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Bienvenido(a) a Nebraska Total Care

¿Qué es la Lista de medicamentos recomendados de Nebraska Total Care?

La lista de medicamentos incluye medicamentos usados para tratar enfermedades comunes o problemas de salud. Un equipo de médicos y farmacéuticos se reúne regularmente para decidir qué medicamentos deberían estar en la lista de medicamentos. El equipo revisa medicamentos nuevos y existentes y elije medicamentos que funcionan mejor y son seguros. La lista de medicamentos es una combinación de la Lista de medicamentos preferidos del Estado y el formulario de Nebraska Total Care.

¿Cómo uso la Lista de medicamentos recomendados de Nebraska Total Care?

Busque su medicamento en el índice que está al final de este folleto. El índice muestra todos los medicamentos de la lista de medicamentos. En el índice aparecen tanto medicamentos de marca como genéricos. Junto a su medicamento, usted verá el número de página en el que puede encontrar su medicamento.

La tabla siguiente le dice qué significan las abreviaturas de la Lista de medicamentos.

Abreviatura Término Qué significa AL Límite por edad Algunos medicamentos solo están cubiertos para ciertas

edades. F Formulario Estos medicamentos están cubiertos en la Lista de

medicamentos. PA Autorización previa Su médico debe pedir aprobación de Nebraska Total Care

antes de que se cubran algunos medicamentos.

QL Límite de cantidad Algunos medicamentos solo están cubiertos por cierta cantidad.

NP No preferido Estos medicamentos están en el formulario que puede que todavía necesite cumplir con criterios de autorización previa/clase antes de que sean cubiertos.

RX/OTC Recetados y de venta sin receta (OTC)

Estos medicamentos se producen tanto en forma para venta con receta como en forma para venta sin receta (OTC).

ST Terapia escalonada En algunos casos, primero debe probar ciertos medicamentos antes de que Nebraska Total Care cubra otro medicamento para su condición médica.

Por ejemplo, si tanto el medicamento A como el medicamento B tratan su condición médica, puede que Nebraska Total Care no cubra el medicamento B a menos que usted pruebe el medicamento A primero.

¿Qué pasa si mi medicamento no está en la Lista de medicamentos recomendados de Nebraska Total Care?

Si su medicamento no está en la lista de medicamentos, llame a Servicios para los Miembros al 1-844-385-2192 y pregunte si su medicamento está cubierto. Si su medicamento no está cubierto, puede pedir a su médico que recete un medicamento similar que esté cubierto. Si su médico cree que usted debe tener el medicamento que no está cubierto, su médico puede pedirnos que hagamos una excepción.

¿Puedo ir a cualquier farmacia?

Los miembros deben usar farmacias que están en la red. Estas farmacias tienen contrato con Nebraska Total Care. Para encontrar una farmacia, llame a Servicios para los Miembros al 1844-385-2192.

¿Tiene límites mi cobertura de medicamentos?

Algunos medicamentos tienen límites en la cobertura. Si un medicamento tiene límites, se indicará en la columna de requisitos/límites en la Lista de medicamentos.

¿Cómo puedo obtener excepción a las reglas para cobertura de medicamentos?

Su médico puede pedir una excepción a nuestras reglas para cobertura de medicamentos.

• Su médico puede pedirnos que cubramos su medicamento incluso si no está en la lista de medicamentos.

• Su médico puede pedirnos que hagamos una excepción para límites en su medicamento. Por ejemplo, si su medicamento tiene un límite a la cantidad de 1 tableta por día, su médico puede pedirnos que cubramos más.

Para solicitar una excepción, su médico puede enviarnos por fax un formulario de autorización previa al 1-866-399-0929. Una vez que recibamos la solicitud de su médico, normalmente tomamos nuestra decisión dentro de un plazo de un día hábil. Si necesitamos más información, su médico tiene cinco días hábiles para darnos esa información antes de que tomemos nuestra decisión.

¿Qué pasa si soy un miembro nuevo?

Si es miembro nuevo en nuestro plan, puede que usted esté tomando medicamentos que no están en nuestra lista de medicamentos. Puede que también esté tomando un medicamento que está en nuestra lista de medicamentos, pero el medicamento puede tener algunos límites. En estos casos, debe hablar con su médico para ver si debería cambiar a medicamentos que cubrimos. Su médico puede solicitar una excepción así que podríamos cubrir el medicamento que ha estado tomando. Consulte la sección, “¿Cómo obtengo una excepción a las reglas para la cobertura de medicamentos?” para más información.

¿Qué son medicamentos de venta sin receta?

Los medicamentos de venta sin receta (OTC) son medicamentos que puede comprar sin una

receta. La Lista de medicamentos recomendados de Nebraska Total Care cubre medicamentos OTC similares a los que aparecen en la Lista de medicamentos por contrato de Medicaid del Estado de Nebraska. Sin embargo, si quiere que Nebraska Total Care cubra un medicamento OTC de la lista de medicamentos, su médico debe escribir una receta para ese medicamento.

¿Están cubiertos los medicamentos de marca?

Su beneficio de farmacia no cubre medicamentos de marca cuando hay disponibles medicamentos genéricos a menos que el estado requiera el uso de la marca. Los medicamentos de marca pueden estar cubiertos cuando los medicamentos genéricos no están disponibles. Si su médico dice que el medicamento de marca es necesario desde el punto de vista médico o es preferido por el formulario del estado.

¿Qué es un medicamento genérico?

Un medicamento genérico contiene el mismo ingrediente activo y funciona igual al medicamento de marca. Los medicamentos genéricos deben ser seguros y eficaces.

¿Me dará el farmacéutico un medicamento genérico si hay uno disponible?

Sí. Las farmacias le pueden dar un medicamento genérico, a menos que su médico diga que usted debe tomar el medicamento de marca o preferido por el estado.

¿Hay medicamentos excluidos o con excepción?

Medicamentos excluidos

La Lista de medicamentos recomendados de Nebraska Total Care es similar a la Lista de medicamentos por contrato de Medicaid del Estado de Nebraska y no incluye ciertos medicamentos. Los siguientes tipos de medicamentos no están incluidos en la lista de medicamentos porque están excluidos de cobertura:

• Medicamentos que no tienen aprobación de la FDA • Medicamentos experimentales o en investigación • Medicamentos para ayudarla a quedar embarazada • Medicamentos usados para perder peso • Medicamentos cosméticos o para hacer crecer el cabello • Medicamentos usados para tratar los problemas eréctiles • Medicamentos que no están en el formulario de medicamentos de venta sin receta

¿Necesita más información?

Para más información sobre sus beneficios de farmacia, revise su Manual para Miembros o llame a Servicios para los Miembros al 1-844-385-2192.

Nebraska Total Care cumple con las leyes federales de derechos civiles aplicables y no discrimina en base a raza, color, origen nacional, edad, discapacidad o sexo.

Nebraska Total Care no excluye a las personas ni las trata de manera distinta debido a su raza, color, origen nacional, edad, discapacidad o sexo.

Nebraska Total Care:

• Ofrece ayudas y servicios gratuitos a personas con discapacidades para que se comuniquen eficazmente con nosotros, como intérpretes de lenguaje de señas calificados e información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos).

• Ofrece servicios de idiomas gratuitos a personas cuyo idioma principalno es el inglés, como intérpretes calificados e información escrita en otros idiomas

Si necesita estos servicios, llame al Centro de contacto de Nebraska Total Care al

1-844-385-2192, TTY: 1-844-307-0342, Retransmisión 711.

Si cree que Nebraska Total Care no le ha proporcionado estos servicios o lo(a) ha discriminado de otra manera en base a raza, color, origen nacional, edad,discapacidad o sexo, puede presentar una queja llamando al número anterior ydiciéndoles que necesita ayuda para presentar una queja; el Centro de Servicios para los Miembros de Nebraska Total Care está disponible para ayudarle.

Además, puede usar el portal para miembros en nuestro sitio web en:

www.NebraskaTotalCare.com

Dénosla en persona o por correo:

Nebraska Total Care ATTN: Grievances:

2525 North 117th Ave

Omaha NE, 68164

Cuando presente una queja asegúrese de incluir:

• Su primer nombre y apellido • Su número de identificación de Medicaid de Nebraska • Su dirección y número telefónico • Lo que lo tiene descontento • Qué le gustaría que pase

http://www.nebraskatotalcare.com/

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS 1.25MG-1.25MG-1.25MG-1.25MG (Amphetamine-Dextroamphetamine)

F

QL(12 eadaily); AL; Atleast 5 yrs old

ADDERALL TABS 1.875MG-1.875MG-1.875MG-1.875MG (Amphetamine-Dextroamphetamine)

F

QL(8 ea daily);AL; At least 5 yrs old


F



F

QL(4.8 eadaily); AL; Atleast 5 yrs old


F


ADDERALL TABS 5MG-5MG-5MG-5MG (Amphetamine-Dextroamphetamine)

F



F


ADDERALL XR CP24 1.25MG-1.25MG-1.25MG-1.25MG (Amphetamine-Dextroamphetamine)

F



F



F


Drug Name DrugTier

Requirements/Limits

ADDERALL XR CP24 5MG-5MG-5MG-5MG (Amphetamine-Dextroamphetamine)

F



F

QL(2 ea daily)


F


ADZENYS XR-ODT TBED NP AL; At least 6 yrs old amphetamine-dextroamphetamine cp241.25mg-1.25mg-1.25mg-1.25mg

NP


amphetamine-dextroamphetamine cp242.5mg-2.5mg-2.5mg-2.5mg

NP QL(6 ea daily);AL; At least 5 yrs old


NP


amphetamine-dextroamphetamine cp245mg-5mg-5mg-5mg



NP

QL(2 ea daily)



amphetamine-dextroamphetamine tabs1.25mg-1.25mg-1.25mg-1.25mg

F



F



F QL(6 ea daily);AL; At least 5 yrs old

Nebraska Total Care Updated December 1, 2017

1

Drug Name DrugTier

Requirements/Limits


F



F


amphetamine-dextroamphetamine tabs5mg-5mg-5mg-5mg




DESOXYN TABS (Methamphetamine HCl) NP

PA; QL(1 eadaily); AL; Atleast 5 yrs old

DEXEDRINE CP24 10 MG (DextroamphetamineSulfate)

NP

PA; QL(6 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old


NP



NP


dextroamphetamine sulfatecp24 10 mg F






dextroamphetamine sulfatesoln 5 mg/5ml F

PA; QL(12 mldaily); AL; Atleast 5 yrs old -Up to 18 yrs old

Drug Name DrugTier

Requirements/Limits

dextroamphetamine sulfatetabs 10 mg NP

QL(6 ea daily);AL; At least 5 yrs old - Up to18 yrs old

dextroamphetamine sulfatetabs 5 mg NP

QL(12 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old

EVEKEO TABS NP AL; At least 5 yrs old

methamphetamine hcl tabs F PA; QL(1 eadaily); AL; Atleast 5 yrs old

MYDAYIS CP24 12.5MG-12.5MG-12.5MG-12.5MG, 3.125MG-3.125MG-3.125MG-3.125MG

NP

AL; At least 5 yrs old

MYDAYIS CP24 6.25MG-6.25MG-6.25MG-6.25MG, 9.375MG-9.375MG-9.375MG-9.375MG

NP

PROCENTRA SOLN (DextroamphetamineSulfate)

NP

PA; QL(12 mldaily); AL; Atleast 5 yrs old -Up to 18 yrs old

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

F AL; At least 5 yrs old

VYVANSE CHEW 10 MG NP QL(1 ea daily);AL; At least 5 yrs old

VYVANSE CHEW 30 MG, 50 MG, 20 MG, 60 MG, 40 MG


ZENZEDI TABS 15 MG NP


ZENZEDI TABS 2.5 MG NP

QL(24 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old




2

Drug Name DrugTier

Requirements/Limits



ZENZEDI TABS 7.5 MG NP


Analeptics CAFCIT SOLN (Caffeine Citrate) NP

caffeine citrate soln F

caffeine tabs F

VIVARIN TABS (Caffeine) NP

Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps 25mg, 18 mg, 10 mg, 40 mg NP


atomoxetine hcl caps 60mg, 80 mg, 100 mg NP


clonidine hcl (adhd) tb12 NP QL(2 ea daily);AL; At least 6 yrs old

guanfacine hcl (adhd) tb24 F PA; QL(1 eadaily); AL; Atleast 6 yrs old

INTUNIV TB24 (Guanfacine HCl (ADHD)) NP


KAPVAY TB12 (Clonidine HCl (ADHD)) NP


STRATTERA CAPS 10 MG, 25 MG, 18 MG, 40 MG (Atomoxetine HCl)


STRATTERA CAPS 100 MG, 60 MG, 80 MG (Atomoxetine HCl)


Stimulants - Misc.

APTENSIO XR CP24 NP QL(1 ea daily);AL; At least 5 yrs old

Drug Name DrugTier

Requirements/Limits

armodafinil tabs NP QL(1 ea daily);AL; At least 18 yrs old

CONCERTA TBCR 18 MG (Methylphenidate HCl) NP PA

CONCERTA TBCR 27 MG, 54 MG (MethylphenidateHCl)

NP PA; QL(1 eadaily); AL; Atleast 5 yrs old

CONCERTA TBCR 36 MG (Methylphenidate HCl) NP


DAYTRANA PTCH F


dexmethylphenidate hclcp24 10 mg, 25 mg, 30 mg,40 mg, 15 mg, 5 mg, 35mg, 20 mg

NP


dexmethylphenidate hcltabs 10 mg NP


dexmethylphenidate hcltabs 2.5 mg NP


dexmethylphenidate hcltabs 5 mg NP


FOCALIN TABS 10 MG (Dexmethylphenidate HCl) F


FOCALIN TABS 2.5 MG (Dexmethylphenidate HCl) F


FOCALIN TABS 5 MG (Dexmethylphenidate HCl) F


FOCALIN XR CP24 (Dexmethylphenidate HCl) F


METADATE CD CPCR 20 MG, 30 MG, 10 MG (Methylphenidate HCl)

NP PA; QL(1 eadaily)

METADATE CD CPCR 60 MG, 40 MG, 50 MG (Methylphenidate HCl)

NP PA; QL(1 eadaily); AL; Atleast 5 yrs old

METHYLIN CHEW (Methylphenidate HCl) NP


3

Drug Name DrugTier

Requirements/Limits

METHYLIN SOLN (Methylphenidate HCl) NP

METHYLPHENIDATE HCL CHEW 10 MG, 5 MG, 2.5 MG

NP

methylphenidate hcl cp2440 mg, 30 mg, 20 mg F PA; QL(1 ea

daily) methylphenidate hcl cpcr30 mg, 20 mg, 10 mg F PA; QL(1 ea

daily)

methylphenidate hcl cpcr40 mg, 60 mg, 50 mg F


METHYLPHENIDATE HCL ER (LA) CP24 F ST; QL(1 ea

daily) METHYLPHENIDATE HCL ER TB24 18 MG, 54 MG, 36 MG, 27 MG

F PA

METHYLPHENIDATE HCL ER TBCR 18 MG F PA

methylphenidate hcl soln10 mg/5ml, 5 mg/5ml NP

methylphenidate hcl tabs10 mg, 20 mg, 5 mg F

methylphenidate hcl tbcr 10 mg F


methylphenidate hcl tbcr 18 mg F PA



methylphenidate hcl tbcr 27mg, 54 mg F




modafinil tabs NP QL(2 ea daily);AL; At least 18 yrs old

NUVIGIL TABS (Armodafinil) NP


PROVIGIL TABS (Modafinil) NP


Drug Name DrugTier

Requirements/Limits

QUILLICHEW ER CHER F AL; At least 5 yrs old

QUILLIVANT XR SUSR F

RITALIN LA CP24 10 MG F PA; QL(1 eadaily)

RITALIN LA CP24 20 MG, 30 MG, 40 MG (Methylphenidate HCl)


RITALIN LA CP24 60 MG F ST; QL(1 eadaily)

RITALIN TABS (Methylphenidate HCl) NP

ALLERGENIC EXTRACTS/BIOLOGICALS MISC

Allergenic Extracts GRASTEK SUBL F

ORALAIR ADULT SAMPLE KIT SUBL F

ORALAIR ADULT STARTER PACK SUBL F

ORALAIR CHILDREN/ADOLESCENTS STARTER PACK SUBL

F

ORALAIR SUBL F

RAGWITEK SUBL F

ALTERNATIVE MEDICINES

Alternative Medicine - M's melatonin tabs or 5 mg, 10mg, 1 mg, 3 mg F

Alternative Medicine Combinations MELATONIN TABS OR 3MG-10MG F

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections Aminoglycosides BETHKIS NEBU F PA

KITABIS PAK NEBU F

neomycin sulfate tabs F


4

Drug Name DrugTier

Requirements/Limits

TOBI NEBU (Tobramycin) NP

TOBI PODHALER CAPS F PA

TOBRAMYCIN NEBU 4

tobramycin nebu 4

tobramycin sulfate soln ij1.2 gm/30ml, 10 mg/ml, 80mg/2ml, 40 mg/ml

F

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

F

tobramycin sulfate solr ij1.2 gm F

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditions Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

F QL(4 ea per fillretail)

HUMIRA PEN PNKT F QL(4 ea per fillretail)

HUMIRA PEN-CROHNS DISEASESTARTER PNKT F QL(4 ea per fill

retail) HUMIRA PEN-PSORIASIS STARTER PNKT F QL(4 ea per fill

retail) HUMIRA PSKT 20 MG/0.4ML, 10 MG/0.2ML F QL(2 ea per fill

retail) HUMIRA PSKT 40 MG/0.8ML F QL(4 ea per fill

retail)

SIMPONI SOAJ NP

SIMPONI SOSY NP

Antirheumatic - Enzyme Inhibitors XELJANZ TABS NP QL(2 ea daily)

XELJANZ XR TB24 NP

Antirheumatic Antimetabolites

OTREXUP SOAJ 7.5 MG/0.4ML F

PA; Limit 4ml permonth;QL(0.1334 ml daily)

Drug Name DrugTier

Requirements/Limits

RHEUMATREX TABS F

Interleukin-1 Blockers ARCALYST SOLR NP

Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET SOSY NP

Interleukin-6 Receptor Inhibitors ACTEMRA SOSY SC 162 MG/0.9ML NP

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL CAPS (Ibuprofen) NP

ADVIL MIGRAINE CAPS (Ibuprofen) NP

ADVIL TABS (Ibuprofen) NP

ALEVE ARTHRITIS TABS (Naproxen Sodium) NP

ALEVE CAPS (NaproxenSodium) NP

ALEVE TABS (NaproxenSodium) NP

ANAPROX DS TABS (Naproxen Sodium) NP

ARTHROTEC 50 TBEC (Diclofenac w/ Misoprostol) NP

ARTHROTEC 75 TBEC (Diclofenac w/ Misoprostol) NP

CELEBREX CAPS (Celecoxib) NP

celecoxib caps NP

CHILDRENS ADVIL SUSP (Ibuprofen) NP RX/OTC

CHILDRENS MOTRIN SUSP (Ibuprofen) NP RX/OTC

DAYPRO TABS (Oxaprozin) NP

diclofenac potassium tabs NP

diclofenac sodium tb24 or 100 mg F

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


5

Drug Name DrugTier

Requirements/Limits

diclofenac w/ misoprostoltbec NP

DUEXIS TABS NP

EC-NAPROSYN TBEC (Naproxen) NP

etodolac caps NP

etodolac tabs NP

etodolac tb24 NP

FELDENE CAPS (Piroxicam) NP QL(1 ea daily)

FENOPROFEN CALCIUM CAPS 200 MG, 400 MG NP

fenoprofen calcium tabs600 mg NP

FENORTHO CAPS NP

flurbiprofen tabs NP

ibuprofen caps 200 mg NP

ibuprofen chew 100 mg F

ibuprofen susp 100 mg/5ml F RX/OTC

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

ibuprofen tabs 600 mg, 800mg, 100 mg, 400 mg, 200 mg

F

INDOCIN SUPP NP

INDOCIN SUSP NP

indomethacin caps 50 mg,25 mg F

indomethacin cpcr 75 mg NP

INFANTS ADVIL SUSP (Ibuprofen) NP

ketoprofen caps NP

KETOPROFEN ER CP24 NP

Drug Name DrugTier

Requirements/Limits

ketorolac tromethamine tabs or 10 mg F QL(4 ea daily,5

day(s) limit)

LODINE TABS (Etodolac) NP

MECLOFENAMATE SODIUM CAPS NP

mefenamic acid caps NP

MELOXICAM SUSP 7.5 MG/5ML F PA; AL; Up to

11 yrs old meloxicam tabs 7.5 mg, 15 mg F

MOBIC SUSP 7.5 MG/5ML F PA; AL; Up to11 yrs old

MOBIC TABS 7.5 MG, 15 MG (Meloxicam) NP

MOTRIN INFANTS DROPS SUSP (Ibuprofen) NP

nabumetone tabs F

NALFON CAPS NP

NAPRELAN TB24 375 MG, 500 MG (NaproxenSodium)

NP

NAPRELAN TB24 750 MG NP

NAPROSYN SUSP (Naproxen) NP

NAPROSYN TABS (Naproxen) NP

naproxen sodium caps 220 mg F

naproxen sodium tabs 220 mg 4

naproxen sodium tabs 220 mg F

naproxen sodium tabs 550mg, 275 mg NP

naproxen sodium tb24 500mg, 375 mg NP

NAPROXEN SUSP 125 MG/5ML F

naproxen susp 125 mg/5ml F

naproxen tabs 250 mg, 500mg, 375 mg F


6

Drug Name DrugTier

Requirements/Limits

naproxen tbec 375 mg NP

naproxen tbec 500 mg F

naproxen tbec 500 mg 4

oxaprozin tabs NP

piroxicam caps NP QL(1 ea daily)

PONSTEL CAPS (Mefenamic Acid) NP

SPRIX SOLN NP

sulindac tabs F

TIVORBEX CAPS NP

TOLMETIN SODIUM CAPS 400 MG NP

tolmetin sodium caps 400 mg NP

TOLMETIN SODIUM TABS 200 MG, 600 MG NP

VIMOVO TBEC NP

VIVLODEX CAPS NP QL(1 ea daily)

ZIPSOR CAPS NP

ZORVOLEX CAPS NP

Phosphodiesterase 4 (PDE4) Inhibitors OTEZLA TABS NP QL(2 ea daily)

OTEZLA TBPK NP

Pyrimidine Synthesis Inhibitors ARAVA TABS (Leflunomide) NP

leflunomide tabs F

Selective Costimulation Modulators ORENCIA CLICKJECT SOAJ NP

Drug Name DrugTier

Requirements/Limits

ORENCIA SOSY SC 125 MG/ML, 50 MG/0.4ML,87.5 MG/0.7ML

NP

Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT NP

ENBREL SOLR 25 MG F QL(8 ea per fillretail)

ENBREL SOSY 25 MG/0.5ML F QL(4.08 ml per

fill retail)

ENBREL SOSY 50 MG/ML F QL(7.84 ml perfill retail)

ENBREL SURECLICK SOAJ F QL(7.84 ml per

fill retail) ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions Analgesic Combinations aspirin-acetaminophen-caffeine tabs F

butalbital-acetaminophentabs 325mg-50mg F

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

F

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

F

butalbital-aspirin-caffeine caps F

BUTALBITAL/ASPIRIN/CAFFEINE TABS F QL(4 ea daily)

ESGIC TABS (Butalbital-Acetaminophen-Caffeine) NP

EXCEDRIN EXTRA STRENGTH TABS (Aspirin-Acetaminophen-Caffeine)

NP

EXCEDRIN MENSTRUAL COMPLETE TABS (Aspirin-Acetaminophen-Caffeine)

NP

EXCEDRIN MIGRAINE TABS (Aspirin-Acetaminophen-Caffeine)

NP

FIORINAL CAPS (Butalbital-Aspirin-Caffeine) NP


7

Drug Name DrugTier

Requirements/Limits

TENCON TABS F

Analgesics Other acetaminophen caps or500 mg F

acetaminophen chew or 80 mg F

acetaminophen liqd or 160mg/5ml, 1000 mg/30ml,500 mg/15ml

F

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

F

acetaminophen supp re120 mg, 650 mg, 325 mg F QL(0.4 ea

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

F

acetaminophen tabs or 325mg, 500 mg F

acetaminophen tbcr or 650 mg F

acetaminophen tbdp or 80mg, 160 mg F

FEVERALL INFANTS SUPP F

TRIAMINIC FEVER REDUCERPAIN RELIEVER CHILDRENS SYRP

F

TRIAMINIC FEVER REDUCERPAIN RELIEVER INFANTS SYRP

F

TYLENOL 8 HOUR ARTHRITISPAIN TBCR (Acetaminophen)

NP

TYLENOL 8 HOUR TBCR (Acetaminophen) NP

TYLENOL CHILDRENS SUSP (Acetaminophen) NP

TYLENOL EXTRA STRENGTH TABS (Acetaminophen)

NP

TYLENOL INFANTS PAIN+FEVER SUSP (Acetaminophen)

NP

Drug Name DrugTier

Requirements/Limits

TYLENOL INFANTS SUSP (Acetaminophen) NP

TYLENOL SORE THROAT DAYTIME LIQD (Acetaminophen)

NP

TYLENOL TABS (Acetaminophen) NP

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

aspirin chew or 81 mg F

ASPIRIN LOW DOSE TABS F

aspirin supp re 300 mg F QL(0.4 eadaily)

aspirin supp re 600 mg F

aspirin tabs or 325 mg F

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

BUFFERIN TABS (AspirinBuffered (Cal Carb-MagCarb-Mag Oxide))

NP

diflunisal tabs NP

ECOTRIN REGULAR STRENGTH TBEC (Aspirin)

NP

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint Conditions Opioid Agonists ABSTRAL SUBL NP

ACTIQ LPOP (FentanylCitrate) NP

ARYMO ER TBEA 30 MG, 15 MG NP QL(3 ea daily)

ARYMO ER TBEA 60 MG NP QL(2 ea daily)

CODEINE SULFATE TABS 15 MG (Codeine Sulfate) NP



8

Drug Name DrugTier

Requirements/Limits

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


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


CONZIP CP24 NP AL; At least 18 yrs old DEMEROL TABS OR 50 MG, 100 MG (MeperidineHCl)

NP QL(5 ea daily)

DILAUDID LIQD OR 1 MG/ML (HydromorphoneHCl)

NP

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

NP QL(5 ea daily)

DOLOPHINE TABS (Methadone HCl) NP

DURAGESIC PT72 12 MCG/HR (Fentanyl) NP PA; QL(0.5 eadaily) DURAGESIC PT72 75 MCG/HR, 25 MCG/HR, 50MCG/HR, 100 MCG/HR(Fentanyl)

NP

QL(0.5 eadaily)

EMBEDA CPCR NP QL(2 ea daily)

EXALGO T24A 12 MG, 8 MG, 16 MG (Hydromorphone HCl)

NP QL(1 ea daily)

EXALGO T24A 32 MG (Hydromorphone HCl) NP QL(2 ea daily)

fentanyl citrate lpop bu1200 mcg, 800 mcg, 600mcg, 1600 mcg, 200 mcg,400 mcg

NP

fentanyl pt72 12 mcg/hr F PA; QL(0.5 eadaily)

fentanyl pt72 25 mcg/hr,100 mcg/hr, 75 mcg/hr, 50mcg/hr

F QL(0.5 eadaily)

FENTANYL PT72 87.5 MCG/HR, 62.5 MCG/HR,37.5 MCG/HR

NP QL(0.5 eadaily)

FENTORA TABS NP

Drug Name DrugTier

Requirements/Limits

hydromorphone hcl liqd or1 mg/ml NP

HYDROMORPHONE HCL SUPP RE 3 MG NP

hydromorphone hcl t24a or12 mg, 8 mg, 16 mg, 8mg NP QL(1 ea daily)

hydromorphone hcl t24a or32 mg NP QL(2 ea daily)

hydromorphone hcl tabs or4 mg, 2 mg, 8 mg F QL(5 ea daily)

HYSINGLA ER T24A F QL(1 ea daily)

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

NP

QL(4 ea daily)

KADIAN CP24 40 MG, 200 MG NP QL(4 ea daily)

LAZANDA SOLN NP

LEVORPHANOL TARTRATE TABS NP QL(5 ea daily)

MEPERIDINE HCL SOLN OR 50 MG/5ML NP

meperidine hcl tabs or 50mg, 100 mg NP QL(5 ea daily)

methadone hcl conc or 10 mg/ml NP

METHADONE HCL SOLN OR 10 MG/5ML, 5 MG/5ML(Methadone HCl)

NP

methadone hcl soln or 5 mg/5ml, 10 mg/5ml NP

methadone hcl tabs or 10 mg, 5 mg NP

methadone hcl tbso or 40 mg NP

QL(6 eadaily,180day(s) limit)

METHADOSE CONC (Methadone HCl) NP

METHADOSE SUGAR-FREE CONC (Methadone HCl)

NP

morphine sulfate cp24 or30 mg, 60 mg, 50 mg, 10mg, 20 mg, 80 mg, 100 mg

NP QL(4 ea daily)


9

Drug Name DrugTier

Requirements/Limits

MORPHINE SULFATE ER CP24 NP QL(1 ea daily)

morphine sulfate soln or 10mg/5ml, 20 mg/5ml, 100mg/5ml, 20 mg/ml

F PA

MORPHINE SULFATE SUPP RE 20 MG, 10 MG, 30 MG, 5 MG

NP

MORPHINE SULFATE TABS OR 30 MG, 15 MG F QL(5 ea daily)

morphine sulfate tbcr or200 mg, 60 mg, 15 mg, 30mg, 100 mg

F

MS CONTIN TBCR (Morphine Sulfate) NP

NUCYNTA ER TB12 NP

NUCYNTA TABS NP QL(5 ea daily)

OPANA ER (CRUSH RESISTANT) T12A NP QL(3 ea daily)

OPANA TABS OR 10 MG, 5 MG (Oxymorphone HCl) NP QL(5 ea daily)

OXAYDO TABA NP

oxycodone hcl caps 5 mg NP QL(5 ea daily)

oxycodone hcl conc 100mg/5ml F

oxycodone hcl conc 100mg/5ml 4

OXYCODONE HCL ER T12A 30 MG, 60 MG, 10 MG, 20 MG, 15 MG, 40 MG

4 QL(3 ea daily)

OXYCODONE HCL ER T12A 80 MG 4 QL(4 ea daily)

oxycodone hcl soln 5mg/5ml F

oxycodone hcl tabs 30 mg 4 QL(5 ea daily)

oxycodone hcl tabs 30 mg,10 mg, 20 mg, 5 mg, 15 mg F QL(5 ea daily)

OXYCONTIN T12A 15 MG, 10 MG, 60 MG, 20 MG, 40 MG, 30 MG

F QL(3 ea daily)

OXYCONTIN T12A 80 MG F QL(4 ea daily)

Drug Name DrugTier

Requirements/Limits

oxymorphone hcl tabs 5mg, 10 mg NP QL(5 ea daily)

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

NP QL(3 ea daily)

OXYMORPHONE HYDROCHLORIDE ER TB12

NP QL(3 ea daily)

ROXICODONE TABS (Oxycodone HCl) NP QL(5 ea daily)

SUBSYS LIQD NP

TRAMADOL HCL ER CP24 300 MG, 200 MG, 100 MG NP AL; At least 18 yrs old

tramadol hcl tabs 50 mg F QL(8 ea daily);AL; At least 17 yrs old

tramadol hcl tb24 100 mg,300 mg, 200 mg NP AL; At least 16 yrs old tramadol hcl tb24 200 mg,300 mg, 100 mg NP AL; At least 18 yrs old ULTRAM ER TB24 (Tramadol HCl) NP AL; At least 18 yrs old

ULTRAM TABS (Tramadol HCl) NP


XTAMPZA ER C12A 13.5 MG, 9 MG, 18 MG, 27 MG NP


XTAMPZA ER C12A 36 MG NP


ZOHYDRO ER C12A NP

Opioid Combinations acetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml F AL; At least 12

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


ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINECAPS


ASPIRIN-CAFFEINE-DIHYDROCODEINE CAPS NP



10

Drug Name DrugTier

Requirements/Limits

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

F

butalbital-aspirin-caffeinew/cod caps F

CAPITAL/CODEINE SUSP NP AL; At least 12 yrs old FIORINAL/CODEINE #3CAPS (Butalbital-Aspirin-Caffeine w/Cod)

NP

hydrocodone-acetaminophen soln10mg/15ml-325mg/15ml

NP

hydrocodone-acetaminophen tabs 5mg-325mg, 7.5mg-300mg,7.5mg-325mg, 2.5mg-325mg, 10mg-325mg,10mg-300mg, 5mg-300mg

F

QL(5 ea daily)

hydrocodone-ibuprofentabs 200mg-5mg, 200mg-10mg

4 QL(5 ea daily)

hydrocodone-ibuprofentabs 200mg-7.5mg,200mg-10mg, 200mg-5mg

F QL(5 ea daily)

IBUDONE TABS (Hydrocodone-Ibuprofen) NP QL(5 ea daily)

LORTAB ELIX NP

NORCO TABS (Hydrocodone-Acetaminophen)

NP QL(5 ea daily)

oxycodone w/acetaminophen tabs F QL(5 ea daily)

oxycodone-aspirin tabs NP QL(5 ea daily)

OXYCODONE/ACETAMINOPHEN SOLN NP

OXYCODONE/IBUPROFEN TABS NP QL(5 ea daily)

PERCOCET TABS (Oxycodone w/Acetaminophen)

NP QL(5 ea daily)

PRIMLEV TABS NP QL(5 ea daily)

REPREXAIN TABS (Hydrocodone-Ibuprofen) NP QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

SYNALGOS-DC CAPS NP QL(5 ea daily);AL; At least 12 yrs old

tramadol-acetaminophentabs NP


TREZIX CAPS NP QL(5 ea daily);AL; At least 12 yrs old

TYLENOL/CODEINE #3TABS (Acetaminophen w/Codeine)


TYLENOL/CODEINE #4TABS (Acetaminophen w/Codeine)


ULTRACET TABS (Tramadol-Acetaminophen) NP


VICOPROFEN TABS (Hydrocodone-Ibuprofen) NP QL(5 ea daily)

XARTEMIS XR TBCR NP QL(4 ea daily)

XODOL TABS (Hydrocodone-Acetaminophen)

NP QL(5 ea daily)

ZAMICET SOLN NP

Opioid Partial Agonists

BELBUCA FILM NP QL(2 ea daily);AL; At least 18 yrs old

BUNAVAIL FILM 2.1MG-0.3MG NP


BUNAVAIL FILM 6.3MG-1MG, 4.2MG-0.7MG NP


buprenorphine hcl subl NP QL(3 ea daily);AL; At least 16 yrs old

buprenorphine hcl-naloxone hcl dihydrate subl NP

BUPRENORPHINE PTWK 10 MCG/HR 4

4 per 28days;QL(4 eaper 28 daysretail)


11

Drug Name DrugTier

Requirements/Limits

BUPRENORPHINE PTWK 15 MCG/HR, 10 MCG/HR 4

Limit 4 per 28days;QL(4 eaper 28 daysretail)

BUPRENORPHINE PTWK 5 MCG/HR 4

Limit 4 per 28days;QL(0.143ea daily)

BUPRENORPHINE PTWK 7.5 MCG/HR 4 QL(0.143 ea

daily) butorphanol tartrate soln na10 mg/ml NP QL(0.334 mldaily)

BUTRANS PTWK 15 MCG/HR, 10 MCG/HR, 20MCG/HR

F

Limit 4 per 28days;QL(4 eaper 28 daysretail)

BUTRANS PTWK 5 MCG/HR F

Limit 4 per 28days;QL(0.143ea daily)

BUTRANS PTWK 7.5 MCG/HR F QL(0.143 ea

daily) pentazocine w/ naloxonetabs NP QL(5 ea daily)

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


SUBOXONE FILM 8MG-2MG, 2MG-0.5MG F


ZUBSOLV SUBL 11.4MG-2.9MG, 0.7MG-0.18MG NP






ANDROGENS-ANABOLIC - Drugs to RegulateHormones Androgens ANDRODERM PT24 NP

ANDROGEL GEL 20.25 MG/1.25GM, 40.5MG/2.5GM

F

Drug Name DrugTier

Requirements/Limits

ANDROGEL GEL 50 MG/5GM, 25 MG/2.5GM(Testosterone)

F

ANDROGEL PUMP GEL F

AXIRON SOLN (Testosterone) NP

DEPO-TESTOSTERONE SOLN (Testosterone Cypionate)

NP

FORTESTA GEL NP

NATESTO GEL NP

TESTIM GEL (Testosterone) NP

TESTONE CIK KIT F

testosterone cypionate soln F

TESTOSTERONE GEL TD 1 %, 25 MG/2.5GM, 50MG/5GM

4

TESTOSTERONE GEL TD 10 MG/ACT NP

testosterone gel td 25mg/2.5gm, 1 %, 50 mg/5gm 4

testosterone gel td 25mg/2.5gm, 50 mg/5gm 4 PA

TESTOSTERONE PUMP GEL 4

testosterone soln td 30 mg/act NP

VOGELXO GEL 4

VOGELXO PUMP GEL 4

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Hydrocortisone(Intrarectal))

NP

hydrocortisone (intrarectal) enem F

UCERIS FOAM NP


12

Drug Name DrugTier

Requirements/Limits

Rectal Combinations ANALPRAM-HC LOTN 1%-2.5% F

phenylephrine in hard fat supp F

phenylephrine-cocoa buttersupp 88.44%-0.25% F

phenylephrine-mineral oil-petrolatum oint 14%-74.9%-0.25%

F

phenylephrine-shark liveroil-cocoa butter supp F

phenylephrine-shark liveroil-mineral oil-petrolatumoint

F

phenylephrine-witch hazelgel F

pramoxine-phenylephrine-glycerin-petrolatum crea F

PREPARATION H CREA (Pramoxine-Phenylephrine-Glycerin-Petrolatum)

NP

PREPARATION H GEL (Phenylephrine-WitchHazel)

NP

PREPARATION H OINT (Phenylephrine-Mineral Oil-Petrolatum)

NP

PREPARATION H TOTABLES BURN RELIEF GEL (Phenylephrine-WitchHazel)

NP

PREPARATION H TOTABLES PAIN RELIEF CREA (Pramoxine-Phenylephrine-Glycerin-Petrolatum)

NP

Rectal Local Anesthetics dibucaine (rectal) oint F

NUPERCAINAL OINT (Dibucaine (Rectal)) NP

pramoxine hcl (rectal) foam F

PROCTOFOAM FOAM (Pramoxine HCl (Rectal)) NP

Drug Name DrugTier

Requirements/Limits

Rectal Steroids ANUSOL-HC CREA (Hydrocortisone (Rectal)) F

hydrocortisone (rectal) crea F

PROCTOCORT CREA (Hydrocortisone (Rectal)) NP

ANTACIDS - Ulcer and Stomach Acid Drugs

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

F

QL(24 ml daily)

alum & mag hydrox-simethicone liqd400mg/5ml-40mg/5ml-400mg/5ml

F

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

F

QL(24 ml daily)

alum & mag hydrox-simethicone susp400mg/5ml-400mg/5ml-40mg/5ml-40mg/5ml-400mg/5ml-400mg/5ml,400mg/5ml-40mg/5ml-400mg/5ml

F

HYVEE ADVANCED ANTACID MAXIMUM STRENGTH SUSP (Alum & Mag Hydrox-Simethicone)

NP

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

calcium carbonate (antacid)tabs 648 mg F

CALCIUM CARBONATE TABS 648 MG F

TUMS CHEW (Calcium Carbonate (Antacid)) NP


13

Drug Name DrugTier

Requirements/Limits

TUMS LASTING EFFECTS CHEW (Calcium Carbonate (Antacid))

NP

Antacids - Magnesium Salts magnesium oxide tabs 400 mg F

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial Infections Anti-infective Agents - Misc. CAYSTON SOLR NP

FLAGYL CAPS (Metronidazole) NP

FLAGYL TABS (Metronidazole) NP

metronidazole caps 375 mg NP

metronidazole tabs 500 mg, 250 mg F

TINDAMAX TABS (Tinidazole) NP

tinidazole tabs NP

VANCOCIN HCL CAPS (Vancomycin HCl) NP

vancomycin hcl caps or250 mg, 125 mg NP

vancomycin hcl solr iv 1000 mg F QL(2 ea daily)

vancomycin hcl solr iv 500 mg F QL(4 ea daily)

XIFAXAN TABS NP

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

NP

BACTRIM TABS (Sulfamethoxazole-Trimethoprim)

NP

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

F

Drug Name DrugTier

Requirements/Limits

sulfamethoxazole-trimethoprim tabs or160mg-800mg, 80mg-400mg

F

Antiprotozoal Agents ALINIA SUSR 100 MG/5ML NP QL(50 ml daily)

ALINIA TABS 500 MG NP QL(2 ea daily,6ea per fill retail) Ketolides KETEK TABS NP

Leprostatics dapsone tabs F

Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG (ClindamycinHCl)

NP

CLEOCIN PEDIATRIC GRANULES SOLR (Clindamycin PalmitateHydrochloride)

NP

clindamycin hcl caps 300mg, 150 mg F

clindamycin palmitatehydrochloride solr F

Oxazolidinones

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

ANTIANGINAL AGENTS - Drugs to Treat ChestPain Nitrates DILATRATE SR CPCR NP

GONITRO PACK NP

ISORDIL TITRADOSE TABS 40 MG NP

ISORDIL TITRADOSE TABS 5 MG (Isosorbide Dinitrate)

NP

ISOSORBIDE DINITRATE ER TBCR F


14

Drug Name DrugTier

Requirements/Limits

isosorbide dinitrate tabs F

isosorbide mononitrate tabs F

isosorbide mononitrate tb24 F

NITRO-BID OINT NP

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

NP

NITRO-DUR PT24 0.3 MG/HR, 0.8 MG/HR NP

nitroglycerin cpcr or 9 mg,2.5 mg, 6.5 mg F

NITROGLYCERIN LINGUAL AERS NP

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

F

nitroglycerin soln tl 0.4mg/spray NP

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

NITROLINGUAL PUMPSPRAY SOLN (Nitroglycerin)

NP

NITROMIST AERS NP

NITROSTAT SUBL (Nitroglycerin) F

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc. buspirone hcl tabs F

HYDROXYZINE HCL SOLN IM 25 MG/ML F

hydroxyzine hcl syrp or 10mg/5ml F

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

HYDROXYZINE PAMOATE CAPS 100 MG F

hydroxyzine pamoate caps50 mg, 25 mg F

Drug Name DrugTier

Requirements/Limits

meprobamate tabs NP

VISTARIL CAPS (Hydroxyzine Pamoate) NP

Benzodiazepines ALPRAZOLAM INTENSOL CONC NP

alprazolam tabs 0.5 mg, 1mg, 2 mg, 0.25 mg F

alprazolam tb24 2 mg, 0.5mg, 1 mg, 3 mg NP

alprazolam tbdp 0.5 mg, 2mg, 1 mg, 0.25 mg NP

ATIVAN SOLN IJ 2 MG/ML(Lorazepam) NP

ATIVAN TABS OR 0.5 MG, 1 MG, 2 MG (Lorazepam) NP

chlordiazepoxide hcl caps F

clorazepate dipotassiumtabs NP

diazepam conc or 5 mg/ml NP

DIAZEPAM SOLN OR 1 MG/ML F

diazepam tabs or 2 mg, 5mg, 10 mg F

lorazepam conc or 2 mg/ml F

lorazepam soln ij 2 mg/ml,20 mg/10ml F

lorazepam tabs or 2 mg, 1mg, 0.5 mg F

oxazepam caps NP

TRANXENE T TABS (Clorazepate Dipotassium) NP

VALIUM TABS (Diazepam) NP

XANAX TABS (Alprazolam) NP

XANAX XR TB24 (Alprazolam) NP

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms Antiarrhythmics Type I-A


15

Drug Name DrugTier

Requirements/Limits

disopyramide phosphate caps F

NORPACE CAPS (Disopyramide Phosphate) NP

NORPACE CR CP12 150 MG F

quinidine gluconate tbcr or324 mg F

QUINIDINE SULFATE ER TBCR F

QUINIDINE SULFATE TABS OR 200 MG, 300 MG

F

Antiarrhythmics Type I-B mexiletine hcl caps F

Antiarrhythmics Type I-C flecainide acetate tabs F

propafenone hcl tabs 225mg, 300 mg, 150 mg F

RYTHMOL TABS (Propafenone HCl) NP

Antiarrhythmics Type III amiodarone hcl tabs or 200 mg F

CORDARONE TABS (Amiodarone HCl) NP

dofetilide caps F

TIKOSYN CAPS (Dofetilide) NP

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu F

Bronchodilators - Anticholinergics ATROVENT HFA AERS F

INCRUSE ELLIPTA AEPB NP

ipratropium bromide soln F

Drug Name DrugTier

Requirements/Limits

SEEBRI NEOHALER CAPS NP

SPIRIVA HANDIHALER CAPS F

SPIRIVA RESPIMAT AERS NP

TUDORZA PRESSAIR AEPB NP

Leukotriene Modulators ACCOLATE TABS (Zafirlukast) NP

montelukast sodium chew 4 mg F

QL(1 ea daily);AL; Up to 11yrs old

montelukast sodium chew 5 mg F


montelukast sodium pack 4 mg NP


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

SINGULAIR CHEW 4 MG (Montelukast Sodium) NP


SINGULAIR CHEW 5 MG (Montelukast Sodium) NP


SINGULAIR PACK 4 MG (Montelukast Sodium) NP


SINGULAIR TABS 10 MG (Montelukast Sodium) NP QL(1 ea daily)

zafirlukast tabs NP

zileuton tb12 NP

ZYFLO CR TB12 (Zileuton) NP

ZYFLO TABS NP

Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TABS NP

Steroid Inhalants


16

Drug Name DrugTier

Requirements/Limits

AEROSPAN AERS NP

ALVESCO AERS NP AL; At least 12 yrs old ARMONAIR RESPICLICK 113 AEPB NP AL; At least 12 yrs old ARMONAIR RESPICLICK 232 AEPB NP AL; At least 12 yrs old ARMONAIR RESPICLICK 55 AEPB NP AL; At least 12 yrs old

ARNUITY ELLIPTA AEPB NP

ASMANEX HFA AERO NP QL(3 gm per fillretail); AL; Atleast 12 yrs old

ASMANEX TWISTHALER 120 METERED DOSES AEPB




ASMANEX TWISTHALER 30 METERED DOSES AEPB 110 MCG/INH

F QL(3 ea per fillretail); AL; Upto 11 yrs old

ASMANEX TWISTHALER 30 METERED DOSES AEPB 220 MCG/INH





F QL(3 ea per fillretail); AL; Upto 11 yrs old

budesonide (inhalation) susp F AL; Up to 8 yrs

old

FLOVENT DISKUS AEPB NP

FLOVENT HFA AERO NP

PULMICORT FLEXHALER AEPB NP

PULMICORT SUSP (Budesonide (Inhalation)) NP AL; Up to 8 yrsold

QVAR AERS F

Sympathomimetics

Drug Name DrugTier

Requirements/Limits

ADVAIR DISKUS AEPB F QL(2 ea daily)

ADVAIR HFA AERO NP

Limit 1 inhaler per month;QL(1gm per fillretail,1 gm per30 days retail)

AIRDUO RESPICLICK 113/14 AEPB NP AL; At least 12 yrs old AIRDUO RESPICLICK 232/14 AEPB NP AL; At least 12 yrs old albuterol sulfate nebu in 0.5 %, 0.083 % F

albuterol sulfate nebu in 1.25 mg/3ml, 0.63 mg/3ml NP

albuterol sulfate syrp or 2mg/5ml F

albuterol sulfate tabs or 4 mg, 2 mg NP

albuterol sulfate tb12 or 4 mg, 8 mg F

ANORO ELLIPTA AEPB NP

ARCAPTA NEOHALER CAPS F ST

BEVESPI AEROSPHERE AERO NP

BREO ELLIPTA AEPB NP

BROVANA NEBU NP

COMBIVENT RESPIMAT AERS F

DULERA AERO F

FLUTICASONE PROPIONATE/SALMETEROL AEPB

NP AL; At least 12 yrs old

FORADIL AEROLIZER CAPS F

ipratropium-albuterol soln F

levalbuterol hcl nebu NP

LEVALBUTEROL TARTRATE HFA AERO NP


17

Drug Name DrugTier

Requirements/Limits

METAPROTERENOL SULFATE SYRP NP

METAPROTERENOL SULFATE TABS NP

PERFOROMIST NEBU NP

PROAIR HFA AERS F QL(1 gm per fillretail,2 gm per30 days retail)

PROAIR RESPICLICK AEPB NP

QL(1 ea per fillretail,2 ea per30 days retail)

PROVENTIL HFA AERS F QL(1 gm per fillretail,2 gm per30 days retail)

SEREVENT DISKUS AEPB F ST

STIOLTO RESPIMAT AERS NP

STRIVERDI RESPIMAT AERS NP

SYMBICORT AERO F

terbutaline sulfate tabs or 5 mg, 2.5 mg F

TRELEGY ELLIPTA AEPB NP

QL(28 ea per14 days retail);AL; At least 18 yrs old

UTIBRON NEOHALER CAPS NP

VENTOLIN HFA AERS 4

QL(18 gm perfill retail,36 gmper 30 daysretail)

VENTOLIN HFA AERS 4 QL(8 gm per fillretail,16 gm per30 days retail)

VOSPIRE ER TB12 (Albuterol Sulfate) NP

XOPENEX CONCENTRATE NEBU (Levalbuterol HCl)

NP

XOPENEX HFA AERO NP

XOPENEX NEBU (Levalbuterol HCl) NP

Drug Name DrugTier

Requirements/Limits

Xanthines ELIXOPHYLLIN ELIX F

THEO-24 CP24 F

theophylline soln F

theophylline tb12 F

theophylline tb24 F

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants COUMADIN TABS (Warfarin Sodium) NP

warfarin sodium tabs F

Direct Factor Xa Inhibitors ELIQUIS TABS F

SAVAYSA TABS NP QL(1 ea daily)

XARELTO STARTER PACK TBPK F

XARELTO TABS 10 MG F QL(35 ea perfill retail)

XARELTO TABS 15 MG F QL(2 ea daily)

XARELTO TABS 20 MG F QL(1 ea daily)

Heparins And Heparinoid-Like Agents ARIXTRA SOLN (Fondaparinux Sodium) NP

enoxaparin sodium soln ij300 mg/3ml F QL(15 ml per

fill retail) enoxaparin sodium soln sc100 mg/ml, 150 mg/ml F QL(30 ml per

fill retail) enoxaparin sodium soln sc120 mg/0.8ml, 40 mg/0.4ml F QL(24 ml per

fill retail) enoxaparin sodium soln sc30 mg/0.3ml F QL(18 ml per



fill retail)


18

Drug Name DrugTier

Requirements/Limits

fondaparinux sodium soln NP

FRAGMIN SOLN NP

heparin sodium (porcine)soln F

LOVENOX SOLN IJ 300 MG/3ML (EnoxaparinSodium)

NP QL(15 ml perfill retail)

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


LOVENOX SOLN SC 120 MG/0.8ML, 40 MG/0.4ML(Enoxaparin Sodium)


LOVENOX SOLN SC 30 MG/0.3ML (EnoxaparinSodium)






Thrombin Inhibitors PRADAXA CAPS F

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists FYCOMPA SUSP F

FYCOMPA TABS F

Anticonvulsants - Benzodiazepines clonazepam tabs F

clonazepam tbdp F

DIASTAT ACUDIAL GEL F AL; Up to 21yrs old

DIASTAT PEDIATRIC GEL F AL; Up to 21yrs old

DIAZEPAM GEL RE 2.5 MG, 10 MG, 20 MG F AL; Up to 21

yrs old DIAZEPAM RECTAL GEL GEL F AL; Up to 21

yrs old

Drug Name DrugTier

Requirements/Limits

KLONOPIN TABS (Clonazepam) NP

ONFI SUSP F

ONFI TABS F

Anticonvulsants - Misc. APTIOM TABS F

BANZEL SUSP 40 MG/ML F AL; Up to 11yrs old

BANZEL TABS 200 MG, 400 MG F

PA; QL(3 eadaily); AL; Upto 11 yrs old

BRIVIACT SOLN IV 50 MG/5ML F PA

BRIVIACT SOLN OR 10 MG/ML F

BRIVIACT TABS OR 10 MG, 25 MG, 75 MG, 50 MG, 100 MG

F

carbamazepine chew or100 mg F PA; AL; At least

4 yrs old carbamazepine cp12 or200 mg, 300 mg, 100 mg F AL; At least 4

yrs old CARBAMAZEPINE POWD XX F PA; AL; At least

4 yrs old carbamazepine susp or100 mg/5ml F PA; AL; At least

4 yrs old carbamazepine tabs or 200 mg F PA; AL; At least

4 yrs old carbamazepine tb12 or 400mg, 100 mg, 200 mg F PA; AL; At least

4 yrs old CARBATROL CP12 (Carbamazepine) NP AL; At least 4 yrs old FANATREX FUSEPAQ SUSP F PA

gabapentin caps F

gabapentin soln F

gabapentin tabs F

KEPPRA SOLN IV 500 MG/5ML (Levetiracetam) NP PA

KEPPRA SOLN OR 100 MG/ML (Levetiracetam) NP


19

Drug Name DrugTier

Requirements/Limits

KEPPRA TABS OR 1000 MG, 250 MG, 750 MG, 500 MG (Levetiracetam)

NP

KEPPRA XR TB24 (Levetiracetam) NP

LAMICTAL CHEWABLE DISPERSIBLE CHEW 25 MG (Lamotrigine)


LAMICTAL CHEWABLE DISPERSIBLE CHEW 5 MG (Lamotrigine)

NP PA; QL(4 eadaily); AL; Upto 11 yrs old

LAMICTAL ODT KIT (Lamotrigine) NP

LAMICTAL ODT TBDP (Lamotrigine) NP

LAMICTAL STARTER/NOTTAKING CARBAMAZEPINE KIT (Lamotrigine)

NP

LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATE KIT (Lamotrigine)

NP

LAMICTAL STARTER/TAKINGVALPROATE KIT (Lamotrigine)

NP

LAMICTAL TABS (Lamotrigine) NP PA; QL(4 eadaily)

LAMICTAL XR KIT F PA

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

NP

PA

lamotrigine chew 25 mg F PA; QL(4 eadaily)

lamotrigine chew 5 mg F PA; QL(4 eadaily); AL; Upto 11 yrs old

lamotrigine kit 25 mg, F

lamotrigine tabs 25 mg,150 mg, 200 mg, 100 mg F PA; QL(4 ea

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

F PA

Drug Name DrugTier

Requirements/Limits

lamotrigine tbdp 25 mg,100 mg, 200 mg, 50 mg F

levetiracetam in sodium chloride soln 1000mg/100ml-750mg/100ml

F

levetiracetam in sodium chloride soln 1500mg/100ml-540mg/100ml,500mg/100ml-820mg/100ml

F

PA

LEVETIRACETAM SOLN IV 1000MG/100ML-750MG/100ML(Levetiracetam in Sodium Chloride)

NP

levetiracetam soln iv 500 mg/5ml F PA

LEVETIRACETAM SOLN IV 500MG/100ML-820MG/100ML,1500MG/100ML-540MG/100ML(Levetiracetam in Sodium Chloride)

NP

PA

levetiracetam soln or 100 mg/ml, 500 mg/5ml F

levetiracetam tabs or 250 mg, 500 mg, 1000 mg, 750 mg

F

levetiracetam tb24 or 750 mg, 500 mg F

LYRICA CAPS 225 MG, 300 MG F QL(2 ea daily)

LYRICA CAPS 25 MG, 150 MG, 50 MG, 200 MG, 75 MG, 100 MG

F QL(3 ea daily)

LYRICA SOLN 20 MG/ML F QL(30 ml daily)

MYSOLINE TABS (Primidone) NP

NEURONTIN CAPS (Gabapentin) NP

NEURONTIN SOLN (Gabapentin) NP

NEURONTIN TABS (Gabapentin) NP


20

Drug Name DrugTier

Requirements/Limits

oxcarbazepine susp 60mg/ml, 300 mg/5ml F PA

oxcarbazepine tabs 300mg, 150 mg F PA; AL; At least

4 yrs old oxcarbazepine tabs 600 mg F AL; At least 4

yrs old

OXTELLAR XR TB24 F PA

POTIGA TABS 200 MG, 400 MG, 300 MG F


POTIGA TABS 50 MG F QL(9 ea daily);AL; At least 18 yrs old

primidone tabs F

QUDEXY XR CS24 F

SPRITAM TB3D F

TEGRETOL SUSP (Carbamazepine) NP PA; AL; At least 4 yrs old TEGRETOL TABS (Carbamazepine) NP PA; AL; At least 4 yrs old TEGRETOL-XR TB12 (Carbamazepine) NP PA; AL; At least 4 yrs old TOPAMAX SPRINKLE CPSP (Topiramate) NP AL; At least 11 yrs old TOPAMAX TABS (Topiramate) NP

topiramate cpsp 15 mg, 25 mg F AL; At least 11

yrs old

TOPIRAMATE ER CS24 F

topiramate tabs 200 mg, 25mg, 100 mg, 50 mg F

TRILEPTAL SUSP 300 MG/5ML (Oxcarbazepine) NP PA

TRILEPTAL TABS 150 MG, 300 MG (Oxcarbazepine)

NP PA; AL; At least 4 yrs old

TRILEPTAL TABS 600 MG (Oxcarbazepine) NP AL; At least 4 yrs old

TROKENDI XR CP24 F

VIMPAT SOLN F PA

Drug Name DrugTier

Requirements/Limits

VIMPAT TABS F PA

ZONEGRAN CAPS (Zonisamide) NP

zonisamide caps F

Carbamates felbamate susp F

felbamate tabs F

FELBATOL SUSP (Felbamate) NP

FELBATOL TABS (Felbamate) NP

GABA Modulators GABITRIL TABS 16 MG, 12 MG F

GABITRIL TABS 2 MG, 4 MG (Tiagabine HCl) NP

SABRIL PACK (Vigabatrin) NP PA

SABRIL TABS F PA; QL(6 eadaily)

tiagabine hcl tabs F

vigabatrin pack F PA

Hydantoins CEREBYX SOLN (Fosphenytoin Sodium) NP PA

DILANTIN CAPS 100 MG (Phenytoin SodiumExtended)

NP

DILANTIN CAPS 30 MG F

DILANTIN INFATABS CHEW (Phenytoin) NP

DILANTIN-125 SUSP (Phenytoin) NP

fosphenytoin sodium soln F PA

PEGANONE TABS F

PHENYTEK CAPS (Phenytoin SodiumExtended)

NP


21

Drug Name DrugTier

Requirements/Limits

phenytoin chew F

phenytoin sodium extended caps F

phenytoin sodium soln F PA

phenytoin susp F

Succinimides CELONTIN CAPS F

ethosuximide caps F

ethosuximide soln F

ZARONTIN CAPS (Ethosuximide) NP

ZARONTIN SOLN (Ethosuximide) NP

Valproic Acid DEPACON SOLN (Valproate Sodium) NP PA

DEPAKENE CAPS (Valproic Acid) NP

DEPAKENE SOLN (Valproate Sodium) NP

DEPAKOTE ER TB24 (Divalproex Sodium) NP PA; AL; At least 4 yrs old DEPAKOTE SPRINKLES CSDR (Divalproex Sodium) NP PA; AL; At least 4 yrs old DEPAKOTE TBEC (Divalproex Sodium) NP PA; AL; At least 4 yrs old divalproex sodium csdr or125 mg F PA; AL; At least

4 yrs old divalproex sodium tb24 or250 mg, 500 mg F PA; AL; At least

4 yrs old divalproex sodium tbec or500 mg, 125 mg, 250 mg F PA; AL; At least

4 yrs old valproate sodium soln iv100 mg/ml, 500 mg/5ml F PA

valproate sodium soln or250 mg/5ml F

valproic acid caps F

ANTIDEPRESSANTS - Drugs to Treat Depression

Drug Name DrugTier

Requirements/Limits

Alpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs F AL; At least 4 yrs old

mirtazapine tbdp F AL; At least 4 yrs old

REMERON SOLTAB TBDP (Mirtazapine) NP AL; At least 4 yrs old REMERON TABS (Mirtazapine) NP AL; At least 4 yrs old Antidepressant Combinations PRAMLYTE THPK F

Antidepressants - Misc.

APLENZIN TB24 F QL(1 ea daily);AL; At least 4 yrs old

bupropion hcl tabs 75 mg,100 mg F AL; At least 4

yrs old bupropion hcl tb12 200 mg,100 mg, 150 mg F AL; At least 4

yrs old

bupropion hcl tb24 300 mg,150 mg F


FORFIVO XL TB24 F QL(1 ea daily);AL; At least 4 yrs old

MAPROTILINE HCL TABS F AL; At least 4 yrs old

WELLBUTRIN SR TB12 (Bupropion HCl) NP AL; At least 4 yrs old WELLBUTRIN TABS (Bupropion HCl) NP AL; At least 4 yrs old

WELLBUTRIN XL TB24 (Bupropion HCl) NP


Monoamine Oxidase Inhibitors (MAOIs)

EMSAM PT24 F QL(1 ea daily);AL; At least 18 yrs old

MARPLAN TABS F AL; At least 4 yrs old

NARDIL TABS (Phenelzine Sulfate) NP AL; At least 4 yrs old PARNATE TABS (Tranylcypromine Sulfate) NP AL; At least 4 yrs old


22

Drug Name DrugTier

Requirements/Limits

phenelzine sulfate tabs F AL; At least 4 yrs old

tranylcypromine sulfatetabs F AL; At least 4

yrs old Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS (CitalopramHydrobromide) NP AL; At least 4 yrs old citalopram hydrobromidesoln 10 mg/5ml F

citalopram hydrobromidetabs 10 mg, 20 mg, 40 mg F AL; At least 4

yrs old

escitalopram oxalate soln F AL; At least 6 yrs old

escitalopram oxalate tabs F AL; At least 6 yrs old

FLUOXETINE DR CPDR F AL; At least 4 yrs old

fluoxetine hcl caps 20 mg,10 mg, 40 mg F AL; At least 4

yrs old fluoxetine hcl soln 20 mg/5ml F

fluoxetine hcl tabs 20 mg,60 mg, 10 mg F AL; At least 4

yrs old FLUOXETINE HCL TABS 60 MG F AL; At least 4

yrs old FLUOXETINE HCL TABS 60 MG (Fluoxetine HCl) NP AL; At least 4 yrs old fluvoxamine maleate cp24150 mg, 100 mg F

fluvoxamine maleate tabs 100 mg, 50 mg, 25 mg F AL; At least 8

yrs old LEXAPRO SOLN (Escitalopram Oxalate) NP AL; At least 6 yrs old LEXAPRO TABS (Escitalopram Oxalate) NP AL; At least 6 yrs old paroxetine hcl tabs 10 mg,40 mg, 20 mg, 30 mg F AL; At least 13

yrs old paroxetine hcl tb24 12.5 mg F AL; At least 13

yrs old paroxetine hcl tb24 37.5mg, 25 mg F

PAXIL CR TB24 12.5 MG (Paroxetine HCl) NP AL; At least 13 yrs old PAXIL CR TB24 25 MG, 37.5 MG (Paroxetine HCl) NP

Drug Name DrugTier

Requirements/Limits

PAXIL SUSP 10 MG/5ML F

PAXIL TABS 20 MG, 30 MG, 10 MG, 40 MG (Paroxetine HCl)


PEXEVA TABS F PA; AL; At least 13 yrs old

PROZAC CAPS (Fluoxetine HCl) NP AL; At least 4 yrs old PROZAC WEEKLY CPDR (Fluoxetine HCl) NP AL; At least 4 yrs old sertraline hcl conc 20 mg/ml F

sertraline hcl tabs 25 mg,100 mg, 50 mg F AL; At least 4

yrs old ZOLOFT CONC 20 MG/ML(Sertraline HCl) NP

ZOLOFT TABS 50 MG, 100 MG, 25 MG (Sertraline HCl)


Serotonin Modulators

BRINTELLIX TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old

NEFAZODONE HCL TABS 200 MG, 100 MG, 150 MG F AL; At least 4

yrs old nefazodone hcl tabs 50 mg,250 mg F AL; At least 4

yrs old trazodone hcl tabs or 100 mg, 50 mg F AL; At least 14

yrs old

trazodone hcl tabs or 150 mg F


trazodone hcl tabs or 300 mg F


TRINTELLIX TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old

VIIBRYD STARTER PACK KIT F


VIIBRYD TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old

Serotonin-Norepinephrine Reuptake Inhibitors


23

Drug Name DrugTier

Requirements/Limits

CYMBALTA CPEP (Duloxetine HCl) NP AL; At least 13 yrs old

DESVENLAFAXINE ER TB24 100 MG, 50 MG F


desvenlafaxine succinate tb24 F ST

duloxetine hcl cpep 20 mg,60 mg, 30 mg F AL; At least 13

yrs old DULOXETINE HCL CPEP 40 MG F AL; At least 13

yrs old EFFEXOR XR CP24 (Venlafaxine HCl) NP AL; At least 13 yrs old

FETZIMA CP24 F PA; AL; At least 18 yrs old

FETZIMA TITRATION PACK C4PK F PA; AL; At least

18 yrs old

KHEDEZLA TB24 F QL(1 ea daily);AL; At least 13 yrs old

PRISTIQ TB24 (Desvenlafaxine Succinate) NP ST

venlafaxine hcl cp24 F AL; At least 13 yrs old

VENLAFAXINE HCL ER TB24 225 MG F AL; At least 13

yrs old VENLAFAXINE HCL ER TB24 37.5 MG, 75 MG, 150 MG (Venlafaxine HCl)


venlafaxine hcl tabs F AL; At least 13 yrs old

venlafaxine hcl tb24 F AL; At least 13 yrs old

Tricyclic Agents

amitriptyline hcl tabs F AL; At least 4 yrs old

AMOXAPINE TABS F AL; At least 4 yrs old

ANAFRANIL CAPS (Clomipramine HCl) NP AL; At least 4 yrs old

clomipramine hcl caps F AL; At least 4 yrs old

desipramine hcl tabs F AL; At least 4 yrs old

Drug Name DrugTier

Requirements/Limits

doxepin hcl caps 100 mg,75 mg, 150 mg, 50 mg, 10mg, 25 mg


doxepin hcl conc 10 mg/ml F

ELAVIL TABS (Amitriptyline HCl) NP AL; At least 4 yrs old

imipramine hcl tabs F AL; At least 4 yrs old

imipramine pamoate caps F AL; At least 4 yrs old

NORPRAMIN TABS (Desipramine HCl) NP AL; At least 4 yrs old nortriptyline hcl caps 50mg, 25 mg, 75 mg, 10 mg F AL; At least 4

yrs old NORTRIPTYLINE HCL SOLN 10 MG/5ML F

PAMELOR CAPS (Nortriptyline HCl) NP AL; At least 4 yrs old

protriptyline hcl tabs F AL; At least 4 yrs old

SURMONTIL CAPS (Trimipramine Maleate) NP AL; At least 4 yrs old TOFRANIL TABS (Imipramine HCl) NP AL; At least 4 yrs old TOFRANIL-PM CAPS (Imipramine Pamoate) NP AL; At least 4 yrs old

trimipramine maleate caps F AL; At least 4 yrs old

ANTIDIABETICS - Drugs to Regulate Blood Sugar

Alpha-Glucosidase Inhibitors acarbose tabs F

GLYSET TABS (Miglitol) F

miglitol tabs NP

PRECOSE TABS (Acarbose) NP

Antidiabetic - Amylin Analogs SYMLINPEN 120 SOPN NP

SYMLINPEN 60 SOPN NP

Antidiabetic Combinations


24

Drug Name DrugTier

Requirements/Limits

ACTOPLUS MET TABS (Pioglitazone HCl-Metformin HCl)

NP

ACTOPLUS MET XR TB24 NP

ALOGLIPTIN/METFORMINHCL TABS NP


ALOGLIPTIN/PIOGLITAZONE TABS NP


DUETACT TABS (Pioglitazone HCl-Glimepiride)

NP

glipizide-metformin hcl tabs F

GLUCOVANCE TABS (Glyburide-Metformin) NP

glyburide-metformin tabs F

GLYXAMBI TABS NP QL(1 ea daily);AL; At least 18 yrs old

INVOKAMET TABS F PA

INVOKAMET XR TB24 NP

JANUMET TABS F QL(2 ea daily);AL; At least 18 yrs old

JANUMET XR TB24 F QL(1 ea daily);AL; At least 18 yrs old

JENTADUETO TABS F QL(2 ea daily);AL; At least 18 yrs old

JENTADUETO XR TB24 2.5MG-1000MG NP


JENTADUETO XR TB24 5MG-1000MG NP


KAZANO TABS NP QL(2 ea daily);AL; At least 18 yrs old

KOMBIGLYZE XR TB24 NP QL(1 ea daily);AL; At least 18 yrs old

Drug Name DrugTier

Requirements/Limits

OSENI TABS NP QL(1 ea daily);AL; At least 18 yrs old

pioglitazone hcl-glimepiridetabs NP

pioglitazone hcl-metforminhcl tabs NP

PRANDIMET TABS (Repaglinide-MetforminHCl)

NP

QTERN TABS NP QL(1 ea daily)

REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS

NP

SOLIQUA 100/33 SOPN NP

SYNJARDY TABS NP QL(2 ea daily);AL; At least 18 yrs old

SYNJARDY XR TB24 NP QL(1 ea daily)

XIGDUO XR TB24 10MG-500MG, 5MG-500MG, 10MG-1000MG

NP QL(1 ea daily)

XIGDUO XR TB24 5MG-1000MG NP QL(2 ea daily)

XULTOPHY 100/3.6 SOPN NP

Biguanides FORTAMET TB24 (Metformin HCl) NP

GLUCOPHAGE TABS (Metformin HCl) NP

GLUCOPHAGE XR TB24 (Metformin HCl) NP

GLUMETZA TB24 (Metformin HCl) NP

metformin hcl tabs 500 mg,850 mg, 1000 mg F

metformin hcl tb24 1000 mg, 500 mg NP

metformin hcl tb24 750 mg,500 mg F

RIOMET SOLN NP


25

Drug Name DrugTier

Requirements/Limits

Diabetic Other CVS GLUCOSE CHEW 4 GM F QL(1.67 ea

daily) CVS GLUCOSE CHEW 4GM-6MG F

DEX4 CHEW F

DEX4 FAST ACTING GLUCOSE CHEW 4GM-6MG

F

DEX4 NATURALS CHEW F

DEX4 POUCH PACK CHEW F

DEX4 QUICK DISSOLVE GLUCOSE CHEW F QL(1.67 ea

daily) dextrose (diabetic use) gel15 gm/38gm, 40 % F

GLUCAGEN HYPOKIT SOLR F

GLUCAGON EMERGENCY KIT KIT F

GLUCOSE CHEW 4 GM F QL(1.67 eadaily)

GLUCOSE CHEW 4GM-4GM-6MG, 4GM-6MG F

GLUCOSE INSTANT ENERGY CHEW F

GNP GLUCOSE CHEW 4 GM F QL(1.67 ea

daily) GNP GLUCOSE CHEW 4GM-6MG F

GNP QUICK DISSOLVE GLUCOSE CHEW F QL(1.67 ea

daily) GOODSENSE GLUCOSE CHEW F

HM GLUCOSE CHEW F

HY-VEE GLUCOSE CHEW F

INSTA-GLUCOSE GEL F

KROGER GLUCOSE CHEW F

LEADER GLUCOSE CHEW F

Drug Name DrugTier

Requirements/Limits

LEADER QUICK DISSOLVE GLUCOSE CHEW

F QL(1.67 eadaily)

LONGS GLUCOSE CHEW F

MEIJER GLUCOSE CHEW F

PREFERRED PLUS GLUCOSE CHEW F

PX GLUCOSE CHEW F

RA GLUCOSE CHEW F

RELION GLUCOSE CHEW F

SM GLUCOSE CHEW 4 GM F QL(1.67 ea

daily) SM GLUCOSE CHEW 4GM-6MG F

SMART SENSE GLUCOSE CHEW F

SMART SENSE GLUCOSE TABLETS CHEW

F

TGT GLUCOSE CHEW F

UP & UP GLUCOSE CHEW F

VALUE PLUS GLUCOSE CHEW F

WALGREENS GLUCOSE CHEW 4 GM F QL(1.67 ea

daily) WALGREENS GLUCOSE CHEW 4GM-6MG F

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

ALOGLIPTIN TABS NP QL(1 ea daily);AL; At least 18 yrs old

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

NESINA TABS NP QL(1 ea daily);AL; At least 18 yrs old

ONGLYZA TABS NP QL(1 ea daily);AL; At least 18 yrs old


26

Drug Name DrugTier

Requirements/Limits

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

Incretin Mimetic Agents (GLP-1 Receptor ADLYXIN SOPN NP

ADLYXIN STARTER PACK PNKT NP

BYDUREON BCISE AUIJ NP

BYDUREON PEN PEN F

PA; QL(4 eaper 28 daysretail); AL; Atleast 18 yrs old

BYDUREON SRER F

PA; QL(4 eaper 28 daysretail); AL; Atleast 18 yrs old

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

TANZEUM PEN NP

TRULICITY SOPN NP

VICTOZA SOPN F

Insulin Sensitizing Agents ACTOS TABS (Pioglitazone HCl) NP

AVANDIA TABS NP

pioglitazone hcl tabs F

Insulin AFREZZA POWD NP

APIDRA SOLN F ST

APIDRA SOLOSTAR SOPN F ST

BASAGLAR KWIKPEN SOPN 4

FIASP FLEXTOUCH SOPN 4

FIASP SOLN F

Drug Name DrugTier

Requirements/Limits

HUMALOG JUNIOR KWIKPEN SOPN 4

HUMALOG KWIKPEN SOPN 100 UNIT/ML F

HUMALOG KWIKPEN SOPN 200 UNIT/ML NP

HUMALOG MIX 50/50KWIKPEN SUPN NP

HUMALOG MIX 50/50SUSP F

HUMALOG MIX 75/25KWIKPEN SUPN NP

HUMALOG MIX 75/25SUSP F

HUMALOG SOCT F

HUMALOG SOLN F

HUMULIN 70/30 KWIKPENSUPN NP

HUMULIN 70/30 SUSP F Limit 40ml permonth;QL(1.334 ml daily)

HUMULIN N KWIKPEN SUPN NP

HUMULIN N SUSP F Limit 40ml permonth;QL(1.334 ml daily)

HUMULIN R SOLN F Limit 40ml permonth;QL(1.334 ml daily)

HUMULIN R U-500 (CONCENTRATED) SOLN F

HUMULIN R U-500 KWIKPEN SOPN NP

LANTUS SOLN F

LANTUS SOLOSTAR SOPN F

LEVEMIR FLEXTOUCH SOPN F

LEVEMIR SOLN F

NOVOLIN 70/30 RELIONSUSP 4

Limit 40ml permonth;QL(1.334 ml daily)


27

Drug Name DrugTier

Requirements/Limits

NOVOLIN 70/30 SUSP 4 Limit 40ml permonth;QL(1.334 ml daily)

NOVOLIN N RELION SUSP 4


NOVOLIN N SUSP 4 Limit 40ml permonth;QL(1.334 ml daily)

NOVOLIN R RELION SOLN 4


NOVOLIN R SOLN 4 Limit 40ml permonth;QL(1.334 ml daily)

NOVOLOG FLEXPEN SOPN F

NOVOLOG MIX 70/30PREFILLED FLEXPEN SUPN

F

NOVOLOG MIX 70/30SUSP F

NOVOLOG PENFILL SOCT F

NOVOLOG SOLN F

TOUJEO SOLOSTAR SOPN NP

TRESIBA FLEXTOUCH SOPN NP

Meglitinide Analogues nateglinide tabs NP

PRANDIN TABS (Repaglinide) NP

repaglinide tabs F

STARLIX TABS (Nateglinide) NP

Sodium-Glucose Co-Transporter 2 (SGLT2) FARXIGA TABS F

INVOKANA TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old

JARDIANCE TABS NP QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

Sulfonylureas AMARYL TABS (Glimepiride) NP

CHLORPROPAMIDE TABS NP

DIABETA TABS F

glimepiride tabs F

glipizide tabs F

glipizide tb24 F

GLUCOTROL TABS (Glipizide) NP

GLUCOTROL XL TB24 (Glipizide) NP

glyburide micronized tabs F

glyburide tabs F

GLYNASE TABS (Glyburide Micronized) NP

TOLAZAMIDE TABS NP

TOLBUTAMIDE TABS NP

ANTIDIARRHEALS - Drugs to Treat Diarrhea

Antidiarrheal Agents - Misc. bismuth subsalicylate susp525 mg/30ml, 262mg/15ml, 527 mg/30ml

F

PEPTO-BISMOL SUSP 524 MG/30ML, 262MG/15ML (Bismuth Subsalicylate)

NP

Antidiarrheal Combinations lactobacillus acidophilus-pectin caps F

Antiperistaltic Agents diphenoxylate w/ atropinetabs F

DIPHENOXYLATE/ATROPINE LIQD F


28

Drug Name DrugTier

Requirements/Limits

IMODIUM A-D CAPS 2 MG (Loperamide HCl) NP RX/OTC

IMODIUM A-D TABS 2 MG (Loperamide HCl) NP

LOMOTIL TABS (Diphenoxylate w/Atropine)

NP

loperamide hcl caps 2 mg NP RX/OTC

loperamide hcl caps 2 mg F RX/OTC

loperamide hcl tabs 2 mg F

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents CHEMET CAPS F

JADENU TABS F PA

Opioid Antagonists EVZIO SOAJ NP

NALOXONE HCL SOCT 0.4 MG/ML F

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

NALOXONE HCL SOSY 2 MG/2ML F

naltrexone hcl tabs F AL; At least 19 yrs old

NARCAN LIQD F

ANTIEMETICS - Drugs to Treat Nausea andVomiting 5-HT3 Receptor Antagonists ANZEMET TABS OR 100 MG, 50 MG NP

granisetron hcl tabs or 1 mg NP

ondansetron hcl soln ij 40mg/20ml, 4 mg/2ml F QL(16 ml daily)

ondansetron hcl soln or 4 mg/5ml F

QL(16 mldaily,150 mlper fill retail)

Drug Name DrugTier

Requirements/Limits

ondansetron hcl tabs or 8 mg, 4 mg F QL(2 ea daily)

ondansetron tbdp F

SANCUSO PTCH NP

ZOFRAN ODT TBDP (Ondansetron) NP

ZOFRAN SOLN 4 MG/5ML(Ondansetron HCl) NP

QL(16 mldaily,150 mlper fill retail)

ZOFRAN TABS 4 MG, 8 MG (Ondansetron HCl) NP QL(2 ea daily)

ZUPLENZ FILM NP

Antiemetics - Anticholinergic dimenhydrinate tabs or 50 mg F

DRAMAMINE TABS (Dimenhydrinate) NP

meclizine hcl chew 25 mg F

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

scopolamine pt72 NP

TIGAN CAPS OR 300 MG (Trimethobenzamide HCl) NP

TRANSDERM-SCOP PT72 F

TRANSDERM-SCOP PT72 (Scopolamine) F

trimethobenzamide hcl caps NP

Antiemetics - Miscellaneous AKYNZEO CAPS NP

CESAMET CAPS NP

DICLEGIS TBEC F PA; QL(2 eadaily)

dronabinol caps F AL; At least 18 yrs old

EMETROL SOLN (Fructose-Dextrose-Phosphoric Acid)

NP


29

Drug Name DrugTier

Requirements/Limits

fructose-dextrose-phosphoric acid liqd F

fructose-dextrose-phosphoric acid soln F

MARINOL CAPS (Dronabinol) NP AL; At least 18 yrs old Substance P/Neurokinin 1 (NK1) Receptor aprepitant caps NP

EMEND CAPS OR 125 MG, 40 MG, 80 MG (Aprepitant)

NP

EMEND SUSR OR 125 MG NP

EMEND TRIPACK CAPS (Aprepitant) NP

VARUBI TABS NP

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungals ANCOBON CAPS (Flucytosine) NP

flucytosine caps NP

GRIFULVIN V TABS (Griseofulvin Microsize) NP

GRIS-PEG TABS (Griseofulvin Ultramicrosize)

NP

griseofulvin microsize susp F

griseofulvin microsize tabs F

griseofulvin ultramicrosizetabs NP

LAMISIL PACK 187.5 MG, 125 MG NP

LAMISIL TABS 250 MG (Terbinafine HCl) NP

nystatin tabs F

terbinafine hcl tabs F

Imidazole-Related Antifungals

Drug Name DrugTier

Requirements/Limits

CRESEMBA CAPS OR 186 MG NP

DIFLUCAN SUSR (Fluconazole) NP

DIFLUCAN TABS (Fluconazole) NP

fluconazole susr F

fluconazole tabs F

itraconazole caps NP

ketoconazole tabs NP

NOXAFIL SUSP 40 MG/ML NP

NOXAFIL TBEC 100 MG NP AL; At least 13 yrs old

ONMEL TABS NP

SPORANOX CAPS 100 MG (Itraconazole) NP

SPORANOX PULSEPAK CAPS (Itraconazole) NP

SPORANOX SOLN 10 MG/ML NP

VFEND SUSR (Voriconazole) NP

VFEND TABS (Voriconazole) NP

voriconazole susr or 40 mg/ml NP

voriconazole tabs or 200 mg, 50 mg NP

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines CHLOR-TRIMETON ALLERGY TBCR (ChlorpheniramineMaleate)

NP

CHLOR-TRIMETON SYRP (ChlorpheniramineMaleate)

NP

CHLOR-TRIMETON TABS (ChlorpheniramineMaleate)

NP


30

Drug Name DrugTier

Requirements/Limits

chlorpheniramine maleate syrp F

chlorpheniramine maleatetabs F

chlorpheniramine maleatetbcr F

Antihistamines - Ethanolamines BENADRYL ALLERGY CAPS (DiphenhydramineHCl)

NP QL(4 ea daily)

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

NP

BENADRYL ALLERGY TABS (DiphenhydramineHCl)

NP

clemastine fumarate tabs 1.34 mg F QL(4 ea daily)

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

diphenhydramine hcl capsor 50 mg F RX/OTC

diphenhydramine hcl elix or12.5 mg/5ml F RX/OTC

diphenhydramine hcl liqd or12.5 mg/5ml, 25 mg/10ml,50 mg/20ml

F

diphenhydramine hcl tabsor 25 mg F

TAVIST ALLERGY TABS (Clemastine Fumarate) NP QL(4 ea daily)

Antihistamines - Non-Sedating ALLEGRA ALLERGY CHILDRENS SUSP 30 MG/5ML (Fexofenadine HCl)

NP

ST

ALLEGRA ALLERGY TABS 180 MG (Fexofenadine HCl)

NP QL(1 ea daily)

ALLEGRA ALLERGY TABS 60 MG (Fexofenadine HCl)

NP

cetirizine hcl chew 5 mg,10 mg NP

Drug Name DrugTier

Requirements/Limits

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

QL(240 ml perfill retail); AL;Up to 12 yrsold; RX/OTC

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


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

CLARINEX SYRP 0.5 MG/ML F ST

CLARINEX TABS 5 MG (Desloratadine) NP

CLARITIN CAPS 10 MG (Loratadine) NP

CLARITIN REDITABS TBDP 10 MG (Loratadine) NP

CLARITIN REDITABS TBDP 5 MG F

CLARITIN SYRP 5 MG/5ML (Loratadine) NP

CLARITIN TABS 10 MG (Loratadine) NP QL(1 ea daily)

DESLORATADINE ODT TBDP NP

desloratadine tabs NP

fexofenadine hcl susp or 30mg/5ml F ST

fexofenadine hcl tabs or 180 mg NP QL(1 ea daily)

fexofenadine hcl tabs or 60 mg NP

levocetirizine dihydrochloride soln 2.5mg/5ml

NP RX/OTC

levocetirizine dihydrochloride tabs 5 mg F RX/OTC

loratadine caps 10 mg NP

loratadine soln 5 mg/5ml F

loratadine syrp 5 mg/5ml F

loratadine tabs 10 mg F QL(1 ea daily)


31

Drug Name DrugTier

Requirements/Limits

loratadine tbdp 10 mg NP

XYZAL ALLERGY 24HR CHILDRENS SOLN (Levocetirizine Dihydrochloride)

NP

RX/OTC

XYZAL ALLERGY 24HR TABS (Levocetirizine Dihydrochloride)

NP RX/OTC

XYZAL SOLN (Levocetirizine Dihydrochloride)

NP RX/OTC

XYZAL TABS (Levocetirizine Dihydrochloride)

NP RX/OTC

ZYRTEC ALLERGY TABS (Cetirizine HCl) NP QL(1 ea daily)

ZYRTEC CHILDRENS ALLERGY SYRP (Cetirizine HCl)

NP


Antihistamines - Phenothiazines promethazine hcl soln or6.25 mg/5ml F

promethazine hcl supp re12.5 mg, 25 mg, 50 mg F

promethazine hcl supp re50 mg 4

promethazine hcl syrp or6.25 mg/5ml F

promethazine hcl tabs or25 mg, 12.5 mg, 50 mg F

Antihistamines - Piperidines cyproheptadine hcl syrp F

cyproheptadine hcl tabs F

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Antihyperlipidemics - Combinations ezetimibe-simvastatin tabs NP

VYTORIN TABS (Ezetimibe-Simvastatin) NP

Antihyperlipidemics - Misc.

Drug Name DrugTier

Requirements/Limits

KYNAMRO SOSY NP

LOVAZA CAPS (Omega-3-acid Ethyl Esters) NP

omega-3-acid ethyl esters caps NP

VASCEPA CAPS NP

Bile Acid Sequestrants cholestyramine light pack F

cholestyramine light powd F

cholestyramine pack F

cholestyramine powd F

COLESTID FLAVORED GRAN (Colestipol HCl) NP

COLESTID FLAVORED PACK (Colestipol HCl) NP

COLESTID GRAN (Colestipol HCl) NP

COLESTID PACK (Colestipol HCl) NP

COLESTID TABS (Colestipol HCl) NP

colestipol hcl gran 5 gm NP

colestipol hcl pack 5 gm NP

colestipol hcl tabs 1 gm F

QUESTRAN LIGHT POWD (Cholestyramine Light) NP

QUESTRAN PACK (Cholestyramine) NP

QUESTRAN POWD (Cholestyramine) NP

WELCHOL PACK NP

WELCHOL TABS NP

Fibric Acid Derivatives ANTARA CAPS NP


32

Drug Name DrugTier

Requirements/Limits

choline fenofibrate cpdr F

FENOFIBRATE CAPS 150 MG, 50 MG NP

fenofibrate micronized caps NP

fenofibrate tabs 145 mg, 48 mg F

fenofibrate tabs 160 mg,120 mg, 54 mg, 40 mg NP

FENOFIBRIC ACID TABS NP

FENOGLIDE TABS (Fenofibrate) NP

FIBRICOR TABS NP

gemfibrozil tabs F

LIPOFEN CAPS NP

LOFIBRA CAPS (Fenofibrate Micronized) NP

LOFIBRA TABS (Fenofibrate) NP

LOPID TABS (Gemfibrozil) NP

TRICOR TABS (Fenofibrate) NP

TRIGLIDE TABS NP

TRILIPIX CPDR (Choline Fenofibrate) NP

HMG CoA Reductase Inhibitors ALTOPREV TB24 NP

atorvastatin calcium tabs F

CRESTOR TABS (Rosuvastatin Calcium) NP

fluvastatin sodium caps NP

fluvastatin sodium tb24 NP

LESCOL XL TB24 (Fluvastatin Sodium) NP

LIPITOR TABS (Atorvastatin Calcium) NP

Drug Name DrugTier

Requirements/Limits

LIVALO TABS NP

lovastatin tabs F

MEVACOR TABS (Lovastatin) NP

PRAVACHOL TABS (Pravastatin Sodium) NP

pravastatin sodium tabs F

rosuvastatin calcium tabs F

simvastatin tabs F

ZOCOR TABS (Simvastatin) NP

Intestinal Cholesterol Absorption Inhibitors ezetimibe tabs NP

ZETIA TABS (Ezetimibe) NP

Microsomal Triglyceride Transfer Protein (MTP) JUXTAPID CAPS NP

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr F

NIACOR TABS NP

NIASPAN TBCR (Niacin (Antihyperlipidemic)) NP

Proprotein Convertase Subtilisin/Kexin Type 9

PRALUENT SOPN NP QL(0.0667 mldaily); AL; Atleast 18 yrs old

PRALUENT SOSY NP QL(0.0667 mldaily); AL; Atleast 18 yrs old

REPATHA PUSHTRONEX SYSTEM SOCT NP

Limit 3.5ml permonth;QL(0.117 ml daily); AL;At least 13 yrsold

REPATHA SOSY NP


33

Drug Name DrugTier

Requirements/Limits

REPATHA SURECLICK SOAJ NP

QL(0.034 mldaily); AL; Atleast 13 yrs old

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure ACE Inhibitors ACCUPRIL TABS (Quinapril HCl) NP

ACEON TABS (PerindoprilErbumine) NP

ALTACE CAPS (Ramipril) NP

benazepril hcl tabs F

captopril tabs or 50 mg, 25mg, 12.5 mg, 100 mg NP

enalapril maleate tabs F

EPANED SOLN NP

EPANED SOLR NP

fosinopril sodium tabs NP

lisinopril tabs F

LOTENSIN TABS (Benazepril HCl) NP

MAVIK TABS (Trandolapril) NP

moexipril hcl tabs NP

perindopril erbumine tabs NP

PRINIVIL TABS (Lisinopril) NP

QBRELIS SOLN NP

quinapril hcl tabs F

ramipril caps F

trandolapril tabs NP

VASOTEC TABS (EnalaprilMaleate) NP

ZESTRIL TABS (Lisinopril) NP

Drug Name DrugTier

Requirements/Limits

Angiotensin II Receptor Antagonists ATACAND TABS (Candesartan Cilexetil) NP

AVAPRO TABS (Irbesartan) NP

BENICAR TABS (Olmesartan Medoxomil) NP

candesartan cilexetil tabs NP

COZAAR TABS (Losartan Potassium) NP

DIOVAN TABS (Valsartan) NP

EDARBI TABS NP

EPROSARTAN MESYLATE TABS NP

irbesartan tabs F

losartan potassium tabs F

MICARDIS TABS (Telmisartan) NP

olmesartan medoxomil tabs or 20 mg, 40 mg, 5 mg NP

telmisartan tabs NP

valsartan tabs F

Antiadrenergic Antihypertensives CARDURA TABS (Doxazosin Mesylate) NP

CATAPRES TABS (Clonidine HCl) NP

CATAPRES-TTS-1 PTWK (Clonidine HCl) F



clonidine hcl ptwk td 0.1mg/24hr, 0.2 mg/24hr, 0.3mg/24hr

NP

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

doxazosin mesylate tabs F


34

Drug Name DrugTier

Requirements/Limits

guanfacine hcl tabs F

methyldopa tabs F

MINIPRESS CAPS (Prazosin HCl) NP

prazosin hcl caps F

RESERPINE TABS NP

TENEX TABS (Guanfacine HCl) NP

terazosin hcl caps F

Antihypertensive Combinations ACCURETIC TABS (Quinapril-Hydrochlorothiazide)

NP

amlodipine besylate-benazepril hcl caps F

amlodipine besylate-olmesartan medoxomil tabs NP

amlodipine besylate-valsartan tabs NP

amlodipine-valsartan-hydrochlorothiazide tabs NP

ATACAND HCT TABS (Candesartan Cilexetil-Hydrochlorothiazide)

NP

atenolol & chlorthalidone tabs F

AVALIDE TABS (Irbesartan-Hydrochlorothiazide)

NP

AZOR TABS (AmlodipineBesylate-OlmesartanMedoxomil)

NP

benazepril &hydrochlorothiazide tabs F

BENICAR HCT TABS (Olmesartan Medoxomil-Hydrochlorothiazide)

NP

bisoprolol &hydrochlorothiazide tabs F

BYVALSON TABS NP QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

candesartan cilexetil-hydrochlorothiazide tabs NP

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS NP

CLORPRES TABS NP

CORZIDE TABS (Nadolol & Bendroflumethiazide) NP

DIOVAN HCT TABS (Valsartan-Hydrochlorothiazide)

NP

DUTOPROL TB24 NP

EDARBYCLOR TABS NP

enalapril maleate &hydrochlorothiazide tabs F

EXFORGE HCT TABS (Amlodipine-Valsartan-Hydrochlorothiazide)

NP

EXFORGE TABS (Amlodipine Besylate-Valsartan)

NP

fosinopril sodium &hydrochlorothiazide tabs NP

HYZAAR TABS (Losartan Potassium & Hydrochlorothiazide)

NP

irbesartan-hydrochlorothiazide tabs F

lisinopril &hydrochlorothiazide tabs F

LOPRESSOR HCT TABS (Metoprolol &Hydrochlorothiazide)

NP

losartan potassium &hydrochlorothiazide tabs F

LOTENSIN HCT TABS (Benazepril &Hydrochlorothiazide)

NP

LOTREL CAPS (Amlodipine Besylate-Benazepril HCl)

NP

METHYLDOPA/HYDROCHLOROTHIAZIDE TABS NP

metoprolol &hydrochlorothiazide tabs NP


35

Drug Name DrugTier

Requirements/Limits

METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE TB24

NP

METOPROLOL/HYDROCHLOROTHIAZIDE TABS NP

MICARDIS HCT TABS (Telmisartan-Hydrochlorothiazide)

NP

moexipril-hydrochlorothiazide tabs NP

nadolol & bendroflumethiazide tabs NP

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

NP

olmesartan medoxomil-hydrochlorothiazide tabs NP

PRESTALIA TABS NP QL(1 ea daily)

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS NP

quinapril-hydrochlorothiazide tabs NP

TARKA TBCR (Trandolapril-VerapamilHCl)

NP

TEKTURNA HCT TABS NP

telmisartan-amlodipine tabs NP

telmisartan-hydrochlorothiazide tabs NP

TENORETIC 100 TABS (Atenolol & Chlorthalidone) NP

TENORETIC 50 TABS (Atenolol & Chlorthalidone) NP

trandolapril-verapamil hcltbcr NP

TRIBENZOR TABS (Olmesartan Medoxomil-Amlodipine-Hydrochlorothiazide)

NP

TWYNSTA TABS (Telmisartan-Amlodipine) NP

valsartan-hydrochlorothiazide tabs F

Drug Name DrugTier

Requirements/Limits

VASERETIC TABS (Enalapril Maleate &Hydrochlorothiazide)

NP

ZESTORETIC TABS (Lisinopril &Hydrochlorothiazide)

NP

ZIAC TABS (Bisoprolol &Hydrochlorothiazide) NP

Direct Renin Inhibitors TEKTURNA TABS NP QL(1 ea daily)

Selective Aldosterone Receptor Antagonists eplerenone tabs NP

INSPRA TABS (Eplerenone) NP

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

minoxidil tabs F

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations

COARTEM TABS F QL(24 ea perfill retail)

Antimalarials CHLOROQUINE PHOSPHATE TABS 250 MG

F

chloroquine phosphate tabs500 mg, 250 mg F

hydroxychloroquine sulfatetabs F

mefloquine hcl tabs F

MEFLOQUINE HCL TABS F

PLAQUENIL TABS (HydroxychloroquineSulfate)

NP

PRIMAQUINE PHOSPHATE TABS F

ANTIMYASTHENIC/CHOLINERGIC AGENTS


36

Drug Name DrugTier

Requirements/Limits

Antimyasthenic/Cholinergic Agents MESTINON TABS 60 MG (Pyridostigmine Bromide) NP

MESTINON TIMESPAN TBCR (PyridostigmineBromide)

NP

pyridostigmine bromidetabs F

pyridostigmine bromidetbcr F

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Antimycobacterial Agents ethambutol hcl tabs F

ISONIAZID SYRP OR 50 MG/5ML F

isoniazid tabs or 100 mg,300 mg F

MYAMBUTOL TABS (Ethambutol HCl) NP

pyrazinamide tabs F

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

rifampin caps or 150 mg,300 mg F

TRECATOR TABS F

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

CYCLOPHOSPHAMIDE CAPS OR 25 MG, 50 MG F

GLEOSTINE CAPS F

HEXALEN CAPS NP

LEUKERAN TABS F

LOMUSTINE CAPS F

melphalan tabs NP

Drug Name DrugTier

Requirements/Limits

MYLERAN TABS F

TEMODAR CAPS OR 20 MG, 180 MG, 100 MG, 5 MG, 140 MG, 250 MG (Temozolomide)

NP

temozolomide caps F

Antimetabolites capecitabine tabs F PA

mercaptopurine tabs F

methotrexate sodium soln ij1 gm/40ml, 200 mg/8ml,100 mg/4ml, 250 mg/10ml,50 mg/2ml

F

METHOTREXATE SODIUM SOLN IJ 250 MG/10ML

F

methotrexate sodium solr ij1 gm F

methotrexate sodium tabs or 2.5 mg F

PURIXAN SUSP NP

TABLOID TABS NP AL; Up to 18yrs old

TREXALL TABS F

XELODA TABS (Capecitabine) NP PA

Antineoplastic - BCL-2 Inhibitors VENCLEXTA STARTING PACK TBPK F PA

VENCLEXTA TABS F PA

Antineoplastic - Hedgehog Pathway Inhibitors ERIVEDGE CAPS F

ODOMZO CAPS F

Antineoplastic - Hormonal and Related Agents

anastrozole tabs F AL; At least 18 yrs old

ARIMIDEX TABS (Anastrozole) NP AL; At least 18 yrs old


37

Drug Name DrugTier

Requirements/Limits

AROMASIN TABS (Exemestane) NP AL; At least 18 yrs old

bicalutamide tabs F AL; At least 18 yrs old

CASODEX TABS (Bicalutamide) NP AL; At least 18 yrs old

EMCYT CAPS NP

exemestane tabs F AL; At least 18 yrs old

FARESTON TABS NP AL; At least 18 yrs old

FEMARA TABS (Letrozole) NP AL; At least 18 yrs old

flutamide caps F AL; At least 18 yrs old

letrozole tabs F AL; At least 18 yrs old

MEGACE ORAL SUSP (Megestrol Acetate) NP

megestrol acetate susp F

megestrol acetate tabs F

NILANDRON TABS (Nilutamide) NP AL; At least 18 yrs old

nilutamide tabs NP AL; At least 18 yrs old

tamoxifen citrate tabs F AL; At least 18 yrs old

XTANDI CAPS NP QL(4 ea daily);AL; At least 19 yrs old

ZYTIGA TABS NP QL(2 ea daily);AL; At least 18 yrs old

Antineoplastic - Immunomodulators POMALYST CAPS NP

Antineoplastic Combinations LONSURF TABS NP

Antineoplastic Enzyme Inhibitors AFINITOR DISPERZ TBSO NP

Drug Name DrugTier

Requirements/Limits

AFINITOR TABS F

ALECENSA CAPS F PA

ALUNBRIG TABS NP

BOSULIF TABS NP

CABOMETYX TABS F PA

CALQUENCE CAPS NP QL(2 ea daily)

CAPRELSA TABS F

COMETRIQ KIT NP

COTELLIC TABS F

FARYDAK CAPS NP

GILOTRIF TABS F

GLEEVEC TABS (Imatinib Mesylate) F

IBRANCE CAPS NP QL(1 ea daily)

ICLUSIG TABS 15 MG NP QL(2 ea daily)

ICLUSIG TABS 45 MG NP QL(1 ea daily)

IDHIFA TABS NP QL(1 ea daily)

imatinib mesylate tabs NP

IMBRUVICA CAPS F

INLYTA TABS F

IRESSA TABS F

JAKAFI TABS F

LENVIMA 10 MG DAILY DOSE CPPK NP




38

Drug Name DrugTier

Requirements/Limits




LYNPARZA CAPS NP

LYNPARZA TABS NP

MEKINIST TABS F

NERLYNX TABS NP

NEXAVAR TABS F

NINLARO CAPS F PA

RUBRACA TABS NP QL(4 ea daily)

RYDAPT CAPS NP QL(8 ea daily)

SPRYCEL TABS F

STIVARGA TABS NP

SUTENT CAPS F

TAFINLAR CAPS F

TAGRISSO TABS NP QL(1 ea daily)

TARCEVA TABS F

TASIGNA CAPS F QL(4 ea daily)

TYKERB TABS NP

VOTRIENT TABS F

XALKORI CAPS F

ZEJULA CAPS NP QL(3 ea daily)

ZELBORAF TABS F

ZOLINZA CAPS NP

Drug Name DrugTier

Requirements/Limits

ZYDELIG TABS NP

ZYKADIA CAPS NP

Antineoplastics Misc. HYDREA CAPS (Hydroxyurea) NP

hydroxyurea caps F

MATULANE CAPS F

tretinoin (chemotherapy) caps NP

Chemotherapy Rescue/Antidote Agents amifostine solr F

ETHYOL SOLR F

LEUCOVORIN CALCIUM TABS OR 15 MG, 10 MG F

leucovorin calcium tabs or 5 mg, 25 mg F

Topoisomerase I Inhibitors HYCAMTIN CAPS OR 1 MG, 0.25 MG F

ANTIPARKINSON AGENTS - Drugs to TreatParkinson's Disease Antiparkinson Adjuvants carbidopa tabs NP

LODOSYN TABS (Carbidopa) NP

Antiparkinson Anticholinergics benztropine mesylate tabsor 2 mg, 1 mg, 0.5 mg F

trihexyphenidyl hcl elix F

trihexyphenidyl hcl tabs F

Antiparkinson COMT Inhibitors COMTAN TABS (Entacapone) NP

entacapone tabs NP


39

Drug Name DrugTier

Requirements/Limits

TASMAR TABS (Tolcapone) NP

tolcapone tabs NP

Antiparkinson Dopaminergics amantadine hcl caps 100 mg F

amantadine hcl syrp 50mg/5ml F

amantadine hcl tabs 100 mg NP

bromocriptine mesylate caps F

bromocriptine mesylatetabs F

carbidopa-levodopa tabs25mg-250mg, 10mg-100mg, 25mg-100mg

F

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

F

carbidopa-levodopa tbdp10mg-100mg, 25mg-250mg, 25mg-100mg

NP

CARBIDOPA/LEVODOPA/ENTACAPONE TABS F

DUOPA SUSP NP

MIRAPEX ER TB24 (PramipexoleDihydrochloride)

NP

MIRAPEX TABS (PramipexoleDihydrochloride)

NP

NEUPRO PT24 NP

PARLODEL CAPS (Bromocriptine Mesylate) NP

PARLODEL TABS (Bromocriptine Mesylate) NP

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

F

Drug Name DrugTier

Requirements/Limits

pramipexoledihydrochloride tb24 2.25mg, 0.375 mg, 1.5 mg, 0.75mg, 3 mg, 4.5 mg, 3.75 mg

NP

REQUIP TABS (RopiniroleHydrochloride) NP

REQUIP XL TB24 (Ropinirole Hydrochloride) NP

ropinirole hydrochloridetabs 2 mg, 0.25 mg, 5 mg,3 mg, 0.5 mg, 1 mg, 4 mg

F

ropinirole hydrochloridetb24 4 mg, 6 mg, 12 mg, 8mg, 2 mg

NP

RYTARY CPCR NP

SINEMET CR TBCR (Carbidopa-Levodopa) NP

SINEMET TABS (Carbidopa-Levodopa) NP

STALEVO 100 TABS 4

STALEVO 125 TABS 4

STALEVO 150 TABS 4

STALEVO 200 TABS 4

STALEVO 50 TABS 4

STALEVO 75 TABS 4

Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (RasagilineMesylate) NP QL(1 ea daily)

ELDEPRYL CAPS (Selegiline HCl) NP

rasagiline mesylate tabs or0.5 mg, 1 mg NP QL(1 ea daily)

selegiline hcl caps NP

selegiline hcl tabs F

XADAGO TABS NP QL(1 ea daily)

ZELAPAR TBDP NP


40

Drug Name DrugTier

Requirements/Limits

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders Antimanic Agents LITHIUM CARBONATE CAPS 150 MG, 600 MG (Lithium Carbonate)


lithium carbonate caps 150mg, 600 mg, 300 mg F AL; At least 4

yrs old lithium carbonate tabs 300 mg F AL; At least 4

yrs old lithium carbonate tbcr 300 mg, 450 mg F AL; At least 4

yrs old

LITHIUM SOLN F

LITHOBID TBCR (Lithium Carbonate) NP AL; At least 4 yrs old Antipsychotics - Misc. EQUETRO CP12 F PA

GEODON CAPS OR 20 MG (Ziprasidone HCl) NP








GEODON SOLR IM 20 MG F PA; QL(6 eadaily)

LATUDA TABS 60 MG, 40 MG, 20 MG, 120 MG F


LATUDA TABS 80 MG F PA; QL(2 eadaily); AL; Atleast 18 yrs old

NUPLAZID TABS F QL(2 ea daily);AL; At least 18 yrs old

VRAYLAR CAPS F PA; QL(1 eadaily); AL; Atleast 18 yrs old

Drug Name DrugTier

Requirements/Limits

VRAYLAR CPPK F PA; QL(1 eadaily); AL; Atleast 18 yrs old

ziprasidone hcl caps 20 mg F QL(8 ea daily);AL; At least 6 yrs old




Benzisoxazoles

FANAPT TABS F PA; AL; At least 6 yrs old

FANAPT TITRATION PACK TABS F PA; AL; At least

6 yrs old INVEGA SUSTENNA SUSP F PA

INVEGA TB24 6 MG (Paliperidone) NP


INVEGA TB24 9 MG, 3 MG, 1.5 MG (Paliperidone) NP


INVEGA TRINZA SUSP F PA

paliperidone tb24 6 mg F QL(2 ea daily);AL; At least 12 yrs old

paliperidone tb24 9 mg, 3mg, 1.5 mg F


RISPERDAL CONSTA SUSR F QL(1 ea per 14

days retail) RISPERDAL M-TAB TBDP (Risperidone) NP AL; At least 5 yrs old RISPERDAL SOLN (Risperidone) NP AL; At least 5 yrs old RISPERDAL TABS (Risperidone) NP AL; At least 5 yrs old

risperidone soln F AL; At least 5 yrs old


41

Drug Name DrugTier

Requirements/Limits

risperidone tabs F AL; At least 5 yrs old

risperidone tbdp F AL; At least 5 yrs old

Butyrophenones HALDOL DECANOATE 100 SOLN (HaloperidolDecanoate)

NP

HALDOL DECANOATE 50 SOLN (HaloperidolDecanoate)

NP

HALDOL SOLN (Haloperidol Lactate) NP

haloperidol decanoate soln F

haloperidol lactate conc F

haloperidol lactate soln F

haloperidol tabs or 10 mg,1 mg, 2 mg, 20 mg, 5 mg,0.5 mg


Dibenzapines ADASUVE AEPB F

CLOZAPINE ODT TBDP F AL; At least 6 yrs old

clozapine tabs F AL; At least 6 yrs old

clozapine tbdp F AL; At least 6 yrs old

CLOZARIL TABS (Clozapine) NP AL; At least 6 yrs old FAZACLO TBDP 100 MG, 25 MG (Clozapine) NP AL; At least 6 yrs old FAZACLO TBDP 12.5 MG, 150 MG, 200 MG F AL; At least 6

yrs old

loxapine succinate caps F AL; At least 6 yrs old

olanzapine solr F AL; At least 6 yrs old

olanzapine tabs F AL; At least 6 yrs old

olanzapine tbdp F AL; At least 6 yrs old

Drug Name DrugTier

Requirements/Limits

quetiapine fumarate tabs400 mg, 100 mg, 200 mg,25 mg, 300 mg, 50 mg


quetiapine fumarate tb24200 mg, 150 mg F


quetiapine fumarate tb24300 mg, 50 mg, 400 mg F


SAPHRIS SUBL F PA; QL(2 eadaily); AL; Atleast 10 yrs old

SEROQUEL TABS (Quetiapine Fumarate) NP AL; At least 6 yrs old SEROQUEL XR TB24 150 MG, 200 MG (QuetiapineFumarate)


SEROQUEL XR TB24 300 MG, 50 MG, 400 MG (Quetiapine Fumarate)


VERSACLOZ SUSP F

ZYPREXA RELPREVV SUSR F

ZYPREXA SOLR (Olanzapine) NP AL; At least 6 yrs old ZYPREXA TABS (Olanzapine) NP AL; At least 6 yrs old ZYPREXA ZYDIS TBDP (Olanzapine) NP AL; At least 6 yrs old Dihydroindolones MOLINDONE HYDROCHLORIDE TABS F AL; At least 6

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

F

chlorpromazine hcl tabs or50 mg, 10 mg, 100 mg, 25mg, 200 mg


fluphenazine decanoatesoln ij F AL; At least 6

yrs old FLUPHENAZINE HCL CONC OR 5 MG/ML F AL; At least 6

yrs old FLUPHENAZINE HCL ELIX OR 2.5 MG/5ML F AL; At least 6

yrs old


42

Drug Name DrugTier

Requirements/Limits

FLUPHENAZINE HCL SOLN IJ 2.5 MG/ML F AL; At least 6

yrs old fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg F AL; At least 6

yrs old

perphenazine tabs 16 mg F QL(4 ea daily);AL; At least 6 yrs old

perphenazine tabs 2 mg F QL(32 eadaily); AL; Atleast 6 yrs old

perphenazine tabs 4 mg F QL(16 eadaily); AL; Atleast 6 yrs old

perphenazine tabs 8 mg F QL(8 ea daily);AL; At least 6 yrs old

prochlorperazine edisylatesoln F

prochlorperazine maleatetabs F

prochlorperazine supp NP

thioridazine hcl tabs F AL; At least 6 yrs old

trifluoperazine hcl tabs F AL; At least 6 yrs old

Quinolinone Derivatives

ABILIFY TABS 10 MG, 15 MG, 5 MG (Aripiprazole) NP


ABILIFY TABS 2 MG (Aripiprazole) NP


ABILIFY TABS 30 MG, 20 MG (Aripiprazole) NP


aripiprazole soln 1 mg/ml F

aripiprazole tabs 15 mg, 5mg, 10 mg F


aripiprazole tabs 2 mg F QL(2 ea daily);AL; At least 6 yrs old

aripiprazole tabs 20 mg, 30 mg F


Drug Name DrugTier

Requirements/Limits

aripiprazole tbdp 15 mg, 10 mg F


ARISTADA PRSY F

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

Thioxanthenes

thiothixene caps F AL; At least 6 yrs old

ANTISEPTICS & DISINFECTANTS - Drugs toPrevent Bacterial Skin Infections Antiseptics & Disinfectants formaldehyde soln 10%, 10% F

Chlorine Antiseptics chlorhexidine gluconateliqd ex 4 % F

chlorhexidine gluconatesoln ex 4 % F

HIBICLENS LIQD (Chlorhexidine Gluconate) NP

ANTIVIRALS - Drugs to Treat Viral Infections

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

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

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

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

APTIVUS CAPS 250 MG F QL(4 ea daily)

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

ATRIPLA TABS F QL(1 ea daily)

COMBIVIR TABS (Lamivudine-Zidovudine) NP QL(2 ea daily)

COMPLERA TABS F QL(1 ea daily)


43

Drug Name DrugTier

Requirements/Limits

CRIXIVAN CAPS 200 MG F QL(9 ea daily)

CRIXIVAN CAPS 400 MG F QL(6 ea daily)

DESCOVY TABS F QL(1 ea daily);AL; At least 12 yrs old

didanosine cpdr F QL(1 ea daily)

EDURANT TABS F QL(1 ea daily)

EMTRIVA CAPS 200 MG F QL(1 ea daily)

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

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

EPIVIR TABS 150 MG (Lamivudine) NP QL(2 ea daily)

EPIVIR TABS 300 MG (Lamivudine) NP QL(1 ea daily)

EPZICOM TABS (Abacavir Sulfate-Lamivudine) NP QL(1 ea daily)

EVOTAZ TABS F QL(1 ea daily)

fosamprenavir calcium tabs F QL(4 ea daily)

GENVOYA TABS F QL(1 ea daily);AL; At least 12 yrs old

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

INTELENCE TABS 200 MG F QL(2 ea daily)

INVIRASE CAPS 200 MG F QL(10 ea daily)

INVIRASE TABS 500 MG F QL(4 ea daily)

ISENTRESS CHEW 100 MG F QL(6 ea daily)

ISENTRESS CHEW 25 MG F QL(12 ea daily)

ISENTRESS PACK 100 MG F QL(2 ea daily)

ISENTRESS TABS 400 MG F QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

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

NP QL(16 ml daily)

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

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

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

lamivudine tabs 150 mg F QL(2 ea daily)

lamivudine tabs 300 mg F QL(1 ea daily)

lamivudine-zidovudine tabs F QL(2 ea daily)

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

LEXIVA TABS 700 MG (Fosamprenavir Calcium) NP QL(4 ea daily)

lopinavir-ritonavir soln F QL(16 ml daily)

NEVIRAPINE SUSP 50 MG/5ML F QL(40 ml daily)

nevirapine tabs 200 mg F QL(2 ea daily)

nevirapine tb24 100 mg F QL(3 ea daily)

nevirapine tb24 400 mg F QL(1 ea daily)

NORVIR CAPS 100 MG F QL(12 ea daily)

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

NORVIR TABS 100 MG F QL(12 ea daily)

ODEFSEY TABS F

PREZCOBIX TABS F QL(1 ea daily)

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

PREZISTA TABS 150 MG F QL(3 ea daily)

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

PREZISTA TABS 800 MG F QL(1 ea daily)


44

Drug Name DrugTier

Requirements/Limits

RESCRIPTOR TABS 100 MG F QL(12 ea daily)

RESCRIPTOR TABS 200 MG F QL(6 ea daily)

RETROVIR CAPS 100 MG (Zidovudine) NP QL(6 ea daily)

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

REYATAZ CAPS 150 MG, 200 MG F QL(2 ea daily)

REYATAZ CAPS 300 MG F

REYATAZ PACK 50 MG F QL(6 ea daily)

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

SELZENTRY TABS 25 MG F QL(3 ea daily)

SELZENTRY TABS 300 MG F QL(4 ea daily)

stavudine caps 40 mg, 30mg, 15 mg, 20 mg F QL(2 ea daily)

stavudine solr 1 mg/ml F QL(80 ml daily)

STRIBILD TABS F QL(1 ea daily)

SUSTIVA CAPS 200 MG F QL(1 ea daily)

SUSTIVA CAPS 50 MG F QL(2 ea daily)

SUSTIVA TABS 600 MG F QL(1 ea daily)

TIVICAY TABS 25 MG, 10 MG F

TIVICAY TABS 50 MG F QL(2 ea daily)

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

TRIZIVIR TABS (Abacavir Sulfate-Lamivudine-Zidovudine)

NP QL(2 ea daily)

TRUVADA TABS F QL(1 ea daily)

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

Drug Name DrugTier

Requirements/Limits

VIDEX EC CPDR (Didanosine) NP QL(1 ea daily)

VIDEXPEDIATRIC SOLR F QL(20 ml daily)

VIRACEPT TABS 250 MG F QL(9 ea daily)

VIRACEPT TABS 625 MG F QL(4 ea daily)

VIRAMUNE SUSP 50 MG/5ML F QL(40 ml daily)

VIRAMUNE TABS 200 MG (Nevirapine) NP QL(2 ea daily)

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

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

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

VIREAD TABS 250 MG, 150 MG, 200 MG, 300 MG F QL(1 ea daily)

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

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

NP QL(2 ea daily)

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

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

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

zidovudine caps 100 mg F QL(6 ea daily)

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

zidovudine tabs 300 mg F QL(2 ea daily)

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

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

Hepatitis Agents adefovir dipivoxil tabs F PA


45

Drug Name DrugTier

Requirements/Limits

BARACLUDE SOLN 0.05 MG/ML F PA

BARACLUDE TABS 1 MG, 0.5 MG (Entecavir) NP PA

COPEGUS TABS (Ribavirin (Hepatitis C)) NP PA

DAKLINZA TABS F PA; QL(1 eadaily)

entecavir tabs F PA

EPCLUSA TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old

EPIVIR HBV SOLN 5 MG/ML F PA

EPIVIR HBV TABS 100 MG (Lamivudine (HBV)) NP PA

HARVONI TABS F PA; QL(28 eaper fill retail)

HEPSERA TABS (Adefovir Dipivoxil) NP PA

lamivudine (hbv) tabs F PA

MAVYRET TABS F PA; QL(3 eadaily); AL; Atleast 18 yrs old

OLYSIO CAPS NP

PEG-INTRON KIT F PA; QL(0.143ea daily)

PEG-INTRON REDIPEN KIT F PA; QL(0.143

ea daily) PEG-INTRON REDIPEN PAK 4 KIT F PA; QL(0.143

ea daily) PEGASYS PROCLICK SOLN F PA

PEGASYS SOLN F PA

PEGINTRON KIT F PA; QL(0.143ea daily)

REBETOL CAPS 200 MG (Ribavirin (Hepatitis C)) NP PA

REBETOL SOLN 40 MG/ML NP

ribavirin (hepatitis c) caps F PA

Drug Name DrugTier

Requirements/Limits

ribavirin (hepatitis c) tabs F PA

SOVALDI TABS NP QL(28 ea perfill retail)

TECHNIVIE TABS F PA; QL(2 eadaily)

TYZEKA TABS F PA

VIEKIRA PAK TBPK F PA; QL(4 eadaily,28 day(s)limit)

VIEKIRA XR TB24 F PA; QL(3 eadaily); AL; Atleast 18 yrs old

VOSEVI TABS NP QL(1 ea daily);AL; At least 18 yrs old

ZEPATIER TABS NP

Herpes Agents acyclovir caps F

acyclovir susp F

acyclovir tabs F

famciclovir tabs F

FAMVIR TABS (Famciclovir) NP

SITAVIG TABS NP

valacyclovir hcl tabs 1 gm,1000 mg F

QL(3 eadaily,10 day(s)limit)

valacyclovir hcl tabs 500 mg F

VALTREX TABS 1 GM (Valacyclovir HCl) NP

QL(3 eadaily,10 day(s)limit)

VALTREX TABS 500 MG (Valacyclovir HCl) NP

ZOVIRAX CAPS OR 200 MG (Acyclovir) NP

ZOVIRAX SUSP OR 200 MG/5ML (Acyclovir) NP


46

Drug Name DrugTier

Requirements/Limits

ZOVIRAX TABS OR 400 MG, 800 MG (Acyclovir) NP

Influenza Agents FLUMADINE TABS (Rimantadine Hydrochloride)

NP

oseltamivir phosphate caps30 mg, 45 mg NP

Limit 10ea in 180 days;QL(12 eaper fill retail)

oseltamivir phosphate caps75 mg NP QL(12 ea perfill retail) oseltamivir phosphate susr6 mg/ml F QL(120 ml per

fill retail) RELENZA DISKHALER AEPB F AL; At least 5

yrs old rimantadine hydrochloridetabs F

TAMIFLU CAPS 30 MG, 45 MG (Oseltamivir Phosphate)

F

Limit 10ea in 180 days;QL(12 eaper fill retail)

TAMIFLU CAPS 75 MG (Oseltamivir Phosphate) F QL(12 ea per

fill retail) TAMIFLU SUSR 6 MG/ML(Oseltamivir Phosphate) NP QL(120 ml perfill retail) BETA BLOCKERS - Drugs to Treat High BloodPressure Alpha-Beta Blockers carvedilol phosphate cp24 NP

carvedilol tabs F

COREG CR CP24 (Carvedilol Phosphate) NP

COREG TABS (Carvedilol) NP

labetalol hcl tabs or 100 mg, 200 mg, 300 mg F

Beta Blockers Cardio-Selective acebutolol hcl caps NP

atenolol tabs F

betaxolol hcl tabs NP

Drug Name DrugTier

Requirements/Limits

bisoprolol fumarate tabs NP

BYSTOLIC TABS NP

LOPRESSOR TABS (Metoprolol Tartrate) NP

metoprolol succinate tb24 F

metoprolol tartrate tabs or50 mg, 25 mg, 100 mg F

METOPROLOL TARTRATE TABS OR 75 MG, 37.5 MG

F

SECTRAL CAPS (Acebutolol HCl) NP

TENORMIN TABS (Atenolol) NP

TOPROL XL TB24 (Metoprolol Succinate) NP

ZEBETA TABS (BisoprololFumarate) NP

Beta Blockers Non-Selective BETAPACE AF TABS (Sotalol HCl (AFIB/AFL)) NP

BETAPACE TABS (Sotalol HCl) NP

CORGARD TABS (Nadolol) NP

HEMANGEOL SOLN NP

INDERAL LA CP24 (Propranolol HCl) NP

INDERAL XL CP24 NP

INNOPRAN XL CP24 NP

nadolol tabs NP

pindolol tabs NP

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

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

F


47

Drug Name DrugTier

Requirements/Limits

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

F

sotalol hcl (afib/afl) tabs F

sotalol hcl tabs F

SOTYLIZE SOLN NP

TIMOLOL MALEATE TABS NP

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure Calcium Channel Blockers ADALAT CC TB24 (Nifedipine) NP

amlodipine besylate tabs F

CALAN SR TBCR (Verapamil HCl) NP

CALAN TABS (VerapamilHCl) NP

CARDIZEM CD CP24 (Diltiazem HCl Coated Beads)

NP

CARDIZEM LA TB24 120 MG NP

CARDIZEM LA TB24 300 MG, 360 MG, 180 MG, 420 MG, 240 MG (Diltiazem HCl Coated Beads)

NP

CARDIZEM TABS (Diltiazem HCl) NP

diltiazem hcl coated beads cp24 120 mg, 240 mg, 180mg, 360 mg, 300 mg

F

diltiazem hcl coated beads tb24 360 mg, 180 mg, 300mg, 240 mg, 420 mg

NP

diltiazem hcl cp12 or 90mg, 60 mg, 120 mg F

diltiazem hcl cp24 or 180mg, 120 mg, 240 mg F

diltiazem hcl extended release beads cp24 F

diltiazem hcl tabs or 30 mg,90 mg, 60 mg, 120 mg F

Drug Name DrugTier

Requirements/Limits

felodipine tb24 NP

isradipine caps NP

nicardipine hcl caps or 30mg, 20 mg NP

nifedipine caps F

nifedipine tb24 F

nimodipine caps NP

NISOLDIPINE ER TB24 NP

nisoldipine tb24 NP

NORVASC TABS (Amlodipine Besylate) NP

NYMALIZE SOLN NP

PROCARDIA CAPS (Nifedipine) NP

PROCARDIA XL TB24 (Nifedipine) NP

SULAR TB24 (Nisoldipine) NP

TIAZAC CP24 (Diltiazem HCl Extended Release Beads)

NP

verapamil hcl cp24 or 120mg, 100 mg, 180 mg, 360mg, 200 mg, 240 mg, 300 mg

NP

verapamil hcl tabs or 40mg, 120 mg, 80 mg F

verapamil hcl tbcr or 240mg, 120 mg, 180 mg F

VERELAN CP24 (Verapamil HCl) NP

VERELAN PM CP24 (Verapamil HCl) NP

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm Cardiac Glycosides DIGOXIN SOLN OR 0.05 MG/ML F


48

Drug Name DrugTier

Requirements/Limits

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

F

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

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation Conditions Cardiovascular Agents Misc. - Combinations amlodipine besylate-atorvastatin calcium tabs NP

BIDIL TABS NP

CADUET TABS (Amlodipine Besylate-Atorvastatin Calcium)

NP

ENTRESTO TABS F PA; QL(2 eadaily)

Peripheral Vasodilators inositol niacinate caps F

Prostaglandin Vasodilators ORENITRAM TBCR NP

TYVASO REFILL SOLN F QL(81.2 ml perfill retail)

TYVASO SOLN F QL(81.2 ml perfill retail)

TYVASO STARTER SOLN F QL(81.2 ml perfill retail)

VENTAVIS SOLN 10 MCG/ML F QL(5 ml daily)

VENTAVIS SOLN 20 MCG/ML F QL(3 ml daily)

Pulmonary Hypertension - Endothelin Receptor LETAIRIS TABS F

OPSUMIT TABS NP

TRACLEER TABS F

Pulmonary Hypertension - Phosphodiesterase

ADCIRCA TABS F PA; QL(3 eadaily)

REVATIO SUSR OR 10 MG/ML F PA

Drug Name DrugTier

Requirements/Limits

REVATIO TABS OR 20 MG (Sildenafil Citrate (Pulmonary Hypertension))


sildenafil citrate (pulmonaryhypertension) tabs or 20 mg

F PA; QL(3 eadaily)

Pulmonary Hypertension - Prostacyclin Receptor UPTRAVI TABS NP

UPTRAVI TBPK NP

Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS NP

Sinus Node Inhibitors CORLANOR TABS NP QL(2 ea daily)

CEPHALOSPORINS - Drugs to Treat BacterialInfections Cephalosporins - 1st Generation cefadroxil caps 500 mg F

cefadroxil susr 250 mg/5ml,500 mg/5ml F

cefadroxil tabs 1 gm NP

cephalexin caps 250 mg,750 mg, 500 mg F

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

CEPHALEXIN TABS 250 MG, 500 MG NP

KEFLEX CAPS (Cephalexin) NP

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

CEFACLOR ER TB12 NP

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

NP

cefprozil susr F

cefprozil tabs F


49

Drug Name DrugTier

Requirements/Limits

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

CEFTIN TABS 250 MG, 500 MG (Cefuroxime Axetil)

NP

cefuroxime axetil tabs F

Cephalosporins - 3rd Generation CEDAX CAPS NP

CEDAX SUSR NP

cefdinir caps F

cefdinir susr F

cefixime susr F

cefpodoxime proxetil susr NP

cefpodoxime proxetil tabs NP

CEFTIBUTEN CAPS NP

CEFTIBUTEN SUSR NP

ceftriaxone sodium solr ij500 mg, 250 mg, 1 gm F QL(10 ea per

fill retail) ceftriaxone sodium solr iv 1 gm F

SUPRAX CAPS 400 MG F

SUPRAX CHEW 100 MG, 200 MG NP

SUPRAX SUSR 200 MG/5ML, 100 MG/5ML(Cefixime)

NP

SUPRAX SUSR 500 MG/5ML NP

CHEMICALS

Liquids GLYCERIN LIQD F RX/OTC

GLYCERINE LIQD F RX/OTC

GLYCEROL FORMAL LIQD F RX/OTC

Drug Name DrugTier

Requirements/Limits

CONTRACEPTIVES - Drugs to PreventPregnancy Combination Contraceptives - Oral BEYAZ TABS (Drospirenone-EthinylEstradiol-Levomefolate Calcium)

F

BREVICON-28 TABS (Norethindrone & Eth Estradiol)

F

CYCLESSA TABS (Desogestrel-EthinylEstradiol (Triphasic))

F

DESOGEN TABS (Desogestrel & EthinylEstradiol)

NP

desogestrel & ethinylestradiol tabs F

desogestrel-ethinylestradiol (biphasic) tabs F

desogestrel-ethinylestradiol (triphasic) tabs F

drospirenone-ethinylestradiol tabs F

drospirenone-ethinylestradiol-levomefolate calcium tabs

F

DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM TABS

F

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

F

ethynodiol diacet & ethestrad tabs F

FEMCON FE CHEW (Norethindrone & EthinylEstradiol-Fe)

F

GENERESS FE CHEW (Norethindrone & EthinylEstradiol-Fe)

F

levonorgestrel & ethestradiol tabs F

LEVONORGESTREL AND ETHINYL ESTRADIOL TABS

F


50

Drug Name DrugTier

Requirements/Limits

levonorgestrel-eth estradiol(triphasic) tabs F

levonorgestrel-ethinylestradiol (91-day) tabs F

levonorgestrel-ethinylestradiol (continuous) tabs F

LO LOESTRIN FE TABS F

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

F

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

F

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

F

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

F

LOSEASONIQUE TABS (Levonorgestrel-EthinylEstradiol (91-Day))

F

MINASTRIN 24 FE CHEW (Norethin Acet & Estrad-Fe)

F

MIRCETTE TABS (Desogestrel-EthinylEstradiol (Biphasic))

F

MODICON TABS (Norethindrone & Eth Estradiol)

F

NATAZIA TABS F

NECON 1/50-28 TABS F

NECON 10/11-28 TABS F

norethin acet & estrad-fe chew F

norethin acet & estrad-fe tabs F

norethindrone & eth estradiol tabs F

norethindrone & ethinylestradiol-fe chew F

Drug Name DrugTier

Requirements/Limits

norethindrone acet & eth estra tabs F

norethindrone acetate-ethinyl estradiol-fe tabs F

norethindrone-eth estradiol (triphasic) tabs F

norgestimate-ethinylestradiol (triphasic) tabs F

norgestimate-ethinylestradiol tabs F

norgestrel & ethinylestradiol tabs F

NORINYL 1+35 TABS (Norethindrone & Eth Estradiol)

F

NORINYL 1+50 TABS F

OGESTREL TABS F

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

F

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

F

ORTHO-CYCLEN TABS (Norgestimate-EthinylEstradiol)

F

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

F

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

F

OVCON-35 TABS (Norethindrone & Eth Estradiol)

F

QUARTETTE TABS (Levonorgestrel-EthinylEstradiol (91-Day))

F

SAFYRAL TABS F

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

F


51

Drug Name DrugTier

Requirements/Limits

TAYTULLA CAPS F

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

F

YASMIN 28 TABS (Drospirenone-EthinylEstradiol)

F

YAZ TABS (Drospirenone-Ethinyl Estradiol) F

Combination Contraceptives - Vaginal NUVARING RING F

Emergency Contraceptives ELLA TABS F

levonorgestrel (emergencyoc) tabs F QL(4 ea per

350 days retail) PLAN B ONE-STEP TABS (Levonorgestrel(Emergency OC))

F QL(4 ea per350 days retail)

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

NP

QL(1 ml per fillretail)

DEPO-PROVERA CONTRACEPTIVE SUSY (MedroxyprogesteroneAcetate (Contraceptive))

4

medroxyprogesteroneacetate (contraceptive) susp

F QL(1 ml per fillretail)

medroxyprogesteroneacetate (contraceptive) susy

F

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

F

norethindrone (contraceptive) tabs F

ORTHO MICRONOR TABS (Norethindrone (Contraceptive))

F

Drug Name DrugTier

Requirements/Limits

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions Glucocorticosteroids CORTEF TABS (Hydrocortisone) NP

CORTISONE ACETATE TABS F

dexamethasone elix 0.5 mg/5ml F

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

F

DEXAMETHASONE SOLN 0.5 MG/5ML F

DEXAMETHASONE TABS 2 MG, 1 MG F

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

F

hydrocortisone tabs F

MEDROL DOSEPAK TBPK (Methylprednisolone) NP

MEDROL TABS 4 MG, 8 MG (Methylprednisolone) NP

methylprednisolone tabs 4mg, 8 mg F

methylprednisolone tbpk 4 mg F

MILLIPRED TABS 5 MG F

PEDIAPRED SOLN (Prednisolone Sodium Phosphate)

NP

prednisolone sodiumphosphate soln or 20mg/5ml, 6.7 mg/5ml, 15mg/5ml, 5 mg/5ml

F

prednisolone soln F

prednisolone syrp F

PREDNISONE INTENSOL CONC F

PREDNISONE SOLN 5 MG/5ML F


52

Drug Name DrugTier

Requirements/Limits

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

PREDNISONE TABS 50 MG F

PREDNISONE TBPK 10 MG, 5 MG F

UCERIS TB24 NP

VERIPRED 20 SOLN (Prednisolone Sodium Phosphate)

NP

Mineralocorticoids fludrocortisone acetate tabs F

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy Symptoms Antitussives benzonatate caps 100 mg F

benzonatate caps 200 mg F QL(1 ea daily)

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

F

TESSALON PERLES CAPS (Benzonatate) NP

Cough/Cold/Allergy Combinations brompheniramine &phenyleph elix 1mg/5ml-2.5mg/5ml, 1mg/5ml-1mg/5ml-2.5mg/5ml-2.5mg/5ml

F

brompheniramine &pseudoeph elix F

brompheniramine &pseudoeph liqd F

CHERACOL PLUS LIQD (Dextromethorphan-Guaifenesin)

NP

CHERACOL-D COUGH LIQD (Dextromethorphan-Guaifenesin)

NP

chlorpheniramine &pseudoeph tabs 60mg-4mg F

chlorpheniramine-acetaminophen tabs F

Drug Name DrugTier

Requirements/Limits

CLARITIN-D 24 HOUR TB24 (Loratadine & Pseudoephedrine)

NP

CORICIDIN HBP COLD & FLU TABS (Chlorpheniramine-Acetaminophen)

NP

DECON-A ELIX 2MG/5ML-5MG/5ML F

dextromethorphan-guaifenesin liqd20mg/10ml-200mg/10ml,10mg/5ml-100mg/5ml,10mg/5ml-10mg/5ml-100mg/5ml-100mg/5ml,15mg/7.5ml-150mg/7.5ml,10mg/5ml-200mg/5ml

F

dextromethorphan-guaifenesin soln20mg/10ml-200mg/10ml,10mg/5ml-100mg/5ml

F

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

F

dextromethorphan-guaifenesin tb12 30mg-600mg

F QL(2 ea daily)

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

NP

guaifenesin-codeine liqd100mg/5ml-10mg/5ml F AL; At least 12

yrs old guaifenesin-codeine soln100mg/5ml-10mg/5ml F AL; At least 12

yrs old guaifenesin-codeine syrp100mg/5ml-10mg/5ml F AL; At least 12

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

F

MUCINEX D TB12 (Pseudoephedrine-Guaifenesin)

NP


53

Drug Name DrugTier

Requirements/Limits

MUCINEX DM TB12 (Dextromethorphan-Guaifenesin)

NP QL(2 ea daily)

NEXAFED SINUS PRESSURE +PAIN TABS F

NORTUSS-EX LIQD F

phenylephrine-brompheniramine-dm elix1mg/5ml-5mg/5ml-2.5mg/5ml, 1mg/5ml-1mg/5ml-5mg/5ml-5mg/5ml-2.5mg/5ml-2.5mg/5ml

F

phenylephrine-chlorphen-dm liqd 15mg/5ml-4mg/5ml-10mg/5ml

F

phenylephrine-dm-gg w/apap tabs 10mg-325mg-200mg-5mg, 10mg-10mg-325mg-325mg-200mg-200mg-5mg-5mg

F

promethazine &phenylephrine soln F AL; At least 2

yrs old promethazine &phenylephrine syrp F AL; At least 2

yrs old promethazine w/codeine syrp F AL; At least 2

yrs old

promethazine-dm syrp F AL; At least 2 yrs old

promethazine-phenylephrine-codeine syrp

F

PROMETHAZINE/PHENYLEPHRINE SYRP F AL; At least 2

yrs old pseudoephed-bromphen-dm syrp 2mg/5ml-30mg/5ml-10mg/5ml

F

pseudoephedrine w/codeine-gg soln F

pseudoephedrine-guaifenesin tb12 60mg-600mg

F

ROBITUSSIN DM SYRP (Dextromethorphan-Guaifenesin)

NP

Drug Name DrugTier

Requirements/Limits

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

NP

ROBITUSSIN PEAK COLD DM SYRP (Dextromethorphan-Guaifenesin)

NP

TRIAMINIC COLD & ALLERGY SYRP F

TUSNEL C SYRP F

TYLENOL COLD & FLU SEVERE TABS (Phenylephrine-DM-GG w/APAP)

NP

Expectorants guaifenesin liqd 400mg/20ml, 100 mg/5ml F

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

F

guaifenesin syrp 100mg/5ml, 200 mg/10ml F

guaifenesin tabs 200 mg F

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

MUCINEX TB12 (Guaifenesin) NP QL(40 ea perfill retail) Misc. Respiratory Inhalants camphor-eucalyptus-menthol oint ex 1.2%-2.6%-4.8%

F

camphor-eucalyptus-menthol-turpentine oil-whitepetrolatum oint

F

HYPER-SAL NEBU (Sodium Chloride (Inhalant))

NP

HYPERSAL NEBU 3.5 % F

HYPERSAL NEBU 7 % (Sodium Chloride (Inhalant))

NP


54

Drug Name DrugTier

Requirements/Limits

MEDICATED CHEST RUB OINT F

NEBUSAL NEBU F

sodium chloride (inhalant) aers F

sodium chloride (inhalant)nebu F

VAPORX BALM OINT F

VICKS VAPORUB OINT F

Mucolytics acetylcysteine soln F

DERMATOLOGICALS - Drugs to Treat SkinConditions Acne Products ABSORICA CAPS 30 MG, 40 MG, 20 MG, 10 MG F

ACANYA GEL NP

ACNE MEDICATION 10 LOTN F

ACNE MEDICATION 5 LOTN F

ACZONE GEL 5 % (Dapsone (Topical)) NP

ACZONE GEL 7.5 % NP

adapalene crea 0.1 % NP

adapalene gel 0.1 % 4 RX/OTC

adapalene gel 0.3 % NP

ADAPALENE LOTN 0.1 % F

adapalene-benzoylperoxide gel NP

AKTIPAK PACK NP

ATRALIN GEL (Tretinoin) NP AL; Up to 25yrs old AVAR LS CLEANSER LIQD (Sulfacetamide Sodium w/ Sulfur)

NP

Drug Name DrugTier

Requirements/Limits

AVAR-E LS CREA (Sulfacetamide Sodium w/Sulfur)

NP

AZELEX CREA F AL; Up to 18yrs old

BENZAC AC WASH LIQD (Benzoyl Peroxide) NP RX/OTC

BENZACLIN GEL (Clindamycin Phosphate-Benzoyl Peroxide)

NP

BENZACLIN WITH PUMP GEL (ClindamycinPhosphate-BenzoylPeroxide)

F

Limit 50ea permonth;QL(1.667 gm daily)

BENZAMYCIN GEL (Benzoyl Peroxide-Erythromycin)

NP

BENZEFOAM FOAM (Benzoyl Peroxide) NP RX/OTC

BENZEFOAM ULTRA FOAM (Benzoyl Peroxide) NP

BENZEFOAMULTRA FOAM (Benzoyl Peroxide) NP

benzoyl peroxide foam 5.3% NP RX/OTC

benzoyl peroxide foam 9.8% NP

benzoyl peroxide gel 10 % F RX/OTC

BENZOYL PEROXIDE GEL 2.5 % F

benzoyl peroxide gel 5 % F

benzoyl peroxide gel 8 % NP

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

benzoyl peroxide liqd 4 % F

benzoyl peroxide liqd 7 % NP

benzoyl peroxide lotn 6 % NP RX/OTC

benzoyl peroxide misc 6 % NP

benzoyl peroxide-erythromycin gel NP


55

Drug Name DrugTier

Requirements/Limits

BP CLEANSING WASH EMUL NP

CLARIFOAM EF FOAM (Sulfacetamide Sodium w/Sulfur)

NP

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

F

CLEOCIN-T GEL (Clindamycin Phosphate(Topical))

NP

CLEOCIN-T LOTN (Clindamycin Phosphate(Topical))

NP

CLEOCIN-T SOLN (Clindamycin Phosphate(Topical))

NP

CLEOCIN-T SWAB (Clindamycin Phosphate(Topical))

NP

CLINDAGEL GEL NP

clindamycin phosphate(topical) foam NP

clindamycin phosphate(topical) gel NP

clindamycin phosphate(topical) lotn NP

clindamycin phosphate(topical) soln F

clindamycin phosphate(topical) swab NP

clindamycin phosphate-benzoyl peroxide(refrigerate) gel

NP

clindamycin phosphate-benzoyl peroxide gel 4

Limit 50ea permonth;QL(1.667 gm daily)

clindamycin phosphate-benzoyl peroxide gel 4

Limit 50gms permonth;QL(1.667 gm daily)

clindamycin phosphate-benzoyl peroxide gel 4 QL(1.667 gm

daily) clindamycin phosphate-tretinoin gel NP

Drug Name DrugTier

Requirements/Limits

dapsone (topical) gel NP

DESQUAM-X WASH LIQD (Benzoyl Peroxide) NP RX/OTC

DIFFERIN CREA 0.1 % (Adapalene) F

DIFFERIN GEL 0.1 % (Adapalene) F RX/OTC

DIFFERIN GEL 0.1 % (Adapalene) NP RX/OTC

DIFFERIN GEL 0.3 % (Adapalene) F

DIFFERIN LOTN 0.1 % F

DUAC GEL (ClindamycinPhosphate-BenzoylPeroxide (Refrigerate))

NP

EPIDUO FORTE GEL NP

EPIDUO GEL (Adapalene-Benzoyl Peroxide) NP

ERYGEL GEL (Erythromycin (Acne Aid)) NP

erythromycin (acne aid) gel NP

erythromycin (acne aid)pads NP

erythromycin (acne aid)soln F

EVOCLIN FOAM (Clindamycin Phosphate(Topical))

NP

FABIOR FOAM NP

isotretinoin caps F

KLARON LOTN (Sulfacetamide Sodium (Acne))

NP

ONEXTON GEL NP

PANOXYL-4 CREAMY WASH LIQD (BenzoylPeroxide)

NP

RETIN-A CREA (Tretinoin) F

PA; QL(20 gmper fill retail);AL; Up to 25yrs old


56

Drug Name DrugTier

Requirements/Limits

RETIN-A GEL (Tretinoin) F


RETIN-A MICRO GEL (Tretinoin Microsphere) NP


RETIN-A MICRO PUMP GEL 0.04 %, 0.1 % (Tretinoin Microsphere)

NP


RETIN-A MICRO PUMP GEL 0.08 % F


ROSULA PADS 5%-10% NP

SODIUM SULFACETAMIDE/SULFUR CLEANSER IN UREA EMUL

NP

SODIUM SULFACETAMIDE/SULFUR LOTN

NP

SODIUM SULFACETAMIDE/SULFUR SUSP

NP

SSS 10-5 FOAM NP

sulfacetamide sodium (acne) lotn NP

sulfacetamide sodium (acne) susp NP

sulfacetamide sodium w/sulfur crea 2%-10% NP

sulfacetamide sodium w/sulfur emul 1%-10%, 5%-10%

NP

sulfacetamide sodium w/sulfur liqd 4%-9%, 2%-2%-10%-10%, 2%-10%, 4.5%-9%

NP

sulfacetamide sodium w/sulfur lotn 5%-10% NP

sulfacetamide sodium w/sulfur pads 4%-10%, 4%-4%-10%-10%

NP

Drug Name DrugTier

Requirements/Limits

sulfacetamide sodium w/sulfur susp 4%-8% NP

SUMADAN WASH LIQD (Sulfacetamide Sodium w/Sulfur)

NP

SUMAXIN PADS (Sulfacetamide Sodium w/Sulfur)

NP

SUMAXIN TS SUSP (Sulfacetamide Sodium w/Sulfur)

NP

SUMAXIN WASH LIQD (Sulfacetamide Sodium w/Sulfur)

NP

tretinoin crea 0.025 %, 0.1%, 0.05 % NP


tretinoin gel 0.025 %, 0.01% NP


tretinoin gel 0.05 % NP AL; Up to 25yrs old

tretinoin microsphere gel F


VELTIN GEL NP

ZIANA GEL (ClindamycinPhosphate-Tretinoin) NP

Agents for Wrinkles/Lipoatrophy/Other Aesthetic

REFISSA CREA F


TRETINOIN EMOLLIENT CREA F


Analgesics - Topical menthol (topical analgesic)gel 2 % F

Anti-inflammatory Agents - Topical diclofenac sodium (topical)gel NP


57

Drug Name DrugTier

Requirements/Limits

diclofenac sodium (topical)soln NP

FLECTOR PTCH NP

LEXIXRYL THPK NP

PENNSAID SOLN NP

VOLTAREN GEL (Diclofenac Sodium (Topical))

NP

VOPAC MDS KIT NP

XRYLIX THPK NP

Antibiotics - Topical ALTABAX OINT NP

BACIGUENT OINT (Bacitracin (Topical)) NP

bacitracin (topical) oint F

bacitracin zinc oint F

bacitracin-polymyxin b oint F

BACTROBAN CREA (Mupirocin Calcium(Topical))

NP

BACTROBAN OINT (Mupirocin) NP

CENTANY AT KIT NP

CENTANY OINT 4

gentamicin sulfate (topical) crea NP

GENTAMICIN SULFATE OINT EX 0.1 % NP

mupirocin calcium (topical) crea NP

mupirocin oint F

neomycin-bacitracin-polymyxin oint F

neomycin-bacitracin-polymyxin-pramoxine oint F

Drug Name DrugTier

Requirements/Limits

neomycin-polymyxin w/pramoxine crea F

NEOSPORIN ORIGINAL OINT (Neomycin-Bacitracin-Polymyxin)

NP

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

NP

POLYSPORIN OINT (Bacitracin-Polymyxin B) NP

Antifungals - Topical ALEVAZOL OINT NP

ALOE VESTA ANTIFUNGAL OINT (Miconazole Nitrate (Topical))

NP

ALOE VESTA CLEAR ANTIFUNGAL OINT (Miconazole Nitrate (Topical))

NP

AZOLEN TINCTURE SOLN NP

butenafine hcl crea NP RX/OTC

CICLODAN CREAM KIT KIT NP

ciclopirox gel NP

ciclopirox olamine crea NP

ciclopirox olamine susp NP

ciclopirox sham NP

ciclopirox soln NP

clotrimazole (topical) crea F RX/OTC

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

clotrimazole (topical) soln NP RX/OTC


58

Drug Name DrugTier

Requirements/Limits

clotrimazole (topical) soln 4 QL(60 ml perfill retail);RX/OTC

clotrimazole w/betamethasone crea F

clotrimazole w/betamethasone lotn NP

econazole nitrate crea NP

ERTACZO CREA NP

EXELDERM CREA NP

EXELDERM SOLN NP

EXTINA FOAM (Ketoconazole (Topical)) NP

FUNGOID TINCTURE KIT NP

FUNGOID TINCTURE SOLN NP

JUBLIA SOLN NP

ketoconazole (topical) crea F

ketoconazole (topical) foam NP

ketoconazole (topical)sham F

LAMISIL ADVANCED GEL NP

LAMISIL AT CREA (Terbinafine HCl (Topical)) F

LAMISIL AT JOCK ITCH CREA (Terbinafine HCl (Topical))

F

LAMISIL AT SPRAY SOLN F

LOPROX CREA 0.77 % (Ciclopirox Olamine) NP

LOPROX KIT 0.77% NP

LOPROX KIT KIT NP

LOPROX SHAMPOO SHAM (Ciclopirox) NP

LOPROX SUSP 0.77 % (Ciclopirox Olamine) NP

Drug Name DrugTier

Requirements/Limits

LOTRIMIN AF AERO 2 % F

LOTRIMIN AF CREA 1 % (Clotrimazole (Topical)) NP RX/OTC

LOTRIMIN AF FOR HER CREA (Clotrimazole (Topical))

NP RX/OTC

LOTRIMIN AF JOCK ITCH CREA (Clotrimazole (Topical))

NP RX/OTC

LOTRIMIN ULTRA CREA NP RX/OTC

LOTRIMIN ULTRA CREA (Butenafine HCl) NP RX/OTC

LOTRISONE CREA (Clotrimazole w/Betamethasone)

NP

LUZU CREA NP

MENTAX CREA NP RX/OTC

MICATIN CREA (Miconazole Nitrate (Topical))

NP

miconazole nitrate (topical) aero F

miconazole nitrate (topical) aerp F

miconazole nitrate (topical) crea F

miconazole nitrate (topical)oint NP

miconazole nitrate (topical)powd F

naftifine hcl crea NP

NAFTIN CREA 2 % (Naftifine HCl) NP

NAFTIN GEL 1 %, 2 % NP

NIZORAL SHAM (Ketoconazole (Topical)) NP

nystatin (topical) crea F

nystatin (topical) oint F

nystatin (topical) powd F


59

Drug Name DrugTier

Requirements/Limits

nystatin-triamcinolone crea NP

nystatin-triamcinolone oint NP

oxiconazole nitrate crea NP

OXISTAT CREA (Oxiconazole Nitrate) NP

OXISTAT LOTN NP

PENLAC NAIL LACQUER SOLN (Ciclopirox) NP

terbinafine hcl (topical) crea F

TINACTIN AERO (Tolnaftate) NP

TINACTIN AERP (Tolnaftate) NP

TINACTIN CREA (Tolnaftate) NP

TINACTIN DEODORANT AERP (Tolnaftate) NP

TINACTIN JOCK ITCH AERP (Tolnaftate) NP

TINACTIN JOCK ITCH CREA (Tolnaftate) NP

TINACTIN POWD (Tolnaftate) NP

tolnaftate aero F

tolnaftate aerp F

tolnaftate crea F

tolnaftate liqd F

tolnaftate powd F

tolnaftate soln F

VUSION OINT NP

Antihistamines-Topical BENADRYL EXTRA STRENGTH CREA (Diphenhydramine-ZincAcetate)

NP

Drug Name DrugTier

Requirements/Limits

diphenhydramine-zincacetate crea 0.1%-2%,0.1%-0.1%-2%-2%

F

Antineoplastic or Premalignant Lesion Agents -CARAC CREA F

EFUDEX CREA (Fluorouracil (Topical)) NP

fluorouracil (topical) crea F

fluorouracil (topical) soln F

FLUOROURACIL CREA 0.5 % F

FLUOROURACIL SOLN 5 %, 2 % F

Antipruritics - Topical camphor & menthol lotn0.5%-0.5% F

SARNA LOTN (Camphor &Menthol) NP

Antipsoriatics 8-MOP CAPS NP

acitretin caps NP

calcipotriene crea F

calcipotriene oint NP

calcipotriene soln F

CALCITRIOL OINT EX 3 MCG/GM NP

COSENTYX SENSOREADY PEN SOAJ NP

COSENTYX SOSY NP

DOVONEX CREA (Calcipotriene) NP

methoxsalen rapid caps NP

OXSORALEN ULTRA CAPS (Methoxsalen Rapid) NP

SORIATANE CAPS (Acitretin) F


60

Drug Name DrugTier

Requirements/Limits

SORILUX FOAM NP

TALTZ SOAJ NP

tazarotene crea NP

TAZORAC CREA 0.05 % NP

TAZORAC CREA 0.1 % (Tazarotene) NP

TAZORAC GEL 0.1 %, 0.05 % NP

TREMFYA SOSY NP QL(1 ml per 28days retail)

VECTICAL OINT NP

Antiseborrheic Products DHS ZINC SHAM (Pyrithione Zinc) NP

OVACE PLUS WASH LIQD (Sulfacetamide Sodium) NP

OVACE WASH LIQD (Sulfacetamide Sodium) NP

pyrithione zinc sham 2 %, F

salicylic acid & sulfur sham F

SEBULEX SHAM (SalicylicAcid & Sulfur) NP

selenium sulfide lotn 2.5 % F

sulfacetamide sodium liqd ex NP

Antivirals - Topical ABREVA CREA F

acyclovir topical oint NP

DENAVIR CREA NP

XERESE CREA NP

ZOVIRAX CREA EX 5 % NP

ZOVIRAX OINT EX 5 % (Acyclovir Topical) NP

Burn Products

Drug Name DrugTier

Requirements/Limits

SILVADENE CREA (Silver Sulfadiazine) NP

silver sulfadiazine crea F

Corticosteroids - Topical ACLOVATE CREA (Alclometasone Dipropionate)

NP

alclometasone dipropionate crea NP

alclometasone dipropionateoint NP

AMCINONIDE CREA NP

AMCINONIDE LOTN NP

AMCINONIDE OINT NP

APEXICON E CREA NP

AUGMENTED BETAMETHASONE DIPROPIONATE GEL

NP

betamethasone dipropionate (topical) crea NP

betamethasone dipropionate (topical) lotn NP

betamethasone dipropionate (topical) oint NP

betamethasone dipropionate augmented crea

NP

betamethasone dipropionate augmentedgel

NP

betamethasone dipropionate augmentedlotn

NP

betamethasone dipropionate augmentedoint

NP

betamethasone valerate crea 0.1 % F

betamethasone valerate foam 0.12 % NP

betamethasone valerate lotn 0.1 % F


61

Drug Name DrugTier

Requirements/Limits

betamethasone valerate oint 0.1 % F

calcipotriene-betamethasone dipropionate oint


CAPEX SHAM NP

clobetasol propionate crea F

clobetasol propionateemollient base crea F

clobetasol propionateemulsion foam NP

clobetasol propionate foam NP

clobetasol propionate gel F

clobetasol propionate liqd NP

clobetasol propionate lotn NP

clobetasol propionate oint F

clobetasol propionate sham NP

clobetasol propionate soln F

CLOBEX LIQD (Clobetasol Propionate) NP

CLOBEX LOTN (Clobetasol Propionate) NP

CLOBEX SHAM (Clobetasol Propionate) NP

CLOCORTOLONE PIVALATE CREA NP

CLOCORTOLONE PIVALATE PUMP CREA NP

CLODERM CREA NP

CLODERM PUMP CREA NP

CORDRAN CREA 0.05 % (Flurandrenolide) NP

CORDRAN LOTN 0.05 % (Flurandrenolide) NP

CORDRAN OINT 0.05 % (Flurandrenolide) NP

Drug Name DrugTier

Requirements/Limits

CORDRAN TAPE 4 MCG/SQCM NP

CORDRAN TAPE TAPE NP

CUTIVATE CREA (Fluticasone Propionate) NP

CUTIVATE LOTN (Fluticasone Propionate) NP

CVS HDYROCORTISONE ACETATE CREA F

DERMA-SMOOTHE/FSBODY OIL (Fluocinolone Acetonide)

NP

DERMA-SMOOTHE/FSSCALP OIL (Fluocinolone Acetonide)

NP

DERMACINRX SILAPAK KIT (Triamcinolone Acetonide-Dimethicone-Silicone)

NP

DERMATOP CREA (Prednicarbate) NP

DERMATOP OINT (Prednicarbate) NP

DESONATE GEL NP

desonide crea NP

desonide lotn NP

desonide oint NP

DESOWEN CREA (Desonide) NP

DESOWEN LOTN (Desonide) NP

desoximetasone crea NP

desoximetasone gel NP

desoximetasone oint NP

DIFLORASONE DIACETATE CREA NP

DIFLORASONE DIACETATE OINT NP


62

Drug Name DrugTier

Requirements/Limits

DIPROLENE AF CREA (Betamethasone Dipropionate Augmented)

NP

DIPROLENE LOTN (Betamethasone Dipropionate Augmented)

NP

DIPROLENE OINT (Betamethasone Dipropionate Augmented)

NP

ELOCON CREA (Mometasone Furoate) NP

ELOCON LOTN (Mometasone Furoate) NP

ELOCON OINT (Mometasone Furoate) NP

ENSTILAR FOAM NP

EPIFOAM FOAM F

fluocinolone acetonide crea NP

fluocinolone acetonide oil NP

fluocinolone acetonide oint NP

fluocinolone acetonide soln NP

fluocinonide crea NP

fluocinonide emulsified base crea NP

fluocinonide gel NP

fluocinonide oint NP

fluocinonide soln NP

flurandrenolide crea NP

flurandrenolide lotn NP

flurandrenolide oint NP

fluticasone propionate crea0.05 % F

fluticasone propionate lotn0.05 % NP

Drug Name DrugTier

Requirements/Limits

fluticasone propionate oint0.005 % F

halobetasol propionate crea F

halobetasol propionate oint F

HALOG CREA NP

HALOG OINT NP

hydrocortisone (topical)crea 0.5 %, 2.5 % F

hydrocortisone (topical)crea 1%, 1 % F RX/OTC

hydrocortisone (topical) lotn2.5 %, 1 % F

hydrocortisone (topical) oint1 % F QL(2 gm daily);

RX/OTC hydrocortisone (topical) oint2.5 %, 0.5 % F

hydrocortisone (topical)soln 1 % F

hydrocortisone acetate(topical) crea F

hydrocortisone butyrate crea NP

hydrocortisone butyratehydrophilic lipo base crea NP

hydrocortisone butyrateoint NP

hydrocortisone butyratesoln NP

hydrocortisone valerate crea NP

hydrocortisone valerate oint NP

hydrocortisone-aloe vera crea F

KENALOG AERS (Triamcinolone Acetonide (Topical))

NP

LOCOID CREA (Hydrocortisone Butyrate) NP

LOCOID LIPOCREAM CREA (HydrocortisoneButyrate Hydrophilic LipoBase)

NP


63

Drug Name DrugTier

Requirements/Limits

LOCOID OINT (Hydrocortisone Butyrate) NP

LOCOID SOLN (Hydrocortisone Butyrate) NP

LUXIQ FOAM (Betamethasone Valerate) NP

MICORT-HC CREA NP

mometasone furoate crea F

mometasone furoate oint F

mometasone furoate soln F

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

NP RX/OTC

OLUX FOAM (Clobetasol Propionate) NP

OLUX-E FOAM (Clobetasol Propionate Emulsion) NP

PANDEL CREA NP

prednicarbate crea NP

prednicarbate oint NP

PSORCON CREA NP

SERNIVO EMUL NP

SYNALAR CREA (Fluocinolone Acetonide) NP

SYNALAR OINT (Fluocinolone Acetonide) NP

SYNALAR SOLN (Fluocinolone Acetonide) NP

TACLONEX OINT (Calcipotriene-Betamethasone Dipropionate)

NP

AL; At least 18 yrs old

TACLONEX SUSP NP AL; At least 18 yrs old TEMOVATE CREA (Clobetasol Propionate) NP

TEMOVATE E CREA (Clobetasol PropionateEmollient Base)

NP

Drug Name DrugTier

Requirements/Limits

TEMOVATE GEL (Clobetasol Propionate) NP

TEMOVATE OINT (Clobetasol Propionate) NP

TEMOVATE SOLN (Clobetasol Propionate) NP

TEXACORT SOLN NP

TOPICORT CREA 0.05 %, 0.25 % (Desoximetasone) NP

TOPICORT GEL 0.05 % (Desoximetasone) NP

TOPICORT LIQD 0.25 % NP

TOPICORT OINT 0.25 %, 0.05 % (Desoximetasone) NP

triamcinolone acetonide (topical) aers 0.147 mg/gm NP

triamcinolone acetonide (topical) crea 0.5 %, 0.1 %,0.025 %

F

triamcinolone acetonide (topical) lotn 0.025 %, 0.1%

F

triamcinolone acetonide (topical) oint 0.5 %, 0.1 %,0.025 %

F

triamcinolone acetonide-dimethicone-silicone kit NP

TRIANEX OINT NP

TRIDESILON CREA (Desonide) NP

ULTRAVATE CREA (Halobetasol Propionate) NP

ULTRAVATE LOTN NP

ULTRAVATE OINT (Halobetasol Propionate) NP

VANOS CREA (Fluocinonide) NP

WESTCORT OINT (Hydrocortisone Valerate) NP

Eczema Agents DUPIXENT SOSY NP


64

Drug Name DrugTier

Requirements/Limits

Emollient/Keratolytic Agents CARMOL 20 CREA (Urea) NP

urea crea 20 %, 40 % F

urea lotn 40 % F

Emollients

A + D PERSONAL CARE LOTION LOTN F

AL; Up to 18yrs old;RX/OTC

ALBOLENE CREA F AL; Up to 18yrs old;RX/OTC

ALOE AFTERSUN LOTION LOTN F


AMLACTIN CERAPEUTIC LOTN F


AMLACTIN ULTRA CREA F AL; Up to 18yrs old;RX/OTC

AQUA GLYCOLIC FACE CREAM CREA F


AQUA GLYCOLIC HAND & BODYLOTION LOTN F


AQUA LACTEN LOTN F AL; Up to 18yrs old;RX/OTC

AQUADERM CREA F AL; Up to 18yrs old;RX/OTC

AQUADERM TREATMENT/MOISTURIZER LOTN

F AL; Up to 18yrs old;RX/OTC

AQUAMED LOTN F AL; Up to 18yrs old;RX/OTC

AQUAPHILIC OINT F AL; Up to 18yrs old

AQUAPHOR ADVANCED THERAPY OINT F AL; Up to 18

yrs old

AQUAPHOR OINT F AL; Up to 18yrs old

Drug Name DrugTier

Requirements/Limits

AVEENO ACTIVE NATURALS DAILY MOISTURIZING BODY YOGURT LOTN

F


AVEENO ACTIVE NATURALS DAILY MOISTURIZING BODY YOGURT/APRICO LOTN

F


AVEENO ACTIVE NATURALS SKIN RELIEF MOISTURE REPAIR CREA

F


AVEENO DAILY MOISTURIZINGSPF 15 LOTN


AVEENO INTENSE RELIEF HAND CREA F


AVEENO POSITIVELY AGELESS LIFT & FIRM EYE CREA


AVEENO POSITIVELY AGELESS NIGHT CREA F


AVEENO POSITIVELY AGELESSFIRMING BODY LOTN


AVEENO POSITIVELY AGELESSSKIN STRENGTHENING BODY CREAM CREA

F


AVEENO POSITIVELY AGELESSSKIN STRENGTHENING HAND CREAM CREA

F


AVEENO POSITIVELY NOURISHING 24-HOUR ULTRA-HYDRATING CREA

F


AVEENO POSITIVELY NOURISHING ENERGIZING LOTN


AVEENO POSITIVELY RADIANT LOTN F



65

Drug Name DrugTier

Requirements/Limits

AVEENO POSITIVELY RADIANTOVERNIGHT HYDRATING FACIAL MOISTURI CREA

F


AVEENO STRESS RELIEF MOISTURIZING LOTN F


BASLE CREA F AL; Up to 18yrs old;RX/OTC

BETA CARE CREA F AL; Up to 18yrs old;RX/OTC

BETA CARE LOTN F AL; Up to 18yrs old;RX/OTC

BETA XMA CREA F AL; Up to 18yrs old;RX/OTC

BOUDREAUXS BABY BUTT SMOOTH DRY SKIN OINT

F AL; Up to 18yrs old

CAM LOTN F AL; Up to 18yrs old;RX/OTC

CARB-O-LAN 10 CREA F AL; Up to 18yrs old;RX/OTC

CARB-O-LAN 20 CREA F AL; Up to 18yrs old;RX/OTC

CARB-O-PHILIC/20 CREA F AL; Up to 18yrs old;RX/OTC

CARB-O-SAL 5 CREA F AL; Up to 18yrs old;RX/OTC

CERAVE AM SPF 30 LOTN F


CERAVE CREA F AL; Up to 18yrs old;RX/OTC

CERAVE LOTN F AL; Up to 18yrs old;RX/OTC

Drug Name DrugTier

Requirements/Limits

CERAVE PM LOTN F AL; Up to 18yrs old;RX/OTC

CERAVE RENEWING SA CREA F


CERAVE SA RENEWING LOTN F


CETAPHIL CREA F AL; Up to 18yrs old;RX/OTC

CETAPHIL DAILY ADVANCE ULTRA HYDRATING LOTN


CETAPHIL DAILY FACIAL MOISTURIZER LOTN F


CETAPHIL DERMACONTROL MOISTURIZER/SPF 30LOTN

F


CETAPHIL MOISTURIZING CREA (Emollient)

NP AL; Up to 18yrs old;RX/OTC

CETAPHIL MOISTURIZING LOTN F


CETAPHIL RESTORADERM LOTN F


CETAPHIL THERAPEUTIC HAND CREA F


CLN FACIAL MOISTURIZER NOURISHING LOTN


COCOA BUTTER HAND & BODYLOTION LOTN F


COCOA BUTTER LOTN F AL; Up to 18yrs old;RX/OTC

COCONUT OIL BEAUTY CREA F



66

Drug Name DrugTier

Requirements/Limits

CVS DAILY ULTRA MOISTURELOTION LOTN F


CVS MOISTURIZING CREAM CREA F


DAILY CONDITIONING TREATMENT OINT F AL; Up to 18

yrs old

DERMABASEOIL IN WATER CREA F


DERMAIDE ALOE CREA F AL; Up to 18yrs old;RX/OTC

DERMAL THERAPY EXTRA STRENGTH BODY LOTION LOTN


DERMAL THERAPY FACE CAREMOISTURIZING LOTION LOTN


DERMAL THERAPY FOOT MASSAGE LOTN F


DERMAL THERAPY HAND ELBOW & KNEE CREAM LOTN


DERMAL THERAPY HEEL CARE LOTN F


DERMALUBE DAILY MOISTURIZING LOTION LOTN


DERMEND MOISTURIZING BRUISE FORMULA CREA


DHEA CREA EX 1% F AL; Up to 18yrs old;RX/OTC

DIABETIDERM CREA F AL; Up to 18yrs old;RX/OTC

DIABETIDERM FOOT REJUVENATING CREA F


DIABETIDERM HAND & BODY LOTN F


Drug Name DrugTier

Requirements/Limits

DIABETIDERM LOTN F AL; Up to 18yrs old;RX/OTC

DMAE CREA F AL; Up to 18yrs old;RX/OTC

DML FORTE CREA F AL; Up to 18yrs old;RX/OTC

DROXY CREAM CREA F AL; Up to 18yrs old;RX/OTC

ELON SKIN REPAIR SYSTEM CREA F


ELTA CREA F AL; Up to 18yrs old;RX/OTC

EMOLLIA-CREME CREA F AL; Up to 18yrs old;RX/OTC

EMOLLIA-LOTION LOTN F AL; Up to 18yrs old;RX/OTC

emollient crea F AL; Up to 18yrs old;RX/OTC

emollient lotn 1.25 % F AL; Up to 18yrs old;RX/OTC

emollient oint 52 %,0.16gm/30gm-300mg/30gm-100unit/30gm, 41 %

F

AL; Up to 18yrs old

EPILYT LOTN F AL; Up to 18yrs old;RX/OTC

EQ THERAPEUTIC MOISTURIZING CREAM CREA


EQL ADVANCED RECOVERY SKIN CARE LOTN


EQL MOISTURIZING CREAM CREA F



67

Drug Name DrugTier

Requirements/Limits

EQL ULTRA MOISTURIZING DAILY LOTION LOTN


EUCERIN BABY LOTN F AL; Up to 18yrs old;RX/OTC

EUCERIN CALMING DAILY MOISTURIZER CREA (Emollient)


EUCERIN DAILY PROTECTION/SPF 30LOTN


EUCERIN INTENSIVE REPAIR LOTN F


EUCERIN INTENSIVE REPAIRHAND CREA F


EUCERIN LOTN F AL; Up to 18yrs old;RX/OTC

EUCERIN ORIGINAL HEALINGSOOTHING REPAIR LOTN


EUCERIN PLUS CREA F AL; Up to 18yrs old;RX/OTC

EUCERIN PLUS INTENSIVE REPAIR CREA (Emollient)


EUCERIN PLUS LOTN F AL; Up to 18yrs old;RX/OTC

EUCERIN SKIN CALMING DAILY MOISTURIZING CREA (Emollient)


EUCERIN SMOOTHING REPAIRADVANCED FORMULA LOTN


FORMULA 405 ENRICHED EYE CREA F


FORMULA 405 FACE CREAM CREA F


FORMULA 405 LIGHT TEXTURED MOISTURIZER CREA


Drug Name DrugTier

Requirements/Limits

FORMULA 405 MOISTURIZING LOTN F


GENTLE CREA F AL; Up to 18yrs old;RX/OTC

GERI-SOFT LOTN F AL; Up to 18yrs old;RX/OTC

glycerin (topical) liqd F

GNP ADVANCED RECOVERY LOTN F


GOLD BOND MEDICATED BODYLOTION EXTRA STRENGTH LOTN


GOLD BOND MEDICATED BODYLOTION LOTN F


GOLD BOND ULTIMATE DIABETICS' DRY RELIEF LOTN


GOLD BOND ULTIMATE HEALING CREA F


GOLD BOND ULTIMATE HEALING LOTN F


GOLD BOND ULTIMATE HEALING OINT F AL; Up to 18

yrs old

GOLD BOND ULTIMATE LOTN F


GOLD BOND ULTIMATE PROTECTION LOTN F


GOLD BOND ULTIMATE RESTORING LOTN F


GOLD BOND ULTIMATE SHEERRIBBONS PEARLRADIANCE LOTN


GOLD BOND ULTIMATE SHEERRIBBONS SILKSOFTNESS LOTN



68

Drug Name DrugTier

Requirements/Limits

GOLD BOND ULTIMATE SOFTENING LOTN F


GOLD BOND ULTIMATE SOOTHING CREA F


GOLD BOND ULTIMATE SOOTHING LOTN F


GRX VITAMIN E LOTN F AL; Up to 18yrs old;RX/OTC

HYDRASYN25 CREA F AL; Up to 18yrs old;RX/OTC

HYDRO-LAN CREA F AL; Up to 18yrs old;RX/OTC

J & J BURN CREAM CREA F AL; Up to 18yrs old;RX/OTC

KERADAN CREA F AL; Up to 18yrs old;RX/OTC

KERI ADVANCED MOISTURE THERAPY LOTN


KERI BASIC ESSENTIALS LOTN F


KERI LONG LASTING CREA F


KERI NOURISHING SHEA BUTTER LOTN F


KERI ORIGINAL LOTN F AL; Up to 18yrs old;RX/OTC

KERI OVERNIGHT LOTN F AL; Up to 18yrs old;RX/OTC

KERI RENEWAL MILK BODY LOTN F


KERI RENEWAL SKIN FIRMING LOTN F


Drug Name DrugTier

Requirements/Limits

KERI RENEWAL STRETCH MARK MINIMIZER LOTN


KERI SENSITIVE SKIN LOTN F


LAC-HYDRIN CREA (Lactic Acid (AmmoniumLactate))


LAC-HYDRIN LOTN (Lactic Acid (Ammonium Lactate)) NP


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


lactic acid (ammoniumlactate) crea 12 % F


lactic acid (ammoniumlactate) lotn 12 % F


LACTINOL HX CREA F AL; Up to 18yrs old;RX/OTC

LADY ESTHER 4 PURPOSE FACE CREAM CREA


LANAPHILIC OINT F AL; Up to 18yrs old

LANOLOR CREA F AL; Up to 18yrs old;RX/OTC

LANTISEPTIC THERAPEUTIC CREA F


LEADER FINGER CREAM CREA F


LUBRIDERM ADVANCED THERAPY LOTN F


LUBRIDERM DAILY MOISTURE/NORMAL TODRY SKIN LOTN


LUBRIDERM DAILY MOISTURESHEA + CALMING LAVENDER JASMINE LOTN

F



69

Drug Name DrugTier

Requirements/Limits

LUBRIDERM INTENSE SKIN REPAIR LOTN F


LUBRIDERM LOTN F AL; Up to 18yrs old;RX/OTC

LUBRIDERM MENS 3-IN-1 LOTN F


LUBRIDERM SERIOUSLY SENSITIVE LOTN F


LUBRIDERM SKIN NOURISHINGWITH SHEA AND COCOA BUTTERS LOTN

F


LUBRIDERM SOOTHING RELIEF/COOLING LOTN F


LUBRISOFT LOTN F AL; Up to 18yrs old;RX/OTC

MAXAM LOTN F AL; Up to 18yrs old;RX/OTC

MEDELA TENDER CARE LANOLIN CREA F


MEDERMA AG FACE CREAM CREA F


MEDERMA AG HAND & BODY LOTION LOTN F


MEDERMA STRETCH MARKS THERAPY CREA F


MOISTURIZING CREAM CREA F


MOTHERS FRIEND CREA F AL; Up to 18yrs old;RX/OTC

MOTHERS FRIEND LOTN F AL; Up to 18yrs old;RX/OTC

Drug Name DrugTier

Requirements/Limits

MSM SKIN LOTION LOTN F AL; Up to 18yrs old;RX/OTC

NEOSALUS LOTN F AL; Up to 18yrs old;RX/OTC

NEUTROGENA BODY LIGHT SESAME FORMULA LOTN


NEUTROGENA HAND CREA F


NEUTROGENA HAND/NORWEGIANFORMULA/FAST ABSORBINGCREA

F


NEUTROGENA HEALTHY SKIN CREA F


NEUTROGENA HEALTHY SKIN FACE SPF 15 LOTN F


NEUTROGENA MOISTURE SENSITIVE SKIN LOTN


NISEKO HYDRATING FACIAL MOISTURIZER CREA


NIVEA CREA F AL; Up to 18yrs old;RX/OTC

NIVEA EXTRA ENRICHED LOTION LOTN F


NIVEA EXTRA ENRICHED LOTN F


NIVEA GENTLE BODY EXFOLIATOR LOTN F


NIVEA LIGHT CREA F AL; Up to 18yrs old;RX/OTC

NIVEA LIGHT LOTN F AL; Up to 18yrs old;RX/OTC


70

Drug Name DrugTier

Requirements/Limits

NIVEA LOTN F AL; Up to 18yrs old;RX/OTC

NIVEA ORIGINAL LOTN F AL; Up to 18yrs old;RX/OTC

NIVEA ORIGINAL MOISTURE LOTN F


NIVEA SOFT CREA F AL; Up to 18yrs old;RX/OTC

NIVEA VISAGE CREA F AL; Up to 18yrs old;RX/OTC

NIVEA VISAGE INNER BEAUTY NIGHTTIME RENEWAL CREA


NIVEA VISAGE LOTN F AL; Up to 18yrs old;RX/OTC

NUTRADERM ADVANCED FORMULA LOTN F


NUTRADERM CREA 2.5%-2.5%-2.5%-2.5%-2.5%-2.5%


NUTRADERM LOTN 2.5%-2.5%-2.5%-2.5%-2.5% F


NUTRASEB CREA F AL; Up to 18yrs old;RX/OTC

OINTMENT BASE OINT F AL; Up to 18yrs old

PEN-KERA CREA F AL; Up to 18yrs old;RX/OTC

PENTRAVAN CREA F AL; Up to 18yrs old;RX/OTC

PENTRAVAN PLUS CREA F AL; Up to 18yrs old;RX/OTC

PETROLATUM OINT F AL; Up to 18yrs old

Drug Name DrugTier

Requirements/Limits

PRETTY FEET & HANDS CREA F


RA GENTLE SKIN CREAM CREA F


RA RENEWAL DRY SKIN THERAPY LOTN F


RADIAGUARD ADVANCED LOTN F


RESTA CREA F AL; Up to 18yrs old;RX/OTC

RESTA LITE LOTN F AL; Up to 18yrs old;RX/OTC

RISABAL-PH CREA F AL; Up to 18yrs old;RX/OTC

ROC DEEP WRINKLE SERUM LOTN F


ROC MULTI CORREXION 5 IN1 RESTORING EYE CREAM CREA


ROC MULTI CORREXION 5 IN1 RESTORING NIGHT CREAM CREA


ROC MULTI CORREXION LIFTANTI-GRAVITY NIGHT CREA


ROC RETINOL CORREXION CREA F


ROC RETINOL CORREXION MAX CREA F


ROC RETINOL CORREXION NIGHT CREA


ROC RETINOL CORREXION SENSITIVE EYE CREA


ROC RETINOL CORREXION SENSITIVE NIGHT CREA



71

Drug Name DrugTier

Requirements/Limits

ROSE MILK LOTN F AL; Up to 18yrs old;RX/OTC

SKIN REPAIR LOTN F AL; Up to 18yrs old;RX/OTC

SOOTHE & COOL MOISTURIZING BODY LOTION WITH ALOE LOTN

F


SOOTHE & COOL SKIN CREAMWITH ALOE & VITAMINS A, D & E CREA


SORBOLENE CREA F AL; Up to 18yrs old;RX/OTC

SPECIAL CARE CREAM CREA F


ST IVES SWISS FORMULA 24HOUR MOISTURE LOTN


STUDIO 35 EXTRA MOISTURIZING LOTION LOTN


STUDIO 35 MOISTURIZING SKIN CREA


SWEEN CREAM CREA F AL; Up to 18yrs old

THERABETIC SKIN CARE LOTN F


THERAPEUTIC MOISTURIZING CREA F


THERAPLEX HYDROLOTION LOTN F


TRIPLE CREAM CREA F AL; Up to 18yrs old;RX/OTC

TROPAZONE LOTN F AL; Up to 18yrs old;RX/OTC

UDDERLY SMOOTH CREA F


Drug Name DrugTier

Requirements/Limits

UDDERLY SMOOTH EXTRA CARE CREA F


UDDERLY SMOOTH EXTRA CARE20 CREA F


VANICREAM CREA F AL; Up to 18yrs old;RX/OTC

VANICREAM LITE LOTN F AL; Up to 18yrs old;RX/OTC

VELVACHOL CREA F AL; Up to 18yrs old;RX/OTC

VITAMIN E WITH PANTHENOL CREA F


vitamins a & d (topical) oint F AL; Up to 18yrs old

VP DERMABASE CREA F AL; Up to 18yrs old;RX/OTC

WIBI LOTN F AL; Up to 18yrs old;RX/OTC

ZIMS CRACK CREME DAYTIME CREA F


Enzymes - Topical SANTYL OINT F

Immunomodulating Agents - Topical ALDARA CREA (Imiquimod) NP QL(0.2667 eadaily)

imiquimod crea F QL(0.2667 eadaily)

ZYCLARA CREA NP

ZYCLARA PUMP CREA NP

Immunosuppressive Agents - Topical

ELIDEL CREA F AL; At least 2 yrs old

PROTOPIC OINT (Tacrolimus (Topical)) NP AL; At least 2 yrs old


72

Drug Name DrugTier

Requirements/Limits

tacrolimus (topical) oint NP AL; At least 2 yrs old Keratolytic/Antimitotic Agents BENSAL HP OINT NP

BETASAL SHAM F

COMPOUND W LIQD (Salicylic Acid) NP

COMPOUND W MAXIMUM STRENGTH GEL (SalicylicAcid)

NP

CONDYLOX SOLN (Podofilox) NP

CVS PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER SHAM

F

CVS THERAPEUTIC MAXIMUM STRENGTH SHAM

F

DENOREX EXTRA STRENGTH 2-IN-1 SHAM F

DERMAREST PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER SHAM

F

NEUTROGENA T/SALSHAM F

P & S SHAM F

podofilox soln F

salicylic acid gel 17 % F

salicylic acid liqd 17 % F

salicylic acid soln 17 % F

SELSUN BLUE DEEP CLEANSING SHAM F

SELSUN BLUE NATURALS DRYSCALP SHAM

F

SELSUN BLUE NATURALS SHAM F

Drug Name DrugTier

Requirements/Limits

THERAPEUTIC T+PLUS MAXIMUM STRENGTH SHAM

F

Liniments ASPERCREME/ALOECREA (Trolamine Salicylate)

NP

BENGAY GREASELESS CREA (Menthol-MethylSalicylate (Liniments))

NP

BENGAY ULTRA STRENGTH CREA (Camphor-Menthol-MethylSalicylate)

NP

BLUE-EMU SUPER STRENGTH CREA F

camphor-menthol-methylsalicylate crea 10%-30%-4%

F

liniments & rubs crea 10%-0.025%-15%, 0.01%-5%-10%, 1.2%-2.6%-4.7%,

F

menthol-methyl salicylate(liniments) crea 8%-30%,1%-15%, 3%-10%, 10%-30%, 10%-15%, 4%-25%

F

menthol-methyl salicylate(liniments) oint 6%-14%,7.6%-29%, 10%-15%

F

MOBISYL CREA (Trolamine Salicylate) NP

MYOFLEX CREA (Trolamine Salicylate) NP

SPORTSCREME CREA (Trolamine Salicylate) NP

TRIXAICIN CREA F

trolamine salicylate crea F

VICKS BABYRUB CREA F

Local Anesthetics - Topical ARTHRITIS PAIN RELIEVING CREA F

capsaicin crea 0.075 %, 0.1%, 0.025 % F


73

Drug Name DrugTier

Requirements/Limits

CAPZASIN-HP CREA (Capsaicin) NP

dibucaine oint F

EMLA CREA (Lidocaine-Prilocaine) NP

lidocaine hcl crea ex 3 % F

lidocaine hcl gel ex 2 % F RX/OTC

lidocaine oint 5 % F

lidocaine ptch 5 % F

lidocaine-prilocaine crea F

LIDODERM PTCH (Lidocaine) NP

pramoxine-zinc acetate lotn F

ZOSTRIX DIABETIC FOOT PAIN CREA (Capsaicin) NP

Misc. Topical A+D FIRST AID OINT F

ABSORBASE OINT F

ALOE VESTA PROTECTIVE OINT F

AMERIDERM PERISHIELD OINT F

AQUAPHOR LIP REPAIR OINT F

BASIS FACIAL MOISTURIZER CREA F


BASIS OVERNIGHT CREA F AL; Up to 18yrs old;RX/OTC

BAZA CLEANSE & PROTECT LOTN F

BODI PROTECT OINT F

CARRINGTON MOISTURE BARRIER CREA F


Drug Name DrugTier

Requirements/Limits

CARRINGTON MOISTURE BARRIER/ZINC CREA F


CERAVE OINT F

CHAPSTICK OVERNIGHT OINT F

CHAPSTICK ULTRA MOISTUREDAYTIME FORMULA OINT

F

CHAPSTICK ULTRASMOOTH FORTIFY OINT

F

CHAPSTICK ULTRASMOOTH NOURISH OINT

F

CHAPSTICK ULTRASMOOTH REJUVENATE OINT

F

CHAPSTICK ULTRASMOOTH SOOTHE OINT

F

CRITIC-AID CLEAR MOISTUREBARRIER OINT

F

DERMADROX OINT F

DR SMITHS DIAPER OINT (Zinc Oxide (Topical)) NP

DRYSOL SOLN F

EUCERIN CREA (Skin Protectants, Misc.) NP


GERI PROTECT OINT F

GOLD BOND EXTRA STRENGTH POWD F

GOLD BOND POWD F

HYDROCERIN CREA F AL; Up to 18yrs old;RX/OTC

LANTISEPTIC SKIN PROTECTANT OINT F

lubricants gel F


74

Drug Name DrugTier

Requirements/Limits

menthol-zinc oxide powd0.15%-1% F

NEOSPORIN LIP HEALTH OVERNIGHT RENEWAL THERAPY OINT

F

PALOMAR E OINT F

PELEVERUS CLEAR OINT F

PELEVERUS GOLD OINT F

PELEVERUS OINT F

PETROLEUM JELLY LIP TREATMENT OINT F

PROSHIELD PROTECTIVE HANDCREAM CREA


RA RENEWAL ADVANCED HEALING OINT

F

REMEDY CLEAR-AID OINT F

RESTORE CLEANSER & MOISTURIZER LIQD F

SENSI-CARE MOISTURIZING CREA F


SENSI-CARE PROTECTIVE BARRIER OINT

F

skin protectants, misc. crea F AL; Up to 18yrs old;RX/OTC

skin protectants, misc. oint51.1 %, , 0.7%-0.4%-1.7%,0.5%-6.3%-70%

F

SOOTHE & COOL FREE MEDSEPTIC OINT F

SOOTHE & COOL FREE MOISTURE BARRIER OINT

F

SOOTHE & COOL FREE SKIN PASTE OINT F

SOOTHE & COOL MOISTURE BARRIER OINT

F

Drug Name DrugTier

Requirements/Limits

SOOTHE & COOL PROTECT MOISTURE BARRIER OINT

F

SORBIDON HYDRATE CREA F


witch hazel (hamamelisvirginiana) pads 20 %, , 50%

F

witch hazel-glycerin pads F

zinc oxide (topical) oint 10%, 20 %, 40 % F

Phosphodiesterase 4 (PDE4) Inhibitors - Topical

EUCRISA OINT NP AL; At least 2 yrs old Rosacea Agents DOXYCYCLINE CPDR NP

METROCREAM CREA (Metronidazole (Topical)) NP

METROLOTION LOTN (Metronidazole (Topical)) NP

metronidazole (topical)crea 0.75 % F

metronidazole (topical) gel0.75 % F

metronidazole (topical) lotn0.75 % F

ORACEA CPDR NP

Scabicides & Pediculicides ELIMITE CREA (Permethrin) NP

EURAX CREA NP

EURAX LOTN NP

LINDANE LOTN F ST

lindane lotn F ST

lindane sham NP

LINDANE SHAM NP


75

Drug Name DrugTier

Requirements/Limits

malathion lotn NP

NATROBA SUSP F

NIX CREME RINSE LIQD (Permethrin) NP

OVIDE LOTN (Malathion) NP

permethrin crea ex 5 % F

permethrin liqd ex 1 % F

permethrin lotn ex 1 % F

pyrethrins-piperonylbutoxide liqd 0.33%-4% F

pyrethrins-piperonylbutoxide sham 0.33%-4%,0.3%-0.33%-4%

F

RID ESSENTIAL LICE ELIMINATION KIT KIT F

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

NP

SKLICE LOTN F

SPINOSAD SUSP 4

Tar Products coal tar extract sham 0.5 %, 1 % F

DHS TAR GEL SHAM (Coal Tar Extract) NP

DHS TAR SHAM (Coal Tar Extract) NP

NEUTROGENA T/GELCONDITIONER LIQD F

NEUTROGENA T/GELSHAM (Coal Tar Extract) NP

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

NP

THERAPLEX T SHAM (Coal Tar Extract) NP

Wound Care Products

Drug Name DrugTier

Requirements/Limits

2ND SKIN MOIST BURN PADS1.5"X2" PADS F RX/OTC

2ND SKIN MOIST BURN PADS2"X3" PADS F RX/OTC

2ND SKIN MOIST BURN PADS3"X4" PADS F RX/OTC

2ND SKIN MOIST DRESSING KIT PADS F RX/OTC

2ND SKIN MOIST GEL PADS 1"X1" PADS F RX/OTC

2ND SKIN MOIST GEL PADS 3" ROUND PADS F RX/OTC

ACTICOAT 7 2"X2" PADS F RX/OTC

ACTICOAT 7 4"X5" PADS F RX/OTC

ACTICOAT ABSORBENT ANTIMICROBIAL DRESSING 4"X5" PADS

F RX/OTC

ACTICOAT ANTIMICROBIAL DRESSING 2"X2" PADS

F RX/OTC

ACTICOAT ANTIMICROBIAL DRESSING 4"X4" PADS

F RX/OTC

ACTICOAT FLEX 3 BARRIER DRESSING 4"'X4" PADS

F RX/OTC

ADAPTIC NON-ADHERING DRESSING 3" X 3" PADS

F RX/OTC

ALLEVYN ADHESIVE PADS F RX/OTC

ALLEVYN AG ADHESIVE PADS F RX/OTC

ALLEVYN AG GENTLE BORDER PADS F RX/OTC

ALLEVYN AG NON-ADHESIVE PADS F RX/OTC

ALLEVYN AG SACRUM PADS F RX/OTC

ALLEVYN COMPRESSION PADS F RX/OTC

ALLEVYN GENTLE BORDER HEEL PADS F RX/OTC

ALLEVYN GENTLE BORDER LITE PADS F RX/OTC


76

Drug Name DrugTier

Requirements/Limits

ALLEVYN GENTLE BORDER MULTISITE PADS

F RX/OTC

ALLEVYN GENTLE BORDER PADS F RX/OTC

ALLEVYN GENTLE BORDER SACRUM PADS F RX/OTC

ALLEVYN GENTLE PADS F RX/OTC

ALLEVYN HEEL PADS F RX/OTC

ALLEVYN LIFE HEEL PADS F RX/OTC

ALLEVYN LIFE PADS F RX/OTC

ALLEVYN LIFE SACRUM PADS F RX/OTC

ALLEVYN NON-ADHESIVE PADS F RX/OTC

ALLEVYN PLUS ADHESIVE PADS F RX/OTC

ALLEVYN PLUS CAVITY PADS EX F RX/OTC

ALLEVYN PLUS SACRUM PADS F RX/OTC

ALLEVYN SACRUM PADS F RX/OTC

ALLEVYN TRACHEOSTOMY 3-1/2"X3-1/2" PADS

F RX/OTC

AMERIGEL HYDROGEL SATURATED GAUZE DRESSING 2" X 2" PADS

F RX/OTC

AQUACEL EXTRA/HYDROFIBERPADS

F RX/OTC

AQUACEL FOAM 3.2"X3.2" PADS F RX/OTC

AQUACEL FOAM 4"X4" PADS F RX/OTC




Drug Name DrugTier

Requirements/Limits


AQUACEL FOAM 8"X5.5" PADS F RX/OTC


AQUASITE IMPREGNATED DRESSING 2"X2" PADS

F RX/OTC


F RX/OTC


F RX/OTC

AQUASITE IMPREGNATED GAUZE 2"X2" PADS

F RX/OTC

AQUASITE IMPREGNATED GAUZE 4"X4" PADS

F RX/OTC

AQUASITE SHEET DRESSING 4"X4" PADS F RX/OTC

ARGLAES FILM 2-3/8" X 3-1/8" PADS F RX/OTC

ARGLAES FILM 3" X 14" PADS F RX/OTC

ARGLAES FILM 4" X 4-3/4"PADS F RX/OTC

ARGLAES FILM 4-3/4" X10" PADS F RX/OTC

ARGLAES ISLAND 2-3/8"X 3-1/8" PADS F RX/OTC

ARGLAES ISLAND 4" X 4-3/4" PADS F RX/OTC

ARGLAES ISLAND 4-3/4"X 10" PADS F RX/OTC

BIOBRANE 10"X15" PADS F RX/OTC




BIOBRANE-L 10"X15" PADS F RX/OTC


77

Drug Name DrugTier

Requirements/Limits



CARBOFLEX ODOR CONTROL DRESSING PADS

F RX/OTC

CARRAGAUZE 2 X 2 PADS F RX/OTC

CARRAGAUZE 4 X 4 PADS F RX/OTC

COMFEEL PLUS CLEARDRESSING PADS F RX/OTC

COMFEEL PLUS CONTOURDRESSING PADS

F RX/OTC

COMFEEL PLUS DRESSING PADS F RX/OTC

COMFEEL PLUS TRIANGLEDRESSING PADS

F RX/OTC

COMFEEL PLUS ULCER DRESSING PADS F RX/OTC

COMFEEL PLUS ULCERDRESSING PADS F RX/OTC

COMFEEL ULCER CAREDRESSING PADS F RX/OTC

COMFORT-AID 1.5"X2.5" PADS F RX/OTC

CONTREET FOAM CAVITY PADS F RX/OTC

CONTREET FOAM HEEL PADS F RX/OTC

CONTREET FOAM PADS F RX/OTC

CONTREET FOAM SACRAL PADS F RX/OTC

CONTREET HYDROCOLLOID PADS F RX/OTC

CURITY HEAVY DRAINAGE PACK PADS F RX/OTC

CURITY SALINE DRESSING 8"X4" PADS F RX/OTC

CURITY SODIUM CHLORIDE DRESSING 6"X6-3/4" PADS

F RX/OTC

Drug Name DrugTier

Requirements/Limits

DERMA-GEL 4" X 4" PADS F RX/OTC

DERMAGAUZE DRESSING PADS F RX/OTC

DERMAGRAN HYDROPHILIC WOUND DRESSING 2"X2" PADS

F RX/OTC


F RX/OTC


F RX/OTC

DOCTORS CHOICE BURNS/SCALDS/ABRASIONS PADS

F RX/OTC

DOME-PASTE BANDAGE PADS F RX/OTC

DRAWTEX ADVANCED WOUND CARE 2"X2" PADS

F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC

DUDRESS ISLAND DRESSING 4"X4" PADS F RX/OTC

DUDRESS ISLAND DRESSING 6"X6" PADS F RX/OTC

ELASTO-GEL 12"X12" PADS F RX/OTC


ELASTO-GEL 3" ROUND PADS F RX/OTC




78

Drug Name DrugTier

Requirements/Limits



ELASTO-GEL CAST/SPLINT 12"X12"PADS

F RX/OTC

ELASTO-GEL CAST/SPLINT 4"X4" PADS F RX/OTC

ELASTO-GEL CAST/SPLINT 6"X8" PADS F RX/OTC

ELASTO-GEL CAST/SPLINT 8"X16"PADS

F RX/OTC

ELASTO-GEL FACE MASK PADS F RX/OTC

ELASTO-GEL PLUS 2"X3" PADS F RX/OTC



ELTA DERMAL WOUND DRESSING PADS F RX/OTC

EXU-DRY 15"X18" PADS F RX/OTC







EXU-DRY ARM 27"X31" PADS F RX/OTC

EXU-DRY ARM/SHOULDER TIES27"X31" PADS

F RX/OTC

EXU-DRY BURN JACKET 31"X32" PADS F RX/OTC

EXU-DRY BURN JACKET CHILD 17"X20" PADS F RX/OTC

Drug Name DrugTier

Requirements/Limits

EXU-DRY BUTTOCKS 23"X53" PADS F RX/OTC

EXU-DRY ELBOW/KNEE/HEEL10"X17" PADS

F RX/OTC

EXU-DRY FACE 9"X14" PADS F RX/OTC

EXU-DRY INCISION 3"X9" PADS F RX/OTC

EXU-DRY NON-PERMEABLE PAD 24"X36" PADS

F RX/OTC

EXU-DRY PADDED HAND 12"X13" PADS F RX/OTC

EXU-DRY PADDED HAND CHILD 8"X8" PADS F RX/OTC

EXU-DRY PADDED NECK 6"X25" PADS F RX/OTC

EXU-DRY PERMEABLE PAD 24"X36" PADS F RX/OTC

EXU-DRY SCALP 3"X14" PADS F RX/OTC

EXU-DRY SLIT TUBE 2"X3" PADS F RX/OTC

FIBRACOL COLLAGEN-ALGINATE WOUND DRESSING/2" X 2" PADS

F RX/OTC

FIBRACOL COLLAGEN-ALGINATE WOUND DRESSING/4" X 8-3/4"PADS

F

RX/OTC

FOAM DRESSING BORDERED PADS F RX/OTC

FOAM DRESSING CIRCULAR BORDERED PADS

F RX/OTC

FOAM DRESSING NON-BORDERED PADS F RX/OTC

GRX HYDROGEL GAUZE 2X2 PADS F RX/OTC

GRX HYDROGEL GAUZE 4X4 PADS F RX/OTC

HYCOLOID-GRX PADS F RX/OTC

HYDROCOL II PADS F RX/OTC


79

Drug Name DrugTier

Requirements/Limits

HYDROCOL II SACRAL PADS F RX/OTC

HYDROCOL II THIN PADS F RX/OTC

HYDROFERA BLUE 4"X4" PADS F RX/OTC

HYDROFERA BLUE FOAM DRESSING 2"X2" PADS

F RX/OTC


F RX/OTC


F RX/OTC

HYDROFERA BLUE FOAM DRESSING PADS F RX/OTC

HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE FILM PADS

F

RX/OTC

HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE FILM/2-1/4X8PADS

F

RX/OTC

HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE FILM/4"X4"PADS

F

RX/OTC

HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE FILM/ISLANDPADS

F

RX/OTC

HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE/OSTOMY/2.5"PADS

F

RX/OTC

HYDROFERA BLUE FOAM DRESSING/TUNNELING/9MM PADS

F

RX/OTC

HYDROFERA BLUE HEAVY DRAINAGE 4"X4" PADS

F RX/OTC

Drug Name DrugTier

Requirements/Limits

HYDROFERA BLUE HEAVY DRAINAGE 6"X6" PADS

F RX/OTC

HYDROFERA BLUE READY FOAMDRESSING 2.5"X2.5" PADS

F RX/OTC

HYDROFERA BLUE READY FOAMDRESSING 4"X5" PADS

F RX/OTC

HYDROFERA BLUE READY FOAMDRESSING 8"X8" PADS

F RX/OTC

KALTOSTAT FORTEX PADS F RX/OTC

KALTOSTAT PADS F RX/OTC

KALTOSTAT WOUND DRESSING PADS F RX/OTC

KENDALL ALGINATE HYDROCOLLOID DRESSING 4"X4" PADS

F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC

KENDALL ZINC CALCIUM ALGINATE DRESSING 2"X2" PADS

F RX/OTC


F RX/OTC


F RX/OTC

KERAMATRIX REPLICINE 10CMX10CM PADS F RX/OTC

KERAMATRIX REPLICINE 5CMX5CM PADS F RX/OTC


80

Drug Name DrugTier

Requirements/Limits

KERLIX SUPER SPONGE SALINE DRESSING PADS F RX/OTC

MAXORB EXTRA AG+ PADS F RX/OTC

MEDI-PAK PERFORMANCE PLUSCOMBINE ABD PAD/8" X 7.5" PADS

F

RX/OTC

MEDIHONEY CALCIUM ALGINATE DRESSING 4"X5" PADS

F RX/OTC

MEDIHONEY CALCIUM ALGINATE DRESSING/2"X2" PADS

F RX/OTC

MEDIHONEY WOUND & BURN DRESSING 3/4"X12" PADS

F RX/OTC

MEDIHONEY WOUND/BURNDRESSING4"X5" PADS

F RX/OTC

NU-GEL WOUND DRESSING/3-3/4" X 3-3/4"PADS

F RX/OTC

NU-GEL WOUND DRESSING/6"X 8" PADS F RX/OTC

POLYMEM ALGINATE DRESSING/3" X 3" PADS F RX/OTC



POLYMEM ALGINATE DRESSING/6.5" X 7.5"PADS

F RX/OTC

POLYMEM SILVER DRESSING/4.25" X 4.25"PADS

F RX/OTC

PRIMACOL BORDERED DRESSING 2"X2" PADS F RX/OTC



PRIMACOL DRESSING 4"X4" PADS F RX/OTC


Drug Name DrugTier

Requirements/Limits


PRIMACOL SPECIALTY DRESSING PADS F RX/OTC

REPLICARE 1-1/2"X2-1/2"PADS F RX/OTC

REPLICARE 4"X4" PADS F RX/OTC



REPLICARE THIN 2"X2.75" PADS F RX/OTC

REPLICARE THIN 3.5"X5.5" PADS F RX/OTC

REPLICARE THIN 6"X8" PADS F RX/OTC

REPLICARE ULTRA 4"X4" PADS F RX/OTC

REPLICARE ULTRA 6"X6" PADS F RX/OTC

REPLICARE ULTRA SACRUM 7"X8" PADS F RX/OTC

RESTORE CX WOUND CARE DRESSING-STERILE PADS

F RX/OTC

RESTORE DRESSING FOR PSORIASIS-STERILE PADS

F RX/OTC

RESTORE EXTRA THIN DRESSING 4"X4" PADS F RX/OTC



RESTORE HYDROGEL GAUZE PAD 4"X4" PADS F RX/OTC

RESTORE PLUS WOUND CARE DRESSING 4"X4" PADS

F RX/OTC

RESTORE PLUS WOUND CARE DRESSING 4"X4" TAPERED EDGE PADS

F RX/OTC


F RX/OTC


81

Drug Name DrugTier

Requirements/Limits


F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC

RESTORE PLUS WOUND CARE DRESSING TRIANGLE PADS

F RX/OTC

RESTORE SILVER DRESSING 2"X2" PADS F RX/OTC

RESTORE SILVER DRESSING 4"X4" NON-ADHESIVE PADS

F RX/OTC

RESTORE SILVER DRESSING 4"X4.75" PADS

F RX/OTC

RESTORE SILVER DRESSING 4"X5" CONTACT LAYER PADS

F RX/OTC

RESTORE SILVER DRESSING 6"X8" CONTACT LAYER PADS

F RX/OTC

RESTORE SILVER DRESSING 6"X8" NON-ADHESIVE PADS

F RX/OTC

RESTORE WOUND CARE DRESSING 4"X4" ADHESIVE PADS

F RX/OTC

RESTORE WOUND CARE DRESSING 4"X4" NON-ADHESIVE PADS

F RX/OTC

RESTORE WOUND CARE DRESSING 4"X4" PADS F RX/OTC

RESTORE WOUND CARE DRESSING 4"X5" CONTACT LAYER PADS

F RX/OTC


F RX/OTC

Drug Name DrugTier

Requirements/Limits


F RX/OTC

RESTORE WOUND CARE DRESSING 6"X8" CONTACT LAYER PADS

F RX/OTC

RESTORE WOUND CARE DRESSING 6"X8" NON-ADHESIVE PADS

F RX/OTC



RTD WOUND CARE DRESSING2" X 2" PADS F RX/OTC



SEASORB-AG PADS F RX/OTC

SKINTEGRITY 2" X 2" PADS F RX/OTC

SKINTEGRITY 4" X 4" PADS F RX/OTC

SOLOSITE CONFORMABLE WOUND 2"X2" PADS

F RX/OTC

SOLOSITE CONFORMABLE WOUND 4"X4" PADS

F RX/OTC

SORBACELL FOAM DRESSING 4"X4" PADS F RX/OTC

SORBACELL FOAM DRESSINGSTRIP 1"X8" PADS

F RX/OTC

SORBSAN TOPICAL WOUND DRESSING 12" PADS

F RX/OTC

SORBSAN TOPICAL WOUND DRESSING 2" X 2" PADS

F RX/OTC

SORBSAN TOPICAL WOUND DRESSING 3 X 3 PADS

F RX/OTC


82

Drug Name DrugTier

Requirements/Limits

SORBSAN TOPICAL WOUND DRESSING 4 X 4 PADS

F RX/OTC

SORBSAN TOPICAL WOUND DRESSING 4" X 8" PADS

F RX/OTC

STRATASORB COMPOSITE ISLAND DRESSING 4" X 4" PADS

F RX/OTC

TEGADERM AG MESH DRESSING WITH SILVER 2"X2" PADS

F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC

TEGADERM ALGINATE AG DRESSING PADS F RX/OTC

TEGADERM HIGH GELLING ALGINATE DRESSING 4"X4" PADS

F RX/OTC

TEGADERM HIGH INTEGRITY ALGINATE DRESSING 4"X4" PADS

F RX/OTC

TEGADERM MATRIX DRESSING PADS F RX/OTC

TOE-AID PADS F RX/OTC

TRIPLE HELIX COLLAGEN 2"X2" PADS F RX/OTC

ULTEC HYDROCOLLOID DRESSING PADS F RX/OTC

VASELINE PETROLATUM GAUZE PADS F RX/OTC

VASELINE PETROLATUM GAUZECISION DRESSING OVERWRAP PADS

F

RX/OTC

VASELINE PETROLATUM GAUZECISION DRESSING PADS

F RX/OTC

Drug Name DrugTier

Requirements/Limits

VASELINE PETROLATUM GAUZEOVERWRAP PADS F RX/OTC

VASELINE PETROLATUM GAUZESTRIP OVERWRAP PADS

F RX/OTC

VASELINE PETROLATUM GAUZESTRIP PADS F RX/OTC

VASELINE PETROLATUM GAUZETUBE FOIL OVERWRAP PADS

F RX/OTC

VIGILON PRIMARY WOUND DRESSING/13" X24" PADS

F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC

wound dressings pads F RX/OTC

WOUNDGARD 2-1/2"X2-1/2" PADS F RX/OTC

WOUNDGARD 4"X4-1/4"PADS F RX/OTC

WOUNDGARD 4"X6" PADS F RX/OTC

XEROFLO DRESSING 1"X8" PADS F RX/OTC



DIAGNOSTIC PRODUCTS

Diagnostic Drugs GLUCAGEN DIAGNOSTIC SOLR F

Diagnostic Tests ACCU-CHEK ACTIVE STRIPS STRP NP RX/OTC

ACCU-CHEK AVIVA PLUS STRP VI NP RX/OTC


83

Drug Name DrugTier

Requirements/Limits

ACCU-CHEK AVIVA STRP VI NP RX/OTC

ACCU-CHEK COMPACT PLUS STRP NP RX/OTC

ACCU-CHEK COMPACT TEST DRUM STRP NP RX/OTC

ACCU-CHEK SMARTVIEW STRIPS STRP NP RX/OTC

ACCUTREND GLUCOSE STRP NP RX/OTC

ACURA BLOOD GLUCOSE TESTSTRIPS STRP

NP RX/OTC

ADVANCE INTUITION TEST STRIPS STRP NP RX/OTC

ADVANCE MICRO-DRAW TEST STRIPS STRP NP RX/OTC

ADVOCATE REDI-CODE STRP VI NP RX/OTC

ADVOCATE REDI-CODE+ TESTSTRIPS STRP NP RX/OTC

ADVOCATE TEST STRIPS STRP NP RX/OTC

AGAMATRIX AMP NO CODE TEST STRIPS STRP

NP RX/OTC

AGAMATRIX JAZZ TEST STRIPS STRP NP RX/OTC

AGAMATRIX KEYNOTE TEST STRIPS STRP NP RX/OTC

AGAMATRIX PRESTO TEST STRIPS STRP NP RX/OTC

ASSURE 3 TEST STRIPS STRP NP RX/OTC

ASSURE 4 TEST STRIPS STRP NP RX/OTC

ASSURE II CHECK STRIP STRP NP RX/OTC

ASSURE II STRP NP RX/OTC

ASSURE II TEST STRIPS STRP NP RX/OTC

ASSURE PLATINUM TEST STRIPS STRP NP RX/OTC

ASSURE PRISM MULTI TEST STRIPS STRP NP RX/OTC

Drug Name DrugTier

Requirements/Limits

ASSURE PRO TEST STRIPS STRP NP RX/OTC

AT LAST TEST STRIPS STRP NP RX/OTC

BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

BAYER CONTOUR NEXT BLOODGLUCOSE TEST STRP

NP RX/OTC

BG STAR BLOOD GLUCOSE TEST STRP NP RX/OTC

BIOSCANNER GLUCOSE TEST STRIPS STRP NP RX/OTC

BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NP RX/OTC

BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC

CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM STRP

NP RX/OTC

CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE STRP

NP RX/OTC

CARESENS N BLOOD GLUCOSETEST STRIPS STRP

NP RX/OTC

CHEK-STIX COMBO PAK URINALYSIS CONTROL STRP

F

CHEK-STIX CONTROL STRP F

CHEMSTRIP-K STRP F

CLEVER CHEK AUTO-CODE TEST STRIPS STRP

NP RX/OTC

CLEVER CHEK AUTO-CODE VOICE TEST STRIPS STRP

NP RX/OTC

CLEVER CHEK TEST STRIPS STRP NP RX/OTC

CLEVER CHOICE AUTO-CODE PRO TEST STRIPS STRP

NP RX/OTC

CLEVER CHOICE MICRO TESTSTRIPS STRP NP RX/OTC


84

Drug Name DrugTier

Requirements/Limits

CONTROL AST STRP NP RX/OTC

CONTROL TEST STRIPS STRP NP RX/OTC

COOL BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC

CVS ADVANCED GLUCOSE METER TEST STRIPS STRP

NP RX/OTC

DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

DUO-CARE TEST STRIPS STRP NP RX/OTC

EASY PLUS BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

EASY PLUS II BLOOD GLUCOSE TEST STRP NP RX/OTC

EASY STEP TEST STRIPS STRP NP RX/OTC

EASY TALK BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

EASY TOUCH GLUCOSE TEST STRIPS STRP NP RX/OTC

EASY TOUCH HEALTHPRO GLUCOSE TEST STRIPS STRP

NP RX/OTC

EASY TRAK BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

EASYGLUCO PLUS STRP NP RX/OTC

EASYGLUCO STRP VI NP RX/OTC

EASYMAX 15 TEST STRIPS STRP NP RX/OTC

EASYMAX TEST STRIPS STRP NP RX/OTC

EASYPLUS BLOOD GLUCOSE TEST STRIP STRP

NP RX/OTC

EASYPRO BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

Drug Name DrugTier

Requirements/Limits

EASYPRO PLUS STRP VI NP RX/OTC

ELEMENT COMPACT TEST STRIPS STRP NP RX/OTC

ELEMENT TEST STRIPS STRP NP RX/OTC

EMBRACE BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

EMBRACE EVO BLOOD GLUCOSETEST STRIPS STRP

NP RX/OTC

EMBRACE PRO BLOOD GLUCOSETEST STRIPS STRP

NP RX/OTC

EQ BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC

EQL TRUETEST BLOOD GLUCOSE TEST STRP NP RX/OTC

EQL TRUETRACK TEST STRP NP RX/OTC

EVENCARE + BLOOD GLUCOSETEST STRIP STRP

NP RX/OTC

EVENCARE BLOOD GLUCOSE TEST STRIP STRP

NP RX/OTC

EVENCARE G2 TEST STRIPS STRP NP RX/OTC

EVENCARE G3 TEST STRIPS STRP NP RX/OTC

EVENCARE MINI BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

EVOLUTION AUTOCODE STRP VI NP RX/OTC

EXACTECH R-S-G TEST STRIPS STRP NP RX/OTC

EXACTECH TEST STRIPS STRP NP RX/OTC

EZ SMART BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

EZ SMART PLUS BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC


85

Drug Name DrugTier

Requirements/Limits

FIFTY50 GLUCOSE TEST STRIP 2.0 STRP NP RX/OTC

FORA BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC

FORA D15G BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

FORA D20 BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

FORA D40/G31 BLOODGLUCOSE TEST STRIPS STRP

NP RX/OTC

FORA G20 BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

FORA G30A BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

FORA GD20 TEST STRIPS STRP NP RX/OTC

FORA GD50 BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

FORA TN'G/TN'G VOICEBLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

FORA V10 BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC


NP RX/OTC


NP RX/OTC

FORA V30A BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

FORACARE GD40 STRP NP RX/OTC

FORACARE PREMIUM V10 TESTSTRIPS STRP NP RX/OTC

FORACARE TEST N GO TEST STRIPS STRP NP RX/OTC

Drug Name DrugTier

Requirements/Limits

FORTISCARE BLOOD GLUCOSETEST STRIP STRP

NP RX/OTC

FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS STRP

NP RX/OTC

FREESTYLE INSULINX BLOODGLUCOSE TEST STRP

NP RX/OTC

FREESTYLE LITE TEST STRIPS STRP NP RX/OTC

FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

FREESTYLE TEST STRIPS STRP NP RX/OTC

GE100 BLOOD GLUCOSE TESTSTRIPS STRP NP RX/OTC

GENSTRIP 50 STRP NP RX/OTC

GHT TEST STRIPS STRP NP RX/OTC

GLUCO PERFECT 3 TEST STRIPS STRP NP RX/OTC

GLUCOCARD 01 SENSOR PLUS STRP NP RX/OTC

GLUCOCARD 01 SENSOR PLUSTEST STRIPS STRP NP RX/OTC

GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS STRP

NP

RX/OTC

GLUCOCARD SHINE TEST STRIPS STRP NP RX/OTC

GLUCOCARD VITAL TEST STRIPS STRP NP RX/OTC

GLUCOCARD X-SENSOR STRP NP RX/OTC

GLUCOCOM TEST STRIPS STRP NP RX/OTC

GLUCONAVII BLOOD GLUCOSETEST STRIPS STRP

F QL(5 ea daily);RX/OTC

GLUCONAVII BLOOD GLUCOSETEST STRIPS STRP

NP RX/OTC


86

Drug Name DrugTier

Requirements/Limits

GLUCOSE METER TEST STRIPS ADVANCED STRP

NP RX/OTC

GMATE BLOOD GLUCOSE TESTSTRIPS STRP

NP RX/OTC

GNP EASY TOUCH GLUCOSE TEST STRIPS STRP

NP RX/OTC

IN TOUCH BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

INFINITY BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

KETOCARE STRP F

KETONE TEST STRIPS STRP F

KETOSTIX STRP F

KROGER BLOOD GLUCOSE TESTSTRIPS STRP

NP RX/OTC

KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

KROGER TEST STRIPS STRP NP RX/OTC

LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS STRP

NP

RX/OTC

LIBERTY TEST STRIPS STRP NP RX/OTC

LIBERTY TEST STRIPS STRP F QL(6.67 ea

daily); RX/OTC MAXIMA BLOOD GLUCOSE TESTSTRIPS STRP

NP RX/OTC

MEIJER BLOOD GLUCOSE TESTSTRIPS STRP

NP RX/OTC

MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

Drug Name DrugTier

Requirements/Limits

MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

MICRODOT TEST STRIPS STRP NP RX/OTC

MYGLUCOHEALTH BLOOD GLUCOSE TEST STRP

NP RX/OTC

NEUTEK 2TEK TEST STRIPS STRP NP RX/OTC

NEXGEN TEST STRIPS STRP NP RX/OTC

NOVA MAX GLUCOSE TEST STRIPS STRP NP RX/OTC

NOVA MAX PLUS KETONE TESTSTRIPS STRP

F

ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

ON CALL PLUS BLOOD GLUCOSE TEST STRP NP RX/OTC

ON CALL VIVID BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

ON CALL VIVID BLOOD GLUCOSE TEST STRP NP RX/OTC

ONETOUCH ULTRA BLUE STRP NP RX/OTC

ONETOUCH VERIO TEST STRIPS STRP NP RX/OTC

OPTIUM TEST STRIPS STRP NP RX/OTC

OPTIUMEZ TEST STRIPS STRP NP RX/OTC

OPTUMRX BLOOD GLUCOSE TEST STRP NP RX/OTC

PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS STRP

NP

RX/OTC


87

Drug Name DrugTier

Requirements/Limits

PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS STRP

NP

RX/OTC

POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

PRECISION PCX PLUS TEST STRIPS STRP NP RX/OTC

PRECISION PCX STRP NP RX/OTC

PRECISION POINT OF CARE TEST STRIPS STRP

NP RX/OTC

PRECISION QID TEST STRIPS STRP NP RX/OTC

PRECISION SOF-TACT TEST STRIPS STRP NP RX/OTC

PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

PRECISION XTRA STRP VI F

PREMIUM BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

PTS PANELS GLUCOSE TEST STRP NP RX/OTC

PTS PANELS KETONE TEST STRP NP

PTS PANELS KETONE TEST STRP F

QUICKTEK TEST STRIPS STRP NP RX/OTC

QUINTET AC BLOOD GLUCOSETEST STRIPS STRP

NP RX/OTC

QUINTET BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

RA TRUETEST STRIPS STRP NP RX/OTC

Drug Name DrugTier

Requirements/Limits

REFUAH PLUS BLOOD GLUCOSETEST STRIPS STRP

NP RX/OTC

RELION BLOOD GLUCOSE TESTSTRIPS STRP

NP RX/OTC

RELION CONFIRM/MICROTEST STRIPS STRP NP RX/OTC

RELION KETONE STRP F

RELION KETONE TEST STRIPS STRP F

RELION PRIME BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

RELION ULTIMA BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

RELION ULTIMA TEST STRIPS STRP NP RX/OTC

REVEAL BLOOD GLUCOSE TEST STRP NP RX/OTC

REXALL BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC


NP RX/OTC


NP RX/OTC

SMART SENSE PREMIUM BLOODGLUCOSE STRIPS STRP

NP RX/OTC

SMART SENSE VALUE BLOOD GLUCOSE STRIPS STRP

NP RX/OTC

SMARTEST BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

SOLUS V2 AUDIBLE TEST STRP NP RX/OTC

SUPREME TEST STRIPS STRP NP RX/OTC


88

Drug Name DrugTier

Requirements/Limits

SURE EDGE BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

SURECHEK BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

TELCARE BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

TGT BLOOD GLUCOSE TEST STRIPS PREMIUM STRP

NP RX/OTC

TGT BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

F QL(6.67 eadaily); RX/OTC

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

NP RX/OTC

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP

NP RX/OTC

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP


TRUETEST BLOOD GLUCOSE TEST STRIPS STRP


TRUETEST BLOOD GLUCOSE TEST STRP F QL(6.67 ea

daily); RX/OTC

TRUETEST STRIPS STRP F QL(6.67 eadaily); RX/OTC

TRUETEST STRIPS STRP NP RX/OTC

TRUETRACK BLOOD GLUCOSE TEST STRP F QL(6.67 ea

daily); RX/OTC

TRUETRACK TEST STRP NP RX/OTC

TRUETRACK TEST STRP F QL(6.67 eadaily); RX/OTC

ULTIMA TEST STRIPS STRP NP RX/OTC

Drug Name DrugTier

Requirements/Limits

ULTRATRAK PRO TEST STRIPS STRP NP RX/OTC

ULTRATRAK ULTIMATE TEST STRIPS STRP NP RX/OTC

UNISTRIP1 GENERIC STRP NP RX/OTC

VERASENS BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

VICTORY AGM-4000 TEST STRIPS STRP NP RX/OTC

VOCAL POINT BLOOD GLUCOSE TEST STRIPS STRP

NP RX/OTC

WAVESENSE PRESTO TEST STRIPS STRP NP RX/OTC

DIETARY PRODUCTS/DIETARY MANAGEMENTPRODUCTS Dietary Management Products CARDIOTEK-RX TABS F

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes Digestive Enzymes CREON CPEP F

LACTAID FAST ACT CHEW (Lactase) NP

LACTAID FAST ACT TABS (Lactase) NP

LACTAID TABS (Lactase) NP

lactase chew 9000 unit F

lactase tabs 9000 unit,3000 unit F

PANCREAZE CPEP NP

PERTZYE CPEP NP

ULTRESA CPEP NP PA

VIOKACE TABS NP

ZENPEP CPEP F


89

Drug Name DrugTier

Requirements/Limits

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood Pressure Carbonic Anhydrase Inhibitors acetazolamide cp12 F

acetazolamide tabs F

DIAMOX CP12 (Acetazolamide) NP

methazolamide tabs F

NEPTAZANE TABS (Methazolamide) NP

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

NP

ALDACTAZIDE TABS 50MG-50MG NP

amiloride & hydrochlorothiazide tabs F

DYAZIDE CAPS (Triamterene & Hydrochlorothiazide)

NP

MAXZIDE TABS (Triamterene & Hydrochlorothiazide)

NP

MAXZIDE-25 TABS (Triamterene & Hydrochlorothiazide)

NP

spironolactone &hydrochlorothiazide tabs F

triamterene & hydrochlorothiazide caps F

triamterene & hydrochlorothiazide tabs F

TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS F

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

BUMEX TABS (Bumetanide) NP

DEMADEX TABS (Torsemide) NP

Drug Name DrugTier

Requirements/Limits

EDECRIN TABS (Ethacrynic Acid) NP

ethacrynic acid tabs NP

furosemide soln ij 10 mg/ml F

furosemide soln or 10 mg/ml F

FUROSEMIDE SOLN OR 8 MG/ML F

furosemide tabs or 20 mg,80 mg, 40 mg F

LASIX TABS (Furosemide) NP

torsemide tabs F

Potassium Sparing Diuretics ALDACTONE TABS (Spironolactone) NP

amiloride hcl tabs F

CAROSPIR SUSP NP

DYRENIUM CAPS NP

spironolactone tabs or 25mg, 100 mg, 50 mg F

Thiazides and Thiazide-Like Diuretics CHLOROTHIAZIDE TABS 250 MG F

chlorothiazide tabs 500 mg F

chlorthalidone tabs F

DIURIL SUSP NP

hydrochlorothiazide caps F

hydrochlorothiazide tabs F

indapamide tabs F

METHYCLOTHIAZIDE TABS F

metolazone tabs F


90

Drug Name DrugTier

Requirements/Limits

MICROZIDE CAPS (Hydrochlorothiazide) NP

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate Hormones Bone Density Regulators ACTONEL TABS 150 MG (Risedronate Sodium) NP QL(0.034 eadaily) ACTONEL TABS 30 MG (Risedronate Sodium) NP

ACTONEL TABS 35 MG (Risedronate Sodium) NP

Limit 4ea in 28 days;QL(0.143ea daily)

ACTONEL TABS 5 MG (Risedronate Sodium) NP QL(1 ea daily)

ALENDRONATE SODIUM SOLN 70 MG/75ML NP


alendronate sodium tabs 10 mg, 5 mg F QL(1 ea daily)

alendronate sodium tabs 35 mg, 70 mg F


ALENDRONATE SODIUM TABS 40 MG F

ATELVIA TBEC (Risedronate Sodium) NP


BINOSTO TBEF NP

BONIVA TABS OR 150 MG (Ibandronate Sodium) NP QL(0.034 eadaily)

calcitonin (salmon) soln F QL(0.124 mldaily)

ETIDRONATE DISODIUM TABS 200 MG NP QL(4 ea daily)

ETIDRONATE DISODIUM TABS 400 MG NP QL(1 ea daily)

FORTEO SOLN NP

FORTICAL SOLN F QL(0.124 mldaily)

FOSAMAX PLUS D TABS NP QL(0.143 eadaily)

Drug Name DrugTier

Requirements/Limits

FOSAMAX TABS (Alendronate Sodium) NP


ibandronate sodium tabs or 150 mg NP QL(0.034 eadaily) MIACALCIN SOLN IJ 200 UNIT/ML F QL(0.07 ml

daily) MIACALCIN SOLN NA 200 UNIT/ACT (Calcitonin (Salmon))

NP QL(0.124 mldaily)

risedronate sodium tabs 150 mg NP QL(0.034 eadaily) risedronate sodium tabs 30 mg NP

risedronate sodium tabs 35 mg NP


risedronate sodium tabs 5 mg NP QL(1 ea daily)

risedronate sodium tbec 35 mg NP


TYMLOS SOPN NP 1 per 30days;QL(0.052ml daily)

Growth Hormones GENOTROPIN MINIQUICK SOLR F PA

GENOTROPIN SOLR F PA

HUMATROPE COMBO PACK SOLR NP

HUMATROPE SOLR NP

NORDITROPIN FLEXPRO SOLN F PA

NUTROPIN AQ NUSPIN 10 SOLN F PA



NUTROPIN AQ PEN SOLN F PA

OMNITROPE SOLN 10 MG/1.5ML NP


91

Drug Name DrugTier

Requirements/Limits

OMNITROPE SOLN 10 MG/1.5ML, 5 MG/1.5ML 4 PA

OMNITROPE SOLR 5.8 MG NP

SAIZEN CLICK.EASY SOLR F PA

SAIZEN SOLR F PA

SAIZENPREP RECONSTITUTIONKIT SOLR

F PA

SEROSTIM SOLR NP

ZOMACTON SOLR 10 MG NP

ZOMACTON SOLR 5 MG 4 PA

ZORBTIVE SOLR NP

Hormone Receptor Modulators EVISTA TABS (Raloxifene HCl) NP QL(1 ea daily)

raloxifene hcl tabs F QL(1 ea daily)

Metabolic Modifiers calcitriol caps or 0.5 mcg,0.25 mcg F

calcitriol soln or 1 mcg/ml F AL; Up to 11yrs old

CARNITOR SF SOLN (Levocarnitine (MetabolicModifiers))

NP

CARNITOR SOLN OR 1 GM/10ML (Levocarnitine (Metabolic Modifiers))

NP

CARNITOR TABS OR 330 MG (Levocarnitine (Metabolic Modifiers))

NP RX/OTC

levocarnitine (metabolicmodifiers) soln 1 gm/10ml F

levocarnitine (metabolicmodifiers) tabs 330 mg F RX/OTC

RAYALDEE CPCR F QL(2 ea daily)

ROCALTROL CAPS 0.5 MCG, 0.25 MCG (Calcitriol) NP

Drug Name DrugTier

Requirements/Limits

ROCALTROL SOLN 1 MCG/ML (Calcitriol) NP AL; Up to 11yrs old Posterior Pituitary Hormones DDAVP SOLN NA 0.01 % (Desmopressin AcetateRefrigerated)

NP

DDAVP SOLN NA 0.01 % (Desmopressin AcetateSpray)

NP PA

DDAVP TABS OR 0.1 MG, 0.2 MG (DesmopressinAcetate)

NP

desmopressin acetaterefrigerated soln F

desmopressin acetatespray refrigerated soln F PA

desmopressin acetatespray soln F PA

desmopressin acetate tabsor 0.1 mg, 0.2 mg F

Somatostatic Agents SIGNIFOR LAR SRER F PA

ESTROGENS - Hormone Replacement/ModifyingDrugs Estrogen Combinations ACTIVELLA TABS (Estradiol & Norethindrone Acetate)

NP

COMBIPATCH PTTW F

estradiol & norethindrone acetate tabs F

PREMPRO TABS F

Estrogens ALORA PTTW F

CLIMARA PTWK (Estradiol) NP

ESTRACE TABS OR 2 MG, 1 MG, 0.5 MG (Estradiol)

NP


92

Drug Name DrugTier

Requirements/Limits

estradiol pttw td 0.025mg/24hr, 0.1 mg/24hr,0.0375 mg/24hr, 0.075mg/24hr, 0.05 mg/24hr

F

estradiol ptwk td 0.1mg/24hr, 0.05 mg/24hr,0.06 mg/24hr, 0.025mg/24hr, 37.5 mcg/24hr,0.075 mg/24hr

F

estradiol tabs or 0.5 mg, 2mg, 1 mg F

ESTROPIPATE TABS F

MINIVELLE PTTW F

PREMARIN TABS OR 0.45 MG, 1.25 MG, 0.3 MG, 0.625 MG, 0.9 MG

F

VIVELLE-DOT PTTW (Estradiol) NP

FLUOROQUINOLONES - Drugs to Treat BacterialInfections Fluoroquinolones AVELOX ABC PACK TABS (Moxifloxacin HCl) NP

AVELOX TABS OR 400 MG (Moxifloxacin HCl) NP

CIPRO SUSR (Ciprofloxacin) NP

CIPRO TABS (Ciprofloxacin HCl) NP

CIPRO XR TB24 (Ciprofloxacin-CiprofloxacinHCl)

NP

CIPROFLOXACIN HCL TABS 100 MG F

ciprofloxacin hcl tabs 750mg, 500 mg, 250 mg F

ciprofloxacin susr or 500mg/5ml, 250 mg/5ml NP

ciprofloxacin-ciprofloxacinhcl tb24 NP

LEVAQUIN TABS (Levofloxacin) NP

LEVOFLOXACIN SOLN OR 25 MG/ML NP

Drug Name DrugTier

Requirements/Limits

levofloxacin soln or 25 mg/ml NP

levofloxacin tabs or 500 mg, 750 mg, 250 mg F

moxifloxacin hcl tabs or 400 mg NP

OFLOXACIN TABS 300 MG NP

ofloxacin tabs 400 mg NP

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal Drugs Antiflatulents GAS-X CHEW (Simethicone) NP

GAS-X EXTRA STRENGTH CHEW 125 MG (Simethicone)

NP

MYLICON INFANTS GAS RELIEF SUSP (Simethicone)

NP

MYLICON SUSP (Simethicone) NP

PHAZYME CAPS (Simethicone) NP

PHAZYME ULTRA STRENGTH CAPS (Simethicone)

NP

simethicone caps 180 mg,125 mg, 125mg F

simethicone chew 125 mg,80 mg F

simethicone susp 20mg/0.3ml, 40 mg/0.6ml F

Bile Acid Synthesis Disorder Agents CHOLBAM CAPS NP

Farnesoid X Receptor (FXR) Agonists OCALIVA TABS NP QL(1 ea daily)

Gallstone Solubilizing Agents ACTIGALL CAPS (Ursodiol) NP

CHENODAL TABS NP


93

Drug Name DrugTier

Requirements/Limits

URSO 250 TABS (Ursodiol) NP

URSO FORTE TABS (Ursodiol) NP

ursodiol caps 300 mg NP

ursodiol tabs 500 mg, 250 mg F

Gastrointestinal Chloride Channel Activators

AMITIZA CAPS F QL(2 ea daily);AL; At least 18 yrs old

Gastrointestinal Stimulants metoclopramide hcl soln or10 mg/10ml, 5 mg/5ml F

metoclopramide hcl tabs or5 mg, 10 mg F

METOCLOPRAMIDE ODT TBDP NP

METOZOLV ODT TBDP (Metoclopramide HCl) NP

REGLAN TABS (Metoclopramide HCl) NP

Inflammatory Bowel Agents APRISO CP24 F

ASACOL HD TBEC NP

AZULFIDINE EN-TABS TBEC (Sulfasalazine) NP

AZULFIDINE TABS (Sulfasalazine) NP

balsalazide disodium caps F

CANASA SUPP F

CIMZIA KIT NP QL(1 ea per fillretail)

CIMZIA STARTER KIT KIT NP QL(3 ea per fillretail) COLAZAL CAPS (Balsalazide Disodium) NP

DELZICOL CPDR NP

DIPENTUM CAPS NP

Drug Name DrugTier

Requirements/Limits

GIAZO TABS NP

LIALDA TBEC (Mesalamine) NP

MESALAMINE DR TBEC NP

mesalamine enem NP

mesalamine tbec NP

mesalamine w/ cleanser kit NP

PENTASA CPCR F PA

ROWASA KIT (Mesalamine w/ Cleanser) NP

SFROWASA ENEM NP

sulfasalazine tabs F

sulfasalazine tbec F

Intestinal Acidifiers lactulose (encephalopathy)soln F

Irritable Bowel Syndrome (IBS) Agents alosetron hcl tabs NP

LINZESS CAPS F QL(1 ea daily);AL; At least 18 yrs old

LOTRONEX TABS (Alosetron HCl) NP

VIBERZI TABS NP QL(2 ea daily);AL; At least 18 yrs old

Peripheral Opioid Receptor Antagonists MOVANTIK TABS NP QL(1 ea daily)

RELISTOR TABS OR 150 MG NP


SYMPROIC TABS NP QL(2 ea daily);AL; At least 18 yrs old

Phosphate Binder Agents


94

Drug Name DrugTier

Requirements/Limits

AURYXIA TABS NP

calcium acetate (phosphatebinder) caps F

calcium acetate (phosphatebinder) tabs F RX/OTC

ELIPHOS TABS (Calcium Acetate (PhosphateBinder))

NP RX/OTC

FOSRENOL CHEW 1000 MG, 750 MG, 500 MG (Lanthanum Carbonate)

NP

FOSRENOL PACK 1000 MG, 750 MG NP

lanthanum carbonate chew NP

PHOSLYRA SOLN F

RENAGEL TABS F

RENVELA PACK (Sevelamer Carbonate) NP

RENVELA TABS (Sevelamer Carbonate) NP

sevelamer carbonate pack NP

sevelamer carbonate tabs NP

VELPHORO CHEW NP

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System Alkalinizers potassium citrate(alkalinizer) tbcr 1080 mg,540 mg

F

SHOHLS SOLUTION MODIFIED SOLN (Sodium Citrate & Citric Acid)

NP RX/OTC

sodium citrate & citric acid soln F RX/OTC

UROCIT-K 10 TBCR (Potassium Citrate (Alkalinizer))

NP

Drug Name DrugTier

Requirements/Limits

UROCIT-K 5 TBCR (Potassium Citrate (Alkalinizer))

NP

Genitourinary Irrigants neomycin/polymyxin b gusoln F

NEOSPORIN GU IRRIGANT SOLN (Neomycin/Polymyxin BGU)

NP

sodium chloride (guirrigant) soln F

Interstitial Cystitis Agents ELMIRON CAPS F

Prostatic Hypertrophy Agents alfuzosin hcl tb24 F

AVODART CAPS (Dutasteride) NP

CARDURA XL TB24 NP

dutasteride caps F

dutasteride-tamsulosin hcl caps NP

finasteride tabs F AL; At least 13 yrs old

FLOMAX CAPS (Tamsulosin HCl) NP

JALYN CAPS (Dutasteride-Tamsulosin HCl) NP

PROSCAR TABS (Finasteride) NP AL; At least 13 yrs old

RAPAFLO CAPS NP

tamsulosin hcl caps F

UROXATRAL TB24 (Alfuzosin HCl) NP

Urinary Analgesics phenazopyridine hcl tabs200 mg, 95 mg, 100 mg F

PYRIDIUM TABS (Phenazopyridine HCl) NP


95

Drug Name DrugTier

Requirements/Limits

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations colchicine w/ probenecidtabs F

Gout Agents allopurinol tabs F

COLCHICINE CAPS NP

COLCHICINE TABS NP

COLCRYS TABS NP

MITIGARE CAPS NP

ULORIC TABS NP

ZURAMPIC TABS NP QL(1 ea daily);AL; At least 18 yrs old

ZYLOPRIM TABS (Allopurinol) NP

Uricosurics probenecid tabs F

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood Disorders Hematorheologic Agents pentoxifylline tbcr F

Plasma Kallikrein Inhibitors KALBITOR SOLN F PA

Platelet Aggregation Inhibitors AGGRENOX CP12 (Aspirin-Dipyridamole) F

aspirin-dipyridamole cp12 NP

BRILINTA TABS F

cilostazol tabs F

clopidogrel bisulfate tabs F

Drug Name DrugTier

Requirements/Limits

dipyridamole tabs or 25mg, 50 mg, 75 mg F

DURLAZA CP24 NP QL(1 ea daily)

EFFIENT TABS (PrasugrelHCl) NP

PERSANTINE TABS (Dipyridamole) NP

PLAVIX TABS (ClopidogrelBisulfate) NP

PLETAL TABS (Cilostazol) NP

prasugrel hcl tabs NP

YOSPRALA TBEC NP QL(1 ea daily)

ZONTIVITY TABS NP

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders Cobalamins B-12 DOTS TBDP F

cyanocobalamin soln ij1000 mcg/ml F QL(1 ml per fill

retail) cyanocobalamin tabs or500 mcg, 100 mcg, 250mcg, 1000 mcg

F

cyanocobalamin tbcr or1000 mcg F

Folic Acid/Folates FOLIC ACID SOLN IJ 5 MG/ML F PA

folic acid tabs or 1 mg F RX/OTC

folic acid tabs or 400 mcg,800 mcg F

Hematopoietic Growth Factors EPOGEN SOLN F

GRANIX SOSY NP


96

Drug Name DrugTier

Requirements/Limits

MIRCERA SOSY 50 MCG/0.3ML, 200MCG/0.3ML, 100MCG/0.3ML, 75MCG/0.3ML

NP

NEUPOGEN SOLN 300 MCG/ML, 480 MCG/1.6ML F

NEUPOGEN SOSY 300 MCG/0.5ML, 480MCG/0.8ML

NP

PROCRIT SOLN 10000 UNIT/ML, 40000 UNIT/ML,4000 UNIT/ML, 3000UNIT/ML, 2000 UNIT/ML,20000 UNIT/ML

F

ZARXIO SOSY NP

Hematopoietic Mixtures CENTRATEX CAPS NP

ferrous fumarate-fa-b complex-c-zn-mg-mn-cutabs

F

folic acid-vitamin b6-vitamin b12 tabs 115mcg-800mcg-10mg

F

HEMOCYTE PLUS CAPS NP

ICAR-C PLUS TABS (Iron-Vitamin C-Vitamin B12-Folic Acid)

NP RX/OTC

INTEGRA CAPS F

iron polysaccharidecomplex-vit b12-folic acid caps

F

iron-vitamin c-vitamin b12-folic acid tabs NP RX/OTC

PUREFE PLUS CAPS NP

Iron FEOSOL TABS 200 MG (Ferrous Sulfate Dried) NP

FER-IN-SOL SOLN (Ferrous Sulfate) NP

FERGON TABS (Ferrous Gluconate) NP

Drug Name DrugTier

Requirements/Limits

ferrous fumarate tabs 324 mg F

FERROUS GLUCONATE TABS 225 MG F

ferrous gluconate tabs 240mg, 27 mg, 324 mg F

ferrous sulfate dried tabs 65 mg, 200 mg F

ferrous sulfate elix 220 mg/5ml F

FERROUS SULFATE LIQD 220 MG/5ML F

ferrous sulfate soln 15 mg/ml F

FERROUS SULFATE SYRP 300 MG/5ML F

ferrous sulfate tabs 325 mg, 65 mg F

FERROUS SULFATE TBCR 140 MG F

ferrous sulfate tbcr 142 mg,45 mg F

FERROUS SULFATE TBEC 324 MG F

HEMOCYTE TABS (Ferrous Fumarate) NP

polysaccharide ironcomplex caps 150 mg F

SLOW FE TBCR (Ferrous Sulfate) NP

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood Disorders Hemostatics - Systemic AMICAR TABS 500 MG F PA

LYSTEDA TABS (Tranexamic Acid) NP Limit 1ea permonth tranexamic acid tabs or 650 mg F Limit 1ea per

month HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS Antihistamine Hypnotics diphenhydramine hcl(sleep) caps 50 mg F


97

Drug Name DrugTier

Requirements/Limits

diphenhydramine hcl(sleep) tabs 25 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) tabs 50 mg F

diphenhydramine-acetaminophen (sleep)tabs 25mg-500mg, 30unit-50mg-15mg-1.5mg-25mg-18mg-2500unit-500mg-10mg-1.7mg-6mcg-400mcg-2mg, 25mg-25mg-500mg-500mg

F

doxylamine succinate(sleep) tabs F

NYTOL MAXIMUM STRENGTH TABS (Diphenhydramine HCl(Sleep))

NP

TYLENOL PM EXTRA STRENGTH TABS (Diphenhydramine-Acetaminophen (sleep))

NP

UNISOM SLEEPGELS CAPS (DiphenhydramineHCl (Sleep))

NP

UNISOM TABS (Doxylamine Succinate(Sleep))

NP

Barbiturate Hypnotics phenobarbital elix 20mg/5ml F

phenobarbital soln 20mg/5ml F

PHENOBARBITAL TABS 100 MG, 60 MG, 15 MG, 30 MG

F

phenobarbital tabs 64.8mg, 97.2 mg, 16.2 mg, 32.4 mg

F

Hypnotics - Tricyclic Agents SILENOR TABS NP

Non-Barbiturate Hypnotics AMBIEN CR TBCR (Zolpidem Tartrate) NP ST; QL(1 eadaily) AMBIEN TABS (ZolpidemTartrate) NP QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

EDLUAR SUBL F ST; QL(1 eadaily)

estazolam tabs NP

eszopiclone tabs F PA; QL(1 eadaily); AL; Atleast 18 yrs old

FLURAZEPAM HCL CAPS F ST

HALCION TABS (Triazolam) NP ST

INTERMEZZO SUBL (Zolpidem Tartrate) NP QL(1 ea daily)

LUNESTA TABS (Eszopiclone) NP


RESTORIL CAPS (Temazepam) NP

SONATA CAPS (Zaleplon) NP

temazepam caps 22.5 mg,7.5 mg NP

temazepam caps 30 mg,15 mg F

TRIAZOLAM TABS 0.125 MG F ST

triazolam tabs 0.25 mg F ST

zaleplon caps F

zolpidem tartrate subl sl1.75 mg, 3.5 mg NP QL(1 ea daily)

zolpidem tartrate tabs or 5mg, 10 mg F QL(1 ea daily)

zolpidem tartrate tbcr or12.5 mg, 6.25 mg F ST; QL(1 ea

daily)

ZOLPIMIST SOLN NP

Orexin Receptor Antagonists

BELSOMRA TABS NP QL(1 ea daily);AL; At least 19 yrs old

Selective Melatonin Receptor Agonists HETLIOZ CAPS NP QL(1 ea daily)


98

Drug Name DrugTier

Requirements/Limits

ROZEREM TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives calcium polycarbophil tabs F

CITRUCEL FIBER LAXATIVE POWD (Methylcellulose (Laxative))

NP

EVAC POWD (Psyllium) NP

FIBERCON TABS (Calcium Polycarbophil) NP

HYDROCIL INSTANT POWD (Psyllium) NP

KONSYL POWD 100 % (Psyllium) NP

METAMUCIL CAPS 0.52 GM (Psyllium) NP

methylcellulose (laxative)powd 2 gm/10.2gm, 2gm/19gm,

F

psyllium caps 0.52 gm, 520 mg F

psyllium powd 95 %, 58.6%, 28.3 %, 100 % F

Laxative Combinations COLYTE-FLAVOR PACKS SOLR (PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

NP

GOLYTELY SOLR 236GM-22.74GM-5.86GM-2.97GM-6.74GM (PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

NP

NULYTELY/FLAVORPACKS SOLR (PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride)

NP

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr

F

Drug Name DrugTier

Requirements/Limits

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

F

sennosides-docusate sodium tabs F QL(4 ea daily)

SENOKOT S TABS (Sennosides-Docusate Sodium)

NP QL(4 ea daily)

Laxatives - Miscellaneous glycerin (laxative) supp 1gm, 80.7 %, 2 gm, 1.2 gm F

GLYCERIN ADULT SUPP (Glycerin (Laxative)) NP

lactulose soln F

MIRALAX POWD (Polyethylene Glycol 3350) NP QL(34 gmdaily); RX/OTC PEDIA-LAX SUPP RE 1 GM (Glycerin (Laxative)) NP

polyethylene glycol 3350powd or F QL(34 gm

daily); RX/OTC Saline Laxatives FLEET ENEMA ENEM (Sodium Phosphates) NP

FLEET ENEMA SIX PACK ENEM (Sodium Phosphates)

NP

FLEET PEDIATRIC ENEM (Sodium Phosphates) NP

magnesium citrate soln1.745gm/30ml, , 1.745gm/30ml

F

magnesium hydroxide susp400 mg/5ml, 1200mg/15ml, , 7.75 %

F QL(32 ml daily)

sodium phosphates enemre 9.5gm/59ml-3.5gm/59ml,19gm/118ml-7gm/118ml,16gm/133ml-6gm/133ml,19gm/118ml-19gm/118ml-7gm/118ml-7gm/118ml

F

Stimulant Laxatives bisacodyl supp F

bisacodyl tbec F


99

Drug Name DrugTier

Requirements/Limits

DULCOLAX SUPP (Bisacodyl) NP

DULCOLAX TBEC (Bisacodyl) NP

EX-LAX MAXIMUM STRENGTH TABS (Sennosides)

NP

sennosides liqd 8.8 mg/5ml F

sennosides syrp 8.8mg/5ml F

sennosides tabs 8.6 mg, 25 mg F

SENOKOT TABS (Sennosides) NP

Surfactant Laxatives COLACE CAPS (Docusate Sodium) NP QL(3 ea daily)

docusate calcium caps F

docusate sodium caps 100 mg F QL(3 ea daily)

docusate sodium liqd 150mg/15ml, 50 mg/5ml F

docusate sodium syrp 60mg/15ml F

MACROLIDES - Drugs to Treat BacterialInfections Azithromycin AZITHROMYCIN PACK OR 1 GM F

azithromycin susr or 100mg/5ml, 200 mg/5ml F

azithromycin tabs or 600mg, 500 mg, 250 mg F

ZITHROMAX PACK OR 1 GM 4

ZITHROMAX SUSR OR 200 MG/5ML, 100 MG/5ML(Azithromycin)

NP

ZITHROMAX TABS OR 600 MG, 250 MG, 500 MG (Azithromycin)

NP

ZITHROMAX TRI-PAK TABS (Azithromycin) NP

Drug Name DrugTier

Requirements/Limits

ZITHROMAX Z-PAK TABS (Azithromycin) NP

ZMAX SUSR NP QL(1 ea per fillretail) Clarithromycin BIAXIN SUSR (Clarithromycin) NP

BIAXIN TABS (Clarithromycin) NP

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

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

clarithromycin tabs 500 mg,250 mg F

clarithromycin tb24 500 mg NP

Erythromycins E.E.S. 400 TABS NP

E.E.S. GRANULES SUSR (ErythromycinEthylsuccinate)

NP

ERY-TAB TBEC NP

ERYPED 200 SUSR (ErythromycinEthylsuccinate)

NP

ERYPED 400 SUSR NP

ERYTHROCIN STEARATE TABS NP

erythromycin base cpep250 mg NP

ERYTHROMYCIN BASE TABS 250 MG, 500 MG NP

erythromycinethylsuccinate susr 200mg/5ml

NP

ERYTHROMYCIN ETHYLSUCCINATE TABS 400 MG

NP

PCE TBEC NP

Fidaxomicin


100

Drug Name DrugTier

Requirements/Limits

DIFICID TABS NP

MEDICAL DEVICES AND SUPPLIES

Contraceptives AIMSCO LUBRICATED MISC F

ATLAS COLORED LUBRICATEDCONDOM DEVI

F

ATLAS LUBRICATED CONDOM DEVI F

ATLAS LUBRICATED CONDOM/SPERMICIDEDEVI

F

CLASS ACT LUBRICATED MISC F

DUREX EXTRA SENSITIVE DEVI F

ELEXA NATURAL FEEL MISC F

ELEXA STIMULATING MISC F

ELEXA ULTRA SENSITIVE MISC F

EXTRA SENSITIVE SPERMICIDAL DEVI F

FANTASY LUBRICATED MISC F

FANTASY LUBRICATED/SPERMICIDE MISC

F

HIGH SENSATION SPERMICIDAL DEVI F

INTENSE SENSATION DEVI F

KAMELEON LUBRICATED MISC F

KIMONO COLORS DEVI F

KIMONO LUBRICATED MISC F

KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED MISC

F

Drug Name DrugTier

Requirements/Limits

KIMONO PLUS SPERMICIDE LUBRICATED MISC

F

KIMONO PLUS SPERMICIDE/LUBRICATED MISC

F

KIMONO PS LUBRICATED MISC F

KIMONO PS PLUS SPERMICIDE/LUBRICATED MISC

F

KIMONO SENSATION LUBRICATED MISC F

KIMONO SENSATION PLUS SPERMICIDE LUBRICATED MISC

F

KIMONO SPECIAL DEVI F

MAXX LUBRICATED MISC F

MAXX PLUS SPERMICIDE LUBRICATED MISC F

PREMIUM CONDOMS LUBRICATED MISC F

REALITY LATEX CONDOMS/LUBRICATEDMISC

F

REALITY LATEX/ULTRATEXTURED DEVI F

REALITY LATEX/ULTRATHIN DEVI F

TROJAN EXTENDED PLEASURE/LUBRICATEDDEVI

F

TROJAN MAGNUM MISC F

TROJAN MAGNUM WARM SENSATIONS DEVI F

TROJAN MAGNUM XL LUBRICATED DEVI F

TROJAN PLEASURE MESH/SPERMICIDALDEVI

F

TROJAN RIBBED W/SPERMICIDAL MISC F


101

Drug Name DrugTier

Requirements/Limits

TROJAN SHARED SENSATION/LUBRICATED DEVI

F

TROJAN SUPRAS SPERMICIDAL DEVI F

TROJAN TWISTED PLEASURE DEVI F

TROJAN ULTRA PLEASURE/LUBRICATEDDEVI

F

TROJAN VERY SENSITIVE LUBRICATED MISC

F

TROJAN VERY SENSITIVE SPERMICIDAL LUBRICANT MISC

F

TROJAN VERY THIN LUBRICATED MISC F

TROJAN VERY THIN SPERMICIDAL LUBRICANT MISC

F

TROJAN-ENZ LUBRICANT MISC F

TROJAN-ENZ LUBRICATED MISC F

TROJAN-ENZ W/SPERMICIDAL MISC F

TRUSTEX COLOR CONDOMS + LUBE MISC F

TRUSTEX LUBRICATED EXTRALARGE MISC F

TRUSTEX LUBRICATED EXTRASTRENGTH MISC F

TRUSTEX LUBRICATED MISC F

TRUSTEX LUBRICATED/RIBBED/STUDDED MISC

F

TRUSTEX LUBRICATED/SPERMICIDE EXTRA LARGE MISC

F

TRUSTEX LUBRICATED/SPERMICIDE EXTRA STRENGTH MISC

F

Drug Name DrugTier

Requirements/Limits

TRUSTEX LUBRICATED/SPERMICIDE MISC

F

TRUSTEX NATURAL CONDOMS +LUBE/LUBRICATEDMISC

F

TRUSTEX WITH NONOXYNOL-9/RIBBED/STUDDEDMISC

F

TRUSTEX/RIALUBRICATED MISC F

TRUSTEX/RIALUBRICATED SPERMICIDE MISC

F

TRUSTEX/RIALUBRICATED/SPERMICIDE MISC

F

ULTIMATE FEELING DEVI F

Diabetic Supplies 1ST CHOICE LANCETS SUPERTHIN MISC F QL(6.67 ea

daily) 1ST CHOICE LANCETS THIN MISC F QL(6.67 ea

daily) 1ST CHOICE LANCETS ULTRATHIN MISC F QL(6.67 ea

daily) 1ST TIER UNILET COMFORTOUCH LANCETS 28G MISC

F QL(6.67 eadaily)

1ST TIER UNILET COMFORTOUCH LANCETS 30G MISC

F QL(6.67 eadaily)

ACCU-CHEK ACTIVE GLUCOSECONTROL SOLUTION LIQD

NP

ACCU-CHEK AVIVA SOLN VI NP

ACCU-CHEK COMPACT PLUS CLEAR CONTROL SOLUTION (2 LEVELS) SOLN

NP

ACCU-CHEK FASTCLIX LANCETS MISC NP

ACCU-CHEK MULTICLIX LANCETS MISC NP


102

Drug Name DrugTier

Requirements/Limits

ACCU-CHEK SAFE-T-PRO LANCETS MISC NP

ACCU-CHEK SAFE-T-PRO PLUSLANCETS MISC NP

ACCU-CHEK SMARTVIEW CONTROL LIQD NP

ACCU-CHEK SOFT TOUCH LANCETS MISC NP

ACCU-CHEK SOFTCLIX LANCETS MISC NP

ACCUTREND GLUCOSE CONTROL SOLN NP

ACTI-LANCE LANCETS 28G MISC NP

ACTI-LANCE LITE SAFETY LANCETS 28G MISC

NP

ACTI-LANCE SPECIAL SAFETY LANCETS 17G MISC

NP

ACTI-LANCE SPECIAL SAFETYLANCETS 17G MISC

NP

ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G MISC

NP

ACTIVE 1ST BLOOD LANCETS30G/EASYTWIST CAP MISC

NP

ACURA CONTROL SOLUTION HIGH SOLN NP

ACURA CONTROL SOLUTION LOW SOLN NP

ACURA CONTROL SOLUTION NORMAL SOLN

NP

ADJUSTABLE LANCING DEVICE MISC F QL(1 ea per

160 days retail) ADVANCE INTUITION CONTROL SOLUTION LIQD

NP

ADVANCE MICRO-DRAW CONTROL LEVEL 1-2 LIQD

NP

ADVANCE MICRO-DRAW NORMAL CONTROL LIQD NP

Drug Name DrugTier

Requirements/Limits

ADVOCATE CONTROL SOLUTIONHIGH LIQD NP

ADVOCATE CONTROL SOLUTIONLOW LIQD NP

ADVOCATE LANCETS 30G MISC NP

ADVOCATE LANCETS MISC NP

ADVOCATE LANCING DEVICE MISC F QL(1 ea per

160 days retail) ADVOCATE RAPID-SAFE LANCING DEVICE MISC F QL(1 ea per

160 days retail) ADVOCATE REDI-CODE+ CONTROL SOLUTION HIGH SOLN

NP

ADVOCATE REDI-CODE+ CONTROL SOLUTION LOW SOLN

NP

ADVOCATE SAFETY LANCETS 26G MISC NP

ADVOCATE SAFETY LANCETS MISC NP

AGAMATRIX CONTROL HIGH SOLN NP

AGAMATRIX CONTROL NORMAL SOLN NP

AGAMATRIX CONTROL NORMAL& HIGH SOLN NP

AGAMATRIX ULTRA-THIN LANCETS 33G MISC F QL(6.67 ea

daily) ALTERNATE SITE LANCING DEVICE MISC F QL(1 ea per

160 days retail) AQUA LANCE ADJUSTABLE LANCING DEVICE DEVI


ASSURE 3 CONTROL LEVEL 1/2 LIQD NP

ASSURE 4 CONTROL LEVEL 1/2 LIQD NP

ASSURE COMFORT LANCETS ULTRA THIN 28G MISC

NP

ASSURE COMFORT LANCETS ULTRA THIN 30G MISC

NP


103

Drug Name DrugTier

Requirements/Limits

ASSURE DOSE NORMAL CONTROL SOLN NP

ASSURE DOSE NORMAL/HIGH CONTROLSOLN

NP

ASSURE HAEMOLANCE PLUS HIGH FLOW 18G MISC

NP

ASSURE HAEMOLANCE PLUS LOW FLOW 25G MISC

NP

ASSURE HAEMOLANCE PLUS MICRO FLOW 28G MISC

NP

ASSURE HAEMOLANCE PLUS NORMAL FLOW 21G MISC

NP

ASSURE HAEMOLANCE PLUS PEDIATRIC BLADE MISC

NP

ASSURE II CONTROL LEVEL 1 LIQD NP

ASSURE II CONTROL LEVEL 1/2 LIQD NP

ASSURE LANCE LANCETS 21G MISC NP

ASSURE LANCE LANCETS MISC NP

ASSURE LANCE PLUS SAFETYLANCETS 25G MISC

NP

ASSURE LANCE PLUS SAFETYLANCETS 30G MISC

NP

ASSURE LANCETS MISC NP

ASSURE PRISM CONTROL LEVEL 1/2SOLN

NP

ASSURE PRO CONTROL LEVEL1/2 LIQD NP

AT LAST CONTROL SOLUTION SOLN NP

AT LAST LANCETS MISC NP

AURORA LANCET SUPER THIN30G MISC F QL(6.67 ea

daily)

Drug Name DrugTier

Requirements/Limits

AURORA LANCET THIN 23G MISC F QL(6.67 ea

daily)

AUTO-LANCET MINI MISC F QL(1 ea per160 days retail)

AUTO-LANCET MISC F QL(1 ea per160 days retail)

AUTOLET IMPRESSION LANCING DEVICE MISC F QL(1 ea per

160 days retail) AUTOLET LANCING DEVICE MISC F QL(1 ea per

160 days retail)

AUTOLET MINI MISC F QL(1 ea per160 days retail)

AUTOLET PLUS MISC F QL(1 ea per160 days retail)

BAYER BREEZE 2 HIGH CONTROL LIQD NP

BAYER BREEZE 2 LOW CONTROL LIQD NP

BAYER BREEZE 2 NORMAL CONTROL LIQD NP

BAYER CONTOUR HIGH CONTROL LIQD NP

BAYER CONTOUR LOW CONTROL LIQD NP

BAYER CONTOUR NEXT CONTROL LEVEL 1 SOLN NP

BAYER CONTOUR NEXT CONTROL LEVEL 2 SOLN NP

BAYER CONTOUR NORMAL CONTROL LIQD NP

BAYER MICROLET 2 LANCING DEVICE MISC F QL(1 ea per

160 days retail) BAYER MICROLET LANCETS MISC NP

BD LANCET DEVICE MISC F QL(1 ea per

160 days retail) BD LANCET ULTRAFINE 30G MISC NP

BD LANCET ULTRAFINE 30G MISC F QL(6.67 ea

daily) BD LANCET ULTRAFINE 33G MISC NP

BD MICROTAINER LANCETS MISC NP

BULLSEYE MINI SAFETY LANCETS MISC NP


104

Drug Name DrugTier

Requirements/Limits

BULLSEYE SAFETY LANCETS MISC NP

CARDIOCOM LANCING DEVICE MISC F QL(1 ea per

160 days retail) CAREONE ADVANCED LANCINGDEVICE MISC F QL(1 ea per

160 days retail) CAREONE LANCET THIN MISC F QL(6.67 ea

daily) CAREONE LANCET ULTRA THIN MISC F QL(6.67 ea

daily) CARESENS CONTROL A SOLUTION SOLN NP

CARETOUCH LANCING DEVICEWITH EJECTOR MISC


CARETOUCH TWIST LANCETS 28G MISC NP



CLEANLET LANCETS 28G MISC F QL(6.67 ea

daily) CLEVER CHEK LANCETS ULTRATHIN 30G MISC NP

CLEVER CHEK LANCETS ULTRATHIN MISC NP

CLEVER CHOICE GLUCOSE CONTROL HIGH LIQD

NP

CLEVER CHOICE GLUCOSE CONTROL LOW LIQD

NP

CLOSERCARE MISC F QL(1 ea per160 days retail)

COAGUCHEK LANCETS MISC NP

COMFORT ASSURED LANCETS MICRO THIN 33G MISC

NP

COMFORT ASSURED LANCETS SUPER THIN 28G MISC

F QL(6.67 eadaily)

COMFORT ASSURED LANCETS SUPER THIN 28G MISC

NP

Drug Name DrugTier

Requirements/Limits

COMFORT LANCETS MISC F QL(6.67 ea

daily) CONTROL SOLUTION NORMAL SOLN NP

COOL CONTROL SOLUTION A SOLN NP

COOL CONTROL SOLUTION B SOLN NP

CVS LANCETS 21G MISC F QL(6.67 eadaily)

CVS LANCETS MICRO THIN 33G MISC F QL(6.67 ea

daily) CVS LANCETS MICRO-THIN 33G MISC F QL(6.67 ea

daily) CVS LANCETS ORIGINAL MISC F QL(6.67 ea

daily) CVS LANCETS THIN 26G MISC F QL(6.67 ea

daily) CVS LANCETS ULTRA THIN 30G MISC F QL(6.67 ea

daily) CVS LANCETS ULTRA-THIN 30G MISC F QL(6.67 ea

daily) CVS LANCING DEVICE MISC F QL(1 ea per

160 days retail) CVS ULTRA THIN LANCETS MISC F QL(6.67 ea

daily) DIASTAR EASY TEST II LANCETS 30G MISC NP

DIASTAR EASY TEST LANCETS30G MISC NP

DIATRUE GLUCOSE CONTROL SOLUTION LEVEL 1 SOLN

NP


NP


NP

DROPLET LANCETS ULTRA THIN 30G MISC F QL(6.67 ea

daily) DROPLET LANCING DEVICE MISC F QL(1 ea per

160 days retail) DRUG MART ADJUSTABLE LANCING DEVICE MISC



105

Drug Name DrugTier

Requirements/Limits

DRUG MART LANCETS THIN MISC F QL(6.67 ea

daily) DRUG MART ON-THE-GO LANCETS GENTLE 30G MISC

NP

DRUG MART UNILET LANCETSSUPER THIN 30G MISC

F QL(6.67 eadaily)

DRUG MART UNILET LANCETSULTRA THIN 28G MISC

F QL(6.67 eadaily)

DUANE READE LANCET ALTERNATE SITE 26G MISC

F QL(6.67 eadaily)

DUANE READE LANCET SUPERTHIN 30G MISC F QL(6.67 ea

daily) DUANE READE LANCET ULTRATHIN 28G MISC F QL(6.67 ea

daily) DUO-CARE CONTROL SOLUTION LIQD NP

E-Z JECT LANCETS 21G MISC F QL(6.67 ea

daily) E-Z JECT LANCETS COLOR MISC F QL(6.67 ea

daily)

E-Z JECT LANCETS MISC F QL(6.67 eadaily)

E-Z JECT LANCETS SUPER THIN 30G MISC F QL(6.67 ea

daily) E-Z JECT LANCETS THIN 26G MISC F QL(6.67 ea

daily) E-ZJECT LANCETS MICRO-THIN 33G MISC F QL(6.67 ea

daily) EASY COMFORT LANCETS 30G/PULL TOPMISC

NP

EASY COMFORT LANCETS 30G/THIN TOPMISC

NP

EASY COMFORT LANCETS MISC NP

EASY MINI EJECT LANCING DEVICE MISC F QL(1 ea per

160 days retail) EASY MINI LANCING DEVICE MISC F QL(1 ea per

160 days retail) EASY PLUS II CONTROL SOLUTION HIGH SOLN NP

Drug Name DrugTier

Requirements/Limits

EASY PLUS II CONTROL SOLUTION LOW SOLN NP

EASY STEP CONTROL SOLUTION HIGH SOLN NP

EASY STEP CONTROL SOLUTION LOW SOLN NP

EASY STEP CONTROL SOLUTION NORMAL SOLN

NP

EASY TALK CONTROL SOLUTION HIGH SOLN NP

EASY TALK CONTROL SOLUTION LOW SOLN NP

EASY TALK CONTROL SOLUTION NORMAL SOLN

NP

EASY TOUCH CONTROL SOLUTION/HIGH & LOWSOLN

NP

EASY TOUCH HEALTHPRO CONTROL SOLUTION/HIGH & LOWSOLN

NP

EASY TOUCH LANCETS 21G/PRESSUREACTIVATED MISC

NP


NP


NP

EASY TOUCH LANCETS 26G/PULL-TOP MISC F QL(6.67 ea

daily) EASY TOUCH LANCETS 26G/TWIST MISC F QL(6.67 ea

daily) EASY TOUCH LANCETS 28G/PRESSUREACTIVATED MISC

NP



daily) EASY TOUCH LANCETS 30G/BUTTON-ACTIVATEDMISC

NP


106

Drug Name DrugTier

Requirements/Limits


NP



daily) EASY TOUCH LANCETS 32G/PRESSUREACTIVATED MISC

NP




daily) EASY TOUCH LANCING DEVICE/EJECTOR MISC F QL(1 ea per

160 days retail) EASY TOUCH SAFETY LANCETS21G/PRESSUREACTIVATED MISC

NP

EASY TOUCH SAFETY LANCETS23G/PRESSUREACTIVATED MISC

NP

EASY TOUCH SAFETY LANCETS26G/BUTTONACTIVATED MISC

NP


NP

EASY TOUCH SAFETY LANCETS28G/BUTTONACTIVATED MISC

NP


NP

EASY TRAK GLUCOSE CONTROLSOLUTION HIGH SOLN

NP

EASY TRAK GLUCOSE CONTROLSOLUTION LOW SOLN

NP

EASY TRAK GLUCOSE CONTROLSOLUTION NORMAL SOLN

NP

EASY TWIST & CAP LANCETS MISC NP

Drug Name DrugTier

Requirements/Limits

EASYGLUCO CONTROL SOLUTION HIGH SOLN NP

EASYGLUCO CONTROL SOLUTION LOW SOLN NP

EASYGLUCO CONTROL SOLUTION NORMAL SOLN

NP

EASYGLUCO PLUS CONTROL SOLUTION LEVEL 1 SOLN

NP

EASYMAX 15 LEVEL 1 GLUCOSE CONTROL SOLUTION SOLN

NP

EASYMAX 15 LEVEL 2 GLUCOSE CONTROL SOLUTION SOLN

NP

EASYMAX CONTROL SOLUTIONHIGH SOLN NP

EASYMAX CONTROL SOLUTIONLOW SOLN NP

EASYMAX CONTROL SOLUTIONNORMAL SOLN

NP

EASYTEST II LANCETS MISC F QL(6.67 ea

daily) EASYTEST LANCETS MISC F QL(6.67 ea

daily) ELEMENT COMPACT CONTROL SOLUTION LEVEL 2 SOLN

NP

ELEMENT COMPACT CONTROL SOLUTION LEVEL 3 SOLN

NP

ELEMENT HIGH CONTROL LIQD NP

ELEMENT LOW CONTROL LIQD NP

ELEMENT NORMAL CONTROL LIQD NP

EMBRACE CONTROL SOLUTIONLOW SOLN NP

EMBRACE EVO GLUCOSE CONTROL SOLUTION LEVEL 1 LIQD

NP

EMBRACE EVO GLUCOSE CONTROL SOLUTION LEVEL 2 LIQD

NP


107

Drug Name DrugTier

Requirements/Limits

EMBRACE GLUCOSE CONTROL SOLUTION HIGH LIQD

NP

EMBRACE LANCETS ULTRA THIN 30G MISC NP

EMBRACE PRO GLUCOSE CONTROL SOLUTION LIQD

NP

EQL COLOR LANCETS 21G MISC F QL(6.67 ea

daily) EQL COLOR LANCETS MICRO THIN 33G MISC F QL(6.67 ea

daily) EQL SUPER THIN LANCETS 30G MISC F QL(6.67 ea

daily) EQL THIN LANCETS 26G MISC F QL(6.67 ea

daily) EVENCARE CONTROL SOLUTION LIQD NP

EVENCARE G2 GLUCOSE CONTROL SOLUTION/LOW-HIGHSOLN

NP

EVENCARE G3 GLUCOSE CONTROL SOLUTION/LOW-HIGHSOLN

NP

EVENCARE MINI GLUCOSE CONTROL SOLUTION NORMAL SOLN

NP

EVOLUTION CONTROL SOLUTION NORMAL SOLN

NP

EZ SMART BLOOD GLUCOSE LANCETS MISC

F QL(6.67 eadaily)

EZ-LETS LANCETS 21G MISC NP

EZ-LETS LANCETS 23G MISC F QL(6.67 ea

daily) EZ-LETS LANCETS 26G SUPER-SOFT MISC F QL(6.67 ea

daily) EZ-LETS LANCETS 28G ULTRA-SOFT MISC F QL(6.67 ea

daily) EZ-LETS LANCETS 30G MISC F QL(6.67 ea

daily)

Drug Name DrugTier

Requirements/Limits

FIFTY50 CONTROL SOLUTION2.0 SOLN NP

FIFTY50 LANCING DEVICE MISC F QL(1 ea per

160 days retail) FIFTY50 SAFETY SEAL LANCETS 30G MISC NP

FIFTY50 SAFETY SEAL LANCETS 32G MISC NP

FIFTY50 UNILET LANCETS 33G MISC NP

FINE 30 MISC NP

FINGERSTIX LANCETS MISC NP

FORA CONTROL SOLUTION HIGH SOLN NP

FORA CONTROL SOLUTION LOW SOLN NP

FORA CONTROL SOLUTION NORMAL SOLN

NP

FORA LANCETS MISC NP

FORA LANCETS MISC F QL(6.67 eadaily)

FORA LANCING DEVICE MISC F QL(1 ea per

160 days retail) FORA LANCING DEVICE/CLEARCAP MISC F QL(1 ea per

160 days retail) FORACARE GDH CONTROL SOLUTION HIGH SOLN

NP

FORACARE GDH CONTROL SOLUTION LOW SOLN

NP

FORACARE GDH CONTROL SOLUTION NORMAL SOLN

NP

FORTISCARE CONTROL SOLUTIONS HIGH SOLN NP

FORTISCARE CONTROL SOLUTIONS LOW SOLN NP

FORTISCARE CONTROL SOLUTIONS NORMAL SOLN

NP


108

Drug Name DrugTier

Requirements/Limits

FREDS PHARMACY AUTOLET LANCING DEVICE MISC


FREDS PHARMACY UNILET LANCETS SUPER THIN 30G MISC

F QL(6.67 eadaily)

FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G MISC

F QL(6.67 eadaily)

FREESTYLE CONTROL SOLUTION HIGH/LOWLIQD

NP

FREESTYLE CONTROL SOLUTION LIQD NP

FREESTYLE LANCETS MISC NP

FREESTYLE UNISTICK II LANCETS MISC NP

GE100 CONTROL SOLUTION NORMAL SOLN

NP

GENTLE-LET GP LANCETS MISC F QL(6.67 ea

daily) GENTLE-LET LANCETS GENERAL PURPOSE STYLE/FINE POINT MISC

F QL(6.67 eadaily)

GENTLE-LET LANCETS GENERAL PURPOSE STYLE/MEDIUM POINTMISC

F

QL(6.67 eadaily)

GENTLE-LET LANCETS SAFETY STYLE/FINEPOINT MISC

F QL(6.67 eadaily)

GENTLE-LET LANCETS SAFETY STYLE/MEDIUMPOINT MISC

F QL(6.67 eadaily)

GLOBAL INJECT EASE LANCETS 28G MISC NP

GLOBAL INJECT EASE LANCETS 30G MISC NP

GLOBAL LANCING DEVICE MISC F QL(1 ea per

160 days retail) GLUCOCARD 01 CONTROL SOLUTION NORMAL/HIGH LIQD

NP

Drug Name DrugTier

Requirements/Limits

GLUCOCARD 01 CONTROL SOLUTION/NORMALSOLN

NP

GLUCOCARD EXPRESSION CONTROL SOLUTION LEVEL 1 SOLN

NP

GLUCOCARD SHINE CONTROL SOLUTION LEVEL 1 SOLN

NP

GLUCOCARD X-METER CONTROLSOLUTION/NORMAL SOLN

NP

GLUCOCOM HIGH CONTROL LIQD NP

GLUCOCOM LANCETS 28G MISC NP



GLUCOCOM NORMAL CONTROL LIQD NP

GLUCOLET 2 AUTOMATIC LANCING DEVICE MISC


GLUCOSE CONTROL NORMAL SOLN NP

GLUCOSE CONTROL SOLUTION SOLN NP

GLUCOSOURCE LANCET DEVICE MISC F QL(1 ea per

160 days retail) GLUCOSOURCE LANCETS MISC F QL(6.67 ea

daily) GMATE CONTROL SOLUTION LEVEL 2 SOLN

NP

GMATE LANCETS 30G MISC NP

GMATE LANCING DEVICE MISC F QL(1 ea per

160 days retail) GNP EASY TOUCH CONTROL SOLUTION HIGH/LOW SOLN

NP

GNP LANCETS 21G MISC F QL(6.67 eadaily)


109

Drug Name DrugTier

Requirements/Limits

GNP LANCETS MICRO THIN 33G MISC F QL(6.67 ea

daily)

GNP LANCETS MISC F QL(6.67 eadaily)

GNP LANCETS SUPER THIN 30G MISC F QL(6.67 ea

daily) GNP LANCETS THIN 26G MISC F QL(6.67 ea

daily) GNP LANCETS THIN MISC F QL(6.67 ea

daily) GNP MICRO THIN LANCETS 33G MISC F QL(6.67 ea

daily) GNP SUPER THIN LANCETS/30G MISC F QL(6.67 ea

daily) GOODSENSE LANCING DEVICE MISC F QL(1 ea per

160 days retail) H-E-B INCONTROL ADVANCEDLANCING DEVICE MISC


H-E-B INCONTROL LANCETS MICRO THIN 33G MISC

F QL(6.67 eadaily)

H-E-B INCONTROL LANCETS SUPER THIN 30G MISC

F QL(6.67 eadaily)

H-E-B INCONTROL LANCETS ULTRA THIN 28G MISC

F QL(6.67 eadaily)

HAEMOLANCE LOW FLOW LANCETS MISC NP

HAEMOLANCE MISC NP

HAEMOLANCE PLUS HIGH FLOW MISC NP

HAEMOLANCE PLUS LOW FLOW MISC NP

HAEMOLANCE PLUS MAX FLOW MISC NP

HAEMOLANCE PLUS MISC NP

HAEMOLANCE PLUS PEDIATRIC FLOW MISC NP

HEALTH CARE LANCING DEVICE MISC F QL(1 ea per

160 days retail) HEALTHWISE LANCETS 30G MISC NP

Drug Name DrugTier

Requirements/Limits

HEALTHWISE LANCING PEN MISC F QL(1 ea per

160 days retail) HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE MISC


HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G MISC

F QL(6.67 eadaily)

HY-VEE LANCETS MISC F QL(6.67 eadaily)

HY-VEE THIN LANCETS MISC F QL(6.67 ea

daily) IN TOUCH GLUCOSE CONTROLSOLUTION SOLN

NP

IN TOUCH LANCING DEVICE MISC F QL(1 ea per

160 days retail) IN TOUCH STERILE LANCETS30G MISC NP

INFINITY CONTROL SOLUTION HIGH SOLN NP

INFINITY CONTROL SOLUTION LOW SOLN NP

INFINITY CONTROL SOLUTION NORMAL SOLN

NP

KINNEY LANCETS MISC F QL(6.67 eadaily)

KINNEY THIN LANCETS MISC F QL(6.67 ea

daily) KROGER LANCETS 21G MISC F QL(6.67 ea

daily) KROGER LANCETS MICRO THIN33G MISC F QL(6.67 ea

daily)

KROGER LANCETS MISC F QL(6.67 eadaily)

KROGER LANCETS SUPER THIN MISC F QL(6.67 ea

daily) KROGER LANCETS THIN 26G MISC F QL(6.67 ea

daily) KROGER LANCETS THIN MISC F QL(6.67 ea

daily) KROGER LANCETS ULTRATHIN30G MISC F QL(6.67 ea

daily) KROGER LANCING DEVICE MISC F QL(1 ea per

160 days retail)


110

Drug Name DrugTier

Requirements/Limits

LANCET DEVICE ADJUSTABLE MISC F QL(1 ea per

160 days retail) LANCET DEVICE WITH EJECTOR MISC F QL(1 ea per

160 days retail) LANCETS 26G TWIST TOP MISC F QL(6.67 ea

daily)

LANCETS 28G MISC F QL(6.67 eadaily)

LANCETS 30G MISC F QL(6.67 eadaily)

LANCETS 30G MISC NP

LANCETS 30G TWIST TOP MISC NP

LANCETS 30G/TWISTTOP MISC NP

LANCETS 31G TWIST TOP MISC NP

LANCETS 33G UNIVERSAL DESIGN MISC

NP

LANCETS MICRO THIN 33G MISC NP

LANCETS MISC F QL(6.67 eadaily)

LANCETS MISC NP

LANCETS SAFETY SEAL 21G MISC F QL(6.67 ea

daily) LANCETS SAFETY SEAL 26G MISC F QL(6.67 ea

daily) LANCETS SAFETY SEAL 28G MISC F QL(6.67 ea

daily) LANCETS SAFETY SEAL 30G MISC NP

LANCETS SUPER THIN 28G MISC NP

LANCETS THIN MISC F QL(6.67 eadaily)

LANCETS TWIST TOP MISC NP

LANCETS ULTRA FINE MISC NP

LANCETS ULTRA THIN 30G MISC NP

Drug Name DrugTier

Requirements/Limits

LANCETS ULTRA THIN MISC F QL(6.67 ea

daily) LANCETSBULLSEYE SAFETY MISC NP

LANCING DEVICE ADJUSTABLE MISC F QL(1 ea per

160 days retail)

LANCING DEVICE MISC F QL(1 ea per160 days retail)

LANZO MISC F QL(1 ea per160 days retail)

LEADER ADVANCED LANCING DEVICE MISC F QL(1 ea per

160 days retail) LIBERTY CONTROL SOLUTION HIGH SOLN NP

LIBERTY CONTROL SOLUTIONNORMAL SOLN

NP

LIBERTY GLUCOSE CONTROL LEVEL 1 SOLN NP

LIBERTY GLUCOSE CONTROL LEVEL 2 SOLN NP

LIBERTY GLUCOSE CONTROL MID SOLN NP

LIBERTY GLUCOSE CONTROL NORMAL LIQD NP

LIBERTY MEDICAL LANCETS 30G MISC NP

LIBERTY MINI LANCING DEVICE MISC F QL(1 ea per

160 days retail) LIFESCAN UNISTIK 2 DEEP PENETRATION MISC

NP

LIFESCAN UNISTIK II LANCETS MISC NP

LITE TOUCH LANCETS MISC NP

LITE TOUCH LANCING DEVICE MISC F QL(1 ea per

160 days retail) LITE TOUCH LANCING PEN MISC F QL(1 ea per

160 days retail) LITETOUCH LANCETS MICRO THIN 33G MISC NP

LIVE BETTER ADVANCED LANCING DEVICE MISC F QL(1 ea per

160 days retail) LIVE BETTER LANCET SUPERTHIN 30G MISC F QL(6.67 ea

daily)


111

Drug Name DrugTier

Requirements/Limits

LIVE BETTER LANCET ULTRATHIN 28G MISC F QL(6.67 ea

daily) LONGS LANCETS STANDARD MISC F QL(6.67 ea

daily) LONGS LANCETS THIN MISC F QL(6.67 ea

daily) LONGS LANCETS ULTRA THIN MISC NP

MAXIMA CONTROL SOLUTION SOLN NP

MAXIMA CONTROL SOLUTION/NORMALSOLN

NP

MEDICHOICE PRE-SET SAFETY LANCET DUAL USE MISC

NP

MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW MISC

NP

MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW MISC

NP

MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW MISC

NP

MEDICHOICE SAFETY LANCETEXTRA MISC NP

MEDICHOICE SAFETY LANCETNORMAL MISC NP

MEDISENSE GLUCOSE KETONECONTROL SOLUTION 1-LOW,1-MED,1 HIGH LIQD

NP

MEDISENSE GLUCOSE KETONECONTROL SOLUTION 1-NORMAL LIQD

NP

MEDISENSE HIGH/LOWCONTROL SOLUTION LIQD

NP

MEDISENSE HIGH/MID/LOWCONTROL SOLUTION LIQD

NP

MEDISENSE MID CONTROL SOLUTION LIQD

NP

Drug Name DrugTier

Requirements/Limits

MEDISENSE THIN LANCETS MISC F QL(6.67 ea

daily) MEDLANCE PLUS EXTRA LANCETS 21G MISC NP

MEDLANCE PLUS LANCETS LITE 25G MISC NP

MEDLANCE PLUS LANCETS MISC NP

MEDLANCE PLUS LITE LANCETS 25G MISC NP

MEDLANCE PLUS SPECIAL LANCETS 0.8MM MISC

NP

MEDLANCE PLUS SUPERLITE 30G MISC NP

MEDLANCE PLUS SUPERLITE 30G/COMFORT MAXMISC

NP

MEDLANCE PLUS UNIVERSAL LANCETS 21G MISC

NP

MEDLANCE PLUS/LITE25G MISC NP

MEDLANCE/EXTRA MISC NP

MEDLANCE/LITE MISC NP

MEDLANCE/UNIVERSALMISC NP

MEIJER COLOR LANCETS UNIVERSAL 33G MISC

F QL(6.67 eadaily)

MEIJER LANCETS MISC F QL(6.67 eadaily)

MEIJER LANCETS THIN MISC F QL(6.67 ea

daily) MEIJER LANCETS UNIVERSAL21G MISC F QL(6.67 ea



daily) MEIJER SUPER THIN LANCETS MISC F QL(6.67 ea

daily)


112

Drug Name DrugTier

Requirements/Limits

MICRODOT CONTROL SOLUTIONHIGH/LOWSOLN

NP

MICROLET LANCETS MISC NP

MICROLET NEXT MISC F QL(1 ea per160 days retail)

MICROTAINER SAFETY FLOW LANCET/STERILE/SINGLE-USE MISC

NP

MINI LANCING DEVICE MISC F QL(1 ea per

160 days retail) MONOLET LANCETS MISC NP

MONOLET LANCETS MISC F QL(6.67 ea

daily) MONOLET OPD LANCETS MISC F QL(6.67 ea

daily) MONOLETTOR SAFETY LANCETS MISC NP

MULTI-LANCET DEVICE MISC F QL(1 ea per

160 days retail) MYGLUCOHEALTH CONTROL LOW/NORMAL/HIGHSOLN

NP

MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G MISC

NP

NETGROUP LANCETS MISC NP

NEUTEK 2TEK CONTROL SOLUTIONS SOLN NP

NEXGEN NORMAL CONTROL LIQD NP

NOVA MAX PLUS GLU/KET CONTROLSOLUTION-MID LIQD

NP

NOVA SAFETY LANCETS 23G MISC NP

NOVA SAFETY LANCETS 28G MISC NP

NOVA SUREFLEX LANCETS MISC NP

NOVA SUREFLEX LANCETS MISC F QL(6.67 ea

daily)

Drug Name DrugTier

Requirements/Limits

NOVA SUREFLEX LANCING DEVICE MISC F QL(1 ea per

160 days retail) ON CALL EXPRESS GLUCOSE CONTROL SOLUTION SOLN

NP

ON CALL LANCETS MISC NP

ON CALL LANCING DEVICE MISC F QL(1 ea per

160 days retail) ON CALL PLUS GLUCOSE CONTROL LEVEL 1/2 SOLN

NP

ON CALL PLUS LANCETS MISC NP

ON CALL PLUS LANCING DEVICE MISC F QL(1 ea per

160 days retail) ON CALL VIVID GLUCOSE CONTROL LEVEL 1/2 SOLN

NP

ONETOUCH CLUB LANCETS FINE POINT MISC

NP

ONETOUCH COMBO PACK MISC NP

ONETOUCH DELICA LANCETS EXTRA FINE 33G MISC

NP

ONETOUCH DELICA LANCETS FINE 30G MISC NP

ONETOUCH DELICA LANCING DEVICE MISC F QL(1 ea per

160 days retail) ONETOUCH FINEPOINT LANCETS MISC NP

ONETOUCH LANCETS MISC F QL(6.67 ea

daily) ONETOUCH ULTRA CONTROL SOLN NP

ONETOUCH ULTRASOFT LANCETS MISC NP

ONETOUCH VERIO CONTROL SOLUTION HIGH SOLN

NP

ONETOUCH VERIO MID CONTROL SOLUTION SOLN

NP


113

Drug Name DrugTier

Requirements/Limits

OPTUMRX GLUCOSE CONTROL LEVEL 1/2SOLN

NP

PC LANCETS SUPER THIN 30G MISC F QL(6.67 ea

daily) PERFECT LANCETS 30G MISC F QL(6.67 ea

daily) PERFECT PRESSURE ACTIVATED SAFETY LANCETS 28G MISC

NP

PHARMACIST CHOICE ULTRA THIN LANCETS 28G MISC

NP


NP


NP


NP

PHARMACIST CHOICE ULTRA THIN LANCETS MISC

NP

PHARMACY COUNTER LANCETS MISC F QL(6.67 ea

daily) POCKETCHEM EZ CONTROL LEVEL 1 SOLN NP

PRECISION GLUCOSE CONTROL LIQD NP

PRECISION GLUCOSE CONTROLSOLUTION (TRI-LEVEL/HI/LO/NORMAL) SOLN

NP

PRECISION GLUCOSE KETONECONTROL SOLUTION 1-LOW, 1-HIGH LIQD

NP

PRECISION GLUCOSE/KETONECONTROL SOLUTIONS 1-HI 1-LO LIQD

NP

PRECISION THIN LANCETS MISC F QL(6.67 ea

daily)

Drug Name DrugTier

Requirements/Limits

PRECISION THINS GP LANCET MISC F QL(6.67 ea

daily) PRECISION ULTRA LANCET MISC F QL(6.67 ea

daily) PREFERRED PLUS LANCETS COLORED 21G MISC

F QL(6.67 eadaily)

PREFERRED PLUS LANCETS SUPER THIN 30G MISC

F QL(6.67 eadaily)

PREFERRED PLUS LANCETS THIN 26G MISC F QL(6.67 ea

daily) PRESSURE ACTIVATED SAFETYLANCET 21G MISC

NP

PRO COMFORT LANCETS 30G MISC NP

PRO COMFORT LANCETS 31G MISC F QL(6.67 ea

daily) PRODIGY CONTROL SOLUTIONHIGH SOLN NP

PRODIGY CONTROL SOLUTIONLOW SOLN NP

PRODIGY LANCING DEVICE MISC F QL(1 ea per

160 days retail) PRODIGY PRESSURE ACTIVATED SAFETY LANCETS MISC

NP

PRODIGY SAFETY LANCETS MISC NP

PRODIGY TWIST TOP LANCETS MISC F QL(6.67 ea

daily) PRODIGY TWIST TOP LANCETS MISC NP

PSS SELECT GP LANCETS MISC F QL(6.67 ea

daily) PSS SELECT SAFETY LANCETS MISC F QL(6.67 ea

daily) PUSH BUTTON SAFETY LANCETS 21G MISC NP

PUSH BUTTON SAFETY LANCETS 28G MISC NP

PX ADVANCED LANCING DEVICE MISC F QL(1 ea per

160 days retail) PX LANCET AUTO INJECTOR MISC F QL(1 ea per

160 days retail)


114

Drug Name DrugTier

Requirements/Limits

PX LANCETS ULTRA THIN 28G MISC NP

PX LANCETS ULTRA THIN MISC F QL(6.67 ea

daily) QC ADVANCED LANCING DEVICE MISC F QL(1 ea per

160 days retail) QC LANCETS SUPER THIN MISC F QL(6.67 ea

daily) QC LANCETS ULTRA THIN MISC F QL(6.67 ea

daily) QC UNILET LANCETS 28G/ULTRA THIN MISC F QL(6.67 ea

daily) QC UNILET LANCETS 33G/MICRO THIN MISC F QL(6.67 ea

daily) QUICKTEK CONTROL SOLUTION LIQD NP

QUINTET GLUCOSE CONTROL/HIGH/NORMALSOLN

NP

RA E-ZJECT COLOR LANCETSMICRO-THIN 33G MISC

F QL(6.67 eadaily)

RA E-ZJECT LANCETS 28G MISC F QL(6.67 ea

daily) RA E-ZJECT LANCETS THIN 26G MISC F QL(6.67 ea

daily) RA E-ZJECT LANCETS THIN 28G MISC F QL(6.67 ea

daily) RA E-ZJECT LANCETS ULTRATHIN 30G MISC F QL(6.67 ea

daily) RA LANCING DEVICE MISC F QL(1 ea per

160 days retail) READYLANCE SAFETY LANCETS/21G/2.2MMMISC

NP

READYLANCE SAFETY LANCETS/23G/1.8MMMISC

NP


NP


NP


NP

Drug Name DrugTier

Requirements/Limits

REALITY LANCETS MISC F QL(6.67 eadaily)

REALITY TRIGGER LANCETS MISC NP

REFUAH PLUS GLUCOSE CONTROL SOLUTION SOLN

NP

RELION 2-IN-1 LANCING DEVICE 25G MISC F QL(1 ea per

160 days retail) RELION 2-IN-1 LANCING DEVICE 30G MISC F QL(1 ea per

160 days retail) RELION LANCETS MICRO-THIN33G MISC F QL(6.67 ea

daily) RELION LANCETS STANDARD 21G MISC F QL(6.67 ea

daily) RELION LANCETS THIN 26G MISC F QL(6.67 ea

daily) RELION LANCETS ULTRA-THIN30G MISC F QL(6.67 ea

daily) RELION LANCING DEVICE MISC F QL(1 ea per

160 days retail) RELION ULTRA THIN LANCETS30G MISC F QL(6.67 ea

daily) RELION ULTRA THIN PLUS LANCETS 32G MISC

F QL(6.67 eadaily)

RELION ULTRA THIN PLUS LANCETS 33G MISC

F QL(6.67 eadaily)

REXALL LANCETS ULTRA THIN MISC F QL(6.67 ea

daily) RIGHTEST GC300 HIGH CONTROL LIQD NP

RIGHTEST GC300 NORMAL CONTROL LIQD NP

RIGHTEST GD500 LANCING DEVICE MISC F QL(1 ea per

160 days retail) RIGHTEST GL300 LANCETS MISC F QL(6.67 ea

daily) SAFE-T-LANCE LOW FLOW 25G MISC NP

SAFE-T-LANCE NORMAL FLOW21G MISC NP

SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW MISC

NP


115

Drug Name DrugTier

Requirements/Limits

SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW MISC

NP

SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW MISC

NP

SAFETY LANCET 21G/PRESSUREACTIVATED MISC

NP

SAFETY LANCET 28G/PRESSUREACTIVATED MISC

NP

SAFETY LANCETS 21G MISC NP

SAFETY LANCETS 28G MISC NP

SAFETY LANCETS MISC NP

SAFETY LET LANCETS MISC NP

SAFETY SEAL LANCETS 28G MISC F QL(6.67 ea

daily) SAFETY SEAL LANCETS 30G MISC F QL(6.67 ea

daily) SAPSCARE TWIST TOP LANCETS 30G MISC NP

SB LANCETS THIN MISC F QL(6.67 eadaily)

SB LANCETS ULTRA THIN MISC F QL(6.67 ea

daily) SELECT-LITE LANCING DEVICE MISC F QL(1 ea per

160 days retail) SHOPKO AUTOLET LANCING DEVICE MISC F QL(1 ea per

160 days retail) SHOPKO ON-THE-GO COMFORTLANCETS 30G MISC

NP

SHOPKO UNILET LANCETS SUPER THIN 30G MISC

F QL(6.67 eadaily)

SHOPKO UNILET LANCETS ULTRA THIN 28G MISC

F QL(6.67 eadaily)

SIDE BUTTON SAFETY LANCET21G MISC NP

SIMPLE DIAGNOSTICS LANCING DEVICE MISC F QL(1 ea per

160 days retail)

Drug Name DrugTier

Requirements/Limits

SINGLE-LET MISC NP

SM MICRO THIN LANCETS 33G MISC F QL(6.67 ea

daily) SM TRUEDRAW LANCING DEVICE MISC F QL(1 ea per

160 days retail) SMART DIABETES VANTAGE LANCING DEVICE MISC


SMART SENSE COLOR LANCETS UNIVERSAL 33G MISC

F QL(6.67 eadaily)

SMART SENSE STANDARD LANCETS UNIVERSAL 21G MISC

F QL(6.67 eadaily)

SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G MISC

F QL(6.67 eadaily)

SMART SENSE THIN LANCETSUNIVERSAL 26G MISC

F QL(6.67 eadaily)

SMARTEST CONTROL SOLUTIONMEDIUM SOLN NP

SMARTEST LANCETS 28G MISC NP

SOLARTEK GLUCOSE CONTROLSOLUTIONS LIQD

NP

SOLUS V2 CONTROL HIGH SOLN NP

SOLUS V2 CONTROL LOW SOLN NP

SOLUS V2 LANCING DEVICE MISC F QL(1 ea per

160 days retail) SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G MISC

NP

SOLUS V2 TWIST LANCETS 30G MISC NP

STERILANCE TL MISC F QL(6.67 eadaily)

SUPER THIN LANCETS MISC F QL(6.67 ea

daily) SUPREME II HIGH/LOWCONTROL SOLUTION LIQD

NP


116

Drug Name DrugTier

Requirements/Limits

SURE COMFORT LANCETS 28G MISC NP

SURE COMFORT LANCETS 30G MISC NP

SURE COMFORT LANCING PEN MISC F QL(1 ea per

160 days retail) SURE-LANCE FLAT LANCETS MISC NP

SURE-LANCE LANCETS 26G MISC NP

SURE-LANCE THIN LANCETS 28G MISC NP

SURE-LANCE ULTRA THIN LANCETS MISC NP

SURE-PEN MISC F QL(1 ea per160 days retail)

SURE-TOUCH LANCETS UNIVERSAL MISC NP

SURELITE LANCETS MISC F QL(6.67 ea

daily) SURESTEP GLUCOSE CONTROL SOLN NP

SURESTEP GLUCOSE CONTROLSOLUTION SOLN

NP

SURESTEP PRO HIGH GLUCOSECONTROL LIQD

NP

SURESTEP PRO LOW GLUCOSECONTROL LIQD

NP

SURESTEP PRO NORMAL GLUCOSE CONTROL LIQD

NP

TAI DOC CONTROL SOLN NP

TECHLITE AST LANCETS MISC F QL(6.67 ea

daily) TECHLITE LANCETS 30G MISC F QL(6.67 ea

daily) TECHLITE LANCETS MISC F QL(6.67 ea

daily) TELCARE GLUCOSE CONTROL SOLUTION LEVEL 1/2 SOLN

NP

Drug Name DrugTier

Requirements/Limits

TGT ADVANCED LANCING DEVICE MISC F QL(1 ea per

160 days retail) TGT LANCET ALTERNATE SITE MISC F QL(6.67 ea

daily) TGT LANCET MICRO THIN 33G MISC F QL(6.67 ea

daily) TGT LANCET SUPER THIN 30G MISC F QL(6.67 ea

daily) TGT LANCET THIN 23G MISC F QL(6.67 ea

daily) TGT LANCET THIN 26G MISC F QL(6.67 ea

daily) TGT LANCET ULTRA THIN 28G MISC F QL(6.67 ea

daily) TGT LANCET ULTRA THIN 30G MISC F QL(6.67 ea

daily) TGT LANCING DEVICE MISC F QL(1 ea per

160 days retail) THINLETS GP LANCETS MISC F QL(6.67 ea

daily)

THINLETS LANCET MISC F QL(6.67 eadaily)

TODAYS HEALTH ADVANCED LANCING DEVICE MISC


TODAYS HEALTH SUPER THINLANCETS 30G MISC F QL(6.67 ea

daily) TODAYS HEALTH ULTRA THINLANCETS 28G MISC F QL(6.67 ea

daily) TRAVEL LANCETS 30G MISC NP

TRUE METRIX CONTROL SOLUTION LEVEL 1 SOLN

F


F QL(1 ea per 75days retail)



TRUECONTROL GLUCOSE CONTROL LEVEL 0 LIQD


TRUECONTROL GLUCOSE CONTROL LEVEL 1 LIQD



117

Drug Name DrugTier

Requirements/Limits

TRUEDRAW LANCING DEVICE MISC F QL(1 ea per

160 days retail) TRUEPLUS LANCETS 26G MISC F QL(6.67 ea

daily) TRUEPLUS LANCETS 28G MISC F QL(6.67 ea

daily) TRUEPLUS LANCETS 28G SUPER THIN MISC NP

TRUEPLUS LANCETS 28G SUPER THIN MISC F QL(6.67 ea

daily) TRUEPLUS LANCETS 30G MISC F QL(6.67 ea

daily) TRUEPLUS LANCETS 30G ULTRA THIN MISC F QL(6.67 ea

daily) TRUEPLUS LANCETS 30G ULTRA THIN MISC NP

TRUEPLUS LANCETS 33G MICRO THIN MISC NP

TRUEPLUS LANCETS 33G MISC F QL(6.67 ea

daily) TRUEPLUS SAFETY LANCETS 28G MISC NP

TRUETEST GLUCOSE CONTROLLEVEL 1 LIQD F QL(1 ea per 75

days retail) TRUETEST GLUCOSE CONTROLLEVEL 2 LIQD F QL(1 ea per 75

days retail) TRUETEST GLUCOSE CONTROLLEVEL 3 LIQD F QL(1 ea per 75

days retail) ULTI-LANCE AUTOMATIC/CLEAR TIP MISC F QL(1 ea per

160 days retail) ULTICARE THIN LANCETS 30G MISC NP

ULTILET CLASSIC LANCETS MISC NP

ULTILET CLASSIC LANCETS MISC F QL(6.67 ea

daily) ULTILET LANCETS 33G MISC NP

ULTILET LANCETS MISC NP

ULTILET SAFETY LANCETS 23G MISC NP

ULTRA THIN LANCETS 28G MISC F QL(6.67 ea

daily) ULTRA THIN LANCETS 30G MISC F QL(6.67 ea

daily)

Drug Name DrugTier

Requirements/Limits

ULTRA-THIN II AUTO LANCET MISC NP

ULTRA-THIN II LANCETS 28G MISC NP

ULTRA-THIN II LANCETS 30G MISC NP

ULTRA-THIN II SAFETY AUTOLANCETS 26G MISC

NP

ULTRATRAK PRO CONTROL SOLUTION 2 LEVELS SOLN

NP

ULTRATRAK PRO NORMAL CONTROL SOLN

NP

ULTRATRAK ULTIMATE CONTROL SOLUTION 2 LEVELS SOLN

NP

UNILET COMFORTOUCH LANCET MISC F QL(6.67 ea

daily)

UNILET EXCELITE II MISC F QL(6.67 eadaily)

UNILET EXCELITE MISC F QL(6.67 eadaily)

UNILET G.P. LANCET MISC F QL(6.67 ea

daily) UNILET G.P. SUPERLITE LANCET MISC F QL(6.67 ea

daily) UNILET GP 28 ULTRA THIN MISC F QL(6.67 ea

daily)

UNILET LANCET MISC F QL(6.67 eadaily)

UNILET LANCETS MICRO-THIN33G MISC F QL(6.67 ea

daily) UNILET LANCETS SUPER-THIN30G MISC F QL(6.67 ea

daily) UNILET LANCETS ULTRA-THIN 28G MISC F QL(6.67 ea

daily) UNILET SUPERLITE LANCET MISC F QL(6.67 ea

daily)

UNISTIK 3 GENTLE MISC NP

UNISTIK SAFETY LANCETS 28G MISC NP

UNISTIK SAFETY LANCETS 30G MISC NP


118

Drug Name DrugTier

Requirements/Limits

UNISTIK TOUCH SAFETY LANCETS 21G MISC NP




UNISTRIP CONTROL SOLUTIONHIGH SOLN NP

UNISTRIP CONTROL SOLUTIONLOW SOLN NP

UNIVERSAL 1 LANCETS THIN26G MISC F QL(6.67 ea

daily) UNIVERSAL 1 LANCETS ULTRA THIN 30G MISC F QL(6.67 ea

daily) UNIVERSAL 1 LANCETS/33G/MICRO-THIN MISC

NP

VALUE PLUS LANCETS STANDARD 21G MISC F QL(6.67 ea

daily) VALUE PLUS LANCETS SUPERTHIN 30G MISC F QL(6.67 ea

daily) VALUE PLUS LANCETS THIN 26G MISC F QL(6.67 ea

daily) VALUE PLUS LANCING DEVICE MISC F QL(1 ea per

160 days retail) VALUMARK LANCET SUPER THIN 30G MISC F QL(6.67 ea

daily) VALUMARK LANCET ULTRA THIN 28G MISC F QL(6.67 ea

daily) VERASENS GLUCOSE CONTROLLEVEL 1 LIQD NP

VICTORY CONTROL LEVEL 1/2 SOLN NP

VIDA MIA AUTOLET LANCINGDEVICE MISC F QL(1 ea per

160 days retail) VIDA MIA UNILET LANCETS SUPER THIN 30G MISC

F QL(6.67 eadaily)

VIDA MIA UNILET LANCETS ULTRA THIN 28G MISC

F QL(6.67 eadaily)

VITALET PRO LANCETS MISC NP

Drug Name DrugTier

Requirements/Limits

VITALET PRO PLUS LANCETS MISC NP

W&F LANCETS 26G MISC F QL(6.67 eadaily)

W&F LANCETS COLORED 21G MISC F QL(6.67 ea

daily) WALGREENS ADVANCED TRAVELLANCETS 28G MISC

NP

WALGREENS COMFORT ASSUREDLANCETS MICRO THIN/33G MISC

F QL(6.67 eadaily)

WALGREENS COMFORT ASSUREDLANCETS SUPER THIN/28G MISC

F QL(6.67 eadaily)

WALGREENS LANCETS MISC NP

WALGREENS THIN LANCETS MISC F QL(6.67 ea

daily) WALGREENS THIN LANCETS MISC NP

WALGREENS ULTRA THIN LANCETS MISC NP

Misc. Devices ALCOH-GLOVE CONTOURED WIPE PADS NP RX/OTC

ALCOHOL PADS PADS NP RX/OTC

ALCOHOL PREP PADS PADS F QL(13.34 ea

daily); RX/OTC ALCOHOL PREP PADS PADS NP RX/OTC

ALCOHOL PREPS PADS F QL(13.34 eadaily); RX/OTC

ALCOHOL SWABS PADS NP RX/OTC

ALCOHOL SWABS PADS F QL(13.34 eadaily); RX/OTC

ALCOHOL SWABSTICK PADS NP RX/OTC

ALCOHOL WIPES PADS F QL(13.34 eadaily); RX/OTC

BD SWABS SINGLE USE BUTTERFLY PADS F QL(13.34 ea

daily); RX/OTC BD SWABS SINGLE USE PADS F QL(13.34 ea

daily); RX/OTC


119

Drug Name DrugTier

Requirements/Limits

CARETOUCH ALCOHOL PREP PADS PADS NP RX/OTC

CURITY ALCOHOL PREPS/MEDIUM 2 PLYPADS


CURITY ALCOHOL SWABS PADS F QL(13.34 ea

daily); RX/OTC CVS ALCOHOL PREP SWABS PADS F QL(13.34 ea

daily); RX/OTC CVS ALCOHOL SWABS PADS F QL(13.34 ea

daily); RX/OTC

CVS PREP PADS PADS F QL(13.34 eadaily); RX/OTC

EASY TOUCH ALCOHOL PREP PADS/MEDIUMPADS


EQL ALCOHOL SWABS PADS F QL(13.34 ea

daily); RX/OTC FIFTY50 ALCOHOL PREP PADS PADS F QL(13.34 ea

daily); RX/OTC GLOBAL ALCOHOL PREP EASEPADS PADS NP RX/OTC

GNP ALCOHOL SWABS PADS F QL(13.34 ea

daily); RX/OTC H-E-B INCONTROL ALCOHOL PADS PADS F QL(13.34 ea

daily); RX/OTC HEALTHWISE ALCOHOL PREP PADS PADS NP RX/OTC

MEIJER ALCOHOL SWABS EXTRA-THICK PADS


PHARMACIST CHOICE ALCOHOLPREP PADS PADS

NP RX/OTC

PRO COMFORT ALCOHOL PADS PADS NP RX/OTC

QC ALCOHOL SWABS PADS F QL(13.34 ea

daily); RX/OTC RA ALCOHOL SWABS PADS F QL(13.34 ea

daily); RX/OTC

REALITY SWABS PADS F QL(13.34 eadaily); RX/OTC

RELION ALCOHOL SWABS PADS F QL(13.34 ea

daily); RX/OTC SAPS CARE ALCOHOL PREP PADS PADS NP RX/OTC

Drug Name DrugTier

Requirements/Limits

SB ALCOHOL PREP PADS PADS F QL(13.34 ea

daily); RX/OTC SHOPKO ALCOHOL SWABS PADS F QL(13.34 ea

daily); RX/OTC SM ALCOHOL PREP PADS PADS F QL(13.34 ea

daily); RX/OTC SURE COMFORT ALCOHOL PREP PADS PADS

NP RX/OTC

SURE-PREP ALCOHOL PREP PADS PADS NP RX/OTC

TGT ALCOHOL SWABS PADS F QL(13.34 ea

daily); RX/OTC ULTICARE ALCOHOL SWABS PADS F QL(13.34 ea

daily); RX/OTC WEBCOL ALCOHOL PREP LARGE 1 PLY PADS


WEBCOL ALCOHOL PREP LARGE 2 PLY PADS


WEBCOL ALCOHOL PREP MEDIUM 2 PLY PADS


Oral Hygiene Products AQUAFRESH CAVITY PROTECTION PSTE F RX/OTC

AQUAFRESH EXTREME CLEAN PSTE F RX/OTC

AQUAFRESH FOR KIDS PSTE F RX/OTC

AQUAFRESH SENSITIVE PSTE F RX/OTC

AQUAFRESH TARTAR CONTROL PSTE F RX/OTC

AQUAFRESH TOOTHPASTE PSTE F RX/OTC

AQUAFRESH WHITENING PSTE F RX/OTC

BIOTENE DRY MOUTH GENTLEFORMULA PSTE F RX/OTC

BIOTENE DRY MOUTH PSTE F RX/OTC

BIOTENE PBF DRY MOUTH PSTE F RX/OTC


120

Drug Name DrugTier

Requirements/Limits

COLGATE PLATINUM PSTE F RX/OTC

CREST TARTAR CONTROL PSTE F RX/OTC

CREST TARTAR CONTROL/BAKING SODATOOTHPASTE PSTE

F RX/OTC

CREST TOOTHPASTE PSTE F RX/OTC

CREST TOOTHPASTE/REGULARPSTE

F RX/OTC

CREST TOOTHPASTEREGULAR PSTE

F RX/OTC

MI PASTE PLUS PSTE F RX/OTC

MI PASTE PSTE F RX/OTC

PEARL DROPS EXTRA STRENGTH PSTE F RX/OTC

RA FLUORIDE TOOTHPASTE PSTE F RX/OTC

RA SENSITIVE TOOTHPASTE/FLUORIDEPSTE

F RX/OTC

RA WHITENING TOOTHPASTE/FLUORIDEPSTE

F RX/OTC

SENSITIVE TOOTHPASTE EXTRA WHITENING/FLUORIDEMAX ST PSTE

F

RX/OTC

SENSITIVE TOOTHPASTE/FLUORIDE/MAXIMUM STRENGTHPSTE

F

RX/OTC

SENSODYNE MAXIMUM STRENGTH PSTE F RX/OTC

SENSODYNE MAXIMUM STRENGTH TARTAR CONTROL PLUS WHITENING PSTE

F

RX/OTC

SENSODYNE PRONAMEL FRESHBREATH PSTE F RX/OTC

SENSODYNE PRONAMEL PSTE F RX/OTC

Drug Name DrugTier

Requirements/Limits

VIADENT ADVANCED CARE TOOTHPASTE PSTE

F RX/OTC

VIADENT TOOTHPASTE FLUORIDE PSTE F RX/OTC

VIADENT TOOTHPASTE PLAQUEFIGHTING PSTE F RX/OTC

VIADENT TOOTHPASTE PSTE F RX/OTC

Parenteral Therapy Supplies 1ST TIER UNIFINE PENTIPS/MINI/31GX5MMMISC


1ST TIER UNIFINE PENTIPS29GX12MM MISC


1ST TIER UNIFINE PENTIPS31GX6MM MISC F QL(5 ea daily)

1ST TIER UNIFINE PENTIPS31GX8MM MISC F QL(5 ea daily);

RX/OTC 1ST TIER UNIFINE PENTIPS32GX4MM MISC F QL(5 ea daily);

RX/OTC 1ST TIER UNIFINE PENTIPSPLUS 31GX8MM MISC


1ST TIER UNIFINE PENTIPSPLUS 32GX4MM MISC


1ST TIER UNIFINE PENTIPSPLUS/MINI/31GX5MM MISC


1ST TIER UNIFINE PENTIPSPLUS/ORIGINAL/29GX12MM MISC


1ST TIER UNIFINE PENTIPSPLUS/ULTRASHORT/31GX6MM MISC

F QL(5 ea daily)

ADVOCATE INSULIN PEN NEEDLES 29GX12.7MM MISC

F QL(5 ea daily)

ADVOCATE INSULIN PEN NEEDLES 31GX5MM MISC


ADVOCATE INSULIN PEN NEEDLES 31GX8MM MISC



121

Drug Name DrugTier

Requirements/Limits

ADVOCATE INSULIN SYRINGE/U-100/0.3ML/29GX1/2" MISC


ADVOCATE INSULIN SYRINGE/U-100/0.3ML/30GX5/16"MISC

F

QL(5 ea daily);RX/OTC


F

QL(5 ea daily)

ADVOCATE INSULIN SYRINGE/U-100/0.5ML/29GX1/2" MISC



F



F

QL(5 ea daily)

ADVOCATE INSULIN SYRINGE/U-100/1ML/29GX1/2" MISC





F QL(5 ea daily)

ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


ANTI-STICK INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


ASSURE ID INSULIN SAFETYSYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


Drug Name DrugTier

Requirements/Limits

ASSURE ID INSULIN SAFETYSYRINGE/U-100/1ML/29G X 1/2" MISC


AURORA PEN NEEDLES 29GX12MM MISC F QL(5 ea daily);

RX/OTC AURORA PEN NEEDLES 31G X6MM MISC F QL(5 ea daily)

AURORA PEN NEEDLES 31G X8MM MISC F QL(5 ea daily);

RX/OTC AURORA UNIFINE PENTIPS/32GX5/32" MISC F QL(5 ea daily);

RX/OTC AURORA UNIFINE PENTIPS/MINI/31GX3/16"MISC


B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31GX 5/16" MISC

F QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE II/0.5ML/31GX 5/16" MISC

F QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE II/1ML/31G X5/16" MISC

F QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE/0.3ML/30G X1/2" MISC

F QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X1/2" MISC

F QL(5 ea daily)

BD LO-DOSE INSULIN SYRINGE MICROFINE IV/0.5ML/28G X 1/2" MISC


BD AUTOSHIELD 29G X 5/16" MISC F QL(5 ea daily)

BD INSULIN SYRINGE LUER-LOK/U-100/1MLMISC


BD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X 1/2"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE MICROFINE IV/U-100/0.5ML/28G X 1/2"MISC

F



122

Drug Name DrugTier

Requirements/Limits

BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/27G X 5/8" MISC

F QL(5 ea daily)

BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/28G X 1/2" MISC


BD INSULIN SYRINGE MICROFINE/U-100/0.3ML/28G X 1/2"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE MICROFINE/U-100/0.5ML/28G X 1/2"MISC

F


BD INSULIN SYRINGE MICROFINE/U-100/1ML/27G X 5/8" MISC

F QL(5 ea daily)

BD INSULIN SYRINGE MICROFINE/U-100/1ML/28G X 1/2" MISC


BD INSULIN SYRINGE SAFETYGLIDE/0.5ML/29GX 1/2" MISC


BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X1/2" MISC


BD INSULIN SYRINGE SAFETYGLIDE/U-100/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE SLIP TIP/U-100/1ML MISC F QL(5 ea daily);

RX/OTC BD INSULIN SYRINGE ULTRAFINE HALF-UNIT/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE II/SHORT/0.5ML/31G X5/16" MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE II/SHORT/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/0.3ML/30G X1/2" MISC

F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


F QL(5 ea daily)


F QL(5 ea daily)


F QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/1ML/30G X1/2" MISC

F QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/1ML/31G X5/16" MISC

F QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F

QL(5 ea daily)


F



F

QL(5 ea daily)


F

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/29G X 1/2" MISC


BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/30G X 1/2" MISC

F QL(5 ea daily)


123

Drug Name DrugTier

Requirements/Limits

BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X 15/64"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/25GX 1" MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/25GX 5/8" MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/26GX 1/2" MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC

F QL(5 ea daily)

BD INSULIN SYRINGE/U-100/1ML/27G X 1/2" MISC F QL(5 ea daily);

RX/OTC BD INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC F QL(5 ea daily);

RX/OTC BD INTEGRA INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


BD INTEGRA SYRINGE/RETRACTINGNEEDLE/1ML/25G X 1"MISC

F

QL(5 ea daily)

BD PEN NEEDLE/MINI/ULTRAFINE/31G X 3/16" MISC


BD PEN NEEDLE/NANO/ULTRAFINE/32G X 4MM MISC


BD PEN NEEDLE/SHORT/ULTRAFINE/31G X 5/16" MISC


BD PEN NEEDLE/ULTRAFINE/29GX 12.7MM MISC

F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

BD PEN NEEDLE/ULTRAFINE/29GX1/2" 12.7MM MISC

F QL(5 ea daily)

BD PEN NEEDLES SHORT/ULTRAFINE/31GX 5/16" MISC


BD SAFETY-GLIDE INSULIN SYRINGE/0.5ML/29G X1/2" MISC

F


BD SAFETY-LOK INSULIN SYRINGE/PERMNEEDLE/UF/1ML/29G X1/2" MISC

F


BD SAFETYGLIDE INSULIN SYSYRINGE/0.5ML/30G X5/16" MISC

F


BD ULTRA-FINE MICRO PEN NEEDLES 6MM X 32G MISC

F QL(5 ea daily)

CAREFINE PEN NEEDLE 32GX4MM MISC F QL(5 ea daily);

RX/OTC CAREFINE PEN NEEDLES 29GX1/2" MISC F QL(5 ea daily);

RX/OTC CAREFINE PEN NEEDLES 30GX5/16"MISC


CAREFINE PEN NEEDLES 31GX6MM MISC

F QL(5 ea daily)






F QL(5 ea daily)

CAREONE INSULIN SYRINGES/0.3ML/30G X1/2" MISC

F QL(5 ea daily)


F QL(5 ea daily)


124

Drug Name DrugTier

Requirements/Limits


F QL(5 ea daily)


F QL(5 ea daily)

CAREONE INSULIN SYRINGES/1ML/30G X1/2" MISC

F QL(5 ea daily)

CAREONE INSULIN SYRINGES/1ML/31GX5/16" MISC

F QL(5 ea daily)

CAREONE UNIFINE PENTIPS 29GX12MM MISC


CAREONE UNIFINE PENTIPS 31GX5MM MISC F QL(5 ea daily);

RX/OTC CAREONE UNIFINE PENTIPS 31GX6MM MISC F QL(5 ea daily)

CAREONE UNIFINE PENTIPS 31GX8MM MISC F QL(5 ea daily);

RX/OTC CAREONE UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC


CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 29GX12MM MISC

F



F



F

QL(5 ea daily)


F



F


CARETOUCH PEN NEEDLES 31G X 6 MM MISC

F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

CARETOUCH PEN NEEDLES 31GX 5MM MISC








CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES 31GX8MM MISC

F


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/29G X1/2" MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)


F



F



F

QL(5 ea daily)


F



125

Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)


F

QL(5 ea daily)

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/28G X 1/2"MISC

F


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/29G X 1/2"MISC

F


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/30G X5/16" MISC

F


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/U-100/1ML/31GX5/16" MISC

F

QL(5 ea daily)

CLEVER CHOICE COMFORT EZPEN NEEDLES 29GX12MM MISC

F



F



F

QL(5 ea daily)


F



F



F


Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)

CLICKFINE PEN NEEDLE 32GX5/32" MISC F QL(5 ea daily);

RX/OTC CLICKFINE PEN NEEDLE UNIVERSAL/31GX1/4"MISC

F QL(5 ea daily)

CLICKFINE PEN NEEDLE UNIVERSAL/31GX5/16"MISC


CLICKFINE PEN NEEDLES/31GX1/4" MISC F QL(5 ea daily)

CLICKFINE PEN NEEDLES/31GX5/16"MISC


CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16"MISC


COMFORT ASSIST INSULIN SYRINGE 0.3ML/29G X 1/2" MISC


COMFORT ASSIST INSULIN SYRINGE/0.3ML/30G X5/16" MISC

F



F

QL(5 ea daily)


F



F



F

QL(5 ea daily)

COMFORT ASSIST INSULIN SYRINGE/1ML/29G X 1/2"MISC

F



126

Drug Name DrugTier

Requirements/Limits

COMFORT ASSIST INSULIN SYRINGE/1ML/30G X5/16" MISC

F


COMFORT ASSIST INSULIN SYRINGE/1ML/31G X5/16" MISC

F

QL(5 ea daily)

DROPLET PEN NEEDLES 29GX12MM MISC F QL(5 ea daily);

RX/OTC DROPLET PEN NEEDLES 31GX5MM MISC F QL(5 ea daily);

RX/OTC DROPLET PEN NEEDLES 31GX6MM MISC F QL(5 ea daily)

DROPLET PEN NEEDLES 31GX8MM MISC F QL(5 ea daily);



RX/OTC DROPLET PEN NEEDLES 32GX6MM MISC F QL(5 ea daily)

DRUG MART UNIFINE PENTIPS 31GX5MM MISC F QL(5 ea daily);

RX/OTC DRUG MART UNIFINE PENTIPS29G X 12MM MISC


DRUG MART UNIFINE PENTIPS31GX6MM MISC F QL(5 ea daily)

DRUG MART UNIFINE PENTIPS31GX8MM MISC F QL(5 ea daily);

RX/OTC DRUG MART UNIFINE PENTIPS32GX4MM MISC F QL(5 ea daily);

RX/OTC DRUG MART UNIFINE PENTIPSPLUS 32GX4MM MISC


DUANE READE UNIFINE PENTIPS 29G X 12MM MISC


DUANE READE UNIFINE PENTIPS 31G X 6MM ULTRA SHORT MISC

F QL(5 ea daily)

DUANE READE UNIFINE PENTIPS 31G X 8MM SHORT MISC


Drug Name DrugTier

Requirements/Limits

EASY COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" MISC





F QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC


EASY COMFORT INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC

F

QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

F QL(5 ea daily)

EASY COMFORT PEN NEEDLES31GX1/4" MISC F QL(5 ea daily)

EASY COMFORT PEN NEEDLES31GX3/16" MISC F QL(5 ea daily);

RX/OTC EASY COMFORT PEN NEEDLES31GX5/16" MISC F QL(5 ea daily);

RX/OTC EASY COMFORT PEN NEEDLES32GX5/32" MISC F QL(5 ea daily);

RX/OTC EASY TOUCH 32GX5MM MISC F QL(5 ea daily);

RX/OTC EASY TOUCH 32GX6MM MISC F QL(5 ea daily)

EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2"MISC

F



F

QL(5 ea daily)


F



127

Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)

EASY TOUCH INSULIN SYRINGE/0.3ML/30G X5/16" MISC



F QL(5 ea daily)





EASY TOUCH INSULIN SYRINGE/1ML/30G X5/16" MISC


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X 1/2"MISC

F


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/30G X 5/16"MISC

F


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/29G X 1/2" MISC


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/30G X 1/2" MISC

F QL(5 ea daily)

EASY TOUCH INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

F

QL(5 ea daily)


F

QL(5 ea daily)


F


Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)


F

QL(5 ea daily)

EASY TOUCH INSULIN SYRINGE/U-100/1ML/27GX 1/2" MISC







F QL(5 ea daily)


F QL(5 ea daily)

EASY TOUCH PEN NEEDLE 30G X 5/16"MISC


EASY TOUCH PEN NEEDLES 29GX1/2" MISC F QL(5 ea daily);

RX/OTC EASY TOUCH PEN NEEDLES 31GX1/4" MISC F QL(5 ea daily)

EASY TOUCH PEN NEEDLES 31GX5/16"MISC


EASY TOUCH PEN NEEDLES 32GX1/4" MISC F QL(5 ea daily)





EASY TOUCH PEN NEEDLES/31G X 3/16"MISC


EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2" MISC

F



128

Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML/30GX1/2"MISC

F

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGE/0.3ML/31G X5/16" MISC

F QL(5 ea daily)





ELITE-THIN INSULIN SYRINGE/1ML/30G X5/16" MISC


ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC





F QL(5 ea daily)

EQL INSULIN SYRINGE/0.3ML/29G X1/2" MISC




Drug Name DrugTier

Requirements/Limits


F QL(5 ea daily)






F QL(5 ea daily)

EQL INSULIN SYRINGE/1ML/29G X 1/2"MISC


EQL INSULIN SYRINGE/1ML/30G X5/16" MISC


EQL INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

EQL INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F


EQL INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


EQL INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


EQL SHORT PEN NEEDLES 31G X 8MM MISC


EQL ULTRA COMFORT INSULINSYRINGE/0.3ML/31G X 5/16" MISC

F QL(5 ea daily)

EQL ULTRA COMFORT INSULINSYRINGE/1ML/30G X 5/16" MISC


EQL ULTRA SHORT PEN NEEDLES 31G X 6MM MISC

F QL(5 ea daily)

EXEL COMFORT POINT INSULIN PEN NEEDLES 29G X 12MM MISC



129

Drug Name DrugTier

Requirements/Limits


F QL(5 ea daily)



EXEL COMFORT POINT INSULIN SYRINGE/0.3ML/29G X1/2" MISC

F



F



F



F



F


EXEL COMFORT POINT INSULIN SYRINGE/1ML/28G X 1/2"MISC

F


EXEL COMFORT POINT INSULIN SYRINGE/1ML/29G X 1/2"MISC

F


EXEL COMFORT POINT INSULIN SYRINGE/1ML/30G X5/16" MISC

F


FIFTY50 PEN NEEDLES 31G X3/16" (5MM) MISC F QL(5 ea daily);

RX/OTC FIFTY50 PEN NEEDLES 31G X5/16" (8MM) MISC F QL(5 ea daily);

RX/OTC FIFTY50 PEN NEEDLES 31GX5MM MISC F QL(5 ea daily);

RX/OTC FIFTY50 PEN NEEDLES/31GX8MMMISC


Drug Name DrugTier

Requirements/Limits

FIFTY50 PEN NEEDLES/32GX4MMMISC


FIFTY50 PEN NEEDLES/32GX6MMMISC

F QL(5 ea daily)

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.3ML/31G X5/16" MISC

F

QL(5 ea daily)

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.5ML/31G X5/16" MISC

F

QL(5 ea daily)

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/1ML/31G X5/16" MISC

F

QL(5 ea daily)

FREDS PHARMACY UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC

F


FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX5MM MISC


FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX8MM MISC


FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC

F


FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGES/U-100/1ML/30G X 5/16"MISC

F


GLOBAL EASE INJECT PEN NEEDLES 29GX12MM MISC



130

Drug Name DrugTier

Requirements/Limits





GLOBAL EASE INJECT PEN NEEEDLES 31GX5MM MISC


GLOBAL EASY GLIDE INSULINSYRINGE/U-100/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

GLOBAL EASY GLIDE PEN NEEDLES 32GX4MM MISC


GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)


F



F



F

QL(5 ea daily)


F


Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC





F QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

GLOBAL INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

F

QL(5 ea daily)

GLOBAL INSULIN SYRINGES/U-100/0.3ML/30GX5/16"MISC

F


GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

F

QL(5 ea daily)


F



F

QL(5 ea daily)


F

QL(5 ea daily)


131

Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)

GLUCOPRO INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

F QL(5 ea daily)




F QL(5 ea daily)

GNP CLICKFINE PEN NEEDLEUNIVERSAL/31GX5/16" MISC


GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX1/4" MISC

F QL(5 ea daily)

GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16"MISC

F


GNP INSULIN SYRINGE/0.3ML/29G X1/2" MISC





F QL(5 ea daily)








F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

GNP INSULIN SYRINGE/1ML/28G X 1/2"MISC


GNP INSULIN SYRINGE/1ML/29G X 1/2"MISC


GNP INSULIN SYRINGE/1ML/30G X5/16" MISC


GNP INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X1/2" MISC

F


GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" SHORT MISC

F



F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)

GNP ULTRA COMFORT INSULIN SYRINGE/1ML/28G X 1/2"MISC

F


GNP ULTRA COMFORT INSULIN SYRINGE/1ML/29G X 1/2"MISC

F



132

Drug Name DrugTier

Requirements/Limits

GNP ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" SHORT MISC

F


GNP ULTRA COMFORT INSULIN SYRINGE/1ML/31G X5/16" SHORT MISC

F

QL(5 ea daily)

H-E-B IN CONTROL PEN NEEDLES 31GX5MM MISC



F QL(5 ea daily)



H-E-B IN CONTROL PEN NEEDLES/NANO/32GX4MM MISC


H-E-B IN CONTROL UNIFINEPENTIPS PLUS 31GX5MM MISC


H-E-B IN CONTROL UNIFINEPENTIPS PLUS 32GX4MM MISC


H-E-B INCONTROL PEN NEEDLES 29GX12MM MISC


HEALTHWISE MINI PEN NEEDLES 31GX6MM MISC

F QL(5 ea daily)

HEALTHWISE PEN NEEDLES 29GX12MM MISC


HEALTHWISE SHORT PEN NEEDLES 31GX8MM MISC


HEALTHWISE UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC


HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 29GX12MM MISC

F


Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)


F



F


INSULIN SYRINGE/0.3ML/29G X 1"MISC

F QL(5 ea daily)

INSULIN SYRINGE/0.3ML/29G X1/2" MISC





F QL(5 ea daily)


F QL(5 ea daily)






F QL(5 ea daily)




F QL(5 ea daily)


133

Drug Name DrugTier

Requirements/Limits

INSULIN SYRINGE/1ML/28G X 1/2"MISC


INSULIN SYRINGE/1ML/29G X 1/2"MISC


INSULIN SYRINGE/1ML/30G X5/16" MISC


INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC






INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC F QL(5 ea daily);

RX/OTC INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC F QL(5 ea daily);

RX/OTC INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC


INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F QL(5 ea daily)

INSULIN SYRINGES/0.5ML/27GX1/2" MISC

F QL(5 ea daily)








F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


F QL(5 ea daily)

INSULIN SYRINGES/1ML/27GX/1/2"MISC


INSULIN SYRINGES/1ML/27GX1/2"MISC







F QL(5 ea daily)

INSULIN SYRINGES/1ML/31GX5/16" MISC

F QL(5 ea daily)

INSUPEN 29G X 12MM MISC F QL(5 ea daily);

RX/OTC INSUPEN 31G X 5MM MISC F QL(5 ea daily);



RX/OTC INSUPEN PEN NEEDLES 32G X4MM MISC F QL(5 ea daily);

RX/OTC INSUPEN SENSITIVE 32GX6MM MISC F QL(5 ea daily)

INSUPEN ULTRAFIN 29GX12MM MISC F QL(5 ea daily);

RX/OTC INSUPEN ULTRAFIN 30GX8MM MISC F QL(5 ea daily);

RX/OTC INSUPEN ULTRAFIN 31GX6MM MISC F QL(5 ea daily)

INSUPEN ULTRAFIN 31GX8MM MISC F QL(5 ea daily);

RX/OTC KINRAY INSULIN SYRINGE PREFERRED PLUS/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)


134

Drug Name DrugTier

Requirements/Limits

KINRAY INSULIN SYRINGE PREFERRED PLUS/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

KINRAY INSULIN SYRINGE PREFERRED PLUS/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

KINRAY INSULIN SYRINGE/0.5ML/29G X1/2" MISC


KMART VALU PLUS INSULIN SYRINGE/1ML/29G MISC


KMART VALU PLUS INSULIN SYRINGE/1ML/30G MISC


KROGER INSULIN SYRINGE/0.3ML/29G X1/2" MISC





F QL(5 ea daily)






F QL(5 ea daily)

KROGER INSULIN SYRINGE/1ML/29G X 1/2"MISC


KROGER INSULIN SYRINGE/1ML/30G X5/16" MISC


KROGER INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

KROGER PEN NEEDLES 29G X12MM MISC F QL(5 ea daily);

RX/OTC KROGER PEN NEEDLES 31G X8MM MISC F QL(5 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

KROGER PEN NEEDLES 31GX1/4" MISC F QL(5 ea daily)

LEADER INSULIN SYRINGE/0.3ML/29G X1/2" MISC





F QL(5 ea daily)








F QL(5 ea daily)

LEADER INSULIN SYRINGE/1ML/28G X 1/2"MISC


LEADER INSULIN SYRINGE/1ML/29G X 1/2"MISC


LEADER INSULIN SYRINGE/1ML/30G X5/16" MISC


LEADER INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

LEADER UNIFINE PENTIPS PLUS/MINI/31GX3/16"MISC

F


LEADER UNIFINE PENTIPS PLUS/SHORT/31GX5/16"MISC

F


LEADER UNIFINE PENTIPS/MINI/31GX3/16"MISC



135

Drug Name DrugTier

Requirements/Limits

LEADER UNIFINE PENTIPS/NANO/32GX5/32" MISC


LEADER UNIFINE PENTIPS/PLUS/32GX5/32" MISC


LITE TOUCH PEN NEEDLES/31G X 3/16"MISC


LITETOUCH INSULIN SYRINGE/0.3ML/29G X1/2" MISC





F QL(5 ea daily)




F QL(5 ea daily)

LITETOUCH INSULIN SYRINGE/1ML/30G X5/16" MISC


LITETOUCH INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


LITETOUCH INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


LITETOUCH INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC





F QL(5 ea daily)

LITETOUCH PEN NEEDLES 29GX12.7MM MISC

F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

LITETOUCH PEN NEEDLES 31G X 6MM MISC

F QL(5 ea daily)

LITETOUCH PEN NEEDLES 31GX8MM SHORT MISC


LIVE BETTER PEN NEEDLES 29G X 12MM MISC





F QL(5 ea daily)

LONGS INSULIN SYRINGE/0.5ML/31G X5/16" MISC

F QL(5 ea daily)

MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F



F


MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X 1/2" MISC


MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/30G X 5/16"MISC

F


MARATHON MEDICAL PENTIPS29GX12MM MISC


MARATHON MEDICAL PENTIPS31GX5MM MISC F QL(5 ea daily);

RX/OTC MARATHON MEDICAL PENTIPS31GX8MM MISC F QL(5 ea daily);

RX/OTC


136

Drug Name DrugTier

Requirements/Limits

MARATHON MEDICAL PENTIPS32GX4MM MISC F QL(5 ea daily);

RX/OTC MAXI-COMFORT INSULIN SYRINGE/U-100/0.5ML/28GX1/2" MISC


MAXI-COMFORT INSULIN SYRINGE/U-100/1ML/28GX1/2" MISC


MEDIC INSULIN SYRINGE/0.3ML/30G X5/16" MISC


MEDIC INSULIN SYRINGE/0.5ML/30G X5/16" MISC


MEDICINE SHOPPE PEN NEEDLES 29G X 12MM MISC



F QL(5 ea daily)



MEIJER PEN NEEDLES 29G X12MM MISC F QL(5 ea daily);

RX/OTC MEIJER PEN NEEDLES 31G X6MM MISC F QL(5 ea daily)

MEIJER PEN NEEDLES 31G X8MM MISC F QL(5 ea daily);

RX/OTC MM PEN NEEDLES 31G X 1/4" MISC F QL(5 ea daily)

MM PEN NEEDLES 31G X 3/16" MISC F QL(5 ea daily);

RX/OTC MM PEN NEEDLES 31G X 5/16" MISC F QL(5 ea daily);

RX/OTC MM PEN NEEDLES 32G X 5/32" MISC F QL(5 ea daily);

RX/OTC MONOJECT INSULIN SYRINGE/1ML MISC F QL(5 ea daily);

RX/OTC MONOJECT INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/25G X 5/8"MISC

F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/27G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/PERMNEEDLE/1ML/28G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/PERMNEEDLE/U-100/0.5ML/28GX 1/2" MISC

F


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29GX1/2"MISC

F


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/SOFTPACK/1ML/27G X 1/2" MISC


MONOJECT INSULIN SYRINGE/SOFTPACK/U-100/0.5ML/28G X 1/2"MISC

F


MONOJECT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC

F



F



F



137

Drug Name DrugTier

Requirements/Limits

MONOJECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC


MONOJECT INSULIN SYRINGE/U-100/1ML/30GX 5/16" MISC


MONOJECT INSULIN SYRINGEREGULAR LUER TIP/SOFTPACK/1ML MISC


MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X1/2" MISC

F



F



F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)

MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/28G X 1/2"MISC

F


MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/29G X 1/2"MISC

F


Drug Name DrugTier

Requirements/Limits

MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC

F


MOORE MED MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


MOORE MED MONOJECT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


MOORE MED MONOJECT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


MOORE MED MONOJECT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC


MS INSULIN SYRINGE/0.3ML/31G X5/16" MISC

F QL(5 ea daily)

MS INSULIN SYRINGE/0.5ML/31G X5/16" MISC

F QL(5 ea daily)

MS INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

NOVOFINE 30GX8MM MISC F QL(5 ea daily);

RX/OTC NOVOFINE 32GX6MM MISC F QL(5 ea daily)

NOVOFINE AUTOCOVER 30GX8MM MISC F QL(5 ea daily);

RX/OTC NOVOFINE PLUS 32GX4MM MISC F QL(5 ea daily);

RX/OTC NOVOTWIST 30GX8MM MISC F QL(5 ea daily);

RX/OTC NOVOTWIST 32GX5MM MISC F QL(5 ea daily);

RX/OTC PC UNIFINE PENTIPS 29G X1/2" MISC F QL(5 ea daily);

RX/OTC PC UNIFINE PENTIPS 31G X5MM MINI MISC F QL(5 ea daily);

RX/OTC PC UNIFINE PENTIPS 31G X6MM ULTRA SHORT MISC

F QL(5 ea daily)


138

Drug Name DrugTier

Requirements/Limits

PC UNIFINE PENTIPS 31G X8MM SHORT MISC F QL(5 ea daily);

RX/OTC PEN NEEDLES 29G X 12MM MISC F QL(5 ea daily);

RX/OTC PEN NEEDLES 29GX1/2"MISC F QL(5 ea daily);


RX/OTC PEN NEEDLES 30GX8MM MISC F QL(5 ea daily);

RX/OTC PEN NEEDLES 31G X 1/4"SHORT MISC F QL(5 ea daily)

PEN NEEDLES 31G X 3/16" MISC F QL(5 ea daily);


RX/OTC PEN NEEDLES 31G X 6MM MISC F QL(5 ea daily)

PEN NEEDLES 31G X 8MM MISC F QL(5 ea daily);


RX/OTC PEN NEEDLES 31GX6MM (1/4") MISC F QL(5 ea daily)

PEN NEEDLES 31GX8MM (5/16") MISC F QL(5 ea daily);

RX/OTC PEN NEEDLES 31GX8MM MISC F QL(5 ea daily);



RX/OTC PEN NEEDLES 32G X 6MM MISC F QL(5 ea daily)

PEN NEEDLES 32GX4MM MISC F QL(5 ea daily);

RX/OTC PENTIPS 29G X 12MM MISC F QL(5 ea daily);

RX/OTC PENTIPS 29GX12MM MISC F QL(5 ea daily);



RX/OTC

PENTIPS 31GX5MM MISC F QL(5 ea daily);RX/OTC

Drug Name DrugTier

Requirements/Limits

PENTIPS 31GX6MM MISC F QL(5 ea daily)


PENTIPS 32G X 4MM MISC F QL(5 ea daily);

RX/OTC


PRECISION SURE-DOSE INSULIN SYRINGE/0.3ML/30G X5/16" MISC

F



F



F



F

QL(5 ea daily)

PRECISION SURE-DOSE INSULIN SYRINGE/1ML/28G X 1/2"MISC

F


PRECISION SURE-DOSE PLUSINSULIN SYRINGE/0.3ML/29G X1/2" MISC

F


PRECISION SURE-DOSE PLUSINSULIN SYRINGE/1ML/29G X 1/2"MISC

F


PREFERRED PLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F



139

Drug Name DrugTier

Requirements/Limits


F



F


PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC


PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


PREFERRED PLUS UNIFINE PENTIPS 29G X 12MM MISC


PREFERRED PLUS UNIFINE PENTIPS 31G X 6MM ULTRA SHORT MISC

F

QL(5 ea daily)

PREFERRED PLUS UNIFINE PENTIPS 31G X 8MM SHORT MISC


PREFERRED PLUS UNIFINE PENTIPS 32GX4MM MISC


PREFERRED PLUS UNIFINE PENTIPS/MINI/31GX5MMMISC

F


PRO COMFORT PEN NEEDLES/31G X 8MMMISC







F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

PRODIGY INSULIN SYRING/U-100/0.3ML/31GX 5/16" MISC

F QL(5 ea daily)

PRODIGY INSULIN SYRINGE/1/2ML/31G X5/16" MISC

F QL(5 ea daily)

PRODIGY INSULIN SYRINGE/1ML/28G X 1/2"MISC


PX EXTRA SHORT PEN NEEDLES 31GX6MM MISC

F QL(5 ea daily)

PX INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

F QL(5 ea daily)


F QL(5 ea daily)


F QL(5 ea daily)


F QL(5 ea daily)

PX INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC F QL(5 ea daily)

PX INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F QL(5 ea daily)

PX MINI PEN NEEDLES 31GX5MM MISC F QL(5 ea daily);

RX/OTC PX PEN NEEDLE 29GX12MM MISC F QL(5 ea daily);

RX/OTC PX PEN NEEDLE 31GX8MM MISC F QL(5 ea daily);

RX/OTC PX SHORTLENGTH PEN NEEDLES/31GX8MMMISC


QC PEN NEEDLES 29G X 12MM MISC F QL(5 ea daily);

RX/OTC QC PEN NEEDLES 31G X 6MM MISC F QL(5 ea daily)

QC PEN NEEDLES 31G X 8MM MISC F QL(5 ea daily);

RX/OTC QC UNIFINE PENTIPS 32GX4MM MISC F QL(5 ea daily);

RX/OTC


140

Drug Name DrugTier

Requirements/Limits

RA INSULIN SYRINGE/0.5ML/29G X1/2" MISC


RA INSULIN SYRINGE/1ML/29G X 1/2"MISC


RA INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC


RA INSULIN SYRINGE/U-100/1 ML/30G X 5/16"MISC


RA PEN NEEDLES 31G X 5MM3/16" MISC F QL(5 ea daily);

RX/OTC RA PEN NEEDLES 31G X 8MM5/16" MISC F QL(5 ea daily);

RX/OTC REALITY INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


REALITY INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


REALITY INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC


REALITY INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


RELION INSULIN SYRINGE 1ML/31GX15/64" MISC

F QL(5 ea daily)

RELION INSULIN SYRINGE/U-00/1ML/29GX 1/2" MISC


RELION INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


F



F



F

QL(5 ea daily)




F QL(5 ea daily)


F QL(5 ea daily)

RELION MINI PEN NEEDLES 31GX6MM MISC

F QL(5 ea daily)

RELION PEN NEEDLES 29GX12MM MISC F QL(5 ea daily);

RX/OTC RELION PEN NEEDLES 31GX6MM MISC F QL(5 ea daily)

RELION PEN NEEDLES 31GX8MM MISC F QL(5 ea daily);

RX/OTC RELION PEN NEEDLES 32GX4MM MISC F QL(5 ea daily);

RX/OTC RELION SHORT PEN NEEDLES31GX8MM MISC F QL(5 ea daily);

RX/OTC SAFESNAP INSULIN SYRINGE/0.3ML/30G X5/16" MISC


SAFESNAP INSULIN SYRINGE/0.5ML/29G X1/2" MISC


SAFESNAP INSULIN SYRINGE/0.5ML/30G X5/16" MISC


SAFESNAP INSULIN SYRINGE/1ML/28G X 1/2"MISC



141

Drug Name DrugTier

Requirements/Limits

SAFESNAP INSULIN SYRINGE/1ML/29G X 1/2"MISC


SAFETY INSULIN SYRINGES 0.5ML/29GX1/2" MISC


SAFETY INSULIN SYRINGES 0.5ML/30GX5/16" MISC


SAFETY INSULIN SYRINGES 1ML/27GX1/2"MISC





F QL(5 ea daily)

SAFETY-GLIDE INSULIN SYRINGE/0.3ML/29G X1/2" MISC


SB INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC


SB INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC


SB INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC F QL(5 ea daily);

RX/OTC SB INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC


SB INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F QL(5 ea daily)

SCHNUCKS INSULIN SYRINGEULTI-FINE/U-100/0.5ML/29G X 1/2"MISC

F


SCHNUCKS INSULIN SYRINGEULTI-FINE/U-100/0.5ML/30G X 5/16"MISC

F


SHOPKO UNIFINE PENTIPS PEN NEEDLES/MICRO/32GX4MM MISC

F


Drug Name DrugTier

Requirements/Limits

SHOPKO UNIFINE PENTIPS PEN NEEDLES/MINI/31GX5MMMISC

F


SHOPKO UNIFINE PENTIPS PEN NEEDLES/ORIGINAL/29GX12MM MISC

F


SHOPKO UNIFINE PENTIPS PEN NEEDLES/SHORT/31GX8MM MISC

F


SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/MICRO/REMOVR/32GX4MM MISC

F


SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/MINI/REMOVER/31GX5MM MISC

F


SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/REMOVER/29GX12MM MISC

F


SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/SHORT/REMOVR/31GX8MM MISC

F


SM INSULIN SYRINGE/1ML/31G X5/16" MISC

F QL(5 ea daily)

SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F


SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16MISC

F

QL(5 ea daily)


142

Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)


F



F



F

QL(5 ea daily)


F


SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X 5/16MISC

F

QL(5 ea daily)

SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC





F QL(5 ea daily)

SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

SURE COMFORT PEN NEEDLES29GX1/2"12.7MM MISC

F QL(5 ea daily)

SURE COMFORT PEN NEEDLES30GX5/16"SHORT MISC


Drug Name DrugTier

Requirements/Limits

SURE COMFORT PEN NEEDLES31GX3/16"(5MM) MISC


SURE COMFORT PEN NEEDLES31GX5/16"(8MM) MISC


SURE COMFORT PEN NEEDLES32GX5/32" MISC F QL(5 ea daily);

RX/OTC SURE COMFORT PEN NEEDLES32GX6MM MISC F QL(5 ea daily)

SURE-FINE PEN NEEDLES 29GX1/2"12.7MM MISC

F QL(5 ea daily)

SURE-FINE PEN NEEDLES 31GX3/16" 5MMMISC


SURE-FINE PEN NEEDLES 31GX5/16" 8MMMISC


SURE-JECT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)


143

Drug Name DrugTier

Requirements/Limits

SURE-JECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC







F QL(5 ea daily)

TECHLITE PEN NEEDLES 29GX 12 MM MISC F QL(5 ea daily);

RX/OTC TECHLITE PEN NEEDLES 31GX 5MM MISC F QL(5 ea daily);

RX/OTC TECHLITE PEN NEEDLES/31GX 5MMMISC


TECHLITE PEN NEEDLES/31GX 6 MMMISC

F QL(5 ea daily)

TECHLITE PEN NEEDLES/31GX 8MMMISC





F QL(5 ea daily)

TODAYS HEALTH MINI PEN NEEDLES 31G X 1/4"MISC

F QL(5 ea daily)

TODAYS HEALTH ORIGINAL PEN NEEDLES 29G X 1/2" MISC


TODAYS HEALTH SHORT PEN NEEDLES 31G X 5/16" MISC


TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX1/4" MISC

F QL(5 ea daily)

TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX5/16" MISC


Drug Name DrugTier

Requirements/Limits

TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC

F


TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/31G X5/16" MISC

F

QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F


TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC

F


TOPCO INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



144

Drug Name DrugTier

Requirements/Limits


F


TOPCO INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC


TOPCO INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)

TRUEPLUS INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC






Drug Name DrugTier

Requirements/Limits


F QL(5 ea daily)

TRUEPLUS PEN NEEDLES 29GX12MM MISC





F QL(5 ea daily)





ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X1/2" MISC

F


ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2"MISC

F


ULTICARE INSULIN SYRINGE/0.3ML/29G X1/2" MISC



F QL(5 ea daily)








F QL(5 ea daily)




145

Drug Name DrugTier

Requirements/Limits

ULTICARE INSULIN SYRINGE/1ML/28G X 1/2"MISC





F QL(5 ea daily)

ULTICARE INSULIN SYRINGE/1ML/30G X5/16" MISC


ULTICARE INSULIN SYRINGE/SHORT/0.3ML/30G X 5/16" MISC



F QL(5 ea daily)




F QL(5 ea daily)

ULTICARE INSULIN SYRINGE/SHORT/1ML/30G X 5/16" MISC


ULTICARE INSULIN SYRINGE/SHORT/1ML/31G X 5/16" MISC

F QL(5 ea daily)

ULTICARE INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

ULTICARE INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC



F QL(5 ea daily)




F QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTICARE MICRO PEN NEEDLES 31G X 8MM MISC


ULTICARE MICRO PEN NEEDLES 32G X 4MM MISC



146

Drug Name DrugTier

Requirements/Limits

ULTICARE MICRO PEN NEEDLES/32G X 4MMMISC


ULTICARE MINI PEN NEEDLES 31GX6MM MISC

F QL(5 ea daily)

ULTICARE MINI PEN NEEDLES ULTI-FINE IV MISC

F QL(5 ea daily)

ULTICARE MINI PEN NEEDLES/31G X 6MMMISC

F QL(5 ea daily)

ULTICARE MINI PEN NEEDLES31GX6MM MISC F QL(5 ea daily)

ULTICARE ORIGINAL PEN NEEDLES ULTI-FINE MISC


ULTICARE PEN NEEDLES 31GX 5MM/MINI MISC F QL(5 ea daily);

RX/OTC ULTICARE PEN NEEDLES/29GX 12.7MMMISC

F QL(5 ea daily)

ULTICARE SHORT PEN NEEDLES 31GX8MM MISC


ULTICARE SHORT PEN NEEDLES ULTI-FINE IV MISC


ULTICARE SHORT PEN NEEDLES/31G X 8MMMISC


ULTILET INSULIN SYRINGE/0.3ML/30G X8MM MISC



F QL(5 ea daily)



ULTILET INSULIN SYRINGE/1ML/30G X8MM MISC


ULTILET INSULIN SYRINGE/1ML/31G X8MM MISC

F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X 12.7MM MISC

F QL(5 ea daily)

ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X 5/16" MISC



F QL(5 ea daily)




F QL(5 ea daily)

ULTILET INSULIN SYRINGE/SHORT/1ML/30G X 5/16" MISC


ULTILET INSULIN SYRINGE/SHORT/1ML/31G X 5/16" MISC

F QL(5 ea daily)

ULTILET INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC

F

QL(5 ea daily)

ULTILET INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

F QL(5 ea daily)

ULTILET PEN NEEDLE 29GX12.7MM MISC F QL(5 ea daily)

ULTILET PEN NEEDLE 31GX5MM MISC F QL(5 ea daily);

RX/OTC ULTILET PEN NEEDLE 31GX8MM MISC F QL(5 ea daily);

RX/OTC ULTILET PEN NEEDLE 32GX4MM MISC F QL(5 ea daily);

RX/OTC ULTILET PEN NEEDLE 32GX4MM/SHORT MISC F QL(5 ea daily);

RX/OTC ULTILET SHORT PEN NEEDLES 31GX5/16"MISC


ULTILET SHORT PEN NEEDLES31GX3/16" MISC F QL(5 ea daily);

RX/OTC ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC

F



147

Drug Name DrugTier

Requirements/Limits

ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)

ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC


ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.3ML/30GX5/16"MISC

F


Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)


F



F

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/30GX5/16" MISC


ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/31GX5/16" MISC

F QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE/U-100/0.3ML/29GX1/2" MISC


ULTRA-THIN II INSULIN SYRINGE/U-100/0.5ML/29GX1/2" MISC


ULTRA-THIN II INSULIN SYRINGE/U-100/1ML/29GX1/2" MISC


ULTRA-THIN II MINI PEN NEEEDLES/31GX3/16"MISC


ULTRA-THIN II PEN NEEDLES 29GX1/2" MISC F QL(5 ea daily)

ULTRA-THIN II PEN NEEDLES/SHORT/31GX5/16" MISC


UNIFINE PENTIPS 29GX12MM MISC F QL(5 ea daily);

RX/OTC UNIFINE PENTIPS 31G X 3/16" MISC F QL(5 ea daily);

RX/OTC UNIFINE PENTIPS 31GX5MM MISC F QL(5 ea daily);

RX/OTC UNIFINE PENTIPS 31GX6MM MISC F QL(5 ea daily)

UNIFINE PENTIPS 31GX8MM MISC F QL(5 ea daily);

RX/OTC UNIFINE PENTIPS 32GX4MM MISC F QL(5 ea daily);

RX/OTC


148

Drug Name DrugTier

Requirements/Limits

UNIFINE PENTIPS PLUS 29GX12MM MISC F QL(5 ea daily);

RX/OTC UNIFINE PENTIPS PLUS 31GX5MM MISC F QL(5 ea daily);

RX/OTC UNIFINE PENTIPS PLUS 31GX6MM MISC F QL(5 ea daily)

UNIFINE PENTIPS PLUS 31GX8MM MISC F QL(5 ea daily);

RX/OTC UNIFINE PENTIPS PLUS 32GX4MM MISC F QL(5 ea daily);

RX/OTC V-R MONOJECT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F


V-R MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


V-R MONOJECT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


V-R MONOJECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC


V-R MONOJECT INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


VALUE HEALTH INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


VALUE HEALTH INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


VALUMARK PEN NEEDLES 29GX12MM MISC


VALUMARK PEN NEEDLES 31GX 6MM MISC

F QL(5 ea daily)

VALUMARK PEN NEEDLES 31GX 8MM MISC


VANISHPOINT INSULIN SYRINGE/0.5ML/30G X1/2" MISC

F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

VANISHPOINT INSULIN SYRINGE/0.5ML/30G X5/16" MISC


VANISHPOINT INSULIN SYRINGE/1ML/29G X 1/2"MISC


VANISHPOINT INSULIN SYRINGE/1ML/30G X5/16" MISC


VIDA MIA UNIFINE PENTIPS32GX4MM MISC F QL(5 ea daily);

RX/OTC VIDA MIA UNIFINE PENTIPSMINI 31GX6MM MISC

F QL(5 ea daily)

VIDA MIA UNIFINE PENTIPSORIGINAL 29GX12MM MISC


VIDA MIA UNIPFINE PENTIPSSHORT 31GX8MM MISC


VP INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC


WEGMANS UNIFINE PENTIPS PLUS 32GX4MM MISC


WEGMANS UNIFINE PENTIPS PLUS/MINI/31GX5MMMISC

F


WEGMANS UNIFINE PENTIPS PLUS/SHORT/31GX8MMMISC

F


WEGMANS UNIFINE PENTIPS PLUS/ULTRASHORT/31GX6MM MISC

F QL(5 ea daily)

Respiratory Therapy Supplies

ACE AEROSOL CLOUD ENHANCER MISC F

QL(1 ea per350 daysretail); RX/OTC

ACTIVITY POUCH MISC F QL(1 ea per350 daysretail); RX/OTC

ADULT AEROSOL MASK MISC F



149

Drug Name DrugTier

Requirements/Limits

ADULT MASK LARGE MISC F


ADULT MASK MISC F QL(1 ea per350 daysretail); RX/OTC

AEROCHAMBER MINI AEROSOLCHAMBER DEVI

F QL(2 ea per350 daysretail); RX/OTC

AEROCHAMBER MV MISC F


AEROCHAMBER PLUS FLOW VU MISC F


AEROCHAMBER PLUS FLOW-VU MISC F


AEROCHAMBER PLUS FLOW-VU/LARGE MASKMISC


AEROCHAMBER PLUS FLOW-VU/MASK MISC F


AEROCHAMBER PLUS FLOW-VU/MEDIUM MASKMISC


AEROCHAMBER PLUS FLOW-VU/SMALL MASKMISC


AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VUMISC

F


AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL MISC F


AEROCHAMBER Z-STAT PLUS/LARGE MASK MISC F


AEROCHAMBER Z-STAT PLUS/MEDIUM MASKMISC


AEROCHAMBER Z-STAT PLUS/SMALL MASK MISC F


Drug Name DrugTier

Requirements/Limits

AEROCHAMBER/FLOWSIGNAL MISC F


AEROTRACH PLUS MISC F QL(1 ea per350 daysretail); RX/OTC

AEROVENT PLUS HOLDING CHAMBER/COLLAPSIBLEDEVI

F


AIRS PEDIATRIC AEROSOL MASK MISC F


ALL FLOW 1000 PULMONARY FUNCTION FILTER MISC


ARIAL CHAMBER DEVI F QL(2 ea per350 daysretail); RX/OTC

BREATHERITE COLLAPSIBLEADULT SPACER W/MASK MISC


BREATHERITE COLLAPSIBLECHILD SPACER W/MASK MISC


BREATHERITE COLLAPSIBLEINFANT SPACER W/MASK MISC


BREATHERITE COLLAPSIBLESMALL CHILD SPACER W/MASKMISC

F


BREATHERITE COLLAPSIBLESPACER W/ NEONATE MASK MISC


BREATHERITE MISC F QL(2 ea per350 daysretail); RX/OTC

BREATHERITE RIGID SPACERW/MASK MISC F


BREATHERITE W/LARGEMASK MISC F


BREATHERITE W/MEDIUM MASK MISC F



150

Drug Name DrugTier

Requirements/Limits

BREATHERITE W/SMALLMASK MISC F


BUBBLES THE FISH II PEDIATRIC MASK/PVCMISC


CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/ADULT LARGEDEVI

F


CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM DEVI

F


CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/SMALL DEVI

F


CO MONITOR REPLACEMENT TPIECES MISC


COMPACT SPACE CHAMBER/ANTI-STATICDEVI


COMPACT SPACE CHAMBER/ANTI-STATIC/LARGE MASKDEVI

F


COMPACT SPACE CHAMBER/ANTI-STATIC/MEDIUM MASKDEVI

F


COMPACT SPACE CHAMBER/ANTI-STATIC/SMALL MASKDEVI

F


CONE MASK MISC F QL(1 ea per350 daysretail); RX/OTC

E-Z SPACER DEVI F QL(2 ea per350 daysretail); RX/OTC

E-Z SPACER THE BODY GUARDS PACK DEVI F


Drug Name DrugTier

Requirements/Limits

EARLOOP MASK MISC F QL(1 ea per350 daysretail); RX/OTC

EASIVENT MISC F QL(2 ea per350 daysretail); RX/OTC

EASIVENT/MASK-LARGEMISC F


EASIVENT/MASK-MEDIUM MISC F


EASIVENT/MASK-SMALLMISC F


EBASE CONTROLLER KIT MISC F


EFLOW SCF AEROSOL HEAD MISC F


ELITE DC AUTO ADAPTER MISC F


FILTER AIR PP MISC F QL(1 ea per350 daysretail); RX/OTC

FLEXICHAMBER DEVI F QL(2 ea per350 daysretail); RX/OTC

FULL KIT NEBULIZER SET MISC F


HEALTHY LIVING REPLACEMENT FILTERS MISC


HEALTHY LIVING REPLACEMENT KIT FOR NEBULIZER MISC


HEALTHY LIVING REPLACEMENT MASKS MISC


HUDSON RCI SEE-THRU AEROSOL MASK ELONGATED/ADULTMISC

F



151

Drug Name DrugTier

Requirements/Limits

INNOSPIRE REPLACEMENT FILTER MISC


INSPIRACHAMBER/ANTI-STATIC VALVED/MOUTHPIECEDEVI

F


INSPIRACHAMBER/LARGE DEVI F


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM DEVI


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL DEVI


INSPIREASE DRUG DELIVERYSYSTEM MISC F


INSPIREASE RESERVOIR BAGS MISC F

LITEAIRE DEVI F QL(2 ea per350 daysretail); RX/OTC

LITETOUCH MASK LARGE MISC F


LITETOUCH MASK MEDIUM MISC F


LITETOUCH MASK SMALL MISC F


MICROCHAMBER MISC F QL(2 ea per350 daysretail); RX/OTC

MICROELITE FILTER REPLACEMENTS MISC F


MICROELITE RECHARGEABLE BATTERY MISC


MICROSPACER MISC F QL(2 ea per350 daysretail); RX/OTC

MINIELITE FILTER REPLACEMENTS MISC F


Drug Name DrugTier

Requirements/Limits

MINIELITE RECHARGEABLE BATTERY MISC


NEBULIZER AIR TUBE/PLUGS MISC F


NEBULIZER PEDIATRIC MASK MISC F


NOSE CLIP MISC F QL(1 ea per350 daysretail); RX/OTC

OPTICHAMBER ADVANTAGE MISC F


OPTICHAMBER ADVANTAGE/LARGEMASK MISC


OPTICHAMBER ADVANTAGE/MEDIUMFACE MASK MISC


OPTICHAMBER ADVANTAGE/SMALLFACE MASK MISC


OPTICHAMBER DIAMOND DEVI F


OPTICHAMBER DIAMOND MISC F


OPTICHAMBER DIAMOND/LARGEFACEMASK DEVI


OPTICHAMBER DIAMOND/MEDIUM FACEMASK MISC


OPTICHAMBER DIAMOND/SMALLFACEMASK MISC


OPTICHAMBER FACE MASK/LARGE MISC F


OPTICHAMBER FACE MASK/MEDIUM MISC F


OPTICHAMBER FACE MASK/SMALL MISC F



152

Drug Name DrugTier

Requirements/Limits

OPTIHALER MDI DRUG DELIVERY SYSTEM DEVI F


OPTIHALER MISC F QL(2 ea per350 daysretail); RX/OTC

PARI ALTERA NEBULIZER HANDSET MISC


PARI BABY CONVERSION KITSIZE 1 MISC F






PARI ERAPID NEBULIZER HANDSET MISC F


PARI EXPIRATORY FILTER VALVE SET DEVI F


PARI MASK SET MISC F QL(1 ea per350 daysretail); RX/OTC

PARI SOFT PLASTIC ADULT MASK MISC F


PARI SOFT PLASTIC PEDIATRIC MASK MISC F


PEDIATRIC AEROSOL MASK MISC F


PEDIATRIC MOUTHPIECE/DISPOSABLE MISC


PFLEX MISC F QL(1 ea per350 daysretail); RX/OTC

PILLOW MASK/ADULTMISC F


PILLOW MASK/CHILDMISC F


Drug Name DrugTier

Requirements/Limits

PILLOW MASK/PEDIATRIC MISC F


POCKET CHAMBER DEVI F QL(2 ea per350 daysretail); RX/OTC

POCKET SPACER DEVI F QL(2 ea per350 daysretail); RX/OTC

REPLACEMENT AIR FILTER MISC F


REPLACEMENT FILTERS MISC F


RITEFLO DEVI F QL(2 ea per350 daysretail); RX/OTC

SAMI THE SEAL REPLACEMENTFILTERS MISC


SIDESTREAM ADULT FACE MASK MISC F


SIDESTREAM PEDIATRIC FACEMASK MISC F


SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL MISC


SIDESTREAM PEDIATRIC FACEMASK/TUCKER THETURTLE MISC


SIDESTREAM PLUS ADULT FACE MASK MISC F


SILICONE MASK FOR BREATHERITE CHAMBER/ADULT MISC


SILICONE MASK FOR BREATHERITE CHAMBER/INFANT MISC


SILICONE MASK FOR BREATHERITE CHAMBER/PEDIATRICMISC

F



153

Drug Name DrugTier

Requirements/Limits

SILICONE MASK FOR BREATHRITE CHAMBER/ADULT MISC


SOOTHENEB NBL 100 CHILD MASK MISC F


SOOTHENEB NBL 100 MEDICATION CUP MISC F


SOOTHENEB NBL 100 MESH CAP MISC F


SOOTHENEB NBL100 ADULT MASK MISC F


THRESHOLD IMT MISC F QL(1 ea per350 daysretail); RX/OTC

TUBING/WING TIP MISC F QL(1 ea per350 daysretail); RX/OTC

VALVED HOLDING CHAMBER DEVI F


VORTEX VALVED HOLDING CHAMBER DEVI


WATCHHALER DEVI F QL(2 ea per350 daysretail); RX/OTC

WINDMILL TRAINER MISC F


MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches Migraine Combinations CAFERGOT TABS (Ergotamine w/ Caffeine) NP

ergotamine w/ caffeine tabs NP

isometheptene-caffeine-acetaminophen tabs NP

isometheptene-dichloralphenazone-acetaminophen caps

NP

MIGERGOT SUPP NP

Drug Name DrugTier

Requirements/Limits

MIGRANOW THPK NP

PRODRIN TABS (Isometheptene-Caffeine-Acetaminophen)

NP

SUMATRIPTAN/NAPROXEN SODIM TABS NP QL(2 ea per 29days retail) TREXIMET TABS 85MG-500MG, 10MG-60MG NP QL(2 ea per 29days retail) Migraine Products - NSAIDs CAMBIA PACK NP

Migraine Products DIHYDROERGOTAMINE MESYLATE SOLN NA 4 MG/ML

NP

ERGOMAR SUBL NP

MIGRANAL SOLN NP

Serotonin Agonists

almotriptan malate tabs NP QL(0.62 eadaily)

AMERGE TABS (Naratriptan HCl) NP

Limit 18ea permonth;QL(0.6ea daily)

AXERT TABS (AlmotriptanMalate) NP QL(0.62 eadaily) eletriptan hydrobromidetabs NP QL(18 ea per29 days retail) FROVA TABS (FrovatriptanSuccinate) NP QL(0.62 eadaily)

frovatriptan succinate tabs NP QL(0.62 eadaily)

IMITREX SOLN NA 20 MG/ACT (Sumatriptan) NP

6 per monthQL(0.2 eadaily); AL; Atleast 12 yrs old

IMITREX SOLN NA 5 MG/ACT (Sumatriptan) NP


IMITREX SOLN SC 6 MG/0.5ML (SumatriptanSuccinate)

NP Limit 18ml permonth;QL(0.6ml daily)


154

Drug Name DrugTier

Requirements/Limits

IMITREX STATDOSE REFILL SOCT 4 MG/0.5ML(Sumatriptan Succinate)

NP QL(0.6 mldaily)

IMITREX STATDOSE REFILL SOCT 6 MG/0.5ML(Sumatriptan Succinate)

NP

Limit 18ml permonth;QL(18ml per 29 daysretail)

IMITREX STATDOSE SYSTEM SOAJ 4 MG/0.5ML (SumatriptanSuccinate)

NP


IMITREX STATDOSE SYSTEM SOAJ 6 MG/0.5ML (SumatriptanSuccinate)

NP

Limit 18ml permonth

IMITREX TABS OR 50 MG, 25 MG, 100 MG (Sumatriptan Succinate)

NP Limit 18ea permonth;QL(0.6ea daily)

MAXALT TABS (RizatriptanBenzoate) NP


MAXALT-MLT TBDP (Rizatriptan Benzoate) NP QL(0.6 eadaily)

naratriptan hcl tabs NP Limit 18ea permonth;QL(0.6ea daily)

ONZETRA XSAIL EXHP NP QL(0.62 eadaily) RELPAX TABS (EletriptanHydrobromide) F QL(18 ea per

29 days retail)

rizatriptan benzoate tabs10 mg, 5 mg F


rizatriptan benzoate tbdp 5mg, 10 mg F QL(0.6 ea

daily)

sumatriptan soln 20 mg/act F

6 per monthQL(0.2 eadaily); AL; Atleast 12 yrs old

sumatriptan soln 5 mg/act F QL(0.2 eadaily); AL; Atleast 12 yrs old

sumatriptan succinate soajsc 4 mg/0.5ml F


sumatriptan succinate soajsc 6 mg/0.5ml F QL(18 ml per

fill retail)

Drug Name DrugTier

Requirements/Limits

sumatriptan succinate soajsc 6 mg/0.5ml 4

Limit 18ml permonth;QL(18ml per fill retail)

sumatriptan succinate soctsc 4 mg/0.5ml F QL(0.6 ml

daily)

sumatriptan succinate soctsc 6 mg/0.5ml F


sumatriptan succinate solnsc 6 mg/0.5ml F

Limit 18ml permonth;QL(0.6ml daily)

SUMATRIPTAN SUCCINATE SOSY SC 6 MG/0.5ML

F


sumatriptan succinate tabsor 100 mg, 25 mg, 50 mg F


SUMAVEL DOSEPRO SOTJ NP QL(0.62 mldaily)

ZECUITY PTCH NP QL(0.62 eadaily) ZEMBRACE SYMTOUCH SOAJ NP

zolmitriptan tabs 5 mg, 2.5 mg NP QL(0.62 eadaily) zolmitriptan tbdp 5 mg, 2.5 mg NP

ZOMIG SOLN NA 5 MG, 2.5 MG NP

ZOMIG TABS OR 2.5 MG, 5 MG (Zolmitriptan) NP QL(0.62 eadaily) ZOMIG ZMT TBDP (Zolmitriptan) NP

MINERALS & ELECTROLYTES

Calcium calcium carbonate tabs 1500 mg, 600mg, 1250 mg,600 mg, 500 mg

F

calcium carbonate-cholecalciferol chew 500mg-400unit, 500mg-100unit

F


155

Drug Name DrugTier

Requirements/Limits

calcium carbonate-cholecalciferol tabs 500mg-200unit, 500mg-400unit,500mg-500mg-400unit-400unit, 250mg-125unit,600mg-800unit, 600mg-400unit, 600mg-200unit,600mg-600mg-800unit-400unit

F

calcium carbonate-ergocalciferol tabs F

calcium carbonate-vitamin d tabs 125unit-500mg,600mg-400unit, 200unit-500mg, 500mg-200unit,500mg-500mg-200unit-200unit, 600mg-200unit,125unit-250mg, 500mg-125unit, 200unit-600mg,500mg-400unit, 250mg-125unit, 400unit-600mg

F

calcium citrate tabs 200 mg, 950 mg F

calcium citrate-vitamin d tabs 315mg-250unit,315mg-200unit

F

CALCIUM GLUCONATE TABS OR 500 MG F

calcium tabs 500 mg F

CALCIUM TABS 600MG-200UNIT F

calcium w/ vitamin d tabs F

calcium-magnesium-zinctabs 333mg-5mg-133mg,5mg-133.333mg-333.333mg, 5mg-134mg-334mg, 5mg-133.33mg-333.33mg, 5mg-133mg-333mg

F

CALTRATE 600+D TABS (Calcium Carbonate-Cholecalciferol)

NP

CITRACAL + D3 MAXIMUM TABS (Calcium Citrate-Vitamin D)

NP

Drug Name DrugTier

Requirements/Limits

CITRACAL MAXIMUM TABS (Calcium Citrate-Vitamin D)

NP

GNP VITAMIN D-400 TABS F

oyster shell tabs F

RA OYSTER SHELL CALCIUM/VITAMIN DTABS

F

Electrolyte Mixtures CERALYTE 70 SOLN 60MEQ/L-70MEQ/L-20MEQ/L-30MEQ/L

F QL(6084 ml perfill retail)

CERASPORT EX1 SOLN F QL(6084 ml perfill retail)

CERASPORT SOLN 4MEQ/L-18MEQ/L-20MEQ/L-6MEQ/L

F QL(6084 ml perfill retail)

ENFAMIL ENFALYTE SOLN F QL(6084 ml per

fill retail) EQUALYTE SOLN (Oral Electrolytes) NP QL(6084 ml perfill retail)

oral electrolytes soln F QL(6084 ml perfill retail)

PEDIALYTE ADVANCED CARE SOLN (Oral Electrolytes)


PEDIALYTE FREEZER POPS SOLN (Oral Electrolytes)


PEDIALYTE SINGLES SOLN (Oral Electrolytes) NP QL(6084 ml perfill retail)


156

Drug Name DrugTier

Requirements/Limits

PEDIALYTE SOLN 4.7MEQ/237ML-10.6MEQ/237ML-8.3MEQ/237ML, 20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L,2.1MEQ/59ML-2.7MEQ/59ML-0.5MG/59ML-1.2MEQ/59ML-1.5GM/59ML, 35MEQ/L-45MEQ/L-7.8MG/L-20MEQ/L-25GM/L,20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L(Oral Electrolytes)

NP

QL(6084 ml perfill retail)

Fluoride LURIDE SOLN (Sodium Fluoride) NP QL(50 ml perfill retail) sodium fluoride chew 2.2 mg, 1.1 mg, 0.25 mg, 1 mg,0.5 mg

F

sodium fluoride soln 0.125 mg/drop, 0.5 mg/ml F QL(50 ml per

fill retail) Iodine Products SSKI SOLN F

Magnesium MAG64 TBCR F

MAGNESIUM GLUCONATE TABS 500 MG

F

magnesium gluconate tabs500 mg F

magnesium oxide (mgsupplement) tabs 400 mg,241.3 mg

F

MAGONATE LIQD F

MAGOX 400 TABS (Magnesium Oxide (MgSupplement))

NP

NU-MAG TBEC F

SLOW-MAG TBEC F

Drug Name DrugTier

Requirements/Limits

Manganese MANGANESE GLUCONATE TABS NP

Mineral Combinations ADVANCED CALCIUM/VITAMIND/MAGNESIUM TABS

F

BONE DENSITY BUILDER TABS F

CAL MAG ZINC +D3 TABS F

CAL-MAG-ZINC-D TABS F

CAL-MAG-ZINC-D3 TABS F

CALCIUM/MAGNESIUM/ZINC TABS 5MG-133MG-333MG-200UNIT

F

CALCIUM/MAGNESIUM/ZINC/VITAMIN D3 TABS F

CITRACAL PLUS TABS F

FEM-CAL CITRATE TABS F

MULTI MEGA MINERALS TABS F

multiple minerals w/vitamins tabs F

MULTISOURCE CALCIUM MAGNESIUM & D FORMULA TABS

F

NATRUL-CAL TABS F

PROSTEON TABS F

THERACAL D2000 TABS F

THERACAL D4000 TABS F

THERACAL RAPID REPLETION TABS F

Phosphate K-PHOS NEUTRAL TABS (Pot Phosphate Monobasicw/ Sod Phosphate Dibasic& Monobasic)

NP


157

Drug Name DrugTier

Requirements/Limits

PHOS-NAK POWDER CONCENTRATE PACK F

pot phosphate monobasicw/ sod phosphate dibasic &monobasic tabs

F

Potassium K-TAB TBCR 10 MEQ (Potassium Chloride) NP

K-TAB TBCR 8 MEQ F

KLOR-CON M15 TBCR F

MICRO-K CPCR (Potassium Chloride) NP

potassium bicarbonate tbef F

potassium chloride cpcr or8 meq, 10 meq F

POTASSIUM CHLORIDE ER TBCR 8 MEQ F

potassium chloridemicroencapsulated crystalser tbcr

F

potassium chloride pack or20 meq F

potassium chloride soln or10 %, 20 % F

POTASSIUM CHLORIDE SOLN OR 20 % F

potassium chloride tbcr or10 meq, 8 meq F

POTASSIUM GLUCONATE TABS 2.5 MEQ

F

potassium tabs 99 mg F

Sodium sodium chloride soln ij 0.9% F

sodium chloride soln iv 0.9 % F

sodium chloride tabs or 1 gm F

Trace Minerals SE PLUS PROTEIN TABS (Selenium) NP

Drug Name DrugTier

Requirements/Limits

selenium tabs or 200 mcg F

SELENIUM TBCR OR 200 MCG F

Zinc zinc gluconate tabs or 50 mg F

zinc sulfate caps or 220 mg F

zinc tabs or 50 mg F

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents CUPRIMINE CAPS F

Immunomodulators REVLIMID CAPS F QL(1 ea daily)

THALOMID CAPS NP

Immunosuppressive Agents AZASAN TABS F

azathioprine tabs or 50 mg F

CELLCEPT CAPS (Mycophenolate Mofetil) NP

CELLCEPT SUSR (Mycophenolate Mofetil) NP

CELLCEPT TABS (Mycophenolate Mofetil) NP

cyclosporine caps or 100mg, 25 mg F

cyclosporine modified (formicroemulsion) caps F

cyclosporine modified (formicroemulsion) soln F

CYCLOSPORINE MODIFIED CAPS (Cyclosporine Modified (ForMicroemulsion))

NP

IMURAN TABS (Azathioprine) NP

mycophenolate mofetil caps F


158

Drug Name DrugTier

Requirements/Limits

mycophenolate mofetil susr F

mycophenolate mofetil tabs F

mycophenolate sodiumtbec F

MYFORTIC TBEC (Mycophenolate Sodium) NP

NEORAL CAPS (Cyclosporine Modified(For Microemulsion))

NP

NEORAL SOLN (Cyclosporine Modified(For Microemulsion))

NP

PROGRAF CAPS OR 1 MG, 0.5 MG, 5 MG (Tacrolimus)

NP

RAPAMUNE SOLN 1 MG/ML F

RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (Sirolimus)

NP

SANDIMMUNE CAPS OR 100 MG, 25 MG (Cyclosporine)

NP

sirolimus tabs F

tacrolimus caps F

Irrigation Solutions water for irrigation, sterilesoln F

Potassium Removing Agents KAYEXALATE POWD (Sodium PolystyreneSulfonate)

NP

sodium polystyrenesulfonate powd or F

sodium polystyrenesulfonate susp or 15gm/60ml

F

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral ANBESOL MAXIMUM STRENGTH LIQD (Benzocaine (Dental))

NP

Drug Name DrugTier

Requirements/Limits

benzocaine (dental) liqd 20% F

benzocaine-menthol (mouth-throat) lozg 3.6mg-15mg, 2.6mg-15mg

F

CEPACOL SORE THROAT EXTRA STRENGTH LOZG (Benzocaine-Menthol (Mouth-Throat))

NP

CEPACOL SORE THROAT EXTRASTRENGTH LOZG (Benzocaine-Menthol (Mouth-Throat))

NP

CEPACOL SORE THROAT LOZG 2.6MG-15MG, 3.6MG-15MG (Benzocaine-Menthol (Mouth-Throat))

NP

CEPACOL SORE THROAT MAXIMUM NUMBING LOZG

F

lidocaine hcl (mouth-throat)soln F

Anti-infectives - Throat clotrimazole lozg F

clotrimazole troc F

nystatin (mouth-throat) susp F

ORAVIG TABS NP

Antiseptics - Mouth/Throat CHERACOL SORE THROAT LIQD (Phenol (Antiseptic))

NP

chlorhexidine gluconate(mouth-throat) soln F

PAIN-A-LAY LIQD (Phenol (Antiseptic)) NP

PERIDEX SOLN (Chlorhexidine Gluconate (Mouth-Throat))

NP

phenol (antiseptic) liqd F

Dental Products


159

Drug Name DrugTier

Requirements/Limits

PREVIDENT 5000 DRY MOUTH GEL (Sodium Fluoride (Dental))

NP

PREVIDENT 5000 PLUS CREA (Sodium Fluoride (Dental))

NP

PREVIDENT FLUORIDE GEL (Sodium Fluoride (Dental))

NP

sodium fluoride (dental)crea dt 1.1 % F

sodium fluoride (dental) geldt 1.1 % F

THERA-FLUR-N GEL (Sodium Fluoride (Dental)) NP

Lozenges CEPASTAT LOZG F

DENTIVA LOZG F

DIABETIC TUSSIN COUGH DROPS LOZG F

SALESE LOZG F

throat lozenges lozg F

ZINC W/A&C LOZG F

Steroids - Mouth/Throat triamcinolone acetonide (mouth) pste F

Throat Products - Misc. AQUORAL SOLN F RX/OTC

BIOTENE DRY MOUTH MOISTURIZING SPRAY SOLN

F RX/OTC

CAPHOSOL SOLN F RX/OTC

CVS DRY MOUTH SPRAY SOLN F RX/OTC

DRY MOUTH SPRAY SOLN F RX/OTC

EQL DRY MOUTH ORAL RINSE SOLN F RX/OTC

MOI-STIR SOLN F RX/OTC

Drug Name DrugTier

Requirements/Limits

MOUTHKOTE SOLN F RX/OTC

NUMOISYN LIQD F RX/OTC

ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT SOLN

F RX/OTC

pilocarpine hcl (oral) tabs 5 mg F

RA DRY MOUTH SOLN F RX/OTC

SALAGEN TABS 5 MG (Pilocarpine HCl (Oral)) NP

MULTIVITAMINS

B-Complex Vitamins b-complex vitamins caps or60mg-60mg-5mg-20mg-3mg-1mcg-3mg-0.5mg,70mg-100mg-1mg-10mg-2mg-1.5mg-100mcg,60mg-60mg-3mg-5mg-20mg-3mg-1mcg-0.5mg

F

b-complex vitamins tabs or0.1mg-20mg-2mg-5mcg-3mg-1mg, 15mg-2mg-5mg-2mcg-2mg-2mg, 3mg-3mg-20mg-20mg-3mg-3mg-10mg-10mg-6mcg-6mcg-2mg-2mg, 3mg-20mg-3mg-10mg-6mcg-2mg, 10mg-10mg-2mg-1.5mg-0.2mg,100mg-50mg-40mg-10mg-20mg-5mg-4.6mg-1mcg-5mg-1mg, 3mg-10mg-20mg-3mg-6mcg-2mg,83mg-3mg-20mg-2mg-5mcg-1mg, 30mg-50mg-50mg-50mg-50mg-50mg-50mcg-50mg-100mcg-50mcg-50mg, 10mg-14mg-25mcg-7mg-4.5mg

F

B-Complex w/ C


160

Drug Name DrugTier

Requirements/Limits

b complex w/ c caps 10mg-50mg-10mg-15mg-5mg-300mg, 10.2mg-10mg-15mg-50mg-5mg-300mg, F 10mg-50mg-10.2mg-15mg-5mg-300mg, 15mg-10mg-50mg-10mg-5mg-300mg b complex w/ c tabs 15mg-10mg-50mg-10.2mg-6mcg-400mcg-5mg-300mg,50mg-10.2mg-10mg-15mg-5mg-300mg, 15mg-50mg-10.2mg-10mg-5mg-300mg,10.2mg-10.2mg-10mg-10mg-50mg-50mg-15mg-15mg-5mg-5mg-300mg-300mg, 15mg-10mg-50mg-10.2mg-5mg-300mg,100mg-100mg-5.5mg-20mg-15mcg-25mg-400mcg-5mcg-2mg-150mg, 10mg-10mg-15mg-50mg-5mg-300mg, 50mg-15mg-10mg-10.2mg-5mg-300mg, 50mg-10mg-10mg- F 15mg-5mg-300mg, 15mg-150mg-10mg-50mg-10.2mg-5mg-300mg,100mg-10mg-20mg-10mcg-15mg-5mg-500mg,15mg-10.2mg-10mg-50mg-5mg-300mg, 100mg-100mg-25mg-20mg-6mg-15mcg-100mg-5mcg-2mg-150mg, 15mg-20mg-50mg-10mg-10mcg-5mg-300mg,15mg-10mg-50mg-10mg-5mg-300mg, 100mg-20mg-5.5mg-15mcg-2mg-25mg-150mg-400mcg-5mcg-150mg, 10.2mg-10mg-15mg-50mg-5mg-300mg b-complex w/ c & calciumtabs F

b-complex w/ c & e + zntabs F

PRONUTRIENTS SUPER B-COMPLEX+ANTIOXIDANT S TABS

F

Drug Name DrugTier

Requirements/Limits

B-Complex w/ Folic Acid B-100 COMPLEX TABS F

b-complex w/ c & folic acidcaps 1.5mg-5mg-20mg-1.7mg-6mcg-1mg-150mcg-10mg-100mg, 5mg-1.7mg-6mcg-20mg-1.5mg-1mg-150mcg-10mg-100mg

F

b-complex w/ c & folic acidtabs 5mg-25mg-20mg-15mcg-100mg-400mcg-30mcg-2mg-150mg, 50mg-50mg-50mg-50mg-50mcg-400mcg-50mcg-50mg-500mg, 30unit-10mg-100mg-10mg-20mg-12mcg-400mcg-45mcg-5mg-500mg, 18mg-5mg-45mg-10mg-10mcg-400mcg-5mg-250mg,25mg-5mg-10mg-250mcg-5mg-400mcg-300mcg-5mg-120mg, 15mg-50mg-10.2mg-10mg-400mcg-300mcg-5mg-300mg,30unit-100mg-10mg-1mg-20mg-1mg-1mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 5mg-25mg-50mg-5mg-37.5mcg-200mcg-15mcg-5mg-150mg, 100mg-100mg-5.5mg-25mg-20mg-30mcg-400mcg-45mcg-5mg-180mg, 50mg-50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-500mg,25mg-5.5mg-25mg-20mg-100mcg-400mcg-1000mcg-5mg-60mg, 15mg-50mg-10.2mg-10mg-6mcg-400mcg-5mg-300mg,30unit-10mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 15mg-100mg-15mg-18mg-5mcg-0.5mg-4mg-500mg,100mg-5.5mg-25mg-20mg-15mcg-400mcg-30mcg-2mg-150mg

F

RX/OTC


161

Drug Name DrugTier

Requirements/Limits

b-complex w/ folic acid tabs10mg-20mg-1.7mg-6mcg-1.5mg-400mcg-2mg,40mcg-1mg-6mg-5mcg-3mg-2mcg-19mcg, 1.5mg-20mg-1.7mg-6mcg-400mcg-2mg, 100mg-100mg-100mg-100mg-10mcg-400mcg-100mcg-100mg, 50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg, 100mg-100mg-100mg-100mcg-400mcg-100mg, 15mg-100mg-200mg-17mg-60mcg-400mcg-20mg,10mg-10mg-50mg-10mg-10mg-10mg-10mcg-10mg-400mcg-10mcg-10mg,30mg-20mg-50mg-30mg-10mg-10mcg-400mcg-8mg, 1.7mg-10mg-6mcg-1.2mg-20mg-0.4mg-2mg

F

Drug Name DrugTier

Requirements/Limits

b-complex w/biotin & folicacid tabs 50mg-50mg-50mg-50mg-0.4mg-50mcg-50mg, 50mg-50mg-50mg-50mg-50mcg-100mcg-50mcg-50mg, 50mg-50mg-12.5mg-50mg-12.5mcg-400mcg-45mcg-5mg-180mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-400mcg-100mcg-100mg,100mg-30mg-100mg-100mcg-100mg-100mg-100mg-100mcg-400mcg-100mcg-100mg, 50mg-50mg-50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg-50mg, 5mg-25mg-12.5mg-125mcg-125mg-7.5mg-50mg-12.5mcg-200mcg-50mcg-5mg, 50mg-200mg-100mg-50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg, 10mg-10mg-10mg-10mg-10mcg-100mcg-10mcg-10mg, 40mg-20mg-50mg-50mcg-50mcg-5mg-25mcg-5mg-100mcg-25mcg-5mg, 100mg-100mg-100mg-100mcg-100mg-400mcg-100mcg-100mg, 50mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-400mcg-100mcg, 50mg-50mg-50mg-50mg-50mcg-400mcg-50mcg-50mg,25mg-100mg-25mg-25mcg-25mg-400mcg-25mcg-25mg, 50mg-50mg-50mg-50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg, 100mg-100mg-100mg-100mg-100mcg-400mcg-100mcg-100mg, 20mg-1.7mg-6mcg-1.5mg-200mcg-30mcg-2mg, 50mg-50mg-50mg-50mg-50mcg-50mg-50mg-50mcg-400mcg-

F


162

Drug Name DrugTier

Requirements/Limits

50mcg-50mg, 50mg-50mg-50mg-12.5mg-12.5mcg-50mcg-25mcg-12.5mg,10mg-30mg-10mg-100mg-20mg-20mg-10mg-25mcg-100mcg-10mcg-10mg-200mg, 25mg-25mg-25mg-25mcg-25mg-25mg-25mcg-0.3mg, 100mg-30mg-100mg-100mg-100mcg-100mg-100mg-100mcg-0.4mg-100mcg-100mg MILCO-B-FORTE TABS (B-Complex w/ C & FolicAcid)

NP RX/OTC

SM B-COMPLEX/VITAMINC TABS F RX/OTC

B-Complex w/ Minerals b-complex w/ minerals liqd F

Bioflavonoid Products ADRENAL C FORMULA TABS F RX/OTC

ADVANCED C PLUS TABS F RX/OTC

ASCOCID-1000 TBCR F

ASCOCID-500-D TBCR F

Drug Name DrugTier

Requirements/Limits

bioflavonoid products tabs6mg-500mg, 500mg-50mg-500mg, 1mg-10mg-100mg-25mg-50mg-500mg, 25mg-50mg-25mg-25mg-25mg-40mg-500mg, 20mg-100mg-110mg-20mg-1000mg, 150mg-250mg-500mg-250mg, 100mg-100mg-500mg, 2mg-20mg-200mg-50mg-100mg-1000mg, 900mg-100mg,18mg-30mg-1000mg,200mg-50mg-500mg,100mg-100mg-50mg,1000mg, 100mg-50mg-500mg, 200mg-10mg-10mg-500mg, 550mg-500mg, 200mg-110mg-1000mg, 500mg, 200mg-65mg-10mg-10mg-500mg,100mg-50mg-100mg,25mg-50mg-50mg-10mg-5mg-1000mg, 200mg-500mg, 25mg-1000mg,200mg-55mg-500mg,300mg-200mg

F

RX/OTC

bioflavonoid products tbcr50mg-500mg, 1500mg,100mg-1000mg, 50mg-50mg-1000mg, 20mg-20mg-20mg-1000mg,25mg-1000mg, 50mg-50mg-1500mg, 40mg-25mg-25mg-5mg-500mg

F

CEMILL PLUS TABS F RX/OTC

DAFLONEX-XL TBCR F

ESTER-C TABS 200MG-60MG-500MG F RX/OTC

FRUIT C 200 CHEW F

NAT-RUL C-COMPLEX TABS F RX/OTC

NAT-RUL C-COMPLEX TR TBCR F

PERIDIN-C TABS (Bioflavonoid Products) NP RX/OTC


163

Drug Name DrugTier

Requirements/Limits

SUPER C-500 COMPLEX TBCR F

VITAMIN C CHEW 500MG, 25MG-500MG F

Multiple Vitamins w/ Calcium HM ONE DAILY ESSENTIAL TABS F

multiple vitamins w/calcium tabs F

ONE-A-DAY WOMENS FORMULA TABS (MultipleVitamins w/ Calcium)

NP

SM ONE DAILY ESSENTIAL TABS F

Multiple Vitamins w/ Iron DAILY MULTIPLE VITAMIN PLUS IRON TABS

F

multiple vitamins w/ irontabs F

Multiple Vitamins w/ Minerals ADULT ONE DAILY GUMMIES CHEW F

ADVANCED DIABETIC MULTIVITAMIN FORMULA TABS

F RX/OTC

AIRBORNE LOZG F

ALIVE ENERGY 50+ TABS F RX/OTC

ALIVE MENS ENERGY TABS F RX/OTC

ALIVE ONCE DAILY WOMENS 50+ ULTRA POTENCY TABS

F RX/OTC

ALIVE ONCE DAILY WOMENS ULTRA POTENCY TABS

F RX/OTC

ALIVE WOMENS 50+ TABS F RX/OTC

ALIVE WOMENS ENERGY TABS F RX/OTC

ALIVE WOMENS GUMMY VITAMINS CHEW F

ANTIOXIDANT FORMULA SG CPCR F

Drug Name DrugTier

Requirements/Limits

ANTIOXIDANT FORTE TABS F RX/OTC

AP-ZEL TABS F RX/OTC

APATATE FORTE LIQD F RX/OTC

AQUADEKS CAPS 18167UNIT-10MG-10MG-75MCG-80MG-1.5MG-10MG-12MG-75MG-10MG-700MCG-1.7MG-12MCG-800UNIT-200MCG-150UNIT-100MCG-1.9MG

F

RX/OTC

AQUADEKS CHEW 5MG-5MG-37.5MCG-15MG-0.75MG-5MG-6MG-35MG-5MG-350MCG-0.85MG-9083.5UNIT-6MCG-400UNIT-100MCG-50UNIT-50MCG-0.95MG

F

BACMIN TABS F RX/OTC

BARIATRIC FUSION CHEW F

BASIC AM TABS F RX/OTC

BASIC PM TABS F RX/OTC

BIO-35 GLUTEN-FREE CAPS F RX/OTC

BIO-35 IRON FREE CAPS F RX/OTC

BIOCAL CAPS F RX/OTC

BIOSUPP LIQD F RX/OTC

BIOTECT PLUS CAPS F RX/OTC

BIOTECT PLUS LIQD F RX/OTC

BIOVOL SYRP F

BURIED TREASURE ACTIVE 55PLUS SENIOR COMPLEX LIQD

F RX/OTC

C-BUFF POWD F

CAL-DAY 1000 TABS F RX/OTC


164

Drug Name DrugTier

Requirements/Limits

CELLULAR SECURITY CAPS F RX/OTC

CENTRAVITES 50 PLUS TABS F RX/OTC

CENTRAVITES ADULTS TABS F RX/OTC

CENTRUM ADULTS TABS (Multiple Vitamins w/Minerals)

NP RX/OTC

CENTRUM CARDIO TABS F RX/OTC

CENTRUM CHEW 18MG-30UNIT-20MCG-1MG-50MG-150MCG-20MCG-108MG-40MG-2MG-15MG-1.5MG-10MG-3500UNIT-20MG-10MCG-1.7MG-6MCG-400MCG-45MCG-2MG-60MG-400UNIT

F

CENTRUM FLAVOR BURST ADULT CHEW F

CENTRUM FLAVOR BURST CHEW F

CENTRUM FLAVOR BURST KIDS CHEW F

Drug Name DrugTier

Requirements/Limits

CENTRUM LIQD 2500UNIT/15ML-150MCG/15ML-3MG/15ML-25MCG/15ML-25MCG/15ML-2.5MG/15ML-9MG/15ML-30UNIT/15ML-400UNIT/15ML-20MG/15ML-1.7MG/15ML-10MG/15ML-6MCG/15ML-1.5MG/15ML-300MCG/15ML-2MG/15ML-60MG/15ML,150MCG/15ML-3MG/15ML-25MCG/15ML-25MCG/15ML-2MG/15ML-9MG/15ML-20MG/15ML-1.7MG/15ML-10MG/15ML-1300UNIT/15ML-6MCG/15ML-400UNIT/15ML-1.1MG/15ML-30UNIT/15ML-300MCG/15ML-2MG/15ML-60MG/15ML(Multiple Vitamins w/Minerals)

NP

RX/OTC

CENTRUM MEN TABS F RX/OTC

CENTRUM MULTIGUMMIES ADULTS CHEW

F

CENTRUM MULTIGUMMIES MEN CHEW

F

CENTRUM MULTIGUMMIES WOMEN CHEW

F

CENTRUM MULTIVITAMIN FLAVOR BURST DRINK PACK

F

CENTRUM SILVER 50+MEN TABS (MultipleVitamins w/ Minerals)

NP RX/OTC

CENTRUM SILVER 50+WOMEN TABS (Multiple Vitamins w/Minerals)

NP

RX/OTC


165

Drug Name DrugTier

Requirements/Limits

CENTRUM SILVER ADULT 50+ TABS (MultipleVitamins w/ Minerals)

NP RX/OTC

CENTRUM SILVER CHEW 4MG-10MCG-22.5MCG-100MCG-4.5MG-10MCG-125MG-70UNIT-100MCG-25MCG-200MG-5MCG-50MG-2MG-15MG-2.2MG-10MG-4000UNIT-250MCG-12MG-2.7MG-25MCG-400UNIT-500MCG-45MCG-7MG-75MG

F

CENTRUM SILVER TABS 2MG-72MG-10MCG-20MCG-150MCG-2MG-5MCG-48MG-150MCG-75MCG-200MG-150MCG-80MG-100MG-45UNIT-2MG-15MG-1.5MG-300MCG-10MG-3500UNIT-250MCG-20MG-10MCG-1.7MG-25MCG-400MCG-30MCG-3MG-60MG-400UNIT, 45MCG-2MG-72MG-10MCG-55MCG-2.3MG-5MCG-0.5MG-20MG-50UNIT-150MCG-45MCG-220MG-80MG-50MG-150MCG-11MG-1.5MG-10MG-2500UNIT-20MG-30MCG-1.7MG-25MCG-500UNIT-400MCG-30MCG-3MG-60MG (Multiple Vitamins w/Minerals)

NP

RX/OTC

CENTRUM SILVER ULTRA MENS TABS F RX/OTC

CENTRUM SILVER ULTRA WOMENS TABS F RX/OTC

CENTRUM SPECIALIST HEART TABS F RX/OTC

CENTRUM SPECIALIST IMMUNE SUPPORT TABS F RX/OTC

CENTRUM SPECIALIST VISION TABS F RX/OTC

Drug Name DrugTier

Requirements/Limits

CENTRUM TABS 35MCG-2MG-72MG-10MCG-55MCG-75MCG-2.3MG-10MCG-5MCG-0.5MG-20MG-150MCG-45MCG-80MG-200MG-30UNIT-11MG-50MG-1.5MG-18MG-10MG-3500UNIT-20MG-25MCG-1.7MG-6MCG-400UNIT-400MCG-30MCG-2MG-60MG (Multiple Vitamins w/Minerals)

NP

RX/OTC

CENTRUM ULTRA MENS TABS (Multiple Vitamins w/Minerals)

NP RX/OTC

CENTRUM ULTRA WOMENS TABS F RX/OTC

CENTRUM VITAMINTS CHEW F

CENTRUM WOMEN TABS (Multiple Vitamins w/Minerals)

NP RX/OTC

CEROVITE ADVANCED FORMULA LIQD F RX/OTC

CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS TABS

F RX/OTC

CHOICEFUL MULTIVITAMIN CAPS 15MG-1MG-8MG-18MG-700MCG-1.5MG-14000UNIT-5MCG-1000UNIT-180MCG-170UNIT-80MCG-1.9MG-30MG

F

RX/OTC

CHOICEFUL MULTIVITAMIN CHEW 15MG-1.2MG-10MG-8MG-600MCG-1.4MG-13000UNIT-6MCG-800UNIT-180MCG-180UNIT-80MCG-1.5MG-60MG

F

CLINICAL NUTRIENTS 45-PLUS WOMEN TABS F RX/OTC

CLINICAL NUTRIENTS 50-PLUS MEN TABS F RX/OTC


166

Drug Name DrugTier

Requirements/Limits

CLINICAL NUTRIENTS ANTIOXIDANT CAPS F RX/OTC

CLINICAL NUTRIENTS FOR FEMALE TEENS TABS

F RX/OTC

CLINICAL NUTRIENTS FOR MALE TEENS TABS F RX/OTC

CLINICAL NUTRIENTS FOR MEN TABS F RX/OTC

CLINICAL NUTRIENTS FOR WOMEN TABS F RX/OTC

COMPLETE FORMULATION D3000 CAPS

F RX/OTC

COMPLETE FORMULATION MULTIVITAMIN SUPPLEMENT CAPS

F

RX/OTC

CONCEPTIONXR MOTILITY SUPPORT FORMULA MISC

F

CORVITE TABS (MultipleVitamins w/ Minerals &Folic Acid)

NP

CVS AIRSHIELD IMMUNITY SUPPORT CHEW

F

CVS DIABETES HEALTH SUPPORT MISC F

CVS ONE DAILY MENS 50+ ADVANCED TABS F RX/OTC

CVS SPECTRAVITE ADULT 50+ CHEW 4MG-10MCG-25MCG-100MCG-4.5MG-10MCG-5MCG-125MG-70UNIT-100MCG-25MCG-200MG-150MCG-2MG-15MG-50MG-2.2MG-10MG-4000UNIT-250MCG-12MG-2.7MG-25MCG-400UNIT-500MCG-45MCG-7MG-75MG

F

Drug Name DrugTier

Requirements/Limits

CVS SPECTRAVITE ADULT 50+ TABS 45MCG-2MG-72MG-10MCG-55MCG-2.3MG-5MCG-0.5MG-20MG-50UNIT-150MCG-45MCG-220MG-150MCG-80MG-11MG-50MG-1.5MG-300MCG-10MG-2500UNIT-250MCG-20MG-30MCG-1.7MG-25MCG-500UNIT-400MCG-30MCG-3MG-60MG

F

RX/OTC

CVS SPECTRAVITE ADULT GUMMIES CHEW F

CVS SPECTRAVITE ULTRA MEN50+ TABS F RX/OTC

CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR TABS

F RX/OTC

CVS SPECTRAVITE ULTRA MENS HEALTH TABS

F RX/OTC

CVS SPECTRAVITE ULTRA WOMEN TABS F RX/OTC

CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR TABS

F RX/OTC

CVS SPECTRAVITE ULTRA WOMENS HEALTH TABS

F RX/OTC

DAILY HEART HEALTH SUPPORT MISC F

DAILY PAK MAXIMUM MULTIVITAMIN/ASIANGINSENG EXTRACT MISC

F

DECUBI-VITE CAPS F RX/OTC

DEKAS BARIATRIC CHEW F

DEKAS PLUS CAPS 75MCG-10MG-150UNIT-10MG-12MG-75MG-10MG-1000MCG-1.7MG-18167UNIT-12MCG-3000UNIT-1.5MG-200MCG-100MCG-1.9MG

F

RX/OTC


167

Drug Name DrugTier

Requirements/Limits

DEKAS PLUS CHEW 10MG-75MCG-100UNIT-10MG-12MG-70MG-10MG-1000MCG-1.7MG-18167UNIT-12MCG-2000UNIT-1.5MG-200MCG-100MCG-1.9MG

F

DERMAVITE TABS F RX/OTC

DIABETES HEALTH PACK MISC F

DIABETES SUPPORT PACK MISC F

ELDERTONIC ELIX F

ELLIS TONIC ELIX F

EMERGEN-C BLUE PACK F

EMERGEN-C FIVE PACK F

EMERGEN-C HEART HEALTH PACK F

EMERGEN-C IMMUNE PACK F

EMERGEN-C IMMUNE PLUS PACK F

EMERGEN-C IMMUNE PLUS/VITAMIN D CHEW F

EMERGEN-C IMMUNE+ WARMERS PACK F

EMERGEN-C JOINT HEALTH PACK F

EMERGEN-C KIDZ PACK F

EMERGEN-C MSM LITE PACK F

EMERGEN-C PINK PACK F

EMERGEN-C SUPER FRUIT PACK F

EMERGEN-C VITAMIN C CHEW F

EMERGEN-C VITAMIN C LITE PACK F

EMERGEN-C VITAMIN C PACK F

Drug Name DrugTier

Requirements/Limits

EMERGEN-C VITAMIN D & CALCIUM PACK F

END FATIGUE DAILY ENERGYENFUSION POWD

F

ENERGY BOOSTER PACK F

EQ COMPLETE MULTIVITAMINADULTS UNDER 50 TABS

F RX/OTC

EQ MULTIVITAMINS ADULT GUMMY CHEW F

EQ ONE DAILY MENS 50+ TABS F RX/OTC

EQ ONE DAILY MENS HEALTH TABS F RX/OTC

EQ ONE DAILY WOMENS 50+ TABS F RX/OTC

EQ ONE DAILY WOMENS HEALTH TABS F RX/OTC

EQL CENTURY MATURE ADULTS50+ TABS F RX/OTC

EQL CENTURY MENS TABS F RX/OTC

EQL CENTURY WOMENS TABS F RX/OTC

EQL MEGA SELECT MENS TABS F RX/OTC

EQL MEGA SELECT WOMENS TABS F RX/OTC

EQL ONE DAILY ADULT GUMMIES CHEW F

EQL ONE DAILY DIET SUPPORT TABS F RX/OTC

EQL ONE DAILY MENS 50+ ADVANCED TABS F RX/OTC

EQL ONE DAILY MENS TABS F RX/OTC

EQL PROTECTAVISION CAPS F RX/OTC

EQL SUPER ENERGY BOOSTER PACK F

EYE HEALTH CAPS F RX/OTC

FITNESS TABS FOR MEN AM/PM/LYCOPENE TABS F RX/OTC


168

Drug Name DrugTier

Requirements/Limits

FITNESS TABS FOR WOMEN AM/PM/LYCOPENE TABS

F RX/OTC

FORTAVIT CAPS F RX/OTC

FORTAVIT LIQD F RX/OTC

FOSFREE TABS (MultipleVitamins w/ Minerals) NP RX/OTC

FREEDAVITE TABS F RX/OTC

GERI-FREEDA SENIOR FORMULA TABS F RX/OTC

HAIR-VITES TABS F RX/OTC

HAIR/SKIN/NAILS TABS F RX/OTC

HM COMPLETE 50+ MENS ULTIMATE TABS F RX/OTC

HM COMPLETE 50+ WOMENS ULTIMATE TABS

F RX/OTC

HM COMPLETE TABS F RX/OTC

HM HAIR/SKIN/NAILSTABS F RX/OTC

HM ONE DAILY MENS TABS F RX/OTC

HM ONE DAILY WOMENS TABS F RX/OTC

HYALEX TABS F RX/OTC

ICAPS AREDS FORMULA TABS F RX/OTC

ICAPS PLUS TABS F RX/OTC

IMMUNE SUPPORT CHEW F

IMMUNE SUPPORT VITAMIN C PACK F

K-PAX IMMUNE SUPPORT FORMULA DOUBLE STRENGTH CAPS

F

RX/OTC

K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH TABS

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

K-PAX IMMUNE SUPPORT FORMULA SINGLE STRENGTH CAPS

F

RX/OTC

KP MENS DAILY PACK MISC F

KP WOMENS DAILY PACK MISC F

LIFE PACK MENS MISC F

LIFE PACK WOMENS MISC F

M2 B-60 TBCR F

MACULAR VITAMIN BENEFIT TABS F RX/OTC

MAXIMIN PACK PACK F

MEGA MULTI MEN TBCR F

MEGA MULTI WOMEN TBCR F

MEGA MULTIVITAMIN FOR MEN TABS F RX/OTC

MEGA MULTIVITAMIN FOR WOMEN TABS F RX/OTC

MEGA MULTIVITAMIN POWD F

MEGAVITE FRUITS & VEGGIES TABS F RX/OTC

MEGAVITE GOLDEN YEARS 55+ TABS F RX/OTC

MENS 50+ ADVANCED CAPS F RX/OTC

MENS 50+ MULTI VITAMIN &MINERAL FORMULA TABS

F RX/OTC

MENS MULTI VITAMIN & MINERAL FORMULA TABS

F RX/OTC

MENS PACK MISC F

MH MACULAR HEALTH MISC F

MULTI FOR HER PACK F


169

Drug Name DrugTier

Requirements/Limits

MULTI FOR HIM PACK F

MULTI-BETIC DIABETES TABS F RX/OTC

MULTI-VITAMIN MONOCAPS TABS F RX/OTC

multiple vitamins w/minerals & folic acid tabs F

Drug Name DrugTier

Requirements/Limits

multiple vitamins w/minerals caps 1mg-200unit-12.5mg-1mg-5mg-250mg, 50mcg-7.5mg-400unit-500mg, 70mcg-120mcg-4mg-60unit-150mcg-75mcg-2500unit-2mg-15mg-100mg-1.5mg-200mg-10mg-20mg-80mcg-1.7mg-25mcg-1000unit-400mcg-30mcg-6mg-60mg, 250mg-160mg-1mg-90mg-9mg-1mg-5mg-30unit-150mg, 18mg-90mg-30mcg-70mcg-15mg-400unit-300mcg-20mg-25mg-10mg, 25mg-20mg-12500unit-7.5mg-200unit-100mcg-1mg-40mg-25mg-1.75mg-5mg-250mg, 375mg-0.5mg-300mg-3.75mg-5mcg-68.75unit-100mcg-0.5mg-25mg, 12500unit-200unit-7.5mg-1mg-40mg-250mg,2973unit-14mcg-42.3mg-42.3mcg-4.3mg-14mcg-56.7mg-4.3mcg-2.7mg-56.7mg-1mg-11.3mg-1mg-5.7mg-3.3mcg-106.3unit-255mcg-8.3unit-42.3mcg-1.7mg-85mg, 90mcg-4mg-552mcg-2mg-10mcg-6mg-105mcg-180mcg-10mcg-5mcg-33unit-150mcg-150mcg-16mg-2mg-22.5mg-4mg-4.5mg-234mcg-100mcg-10mg-21mg-20mg-2500unit-9.5mg-20mg-20mcg-3.4mg-25mcg-1000unit-400mcg-30mcg-6mg-72mg,33.3mg-20mg-6.7mg-20mg-33.3mcg-166.7mcg-0.33mg-83.3mg-6.7mg-16.7mcg-33.3mg-33.3mcg-0.33mg-16.5mg-1.67mcg-20.8mcg-33.3mg-0.83mg-66.7unit-33.3mcg-25mg-33.3mg-4mg-0.5mg-3.3mg-0.67mg-8.3mg-1.67mg-83.3mg-41.7mg-16.7mcg-

F

RX/OTC


170

Drug Name DrugTier

Requirements/Limits

1.67mg-833.3unit-66.7unit-3.3mg-133.3mcg-50mcg-16.7mg-83.3mg, 20mcg-120mcg-4mg-50unit-150mcg-45mcg-100mg-2500unit-2mg-15mg-40mg-1.5mg-18mg-10mg-20mg-40mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 200unit-0.8mg-34.8mg-5mg-226mg,0.75mg-0.5mg-100unit-500unit-7.5mcg-3.75mg-125mg, 105mcg-120mcg-2mg-45unit-100mg-2mg-15mg-120mg-1.2mg-600mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 22mg-30unit-2mg-15mg-6mg-60mg, 22mg-2mg-15mg-6mg-30unit-60mg, 0.667mg-10unit-83.333mg-50mcg-66.667mg-133.333mg-2000unit-3.333mg-1.667mg-33.333mg-3mg-20mg-5mg-33.333mg-166.667mg-0.567mg-2mcg-0.5mg-6.667mg-133.333mcg-200mcg-0.667mg-20mg, 75mcg-2mg-552mcg-2mg-10mcg-6mg-70mcg-120mcg-10mcg-5mcg-33unit-150mcg-150mcg-16mg-2mg-15mg-4mg-3mg-234mcg-100mcg-10mg-21mg-18mg-20mg-2500unit-9.5mg-20mg-20mcg-1.7mg-15mcg-1000unit-600mcg-30mcg-4mg-72mg, 30unit-2mg-15mg-6mg-60mg, 200unit-12500unit-1mg-40mg-250mg, 280mg-34mcg-1mg-7mg-0.9mg-2.3mg-10unit-2mg-45mg-600mcg-10mg-1.3mg-2.4mcg-1.3mg-16mg-1.2mg-240mcg, 10mg-7.5mg-

Drug Name DrugTier

Requirements/Limits

1mg-200unit-25mcg-20mg-10mg-1mg-5mg-5mg-500unit-100mcg-10mg-250mg, 40mcg-120mcg-4mg-50unit-150mcg-45mcg-100mg-2500unit-2mg-15mg-40mg-1.5mg-10mg-20mg-40mcg-1.7mg-18mcg-1000unit-400mcg-30mcg-4mg-60mg, 50mcg-25000unit-400unit-500mg,10mg-23.333mcg-1mg-10mg-5mg-25mcg-40mcg-10mg-0.667mg-50mcg-133.333mg-10unit-10mg-33.333mg-15mg-6.667mg-3333.333unit-16.667mg-3.333mg-3.333mg-1.133mg-33.333mcg-1000unit-4mg-266.667mcg-200mcg-1.333mg-40mg,3964unit-19mcg-56.7mg-56.7mcg-5.7mg-19mcg-75.7mg-5.7mcg-3.7mg-75.7mg-1mg-15mg-1.3mg-7.7mg-4.7mcg-141.7unit-0.33mg-11.3unit-56.7mcg-2.3mg-113.3mg, 25mcg-5000unit-100unit-200mg,613.5mg-250mg-175mg-0.75mg-135mg-0.85mg-1500mcg-200unit-215mg-150mcg-0.5mg-30mg,70mg-4mg-80mg-50unit-10mg-10mg-25mg-5mg-8000unit-10mcg-1mg-2mg-150mg, 15mg-2mg-200mcg-200mcg-150mcg-150mcg-25mg-5mg-7.2mg-5000unit-5mg-100unit-25mg-25mg-50mg-100mg-25mg-25mg-25mg-100mcg-400unit-400mcg-300mcg-25mg-150mg,15mcg-1.5mg-200unit-10000unit-1mg-7.5mg-250mg, 200unit-1mg-10mg-1mg-5mg-250mg,166.667mg-133.333mg-6.667mg-16.667unit-3.333mg-33.333mg,70mcg-120mcg-4mg-


171

Drug Name DrugTier

Requirements/Limits

150mcg-75mcg-200mg-2500unit-2mg-15mg-100mg-1.5mg-10mg-20mg-80mcg-1.7mg-25mcg-1000unit-400mcg-60unit-30mcg-6mg-60mg, 20mcg-120mcg-4mg-50unit-150mcg-45mcg-2500unit-2mg-15mg-40mg-1.5mg-100mg-18mg-10mg-20mg-40mcg-1.7mg-6mcg-1000unit-600mcg-30mcg-2mg-60mg, 20mcg-120mcg-4mg-50unit-150mcg-45mcg-100mg-2500unit-2mg-15mg-40mg-1.5mg-18mg-10mg-20mg-40mcg-1.7mg-6mcg-1000unit-600mcg-30mcg-2mg-60mg, 12500unit-200unit-7.5mg-1mg-40mg-3mg-250mg, 70mcg-1mg-120mcg-150mcg-75mcg-5000unit-2mg-120mg-40mg-15mg-1.5mg-500mcg-30mg-2mg-20mg-100mcg-1.7mg-10mg-6mcg-2000unit-200mcg-30unit-30mcg-2mg,200unit-14320unit-0.8mg-34.8mg-226mg, 25mg-20mg-200unit-100mcg-1mg-40mg-25mg-1.75mg-5mg-250mg, 70mcg-120mcg-4mg-60unit-150mcg-75mcg-200mg-2500unit-2mg-15mg-100mg-1.5mg-10mg-20mg-80mcg-1.7mg-25mcg-1000unit-400mcg-30mcg-6mg-60mg, 200mg-14320unit-0.8mg-34.8mg-226mg, 50mg-2mg-15unit-2500unit-25mcg-25mg-25mg-50mg-3mg-12mcg-500unit-3mg-800mcg-25mcg-6mg-250mg,491.667mg-88.333mg-1mg-5mg-1000unit-273.333unit-20unit-26.667mg, 5mg-70mcg-25mg-1mg-35mg-5mg-

Drug Name DrugTier

Requirements/Limits

5mg-1mg-7.5mg-75mcg-100mcg-10mg-10000unit-25mg-25unit-150mcg-50mg-15mg-25mg-25mg-25mcg-50mg-100mg-250mcg-150mcg-25mg-100mcg-400unit-400mcg-30mcg-25mg-150mg,833.33unit-16.67mg-33.33mcg-66.67unit-33.33mcg-66.67mg-2.5mg-3.33mcg-200mcg-33.33mcg-0.25mg-16.5mg-8.33mcg-1.67mg-66.67mg-2.5mg-2500unit-12.5mg-8.33mg-30mg-12.5mg-12.5mg-6.33mg-16.67mg-12.5mcg-33.33unit-6.67mg-66.67mcg-50mcg-12.5mg-4.17mg-166.67mg, 200unit-1mg-40mg-3mg-250mg,25mcg-10000unit-125unit-200mg, 15mg-16000unit-1.5mg-12mg-20mg-800mcg-1.7mg-6mcg-1000unit-200mcg-200unit-100mcg-1.9mg-100mg,2.6mg-10mcg-100mg-150mcg-130mg-15mg-2mg-10mcg-37.5mg-10mcg-100mg-27mg-5000unit-30unit-400unit-1500unit-1.7mg-10mg-6mcg-1.5mg-20mg-0.4mg-30mcg-2mg-60mg,8000unit-70mg-4mg-80mg-50unit-10mg-10mg-25mg-5mg-10mcg-1mg-2mg-150mg, 4.167mcg-8.333mg-20mg-1mg-10mg-0.333mg-10mg-2.5mg-1.667mg-3.333mg-5mg-8.333mg-1.667mg-1666.667unit-2.667mcg-666.667unit-133.333mcg-10unit-1666.667mcg-1.667mg-30mg, 25mg-100unit-45mg-500mg


172

Drug Name DrugTier

Requirements/Limits

multiple vitamins w/minerals chew 1.25mg-20mcg-2.5mg-1000unit-10mcg-19mg-2.5mcg-100unit-100mcg-10unit-37.5mcg-0.5mg-15mg,2.5mg-20unit-40mcg-5mg-2000unit-4mcg-400unit-200mcg-75mcg-1mg-30mg, 55mcg-2.5mg-15unit-75mcg-5mg-20mcg-30mcg-2000unit-7.5mcg-200unit-200mcg-300mcg-2.5mg-37.5mg, 15unit-37.5mcg-3.75mg-5mg-1250unit-10mg-3mcg-500unit-200mcg-75mcg-1mg-30mg, 20mcg-1mg-50mg-30unit-150mcg-20mcg-108mg-2mg-15mg-40mg-18mg-10mg-3500unit-20mg-10mcg-1.7mg-6mcg-400unit-1.5mg-400mcg-45mcg-2mg-60mg, 55mcg-2.5mg-15unit-75mcg-5mg-2000unit-20mcg-30mcg-7.5mcg-200unit-200mcg-300mcg-2.5mg-37.5mg,16000unit-15mg-1.5mg-12mg-100mg-10mg-800mcg-1.7mg-6mcg-1000unit-200mcg-200unit-100mcg-1.9mg, 1mg-7.5mg-1mg-60mcg-1mg-75mg-75mcg-25mcg-7.5mg-25mg-35mcg-15mg-75unit-6.25mg-5mg-22.5mg-10mg-10mg-10mg-500mcg-1.7mg-5000unit-500mcg-1500unit-400mcg-300mcg-2mg-45mg, 5mcg-3.333mg-0.033mg-0.333mg-66.666unit-3.333unit-333.333mg,50mg-15unit-20mcg-1.25mg-1250unit-4.5mcg-400unit-200mcg-75mcg-1mg-15mg, 50mg-1.25mg-20mcg-1250unit-4.5mcg-400unit-200mcg-15unit-75mcg-1mg-15mg, 4mg-

F

Drug Name DrugTier

Requirements/Limits

10mcg-22.5mcg-100mcg-4.5mg-10mcg-5mcg-125mg-70unit-25mcg-100mcg-2mg-15mg-50mg-2.2mg-200mg-10mg-4000unit-250mcg-12mg-2.7mg-25mcg-400unit-500mcg-45mcg-7mg-75mg,15unit-4.5mg-0.5mg-2.5mg-50mg, 4mg-10mcg-22.5mcg-100mcg-4.5mg-10mcg-5mcg-125mg-70unit-100mcg-25mcg-200mg-2mg-15mg-50mg-2.2mg-10mg-4000unit-250mcg-12mg-2.7mg-25mcg-400unit-500mcg-45mcg-7mg-75mg, 2.5mg-20unit-40mcg-5mg-2000unit-20mcg-30mcg-5mcg-200unit-200mcg-75mcg-1mg-30mg, 10unit-20mcg-1.25mg-10mcg-15mcg-1000unit-2.5mcg-100unit-37.5mcg-0.5mg-15mg, 3.75mcg-2mg-7.5unit-10mg-0.75mg-11.25mg-500unit-250mg,3.75mcg-0.75mg-7.5unit-10mg-2mg-500unit-250mg,40mcg-2.5mg-5mg-20mcg-30mcg-2000unit-5mcg-200unit-200mcg-20unit-75mcg-1mg-30mg, 75mcg-18.75mcg-60mcg-7.5unit-5mg-137.5mcg-1.5mg-20mcg-1250unit-6mcg-400unit-5mg-200mcg-7.5mcg-2mg-15mg, 25mg-20unit-40mcg-5mg-2000unit-20mcg-30mcg-5mcg-200unit-200mcg-75mcg-1mg-30mg, 20mcg-1mg-50mg-60unit-150mcg-20mg-108mg-2mg-15mg-40mg-1.5mg-18mg-10mg-3500unit-20mg-10unit-1.7mg-6mcg-400unit-400mcg-45mcg-2mg-60mg,75mcg-9.4mcg-1.9mg-60mcg-15unit-19mcg-1mg-5mg-3mcg-20mcg-


173

Drug Name DrugTier

Requirements/Limits

1250unit-9mcg-200unit-10mg-150mcg-15mcg-2mg-15mg, 140mg-7.5unit-1mg-2.5mg-2.5mg-5mg-30mcg-20mcg-1250unit-3mcg-400unit-200mcg-150mcg-1mg-30mg,20unit-40mcg-2.5mg-5mg-20mcg-30mcg-2000unit-5mcg-200unit-200mcg-75mcg-1mg-30mg, 5mg-113.5mg-1.9mg-10unit-5mg-25mg-25mg-1250unit-10mg-3mcg-1000unit-200mcg-0.9mg, 55mcg-15unit-75mcg-2.5mg-5mg-20mcg-30mcg-2000unit-7.5mcg-200unit-200mcg-300mcg-2.5mg-37.5mg,50mg-1.25mg-15unit-20mcg-1250unit-4.5mcg-400unit-200mcg-75mcg-1mg-15mg

Drug Name DrugTier

Requirements/Limits

multiple vitamins w/minerals liqd 25mcg/15ml-2mg/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-9mg/15ml-20mg/15ml-1.7mg/15ml-10mg/15ml-1300unit/15ml-6mcg/15ml-400unit/15ml-2mg/15ml-1.5mg/15ml-30unit/15ml-300mcg/15ml-60mg/15ml,1000mg/15ml-2mg/15ml-15mg/15ml-15mcg/15ml-10mg/15ml-50mg/15ml-15mg/15ml-50mg/15ml-5000unit/15ml-50mcg/15ml-50mg/15ml-800mcg/15ml-150mcg/15ml-50mg/15ml,25mcg/15ml-2mg/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-9mg/15ml-1.7mg/15ml-10mg/15ml-20mg/15ml-1300unit/15ml-6mcg/15ml-400unit/15ml-1.5mg/15ml-30unit/15ml-300mcg/15ml-2mg/15ml-60mg/15ml, 25mcg/15ml-2mg/15ml-30unit/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-9mg/15ml-20mg/15ml-1.7mg/15ml-10mg/15ml-1300unit/15ml-6mcg/15ml-1000unit/15ml-2mg/15ml-1.5mg/15ml-300mcg/15ml-60mg/15ml,7.5mg/5ml-2500unit/5ml-750mcg/5ml-25mcg/5ml-5mg/5ml-2.5unit/5ml-75mg/5ml-100unit/5ml-12.5mg/5ml-10mg/5ml-5mcg/5ml-7.5mg/5ml-200mcg/5ml-25mcg/5ml-225mg/5ml-250mg/5ml,37mg/15ml-112.5mcg/15ml-75mg/15ml-15mg/15ml-15mg/15ml-45mg/15ml-2.55mg/15ml-5250unit/15ml-18mcg/15ml-600unit/15ml-2.25mg/15ml-300mcg/15ml-45unit/15ml-

F

RX/OTC


174

Drug Name DrugTier

Requirements/Limits

150mcg/15ml-3mg/15ml-90mg/15ml, 1.7mg/15ml-25mcg/15ml-2mg/15ml-30unit/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-9mg/15ml-10mg/15ml-20mg/15ml-6mcg/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml,2mg/15ml-30unit/15ml-150mcg/15ml-25mcg/15ml-25mcg/15ml-3mg/15ml-400unit/15ml-9mg/15ml-1.7mg/15ml-20mg/15ml-10mg/15ml-2500unit/15ml-6mcg/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml, 2500unit/15ml-150mcg/15ml-3mg/15ml-25mcg/15ml-25mcg/15ml-2.5mg/15ml-9mg/15ml-30unit/15ml-400unit/15ml-20mg/15ml-1.7mg/15ml-10mg/15ml-6mcg/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml,250mcg/15ml-2mg/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-30unit/15ml-9mg/15ml-20mg/15ml-1.7mg/15ml-10mg/15ml-6mcg/15ml-400unit/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml

Drug Name DrugTier

Requirements/Limits

multiple vitamins w/minerals tabs 72mg-25mcg-2500unit-5mcg-20mcg-2mg-109mg-150mcg-162mg-10mcg-65mcg-150mcg-10mcg-2mg-80mg-160mcg-3.5mg-100mg-400unit-15mg-1.5mg-18mg-20mg-1.7mg-10mg-6mcg-400mcg-30unit-30mg-2mg-60mg,16.667mcg-133.333unit-53.333mg-8333.333unit-166.667mg, 32mg-70mcg-200mcg-2mg-30unit-300mg-2500unit-2mg-15mg-50mg-1.9mg-18mg-12.5mg-25mg-80mcg-2.125mg-7.5mcg-400unit-400mcg-2.5mg-60mg,15mcg-2500unit-500mg-7.5mg-1mg-50mg-18mg-15unit-200unit-6mcg-0.4mg-90mg, 10mcg-5mg-2mg-15mg-30unit-150mcg-15mcg-10mg-40mg-15mcg-100mg-3mg-27mg-10mg-30mg-3.4mg-5500unit-9mcg-400unit-400mcg-15mcg-3mg-120mg, 120mg-20mcg-180mcg-4mg-2mg-33unit-150mcg-90mcg-22.5mg-50mg-4.5mg-405mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg,35mcg-72mg-10mcg-100mcg-2.3mg-10mcg-5mcg-0.9mg-20mg-45unit-150mcg-50mcg-80mg-210mg-100mg-2mg-150mcg-11mg-1.2mg-600mcg-8mg-15mg-3500unit-16mg-60mcg-1.3mg-6mcg-600unit-200mcg-40mcg-2mg-90mg,200unit-2500unit-25mcg-75mg, 5000unit-30unit-40mcg-2mg-40mg-2mg-60mg, 66.667mcg-4.167mcg-66.667unit-

F

RX/OTC


175

Drug Name DrugTier

Requirements/Limits

33.333mg-33.333mcg-50mcg-83.333mg-7.5mg-11.667mg-33.333mg-3.333mg-333.333mg-33.333mg-33.333mg-16.667mg-1666.667unit-33.333mcg-16.667mg-266.667mcg-100mcg-16.667mg-133.333unit,200mcg-70mcg-5mg-150mcg-75mcg-50unit-2mg-15mg-150mg-3mg-100mg-20mg-5000unit-25mg-10mcg-3.4mg-30mcg-500unit-500mcg-666mcg-4mg-100mg,600mcg-12mg-72mg-10mcg-35mcg-1.5mg-2.3mg-5mcg-110mg-50unit-150mcg-45mcg-2mg-80mg-220mg-150mcg-50mg-1.5mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-30mcg-600unit-500mcg-300mcg-3mg-90mg,10mcg-20mcg-25mcg-120mcg-2mg-10mcg-5mcg-72mg-2mg-108mg-30unit-75mcg-150mcg-162mg-150mcg-2mg-80mg-15mg-100mg-1.5mg-18mg-10mg-5000unit-250mcg-20mg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 10mcg-0.5mg-35mg-107.5unit-37.5mcg-30mcg-18.75mcg-0.9mg-21.15mg-25mg-0.38mg-0.075mg-83.25mg-0.83mg-2.5mg-1.67mg-2.5mg-6.25mcg-2.5mg-1.5mcg-100unit-0.5mg-100mcg-7.5mcg-128mg,34mg-10mcg-100mg-150mcg-130mg-15mg-2mg-10mcg-37.5mg-10mcg-2.5mg-100mg-18mg-30unit-400unit-5000unit-1.7mg-10mg-6mcg-1.5mg-20mg-400mcg-30mcg-2mg-

Drug Name DrugTier

Requirements/Limits

60mg, 150mcg-72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-5mcg-109mg-30unit-150mcg-160mcg-80mg-162mg-2mg-2mg-15mg-100mg-1.5mg-18mg-10mg-5000unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,7.5mg-10mcg-150mcg-41mg-15mg-2mg-15mcg-7.5mg-15mcg-5mg-100mg-27mg-30unit-400unit-5500unit-30mg-3.4mg-10mg-9mcg-3mg-0.4mg-15mcg-3mg-120mg,110mcg-120mcg-2mg-22.5unit-100mg-2mg-15mg-120mg-1.2mg-300mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-700unit-400mcg-30mcg-3mg-60mg,72mg-10mcg-3500unit-20mcg-48mg-150mcg-200mg-15mg-10mcg-2mg-150mcg-150mcg-2mg-80mg-5mcg-75mcg-2mg-100mg-45unit-400unit-300mcg-250mcg-1.7mg-10mg-25mcg-20mg-1.5mg-400mcg-30mcg-3mg-60mg,40mcg-5000unit-30mg-2mg-40mg-60mg, 120mg-105mcg-180mcg-4mg-2mg-33unit-150mcg-90mcg-40mg-22.5mg-100mg-4.5mg-600mcg-120mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg,25mcg-300mcg-25mcg-25mcg-27mg-5mg-2mg-125mg-34unit-150mcg-162mg-30mg-5000unit-15mg-100mg-2.25mg-27mg-10mg-20mg-25mcg-2.6mg-9mcg-400unit-400mcg-45mcg-3mg-90mg,2mg-12mg-8mg-500mcg,


176

Drug Name DrugTier

Requirements/Limits

72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-2mg-109mg-30unit-150mcg-160mcg-2mg-80mg-100mg-150mcg-15mg-1.5mg-162mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 25mcg-50mcg-200mg-10.5mg-25mcg-500mcg-50mcg-500mcg-2.4mg-32mg-50mcg-5mg-100mg-3.6mg, 1mg-5mg-45mg-150mcg-60mg-15mg-2mg-16mg-1.5mg-5000unit-1.7mg-10mg-6mcg-400unit-20mg-400mcg-30unit-2mg-60mg,18mg-0.8mg-1.3mg-7mg-50unit-25mg-100mg-10mg-25mg-25mcg-10mg-0.4mg-300mg, 46mg-60mg-3mg-24mg-20mg-20mg-5mg-20mcg-100mg-400mcg-100mcg-20mg-500mg,105mcg-2500unit-60unit-4mg-75mcg-150mcg-162mg-2mg-120mcg-100mg-20mg-15mg-1.5mg-80mcg-1.7mg-10mg-25mcg-1000unit-400mcg-30mcg-6mg-180mg,0.2mg-35mcg-150mcg-30mg-2mg-50unit-15mg-7.5mg-10mg-30mg-100mg-30mg-5000unit-30mcg-30mg-400mcg-30mcg-30mg-300mg-400unit,25mg-1mg-12.5mg-1mg-75mcg-50mcg-1mg-50mcg-1mg-25mcg-2.5mg-13.5mg-12.5mg-7.5mg-100mg-40mg-250mg-5mg-40mg-250mcg-40mg-10mcg-5mg-37.5mcg-40mg-5000unit-40mcg-200unit-200mcg-50unit-40mcg-40mg-100mg, 2mg-72mg-20mcg-150mcg-5mcg-48mg-75mcg-200mg-10mcg-150mcg-

Drug Name DrugTier

Requirements/Limits

150mcg-80mg-2mg-100mg-300mcg-10mg-20mg-10mcg-1.7mg-25mcg-400unit-1.5mg-400mcg-30mcg-3mg, 7mg-10mcg-50mcg-25mcg-7.5mg-10mcg-5mcg-125mg-30unit-50mcg-2mg-150mcg-162mg-50mcg-150mcg-7.7mg-3mg-15mg-100mg-5mg-300mcg-25mg-3500unit-275mcg-30mg-5mg-10mg-12mcg-400unit-400mcg-40mcg-5mg-90mg, 1mg-1.5mg-15mg-5.5unit-0.15mg-1mg-5mg-10mg-10mg-10000unit-30mg-5mg-3mcg-400unit-1.7mg-100mg, 35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-2mg-80mg-75mcg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 10mg-25mg-10mg-10mg-75mg-15mcg-105mcg-4mg-15mcg-7.5mcg-48mg-60unit-150mcg-112.5mcg-200mg-180mg-225mcg-10mg-2mg-80mg-3000unit-2mg-22.5mg-100mg-1.5mg-350mcg-3000unit-300mcg-20mg-1.7mg-15mg-30mcg-400unit-400mcg-30mcg-3mg-120mg, 120mg-27mcg-4.2mg-180mcg-30unit-150mcg-90mcg-500mg-50mg-2.2mg-24mg-4.5mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-1000unit-400mcg-30mcg-6mg-120mg, 2mg-72mg-10mcg-20mcg-120mcg-2mg-5mcg-2mg-109mg-30unit-150mcg-75mcg-162mg-10mcg-80mg-150mcg-15mg-


177

Drug Name DrugTier

Requirements/Limits

100mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-1.5mg-400mcg-30mcg-2mg-60mg, 2mg-72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-5mcg-2mg-109mg-30unit-150mcg-160mcg-162mg-80mg-150mcg-15mg-100mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-400unit-1.5mg-400mcg-30mcg-2mg-60mg, 35mcg-2mg-72mg-10mcg-100mcg-150mcg-2.3mg-10mcg-5mcg-0.9mg-20mg-45unit-150mcg-50mcg-210mg-80mg-11mg-100mg-1.2mg-600mcg-8mg-15mg-3500unit-16mg-60mcg-1.3mg-6mcg-600unit-200mcg-40mcg-2mg-90mg, 3333.3unit-0.66mg-25mg-115mg-5mg-0.033mg-15mg-10mg-0.33mg-25mcg-26.6mg-20unit-133.3unit-16.6mg-5mg-5mg-5mcg-15mg-10mg-0.025mg-5mcg-5mg-10mg-66.6mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-50mg-150mcg-11mg-1.5mg-300mcg-220mg-10mg-250mcg-20mg-30mcg-1.7mg-2500unit-25mcg-500unit-400mcg-30mcg-3mg-60mg, 70mcg-2500unit-60unit-4mg-75mcg-150mcg-200mg-2mg-120mcg-100mg-20mg-15mg-1.5mg-80mcg-1.7mg-10mg-25mcg-1000unit-400mcg-30mcg-6mg-180mg, 120mg-105mcg-4mg-180mcg-2mg-33unit-150mcg-90mcg-40mg-22.5mg-

Drug Name DrugTier

Requirements/Limits

100mg-4.5mg-600mcg-120mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg,40mcg-5000unit-2mg-40mg-30unit-60mg,110mcg-120mcg-2mg-210mg-140mg-22.5unit-2mg-15mg-1.35mg-300mcg-16mg-3500unit-18mg-20mcg-1.7mg-18mcg-700unit-400mcg-75mcg-3mg-60mg,5000unit-10mcg-31mg-150mcg-40mg-15mg-2mg-15mcg-10mg-15mcg-5mg-100mg-27mg-30unit-400unit-3mg-3.4mg-10mg-9mcg-20mg-400mcg-30mcg-3mg-90mg, 32mg-70mcg-200mcg-2mg-2mg-30unit-300mg-50mg-2500unit-15mg-1.9mg-18mg-12.5mg-25mg-80mcg-2.125mg-7.5mcg-400unit-400mcg-2.5mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-50mg-75mcg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 20mcg-120mcg-2mg-2mg-30unit-450mg-50mg-15mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-800unit-1.5mg-0.4mg-30mcg-2mg-60mg, 50mcg-2mg-72mg-19mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mg-45mcg-80mg-10mcg-11mg-50mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-1000unit-400mcg-30mcg-3mg-60mg, 30unit-10mg-


178

Drug Name DrugTier

Requirements/Limits

70mcg-5000unit-10mg-25mcg-100mcg-100mg-30mg-25mcg-2mg-200mcg-2.4mg-25mg-100mcg-6mg-100mg-5000unit-10mg-8mg-10mg-10mg-15mg-25mg-25mcg-400unit-15mg-25mg-400mcg-300mcg-25mg-100mg, 2mg-72mg-72mg-10mcg-10mcg-20mcg-20mcg-120mcg-120mcg-2mg-2mg-10mcg-10mcg-30unit-30unit-75mcg-75mcg-80mg-80mg-162mg-162mg-100mg-100mg-150mcg-150mcg-15mg-15mg-1.5mg-1.5mg-300mcg-300mcg-150mcg-150mcg-10mg-10mg-3500unit-3500unit-250mcg-250mcg-20mg-20mg-25mcg-25mcg-1.7mg-1.7mg-6mcg-6mcg-400unit-400unit-400mcg-400mcg-30mcg-30mcg-2mg-2mg-60mg-60mg,32mg-70mcg-80mcg-200mcg-2mg-2mg-30unit-2500unit-15mg-50mg-1.9mg-300mg-18mg-12.5mg-25mg-2.125mg-7.5mcg-400unit-400mcg-2.5mg-60mg, 7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-2mg-31mg-60unit-150mcg-75mcg-40mg-2mg-7.5mg-100mg-150mcg-15mg-3mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-400mcg-30mcg-6mg-90mg, 37mg-121mg-2.2mg-15mcg-15mg-1mg-125mg, 20mcg-120mcg-2mg-2mg-30unit-15mg-50mg-5mg-450mg-15mg-5mg-10mg-25mcg-1.7mg-2500unit-5mcg-500unit-400mcg-30mcg-2mg-60mg, 120mcg-2mg-2500unit-2mg-30unit-

Drug Name DrugTier

Requirements/Limits

20mcg-50mg-15mg-1.5mg-450mg-18mg-5mg-25mcg-1.7mg-6mcg-400unit-10mg-400mcg-30mcg-2mg-60mg, 0.6mg-10mg-10mg-897mcg-58mg-25unit-150mcg-125mg-0.6mg-20mg-5mg-10mg-3.3mg-15mg-10mg-10mg-25mg-5mg-2500unit-25mcg-50unit-7.2mg-7.5mg-25mcg-25mcg-6.5mg-3.5mg-50mg, 25mg-120mcg-25mg-70mcg-80mcg-5000unit-2mg-50unit-150mcg-75mcg-150mcg-2mg-15mg-100mg-225mg-9mg-275mcg-20mg-1.7mg-10mg-12mcg-400unit-1.5mg-400mcg-30mcg-2mg-120mg, 35mcg-1mg-1mg-60mcg-7mg-25unit-75mcg-37.5mcg-100mg-50mg-500unit-11.5mg-0.75mg-150mcg-1mg-5mg-5mg-10mg-15mcg-0.85mg-3mcg-200unit-200mcg-15mcg-1mg-75mg, 45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.9mg-110mg-50unit-150mcg-220mg-80mg-45mcg-50mg-2mg-150mcg-11mg-1.5mg-300mcg-2500unit-250mcg-20mg-30mcg-1.7mg-10mg-25mcg-500unit-500mcg-30mcg-3mg-90mg, 30unit-10mg-18mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,25mcg-30mg-60mg-30unit-


179

Drug Name DrugTier

Requirements/Limits

5mg-100mg-50mg-50mg-25mcg-50mg-400mcg-50mg-600mg, 17.5mcg-20mg-0.5mg-10mg-75unit-5mg-125mg, 180mg-20mcg-120mcg-2mg-30unit-300mg-2mg-15mg-50mg-2.4mg-18mg-5mg-2500unit-10mg-25mcg-2.7mg-9.5mcg-800unit-400mcg-30mcg-3.2mg-60mg, 10unit-150mcg-125mg-1mg-5mg-400unit-5000unit-20mg-1.7mg-3mcg-1.5mg-100mcg-1mg-50mg, 72mg-10mcg-5000unit-20mcg-46mg-150mcg-200mg-15mg-10mcg-2mg-130mcg-150mcg-2mg-60mg-5mcg-160mcg-3.5mg-100mg-4mg-45unit-400unit-15mg-1.7mg-10mg-25mcg-3mg-20mg-400mcg-30mcg-60mg, 50mg-25mg-60mg-45mg-72.5mg-10mcg-18mg-70mcg-4mg-10mcg-5mcg-48mg-60unit-150mcg-75mcg-100mg-120mcg-150mcg-4mg-80mg-2000unit-2mg-15mg-40mg-4.5mg-3000unit-250mcg-35mg-25mcg-5.1mg-10mg-21mcg-400unit-400mcg-40mcg-6mg-120mg, 15unit-20mg-30mg-1.5mg-20mg-1.5mg-2500unit-50mcg-400unit-400mcg-5mg-30mg,105mcg-120mcg-2mg-45unit-100mg-2mg-15mg-120mg-1.2mg-600mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 50mcg-1.75mg-5mg-0.5mg-1.5mg-25mcg-32mg-12.5mcg-200mg-0.75mg-3.75mg-75mg-1.25mg-11.25mcg-5mg-5mg-12.5mg-75mcg-5mg-12.5mcg-200unit-

Drug Name DrugTier

Requirements/Limits

5mg-200mcg-6.25mg-30mg, 60mg-50mg-4mg-72mg-10mcg-70mcg-120mcg-4mg-10mcg-5mcg-2mg-48mg-60unit-150mcg-75mcg-100mg-80mg-60mcg-15mg-40mg-18mg-10mg-5000unit-40mg-25mcg-5.1mg-18mcg-4.5mg-400mcg-40mcg-6mg-120mg-400unit,0.6mg-10mg-50mg-10mg-897mcg-73mg-54mg-25unit-150mcg-0.5mg-20mg-5mg-10mg-3.3mg-15mg-10mg-10mg-25mg-5mg-2500unit-25mcg-50unit-7.2mg-7.5mg-25mcg-25mcg-6.5mg-3.5mg-50mg, 60mg-50mg-72mg-70mcg-4mg-5mcg-48mg-60unit-75mcg-150mcg-100mg-10mcg-120mcg-60mcg-10mcg-4mg-80mg-40mg-2mg-15mg-4.5mg-18mg-3500unit-40mg-25mcg-5.1mg-10mg-18mcg-400mcg-40mcg-6mg-120mg-400unit, 35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-80mg-2mg-150mcg-11mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg,5mg-200mcg-30unit-200mg-60mg-15mg-50mg-1.5mg-5mg-2500unit-10mg-1mg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg, 72mg-20mcg-3500unit-45unit-2mg-48mg-150mcg-75mcg-80mg-200mg-10mcg-2mg-150mcg-150mcg-2mg-5mcg-15mg-100mg-1.5mg-300mcg-10mg-250mcg-


180

Drug Name DrugTier

Requirements/Limits

20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 70mcg-200mcg-2mg-2mg-30unit-50mg-15mg-1.9mg-200mg-18mg-12.5mg-2500unit-25mg-80mcg-2.1mg-7.5mcg-400unit-400mcg-2.5mg-10mg-60mg,8.333mg-1mg-15mg-1.667mg-50mg-37.5mcg-236.667mg-3.333mg-1.667mg-2.5mg-4.167mcg-33.333mg-8.333mg-1mg-4.167mg-8.333mg-5mg-8.333mg-10mg-8.333mg-0.667mg-1666.666unit-2.667mcg-33.333unit-1.667mg-66.667mcg-5unit-1000mcg-1.667mg-40mg,30unit-10mg-70mcg-5000unit-10mg-25mcg-100mcg-100mg-30mg-25mcg-2mg-200mcg-2.4mg-25mg-100mcg-6mg-100mg-20mg-5000unit-10mg-8mg-10mg-10mg-15mg-25mg-25mcg-400unit-15mg-25mg-400mcg-300mcg-25mg-100mg, 7mg-5mg-30unit-200mg-60mg-15mg-50mg-1.5mg-5mg-2500unit-10mg-1mg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg, 150mcg-50mcg-10mcg-72mg-55mcg-35unit-2.3mg-20mg-150mcg-50mcg-15mg-80mg-500mg-5mcg-50mg-0.5mg-15mg-1.1mg-8mg-3500unit-300mcg-14mg-50mcg-1.1mg-5mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 35mg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-

Drug Name DrugTier

Requirements/Limits

400unit-30mcg-2mg-60mg,35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,2mg-72mg-10mcg-55mcg-25mcg-35mcg-2.3mg-10mcg-5mcg-109mg-30unit-45mcg-150mcg-150mcg-80mg-0.9mg-11mg-100mg-1.5mg-300mcg-200mg-18mg-10mg-3500unit-250mcg-20mg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 105mcg-120mcg-2mg-45unit-100mg-120mg-2mg-15mg-1.2mg-0.6mg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400mcg-30mcg-3mg-90mg-400unit,15mg-30unit-20mg-10mg-4mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-300mg, 60mcg-2mg-72mg-10mcg-100mcg-4mg-5mcg-0.7mg-20mg-60unit-150mcg-50mcg-250mg-80mg-150mcg-15mg-50mg-1.5mg-600mcg-10mg-3500unit-300mcg-20mg-60mcg-1.7mg-100mcg-600unit-300mcg-30mcg-6mg-120mg, 55mcg-5mg-100unit-1000unit-2mg-40mg-2mg-40mg-3mg-5mg-300mg, 25mg-200mcg-25mg-200mcg-200mcg-7.5mg-13mcg-6.5mcg-60unit-200mcg-150mcg-79.95mg-13mcg-2500unit-500mcg-3.5mg-17mg-100mg-4.5mg-200mg-12.5mg-500mcg-25mg-10mcg-5.1mg-


181

Drug Name DrugTier

Requirements/Limits

30mcg-400unit-400mcg-60mcg-6mg-75mg, 20mcg-120mcg-2mg-2mg-22.5unit-150mcg-15mg-1.5mg-500mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg, 50mcg-2mg-72mg-10mcg-50mcg-55mcg-150mcg-2.3mg-5mcg-0.5mg-20mg-150mg-80mg-500mg-50mg-35unit-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 50mg-162mg-0.25mg-25000unit-15mg-24.3mg-0.1mg-53.5mg-50mg-6.15mg-2.2mg-7.2mg-12.5unit-400unit-25mg-5mg-15mg-12.5mg-50mg-250mg-150mg-25mg-50mcg-25mg-0.4mg-1mcg-15mg-150mg, 3mg-30mg-23.9mg-30unit-70mg-25mg-10mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 20mcg-120mcg-2mg-2mg-22.5unit-500mg-15mg-50mg-1.5mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 8.333mg-1mg-10mg-50mg-37.5mcg-244.333mg-3.333mg-1.667mg-2.5mg-4.167mcg-33.333mg-8.333mg-1mg-4.167mg-8.333mg-5mg-8.333mg-10mg-25mg-1.667mg-1666.667unit-2.667mcg-33.333unit-1.667mg-66.667mcg-5unit-1000mcg-1.667mg-40mg,150mcg-15mg-2mg-5mg-18mg-30mg-65mg-125mg-100mg-6mcg-35mg-400mcg-300mcg, 5000unit-125mg-18mg-150mcg-

Drug Name DrugTier

Requirements/Limits

160mg-100mg-15mg-400unit-1.7mg-6mcg-1.2mg-20mg-0.4mg-2mg-60mg, 40mcg-30unit-44mg-5000unit-2mg-40mg-60mg,20mcg-2mg-120mcg-2mg-30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-800unit-400mcg-30mcg-2mg-60mg,5000unit-450mg-15mg-27mg-30unit-400unit-1.5mg-1.7mg-10mg-6mcg-20mg-400mcg-2mg-60mg,100mcg-50mcg-25mcg-2.5mg-7.5mg-75mcg-50mg-30unit-100mg-50mg-1.5mg-100mg-10mg-250mcg-20mg-1.7mg-2500unit-5mcg-200unit-200mcg-75mcg-2.5mg-60mg, 30unit-5000unit-1.7mg-10mg-6mcg-1.5mg-20mg-0.4mg-2mg-60mg-400unit, 50mg-20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-2.4mg-300mg-18mg-5mg-2500unit-10mg-25mcg-2.7mg-9.5mcg-600unit-400mcg-30mcg-3.2mg-120mg-60mg, 16.67mg-66.67unit-2500unit-16.67mg-33.33mg-25mcg-83.33mg-5mg-4.17mcg-33.33mcg-0.4mg-16.5mg-8.33mcg-3.33mg-83.33mg-8.33mg-16.67mg-33.33mg-8.33mg-66.67mg-16.67mcg-16.67unit-16.67mg-31.67mg-133.33mcg-50mcg-16.67mg-100mg-200mg,70mcg-30unit-15mg-1.5mg-20mg-1.7mg-10mg-6mcg-2000unit-800mcg-300mcg-10mg-80mg,45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-220mg-


182

Drug Name DrugTier

Requirements/Limits

80mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.05mg-20mg-35unit-150mcg-50mcg-500mg-80mg-150mcg-15mg-50mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 16.666mg-1mg-3.333mg-42.666mg-5unit-86.666mg-0.666mg-2.5mg-16.666mg-3.333mg-3.333mg-5mg-8.333mg-10mg-3.333mg-1.666mg-1666.666unit-2.666mcg-333.333unit-1.666mg-66.666mcg-1666.666mcg-1.666mg-20mg, 2mg-7.5mg-10mcg-70mcg-120mcg-2mg-10mcg-5mcg-31mg-60unit-150mcg-75mcg-40mg-150mcg-7.5mg-2mg-15mg-100mg-9mg-10mg-5000unit-250mcg-20mg-28mcg-3.4mg-12mcg-400unit-3mg-400mcg-30mcg-6mg-90mg,150mcg-5mg-15mg-2mg-30mg-100mg-125mg-500mg-6mcg-35mg-400mcg-100mcg, 30unit-45mg-1.5mg-10mg-3000unit-20mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg, 45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.9mg-110mg-50unit-150mcg-45mcg-80mg-220mg-2mg-50mg-150mcg-11mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-500mcg-30mcg-3mg-

Drug Name DrugTier

Requirements/Limits

90mg, 36mg-10mcg-25mcg-25mcg-120mcg-2mg-10mcg-5mcg-77mg-50unit-150mcg-25mcg-100mg-2mg-40mg-100mg-20mg-150mcg-2mg-15mg-1.5mg-9mg-10mg-3000unit-250mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-120mg,35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-50mg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,117mcg-180mcg-4.2mg-2.2mg-25.5unit-150mcg-90mcg-110mg-24mg-4.5mg-370mcg-120mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-6mg-120mg, 7.5mg-28mcg-5000unit-21mcg-31mg-150mcg-40mg-15mg-10mcg-2mg-26mcg-150mcg-10mcg-2mg-7.5mg-5mcg-32mcg-3.5mg-100mg-18mg-30unit-400unit-3.4mg-10mg-9mcg-3mg-20mg-3mg-400mcg-30mcg-90mg,7.5mg-10mcg-31mg-150mcg-40mg-15mg-2mg-15mcg-7.5mg-15mcg-5mg-100mg-27mg-2500unit-30unit-400unit-2500unit-20mg-3.4mg-10mg-9mcg-3mg-0.4mg-30mcg-3mg-90mg, 100mcg-70mcg-150mcg-75mcg-10mcg-2mg-60unit-250mcg-2mg-15mg-100mg-10mg-100mg-18mg-10mg-25mg-100mg-100mcg-10mg-3000unit-25mcg-2000unit-400mcg-30mcg-6mg-100mg, 27mcg-180mcg-


183

Drug Name DrugTier

Requirements/Limits

4.2mg-30unit-150mcg-90mcg-50mg-2.2mg-24mg-4.5mg-500mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-1000unit-400mcg-30mcg-6mg-120mg, 35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-2mg-50mg-75mcg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 120mcg-50mg-4mg-72mg-10mcg-70mcg-4mg-10mcg-5mcg-0.9mg-48mg-60unit-150mcg-75mcg-80mg-100mg-40mg-60mcg-11mg-4.5mg-18mg-12mg-3500unit-40mg-25mcg-5.1mg-18mcg-400unit-400mcg-50mcg-6mg-120mg,110mcg-120mcg-2mg-22.5unit-210mg-100mg-2mg-15mg-120mg-1.2mg-300mcg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-700unit-400mcg-30mcg-3mg-60mg, 55mcg-60unit-1000unit-2mg-40mg-200mg, 70mcg-2mg-150mcg-2mg-30unit-2500unit-15mg-50mg-1.9mg-300mg-18mg-12.5mg-25mg-80mcg-2.1mg-7.5mcg-400unit-400mcg-2.5mg-60mg,10000unit-25mcg-200unit-200mg, 0.5mg-25000unit-30mg-0.15mg-6mg-25mg-7mg-100unit-1000unit-30mg-5mg-10mg-50mg-10mg-30mg-80mg-30mg-80mg-80mg-80mg-80mg-80mg-80mcg-80mg-400mcg-80mcg-80mg-250mg, 2mg-72mg-10mcg-55mcg-25mcg-1.8mg-10mcg-5mcg-20mg-

Drug Name DrugTier

Requirements/Limits

150mcg-50mcg-80mg-150mcg-100mg-35unit-0.9mg-8mg-1.1mg-500mg-18mg-15mg-3500unit-14mg-50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-20mg-30unit-150mcg-45mcg-200mg-75mcg-80mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,12.5mg-100mcg-9mg-1mg-1mg-25unit-75mcg-37.5mcg-5mcg-2500unit-50mcg-7.5mg-50mg-12.5mg-25mg-375mcg-250mg-50mcg-25mg-375mcg-17.5mg-40mcg-25mg-40mcg-200unit-200mcg-150mcg-25mg-50mg, 2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-45mcg-50mg-150mcg-11mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,110mcg-120mcg-2mg-2mg-22.5unit-15mg-140mg-1.35mg-300mcg-210mg-16mcg-3500unit-18mg-20mcg-1.7mg-18mcg-700unit-400mcg-75mcg-3mg-60mg, 25mg-10mg-25mg-170mg-5unit-150mcg-1.8mg-20mg-16mg-200mg-6mcg-400mcg-300mcg, 110mcg-120mcg-2mg-2mg-22.5unit-15mg-140mg-1.35mg-300mcg-210mg-16mg-3500unit-18mg-20mcg-1.7mg-18mcg-700unit-400mcg-75mcg-


184

Drug Name DrugTier

Requirements/Limits

3mg-60mg, 7160unit-100unit-0.4mg-17.4mg-113mg, 7.5mg-10mcg-31mg-150mcg-40mg-15mg-2mg-15mcg-7.5mg-15mcg-5mg-100mg-27mg-1250unit-30unit-400unit-5000unit-30mg-3.4mg-10mg-9mcg-3mg-0.4mg-35mcg-3mg-90mg, 2mg-72mg-10mcg-20mcg-10mcg-150mcg-2mg-5mcg-48mg-45unit-75mcg-150mcg-150mcg-80mg-2mg-15mg-100mg-1.5mg-300mcg-200mg-10mg-3500unit-250mcg-20mg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 2mg-7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-31mg-60unit-150mcg-75mcg-7.5mg-40mg-150mcg-2mg-15mg-100mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-3mg-400mcg-30mcg-6mg-90mg, 2mg-72mg-10mcg-20mcg-25mcg-120mcg-2mg-10mcg-5mcg-109mg-30unit-75mcg-150mcg-150mcg-80mg-2mg-15mg-100mg-1.5mg-300mcg-162mg-18mg-10mg-3500unit-250mcg-20mg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-150mcg-80mg-11mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 72mg-20mcg-2mg-5mcg-48mg-45unit-75mcg-150mcg-200mg-10mcg-150mcg-2mg-

Drug Name DrugTier

Requirements/Limits

80mg-150mcg-2mg-15mg-100mg-1.5mg-300mcg-3500unit-250mcg-20mg-10mcg-1.7mg-10mg-25mcg-400mcg-30mcg-3mg-60mg-400unit, 2mg-10mcg-20mcg-120mcg-2mg-10mcg-5mcg-2mg-109mg-30unit-150mcg-75mcg-72mg-162mg-150mcg-80mg-15mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-500mg-80mg-50mg-150mcg-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 117mcg-180mcg-4.2mg-25.5unit-150mcg-90mcg-110mg-2.2mg-24mg-4.5mg-370mcg-120mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-6mg-120mg, 50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-500mg-150mcg-80mg-15mg-50mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 20mcg-120mcg-2mg-22.5unit-150mcg-20mg-2mg-15mg-1.5mg-500mg-18mg-10mg-2500unit-25mcg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg,35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-


185

Drug Name DrugTier

Requirements/Limits

150mcg-45mcg-200mg-80mg-2mg-75mcg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 12.5mg-2.5mg-1mg-5mg-5mg-12.5mg-0.5mg-12.5mg-12.5mg-12.5mg-5mg-36mg-6.5mcg-100mcg-3.75mg-100mcg-6.5mcg-2.5mg-2.5mg-3.25mcg-65mg-30unit-75mcg-104mcg-250mg-1mg-40mg-1.75mg-7.5mg-100mg-6mg-13.5mg-15mg-3750unit-37.5mcg-20mg-40mcg-8.5mg-9mcg-200unit-200mcg-30mcg-5mg-60mg, 40mcg-30unit-5000unit-2mg-40mg-60mg,105mcg-120mcg-2mg-45unit-210mg-99mg-2mg-15mg-120mg-1.2mg-600mcg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400mcg-30mcg-3mg-90mg-400unit,20mcg-120mcg-2mg-2mg-30unit-50mg-15mg-1.5mg-450mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 60mcg-72mg-10mcg-100mcg-4mg-5mcg-0.7mg-20mg-60unit-150mcg-50mcg-80mg-250mg-2mg-50mg-150mcg-15mg-1.5mg-600mcg-10mg-3500unit-300mcg-20mg-60mcg-1.7mg-100mcg-600unit-300mcg-30mcg-6mg-120mg, 5000unit-450mg-15mg-27mg-30unit-1.5mg-1.7mg-10mg-6mcg-20mg-0.4mg-2mg-60mg-400unit,10000unit-0.125mg-150mcg-0.161mg-15mg-2mg-1.25mg-100mg-24mg-30unit-400unit-100mg-

Drug Name DrugTier

Requirements/Limits

10mg-20mg-6mcg-10mg-0.4mg-5mg-250mg,55mcg-2mg-60unit-1000unit-40mg-2mg-200mg, 34mg-105mcg-180mcg-4mg-2mg-33unit-150mcg-90mcg-40mg-22.5mg-100mg-4.5mg-120mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg, 5mg-90mg-10mcg-45mcg-3500unit-2mg-10mcg-5mcg-30unit-150mcg-25mcg-2mg-100mcg-99mg-40mg-150mcg-15mg-3mg-250mg-9mg-10mg-40mg-25mcg-3.4mg-12mcg-400unit-400mcg-300mcg-4mg-60mg, 10mg-25mcg-25mcg-4000unit-15mg-50mg-5mcg-50unit-100mg-15mg-0.25mg-1mg-10mg-5mg-15mg-1000unit-10mg-100unit-10mg-10mcg-5mg-15mg-10mg-25mg-10mg-10mg-25mg-15mg-25mg-200mcg-1mcg-100mg, 120mg-20mcg-100mcg-33unit-150mcg-90mcg-4mg-2mg-22.5mg-50mg-4.5mg-405mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg, 40mcg-2mg-30unit-5000unit-40mg-60mg, 10mg-70mcg-20mcg-120mcg-2mg-33unit-100mg-2mg-15mg-120mg-1.1mg-240mg-5mg-3000unit-14mg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-75mg, 25mcg-72mg-10mcg-55mcg-1.8mg-10mcg-5mcg-0.9mg-20mg-35unit-150mcg-50mcg-80mg-500mg-2mg-100mg-150mcg-8mg-1.1mg-18mg-15mg-3500unit-14mg-


186

Drug Name DrugTier

Requirements/Limits

50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 12.667mg-1mg-30mg-5unit-66.667mg-0.667mg-2.5mg-16.667mg-16.667mg-3.333mg-5mg-8.333mg-10mg-3.333mg-0.667mg-1666.667unit-2.667mcg-333.333unit-1.667mg-66.667mcg-1mg-1.667mg-20mg, 105mcg-20mcg-120mcg-2mg-45unit-100mg-2mg-15mg-120mg-1.2mg-600mcg-210mg-5mg-3500unit-16mg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 22.5mg-27mg-45unit-400unit-2mg-5000unit-30mg-2.6mg-9mcg-0.4mg-20.6mg-90mg, 200unit-1mg-40mg-1mg-5mg-250mg, 12.5mg-1.5mg-10mg-20mg-1.7mg-6mcg-800mcg-300mcg-10mg-60mg, 16.67mg-66.67unit-2500unit-16.67mg-33.33mg-25mcg-83.33mg-5mg-4.17mcg-0.33mg-33.33mcg-0.4mg-16.5mg-8.33mcg-3.33mg-83.33mg-3.33mg-8.33mg-16.67mg-33.33mg-8.33mg-66.67mg-16.67mcg-66.67unit-16.67mg-31.67mg-133.33mcg-50mcg-16.67mg-100mg-200mg, 16.7unit-16.7mcg-12.5mcg-4.16mg-0.08mg-16.7mcg-7.9mg-1.67mg-41.7mg-2.5mg-16.7unit-4.16mg-4.16mg-52.08mg-4.16mg-2083.3unit-10.4mcg-4.16mg-33.3mcg-4.16mg-250mg, 2mg-72mg-72mg-10mcg-10mcg-20mcg-20mcg-150mcg-150mcg-2mg-2mg-5mcg-5mcg-48mg-48mg-45unit-45unit-150mcg-150mcg-75mcg-

Drug Name DrugTier

Requirements/Limits

75mcg-80mg-80mg-200mg-200mg-100mg-100mg-150mcg-150mcg-2mg-2mg-15mg-15mg-1.5mg-1.5mg-300mcg-300mcg-10mg-10mg-3500unit-3500unit-250mcg-250mcg-20mg-20mg-10mcg-10mcg-1.7mg-1.7mg-25mcg-25mcg-400unit-400unit-400mcg-400mcg-30mcg-30mcg-3mg-3mg-60mg-60mg,27mg-70mcg-150mcg-2mg-2mg-30unit-2500unit-15mg-50mg-1.9mg-300mg-18mg-12.5mg-25mg-80mcg-2.125mg-7.5mcg-400unit-400mcg-2.5mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-15mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,12.5mcg-2.5mg-1mg-2.5mg-37.5mcg-75mg-15unit-2500unit-1mg-11.25mg-50mg-15mg-2.5mg-10mg-9mg-10mg-10mg-200unit-300mcg,72mg-50unit-55mcg-110mg-150mcg-220mg-11mg-10mcg-0.9mg-45mcg-150mcg-2mg-80mg-5mcg-45mcg-2.3mg-50mg-300mcg-2500unit-250mcg-20mg-30mcg-1.7mg-10mg-25mcg-500unit-1.5mg-500mcg-30mcg-3mg-90mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-150mcg-45mcg-80mg-50mg-50unit-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-


187

Drug Name DrugTier

Requirements/Limits

1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 1mg-1.5mg-5.5unit-0.15mg-1mg-5mg-15mg-15mg-10mg-10000unit-100mg-10mg-7.5mcg-400unit-2mg-150mg, 2mg-72mg-10mcg-20mcg-3.5mg-65mcg-10mcg-5mcg-2mg-109mg-30unit-150mcg-160mcg-80mg-162mg-150mcg-15mg-100mg-1.5mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 1mg-1mg-25mg-1mg-0.5mg-1mg-25mg-5mg-2mg-13mcg-90mg-200mcg-10mg-80mcg-5000unit-7.5mg-2mg-10mg-6.5mcg-80mg-60unit-200mcg-150mcg-165mg-200mcg-1mg-13mcg-2mg-100mg-0.5mg-3.5mg-15mg-100mg-300mcg-18mg-275mcg-40mg-5.1mg-10mg-24mcg-400unit-4.5mg-400mcg-60mcg-6mg-120mg,200mcg-5mg-50mcg-66mg-2.5mg-50unit-400unit-20mg-50mg-20mg-5000unit-100mg-20mg-25mg-50mcg-1000mcg-200mcg-25mg-500mg,52mcg-2mg-72mg-10mcg-50mcg-22mcg-2.3mg-5mcg-0.5mg-20mg-150mcg-80mg-100mg-35unit-15mg-1.1mg-300mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 34mg-25mcg-6000unit-10mcg-15mcg-125mg-150mcg-162mg-15mg-10mcg-2mg-15mcg-80mcg-37.5mg-5mcg-15mcg-2.5mg-100mg-18mg-30unit-400unit-

Drug Name DrugTier

Requirements/Limits

1.7mg-10mg-6mcg-1.5mg-20mg-400mcg-45mcg-2mg-60mg, 400mg-16mcg-1mg-29mg-5mcg-10mcg-60mcg-1mg-5mcg-2.5mcg-0.35mg-40mg-15unit-75mcg-37.5mcg-54mg-32mg-3.75mg-20mg-0.75mg-3mg-5mg-1750unit-10mg-12.5mcg-0.85mg-100mcg-200unit-200mcg-15mcg-2.5mg-30mg, 5mcg-5mcg-1mg-15.8mg-11.6mg-4.5mg-150mcg-3.75mg-10mg-1mg-5000unit-20mg-2.5mg-1mcg-400unit-2mg-1mg-50mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-80mg-100mg-150mcg-11mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg,120mg-20mcg-180mcg-4mg-2mg-22.5unit-150mcg-90mcg-500mg-22.5mg-50mg-4.5mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-1000unit-400mcg-30mcg-6mg-60mg, 7.5mg-21mcg-26mcg-3.5mg-2mg-31mg-30unit-150mcg-32mcg-7.5mg-15mg-100mg-3mg-40mg-18mg-10mg-5000unit-20mg-28mcg-3.4mg-9mcg-400unit-400mcg-30mcg-3mg-90mg,150mcg-70mcg-2mg-2mg-7.5mg-2mg-5mcg-31mg-60unit-150mcg-75mcg-40mg-10mcg-50mcg-10mcg-7.5mg-15mg-100mg-3mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-400mcg-30mcg-6mg-90mg,


188

Drug Name DrugTier

Requirements/Limits

150mcg-120mcg-70mcg-2mg-2mg-30unit-150mcg-75mcg-15mg-50mg-4.5mg-700mcg-500mg-18mg-15mg-3500unit-100mcg-20mg-60mcg-5.1mg-18mcg-1000unit-400mcg-300mcg-6mg-60mg, 2mg-72mg-10mcg-20mcg-65mcg-3.5mg-5mcg-2mg-109mg-15mg-30unit-150mcg-160mcg-162mg-10mcg-80mg-150mcg-100mg-1.5mg-18mg-2500unit-20mg-25mcg-1.7mg-10mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-1.5mg-500mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 40mcg-5000unit-30unit-2mg-40mg-60mg,72mg-10mcg-20mcg-150mcg-2mg-5mcg-48mg-45unit-150mcg-75mcg-200mg-2mg-80mg-150mcg-2mg-15mg-100mg-1.5mg-300mcg-10mg-3500unit-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-220mg-150mcg-80mg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 105mcg-200mcg-2mg-154mg-45unit-75mcg-99mg-200mg-2500unit-2mg-22.5mg-100mg-2.2mg-15mg-25mg-25mcg-2.5mg-9mcg-400unit-400mcg-450mcg-3mg-

Drug Name DrugTier

Requirements/Limits

90mg, 25mg-50mg-50mcg-1mg-10000unit-5mg-100mcg-7.5mg-18mg-75mcg-35mg-25mg-1mg-10mg-25unit-400unit-150mcg-15mg-5mg-6mg-25mg-25mcg-50mg-100mg-250mcg-150mcg-25mg-100mcg-25mg-400mcg-30mcg-25mg-150mg, 105mcg-120mcg-2mg-45unit-100mg-2mg-15mg-120mg-1.2mg-600mcg-210mg-5mg-1500unit-18mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg,40mcg-6000unit-50unit-5mg-2mg-40mg-40mg-3mg-5mg-200mg, 2mg-72mg-10mcg-20mcg-45unit-150mcg-2mg-5mcg-2mg-48mg-150mcg-75mcg-80mg-200mg-150mcg-15mg-100mg-1.5mg-300mcg-10mg-3500unit-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 77mg-24mg-30unit-3mg-10mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 10mcg-15mcg-5mg-31mg-30unit-150mcg-15mcg-7.5mg-40mg-2mg-15mg-100mg-3mg-18mg-10mg-5500unit-30mg-3.4mg-9mcg-400unit-400mcg-15mcg-3mg-120mg, 120mg-20mcg-4mg-180mcg-2mg-33unit-150mcg-90mcg-50mg-22.5mg-4.5mg-405mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg, 120mcg-20mcg-22.5unit-2mg-2mg-150mcg-15mg-1.5mg-500mg-18mg-10mg-2500unit-20mg-25mcg-


189

Drug Name DrugTier

Requirements/Limits

1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg, 20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-1.6mg-500mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 105mcg-120mcg-2mg-45unit-99mg-210mg-120mg-2mg-15mg-1.2mg-600mcg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 60mcg-10mcg-72mg-10mcg-100mcg-4mg-5mcg-0.7mg-20mg-150mcg-50mcg-250mg-80mg-150mcg-15mg-50mg-1.5mg-600mcg-10mg-300mcg-20mg-60mcg-1.7mg-3500unit-100mcg-600unit-300mcg-60unit-30mcg-6mg-120mg,70mcg-2500unit-50unit-4mg-75mcg-150mcg-162mg-2mg-120mcg-20mg-15mg-100mg-1.5mg-80mcg-1.7mg-10mg-18mcg-1000unit-400mcg-30mcg-4mg-180mg, 60mg-50mg-72mg-10mcg-70mcg-4mg-10mcg-5mcg-48mg-60unit-150mcg-75mcg-80mg-120mcg-4mg-40mg-60mcg-2mg-15mg-4.5mg-100mg-18mg-10mg-3500unit-40mg-25mcg-5.1mg-16mcg-400mcg-40mcg-6mg-120mg-400unit, 0.05mg-50mcg-60unit-20mcg-3mg-15mg-50mg-20mg-10mg-100mg-20mg-25mg-50mcg-1mg-0.15mg-25mg-500mg-400unit, 150mcg-65mcg-72mg-10mcg-20mcg-3.5mg-10mcg-5mcg-2mg-125mg-30unit-150mcg-160mcg-162mg-15mg-80mg-2mg-20mg-

Drug Name DrugTier

Requirements/Limits

100mg-1.5mg-18mg-10mg-5000unit-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-90mg,110mcg-120mcg-2mg-22.5unit-2mg-15mg-140mg-1.35mg-300mcg-210mg-16mg-3500unit-18mg-20mcg-1.7mg-18mcg-700unit-400mcg-75mcg-3mg-60mg,833.33unit-0.03mg-8.33mg-1mg-0.33mg-0.33mg-11.33mg-3.33mg-4.67unit-66.67unit-10mg-43.55mg-0.67mg-2.5mg-1.67mg-3.33mg-0.03mg-1.33mg-33.33mg, 12.5mg-100mcg-25mg-5mg-15mg-0.5mg-12.5mg-20mg-5mg-36mg-6.5mcg-100mcg-3.75mg-100mcg-6.5mcg-2.5mg-2.5mg-12.5mg-3.25mcg-65mg-30unit-75mcg-82.5mg-1mg-40mg-1.75mg-12.5mg-50mg-2.25mg-3750unit-37.5mcg-20mg-40mcg-2.55mg-5mg-9mcg-200unit-200mcg-150mcg-3mg-90mg,5000unit-5mcg-10mg-150mcg-19mg-3.75mg-5mcg-1mg-10mg-4.5mg-2.5mg-1mg-1mcg-400unit-1mg-20mg-2mg-50mg,50mg-30mg-150mcg-1.35mg-75mg-30unit-100mg-1.1mg-100mg-15mg-10mg-6.5mg-5mg-10mg-5000unit-12mcg-400unit-5mg-20mg-400mcg-2mg-150mg,0.5mg-0.375mg-1.5mg-80mg-15unit-75mcg-100mg-2.5mg-7.5mg-5mg-5000unit-15mg-2.5mg-1mcg-400unit-400mcg-1mg-60mg, 33.333mg-33.333mcg-50mcg-83.333mg-7.5mg-66.667mcg-11.667mg-4.167mcg-33.333mg-


190

Drug Name DrugTier

Requirements/Limits

3.333mg-333.333mg-6mg-33.333mg-33.333mg-16.667mg-33.333mcg-16.667mg-266.667mcg-66.667unit-100mcg-16.667mg-1666.667unit-133.333unit, 25mcg-3mg-2mg-500mg-30unit-2mg-10mg-2mg-10mg-10mg,6.25mcg-72.5mg-50mg-30unit-100mg-2.5mg-0.5mg-7.5mg-0.75mg-2500unit-250mcg-10mg-0.85mg-500unit-50mg-100mcg-1500mcg-60mg,2mg-72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-5mcg-109mg-30unit-150mcg-160mcg-162mg-80mg-150mcg-2mg-15mg-100mg-1.5mg-600mcg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg-400unit, 1mg-25mg-5mg-25mg-1mg-500mcg-1mg-1mg-5mg-2mg-90mg-13mcg-200mcg-10mg-200mcg-7.5mg-13mcg-2mg-5mg-6.5mcg-130mg-60unit-150mcg-200mcg-165mg-2mg-100mg-500mcg-3.5mg-15mg-100mg-4.5mg-3.6mg-10mg-7500unit-500mcg-40mg-80mcg-5.1mg-24mcg-400mcg-60mcg-6mg-120mg-400unit, 2mg-36mg-250mg-25mcg-50unit-2mg-5mcg-77mg-25mcg-150mcg-10mcg-2mg-120mcg-10mcg-40mg-18mg-20mg-400unit-150mcg-15mg-100mg-1.5mg-3000unit-250mcg-100mcg-1.7mg-10mg-6mcg-400mcg-30mcg-2mg-120mg, 45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.9mg-50unit-45mcg-150mcg-220mg-80mg-2mg-150mcg-11mg-

Drug Name DrugTier

Requirements/Limits

50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-500mcg-30mcg-3mg-90mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.9mg-110mg-50unit-150mcg-45mcg-220mg-150mcg-80mg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-500mcg-30mcg-3mg-90mg,5000unit-40mcg-40mg-2mg-30unit-60mg, 30unit-0.1mg-5mg-3mg-22.5mg-50mg-20mg-27mg-5000unit-100mg-20mg-25mg-50mcg-0.8mg-0.15mg-25mg-500mg,30unit-1.5mg-75mg-18mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg,45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-2mg-50mg-150mcg-11mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,2mg-72mg-10mcg-55mcg-200mg-35mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-80mg-150mcg-11mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 45mcg-45mcg-72mg-72mg-10mcg-10mcg-55mcg-55mcg-2.3mg-2.3mg-5mcg-5mcg-0.9mg-0.9mg-110mg-110mg-50unit-50unit-150mcg-150mcg-45mcg-


191

Drug Name DrugTier

Requirements/Limits

45mcg-220mg-220mg-2mg-2mg-80mg-80mg-50mg-50mg-150mcg-150mcg-11mg-11mg-1.5mg-1.5mg-300mcg-300mcg-10mg-10mg-2500unit-2500unit-250mcg-250mcg-20mg-20mg-30mcg-30mcg-1.7mg-1.7mg-25mcg-25mcg-500unit-500unit-500mcg-500mcg-30mcg-30mcg-3mg-3mg-90mg-90mg,50mcg-2mg-72mg-10mcg-19mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-50mg-20mg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 200mcg-12mg-72mg-1.5mg-2.3mg-35mcg-110mg-50unit-150mcg-2mg-80mg-220mg-10mcg-150mcg-5mcg-45mcg-50mg-1.5mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-30mcg-600unit-500mcg-300mcg-3mg-90mg, 72mg-5mcg-20mcg-109mg-150mcg-162mg-10mcg-120mcg-10mcg-2mg-80mg-75mcg-2mg-150mcg-2mg-15mg-100mg-1.5mg-300mcg-18mg-3500unit-250mcg-20mg-25mcg-1.7mg-10mg-6mcg-400mcg-30unit-30mcg-2mcg-60mg-400unit, 27mcg-180mcg-4.2mg-30unit-150mcg-90mcg-2.2mg-24mg-50mg-4.5mg-500mg-10mg-3500unit-20mg-20mcg-3.4mg-25mcg-1000unit-400mcg-30mcg-6mg-120mg, 4.58mg-16.66unit-4.58mg-1.66mg-0.0125mg-25mg-16.66mg-12.5mg-

Drug Name DrugTier

Requirements/Limits

25mg-2.5mg-0.33mg-0.16mg-12.5mg-0.016mg-0.83mg-41.66mg-1.66mg-16.66mg-1.66mg-66.66unit-4.16mg-4.16mg-8.33mg-4.16mg-2.5mg-16.66mg-833.33unit-33.33mg-16.66mg-25mg-1.66mg-16.66mcg-4.16mg-8.33mg-0.16mg-4.16mg-8.33mg-33.33mg, 30unit-1.5mg-45mg-10mcg-3000unit-20mg-1.7mg-6mcg-400unit-0.4mg-2mg-60mg, 50mg-20mcg-120mcg-2mg-22.5unit-300mg-50mg-2mg-15mg-2.4mg-18mg-5mg-2500unit-10mg-25mcg-2.7mg-9.5mcg-800unit-400mcg-30mcg-3.2mg-120mg-60mg, 70mcg-120mcg-4mg-2mg-50unit-150mcg-75mcg-100mg-15mg-1.5mg-162mg-18mg-10mg-2500unit-20mg-80mcg-1.7mg-6mcg-1000unit-400mcg-30mg-2mg-180mg, 72mg-10mcg-5000unit-45unit-20mcg-48mg-150mcg-200mg-15mg-10mcg-2mg-130mcg-150mcg-2mg-80mg-5mcg-160mcg-3.5mg-100mg-4mg-400unit-1.5mg-20mg-1.7mg-10mg-25mcg-400mcg-30mcg-3mg-60mg,7.5mg-5000unit-10mcg-31mcg-150mcg-40mg-15mg-2mg-15mcg-7.5mg-15mcg-5mg-100mg-27mg-30unit-400unit-3.4mg-10mg-9mcg-3mg-20mg-0.04mg-30mcg-3mg-90mg,117mcg-180mcg-4.2mg-2.2mg-25.5unit-150mcg-90mcg-24mg-110mg-4.5mg-370mcg-120mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-


192

Drug Name DrugTier

Requirements/Limits

6mg-120mg, 12.667mg-1mg-30mg-5unit-5unit-66.667mg-0.667mg-2.5mg-2.5mg-16.667mg-4.167mcg-16.667mg-4.167mg-3.333mg-5mg-8.333mg-10mg-3.333mg-0.667mg-1666.667unit-1666.667unit-2.667mcg-333.333unit-1.667mg-1.667mg-66.667mcg-1mg-1.667mg-20mg, 20mcg-120mcg-150mcg-75mcg-10mcg-2mg-250mcg-2mg-15mg-100mg-5mg-100mg-10mg-20mg-100mg-5mg-3500unit-30mcg-400mcg-30unit-30mcg-5mg-100mg,10000unit-57mg-0.15mg-125mg-5mg-2mg-2mg-40mg-15mg-100unit-400unit-25mg-10mg-25mg-15mcg-10mg-400mcg-25mcg-10mg-250mg, 8mg-30unit-10mcg-150mcg-40mg-15mg-2mg-15mcg-8mg-15mcg-2mg-60mg-9mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-1.5mg-400mcg-30mcg-2mg-90mg, 2500unit-30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-10mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg,50mcg-2mg-10mcg-7.5mg-70mcg-2mg-10mcg-5mcg-2mg-31mg-60unit-150mcg-75mcg-40mg-150mcg-7.5mg-15mg-100mg-3mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-400mcg-30mcg-6mg-90mg, 72mg-2.5mg-5mcg-20mcg-48mg-45unit-150mcg-2mg-200mg-10mcg-130mcg-150mcg-80mg-160mcg-4mg-2mg-15mg-100mg-1.5mg-5000unit-20mg-10mcg-1.7mg-10mg-25mcg-400mcg-30mcg-3mg-

Drug Name DrugTier

Requirements/Limits

60mg-400unit, 7.5mg-5mg-10mcg-2mg-31mg-30unit-150mcg-15mg-40mg-15mcg-7.5mg-15mcg-1250unit-100mg-3mg-27mg-5000unit-30mg-3.4mg-10mg-9mcg-0.4mg-35mcg-3mg-90mg-400unit,35mcg-72mg-10mcg-55mcg-10mcg-5mcg-109mg-30unit-150mcg-45mcg-80mg-200mg-0.9mg-2.3mg-100mg-1250unit-2mg-150mcg-11mg-1.5mg-300mcg-18mg-3500unit-250mcg-20mg-25mcg-1.7mg-10mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 120mg-110mcg-180mcg-4mg-2mg-22.5unit-150mcg-90mcg-120mg-22.5mg-100mg-4.5mg-300mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-6mg-60mg, 35mcg-35mcg-72mg-72mg-10mcg-10mcg-55mcg-55mcg-2.3mg-2.3mg-10mcg-10mcg-5mcg-5mcg-0.9mg-0.9mg-109mg-109mg-30unit-30unit-150mcg-150mcg-45mcg-45mcg-80mg-80mg-200mg-200mg-2mg-2mg-100mg-100mg-150mcg-150mcg-11mg-11mg-1.5mg-1.5mg-300mcg-300mcg-18mg-18mg-10mg-10mg-3500unit-3500unit-250mcg-250mcg-20mg-20mg-25mcg-25mcg-1.7mg-1.7mg-6mcg-6mcg-400unit-400unit-500mcg-500mcg-30mcg-30mcg-2mg-2mg-90mg-90mg, 33.333mcg-0.667mg-1.667mg-3.333mg-26.667mg-5mcg-66.667unit-5mg-66.667mg-1666.667unit-5mg-16.667mg-66.667mg-


193

Drug Name DrugTier

Requirements/Limits

133.333mg-16.667mcg-133.333unit-16.667mg-133.333mg-16.667mg-333.333mcg-50mcg-16.667mg-333.333mg-166.667mg, 60mg-5000unit-50mcg-12mg-1.5mg-75mg-13.5mg-25mg-15mg-1.3mg-200mg-1.25mg-30unit-500mg,150mcg-60mcg-10mcg-72mg-100mcg-60unit-4mg-20mg-150mcg-50mcg-15mg-80mg-250mg-5mcg-50mg-0.7mg-15mg-1.5mg-600mcg-3500unit-300mcg-20mg-60mcg-1.7mg-10mg-100mcg-600unit-300mcg-30mcg-6mg-120mg,120mg-20mcg-2500unit-4mg-180mcg-2mg-33unit-150mcg-90mcg-22.5mg-50mg-4.5mg-405mg-15mg-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg, 72mg-65mcg-3.5mg-5mcg-20mcg-2mg-109mg-30unit-150mcg-10mcg-150mcg-10mcg-2mg-80mg-160mcg-100mg-15mg-1.5mg-162mg-18mg-2500unit-20mg-25mcg-1.7mg-10mg-6mcg-400mcg-30mcg-2mg-60mg-400unit, 5mg-25mg-100mcg-1mg-5mg-5mcg-1mg-1mg-25unit-75mcg-37.5mcg-60mcg-2500unit-12.5mg-50mg-12.5mg-25mg-475mcg-100mg-12.5mg-25mg-475mcg-25mg-5mg-5mg-40mcg-25mg-25mcg-100unit-200mcg-150mcg-25mg-150mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-50mg-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-

Drug Name DrugTier

Requirements/Limits

20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 25mcg-12.5mg-2.5mg-1mg-5mcg-50mcg-250mg-75mcg-2mg-50mcg-1mg-25mcg-2.5mg-13.5mcg-12.5mg-7.5mg-50mg-40mg-5mg-40mg-250mcg-40mg-10mcg-5mg-37.5mcg-40mg-5000unit-40mg-200unit-200mg-50unit-40mg-40mg-100mg,833unit-41.7mg-1.7mg-83mcg-250mcg-28.3mg-5unit-33unit-5mg-5mg-16.7mg-16.7mg-2.5mg-8.3mg-1.7mcg-1.7mg-2.5mg-66.7mcg-8.3mcg-83mg-83mg, 7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-2mg-31mg-60unit-150mcg-75mcg-40mg-2mg-7.5mg-150mcg-15mg-100mg-3mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-400mcg-30mcg-6mg-90mg, 45mg-25mg-40mg-1mg-37.5mcg-100mcg-25mcg-35mcg-1mg-75mcg-1mg-15unit-200mg-7.5mg-0.75mg-125mg-5mg-10mg-0.85mg-2500unit-3mcg-200unit-1mg-200mcg-150mcg-30mg, 30unit-15mg-1.5mg-450mg-27mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg, 72mg-10mcg-6000unit-5mcg-25mcg-48mg-150mcg-200mg-15mg-10mcg-2mg-100mcg-10mcg-80mg-25mcg-2.5mg-100mg-9mg-45unit-400unit-1.5mg-20mg-1.7mg-10mg-25mcg-200mcg-30mcg-3mg-60mg,33.333mg-33.333mg-0.667mg-3.333mcg-73.333mcg-0.667mg-


194

Drug Name DrugTier

Requirements/Limits

1.667mcg-16mg-133.333unit-50mcg-25mcg-24mg-166.667mg-116.667mcg-50mcg-26.667mg-0.667mg-5mg-33.333mg-16.667mg-0.5mg-100mcg-3.333mg-1666.667unit-83.333mcg-6.667mg-3.333mcg-0.567mg-8.333mcg-133.333unit-166.667mcg-10mcg-1mg-166.667mg,5000unit-5000unit-450mg-450mg-15mg-15mg-27mg-27mg-30unit-30unit-400unit-400unit-1.7mg-1.7mg-10mg-10mg-6mcg-6mcg-20mg-20mg-1.5mg-1.5mg-400mcg-400mcg-2mg-2mg-60mg-60mg,16.667mcg-53mg-133.333unit-8333.333unit-166.667mg, 110mcg-120mcg-2mg-22.5unit-2mg-15mg-120mg-1.2mg-300mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-700unit-400mcg-30mcg-3mg-60mg, 2mg-72mg-10mcg-55mcg-45mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-50mg-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,23.9mg-30unit-3mg-10mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 16.67mg-66.67unit-2500unit-16.67mg-33.33mg-25mcg-83.33mg-5mg-4.17mcg-0.33mg-33.33mcg-0.4mg-16.5mg-8.33mcg-3.33mg-83.33mg-8.33mg-16.67mg-33.33mg-8.33mg-66.67mg-16.67mcg-16.67unit-16.67mg-31.67mg-

Drug Name DrugTier

Requirements/Limits

133.33mcg-50mcg-16.67mg-100mg-200mg,32mcg-2mg-72mg-10mcg-18mcg-1.8mg-10mcg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-100mg-8mg-1.1mg-200mg-18mg-15mg-3500unit-14mg-50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 30unit-450mg-15mg-27mg-2500unit-2500unit-20mg-1.7mg-10mg-6mcg-1.5mg-400mcg-2mg-60mg-400unit, 72mg-10mcg-5000unit-20mcg-48mg-150mcg-200mg-15mg-10mcg-2mg-130mcg-150mcg-2mg-80mg-5mcg-160mg-3.5mg-100mg-4mg-45unit-400unit-20mg-1.7mg-10mg-25mcg-3mg-1.5mg-400mcg-30mcg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-150mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-80mg-11mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-2500unit-1.7mg-6mcg-400unit-10mg-400mcg-2mg-60mg,45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-2mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,36.3mg-25mcg-5000unit-10mcg-5mcg-20mcg-109mg-150mcg-162mg-


195

Drug Name DrugTier

Requirements/Limits

15mg-10mcg-2mg-25mcg-150mcg-2mcg-40mg-25mcg-2.5mg-100mg-18mg-30unit-400unit-1.5mg-20mg-1.7mg-10mg-6mcg-400mcg-30mcg-2mg-60mg, 50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-500mg-50mg-150mcg-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 50mg-20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-2.4mg-300mg-18mg-5mg-2500unit-10mg-25mcg-2.7mg-9.5mcg-800unit-400mcg-30mcg-3.2mg-120mg-60mg, 50mcg-10mg-80mg-125mg-200unit-33mg-25mg-5000unit-50mg-25mg-25mg-25mg-1mg-100unit-300mcg-500mg, 72mg-25mcg-5000unit-20mcg-109mg-150mcg-162mg-15mg-10mcg-2mg-65mcg-150mcg-10mcg-2mg-80mg-5mcg-160mg-3.5mg-100mg-18mg-30unit-400unit-20mg-1.7mg-10mg-6mcg-2mg-1.5mg-400mcg-30mcg-60mg,2500unit-0.9mg-11mg-2500mcg-100mg, 36.3mg-10mcg-5000unit-25mcg-2.5mg-10mcg-5mcg-20mcg-109mg-30unit-150mcg-25mcg-150mcg-162mg-2mg-40mg-400unit-150mcg-2mg-15mg-100mg-1.5mg-18mg-10mg-20mg-25mcg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg, 45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-45mcg-100mcg-80mg-

Drug Name DrugTier

Requirements/Limits

2mg-150mcg-11mg-50mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 120mg-105mcg-2500unit-180mcg-33unit-150mcg-90mcg-40mg-4mg-2mg-22.5mg-100mg-4.5mg-600mcg-120mg-15mg-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg, 105mcg-120mcg-2mg-45unit-100mg-210mg-2mg-15mg-120mg-1.2mg-600mcg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 0.5mg-15mg-155mcg-9.5mg-15unit-150mg-9.5mg-22mg-12.5mcg-99mg-12.5mg-1mg-222mcg-99mg-122mg-22mcg, 50mcg-2mg-72mg-10mcg-55mcg-3500unit-2.3mg-5mcg-0.5mg-20mg-8mg-150mcg-50mcg-500mg-80mg-150mcg-15mg-50mg-1.1mg-5mg-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-35unit-30mcg-5mg-100mg,400mg-1mg-29mg-5mcg-10mcg-60mcg-1mg-5mcg-2.5mcg-0.35mg-40mg-15unit-75mcg-37.5mcg-32mg-54mg-20mg-16mcg-3.75mg-0.75mg-3mg-5mg-1750unit-10mg-12.5mcg-0.85mg-100mcg-200unit-200mcg-15mcg-2.5mg-30mg, 0.12mg-3.75mg-5unit-15mg-10mg-3.33mg-0.33mcg-1.67mg, 10mcg-10mcg-2.5mg-2mg-15mg-100mg-30unit-150mcg-40mg-130mg-10mcg-100mg-1.5mg-10mg-5000unit-20mg-1.7mg-


196

Drug Name DrugTier

Requirements/Limits

6mcg-400mcg-30mcg-2mg-60mg-400unit, 2mg-72mg-10mcg-20mcg-150mcg-2mg-5mcg-2mg-48mg-45unit-150mcg-75mcg-200mg-80mg-150mcg-15mg-100mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-1.5mg-400mcg-30mcg-2mg-60mg, 7.5mg-10mcg-15mcg-5mg-31mg-30unit-150mcg-15mcg-44mg-7.5mg-2mg-15mg-100mg-18mg-10mg-5500unit-30mg-3.4mg-9mcg-400unit-3mg-400mcg-15mcg-3mg-120mg, 30mg-2mg-72mg-10mcg-20mcg-120mcg-10mcg-5mcg-2mg-109mg-30unit-150mcg-0.75mcg-150mcg-80mg-2mg-300mcg-10mg-18mg-3500unit-250mcg-10mg-10mg-25mcg-400unit-400mcg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-50mg-150mcg-11mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-2500unit-10mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg, 20mcg-5250unit-120mcg-2mg-2mg-15mg-1.5mg-450mg-27mg-10mg-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30unit-30mcg-2mg-60mg, 7160unit-0.4mg-17.4mg-100unit-113mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-

Drug Name DrugTier

Requirements/Limits

30unit-150mcg-45mcg-200mg-75mcg-80mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 35mcg-72mg-10mcg-100mcg-2.3mg-10mcg-5mcg-0.9mg-20mg-45unit-150mcg-50mcg-80mg-210mg-2mg-100mg-150mcg-11mg-1.2mg-600mcg-8mg-15mg-3500unit-16mg-60mcg-1.3mg-6mcg-600unit-200mcg-40mcg-2mg-90mg,20mcg-120mcg-2mg-150mcg-500mg-22.5unit-2mg-15mg-1.5mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg, 5000unit-30unit-40mcg-2mg-40mg-60mg, 1mg-25mg-5mg-25mg-10mg-72mg-80mcg-5mg-10mg-200mcg-130mg-60unit-150mcg-165mg-15mg-13mcg-3.5mg-200mcg-200mcg-13mcg-2mg-80mg-6.5mcg-208mcg-7.5mg-100mg-18mg-7500unit-5mg-5.1mg-10mg-18mcg-6mg-40mg-4.5mg-400mcg-60mcg-120mg-400unit,72mg-10mcg-20mcg-25mcg-2mg-10mcg-5mcg-109mg-75mcg-150mcg-162mg-120mcg-2mg-80mg-100mg-30unit-150mcg-2mg-15mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg-400unit,2mg-72mg-10mcg-20mcg-150mcg-2mg-5mcg-48mg-45unit-150mcg-75mcg-80mg-150mcg-2mg-15mg-100mg-1.5mg-200mg-10mg-3500unit-250mcg-


197

Drug Name DrugTier

Requirements/Limits

20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 2mg-72mg-10mcg-20mcg-120mcg-2mg-10mcg-5mcg-109mg-30unit-150mcg-75mcg-162mg-80mg-150mcg-2mg-15mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg-400unit,30unit-2mg-15mg-6mg-60mg, 2mg-72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-5mcg-2mg-15mg-109mg-30unit-150mcg-160mcg-162mg-80mg-150mcg-100mg-1.5mg-18mg-10mcg-2500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 45mg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-220mg-150mcg-80mg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-75mcg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 117mcg-180mcg-4.2mg-25.5unit-150mcg-90mcg-120mg-110mg-2.2mg-24mg-4.5mg-370mcg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-6mg-120mg, 72mg-10mcg-20mcg-65mcg-3.5mg-

Drug Name DrugTier

Requirements/Limits

10mcg-5mcg-2mg-109mg-30unit-150mcg-160mcg-162mg-2mg-80mg-150mcg-15mg-100mg-1.5mg-18mg-10mg-20mg-25mcg-1.7mg-2500unit-6mcg-400unit-400mcg-30mcg-2mg-50mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-75mcg-80mg-50mg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,5mg-0.5mg-250mcg-1.5mg-50mg-750mcg-50mg-15unit-100mg-60mg-7.5mg-5mg-0.75mg-6.75mg-2500unit-5mg-10mg-0.85mg-100unit-50mg-25mg-100mcg-1500mcg-100mg, 100unit-7160unit-0.4mg-17.4mg-113mg, 25mcg-2mg-72mg-10mcg-55mcg-1.8mg-10mcg-5mcg-0.9mg-20mg-35unit-150mcg-50mcg-80mg-500mg-100mg-150mcg-8mg-1.1mg-18mg-15mg-3500unit-14mg-50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 60mcg-2mg-72mg-10mcg-100mcg-4mg-5mcg-0.7mg-20mg-60unit-150mcg-50mcg-80mg-250mg-50mg-150mcg-15mg-1.5mg-600mcg-10mg-3500unit-300mcg-20mg-60mcg-1.7mg-100mcg-600unit-300mcg-30mcg-6mg-120mg, 7.5mg-28mcg-5000unit-21mcg-31mg-150mcg-40mg-15mg-10mcg-2mg-26mcg-150mcg-10mcg-2mg-7.5mg-5mcg-32mcg-3.5mg-100mg-18mg-


198

Drug Name DrugTier

Requirements/Limits

30unit-400unit-3.4mg-10mg-9mcg-3mg-20mg-400mcg-30mcg-3mg-90mg, 40mcg-2mg-30unit-1000unit-40mg-60mg,35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 69mg-30unit-10mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 25mcg-5mg-2mg-5mg-75mcg-150mg-30unit-150mg-2mg-22.5mg-100mg-30mg-5mg-10mg-18mg-5000unit-10mg-10mg-400unit, 2mg-72mg-10mcg-55mcg-45mcg-2.3mg-5mcg-0.5mg-20mg-20mg-150mcg-45mcg-80mg-50mg-50unit-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 1666.67unit-8.33mg-4.17mcg-50mg-37.5mcg-100mg-2.5mg-1.67mg-33.33mg-1mg-5unit-33.33unit-8.33mg-4.17mg-8.33mg-10mg-8.33mg-10mg-1.67mg-5mg-2.67mcg-1.67mg-25mg-66.67mcg-66.67mcg-1.67mg-20mg,20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-1.5mg-500mg-18mg-5mg-2500unit-25mcg-1.7mg-6mcg-1000unit-10mg-400mcg-30mcg-2mg-60mg, 36.3mg-10mcg-25mcg-5000unit-25mcg-2.5mg-10mcg-5mg-125mg-

Drug Name DrugTier

Requirements/Limits

30unit-150mcg-25mcg-162mg-10mcg-40mg-400unit-2mg-15mg-100mg-1.5mg-18mg-10mg-20mg-25mcg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg,105mcg-2mg-45unit-99mg-120mcg-2mg-15mg-120mg-1.2mg-600mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 45mcg-2mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 72mg-10mcg-20mcg-2mg-10mcg-5mcg-109mg-30unit-150mcg-75mcg-162mg-120mg-150mcg-2mg-80mg-2mg-15mg-100mg-1.5mg-300mcg-3500unit-250mcg-20mg-1.7mg-10mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,50mcg-100unit-10000unit-400unit, 120mg-105mcg-180mcg-4mg-2mg-33unit-150mcg-90mcg-40mg-100mg-22.5mg-4.5mg-600mcg-120mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg, 34mg-105mcg-180mcg-4mg-60unit-150mcg-90mcg-37.5mg-100mg-2mg-22.5mg-4.5mg-120mg-15mg-5000unit-20mg-20mcg-3.4mg-30mcg-400unit-400mcg-30mcg-6mg-120mg, 117mcg-180mcg-4.2mg-2.2mg-150mcg-90mcg-110mg-24mg-4.5mg-370mcg-120mg-


199

Drug Name DrugTier

Requirements/Limits

15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-25.5unit-30mcg-6mg-120mg,30unit-10mg-70mcg-10000unit-10mg-25mcg-52mg-100mcg-100mg-30mg-25mcg-2mg-500mcg-2.4mg-25mg-100mcg-6mg-100mg-20mg-10mg-8mg-10mg-10mg-15mg-25mg-25mcg-400unit-15mg-25mg-400mcg-300mcg-25mg-100mg, 10mg-25mg-10mg-10mg-10mg-36mg-10mcg-27mg-70mcg-120mcg-2mg-10mcg-5mcg-77mg-45unit-150mcg-75mcg-250mg-150mcg-40mg-2mg-15mg-100mg-1.875mg-12.5mg-5000unit-300mcg-25mg-80mcg-2.1mg-7.5mcg-400unit-400mcg-37.5mcg-2.5mg-120mg, 60mcg-72mg-21mcg-4mg-0.5mg-20mg-60unit-150mcg-50mcg-80mg-210mg-15mg-75mg-1.5mg-600mcg-10mg-3500unit-300mcg-20mg-60mcg-1.7mg-100mcg-600unit-300mcg-30mcg-6mg-120mg, 1mg-150mcg-125unit-125mcg-35mg-35mg-10mg-25mg-125mcg-35mg-400mcg-35mg-3.4mg-5mg-70mcg-400unit-1.25mg-75mcg-35mg-500mg, 10mcg-15mcg-5mg-2mg-15mg-30unit-150mcg-15mcg-10mg-40mg-100mg-3mg-27mg-10mg-30mg-3.4mg-5500unit-9mcg-400unit-400mcg-15mcg-3mg-120mg, 0.5mg-1mg-50mg-50mg-100mg-7.5mg-30unit-0.75mg-2500unit-250mcg-10mg-0.85mg-100unit-50mg-25mg-100mcg-1250mcg-50mg-

Drug Name DrugTier

Requirements/Limits

60mg, 10000unit-150mcg-1.5mg-2mg-1mg-65mg-12mg-15unit-100mg-10mg-20mg-5mcg-10mg-0.4mg-5mg-120mg-400unit,72mg-10mcg-20mcg-150mcg-2mg-5mcg-48mg-45unit-150mcg-75mcg-80mg-200mg-150mcg-100mg-2mg-2mg-15mg-1.5mg-10mg-5000unit-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg,117mcg-180mcg-4.2mg-2.2mg-30unit-150mcg-90mcg-24mg-110mg-4.5mg-370mcg-120mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-6mg-120mg, 1mg-5mg-25mg-10mg-25mg-10mg-13mcg-72mg-200mcg-5mg-80mcg-5000unit-7.5mg-5mg-10mg-6.5mcg-80mg-60unit-200mcg-150mcg-165mg-200mcg-200mcg-13mcg-2mg-80mg-3.5mg-15mg-100mg-300mcg-18mg-275mcg-40mg-5.1mg-10mg-18mcg-400unit-4.5mg-400mcg-60mcg-6mg-120mg, 2mg-72mg-10mcg-20mcg-150mcg-2mg-5mcg-48mg-45unit-150mcg-75mcg-200mg-80mg-150mcg-2mg-15mg-100mg-1.5mg-300mcg-10mg-3500unit-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg,35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-50mg-75mcg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,


200

Drug Name DrugTier

Requirements/Limits

2mg-7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-40mg-31mg-60unit-150mcg-75mcg-7.5mg-150mcg-2mg-15mg-100mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-3mg-400mcg-30mcg-6mg-90mg, 8.333mg-3.333mg-3.333mg-3.333mg-33.333mg-33.333mg-16.666mg-3.333mg-3.333mg-3.333mg-33.333mg-3.333mg-11.666mg-0.833mg-1.666mg-6.666mg-1.666mg-6.666mg-1.666mg-8.333mg-33.333mg-3.333mg-25mcg-10mg-50mcg-83.333mg-5mg-0.333mg-33.333mcg-0.333mg-20mg-16.666mcg-1.333mg-33.333mg-5mg-5000unit-33.333mg-83.333unit-333.333mg-1.333mg-8.333mg-6.666mg-8.333mg-8.333mg-8.333mg-8.333mg-8.333mg-8.333mg-8.333mg-8.333mcg-133.333unit-8.333mg-8.333mg-133.333mcg-16.666mcg-8.333mg-333.333mg,10mcg-20mcg-120mcg-2mg-10mcg-5mcg-2mg-109mg-30unit-150mcg-75mcg-150mcg-2mg-300mcg-10mg-18mg-3500unit-250mcg-10mg-10mg-25mcg-400unit,32mcg-72mg-18mcg-1.8mg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-200mg-8mg-100mg-1.1mg-18mg-15mg-3500unit-14mg-50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 110mcg-120mcg-2mg-210mg-

Drug Name DrugTier

Requirements/Limits

22.5unit-2mg-15mg-120mg-1.2mg-300mcg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-700unit-400mcg-30mcg-3mg-60mg, 25mg-75mg-10mcg-18mg-70mcg-2.5mg-10mcg-5mcg-77mg-45unit-150mcg-75mcg-162mg-120mcg-150mcg-2mg-80mg-2000unit-2mg-15mg-100mg-1.9mg-3000unit-300mcg-25mg-25mcg-2.1mg-12.5mg-7.5mcg-400unit-400mcg-37.5mcg-2.5mg-120mg,16.6mcg-16.66mg-16.6mcg-66unit-5mg-8333unit-33.3unit-16.66mcg-8.33mg-133.33mcg-8.3mg-166mg,0.5mg-0.37mg-1.5mg-80mg-15unit-75mcg-100mg-2.5mg-2.5mg-5000unit-15mg-2.5mg-5mg-1mcg-400unit-400mcg-1mg-60mg,50mcg-10mg-60mg-100unit-125mg-33mg-25mg-5000unit-50mg-25mg-25mg-200unit-1mg-300mcg-25mg-500mg,36.3mg-25mcg-10mcg-25mcg-125mg-150mcg-162mg-15mg-10mcg-2mg-25mcg-150mcg-10mcg-40mg-5mcg-25mcg-2.5mg-100mg-18mg-30unit-400unit-5000unit-20mg-2mg-10mg-6mcg-1.7mg-400mcg-30mcg-3mg-60mg,20mcg-120mcg-2mg-2mg-30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg,55mcg-60unit-1000unit-2mg-40mg-2mg-200mg,20mg-0.5mg-12.5mg-100mcg-25mg-15mg-12.5mg-5mg-6.5mcg-


201

Drug Name DrugTier

Requirements/Limits

100mcg-100mcg-3.75mg-6.5mcg-2.5mg-2.5mg-5mg-12.5mg-3.25mcg-36mg-65mg-30unit-75mcg-82.5mg-1mg-40mg-1.75mg-12.5mg-50mg-2.25mg-5mg-3750unit-37.5mcg-20mg-40mcg-2.55mg-9mcg-200unit-200mcg-150mcg-3mg-90mg, 2mg-72mg-10mcg-55mcg-45mcg-2.3mg-5mcg-0.5mg-20mg-150mcg-45mcg-80mg-50mg-50unit-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 17mcg-53mg-133unit-8333unit-167mg,10mg-0.5mg-10mg-17.5mcg-75mcg-120mg-1mg-30unit-60mg-35mg-7.5mg-9mg-10mg-100mg-10mg-10mg-5000unit-10mcg-10mg-400mcg-30mcg-10mg-200mg-400unit, 120mcg-50mg-72mg-10mcg-70mcg-4mg-10mcg-5mcg-0.9mg-48mg-60unit-150mcg-75mcg-100mg-80mg-4mg-60mcg-11mg-40mg-4.5mg-18mg-12mg-3500unit-40mg-25mcg-5.1mg-18mcg-400unit-400mcg-50mcg-6mg-120mg, 100mcg-200unit-5000unit-250mg,5000unit-5000unit-40mcg-40mcg-40mg-40mg-2mg-2mg-30unit-30unit-60mg-60mg, 21mcg-28mcg-5000unit-26mcg-3.5mg-2mg-31mg-30unit-150mcg-32mcg-7.5mg-40mg-10mcg-150mcg-10mcg-2mg-7.5mg-5mcg-15mg-100mg-18mg-10mg-20mg-3.4mg-9mcg-400unit-3mg-400mcg-30mcg-3mg-

Drug Name DrugTier

Requirements/Limits

90mg, 25mg-25mg-35mg-50mcg-12.5mg-35mg-25mcg-15mg-15mg-35mg-5mcg-25mg-100mg-75mcg-5000unit-2.5mg-1mg-12.5mg-50mg-2.5mg-15mg-175mcg-5mg-15mg-250mcg-15mg-5mg-5mg-37.5mcg-15mg-15mcg-100unit-5mg-200mcg-50unit-125mcg-15mg-25mg-150mg, 15mg-25mg-1.5mg-50mg-5mg-64mg-7.5unit-25mg-1mg-3.75mg-5mg-130mg-4mg-5mg-7.5mg-12.5mg-15mg-5mg-2.5mg-2500unit-4mcg-500unit-2.5mg-100mcg-2500mcg-2.5mg-30mg,34mg-105mcg-4mg-2mg-33unit-90mcg-150mcg-120mg-180mcg-37.5mg-20mg-22.5mg-100mg-4.5mg-2500unit-20mcg-3.4mg-15mg-25mcg-400unit-400mcg-30mcg-6mg-120mg, 72mg-25mcg-5000unit-10mcg-20mcg-109mg-30unit-150mcg-162mg-15mg-10mcg-2mg-65mcg-150mcg-2mg-80mg-5mcg-160mcg-3.5mg-100mg-18mg-400unit-1.5mg-20mg-1.7mg-10mg-6mcg-400mcg-30mcg-2mg-60mg,18mcg-20mcg-2mg-105mcg-99mg-2mg-120mcg-45unit-400unit-15mg-120mg-1.2mg-0.6mg-210mg-3500unit-1.7mg-5mg-3mg-16mg-400mcg-30mcg-90mg,20mcg-120mcg-2mg-2mg-30unit-300mg-50mg-15mg-2.3mg-18mg-10mg-2500unit-30mg-25mcg-2.6mg-9mcg-800unit-400mcg-300mcg-3mg-120mg, 20mcg-120mcg-2mg-2mg-22.5unit-150mcg-500mg-15mg-


202

Drug Name DrugTier

Requirements/Limits

1.5mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-150mcg-80mg-11mg-100mg-1.5mg-300mcg-18mg-3500unit-250mcg-20mg-25mcg-1.7mg-10mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 3.333mg-66.667mcg-50mg-10mg-15mg-5mg-50mcg-0.667mg-100mcg-25mcg-100mg-5mg-50mg-0.667mg-5.333mg-66.667mcg-22.333unit-0.667mg-33.333mg-0.667mg-25mcg-20mg-1666.667unit-0.5mg-10mg-71.667mg-26.667mcg-20mg-166.667mcg-266.667unit-20mg-30mg-266.667mcg-200mcg-8.333mg-100mg, 120mg-20mcg-2500unit-180mcg-33unit-150mcg-90mcg-4mg-2mg-22.5mg-50mg-4.5mg-405mg-15mcg-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg,1400unit-0.67mg-5unit-140unit-41.7mg-3.3mg-66.7mg-11.7mg-100mg-33.3mg-3.3mg-50mcg-0.33mg-3.3mg, 50mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-500mg-2mg-50mg-150mcg-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 72mg-10mcg-20mcg-3500unit-150mcg-2mg-5mcg-48mg-

Drug Name DrugTier

Requirements/Limits

45unit-150mcg-75mcg-150mcg-2mg-80mg-2mg-15mg-100mg-1.5mg-300mcg-200mg-10mg-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg


203

Drug Name DrugTier

Requirements/Limits

multiple vitamins w/minerals tbcr 5mg-90mg-10mcg-45mcg-100mcg-2mg-10mcg-5mcg-2mg-30unit-150mcg-25mcg-99mg-250mg-40mg-150mcg-15mg-3mg-25mg-9mg-10mg-3500unit-40mg-25mcg-3.4mg-12mcg-400unit-400mcg-300mcg-4mg-60mg, 12.5mg-25mg-50mg-35mcg-5mg-60mcg-18mg-37.5mcg-75mcg-35mg-1mg-5000unit-25mg-1mg-7.5mg-4mg-200unit-25mg-25mg-12.5mg-6mg-20mg-15mg-25mg-50mg-50mg-125mcg-125mcg-25mg-25mcg-200mcg-50unit-150mcg-25mg-125mg, 25mg-20mg-25000unit-100unit-15mg-15mg-180mcg-15mg-50mg-100mcg-50mg-15mg-10mcg-100mcg-100mcg-10mcg-50mg-10mcg-100mcg-25mg-18mg-1000unit-30mg-50mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-400mcg-100mcg-100mg-300mg, 6.1mg-75mcg-5mcg-25mcg-10mcg-0.25mg-150unit-150mcg-10mg-10000unit-25mcg-15mg-7.2mg-25mcg-50mg-25mcg-75mcg-10mg-75mg-75mg-75mcg-75mcg-75mg-75mg-400mcg-75mcg-75mg-250mg-400unit, 5mg-25mg-25mcg-0.225mg-50mg-20mg-25mcg-25mg-6.1mg-20mg-25mg-6000unit-25mg-100unit-600unit-25mg-25mg-100mg-9000unit-100mg-100mg-100mg-100mg-100mg-150mcg-100mg-400mcg-100mcg-100mg-200mg, 10mcg-10mcg-

F

Drug Name DrugTier

Requirements/Limits

25mg-150mcg-5mg-150unit-4.6mg-25mg-0.66mg-1.9mg-0.3mg-25mg-4mg-1.65mg-25mg-75mg-75mg-10000unit-75mg-75mg-75mg-75mg-75mcg-75mg-400mcg-75mcg-75mg-250mg-1000unit, 30mcg-25mg-100mcg-20mg-15mg-15mg-180mcg-50mg-100mcg-100unit-50mg-50mg-10mcg-100mcg-50mcg-25000unit-100mcg-15mg-25mg-30mg-18mg-50mg-100mg-100mg-100mg-100mcg-100mg-100mg-100mg-1000unit-100mg-100mcg-100mcg-100mg-500mg MULTIVITAL PLATINUM TABS F RX/OTC

MULTIVITAMIN ADULT CHEW F

MULTIVITAMIN ADULT EXTRAVITAMIN C CHEW F

MULTIVITAMIN ADULTS TABS F RX/OTC

MULTIVITAMIN MEN TABS F RX/OTC

MULTIVITAMINS W/A,B,D,E,AND K PLUS ZINC CAPS

F RX/OTC

MVW COMPLETE FORMULATIONCHEWABL ES MULTIVITAMIN CHEW

F

NAT-RUL THERAVITE-M/HIGHPOTENCY TABS F RX/OTC

NATRUL-100 TBCR F

NATRUL-CHEWS CHEW F

NATRUL-MEGA-75 TABS F RX/OTC

NATRUL-VITES TABS F RX/OTC

NICADAN TABS F RX/OTC


204

Drug Name DrugTier

Requirements/Limits

NICADAN ZX TABS F RX/OTC

NICAZEL FORTE TABS F RX/OTC

NICAZEL TABS F RX/OTC

NO IRON MULTIPLE VITAMIN/MINERALSTABS

F RX/OTC

NUTRICAP TABS F RX/OTC

OCUVITE ADULT 50+ CAPS F RX/OTC

OCUVITE ADULT FORMULA CAPS F RX/OTC

OCUVITE LUTEIN CAPS F RX/OTC

ONCOVITE TABS F RX/OTC

ONE DAILY MENS FORMULA W/O IRONTABS

F RX/OTC

ONE DAILY PLUS IRON TABS F RX/OTC

ONE-A-DAY ENERGY TABS F RX/OTC

ONE-A-DAY FOR HER VITACRAVES TEEN MULTI GUMMIES CHEW

F

ONE-A-DAY FOR HIM/VITACRAVES TEENMULTI GUMMIES CHEW

F

ONE-A-DAY MENOPAUSE FORMULA TABS F RX/OTC

ONE-A-DAY MENS 50+ ADVANTAGE TABS F RX/OTC

ONE-A-DAY MENS HEALTH FORMULA TABS F RX/OTC

ONE-A-DAY MENS PRO EDGE TABS F RX/OTC

ONE-A-DAY MENS VITACRAVES GUMMIES CHEW

F

ONE-A-DAY TEEN ADVANTAGEFOR HIM TABS

F RX/OTC

Drug Name DrugTier

Requirements/Limits

ONE-A-DAY VITACRAVES CHEW F

ONE-A-DAY VITACRAVES GUMMIES/IMMUNITYSUPPORT CHEW

F

ONE-A-DAY VITACRAVES SOURGUMMIES CHEW F

ONE-A-DAY VITACRAVES WOMENS MULTI CHEW F

ONE-A-DAY WEIGHT SMART ADVANCED TABS (Multiple Vitamins w/Minerals)

NP

RX/OTC

ONE-A-DAY WOMENS 50+ ADVANTAGE TABS (Multiple Vitamins w/Minerals)

NP

RX/OTC

ONE-A-DAY WOMENS ACTIVE MIND & BODY TABS (Multiple Vitamins w/Minerals)

NP

RX/OTC

ONE-A-DAY WOMENS PETITES TABS (MultipleVitamins w/ Minerals)

NP RX/OTC

ONE-A-DAY WOMENS PLUS HEALTHY SKIN SUPPORT TABS (MultipleVitamins w/ Minerals)

NP

RX/OTC

ONE-A-DAY WOMENS VITACRAVES GUMMIES CHEW

F

OPTI-WOMAN TABS F RX/OTC

OPTIMUM AIRVITES CHEW F

OPTISOURCE POST BARIATRIC SURGERY CHEW

F

OPTIVITE P.M.T. TABS (Multiple Vitamins w/Minerals)

NP RX/OTC

OPURITY TABS F RX/OTC

OPURITY/BYPASSOPTIMIZED CHEW F

PA MENS 50 PLUS VITAPAK MISC F


205

Drug Name DrugTier

Requirements/Limits

PA MENS VITAPAK MISC F

PA WOMENS 50 PLUS VITAPAK MISC F

PA WOMENS VITAPAK MISC F

PARVLEX TABS F RX/OTC

PHLEXY-VITS POWD F

PHYTOMULTI TABS F RX/OTC

PREMIUM PACKETS MISC F

PRESCRIPTIVE FORMULAS OPTIMAL VITAMIN PACKS MENS MISC

F

PRESCRIPTIVE FORMULAS OPTIMAL VITAMIN PACKS WOMENS MISC

F

PRESERVISION AREDS 2 + MULTI VITAMIN CAPS F RX/OTC

PRESERVISION AREDS 2 CAPS F RX/OTC

PRESERVISION AREDS CAPS F RX/OTC

PRESERVISION AREDS TABS F RX/OTC

PRESERVISION/LUTEINCAPS F RX/OTC

PRO-CAL TABS 145MG-187.5MG-40MG-100UNIT-7.5MG

F RX/OTC

PROCERV HP TABS F RX/OTC

PRORENAL+D TABS F RX/OTC

PRORENAL+D/OMEGA-3CAPS F RX/OTC

PROTECT CARDIO AF CAPS F RX/OTC

PROTECT PLUS CAPS F RX/OTC

PROTECT PLUS NF LIQD F RX/OTC

Drug Name DrugTier

Requirements/Limits

PROTECT PLUS SO CAPS F RX/OTC

QUENCH TABS F RX/OTC

QUIN B STRONG TABS F RX/OTC

QUINTABS-M TABS F RX/OTC

RA CENTRAL-VITE UNDER 50MENS TABS F RX/OTC

RA CENTRAL-VITE UNDER 50WOMENS TABS

F RX/OTC

RA ESSENCE-C PACK F

RAGUS TABS (MultipleVitamins w/ Minerals) NP RX/OTC

RENAPLEX-D TABS F RX/OTC

REPLACE CAPS F RX/OTC

REQ 49+ TABS F RX/OTC

SAVISION CAPS F RX/OTC

SENIOR VITES TBCR F

SENTRY SENIOR TABS F RX/OTC

SENTRY SENIOR/LUTEINTABS F RX/OTC

SENTRY TABS F RX/OTC

SIDEROL TABS F RX/OTC

SKIN BEAUTY & WELLNESS PACK F

SM ONE DAILY MENS TABS F RX/OTC

SM ONE DAILY WOMENS TABS F RX/OTC

SOLO TABS F RX/OTC


206

Drug Name DrugTier

Requirements/Limits

STROVITE FORTE SYRP 55MCG/15ML-5MG/15ML-3MG/15ML-50MCG/15ML-15MG/15ML-50MG/15ML-10MG/15ML-17MG/15ML-100MG/15ML-25MG/15ML-4000UNIT/15ML-20MCG/15ML-400UNIT/15ML-15MG/15ML-1MG/15ML-30UNIT/15ML-150MCG/15ML-20MG/15ML-300MG/15ML

F

STROVITE FORTE TABS 0.1MG-50MCG-60UNIT-25MCG-1000UNIT-15MG-3MG-50MG-20MG-10MG-25MG-3000UNIT-100MG-20MG-50MCG-0.8MG-0.15MG-25MG-500MG (Multiple Vitamins w/Minerals)

NP

RX/OTC

STROVITE ONE TABS F RX/OTC

SUPER ANTIOXIDANT CAPS F RX/OTC

SUPER NU-THERA POWD F

SUPERB NAILS TABS F RX/OTC

SUPERVITE EC TBEC F

SUPPORT LIQD F RX/OTC

SYNAGEX CAPS F

SYNATEK CAPS F

T-VITES TABS F RX/OTC

THERA M PLUS TABS F RX/OTC

THERA-M TABS F RX/OTC

THERA-TABS M TABS F RX/OTC

THERABETIC MULTI-VITAMIN TABS F RX/OTC

Drug Name DrugTier

Requirements/Limits

THERAGRAN-M ADVANCED 50 PLUS TABS

F RX/OTC

THERAGRAN-M ADVANCED TABS F RX/OTC

THERAGRAN-M PREMIER 50 PLUS TABS F RX/OTC

THERAGRAN-M PREMIER TABS F RX/OTC

THERAGRAN-M TABS F RX/OTC

THERAMILL FORTE CAPS (Multiple Vitamins w/Minerals)

NP RX/OTC

THERANATAL LACTATION COMPLETE MISC

F

THERANATAL LACTATION ONE CAPS F RX/OTC

THERANATAL LACTATION SUPPORT MISC

F

THEREMS-H TABS F RX/OTC

THEREMS-M TABS F RX/OTC

ULTRA MEGA GOLD TBCR F

ULTRA MEGA TBCR F

ULTRA MEGA TWO TBCR F

ULTRA MENS PACK MISC F

ULTRA WOMENS PACK MISC F

UNICOMPLEX-M TABS F RX/OTC

VITA-BOB CAPS F RX/OTC

VITABEX CAPS F RX/OTC

VITALINE TOTAL FORMULA 2 TABS F RX/OTC

VITALINE TOTAL FORMULA 3 TABS F RX/OTC

VITAMENT PACK F


207

Drug Name DrugTier

Requirements/Limits

VITAMIN C EFFERVESCENT BLEND PACK

F

VITAMIN C/ELECTROLYTES PACK F

VITAMIN D3 COMPLETE TABS F RX/OTC

VITAMINS TO GO MAXIMUM MISC F

VITAMINS TO GO MEN MISC F

VITAMINS TO GO WOMEN MISC F

VITAROCA PLUS TABS (Multiple Vitamins w/Minerals)

NP RX/OTC

VITASANA TABS F RX/OTC

VITATRUM TABS F RX/OTC

VITRUM 50+ SENIOR MULTI TABS F RX/OTC

VP-ZEL TABS F RX/OTC

WHOLE FOOD MULTIVITAMIN TABS F RX/OTC

WOMENS 50+ MULTI VITAMIN& MINERAL FORMULA TABS

F RX/OTC

WOMENS BIOMULTIPLE TABS F RX/OTC

WOMENS MULTI VITAMIN & MINERAL FORMULA TABS

F RX/OTC

WOMENS PACK MISC F

YELETS TEENAGE FORMULA TABS F RX/OTC

YOUR LIFE MULTI ADULT GUMMIES CHEW F

YOUR LIFE TEEN MULTIVITAMIN GUMMIES CHEW

F

Drug Name DrugTier

Requirements/Limits

ZINC LOZG OR 50MG-15MG-10MG-500UNIT-100MG, 50MG-15MG-500UNIT-100MG, 10MG-5MG-10MG-10MG-15MG-500UNIT-60MG

F

Multivitamins CARDENZ TABS (MultipleVitamin) NP

DEKAS ESSENTIAL CAPS 150UNIT-1000MCG-2000UNIT-2000UNIT

F

multiple vitamin caps F

multiple vitamin tabs F

OMNICAP TABS F

ONE-A-DAY ESSENTIAL TABS (Multiple Vitamin) NP

ONE-A-DAY MENS TABS (Multiple Vitamin) NP

QUINTABS TABS F

THERA TABS F

ZE-PLUS CAPS (MultipleVitamin) NP

Ped MV w/ Fluoride FLORIVA PLUS SOLN F

MULTIVITAMIN/FLUORIDE CHEW F

pediatric multivitamins w/flchew F

pediatric multivitamins w/flsoln F

pediatric vitamins acd w/fluoride soln F

POLY-VI-FLOR CHEW F

POLY-VI-FLOR FS STRP F

POLY-VI-FLOR SUSP F

QUFLORA PEDIATRIC CHEW F


208

Drug Name DrugTier

Requirements/Limits

QUFLORA PEDIATRIC SOLN F

Ped MV w/ Iron pediatric multiple vitaminsw/ iron chew F

pediatric multiple vitaminsw/ iron soln F

POLY-VI-SOL/IRON SOLN(Pediatric Multiple Vitaminsw/ Iron)

F

Ped Multi Vitamins w/Fl & FE ESCAVITE LQ LIQD F

ped multivitamins w/fl &iron soln F

TRI-VIT/FLUORIDE/IRONSOLN F

Ped Multiple Vitamins w/ Minerals FLINTSTONES GUMMIES CHEW (Pediatric MultipleVitamin w/ Minerals & C)

NP

FLINTSTONES GUMMIES COMPLETE CHEW 1.25MG-15MCG-2.5MG-1000UNIT-1.5MCG-300UNIT-100MCG-9UNIT-37.5MCG-0.5MG-15MG (Pediatric Multiple Vitaminw/ Minerals & C)

NP

FLINTSTONES GUMMIES COMPLETE CHEW 1.25MG-15MCG-2.5MG-1000UNIT-1.5MG-300UNIT-100MCG-9UNIT-37.5MCG-0.5MG-15MG

F

FLINTSTONES GUMMIES PLUSIMMUNITY SUPPORT/EXTRA CCHEW (Pediatric MultipleVitamin w/ Minerals & C)

NP

FLINTSTONES SOUR GUMMIES CHEW (Pediatric Multiple Vitaminw/ Minerals & C)

NP

FLINTSTONES TODDLER/TASTISMOOTHCHEW

F

Drug Name DrugTier

Requirements/Limits

GNP CHILDRENS COMPLETE CHEWABLES CHEW

F

HEALTHY KIDS GUMMIES CHEW F

NF FORMULAS CHILDRENS CHEWABLE CHEW

F

ONE-A-DAY SCOOBY-DOO GUMMIES CHEW (Pediatric Multiple Vitaminw/ Minerals & C)

NP

ONE-A-DAY/JOLLYRANCHER CHEW (Pediatric Multiple Vitaminw/ Minerals & C)

NP


209

Drug Name DrugTier

Requirements/Limits

pediatric multiple vitamin w/minerals & c chew 10unit-20mcg-1.25mg-10mcg-15mcg-1000unit-2.5mcg-100unit-37.5mcg-0.5mg-15mg, 1.3mg-9unit-15mcg-2.5mg-1000unit-1.5mcg-300unit-100mcg-38mcg-0.5mg-15mg, 8.25unit-20mcg-1.2mg-2.75mg-10mcg-10mcg-1300unit-2.15mcg-40unit-130mcg-33mcg-0.4mg-10mg,1.05mg-200mg-60mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-300mcg-15unit-1.05mg, 16.5unit-42mcg-2.7mg-5.2mg-40mcg-40mcg-2100unit-6mcg-400unit-260mcg-60mcg-2mg-20mg, 18mg-20mcg-1mg-50mg-30unit-150mcg-20mcg-108mg-40mg-2mg-15mg-1.5mg-10mg-3500unit-20mg-10mcg-1.7mg-6mcg-400mcg-45mcg-2mg-60mg-400unit, 9unit-15mcg-1.25mg-2.5mg-19mg-1000unit-3mcg-200unit-100mcg-37.5mcg-0.5mg-15mg, 10unit-37.5mcg-1.5mg-187.5mcg-2.5mg-2.5mg-212.5mcg-1250unit-3mcg-200unit-200mcg-75mcg-1mg-20mg, 100mg-150mcg-100mg-30unit-2mg-12mg-20mg-1.5mg-18mg-3000unit-15mg-1.7mg-10mg-6mcg-400mcg-40mcg-2mg-60mg-400unit,5000unit-100mg-30unit-150mcg-100mg-2mg-15mg-20mg-1.5mg-18mg-20mg-1.7mg-10mg-6mcg-400mcg-40mcg-2mg-60mg-400unit, 100mg-30unit-150mcg-100mg-20mg-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-38mg-1.7mg-6mcg-

F

Drug Name DrugTier

Requirements/Limits

400mcg-40mcg-2mg-60mg-400unit, 2.5mg-20unit-40mcg-5mg-2000unit-20mcg-38mg-5mcg-200unit-200mcg-75mcg-1mg-30mg,6.25mg-6.25mg-5mg-1667unit-10unit-40mg,9unit-15mcg-1.25mg-2.5mg-1000unit-1.5mcg-300unit-100mcg-37.5mcg-0.5mg-15mg, 30unit-150mcg-100mg-8mg-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-1.7mg-6mcg-600unit-400mcg-40mcg-2mg-60mg, 200unit-21mg-1.35mg-2.6mg-20mcg-20mcg-1050unit-3mcg-200unit-130mcg-30mcg-1mg-10mg, 5mg-10mg-2mg-10mg-5mg-10mcg-10mcg-5mcg-100mg-30unit-150mcg-125mg-2mg-15mg-1mg-40mg-2mg-18mg-300mg-5000unit-25mg-2.2mg-10mg-8mcg-400unit-2mg-400mcg-40mcg-2.5mg,100mg-30unit-150mcg-130mg-2mg-15mg-20mg-1.5mg-18mg-10mg-5000unit-13.5mg-1.7mg-6mcg-400mcg-40mcg-2mg-60mg-400unit, 1mg-1mg-3mg-2.5mg-30mcg-0.5mg-5mg-25mg-75mcg-50mg-0.5mg-15unit-10mcg-5mg-0.75mg-2.5mg-1.25mg-2500unit-2.5mg-20mcg-0.85mg-3mcg-200unit-200mcg-75mcg-0.5mg-60mg, 100mg-30unit-150mcg-100mg-10mg-2mg-12mg-20mg-1.5mg-18mg-10mg-60mg-3000unit-15mg-38mg-1.7mg-400unit-400mcg-40mcg-2mg, 15mg-1.5mg-12mg-10mg-1000mcg-1.7mg-16000unit-6mcg-1500unit-200mcg-200unit-


210

Drug Name DrugTier

Requirements/Limits

100mcg-1.9mg-100mg,1.35mg-8.25unit-21mcg-2.6mg-20mcg-20mcg-1050unit-3mcg-200unit-70mcg-30mcg-1mg-10mg,100mg-5000unit-150mcg-100mg-15mg-2mg-8mg-20mg-18mg-30unit-400unit-1.7mg-10mg-6mcg-1.5mg-20mg-400mcg-40mcg-2mg-60mg, 16.5unit-42mcg-2.7mg-5.2mg-40mcg-40mcg-2100unit-6mcg-600unit-260mcg-60mcg-2mg-20mg, 100mg-100mg-150mcg-20mg-2mg-12mg-1.5mg-18mg-10mg-60mg-3000unit-15mg-38mg-1.7mg-6mcg-400unit-400mcg-30unit-40mcg-2mg, 1.25mg-9unit-15mcg-2.5mg-1000unit-20mcg-20mcg-1.5mcg-200unit-100mcg-37.5mcg-0.5mg-10mg, 15mcg-1mg-2mg-1mg-1.25mg-5mcg-5mcg-1250unit-1.5mcg-25unit-100mcg-7.5unit-22.5mcg-0.25mg-7.5mg, 100mg-30unit-150mcg-100mg-20mg-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-1.7mg-6mcg-400unit-400mcg-40mcg-2mg-60mg, 15unit-1.05mg-1998unit-10mg-1.2mg-4.5mcg-400unit-300mcg-1.05mg-60mg, 100mg-150mcg-100mg-10mg-20mg-400unit-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-38mg-1.7mg-6mcg-400mcg-30unit-40mcg-2mg-60mg,50mg-20mcg-150mcg-20mcg-160mg-15mg-2mg-20mcg-1mg-40mg-30unit-18mg-10mg-5000unit-20mg-10mcg-1.7mg-6mcg-1.5mg-45mcg-2mg-60mg-400unit, 9unit-21mcg-

Drug Name DrugTier

Requirements/Limits

1.35mg-2.6mg-20mcg-20mcg-1050unit-3mcg-300unit-100mcg-37.5mcg-1mg-20mg, 7.5unit-15mcg-50mcg-1mg-1mg-1.25mg-5mcg-750unit-1.5mcg-200unit-100mcg-22.5mcg-0.25mg-7.5mg, 1.3mg-15mcg-2.5mg-1000unit-1.5mcg-300unit-100mcg-9unit-38mcg-0.5mg-15mg,20mcg-1mg-50mg-30unit-150mcg-20mcg-108mg-2mg-15mg-40mg-1.5mg-18mg-10mg-3500unit-20mg-10mcg-1.7mg-6mcg-400unit-400mcg-45mcg-2mg-60mg, 100mg-30unit-150mcg-100mg-20mg-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-1.7mg-6mcg-400mcg-40mcg-2mg-60mg-400unit,15mg-15mcg-15unit-1mg-75mcg-37.5mcg-12.5mg-6.25mg-2.5mg-1.5mg-2.5mg-7.5mg-2500unit-10mg-1.7mg-3.75mcg-300unit-200mcg-50mcg-2mg-60mg, 183unit-500mcg-1.33mg-6mg-0.6mcg-150mcg-6mcg-1.1mg-45mg, 1.3mg-10unit-20mcg-2.5mg-1000unit-10mcg-19mg-2.5mcg-100unit-100mcg-38mcg-0.5mg-15mg,8.25unit-21mcg-1.35mg-2.6mg-20mcg-20mcg-1050unit-3mcg-200unit-70mcg-30mcg-1mg-10mg,15mg-1.5mg-12mg-100mg-10mg-1000mcg-1.7mg-16000unit-6mcg-1500unit-200mcg-200unit-100mcg-1.9mg, 15mg-1.5mg-12mg-100mg-10mg-1000mcg-1.7mg-16000unit-6mcg-3000unit-200mcg-200unit-100mcg-1.9mg, 20unit-40mcg-2.5mg-5mg-2000unit-20mcg-38mg-


211

Drug Name DrugTier

Requirements/Limits

5mcg-200unit-200mcg-75mcg-1mg-30mg, 15unit-0.8mg-8mg-1.05mg-12mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 1.3mg-9unit-15mcg-2.5mg-1000unit-19mg-1.5mg-200unit-100mcg-38mcg-0.5mg-15mg, 2.5mg-40mcg-5mg-2000unit-20mcg-38mg-5mcg-200unit-200mcg-20unit-75mcg-1mg-30mg, 1.3mg-9unit-15mcg-2.5mg-1000unit-19mg-1.5mcg-200unit-100mcg-38mcg-0.5mg-15mg, 200unit-16000unit-15mg-1.5mg-12mg-100mg-10mg-800mcg-1.7mg-6mcg-1000unit-200mcg-100mcg-1.9mg, 100mg-100mg-30unit-150mcg-10mg-20mg-2mg-12mg-1.5mg-18mg-10mg-60mg-3000unit-15mg-38mg-1.7mg-6mcg-400unit-400mcg-40mcg-2mg pediatric multiple vitamin w/minerals & c liqd 0.6mg/ml-5751unit/ml-3mg/ml-5mg/ml-10mcg/ml-15mg/ml-2mg/ml-3mg/ml-6mg/ml-400mcg/ml-400unit/ml-0.6mg/ml-50unit/ml-15mcg/ml-0.6mg/ml-45mg/ml

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

pediatric multiple vitamin w/minerals & c soln 5mg/ml-3mg/ml-6mg/ml-400mcg/ml-0.6mg/ml-4627unit/ml-4mcg/ml-500unit/ml-0.5mg/ml-50unit/ml-15mcg/ml-0.6mg/ml-45mg/ml,50unit/ml-5mg/ml-3mg/ml-45mg/ml-6mg/ml-400mcg/ml-0.6mg/ml-4627unit/ml-4mcg/ml-500unit/ml-0.5mg/ml-15mcg/ml-0.6mg/ml,0.6mg/ml-300mcg/ml-7.5mg/ml-50unit/ml-3mg/ml-6mg/ml-3170unit/ml-4mcg/ml-400unit/ml-0.5mg/ml-15mcg/ml-0.6mg/ml-45mg/ml

F

RX/OTC

VITALETS CHEW F

VITALETS CHILDRENS CHEW F

VITAMAX CHEW F

ZOO FRIENDS COMPLETE CHEW F

Pediatric Multiple Vitamins ONE-A-DAY VITACRAVES GUMMIES+OMEGA-3 DHA CHEW (Pediatric Multiple Vitamin w/ C & FA)

NP

pediatric multiple vitamin w/c & fa chew F

pediatric multiple vitamin w/c soln F

pediatric multiple vitamin w/extra c & fa chew F

pediatric multiple vitaminsliqd F

POLY-VI-SOL SOLN (Pediatric Multiple Vitaminw/ C)

NP

Pediatric Vitamins BPROTECTED PEDIA TRI-VITE SOLN F


212

Drug Name DrugTier

Requirements/Limits

HONEY BEARS CHEW F

MULTIVITAMIN GUMMIES CHILDRENS CHEW F

pediatric vitamins adc soln F

Prenatal Vitamins ACTIVE OB CAPS NP

BAL-CARE DHA MISC NP

BP FOLINATAL PLUS B TABS F

BP MULTINATAL PLUS CHEW 3.5UNIT-2MG-15MG-50MG-250MG-40MG-6MCG-1MG-2MG-50MG

F

RX/OTC

BP MULTINATAL PLUS TABS 30UNIT-2MG-15MG-100MG-3MG-200MG-30MG-20MG-3.4MG-12MCG-1MG-50MG-60MG

F

C-NATE DHA CAPS NP

CALCIUM PNV CAPS NP

CITRANATAL 90 DHA MISC NP

CITRANATAL ASSURE MISC NP

CITRANATAL B-CALM MISC NP

CITRANATAL DHA MISC NP

CITRANATAL HARMONY CAPS NP

CITRANATAL RX TABS NP

CLASSIC PRENATAL TABS NP

CO-NATAL FA TABS NP

COMPLETE NATAL DHA MISC F

COMPLETENATE CHEW F AL; Up to 49yrs old

Drug Name DrugTier

Requirements/Limits

CONCEPT DHA CAPS F

CONCEPT OB CAPS F

CVS PRENATAL TABS NP

DOTHELLE DHA CAPS F

ELITE-OB TABS NP

ENBRACE HR CAPS NP

ENFAMIL EXPECTA MISC F

EQL PRENATAL FORMULA TABS NP

EXTRA-VIRT PLUS DHA CAPS NP

EZFE FORTE CAPS F

FOCALGIN 90 DHA MISC NP

FOCALGIN CA MISC NP

FOLCAL DHA CAPS NP

FOLCAPS OMEGA 3 CAPS NP

FOLIVANE-OB CAPS F

GNP DAILY PRENATAL MISC F

GNP PRENATAL TABS NP

GOODSENSE PRENATAL VITAMINS TABS NP

HEMENATAL OB + DHA MISC F

HEMENATAL OB TABS NP

HM ONE DAILY PRENATAL COMBO MISC F

HM PRENATAL TABS NP

INATAL ADVANCE TABS F

INATAL GT TABS F


213

Drug Name DrugTier

Requirements/Limits

INATAL ULTRA TABS F

INFANATE BALANCE CAPS NP

KP PRENATAL MULTIVITAMINS TABS NP

KPN PRENATAL TABS NP

M-VIT TABS F AL; Up to 50yrs old;RX/OTC

MACNATAL CN DHA CAPS NP

MARNATAL-F CAPS NP

MTERYTI FOLIC 5 TBPK NP

MTERYTI TBPK NP

MULTI PRENATAL TABS NP

MYNATAL ADVANCE TABS F

MYNATAL PLUS TABS NP

MYNATAL ULTRACAPLET TABS F

MYNATAL-Z TABS NP

NAT-RUL PRENATAL VITAMINS TABS NP

NATALVIT TABS F

NATELLE ONE CAPS NP

NEEVO DHA CAPS NP

NESTABS ABC MISC NP

NESTABS DHA MISC NP

NESTABS ONE CAPS NP

NESTABS TABS NP

NEWGEN TABS NP

NEXA PLUS CAPS NP

Drug Name DrugTier

Requirements/Limits

NIVA-PLUS TABS F AL; Up to 50yrs old;RX/OTC

O-CAL FA TABS 4 AL; Up to 50yrs old;RX/OTC

O-CAL PRENATAL TABS NP

OB COMPLETE GOLD CAPS NP

OB COMPLETE ONE CAPS NP

OB COMPLETE PETITE CAPS NP

OB COMPLETE PREMIER TABS NP

OB COMPLETE TABS NP

OB COMPLETE/DHACAPS F

ONE-A-DAY WOMENS PRENATAL MISC F

PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID TABS

NP

PNV FOLIC ACID + IRON MULTIVITAMIN TABS F


PNV OB+DHA MISC NP

PNV PRENATAL PLUS MULTIVITAMIN + DHA MISC

NP

PNV PRENATAL PLUS MULTIVITAMIN TABS F


PNV TABS 29-1 TABS NP

PNV-DHA CAPS F

PNV-DHA+DOCUSATE CAPS NP

PNV-OMEGA CAPS NP

PNV-SELECT TABS F

PNV-TOTAL CAPS F


214

Drug Name DrugTier

Requirements/Limits

PNV-VP-U CAPS NP

PR NATAL 400 EC MISC NP

PR NATAL 400 MISC NP

PR NATAL 430 EC MISC NP

PR NATAL 430 MISC NP

PREFERA OB TABS NP

PREFERAOB +DHA MISC NP

PREFERAOB ONE CAPS NP

PRENAISSANCE BALANCE CAPS NP

PRENAISSANCE CAPS NP

PRENAISSANCE HARMONY DHA MISC F

PRENAISSANCE NEXT TABS NP

PRENAISSANCE NEXT-B TABS F

PRENAISSANCE PLUS CAPS NP

PRENATA CHEW F

PRENATABS FA TABS NP

PRENATABS RX TABS NP

PRENATAL 19 CHEW 30UNIT-1000UNIT-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG, 1000UNIT-400UNIT-20MG-25MG-3MG-200MG-29MG-7MG-6MG-3MG-12MCG-1MG-30UNIT-20MG-100MG

F

AL; Up to 49yrs old

Drug Name DrugTier

Requirements/Limits

PRENATAL 19 TABS 1000UNIT-30UNIT-20MG-25MG-3MG-200MG-29MG-15MG-3MG-7MG-12MCG-400UNIT-20MG-1MG-100MG, 30UNIT-1000UNIT-20MG-25MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG

NP

PRENATAL FORMULA A-FREE TABS F

PRENATAL FORMULA TABS 30UNIT-200MG-4000UNIT-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-800MCG-2.6MG-120MG-400UNIT

NP

PRENATAL LOW IRON TABS NP

PRENATAL MULTIVITAMIN + DHA MISC

F

PRENATAL MULTIVITAMIN TABS NP

PRENATAL ONE DAILY TABS NP

PRENATAL PLUS IRON TABS NP

PRENATAL PLUS TABS F AL; Up to 50yrs old;RX/OTC


215

Drug Name DrugTier

Requirements/Limits

PRENATAL TABS 160MG-11UNIT-200MG-25MG-1.84MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-800MCG-2.6MG-100MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 3.75UNIT-0.5MG-50MG-0.5MG-25MG-15MG-3.75MG-6.75MG-2.5MG-5MG-0.75MG-500UNIT-2.5MCG-0.5MG-200MCG-25MCG-0.75MG-100UNIT, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-0.8MG-2.6MG- NP

120MG, 11UNIT-263MG-25MG-1.5MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG, 4000UNIT-30UNIT-200MG-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-4000UNIT-8MCG-400UNIT-800MCG-2.6MG-120MG, 4000UNIT-30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG PRENATAL TABS 22MG- AL; Up to 502MG-25MG-1.84MG- yrs old;200MG-27MG-4000UNIT-20MG-3MG-12MCG- F RX/OTC

400UNIT-1MG-10MG-120MG PRENATAL VITAMIN & MINERAL TABS NP

PRENATAL VITAMIN TABS NP

PRENATAL VITAMIN/IRON TABS NP

Drug Name DrugTier

Requirements/Limits

PRENATAL VITAMINS PLUS LOW IRON TABS F


PRENATAL VITAMINS TABS 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG

NP

PRENATAL-U CAPS NP

PRENATE AM TABS NP

PRENATE CHEW NP

PRENATE DHA CAPS 18MG-600MCG-40UNIT-300MG-50MG-155MG-25MCG-400UNIT-400MCG-26MG-90MG

NP

PRENATE DHA CAPS 600MCG-10UNIT-300MG-50MG-145MG-28MG-13MCG-220UNIT-400MCG-26MG-90MG

F

PRENATE ELITE TABS 20MG-600MCG-40UNIT-150MCG-2600UNIT-1.5MG-15MG-25MG-155MG-3MG-21MG-3.5MG-13MCG-600UNIT-400MCG-330MCG-21MG-75MG

NP

PRENATE ELITE TABS 600MCG-10UNIT-150MCG-2600UNIT-1.5MG-15MG-15MG-25MG-3MG-100MG-26MG-6MG-21MG-3.5MG-13MCG-450UNIT-400MCG-330MCG-21MG-75MG, 600MCG-10UNIT-150MCG-2600UNIT-1.5MG-15MG-25MG-3MG-100MG-26MG-6MG-21MG-3.5MG-13MCG-450UNIT-400MCG-330MCG-21MG-75MG

F

PRENATE ENHANCE CAPS NP


216

Drug Name DrugTier

Requirements/Limits

PRENATE ESSENTIAL CAPS 18MG-40MG-600MCG-10UNIT-150MCG-300MG-50MG-155MG-13MCG-220UNIT-400MCG-280MCG-26MG-90MG

NP

PRENATE ESSENTIAL CAPS 29MG-600MCG-40MG-10UNIT-150MCG-300MG-50MG-145MG-13MCG-220UNIT-400MCG-280MCG-26MG-90MG

F

PRENATE MINI CAPS 25MG-600MCG-10UNIT-150MCG-18MG-350MG-25MG-80MG-13MCG-1000UNIT-400MCG-280MCG-26MG-60MG

NP

PRENATE MINI CAPS 25MG-600MCG-29MG-10UNIT-150MCG-350MG-25MG-100MG-13MCG-220UNIT-400MCG-280MCG-26MG-60MG

F

PRENATE PIXIE CAPS NP

PRENATE RESTORE CAPS NP

PRENATE STAR TABS NP

PREPLUS TABS F AL; Up to 50yrs old;RX/OTC

PREQUE 10 TABS NP

PRETAB TABS NP

PRIMACARE CAPS NP

PROFE FORTE CAPS F

PROVIDA DHA CAPS NP

PROVIDA OB CAPS NP

PUREFE OB PLUS CAPS NP

Drug Name DrugTier

Requirements/Limits

PX PRENATAL MULTIVITAMINS TABS NP

QC PRENATAL TABS NP

R-NATAL OB CAPS NP

RA ONE DAILY MISC F

RA PRENATAL FORMULA/FOLICACIDTABS

NP

RA PRENATAL TABS NP

RELNATE DHA CAPS NP

RIGHT STEP PRENATAL TABS NP

RULAVITE DHA CAPS F

SE-NATAL 19 CHEW 30UNIT-1000UNIT-100MG-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG

4

AL; Up to 49yrs old

SE-NATAL 19 TABS 30UNIT-1000UNIT-20MG-25MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-3MG-20MG-1MG-100MG

NP

SE-TAN DHA CAPS F

SELECT-OB CHEW NP

SELECT-OB+DHA MISC NP

SM ONE DAILY PRENATAL MISC F

SM PRENATAL VITAMINS TABS NP

STUART ONE CAPS NP

TARON-BC MISC F

TARON-C DHA CAPS F

TARON-PREX CAPS F


217

Drug Name DrugTier

Requirements/Limits

THERANATAL CORE NUTRITION TABS F


THRIVITE 19 TABS NP

THRIVITE RX TABS NP

TL FOLATE TABS F

TL-CARE DHA CAPS NP

TL-SELECT CAPS NP

TRI-TABS DHA MISC NP

TRIADVANCE TABS F

TRICARE PRENATAL 1 CHEW NP

TRICARE PRENATAL CHEW NP

TRICARE PRENATAL COMPLEAT MISC F

TRICARE PRENATAL DHA ONE CAPS NP

TRICARE PRENATAL THPK NP

TRICARE TABS 4 AL; Up to 50yrs old;RX/OTC

TRINATAL GT TABS F

TRINATAL RX 1 TABS NP

TRINATE TABS NP

TRISTART DHA CAPS NP

TRIVEEN-DUO DHA MISC NP

TRIVEEN-PRX RNF CAPS NP

ULTIMATECARE ONE CAPS NP

ULTIMATECARE ONE NF CAPS NP

VEMAVITE-PRX 2 CAPS NP

Drug Name DrugTier

Requirements/Limits

VENA-BAL DHA MISC NP

VINATE CARE CHEW F RX/OTC

VINATE DHA RF CAPS NP

VINATE II TABS F

VINATE M TABS F AL; Up to 49yrs old

VINATE ONE TABS NP

VIRT NATE TABS NP

VIRT-ADVANCE TABS F

VIRT-C DHA CAPS F

VIRT-NATE DHA CAPS NP

VIRT-PN DHA CAPS F

VIRT-PN PLUS CAPS NP

VIRT-PN TABS F

VIRT-SELECT CAPS NP

VIRT-VITE GT TABS F

VIRTPREX CAPS NP

VITAFOL FE+ CPPK NP

VITAFOL GUMMIES CHEW NP

VITAFOL ULTRA CAPS NP

VITAFOL-NANO TABS NP

VITAFOL-OB TABS NP

VITAFOL-OB+DHA MISC NP

VITAFOL-ONE CAPS NP

VIVA DHA CAPS NP

VOL-NATE TABS NP


218

Drug Name DrugTier

Requirements/Limits

VOL-PLUS TABS F AL; Up to 50yrs old;RX/OTC

VOL-TAB RX TABS NP

VP-CH PLUS CAPS NP

VP-CH-PNV CAPS NP

VP-GGR-B6 PRENATAL TABS NP

VP-HEME OB + DHA MISC F

VP-HEME OB TABS NP

VP-HEME ONE CAPS NP

VP-PNV-DHA CAPS NP

ZATEAN-CH CAPS NP

ZATEAN-PN DHA CAPS F

ZATEAN-PN PLUS CAPS NP

Specialty Vitamins Products ADRENAL STRESS CALM TABS F RX/OTC

ADVANCED COLLAGEN TABS F RX/OTC

ALLERWELL ALLERGY FORMULA TABS F RX/OTC

BIOTIN PLUS KERATIN TABS F RX/OTC

BRAIN MIGHT/DHA & COQ10 TABS F RX/OTC

BRAIN TABS F RX/OTC

CA-PLUS TABS F RX/OTC

CARDIO TONE TABS F RX/OTC

CENTRUM PERFORMANCE TABS F RX/OTC

CENTRUM SPECIALIST ENERGY TABS F RX/OTC

CU-PLUS TABS F RX/OTC

Drug Name DrugTier

Requirements/Limits

CVS HAIR/SKIN/NAILSTABS F RX/OTC

ELON MATRIX 5000 TABS F RX/OTC

ELON MATRIX PLUS TABS F RX/OTC

ELON MATRIX 5000 COMPLETE TABS F RX/OTC

ELON MATRIX COMPLETE TABS F RX/OTC

ELON R3 TABS F RX/OTC

GREEN SOURCE TABS F RX/OTC

HAIR FARE TABS F RX/OTC

HAIR NOURISHING SUPPLEMENT TABS F RX/OTC

HEALTHY HEART COMPLEX TABS F RX/OTC

HEART TABS F RX/OTC

HM ESTROPLUS TABS F RX/OTC

KIDNEY TABS 280 MG F RX/OTC

LIPIDSHIELD PLUS TABS F RX/OTC

LUNG TABS F RX/OTC

LYMPH TABS F RX/OTC

M2 CALCIUM TABS F RX/OTC

M2 CHROMIUM TABS F RX/OTC

MAMMARY TABS F RX/OTC

MENOPAUSE RELIEF TABS F RX/OTC

MG-PLUS PROTEIN TABS F RX/OTC

MIL ADREGEN TABS F RX/OTC

MILADRENE FORTE TABS F RX/OTC

MILPAN TABS F RX/OTC


219

Drug Name DrugTier

Requirements/Limits

MULTI-GLAN TABS F RX/OTC

NEW LIFE HAIR TABS F RX/OTC

ORCHIC TABS F RX/OTC

OVARY TABS F RX/OTC

PARATHYROID TABS F RX/OTC

PITUITARY TABS F RX/OTC

PROSTATE TABS F RX/OTC

RA EAR CARE TABS F RX/OTC

Drug Name DrugTier

Requirements/Limits

specialty vitamins productstabs 32mg-70mcg-200mg-2mg-30unit-2500unit-15mg-50mg-300mg-18mg-12.5mg-25mg-80mcg-2.125mg-7.5mcg-400unit-1.9mg-400mcg-2.5mg-60mg, 80mg-120mcg-8.25mg-25mg-80mg-70mcg-50mg-1.5mg-5mg-100mg-20mg-5mg-25mcg-400mcg-30unit-20mg, 9mg-100mcg-75mg-75mg-100mg-15unit-2mg-5mg-500mcg-2mg, 100mg-10%-100mg-100mg-100mg-10mg-25mg-40mg-30mg-8mcg-25unit-30mg-25mg,200mg-150mg-50unit-200mg-50mg, 5unit-6mcg-10mg-5mg-0.15mg-15mg-15mg-30mg-100mg-50mg-250mg-35mg-400mcg-111mcg, 8.333mg-1mg-10mg-50mg-5unit-37.5mcg-237mg-1.67mg-2.5mg-4.167mcg-33.333mg-8.333mg-1mg-4.167mg-8.333mg-5mg-8.333mg-10mg-25mg-1.67mg-1666.67unit-2.67mcg-33.333unit-1.67mg-66.67mcg-1mg-1.67mg-40mg, 50mg-60mg-72mg-10mcg-70mcg-120mcg-4mg-10mcg-5mcg-48mg-60unit-150mcg-75mcg-60mcg-4mg-80mg-2mg-15mg-40mg-4.5mg-100mg-18mg-10mg-5000unit-40mg-25mcg-5.1mg-18mcg-400unit-400mcg-40mcg-6mg-120mg, 50mg-60mg-4mg-10mcg-70mcg-120mcg-4mg-10mcg-5mcg-72mg-48mg-75mcg-150mcg-100mg-60mcg-80mg-2mg-15mg-40mg-4.5mg-18mg-10mg-5000unit-40mg-25mcg-5.1mg-18mcg-400mcg-

F

RX/OTC


220

Drug Name DrugTier

Requirements/Limits

60unit-40mcg-6mg-120mg-400unit, 2mg-150mcg-5mg-15mg-18mg-100mg-125mg-250mg-6mcg-100mg-400mcg-400mcg,15mg-4mg-150mcg-2mg-35mg-100mg-5000unit-35mg-125mg-250mg-2mg-6mcg-400mcg-300mcg-2mg, 50mg-60mg-4mg-72mg-10mcg-70mcg-120mcg-4mg-10mcg-5mcg-48mg-150mcg-75mcg-100mg-60mcg-80mg-2mg-15mg-40mg-4.5mg-18mg-10mg-5000unit-40mg-25mcg-5.1mg-18mcg-400mcg-60unit-40mcg-6mg-120mg-400unit, 25mg-100mg-25mg-25mg-125mcg-150mg-10mg-10mg-25mg-5mg-12.5mg-5mg-5mcg-12.5mg-5mg, 60mg-120mcg-50mg-10mcg-70mcg-4mg-10mcg-5mcg-48mg-60unit-150mcg-75mcg-72mg-100mg-0.9mg-4mg-60mcg-11mg-40mg-4.5mg-18mg-12mg-3500unit-40mg-25mcg-5.1mg-18mcg-400unit-400mcg-50mcg-6mg-120mg, 60mg-120mcg-50mg-72mg-10mcg-70mcg-4mg-10mcg-5mcg-0.9mg-48mg-150mcg-75mcg-80mg-100mg-4mg-60mcg-11mg-40mg-4.5mg-18mg-12mg-3500unit-40mg-25mcg-5.1mg-18mcg-400unit-400mcg-60unit-50mcg-6mg-120mg,400mg-5mcg-10mcg-1mg-5mcg-2.5mcg-40mg-15unit-75mcg-18.75mcg-32mg-54mg-0.35mg-60mcg-1mg-16mcg-3.75mg-20mg-0.75mg-3mg-5mg-1750unit-10mg-12.5mcg-0.85mg-100mcg-200unit-200mcg-15mcg-

Drug Name DrugTier

Requirements/Limits

2.5mg-30mg, 25mg-25mg-12.5mg-1mg-17.5mcg-50mg-7.5mg-10mcg-0.5mg-50mg-10mg-3.75mg-17.5mg-7.5mg-15mg-12.5mg-12.5mcg-100mcg-18.75mg-500mg,80mg-120mcg-25mg-80mg-70mcg-50mcg-100mg-1.5mg-30unit-5mg-20mg-5mg-25mcg-800unit-400mcg-20mg SPLEEN TABS F RX/OTC

STOMACH TABS F RX/OTC

THERABETIC EYE HEALTH TABS F RX/OTC

THYMUS TABS 140 MG F RX/OTC

UTERUS TABS F RX/OTC

VITAMINS FOR THE HAIR TABS F RX/OTC

ZN-PLUS TABS F RX/OTC

Vitamin Mixtures cod liver oil caps 20mg-35mg-1250unit-45mg-133.333unit, 1250unit-133unit, 50mg-110mg-250unit-110mg-100unit-10unit, 1250unit-130unit,200unit-4000unit, 34mg-1250unit-415mg-32mg-135unit, 1250unit-135unit,1250unit-133.33unit, 52mg-2500unit-600mg-52mg-270unit, , 530mg-1250unit-130unit, 110mg-2664unit-1000mg-100mg-200unit, 10minim, 90mg-37mg-415mg-36mg-1250unit-135unit

F

COD LIVER OIL FOR KIDS OIL F RX/OTC


221

Drug Name DrugTier

Requirements/Limits

COD LIVER OIL OIL 4000UNIT/5ML-400UNIT/5ML,5000UNIT/5ML-500UNIT/5ML

F

RX/OTC

CVS COD LIVER OIL OIL F RX/OTC

NORWEGIAN COD LIVER OIL OIL F RX/OTC

QC COD LIVER OIL OIL F RX/OTC

RA COD LIVER OIL OIL F RX/OTC

vitamins a & d caps700unit-400unit, 1250unit-135unit, 10000unit-5000unit, 8000unit-400unit,10000unit-400unit,1250unit-133unit, 5000unit-400unit

F

Vitamins w/ Lipotropics ACTIFLOVIT EAR HEALTH TABS F

LIPOTRIAD TABS (Vitamins w/ Lipotropics) NP

Drug Name DrugTier

Requirements/Limits

vitamins w/ lipotropics tabs500mg-29mg-0.333mg-1.67mg-3.33mg-1mg-1.67mcg-0.333mg-100mg,100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-200mcg-100mcg-100mg,50mg-0.5mg-7.5mg-25mg-5mg-50mg-50mg-125mg-12.5mcg-5mg-125mg-50mcg-50mg, 100mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg,50mg-50mg-50mg-50mg-50mg-50mg-50mg-50mcg-400mcg-50mcg-50mg,266.667mg-29mg-0.333mg-1.667mg-3.333mg-111.333mg-111.333mg-1mg-1.667mcg-0.333mg-100mg,100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mcg-100mcg-100mg, 77mg-100mcg-100mg-100mg-100mcg-100mcg-100mg-100mcg-100mg-400mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg, 20mg-50mg-30mg-10mg-10mcg-30mg-8mg,60mg-60mg-60mg-60mg-60mg-60mg-60mcg-60mg-100mcg-60mcg-60mg-600mg, 29mg-0.333mg-1.666mg-3.333mg-1mg-1.666mcg-0.333mg-100mg,100mg-43.33mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg, 25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mcg-30mcg-4mg-150mg, 200mg-29mg-0.33mg-1.67mg-3.33mg-111.33mg-111.33mg-1mg-

F


222

Drug Name DrugTier

Requirements/Limits

1.67mcg-0.33mg-100mg,25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mg-30mcg-4mg,200mg-29mg-0.34mg-1.67mg-3.34mg-111mg-111mg-1mg-1.67mcg-0.34mg-100mg, 50mg-50mg-50mg-50mg-50mg-50mg-50mcg-50mg-100mcg-50mcg-50mg,50mg-50mg-50mg-50mcg-50mg-50mcg-50mcg-50mg, 10000unit-10mg-18mg-100unit-225mcg-10mg-150mg-100mg-30mg-10mg-25mg-25mg-50mg-50mg-10mg-50mg-50mg-200mcg-400unit-50mg-400mcg-50mg-250mg, 50mg-50mg-50mg-50mg-50mg-50mg-50mg-50mcg-100mcg-50mcg-50mg, 100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg,30mg-56mg-2mg-10mg-83mg-240mg-3mg-2mcg-3mg-110mg-2mg MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms Central Muscle Relaxants AMRIX CP24 NP

baclofen tabs or 10 mg, 20 mg F

carisoprodol tabs 250 mg NP

carisoprodol tabs 350 mg NP QL(4 ea daily)

chlorzoxazone tabs F

cyclobenzaprine hcl tabs F

FEXMID TABS (Cyclobenzaprine HCl) NP

GABLOFEN SOSY F

LORZONE TABS NP

Drug Name DrugTier

Requirements/Limits

METAXALONE TABS 400 MG NP

metaxalone tabs 800 mg NP

methocarbamol tabs or 500 mg, 750 mg F

orphenadrine citrate tb12 or100 mg NP

PARAFON FORTE DSC TABS (Chlorzoxazone) NP

ROBAXIN TABS OR 500 MG (Methocarbamol) NP

ROBAXIN-750 TABS (Methocarbamol) NP

SKELAXIN TABS (Metaxalone) NP

SOMA TABS 250 MG (Carisoprodol) NP

SOMA TABS 350 MG (Carisoprodol) NP QL(4 ea daily)

tizanidine hcl caps 6 mg, 4mg, 2 mg NP

tizanidine hcl tabs 4 mg, 2 mg F

ZANAFLEX CAPS (Tizanidine HCl) NP

ZANAFLEX TABS (Tizanidine HCl) NP

Direct Muscle Relaxants DANTRIUM CAPS (Dantrolene Sodium) NP

dantrolene sodium caps or100 mg, 25 mg, 50 mg NP

Muscle Relaxant Combinations carisoprodol w/ aspirin tabs NP

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus Nasal Agent Combinations DYMISTA SUSP NP

Nasal Agents - Misc. AYR NASAL DROPS SOLN F


223

Drug Name DrugTier

Requirements/Limits

DERMACINRX TICANASE PAK THPK NP

OCEAN NASAL SPRAY SOLN (Saline) NP

saline gel na F

saline soln na 0.65%-0.002%, 0.65%, 0.65 % F

Nasal Antiallergy ASTEPRO SOLN (Azelastine HCl) NP

azelastine hcl soln NP

cromolyn sodium (nasal) aers F QL(0.867 ml

daily) NASALCROM AERS (Cromolyn Sodium (Nasal)) NP QL(0.867 mldaily)

olopatadine hcl (nasal) soln NP

PATANASE SOLN (Olopatadine HCl (Nasal)) F

Nasal Anticholinergics ATROVENT SOLN (Ipratropium Bromide(Nasal))

NP

ipratropium bromide (nasal)soln F

Nasal Steroids BECONASE AQ SUSP NP

budesonide (nasal) susp NP RX/OTC

FLONASE ALLERGY RELIEF CHILDRENS SUSP (Fluticasone Propionate (Nasal))

NP

QL(0.534 mldaily); RX/OTC

FLONASE ALLERGY RELIEF SUSP (Fluticasone Propionate (Nasal))

NP QL(0.534 mldaily); RX/OTC

FLONASE SENSIMIST SUSP NP RX/OTC

FLUNISOLIDE SOLN NP

fluticasone propionate(nasal) susp F QL(0.534 ml

daily); RX/OTC

Drug Name DrugTier

Requirements/Limits

mometasone furoate (nasal) susp F AL; Up to 12

yrs old NASACORT ALLERGY 24HR AERO NP RX/OTC

NASACORT ALLERGY 24HR AERO (Triamcinolone Acetonide (Nasal))

NP

RX/OTC

NASACORT ALLERGY 24HR CHILDRENS AERO (Triamcinolone Acetonide (Nasal))

NP

RX/OTC

NASONEX SUSP (Mometasone Furoate (Nasal))

NP AL; Up to 12yrs old

OMNARIS SUSP NP

QNASL AERS NP

QNASL CHILDRENS AERS NP

RHINOCORT AQUA SUSP (Budesonide (Nasal)) NP RX/OTC

triamcinolone acetonide (nasal) aero NP RX/OTC

triamcinolone acetonide (nasal) aero F RX/OTC

VERAMYST SUSP NP RX/OTC

ZETONNA AERS NP

Sympathomimetic Decongestants AFRIN 12 HOUR SOLN (Oxymetazoline HCl) NP

AFRIN ALL NIGHT NODRIP SOLN (Oxymetazoline HCl)

NP

AFRIN NASAL SPRAY SOLN (Oxymetazoline HCl) NP

AFRIN NODRIP EXTRA MOISTURIZING SOLN (Oxymetazoline HCl)

NP

AFRIN NODRIP ORIGINAL SOLN (Oxymetazoline HCl) NP

AFRIN NODRIP SEVERE CONGESTION SOLN (Oxymetazoline HCl)

NP


224

Drug Name DrugTier

Requirements/Limits

AFRIN NODRIP SINUS SOLN (Oxymetazoline HCl) NP

AFRIN SINUS SOLN (Oxymetazoline HCl) NP

AFRIN SOLN (Oxymetazoline HCl) NP

DRISTAN SPRAY SOLN (Oxymetazoline HCl) NP

DURATION 12 HOUR SOLN (Oxymetazoline HCl) NP

DURATION SPRAY SOLN (Oxymetazoline HCl) NP

NASAL DECONGESTANT SYRP F

NEO-SYNEPHRINE 12 HOUR EXTRA MOISTURIZING SOLN (Oxymetazoline HCl)

NP

oxymetazoline hcl soln F

phenylephrine hcl (oral)tabs F

pseudoephedrine hcl liqd F

pseudoephedrine hcl tabs F

pseudoephedrine hcl tb12 F

SUDAFED CHILDRENS LIQD (PseudoephedrineHCl)

NP

SUDAFED CONGESTION TABS (PseudoephedrineHCl)

NP

SUDAFED NASAL DECONGESTANT MAXIMUM STRENGTH TABS (PseudoephedrineHCl)

NP

SUDAFED PE CONGESTION TABS (Phenylephrine HCl (Oral))

NP

VICKS SINEX 12 HOUR DECONGESTANT SOLN (Oxymetazoline HCl)

NP

Drug Name DrugTier

Requirements/Limits

VICKS SINEX 12 HOUR DECONGESTANT ULTRA FINE MIST SOLN (Oxymetazoline HCl)

NP

VICKS SINEX 12 HOUR DECONGESTANT ULTRA FINE MIST/MOISTURIZNGSOLN (Oxymetazoline HCl)

NP

VICKS SINEX MOISTURIZING SOLN (Oxymetazoline HCl)

NP

VICKS SINEX SEVERE NASALDECONGESTANT SOLN (Oxymetazoline HCl)

NP

VICKS SINEX SOLN (Oxymetazoline HCl) NP

NUTRIENTS

Misc. Nutritional Substances


225

Drug Name DrugTier

Requirements/Limits

omega-3 fatty acids caps210mg-1000mg-75mg-90mg, 300mg-180mg-1000mg-120mg-1unit,300mg-200mg-1unit,300mg-180mg-120mg,300mg-1000mg-1unit,400mg-1000mg-300mg,180mg-120mg-1.8unit,300mg-1000mg-200mg,180mg-1unit-1000mg-120mg, 180mg-1000mg-120mg-1unit, 350mg-1000mg-250mg, 300mg-1000mg, 1000mg,1000mg-180mg-120mg,300mg-180mg-1000mg-120mg, 1000mg-180mg-120mg-1unit, 300mg-1000mg-200mg-1unit,600mg-1000mg, 100mg- F 1000mg-500mg-10unit,500mg-1000mg-250mg,300mg-1unit-1000mg,1000mg-180mg-120mg-1mg, 160mg-1000mg-100mg, 40mg-340mg-180mg-1000mg-120mg-5unit, 100mg-300mg-1000mg-200mg, 270mg-1000mg-180mg, 300mg-180mg-1gm-120mg,700mg-350mg-1000mg-250mg, 180mg-1000mg-120mg, 1000 mg, 350mg-1000mg, 180mg-120mg-5unit, 340mg-180mg-1000mg-120mg-5unit,180mg-120mg, 340mg-180mg-1unit-1000mg-120mg

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants artificial tear ointment oint F

artificial tear solution soln F

ARTIFICIAL TEARS SOLN F

Drug Name DrugTier

Requirements/Limits

carboxymethylcellulosesodium (ophth) soln F

carboxymethylcellulose-glycerin soln F

carboxymethylcellulose-hypromellose gel F

GENTEAL GEL (Carboxymethylcellulose-Hypromellose)

NP

GENTEAL MILD SOLN F

GENTEAL MILD TO MODERATE SOLN (Hypromellose (Ophth))

NP

GENTEAL SEVERE GEL F

GENTEAL TEARS MODERATEPF SOLN F

GONAK SOLN (Hypromellose(Gonioscopic))

NP

GONIOSOL SOLN (Hypromellose(Gonioscopic))

NP

HYPOTEARS SOLN F

hypromellose (gonioscopic)soln F

hypromellose (ophth) soln F

ISOPTO TEARS SOLN F

polyethylene glycol-propylene glycol (ophth)soln

F

polyvinyl alcohol soln F

polyvinyl alcohol-povidone(ophth) soln F

REFRESH LIQUIGEL SOLN F

REFRESH OPTIVE ADVANCED SENSITIVE SOLN

F

REFRESH OPTIVE ADVANCED SOLN F


226

Drug Name DrugTier

Requirements/Limits

REFRESH OPTIVE MEGA-3 SOLN F

REFRESH OPTIVE SENSITIVE SOLN F

REFRESH OPTIVE SOLN (Carboxymethylcellulose-Glycerin)

NP

REFRESH SOLN (Polyvinyl Alcohol-Povidone (Ophth))

NP

REFRESH TEARS SOLN (CarboxymethylcelluloseSodium (Ophth))

NP

SYSTANE OVERNIGHT THERAPY LUBRICANT EYE GEL

F

SYSTANE SOLN (Polyethylene Glycol-Propylene Glycol (Ophth))

NP

SYSTANE ULTRA HOME & AWAY PACK SOLN (Polyethylene Glycol-Propylene Glycol (Ophth))

NP

SYSTANE ULTRA SOLN (Polyethylene Glycol-Propylene Glycol (Ophth))

NP

TEARS NATURALE PM OINT (White Petrolatum-Mineral Oil)

NP

white petrolatum-mineral oiloint F

Beta-blockers - Ophthalmic BETAGAN SOLN (Levobunolol HCl) NP

betaxolol hcl (ophth) soln NP

BETIMOL SOLN 0.5 % NP

BETOPTIC-S SUSP NP

carteolol hcl (ophth) soln F

COMBIGAN SOLN F

COSOPT PF SOLN NP

Drug Name DrugTier

Requirements/Limits

COSOPT SOLN (Dorzolamide HCl-Timolol Maleate)

NP

dorzolamide hcl-timolol maleate soln F

ISTALOL SOLN NP

ISTALOL SOLN (Timolol Maleate (Ophth)) NP

levobunolol hcl soln F

timolol maleate (ophth) solg0.25 %, 0.5 % F

timolol maleate (ophth) soln0.5 % NP

timolol maleate (ophth) soln0.5 %, 0.25 % F

TIMOPTIC OCUDOSE SOLN NP

TIMOPTIC SOLN (Timolol Maleate (Ophth)) NP

TIMOPTIC-XE SOLG (Timolol Maleate (Ophth)) NP

Cycloplegic Mydriatics ATROPINE SULFATE SOLN OP 1 % F

CYCLOGYL SOLN (Cyclopentolate HCl) NP

cyclopentolate hcl soln F

MYDRIACYL SOLN (Tropicamide) NP

tropicamide soln F

Miotics ISOPTO CARPINE SOLN (Pilocarpine HCl) F

PHOSPHOLINE IODIDE SOLR NP

pilocarpine hcl soln F

Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.1 % NP

ALPHAGAN P SOLN 0.15 % (Brimonidine Tartrate) F


227

Drug Name DrugTier

Requirements/Limits

apraclonidine hcl soln NP

brimonidine tartrate soln op0.15 % NP

brimonidine tartrate soln op0.2 % F

IOPIDINE SOLN 0.5 % (Apraclonidine HCl) NP

IOPIDINE SOLN 1 % NP

SIMBRINZA SUSP F

Ophthalmic Anti-infectives

AZASITE SOLN NP QL(2.5 ml perfill retail) BACITRACIN OINT OP 500 UNIT/GM NP

bacitracin-polymyxin b(ophth) oint NP

BESIVANCE SUSP NP

BLEPH-10 SOLN (Sulfacetamide Sodium (Ophth))

NP

CILOXAN OINT NP

CILOXAN SOLN (Ciprofloxacin HCl (Ophth)) NP

ciprofloxacin hcl (ophth)soln F

erythromycin (ophth) oint F

gatifloxacin (ophth) soln NP

GENTAK OINT F

gentamicin sulfate (ophth)oint F

gentamicin sulfate (ophth)soln F

levofloxacin (ophth) soln NP

MOXEZA SOLN F

moxifloxacin hcl (ophth)soln NP

Drug Name DrugTier

Requirements/Limits

NATACYN SUSP NP

neomycin-bacitracin zn-polymyxin oint NP

neomycin-polymyxin-gramicidin soln NP

NEOSPORIN SOLN (Neomycin-Polymyxin-Gramicidin)

NP

OCUFLOX SOLN (Ofloxacin (Ophth)) NP

ofloxacin (ophth) soln F

polymyxin b-trimethoprimsoln F

POLYTRIM SOLN (Polymyxin B-Trimethoprim)

NP

sulfacetamide sodium (ophth) soln NP

SULFACETAMIDE SODIUM OINT OP NP

tobramycin (ophth) soln F

TOBREX OINT F

TOBREX SOLN (Tobramycin (Ophth)) NP

trifluridine soln F

VIGAMOX SOLN (Moxifloxacin HCl (Ophth)) F

VIROPTIC SOLN (Trifluridine) NP

ZYMAXID SOLN (Gatifloxacin (Ophth)) NP

Ophthalmic Decongestants NAPHAZOLINE HCL SOLN F

phenylephrine hcl (ophth)soln 2.5 % F

tetrahydrozoline hcl (ophth)soln F

tetrahydrozoline w/polyethylene glycol soln F


228

Drug Name DrugTier

Requirements/Limits

tetrahydrozoline-dextran-polyethylene glycol-povidone soln

F

VISINE ADVANCED RELIEF SOLN (Tetrahydrozoline-Dextran-Polyethylene Glycol-Povidone)

NP

VISINE EXTRA SOLN (Tetrahydrozoline HCl(Ophth))

NP

VISINE SOLN (Tetrahydrozoline HCl(Ophth))

NP

Ophthalmic Immunomodulators RESTASIS EMUL F

RESTASIS MULTIDOSE EMUL 4

Ophthalmic Integrin Antagonists XIIDRA SOLN NP

Ophthalmic Steroids ALREX SUSP F

bacitracin-poly-neomycin-hc oint NP

BLEPHAMIDE S.O.P. OINT NP

BLEPHAMIDE SUSP NP

DEXAMETHASONE SODIUM PHOSPHATE SOLN OP 0.1 %

F

DUREZOL EMUL F

FLAREX SUSP F

fluorometholone (ophth) susp F

FML FORTE SUSP NP

FML LIQUIFILM SUSP (Fluorometholone (Ophth)) NP

FML OINT NP

Drug Name DrugTier

Requirements/Limits

LOTEMAX GEL NP

LOTEMAX OINT NP

LOTEMAX SUSP F

MAXIDEX SUSP F

MAXITROL OINT (Neomycin-Polymy-Dexameth)

NP

MAXITROL SUSP (Neomycin-Polymy-Dexameth)

NP

neomycin-polymy-dexameth oint F

neomycin-polymy-dexameth susp F

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP

NP

OMNIPRED SUSP (Prednisolone Acetate (Ophth))

NP

PRED FORTE SUSP (Prednisolone Acetate (Ophth))

NP

PRED MILD SUSP F

PRED-G S.O.P. OINT F

PRED-G SUSP F

prednisolone acetate(ophth) susp NP

PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 %

NP

sulfacetamide sod-prednisolone soln F

TOBRADEX OINT F

TOBRADEX ST SUSP NP

TOBRADEX SUSP (Tobramycin-Dexamethasone)

F


229

Drug Name DrugTier

Requirements/Limits

tobramycin-dexamethasone susp NP

VEXOL SUSP NP

ZYLET SUSP NP

Ophthalmics - Misc. ACULAR LS SOLN (Ketorolac Tromethamine (Ophth))

NP

ACULAR SOLN (Ketorolac Tromethamine (Ophth)) NP

ACUVAIL SOLN NP

ALOCRIL SOLN NP

ALOMIDE SOLN NP

azelastine hcl (ophth) soln NP

AZOPT SUSP F

BEPREVE SOLN NP

bromfenac sodium (ophth)soln NP

BROMFENAC SOLN NP

BROMSITE SOLN NP

cromolyn sodium (ophth)soln F

diclofenac sodium (ophth)soln F

dorzolamide hcl soln F

ELESTAT SOLN (Epinastine HCl (Ophth)) NP

EMADINE SOLN NP

epinastine hcl (ophth) soln NP

EYEAID IRRIGATING SOLUTION SOLN (Ophthalmic IrrigationSolution)

NP

FLURBIPROFEN SODIUM SOLN F

Drug Name DrugTier

Requirements/Limits

flurbiprofen sodium soln F

ILEVRO SUSP NP

ketorolac tromethamine (ophth) soln NP

ketotifen fumarate (ophth)soln F

LASTACAFT SOLN NP

MURO 128 OINT 5 % (Sodium Chloride Hypertonic)

NP

MURO 128 SOLN 2 % F

MURO 128 SOLN 5 % (Sodium Chloride Hypertonic)

NP

NEVANAC SUSP NP

OCUFEN SOLN (Flurbiprofen Sodium) NP

olopatadine hcl soln NP

ophthalmic irrigationsolution soln F

PATADAY SOLN (Olopatadine HCl) F

PATANOL SOLN (Olopatadine HCl) NP

PAZEO SOLN F

PROLENSA SOLN NP

sodium chloride hypertonicoint F

sodium chloride hypertonicsoln F

TRUSOPT SOLN (Dorzolamide HCl) NP

ZADITOR SOLN (Ketotifen Fumarate (Ophth)) NP

Prostaglandins - Ophthalmic BIMATOPROST SOLN NP

latanoprost soln F


230

Drug Name DrugTier

Requirements/Limits

LUMIGAN SOLN NP

TRAVATAN Z SOLN F

TRAVOPROST SOLN NP

XALATAN SOLN (Latanoprost) NP

ZIOPTAN SOLN NP

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous acetic acid (otic) soln F

ACETIC ACID/ALUMINUMACETATE SOLN NP

carbamide peroxide (otic)soln F

DEBROX SOLN (Carbamide Peroxide (Otic))

NP

Otic Anti-infectives CETRAXAL SOLN F

CIPROFLOXACIN SOLN OT 0.2 % F

FLOXIN OTIC SOLN (Ofloxacin (Otic)) F

ofloxacin (otic) soln F

Otic Combinations CIPRO HC SUSP NP

CIPRODEX SUSP F

COLY-MYCIN S SUSP NP

CORTISPORIN-TC SUSP NP

neomycin-polymyxin-hc(otic) soln F

neomycin-polymyxin-hc(otic) susp F

OTOVEL SOLN NP

Drug Name DrugTier

Requirements/Limits

PRAMOTIC LIQD F

Otic Steroids DERMOTIC OIL (Fluocinolone Acetonide (Otic))

NP

fluocinolone acetonide (otic) oil F

hydrocortisone w/aceticacid soln NP

OXYTOCICS - Drugs to Prevent/Control UterineBleeding Oxytocics METHERGINE TABS F

methylergonovine maleatetabs or 0.2 mg F

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins amoxicillin caps 500 mg,250 mg F

AMOXICILLIN CHEW 125 MG, 250 MG F

AMOXICILLIN ER TB24 NP

amoxicillin susr 200 mg/5ml, 250 mg/5ml, 125mg/5ml, 400 mg/5ml

F

amoxicillin tabs 500 mg,875 mg F

AMPICILLIN CAPS 500 MG F

ampicillin caps 500 mg,250 mg F

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

MOXATAG TB24 NP

Natural Penicillins penicillin v potassium solr250 mg/5ml, 125 mg/5ml F

PENICILLIN V POTASSIUM SOLR 250 MG/5ML, 125 MG/5ML

F


231

Drug Name DrugTier

Requirements/Limits

penicillin v potassium tabs250 mg, 500 mg F

Penicillin Combinations amoxicillin & potclavulanate susr 250mg/5ml-62.5mg/5ml,600mg/5ml-42.9mg/5ml,200mg/5ml-28.5mg/5ml,400mg/5ml-57mg/5ml

F

amoxicillin & potclavulanate tabs 500mg-125mg, 875mg-125mg,250mg-125mg

F

amoxicillin & potclavulanate tb12 1000mg-62.5mg

NP

AMOXICILLIN/CLAVULANATE POTASSIUM CHEW F

AUGMENTIN ES-600 SUSR (Amoxicillin & Pot Clavulanate)

NP

AUGMENTIN SUSR 125MG/5ML-31.25MG/5ML NP

AUGMENTIN SUSR 250MG/5ML-62.5MG/5ML(Amoxicillin & Pot Clavulanate)

NP

AUGMENTIN TABS 875MG-125MG, 500MG-125MG (Amoxicillin & Pot Clavulanate)

NP

AUGMENTIN XR TB12 (Amoxicillin & Pot Clavulanate)

NP

Penicillinase-Resistant Penicillins dicloxacillin sodium caps F

PROGESTINS - Hormone Replacement/ModifyingDrugs Progestins AYGESTIN TABS (Norethindrone Acetate) NP

MAKENA OIL F

medroxyprogesteroneacetate tabs or 2.5 mg, 10mg, 5 mg

F

Drug Name DrugTier

Requirements/Limits

norethindrone acetate tabs F

progesterone micronized caps F

PROMETRIUM CAPS (Progesterone Micronized) NP

PROVERA TABS (MedroxyprogesteroneAcetate)

NP

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental andEmotional Conditions Agents for Chemical Dependency ANTABUSE TABS 250 MG (Disulfiram) NP

disulfiram tabs 250 mg F

Anti-Cataplectic Agents XYREM SOLN F PA

Antidementia Agents ARICEPT TABS (DonepezilHydrochloride) NP

donepezil hydrochloridetabs 23 mg NP

donepezil hydrochloridetabs 5 mg, 10 mg F

donepezil hydrochloridetbdp 5 mg, 10 mg F

EXELON CAPS OR 3 MG, 4.5 MG, 6 MG, 1.5 MG (Rivastigmine Tartrate)

NP

EXELON PT24 TD 13.3 MG/24HR (Rivastigmine) F

EXELON PT24 TD 9.5 MG/24HR, 4.6 MG/24HR(Rivastigmine)

F QL(1 ea daily)

galantamine hydrobromidecp24 16 mg, 8 mg, 24 mg NP

GALANTAMINE HYDROBROMIDE SOLN 4 MG/ML

NP

galantamine hydrobromidetabs 4 mg, 8 mg, 12 mg NP

memantine hcl soln 2 mg/ml NP QL(10 ml daily)


232

Drug Name DrugTier

Requirements/Limits

memantine hcl tabs 5 mg,10 mg, F

NAMENDA SOLN 10 MG/5ML (Memantine HCl) NP QL(10 ml daily)

NAMENDA TABS 5 MG, 10 MG (Memantine HCl) NP

NAMENDA TITRATION PAK TABS (Memantine HCl)

NP

NAMENDA XR CP24 NP

NAMENDA XR TITRATION PACK CP24 NP

NAMZARIC C4PK NP

NAMZARIC CP24 NP

RAZADYNE ER CP24 (Galantamine Hydrobromide)

NP

RAZADYNE TABS (Galantamine Hydrobromide)

NP

rivastigmine pt24 13.3mg/24hr NP

rivastigmine pt24 4.6mg/24hr, 9.5 mg/24hr NP QL(1 ea daily)

rivastigmine tartrate caps NP

Combination Psychotherapeutics olanzapine-fluoxetine hcl caps F AL; At least 6

yrs old PERPHENAZINE/AMITRIPTYLINE TABS F AL; At least 6

yrs old SYMBYAX CAPS (Olanzapine-FluoxetineHCl)


Fibromyalgia Agents

SAVELLA TABS F PA; QL(2 eadaily); AL; Atleast 13 yrs old

SAVELLA TITRATION PACK MISC F


Movement Disorder Drug Therapy

Drug Name DrugTier

Requirements/Limits

INGREZZA CAPS F QL(1 ea daily);AL; At least 19 yrs old

Multiple Sclerosis Agents AMPYRA TB12 NP QL(2 ea daily)

AUBAGIO TABS NP QL(1 ea daily)

AVONEX KIT 30 MCG/VIAL F


AVONEX PEN AJKT F QL(0.1429 eadaily)

AVONEX PSKT 30 MCG/0.5ML F QL(0.1429 ml

daily)

BETASERON KIT F Limit 15ea permonth;QL(0.5ea daily)

BETASERON KIT 4 Limit 15ea permonth;QL(0.5ea daily)

COPAXONE SOSY 20 MG/ML (Glatiramer Acetate)

F QL(1 ml daily)

COPAXONE SOSY 40 MG/ML (Glatiramer Acetate)

NP Limit 12ml in 28 days;QL(0.43ml daily)

EXTAVIA KIT 4 Limit 15ea permonth;QL(0.5ea daily)

GILENYA CAPS F QL(1 ea daily)

glatiramer acetate sosy 20mg/ml NP QL(1 ml daily)

glatiramer acetate sosy 40mg/ml NP

Limit 12ml in 28 days;QL(0.43ml daily)

PLEGRIDY SOPN NP Limit 1ml in 28 days;QL(0.036ml daily)

PLEGRIDY SOSY NP Limit 1ml in 28 days;QL(0.036ml daily)

PLEGRIDY STARTER PACK SOPN NP



233

Drug Name DrugTier

Requirements/Limits

PLEGRIDY STARTER PACK SOSY NP


REBIF REBIDOSE SOAJ F PA; QL(0.2 mldaily)

REBIF REBIDOSE TITRATIONPACK SOAJ F PA; QL(0.2 ml

daily)

REBIF SOSY F PA; QL(0.2 mldaily)

REBIF TITRATION PACK SOSY F PA; QL(0.2 ml

daily)

TECFIDERA CPDR NP

TECFIDERA STARTER PACK MISC NP

ZINBRYTA SOSY NP

Premenstrual Dysphoric Disorder (PMDD) Agents FLUOXETINE CAPS F

Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATES TABS F

ORAP TABS 1 MG (Pimozide) NP


ORAP TABS 2 MG (Pimozide) NP


pimozide tabs 1 mg F QL(10 eadaily); AL; Atleast 6 yrs old

pimozide tabs 2 mg F QL(5 ea daily);AL; At least 6 yrs old

Smoking Deterrents

bupropion hcl (smokingdeterrent) tb12 F


CHANTIX CONTINUING MONTHPAK TABS F


CHANTIX STARTING MONTH PAK TABS F


Drug Name DrugTier

Requirements/Limits

CHANTIX TABS F PA; QL(2 eadaily); AL; Atleast 18 yrs old

NICODERM CQ PT24 14 MG/24HR, 21 MG/24HR(Nicotine)


NICODERM CQ PT24 7 MG/24HR (Nicotine) NP


NICORETTE GUM (Nicotine Polacrilex) NP PA; AL; At least 18 yrs old NICORETTE LOZG (Nicotine Polacrilex) NP PA; AL; At least 18 yrs old NICORETTE MINI LOZG (Nicotine Polacrilex) NP PA; AL; At least 18 yrs old NICORETTE STARTER KIT GUM (Nicotine Polacrilex)


nicotine polacrilex gum F PA; AL; At least 18 yrs old

nicotine polacrilex lozg F PA; AL; At least 18 yrs old

nicotine pt24 14 mg/24hr,21 mg/24hr F PA; AL; At least

18 yrs old

nicotine pt24 7 mg/24hr F PA; QL(1 eadaily); AL; Atleast 18 yrs old

NICOTINE TRANSDERMAL SYSTEM KIT

F PA; AL; At least 18 yrs old

NICOTROL INHALER INHA F PA; AL; At

least 18 yrs old

NICOTROL NS SOLN F PA; AL; At least 18 yrs old

ZYBAN TB12 (BupropionHCl (Smoking Deterrent)) NP


Vasomotor Symptom Agents BRISDELLE CAPS (Paroxetine Mesylate(Vasomotor))

NP

paroxetine mesylate(vasomotor) caps F

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung Conditions Cystic Fibrosis Agents


234

Drug Name DrugTier

Requirements/Limits

KALYDECO PACK 50 MG, 75 MG F PA; QL(2 ea

daily)

KALYDECO TABS 150 MG F PA

ORKAMBI TABS 100MG-125MG NP


ORKAMBI TABS 200MG-125MG F


PULMOZYME SOLN F PA

Pulmonary Fibrosis Agents ESBRIET CAPS NP

OFEV CAPS NP QL(2 ea daily)

TETRACYCLINES - Drugs to Treat BacterialInfections Tetracyclines ACTICLATE TABS (Doxycycline Hyclate) NP

ADOXA CAPS (Doxycycline(Monohydrate))

NP

ADOXA PAK 1/100 TABS(Doxycycline(Monohydrate))

NP


NP


NP

ADOXA TABS (Doxycycline(Monohydrate))

NP

demeclocycline hcl tabs F PA

DORYX MPC TBEC NP

DORYX TBEC (Doxycycline Hyclate) NP

doxycycline (monohydrate)caps 100 mg, 50 mg F

doxycycline (monohydrate)caps 75 mg, 150 mg NP

Drug Name DrugTier

Requirements/Limits

doxycycline (monohydrate)susr 25 mg/5ml NP

doxycycline (monohydrate)tabs 100 mg, 50 mg, 75mg, 150 mg

NP

doxycycline hyclate caps or100 mg, 50 mg F

doxycycline hyclate tabs or75 mg, 150 mg, 20 mg, 100 mg

F

doxycycline hyclate tbec or100 mg, 50 mg, 150 mg, 75mg, 200 mg

NP

MINOCIN CAPS (Minocycline HCl) NP

minocycline hcl caps 50mg, 75 mg, 100 mg F

MINOCYCLINE HCL ER TB24 NP

minocycline hcl tabs 75 mg,50 mg, 100 mg NP

minocycline hcl tb24 90mg, 135 mg, 45 mg NP

MONODOX CAPS (Doxycycline(Monohydrate))

NP

MORGIDOX 1X100MG KIT NP

MORGIDOX 1X50MG KIT KIT NP

MORGIDOX 2X100MG KIT NP

SOLODYN TB24 NP

tetracycline hcl caps 250mg, 500 mg NP

TETRACYCLINE HCL CAPS 500 MG, 250 MG (Tetracycline HCl)

NP

VIBRAMYCIN CAPS 100 MG (Doxycycline Hyclate) NP

VIBRAMYCIN SUSR 25 MG/5ML (Doxycycline(Monohydrate))

NP

VIBRAMYCIN SYRP 50 MG/5ML NP


235

Drug Name DrugTier

Requirements/Limits

XIMINO CP24 NP QL(1 ea daily);AL; At least 12 yrs old

THYROID AGENTS - Drugs to Regulate ThyroidHormones Antithyroid Agents methimazole tabs F

propylthiouracil tabs F

TAPAZOLE TABS (Methimazole) NP

Thyroid Hormones ARMOUR THYROID TABS 30 MG, 90 MG, 15 MG, 60 MG, 120 MG (Thyroid)

F

ARMOUR THYROID TABS 300 MG, 240 MG, 180 MG F

CYTOMEL TABS (Liothyronine Sodium) NP

levothyroxine sodium tabsor 150 mcg, 112 mcg, 300mcg, 50 mcg, 88 mcg, 125mcg, 75 mcg, 175 mcg,100 mcg, 137 mcg, 200mcg, 25 mcg

F

liothyronine sodium tabs or5 mcg, 50 mcg, 25 mcg F

SYNTHROID TABS (Levothyroxine Sodium) NP

thyroid tabs F

THYROLAR-1 TABS NP

THYROLAR-1/2 TABS NP

THYROLAR-1/4 TABS NP

THYROLAR-2 TABS NP

THYROLAR-3 TABS NP

TIROSINT CAPS NP

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach Conditions Antispasmodics

Drug Name DrugTier

Requirements/Limits

ANASPAZ TBDP (Hyoscyamine Sulfate) NP

ATROPINE SULFATE SOSY IJ 0.25 MG/5ML F

BENTYL CAPS OR 10 MG (Dicyclomine HCl) NP

BENTYL TABS OR 20 MG (Dicyclomine HCl) NP

dicyclomine hcl caps or 10 mg F

dicyclomine hcl soln or 10mg/5ml F

dicyclomine hcl tabs or 20 mg F

glycopyrrolate tabs or 1mg, 2 mg F

hyoscyamine sulfate elix F

hyoscyamine sulfate soln F

hyoscyamine sulfate subl F

hyoscyamine sulfate tabs F

hyoscyamine sulfate tb12 F

hyoscyamine sulfate tbdp F

LEVBID TB12 (Hyoscyamine Sulfate) NP

LEVSIN TABS OR 0.125 MG (Hyoscyamine Sulfate) NP

LEVSIN/SL SUBL(Hyoscyamine Sulfate) NP

ROBINUL FORTE TABS (Glycopyrrolate) NP

ROBINUL TABS OR 1 MG (Glycopyrrolate) NP

H-2 Antagonists CIMETIDINE HCL SOLN NP

cimetidine hcl soln NP

cimetidine tabs 200 mg NP RX/OTC

cimetidine tabs 800 mg,300 mg, 400 mg NP


236

Drug Name DrugTier

Requirements/Limits

famotidine susr 40 mg/5ml NP

famotidine tabs 20 mg F RX/OTC

famotidine tabs 40 mg, 10 mg F

nizatidine caps 300 mg,150 mg NP

NIZATIDINE SOLN 15 MG/ML NP

PEPCID AC MAXIMUM STRENGTH TABS (Famotidine)

NP RX/OTC

PEPCID AC TABS (Famotidine) NP

PEPCID SUSR 40 MG/5ML(Famotidine) NP

PEPCID TABS 20 MG (Famotidine) NP RX/OTC

PEPCID TABS 40 MG (Famotidine) NP

ranitidine hcl caps or 300mg, 150 mg NP

ranitidine hcl syrp or 75mg/5ml, 150 mg/10ml, 15mg/ml

F

ranitidine hcl tabs or 150 mg F RX/OTC

ranitidine hcl tabs or 300 mg, 75 mg F

TAGAMET HB TABS (Cimetidine) NP RX/OTC

ZANTAC 150 MAXIMUM STRENGTH TABS (Ranitidine HCl)

NP RX/OTC

ZANTAC 75 TABS (Ranitidine HCl) NP

ZANTAC TABS OR 150 MG (Ranitidine HCl) NP RX/OTC

ZANTAC TABS OR 300 MG (Ranitidine HCl) NP

Misc. Anti-Ulcer CARAFATE SUSP 1 GM/10ML F AL; Up to 6 yrs

old CARAFATE TABS 1 GM (Sucralfate) NP

Drug Name DrugTier

Requirements/Limits

sucralfate tabs F

Proton Pump Inhibitors ACIPHEX SPRINKLE CPSP NP

ACIPHEX TBEC (Rabeprazole Sodium) NP QL(1 ea daily)

DEXILANT CPDR NP

esomeprazole magnesiumcpdr 20 mg NP QL(1 ea daily);RX/OTC esomeprazole magnesiumcpdr 40 mg NP QL(1 ea daily)

ESOMEPRAZOLE STRONTIUM CPDR 49.3 MG, 24.65 MG

NP

lansoprazole cpdr 15 mg NP QL(1 ea daily);RX/OTC

lansoprazole cpdr 30 mg NP QL(1 ea daily)

NEXIUM 24HR CLEAR MINIS CPDR (EsomeprazoleMagnesium)

NP


NEXIUM 24HR CPDR (EsomeprazoleMagnesium)

NP QL(1 ea daily);RX/OTC

NEXIUM CPDR 20 MG (EsomeprazoleMagnesium)


NEXIUM CPDR 40 MG (EsomeprazoleMagnesium)

NP QL(1 ea daily)

NEXIUM PACK 20 MG, 40 MG, 5 MG, 2.5 MG, 10 MG NP QL(1 ea daily)

omeprazole cpdr 10 mg F

omeprazole cpdr 20 mg F QL(4 ea daily)

omeprazole cpdr 40 mg F QL(2 ea daily)

pantoprazole sodium tbecor 40 mg, 20 mg F QL(2 ea daily)

PREVACID 24HR CPDR (Lansoprazole) NP QL(1 ea daily);RX/OTC PREVACID CPDR 15 MG (Lansoprazole) NP QL(1 ea daily);RX/OTC


237

Drug Name DrugTier

Requirements/Limits

PREVACID CPDR 30 MG (Lansoprazole) NP QL(1 ea daily)

PREVACID SOLUTAB TBDP NP QL(1 ea daily)

PRILOSEC CPDR 10 MG (Omeprazole) NP

PRILOSEC CPDR 20 MG (Omeprazole) NP QL(4 ea daily)

PRILOSEC CPDR 40 MG (Omeprazole) NP QL(2 ea daily)

PRILOSEC PACK 2.5 MG, 10 MG NP

PROTONIX PACK OR 40 MG NP QL(2 ea daily)

PROTONIX TBEC OR 20 MG, 40 MG (PantoprazoleSodium)

NP QL(2 ea daily)

rabeprazole sodium tbec NP QL(1 ea daily)

Ulcer Drugs - Prostaglandins CYTOTEC TABS (Misoprostol) NP

misoprostol tabs F

Ulcer Therapy Combinations amoxicillin-clarithromycinw/ lansoprazole misc NP

OMECLAMOX-PAK MISC NP QL(30 ea per365 days retail) omeprazole-sodiumbicarbonate caps 20mg-1100mg


omeprazole-sodiumbicarbonate caps 40mg-1100mg

NP QL(1 ea daily)

omeprazole-sodiumbicarbonate pack 20mg-1680mg, 40mg-1680mg

NP

PREVPAC MISC (Amoxicillin-Clarithromycinw/ Lansoprazole)

NP

PYLERA CAPS F

ZEGERID CAPS 20MG-1100MG (Omeprazole-Sodium Bicarbonate)


Drug Name DrugTier

Requirements/Limits

ZEGERID CAPS 40MG-1100MG (Omeprazole-Sodium Bicarbonate)

NP QL(1 ea daily)

ZEGERID OTC CAPS (Omeprazole-SodiumBicarbonate)


ZEGERID PACK 40MG-1680MG, 20MG-1680MG (Omeprazole-SodiumBicarbonate)

NP

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney Infections Urinary Anti-infective Combinations methenamine-hyosc-methylene blue-sod phos-phenyl sal tabs 40.8mg-0.12mg-36.2mg-81.6mg-10.8mg, 40.8mg-36.2mg-0.12mg-81.6mg-10.8mg

F

Urinary Anti-infectives FURADANTIN SUSP (Nitrofurantoin) NP

HIPREX TABS (Methenamine Hippurate) NP

MACROBID CAPS (Nitrofurantoin MonohydMacro)

NP

MACRODANTIN CAPS (Nitrofurantoin Macrocrystal)

NP

methenamine hippuratetabs F

METHENAMINE MANDELATE TABS 0.5 GM

F

methenamine mandelate tabs 1 gm F

nitrofurantoin macrocrystal caps F

nitrofurantoin monohyd macro caps F

nitrofurantoin susp F

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms Urinary Antispasmodic - Antimuscarinics


238

Drug Name DrugTier

Requirements/Limits

darifenacin hydrobromidetb24 NP QL(1 ea daily)

DETROL LA CP24 (Tolterodine Tartrate) NP

DETROL TABS (Tolterodine Tartrate) NP

DITROPAN XL TB24 (Oxybutynin Chloride) NP

ENABLEX TB24 (Darifenacin Hydrobromide)

NP QL(1 ea daily)

GELNIQUE GEL NP

GELNIQUE PUMP GEL NP

oxybutynin chloride syrp F

oxybutynin chloride tabs F

oxybutynin chloride tb24 F

OXYTROL FOR WOMEN PTTW NP RX/OTC

OXYTROL PTTW NP RX/OTC

tolterodine tartrate cp24 NP

tolterodine tartrate tabs NP

TOVIAZ TB24 F

trospium chloride cp24 NP

trospium chloride tabs NP

VESICARE TABS F

Urinary Antispasmodics - Beta-3 Adrenergic MYRBETRIQ TB24 NP

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs F

URECHOLINE TABS (Bethanechol Chloride) NP

Urinary Antispasmodics - Direct Muscle Relaxants

Drug Name DrugTier

Requirements/Limits

flavoxate hcl tabs F

VACCINES

Bacterial Vaccines

BEXSERO SUSY F

QL(1 ml per350 daysretail,1 ml per350 days mail);AL; At least 19 yrs old

MENACTRA INJ F


MENOMUNE-A/C/Y/W-135INJ F

QL(1 ea per350 daysretail,1 ea per350 days mail);AL; At least 19 yrs old

MENVEO SOLR F

QL(1 ea per350 daysretail,1 ea per350 days mail);AL; At least 19 yrs old

PNEUMOVAX 23 INJ F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old

PNEUMOVAX 23/1 DOSEINJ F

QL(0.5 ml perfill retail); AL; Atleast 19 yrs old

PREVNAR 13 SUSP F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old

TRUMENBA SUSY F


Viral Vaccines AFLURIA 2015-2016 SUSP NP


239

Drug Name DrugTier

Requirements/Limits

AFLURIA 2016-2017 SUSP F


AFLURIA 2017-2018 SUSP F


AFLURIA PF 2015-2016 SUSY NP

AFLURIA PF 2016-2017 SUSY F


AFLURIA PF 2017-2018 SUSY F


AFLURIA QUADRIVALENT 2016-2017 SUSY NP

AFLURIA QUADRIVALENT 2017-2018 SUSP F


AFLURIA QUADRIVALENT 2017-2018 SUSY F


FLUAD 2016-2017 SUSY F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old

FLUAD 2017-2018 SUSY F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old

FLUARIX QUADRIVALENT 2015-2016 SUSY NP

FLUARIX QUADRIVALENT 2016-2017 SUSY F


FLUARIX QUADRIVALENT 2017-2018 SUSY F


FLUBLOK 2015-2016 SOLN NP

FLUBLOK 2016-2017 SOLN F


FLUCELVAX QUADRIVALENT 2016-2017 SUSY

F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old

FLUCELVAX QUADRIVALENT 2017-2018 SUSP


Drug Name DrugTier

Requirements/Limits

FLUCELVAX QUADRIVALENT 2017-2018 SUSY


FLULAVAL QUADRIVALENT 2014-2015 SUSY

NP

FLULAVAL QUADRIVALENT 2015-2016 SUSP

NP









FLUVIRIN 2015-2016 SUSP NP

FLUVIRIN 2015-2016 SUSY NP

FLUVIRIN 2016-2017 SUSP F


FLUVIRIN 2016-2017 SUSY F


FLUVIRIN 2017-2018 SUSP F


FLUVIRIN 2017-2018 SUSY F


FLUZONE HIGH-DOSE PF 2015-2016 SUSY NP

FLUZONE HIGH-DOSE PF 2016-2017 SUSY F


FLUZONE HIGH-DOSE PF 2017-2018 SUSY NP

FLUZONE INTRADERMAL QUADRIVALENT 2015-2016 SUPN

NP


240

Drug Name DrugTier

Requirements/Limits





FLUZONE QUADRIVALENT 2015-2016 SUSP

NP

FLUZONE QUADRIVALENT 2015-2016 SUSY

NP









FLUZONE SPLIT 2015-2016 SUSP NP

ZOSTAVAX SUSR F

QL(1 ea per350 daysretail); AL; Atleast 19 yrs old

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low Hormones Vaginal Anti-infectives CLEOCIN CREA VA 2 % (Clindamycin PhosphateVaginal)

NP

CLEOCIN SUPP VA 100 MG F

clindamycin phosphatevaginal crea F

CLINDESSE CREA F

clotrimazole vaginal crea F

GYNAZOLE-1 CREA F

Drug Name DrugTier

Requirements/Limits

GYNE-LOTRIMIN 3 CREA (Clotrimazole Vaginal) NP

GYNE-LOTRIMIN CREA (Clotrimazole Vaginal) NP

METROGEL-VAGINAL GEL (Metronidazole Vaginal)

NP

metronidazole vaginal gel F

metronidazole vaginal gel 4

miconazole nitrate vaginalcrea 2 % F

miconazole nitrate vaginalkit F

miconazole nitrate vaginalsupp 100 mg F

MONISTAT 3 COMBINATION PACK KIT (Miconazole Nitrate Vaginal)

NP

MONISTAT 7 SIMPLY CURE CREA (Miconazole Nitrate Vaginal)

NP

NUVESSA GEL NP

TERAZOL 3 CREA (Terconazole Vaginal) NP

TERAZOL 7 CREA (Terconazole Vaginal) NP

terconazole vaginal crea F

terconazole vaginal supp F

Vaginal Estrogens ESTRACE CREA VA 0.1 MG/GM F

PREMARIN CREA VA 0.625 MG/GM F

Vaginal Progestins CRINONE GEL F

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions Anaphylaxis Therapy Agents


241

Drug Name DrugTier

Requirements/Limits

ADRENACLICK SOAJ 0.15 MG/0.15ML 4

ADRENACLICK SOAJ 0.3 MG/0.3ML 4 QL(4 ea per fill

retail)

AUVI-Q SOAJ 4

epinephrine (anaphylaxis)soaj 0.15 mg/0.15ml F

epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml 4

QL(2 ea per fillretail,30 claims per fill retail)

epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml 4

Limit 2 permonth;QL(2 eaper 30 daysretail)

EPINEPHRINE SOAJ F QL(4 ea per fillretail)

EPINEPHRINE SOAJ 4 QL(4 ea per fillretail)

EPIPEN 2-PAK SOAJ F QL(4 ea per fillretail)

EPIPEN-JR 2-PAK SOAJ F Limit 2 permonth;QL(0.067 ea daily)

Vasopressors midodrine hcl tabs F

VITAMINS

Oil Soluble Vitamins BETA CAROTENE CAPS 10000 UNIT F

beta carotene caps 25000unit F

cholecalciferol caps 2000unit, 1000 unit F

cholecalciferol caps 5000unit F QL(2 ea daily)

cholecalciferol caps 50000unit F QL(0.267 ea

daily) cholecalciferol liqd 400unit/ml F

cholecalciferol tabs 400 unit, 1000 unit, 50000 unit,2000 unit

F

Drug Name DrugTier

Requirements/Limits

D-VI-SOL LIQD (Cholecalciferol) NP

DECARA CAPS F

DRISDOL CAPS 50000 UNIT (Ergocalciferol) NP AL; At least 17 yrs old DRISDOL SOLN 8000 UNIT/ML (Ergocalciferol) NP QL(2 ml daily)

ergocalciferol caps 50000unit F AL; At least 17

yrs old ergocalciferol soln 8000unit/ml F QL(2 ml daily)

MEPHYTON TABS F

vitamin a caps 8000 unit,10000 unit F

vitamin a tabs 10000 unit F

vitamin e caps or 1000 unit,100 unit, 400 unit, 200 unit F

vitamin e soln or 15 unit/0.3ml F

Water Soluble Vitamins ascorbic acid chew or 250 mg, 500mg, 500 mg,7.5mg-500mg, 250mg

F

ascorbic acid liqd or 500mg/5ml F

ascorbic acid tabs or 1000 mg, 1000mg, 37mg-1000mg

F

ascorbic acid tabs or 37mg-500mg, 500 mg, 14mg-25mg-500mg, 250 mg,500mg, 10mg-500mg

F

QL(3.34 eadaily)

ascorbic acid tbcr or 500 mg, 1000 mg, 500mg F

B-1 TABS F

biotin caps 5 mg, 5000 mcg F

biotin tabs 300 mcg F

niacin cpcr 250 mg, 500 mg F

niacin tabs 50 mg, 500 mg F


242

Drug Name DrugTier

Requirements/Limits

niacin tbcr 250 mg, 500 mg F

niacinamide tabs 500 mg F

pyridoxine hcl tabs or 25mg, 50 mg, 100 mg F

riboflavin tabs 100 mg F QL(3.34 eadaily)

SLO-NIACIN TBCR 500 MG (Niacin) NP

thiamine hcl tabs or 100 mg, 50 mg F QL(3.34 ea

daily) thiamine mononitrate tabs or F QL(3.34 ea

daily) VITAMIN C SYRP 500 MG/5ML F


243

Index 1ST CHOICE LANCETS ABSORBASE 74 ACIPHEX 237 SUPERTHIN 102 ABSORICA 55 ACIPHEX SPRINKLE 2371ST CHOICE LANCETS THIN

ABSTRAL 8 acitretin 60102 1ST CHOICE LANCETS ACANYA 55 ACLOVATE 61 ULTRATHIN 102 acarbose 24 ACNE MEDICATION 10 551ST TIER UNIFINE ACCOLATE 16 ACNE MEDICATION 5 55PENTIPS/MINI/31GX5MM 121

ACCU-CHEK ACTIVE ACTEMRA 51ST TIER UNIFINE GLUCOSECONTROLPENTIPS29GX12MM 121 ACTI-LANCE LANCETS

1ST TIER UNIFINE SOLUTION 102 28G 103ACCU-CHEK ACTIVEPENTIPS31GX6MM 121 ACTI-LANCE LITE SAFETYSTRIPS 831ST TIER UNIFINE LANCETS 28G 103

PENTIPS31GX8MM 121 ACCU-CHEK AVIVA 84 ACTI-LANCE SPECIAL SAFETY 1ST TIER UNIFINE LANCETS 17G 103ACCU-CHEK AVIVA PLUS83 PENTIPS32GX4MM 121 ACTI-LANCE SPECIALACCU-CHEK COMPACT1ST TIER UNIFINE SAFETYLANCETS 17G 103PLUS 84PENTIPSPLUS 31GX8MM 121 ACTI-LANCE UNIVERSALACCU-CHEK COMPACT PLUS1ST TIER UNIFINE SAFETY LANCETS 23G 103CLEAR CONTROL SOLUTIONPENTIPSPLUS 32GX4MM 121 ACTICLATE 235(2 LEVELS) 1021ST TIER UNIFINE ACCU-CHEK COMPACT TEST ACTICOAT 7 2"X2" 76PENTIPSPLUS/MINI/31GX5MM DRUM 84 ACTICOAT 7 4"X5" 76121 ACCU-CHEK FASTCLIX1ST TIER UNIFINE ACTICOAT ABSORBENTLANCETS 102PENTIPSPLUS/ORIGINAL/29GX ANTIMICROBIAL DRESSINGACCU-CHEK MULTICLIX12MM 121 4"X5" 76LANCETS 1021ST TIER UNIFINE ACTICOAT ANTIMICROBIALACCU-CHEK SAFE-T-PROPENTIPSPLUS/ULTRA DRESSING 2"X2" 76LANCETS 103SHORT/31GX6MM 121 ACTICOAT ANTIMICROBIALACCU-CHEK SAFE-T-PRO1ST TIER UNILET DRESSING 4"X4" 76PLUSLANCETS 103COMFORTOUCH LANCETS ACTICOAT FLEX 3 BARRIERACCU-CHEK SMARTVIEW28G 102 DRESSING 4"'X4" 76CONTROL 1031ST TIER UNILET ACTIFLOVIT EAR HEALTH222ACCU-CHEK SMARTVIEWCOMFORTOUCH LANCETS STRIPS 84 ACTIGALL 93 30G 102 ACCU-CHEK SOFT TOUCH ACTIQ 82ND SKIN MOIST BURN LANCETS 103 ACTIVE 1ST BLOODPADS1.5"X2" 76 ACCU-CHEK SOFTCLIX LANCETS30G/EASY TWIST2ND SKIN MOIST BURN LANCETS 103 CAP 103PADS2"X3" 76 ACCUPRIL 342ND SKIN MOIST BURN ACTIVE OB 213

ACCURETIC 35PADS3"X4" 76 ACTIVELLA 92 2ND SKIN MOIST DRESSING ACCUTREND GLUCOSE 84 ACTIVITY POUCH 149KIT 76 ACCUTREND GLUCOSE ACTONEL 912ND SKIN MOIST GEL PADS CONTROL 103 1"X1" 76 ACE AEROSOL CLOUD ACTOPLUS MET 25 2ND SKIN MOIST GEL PADS 3" ENHANCER 149 ACTOPLUS MET XR 25ROUND 76 acebutolol hcl 47 ACTOS 278-MOP 60 ACEON 34 ACULAR 230A + D PERSONAL CARE acetaminophen 8LOTION 65 ACULAR LS 230

acetaminophen w/ codeine 10 ACURA BLOOD GLUCOSEA+D FIRST AID 74 ACETAMINOPHEN/CAFFEINE TESTSTRIPS 84abacavir sulfate 43 /DIHYDROCODEINE 10 ACURA CONTROL SOLUTION

abacavir sulfate-lamivudine 43 acetazolamide 90 HIGH 103 abacavir sulfate-lamivudine- ACURA CONTROL SOLUTIONacetic acid (otic) 231zidovudine 43 LOW 103ACETIC ACID/ALUMINUMABILIFY 43 ACURA CONTROL SOLUTIONACETATE 231 NORMAL 103ABREVA 61 acetylcysteine 55 ACUVAIL 230

Index 1

acyclovir 46 acyclovir topical 61 ACZONE 55 ADALAT CC 48 adapalene 55 ADAPALENE 55 adapalene-benzoyl peroxide 55 ADAPTIC NON-ADHERING DRESSING 3" X 3" 76 ADASUVE 42 ADCIRCA 49 ADDERALL 1 ADDERALL XR 1 adefovir dipivoxil 45 ADEMPAS 49 ADJUSTABLE LANCING DEVICE 103 ADLYXIN 27 ADLYXIN STARTER PACK 27 ADOXA 235 ADOXA PAK 1/100 235 ADOXA PAK 1/150 235 ADOXA PAK 2/100 235 ADRENACLICK 242 ADRENAL C FORMULA 163 ADRENAL STRESS CALM 219 ADULT AEROSOL MASK 149

ADVIL MIGRAINE 5 ADVOCATE CONTROL SOLUTIONHIGH 103 ADVOCATE CONTROL SOLUTIONLOW 103 ADVOCATE INSULIN PEN NEEDLES 29GX12.7MM 121 ADVOCATE INSULIN PEN NEEDLES 31GX5MM 121 ADVOCATE INSULIN PEN NEEDLES 31GX8MM 121 ADVOCATE INSULIN SYRINGE/U-100/0.3ML/29GX1/2" 122 ADVOCATE INSULIN SYRINGE/U-100/0.3ML/30GX5/16" 122 ADVOCATE INSULIN SYRINGE/U-100/0.3ML/31GX5/16" 122 ADVOCATE INSULIN SYRINGE/U-100/0.5ML/29GX1/2" 122 ADVOCATE INSULIN SYRINGE/U-100/0.5ML/30GX5/16" 122 ADVOCATE INSULIN SYRINGE/U-100/0.5ML/31GX5/16" 122 ADVOCATE INSULIN SYRINGE/U-100/1ML/29GX1/2" 122 ADVOCATE INSULIN

ADVOCATE TEST STRIPS 84 ADZENYS XR-ODT 1 AEROCHAMBER MINI AEROSOLCHAMBER 150 AEROCHAMBER MV 150 AEROCHAMBER PLUS FLOW VU 150 AEROCHAMBER PLUS FLOW-VU 150 AEROCHAMBER PLUS FLOW-VU/LARGE MASK 150 AEROCHAMBER PLUS FLOW-VU/MASK 150 AEROCHAMBER PLUS FLOW-VU/MEDIUM MASK 150 AEROCHAMBER PLUS FLOW-VU/SMALL MASK 150 AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VU 150 AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL 150 AEROCHAMBER Z-STAT PLUS/LARGE MASK 150 AEROCHAMBER Z-STAT PLUS/MEDIUM MASK 150 AEROCHAMBER Z-STAT PLUS/SMALL MASK 150 AEROCHAMBER/FLOWSIGNAL

150 AEROSPAN 17 AEROTRACH PLUS 150

ADULT MASK ADULT MASK LARGE ADULT ONE DAILY GUMMIES ADVAIR DISKUS ADVAIR HFA

150 150

164 17 17

SYRINGE/U-100/1ML/30GX5/16"ADVOCATE INSULIN SYRINGE/U-100/1ML/31GX5/16" ADVOCATE LANCETS ADVOCATE LANCETS

122

122 103

AEROVENT PLUS HOLDING CHAMBER/COLLAPSIBLE 150 AFINITOR 38 AFINITOR DISPERZ 38 AFLURIA 2015-2016 239 AFLURIA 2016-2017 240

ADVANCE INTUITION 30G 103 AFLURIA 2017-2018 240 CONTROL SOLUTION 103 ADVANCE INTUITION TEST STRIPS 84 ADVANCE MICRO-DRAW

ADVOCATE LANCING DEVICE 103 ADVOCATE RAPID-SAFE LANCING DEVICE 103

AFLURIA PF 2015-2016 AFLURIA PF 2016-2017 AFLURIA PF 2017-2018

240 240 240

CONTROL LEVEL 1-2 103 ADVANCE MICRO-DRAW NORMAL CONTROL 103 ADVANCE MICRO-DRAW TEST STRIPS 84 ADVANCED C PLUS 163

ADVOCATE REDI-CODE 84 ADVOCATE REDI-CODE+ CONTROL SOLUTION HIGH 103 ADVOCATE REDI-CODE+ CONTROL SOLUTION

AFLURIA QUADRIVALENT 2016-2017 240 AFLURIA QUADRIVALENT 2017-2018 240 AFREZZA 27 AFRIN 225

ADVANCED CALCIUM/VITAMIND/MAGNESIUM 157 ADVANCED COLLAGEN 219 ADVANCED DIABETIC MULTIVITAMIN FORMULA164 ADVIL 5

LOW 103 ADVOCATE REDI-CODE+ TESTSTRIPS 84 ADVOCATE SAFETY LANCETS 103 ADVOCATE SAFETY LANCETS 26G 103

AFRIN 12 HOUR AFRIN ALL NIGHT NODRIP AFRIN NASAL SPRAY AFRIN NODRIP EXTRA MOISTURIZING

224

224 224

224

Index 2

AFRIN NODRIP ORIGINAL224 ALEVE ARTHRITIS 5 ALLEVYN TRACHEOSTOMY 3-AFRIN NODRIP SEVERE alfuzosin hcl 95 1/2"X3-1/2" 77 CONGESTION 224 allopurinol 96ALINIA 14AFRIN NODRIP SINUS 225 almotriptan malate 154ALIVE ENERGY 50+ 164AFRIN SINUS 225 ALOCRIL 230ALIVE MENS ENERGY 164AGAMATRIX AMP NO CODE ALOE AFTERSUN LOTION 65ALIVE ONCE DAILY WOMENSTEST STRIPS 84 50+ ULTRA POTENCY 164 ALOE VESTA ANTIFUNGAL58AGAMATRIX CONTROL ALIVE ONCE DAILY WOMENS ALOE VESTA CLEARHIGH 103 ULTRA POTENCY 164 ANTIFUNGAL 58AGAMATRIX CONTROL

ALIVE WOMENS 50+ 164 ALOE VESTA PROTECTIVE74NORMAL 103 AGAMATRIX CONTROL ALIVE WOMENS ALOGLIPTIN 26 NORMAL& HIGH 103 ENERGY 164 ALOGLIPTIN/METFORMINAGAMATRIX JAZZ TEST ALIVE WOMENS GUMMY HCL 25 STRIPS 84 VITAMINS 164 ALOGLIPTIN/PIOGLITAZONEAGAMATRIX KEYNOTE TEST ALKERAN 37 25 STRIPS 84 ALL FLOW 1000 PULMONARY ALOMIDE 230AGAMATRIX PRESTO TEST FUNCTION FILTER 150 ALORA 92STRIPS 84 ALLEGRA ALLERGY 31AGAMATRIX ULTRA-THIN alosetron hcl 94ALLEGRA ALLERGYLANCETS 33G 103 ALPHAGAN P 227CHILDRENS 31AGGRENOX 96 ALLERWELL ALLERGY alprazolam 15 AIMSCO LUBRICATED 101 FORMULA 219 ALPRAZOLAM INTENSOL 15 AIRBORNE 164 ALLEVYN ADHESIVE 76 ALREX 229 AIRDUO RESPICLICK ALLEVYN AG ADHESIVE 76 ALTABAX 58113/14 17 ALLEVYN AG GENTLE ALTACE 34AIRDUO RESPICLICK BORDER 76 232/14 17 ALLEVYN AG NON- ALTERNATE SITE LANCING AIRS PEDIATRIC AEROSOL ADHESIVE 76 DEVICE 103 MASK 150 ALTOPREV 33ALLEVYN AG SACRUM 76 AKTIPAK 55 ALLEVYN alum & mag hydrox-

simethicone 13AKYNZEO 29 COMPRESSION 76 ALUNBRIG 38ALBOLENE 65 ALLEVYN GENTLE 77

ALLEVYN GENTLE ALVESCO 17albuterol sulfate 17 BORDER 77 amantadine hcl 40alclometasone dipropionate 61 ALLEVYN GENTLE BORDER AMARYL 28ALCOH-GLOVE CONTOURED HEEL 76

WIPE 119 AMBIEN 98ALLEVYN GENTLE BORDER ALCOHOL PADS 119 LITE 76 AMBIEN CR 98 ALCOHOL PREP PADS 119 ALLEVYN GENTLE BORDER AMCINONIDE 61MULTISITE 77ALCOHOL PREPS 119 AMERGE 154ALLEVYN GENTLE BORDERALCOHOL SWABS 119 SACRUM 77 AMERIDERM PERISHIELD 74 ALCOHOL SWABSTICK 119 ALLEVYN HEEL 77 AMERIGEL HYDROGEL

SATURATED GAUZEALCOHOL WIPES 119 ALLEVYN LIFE 77 DRESSING 2" X 2" 77ALDACTAZIDE 90 ALLEVYN LIFE HEEL 77 AMICAR 97ALDACTONE 90 ALLEVYN LIFE SACRUM 77 amifostine 39ALDARA 72 ALLEVYN NON- amiloride &ADHESIVE 77ALECENSA 38 hydrochlorothiazide 90ALLEVYN PLUSALENDRONATE SODIUM 91 amiloride hcl 90ADHESIVE 77 alendronate sodium 91 amiodarone hcl 16ALLEVYN PLUS CAVITY 77 ALENDRONATE SODIUM 91 94ALLEVYN PLUS SACRUM77 AMITIZA ALEVAZOL 58 ALLEVYN SACRUM 77 amitriptyline hcl 24 ALEVE 5 AMLACTIN CERAPEUTIC 65

Index 3

AMLACTIN ULTRA 65 ANTI-STICK INSULIN AQUAFRESH

amlodipine besylate 48 amlodipine besylate-atorvastatincalcium 49 amlodipine besylate-benazeprilhcl 35 amlodipine besylate-olmesartanmedoxomil 35 amlodipine besylate-valsartan 35 amlodipine-valsartan-hydrochlorothiazide 35 AMOXAPINE 24 amoxicillin 231 AMOXICILLIN 231 amoxicillin 231 amoxicillin & potclavulanate 232 AMOXICILLIN ER 231 amoxicillin-clarithromycin w/lansoprazole 238 AMOXICILLIN/CLAVULANATEPOTASSIUM 232 amphetamine-dextroamphetamine 1,2 AMPICILLIN 231 ampicillin 231 AMPICILLIN 231 AMPYRA 233 AMRIX 223 ANAFRANIL 24 ANALPRAM-HC 13 ANAPROX DS 5 ANASPAZ 236 anastrozole 37 ANBESOL MAXIMUMSTRENGTH 159 ANCOBON 30 ANDRODERM 12 ANDROGEL 12 ANDROGEL PUMP 12 ANORO ELLIPTA 17 ANTABUSE 232 ANTARA 32 ANTI-STICK INSULINSYRINGE/U-100/0.5ML/28G X1/2" 122 ANTI-STICK INSULINSYRINGE/U-100/0.5ML/29G X1/2" 122

SYRINGE/U-100/1ML/29G X1/2" 122 ANTIOXIDANT FORMULASG 164 ANTIOXIDANT FORTE 164 ANUSOL-HC 13 ANZEMET 29 AP-ZEL 164 APATATE FORTE 164 APEXICON E 61 APIDRA 27 APIDRA SOLOSTAR 27 APLENZIN 22 apraclonidine hcl 228 aprepitant 30 APRISO 94 APTENSIO XR 3 APTIOM 19 APTIVUS 43 AQUA GLYCOLIC FACECREAM 65 AQUA GLYCOLIC HAND &BODYLOTION 65 AQUA LACTEN 65 AQUA LANCE ADJUSTABLELANCING DEVICE 103 AQUACELEXTRA/HYDROFIBER 77 AQUACEL FOAM3.2"X3.2" 77 AQUACEL FOAM 4"X4" 77 AQUACEL FOAM 5"X5" 77 AQUACEL FOAM 6"X6" 77 AQUACEL FOAM 6"X8" 77 AQUACEL FOAM 7"X7" 77 AQUACEL FOAM 8"X5.5" 77 AQUACEL FOAM 8"X7" 77 AQUADEKS 164 AQUADERM 65 AQUADERM TREATMENT/MOISTURIZER

65 AQUAFRESH CAVITYPROTECTION 120 AQUAFRESH EXTREMECLEAN 120 AQUAFRESH FOR KIDS 120 AQUAFRESHSENSITIVE 120 AQUAFRESH TARTARCONTROL 120

TOOTHPASTE 120 AQUAFRESH WHITENING 120 AQUAMED 65 AQUAPHILIC 65 AQUAPHOR 65 AQUAPHOR ADVANCEDTHERAPY 65 AQUAPHOR LIP REPAIR 74 AQUASITE IMPREGNATEDDRESSING 2"X2" 77 AQUASITE IMPREGNATEDDRESSING 4"X4" 77 AQUASITE IMPREGNATEDDRESSING 4"X8" 77 AQUASITE IMPREGNATEDGAUZE 2"X2" 77 AQUASITE IMPREGNATEDGAUZE 4"X4" 77 AQUASITE SHEET DRESSING4"X4" 77 AQUORAL 160 ARAVA 7 ARCALYST 5 ARCAPTA NEOHALER 17 ARGLAES FILM 2-3/8" X 3-1/8" 77 ARGLAES FILM 3" X 14" 77 ARGLAES FILM 4" X 4-3/4" 77 ARGLAES FILM 4-3/4" X 10"77 ARGLAES ISLAND 2-3/8" X 3-1/8" 77 ARGLAES ISLAND 4" X 4-3/4" 77 ARGLAES ISLAND 4-3/4" X10" 77 ARIAL CHAMBER 150 ARICEPT 232 ARIMIDEX 37 aripiprazole 43 ARISTADA 43 ARIXTRA 18 armodafinil 3 ARMONAIR RESPICLICK113 17 ARMONAIR RESPICLICK232 17 ARMONAIR RESPICLICK55 17 ARMOUR THYROID 236 ARNUITY ELLIPTA 17 AROMASIN 38

Index 4

ARTHRITIS PAIN ASSURE HAEMOLANCE ATRIPLA 43 RELIEVING 73 PLUS PEDIATRIC ATROPINE SULFATE 227,236ARTHROTEC 50 5 BLADE 104 ATROVENT 224ASSURE ID INSULINARTHROTEC 75 5 SAFETYSYRINGE/U- ATROVENT HFA 16artificial tear ointment 226 100/0.5ML/29G X 1/2" 122 AUBAGIO 233artificial tear solution 226 ASSURE ID INSULIN AUGMENTED ARTIFICIAL TEARS 226 SAFETYSYRINGE/U- BETAMETHASONE100/1ML/29G X 1/2" 122ARYMO ER 8 DIPROPIONATE 61

ASSURE II 84 AUGMENTIN 232ASACOL HD 94 ASSURE II CHECK STRIP84 AUGMENTIN ES-600 232ASCOCID-1000 163 ASSURE II CONTROL LEVEL AUGMENTIN XR 232ASCOCID-500-D 163 1 104 AURORA LANCET SUPERascorbic acid 242 ASSURE II CONTROL LEVEL THIN30G 1041/2 104ASMANEX HFA 17 AURORA LANCET THINASSURE II TEST STRIPS 84ASMANEX TWISTHALER 120 23G 104ASSURE LANCEMETERED DOSES 17 AURORA PEN NEEDLES

ASMANEX TWISTHALER 14 LANCETS 104 29GX12MM 122ASSURE LANCE LANCETSMETERED DOSES 17 AURORA PEN NEEDLES 31G ASMANEX TWISTHALER 30 21G 104 X6MM 122ASSURE LANCE PLUSMETERED DOSES 17 AURORA PEN NEEDLES 31G ASMANEX TWISTHALER 60 SAFETYLANCETS 25G 104 X8MM 122ASSURE LANCE PLUSMETERED DOSES 17 AURORA UNIFINE ASMANEX TWISTHALER 7 SAFETYLANCETS 30G 104 PENTIPS/32GX5/32" 122 METERED DOSES 17 ASSURE LANCETS 104 AURORA UNIFINE ASPERCREME/ALOE 73 ASSURE PLATINUM TEST PENTIPS/MINI/31GX3/16" 122 aspirin 8 STRIPS 84 AURYXIA 95

ASSURE PRISM CONTROLaspirin buffered (cal carb-mag AUTO-LANCET 104LEVEL 1/2 104carb-mag oxide) 8 ASSURE PRISM MULTI TEST AUTO-LANCET MINI 104 ASPIRIN LOW DOSE 8 STRIPS 84 AUTOLET IMPRESSION aspirin-acetaminophen- ASSURE PRO CONTROL LANCING DEVICE 104 caffeine 7 LEVEL1/2 104 AUTOLET LANCING ASPIRIN-CAFFEINE- ASSURE PRO TEST DEVICE 104 DIHYDROCODEINE 10 STRIPS 84 AUTOLET MINI 104 aspirin-dipyridamole 96 ASTEPRO 224 AUTOLET PLUS 104ASSURE 3 CONTROL LEVEL AT LAST CONTROL AUVI-Q 2421/2 103 SOLUTION 104 AVALIDE 35ASSURE 3 TEST STRIPS 84 AT LAST LANCETS 104 ASSURE 4 CONTROL LEVEL AVANDIA 27AT LAST TEST STRIPS 841/2 103 AVAPRO 34ATACAND 34ASSURE 4 TEST STRIPS 84 AVAR LS CLEANSER 55ATACAND HCT 35ASSURE COMFORT LANCETS AVAR-E LS 55ULTRA THIN 28G 103 ATELVIA 91 AVEENO ACTIVE NATURALSASSURE COMFORT LANCETS atenolol 47 DAILY MOISTURIZING BODYULTRA THIN 30G 103 atenolol & chlorthalidone 35 YOGURT 65ASSURE DOSE NORMAL

ATIVAN 15 AVEENO ACTIVE NATURALSCONTROL 104 DAILY MOISTURIZING BODYASSURE DOSE NORMAL/HIGH ATLAS COLORED CONTROL 104 LUBRICATEDCONDOM 101 YOGURT/APRICO 65

AVEENO ACTIVE NATURALSASSURE HAEMOLANCE PLUS ATLAS LUBRICATED SKIN RELIEF MOISTUREHIGH FLOW 18G 104 CONDOM 101 REPAIR 65ASSURE HAEMOLANCE PLUS ATLAS LUBRICATED

LOW FLOW 25G 104 CONDOM/SPERMICIDE 101 AVEENO DAILY MOISTURIZINGSPF 15 65ASSURE HAEMOLANCE PLUS atomoxetine hcl 3 AVEENO INTENSE RELIEFMICRO FLOW 28G 104 atorvastatin calcium 33 HAND 65ASSURE HAEMOLANCE PLUS ATRALIN 55NORMAL FLOW 21G 104

Index 5

AVEENO POSITIVELY B-1 242 BASIS OVERNIGHT 74 AGELESS LIFT & FIRM EYE 65 AVEENO POSITIVELY AGELESS NIGHT 65 AVEENO POSITIVELY AGELESSFIRMING BODY 65 AVEENO POSITIVELY AGELESSSKIN STRENGTHENING BODY CREAM 65 AVEENO POSITIVELY AGELESSSKIN STRENGTHENING HAND CREAM 65 AVEENO POSITIVELY NOURISHING 24-HOUR ULTRA-HYDRATING 65 AVEENO POSITIVELY NOURISHING ENERGIZING65 AVEENO POSITIVELY RADIANT 65 AVEENO POSITIVELY RADIANTOVERNIGHT HYDRATING FACIAL MOISTURI 66 AVEENO STRESS RELIEF MOISTURIZING 66 AVELOX 93 AVELOX ABC PACK 93

B-100 COMPLEX 161 B-12 DOTS 96 b-complex vitamins 160 b-complex w/ c & calcium 161 b-complex w/ c & e + zn 161 b-complex w/ c & folicacid 161 b-complex w/ folic acid 162 b-complex w/ minerals 163 b-complex w/biotin & folicacid 162 B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X5/16" 122 B-D INSULIN SYRINGE ULTRAFINE II/0.5ML/31G X5/16" 122 B-D INSULIN SYRINGE ULTRAFINE II/1ML/31G X5/16" 122 B-D INSULIN SYRINGE ULTRAFINE/0.3ML/30G X1/2" 122 B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X1/2" 122 BACIGUENT 58

BASLE 66 BAYER BREEZE 2 HIGH CONTROL 104 BAYER BREEZE 2 LOW CONTROL 104 BAYER BREEZE 2 NORMAL CONTROL 104 BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS 84 BAYER CONTOUR HIGH CONTROL 104 BAYER CONTOUR LOW CONTROL 104 BAYER CONTOUR NEXT BLOODGLUCOSE TEST 84 BAYER CONTOUR NEXT CONTROL LEVEL 1 104 BAYER CONTOUR NEXT CONTROL LEVEL 2 104 BAYER CONTOUR NORMAL CONTROL 104 BAYER MICROLET 2 LANCING DEVICE 104 BAYER MICROLET LANCETS 104 BAZA CLEANSE & PROTECT 74 BD LO-DOSE INSULIN SYRINGE MICROFINE

AVODART AVONEX AVONEX PEN

95 233 233

BACITRACIN bacitracin (topical) bacitracin zinc

228 58 58

IV/0.5ML/28G X 1/2" 122 BD AUTOSHIELD 29G X 5/16" 122 BD INSULIN SYRINGE LUER-

AXERT AXIRON AYGESTIN AYR NASAL DROPS AZASAN AZASITE

154 12

232 223 158 228

bacitracin-poly-neomycin-hc229

bacitracin-polymyxin b 58 bacitracin-polymyxin b(ophth) 228 baclofen 223 BACMIN 164

LOK/U-100/1MLBD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X 1/2"BD INSULIN SYRINGE MICROFINE IV/U-100/0.5ML/28G X 1/2"BD INSULIN SYRINGE

122

122

122

azathioprine azelastine hcl azelastine hcl (ophth) AZELEX AZILECT

158 224 230 55 40

BACTRIM BACTRIM DS BACTROBAN BAL-CARE DHA balsalazide disodium

14 14 58

213 94

MICROFINE IV/U-100/1ML/27GX 5/8" 123 BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/28GX 1/2" 123 BD INSULIN SYRINGE

AZITHROMYCIN azithromycin

100 100

BANZEL BARACLUDE

19 46

MICROFINE/U-100/0.3ML/28G X1/2" 123 BD INSULIN SYRINGE

AZOLEN TINCTURE AZOPT AZOR AZULFIDINE AZULFIDINE EN-TABS

58 230 35 94 94

BARIATRIC FUSION BASAGLAR KWIKPEN BASIC AM BASIC PM BASIS FACIAL

164 27

164 164

MICROFINE/U-100/0.5ML/28G X1/2" 123 BD INSULIN SYRINGE MICROFINE/U-100/1ML/27G X5/8" 123 BD INSULIN SYRINGE

b complex w/ c 161 MOISTURIZER 74 MICROFINE/U-100/1ML/28G X1/2" 123

Index 6

BD INSULIN SYRINGE BD INSULIN SYRINGE BD PEN NEEDLES SAFETYGLIDE/0.5ML/29G X ULTRAFINE/U-100/1ML/29G X SHORT/ULTRAFINE/31G X1/2" 123 1/2" 123 5/16" 124 BD INSULIN SYRINGE BD INSULIN SYRINGE BD SAFETY-GLIDE INSULIN SAFETYGLIDE/1ML/29G X ULTRAFINE/U-100/1ML/30G X SYRINGE/0.5ML/29G X1/2" 123 1/2" 123 1/2" 124 BD INSULIN SYRINGE BD INSULIN SYRINGE BD SAFETY-LOK INSULIN SAFETYGLIDE/U- ULTRAFINE/U-100/1ML/31G X SYRINGE/PERM100/0.3ML/31G X 5/16" 123 15/64" 124 NEEDLE/UF/1ML/29G XBD INSULIN SYRINGE SLIP BD INSULIN SYRINGE 1/2" 124 TIP/U-100/1ML 123 ULTRAFINE/U-100/1ML/31G X BD SAFETYGLIDE INSULIN BD INSULIN SYRINGE 5/16" 124 SYSYRINGE/0.5ML/30G XULTRAFINE HALF- BD INSULIN 5/16" 124 UNIT/0.3ML/31G X 5/16" 123 SYRINGE/DETACHABLE BD SWABS SINGLE USE 119 BD INSULIN SYRINGE NEEDLE/U-100/1ML/25G X BD SWABS SINGLE USEULTRAFINE 1" 124 BUTTERFLY 119II/SHORT/0.5ML/31G X BD INSULIN BD ULTRA-FINE MICRO PEN5/16" 123 SYRINGE/DETACHABLE NEEDLES 6MM X 32G 124BD INSULIN SYRINGE NEEDLE/U-100/1ML/25G X BECONASE AQ 224ULTRAFINE II/SHORT/1ML/31G 5/8" 124 BELBUCA 11X 5/16" 123 BD INSULIN BD INSULIN SYRINGE SYRINGE/DETACHABLE BELSOMRA 98 ULTRAFINE/0.3ML/30G X NEEDLE/U-100/1ML/26G X BENADRYL ALLERGY 31 1/2" 123 1/2" 124 BENADRYL ALLERGYBD INSULIN SYRINGE BD INSULIN SYRINGE/U- CHILDRENS 31ULTRAFINE/0.3ML/31G X 100/0.5ML/30G X 1/2" 124 BENADRYL EXTRA5/16" 123 BD INSULIN SYRINGE/U- STRENGTH 60BD INSULIN SYRINGE 100/1ML/27G X 1/2" 124 benazepril &ULTRAFINE/0.5ML/30G X BD INSULIN SYRINGE/U- hydrochlorothiazide 351/2" 123 100/1ML/28G X 1/2" 124 benazepril hcl 34BD INSULIN SYRINGE BD INTEGRA INSULIN

BENGAY GREASELESS 73ULTRAFINE/0.5ML/31G X SYRINGE/U-100/1ML/29G X5/16" 123 1/2" 124 BENGAY ULTRA BD INSULIN SYRINGE BD INTEGRA STRENGTH 73 ULTRAFINE/1ML/30G X SYRINGE/RETRACTING BENICAR 34 1/2" 123 NEEDLE/1ML/25G X 1" 124 BENICAR HCT 35BD INSULIN SYRINGE BD LANCET DEVICE 104 BENSAL HP 73ULTRAFINE/1ML/31G X BD LANCET ULTRAFINE5/16" 123 30G 104 BENTYL 236 BD INSULIN SYRINGE BENZAC AC WASH 55BD LANCET ULTRAFINEULTRAFINE/U-100/0.3ML/29G X 33G 104 BENZACLIN 551/2" 123 BD MICROTAINER BENZACLIN WITH PUMP 55BD INSULIN SYRINGE LANCETS 104ULTRAFINE/U-100/0.3ML/30G X BD PEN BENZAMYCIN 55 1/2" 123 NEEDLE/MINI/ULTRAFINE/31 BENZEFOAM 55 BD INSULIN SYRINGE G X 3/16" 124 BENZEFOAM ULTRA 55ULTRAFINE/U-100/0.3ML/31G X BD PEN BENZEFOAMULTRA 555/16" 123 NEEDLE/NANO/ULTRAFINE/3BD INSULIN SYRINGE 2G X 4MM 124 benzocaine (dental) 159 ULTRAFINE/U-100/0.5ML/29G X BD PEN benzocaine-menthol (mouth-1/2" 123 NEEDLE/SHORT/ULTRAFINE/ throat) 159 BD INSULIN SYRINGE 31G X 5/16" 124 benzonatate 53ULTRAFINE/U-100/0.5ML/30G X BD PEN benzoyl peroxide 551/2" 123 NEEDLE/ULTRAFINE/29G XBD INSULIN SYRINGE BENZOYL PEROXIDE 5512.7MM 124ULTRAFINE/U-100/0.5ML/31G X BD PEN benzoyl peroxide 55 5/16" 123 NEEDLE/ULTRAFINE/29GX1/2 benzoyl peroxide-

" 12.7MM 124 erythromycin 55

Index 7

benztropine mesylate 39 BIOTENE DRY MOUTH 120 BREATHERITE BEPREVE 230 BIOTENE DRY MOUTH COLLAPSIBLESPACER W/

NEONATE MASK 150GENTLEFORMULA 120BESIVANCE 228 BREATHERITE RIGIDBIOTENE DRY MOUTHBETA CARE 66 MOISTURIZING SPRAY 160 SPACERW/MASK 150

BREATHERITE W/LARGEBETA CAROTENE 242 BIOTENE PBF DRY MASK 150MOUTH 120beta carotene 242 BREATHERITE W/MEDIUMbiotin 242BETA XMA 66 MASK 150BIOTIN PLUS KERATIN 219BETAGAN 227 BREATHERITE W/SMALL

betamethasone dipropionate BIOVOL 164 MASK 151 (topical) 61 bisacodyl 99 BREO ELLIPTA 17 betamethasone dipropionate bismuth subsalicylate 28 BREVICON-28 50 augmented 61 bisoprolol & BRILINTA 96betamethasone valerate 61 hydrochlorothiazide 35 brimonidine tartrate 228BETAPACE 47 bisoprolol fumarate 47 BRINTELLIX 23BETAPACE AF 47 BLEPH-10 228 BRISDELLE 234BETASAL 73 BLEPHAMIDE 229 BRIVIACT 19BETASERON 233 BLEPHAMIDE S.O.P. 229 BROMFENAC 230betaxolol hcl 47 BLOOD GLUCOSE TEST bromfenac sodium (ophth) 230STRIPS 84betaxolol hcl (ophth) 227 BLOOD GLUCOSE TEST bromocriptine mesylate 40bethanechol chloride 239 STRIPS PREMIUM 84 brompheniramine &BETHKIS 4 BLUE-EMU SUPER phenyleph 53 BETIMOL 227 STRENGTH 73 brompheniramine &

BODI PROTECT 74 pseudoeph 53BETOPTIC-S 227 BONE DENSITY BROMSITE 230BEVESPI AEROSPHERE 17 BUILDER 157 BROVANA 17BEXSERO 239 BONIVA 91 BUBBLES THE FISH II

BEYAZ 50 BOSULIF 38 PEDIATRIC MASK/PVC 151 BG STAR BLOOD GLUCOSE BOUDREAUXS BABY BUTT budesonide (inhalation) 17TEST 84 SMOOTH DRY SKIN 66 budesonide (nasal) 224BIAXIN 100 BP CLEANSING WASH 56 BUFFERIN 8bicalutamide 38 BP FOLINATAL PLUS B 213 BULLSEYE MINI SAFETYBIDIL 49 BP MULTINATAL PLUS 213 LANCETS 104 BIMATOPROST 230 BULLSEYE SAFETYBPROTECTED PEDIA TRI-

LANCETS 105BINOSTO 91 VITE 212 bumetanide 90BIO-35 GLUTEN-FREE 164 BRAIN 219

BRAIN MIGHT/DHA & CO BUMEX 90BIO-35 IRON FREE 164 Q10 219 BUNAVAIL 11BIOBRANE 10"X15" 77 BREATHERITE 150 BUPRENORPHINE 11,12BIOBRANE 15"X20" 77 BREATHERITE buprenorphine hcl 11BIOBRANE 5"X15" 77 COLLAPSIBLEADULT buprenorphine hcl-naloxone hclBIOBRANE 5"X5" 77 SPACER W/MASK 150 dihydrate 11BREATHERITEBIOBRANE-L 10"X15" 77 bupropion hcl 22COLLAPSIBLECHILD SPACERBIOBRANE-L 5"X15" 78 W/MASK 150 bupropion hcl (smokingBIOBRANE-L 5"X5" 78 BREATHERITE deterrent) 234

COLLAPSIBLEINFANT BURIED TREASURE ACTIVEBIOCAL 164 SPACER W/MASK 150 55PLUS SENIOR

bioflavonoid products 163 BREATHERITE COMPLEX 164 BIOSCANNER GLUCOSE TEST COLLAPSIBLESMALL CHILD buspirone hcl 15STRIPS 84 SPACER W/MASK 150 butalbital-acetaminophen 7BIOSUPP 164 butalbital-acetaminophen-BIOTECT PLUS 164 caffeine 7

Index 8

butalbital-acetaminophen- calcium citrate 156 carbidopa-levodopa 40 caffeine w/ codeine 11 calcium citrate-vitamin d 156 CARBIDOPA/LEVODOPA/ENTAbutalbital-aspirin-caffeine 7 CAPONE 40CALCIUM GLUCONATE 156butalbital-aspirin-caffeine CARBOFLEX ODOR CONTROL

CALCIUM PNV 213w/cod 11 DRESSING 78 BUTALBITAL/ASPIRIN/CAFFEIN calcium polycarbophil 99 carboxymethylcellulose sodiumE 7 (ophth) 226calcium w/ vitamin d 156 butenafine hcl 58 carboxymethylcellulose-glycerincalcium-magnesium-zinc 156 butorphanol tartrate 12 226

CALCIUM/MAGNESIUM/ZINC carboxymethylcellulose-BUTRANS 12 157 hypromellose 226

CALCIUM/MAGNESIUM/ZINC/BYDUREON 27 CARDENZ 208VITAMIN D3 157BYDUREON BCISE 27 CARDIO TONE 219CALQUENCE 38BYDUREON PEN 27 CARDIOCOM LANCINGCALTRATE 600+D 156 DEVICE 105BYETTA 27 CAM 66 CARDIOTEK-RX 89BYSTOLIC 47 CAMBIA 154 CARDIZEM 48BYVALSON 35 camphor & menthol 60 CARDIZEM CD 48C-BUFF 164 camphor-eucalyptus-menthol CARDIZEM LA 48C-NATE DHA 213 54 CA-PLUS 219 camphor-eucalyptus-menthol- CARDURA 34

turpentine oil-white CARDURA XL 95CABOMETYX 38 petrolatum 54 CAREFINE PEN NEEDLECADUET 49 camphor-menthol-methyl 32GX4MM 124 CAFCIT 3 salicylate 73 CAREFINE PEN NEEDLES CAFERGOT 154 CANASA 94 29GX1/2" 124

CAREFINE PEN NEEDLEScaffeine 3 candesartan cilexetil 34 30GX5/16" 124candesartan cilexetil-caffeine citrate 3 CAREFINE PEN NEEDLEShydrochlorothiazide 35CAL MAG ZINC +D3 157 31GX6MM 124capecitabine 37 CAREFINE PEN NEEDLESCAL-DAY 1000 164 CAPEX 62 31GX8MM 124CAL-MAG-ZINC-D 157 CAREFINE PEN NEEDLESCAPHOSOL 160CAL-MAG-ZINC-D3 157 32GX5MM 124CAPITAL/CODEINE 11 CAREFINE PEN NEEDLESCALAN 48 CAPRELSA 38 32GX6MM 124CALAN SR 48 capsaicin 73 CAREONE ADVANCED calcipotriene 60 LANCINGDEVICE 105captopril 34calcipotriene-betamethasone CAREONE BLOOD GLUCOSECAPTOPRIL/HYDROCHLOROdipropionate 62 TEST STRIPS/PREMIUM 84THIAZIDE 35calcitonin (salmon) 91 CAREONE BLOOD GLUCOSECAPZASIN-HP 74 TEST STRIPS/VALUE 84CALCITRIOL 60 CARAC 60 CAREONE INSULINcalcitriol 92 CARAFATE 237 SYRINGES/0.3ML/30G Xcalcium 156 1/2" 124CARB-O-LAN 10 66 CAREONE INSULINCALCIUM 156 calcium acetate (phosphate CARB-O-LAN 20 66 SYRINGES/0.3ML/31G Xbinder) 95 CARB-O-PHILIC/20 66 5/16" 124

CAREONE INSULINCALCIUM CARBONATE 13 CARB-O-SAL 5 66 SYRINGES/0.5ML/30G X

calcium carbonate 155 carbamazepine 19 1/2" 125 calcium carbonate (antacid) 13 CARBAMAZEPINE 19 CAREONE INSULIN calcium carbonate- carbamazepine 19 SYRINGES/0.5ML/31G Xcholecalciferol 155,156 5/16" 125carbamide peroxide (otic) 231 CAREONE INSULINcalcium carbonate- CARBATROL 19ergocalciferol 156 SYRINGES/1ML/30G Xcalcium carbonate-vitamin carbidopa 39 1/2" 125 d 156

Index 9

CAREONE INSULIN CARNITOR 92 CENTRUM FLAVOR SYRINGES/1ML/31GX5/16"

125 CAREONE LANCET THIN 105 CAREONE LANCET ULTRA THIN 105 CAREONE UNIFINE PENTIPS

CARNITOR SF 92 CAROSPIR 90 CARRAGAUZE 2 X 2 78 CARRAGAUZE 4 X 4 78 CARRINGTON MOISTURE

BURST 165 CENTRUM FLAVOR BURST ADULT 165 CENTRUM FLAVOR BURST KIDS 165 CENTRUM MEN 165

29GX12MM 125 BARRIER 74 CENTRUM MULTIGUMMIES CAREONE UNIFINE PENTIPS CARRINGTON MOISTURE ADULTS 165 31GX5MM 125 CAREONE UNIFINE PENTIPS 31GX6MM 125 CAREONE UNIFINE PENTIPS

BARRIER/ZINC carteolol hcl (ophth) carvedilol

74 227 47

CENTRUM MULTIGUMMIES MEN 165 CENTRUM MULTIGUMMIES WOMEN 165

31GX8MM 125 CAREONE UNIFINE PENTIPS PEN NEEDLES 32GX4MM 125 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES

carvedilol phosphate CASODEX CATAPRES CATAPRES-TTS-1

47 38 34 34

CENTRUM MULTIVITAMIN FLAVOR BURST DRINK 165 CENTRUM PERFORMANCE 219 CENTRUM SILVER 166

29GX12MM 125 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX5MM 125 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX6MM 125 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX8MM 125 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 32GX4MM 125 CARESENS CONTROL A

CATAPRES-TTS-2 CATAPRES-TTS-3 CAYSTON CEDAX cefaclor CEFACLOR CEFACLOR ER cefadroxil cefdinir cefixime cefpodoxime proxetil

34 34 14 50 49 49 49 49 50 50 50

CENTRUM SILVER 50+MEN 165 CENTRUM SILVER 50+WOMEN 165 CENTRUM SILVER ADULT 50+ 166 CENTRUM SILVER ULTRA MENS 166 CENTRUM SILVER ULTRA WOMENS 166 CENTRUM SPECIALIST ENERGY 219 CENTRUM SPECIALIST HEART 166

SOLUTION 105 CARESENS N BLOOD GLUCOSETEST STRIPS 84 CARETOUCH ALCOHOL PREP PADS 120 CARETOUCH LANCING DEVICEWITH EJECTOR 105 CARETOUCH PEN NEEDLES 31G X 6 MM 125 CARETOUCH PEN NEEDLES

cefprozil CEFTIBUTEN CEFTIN ceftriaxone sodium cefuroxime axetil CELEBREX celecoxib CELEXA

49 50 50 50 50 5 5

23

CENTRUM SPECIALIST IMMUNE SUPPORT 166 CENTRUM SPECIALIST VISION 166 CENTRUM ULTRA MENS 166 CENTRUM ULTRA WOMENS 166 CENTRUM VITAMINTS 166 CENTRUM WOMEN 166

31GX 5MM 125 CARETOUCH PEN NEEDLES 31GX 8MM 125 CARETOUCH PEN NEEDLES 32GX 4MM 125 CARETOUCH PEN NEEDLES 32GX 5MM 125 CARETOUCH TWIST LANCETS 28G 105 CARETOUCH TWIST LANCETS 30G 105 CARETOUCH TWIST LANCETS 33G 105 carisoprodol 223 carisoprodol w/ aspirin 223 CARMOL 20 65

CELLCEPT 158 CELLULAR SECURITY 165 CELONTIN 22 CEMILL PLUS 163 CENTANY 58 CENTANY AT 58 CENTRATEX 97 CENTRAVITES 50 PLUS 165 CENTRAVITES ADULTS 165 CENTRUM 165,166 CENTRUM ADULTS 165 CENTRUM CARDIO 165

CEPACOL SORE THROAT159 CEPACOL SORE THROAT EXTRA STRENGTH 159 CEPACOL SORE THROAT EXTRASTRENGTH 159 CEPACOL SORE THROAT MAXIMUM NUMBING 159 CEPASTAT 160 cephalexin 49 CEPHALEXIN 49 CERALYTE 70 156 CERASPORT 156 CERASPORT EX1 156 CERAVE 66

Index 10

CERAVE AM SPF 30 66 CERAVE PM 66 CERAVE RENEWING SA 66 CERAVE SA RENEWING 66 CEREBYX 21 CEROVITE ADVANCED FORMULA 166 CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS 166 CESAMET 29 CETAPHIL 66 CETAPHIL DAILY ADVANCE ULTRA HYDRATING 66 CETAPHIL DAILY FACIAL MOISTURIZER 66 CETAPHIL DERMACONTROL MOISTURIZER/SPF 30 66 CETAPHIL MOISTURIZING 66 CETAPHIL RESTORADERM 66 CETAPHIL THERAPEUTIC

CHLOR-TRIMETON 30 CHLOR-TRIMETON ALLERGY 30 chlordiazepoxide hcl 15 chlorhexidine gluconate 43 chlorhexidine gluconate(mouth-throat) 159 CHLOROQUINE PHOSPHATE 36 chloroquine phosphate 36 CHLOROTHIAZIDE 90 chlorothiazide 90 chlorpheniramine &pseudoeph 53 chlorpheniramine maleate 31 chlorpheniramine-acetaminophen 53 CHLORPROMAZINE HCL 42 chlorpromazine hcl 42 CHLORPROPAMIDE 28 chlorthalidone 90

ciprofloxacin-ciprofloxacinhcl citalopram hydrobromide CITRACAL + D3 MAXIMUM CITRACAL MAXIMUM CITRACAL PLUS CITRANATAL 90 DHA CITRANATAL ASSURE CITRANATAL B-CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX CITRUCEL FIBER LAXATIVE CLARIFOAM EF CLARINEX CLARITHROMYCIN clarithromycin CLARITIN

93 23

156 156 157 213 213 213 213 213 213

99 56 31

100 100 31

HAND 66 chlorzoxazone 223 CLARITIN REDITABS 31 cetirizine hcl 31 CHOICEFUL CLARITIN-D 24 HOUR 53 CETRAXAL CHANTIX CHANTIX CONTINUING

231 234

MULTIVITAMIN CHOLBAM cholecalciferol

166 93

242

CLASS ACT LUBRICATED 101 CLASSIC PRENATAL 213 CLEAN & CLEAR ADVANTAGE

MONTHPAK 234 CHANTIX STARTING MONTH PAK 234 CHAPSTICK OVERNIGHT 74 CHAPSTICK ULTRA MOISTUREDAYTIME FORMULA 74 CHAPSTICK ULTRASMOOTH FORTIFY 74 CHAPSTICK ULTRASMOOTH

cholestyramine cholestyramine light choline fenofibrate CICLODAN CREAM KIT ciclopirox ciclopirox olamine cilostazol CILOXAN

32 32 33 58 58 58 96

228

3-IN-1 EXFOLIATING CLEANSER 56 CLEANLET LANCETS 28G105 clemastine fumarate 31 CLEOCIN 14,241 CLEOCIN PEDIATRIC GRANULES 14 CLEOCIN-T 56 CLEVER CHEK AUTO-CODE

NOURISH 74 CHAPSTICK ULTRASMOOTH REJUVENATE 74 CHAPSTICK ULTRASMOOTH

cimetidine CIMETIDINE HCL cimetidine hcl

236 236 236

TEST STRIPS 84 CLEVER CHEK AUTO-CODE VOICE TEST STRIPS 84 CLEVER CHEK LANCETS

SOOTHE CHEK-STIX COMBO PAK URINALYSIS CONTROL CHEK-STIX CONTROL CHEMET CHEMSTRIP-K CHENODAL CHERACOL PLUS CHERACOL SORE THROAT CHERACOL-D COUGH CHILDRENS ADVIL

74

84 84 29 84 93 53

159 53 5

CIMZIA CIMZIA STARTER KIT CIPRO CIPRO HC CIPRO XR CIPRODEX ciprofloxacin CIPROFLOXACIN CIPROFLOXACIN HCL ciprofloxacin hcl ciprofloxacin hcl (ophth)

94 94 93

231 93

231 93

231 93 93

228

ULTRATHIN 105 CLEVER CHEK LANCETS ULTRATHIN 30G 105 CLEVER CHEK TEST STRIPS 84 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/ADULT LARGE151 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM 151 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/SMALL 151

CHILDRENS MOTRIN 5

Index 11

CLEVER CHOICE AUTO-CODE CLEVER CHOICE COMFORT CLINICAL NUTRIENTS 50-PLUS PRO TEST STRIPS 84 EZPEN NEEDLES MEN 166 CLEVER CHOICE COMFORT 29GX12MM 126 CLINICAL NUTRIENTS EZINSULIN PEN NEEDLES CLEVER CHOICE COMFORT ANTIOXIDANT 167 31GX8MM 125 EZPEN NEEDLES CLINICAL NUTRIENTS FOR CLEVER CHOICE COMFORT 31GX5MM 126 FEMALE TEENS 167 EZINSULIN CLEVER CHOICE COMFORT CLINICAL NUTRIENTS FOR SYRINGE/0.3ML/29G X EZPEN NEEDLES MALE TEENS 167 1/2" 125 31GX6MM 126 CLINICAL NUTRIENTS FOR CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT MEN 167 EZINSULIN EZPEN NEEDLES CLINICAL NUTRIENTS FOR SYRINGE/0.3ML/30G X 31GX8MM 126 WOMEN 167 1/2" 125 CLEVER CHOICE COMFORT CLN FACIAL MOISTURIZER CLEVER CHOICE COMFORT EZPEN NEEDLES NOURISHING 66 EZINSULIN 32GX4MM 126 clobetasol propionate 62 SYRINGE/0.3ML/30G X CLEVER CHOICE COMFORT clobetasol propionate emollient5/16" 125 EZPEN NEEDLES base 62 CLEVER CHOICE COMFORT 32GX5MM 126 clobetasol propionateEZINSULIN CLEVER CHOICE COMFORT emulsion 62 SYRINGE/0.3ML/31G X EZPEN NEEDLES CLOBEX 62

32GX6MM 1265/16" 125 CLOCORTOLONECLEVER CHOICE COMFORT CLEVER CHOICE GLUCOSE PIVALATE 62EZINSULIN CONTROL HIGH 105 CLOCORTOLONE PIVALATESYRINGE/0.5ML/28G X CLEVER CHOICE GLUCOSE PUMP 621/2" 125 CONTROL LOW 105 CLODERM 62CLEVER CHOICE COMFORT CLEVER CHOICE MICRO EZINSULIN TESTSTRIPS 84 CLODERM PUMP 62 SYRINGE/0.5ML/29G X CLICKFINE PEN NEEDLE clomipramine hcl 24 1/2" 125 32GX5/32" 126 clonazepam 19 CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLE clonidine hcl 34EZINSULIN UNIVERSAL/31GX1/4" 126

CLICKFINE PEN NEEDLE clonidine hcl (adhd) 3SYRINGE/0.5ML/30G X1/2" 125 UNIVERSAL/31GX5/16" 126 clopidogrel bisulfate 96

CLICKFINE PENCLEVER CHOICE COMFORT clorazepate dipotassium 15EZINSULIN NEEDLES/31GX1/4" 126

CLICKFINE PEN CLORPRES 35SYRINGE/0.5ML/30G X5/16" 125 NEEDLES/31GX5/16" 126 CLOSERCARE 105

CLICKFINE UNIVERSAL PENCLEVER CHOICE COMFORT clotrimazole 159NEEDLES 31GX5/16" 126EZINSULIN clotrimazole (topical) 58SYRINGE/0.5ML/31G X CLIMARA 92 clotrimazole vaginal 2415/16" 126 CLINDAGEL 56

CLEVER CHOICE COMFORT clotrimazole w/clindamycin hcl 14 betamethasone 59EZINSULIN clindamycin palmitateSYRINGE/1.0ML/30G X clozapine 42hydrochloride 141/2" 126 CLOZAPINE ODT 42clindamycin phosphateCLEVER CHOICE COMFORT (topical) 56 CLOZARIL 42EZINSULIN SYRINGE/1ML/28G clindamycin phosphate CO MONITOR REPLACEMENTX 1/2" 126 vaginal 241 TPIECES 151CLEVER CHOICE COMFORT clindamycin phosphate-benzoyl CO-NATAL FA 213EZINSULIN SYRINGE/1ML/29G peroxide 56X 1/2" 126 COAGUCHEK LANCETS 105clindamycin phosphate-benzoylCLEVER CHOICE COMFORT peroxide (refrigerate) 56 coal tar extract 76 EZINSULIN SYRINGE/1ML/30G clindamycin phosphate- COARTEM 36X 5/16" 126 tretinoin 56 COCOA BUTTER 66CLEVER CHOICE COMFORT CLINDESSE 241EZINSULIN SYRINGE/U- COCOA BUTTER HAND &

CLINICAL NUTRIENTS 45-100/1ML/31GX5/16" 126 BODYLOTION 66PLUS WOMEN 166 COCONUT OIL BEAUTY 66

Index 12

cod liver oil 221 COMFORT ASSIST INSULIN CONTREET SYRINGE/1ML/29G X HYDROCOLLOID 78COD LIVER OIL 222 1/2" 126 CONTROL AST 85COD LIVER OIL FOR KIDS221 COMFORT ASSIST INSULIN CONTROL SOLUTION

CODEINE SULFATE 8,9 SYRINGE/1ML/30G X NORMAL 1055/16" 127codeine sulfate 9 CONTROL TEST STRIPS 85COMFORT ASSIST INSULINCOLACE 100 CONZIP 9SYRINGE/1ML/31G X

COLAZAL 94 5/16" 127 COOL BLOOD GLUCOSE TEST COLCHICINE 96 COMFORT ASSURED STRIPS 85

COOL CONTROL SOLUTIONLANCETS MICRO THINcolchicine w/ probenecid 96 A 10533G 105COLCRYS 96 COOL CONTROL SOLUTIONCOMFORT ASSURED B 105COLESTID 32 LANCETS SUPER THIN

28G COPAXONECOLESTID FLAVORED 32 105 233

colestipol hcl 32 COMFORT LANCETS 105 COPEGUS 46 COMFORT-AID 1.5"X2.5" 78 CORDARONE 16COLGATE PLATINUM 121 COMPACT SPACE CORDRAN 62COLY-MYCIN S 231 CHAMBER/ANTI-STATIC CORDRAN TAPE 62COLYTE-FLAVOR PACKS 99 151 COREG 47COMBIGAN 227 COMPACT SPACE

COMBIPATCH 92 CHAMBER/ANTI- COREG CR 47 STATIC/LARGE MASK 151 CORGARD 47COMBIVENT RESPIMAT 17 COMPACT SPACE CORICIDIN HBP COLD &COMBIVIR 43 CHAMBER/ANTI- FLU 53

COMETRIQ 38 STATIC/MEDIUM MASK 151 CORLANOR 49COMPACT SPACECOMFEEL PLUS CLEARDRESSING 78 CHAMBER/ANTI- CORTEF 52 COMFEEL PLUS STATIC/SMALL MASK 151 CORTENEMA 12 CONTOURDRESSING 78 COMPLERA 43 CORTISONE ACETATE 52 COMFEEL PLUS COMPLETE FORMULATION CORTISPORIN-TC 231DRESSING 78 D3000 167 CORVITE 167COMFEEL PLUS COMPLETE FORMULATION TRIANGLEDRESSING 78 MULTIVITAMIN CORZIDE 35 COMFEEL PLUS ULCER SUPPLEMENT 167 COSENTYX 60DRESSING 78 COMPLETE NATAL DHA213 COSENTYX SENSOREADYCOMFEEL PLUS COMPLETENATE 213 PEN 60ULCERDRESSING 78 COSOPT 227COMFEEL ULCER COMPOUND W 73 CAREDRESSING 78 COMPOUND W MAXIMUM COSOPT PF 227 COMFORT ASSIST INSULIN STRENGTH 73 COTELLIC 38 SYRINGE 0.3ML/29G X COMTAN 39 COUMADIN 181/2" 126 CONCEPT DHA 213 COZAAR 34COMFORT ASSIST INSULIN CONCEPT OB 213SYRINGE/0.3ML/30G X CREON 89 5/16" 126 CONCEPTIONXR MOTILITY CRESEMBA 30COMFORT ASSIST INSULIN SUPPORT FORMULA 167 CREST TARTARSYRINGE/0.3ML/31G X CONCERTA 3 CONTROL 1215/16" 126 CONDYLOX 73 CREST TARTARCOMFORT ASSIST INSULIN CONE MASK 151 CONTROL/BAKING SODASYRINGE/0.5ML/29G X TOOTHPASTE 121CONTREET FOAM 781/2" 126 CREST TOOTHPASTE 121COMFORT ASSIST INSULIN CONTREET FOAM

CRESTSYRINGE/0.5ML/30G X CAVITY 78 TOOTHPASTE/REGULAR 1215/16" 126 CONTREET FOAM HEEL 78 CRESTCOMFORT ASSIST INSULIN CONTREET FOAM TOOTHPASTEREGULAR 121SYRINGE/0.5ML/31G X SACRAL 78 CRESTOR 335/16" 126

Index 13

CRINONE 241 CVS PREP PADS 120 dantrolene sodium 223 CRITIC-AID CLEAR MOISTUREBARRIER 74 CRIXIVAN 44 cromolyn sodium 16 cromolyn sodium (nasal) 224 cromolyn sodium (ophth) 230 CU-PLUS 219 CUPRIMINE 158 CURITY ALCOHOL PREPS/MEDIUM 2 PLY 120 CURITY ALCOHOL SWABS 120 CURITY HEAVY DRAINAGE PACK 78 CURITY SALINE DRESSING 8"X4" 78 CURITY SODIUM CHLORIDE DRESSING 6"X6-3/4" 78 CUTIVATE 62 CVS ADVANCED GLUCOSE

CVS PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER 73 CVS SPECTRAVITE ADULT 50+ 167 CVS SPECTRAVITE ADULT GUMMIES 167 CVS SPECTRAVITE ULTRA MEN50+ 167 CVS SPECTRAVITE ULTRA MENS HEALTH 167 CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR 167 CVS SPECTRAVITE ULTRA WOMEN 167 CVS SPECTRAVITE ULTRA WOMENS HEALTH 167 CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR 167 CVS THERAPEUTIC MAXIMUM STRENGTH 73

dapsone 14 dapsone (topical) 56 darifenacin hydrobromide 239 DAYPRO 5 DAYTRANA 3 DDAVP 92 DEBROX 231 DECARA 242 DECON-A 53 DECUBI-VITE 167 DEKAS BARIATRIC 167 DEKAS ESSENTIAL 208 DEKAS PLUS 167,168 DELZICOL 94 DEMADEX 90 demeclocycline hcl 235 DEMEROL 9

METER TEST STRIPS 85 CVS ULTRA THIN DENAVIR 61 CVS AIRSHIELD IMMUNITY LANCETS 105 DENOREX EXTRA STRENGTH SUPPORT CVS ALCOHOL PREP SWABS CVS ALCOHOL SWABS CVS COD LIVER OIL CVS DAILY ULTRA MOISTURELOTION

167

120 120 222

67

cyanocobalamin CYCLESSA cyclobenzaprine hcl CYCLOGYL cyclopentolate hcl CYCLOPHOSPHAMIDE

96 50

223 227 227 37

2-IN-1 DENTIVA DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER

73 160 22 22 22 22

CVS DIABETES HEALTH SUPPORT 167 CVS DRY MOUTH SPRAY 160

cyclosporine CYCLOSPORINE MODIFIED

158

158

DEPAKOTE SPRINKLES DEPO-PROVERA CONTRACEPTIVE

22

52 CVS GLUCOSE 26 CVS HAIR/SKIN/NAILS 219 CVS HDYROCORTISONE ACETATE 62 CVS LANCETS 21G 105 CVS LANCETS MICRO THIN 33G 105 CVS LANCETS MICRO-THIN

cyclosporine modified (formicroemulsion) 158 CYMBALTA 24 cyproheptadine hcl 32 CYTOMEL 236 CYTOTEC 238 D-VI-SOL 242

DEPO-TESTOSTERONE DERMA-GEL 4" X 4" DERMA-SMOOTHE/FSBODY DERMA-SMOOTHE/FSSCALP DERMABASEOIL IN WATER

12 78

62

62

67 33G 105 DAFLONEX-XL 163 DERMACINRX SILAPAK 62 CVS LANCETS ORIGINAL 105 DAILY CONDITIONING DERMACINRX TICANASE CVS LANCETS THIN 26G 105 CVS LANCETS ULTRA THIN 30G 105 CVS LANCETS ULTRA-THIN 30G 105 CVS LANCING DEVICE 105 CVS MOISTURIZING CREAM 67 CVS ONE DAILY MENS 50+ ADVANCED 167

TREATMENT 67 DAILY HEART HEALTH SUPPORT 167 DAILY MULTIPLE VITAMIN PLUS IRON 164 DAILY PAK MAXIMUM MULTIVITAMIN/ASIANGINSENG EXTRACT 167 DAKLINZA 46 DALIRESP 16

PAK 224 DERMADROX 74 DERMAGAUZE DRESSING 78 DERMAGRAN HYDROPHILIC WOUND DRESSING 2"X2" 78 DERMAGRAN HYDROPHILIC WOUND DRESSING 4"X4" 78 DERMAGRAN HYDROPHILIC WOUND DRESSING 8"X4" 78 DERMAIDE ALOE 67

CVS PRENATAL 213 DANTRIUM 223

Index 14

DERMAL THERAPY EXTRA STRENGTH BODY LOTION 67 DERMAL THERAPY FACE CAREMOISTURIZING LOTION 67 DERMAL THERAPY FOOT MASSAGE 67 DERMAL THERAPY HAND ELBOW & KNEE CREAM 67 DERMAL THERAPY HEEL CARE 67 DERMALUBE DAILY MOISTURIZING LOTION 67 DERMAREST PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER 73 DERMATOP 62 DERMAVITE 168 DERMEND MOISTURIZING BRUISE FORMULA 67 DERMOTIC 231 DESCOVY 44 desipramine hcl 24 desloratadine 31 DESLORATADINE ODT 31 desmopressin acetate 92 desmopressin acetaterefrigerated 92 desmopressin acetate spray 92 desmopressin acetate sprayrefrigerated 92 DESOGEN 50 desogestrel & ethinylestradiol 50 desogestrel-ethinyl estradiol(biphasic) 50 desogestrel-ethinyl estradiol(triphasic) 50 DESONATE 62 desonide 62 DESOWEN 62 desoximetasone 62 DESOXYN 2 DESQUAM-X WASH 56 DESVENLAFAXINE ER 24 desvenlafaxine succinate 24 DETROL 239 DETROL LA 239 DEX4 26 DEX4 FAST ACTING GLUCOSE 26 DEX4 NATURALS 26 DEX4 POUCH PACK 26

DEX4 QUICK DISSOLVE GLUCOSE 26 dexamethasone 52 DEXAMETHASONE 52 dexamethasone 52 dexamethasone sodium phosphate 52 DEXAMETHASONE SODIUM PHOSPHATE 229 DEXEDRINE 2 DEXILANT 237 dexmethylphenidate hcl 3 dextroamphetamine sulfate 2 dextromethorphan-guaifenesin

53 dextrose (diabetic use) 26 DHEA 67 DHS TAR 76 DHS TAR GEL 76 DHS ZINC 61 DIABETA 28 DIABETES HEALTH PACK 168 DIABETES SUPPORT PACK 168 DIABETIC TUSSIN COUGH DROPS 160 DIABETIDERM 67 DIABETIDERM FOOT REJUVENATING 67 DIABETIDERM HAND & BODY 67 DIAMOX 90 DIASTAR EASY TEST II LANCETS 30G 105 DIASTAR EASY TEST LANCETS30G 105 DIASTAT ACUDIAL 19 DIASTAT PEDIATRIC 19 DIATRUE GLUCOSE CONTROL SOLUTION LEVEL 1 105 DIATRUE GLUCOSE CONTROL SOLUTION LEVEL 2 105 DIATRUE GLUCOSE CONTROL SOLUTION LEVEL 3 105 DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS 85 diazepam 15 DIAZEPAM 15 diazepam 15

DIAZEPAM 19 DIAZEPAM RECTAL GEL 19 dibucaine 74 dibucaine (rectal) 13 DICLEGIS 29 diclofenac potassium 5 diclofenac sodium 5 diclofenac sodium (ophth) 230 diclofenac sodium (topical) 57 diclofenac w/ misoprostol 6 dicloxacillin sodium 232 dicyclomine hcl 236 didanosine 44 DIFFERIN 56 DIFICID 101 DIFLORASONE DIACETATE 62 DIFLUCAN 30 diflunisal 8 DIGOXIN 48 digoxin 49 DIHYDROERGOTAMINE MESYLATE 154 DILANTIN 21 DILANTIN INFATABS 21 DILANTIN-125 21 DILATRATE SR 14 DILAUDID 9 diltiazem hcl 48 diltiazem hcl coated beads 48 diltiazem hcl extended release beads 48 dimenhydrinate 29 DIMETAPP COLD & ALLERGY 53 DIOVAN 34 DIOVAN HCT 35 DIPENTUM 94 diphenhydramine hcl 31 diphenhydramine hcl(sleep) 97,98 diphenhydramine-acetaminophen(sleep) 98 diphenhydramine-zinc acetate 60 diphenoxylate w/ atropine 28 DIPHENOXYLATE/ATROPINE

28 DIPROLENE 63 DIPROLENE AF 63

Index 15

dipyridamole 96 disopyramide phosphate 16 disulfiram 232 DITROPAN XL 239 DIURIL 90 divalproex sodium 22 DMAE 67

DROPLET PEN NEEDLES 29GX12MM 127 DROPLET PEN NEEDLES 31GX5MM 127 DROPLET PEN NEEDLES 31GX6MM 127 DROPLET PEN NEEDLES 31GX8MM 127 DROPLET PEN NEEDLES

DUANE READE UNIFINE PENTIPS 31G X 6MM ULTRA SHORT 127 DUANE READE UNIFINE PENTIPS 31G X 8MM SHORT 127 DUDRESS ISLAND DRESSING 4"X4" 78 DUDRESS ISLAND DRESSING

DML FORTE 67 32GX4MM 127 6"X6" 78 DROPLET PEN NEEDLESDOCTORS CHOICE DUETACT 25

BURNS/SCALDS/ABRASIONS 32GX5MM 127 DUEXIS 6DROPLET PEN NEEDLES78 DULCOLAX 10032GX6MM 127docusate calcium 100 drospirenone-ethinyl DULERA 17docusate sodium 100 estradiol 50 duloxetine hcl 24dofetilide 16 drospirenone-ethinyl estradiol- DULOXETINE HCL 24levomefolate calcium 50DOLOPHINE 9 DROSPIRENONE/ETHINYL DUO-CARE CONTROL DOME-PASTE BANDAGE 78 ESTRADIOL/LEVOMEFOLATE SOLUTION 106 donepezil hydrochloride 232 CALCIUM 50 DUO-CARE TEST STRIPS 85 DORYX 235 DROXY CREAM 67 DUOPA 40

DRUG MART ADJUSTABLEDORYX MPC 235 DUPIXENT 64 LANCING DEVICE 105dorzolamide hcl 230 DURAGESIC 9DRUG MART LANCETSdorzolamide hcl-timolol DURATION 12 HOUR 225THIN 106maleate 227 DRUG MART ON-THE-GO DURATION SPRAY 225

DOTHELLE DHA 213 LANCETS GENTLE 30G 106 DUREX EXTRA DOVONEX 60 DRUG MART UNIFINE SENSITIVE 101

PENTIPS 31GX5MM 127doxazosin mesylate 34 DUREZOL 229DRUG MART UNIFINEdoxepin hcl 24 DURLAZA 96PENTIPS29G X 12MM 127 DOXYCYCLINE 75 DRUG MART UNIFINE dutasteride 95 doxycycline (monohydrate) 235 PENTIPS31GX6MM 127 dutasteride-tamsulosin hcl 95

DRUG MART UNIFINEdoxycycline hyclate 235 DUTOPROL 35PENTIPS31GX8MM 127doxylamine succinate DRUG MART UNIFINE DYAZIDE 90 (sleep) 98 PENTIPS32GX4MM 127 DYMISTA 223DR SMITHS DIAPER 74 DRUG MART UNIFINE DYRENIUM 90DRAMAMINE 29 PENTIPSPLUS E-Z JECT LANCETS 106DRAWTEX ADVANCED WOUND 32GX4MM 127

DRUG MART UNILET E-Z JECT LANCETS 21G 106CARE 2"X2" 78 DRAWTEX ADVANCED WOUND LANCETSSUPER THIN E-Z JECT LANCETS CARE 3"X3" 78 30G 106 COLOR 106 DRAWTEX ADVANCED WOUND DRUG MART UNILET E-Z JECT LANCETS SUPER CARE 4"X4" 78 LANCETSULTRA THIN THIN 30G 106 DRAWTEX ADVANCED WOUND 28G 106 E-Z JECT LANCETS THIN CARE 6"X8" 78 DRY MOUTH SPRAY 160 26G 106 DRAWTEX ADVANCED WOUND E-Z SPACER 151DRYSOL 74CARE 8"X8" 78 E-Z SPACER THE BODYDUAC 56DRISDOL 242 GUARDS PACK 151DUANE READE LANCET E-ZJECT LANCETS MICRO-DRISTAN SPRAY 225 ALTERNATE SITE 26G 106 THIN 33G 106dronabinol 29 DUANE READE LANCET E.E.S. 400 100DROPLET LANCETS ULTRA SUPERTHIN 30G 106 THIN 30G 105 DUANE READE LANCET E.E.S. GRANULES 100 DROPLET LANCING ULTRATHIN 28G 106 EARLOOP MASK 151 DEVICE 105 DUANE READE UNIFINE EASIVENT 151PENTIPS 29G X 12MM 127

Index 16

EASIVENT/MASK-LARGE 151 EASY TALK BLOOD EASY TOUCH INSULIN EASIVENT/MASK-MEDIUM GLUCOSE TEST STRIPS 85 SYRINGE/SAFETY/U-

151 EASY TALK CONTROL 100/1ML/30G X 1/2" 128 SOLUTION HIGH 106 EASY TOUCH INSULINEASIVENT/MASK-SMALL 151 EASY TALK CONTROL SYRINGE/U-100/0.3ML/30G XEASY COMFORT INSULIN SOLUTION LOW 106 1/2" 128SYRINGE/0.3ML/30G X EASY TALK CONTROL EASY TOUCH INSULIN5/16" 127 SOLUTION NORMAL 106 SYRINGE/U-100/0.5ML/27G XEASY COMFORT INSULIN EASY TOUCH 1/2" 128SYRINGE/0.5ML/30G X 32GX5MM 127 EASY TOUCH INSULIN5/16" 127 EASY TOUCH SYRINGE/U-100/0.5ML/28G XEASY COMFORT INSULIN 32GX6MM 127 1/2" 128SYRINGE/0.5ML/31G X EASY TOUCH ALCOHOL EASY TOUCH INSULIN5/16" 127 PREP PADS/MEDIUM 120 SYRINGE/U-100/0.5ML/30G XEASY COMFORT INSULIN EASY TOUCH CONTROL 1/2" 128SYRINGE/1ML/30G X SOLUTION/HIGH & LOW106 EASY TOUCH INSULIN5/16" 127 EASY TOUCH FLIPLOCK SYRINGE/U-100/0.5ML/31G XEASY COMFORT INSULIN SAFETY INSULIN SYRINGE 5/16" 128SYRINGE/1ML/31G X 1ML/29GX1/2" 127 EASY TOUCH INSULIN5/16" 127 EASY TOUCH FLIPLOCK SYRINGE/U-100/1ML/27G XEASY COMFORT INSULIN SAFETY INSULIN SYRINGE 1/2" 128SYRINGE/U-100/0.5ML/30G X 1ML/30GX1/2" 127 EASY TOUCH INSULIN1/2" 127 EASY TOUCH FLIPLOCK SYRINGE/U-100/1ML/28G XEASY COMFORT INSULIN SAFETY INSULIN SYRINGE 1/2" 128SYRINGE/U-100/1ML/30G X 1ML/30GX5/16" 127 EASY TOUCH INSULIN1/2" 127 EASY TOUCH FLIPLOCK SYRINGE/U-100/1ML/29G XEASY COMFORT SAFETY INSULIN SYRINGE 1/2" 128LANCETS 106 1ML/31GX5/16" 128 EASY TOUCH INSULINEASY COMFORT LANCETS EASY TOUCH GLUCOSE SYRINGE/U-100/1ML/30G X30G/PULL TOP 106 TEST STRIPS 85 1/2" 128EASY COMFORT LANCETS EASY TOUCH HEALTHPRO EASY TOUCH INSULIN30G/THIN TOP 106 CONTROL SOLUTION/HIGH & SYRINGE/U-100/1ML/31G XEASY COMFORT PEN LOW 106 5/16" 128NEEDLES31GX1/4" 127 EASY TOUCH HEALTHPRO EASY TOUCH LANCETSEASY COMFORT PEN GLUCOSE TEST STRIPS 85 21G/PRESSURENEEDLES31GX3/16" 127 EASY TOUCH INSULIN ACTIVATED 106EASY COMFORT PEN SYRINGE/0.3ML/30G X EASY TOUCH LANCETSNEEDLES31GX5/16" 127 5/16" 128 23G/PRESSUREEASY COMFORT PEN EASY TOUCH INSULIN ACTIVATED 106NEEDLES32GX5/32" 127 SYRINGE/0.3ML/31G X EASY TOUCH LANCETSEASY MINI EJECT LANCING 5/16" 128 26G/PRESSUREDEVICE 106 EASY TOUCH INSULIN ACTIVATED 106EASY MINI LANCING SYRINGE/0.5ML/29G X EASY TOUCH LANCETSDEVICE 106 1/2" 128 26G/PULL-TOP 106EASY PLUS BLOOD GLUCOSE EASY TOUCH INSULIN EASY TOUCH LANCETSTEST STRIPS 85 SYRINGE/0.5ML/30G X 26G/TWIST 106EASY PLUS II BLOOD 5/16" 128 EASY TOUCH LANCETSGLUCOSE TEST 85 EASY TOUCH INSULIN 28G/PRESSUREEASY PLUS II CONTROL SYRINGE/1ML/30G X ACTIVATED 106SOLUTION HIGH 106 5/16" 128 EASY TOUCH LANCETSEASY PLUS II CONTROL EASY TOUCH INSULIN 28G/PULL-TOP 106SOLUTION LOW 106 SYRINGE/SAFETY/U- EASY TOUCH LANCETSEASY STEP CONTROL 100/0.5ML/29G X 1/2" 128 28G/TWIST 106SOLUTION HIGH 106 EASY TOUCH INSULIN EASY TOUCH LANCETSEASY STEP CONTROL SYRINGE/SAFETY/U- 30G/BUTTON-ACTIVATEDSOLUTION LOW 106 100/0.5ML/30G X 5/16" 128 106EASY STEP CONTROL EASY TOUCH INSULIN EASY TOUCH LANCETSSOLUTION NORMAL 106 SYRINGE/SAFETY/U- 30G/PRESSUREEASY STEP TEST STRIPS 85 100/1ML/29G X 1/2" 128 ACTIVATED 107

Index 17

EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK EDARBYCLOR 35 30G/PULL-TOP 107 SAFETY SYRINGE EDECRIN 90EASY TOUCH LANCETS 1ML/30GX1/2" 129 EDLUAR 9830G/TWIST 107 EASY TRAK BLOOD EASY TOUCH LANCETS GLUCOSE TEST STRIPS 85 EDURANT 44 32G/PRESSURE EASY TRAK GLUCOSE EFFEXOR XR 24ACTIVATED 107 CONTROLSOLUTION EFFIENT 96EASY TOUCH LANCETS HIGH 107 EFLOW SCF AEROSOL32G/PULL-TOP 107 EASY TRAK GLUCOSE

HEAD 151EASY TOUCH LANCETS CONTROLSOLUTION 32G/TWIST 107 LOW 107 EFUDEX 60 EASY TOUCH LANCETS EASY TRAK GLUCOSE ELASTO-GEL 12"X12" 78 33G/TWIST 107 CONTROLSOLUTION ELASTO-GEL 2"X3" 78EASY TOUCH LANCING NORMAL 107 ELASTO-GEL 3" ROUND 78DEVICE/EJECTOR 107 EASY TWIST & CAP EASY TOUCH PEN NEEDLE LANCETS 107 ELASTO-GEL 4"X4" 78 30G X 5/16" 128 85 78EASYGLUCO ELASTO-GEL 5"X5"EASY TOUCH PEN NEEDLES EASYGLUCO CONTROL ELASTO-GEL 6"X8" 7929GX1/2" 128 SOLUTION HIGH 107EASY TOUCH PEN NEEDLES ELASTO-GEL 8"X16" 79EASYGLUCO CONTROL31GX1/4" 128 ELASTO-GEL CAST/SPLINTSOLUTION LOW 107EASY TOUCH PEN NEEDLES 12"X12" 79EASYGLUCO CONTROL31GX5/16" 128 ELASTO-GEL CAST/SPLINTSOLUTION NORMAL 107EASY TOUCH PEN NEEDLES 4"X4" 79EASYGLUCO PLUS 8532GX1/4" 128 ELASTO-GEL CAST/SPLINTEASYGLUCO PLUSEASY TOUCH PEN NEEDLES 6"X8" 79CONTROL SOLUTION LEVEL32GX3/16" 128 ELASTO-GEL CAST/SPLINT

1 107EASY TOUCH PEN NEEDLES 8"X16" 79EASYMAX 15 LEVEL 132GX5/32" 128 ELASTO-GEL FACE MASK 79GLUCOSE CONTROLEASY TOUCH PEN ELASTO-GEL PLUS 2"X3" 79NEEDLES/31G X 3/16" 128 SOLUTION 107 EASYMAX 15 LEVEL 2 ELASTO-GEL PLUS 4"X4" 79EASY TOUCH SAFETY

LANCETS21G/PRESSURE GLUCOSE CONTROL ELASTO-GEL PLUS 8"X8" 79SOLUTION 107ACTIVATED 107 ELAVIL 24EASYMAX 15 TESTEASY TOUCH SAFETY ELDEPRYL 40LANCETS23G/PRESSURE STRIPS 85 EASYMAX CONTROL ELDERTONIC 168ACTIVATED 107 SOLUTIONHIGH 107EASY TOUCH SAFETY ELEMENT COMPACTEASYMAX CONTROLLANCETS26G/BUTTON CONTROL SOLUTION LEVELSOLUTIONLOW 107ACTIVATED 107 2 107EASYMAX CONTROLEASY TOUCH SAFETY ELEMENT COMPACTSOLUTIONNORMAL 107LANCETS26G/PRESSURE CONTROL SOLUTION LEVEL EASYMAX TEST STRIPS 85ACTIVATED 107 3 107

EASY TOUCH SAFETY EASYPLUS BLOOD ELEMENT COMPACT TEST LANCETS28G/BUTTON GLUCOSE TEST STRIP 85 STRIPS 85 ACTIVATED 107 EASYPRO BLOOD GLUCOSE ELEMENT HIGH EASY TOUCH SAFETY TEST STRIPS 85 CONTROL 107 LANCETS28G/PRESSURE EASYPRO PLUS 85 ELEMENT LOW ACTIVATED 107 CONTROL 107EASYTEST II LANCETS 107EASY TOUCH SHEATHLOCK ELEMENT NORMALEASYTEST LANCETS 107SAFETY INSULIN SYRINGE CONTROL 107

EBASE CONTROLLER1ML/29GX1/2" 128 ELEMENT TEST STRIPS 85KIT 151EASY TOUCH SHEATHLOCK ELESTAT 230SAFETY INSULIN SYRINGE EC-NAPROSYN 6

eletriptan hydrobromide 1541ML/30GX5/16" 129 econazole nitrate 59 EASY TOUCH SHEATHLOCK ELEXA NATURAL FEEL 101ECOTRIN REGULARSAFETY INSULIN SYRINGE ELEXA STIMULATING 101STRENGTH 81ML/31GX5/16" 129 EDARBI 34 ELEXA ULTRA SENSITIVE101

Index 18

ELIDEL 72 EMBRACE CONTROL enalapril maleate &SOLUTIONLOW 107 hydrochlorothiazide 35ELIMITE 75 EMBRACE EVO BLOOD ENBRACE HR 213ELIPHOS 95 GLUCOSETEST STRIPS 85 ENBREL 7ELIQUIS 18 EMBRACE EVO GLUCOSE

ENBREL MINI 7ELITE DC AUTO CONTROL SOLUTION LEVEL ADAPTER 151 1 107 ENBREL SURECLICK 7

EMBRACE EVO GLUCOSE END FATIGUE DAILYELITE-OB 213 CONTROL SOLUTION LEVEL ENERGYENFUSION 168ELITE-THIN INSULIN 2 107SYRINGE/0.3ML/31G X ENERGY BOOSTER 168EMBRACE GLUCOSE5/16" 129 ENFAMIL ENFALYTE 156CONTROL SOLUTIONELITE-THIN INSULIN ENFAMIL EXPECTA 213HIGH 108SYRINGE/0.5ML/29G X EMBRACE LANCETS ULTRA enoxaparin sodium 181/2" 129 THIN 30G 108ELITE-THIN INSULIN ENSTILAR 63EMBRACE PRO BLOODSYRINGE/0.5ML/30G X entacapone 39GLUCOSETEST STRIPS 855/16" 129 EMBRACE PRO GLUCOSE entecavir 46ELITE-THIN INSULIN CONTROL SOLUTION 108SYRINGE/1ML/30G X ENTRESTO 49 EMCYT 385/16" 129 EPANED 34

ELITE-THIN INSULIN EMEND 30 EPCLUSA 46SYRINGE/U-100/0.5ML/28G X EMEND TRIPACK 30 EPIDUO 561/2" 129 EMERGEN-C BLUE 168ELITE-THIN INSULIN EPIDUO FORTE 56 SYRINGE/U-100/0.5ML/31G X EMERGEN-C FIVE 168 EPIFOAM 63 5/16" 129 EMERGEN-C HEART EPILYT 67ELITE-THIN INSULIN HEALTH 168

epinastine hcl (ophth) 230SYRINGE/U-100/1ML/28G X EMERGEN-C IMMUNE 168 1/2" 129 EMERGEN-C IMMUNE EPINEPHRINE 242 ELITE-THIN INSULIN PLUS 168 epinephrine (anaphylaxis) 242SYRINGE/U-100/1ML/29G X EMERGEN-C IMMUNE EPIPEN 2-PAK 2421/2" 129 PLUS/VITAMIN D 168 ELITE-THIN INSULIN EMERGEN-C IMMUNE+ EPIPEN-JR 2-PAK 242 SYRINGE/U-100/1ML/31G X WARMERS 168 EPIVIR 44 5/16" 129 EMERGEN-C JOINT EPIVIR HBV 46ELIXOPHYLLIN 18 HEALTH 168 eplerenone 36ELLA 52 EMERGEN-C KIDZ 168

EPOGEN 96ELLIS TONIC 168 EMERGEN-C MSM LITE 168

EPROSARTAN MESYLATE 34ELMIRON 95 EMERGEN-C PINK 168

EPZICOM 44EMERGEN-C SUPERELOCON 63 EQ BLOOD GLUCOSE TESTFRUIT 168ELON MATRIX 5000 219 STRIPS 85EMERGEN-C VITAMIN C168 EQ COMPLETEELON MATRIX PLUS 219 EMERGEN-C VITAMIN C MULTIVITAMINADULTS UNDERELON MATRIX 5000 LITE 168 50 168COMPLETE 219 EMERGEN-C VITAMIN D & EQ MULTIVITAMINS ADULTELON MATRIX CALCIUM 168 GUMMY 168COMPLETE 219 EMETROL 29 EQ ONE DAILY MENS 50+ 168ELON R3 219 EMLA 74 EQ ONE DAILY MENSELON SKIN REPAIR EMOLLIA-CREME 67 HEALTH 168SYSTEM 67 EQ ONE DAILY WOMENSELTA 67 EMOLLIA-LOTION 67 50+ 168ELTA DERMAL WOUND emollient 67 EQ ONE DAILY WOMENSDRESSING 79 EMSAM 22 HEALTH 168

EMADINE 230 EMTRIVA 44 EQ THERAPEUTIC EMBEDA 9 MOISTURIZING CREAM 67ENABLEX 239EMBRACE BLOOD GLUCOSE EQL ADVANCED RECOVERY

enalapril maleate 34TEST STRIPS 85 SKIN CARE 67

Index 19

EQL ALCOHOL SWABS 120 EQL PROTECTAVISION 168 estazolam 98 EQL CENTURY MATURE EQL SHORT PEN NEEDLES ESTER-C 163 ADULTS50+ 168 31G X 8MM 129 ESTRACE 92,241EQL CENTURY MENS 168 EQL SUPER ENERGY

estradiol 93BOOSTER 168EQL CENTURY WOMENS 168 EQL SUPER THIN LANCETS estradiol & norethindroneEQL COLOR LANCETS 30G 108 acetate 9221G 108 EQL THIN LANCETS ESTROPIPATE 93EQL COLOR LANCETS MICRO 26G 108 ESTROSTEP FE 50THIN 33G 108 EQL TRUETEST BLOODEQL DRY MOUTH ORAL eszopiclone 98GLUCOSE TEST 85RINSE 160 EQL TRUETRACK TEST 85 ethacrynic acid 90EQL INSULIN

EQL ULTRA COMFORT ethambutol hcl 37SYRINGE/0.3ML/29G XINSULINSYRINGE/0.3ML/31G ethosuximide1/2" 129 22

EQL INSULIN X 5/16" 129 ethynodiol diacet & ethEQL ULTRA COMFORTSYRINGE/0.3ML/30G X estrad 50INSULINSYRINGE/1ML/30G X5/16" 129 ETHYOL 39

EQL INSULIN 5/16" 129 ETIDRONATE DISODIUM 91EQL ULTRA MOISTURIZINGSYRINGE/0.3ML/31G XDAILY LOTION 68 etodolac 65/16" 129 EQL ULTRA SHORT PENEQL INSULIN EUCERIN 68NEEDLES 31G X 6MM 129SYRINGE/0.5ML/29G X EUCERIN BABY 68

1/2" 129 EQUALYTE 156 EUCERIN CALMING DAILYEQL INSULIN EQUETRO 41 MOISTURIZER 68SYRINGE/0.5ML/30G X ergocalciferol 242 EUCERIN DAILY5/16" 129 ERGOLOID PROTECTION/SPF 30 68EQL INSULIN MESYLATES 234 EUCERIN INTENSIVESYRINGE/0.5ML/31G X REPAIR 68ERGOMAR 1545/16" 129 EUCERIN INTENSIVEEQL INSULIN ergotamine w/ caffeine 154 REPAIRHAND 68SYRINGE/1ML/29G X 1/2" 129 ERIVEDGE 37 EUCERIN ORIGINALEQL INSULIN ERTACZO 59 HEALINGSOOTHINGSYRINGE/1ML/30G X REPAIR 68ERY-TAB 1005/16" 129 EUCERIN PLUS 68EQL INSULIN ERYGEL 56 EUCERIN PLUS INTENSIVESYRINGE/1ML/31G X ERYPED 200 100 REPAIR 685/16" 129 ERYPED 400 100 EUCERIN SKIN CALMINGEQL INSULIN SYRINGE/U-

ERYTHROCIN DAILY MOISTURIZING 68100/0.3ML/29G X 1/2" 129 EUCERIN SMOOTHINGEQL INSULIN SYRINGE/U- STEARATE 100 REPAIRADVANCED100/0.5ML/29G X 1/2" 129 erythromycin (acne aid) 56 FORMULA 68EQL INSULIN SYRINGE/U- erythromycin (ophth) 228 EUCRISA 75100/1ML/29G X 1/2" 129 erythromycin base 100EQL MEGA SELECT EURAX 75

ERYTHROMYCIN BASE 100MENS 168 EVAC 99EQL MEGA SELECT erythromycinEVEKEO 2WOMENS 168 ethylsuccinate 100

EQL MOISTURIZING ERYTHROMYCIN EVENCARE + BLOOD ETHYLSUCCINATE 100 GLUCOSETEST STRIP 85CREAM 67

EVENCARE BLOOD GLUCOSEEQL ONE DAILY ADULT ESBRIET 235 TEST STRIP 85GUMMIES 168 ESCAVITE LQ 209 EVENCARE CONTROLEQL ONE DAILY DIET escitalopram oxalate 23 SOLUTION 108SUPPORT 168

ESGIC 7 EVENCARE G2 GLUCOSEEQL ONE DAILY MENS 168 CONTROL SOLUTION/LOW-EQL ONE DAILY MENS 50+ esomeprazoleADVANCED 168 magnesium 237 HIGH 108

EVENCARE G2 TESTESOMEPRAZOLEEQL PRENATAL STRIPS 85STRONTIUM 237FORMULA 213

Index 20

EVENCARE G3 GLUCOSE EXEL COMFORT POINT EZ SMART BLOOD GLUCOSE CONTROL SOLUTION/LOW- INSULIN SYRINGE/1ML/29G X LANCETS 108 HIGH 108 1/2" 130 EZ SMART BLOOD GLUCOSE EVENCARE G3 TEST EXEL COMFORT POINT TEST STRIPS 85 STRIPS 85 INSULIN SYRINGE/1ML/30G X EZ SMART PLUS BLOOD EVENCARE MINI BLOOD 5/16" 130 GLUCOSE TEST STRIPS 85 GLUCOSE TEST STRIPS 85 EXELDERM 59 EZ-LETS LANCETS 21G 108 EVENCARE MINI GLUCOSE EXELON 232 EZ-LETS LANCETS 23G 108CONTROL SOLUTION EZ-LETS LANCETS 26Gexemestane 38NORMAL 108 SUPER-SOFT 108EVISTA 92 EXFORGE 35 EZ-LETS LANCETS 28G EVOCLIN 56 EXFORGE HCT 35 ULTRA-SOFT 108 EVOLUTION AUTOCODE 85 EXTAVIA 233 EZ-LETS LANCETS 30G 108 EVOLUTION CONTROL EXTINA 59 ezetimibe 33 SOLUTION NORMAL 108 EXTRA SENSITIVE ezetimibe-simvastatin 32EVOTAZ 44 SPERMICIDAL 101 EZFE FORTE 213EVZIO 29 EXTRA-VIRT PLUS DHA 213 FABIOR 56EX-LAX MAXIMUM EXU-DRY 15"X18" 79 famciclovir 46STRENGTH 100 EXU-DRY 15"X24" 79EXACTECH R-S-G TEST famotidine 237EXU-DRY 20"X28" 79STRIPS 85 FAMVIR 46EXU-DRY 3"X4" 79EXACTECH TEST STRIPS 85 FANAPT 41EXU-DRY 4"X6" 79EXALGO 9 FANAPT TITRATION PACK 41EXCEDRIN EXTRA EXU-DRY 6"X9" 79 FANATREX FUSEPAQ 19STRENGTH 7 EXU-DRY 9"X15" 79 EXCEDRIN MENSTRUAL FANTASY LUBRICATED 101EXU-DRY ARM 27"X31" 79COMPLETE 7 FANTASYEXU-DRY ARM/SHOULDEREXCEDRIN MIGRAINE 7 LUBRICATED/SPERMICIDETIES 27"X31" 79 101EXEL COMFORT POINT EXU-DRY BURN JACKETINSULIN PEN NEEDLES 29G X FARESTON 3831"X32" 7912MM 129 EXU-DRY BURN JACKET FARXIGA 28 EXEL COMFORT POINT CHILD 17"X20" 79 FARYDAK 38INSULIN PEN NEEDLES 31G X EXU-DRY BUTTOCKS FAZACLO 426MM 130 23"X53" 79EXEL COMFORT POINT felbamate 21EXU-DRYINSULIN PEN NEEDLES 31G X ELBOW/KNEE/HEEL FELBATOL 21 8MM 130 10"X17" 79 FELDENE 6EXEL COMFORT POINT EXU-DRY FACE 9"X14" 79INSULIN SYRINGE/0.3ML/29G X felodipine 48

EXU-DRY INCISION 3"X9"791/2" 130 FEM-CAL CITRATE 157 EXEL COMFORT POINT EXU-DRY NON-PERMEABLE FEMARA 38INSULIN SYRINGE/0.3ML/30G X PAD 24"X36" 79 5/16" 130 EXU-DRY PADDED HAND FEMCON FE 50 EXEL COMFORT POINT 12"X13" 79 FENOFIBRATE 33 INSULIN SYRINGE/0.5ML/28G X EXU-DRY PADDED HAND fenofibrate 33 1/2" 130 CHILD 8"X8" 79 fenofibrate micronized 33EXU-DRY PADDED NECKEXEL COMFORT POINT

6"X25" 79 FENOFIBRIC ACID 33INSULIN SYRINGE/0.5ML/29G X1/2" 130 EXU-DRY PERMEABLE PAD FENOGLIDE 33

24"X36" 79EXEL COMFORT POINT FENOPROFEN CALCIUM 6INSULIN SYRINGE/0.5ML/30G X EXU-DRY SCALP 3"X14" 79

fenoprofen calcium 65/16" 130 EXU-DRY SLIT TUBE EXEL COMFORT POINT 2"X3" 79 FENORTHO 6 INSULIN SYRINGE/1ML/28G X EYE HEALTH 168 fentanyl 9 1/2" 130 EYEAID IRRIGATING FENTANYL 9

SOLUTION 230 fentanyl citrate 9

Index 21

FENTORA 9 FIFTY50 PEN FLONASE ALLERGY RELIEF NEEDLES/32GX6MM 130 CHILDRENS 224FEOSOL 97 FIFTY50 SAFETY SEAL FLONASE SENSIMIST 224FER-IN-SOL 97 LANCETS 30G 108 FLORIVA PLUS 208FERGON 97 FIFTY50 SAFETY SEAL

FLOVENT DISKUS 17LANCETS 32G 108ferrous fumarate 97 FIFTY50 SUPERIOR FLOVENT HFA 17ferrous fumarate-fa-b complex-c-zn-mg-mn-cu 97 COMFORTINSULIN FLOXIN OTIC 231

SYRINGE/0.3ML/31G XFERROUS GLUCONATE 97 FLUAD 2016-2017 2405/16" 130 ferrous gluconate 97 FIFTY50 SUPERIOR FLUAD 2017-2018 240 ferrous sulfate 97 COMFORTINSULIN FLUARIX QUADRIVALENT

SYRINGE/0.5ML/31G X 2015-2016 240FERROUS SULFATE 97 5/16" 130 FLUARIX QUADRIVALENTferrous sulfate 97 FIFTY50 SUPERIOR 2016-2017 240 FERROUS SULFATE 97 COMFORTINSULIN FLUARIX QUADRIVALENT ferrous sulfate 97 SYRINGE/1ML/31G X 2017-2018 240

5/16" 130 FLUBLOK 2015-2016 240FERROUS SULFATE 97 FIFTY50 UNILET LANCETS FLUBLOK 2016-2017 240ferrous sulfate 97 33G 108 FLUCELVAX QUADRIVALENTFERROUS SULFATE 97 FILTER AIR PP 151 2016-2017 240 ferrous sulfate dried 97 finasteride 95 FLUCELVAX QUADRIVALENT

2017-2018 240FETZIMA 24 FINE 30 108 fluconazole 30FETZIMA TITRATION PACK24 FINGERSTIX LANCETS 108 flucytosine 30FEVERALL INFANTS 8 FIORINAL 7 fludrocortisone acetate 53FEXMID 223 FIORINAL/CODEINE #3 11 FLULAVAL QUADRIVALENTfexofenadine hcl 31 FITNESS TABS FOR MEN 2014-2015 240AM/PM/LYCOPENE 168FIASP 27 FLULAVAL QUADRIVALENTFITNESS TABS FOR WOMENFIASP FLEXTOUCH 27 2015-2016 240AM/PM/LYCOPENE 169 FLULAVAL QUADRIVALENTFIBERCON 99 FLAGYL 14 2016-2017 240FIBRACOL COLLAGEN- FLAREX 229 FLULAVAL QUADRIVALENTALGINATE WOUND flavoxate hcl 239 2017-2018 240DRESSING/2" X 2" 79 FLUMADINE 47FIBRACOL COLLAGEN- flecainide acetate 16

ALGINATE WOUND FLUNISOLIDE 224FLECTOR 58DRESSING/4" X 8-3/4" 79 fluocinolone acetonide 63FLEET ENEMA 99FIBRICOR 33 fluocinolone acetonideFLEET ENEMA SIX PACK 99FIFTY50 ALCOHOL PREP (otic) 231

FLEET PEDIATRIC 99PADS 120 fluocinonide 63 FIFTY50 CONTROL FLEXICHAMBER 151 fluocinonide emulsified base 63SOLUTION2.0 108 FLINTSTONESFIFTY50 GLUCOSE TEST fluorometholone (ophth) 229GUMMIES 209STRIP 2.0 86 FLINTSTONES GUMMIES FLUOROURACIL 60 FIFTY50 LANCING COMPLETE 209 fluorouracil (topical) 60DEVICE 108 FLINTSTONES GUMMIES FLUOXETINE 234FIFTY50 PEN NEEDLES 31G PLUSIMMUNITYX3/16" (5MM) 130 SUPPORT/EXTRA C 209 FLUOXETINE DR 23 FIFTY50 PEN NEEDLES 31G FLINTSTONES SOUR fluoxetine hcl 23 X5/16" (8MM) 130 GUMMIES 209 FLUOXETINE HCL 23FIFTY50 PEN NEEDLES FLINTSTONES fluphenazine decanoate 4231GX5MM 130 TODDLER/TASTISMOOTHFIFTY50 PEN 209 FLUPHENAZINE HCL 42,43NEEDLES/31GX8MM 130 FLOMAX 95 fluphenazine hcl 43FIFTY50 PEN FLONASE ALLERGY flurandrenolide 63NEEDLES/32GX4MM 130 RELIEF 224 FLURAZEPAM HCL 98

Index 22

flurbiprofen 6 folic acid 96 FORMULA 405 ENRICHED EYE 68FLURBIPROFEN SODIUM 230 folic acid-vitamin b6-vitamin FORMULA 405 FACEb12 97flurbiprofen sodium 230 CREAM 68FOLIVANE-OB 213flutamide 38 FORMULA 405 LIGHT

fondaparinux sodium 19 TEXTURED MOISTURIZER 68fluticasone propionate 63 FORA BLOOD GLUCOSE FORMULA 405fluticasone propionate TEST STRIPS 86 MOISTURIZING 68(nasal) 224 FORA CONTROL SOLUTION FORTAMET 25FLUTICASONE HIGH 108PROPIONATE/SALMETEROL FORTAVIT 169FORA CONTROL SOLUTION17 LOW 108 FORTEO 91

fluvastatin sodium 33 FORA CONTROL SOLUTION FORTESTA 12 FLUVIRIN 2015-2016 240 NORMAL 108 FORTICAL 91FORA D15G BLOODFLUVIRIN 2016-2017 240 FORTISCARE BLOODGLUCOSE TEST STRIPS 86FLUVIRIN 2017-2018 240 GLUCOSETEST STRIP 86FORA D20 BLOOD GLUCOSE FORTISCARE CONTROLfluvoxamine maleate 23 TEST STRIPS 86 SOLUTIONS HIGH 108FLUZONE HIGH-DOSE PF 2015- FORA D40/G31 BLOOD FORTISCARE CONTROL2016 240 GLUCOSE TEST STRIPS 86 SOLUTIONS LOW 108FLUZONE HIGH-DOSE PF 2016- FORA G20 BLOOD GLUCOSE FORTISCARE CONTROL2017 240 TEST STRIPS 86 SOLUTIONS NORMAL 108FLUZONE HIGH-DOSE PF 2017- FORA G30A BLOOD FOSAMAX 912018 240 GLUCOSE TEST STRIPS 86 FLUZONE INTRADERMAL FORA GD20 TEST FOSAMAX PLUS D 91 QUADRIVALENT 2015- STRIPS 86 fosamprenavir calcium 44 2016 240 FORA GD50 BLOOD FOSFREE 169FLUZONE INTRADERMAL GLUCOSE TEST STRIPS 86 QUADRIVALENT 2016- FORA LANCETS 108 fosinopril sodium 34 2017 241 fosinopril sodium &FORA LANCING DEVICE108 hydrochlorothiazide 35FLUZONE INTRADERMAL FORA LANCINGQUADRIVALENT 2017- fosphenytoin sodium 21DEVICE/CLEARCAP 1082018 241 FORA TN'G/TN'G VOICE FOSRENOL 95FLUZONE QUADRIVALENT BLOOD GLUCOSE TEST FRAGMIN 192015-2016 241 STRIPS 86 FREDS PHARMACY AUTOLETFLUZONE QUADRIVALENT FORA V10 BLOOD GLUCOSE LANCING DEVICE 1092016-2017 241 TEST STRIPS 86 FREDS PHARMACY UNIFINEFLUZONE QUADRIVALENT FORA V12 BLOOD GLUCOSE PENTIPS PEN NEEDLES2017-2018 241 TEST STRIPS 86FLUZONE SPLIT 2015- 32GX4MM 130FORA V20 BLOOD GLUCOSE FREDS PHARMACY UNIFINE2016 241 TEST STRIPS 86 PENTIPS PLUS 31GX5MM130FML 229 FORA V30A BLOOD FREDS PHARMACY UNIFINEFML FORTE 229 GLUCOSE TEST STRIPS 86 PENTIPS PLUS 31GX8MM130 FML LIQUIFILM 229 FORACARE GD40 86 FREDS PHARMACY UNILET FOAM DRESSING FORACARE GDH CONTROL LANCETS SUPER THIN BORDERED 79 SOLUTION HIGH 108 30G 109 FOAM DRESSING CIRCULAR FORACARE GDH CONTROL FREDS PHARMACY UNILET BORDERED 79 SOLUTION LOW 108 LANCETS ULTRA THIN FOAM DRESSING NON- FORACARE GDH CONTROL 28G 109 BORDERED 79 SOLUTION NORMAL 108 FREEDAVITE 169

FORACARE PREMIUM V10FOCALGIN 90 DHA 213 FREESTYLE CONTROLTESTSTRIPS 86FOCALGIN CA 213 SOLUTION 109FORACARE TEST N GO TEST FREESTYLE CONTROLFOCALIN 3 STRIPS 86 SOLUTION HIGH/LOW 109FOCALIN XR 3 FORADIL AEROLIZER 17 FREESTYLE INSULINX FOLCAL DHA 213 FORFIVO XL 22 BLOODGLUCOSE TEST 86 FOLCAPS OMEGA 3 213 formaldehyde 43 FOLIC ACID 96

Index 23

FREESTYLE INSULINXBLOODGLUCOSE TESTSTRIPS 86 FREESTYLE LANCETS 109 FREESTYLE LITE TESTSTRIPS 86 FREESTYLE PRECISIONINSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 130 FREESTYLE PRECISIONINSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 130 FREESTYLE PRECISIONINSULIN SYRINGE/U-100/1ML/31G X 5/16" 130 FREESTYLE PRECISIONINSULIN SYRINGES/U-100/1ML/30G X 5/16" 130 FREESTYLE PRECISION NEOBLOOD GLUCOSE TESTSTRIPS 86 FREESTYLE TEST STRIPS 86 FREESTYLE UNISTICK IILANCETS 109 FROVA 154 frovatriptan succinate 154 fructose-dextrose-phosphoricacid 30 FRUIT C 200 163 FULL KIT NEBULIZERSET 151 FUNGOID TINCTURE 59 FURADANTIN 238 furosemide 90 FUROSEMIDE 90 furosemide 90 FYCOMPA 19 gabapentin 19 GABITRIL 21 GABLOFEN 223 galantamine hydrobromide 232 GALANTAMINEHYDROBROMIDE 232 galantamine hydrobromide 232 GAS-X 93 GAS-X EXTRA STRENGTH 93 gatifloxacin (ophth) 228 GE100 BLOOD GLUCOSETESTSTRIPS 86 GE100 CONTROL SOLUTIONNORMAL 109 GELNIQUE 239 GELNIQUE PUMP 239

gemfibrozil 33 GENERESS FE 50 GENOTROPIN 91 GENOTROPINMINIQUICK 91 GENSTRIP 50 86 GENTAK 228 GENTAMICIN SULFATE 58 gentamicin sulfate(ophth) 228 gentamicin sulfate (topical) 58 GENTEAL 226 GENTEAL MILD 226 GENTEAL MILD TOMODERATE 226 GENTEAL SEVERE 226 GENTEAL TEARSMODERATEPF 226 GENTLE 68 GENTLE-LET GPLANCETS 109 GENTLE-LET LANCETSGENERAL PURPOSESTYLE/FINE POINT 109 GENTLE-LET LANCETSGENERAL PURPOSESTYLE/MEDIUM POINT 109 GENTLE-LET LANCETSSAFETY STYLE/FINEPOINT 109 GENTLE-LET LANCETSSAFETY STYLE/MEDIUMPOINT 109 GENVOYA 44 GEODON 41 GERI PROTECT 74 GERI-FREEDA SENIORFORMULA 169 GERI-SOFT 68 GHT TEST STRIPS 86 GIAZO 94 GILENYA 233 GILOTRIF 38 glatiramer acetate 233 GLEEVEC 38 GLEOSTINE 37 glimepiride 28 glipizide 28 glipizide-metformin hcl 25 GLOBAL ALCOHOL PREPEASEPADS 120

GLOBAL EASE INJECT PENNEEDLES 29GX12MM 130 GLOBAL EASE INJECT PENNEEDLES 31GX8MM 131 GLOBAL EASE INJECT PENNEEDLES 32GX4MM 131 GLOBAL EASE INJECT PENNEEEDLES 31GX5MM 131 GLOBAL EASY GLIDEINSULINSYRINGE/U-100/0.3ML/31G X 5/16" 131 GLOBAL EASY GLIDE PENNEEDLES 32GX4MM 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.3ML/29G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.3ML/30G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.3ML/30G X5/16" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.3ML/31G X5/16" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/28G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/29G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/30G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/30G X5/16" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/31G X5/16" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/28G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/29G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/30G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/30G X5/16" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/31G X5/16" 131 GLOBAL INJECT EASELANCETS 28G 109 GLOBAL INJECT EASELANCETS 30G 109

Index 24

GLOBAL INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" 131 GLOBAL INSULIN SYRINGES/U-100/0.3ML/30GX5/16" 131 GLOBAL LANCING DEVICE 109 GLUCAGEN DIAGNOSTIC 83 GLUCAGEN HYPOKIT 26 GLUCAGON EMERGENCY KIT 26 GLUCO PERFECT 3 TEST STRIPS 86 GLUCOCARD 01 CONTROL SOLUTION NORMAL/HIGH 109 GLUCOCARD 01 CONTROL SOLUTION/NORMAL 109 GLUCOCARD 01 SENSOR PLUS 86 GLUCOCARD 01 SENSOR PLUSTEST STRIPS 86 GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS 86 GLUCOCARD EXPRESSION CONTROL SOLUTION LEVEL 1 109 GLUCOCARD SHINE CONTROL SOLUTION LEVEL 1 109 GLUCOCARD SHINE TEST STRIPS 86 GLUCOCARD VITAL TEST

GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 131 GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 131 GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 131 GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 132 GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 132 GLUCOPRO INSULIN SYRINGE/U-100/1ML/30G X1/2" 132 GLUCOPRO INSULIN SYRINGE/U-100/1ML/30G X5/16" 132 GLUCOPRO INSULIN SYRINGE/U-100/1ML/31G X5/16" 132 GLUCOSE 26 GLUCOSE CONTROL NORMAL 109 GLUCOSE CONTROL SOLUTION 109 GLUCOSE INSTANT ENERGY 26 GLUCOSE METER TEST

GMATE BLOOD GLUCOSE TESTSTRIPS 87 GMATE CONTROL SOLUTION LEVEL 2 109 GMATE LANCETS 30G 109 GMATE LANCING DEVICE109 GNP ADVANCED RECOVERY 68 GNP ALCOHOL SWABS 120 GNP CHILDRENS COMPLETE CHEWABLES 209 GNP CLICKFINE PEN NEEDLEUNIVERSAL/31GX5/16"

132 GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX1/4" 132 GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16" 132 GNP DAILY PRENATAL 213 GNP EASY TOUCH CONTROL SOLUTION HIGH/LOW 109 GNP EASY TOUCH GLUCOSE TEST STRIPS 87 GNP GLUCOSE 26 GNP INSULIN SYRINGE/0.3ML/29G X1/2" 132 GNP INSULIN SYRINGE/0.3ML/30G X5/16" 132 GNP INSULIN

STRIPS 86 GLUCOCARD X-METER CONTROLSOLUTION/NORMAL

109 GLUCOCARD X-SENSOR 86 GLUCOCOM HIGH CONTROL 109 GLUCOCOM LANCETS 28G 109 GLUCOCOM LANCETS 30G 109 GLUCOCOM LANCETS 33G 109 GLUCOCOM NORMAL CONTROL 109 GLUCOCOM TEST STRIPS 86 GLUCOLET 2 AUTOMATIC LANCING DEVICE 109 GLUCONAVII BLOOD GLUCOSETEST STRIPS 86 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 131

STRIPS ADVANCED 87 GLUCOSOURCE LANCET DEVICE 109 GLUCOSOURCE LANCETS 109 GLUCOTROL 28 GLUCOTROL XL 28 GLUCOVANCE 25 GLUMETZA 25 glyburide 28 glyburide micronized 28 glyburide-metformin 25 GLYCERIN 50 glycerin (laxative) 99 glycerin (topical) 68 GLYCERIN ADULT 99 GLYCERINE 50 GLYCEROL FORMAL 50 glycopyrrolate 236 GLYNASE 28 GLYSET 24 GLYXAMBI 25

SYRINGE/0.3ML/31G X5/16" 132 GNP INSULIN SYRINGE/0.5ML/28G X1/2" 132 GNP INSULIN SYRINGE/0.5ML/29G X1/2" 132 GNP INSULIN SYRINGE/0.5ML/30G X5/16" 132 GNP INSULIN SYRINGE/0.5ML/31G X5/16" 132 GNP INSULIN SYRINGE/1ML/28G X 1/2" 132 GNP INSULIN SYRINGE/1ML/29G X 1/2" 132 GNP INSULIN SYRINGE/1ML/30G X5/16" 132 GNP INSULIN SYRINGE/1ML/31G X5/16" 132 GNP LANCETS 110 GNP LANCETS 21G 109

Index 25

GNP LANCETS MICRO THIN GOLD BOND ULTIMATE H-E-B IN CONTROL PEN 33G 110 DIABETICS' DRY RELIEF 68 NEEDLES/NANO/32GX4MMGNP LANCETS SUPER THIN GOLD BOND ULTIMATE 133 30G 110 HEALING 68 H-E-B IN CONTROL GNP LANCETS THIN 110 GOLD BOND ULTIMATE UNIFINEPENTIPS PLUS

PROTECTION 68 31GX5MM 133GNP LANCETS THIN 26G 110 GOLD BOND ULTIMATE H-E-B IN CONTROLGNP MICRO THIN LANCETS RESTORING 68 UNIFINEPENTIPS PLUS33G 110 GOLD BOND ULTIMATE 32GX4MM 133GNP PRENATAL 213 SHEERRIBBONS H-E-B INCONTROLGNP QUICK DISSOLVE PEARLRADIANCE 68 ADVANCEDLANCINGGLUCOSE 26 GOLD BOND ULTIMATE DEVICE 110GNP SUPER THIN SHEERRIBBONS H-E-B INCONTROL ALCOHOLLANCETS/30G 110 SILKSOFTNESS 68 PADS 120GNP ULTRA COMFORT GOLD BOND ULTIMATE H-E-B INCONTROL LANCETSINSULIN SYRINGE/0.3ML/29G X SOFTENING 69 MICRO THIN 33G 1101/2" 132 GOLD BOND ULTIMATE H-E-B INCONTROL LANCETSGNP ULTRA COMFORT SOOTHING 69 SUPER THIN 30G 110INSULIN SYRINGE/0.3ML/30G X H-E-B INCONTROL LANCETSGOLYTELY 995/16" SHORT 132 ULTRA THIN 28G 110GONAK 226GNP ULTRA COMFORT H-E-B INCONTROL PEN INSULIN SYRINGE/0.3ML/31G X GONIOSOL 226 NEEDLES 29GX12MM 133 5/16" SHORT 132 14GONITRO HAEMOLANCE 110GNP ULTRA COMFORT GOODSENSE GLUCOSE 26 HAEMOLANCE LOW FLOWINSULIN SYRINGE/0.5ML/28G X GOODSENSE LANCING LANCETS 1101/2" 132 DEVICE 110 HAEMOLANCE PLUS 110GNP ULTRA COMFORT GOODSENSE PRENATAL HAEMOLANCE PLUS HIGHINSULIN SYRINGE/0.5ML/29G X VITAMINS 213 FLOW 1101/2" 132 granisetron hcl 29 HAEMOLANCE PLUS LOWGNP ULTRA COMFORT

FLOW 110INSULIN SYRINGE/0.5ML/30G X GRANIX 96 HAEMOLANCE PLUS MAX5/16" SHORT 132 GRASTEK 4 FLOW 110GNP ULTRA COMFORT GREEN SOURCE 219 HAEMOLANCE PLUSINSULIN SYRINGE/0.5ML/31G X

GRIFULVIN V 30 PEDIATRIC FLOW 1105/16" SHORT 132 HAIR FARE 219GNP ULTRA COMFORT GRIS-PEG 30

INSULIN SYRINGE/1ML/28G X griseofulvin microsize 30 HAIR NOURISHING 1/2" 132 SUPPLEMENT 219griseofulvin ultramicrosize 30GNP ULTRA COMFORT HAIR-VITES 169GRX HYDROGEL GAUZEINSULIN SYRINGE/1ML/29G X HAIR/SKIN/NAILS 1692X2 791/2" 132 GRX HYDROGEL GAUZE HALCION 98GNP ULTRA COMFORT INSULIN SYRINGE/1ML/30G X 4X4 79 HALDOL 42

GRX VITAMIN E 695/16" SHORT 133 HALDOL DECANOATE 100 42 GNP ULTRA COMFORT guaifenesin 54 HALDOL DECANOATE 50 42INSULIN SYRINGE/1ML/31G X guaifenesin-codeine 53 halobetasol propionate 635/16" SHORT 133 guanfacine hcl 35GNP VITAMIN D-400 156 HALOG 63

guanfacine hcl (adhd) 3GOLD BOND 74 haloperidol 42 GYNAZOLE-1 241GOLD BOND EXTRA haloperidol decanoate 42

STRENGTH 74 GYNE-LOTRIMIN 241 haloperidol lactate 42GOLD BOND MEDICATED GYNE-LOTRIMIN 3 241 HARVONI 46BODYLOTION 68 H-E-B IN CONTROL PEN HEALTH CARE LANCINGGOLD BOND MEDICATED NEEDLES 31GX5MM 133 DEVICE 110BODYLOTION EXTRA H-E-B IN CONTROL PEN HEALTHWISE ALCOHOL PREPSTRENGTH 68 NEEDLES 31GX6MM 133 PADS 120GOLD BOND ULTIMATE 68 H-E-B IN CONTROL PEN HEALTHWISE LANCETS

NEEDLES 31GX8MM 133 30G 110

Index 26

HEALTHWISE LANCING HIPREX 238 HY-VEE LANCETS 110 PEN 110 HM COMPLETE 169 HY-VEE THIN LANCETS 110HEALTHWISE MINI PEN HM COMPLETE 50+ MENS HYALEX 169NEEDLES 31GX6MM 133 ULTIMATE 169HEALTHWISE PEN NEEDLES HYCAMTIN 39HM COMPLETE 50+29GX12MM 133 HYCOLOID-GRX 79WOMENS ULTIMATE 169HEALTHWISE SHORT PEN

HM ESTROPLUS 219 hydralazine hcl 36NEEDLES 31GX8MM 133 HEALTHWISE UNIFINE HM GLUCOSE 26 HYDRASYN25 69 PENTIPS PEN NEEDLES HYDREA 39HM HAIR/SKIN/NAILS 16932GX4MM 133 HM ONE DAILY HYDRO-LAN 69HEALTHY ACCENTS AUTOLET ESSENTIAL 164 HYDROCERIN 74IMPRESSION LANCING HM ONE DAILY MENS 169DEVICE 110 hydrochlorothiazide 90HM ONE DAILY PRENATALHEALTHY ACCENTS UNIFINE HYDROCIL INSTANT 99COMBO 213PENTIPS PEN NEEDLES HM ONE DAILY hydrocodone w/29GX12MM 133 WOMENS 169 homatropine 53HEALTHY ACCENTS UNIFINE hydrocodone-HM PRENATAL 213PENTIPS PEN NEEDLES acetaminophen 1131GX5MM 133 HONEY BEARS 213 hydrocodone-ibuprofen 11HEALTHY ACCENTS UNIFINE HUDSON RCI SEE-THRU HYDROCOL II 79PENTIPS PEN NEEDLES AEROSOL MASK 31GX6MM 133 ELONGATED/ADULT 151 HYDROCOL II SACRAL 80 HEALTHY ACCENTS UNIFINE HUMALOG 27 HYDROCOL II THIN 80PENTIPS PEN NEEDLES HUMALOG JUNIOR hydrocortisone 5231GX8MM 133 KWIKPEN 27HEALTHY ACCENTS UNIFINE hydrocortisone (intrarectal) 12

HUMALOG KWIKPEN 27PENTIPS PEN NEEDLES hydrocortisone (rectal) 13 32GX4MM 133 HUMALOG MIX 50/50 27 hydrocortisone (topical) 63HEALTHY ACCENTS UNILET HUMALOG MIX 50/50 hydrocortisone acetateLANCETS SUPER THIN KWIKPEN 27 (topical) 6330G 110 HUMALOG MIX 75/25 27 hydrocortisone butyrate 63HEALTHY HEART HUMALOG MIX 75/25COMPLEX 219 hydrocortisone butyrateKWIKPEN 27 hydrophilic lipo base 63HEALTHY KIDS GUMMIES209 HUMATROPE 91 hydrocortisone valerate 63HEALTHY LIVING HUMATROPE COMBOREPLACEMENT FILTERS 151 PACK 91 hydrocortisone w/aceticHEALTHY LIVING acid 231HUMIRA 5REPLACEMENT KIT FOR hydrocortisone-aloe vera 63HUMIRA PEDIATRIC CROHNSNEBULIZER 151 HYDROFERA BLUE 4"X4" 80DISEASE STARTER PACK 5HEALTHY LIVING HYDROFERA BLUE FOAMHUMIRA PEN 5REPLACEMENT MASKS 151 DRESSING 80HUMIRA PEN-CROHNSHEART 219 HYDROFERA BLUE FOAMDISEASESTARTER 5HEMANGEOL 47 DRESSING 2"X2" 80HUMIRA PEN-PSORIASIS HYDROFERA BLUE FOAMHEMENATAL OB 213 STARTER 5 DRESSING 4"X4" 80HEMENATAL OB + DHA 213 HUMULIN 70/30 27 HYDROFERA BLUE FOAM

HUMULIN 70/30HEMOCYTE 97 DRESSING 6"X6" 80KWIKPEN 27 HYDROFERA BLUE FOAMHEMOCYTE PLUS 97 HUMULIN N 27 DRESSING/MOISTUREheparin sodium (porcine) 19 HUMULIN N KWIKPEN 27 RETENTIVE FILM 80

HEPSERA 46 HYDROFERA BLUE FOAMHUMULIN R 27HETLIOZ 98 DRESSING/MOISTUREHUMULIN R U-500 RETENTIVE FILM/2-1/4X8 80HEXALEN 37 (CONCENTRATED) 27 HYDROFERA BLUE FOAMHIBICLENS 43 HUMULIN R U-500 DRESSING/MOISTUREHIGH SENSATION KWIKPEN 27 RETENTIVE FILM/4"X4" 80SPERMICIDAL 101 HY-VEE GLUCOSE 26

Index 27

HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE FILM/ISLAND 80 HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE/OSTOMY/2.5" 80 HYDROFERA BLUE FOAM DRESSING/TUNNELING/9MM

80 HYDROFERA BLUE HEAVY DRAINAGE 4"X4" 80 HYDROFERA BLUE HEAVY DRAINAGE 6"X6" 80 HYDROFERA BLUE READY FOAMDRESSING 2.5"X2.5" 80 HYDROFERA BLUE READY FOAMDRESSING 4"X5" 80 HYDROFERA BLUE READY FOAMDRESSING 8"X8" 80 hydromorphone hcl 9 HYDROMORPHONE HCL 9 hydromorphone hcl 9 hydroxychloroquine sulfate 36 hydroxyurea 39 HYDROXYZINE HCL 15 hydroxyzine hcl 15 HYDROXYZINE PAMOATE 15 hydroxyzine pamoate 15 hyoscyamine sulfate 236 HYPER-SAL 54 HYPERSAL 54 HYPOTEARS 226 hypromellose (gonioscopic) 226 hypromellose (ophth) 226 HYSINGLA ER 9 HYVEE ADVANCED ANTACID MAXIMUM STRENGTH 13 HYZAAR 35 ibandronate sodium 91 IBRANCE 38 IBUDONE 11 ibuprofen 6 ICAPS AREDS FORMULA 169 ICAPS PLUS 169 ICAR-C PLUS 97 ICLUSIG 38 IDHIFA 38 ILEVRO 230 imatinib mesylate 38 IMBRUVICA 38 imipramine hcl 24

imipramine pamoate 24 imiquimod 72 IMITREX 154,155 IMITREX STATDOSE REFILL 155 IMITREX STATDOSE SYSTEM 155 IMMUNE SUPPORT 169 IMMUNE SUPPORT VITAMIN C 169 IMODIUM A-D 29 IMURAN 158 IN TOUCH BLOOD GLUCOSE TEST STRIPS 87 IN TOUCH GLUCOSE CONTROLSOLUTION 110 IN TOUCH LANCING DEVICE 110 IN TOUCH STERILE LANCETS30G 110 INATAL ADVANCE 213 INATAL GT 213 INATAL ULTRA 214 INCRUSE ELLIPTA 16 indapamide 90 INDERAL LA 47 INDERAL XL 47 INDOCIN 6 indomethacin 6 INFANATE BALANCE 214 INFANTS ADVIL 6 INFINITY BLOOD GLUCOSE TEST STRIPS 87 INFINITY CONTROL SOLUTION HIGH 110 INFINITY CONTROL SOLUTION LOW 110 INFINITY CONTROL SOLUTION NORMAL 110 INGREZZA 233 INLYTA 38 INNOPRAN XL 47 INNOSPIRE REPLACEMENT FILTER 152 inositol niacinate 49 INSPIRACHAMBER/ANTI-STATIC VALVED/MOUTHPIECE 152 INSPIRACHAMBER/LARGE

152 INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM 152

INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL

152 INSPIREASE DRUG DELIVERYSYSTEM 152 INSPIREASE RESERVOIR BAGS 152 INSPRA 36 INSTA-GLUCOSE 26 INSULIN SYRINGE/0.3ML/29G X1" 133 INSULIN SYRINGE/0.3ML/29G X1/2" 133 INSULIN SYRINGE/0.3ML/30G X5/16" 133 INSULIN SYRINGE/0.3ML/31G X5/16" 133 INSULIN SYRINGE/0.5ML/27G X1/2" 133 INSULIN SYRINGE/0.5ML/28G X1/2" 133 INSULIN SYRINGE/0.5ML/29G X1/2" 133 INSULIN SYRINGE/0.5ML/30G X1/2" 133 INSULIN SYRINGE/0.5ML/30G X5/16" 133 INSULIN SYRINGE/0.5ML/31G X5/16" 133 INSULIN SYRINGE/1ML/28G X1/2" 134 INSULIN SYRINGE/1ML/29G X1/2" 134 INSULIN SYRINGE/1ML/30G X5/16" 134 INSULIN SYRINGE/1ML/31G X5/16" 134 INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 134 INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 134 INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 134 INSULIN SYRINGE/U-100/1ML/28G X 1/2" 134 INSULIN SYRINGE/U-100/1ML/29G X 1/2" 134 INSULIN SYRINGE/U-100/1ML/30G X 5/16" 134 INSULIN SYRINGE/U-100/1ML/31G X 5/16" 134 INSULIN SYRINGES/0.5ML/27GX1/2"

134 INSULIN SYRINGES/0.5ML/28GX1/2"

134

Index 28

INSULIN IOPIDINE 228 K-PAX IMMUNE SUPPORTSYRINGES/0.5ML/29GX1/2" FORMULA SINGLEipratropium bromide 16

134 STRENGTH 169ipratropium bromideINSULIN K-PHOS NEUTRAL 157(nasal) 224SYRINGES/0.5ML/30GX5/16" ipratropium-albuterol 17 K-TAB 158134 KADIAN 9INSULIN irbesartan 34

SYRINGES/0.5ML/31GX irbesartan-hydrochlorothiazide KALBITOR 96 5/16" 134 35 KALETRA 44INSULIN IRESSA 38 KALTOSTAT 80SYRINGES/0.5ML/31GX5/16" iron polysaccharide complex-vit KALTOSTAT FORTEX 80134 b12-folic acid 97INSULIN KALTOSTAT WOUNDiron-vitamin c-vitamin b12-folicSYRINGES/1ML/27GX/1/2" DRESSING 80acid 97

134 KALYDECO 235ISENTRESS 44INSULIN isometheptene-caffeine- KAMELEON LUBRICATED 101SYRINGES/1ML/27GX1/2" 134 acetaminophen 154 KAPVAY 3INSULIN isometheptene-SYRINGES/1ML/28GX1/2" 134 KAYEXALATE 159dichloralphenazone-INSULIN KAZANO 25acetaminophen 154SYRINGES/1ML/29GX1/2" 134 KEFLEX 49ISONIAZID 37INSULIN SYRINGES/1ML/30GX1/2" 134 isoniazid 37 KENALOG 63 INSULIN KENDALL ALGINATEISOPTO CARPINE 227SYRINGES/1ML/31GX5/16" HYDROCOLLOID DRESSINGISOPTO TEARS 226134 4"X4" 80

ISORDIL TITRADOSE 14 KENDALL ALGINATEINSUPEN 29G X 12MM 134 HYDROCOLLOID DRESSINGisosorbide dinitrate 15INSUPEN 31G X 5MM 134 4"X5" 80ISOSORBIDE DINITRATEINSUPEN 31G X 8MM 134 KENDALL ALGINATEER 14INSUPEN 32G X 4MM 134 HYDROCOLLOID DRESSINGisosorbide mononitrate 15INSUPEN PEN NEEDLES 32G 6"X6" 80

X4MM 134 isotretinoin 56 KENDALL ALGINATE INSUPEN SENSITIVE isradipine 48 HYDROCOLLOID DRESSING 32GX6MM 134 ISTALOL 227 6"X7" 80 INSUPEN ULTRAFIN KENDALL ALGINATEitraconazole 3029GX12MM 134 HYDROCOLLOID DRESSING

J & J BURN CREAM 69INSUPEN ULTRAFIN 8"X8" 80 30GX8MM 134 JADENU 29 KENDALL ZINC CALCIUM INSUPEN ULTRAFIN ALGINATE DRESSINGJAKAFI 3831GX6MM 134 2"X2" 80JALYN 95INSUPEN ULTRAFIN KENDALL ZINC CALCIUM 31GX8MM 134 JANUMET 25 ALGINATE DRESSING INTEGRA 97 JANUMET XR 25 4"X4" 80

KENDALL ZINC CALCIUMINTELENCE 44 JANUVIA 26 ALGINATE DRESSINGINTENSE SENSATION 101 JARDIANCE 28 4"X8" 80 INTERMEZZO 98 JENTADUETO 25 KEPPRA 19,20 INTUNIV 3 JENTADUETO XR 25 KEPPRA XR 20 INVEGA 41 JUBLIA 59 KERADAN 69 INVEGA SUSTENNA 41 JUXTAPID 33 KERAMATRIX REPLICINE INVEGA TRINZA 41 K-PAX IMMUNE SUPPORT 10CMX10CM 80

KERAMATRIX REPLICINEFORMULA DOUBLEINVIRASE 44 5CMX5CM 80STRENGTH 169INVOKAMET 25 KERI ADVANCED MOISTUREK-PAX IMMUNE SUPPORT THERAPY 69INVOKAMET XR 25 FORMULA PROFESSIONAL

STRENGTH KERI BASIC ESSENTIALSINVOKANA 28 169 69 KERI LONG LASTING 69

Index 29

KERI NOURISHING SHEA KINRAY INSULIN SYRINGE KROGER LANCETS 21G 110 BUTTER 69 PREFERRED KROGER LANCETS MICRO KERI ORIGINAL 69 PLUS/0.5ML/31G X 5/16" 135 THIN33G 110

KINRAY INSULIN SYRINGEKERI OVERNIGHT 69 KROGER LANCETS SUPERPREFERRED PLUS/1ML/31G THIN 110KERI RENEWAL MILK X 5/16" 135BODY 69 KROGER LANCETS THIN 110KINRAY INSULINKERI RENEWAL SKIN KROGER LANCETS THINSYRINGE/0.5ML/29G XFIRMING 69 26G 1101/2" 135KERI RENEWAL STRETCH KROGER LANCETSKITABIS PAK 4MARK MINIMIZER 69 ULTRATHIN30G 110

KERI SENSITIVE SKIN 69 KLARON 56 KROGER LANCING DEVICE 110KERLIX SUPER SPONGE KLONOPIN 19 KROGER PEN NEEDLES 29GSALINE DRESSING 81 KLOR-CON M15 158 X12MM 135KETEK 14 KMART VALU PLUS INSULIN KROGER PEN NEEDLES 31G

KETOCARE 87 SYRINGE/1ML/29G 135 X8MM 135KMART VALU PLUS INSULINketoconazole 30 KROGER PEN NEEDLESSYRINGE/1ML/30G 135 31GX1/4" 135ketoconazole (topical) 59 KOMBIGLYZE XR 25 KROGER PREMIUM BLOODKETONE TEST STRIPS 87 KONSYL 99 GLUCOSE TEST STRIPS 87

ketoprofen 6 KROGER TEST STRIPS 87KP MENS DAILY PACK 169KETOPROFEN ER 6 KP PRENATAL KYNAMRO 32 ketorolac tromethamine 6 MULTIVITAMINS 214 labetalol hcl 47 ketorolac tromethamine KP WOMENS DAILY LAC-HYDRIN 69(ophth) 230 PACK 169

LAC-HYDRIN TWELVE 69KETOSTIX 87 KPN PRENATAL 214 LACTAID 89ketotifen fumarate (ophth) 230 KROGER BLOOD GLUCOSE

TESTSTRIPS 87 LACTAID FAST ACT 89KHEDEZLA 24 KROGER GLUCOSE 26 lactase 89KIDNEY 219 KROGER INSULIN lactic acid (ammoniumKIMONO COLORS 101 SYRINGE/0.3ML/29G X lactate) 69 KIMONO LUBRICATED 101 1/2" 135 LACTINOL HX 69 KIMONO MICRO THIN PLUS KROGER INSULIN lactobacillus acidophilus-SPERMICIDE SYRINGE/0.3ML/30G X pectin 28LUBRICATED 101 5/16" 135 lactulose 99KIMONO PLUS SPERMICIDE KROGER INSULIN LUBRICATED 101 SYRINGE/0.3ML/31G X lactulose (encephalopathy) 94 KIMONO PLUS 5/16" 135 LADY ESTHER 4 PURPOSE SPERMICIDE/LUBRICATED KROGER INSULIN FACE CREAM 69

101 SYRINGE/0.5ML/29G X LAMICTAL 20 1/2" 135KIMONO PS LUBRICATED101 LAMICTAL CHEWABLEKROGER INSULINKIMONO PS PLUS DISPERSIBLE 20SYRINGE/0.5ML/30G XSPERMICIDE/LUBRICATED LAMICTAL ODT 205/16" 135101 LAMICTAL STARTER/NOTKROGER INSULINKIMONO SENSATION TAKING CARBAMAZEPINE 20SYRINGE/0.5ML/31G XLUBRICATED 101 LAMICTAL STARTER/TAKING5/16" 135KIMONO SENSATION PLUS CARBAMAZEPINE/NOT TAKINGKROGER INSULINSPERMICIDE VALPROATE 20SYRINGE/1ML/29G XLUBRICATED 101 LAMICTAL STARTER/TAKING1/2" 135KIMONO SPECIAL 101 VALPROATE 20KROGER INSULIN LAMICTAL XR 20KINERET 5 SYRINGE/1ML/30G X

KINNEY LANCETS 110 5/16" 135 LAMISIL 30 KROGER INSULIN LAMISIL ADVANCED 59KINNEY THIN LANCETS 110 SYRINGE/1ML/31G XKINRAY INSULIN SYRINGE LAMISIL AT 595/16" 135PREFERRED PLUS/0.3ML/31G LAMISIL AT JOCK ITCH 59KROGER LANCETS 110X 5/16" 134

Index 30

LAMISIL AT SPRAY 59 LANTUS 27 LEADER UNIFINE

lamivudine lamivudine (hbv)

44 46

LANTUS SOLOSTAR LANZO

27 111

PENTIPS/NANO/32GX5/32"136

LEADER UNIFINE lamivudine-zidovudine 44 lamotrigine 20 LANAPHILIC 69 LANCET DEVICE ADJUSTABLE 111 LANCET DEVICE WITH EJECTOR 111 LANCETS 111 LANCETS 26G TWIST TOP 111 LANCETS 28G 111 LANCETS 30G 111 LANCETS 30G TWIST TOP 111 LANCETS 30G/TWISTTOP 111 LANCETS 31G TWIST TOP 111 LANCETS 33G UNIVERSAL DESIGN 111 LANCETS MICRO THIN 33G 111 LANCETS SAFETY SEAL 21G 111 LANCETS SAFETY SEAL 26G 111 LANCETS SAFETY SEAL 28G 111 LANCETS SAFETY SEAL 30G 111 LANCETS SUPER THIN 28G 111 LANCETS THIN 111 LANCETS TWIST TOP 111 LANCETS ULTRA FINE 111 LANCETS ULTRA THIN 111 LANCETS ULTRA THIN 30G 111 LANCETSBULLSEYE SAFETY 111 LANCING DEVICE 111 LANCING DEVICE ADJUSTABLE 111 LANOLOR 69 LANOXIN 49 lansoprazole 237 lanthanum carbonate 95 LANTISEPTIC SKIN

LASIX 90 LASTACAFT 230 latanoprost 230 LATUDA 41 LAZANDA 9 LEADER ADVANCED LANCING DEVICE 111 LEADER FINGER CREAM69 LEADER GLUCOSE 26 LEADER INSULIN SYRINGE/0.3ML/29G X1/2" 135 LEADER INSULIN SYRINGE/0.3ML/30G X5/16" 135 LEADER INSULIN SYRINGE/0.3ML/31G X5/16" 135 LEADER INSULIN SYRINGE/0.5ML/28G X1/2" 135 LEADER INSULIN SYRINGE/0.5ML/29G X1/2" 135 LEADER INSULIN SYRINGE/0.5ML/30G X5/16" 135 LEADER INSULIN SYRINGE/0.5ML/31G X5/16" 135 LEADER INSULIN SYRINGE/1ML/28G X1/2" 135 LEADER INSULIN SYRINGE/1ML/29G X1/2" 135 LEADER INSULIN SYRINGE/1ML/30G X5/16" 135 LEADER INSULIN SYRINGE/1ML/31G X5/16" 135 LEADER QUICK DISSOLVE GLUCOSE 26 LEADER UNIFINE PENTIPS PLUS/MINI/31GX3/16" 135 LEADER UNIFINE PENTIPS PLUS/SHORT/31GX5/16"

135 LEADER UNIFINE

PENTIPS/PLUS/32GX5/32"136

leflunomide 7 LENVIMA 10 MG DAILY DOSE 38 LENVIMA 14 MG DAILY DOSE 38 LENVIMA 18 MG DAILY DOSE 38 LENVIMA 20 MG DAILY DOSE 39 LENVIMA 24 MG DAILY DOSE 39 LENVIMA 8 MG DAILY DOSE 39 LESCOL XL 33 LETAIRIS 49 letrozole 38 LEUCOVORIN CALCIUM 39 leucovorin calcium 39 LEUKERAN 37 levalbuterol hcl 17 LEVALBUTEROL TARTRATE HFA 17 LEVAQUIN 93 LEVBID 236 LEVEMIR 27 LEVEMIR FLEXTOUCH 27 LEVETIRACETAM 20 levetiracetam 20 LEVETIRACETAM 20 levetiracetam 20 levetiracetam in sodium chloride 20 levobunolol hcl 227 levocarnitine (metabolicmodifiers) 92 levocetirizine dihydrochloride31 LEVOFLOXACIN 93 levofloxacin 93 levofloxacin (ophth) 228 levonorgestrel & ethestradiol 50 levonorgestrel (emergencyoc) 52 LEVONORGESTREL AND

PROTECTANT LANTISEPTIC THERAPEUTIC

74

69

PENTIPS/MINI/31GX3/16"135

ETHINYL ESTRADIOL levonorgestrel-eth estradiol(triphasic)

50

51

Index 31

levonorgestrel-ethinyl estradiol lisinopril 34 LITHIUM 41 (91-day) 51 lisinopril & LITHIUM CARBONATE 41levonorgestrel-ethinyl estradiol hydrochlorothiazide 35 lithium carbonate 41(continuous) 51 LITE TOUCH LANCETS 111LEVORPHANOL TARTRATE 9 LITHOBID 41LITE TOUCH LANCING levothyroxine sodium 236 DEVICE 111 LIVALO 33

LITE TOUCH LANCING LIVE BETTER ADVANCEDLEVSIN 236 PEN 111 LANCING DEVICE 111LEVSIN/SL 236 LITE TOUCH PEN LIVE BETTER LANCET

LEXAPRO 23 NEEDLES/31G X 3/16" 136 SUPERTHIN 30G 111 LIVE BETTER LANCETLEXIVA 44 LITEAIRE 152 ULTRATHIN 28G 112LEXIXRYL 58 LITETOUCH INSULIN LIVE BETTER PEN NEEDLESSYRINGE/0.3ML/29G XLIALDA 94 29G X 12MM 1361/2" 136LIBERTY CONTROL SOLUTION LIVE BETTER PEN NEEDLESLITETOUCH INSULINHIGH 111 31G X 12MM 136SYRINGE/0.3ML/30G XLIBERTY CONTROL LIVE BETTER PEN NEEDLES5/16" 136SOLUTIONNORMAL 111 31G X 6MM 136LITETOUCH INSULINLIBERTY GLUCOSE CONTROL LO LOESTRIN FE 51SYRINGE/0.3ML/31G XLEVEL 1 111 5/16" 136 LOCOID 63LIBERTY GLUCOSE CONTROL

LEVEL 2 111 LITETOUCH INSULIN LOCOID LIPOCREAM 63 SYRINGE/0.5ML/30G XLIBERTY GLUCOSE CONTROL LODINE 65/16" 136MID 111 LODOSYN 39LITETOUCH INSULINLIBERTY GLUCOSE CONTROL

NORMAL 111 SYRINGE/0.5ML/31G X LOESTRIN 1.5/30-21 51 LIBERTY MEDICAL LANCETS 5/16" 136 LOESTRIN 1/20-21 51LITETOUCH INSULIN30G 111 LOESTRIN FE 1.5/30 51LIBERTY MINI LANCING SYRINGE/1ML/30G X

LOESTRIN FE 1/20 51DEVICE 111 5/16" 136 LIBERTY NEXT GENERATION LITETOUCH INSULIN LOFIBRA 33 BLOOD GLUCOSE TEST SYRINGE/U-100/0.5ML/28G X LOMOTIL 29 STRIPS 87 1/2" 136 LOMUSTINE 37LITETOUCH INSULINLIBERTY TEST STRIPS 87 SYRINGE/U-100/0.5ML/29G X LONGS GLUCOSE 26lidocaine 74 1/2" 136 LONGS INSULIN lidocaine hcl 74 LITETOUCH INSULIN SYRINGE/0.5ML/31G Xlidocaine hcl (mouth-throat) 159 SYRINGE/U-100/1ML/28G X 5/16" 136

1/2" 136 LONGS LANCETSlidocaine-prilocaine 74 LITETOUCH INSULIN STANDARD 112LIDODERM 74 SYRINGE/U-100/1ML/29G X LONGS LANCETS THIN 112 LIFE PACK MENS 169 1/2" 136 LONGS LANCETS ULTRALITETOUCH INSULINLIFE PACK WOMENS 169 THIN 112SYRINGE/U-100/1ML/31G XLIFESCAN UNISTIK 2 DEEP LONSURF 385/16" 136PENETRATION 111 LITETOUCH LANCETS MICRO loperamide hcl 29LIFESCAN UNISTIK II THIN 33G 111 LOPID 33LANCETS 111 LITETOUCH MASKLINDANE 75 lopinavir-ritonavir 44LARGE 152 LOPRESSOR 47lindane 75 LITETOUCH MASK

MEDIUM LOPRESSOR HCTliniments & rubs 73 152 35 LITETOUCH MASK LOPROX 59LINZESS 94 SMALL 152

liothyronine sodium 236 LITETOUCH PEN NEEDLES LOPROX KIT 59 LOPROX SHAMPOO 59LIPIDSHIELD PLUS 219 29GX12.7MM 136

LITETOUCH PEN NEEDLES loratadine 31LIPITOR 33 31G X 6MM 136 loratadine &LIPOFEN 33 LITETOUCH PEN NEEDLES pseudoephedrine 53LIPOTRIAD 222 31GX8MM SHORT 136 lorazepam 15

Index 32

LORTAB 11 LYSTEDA 97 MARINOL 30 LORZONE 223 M-VIT 214 MARNATAL-F 214 losartan potassium 34 losartan potassium &hydrochlorothiazide 35 LOSEASONIQUE 51 LOTEMAX 229 LOTENSIN 34 LOTENSIN HCT 35 LOTREL 35 LOTRIMIN AF 59 LOTRIMIN AF FOR HER 59 LOTRIMIN AF JOCK ITCH 59 LOTRIMIN ULTRA 59 LOTRISONE 59 LOTRONEX 94 lovastatin 33 LOVAZA 32 LOVENOX 19 loxapine succinate 42 lubricants 74 LUBRIDERM 70 LUBRIDERM ADVANCED THERAPY 69 LUBRIDERM DAILY MOISTURE/NORMAL TO DRYSKIN 69 LUBRIDERM DAILY MOISTURESHEA + CALMING LAVENDER JASMINE 69 LUBRIDERM INTENSE SKIN REPAIR 70 LUBRIDERM MENS 3-IN-1 70 LUBRIDERM SERIOUSLY SENSITIVE 70 LUBRIDERM SKIN NOURISHINGWITH SHEA AND COCOA BUTTERS 70 LUBRIDERM SOOTHING RELIEF/COOLING 70 LUBRISOFT 70 LUMIGAN 231 LUNESTA 98 LUNG 219 LURIDE 157 LUXIQ 64 LUZU 59 LYMPH 219 LYNPARZA 39

M2 B-60 169 M2 CALCIUM 219 M2 CHROMIUM 219 MACNATAL CN DHA 214 MACROBID 238 MACRODANTIN 238 MACULAR VITAMIN BENEFIT 169 MAG64 157 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/29G X1/2" 136 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/30G X5/16" 136 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/29G X1/2" 136 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/30G X5/16" 136 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X1/2" 136 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/30G X5/16" 136 magnesium citrate 99 MAGNESIUM GLUCONATE 157 magnesium gluconate 157 magnesium hydroxide 99 magnesium oxide 14 magnesium oxide (mgsupplement) 157 MAGONATE 157 MAGOX 400 157 MAKENA 232 malathion 76 MAMMARY 219 MANGANESE GLUCONATE 157 MAPROTILINE HCL 22 MARATHON MEDICAL PENTIPS29GX12MM 136 MARATHON MEDICAL PENTIPS31GX5MM 136 MARATHON MEDICAL PENTIPS31GX8MM 136 MARATHON MEDICAL

MARPLAN 22 MATULANE 39 MAVIK 34 MAVYRET 46 MAXALT 155 MAXALT-MLT 155 MAXAM 70 MAXI-COMFORT INSULIN SYRINGE/U-100/0.5ML/28GX1/2" 137 MAXI-COMFORT INSULIN SYRINGE/U-100/1ML/28GX1/2"

137 MAXIDEX 229 MAXIMA BLOOD GLUCOSE TESTSTRIPS 87 MAXIMA CONTROL SOLUTION 112 MAXIMA CONTROL SOLUTION/NORMAL 112 MAXIMIN PACK 169 MAXITROL 229 MAXORB EXTRA AG+ 81 MAXX LUBRICATED 101 MAXX PLUS SPERMICIDE LUBRICATED 101 MAXZIDE 90 MAXZIDE-25 90 meclizine hcl 29 MECLOFENAMATE SODIUM 6 MEDELA TENDER CARE LANOLIN 70 MEDERMA AG FACE CREAM 70 MEDERMA AG HAND & BODY LOTION 70 MEDERMA STRETCH MARKS THERAPY 70 MEDI-PAK PERFORMANCE PLUSCOMBINE ABD PAD/8" X7.5" 81 MEDIC INSULIN SYRINGE/0.3ML/30G X5/16" 137 MEDIC INSULIN SYRINGE/0.5ML/30G X5/16" 137 MEDICATED CHEST RUB 55 MEDICHOICE PRE-SET SAFETY LANCET DUAL

LYRICA 20 PENTIPS32GX4MM 137 USE 112

Index 33

MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW 112 MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW 112 MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW 112 MEDICHOICE SAFETY

MEDLANCE PLUS UNIVERSAL LANCETS 21G 112 MEDLANCE PLUS/LITE25G 112 MEDLANCE/EXTRA 112 MEDLANCE/LITE 112 MEDLANCE/UNIVERSAL112 MEDROL 52

MEIJER SUPER THIN LANCETS 112 MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS 87 MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS 87 MEKINIST 39 melatonin 4 MELATONIN 4

LANCETEXTRA 112 MEDICHOICE SAFETY LANCETNORMAL 112 MEDICINE SHOPPE PEN NEEDLES 29G X 12MM 137 MEDICINE SHOPPE PEN NEEDLES 31G X 6MM 137 MEDICINE SHOPPE PEN NEEDLES 31G X 8MM 137 MEDIHONEY CALCIUM ALGINATE DRESSING 4"X5" 81 MEDIHONEY CALCIUM ALGINATE DRESSING/2"X2" 81 MEDIHONEY WOUND & BURN

MEDROL DOSEPAK 52 medroxyprogesterone acetate 232 medroxyprogesterone acetate(contraceptive) 52 mefenamic acid 6 mefloquine hcl 36 MEFLOQUINE HCL 36 MEGA MULTI MEN 169 MEGA MULTI WOMEN 169 MEGA MULTIVITAMIN 169 MEGA MULTIVITAMIN FOR MEN 169 MEGA MULTIVITAMIN FOR

MELOXICAM 6 meloxicam 6 melphalan 37 memantine hcl 232,233 MENACTRA 239 MENOMUNE-A/C/Y/W-135

239 MENOPAUSE RELIEF 219 MENS 50+ ADVANCED 169 MENS 50+ MULTI VITAMIN &MINERAL FORMULA 169 MENS MULTI VITAMIN & MINERAL FORMULA 169 MENS PACK 169

DRESSING 3/4"X12" 81 MEDIHONEY WOUND/BURNDRESSING4"X5" 81 MEDISENSE GLUCOSE KETONECONTROL SOLUTION 1-LOW,1-MED,1 HIGH 112 MEDISENSE GLUCOSE KETONECONTROL SOLUTION 1-NORMAL 112 MEDISENSE HIGH/LOWCONTROL SOLUTION 112 MEDISENSE HIGH/MID/LOWCONTROL SOLUTION 112 MEDISENSE MID CONTROL SOLUTION 112 MEDISENSE THIN LANCETS 112 MEDLANCE PLUS EXTRA LANCETS 21G 112 MEDLANCE PLUS LANCETS 112 MEDLANCE PLUS LANCETS LITE 25G 112 MEDLANCE PLUS LITE LANCETS 25G 112 MEDLANCE PLUS SPECIAL LANCETS 0.8MM 112 MEDLANCE PLUS SUPERLITE 30G 112 MEDLANCE PLUS SUPERLITE 30G/COMFORT MAX 112

WOMEN 169 MEGACE ORAL 38 MEGAVITE FRUITS & VEGGIES 169 MEGAVITE GOLDEN YEARS 55+ 169 megestrol acetate 38 MEIJER ALCOHOL SWABS EXTRA-THICK 120 MEIJER BLOOD GLUCOSE TESTSTRIPS 87 MEIJER COLOR LANCETS UNIVERSAL 33G 112 MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS 87 MEIJER GLUCOSE 26 MEIJER LANCETS 112 MEIJER LANCETS THIN 112 MEIJER LANCETS UNIVERSAL21G 112 MEIJER LANCETS UNIVERSAL30G 112 MEIJER LANCETS UNIVERSAL33G 112 MEIJER PEN NEEDLES 29G X12MM 137 MEIJER PEN NEEDLES 31G X6MM 137 MEIJER PEN NEEDLES 31G X8MM 137 MEIJER PREMIUM BLOOD

MENTAX 59 menthol (topical analgesic) 57 menthol-methyl salicylate(liniments) 73 menthol-zinc oxide 75 MENVEO 239 MEPERIDINE HCL 9 meperidine hcl 9 MEPHYTON 242 meprobamate 15 mercaptopurine 37 mesalamine 94 MESALAMINE DR 94 mesalamine w/ cleanser 94 MESTINON 37 MESTINON TIMESPAN 37 METADATE CD 3 METAMUCIL 99 METAPROTERENOL SULFATE 18 METAXALONE 223 metaxalone 223 metformin hcl 25 methadone hcl 9 METHADONE HCL 9 methadone hcl 9

GLUCOSE TEST STRIPS 87 METHADOSE 9

Index 34

METHADOSE SUGAR-FREE 9 MEVACOR 33 MINIVELLE 93 methamphetamine hcl 2 mexiletine hcl 16 MINOCIN 235 methazolamide 90 MG-PLUS PROTEIN 219 minocycline hcl 235 methenamine hippurate METHENAMINE

238 MH MACULAR HEALTH 169 MI PASTE 121

MINOCYCLINE HCL ER minoxidil

235 36

MANDELATE 238 methenamine mandelate 238 methenamine-hyosc-methyleneblue-sod phos-phenyl sal 238 METHERGINE 231

MI PASTE PLUS MIACALCIN MICARDIS MICARDIS HCT

121 91 34 36

MIRALAX MIRAPEX MIRAPEX ER MIRCERA

99 40 40 97

methimazole 236 MICATIN 59 MIRCETTE 51 methocarbamol 223 methotrexate sodium 37 METHOTREXATE SODIUM 37 methotrexate sodium 37 methoxsalen rapid 60 METHYCLOTHIAZIDE 90 methylcellulose (laxative) 99 methyldopa 35 METHYLDOPA/HYDROCHLOROTHIAZIDE 35 methylergonovine maleate 231 METHYLIN 3 METHYLPHENIDATE HCL 4 methylphenidate hcl 4 METHYLPHENIDATE HCL ER 4 METHYLPHENIDATE HCL ER (LA) 4 methylprednisolone 52 metoclopramide hcl 94 METOCLOPRAMIDE ODT 94 metolazone 90 metoprolol &hydrochlorothiazide 35 metoprolol succinate 47 METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE

36

miconazole nitrate (topical)59 miconazole nitrate vaginal 241 MICORT-HC 64 MICRO-K 158 MICROCHAMBER 152 MICRODOT CONTROL SOLUTIONHIGH/LOW 113 MICRODOT TEST STRIPS 87 MICROELITE FILTER REPLACEMENTS 152 MICROELITE RECHARGEABLE BATTERY 152 MICROLET LANCETS 113 MICROLET NEXT 113 MICROSPACER 152 MICROTAINER SAFETY FLOW LANCET/STERILE/SINGLE-USE 113 MICROZIDE 91 midodrine hcl 242 MIGERGOT 154 miglitol 24 MIGRANAL 154 MIGRANOW 154 MIL ADREGEN 219

mirtazapine 22 misoprostol 238 MITIGARE 96 MM PEN NEEDLES 31G X 1/4" 137 MM PEN NEEDLES 31G X 3/16" 137 MM PEN NEEDLES 31G X 5/16" 137 MM PEN NEEDLES 32G X 5/32" 137 MOBIC 6 MOBISYL 73 modafinil 4 MODICON 51 moexipril hcl 34 moexipril-hydrochlorothiazide

36 MOI-STIR 160 MOISTURIZING CREAM 70 MOLINDONE HYDROCHLORIDE 42 mometasone furoate 64 mometasone furoate (nasal) 224 MONISTAT 3 COMBINATION PACK 241 MONISTAT 7 SIMPLY CURE 241 MONISTAT SOOTHING CARE

metoprolol tartrate 47 METOPROLOL TARTRATE 47

MILADRENE FORTE MILCO-B-FORTE

219 163

ITCH RELIEF MONODOX

64 235

METOPROLOL/HYDROCHLOROTHIAZIDE 36 METOZOLV ODT 94 METROCREAM 75 METROGEL-VAGINAL 241 METROLOTION 75 metronidazole 14 metronidazole (topical) 75 metronidazole vaginal 241

MILLIPRED 52 MILPAN 219 MINASTRIN 24 FE 51 MINI LANCING DEVICE 113 MINIELITE FILTER REPLACEMENTS 152 MINIELITE RECHARGEABLE BATTERY 152 MINIPRESS 35

MONOJECT INSULIN SYRINGE/1MLMONOJECT INSULIN SYRINGE/1ML/31G X5/16"MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/25G X 5/8"MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/27G X 1/2"

137

137

137

137

Index 35

MONOJECT INSULIN SYRINGE/PERMNEEDLE/1ML/28G X 1/2" 137 MONOJECT INSULIN SYRINGE/PERM NEEDLE/U-100/0.5ML/28G X 1/2" 137 MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29G X 1/2" 137 MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29GX1/2" 137 MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2" 137 MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2" 137 MONOJECT INSULIN SYRINGE/SOFTPACK/1ML/27GX 1/2" 137 MONOJECT INSULIN SYRINGE/SOFTPACK/U-100/0.5ML/28G X 1/2" 137 MONOJECT INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 137 MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 137 MONOJECT INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 137 MONOJECT INSULIN SYRINGE/U-100/1ML/28G X1/2" 138 MONOJECT INSULIN SYRINGE/U-100/1ML/30G X5/16" 138 MONOJECT INSULIN SYRINGEREGULAR LUER TIP/SOFTPACK/1ML 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X1/2" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X5/16" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/28G X1/2" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/29G X1/2" 138

MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X5/16" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/28G X1/2" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/29G X1/2" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" 138 MONOLET LANCETS 113 MONOLET OPD LANCETS 113 MONOLETTOR SAFETY LANCETS 113 montelukast sodium 16 MOORE MED MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 138 MOORE MED MONOJECT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 138 MOORE MED MONOJECT INSULIN SYRINGE/U-100/1ML/28G X 1/2" 138 MOORE MED MONOJECT INSULIN SYRINGE/U-100/1ML/29G X 1/2" 138 MORGIDOX 1X100MG 235 MORGIDOX 1X50MG KIT 235 MORGIDOX 2X100MG 235 morphine sulfate 9,10 MORPHINE SULFATE 10 morphine sulfate 10 MORPHINE SULFATE ER 10 MOTHERS FRIEND 70 MOTRIN INFANTS DROPS 6 MOUTHKOTE 160 MOVANTIK 94 MOXATAG 231 MOXEZA 228 moxifloxacin hcl 93 moxifloxacin hcl (ophth) 228

MS CONTIN 10 MS INSULIN SYRINGE/0.3ML/31G X5/16"MS INSULIN

138

SYRINGE/0.5ML/31G X5/16" 138 MS INSULIN SYRINGE/1ML/31GX 5/16" 138 MSM SKIN LOTION 70 MTERYTI 214 MTERYTI FOLIC 5 214 MUCINEX 54 MUCINEX D 53 MUCINEX DM 54 MULTI FOR HER 169 MULTI FOR HIM 170 MULTI MEGA MINERALS 157 MULTI PRENATAL 214 MULTI-BETIC DIABETES 170 MULTI-GLAN 220 MULTI-LANCET DEVICE 113 MULTI-VITAMIN MONOCAPS 170 multiple minerals w/vitamins 157 multiple vitamin 208 multiple vitamins w/ calcium164 multiple vitamins w/ iron 164 multiple vitamins w/minerals 175,204 multiple vitamins w/ minerals &folic acid 170 MULTISOURCE CALCIUM MAGNESIUM & D FORMULA 157 MULTIVITAL PLATINUM 204 MULTIVITAMIN ADULT 204 MULTIVITAMIN ADULT EXTRAVITAMIN C 204 MULTIVITAMIN ADULTS 204 MULTIVITAMIN GUMMIES CHILDRENS 213 MULTIVITAMIN MEN 204 MULTIVITAMIN/FLUORIDE

208 MULTIVITAMINS W/A,B,D,E,AND K PLUS ZINC 204 mupirocin 58 mupirocin calcium (topical) 58 MURO 128 230

Index 36

MVW COMPLETE naproxen sodium 6 neomycin-polymyxin w/FORMULATIONCHEWABLES pramoxine 58naratriptan hcl 155MULTIVITAMIN 204 neomycin-polymyxin-gramicidin

NARCAN 29MYAMBUTOL 37 228 NARDIL 22 neomycin-polymyxin-hcmycophenolate mofetil 158 NASACORT ALLERGY (otic) 231

mycophenolate sodium 159 24HR 224 neomycin/polymyxin b gu 95 MYDAYIS 2 NASACORT ALLERGY 24HR NEOMYCIN/POLYMYXIN/HYDRMYDRIACYL 227 CHILDRENS 224 OCORTISONE 229

NASALMYFORTIC 159 NEORAL 159DECONGESTANT 225MYGLUCOHEALTH BLOOD NEOSALUS 70NASALCROM 224GLUCOSE TEST 87 NEOSPORIN 228

MYGLUCOHEALTH CONTROL NASONEX 224 NEOSPORIN GU IRRIGANT95LOW/NORMAL/HIGH 113 NAT-RUL C-COMPLEX 163 NEOSPORIN LIP HEALTHMYGLUCOHEALTH MGH NAT-RUL C-COMPLEX OVERNIGHT RENEWALSOFTLANCE LANCETS TR 163 THERAPY 7530G 113 NAT-RUL PRENATAL NEOSPORIN ORIGINAL 58MYLERAN 37 VITAMINS 214 NEOSPORIN PLUS PAINNAT-RUL THERAVITE-MYLICON 93

MYLICON INFANTS GAS M/HIGHPOTENCY 204 RELIEF MAXIMUM STRENGTH 58NATACYN 228RELIEF 93 NEPTAZANE 90MYNATAL ADVANCE 214 NATALVIT 214 NERLYNX 39MYNATAL PLUS 214 NATAZIA 51 NESINA 26MYNATAL ULTRACAPLET 214 nateglinide 28 NESTABS 214MYNATAL-Z 214 NATELLE ONE 214 NESTABS ABC 214MYOFLEX 73 NATESTO 12 NESTABS DHA 214MYRBETRIQ 239 NATROBA 76 NESTABS ONE 214MYSOLINE 20 NATRUL-100 204 NETGROUP LANCETS 113nabumetone 6 NATRUL-CAL 157 NEUPOGEN 97nadolol 47 NATRUL-CHEWS 204 NEUPRO 40nadolol & NATRUL-MEGA-75 204

bendroflumethiazide 36 NEURONTIN 20NATRUL-VITES 204naftifine hcl 59 NEUTEK 2TEK CONTROLNEBULIZER AIR SOLUTIONS 113NAFTIN 59 TUBE/PLUGS 152 NEUTEK 2TEK TESTNEBULIZER PEDIATRICNALFON 6 STRIPS 87MASK 152NALOXONE HCL 29 NEUTROGENA BODY LIGHTNEBUSAL 55 SESAME FORMULA 70naloxone hcl 29 NECON 1/50-28 51 NEUTROGENA HAND 70NALOXONE HCL 29 NECON 10/11-28 51 NEUTROGENAnaltrexone hcl 29 NEEVO DHA 214 HAND/NORWEGIANFORMULA/NAMENDA 233 FAST ABSORBING 70NEFAZODONE HCL 23NAMENDA TITRATION NEUTROGENA HEALTHY

nefazodone hcl 23PAK 233 SKIN 70 NAMENDA XR 233 NEO-SYNEPHRINE 12 HOUR NEUTROGENA HEALTHY SKIN

EXTRA MOISTURIZING 225 FACE SPF 15 70NAMENDA XR TITRATION PACK 233 neomycin sulfate 4 NEUTROGENA MOISTURE NAMZARIC 233 neomycin-bacitracin zn- SENSITIVE SKIN 70

polymyxin 228 NEUTROGENA T/GEL 76NAPHAZOLINE HCL 228 neomycin-bacitracin-polymyxin NEUTROGENA T/GELNAPRELAN 6 58 CONDITIONER 76 NAPROSYN 6 neomycin-bacitracin-polymyxin- NEUTROGENA T/GEL

pramoxine 58 STUBBORN ITCHNAPROXEN 6 neomycin-polymy- CONTROL 76 naproxen 6,7 dexameth 229 NEUTROGENA T/SAL 73

Index 37

NEVANAC NEVIRAPINE nevirapine NEW LIFE HAIR NEWGEN

230 44 44

220 214

NITRO-DUR nitrofurantoin nitrofurantoin macrocrystalnitrofurantoin monohyd macro

15 238

238

238

norgestimate-ethinylestradiol 51 norgestimate-ethinyl estradiol(triphasic) 51 norgestrel & ethinyl estradiol 51 NORINYL 1+35 51

NEXA PLUS 214 NEXAFED SINUS PRESSURE +PAIN 54 NEXAVAR 39 NEXGEN NORMAL

nitroglycerin NITROGLYCERIN LINGUAL NITROLINGUAL PUMPSPRAY

15

15

15

NORINYL 1+50 NORPACE NORPACE CR NORPRAMIN

51 16 16 24

CONTROL 113 NITROMIST 15 nortriptyline hcl 24 NEXGEN TEST STRIPS 87 NITROSTAT 15 NORTRIPTYLINE HCL 24 NEXIUM 237 NIVA-PLUS 214 NORTUSS-EX 54 NEXIUM 24HR 237 NIVEA 70 NORVASC 48 NEXIUM 24HR CLEAR NIVEA EXTRA NORVIR 44 MINIS 237 NF FORMULAS CHILDRENS CHEWABLE 209 niacin 242 niacin (antihyperlipidemic) 33 niacinamide 243 NIACOR 33 NIASPAN 33

ENRICHED 70 NIVEA EXTRA ENRICHED LOTION 70 NIVEA GENTLE BODY EXFOLIATOR 70 NIVEA LIGHT 70 NIVEA ORIGINAL 71 NIVEA ORIGINAL MOISTURE 71

NORWEGIAN COD LIVER OIL 222 NOSE CLIP 152 NOVA MAX GLUCOSE TEST STRIPS 87 NOVA MAX PLUS GLU/KETCONTROL SOLUTION-MID 113 NOVA MAX PLUS KETONE

NICADAN 204 NICADAN ZX 205 nicardipine hcl 48 NICAZEL 205 NICAZEL FORTE 205 NICODERM CQ 234 NICORETTE 234 NICORETTE MINI 234 NICORETTE STARTER KIT 234 nicotine 234 nicotine polacrilex 234 NICOTINE TRANSDERMAL

NIVEA SOFT NIVEA VISAGE NIVEA VISAGE INNER BEAUTY NIGHTTIME RENEWAL NIX CREME RINSE nizatidine NIZATIDINE NIZORAL NO IRON MULTIPLE VITAMIN/MINERALS NOR-QD NORCO

71 71

71 76

237 237 59

205 52 11

TESTSTRIPS 87 NOVA SAFETY LANCETS 23G 113 NOVA SAFETY LANCETS 28G 113 NOVA SUREFLEX LANCETS 113 NOVA SUREFLEX LANCING DEVICE 113 NOVOFINE 30GX8MM 138 NOVOFINE 32GX6MM 138 NOVOFINE AUTOCOVER 30GX8MM 138 NOVOFINE PLUS 32GX4MM 138

SYSTEM NICOTROL INHALER NICOTROL NS nifedipine NILANDRON

234 234 234 48 38

NORDITROPIN FLEXPRO91 norethin acet & estrad-fe 51 norethindrone & eth estradiol 51 norethindrone & ethinylestradiol-fe 51

NOVOLIN 70/30 NOVOLIN 70/30 RELION NOVOLIN N NOVOLIN N RELION NOVOLIN R

28 27 28 28 28

nilutamide 38 norethindrone NOVOLIN R RELION 28 nimodipine 48 NINLARO 39 NISEKO HYDRATING FACIAL MOISTURIZER 70 nisoldipine 48

(contraceptive) 52 norethindrone acet & eth estra 51 norethindrone acetate 232 norethindrone acetate-ethinylestradiol-fe 51

NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG MIX 70/30PREFILLED FLEXPEN

28 28 28

28 NISOLDIPINE ER 48 norethindrone-eth estradiol NOVOLOG PENFILL 28 NITRO-BID 15 (triphasic) 51 NOVOTWIST 30GX8MM 138

Index 38

NOVOTWIST 32GX5MM 138 ODEFSEY 44 ON CALL VIVID GLUCOSE NOXAFIL 30 NU-GEL WOUND DRESSING/3-3/4" X 3-3/4" 81 NU-GEL WOUND DRESSING/6"X 8" 81 NU-MAG 157 NUCYNTA 10

ODOMZO OFEV OFLOXACIN ofloxacin ofloxacin (ophth) ofloxacin (otic)

37 235 93 93

228 231

CONTROL LEVEL 1/2 113 ONCOVITE 205 ondansetron 29 ondansetron hcl 29 ONE DAILY MENS FORMULA W/O IRON 205 ONE DAILY PLUS IRON 205

NUCYNTA ER 10 OGESTREL 51 ONE-A-DAY ENERGY 205 NULYTELY/FLAVORPACKS 99 NUMOISYN 160 NUPERCAINAL 13 NUPLAZID 41 NUTRADERM 71 NUTRADERM ADVANCED FORMULA 71 NUTRASEB 71 NUTRICAP 205

OINTMENT BASE 71 olanzapine 42 olanzapine-fluoxetine hcl 233 olmesartan medoxomil 34 olmesartan medoxomil-amlodipine-hydrochlorothiazide

36 olmesartan medoxomil-hydrochlorothiazide 36 olopatadine hcl 230

ONE-A-DAY ESSENTIAL 208 ONE-A-DAY FOR HER VITACRAVES TEEN MULTI GUMMIES 205 ONE-A-DAY FOR HIM/VITACRAVES TEEN MULTIGUMMIES 205 ONE-A-DAY MENOPAUSE FORMULA 205 ONE-A-DAY MENS 208 ONE-A-DAY MENS 50+

NUTROPIN AQ NUSPIN 10 91 NUTROPIN AQ NUSPIN 20 91 NUTROPIN AQ NUSPIN 5 91 NUTROPIN AQ PEN 91 NUVARING 52 NUVESSA 241 NUVIGIL 4

olopatadine hcl (nasal) 224 OLUX 64 OLUX-E 64 OLYSIO 46 OMECLAMOX-PAK 238 omega-3 fatty acids 226 omega-3-acid ethyl esters 32

ADVANTAGE 205 ONE-A-DAY MENS HEALTH FORMULA 205 ONE-A-DAY MENS PRO EDGE 205 ONE-A-DAY MENS VITACRAVES GUMMIES 205 ONE-A-DAY SCOOBY-DOO GUMMIES 209

NYMALIZE nystatin nystatin (mouth-throat)

48 30

159

omeprazole omeprazole-sodiumbicarbonate OMNARIS

237

238 224

ONE-A-DAY TEEN ADVANTAGEFOR HIM 205 ONE-A-DAY VITACRAVES 205 ONE-A-DAY VITACRAVES

nystatin (topical) 59 OMNICAP 208 GUMMIES+OMEGA-3 nystatin-triamcinolone NYTOL MAXIMUM STRENGTH O-CAL FA O-CAL PRENATAL OB COMPLETE

60

98 214 214 214

OMNIPRED 229 OMNITROPE 91,92 ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS 87 ON CALL EXPRESS GLUCOSE CONTROL

DHA 212 ONE-A-DAY VITACRAVES GUMMIES/IMMUNITYSUPPORT 205 ONE-A-DAY VITACRAVES SOURGUMMIES 205 ONE-A-DAY VITACRAVES

OB COMPLETE GOLD OB COMPLETE ONE OB COMPLETE PETITE

214 214 214

SOLUTION ON CALL LANCETS ON CALL LANCING DEVICE

113 113

113

WOMENS MULTI 205 ONE-A-DAY WEIGHT SMART ADVANCED 205 ONE-A-DAY WOMENS 50+

OB COMPLETE PREMIER 214 ON CALL PLUS BLOOD ADVANTAGE 205 OB COMPLETE/DHA OCALIVA OCEAN NASAL SPRAY

214 93

224

GLUCOSE TEST 87 ON CALL PLUS GLUCOSE CONTROL LEVEL 1/2 113 ON CALL PLUS

ONE-A-DAY WOMENS ACTIVE MIND & BODY 205 ONE-A-DAY WOMENS FORMULA 164

OCUFEN OCUFLOX OCUVITE ADULT 50+ OCUVITE ADULT FORMULA

230 228 205

205

LANCETS 113 ON CALL PLUS LANCING DEVICE 113 ON CALL VIVID BLOOD GLUCOSE TEST 87 ON CALL VIVID BLOOD

ONE-A-DAY WOMENS PETITES 205 ONE-A-DAY WOMENS PLUS HEALTHY SKIN SUPPORT205 ONE-A-DAY WOMENS PRENATAL 214

OCUVITE LUTEIN 205 GLUCOSE TEST STRIPS 87

Index 39

ONE-A-DAY WOMENS VITACRAVES GUMMIES 205 ONE-A-DAY/JOLLYRANCHER 209 ONETOUCH CLUB LANCETS FINE POINT 113 ONETOUCH COMBO PACK 113 ONETOUCH DELICA LANCETS EXTRA FINE 33G 113 ONETOUCH DELICA LANCETS FINE 30G 113 ONETOUCH DELICA LANCING DEVICE 113 ONETOUCH FINEPOINT LANCETS 113 ONETOUCH LANCETS 113 ONETOUCH ULTRA BLUE 87 ONETOUCH ULTRA CONTROL 113 ONETOUCH ULTRASOFT LANCETS 113 ONETOUCH VERIO CONTROL SOLUTION HIGH 113 ONETOUCH VERIO MID CONTROL SOLUTION 113 ONETOUCH VERIO TEST STRIPS 87 ONEXTON 56 ONFI 19 ONGLYZA 26 ONMEL 30 ONZETRA XSAIL 155 OPANA 10 OPANA ER (CRUSHRESISTANT) 10 ophthalmic irrigationsolution 230 OPSUMIT 49 OPTI-WOMAN 205 OPTICHAMBER ADVANTAGE 152 OPTICHAMBER ADVANTAGE/LARGEMASK 152 OPTICHAMBER ADVANTAGE/MEDIUM FACEMASK 152 OPTICHAMBER ADVANTAGE/SMALL FACEMASK 152 OPTICHAMBER DIAMOND152 OPTICHAMBER DIAMOND/LARGEFACEMASK 152

OPTICHAMBER DIAMOND/MEDIUM FACEMASK 152 OPTICHAMBER DIAMOND/SMALLFACEMASK 152 OPTICHAMBER FACE MASK/LARGE 152 OPTICHAMBER FACE MASK/MEDIUM 152 OPTICHAMBER FACE MASK/SMALL 152 OPTIHALER 153 OPTIHALER MDI DRUG DELIVERY SYSTEM 153 OPTIMUM AIRVITES 205 OPTISOURCE POST BARIATRIC SURGERY 205 OPTIUM TEST STRIPS 87 OPTIUMEZ TEST STRIPS 87 OPTIVITE P.M.T. 205 OPTUMRX BLOOD GLUCOSE TEST 87 OPTUMRX GLUCOSE CONTROL LEVEL 1/2 114 OPURITY 205 OPURITY/BYPASSOPTIMIZED 205 ORACEA 75 oral electrolytes 156 ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT 160 ORALAIR 4 ORALAIR ADULT SAMPLE KIT 4 ORALAIR ADULT STARTER PACK 4 ORALAIR CHILDREN/ADOLESCENTSSTARTER PACK 4 ORAP 234 ORAVIG 159 ORCHIC 220 ORENCIA 7 ORENCIA CLICKJECT 7 ORENITRAM 49 ORKAMBI 235 orphenadrine citrate 223 ORTHO MICRONOR 52 ORTHO TRI-CYCLEN 51 ORTHO TRI-CYCLEN LO 51 ORTHO-CYCLEN 51

ORTHO-NOVUM 1/35 51 ORTHO-NOVUM 7/7/7 51 oseltamivir phosphate 47 OSENI 25 OTEZLA 7 OTOVEL 231 OTREXUP 5 OVACE PLUS WASH 61 OVACE WASH 61 OVARY 220 OVCON-35 51 OVIDE 76 oxaprozin 7 OXAYDO 10 oxazepam 15 oxcarbazepine 21 oxiconazole nitrate 60 OXISTAT 60 OXSORALEN ULTRA 60 OXTELLAR XR 21 oxybutynin chloride 239 oxycodone hcl 10 OXYCODONE HCL ER 10 oxycodone w/acetaminophen 11 oxycodone-aspirin 11 OXYCODONE/ACETAMINOPHEN 11 OXYCODONE/IBUPROFEN 11 OXYCONTIN 10 oxymetazoline hcl 225 oxymorphone hcl 10 OXYMORPHONE HYDROCHLORIDE ER 10 OXYTROL 239 OXYTROL FOR WOMEN 239 oyster shell 156 P & S 73 PA MENS 50 PLUS VITAPAK 205 PA MENS VITAPAK 206 PA WOMENS 50 PLUS VITAPAK 206 PA WOMENS VITAPAK 206 PAIN-A-LAY 159 paliperidone 41 PALOMAR E 75 PAMELOR 24

Index 40

PANCREAZE 89 PEDIALYTE ADVANCED PEN NEEDLES 31G X CARE 156 5MM 139PANDEL 64 PEDIALYTE FREEZER PEN NEEDLES 31G XPANOXYL-4 CREAMY POPS 156 6MM 139WASH 56 PEDIALYTE SINGLES 156 PEN NEEDLES 31G X

pantoprazole sodium 237 8MM 139PEDIAPRED 52PARAFON FORTE DSC 223 PEN NEEDLES 31GX5/16" 139PEDIATRIC AEROSOLPARATHYROID 220 PEN NEEDLES 31GX6MMMASK 153 PARI ALTERA NEBULIZER PEDIATRIC (1/4") 139 HANDSET 153 MOUTHPIECE/DISPOSABLE PEN NEEDLES 31GX8MM 139 PARI BABY CONVERSION 153 PEN NEEDLES 31GX8MM KITSIZE 1 153 pediatric multiple vitamin w/ (5/16") 139 PARI BABY CONVERSION c 212 PEN NEEDLES 32G X KITSIZE 2 153 pediatric multiple vitamin w/ c & 4MM 139 PARI BABY CONVERSION fa 212 PEN NEEDLES 32G X KITSIZE 3 153 pediatric multiple vitamin w/ 5MM 139 PARI ERAPID NEBULIZER extra c & fa 212 PEN NEEDLES 32G X HANDSET 153 pediatric multiple vitamin w/ 6MM 139 PARI EXPIRATORY FILTER minerals & c 210,212 PEN NEEDLES 32GX4MM 139VALVE SET 153 pediatric multiple vitamins212 PEN-KERA 71PARI MASK SET 153 pediatric multiple vitamins w/ penicillin v potassium 231PARI SOFT PLASTIC ADULT iron 209 PENICILLIN VMASK 153 pediatric multivitaminsPARI SOFT PLASTIC w/fl 208 POTASSIUM 231 PEDIATRIC MASK 153 pediatric vitamins acd w/ penicillin v potassium 232 PARLODEL 40 fluoride 208 PENLAC NAIL LACQUER 60 PARNATE 22 pediatric vitamins adc 213 PENNSAID 58

peg 3350-kcl-sod bicarb-sodparoxetine hcl 23 PENTASA 94chloride-sod sulfateparoxetine mesylate 99 pentazocine w/ naloxone 12peg 3350-potassium chloride-(vasomotor) 234 sod bicarbonate-sod PENTIPS 29G X 12MM 139

PARVLEX 206 chloride 99 PENTIPS 29GX12MM 139PATADAY 230 PEG-INTRON 46 PENTIPS 31G X 5MM 139PATANASE 224 PEG-INTRON REDIPEN 46 PENTIPS 31G X 8MM 139PATANOL 230 PEG-INTRON REDIPEN PAK PENTIPS 31GX5MM 139PAXIL 23 4 46 PENTIPS 31GX6MM 139PEGANONE 21PAXIL CR 23 PENTIPS 31GX8MM 139PEGASYS 46PAZEO 230 PENTIPS 32G X 4MM 139PC LANCETS SUPER THIN PEGASYS PROCLICK 46

PENTIPS 32GX4MM 13930G 114 PEGINTRON 46 PC UNIFINE PENTIPS 29G pentoxifylline 96PELEVERUS 75X1/2" 138 PENTRAVAN 71PELEVERUS CLEAR 75PC UNIFINE PENTIPS 31G PENTRAVAN PLUS 71X5MM MINI 138 PELEVERUS GOLD 75 PC UNIFINE PENTIPS 31G PEN NEEDLES 29G X PEPCID 237 X6MM ULTRA SHORT 138 12MM 139 PEPCID AC 237 PC UNIFINE PENTIPS 31G PEN NEEDLES PEPCID AC MAXIMUMX8MM SHORT 139 29GX1/2" 139 STRENGTH 237 PCE 100 PEN NEEDLES PEPTO-BISMOL 28 PEARL DROPS EXTRA 30GX5/16" 139 PERCOCET 11STRENGTH 121 PEN NEEDLES ped multivitamins w/fl & 30GX8MM 139 PERFECT LANCETS 30G 114 iron 209 PEN NEEDLES 31G X 1/4" PERFECT PRESSURE

SHORT 139 ACTIVATED SAFETY LANCETSPEDIA-LAX 99 PEN NEEDLES 31G X 28G 114PEDIALYTE 157 3/16" 139 PERFOROMIST 18

Index 41

PERIDEX 159 PERIDIN-C 163 perindopril erbumine 34 permethrin 76 perphenazine 43 PERPHENAZINE/AMITRIPTYLINE 233

phenylephrine-mineral oil-petrolatum 13 phenylephrine-shark liver oil-cocoa butter 13 phenylephrine-shark liver oil-mineral oil-petrolatum 13 phenylephrine-witch hazel 13 PHENYTEK 21

PNV PRENATAL PLUS MULTIVITAMIN + DHA PNV TABS 29-1 PNV-DHA PNV-DHA+DOCUSATE PNV-OMEGA PNV-SELECT

214 214 214 214 214 214

PERSANTINE PERTZYE PETROLATUM PETROLEUM JELLY LIP TREATMENT

96 89 71

75

phenytoin phenytoin sodium phenytoin sodiumextended PHLEXY-VITS

22 22

22 206

PNV-TOTAL 214 PNV-VP-U 215 POCKET CHAMBER 153 POCKET SPACER 153 POCKETCHEM EZ BLOOD

PEXEVA 23 PHOS-NAK POWDER GLUCOSE TEST STRIPS 88 PFLEX PHARMACIST CHOICE

153 CONCENTRATE PHOSLYRA

158 95

POCKETCHEM EZ CONTROL LEVEL 1 114

ALCOHOLPREP PADS 120 PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS 87 PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS 88 PHARMACIST CHOICE ULTRA THIN LANCETS 114 PHARMACIST CHOICE ULTRA THIN LANCETS 28G 114 PHARMACIST CHOICE ULTRA THIN LANCETS 30G 114 PHARMACIST CHOICE ULTRA THIN LANCETS 31G 114 PHARMACIST CHOICE ULTRA THIN LANCETS 33G 114 PHARMACY COUNTER LANCETS 114 PHAZYME 93 PHAZYME ULTRA STRENGTH 93 phenazopyridine hcl 95 phenelzine sulfate 23 phenobarbital 98 PHENOBARBITAL 98 phenobarbital 98 phenol (antiseptic) 159 phenylephrine hcl (ophth) 228 phenylephrine hcl (oral) 225 phenylephrine in hard fat 13 phenylephrine-brompheniramine-dm 54 phenylephrine-chlorphen-dm

54 phenylephrine-cocoa butter 13 phenylephrine-dm-gg w/ apap 54

PHOSPHOLINE IODIDE 227 PHYTOMULTI 206 PILLOW MASK/ADULT 153 PILLOW MASK/CHILD 153 PILLOW MASK/PEDIATRIC 153 pilocarpine hcl 227 pilocarpine hcl (oral) 160 pimozide 234 pindolol 47 pioglitazone hcl 27 pioglitazone hcl-glimepiride 25 pioglitazone hcl-metforminhcl 25 piroxicam 7 PITUITARY 220 PLAN B ONE-STEP 52 PLAQUENIL 36 PLAVIX 96 PLEGRIDY 233 PLEGRIDY STARTER PACK 233 PLETAL 96 PNEUMOVAX 23 239 PNEUMOVAX 23/1DOSE 239 PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID 214 PNV FOLIC ACID + IRON MULTIVITAMIN 214 PNV OB+DHA 214 PNV PRENATAL PLUS MULTIVITAMIN 214

podofilox 73 POLY-VI-FLOR 208 POLY-VI-FLOR FS 208 POLY-VI-SOL 212 POLY-VI-SOL/IRON 209 polyethylene glycol 3350 99 polyethylene glycol-propyleneglycol (ophth) 226 POLYMEM ALGINATE DRESSING/3" X 3" 81 POLYMEM ALGINATE DRESSING/4" X 4" 81 POLYMEM ALGINATE DRESSING/5" X 5" 81 POLYMEM ALGINATE DRESSING/6.5" X 7.5" 81 POLYMEM SILVER DRESSING/4.25" X 4.25" 81 polymyxin b-trimethoprim 228 polysaccharide iron complex 97 POLYSPORIN 58 POLYTRIM 228 polyvinyl alcohol 226 polyvinyl alcohol-povidone(ophth) 226 POMALYST 38 PONSTEL 7 pot phosphate monobasic w/ sodphosphate dibasic &monobasic 158 potassium 158 potassium bicarbonate 158 potassium chloride 158 POTASSIUM CHLORIDE 158 potassium chloride 158 POTASSIUM CHLORIDE ER 158

Index 42

potassium chloride PRECISION SURE-DOSE PREFERRED PLUS INSULIN microencapsulated crystals INSULIN SYRINGE/0.5ML/29G SYRINGE/U-100/0.5ML/28G Xer 158 X 1/2" 139 1/2" 139 potassium citrate PRECISION SURE-DOSE PREFERRED PLUS INSULIN (alkalinizer) 95 INSULIN SYRINGE/0.5ML/30G SYRINGE/U-100/0.5ML/29G XPOTASSIUM X 3/8" 139 1/2" 140 GLUCONATE 158 PRECISION SURE-DOSE PREFERRED PLUS INSULIN POTIGA 21 INSULIN SYRINGE/1ML/28G X SYRINGE/U-100/0.5ML/30G X

1/2" 139 5/16" 140PR NATAL 400 215 PRECISION SURE-DOSE PREFERRED PLUS INSULINPR NATAL 400 EC 215 PLUSINSULIN SYRINGE/U-100/1ML/28G XPR NATAL 430 215 SYRINGE/0.3ML/29G X 1/2" 140 PR NATAL 430 EC 215 1/2" 139 PREFERRED PLUS INSULIN

PRECISION SURE-DOSE SYRINGE/U-100/1ML/29G XPRADAXA 19 PLUSINSULIN 1/2" 140PRALUENT 33 SYRINGE/1ML/29G X PREFERRED PLUS INSULIN pramipexole dihydrochloride 40 1/2" 139 SYRINGE/U-100/1ML/30G X

PRECISION THIN 5/16" 140PRAMLYTE 22 LANCETS 114 PREFERRED PLUS LANCETSPRAMOTIC 231 PRECISION THINS GP COLORED 21G 114

pramoxine hcl (rectal) 13 LANCET 114 PREFERRED PLUS LANCETS pramoxine-phenylephrine- PRECISION ULTRA SUPER THIN 30G 114 glycerin-petrolatum 13 LANCET 114 PREFERRED PLUS LANCETS pramoxine-zinc acetate 74 PRECISION XTRA 88 THIN 26G 114

PREFERRED PLUS UNIFINEPRANDIMET 25 PRECISION XTRA BLOOD PENTIPS 29G X 12MM 140GLUCOSE TEST STRIPS 88PRANDIN 28 PREFERRED PLUS UNIFINEPRECOSE 24prasugrel hcl 96 PENTIPS 31G X 6MM ULTRA

PRED FORTE 229 SHORT 140PRAVACHOL 33 PRED MILD 229 PREFERRED PLUS UNIFINEpravastatin sodium 33 PENTIPS 31G X 8MMPRED-G 229prazosin hcl 35 SHORT 140PRED-G S.O.P. 229PRECISION GLUCOSE PREFERRED PLUS UNIFINE

CONTROL 114 prednicarbate 64 PENTIPS 32GX4MM 140 PRECISION GLUCOSE prednisolone 52 PREFERRED PLUS UNIFINE CONTROLSOLUTION (TRI- prednisolone acetate PENTIPS/MINI/31GX5MM 140 LEVEL/HI/LO/NORMAL) 114 (ophth) 229 PREMARIN 93,241PRECISION GLUCOSE prednisolone sodium PREMIUM BLOOD GLUCOSEKETONECONTROL SOLUTION phosphate 52 TEST STRIPS 881-LOW, 1-HIGH 114 PREDNISOLONE SODIUM PREMIUM CONDOMSPRECISION PHOSPHATE 229 LUBRICATED 101GLUCOSE/KETONECONTROL PREDNISONE 52 PREMIUM PACKETS 206SOLUTIONS 1-HI 1-LO 114 prednisone 53 PREMPRO 92PRECISION PCX 88

PREDNISONE 53 PRENAISSANCE 215PRECISION PCX PLUS TEST STRIPS 88 PREDNISONE INTENSOL 52 PRENAISSANCE PRECISION POINT OF CARE BALANCE 215PREFERA OB 215 PRENAISSANCE HARMONYTEST STRIPS 88 PREFERAOB +DHA 215PRECISION QID TEST DHA 215 STRIPS 88 PREFERAOB ONE 215 PRENAISSANCE NEXT 215 PRECISION SOF-TACT TEST PREFERRED PLUS PRENAISSANCE NEXT-B 215 STRIPS 88 GLUCOSE 26 PRENAISSANCE PLUS 215PRECISION SURE-DOSE PREFERRED PLUS INSULIN INSULIN SYRINGE/0.3ML/30G X SYRINGE/U-100/0.3ML/29G X PRENATA 215 5/16" 139 1/2" 139 PRENATABS FA 215 PRECISION SURE-DOSE PREFERRED PLUS INSULIN PRENATABS RX 215INSULIN SYRINGE/0.5ML/28G X SYRINGE/U-100/0.3ML/30G X PRENATAL 2161/2" 139 5/16" 139

PRENATAL 19 215

Index 43

PRENATAL FORMULA 215 PRETTY FEET & HANDS 71 PROCARDIA XL 48 PRENATAL FORMULA A-FREE 215 PRENATAL LOW IRON 215 PRENATAL MULTIVITAMIN 215 PRENATAL MULTIVITAMIN + DHA 215 PRENATAL ONE DAILY 215 PRENATAL PLUS 215 PRENATAL PLUS IRON 215

PREVACID 237,238 PREVACID 24HR 237 PREVACID SOLUTAB 238 PREVIDENT 5000 DRY MOUTH 160 PREVIDENT 5000 PLUS 160 PREVIDENT FLUORIDE 160 PREVNAR 13 239 PREVPAC 238

PROCENTRA PROCERV HP prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCTOCORT PROCTOFOAM PRODIGY CONTROL

2 206 43 43 43 97 13 13

PRENATAL VITAMIN 216 PREZCOBIX 44 SOLUTIONHIGH 114 PRENATAL VITAMIN & PREZISTA 44 PRODIGY CONTROL MINERAL 216 PRENATAL VITAMIN/IRON 216 PRENATAL VITAMINS 216 PRENATAL VITAMINS PLUS LOW IRON 216 PRENATAL-U 216 PRENATE 216 PRENATE AM 216 PRENATE DHA 216 PRENATE ELITE 216

PRILOSEC 238 PRIMACARE 217 PRIMACOL BORDERED DRESSING 2"X2" 81 PRIMACOL BORDERED DRESSING 4"X4" 81 PRIMACOL BORDERED DRESSING 6"X6" 81 PRIMACOL DRESSING 4"X4" 81 PRIMACOL DRESSING 6"X6" 81

SOLUTIONLOW 114 PRODIGY INSULIN SYRING/U-100/0.3ML/31G X 5/16" 140 PRODIGY INSULIN SYRINGE/1/2ML/31G X5/16" 140 PRODIGY INSULIN SYRINGE/1ML/28G X 1/2" 140 PRODIGY LANCING DEVICE 114 PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS 88 PRODIGY PRESSURE

PRENATE ENHANCE 216 PRIMACOL DRESSING ACTIVATED SAFETY PRENATE ESSENTIAL PRENATE MINI PRENATE PIXIE PRENATE RESTORE

217 217 217 217

8"X8" PRIMACOL SPECIALTY DRESSING PRIMAQUINE PHOSPHATE

81

81

36

LANCETS PRODIGY SAFETY LANCETS PRODIGY TWIST TOP LANCETS

114

114

114 PRENATE STAR 217 primidone 21 PRODRIN 154

PREPARATION H 13 PRIMLEV 11 PROFE FORTE 217 PREPARATION H TOTABLES BURN RELIEF 13 PREPARATION H TOTABLES PAIN RELIEF 13 PREPLUS 217 PREQUE 10 217 PRESCRIPTIVE FORMULAS OPTIMAL VITAMIN PACKS MENS 206 PRESCRIPTIVE FORMULAS OPTIMAL VITAMIN PACKS WOMENS 206 PRESERVISION AREDS 206 PRESERVISION AREDS 2 206 PRESERVISION AREDS 2 + MULTI VITAMIN 206 PRESERVISION/LUTEIN 206 PRESSURE ACTIVATED SAFETYLANCET 21G 114 PRESTALIA 36 PRETAB 217

PRINIVIL 34 PRISTIQ 24 PRO COMFORT ALCOHOL PADS 120 PRO COMFORT LANCETS 30G 114 PRO COMFORT LANCETS 31G 114 PRO COMFORT PEN NEEDLES/31G X 8MM 140 PRO COMFORT PEN NEEDLES/32G X 4MM 140 PRO COMFORT PEN NEEDLES/32G X 5MM 140 PRO COMFORT PEN NEEDLES/32G X 6MM 140 PRO-CAL 206 PROAIR HFA 18 PROAIR RESPICLICK 18 probenecid 96 PROCARDIA 48

progesterone micronized 232 PROGRAF 159 PROLENSA 230 promethazine &phenylephrine 54 promethazine hcl 32 promethazine w/codeine 54 promethazine-dm 54 promethazine-phenylephrine-codeine 54 PROMETHAZINE/PHENYLEPHRINE 54 PROMETRIUM 232 PRONUTRIENTS SUPER B-COMPLEX+ANTIOXIDANTS

161 propafenone hcl 16 propranolol hcl 47 PROPRANOLOL HCL 47 propranolol hcl 48

Index 44

PROPRANOLOL/HYDROCHLOROTHIAZIDE 36 propylthiouracil 236 PRORENAL+D 206 PRORENAL+D/OMEGA-3 206 PROSCAR 95 PROSHIELD PROTECTIVE HANDCREAM 75 PROSTATE 220 PROSTEON 157 PROTECT CARDIO AF 206 PROTECT PLUS 206 PROTECT PLUS NF 206 PROTECT PLUS SO 206 PROTONIX 238 PROTOPIC 72 protriptyline hcl 24 PROVENTIL HFA 18

PX ADVANCED LANCING DEVICE 114 PX EXTRA SHORT PEN NEEDLES 31GX6MM 140 PX GLUCOSE 26 PX INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" 140 PX INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 140 PX INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" 140 PX INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 140 PX INSULIN SYRINGE/U-100/1ML/30G X 1/2" 140 PX INSULIN SYRINGE/U-100/1ML/31G X 5/16" 140 PX LANCET AUTO INJECTOR 114 PX LANCETS ULTRA THIN 115 PX LANCETS ULTRA THIN

QC PRENATAL QC UNIFINE PENTIPS 32GX4MM QC UNILET LANCETS 28G/ULTRA THINQC UNILET LANCETS 33G/MICRO THIN QNASL QNASL CHILDRENS QTERN QUARTETTE QUDEXY XR QUENCH QUESTRAN QUESTRAN LIGHT quetiapine fumarate QUFLORA PEDIATRIC QUICKTEK CONTROL SOLUTION

217

140

115

115 224 224 25 51 21

206 32 32 42

208

115 PROVERA PROVIDA DHA PROVIDA OB PROVIGIL

232 217 217

4

28G PX MINI PEN NEEDLES 31GX5MM PX PEN NEEDLE 29GX12MM

115

140

140

QUICKTEK TEST STRIPS QUILLICHEW ER QUILLIVANT XR QUIN B STRONG

88 4 4

206 PROZAC 23 PROZAC WEEKLY 23 pseudoephed-bromphen-dm 54 pseudoephedrine hcl 225 pseudoephedrine w/ codeine-gg 54 pseudoephedrine-guaifenesin

54 PSORCON 64 PSS SELECT GP LANCETS 114 PSS SELECT SAFETY LANCETS 114 psyllium 99 PTS PANELS GLUCOSE TEST 88 PTS PANELS KETONE TEST 88 PULMICORT 17 PULMICORT FLEXHALER 17 PULMOZYME 235

PX PEN NEEDLE 31GX8MM 140 PX PRENATAL MULTIVITAMINS 217 PX SHORTLENGTH PEN NEEDLES/31GX8MM 140 PYLERA 238 pyrazinamide 37 pyrethrins-piperonylbutoxide 76 PYRIDIUM 95 pyridostigmine bromide 37 pyridoxine hcl 243 pyrithione zinc 61 QBRELIS 34 QC ADVANCED LANCING DEVICE 115 QC ALCOHOL SWABS 120 QC COD LIVER OIL 222 QC LANCETS SUPER THIN 115

quinapril hcl 34 quinapril-hydrochlorothiazide

36 quinidine gluconate 16 QUINIDINE SULFATE 16 QUINIDINE SULFATE ER 16 QUINTABS 208 QUINTABS-M 206 QUINTET AC BLOOD GLUCOSETEST STRIPS 88 QUINTET BLOOD GLUCOSE TEST STRIPS 88 QUINTET GLUCOSE CONTROL/HIGH/NORMAL

115 QVAR 17 R-NATAL OB 217 RA ALCOHOL SWABS 120 RA CENTRAL-VITE UNDER 50MENS 206 RA CENTRAL-VITE UNDER

PUREFE OB PLUS PUREFE PLUS PURIXAN PUSH BUTTON SAFETY LANCETS 21G PUSH BUTTON SAFETY LANCETS 28G

217 97 37

114

114

QC LANCETS ULTRA THIN 115 QC PEN NEEDLES 29G X 12MM 140 QC PEN NEEDLES 31G X 6MM 140 QC PEN NEEDLES 31G X 8MM 140

50WOMENS RA COD LIVER OIL RA DRY MOUTH RA E-ZJECT COLOR LANCETSMICRO-THIN 33G RA E-ZJECT LANCETS 28G

206 222 160

115

115

Index 45

RA E-ZJECT LANCETS THIN RAZADYNE 233 REFUAH PLUS GLUCOSE 26G 115 RA E-ZJECT LANCETS THIN 28G 115 RA E-ZJECT LANCETS ULTRATHIN 30G 115 RA EAR CARE 220

RAZADYNE ER READYLANCE SAFETY LANCETS/21G/2.2MMREADYLANCE SAFETY LANCETS/23G/1.8MMREADYLANCE SAFETY

233

115

115

CONTROL SOLUTION REGLAN RELENZA DISKHALER RELION 2-IN-1 LANCING DEVICE 25G RELION 2-IN-1 LANCING

115 94 47

115

RA ESSENCE-C RA FLUORIDE

206 LANCETS/26G/1.8MMREADYLANCE SAFETY

115 DEVICE 30G RELION ALCOHOL

115

TOOTHPASTE 121 RA GENTLE SKIN CREAM 71

LANCETS/28G/1.8MMREADYLANCE SAFETY

115 SWABS 120 RELION BLOOD GLUCOSE

RA GLUCOSE 26 RA INSULIN SYRINGE/0.5ML/29G X1/2" 141 RA INSULIN SYRINGE/1ML/29GX 1/2" 141 RA INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 141 RA INSULIN SYRINGE/U-100/1ML/30G X 5/16" 141 RA LANCING DEVICE 115 RA ONE DAILY 217 RA OYSTER SHELL CALCIUM/VITAMIN D 156 RA PEN NEEDLES 31G X 5MM3/16" 141 RA PEN NEEDLES 31G X 8MM5/16" 141 RA PRENATAL 217 RA PRENATAL FORMULA/FOLICACID 217 RA RENEWAL ADVANCED HEALING 75 RA RENEWAL DRY SKIN THERAPY 71 RA SENSITIVE

LANCETS/30G/1.6MM 115 REALITY INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 141 REALITY INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 141 REALITY INSULIN SYRINGE/U-100/1ML/28G X1/2" 141 REALITY INSULIN SYRINGE/U-100/1ML/29G X1/2" 141 REALITY LANCETS 115 REALITY LATEX CONDOMS/LUBRICATED 10 1 REALITY LATEX/ULTRATEXTURED 101 REALITY LATEX/ULTRATHIN 101 REALITY SWABS 120 REALITY TRIGGER LANCETS 115 REBETOL 46 REBIF 234

TESTSTRIPS 88 RELION CONFIRM/MICROTEST STRIPS 88 RELION GLUCOSE 26 RELION INSULIN SYRINGE 1ML/31GX15/64" 141 RELION INSULIN SYRINGE/U-00/1ML/29G X 1/2" 141 RELION INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 141 RELION INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 141 RELION INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 141 RELION INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 141 RELION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 141 RELION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 141 RELION INSULIN SYRINGE/U-100/1ML/30G X 5/16" 141 RELION INSULIN SYRINGE/U-100/1ML/31G X 15/64" 141 RELION INSULIN SYRINGE/U-100/1ML/31G X 5/16" 141 RELION KETONE 88

TOOTHPASTE/FLUORIDE 121

REBIF REBIDOSE REBIF REBIDOSE

234 RELION KETONE TEST STRIPS 88

RA TRUETEST STRIPS 88 TITRATIONPACK 234 RELION LANCETS MICRO-RA WHITENING TOOTHPASTE/FLUORIDE

121 rabeprazole sodium 238 RADIAGUARD ADVANCED 71 RAGUS 206 RAGWITEK 4 raloxifene hcl 92 ramipril 34 ranitidine hcl 237 RAPAFLO 95 RAPAMUNE 159 rasagiline mesylate 40 RAYALDEE 92

REBIF TITRATION PACK234 REFISSA 57 REFRESH 227 REFRESH LIQUIGEL 226 REFRESH OPTIVE 227 REFRESH OPTIVE ADVANCED 226 REFRESH OPTIVE ADVANCED SENSITIVE 226 REFRESH OPTIVE MEGA-3 227 REFRESH OPTIVE SENSITIVE 227 REFRESH TEARS 227 REFUAH PLUS BLOOD GLUCOSETEST STRIPS 88

THIN33G 115 RELION LANCETS STANDARD 21G 115 RELION LANCETS THIN 26G 115 RELION LANCETS ULTRA-THIN30G 115 RELION LANCING DEVICE 115 RELION MINI PEN NEEDLES 31GX6MM 141 RELION PEN NEEDLES 29GX12MM 141 RELION PEN NEEDLES 31GX6MM 141 RELION PEN NEEDLES 31GX8MM 141

Index 46

82

RELION PEN NEEDLES RESCRIPTOR 45 RESTORE WOUND CARE 32GX4MM 141 DRESSING 4"X4"RESERPINE 35RELION PRIME BLOOD ADHESIVERESTA 71GLUCOSE TEST STRIPS 88 RESTORE WOUND CARE RELION SHORT PEN RESTA LITE 71 DRESSING 4"X4" NON-NEEDLES31GX8MM 141 ADHESIVE 82RESTASIS 229RELION ULTIMA BLOOD RESTORE WOUND CARERESTASIS MULTIDOSE 229GLUCOSE TEST STRIPS 88 DRESSING 4"X5" CONTACTRESTORE CLEANSER &RELION ULTIMA TEST LAYER 82MOISTURIZER 75STRIPS 88 RESTORE WOUND CARERESTORE CX WOUND CARERELION ULTRA THIN DRESSING 6"X6"DRESSING-STERILE 81LANCETS30G 115 ADHESIVE 82RESTORE DRESSING FORRELION ULTRA THIN PLUS RESTORE WOUND CAREPSORIASIS-STERILE 81LANCETS 32G 115 DRESSING 6"X8" 82RESTORE EXTRA THINRELION ULTRA THIN PLUS RESTORE WOUND CAREDRESSING 4"X4" 81LANCETS 33G 115 DRESSING 6"X8"RESTORE EXTRA THINRELISTOR 94 ADHESIVE 82DRESSING 6"X8" 81 RESTORE WOUND CARERELNATE DHA 217 RESTORE EXTRA THIN DRESSING 6"X8" CONTACTRELPAX 155 DRESSING 8"X8" 81 LAYER 82RESTORE HYDROGELREMEDY CLEAR-AID 75 RESTORE WOUND CAREGAUZE PAD 4"X4" 81REMERON 22 DRESSING 6"X8" NON-RESTORE PLUS WOUND ADHESIVE 82REMERON SOLTAB 22 CARE DRESSING 4"X4" 81 RESTORE WOUND CARERENAGEL 95 RESTORE PLUS WOUND DRESSING 8"X8" 82CARE DRESSING 4"X4"RENAPLEX-D 206 RESTORIL 98TAPERED EDGE 81RENVELA 95 RESTORE PLUS WOUND RETIN-A 56 repaglinide 28 CARE DRESSING 6"X6" RETIN-A MICRO 57 REPAGLINIDE/METFORMIN TAPERED EDGE 81 RETIN-A MICRO PUMP 57HYDROCHLORIDE 25 RESTORE PLUS WOUND

RETROVIR 45CARE DRESSING 6"X8" 82REPATHA 33 RESTORE PLUS WOUND REVATIO 49REPATHA PUSHTRONEX CARE DRESSING 6"X8" REVEAL BLOOD GLUCOSESYSTEM 33 TAPERED EDGE 82 TEST 88REPATHA SURECLICK 34 RESTORE PLUS WOUND REVLIMID 158REPLACE 206 CARE DRESSING 8"X8" 82 REXALL BLOOD GLUCOSEREPLACEMENT AIR RESTORE PLUS WOUND TEST STRIPS 88FILTER 153 CARE DRESSING 8"X8" REXALL LANCETS ULTRAREPLACEMENT FILTERS 153 TAPERED EDGE 82 THIN 115RESTORE PLUS WOUNDREPLICARE 1-1/2"X2-1/2" 81 REXULTI 43CARE DRESSINGREPLICARE 4"X4" 81 REYATAZ 45TRIANGLE 82

REPLICARE 6"X6" 81 RESTORE SILVER DRESSING RHEUMATREX 5 REPLICARE 8"X8" 81 2"X2" 82 RHINOCORT AQUA 224RESTORE SILVER DRESSINGREPLICARE THIN 2"X2.75" 81 ribavirin (hepatitis c) 464"X4" NON-ADHESIVE 82REPLICARE THIN 3.5"X5.5" 81 RESTORE SILVER DRESSING riboflavin 243 REPLICARE THIN 6"X8" 81 4"X4.75" 82 RID 76

RESTORE SILVER DRESSINGREPLICARE ULTRA 4"X4" 81 RID ESSENTIAL LICE4"X5" CONTACT LAYER 82 ELIMINATION KIT 76REPLICARE ULTRA 6"X6" 81 RESTORE SILVER DRESSING RIFADIN 37REPLICARE ULTRA SACRUM 6"X8" CONTACT LAYER 827"X8" 81 RESTORE SILVER DRESSING rifampin 37 REPREXAIN 11 6"X8" NON-ADHESIVE 82 RIGHT STEP PRENATAL 217 REQ 49+ 206 RESTORE WOUND CARE RIGHTEST GC300 HIGH REQUIP 40 DRESSING 4"X4" 82 CONTROL 115

RIGHTEST GC300 NORMALREQUIP XL 40 CONTROL 115

Index 47

RIGHTEST GD500 LANCING DEVICE 115 RIGHTEST GL300 LANCETS 115 RIGHTEST GS100 BLOOD

ropinirole hydrochloride ROSE MILK ROSULA rosuvastatin calcium

40 72 57 33

SAFETY INSULIN SYRINGES 1ML/30GX1/2" 142 SAFETY LANCET 21G/PRESSUREACTIVATED 116

GLUCOSE TEST STRIPS RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS rimantadine hydrochloride RIOMET RISABAL-PH risedronate sodium

88

88

88 47 25 71 91

ROWASA ROXICODONE ROZEREM RTD WOUND CARE DRESSING2" X 2" RTD WOUND CARE DRESSING4" X 4" RTD WOUND CARE DRESSING4" X 5"

94 10 99

82

82

82

SAFETY LANCET 28G/PRESSUREACTIVATED SAFETY LANCETS SAFETY LANCETS 21G SAFETY LANCETS 28G SAFETY LET LANCETS SAFETY SEAL LANCETS 28G

116 116 116 116 116

116 RISPERDAL 41 RUBRACA 39 SAFETY SEAL LANCETS RISPERDAL CONSTA RISPERDAL M-TAB risperidone RITALIN

41 41 41 4

RULAVITE DHA RYDAPT RYTARY RYTHMOL

217 39 40 16

30G SAFETY-GLIDE INSULIN SYRINGE/0.3ML/29G X1/2" SAFYRAL

116

142 51

RITALIN LA 4 SABRIL 21 SAIZEN 92 RITEFLO 153 rivastigmine 233 rivastigmine tartrate 233 rizatriptan benzoate 155 ROBAXIN 223 ROBAXIN-750 223 ROBINUL 236 ROBINUL FORTE 236 ROBITUSSIN DM 54 ROBITUSSIN PEAK COLD COUGH+ CHEST CONGESTION DM MAX STRENGTH 54 ROBITUSSIN PEAK COLD DM 54 ROC DEEP WRINKLE SERUM 71 ROC MULTI CORREXION 5 IN1 RESTORING EYE CREAM 71 ROC MULTI CORREXION 5 IN1 RESTORING NIGHT CREAM 71 ROC MULTI CORREXION LIFTANTI-GRAVITY NIGHT 71 ROC RETINOL CORREXION 71 ROC RETINOL CORREXION MAX 71 ROC RETINOL CORREXION NIGHT 71 ROC RETINOL CORREXION SENSITIVE EYE 71 ROC RETINOL CORREXION SENSITIVE NIGHT 71 ROCALTROL 92

SAFE-T-LANCE LOW FLOW 25G 115 SAFE-T-LANCE NORMAL FLOW21G 115 SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW 115 SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW 116 SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW 116 SAFESNAP INSULIN SYRINGE/0.3ML/30G X5/16" 141 SAFESNAP INSULIN SYRINGE/0.5ML/29G X1/2" 141 SAFESNAP INSULIN SYRINGE/0.5ML/30G X5/16" 141 SAFESNAP INSULIN SYRINGE/1ML/28G X1/2" 141 SAFESNAP INSULIN SYRINGE/1ML/29G X1/2" 142 SAFETY INSULIN SYRINGES 0.5ML/29GX1/2" 142 SAFETY INSULIN SYRINGES 0.5ML/30GX5/16" 142 SAFETY INSULIN SYRINGES 1ML/27GX1/2" 142 SAFETY INSULIN SYRINGES 1ML/29GX1/2" 142

SAIZEN CLICK.EASY 92 SAIZENPREP RECONSTITUTIONKIT 92 SALAGEN 160 SALESE 160 salicylic acid 73 salicylic acid & sulfur 61 saline 224 SAMI THE SEAL REPLACEMENTFILTERS 153 SANCUSO 29 SANDIMMUNE 159 SANTYL 72 SAPHRIS 42 SAPS CARE ALCOHOL PREP PADS 120 SAPSCARE TWIST TOP LANCETS 30G 116 SARNA 60 SAVAYSA 18 SAVELLA 233 SAVELLA TITRATION PACK 233 SAVISION 206 SB ALCOHOL PREP PADS 120 SB INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 142 SB INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 142 SB INSULIN SYRINGE/U-100/1ML/29G X 1/2" 142

Index 48

SB INSULIN SYRINGE/U-100/1ML/30G X 5/16"SB INSULIN SYRINGE/U-100/1ML/31G X 5/16" SB LANCETS THIN

142

142 116

SENSODYNE MAXIMUM STRENGTH 121 SENSODYNE MAXIMUM STRENGTH TARTAR CONTROL PLUS

SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/REMOVER/29GX12MM 142 SHOPKO UNIFINE PENTIPS

SB LANCETS ULTRA THIN SCHNUCKS INSULIN SYRINGEULTI-FINE/U-100/0.5ML/29G X 1/2"SCHNUCKS INSULIN SYRINGEULTI-FINE/U-100/0.5ML/30G X 5/16" scopolamine SE PLUS PROTEIN SE-NATAL 19

116

142

142 29

158 217

WHITENING 121 SENSODYNE PRONAMEL 121 SENSODYNE PRONAMEL FRESHBREATH 121 SENTRY 206 SENTRY SENIOR 206 SENTRY SENIOR/LUTEIN 206 SEREVENT DISKUS 18 SERNIVO 64

PLUS PEN NEEDLES/SHORT/REMOVR/31GX8MM 142 SHOPKO UNILET LANCETS SUPER THIN 30G 116 SHOPKO UNILET LANCETS ULTRA THIN 28G 116 SIDE BUTTON SAFETY LANCET21G 116 SIDEROL 206 SIDESTREAM ADULT FACE MASK 153

SE-TAN DHA 217 SEROQUEL 42 SIDESTREAM PEDIATRIC SEASONIQUE SEASORB-AG SEBULEX

51 82 61

SEROQUEL XR SEROSTIM sertraline hcl

42 92 23

FACEMASK 153 SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL 153

SECTRAL 47 sevelamer carbonate 95 SIDESTREAM PEDIATRIC SEEBRI NEOHALER SELECT-LITE LANCING DEVICE SELECT-OB SELECT-OB+DHA selegiline hcl selenium

16

116 217 217 40

158

SFROWASA 94 SHOHLS SOLUTION MODIFIED 95 SHOPKO ALCOHOL SWABS 120 SHOPKO AUTOLET LANCING DEVICE 116 SHOPKO ON-THE-GO

FACEMASK/TUCKER THETURTLE 153 SIDESTREAM PLUS ADULT FACE MASK 153 SIGNIFOR LAR 92 sildenafil citrate (pulmonaryhypertension) 49 SILENOR 98

SELENIUM 158 selenium sulfide 61 SELSUN BLUE DEEP CLEANSING 73 SELSUN BLUE NATURALS 73 SELSUN BLUE NATURALS

COMFORTLANCETS 30G 116 SHOPKO UNIFINE PENTIPS PEN NEEDLES/MICRO/32GX4MM

142 SHOPKO UNIFINE PENTIPS

SILICONE MASK FOR BREATHERITE CHAMBER/ADULTSILICONE MASK FOR BREATHERITE CHAMBER/INFANTSILICONE MASK FOR

153

153

DRYSCALP 73 PEN BREATHERITE SELZENTRY SENIOR VITES sennosides sennosides-docusate sodium SENOKOT SENOKOT S

45 206 100

99 100 99

NEEDLES/MINI/31GX5MM142

SHOPKO UNIFINE PENTIPS PEN NEEDLES/ORIGINAL/29GX12MM 142 SHOPKO UNIFINE PENTIPS PEN

CHAMBER/PEDIATRICSILICONE MASK FOR BREATHRITE CHAMBER/ADULT SILVADENE silver sulfadiazine SIMBRINZA

153

154 61 61

228

SENSI-CARE MOISTURIZING 75 SENSI-CARE PROTECTIVE BARRIER 75 SENSITIVE TOOTHPASTE EXTRA WHITENING/FLUORIDEMAX ST 121 SENSITIVE

NEEDLES/SHORT/31GX8MM142

SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/MICRO/REMOVR/32GX4MM 142 SHOPKO UNIFINE PENTIPS PLUS PEN

simethicone SIMPLE DIAGNOSTICS LANCING DEVICE SIMPONI simvastatin SINEMET SINEMET CR

93

116 5

33 40 40

TOOTHPASTE/FLUORIDE/MAXIMUM STRENGTH 121

NEEDLES/MINI/REMOVER/31GX5MM 142

SINGLE-LET SINGULAIR

116 16

Index 49

sirolimus 159 SMARTEST BLOOD SOOTHE & COOL SITAVIG SIVEXTRO

46 14

GLUCOSE TEST STRIPS 88 SMARTEST CONTROL SOLUTIONMEDIUM 116

MOISTURIZING BODY LOTION WITH ALOE 72 SOOTHE & COOL PROTECT

SKELAXIN 223 SMARTEST LANCETS MOISTURE BARRIER 75 SKIN BEAUTY & 28G 116 SOOTHE & COOL SKIN WELLNESS 206 sodium chloride 158 CREAMWITH ALOE & skin protectants, misc. SKIN REPAIR SKINTEGRITY 2" X 2" SKINTEGRITY 4" X 4" SKLICE SLO-NIACIN

75 72 82 82 76

243

sodium chloride (guirrigant) 95 sodium chloride (inhalant) 55 sodium chloride hypertonic 230 sodium citrate & citric acid 95 sodium fluoride 157

VITAMINS A, D & E 72 SOOTHENEB NBL 100 CHILD MASK 154 SOOTHENEB NBL 100 MEDICATION CUP 154 SOOTHENEB NBL 100 MESH CAP 154 SOOTHENEB NBL100 ADULT

SLOW FE 97 SLOW-MAG 157 SM ALCOHOL PREP PADS 120 SM B-COMPLEX/VITAMINC 163 SM GLUCOSE 26 SM INSULIN SYRINGE/1ML/31GX 5/16" 142 SM MICRO THIN LANCETS

sodium fluoride (dental) 160 sodium phosphates 99 sodium polystyrenesulfonate 159 SODIUM SULFACETAMIDE/SULFUR

57 SODIUM SULFACETAMIDE/SULFURCLEANSER IN UREA 57

MASK 154 SORBACELL FOAM DRESSING 4"X4" 82 SORBACELL FOAM DRESSINGSTRIP 1"X8" 82 SORBIDON HYDRATE 75 SORBOLENE 72 SORBSAN TOPICAL WOUND DRESSING 12" 82 SORBSAN TOPICAL WOUND

33G 116 SOLARTEK GLUCOSE DRESSING 2" X 2" 82 SM ONE DAILY CONTROLSOLUTIONS 116 SORBSAN TOPICAL WOUND ESSENTIAL 164 SM ONE DAILY MENS 206 SM ONE DAILY PRENATAL 217 SM ONE DAILY WOMENS 206 SM PRENATAL VITAMINS 217 SM TRUEDRAW LANCING DEVICE 116

SOLIQUA 100/33 25 SOLO 206 SOLODYN 235 SOLOSITE CONFORMABLE WOUND 2"X2" 82 SOLOSITE CONFORMABLE WOUND 4"X4" 82 SOLUS V2 AUDIBLE

DRESSING 3 X 3 82 SORBSAN TOPICAL WOUND DRESSING 4 X 4 83 SORBSAN TOPICAL WOUND DRESSING 4" X 8" 83 SORIATANE 60 SORILUX 61 sotalol hcl 48

SMART DIABETES VANTAGE LANCING DEVICE 116 SMART SENSE COLOR LANCETS UNIVERSAL

TEST SOLUS V2 CONTROL HIGH SOLUS V2 CONTROL

88

116

sotalol hcl (afib/afl) SOTYLIZE SOVALDI

48 48 46

33G 116 LOW 116 SPECIAL CARE CREAM 72 SMART SENSE GLUCOSE 26 SMART SENSE GLUCOSE TABLETS 26 SMART SENSE PREMIUM BLOODGLUCOSE STRIPS 88 SMART SENSE STANDARD LANCETS UNIVERSAL 21G 116 SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G 116 SMART SENSE THIN LANCETSUNIVERSAL 26G 116 SMART SENSE VALUE BLOOD GLUCOSE STRIPS 88

SOLUS V2 LANCING DEVICE 116 SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G 116 SOLUS V2 TWIST LANCETS 30G 116 SOMA 223 SONATA 98 SOOTHE & COOL FREE MEDSEPTIC 75 SOOTHE & COOL FREE MOISTURE BARRIER 75 SOOTHE & COOL FREE SKIN PASTE 75 SOOTHE & COOL MOISTURE BARRIER 75

specialty vitamins products 220 SPINOSAD 76 SPIRIVA HANDIHALER 16 SPIRIVA RESPIMAT 16 spironolactone 90 spironolactone &hydrochlorothiazide 90 SPLEEN 221 SPORANOX 30 SPORANOX PULSEPAK 30 SPORTSCREME 73 SPRITAM 21 SPRIX 7 SPRYCEL 39

Index 50

SSKI 157 sulfasalazine 94 SURE COMFORT INSULIN SSS 10-5 57 ST IVES SWISS FORMULA 24HOUR MOISTURE 72 STALEVO 100 40 STALEVO 125 40 STALEVO 150 40 STALEVO 200 40 STALEVO 50 40 STALEVO 75 40 STARLIX 28 stavudine 45 STERILANCE TL 116 STIOLTO RESPIMAT 18 STIVARGA 39 STOMACH 221 STRATASORB COMPOSITE ISLAND DRESSING 4" X 4" 83 STRATTERA 3 STRIBILD 45 STRIVERDI RESPIMAT 18 STROVITE FORTE 207 STROVITE ONE 207 STUART ONE 217 STUDIO 35 EXTRA MOISTURIZING LOTION 72 STUDIO 35 MOISTURIZING SKIN 72 SUBOXONE 12 SUBSYS 10 sucralfate 237 SUDAFED CHILDRENS 225 SUDAFED CONGESTION 225

sulindac 7 SUMADAN WASH 57 sumatriptan 155 sumatriptan succinate 155 SUMATRIPTAN SUCCINATE 155 sumatriptan succinate 155 SUMATRIPTAN/NAPROXENSODIM 154 SUMAVEL DOSEPRO 155 SUMAXIN 57 SUMAXIN TS 57 SUMAXIN WASH 57 SUPER ANTIOXIDANT 207 SUPER C-500 COMPLEX 164 SUPER NU-THERA 207 SUPER THIN LANCETS 116 SUPERB NAILS 207 SUPERVITE EC 207 SUPPORT 207 SUPRAX 50 SUPREME II HIGH/LOWCONTROL SOLUTION 116 SUPREME TEST STRIPS 88 SURE COMFORT ALCOHOL PREP PADS 120 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 142 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 142 SURE COMFORT INSULIN

SYRINGE/U-100/0.5ML/30G X5/16" 143 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X5/16 143 SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X1/2" 143 SURE COMFORT INSULIN SYRINGE/U-100/1ML/29G X1/2" 143 SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X1/2" 143 SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X5/16" 143 SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X5/16" 143 SURE COMFORT LANCETS 28G 117 SURE COMFORT LANCETS 30G 117 SURE COMFORT LANCING PEN 117 SURE COMFORT PEN NEEDLES29GX1/2"12.7MM 143 SURE COMFORT PEN NEEDLES30GX5/16"SHORT 143 SURE COMFORT PEN NEEDLES31GX3/16"(5MM) 143 SURE COMFORT PEN NEEDLES31GX5/16"(8MM) 143 SURE COMFORT PEN

SUDAFED NASAL DECONGESTANT MAXIMUM STRENGTH 225

SYRINGE/U-100/0.3ML/30G X5/16" 142 SURE COMFORT INSULIN

NEEDLES32GX5/32"SURE COMFORT PEN NEEDLES32GX6MM

143

143 SUDAFED PE CONGESTION SULAR

225 48

SYRINGE/U-100/0.3ML/31G X5/16 142 SURE COMFORT INSULIN

SURE EDGE BLOOD GLUCOSE TEST STRIPS 89 SURE-FINE PEN NEEDLES

sulfacetamide sod-prednisolone 229 sulfacetamide sodium 61 SULFACETAMIDE SODIUM 228 sulfacetamide sodium (acne)57 sulfacetamide sodium (ophth) 228 sulfacetamide sodium w/sulfur 57 sulfamethoxazole-trimethoprim

14

SYRINGE/U-100/0.3ML/31G X5/16" 143 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 143 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 143 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 143

29GX1/2" 12.7MM 143 SURE-FINE PEN NEEDLES 31GX3/16" 5MM 143 SURE-FINE PEN NEEDLES 31GX5/16" 8MM 143 SURE-JECT INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 143 SURE-JECT INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 143

Index 51

SURE-JECT INSULIN SUTENT 39 TEARS NATURALE PM 227 SYRINGE/U-100/0.3ML/31G X5/16" 143 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 143 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 143 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 143 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 143 SURE-JECT INSULIN SYRINGE/U-100/1ML/28G X1/2" 144 SURE-JECT INSULIN SYRINGE/U-100/1ML/29G X1/2" 144 SURE-JECT INSULIN SYRINGE/U-100/1ML/30G X5/16" 144 SURE-JECT INSULIN SYRINGE/U-100/1ML/31G X5/16" 144 SURE-LANCE FLAT LANCETS 117 SURE-LANCE LANCETS 26G 117 SURE-LANCE THIN LANCETS 28G 117 SURE-LANCE ULTRA THIN LANCETS 117 SURE-PEN 117 SURE-PREP ALCOHOL PREP PADS 120 SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS 89 SURE-TOUCH LANCETS UNIVERSAL 117 SURECHEK BLOOD GLUCOSE TEST STRIPS 89 SURELITE LANCETS 117 SURESTEP GLUCOSE CONTROL 117 SURESTEP GLUCOSE

SWEEN CREAM 72 SYMBICORT 18 SYMBYAX 233 SYMLINPEN 120 24 SYMLINPEN 60 24 SYMPROIC 94 SYNAGEX 207 SYNALAR 64 SYNALGOS-DC 11 SYNATEK 207 SYNJARDY 25 SYNJARDY XR 25 SYNTHROID 236 SYSTANE 227 SYSTANE OVERNIGHT THERAPY LUBRICANT EYE 227 SYSTANE ULTRA 227 SYSTANE ULTRA HOME & AWAY PACK 227 T-VITES 207 TABLOID 37 TACLONEX 64 tacrolimus 159 tacrolimus (topical) 73 TAFINLAR 39 TAGAMET HB 237 TAGRISSO 39 TAI DOC CONTROL 117 TALTZ 61 TAMIFLU 47 tamoxifen citrate 38 tamsulosin hcl 95 TANZEUM 27 TAPAZOLE 236 TARCEVA 39 TARKA 36 TARON-BC 217 TARON-C DHA 217

TECFIDERA 234 TECFIDERA STARTER PACK 234 TECHLITE AST LANCETS 117 TECHLITE LANCETS 117 TECHLITE LANCETS 30G 117 TECHLITE PEN NEEDLES 29GX 12 MM 144 TECHLITE PEN NEEDLES 31GX 5MM 144 TECHLITE PEN NEEDLES/31GX5MM 144 TECHLITE PEN NEEDLES/31GX6 MM 144 TECHLITE PEN NEEDLES/31GX8MM 144 TECHLITE PEN NEEDLES/32GX4MM 144 TECHLITE PEN NEEDLES/32GX6MM 144 TECHNIVIE 46 TEGADERM AG MESH DRESSING WITH SILVER 2"X2" 83 TEGADERM AG MESH DRESSING WITH SILVER 4"X5" 83 TEGADERM AG MESH DRESSING WITH SILVER 4"X8" 83 TEGADERM AG MESH DRESSING WITH SILVER 8"X8" 83 TEGADERM ALGINATE AG DRESSING 83 TEGADERM HIGH GELLING ALGINATE DRESSING 4"X4" 83 TEGADERM HIGH INTEGRITY ALGINATE DRESSING 4"X4" 83 TEGADERM MATRIX DRESSING 83 TEGRETOL 21 TEGRETOL-XR 21 TEKTURNA 36

CONTROLSOLUTION 117 SURESTEP PRO HIGH GLUCOSECONTROL 117 SURESTEP PRO LOW GLUCOSECONTROL 117 SURESTEP PRO NORMAL GLUCOSE CONTROL 117 SURMONTIL 24 SUSTIVA 45

TARON-PREX TASIGNA TASMAR TAVIST ALLERGY TAYTULLA tazarotene TAZORAC

217 39 40 31 52 61 61

TEKTURNA HCT 36 TELCARE BLOOD GLUCOSE TEST STRIPS 89 TELCARE GLUCOSE CONTROL SOLUTION LEVEL 1/2 117 telmisartan 34 telmisartan-amlodipine 36 telmisartan-hydrochlorothiazide

36

Index 52

temazepam 98 TGT LANCET ULTRA THIN thioridazine hcl 43 28G 117TEMODAR 37 thiothixene 43TGT LANCET ULTRA THIN

TEMOVATE 64 THRESHOLD IMT 15430G 117 TEMOVATE E 64 TGT LANCING DEVICE 117 THRIVITE 19 218 temozolomide 37 THALOMID 158 THRIVITE RX 218 TENCON 8 THEO-24 18 throat lozenges 160 TENEX TENORETIC 100

35 36

theophylline THERA

18 208

THYMUS thyroid

221 236

TENORETIC 50 36 THERA M PLUS 207 THYROLAR-1 236 TENORMIN 47 THERA-FLUR-N 160 THYROLAR-1/2 236 TERAZOL 3 241 THERA-M 207 THYROLAR-1/4 236 TERAZOL 7 241 THERA-TABS M 207 THYROLAR-2 236 terazosin hcl 35 THERABETIC EYE THYROLAR-3 236 terbinafine hcl terbinafine hcl (topical)

30 60

HEALTH THERABETIC MULTI-VITAMIN

221

207

tiagabine hcl TIAZAC

21 48

terbutaline sulfate 18 THERABETIC SKIN CARE72 TIGAN 29 terconazole vaginal 241 THERACAL D2000 157 TIKOSYN 16 TESSALON PERLES 53 THERACAL D4000 157 TIMOLOL MALEATE 48 TESTIM TESTONE CIK

12 12

THERACAL RAPID REPLETION 157

timolol maleate (ophth) TIMOPTIC

227 227

TESTOSTERONE testosterone testosterone cypionate

12 12 12

THERAGRAN-M 207 THERAGRAN-M ADVANCED 207 THERAGRAN-M ADVANCED

TIMOPTIC OCUDOSE TIMOPTIC-XE TINACTIN

227 227 60

TESTOSTERONE PUMP 12 50 PLUS 207 TINACTIN DEODORANT 60 tetracycline hcl TETRACYCLINE HCL

235 235

THERAGRAN-M PREMIER 207 THERAGRAN-M PREMIER 50

TINACTIN JOCK ITCH TINDAMAX

60 14

tetrahydrozoline hcl (ophth) 228 tetrahydrozoline w/ polyethyleneglycol 228 tetrahydrozoline-dextran-polyethylene glycol-povidone 229 TEXACORT 64

PLUS 207 THERAMILL FORTE 207 THERANATAL CORE NUTRITION 218 THERANATAL LACTATION COMPLETE 207 THERANATAL LACTATION

tinidazole TIROSINT TIVICAY TIVORBEX tizanidine hcl TL FOLATE

14 236 45 7

223 218

TGT ADVANCED LANCING DEVICE 117 TGT ALCOHOL SWABS 120 TGT BLOOD GLUCOSE TEST STRIPS 89 TGT BLOOD GLUCOSE TEST STRIPS PREMIUM 89 TGT GLUCOSE 26 TGT LANCET ALTERNATE SITE 117 TGT LANCET MICRO THIN 33G 117 TGT LANCET SUPER THIN 30G 117 TGT LANCET THIN 23G 117 TGT LANCET THIN 26G 117

ONE 207 THERANATAL LACTATION SUPPORT 207 THERAPEUTIC MOISTURIZING 72 THERAPEUTIC T+PLUS MAXIMUM STRENGTH 73 THERAPLEX HYDROLOTION 72 THERAPLEX T 76 THEREMS-H 207 THEREMS-M 207 thiamine hcl 243 thiamine mononitrate 243 THINLETS GP LANCETS117 THINLETS LANCET 117

TL-CARE DHA TL-SELECT TOBI TOBI PODHALER TOBRADEX TOBRADEX ST TOBRAMYCIN tobramycin tobramycin (ophth) tobramycin sulfate TOBRAMYCIN SULFATE tobramycin sulfate tobramycin-dexamethasone

218 218

5 5

229 229

5 5

228 5 5 5

230

Index 53

TOBREX 228 TOPCARE ULTRA COMFORT TRI-TABS DHA 218 TODAYS HEALTH ADVANCED LANCING DEVICE 117 TODAYS HEALTH MINI PEN NEEDLES 31G X 1/4" 144 TODAYS HEALTH ORIGINAL PEN NEEDLES 29G X 1/2" 144 TODAYS HEALTH SHORT PEN NEEDLES 31G X 5/16" 144 TODAYS HEALTH SUPER THINLANCETS 30G 117 TODAYS HEALTH ULTRA THINLANCETS 28G 117 TOE-AID 83 TOFRANIL 24 TOFRANIL-PM 24 TOLAZAMIDE 28 TOLBUTAMIDE 28

INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" 144 TOPCO INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 144 TOPCO INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 144 TOPCO INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 145 TOPCO INSULIN SYRINGE/U-100/1ML/28G X 1/2" 145 TOPCO INSULIN SYRINGE/U-100/1ML/29G X 1/2" 145 TOPICORT 64 topiramate 21 TOPIRAMATE ER 21

TRI-VIT/FLUORIDE/IRON 209 TRIADVANCE 218 triamcinolone acetonide (mouth) 160 triamcinolone acetonide (nasal) 224 triamcinolone acetonide (topical) 64 triamcinolone acetonide-dimethicone-silicone 64 TRIAMINIC COLD & ALLERGY 54 TRIAMINIC FEVER REDUCERPAIN RELIEVER CHILDRENS 8 TRIAMINIC FEVER REDUCERPAIN RELIEVER INFANTS 8

tolcapone TOLMETIN SODIUM tolmetin sodium TOLMETIN SODIUM

40 7 7 7

TOPROL XL torsemide TOUJEO SOLOSTAR TOVIAZ

47 90 28

239

triamterene & hydrochlorothiazide 90 TRIAMTERENE/HYDROCHLOROTHIAZIDE 90 TRIANEX 64

tolnaftate 60 TRACLEER 49 TRIAZOLAM 98 tolterodine tartrate 239 TRADJENTA 27 triazolam 98 TOPAMAX 21 tramadol hcl 10 TRIBENZOR 36 TOPAMAX SPRINKLE 21 TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX1/4" 144 TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX5/16" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X5/16" 144 TOPCARE ULTRA COMFORT

TRAMADOL HCL ER 10 tramadol-acetaminophen 11 trandolapril 34 trandolapril-verapamil hcl 36 tranexamic acid 97 TRANSDERM-SCOP 29 TRANXENE T 15 tranylcypromine sulfate 23 TRAVATAN Z 231 TRAVEL LANCETS 30G 117 TRAVOPROST 231

TRICARE 218 TRICARE PRENATAL 218 TRICARE PRENATAL 1 218 TRICARE PRENATAL COMPLEAT 218 TRICARE PRENATAL DHA ONE 218 TRICOR 33 TRIDESILON 64 trifluoperazine hcl 43 trifluridine 228 TRIGLIDE 33

INSULIN SYRINGE/0.5ML/30G X5/16" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" 144 TOPCARE ULTRA COMFORT

trazodone hcl TRECATOR TRELEGY ELLIPTA TREMFYA TRESIBA FLEXTOUCH tretinoin tretinoin (chemotherapy)

23 37 18 61 28 57 39

trihexyphenidyl hcl TRILEPTAL TRILIPIX trimethobenzamide hcl trimipramine maleate TRINATAL GT TRINATAL RX 1

39 21 33 29 24

218 218

INSULIN SYRINGE/1ML/31G X5/16" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 144

TRETINOIN EMOLLIENT 57 tretinoin microsphere 57 TREXALL 37 TREXIMET 154 TREZIX 11

TRINATE 218 TRINTELLIX 23 TRIPLE CREAM 72 TRIPLE HELIX COLLAGEN 2"X2" 83

TRI-NORINYL 28 52 TRISTART DHA 218

Index 54

TRIUMEQ TRIVEEN-DUO DHA TRIVEEN-PRX RNF

45 218 218

TRUECONTROL GLUCOSE CONTROL LEVEL 0 117 TRUECONTROL GLUCOSE CONTROL LEVEL 1 117

TRUEPLUS PEN NEEDLES 31GX8MM 145 TRUEPLUS PEN NEEDLES 32GX4MM 145

TRIXAICIN 73 TRUEDRAW LANCING TRUEPLUS SAFETY LANCETS TRIZIVIR 45 TROJAN EXTENDED PLEASURE/LUBRICATED 101 TROJAN MAGNUM 101 TROJAN MAGNUM WARM SENSATIONS 101 TROJAN MAGNUM XL LUBRICATED 101 TROJAN PLEASURE MESH/SPERMICIDAL 101 TROJAN RIBBED W/SPERMICIDAL 101 TROJAN SHARED SENSATION/LUBRICATED

102 TROJAN SUPRAS SPERMICIDAL 102 TROJAN TWISTED PLEASURE 102 TROJAN ULTRA PLEASURE/LUBRICATED 102 TROJAN VERY SENSITIVE LUBRICATED 102 TROJAN VERY SENSITIVE SPERMICIDAL LUBRICANT 102 TROJAN VERY THIN LUBRICATED 102 TROJAN VERY THIN SPERMICIDAL LUBRICANT 102 TROJAN-ENZ LUBRICANT102 TROJAN-ENZ LUBRICATED 102 TROJAN-ENZ W/SPERMICIDAL 102 TROKENDI XR 21 trolamine salicylate 73 TROPAZONE 72 tropicamide 227 trospium chloride 239 TRUE METRIX BLOOD GLUCOSETEST STRIPS 89 TRUE METRIX CONTROL SOLUTION LEVEL 1 117 TRUE METRIX CONTROL SOLUTION LEVEL 2 117 TRUE METRIX CONTROL SOLUTION LEVEL 3 117 TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS 89

DEVICE 118 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 145 TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X1/2" 145 TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X1/2" 145 TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X5/16" 145 TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X5/16" 145 TRUEPLUS LANCETS 26G 118 TRUEPLUS LANCETS 28G 118 TRUEPLUS LANCETS 28G SUPER THIN 118 TRUEPLUS LANCETS 30G 118 TRUEPLUS LANCETS 30G ULTRA THIN 118 TRUEPLUS LANCETS 33G 118 TRUEPLUS LANCETS 33G MICRO THIN 118 TRUEPLUS PEN NEEDLES 29GX12MM 145 TRUEPLUS PEN NEEDLES 31GX5MM 145 TRUEPLUS PEN NEEDLES 31GX6MM 145

28G 118 TRUETEST BLOOD GLUCOSE TEST 89 TRUETEST BLOOD GLUCOSE TEST STRIPS 89 TRUETEST GLUCOSE CONTROLLEVEL 1 118 TRUETEST GLUCOSE CONTROLLEVEL 2 118 TRUETEST GLUCOSE CONTROLLEVEL 3 118 TRUETEST STRIPS 89 TRUETRACK BLOOD GLUCOSE TEST 89 TRUETRACK TEST 89 TRULICITY 27 TRUMENBA 239 TRUSOPT 230 TRUSTEX COLOR CONDOMS + LUBE 102 TRUSTEX LUBRICATED 102 TRUSTEX LUBRICATED EXTRALARGE 102 TRUSTEX LUBRICATED EXTRASTRENGTH 102 TRUSTEX LUBRICATED/RIBBED/STUDDED 102 TRUSTEX LUBRICATED/SPERMICIDE

102 TRUSTEX LUBRICATED/SPERMICIDEEXTRA LARGE 102 TRUSTEX LUBRICATED/SPERMICIDEEXTRA STRENGTH 102 TRUSTEX NATURAL CONDOMS +LUBE/LUBRICATED 102 TRUSTEX WITH NONOXYNOL-9/RIBBED/STUDDED 102 TRUSTEX/RIALUBRICATED 102 TRUSTEX/RIA LUBRICATEDSPERMICIDE 102 TRUSTEX/RIALUBRICATED/SPERMICIDE

102 TRUVADA 45 TUBING/WING TIP 154 TUDORZA PRESSAIR 16

Index 55

TUMS 13 ULTICARE INSULIN ULTICARE INSULIN TUMS LASTING EFFECTS TUSNEL C

14 54

SYRINGE/0.3ML/30G X5/16"ULTICARE INSULIN

145 SYRINGE/U-100/0.5ML/29G X1/2" 146 ULTICARE INSULIN

TWYNSTA TYBOST TYKERB TYLENOL TYLENOL 8 HOUR

36 45 39 8 8

SYRINGE/0.5ML/28G X1/2"ULTICARE INSULIN SYRINGE/0.5ML/29G X1/2"ULTICARE INSULIN

145

145

SYRINGE/U-100/0.5ML/30G X1/2" 146 ULTICARE INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 146 ULTICARE INSULIN

TYLENOL 8 HOUR ARTHRITISPAIN TYLENOL CHILDRENS TYLENOL COLD & FLU SEVERE TYLENOL EXTRA STRENGTH TYLENOL INFANTS TYLENOL INFANTS PAIN+FEVER TYLENOL PM EXTRA STRENGTH TYLENOL SORE THROAT DAYTIME TYLENOL/CODEINE #3 TYLENOL/CODEINE #4 TYMLOS TYVASO TYVASO REFILL

8 8

54

8 8

8

98

8 11 11 91 49 49

SYRINGE/0.5ML/30G X1/2" 145 ULTICARE INSULIN SYRINGE/0.5ML/30G X5/16" 145 ULTICARE INSULIN SYRINGE/1ML/28G X1/2" 146 ULTICARE INSULIN SYRINGE/1ML/29G X1/2" 146 ULTICARE INSULIN SYRINGE/1ML/30G X1/2" 146 ULTICARE INSULIN SYRINGE/1ML/30G X5/16" 146 ULTICARE INSULIN SYRINGE/SHORT/0.3ML/30GX 5/16" 146 ULTICARE INSULIN

SYRINGE/U-100/0.5ML/31G X5/16" 146 ULTICARE INSULIN SYRINGE/U-100/1ML/29G X1/2" 146 ULTICARE INSULIN SYRINGE/U-100/1ML/30G X1/2" 146 ULTICARE INSULIN SYRINGE/U-100/1ML/30G X5/16" 146 ULTICARE INSULIN SYRINGE/U-100/1ML/31G X5/16" 146 ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.3ML/31G X 5/16" 146 ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.5ML/31G X 5/16" 146 ULTICARE INSULIN

TYVASO STARTER 49 TYZEKA 46 UCERIS 12 UDDERLY SMOOTH 72 UDDERLY SMOOTH EXTRA CARE 72 UDDERLY SMOOTH EXTRA CARE20 72

SYRINGE/SHORT/0.3ML/31GX 5/16" 146 ULTICARE INSULIN SYRINGE/SHORT/0.5ML/30GX 5/16" 146 ULTICARE INSULIN SYRINGE/SHORT/0.5ML/31GX 5/16" 146 ULTICARE INSULIN

SYRINGEULTRAFINE U-100/1ML/31G X 5/16" 146 ULTICARE MICRO PEN NEEDLES 31G X 8MM 146 ULTICARE MICRO PEN NEEDLES 32G X 4MM 146 ULTICARE MICRO PEN NEEDLES/32G X 4MM 147 ULTICARE MINI PEN NEEDLES

ULORIC 96 ULTEC HYDROCOLLOID DRESSING 83 ULTI-LANCE AUTOMATIC/CLEAR TIP 118 ULTICARE ALCOHOL SWABS 120 ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X1/2" 145 ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2" 145 ULTICARE INSULIN SYRINGE/0.3ML/29G X1/2" 145 ULTICARE INSULIN SYRINGE/0.3ML/30G X1/2" 145

SYRINGE/SHORT/1ML/30G X5/16" 146 ULTICARE INSULIN SYRINGE/SHORT/1ML/31G X5/16" 146 ULTICARE INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 146 ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 146 ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 146 ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 146

31GX6MM 147 ULTICARE MINI PEN NEEDLES ULTI-FINE IV 147 ULTICARE MINI PEN NEEDLES/31G X 6MM 147 ULTICARE MINI PEN NEEDLES31GX6MM 147 ULTICARE ORIGINAL PEN NEEDLES ULTI-FINE 147 ULTICARE PEN NEEDLES 31GX 5MM/MINI 147 ULTICARE PEN NEEDLES/29GX 12.7MM 147 ULTICARE SHORT PEN NEEDLES 31GX8MM 147 ULTICARE SHORT PEN NEEDLES ULTI-FINE IV 147 ULTICARE SHORT PEN NEEDLES/31G X 8MM 147

Index 56

ULTICARE THIN LANCETS ULTILET SHORT PEN ULTRA-THIN II INSULIN 30G 118 ULTILET CLASSIC LANCETS 118 ULTILET INSULIN SYRINGE/0.3ML/30G X8MM 147 ULTILET INSULIN SYRINGE/0.3ML/31G X8MM 147 ULTILET INSULIN SYRINGE/0.5ML/30G X8MM 147 ULTILET INSULIN SYRINGE/1ML/30G X 8MM147 ULTILET INSULIN

NEEDLES31GX3/16" 147 ULTIMA TEST STRIPS 89 ULTIMATE FEELING 102 ULTIMATECARE ONE 218 ULTIMATECARE ONE NF 218 ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 147 ULTRA MEGA 207 ULTRA MEGA GOLD 207 ULTRA MEGA TWO 207 ULTRA MENS PACK 207

SYRINGE SHORT/U-100/0.3ML/31GX5/16"ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.5ML/30GX5/16"ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.5ML/31GX5/16"ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/30GX5/16"ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/31GX5/16"ULTRA-THIN II INSULIN

148

148

148

148

148

SYRINGE/1ML/31G X 8MM147 ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X12.7MM 147 ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X5/16" 147 ULTILET INSULIN SYRINGE/SHORT/0.3ML/31G X5/16" 147 ULTILET INSULIN SYRINGE/SHORT/0.5ML/30G X5/16" 147 ULTILET INSULIN SYRINGE/SHORT/0.5ML/31G X5/16" 147 ULTILET INSULIN SYRINGE/SHORT/1ML/30G X5/16" 147 ULTILET INSULIN SYRINGE/SHORT/1ML/31G X5/16" 147 ULTILET INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" 147 ULTILET INSULIN SYRINGE/U-100/1ML/30G X 1/2" 147 ULTILET LANCETS 118 ULTILET LANCETS 33G 118 ULTILET PEN NEEDLE 29GX12.7MM 147 ULTILET PEN NEEDLE 31GX5MM 147 ULTILET PEN NEEDLE 31GX8MM 147 ULTILET PEN NEEDLE 32GX4MM 147 ULTILET PEN NEEDLE 32GX4MM/SHORT 147 ULTILET SAFETY LANCETS 23G 118 ULTILET SHORT PEN NEEDLES 31GX5/16" 147

ULTRA THIN LANCETS 28G 118 ULTRA THIN LANCETS 30G 118 ULTRA WOMENS PACK 207 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/28G X1/2" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/29G X1/2" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X5/16" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X5/16" 148 ULTRA-THIN II AUTO LANCET 118 ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.3ML/30GX5/16" 148

SYRINGE/U-100/0.3ML/29GX1/2" 148 ULTRA-THIN II INSULIN SYRINGE/U-100/0.5ML/29GX1/2" 148 ULTRA-THIN II INSULIN SYRINGE/U-100/1ML/29GX1/2"

148 ULTRA-THIN II LANCETS 28G 118 ULTRA-THIN II LANCETS 30G 118 ULTRA-THIN II MINI PEN NEEEDLES/31GX3/16" 148 ULTRA-THIN II PEN NEEDLES 29GX1/2" 148 ULTRA-THIN II PEN NEEDLES/SHORT/31GX5/16"

148 ULTRA-THIN II SAFETY AUTOLANCETS 26G 118 ULTRACET 11 ULTRAM 10 ULTRAM ER 10 ULTRATRAK PRO CONTROL SOLUTION 2 LEVELS 118 ULTRATRAK PRO NORMAL CONTROL 118 ULTRATRAK PRO TEST STRIPS 89 ULTRATRAK ULTIMATE CONTROL SOLUTION 2 LEVELS 118 ULTRATRAK ULTIMATE TEST STRIPS 89 ULTRAVATE 64 ULTRESA 89 UNICOMPLEX-M 207 UNIFINE PENTIPS 29GX12MM 148

Index 57

UNIFINE PENTIPS 31G X UNISTRIP1 GENERIC 89 VALUE PLUS LANCETS 3/16" 148 UNIVERSAL 1 LANCETS STANDARD 21G 119 UNIFINE PENTIPS VALUE PLUS LANCETSTHIN26G 11931GX5MM 148 SUPERTHIN 30G 119UNIVERSAL 1 LANCETSUNIFINE PENTIPS VALUE PLUS LANCETS THINULTRA THIN 30G 11931GX6MM 148 26G 119UNIVERSAL 1UNIFINE PENTIPS VALUE PLUS LANCINGLANCETS/33G/MICRO-THIN31GX8MM 148 DEVICE 119119UNIFINE PENTIPS VALUMARK LANCET SUPERUP & UP GLUCOSE 2632GX4MM 148 THIN 30G 119

UPTRAVI 49UNIFINE PENTIPS PLUS VALUMARK LANCET ULTRA 29GX12MM 149 urea 65 THIN 28G 119 UNIFINE PENTIPS PLUS VALUMARK PEN NEEDLESURECHOLINE 23931GX5MM 149 29GX12MM 149UROCIT-K 10 95UNIFINE PENTIPS PLUS VALUMARK PEN NEEDLES 31GX6MM 149 UROCIT-K 5 95 31GX 6MM 149 UNIFINE PENTIPS PLUS VALUMARK PEN NEEDLESUROXATRAL 95 31GX8MM 149 31GX 8MM 149URSO 250 94UNIFINE PENTIPS PLUS VALVED HOLDING

URSO FORTE 9432GX4MM 149 CHAMBER 154 UNILET COMFORTOUCH ursodiol 94 VANCOCIN HCL 14 LANCET 118 UTERUS 221 vancomycin hcl 14UNILET EXCELITE 118 UTIBRON NEOHALER 18 VANICREAM 72UNILET EXCELITE II 118 V-R MONOJECT INSULIN VANICREAM LITE 72UNILET G.P. LANCET 118 SYRINGE/U-100/0.3ML/29G X VANISHPOINT INSULINUNILET G.P. SUPERLITE 1/2" 149 SYRINGE/0.5ML/30G XLANCET 118 V-R MONOJECT INSULIN 1/2"UNILET GP 28 ULTRA SYRINGE/U-100/0.5ML/28G X 149

VANISHPOINT INSULINTHIN 118 1/2" 149 SYRINGE/0.5ML/30G XUNILET LANCET 118 V-R MONOJECT INSULIN 5/16" 149 UNILET LANCETS MICRO- SYRINGE/U-100/0.5ML/29G X VANISHPOINT INSULIN

1/2" 149THIN33G 118 SYRINGE/1ML/29G X 1/2" 149V-R MONOJECT INSULINUNILET LANCETS SUPER- VANISHPOINT INSULINSYRINGE/U-100/1ML/28G XTHIN30G 118 SYRINGE/1ML/30G X

UNILET LANCETS ULTRA-THIN 1/2" 149 5/16" 149V-R MONOJECT INSULIN28G 118 VANOS 64UNILET SUPERLITE SYRINGE/U-100/1ML/29G X

VAPORX BALM 55LANCET 118 1/2" 149 UNISOM 98 valacyclovir hcl 46 VARUBI 30

UNISOM SLEEPGELS 98 VALCYTE 45 VASCEPA 32 VASELINE PETROLATUMUNISTIK 3 GENTLE 118 valganciclovir hcl 45 GAUZE 83UNISTIK SAFETY LANCETS VALIUM 15 VASELINE PETROLATUM28G 118 valproate sodium 22 GAUZECISION DRESSING 83UNISTIK SAFETY LANCETS valproic acid 22 VASELINE PETROLATUM30G 118 GAUZECISION DRESSINGUNISTIK TOUCH SAFETY valsartan 34 OVERWRAP 83LANCETS 21G 119 valsartan-hydrochlorothiazide VASELINE PETROLATUMUNISTIK TOUCH SAFETY 36 GAUZEOVERWRAP 83LANCETS 23G 119 VALTREX 46 VASELINE PETROLATUMUNISTIK TOUCH SAFETY VALUE HEALTH INSULIN GAUZESTRIP 83LANCETS 28G 119 SYRINGE/U-100/0.5ML/29G X VASELINE PETROLATUMUNISTIK TOUCH SAFETY 1/2" 149 GAUZESTRIP OVERWRAP 83LANCETS 30G 119 VALUE HEALTH INSULIN VASELINE PETROLATUMUNISTRIP CONTROL SYRINGE/U-100/1ML/29G X GAUZETUBE FOILSOLUTIONHIGH 119 1/2" 149 OVERWRAP 83UNISTRIP CONTROL VALUE PLUS GLUCOSE 26 VASERETIC 36SOLUTIONLOW 119

Index 58

VASOTEC 34 VICOPROFEN 11 VIRT-ADVANCE 218 VECTICAL 61 VICTORY AGM-4000 TEST VIRT-C DHA 218 VELPHORO VELTIN VELVACHOL

95 57 72

STRIPS 89 VICTORY CONTROL LEVEL 1/2 119 VICTOZA 27

VIRT-NATE DHA VIRT-PN VIRT-PN DHA

218 218 218

VEMAVITE-PRX 2 218 VIDA MIA AUTOLET VIRT-PN PLUS 218 VENA-BAL DHA VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl VENLAFAXINE HCL ER VENTAVIS VENTOLIN HFA

218 37

37 24 24 49 18

LANCINGDEVICE 119 VIDA MIA UNIFINE PENTIPS32GX4MM 149 VIDA MIA UNIFINE PENTIPSMINI 31GX6MM149 VIDA MIA UNIFINE PENTIPSORIGINAL 29GX12MM 149 VIDA MIA UNILET LANCETS SUPER THIN 30G 119

VIRT-SELECT VIRT-VITE GT VIRTPREX VISINE VISINE ADVANCED RELIEF VISINE EXTRA VISTARIL

218 218 218 229

229 229 15

VERAMYST 224 VIDA MIA UNILET LANCETS VITA-BOB 207 verapamil hcl 48 VERASENS BLOOD GLUCOSE TEST STRIPS 89 VERASENS GLUCOSE CONTROLLEVEL 1 119

ULTRA THIN 28G VIDA MIA UNIPFINE PENTIPSSHORT 31GX8MM VIDEX EC

119

149 45

VITABEX VITAFOL FE+ VITAFOL GUMMIES VITAFOL ULTRA

207 218 218 218

VERELAN 48 VIDEXPEDIATRIC 45 VITAFOL-NANO 218 VERELAN PM 48 VIEKIRA PAK 46 VITAFOL-OB 218 VERIPRED 20 53 VIEKIRA XR 46 VITAFOL-OB+DHA 218 VERSACLOZ 42 vigabatrin 21 VITAFOL-ONE 218 VESICARE 239 VIGAMOX 228 VITALET PRO LANCETS 119 VEXOL 230 VFEND 30 VIADENT ADVANCED CARE TOOTHPASTE 121 VIADENT TOOTHPASTE 121 VIADENT TOOTHPASTE FLUORIDE 121 VIADENT TOOTHPASTE PLAQUEFIGHTING 121 VIBERZI 94 VIBRAMYCIN 235 VICKS BABYRUB 73 VICKS SINEX 225 VICKS SINEX 12 HOUR DECONGESTANT 225 VICKS SINEX 12 HOUR DECONGESTANT ULTRA FINE MIST 225 VICKS SINEX 12 HOUR DECONGESTANT ULTRA FINE

VIGILON PRIMARY WOUND DRESSING/13" X 24" 83 VIGILON PRIMARY WOUND DRESSING/3" X 8" 83 VIGILON PRIMARY WOUND DRESSING/4" X 4" 83 VIGILON PRIMARY WOUND DRESSING/6" X 8" 83 VIIBRYD 23 VIIBRYD STARTER PACK23 VIMOVO 7 VIMPAT 21 VINATE CARE 218 VINATE DHA RF 218 VINATE II 218 VINATE M 218 VINATE ONE 218 VIOKACE 89 VIRACEPT 45

VITALET PRO PLUS LANCETS 119 VITALETS 212 VITALETS CHILDRENS 212 VITALINE TOTAL FORMULA 2 207 VITALINE TOTAL FORMULA 3 207 VITAMAX 212 VITAMENT 207 vitamin a 242 VITAMIN C 164,243 VITAMIN C EFFERVESCENT BLEND 208 VITAMIN C/ELECTROLYTES 208 VITAMIN D3 COMPLETE 208 vitamin e 242 VITAMIN E WITH PANTHENOL 72

MIST/MOISTURIZNGVICKS SINEX MOISTURIZING VICKS SINEX SEVERE

225

225

VIRAMUNE VIRAMUNE XR VIREAD

45 45 45

vitamins a & d 222 vitamins a & d (topical) 72 VITAMINS FOR THE HAIR 221

NASALDECONGESTANT 225 VIROPTIC 228 VITAMINS TO GO VICKS VAPORUB 55 VIRT NATE 218 MAXIMUM

VITAMINS TO GO MEN 208 208

Index 59

VITAMINS TO GO WALGREENS COMFORT WOUNDGARD 2-1/2"X2-WOMEN 208 ASSUREDLANCETS MICRO 1/2" 83 vitamins w/ lipotropics 222 THIN/33G 119 WOUNDGARD 4"X4-1/4" 83

WALGREENS COMFORTVITAROCA PLUS 208 WOUNDGARD 4"X6" 83ASSUREDLANCETS SUPERVITASANA 208 XADAGO 40THIN/28G 119 VITATRUM 208 WALGREENS GLUCOSE 26 XALATAN 231 VITEKTA 45 WALGREENS LANCETS 119 XALKORI 39 VITRUM 50+ SENIOR WALGREENS THIN XANAX 15 MULTI 208 LANCETS 119 XANAX XR 15VIVA DHA 218 WALGREENS ULTRA THIN XARELTO 18LANCETS 119VIVARIN 3 XARELTO STARTER PACK 18warfarin sodium 18VIVELLE-DOT 93 XARTEMIS XR 11WATCHHALER 154VIVLODEX 7 VOCAL POINT BLOOD water for irrigation, sterile 159 XELJANZ 5

XELJANZ XR 5GLUCOSE TEST STRIPS 89 WAVESENSE PRESTO TEST VOGELXO 12 STRIPS 89 XELODA 37

WEBCOL ALCOHOL PREPVOGELXO PUMP 12 XERESE 61LARGE 1 PLY 120 XEROFLO DRESSINGVOL-NATE 218 WEBCOL ALCOHOL PREP 1"X8" 83VOL-PLUS 219 LARGE 2 PLY 120 XEROFLO DRESSINGWEBCOL ALCOHOL PREPVOL-TAB RX 219 2"X2" 83MEDIUM 2 PLY 120VOLTAREN 58 XEROFLO DRESSINGWEGMANS UNIFINE PENTIPS 5"X9" 83VOPAC MDS 58 PLUS 32GX4MM 149 XIFAXAN 14WEGMANS UNIFINE PENTIPSvoriconazole 30 PLUS/MINI/31GX5MM 149 XIGDUO XR 25VORTEX VALVED HOLDING WEGMANS UNIFINE PENTIPSCHAMBER 154 XIIDRA 229PLUS/SHORT/31GX8MM149VOSEVI 46 XIMINO 236WEGMANS UNIFINE PENTIPS

VOSPIRE ER 18 PLUS/ULTRA XODOL 11 VOTRIENT 39 SHORT/31GX6MM 149 XOPENEX 18

WELCHOL 32VP DERMABASE 72 XOPENEX CONCENTRATE 18 VP INSULIN SYRINGE/U- WELLBUTRIN 22 XOPENEX HFA 18 100/0.3ML/29G X 1/2" 149 WELLBUTRIN SR 22 XRYLIX 58VP-CH PLUS 219 WELLBUTRIN XL 22 XTAMPZA ER 10VP-CH-PNV 219 WESTCORT 64 XTANDI 38VP-GGR-B6 PRENATAL 219 white petrolatum-mineral XULTOPHY 100/3.6 25VP-HEME OB 219 oil 227 XYREM 232WHOLE FOODVP-HEME OB + DHA 219 MULTIVITAMIN 208 XYZAL 32VP-HEME ONE 219 WIBI 72 XYZAL ALLERGY 24HR 32VP-PNV-DHA 219 WINDMILL TRAINER 154 XYZAL ALLERGY 24HR VP-ZEL 208 witch hazel (hamamelis CHILDRENS 32 VRAYLAR 41 virginiana) 75 YASMIN 28 52 VUSION 60 witch hazel-glycerin 75 YAZ 52 VYTORIN 32 WOMENS 50+ MULTI YELETS TEENAGE

VITAMIN& MINERAL FORMULA 208VYVANSE 2 FORMULA 208 YOSPRALA 96W&F LANCETS 26G 119 WOMENS BIOMULTIPLE208 YOUR LIFE MULTI ADULTW&F LANCETS COLORED WOMENS MULTI VITAMIN & GUMMIES 20821G 119 MINERAL FORMULA 208 YOUR LIFE TEENWALGREENS ADVANCED WOMENS PACK 208 MULTIVITAMIN GUMMIES 208TRAVELLANCETS 28G 119 wound dressings 83 ZADITOR 230

zafirlukast 16

Index 60

zaleplon 98 ZAMICET 11 ZANAFLEX 223 ZANTAC 237 ZANTAC 150 MAXIMUMSTRENGTH 237 ZANTAC 75 237 ZARONTIN 22 ZARXIO 97 ZATEAN-CH 219 ZATEAN-PN DHA 219 ZATEAN-PN PLUS 219 ZE-PLUS 208 ZEBETA 47 ZECUITY 155 ZEGERID 238 ZEGERID OTC 238 ZEJULA 39 ZELAPAR 40 ZELBORAF 39 ZEMBRACE SYMTOUCH 155 ZENPEP 89 ZENZEDI 2,3 ZEPATIER 46 ZERIT 45 ZESTORETIC 36 ZESTRIL 34 ZETIA 33 ZETONNA 224 ZIAC 36 ZIAGEN 45 ZIANA 57 zidovudine 45 zileuton 16 ZIMS CRACK CREMEDAYTIME 72 ZINBRYTA 234 zinc 158 ZINC 208 zinc gluconate 158 zinc oxide (topical) 75 zinc sulfate 158 ZINC W/A&C 160 ZIOPTAN 231 ziprasidone hcl 41 ZIPSOR 7 ZITHROMAX 100

Index 61

ZITHROMAX TRI-PAK 100 ZITHROMAX Z-PAK 100 ZMAX 100 ZN-PLUS 221 ZOCOR 33 ZOFRAN 29 ZOFRAN ODT 29 ZOHYDRO ER 10 ZOLINZA 39 zolmitriptan 155 ZOLOFT 23 zolpidem tartrate 98 ZOLPIMIST 98 ZOMACTON 92 ZOMIG 155 ZOMIG ZMT 155 ZONEGRAN 21 zonisamide 21 ZONTIVITY 96 ZOO FRIENDSCOMPLETE 212 ZORBTIVE 92 ZORVOLEX 7 ZOSTAVAX 241 ZOSTRIX DIABETIC FOOTPAIN 74 ZOVIRAX 47,61 ZUBSOLV 12 ZUPLENZ 29 ZURAMPIC 96 ZYBAN 234 ZYCLARA 72 ZYCLARA PUMP 72 ZYDELIG 39 ZYFLO 16 ZYFLO CR 16 ZYKADIA 39 ZYLET 230 ZYLOPRIM 96 ZYMAXID 228 ZYPREXA 42 ZYPREXA RELPREVV 42 ZYPREXA ZYDIS 42 ZYRTEC ALLERGY 32 ZYRTEC CHILDRENSALLERGY 32 ZYTIGA 38

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