Download - HealthyU Managed Medicaid Formulary U Formulary.pdftestosterone cypionate G testosterone enanthate G ANESTHETICS-LOCAL lidocaine gel G 2 The contents of this document are confidential

Effective January 1, 2015

Notes QL = Quantity Limits may applyB = Brand Drug PA = Prior Authorization may be requiredG = Generic Drug A = Age EditO = Over the Counter (OTC) ST = Step Therapy may be required

Preferred Drug Category

ACNE THERAPY

Acne Therapy - Oral

amnesteem G A; QL; PA

amoxicillin G

Claravis B A; QL; PA

clindamycin G

doxycycline G

erythromycin G

metronidazole G

minocycline G

myorisan G A; QL; PA

zenatane G A; QL; PA

Acne Treatment - Retinoids

adapalene G

tretinoin, cream, gel G A, QL

Acne Treatment Topical (Antibiotics)

Clinda-Derm B PA, QL

Clindamax B PA, QL

Clindamycin, gel, lotion, swab, sol G

erythromycin G

erythromycin-benzoyl peroxide G

metronidazole cream G

Acne Therapy Topical - Miscellaneous

benzoyl peroxide, 4-6%, gel, cr, lot G

This Formulary is a list of the most frequently prescribed medications and may not include all drugs covered under your pharmacy drug benefit. Inclusion of a drug does not guarantee coverage. Check your plan benefit materials for more information about your pharmacy benefit including copayment amounts. This list may change as new drugs are added or due to other factors.

HealthyU Managed Medicaid Formulary

Notes

1

The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.

Preferred Drug Category Notes

Oscion B PA, QL

salicylic acid G

sodium sulfacetamide, cr, liq, G

sodium sulfacetamide/sulfur G

ALZHEIMER'S CHOLINOMIMETICS

Aricept B PA, QL

Aricept ODT B PA, QL

donepezil G QL

Exelon B PA,QL

Exelon Patch B PA, QL

galantamine G QL

Namenda B PA, QL

rivastigmine G QL

ANALGESICS (Non-Opioid)

acetaminophen O

aspirin O

ANAPHYLAXIS THERAPY AGENTS

Epipen B QL

Epipen-Jr B QL

Auvi-Q B QL

ANDROGENS

Androgenic Agents-Topical

Androderm B PA, QL

Androgel B PA, QL

Axiron B PA, QL

Testim B PA, QL

Androgenic Agents - Other

Android B PA, QL

Androxy B PA, QL

Delatestryl B PA, QL

Depo-Tesosterone B PA, QL

Methitest B PA, QL

testosterone cypionate G

testosterone enanthate G

ANESTHETICS-LOCAL

lidocaine gel G

2



lidocaine viscous G

ANTI-ANGINAL AGENTS

isosorbide dinitrate G

nitroglycerin sublingual G

nitroglycerin topical G

ANTIARRHYTHMICS

amiodarone G

disopyramide G

mexiletine G

propafenone IR G

quinidine gluconate G

cefdinir G

Suprax, liq, tabs B

cefpodoxime G

ANTIBIOTICS - QUINOLONES

Avelox B QL

Cipro Suspension B

ciprofloxacin G

ciprofloxacin ER G

Levaquin B PA; QL

levofloxacin G QL

ofloxacin G

ANTIBIOTICS - Misc.

amoxicillin G

amoxicillin/clavulanic acid G

azithromycin G

cefadroxil G QL

cephalexin G

clarithromycin G QL

dicloxacillin G

erythromycin G

metronidazole G

minocycline G

nitrofurantoin G

penicillin G

ANTIBIOTICS - CEPHALOSPORINS, 3rd GENERATION ORAL

3



rifampin G

sulfamethoxazole/trimethoprim G

tetracycline G

trimethoprim G

ANTIBIOTICS -Topical

mupirocin, oint G

neomycin/polymyxin/bacitracin O

ANTICOAGULANTS

ANTICOAGULANTS - Oral

warfarin G

Xarelto B PA

ANTICOAGULANTS - Injectable

Arixtra B PA; QL

enoxaparin sodium G PA; QL

fondaparinux G QL

Fragmin B QL

Lovenox B PA; QL

ANTIDIABETIC AGENTS – Oral

DPP-4 Inhibitors

Januvia B QL, ST

DPP-4 Inhibitor Combinations

Janumet B QL, ST

Janumet XR B QL, ST

Sulfonylureas

glimepiride G

glipizide G

glyburide G

Antidiabetic Agents - Misc.

glyburide/metformin G

metformin G QL

pioglitazone G QL, ST

pioglitazone/metformin G QL, ST

ANTIDIABETIC AGENTS – Injectable

GLP-1 Receptor Agonists

Bydureon B ST, QL

Byetta B ST, QL

4



Victoza B ST, QL

ANTIDIARRHEALS

loperamide AD O

ANTIEMETICS

granisetron G QL

ondansetron G QL

Antiemetics- Misc.

meclizine G

prochlorperazine G

promethazine G

ANTIFUNGALS

Antifungals (Oral)

clotrimazole G

Diflucan B PA, QL

fluconazole G QL

griseofulvin G QL

itraconazole G QL

ketoconazole G

nystatin G

Oravig B PA

terbinafine G QL

Vfend B QL

voriconazole G QL

Antifungals (Topical)

ciclopirox G QL

clotrimazole, cream, solution G

Lotrimin AF, cream, solution-Generic only O PA

econazole nitrate, cream G

ketoconazole, shampoo, cr., foam G

nystatin, powder, oint., cream G

Nystop, powder B

selenium sulfide G

Antifungals (Vaginal)

3-day vaginal cream O

clotrimazole 3, cream/applicator O

Antiemetics (5 HT-3 Antagonists, Neurokinin-1 Antagonists)

5



clotrimazole, cream/applicator O

miconazole 1-3 G

miconazole 7, cream/applicator G

miconazole nitrate G

terconazole G

ANTI-GOUT AGENTS

allopurinol G

colchicine G

probenecid G

ANTIHISTAMINE - Nasal Agents

Astelin B PA, QL; ST

azelastine HCL G QL

ANTIHISTAMINE - Ocular Agents

azelastine G

cromolyn G

epinastine G QL

ketotifen G QL

Optivar B ST

Patanol B PA, QL

ANTIHISTAMINE - Oral Agents

cetirizine O

diphenhydramine O

doxylamine O

hydroxyzine G

levocetirizine G

loratadine O

ANTIHYPERLIPIDEMIC AGENTS

Fibric Acid & Miscellaneous Derivatives

Antara B QL; ST

cholestyramine G

choline fenofibrate G QL

colestipol G

fenofibrate G QL

gemfibrozil G

Lovaza B QL; ST

niacin ER G ST, QL

6



Niacor B PA, QL

Tricor B ST; QL

Zetia B QL

atorvastatin G QL

Crestor B PA, QL; ST

Lipitor B PA, QL; ST

simvastatin G QL

Altoprev B PA, QL; ST

fluvastatin and fluvastatin XL G PA, QL

Lescol, and Lescol XL B PA, QL; ST

lovastatin G QL

Mevacor B PA, QL; ST

Pravachol G PA, QL; ST

pravastatin G QL

Cholesterol-Lowering Combinations

Vytorin B ST, QL

Statin-Hypotensive Combinations

Caduet B PA, QL

atorvastatin/amlodipine G PA, QL

ANTIHYPERTENSIVE AGENTS

Alpha/Beta-Adrenergic Blocking Agents

carvedilol G

labetalol G

Angiotensin Converting Enzyme (ACE) Inhibitors

benazepril G

captopril G

enalapril G

fosinopril G

lisinopril G

moexipril G

quinapril G

ramipril G QL

trandolapril G

benazepril / HCTZ (generic) G

Angiotensin Converting Enzyme (ACE) Inhibitor Combinations

HMG Co-A Reductase Inhibitors (“Statins”)

7



captopril / HCTZ (generic) G

enalapril / HCTZ (generic) G

fosinopril / HCTZ (generic) G

lisinopril / HCTZ (generic) G

moexipril / HCTZ (generic) G

quinapril / HCTZ (generic) G

Angiotensin Receptor Blockers (ARBs)

Avapro B PA, QL; ST

Benicar B ST, QL

Diovan B ST, QL

irbesartan G QL

losartan G QL

Avalide B PA, QL; ST

Benicar HCT B ST, QL

Diovan HCT B ST, QL

irbesartan/hctz G QL

losartan/hctz G QL

valsartan/hctz G ST, QL

Angiotensin Receptor Blocker (ARB) + Calcium Channel Blocker CombinationsAzor B PA, QL

Exforge HCT B PA, QL

Beta-Adrenergic Blocking Agents

acebutolol G

atenolol G

betaxolol G

bisoprolol G

metoprolol G

nadolol G

pindolol G

propranolol G

sotalol G

timolol G

Beta-Adrenergic Blocking Agent Combinations

atenolol/chlorthalidone G

Angiotensin Receptor Blocker (ARB) + Thiazide Combinations

8



bisoprolol/HCTZ G

metoprolol/HCTZ G

nadolol/bendroflumethiazide G

propranolol/HCTZ G

Calcium Channel Blocking Agents

amlodipine G QL

diltiazem G

felodipine G

isradipine G

nicardipine G

nifedipine G

nimodipine G

nisoldipine G QL

verapamil G

Direct Renin Inhibitors

Tekturna B ST, QL

Direct Renin Inhibitors/ Combinations

Tekamlo B ST, QL

Direct Renin Inhibitors/HCTZ

Tekturna HCT B ST, QL

ANTINEOPLASTICS

Antineoplastics PA

ANTI-VIRALS

Antiretrovirals Class Covered

acyclovir G

Tamiflu B QL

valacyclovir G

ASTHMA MEDICATIONS

Asthma Medication Chambers/Spacers

Aerochamber B

Arial O

Breatherite B

Easivent B

E-Z Spacer B

Inspirease B

9



LiteAire B

Microchamber B

Microspacer B

Nessi O

Optichamber B

Optihaler B

Pocket Chamber B

Pocket Spacer B

RiteFlo B

Valved Holding Chamber B

Vortex Valved Holding Chamber B

Watchhaler B

Beta Agonists (Long Acting ) – Solutions for Nebulizer

Brovana B PA

Perforomist B PA

Beta Agonists (Long Acting ) – Metered Dose Inhalers

Serevent Diskus B QL

Beta Agonists (Short Acting ) – Solution for Nebulizer

albuterol G

levalbuterol G PA

metaproterenol G

Xopenex Soln B PA

Beta Agonists (Short Acting ) – Metered Dose Inhalers

albuterol G

Ventolin HFA B QL

Xopenex HFA Inhalation B PA, QL

Combination Corticosteroid / LABA Inhalers

Advair Diskus B QL

Advair HFA B QL

Dulera B QL

Symbicort B QL

Corticosteroids – Metered Dose Inhalers

Asmanex B QL

Azmacort B QL

Flovent Discus B QL

Flovent HFA B QL

10



Qvar B QL

Corticosteroids – Solution for Nebulizer

budesonide ampules G QL

Leukotriene Medications

Accolate B PA, QL

montelukast G QL

zafirlukast G QL

Zyflo CR B ST, QL

BENIGN PROSTATIC HYPERPLASIA (BPH)

alfuzosin G

Avodart B PA, QL; ST

doxazosin G QL

finasteride G QL

Flomax B PA, QL; ST

prazosin G QL

tamsulosin G QL

terazosin G

Uroxatral B PA, QL; ST

BRONCHODILATOR - Inhaled Anticholinergic

Atrovent, HFA B QL

ipratropium G

Spiriva B QL

Combivent B QL

Combivent Respimat B QL

ipratropium/albuterol G

Tudorza B

CONTRACEPTIVES

Contraceptives - Low Dose and Mono-phasic

Altavera G QL

Amethyst G QL

Apri G QL

Aviane G QL

Balziva B QL

Beyaz B QL

BRONCHODILATOR - Inhaled Anticholinergic Combinations

BRONCHODILATOR - Long-acting Anticholinergic

11



Briellyn G QL

Cryselle G QL

Cyclafem G QL

Desogen B QL

Emoquette G QL

Femcon FE B QL

Generess FE B QL

Gianvi G QL

Gildess FE 1mg-20mcg only G QL

Jolessa G QL

Junel G QL

Junel FE G QL

Lessina G QL

Levlen 28 B QL

Levora-28 B QL

Loestrin G QL

Loestrin FE G QL

Loryna G QL

Low-Ogestrel G QL

Lutera G QL

Lybrel G QL

Microgestin G QL

Microgestin FE G QL

Modicon G QL

Mononessa G QL

Necon G QL

Nordette-28 G QL

Norgestrel-Ethinyl Estradiol G QL

Norinyl 1+35 G QL

Norinyl 1+50 G QL

Nortrel G QL

Ocella G QL

Ogestrel G QL

Ortho-Cept G QL

Ortho-Cyclen G QL

Ortho-Novum G QL

12



Ovcon-50 G QL

Portia G QL

Previfem G QL

Quasense G QL

Reclipsen G QL

Safyral G QL

Seasonale G QL

Solia G QL

Sprintec G QL

Sronyx G QL

Syeda G QL

Yasmin 28 G QL

Yaz G QL

Zarah G QL

Zenchent G QL

Zeosa G QL

Zovia G QL

Contraceptives - Bi-phasic

Amethia G QL

Azurette G QL

Camrese G QL

Camrese LO G QL

Kariva G QL

Loseasonique B QL

Mircette B QL

Necon 10-11 G QL

Seasonique B QL

Contraceptives - Tri-phasic/Multi-phasic

Aranelle G QL

Caziant G QL

Cyclafem G QL

Cyclessa B QL

Enpresse G QL

Estrostep FE B QL

Necon G QL

Nortrel G QL

13



Ortho Evra B QL

Ortho Tri-Cyclen B QL

Ortho Tri-Cyclen Lo B QL

Ortho-Novum 7 Days x 3 B QL

Tilia FE G QL

Tri-Legest FE G QL

Tri-Norinyl 7-9-5 B QL

Tri-Previfem G QL

Tri-Sprintec G QL

Trinessa G QL

Trivora-28 G QL

Velivet G QL

Contraceptives - Emergency

levonorgestrel G QL

Next Choice B QL

Plan B One-Step B QL

Contraceptives - Progestin Only

Camila G QL

Errin G QL

Heather G QL

Jolivette G QL

Micronor B QL

Nor-Q-D G QL

Nora-BE G QL

Norethindrone G QL

Contraceptives - Misc

Nuvaring B

Contraceptive creams, foams, tablets, sponges and condoms O

CORTICOSTEROIDS

Corticosteroids - Oral

dexamethasone G

methylprednisolone G

prednisolone G

prednisone G

Corticosteroids - Topical

betamethasone dipropionate G

14



betamethasone valerate G

fluocinolone G

hydrocortisone G

triamcinolone G

Antitussives

guaifenesin/codeine G

guaifenesin/DM O

promethazine/codeine G

Decongestants and Decongestant Combos

loratadine D O

pseudoephedrine O

Triaminic(s) O

Expectorants

guaifenesin O

guaifenesin SR O

Pulmozyme B PA;QL

Tobi B PA;QL

alcohol swabs O QL

Ascensia O

Breeze 2 O

Contour O

Bayer Products O

Freestyle Products O

Insulin syringes with needles-Disposable O QL

lancets O QL

TB Syringe B QL

Precision Products O

Abbott Products O

Urine Testing Products (Clinistix, Clinitest, Diastix, Ketostix) O

Diuretics

acetazolamide G

bumetanide G

DIURETICS

COUGH and COLD AGENTS

CYSTIC FIBROSIS AGENTS

DIABETIC TEST SUPPLIES and ADJUNCTS

15



chlorthalidone G

furosemide G

hydrochlorothiazide G

metolazone G

spironolactone G

Diuretic Combinations

spironolactone/hydrochlorothiazide G

triamterene/hydrochlorothizide G

Estrogens (Oral)

Cenestin B PA

estradiol G

estropipate G

Menest B PA

Estrogens (Combinations)

Combipatch B PA, QL

estradiol-norethindrone G

Jevantique G

Jinteli G

Mimvey G

Prempro B QL

Estrogens (Topical)

estradiol patch G

Vivelle-DOT B PA; QL

Estrogens (Vaginal)

Estring B QL

Premarin Cream B QL

Vagifem B QL

Alpha Adrenergic

Alphagan P B PA

apraclonidine G

brimonidine G

lopidine G

Beta Blocker

betaxolol G

EYEDROP

ESTROGENS

16



timolol G

Beta Blocker Combination

dorzolamide/timolol G

Misc.

dorzolamide G

pilocarpine G

Prostaglandin

latanoprost G QL

Travatan B ST

H2 Receptor Blockers

cimetidine G

famotidine O

ranitidine G

Proton Pump Inhibitors

lansoprazole G QL

omeprazole (generic) B QL

pantoprazole G QL

Prilosec OTC O QL

Gastrointestinal Agents-Misc.

calcium carbonate (antacid) O

calcium carbonate/mag. hydroxide (antacid) O

metoclopramide G

sucralfate G

Genotropin B PA; QL

Norditropin B PA; QL

Aranesp B PA; QL

Epogen B PA; QL

Procrit B PA; QL

Neulasta B PA; QL

Neupogen B PA; QL

Baraclude B PA; QL

HEPATITIS B AGENTS

GASTROINTESTINAL AGENTS

GROWTH HORMONES

GRANULOCYTE COLONY-STIMULATING FACTORS

HEMATOPOIETIC AGENTS - Erythropoietins

17



Hepsera B PA; QL

Viread B PA; QL

Interferons

Pegasys B PA; QL

Peg-Intron B PA; QL

Nucleoside Analogues

Rebetol B PA; QL

ribavirin G PA; QL

Polymerase Inhibitors

Sovaldi B PA; QL

Protease Inhibitors

Victrelis B PA; QL

temazepam G QL

zaleplon G QL

zolpidem G QL

Apriso B QL

Asacol / HD B QL

balsalazide G

Delzicol B

mesalamine G

sulfasalazine G

Cimzia B PA; QL

Enbrel B PA; QL

Humira B PA; QL

Rapid Acting Insulins

Apidra B QL

Novolin-R B QL

Novolog B QL

Intermediate Acting Insulins

Novolin-N B QL

Long Acting Insulins

INSULINS

HEPATITIS C AGENTS

HYPNOTICS

INFLAMMATORY BOWEL AGENTS

IMMUNOMODULATORS

18



Lantus B QL

Levemir B QL

Insulin Mixtures

Novolin 70/30 B QL

Novalog 70/30 B QL

bisacodyl O

citrate of magnesia O

docusate sodium O

Milk of Magnesia O

Miralax O

polyethylene glycol O

psyllium muciloid powder O

Senna O

sennosides/docusate O

Senokot 8.6 mg-Generic only O

calcitriol G

Sensipar B PA, QL

Axert B ST, QL

butalbital/apap/caffeine G QL

Cafergot G

Imitrex, Spray, Pen, Sub-Q vial B QL; ST

Maxalt (all dosage forms) B ST, QL

naratriptan G QL

rizatriptan G QL

sumatriptan G QL

zolmitriptan G QL

Avonex B PA, QL

Betaseron B PA, QL

Copaxone B PA, QL

Gilenya B PA, QL

Rebif B PA, QL

Tecfidera B PA

LAXATIVES

METABOLIC MODIFIERS

MIGRAINE AGENTS

MULTIPLE SCLEROSIS AGENTS

19



flunisolide G QL

fluticasone propionate G QL

Nasonex B ST, QL

triamcinolone spray G QL

Veramyst B ST, QL

Cox-2 Inhibitors

Celebrex B ST, QL

Non-Selective Non-Steroidal Anti-Inflamatories

Advil B QL

Anaprox DS B PA, QL

Cataflam B PA, QL

diclofenac potassium G QL

diclofenac sodium G QL

etodolac G

flurbiprofen G

ibuprofen G QL

Indocin B PA

Indocin Suppository B QL

indomethacin G

ketoprofen G

ketorolac injectable G

meloxicam G QL

Mobic B PA, QL

Motrin B PA, QL

nabumetone G

Nalfon G ST, QL

Naprosyn B PA, QL

naproxen G QL

naproxen sodium G

Oxaprozin B

sulindac G

tolmetin G

AK-POLY-BAC B

OPTHALMIC ANTIBIOTICS

NASAL CORTICOSTEROIDS

NON-STEROIDAL ANTI-INFLAMMATORIES

20



bacitracin G

bacitracin/polymyxin B G

Ciloxan, drops, oint. B PA

ciprofloxacin G

erythromycin, oint G

Garamycin G

Gentak G

gentamicin oint G

gentamicin, drops G

Ilotycin G

levofloxacin G

neomycin-polymyxn B/Gramicidin G

Neosporin B PA

Ocuflox B PA

ofloxacin G

polymyxin B/trimethoprim G

Polytrim B PA

Terramycin/Polymyxin B B

Tobrex B

Vigamox B

Opthalmic Anti-Inflammatory Corticosteroid Agents

Alrex B

dexamethasone sodium phosphate G QL

Flarex B QL

fluorometholone G QL

FML, FML Forte, FML S.O.P. oint. B PA, QL

Lotemax B QL

Maxidex B QL

Pred Forte B PA, QL

Pred Mild B QL

prednisolone acetate G QL

prednisolone sodium phosphate G QL

Opthalmic Anti-Inflammatory NSAID Agents

Acular B PA

Acuvail B

OPHTHALMIC ANTI-INFLAMMATORY AGENTS

21



bromfenac sodium G

diclofenac sodium G

flurbiprofen sodium G

Ilevro B

ketorolac tromethamine G

Ocufen B PA

Opthalmic Anti-Inflammatory Combination Agents

Bleph-10 B PA, QL

Blephamide, Blephamide S.O.P. B QL

Maxitrol B PA, QL

neomycin-polymyxin-HC G

neomycin/bacitracin/polymyxin/hc G

neomycin/polymyxin/dexamethasone G

sulfacetamide sodium G

sulfacetamide-prednisolone G

Tobradex B PA (for drops), QL

tobramycin-dexamethasone G QL

Opioid Narcotics

apap/codeine G QL

Avinza B PA, QL; ST

fentanyl patch (generic) G QL

hydrocodone/APAP G QL

hydromorphone G QL

methadone (generic) G QL

morphine sulfate ER (generic) G QL

morphine sulfate IR G QL

Opana ER B QL

opioids (long / short acting) G QL

oxycodone G QL

oxycodone/APAP G QL

oxymorphone G QL

tramadol G QL

alendronate G QL

etidronate G QL

OPIOID NARCOTICS

OSTEOPOROSIS AGENTS

22



ibandronate G QL

antipyrine/benzocaine G

Ciprodex B

Cipro HC B

ofloxacin G

Creon B

Zenpep B

COMT Inhibitors & Combinations

carbidopa/levodopa G QL

MAO Inhibitors

selegiline G QL

Nonergot-Derived Dopamine Receptor Agonists

Mirapex B PA, QL

Mirapex ER B PA, QL

pramipexole G

ropinirole G

calcium acetate (phosphate binder) G

Fosrenol B

Renagel B

Renvela B

Aggrenox B PA

Agrylin B PA

anagrelide G PA

cilostazol G PA

clopidogrel 75mg G QL

dipyrimadole G PA

Effient B PA

pentoxifylline G PA

Pletal B PA

ticlopidine G

Trental B PA

PARKINSON'S AGENTS

PHOSPHATE BINDER AGENTS

PLATELET AGGREGATION INHIBITORS

OTIC AGENTS

PANCREATIC ENZYMES

23



potassium chloride G

17-alpha hydroxyprogesterone (compound) G

Makena B

Pulmonary Antihypertenives-Endothelin Antagonists

Letairis B PA

Tracleer B PA

Pulmonary Antihypertenives-Phosphodiesterase-5 Enzyme InhibitorsAdcirca B PA

Revatio B PA

sildenafil G

Pulmonary Antihypertenives-Prostacyclines

epoprostenol inj G PA

Ventavis B PA

lindane G QL

malathion G QL

Nix B/G QL

Rid B/G QL

Agents for Acute Injury Treatment

carisoprodol G QL

chlorzoxazone G QL

cyclobenzaprine G QL

metaxalone G QL

methocarbamol G QL

orphenadrine G QL

Skelaxin B PA, QL

Agents for Long Term Treatment

baclofen G QL

dantrolene G

Lioresal G PA

tizanidine G QL

POTASSIUM SUPPLEMENTS

PROGESTINS

PULMONARY ANTIHYPERTENSIVES

SCABICIDES

SKELETAL MUSCLE RELAXANTS

24



Combination Agents for Short Term Use

carisoprodol compound G QL

carisoprodol compound with codeine G QL

orphenadrine compound G QL

Chantix B PA; QL

Nicorette O

Nicoderm O

Nicorelief O

Commit O

Nicotine Gum O

Nicotine Patch O

Armour Thyroid B

levothyroxine G

liothyronine G

phenazopyridine G

Long Acting Agents

Ditropan XL B PA, QL; ST

Enablex B ST,QL

oxybutynin XL G

Toviaz B ST, QL

Vesicare B ST, QL

Short Acting Agents

flavoxate G

oxybutynin G

calcitriol G

calcium (oyster shell not covered) O

ferrous gluconate O

ferrous sulfate O

folic acid G

Inatal Advance B

Inatal GT B

URINARY ANALGESICS

URINARY ANTISPASMODICS

VITAMINS / MINERALS / SUPPLEMENTS

SMOKING DETERRENTS

THYROID AGENTS

25



Inatal Ultra B

M-Vit B

Marnatal-F B

Maxinate B

Mephyton B

O-Cal FA B

O-Cal Prenatal B

pediatric multiple vitamins G A

Prenatal Low Iron B

Prenatal Vitamins Plus B

prenatal vitamins with folic acid G PA

PureFe OB Plus B

PNV Folic Acid + Iron B

Se-Natal 19 B

Taron-Bc B

TriAdvance B

Trinatal GT B

Trinatal Rx 1 B

Trinatal Ultra B

Triveen-U B

Tri-Vi-Sol O

Tri-Vita O

Tri-Vitamin O

Vinate GT B

Vinate II B

Vinate M B

Vinate One B

Vinate Ultra B

Vol-nate B

Vol-Plus B

Vol-tab Rx B

26
