2018 Comprehensive Dual Eligible Drug List (List of Covered Drugs)

Transcription

1 2018 Comprehensive Dual Eligible Drug List (List of Covered Drugs) WellCare of Nebraska 00 lease read: This document contains information about the drugs we cover in this plan. Last updated (4/01/2018)

2 This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *Alternative Medicines* *Alternative Medicine - Ly*** lycopene oral capsule 10 mg *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 mg melatonin oral tablet 1 mg, 3 mg *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 40 mg/ml ibuprofen junior strength oral tablet chewable 100 mg ibuprofen oral capsule 200 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 200 mg naproxen sodium oral capsule 220 mg naproxen sodium oral tablet 220 mg *Analgesics - Nonnarcotic* *Analgesic Combinations*** EXCEDRIN EXTRA STRENGTH ORAL TABLET MG sm tension headache oral tablet mg womens menstrual relief oral tablet mg *Analgesics Other*** ACEHEN RECTAL SUOSITORY 120 MG, 325 MG, 650 MG acetaminophen oral solution 160 mg/5ml acetaminophen oral tablet 325 mg QL (279 EA per 31 days) acetaminophen oral tablet 500 mg QL (186 EA per 31 days) apap extra strength oral tablet 500 mg QL (186 EA per 31 days) apap oral tablet 325 mg QL (279 EA per 31 days) childrens mapap rapid tabs oral tablet dispersible 80 mg childrens non-asa pain relief oral tablet chewable 80 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 1

3 Drug Name reference Details Coverage Details childrens non-aspirin oral tablet chewable 80 mg childrens pain reliever oral tablet chewable 80 mg childrens silapap oral liquid 160 mg/5ml childrens tactinal oral tablet chewable 80 mg ed-apap oral liquid 160 mg/5ml FEVERALL INFANTS RECTAL SUOSITORY 80 MG infants silapap oral solution 100 mg/ml JUNIOR MAA ORAL TABLET DISERSIBLE 160 MG MAA ACETAMINOHEN EXTRA STR ORAL LIQUID 500 MG/15ML mapap arthritis pain oral tablet extended release 650 mg MAA CHILDRENS ORAL SUSENSION 160 MG/5ML QL (93 EA per 31 days) mapap oral capsule 500 mg QL (186 EA per 31 days) mapap oral tablet 325 mg QL (279 EA per 31 days) mapap oral tablet 500 mg QL (186 EA per 31 days) mapap oral tablet chewable 80 mg maxapap maximum strength oral tablet 500 mg QL (186 EA per 31 days) maxapap regular strength oral tablet 325 mg QL (279 EA per 31 days) non-aspirin extra strength oral tablet 500 mg QL (186 EA per 31 days) non-aspirin oral tablet 325 mg QL (279 EA per 31 days) non-aspirin pain relief oral tablet 325 mg QL (279 EA per 31 days) nortemp infants oral suspension 80 mg/0.8ml pain & fever childrens oral solution 160 mg/5ml pain relief extra strength oral tablet 500 mg QL (186 EA per 31 days) pain relief oral tablet 500 mg QL (186 EA per 31 days) HARBETOL EXTRA STRENGTH ORAL TABLET 500 MG QL (186 EA per 31 days) HARBETOL ORAL TABLET 325 MG QL (279 EA per 31 days) q-pap oral tablet 325 mg QL (279 EA per 31 days) tactinal extra strength oral tablet 500 mg QL (186 EA per 31 days) tactinal oral tablet 325 mg QL (279 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 2

4 Drug Name reference Details Coverage Details *Salicylate Combinations*** effervescent pain relief oral tablet effervescent mg tri-buffered aspirin oral tablet 325 mg *Salicylates*** aspirin childrens oral tablet chewable 81 mg aspirin ec low dose oral tablet delayed release 81 mg aspirin ec oral tablet delayed release 325 mg aspirin oral tablet 325 mg, 81 mg aspirin oral tablet chewable 81 mg aspirin rectal suppository 300 mg, 600 mg ECIRIN ORAL TABLET DELAYED RELEASE 325 MG eq aspirin oral tablet delayed release 500 mg sb backache extra strength oral tablet 500 mg *Anorectal Agents* *Rectal Anesthetic Combinations*** hemorrhoidal rectal cream % *Rectal Combinations - Misc.*** eq hemorrhoidal rectal suppository % goodsense hemorrhoidal rectal ointment % hemorrhoidal rectal ointment % hemorrhoidal rectal suppository 0.25 %, %, % sm hemorrhoidal rectal cream % *Rectal Local Anesthetics*** dibucaine rectal ointment 1 % lidocaine (anorectal) external cream 5 % ROCTOFOAM RECTAL FOAM 1 % *Antacids* *Antacid & Simethicone*** antacid anti-gas max strength oral suspension mg/5ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 3

5 Drug Name reference Details Coverage Details antacid anti-gas oral suspension mg/5ml antacid extra strength oral suspension mg/5ml antacid iii oral suspension mg/5ml gnp antacid & anti-gas oral tablet chewable mg MAALOX ADVANCED MAX ST ORAL SUSENSION MG/5ML MAALOX MAX ORAL SUSENSION MG/5ML MAALOX MULTI SYMTOM MAX ST ORAL SUSENSION MG/5ML milantex extra strength oral suspension mg/5ml MINTOX LUS ORAL TABLET CHEWABLE MG *Antacid Combinations*** ACID GONE ORAL TABLET CHEWABLE MG GAVISCON EXTRA RELIEF FORMULA ORAL SUSENSION MG/10ML GAVISCON ORAL SUSENSION MG/15ML GAVISCON ORAL TABLET CHEWABLE MG gnp antacid oral tablet chewable mg gnp foaming antacid oral tablet chewable mg mag-al oral liquid mg/5ml MI-ACID ORAL TABLET CHEWABLE MG *Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 mg/5ml *Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325 mg, 650 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 4

6 Drug Name reference Details Coverage Details *Antacids - Calcium Salts*** antacid oral tablet chewable 500 mg calcium antacid extra strength oral tablet chewable 750 mg calcium antacid oral tablet chewable 500 mg calcium antacid ultra max st oral tablet chewable 1000 mg calcium carbonate antacid oral suspension 1250 mg/5ml calcium carbonate antacid oral tablet 648 mg calcium carbonate antacid oral tablet chewable 500 mg CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG MAALOX ORAL TABLET CHEWABLE 600 MG TITRALAC ORAL TABLET CHEWABLE 420 MG TUMS CHEWY DELIGHTS ORAL TABLET CHEWABLE 1177 MG *Antacids - Magnesium Salts*** magnesium oxide oral tablet 250 mg, 400 mg, 420 mg *Anthelmintics* *Anthelmintics*** reeses pinworm medicine oral suspension 144 mg/ml *Antiasthmatic And Bronchodilator Agents* *Mixed Adrenergics*** S2 INHALATION NEBULIZATION SOLUTION 2.25 % *Antidiabetics* *Diabetic Other - Combinations*** ra glucose oral tablet chewable 4-6 gm-mg *Diabetic Other*** BD GLUCOSE ORAL TABLET CHEWABLE 5 GM glucose oral tablet chewable 4 gm =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 5

7 Drug Name reference Details Coverage Details INSTA-GLUCOSE ORAL GEL 77.4 % *Human Insulin*** HUMULIN 70/30 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (70-30) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML HUMULIN N KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML *Antidiarrheals* *Antidiarrheal Agents - Misc.*** bismatrol oral suspension 262 mg/15ml bismatrol oral tablet chewable 262 mg bismuth oral tablet chewable 262 mg diotame oral tablet chewable 262 mg gnp pink bismuth oral tablet 262 mg KAOECTATE EXTRA STRENGTH ORAL SUSENSION 525 MG/15ML KAOECTATE ORAL SUSENSION 262 MG/15ML KAO-TIN ORAL SUSENSION 262 MG/15ML pink bismuth oral suspension 262 mg/15ml pink bismuth oral tablet chewable 262 mg stomach relief oral suspension 262 mg/15ml, 527 mg/30ml stomach relief oral tablet chewable 262 mg stomach relief plus oral suspension 525 mg/15ml *Antidiarrheal Combinations*** acidophilus/pectin oral capsule *Antiperistaltic Agents*** anti-diarrheal oral liquid 1 mg/5ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 6

8 Drug Name reference Details Coverage Details LOERAMIDE A-D ORAL TABLET 2 MG loperamide hcl oral liquid 1 mg/5ml loperamide hcl oral suspension 1 mg/7.5ml sm anti-diarrheal oral capsule 2 mg *Antidotes And Specific Antagonists* *Antidotes And Specific Antagonists*** actidose/sorbitol oral liquid 25 gm/120ml actidose-aqua oral liquid 25 gm/120ml EZ CHAR ORAL SUSENSION RECONSTITUTED ipecac oral syrup *Antidotes* *Antidotes*** actidose/sorbitol oral liquid 25 gm/120ml actidose-aqua oral liquid 25 gm/120ml EZ CHAR ORAL SUSENSION RECONSTITUTED ipecac oral syrup *Antiemetics* *Antiemetic Combinations*** anti-nausea oral solution *Antiemetics - Anticholinergic*** dimenhydrinate oral tablet 50 mg meclizine hcl oral tablet 12.5 mg, 25 mg travel sickness oral tablet chewable 25 mg *Antihistamines* *Antihistamines - Alkylamines*** ALA-HIST IR ORAL TABLET 2 MG aller-chlor oral syrup 2 mg/5ml aller-chlor oral tablet 4 mg allergy oral tablet 4 mg allergy relief oral tablet 4 mg chlorhist oral tablet 4 mg chlorpheniramine maleate er oral tablet extended release 12 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 7

9 Drug Name reference Details Coverage Details DIABETIC TUSSIN ALLERGY ORAL SYRU 2 MG/5ML ED CHLORED ORAL LIQUID 2 MG/ML J-TAN D ORAL LIQUID 1 MG/ML VANAHIST D ORAL LIQUID MG/ML *Antihistamines - Ethanolamines*** aler-cap oral capsule 25 mg aler-dryl oral tablet 50 mg alertab oral tablet 25 mg allergy relief childrens oral liquid 12.5 mg/5ml altaryl oral elixir 12.5 mg/5ml altaryl oral syrup 12.5 mg/5ml anti-hist allergy oral tablet 25 mg BANOHEN ORAL CASULE 25 MG BANOHEN ORAL LIQUID 12.5 MG/5ML BANOHEN ORAL TABLET 25 MG BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 MG/5ML complete allergy medication oral tablet 25 mg complete allergy relief oral tablet 25 mg diphenhist oral capsule 25 mg diphenhist oral liquid 12.5 mg/5ml diphenhist oral tablet 25 mg diphenhydramine hcl oral capsule 25 mg, 50 mg diphenhydramine hcl oral tablet 25 mg genahist oral capsule 25 mg gnp dayhist allergy oral tablet 1.34 mg pharbedryl oral capsule 25 mg, 50 mg q-dryl oral capsule 25 mg q-dryl oral liquid 12.5 mg/5ml SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID 12.5 MG/5ML siladryl allergy oral liquid 12.5 mg/5ml silphen cough oral syrup 12.5 mg/5ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 8

10 Drug Name reference Details Coverage Details TOTAL ALLERGY MEDICINE ORAL LIQUID 12.5 MG/5ML total allergy oral tablet 25 mg *Antihistamines - Non-Sedating*** allergy oral tablet dispersible 10 mg cetirizine hcl childrens alrgy oral syrup 1 mg/ml QL (300 ML per 31 days) cetirizine hcl childrens oral solution 1 mg/ml QL (300 ML per 31 days) cetirizine hcl oral tablet 10 mg, 5 mg cetirizine hcl oral tablet chewable 10 mg, 5 mg childrens loratadine oral syrup 5 mg/5ml QL (310 ML per 31 days) fexofenadine hcl childrens oral suspension 30 mg/5ml fexofenadine hcl oral tablet 180 mg, 60 mg loratadine hives relief oral solution 5 mg/5ml QL (300 ML per 31 days) loratadine oral tablet 10 mg *Antiseptics & Disinfectants* *Chlorine Antiseptic Combinations*** dakins (1/2 strength) external solution % dakins (1/4 strength) external solution % dakins external solution % *Chlorine Antiseptics*** chlorhexidine gluconate external liquid 2 % chlorhexidine gluconate external liquid 4 % QL (480 ML per 31 days) REMEDY ANTIMICROBIAL CLEANSER EXTERNAL LIQUID 0.12 % *Iodine Antiseptics*** BETADINE SKIN CLEANSER EXTERNAL SOLUTION 7.5 % BETADINE SWAB AID EXTERNAL SWAB 10 % OERAND OVIDONE-IODINE EXTERNAL SOLUTION 10 % povidone-iodine external ointment 10 % povidone-iodine external solution 10 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 9

11 Drug Name reference Details Coverage Details *Cardiovascular Agents - Misc.* *eripheral Vasodilators*** niacin flush free oral capsule 500 mg *Chemicals* *Fixed Oils*** hm castor oil oil *Liquids*** camphor spirit spirit glycerin liquid *Solvents*** sm isopropyl alcohol solution 50 % *Contraceptives* *Emergency Contraceptives*** MY WAY ORAL TABLET 1.5 MG *Cough/Cold/Allergy* *Antihistamine-Analgesics*** ACETA-GESIC ORAL TABLET MG *Antitussive - Nonnarcotic*** benzonatate oral capsule 100 mg, 200 mg dextromethorphan polistirex er oral suspension extended release 30 mg/5ml ROBITUSSIN CHILDRENS COUGH LA ORAL SYRU 7.5 MG/5ML *Antitussive - Opioid*** hydrocodone-homatropine oral syrup mg/5ml hydrocodone-homatropine oral tablet mg *Antitussive-Antihistamine-Analgesic*** DELSYM NIGHT TIME MULTI-SYMT ORAL LIQUID MG/15ML *Antitussive-Expectorant*** cheratussin ac oral syrup mg/5ml DIABETIC TUSSIN MAX ST ORAL LIQUID MG/5ML extra action cough oral syrup mg/5ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 10

12 Drug Name reference Details Coverage Details MUCINEX FAST-MAX DM MAX ORAL LIQUID MG/20ML mucus relief dm cough oral tablet mg tussin dm oral liquid mg/5ml *Antitussive-Expectorants-Decongestant*** cheratussin dac oral solution mg/5ml LORTUSS EX ORAL LIQUID MG/5ML robafen cf cough/cold oral syrup mg/5ml TUSNEL C ORAL SYRU MG/5ML tussin cf cough & cold oral liquid mg/5ml *Aromatic Inhalants*** gnp chest rub external ointment % sm medicated chest rub external ointment % *Decongestant & Antihistamine*** ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HOUR MG ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HOUR MG allergy relief/nasal decongest oral tablet extended release 24 hour mg BROTA ORAL LIQUID 1-15 MG/5ML cetirizine-pseudoephedrine er oral tablet extended release 12 hour mg childrens cold & allergy oral elixir mg/5ml ED A-HIST ORAL TABLET 4-10 MG fexofenadine-pseudoephed er oral tablet extended release 24 hour mg Q-TA ORAL ELIXIR 1-15 MG/5ML SUDOGEST SINUS/ALLERGY ORAL TABLET 4-60 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 11

13 Drug Name reference Details Coverage Details TRIAMINIC COLD & ALLERGY ORAL SYRU MG/5ML triprolidine-pse oral tablet mg *Decongestant W/ Expectorant*** tussin pe oral liquid mg/5ml *Expectorants*** diabetic siltussin das-na oral liquid 100 mg/5ml mucus relief oral tablet 400 mg refenesen 400 oral tablet 400 mg refenesen oral tablet 200 mg robafen oral syrup 100 mg/5ml *Misc. Respiratory Inhalants*** BRONCHO SALINE INHALATION AEROSOL SOLUTION 0.9 % sodium chloride inhalation nebulization solution 0.9 % *Non-Narc Antitussive-Antihistamine*** DIMETA LONG ACT COUGH/COLD ORAL SYRU MG/5ML promethazine-dm oral syrup mg/5ml ROBITUSSIN CHILD COUGH/COLD LA ORAL LIQUID MG/5ML *Non-Narc Antitussive-Decongestant- Antihistamine*** brotapp dm oral liquid mg/5ml cold/cough childrens oral elixir mg/5ml kidkare cough/cold oral liquid mg/5ml m-end dm oral liquid mg/5ml nohist-dm oral liquid mg/5ml rynex dm oral liquid mg/5ml VANACOF ORAL LIQUID MG/5ML *Opioid Antitussive-Antihistamine*** hydrocod polst-cpm polst er oral suspension extended release 10-8 mg/5ml promethazine-codeine oral syrup mg/5ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 12

14 Drug Name reference Details Coverage Details TUSSICAS ORAL CASULE EXTENDED RELEASE 12 HOUR 10-8 MG, 5-4 MG *Opioid Antitussive-Decongestant- Antihistamine*** phenylhistine dh oral liquid mg/5ml promethazine vc/codeine oral syrup mg/5ml *Dermatologicals* *Acne roducts*** acne medication 10 external lotion 10 % acne medication 5 external lotion 5 % BENZERO EXTERNAL FOAM 5.3 % BENZERO SHORT CONTACT EXTERNAL FOAM 9.8 % benzoyl peroxide cleanser external lotion 3 %, 6 %, 9 % benzoyl peroxide external gel 10 %, 2.5 %, 5 % benzoyl peroxide wash external liquid 5 % ANOXYL WASH EXTERNAL LIQUID 10 % ANOXYL-4 CREAMY WASH EXTERNAL LIQUID 4 % *Analgesics - Topical*** MINERAL ICE EXTERNAL GEL 2 % *Antibiotic Mixtures Topical*** bacitracin-neomycin-polymyxin external ointment double antibiotic external ointment unit/gm sm antibiotic plus pain relief external cream triple antibiotic external ointment , triple antibiotic plus external ointment 1 % *Antibiotics - Topical*** bacitracin external ointment 500 unit/gm bacitracin zinc external ointment 500 unit/gm =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 13

15 Drug Name reference Details Coverage Details *Antifungals - Topical Combinations*** BAZA EXTERNAL KIT BREEZEE MIST EXTERNAL AEROSOL OWDER *Antifungals - Topical*** anti-fungal external powder 1 % athletes foot spray external aerosol 1 % FUNGOID-D EXTERNAL CREAM 1 % gnp gentian violet external solution 1 % LAMISIL ADVANCED EXTERNAL GEL 1 % LAMISIL AF DEFENSE EXTERNAL AEROSOL OWDER 1 % terbinafine hcl external cream 1 % tolnaftate external solution 1 % *Antihistamines - Topical*** anti-itch maximum strength external cream 2 % anti-itch maximum strength external solution 2 % BENADRYL ITCH STOING EXTERNAL GEL 2 % itch relief external cream 2 % *Antihistamine-Topical Combinations*** gnp itch relief extra strength external liquid % itch relief extra strength external cream % sm caldyphen clear external lotion 1-2 % *Antipruritic Combinations - Topical*** camphor phenol cold sore external gel % gnp anti-itch external lotion % qc antiseptic pain relief external liquid % *Antiseborrheic Combinations*** sebex external shampoo 2-2 % *Antiseborrheic roducts*** anti-dandruff external shampoo 1 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 14

16 Drug Name reference Details Coverage Details DHS ZINC EXTERNAL SHAMOO 2 % *Antivirals - Topical*** ABREVA EXTERNAL CREAM 10 % *Astringents*** DR SMITHS DIAER EXTERNAL OINTMENT 10 % medi pads external pad % SECURA ROTECTIVE EXTERNAL CREAM 10 % zinc oxide external ointment 20 % *Corticosteroids - Topical*** AVEENO ANTI-ITCH MAX ST EXTERNAL CREAM 1 % hydrocortisone external cream 0.5 %, 1 % hydrocortisone external lotion 1 % hydrocortisone external ointment 0.5 %, 1 % hydrocortisone max st external cream 1 % hydrocortisone max st/12 moist external cream 1 % HYDROSKIN EXTERNAL CREAM 1 % kp hydrocortisone external cream 1 % REARATION H HYDROCORTISONE EXTERNAL CREAM 1 % SCALICIN MAXIMUM STRENGTH EXTERNAL SOLUTION 1 % tgt anti-itch/aloe/vit e external cream 1 % *Emollient Combinations*** mineral oil-hydrophil petrolat external ointment *Emollient/Keratolytic Agents*** urea 20 intensive hydrating external cream 20 % *Emollients*** AMLACTIN EXTERNAL LOTION 12 % QL (400 GM per 31 days) ammonium lactate external cream 12 % QL (400 GM per 31 days) ammonium lactate external lotion 12 % QL (400 GM per 31 days) BAZA CLEAR EXTERNAL OINTMENT gnp glycerin external liquid 99.5 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 15

17 Drug Name reference Details Coverage Details ra hydrating healing external ointment SWEEN 24 EXTERNAL CREAM *Eyelid Cleansers & Lubricants*** SYSTANE LID WIES EXTERNAL AD *Imidazole-Related Antifungals - Topical*** alevazol external ointment 1 % antifungal external cream 2 % clotrimazole external cream 1 % clotrimazole external solution 1 % CRITIC-AID CLEAR AF EXTERNAL OINTMENT 2 % DESENEX EXTERNAL OWDER 2 % DESENEX SRAY EXTERNAL AEROSOL 2 % FUNGOID TINCTURE EXTERNAL KIT 2 % FUNGOID TINCTURE EXTERNAL SOLUTION 2 % miconazole nitrate external aerosol powder 2 % *Keratolytic/Antimitotic Agents*** CLEAR AWAY 1-STE WART REMOVER EXTERNAL AD 40 % COMOUND W EXTERNAL LIQUID 17 % COMOUND W MAXIMUM STRENGTH EXTERNAL GEL 17 % DHS SAL EXTERNAL SHAMOO 3 % FREEZONE EXTERNAL LIQUID 17.6 % gnp scalp relief external liquid 3 % SALACTIC FILM EXTERNAL SOLUTION 17 % *Liniment Combinations*** gnp cold & hot extra strength external ointment % THERA-GESIC LUS EXTERNAL CREAM =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 16

18 Drug Name reference Details Coverage Details *Liniments*** BLUE-EMU SUER STRENGTH EXTERNAL CREAM MOBISYL EXTERNAL CREAM 10 % sm cold & hot therapy balm external ointment % sm pain relief/menthol external gel trixaicin external cream % *Local Anesthetics - Topical*** burn relief external aerosol 0.5 % capsaicin external cream % dibucaine external ointment 1 % gnp capsaicin external liquid 0.15 % lidocaine external cream 4 % trixaicin hp external cream % *Lubricants*** MAXILUBE EXTERNAL GEL *Misc. Topical Combinations*** SENSI-CARE ROTECTIVE BARRIER EXTERNAL OINTMENT % *Misc. Topical*** sm medicated wipes external pad 50 % sm witch hazel external liquid sm witch hazel external solution 86 % *Scabicide Combinations*** lice killing maximum strength external shampoo % sm lice killing external shampoo % *Scabicides & ediculicides*** hm lice treatment external liquid 1 % permethrin external lotion 1 % QL (60 ML per 31 days) *Skin Cleansers*** BEDSIDE-CARE EXTERNAL SOLUTION *Skin rotectants*** ALOE VESTA SKIN CONDITIONER EXTERNAL LOTION 3 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 17

19 Drug Name reference Details Coverage Details AMERIHOR EXTERNAL OINTMENT BAZA CLEANSE & ROTECT EXTERNAL LOTION 2 % MINERIN EXTERNAL CREAM SECURA DIMETHICONE ROTECTANT EXTERNAL CREAM 5 % SWEEN 24 SKIN ROTECTANT EXTERNAL CREAM 6 % THERASEAL HAND ROTECTION EXTERNAL LOTION 1 % *Tar roducts*** IONIL-T EXTERNAL SHAMOO 1 % TERA-GEL TAR EXTERNAL SHAMOO 0.5 % X-SEB T EARL EXTERNAL SHAMOO 10 % *Topical Anesthetic Combinations*** CALADRYL EXTERNAL LOTION 1-8 % CALLERGY CLEAR EXTERNAL LOTION % gnp aloe vera/lidocaine external gel 0.5 % gnp medicated first aid spray external aerosol % ITCH-X EXTERNAL GEL 1-10 % ITCH-X EXTERNAL SOLUTION 1-10 % LANACANE FIRST AID 2-IN-1 EXTERNAL AEROSOL % lidocaine-transparent dressing external kit 4 % *Topical Steroid Combinations*** hydrocortisone-aloe external cream 0.5 %, 1 % sm hydrocortisone plus external cream 1 % *Dietary roducts/dietary Management roducts* *Dietary Management roduct Combinations*** FOLBIC RF ORAL TABLET MG FOLTANX ORAL TABLET MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 18

20 Drug Name reference Details Coverage Details FOLTANX RF ORAL CASULE MG l-methylfolate forte oral capsule mg, mg METAFOLBIC ORAL TABLET MG METAFOLBIC LUS ORAL TABLET MG METAFOLBIC LUS RF ORAL TABLET MG *Digestive Aids* *Digestive Enzymes*** lactase enzyme oral tablet 3000 unit lactase fast acting oral tablet 9000 unit *Gastrointestinal Agents - Misc.* *Antiflatulents*** anti-gas oral capsule 166 mg GAS-X EXTRA STRENGTH ORAL CASULE 125 MG GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE 125 MG GAS-X ULTRA STRENGTH ORAL CASULE 180 MG mi-acid gas relief oral tablet chewable 80 mg mytab gas oral tablet chewable 80 mg simethicone oral suspension 40 mg/0.6ml simethicone oral tablet chewable 80 mg *hosphate Binder Agents*** CALHRON ORAL TABLET 667 MG *Genitourinary Agents - Miscellaneous* *Urinary Analgesics*** phenazopyridine hcl oral tablet 95 mg urinary pain relief max st oral tablet 97.5 mg *Hematopoietic Agents* *Cobalamin Combinations*** vitamin b12-folic acid oral tablet mcg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 19

21 Drug Name reference Details Coverage Details *Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml vitamin b-12 er oral tablet extended release 1000 mcg vitamin b-12 oral lozenge 500 mcg vitamin b-12 oral tablet 100 mcg, 1000 mcg, 250 mcg, 500 mcg vitamin b-12 sublingual tablet sublingual 1000 mcg *Folic Acid/Folate Combinations*** FOLTABS 800 ORAL TABLET MCG-MG-MCG *Folic Acid/Folates*** folic acid oral tablet 1 mg, 400 mcg, 800 mcg *Iron Combinations*** FOLITAB 500 ORAL TABLET EXTENDED RELEASE MG INTEGRA ORAL CASULE MG iron 100 plus oral tablet mg TANDEM ORAL CASULE MG *Iron*** FERATE ORAL TABLET 240 (27 FE) MG FER-IN-SOL ORAL SOLUTION 75 (15 FE) MG/ML FERRIMIN 150 ORAL TABLET 150 MG ferro-bob oral tablet 325 (65 fe) mg ferrous fumarate oral tablet 29 mg ferrous gluconate oral tablet 324 (37.5 fe) mg, 324 (38 fe) mg ferrous sulfate er oral tablet extended release 140 (45 fe) mg ferrous sulfate oral elixir 220 (44 fe) mg/5ml ferrous sulfate oral liquid 220 (44 fe) mg/5ml ferrous sulfate oral syrup 300 (60 fe) mg/5ml ferrous sulfate oral tablet 325 (65 fe) mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 20

22 Drug Name reference Details Coverage Details ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg ferrousul oral tablet 325 (65 fe) mg gnp iron oral tablet 200 (65 fe) mg gnp iron oral tablet extended release 142 (45 fe) mg HEMOCYTE ORAL TABLET 324 (106 FE) MG iron oral tablet 325 (65 fe) mg, 90 (18 fe) mg OLY-IRON 150 ORAL CASULE 150 MG slow release iron oral tablet extended release 160 (50 fe) mg sm slow release iron oral tablet extended release 143 (45 fe) mg *Hypnotics* *Antihistamine Hypnotic Combinations*** headache pm oral tablet mg QL (62 EA per 31 days) mapap pm oral tablet mg QL (62 EA per 31 days) pain relief pm extra strength oral tablet mg QL (62 EA per 31 Days) pain reliever pm oral tablet mg QL (62 EA per 31 days) *Antihistamine Hypnotics*** compoz oral capsule 50 mg compoz oral tablet 50 mg diphenhydramine hcl (sleep) oral tablet 50 mg NYTOL ORAL TABLET 25 MG SIMLY SLEE ORAL TABLET 25 MG sleep aid oral tablet 25 mg sleep tabs oral tablet 25 mg sleep-tabs oral tablet 25 mg SOMINEX ORAL TABLET 25 MG tetra-formula nighttime sleep oral tablet 50 mg *Laxatives* *Bulk Laxatives*** CITRUCEL ORAL OWDER CITRUCEL ORAL TABLET 500 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 21

23 Drug Name reference Details Coverage Details fiber laxative oral tablet 625 mg fiber oral tablet 625 mg FIBERGEN ORAL TABLET 625 MG fiber-lax oral tablet 625 mg KONSYL FIBER ORAL TABLET 625 MG KONSYL ORAL ACKET 100 %, 60.3 % METAMUCIL ORAL WAFER METAMUCIL SMOOTH TEXTURE ORAL ACKET 28 % METAMUCIL SMOOTH TEXTURE ORAL OWDER 28.3 %, 58.6 % natural fiber therapy oral powder 30.9 %, % natural vegetable fiber oral powder % REGULOID ORAL CASULE 0.52 GM UNIFIBER ORAL OWDER *Laxative Combinations*** SENNA ROMT ORAL CASULE MG *Laxatives - Miscellaneous*** cvs glycerin adult rectal suppository 2 gm EDIA-LAX RECTAL SUOSITORY 1 GM peg 3350 oral packet peg 3350 oral powder SANI-SU EDIATRIC RECTAL SUOSITORY 1.2 GM sorbitol oral solution 70 % *Laxatives & Dss*** DOC-Q-LAX ORAL TABLET MG ERI-COLACE ORAL TABLET MG senna plus oral tablet mg senna s oral tablet mg senna-docusate sodium oral tablet mg SENNALAX-S ORAL TABLET MG senna-s oral tablet mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 22

24 Drug Name reference Details Coverage Details senna-time s oral tablet mg sennosides-docusate sodium oral tablet mg *Lubricant Laxatives*** FLEET OIL RECTAL ENEMA sm mineral oil oral oil *Saline Laxative Mixtures*** enema rectal enema 7-19 gm/118ml ra saline laxative oral solution gm/5ml *Saline Laxatives*** citrate of magnesia oral solution gm/30ml CITROMA ORAL SOLUTION GM/30ML DULCOLAX MILK OF MAGNESIA ORAL SUSENSION 400 MG/5ML gnp epsom salt oral granules magnesium citrate oral solution gm/30ml milk of magnesia concentrate oral suspension 2400 mg/10ml milk of magnesia oral suspension 400 mg/5ml, 7.75 % *Stimulant Laxatives*** BISAC-EVAC RECTAL SUOSITORY 10 MG biscolax rectal suppository 10 mg CARTERS LITTLE ILLS ORAL TABLET DELAYED RELEASE 5 MG correct oral tablet delayed release 5 mg CORRECTOL ORAL TABLET DELAYED RELEASE 5 MG ducodyl oral tablet delayed release 5 mg EX-LAX ORAL TABLET CHEWABLE 15 MG EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG FEENAMINT ORAL TABLET DELAYED RELEASE 5 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 23

25 Drug Name reference Details Coverage Details FLEET BISACODYL RECTAL ENEMA 10 MG/30ML FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG gentle laxative oral tablet delayed release 5 mg gnp castor oil oral oil 100 % laxative rectal suppository 10 mg natural senna laxative oral tablet mg senexon oral liquid 8.8 mg/5ml senexon oral tablet 8.6 mg senna lax oral tablet 8.6 mg senna laxative oral tablet 25 mg, 8.6 mg senna oral syrup 8.8 mg/5ml senna oral tablet 8.6 mg SENNA SMOOTH ORAL TABLET 15 MG SENNACON ORAL TABLET 8.6 MG senna-lax oral tablet 8.6 mg senna-tabs oral tablet 8.6 mg senna-time oral tablet 8.6 mg SENNO ORAL TABLET 8.6 MG SENOKOT XTRA ORAL TABLET 17.2 MG stimulant laxative oral tablet delayed release 5 mg womens laxative oral tablet delayed release 5 mg *Surfactant Laxatives*** COLACE CLEAR ORAL CASULE 50 MG CORRECTOL EXTRA GENTLE ORAL CASULE 100 MG diocto oral liquid 50 mg/5ml diocto oral syrup 60 mg/15ml docqlace oral capsule 100 mg docu soft oral capsule 100 mg docusate calcium oral capsule 240 mg docusate sodium oral tablet 100 mg DOCUSIL ORAL CASULE 100 MG DOK ORAL CASULE 100 MG, 250 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 24

26 Drug Name reference Details Coverage Details DOK ORAL TABLET 100 MG dss oral capsule 100 mg, 250 mg DULCOLAX STOOL SOFTENER ORAL CASULE 100 MG ENEMEEZ MINI RECTAL ENEMA 283 MG ENEMEEZ LUS RECTAL ENEMA MG KAO-TIN ORAL CASULE 240 MG laxa basic oral capsule 100 mg EDIA-LAX ORAL LIQUID 50 MG/15ML silace oral liquid 150 mg/15ml silace oral syrup 60 mg/15ml SOF-LAX ORAL CASULE 100 MG stool softener oral capsule 100 mg, 250 mg SURFAK ORAL CASULE 240 MG *Medical Devices* *Respiratory Therapy Supplies*** ACE AEROSOL CLOUD ENHANCER QL (2 EA per 365 days) IN-CHECK DIAL FLOW TRAINER DEVICE QL (2 EA per 365 days) FLEX QL (2 EA per 365 days) THRESHOLD IMT QL (2 EA per 365 days) THRESHOLD E DEVICE QL (2 EA per 365 days) WINDMILL TRAINER QL (2 EA per 365 days) *Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER MV QL (2 EA per 365 days) AEROCHAMBER LUS FLO-VU QL (2 EA per 365 days) AEROCHAMBER LUS FLO-VU LARGE QL (2 EA per 365 days) AEROCHAMBER LUS FLO-VU SMALL QL (2 EA per 365 days) AEROCHAMBER LUS FLO-VU W/MASK QL (2 EA per 365 days) AEROCHAMBER W/FLOWSIGNAL QL (2 EA per 365 days) AEROCHAMBER Z-STAT LUS QL (2 EA per 365 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 25

27 Drug Name reference Details Coverage Details AEROCHAMBER Z-STAT LUS CHAMBR QL (2 EA per 365 days) EASIVENT QL (2 EA per 365 days) MICROCHAMBER QL (2 EA per 365 days) MICROSACER QL (2 EA per 365 days) OTICHAMBER ADVANTAGE QL (2 EA per 365 days) OTIHALER QL (2 EA per 365 days) OTIHALER DEVICE QL (2 EA per 365 days) OCKET CHAMBER DEVICE QL (2 EA per 365 days) OCKET SACER DEVICE QL (2 EA per 365 days) WATCHHALER DEVICE QL (2 EA per 365 days) *Minerals & Electrolytes* *Calcium Combinations*** cal/mag oral tablet mg CALCET CREAMY BITES ORAL TABLET CHEWABLE MG-UNIT CALCITRATE ORAL TABLET MG-UNIT cal-citrate plus vitamin d oral tablet mg-unit calcium + d3 oral tablet mg-unit calcium 500/d oral tablet chewable mgunit calcium 600+d plus minerals oral tablet mg-unit calcium 600-d oral tablet mg-unit calcium carb-cholecalciferol oral tablet mg-unit calcium carbonate-vitamin d oral tablet mg-unit, mg-unit calcium high potency/vitamin d oral tablet mg-unit calcium oral tablet mg-unit calcium oral tablet chewable mg-unit calcium-carb d oral tablet mgunit =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 26

28 Drug Name reference Details Coverage Details calcium-magnesium-vitamin d oral tablet mg-mg-unit calcium-magnesium-zinc oral tablet mg calcium-vitamin d oral tablet mg-unit, mg-unit, mg-unit CALTRATE 600+D ORAL TABLET MG-UNIT gnp vitamin d-400 oral tablet mg-unit liquid calcium/vitamin d oral capsule mg-unit MAGNEBIND 300 ORAL TABLET MG OS-CAL EXTRA D3 ORAL TABLET MG-UNIT OYSCO 500+D ORAL TABLET MG-UNIT oyst-cal d oral tablet mg-unit oyster calcium + d oral tablet mg-unit oyster shell calcium + d oral tablet mgunit oyster shell calcium d oral tablet mg-unit oyster shell calcium/d oral tablet mgunit, mg-unit oyster shell calcium/vitamin d oral tablet mg-unit, mg-unit oyster shell/vitamin d oral tablet mgunit parva-cal oral tablet mg-unit, mg-unit risacal-d oral tablet mg-mg-unit sm calcium citrate-vit d oral tablet mgunit sm calcium soft chews oral tablet chewable mg-unt-mcg super cal/mag oral tablet mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 27

29 Drug Name reference Details Coverage Details *Calcium*** CAL-CARB FORTE ORAL TABLET 1250 (500 CA) MG CALCI-CHEW ORAL TABLET CHEWABLE 1250 (500 CA) MG CALCITRATE ORAL TABLET 950 MG calcium 600 oral tablet 600 mg calcium acetate oral tablet 668 (169 ca) mg calcium carbonate oral suspension 1250 (500 ca) mg/5ml calcium carbonate oral tablet 1250 (500 ca) mg, 1500 (600 ca) mg, 600 mg calcium carbonate oral tablet chewable 260 mg calcium citrate oral granules 760 mg/3.5gm calcium citrate oral tablet 250 mg calcium gluconate oral tablet 50 mg, 500 mg calcium high potency oral tablet 600 mg calcium lactate oral tablet 100 mg, 648 mg calcium oral tablet 600 mg calcium oyster shell oral tablet 1250 (500 ca) mg calcium-carb 600 oral tablet 600 mg cal-lac oral capsule 500 mg CALTRATE 600 ORAL TABLET 1500 (600 CA) MG chelated calcium oral tablet 200 mg OYSCO 500 ORAL TABLET 500 MG OYSTERCAL ORAL TABLET 500 MG *Electrolytes Oral*** ORALYTE ORAL SOLUTION *Iodine roducts*** kelp oral tablet 150 mcg *Magnesium Combinations*** SLOW-MAG ORAL TABLET DELAYED RELEASE MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 28

30 Drug Name reference Details Coverage Details *Magnesium*** chelated magnesium oral tablet 100 mg MAG64 ORAL TABLET EXTENDED RELEASE 535 (64 MG) MG mag-delay oral tablet extended release 535 (64 mg) mg magnacaps oral capsule 100 mg magnesium gluconate oral tablet 27.5 mg magnesium oral tablet 250 mg magnesium oxide oral tablet 400 (240 mg) mg MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG MAGONATE ORAL LIQUID 1000 (54 MG) MG/5ML MAG-TAB SR ORAL TABLET EXTENDED RELEASE 84 MG (7MEQ) *Mineral Combinations*** gnp cal mag zinc +d3 oral tablet *otassium*** potassium oral tablet 99 mg *Sodium*** sodium chloride oral tablet 1 gm *Trace Minerals*** chromium oral tablet 200 mcg chromium picolinate oral tablet 200 mcg oceanic selenium oral tablet 50 mcg selenium er oral tablet extended release 200 mcg sm selenium oral tablet 200 mcg *Zinc*** ORAZINC ORAL CASULE 220 (50 ZN) MG zinc gluconate oral tablet 50 mg zinc mouth/throat lozenge 10 mg zinc oral tablet 30 mg, 50 mg zinc sulfate oral capsule 220 (50 zn) mg zinc sulfate oral tablet 220 (50 zn) mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 29

31 Drug Name reference Details Coverage Details zinc-220 oral capsule 220 (50 zn) mg *Mouth/Throat/Dental Agents* *Anesthetics Topical Oral - Combinations*** CEACOL EXTRA STRENGTH MOUTH/THROAT LOZENGE MG sore throat mouth/throat lozenge mg *Antiseptics - Mouth/Throat*** sore throat spray mouth/throat liquid 1.4 % *Lozenge - Combinations*** DELSYM COUGH RELIEF MOUTH/THROAT LOZENGE 5-5 MG *Multivitamins* *B-Complex Vitamins*** b-complex/b-12 oral tablet *B-Complex W/ C & E + Zn*** bee zee oral tablet *B-Complex W/ C & Folic Acid*** b-complex/vitamin c oral tablet DIALYVITE 800 ORAL TABLET 0.8 MG NEHRONEX ORAL TABLET RENAL ORAL CASULE 1 MG rena-vite rx oral tablet 1 mg reno caps oral capsule 1 mg vita-bee/c oral tablet *B-Complex W/ C*** total b/c oral tablet vitamin b complex-c oral capsule *B-Complex W/ Folic Acid*** sm balanced b-100 oral tablet *B-Complex W/ Minerals*** geravim oral liquid *B-Complex W/Biotin & Folic Acid*** SUER QUINTS B-50 ORAL TABLET *Multiple Vitamins W/ Calcium*** gnp one daily womens health oral tablet =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 30

32 Drug Name reference Details Coverage Details *Multiple Vitamins W/ Iron*** daily-vite/iron/beta-carotene oral tablet *Multiple Vitamins W/ Minerals*** advanced diabetic multivitamin oral tablet AQUADEKS ORAL TABLET CHEWABLE centamin oral liquid centavite a-z complete-mineral oral tablet centavite oral liquid CEROVITE ADVANCED FORMULA ORAL TABLET CERTAVITE/ANTIOXIDANTS ORAL LIQUID gerivite complete oral tablet ICAS ORAL CASULE multivitamin & mineral oral liquid SUER NU-THERA ORAL TABLET thera vital m oral tablet therabasic-m oral tablet therapeutic liquid oral solution therapeutic-m oral tablet TOTAL FORMULA 3 ORAL TABLET vitamins a-d-e/selenium oral tablet zinc oral lozenge *Multivitamins*** daily multiple vitamins oral tablet daily vite oral tablet daily vites oral tablet multi-day oral tablet multi-vitamin oral tablet multi-vitamins oral tablet once daily oral tablet one-daily multi vitamins oral tablet THERA ORAL TABLET THERA/BETA-CAROTENE ORAL TABLET =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 31

33 Drug Name reference Details Coverage Details therapeutic oral tablet thera-tabs oral tablet *ed Multiple Vitamins W/ Minerals & C*** AQUADEKS ORAL LIQUID gnp childrens complete oral tablet chewable 30 mg gnp zoochews gummies oral tablet chewable VITALETS ORAL TABLET CHEWABLE 40 MG zoo friends oral tablet chewable 60 mg *ed Mv W/ Fluoride*** multi-vitamin/fluoride oral tablet chewable 0.5 mg *ed Mv W/ Iron*** animal shapes plus iron oral tablet chewable 15 mg polyvitamin/iron oral solution 10 mg/ml *ed Vitamins Acd W/ Iron*** MYKIDZ IRON ORAL SUSENSION 10 MG/2ML *ediatric Multiple Vitamins W/ C & Fa*** ANIMAL SHAES ORAL TABLET CHEWABLE WITH C & FA *ediatric Multiple Vitamins W/ C*** polyvitamin oral solution 35 mg/ml *ediatric Multiple Vitamins W/ Extra C & Fa*** gnp childrens chewables/ex c oral tablet chewable *ediatric Multiple Vitamins*** multi-delyn oral liquid *ediatric Vitamins A & D W/ C*** tri-vitamin oral solution *renatal Mv & Min W/Fe-Fa*** kpn prenatal oral tablet 0.1 mg pnv prenatal plus multivit+dha oral 27-1 & 312 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 32

34 Drug Name reference Details Coverage Details prenatal formula a-free oral tablet mg prenatal low iron oral tablet mg prenatal oral tablet mg prenatal vitamins oral tablet mg VINACAL B ORAL 20-1 & 25 (2) MG *renatal Mv & Min W/Fe-Fa-Dha*** ENFAMIL EXECTA ORAL & 200 MG *Specialty Vitamins roducts*** ICAS LUTEIN-ZEAXANTHIN ORAL TABLET EXTENDED RELEASE vitamins for hair oral tablet *Vitamins A & D*** cod liver oil oral capsule vitamin a & d oral tablet unit *Vitamins W/ Lipotropics*** balanced b-50 oral tablet *Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.*** altamist spray nasal solution 0.65 % AYR NASAL SOLUTION 0.65 % deep sea nasal spray nasal solution 0.65 % HUMIST NASAL SOLUTION 0.65 % LITTLE NOSES SALINE NASAL SOLUTION 0.65 % NASAL MOIST NASAL SOLUTION 0.65 % na-zone nasal solution 0.65 % OCEAN FOR KIDS NASAL SOLUTION 0.65 % saline mist spray nasal solution 0.65 % saline nasal spray nasal solution 0.65 % sea soft nasal mist nasal solution 0.65 % *Nasal Agents Misc. - Combinations*** OCEAN COMLETE SINUS RINSE NASAL AEROSOL SOLUTION sinus wash kettle neti pot nasal kit mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 33

35 Drug Name reference Details Coverage Details sinus wash saline refills nasal packet mg *Nasal Decongestant Inhalers*** BENZEDREX NASAL INHALER *Nasal Mast Cell Stabilizers*** cromolyn sodium nasal aerosol solution 5.2 mg/act *Systemic Decongestants*** childrens silfedrine oral liquid 15 mg/5ml nasal decongestant oral syrup 30 mg/5ml nasal decongestant pe max st oral tablet 10 mg pseudoephedrine hcl oral tablet 30 mg, 60 mg SUDAFED 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR 120 MG *Topical Decongestants*** nasal four nasal solution 1 % nasal spray extra moisturizing nasal solution 0.05 % *Nutrients* *Amino Acids-Single*** l-tryptophan oral tablet 500 mg *Misc. Nutritional Substances*** fish oil oral capsule 1000 mg, 500 mg fish oil oral capsule delayed release 1000 mg omega-3 oral capsule 1400 mg sm omega-3 fish oil oral capsule 1200 mg *Ophthalmic Agents* *Artificial Tear And Lubricant Combinations*** artificial tears ophthalmic ointment % GENTEAL OHTHALMIC GEL % gnp artificial tears ophthalmic solution 5-6 mg/ml HYOTEARS OHTHALMIC SOLUTION 1-1 % REFRESH OHTHALMIC SOLUTION % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 34

36 Drug Name reference Details Coverage Details REFRESH OTIVE ADVANCED OHTHALMIC SOLUTION % REFRESH OTIVE OHTHALMIC GEL % REFRESH OTIVE OHTHALMIC SOLUTION % REFRESH OTIVE SENSITIVE OHTHALMIC SOLUTION % SYSTANE OHTHALMIC SOLUTION % *Artificial Tear Ointments*** tears again ophthalmic ointment ULTRA FRESH M OHTHALMIC OINTMENT *Artificial Tear Solutions*** tears again ophthalmic solution *Artificial Tears And Lubricants*** artificial tears ophthalmic solution 1.4 % QL (15 ML per 31 days) GENTEAL MILD TO MODERATE OHTHALMIC SOLUTION 0.3 % ISOTO TEARS OHTHALMIC SOLUTION 0.5 % liquitears ophthalmic solution 1.4 % QL (15 ML per 31 Days) natures tears ophthalmic solution 0.4 % polyvinyl alcohol ophthalmic solution 1.4 % QL (15 ML per 31 Days) REFRESH CELLUVISC OHTHALMIC SOLUTION 1 % REFRESH LUS OHTHALMIC SOLUTION 0.5 % SYSTANE OVERNIGHT THERAY OHTHALMIC GEL 0.3 % *Gonioscopic Solutions*** GONAK OHTHALMIC SOLUTION 2.5 % *Ophthalmic Antiallergic*** ALAWAY OHTHALMIC SOLUTION % ketotifen fumarate ophthalmic solution % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 35

37 Drug Name reference Details Coverage Details *Ophthalmic Decongestant Combinations*** gnp eye drops ophthalmic solution % hm eye drops ophthalmic solution % *Ophthalmic Decongestants*** eye drops ophthalmic solution 0.05 % *Ophthalmic Hyperosmolar roducts*** MURO 128 OHTHALMIC SOLUTION 2 % sodium chloride (hypertonic) ophthalmic ointment 5 % sodium chloride (hypertonic) ophthalmic solution 5 % *Ophthalmic Irrigation Solutions*** eye irrigating ophthalmic solution % EYE STREAM OHTHALMIC SOLUTION *Otic Agents* *Otic Agents - Miscellaneous*** auraphene-b otic solution 6.5 % ear drops earwax aid otic solution 6.5 % earwax treatment drops otic solution 6.5 % E-R-O EAR DROS OTIC SOLUTION 6.5 % E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % MURINE EAR OTIC SOLUTION 6.5 % MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % OTIX OTIC SOLUTION 6.5 % SWIM EAR OTIC LIQUID 95 % *sychotherapeutic And Neurological Agents - Misc.* *Smoking Deterrents*** NICORETTE MINI MOUTH/THROAT LOZENGE 2 MG QL (620 EA per 31 days) nicotine polacrilex mouth/throat gum 2 mg, 4 mg QL (4032 EA per 365 days) nicotine polacrilex mouth/throat lozenge 4 mg QL (620 EA per 31 days) nicotine transdermal kit mg/24hr QL (56 EA per 365 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 36

38 Drug Name reference Details Coverage Details nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr *Ulcer Drugs* *H-2 Antagonist-Antacid Combinations*** dual action complete oral tablet chewable mg *H-2 Antagonists*** acid reducer maximum strength oral tablet 20 mg acid reducer oral tablet 75 mg cimetidine oral tablet 200 mg famotidine oral tablet 10 mg ZANTAC 150 MAXIMUM STRENGTH ORAL TABLET 150 MG *roton ump Inhibitors*** omeprazole oral tablet delayed release 20 mg *Vaginal roducts* *Imidazole-Related Antifungals*** clotrimazole vaginal cream 1 % gnp tioconazole 1 vaginal ointment 6.5 % GYNE-LOTRIMIN 3 VAGINAL CREAM 2 % miconazole 1 vaginal kit 1200 & 2 mg & % miconazole 3 applicator vaginal kit 200 & 2 mg- % (9gm) miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) miconazole nitrate vaginal cream 2 % miconazole nitrate vaginal suppository 100 mg MONISTAT 3 VAGINAL CREAM 4 % *Miscellaneous Vaginal roducts*** anti-itch vaginal cream 5-2 % *Vitamins* *Biotin*** biotin oral capsule 5000 mcg biotin oral tablet 10 mg, 300 mcg, 5 mg QL (140 EA per 365 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 37

39 Drug Name reference Details Coverage Details *Vitamin A*** beta carotene oral capsule unit vitamin a oral capsule unit, 8000 unit vitamin a palmitate oral tablet unit, unit vitamin a-beta carotene oral tablet unit *Vitamin B-1*** vitamin b-1 oral tablet 100 mg, 250 mg, 50 mg *Vitamin B-2*** vitamin b-2 oral tablet 100 mg *Vitamin B-3*** ENDUR-ACIN ORAL TABLET EXTENDED RELEASE 500 MG niacin er oral capsule extended release 250 mg, 500 mg niacin er oral tablet extended release 250 mg niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg niacinamide oral tablet 500 mg *Vitamin B-6*** vitamin b-6 er oral tablet extended release 200 mg vitamin b-6 oral tablet 100 mg, 25 mg, 250 mg, 50 mg, 500 mg *Vitamin C*** ascorbic acid oral tablet 1000 mg, 250 mg, 500 mg ascorbic acid oral tablet chewable 250 mg c-500 oral tablet chewable 500 mg vita-c oral crystals vitamin c er oral capsule extended release 500 mg vitamin c er oral tablet extended release 500 mg vitamin c oral powder vitamin c oral syrup 500 mg/5ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 38

40 Drug Name reference Details Coverage Details vitamin c oral tablet 100 mg, 1000 mg, 250 mg, 500 mg vitamin c oral tablet chewable 100 mg, 250 mg *Vitamin D*** CALCIFEROL ORAL SOLUTION 8000 UNIT/ML d oral capsule unit d 5000 oral tablet 5000 unit DECARA ORAL CASULE UNIT, UNIT DIALYVITE VITAMIN D3 MAX ORAL TABLET UNIT D-VI-SOL ORAL LIQUID 400 UNIT/ML vitamin d (ergocalciferol) oral capsule unit vitamin d oral tablet 2000 unit vitamin d2 oral tablet 400 unit vitamin d3 oral capsule 1000 unit, 2000 unit, 400 unit, 5000 unit vitamin d3 oral tablet 1000 unit, 3000 unit vitamin d3 oral tablet chewable 400 unit vitamin d-400 oral tablet 400 unit *Vitamin E*** vitamin e oral capsule 100 unit, 1000 unit, 200 unit, 400 unit vitamin e oral tablet chewable 400 unit *Vitamin K*** vitamin k (phytonadione) oral tablet 100 mcg QL (4 EA per 28 Days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 39