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

Transcription

1 Comprehensive Dual Eligible referred Drug List (List of Covered Drugs) Ohana Health lan lease read: This document contains information about the drugs we cover in this plan. Last updated (1/01/2015)

2 Non-referred Drugs Ohana Dual Eligible Cough & Cold Drug List ANTITUSSIVES,NON -NARCOTIC NON-NARC ANTITUSS -1ST GEN. ANTIHISTAMINE -DECONGEST Brompheniramine/Dextromethorphan HBr/seudoephedrine HCl NON-NARC ANTITUSS -1ST GEN. ANTIHIST-ANALGESIC COMBINATION EXECTORANTS DECONGESTANT -EXECTORANT COMBINATIONS referred Drugs Benzonatate TESSALON 200 MG CASULE BENZONATATE 100 MG CASULE BENZONATATE 200 MG CASULE Dextromethorphan olistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSENSION Dextromethorphan HBr ROBITUSSIN EDIATRIC COUGH SY Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF LUS LOZENGE ALLANHIST DX DROS BROMFED DM SYRU C-HEN DM D-COF SYRU BROMHIST DX DROS BROTA DM LIQUID ENDACOF-D DROS Brophenaramine/Dextromethorphan HBr/henylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM Chlorpheniramine/Dextromethorphan HBr/henylephrine HCl RONDEX-DM SYRU SILDEC E-DM SYRU DE-CHLOR DM LIQUID CORFEN DM Chlorpheniramine/Dextromethorphan HBr/seudoephedrine HCl Q-TA DM ELIXIR DIMAHEN DM ELIXIR NOHIST-DM TRI-DEX E EDIATRIC COUGH-COLD LIQUID MESEHIST DM KIDKARE COUGH/COLD Dexchlorpheniramine/seudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETA LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID romethazine HCl/Dextromethorphan HBr ROMETHAZINE-DM SYRU Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMTOM Guaifenesin/henylephrine HCl DONATUSSIN DROS E-GUAI DROS DESEC LIQUID RESCON-GG LIQUID Last updated 07/31/14 age 1 of 2

3 DURATUSS DM ELIXIR SIMUC-DM ELIXIR Ohana Dual Eligible Cough & Cold Drug List Non-referred Drugs referred Drugs NON -NARCOTIC DECONGESTANT -EXECTORANT-ANTITUSSIVE SU-TUSS DM ELIXIR Guaifenesin/Dextromethorphan HBr/henylephreine ROBAFEN CF SYRU NON -NARCOTIC ANTITUSSIVE AND EXECTORANT COMB. Dextromethorphan HBr/Guaifenesin MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID GUAIFENESIN DM SYRU Q-TUSSIN-DM SYRU EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRU REFENESEN DM SILTUSSIN DM DAS COUGH SYRU MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID NARCOTIC ANTITUSSIVE -1ST GENERATION ANTIHISTAMINE Chlorpheniramine/Hydrocodone olistirex TUSSIONEX ENNKINETIC SUS TUSSICAS (min. age 6 years old) HYDROCODONE-CHLORHENIRAMINE SUSENSION (min. age 6 years old) Codeine hosphate/romethazine HCl ROMETHAZINE-CODEINE SYRU (min. age 6 years old) NARCOTIC ANTITUSSIVE -1ST GEN. ANTIHISTAMINE -DECONGESTANT Dexbrompheniramine/Hydrocodone Bit/henylephrine HCl Codeine/henylephrine HCl/romethazine CYTUSS-HC NR SYRU HC/E/DBROM SYRU ROMETH VC W/COD SYRU ROMETHAZINE VC/COD SYRU HC 2.5-E 5-DBROM 1 MG SYRU seudoephedrine HCl/Codeine/Chlorpheniramine HENYLHISTINE DH NARCOTIC ANTITUSSIVE -ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROMET SYRU HYDROCODONE-HOMATROINE NARCOTIC ANTITUSSIVE-EXECTORANT COMBINATION Guaifenesin/Hydrocodone Bit Codeine hosphate/guaifenesin HYDROCODONE-GUAIFENESIN SYRU CHERATUSSIN AC SYRU NARCOF SYRU TUSSICLEAR DH SYRU GUAIFENESIN-CODEINE SYRU IOHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT -EXECTORANT COMBINATIONS Codeine hosphate/guaifenesin/seudoephedrine HCl CHERATUSSIN DAC SYRU Last updated 07/31/14 age 2 of 2

4 This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Anti-Obesity Agents**-*Lipase Inhibitors*** XENICAL ORAL CASULE 120 MG A *Alternative Medicines* *Alternative Medicine - C's**-*Alternative Medicine - Ch's*** charcoal oral capsule 200 mg *Alternative Medicine - M's**-*Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 mg *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 200 mg ibuprofen junior strength oral tablet chewable 100 mg *Analgesics - Nonnarcotic* *Analgesics Other**-*Analgesics Other*** ACEHEN 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 oral tablet 325 mg ; QL (279 EA per 31 days) apap extra strength oral tablet 500 mg ; QL (186 EA per 31 days) 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, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 1

5 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 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 mapap arthritis pain oral tablet extendedrelease* 650 mg ; QL (93 EA per 31 days) 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 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 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 oral tablet 500 mg ; QL (186 EA per 31 days) pain relief extra strength oral tablet 500 mg ; QL (186 EA per 31 days) HARBETOL ORAL TABLET 325 MG ; QL (279 EA per 31 days) HARBETOL EXTRA STRENGTH ORAL TABLET 500 MG ; QL (186 EA per 31 days) q-pap oral tablet 325 mg ; QL (279 EA per 31 days) tactinal oral tablet 325 mg ; QL (279 EA per 31 days) tactinal extra strength oral tablet 500 mg ; QL (186 EA per 31 days) *Salicylates**-*Salicylate Combinations*** tri-buffered aspirin oral tablet 325 mg *Salicylates**-*Salicylates*** aspirin oral tablet 325 mg, 81 mg aspirin oral tablet chewable 81 mg aspirin oral tablet delayed release 81 mg aspirin adult low strength oral tablet delayed release 81 mg aspirin childrens oral tablet chewable 81 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 2

6 reference Details Coverage Details aspirin ec oral tablet delayed release 325 mg, 81 mg aspirin ec low dose oral tablet delayed release 81 mg aspirin low dose oral tablet 81 mg ECIRIN ORAL TABLET DELAYED RELEASE 325 MG *Anorectal Agents* *Rectal Combinations**-*Rectal Combinations - Misc.*** hem-prep suppository % *Antacids* *Antacid Combinations**-*Antacid & Simethicone*** alamag plus oral tablet chewable mg ALMACONE ORAL SUSENSION MG/5ML antacid oral suspension mg/5ml antacid anti-gas oral suspension mg/5ml antacid anti-gas max strength oral suspension mg/5ml antacid extra strength oral suspension mg/5ml antacid i oral suspension mg/5ml antacid iii oral suspension mg/5ml geri-lanta oral suspension mg/5ml MAALOX ADVANCED ORAL SUSENSION MG/5ML MAALOX ADVANCED MAX ST ORAL SUSENSION MG/5ML MAALOX MAX ORAL SUSENSION MG/5ML MAALOX MULTI SYMTOM MAX ST ORAL SUSENSION MG/5ML MAALOX REGULAR STRENGTH ORAL SUSENSION MG/5ML milantex oral suspension mg/5ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 3

7 reference Details Coverage Details milantex extra strength oral suspension mg/5ml MINTOX LUS ORAL TABLET CHEWABLE MG *Antacid Combinations**-*Antacid Combinations*** ACID GONE ORAL TABLET CHEWABLE MG gnp foaming antacid oral tablet chewable mg MI-ACID ORAL TABLET CHEWABLE MG *Antacids - Aluminum Salts**-*Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 mg/5ml *Antacids - Bicarbonate**-*Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325 mg, 650 mg *Antacids - Calcium Salts**-*Antacids - Calcium Salts*** alcalak oral tablet chewable 420 mg antacid oral tablet chewable 420 mg, 500 mg CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG calcium antacid oral tablet chewable 500 mg calcium antacid extra strength oral tablet chewable 750 mg calcium carbonate antacid oral tablet 648 mg calcium carbonate antacid oral tablet chewable 500 mg MAALOX ORAL TABLET CHEWABLE 600 MG TITRALAC ORAL TABLET CHEWABLE 420 MG *Antacids - Magnesium Salts**-*Antacids - Magnesium Salts*** magnesium oxide oral tablet 400 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 4

8 reference Details Coverage Details *Antidiabetics* *Diabetic Other**-*Diabetic Other*** BD GLUCOSE ORAL TABLET CHEWABLE 5 GM glucose oral tablet chewable 4 gm *Antidiarrheals* *Antidiarrheal Agents - Misc.**-*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 kao-tin oral suspension 262 mg/15ml KAOECTATE ORAL SUSENSION 262 MG/15ML KAOECTATE EXTRA STRENGTH ORAL SUSENSION 525 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 *Antiperistaltic Agents**-*Antiperistaltic Agents*** anti-diarrheal oral liquid 1 mg/5ml LOERAMIDE A-D ORAL TABLET 2 MG loperamide hcl oral liquid 1 mg/5ml *Antidotes* *Antidotes**-*Antidotes*** actidose-aqua oral liquid 15 gm/72ml, 25 gm/120ml, 50 gm/240ml actidose/sorbitol oral liquid 25 gm/120ml, 50 gm/240ml charcoal oral capsule 260 mg charcoal activated oral tablet 250 mg CHARCOCAS ORAL CASULE 260 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 5

9 reference Details Coverage Details ipecac oral syrup KERR INSTA-CHAR ORAL LIQUID 25 GM/120ML, 50 GM/240ML KERR INSTA-CHAR IN SORBITOL ORAL LIQUID 25 GM/120ML, 50 GM/240ML LITTLE REMEDIES OISON TREAT ORAL SUSENSION RECONSTITUTED 15 GM/120ML *Antiemetics* *Antiemetics - Anticholinergic**-*Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 mg, 25 mg *Antihistamines* *Antihistamines - Alkylamines**-*Antihistamines - Alkylamines*** 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 chlorphen oral tablet 4 mg DIABETIC TUSSIN ALLERGY ORAL SYRU 2 MG/5ML *Antihistamines - Ethanolamines**-*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 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 6

10 reference Details Coverage Details 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 DORMIN ORAL CASULE 25 MG genahist oral capsule 25 mg pharbedryl oral capsule 25 mg, 50 mg q-dryl oral capsule 25 mg q-dryl oral liquid 12.5 mg/5ml quenalin oral syrup 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 SIMLY ALLERGY ORAL TABLET 25 MG total allergy oral tablet 25 mg TOTAL ALLERGY MEDICINE ORAL LIQUID 12.5 MG/5ML *Antihistamines - Non-Sedating**-*Antihistamines - Non-Sedating*** cetirizine hcl oral tablet 10 mg, 5 mg cetirizine hcl childrens oral solution 1 mg/ml cetirizine hcl childrens alrgy oral syrup 1 mg/ml childrens loratadine oral syrup 5 mg/5ml ; QL (310 ML per 31 days) loratadine oral tablet 10 mg loratadine hives relief oral solution 5 mg/5ml ; QL (300 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 7

11 reference Details Coverage Details *Antiseptics & Disinfectants* *Iodine Antiseptics**-*Iodine Antiseptics*** OERAND OVIDONE-IODINE EXTERNAL SOLUTION 10 % povidone-iodine external ointment 10 % povidone-iodine external solution 10 % povidone-iodine external swab 10 %, 7.5 % *Assorted Classes* *Assorted Classes**-*Assorted Classes*** gelatin oral capsule 650 mg *Cough/Cold/Allergy* *Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine*** ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* MG BROTA ORAL LIQUID 1-15 MG/5ML Q-TA ORAL ELIXIR 1-15 MG/5ML *Expectorants**-*Expectorants*** mucus relief oral tablet 400 mg refenesen oral tablet 200 mg refenesen 400 oral tablet 400 mg robafen oral syrup 100 mg/5ml *Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants*** sodium chloride inhalation nebulization solution 0.9 % *Dermatologicals* *Acne roducts**-*acne roducts*** acne medication external lotion 10 % acne medication 10 external 10 % acne-clear external 10 % benzoyl peroxide external 10 %, 5 % CLEAN & CLEAR ERSA-GEL EX ST EXTERNAL 5 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 8

12 reference Details Coverage Details CLEAN & CLEAR ERSA-GEL MAX ST EXTERNAL 10 % CLEARLEX V EXTERNAL 5 % CLEARSKIN EXTERNAL CREAM 10 % NEUTROGENA ON-THE-SOT EXTERNAL CREAM 2.5 % ANOXYL WASH EXTERNAL LIQUID 10 % *Antibiotics - Topical**-*Antibiotic Mixtures Topical*** bacitracin-neomycin-polymyxin external ointment double antibiotic external ointment unit/gm triple antibiotic external ointment , *Antibiotics - Topical**-*Antibiotics - Topical*** bacitracin external ointment 500 unit/gm bacitracin zinc external ointment 500 unit/gm *Antifungals - Topical**-*Antifungals - Topical*** anti-fungal external powder 1 % terbinafine hcl external cream 1 % tolnaftate external cream 1 % tolnaftate external solution 1 % tolnaftate antifungal external cream 1 % *Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** clotrimazole external cream 1 % clotrimazole external solution 1 % clotrimazole anti-fungal external cream 1 % *Antihistamines-Topical**-*Antihistamines - Topical*** anti-itch maximum strength external cream 2 % BENADRYL ITCH STOING EXTERNAL 2 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 9

13 reference Details Coverage Details itch relief external cream 2 % *Corticosteroids - Topical**-*Corticosteroids - Topical*** AVEENO ANTI-ITCH MAX ST EXTERNAL CREAM 1 % hydrocortisone external cream 0.5 % 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 % tgt anti-itch/aloe/vit e external cream 1 % *Corticosteroids - Topical**-*Topical Steroid Combinations*** hydrocortisone-aloe external cream 1 % sm hydrocortisone plus external cream 1 % *Misc. Topical**-*Misc. Topical*** REARATION H EXTERNAL AD 50 % *Scabicides & ediculicides**-*scabicides & ediculicides*** A-200 AEROSOL 0.5 % permethrin external lotion 1 % ; QL (60 ML per 31 days) *Sunscreens**-*Sunscreens*** NEUTROGENA MOISTURE SF15 EXTERNAL LOTION *Tar roducts**-*tar roducts*** BETA CARE BETATAR GEL EXTERNAL SHAMOO 2.5 % ELTA TAR EXTERNAL CREAM 2 % IONIL-T EXTERNAL SHAMOO 1 % MG217 MEDICATED TAR EXTERNAL SHAMOO 15 % NEUTROGENA T/GEL EX ST EXTERNAL SHAMOO 1 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 10

14 reference Details Coverage Details pc-tar external shampoo 1 % TERA-GEL TAR EXTERNAL SHAMOO 0.5 % *Gastrointestinal Agents - Misc.* *Antiflatulents**-*Antiflatulents*** 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 *Genitourinary Agents - Miscellaneous* *Urinary Analgesics**-*Urinary Analgesics*** phenazopyridine hcl oral tablet 95 mg *Hematopoietic Agents* *Cobalamins**-*Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml vitamin b-12 oral tablet 1000 mcg, 250 mcg, 500 mcg vitamin b-12 sublingual tablet sublingual 1000 mcg vitamin b-12 er oral tablet extendedrelease* 1000 mcg *Folic Acid/Folates**-*Folic Acid/Folates*** folic acid oral tablet 1 mg *Iron**-*Iron*** ferro-bob oral tablet 325 (65 fe) mg ferrous sulfate oral elixir 220 (44 fe) mg/5ml ferrous sulfate oral solution 75 (15 fe) mg/ml ferrous sulfate oral tablet 325 (65 fe) mg ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg ferrousul oral tablet 325 (65 fe) mg iron oral tablet 325 (65 fe) mg, 90 (18 fe) mg *Hypnotics* *Antihistamine Hypnotics**-*Antihistamine Hypnotic Combinations*** acetaminophen pm oral tablet mg ; QL (62 EA per 31 Days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 11

15 reference Details Coverage Details 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**-*Antihistamine Hypnotics*** compoz oral capsule 50 mg compoz oral tablet 50 mg NYTOL ORAL TABLET 25 MG SIMLY SLEE ORAL TABLET 25 MG sleep tabs oral tablet 25 mg sleep-tabs oral tablet 25 mg SOMINEX ORAL TABLET 25 MG SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 MG tetra-formula nighttime sleep oral tablet 50 mg *Laxatives* *Bulk Laxatives**-*Bulk Laxatives*** fiber oral tablet 625 mg fiber laxative oral tablet 625 mg fiber therapy oral powder 58.6 % fiber-lax oral tablet 625 mg FIBERGEN ORAL TABLET 625 MG KONSYL ORAL ACKET 100 % KONSYL FIBER ORAL TABLET 625 MG METAMUCIL ORAL OWDER 30.9 % METAMUCIL MULTIHEALTH FIBER ORAL OWDER 58.6 % 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 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 12

16 reference Details Coverage Details REGULOID ORAL CASULE 0.52 GM *Laxative Combinations**-*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 senna-s oral tablet mg senna-time s oral tablet mg SENNALAX-S ORAL TABLET MG sennosides-docusate sodium oral tablet mg *Laxatives - Miscellaneous**-*Laxatives - Miscellaneous*** glycerin (adult) suppository 2.1 gm glycerin (pediatric) suppository 1.2 gm sorbitol oral solution 70 % *Saline Laxatives**-*Saline Laxative Mixtures*** enema enema 7-19 gm/118ml sm oral saline laxative oral solution gm/5ml *Saline Laxatives**-*Saline Laxatives*** citrate of magnesia oral solution gm/30ml CITROMA ORAL SOLUTION GM/30ML DULCOLAX MILK OF MAGNESIA ORAL SUSENSION 400 MG/5ML magnesium citrate oral solution gm/30ml milk of magnesia oral suspension 400 mg/5ml, 7.75 % *Stimulant Laxatives**-*Stimulant Laxatives*** BISAC-EVAC SUOSITORY 10 MG biscolax suppository 10 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 13

17 reference Details Coverage Details 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 FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG gentle laxative oral tablet delayed release 5 mg laxative suppository 10 mg natural senna laxative oral tablet mg senexon oral liquid 8.8 mg/5ml senexon oral tablet 8.6 mg senna oral syrup 8.8 mg/5ml senna oral tablet 15 mg, 8.6 mg senna lax oral tablet 8.6 mg senna laxative oral tablet 8.6 mg senna maximum strength oral tablet 25 mg SENNA SMOOTH ORAL TABLET 15 MG senna-lax oral tablet 8.6 mg senna-tabs oral tablet 8.6 mg senna-time oral tablet 8.6 mg SENNACON ORAL TABLET 8.6 MG SENNO ORAL TABLET 8.6 MG stimulant laxative oral tablet delayed release 5 mg womens laxative oral tablet delayed release 5 mg *Surfactant Laxatives**-*Surfactant Laxatives*** CORRECTOL EXTRA GENTLE ORAL CASULE 100 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 14

18 reference Details Coverage Details d.o.s. oral capsule 250 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 sodium oral tablet 100 mg DOCUSIL ORAL CASULE 100 MG dok oral capsule 100 mg, 250 mg dok oral tablet 100 mg dss oral capsule 100 mg, 250 mg DULCOLAX STOOL SOFTENER ORAL CASULE 100 MG ENEMEEZ MINI ENEMA 283 MG kao-tin oral capsule 240 mg laxa basic oral capsule 100 mg 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 stool softener laxative dc oral capsule 240 mg sur-q-lax oral capsule 240 mg SURFAK ORAL CASULE 240 MG *Medical Devices* *Respiratory Therapy Supplies**-*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) *Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER MV 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, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 15

19 reference Details Coverage Details 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) 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**-*Calcium Combinations*** calcium oral tablet mg-unit calcium + d3 oral tablet mg-unit calcium 600-d oral tablet mg-unit calcium carbonate-vitamin d oral tablet mg-unit, mg-unit calcium high potency/vitamin d oral tablet mg-unit calcium-carb d oral tablet mg-unit calcium-vitamin d oral tablet mg-unit, mg-unit, mg-unit CALTRATE 600+D ORAL TABLET MG-UNIT liquid calcium/vitamin d oral capsule mg-unit OYSCO 500+D ORAL TABLET MG-UNIT =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 16

20 reference Details Coverage Details OYSCO 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 mg-unit oyster shell calcium d oral tablet mg-unit oyster shell calcium/d oral tablet mg-unit, mg-unit oyster shell calcium/vitamin d oral tablet mg-unit oyster shell/vitamin d oral tablet mg-unit *Calcium**-*Calcium*** CAL-CARB FORTE ORAL TABLET 1250 MG calcarb 600 oral tablet 1500 mg CALCI-CHEW ORAL TABLET CHEWABLE 1250 MG calcium 600 oral tablet 600 mg calcium carbonate oral suspension 1250 mg/5ml calcium carbonate oral tablet 1250 mg, 600 mg calcium high potency oral tablet 600 mg calcium oyster shell oral tablet 1250 mg calcium-carb 600 oral tablet 600 mg CALTRATE 600 ORAL TABLET 1500 MG OYSCO 500 ORAL TABLET 500 MG OYSTERCAL ORAL TABLET 500 MG *Electrolyte Mixtures**-*Electrolytes Oral*** ORALYTE FREEZER OS ORAL SOLUTION ; QL (4000 ML per 31 days) REHYDRALYTE ORAL SOLUTION ; QL (4000 ML per 31 days) revital freezer pops oral solution ; QL (4000 ML per 31 days) revital liquid squeezers oral solution ; QL (4000 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 17

21 reference Details Coverage Details *Magnesium**-*Magnesium*** mag-delay oral tablet extendedrelease* 535 (64 mg) mg mag-sr oral tablet extendedrelease* 535 (64 mg) mg MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG magnacaps oral capsule 100 mg magnesium oral tablet 250 mg magnesium oxide oral tablet 400 (240 mg) mg MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG *Sodium**-*Sodium*** sodium chloride oral tablet 1 gm *Zinc**-*Zinc*** ORAZINC ORAL CASULE 220 MG zinc oral tablet 25 mg, 50 mg zinc gluconate oral tablet 100 mg, 30 mg, 50 mg zinc methionate oral capsule 50 mg zinc picolinate oral tablet 25 mg zinc sulfate oral capsule 220 mg zinc sulfate oral tablet 220 (50 zn) mg zinc-220 oral capsule 220 mg *Multivitamins* *B-Complex W/ Folic Acid**-*B-Complex W/ C & Folic Acid*** NEHRONEX ORAL TABLET rena-vite rx oral tablet 1 mg RENAL ORAL CASULE 1 MG reno caps oral capsule 1 mg *Multiple Vitamins W/ Minerals**-*Multiple Vitamins W/ Minerals*** centamin oral liquid centavite oral liquid =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 18

22 reference Details Coverage Details centavite a-z complete-mineral oral tablet CEROVITE ADVANCED FORMULA ORAL TABLET CERTAVITE/ANTIOXIDANTS ORAL LIQUID formula twenty-one oral tablet gerivite complete oral tablet golden age vitamin/minerals oral liquid 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 *Multivitamins**-*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-tabs oral tablet THERA/BETA-CAROTENE ORAL TABLET therapeutic oral tablet *ed Mv W/ Fluoride**-*ed Mv W/ Fluoride*** multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml multi-vitamin/fluoride oral tablet chewable 0.5 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 19

23 reference Details Coverage Details multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg multivitamins/fluoride oral tablet chewable 0.25 mg *Specialty Vitamins roducts**-*specialty Vitamins roducts*** vitamins for hair oral tablet *Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.**-*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 % na-zone nasal solution 0.65 % NASAL MOIST 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 Antiallergy**-*Nasal Mast Cell Stabilizers*** cromolyn sodium nasal aerosol, solution 5.2 mg/act *Sympathomimetic Decongestants**-*Systemic Decongestants*** nasal decongestant oral syrup 30 mg/5ml pseudoephedrine hcl oral tablet 30 mg, 60 mg SUDAFED 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR* 120 MG *Ophthalmic Agents* *Artificial Tears And Lubricants**-*Artificial Tear And Lubricant Combinations*** artificial tears ophthalmic ointment % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 20

24 reference Details Coverage Details HYOTEARS OHTHALMIC SOLUTION 1-1 % *Artificial Tears And Lubricants**-*Artificial Tear Ointments*** tears again ophthalmic ointment ULTRA FRESH M OHTHALMIC OINTMENT *Artificial Tears And Lubricants**-*Artificial Tear Solutions*** tears again ophthalmic solution *Artificial Tears And Lubricants**-*Artificial Tears And Lubricants*** artificial tears ophthalmic solution 1.4 % ; QL (15 ML per 31 days) liquitears ophthalmic solution 1.4 % ; QL (15 ML per 31 Days) polyvinyl alcohol ophthalmic solution 1.4 % ; QL (15 ML per 31 Days) *Ophthalmics - Misc.**-*Ophthalmic Antiallergic*** ALAWAY OHTHALMIC SOLUTION % ketotifen fumarate ophthalmic solution % *Otic Agents* *Otic Agents - Miscellaneous**-*Otic Agents - Miscellaneous*** auraphene-b otic solution 6.5 % AURO EARDROS OTIC SOLUTION 6.5 % E-R-O EAR DROS OTIC SOLUTION 6.5 % E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % ear drops earwax aid otic solution 6.5 % earwax treatment drops otic solution 6.5 % MURINE EAR OTIC SOLUTION 6.5 % MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % OTIX OTIC SOLUTION 6.5 % thera-ear otic solution 6.5 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 21

25 reference Details Coverage Details *sychotherapeutic And Neurological Agents - Misc.* *Smoking Deterrents**-*Smoking Deterrents*** nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr ; QL (70 EA per 365 days) nicotine polacrilex mouth/throat gum 2 mg, 4 mg ; QL (2016 EA per 365 days) *Ulcer Drugs* *H-2 Antagonists**-*H-2 Antagonists*** acid reducer oral tablet 75 mg cimetidine oral tablet 200 mg cimetidine acid reducer oral tablet 200 mg famotidine oral tablet 10 mg heartburn relief oral tablet 10 mg, 200 mg heartburn relief max st oral tablet 20 mg ranitidine acid reducer oral tablet 75 mg *roton ump Inhibitors**-*roton ump Inhibitors*** omeprazole oral tablet delayed release 20 mg *Vaginal roducts* *Spermicides**-*Spermicides*** ENCARE VAGINAL SUOSITORY 100 MG OTIONS CONCETROL VAGINAL 4 % VCF VAGINAL CONTRACETIVE VAGINAL FOAM 12.5 % *Vaginal Anti-Infectives**-*Imidazole-Related Antifungals*** miconazole 3 combo pack vaginal kit mg-% (9gm) miconazole 7 vaginal cream 2 % miconazole 7 vaginal suppository 100 mg miconazole nitrate vaginal cream 2 % miconazole nitrate vaginal suppository 100 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 22

26 reference Details Coverage Details *Vitamins* *Oil Soluble Vitamins**-*Vitamin D*** CALCIFEROL ORAL SOLUTION 8000 UNIT/ML vitamin d oral capsule 1000 unit vitamin d oral tablet 400 unit vitamin d (ergocalciferol) oral capsule unit QL (4 EA per 28 days) vitamin d-400 oral tablet 400 unit vitamin d3 oral capsule 2000 unit vitamin d3 oral tablet 1000 unit, 400 unit *Oil Soluble Vitamins**-*Vitamin K*** MEHYTON ORAL TABLET 5 MG *Water Soluble Vitamins**-*Vitamin B-3*** ENDUR-ACIN ORAL TABLET EXTENDEDRELEASE* 250 MG, 500 MG niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg niacin er oral capsule extended release* 250 mg, 500 mg niacin er oral tablet extendedrelease* 250 mg, 500 mg, 750 mg niacin-50 oral tablet 50 mg SLO-NIACIN ORAL TABLET EXTENDEDRELEASE* 250 MG *Water Soluble Vitamins**-*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 vitamin c oral syrup 500 mg/5ml vitamin c oral tablet 100 mg, 1000 mg, 250 mg, 500 mg vitamin c oral tablet chewable 100 mg, 250 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 23

27 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 24

28 Index A ACE AEROSOL CLOUD ENHANCER ACEHEN... 1 acetaminophen... 1 acetaminophen pm ACID GONE... 4 acid reducer acne medication... 8 acne medication acne-clear... 8 actidose/sorbitol... 5 actidose-aqua... 5 AEROCHAMBER MV AEROCHAMBER LUS FLO-VU AEROCHAMBER LUS FLO-VU LARGE AEROCHAMBER LUS FLO-VU SMALL AEROCHAMBER LUS FLO-VU W/MASK AEROCHAMBER W/FLOWSIGNAL AEROCHAMBER Z-STAT LUS AEROCHAMBER Z-STAT LUS CHAMBR alamag plus... 3 ALAVERT ALLERGY/SINUS... 8 ALAWAY alcalak... 4 aler-cap... 6 aler-dryl... 6 alertab... 6 aller-chlor... 6 allergy... 6 allergy relief... 6 allergy relief childrens... 6 ALMACONE... 3 altamist spray altaryl... 6 aluminum hydroxide gel... 4 antacid... 3 antacid anti-gas... 3 antacid anti-gas max strength... 3 antacid extra strength... 3 antacid i... 3 antacid iii... 3 anti-diarrheal... 5 anti-fungal... 9 anti-hist allergy... 6 anti-itch maximum strength... 9 apap... 1 apap extra strength... 1 artificial tears ascorbic acid aspirin... 2 aspirin adult low strength aspirin childrens aspirin ec... 3 aspirin ec low dose... 3 aspirin low dose... 3 auraphene-b AURO EARDROS AVEENO ANTI-ITCH MAX ST AYR bacitracin... 9 bacitracin zinc... 9 bacitracin-neomycin-polymyxin... 9 BANOHEN... 6, 7 BD GLUCOSE... 5 BENADRYL ALLERGY CHILDRENS... 7 BENADRYL ITCH STOING... 9 benzoyl peroxide... 8 BETA CARE BETATAR GEL BISAC-EVAC biscolax bismatrol... 5 bismuth... 5 BROTA... 8 c calcarb CAL-CARB FORTE CALCI-CHEW CALCIFEROL calcium calcium + d3 calcium calcium 600-d calcium antacid... 4 calcium antacid extra strength... 4 calcium carbonate calcium carbonate antacid... 4 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 25

29 calcium carbonate-vitamin d calcium high potency calcium high potency/vitamin d calcium oyster shell calcium-carb 600 calcium-carb d calcium-vitamin d CAL-GEST ANTACID... 4 CALTRATE 600 CALTRATE 600+D CARTERS LITTLE ILLS centamin centavite centavite a-z complete-mineral CEROVITE ADVANCED FORMULA CERTAVITE/ANTIOXIDANT S cetirizine hcl... 7 cetirizine hcl childrens... 7 cetirizine hcl childrens alrgy... 7 charcoal... 1 charcoal activated... 5 CHARCOCAS... 5 childrens loratadine... 7 childrens non-asa pain relief... 1 childrens non-aspirin childrens pain reliever childrens silapap =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 26 childrens tactinal chlorhist... 6 chlorphen... 6 cimetidine cimetidine acid reducer citrate of magnesia CITROMA CLEAN & CLEAR ERSA-GEL EX ST... 8 CLEAN & CLEAR ERSA-GEL MAX ST... 9 CLEARLEX V... 9 CLEARSKIN... 9 clotrimazole... 9 clotrimazole anti-fungal... 9 complete allergy medication... 7 complete allergy relief... 7 compoz correct CORRECTOL CORRECTOL EXTRA GENTLE cromolyn sodium cyanocobalamin d.o.s daily multiple vitamins daily vite daily vites deep sea nasal spray DIABETIC TUSSIN ALLERGY... 6 diocto diotame... 5 diphenhist... 7 diphenhydramine hcl... 7 docqlace DOC-Q-LAX docu soft docusate sodium DOCUSIL dok DORMIN... 7 double antibiotic... 9 dss ducodyl DULCOLAX MILK OF MAGNESIA DULCOLAX STOOL SOFTENER ear drops earwax aid earwax treatment drops EASIVENT ECIRIN... 3 ed-apap... 2 ELTA TAR ENCARE ENDUR-ACIN enema ENEMEEZ MINI E-R-O EAR DROS E-R-O EAR WAX REMOVAL SYSTEM EX-LAX EX-LAX ULTRA famotidine FEENAMINT ferro-bob ferrous sulfate ferrousul fiber fiber laxative fiber therapy... 12

30 FIBERGEN fiber-lax FLEET LAXATIVE folic acid formula twenty-one gelatin... 8 genahist... 7 gentle laxative geri-lanta... 3 gerivite complete glucose... 5 glycerin (adult) glycerin (pediatric) gnp foaming antacid... 4 golden age vitamin/minerals headache pm heartburn relief heartburn relief max st hem-prep... 3 HUMIST hydrocortisone hydrocortisone max st hydrocortisone max st/12 moist hydrocortisone-aloe HYDROSKIN HYOTEARS ibuprofen... 1 ibuprofen junior strength... 1 IN-CHECK DIAL FLOW TRAINER IONIL-T ipecac... 6 iron itch relief KAOECTATE... 5 KAOECTATE EXTRA STRENGTH... 5 kao-tin... 5 KERR INSTA-CHAR... 6 KERR INSTA-CHAR IN SORBITOL... 6 ketotifen fumarate KONSYL KONSYL FIBER kp hydrocortisone laxa basic laxative liquid calcium/vitamin d liquitears LITTLE NOSES SALINE LITTLE REMEDIES OISON TREAT... 6 LOERAMIDE A-D... 5 loperamide hcl... 5 loratadine... 7 loratadine hives relief... 7 MAALOX... 4 MAALOX ADVANCED... 3 MAALOX ADVANCED MAX ST... 3 MAALOX MAX... 3 MAALOX MULTI SYMTOM MAX ST... 3 MAALOX REGULAR STRENGTH... 3 MAG mag-delay magnacaps magnesium magnesium citrate magnesium oxide... 4 MAGNESIUM-OXIDE mag-sr MAG-TAB SR mapap... 2 mapap arthritis pain mapap pm maxapap maximum strength maxapap regular strength meclizine hcl... 6 melatonin maximum strength... 1 MEHYTON METAMUCIL METAMUCIL MULTIHEALTH FIBER METAMUCIL SMOOTH TEXTURE MG217 MEDICATED TAR MI-ACID... 4 mi-acid gas relief miconazole 3 combo pack miconazole miconazole nitrate MICROCHAMBER MICROSACER milantex... 3 milantex extra strength... 4 milk of magnesia MINTOX LUS... 4 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 27

31 mucus relief... 8 multi-day multi-vit/fluoride multi-vitamin multivitamin & mineral multivitamin/fluoride multi-vitamin/fluoride multi-vitamins multivitamins/fluoride MURINE EAR MURINE EAR WAX REMOVAL SYSTEM mytab gas nasal decongestant NASAL MOIST natural fiber therapy natural senna laxative natural vegetable fiber na-zone NEHRONEX NEUTROGENA MOISTURE SF NEUTROGENA ON-THE-SOT... 9 NEUTROGENA T/GEL EX ST niacin niacin er niacin nicotine nicotine polacrilex non-aspirin... 2 non-aspirin extra strength =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 28 non-aspirin pain relief nortemp infants NYTOL OCEAN FOR KIDS omeprazole once daily one-daily multi vitamins OERAND OVIDONE-IODINE... 8 OTICHAMBER ADVANTAGE OTIHALER OTIONS CONCETROL ORALYTE FREEZER OS ORAZINC OTIX OYSCO 500 OYSCO 500+D OYSCO D oyst-cal d oyster calcium + d oyster shell calcium + d oyster shell calcium d oyster shell calcium/d oyster shell calcium/vitamin d oyster shell/vitamin d OYSTERCAL pain & fever childrens pain relief... 2 pain relief extra strength pain relief pm extra strength pain reliever pm ANOXYL WASH... 9 pc-tar ERI-COLACE permethrin FLEX pharbedryl... 7 HARBETOL HARBETOL EXTRA STRENGTH phenazopyridine hcl pink bismuth... 5 OCKET CHAMBER OCKET SACER polyvinyl alcohol povidone-iodine... 8 REARATION H REARATION H HYDROCORTISONE pseudoephedrine hcl q-dryl... 7 q-pap... 2 Q-TA... 8 quenalin... 7 ranitidine acid reducer refenesen... 8 refenesen REGULOID REHYDRALYTE RENAL rena-vite rx reno caps revital freezer pops

32 revital liquid squeezers robafen... 8 saline mist spray saline nasal spray SCOT-TUSSIN ALLERGY RELIEF... 7 sea soft nasal mist senexon senna senna lax senna laxative senna maximum strength senna plus senna s SENNA SMOOTH SENNACON senna-docusate sodium senna-lax SENNALAX-S senna-s senna-tabs senna-time senna-time s SENNO sennosides-docusate sodium silace siladryl allergy... 7 silphen cough... 7 simethicone SIMLY ALLERGY... 7 SIMLY SLEE sleep tabs sleep-tabs SLO-NIACIN sm hydrocortisone plus sm oral saline laxative sodium bicarbonate... 4 sodium chloride... 8 SOF-LAX SOMINEX SOMINEX MAXIMUM STRENGTH sorbitol stimulant laxative stomach relief... 5 stomach relief plus... 5 stool softener stool softener laxative dc SUDAFED 12 HOUR SUER NU-THERA SURFAK sur-q-lax tactinal... 2 tactinal extra strength tears again TERA-GEL TAR terbinafine hcl... 9 tetra-formula nighttime sleep tgt anti-itch/aloe/vit e THERA thera vital m THERA/BETA-CAROTENE therabasic-m thera-ear therapeutic therapeutic liquid therapeutic-m thera-tabs THRESHOLD IMT THRESHOLD E TITRALAC... 4 tolnaftate... 9 tolnaftate antifungal... 9 total allergy... 7 TOTAL ALLERGY MEDICINE... 7 TOTAL FORMULA 3 tri-buffered aspirin triple antibiotic... 9 ULTRA FRESH M VCF VAGINAL CONTRACETIVE vitamin b vitamin b-12 er vitamin c vitamin d vitamin d (ergocalciferol) vitamin d vitamin d vitamins for hair WATCHHALER WINDMILL TRAINER womens laxative XENICAL... 1 zinc zinc gluconate zinc methionate =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 29

33 zinc picolinate zinc sulfate zinc =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 30