Medi-Cal Formulary Foreword The Care1st Medi-Cal Formulary is a list of covered and preferred drug agents for Care1st Medi-Cal members. The drug list includes drugs used to treat common diseases or health problems. A team of doctors and pharmacists (Pharmacy and Therapeutics (P&T) Committee) meets quarterly to decide which drugs should be on the drug list. The P&T Committee reviews new and existing drugs and chooses drugs that work best and are proven to be safe. Consequently, the formulary is updated regularly and is subject to change without notice. How do I use the Care1st Medi-Cal Formulary? To look for a drug, check the index at the end of the document. The index lists all of the drugs on the Formulary. Next to your drug, you will see the page number where you can find your drug. To look for a therapeutic class, check the Table of Contents. The Formulary covers generics whenever available. Brand name drugs that don t have a generic equivalent are listed in capital bold letters. Any drug not found in this Formulary listing shall be considered a Non-Formulary drug. What if my drug is not on the Care1st Medi-Cal Formulary? If your doctor thinks you need to take a drug that is not on formulary, you can ask your doctor to prescribe a similar drug that is on formulary, or your doctor can call us at 1-877-792-2731, or submit a written request for prior authorization review via fax at 1-866-712-2731. Some drugs require Care1st Health Plan approval. What if I have additional questions? If you want a copy of the Care1st Health Plan Medi-Cal Formulary, or have additional questions, please call Care1st Health Plan s Member Services at 1-800-605-2556 (Los Angeles County) or 1-855-699-5557 (San Diego County).
Reference The tables below tells you what the status and abbreviations means on the Drug List Mean. Status Medical Benefit (Tier 3) What Does it mean These drugs are covered on the Drug List (Formulary) at $0 co-payment. These drugs are carved out by the Department of Health Care Services. This means these drugs are covered by the Medi-Cal Fee-for Service program and can be billed to the State by the pharmacy. These drugs may be available at the provider s office or medical setting. Abbreviations What does it stand for What does it mean Age Age Restrictions Some drugs are only covered for certain ages. PA Prior Authorization Required Your doctor must ask for approval from Care1st before some drugs will be covered. QL Quantity Limit Some drugs are only covered for a certain amount. ST Step Therapy Required In some cases, you must first try certain drugs before Care1st covers another drug for your medical condition.
Care 1st Health Plan Medi-Cal Drug Formulary The co-payment for formulary covered medications is $0 Table of Contents Allergy...5 Antiemesis/Antivertigo...7 Asthma And Copd...8 Autonomic Nervous System Disorders... 12 Behavioral Health - Antidepressants... 12 Behavioral Health - Other... 14 Cardiovascular Disease - Arrhythmia...24 Cardiovascular Disease - Cardiac Stimulant... 24 Cardiovascular Disease - Hypertension... 25 Cardiovascular Disease - Lipid Irregularity... 31 Cardiovascular Disease - Vasodilation...32 Contraception/Oxytocics... 33 Cough And Cold... 36 Dermatology - Acne...38 Dermatology - Antiinfective...39 Dermatology - Antiinflammatory... 41 Dermatology - Antipruritic Drugs...44 Dermatology - Miscellaneous... 44 Dermatology - Psoriasis/Eczema...45 Diabetes...46 Ear - General Disorders... 49 Electrolyte Regulation... 49 Endocrine Disorder - Other... 51 Endocrine Disorder - Thyroid... 53 Eye - General Disorders...54 Eye - Glaucoma... 57 Fluid Replacement...58 Gout And Related Diseases... 58 Hematological Disorders... 59 Hormonal Deficiency... 63 Immunization... 64 Immunosuppression/Modulation...68 Infectious Disease - Bacterial... 68 Infectious Disease - Fungal...72 Infectious Disease - Miscellaneous... 73 Infectious Disease - Parasitic...73 Infectious Disease - Viral...74 Inflammatory Disease... 80 Local Anesthesia...82 Lower Gastrointestinal Disorders - Bowel Inflammat...82 Lower Gastrointestinal Disorders - Other...84 3
Medical Supplies... 85 Miscellaneous Agents...87 Neoplastic Disease... 88 Neurological Disease - Miscellaneous... 89 Oral/Pharyngeal Disorders...89 Other Drugs... 90 Other Respiratory Disorders... 91 Pain Management - Analgesics... 92 Parkinsons Disease...99 Seizure Disorder... 100 Skeletal Muscle Disorder...102 Smoking Cessation... 102 Upper Gastrointestinal Disorders - Digestive...103 Upper Gastrointestinal Disorders - Spastic Disease... 104 Upper Gastrointestinal Disorders - Ulcer Disease... 104 Urinary Tract - Functional Disorders...107 Vaginal Disorders...108 Vitamin And/Or Mineral Deficiency... 109 Weight Reduction...115 4
Care 1st Health Plan Medi-Cal Drug Formulary The co-payment for formulary covered medications is $0 CURRENT AS OF 12/1/2017 Drug Reference STATUS Notes Allergy Antihistamines - 1St Generation chlorpheniramine maleate oral tablet 4 Chlor-Trimeton clemastine fumarate oral tablet 2.68 cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 diphenhydramine hcl oral capsule 25, 50 diphenhydramine hcl oral liquid 12.5 /5ml Banophen Banophen diphenhydramine hcl oral tablet 25 Alka-Seltzer Plus Allergy hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 Vistaril Age (Min 2 Years) Age (Min 2 Years) 5
Antihistamines - 2Nd Generation cetirizine hcl childrens oral solution 5 /5ml KLS Aller-Tec Childrens cetirizine hcl oral solution 1 /ml KLS Aller-Tec Childrens cetirizine hcl oral tablet 10 KLS Aller-Tec cetirizine hcl oral tablet 5 fexofenadine hcl oral tablet 180, 60 Allegra Allergy loratadine oral solution 5 /5ml Claritin ST (Requires trial of loratadine for 15 days in the last 90 days); Age (Max 5 Years) ST (Requires trial of loratadine for 15 days in the last 90 days); Age (Max 5 Years) ST (Required use of Loratadine for 15 days in the last 90 days) QL (150 ML per 30 days); Age (Max 6 Years) loratadine oral tablet 10 Claritin QL (30 EA per 30 days) ALAVERT ORAL TABLET DISPERSIBLE 10 MG Nasal Antihistamine azelastine hcl nasal solution 0.1 % Nasal Anti-Inflammatory Steroids fluticasone propionate nasal suspension 50 mcg/act triamcinolone acetonide nasal aerosol 55 mcg/act NASACORT ALLERGY 24HR CHILDREN NASAL AEROSOL 55 MCG/ACT NASACORT ALLERGY 24HR NASAL AEROSOL 55 MCG/ACT Nasal Mast Cell Stabilizers Agents cromolyn sodium nasal aerosol solution 5.2 /act ClariSpray Nasacort Allergy 24HR Nasacort Allergy 24HR Nasacort Allergy 24HR NasalCrom Age (Max 12 Years) QL (1 BOX per 30 days) QL (16 GM per 30 days) QL (17 GM per 30 days) QL (17 GM per 30 days) 6
Antiemesis/Antivertigo Antiemetic/Antivertigo Agents granisetron hcl oral tablet 1 PA meclizine hcl oral tablet 12.5 meclizine hcl oral tablet 25 Dramamine Less Drowsy meclizine hcl oral tablet chewable 25 motion sickness relief oral tablet chewable 25 motion-time oral tablet chewable 25 ondansetron hcl oral solution 4 /5ml Zofran PA ondansetron hcl oral tablet 24 PA ondansetron hcl oral tablet 4, 8 Zofran ondansetron oral tablet dispersible 4, 8 prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 25 promethazine hcl rectal suppository 12.5, 25 promethazine hcl rectal suppository 50 trimethobenzamide hcl oral capsule 300 Zofran ODT Compro Phenadoz Phenergan Tigan COMPRO RECTAL SUPPOSITORY 25 MG Compro DRAMAMINE LESS DROWSY ORAL TABLET 25 MG PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG Dramamine Less Drowsy Phenadoz Phenadoz QL (2 FILLS OF 12 TABLETS IN 30 DAYS); QL (3 EA per 1 day) QL (2 FILLS OF 12 TABLETS IN 30 DAYS); QL (3 EA per 1 day) 7
PROMETHEGAN RECTAL SUPPOSITORY 50 MG Asthma And Copd Anticholinergic, Orally Inhaled Short Acting ipratropium bromide inhalation solution 0.02 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT Anticholinergics, Orally Inhaled Long Acting INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH Beta-Adrenergic Agents, Inhaled, Short Acting albuterol sulfate er oral tablet extended release 12 hour 4, 8 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5% Phenergan albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 terbutaline sulfate oral tablet 2.5, 5 PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT 8 RESTRICTED TO THE DIAGNOSIS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD). QL (RESTRICTED TO 2 UNITS PER 30 DAYS); QL (2 UNITS per 30 days) QL (RESTRICTED TO 2 UNITS PER 30 DAYS); QL (2 UNITS per 30 days)
Beta-Adrenergic Agents, Orally Inhaled,Long Acting FORADIL AEROLIZER INHALATION CAPSULE 12 MCG SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE Beta-Adrenergic Agents metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 Beta-Adrenergic And Anticholinergic Combinations BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 MCG/ACT COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT ST (REQUIRES A CONCOMITANT FILL OF AN INHALED CORTICOSTEROID WITHIN THE LAST 30 DAYS) ST (REQUIRES A CONCOMITANT FILL OF AN INHALED CORTICOSTEROID WITHIN THE LAST 30 DAYS); QL (60 EA per 30 days) ST (REQUIRES A PRIOR USE OF EITHER A LONG ACTING MUSCARINIC ANTAGONIST (LAMA) OR LONG ACTING BETA AGONIST (LABA) FOR 15 DAYS IN THE LAST 45 DAYS. ) 9
Beta-Adrenergic And Glucocorticoid Combinations fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 mcg/act fluticasone-salmeterol inhalation aerosol powder breath activated 232-14 mcg/act fluticasone-salmeterol inhalation aerosol powder breath activated 55-14 mcg/act Glucocorticoids, Orally Inhaled budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT Leukotriene Receptor Antagonists AirDuo RespiClick 113/14 AirDuo RespiClick 232/14 AirDuo RespiClick 55/14 Pulmicort ST (REQUIRES A FILL OF AN INHALED CORTICOSTEROID WITHIN THE LAST 90 DAYS); QL (1 EA per 30 days) ST (REQUIRES A FILL OF AN INHALED CORTICOSTEROID WITHIN THE LAST 90 DAYS); QL (1 EA per 30 days) ST (REQUIRES A FILL OF AN INHALED CORTICOSTEROID WITHIN THE LAST 90 DAYS); QL (1 EA per 30 days) Age (Max 6 Years) montelukast sodium oral packet 4 Singulair 10 ST (Requires use of InhaledCorticosteroid within last 120 days)
montelukast sodium oral tablet 10 Singulair QL (30 EA per 30 days) montelukast sodium oral tablet chewable 4, 5 Respiratory Aids,Devices,Equipment adult mask large Singulair Ace Aerosol Cloud Enhancer QL (30 EA per 30 days) pediatric medium mask CPR Microshield pediatric small mask CPR Microshield silicone mask/infant Ace Aerosol Cloud Enhancer EASIVENT MASK LARGE LITETOUCH MASK LARGE LITETOUCH MASK MEDIUM LITETOUCH MASK SMALL Ace Aerosol Cloud Enhancer Ace Aerosol Cloud Enhancer Ace Aerosol Cloud Enhancer OPTICHAMBER DIAMOND OPTICHAMBER DIAMOND-LG MASK DEVICE OPTICHAMBER DIAMOND-MD MASK OPTICHAMBER DIAMOND-SM MASK PFLEX Xanthines theophylline er oral tablet extended release 12 hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 Ace Aerosol Cloud Enhancer Theochron theophylline oral solution 80 /15ml ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML 11
THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG Autonomic Nervous System Disorders Alzheimer's Therapy, Nmda Receptor Antagonists Theochron memantine hcl oral tablet 10, 5 Namenda Cholinesterase Inhibitors donepezil hcl oral tablet 10, 5 Aricept donepezil hcl oral tablet dispersible 10, 5 pyridostigmine bromide er oral tablet extended release 180 Mestinon pyridostigmine bromide oral tablet 60 Mestinon MESTINON ORAL SYRUP 60 MG/5ML Behavioral Health - Antidepressants Alpha-2 Receptor Antagonist Antidepressants mirtazapine oral tablet 15, 30, 45 mirtazapine oral tablet dispersible 15, 30, 45 Maois - Non-Selective & Irreversible phenelzine sulfate oral tablet 15 Remeron Remeron SolTab Nardil tranylcypromine sulfate oral tablet 10 Parnate QL (30 EA per 30 days); Age (Min 18 Years) QL (30 EA per 30 days); Age (Min 18 Years) 12
MARPLAN ORAL TABLET 10 MG NARDIL ORAL TABLET 15 MG PARNATE ORAL TABLET 10 MG Norepinephrine And Dopamine Reuptake Inhib (Ndris) bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 Nardil Parnate Wellbutrin SR QL (60 EA per 30 days) Wellbutrin XL bupropion hcl oral tablet 100, 75 Selective Serotonin Reuptake Inhibitor (Ssris) citalopram hydrobromide oral tablet 10, 20, 40 escitalopram oxalate oral tablet 10, 20, 5 fluoxetine hcl (pmdd) oral capsule 10 CeleXA Lexapro fluoxetine hcl (pmdd) oral capsule 20 QL (30 EA per 30 days); Age (Min 18 Years) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (120 EA per 30 days) fluoxetine hcl oral capsule 10 PROzac QL (30 EA per 30 days) fluoxetine hcl oral capsule 20 PROzac fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 sertraline hcl oral tablet 100, 25, 50 Serotonin-2 Antagonist/Reuptake Inhibitors (Saris) trazodone hcl oral tablet 100, 150, 50 Paxil Zoloft QL (120 EA per 30 days) Age (Min 8 Years) QL (30 EA per 30 days) QL (60 EA per 30 days) 13
Serotonin-Norepinephrine Reuptake-Inhib (Snris) duloxetine hcl oral capsule delayed release particles 20, 30, 60 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib amitriptyline hcl oral tablet 10, 100, 150, 50, 75 Cymbalta Effexor XR QL (30 EA per 30 days) QL (60 EA per 30 days) amitriptyline hcl oral tablet 25 Elavil amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 Anafranil PA desipramine hcl oral tablet 10, 25 Norpramin desipramine hcl oral tablet 100, 150, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 Behavioral Health - Other Adrenergics, Aromatic, Non- Catecholamine amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 Tofranil Pamelor Adderall XR QL (30 EA per 30 days); Age (Min 6 Years and Max 18 Years) 14
amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 30, 5, 7.5 dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 Adderall Dexedrine Zenzedi ZENZEDI ORAL TABLET 10 MG, 5 MG Zenzedi Anti-Alcoholic Preparations acamprosate calcium oral tablet delayed release 333 disulfiram oral tablet 250 Antabuse VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG Anti-Anxiety Drugs alprazolam oral tablet 0.25, 0.5, 1, 2 buspirone hcl oral tablet 10, 15, 30, 5, 7.5 Xanax diazepam oral concentrate 5 /ml Diazepam Intensol diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 Valium lorazepam oral concentrate 2 /ml LORazepam Intensol lorazepam oral tablet 0.5, 1, 2 Ativan oxazepam oral capsule 10, 15, 30 ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML Diazepam Intensol Age (Min 3 Years and Max 18 Years) Age (Min 3 Years and Max 18 Years) Age (Min 3 Years and Max 18 Years) Age (Min 3 Years and Max 18 Years) QL (100 EA per 30 days) QL (100 EA per 30 days) QL (LIMIT #100 PER 30 DAYS); QL (100 EA per 30 days) 15
LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML Anti-Mania Drugs lithium carbonate er oral tablet extended release 300 lithium carbonate er oral tablet extended release 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG Antipsych,Dopamine Antag.,Diphenylbutylpiperidines pimozide oral tablet 1, 2 ORAP ORAL TABLET 1 MG, 2 MG Antipsychotic-Atypical,D3/D2 Partial Ag-5Ht Mixed VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG Antipsychotics, Atyp, D2 Partial Agonist/5Ht Mixed aripiprazole oral solution 1 /ml aripiprazole oral tablet 10, 15, 2, 20, 30, 5 aripiprazole oral tablet dispersible 10, 15 LORazepam Intensol Lithobid Lithobid Orap Orap Abilify 16
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 400 MG ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG Antipsychotics, Dopamine & Serotonin Antagonists loxapine succinate oral capsule 10, 25, 5, 50 ADASUVE INHALATION AEROSOL POWDER BREATH ACTIVATED 10 MG Antipsychotics,Atypical,Dopamine, & Serotonin Antag clozapine oral tablet 100, 25 clozapine oral tablet 200, 50 clozapine oral tablet dispersible 100, 12.5, 150, 200, 25 olanzapine intramuscular solution reconstituted 10 olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet dispersible 10, 15, 20, 5 Abilify Clozaril FazaClo ZyPREXA ZyPREXA ZyPREXA Zydis paliperidone er oral tablet extended release 24 hour 1.5, 3, 6, 9 Invega quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 risperidone oral solution 1 /ml SEROquel RisperDAL 17
risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25 risperidone oral tablet dispersible 0.5, 1, 3, 4 risperidone oral tablet dispersible 2 ziprasidone hcl oral capsule 20, 40, 60, 80 CLOZARIL ORAL TABLET 100 MG, 25 MG FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG RisperDAL RisperDAL M-TAB RisperiDONE M-TAB Geodon Clozaril FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG FazaClo GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG INVEGA ORAL TABLET EXTENDED RELEASE 24 HOUR 1.5 MG, 3 MG, 6 MG, 9 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG Geodon Invega 18
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG RISPERDAL M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 3 MG, 4 MG RisperDAL M-TAB RISPERDAL M-TAB ORAL TABLET DISPERSIBLE 2 MG RISPERDAL ORAL SOLUTION 1 MG/ML RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG RisperiDONE M-TAB RisperDAL RisperDAL RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 3 MG, 4 MG RisperDAL M-TAB RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 2 MG SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG VERSACLOZ ORAL SUSPENSION 50 MG/ML ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTED 10 MG ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 MG ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 20 MG, 5 MG RisperiDONE M-TAB SEROquel ZyPREXA ZyPREXA ZyPREXA Zydis 19
Antipsychotics,Dopamine Antagonists, Thioxanthenes thiothixene oral capsule 1, 10, 2, 5 Antipsychotics,Dopamine Antagonists,Butyrophenones haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/ML HALDOL INJECTION SOLUTION 5 MG/ML Antipsychotics,Dopamine Antagonst,Dihydroindolones molindone hcl oral tablet 10, 25, 5 Anti-Psychotics,Phenothiazines chlorpromazine hcl injection solution 25 /ml, 50 /2ml chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml Haldol Decanoate Haldol Haldol Decanoate Haldol 20
fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 Barbiturates phenobarbital oral elixir 20 /5ml phenobarbital oral solution 20 /5ml phenobarbital oral tablet 100, 15, 30, 32.4, 60, 64.8, 97.2 Monoamine Oxidase(Mao) Inhibitors EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR Narcotic Antagonists naloxone hcl injection solution 0.4 /ml, 4 /10ml naloxone hcl injection solution cartridge 0.4 /ml naloxone hcl injection solution prefilled syringe 2 /2ml naltrexone hcl oral tablet 50 EVZIO INJECTION SOLUTION AUTO- INJECTOR 0.4 MG/0.4ML NARCAN NASAL LIQUID 4 MG/0.1ML REVIA ORAL TABLET 50 MG Sedative-Hypnotics,Non- Barbiturate flurazepam hcl oral capsule 15, 30 Age (Max 65 Years) 21
temazepam oral capsule 15, 30, 7.5 triazolam oral tablet 0.125 Restoril QL (14 EA per 30 days) triazolam oral tablet 0.25 Halcion QL (14 EA per 30 days) zaleplon oral capsule 10, 5 Sonata zolpidem tartrate oral tablet 10, 5 Ambien Selective Serotonin 5-Ht2a Inverse Agonists (Ssia) NUPLAZID ORAL TABLET 17 MG Ssri &Antipsych,Atyp,Dopamine&Serot onin Antag Comb olanzapine-fluoxetine hcl oral capsule 12-25, 12-50, 3-25, 6-25, 6-50 SYMBYAX ORAL CAPSULE 12-25 MG, 12-50 MG, 3-25 MG, 6-25 MG, 6-50 MG Tx For Attention Deficit- Hyperact(Adhd)/Narcolepsy methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er oral tablet extended release 10 Symbyax Symbyax ST (Requires use of zolpidemwithin the last 90 days) Age (Min 6 Years and Max 18 Years) ST (Trial of Dextroamphetamine Sulfate, Dextroamphetamine/a mphetamine, Methylphenidate); QL (30 EA per 30 days); Age (Min 6 Years and Max 18 Years) 22
methylphenidate hcl er oral tablet extended release 18, 27, 36, 54 methylphenidate hcl er oral tablet extended release 20 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36, 54 methylphenidate hcl oral tablet 10, 20, 5 METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG Concerta Metadate ER Ritalin Metadate ER ST (Trial of Dextroamphetamine Sulfate, Dextroamphetamine/a mphetamine, Methylphenidate in the last 120 days); QL (30 EA per 30 days); Age (Min 6 Years and Max 18 Years) ST (Trial of Dextroamphetamine Sulfate, Dextroamphetamine/a mphetamine, Methylphenidate); QL (30 EA per 30 days); Age (Min 6 Years and Max 18 Years) ST (Trial of Dextroamphetamine Sulfate, Dextroamphetamine/a mphetamine, Methylphenidate in the last 120 days); QL (30 EA per 30 days); Age (Min 6 Years and Max 18 Years) Age (Min 6 Years and Max 18 Years) ST (Trial of Dextroamphetamine Sulfate, Dextroamphetamine/a mphetamine, Methylphenidate); QL (30 EA per 30 days); Age (Min 6 Years and Max 18 Years) 23
Tx For Attention Deficit- Hyperact.(Adhd), Nri-Type STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG, 60 MG Cardiovascular Disease - Arrhythmia Antiarrhythmics PA amiodarone hcl oral tablet 200 Pacerone disopyramide phosphate oral capsule 100 flecainide acetate oral tablet 100, 150, 50 mexiletine hcl oral capsule 150, 200, 250 propafenone hcl oral tablet 150, 225, 300 quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 Norpace PACERONE ORAL TABLET 200 MG Pacerone Cardiovascular Disease - Cardiac Stimulant Digitalis Glycosides digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg Digitek DIGITEK ORAL TABLET 125 MCG, 250 MCG Digitek DIGOX ORAL TABLET 125 MCG, 250 MCG Digitek LANOXIN ORAL TABLET 125 MCG, 250 MCG Digitek 24
Cardiovascular Disease - Hypertension Ace Inhibitor/Calcium Channel Blocker Combination amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 amlodipine besy-benazepril hcl oral capsule 2.5-10, 5-40 Ace Inhibitor/Thiazide & Thiazide- Like Diuretic benazepril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 benazepril-hydrochlorothiazide oral tablet 5-6.25 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, 50-25 lisinopril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 Alpha/Beta-Adrenergic Blocking Agents carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl oral tablet 100, 200, 300 Alpha-Adrenergic Blocking Agents doxazosin mesylate oral tablet 1, 2, 4, 8 phenoxybenzamine hcl oral capsule 10 Lotrel Lotensin HCT Zestoretic Coreg Cardura Dibenzyline prazosin hcl oral capsule 1, 2, 5 Minipress terazosin hcl oral capsule 1, 10, 2, 5 QL (30 EA per 30 days); Age (Min 18 Years) QL (30 EA per 30 days); Age (Min 18 Years) 25
Angiotensin Receptor Antag./Thiazide Diuretic Comb losartan potassium-hctz oral tablet 100-12.5, 100-25, 50-12.5 valsartan-hydrochlorothiazide oral tablet 160-12.5, 80-12.5 valsartan-hydrochlorothiazide oral tablet 160-25, 320-12.5, 320-25 Antihypertensives, Ace Inhibitors benazepril hcl oral tablet 10, 20, 40 Hyzaar Diovan HCT Diovan HCT Lotensin benazepril hcl oral tablet 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 fosinopril sodium oral tablet 10, 20, 40 Vasotec lisinopril oral tablet 10, 20, 5 Prinivil lisinopril oral tablet 2.5, 30, 40 Zestril moexipril hcl oral tablet 15, 7.5 quinapril hcl oral tablet 10, 20, 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 Accupril Altace trandolapril oral tablet 1, 2 trandolapril oral tablet 4 Mavik Antihypertensives, Angiotensin Receptor Antagonist losartan potassium oral tablet 100, 25, 50 Cozaar ST (Required use of losartan or losartan HCT in the last 90 days.) ST (REQUIRES A TRIAL ON ACE INHIBITOR AND LOSARTAN) Age (Min 55 Years) 26
valsartan oral tablet 160, 320, 40, 80 Antihypertensives, Sympatholytic clonidine hcl oral tablet 0.1, 0.2, 0.3 Diovan Catapres guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 reserpine oral tablet 0.1, 0.25 Antihypertensives, Vasodilators hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 Beta-Adrenergic Blocking Agents/Thiazide & Related atenolol-chlorthalidone oral tablet 100-25 atenolol-chlorthalidone oral tablet 50-25 bisoprolol-hydrochlorothiazide oral tablet 10-6.25, 2.5-6.25, 5-6.25 Beta-Adrenergic Blocking Agents Tenoretic 100 Tenoretic 50 Ziac atenolol oral tablet 100, 25, 50 Tenormin bisoprolol fumarate oral tablet 10, 5 metoprolol succinate er oral tablet extended release 24 hour 100, 25, 50 metoprolol succinate er oral tablet extended release 24 hour 200 metoprolol tartrate oral tablet 100, 50 Toprol XL Toprol XL Lopressor metoprolol tartrate oral tablet 25 nadolol oral tablet 20, 40, 80 Corgard ST (REQUIRES A TRIAL ON ACE INHIBITOR AND LOSARTAN) QL (30 EA per 30 days) QL (60 EA per 30 days) 27
pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 80 Inderal LA Betapace AF Betapace sotalol hcl oral tablet 240 Sorine SORINE ORAL TABLET 120 MG, 160 MG, 80 MG Betapace SORINE ORAL TABLET 240 MG Sorine Calcium Channel Blocking Agents amlodipine besylate oral tablet 10, 2.5, 5 diltiazem cd oral capsule extended release 24 hour 120, 180, 240 diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 360 diltiazem hcl er coated beads oral capsule extended release 24 hour 300 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 120, 180, 240 diltiazem hcl oral tablet 120, 30, 60 Norvasc Cardizem CD Taztia XT Cardizem CD Cartia XT Cardizem diltiazem hcl oral tablet 90 28
dilt-xr oral capsule extended release 24 hour 120, 180, 240 felodipine er oral tablet extended release 24 hour 10, 2.5, 5 nicardipine hcl oral capsule 20, 30 nifedipine er oral tablet extended release 24 hour 30, 60, 90 nifedipine er osmotic release oral tablet extended release 24 hour 30, 90 nifedipine er osmotic release oral tablet extended release 24 hour 60 Adalat CC Procardia XL Nifedical XL nifedipine oral capsule 10 Procardia nifedipine oral capsule 20 nisoldipine er oral tablet extended release 24 hour 20, 30, 40 verapamil hcl er oral tablet extended release 120, 180, 240 Calan SR verapamil hcl oral tablet 120, 80 Calan verapamil hcl oral tablet 40 AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG Adalat CC Cardizem CD Cardizem CD Cartia XT Procardia XL Nifedical XL Taztia XT 29
Loop Diuretics bumetanide oral tablet 0.5, 1, 2 furosemide oral solution 10 /ml, 8 /ml furosemide oral tablet 20, 40, 80 Potassium Sparing Diuretics In Combination amiloride-hydrochlorothiazide oral tablet 5-50 Bumex Lasix spironolactone-hctz oral tablet 25-25 Aldactazide triamterene-hctz oral capsule 37.5-25 Dyazide triamterene-hctz oral capsule 50-25 triamterene-hctz oral tablet 37.5-25 Maxzide-25 triamterene-hctz oral tablet 75-50 Maxzide Potassium Sparing Diuretics amiloride hcl oral tablet 5 spironolactone oral tablet 100, 25, 50 Thiazide And Related Diuretics Aldactone chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 25, 50 hydrochlorothiazide oral capsule 12.5 Microzide hydrochlorothiazide oral tablet 25, 50 indapamide oral tablet 1.25, 2.5 methyclothiazide oral tablet 5 metolazone oral tablet 10, 2.5, 5 DIURIL ORAL SUSPENSION 250 MG/5ML 30
Cardiovascular Disease - Lipid Irregularity Antihyperlipidemic - H Coa Reductase Inhibitors atorvastatin calcium oral tablet 10, 20, 40, 80 lovastatin oral tablet 10, 20 Lipitor QL (30 EA per 30 days) QL (30 EA per 30 days) lovastatin oral tablet 40 Mevacor QL (30 EA per 30 days) simvastatin oral tablet 10, 20, 40, 5 Bile Salt Sequestrants cholestyramine light oral powder 4 gm/dose Zocor Prevalite cholestyramine oral powder 4 gm/dose Questran colestipol hcl oral granules 5 gm Colestid colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid COLESTID FLAVORED ORAL PACKET 5 GM Colestid PREVALITE ORAL POWDER 4 GM/DOSE Prevalite Lipotropics fenofibrate micronized oral capsule 134, 67 fenofibrate micronized oral capsule 200 Lofibra fenofibrate oral tablet 160 Triglide fenofibrate oral tablet 54 Lofibra gemfibrozil oral tablet 600 Lopid ST (Requires use of a statin for 60 days in the last 120 days) ST (Requires use of a statin for 60 days in the last 120 days) ST (Requires use of a statin for 60 days in the last 120 days) ST (Requires use of a statin for 60 days in the last 120 days) 31
omega-3-acid ethyl esters oral capsule 1 gm Lovaza PA TRIGLIDE ORAL TABLET 160 MG Triglide ZETIA ORAL TABLET 10 MG Niacin Preparations niacin er oral capsule extended release 250, 500 niacin er oral tablet extended release 1000 niacin er oral tablet extended release 250, 500 niacin er oral tablet extended release 750 niacin oral tablet 100, 250, 50, 500 Cardiovascular Disease - Vasodilation Vasodilators,Coronary isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 PA Endur-Acin Slo-Niacin isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 nitroglycerin er oral capsule extended release 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 Nitro-Time Nitrostat ST (Requires use of a statin for 60 days in the last 120 days) 32
nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual solution 0.4 /spray MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG Contraception/Oxytocics Contraceptives, Intravaginal, Systemic NUVARING VAGINAL RING 0.12-0.015 MG/24HR Contraceptives,Injectable medroxyprogesterone acetate intramuscular suspension 150 /ml Minitran Nitrolingual Minitran Nitro-Time Depo-Provera medroxyprogesterone acetate intramuscular suspension prefilled syringe Depo-Provera 150 /ml Contraceptives,Intravaginal VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM 12.5 % Contraceptives,Oral desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 (21/5) desogestrel-ethinyl estradiol oral tablet 0.15-30 -mcg ST (Requires trial of oralcontraceptives in past 90 days); QL (1 EA per 28 days) QL (1 ML per 63 days) QL (1 ML per 68 days) Azurette Apri 33
levonorgestrel oral tablet 1.5 Aftera QL (1 EA per 1 FILL) levonorgestrel-ethinyl estrad oral tablet 0.1-20 -mcg levonorgestrel-ethinyl estrad oral tablet 0.15-30 -mcg Aubra Altavera levonorg-eth estrad triphasic oral tablet Enpresse-28 norethin ace-eth estrad-fe oral tablet 1-20 -mcg norethindrone acet-ethinyl est oral tablet 1-20 -mcg Blisovi FE 1/20 Junel 1/20 norethindrone oral tablet 0.35 Camila norgestimate-eth estradiol oral tablet 0.25-35 -mcg norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25-35 mcg AZURETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) BREVICON (28) ORAL TABLET 0.5-35 MG- MCG Estarylla Ortho Tri-Cyclen (28) Azurette ERRIN ORAL TABLET 0.35 MG Camila JOLIVETTE ORAL TABLET 0.35 MG Camila KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) LEENA ORAL TABLET 0.5/1/0.5-35 MG- MCG LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG Azurette Altavera Blisovi FE 1/20 34
NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG NECON 1/35 (28) ORAL TABLET 1-35 MG- MCG NECON 1/50 (28) ORAL TABLET 1-50 MG- MCG NECON 10/11 (28) ORAL TABLET 35 MCG NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG NORA-BE ORAL TABLET 0.35 MG Camila NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG OGESTREL ORAL TABLET 0.5-50 MG-MCG ZENCHENT ORAL TABLET 0.4-35 MG-MCG ZOVIA 1/35E (28) ORAL TABLET 1-35 MG- MCG ZOVIA 1/50E (28) ORAL TABLET 1-50 MG- MCG Contraceptives,Transdermal XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR Diaphragms/Cervical Cap CAYA VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 % QL (3 EA per 28 days) 35
WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 % Oxytocics methylergonovine maleate oral tablet 0.2 Cough And Cold 1St Gen Antihistamine & Decongestant Combinations promethazine vc plain oral syrup 6.25-5 /5ml promethazine-phenylephrine oral syrup 6.25-5 /5ml Methergine rynex pse oral liquid 1-15 /5ml Brotapp APRODINE ORAL TABLET 2.5-60 MG BROTAPP ORAL LIQUID 1-15 MG/5ML Brotapp Q-TAPP ORAL ELIXIR 1-15 MG/5ML Brotapp Antitussives,Non-Narcotic benzonatate oral capsule 100 Tessalon Perles Decongestant-Expectorant Combinations pseudoephedrine-guaifenesin er oral tablet extended release 12 hour 60-600 Decongestants, Oral pseudoephedrine hcl er oral tablet extended release 12 hour 120 Mucinex D Shopko Nasal Decongestant Age (Min 2 Years) Age (Min 2 Years) 36
Expectorants guaifenesin er oral tablet extended release 12 hour 600 mucus-er oral tablet extended release 12 hour 600 Narcotic Antituss-1St Gen. Antihistamine-Decongest phenyleph-promethazine-cod oral syrup 5-6.25-10 /5ml phenylhistine dh oral liquid 30-2-10 /5ml promethazine vc/codeine oral syrup 6.25-5-10 /5ml Narcotic Antitussive-1St Generation Antihistamine promethazine-codeine oral syrup 6.25-10 /5ml Narcotic Antitussive-Expectorant Combination EQ Mucus ER EQ Mucus ER Age (Min 2 Years) Age (Min 2 Years) cheratussin ac oral syrup 100-10 /5ml guaifenesin ac oral syrup 100-10 /5ml guaifenesin-codeine oral solution 100-10 /5ml virtussin a/c oral solution 100-10 /5ml Non-Narc Antituss-1St Gen. Antihistamine-Decongest brotapp dm oral liquid 15-1-5 /5ml kidkare cough/cold oral liquid 15-1-5 /5ml pedia relief cough/cold oral liquid 15-1-5 /5ml pediatric cough/cold oral liquid 15-1-5 /5ml QL (LIMIT 240ML (8OZ) PER 30 DAYS); QL (240 ML per 30 days); Age (Min 2 Years) 37
Q-TAPP DM ORAL ELIXIR 15-1-5 MG/5ML Non-Narc Antitussive-1St Gen Antihistamine Comb. promethazine-dm oral syrup 6.25-15 /5ml Non-Narcotic Antitussive And Expectorant Comb. dextromethorphan-guaifenesin oral syrup 10-100 /5ml Robafen DM Cough Clear guaifenesin-dm oral syrup 100-10 /5ml Robafen DM Cough Clear mucus-dm oral tablet extended release 12 hour 30-600 Nose Preparations, Vasoconstrictors(Otc) Mucinex DM Age (Min 2 Years) anefrin spray nasal solution 0.05 % Afrin 12 Hour PA anefrin spray/moisturizing nasal solution 0.05 % Afrin 12 Hour PA ephrine nose drops nasal solution 1 % 4-Way Fast Acting LITTLE NOSES DECONGESTANT NASAL SOLUTION 0.125 % NEO-SYNEPHRINE COLD & SINUS NASAL SOLUTION 0.25 %, 0.5 % NEO-SYNEPHRINE NASAL SOLUTION 0.25 %, 0.5 % VICKS SINEX 12 HOUR DECONGEST NASAL SOLUTION 0.05 % Sympathomimetic Agents pseudoephedrine hcl oral tablet 30 ZEPHREX-D ORAL TABLET ABUSE- DETERRENT 30 MG Dermatology - Acne Rosacea Agents, Topical Afrin 12 Hour Shopko Nasal Decongestant Max PA metronidazole external cream 0.75 % MetroCream 38
metronidazole external gel 0.75 % Rosadan metronidazole external gel 1 % Metrogel Topical Preparations,Antibacterials chlorhexidine gluconate external liquid 4 % Vitamin A Derivatives DIFFERIN EXTERNAL GEL 0.1 % Dermatology - Antiinfective Topical Antibiotics bacitracin zinc external ointment 500 unit/gm bacitracin-neomycin-polymyxin external ointment 400-5-5000 benzoyl peroxide-erythromycin external gel 5-3 % Betasept Surgical Scrub Age (Max 25 Years) Lanabiotic Benzamycin clindamycin phosphate external gel 1 % Cleocin-T clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % Cleocin-T Cleocin-T clindamycin phosphate external swab 1 % Cleocin-T double antibiotic external ointment 500-10000 unit/gm Polysporin ery external pad 2 % erythromycin external pad 2 % erythromycin external solution 2 % gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % ST (Requiring a prior trial in the last 120 days of either: adapalene, erythromycin topical, clindamycin topical, or benzoyl peroxide gel/cream/lotion) 39
medi-first triple antibiotic external ointment 5-400-5000 -unit Lanabiotic mupirocin calcium external cream 2 % Bactroban PA mupirocin external ointment 2 % Centany triple antibiotic external ointment 3.5-400-5000 Topical Antifungals ciclopirox external gel 0.77 % Lanabiotic PA ciclopirox external shampoo 1 % Loprox PA ciclopirox olamine external cream 0.77 % Ciclodan PA ciclopirox olamine external suspension 0.77 % Loprox PA clotrimazole external cream 1 % Clotrimazole GRx clotrimazole external solution 1 % FungiCure Intensive/NailGuard ketoconazole external cream 2 % ketoconazole external shampoo 2 % Nizoral miconazole nitrate external aerosol powder 2 % Cruex Prescription Strength miconazole nitrate external cream 2 % Carrington Antifungal nystatin external cream 100000 unit/gm nystatin external ointment 100000 unit/gm terbinafine hcl external cream 1 % LamISIL AT tolnaftate external cream 1 % Fungoid-D tolnaftate external solution 1 % Blis-To-Sol LAMISIL AT SPRAY EXTERNAL SOLUTION 1 % LOTRIMIN AF EXTERNAL AEROSOL 2 % MICATIN EXTERNAL CREAM 2 % Carrington Antifungal Topical Antiparasitics complete lice treatment combination kit 0.33-4-0.5 % CVS Lice Solution 40 QL (22 GM per 30 days)
lice killing maximum strength external shampoo 0.33-4 % Licide lice solution combination kit 0.33-4-0.5 % CVS Lice Solution lice treatment external liquid 1 % Nix Creme Rinse lice treatment external lotion 1 % permethrin external cream 5 % Elimite stop lice complete treatment combination kit 0.33-4-0.5 % stop lice maximum strength external shampoo 0.33-4 % RID COMPLETE LICE ELIMINATION COMBINATION KIT RID ESSENTIAL LICE ELIMINATION EXTERNAL KIT 0.33-4 % CVS Lice Solution Licide CVS Lice Solution RID EXTERNAL LIQUID 0.33-4 % RID LICE KILLING SHAMPOO EXTERNAL SHAMPOO 0.33-4 % Topical Sulfonamides Licide silver sulfadiazine external cream 1 % Silvadene SSD EXTERNAL CREAM 1 % Silvadene Dermatology - Antiinflammatory Topical Antibiotics/Antiinflammatory,Ster oidal CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5 CORTISPORIN EXTERNAL OINTMENT 1 % Topical Anti-Inflammatory Steroidal ala-cort external cream 1 % Aveeno Anti-Itch Max St betamethasone dipropionate aug external cream 0.05 % Diprolene AF ST (Requires use of triamcinolone or hydrocortisone within the last 60 days) 41
betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % clobetasol propionate external cream 0.05 % Temovate clobetasol propionate external gel 0.05 % Temovate clobetasol propionate external ointment 0.05 % clobetasol propionate external solution 0.05 % Temovate Cormax Scalp Application desonide external cream 0.05 % DesOwen desonide external lotion 0.05 % DesOwen ST (Requires use of triamcinolone or hydrocortisone within the last 60 days.) ST (Requires use of triamcinolone or hydrocortisone within the last 60 days.) ST (Requires use of hydrocortisone within the last 60 days) ST (Requires use of hydrocortisone within the last 60 days) ST (Requires use of hydrocortisone within the last 60 days) ST (Requires use of hydrocortisone within the last 60 days) ST (Requires use of triamcinolone or hydrocortisone within the last 60 days) ST (Requires use of triamcinolone or hydrocortisone within the last 60 days) 42
desonide external ointment 0.05 % fluocinolone acetonide external cream 0.01 % fluocinolone acetonide external cream 0.025 % fluocinolone acetonide external ointment 0.025 % fluocinolone acetonide external solution 0.01 % Synalar Synalar Synalar fluocinonide external cream 0.05 % fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % hydrocortisone external cream 0.5 %, 2.5 % hydrocortisone external cream 1 % Aveeno Anti-Itch Max St hydrocortisone external lotion 1 % Anti-Itch Intensive Healing hydrocortisone external lotion 2.5 % hydrocortisone external ointment 0.5 %, 2.5 % hydrocortisone external ointment 1 % Cortizone-10 hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % Westcort ST (Requires use of triamcinolone or hydrocortisone within the last 60 days) ST (Requires use of triamcinolone or hydrocortisone within the last 60 days) ST (Requires use of triamcinolone or hydrocortisone within the last 60 days) ST (Requires use of triamcinolone or hydrocortisone within the last 60 days) ST (Requires use of triamcinolone or hydrocortisone within the last 60 days) 43
hydrocortisone-aloe external cream 0.5 % hydrocortisone-aloe external cream 1 % mometasone furoate external cream 0.1 % mometasone furoate external ointment 0.1 % Cortizone-10 Intensive Healing Elocon Elocon prednicarbate external cream 0.1 % prednicarbate external ointment 0.1 % Dermatop triamcinolone acetonide external aerosol solution 0.147 /gm triamcinolone acetonide external cream 0.025 % triamcinolone acetonide external cream 0.1 %, 0.5 % triamcinolone acetonide external lotion 0.025 %, 0.1 % triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % Dermatology - Antipruritic Drugs Antipruritics,Topical Kenalog Triderm calahist external lotion 1-8 % Caladryl calamine medicated external lotion 1-8 % Caladryl CALADRYL EXTERNAL LOTION 1-8 % Caladryl Dermatology - Miscellaneous Antiperspirants DRYSOL EXTERNAL SOLUTION 20 % Antiseborrheic Agents selenium sulfide external lotion 2.5 % SELSUN BLUE DAILY EXTERNAL LOTION 1 % SELSUN BLUE MEDICATED EXTERNAL LOTION 1 % 44
SELSUN BLUE MOISTURIZING EXTERNAL LOTION 1 % Emollients ammonium lactate external cream 12 % Geri-Hydrolac 12 ammonium lactate external lotion 12 % AL12 AMLACTIN EXTERNAL LOTION 12 % AL12 Irrigants sodium chloride irrigation solution 0.9 % Keratolytics benzoyl peroxide external gel 10 % Argyle Sterile Saline Clean & Clear Persa-Gel Max St Medical Benefit (Tier 3) benzoyl peroxide external gel 2.5 %, 5 % benzoyl peroxide wash external liquid 10 % Desquam-X Wash benzoyl peroxide wash external liquid 5 % Benzac AC Wash podofilox external solution 0.5 % Topical Anti-Inflammatory Steroid- Local Anesthetic EPIFOAM EXTERNAL FOAM 1-1 % Topical/Mucous Membr./Subcut. Enzymes SANTYL EXTERNAL OINTMENT 250 UNIT/GM Dermatology - Psoriasis/Eczema Antipsoriatics Agents DRITHO-CREME HP EXTERNAL CREAM 1 % Topical Immunosuppressive Agents tacrolimus external ointment 0.03 %, 0.1 % ELIDEL EXTERNAL CREAM 1 % Protopic PA PA QL (60 GM per 30 days) 45
Diabetes Antihypergly, (Dpp-4) Inhibitor & Biguanide Comb. alogliptin-metformin hcl oral tablet 12.5-1000, 12.5-500 Antihypergly,Dpp-4 Enzyme Inhib &Thiazolidinedione alogliptin-pioglitazone oral tablet 12.5-15, 12.5-30, 12.5-45, 25-15, 25-30, 25-45 Antihyperglycemic, Dpp-4 Inhibitors alogliptin benzoate oral tablet 12.5, 25, 6.25 Antihyperglycemic, Insulin-Release Stimulant Type Kazano Oseni Nesina PA PA PA glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glipizide oral tablet 10, 5 Glucotrol glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glyburide oral tablet 1.25, 2.5, 5 Glucotrol XL nateglinide oral tablet 120, 60 Starlix tolbutamide oral tablet 500 Antihyperglycemic, Insulin- Response Enhancer (N-S) pioglitazone hcl oral tablet 15, 30, 45 Actos 46 ST (Requires use of Metformin or a Sulfonylurea within last 90 days) ST (Requires concomitant use of Sulfonylurea or Metformin)
AVANDIA ORAL TABLET 2 MG, 4 MG Antihyperglycemic,Biguanide Type(Non-Sulfonylurea) metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 Antihyperglycemic,Insulin-Rel Stim.& Biguanide Cmb glyburide-metformin oral tablet 1.25-250 glyburide-metformin oral tablet 2.5-500, 5-500 Blood Sugar Diagnostics FREESTYLE INSULINX TEST IN VITRO STRIP Glucophage XR Glucophage QL (60 EA per 30 days) Glucovance FREESTYLE LITE TEST IN VITRO STRIP FREESTYLE TEST IN VITRO STRIP Hyperglycemics GLUCAGON EMERGENCY INJECTION KIT 1 MG Insulins BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML PA PA QL (LIMIT OF 100 PER 30 DAYS); QL (100 EA per 30 days) QL (LIMIT OF 100 PER 30 DAYS); QL (100 EA per 23 days) QL (LIMIT OF 100 PER 30 DAYS); QL (100 EA per 30 days) 47
HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML Urine Glucose Test Aids PA PA DIASTIX IN VITRO STRIP 48
Ear - General Disorders Ear Preparations, Misc. Anti- Infectives acetic acid otic solution 2 % hydrocortisone-acetic acid otic solution 1-2 % Acetasol HC ACETASOL HC OTIC SOLUTION 2-1 % Acetasol HC Ear Preparations,Antibiotics neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 ofloxacin otic solution 0.3 % Floxin Otic Ear Preparations,Ear Wax Removers carbamoxide ear drops otic solution 6.5 % Debrox ear drops earwax aid otic solution 6.5 % Debrox ear drops otic solution 6.5 % Debrox ear wax removal drops otic solution 6.5 % Debrox ear wax removal kit otic solution 6.5 % Debrox earwax treatment drops otic solution 6.5 % Debrox DEBROX OTIC SOLUTION 6.5 % Debrox MURINE EAR OTIC SOLUTION 6.5 % Debrox MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % Electrolyte Regulation Electrolyte Depleters calcium acetate (phos binder) oral capsule 667 Debrox PhosLo QL (1 FILLS IN 30 DAYS); QL (5 ML per 30 days) QL (270 EA per 30 days); Age (Min 21 Years) 49
calcium acetate (phos binder) oral tablet 667 Calphron calcium acetate oral capsule 667 PhosLo sodium polystyrene sulfonate oral suspension 15 gm/60ml Kionex ELIPHOS ORAL TABLET 667 MG Calphron FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG PA KIONEX ORAL SUSPENSION 15 GM/60ML Kionex SPS ORAL SUSPENSION 15 GM/60ML Kionex Electrolyte Maintenance h-e-b oral electrolyte oral solution pediatric electrolyte-zinc oral solution ringers intravenous solution ORALYTE ORAL SOLUTION Potassium Replacement effervescent pot chloride oral tablet effervescent 25 meq k-effervescent oral tablet effervescent 25 meq Advantage Care Electrolyte Ped Advantage Care Electrolyte Ped Advantage Care Electrolyte Ped PA Effer-K 50 QL (270 EA per 30 days); Age (Min 21 Years) QL (270 EA per 30 days); Age (Min 21 Years) QL (240 ML per 30 days) QL (270 EA per 30 days); Age (Min 21 Years) QL (240 ML per 30 days) QL (240 ML per 30 days) QL (LIMIT OF 2 FILLS OF 2 LITERS PER MONTH); QL (2000 ML per 1 FILL); Age (Max 3 Years) QL (2 PER MONTH); QL (2000 ML per 1 FILL); Age (Max 3 Years) QL (LIMIT OF 2 FILLS OF 2 LITERS PER MONTH); QL (2000 ML per 1 FILL); Age (Max 3 Years)
k-vescent oral tablet effervescent 25 meq Effer-K potassium chloride crys er oral tablet extended release 10 meq potassium chloride crys er oral tablet extended release 20 meq potassium chloride er oral capsule extended release 10 meq potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq potassium chloride in nacl intravenous solution 10-0.9 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-% potassium chloride oral solution 20 meq/15ml (10%) potassium gluconate oral tablet 595 (99 k) Klor-Con M10 Klor-Con M20 Klor-Con Sprinkle K-Tab PA potassium oral tablet 99 EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ KLOR-CON M10 ORAL TABLET EXTENDED RELEASE 10 MEQ KLOR-CON M20 ORAL TABLET EXTENDED RELEASE 20 MEQ KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 10 MEQ Sodium/Saline Preparations sodium chloride intravenous solution 0.9 % Endocrine Disorder - Other Antidiuretic And Vasopressor Hormones desmopressin ace rhinal tube nasal solution 0.01 % desmopressin ace spray refrig nasal solution 0.01 % Effer-K Klor-Con M10 Klor-Con M20 Klor-Con Sprinkle PA DDAVP Rhinal Tube Age (Min 8 Years and Max 14 Years) PA; Age (Min 8 Years and Max 14 Years) 51
desmopressin acetate injection solution 4 mcg/ml desmopressin acetate oral tablet 0.1, 0.2 desmopressin acetate spray nasal solution 0.01 % Antineoplastic Lhrh(Gnrh) Agonist,Pituitary Suppr. leuprolide acetate injection kit 1 /0.2ml Bone Resorption Inhibitor & Vitamin D Combinations FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT Bone Resorption Inhibitors alendronate sodium oral tablet 10, 40 DDAVP DDAVP DDAVP PA PA PA alendronate sodium oral tablet 35 alendronate sodium oral tablet 5 alendronate sodium oral tablet 70 Fosamax calcitonin (salmon) nasal solution 200 unit/act Calcimimetic,Parathyroid Calcium Enhancer SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG Lhrh(Gnrh) Agonist Analog Pituitary Suppressants SYNAREL NASAL SOLUTION 2 MG/ML Lhrh(Gnrh)Agnst Pit.Sup-Central Precocious Puberty LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 15 MG Miacalcin PA; Age (Min 8 Years and Max 14 Years) Age (Min 8 Years and Max 14 Years) PA; Age (Min 8 Years and Max 14 Years) Age (Min 65 Years) PA PA PA PA 52
Pituitary Suppressive Agents danazol oral capsule 100, 200, 50 Endocrine Disorder - Thyroid Antithyroid Preparations methimazole oral tablet 10, 5 Tapazole propylthiouracil oral tablet 50 Thyroid Hormones levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg np thyroid oral tablet 30, 60, 90 ARMOUR THYROID ORAL TABLET 120 MG, 15 MG ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG Levo-T Armour Thyroid ARMOUR THYROID ORAL TABLET 30 MG Armour Thyroid ARMOUR THYROID ORAL TABLET 60 MG, 90 MG LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG Armour Thyroid Levo-T Levo-T Levo-T 53
UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG Eye - General Disorders Eye Antibiotic-Corticoid Combinations bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % NEO-POLYCIN HC OPHTHALMIC OINTMENT 1 % TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % Eye Antihistamines ketotifen fumarate ophthalmic solution 0.025 % ALAWAY OPHTHALMIC SOLUTION 0.025 % Eye Antiinflammatory Agents dexamethasone sodium phosphate ophthalmic solution 0.1 % diclofenac sodium ophthalmic solution 0.1 % fluorometholone ophthalmic suspension 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % Levo-T Neo-Polycin HC Maxitrol Maxitrol TobraDex Neo-Polycin HC Alaway Alaway FML Liquifilm 54
ketorolac tromethamine ophthalmic solution 0.5 % prednisolone acetate ophthalmic suspension 1 % prednisolone sodium phosphate ophthalmic solution 1 % FML FORTE OPHTHALMIC SUSPENSION 0.25 % Acular Omnipred FML OPHTHALMIC OINTMENT 0.1 % PRED MILD OPHTHALMIC SUSPENSION 0.12 % Eye Antivirals trifluridine ophthalmic solution 1 % Viroptic Eye Local Anesthetics proparacaine hcl ophthalmic solution 0.5 % Eye Sulfonamides sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % sulfacetamide-prednisolone ophthalmic solution 10-0.23 % Alcaine PA Bleph-10 BLEPH-10 OPHTHALMIC SOLUTION 10 % Bleph-10 BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % Eye Vasoconstrictors (Rx Only) phenylephrine hcl ophthalmic solution 10 %, 2.5 % Ophthalmic Antibiotics bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm Altafrin Polycin 55
ciprofloxacin hcl ophthalmic solution 0.3 % erythromycin ophthalmic ointment 5 /gm gentamicin sulfate ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic solution 0.3 % neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000 neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025 Ciloxan Gentak Neo-Polycin Neosporin ofloxacin ophthalmic solution 0.3 % Ocuflox polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-% Polytrim tobramycin ophthalmic solution 0.3 % Tobrex CILOXAN OPHTHALMIC OINTMENT 0.3 % GENTAK OPHTHALMIC OINTMENT 0.3 % Gentak NEO-POLYCIN OPHTHALMIC OINTMENT 3.5-400-10000 POLYCIN OPHTHALMIC OINTMENT 500-10000 UNIT/GM Neo-Polycin Polycin TOBREX OPHTHALMIC OINTMENT 0.3 % Ophthalmic Mast Cell Stabilizers cromolyn sodium ophthalmic solution 4 % ALOMIDE OPHTHALMIC SOLUTION 0.1 % Ophthalmic Preparations, Miscellaneous sochlor ophthalmic solution 5 % Altachlore sodium chloride (hypertonic) ophthalmic solution 5 % Altachlore MURO 128 OPHTHALMIC SOLUTION 2 % MURO 128 OPHTHALMIC SOLUTION 5 % Altachlore 56
Eye - Glaucoma Carbonic Anhydrase Inhibitors acetazolamide oral tablet 125, 250 methazolamide oral tablet 25 Neptazane methazolamide oral tablet 50 Miotics/Other Intraoc. Pressure Reducers apraclonidine hcl ophthalmic solution 0.5 % Iopidine betaxolol hcl ophthalmic solution 0.5 % brimonidine tartrate ophthalmic solution 0.2 % dorzolamide hcl ophthalmic solution 2 % Trusopt dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 /ml Cosopt latanoprost ophthalmic solution 0.005 % Xalatan levobunolol hcl ophthalmic solution 0.5 % Betagan pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 %, 0.5 % ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % Isopto Carpine Timoptic-XE Timoptic QL (10 ML per 30 days) IOPIDINE OPHTHALMIC SOLUTION 1 % PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 % QL (1 FILLS IN 23 DAYS); QL (1 BOX per 30 days) 57
Mydriatics atropine sulfate ophthalmic ointment 1 % atropine sulfate ophthalmic solution 1 % cyclopentolate hcl ophthalmic solution 0.5 %, 2 % cyclopentolate hcl ophthalmic solution 1 % Cyclogyl Cyclogyl homatropine hbr ophthalmic solution 5 % Homatropaire HOMATROPAIRE OPHTHALMIC SOLUTION 5 % Fluid Replacement Iv Solutions: Dextrose And Lactated Ringers dextrose in lactated ringers intravenous solution 5 % Iv Solutions: Dextrose-Saline dextrose-nacl intravenous solution 10-0.45 %, 5-0.45 % Iv Solutions: Dextrose-Water dextrose intravenous solution 10 %, 5 % Gout And Related Diseases Colchicine Homatropaire PA PA PA colchicine oral tablet 0.6 Colcrys colchicine-probenecid oral tablet 0.5-500 Hyperuricemia Tx - Purine Inhibitors allopurinol oral tablet 100, 300 Zyloprim Uricosuric Agents probenecid oral tablet 500 QL (LIMIT 90 TAB PER 30 DAYS) 58
Hematological Disorders Anticoagulants,Coumarin Type warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG Antihemophilic Factors adynovate intravenous solution reconstituted 1000 unit, 2000 unit, 250 unit, 500 unit obizur intravenous solution reconstituted 500 unit ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT AFSTYLA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT, 750 UNIT FEIBA INTRAVENOUS SOLUTION RECONSTITUTED HELIXATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT Coumadin Coumadin Coumadin 59
HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1501-2000 UNIT, 1700 UNIT, 220-400 UNIT, 250 UNIT, 500 UNIT, 801-1500 UNIT HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT KOGENATE FS BIO-SET INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT MONOCLATE-P INTRAVENOUS KIT 1000 UNIT, 1500 UNIT NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT 60
WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 UNIT WILATE INTRAVENOUS SOLUTION RECONSTITUTED 450-450 UNIT, 900-900 UNIT XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT Blood Factors,Miscellaneous CORIFACT INTRAVENOUS KIT 1000-1600 UNIT VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 1300 UNIT, 650 UNIT Factor Ix Preparations rixubis intravenous solution reconstituted 1000 unit, 2000 unit, 250 unit, 3000 unit, 500 unit ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT BEBULIN INTRAVENOUS SOLUTION RECONSTITUTED 200-1200 UNIT BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1500 UNIT Ixinity Ixinity 61
MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT PROFILNINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT Factor X Preparations COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT Factor Xiii Preparations TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 2000-3125 UNIT Hematinics,Other EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML Hemorrheologic Agents pentoxifylline er oral tablet extended release 400 Heparin And Related Preparations enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml Platelet Aggregation Inhibitors Lovenox PA PA PA cilostazol oral tablet 100, 50 62
clopidogrel bisulfate oral tablet 75 Plavix Age (Min 18 Years) dipyridamole oral tablet 25, 50, 75 Platelet Reducing Agents anagrelide hcl oral capsule 0.5 Agrylin anagrelide hcl oral capsule 1 Sickle Cell Anemia Agents DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG Vitamin K Preparations MEPHYTON ORAL TABLET 5 MG Hormonal Deficiency Androgenic Agents testosterone transdermal gel 12.5 /act (1%) testosterone transdermal gel 50 /5gm (1%) Vogelxo Pump AndroGel PA PA ANDROXY ORAL TABLET 10 MG Estrogen/Androgen Combinations est estrogens-methyltest hs oral tablet 0.625-1.25 est estrogens-methyltest oral tablet 1.25-2.5 COVARYX HS ORAL TABLET 0.625-1.25 MG Covaryx HS PA Covaryx Covaryx HS PA COVARYX ORAL TABLET 1.25-2.5 MG Covaryx EEMT HS ORAL TABLET 0.625-1.25 MG Covaryx HS PA EEMT ORAL TABLET 1.25-2.5 MG Covaryx Estrogenic Agents estradiol oral tablet 0.5, 1, 2 Estrace estradiol transdermal patch twice weekly 0.025 /24hr, 0.05 /24hr, 0.075 /24hr, 0.1 /24hr Alora 63
estradiol transdermal patch twice weekly 0.0375 /24hr estradiol transdermal patch weekly 0.025 /24hr, 0.05 /24hr, 0.075 /24hr, 0.1 /24hr ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.0375 MG/24HR PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG Minivelle Climara Alora Alora Minivelle PREMPHASE ORAL TABLET 0.625-5 MG PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG Progestational Agents medroxyprogesterone acetate oral tablet 10, 2.5, 5 Provera norethindrone acetate oral tablet 5 Aygestin DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML MAKENA INTRAMUSCULAR OIL 250 MG/ML Immunization Antisera HYPERTET S/D INTRAMUSCULAR INJECTABLE 250 UNIT/ML NABI-HB INTRAMUSCULAR SOLUTION PA Medical Benefit (Tier 3) Medical Benefit (Tier 3) 64
Gram Negative Cocci Vaccines BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE MENACTRA INTRAMUSCULAR INJECTABLE MENOMUNE SUBCUTANEOUS INJECTABLE MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE Gram Positive Cocci Vaccines PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML PREVNAR 13 INTRAMUSCULAR SUSPENSION Influenza Virus Vaccines medical provider ez afluria pf intramuscular prefilled syringe kit 0.5 ml medical provider ez flu shot intramuscular prefilled syringe kit 0.25 ml AFLURIA INTRAMUSCULAR SUSPENSION AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML QL (2 PER LIFETIME); Age (Min 19 Years and Max 25 Years) Age (Min 19 Years) Age (Min 56 Years) QL (1 PER LIFETIME); Age (Min 19 Years and Max 55 Years) QL (3 PER LIFETIME); Age (Min 19 Years and Max 25 Years) QL (2 PER LIFETIME); Age (Min 19 Years) QL (1 PER LIFETIME); Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) 65
FLUBLOK INTRAMUSCULAR SOLUTION FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUVIRIN INTRAMUSCULAR SUSPENSION Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) FLUVIRIN INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUZONE QUADRIVALENT INTRADERMAL SUSPENSION PEN-INJECTOR 9 MCG/STRAIN FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION, 0.5 ML FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML MEDICAL PROVIDER EZ FLUVIRIN INTRAMUSCULAR PREFILLED SYRINGE KIT 0.5 ML Neurotoxic Virus Vaccines IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED Vaccine/Toxoid Preparations,Combinations tetanus-diphtheria toxoids td intramuscular suspension 2-2 lf/0.5ml Age (Min 19 Years) Age (Min 65 Years) Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) Age (Min 19 Years) Medical Benefit (Tier 3) Age (Min 19 Years) Age (Min 19 Years) 66
ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF-MCG/0.5 BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 M-M-R II SUBCUTANEOUS INJECTABLE TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU Viral/Tumorigenic Vaccines CERVARIX INTRAMUSCULAR SUSPENSION ENGERIX-B INJECTION SUSPENSION 20 MCG/ML GARDASIL 9 INTRAMUSCULAR SUSPENSION GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE GARDASIL INTRAMUSCULAR SUSPENSION HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML TWINRIX INTRAMUSCULAR SUSPENSION 720-20 VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML ZOSTAVAX SUBCUTANEOUS SOLUTION RECONSTITUTED 19400 UNT/0.65ML Age (Min 19 Years) Age (Min 19 Years) QL (2 PER LIFETIME); Age (Min 19 Years) Age (Min 19 Years) QL (3 PER LIFETIME); Age (Min 19 Years and Max 27 Years) QL (3 PER LIFETIME); Age (Min 19 Years) QL (3 PER LIFETIME); Age (Min 19 Years and Max 27 Years) QL (3 PER LIFETIME); Age (Min 19 Years and Max 27 Years) QL (3 PER LIFETIME); Age (Min 19 Years and Max 27 Years) QL (2 PER LIFETIME); Age (Min 19 Years) QL (3 PER LIFETIME); Age (Min 19 Years) QL (3 PER LIFETIME); Age (Min 19 Years) QL (2 PER LIFETIME); Age (Min 19 Years) QL (2 PER LIFETIME); Age (Min 19 Years) QL (1 PER LIFETIME); Age (Min 60 Years) 67
Immunosuppression/Modulation Immunomodulators INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT Immunosuppressives PA PA azathioprine oral tablet 50 Imuran cyclosporine modified oral capsule 100, 25 cyclosporine modified oral solution 100 /ml Gengraf Gengraf cyclosporine oral capsule 100, 25 SandIMMUNE mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 tacrolimus oral capsule 0.5, 1, 5 GENGRAF ORAL CAPSULE 100 MG, 25 MG CellCept CellCept CellCept Prograf PA PA PA PA Gengraf GENGRAF ORAL SOLUTION 100 MG/ML Gengraf RAPAMUNE ORAL SOLUTION 1 MG/ML PA SANDIMMUNE ORAL CAPSULE 25 MG SandIMMUNE SANDIMMUNE ORAL SOLUTION 100 MG/ML Infectious Disease - Bacterial Absorbable Sulfonamides sulfamethoxazole-trimethoprim oral suspension 200-40 /5ml Sulfatrim Pediatric 68
sulfamethoxazole-trimethoprim oral tablet 400-80 sulfamethoxazole-trimethoprim oral tablet 800-160 SULFATRIM PEDIATRIC ORAL SUSPENSION 200-40 MG/5ML Cephalosporins - 1St Generation Bactrim Bactrim DS Sulfatrim Pediatric cephalexin oral capsule 250, 500 Keflex cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml Cephalosporins - 2Nd Generation cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml Cephalosporins - 3Rd Generation cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml Chemotherapeutics, Antibacterial, Misc. QL (20 EA per 10 days) trimethoprim oral tablet 100 urin ds oral tablet Phosphasal PA PHOSPHASAL ORAL TABLET 81.6 MG Phosphasal PA URETRON D/S ORAL TABLET Macrolides PA QL (200 ML per 10 days) azithromycin oral packet 1 gm Zithromax QL (1 DAY per 30 days) azithromycin oral suspension reconstituted 100 /5ml, 200 /5ml Zithromax azithromycin oral tablet 250 Zithromax QL (2 FILLS IN 30 DAYS); QL (30 ML per 1 FILL) QL (2 FILLS IN 30 DAYS); QL (6 EA per 1 FILL) 69
azithromycin oral tablet 500 Zithromax QL (2 FILLS IN 30 DAYS); QL (3 EA per 3 days) azithromycin oral tablet 600 Zithromax QL (2 EA per 7 days) clarithromycin oral tablet 500 Biaxin erythromycin base oral capsule delayed release particles 250 erythromycin base oral tablet 250, 500 erythromycin ethylsuccinate oral suspension reconstituted 200 /5ml erythromycin ethylsuccinate oral tablet 400 E.E.S. Granules E.E.S. 400 E.E.S. 400 ORAL TABLET 400 MG E.E.S. 400 E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG Nitrofuran Derivatives nitrofurantoin macrocrystal oral capsule 100, 50 nitrofurantoin monohyd macro oral capsule 100 E.E.S. Granules Macrodantin Macrobid nitrofurantoin oral suspension 25 /5ml Furadantin Penicillins amoxicillin oral capsule 250, 500 ST (Requires concomitant amoxicillin and PPI fill. Qty restricted to 14days supply/year); QL (1 FILLS IN 365 DAYS) 70
amoxicillin oral suspension reconstituted 125 /5ml, 200 /5ml, 250 /5ml, 400 /5ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 125, 250 amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1000-62.5 amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 /5ml, 400-57 /5ml amoxicillin-pot clavulanate oral suspension reconstituted 600-42.9 /5ml amoxicillin-pot clavulanate oral tablet 250-125 amoxicillin-pot clavulanate oral tablet 500-125, 875-125 amoxicillin-pot clavulanate oral tablet chewable 200-28.5, 400-57 Augmentin XR Augmentin ES-600 Augmentin ampicillin oral capsule 250, 500 ampicillin oral suspension reconstituted 125 /5ml, 250 /5ml dicloxacillin sodium oral capsule 250, 500 penicillin v potassium oral solution reconstituted 125 /5ml, 250 /5ml penicillin v potassium oral tablet 250, 500 Quinolones ciprofloxacin hcl oral tablet 100 ciprofloxacin hcl oral tablet 250, 500 ciprofloxacin hcl oral tablet 750 Cipro QL (1 FILLS IN 30 DAYS); QL (40 EA per 1 FILL) QL (1 FILLS IN 30 DAYS); QL (300 ML per 1 FILL) PA; Age (Min 18 Years) Age (Min 18 Years) Age (Min 18 Years) 71
levofloxacin oral tablet 250, 500, 750 Levaquin Age (Min 18 Years) moxifloxacin hcl oral tablet 400 Avelox PA; Age (Min 18 Years) Tetracyclines doxycycline hyclate oral capsule 100 Morgidox Age (Min 8 Years) doxycycline monohydrate oral capsule 100, 50 minocycline hcl oral capsule 100, 50 Infectious Disease - Fungal Antifungal Agents Mondoxyne NL Minocin clotrimazole mouth/throat lozenge 10 clotrimazole mouth/throat troche 10 fluconazole in dextrose intravenous solution 200 /100ml, 400 /200ml fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 200, 50 Diflucan Age (Min 8 Years) PA Diflucan fluconazole oral tablet 150 Diflucan flucytosine oral capsule 250, 500 Ancobon QL (70 ML per 30 days) itraconazole oral capsule 100 Sporanox PA ketoconazole oral tablet 200 terbinafine hcl oral tablet 250 LamISIL Antifungal Antibiotics griseofulvin microsize oral suspension 125 /5ml QL (LIMIT TO 2 FILLS OF 2 TABLETS IN 30 DAYS); QL (2 EA per 30 FILLs) QL (30 EA per 30 days) griseofulvin microsize oral tablet 500 QL (20 ML per 1 day); Age (Max 12 Years) QL (FILL LIMIT OF 60 DAYS IN 1 YEAR); QL (60 EA per 30 days); Age (Max 18 Years) 72
griseofulvin ultramicrosize oral tablet 125, 250 nystatin mouth/throat suspension 100000 unit/ml Gris-PEG nystatin oral tablet 500000 unit Infectious Disease - Miscellaneous Aminoglycosides neomycin sulfate oral tablet 500 Antileprotics dapsone oral tablet 100, 25 THALOMID ORAL CAPSULE 50 MG Anti-Mycobacterium Agents ethambutol hcl oral tablet 100, 400 PA Myambutol isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 Antitubercular Antibiotics rifampin oral capsule 150, 300 Rifadin PRIFTIN ORAL TABLET 150 MG Lincosamides clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml Infectious Disease - Parasitic Amebacides Cleocin Cleocin paromomycin sulfate oral capsule 250 QL (FILL LIMIT OF 60 DAYS IN 1 YEAR); QL (60 EA per 30 days); Age (Max 18 Years) Age (Min 12 Years) 73
Anaerobic Antiprotozoal- Antibacterial Agents metronidazole in nacl intravenous solution 5-0.79 /ml-% PA metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl Anthelmintics BILTRICIDE ORAL TABLET 600 MG EMVERM ORAL TABLET CHEWABLE 100 MG Antimalarial Drugs chloroquine phosphate oral tablet 250 chloroquine phosphate oral tablet 500 hydroxychloroquine sulfate oral tablet 200 PA Plaquenil mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 Infectious Disease - Viral Antivirals, General acyclovir oral capsule 200 Zovirax acyclovir oral suspension 200 /5ml Zovirax acyclovir oral tablet 400, 800 Zovirax valacyclovir hcl oral tablet 1 gm Valtrex QL (2 EA per 15 days) RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML QL (20 EA per 23 days) QL (1 FILLS IN 180 DAYS); QL (10 EA per 30 days) QL (1 FILLS IN 180 DAYS); QL (120 ML per 180 days) 74
Antivirals, Hiv-Spec, Non-Peptidic Protease Inhib APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML PREZCOBIX ORAL TABLET 800-150 MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG Antivirals, Hiv-Spec, Nucleoside- Nucleotide Analog DESCOVY ORAL TABLET 200-25 MG TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG Antivirals, Hiv-Spec., Nucleoside Analog, Rti Comb abacavir-lamivudine-zidovudine oral tablet 300-150-300 lamivudine-zidovudine oral tablet 150-300 COMBIVIR ORAL TABLET 150-300 MG EPZICOM ORAL TABLET 600-300 MG TRIZIVIR ORAL TABLET 300-150-300 MG Antivirals, Hiv-Specific, Ccr5 Co- Receptor Antag. SELZENTRY ORAL TABLET 150 MG, 300 MG Trizivir Combivir Combivir Trizivir PA 75
Antivirals, Hiv-Specific, Fusion Inhibitors FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG Antivirals, Hiv-Specific, Non- Nucleoside, Rti nevirapine er oral tablet extended release 24 hour 100, 400 nevirapine oral suspension 50 /5ml nevirapine oral tablet 200 EDURANT ORAL TABLET 25 MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG RESCRIPTOR ORAL TABLET 100 MG, 200 MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG VIRAMUNE ORAL SUSPENSION 50 MG/5ML VIRAMUNE ORAL TABLET 200 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 400 MG Antivirals, Hiv-Specific, Nucleoside Analog, Rti abacavir sulfate oral tablet 300 lamivudine oral solution 10 /ml Viramune XR Viramune Viramune Viramune Viramune Viramune XR Ziagen Epivir 76
lamivudine oral tablet 150, 300 stavudine oral capsule 15, 20, 30, 40 stavudine oral solution reconstituted 1 /ml EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR ORAL SOLUTION 10 MG/ML EPIVIR ORAL TABLET 150 MG, 300 MG ZERIT ORAL CAPSULE 15 MG, 20 MG, 30 MG, 40 MG ZERIT ORAL SOLUTION RECONSTITUTED 1 MG/ML ZIAGEN ORAL SOLUTION 20 MG/ML ZIAGEN ORAL TABLET 300 MG Antivirals, Hiv-Specific, Nucleotide Analog, Rti VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG Antivirals, Hiv-Specific, Protease Inhibitor Comb KALETRA ORAL SOLUTION 400-100 MG/5ML KALETRA ORAL TABLET 100-25 MG, 200-50 MG Epivir Zerit Zerit Epivir Epivir Zerit Zerit Ziagen 77
Antivirals, Hiv-Specific, Protease Inhibitors CRIXIVAN ORAL CAPSULE 200 MG, 400 MG EVOTAZ ORAL TABLET 300-150 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL PACKET 50 MG VIRACEPT ORAL TABLET 250 MG, 625 MG Antivirals,Hiv-1 Integrase Strand Transfer Inhibtr ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG 78
VITEKTA ORAL TABLET 150 MG, 85 MG Artv Cmb Nucleoside,Nucleotide,&Non- Nucleoside Rti ATRIPLA ORAL TABLET 600-200-300 MG COMPLERA ORAL TABLET 200-25-300 MG ODEFSEY ORAL TABLET 200-25-25 MG Arv Cmb-Nrti,N(T)Rti, Integrase Inhibitor GENVOYA ORAL TABLET 150-150-200-10 MG STRIBILD ORAL TABLET 150-150-200-300 MG Arv Comb-Nrtis & Integrase Inhibitor TRIUMEQ ORAL TABLET 600-50-300 MG Cytochrome P450 Inhibitors TYBOST ORAL TABLET 150 MG Hepatitis B Treatment Agents lamivudine oral tablet 100 Epivir HBV PA EPIVIR HBV ORAL SOLUTION 5 MG/ML VEMLIDY ORAL TABLET 25 MG Hepatitis C Treatment Agents PA ribavirin oral tablet 200 Copegus PA PEG-INTRON REDIPEN SUBCUTANEOUS KIT 50 MCG/0.5ML PA RIBASPHERE ORAL TABLET 200 MG Copegus PA 79
Hepatitis C Virus- Ns5a And Ns3/4A Inhibitor Comb MAVYRET ORAL TABLET 100-40 MG Inflammatory Disease Anti-Arthritic And Chelating Agents PA CUPRIMINE ORAL CAPSULE 250 MG Anti-Arthritic, Folate Antagonist Agents RHEUMATREX ORAL TABLET 2.5 MG Anti-Inflammatory, Pyrimidine Synthesis Inhibitor leflunomide oral tablet 10, 20 Arava Glucocorticoids dexamethasone oral elixir 0.5 /5ml dexamethasone oral solution 0.5 /5ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 2, 4, 6 hydrocortisone oral tablet 10, 20, 5 methylprednisolone oral tablet 16, 32, 4, 8 methylprednisolone oral tablet therapy pack 4 Cortef Medrol Medrol prednisolone oral solution 15 /5ml prednisolone oral syrup 15 /5ml prednisolone sodium phosphate oral solution 15 /5ml prednisolone sodium phosphate oral solution 6.7 (5 base) /5ml Pediapred prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 5, 50 prednisone oral tablet 20 Deltasone 80
prednisone oral tablet therapy pack 10 (21), 10 (48), 5 (21), 5 (48) DELTASONE ORAL TABLET 20 MG Deltasone DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML MILLIPRED DP ORAL TABLET THERAPY PACK 5 MG (21), 5 MG (48) MILLIPRED ORAL TABLET 5 MG PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML Gold Salts RIDAURA ORAL CAPSULE 3 MG Mineralocorticoids PA fludrocortisone acetate oral tablet 0.1 Nsaids, Cyclooxygenase 2 Inhibitor - Type celecoxib oral capsule 100, 200 CeleBREX PA Nsaids, Cyclooxygenase Inhibitor- Type celecoxib oral capsule 400 CeleBREX PA childrens ibuprofen oral suspension 100 /5ml diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac er oral tablet extended release 24 hour 600 Childrens Advil PA flurbiprofen oral tablet 100, 50 ibu-200 oral tablet 200 Advil ibu-drops oral suspension 50 /1.25ml Infants Advil ibuprofen junior strength oral tablet chewable 100 Advil Junior Strength QL (2 FILLS OF 120ML IN 30 DAYS); QL (120 ML per 1 FILL) 81
ibuprofen oral suspension 100 /5ml Childrens Advil ibuprofen oral tablet 200 Advil ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 infants ibuprofen oral suspension 50 /1.25ml Infants Advil ketoprofen oral capsule 50, 75 meloxicam oral tablet 15, 7.5 Mobic naproxen kit oral tablet 500 Naprosyn naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral tablet 275 naproxen sodium oral tablet 550 Anaprox DS piroxicam oral capsule 10, 20 Feldene sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 MOTRIN INFANTS DROPS ORAL SUSPENSION 50 MG/1.25ML Local Anesthesia Local Anesthetics lidocaine viscous mouth/throat solution 2 % Lower Gastrointestinal Disorders - Bowel Inflammat Chronic Inflam. Colon Dx, 5-A- Salicylat,Rectal Tx Infants Advil mesalamine rectal enema 4 gm 82 QL (2 FILLS OF 120ML IN 30 DAYS); QL (120 ML per 1 ML PER FILL)
Drug Tx-Chronic Inflam. Colon Dx,5-Aminosalicylat balsalazide disodium oral capsule 750 Colazal sulfasalazine oral tablet 500 Azulfidine sulfasalazine oral tablet delayed release 500 DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG Azulfidine EN-tabs DIPENTUM ORAL CAPSULE 250 MG PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG Hemorrhoidal Prep, Anti-Infam Steroid/Local Anesth hydrocortisone ace-pramoxine external cream 2.5-1 % hydrocortisone ace-pramoxine rectal cream 1-1 % hydrocortisone ace-pramoxine rectal cream 2.5-1 % Pramosone Analpram-HC Analpram HC ANALPRAM-HC RECTAL CREAM 1-1 % Analpram-HC PROCTOFOAM HC RECTAL FOAM 1-1 % Rectal Preparations anucort-hc rectal suppository 25 Anusol-HC hydrocortisone acetate rectal suppository 25 Anusol-HC hydrocortisone rectal cream 1 % Procto-Pak PROCTO-PAK RECTAL CREAM 1 % Procto-Pak PROCTOSOL HC RECTAL CREAM 2.5 % PROCTOZONE-HC RECTAL CREAM 2.5 % Rectal/Lower Bowel Prep.,Glucocort. (Non-Hemorr) hydrocortisone rectal enema 100 /60ml Colocort 83
COLOCORT RECTAL ENEMA 100 MG/60ML Lower Gastrointestinal Disorders - Other Ammonia Inhibitors Colocort enulose oral solution 10 gm/15ml generlac oral solution 10 gm/15ml lactulose encephalopathy oral solution 10 gm/15ml Antidiarrheals bismuth oral tablet chewable 262 Pepto-Bismol bismuth subsalicylate oral tablet chewable 262 diphenoxylate-atropine oral liquid 2.5-0.025 /5ml diphenoxylate-atropine oral tablet 2.5-0.025 Pepto-Bismol Lomotil loperamide hcl oral capsule 2 Imodium A-D loperamide hcl oral liquid 1 /5ml Bile Salts ursodiol oral capsule 300 Actigall Laxatives And Cathartics bisacodyl ec oral tablet delayed release 5 citrate of magnesia oral solution, 1.745 gm/30ml Alophen Citroma constulose oral solution 10 gm/15ml dioctyl s.s. oral capsule 100 Colace docusate sodium oral capsule 100 Colace docusate sodium oral capsule 250 DOK docusate sodium oral liquid 50 /5ml ducodyl oral tablet delayed release 5 Alophen 84
lactulose oral solution 10 gm/15ml, 20 gm/30ml magnesium citrate oral solution 1.745 gm/30ml peg 3350/electrolytes oral solution reconstituted 240 gm Citroma Colyte with Flavor Packs polyethylene glycol 3350 oral powder ClearLax AMITIZA ORAL CAPSULE 24 MCG PA DOK ORAL CAPSULE 100 MG Colace DOK ORAL CAPSULE 250 MG DOK GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM Laxatives, Local/Rectal bisacodyl laxative rectal suppository 10 Colyte with Flavor Packs Bisac-Evac bisacodyl rectal suppository 10 Bisac-Evac glycerin (adult) rectal suppository 2 gm Sani-Supp Adult glycerin (adult) rectal suppository 2.1 gm glycerin (infants & children) rectal suppository 1 gm glycerin (infants & children) rectal suppository 1.2 gm Pedia-Lax Sani-Supp Pediatric laxative rectal suppository 10 Bisac-Evac PEDIA-LAX RECTAL SUPPOSITORY 1 GM Pedia-Lax Medical Supplies Durable Medical Equipment,Misc(Group 1) assure comfort lancets 28g assure comfort lancets 30g lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets QL (527 GM per 30 days) 85
lancets 30g preferred plus lancets thin sapscare twist top lancets BD LANCET ULTRAFINE 33G E-Z JECT LANCETS THIN 26G FREESTYLE LANCETS LANCETS ULTRA FINE MEDISENSE THIN LANCETS PHARMACIST CHOICE LANCETS Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets STERILANCE PA STERILANCE TL Syringes And Accessories BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML BD INSULIN SYR ULTRAFINE II 31G X 5/16" 1 ML Accu-Chek FastClix Lancets BD INSULIN SYRINGE 29G X 1/2" 0.5 ML BD INSULIN SYRINGE 29G X 1/2" 1 ML BD INSULIN SYRINGE 30G X 1/2" 0.5 ML BD INSULIN SYRINGE HALF-UNIT 31G X 5/16" 0.3 ML BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.3 ML BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.5 ML 86
BD INSULIN SYRINGE MICROFINE 28G X 1/2" 1 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 1 ML BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.3 ML, 30G X 1/2" 1 ML BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.5 ML BD INSULIN SYRINGE ULTRAFINE 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.5 ML BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.5 ML BD SAFETY-LOK INSULIN SYRINGE 29G X 1/2" 1 ML ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML ULTICARE INSULIN SAFETY SYR 29G X 1/2" 1 ML Miscellaneous Agents Anaphylaxis Therapy Agents epinephrine injection solution autoinjector 0.15 /0.3ml epinephrine injection solution autoinjector 0.3 /0.3ml Parasympathetic Agents bethanechol chloride oral tablet 10, 25, 5, 50 EpiPen Jr 2-Pak Auvi-Q Urecholine QL (2 EA per 1 FILL) QL (2 EA per 1 FILL) 87
Neoplastic Disease Alkylating Agents cyclophosphamide oral tablet 25, 50 PA hydroxyurea oral capsule 500 Hydrea PA lomustine oral capsule 10, 100, 40 Gleostine PA temozolomide oral capsule 20 Temodar PA ALKERAN ORAL TABLET 2 MG PA CEENU ORAL CAPSULE 10 MG Gleostine CEENU ORAL CAPSULE 40 MG Gleostine PA GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG Gleostine PA HEXALEN ORAL CAPSULE 50 MG LEUKERAN ORAL TABLET 2 MG PA MYLERAN ORAL TABLET 2 MG Antiandrogenic Agents bicalutamide oral tablet 50 Casodex PA flutamide oral capsule 125 Antimetabolites PA capecitabine oral tablet 500 Xeloda PA mercaptopurine oral tablet 50 PA methotrexate oral tablet 2.5 ADRUCIL INTRAVENOUS SOLUTION 2.5 GM/50ML, 5 GM/100ML TABLOID ORAL TABLET 40 MG Antineoplastic Aromatase Inhibitors PA PA anastrozole oral tablet 1 Arimidex letrozole oral tablet 2.5 Femara PA; QL (LIMIT 90 TAB PER 30 DAYS) 88
Antineoplastics,Miscellaneous etoposide oral capsule 50 tretinoin oral capsule 10 LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG Chemotherapy Rescue/Antidote Agents leucovorin calcium oral tablet 10, 15, 25, 5 Selective Estrogen Receptor Modulators (Serm) PA PA PA PA tamoxifen citrate oral tablet 10, 20 FARESTON ORAL TABLET 60 MG Steroid Antineoplastics megestrol acetate oral tablet 20, 40 EMCYT ORAL CAPSULE 140 MG Neurological Disease - Miscellaneous Amyotrophic Lateral Sclerosis Agents PA PA riluzole oral tablet 50 Rilutek PA Fibromyalgia Agents,Serotonin- Norepineph Ru Inhib SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG Oral/Pharyngeal Disorders Dental Aids And Preparations chlorhexidine gluconate mouth/throat solution 0.12 % PA PA Paroex 89
triamcinolone acetonide mouth/throat paste 0.1 % Oralone ORALONE MOUTH/THROAT PASTE 0.1 % Oralone PAROEX MOUTH/THROAT SOLUTION 0.12 % PERIOGARD MOUTH/THROAT SOLUTION 0.12 % Nose Preparations, Miscellaneous (Rx) ipratropium bromide nasal solution 0.03 %, 0.06 % Periodontal Collagenase Inhibitors doxycycline hyclate oral tablet 20 Other Drugs Appetite Stim. For Anorexia,Cachexia,Wasting Synd. megestrol acetate oral suspension 40 /ml, 400 /10ml Condoms premium condoms lubricated Paroex Paroex Atlas Color Lubricated Condom QL (60 EA per 30 days) PA FC2 FEMALE CONDOM General Inhalation Agents sodium chloride inhalation nebulization solution 0.9 %, 10 % sodium chloride inhalation nebulization solution 3 % NEBUSAL INHALATION NEBULIZATION SOLUTION 3 % Insecticides Nebusal Nebusal RID AEROSOL 0.5 % Metabolic Deficiency Agents levocarnitine oral solution 1 gm/10ml Carnitor 90
levocarnitine oral tablet 330 Carnitor CARNITOR SF ORAL SOLUTION 1 GM/10ML Metallic Poison,Agents To Treat CHEMET ORAL CAPSULE 100 MG Needles/Needleless Devices pen needles 3/16" 31g x 5 mm Carnitor Advocate Insulin Pen Needles PA pen needles 5/16" 30g x 8 mm CareFine Pen Needles pen needles 5/16" 31g x 8 mm BD PEN NEEDLE MINI U/F 31G X 5 MM Advocate Insulin Pen Needles Advocate Insulin Pen Needles BD PEN NEEDLE NANO U/F 32G X 4 MM BD PEN NEEDLE SHORT U/F 31G X 8 MM BD PEN NEEDLE ULTRAFINE 29G X 12.7MM Advocate Insulin Pen Needles NOVOFINE 30G X 8 MM CareFine Pen Needles NOVOFINE 32G X 6 MM NOVOFINE AUTOCOVER 30G X 8 MM CareFine Pen Needles NOVOFINE PLUS 32G X 4 MM Parenteral Amino Acid Solutions And Combinations amino acid infusion intravenous solution 15 % Protein Replacement CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % Other Respiratory Disorders Mucolytics acetylcysteine inhalation solution 10 %, 20 % Aminosyn II PA PA 91
Pain Management - Analgesics Analgesic, Non-Salicylate & Barbiturate Comb. butalbital-acetaminophen oral tablet 50-325 Tencon TENCON ORAL TABLET 50-325 MG Tencon Analgesic, Salicylate, Barbiturate,& Xanthine Cmb butalbital-aspirin-caffeine oral capsule 50-325-40 Analgesic,Non- Salicylate,Barbiturate,&Xanthine Cmb butalbital-apap-caffeine oral tablet 50-325-40 Analgesic/Antipyretics, Salicylates aspirin ec oral tablet delayed release 325 aspirin ec oral tablet delayed release 81 Fiorinal Esgic Bayer Aspirin Regimen Aspir-Low diflunisal oral tablet 500 salsalate oral tablet 500, 750 EXCEDRIN MIGRAINE ORAL TABLET 250-250-65 MG Analgesic/Antipyretics,Non- Salicylate acetaminophen extra strength oral tablet 500 Healthy Mama Shake That Ache acetaminophen oral liquid 160 /5ml Little Remedies for Fever acetaminophen oral solution 160 /5ml 92 QL (1 FILL OF 60 TABLETS IN 30 DAYS); QL (60 EA per 30 days) QL (2 FILLS OF 120ML IN 30 DAYS); QL (120 ML per 1 FILL) QL (2 FILLS OF 120ML IN 30 DAYS); QL (120 ML per 1 ML PER FILL)
acetaminophen oral tablet 325 Pharbetol acetaminophen oral tablet 500 acetaminophen oral tablet chewable 80 acetaminophen rectal suppository 120, 650 apap extra strength oral tablet 500 Healthy Mama Shake That Ache Childrens Medi-Tabs Acephen Healthy Mama Shake That Ache QL (1 FILLS OF 60 TABLETS IN 30 DAYS); QL (60 EA per 30 days) QL (1 FILLS OF 60 TABLETS IN 30 DAYS); QL (60 EA per 30 days) QL (1 FILLS OF 30 TABLETS IN 30 DAYS); QL (30 EA per 30 days) QL (1 FILLS IN 30 DAYS) apap oral tablet 325 Pharbetol non-aspirin pain relief oral tablet 325 Pharbetol pain relief extra strength oral tablet 500 Healthy Mama Shake That Ache pain reliever oral tablet 325 Pharbetol Analgesics,Narcotics butorphanol tartrate nasal solution 10 /ml codeine sulfate oral tablet 15, 30, 60 fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr fentanyl transdermal patch 72 hour 50 mcg/hr PA PA Duragesic-100 Duragesic-25 Duragesic-50 QL (1 FILLS OF 60 TABLETS IN 30 DAYS); QL (60 EA per 30 days) QL (1 FILLS OF 60 TABLETS IN 30 DAYS); QL (60 EA per 30 days) QL (1 FILL OF 60 TABLETS IN 30 DAYS); QL (60 EA per 30 days) QL (1 FILL OF 60 TABLETS IN 30 DAYS); QL (60 EA per 1 FILL) QL (1 FILL OF 60 TABLETS IN 30 DAYS); QL (60 EA per 30 days) PA; QL (10 EA per 30 days) PA; QL (10 EA per 30 days) PA; QL (10 EA per 30 days) 93
fentanyl transdermal patch 72 hour 75 mcg/hr hydrocodone-acetaminophen oral solution 7.5-500 /15ml hydrocodone-acetaminophen oral tablet 10-325 hydrocodone-acetaminophen oral tablet 5-325 hydrocodone-acetaminophen oral tablet 7.5-325 Duragesic-75 Lorcet HD Lorcet Lorcet Plus hydromorphone hcl oral liquid 1 /ml Dilaudid hydromorphone hcl oral tablet 2, 4 Dilaudid PA; QL (10 EA per 30 days) QL (LIMIT 240 ML OF HYDROCODONE SOLUTION PER 30 DAYS LIMIT 100 TABS OF HYDROCODONE PRODUCTS PER 30 DAYS); QL (240 ML per 30 days) QL (LIMIT 100 TABS OF HYDROCODONE PRODUCTS PER 30 DAYS); QL (100 EA per 30 days) QL (LIMIT 100 TABS OF HYDROCODONE PRODUCTS PER 30 DAYS); QL (100 EA per 30 days) QL (LIMIT 100 TABS OF HYDROCODONE PRODUCTS PER 30 DAYS); QL (100 EA per 30 days) QL (LIMIT #60 PER 30 DAYS); QL (60 EA per 30 days) hydromorphone hcl oral tablet 8 Dilaudid QL (60 EA per 30 days) hydromorphone hcl rectal suppository 3 meperidine hcl oral tablet 100, 50 Demerol methadone hcl oral concentrate 10 /ml Methadone HCl Intensol PA QL (LIMIT #100 PER 30 DAYS); QL (100 EA per 30 days) 94
methadone hcl oral solution 10 /5ml, 5 /5ml PA methadone hcl oral tablet 10, 5 Dolophine methadone hcl oral tablet soluble 40 Methadose PA morphine sulfate (concentrate) oral solution 100 /5ml morphine sulfate er oral tablet extended release 100, 200, 60 morphine sulfate er oral tablet extended release 15 morphine sulfate er oral tablet extended release 30 morphine sulfate oral solution 10 /5ml, 20 /5ml MS Contin MS Contin MS Contin PA PA QL (LIMIT #60 PER 30 DAYS); QL (60 EA per 30 days) QL (90 EA per 30 days) QL (60 EA per 30 days) PA morphine sulfate oral tablet 15, 30 morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10, 20, 40, 80 oxycodone hcl oral capsule 5 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 15, 30, 5 OxyCONTIN Roxicodone PA PA PA PA QL (LIMIT # 90 TAB PER 30 DAYS); QL (90 EA per 30 days) QL (LIMIT #24 SUPPOSITORIES IN 30 DAYS); QL (24 EA per 30 days) PA; QL (60 EA per 30 days) 95
oxycodone-acetaminophen oral solution 5-325 /5ml oxycodone-acetaminophen oral tablet 5-325 oxycodone-aspirin oral tablet 4.8355-325 Endocet tramadol hcl oral tablet 50 Ultram BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR ENDOCET ORAL TABLET 5-325 MG Endocet METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML METHADOSE ORAL TABLET SOLUBLE 40 MG Antimigraine Preparations isometheptene-dichloral-apap oral capsule 65-100-325 rizatriptan benzoate oral tablet 10, 5 Methadone HCl Intensol Methadose PA PA Nodolor Maxalt QL (LIMIT 100 TABS PER 30 DAYS TOTAL OXYCODONE APAP AND OXYCODONE ASA PER MONTH); QL (100 ML per 30 days) QL (LIMIT 100 TABS PER 30 DAYS TOTAL OXYCODONE APAP AND OXYCODONE ASA PER MONTH); QL (100 EA per 30 days) QL (100 EA per 30 days) QL (LIMIT 100 TABS PER 30 DAYS TOTAL OXYCODONE APAP AND OXYCODONE ASA PER MONTH); QL (100 EA per 30 days) QL (12 EA per 30 days); Age (Min 6 Years) 96
sumatriptan nasal solution 20 /act, 5 /act sumatriptan succinate oral tablet 100, 25, 50 sumatriptan succinate refill subcutaneous solution cartridge 6 /0.5ml sumatriptan succinate subcutaneous solution 6 /0.5ml sumatriptan succinate subcutaneous solution auto-injector 6 /0.5ml sumatriptan succinate subcutaneous solution prefilled syringe 6 /0.5ml Imitrex Imitrex Imitrex STATdose Refill Imitrex Imitrex STATdose System CAFERGOT ORAL TABLET 1-100 MG NODOLOR ORAL CAPSULE 325-65-100 MG Narc.& Non- Sal.Analgesic,Barbiturate &Xanthine Cmb butalbital-apap-caff-cod oral capsule 50-325-40-30 Narcotic & Salicylate Analgesics, Barb.& Xanthine butalbital-asa-caff-codeine oral capsule 50-325-40-30 ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG Nodolor Ascomp-Codeine Ascomp-Codeine QL (1 FILLS IN 30 DAYS); QL (6 EA per 30 days) QL (1 FILLS IN 30 DAYS); QL (9 EA per 30 days) QL (1 FILLS IN 30 DAYS); QL (2 ML per 1 FILL) QL (1 FILLS IN 30 DAYS); QL (2 BOX per 1 FILL) QL (1 FILLS IN 30 DAYS); QL (2 ML per 1 FILL) QL (1 FILLS IN 30 DAYS); QL (2 ML per 1 FILL) QL (60 EA per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) 97
Narcotic Analgesic & Non- Salicylate Analgesic Comb acetaminophen-codeine #2 oral tablet 300-15 acetaminophen-codeine #3 oral tablet 300-30 acetaminophen-codeine #4 oral tablet 300-60 acetaminophen-codeine oral solution 120-12 /5ml acetaminophen-codeine oral tablet 300-15 acetaminophen-codeine oral tablet 300-60 Narcotic Withdrawal Therapy Agents buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 Tylenol with Codeine #3 Tylenol with Codeine #4 Tylenol with Codeine #4 Buprenex 98 QL (LIMIT 100 TABS TOTAL APAP/CODEINE TABLETS PER MONTH); QL (100 EA per 30 days) QL (LIMIT 100 TABS TOTAL APAP/CODEINE TABLETS PER MONTH); QL (100 EA per 25 days) QL (LIMIT 100 TABS TOTAL APAP/CODEINE TABLETS PER MONTH); QL (100 EA per 30 days) QL (240 ML per 30 days) QL (LIMIT 100 TABS TOTAL APAP/CODEINE TABLETS PER MONTH); QL (100 EA per 30 days) QL (LIMIT 100 TABS TOTAL APAP/CODEINE TABLETS PER MONTH); QL (100 EA per 25 days)
BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 MG BUPRENEX INJECTION SOLUTION 0.3 MG/ML PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT 74.2 MG SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG Parkinsons Disease Antiparkinsonism Drugs,Anticholinergic benztropine mesylate injection solution 1 /ml benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 COGENTIN INJECTION SOLUTION 1 MG/ML Antiparkinsonism Drugs,Other amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral tablet 2.5 carbidopa-levodopa er oral tablet extended release 25-100, 50-200 Buprenex Cogentin Cogentin Parlodel Sinemet CR 99
carbidopa-levodopa oral tablet 10-100, 25-100, 25-250 Sinemet entacapone oral tablet 200 Comtan pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 Mirapex Requip selegiline hcl oral capsule 5 Eldepryl selegiline hcl oral tablet 5 Seizure Disorder Anticonvulsants carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 100, 200, 400 carbamazepine oral suspension 100 /5ml Carbatrol TEGretol-XR TEGretol carbamazepine oral tablet 200 Epitol carbamazepine oral tablet chewable 100 clonazepam oral tablet 0.5, 1, 2 KlonoPIN diazepam rectal gel 10 Diastat AcuDial divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250, 500 Depakote Sprinkles Depakote ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin gabapentin oral capsule 100, 300, 400 Neurontin 100 ST (Requires concomitant use of levodopa-carbidopa agent) QL (120 EA per 30 days)
gabapentin oral solution 250 /5ml Neurontin gabapentin oral tablet 600, 800 Neurontin lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25, 5 levetiracetam er oral tablet extended release 24 hour 500 levetiracetam er oral tablet extended release 24 hour 750 LaMICtal LaMICtal Keppra XR PA Keppra XR levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral tablet 150, 300, 600 Keppra Trileptal phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 Dilantin primidone oral tablet 250, 50 Mysoline topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 Topamax Sprinkle Topamax valproate sodium oral syrup 250 /5ml valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene zonisamide oral capsule 100, 25 Zonegran zonisamide oral capsule 50 CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG Carbatrol CELONTIN ORAL CAPSULE 300 MG DEPAKENE ORAL CAPSULE 250 MG Depakene DEPAKENE ORAL SYRUP 250 MG/5ML QL (6 EA per 1 day) QL (120 EA per 30 days) 101
DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG Dilantin Infatabs DILANTIN ORAL CAPSULE 100 MG Dilantin DILANTIN ORAL CAPSULE 30 MG DILANTIN ORAL SUSPENSION 125 MG/5ML PHENYTOIN INFATABS ORAL TABLET CHEWABLE 50 MG TEGRETOL ORAL SUSPENSION 100 MG/5ML Dilantin Dilantin Infatabs TEGretol TEGRETOL ORAL TABLET 200 MG Epitol TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 400 MG Skeletal Muscle Disorder Skeletal Muscle Relaxants TEGretol-XR baclofen oral tablet 10, 20 carisoprodol oral tablet 350 Soma cyclobenzaprine hcl oral tablet 10 methocarbamol oral tablet 500 Robaxin methocarbamol oral tablet 750 Robaxin-750 Smoking Cessation Smoking Deterrent Agents (Ganglionic Stim,Others) nicotine polacrilex mouth/throat gum 2 KLS Quit2 PA 102 QL (LIMIT # 90 TAB PER 30 DAYS); QL (90 EA per 30 days) QL (LIMIT # 90 TAB PER 30 DAYS); QL (90 EA per 30 days) QL (LIMIT # 90 TAB PER 30 DAYS); QL (90 EA per 30 days) QL (LIMIT # 90 TAB PER 30 DAYS); QL (90 EA per 30 days) QL (LIMIT # 90 TAB PER 30 DAYS); QL (90 EA per 30 days)
nicotine polacrilex mouth/throat gum 4 nicotine polacrilex mouth/throat lozenge 4 nicotine step 1 transdermal patch 24 hour 21 /24hr nicotine step 2 transdermal patch 24 hour 14 /24hr nicotine step 3 transdermal patch 24 hour 7 /24hr nicotine transdermal patch 24 hour 14 /24hr, 21 /24hr, 7 /24hr NICOTROL INHALATION INHALER 10 MG NICOTROL NS NASAL SOLUTION 10 MG/ML Smoking Deterrent-Nicotinic Recept.Partial Agonist CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 Smoking Deterrents, Other bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 Upper Gastrointestinal Disorders - Digestive Antiflatulents infants simethicone oral suspension 20 /0.3ml KLS Quit4 Commit PA PA Nicoderm CQ Nicoderm CQ Nicoderm CQ Nicoderm CQ Zyban Little Remedies for Tummys PA PA PA PA PA PA simethicone oral capsule 125 Gas-X Extra Strength simethicone oral suspension 40 /0.6ml Little Remedies for Tummys simethicone oral tablet chewable 125 Gas-X Extra Strength QL (84 EA per 365 days) QL (84 EA per 365 days) QL (84 EA per 365 days) QL (84 EA per 365 days) 103
simethicone oral tablet chewable 80 Gas-X GAS-X EXTRA STRENGTH ORAL CAPSULE 125 MG Pancreatic Enzymes pancrelipase (lip-prot-amyl) oral capsule delayed release particles 5000 unit Upper Gastrointestinal Disorders - Spastic Disease Anticholinergics/Antispasmodics Gas-X Extra Strength Zenpep PA dicyclomine hcl oral capsule 10 Bentyl dicyclomine hcl oral solution 10 /5ml dicyclomine hcl oral tablet 20 Bentyl Belladonna Alkaloids hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 hyoscyamine sulfate oral elixir 0.125 /5ml hyoscyamine sulfate oral solution 0.125 /ml Levbid hyoscyamine sulfate oral tablet 0.125 Levsin hyoscyamine sulfate sublingual tablet sublingual 0.125 Levsin/SL hyosyne oral elixir 0.125 /5ml hyosyne oral solution 0.125 /ml Upper Gastrointestinal Disorders - Ulcer Disease Antacids aluminum hydroxide gel oral suspension 320 /5ml aluminum hydroxide oral suspension 600 /5ml antacid advanced oral suspension 400-400-40 /5ml Almacone Double Strength 104
antacid calcium extra strength oral tablet chewable 750 antacid calcium oral tablet chewable 500 antacid extra strength oral tablet chewable 750 antacid oral suspension 200-200-20 /5ml Antacid Flavor Chews Cal-Gest Antacid Antacid Flavor Chews Almacone antacid oral tablet chewable 500 Cal-Gest Antacid calcium antacid extra strength oral tablet chewable 750 calcium antacid oral tablet chewable 500 calcium carbonate antacid oral tablet chewable 500 calcium carbonate antacid oral tablet chewable 750 mag-al plus oral liquid 200-200-20 /5ml mag-al plus xs oral liquid 400-400-40 /5ml GAVISCON EXTRA RELIEF FORMULA ORAL SUSPENSION 508-475 MG/10ML GAVISCON EXTRA STRENGTH ORAL SUSPENSION 254-237.5 MG/5ML MAALOX ADVANCED ORAL SUSPENSION 200-200-20 MG/5ML Anticholinergics,Quaternary Ammonium chlordiazepoxide-clidinium oral capsule 5-2.5 Antacid Flavor Chews Cal-Gest Antacid Cal-Gest Antacid Antacid Flavor Chews Almacone Almacone Double Strength Almacone Librax propantheline bromide oral tablet 15 Anti-Ulcer Preparations misoprostol oral tablet 100 mcg, 200 mcg Cytotec PA sucralfate oral tablet 1 gm Carafate 105
Histamine H2-Receptor Inhibitors cimetidine 200 oral tablet 200 Tagamet HB cimetidine hcl oral solution 300 /5ml cimetidine oral tablet 200 Tagamet HB cimetidine oral tablet 300, 400, 800 famotidine oral tablet 10 Pepcid AC PA famotidine oral tablet 20, 40 Pepcid ranitidine hcl oral syrup 15 /ml, 150 /10ml, 75 /5ml ranitidine hcl oral tablet 150 Wal-Zan 150 Maximum Strength ranitidine hcl oral tablet 300 Zantac ranitidine hcl oral tablet 75 Wal-Zan 75 ZANTAC 75 ORAL TABLET 75 MG Wal-Zan 75 Intestinal Motility Stimulants metoclopramide hcl oral solution 10 /10ml, 5 /5ml metoclopramide hcl oral tablet 10, 5 Proton-Pump Inhibitors lansoprazole oral capsule delayed release 15 omeprazole oral capsule delayed release 10 omeprazole oral capsule delayed release 20 omeprazole oral capsule delayed release 40 pantoprazole sodium oral tablet delayed release 20, 40 pediatric electrolyte oral solution Reglan Prevacid PriLOSEC Protonix Advantage Care Electrolyte Ped ST (Requires a trial on omeprazole for 30 days in the last 90 days) QL (60 EA per 30 days) QL (30 EA per 30 days) 106
Urinary Tract - Functional Disorders Benign Prostatic Hypertrophy/Micturition Agents alfuzosin hcl er oral tablet extended release 24 hour 10 Uroxatral PA finasteride oral tablet 5 Proscar tamsulosin hcl oral capsule 0.4 Flomax Urinary Ph Modifiers citric acid-sodium citrate oral solution 334-500 /5ml Shohls Modified cytra-2 oral solution 500-334 /5ml Shohls Modified pot & sod cit-cit ac oral solution 550-500- 334 /5ml sod citrate-citric acid oral solution 500-334 /5ml tricitrates oral solution 550-500-334 /5ml Shohls Modified virtrate-2 oral solution 500-334 /5ml Shohls Modified virtrate-3 oral solution 550-500-334 /5ml CYTRA-3 ORAL SYRUP 550-500-334 MG/5ML Urinary Tract Anesthetic/Analgesic Agnt (Azo-Dye) phenazopyridine hcl oral tablet 100 Pyridium phenazopyridine hcl oral tablet 200 Phenazo urinary pain relief oral tablet 95 AZO Urinary Pain Relief AZO URINARY PAIN RELIEF ORAL TABLET 95 MG AZO Urinary Pain Relief 107
Urinary Tract Antispasmodic/Antiincontinence Agent oxybutynin chloride er oral tablet extended release 24 hour 10, 15, 5 Ditropan XL oxybutynin chloride oral syrup 5 /5ml oxybutynin chloride oral tablet 5 Vaginal Disorders Vaginal Antibiotics clindamycin phosphate vaginal cream 2 % Cleocin metronidazole vaginal gel 0.75 % MetroGel-Vaginal CLEOCIN VAGINAL SUPPOSITORY 100 MG VANDAZOLE VAGINAL GEL 0.75 % MetroGel-Vaginal Vaginal Antifungals clotrimazole vaginal cream 1 % Gyne-Lotrimin clotrimazole-7 vaginal cream 1 % Gyne-Lotrimin miconazole 7 vaginal cream 2 % Monistat 7 Simply Cure miconazole 7 vaginal suppository 100 miconazole nitrate vaginal cream 2 % Monistat 7 Simply Cure miconazole nitrate vaginal suppository 100 tioconazole-1 vaginal ointment 6.5 % Monistat 1-Day MONISTAT 3 VAGINAL CREAM 4 % MONISTAT 7 SIMPLY CURE VAGINAL CREAM 2 % Monistat 7 Simply Cure VAGISTAT-1 VAGINAL OINTMENT 6.5 % Monistat 1-Day Vaginal Estrogen Preparations ESTRACE VAGINAL CREAM 0.1 MG/GM PREMARIN VAGINAL CREAM 0.625 MG/GM QL (43 GM per 30 days) 108
Vitamin And/Or Mineral Deficiency Calcium Replacement calcium 500 + d oral tablet 500-125 unit calcium 500 + d3 oral tablet 500-600 unit calcium 500+d high potency oral tablet 500-400 -unit calcium 500+d oral tablet 500-400 unit calcium 500+d3 oral tablet 500-400 unit calcium carbonate antacid oral tablet 648 calcium carbonate oral tablet 1250 (500 ca) calcium carbonate-vitamin d oral tablet 600-400 -unit calcium gluconate oral tablet 500, 650 Os-Cal Extra D3 Oystercal-D Oystercal-D Cal-Carb Forte calcium high potency oral tablet 600 High Potency Calcium calcium lactate oral tablet 648 calcium oyster shell oral tablet 1250 (500 ca) calcium-vitamin d3 oral tablet 250-125 -unit calcium-vitamin d3 oral tablet 500-400 -unit oyster shell calcium + d3 oral tablet 500-400 -unit oyster shell calcium 500 + d oral tablet 500-125 -unit Cal-Carb Forte Oystercal-D Oystercal-D oyster shell calcium oral tablet 500 Oysco 500 oyster shell calcium/d oral tablet 250-125 -unit, 500-400 -unit 109
oyster shell calcium/d3 oral tablet 500-400 -unit OYSCO 500 ORAL TABLET 500 MG Oysco 500 OYSCO 500+D ORAL TABLET 500-200 MG- UNIT OYSCO D ORAL TABLET 250-125 MG- UNIT OYSTERCAL-D ORAL TABLET 500-400 MG- UNIT Fluoride Preparations fluoritab oral solution 0.275 (0.125 f) /drop sodium fluoride oral solution 1.1 (0.5 f) /ml sodium fluoride oral tablet chewable 0.55 (0.25 f), 1.1 (0.5 f), 2.2 (1 f) PHOS FLUR MOUTH/THROAT SOLUTION 0.044 % PHOS-FLUR ORTHO DEFENSE MOUTH/THROAT SOLUTION 0.044 % Folic Acid Preparations Oystercal-D Fluor-a-day Ludent folic acid oral capsule 20 folic acid oral tablet 1, 400 mcg folic acid oral tablet 800 mcg FA-8 Iron Replacement fer-iron oral solution 75 (15 fe) /ml BProtected Pedia Iron ferrex 150 forte oral capsule 150-25-1 -mcg- ferrous sulfate oral elixir 220 (44 fe) /5ml ferrous sulfate oral liquid 220 (44 fe) /5ml ferrous sulfate oral solution 75 (15 fe) /ml iferex 150 Forte FeroSul BProtected Pedia Iron 110
ferrous sulfate oral syrup 300 (60 fe) /5ml ferrous sulfate oral tablet 325 (65 fe) ferrous sulfate oral tablet delayed release 324 (65 fe), 325 (65 fe) iron high-potency oral tablet 325 iron oral tablet 325 (65 fe) myferon 150 forte oral capsule 150-25-1 -mcg- poly-iron 150 forte oral capsule 150-25-1 -mcg- slow release iron oral tablet extended release 160 (50 fe), 47.5 iferex 150 Forte iferex 150 Forte FEOSOL ORAL TABLET 200 (65 FE) MG FEROSUL ORAL ELIXIR 220 (44 FE) MG/5ML FOLITAB 500 ORAL TABLET EXTENDED RELEASE 525-500-0.8 MG FeroSul HEMATOGEN ORAL CAPSULE IFEREX 150 FORTE ORAL CAPSULE 150-25-1 MG-MCG-MG Pediatric Vitamin Preparations multi vitamin/fluoride oral tablet chewable 0.25, 1 multi-vit/fluoride oral solution 0.25 /ml iferex 150 Forte MVC-Fluoride Floriva Plus multi-vit/fluoride oral solution 0.5 /ml Quflora Pediatric multi-vit/fluoride/iron oral solution 0.25-10 /ml multi-vitamin/fluoride oral solution 0.25 /ml multi-vitamin/fluoride oral tablet chewable 0.25, 0.5, 1 multi-vitamin/fluoride/iron oral solution 0.25-10 /ml Floriva Plus MVC-Fluoride 111
multi-vitamins/fluoride oral solution 0.5 /ml Quflora Pediatric poly vitamin oral tablet chewable Animal Shapes poly-vita oral solution 35 /ml polyvitamin oral solution 35 /ml triple-vitamin/fluoride oral solution 0.25 /ml tri-vit/fluoride oral solution 0.25 /ml, 0.5 /ml BProtected Pedia Poly- Vite BProtected Pedia Poly- Vite tri-vitamin oral solution 1500-400-35 BProtected Pedia Tri-Vite vitamins acd-fluoride oral solution 0.25 /ml TRI-VI-SOL ORAL SOLUTION 750-400-35 UNIT-MG/ML Prenatal Vitamin Preparations mynatal plus oral tablet Vitafol-OB mynatal-z oral tablet Vitafol-OB mynate 90 plus oral tablet extended release pnv prenatal plus multivitamin oral tablet 27-1 M-Vit prenatabs fa oral tablet 29-1 Co-Natal FA prenatal 19 oral tablet prenatal 19 oral tablet chewable prenatal low iron oral tablet 27-0.8 Right Step Prenatal prenatal low iron oral tablet 27-1 M-Vit prenatal one daily oral tablet 27-0.8 Right Step Prenatal prenatal oral tablet 27-0.8 Right Step Prenatal prenatal oral tablet 27-1 M-Vit prenatal oral tablet 28-0.8 prenatal plus iron oral tablet 29-1 Prenatabs Rx prenatal plus oral tablet 27-1 M-Vit 112
prenatal vitamin plus low iron oral tablet 27-1 M-Vit prenatal vitamins oral tablet 28-0.8 prenatal/iron oral tablet preplus oral tablet 27-1 M-Vit se-natal 19 oral tablet 29-1 se-natal 19 oral tablet chewable 29-1 thrivite 19 oral tablet 29-1 triadvance oral tablet 90-1 inatal Advance trinatal gt oral tablet 90-1 inatal Advance virt-advance oral tablet 90-1 inatal Advance virt-vite gt oral tablet 90-1 inatal Advance vol-plus oral tablet 27-1 M-Vit INATAL ADVANCE ORAL TABLET inatal Advance INATAL ULTRA ORAL TABLET inatal Advance MYNATAL ADVANCE ORAL TABLET inatal Advance MYNATAL ORAL CAPSULE MYNATAL ORAL TABLET 90-1 MG inatal Advance NIVA-PLUS ORAL TABLET 27-1 MG M-Vit O-CAL FA ORAL TABLET 27-1 MG M-Vit O-CAL PRENATAL ORAL TABLET PRENATABS RX ORAL TABLET 29-1 MG Prenatabs Rx TRINATE ORAL TABLET Vitamin A Preparations a-10000 oral capsule 10000 unit vitamin a oral capsule 10000 unit, 8000 unit vitamin a palmitate oral capsule 10000 unit Vitamin B1 Preparations b-1 oral tablet 100 thiamine hcl oral tablet 100 113
vitamin b-1 oral tablet 100 Vitamin B12 Preparations b-12 oral tablet 500 mcg vitamin b-12 oral tablet 500 mcg B-12 DOTS ORAL TABLET DISPERSIBLE 500 MCG Vitamin B6 Preparations b6 natural oral tablet 100 b-6 oral tablet 100, 250, 50 pyridoxine hcl oral tablet 100, 25, 50 vitamin b-6 er oral tablet extended release 200 vitamin b-6 oral tablet 100, 25, 50 vitamin b6 oral tablet 250 Vitamin C Preparations c 250 oral tablet 250 c 500 oral tablet 500 PureWay-C calcium ascorbate oral tablet 500 vitamin c oral syrup 500 /5ml vitamin c oral tablet 1000, 250 vitamin c oral tablet 500 PureWay-C v-r vitamin c oral tablet 1000 Vitamin D Preparations calcitriol oral capsule 0.25 mcg, 0.5 mcg Rocaltrol calcitriol oral solution 1 mcg/ml Rocaltrol ergocalciferol oral solution 8000 unit/ml Calcidol vitamin d (cholecalciferol) oral capsule 400 unit vitamin d (cholecalciferol) oral tablet 400 unit 114
vitamin d (ergocalciferol) oral capsule 50000 unit Drisdol vitamin d2 oral tablet 400 unit vitamin d3 oral capsule 400 unit vitamin d-400 oral tablet 400 unit CALCIDOL ORAL SOLUTION 8000 UNIT/ML CALCIFEROL ORAL SOLUTION 8000 UNIT/ML Weight Reduction Fat Absorption Decreasing Agents ALLI ORAL CAPSULE 60 MG Calcidol Calcidol PA 115
116
Index a-10000... 113 abacavir sulfate... 76 abacavir-lamivudine-zidovudine 75 ABILIFY... 17 ABILIFY MAINTENA...17 acamprosate calcium... 15 acetaminophen... 92, 93 acetaminophen extra strength...92 acetaminophen-codeine... 98 acetaminophen-codeine #2... 98 acetaminophen-codeine #3... 98 acetaminophen-codeine #4... 98 ACETASOL HC... 49 acetazolamide... 57 acetic acid...49 acetylcysteine...91 acyclovir... 74 ADACEL...67 ADASUVE...17 ADRUCIL... 88 adult mask large... 11 ADVATE... 59 adynovate...59 AFEDITAB CR... 29 AFLURIA... 65 AFLURIA PRESERVATIVE FREE... 65 AFLURIA QUADRIVALENT... 65 AFSTYLA... 59 ala-cort... 41 ALAVERT...6 ALAWAY... 54 albuterol sulfate... 8 albuterol sulfate er...8 alendronate sodium... 52 alfuzosin hcl er... 107 ALKERAN... 88 ALLI...115 allopurinol... 58 alogliptin benzoate...46 alogliptin-metformin hcl... 46 alogliptin-pioglitazone...46 ALOMIDE...56 ALORA... 64 ALPHAGAN P...57 ALPHANATE/VWF COMPLEX/HUMAN... 59 ALPHANINE SD... 61 alprazolam...15 ALPRAZOLAM INTENSOL... 15 ALPROLIX...61 aluminum hydroxide... 104 aluminum hydroxide gel...104 amantadine hcl...99 amiloride hcl...30 amiloride-hydrochlorothiazide...30 amino acid infusion... 91 amiodarone hcl... 24 AMITIZA... 85 amitriptyline hcl... 14 AMLACTIN...45 amlodipine besy-benazepril hcl..25 amlodipine besylate... 28 ammonium lactate... 45 amoxapine...14 amoxicillin... 70, 71 amoxicillin-pot clavulanate... 71 amoxicillin-pot clavulanate er... 71 amphetamine-dextroamphet er 14 amphetaminedextroamphetamine... 15 ampicillin... 71 anagrelide hcl... 63 ANALPRAM-HC... 83 anastrozole...88 ANDROXY...63 anefrin spray... 38 anefrin spray/moisturizing... 38 antacid...105 antacid advanced... 104 antacid calcium... 105 antacid calcium extra strength.105 antacid extra strength... 105 anucort-hc... 83 apap...93 apap extra strength...93 apraclonidine hcl... 57 APRODINE... 36 APTIVUS... 75 aripiprazole... 16 ARISTADA...17 ARMOUR THYROID... 53 ASCOMP-CODEINE...97 aspirin ec... 92 assure comfort lancets 28g... 85 assure comfort lancets 30g... 85 atenolol... 27 atenolol-chlorthalidone...27 atorvastatin calcium...31 ATRIPLA...79 atropine sulfate... 58 ATROVENT HFA...8 AVANDIA...47 azathioprine... 68 azelastine hcl...6 azithromycin...69, 70 AZO URINARY PAIN RELIEF...107 AZURETTE...34 b-1... 113 b-12... 114 B-12 DOTS... 114 b-6... 114 b6 natural... 114 bacitracin...55 bacitracin zinc...39 bacitracin-neomycin-polymyxin. 39 bacitracin-polymyxin b... 55 bacitra-neomycin-polymyxin-hc.54 baclofen...102 balsalazide disodium... 83 BASAGLAR KWIKPEN... 47 BD INSULIN SYR ULTRAFINE II... 86 BD INSULIN SYRINGE... 86 BD INSULIN SYRINGE HALF- UNIT... 86 BD INSULIN SYRINGE MICROFINE...86, 87 117
BD INSULIN SYRINGE ULTRAFINE... 87 BD LANCET ULTRAFINE 33G...86 BD PEN NEEDLE MINI U/F...91 BD PEN NEEDLE NANO U/F...91 BD PEN NEEDLE SHORT U/F...91 BD PEN NEEDLE ULTRAFINE...91 BD SAFETYGLIDE INSULIN SYRINGE... 87 BD SAFETY-LOK INSULIN SYRINGE... 87 BEBULIN... 61 BELBUCA... 96 benazepril hcl... 26 benazepril-hydrochlorothiazide. 25 BENEFIX...61 benzonatate... 36 benzoyl peroxide... 45 benzoyl peroxide wash...45 benzoyl peroxide-erythromycin. 39 benztropine mesylate...99 betamethasone dipropionate... 42 betamethasone dipropionate aug...41 betamethasone valerate... 42 betaxolol hcl... 57 bethanechol chloride... 87 BETIMOL...57 BETOPTIC-S... 57 BEVESPI AEROSPHERE... 9 BEXSERO...65 bicalutamide...88 BILTRICIDE...74 bisacodyl...85 bisacodyl ec... 84 bisacodyl laxative... 85 bismuth... 84 bismuth subsalicylate...84 bisoprolol fumarate...27 bisoprolol-hydrochlorothiazide..27 BLEPH-10...55 BLEPHAMIDE...55 BOOSTRIX...67 BREVICON (28)... 34 brimonidine tartrate... 57 bromocriptine mesylate...99 BROTAPP...36 brotapp dm... 37 budesonide...10 bumetanide... 30 BUNAVAIL... 99 BUPRENEX...99 buprenorphine hcl...98 buprenorphine hcl-naloxone hcl 98 bupropion hcl... 13 bupropion hcl er (smoking det) 103 bupropion hcl er (sr)...13 bupropion hcl er (xl)...13 buspirone hcl...15 butalbital-acetaminophen...92 butalbital-apap-caff-cod...97 butalbital-apap-caffeine...92 butalbital-asa-caff-codeine... 97 butalbital-aspirin-caffeine... 92 butorphanol tartrate... 93 BUTRANS...96 c 250... 114 c 500... 114 CAFERGOT...97 CALADRYL...44 calahist... 44 calamine medicated... 44 CALCIDOL... 115 CALCIFEROL...115 calcitonin (salmon)... 52 calcitriol...114 calcium 500 + d... 109 calcium 500 + d3... 109 calcium 500+d... 109 calcium 500+d high potency... 109 calcium 500+d3... 109 calcium acetate... 50 calcium acetate (phos binder)... 49, 50 calcium antacid... 105 calcium antacid extra strength.105 calcium ascorbate... 114 calcium carbonate...109 calcium carbonate antacid105, 109 calcium carbonate-vitamin d...109 calcium gluconate... 109 calcium high potency... 109 calcium lactate... 109 calcium oyster shell...109 calcium-vitamin d3...109 capecitabine... 88 captopril... 26 captopril-hydrochlorothiazide...25 carbamazepine... 100 carbamazepine er...100 carbamoxide ear drops... 49 CARBATROL...101 carbidopa-levodopa... 100 carbidopa-levodopa er... 99 carisoprodol... 102 CARNITOR SF...91 CARTIA XT... 29 carvedilol...25 CAYA...35 CEENU... 88 cefaclor...69 cefdinir... 69 celecoxib...81 CELONTIN...101 cephalexin... 69 CERVARIX... 67 cetirizine hcl... 6 cetirizine hcl childrens...6 CHANTIX...103 CHANTIX CONTINUING MONTH PAK...103 CHANTIX STARTING MONTH PAK...103 CHEMET...91 cheratussin ac...37 childrens ibuprofen... 81 chlordiazepoxide-clidinium... 105 chlorhexidine gluconate... 39, 89 chloroquine phosphate... 74 118
chlorothiazide...30 chlorpheniramine maleate...5 chlorpromazine hcl...20 chlorthalidone... 30 cholestyramine...31 cholestyramine light...31 ciclopirox... 40 ciclopirox olamine... 40 cilostazol...62 CILOXAN...56 cimetidine...106 cimetidine 200...106 cimetidine hcl... 106 ciprofloxacin hcl... 56, 71 citalopram hydrobromide... 13 citrate of magnesia...84 citric acid-sodium citrate...107 clarithromycin... 70 clemastine fumarate... 5 CLEOCIN... 108 clindamycin hcl...73 clindamycin palmitate hcl... 73 clindamycin phosphate... 39, 108 CLINIMIX/DEXTROSE (4.25/5)... 91 clobetasol propionate... 42 clomipramine hcl...14 clonazepam... 100 clonidine hcl... 27 clopidogrel bisulfate...63 clotrimazole...40, 72, 108 clotrimazole-7... 108 clozapine... 17 CLOZARIL...18 COAGADEX...62 codeine sulfate...93 COGENTIN... 99 colchicine...58 colchicine-probenecid... 58 COLESTID FLAVORED... 31 colestipol hcl... 31 COLOCORT... 84 COMBIVENT RESPIMAT... 9 COMBIVIR... 75 COMPLERA... 79 complete lice treatment...40 COMPRO... 7 constulose... 84 CORIFACT... 61 CORTISPORIN... 41 COUMADIN... 59 COVARYX...63 COVARYX HS... 63 CRIXIVAN...78 cromolyn sodium...6, 56 CUPRIMINE... 80 cyclobenzaprine hcl...102 cyclopentolate hcl... 58 cyclophosphamide... 88 cyclosporine... 68 cyclosporine modified... 68 cyproheptadine hcl...5 cytra-2... 107 CYTRA-3...107 danazol... 53 dapsone...73 DEBROX...49 DELTASONE... 81 DELZICOL... 83 DEPAKENE... 101 DEPO-PROVERA... 64 DESCOVY... 75 desipramine hcl... 14 desmopressin ace rhinal tube... 51 desmopressin ace spray refrig... 51 desmopressin acetate... 52 desmopressin acetate spray...52 desogestrel-ethinyl estradiol...33 desonide...42, 43 dexamethasone...80 DEXAMETHASONE INTENSOL...81 dexamethasone sodium phosphate... 54 dextroamphetamine sulfate...15 dextroamphetamine sulfate er.. 15 dextromethorphan-guaifenesin. 38 dextrose... 58 dextrose in lactated ringers...58 dextrose-nacl...58 DIASTIX...48 diazepam... 15, 100 DIAZEPAM INTENSOL... 15 diclofenac sodium... 54, 81 diclofenac sodium er... 81 dicloxacillin sodium... 71 dicyclomine hcl...104 DIFFERIN...39 diflunisal... 92 DIGITEK... 24 DIGOX...24 digoxin...24 DILANTIN...102 DILANTIN INFATABS... 102 diltiazem cd... 28 diltiazem hcl... 28 diltiazem hcl er... 28 diltiazem hcl er beads...28 diltiazem hcl er coated beads...28 dilt-xr... 29 dioctyl s.s...84 DIPENTUM... 83 diphenhydramine hcl... 5 diphenoxylate-atropine...84 dipyridamole... 63 disopyramide phosphate...24 disulfiram... 15 DIURIL... 30 divalproex sodium...100 docusate sodium... 84 DOK... 85 donepezil hcl... 12 dorzolamide hcl...57 dorzolamide hcl-timolol mal... 57 double antibiotic... 39 doxazosin mesylate... 25 doxepin hcl... 14 doxycycline hyclate... 72, 90 doxycycline monohydrate... 72 DRAMAMINE LESS DROWSY... 7 DRITHO-CREME HP... 45 119
DROXIA...63 DRYSOL...44 ducodyl...84 duloxetine hcl...14 E.E.S. 400...70 E.E.S. GRANULES...70 ear drops... 49 ear drops earwax aid...49 ear wax removal drops...49 ear wax removal kit...49 earwax treatment drops... 49 EASIVENT MASK LARGE...11 EDURANT... 76 EEMT... 63 EEMT HS... 63 EFFER-K... 51 effervescent pot chloride... 50 ELIDEL...45 ELIPHOS...50 ELIXOPHYLLIN... 11 ELOCTATE...59 EMCYT... 89 EMSAM... 21 EMTRIVA... 77 EMVERM... 74 enalapril maleate... 26 ENDOCET...96 ENGERIX-B...67 enoxaparin sodium...62 entacapone... 100 enulose...84 ephrine nose drops... 38 EPIFOAM... 45 epinephrine... 87 EPIVIR...77 EPIVIR HBV...79 EPOGEN...62 EPZICOM... 75 ergocalciferol...114 ERRIN...34 ery... 39 ERY-TAB...70 ERYTHROCIN STEARATE...70 erythromycin... 39, 56 erythromycin base... 70 erythromycin ethylsuccinate...70 escitalopram oxalate... 13 est estrogens-methyltest... 63 est estrogens-methyltest hs...63 ESTRACE... 108 estradiol...63, 64 ethambutol hcl... 73 ethosuximide...100 etodolac er... 81 etoposide... 89 EVOTAZ... 78 EVZIO...21 EXCEDRIN MIGRAINE...92 E-Z JECT LANCETS THIN 26G... 86 famotidine...106 FANAPT... 18 FANAPT TITRATION PACK...18 FARESTON... 89 FAZACLO...18 FC2 FEMALE CONDOM...90 FEIBA... 59 felodipine er... 29 fenofibrate... 31 fenofibrate micronized...31 fentanyl... 93, 94 FEOSOL...111 fer-iron... 110 FEROSUL...111 ferrex 150 forte... 110 ferrous sulfate... 110, 111 fexofenadine hcl...6 finasteride... 107 flecainide acetate... 24 FLOVENT DISKUS...10 FLOVENT HFA...10 FLUAD...65 FLUARIX QUADRIVALENT... 65 FLUBLOK...66 FLUCELVAX QUADRIVALENT... 66 fluconazole... 72 fluconazole in dextrose... 72 flucytosine... 72 fludrocortisone acetate...81 FLULAVAL QUADRIVALENT...66 fluocinolone acetonide...43 fluocinonide... 43 fluoritab...110 fluorometholone... 54 fluoxetine hcl...13 fluoxetine hcl (pmdd)... 13 fluphenazine decanoate...20 fluphenazine hcl... 20, 21 flurazepam hcl...21 flurbiprofen... 81 flurbiprofen sodium... 54 flutamide... 88 fluticasone propionate... 6 fluticasone-salmeterol... 10 FLUVIRIN... 66 fluvoxamine maleate...13 FLUZONE HIGH-DOSE...66 FLUZONE QUADRIVALENT... 66 FML...55 FML FORTE... 55 folic acid... 110 FOLITAB 500...111 FORADIL AEROLIZER... 9 FOSAMAX PLUS D... 52 fosinopril sodium...26 FOSRENOL... 50 FREESTYLE INSULINX TEST...47 FREESTYLE LANCETS...86 FREESTYLE LITE TEST... 47 FREESTYLE TEST... 47 furosemide... 30 FUZEON... 76 gabapentin... 100, 101 GARDASIL...67 GARDASIL 9... 67 GAS-X EXTRA STRENGTH... 104 GAVILYTE-C... 85 GAVISCON EXTRA RELIEF FORMULA...105 GAVISCON EXTRA STRENGTH..105 120
gemfibrozil...31 generlac...84 GENGRAF...68 GENTAK... 56 gentamicin sulfate...39, 56 GENVOYA... 79 GEODON...18 GLEOSTINE... 88 glimepiride... 46 glipizide... 46 glipizide er... 46 glipizide xl...46 GLUCAGON EMERGENCY...47 glyburide... 46 glyburide-metformin...47 glycerin (adult)... 85 glycerin (infants & children)... 85 granisetron hcl... 7 griseofulvin microsize...72 griseofulvin ultramicrosize... 73 guaifenesin ac...37 guaifenesin er...37 guaifenesin-codeine... 37 guaifenesin-dm...38 guanfacine hcl... 27 HALDOL... 20 HALDOL DECANOATE...20 haloperidol... 20 haloperidol decanoate... 20 haloperidol lactate... 20 HAVRIX...67 h-e-b oral electrolyte...50 HELIXATE FS... 59 HEMATOGEN...111 HEMOFIL M... 60 heparin sodium (porcine)...62 HEXALEN... 88 HOMATROPAIRE...58 homatropine hbr... 58 HUMALOG...48 HUMALOG KWIKPEN... 47 HUMALOG MIX 75/25... 48 HUMALOG MIX 75/25 KWIKPEN...47 HUMATE-P... 60 HUMULIN 70/30... 48 HUMULIN 70/30 KWIKPEN...48 HUMULIN N...48 HUMULIN R...48 HUMULIN R U-500 (CONCENTRATED)... 48 hydralazine hcl... 27 hydrochlorothiazide... 30 hydrocodone-acetaminophen...94 hydrocortisone... 43, 80, 83 hydrocortisone ace-pramoxine.. 83 hydrocortisone acetate... 83 hydrocortisone valerate... 43 hydrocortisone-acetic acid...49 hydrocortisone-aloe... 44 hydromorphone hcl...94 hydroxychloroquine sulfate... 74 hydroxyurea... 88 hydroxyzine hcl...5 hydroxyzine pamoate...5 hyoscyamine sulfate...104 hyoscyamine sulfate er... 104 hyosyne... 104 HYPERTET S/D...64 ibu-200... 81 ibu-drops... 81 ibuprofen...82 ibuprofen junior strength...81 IDELVION...61 IFEREX 150 FORTE...111 imipramine hcl...14 IMOVAX RABIES...66 INATAL ADVANCE... 113 INATAL ULTRA...113 INCRUSE ELLIPTA... 8 indapamide... 30 indomethacin... 82 indomethacin er... 82 infants ibuprofen...82 infants simethicone...103 INTELENCE...76 INTRON A... 68 INVEGA...18 INVEGA SUSTENNA...18 INVEGA TRINZA...18 INVIRASE... 78 IOPIDINE...57 ipratropium bromide...8, 90 iron... 111 iron high-potency... 111 ISENTRESS... 78 isometheptene-dichloral-apap...96 isoniazid...73 isosorbide dinitrate... 32 isosorbide dinitrate er...32 isosorbide mononitrate...32 isosorbide mononitrate er... 32 itraconazole...72 IXINITY...61 JANTOVEN...59 JOLIVETTE...34 KALETRA...77 KARIVA... 34 k-effervescent... 50 ketoconazole... 40, 72 ketoprofen...82 ketorolac tromethamine... 55 ketotifen fumarate... 54 kidkare cough/cold...37 KIONEX...50 KLOR-CON M10...51 KLOR-CON M20...51 KLOR-CON SPRINKLE...51 KOATE-DVI... 60 KOGENATE FS...60 KOGENATE FS BIO-SET...60 KOVALTRY... 60 k-vescent... 51 labetalol hcl... 25 lactulose... 85 lactulose encephalopathy... 84 LAMISIL AT SPRAY...40 lamivudine...76, 77, 79 121
lamivudine-zidovudine... 75 lamotrigine... 101 lancets... 85 lancets 30g... 86 LANCETS ULTRA FINE...86 LANOXIN... 24 lansoprazole... 106 latanoprost...57 LATUDA... 18 laxative... 85 LEENA... 34 leflunomide... 80 letrozole... 88 leucovorin calcium... 89 LEUKERAN... 88 leuprolide acetate... 52 levetiracetam... 101 levetiracetam er... 101 levobunolol hcl... 57 levocarnitine...90, 91 levofloxacin... 72 levonorgestrel... 34 levonorgestrel-ethinyl estrad...34 levonorg-eth estrad triphasic...34 LEVORA 0.15/30 (28)... 34 LEVO-T...53 levothyroxine sodium...53 LEVOXYL... 53 LEXIVA... 78 lice killing maximum strength... 41 lice solution... 41 lice treatment...41 lidocaine viscous... 82 lisinopril...26 lisinopril-hydrochlorothiazide... 25 LITETOUCH MASK LARGE...11 LITETOUCH MASK MEDIUM... 11 LITETOUCH MASK SMALL... 11 lithium... 16 lithium carbonate...16 lithium carbonate er...16 LITHOBID...16 LITTLE NOSES DECONGESTANT. 38 lomustine... 88 loperamide hcl...84 loratadine... 6 lorazepam...15 LORAZEPAM INTENSOL... 16 losartan potassium...26 losartan potassium-hctz... 26 LOTRIMIN AF...40 lovastatin...31 LOW-OGESTREL...34 loxapine succinate...17 LUPRON DEPOT-PED (1- MONTH)... 52 LYSODREN... 89 MAALOX ADVANCED... 105 mag-al plus... 105 mag-al plus xs...105 magnesium citrate... 85 MAKENA...64 MARPLAN...13 MATULANE...89 MAVYRET... 80 meclizine hcl...7 medical provider ez afluria pf...65 medical provider ez flu shot...65 MEDICAL PROVIDER EZ FLUVIRIN... 66 medi-first triple antibiotic... 40 MEDISENSE THIN LANCETS...86 medroxyprogesterone acetate... 33, 64 mefloquine hcl...74 megestrol acetate... 89, 90 meloxicam... 82 memantine hcl... 12 MENACTRA... 65 MENEST...64 MENOMUNE... 65 MENVEO...65 meperidine hcl... 94 MEPHYTON... 63 mercaptopurine... 88 mesalamine... 82 MESTINON... 12 METADATE ER...23 metaproterenol sulfate... 9 metformin hcl...47 metformin hcl er... 47 methadone hcl... 94, 95 METHADONE HCL INTENSOL... 96 METHADOSE... 96 methazolamide...57 methimazole... 53 methocarbamol...102 methotrexate... 88 methyclothiazide...30 methyldopa... 27 methylergonovine maleate... 36 methylphenidate hcl... 23 methylphenidate hcl er... 22, 23 methylphenidate hcl er (cd)... 22 methylprednisolone... 80 metoclopramide hcl... 106 metolazone... 30 metoprolol succinate er... 27 metoprolol tartrate... 27 metronidazole... 38, 39, 74, 108 metronidazole in nacl...74 mexiletine hcl... 24 MICATIN...40 miconazole 7... 108 miconazole nitrate... 40, 108 MICROGESTIN 1.5/30... 34 MICROGESTIN FE 1.5/30...34 MICROGESTIN FE 1/20...34 MILLIPRED...81 MILLIPRED DP... 81 MINITRAN... 33 MINIVELLE...64 minocycline hcl...72 minoxidil...27 mirtazapine... 12 misoprostol... 105 M-M-R II... 67 moexipril hcl...26 molindone hcl...20 122
mometasone furoate... 44 MONISTAT 3...108 MONISTAT 7 SIMPLY CURE...108 MONOCLATE-P...60 MONONINE...62 montelukast sodium...10, 11 morphine sulfate...95 morphine sulfate (concentrate). 95 morphine sulfate er...95 motion sickness relief...7 motion-time... 7 MOTRIN INFANTS DROPS... 82 moxifloxacin hcl...72 mucus-dm...38 mucus-er... 37 multi vitamin/fluoride... 111 multi-vit/fluoride...111 multi-vit/fluoride/iron...111 multi-vitamin/fluoride...111 multi-vitamin/fluoride/iron...111 multi-vitamins/fluoride... 112 mupirocin... 40 mupirocin calcium... 40 MURINE EAR... 49 MURINE EAR WAX REMOVAL SYSTEM... 49 MURO 128...56 mycophenolate mofetil...68 myferon 150 forte... 111 MYLERAN... 88 MYNATAL... 113 MYNATAL ADVANCE...113 mynatal plus... 112 mynatal-z...112 mynate 90 plus...112 NABI-HB... 64 nadolol...27 naloxone hcl... 21 naltrexone hcl...21 naproxen... 82 naproxen kit... 82 naproxen sodium... 82 NARCAN... 21 NARDIL... 13 NASACORT ALLERGY 24HR... 6 NASACORT ALLERGY 24HR CHILDREN... 6 nateglinide...46 NEBUSAL... 90 NECON 0.5/35 (28)...35 NECON 1/35 (28)...35 NECON 1/50 (28)...35 NECON 10/11 (28)...35 NECON 7/7/7... 35 neomycin sulfate...73 neomycin-bacitracin zn-polymyx56 neomycin-polymyxin-dexameth.54 neomycin-polymyxin-gramicidin 56 neomycin-polymyxin-hc... 49, 54 NEO-POLYCIN...56 NEO-POLYCIN HC... 54 NEO-SYNEPHRINE... 38 NEO-SYNEPHRINE COLD & SINUS...38 nevirapine... 76 nevirapine er... 76 niacin... 32 niacin er...32 nicardipine hcl... 29 nicotine...103 nicotine polacrilex... 102, 103 nicotine step 1...103 nicotine step 2...103 nicotine step 3...103 NICOTROL...103 NICOTROL NS... 103 NIFEDICAL XL...29 nifedipine... 29 nifedipine er... 29 nifedipine er osmotic release...29 nisoldipine er...29 NITRO-BID... 33 NITRO-DUR... 33 nitrofurantoin...70 nitrofurantoin macrocrystal... 70 nitrofurantoin monohyd macro. 70 nitroglycerin... 32, 33 nitroglycerin er...32 NITRO-TIME... 33 NIVA-PLUS...113 NODOLOR...97 non-aspirin pain relief... 93 NORA-BE... 35 norethin ace-eth estrad-fe... 34 norethindrone... 34 norethindrone acetate... 64 norethindrone acet-ethinyl est.. 34 norgestimate-eth estradiol... 34 norgestim-eth estrad triphasic...34 NORTREL 0.5/35 (28)... 35 NORTREL 1/35 (21)... 35 NORTREL 1/35 (28)... 35 NORTREL 7/7/7...35 nortriptyline hcl...14 NORVIR... 78 NOVOEIGHT... 60 NOVOFINE...91 NOVOFINE AUTOCOVER... 91 NOVOFINE PLUS...91 NOVOLIN 70/30... 48 NOVOLIN 70/30 RELION... 48 NOVOLIN N... 48 NOVOLIN N RELION... 48 NOVOLIN R...48 NOVOLIN R RELION...48 NOVOSEVEN RT... 60 np thyroid...53 NUPLAZID...22 NUVARING... 33 NUWIQ... 60 nystatin...40, 73 obizur... 59 O-CAL FA... 113 O-CAL PRENATAL... 113 ODEFSEY...79 ofloxacin... 49, 56 OGESTREL...35 olanzapine... 17 olanzapine-fluoxetine hcl... 22 123
omega-3-acid ethyl esters...32 omeprazole... 106 ondansetron...7 ondansetron hcl... 7 OPTICHAMBER DIAMOND...11 OPTICHAMBER DIAMOND-LG MASK...11 OPTICHAMBER DIAMOND-MD MASK...11 OPTICHAMBER DIAMOND-SM MASK...11 ORALONE... 90 ORALYTE...50 ORAP... 16 oxazepam... 15 oxcarbazepine... 101 oxybutynin chloride...108 oxybutynin chloride er... 108 oxycodone hcl... 95 oxycodone hcl er... 95 oxycodone-acetaminophen... 96 oxycodone-aspirin...96 OYSCO 500... 110 OYSCO 500+D...110 OYSCO D...110 oyster shell calcium...109 oyster shell calcium + d3... 109 oyster shell calcium 500 + d... 109 oyster shell calcium/d... 109 oyster shell calcium/d3... 110 OYSTERCAL-D...110 PACERONE...24 pain relief extra strength...93 pain reliever... 93 paliperidone er...17 pancrelipase (lip-prot-amyl)...104 pantoprazole sodium... 106 PARNATE...13 PAROEX... 90 paromomycin sulfate... 73 paroxetine hcl...13 pedia relief cough/cold... 37 PEDIA-LAX... 85 pediatric cough/cold... 37 pediatric electrolyte... 106 pediatric electrolyte-zinc...50 pediatric medium mask...11 pediatric small mask...11 peg 3350/electrolytes... 85 PEG-INTRON REDIPEN... 79 pen needles 3/16"...91 pen needles 5/16"...91 penicillin v potassium...71 PENTASA... 83 pentoxifylline er... 62 PERIOGARD...90 permethrin... 41 perphenazine... 21 PFLEX...11 PHARMACIST CHOICE LANCETS.86 PHENADOZ...7 phenazopyridine hcl... 107 phenelzine sulfate... 12 phenobarbital...21 phenoxybenzamine hcl... 25 phenyleph-promethazine-cod...37 phenylephrine hcl...55 phenylhistine dh...37 phenytoin... 101 PHENYTOIN INFATABS...102 phenytoin sodium extended... 101 PHOS FLUR... 110 PHOS-FLUR ORTHO DEFENSE.. 110 PHOSPHASAL... 69 PHOSPHOLINE IODIDE... 57 pilocarpine hcl... 57 pimozide...16 pindolol... 28 pioglitazone hcl... 46 piroxicam...82 PNEUMOVAX 23... 65 pnv prenatal plus multivitamin 112 podofilox... 45 poly vitamin...112 POLYCIN... 56 polyethylene glycol 3350... 85 poly-iron 150 forte... 111 polymyxin b-trimethoprim... 56 poly-vita...112 polyvitamin...112 pot & sod cit-cit ac... 107 potassium...51 potassium chloride...51 potassium chloride crys er... 51 potassium chloride er...51 potassium chloride in nacl...51 potassium gluconate... 51 pramipexole dihydrochloride...100 prazosin hcl... 25 PRED MILD... 55 prednicarbate...44 prednisolone... 80 prednisolone acetate... 55 prednisolone sodium phosphate... 55, 80 prednisone... 80, 81 PREDNISONE INTENSOL...81 preferred plus lancets thin... 86 PREMARIN...64, 108 premium condoms lubricated...90 PREMPHASE... 64 PREMPRO...64 prenatabs fa... 112 PRENATABS RX... 113 prenatal... 112 prenatal 19... 112 prenatal low iron...112 prenatal one daily... 112 prenatal plus... 112 prenatal plus iron... 112 prenatal vitamin plus low iron. 113 prenatal vitamins... 113 prenatal/iron... 113 preplus... 113 PREVALITE...31 PREVNAR 13...65 PREZCOBIX... 75 PREZISTA... 75 PRIFTIN...73 124
primaquine phosphate...74 primidone...101 PROAIR HFA... 8 probenecid... 58 PROBUPHINE IMPLANT KIT... 99 prochlorperazine... 7 prochlorperazine maleate...7 PROCRIT... 62 PROCTOFOAM HC...83 PROCTO-PAK...83 PROCTOSOL HC... 83 PROCTOZONE-HC...83 PROFILNINE...62 PROFILNINE SD... 62 promethazine hcl...5, 7 promethazine vc plain...36 promethazine vc/codeine... 37 promethazine-codeine... 37 promethazine-dm...38 promethazine-phenylephrine... 36 PROMETHEGAN... 7, 8 propafenone hcl... 24 propantheline bromide... 105 proparacaine hcl...55 propranolol hcl... 28 propranolol hcl er...28 propylthiouracil... 53 pseudoephedrine hcl...38 pseudoephedrine hcl er... 36 pseudoephedrine-guaifenesin er... 36 PULMICORT FLEXHALER... 10 pyrazinamide...73 pyridostigmine bromide...12 pyridostigmine bromide er...12 pyridoxine hcl... 114 Q-TAPP... 36 Q-TAPP DM... 38 quetiapine fumarate... 17 quinapril hcl...26 quinidine gluconate er... 24 quinidine sulfate...24 QVAR...10 RABAVERT...66 ramipril...26 ranitidine hcl... 106 RAPAMUNE...68 RECOMBINATE... 60 RECOMBIVAX HB... 67 RELENZA DISKHALER...74 RESCRIPTOR... 76 reserpine... 27 REVIA...21 REXULTI...17 REYATAZ...78 RHEUMATREX... 80 RIBASPHERE... 79 ribavirin... 79 RID...41, 90 RID COMPLETE LICE ELIMINATION... 41 RID ESSENTIAL LICE ELIMINATION... 41 RID LICE KILLING SHAMPOO...41 RIDAURA... 81 rifampin...73 riluzole...89 ringers... 50 RISPERDAL...19 RISPERDAL CONSTA... 19 RISPERDAL M-TAB... 19 risperidone... 17, 18 RISPERIDONE M-TAB... 19 rixubis...61 rizatriptan benzoate...96 ropinirole hcl... 100 rynex pse... 36 salsalate...92 SANDIMMUNE... 68 SANTYL... 45 SAPHRIS...19 sapscare twist top lancets... 86 SAVELLA... 89 SAVELLA TITRATION PACK...89 selegiline hcl...100 selenium sulfide... 44 SELSUN BLUE DAILY... 44 SELSUN BLUE MEDICATED...44 SELSUN BLUE MOISTURIZING...45 SELZENTRY... 75 se-natal 19...113 SENSIPAR... 52 SEREVENT DISKUS...9 SEROQUEL...19 SEROQUEL XR...19 sertraline hcl...13 silicone mask/infant... 11 silver sulfadiazine... 41 simethicone...103, 104 simvastatin... 31 slow release iron... 111 sochlor...56 sod citrate-citric acid...107 sodium chloride...45, 51, 90 sodium chloride (hypertonic)... 56 sodium fluoride... 110 sodium polystyrene sulfonate...50 SORINE... 28 sotalol hcl... 28 sotalol hcl (af)...28 spironolactone... 30 spironolactone-hctz...30 SPS...50 SSD... 41 stavudine...77 STERILANCE PA... 86 STERILANCE TL... 86 stop lice complete treatment...41 stop lice maximum strength...41 STRATTERA...24 STRIBILD... 79 SUBOXONE...99 sucralfate...105 sulfacetamide sodium... 55 sulfacetamide-prednisolone... 55 sulfamethoxazole-trimethoprim... 68, 69 sulfasalazine... 83 SULFATRIM PEDIATRIC... 69 125
sulindac... 82 sumatriptan...97 sumatriptan succinate...97 sumatriptan succinate refill...97 SUSTIVA... 76 SYMBYAX... 22 SYNAREL...52 SYNTHROID... 53 TABLOID... 88 tacrolimus...45, 68 TAMIFLU...74 tamoxifen citrate...89 tamsulosin hcl... 107 TAZTIA XT...29 TEGRETOL...102 TEGRETOL-XR... 102 temazepam...22 temozolomide... 88 TENCON...92 TENIVAC... 67 terazosin hcl... 25 terbinafine hcl... 40, 72 terbutaline sulfate...8 testosterone...63 tetanus-diphtheria toxoids td... 66 THALOMID... 73 THEO-24... 12 THEOCHRON... 12 theophylline... 11 theophylline er... 11 thiamine hcl...113 thioridazine hcl...21 thiothixene... 20 thrivite 19...113 timolol maleate... 57 tioconazole-1...108 TIVICAY...78 TOBRADEX... 54 tobramycin... 56 tobramycin-dexamethasone... 54 TOBREX... 56 tolbutamide...46 tolmetin sodium... 82 tolnaftate...40 topiramate... 101 tramadol hcl... 96 trandolapril...26 tranylcypromine sulfate... 12 trazodone hcl...13 tretinoin... 89 TRETTEN... 62 triadvance...113 triamcinolone acetonide.. 6, 44, 90 triamterene-hctz... 30 triazolam... 22 tricitrates...107 trifluoperazine hcl... 21 trifluridine... 55 TRIGLIDE...32 trihexyphenidyl hcl...99 trimethobenzamide hcl... 7 trimethoprim...69 trinatal gt...113 TRINATE... 113 triple antibiotic...40 triple-vitamin/fluoride... 112 TRIUMEQ...79 TRI-VI-SOL... 112 tri-vit/fluoride...112 tri-vitamin...112 TRIZIVIR...75 TRUMENBA... 65 TRUVADA... 75 TWINRIX...67 TYBOST...79 ULTICARE INSULIN SAFETY SYR. 87 UNITHROID... 54 URETRON D/S... 69 urin ds...69 urinary pain relief...107 ursodiol... 84 VAGISTAT-1...108 valacyclovir hcl... 74 valproate sodium... 101 valproic acid... 101 valsartan...27 valsartan-hydrochlorothiazide... 26 VANDAZOLE... 108 VAQTA...67 VARIVAX...67 VCF VAGINAL CONTRACEPTIVE. 33 VEMLIDY...79 venlafaxine hcl...14 venlafaxine hcl er... 14 VENTOLIN HFA... 8 verapamil hcl... 29 verapamil hcl er...29 VERSACLOZ... 19 VICKS SINEX 12 HOUR DECONGEST... 38 VIRACEPT... 78 VIRAMUNE...76 VIRAMUNE XR...76 VIREAD... 77 virt-advance...113 virtrate-2... 107 virtrate-3... 107 virtussin a/c... 37 virt-vite gt...113 vitamin a...113 vitamin a palmitate... 113 vitamin b-1... 114 vitamin b-12... 114 vitamin b6... 114 vitamin b-6... 114 vitamin b-6 er... 114 vitamin c...114 vitamin d (cholecalciferol)...114 vitamin d (ergocalciferol)... 115 vitamin d2... 115 vitamin d3... 115 vitamin d-400... 115 vitamins acd-fluoride...112 VITEKTA...79 VIVITROL... 15 vol-plus...113 VONVENDI... 61 v-r vitamin c...114 VRAYLAR... 16 126
warfarin sodium... 59 WIDE-SEAL DIAPHRAGM 60... 35 WIDE-SEAL DIAPHRAGM 65... 35 WIDE-SEAL DIAPHRAGM 70... 35 WIDE-SEAL DIAPHRAGM 75... 36 WIDE-SEAL DIAPHRAGM 80... 36 WIDE-SEAL DIAPHRAGM 85... 36 WIDE-SEAL DIAPHRAGM 90... 36 WIDE-SEAL DIAPHRAGM 95... 36 WILATE...61 XULANE... 35 XYNTHA...61 XYNTHA SOLOFUSE...61 zaleplon... 22 ZANTAC 75... 106 ZENCHENT... 35 ZENZEDI...15 ZEPHREX-D... 38 ZERIT... 77 ZETIA... 32 ZIAGEN... 77 ziprasidone hcl... 18 zolpidem tartrate... 22 zonisamide... 101 ZOSTAVAX...67 ZOVIA 1/35E (28)... 35 ZOVIA 1/50E (28)... 35 ZUBSOLV... 99 ZYPREXA...19 ZYPREXA RELPREVV... 19 ZYPREXA ZYDIS... 19 127
Discrimination is Against the Law Care1st Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Care1st Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Care1st Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact our Member Services Department at 1-800-605-2556 (TTY: 711), during 8am-8pm, seven days a week. If you believe that Care1st Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Michelle Pacheco, Grievance Coordinator. Mailing Address: ATTN: Civil Rights Coordinator Grievances Department - Care1st Health Plan 601 Potrero Grande Dr. Monterey Park, CA 91755 Telephone Number: 1-844-883-2233 (TTY: 711), from 7:00am to 8:00pm, during Monday through Friday Fax Number: 1-323-889-2228 Email Address: CRC@care1st.com Grievances must be submitted to CRC@care1st.com within 60 calendar days from the time you have become aware of any alleged discrimination. A complaint must be in writing, or reported verbally, containing your name and address. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought. You can also go to our website at https:// and submit your complaint. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Such complaints must be filed within 180 days from the date of the alleged discrimination. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. IMPORTANT NOTE: To view this notice in a different language, you can go to our website at https:///affordable-care-act.asp.
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