Aetna Better Health of West Virginia Formulary Guide March ......testosterone cypionate...

AETNA BETTER HEALTH® Formulary Guide

Aetna Better Health of West Virginia Formulary Guide

March 2017

Updated: 03/01/2017 P a g e | 2


https://www.aetnabetterhealth.com/westvirginia/

What is the Aetna Better Health of West Virginia Formulary?

This is a drug list created by Aetna Better Health (“plan”). The plan will cover drugs on this list in addition to the West Virginia Bureau of Medical Services Preferred Drug List (located at http://www.dhhr.wv.gov/bms/BMS%20Pharmacy/Pages/Preferred-Drug-List.aspx). Some drugs may have coverage rules. If the rules for that drug are met, the plan w ill cover the dr ug. Drugs must also be filled at a pl an network pharmacy.

Can the Plan’s Drug List change?

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

How do I use the Plan’s Formulary?

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

• Column #2: shows coverage rules for the drug

Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, “Ear-Nose-Throat Medications.” If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug.

What are generic drugs?

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

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

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

http://www.dhhr.wv.gov/bms/BMS%20Pharmacy/Pages/Preferred-Drug-List.aspx

https://www.aetnabetterhealth.com/westvirginia/

http://www.dhhr.wv.gov/bms/BMS%20Pharmacy/Pages/Preferred-Drug-List.aspx


Are there Medication Copays?

Copays will vary based on the tier level and cost of the drug. The table below shows your out-of-pocket maximums by tier and copay by amount based on total allowed drug cost.

Tier Level Out of Pocket Maximum 1 $0 2 $71.00 3 $143.00

Total Allowed C harge Co-pay Amount $0.00 - $5.00 $0.00 $5.01 - $10.00 $0.50 $10.01 - $25.00 $1.00 $25.01 - $50.00 $2.00 $50.01 and above $3.00

What are some types of coverage rules?

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

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

• Step Therapy (ST): This means you may need to try certain drugs first to treatyour condition.

After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered.

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

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

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

Updated: 03/01/2017 P a g e | 3

Aetna Better Health West Virginia

Table of Contents

TablfCooeenntts

*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................................3*ANALGESICS - ANTI-INFLAMMATORY*........................................................................................................ 3*ANALGESICS - NONNARCOTIC*.......................................................................................................................3*ANDROGENS-ANABOLIC*................................................................................................................................. 4*ANORECTAL AGENTS*.......................................................................................................................................5*ANTACIDS*............................................................................................................................................................5*ANTIANGINAL AGENTS*................................................................................................................................... 5*ANTIANXIETY AGENTS*....................................................................................................................................6*ANTIARRHYTHMICS*......................................................................................................................................... 6*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*.............................................................................. 7*ANTICOAGULANTS*........................................................................................................................................... 7*ANTIDEPRESSANTS*...........................................................................................................................................7*ANTIDIABETICS*................................................................................................................................................. 8*ANTIDIARRHEALS*.............................................................................................................................................8*ANTIDOTES*......................................................................................................................................................... 9*ANTIEMETICS*..................................................................................................................................................... 9*ANTIHISTAMINES*.............................................................................................................................................. 9*ANTIHYPERTENSIVES*.................................................................................................................................... 10*ANTI-INFECTIVE AGENTS - MISC.*............................................................................................................... 11*ANTIMALARIALS*.............................................................................................................................................11*ANTIMYASTHENIC AGENTS*......................................................................................................................... 11*ANTIMYASTHENIC/CHOLINERGIC AGENTS*............................................................................................. 11*ANTIMYCOBACTERIAL AGENTS*................................................................................................................. 12*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*................................................................................12*ANTIPSYCHOTICS/ANTIMANIC AGENTS*................................................................................................... 14*ASSORTED CLASSES*....................................................................................................................................... 14*CARDIOTONICS*................................................................................................................................................ 15*CHEMICALS*.......................................................................................................................................................15*CONTRACEPTIVES*...........................................................................................................................................16*CORTICOSTEROIDS*......................................................................................................................................... 20*COUGH/COLD/ALLERGY*................................................................................................................................21*DERMATOLOGICALS*...................................................................................................................................... 23*DIAGNOSTIC PRODUCTS*................................................................................................................................25*DIURETICS*.........................................................................................................................................................26*ENDOCRINE AND METABOLIC AGENTS - MISC.*......................................................................................26*ESTROGENS*.......................................................................................................................................................27*GASTROINTESTINAL AGENTS - MISC.*........................................................................................................27*GENITOURINARY AGENTS - MISCELLANEOUS*....................................................................................... 28*HEMATOLOGICAL AGENTS - MISC.*............................................................................................................ 28*HEMATOPOIETIC AGENTS*.............................................................................................................................28*LAXATIVES*....................................................................................................................................................... 29*MEDICAL DEVICES*..........................................................................................................................................30*MIGRAINE PRODUCTS*....................................................................................................................................43*MINERALS & ELECTROLYTES*......................................................................................................................43

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TablfCooeenntts

*MOUTH/THROAT/DENTAL AGENTS*............................................................................................................45*MULTIVITAMINS*..............................................................................................................................................46*NASAL AGENTS - SYSTEMIC AND TOPICAL*............................................................................................. 51*OPHTHALMIC AGENTS*...................................................................................................................................51*OTIC AGENTS*....................................................................................................................................................52*OXYTOCICS*.......................................................................................................................................................52*PASSIVE IMMUNIZING AGENTS*...................................................................................................................52*PENICILLINS*......................................................................................................................................................52*PHARMACEUTICAL ADJUVANTS*................................................................................................................ 53*POTASSIUM REMOVING AGENTS***............................................................................................................57*PROGESTINS*......................................................................................................................................................57*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*..........................................................57*RESPIRATORY AGENTS - MISC.*....................................................................................................................58*SULFONAMIDES*...............................................................................................................................................58*THYROID AGENTS*........................................................................................................................................... 58*ULCER DRUGS*.................................................................................................................................................. 58*URINARY ANTI-INFECTIVES*.........................................................................................................................60*URINARY ANTISPASMODICS*........................................................................................................................60*VAGINAL PRODUCTS*......................................................................................................................................60*VASOPRESSORS*............................................................................................................................................... 61*VITAMINS*.......................................................................................................................................................... 61

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Aetna Better Health West Virginia

CURRENT AS OF 03/01/2017

Formulary Drug Name Reference Restrictions *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* *Analeptics***caffeine citrate oral solution Cafcit

*ANALGESICS - ANTI-INFLAMMATORY* *Pyrimidine Synthesis Inhibitors***leflunomide oral tablet Arava

*ANALGESICS - NONNARCOTIC**Analgesics Other***acetaminophen extra strength oral liquid Tylenol Sore Throat Daytime OTC acetaminophen oral capsule OTC acetaminophen oral liquid Little Remedies for Fever OTC acetaminophen oral solution 160 mg/5ml Little Fevers Fever-Pain Rel OTC acetaminophen oral tablet 500 mg Medi-Tabs Extra Strength OTC acetaminophen oral tablet chewable 80 mg Childrens Medi-Tabs OTC acetaminophen rectal suppository 120 mg Feverall OTC childrens acetaminophen oral suspension 160 mg/5ml Nortemp OTC

childrens acetaminophen oral tablet dispersible Tylenol Childrens Meltaways OTC

childrens apap oral tablet chewable Childrens Medi-Tabs OTC childrens aspirin free oral elixir Medi-Tabs Childrens OTC extra strength acetaminophen oral capsule OTC infants pain reliever oral suspension Infants Medi-Tabs OTC CHLORASEPTIC SORE THROAT ORAL LIQUID CVS Pain Relief Adult OTC

PEDIACARE INFANTS ORAL SUSPENSION Childrens Pain Reliever OTC

TRIAMINIC FEVER REDUCER ORAL SYRUP OTC

3

Formulary Drug Name Reference Restrictions *Analgesics-Sedatives***butalbital-acetaminophen oral tablet 50-325 mg Tencon

butalbital-apap-caffeine oral capsule 50-325-40 mg Esgic

butalbital-apap-caffeine oral tablet 50-325-40 mg Fioricet

butalbital-asa-caffeine oral capsule Fiorinal butalbital-aspirin-caffeine oral capsule Fiorinal marten-tab oral tablet Tencon CAPACET ORAL CAPSULE Margesic ESGIC ORAL CAPSULE Margesic TENCON ORAL TABLET 50-325 MG Butalbital-Acetaminophen ZEBUTAL ORAL CAPSULE 50-325-40 MG Margesic

*Salicylate Combinations***buffered aspirin oral tablet Bufferin OTC choline-mag trisalicylate oral liquid

*Salicylates***aspirin childrens oral tablet chewable Bayer Low Dose OTC aspirin oral tablet 325 mg Bayer Aspirin OTC aspirin oral tablet chewable Bayer Low Dose OTC aspirin oral tablet delayed release 325 mg Bayer Aspirin Regimen OTC aspirin oral tablet delayed release 81 mg Bayer Low Dose OTC aspirtab oral tablet delayed release Bayer Aspirin Regimen OTC salsalate oral tablet Disalcid BAYER ADVANCED ASPIRIN REG ST ORAL TABLET Aspirin OTC

BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED RELEASE Aspirin OTC

BAYER ASPIRIN REGIMEN ORAL TABLET DELAYED RELEASE Aspirtab OTC

ECOTRIN LOW STRENGTH ORAL TABLET DELAYED RELEASE Aspirin OTC

ECOTRIN ORAL TABLET DELAYED RELEASE Aspirtab OTC

*ANDROGENS-ANABOLIC**Androgens***danazol oral capsule methyltestosterone oral capsule Android

4

Formulary Drug Name Reference Restrictions testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml Depo-Testosterone PA

testosterone enanthate intramuscular solution PA

*ANORECTAL AGENTS**Intrarectal Steroids***hydrocortisone rectal enema Cortenema COLOCORT RECTAL ENEMA Hydrocortisone

*Rectal Anesthetic/Steroids***hydrocortisone ace-pramoxine rectal cream 1-1 % Analpram-HC

lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 % pramcort rectal cream Analpram-HC PROCTOFOAM HC RECTAL FOAM

*Rectal Steroids***hydrocortisone rectal cream Proctocort PROCTO-MED HC RECTAL CREAM Hemorrhoidal-HC PROCTO-PAK RECTAL CREAM Hydrocortisone PROCTOSOL HC RECTAL CREAM Hemorrhoidal-HC PROCTOZONE-HC RECTAL CREAM Hemorrhoidal-HC

*ANTACIDS**Antacids - Bicarbonate***sodium bicarbonate oral powder

*Antacids - Calcium Salts***antacid oral tablet chewable 500 mg Tums OTC calcium carbonate antacid oral tablet chewable 500 mg Tums OTC

TUMS FRESHERS ORAL TABLET CHEWABLE Calcium Antacid OTC

*Antacids - Magnesium Salts***magnesium oxide oral tablet 400 mg Mag-Oxide OTC

*ANTIANGINAL AGENTS**Nitrates***isosorbide dinitrate er oral tablet extended release isosorbide dinitrate oral tablet Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour Imdur

isosorbide mononitrate oral tablet

5

Formulary Drug Name Reference Restrictions nitroglycerin er oral capsule extended release 2.5 mg, 6.5 mg Nitro-Time

nitroglycerin transdermal patch 24 hour Nitro-Dur MINITRAN TRANSDERMAL PATCH 24 HOUR Nitroglycerin

NITRO-BID TRANSDERMAL OINTMENT NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG Nitroglycerin ER

*ANTIANXIETY AGENTS**Antianxiety Agents - Misc.***buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg buspirone hcl oral tablet 30 mg PA hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule Vistaril

*Benzodiazepines***alprazolam er oral tablet extended release 24 hour Xanax XR

alprazolam oral tablet Xanax alprazolam oral tablet dispersible Niravam alprazolam xr oral tablet extended release 24 hour Xanax XR

chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet Tranxene-T diazepam oral solution 1 mg/ml lorazepam oral concentrate LORazepam Intensol lorazepam oral tablet Ativan oxazepam oral capsule ALPRAZOLAM INTENSOL ORAL CONCENTRATE LORAZEPAM INTENSOL ORAL CONCENTRATE LORazepam

*ANTIARRHYTHMICS**Antiarrhythmics Type I-A***disopyramide phosphate oral capsule Norpace quinidine gluconate er oral tablet extended release quinidine sulfate oral tablet

6

Formulary Drug Name Reference Restrictions *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule

*Antiarrhythmics Type I-C*** flecainide acetate oral tablet Tambocor propafenone hcl oral tablet Rythmol

*Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200 mg Cordarone amiodarone hcl oral tablet 400 mg Pacerone PACERONE ORAL TABLET 200 MG, 400 MG Amiodarone HCl

*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution

*Xanthines*** theophylline er oral tablet extended release 12 hour Theochron

theophylline er oral tablet extended release 24 hour ELIXOPHYLLIN ORAL ELIXIR Theophylline THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

Theophylline ER

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

*ANTIDEPRESSANTS* *Antidepressants - Misc.*** maprotiline hcl oral tablet

*Tricyclic Agents*** amitriptyline hcl oral tablet amoxapine oral tablet clomipramine hcl oral capsule Anafranil desipramine hcl oral tablet Norpramin

7

Formulary Drug Name Reference Restrictions doxepin hcl oral capsule doxepin hcl oral concentrate nortriptyline hcl oral capsule Pamelor protriptyline hcl oral tablet Vivactil

*ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet Precose

*Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED QLL (2 EA per 30 days)

GLUCAGON EMERGENCY INJECTION KIT QLL (2 EA per 30 days)

*Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet Metaglip glyburide-metformin oral tablet Glucovance

*Sulfonylureas*** chlorpropamide oral tablet glimepiride oral tablet Amaryl glipizide er oral tablet extended release 24 hour GlipiZIDE XL

glipizide oral tablet Glucotrol glipizide xl oral tablet extended release 24 hour GlipiZIDE XL

glyburide micronized oral tablet Glynase glyburide oral tablet Diabeta tolazamide oral tablet tolbutamide oral tablet

*ANTIDIARRHEALS* *Antiperistaltic Agents*** anti-diarrheal oral capsule Imodium A-D OTC diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet Lonox lofene oral tablet Lonox loperamide hcl oral capsule Imodium A-D paregoric oral tincture

8

Formulary Drug Name Reference Restrictions *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE

*Opioid Antagonists*** naltrexone hcl oral tablet Depade

*ANTIEMETICS* *5-Ht3 Receptor Antagonists*** ondansetron hcl oral tablet 24 mg QLL (2 EA per 30 days)

*Antiemetics - Anticholinergic*** meclizine hcl oral tablet Antivert meclizine hcl oral tablet chewable OTC motion sickness relief oral tablet chewable OTC trimethobenzamide hcl oral capsule Tigan DRAMAMINE LESS DROWSY ORAL TABLET Motion Sickness Relief II OTC

*ANTIHISTAMINES* *Antihistamines - Ethanolamines*** allergy childrens oral liquid Total Allergy Medicine OTC allergy relief childrens oral liquid Total Allergy Medicine OTC allergy relief oral capsule Benadryl OTC allerhist-1 oral tablet Tavist Allergy OTC clemastine fumarate oral tablet 1.34 mg Tavist Allergy OTC clemastine fumarate oral tablet 2.68 mg complete allergy medicine oral capsule Benadryl OTC diphenhist oral capsule Benadryl OTC diphenhydramine hcl oral capsule Benadryl diphenhydramine hcl oral elixir Medi-Phedryl silphen cough oral syrup OTC DAYHIST ALLERGY 12 HOUR RELIEF ORAL TABLET SM Allergy Relief OTC

*Antihistamines - Non-Sedating*** all day allergy childrens oral tablet chewable 10 mg ZyrTEC Childrens Allergy OTC; QLL (1 UNIT per 1 day)

all day allergy oral tablet KLS Aller-Tec OTC; QLL (1 UNIT per 1 day)

allergy relief child oral syrup Claritin OTC; QLL (300 ML per 30 days)

allergy relief childrens oral tablet chewable ZyrTEC Childrens Allergy OTC; QLL (1 UNIT per 1 day) cetirizine hcl allergy child oral solution Wal-Zyr Childrens QLL (300 ML per 30 days)

9

Formulary Drug Name Reference Restrictions

cetirizine hcl childrens oral solution 5 mg/5ml Wal-Zyr Childrens OTC; QLL (300 ML per 30 days)

cetirizine hcl hives relief oral solution Wal-Zyr Childrens OTC; QLL (300 ML per 30 days)

cetirizine hcl oral tablet OTC; QLL (1 UNIT per 1 day) cetirizine hcl oral tablet chewable ZyrTEC Childrens Allergy OTC; QLL (1 UNIT per 1 day) loratadine allergy relief oral tablet dispersible Wal-itin Aller-Melts OTC; QLL (1 UNIT per 1 day)

loratadine hives relief oral solution Claritin OTC; QLL (300 ML per 30 days)

loratadine oral tablet Claritin OTC; QLL (1 UNIT per 1 day) ALAVERT ORAL TABLET Loratadine OTC; QLL (1 UNIT per 1 day) ALAVERT ORAL TABLET DISPERSIBLE Allergy Relief OTC; QLL (1 UNIT per 1 day)

CLARITIN ALLERGY CHILDRENS ORAL SYRUP SM Childrens Loratadine OTC; QLL (300 ML per 30

days) TRIAMINIC ALLERCHEWS ORAL TABLET DISPERSIBLE Allergy Relief OTC; QLL (1 UNIT per 1 day)

*Antihistamines - Phenothiazines*** promethazine hcl oral solution promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl rectal suppository Phenadoz PHENADOZ RECTAL SUPPOSITORY Promethazine HCl PHENERGAN RECTAL SUPPOSITORY Promethazine HCl PROMETHEGAN RECTAL SUPPOSITORY Promethazine HCl

*Antihistamines - Piperidines*** cyproheptadine hcl oral syrup cyproheptadine hcl oral tablet

*ANTIHYPERTENSIVES* *Ace Inhibitors*** captopril oral tablet 12.5 mg, 25 mg, 50 mg QLL (90 EA per 30 days)

*Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet

*Antiadrenergics - Centrally Acting*** methyldopa oral tablet

10

Formulary Drug Name Reference Restrictions *Antiadrenergics - Peripherally Acting*** prazosin hcl oral capsule Minipress

*Vasodilators*** hydralazine hcl oral tablet minoxidil oral tablet

*ANTI-INFECTIVE AGENTS -MISC.* *Anti-Infective Agents - Misc.*** trimethoprim oral tablet vancomycin hcl intravenous solution reconstituted

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

sulfamethoxazole-trimethoprim oral tablet Bactrim SULFATRIM PEDIATRIC ORAL SUSPENSION

Sulfamethoxazole-Trimethoprim

*Leprostatics*** dapsone oral tablet

*Lincosamides*** clindamycin hcl oral capsule Cleocin clindamycin palmitate hcl oral solution reconstituted Cleocin

*ANTIMALARIALS* *Antimalarials*** hydroxychloroquine sulfate oral tablet Plaquenil mefloquine hcl oral tablet

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

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

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

11

Formulary Drug Name Reference Restrictions *ANTIMYCOBACTERIAL AGENTS* *Antimycobacterial Agents*** ethambutol hcl oral tablet Myambutol isoniazid oral syrup isoniazid oral tablet pyrazinamide oral tablet rifampin oral capsule Rifadin

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

*Antiadrenals*** LYSODREN ORAL TABLET

*Antiandrogens*** bicalutamide oral tablet Casodex flutamide oral capsule nilutamide oral tablet Nilandron

*Antiestrogens*** tamoxifen citrate oral tablet FARESTON ORAL TABLET

*Antimetabolites*** capecitabine oral tablet Xeloda PA mercaptopurine oral tablet Purinethol methotrexate oral tablet methotrexate sodium (pf) injection solution 1 gm/40ml, 100 mg/4ml, 200 mg/8ml, 250 mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml TABLOID ORAL TABLET

*Antineoplastic - Tyrosine Kinase Inhibitors*** imatinib mesylate oral tablet Gleevec PA IMBRUVICA ORAL CAPSULE PA; QLL (120 EA per 30 days) TARCEVA ORAL TABLET PA

12

Formulary Drug Name Reference Restrictions *Antineoplastics Misc.*** hydroxyurea oral capsule Hydrea INTRON A INJECTION SOLUTION PA INTRON A INJECTION SOLUTION RECONSTITUTED PA

MATULANE ORAL CAPSULE

*Aromatase Inhibitors*** anastrozole oral tablet Arimidex letrozole oral tablet Femara

*Estrogens-Antineoplastic*** EMCYT ORAL CAPSULE

*Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet

*Imidazotetrazines*** temozolomide oral capsule Temodar PA

*Lhrh Analogs*** LUPRON DEPOT INTRAMUSCULAR KIT PA

*Mitotic Inhibitors*** etoposide oral capsule

*Nitrogen Mustards*** ALKERAN ORAL TABLET LEUKERAN ORAL TABLET

*Nitrosoureas*** GLEOSTINE ORAL CAPSULE 10 MG Lomustine

*Retinoids*** tretinoin oral capsule

*Selective Retinoid X Receptor Agonists*** bexarotene oral capsule Targretin

*Urinary Tract Protective Agents*** MESNEX ORAL TABLET

13

Formulary Drug Name Reference Restrictions *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended release Lithobid

lithium carbonate oral capsule lithium carbonate oral tablet lithium oral solution

*Butyrophenones*** haloperidol decanoate intramuscular solution Haldol Decanoate haloperidol oral tablet

*Dibenzoxazepines*** loxapine succinate oral capsule Loxitane

*Phenothiazines*** chlorpromazine hcl oral tablet fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet perphenazine oral tablet prochlorperazine maleate oral tablet Compazine prochlorperazine rectal suppository Compro thioridazine hcl oral tablet trifluoperazine hcl oral tablet COMPRO RECTAL SUPPOSITORY Prochlorperazine

*Thioxanthenes*** thiothixene oral capsule

*ASSORTED CLASSES* *Antileprotics*** THALOMID ORAL CAPSULE 100 MG PA; QLL (112 EA per 28 days) THALOMID ORAL CAPSULE 150 MG, 200 MG PA; QLL (56 EA per 28 days)

THALOMID ORAL CAPSULE 50 MG PA; QLL (224 EA per 28 days)

*Irrigation Solutions*** sterile water for irrigation irrigation solution Argyle Sterile Water

*Potassium Removing Resins*** sodium polystyrene sulfonate oral powder Kayexalate sodium polystyrene sulfonate oral suspension SPS KIONEX ORAL POWDER Kalexate 14

Formulary Drug Name Reference Restrictions KIONEX ORAL SUSPENSION Sodium Polystyrene Sulfonate SPS ORAL SUSPENSION Sodium Polystyrene Sulfonate

*CARDIOTONICS* *Cardiac Glycosides*** digoxin oral solution digoxin oral tablet Lanoxin DIGITEK ORAL TABLET Digoxin DIGOX ORAL TABLET Digoxin

*CHEMICALS* *Bulk Chemicals - Et's*** ethyl oleate liquid

*Bulk Chemicals - Hy's*** hydroxyprogesterone caproate powder

*Bulk Chemicals - Pr's*** propylene glycol liquid

*Bulk Chemicals - So's*** sodium bicarbonate powder Nice Pure Baking Soda NICE PURE BAKING SODA POWDER Sodium Bicarbonate OTC

*Bulk Chemicals - St's*** stevia extract powder stevia extract powder 90 % OTC

*Fixed Oils*** castor oil oil cottonseed oil oil cvs castor oil oil OTC hm castor oil oil OTC olive oil oil qc castor oil oil OTC qc sweet oil oil OTC sesame oil oil sm sweet oil oil OTC sweet oil oil OTC

*Liquids*** benzyl benzoate liquid glycerin liquid glycerine liquid glycerol formal liquid

15

Formulary Drug Name Reference Restrictions *CONTRACEPTIVES* *Biphasic Contraceptives - Oral*** desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5) Kariva

viorele oral tablet Kariva AZURETTE ORAL TABLET Viorele BEKYREE ORAL TABLET Viorele KARIVA ORAL TABLET Viorele KIMIDESS ORAL TABLET Viorele NECON 10/11 (28) ORAL TABLET PIMTREA ORAL TABLET Viorele

*Combination Contraceptives -Oral*** alyacen 1/35 oral tablet Necon 1/35 (28) briellyn oral tablet Philith desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg Reclipsen

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg Ocella

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg Lessina-28

levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg Kurvelo

marlissa oral tablet Kurvelo norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg Microgestin FE 1/20

norethindrone acet-ethinyl est oral tablet Gildess 1/20 norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg MonoNessa

ALTAVERA ORAL TABLET Marlissa APRI ORAL TABLET Desogestrel-Ethinyl Estradiol AUBRA ORAL TABLET Levonorgestrel-Ethinyl Estrad AVIANE ORAL TABLET Levonorgestrel-Ethinyl Estrad BALZIVA ORAL TABLET Briellyn BLISOVI FE 1.5/30 ORAL TABLET BLISOVI FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE CHATEAL ORAL TABLET Marlissa CRYSELLE-28 ORAL TABLET CYCLAFEM 1/35 ORAL TABLET Alyacen 1/35 CYRED ORAL TABLET Desogestrel-Ethinyl Estradiol

16

Formulary Drug Name Reference Restrictions DASETTA 1/35 ORAL TABLET Alyacen 1/35 DELYLA ORAL TABLET Levonorgestrel-Ethinyl Estrad ELINEST ORAL TABLET EMOQUETTE ORAL TABLET Desogestrel-Ethinyl Estradiol ENSKYCE ORAL TABLET Desogestrel-Ethinyl Estradiol ESTARYLLA ORAL TABLET Norgestimate-Eth Estradiol FALMINA ORAL TABLET Levonorgestrel-Ethinyl Estrad GILDAGIA ORAL TABLET Briellyn GILDESS FE 1.5/30 ORAL TABLET GILDESS FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE JULEBER ORAL TABLET Desogestrel-Ethinyl Estradiol JUNEL 1.5/30 ORAL TABLET

JUNEL 1/20 ORAL TABLET Norethindrone Acet-Ethinyl Est

JUNEL FE 1.5/30 ORAL TABLET JUNEL FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE KELNOR 1/35 ORAL TABLET KURVELO ORAL TABLET Marlissa LARIN 1.5/30 ORAL TABLET

LARIN 1/20 ORAL TABLET Norethindrone Acet-Ethinyl Est

LARIN FE 1.5/30 ORAL TABLET LARIN FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE LARISSIA ORAL TABLET Levonorgestrel-Ethinyl Estrad LESSINA ORAL TABLET Levonorgestrel-Ethinyl Estrad LEVORA 0.15/30 (28) ORAL TABLET Marlissa LOW-OGESTREL ORAL TABLET LUTERA ORAL TABLET Levonorgestrel-Ethinyl Estrad MICROGESTIN 1.5/30 ORAL TABLET

MICROGESTIN 1/20 ORAL TABLET Norethindrone Acet-Ethinyl Est

MICROGESTIN FE 1.5/30 ORAL TABLET MICROGESTIN FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE MONO-LINYAH ORAL TABLET Norgestimate-Eth Estradiol MONONESSA ORAL TABLET Norgestimate-Eth Estradiol NECON 0.5/35 (28) ORAL TABLET NECON 1/35 (28) ORAL TABLET Alyacen 1/35 NECON 1/50 (28) ORAL TABLET

17

Formulary Drug Name Reference Restrictions NORTREL 0.5/35 (28) ORAL TABLET NORTREL 1/35 (21) ORAL TABLET Alyacen 1/35 NORTREL 1/35 (28) ORAL TABLET Alyacen 1/35 OCELLA ORAL TABLET Drospirenone-Ethinyl Estradiol OGESTREL ORAL TABLET ORSYTHIA ORAL TABLET Levonorgestrel-Ethinyl Estrad PHILITH ORAL TABLET Briellyn PIRMELLA 1/35 ORAL TABLET Alyacen 1/35 PORTIA-28 ORAL TABLET Marlissa PREVIFEM ORAL TABLET Norgestimate-Eth Estradiol RECLIPSEN ORAL TABLET Desogestrel-Ethinyl Estradiol SPRINTEC 28 ORAL TABLET Norgestimate-Eth Estradiol SRONYX ORAL TABLET Levonorgestrel-Ethinyl Estrad SYEDA ORAL TABLET Drospirenone-Ethinyl Estradiol TARINA FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE VIENVA ORAL TABLET Levonorgestrel-Ethinyl Estrad VYFEMLA ORAL TABLET Briellyn WERA ORAL TABLET ZARAH ORAL TABLET Drospirenone-Ethinyl Estradiol ZENCHENT ORAL TABLET Briellyn ZOVIA 1/35E (28) ORAL TABLET ZOVIA 1/50E (28) ORAL TABLET Ethynodiol Diac-Eth Estradiol

*Combination Contraceptives -Vaginal*** NUVARING VAGINAL RING

*Copper Contraceptives - Iud*** PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

QLL (1 EA per 999 days)

*Copper Contraceptives - Iud*** (New) PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

QLL (1 EA per 999 days)

*Emergency Contraceptives*** levonorgestrel oral tablet 1.5 mg Next Choice One Dose AFTERA ORAL TABLET Levonorgestrel OTC ECONTRA EZ ORAL TABLET Levonorgestrel OTC FALLBACK SOLO ORAL TABLET Levonorgestrel OTC

18

Formulary Drug Name Reference Restrictions MY WAY ORAL TABLET Levonorgestrel NEXT CHOICE ONE DOSE ORAL TABLET Levonorgestrel

OPCICON ONE-STEP ORAL TABLET Levonorgestrel OTC REACT ORAL TABLET Levonorgestrel OTC TAKE ACTION ORAL TABLET Levonorgestrel OTC

*Progestin Contraceptives -Injectable*** medroxyprogesterone acetate intramuscular suspension Depo-Provera

*Progestin Contraceptives - Iud*** KYLEENA INTRAUTERINE INTRAUTERINE DEVICE QLL (1 EA per 999 days)

LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE QLL (1 EA per 999 days)

MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE QLL (1 EA per 999 days)

SKYLA INTRAUTERINE INTRAUTERINE DEVICE QLL (1 EA per 999 days)

*Progestin Contraceptives - Oral*** norethindrone oral tablet Jolivette CAMILA ORAL TABLET Norethindrone DEBLITANE ORAL TABLET Norethindrone ERRIN ORAL TABLET Norethindrone HEATHER ORAL TABLET Norethindrone JENCYCLA ORAL TABLET Norethindrone JOLIVETTE ORAL TABLET Norethindrone LYZA ORAL TABLET Norethindrone NORA-BE ORAL TABLET Norethindrone NORLYROC ORAL TABLET Norethindrone SHAROBEL ORAL TABLET Norethindrone

*Triphasic Contraceptives - Oral*** alyacen 7/7/7 oral tablet Nortrel 7/7/7 levonorg-eth estrad triphasic oral tablet Myzilra norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg Tri-Linyah

ARANELLE ORAL TABLET CAZIANT ORAL TABLET CYCLAFEM 7/7/7 ORAL TABLET Alyacen 7/7/7

19

Formulary Drug Name Reference Restrictions DASETTA 7/7/7 ORAL TABLET Alyacen 7/7/7 ENPRESSE-28 ORAL TABLET Levonorg-Eth Estrad Triphasic LEENA ORAL TABLET LEVONEST ORAL TABLET Levonorg-Eth Estrad Triphasic MYZILRA ORAL TABLET Levonorg-Eth Estrad Triphasic NECON 7/7/7 ORAL TABLET Alyacen 7/7/7 NORTREL 7/7/7 ORAL TABLET Alyacen 7/7/7 PIRMELLA 7/7/7 ORAL TABLET Alyacen 7/7/7 TILIA FE ORAL TABLET

TRI-ESTARYLLA ORAL TABLET Norgestim-Eth Estrad Triphasic

TRI-LEGEST FE ORAL TABLET

TRI-LINYAH ORAL TABLET Norgestim-Eth Estrad Triphasic

TRINESSA (28) ORAL TABLET Norgestim-Eth Estrad Triphasic

TRI-PREVIFEM ORAL TABLET Norgestim-Eth Estrad Triphasic

TRI-SPRINTEC ORAL TABLET Norgestim-Eth Estrad Triphasic

TRIVORA (28) ORAL TABLET Levonorg-Eth Estrad Triphasic VELIVET ORAL TABLET

*CORTICOSTEROIDS* *Glucocorticosteroids*** cortisone acetate oral tablet dexamethasone oral elixir Baycadron dexamethasone oral solution dexamethasone oral tablet 0.5 mg, 0.75 mg, 1.5 mg, 2 mg, 4 mg, 6 mg hydrocortisone oral tablet Cortef methylprednisolone oral tablet Medrol methylprednisolone oral tablet therapy pack Medrol prednisolone oral solution Prelone prednisolone oral syrup 15 mg/5ml Prelone prednisolone sodium phosphate oral solution 15 mg/5ml Orapred

prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml Pediapred

prednisone oral solution prednisone oral tablet

20

Formulary Drug Name Reference Restrictions prednisone oral tablet therapy pack DELTASONE ORAL TABLET PredniSONE DEXPAK 10 DAY ORAL TABLET THERAPY PACK DEXPAK 6 DAY ORAL TABLET THERAPY PACK QLL (21 EA per 21 days)

MILLIPRED ORAL TABLET

*Mineralocorticoids*** fludrocortisone acetate oral tablet

*COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic*** benzonatate oral capsule 100 mg Tessalon Perles benzonatate oral capsule 200 mg Tessalon

*Antitussive - Opioid*** hydrocodone-homatropine oral syrup hydromet oral syrup

*Antitussive-Expectorant*** cheratussin ac oral syrup OTC childrens mucus relief cough oral liquid Mucinex Fast-Max DM Max OTC dextromethorphan-guaifenesin oral solution Cheracol Plus OTC dextromethorphan-guaifenesin oral syrup Robitussin DM Sugar Free OTC

diabetic siltussin-dm max st oral liquid Wal-Tussin Cough/Chest DM Max OTC

diabetic siltussin-dm oral liquid Cheracol Plus OTC guaiatussin ac oral syrup OTC guaifenesin-codeine oral solution OTC guaifenesin-dm oral syrup Robitussin DM Sugar Free OTC intense cough reliever oral liquid 30-200 mg/5ml OTC

m-clear wc oral solution CGU WC OTC medi-tussin dm double strength oral liquid OTC mucus relief cough childrens oral liquid Mucinex Fast-Max DM Max OTC neotuss oral liquid OTC relcof c oral solution CGU WC OTC trymine cg oral liquid Mar-Cof CG Expectorant OTC DELSYM CGH/CHEST CONG DM CHILD ORAL LIQUID DM Max Maximum Strength OTC

DELSYM COUGH/CHEST CONGEST DM ORAL LIQUID DM Max Maximum Strength OTC

21

Formulary Drug Name Reference Restrictions DIABETIC TUSSIN DM ORAL LIQUID PX Tussin DM OTC DIABETIC TUSSIN FOR CHILDREN ORAL LIQUID PX Tussin DM OTC

DIABETIC TUSSIN MAX ST ORAL LIQUID

TGT Cough Formula DM Max Adult OTC

MUCINEX COUGH CHILDRENS ORAL LIQUID DM Max Maximum Strength OTC

ROBITUSSIN COLD COUGH+ CHEST ORAL LIQUID PX Tussin DM OTC

ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID DM Max Maximum Strength OTC

ROBITUSSIN TO GO CGH/CHEST DM ORAL LIQUID PX Tussin DM OTC

*Decongestant & Antihistamine*** allergy relief d-24 oral tablet extended release 24 hour Claritin-D 24 Hour OTC; QLL (1 UNIT per 1 day)

allergy relief-d oral tablet extended release 24 hour Claritin-D 24 Hour OTC; QLL (1 UNIT per 1 day)

loratadine-d 12hr oral tablet extended release 12 hour Claritin-D 12 Hour OTC; QLL (2 UNITS per 1 day)

loratadine-d 24hr oral tablet extended release 24 hour Claritin-D 24 Hour OTC; QLL (1 UNIT per 1 day)

ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HOUR

TGT Allergy/Congestion Relief OTC; QLL (2 UNITS per 1 day)

*Expectorants***

eq tussin oral liquid Robitussin Mucus+Chest Congest OTC

guaifenesin oral liquid Robitussin Mucus+Chest Congest OTC

guaifenesin oral solution Robitussin Mucus+Chest Congest OTC

guaifenesin oral syrup Diabetic Tussin EX OTC guaifenesin oral tablet 200 mg OTC organ-i nr oral tablet OTC refenesen oral tablet OTC

scot-tussin expectorant oral liquid Robitussin Mucus+Chest Congest OTC

BUCKLEYS CHEST CONGESTION ORAL LIQUID

CVS Tussin Adult Chest Congest OTC

DIABETIC TUSSIN EX ORAL SYRUP Tussin OTC

22

Formulary Drug Name Reference Restrictions MUCINEX CHEST CONGESTION CHILD ORAL LIQUID


ROBITUSSIN MUCUS+CHEST CONGEST ORAL LIQUID


*Misc. Respiratory Inhalants*** sodium chloride inhalation nebulization solution 0.9 %, 10 % sodium chloride inhalation nebulization solution 3 % Nebusal

sodium chloride inhalation nebulization solution 7 % HyperSal

NEBUSAL INHALATION NEBULIZATION SOLUTION 3 % Sodium Chloride

PULMOSAL INHALATION NEBULIZATION SOLUTION Sodium Chloride

*Mucolytics*** acetylcysteine inhalation solution

*Non-Narc Antitussive-Antihistamine*** promethazine-dm oral syrup

*Opioid Antitussive-Antihistamine*** promethazine-codeine oral syrup QLL (120 UNITS per 1 RX)

*Opioid Antitussive-Decongestant-Antihistamine*** phenyleph-promethazine-cod oral syrup QLL (120 UNITS per 1 RX) promethazine vc/codeine oral syrup QLL (120 UNITS per 1 RX)

*DERMATOLOGICALS* *Acne Products*** CLARAVIS ORAL CAPSULE ST MYORISAN ORAL CAPSULE ST ZENATANE ORAL CAPSULE ST

*Antibiotic Mixtures Topical*** bacitracin-neomycin-polymyxin external ointment Neosporin Original OTC

triple antibiotic external ointment 3.5-400-5000 , 5-400-5000 Neosporin Original OTC

*Antifungals - Topical*** antifungal external cream 1 % Medi-First Anti-Fungal OTC tolnaftate antifungal external cream Medi-First Anti-Fungal OTC

23

Formulary Drug Name Reference Restrictions tolnaftate external cream Medi-First Anti-Fungal OTC

*Antineoplastic Antimetabolites -Topical*** fluorouracil external solution

*Antiseborrheic Combinations*** selenium sulfide external shampoo selenium sulf-pyrithione-urea external shampoo

*Antiseborrheic Products*** selenium sulfide external lotion Selsun

*Burn Products*** silver sulfadiazine external cream Thermazene SSD EXTERNAL CREAM Silver Sulfadiazine

*Emollients*** ammonium lactate external cream Lac-Hydrin ammonium lactate external lotion LAClotion glycerin external liquid OTC ra gentle skin external cream Hydro-Lan OTC ALBOLENE EXTERNAL CREAM RA Renewal Moisturizing OTC AMLACTIN EXTERNAL LOTION CVS Skin Treatment OTC AVEENO INTENSE RELIEF HAND EXTERNAL CREAM RA Renewal Moisturizing OTC

CERAVE EXTERNAL CREAM RA Renewal Moisturizing OTC CETAPHIL EXTERNAL CREAM RA Renewal Moisturizing OTC CETAPHIL MOISTURIZING EXTERNAL CREAM RA Renewal Moisturizing OTC

EUCERIN PLUS INTENSIVE REPAIR EXTERNAL CREAM RA Renewal Moisturizing OTC

GERI-HYDROLAC 12 EXTERNAL CREAM Ammonium Lactate OTC

GOLD BOND ULTIMATE HEALING EXTERNAL CREAM RA Renewal Moisturizing OTC

NEUTROGENA HAND EXTERNAL CREAM RA Renewal Moisturizing OTC

NEUTROGENA HEALTHY SKIN EXTERNAL CREAM RA Renewal Moisturizing OTC

NIVEA EXTERNAL CREAM RA Renewal Moisturizing OTC NUTRADERM EXTERNAL CREAM RA Renewal Moisturizing OTC

24

Formulary Drug Name Reference Restrictions *Imidazole-Related Antifungals -Topical*** clotrimazole af external cream Desenex OTC clotrimazole anti-fungal external cream Desenex clotrimazole external cream Desenex

clotrimazole external solution FungiCure Intensive/NailGuard

DESENEX EXTERNAL CREAM CVS Ringworm OTC DESENEX EXTERNAL POWDER CVS Anti-Fungal OTC FUNGICURE INTENSIVE/NAILGUARD EXTERNAL SOLUTION Clotrimazole OTC

LOTRIMIN AF EXTERNAL POWDER CVS Anti-Fungal OTC ZEASORB-AF EXTERNAL POWDER CVS Anti-Fungal OTC

*Keratolytic/Antimitotic Agents*** salicylic acid external cream Salacyn salicylic acid external foam Salvax salicylic acid external lotion Salacyn salicylic acid external shampoo Aliclen SALACYN EXTERNAL CREAM Salicylic Acid SALACYN EXTERNAL LOTION Salicylic Acid

*Local Anesthetics - Topical*** lidocaine hcl external solution Xylocaine

*Rosacea Agents*** metronidazole external cream Rosadan metronidazole external lotion MetroLotion ROSADAN EXTERNAL CREAM MetroNIDAZOLE

*DIAGNOSTIC PRODUCTS* *Diagnostic Tests*** NOVA MAX PLUS KETONE TEST IN VITRO STRIP OTC

ONETOUCH ULTRA BLUE IN VITRO STRIP Blood Glucose Test OTC; QLL (150 EA per 30

days)

ONETOUCH VERIO IN VITRO STRIP Blood Glucose Test OTC; QLL (150 EA per 30 days)

PRECISION XTRA KETONE IN VITRO STRIP OTC

PTS PANELS KETONE TEST IN VITRO STRIP OTC

25

Formulary Drug Name Reference Restrictions *DIURETICS* *Carbonic Anhydrase Inhibitors*** acetazolamide er oral capsule extended release 12 hour Diamox Sequels

acetazolamide oral tablet methazolamide oral tablet Neptazane

*Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet spironolactone-hctz oral tablet Aldactazide triamterene-hctz oral capsule Dyazide triamterene-hctz oral tablet Maxzide-25

*Loop Diuretics*** bumetanide oral tablet Bumex furosemide oral solution 10 mg/ml, 8 mg/ml furosemide oral tablet Lasix torsemide oral tablet Demadex

*Potassium Sparing Diuretics*** amiloride hcl oral tablet spironolactone oral tablet Aldactone

*Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet chlorthalidone oral tablet 25 mg, 50 mg hydrochlorothiazide oral capsule Microzide hydrochlorothiazide oral tablet indapamide oral tablet methyclothiazide oral tablet metolazone oral tablet Zaroxolyn

*ENDOCRINE AND METABOLIC AGENTS - MISC.* *Calcimimetic Agents*** SENSIPAR ORAL TABLET 60 MG QLL (2 UNITS per 1 day)

*Carnitine Replenisher - Agents*** levocarnitine oral solution Carnitor SF levocarnitine oral tablet Carnitor

*Hyperparathyroid Treatment -Vitamin D Analogs*** calcitriol oral capsule Rocaltrol 26

Formulary Drug Name Reference Restrictions calcitriol oral solution Rocaltrol

*Somatostatic Agents*** octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

SandoSTATIN PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT PA

*Vasopressin*** desmopressin ace rhinal tube nasal solution DDAVP Rhinal Tube desmopressin ace spray refrig nasal solution Minirin desmopressin acetate oral tablet DDAVP desmopressin acetate spray nasal solution DDAVP

*ESTROGENS* *Estrogen & Progestin*** estradiol-norethindrone acet oral tablet Activella AMABELZ ORAL TABLET Estradiol-Norethindrone Acet MIMVEY LO ORAL TABLET Estradiol-Norethindrone Acet MIMVEY ORAL TABLET Estradiol-Norethindrone Acet PREMPHASE ORAL TABLET PREMPRO ORAL TABLET

*Estrogens*** estradiol oral tablet Estrace estradiol transdermal patch weekly Climara estropipate oral tablet Ortho-Est 0.625 MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG PREMARIN ORAL TABLET

*GASTROINTESTINAL AGENTS -MISC.* *Gallstone Solubilizing Agents*** ursodiol oral capsule Actigall ursodiol oral tablet Urso 250

*Gastrointestinal Stimulants*** metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml metoclopramide hcl oral tablet Reglan

*Intestinal Acidifiers*** enulose oral solution

27

Formulary Drug Name Reference Restrictions generlac oral solution lactulose encephalopathy oral solution

*GENITOURINARY AGENTS -MISCELLANEOUS* *Citrates*** citric acid-sodium citrate oral solution Shohls Modified cytra k crystals oral packet Polycitra-K potassium citrate er oral tablet extended release 10 meq (1080 mg) Urocit-K 10

potassium citrate er oral tablet extended release 5 meq (540 mg) Urocit-K 5

potassium citrate-citric acid oral packet Polycitra-K potassium citrate-citric acid oral solution tricitrates oral solution virtrate-2 oral solution Shohls Modified virtrate-3 oral solution virtrate-k oral solution TARON-CRYSTALS ORAL PACKET Cytra K Crystals

*Urinary Analgesics*** phenazopyridine hcl oral tablet 100 mg, 200 mg Pyridium

PHENAZO ORAL TABLET 200 MG Phenazopyridine HCl

*HEMATOLOGICAL AGENTS -MISC.* *Quinazoline Agents*** anagrelide hcl oral capsule Agrylin

*HEMATOPOIETIC AGENTS* *Cobalamins*** cyanocobalamin injection solution

*Cytotoxic Agents*** DROXIA ORAL CAPSULE

*Folic Acid/Folates*** folic acid oral tablet 1 mg

*Iron Combinations*** fe c tab plus oral tablet FE C Plus OTC iron 100 plus oral tablet FE C Plus OTC myferon 150 forte oral capsule iFerex 150 Forte poly-iron 150 forte oral capsule iFerex 150 Forte

28

Formulary Drug Name Reference Restrictions polysaccharide iron forte oral capsule iFerex 150 Forte tl-hem 150 oral tablet Hemax FOLIVANE-PLUS ORAL CAPSULE ICAR-C PLUS ORAL TABLET Iron 100 Plus IFEREX 150 FORTE ORAL CAPSULE Poly-Iron 150 Forte INTEGRA PLUS ORAL CAPSULE

*Iron W/ Folic Acid*** FOLIVANE-F ORAL CAPSULE INTEGRA F ORAL CAPSULE

*Iron*** fe tabs oral tablet delayed release OTC ferretts oral tablet Hemocyte OTC ferrex 150 oral capsule Nu-Iron OTC ferric x-150 oral capsule Nu-Iron OTC ferrous fumarate oral tablet 324 (106 fe) mg Hemocyte OTC ferrous sulfate oral elixir FeroSul OTC ferrous sulfate oral liquid OTC ferrous sulfate oral tablet 325 (65 fe) mg Feosol OTC ferrous sulfate oral tablet delayed release 325 (65 fe) mg OTC

ferrousul oral tablet Feosol OTC iron high-potency oral tablet Feosol OTC iron oral tablet 325 (65 fe) mg Feosol OTC myferon 150 oral capsule Nu-Iron OTC px iron oral tablet 200 (65 fe) mg Feosol OTC wee care oral suspension Icar OTC EZFE 200 ORAL CAPSULE OTC FEOSOL ORAL TABLET 325 (65 FE) MG Ferrous Sulfate OTC FEROSUL ORAL ELIXIR Ferrous Sulfate OTC IFEREX 150 ORAL CAPSULE Ferrex 150 OTC NU-IRON ORAL CAPSULE Ferrex 150 OTC POLY-IRON 150 ORAL CAPSULE Ferrex 150 OTC

*LAXATIVES* *Laxatives - Miscellaneous*** constulose oral solution lactulose oral solution sorbitol oral solution OTC

29

Formulary Drug Name Reference Restrictions *Stimulant Laxatives*** castor oil stimulant laxative oral oil OTC geri-kot oral tablet Evac-U-Gen OTC senna oral tablet 8.6 mg Evac-U-Gen OTC senna-lax oral tablet Evac-U-Gen OTC DR EDWARDS OLIVE LAXATIVE ORAL TABLET Senna OTC

SENNACON ORAL TABLET Senna OTC

*Surfactant Laxatives*** docqlace oral capsule Colace OTC docusate sodium oral capsule 100 mg Colace OTC stool softener oral capsule 100 mg Colace OTC CORRECTOL EXTRA GENTLE ORAL CAPSULE Stool Softener OTC

DOCUSIL ORAL CAPSULE Stool Softener OTC DOK ORAL CAPSULE 100 MG Colace OTC PHILLIPS STOOL SOFTENER ORAL CAPSULE Stool Softener OTC

SOF-LAX ORAL CAPSULE Stool Softener OTC

*MEDICAL DEVICES* *Diaphragms*** WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM

*Glucose Monitoring Test Supplies*** control in vitro solution Xpres Control OTC

30

Formulary Drug Name Reference Restrictions diatrue control level 1 in vitro solution Bayer Contour Next Control OTC diatrue control level 2 in vitro solution Xpres Control OTC diatrue control level 3 in vitro solution Eclipse Control OTC easy plus ii control in vitro solution Eclipse Control OTC easy talk control in vitro solution Eclipse Control OTC easy trak control in vitro solution Eclipse Control OTC element compact control 2 in vitro solution On Call Plus Glucose Control OTC element compact control 3 in vitro solution On Call Plus Glucose Control OTC ge100 control in vitro solution Xpres Control OTC glucose control in vitro solution On Call Plus Glucose Control OTC lancets UltiCare Thin Lancets 30G OTC select-lite device/lancets kit Autolet Lite Starter Pack OTC supreme ii high/low control in vitro liquid On Call Plus Glucose Control OTC ACCU-CHEK AVIVA IN VITRO SOLUTION Supreme II High/Low Control OTC

ACCU-CHEK COMPACT PLUS CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

ACCU-CHEK FASTCLIX LANCET KIT Select-Lite Device/Lancets OTC ACCU-CHEK MULTICLIX LANCET DEV KIT Select-Lite Device/Lancets OTC

ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

ACCU-CHEK SOFTCLIX LANCET DEV KIT Select-Lite Device/Lancets OTC

ACCUTREND GLUCOSE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

ACURA CONTROL IN VITRO SOLUTION Easy Check Control OTC

ADVANCE INTUITION CONTROL IN VITRO LIQUID Control OTC

ADVANCE MICRO-DRAW CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

ADVANCE MICRO-DRAW NORMAL IN VITRO LIQUID Supreme II High/Low Control OTC

ADVOCATE CONTROL SOLUTION IN VITRO LIQUID Easy Check Control OTC

ADVOCATE REDI-CODE+ CONTROL IN VITRO SOLUTION Easy Check Control OTC

AGAMATRIX CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

ASSURE 3 CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

31

Formulary Drug Name Reference Restrictions ASSURE 4 CONTROL LEVEL 1 & 2 IN VITRO LIQUID Supreme II High/Low Control OTC

ASSURE DOSE CONTROL IN VITRO SOLUTION Control OTC

ASSURE DOSE NORM/HIGH CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

ASSURE II CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

ASSURE II CONTROL LEVEL 1 & 2 IN VITRO LIQUID Supreme II High/Low Control OTC

ASSURE PRISM CONTROL LEVEL 1&2 IN VITRO SOLUTION Supreme II High/Low Control OTC

ASSURE PRO CONTROL LEVEL 1 & 2 IN VITRO LIQUID Supreme II High/Low Control OTC

AT LAST CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

AUTOLET II CLINISAFE KIT Select-Lite Device/Lancets OTC AUTOLET LITE CLINISAFE KIT Select-Lite Device/Lancets OTC AUTOLET LITE STARTER PACK KIT Select-Lite Device/Lancets OTC BAYER BREEZE 2 CONTROL IN VITRO LIQUID Easy Check Control OTC

BAYER CONTOUR IN VITRO LIQUID Easy Check Control OTC BAYER CONTOUR NEXT CONTROL IN VITRO SOLUTION Control OTC

CARESENS CONTROL A IN VITRO SOLUTION Supreme II High/Low Control OTC

CLEVER CHOICE GLUCOSE CONTROL IN VITRO LIQUID Easy Check Control OTC

COOL CONTROL A IN VITRO SOLUTION Supreme II High/Low Control OTC

COOL CONTROL B IN VITRO SOLUTION Supreme II High/Low Control OTC

DUO-CARE CONTROL SOLUTION IN VITRO LIQUID Supreme II High/Low Control OTC

EASY STEP CONTROL IN VITRO SOLUTION Easy Check Control OTC

EASY TOUCH CONTROL HIGH & LOW IN VITRO SOLUTION Supreme II High/Low Control OTC

EASY TOUCH HEALTHPRO CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

EASYGLUCO CONTROL IN VITRO SOLUTION Easy Check Control OTC

32

Formulary Drug Name Reference Restrictions EASYGLUCO PLUS LEVEL 1 IN VITRO SOLUTION Supreme II High/Low Control OTC

EASYMAX 15 LEVEL 1 CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

EASYMAX 15 LEVEL 2 CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

EASYMAX CONTROL IN VITRO SOLUTION Easy Check Control OTC

ELEMENT CONTROL IN VITRO LIQUID Easy Check Control OTC

EMBRACE CONTROL IN VITRO SOLUTION Easy Check Control OTC

EMBRACE EVO CONTROL LEVEL 1 IN VITRO LIQUID Easy Check Control OTC

EMBRACE EVO CONTROL LEVEL 2 IN VITRO LIQUID Control OTC

EMBRACE GLUCOSE CONTROL IN VITRO LIQUID Easy Check Control OTC

EMBRACE PRO GLUCOSE CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

EVENCARE CONTROL LOW/HIGH IN VITRO LIQUID Supreme II High/Low Control OTC

EVENCARE G2 LOW/HIGH CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

EVENCARE G3 LOW/HIGH CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

EVENCARE MINI CONTROL IN VITRO SOLUTION Control OTC

EVOLUTION CONTROL IN VITRO SOLUTION Control OTC

FIFTY50 CONTROL 2.0 IN VITRO SOLUTION Supreme II High/Low Control OTC

FORA CONTROL IN VITRO SOLUTION Easy Check Control OTC FORACARE GDH CONTROL IN VITRO SOLUTION Easy Check Control OTC

FORTISCARE CONTROL IN VITRO SOLUTION Easy Check Control OTC

FREESTYLE CONTROL SOLUTION IN VITRO LIQUID Supreme II High/Low Control OTC

GLUCOCARD 01 CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

GLUCOCARD 01 CONTROL IN VITRO SOLUTION Control OTC

33

Formulary Drug Name Reference Restrictions GLUCOCARD EXPRESSION CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

GLUCOCARD SHINE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

GLUCOCARD X-SENSOR CONTROL IN VITRO SOLUTION Control OTC

GLUCOCOM CONTROL IN VITRO LIQUID Easy Check Control OTC

GMATE CONTROL LEVEL 2 IN VITRO SOLUTION Supreme II High/Low Control OTC

GNP EASY TOUCH CONT HIGH/LOW IN VITRO SOLUTION Supreme II High/Low Control OTC

HYPOLANCE AST LANCING KIT Select-Lite Device/Lancets OTC IN TOUCH GLUCOSE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

INFINITY CONTROL IN VITRO SOLUTION Easy Check Control OTC

LIBERTY GLUCOSE CONTROL IN VITRO LIQUID Control OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

LIBERTY GLUCOSE CONTROL MID IN VITRO SOLUTION Supreme II High/Low Control OTC

MAXIMA CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

MEDISENSE GLUCOSE KETONE CONTR IN VITRO LIQUID Supreme II High/Low Control OTC

MEDISENSE HI/MID/LOW CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

MEDISENSE HIGH/LOW CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

MEDISENSE MID CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

MICRODOT CONTROL HIGH/LOW IN VITRO SOLUTION Supreme II High/Low Control OTC

MULTI-LANCET DEVICE 2 KIT Select-Lite Device/Lancets OTC MYGLUCOHEALTH CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

NEUTEK 2TEK CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

NEXGEN CONTROL IN VITRO LIQUID Control OTC NOVA MAX PLUS GLU/KET CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

34

Formulary Drug Name Reference Restrictions ON CALL EXPRESS GLUCOSE CONTR IN VITRO SOLUTION Supreme II High/Low Control OTC

ON CALL PLUS GLUCOSE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

ON CALL VIVID GLUCOSE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

ONETOUCH ULTRA 2 KIT Blood Glucose Monitor System OTC

ONETOUCH ULTRA CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

ONETOUCH ULTRA MINI KIT Blood Glucose Monitor System OTC

ONETOUCH ULTRALINK KIT Blood Glucose Monitor System OTC

ONETOUCH VERIO IN VITRO SOLUTION Supreme II High/Low Control OTC

ONETOUCH VERIO IQ SYSTEM KIT Blood Glucose Monitor System OTC

ONETOUCH VERIO KIT Blood Glucose Monitor System OTC

ONETOUCH VERIO SYNC SYSTEM KIT Blood Glucose Monitor System OTC

OPTUMRX GLUCOSE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

PENLET II BLOOD SAMPLER KIT Select-Lite Device/Lancets OTC POCKETCHEM EZ CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

PRECISION GLUCOSE CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

PRECISION GLUCOSE CONTROL SOLN IN VITRO SOLUTION Supreme II High/Low Control OTC

PRECISION GLUCOSE KETONE CONTR IN VITRO LIQUID Supreme II High/Low Control OTC

PRECISION GLUCOSE/KETONE CONTR IN VITRO LIQUID Supreme II High/Low Control OTC

PRODIGY CONTROL SOLUTION IN VITRO SOLUTION Easy Check Control OTC

QUICKTEK CONTROL SOLUTION IN VITRO LIQUID Supreme II High/Low Control OTC

QUINTET CONTROL HIGH/NORMAL IN VITRO SOLUTION Supreme II High/Low Control OTC

REFUAH PLUS GLUCOSE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

35

Formulary Drug Name Reference Restrictions RELION LANCING DEVICE KIT Select-Lite Device/Lancets OTC RIGHTEST GC300 CONTROL IN VITRO LIQUID Easy Check Control OTC

SMARTEST CONTROL MEDIUM IN VITRO SOLUTION Supreme II High/Low Control OTC

SOLARTEK GLUCOSE CONTROL IN VITRO LIQUID Supreme II High/Low Control OTC

SOLUS V2 CONTROL IN VITRO SOLUTION Easy Check Control OTC

SURESTEP GLUCOSE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID Easy Check Control OTC

SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID Easy Check Control OTC

SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID Control OTC

TAI DOC CONTROL IN VITRO SOLUTION Xpres Control OTC

TELCARE GLUCOSE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

TRUE METRIX LEVEL 1 IN VITRO SOLUTION Easy Check Control OTC

TRUE METRIX LEVEL 2 IN VITRO SOLUTION Control OTC

TRUE METRIX LEVEL 3 IN VITRO SOLUTION Easy Check Control OTC

TRUECONTROL GLUCOSE CONT LEV 0 IN VITRO LIQUID Supreme II High/Low Control OTC

TRUECONTROL GLUCOSE CONT LEV 1 IN VITRO LIQUID Supreme II High/Low Control OTC

TRUETEST CONTROL LEVEL 1 IN VITRO LIQUID Supreme II High/Low Control OTC



ULTRATRAK PRO CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

ULTRATRAK ULTIMATE CONTROL IN VITRO SOLUTION Supreme II High/Low Control OTC

UNISTRIP CONTROL IN VITRO SOLUTION Easy Check Control OTC

36

Formulary Drug Name Reference Restrictions VICTORY CONTROL LEVEL 1/2 IN VITRO SOLUTION Supreme II High/Low Control OTC

*Misc. Devices***

folding paddle walker Sprague Rappaport Stethoscope OTC; QLL (1 UNIT per 1 day)

*Needles & Syringes*** easy comfort insulin syringe 30g x 5/16" 0.3 ml TRUEplus Insulin Syringe OTC

elite-thin insulin syringe 31g x 5/16" 0.5 ml TRUEplus Insulin Syringe OTC global inject ease insulin syr 29g x 1/2" 0.3 ml V-R Mono Insulin Syringe OTC global inject ease insulin syr 30g x 5/16" 0.3 ml TRUEplus Insulin Syringe OTC

insulin syringe 29g x 1" 0.3 ml OTC insulin syringe 29g x 1/2" 0.3 ml V-R Mono Insulin Syringe OTC insulin syringe 29g x 1/2" 1 ml BD Insulin Syringe OTC insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

TRUEplus Insulin Syringe OTC

insulin syringe/needle Easy Touch Insulin Syringe OTC kmart valu insulin syringe 29g OTC kmart valu insulin syringe 30g OTC leader insulin syringe 29g x 1/2" 0.3 ml V-R Mono Insulin Syringe OTC leader insulin syringe 30g x 5/16" 0.3 ml TRUEplus Insulin Syringe OTC medic insulin syringe 30g x 5/16" 0.3 ml TRUEplus Insulin Syringe OTC preferred plus insulin syringe 29g x 1/2" 0.3 ml V-R Mono Insulin Syringe OTC

preferred plus insulin syringe 30g x 5/16" 0.3 ml TRUEplus Insulin Syringe OTC

sure comfort insulin syringe 29g x 1/2" 0.3 ml V-R Mono Insulin Syringe OTC sure comfort insulin syringe 30g x 1/2" 0.3 ml BD Insulin Syringe Ultrafine OTC sure comfort insulin syringe 30g x 5/16" 0.3 ml TRUEplus Insulin Syringe OTC

topco insulin syringe 28g x 1/2" 1 ml TRUEplus Insulin Syringe OTC topco insulin syringe 29g x 1/2" 0.3 ml V-R Mono Insulin Syringe OTC ultra comfort insulin syringe 30g x 5/16" 0.3 ml TRUEplus Insulin Syringe OTC

ultra-comfort insulin syringe 29g x 1/2" 0.3 ml V-R Mono Insulin Syringe OTC ultra-comfort insulin syringe 30g x 5/16" 0.3 ml TRUEplus Insulin Syringe OTC

ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

37

Formulary Drug Name Reference Restrictions BD INSULIN SYR ULTRAFINE II Drug Mart Ultra Comfort Syr OTC BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27G X 1/2" 1 ML

OTC

BD INSULIN SYRINGE 30G X 1/2" 0.5 ML Hy-Vee Insulin Syringe OTC

BD INSULIN SYRINGE 31G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr OTC

BD INSULIN SYRINGE HALF-UNIT Drug Mart Ultra Comfort Syr OTC BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML OTC

BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

BD INSULIN SYRINGE MICROFINE 28G X 1/2" 1 ML Leader Insulin Syringe OTC

BD INSULIN SYRINGE U-100 1 ML Kmart Valu Insulin Syringe 30G OTC

BD INSULIN SYRINGE ULTRAFINE Kroger Insulin Syringe OTC COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

COMFORT EZ INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML Insulin Syringe/Needle OTC

EASY TOUCH INSULIN SYRINGE 27G X 1/2" 1 ML OTC

EASY TOUCH INSULIN SYRINGE 30G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr OTC

EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

LITETOUCH INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

LITETOUCH INSULIN SYRINGE 30G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr OTC

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML Kroger Insulin Syringe

MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML OTC

MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML MONOJECT INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Kroger Insulin Syringe

38

Formulary Drug Name Reference Restrictions MONOJECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr

MONOJECT INSULIN SYRINGE 30G X 5/16" 1 ML Ultra-Comfort Insulin Syringe

MONOJECT INSULIN SYRINGE U-100 1 ML

Kmart Valu Insulin Syringe 30G

MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr

PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

PRECISION SURE-DOSE SYRINGE 30G X 3/8" 0.5 ML OTC

PRECISION SURE-DOSE SYRINGE 30G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr OTC

RELI-ON INSULIN SYRINGE 29G 0.3 ML, 29G 0.5 ML QC Insulin Syringe OTC

RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

RELION INSULIN SYRINGE 30G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr OTC

SAFETY-GLIDE SYRINGE Kroger Insulin Syringe OTC SURE-JECT INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

SURE-JECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr OTC

TRUEPLUS INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 30G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr OTC

ULTILET INSULIN SYRINGE SHORT 30G X 5/16" 0.3 ML Drug Mart Ultra Comfort Syr OTC

ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML

Drug Mart Ultra Comfort Syr OTC

ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

V-R MONO INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

39

Formulary Drug Name Reference Restrictions *Peak Flow Meters*** peak flow meter device Assess Peak Flow Meter OTC; QLL (2 EA per 365 days) peak flow meter universal rang device Assess Peak Flow Meter OTC; QLL (2 EA per 365 days) AEROGEAR ACTION ASTHMA KIT KIT QLL (2 EA per 365 days)

AIRZONE PEAK FLOW METER DEVICE

Peak Flow Meter Universal Rang OTC; QLL (2 EA per 365 days)

ASSESS FULL RANGE PEAK METER DEVICE


ASSESS LOW RANGE PEAK METER DEVICE


ASSESS PEAK FLOW METER DEVICE Peak Flow Meter Universal Rang OTC; QLL (2 EA per 365 days)

ASTHMA CHECK METER-ZONE SYSTEM DEVICE


ASTHMAMENTOR DEVICE Peak Flow Meter Universal Rang OTC; QLL (2 EA per 365 days)

ASTHMAPACK FOR CHILDREN KIT OTC; QLL (2 EA per 365 days) ASTHMAPACK I KIT QLL (2 EA per 365 days) ASTHMAPACK II KIT QLL (2 EA per 365 days) ASTHMAPACK III KIT QLL (2 EA per 365 days) MICROLIFE DIGITAL PEAK FLOW DEVICE


MINI WRIGHT PEAK FLOW METER DEVICE


PEAK AIR PEAK FLOW METER DEVICE


PERSONAL BEST FULL RANGE DEVICE


PERSONAL BEST LOW RANGE DEVICE


PIKO 1 DEVICE Peak Flow Meter Universal Rang OTC; QLL (2 EA per 365 days)

POCKET PEAK FLOW METER DEVICE Peak Flow Meter Universal Rang OTC; QLL (2 EA per 365 days)

POCKETPEAK PEAK FLOW METER DEVICE


TRUZONE PEAK FLOW METER DEVICE

Peak Flow Meter Universal Rang QLL (2 EA per 365 days)

*Spacer/Aerosol-Holding Chambers & Supplies*** valved holding chamber device Pocket Chamber QLL (2 EA per 365 days)

40

Formulary Drug Name Reference Restrictions AEROCHAMBER MINI CHAMBER DEVICE Valved Holding Chamber QLL (2 EA per 365 days)

AEROCHAMBER MV Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU MEDIUM Valved Holding Chamber QLL (2 EA per 365 days)

AEROCHAMBER PLUS FLO-VU SMALL Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK Valved Holding Chamber QLL (2 EA per 365 days)

AEROCHAMBER PLUS FLOW VU Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER W/FLOWSIGNAL Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS CHAMBR Valved Holding Chamber QLL (2 EA per 365 days)

AEROCHAMBER Z-STAT PLUS/LARGE Valved Holding Chamber QLL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS/MEDIUM Valved Holding Chamber QLL (2 EA per 365 days)

AEROCHAMBER Z-STAT PLUS/SMALL Valved Holding Chamber QLL (2 EA per 365 days) AEROVENT PLUS DEVICE Valved Holding Chamber QLL (2 EA per 365 days) ARIAL CHAMBER DEVICE Valved Holding Chamber OTC; QLL (2 EA per 365 days) BREATHERITE Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE COLL SPACER ADULT Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE COLL SPACER CHILD Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE COLL SPACER INFANT Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE RIGID SPACER/MASK Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE SPACER NEONATE Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE SPACER SMALL CHILD Valved Holding Chamber QLL (2 EA per 365 days)

BREATHERITE/LARGE MASK Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE/MEDIUM MASK Valved Holding Chamber QLL (2 EA per 365 days) BREATHERITE/SMALL MASK Valved Holding Chamber QLL (2 EA per 365 days) CLEVER CHOICE HOLDING CHAMBER DEVICE Valved Holding Chamber QLL (2 EA per 365 days)

COMPACT SPACE CHAMBER DEVICE Valved Holding Chamber QLL (2 EA per 365 days) COMPACT SPACE CHAMBER/LG MASK DEVICE Valved Holding Chamber QLL (2 EA per 365 days)

COMPACT SPACE CHAMBER/MED MASK DEVICE Valved Holding Chamber QLL (2 EA per 365 days)

COMPACT SPACE CHAMBER/SM MASK DEVICE Valved Holding Chamber QLL (2 EA per 365 days)

41

Formulary Drug Name Reference Restrictions EASIVENT Valved Holding Chamber QLL (2 EA per 365 days) EASIVENT MASK LARGE Valved Holding Chamber QLL (2 EA per 365 days) EASIVENT MASK MEDIUM Valved Holding Chamber QLL (2 EA per 365 days) EASIVENT MASK SMALL Valved Holding Chamber QLL (2 EA per 365 days) E-Z SPACER DEVICE Valved Holding Chamber QLL (2 EA per 365 days) E-Z SPACER THE BODY GUARDS PK DEVICE Valved Holding Chamber QLL (2 EA per 365 days)

FLEXICHAMBER ADULT MASK/SMALL QLL (2 EA per 365 days)

FLEXICHAMBER CHILD MASK/LARGE QLL (2 EA per 365 days)

FLEXICHAMBER CHILD MASK/SMALL QLL (2 EA per 365 days)

FLEXICHAMBER DEVICE Valved Holding Chamber QLL (2 EA per 365 days) INSPIRACHAMBER/LARGE DEVICE Valved Holding Chamber QLL (2 EA per 365 days) INSPIRACHAMBER/MEDIUM DEVICE Valved Holding Chamber QLL (2 EA per 365 days) INSPIRACHAMBER/MOUTHPIECE DEVICE Valved Holding Chamber QLL (2 EA per 365 days)

INSPIRACHAMBER/SMALL DEVICE Valved Holding Chamber QLL (2 EA per 365 days) INSPIREASE Valved Holding Chamber QLL (2 EA per 365 days) LITEAIRE DEVICE Valved Holding Chamber QLL (2 EA per 365 days) MASK VORTEX OTC; QLL (2 EA per 365 days) MICROCHAMBER Valved Holding Chamber QLL (2 EA per 365 days) MICROSPACER Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER ADVANTAGE Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER ADVANTAGE-LG MASK Valved Holding Chamber QLL (2 EA per 365 days)

OPTICHAMBER ADVANTAGE-MED MASK Valved Holding Chamber QLL (2 EA per 365 days)

OPTICHAMBER ADVANTAGE-SM MASK Valved Holding Chamber QLL (2 EA per 365 days)

OPTICHAMBER DIAMOND Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER DIAMOND DEVICE Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER DIAMOND-LG MASK DEVICE Valved Holding Chamber QLL (2 EA per 365 days)

OPTICHAMBER DIAMOND-MD MASK Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER DIAMOND-SM MASK Valved Holding Chamber QLL (2 EA per 365 days) OPTICHAMBER FACE MASK-LARGE Valved Holding Chamber OTC; QLL (2 EA per 365 days) OPTICHAMBER FACE MASK-MEDIUM Valved Holding Chamber OTC; QLL (2 EA per 365 days) OPTICHAMBER FACE MASK-SMALL Valved Holding Chamber OTC; QLL (2 EA per 365 days)

42

Formulary Drug Name Reference Restrictions OPTIHALER Valved Holding Chamber QLL (2 EA per 365 days) OPTIHALER DEVICE Valved Holding Chamber QLL (2 EA per 365 days) PANDA MASK LARGE OTC; QLL (2 EA per 365 days) PANDA MASK MEDIUM OTC; QLL (2 EA per 365 days) PANDA MASK SMALL OTC; QLL (2 EA per 365 days) PEDIATRIC PANDA MASK OTC; QLL (2 EA per 365 days) POCKET CHAMBER DEVICE Valved Holding Chamber QLL (2 EA per 365 days) POCKET SPACER DEVICE Valved Holding Chamber QLL (2 EA per 365 days) RITEFLO DEVICE Valved Holding Chamber QLL (2 EA per 365 days) VORTEX VALVED HOLDING CHAMBER DEVICE Valved Holding Chamber QLL (2 EA per 365 days)

WATCHHALER DEVICE Valved Holding Chamber QLL (2 EA per 365 days)

*MIGRAINE PRODUCTS* *Ergot Combinations*** MIGERGOT RECTAL SUPPOSITORY

*MINERALS & ELECTROLYTES* *Bicarbonates*** sodium bicarbonate intravenous solution 8.4 %

*Calcium Combinations*** calcium oral tablet chewable 500-100 mg-unit OTC calcium/c/d oral tablet chewable OTC

*Calcium*** calcium carbonate oral suspension OTC calcium carbonate oral tablet 1250 (500 ca) mg Cal-Carb Forte OTC

calcium oyster shell oral tablet Cal-Carb Forte OTC oyster shell calcium oral tablet 500 mg Oystercal OTC CAL-CARB FORTE ORAL TABLET CVS Calcium Carbonate OTC CALCI-CHEW ORAL TABLET CHEWABLE Chewable Calcium OTC

*Fluoride*** fluoritab oral solution Flura-Drops fluoritab oral tablet chewable Luride sodium fluoride oral solution Luride sodium fluoride oral tablet sodium fluoride oral tablet chewable Luride FLUOR-A-DAY ORAL SOLUTION Fluoritab

43

Formulary Drug Name Reference Restrictions FLURA-DROPS ORAL SOLUTION 0.275 (0.125 F) MG/DROP Fluoritab

KARIDIUM ORAL SOLUTION Fluoritab LOZI-FLUR MOUTH/THROAT LOZENGE LUDENT ORAL TABLET CHEWABLE Fluoritab NAFRINSE DROPS ORAL SOLUTION Fluoritab NAFRINSE ORAL TABLET CHEWABLE Fluoritab

*Magnesium*** magnesium oxide oral tablet 400 (240 mg) mg OTC magnesium oxide oral tablet 400 (241.3 mg) mg MagOx 400 OTC

mgo oral tablet MagOx 400 OTC MAGNESIUM-OXIDE ORAL TABLET Magnesium Oxide OTC

*Phosphate*** av-phos 250 neutral oral tablet Phospha 250 Neutral virt-phos 250 neutral oral tablet Phospha 250 Neutral K-PHOS ORAL TABLET PHOSPHA 250 NEUTRAL ORAL TABLET Virt-Phos 250 Neutral

*Potassium Combinations*** effervescent pot chloride oral tablet effervescent pot bicarb-pot chloride oral tablet effervescent

*Potassium*** k-effervescent oral tablet effervescent Klor-Con/EF k-vescent oral tablet effervescent Klor-Con/EF potassium bicarbonate oral tablet effervescent Klor-Con/EF potassium chloride crys er oral tablet extended release Klor-Con M10

potassium chloride er oral capsule extended release Micro-K

potassium chloride er oral tablet extended release 10 meq K-Tabs

potassium chloride er oral tablet extended release 8 meq Klor-Con

potassium chloride oral packet Klor-Con potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) K-Sol

44

Formulary Drug Name Reference Restrictions EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ K-Vescent

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE Potassium Chloride ER

KLOR-CON M10 ORAL TABLET EXTENDED RELEASE Potassium Chloride Crys ER

KLOR-CON M20 ORAL TABLET EXTENDED RELEASE Potassium Chloride Crys ER

KLOR-CON ORAL PACKET 20 MEQ K-Vescent KLOR-CON ORAL TABLET EXTENDED RELEASE Potassium Chloride ER

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE Potassium Chloride ER

KLOR-CON/EF ORAL TABLET EFFERVESCENT K-Vescent

K-PRIME ORAL TABLET EFFERVESCENT K-Vescent

*MOUTH/THROAT/DENTAL AGENTS* *Anesthetics Topical Oral*** lidocaine viscous mouth/throat solution

*Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat solution Periogard PAROEX MOUTH/THROAT SOLUTION Chlorhexidine Gluconate PERIOGARD MOUTH/THROAT SOLUTION Chlorhexidine Gluconate

*Fluoride Dental Products*** neutral sodium fluoride mouth/throat solution CaviRinse sf 5000 plus dental cream Denta 5000 Plus sf dental gel NeutraGard Advanced CAVAREST DENTAL GEL SF DENTA 5000 PLUS DENTAL CREAM Dentall 1100 Plus DENTAGEL DENTAL GEL SF KARIGEL DENTAL GEL SF KARIGEL-N DENTAL GEL SF NEUTRAGARD ADVANCED DENTAL GEL SF

PERIOMED MOUTH/THROAT CONCENTRATE Stannous Fluoride OTC

PHOS-FLUR DENTAL GEL SF

45

Formulary Drug Name Reference Restrictions PREVIDENT MOUTH/THROAT SOLUTION Neutral Sodium Fluoride

*Saliva Stimulants*** pilocarpine hcl oral tablet Salagen

*Steroids - Mouth/Throat*** triamcinolone acetonide mouth/throat paste Oralone ORALONE MOUTH/THROAT PASTE Triamcinolone Acetonide

*MULTIVITAMINS* *B-Complex W/ C & E + Zn*** stress formula/zinc oral tablet OTC

*B-Complex W/ C & Folic Acid*** folbee plus oral tablet mynephrocaps oral capsule Nephrocaps rena-vite rx oral tablet Dialyvite reno caps oral capsule Nephrocaps stress formula oral tablet Milco-B-Forte OTC triphrocaps oral capsule Nephrocaps virt-caps oral capsule Nephrocaps virt-vite plus oral tablet vol-care rx oral tablet Dialyvite vp-vite rx oral tablet Dialyvite DIALYVITE ORAL TABLET Rena-Vite Rx NEPHRONEX ORAL TABLET Rena-Vite Rx RENAL ORAL CAPSULE Mynephrocaps

*Multiple Vitamins W/ Minerals*** b-plex plus oral tablet Strovite Forte daily multi oral tablet Strovite Forte OTC multi-day plus minerals oral tablet Strovite Forte OTC multivitamin gummies mens oral tablet chewable SourceCF OTC

multi-vitamin gummies oral tablet chewable SourceCF OTC multivitamin gummies womens oral tablet chewable SourceCF OTC

multi-vitamin/minerals oral tablet Strovite Forte OTC thera-m oral tablet Strovite Forte OTC OCUVITE ORAL TABLET One Daily Calcium/Iron/Zinc OTC

*Ped Multi Vitamins W/Fl & Fe*** multi-vit/fluoride/iron oral solution Escavite LQ

46

Formulary Drug Name Reference Restrictions *Ped Multiple Vitamins W/ Minerals & C*** polyvitamin/iron oral tablet chewable Flintstones Complete OTC CENTRUM KIDS COMPLETE ORAL TABLET CHEWABLE 60 MG SM Animal Shapes Complete OTC

CEROVITE JR ORAL TABLET CHEWABLE Flintstones Complete OTC

FLINTSTONES COMPLETE ORAL TABLET CHEWABLE SM Animal Shapes Complete OTC

FLINTSTONES GUMMIES BONE BUILD ORAL TABLET CHEWABLE SM Animal Shapes Complete OTC

VITALETS CHILDRENS ORAL TABLET CHEWABLE OTC

VITALETS ORAL TABLET CHEWABLE 40 MG OTC

*Ped Mv W/ Fluoride*** multi-vit/fluoride oral solution Quflora Pediatric multi-vitamin/fluoride oral solution Quflora Pediatric multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg MVC-Fluoride

multivitamins/fluoride oral tablet chewable MVC-Fluoride FLORIVA PLUS ORAL SOLUTION Multi-Vitamins/Fluoride MVC-FLUORIDE ORAL TABLET CHEWABLE Multi Vita-Bets/Fluoride

QUFLORA PEDIATRIC ORAL SOLUTION Multi-Vitamins/Fluoride

*Ped Mv W/ Iron*** child chewable vitamins/iron oral tablet chewable Flintstones Plus Iron OTC

multi-delyn/iron oral liquid OTC poly-vita/iron oral solution Poly-Vi-Sol/Iron OTC polyvitamin/iron oral solution Poly-Vi-Sol/Iron OTC BPROTECTED PEDIA POLY-VITE/FE ORAL SOLUTION CVS Poly-Vitamin/Iron OTC

FLINTSTONES PLUS IRON ORAL TABLET CHEWABLE SM Animal Shapes/Iron OTC

*Ped Vitamins Acd & Fa W/ Fluoride*** tri-vi-floro oral suspension Tri-Vi-Flor TRI-VI-FLOR ORAL SUSPENSION Tri-Vi-Floro

47

Formulary Drug Name Reference Restrictions *Ped Vitamins Acd Fluoride & Iron*** tri-vit/fluoride/iron oral solution

*Pediatric Multiple Vitamins W/ C & Fa*** childrens chewable vitamins oral tablet chewable

One-A-Day VitaCraves+Omega-3 OTC

FLINSTONES GUMMIES OMEGA-3 DHA ORAL TABLET CHEWABLE Animal Chews OTC

FLINTSTONES PLUS CALCIUM ORAL TABLET CHEWABLE Animal Chews OTC

FLINTSTONES/MY FIRST ORAL TABLET CHEWABLE Animal Chews OTC

*Pediatric Multiple Vitamins W/ C*** poly-vita oral solution Poly-Vi-Sol OTC polyvitamin oral solution Poly-Vi-Sol OTC BPROTECTED PEDIA POLY-VITE ORAL SOLUTION Poly-Vita OTC

*Prenatal Mv & Min W/Fe-Fa*** classic prenatal oral tablet Stuart Prenatal OTC; AL (Max 44 Years) completenate oral tablet chewable Prenatal 19 AL (Max 44 Years) cvs prenatal oral tablet Stuart Prenatal OTC; AL (Max 44 Years) dothelle dha oral capsule Taron-C DHA AL (Max 44 Years) eql prenatal formula oral tablet Stuart Prenatal OTC; AL (Max 44 Years) goodsense prenatal vitamins oral tablet Stuart Prenatal OTC; AL (Max 44 Years) hemenatal ob + dha oral Prefera OB + DHA AL (Max 44 Years) hemenatal ob oral tablet Prefera OB AL (Max 44 Years) hm prenatal oral tablet Stuart Prenatal OTC; AL (Max 44 Years) kp prenatal multivitamins oral tablet Stuart Prenatal OTC; AL (Max 44 Years) kpn prenatal oral tablet OTC; AL (Max 44 Years) mynatal plus oral tablet Vitafol-OB AL (Max 44 Years) mynatal-z oral tablet Vitafol-OB AL (Max 44 Years) mynate 90 plus oral tablet extended release AL (Max 44 Years) pnv fe fum/docusate/folic acid oral tablet Prenatal 19 AL (Max 44 Years) pnv folic acid + iron oral tablet TriCare AL (Max 44 Years) pnv prenatal plus multivitamin oral tablet TriCare AL (Max 44 Years) pnv tabs 29-1 oral tablet Prenatabs Rx AL (Max 44 Years) pnv-omega oral capsule Zatean-Pn Plus AL (Max 44 Years)

48

Formulary Drug Name Reference Restrictions pnv-total oral capsule Elite-OB 400 AL (Max 44 Years) pnv-vp-u oral capsule Prenatal-U AL (Max 44 Years) prenatal 19 oral tablet 29-1 mg Prenatal 19 AL (Max 44 Years) prenatal 19 oral tablet chewable 29-1 mg Prenatal 19 AL (Max 44 Years) pre-natal formula oral tablet OTC; AL (Max 44 Years) prenatal forte oral tablet OTC; AL (Max 44 Years) prenatal oral tablet 27-0.8 mg Right Step Prenatal AL (Max 44 Years) prenatal oral tablet 27-1 mg TriCare AL (Max 44 Years) prenatal plus iron oral tablet Prenatabs Rx AL (Max 44 Years) prenatal plus oral tablet TriCare AL (Max 44 Years) prenatal vitamin plus low iron oral tablet TriCare AL (Max 44 Years) prenatal vitamins oral tablet OTC; AL (Max 44 Years) prenatal/iron oral tablet OTC; AL (Max 44 Years) preplus oral tablet TriCare AL (Max 44 Years) pretab oral tablet Co-Natal FA AL (Max 44 Years) purefe ob plus oral capsule Vinate IC AL (Max 44 Years) px prenatal multivitamins oral tablet Stuart Prenatal OTC; AL (Max 44 Years) qc prenatal oral tablet Stuart Prenatal OTC; AL (Max 44 Years) ra prenatal formula oral tablet Stuart Prenatal OTC; AL (Max 44 Years) ra prenatal oral tablet Stuart Prenatal OTC; AL (Max 44 Years) se-natal 19 oral tablet Prenatal 19 AL (Max 44 Years) se-natal 19 oral tablet chewable Prenatal 19 AL (Max 44 Years) sm prenatal vitamins oral tablet Stuart Prenatal OTC; AL (Max 44 Years) thrivite 19 oral tablet Prenatal 19 AL (Max 44 Years) thrivite rx oral tablet Prenatabs Rx AL (Max 44 Years) trinatal gt oral tablet Prenatal Multivitamin-Ultra AL (Max 44 Years) trinatal rx 1 oral tablet Vinate One AL (Max 44 Years) ultimatecare one nf oral capsule OB-Natal One AL (Max 44 Years) ultimatecare one oral capsule Folcaps Omega 3 AL (Max 44 Years) vena-bal dha oral Bal-Care DHA AL (Max 44 Years) virt nate oral tablet Trinate AL (Max 44 Years) virt-advance oral tablet Prenatal Multivitamin-Ultra AL (Max 44 Years) virt-c dha oral capsule Taron-C DHA AL (Max 44 Years) virt-care one oral capsule Folcaps Omega 3 AL (Max 44 Years) virt-pn oral tablet Zatean-Pn AL (Max 44 Years) virt-pn plus oral capsule Zatean-Pn Plus AL (Max 44 Years) virt-vite gt oral tablet Prenatal Multivitamin-Ultra AL (Max 44 Years) vol-nate oral tablet Trinate AL (Max 44 Years)

49

Formulary Drug Name Reference Restrictions vol-plus oral tablet TriCare AL (Max 44 Years) vol-tab rx oral tablet Prenatabs Rx AL (Max 44 Years) vp-heme ob + dha oral Prefera OB + DHA AL (Max 44 Years) vp-heme ob oral tablet Prefera OB AL (Max 44 Years) BAL-CARE DHA ORAL Vena-Bal DHA AL (Max 44 Years) CITRANATAL RX ORAL TABLET AL (Max 44 Years) CO-NATAL FA ORAL TABLET Prenatabs FA AL (Max 44 Years) CONCEPT DHA ORAL CAPSULE Virt-C DHA AL (Max 44 Years) CONCEPT OB ORAL CAPSULE AL (Max 44 Years) FOLCAPS OMEGA 3 ORAL CAPSULE 27-1 MG UltimateCare ONE AL (Max 44 Years)

FOLIVANE-OB ORAL CAPSULE AL (Max 44 Years) M-VIT ORAL TABLET Prenatal Plus AL (Max 44 Years) MYNATAL ADVANCE ORAL TABLET Trinatal GT AL (Max 44 Years) MYNATAL ORAL CAPSULE AL (Max 44 Years) MYNATAL ORAL TABLET Trinatal GT AL (Max 44 Years) NIVA-PLUS ORAL TABLET Prenatal Plus AL (Max 44 Years) OBSTETRIX DHA ORAL AL (Max 44 Years) O-CAL FA ORAL TABLET Prenatal Plus AL (Max 44 Years) PRENATAL-U ORAL CAPSULE PNV-VP-U AL (Max 44 Years) TARON-BC ORAL AL (Max 44 Years) TARON-C DHA ORAL CAPSULE Virt-C DHA AL (Max 44 Years) THERANATAL CORE NUTRITION ORAL TABLET Prenatal Plus OTC; AL (Max 44 Years)

TRICARE ORAL TABLET Prenatal Plus AL (Max 44 Years) VINATE II ORAL TABLET AL (Max 44 Years) VINATE M ORAL TABLET AL (Max 44 Years) VINATE ONE ORAL TABLET Se-Natal ONE AL (Max 44 Years) VITAFOL-OB ORAL TABLET Mynatal-Z AL (Max 44 Years) ZATEAN-PN PLUS ORAL CAPSULE PNV-Omega AL (Max 44 Years)

*Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil*** complete natal dha oral AL (Max 44 Years) PR NATAL 400 EC ORAL AL (Max 44 Years) PR NATAL 400 ORAL AL (Max 44 Years) PR NATAL 430 EC ORAL SetonET-EC AL (Max 44 Years) PR NATAL 430 ORAL SetonET AL (Max 44 Years) TRIVEEN-DUO DHA ORAL AL (Max 44 Years)

50

Formulary Drug Name Reference Restrictions *Prenatal Mv & Min W/Fe-Fa-Dha*** folcal dha oral capsule 27-1.25-300 mg VemaVite-PRx 2 AL (Max 44 Years) levomefolate dha oral capsule Neevo DHA AL (Max 44 Years)

pnv ob+dha oral CitraNatal DHA QLL (60 EA per 30 days); AL (Max 44 Years)

pnv-dha+docusate oral capsule VemaVite-PRx 2 AL (Max 44 Years) prenaissance oral capsule Nexa Select AL (Max 44 Years) prenaissance plus oral capsule Macnatal CN DHA AL (Max 44 Years) rulavite dha oral capsule Zatean-Pn DHA AL (Max 44 Years) tl-select oral capsule Nexa Select AL (Max 44 Years) virt-pn dha oral capsule Zatean-Pn DHA AL (Max 44 Years) virtprex oral capsule Triveen-PRx RNF AL (Max 44 Years) vp-heme one oral capsule PreferaOB One AL (Max 44 Years) CITRANATAL ASSURE ORAL 35-1 & 300 MG Prenaissance Promise QLL (60 EA per 30 days); AL

(Max 44 Years)

CITRANATAL DHA ORAL Prenaissance DHA QLL (60 EA per 30 days); AL (Max 44 Years)

FOCALGIN CA ORAL Prenaissance Promise QLL (60 EA per 30 days); AL (Max 44 Years)

MACNATAL CN DHA ORAL CAPSULE Prenaissance Plus AL (Max 44 Years) PREFERAOB ONE ORAL CAPSULE VP-HEME One AL (Max 44 Years) TARON-PREX ORAL CAPSULE AL (Max 44 Years) TRIVEEN-PRX RNF ORAL CAPSULE VirtPrex AL (Max 44 Years) VEMAVITE-PRX 2 ORAL CAPSULE Folcal DHA AL (Max 44 Years) ZATEAN-CH ORAL CAPSULE AL (Max 44 Years) ZATEAN-PN DHA ORAL CAPSULE Virt-PN DHA AL (Max 44 Years)

*Specialty Vitamins Products*** MG-PLUS PROTEIN ORAL TABLET CVS Hair/Skin/Nails OTC

*NASAL AGENTS - SYSTEMIC AND TOPICAL* *Nasal Antibiotics*** BACTROBAN NASAL NASAL OINTMENT QLL (10 GM per 30 days)

*OPHTHALMIC AGENTS* *Cycloplegic Mydriatics*** atropine sulfate ophthalmic ointment atropine sulfate ophthalmic solution Isopto Atropine

51

Formulary Drug Name Reference Restrictions cyclopentolate hcl ophthalmic solution 1 %, 2 % Cyclogyl

homatropine hbr ophthalmic solution Homatropaire tropicamide ophthalmic solution HOMATROPAIRE OPHTHALMIC SOLUTION Homatropine HBr

*Ophthalmic Antivirals*** trifluridine ophthalmic solution Viroptic

*OTIC AGENTS* *Otic Agents - Miscellaneous*** acetic acid otic solution VoSol acetic acid-aluminum acetate otic solution

*Otic Steroids*** hydrocortisone-acetic acid otic solution VoSoL HC ACETASOL HC OTIC SOLUTION Hydrocortisone-Acetic Acid

*OXYTOCICS* *Oxytocics*** METHERGINE ORAL TABLET Methylergonovine Maleate

*PASSIVE IMMUNIZING AGENTS* *Immune Serums*** HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE HYPERTET S/D INTRAMUSCULAR INJECTABLE MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE WINRHO SDF INJECTION SOLUTION

*PENICILLINS* *Aminopenicillins*** amoxicillin oral capsule amoxicillin oral suspension reconstituted amoxicillin oral tablet

52

Formulary Drug Name Reference Restrictions amoxicillin oral tablet chewable 125 mg, 250 mg ampicillin oral capsule ampicillin oral suspension reconstituted

*Natural Penicillins*** penicillin v potassium oral solution reconstituted penicillin v potassium oral tablet

*Penicillinase-Resistant Penicillins*** dicloxacillin sodium oral capsule

*PHARMACEUTICAL ADJUVANTS* *Antimicrobial Agents*** benzyl alcohol liquid

*Flavoring Agents*** almond oil bitter flavor liquid Flavorx anise extract liquid Flavorx apple flavor liquid Flavorx apricot flavor liquid Flavorx bacon flavor liquid Flavorx banana concentrate liquid Flavorx banana cream flavor liquid Flavorx banana creme flavor liquid Flavorx banana flavor liquid Flavorx beef (grilled) flavor oil sol liquid Flavorx OTC beef flavor liquid Flavorx beef type flavor natural liquid Flavorx bitter stop flavor liquid Flavorx bitterness mask flavor liquid Flavorx bitterness suppressor flavor liquid Flavorx blackberry flavor liquid Flavorx blueberry flavor liquid Flavorx bubble gum concentrate liquid Flavorx bubble gum flavor liquid Flavorx butter flavor liquid Flavorx butter rum flavor liquid Flavorx butterscotch flavor liquid Flavorx

53

Formulary Drug Name Reference Restrictions caramel flavor liquid Flavorx cheesecake flavor liquid Flavorx cherry flavor liquid Flavorx chicken (grilled) flavor liquid Flavorx OTC chicken flavor liquid Flavorx OTC chicken flavor oil miscible liquid Flavorx OTC chicken flavor oil soluble liquid Flavorx chicken flavor water miscible liquid Flavorx chicken roasted concentrate liquid Flavorx OTC chocolate flavor liquid Flavorx chocolate hazelnut flavor liquid Flavorx coconut flavor liquid Flavorx coffee flavor liquid Flavorx cola flavor liquid Flavorx cotton candy flavor liquid Flavorx cran-raspberry flavor liquid Flavorx creme dementhe flavor liquid Flavorx english toffee flavor liquid Flavorx eugenol flavor liquid Flavorx fish flavor liquid Flavorx grape flavor liquid Flavorx guava flavor liquid Flavorx ham flavor liquid Flavorx honey flavor liquid Flavorx kahlua flavor liquid Flavorx lemon extract liquid Flavorx lemon flavor liquid Flavorx OTC licorice flavor liquid Flavorx liver concentrate liquid Flavorx OTC liver flavor liquid Flavorx mango flavor liquid Flavorx maple flavor liquid Flavorx marshmallow flavor liquid Flavorx mint chocolate chip flavor liquid Flavorx orange concentrate liquid Flavorx OTC orange cream flavor liquid Flavorx orange flavor liquid Flavorx orange oil flavor liquid Flavorx

54

Formulary Drug Name Reference Restrictions peach flavor liquid Flavorx peanut butter flavor liquid Flavorx pina colada flavor liquid Flavorx pineapple flavor liquid Flavorx pralines and cream flavor liquid Flavorx pumpkin flavor liquid Flavorx raspberry flavor liquid Flavorx root beer flavor liquid Flavorx sardine flavor liquid Flavorx OTC shrimp flavor liquid Flavorx stevia glycerite extract liquid Flavorx strawberry flavor liquid Flavorx sweetening enhancer liquid Flavorx OTC tropical punch flavor liquid Flavorx tuna flavor liquid Flavorx OTC tutti frutti flavor liquid Flavorx tutti-frutti flavor liquid Flavorx vanilla butternut flavor liquid Flavorx vanilla flavor liquid Flavorx watermelon flavor liquid Flavorx wild cherry flavor liquid Flavorx FLAVORX LIQUID Strawberry Flavor OTC PCCA SWEETNESS ENHANCER LIQUID Strawberry Flavor

*Oral Vehicles*** cherry concentrate oral syrup OTC cherry oral syrup distilled water oral liquid Nice Distilled Water OTC flavor plus oral liquid Ora-Sweet SF flavor sweet oral syrup VersaPlus grape syrup oral syrup VersaPlus OTC oral suspend oral liquid Ora-Sweet SF oral syrup oral liquid Ora-Sweet SF oral syrup sf oral liquid Ora-Sweet SF purified water oral liquid Nice Distilled Water simple syrup oral syrup sorbitol solution suspension vehicle oral suspension Flavor Blend

55

Formulary Drug Name Reference Restrictions syrpalta oral syrup VersaPlus syrup vehicle oral syrup VersaPlus syrup vehicle sf oral syrup VersaPlus FLAVOR BLEND ORAL SUSPENSION Suspension Vehicle MX-SOL BLEND ORAL SUSPENSION Suspension Vehicle OTC MX-SOL BLEND SF ORAL SUSPENSION Suspension Vehicle OTC MX-SOL ORAL SYRUP Flavor Sweet OTC MX-SOL SF ORAL SYRUP Flavor Sweet OTC MX-SOL SUSPEND ORAL SUSPENSION Suspension Vehicle OTC ORA-BLEND ORAL SUSPENSION Suspension Vehicle ORA-BLEND SF ORAL SUSPENSION Suspension Vehicle ORAL MIX ORAL LIQUID Flavor Sweet ORAL MIX SF ORAL LIQUID Flavor Sweet ORA-PLUS ORAL LIQUID Flavor Sweet ORA-SWEET ORAL SYRUP Flavor Sweet ORA-SWEET SF ORAL SYRUP Flavor Sweet PCCA SWEET-SF ORAL SYRUP Flavor Sweet PCCA SYRUP VEHICLE ORAL SYRUP Flavor Sweet PCCA-PLUS ORAL SUSPENSION Suspension Vehicle SYRPALTA (RED) ORAL SYRUP Flavor Sweet SYRSPEND SF ALKA ORAL SUSPENSION RECONSTITUTED OTC

SYRSPEND SF ORAL LIQUID Flavor Sweet SYRSPEND SF ORAL SUSPENSION RECONSTITUTED OTC

SYRSPEND SF PH4 ORAL SUSPENSION RECONSTITUTED VERSAFREE ORAL SYRUP Flavor Sweet VERSAPLUS ORAL SYRUP Flavor Sweet

*Parenteral Vehicles*** sterile water for injection injection solution sterile water for injection intravenous solution

*Pharmaceutical Excipients*** lactose anhydrous powder lactose hydrous powder OTC lactose monohydrate powder lactose powder OTC

56

Formulary Drug Name Reference Restrictions *POTASSIUM REMOVING AGENTS*** *Potassium Removing Agents*** sodium polystyrene sulfonate oral powder Kayexalate sodium polystyrene sulfonate oral suspension SPS KIONEX ORAL POWDER Kalexate KIONEX ORAL SUSPENSION Sodium Polystyrene Sulfonate SPS ORAL SUSPENSION Sodium Polystyrene Sulfonate

*PROGESTINS* *Progestins*** medroxyprogesterone acetate oral tablet Provera norethindrone acetate oral tablet Aygestin progesterone micronized oral capsule Prometrium

*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS -MISC.* *Alcohol Deterrents*** disulfiram oral tablet Antabuse

*Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet

*Phenothiazines & Tricyclic Agents*** perphenazine-amitriptyline oral tablet

*Smoking Deterrents*** bupropion hcl er (smoking det) oral tablet extended release 12 hour Buproban QLL (2 UNITS per 1 day)

nicotine mini mouth/throat lozenge Commit OTC; QLL (200 EA per 30 days)

nicotine polacrilex mouth/throat gum Nicorette OTC; QLL (200 EA per 30 days)

nicotine polacrilex mouth/throat lozenge Commit OTC; QLL (200 EA per 30 days)

nicotine step 1 transdermal patch 24 hour Nicoderm CQ OTC; QLL (1 UNIT per 1 day) nicotine step 2 transdermal patch 24 hour Nicoderm CQ OTC; QLL (1 UNIT per 1 day) nicotine step 3 transdermal patch 24 hour Nicoderm CQ OTC; QLL (1 UNIT per 1 day) nicotine transdermal kit OTC; QLL (1 UNIT per 1 day) nicotine transdermal patch 24 hour Nicoderm CQ QLL (1 UNIT per 1 day)

57

Formulary Drug Name Reference Restrictions

NICORELIEF MOUTH/THROAT GUM TGT Nicotine OTC; QLL (200 EA per 30 days)

*RESPIRATORY AGENTS -MISC.* *Hydrolytic Enzymes*** PULMOZYME INHALATION SOLUTION PA

*SULFONAMIDES* *Sulfonamides*** sulfadiazine oral tablet

*THYROID AGENTS* *Antithyroid Agents*** methimazole oral tablet Tapazole propylthiouracil oral tablet

*Thyroid Hormones*** levothyroxine sodium oral tablet Synthroid liothyronine sodium oral tablet Cytomel np thyroid oral tablet 30 mg, 60 mg, 90 mg Armour Thyroid ARMOUR THYROID ORAL TABLET NP Thyroid LEVO-T ORAL TABLET Levothyroxine Sodium LEVOXYL ORAL TABLET Levothyroxine Sodium NATURE-THROID ORAL TABLET 130 MG, 16.25 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 81.25 MG, 97.5 MG NATURE-THROID ORAL TABLET 65 MG Thyroid

UNITHROID DIRECT ORAL TABLET Levothyroxine Sodium UNITHROID ORAL TABLET Levothyroxine Sodium WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 97.5 MG WESTHROID ORAL TABLET 65 MG Thyroid WP THYROID ORAL TABLET 130 MG, 16.25 MG, 32.5 MG, 81.25 MG, 97.5 MG WP THYROID ORAL TABLET 65 MG Thyroid

*ULCER DRUGS* *Antispasmodics*** dicyclomine hcl oral capsule Bentyl dicyclomine hcl oral solution dicyclomine hcl oral tablet Bentyl

58

Formulary Drug Name Reference Restrictions *Belladonna Alkaloids*** ed-spaz oral tablet dispersible NuLev hyoscyamine sulfate er oral tablet extended release 12 hour Symax-SR

hyoscyamine sulfate oral elixir hyoscyamine sulfate oral solution hyoscyamine sulfate oral tablet Levsin hyoscyamine sulfate oral tablet dispersible NuLev hyoscyamine sulfate sublingual tablet sublingual HyoMax-SL

hyosyne oral elixir hyosyne oral solution oscimin oral tablet Levsin oscimin oral tablet dispersible NuLev oscimin sr oral tablet extended release 12 hour Symax-SR

oscimin sublingual tablet sublingual HyoMax-SL NULEV ORAL TABLET DISPERSIBLE Hyoscyamine Sulfate SYMAX-SL SUBLINGUAL TABLET SUBLINGUAL Oscimin

SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HOUR Hyoscyamine Sulfate ER

*H-2 Antagonists*** acid reducer maximum strength oral tablet 150 mg

Wal-Zan 150 Maximum Strength OTC

cimetidine acid reducer oral tablet Tagamet HB OTC cimetidine hcl oral solution cimetidine oral tablet Tagamet HB famotidine oral suspension reconstituted Pepcid famotidine oral tablet 20 mg, 40 mg Pepcid heartburn relief max st oral tablet 20 mg Pepcid OTC heartburn relief oral tablet 200 mg Tagamet HB OTC nizatidine oral capsule Axid nizatidine oral solution Axid ranitidine hcl oral capsule ranitidine hcl oral syrup Zantac

ranitidine hcl oral tablet 150 mg Wal-Zan 150 Maximum Strength

ranitidine hcl oral tablet 300 mg Zantac

59

Formulary Drug Name Reference Restrictions *Misc. Anti-Ulcer*** sucralfate oral tablet Carafate CARAFATE ORAL SUSPENSION Sucralfate

*Proton Pump Inhibitors*** FIRST-LANSOPRAZOLE ORAL SUSPENSION FIRST-OMEPRAZOLE ORAL SUSPENSION OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION

*Quaternary Anticholinergics*** propantheline bromide oral tablet

*Ulcer Drugs - Prostaglandins*** misoprostol oral tablet Cytotec

*URINARY ANTI-INFECTIVES* *Urinary Anti-Infectives*** methenamine mandelate oral tablet nitrofurantoin macrocrystal oral capsule Macrodantin nitrofurantoin monohyd macro oral capsule Macrobid nitrofurantoin oral suspension Furadantin MACRODANTIN ORAL CAPSULE 25 MG Nitrofurantoin Macrocrystal

*URINARY ANTISPASMODICS* *Urinary Antispasmodics -Cholinergic Agonists*** bethanechol chloride oral tablet Urecholine

*Urinary Antispasmodics -Cholinergic Agonists*** (New) bethanechol chloride oral tablet Urecholine

*VAGINAL PRODUCTS* *Imidazole-Related Antifungals*** 3 day vaginal vaginal cream Gyne-Lotrimin 3 OTC clotrimazole 3 vaginal cream Gyne-Lotrimin 3 OTC clotrimazole vaginal cream 1 % Gyne-Lotrimin OTC clotrimazole-7 vaginal cream Gyne-Lotrimin OTC miconazole 1 vaginal kit Monistat 1 Combo Pack OTC miconazole 3 applicator vaginal kit Monistat 3 Combo Pack App OTC miconazole 3 combo pack app vaginal kit Monistat 3 Combo Pack App OTC

60

Formulary Drug Name Reference Restrictions miconazole 3 combo pack vaginal kit Vagistat-3 OTC; QLL (1 PKG per 30 days) miconazole 3 vaginal suppository QLL (1 PKG per 30 days) miconazole 7 vaginal cream Monistat 7 OTC miconazole 7 vaginal suppository Monistat 7 OTC miconazole nitrate vaginal cream Monistat 7 OTC miconazole nitrate vaginal suppository Monistat 7 OTC terconazole vaginal cream Terazol 7 terconazole vaginal suppository Terazol 3 VAGISTAT-3 VAGINAL KIT EQL Miconazole 3 OTC; QLL (1 PKG per 30 days) ZAZOLE VAGINAL CREAM 0.8 % Terconazole ZAZOLE VAGINAL SUPPOSITORY Terconazole

*Vaginal Estrogens*** ESTRACE VAGINAL CREAM VAGIFEM VAGINAL TABLET 10 MCG

*VASOPRESSORS* *Vasopressors*** midodrine hcl oral tablet

*VITAMINS* *Vitamin D*** ergocalciferol oral capsule Drisdol vitamin d (ergocalciferol) oral capsule Drisdol vitamin d3 oral capsule 50000 unit D3-50 OTC vitamin d3 oral tablet 50000 unit Dialyvite Vitamin D3 Max OTC OPTIMAL-D ORAL CAPSULE Vitamin D3 OTC REPLESTA ORAL WAFER OTC

*Vitamin K*** MEPHYTON ORAL TABLET

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60acarbose 8ACCU-CHEK AVIVA 31ACCU-CHEK COMPACT PLUS CONTROL 31ACCU-CHEK FASTCLIX LANCET 31ACCU-CHEK MULTICLIX LANCET DEV 31ACCU-CHEK SMARTVIEW CONTROL 31ACCU-CHEK SOFTCLIX LANCET DEV 31ACCUTREND GLUCOSE CONTROL 31acetaminophen 3acetaminophen extra strength . 3ACETASOL HC 52acetazolamide 26acetazolamide er 26acetic acid 52acetic acid-aluminum acetate 52acetylcysteine 23acid reducer maximum strength 59ACURA CONTROL 31ADVANCE INTUITION CONTROL 31ADVANCE MICRO-DRAW CONTROL 31ADVANCE MICRO-DRAW NORMAL 31ADVOCATE CONTROL SOLUTION 31ADVOCATE INSULIN SYRINGE 37ADVOCATE REDI-CODE+ CONTROL 31AEROCHAMBER MINI CHAMBER 41AEROCHAMBER MV 41AEROCHAMBER PLUS FLO-VU 41AEROCHAMBER PLUS FLO-VU LARGE 41AEROCHAMBER PLUS FLO-VU MEDIUM 41AEROCHAMBER PLUS FLO-VU SMALL 41AEROCHAMBER PLUS FLO-VU W/MASK 41

AEROCHAMBER PLUS FLOW VU .................................

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41AEROCHAMBER W/FLOWSIGNAL 41AEROCHAMBER Z-STAT PLUS 41AEROCHAMBER Z-STAT PLUS CHAMBR 41AEROCHAMBER Z-STAT PLUS/LARGE 41AEROCHAMBER Z-STAT PLUS/MEDIUM 41AEROCHAMBER Z-STAT PLUS/SMALL 41AEROGEAR ACTION ASTHMA KIT 40AEROVENT PLUS 41AFTERA 18AGAMATRIX CONTROL 31AIRZONE PEAK FLOW METER 40ALAVERT 10ALAVERT ALLERGY/SINUS 22ALBOLENE 24ALKERAN 13all day allergy 9all day allergy childrens 9allergy childrens 9allergy relief 9allergy relief child 9allergy relief childrens 9allergy relief d-24 22allergy relief-d 22allerhist-1 9almond oil bitter flavor 53alprazolam 6alprazolam er 6ALPRAZOLAM INTENSOL 6alprazolam xr 6ALTAVERA 16alyacen 1/35 16alyacen 7/7/7 19AMABELZ 27amiloride hcl 26amiloride-hydrochlorothiazide 26amiodarone hcl 7amitriptyline hcl 7AMLACTIN 24ammonium lactate 24

amoxapine .................................................................

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7amoxicillin 52, 53ampicillin 53anagrelide hcl 28anastrozole 13anise extract 53antacid 5anti-diarrheal 8antifungal 23apple flavor 53APRI 16apricot flavor 53ARANELLE 19ARIAL CHAMBER 41ARMOUR THYROID 58aspirin 4aspirin childrens 4aspirtab 4ASSESS FULL RANGE PEAK METER 40ASSESS LOW RANGE PEAK METER 40ASSESS PEAK FLOW METER 40ASSURE 3 CONTROL 31ASSURE 4 CONTROL LEVEL 1 & 2 32ASSURE DOSE CONTROL 32ASSURE DOSE NORM/HIGH CONTROL 32ASSURE II CONTROL 32ASSURE II CONTROL LEVEL 1 & 2 32ASSURE PRISM CONTROL LEVEL 1 32ASSURE PRO CONTROL LEVEL 1 & 2 32ASTHMA CHECK METER-ZONE SYSTEM 40ASTHMAMENTOR 40ASTHMAPACK FOR CHILDREN 40ASTHMAPACK I 40ASTHMAPACK II 40ASTHMAPACK III 40AT LAST CONTROL 32atropine sulfate 51AUBRA 16AUTOLET II CLINISAFE 32

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AUTOLET LITE CLINISAFE ..............................

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32AUTOLET LITE STARTER PACK 32AVEENO INTENSE RELIEF HAND 24AVIANE 16av-phos 250 neutral 44AZURETTE 16bacitracin-neomycin-polymyxin 23bacon flavor 53BACTROBAN NASAL 51BAL-CARE DHA 50BALZIVA 16banana concentrate 53banana cream flavor 53banana creme flavor 53banana flavor 53BAYER ADVANCED ASPIRIN REG ST 4BAYER ASPIRIN EC LOW DOSE 4BAYER ASPIRIN REGIMEN 4BAYER BREEZE 2 CONTROL 32BAYER CONTOUR 32BAYER CONTOUR NEXT CONTROL 32BD INSULIN SYR ULTRAFINE II 38BD INSULIN SYRINGE 38BD INSULIN SYRINGE HALF-UNIT 38BD INSULIN SYRINGE MICROFINE 38BD INSULIN SYRINGE ULTRAFINE 38beef (grilled) flavor oil sol 53beef flavor 53beef type flavor natural 53BEKYREE 16benzonatate 21benzyl alcohol 53benzyl benzoate 15bethanechol chloride 60bexarotene 13bicalutamide 12bitter stop flavor 53bitterness mask flavor 53bitterness suppressor flavor 53blackberry flavor 53BLISOVI FE 1.5/30 16

BLISOVI FE 1/20 16blueberry flavor 53b-plex plus 46BPROTECTED PEDIA POLY-VITE 48BPROTECTED PEDIA POLY-VITE/FE 47BREATHERITE 41BREATHERITE COLL SPACER ADULT 41BREATHERITE COLL SPACER CHILD 41BREATHERITE COLL SPACER INFANT 41BREATHERITE RIGID SPACER/MASK 41BREATHERITE SPACER NEONATE 41BREATHERITE SPACER SMALL CHILD 41BREATHERITE/LARGE MASK 41BREATHERITE/MEDIUM MASK 41BREATHERITE/SMALL MASK 41briellyn 16bubble gum concentrate 53bubble gum flavor 53BUCKLEYS CHEST CONGESTION 22buffered aspirin 4bumetanide 26bupropion hcl er (smoking det) 57buspirone hcl 6butalbital-acetaminophen 4butalbital-apap-caffeine 4butalbital-asa-caffeine 4butalbital-aspirin-caffeine 4butter flavor 53butter rum flavor 53butterscotch flavor 53caffeine citrate 3CAL-CARB FORTE 43CALCI-CHEW 43calcitriol 26, 27calcium 43calcium carbonate 43calcium carbonate antacid 5calcium oyster shell 43calcium/c/d 43CAMILA 19

CAPACET 4capecitabine 12captopril 10CARAFATE 60caramel flavor 54CARESENS CONTROL A 32castor oil 15castor oil stimulant laxative 30CAVAREST 45CAZIANT 19CENTRUM KIDS COMPLETE 47CERAVE 24CEROVITE JR 47CETAPHIL 24CETAPHIL MOISTURIZING24cetirizine hcl 10cetirizine hcl allergy child 9cetirizine hcl childrens 10cetirizine hcl hives relief 10CHATEAL 16cheesecake flavor 54CHEMET 9cheratussin ac 21cherry 55cherry concentrate 55cherry flavor 54chicken (grilled) flavor 54chicken flavor 54chicken flavor oil miscible 54chicken flavor oil soluble 54chicken flavor water miscible 54chicken roasted concentrate 54child chewable vitamins/iron 47childrens acetaminophen 3childrens apap 3childrens aspirin free 3childrens chewable vitamins 48childrens mucus relief cough 21CHLORASEPTIC SORE THROAT 3chlordiazepoxide hcl 6chlordiazepoxide-amitriptyline 57chlorhexidine gluconate 45chlorothiazide 26chlorpromazine hcl 14chlorpropamide 8chlorthalidone 26chocolate flavor 54chocolate hazelnut flavor 54choline-mag trisalicylate 4cimetidine 59

64

cimetidine acid reducer ............................................

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59cimetidine hcl 59CITRANATAL ASSURE 51CITRANATAL DHA 51CITRANATAL RX 50citric acid-sodium citrate 28CLARAVIS 23CLARITIN ALLERGY CHILDRENS 10classic prenatal 48clemastine fumarate 9CLEVER CHOICE GLUCOSE CONTROL 32CLEVER CHOICE HOLDING CHAMBER . 41clindamycin hcl 11clindamycin palmitate hcl 11clomipramine hcl 7clorazepate dipotassium 6clotrimazole 25, 60clotrimazole 3 60clotrimazole af 25clotrimazole anti-fungal 25clotrimazole-7 60coconut flavor 54coffee flavor 54cola flavor 54COLOCORT .5COMFORT ASSIST INSULIN SYRINGE 38COMFORT EZ INSULIN SYRINGE 38COMPACT SPACE CHAMBER 41COMPACT SPACE CHAMBER/LG MASK 41COMPACT SPACE CHAMBER/MED MASK 41COMPACT SPACE CHAMBER/SM MASK 41complete allergy medicine 9complete natal dha 50completenate 48COMPRO 14CO-NATAL FA . 50CONCEPT DHA 50CONCEPT OB 50constulose 29control 30COOL CONTROL A 32COOL CONTROL B 32

CORRECTOL EXTRA GENTLE 30cortisone acetate 20cotton candy flavor 54cottonseed oil 15cran-raspberry flavor 54creme dementhe flavor 54cromolyn sodium 7CRYSELLE-28 16cvs castor oil 15cvs prenatal 48cyanocobalamin 28CYCLAFEM 1/35 16CYCLAFEM 7/7/7 19cyclopentolate hcl 52cyproheptadine hcl 10CYRED 16cytra k crystals 28daily multi 46danazol .. 4dapsone 11DASETTA 1/35 . 17DASETTA 7/7/7 20DAYHIST ALLERGY 12 HOUR RELIEF 9DEBLITANE 19DELSYM CGH/CHEST CONG DM CHILD 21DELSYM COUGH/CHEST CONGEST DM 21DELTASONE 21DELYLA 17DENTA 5000 PLUS 45DENTAGEL 45DESENEX 25desipramine hcl 7desmopressin ace rhinal tube 27desmopressin ace spray refrig 27desmopressin acetate 27desmopressin acetate spray 27desogestrel-ethinyl estradiol 16dexamethasone 20DEXPAK 10 DAY 21DEXPAK 6 DAY 21dextromethorphan-guaifenesin 21diabetic siltussin-dm 21diabetic siltussin-dm max st 21DIABETIC TUSSIN DM 22DIABETIC TUSSIN EX 22DIABETIC TUSSIN FOR CHILDREN 22DIABETIC TUSSIN MAX ST 22

DIALYVITE 46diatrue control level 1 31diatrue control level 2 31diatrue control level 3 31diazepam 6dicloxacillin sodium 53dicyclomine hcl 58DIGITEK 15DIGOX 15digoxin 15diphenhist 9diphenhydramine hcl 9diphenoxylate-atropine 8disopyramide phosphate 6distilled water 55disulfiram 57docqlace 30docusate sodium 30DOCUSIL 30DOK 30dothelle dha 48doxepin hcl 8DR EDWARDS OLIVE LAXATIVE 30DRAMAMINE LESS DROWSY 9drospirenone-ethinyl estradiol 16DROXIA 28DUO-CARE CONTROL SOLUTION 32EASIVENT 42EASIVENT MASK LARGE 42EASIVENT MASK MEDIUM 42EASIVENT MASK SMALL 42easy comfort insulin syringe 37easy plus ii control 31EASY STEP CONTROL 32easy talk control 31EASY TOUCH CONTROL HIGH & LOW 32EASY TOUCH HEALTHPRO CONTROL 32EASY TOUCH INSULIN SYRINGE 38easy trak control 31EASYGLUCO CONTROL 32EASYGLUCO PLUS LEVEL 1 33EASYMAX 15 LEVEL 1 CONTROL 33EASYMAX 15 LEVEL 2 CONTROL 33

65

EASYMAX CONTROL .....................................

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33ECONTRA EZ 18ECOTRIN 4ECOTRIN LOW STRENGTH . 4ed-spaz 59EFFER-K 45effervescent pot chloride 44element compact control 2 31element compact control 3 31ELEMENT CONTROL 33ELINEST 17elite-thin insulin syringe 37ELIXOPHYLLIN 7EMBRACE CONTROL 33EMBRACE EVO CONTROL LEVEL 1 33EMBRACE EVO CONTROL LEVEL 2 33EMBRACE GLUCOSE CONTROL 33EMBRACE PRO GLUCOSE CONTROL 33EMCYT 13EMOQUETTE 17english toffee flavor 54ENPRESSE-28 20ENSKYCE 17enulose 27eq tussin 22eql prenatal formula 48ergocalciferol 61ERRIN 19ESGIC 4ESTARYLLA 17ESTRACE 61estradiol 27estradiol-norethindrone acet 27estropipate 27ethambutol hcl 12ethyl oleate 15etoposide 13EUCERIN PLUS INTENSIVE REPAIR 24eugenol flavor 54EVENCARE CONTROL LOW/HIGH 33EVENCARE G2 LOW/HIGH CONTROL 33EVENCARE G3 LOW/HIGH CONTROL 33EVENCARE MINI CONTROL 33

EVOLUTION CONTROL 33EXEL COMFORT POINT INSULIN SYR 38extra strength acetaminophen 3E-Z SPACER 42E-Z SPACER THE BODY GUARDS PK 42EZFE 200 29FALLBACK SOLO 18FALMINA 17famotidine 59FARESTON 12fe c tab plus 28fe tabs 29FEOSOL 29FEROSUL 29ferretts 29ferrex 150 29ferric x-150 29ferrous fumarate 29ferrous sulfate 29ferrousul 29FIFTY50 CONTROL 2.0 33FIRST-LANSOPRAZOLE 60FIRST-OMEPRAZOLE 60fish flavor 54FLAVOR BLEND 56flavor plus 55flavor sweet 55FLAVORX 55flecainide acetate 7FLEXICHAMBER 42FLEXICHAMBER ADULT MASK/SMALL 42FLEXICHAMBER CHILD MASK/LARGE 42FLEXICHAMBER CHILD MASK/SMALL 42FLINSTONES GUMMIES OMEGA-3 DHA 48FLINTSTONES COMPLETE 47FLINTSTONES GUMMIES BONE BUILD . 47FLINTSTONES PLUS CALCIUM 48FLINTSTONES PLUS IRON 47FLINTSTONES/MY FIRST 48FLORIVA PLUS 47fludrocortisone acetate 21FLUOR-A-DAY 43fluoritab 43fluorouracil 24

fluphenazine hcl 14FLURA-DROPS 44flutamide 12FOCALGIN CA 51folbee plus 46folcal dha 51FOLCAPS OMEGA 3 50folding paddle walker 37folic acid 28FOLIVANE-F 29FOLIVANE-OB 50FOLIVANE-PLUS 29FORA CONTROL 33FORACARE GDH CONTROL 33FORTISCARE CONTROL 33FREESTYLE CONTROL SOLUTION 33FUNGICURE INTENSIVE/NAILGUARD 25furosemide 26ge100 control 31generlac 28GERI-HYDROLAC 12 .. 24geri-kot 30GILDAGIA 17GILDESS FE 1.5/30 17GILDESS FE 1/20 17GLEOSTINE 13glimepiride 8glipizide 8glipizide er 8glipizide xl 8glipizide-metformin hcl 8global inject ease insulin syr 37GLUCAGEN HYPOKIT 8GLUCAGON EMERGENCY 8GLUCOCARD 01 CONTROL33GLUCOCARD EXPRESSION CONTROL 34GLUCOCARD SHINE CONTROL 34GLUCOCARD X-SENSOR CONTROL 34GLUCOCOM CONTROL 34glucose control 31glyburide 8glyburide micronized 8glyburide-metformin 8glycerin 15, 24glycerine 15glycerol formal 15

66

GMATE CONTROL LEVEL 2 ..................................................

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34GNP EASY TOUCH CONT HIGH/LOW 34GOLD BOND ULTIMATE HEALING 24goodsense prenatal vitamins 48grape flavor 54grape syrup 55guaiatussin ac 21guaifenesin 22guaifenesin-codeine 21guaifenesin-dm 21guava flavor 54haloperidol 14haloperidol decanoate 14ham flavor 54heartburn relief 59heartburn relief max st 59HEATHER 19hemenatal ob 48hemenatal ob + dha 48heparin sodium (porcine) 7heparin sodium (porcine) pf 7HEXALEN 12hm castor oil 15hm prenatal 48HOMATROPAIRE 52homatropine hbr 52honey flavor 54hydralazine hcl 11hydrochlorothiazide 26hydrocodone-homatropine 21hydrocortisone 5, 20hydrocortisone ace-pramoxine 5hydrocortisone-acetic acid 52hydromet 21hydroxychloroquine sulfate 11hydroxyprogesterone caproate 15hydroxyurea 13hydroxyzine hcl 6hydroxyzine pamoate 6hyoscyamine sulfate 59hyoscyamine sulfate er 59hyosyne 59HYPERRHO S/D 52HYPERTET S/D 52HYPOLANCE AST LANCING 34ICAR-C PLUS 29IFEREX 150 29IFEREX 150 FORTE 29

imatinib mesylate 12IMBRUVICA 12IN TOUCH GLUCOSE CONTROL 34indapamide 26infants pain reliever 3INFINITY CONTROL 34INSPIRACHAMBER/LARGE42INSPIRACHAMBER/MEDIUM 42INSPIRACHAMBER/MOUTHPIECE 42INSPIRACHAMBER/SMALL42INSPIREASE 42insulin syringe 37insulin syringe/needle 37INTEGRA F 29INTEGRA PLUS 29intense cough reliever 21INTRON A 13iron 29iron 100 plus 28iron high-potency 29isoniazid 12isosorbide dinitrate 5isosorbide dinitrate er 5isosorbide mononitrate 5isosorbide mononitrate er 5JENCYCLA 19JOLIVETTE 19JULEBER 17JUNEL 1.5/30 17JUNEL 1/20 17JUNEL FE 1.5/30 17JUNEL FE 1/20 17kahlua flavor 54KARIDIUM 44KARIGEL 45KARIGEL-N 45KARIVA 16k-effervescent 44KELNOR 1/35 17KIMIDESS 16KIONEX 14, 15, 57KLOR-CON 45KLOR-CON 10 45KLOR-CON M10 45KLOR-CON M20 45KLOR-CON SPRINKLE . 45KLOR-CON/EF 45kmart valu insulin syringe 29g 37kmart valu insulin syringe 30g 37

kp prenatal multivitamins 48K-PHOS 44kpn prenatal 48K-PRIME 45KURVELO 17k-vescent 44KYLEENA 19lactose 56lactose anhydrous 56lactose hydrous 56lactose monohydrate 56lactulose 29lactulose encephalopathy 28lancets 31LARIN 1.5/30 17LARIN 1/20 17LARIN FE 1.5/30 17LARIN FE 1/20 17LARISSIA 17leader insulin syringe 37LEENA 20leflunomide 3lemon extract . 54lemon flavor 54LESSINA 17letrozole 13leucovorin calcium 13LEUKERAN 13levocarnitine 26levomefolate dha 51LEVONEST 20levonorgestrel 18levonorgestrel-ethinyl estrad 16levonorg-eth estrad triphasic 19LEVORA 0.15/30 (28) 17LEVO-T 58levothyroxine sodium 58LEVOXYL 58LIBERTY GLUCOSE CONTROL 34LIBERTY GLUCOSE CONTROL MID 34licorice flavor 54lidocaine hcl 25lidocaine viscous 45lidocaine-hydrocortisone ace 5LILETTA (52 MG) 19liothyronine sodium 58LITEAIRE 42LITETOUCH INSULIN SYRINGE 38lithium 14

67

lithium carbonate ..........................................

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14lithium carbonate er 14liver concentrate 54liver flavor 54lofene 8loperamide hcl 8loratadine 10loratadine allergy relief 10loratadine hives relief 10loratadine-d 12hr 22loratadine-d 24hr 22lorazepam 6LORAZEPAM INTENSOL 6LOTRIMIN AF 25LOW-OGESTREL 17loxapine succinate 14LOZI-FLUR 44LUDENT 44LUPRON DEPOT 13LUTERA 17LYSODREN 12LYZA 19MACNATAL CN DHA 51MACRODANTIN 60MAGELLAN INSULIN SAFETY SYR 38magnesium oxide 5, 44MAGNESIUM-OXIDE 44mango flavor 54maple flavor 54maprotiline hcl 7marlissa 16marshmallow flavor 54marten-tab 4MASK VORTEX 42MATULANE 13MAXIMA CONTROL 34m-clear wc 21meclizine hcl 9medic insulin syringe 37MEDISENSE GLUCOSE KETONE CONTR 34MEDISENSE HI/MID/LOW CONTROL 34MEDISENSE HIGH/LOW CONTROL 34MEDISENSE MID CONTROL 34medi-tussin dm double strength 21medroxyprogesterone acetate

19, 57mefloquine hcl 11

MENEST 27MEPHYTON 61mercaptopurine 12MESNEX 13methazolamide 26methenamine mandelate 60METHERGINE 52methimazole 58methotrexate 12methotrexate sodium 12methotrexate sodium (pf) . 12methyclothiazide 26methyldopa 10methyldopa-hydrochlorothiazide10methylprednisolone 20methyltestosterone 4metoclopramide hcl 27metolazone 26metronidazole 25mexiletine hcl 7mgo 44MG-PLUS PROTEIN 51miconazole 1 60miconazole 3 61miconazole 3 applicator 60miconazole 3 combo pack 61miconazole 3 combo pack app 60miconazole 7 61miconazole nitrate 61MICRHOGAM ULTRA-FILTERED PLUS 52MICROCHAMBER 42MICRODOT CONTROL HIGH/LOW 34MICROGESTIN 1.5/30 17MICROGESTIN 1/20 17MICROGESTIN FE 1.5/30 17MICROGESTIN FE 1/20 17MICROLIFE DIGITAL PEAK FLOW 40MICROSPACER 42midodrine hcl 61MIGERGOT 43MILLIPRED 21MIMVEY 27MIMVEY LO 27MINI WRIGHT PEAK FLOW METER 40MINITRAN 6minoxidil 11mint chocolate chip flavor 54MIRENA (52 MG) 19

misoprostol 60MONOJECT INSULIN SYRINGE 38, 39MONOJECT ULTRA COMFORT SYRINGE 39MONO-LINYAH 17MONONESSA 17motion sickness relief 9MUCINEX CHEST CONGESTION CHILD 23MUCINEX COUGH CHILDRENS 22mucus relief cough childrens 21multi-day plus minerals 46multi-delyn/iron 47MULTI-LANCET DEVICE 2 34multi-vit/fluoride 47multi-vit/fluoride/iron 46multi-vitamin gummies 46multivitamin gummies mens 46multivitamin gummies womens 46multivitamin/fluoride 47multi-vitamin/fluoride 47multi-vitamin/minerals 46multivitamins/fluoride 47MVC-FLUORIDE 47M-VIT 50MX-SOL 56MX-SOL BLEND 56MX-SOL BLEND SF 56MX-SOL SF 56MX-SOL SUSPEND 56MY WAY 19myferon 150 29myferon 150 forte 28MYGLUCOHEALTH CONTROL 34MYLERAN 12MYNATAL 50MYNATAL ADVANCE 50mynatal plus 48mynatal-z 48mynate 90 plus 48mynephrocaps 46MYORISAN 23MYZILRA 20NAFRINSE 44NAFRINSE DROPS 44naltrexone hcl 9NATURE-THROID . 58NEBUSAL 23NECON 0.5/35 (28) 17

68

NECON 1/35 (28) ................................................................

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17NECON 1/50 (28) 17NECON 10/11 (28) 16NECON 7/7/7 20neotuss 21NEPHRONEX 46NEUTEK 2TEK CONTROL 34NEUTRAGARD ADVANCED45neutral sodium fluoride 45NEUTROGENA HAND 24NEUTROGENA HEALTHY SKIN 24NEXGEN CONTROL 34NEXT CHOICE ONE DOSE 19NICE PURE BAKING SODA 15NICORELIEF 58nicotine 57nicotine mini 57nicotine polacrilex 57nicotine step 1 57nicotine step 2 57nicotine step 3 57nilutamide 12NITRO-BID 6nitrofurantoin 60nitrofurantoin macrocrystal 60nitrofurantoin monohyd macro 60nitroglycerin 6nitroglycerin er 6NITRO-TIME 6NIVA-PLUS 50NIVEA 24nizatidine 59NORA-BE 19norethin ace-eth estrad-fe 16norethindrone 19norethindrone acetate 57norethindrone acet-ethinyl est 16norgestimate-eth estradiol 16norgestim-eth estrad triphasic 19NORLYROC 19NORTREL 0.5/35 (28) 18NORTREL 1/35 (21) 18NORTREL 1/35 (28) 18NORTREL 7/7/7 20nortriptyline hcl 8NOVA MAX PLUS GLU/KET CONTROL 34NOVA MAX PLUS KETONE TEST 25np thyroid 58NU-IRON 29

NULEV 59NUTRADERM 24NUVARING 18OBSTETRIX DHA 50O-CAL FA 50OCELLA 18octreotide acetate 27OCUVITE 46OGESTREL 18olive oil 15OMEPRAZOLE+SYRSPEND SF ALKA 60ON CALL EXPRESS GLUCOSE CONTR 35ON CALL PLUS GLUCOSE CONTROL 35ON CALL VIVID GLUCOSE CONTROL 35ondansetron hcl 9ONETOUCH ULTRA 2 35ONETOUCH ULTRA BLUE 25ONETOUCH ULTRA CONTROL 35ONETOUCH ULTRA MINI 35ONETOUCH ULTRALINK 35ONETOUCH VERIO 25, 35ONETOUCH VERIO IQ SYSTEM 35ONETOUCH VERIO SYNC SYSTEM 35OPCICON ONE-STEP 19OPTICHAMBER ADVANTAGE 42OPTICHAMBER ADVANTAGE-LG MASK 42OPTICHAMBER ADVANTAGE-MED MASK 42OPTICHAMBER ADVANTAGE-SM MASK 42OPTICHAMBER DIAMOND 42OPTICHAMBER DIAMOND-LG MASK 42OPTICHAMBER DIAMOND-MD MASK 42OPTICHAMBER DIAMOND-SM MASK 42OPTICHAMBER FACE MASK-LARGE 42OPTICHAMBER FACE MASK-MEDIUM 42OPTICHAMBER FACE MASK-SMALL 42

OPTIHALER 43OPTIMAL-D 61OPTUMRX GLUCOSE CONTROL 35ORA-BLEND 56ORA-BLEND SF 56ORAL MIX 56ORAL MIX SF 56oral suspend 55oral syrup 55oral syrup sf 55ORALONE 46orange concentrate 54orange cream flavor 54orange flavor 54orange oil flavor 54ORA-PLUS 56ORA-SWEET 56ORA-SWEET SF 56organ-i nr 22ORSYTHIA 18oscimin 59oscimin sr 59oxazepam 6oyster shell calcium 43PACERONE 7PANDA MASK LARGE 43PANDA MASK MEDIUM 43PANDA MASK SMALL 43PARAGARD INTRAUTERINE COPPER 18paregoric 8PAROEX 45PCCA SWEETNESS ENHANCER 55PCCA SWEET-SF 56PCCA SYRUP VEHICLE 56PCCA-PLUS 56peach flavor 55PEAK AIR PEAK FLOW METER 40peak flow meter 40peak flow meter universal rang 40peanut butter flavor 55PEDIACARE INFANTS 3PEDIATRIC PANDA MASK 43penicillin v potassium 53PENLET II BLOOD SAMPLER 35PERIOGARD 45PERIOMED 45perphenazine 14

69

perphenazine-amitriptyline .........

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57PERSONAL BEST FULL RANGE 40PERSONAL BEST LOW RANGE 40PHENADOZ 10PHENAZO 28phenazopyridine hcl 28PHENERGAN 10phenyleph-promethazine-cod 23PHILITH 18PHILLIPS STOOL SOFTENER 30PHOS-FLUR 45PHOSPHA 250 NEUTRAL 44PIKO 1 40pilocarpine hcl 46PIMTREA 16pina colada flavor 55pineapple flavor 55PIRMELLA 1/35 18PIRMELLA 7/7/7 20pnv fe fum/docusate/folic acid 48pnv folic acid + iron 48pnv ob+dha 51pnv prenatal plus multivitamin 48pnv tabs 29-1 48pnv-dha+docusate 51pnv-omega 48pnv-total 49pnv-vp-u 49POCKET CHAMBER 43POCKET PEAK FLOW METER 40POCKET SPACER 43POCKETCHEM EZ CONTROL 35POCKETPEAK PEAK FLOW METER 40POLY-IRON 150 29poly-iron 150 forte 28polysaccharide iron forte 29poly-vita 48poly-vita/iron 47polyvitamin 48polyvitamin/iron 47PORTIA-28 18pot bicarb-pot chloride 44potassium bicarbonate 44potassium chloride 44potassium chloride crys er 44potassium chloride er 44

potassium citrate er 28potassium citrate-citric acid 28PR NATAL 400 50PR NATAL 400 EC 50PR NATAL 430 50PR NATAL 430 EC 50pralines and cream flavor 55pramcort . 5prazosin hcl 11PRECISION GLUCOSE CONTROL 35PRECISION GLUCOSE CONTROL SOLN 35PRECISION GLUCOSE KETONE CONTR 35PRECISION GLUCOSE/KETONE CONTR 35PRECISION SUREDOSE PLUS SYR 39PRECISION SURE-DOSE SYRINGE 39PRECISION XTRA KETONE25prednisolone 20prednisolone sodium phosphate . 20prednisone 20, 21PREFERAOB ONE 51preferred plus insulin syringe 37PREMARIN 27PREMPHASE 27PREMPRO 27prenaissance 51prenaissance plus 51prenatal 49prenatal 19 49pre-natal formula 49prenatal forte 49prenatal plus 49prenatal plus iron 49prenatal vitamin plus low iron 49prenatal vitamins 49prenatal/iron 49PRENATAL-U 50preplus 49pretab 49PREVIDENT 46PREVIFEM 18prochlorperazine 14prochlorperazine maleate 14PROCTOFOAM HC 5PROCTO-MED HC 5PROCTO-PAK 5

PROCTOSOL HC 5PROCTOZONE-HC 5PRODIGY CONTROL SOLUTION 35progesterone micronized 57promethazine hcl 10promethazine vc/codeine 23promethazine-codeine 23promethazine-dm 23PROMETHEGAN 10propafenone hcl 7propantheline bromide 60propylene glycol 15propylthiouracil 58protriptyline hcl 8PTS PANELS KETONE TEST 25PULMOSAL 23PULMOZYME 58pumpkin flavor 55purefe ob plus 49purified water 55px iron 29px prenatal multivitamins 49pyrazinamide 12pyridostigmine bromide 11qc castor oil 15qc prenatal 49qc sweet oil 15QUFLORA PEDIATRIC 47QUICKTEK CONTROL SOLUTION 35quinidine gluconate er 6quinidine sulfate 6QUINTET CONTROL HIGH/NORMAL 35ra gentle skin 24ra prenatal 49ra prenatal formula 49ranitidine hcl 59raspberry flavor 55REACT 19RECLIPSEN 18refenesen 22REFUAH PLUS GLUCOSE CONTROL 35relcof c 21RELION INSULIN SYRINGE39RELI-ON INSULIN SYRINGE 39RELION LANCING DEVICE 36RENAL 46

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46reno caps 46REPLESTA 61RHOGAM ULTRA-FILTERED PLUS 52RHOPHYLAC 52rifampin 12RIGHTEST GC300 CONTROL 36RITEFLO 43ROBITUSSIN COLD COUGH+ CHEST 22ROBITUSSIN COUGH+CHEST CONG DM 22ROBITUSSIN MUCUS+CHEST CONGEST 23ROBITUSSIN TO GO CGH/CHEST DM 22root beer flavor 55ROSADAN 25rulavite dha 51SAFETY-GLIDE SYRINGE 39SALACYN 25salicylic acid 25salsalate 4SANDOSTATIN LAR DEPOT 27sardine flavor 55scot-tussin expectorant 22select-lite device/lancets 31selenium sulfide 24selenium sulf-pyrithione-urea 24se-natal 19 49senna . 30SENNACON 30senna-lax 30SENSIPAR 26sesame oil 15sf 45sf 5000 plus 45SHAROBEL 19shrimp flavor 55silphen cough 9silver sulfadiazine 24simple syrup 55SKYLA 19sm prenatal vitamins 49sm sweet oil 15SMARTEST CONTROL MEDIUM 36sodium bicarbonate 5, 15, 43sodium chloride 23

sodium fluoride 43sodium polystyrene sulfonate14, 57SOF-LAX 30SOLARTEK GLUCOSE CONTROL 36SOLUS V2 CONTROL 36sorbitol 29, 55spironolactone 26spironolactone-hctz 26SPRINTEC 28 18SPS 15, 57SRONYX 18SSD 24sterile water for injection 56sterile water for irrigation 14stevia extract 15stevia glycerite extract 55stool softener 30strawberry flavor 55stress formula 46stress formula/zinc 46sucralfate 60sulfadiazine 58sulfamethoxazole-trimethoprim 11SULFATRIM PEDIATRIC 11supreme ii high/low control 31sure comfort insulin syringe 37SURE-JECT INSULIN SYRINGE 39SURESTEP GLUCOSE CONTROL 36SURESTEP PRO HIGH GLUCOSE 36SURESTEP PRO LOW GLUCOSE 36SURESTEP PRO NORMAL GLUCOSE 36suspension vehicle 55sweet oil 15sweetening enhancer 55SYEDA 18SYMAX-SL 59SYMAX-SR 59syrpalta 56SYRPALTA (RED) 56SYRSPEND SF 56SYRSPEND SF ALKA 56SYRSPEND SF PH4 56syrup vehicle 56syrup vehicle sf 56TABLOID 12TAI DOC CONTROL 36

TAKE ACTION 19tamoxifen citrate 12TARCEVA 12TARINA FE 1/20 18TARON-BC 50TARON-C DHA 50TARON-CRYSTALS 28TARON-PREX 51TELCARE GLUCOSE CONTROL 36temozolomide 13TENCON 4terconazole 61testosterone cypionate 5testosterone enanthate 5THALOMID 14THEOCHRON 7theophylline er 7thera-m 46THERANATAL CORE NUTRITION 50thioridazine hcl 14thiothixene 14thrivite 19 49thrivite rx 49TILIA FE .20tl-hem 150 29tl-select 51tolazamide 8tolbutamide 8tolnaftate 24tolnaftate antifungal 23topco insulin syringe 37torsemide 26tretinoin 13triamcinolone acetonide 46TRIAMINIC ALLERCHEWS 10TRIAMINIC FEVER REDUCER 3triamterene-hctz 26TRICARE 50tricitrates 28TRI-ESTARYLLA 20trifluoperazine hcl . 14trifluridine 52TRI-LEGEST FE 20TRI-LINYAH 20trimethobenzamide hcl 9trimethoprim 11trinatal gt 49trinatal rx 1 49TRINESSA (28) 20

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46triple antibiotic 23TRI-PREVIFEM 20TRI-SPRINTEC 20TRIVEEN-DUO DHA 50TRIVEEN-PRX RNF 51TRI-VI-FLOR 47tri-vi-floro 47tri-vit/fluoride/iron 48TRIVORA (28) 20tropical punch flavor 55tropicamide 52TRUE METRIX LEVEL 1 36TRUE METRIX LEVEL 2 36TRUE METRIX LEVEL 3 36TRUECONTROL GLUCOSE CONT LEV 0 36TRUECONTROL GLUCOSE CONT LEV 1 36TRUEPLUS INSULIN SYRINGE 39TRUETEST CONTROL LEVEL 1 36TRUETEST CONTROL LEVEL 2 36TRUETEST CONTROL LEVEL 3 36TRUZONE PEAK FLOW METER 40trymine cg 21TUMS FRESHERS 5tuna flavor 55tutti frutti flavor 55tutti-frutti flavor 55ULTICARE INSULIN SYRINGE 39ULTILET INSULIN SYRINGE SHORT 39ultimatecare one 49ultimatecare one nf 49ultra comfort insulin syringe 37ultra-comfort insulin syringe 37ULTRA-THIN II INS SYR SHORT 39ULTRA-THIN II INSULIN SYRINGE 39ULTRATRAK PRO CONTROL 36ULTRATRAK ULTIMATE CONTROL 36UNISTRIP CONTROL 36UNITHROID 58

UNITHROID DIRECT 58ursodiol 27VAGIFEM 61VAGISTAT-3 61valved holding chamber 40vancomycin hcl 11vanilla butternut flavor 55vanilla flavor 55VELIVET 20VEMAVITE-PRX 2 51vena-bal dha 49VERSAFREE 56VERSAPLUS 56VICTORY CONTROL LEVEL 1/2 37VIENVA 18VINATE II 50VINATE M 50VINATE ONE 50viorele 16virt nate 49virt-advance 49virt-c dha 49virt-caps 46virt-care one 49virt-phos 250 neutral 44virt-pn 49virt-pn dha 51virt-pn plus 49virtprex 51virtrate-2 28virtrate-3 28virtrate-k 28virt-vite gt 49virt-vite plus 46VITAFOL-OB 50VITALETS 47VITALETS CHILDRENS 47vitamin d (ergocalciferol) 61vitamin d3 61vol-care rx 46vol-nate 49vol-plus 50vol-tab rx 50VORTEX VALVED HOLDING CHAMBER 43vp-heme ob 50vp-heme ob + dha 50vp-heme one 51vp-vite rx 46V-R MONO INSULIN SYRINGE 39

VYFEMLA 18WATCHHALER 43watermelon flavor 55wee care 29WERA 18WESTHROID 58WIDE-SEAL DIAPHRAGM 60 30WIDE-SEAL DIAPHRAGM 65 30WIDE-SEAL DIAPHRAGM 70 30WIDE-SEAL DIAPHRAGM 75 30WIDE-SEAL DIAPHRAGM 80 30WIDE-SEAL DIAPHRAGM 85 30WIDE-SEAL DIAPHRAGM 90 30WIDE-SEAL DIAPHRAGM 95 30wild cherry flavor 55WINRHO SDF 52WP THYROID 58ZARAH 18ZATEAN-CH 51ZATEAN-PN DHA 51ZATEAN-PN PLUS 50ZAZOLE 61ZEASORB-AF 25ZEBUTAL 4ZENATANE 23ZENCHENT 18ZOVIA 1/35E (28) 18ZOVIA 1/50E (28) 18

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Aetna Better Health of West Virginia Formulary Guide March ......testosterone cypionate...

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