsule 1000 mg Ultra Omega 3 OTC eql omega 3 fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC eql omega 3 fish oil oral capsule delayed release 1200 mg OTC

fish oil burp-less oral capsule 1000 mg Ultra Omega 3 OTC fish oil burp-less oral capsule 1200 mg Theragran-M Fish Oil Conc OTC fish oil concentrate oral capsule 1000 mg Ultra Omega 3 OTC fish oil concentrate oral capsule 300 mg Fish Oil Pearls OTC fish oil concentrate oral capsule 435 mg OTC fish oil double strength oral capsule 1200 mg Theragran-M Fish Oil Conc OTC fish oil extra strength oral capsule 1200 mg Theragran-M Fish Oil Conc OTC fish oil extra strength oral capsule 435 mg OTC fish oil maximum strength oral capsule 1200 mg Theragran-M Fish Oil Conc OTC

fish oil maximum strength oral capsule delayed release 1200 mg OTC

fish oil omega-3 oral capsule 1000 mg Ultra Omega 3 OTC fish oil oral capsule 1000 mg Ultra Omega 3 OTC fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC fish oil oral capsule 435 mg OTC fish oil oral capsule delayed release 1200 mg OTC fish oil triple strength oral capsule 1400 mg OTC fish oil ultra oral capsule 1400 mg OTC fish oil/super potent/no burp oral capsule 1000 mg Ultra Omega 3 OTC

gnp fish oil max st oral capsule delayed release 1200 mg OTC

gnp fish oil oral capsule 1000 mg Ultra Omega 3 OTC gnp fish oil oral capsule 435 mg OTC

220

Formulary Drug Name Reference Restrictions gnp fish oil oral capsule delayed release 1200 mg OTC

hm fish oil oral capsule 1000 mg Ultra Omega 3 OTC hm fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC kp fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC kp omega-3 fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC kp omega-3 fish oil oral capsule delayed release 1200 mg OTC

maxepa oral capsule 1000 mg Ultra Omega 3 OTC norwegian salmon oil oral capsule 1000 mg Ultra Omega 3 OTC omega 3 oral capsule 1000 mg Ultra Omega 3 OTC omega 3 oral capsule 1200 mg Theragran-M Fish Oil Conc OTC omega iii epa+dha oral capsule 1000 mg Ultra Omega 3 OTC omega-3 cf oral capsule 1000 mg Ultra Omega 3 OTC omega-3 fish oil oral capsule 1000 mg Ultra Omega 3 OTC omega-3 fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC omega-3 fish oil oral capsule 300 mg Fish Oil Pearls OTC omega-3 oral capsule 1000 mg Ultra Omega 3 OTC omega-3 oral capsule 1400 mg OTC omega-3 oral capsule 300 mg Fish Oil Pearls OTC omega-3 plus oral capsule 1000 mg Ultra Omega 3 OTC pa fish oil oral capsule 1000 mg Ultra Omega 3 OTC px fish oil oral capsule 1000 mg Ultra Omega 3 OTC ra fish oil oral capsule 1000 mg Ultra Omega 3 OTC sb omega-3 fish oil oral capsule 1000 mg Ultra Omega 3 OTC sm fish oil oral capsule 1000 mg Ultra Omega 3 OTC sm fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC sm omega-3 fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc OTC super omega 3 epa/dha oral capsule 1000 mg Ultra Omega 3 OTC super omega-epa oral capsule 1000 mg Ultra Omega 3 OTC ultra omega-3 fish oil oral capsule 1400 mg OTC ESKIMO PUREFA ORAL CAPSULE 1000 MG SB Omega-3 Fish Oil OTC

FISH OIL PEARLS ORAL CAPSULE 300 MG Fish Oil Concentrate OTC

MAXIMUM EPA ORAL CAPSULE 1000 MG SB Omega-3 Fish Oil OTC

OMERA ORAL CAPSULE 1000 MG SB Omega-3 Fish Oil OTC SEA-OMEGA 30 ORAL CAPSULE 1200 MG KP Omega-3 Fish Oil OTC

221

Formulary Drug Name Reference Restrictions SEA-OMEGA ORAL CAPSULE 1000 MG SB Omega-3 Fish Oil OTC SUPER DHA GEMS ORAL CAPSULE 1000 MG SB Omega-3 Fish Oil OTC

SUPER OMEGA-3 ORAL CAPSULE 1000 MG SB Omega-3 Fish Oil OTC

THERAGRAN-M FISH OIL CONC ORAL CAPSULE 1200 MG KP Omega-3 Fish Oil OTC

THEROMEGA ORAL CAPSULE 1000 MG SB Omega-3 Fish Oil OTC

ULTRA OMEGA 3 ORAL CAPSULE 1000 MG SB Omega-3 Fish Oil OTC

*OPHTHALMIC AGENTS* *Alpha Adrenergic Agonist & Carbonic Anhydrase Inhib Comb*** SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %

*Artificial Tear And Lubricant Combinations*** artificial tears ophthalmic solution 1-0.3 % Moisture Eyes OTC cvs artificial tears ophthalmic solution 1-0.3 % Moisture Eyes OTC

eq artificial tears ophthalmic solution 1-0.3 % Moisture Eyes OTC ra artificial tears ophthalmic solution 1-0.3 % Moisture Eyes OTC ra lubricant eye ophthalmic solution 1-0.3 % Moisture Eyes OTC tgt lubricant eye drops ophthalmic solution 1 -0.3 % Moisture Eyes OTC; QLL (15 ML per 30 days)

SYSTANE OPHTHALMIC GEL 0.4-0.3 % OTC

*Artificial Tear Solutions*** artificial tears ophthalmic solution 0.1-0.3 % Soothe XP OTC cvs natural tears ophthalmic solution 0.1-0.3 % Soothe XP OTC

just tears eye drops ophthalmic solution Soothe XP OTC natural balance tears ophthalmic solution Soothe XP OTC natures tears ophthalmic solution 0.1-0.3 % Soothe XP OTC ra lubricant eye ophthalmic solution 0.1-0.3 % Soothe XP OTC sm artificial tears ophthalmic solution Soothe XP OTC tears again ophthalmic solution Soothe XP OTC tears pure ophthalmic solution 0.1-0.3 % Soothe XP OTC BION TEARS OPHTHALMIC SOLUTION 0.1-0.3 % Just Tears Eye Drops OTC

222

Formulary Drug Name Reference Restrictions GENTEAL TEARS OPHTHALMIC SOLUTION 0.1-0.2-0.3 %, 0.1-0.3 % Just Tears Eye Drops OTC

SOOTHE HYDRATION OPHTHALMIC SOLUTION 1.25 % Just Tears Eye Drops OTC

SOOTHE XP OPHTHALMIC SOLUTION Just Tears Eye Drops OTC

SOOTHE XP XTRA PROTECTION OPHTHALMIC SOLUTION Just Tears Eye Drops OTC

SYSTANE CONTACTS OPHTHALMIC SOLUTION Just Tears Eye Drops OTC; QLL (15 ML per 30 days)

TEARS AGAIN ADVANCED EYELID OPHTHALMIC SOLUTION Just Tears Eye Drops OTC

TEARS NATURALE FREE OPHTHALMIC SOLUTION 0.1-0.3 % Just Tears Eye Drops OTC

*Artificial Tears And Lubricants*** artificial tears ophthalmic solution 1.4 % OTC; QLL (15 ML per 30 days) cvs lubricant drops ophthalmic solution 0.6 % Systane Balance OTC cvs lubricant eye drops ophthalmic solution 0.5 % Refresh Tears OTC

eq restore plus lubricant eye ophthalmic solution 0.5 % Refresh Tears OTC

eq restore tears ophthalmic solution 0.5 % Refresh Tears OTC eq revive plus lubricant eye ophthalmic solution 0.5 % Refresh Tears OTC

gnp lubricating plus eye drops ophthalmic solution 0.5 % Refresh Tears OTC

goodsense lubricating eye drop ophthalmic solution 0.5 % Refresh Tears OTC; QLL (15 EA per 30 days)

hm lubricating plus ophthalmic solution 0.5 % Refresh Tears OTC liquitears ophthalmic solution 1.4 % OTC lubricant eye drops ophthalmic solution 0.5 % Refresh Tears OTC lubricant eye drops ophthalmic solution 0.6 % Systane Balance OTC lubricating plus eye drops ophthalmic solution 0.5 % Refresh Tears OTC

polyvinyl alcohol ophthalmic solution 1.4 % ra lubricant eye drops ophthalmic solution 0.6 % Systane Balance OTC; QLL (10 ML per 30 days)

revive tears ophthalmic solution 0.5 % Refresh Tears OTC sm lubricating plus ophthalmic solution 0.5 % Refresh Tears OTC BIOLLE TEARS OPHTHALMIC SOLUTION 0.5 % Revive Tears OTC

223

Formulary Drug Name Reference Restrictions EQ REVIVE PLUS OPHTHALMIC SOLUTION 0.5 % Revive Tears OTC

REFRESH CELLUVISC OPHTHALMIC SOLUTION 1 % OTC

REFRESH LIQUIGEL OPHTHALMIC SOLUTION 1 % OTC

RETAINE CMC OPHTHALMIC SOLUTION 0.5 % Revive Tears OTC

THERATEARS OPHTHALMIC SOLUTION 0.25 % OTC

ULTRA FRESH OPHTHALMIC SOLUTION 0.5 % Revive Tears OTC

*Beta-Blockers - Ophthalmic Combinations*** dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml Cosopt

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %

*Beta-Blockers - Ophthalmic*** betaxolol hcl ophthalmic solution 0.5 % carteolol hcl ophthalmic solution 1 % levobunolol hcl ophthalmic solution 0.5 % Betagan metipranolol ophthalmic solution 0.3 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % Timoptic-XE

timolol maleate ophthalmic solution 0.25 %, 0.5 % Timoptic

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

*Cycloplegic Mydriatics*** atropine sulfate ophthalmic ointment 1 % atropine sulfate ophthalmic solution 1 % cyclopentolate hcl ophthalmic solution 1 %, 2 % Cyclogyl QLL (3 ML per 30 days)

homatropine hbr ophthalmic solution 5 % Homatropaire tropicamide ophthalmic solution 0.5 % QLL (15 ML per 30 days) tropicamide ophthalmic solution 1 % Mydriacyl QLL (15 ML per 30 days) HOMATROPAIRE OPHTHALMIC SOLUTION 5 % Homatropine HBr

224

Formulary Drug Name Reference Restrictions *Miotics - Cholinesterase Inhibitors*** PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

*Miotics - Direct Acting*** pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % Isopto Carpine

*Ophthalmic Antiallergic*** allergy eye drops ophthalmic solution 0.025 % Alaway OTC azelastine hcl ophthalmic solution 0.05 % cromolyn sodium ophthalmic solution 4 % cvs allergy eye drops ophthalmic solution 0.025 % Alaway OTC

cvs eye itch relief ophthalmic solution 0.025 % Alaway OTC epinastine hcl ophthalmic solution 0.05 % Elestat eq eye itch relief ophthalmic solution 0.025 % Alaway OTC eq itchy eye drops ophthalmic solution 0.025 % Alaway OTC

eye itch relief ophthalmic solution 0.025 % Alaway OTC gnp eye itch relief ophthalmic solution 0.025 % Alaway OTC

gnp itchy eye ophthalmic solution 0.025 % Alaway OTC hm eye itch relief ophthalmic solution 0.025 % Alaway OTC ketotifen fumarate ophthalmic solution 0.025 % Alaway

kp ketotifen fumarate ophthalmic solution 0.025 % Alaway OTC

olopatadine hcl ophthalmic solution 0.1 % Patanol ra antihistamine eye drops ophthalmic solution 0.025 % Alaway OTC

ra eye itch relief ophthalmic solution 0.025 % Alaway OTC sm eye itch relief ophthalmic solution 0.025 % Alaway OTC tgt eye itch relief ophthalmic solution 0.025 % Alaway OTC ALAWAY CHILDRENS ALLERGY OPHTHALMIC SOLUTION 0.025 % Ketotifen Fumarate OTC

ALAWAY OPHTHALMIC SOLUTION 0.025 % Ketotifen Fumarate OTC

CLARITIN EYE OPHTHALMIC SOLUTION 0.025 % Ketotifen Fumarate OTC

PATADAY OPHTHALMIC SOLUTION 0.2 % Olopatadine HCl

225

Formulary Drug Name Reference Restrictions PAZEO OPHTHALMIC SOLUTION 0.7 % THERATEARS ALLERGY OPHTHALMIC SOLUTION 0.025 % Ketotifen Fumarate OTC

WAL-ZYR OPHTHALMIC SOLUTION 0.025 % Ketotifen Fumarate OTC

ZADITOR OPHTHALMIC SOLUTION 0.025 % Ketotifen Fumarate OTC

*Ophthalmic Antibiotics*** bacitracin ophthalmic ointment 500 unit/gm ciprofloxacin hcl ophthalmic solution 0.3 % Ciloxan erythromycin ophthalmic ointment 5 mg/gm gatifloxacin ophthalmic solution 0.5 % Zymaxid gentamicin sulfate ophthalmic ointment 0.3 % Gentak gentamicin sulfate ophthalmic solution 0.3 % levofloxacin ophthalmic solution 0.5 % ofloxacin ophthalmic solution 0.3 % Ocuflox tobramycin ophthalmic solution 0.3 % Tobrex CILOXAN OPHTHALMIC OINTMENT 0.3 % GENTAK OPHTHALMIC OINTMENT 0.3 % Gentamicin Sulfate

MOXEZA OPHTHALMIC SOLUTION 0.5 % TOBREX OPHTHALMIC OINTMENT 0.3 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % Moxifloxacin HCl

*Ophthalmic Antifungal*** NATACYN OPHTHALMIC SUSPENSION 5 %

*Ophthalmic Anti-Infective Combinations*** ak-poly-bac ophthalmic ointment 500-10000 unit/gm Polycin

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm Polycin

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000 Neo-Polycin

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025 Neosporin

226

Formulary Drug Name Reference Restrictions polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-% Polytrim

NEO-POLYCIN OPHTHALMIC OINTMENT 3.5-400-10000 Triple Antibiotic

POLYCIN OPHTHALMIC OINTMENT 500-10000 UNIT/GM AK-Poly-Bac

*Ophthalmic Antivirals*** trifluridine ophthalmic solution 1 % Viroptic QLL (10 ML per 30 days)

*Ophthalmic Carbonic Anhydrase Inhibitors*** dorzolamide hcl ophthalmic solution 2 % Trusopt AZOPT OPHTHALMIC SUSPENSION 1 %

*Ophthalmic Decongestants*** phenylephrine hcl ophthalmic solution 10 %, 2.5 % Altafrin

ALTAFRIN OPHTHALMIC SOLUTION 10 %, 2.5 % Phenylephrine HCl

*Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** diclofenac sodium ophthalmic solution 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % Ocufen

ketorolac tromethamine ophthalmic solution 0.4 % Acular LS

ketorolac tromethamine ophthalmic solution 0.5 % Acular

*Ophthalmic Selective Alpha Adrenergic Agonists*** brimonidine tartrate ophthalmic solution 0.15 % Alphagan P

brimonidine tartrate ophthalmic solution 0.2 % ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % Brimonidine Tartrate

*Ophthalmic Steroid Combinations*** bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % Neo-Polycin HC

227

Formulary Drug Name Reference Restrictions neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1 Maxitrol

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 Maxitrol

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 sulfacetamide-prednisolone ophthalmic solution 10-0.23 % tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % TobraDex

NEO-POLYCIN HC OPHTHALMIC OINTMENT 1 %

Bacitra-Neomycin-Polymyxin-HC

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % Tobramycin-Dexamethasone

*Ophthalmic Steroids*** dexamethasone sodium phosphate ophthalmic solution 0.1 % fluorometholone ophthalmic suspension 0.1 % FML Liquifilm prednisolone acetate ophthalmic suspension 1 % Omnipred

prednisolone sodium phosphate ophthalmic solution 1 % DUREZOL OPHTHALMIC EMULSION 0.05 % FML FORTE OPHTHALMIC SUSPENSION 0.25 % PRED MILD OPHTHALMIC SUSPENSION 0.12 %

*Ophthalmic Sulfonamides*** sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % Bleph-10

*Prostaglandins - Ophthalmic*** latanoprost ophthalmic solution 0.005 % Xalatan TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

*OTIC AGENTS* *Otic Agents - Miscellaneous*** acetic acid otic solution 2 %

228

Formulary Drug Name Reference Restrictions acetic acid-aluminum acetate otic solution 2 %

*Otic Analgesic Combinations*** exotic-hc otic solution 10-10-1 mg/ml Cortic-ND otomax-hc otic solution 10-10-1 mg/ml Cortic-ND CORTIC-ND OTIC SOLUTION 10-10-1 MG/ML Exotic-HC

CYOTIC OTIC SOLUTION 10-10-1 MG/ML Exotic-HC

*Otic Anti-Infectives*** ciprofloxacin hcl otic solution 0.2 % Cetraxal ofloxacin otic solution 0.3 % Floxin Otic

*Otic Steroid-Anti-Infective Combinations*** neomycin-polymyxin-hc otic solution 1 %, 3.5 -10000-1 Cortisporin

neomycin-polymyxin-hc otic suspension 3.5 -10000-1 CIPRODEX OTIC SUSPENSION 0.3-0.1 %

*Otic Steroids*** hydrocortisone-acetic acid otic solution 1-2 % Acetasol HC ACETASOL HC OTIC SOLUTION 2-1 % Hydrocortisone-Acetic Acid

*PASSIVE IMMUNIZING AGENTS* *Antiviral Monoclonal Antibodies*** SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5ML PA; QLL (1 ML per 26 days)

*Immune Serums*** HEPAGAM B INJECTION SOLUTION HYPERHEP B S/D INTRAMUSCULAR SOLUTION HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT, 250 UNIT MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT NABI-HB INTRAMUSCULAR SOLUTION

229

Formulary Drug Name Reference Restrictions RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE 1500 UNIT/2ML QLL (2 ML per 1 Year)

*PENICILLINS* *Aminopenicillins*** amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 125 mg, 250 mg ampicillin oral capsule 250 mg, 500 mg

*Natural Penicillins*** penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg

*Penicillin Combinations*** amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1000-62.5 mg Augmentin XR QLL (28 EA per 30 days)

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml amoxicillin-pot clavulanate oral suspension reconstituted 250-62.5 mg/5ml Augmentin

amoxicillin-pot clavulanate oral suspension reconstituted 600-42.9 mg/5ml Augmentin ES-600

amoxicillin-pot clavulanate oral tablet 250 -125 mg QLL (28 EA per 30 days)

amoxicillin-pot clavulanate oral tablet 500 -125 mg, 875-125 mg Augmentin QLL (28 EA per 30 days)

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg QLL (28 EA per 30 days)

*Penicillinase-Resistant Penicillins*** dicloxacillin sodium oral capsule 250 mg, 500 mg

230

Formulary Drug Name Reference Restrictions *PHARMACEUTICAL ADJUVANTS* *Antimicrobial Agents*** benzyl alcohol liquid

*Flavoring Agents*** almond oil bitter flavor liquid PCCA Sweetness Enhancer anise extract liquid PCCA Sweetness Enhancer apple flavor liquid PCCA Sweetness Enhancer apricot flavor liquid PCCA Sweetness Enhancer bacon flavor liquid PCCA Sweetness Enhancer banana concentrate liquid PCCA Sweetness Enhancer banana cream flavor liquid PCCA Sweetness Enhancer banana creme flavor liquid PCCA Sweetness Enhancer banana flavor liquid PCCA Sweetness Enhancer beef (grilled) flavor oil sol liquid PCCA Sweetness Enhancer OTC beef flavor liquid PCCA Sweetness Enhancer beef type flavor natural liquid PCCA Sweetness Enhancer bitter stop flavor liquid PCCA Sweetness Enhancer bitterness mask flavor liquid PCCA Sweetness Enhancer bitterness suppressor flavor liquid PCCA Sweetness Enhancer blackberry flavor liquid PCCA Sweetness Enhancer blueberry flavor liquid PCCA Sweetness Enhancer bubble gum concentrate liquid PCCA Sweetness Enhancer bubble gum flavor liquid PCCA Sweetness Enhancer butter flavor liquid PCCA Sweetness Enhancer butter rum flavor liquid PCCA Sweetness Enhancer butterscotch flavor liquid PCCA Sweetness Enhancer caramel flavor liquid PCCA Sweetness Enhancer cheesecake flavor liquid PCCA Sweetness Enhancer cherry flavor liquid PCCA Sweetness Enhancer chicken (grilled) flavor liquid PCCA Sweetness Enhancer OTC chicken flavor liquid PCCA Sweetness Enhancer OTC chicken flavor oil miscible liquid PCCA Sweetness Enhancer OTC chicken flavor oil soluble liquid PCCA Sweetness Enhancer chicken flavor water miscible liquid PCCA Sweetness Enhancer chicken roasted concentrate liquid PCCA Sweetness Enhancer OTC chocolate flavor liquid PCCA Sweetness Enhancer chocolate hazelnut flavor liquid PCCA Sweetness Enhancer

231

Formulary Drug Name Reference Restrictions coconut flavor liquid PCCA Sweetness Enhancer coffee flavor liquid PCCA Sweetness Enhancer cola flavor liquid PCCA Sweetness Enhancer cotton candy flavor liquid PCCA Sweetness Enhancer cran-raspberry flavor liquid PCCA Sweetness Enhancer creme dementhe flavor liquid PCCA Sweetness Enhancer english toffee flavor liquid PCCA Sweetness Enhancer eugenol flavor liquid PCCA Sweetness Enhancer fish flavor liquid PCCA Sweetness Enhancer grape flavor liquid PCCA Sweetness Enhancer guava flavor liquid PCCA Sweetness Enhancer ham flavor liquid PCCA Sweetness Enhancer honey flavor liquid PCCA Sweetness Enhancer kahlua flavor liquid PCCA Sweetness Enhancer lemon extract liquid PCCA Sweetness Enhancer lemon flavor liquid PCCA Sweetness Enhancer OTC licorice flavor liquid PCCA Sweetness Enhancer liver concentrate liquid PCCA Sweetness Enhancer OTC liver flavor liquid PCCA Sweetness Enhancer mango flavor liquid PCCA Sweetness Enhancer maple flavor liquid PCCA Sweetness Enhancer marshmallow flavor liquid PCCA Sweetness Enhancer mint chocolate chip flavor liquid PCCA Sweetness Enhancer orange concentrate liquid PCCA Sweetness Enhancer OTC orange cream flavor liquid PCCA Sweetness Enhancer orange flavor liquid PCCA Sweetness Enhancer orange oil flavor liquid PCCA Sweetness Enhancer peach flavor liquid PCCA Sweetness Enhancer peanut butter flavor liquid PCCA Sweetness Enhancer pina colada flavor liquid PCCA Sweetness Enhancer pineapple flavor liquid PCCA Sweetness Enhancer pralines and cream flavor liquid PCCA Sweetness Enhancer pumpkin flavor liquid PCCA Sweetness Enhancer raspberry flavor liquid PCCA Sweetness Enhancer root beer flavor liquid PCCA Sweetness Enhancer sardine flavor liquid PCCA Sweetness Enhancer OTC shrimp flavor liquid PCCA Sweetness Enhancer stevia glycerite extract liquid PCCA Sweetness Enhancer

232

Formulary Drug Name Reference Restrictions strawberry flavor liquid PCCA Sweetness Enhancer sweetening enhancer liquid PCCA Sweetness Enhancer OTC tropical punch flavor liquid PCCA Sweetness Enhancer tuna flavor liquid PCCA Sweetness Enhancer OTC tutti frutti flavor liquid PCCA Sweetness Enhancer tutti-frutti flavor liquid PCCA Sweetness Enhancer vanilla butternut flavor liquid PCCA Sweetness Enhancer vanilla flavor liquid PCCA Sweetness Enhancer watermelon flavor liquid PCCA Sweetness Enhancer wild cherry flavor liquid PCCA Sweetness Enhancer FLAVORX LIQUID Banana Concentrate OTC PCCA SWEETNESS ENHANCER LIQUID Banana Concentrate

*Gelatin Capsules (Empty)*** capsule coni-snap #1 pink capsule DRcaps Size 1 capsule coni-snap #0 blu/white capsule DRcaps Size 1 capsule coni-snap #0 clear capsule DRcaps Size 1 capsule coni-snap #0 dark blue capsule DRcaps Size 1 capsule coni-snap #0 green/clr capsule DRcaps Size 1 capsule coni-snap #0 pink capsule DRcaps Size 1 capsule coni-snap #0 red/white capsule DRcaps Size 1 capsule coni-snap #0 white capsule DRcaps Size 1 capsule coni-snap #00 clear capsule DRcaps Size 1 capsule coni-snap #00 white capsule DRcaps Size 1 capsule coni-snap #000 clear capsule DRcaps Size 1 capsule coni-snap #1 aqua blue capsule DRcaps Size 1 capsule coni-snap #1 blue capsule DRcaps Size 1 capsule coni-snap #1 blue/pink capsule DRcaps Size 1 capsule coni-snap #1 blue/wht capsule DRcaps Size 1 capsule coni-snap #1 brown capsule DRcaps Size 1 capsule coni-snap #1 brwn/ivry capsule DRcaps Size 1 capsule coni-snap #1 clear capsule DRcaps Size 1 capsule coni-snap #1 dk grn/or capsule DRcaps Size 1 capsule coni-snap #1 drk green capsule DRcaps Size 1 capsule coni-snap #1 grey/pink capsule DRcaps Size 1 capsule coni-snap #1 grn/ylw capsule DRcaps Size 1 capsule coni-snap #1 orange capsule DRcaps Size 1 capsule coni-snap #1 pink/blue capsule DRcaps Size 1

233

Formulary Drug Name Reference Restrictions capsule coni-snap #1 pink/clr capsule DRcaps Size 1 capsule coni-snap #1 pink/whit capsule DRcaps Size 1 capsule coni-snap #1 pink/yllw capsule DRcaps Size 1 capsule coni-snap #1 purple capsule DRcaps Size 1 capsule coni-snap #1 red/blue capsule DRcaps Size 1 capsule coni-snap #1 red/white capsule DRcaps Size 1 capsule coni-snap #1 white capsule DRcaps Size 1 capsule coni-snap #1 white/grn capsule DRcaps Size 1 capsule coni-snap #1 wht/clr capsule DRcaps Size 1 capsule coni-snap #1 yellow capsule DRcaps Size 1 capsule coni-snap #1 yellow/gr capsule DRcaps Size 1 capsule coni-snap #2 clear capsule DRcaps Size 1 capsule coni-snap #2 white capsule DRcaps Size 1 capsule coni-snap #3 blu/clear capsule DRcaps Size 1 capsule coni-snap #3 brn/blue capsule DRcaps Size 1 capsule coni-snap #3 gray/ylw capsule DRcaps Size 1 capsule coni-snap #3 green/blu capsule DRcaps Size 1 capsule coni-snap #3 grey/pink capsule DRcaps Size 1 capsule coni-snap #3 maron/blu capsule DRcaps Size 1 capsule coni-snap #3 mint grn capsule DRcaps Size 1 capsule coni-snap #3 olive/clr capsule DRcaps Size 1 capsule coni-snap #3 orange capsule DRcaps Size 1 capsule coni-snap #3 pink/pink capsule DRcaps Size 1 capsule coni-snap #3 pnk/clear capsule DRcaps Size 1 capsule coni-snap #3 red/clear capsule DRcaps Size 1 capsule coni-snap #3 red/red capsule DRcaps Size 1 capsule coni-snap #3 white capsule DRcaps Size 1 capsule coni-snap #3 wht/clr capsule DRcaps Size 1 capsule coni-snap #3 yellow capsule DRcaps Size 1 capsule coni-snap #4 black/grn capsule DRcaps Size 1 capsule coni-snap #4 clear capsule DRcaps Size 1 capsule coni-snap #4 white capsule DRcaps Size 1 capsule size 1 lactose capsule DRcaps Size 1 OTC empty capsule #0 red/white capsule DRcaps Size 1 OTC empty capsule #00 black/red capsule DRcaps Size 1 OTC empty capsule #00 blue/white capsule DRcaps Size 1 OTC empty capsule #00 pink/pink capsule DRcaps Size 1 OTC empty capsule #00 purple capsule DRcaps Size 1 OTC

234

Formulary Drug Name Reference Restrictions empty capsule #00 purple/white capsule DRcaps Size 1 OTC empty capsule #00 red/white capsule DRcaps Size 1 OTC empty capsule #00 yellow/yello capsule DRcaps Size 1 OTC empty capsule capsule DRcaps Size 1 OTC empty capsule size 0 blue capsule DRcaps Size 1 OTC empty capsule size 0 blue/wht capsule DRcaps Size 1 OTC empty capsule size 0 capsule DRcaps Size 1 OTC empty capsule size 0 clear capsule DRcaps Size 1 OTC empty capsule size 0 fun caps capsule DRcaps Size 1 OTC empty capsule size 0 green capsule DRcaps Size 1 OTC empty capsule size 0 green/clr capsule DRcaps Size 1 OTC empty capsule size 0 grn/clear capsule DRcaps Size 1 OTC empty capsule size 0 maroon capsule DRcaps Size 1 OTC empty capsule size 0 orange capsule DRcaps Size 1 OTC empty capsule size 0 pink capsule DRcaps Size 1 empty capsule size 0 purp/wht capsule DRcaps Size 1 empty capsule size 0 purple capsule DRcaps Size 1 empty capsule size 0 red capsule DRcaps Size 1 OTC empty capsule size 0 red/clear capsule DRcaps Size 1 OTC empty capsule size 0 red/white capsule DRcaps Size 1 OTC empty capsule size 0 white capsule DRcaps Size 1 OTC empty capsule size 0 white/clr capsule DRcaps Size 1 OTC empty capsule size 0 yellow capsule DRcaps Size 1 OTC empty capsule size 00 blue capsule DRcaps Size 1 OTC empty capsule size 00 blue opq capsule DRcaps Size 1 empty capsule size 00 clear capsule DRcaps Size 1 empty capsule size 00 drk grn capsule DRcaps Size 1 OTC empty capsule size 00 green capsule DRcaps Size 1 OTC empty capsule size 00 orange capsule DRcaps Size 1 OTC empty capsule size 00 red capsule DRcaps Size 1 OTC empty capsule size 00 white capsule DRcaps Size 1 OTC empty capsule size 000 clear capsule DRcaps Size 1 OTC empty capsule size 000 white capsule DRcaps Size 1 OTC empty capsule size 1 aqua blue capsule DRcaps Size 1 OTC empty capsule size 1 blue capsule DRcaps Size 1 OTC empty capsule size 1 blue/pink capsule DRcaps Size 1 OTC empty capsule size 1 blue/red capsule DRcaps Size 1 OTC empty capsule size 1 blue/wht capsule DRcaps Size 1 OTC

235

Formulary Drug Name Reference Restrictions empty capsule size 1 blueclear capsule DRcaps Size 1 OTC empty capsule size 1 brn/ivory capsule DRcaps Size 1 empty capsule size 1 clear capsule DRcaps Size 1 empty capsule size 1 drk green capsule DRcaps Size 1 empty capsule size 1 green capsule DRcaps Size 1 OTC empty capsule size 1 grey/pink capsule DRcaps Size 1 empty capsule size 1 grn/ornge capsule DRcaps Size 1 empty capsule size 1 grn/white capsule DRcaps Size 1 empty capsule size 1 grn/yllw capsule DRcaps Size 1 empty capsule size 1 ivory capsule DRcaps Size 1 empty capsule size 1 lght blue capsule DRcaps Size 1 OTC empty capsule size 1 maroon/cl capsule DRcaps Size 1 empty capsule size 1 mint grn capsule DRcaps Size 1 empty capsule size 1 orange capsule DRcaps Size 1 empty capsule size 1 orge/clr capsule DRcaps Size 1 empty capsule size 1 orge/yllw capsule DRcaps Size 1 empty capsule size 1 ornge/wht capsule DRcaps Size 1 OTC empty capsule size 1 pink capsule DRcaps Size 1 empty capsule size 1 pink/blue capsule DRcaps Size 1 OTC empty capsule size 1 pink/clr capsule DRcaps Size 1 empty capsule size 1 pink/yllw capsule DRcaps Size 1 empty capsule size 1 pnk/white capsule DRcaps Size 1 empty capsule size 1 purple capsule DRcaps Size 1 OTC empty capsule size 1 pwdr blue capsule DRcaps Size 1 empty capsule size 1 red capsule DRcaps Size 1 empty capsule size 1 red/blue capsule DRcaps Size 1 empty capsule size 1 red/white capsule DRcaps Size 1 empty capsule size 1 white capsule DRcaps Size 1 empty capsule size 1 wht/clear capsule DRcaps Size 1 empty capsule size 1 yellow capsule DRcaps Size 1 empty capsule size 10 clear capsule DRcaps Size 1 OTC empty capsule size 11 clear capsule DRcaps Size 1 OTC empty capsule size 13 clear capsule DRcaps Size 1 OTC empty capsule size 2 blue capsule DRcaps Size 1 OTC empty capsule size 2 clear capsule DRcaps Size 1 empty capsule size 2 green capsule DRcaps Size 1 OTC empty capsule size 2 white capsule DRcaps Size 1 OTC empty capsule size 3 black/grn capsule DRcaps Size 1

236

Formulary Drug Name Reference Restrictions empty capsule size 3 blue capsule DRcaps Size 1 OTC empty capsule size 3 blue opq capsule DRcaps Size 1 empty capsule size 3 blue/clr capsule DRcaps Size 1 empty capsule size 3 blue/wht capsule DRcaps Size 1 empty capsule size 3 clear capsule DRcaps Size 1 empty capsule size 3 dark grn capsule DRcaps Size 1 empty capsule size 3 gray/pink capsule DRcaps Size 1 OTC empty capsule size 3 gray/yllw capsule DRcaps Size 1 OTC empty capsule size 3 green capsule DRcaps Size 1 OTC empty capsule size 3 grey/pink capsule DRcaps Size 1 empty capsule size 3 grey/yllw capsule DRcaps Size 1 empty capsule size 3 grn/blue capsule DRcaps Size 1 empty capsule size 3 marn/blue capsule DRcaps Size 1 empty capsule size 3 marn/clr capsule DRcaps Size 1 empty capsule size 3 maroon capsule DRcaps Size 1 OTC empty capsule size 3 mint grn capsule DRcaps Size 1 empty capsule size 3 olive capsule DRcaps Size 1 OTC empty capsule size 3 olive/clr capsule DRcaps Size 1 empty capsule size 3 orange capsule DRcaps Size 1 empty capsule size 3 orange/wh capsule DRcaps Size 1 empty capsule size 3 pink capsule DRcaps Size 1 empty capsule size 3 pink/blue capsule DRcaps Size 1 empty capsule size 3 pink/wh capsule DRcaps Size 1 empty capsule size 3 pink/yllw capsule DRcaps Size 1 empty capsule size 3 pnk/clear capsule DRcaps Size 1 empty capsule size 3 prple/clr capsule DRcaps Size 1 empty capsule size 3 purple capsule DRcaps Size 1 empty capsule size 3 pwdr blue capsule DRcaps Size 1 empty capsule size 3 red capsule DRcaps Size 1 empty capsule size 3 red/clear capsule DRcaps Size 1 empty capsule size 3 red/white capsule DRcaps Size 1 empty capsule size 3 white capsule DRcaps Size 1 empty capsule size 3 white/clr capsule DRcaps Size 1 empty capsule size 3 yellow capsule DRcaps Size 1 empty capsule size 3 yellw/clr capsule DRcaps Size 1 empty capsule size 4 black capsule DRcaps Size 1 OTC empty capsule size 4 blue/whit capsule DRcaps Size 1 OTC empty capsule size 4 clear capsule DRcaps Size 1

237

Formulary Drug Name Reference Restrictions empty capsule size 4 dark blue capsule DRcaps Size 1 OTC empty capsule size 4 purple capsule DRcaps Size 1 empty capsule size 4 red/white capsule DRcaps Size 1 empty capsule size 4 white capsule DRcaps Size 1 empty capsule size 4 yellow capsule DRcaps Size 1 empty capsule size 5 clear capsule DRcaps Size 1 empty capsule size 7 clear capsule DRcaps Size 1 DRCAPS SIZE 0 CAPSULE Empty Capsule Size 0 Clear DRCAPS SIZE 00 CAPSULE Empty Capsule Size 0 Clear DRCAPS SIZE 1 CAPSULE Empty Capsule Size 0 Clear

*Non Gelatin Capsules (Empty)*** capsule 0 clear dr capsule AR Caps #1 Acid Resistant capsule 0 clear veggie capsule AR Caps #1 Acid Resistant capsule 00 clear veggie capsule AR Caps #1 Acid Resistant OTC capsule 1 clear veggie capsule AR Caps #1 Acid Resistant OTC capsule 3 clear veggie capsule AR Caps #1 Acid Resistant OTC capsule coni-snap #1 veggie capsule AR Caps #1 Acid Resistant capsule coni-snap #3 clear capsule AR Caps #1 Acid Resistant empty capsule size 1 veg clear capsule AR Caps #1 Acid Resistant vegetable capsule #0 green capsule AR Caps #1 Acid Resistant vegetable capsule #0 white capsule AR Caps #1 Acid Resistant vegetable capsule #00 white capsule AR Caps #1 Acid Resistant vegetable capsule #1 white capsule AR Caps #1 Acid Resistant vegetable capsule #2 white capsule AR Caps #1 Acid Resistant vegetable capsule #3 white capsule AR Caps #1 Acid Resistant vegetable capsule #4 white capsule AR Caps #1 Acid Resistant AR CAPS #1 ACID RESISTANT CAPSULE Capsule 1 Clear Veggie OTC

*Oral Vehicles*** cherry concentrate oral syrup OTC cherry oral syrup flavor plus oral liquid Ora-Plus flavor sweet oral syrup Ora-Sweet flavor sweet-sf oral syrup Ora-Sweet grape syrup oral syrup Ora-Sweet OTC oral suspend oral liquid Ora-Plus OTC oral syrup oral syrup Ora-Sweet OTC oral syrup sf oral syrup Ora-Sweet OTC

238

Formulary Drug Name Reference Restrictions raspberry syrup oral syrup simple syrup oral syrup solvatech plus oral suspension Ora-Blend solvatech sweet sf oral syrup Ora-Sweet sorbitol solution , 70 % suspension vehicle oral suspension Ora-Blend syrpalta oral syrup Ora-Sweet syrpalta oral syrup 85 % syrup nf oral syrup 85 % OTC syrup vehicle oral syrup Ora-Sweet syrup vehicle sf oral syrup Ora-Sweet FLAVOR BLEND ORAL SUSPENSION Suspension Vehicle GERBER GOOD START WATER ORAL LIQUID OTC

GOOD START STERILE WATER ORAL LIQUID OTC

MX-SOL BLEND ORAL SUSPENSION Suspension Vehicle OTC MX-SOL BLEND SF ORAL SUSPENSION Suspension Vehicle OTC

MX-SOL ORAL SYRUP Flavor Sweet OTC MX-SOL SF ORAL SYRUP Flavor Sweet OTC MX-SOL SUSPEND ORAL SUSPENSION Suspension Vehicle OTC ORA-BLEND ORAL SUSPENSION Suspension Vehicle ORA-BLEND SF ORAL SUSPENSION Suspension Vehicle ORAL MIX ORAL SUSPENSION Suspension Vehicle OTC ORAL MIX SF ORAL SUSPENSION Suspension Vehicle OTC ORA-PLUS ORAL LIQUID Flavor Plus ORA-SWEET ORAL SYRUP Flavor Sweet ORA-SWEET SF ORAL SYRUP Flavor Sweet PCCA SWEET-SF ORAL SYRUP Flavor Sweet PCCA SYRUP VEHICLE ORAL SYRUP Flavor Sweet PCCA-PLUS ORAL SUSPENSION Suspension Vehicle SIMILAC STERILIZED WATER ORAL LIQUID OTC

SYRPALTA (RED) ORAL SYRUP Flavor Sweet SYRSPEND SF ALKA ORAL SUSPENSION RECONSTITUTED OTC

SYRSPEND SF ORAL LIQUID Flavor Plus SYRSPEND SF ORAL SUSPENSION RECONSTITUTED OTC

239

Formulary Drug Name Reference Restrictions SYRSPEND SF PH4 ORAL SUSPENSION RECONSTITUTED VERSAFREE ORAL SYRUP Flavor Sweet VERSAPLUS ORAL SYRUP Flavor Sweet

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

*Pharmaceutical Excipients*** lactose monohydrate powder xanthan gum powder PCCA SORBITOL LOLLIPOP BASE FLAKES

*POTASSIUM REMOVING AGENTS*** *Potassium Removing Agents*** sodium polystyrene sulfonate oral powder Kionex sodium polystyrene sulfonate oral suspension 15 gm/60ml Kionex

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml KIONEX ORAL POWDER Sodium Polystyrene Sulfonate KIONEX ORAL SUSPENSION 15 GM/60ML Sodium Polystyrene Sulfonate

SPS ORAL SUSPENSION 15 GM/60ML Sodium Polystyrene Sulfonate

*PROGESTINS* *Progestins*** medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg Provera

megestrol acetate oral suspension 625 mg/5ml Megace ES norethindrone acetate oral tablet 5 mg Aygestin progesterone intramuscular oil 50 mg/ml progesterone micronized oral capsule 100 mg, 200 mg Prometrium

MAKENA INTRAMUSCULAR OIL 250 MG/ML

240

Formulary Drug Name Reference Restrictions *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS -MISC.* *Alcohol Deterrents*** acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 250 mg, 500 mg Antabuse

*Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet 10 -25 mg, 5-12.5 mg

*Cholinomimetics - Ache Inhibitors*** donepezil hcl oral tablet 10 mg, 5 mg Aricept donepezil hcl oral tablet dispersible 10 mg, 5 mg galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg Razadyne ER

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg Razadyne

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr Exelon

EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR

Rivastigmine

*Fibromyalgia Agent - Snris*** SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG ST

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG ST

*Ms Agents - Pyrimidine Synthesis Inhibitors*** AUBAGIO ORAL TABLET 14 MG, 7 MG

*Multiple Sclerosis Agents -Interferons*** AVONEX INTRAMUSCULAR KIT 30 MCG AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML

241

Formulary Drug Name Reference Restrictions AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML BETASERON SUBCUTANEOUS KIT 0.3 MG EXTAVIA SUBCUTANEOUS KIT 0.3 MG REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG

*Multiple Sclerosis Agents - Nrf2 Pathway Activators*** TECFIDERA ORAL 120 & 240 MG TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG

*Multiple Sclerosis Agents*** COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML

PA

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML

*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** memantine hcl oral solution 2 mg/ml Namenda memantine hcl oral tablet 10 mg, 5 mg Namenda memantine hcl oral tablet 5 (28)-10 (21) mg Namenda Titration Pak NAMENDA ORAL SOLUTION 10 MG/5ML Memantine HCl

242

Formulary Drug Name Reference Restrictions *Phenothiazines & Tricyclic Agents*** perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg AL (Min 18 Years)

*Premenstrual Dysphoric Disorder (Pmdd) Agents - Ssris*** fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg

*Smoking Deterrents*** bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg Zyban

cvs nicotine mouth/throat lozenge 2 mg Nicorette OTC cvs nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette OTC

cvs nicotine polacrilex mouth/throat lozenge 2 mg Nicorette OTC

cvs nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC

cvs nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr Nicoderm CQ OTC

cvs nts step 1 transdermal patch 24 hour 21 mg/24hr Nicoderm CQ OTC

eq nicotine mouth/throat gum 4 mg Nicorette OTC eq nicotine mouth/throat lozenge 4 mg KLS Quit4 OTC eq nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette OTC

eq nicotine polacrilex mouth/throat lozenge 2 mg Nicorette OTC

eq nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC

eq nicotine step 3 transdermal patch 24 hour 7 mg/24hr Nicoderm CQ OTC

eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr Nicoderm CQ OTC

eql nicotine mouth/throat lozenge 2 mg Nicorette OTC eql nicotine mouth/throat lozenge 4 mg KLS Quit4 OTC eql nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette OTC

eql nicotine polacrilex mouth/throat lozenge 2 mg Nicorette OTC

eql nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC

243

Formulary Drug Name Reference Restrictions gnp nicotine mini mouth/throat lozenge 2 mg Nicorette OTC gnp nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette OTC

gnp nicotine polacrilex mouth/throat lozenge 2 mg Nicorette OTC

gnp nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC

gnp nicotine transdermal patch 24 hour 7 mg/24hr Nicoderm CQ OTC

goodsense nicotine mouth/throat gum 4 mg Nicorette OTC hm nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette OTC

hm nicotine polacrilex mouth/throat lozenge 2 mg Nicorette OTC

hm nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC

hm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr Nicoderm CQ OTC

nicotine mini mouth/throat lozenge 2 mg Nicorette OTC nicotine mini mouth/throat lozenge 4 mg KLS Quit4 OTC nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette OTC

nicotine polacrilex mouth/throat lozenge 2 mg Nicorette OTC nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC nicotine step 1 transdermal patch 24 hour 21 mg/24hr Nicoderm CQ OTC

nicotine step 2 transdermal patch 24 hour 14 mg/24hr Nicoderm CQ OTC

nicotine step 3 transdermal patch 24 hour 7 mg/24hr Nicoderm CQ OTC

nicotine transdermal kit 21-14-7 mg/24hr OTC nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr Nicoderm CQ

px stop smoking aid mouth/throat gum 2 mg, 4 mg Nicorette OTC

px stop smoking aid mouth/throat lozenge 2 mg Nicorette OTC

px stop smoking aid mouth/throat lozenge 4 mg KLS Quit4 OTC

qc nicotine polacrilex mouth/throat gum 4 mg Nicorette OTC ra mini nicotine mouth/throat lozenge 2 mg Nicorette OTC ra mini nicotine mouth/throat lozenge 4 mg KLS Quit4 OTC

244

Formulary Drug Name Reference Restrictions ra nicotine gum mouth/throat gum 2 mg, 4 mg Nicorette OTC ra nicotine mouth/throat gum 2 mg, 4 mg Nicorette OTC ra nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette OTC

ra nicotine polacrilex mouth/throat lozenge 2 mg Nicorette OTC

ra nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC

ra nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr Nicoderm CQ OTC

sm nicotine mouth/throat gum 4 mg Nicorette OTC sm nicotine mouth/throat lozenge 2 mg Nicorette OTC sm nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette OTC

sm nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC

sm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr Nicoderm CQ OTC

sr nicotine mouth/throat gum 2 mg Nicorette OTC sw nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette OTC

sw nicotine polacrilex mouth/throat lozenge 2 mg Nicorette OTC

sw nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC

tgt nicotine mouth/throat gum 2 mg, 4 mg Nicorette OTC tgt nicotine polacrilex mouth/throat gum 2 mg, 4 mg Nicorette OTC

tgt nicotine polacrilex mouth/throat lozenge 2 mg Nicorette OTC

tgt nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC

tgt nicotine step one transdermal patch 24 hour 21 mg/24hr Nicoderm CQ OTC

tgt nicotine step three transdermal patch 24 hour 7 mg/24hr Nicoderm CQ OTC

tgt nicotine step two transdermal patch 24 hour 14 mg/24hr Nicoderm CQ OTC

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG

245

Formulary Drug Name Reference Restrictions CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 KLS QUIT2 MOUTH/THROAT GUM 2 MG RA Nicotine OTC

KLS QUIT2 MOUTH/THROAT LOZENGE 2 MG SW Nicotine Polacrilex OTC

KLS QUIT4 MOUTH/THROAT GUM 4 MG RA Nicotine Gum OTC

KLS QUIT4 MOUTH/THROAT LOZENGE 4 MG CVS Nicotine Polacrilex OTC

NICORELIEF MOUTH/THROAT GUM 2 MG RA Nicotine OTC

NICORELIEF MOUTH/THROAT GUM 4 MG RA Nicotine Gum OTC

THRIVE MOUTH/THROAT GUM 2 MG RA Nicotine OTC

*Sphingosine 1-Phosphate (S1p) Receptor Modulators*** GILENYA ORAL CAPSULE 0.5 MG

*Thienbenzodiazepines & Ssris*** olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg Symbyax AL (Min 18 Years)

*RESPIRATORY AGENTS -MISC.* *Hydrolytic Enzymes*** PULMOZYME INHALATION SOLUTION 1 MG/ML PA; QLL (150 ML per 30 days)

*SEROTONIN MODULATORS*** *Serotonin Modulators*** trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

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

*TETRACYCLINES* *Tetracyclines*** avidoxy oral tablet 100 mg demeclocycline hcl oral tablet 150 mg, 300 mg doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral capsule 100 mg Monodox

246

Formulary Drug Name Reference Restrictions doxycycline monohydrate oral capsule 50 mg Mondoxyne NL doxycycline monohydrate oral suspension reconstituted 25 mg/5ml Vibramycin

doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline hcl oral capsule 100 mg, 50 mg Minocin minocycline hcl oral capsule 75 mg MONDOXYNE NL ORAL CAPSULE 100 MG, 50 MG Doxycycline Monohydrate

*THYROID AGENTS* *Antithyroid Agents*** methimazole oral tablet 10 mg, 5 mg Tapazole propylthiouracil oral tablet 50 mg

*Thyroid Hormones*** levothyroxine sodium oral tablet 100 mcg, 112 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 75 mcg

Unithroid Direct QLL (30 EA per 30 days)

levothyroxine sodium oral tablet 125 mcg, 137 mcg, 50 mcg, 88 mcg Levoxyl QLL (30 EA per 30 days)

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg Cytomel

np thyroid oral tablet 30 mg, 60 mg, 90 mg Armour Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 15 MG NP Thyroid

ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Levothyroxine Sodium

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG


NATURE-THROID ORAL TABLET 130 MG UNITHROID DIRECT ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG


247

Formulary Drug Name Reference Restrictions UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG


WESTHROID ORAL TABLET 130 MG WP THYROID ORAL TABLET 130 MG

*ULCER DRUGS* *Antispasmodics*** dicyclomine hcl oral capsule 10 mg Bentyl dicyclomine hcl oral solution 10 mg/5ml dicyclomine hcl oral tablet 20 mg Bentyl

*Belladonna Alkaloids*** ed-spaz oral tablet dispersible 0.125 mg Anaspaz hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg Symax-SR

hyoscyamine sulfate oral elixir 0.125 mg/5ml hyoscyamine sulfate oral solution 0.125 mg/ml hyoscyamine sulfate oral tablet 0.125 mg Levsin hyoscyamine sulfate oral tablet dispersible 0.125 mg Anaspaz

hyoscyamine sulfate sublingual tablet sublingual 0.125 mg Symax-SL

hyosyne oral elixir 0.125 mg/5ml hyosyne oral solution 0.125 mg/ml oscimin oral tablet 0.125 mg Levsin oscimin oral tablet dispersible 0.125 mg Anaspaz oscimin sr oral tablet extended release 12 hour 0.375 mg Symax-SR

oscimin sublingual tablet sublingual 0.125 mg Symax-SL NULEV ORAL TABLET DISPERSIBLE 0.125 MG Oscimin

SYMAX-SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG Oscimin

SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HOUR 0.375 MG Hyoscyamine Sulfate ER

*H-2 Antagonists*** acid control maximum strength oral tablet 150 mg Zantac OTC

acid control maximum strength oral tablet 20 mg Pepcid AC Maximum Strength OTC

acid control oral tablet 150 mg Zantac OTC

248

Formulary Drug Name Reference Restrictions acid controller max st oral tablet 20 mg Pepcid AC Maximum Strength OTC acid controller oral tablet 10 mg Pepcid AC OTC acid reducer maximum strength oral tablet 150 mg Zantac OTC

acid reducer maximum strength oral tablet 20 mg Pepcid AC Maximum Strength OTC

acid reducer oral tablet 10 mg Pepcid AC OTC acid reducer oral tablet 150 mg Zantac OTC acid reducer oral tablet 75 mg Zantac 75 OTC cimetidine 200 oral tablet 200 mg Tagamet HB OTC cimetidine acid reducer oral tablet 200 mg Tagamet HB OTC cimetidine hcl oral solution 300 mg/5ml cimetidine oral tablet 200 mg Tagamet HB cimetidine oral tablet 300 mg, 400 mg, 800 mg cvs acid controller max st oral tablet 20 mg Pepcid AC Maximum Strength OTC cvs acid reducer max st oral tablet 150 mg Zantac OTC cvs acid reducer oral tablet 10 mg Pepcid AC OTC cvs heartburn relief oral tablet 200 mg Tagamet HB OTC cvs ranitidine oral tablet 75 mg Zantac 75 OTC eq acid reducer max st oral tablet 20 mg Pepcid AC Maximum Strength OTC eq acid reducer oral tablet 10 mg Pepcid AC OTC eq acid reducer oral tablet 150 mg Zantac OTC eq acid reducer oral tablet 200 mg Tagamet HB OTC eq acid reducer oral tablet 75 mg Zantac 75 OTC eq heartburn relief oral tablet 200 mg Tagamet HB OTC eq ranitidine oral tablet 75 mg Zantac 75 OTC eql acid reducer oral tablet 150 mg Zantac OTC eql acid reducer oral tablet 75 mg Zantac 75 OTC eql heartburn prevention oral tablet 10 mg Pepcid AC OTC eql heartburn prevention oral tablet 20 mg Pepcid AC Maximum Strength OTC eql heartburn relief max st oral tablet 150 mg Zantac OTC famotidine oral suspension reconstituted 40 mg/5ml Pepcid

famotidine oral tablet 10 mg Pepcid AC OTC famotidine oral tablet 20 mg Pepcid AC Maximum Strength famotidine oral tablet 40 mg Pepcid gnp acid control 150 max st oral tablet 150 mg Zantac OTC

gnp acid control 75 oral tablet 75 mg Zantac 75 OTC

249

Formulary Drug Name Reference Restrictions gnp acid reducer max st oral tablet 20 mg Pepcid AC Maximum Strength OTC gnp acid reducer oral tablet 10 mg Pepcid AC OTC gnp acid reducer oral tablet 75 mg Zantac 75 OTC gnp heartburn relief 200 oral tablet 200 mg Tagamet HB OTC gnp heartburn relief oral tablet 200 mg Tagamet HB OTC goodsense acid reducer oral tablet 150 mg Zantac OTC goodsense acid reducer oral tablet 75 mg Zantac 75 OTC heartburn relief 150 max st oral tablet 150 mg Zantac OTC heartburn relief max st oral tablet 150 mg Zantac OTC heartburn relief max st oral tablet 20 mg Pepcid AC Maximum Strength OTC heartburn relief oral tablet 10 mg Pepcid AC OTC heartburn relief oral tablet 200 mg Tagamet HB OTC heartburn relief oral tablet 75 mg Zantac 75 OTC hm acid reducer max strength oral tablet 150 mg Zantac OTC

hm acid reducer oral tablet 150 mg Zantac OTC hm acid reducer oral tablet 75 mg Zantac 75 OTC hm famotidine oral tablet 10 mg Pepcid AC OTC hm famotidine oral tablet 20 mg Pepcid AC Maximum Strength OTC kls acid controller max st oral tablet 20 mg Pepcid AC Maximum Strength OTC kls acid reducer max st oral tablet 150 mg Zantac OTC kls acid reducer oral tablet 75 mg Zantac 75 OTC nizatidine oral capsule 150 mg, 300 mg nizatidine oral solution 15 mg/ml px acid reducer max st oral tablet 150 mg Zantac OTC px acid reducer max st oral tablet 20 mg Pepcid AC Maximum Strength OTC px acid reducer oral tablet 10 mg Pepcid AC OTC px acid reducer oral tablet 200 mg Tagamet HB OTC px acid reducer oral tablet 75 mg Zantac 75 OTC px ranitidine oral tablet 75 mg Zantac 75 OTC qc acid controller max st oral tablet 20 mg Pepcid AC Maximum Strength OTC qc acid controller oral tablet 10 mg Pepcid AC OTC ra acid reducer max st oral tablet 150 mg Zantac OTC ra acid reducer max st oral tablet 20 mg Pepcid AC Maximum Strength OTC ra acid reducer oral tablet 10 mg Pepcid AC OTC ra acid reducer oral tablet 200 mg Tagamet HB OTC ra acid reducer oral tablet 75 mg Zantac 75 OTC ranitidine acid reducer oral tablet 75 mg Zantac 75 OTC

250

Formulary Drug Name Reference Restrictions ranitidine hcl oral capsule 150 mg, 300 mg ranitidine hcl oral syrup 15 mg/ml, 150 mg/10ml, 75 mg/5ml ranitidine hcl oral tablet 150 mg, 300 mg Zantac ranitidine hcl oral tablet 75 mg Zantac 75 OTC sb acid controller max st oral tablet 20 mg Pepcid AC Maximum Strength OTC sb acid controller oral tablet 10 mg Pepcid AC OTC sb acid reducer oral tablet 10 mg Pepcid AC OTC sb acid reducer oral tablet 150 mg Zantac OTC sb acid reducer ranitidine oral tablet 75 mg Zantac 75 OTC sb cimetidine oral tablet 200 mg Tagamet HB OTC sm acid reducer max st oral tablet 150 mg Zantac OTC sm acid reducer max st oral tablet 20 mg Pepcid AC Maximum Strength OTC sm acid reducer oral tablet 10 mg Pepcid AC OTC sm acid reducer oral tablet 200 mg Tagamet HB OTC sm acid reducer oral tablet 75 mg Zantac 75 OTC sw acid reducer 150 max st oral tablet 150 mg Zantac OTC tgt acid reducer oral tablet 10 mg Pepcid AC OTC tgt acid reducer oral tablet 200 mg Tagamet HB OTC tgt acid reducer oral tablet 75 mg Zantac 75 OTC WAL-ZAN 150 MAXIMUM STRENGTH ORAL TABLET 150 MG RA Acid Reducer Max St OTC

WAL-ZAN 75 ORAL TABLET 75 MG Ranitidine HCl OTC

*Misc. Anti-Ulcer*** sucralfate oral tablet 1 gm Carafate

*Proton Pump Inhibitors*** cvs lansoprazole oral capsule delayed release 15 mg Prevacid OTC

cvs omeprazole oral capsule delayed release 20.6 (20 base) mg OTC

cvs omeprazole oral tablet delayed release 20 mg OTC

eq lansoprazole oral capsule delayed release 15 mg Prevacid OTC

eq omeprazole magnesium oral capsule delayed release 20 mg OTC

eq omeprazole oral tablet delayed release 20 mg OTC

eql lansoprazole oral capsule delayed release 15 mg Prevacid OTC

251

Formulary Drug Name Reference Restrictions eql omeprazole oral tablet delayed release 20 mg OTC

gnp lansoprazole oral capsule delayed release 15 mg Prevacid OTC

gnp omeprazole oral tablet delayed release 20 mg OTC

goodsense lansoprazole oral capsule delayed release 15 mg Prevacid OTC

heartburn treatment 24 hour oral capsule delayed release 15 mg Prevacid OTC

hm lansoprazole oral capsule delayed release 15 mg Prevacid OTC

hm omeprazole oral tablet delayed release 20 mg OTC

kls lansoprazole oral capsule delayed release 15 mg Prevacid OTC

kls omeprazole oral tablet delayed release 20 mg OTC

kp omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg OTC

lansoprazole oral capsule delayed release 15 mg, 30 mg Prevacid

omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg OTC

omeprazole oral capsule delayed release 10 mg, 40 mg omeprazole oral capsule delayed release 20 mg PriLOSEC

omeprazole oral tablet delayed release 20 mg OTC pantoprazole sodium oral tablet delayed release 20 mg, 40 mg Protonix

px omeprazole oral tablet delayed release 20 mg OTC

qc omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg OTC

ra lansoprazole oral capsule delayed release 15 mg Prevacid OTC

ra omeprazole oral tablet delayed release 20 mg OTC

rabeprazole sodium oral tablet delayed release 20 mg Aciphex

sb omeprazole oral tablet delayed release 20 mg OTC

252

Formulary Drug Name Reference Restrictions sm lansoprazole oral capsule delayed release 15 mg Prevacid OTC

sm omeprazole oral tablet delayed release 20 mg OTC

sw omeprazole oral tablet delayed release 20 mg OTC

tgt omeprazole oral tablet delayed release 20 mg OTC

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML NEXIUM 24HR CLEAR MINIS ORAL CAPSULE DELAYED RELEASE 20 MG Esomeprazole Magnesium OTC

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE 20 MG Esomeprazole Magnesium PA; OTC

NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG Esomeprazole Magnesium

OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 MG/ML PRILOSEC OTC ORAL TABLET DELAYED RELEASE 20 MG OTC

*Quaternary Anticholinergics*** glycopyrrolate oral tablet 1 mg Robinul glycopyrrolate oral tablet 2 mg Robinul-Forte propantheline bromide oral tablet 15 mg

*Ulcer Anti-Infective W/ Bismuth Combinations*** PYLERA ORAL CAPSULE 140-125-125 MG

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

*URINARY ANTI-INFECTIVES* *Urinary Anti-Infectives*** methenamine hippurate oral tablet 1 gm Hiprex methenamine mandelate oral tablet 0.5 gm, 1 gm nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg Macrodantin

nitrofurantoin monohyd macro oral capsule 100 mg Macrobid

253

Formulary Drug Name Reference Restrictions nitrofurantoin oral suspension 25 mg/5ml Furadantin

*URINARY ANTISPASMODICS* *Urinary Antispasmodic -Antimuscarinic (Anticholinergic)*** oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg Ditropan XL

oxybutynin chloride oral syrup 5 mg/5ml oxybutynin chloride oral tablet 5 mg tolterodine tartrate oral tablet 1 mg, 2 mg Detrol trospium chloride er oral capsule extended release 24 hour 60 mg trospium chloride oral tablet 20 mg TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG VESICARE ORAL TABLET 10 MG, 5 MG

*Urinary Antispasmodic -Antimuscarinics (Antichol)***(New) oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg Ditropan XL

oxybutynin chloride oral syrup 5 mg/5ml oxybutynin chloride oral tablet 5 mg tolterodine tartrate oral tablet 1 mg, 2 mg Detrol trospium chloride er oral capsule extended release 24 hour 60 mg trospium chloride oral tablet 20 mg TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG VESICARE ORAL TABLET 10 MG, 5 MG

*Urinary Antispasmodics -Cholinergic Agonists*** bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg Urecholine

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

*Urinary Antispasmodics - Direct Muscle Relaxants*** flavoxate hcl oral tablet 100 mg

254

Formulary Drug Name Reference Restrictions *Urinary Antispasmodics - Direct Muscle Relaxants*** (New) flavoxate hcl oral tablet 100 mg

*VAGINAL PRODUCTS* *Imidazole-Related Antifungals*** cvs miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combination Pack OTC

cvs miconazole 3-day combo app vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combo Pack App OTC

eq miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combination Pack OTC

eql miconazole 3 vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combination Pack OTC

gnp miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combo Pack App OTC

gnp miconazole 3 vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combination Pack OTC

miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combo Pack App OTC

miconazole 3 combo pack app vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combo Pack App OTC

miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combination Pack OTC

miconazole 3 vaginal suppository 200 mg px miconazole 3-day combo vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combination Pack OTC

ra miconazole 3 combo pack app vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combo Pack App OTC

ra miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combination Pack OTC

sm miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combo Pack App OTC

sm miconazole 3 vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combination Pack OTC

terconazole vaginal cream 0.4 % Terazol 7 terconazole vaginal cream 0.8 % terconazole vaginal suppository 80 mg tgt miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) Monistat 3 Combination Pack OTC

MONISTAT 7 COMBO PACK APP VAGINAL KIT 100 & 2 MG-% (9GM) OTC

255

Formulary Drug Name Reference Restrictions *Spermicides*** TODAY SPONGE VAGINAL 1000 MG OTC; QLL (3 EA per 30 days) VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 % OTC

*Vaginal Anti-Infectives*** clindamycin phosphate vaginal cream 2 % Cleocin metronidazole vaginal gel 0.75 % MetroGel-Vaginal CLEOCIN VAGINAL SUPPOSITORY 100 MG VANDAZOLE VAGINAL GEL 0.75 % MetroNIDAZOLE

*Vaginal Estrogens*** ESTRACE VAGINAL CREAM 0.1 MG/GM ESTRING VAGINAL RING 2 MG FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR PREMARIN VAGINAL CREAM 0.625 MG/GM VAGIFEM VAGINAL TABLET 10 MCG Estradiol YUVAFEM VAGINAL TABLET 10 MCG Estradiol

*VASOPRESSORS* *Anaphylaxis Therapy Agents*** epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.3 mg/0.3ml Auvi-Q

epinephrine injection solution auto-injector 0.15 mg/0.3ml EpiPen Jr 2-Pak

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML EPINEPHrine

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML EPINEPHrine

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML

EPINEPHrine

*Vasopressors*** midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg

*VITAMINS* *Vitamin B-3*** gnp niacin oral tablet 250 mg OTC gnp niacin tr oral tablet extended release 250 mg Endur-Acin OTC

256

Formulary Drug Name Reference Restrictions hm niacin oral tablet extended release 250 mg Endur-Acin OTC hm niacin tr oral tablet extended release 250 mg Endur-Acin OTC

kp niacin oral tablet 500 mg OTC niacin er oral capsule extended release 250 mg, 500 mg OTC

niacin er oral tablet extended release 250 mg Endur-Acin OTC niacin er oral tablet extended release 750 mg Slo-Niacin OTC niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg OTC

niacin-50 oral tablet 50 mg OTC px niacin oral tablet 100 mg OTC ra niacin oral tablet 100 mg, 500 mg OTC ra no flush niacin oral tablet 500 mg OTC sm niacin cr oral tablet extended release 250 mg Endur-Acin OTC

ENDUR-ACIN ORAL TABLET EXTENDED RELEASE 250 MG GNP Niacin TR OTC

SLO-NIACIN ORAL TABLET EXTENDED RELEASE 250 MG GNP Niacin TR OTC

*Vitamin B-6*** b6 natural oral tablet 100 mg OTC b-6 oral tablet 100 mg, 50 mg OTC cvs b6 oral tablet 100 mg OTC eql b-6 oral tablet 100 mg OTC gnp vitamin b-6 oral tablet 100 mg OTC hm vitamin b6 oral tablet 100 mg OTC kp vitamin b-6 oral tablet 100 mg OTC neuro-k-50 oral tablet 50 mg OTC pyridoxine hcl oral tablet 100 mg, 25 mg, 50 mg OTC

ra vitamin b-6 oral tablet 100 mg, 50 mg OTC sm vitamin b-6 oral tablet 100 mg OTC vitamin b-6 oral tablet 100 mg, 25 mg, 50 mg OTC vitamin b6 oral tablet 200 mg OTC yl vitamin b-6 oral tablet 100 mg OTC

*Vitamin D*** cvs d3 oral capsule 1000 unit Pronutrients Vitamin D3 OTC cvs d3 oral capsule 2000 unit, 400 unit OTC cvs d3 oral capsule 5000 unit Dialyvite Vitamin D 5000 OTC

257

Formulary Drug Name Reference Restrictions cvs d3 oral tablet chewable 1000 unit VitaJoy Daily D Gummies OTC cvs vitamin d child gummies oral tablet chewable 1000 unit VitaJoy Daily D Gummies OTC

cvs vitamin d3 oral tablet chewable 1000 unit VitaJoy Daily D Gummies OTC d 1000 oral capsule 1000 unit Pronutrients Vitamin D3 OTC d 1000 oral tablet 1000 unit Vitamin D-1000 Max St OTC d 1000 oral tablet chewable 1000 unit VitaJoy Daily D Gummies OTC d 2000 oral tablet 2000 unit Thera-D Rapid Repletion OTC d 400 oral tablet 400 unit OTC d 400 oral tablet chewable 400 unit Healthy Kids Vitamin D3 OTC d 5000 oral capsule 5000 unit Dialyvite Vitamin D 5000 OTC d 5000 oral tablet 5000 unit OTC d-1000 extra strength oral tablet 1000 unit Vitamin D-1000 Max St OTC d-1000 oral tablet 1000 unit Vitamin D-1000 Max St OTC d-2000 maximum strength oral tablet 2000 unit Thera-D Rapid Repletion OTC

d2000 ultra strength oral capsule 2000 unit OTC d3 adult oral tablet chewable 1000 unit VitaJoy Daily D Gummies OTC d3 high potency oral capsule 1000 unit Pronutrients Vitamin D3 OTC d3 high potency oral capsule 2000 unit OTC d3 high potency oral tablet 400 unit OTC d3 kids oral tablet chewable 400 unit Healthy Kids Vitamin D3 OTC d3 maximum strength oral capsule 5000 unit Dialyvite Vitamin D 5000 OTC d3 super strength oral capsule 2000 unit OTC d3-1000 oral capsule 1000 unit Pronutrients Vitamin D3 OTC d3-1000 oral tablet 1000 unit Vitamin D-1000 Max St OTC d-3-5 oral capsule 5000 unit Dialyvite Vitamin D 5000 OTC d-400 oral tablet 400 unit OTC d-5000 oral tablet 5000 unit OTC delta d3 oral tablet 400 unit OTC eql vitamin d3 gummies oral tablet chewable 1000 unit VitaJoy Daily D Gummies OTC

eql vitamin d3 oral capsule 1000 unit Pronutrients Vitamin D3 OTC eql vitamin d3 oral capsule 2000 unit, 400 unit OTC eql vitamin d3 oral capsule 5000 unit Dialyvite Vitamin D 5000 OTC ergocalciferol oral solution 8000 unit/ml Calcidol OTC gnp d 1000 oral capsule 1000 unit Pronutrients Vitamin D3 OTC gnp d 2000 oral tablet chewable 1000 unit VitaJoy Daily D Gummies OTC

258

Formulary Drug Name Reference Restrictions gnp vitamin d maximum strength oral tablet 2000 unit Thera-D Rapid Repletion OTC

gnp vitamin d oral tablet 1000 unit Vitamin D-1000 Max St OTC gnp vitamin d oral tablet chewable 400 unit Healthy Kids Vitamin D3 OTC gnp vitamin d super strength oral tablet 5000 unit OTC

gnp vitamin d3 extra strength oral tablet 1000 unit Vitamin D-1000 Max St OTC

hm vitamin d oral tablet 1000 unit Vitamin D-1000 Max St OTC hm vitamin d oral tablet 400 unit OTC hm vitamin d3 oral capsule 2000 unit OTC kp vitamin d oral capsule 1000 unit Pronutrients Vitamin D3 OTC kp vitamin d oral tablet chewable 400 unit Healthy Kids Vitamin D3 OTC kp vitamin d3 oral capsule 1000 unit Pronutrients Vitamin D3 OTC kp vitamin d3 oral capsule 2000 unit OTC nat-rul vitamin d oral tablet 1000 unit Vitamin D-1000 Max St OTC nat-rul vitamin d oral tablet 2000 unit Thera-D Rapid Repletion OTC nat-rul vitamin d oral tablet 5000 unit OTC natural vitamin d-3 oral tablet 5000 unit OTC pa vitamin d-3 gummy oral tablet chewable 400 unit Healthy Kids Vitamin D3 OTC

pa vitamin d-3 oral capsule 2000 unit OTC pa vitamin d-3 oral capsule 5000 unit Dialyvite Vitamin D 5000 OTC pa vitamin d-3 oral tablet 1000 unit Vitamin D-1000 Max St OTC ra vitamin d-3 oral capsule 2000 unit OTC ra vitamin d-3 oral capsule 5000 unit Dialyvite Vitamin D 5000 OTC ra vitamin d-3 oral tablet 1000 unit Vitamin D-1000 Max St OTC sm vitamin d oral tablet 400 unit OTC sm vitamin d3 oral capsule 2000 unit OTC sm vitamin d3 oral tablet 1000 unit Vitamin D-1000 Max St OTC vitamin d (cholecalciferol) oral capsule 1000 unit Pronutrients Vitamin D3 OTC

vitamin d (cholecalciferol) oral capsule 400 unit OTC

vitamin d (cholecalciferol) oral tablet 1000 unit Vitamin D-1000 Max St OTC

vitamin d (cholecalciferol) oral tablet 400 unit OTC vitamin d (cholecalciferol) oral tablet chewable 400 unit Healthy Kids Vitamin D3 OTC

259

Formulary Drug Name Reference Restrictions vitamin d (ergocalciferol) oral capsule 50000 unit Drisdol

vitamin d high potency oral capsule 1000 unit Pronutrients Vitamin D3 OTC vitamin d oral capsule 2000 unit OTC vitamin d oral tablet 1000 unit Vitamin D-1000 Max St OTC vitamin d oral tablet 2000 unit Thera-D Rapid Repletion OTC vitamin d2 oral tablet 400 unit OTC vitamin d3 adult gummies oral tablet chewable 1000 unit VitaJoy Daily D Gummies OTC

vitamin d3 high potency oral capsule 1000 unit Pronutrients Vitamin D3 OTC

vitamin d3 maximum strength oral capsule 5000 unit Dialyvite Vitamin D 5000 OTC

vitamin d3 oral capsule 1000 unit Pronutrients Vitamin D3 OTC vitamin d-3 oral capsule 1000 unit Pronutrients Vitamin D3 OTC vitamin d3 oral capsule 2000 unit, 400 unit OTC vitamin d3 oral capsule 5000 unit Dialyvite Vitamin D 5000 OTC vitamin d3 oral tablet 1000 unit Vitamin D-1000 Max St OTC vitamin d3 oral tablet 2000 unit Thera-D Rapid Repletion OTC vitamin d3 oral tablet 400 unit, 5000 unit OTC vitamin d3 oral tablet chewable 1000 unit VitaJoy Daily D Gummies OTC vitamin d3 oral tablet chewable 400 unit Healthy Kids Vitamin D3 OTC vitamin d3 oral tablet dispersible 5000 unit OTC vitamin d3 super strength oral tablet 2000 unit Thera-D Rapid Repletion OTC vitamin d-400 oral tablet 400 unit OTC CALCIDOL ORAL SOLUTION 8000 UNIT/ML Ergocalciferol OTC

CALCIFEROL ORAL SOLUTION 8000 UNIT/ML Ergocalciferol OTC

D3 DOTS ORAL TABLET DISPERSIBLE 2000 UNIT OTC

DIALYVITE VITAMIN D 5000 ORAL CAPSULE 5000 UNIT CVS D3 OTC

HEALTHY KIDS VITAMIN D3 ORAL TABLET CHEWABLE 400 UNIT PA Vitamin D-3 Gummy OTC

PRONUTRIENTS VITAMIN D3 ORAL CAPSULE 1000 UNIT D 1000 OTC

REPLESTA ORAL WAFER 50000 UNIT OTC THERA-D 2000 ORAL TABLET 2000 UNIT Vitamin D3 Super Strength OTC

260

Formulary Drug Name Reference Restrictions THERA-D RAPID REPLETION ORAL TABLET 2000 UNIT Vitamin D3 Super Strength OTC

VITAJOY DAILY D GUMMIES ORAL TABLET CHEWABLE 1000 UNIT Vitamin D3 OTC

VITAMIN D-1000 MAX ST ORAL TABLET 1000 UNIT D-1000 OTC

*Vitamin K*** MEPHYTON ORAL TABLET 5 MG

261

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14650+ adult eye health 199a thru z advanced 200a thru z advanced adult . 200a thru z advantage 217a thru z high potency 200a thru z select 200a thru z select 50+ advanced . 200a thru z select 50+ mens 200a thru z select advanced ........ 200a thru z select ultimate women 200a thru z ultimate mens 200A+D PREVENT 111abacavir sulfate 68abacavir sulfate-lamivudine . 66abacavir-lamivudine-zidovudine 66abc plus 200ABC PLUS SENIOR 208ABC PLUS SENIOR ADULTS 50+ 208ABILIFY MAINTENA 65ABREVA 105acamprosate calcium 241acarbose 39ACCU-CHEK AVIVA 150ACCU-CHEK COMPACT PLUS CONTROL 150ACCU-CHEK FASTCLIX LANCET 150ACCU-CHEK FASTCLIX LANCETS 150ACCU-CHEK GUIDE CONTROL 150ACCU-CHEK MULTICLIX LANCET DEV 150ACCU-CHEK MULTICLIX LANCETS 151ACCU-CHEK SAFE-T PRO LANCETS . 151ACCU-CHEK SMARTVIEW CONTROL 151ACCU-CHEK SOFT TOUCH LANCETS 151ACCU-CHEK SOFTCLIX LANCET DEV . 151ACCU-CHEK SOFTCLIX LANCETS 151ACCUTREND GLUCOSE CONTROL 151acebutolol hcl . 71

ACEPHEN 15, 16acetaminophen 11, 12acetaminophen extra strength 11acetaminophen rapid tabs child 11acetaminophen-codeine 21acetaminophen-codeine #2 21acetaminophen-codeine #3 21acetaminophen-codeine #4 21ACETASOL HC 229acetazolamide 124acetazolamide er 124acetic acid . 228acetic acid-aluminum acetate 229acetylcysteine .97acid control 248acid control maximum strength 248acid controller 249acid controller max st . 249acid reducer 249acid reducer maximum strength

249acidophilus 44acidophilus lactobacillus 76acne foaming wash 98acne medication 10 98acne medication 5 98acne treatment . 98acne-clear 98actical 200acti-lance 28g .. 146acti-lance lite lancets 28g 146acti-lance special lancets 17g 146acti-lance universal 23g 146ACTIMMUNE 61ACTINEL PEDIATRIC 92ACTIVE 1ST BLOOD LANCETS 30G 151acyclovir 70, 105adapalene . 98ADCIRCA 75addaprin 6ADDERALL XR 3adjustable lancing device 146adult aspirin ec low strength 17adult gummy 200adult mask 185ADVAIR DISKUS 31ADVANCE INTUITION CONTROL 151

ADVANCE MICRO-DRAW CONTROL 151ADVANCE MICRO-DRAW NORMAL 151advanced eye health 200advanced healing/baby 112ADVANCED MULTI EA 208advanced stress formula/zinc 198ADVIL JUNIOR STRENGTH10ADVOCATE CONTROL SOLUTION 151ADVOCATE INSULIN SYRINGE 175, 176ADVOCATE LANCETS 151ADVOCATE LANCETS 30G

151ADVOCATE LANCING DEVICE 151ADVOCATE RAPID-SAFE LANCING 151ADVOCATE REDI-CODE+ CONTROL 151ADVOCATE SAFETY LANCETS 151ADVOCATE SAFETY LANCETS 26G 151AEROBIKA 185AEROCHAMBER MINI CHAMBER 186AEROCHAMBER MV 186AEROCHAMBER PLUS FLO-VU 186AEROCHAMBER PLUS FLO-VU LARGE 186AEROCHAMBER PLUS FLO-VU MEDIUM 186AEROCHAMBER PLUS FLO-VU SMALL 186AEROCHAMBER PLUS FLO-VU W/MASK 186AEROCHAMBER PLUS FLOW VU 186AEROCHAMBER W/FLOWSIGNAL 187AEROCHAMBER Z-STAT PLUS 187AEROCHAMBER Z-STAT PLUS CHAMBR 187AEROCHAMBER Z-STAT PLUS/LARGE 187

263

AEROCHAMBER Z-STAT PLUS/MEDIUM .....................

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187AEROCHAMBER Z-STAT PLUS/SMALL 187AEROVENT PLUS 187AFEDITAB CR 74AFINITOR 61AFTERA 82AGAMATRIX CONTROL

151, 152AGAMATRIX ULTRA-THIN LANCETS 152agoneaze 120aimsco lubricated 143AIRBORNE 208AIRBORNE GUMMIES 208AIRZONE PEAK FLOW METER 185ak-poly-bac 226AL12 113ala-cort 106ALAHIST DM 97ALAVERT 53ALAWAY 225ALAWAY CHILDRENS ALLERGY 225ALBENZA 29ALBUSTIX 122albuterol sulfate 32albuterol sulfate er . 32alclometasone dipropionate 106ALCOH-GLOVE CONTOURED WIPE 143alcohol pads 142alcohol prep 142alcohol swabs 142ALCOHOL SWABSTICK 143alcohol wipes 142alendronate sodium 125alfuzosin hcl er 131ALIVE MULTI-VITAMIN CHILDRENS 212ALKA-SELTZER PLS SINUS & COUGH 87ALKA-SELTZER PLUS DAY COLD/FLU 88ALKERAN . 62all day allergy 50all day allergy childrens 50all day allergy d 93all day allergy d-12 93all day allergy-d 93

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6all day relief . 6ALL FLOW 1000 PFT FILTER 185ALL FLOW 2000 PFT FILTER 185ALL FLOW 3000 PFT FILTER 185ALL FLOW 4000 PFT FILTER 185ALL FLOW 5000 PFT FILTER 185ALL FLOW 6000 PFT FILTER 185ALL FLOW 7000 PFT FILTER 186all-day allergy childrens 50aller-chlor 48allergy 50allergy 24hour indoor/outdoor ...50allergy childrens 48, 50allergy d-12 . 93allergy eye drops 225allergy medication childrens . 48allergy relief . 50, 218allergy relief child 50allergy relief childrens . 48, 50allergy relief for kids 50allergy spray 24 hour 218ALLI 4allopurinol . 132ALMACONE DOUBLE STRENGTH . 28almond oil bitter flavor 231ALPHAGAN P 227alprazolam 30alprazolam er . 30ALPRAZOLAM INTENSOL 30alprazolam xr 30ALTAFRIN 227altarussin 94altarussin dm 88ALTAVERA 78alternate site lancing device 146alyacen 1/35 77alyacen 7/7/7 84AMABELZ 127amantadine hcl 62amcinonide 106AMETHIA 82amiloride hcl 124amiloride-hydrochlorothiazide .124

amiodarone hcl ...........................................................

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31AMITIZA 129amitriptyline hcl 38AMLACTIN 113amlodipine besy-benazepril hcl ..55amlodipine besylate 72amlodipine besylate-valsartan 57amlodipine-atorvastatin 74amlodipine-valsartan-hctz 57ammonium lactate . 112AMNESTEEM 99AMORYN MOOD BOOSTER

208amoxapine 38amoxicillin 230amoxicillin-pot clavulanate 230amoxicillin-pot clavulanate er 230amphetamine-dextroamphetamine 3ampicillin 230anagrelide hcl 133anastrozole 61ANDROGEL 25ANDROGEL PUMP . 25animal chews 214ANIMAL SHAPES 215animal shapes plus iron 213anise extract 231anodyne lpt 120antacid 27antacid & antigas 26antacid advanced 26antacid anti-gas max strength 26antacid extra strength 26antacid iii 27antacid maximum strength 27antacid plus anti-gas relief . 27antacid/simethicone ds 27anti-bacterial hand 119antibiotic plus pain relief . 100anti-diarrheal . 44antifungal 102, 114anti-fungal 102, 114antifungal foot 102ANTI-ITCH INTENSIVE HEALING 110anti-itch maximum strength 106anti-nausea 45anti-nausea/rekematol 45antioxidant 200antioxidant a/c/e/selenium 200antioxidant formula 200, 211

264

anti-oxidant formula .................... .

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200antioxidant formula/minerals 200antioxidant protection formula 200antioxidant vitamins 200ANTIOXIN 4000 208anti-stick immun syringe 170anti-stick insulin syringe 170ANUSOL-HC . 26apap 12apple flavor 231apra . 12aprepitant 47APRI 78apricot flavor 231APRISO 130APTIVUS . 67aqua lance adjustable lancing 146AQUANIL HC 110AQUANIL SKIN CLEANSER

119AQUAPHILIC/CARBAMIDE

112AR CAPS #1 ACID RESISTANT 238ARANELLE 84ARANESP (ALBUMIN FREE) 133, 134ARCAPTA NEOHALER 32ARGYLE STERILE SALINE

131ARGYLE STERILE WATER 71ARIAL CHAMBER 187aripiprazole 65ARISTADA 66ARMOUR THYROID 247artificial tears 222, 223ARZOL SILVER NIT APPLICATORS 106ASCOMP-CODEINE .21ASHLYNA 82ASMANEX 120 METERED DOSES 33ASMANEX 14 METERED DOSES 33ASMANEX 30 METERED DOSES 33ASMANEX 60 METERED DOSES 33ASMANEX 7 METERED DOSES 33aspir-81 17aspirin 17, 18

aspirin adult low dose ................ ..........

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17aspirin adult low strength . 17aspirin childrens 17aspirin ec 17aspirin ec low dose 17aspirin ec low strength 17aspirin low dose 17aspirin low strength 17ASPIR-LOW . 20aspirtab maximum strength 18ASSESS FULL RANGE PEAK METER 185ASSESS LOW RANGE PEAK METER 185ASSESS PEAK FLOW METER 185ASSURE 3 CONTROL 152ASSURE 4 CONTROL LEVEL 1 & 2 152assure comfort lancets 28g 146assure comfort lancets 30g 146ASSURE DOSE CONTROL 152ASSURE DOSE NORM/HIGH CONTROL 152ASSURE HAEMOLANCE PLUS HIGH . 152ASSURE HAEMOLANCE PLUS LOW 152ASSURE HAEMOLANCE PLUS MICRO 152ASSURE HAEMOLANCE PLUS NORMAL 152ASSURE HAEMOLANCE PLUS PED 152ASSURE ID INSULIN SAFETY SYR 176ASSURE II CONTROL 152ASSURE II CONTROL LEVEL 1 & 2 152ASSURE LANCE LANCETS152ASSURE LANCE LANCETS 21G 152ASSURE LANCE PLUS SAFETY 25G 152ASSURE LANCE PLUS SAFETY 30G 152ASSURE LANCETS 152ASSURE PRISM CONTROL LEVEL 1 152ASSURE PRO CONTROL LEVEL 1 & 2 152

ASTHMA CHECK METER-ZONE SYSTEM .....................

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185ASTHMAMENTOR . 185AT LAST CONTROL 152AT LAST LANCETS 153atenolol . 72atenolol-chlorthalidone 58athletes foot . 102, 114athletes foot af . 102athletes foot powder spray 114athletes foot spray 102, 114ATLAS COLOR CONDOM/SPERMICIDE 144ATLAS COLOR LUBRICATED CONDOM 144ATLAS LUB CONDOM/SPERMICIDE 144ATLAS LUBRICATED CONDOM 144atorvastatin calcium 55ATRIPLA 66atropine sulfate 224ATROVENT HFA . 32AUBAGIO 241AUBRA 78aurora lancet super thin 30g 146aurora lancet thin 23g 146AURYXIA 130AUTO-LANCET 153AUTO-LANCET MINI 153AUTOLET II CLINISAFE 153AUTOLET LANCING DEVICE 153AUTOLET LITE CLINISAFE 153AUTOLET LITE STARTER PACK 153AUTOLET MINI 153AUTOLET PLATFORMS . 153AUTOLET PLUS 153AUVI-Q 256AVANDIA 44AVEENO ANTI-ITCH MAX ST 110AVEENO POSITIVE RADIANT CLEANS 119AVIANE 78avidoxy 246AVITA . 99AVONEX 241AVONEX PEN 241AVONEX PREFILLED 242

265

av-phos 250 neutral ..................................................................... ........................... ........................... ..............................

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196azathioprine 71azelastine hcl . 218, 225azithromycin .. 141AZOPT 227AZURETTE 77b complex-c-folic acid 198b-6 . 257b6 natural 257baby cornstarch . 118baby powder 118bacitracin 101, 226bacitracin zinc ... 101bacitracin-polymyxin b 226bacitra-neomycin-polymyxin-hc

227BACITRAYCIN PLUS 102baclofen 217bacon flavor 231balsalazide disodium 130BALZIVA 78banana concentrate 231banana cream flavor 231banana creme flavor 231banana flavor 231BANOPHEN 49BARACLUDE 69BASAGLAR KWIKPEN 41BAYER ADVANCED ASPIRIN EX ST 20BAYER ADVANCED ASPIRIN REG ST 20BAYER ASPIRIN 20BAYER ASPIRIN EC LOW DOSE 20BAYER ASPIRIN EXTRA STRENGTH 20BAYER BREEZE 2 CONTROL 153BAYER CONTOUR 153BAYER CONTOUR NEXT CONTROL 153BAYER LOW DOSE 20BAYER MICROLET 2 LANCING DEVIC 153BAYER MICROLET LANCETS 153baza antifungal 114b-complex balanced . 198b-complex/vitamin c . 198b-complex-c . 199BD ECLIPSE SYRINGE 176

BD GLUCOSE

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40BD INSULIN SYR ULTRAFINE II 176BD INSULIN SYRINGE 176BD INSULIN SYRINGE HALF-UNIT 176BD INSULIN SYRINGE MICROFINE 176BD INSULIN SYRINGE ULTRAFINE 176, 177BD LANCET ULTRAFINE 30G 153BD LANCET ULTRAFINE 33G 153BD LUER-LOK SYRINGE 177BD MICROTAINER LANCETS 153BD SAFETYGLIDE INSULIN SYRINGE 177BD SAFETYGLIDE SYRINGE/NEEDLE 177BD SAFETY-LOK INSULIN SYRINGE 177BD SWAB SINGLE USE REGULAR 143BD SWABS SINGLE USE BUTTERFLY 143BD SYRINGE/NEEDLE 177BD SYRINGE/NEEDLE SLIP TIP 177beauty lotion 112bec/zinc 198bee zee . 198beef (grilled) flavor oil sol . 231beef flavor . 231beef type flavor natural . 231BEKYREE 77BELVIQ 4benazepril hcl 56benazepril-hydrochlorothiazide . 56BENZACLIN 98BENZACLIN WITH PUMP 98BENZEPRO CREAMY WASH 99BENZIQ WASH . 99benzonatate 85benzoyl peroxide 98benzoyl peroxide cleanser 98benzoyl peroxide wash 98benzphetamine hcl 4benztropine mesylate 62benzyl alcohol 231

benzyl benzoate ........................................................

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77BERINERT 132BETA CARE BETATAR GEL 120beta hc 106betamethasone dipropionate . 106betamethasone dipropionate aug

106betamethasone valerate . 107BETASERON 242betatemp childrens 12betaxolol hcl 72, 224bethanechol chloride 254BETHKIS 5BETOPTIC-S 224bicalutamide 60BILTRICIDE 29biocel . 200biocotron 88biogtuss 92BIOLLE TEARS 223BION TEARS 222bionel pediatric 92bio-statin 47biotin plus/calcium/vit d3 200biotuss 92bisoprolol fumarate 72bisoprolol-hydrochlorothiazide 58bite-a-mins 214bite-a-mins/iron . 213bitter stop flavor 231bitterness mask flavor 231bitterness suppressor flavor 231blackberry flavor 231BLISOVI 24 FE 78BLISOVI FE 1.5/30 . 78BLISOVI FE 1/20 78BLIS-TO-SOL 104blueberry flavor 231body/hair/skin/nails 200BOUDREAUXS BUTT PASTE 106BOUNTY BEARS/C . 215bp foaming wash . 98bp folinatal plus b 217bp gel 98bp multinatal plus 215, 216bp wash 99b-plex 199b-plex plus 200bpo-10 wash 99bpo-5 wash 99

266

Iendx

BPROTECTED MULTI-VITE 208BPROTECTED PEDIA POLY-VITE 215BPROTECTED PEDIA POLY-VITE/FE 214BREATHERITE 187BREATHERITE COLL SPACER ADULT 187BREATHERITE COLL SPACER CHILD 187BREATHERITE COLL SPACER INFANT 187BREATHERITE RIGID SPACER/MASK 187BREATHERITE SPACER NEONATE 187BREATHERITE SPACER SMALL CHILD 187BREATHERITE VALVED MDI CHAMBER 186BREATHERITE/LARGE MASK 187BREATHERITE/MEDIUM MASK 187BREATHERITE/SMALL MASK 187b-redi/red hearts/red roosters 200briellyn 77BRILINTA 124, 132brimonidine tartrate 227bromocriptine mesylate 62brompheniramine tannate 48BRONCHO SALINE 96brontuss sf nr 92bubble gum concentrate 231bubble gum flavor 231BUCKLEYS CHEST CONGESTION 96budesonide 33, 85, 218bullseye mini safety lancets 146BULLSEYE SAFETY LANCETS 153bumetanide 124buprenorphine hcl 24bupropion hcl 37bupropion hcl er (smoking det) 243bupropion hcl er (sr) 37bupropion hcl er (xl) 37buspirone hcl 30butalbital-acetaminophen 16butalbital-apap-caff-cod 21

butalbital-apap-caffeine ....... ........

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16, 17butalbital-asa-caff-codeine . 21butalbital-asa-caffeine 17butalbital-aspirin-caffeine 17butorphanol tartrate 24BUTRANS 24butter flavor 231butter rum flavor 231butterscotch flavor 231BYDUREON 43BYETTA 10 MCG PEN 43BYETTA 5 MCG PEN .. 43cabergoline 125CABOMETYX . 61caffeine anhydrous 3caffeine citrate 3caffeine citrated 3CAL-CARB FORTE . 194CALCIDOL 260CALCIFEROL 260calcipotriene .. 105calcitonin (salmon) . 125CALCITRATE 194CALCITRENE . 105calcitriol 126calcium . 190, 194calcium + d3 190calcium 500 + d 190calcium 500 +d . 190calcium 500/d 190calcium 500/vitamin d 190calcium 500+d 190calcium 500+d high potency 190calcium 500+d3 190calcium 600 193calcium 600 + d 190calcium 600 + minerals 190calcium 600 high potency 193calcium 600/vitamin d . 190calcium 600+d . 190calcium 600+d high potency . 190calcium 600+d plus minerals 190calcium 600+d3 190calcium 600-d 190calcium acetate . 130calcium acetate (phos binder) 130calcium carbonate 194calcium carbonate extra light 194calcium carbonate light 194calcium carbonate-vitamin d 190calcium carbonate-vitamin d3 190calcium citrate 194

calcium folinate .......................... ................

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76calcium high potency 194calcium high potency/vitamin d 190calcium oyster shell . 194calcium-carb 600 194calcium-carb 600 + d 191calcium-vitamin d 191calcium-vitamin d3 . 191calcium-vitamin d-minerals 191CALPHRON 130CALTRATE 600 194CAMILA 83CAMRESE 82CANASA 130candesartan cilexetil .. .57candesartan cilexetil-hctz 57CAPACET 17capecitabine 60capsaicin . 117capsaicin arthritis relief . 117capsule coni-snap #1 pink 233capsule 0 clear dr 238capsule 0 clear veggie 238capsule 00 clear veggie 238capsule 1 clear veggie 238capsule 3 clear veggie 238capsule coni-snap #0 blu/white 233capsule coni-snap #0 clear 233capsule coni-snap #0 dark blue 233capsule coni-snap #0 green/clr 233capsule coni-snap #0 pink 233capsule coni-snap #0 red/white 233capsule coni-snap #0 white 233capsule coni-snap #00 clear . 233capsule coni-snap #00 white 233capsule coni-snap #000 clear 233capsule coni-snap #1 aqua blue233capsule coni-snap #1 blue 233capsule coni-snap #1 blue/pink 233capsule coni-snap #1 blue/wht 233capsule coni-snap #1 brown 233capsule coni-snap #1 brwn/ivry233capsule coni-snap #1 clear 233capsule coni-snap #1 dk grn/or 233capsule coni-snap #1 drk green 233capsule coni-snap #1 grey/pink 233capsule coni-snap #1 grn/ylw 233capsule coni-snap #1 orange . 233capsule coni-snap #1 pink/blue 233capsule coni-snap #1 pink/clr . 234capsule coni-snap #1 pink/whit 234capsule coni-snap #1 pink/yllw 234

267

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234capsule coni-snap #1 red/blue 234capsule coni-snap #1 red/white 234capsule coni-snap #1 veggie 238capsule coni-snap #1 white 234capsule coni-snap #1 white/grn 234capsule coni-snap #1 wht/clr 234capsule coni-snap #1 yellow 234capsule coni-snap #1 yellow/gr 234capsule coni-snap #2 clear 234capsule coni-snap #2 white 234capsule coni-snap #3 blu/clear 234capsule coni-snap #3 brn/blue 234capsule coni-snap #3 clear 238capsule coni-snap #3 gray/ylw 234capsule coni-snap #3 green/blu 234capsule coni-snap #3 grey/pink 234capsule coni-snap #3 maron/blu

234capsule coni-snap #3 mint grn 234capsule coni-snap #3 olive/clr 234capsule coni-snap #3 orange 234capsule coni-snap #3 pink/pink 234capsule coni-snap #3 pnk/clear 234capsule coni-snap #3 red/clear 234capsule coni-snap #3 red/red 234capsule coni-snap #3 white 234capsule coni-snap #3 wht/clr 234capsule coni-snap #3 yellow 234capsule coni-snap #4 black/grn 234capsule coni-snap #4 clear 234capsule coni-snap #4 white 234capsule size 1 lactose 234captopril 56captopril-hydrochlorothiazide ....56CAPZASIN 118CAPZASIN-HP 118CAPZASIN-P 118caramel flavor 231carbamazepine 35carbamazepine er 35carbidopa-levodopa . 63carbidopa-levodopa er 63carbidopa-levodopa-entacapone 63carbinoxamine maleate 48CARDIOCOM LANCING DEVICE 153careone advanced lancing dev . 146careone insulin syringe 170, 171careone lancet thin 23g 146careone lancet ultra thin 28g 146CARESENS CONTROL A 153

CARETOUCH ALCOHOL PREP ........................................

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143CARETOUCH LANCING/EJECTOR 153CARETOUCH TWIST LANCETS 30G 154carisoprodol 217carisoprodol-aspirin 218carisoprodol-aspirin-codeine 218CARRACOLLOID 4"X4" 122CARRACOLLOID 6"X6" 122CARRAVITE 208CARRINGTON ANTIFUNGAL 115carteolol hcl 224CARTIA XT 74carvedilol . 71castor oil 76castor oil stimulant laxative 140CATAPRES-TTS-1 58CATAPRES-TTS-2 58CATAPRES-TTS-3 58CAVAREST 198CAZIANT 84cefaclor 75cefaclor er . 75cefadroxil . 75cefdinir 75cefixime . 75cefpodoxime proxetil 76cefprozil 75CEFTIN 75ceftriaxone sodium 76cefuroxime axetil . 75CELEBREX 6celecoxib 6CELONTIN 37centamin 200centavite 200centavite a-z complete-mineral .200centravites 200centravites 50 plus 200CENTRUM KIDS COMPLETE 212century . 200century mature 200cephalexin 75CEROVITE ADVANCED FORMULA 208CEROVITE JR 212CEROVITE SENIOR . 208certa plus 200

certagen ....................................

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200CERTAVITE/ANTIOXIDANTS 208cetirizine hcl 50cetirizine hcl allergy child . 50cetirizine hcl childrens . 50cetirizine hcl childrens alrgy 50cetirizine hcl hives relief 50cetirizine-pseudoephedrine er 93CHANTIX 245CHANTIX CONTINUING MONTH PAK 245CHANTIX STARTING MONTH PAK 246CHATEAL 78cheesecake flavor 231CHEK-STIX CONTROL 122CHEMET 45CHEMSTRIP 10 MD 123CHEMSTRIP 10/SG 123CHEMSTRIP 2 122CHEMSTRIP 2 GP 123CHEMSTRIP 5 OB 123CHEMSTRIP 7 123CHEMSTRIP 9 123CHEMSTRIP BG LOG BOOK 154CHEMSTRIP K 122CHEMSTRIP MICRAL 122CHEMSTRIP UGK 123cheratussin ac 88cherry 238cherry concentrate 238cherry flavor 231chest congestion childrens 94chest congestion relief dm 88chest congestion/cough relief . 88chewable vite childrens 214chewable vite/iron childrens 213chicken (grilled) flavor 231chicken flavor 231chicken flavor oil miscible 231chicken flavor oil soluble 231chicken flavor water miscible 231chicken roasted concentrate 231child chewable vitamins/iron . 213childrens acetaminophen 12childrens allergy 48childrens animal shapes 212childrens apap 12childrens aspirin 18childrens aspirin free 12

268

childrens aspirin low strength ...........

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18childrens chewable multi vits 214childrens chewable vitamins . 214childrens cough 88childrens ibuprofen 6childrens ibuprofen 100 6childrens loratadine 50childrens mapap rapid tabs 12CHILDRENS MEDI-PROFEN . 10CHILDRENS MEDI-TABS 16childrens mucus relief cough 88childrens mucus relief expect 94childrens multivitamin 212, 214childrens multivitamin/iron 213childrens non-asa pain relief 12childrens non-aspirin 12childrens pain reliever 12childrens pepto 28childrens silapap 12CHILDRENS SOOTHE 28childrens tactinal 12childrens vitamins/iron 213childs ibuprofen 6CHLORASEPTIC SORE THROAT 16chlordiazepoxide hcl 30chlordiazepoxide-amitriptyline .241chlorhexidine gluconate66, 77, 197chloroquine phosphate 59chlorothiazide 124chlorpromazine hcl 65chlorpropamide 44chlorthalidone 124chlorzoxazone 217chocolate flavor 231chocolate hazelnut flavor 231cholestyramine 54cholestyramine light 54choline-mag trisalicylate 17CICLODAN 104ciclopirox 102ciclopirox olamine 102CIDALEAZE 118cilostazol 132CILOXAN 226cimetidine 249cimetidine 200 249cimetidine acid reducer 249cimetidine hcl 249CINRYZE 132CIPRODEX 229

ciprofloxacin ....................................

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127ciprofloxacin hcl 127, 226, 229ciprofloxacin-ciproflox hcl er 128citalopram hydrobromide 38CLARAVIS 99CLARISPRAY 219clarithromycin 141clarithromycin er 141CLARITIN ALLERGY CHILDRENS 53CLARITIN EYE 225CLASS ACT LUBRICATED 144CLEAN & CLEAR ADVANTAGE 3-IN-1 99CLEAN & CLEAR PERSA-GEL MAX ST 99CLEANLET LANCETS 28G 154CLEARPLEX V 99CLEARPLEX X 99clemastine fumarate 48CLEOCIN 256CLEVER CHEK LANCETS 154CLEVER CHOICE GLUCOSE CONTROL 154CLEVER CHOICE HOLDING CHAMBER 187CLIMARA PRO 127CLINDACIN ETZ 98CLINDACIN-P 98clindamycin hcl 59clindamycin palmitate hcl 59clindamycin phos-benzoyl perox 98clindamycin phosphate 97, 256clobetasol propionate 107clobetasol propionate e 107CLODAN 110clonazepam 35clonidine hcl . 57clopidogrel bisulfate 133clorazepate dipotassium . 30CLOSERCARE 154clotrimazole 114, 197clotrimazole af 114clotrimazole anti-fungal . 114CLOTRIMAZOLE GRX 115clotrimazole-betamethasone 102clozapine 64, 65co monitor 185COAGUCHEK LANCETS 154cocoa butter skin 112coconut flavor 232codeine sulfate 22

coffee flavor .................................................................................................

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232cola flavor 232colchicine 132colchicine-probenecid . 132COLCRYS 132cold multi-symptom severe day .. 88colestipol hcl 54collagen 112COLOCORT 25COMBIGAN 224COMBIPATCH . 127COMBISTIX 123COMBIVENT RESPIMAT 31COMFORT ASSIST INSULIN SYRINGE 177comfort assured lancets 28g 146comfort assured lancets 33g 146COMFORT EZ INSULIN SYRINGE 177, 178comfort gel antacid anti-gas 27comfort lancets 146COMPACT SPACE CHAMBER 187COMPACT SPACE CHAMBER/LG MASK 187COMPACT SPACE CHAMBER/MED MASK . 187COMPACT SPACE CHAMBER/SM MASK 187companion 200COMPETE 208COMPLERA .66complere 200complete 201complete daily/lutein 200complete energy 201complete moisture 112complete multivitamin/mineral .201complete pms support complex .201complete senior 201complete womens . 201compoz 136COMPRO 65CONCEPT DHA 216CONDYLOX 117constulose 139CONTRAVE 62control . 146COOL CONTROL A 154COOL CONTROL B 154COPAXONE 242COPEGUS 69

269

coral calcium plus ....................

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201

CORMAX SCALP APPLICATION 110CORTAID MAXIMUM STRENGTH 111CORTANE-B 120CORTIC-ND 229CORTIFOAM 25cortisone acetate 85CORTIZONE-10 111CORTIZONE-10 DIABETICS SKIN 111CORTIZONE-10 ECZEMA 111CORTIZONE-10 HYDRATENSIVE 111CORTIZONE-10 INTENSIVE HEALING 121CORTIZONE-10 PLUS 122CORTIZONE-10/ALOE 122CORVITE FREE 208cotton candy flavor 232cottonseed oil . 76COTTONTAILS A + D 111COTTONTAILS DIAPER RASH 106cough relief . 85cough syrup . 94cran-raspberry flavor 232creme dementhe flavor 232CREON 123CRITIC-AID CLEAR AF 115CRIXIVAN 67cromolyn sodium 31, 225CRUEX PRESCRIPTION STRENGTH 115CRYSELLE-28 78CUPRIMINE 70CURITY ALCOHOL PREPS

143CURITY ALCOHOL SWABS

143CURITY STERILE SALINE 132cvs acid controller max st 249cvs acid reducer 249cvs acid reducer max st 249cvs acne cleansing 99cvs acne foaming face wash 99cvs acne treatment 99cvs advanced 3-in-1 cleanser 99cvs advanced healing 112cvs af spray powder 102cvs alcohol prep pads 142

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cvs all day pain relief . 6cvs allergy . 48cvs allergy childrens 48cvs allergy eye drops 225cvs allergy relief 48, 50cvs allergy relief adult 48cvs allergy relief childrens 50cvs allergy relief-d 93cvs all-purpose skin protect 111cvs antacid plus antigas 27cvs antacid/anti-gas 27cvs antibiotic plus 100cvs anti-diarrheal 44cvs antifungal 102cvs anti-fungal 114cvs anti-itch maximum strength 107cvs artificial tears 222cvs aspirin 18cvs aspirin adult low dose 18cvs aspirin adult low strength 18cvs aspirin ec 18cvs aspirin low dose 18cvs athletes foot 102cvs athletes foot spray 114cvs b6 257cvs baby powder 118cvs bacitracin 101cvs bacitracin zinc 101cvs calcium 194cvs calcium carbonate 194cvs capsaicin 117cvs castor oil 140cvs chest congest/cough child 88cvs chest congestion childrens . 94cvs chest congestion relief dm 88cvs children multivitamin/iron 213cvs childrens allergy 48cvs childrens complete 212cvs childrens ibuprofen 7cvs childs non-aspirin 12cvs clotrimazole 114cvs cortisone intense healing 107cvs cortisone long-lasting 107cvs cortisone maximum strength

107cvs d3 257, 258cvs daily gummies 201cvs daily multiple fe/ca/zn 201cvs daily multiple for men 201cvs daily multiple for women 201cvs daily multiple women 50+ 201cvs diaper rash 105

cvs dm maximum adult ............... .......................

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88cvs dry skin care 112cvs eczema anti-itch 107cvs extra moisturizing 112cvs eye itch relief 225cvs fever reducing childrens 12cvs fish oil 220cvs fluticasone propionate 218cvs foaming acne face wash 99cvs foot & sneaker 103cvs gas relief 128cvs gas relief drops ex st . 128cvs gas relief infants 128cvs gentle skin cleanser 112cvs glucose . 39, 40cvs glucose shot 40cvs glycerin adult 139cvs hair/skin/nails . 217cvs heartburn relief . 249cvs hemorrhoidal 25cvs hydrating skin treatment 112cvs hydrocortisone anti-itch . 107cvs hydrocortisone max st 107cvs ibuprofen 7cvs ibuprofen childrens 7cvs ibuprofen ib . 7cvs ibuprofen infants . 7cvs indoor/outdoor allergy rlf .... 51cvs infants gas relief 128cvs infants pain relief drops 12cvs iron 135cvs isopropyl alcohol wipes . 119cvs itch relief . 114cvs jock itch 103CVS KETONE CARE 123cvs lancets 21g 146cvs lancets micro thin 33g 146cvs lancets original 146cvs lancets thin 26g 146cvs lancets ultra thin 30g 146cvs lancets ultra-thin 30g 146cvs lancing device 147cvs lansoprazole 251cvs laxative dietary supplemnt 140cvs loratadine . 51cvs lubricant drops 223cvs lubricant eye drops 223cvs magnesium 195cvs magnesium oxide 195cvs menopause support 217cvs mens daily gummies 201cvs miconazole 3 combo pack .255

270

cvs miconazole 3-day combo app ............................................

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255cvs moisturizing 112cvs moisturizing extra dry 112cvs motion sickness . 46cvs motion sickness ii 46cvs motion sickness relief 46cvs mucus extended release 94cvs naproxen sodium 7cvs nasal allergy spray 218cvs natural daily fiber 138cvs natural fish oil ..... 220cvs natural tears 222cvs nausea relief . 45cvs nicotine 243cvs nicotine polacrilex 243cvs non-aspirin childrens 12cvs non-aspirin jr 12cvs nts step 1 . 243cvs omeprazole 251cvs oyster shell calcium+vit d 191cvs pain & fever childrens . 12cvs pain & fever infants 12cvs pain relief adult 13cvs pain relief childrens 13cvs pediatric ointment 111cvs permethrin 119cvs prep 142cvs pure glycerin 112CVS PURELAX 140cvs ranitidine 249cvs ringworm 114cvs skin treatment 112cvs sleep aid 136cvs sleep aid nighttime 136cvs special care 112cvs spectravite advanced 201cvs spectravite senior 201cvs spectravite ultra mens 201cvs spectravite womens senior 201cvs stool softener 140cvs stress formula/zinc 198cvs therapeutic 120cvs triple antibiotic max str . 100cvs tussin adult chest congest 94cvs tussin cough 86cvs tussin dm 88cvs tussin dm cough/chest 88cvs tussin long-acting 86cvs tussin maximum strength 86cvs ultra thin lancets 147cvs vision formula 201

cvs vitamin d child gummies ................................

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258cvs vitamin d3 258cvs womens active daily 201cvs womens daily gummies . 201cvs zinc oxide 105cyanocobalamin 133CYCLAFEM 1/35 78CYCLAFEM 7/7/7 84cyclobenzaprine hcl 217cyclopentolate hcl 224cyclosporine 70cyclosporine modified . 70CYOTIC 229cyproheptadine hcl 54CYRED 78cytra k crystals 131d 1000 258d 2000 258d 400 258d 5000 258d-1000 258d-1000 extra strength 258d-2000 maximum strength 258d2000 ultra strength 258d3 adult 258D3 DOTS 260d3 high potency 258d3 kids 258d3 maximum strength 258d3 super strength 258d3-1000 258d-3-5 258d-400 258d-5000 .. 258daily betic 201daily combo multi vitamins 201daily mens health formula 201daily multi 201daily multi 50+ 201daily multiple vitamins/iron 199daily multiple vitamins/min 201daily multivitamin 201daily vitamin formula+iron 199daily vitamin formula+minerals

201daily vitamin plus 201daily vite multivitamin/iron . 199daily womens health formula 201daily-vitamin maximum formula

201daily-vitamin/iron 199daily-vite/iron/beta-carotene 199

danazol ....................................... ....................

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24dantrolene sodium 218dapsone 59DARAPRIM 59DASETTA 1/35 78DASETTA 7/7/7 84day time pe cold/flu relief . 87DAYSEE 83daytime cold/flu relief . 87day-time pe cold/flu relief 87DAYTRANA 5DEBLITANE 83DELSYM CGH/CHEST CONG DM CHILD 91DELSYM COUGH/CHEST CONGEST DM 91delta d3 258DELTASONE 85DELYLA 78demeclocycline hcl . 246DENTA 5000 PLUS 198DENTAGEL 198DERMACINRX EMPRICAINE 121DERMACINRX PRIZOPAK 121DERMADAILY 113DERMAFUNGAL 115DERMAPHOR 113DERMAREST ECZEMA 111DERMAVANTAGE 113DERMAZENE 102DESCOVY 66DESENEX 115DESENEX JOCK ITCH 116desipramine hcl 38DESITIN 111desmopressin ace rhinal tube 126desmopressin ace spray refrig 126desmopressin acetate 126desmopressin acetate spray . 126desogestrel-ethinyl estradiol 77desonide 107desoximetasone 107DEVILBISS COMPRESSOR186DEX4 40DEX4 GLUCOSE 40DEX4 NATURALS 40DEX4 POUCH PACK 40DEX4 QUICK DISSOLVE GLUCOSE 40dexamethasone . 85

271

dexamethasone sodium phosphate ..................................

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228dextroamphetamine sulfate . 3dextromethorphan-guaifenesin 88diabetes health formula 201diabetic siltussin das-na 94diabetic siltussin-dm 88diabetic siltussin-dm max st 88DIABETIC TUSSIN 96DIABETIC TUSSIN ALLERGY 48DIABETIC TUSSIN DM 91DIABETIC TUSSIN EX 96DIABETIC TUSSIN FOR CHILDREN 91DIABETIC TUSSIN MAX ST 91DIABETIDERM CLEANSING 120dialysis safety syringe/needle 171dialyvite 800/ultra d 201DIALYVITE VITAMIN D 5000 260diaper rash 105DIASTAR EASY TEST II LANCETS 154DIASTAR EASY TEST LANCETS 154DIASTAT ACUDIAL 35DIASTAT PEDIATRIC 35DIASTIX 122diatrue control level 1 147diatrue control level 2 147diatrue control level 3 147diazepam 30diclofenac potassium 7diclofenac sodium 7, 104, 227diclofenac sodium er 7dicloxacillin sodium . 230dicyclomine hcl 248didanosine 68diethylpropion hcl 4diethylpropion hcl er 4DIFFERIN 100diflorasone diacetate 107diflunisal 18DIGITEK 74DIGOX 74digoxin 74dihydroergotamine mesylate 189DILANTIN 36DILANTIN INFATABS 36diltiazem cd 72

diltiazem hcl ............................... ...........................

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73diltiazem hcl er 73diltiazem hcl er beads 72diltiazem hcl er coated beads72, 73dilt-xr 73dimenhydrinate 46DINO-LIFE 215DINO-LIFE W/EXTRA C 215diocto . 140DIOVAN 57diphenhist 48diphenhydramine hcl . 48diphenhydramine hcl (sleep) 136diphenoxylate-atropine 44dipyridamole 133disopyramide phosphate 31disulfiram 241divalproex sodium 37divalproex sodium er . 37DML 113DOCTORS CHOICE MEN 208docu 140docuprene 140docusate sodium 140DOCUSOL PLUS MINI-ENEMA 141DOK 141donepezil hcl 241dorzolamide hcl 227dorzolamide hcl-timolol mal 224dothelle dha 216double antibiotic + pain rlf . 100doxazosin mesylate 58doxepin hcl 38doxycycline hyclate 246doxycycline monohydrate . 246, 247DR GS CLEAR NAIL 104DRAMAMINE LESS DROWSY . 47DRCAPS SIZE 0 238DRCAPS SIZE 00 238DRCAPS SIZE 1 238DRIMINATE . 47dronabinol 47DROPLET LANCETS ULTRA THIN 30G 154DROPLET LANCING DEVICE 154drospirenone-ethinyl estradiol 77DROXIA 133DRS CHOICE BLISTER CARE 122

drug mart lancets thin 26g .......

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147DRUG MART LANCING DEVICE 154DRUG MART ON-THE-GO LANCET 30G 154DRUG MART UNILET LANCETS 28G 154DRUG MART UNILET LANCETS 30G 154DRY EYE FORMULA 208dry skin treatment 112dry skin treatment adv therapy .112dss 140DULERA 31duloxetine hcl . 38DUO-CARE CONTROL SOLUTION 154DUREX EXTRA SENSITIVE

144DUREZOL 228dyspel 7E.E.S. 400 142E.E.S. GRANULES 142EASIVENT 187EASIVENT MASK LARGE . 187EASIVENT MASK MEDIUM

187EASIVENT MASK SMALL 187easy comfort insulin syringe 171easy comfort lancets 147easy mini eject lancing device 147easy mini lancing device 147easy plus ii control 147EASY STEP CONTROL 154easy talk control . 147EASY TOUCH ALCOHOL PREP MEDIUM 143EASY TOUCH CONTROL HIGH & LOW 154EASY TOUCH FLIPLOCK INSULIN SY 178EASY TOUCH FLIPLOCK SAFETY SYR 178EASY TOUCH FLURINGE 178EASY TOUCH FLURINGE FLIPLOCK 178EASY TOUCH FLURINGE SHEATHLOCK . 178EASY TOUCH HEALTHPRO CONTROL 155EASY TOUCH INSULIN SAFETY SYR 178

272

EASY TOUCH INSULIN SYRINGE ........................

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178, 179EASY TOUCH LANCETS 21G 155EASY TOUCH LANCETS 23G 155EASY TOUCH LANCETS 26G 155EASY TOUCH LANCETS 26G/TWIST 155EASY TOUCH LANCETS 28G 155EASY TOUCH LANCETS 28G/TWIST 155EASY TOUCH LANCETS 30G 155EASY TOUCH LANCETS 30G/TWIST 155EASY TOUCH LANCETS 32G 155EASY TOUCH LANCETS 32G/TWIST 155EASY TOUCH LANCETS 33G/TWIST 155EASY TOUCH LANCING DEVICE 155EASY TOUCH SAFETY LANCETS 21G 155EASY TOUCH SAFETY LANCETS 23G 155EASY TOUCH SAFETY LANCETS 26G 155EASY TOUCH SAFETY LANCETS 28G 155EASY TOUCH SAFETY SYRINGE 179EASY TOUCH SHEATHLOCK SYRINGE 179EASY TOUCH TB SHEATHLOCK SYR 179easy trak control 147EASY TWIST & CAP LANCETS 155EASYGLUCO CONTROL 155EASYGLUCO PLUS LEVEL 1 155EASYMAX 15 LEVEL 1 CONTROL 156EASYMAX 15 LEVEL 1-2 CONTROL 156EASYMAX 15 LEVEL 2 CONTROL 156

EASYMAX CONTROL .........

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156EASYMAX CONTROL NORMAL/LOW 156EASYTEST II LANCETS 156EASYTEST LANCETS 156ec-81 aspirin 18ecolovit . 201ECONTRA EZ 82ECOTRIN LOW STRENGTH21ed chlorped jr 48ed-apap 13ed-spaz 248EDURANT . 68EFFER-K 197effervescent pot chloride 196EFFIENT 133element compact control 2 147element compact control 3 147ELEMENT CONTROL . 156ELEXA NATURAL FEEL 144ELEXA STIMULATING 144ELEXA ULTRA SENSITIVE

144ELIDEL 118ELINEST 78ELIQUIS 34elite-thin insulin syringe 171ELLA 82ELMIRON 132EMBRACE CONTROL 156EMBRACE EVO CONTROL LEVEL 1 156EMBRACE EVO CONTROL LEVEL 2 156EMBRACE GLUCOSE CONTROL 156EMBRACE LANCETS ULTRA THIN 30G 156EMBRACE PRO GLUCOSE CONTROL 156EMCYT 61EMOQUETTE 78empty capsule . 235empty capsule #0 red/white 234empty capsule #00 black/red 234empty capsule #00 blue/white 234empty capsule #00 pink/pink 234empty capsule #00 purple . 234empty capsule #00 purple/white

235empty capsule #00 red/white 235empty capsule #00 yellow/yello 235

empty capsule size 0 ................. .........

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235empty capsule size 0 blue 235empty capsule size 0 blue/wht . 235empty capsule size 0 clear 235empty capsule size 0 fun caps 235empty capsule size 0 green . 235empty capsule size 0 green/clr 235empty capsule size 0 grn/clear 235empty capsule size 0 maroon 235empty capsule size 0 orange 235empty capsule size 0 pink 235empty capsule size 0 purp/wht 235empty capsule size 0 purple 235empty capsule size 0 red . 235empty capsule size 0 red/clear 235empty capsule size 0 red/white 235empty capsule size 0 white 235empty capsule size 0 white/clr 235empty capsule size 0 yellow 235empty capsule size 00 blue 235empty capsule size 00 blue opq 235empty capsule size 00 clear 235empty capsule size 00 drk grn . 235empty capsule size 00 green 235empty capsule size 00 orange 235empty capsule size 00 red 235empty capsule size 00 white 235empty capsule size 000 clear 235empty capsule size 000 white 235empty capsule size 1 aqua blue 235empty capsule size 1 blue 235empty capsule size 1 blue/pink 235empty capsule size 1 blue/red 235empty capsule size 1 blue/wht 235empty capsule size 1 blueclear 236empty capsule size 1 brn/ivory 236empty capsule size 1 clear 236empty capsule size 1 drk green 236empty capsule size 1 green 236empty capsule size 1 grey/pink 236empty capsule size 1 grn/ornge 236empty capsule size 1 grn/white 236empty capsule size 1 grn/yllw 236empty capsule size 1 ivory 236empty capsule size 1 lght blue 236empty capsule size 1 maroon/cl 236empty capsule size 1 mint grn 236empty capsule size 1 orange 236empty capsule size 1 orge/clr 236empty capsule size 1 orge/yllw 236empty capsule size 1 ornge/wht 236empty capsule size 1 pink 236

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empty capsule size 1 pink/clr 236empty capsule size 1 pink/yllw 236empty capsule size 1 pnk/white 236empty capsule size 1 purple 236empty capsule size 1 pwdr blue 236empty capsule size 1 red 236empty capsule size 1 red/blue 236empty capsule size 1 red/white 236empty capsule size 1 veg clear 238empty capsule size 1 white 236empty capsule size 1 wht/clear 236empty capsule size 1 yellow 236empty capsule size 10 clear 236empty capsule size 11 clear 236empty capsule size 13 clear 236empty capsule size 2 blue 236empty capsule size 2 clear 236empty capsule size 2 green 236empty capsule size 2 white 236empty capsule size 3 black/grn 236empty capsule size 3 blue 237empty capsule size 3 blue opq 237empty capsule size 3 blue/clr 237empty capsule size 3 blue/wht 237empty capsule size 3 clear 237empty capsule size 3 dark grn 237empty capsule size 3 gray/pink 237empty capsule size 3 gray/yllw 237empty capsule size 3 green 237empty capsule size 3 grey/pink 237empty capsule size 3 grey/yllw 237empty capsule size 3 grn/blue 237empty capsule size 3 marn/blue 237empty capsule size 3 marn/clr 237empty capsule size 3 maroon 237empty capsule size 3 mint grn 237empty capsule size 3 olive 237empty capsule size 3 olive/clr 237empty capsule size 3 orange 237empty capsule size 3 orange/wh237empty capsule size 3 pink 237empty capsule size 3 pink/blue 237empty capsule size 3 pink/wh 237empty capsule size 3 pink/yllw 237empty capsule size 3 pnk/clear 237empty capsule size 3 prple/clr 237empty capsule size 3 purple 237empty capsule size 3 pwdr blue 237empty capsule size 3 red 237empty capsule size 3 red/clear 237empty capsule size 3 red/white 237

empty capsule size 3 white ..........

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237empty capsule size 3 white/clr 237empty capsule size 3 yellow 237empty capsule size 3 yellw/clr 237empty capsule size 4 black 237empty capsule size 4 blue/whit 237empty capsule size 4 clear 237empty capsule size 4 dark blue 238empty capsule size 4 purple 238empty capsule size 4 red/white 238empty capsule size 4 white 238empty capsule size 4 yellow 238empty capsule size 5 clear 238empty capsule size 7 clear 238EMTRIVA 68enalapril maleate 56enalapril-hydrochlorothiazide 56ENBREL 11ENBREL SURECLICK 11ENDOCET 24ENDUR-ACIN 257ENEMEEZ PLUS 141english toffee flavor 232enoxaparin sodium 34ENPRESSE-28 84ENSKYCE 79entacapone 63entecavir 69entre-b 93ENTRESTO 219enulose 130ENVIRO-STRESS 208e-ointment 112epa 220EPCLUSA 136epinastine hcl 225epinephrine 256EPIPEN 2-PAK 256EPIPEN JR 2-PAK 256EPITOL 36EPIVIR HBV 69EPOGEN 133, 134eq acetaminophen childrens 13eq acid reducer 249eq acid reducer max st 249eq adult aspirin low strength 18eq allergy relief 51, 218eq allergy relief (cetirizine) 51eq allergy relief childrens 48, 51eq antacid maximum strength 27eq antibiotic + pain relief 100eq anti-diarrheal 44, 45

eq antifungal .......................................

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114eq anti-itch max strength 107eq anti-nausea 46eq artificial tears 222eq aspirin 18eq aspirin adult low dose 18eq aspirin low dose 18eq athletes foot 103, 114eq athletes foot (terbinafine) 103eq athletes foot (tolnaftate) 103eq athletes foot spray 114eq calcium 500+d 191eq childrens aspirin 18eq childrens ibuprofen 7eq childrens loratadine 51eq childrens pain reliever 13eq complete multivit adult 50+ 201eq complete multivitamin child 212eq cough childrens 89eq daytime cold/flu ms relief 87eq eye itch relief 225eq gas relief 128eq heartburn relief 249eq hemorrhoidal max st 25eq hydrocortisone max st 107eq hydrocortisone plus 107eq ibuprofen 7eq ibuprofen infants 7eq infants gas relief 128eq itchy eye drops 225eq jock itch 114eq lansoprazole 251eq loratadine 51eq miconazole 3 combo pack 255eq motion sickness 46eq motion sickness relief 46EQ MUCUS ER 96eq naproxen sodium 7eq nasal allergy 218eq natural fiber laxative 138eq nicotine 243eq nicotine polacrilex 243eq nicotine step 3 243eq nighttime sleep aid 136eq nighttime sleep aid max st 136eq omeprazole 251eq omeprazole magnesium 251eq one daily womens health 201EQ ONE DAILY WOMENS PRO-ACTIVE 208eq pain & fever childrens 13eq pain & fever infants 13

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eq pain relief/rapid burst ..................................

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eq pain reliever junior 13eq ranitidine 249eq restore plus lubricant eye 223eq restore tears 223EQ REVIVE PLUS 224eq revive plus lubricant eye 223eq stool softener 141eq tolnaftate 103eq tussin 94eq tussin dm cough/chest 89eq tussin dm max 89eq vision formula 50+ 201eql absolute moisture dry skin 112eql acetaminophen childrens 13eql acetaminophen infants 13eql acid reducer 249eql advanced healing 112eql advanced recovery 112eql advanced skin therapy 112eql alcohol swabs 142eql all day allergy 51eql all day allergy childrens 51eql all day allergy-d 93eql allergy relief 51eql allergy relief childrens 48eql aloe after sun 112eql antacid advanced max st 27eql antibiotic + pain relief 100eql antifungal 114eql antifungal (tolnaftate) 103eql anti-itch intensive heal 107eql anti-itch maximum strength 108eql anti-nausea 46eql aspirin 18eql aspirin low dose 18eql athletes foot 114eql athletes foot(terbinafine) 103eql b-6 257eql baby basics diaper rash 105eql bacitracin zinc 101eql calcium/vitamin d 191eql castor oil 140eql century 202eql century mature 202eql century mature men 50+ 202eql century mature women 50+ 202eql child multivit/minerals 212eql childrens allergy 48eql childrens ibuprofen 7eql color lancets 21g 147eql color lancets micro 33g 147

eql daytime cold/flu relief 87eql fiber therapy 138eql first aid antibiotic 100eql fish oil 220eql fluticasone childrens 218eql fluticasone propionate 218eql gas relief 128eql heartburn prevention 249eql heartburn relief max st 249eql hemorrhoidal 25eql ibuprofen 7eql ibuprofen infants 7eql infants gas relief 128eql insulin syringe .................... 171eql iron supplement therapy 135eql lansoprazole .......................

.

251eql miconazole 3 255eql motion sickness relief 46eql mucus-er 94eql naproxen sodium 7eql natural fiber 138eql nicotine 243eql nicotine polacrilex 243eql nighttime sleep aid 136eql omega 3 fish oil 220eql omeprazole 252eql one daily mens 50+ advance

202eql one daily mens health 202eql one daily womens 50+ adv 202eql pain & fever infants 13eql scalp relief max strength 117eql sleep aid 136eql stress b-complex c/zinc 198eql super b complex/vitamin c 199eql super thin lancets 30g 147eql therapeutic 120eql thin lancets 26g 147eql tussin cough long-acting 86eql tussin cough/chest dm max 89eql tussin dm cough/chest cong 89eql tussin mucus/chest congest 94eql vision formula 202eql vitamin d3 258eql vitamin d3 gummies 258ergocalciferol 258ERGOMAR 189ERRIN 83ery 97ERYPED 200 142ERYPED 400 142ERY-TAB 142

ERYTHROCIN STEARATE 142erythromycin .......................

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97, 226erythromycin base 141erythromycin ethylsuccinate 142escitalopram oxalate 38ESGIC 17ESKIMO PUREFA 221ESSENTIA 208essential balance 202essential magnesium 195essentra wipes 9x9" 119ESTARYLLA 79estazolam 137ESTRACE 256estradiol 127estradiol-norethindrone acet 126ESTRING 256estropipate 127ethambutol hcl 60ethosuximide 37ethyl oleate 76ethynodiol diac-eth estradiol 77etidronate disodium 125etodolac 7etodolac er 7etoposide 62eugenol flavor 232EVENCARE CONTROL LOW/HIGH 156EVENCARE G2 LOW/HIGH CONTROL 156EVENCARE G3 LOW/HIGH CONTROL 156EVENCARE MINI CONTROL 156EVOLUTION CONTROL 157EVOTAZ 66EXEL COMFORT POINT INSULIN SYR 179EXELON 241exemestane 61exotic-hc 229EXTAVIA 242extra action cough 89eye itch relief 225EYE VITAMINS 208eye vitamins & minerals 202eyeprotect 202EYE-VITES 208E-Z JECT LANCET MICRO-THIN 33G 157

275

E-Z JECT LANCET SUPER THIN 30G ................................

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157

E-Z JECT LANCETS 157E-Z JECT LANCETS 21G 157E-Z JECT LANCETS THIN 26G 157EZ SMART BLOOD GLUCOSE LANCETS 157E-Z SPACER 187E-Z SPACER THE BODY GUARDS PK 187ezetimibe 55EZ-LETS LANCETS 21G 157EZ-LETS LANCETS 23G 157EZ-LETS LANCETS 26G 157EZ-LETS LANCETS 28G 157EZ-LETS LANCETS 30G 157FALLBACK SOLO 82FALMINA 79famciclovir 70famotidine 249FANTASY LUBRICATED 144FANTASY LUBRICATED/SPERMICIDE 144FARESTON 60FARXIGA 43fast acting antacid/anti-gas 27father johns medicine 86fa-vitamin b-6-vitamin b-12 134fe c tab plus 134fe tabs 135felbamate 36felodipine er 73FEMCAP 143FEMRING 256FEMYNOR 79FENESIN DM IR 91fenofibrate 55fenofibrate micronized . 55fenofibric acid 55fenoprofen calcium 7fentanyl 22FEROSUL 135ferro-bob .135ferrous gluconate .135ferrous sulfate 135ferrousul 135fever reducer childrens 13FEVERALL ADULTS 16FEVERALL CHILDRENS 16

FEVERALL JUNIOR STRENGTH ..............................

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16FIFTY50 ALCOHOL PREP 143FIFTY50 SAFETY SEAL LANCETS 157FIFTY50 SUPERIOR COMFORT SYR 179FIFTY50 UNILET LANCETS 33G 157finasteride 131FINE 30 157FINGERSTIX LANCETS 157FIRST-LANSOPRAZOLE 253FIRST-OMEPRAZOLE 253FIRST-VANCOMYCIN 25 59FIRST-VANCOMYCIN 50 59fish flavor 232fish oil 220fish oil burp-less . 220fish oil concentrate 220fish oil double strength 220fish oil extra strength 220fish oil maximum strength 220fish oil omega-3 220FISH OIL PEARLS 221fish oil triple strength 220fish oil ultra 220fish oil/super potent/no burp 220FLANAX PAIN RELIEF 11FLANDERS BUTTOCKS 113FLAVOR BLEND . 239flavor plus 238flavor sweet 238flavor sweet-sf . 238FLAVORX 233flavoxate hcl .254, 255flecainide acetate 31FLECTOR 105FLEET BISACODYL 140FLEXICHAMBER 188FLEXICHAMBER ADULT MASK/SMALL 188FLEXICHAMBER CHILD MASK/LARGE 188FLEXICHAMBER CHILD MASK/SMALL 188FLINSTONES GUMMIES OMEGA-3 DHA 215FLINTSTONES COMPLETE

212FLINTSTONES GUMMIES BONE BUILD 212

FLINTSTONES PLUS CALCIUM ...............................

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215FLINTSTONES PLUS IRON214FLINTSTONES/EXTRA C 215FLINTSTONES/MY FIRST 215FLOVENT DISKUS 33FLOVENT HFA 33fluconazole 47, 48fludrocortisone acetate . 85flunisolide . 218fluocinolone acetonide . 108fluocinonide 108fluocinonide emulsified base 108fluocinonide-e 108FLUORABON 195FLUOR-A-DAY 195FLUORIDEX DAILY RENEWAL 198fluoritab 195fluorometholone 228FLUOROPLEX 105fluorouracil 105fluoxetine hcl 38fluoxetine hcl (pmdd) 243fluphenazine hcl 65FLURA-DROPS 195flurazepam hcl . 137flurbiprofen . 7flurbiprofen sodium 227flutamide 60fluticasone propionate 108, 219fluvastatin sodium 55fluvastatin sodium er 55fluvoxamine maleate 38FML FORTE 228FOCALIN 5FOCALIN XR 5folcal dha 217folding paddle walker 170folic acid 134folplex 2.2 134fondaparinux sodium 34FORA CONTROL 157FORA LANCETS 157FORA LANCING DEVICE 157FORACARE GDH CONTROL 157, 158formula em 46FORTISCARE CONTROL 158fosinopril sodium 56fosinopril sodium-hctz 56FOSRENOL 131

276

FRAGMIN .................................

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34freds pharmacy autolet lancing 147freds pharmacy unilet lanc 28g 147freds pharmacy unilet lanc 30g 147FREESTYLE CONTROL SOLUTION 158FREESTYLE LANCETS 158FREESTYLE PRECISION INS SYR 179FREESTYLE UNISTICK II LANCETS 158fruity chews 214fruity chews/iron 213FUNGICURE INTENSIVE/NAILGUARD 116fungi-guard 103FUNGOID-D 104furosemide 124FUZEON 67FYAVOLV 127g tussin ac 89gabapentin 35GABITRIL 36galantamine hydrobromide 241galantamine hydrobromide er 241gas relief . 128gas relief extra strength 128GAS-X EXTRA STRENGTH129GAS-X INFANT DROPS 129gatifloxacin 226GAVILYTE-C 138GAVILYTE-G 138GAVILYTE-N WITH FLAVOR PACK . 138ge100 control 147gemfibrozil 55generlac 130GENGRAF 70GENOTROPIN 125GENOTROPIN MINIQUICK

125genpril 7GENTAK 226gentamicin sulfate 101, 226GENTEAL TEARS 223gentle skin cleanser 119GENTLE-LET GP LANCETS

158GENTLE-LET LANCETS 158GENTLE-LET PLATFORMS

158GENVOYA 66

GEODON ..................................

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64GERBER GOOD START WATER 239geriaton 199GERI-HYDROLAC 12 113geri-tussin 94geri-tussin dm 89gerivite complete 202g-fen dm 89GIANVI 79GILDAGIA 79GILDESS FE 1.5/30 79GILDESS FE 1/20 79GILENYA 246GLATIRAMER ACETATE ..242glenmax peb dm 97glimepiride 44glipizide 44glipizide er 44glipizide xl 44glipizide-metformin hcl 43global alcohol prep ease 142global easy glide insulin syr 171global inject ease insulin syr

171, 172global inject ease lancets 28g 147global inject ease lancets 30g 147global insulin syringes 172global lancing device 147GLUCAGEN HYPOKIT 40GLUCAGON EMERGENCY 40GLUCO BURST 41GLUCOCARD 01 CONTROL

158GLUCOCARD EXPRESSION CONTROL 158GLUCOCARD SHINE CONTROL 158GLUCOCARD X-SENSOR CONTROL 158GLUCOCOM AUTOLINK TELEMONITOR 158GLUCOCOM CONTROL 158GLUCOCOM LANCETS 28G

158GLUCOCOM LANCETS 30G

158GLUCOCOM LANCETS 33G

158GLUCOPRO INSULIN SYRINGE 179, 180glucose 39, 40

glucose control ......................... ................

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147glucose instant energy 39GLUCOSOURCE LANCET DEVICE 159GLUCOSOURCE LANCETS

159glucoten 202GLUTOSE 15 41glyburide 44glyburide micronized 44glyburide-metformin 44glycerin 77, 112glycerin (adult) 139glycerin (child) 139glycerin (infants & children) 139glycerin (pediatric) 139glycerine 77glycerol formal 77glycopyrrolate . 253GLYDO 118GMATE CONTROL LEVEL 2 159GMATE LANCETS 30G 159GMATE LANCING DEVICE

159gnp 24 hour nasal allergy 219gnp acid control 150 max st 249gnp acid control 75 249gnp acid reducer 250gnp acid reducer max st 250gnp adult aspirin low strength 18gnp alcohol swabs 142gnp all day allergy 51gnp all day allergy childrens 51gnp all day allergy-d 93gnp all day pain relief 8gnp allergy relief . 51gnp animal shapes 214gnp animal shapes plus extra c 215gnp animal shapes plus iron 213gnp antacid maximum strength 27gnp antibiotic plus pramoxine 100gnp anti-diarrheal 45gnp anti-nausea . 46gnp aspirin . 18, 19gnp aspirin low dose 18gnp athletes foot . 114gnp bacitracin zinc 101gnp calcium 194gnp calcium 500/d . 191gnp calcium 600 plus d/mineral191gnp calcium 600/d . 191

277

gnp calcium plus 600 +d ..........

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191

gnp calcium/vitamin d/minerals191gnp capsaicin 117gnp castor oil 140gnp century 202gnp century active performance

202gnp century adult formula 202gnp century adults 50+ senior 202gnp century cardio health 202gnp century mature 202gnp century ultimate mens 202gnp century ultimate womens 202gnp childrens allergy 48gnp childrens chewables/ex c 215gnp childrens chewables/iron 213gnp childrens easy-melts 13gnp childrens ibuprofen 8gnp childrens pain relief 13gnp cough relief 86gnp d 1000 258gnp d 2000 258gnp day time cold/flu 87gnp diabetic support formula 202GNP EASY TOUCH CONT HIGH/LOW 159gnp eye itch relief 225gnp fish oil 220, 221gnp fish oil max st . 220gnp fluticasone propionate 219gnp foaming antacid 28gnp gas relief extra strength 128gnp glucose . 39, 40gnp glycerin 112gnp glycerin (adult) 139gnp glycerin (infant) 139gnp glycerin child 139gnp hair/skin/nails 202gnp healthy eyes 202gnp healthy eyes supervision 202gnp heartburn relief 250gnp heartburn relief 200 250gnp hydrocortisone 108gnp hydrocortisone max st 108gnp hydrocortisone plus 108gnp hydrocortisone/aloe 121gnp hydro-lotion 108gnp ibuprofen 8gnp ibuprofen infants 8gnp infants gas relief . 128gnp infants pain relief 13gnp infants pain/fever 13

gnp insulin syringe ................... ....................................

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172gnp iron 135gnp isopropyl alcohol wipes 119gnp itchy eye 225gnp lancets 147gnp lancets 21g 147gnp lancets micro thin 33g 147gnp lancets super thin 30g 147gnp lancets thin 147gnp lancets thin 26g 147gnp lansoprazole 252gnp little ones childrens 214gnp loratadine 51gnp loratadine childrens 51gnp lubricating plus eye drops 223gnp magnesium 195gnp magnesium oxide 28GNP MASANTI MAXIMUM STRENGTH 28gnp maximum one daily 202gnp mega multi for men 202gnp mega multi for women 202gnp miconazole 3 255gnp miconazole 3 applicator 255gnp miconazole nitrate 115gnp miconazorb af 115gnp micro thin lancets 33g 148gnp motion sickness relief 46gnp mucus er 94gnp mucus relief childrens 94gnp mucus relief cough child 89gnp mucus relief dm 89gnp mucus relief dm max 89gnp naproxen sodium 8gnp natural fiber 138gnp niacin 256gnp niacin tr 256gnp nicotine 244gnp nicotine mini . 244gnp nicotine polacrilex 244gnp nighttime sleep aid . 136gnp omeprazole 252gnp one daily maximum 202gnp one daily mens 50+advanced 202gnp one daily mens health 50+ 202gnp one daily mens/lycopene 202gnp one daily plus iron 199gnp one daily womens 202gnp one daily womens 50+ 202gnp opti-vitamins 202gnp pain & fever childrens 13

gnp pain relief extra strength ..............

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13gnp quick dissolve glucose 40gnp scalp relief . 117gnp slow release iron 135gnp stool softener . 141gnp super thin lancets 30g 148gnp tab tussin dm 89gnp terbinafine hydrochloride 103gnp therapeutic-m 202gnp tolnaftate 103gnp triple antibiotic plus 100gnp tussin 94gnp tussin cough long acting 86gnp tussin dm 89gnp tussin dm cough 89gnp tussin dm max 89gnp tussin mucus & chest cong 94gnp ultra com insulin syringe 172gnp vitamin b-6 257gnp vitamin d 259gnp vitamin d maximum strength

259gnp vitamin d super strength 259gnp vitamin d3 extra strength 259gnp womens one daily 202gnp zinc oxide 105GOOD START STERILE WATER 239goodsense acid reducer 250goodsense all day allergy 51goodsense aspirin 19goodsense aspirin adult low st 19goodsense aspirin low dose 19goodsense daytime 87goodsense glucose 39goodsense ibuprofen 8goodsense ibuprofen childrens . 8goodsense ibuprofen infants 8goodsense lancets 30g 148goodsense lancets 33g 148goodsense lancing device 148goodsense lansoprazole 252goodsense lubricating eye drop 223goodsense naproxen sodium 8goodsense nasoflow 219goodsense natural fiber . 138goodsense nicotine 244goodsense pain & fever child 13goodsense pain & fever infants 14gordomatic 113granisetron hcl 45GRANIX 134

278

grape flavor .............................................................

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232grape syrup 238griseofulvin microsize 47griseofulvin ultramicrosize . 47G-TRON 91guaiasorb dm . 89guaiatussin ac 89guaicon dms . 89guaifenesin 94, 95guaifenesin ac 89guaifenesin dm 89guaifenesin er 94guaifenesin-codeine 89guaifenesin-dm 89guanfacine hcl 57guava flavor 232GYNECORT 10 111HAEMOLANCE 159HAEMOLANCE LOW FLOW LANCETS 159HAEMOLANCE PLUS 159HAEMOLANCE PLUS HIGH FLOW 159HAEMOLANCE PLUS LOW FLOW 159HAEMOLANCE PLUS MAX FLOW 159HAEMOLANCE PLUS PEDIATRIC FLOW 159hair formula extra strength 202hair skin and nails formula 203hair skin nails 203hair vitamins 203hair/skin/nails 203hair/skin/nails/biotin 203halobetasol propionate 108haloperidol 64haloperidol lactate 64ham flavor 232HARVONI 136HEALTH CARE LANCING DEVICE 159healthwise alcohol prep 142healthwise lancets 30g 148healthwise lancing pen 148healthy accents lancing device 148healthy accents unilet lancets 148healthy eyes 203healthy eyes/lutein 203HEALTHY KIDS VITAMIN D3 260

HEALTHY MAMA MOVE IT ALONG ..............................

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141HEALTHYLAX 140heartburn relief 250heartburn relief 150 max st 250heartburn relief max st 250heartburn treatment 24 hour 252HEATHER 83h-e-b aspirin 19h-e-b incontrol adv lancing 148h-e-b incontrol alcohol . 142h-e-b incontrol lancets 28g . 148h-e-b incontrol lancets 30g 148h-e-b incontrol lancets 33g 148HEMA-COMBISTIX 123HEMMOREX-HC 26hemorrhoidal 25, 26hemorrhoidal max st/aloe 25hemorrhoidal max str 25HEPAGAM B 229heparin sodium (porcine) 34heparin sodium (porcine) pf 34HEXALEN 60HIGH POTENCY CALCIUM

194high potency iron 135hi-kovite 2-part formula 203hi-potency multi-vitamin 203hm acetaminophen childrens 14hm acid reducer 250hm acid reducer max strength 250hm advanced antacid max st 27hm all day allergy 51hm allergy childrens 49hm allergy complete childrens 51hm allergy complete-d 93hm allergy relief . 51, 219hm allergy relief childrens 49hm animal shapes 212hm antacid anti-gas ex st 27hm anti-nausea 46hm antioxidant vitamins . 203hm aspirin 19hm aspirin ec low dose 19hm baby cornstarch 118hm bacitracin 101hm calcium-vitamin d 191hm calcium-vitamin d-minerals 191hm castor oil 76hm cetirizine hcl childrens 51hm chest congestion relief dm 89hm complete 203

hm complete 50+ ...................... .................

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203hm complete women 203hm cough relief 86hm day time 87hm eye itch relief 225hm famotidine 250hm fiber 138hm fish oil 221hm gas relief extra strength 128hm gas relief infants drops . 128hm glucose 39hm glycerin 113hm hydrocortisone plus 121hm hydrocortisone-aloe max st 121hm ibuprofen 8hm ibuprofen childrens 8hm ibuprofen ib 8hm ibuprofen infants 8hm lansoprazole 252hm lice treatment 119hm loperamide hcl 45hm loratadine 51hm loratadine childrens 51hm lubricating plus 223hm magnesium 28hm mens 50+ advanced one daily 203hm motion relief 46hm motion sickness 46hm motion sickness relief 46hm mucus er 95hm multivitamin adult gummy 203hm naproxen sodium 8hm niacin 257hm niacin tr 257hm nicotine . 244hm nicotine polacrilex . 244hm nighttime sleep aid 136hm omeprazole 252hm one daily/iron 199hm pain & fever childrens 14hm pain & fever infants 14hm pain relief childrens 14hm stool softener . 141hm super vitamin b complex/c 199hm triple antibiotic max st 100hm tussin adult 95hm tussin adult dm 89hm vitamin b complex/vitamin c

199hm vitamin b6 257hm vitamin d 259

279

hm vitamin d3 ...........................

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259hm womens 50+ advanced daily

203HOMATROPAIRE 224homatropine hbr 224honey flavor 232HUMALOG 41HUMALOG KWIKPEN 41HUMALOG MIX 50/50 41HUMALOG MIX 50/50KWIKPEN 41HUMALOG MIX 75/25 41HUMALOG MIX 75/25 KWIKPEN 41HUMIRA 6HUMIRA PEDIATRIC CROHNS START 5, 6HUMIRA PEN 5, 6HUMIRA PEN-CROHNS STARTER 5, 6HUMIRA PEN-PSORIASIS STARTER 6HUMULIN 70/30 42HUMULIN 70/30 KWIKPEN . 42HUMULIN N 42HUMULIN N KWIKPEN 42HUMULIN R 42HUMULIN R U-500 (CONCENTRATED) 42HUMULIN R U-500 KWIKPEN 42hydralazine hcl 58hydrochlorothiazide . 124hydrocodone-acetaminophen21, 22hydrocodone-homatropine 87hydrocodone-ibuprofen 22HYDROCOL 122hydrocortisone 25, 26, 85, 108, 109hydrocortisone acetate 26, 108hydrocortisone butyr lipo base .108hydrocortisone butyrate 108HYDROCORTISONE IN ABSORBASE 111hydrocortisone intensive heal 109hydrocortisone max st 109hydrocortisone max st/12 moist 109hydrocortisone micronized . 109hydrocortisone plus 109hydrocortisone valerate 109hydrocortisone-acetic acid 229hydrocortisone-aloe 121hydrocortisone-iodoquinol 102

HYDROLATUM .................... ....................................

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114hydromet . 87hydromorphone hcl 22hydrophor 113HYDROSKIN 111hydroxychloroquine sulfate 59hydroxyprogesterone caproate 76hydroxyurea 61hydroxyzine hcl 30hydroxyzine pamoate 30hyoscyamine sulfate 248hyoscyamine sulfate er 248hyosyne 248HYPERHEP B S/D 229HYPERRHO S/D 229HYPERSAL 96HYPOLANCE AST LANCING 159hy-vee all day relief 8hy-vee glucose 39HYVEE IBUPROFEN CHILDRENS 11HY-VEE LANCETS 159hy-vee thin lancets 148ibandronate sodium 125ibu-200 8IBUDONE 22ibu-drops 8ibuprofen 8ibuprofen childrens 8ICAPS 208ICAPS AREDS 2 208ICAPS LUTEIN & OMEGA-3

208ICAPS MV 208ICAR-C PLUS 134imatinib mesylate 61IMBRUVICA 61imipramine hcl 39imiquimod 116IN TOUCH 159IN TOUCH GLUCOSE CONTROL 159IN TOUCH LANCING DEVICE 159IN TOUCH STERILE LANCETS 30G 159INATAL ADVANCE 216INATAL GT 216INATAL ULTRA 216IN-CHECK DIAL FLOW TRAINER 186

IN-CHECK INSPIRATORY FLOW MTR ...........................

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186indapamide 124indomethacin 8indomethacin er 8infants gas relief 128infants ibuprofen ...8infants pain & fever .14infants pain reliever .14infants simethicone 128INFINITY CONTROL 159INSPIRACHAMBER/LARGE

188INSPIRACHAMBER/MEDIUM 188INSPIRACHAMBER/MOUTHPIECE 188INSPIRACHAMBER/SMALL

188INSPIREASE 188instacort 5 109INSTA-GLUCOSE 41insulin syringe 172insulin syringe/needle 173INTELENCE 68intense cough reliever .89INTRON A 61INTROVALE 83INVEGA SUSTENNA 64INVEGA TRINZA 64INVIRASE 67INVOKANA 43IONIL-T . 120ipratropium bromide 32, 218i-prin 9irbesartan 57irbesartan-hydrochlorothiazide 57iron 135iron 100 plus 134iron high-potency . 135ISENTRESS 67ISIBLOOM 79isoniazid 60isopropyl alcohol 119isopropyl alcohol wipes 119isosorbide dinitrate 29isosorbide dinitrate er 29isosorbide mononitrate 29isosorbide mononitrate er 29isradipine 73itraconazole 48ivermectin 29

280

i-vite ...................................................................................................... ................................

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203

i-vite protect 203JANTOVEN 34JANUMET 41JANUMET XR 41JANUVIA 41JENCYCLA 83JENTADUETO 41jevantique lo 126JINTELI 127jock itch 115jock itch relief 115jock itch spray 103jock itch spray powder 103JOHNSONS BABY CORNSTARCH 118JOHNSONS BABY POWDER

118JOHNSONS BABY PURE CORNSTARCH 118JOLESSA 83JOLIVETTE 83JULEBER 79JUNEL 1.5/30 79JUNEL 1/20 79JUNEL FE 1.5/30 79JUNEL FE 1/20 79JUNEL FE 24 79just tears eye drops 222kahlua flavor 232KALBITOR 133KALETRA .. 66KAMELEON LUBRICATED

144KAPVAY 3KARIDIUM 195KARIGEL 198KARIGEL-N 198KARIVA 77k-effervescent 196KELNOR 1/35 79KERICORT 10 111KETOCARE 122ketoconazole 47, 115KETO-DIASTIX 123ketone test 122ketoprofen 9ketorolac tromethamine 9, 227KETOSTIX 122ketotifen fumarate 225KIMIDESS 77kimono 143

KIMONO COLORS ....................................

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144

kimono micro thin 143kimono micro thin plus 143kimono plus 143kimono ps 143kimono ps plus 143kimono sensation 144kimono sensation plus 144KIMONO SPECIAL 144kinney lancets 148kinney thin lancets 148kinray insulin syringe 173KIONEX 71, 240KITABIS PAK 5KLOR-CON 197KLOR-CON 10 197KLOR-CON M10 197KLOR-CON M15 197KLOR-CON M20 197KLOR-CON SPRINKLE 197KLOR-CON/EF 197kls acid controller max st 250kls acid reducer 250kls acid reducer max st 250KLS ALLERCLEAR . 53KLS ALLER-FLO 219KLS ALLER-TEC 53KLS ALLER-TEC CHILDRENS 53KLS ALLER-TEC D 93kls aspirin low dose 19kls hydrocortisone plus 121kls ibuprofen 9kls lansoprazole 252kls naproxen sodium 9kls natural psyllium fiber 138kls omeprazole 252kls pain & fever infants 14kls pain relief childrens 14KLS QUIT2 246KLS QUIT4 246kmart valu insulin syringe 29g 173kmart valu insulin syringe 30g 173KONSYL 139kp adults 50+ daily formula 203kp adults daily formula 203kp aspirin 19kp b complex-c 199kp bacitracin zinc 101kp benzoyl peroxide 99kp benzoyl peroxide wash 99kp calcium 600+d 191

kp cetirizine hcl ....................................................

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51kp clotrimazole 115kp diphenhydramine hcl . 49kp ferrous gluconate 135kp ferrous sulfate 135kp fish oil 221kp fluticasone propionate 219kp folic acid 134kp hydrocortisone 109kp hydrocortisone max st . 109kp ketotifen fumarate 225kp loratadine 51kp mens 50+ daily formula 203kp mens daily formula 203kp miconazole nitrate 115kp niacin 257kp omega-3 fish oil 221kp omeprazole magnesium . 252kp pseudoephedrine hcl 219kp terbinafine hydrochloride 103kp tolnaftate 103KP VISION FORMULA 208KP VISION FORMULA/LUTEIN 209kp vitamin b-6 257kp vitamin d 259kp vitamin d3 259kp womens 50+ daily formula 203kp womens daily formula 203K-PHOS 196K-PHOS NO 2 132K-PRIME 197kroger glucose 39kroger insulin syringe 173kroger lancets 148kroger lancets 21g 148kroger lancets micro thin 33g 148kroger lancets super thin 148kroger lancets thin 148kroger lancets thin 26g 148kroger lancets ultrathin 30g 148kroger lancing device 148ks ibuprofen 9KURVELO .79k-vescent 196KYLEENA . 83labetalol hcl .71LABSTIX 123lactose monohydrate . 240lactulose 139lactulose encephalopathy 130LAMISIL AF DEFENSE 104

281

lamivudine ............................................

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68, 69lamivudine-zidovudine 66lamotrigine 35lamotrigine er 35LANACORT 10 111LANAPHILIC/UREA 112lancet device 148lancet device with ejector 148lancet transporter case ... 148lancets 148lancets 28g 148lancets 30g 148lancets micro thin 33g 148lancets super thin 28g 148lancets thin 148LANCETS ULTRA FINE 159LANCETS ULTRA THIN 160lancets ultra thin 30g 148lancing device 148LAND BEFORE TIME MULTIVITAMIN 214, 215LANOXIN 74lansoprazole 252LANTUS 42LANTUS SOLOSTAR 42LANZO 160LARIN 1.5/30 79LARIN 1/20 79LARIN 24 FE 79LARIN FE 1.5/30 79LARIN FE 1/20 79LARISSIA 80latanoprost 228LATUDA 64leader advanced lancing device148leader glucose 39leader insulin syringe 173leader quick dissolve glucose 40LEENA 84leflunomide 11lemon extract 232lemon flavor 232LESSINA 80LETAIRIS 75letrozole 61leucovorin calcium 62, 76LEUKERAN 62LEUKINE 134LEVA SET/OCCLUSIVE DRESSING 121levalbuterol tartrate 32LEVEMIR 42

LEVEMIR FLEXTOUCH ..................................... ...................................................

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42levetiracetam 35levetiracetam er 35levobunolol hcl 224levocarnitine 125levofloxacin 128, 226LEVONEST 84levonorgest-eth estrad 91-day 82levonorgestrel 82levonorgestrel-ethinyl estrad 78, 82levonorg-eth estrad triphasic 84LEVORA 0.15/30 (28) . 80LEVO-T 247levothyroxine sodium 247LEVOXYL 247LEXIVA 67LIBERTY GLUCOSE CONTROL 160LIBERTY GLUCOSE CONTROL MID 160LIBERTY MEDICAL LANCETS 160LIBERTY MINI LANCING DEVICE 160lice treatment 119LICIDE MAXIMUM STRENGTH 119licorice flavor 232LIDO BDK 121lidocaine 117lidocaine hcl 117, 118, 197lidocaine pak 118lidocaine viscous 197lidocaine-hydrocortisone ace 26lidocaine-prilocaine 120, 121lidopin 118lidopril 121lidopril xr 121LIDO-PRILO CAINE PACK121LIFESCAN UNISTIK 2 160LIFESCAN UNISTIK II LANCETS 160LILETTA (52 MG) 83lindane 119LINZESS 130liothyronine sodium 247LIPROZONEPAK 121liquid pain relief 14liquitears . 223lisinopril 56lisinopril-hydrochlorothiazide 56lite touch lancets 148

LITE TOUCH LANCING DEVICE ..................................

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160LITE TOUCH LANCING PEN 160LITEAIRE 188LITETOUCH INSULIN SYRINGE 180LITETOUCH LANCETS 160lithium 64lithium carbonate 64lithium carbonate er 63little animals 214little animals plus iron 213LITTLE REMEDIES FOR FEVER 16LITTLE REMEDIES FOR TUMMYS 129LITTLE TUMMYS GAS RELIEF 129LITTLE TUMMYS LAXATIVE 140LITTLE TUMMYS NAUSEA RELIEF 46live better adv lancing device 148live better lancet super thin 149live better lancet ultra thin . 149liver concentrate 232liver flavor 232LIVIXIL PAK . 121lohist-dm 97LOMEDIA 24 FE 80longs glucose 39longs insulin syringe 173longs lancets standard . 149longs lancets thin 149longs lancets ultra thin 149loperamide hcl 45lopinavir-ritonavir 66LOPREEZA 127loradamed 51loratadine . 52loratadine allergy relief 52loratadine childrens 52loratadine hives relief 52lorazepam 30LORAZEPAM INTENSOL 30LORCET 22LORCET HD 22LORCET PLUS 22LORYNA 80losartan potassium 57losartan potassium-hctz 57

282

LOTRIMIN AF .......................

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116LOTRIMIN AF DEODORANT POWDER 116LOTRIMIN AF JOCK ITCH POWDER 116LOTRIMIN AF POWDER 116lovastatin 55LOW-OGESTREL 80loxapine succinate .. 65LP LITE PAK 121lubricant eye drops 223lubricating lotion 113lubricating plus eye drops 223LUBRISILK 114LUBRISKIN 114LUDENT 195LUTERA 80LYRICA 36LYSIPLEX PLUS 209LYSODREN 60LYZA 83MAALOX ADVANCED MAX ST 28MAALOX CHILDRENS 28MAALOX MAX 28MAALOX MULTI SYMPTOM MAX ST 28MACULAR HEALTH FORMULA 209MACUVITE 209MACUVITE EYE CARE 209MACUVITE/LUTEIN 209mag-al plus xs 27MAGELLAN INSULIN SAFETY SYR 180magnesium 195, 196magnesium oxide 28, 196magnesium oxide -mg supplement 196magnum-75 203MAKENA 240malathion 119mango flavor 232MAOX 29mapap 14MAPAP ACETAMINOPHEN EXTRA STR 16MAPAP CHILDRENS 16maple flavor 232maprotiline hcl 37marlissa 78marshmallow flavor 232

marten-tab .................................. ....................

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17MASK VORTEX 188MATULANE 61MATZIM LA 74maxepa 221MAXI-COMFORT INSULIN SYRINGE 180MAXIMUM BLUE LABEL 209maximum daily green 203MAXIMUM EPA 221MAXIMUM GREEN LABEL

209MAXIMUM RED LABEL 209maxx 144maxx plus 144MCCARNITINE 125m-clear wc 89meclizine hcl 46meclofenamate sodium 9med-derm hydrocortisone 109medic insulin syringe 173medicated anti-fungal 103medichoice safety lancet 149medichoice safety lancet extra 149medichoice safety lancet norm 149MEDI-FIRST ANTI-FUNGAL 104medi-first hydrocortisone 109MEDI-PASTE 111MEDIPLEX PLUS 209MEDI-PROFEN 11MEDIPROXEN 11MEDISENSE GLUCOSE KETONE CONTR 160MEDISENSE HI/MID/LOW CONTROL 160MEDISENSE HIGH/LOW CONTROL 160MEDISENSE MID CONTROL 160MEDISENSE THIN LANCETS 160MEDI-TABS CHILDRENS 16MEDI-TABS JUNIOR STRENGTH 16medi-tussin dm 90medi-tussin dm diabetic 89medi-tussin dm double strength 90MEDLANCE EXTRA 21G 160MEDLANCE LITE 25G 160MEDLANCE PLUS EXTRA 21G 160

MEDLANCE PLUS LANCETS ...............................

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160MEDLANCE PLUS LITE25G 161MEDLANCE PLUS SPECIAL 0.8MM 161MEDLANCE PLUS SUPERLITE 30G 161MEDLANCE PLUS UNIVERSAL 21G 161MEDLANCE UNIVERSAL 21G 161MEDOLOR PAK 121medroxyprogesterone acetate

83, 240mefloquine hcl 59mega vm-80 203mega-marathon 100 tr 203megestrol acetate 62, 240meijer advanced formula 203meijer alcohol swabs 142meijer allergy relief 52meijer antacid 27meijer anti-diarrheal 45meijer cough syrup dm 90meijer ferrous sulfate 135meijer glucose 39meijer hydrocortisone 109meijer ibuprofen 9meijer jr st aspirin free 14MEIJER LANCETS 161MEIJER LANCETS THIN 161MEIJER LANCETS UNIVERSAL 21G 161MEIJER LANCETS UNIVERSAL 30G 161MEIJER LANCETS UNIVERSAL 33G 161meijer loratadine 52MEIJER SUPER THIN LANCETS 161meijer zinc oxide 105meloxicam ...9memantine hcl 242MENEST 127mens daily formula/lycopene 203MENS HAIR FORMULA ULTRA MAN 209MENS LIFE PACK 209MEPHYTON 261meprobamate 30mercaptopurine 60

283

mesalamine ..................................................................

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130MESNEX 62METAMUCIL SMOOTH TEXTURE 139metaproterenol sulfate 32metformin hcl 39metformin hcl er 39methadone hcl 22methazolamide 124methenamine hippurate 253methenamine mandelate 253methimazole 247methocarbamol 218methotrexate . 60methotrexate sodium 60methotrexate sodium (pf) 60methoxsalen 105methoxsalen rapid 105methyclothiazide 124methyldopa 57methyldopa-hydrochlorothiazide57methylphenidate hcl 4methylphenidate hcl er 4methylprednisolone 85methyltestosterone . 24metipranolol 224metoclopramide hcl 130metolazone 124metoprolol succinate er 72metoprolol tartrate 72metoprolol-hydrochlorothiazide 58metronidazole 58, 118, 119, 256mexiletine hcl 31MG217 MEDICATED TAR 120mi-acid maximum strength 27micaderm 115miconazole 3 255miconazole 3 applicator 255miconazole 3 combo pack 255miconazole 3 combo pack app 255miconazole nitrate 115miconazorb af 115MICRHOGAM ULTRA-FILTERED PLUS 229MICRO GUARD 116MICROCHAMBER 188MICRODOT CONTROL HIGH/LOW 161MICROGESTIN 1.5/30 80MICROGESTIN 1/20 80MICROGESTIN 24 FE 80MICROGESTIN FE 1.5/30 80

MICROGESTIN FE 1/20 ........ ........

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80MICROLET LANCETS 161MICROLET NEXT LANCING DEVICE 161MICROLIFE DIGITAL PEAK FLOW 185MICROSPACER 188MICROTAINER SAFETYFLOW LANCET 161midodrine hcl 256MIGERGOT 189miglitol .39milantex extra strength .27milk of magnesia concentrate 140MILLTRIUM ADVANCED FORMULA 209MILLTRIUM CARDIO 209MILLTRIUM SENIOR 209MILLTRIUM STAMINA PLUS 217MIMVEY 127MIMVEY LO 127mineral oil-hydrophil petrolat 112MINERIN 114mini lancing device 149MINI WRIGHT PEAK FLOW METER 185MINIPRIN LOW DOSE 21MINITRAN .29minocycline hcl 247minoxidil 58mint chocolate chip flavor 232mintox maximum strength .27MIRENA (52 MG) 83mirtazapine 37misoprostol 253MISTASSIST 186mm aspirin 19moexipril hcl 56moexipril-hydrochlorothiazide 56moisture 113moisture recovery 113moisturizing cream 113moisturizing lotion 113moisturizing sensitive skin 113moisturizing vitamin e/aloe 113mometasone furoate 109, 219MONDOXYNE NL 247MONISTAT 7 COMBO PACK APP 255MONOJECT INSULIN SYRINGE 180, 181

MONOJECT LIFESHIELD SYRINGE ................................

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181MONOJECT MAGELLAN SYRINGE 181MONOJECT SYRINGE 181MONOJECT ULTRA COMFORT SYRINGE 181MONOJECTOR END CAPS 161MONOJECTOR OPD END CAPS 161MONOLET LANCETS 161MONOLET OPD LANCETS 161MONOLETTOR SAFETY LANCETS 161MONO-LINYAH 80MONONESSA 80montelukast sodium 32, 33morphine sulfate 23morphine sulfate (concentrate) 23morphine sulfate er 23motion sickness 46motion sickness relief 46motion-time 46MOTRIN IB 11MOVANTIK 130MOXEZA 226moxifloxacin hcl 128ms insulin syringe 173MUCINEX CHEST CONGESTION CHILD 96MUCINEX COUGH CHILDRENS 91MUCINEX FAST-MAXCOLD & SINUS 88MUCINEX FAST-MAX DM MAX 91mucosa dm 90mucosal atomization device 170mucus relief chest congestion 95mucus relief childrens 95mucus relief cough childrens 90mucus relief dm 90mucus relief dm cough 90mucus relief dm max 90mucus relief er 95mucus-er 95MULTAQ 31multi + omega-3 adult gummies

203multi adult gummies 203multi antibiotic plus 101MULTI COMPLETE 209

284

multi complete/iron .................................................

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203multi for her 204multi for her 50+ 203MULTI FOR HIM 209multi for him 50+ 204multi vitamin/minerals 204multi-day plus iron 199multi-day plus minerals 204MULTI-DAY WEIGHTTRIM 209multi-delyn 215multi-lancet device 149MULTI-LANCET DEVICE 2

161MULTI-LEAN 209multilex 204multilex-t 204multimineral plus 204multiple vit/minerals/no iron 204multiple vitamins/iron 199multiple vitamins/womens 204MULTISTIX 123MULTISTIX 10 SG 123MULTISTIX 5 123MULTISTIX 7 123MULTISTIX 8 123MULTISTIX 9 123MULTISTIX 9 SG 123multi-vit/fluoride 213multi-vit/fluoride/iron 212multi-vit/iron/fluoride 212multivitamin 204multivitamin & mineral 204multivitamin adults 204multivitamin adults 50+ 204multivitamin childrens 214multi-vitamin gummies 204multivitamin gummies adult 204multivitamin gummies mens 204multivitamin gummies womens .204multivitamin men 50+ 204multi-vitamin menopausal 204multivitamin women 204multivitamin women 50+ 204multivitamin/extra vitamin d3 204multivitamin/fluoride 213multi-vitamin/fluoride 213multi-vitamin/fluoride/iron 212multi-vitamin/iron 199multi-vitamin/minerals 204multivitamins 211multivitamins/fluoride 213

multivitamins/minerals adult ......................................

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204mupirocin 101MVC-FLUORIDE 213M-VIT 216mv-one 212MX-SOL 239MX-SOL BLEND 239MX-SOL BLEND SF 239MX-SOL SF 239MX-SOL SUSPEND . 239MY WAY 82myamulti 204MYCOCIDE CLINICAL NS 104mycophenolate mofetil 71MYGLUCOHEALTH CONTROL 161MYGLUCOHEALTH LANCETS 30G 161MYLANTA MAXIMUM STRENGTH 28MYLERAN 60mynatal plus 216mynatal-z 216MYORISAN 100my-vitalife 204MYZILRA .84NABI-HB 229nabumetone 9nadolol 72nadolol-bendroflumethiazide 58NAFRINSE .............. 195NAFRINSE DROPS 195naloxone hcl 45naltrexone hcl 45NAMENDA 242naproxen 9naproxen dr 9naproxen sodium 9naproxen sodium er 9NARAMIN 49naratriptan hcl 189NARCAN 45nasal allergy 24 hour 219nasal mist 96NATACYN 226nateglinide 43natrul magnesium 196nat-rul vitamin d 259natural balance tears 222natural fiber 139natural fiber laxative 138natural vitamin d-3 259

natures tears ............................. ................

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222NATURE-THROID 247nausatrol 46nausea control 46nebulizer 185NEBUSAL 96NECON 0.5/35 (28) 80NECON 1/35 (28) 80NECON 1/50 (28) 80NECON 10/11 (28) 77NECON 7/7/7 84neomycin sulfate 5neomycin-bacitracin zn-polymyx

226neomycin-polymyxin-dexameth 228neomycin-polymyxin-gramicidin

226neomycin-polymyxin-hc 228, 229NEO-POLYCIN 227NEO-POLYCIN HC 228NEOSPORIN + PAIN RELIEF MAX ST 101NEOSPORIN + PAIN/ITCH/SCAR . 101neotuss 90NETGROUP LANCETS 162NEUAC 98neuro-k-50 257NEUTEK 2TEK CONTROL 162NEUTRAGARD ADVANCED

198neutral sodium fluoride 197nevirapine 68nevirapine er 68NEXAVAR 61NEXGEN CONTROL 162NEXIUM 253NEXIUM 24HR 253NEXIUM 24HR CLEAR MINIS 253NEXPLANON 83NEXT CHOICE ONE DOSE 82niacin 257niacin er 257niacin er (antihyperlipidemic) ....55niacin-50 257nicardipine hcl 73NICORELIEF 246nicotine 244nicotine mini 244nicotine polacrilex 244nicotine step 1 244

285

nicotine step 2 ......................................................

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244nicotine step 3 244NIFEDICAL XL 74nifedipine 73nifedipine er 73nifedipine er osmotic release ......73night time sleep aid 136nighttime sleep 136nighttime sleep aid . 136NIKKI 80nimodipine 73nisoldipine er 73NITRATEST PAPER 122NITRO-BID 29nitrofurantoin 254nitrofurantoin macrocrystal 253nitrofurantoin monohyd macro 253nitroglycerin 29nitroglycerin er 29NITRO-TIME 29NIVA-PLUS 216NIVEA MOISTURIZING BODY WASH 120NIVEA TOUCH OF SMOOTHNESS 120NIVEA VISAGE GENTLE CLEANSING 120nizatidine 250NOBLE FORMULA HC 111non-aspirin childrens 14non-aspirin jr strength 14NORA-BE 83norethin ace-eth estrad-fe 78norethindrone 83norethindrone acetate 240norethindrone acet-ethinyl est 78norethindrone-eth estradiol 126norgestimate-eth estradiol 78norgestim-eth estrad triphasic 84NORLYDA 83NORLYROC 84NORTEMP 16nortemp infants 14NORTREL 0.5/35 (28) 80NORTREL 1/35 (21) 80NORTREL 1/35 (28) 80NORTREL 7/7/7 84nortriptyline hcl 39NORVIR 67norwegian salmon oil 221NORWICH ASPIRIN 21

NOVA MAX PLUS GLU/KET CONTROL ..............................

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162NOVA MAX PLUS KETONE TEST 122NOVA SAFETY LANCETS 23G 162NOVA SAFETY LANCETS 28G 162NOVA SUREFLEX LANCETS 162NOVA SUREFLEX LANCING DEVICE 162NOVOLIN 70/30 42NOVOLIN 70/30 RELION 42NOVOLIN N 42NOVOLIN N RELION 42NOVOLIN R 42NOVOLIN R RELION 42NOVOLOG 43NOVOLOG FLEXPEN 42NOVOLOG MIX 70/30 43NOVOLOG MIX 70/30FLEXPEN 43NOVOLOG PENFILL 43np thyroid 247NUCYNTA 23NULEV 248NUTRIFAC ZX 209NUTROPIN AQ NUSPIN 10 125NUTROPIN AQ NUSPIN 20 125NUTROPIN AQ NUSPIN 5 126NUVARING 81NYAMYC 104NYATA 104nystatin 47, 103, 197nystatin-triamcinolone 102NYSTOP 104NYTOL 137O-CAL FA 216OCELLA 80octreotide acetate 126OCUSOFT HAND SOAP 120ocutabs 204ocutabs-lutein 204OCUVITE EXTRA 209OCUVITE EYE + MULTI 209OCUVITE EYE HEALTHFORMULA 209OCUVITE EYE HEATLH GUMMIES 209OCUVITE-LUTEIN 209odor control foot & sneaker 103

ODOR EATERS ANTIFUNGAL .......................

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104ODOR EATERS FOOT/SNEAKER SPRAY 104OFF DEEP WOODS 117OFF DEEP WOODS DRY 116OFF DEEP WOODS SPORTSMEN 117OFF FAMILYCARE CLEAN FEEL 117OFF SMOOTH & DRY 117ofloxacin 128, 226, 229OGESTREL 80olanzapine 66olanzapine-fluoxetine hcl 246olive oil 76olopatadine hcl 218, 225omega 3 221omega iii epa+dha 221omega-3 221omega-3 cf 221omega-3 fish oil 221omega-3 plus 221omeprazole 252omeprazole magnesium 252OMEPRAZOLE+SYRSPEND SF ALKA 253OMERA 221OMNIFLEX DIAPHRAGM 145ON CALL EXPRESS GLUCOSE CONTR 162ON CALL LANCETS 162ON CALL LANCING DEVICE 162ON CALL PLUS GLUCOSE CONTROL 162ON CALL PLUS LANCETS 162ON CALL PLUS LANCING DEVICE 162ON CALL VIVID GLUCOSE CONTROL 162once daily/iron 199ondansetron 45ondansetron hcl 45one daily 50 plus 204one daily adults 50+ 204one daily calcium/iron 204one daily complete 204one daily complete for men 204one daily for men 50+ advanced

204one daily for men/lycopene 205

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one daily for women ................. ...

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205one daily for women 50+ adv 205one daily healthy weight 205one daily healthy weight adv 205one daily maximum 205one daily mens 205one daily mens 50+ multivit 205one daily mens 50+/lycopene 205one daily mens health 205one daily multivit/iron-free 205one daily multivitamin men 205one daily multivitamin women 205one daily multivitamin/iron 199ONE DAILY PLUS IRON 209one daily plus minerals 205one daily womens 205one daily womens 50 plus 205one daily womens 50+ 205one daily/minerals 205ONE FLOW SPIROMETER 186ONE-A-DAY TEEN ADVANTAGE/HER 210one-daily/iron 199ONETOUCH CLUB LANCETS FINE PT 162ONETOUCH COMBO PACK

162ONETOUCH DELICA LANCETS 33G 162ONETOUCH DELICA LANCETS FINE 162ONETOUCH DELICA LANCING DEV 162ONETOUCH FINEPOINT LANCETS 162ONETOUCH LANCETS 162ONETOUCH SURESOFT LANCING DEV 162ONETOUCH ULTRA 2 163ONETOUCH ULTRA BLUE 122ONETOUCH ULTRA CONTROL 163ONETOUCH ULTRA MINI 163ONETOUCH ULTRALINK 163ONETOUCH ULTRASOFT LANCETS 163ONETOUCH VERIO 122, 163ONETOUCH VERIO IQ SYSTEM 163OPCICON ONE-STEP 82OPTICHAMBER ADVANTAGE 188

OPTICHAMBER ADVANTAGE-LG MASK ....

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188OPTICHAMBER ADVANTAGE-MED MASK 188OPTICHAMBER ADVANTAGE-SM MASK 188OPTICHAMBER DIAMOND

188OPTICHAMBER DIAMOND-LG MASK 188OPTICHAMBER DIAMOND-MD MASK 188OPTICHAMBER DIAMOND-SM MASK 188OPTICHAMBER FACEMASK-LARGE 188OPTICHAMBER FACEMASK-MEDIUM 188OPTICHAMBER FACEMASK-SMALL 188optic-vites 205optic-vites with lutein 205OPTIHALER 188optimum pms 205OPTION 2 82OPTUMRX GLUCOSE CONTROL 163ORA-BLEND 239ORA-BLEND SF 239ORAL MIX 239ORAL MIX SF 239oral suspend 238oral syrup 238oral syrup sf 238ORALONE 198orange concentrate 232orange cream flavor 232orange flavor 232orange oil flavor 232ORA-PLUS 239ORA-SWEET 239ORA-SWEET SF 239ormir 49orphenadrine citrate er 218ORSYTHIA 81ORTHOVITE 210oscal 500/200 d-3 191OS-CAL CALCIUM + D3 193oscimin 248oscimin sr 248OSCION CLEANSER 100oseltamivir phosphate 70

OSTEOPRIME ULTRA ......................................... ...................................... .................................. ....................................

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210otomax-hc 229oxaprozin 9OXAYDO 23oxazepam 30oxcarbazepine 35oxybutynin chloride 254oxybutynin chloride er 254oxycodone hcl 23oxycodone-acetaminophen 24oxycodone-aspirin 24oxymorphone hcl 23oxymorphone hcl er 23OYSCO 500 195OYSCO 500+D 193oyst-cal d 191oyster calcium + d 191oyster calcium/d3 191oyster shell calcium 192, 194oyster shell calcium + d 191oyster shell calcium + d3 192oyster shell calcium 250+d 192oyster shell calcium 500 + d 192oyster shell calcium 500+d 192oyster shell calcium plus d 192oyster shell calcium/d 192oyster shell calcium/d3 192oyster shell calcium/vitamin d 192oyster shell/vitamin d 192OYSTERCAL 195oyster-cal 250 + d 192oyster-cal 500 194oyster-cal 500 + d 192OYSTERCAL-D 193pa calcium/vitamin d 192pa fish oil 221pa mucus relief 95pa oyster shell calcium 192pa vitamin d-3 259pa vitamin d-3 gummy 259PACERONE 31pain & fever childrens 14pain & fever infants 14pain relief childrens 14pain relief extra strength 14pain reliever 14pain reliever/fever reducer 14PALADIN 111pamidronate disodium 125PAMPRIN ALL DAY RELIEF MAX ST 11PANDA MASK LARGE 188

287

PANDA MASK MEDIUM .............

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188PANDA MASK SMALL 188PANOXYL WASH 100PANOXYL-4 CREAMY WASH 100pantoprazole sodium 252PARAGARD INTRAUTERINE COPPER 82PARI MANUAL INTERRUPTER 186PARI TREK S COMBO PACK 186paricalcitol 126PAROEX 197paromomycin sulfate 5paroxetine hcl . 38PATADAY 225PAZEO 226pc lancets super thin 30g 149PCCA SORBITOL LOLLIPOP BASE 240PCCA SWEETNESS ENHANCER 233PCCA SWEET-SF 239PCCA SYRUP VEHICLE 239PCCA-PLUS 239pc-tar 120peach flavor 232PEAK AIR PEAK FLOW METER 185peak flow meter 184peak flow meter universal rang 184peanut butter flavor 232PEDIACARE CHILDREN 16PEDIACARE CHILDRENS ALLERGY 49PEDIACARE COUGH/CONGESTION 92PEDIACARE INFANT FEVER/PAIN 16PEDIACARE INFANTS 16PEDIACARE INFANTS GAS RELIEF 129PEDIA-LAX 141pediatric formula cough/congst 90PEDIATRIC PANDA MASK188PEDIAVIT 215peg 3350 139peg 3350/electrolytes 138peg 3350-kcl-na bicarb-nacl 138peg-3350/electrolytes 138PEGASYS 69

PEGASYS PROCLICK ........... ............................

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69PEGINTRON 69penicillin v potassium 230PENLET II BLOOD SAMPLER 163PENLET II REPLACEMENT CAP 163PENTASA 130pentazocine-naloxone hcl 24pentoxifylline er 132PERFECT LANCETS 28G 163PERFECT LANCETS 30G 163perindopril erbumine 56PERIOGARD 197PERIOMED 198permethrin 119perphenazine 65perphenazine-amitriptyline 243PERSONAL BEST FULL RANGE 185PERSONAL BEST LOW RANGE 185pharbedryl 49PHARMACIST CHOICE ALCOHOL 119, 143PHARMACIST CHOICE LANCETS 163PHARMACY COUNTER LANCETS 163PHENADOZ 54PHENAZO 132phenazopyridine hcl 132phendimetrazine tartrate 4phenelzine sulfate 37PHENERGAN 54phenobarbital 137phentermine hcl . 4phenylephrine hcl 227PHENYTEK 36phenytoin 36PHENYTOIN INFATABS 37phenytoin sodium extended 36PHILITH 81PHOS-FLUR 198PHOSLYRA 131PHOSPHA 250 NEUTRAL 196PHOSPHOLINE IODIDE 225PHOSPHO-TRIN 250 NEUTRAL 196phytonadione 76PIKO 1 185pilocarpine hcl 198, 225

PIMTREA ................................. ....................

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77pina colada flavor 232pindolol ..72pineapple flavor 232pinworm medicine 29PINXAV 111pioglitazone hcl 44pioglitazone hcl-glimepiride 44pioglitazone hcl-metformin hcl 44PIRMELLA 1/35 81PIRMELLA 7/7/7 84piroxicam 9pnv folic acid + iron 216pnv prenatal plus multivitamin .216pnv-dha 217pnv-dha+docusate 217pnv-select 216pnv-vp-u 216POCKET CHAMBER 189POCKET PEAK FLOW METER 185POCKET SPACER 189POCKETCHEM EZ CONTROL 163POCKETPEAK PEAK FLOW METER 185podactin 103, 115podofilox 117poly vitamin 214POLYCIN 227polyethylene glycol 3350 139polymyxin b-trimethoprim 227polyvinyl alcohol 223poly-vita 215poly-vita/iron 213polyvitamin 215polyvitamin/iron 212, 213PORTIA-28 81pot bicarb-pot chloride 196potassium bicarbonate 196potassium chloride crys er 196potassium chloride er 196potassium citrate er 131potassium citrate-citric acid 131PR BENZOYL PEROXIDE WASH 100PRADAXA 35pralines and cream flavor 232pramipexole dihydrochloride 63pravastatin sodium 55prazosin hcl 58

288

PRECISION GLUCOSE CONTROL ..............................

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163PRECISION GLUCOSE CONTROL SOLN 163PRECISION GLUCOSE KETONE CONTR 163PRECISION GLUCOSE/KETONE CONTR 163PRECISION SUREDOSE PLUS SYR 181PRECISION SURE-DOSE SYRINGE 181, 182PRECISION THIN LANCETS 163PRECISION THINS GP LANCETS 164PRECISION ULTRA LANCET 164PRECISION XTRA KETONE

122PRED MILD 228prednicarbate 109prednisolone 85prednisolone acetate 228prednisolone sodium phosphate

85, 228prednisone 85preferred plus glucose 39preferred plus insulin syringe

173, 174preferred plus lancets colored 149preferred plus lancets thin 149PREFEST 127PREMARIN 127, 256premium condoms lubricated 144premium lidocaine 118PREMPHASE 127PREMPRO 127PRENATABS RX 216prenatal 216prenatal 19 216prenatal plus 216prenatal vitamin plus low iron 216PRENATAL-U 216PRENTIF CAVITY-RIM CERV CAP 143PRENTIF FITTING SET 143PREPARATION H HYDROCORTISONE 111preplus 216pressure activat safety lancet 149

PREVALITE ...................................................................

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54prevent 205PREVIDENT 198PREVIFEM 81PREZCOBIX 67PREZISTA 67, 68PRIFTIN 60prilolid 121PRILOSEC OTC 253PRILOXX LP 121PRIMEAIRE HOLDINGCHAMBER 186primidone .... 36pro comfort alcohol 142pro comfort lancets 30g 149pro comfort lancets 31g 149PROAIR HFA .32probenecid 132prochlorperazine 65prochlorperazine maleate 65PROCRIT 133, 134PROCTOCORT 26PROCTOFOAM HC 26PROCTO-MED HC 26PROCTOSOL HC 26PROCTOZONE-HC 26PRODIGY CONTROL SOLUTION 164PRODIGY INSULIN SYRINGE 182PRODIGY LANCETS 28G 164PRODIGY LANCING DEVICE 164PRODIGY SAFETY LANCETS 26G 164PRODIGY TWIST TOPLANCETS 28G 164pro-ex antifungal 115progesterone 240progesterone micronized 240PROMACTA 136promethazine hcl 54promethazine vc plain 93promethazine vc/codeine 97promethazine-codeine 97promethazine-dm 97promethazine-phenyleph-codeine 97promethazine-phenylephrine 93PROMETHEGAN 54PROMOLAXIN 141

PRONUTRIENTS VITAMIN D3 .............................................

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260propafenone hcl 31propantheline bromide 253propranolol hcl 72propranolol hcl er 72propranolol-hctz 58propylthiouracil 247PROSIGHT 210protriptyline hcl 39PROVENTIL HFA 32PROVIL 11pseudoephedrine hcl 219PSORIASIN 117PSS SELECT GP LANCETS 164PSS SELECT PLATFORMS 164PSS SELECT SAFETY LANCETS 164PTS PANELS KETONE TEST 122PULMICORT 33PULMICORT FLEXHALER 33PULMO-AIDE COMP/PULMO-NEB DISP 186PULMO-AIDE LT COMPRESS/NEBULIZ 186PULMO-AIDE TRAVELER/FILTERS 186PULMONEB LT 186PULMOSAL 97PULMOZYME 246pumpkin flavor 232push button safety lancets 149px acid reducer 250px acid reducer max st 250px advanced formula multivits 205px advanced lancing device 149px all day relief 9px allergy 49px allergy relief 52px allergy relief cetirizine 52px allergy relief d . 93px allergy relief loratadine 52px antacid maximum strength 27px aspirin 19px athletic foot 115px b complex/vitamin c 199px calcium 192px childrens allergy 52px childrens pain relief 15px childrens profen ib 9PX CHILDRENS VITAMIN 213

289

px complete senior multivits ..... ..............................

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205px daytime pe 87px enteric aspirin 19px fish oil 221px gas relief extra strength 128px gas relief infants 128px glucose 39px glycerin 139px hemorrhoidal 25, 26px hydrocream 109px ibuprofen 9px infants profen ib 9px insulin syringe 174px iron 135px lancet auto injector 149px lancets ultra thin 149px mens multivitamins 205px miconazole 3-day combo 255px niacin 257px omeprazole . 252px ranitidine 250px stop smoking aid 244px tussin 95px tussin dm 90px tussin max 86PYLERA 253pyrazinamide 60pyridostigmine bromide 59pyridoxine hcl 257pyrimethamine 76qc acid controller 250qc acid controller max st 250qc advanced lancing device 149qc alcohol swabs 142qc all day allergy 52qc allergy relief 52qc allergy relief childrens 52qc antacid/anti-gas 27qc aspirin 19qc aspirin low dose 19qc athletes foot 103qc bacitracin 102qc calcium fast dissolution 194qc calcium/minerals/vitamin d 192qc castor oil 76qc childrens aspirin 19qc childrens complete 212qc childrens ibuprofen 9qc childrens vitamins/extra c 215qc childrens vitamins/iron 214qc clotrimazole 115qc cough relief 86

qc daily multivit/multimineral .. .......

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205qc daily multivitamins/iron 199qc daytime cold/flu 87qc ferrous sulfate 135qc gas relief 129qc glycerin 113qc hydrocortisone 109qc hydrocortisone max st 109qc ibuprofen 9qc ibuprofen ib 9qc ibuprofen infants 9qc lancets super thin 30g 149qc lancets ultra thin 149qc loratadine allergy relief . 52qc medifin dm 90qc medifin mucus relief child 95qc mens daily multivitamin 205qc multi-vite 205qc multi-vite 50 & over 205qc multi-vite plus 205qc naproxen sodium 9qc nicotine polacrilex 244qc non-aspirin childrens 15qc omeprazole magnesium 252qc pain relief childrens 15qc pain relief infants .15qc rest simply 136qc sleep aid max st 137qc sweet oil 76qc therin-m 205qc tolnaftate 103qc unilet lancets 28g 149qc unilet lancets micro thin 149qc womens daily multivitamin 205q-dryl 49QSYMIA 4q-tussin dm 90QUAKE 186QUASENSE 83quetiapine fumarate 65quetiapine fumarate er 65QUICKTEK CONTROLSOLUTION 164QUILLICHEW ER 5QUILLIVANT XR 5quinapril hcl 56quinapril-hydrochlorothiazide 56quinidine gluconate er 31quinidine sulfate 31quintabs-m 205QUINTET CONTROLHIGH/NORMAL 164

QVAR ........................................ ....

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33ra acetaminophen rapid melts 15ra acid reducer 250ra acid reducer max st 250ra advanced recovery 113ra alcohol swabs 142ra allergy 49ra allergy medication 49ra allergy relief 52ra allergy relief childrens 49, 52ra antacid/anti-gas max st 27ra antacid/gas relief max st 27ra antibiotic plus 101ra antibiotic/pain relief 101ra anti-diarrheal 45ra antifungal 103, 115ra antifungal foot care 103ra antihistamine eye drops 225ra anti-itch maximum strength 109ra anti-nausea 46ra artificial tears 222ra aspirin 19ra aspirin adult low dose 19ra aspirin adult low strength 19ra aspirin childrens 19ra aspirin ec 19ra aspirin ec adult low st 19ra atheletes foot 115ra athletes foot 115ra athletes foot (tolnaftate) 103ra bacitracin 102ra bacitracin zinc first aid 102ra budesonide 219ra calcium 194ra calcium 600 194ra calcium 600/vit d/minerals 192ra calcium 600/vitamin d-3 192ra calcium hi-cal 194ra calcium hi-cal/vitamin d 192ra calcium high potency 194ra calcium plus vitamin d 193ra calcium plus vitamin d3 193ra calcium/minerals/vitamin d 193ra calming daily moisturizing 113RA CENTRAL-VITE 210ra central-vite cardio 217ra central-vite energy 205ra central-vite mens mature 205ra central-vite performance 217RA CENTRAL-VITE SELECT 210ra central-vite senior 205

290

ra central-vite womens mature 205 RA CENTRAL-VITE/ANTIOXIDANTS ........

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210ra cetiri-d 93ra cetirizine 52ra cetirizine hcl child allrgy 52ra childrens aspirin 20ra childrens chewable vit/iron 214ra childrens non-aspirin 15ra clotrimazole 115ra cold/flu relief daytime 87ra col-rite 141ra daytime multi-symp cold/flu 87ra daytime multi-symptom cold 87ra derma 113ra diaper rash 105RA DIPHEDRYL ALLERGY 49ra eye itch relief 225RA E-ZJECT COLOR LANCETS 33G 164RA E-ZJECT LANCETS 28G

164RA E-ZJECT LANCETS THIN 26G 164RA E-ZJECT LANCETS THIN 28G 164RA E-ZJECT LANCETS ULTRA THIN 164ra fever reducer/pain reliever 15ra fiber 139ra fiber supplement 139ra first aid anti-itch spray 110ra fish oil 221ra foot care antifungal 103ra gas relief 129ra gas relief extra strength 129ra gas relief/infants 129ra gentle skin 113ra glucose 39, 40ra glycerin 113ra glycerin adult 139ra glycerin child 139ra hair/skin/nails 205ra hemorrhoidal 25, 26RA HI CAL 193RA HI-CAL 195RA HI-CAL PLUS VITAMIN D 193ra high potency iron 135ra hydrating healing 113ra hydrocortisone max st 110ra hydrocortisone plus 121

ra hydrocortisone plus 12 .........................................

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110ra ibuprofen 10ra ibuprofen childrens 9ra ibuprofen infants 10ra insulin syringe 174ra iron 135ra isopropyl alcohol wipes 119ra jock itch 115ra jock itch max st 103ra lancing device 149ra lansoprazole 252ra laxative 139ra lice treatment 119ra loratadine 52ra loratadine childrens 52ra lubricant eye 222ra lubricant eye drops 223ra magnesium 196ra mature womens dietary supp206ra menopause support 217ra miconazole 3 combo pack 255ra miconazole 3 combo pack app 255ra mini nicotine 244ra moisturizing oatmeal 113ra moisturizing therapy 113ra motion sickness relief 46, 47ra mucus relief 95ra multihealth fiber 139ra naproxen sodium 10ra natural magnesium 196ra niacin 257ra nicotine 245ra nicotine gum 245ra nicotine polacrilex 245ra nighttime sleep aid 137ra no flush niacin 257ra omeprazole 252ra one daily energy formula 206ra one daily gummy vites 206ra one daily maximum 206ra one daily mens 50+ w/vit d3 206ra one daily mens multi 206ra one daily mens/vit d-3 206ra one daily multi-vit plus fe 199ra one daily womens 206ra oyster shell calcium 194ra oyster shell calcium/d 193ra pain reliever ex st 15RA RENEWAL ACNE TREATMENT 100

RA RENEWAL COCOA BUTTER 114ra renewal moisturizing 113ra scalp itch/dandruff relief 117ra sleep aid 137ra sleep aid (diphenhydramine)137ra slow release iron 135ra stomach relief kids 28ra stress formula advanced 206ra stress formula energy 206ra therapeutic 120ra therapeutic m plus beta car ..206ra total moisture 113ra triple antibiotic plus 101RA TUGABOOS BABY 118RA TUGABOOS BABY (TALC) 118ra tussin 95ra tussin cgh/chest congest dm 90ra tussin chest congestion 95ra tussin cough 86, 90ra tussin cough adult 86ra tussin cough dm sugar free 90ra tussin cough/chest dm max 90ra tussin dm 90ra tussin long acting cough 86ra tussin maximum strength 86ra vision vite plus zinc 206ra vitamin b-6 257ra vitamin d-3 259ra vitamins complete childrens .212RA WHOLE SOURCE DIETARY 210RA WHOLE SOURCE DIETARY MATURE 210RA WHOLE SOURCE DIETARY MEN 210RA WHOLE SOURCE FOR MEN 210RA WHOLE SOURCE WOMENS 210ra zinc oxide 106rabano yodado 199rabeprazole sodium 252raloxifene hcl 126ramipril 56ranitidine acid reducer 250ranitidine hcl 251RAPAMUNE 71raspberry flavor 232raspberry syrup 239REACT 82

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291

READYLANCE SAFETY LANCETS 164reality insulin syringe 174reality lancets 149REALITY LATEX CONDOMS 144REALITY LATEX/ULTRA TEXTURED 144REALITY LATEX/ULTRA THIN 144reality swabs 142reality trigger lancets 149REBETOL 69REBIF 242REBIF REBIDOSE 242REBIF REBIDOSE TITRATION PACK 242REBIF TITRATION PACK ..242RECLIPSEN 81recofen d 90recort plus 110RECTIV 25rederm 110reeses pinworm medicine 29refenesen dm 90REFRESH CELLUVISC 224REFRESH LIQUIGEL 224refreshing aloe 113REFUAH PLUS GLUCOSE CONTROL 164REGENECARE HA 118REGULOID 139RELADOR PAK 121RELADOR PAK PLUS 121relcof c 90RELENZA DISKHALER 70RELION ALCOHOL SWABS

143RELION GLUCOSE 40, 41RELION GLUCOSE DRINK . 41RELION INSULIN SYRINGE

182RELI-ON INSULIN SYRINGE 182RELION KETONE 122RELION KETONE TEST 122RELION LANCETS MICRO-THIN 33G 164RELION LANCETS STANDARD 21G 164RELION LANCETS THIN 26G 165

RELION LANCETS ULTRA-THIN 30G ................................

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165RELION LANCING DEVICE

165RELION ULTRA THIN LANCETS 30G 165RELION ULTRA THIN PLUS LANCETS 165RELPAX 189REMEDY ANTIFUNGAL 116REMEDY ANTIFUNGALCLEAR 116REMEDY PHYTOPLEX ANTIFUNGAL 116RENAGEL 131RENAL 210RENAPLEX 210RENVELA 131repaglinide 43repaglinide-metformin hcl 43REPLESTA 260RESCRIPTOR .68RESTFULLY SLEEP 137RETAINE CMC 224RETIN-A 100RETROVIR 69revive tears 223REVLIMID 71REXALL LANCETS ULTRA THIN 30G 165REYATAZ 68RHINOCORT ALLERGY 219RHOGAM ULTRA-FILTERED PLUS 230RHOPHYLAC 230RIBASPHERE 69ribavirin 69RIDAURA . 6rifabutin 60rifampin 60RIGHTEST ALTERNATE SITE ADAPT 165RIGHTEST GC300CONTROL 165RIGHTEST GD500LANCING DEVICE 165RIGHTEST GL300LANCETS 165riluzole 219rimantadine hcl 70RINOFLOW CHAMBER TUBING 170

RINOFLOW NASAL SYSTEM ..................................

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170RISPERDAL CONSTA 64risperidone 64RISPERIDONE M-TAB 64RITEFLO 189rivastigmine 241rivastigmine tartrate 241rizatriptan benzoate 189robafen 95robafen cough 86robafen dm 90ROBAFEN DM CGH/CHEST CONGEST 92ROBAFEN DM COUGHCLEAR 92ROBITUSSIN COLD COUGH+ CHEST 92ROBITUSSIN COLD+FLU DAYTIME 88ROBITUSSIN COUGH+CHEST CONG DM 92ROBITUSSIN LINGERING LA COUGH 86ROBITUSSIN MUCUS+CHEST CONGEST . 96ROBITUSSIN TO GO CGH/CHEST DM 92root beer flavor 232ropinirole hcl 63ropinirole hcl er 63ROSADAN 119rosuvastatin calcium 55ROWEEPRA 36ROZEREM 138SAFE TUSSIN DM 92SAFESNAP INSULIN SYRINGE 182SAFE-T-LANCE 165SAFE-T-LANCE PLUS 165safety insulin syringes 174safety lancet 21g/pressure act 149safety lancet 28g/pressure act 149SAFETY LANCETS 165SAFETY LANCETS 21G 165safety lancets 28g 149SAFETY LET LANCETS 165SAFETY SEAL LANCETS 165safety syringe/needle 174SAFETY-GLIDE SYRINGE .182SALACYN 117salicylic acid 117

292

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117salsalate 20SANDOSTATIN LAR DEPOT 126SANI-SUPP PEDIATRIC 140SANTYL 114saps care alcohol prep 142saps health alcohol prep 142saps health twist top lancets 149sapscare twist top lancets 149SARATOGA 114sardine flavor 232SARNOL-HC 111SAVELLA 241SAVELLA TITRATION PACK 241SAVISION 210SAWYER INSECT REPELLENT 117sb acid controller 251sb acid controller max st 251sb acid reducer 251sb acid reducer ranitidine 251sb alcohol prep 142sb allergy 52sb allergy medicine 49sb allergy relief 52sb anti-fungal 103sb anti-nausea 46sb aspirin 20sb aspirin adult low strength 20sb bacitracin 102sb calcium + d 193sb cetirizine hcl childrens 52sb childrens aspirin 20sb childrens ibuprofen 10sb childrens non-aspirin 15sb cimetidine 251sb clotrimazole foot 115sb cough control 86, 95sb cough control dm 90sb cough control dm max 90sb day time cold/flu relief 87sb gas relief 129sb glycerin adult 139sb glycerin pediatric 139sb hydrocortisone 110sb hydrocortisone max st . 110sb hydrocortisone plus 110sb ibuprofen 10sb infants ibuprofen 10sb insulin syringe 174

sb lancets thin .............................................

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149sb lancets ultra thin 149sb loratadine 52sb loratadine allergy relief . 52sb low dose asa ec 20sb motion sickness 47sb mucus relief dm 90sb naproxen sodium 10sb non-aspirin 15sb omega-3 fish oil 221sb omeprazole 252sb oyster shell calcium 194sb pain reliever childrens . 15sb sleep 137SB TAB TUSSIN DM .92scalacort 110scalp relief maximum strength 110SCALPICIN 117SCALPICIN 2 IN 1 117SCALPICIN MAXIMUM STRENGTH 111SCLEREX 210SCOT-TUSSIN ALLERGY RELIEF 49scot-tussin expectorant 95SEA BUDDIES DAILY MULTIPLE 213SEA-OMEGA 222SEA-OMEGA 30 221SEB-PREV WASH 105SECURA ANTIFUNGAL 116SECURA ANTIFUNGALEXTRA THICK 116select-lite device/lancets 149select-lite lancing device 149SELECT-OB 216SELECT-OB+DHA 217selegiline hcl .63selenium sulfide 105selenium sulf-pyrithione-urea 105SELZENTRY .67senexon 140senior tabs 206senna 140senna-grx 140sennazon 140sentry 206sentry adult 206sentry senior 206SEREVENT DISKUS 32SEROQUEL XR 65sertraline hcl 38

sesame oil ..................................................................

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77SETLAKIN 83sf 197sf 5000 plus 197SHAROBEL 84SHOPKO ALCOHOLSWABS 143SHOPKO ALLERGY RELIEF-D (CETI) 93SHOPKO ATHLETES FOOT

116SHOPKO AUTOLET LANCING DEVICE 165SHOPKO ON-THE-GOLANCETS 30G 165SHOPKO UNILET LANCETS 28G 165SHOPKO UNILET LANCETS 30G 165shrimp flavor 232side button safety lancet . 149silace 141siladryl allergy 49sildenafil citrate 75silphen cough 49silphen dm cough 86siltussin das 95siltussin dm das 90siltussin sa 95siltussin-dm alcohol free 90silver sulfadiazine 106SIMBRINZA 222simeped 129simethicone 129simethicone extra strength 129SIMILAC STERILIZEDWATER 239SIMPLE DIAGNOSTICSLANCING DEV 165simple syrup 239SIMPLY SALINE BABY 97SIMPLY SLEEP 137simvastatin 55SINGLE-LET 165sirolimus 71SKYLA 83sleep aid 137sleep aid (diphenhydramine) 137sleep ii 137sleep tabs 137sleep-aid maximum strength 137sleep-tabs 137

293

SLO-NIACIN .......................... ...................... ........................

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257slow release iron 135sm acid reducer 251sm acid reducer max st 251sm alcohol prep 142sm all day allergy 53sm all day allergy childrens 52sm all day allergy-d 93sm all day pain relief 10sm allergy relief 49, 53, 219sm allergy relief childrens 49sm allergy relief loratadine 53sm animal shapes complete 212sm animal shapes kids first 214sm antacid advanced max st 28sm antacid anti-gas ex st 28sm antacid maximum strength 28sm antibiotic 102sm antibiotic plus pain relief . 101sm anti-dandruff coal tar 120sm anti-diarrheal ..45sm antifungal clotrimazole 115sm antifungal miconazole 115sm antifungal tolnaftate 103sm anti-nausea ..46sm antioxidant vitamins 206sm artificial tears 222sm aspirin 20sm aspirin adult low strength 20sm aspirin ec low strength 20sm athletes foot 103, 104sm b super vitamin complex 199sm baby powder 118sm calcium 500/vitamin d3 193sm calcium 600/vitamin d 193sm calcium/vitamin d 193sm calcium-vitamin d 193sm castor oil 140sm chest congestion relief dm 90sm childrens aspirin 20sm childrens ibuprofen 10sm childrens loratadine 53sm complete 206sm complete 50+ 206sm complete 50+ ultimate mens

206sm complete 50+ ultimate women 206sm complete advanced formula 206sm complete senior formula 206sm cough relief 86sm daily diet support 206

sm day time non drowsy ............. ......

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87sm day time pe cold/flu relief 87sm dry skin therapy 113sm eye itch relief 225sm fiber 139sm fish oil 221sm foaming antacid 28sm gas relief extra strength 129sm gas relief infants 129sm gas relief infants drops 129sm glucose 39, 40sm glycerin 113sm glycerin pediatric 140sm hair/skin/nails 206sm hemorrhoidal .26sm hydrocortisone 110sm hydrocortisone max st 110sm hydrocortisone plus 121sm hydrocortisone-aloe max st .121sm ibuprofen 10sm ibuprofen ib 10sm ibuprofen jr 10sm infants ibuprofen 10sm infants pain reliever 15sm insulin syringe 174sm iron 135sm lancets 33g 150sm lansoprazole 253sm lice killing 119sm lice treatment . 119sm loratadine 53sm loratadine allergy relief 53sm lubricating plus 223sm magnesium 196sm magnesium oxide 196sm miconazole 3 255sm miconazole 3 applicator 255sm motion sickness . 47sm motion sickness relief 47sm mucus er 95sm mucus relief childrens 95sm mucus relief cough children 91sm multiple vitamins/iron 199sm naproxen sodium 10sm niacin cr 257sm nicotine 245sm nicotine polacrilex 245sm nighttime sleep aid 137sm omega-3 fish oil 221sm omeprazole 253sm opti-vitamins 206sm oyster shell calcium/vit d 193

sm oyster shell calcium/vit d3 ..............

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193sm pain & fever childrens 15sm pain & fever infants 15sm pain reliever 15sm pain reliever childrens 15sm pain reliever ex st 15sm skin cleanser gentle 119sm sleep aid maximum strength 137sm sleep aid night time 137sm slow release iron 135sm stool softener 141sm sweet oil 77sm triple antibiotic max st 101sm tussin 95sm tussin cough/chest congest 91sm tussin dm 91sm tussin dm max 91sm tussin mucus+chest congest 95sm vitamin b-6 257sm vitamin d 259sm vitamin d3 259SMART DIABETES VANTAGE LANCING 166SMART SENSE COLOR LANCETS 33G 166SMART SENSE GLUCOSE 40SMART SENSE STANDARD LANCETS 166SMART SENSE SUPER THIN LANCETS 166SMART SENSE THIN LANCETS 26G 166SMARTEST CONTROL MEDIUM 166SMARTEST LANCETS 28G 166SMOOTH LAX 140sod citrate-citric acid 131sodium bicarbonate 28, 190sodium chloride 96, 131sodium fluoride 195sodium polystyrene sulfonate

71, 240SOLARTEK GLUCOSE CONTROL 166SOLTAMOX 60SOLUS V2 CONTROL 166SOLUS V2 LANCETS 28G 166SOLUS V2 LANCING DEVICE 166SOLUS V2 TWIST LANCETS 30G 166solvatech plus 239

294

solvatech sweet sf ..................... ...............................

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239SOMINEX 137SOOTHE & COOL BODY 118SOOTHE & COOL INZO ANTIFUNGAL 116SOOTHE HYDRATION 223SOOTHE XP 223SOOTHE XP XTRA PROTECTION 223sorbitol 77, 140, 239SORBUGEN NR 92SORINE 72sotalol hcl 72sotalol hcl (af) 72spinosad 119SPIRIVA HANDIHALER 32spiro pd 185spironolactone 124spironolactone-hctz 124SPRINTEC 28 81SPS 71, 240sr nicotine 245SRONYX 81SSD 106ST JOSEPH ASPIRIN 21ST JOSEPH LOW DOSE 21stavudine 69STERILANCE PA 166STERILANCE TL 166sterile water for injection 240sterile water for irrigation 71stevia 5stevia extract 76stevia glycerite extract 232steviol glycosides 76stevioside 76stool softener 141stop lice maximum strength 119STRATTERA 3strawberry flavor 233stress b complex/iron 199stress b/zinc 198stress b-complex/c/zinc 206

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stress b-complex/vit c/zinc 198stress formula 199stress formula/iron 199stress formula/zinc 198stress plus zinc 198STRESSTABS ADVANCED .210STRIBILD 67STRIVERDI RESPIMAT 32SUBOXONE 24

sucralfate 251SUDOGEST 219sulfacetamide sodium . 97, 105, 228sulfacetamide sodium (acne) 97sulfacetamide-prednisolone 228sulfadiazine 246sulfamethoxazole-trimethoprim ..59sulfasalazine 130SULFATRIM PEDIATRIC 59sulindac 10sumatriptan 189sumatriptan succinate . 189sumatriptan succinate refill 189SUNVITE ACTIVE ADULT 50+ 210SUNVITE ADVANCED 210super 28 formula 206super antioxidants protector 206super aytinal 206super aytinal 50 plus 206super b complex/vitamin c 199super b-complex/vit c/fa 199super calcium 194super calcium 600 + d 400 . 193super calcium 600 + d3 193SUPER DHA GEMS 222super multiple . 206super natrul-100 206SUPER NU-THERA 210super omega 3 epa/dha 221SUPER OMEGA-3 222super omega-epa 221super thera vite m 206super thin lancets 150super vikaps 206super vita-mins 206superior 35 206SUPRAX 76supreme ii confidence paddles 150supreme ii high/low control 150sure comfort alcohol prep 119, 142sure comfort insulin syringe

174, 175sure comfort lancets 18g 150sure comfort lancets 21g 150sure comfort lancets 23g 150sure comfort lancets 28g 150sure comfort lancets 30g 150sure comfort lancing pen 150sure guard anti-oxidant plus 207sure guard multi vit/mineral 207sure result sr relief 118

SURE-JECT INSULIN SYRINGE ........................

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182, 183SURE-LANCE FLAT LANCETS 166SURE-LANCE LANCETS 26G 166SURE-LANCE THIN LANCETS 28G 166SURE-LANCE ULTRA THIN LANCETS 166SURELITE LANCETS 166SURE-PEN 166SURE-PREP ALCOHOL PREP 143SURESTEP GLUCOSE CONTROL 166SURESTEP PRO HIGH GLUCOSE 166SURESTEP PRO LINEARITY 167SURESTEP PRO LOW GLUCOSE 167SURESTEP PRO NORMAL GLUCOSE 167SURE-TOUCH LANCETS UNIVERSAL 167suspension vehicle 239SUSTIVA 68SUTENT 61sw acid reducer 150 max st 251sw allergy relief . 53sw allergy relief-d 93sw nicotine polacrilex 245sw omeprazole 253sweet oil 77sweetening enhancer 233SYEDA 81SYMAX-SL 248SYMAX-SR 248SYMBICORT 31SYNAGIS 229syringe 175syringe luer slip 175syringe/hypodermic safety 175syrpalta 239SYRPALTA (RED) 239SYRSPEND SF 239SYRSPEND SF ALKA 239SYRSPEND SF PH4 240syrup nf 239syrup vehicle 239syrup vehicle sf . 239

295

SYSTANE ........................................ ....

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222SYSTANE CONTACTS 223TAB-A-VITE MAXIMUM 210tab-a-vite/iron 199TABLOID 60TABTUSSIN DM 92tacrolimus 71, 118TAI DOC CONTROL 167TAKE ACTION . 82TAMIFLU 70tamoxifen citrate 60tamsulosin hcl 131TARCEVA 61TARGRETIN 121TARINA FE 1/20 81TARON-C DHA 216TARON-CRYSTALS 131TASIGNA 61TAZTIA XT 74tears again 222TEARS AGAIN ADVANCED EYELID 223TEARS NATURALE FREE 223tears pure 222TECFIDERA 242TECHLITE AST LANCETS 167TECHLITE LANCETS 167TECHLITE LANCETS 30G 167TECHNIVIE 136TEGRETOL-XR 36TELCARE GLUCOSECONTROL 167temazepam 137temozolomide 62TENCON 17TERA-GEL TAR 120terazosin hcl 58terbinafine hcl 47, 104terbutaline sulfate 32terconazole 255TESTIM 25testosterone 25testosterone cypionate 24testosterone enanthate 24tetra-formula nighttime sleep 137TETTERINE 116tgt acetaminophen childrens .15tgt acetaminophen infants 15tgt acetaminophen melts child 15tgt acid reducer 251tgt alcohol swabs 142tgt all day allergy childrens 53

tgt all day allergy relief .............. .................... ....................

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53tgt all day allergy-d 93tgt allergy childrens 49tgt allergy melts childrens 49tgt allergy relief 53tgt allergy relief childrens 49tgt allergy+ congestion relief 93tgt antifungal 104tgt antifungal spray powder 104tgt anti-itch maximum strength 110tgt anti-itch plus oatmeal 110tgt anti-itch/aloe max st 121tgt anti-itch/aloe/vit e 110tgt aspirin 20tgt aspirin low dose 20tgt athletes foot 104tgt bacitracin 102tgt childrens acetaminophen 15tgt childrens aspirin 20tgt childrens ibuprofen 10tgt clotrimazole 115tgt cold/flu relief day-time 87tgt cough formula dm 91tgt cough formula dm max adult .91tgt eye itch relief 225tgt fiber therapy 139tgt first aid antibiotic 101tgt gas relief extra strength 129tgt gas relief infants 129tgt glucose 39tgt hemorrhoidal 26tgt ibuprofen 10tgt ibuprofen childrens 10tgt infants ibuprofen 10tgt lancet micro thin 33g 150tgt lancet thin 26g 150tgt lancet ultra thin 30g 150tgt lancing device 150tgt loperamide hcl 45tgt loratadine childrens 53tgt lubricant eye drops 222tgt miconazole 3 combo pack 255tgt mucus relief childrens 96tgt mucus relief cough child 91tgt mucus/cough relief 91tgt multivitamin/multimineral 207tgt naproxen sodium 10tgt nicotine 245tgt nicotine polacrilex 245tgt nicotine step one 245tgt nicotine step three 245tgt nicotine step two 245

tgt nighttime sleep aid .............. ..........................

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137tgt omeprazole 253tgt pain/fever acetaminophen 15tgt sleep aid max strength 137tgt tussin dm cough 91THALOMID 70THE TREATMENT FORMULA 3 104THEOCHRON 34theophylline 34theophylline er 33thera vital m ... 207thera vital-m 207therabasic-m 207THERA-D 2000 260THERA-D RAPID REPLETION 261thera-derm 113THERADEX M 210THERADEX M/BETA CAROTENE 210THERAGRAN-M FISH OIL CONC 222THERA-MILL M 210THERAMILL PLUS 210THERANATAL CORENUTRITION 216therapeutic 120therapeutic formula/hematinics 207therapeutic m 207THERAPEUTIC T+PLUS 120therapeutic-m 207therapeutic-m/lutein 207THERATEARS 224THERATEARS ALLERGY 226THERATRUM COMPLETE 211THERATRUM COMPLETE 50 PLUS 210theravim-m 207THEROMEGA 222THINLETS GP LANCETS 167THINLETS LANCET 167thioridazine hcl 65thiothixene 66THRESHOLD PEP 186THRIVE 246THRIVE FOR LIFE WOMENS 211tiagabine hcl 36TILIA FE 84timolol maleate 72, 224tinaspore 104

296

TINEACIDE ........................... ...............

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116tippy toes diaper rash 106TITRALAC 28TIVICAY 67tizanidine hcl 218TOBI PODHALER . 5TOBRADEX 228tobramycin 226tobramycin-dexamethasone . 228TOBREX 226TODAY SPONGE 256todays health lancing device 150todays health thin lancets 28g 150todays health thin lancets 30g 150tolazamide 44tolbutamide 44tolmetin sodium 10tolnaftate 104tolterodine tartrate 254TOLU-SED DM .. .92topcare lancets micro-thin 33g 150topcare ultra comfort ins syr 175topiclear 119topiramate . 36torsemide 124TOTAL ALLERGY MEDICINE . 49TOTAL FORMULA 211TOTAL FORMULA 2 211TOTAL FORMULA 3 211totalday multiple 207TOVIAZ 254TRACER II 3 VOLT BATTERY 167TRACLEER 75TRADJENTA 41tramadol hcl 23tramadol-acetaminophen 24trandolapril 56tranylcypromine sulfate 37TRAVATAN Z 228travel lancets 150TRAVEL LANCETS ADVANCED 28G 167travel sickness 47trav-tabs 47trazodone hcl . 37, 246tretinoin 62, 99TRI FEMYNOR 84triadvance 216triamcinolone acetonide

110, 198, 219

TRIAMINIC ALLERCHEWS 53TRIAMINIC FEVER REDUCER ................................

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16triamterene-hctz 124triazolam 138tri-biozene 101TRICARE 216tricitrates 131TRIDERM 111TRI-ESTARYLLA 84trifluoperazine hcl 65trifluridine 227trihexyphenidyl hcl 62TRI-LEGEST FE 84TRILEPTAL 36TRI-LINYAH 84TRILYTE 138trimethobenzamide hcl 47trimethoprim 58trinatal rx 1 216TRINATE 217TRINESSA (28) 84triple antibiotic pain relief 101triple antibiotic plus 101triple antibiotic plus max st 101triple paste af 115TRI-PREVIFEM 84TRI-SPRINTEC 85TRIUMEQ 67tri-vit/fluoride 214tri-vit/fluoride/iron 214tri-vitamin/fluoride 214TRIVORA (28) 85TROJAN 144TROJAN ASSORTMENTPACK 144TROJAN EXTENDEDPLEASURE/LUBE 144TROJAN EXTRA STRENGTH 144TROJAN MAGNUM 144TROJAN MAGNUM WARM SENSATIONS 144TROJAN MAGNUM XLLUBRICATED 144TROJAN PLEASURE MESH/SPERMICID 144TROJAN PLUS 144TROJAN REGULAR 145TROJAN RIBBED 145TROJAN RIBBED/SPERMICIDAL 145

TROJAN SHARED SENSATION/LUBE ...............

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145TROJAN SUPRAS SPERMICIDAL 145TROJAN TWISTEDPLEASURE 145TROJAN ULTRA PLEASURE LUBRICAT 145TROJAN VERY SENSITIVE LUBRICAT 145TROJAN VERY SENSITIVE SPERMICI 145TROJAN VERY THINLUBRICATED 145TROJAN VERY THINSPERMICIDE 145TROJAN-ENZLUBRICATED 145TROJAN-ENZ/SPERMICIDAL 145tropical liquid nutrition 207tropical punch flavor 233tropicamide 224trospium chloride 254trospium chloride er 254TRUE METRIX LEVEL 1 167TRUE METRIX LEVEL 2 167TRUE METRIX LEVEL 3 167TRUECONTROL GLUCOSE CONT LEV 0 167TRUECONTROL GLUCOSE CONT LEV 1 167TRUEDRAW LANCING DEVICE 167TRUEPLUS DIABETICMULTIVITAMIN 211TRUEPLUS INSULIN SYRINGE 183TRUEPLUS LANCETS 26G 167TRUEPLUS LANCETS 28G 167TRUEPLUS LANCETS 30G 167TRUEPLUS LANCETS 33G 168TRUEPLUS SAFETY LANCETS 28G 168TRUETEST CONTROLLEVEL 1 168TRUETEST CONTROLLEVEL 2 168TRUETEST CONTROLLEVEL 3 168TRUSTEX COLOR CONDOMS + LUBE 145

297

TRUSTEX LUB/RIBBED/STUDDED .....

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145TRUSTEX LUB/SPERMICIDE EX ST 145TRUSTEX LUB/SPERMICIDE XL 145TRUSTEX LUBRICATED 145TRUSTEX LUBRICATED EX LARGE 145TRUSTEX LUBRICATED EXTRA ST 145TRUSTEX LUBRICATED/SPERMICIDE 145TRUSTEX NATURAL CONDOMS + LUBE 145TRUSTEX NON-LUBRICATED 145TRUSTEX RIA LUB/SPERMICIDE 145TRUSTEX RIA LUBRICATED 145TRUSTEX RIA NON-LUBRICATED 145TRUSTEX-NONOXYNOL-9/RIB/STUD 145TRUVADA 67TRUZONE PEAK FLOW METER 185tuna flavor 233tusnel diabetic 91TUSNEL PEDIATRIC 92, 94TUSSIGON 87tussin 96tussin chest congestion 96tussin cough 86tussin cough dm 91tussin cough long-acting 86tussin dm 91tussin dm clear 91tussin dm max . 91tussin dm max adult 91tussin mucus & chest congest 96tussin mucus+chest congestion 96tutti frutti flavor 233tutti-frutti flavor 233TYBOST 66TYKERB 61ULORIC 132ULTICARE ALCOHOLSWABS 143

ULTICARE INSULIN .........................

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SAFETY SYR 183ULTICARE INSULINSYRINGE 183ULTICARE SYRINGE 183ULTI-LANCE AUTOMATIC

168ultilet alcohol swabs 143ULTILET CLASSIC LANCETS 168ULTILET INSULIN SYRINGE 183, 184ULTILET INSULIN SYRINGE SHORT 184ULTILET LANCETS 168ULTILET SAFETY LANCETS 168ULTILET SAFETY LANCETS 23G 168ultimate fat burner 217ultra antioxidant formula 207ultra comfort insulin syringe 175ultra freeda 207ultra freeda/iron 207ULTRA FRESH 224ultra multi formula/iron 207ULTRA OMEGA 3 222ultra omega-3 fish oil . 221ULTRA VITA-TIME 211ULTRACHOICE ADV FORMULA MATURE 211ULTRACHOICE ADVANCED FORMULA 211ultra-comfort insulin syringe 175ULTRALANCE 168ultra-mega 207ULTRA-THIN II AUTO LANCET 168ULTRA-THIN II INS SYR SHORT 184ULTRA-THIN II INSULIN SYRINGE 184ULTRA-THIN II LANCETS 168ULTRATHON INSECT REPELLENT 8 117ULTRATRAK PRO CONTROL 168ULTRATRAK ULTIMATE CONTROL 168UNILET COMFORTOUCH LANCET 168UNILET EXCELITE 168

UNILET EXCELITE II .................

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168UNILET G.P. LANCET 168UNILET G.P. SUPERLITE LANCET 168UNILET GP 28 ULTRA THIN 168UNILET LANCET 169UNILET MICRO-THIN 33G 169UNILET SUPERLITE LANCET 169UNILET SUPER-THIN 30G 169UNILET ULTRA-THIN 28G 169UNISTIK 1 169UNISTIK 2 169UNISTIK 2 COMFORT 169UNISTIK 2 EXTRA 169UNISTIK 2 NEONATAL 169UNISTIK 2 NORMAL 169UNISTIK 2 SUPER 169UNISTIK 3 169UNISTIK 3 COMFORT 169UNISTIK 3 EXTRA 169UNISTIK 3 GENTLE 169UNISTIK 3 NEONATAL 169UNISTIK 3 NORMAL 169UNISTIK CZT COMFORT 169UNISTIK CZT NORMAL 169UNISTIK SAFETY LANCETS 28G 169UNISTIK SAFETY LANCETS 30G 169UNISTIK TOUCH SAFETY LANC 21G 169UNISTIK TOUCH SAFETY LANC 23G 169UNISTIK TOUCH SAFETY LANC 28G 169UNISTIK TOUCH SAFETY LANC 30G 169UNISTRIP CONTROL 169UNITHROID 248UNITHROID DIRECT 247UNIVERSAL 1 LANCETSTHIN 26G 170UNIVERSAL 1 LANCETS THIN 33G 170UNIVERSAL 1 LANCETS ULTRA THIN 170universal ph 122up & up glucose 40URISTIX 123URISTIX 4 123

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217ursodiol 129VAGIFEM 256valacyclovir hcl ... 70valproate sodium . 37valproic acid 37valsartan 57valsartan-hydrochlorothiazide 57value health insulin syringe 175value plus glucose 40value plus lancet standard 21g 150value plus lancets super thin 150value plus lancets thin 26g 150value plus lancing device .. 150valumark lancet super thin 30g 150valumark lancet ultra thin 28g 150valved holding chamber 186vancomycin hcl 58, 59VANDAZOLE 256vanilla butternut flavor 233vanilla flavor 233VANISHPOINT INSULIN SYRINGE 184VANISHPOINT SYRINGE 184varisan vitality 217VAZOBID-PD 94v-c forte 207VCF VAGINAL CONTRACEPTIVE 256vegetable capsule #0 green 238vegetable capsule #0 white 238vegetable capsule #00 white 238vegetable capsule #1 white 238vegetable capsule #2 white 238vegetable capsule #3 white 238vegetable capsule #4 white 238VELIVET 85VEMAVITE-PRX 2 217venlafaxine hcl 38venlafaxine hcl er 38VENTAVIS 74VENTOLIN HFA 32verapamil hcl 73verapamil hcl er 73VERDROCET 22VERSAFREE 240VERSAPLUS 240VESICARE 254VESTURA 81VIC-FORTE . 211VICKS DAYQUIL COLD & FLU 88

VICODIN .................................. ............................ ............................

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22VICODIN ES 22VICODIN HP 22VICTORY CONTROLLEVEL 1/2 170VICTOZA 43VIDA MIA AUTOLETLANCING DEV 170VIDA MIA UNILET LANCETS 28G 170VIDA MIA UNILET LANCETS 30G 170VIDEX . 68VIEKIRA PAK 136VIEKIRA XR 136VIENVA 81VIGAMOX 226VIMPAT .36VINATE II 217VINATE M 217VINATE ONE 217VIOKACE 123viorele 77VIRACEPT 68VIREAD 69virt-c dha 216virt-phos 250 neutral 196virtrate-2 131virtrate-3 131virtrate-k 131virtussin a/c 91vision formula 2 207vision formula eye health 207vision formula/lutein 207vision plus 207vision vitamins 207visivites 207visivites/lutein 207vit b3-azelac-turm-fa-b6-zn-cu .207vita hair 207VITA S FORTE 211vitabasic complete 207vitabasic senior 207vita-bee/c 199VITACEL 211VITAFOL-OB 217VITAJOY DAILY D GUMMIES 261VITALET PRO LANCETS 170VITALET PRO PLUS LANCETS 170vita-min 207

vitamin b6 ................................. ................................

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257vitamin b-6 257vitamin d 260vitamin d (cholecalciferol) 259vitamin d (ergocalciferol) 260vitamin d high potency 260VITAMIN D-1000 MAX ST 261vitamin d2 260vitamin d3 260vitamin d-3 260vitamin d3 adult gummies 260vitamin d3 high potency 260vitamin d3 maximum strength 260vitamin d3 super strength 260vitamin d-400 260vitamin e/folic acid/b-6/b-12 212vitamin k1 . 76vitamins acd-fluoride 214vitamins a-d-e/selenium 207vitamins for hair 217vitamins/minerals 207vitatrum 207VITATRUM COMPLETE 211VITEYES AREDS ADVANCED 211VITEYES AREDS FORMULA 211VITEYES AREDS FORMULA/LUTEIN 211VITEYES COMPANION/LYCOPENE 211VITEYES COMPLETE 211VITEYES SMOKERS ADVANCED 211VITEYES SMOKERS FORMULA/LUTEIN 211VITRUM SENIOR 211VIVITROL 45VOGELXO 25VOGELXO PUMP .. 25vol-plus 216VOLTAREN 105VORTEX HOLDINGCHAMBER/MASK 186VORTEX VALVED HOLDING CHAMBER 189VOTRIENT 61vp insulin syringe 175VYFEMLA 81VYVANSE 3W&F LANCETS 26G 170

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W&F LANCETS COLORED 21G ...........................................

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170WAL-DRAM 47WAL-DRAM II 47WAL-DRYL ALLERGY 49WAL-DRYL ALLERGYCHILDRENS 49WAL-DRYL ALLERGY REL CHILDRENS 50walgreens adv travel lancets 150walgreens glucose 40WALGREENS LANCETS 170walgreens lancets micro thin 150walgreens lancets super thin 150WALGREENS THIN LANCETS 170WALGREENS ULTRA THIN LANCETS 170WAL-ITIN 53WAL-ITIN ALLERGY REDITABS 53WAL-ITIN ALLER-MELTS 53WAL-ITIN CHILDRENS 53WAL-MUCIL 139WAL-PROFEN 11wal-som maximum strength 137WAL-TAP CHILDRENS 94wal-tussin 96WAL-TUSSIN CHEST CONGESTION 96WAL-TUSSIN COUGH 86WAL-TUSSIN COUGHLONG ACTING 86WAL-TUSSIN COUGH/CHEST DM 92WAL-TUSSIN COUGH/CHEST DM MAX 92wal-tussin dm 91WAL-TUSSIN DM CGH/CHEST CONG 92WAL-VERT 54WAL-ZAN 150 MAXIMUM STRENGTH . 251WAL-ZAN 75 251WAL-ZYR 54, 226WAL-ZYR ALL DAY ALLERGY CHILD 54WAL-ZYR CHILDRENS 54WAL-ZYR D 94warfarin sodium 34WATCHHALER 189watermelon flavor 233

WEBCOL ALCOHOL PREP LARGE ....................................

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143WEBCOL ALCOHOL PREP MEDIUM 143weight loss daily multi 217WELCHOL 54WERA 81WESTHROID . 248WIDE-SEAL DIAPHRAGM 60 145WIDE-SEAL DIAPHRAGM 65 145WIDE-SEAL DIAPHRAGM 70 146WIDE-SEAL DIAPHRAGM 75 146WIDE-SEAL DIAPHRAGM 80 146WIDE-SEAL DIAPHRAGM 85 146WIDE-SEAL DIAPHRAGM 90 146WIDE-SEAL DIAPHRAGM 95 146wild cherry flavor 233womens 50+ advanced 207womens daily form/fa/ca/fe 207womens daily formula 207WOMENS LIFE PACK . 211womens multi 207womens multivitamin 208womens one daily 208WP THYROID 248xanthan gum 240XARELTO 34X-SEB T PEARL 120X-SEB T PLUS 120XULANE 81XYLON 22yl vitamin b-6 257YOUR LIFE MULTI MENS 50+ 211YOUR LIFE MULTI WOMENS 50+ 211YUVAFEM 256ZADITOR 226zafirlukast 33zaleplon 138ZARAH 81ZARXIO 134ZEASORB-AF 116ZEBUTAL 17

ZENATANE ..........................................................

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100ZENCHENT 81ZENPEP 123ZENZEDI 3ZEPATIER . 136ZETIA 55ZIAGEN 68zidovudine 69zinc oxide 106zinc-vites 198ziprasidone hcl 64zolmitriptan 189zolpidem tartrate 138ZOMACTON 126zonisamide . 36zoo friends . 212zoo friends gummies 212zoo friends plus extra c 215zoo friends plus iron 214ZOO FRIENDS/EXTRA C 215ZOVIA 1/35E (28) 81ZOVIA 1/50E (28) 81ZOVIRAX 105ZYNCOF 92

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