2019 list of covered drugs (formulary) · 2 2 unitedhealthcare connected® (medicare-medicaid plan)...

2019LIST OF COVERED DRUGS (FORMULARY)

UnitedHealthcare Connected® (Medicare-Medicaid Plan)

Toll-free 1-800-256-6533, TTY 7-1-18 a.m. - 8 p.m. local time, Monday - Friday

www.UHCCommunityPlan.comwww.myuhc.com/CommunityPlan

Formulary ID Number 00019088, Version 17H7833_180629_022455_v01.13 Approved Last updated December 1, 2019

Prescription drug list information

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UnitedHealthcare Connected® (Medicare-Medicaid Plan)

2019 List of Covered Drugs (Formulary)

IntroductionThis document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs are covered by UnitedHealthcare Connected. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UnitedHealthcare Connected. Key terms and their definitions appear in the last chapter of the Member Handbook.

Table of Contents

A. Disclaimers..............................................................................................................................................3

B. Frequently Asked Questions (FAQ)...................................................................................................... 4

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.).................................................................................................... 4

B2. Does the Drug List ever change?...................................................................................................4

B3. What happens when there is a change to the Drug List?............................................................5

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?..................................................................................................................................6

B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?............................................................................................................................... 7

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?.....................................................7

B7. How can you find a drug on the Drug List?.................................................................................. 7

B8. What if the drug you want to take is not on the Drug List?..........................................................8

B9. What if you are a new UnitedHealthcare Connected member and can’t find your drug on the Drug List or have a problem getting your drug?...........................................................................8

B10. Can you ask for an exception to cover your drug?.................................................................... 9

B11. How can you ask for an exception?.............................................................................................9

B12. How long does it take to get an exception?................................................................................9

B13. What are generic drugs?............................................................................................................ 10

B14. What are OTC drugs?.................................................................................................................10

B15. What is your copay?................................................................................................................... 10

C. List of Covered Drugs.......................................................................................................................... 11

D. List of Drugs by Medical Condition.................................................................................................... 13

E. Index of Covered Drugs..................................................................................................................... 145

If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.

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A. Disclaimers

This is a list of drugs that members can get in UnitedHealthcare Connected.

v UnitedHealthcare Connected® (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.

v The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

v Benefits and/or copays may change on January 1 of each year.

v You can always check UnitedHealthcare Connected’s up-to-date List of Covered Drugs online at www.UHCCommunityPlan.com.

v Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook.

v Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details.

v ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free.

v ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al 1-800-256-6533, TTY 7-1-1, de 8 a.m. a 8 p.m., hora local, de lunes a viernes. La llamada es gratuita.

v You can get this document for free in other formats, such as large print, braille, or audio. Call 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free.

v You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future.


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B. Frequently Asked Questions (FAQ)Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

B1. What prescription drugs are on the List of Covered Drugs? (We call the List

of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 13 are the drugs covered by UnitedHealthcare Connected. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”· UnitedHealthcare Connected will cover all medically necessary drugs on the Drug List

if:

o Your doctor or other prescriber says you need them to get better or stay healthy, and

o You fill the prescription at a UnitedHealthcare Connected network pharmacy.

· UnitedHealthcare Connected may have additional steps to access certain drugs (see question B4 below).

You can also see an up-to-date list of drugs that we cover on our website at www.UHCCommunityPlan.com or call Member Services at 1-800-256-6533, TTY 7-1-1.

B2. Does the Drug List ever change?

Yes. UnitedHealthcare Connected may add or remove drugs on the Drug List during the year.

We may also change our rules about drugs. For example, we could:

· Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Connected before you can get a drug.)

· Add or change the amount of a drug you can get (called quantity limits).

· Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, see question B4.

This section is continued on the next page.


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If you are taking a Medicare Part D drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:

· A new, cheaper drug comes along that works as well as a drug on the Drug List now, or

· We learn that a drug is not safe, or

· A drug is removed from the market.

Questions B3 and B6 below have more information on what happens when the Drug List changes.

· You can always check UnitedHealthcare Connected’s up-to-date Drug List online at www.UHCCommunityPlan.com.

· You can also call Member Services to check the current Drug List at 1-800-256-6533, TTY 7-1-1.

B3. What happens when there is a change to the Drug List?

Some changes to the Drug List will happen immediately. For example:

· A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits.

o We may not tell you before we make this change, but we will send you information about the specific change or changes we made.

o You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see questions B10 - B12 for more information on exceptions.

· A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Contact your doctor or other prescriber and ask about your other options.



66We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

· The FDA provides new guidance or there are new clinical guidelines about a drug.

· We add a generic drug that is not new to the market and

· Replace a brand name drug currently on the Drug List or

· Change the coverage rules or limits for the brand name drug.

When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can:

· Get at least a 30-day supply of the drug before the change to the Drug List is made, or

· Ask for an exception from these changes. Please see questions B10 - B12 for more information about exceptions.

B4. Are there any restrictions or limits on drug coverage or any required actions

to take to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you

or your doctor or other prescriber must do something before you can get the drug. For example:

· Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected before you fill your prescription. UnitedHealthcare Connected may not cover the drug if you do not get approval.

· Quantity limits: Sometimes UnitedHealthcare Connected limits the amount of a drug you can get.

· Step therapy: Sometimes UnitedHealthcare Connected requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 13 - 144. You can also get more information by visiting our website at www.UHCCommunityPlan.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.



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You can ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10 - B12 for more information about exceptions.

B5. How will you know if the drug you want has limitations or if there are

required actions to take to get the drug?

The List of Covered Drugs on pages 13 - 144 has a column labeled “Necessary actions, restrictions, or limits on use.”

B6. What happens if we change our rules about some drugs (for example, prior

authorization (approval), quantity limits, and/or step therapy restrictions)?

In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.

B7. How can you find a drug on the Drug List?

There are two ways to find a drug:

· You can search alphabetically (if you know how to spell the drug), or

· You can search by medical condition.

To search alphabetically, go to the Index of Covered Drugs section that begins on page 145. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information.

To search by medical condition, find the section labeled “List of drugs by medical condition” on pages 13 - 144. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.


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B8. What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Member Services at 1-800-256-6533, TTY 7-1-1 and ask about it. If you learn that UnitedHealthcare Connected will not cover the drug, you can do one of these things:

· Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

· You can ask the health plan to make an exception to cover your drug. Please see questions B10 – B12 for more information about exceptions.

B9. What if you are a new UnitedHealthcare Connected member and can’t find

your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Connected. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.

If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication.

We will cover a 30-day supply of your drug if:

· You are taking a drug that is not on our Drug List, or

· Health plan rules do not let you get the amount ordered by your prescriber, or

· The drug requires prior approval by UnitedHealthcare Connected, or

· You are taking a drug that is part of a step therapy restriction.

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:

· We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Connected member.

· This is in addition to the temporary supply during the first 90 days you are a member of UnitedHealthcare Connected.



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If you are going through a change in your level of care, such as being transferred from a hospital to a long-term care facility, any time during the year, we may cover a 31-day temporary supply of the Part D drug you need. This will give you time to talk to your doctor about other treatment options or to try to get an exception. Please see questions B10 - B12 for more information about exceptions.

We will not pay for more of your drug after you get a temporary or emergency supply unless you receive authorization from UnitedHealthcare Connected.

B10. Can you ask for an exception to cover your drug?

Yes. You can ask UnitedHealthcare Connected to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

· For example, UnitedHealthcare Connected may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

· Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

B11. How can you ask for an exception?

To ask for an exception, call Member Services at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook to learn more about exceptions.

B12. How long does it take to get an exception?

First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.

B13. What are generic drugs?

Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).

UnitedHealthcare Connected covers both brand name drugs and generic drugs.

B14. What are OTC drugs?

OTC stands for “over-the-counter.” UnitedHealthcare Connected covers some OTC drugs when they are written as prescriptions by your provider.

You can read the UnitedHealthcare Connected Drug List to see what OTC drugs are covered.

B15. What is your copay?

You can read the UnitedHealthcare Connected Drug List to learn about the copay for each drug. UnitedHealthcare Connected members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays.

Copays are listed by tiers. Tiers are groups of drugs with the same copay.

· Tier 1 drugs have the lowest copay. They are generic drugs. The copay is from $1.25 to $3.40, depending on your income.

· Tier 2 drugs have a higher copay. They are brand name drugs. The copay is from $3.80 to $8.50, depending on your income.

· Tier 3 drugs have $0 copay. They are OTC drugs.


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C. List of Covered Drugs

The following list of covered drugs gives you information about the drugs covered by UnitedHealthcare Connected. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 145. The index alphabetically lists all drugs covered by UnitedHealthcare Connected.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., simvastatin).

The information in the “Necessary actions, restrictions, or limits on use” column tells you if UnitedHealthcare Connected has any rules for covering your drug.

Coverage Rules and Limits

PA - Prior approval (or prior authorization)

For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected before you fill your prescription. UnitedHealthcare Connected may not cover the drug if you do not get approval.

QL - Quantity limits

Sometimes UnitedHealthcare Connected limits the amount of a drug you can get.

ST - Step therapy

Sometimes UnitedHealthcare Connected requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

Other Special Coverage Rules

B/D - Medicare Part B or Part D

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.

LA - Limited access

Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.

MME - Morphine milligram equivalent

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.


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For Track Refered Purpose21212

7D - 7-Day Limit

An opioid drug used for the treatment of acute pain may be limited to a 7 day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan.

DL - Dispensing limit

Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription.

Note: The asterisk (*) next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage).

· In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. For more information on Extra Help, please see the call-out box below.

· These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Texas Medicaid.

· If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at 1-800-256-6533, TTY 7-1-1. You can also read Chapter 9, of the Member Handbook to learn how to appeal a decision.

Extra Help

Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription drug costs, such as premiums, deductibles, and copays. Extra Help is also called the “Low-Income Subsidy,” or “LIS.”

You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

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D. List of Drugs by Medical ConditionThe drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.

Name of DrugWhat the drug

will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useA1

Analgesics

B1

AnalgesicsC1

Acephen

acephen (suppository)* $0 (Tier 3)C1

Acetaminophen

acetaminophen (tablet)* $0 (Tier 3)C1

Acetaminophen/Diphenhydramine acetaminophen/diphenhydramine (tablet)* $0 (Tier 3)C1

Butalbital/Acetaminophen butalbital/acetaminophen (50mg-325mg tablet) $1.25-$3.40 (Tier 1) QLC1

Butalbital/Acetaminophen/Caffeine 50mg-325mg-40mg Tablet, 50mg-325mg-40mg Capsule)

butalbital/acetaminophen/caffeine

50mg-325mg-40mg tablet, 50mg-325mg-40mg

capsule)

$1.25-$3.40 (Tier 1) QL

C1

Butalbital/Aspirin/Caffeine butalbital/aspirin/caffeine (50mg-325mg-40mg

capsule)$1.25-$3.40 (Tier 1) QL

C1

ED-APAP

ed-apap (liquid)* $0 (Tier 3)C1

GNP Arthritis Pain Relief gnp arthritis pain relief (tablet extended-release)* $0 (Tier 3)C1

Mapap

mapap (160mg/5ml liquid, 325mg tablet, 500mg

tablet, 500mg capsule, 80mg tablet chewable)*$0 (Tier 3)

C1

Mapap Acetaminophen Extra Strength

mapap acetaminophen extra strength (liquid)* $0 (Tier 3)C1

Mapap Arthritis Pain mapap arthritis pain (tablet extended-release)* $0 (Tier 3)C1

Mapap Childrens mapap childrens (160mg/5ml suspension, 80mg

tablet dispersible)*$0 (Tier 3)

C1

Mapap PM

mapap pm (tablet)* $0 (Tier 3)C1

Migraine Formula migraine formula (tablet)* $0 (Tier 3)C1

Pain & Fever

pain & fever (tablet)* $0 (Tier 3)C1

Pain & Fever Childrens pain & fever childrens (160mg/5ml oral solution,

80mg tablet chewable)*$0 (Tier 3)


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will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Pain & Fever Extra Strength pain & fever extra strength (tablet)* $0 (Tier 3)C1

Pain & Fever Infants pain & fever infants (suspension)* $0 (Tier 3)C1

Pain Reliever PM Extra Strength pain reliever pm extra strength (tablet)* $0 (Tier 3)C1

QC Arthritis Pain Relief qc arthritis pain relief (tablet extended-release)* $0 (Tier 3)C1

Tencon

tencon (tablet) $1.25-$3.40 (Tier 1) QLC1

Zebutal

zebutal (capsule) $1.25-$3.40 (Tier 1) QLB1

Nonsteroidal Anti-inflammatory DrugsC1

All Day Relief

all day relief (tablet)* $0 (Tier 3)C1

Aspirin

aspirin (325mg tablet, 325mg tablet delayed-release,

81mg tablet delayed-release, 81mg tablet

chewable)*

$0 (Tier 3)

C1

Aspirin EC

aspirin ec (tablet delayed-release)* $0 (Tier 3)C1

Aspirin Low Dose aspirin low dose (tablet chewable)* $0 (Tier 3)C1

Aspir-Low

aspir-low (tablet delayed-release)* $0 (Tier 3)C1

Childrens Aspirin childrens aspirin (tablet chewable)* $0 (Tier 3)C1

Childrens Ibuprofen childrens ibuprofen (otc only) (suspension)* $0 (Tier 3)C1

Childs Ibuprofen childs ibuprofen (otc only) (suspension)* $0 (Tier 3)C1

Diclofenac Epolamine diclofenac epolamine (patch) $3.80-$8.50 (Tier 2) PA, QLC1

Diclofenac Potassium diclofenac potassium (tablet) $1.25-$3.40 (Tier 1)C1

Diclofenac Sodium diclofenac sodium (1% gel) $1.25-$3.40 (Tier 1)C1

Diclofenac Sodium DR diclofenac sodium dr (tablet delayed-release) $1.25-$3.40 (Tier 1)C1

Diclofenac Sodium ER diclofenac sodium er (tablet extended-release 24

hour)$1.25-$3.40 (Tier 1)

C1

Diflunisal

diflunisal (tablet) $1.25-$3.40 (Tier 1)C1

Etodolac

etodolac (200mg capsule, 300mg capsule, 400mg

tablet immediate-release, 500mg tablet immediate-

release)

$1.25-$3.40 (Tier 1)

C1

Flector

FLECTOR (PATCH) $3.80-$8.50 (Tier 2) PA, QLC1

Flurbiprofen

flurbiprofen (tablet) $1.25-$3.40 (Tier 1)C1

GNP Ibuprofen gnp ibuprofen (otc only) (tablet)* $0 (Tier 3)C1

GNP Ibuprofen Junior Strength gnp ibuprofen junior strength (otc only) (tablet

chewable)*$0 (Tier 3)

C1

Goodsense Ibuprofen goodsense ibuprofen (tablet)* $0 (Tier 3)C1

Goodsense Ibuprofen Childrens goodsense ibuprofen childrens (suspension)* $0 (Tier 3)C1

Goodsense Ibuprofen Infants goodsense ibuprofen infants (suspension)* $0 (Tier 3)C1

Goodsense Ibuprofen Junior Strength

goodsense ibuprofen junior strength (otc only) (tablet




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will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Ibu

ibu (rx only) (tablet) $1.25-$3.40 (Tier 1)C1

Ibu-200

ibu-200 (tablet)* $0 (Tier 3)C1

Ibu-Drops Infants ibu-drops infants (suspension)* $0 (Tier 3)C1

Ibuprofen

ibuprofen (otc only) (100mg/5ml suspension, 200mg

capsule, 200mg tablet)*$0 (Tier 3)

C1

Ibuprofen

ibuprofen (rx only) (100mg/5ml suspension, 400mg

tablet, 600mg tablet, 800mg tablet)$1.25-$3.40 (Tier 1)

C1

Ibuprofen Childrens ibuprofen childrens (suspension)* $0 (Tier 3)C1

Indomethacin

indomethacin (25mg capsule, 50mg capsule) $1.25-$3.40 (Tier 1)C1

Infants Ibuprofen infants ibuprofen (otc only) (suspension)* $0 (Tier 3)C1

Ketoprofen

ketoprofen (capsule) $1.25-$3.40 (Tier 1)C1

Meloxicam

meloxicam (tablet) $1.25-$3.40 (Tier 1)C1

Naproxen

naproxen (125mg/5ml suspension, 250mg tablet

immediate-release, 375mg tablet immediate-release,

500mg tablet immediate-release)

$1.25-$3.40 (Tier 1)

C1

Naproxen DR

naproxen dr (tablet delayed-release) (generic ec-

naprosyn)$1.25-$3.40 (Tier 1)

C1

QC Naproxen Sodium qc naproxen sodium (otc only) (tablet)* $0 (Tier 3)C1

SM Ibuprofen

sm ibuprofen (otc only) (tablet)* $0 (Tier 3)C1

Sulindac

sulindac (tablet) $1.25-$3.40 (Tier 1)B1

Opioid Analgesics, Long-actingC1

Buprenorphine

buprenorphine (patch weekly) $1.25-$3.40 (Tier 1) 7D, DL, QLC1

Embeda

EMBEDA (CAPSULE EXTENDED-RELEASE) $3.80-$8.50 (Tier 2)7D, DL, QL,

MMEC1

Fentanyl

fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch

72 hour, 25mcg/hr patch 72 hour, 50mcg/hr patch

72 hour, 75mcg/hr patch 72 hour)

$1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Hydromorphone HCl ER hydromorphone hcl er (tablet extended-release 24

hour abuse-deterrent)$1.25-$3.40 (Tier 1)

7D, DL, QL, MME


16


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Hysingla ER

HYSINGLA ER (TABLET EXTENDED-RELEASE 24 HOUR ABUSE-DETERRENT)

$3.80-$8.50 (Tier 2)7D, DL, QL,

MMEC1

Levorphanol Tartrate

levorphanol tartrate (2mg tablet, 3mg tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Methadone HCl

methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml

oral solution, 5mg/5ml oral solution)$1.25-$3.40 (Tier 1)

7D, DL, QL, MME

C1

Morphine Sulfate ER morphine sulfate er (100mg tablet extended-release,

15mg tablet extended-release, 200mg tablet

extended-release, 30mg tablet extended-release,

60mg tablet extended-release) (generic ms contin)

$1.25-$3.40 (Tier 1)7D, DL, QL,

MME

C1

Nucynta ER

NUCYNTA ER (100MG TABLET EXTENDED-RELEASE 12 HOUR, 150MG TABLET EXTENDED-RELEASE 12 HOUR, 50MG TABLET EXTENDED-RELEASE 12 HOUR, 200MG TABLET EXTENDED-RELEASE 12 HOUR, 250MG TABLET EXTENDED-RELEASE 12 HOUR)

$3.80-$8.50 (Tier 2)7D, DL, QL,

MME

C1

Tramadol HCl ER tramadol hcl er (100mg tablet extended-release 24

hour, 200mg tablet extended-release 24 hour, 300mg

tablet extended-release 24 hour)

$1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Xtampza ER

XTAMPZA ER (CAPSULE EXTENDED-RELEASE 12 HOUR ABUSE-DETERRENT)

$3.80-$8.50 (Tier 2)7D, DL, QL,

MMEB1

Opioid Analgesics, Short-actingC1

Abstral

ABSTRAL (TABLET SUBLINGUAL) $3.80-$8.50 (Tier 2) DL, PA, QLC1

Acetaminophen/Codeine acetaminophen/codeine (120mg-12mg/5ml oral

solution, 300mg-15mg tablet, 300mg-30mg tablet,

300mg-60mg tablet)

$1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Butorphanol Tartrate

butorphanol tartrate (nasal solution) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Codeine Sulfate

codeine sulfate (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Duramorph

DURAMORPH (INJECTION) $3.80-$8.50 (Tier 2) DLC1

Endocet

endocet (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Fentanyl Citrate Oral Transmucosal fentanyl citrate oral transmucosal (lozenge on a

handle)$1.25-$3.40 (Tier 1) DL, PA, QL

C1

Hydrocodone Bitartrate/Acetaminophen

hydrocodone bitartrate/acetaminophen

(7.5mg-325mg/15ml oral solution)$1.25-$3.40 (Tier 1)

7D, DL, QL, MME

C1

Hydrocodone/Acetaminophen hydrocodone/acetaminophen (10mg-325mg tablet,

5mg-325mg tablet, 7.5mg-325mg tablet)$1.25-$3.40 (Tier 1)

7D, DL, QL, MME



17


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Hydrocodone/Ibuprofen

hydrocodone/ibuprofen (7.5mg-200mg tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Hydromorphone HCl hydromorphone hcl (10mg/ml injection, 50mg/5ml

injection)$1.25-$3.40 (Tier 1) DL

C1

Hydromorphone HCl hydromorphone hcl (1mg/ml liquid, 2mg tablet



$1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Hydromorphone HCl HYDROMORPHONE HCL (2MG/ML INJECTION) $3.80-$8.50 (Tier 2) DLC1

Lorcet

lorcet (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Lorcet HD

lorcet hd (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Lorcet Plus

lorcet plus (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Morphine Sulfate morphine sulfate (100mg/5ml oral solution, 10mg/

5ml oral solution, 20mg/5ml oral solution)$1.25-$3.40 (Tier 1)

7D, DL, QL, MME

C1

Morphine Sulfate MORPHINE SULFATE (15MG TABLET IMMEDIATE-

RELEASE, 30MG TABLET IMMEDIATE-RELEASE)$3.80-$8.50 (Tier 2)

7D, DL, QL, MME

C1

Oxycodone HCl

oxycodone hcl (100mg/5ml concentrate, 10mg tablet


20mg tablet immediate-release, 30mg tablet


5mg/5ml oral solution)

$1.25-$3.40 (Tier 1)7D, DL, QL,

MME

C1

Oxycodone/Acetaminophen oxycodone/acetaminophen (10mg-325mg tablet,

2.5mg-325mg tablet, 5mg-325mg tablet,

7.5mg-325mg tablet)

$1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Oxycodone/Aspirin

oxycodone/aspirin (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Oxycodone/Ibuprofen

oxycodone/ibuprofen (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,

MME


18


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Tramadol HCl

tramadol hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Tramadol HCl/Acetaminophen

tramadol hcl/acetaminophen (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEC1

Trezix

trezix (capsule) $1.25-$3.40 (Tier 1)7D, DL, QL,

MMEA1

Anesthetics

B1

Local AnestheticsC1

Lidocaine

lidocaine (rx only) (5% ointment) $1.25-$3.40 (Tier 1) QLC1

Lidocaine

lidocaine (rx only) (5% patch) $1.25-$3.40 (Tier 1) PA, QLC1

Lidocaine HCl

lidocaine hcl (rx only) (4% external solution) $1.25-$3.40 (Tier 1)C1

Lidocaine HCl

lidocaine hcl (rx only) (2% gel) $1.25-$3.40 (Tier 1)C1

Lidocaine Viscous lidocaine viscous (rx only) (2% solution) $1.25-$3.40 (Tier 1)C1

Lidocaine/Prilocaine lidocaine/prilocaine (cream) $1.25-$3.40 (Tier 1)

A1

Anti-Addiction/Substance Abuse Treatment Agents

B1

Alcohol Deterrents/Anti-cravingC1

Acamprosate Calcium DR acamprosate calcium dr (tablet delayed-release) $1.25-$3.40 (Tier 1)C1

Disulfiram

disulfiram (tablet) $1.25-$3.40 (Tier 1)C1

Naltrexone HCl

naltrexone hcl (tablet) $1.25-$3.40 (Tier 1)C1

Vivitrol

VIVITROL (INJECTION) $3.80-$8.50 (Tier 2)B1

Opioid Dependence TreatmentsC1

Buprenorphine HCl buprenorphine hcl (tablet sublingual) $1.25-$3.40 (Tier 1) QLC1

Buprenorphine HCl/Naloxone HCl buprenorphine hcl/naloxone hcl (film) $1.25-$3.40 (Tier 1) QLC1

Buprenorphine HCl/Naloxone HCl buprenorphine hcl/naloxone hcl (tablet sublingual) $1.25-$3.40 (Tier 1) QLC1

Suboxone

SUBOXONE (FILM) $3.80-$8.50 (Tier 2) QLB1

Opioid Reversal Agents C1

Naloxone HCl

naloxone hcl (injection) $1.25-$3.40 (Tier 1)C1

Narcan

NARCAN (LIQUID) $3.80-$8.50 (Tier 2)B1

Smoking Cessation AgentsC1

Bupropion HCl SR bupropion hcl sr (150mg tablet extended-release 12

hour smoking-deterrent)$1.25-$3.40 (Tier 1)

C1

Chantix

CHANTIX (TABLET) $3.80-$8.50 (Tier 2)C1

Chantix Continuing Month Pak CHANTIX CONTINUING MONTH PAK (TABLET) $3.80-$8.50 (Tier 2)



19


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Chantix Starting Month Pak CHANTIX STARTING MONTH PAK (TABLET) $3.80-$8.50 (Tier 2)C1

NicoDerm CQ

nicoderm cq (patch 24 hour)* $0 (Tier 3)C1

NICOrelief

nicorelief (gum)* $0 (Tier 3)C1

Nicorette

nicorette (2mg gum, 4mg gum, 2mg lozenge, 4mg

lozenge)*$0 (Tier 3)

C1

Nicorette Mini

nicorette mini (lozenge)* $0 (Tier 3)C1

Nicorette Starter Kit nicorette starter kit (gum)* $0 (Tier 3)C1

Nicotine Polacrilex nicotine polacrilex (2mg gum, 4mg gum, 2mg

lozenge, 4mg lozenge)*$0 (Tier 3)

C1

Nicotine Transdermal System nicotine transdermal system (kit, 14mg/24hr patch

24 hour, 21mg/24hr patch 24 hour, 7mg/24hr patch

24 hour)*

$0 (Tier 3)

C1

Nicotine Transdermal System Step 1 nicotine transdermal system step 1 (patch 24 hour)* $0 (Tier 3)C1



Nicotrol

NICOTROL (INHALER) $3.80-$8.50 (Tier 2)A1

Antibacterials

B1

AminoglycosidesC1

Amikacin Sulfate amikacin sulfate (injection) $1.25-$3.40 (Tier 1)C1

Gentak

gentak (ophthalmic ointment) $1.25-$3.40 (Tier 1)C1

Gentamicin Sulfate gentamicin sulfate (0.1% cream, 0.1% ointment,

0.3% ophthalmic solution, 40mg/ml injection)$1.25-$3.40 (Tier 1)

C1

Gentamicin Sulfate/0.9% Sodium Chloride

gentamicin sulfate/0.9% sodium chloride (injection) $1.25-$3.40 (Tier 1)C1

Isotonic Gentamicin isotonic gentamicin (injection) $1.25-$3.40 (Tier 1)C1

Neomycin Sulfate neomycin sulfate (tablet) $1.25-$3.40 (Tier 1)C1

Paromomycin Sulfate paromomycin sulfate (capsule) $1.25-$3.40 (Tier 1)C1

Streptomycin Sulfate streptomycin sulfate (injection) $1.25-$3.40 (Tier 1)C1

Tobramycin Sulfate tobramycin sulfate (0.3% ophthalmic solution, 10mg/

ml injection, 80mg/2ml injection)$1.25-$3.40 (Tier 1)


20


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Tobrex

TOBREX (0.3% OPHTHALMIC OINTMENT) $3.80-$8.50 (Tier 2)B1

Antibacterials, OtherC1

Bacitracin

bacitracin (otc only) (ointment)* $0 (Tier 3)C1

Bacitracin

bacitracin (rx only) (ophthalmic ointment) $1.25-$3.40 (Tier 1)C1

Bacitracin Zinc

bacitracin zinc (ointment)* $0 (Tier 3)C1

Bacitracin/Neomycin/Polymyxin bacitracin/neomycin/polymyxin (otc only)

(ointment)*$0 (Tier 3)

C1

Clindamycin HCl

clindamycin hcl (capsule immediate-release) $1.25-$3.40 (Tier 1)C1

Clindamycin Palmitate HCl clindamycin palmitate hcl (oral solution) $1.25-$3.40 (Tier 1)C1

Clindamycin Phosphate clindamycin phosphate (2% cream, 300mg/2ml

injection, 600mg/4ml injection, 900mg/6ml injection)$1.25-$3.40 (Tier 1)

C1

Clindamycin Phosphate in D5W clindamycin phosphate in d5w (injection) $1.25-$3.40 (Tier 1)C1

Colistimethate Sodium colistimethate sodium (injection) $1.25-$3.40 (Tier 1)C1

Dalvance

DALVANCE (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Daptomycin

DAPTOMYCIN (350MG SOLUTION) $3.80-$8.50 (Tier 2)C1

Daptomycin

daptomycin (500mg injection) $1.25-$3.40 (Tier 1)C1

Linezolid

linezolid (100mg/5ml suspension, 600mg/300ml

injection)$1.25-$3.40 (Tier 1)

C1

Linezolid

linezolid (600mg tablet) $1.25-$3.40 (Tier 1) QLC1

Methenamine Hippurate methenamine hippurate (tablet) $1.25-$3.40 (Tier 1)C1

Metronidazole

metronidazole (0.75% cream, 0.75% gel, 1% gel,

0.75% lotion, 250mg tablet immediate-release,


$1.25-$3.40 (Tier 1)

C1

Metronidazole in NaCl 0.79% metronidazole in nacl 0.79% (injection) $1.25-$3.40 (Tier 1)C1

Metronidazole Vaginal metronidazole vaginal (gel) $1.25-$3.40 (Tier 1)C1

Mupirocin

mupirocin (2% ointment) $1.25-$3.40 (Tier 1)C1

Nitrofurantoin

nitrofurantoin (suspension) $1.25-$3.40 (Tier 1)C1

Nitrofurantoin Macrocrystals nitrofurantoin macrocrystals (100mg capsule, 50mg

capsule) (generic macrodantin)$1.25-$3.40 (Tier 1)

C1

Nitrofurantoin Monohydrate nitrofurantoin monohydrate (100mg capsule)

(generic macrobid)$1.25-$3.40 (Tier 1)

C1

Polymyxin B Sulfate polymyxin b sulfate (injection) $1.25-$3.40 (Tier 1)C1

Povidone-Iodine povidone-iodine (10% external solution, 10%

ointment)*$0 (Tier 3)

C1

Tigecycline

tigecycline (injection) $1.25-$3.40 (Tier 1)C1

Tinidazole

tinidazole (tablet) $1.25-$3.40 (Tier 1)C1

Trimethoprim

trimethoprim (tablet) $1.25-$3.40 (Tier 1)



21


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Triple Antibiotic triple antibiotic (ointment)* $0 (Tier 3)C1

Triple Antibiotic Plus triple antibiotic plus (ointment)* $0 (Tier 3)C1

Vancomycin HCl

vancomycin hcl (10gm injection, 1gm injection,

500mg injection, 750mg injection, 125mg capsule,

250mg capsule)

$1.25-$3.40 (Tier 1)

C1

Vancomycin HCl VANCOMYCIN HCL (250MG INJECTION) $3.80-$8.50 (Tier 2)C1

Vandazole

VANDAZOLE (GEL) $3.80-$8.50 (Tier 2)B1

Beta-lactam, CephalosporinsC1

Cefaclor

cefaclor (250mg capsule immediate-release, 500mg

capsule immediate-release)$1.25-$3.40 (Tier 1)

C1

Cefadroxil

cefadroxil (250mg/5ml suspension, 500mg/5ml

suspension, 500mg capsule)$1.25-$3.40 (Tier 1)

C1

Cefazolin Sodium cefazolin sodium (injection) $1.25-$3.40 (Tier 1)C1

Cefdinir

cefdinir (125mg/5ml suspension, 250mg/5ml


C1

Cefepime

cefepime (injection) $1.25-$3.40 (Tier 1)C1

Cefixime

cefixime (100mg/5ml suspension, 200mg/5ml


C1

Cefotaxime Sodium cefotaxime sodium (injection) $1.25-$3.40 (Tier 1)C1

Cefotetan

cefotetan (injection) $1.25-$3.40 (Tier 1)C1

Cefoxitin Sodium cefoxitin sodium (10gm injection, 1gm injection, 2gm


C1

Cefpodoxime Proxetil cefpodoxime proxetil (100mg tablet, 200mg tablet,

100mg/5ml suspension, 50mg/5ml suspension)$1.25-$3.40 (Tier 1)

C1

Cefprozil

cefprozil (125mg/5ml suspension, 250mg/5ml

suspension, 250mg tablet, 500mg tablet)$1.25-$3.40 (Tier 1)

C1

Ceftazidime

ceftazidime (injection) $1.25-$3.40 (Tier 1)C1

Ceftriaxone Sodium ceftriaxone sodium (10gm injection, 1gm injection,

250mg injection, 2gm injection, 500mg injection)$1.25-$3.40 (Tier 1)

C1

Cefuroxime Axetil cefuroxime axetil (tablet) $1.25-$3.40 (Tier 1)


22


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Cefuroxime Sodium cefuroxime sodium (1.5gm injection, 7.5gm injection,

750mg injection)$1.25-$3.40 (Tier 1)

C1

Cephalexin

cephalexin (125mg/5ml suspension, 250mg/5ml

suspension, 250mg capsule, 500mg capsule, 750mg

capsule)

$1.25-$3.40 (Tier 1)

C1

Suprax

suprax (100mg tablet chewable, 200mg tablet

chewable)$1.25-$3.40 (Tier 1)

C1

Suprax

SUPRAX (400MG CAPSULE, 500MG/5ML SUSPENSION) $3.80-$8.50 (Tier 2)C1

Tazicef

tazicef (injection) $1.25-$3.40 (Tier 1)C1

Zerbaxa

ZERBAXA (INJECTION) $3.80-$8.50 (Tier 2) PAB1

Beta-lactam, OtherC1

Aztreonam

aztreonam (injection) $1.25-$3.40 (Tier 1)C1

Ertapenem

ertapenem (solution) $1.25-$3.40 (Tier 1)C1

Imipenem/Cilastatin imipenem/cilastatin (injection) $1.25-$3.40 (Tier 1)C1

Invanz

INVANZ (INJECTION) $3.80-$8.50 (Tier 2)C1

Meropenem

meropenem (injection) $1.25-$3.40 (Tier 1)B1

Beta-lactam, PenicillinsC1

Amoxicillin

amoxicillin (125mg tablet chewable, 250mg tablet

chewable, 125mg/5ml suspension, 200mg/5ml

suspension, 250mg/5ml suspension, 400mg/5ml

suspension, 250mg capsule, 500mg capsule, 500mg

tablet, 875mg tablet)

$1.25-$3.40 (Tier 1)

C1

Amoxicillin/Clavulanate Potassium amoxicillin/clavulanate potassium (200mg-28.5mg

tablet chewable, 400mg-57mg tablet chewable,

200mg/5ml-28.5mg/5ml suspension, 250mg/

5ml-62.5mg/5ml suspension, 400mg/5ml-57mg/5ml

suspension, 600mg/5ml-42.9mg/5ml suspension,

250mg-125mg tablet immediate-release,

500mg-125mg tablet immediate-release,

875mg-125mg tablet immediate-release) (generic

augmentin)

$1.25-$3.40 (Tier 1)

C1

Amoxicillin/Clavulanate Potassium ER

amoxicillin/clavulanate potassium er (tablet

extended-release 12 hour)$1.25-$3.40 (Tier 1)

C1

Ampicillin

ampicillin (capsule) $1.25-$3.40 (Tier 1)C1

Ampicillin Sodium ampicillin sodium (10gm injection, 125mg injection,

1gm injection)$1.25-$3.40 (Tier 1)

C1

Ampicillin-Sulbactam ampicillin-sulbactam (injection) $1.25-$3.40 (Tier 1)C1

Bicillin C-R

BICILLIN C-R (INJECTION) $3.80-$8.50 (Tier 2)



23


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Bicillin L-A

BICILLIN L-A (INJECTION) $3.80-$8.50 (Tier 2)C1

Dicloxacillin Sodium dicloxacillin sodium (capsule) $1.25-$3.40 (Tier 1)C1

Nafcillin Sodium

nafcillin sodium (10gm injection, 1gm injection, 2gm


C1

Oxacillin in Dextrose OXACILLIN IN DEXTROSE (INJECTION) $3.80-$8.50 (Tier 2)C1

Oxacillin Sodium oxacillin sodium (injection) $1.25-$3.40 (Tier 1)C1

Penicillin G Potassium penicillin g potassium (injection) $1.25-$3.40 (Tier 1)C1

Penicillin G Procaine penicillin g procaine (injection) $1.25-$3.40 (Tier 1)C1

Penicillin G Sodium penicillin g sodium (injection) $1.25-$3.40 (Tier 1)C1

Penicillin V Potassium penicillin v potassium (125mg/5ml oral solution,

250mg/5ml oral solution, 250mg tablet, 500mg

tablet)

$1.25-$3.40 (Tier 1)

C1

Piperacillin/Tazobactam piperacillin/tazobactam (injection) $1.25-$3.40 (Tier 1)

B1

MacrolidesC1

Azithromycin

azithromycin (100mg/5ml suspension, 200mg/5ml

suspension, 250mg tablet, 500mg tablet, 600mg

tablet, 500mg injection)

$1.25-$3.40 (Tier 1)

C1

Clarithromycin

clarithromycin (125mg/5ml suspension, 250mg/5ml

suspension, 250mg tablet, 500mg tablet)$1.25-$3.40 (Tier 1)

C1

Clarithromycin ER clarithromycin er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1

Dificid

DIFICID (TABLET) $3.80-$8.50 (Tier 2)C1

E.E.S. Granules E.E.S. GRANULES (SUSPENSION) $3.80-$8.50 (Tier 2)C1

Ery-Tab

ery-tab (tablet delayed-release) $1.25-$3.40 (Tier 1)C1

EryPed 200

ERYPED 200 (SUSPENSION) $3.80-$8.50 (Tier 2)C1

EryPed 400

ERYPED 400 (SUSPENSION) $3.80-$8.50 (Tier 2)C1

Erythrocin Lactobionate erythrocin lactobionate (injection) $1.25-$3.40 (Tier 1)C1

Erythromycin

erythromycin (250mg capsule delayed-release, 5mg/

gm ophthalmic ointment)$1.25-$3.40 (Tier 1)

C1

Erythromycin Base erythromycin base (tablet) $1.25-$3.40 (Tier 1)


24


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Erythromycin DR erythromycin dr (tablet delayed-release) $1.25-$3.40 (Tier 1)C1

Erythromycin Ethylsuccinate erythromycin ethylsuccinate (200mg/5ml

suspension, 400mg tablet, 400mg/5ml suspension)$1.25-$3.40 (Tier 1)

B1

QuinolonesC1

Ciprofloxacin

ciprofloxacin (suspension) $1.25-$3.40 (Tier 1)C1

Ciprofloxacin HCl ciprofloxacin hcl (tablet immediate-release, 0.3%

ophthalmic solution)$1.25-$3.40 (Tier 1)

C1

Ciprofloxacin I.V. in D5W ciprofloxacin i.v. in d5w (injection) $1.25-$3.40 (Tier 1)C1

Levofloxacin

levofloxacin (0.5% ophthalmic solution, 250mg

tablet, 500mg tablet, 750mg tablet, 25mg/ml

injection, 25mg/ml oral solution)

$1.25-$3.40 (Tier 1)

C1

Levofloxacin in D5W levofloxacin in d5w (injection) $1.25-$3.40 (Tier 1)C1

Moxeza

MOXEZA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Moxifloxacin HCl/Sodium HCl moxifloxacin hcl/sodium hcl (injection) $1.25-$3.40 (Tier 1)C1

Moxifloxacin HCl

moxifloxacin hcl (0.5% ophthalmic solution, 400mg

tablet)$1.25-$3.40 (Tier 1)

C1

Ofloxacin

ofloxacin (0.3% ophthalmic solution, 0.3% otic

solution, 300mg tablet, 400mg tablet)$1.25-$3.40 (Tier 1)

B1

SulfonamidesC1

Silver Sulfadiazine silver sulfadiazine (cream) $3.80-$8.50 (Tier 2)C1

Sodium Sulfacetamide sodium sulfacetamide (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

SSD

SSD (CREAM) $3.80-$8.50 (Tier 2)C1

Sulfacetamide Sodium sulfacetamide sodium (ophthalmic ointment) $1.25-$3.40 (Tier 1)C1

Sulfadiazine

sulfadiazine (tablet) $1.25-$3.40 (Tier 1)C1

Sulfamethoxazole/Trimethoprim sulfamethoxazole/trimethoprim (200mg-40mg/5ml

suspension, 400mg-80mg tablet)$1.25-$3.40 (Tier 1)

C1

Sulfamethoxazole/Trimethoprim DS sulfamethoxazole/trimethoprim ds (tablet) $1.25-$3.40 (Tier 1)

B1

TetracyclinesC1

Demeclocycline HCl demeclocycline hcl (tablet) $1.25-$3.40 (Tier 1)C1

Doxy 100

doxy 100 (injection) $1.25-$3.40 (Tier 1)C1

Doxycycline

doxycycline (25mg/5ml suspension) $1.25-$3.40 (Tier 1)C1

Doxycycline Hyclate doxycycline hyclate (100mg capsule, 50mg capsule,

100mg tablet, 20mg tablet immediate-release)$1.25-$3.40 (Tier 1)

C1

Doxycycline Monohydrate doxycycline monohydrate (100mg capsule, 50mg

capsule, 100mg tablet, 50mg tablet, 75mg tablet)$1.25-$3.40 (Tier 1)

C1

Minocycline HCl

minocycline hcl (capsule) $1.25-$3.40 (Tier 1)



25


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Tetracycline HCl

tetracycline hcl (capsule) $1.25-$3.40 (Tier 1)C1

Vibramycin

VIBRAMYCIN (50MG/5ML SYRUP) $3.80-$8.50 (Tier 2)A1

Anticonvulsants

B1

Anticonvulsants, OtherC1

Briviact

BRIVIACT (100MG TABLET, 10MG TABLET, 25MG TABLET, 50MG TABLET, 75MG TABLET, 10MG/ML ORAL SOLUTION)

$3.80-$8.50 (Tier 2) QL

C1

Epidiolex

EPIDIOLEX (SOLUTION) $3.80-$8.50 (Tier 2) PAC1

Levetiracetam

levetiracetam (tablet immediate-release, 100mg/ml

oral solution)$1.25-$3.40 (Tier 1)

C1

Levetiracetam ER levetiracetam er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1

Roweepra

roweepra (tablet immediate-release) $1.25-$3.40 (Tier 1)C1

Roweepra XR

roweepra xr (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1

Spritam

SPRITAM (TABLET DISINTEGRATING SOLUBLE) $3.80-$8.50 (Tier 2)B1

Calcium Channel Modifying AgentsC1

Celontin

CELONTIN (CAPSULE) $3.80-$8.50 (Tier 2)C1

Ethosuximide

ethosuximide (250mg capsule, 250mg/5ml oral

solution)$1.25-$3.40 (Tier 1)

C1

Zonisamide

zonisamide (capsule) $1.25-$3.40 (Tier 1)B1

Gamma-aminobutyric Acid (GABA) Augmenting AgentsC1

Clobazam

clobazam (10mg tablet, 20mg tablet) $1.25-$3.40 (Tier 1) PA, QLC1

Clobazam

clobazam (2.5mg/ml suspension) $1.25-$3.40 (Tier 1) PAC1

Diastat AcuDial DIASTAT ACUDIAL (GEL) $3.80-$8.50 (Tier 2)C1

Diastat Pediatric DIASTAT PEDIATRIC (GEL) $3.80-$8.50 (Tier 2)C1

Gabapentin

gabapentin (100mg capsule, 300mg capsule, 400mg

capsule, 250mg/5ml oral solution, 600mg tablet,

800mg tablet)

$1.25-$3.40 (Tier 1)

C1

Onfi

ONFI (10MG TABLET, 20MG TABLET) $3.80-$8.50 (Tier 2) PA, QL


26


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Onfi

ONFI (2.5MG/ML SUSPENSION) $3.80-$8.50 (Tier 2) PAC1

Phenobarbital

phenobarbital (100mg tablet, 15mg tablet, 16.2mg

tablet, 30mg tablet, 32.4mg tablet, 60mg tablet,

64.8mg tablet, 97.2mg tablet, 20mg/5ml elixir)

$1.25-$3.40 (Tier 1)

C1

Primidone

primidone (tablet) $1.25-$3.40 (Tier 1)C1

Sabril

SABRIL (500MG TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Sympazan

SYMPAZAN (FILM) $3.80-$8.50 (Tier 2) PA, QLC1

Tiagabine HCl

tiagabine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Valproic Acid

valproic acid (250mg capsule, 250mg/5ml oral


C1

Vigabatrin

vigabatrin (500mg packet, 500mg tablet) $1.25-$3.40 (Tier 1) PA, QL, LAC1

Vigadrone

vigadrone (packet) $1.25-$3.40 (Tier 1) PA, QL, LAB1

Glutamate Reducing AgentsC1

Felbamate

felbamate (400mg tablet, 600mg tablet, 600mg/5ml

suspension)$1.25-$3.40 (Tier 1)

C1

Fycompa

FYCOMPA (0.5MG/ML SUSPENSION, 10MG TABLET, 12MG TABLET, 2MG TABLET, 4MG TABLET, 6MG TABLET, 8MG TABLET)

$3.80-$8.50 (Tier 2)

C1

Lamotrigine

lamotrigine (100mg tablet immediate-release, 150mg


release, 25mg tablet immediate-release, 25mg tablet

chewable, 5mg tablet chewable)

$1.25-$3.40 (Tier 1)

C1

Topiramate

topiramate (100mg tablet, 200mg tablet, 25mg

tablet, 50mg tablet, 15mg capsule sprinkle

immediate-release, 25mg capsule sprinkle

immediate-release)

$1.25-$3.40 (Tier 1)

B1

Sodium Channel AgentsC1

Aptiom

APTIOM (TABLET) $3.80-$8.50 (Tier 2) QLC1

Banzel

BANZEL (200MG TABLET, 400MG TABLET, 40MG/ML SUSPENSION)

$3.80-$8.50 (Tier 2)C1

Carbamazepine

carbamazepine (100mg tablet chewable, 100mg/5ml

suspension, 200mg tablet immediate-release)$1.25-$3.40 (Tier 1)

C1

Carbamazepine ER carbamazepine er (100mg capsule extended-release

12 hour, 200mg capsule extended-release 12 hour,

300mg capsule extended-release 12 hour, 100mg

tablet extended-release 12 hour, 200mg tablet

extended-release 12 hour, 400mg tablet extended-

release 12 hour)

$1.25-$3.40 (Tier 1)



27


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Dilantin

dilantin (capsule) $1.25-$3.40 (Tier 1)C1

Dilantin INFATABS dilantin infatabs (tablet chewable) $1.25-$3.40 (Tier 1)C1

Epitol

epitol (tablet) $1.25-$3.40 (Tier 1)C1

Oxcarbazepine

oxcarbazepine (150mg tablet, 300mg tablet, 600mg

tablet, 300mg/5ml suspension)$1.25-$3.40 (Tier 1)

C1

Peganone

PEGANONE (TABLET) $3.80-$8.50 (Tier 2)C1

Phenytek

phenytek (capsule) $1.25-$3.40 (Tier 1)C1

Phenytoin

phenytoin (125mg/5ml suspension, 50mg tablet

chewable)$1.25-$3.40 (Tier 1)

C1

Phenytoin Sodium Extended phenytoin sodium extended (capsule) $1.25-$3.40 (Tier 1)C1

Vimpat

VIMPAT (100MG TABLET, 150MG TABLET, 200MG TABLET, 50MG TABLET, 10MG/ML ORAL SOLUTION)

$3.80-$8.50 (Tier 2) QL

A1

Antidementia Agents

B1

Cholinesterase InhibitorsC1

Donepezil HCl

donepezil hcl (10mg tablet, 5mg tablet) $1.25-$3.40 (Tier 1) QLC1

Donepezil HCl ODT donepezil hcl odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1

Rivastigmine Tartrate rivastigmine tartrate (capsule) $1.25-$3.40 (Tier 1) QLC1

Rivastigmine Transdermal System rivastigmine transdermal system (patch 24 hour) $1.25-$3.40 (Tier 1) QL, ST

B1

N-methyl-D-aspartate (NMDA) Receptor AntagonistC1

Memantine HCl

memantine hcl (10mg tablet, 5mg tablet, 2mg/ml

oral solution)$1.25-$3.40 (Tier 1) PA, QL

C1

Memantine HCl ER memantine hcl er (capsule extended-release 24 hour) $1.25-$3.40 (Tier 1) PA, QLC1

Memantine HCl Titration Pak MEMANTINE HCL TITRATION PAK (TABLET) $3.80-$8.50 (Tier 2) PA

A1

Antidepressants

B1

Antidepressants, OtherC1

Bupropion HCl

bupropion hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)


28


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Bupropion HCl SR bupropion hcl sr (100mg tablet extended-release 12



$1.25-$3.40 (Tier 1)

C1

Bupropion HCl XL bupropion hcl xl (150mg tablet extended-release 24

hour, 300mg tablet extended-release 24 hour)$1.25-$3.40 (Tier 1)

C1

Mirtazapine

mirtazapine (tablet) $1.25-$3.40 (Tier 1)C1

Mirtazapine ODT mirtazapine odt (tablet dispersible) $1.25-$3.40 (Tier 1)

B1

Monoamine Oxidase InhibitorsC1

Emsam

EMSAM (PATCH 24 HOUR) $3.80-$8.50 (Tier 2) QLC1

Marplan

MARPLAN (TABLET) $3.80-$8.50 (Tier 2)C1

Phenelzine Sulfate phenelzine sulfate (tablet) $1.25-$3.40 (Tier 1)C1

Tranylcypromine Sulfate tranylcypromine sulfate (tablet) $1.25-$3.40 (Tier 1)

B1

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)

C1

Citalopram HBr

citalopram hbr (10mg tablet, 20mg tablet, 40mg

tablet, 10mg/5ml oral solution)$1.25-$3.40 (Tier 1)

C1

Desvenlafaxine ER desvenlafaxine er (100mg tablet extended-release 24


tablet extended-release 24 hour) (generic pristiq)

$1.25-$3.40 (Tier 1) QL

C1

Escitalopram Oxalate escitalopram oxalate (10mg tablet, 20mg tablet, 5mg

tablet, 5mg/5ml oral solution)$1.25-$3.40 (Tier 1)

C1

Fetzima

FETZIMA (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2) QL, STC1

Fetzima Titration Pack FETZIMA TITRATION PACK (CAPSULE EXTENDED-

RELEASE 24 HOUR THERAPY PACK)$3.80-$8.50 (Tier 2) ST

C1

Fluoxetine DR

fluoxetine dr (capsule delayed-release) $1.25-$3.40 (Tier 1)C1

Fluoxetine HCl

fluoxetine hcl (20mg/5ml oral solution) $1.25-$3.40 (Tier 1)C1

Fluoxetine HCl

fluoxetine hcl (capsule immediate-release) $1.25-$3.40 (Tier 1)C1

Fluvoxamine Maleate fluvoxamine maleate (tablet) $1.25-$3.40 (Tier 1)C1

Maprotiline HCl

maprotiline hcl (tablet) $1.25-$3.40 (Tier 1)C1

Nefazodone HCl nefazodone hcl (tablet) $1.25-$3.40 (Tier 1)C1

Paroxetine HCl

paroxetine hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)C1

Paxil

PAXIL (10MG/5ML SUSPENSION) $3.80-$8.50 (Tier 2)C1

Sertraline HCl

sertraline hcl (20mg/ml concentrate) $1.25-$3.40 (Tier 1)C1

Sertraline HCl

sertraline hcl (tablet) $1.25-$3.40 (Tier 1)C1

Trazodone HCl

trazodone hcl (tablet) $1.25-$3.40 (Tier 1)C1

Trintellix

TRINTELLIX (TABLET) $3.80-$8.50 (Tier 2) QLC1

Venlafaxine HCl

venlafaxine hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)



29


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Venlafaxine HCl ER venlafaxine hcl er (150mg capsule extended-release

24 hour, 37.5mg capsule extended-release 24 hour,

75mg capsule extended-release 24 hour)

$1.25-$3.40 (Tier 1)

C1

Viibryd

VIIBRYD (TABLET) $3.80-$8.50 (Tier 2) QLC1

Viibryd Starter Pack VIIBRYD STARTER PACK (KIT) $3.80-$8.50 (Tier 2) QL

B1

TricyclicsC1

Amitriptyline HCl

amitriptyline hcl (tablet) $1.25-$3.40 (Tier 1)C1

Amoxapine

amoxapine (tablet) $1.25-$3.40 (Tier 1)C1

Clomipramine HCl clomipramine hcl (capsule) $1.25-$3.40 (Tier 1)C1

Desipramine HCl desipramine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Doxepin HCl

doxepin hcl (100mg capsule, 10mg capsule, 150mg

capsule, 50mg capsule, 75mg capsule, 10mg/ml

concentrate)

$1.25-$3.40 (Tier 1)

C1

Doxepin HCl

doxepin hcl (25mg capsule) $1.25-$3.40 (Tier 1)C1

Imipramine HCl

imipramine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Imipramine Pamoate imipramine pamoate (capsule) $1.25-$3.40 (Tier 1)C1

Nortriptyline HCl

nortriptyline hcl (10mg/5ml oral solution) $1.25-$3.40 (Tier 1)C1

Nortriptyline HCl

nortriptyline hcl (capsule) $1.25-$3.40 (Tier 1)C1

Protriptyline HCl

protriptyline hcl (tablet) $1.25-$3.40 (Tier 1)C1

Trimipramine Maleate trimipramine maleate (capsule) $1.25-$3.40 (Tier 1)

A1

Antiemetics

B1

Antiemetics, OtherC1

Compro

compro (suppository) $1.25-$3.40 (Tier 1)C1

Formula EM

formula em (oral solution)* $0 (Tier 3)C1

Hydroxyzine Pamoate hydroxyzine pamoate (capsule) $1.25-$3.40 (Tier 1)C1

Meclizine HCl

meclizine hcl (otc only) (tablet)* $0 (Tier 3)C1

Meclizine HCl

meclizine hcl (rx only) (tablet) $1.25-$3.40 (Tier 1)C1

Metoclopramide HCl metoclopramide hcl (5mg/5ml oral solution) $1.25-$3.40 (Tier 1)


30


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Metoclopramide HCl metoclopramide hcl (tablet) $1.25-$3.40 (Tier 1)C1

Perphenazine

perphenazine (tablet) $1.25-$3.40 (Tier 1)C1

Prochlorperazine

prochlorperazine (suppository) $1.25-$3.40 (Tier 1)C1

Prochlorperazine Maleate prochlorperazine maleate (tablet) $1.25-$3.40 (Tier 1)C1

Scopolamine

scopolamine (patch 72 hour) $1.25-$3.40 (Tier 1)C1

Transderm-Scop TRANSDERM-SCOP (PATCH 72 HOUR) $3.80-$8.50 (Tier 2)C1

Travel Sickness

travel sickness (otc only) (tablet)* $0 (Tier 3)B1

Emetogenic Therapy AdjunctsC1

Aprepitant

aprepitant (therapy pack, capsule) $1.25-$3.40 (Tier 1) PAC1

Cesamet

CESAMET (CAPSULE) $3.80-$8.50 (Tier 2) PAC1

Dronabinol

dronabinol (capsule) $1.25-$3.40 (Tier 1) PAC1

Emend

EMEND (125MG SUSPENSION) $3.80-$8.50 (Tier 2) PAC1

Granisetron HCl

granisetron hcl (tablet) $1.25-$3.40 (Tier 1) B/D, PA, QLC1

Ondansetron HCl ondansetron hcl (4mg/5ml oral solution) $1.25-$3.40 (Tier 1) B/D, PAC1

Ondansetron HCl ondansetron hcl (tablet) $1.25-$3.40 (Tier 1) B/D, PAC1

Ondansetron ODT ondansetron odt (tablet dispersible) $1.25-$3.40 (Tier 1) B/D, PAC1

Sancuso

SANCUSO (PATCH) $3.80-$8.50 (Tier 2)A1

Antifungals

B1

AntifungalsC1

Abelcet

ABELCET (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

AmBisome

AMBISOME (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Amphotericin B

amphotericin b (injection) $1.25-$3.40 (Tier 1) B/D, PAC1

Antifungal

antifungal (1% aerosol, 1% cream, 2% cream)* $0 (Tier 3)C1

Anti-Fungal Powder anti-fungal powder (otc only)* $0 (Tier 3)C1

Caspofungin Acetate caspofungin acetate (injection) $1.25-$3.40 (Tier 1)C1

Ciclopirox

ciclopirox (0.77% gel, 0.77% suspension, 1%

shampoo)$1.25-$3.40 (Tier 1)

C1

Ciclopirox Nail Lacquer ciclopirox nail lacquer (external solution) $1.25-$3.40 (Tier 1)C1

Ciclopirox Olamine ciclopirox olamine (cream) $1.25-$3.40 (Tier 1)C1

Clotrimazole

clotrimazole (otc only) (1% cream, 1% external

solution)*$0 (Tier 3)

C1

Clotrimazole

clotrimazole (rx only) (1% cream, 1% external

solution, 10mg lozenge)$1.25-$3.40 (Tier 1)

C1

Clotrimazole Anti-Fungal clotrimazole anti-fungal (otc only) (cream)* $0 (Tier 3)C1

Econazole Nitrate econazole nitrate (cream) $1.25-$3.40 (Tier 1)



31


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Eraxis

ERAXIS (INJECTION) $3.80-$8.50 (Tier 2)C1

Fluconazole

fluconazole (100mg tablet, 150mg tablet, 200mg

tablet, 50mg tablet, 10mg/ml suspension, 40mg/ml

suspension)

$1.25-$3.40 (Tier 1)

C1

Fluconazole in NaCl fluconazole in nacl (injection) $1.25-$3.40 (Tier 1)C1

Flucytosine

flucytosine (capsule) $1.25-$3.40 (Tier 1)C1

Fungoid Tincture fungoid tincture (external solution)* $0 (Tier 3)C1

Griseofulvin Microsize griseofulvin microsize (125mg/5ml suspension,

500mg tablet)$1.25-$3.40 (Tier 1)

C1

Griseofulvin Ultramicrosize griseofulvin ultramicrosize (tablet) $1.25-$3.40 (Tier 1)C1

Itraconazole

itraconazole (100mg capsule) $1.25-$3.40 (Tier 1) PA, QLC1

Itraconazole

itraconazole (10mg/ml solution) $1.25-$3.40 (Tier 1) PAC1

Jublia

JUBLIA (EXTERNAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Ketoconazole

ketoconazole (2% cream, 2% foam, 2% shampoo,

200mg tablet)$1.25-$3.40 (Tier 1)

C1

Mentax

MENTAX (RX ONLY) (CREAM) $3.80-$8.50 (Tier 2)C1

Miconazole 3

miconazole 3 (rx only) (suppository) $1.25-$3.40 (Tier 1)C1

Miconazole 7

miconazole 7 (suppository)* $0 (Tier 3)C1

Miconazole Nitrate miconazole nitrate (100mg suppository, 2% cream)* $0 (Tier 3)C1

Mycamine

MYCAMINE (INJECTION) $3.80-$8.50 (Tier 2)C1

Natacyn

NATACYN (SUSPENSION) $3.80-$8.50 (Tier 2)C1

Noxafil

NOXAFIL (100MG TABLET DELAYED-RELEASE) $3.80-$8.50 (Tier 2) PA, QLC1

Noxafil

NOXAFIL (40MG/ML SUSPENSION) $3.80-$8.50 (Tier 2) QLC1

Nyamyc

nyamyc (powder) $1.25-$3.40 (Tier 1)C1

Nystatin

nystatin (cream, ointment, powder, suspension,

tablet)$1.25-$3.40 (Tier 1)

C1

Nystop

nystop (powder) $1.25-$3.40 (Tier 1)C1

Posaconazole DR posaconazole dr (tablet delayed-release) $1.25-$3.40 (Tier 1) PA, QLC1

QC Tolnaftate

qc tolnaftate (cream)* $0 (Tier 3)C1

SM Miconazole 7 sm miconazole 7 (cream)* $0 (Tier 3)


32


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Sporanox

SPORANOX (10MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2) PAC1

Terbinafine HCl

terbinafine hcl (otc only) (cream)* $0 (Tier 3)C1

Terbinafine HCl

terbinafine hcl (rx only) (tablet) $1.25-$3.40 (Tier 1)C1

Terconazole

terconazole (0.4% cream, 0.8% cream, 80mg

suppository)$1.25-$3.40 (Tier 1)

C1

Tioconazole-1

tioconazole-1 (ointment)* $0 (Tier 3)C1

Tolnaftate

tolnaftate (1% cream, 1% powder)* $0 (Tier 3)C1

Voriconazole

voriconazole (200mg injection, 200mg tablet, 50mg

tablet, 40mg/ml suspension)$1.25-$3.40 (Tier 1)

C1

Zeasorb-AF

zeasorb-af (powder)* $0 (Tier 3)A1

Antigout Agents

B1

Antigout AgentsC1

Allopurinol

allopurinol (tablet) $1.25-$3.40 (Tier 1)C1

Colchicine

COLCHICINE (0.6MG CAPSULE) (BRAND EQUIVALENT MITIGARE)

$3.80-$8.50 (Tier 2) QLC1

Colchicine

colchicine (0.6mg tablet) (brand equivalent colcrys) $1.25-$3.40 (Tier 1) QLC1

Febuxostat

febuxostat (tablet) $1.25-$3.40 (Tier 1) STC1

Probenecid

probenecid (tablet) $1.25-$3.40 (Tier 1)C1

Probenecid/Colchicine probenecid/colchicine (tablet) $1.25-$3.40 (Tier 1)

A1

Antimigraine Agents

B1

Ergot AlkaloidsC1

Dihydroergotamine Mesylate dihydroergotamine mesylate (nasal solution) $1.25-$3.40 (Tier 1)C1

Ergotamine Tartrate/Caffeine ergotamine tartrate/caffeine (tablet) $1.25-$3.40 (Tier 1)C1

Migergot

migergot (suppository) $1.25-$3.40 (Tier 1)B1

ProphylacticC1

Aimovig

AIMOVIG (SOLUTION AUTO INJECTOR) $3.80-$8.50 (Tier 2) PA, QLB1

Serotonin (5-HT) 1b/1d Receptor AgonistsC1

Naratriptan HCl

naratriptan hcl (tablet) $1.25-$3.40 (Tier 1) QLC1

Rizatriptan Benzoate rizatriptan benzoate (10mg tablet, 5mg tablet) $1.25-$3.40 (Tier 1) QLC1

Rizatriptan Benzoate ODT rizatriptan benzoate odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1

Sumatriptan

sumatriptan (nasal solution) $1.25-$3.40 (Tier 1) QL



33


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Sumatriptan Succinate sumatriptan succinate (100mg tablet, 25mg tablet,

50mg tablet, 4mg/0.5ml injection, 6mg/0.5ml

solution prefilled syringe), sumatriptan succinate

(6mg/0.5ml injection) (generic imitrex)

$1.25-$3.40 (Tier 1) QL

C1

Sumatriptan Succinate SUMATRIPTAN SUCCINATE (6MG/0.5ML INJECTION) $3.80-$8.50 (Tier 2) QLC1

Sumatriptan Succinate Refill SUMATRIPTAN SUCCINATE REFILL (INJECTION) $3.80-$8.50 (Tier 2) QL

A1

Antimyasthenic Agents

B1

ParasympathomimeticsC1

Guanidine HCl GUANIDINE HCL (TABLET) $3.80-$8.50 (Tier 2)C1

Mestinon

MESTINON (60MG/5ML ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Pyridostigmine Bromide pyridostigmine bromide (tablet immediate-release,

60mg/5ml oral solution)$1.25-$3.40 (Tier 1)

C1

Pyridostigmine Bromide ER pyridostigmine bromide er (tablet extended-release) $1.25-$3.40 (Tier 1)

A1

Antimycobacterials

B1

Antimycobacterials, OtherC1

Dapsone

dapsone (tablet) $1.25-$3.40 (Tier 1)C1

Rifabutin

rifabutin (capsule) $1.25-$3.40 (Tier 1)B1

AntitubercularsC1

Ethambutol HCl

ethambutol hcl (tablet) $1.25-$3.40 (Tier 1)C1

Isoniazid

isoniazid (100mg tablet, 300mg tablet, 50mg/5ml

syrup)$1.25-$3.40 (Tier 1)

C1

Paser

paser (packet) $1.25-$3.40 (Tier 1)C1

Priftin

PRIFTIN (TABLET) $3.80-$8.50 (Tier 2)C1

Pyrazinamide

pyrazinamide (tablet) $1.25-$3.40 (Tier 1)C1

Rifampin

rifampin (150mg capsule, 300mg capsule, 600mg


C1

Rifater

RIFATER (TABLET) $3.80-$8.50 (Tier 2)


34


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Sirturo

SIRTURO (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1

Trecator

TRECATOR (TABLET) $3.80-$8.50 (Tier 2)A1

Antineoplastics

B1

Alkylating AgentsC1

Cyclophosphamide cyclophosphamide (capsule) $1.25-$3.40 (Tier 1) B/D, PAC1

Gleostine

GLEOSTINE (CAPSULE) $3.80-$8.50 (Tier 2)C1

Leukeran

LEUKERAN (TABLET) $3.80-$8.50 (Tier 2)C1

Matulane

MATULANE (CAPSULE) $3.80-$8.50 (Tier 2) LAC1

Valchlor

VALCHLOR (GEL) $3.80-$8.50 (Tier 2) PA, LAB1

Antiandrogens C1

Abiraterone Acetate abiraterone acetate (tablet) $1.25-$3.40 (Tier 1) PA, QLC1

Bicalutamide

bicalutamide (tablet) $1.25-$3.40 (Tier 1)C1

Erleada

ERLEADA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Flutamide

flutamide (capsule) $1.25-$3.40 (Tier 1)C1

Nilutamide

nilutamide (tablet) $1.25-$3.40 (Tier 1)C1

Nubeqa

NUBEQA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Xtandi

XTANDI (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Zytiga

ZYTIGA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAB1

Antiangiogenic AgentsC1

Pomalyst

POMALYST (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Revlimid

REVLIMID (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Thalomid

THALOMID (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLB1

Antiestrogens/ModifiersC1

Emcyt

EMCYT (CAPSULE) $3.80-$8.50 (Tier 2)C1

Fareston

FARESTON (TABLET) $3.80-$8.50 (Tier 2)C1

Soltamox

SOLTAMOX (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Tamoxifen Citrate tamoxifen citrate (tablet) $1.25-$3.40 (Tier 1)C1

Toremifene Citrate toremifene citrate (tablet) $1.25-$3.40 (Tier 1)

B1

AntimetabolitesC1

Droxia

DROXIA (CAPSULE) $3.80-$8.50 (Tier 2)C1

Hydroxyurea

hydroxyurea (capsule) $1.25-$3.40 (Tier 1)C1

Mercaptopurine

mercaptopurine (tablet) $1.25-$3.40 (Tier 1)C1

Purixan

PURIXAN (SUSPENSION) $3.80-$8.50 (Tier 2) PA



35


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Tabloid

TABLOID (TABLET) $3.80-$8.50 (Tier 2) PAB1

AntineoplasticsC1

Xpovio 100mg Once Weekly XPOVIO 100MG ONCE WEEKLY (TABLET THERAPY

PACK)$3.80-$8.50 (Tier 2) PA, QL

C1


PACK)$3.80-$8.50 (Tier 2) PA, QL

C1


PACK)$3.80-$8.50 (Tier 2) PA, QL

C1

Xpovio 80mg Twice Weekly XPOVIO 80MG TWICE WEEKLY (TABLET THERAPY

PACK)$3.80-$8.50 (Tier 2) PA, QL

B1

Antineoplastics, OtherC1

Copiktra

COPIKTRA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Inrebic

INREBIC (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Kisqali

KISQALI (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Kisqali Femara 200 Dose KISQALI FEMARA 200 DOSE (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) PA, QLC1



Leucovorin Calcium leucovorin calcium (tablet) $1.25-$3.40 (Tier 1)C1

Lonsurf

LONSURF (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Lorbrena

LORBRENA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Ninlaro

NINLARO (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Piqray 200mg Daily Dose PIQRAY 200MG DAILY DOSE (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) PA, QLC1



Rozlytrek

ROZLYTREK (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Synribo

SYNRIBO (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Verzenio

VERZENIO (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Zolinza

ZOLINZA (CAPSULE) $3.80-$8.50 (Tier 2) PA


36


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useB1

Aromatase Inhibitors, 3rd GenerationC1

Anastrozole

anastrozole (tablet) $1.25-$3.40 (Tier 1)C1

Exemestane

exemestane (tablet) $1.25-$3.40 (Tier 1)C1

Letrozole

letrozole (tablet) $1.25-$3.40 (Tier 1)B1

Enzyme InhibitorsC1

Balversa

BALVERSA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Rubraca

RUBRACA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Talzenna

TALZENNA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Zejula

ZEJULA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAB1

Molecular Target InhibitorsC1

Afinitor

AFINITOR (TABLET) $3.80-$8.50 (Tier 2) PAC1

Afinitor Disperz AFINITOR DISPERZ (TABLET SOLUBLE) $3.80-$8.50 (Tier 2) PAC1

Alecensa

ALECENSA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Alunbrig

ALUNBRIG (TABLET THERAPY PACK, 180MG TABLET, 30MG TABLET, 90MG TABLET)

$3.80-$8.50 (Tier 2) PA, QL, LAC1

Bosulif

BOSULIF (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Braftovi

BRAFTOVI (CAPSULE) $3.80-$8.50 (Tier 2) PAC1

Cabometyx

CABOMETYX (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Calquence

CALQUENCE (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Caprelsa

CAPRELSA (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1

Cometriq

COMETRIQ (KIT) $3.80-$8.50 (Tier 2) PA, LAC1

Cotellic

COTELLIC (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Daurismo

DAURISMO (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Erivedge

ERIVEDGE (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Erlotinib HCl

erlotinib hcl (tablet) $1.25-$3.40 (Tier 1) PA, QLC1

Farydak

FARYDAK (CAPSULE) $3.80-$8.50 (Tier 2) PAC1

Gilotrif

GILOTRIF (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1

Ibrance

IBRANCE (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Iclusig

ICLUSIG (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Idhifa

IDHIFA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Imatinib Mesylate

imatinib mesylate (tablet) $1.25-$3.40 (Tier 1) PA, QLC1

Imbruvica

IMBRUVICA (140MG CAPSULE, 70MG CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Imbruvica

IMBRUVICA (140MG TABLET, 280MG TABLET, 420MG TABLET, 560MG TABLET)

$3.80-$8.50 (Tier 2) PA, QLC1

Inlyta

INLYTA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LA



37


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Iressa

IRESSA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Jakafi

JAKAFI (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Lenvima

LENVIMA (CAPSULE THERAPY PACK) $3.80-$8.50 (Tier 2) PA, LAC1

Lynparza

LYNPARZA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Mekinist

MEKINIST (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1

Mektovi

MEKTOVI (TABLET) $3.80-$8.50 (Tier 2) PAC1

Nerlynx

NERLYNX (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Nexavar

NEXAVAR (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1

Odomzo

ODOMZO (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Rydapt

RYDAPT (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Sprycel

SPRYCEL (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Stivarga

STIVARGA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Sutent

SUTENT (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Tafinlar

TAFINLAR (CAPSULE) $3.80-$8.50 (Tier 2) PA, LAC1

Tagrisso

TAGRISSO (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Tarceva

TARCEVA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Tasigna

TASIGNA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Tibsovo

TIBSOVO (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Turalio

TURALIO (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Tykerb

TYKERB (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1

Venclexta

VENCLEXTA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Venclexta Starting Pack VENCLEXTA STARTING PACK (TABLET THERAPY

PACK)$3.80-$8.50 (Tier 2) PA, LA

C1

Vitrakvi

VITRAKVI (100MG CAPSULE, 25MG CAPSULE, 20MG/ML SOLUTION)

$3.80-$8.50 (Tier 2) PA, QLC1

Vizimpro

VIZIMPRO (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Votrient

VOTRIENT (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Xalkori

XALKORI (CAPSULE) $3.80-$8.50 (Tier 2) PA, LAC1

Xospata

XOSPATA (TABLET) $3.80-$8.50 (Tier 2) PA, QL


38


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Zelboraf

ZELBORAF (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Zydelig

ZYDELIG (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Zykadia

ZYKADIA (150MG CAPSULE, 150MG TABLET) $3.80-$8.50 (Tier 2) PA, QLB1

RetinoidsC1

Bexarotene

bexarotene (capsule) $1.25-$3.40 (Tier 1) PAC1

Panretin

PANRETIN (GEL) $3.80-$8.50 (Tier 2)C1

Targretin

TARGRETIN (1% GEL) $3.80-$8.50 (Tier 2) PAC1

Tretinoin

tretinoin (10mg capsule) $1.25-$3.40 (Tier 1)B1

Treatment AdjunctsC1

Mesnex

MESNEX (400MG TABLET) $3.80-$8.50 (Tier 2)A1

Antiparasitics

B1

AnthelminticsC1

Albendazole

albendazole (tablet) $1.25-$3.40 (Tier 1) QLC1

Albenza

ALBENZA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Biltricide

BILTRICIDE (TABLET) $3.80-$8.50 (Tier 2)C1

Ivermectin

ivermectin (tablet) $1.25-$3.40 (Tier 1)C1

Praziquantel

praziquantel (tablet) $1.25-$3.40 (Tier 1)B1

AntiprotozoalsC1

Alinia

ALINIA (100MG/5ML SUSPENSION, 500MG TABLET) $3.80-$8.50 (Tier 2)C1

Atovaquone

atovaquone (suspension) $1.25-$3.40 (Tier 1)C1

Atovaquone/Proguanil HCl atovaquone/proguanil hcl (tablet) (generic malarone) $1.25-$3.40 (Tier 1)C1

Benznidazole BENZNIDAZOLE (TABLET) $3.80-$8.50 (Tier 2)C1

Chloroquine Phosphate chloroquine phosphate (tablet) $1.25-$3.40 (Tier 1)C1

Coartem

COARTEM (TABLET) $3.80-$8.50 (Tier 2)C1

Daraprim

DARAPRIM (TABLET) $3.80-$8.50 (Tier 2)C1

Hydroxychloroquine Sulfate hydroxychloroquine sulfate (tablet) $1.25-$3.40 (Tier 1)C1

Mefloquine HCl

mefloquine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Nebupent

NEBUPENT (INHALATION SOLUTION) $3.80-$8.50 (Tier 2) B/D, PA, QLC1

Pentam 300

PENTAM 300 (INJECTION) $3.80-$8.50 (Tier 2)C1

Primaquine Phosphate primaquine phosphate (tablet) $1.25-$3.40 (Tier 1)C1

Quinine Sulfate

quinine sulfate (capsule) $1.25-$3.40 (Tier 1) PAB1

Pediculicides/ScabicidesC1

GNP Lice Treatment gnp lice treatment (liquid)* $0 (Tier 3)



39


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Lindane

lindane (shampoo) $1.25-$3.40 (Tier 1)C1

Malathion

malathion (lotion) $1.25-$3.40 (Tier 1)C1

Permethrin

permethrin (cream) $1.25-$3.40 (Tier 1)A1

Antiparkinson Agents

B1

AnticholinergicsC1

Benztropine Mesylate benztropine mesylate (tablet) $1.25-$3.40 (Tier 1)C1

Trihexyphenidyl HCl trihexyphenidyl hcl (oral solution) $1.25-$3.40 (Tier 1)C1

Trihexyphenidyl HCl trihexyphenidyl hcl (tablet) $1.25-$3.40 (Tier 1)

B1

Antiparkinson Agents, OtherC1

Amantadine HCl

amantadine hcl (100mg capsule, 100mg tablet,

50mg/5ml syrup)$1.25-$3.40 (Tier 1)

C1

Entacapone

entacapone (tablet) $1.25-$3.40 (Tier 1)C1

Tolcapone

tolcapone (tablet) $1.25-$3.40 (Tier 1) QLB1

Dopamine AgonistsC1

Apokyn

APOKYN (INJECTION) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Bromocriptine Mesylate bromocriptine mesylate (2.5mg tablet, 5mg capsule) $1.25-$3.40 (Tier 1)C1

Neupro

NEUPRO (PATCH 24 HOUR) $3.80-$8.50 (Tier 2)C1

Pramipexole Dihydrochloride pramipexole dihydrochloride (tablet immediate-

release)$1.25-$3.40 (Tier 1)

C1

Ropinirole HCl

ropinirole hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)B1

Dopamine Precursors/L-Amino Acid Decarboxylase InhibitorsC1

Carbidopa/Levodopa carbidopa/levodopa (tablet immediate-release) $1.25-$3.40 (Tier 1)C1

Carbidopa/Levodopa ER carbidopa/levodopa er (tablet extended-release) $1.25-$3.40 (Tier 1)C1

Carbidopa/Levodopa ODT carbidopa/levodopa odt (tablet dispersible) $1.25-$3.40 (Tier 1)C1

Carbidopa/Levodopa/Entacapone carbidopa/levodopa/entacapone (tablet) $1.25-$3.40 (Tier 1)C1

Rytary

RYTARY (CAPSULE EXTENDED-RELEASE) $3.80-$8.50 (Tier 2) ST


40


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useB1

Monoamine Oxidase B (MAO-B) InhibitorsC1

Rasagiline Mesylate rasagiline mesylate (0.5mg tablet, 1mg tablet) $1.25-$3.40 (Tier 1)C1

Selegiline HCl

selegiline hcl (5mg capsule, 5mg tablet) $1.25-$3.40 (Tier 1)C1

Zelapar

ZELAPAR (TABLET DISPERSIBLE) $3.80-$8.50 (Tier 2)A1

Antipsychotics

B1

1st Generation/TypicalC1

Chlorpromazine HCl chlorpromazine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Fluphenazine Decanoate fluphenazine decanoate (injection) $1.25-$3.40 (Tier 1)C1

Fluphenazine HCl fluphenazine hcl (10mg tablet, 1mg tablet, 2.5mg

tablet, 5mg tablet, 2.5mg/ml injection, 5mg/ml

concentrate)

$1.25-$3.40 (Tier 1)

C1

Fluphenazine HCl fluphenazine hcl (elixir) $1.25-$3.40 (Tier 1)C1

Haloperidol

haloperidol (0.5mg tablet, 10mg tablet, 1mg tablet,

20mg tablet, 2mg tablet, 5mg tablet, 2mg/ml

concentrate)

$1.25-$3.40 (Tier 1)

C1

Haloperidol Decanoate haloperidol decanoate (injection) $1.25-$3.40 (Tier 1)C1

Haloperidol Lactate haloperidol lactate (injection) $1.25-$3.40 (Tier 1)C1

Loxapine Succinate loxapine succinate (capsule) $1.25-$3.40 (Tier 1)C1

Molindone HCl

molindone hcl (tablet) $1.25-$3.40 (Tier 1)C1

Pimozide

pimozide (tablet) $1.25-$3.40 (Tier 1)C1

Thioridazine HCl

thioridazine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Thiothixene

thiothixene (capsule) $1.25-$3.40 (Tier 1)C1

Trifluoperazine HCl trifluoperazine hcl (tablet) $1.25-$3.40 (Tier 1)

B1

2nd Generation/AtypicalC1

Abilify Maintena ABILIFY MAINTENA (INJECTION) $3.80-$8.50 (Tier 2)C1

Aripiprazole

aripiprazole (10mg tablet, 15mg tablet, 20mg tablet,

2mg tablet, 30mg tablet, 5mg tablet, 1mg/ml oral

solution)

$1.25-$3.40 (Tier 1) QL

C1

Aripiprazole ODT

aripiprazole odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1

Aristada

ARISTADA (INJECTION) $3.80-$8.50 (Tier 2)C1

Aristada Initio ARISTADA INITIO (PREFILLED SYRINGE) $3.80-$8.50 (Tier 2)C1

Fanapt

FANAPT (TABLET) $3.80-$8.50 (Tier 2) QL, STC1

Fanapt Titration Pack FANAPT TITRATION PACK (TABLET) $3.80-$8.50 (Tier 2) STC1

Geodon

GEODON (20MG INJECTION) $3.80-$8.50 (Tier 2)C1

Invega Sustenna INVEGA SUSTENNA (INJECTION) $3.80-$8.50 (Tier 2)



41


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Invega Trinza INVEGA TRINZA (INJECTION) $3.80-$8.50 (Tier 2)C1

Latuda

LATUDA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Nuplazid

NUPLAZID (10MG TABLET, 34MG CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Olanzapine

olanzapine (10mg injection) $1.25-$3.40 (Tier 1)C1

Olanzapine

olanzapine (10mg tablet, 15mg tablet, 2.5mg tablet,

20mg tablet, 5mg tablet, 7.5mg tablet)$1.25-$3.40 (Tier 1) QL

C1

Olanzapine ODT

olanzapine odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1

Paliperidone ER paliperidone er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1) QLC1

Perseris

PERSERIS (PREFILLED SYRINGE) $3.80-$8.50 (Tier 2)C1

Quetiapine Fumarate quetiapine fumarate (tablet immediate-release) $1.25-$3.40 (Tier 1) QLC1

Quetiapine Fumarate ER quetiapine fumarate er (tablet extended-release 24

hour)$1.25-$3.40 (Tier 1) QL

C1

Rexulti

REXULTI (TABLET) $3.80-$8.50 (Tier 2) QLC1

Risperdal Consta RISPERDAL CONSTA (INJECTION) $3.80-$8.50 (Tier 2)C1

Risperidone

risperidone (0.25mg tablet, 0.5mg tablet, 1mg tablet,

2mg tablet, 3mg tablet, 4mg tablet, 1mg/ml oral

solution)

$1.25-$3.40 (Tier 1)

C1

Risperidone ODT

risperidone odt (tablet dispersible) $1.25-$3.40 (Tier 1)C1

Saphris

SAPHRIS (TABLET SUBLINGUAL) $3.80-$8.50 (Tier 2) QLC1

Vraylar

VRAYLAR (1.5MG CAPSULE, 3MG CAPSULE, 4.5MG CAPSULE, 6MG CAPSULE)

$3.80-$8.50 (Tier 2) QL, STC1

Vraylar

VRAYLAR (CAPSULE THERAPY PACK) $3.80-$8.50 (Tier 2) STC1

Ziprasidone HCl

ziprasidone hcl (capsule) $1.25-$3.40 (Tier 1) QLC1

Zyprexa Relprevv ZYPREXA RELPREVV (INJECTION) $3.80-$8.50 (Tier 2)

B1

Treatment-ResistantC1

Clozapine

clozapine (100mg tablet, 25mg tablet, 50mg tablet,

200mg tablet)$1.25-$3.40 (Tier 1)

C1

Clozapine ODT

clozapine odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1

Versacloz

VERSACLOZ (SUSPENSION) $3.80-$8.50 (Tier 2)


42


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useA1

Antivirals

B1

Anti-cytomegalovirus (CMV) AgentsC1

Valganciclovir

valganciclovir (tablet) $1.25-$3.40 (Tier 1) QLC1

Valganciclovir Hydrochlorde valganciclovir hydrochlorde (oral solution) $1.25-$3.40 (Tier 1) QLC1

Zirgan

ZIRGAN (GEL) $3.80-$8.50 (Tier 2)B1

Anti-hepatitis B (HBV) AgentsC1

Baraclude

BARACLUDE (0.05MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Entecavir

entecavir (tablet) $1.25-$3.40 (Tier 1)C1

Epivir HBV

EPIVIR HBV (5MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Lamivudine

lamivudine (100mg tablet) $1.25-$3.40 (Tier 1)C1

Vemlidy

VEMLIDY (TABLET) $3.80-$8.50 (Tier 2) QLB1

Anti-hepatitis C (HCV) Agents, OtherC1

Intron A

INTRON A (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Pegasys

PEGASYS (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Pegasys ProClick PEGASYS PROCLICK (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Ribavirin

ribavirin (200mg tablet) $1.25-$3.40 (Tier 1)C1

Sylatron

SYLATRON (INJECTION) $3.80-$8.50 (Tier 2) PAB1

Anti-hepatitis C (HCV) Direct Acting AgentsC1

Epclusa

EPCLUSA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Harvoni

HARVONI (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Ledipasvir/Sofosbuvir ledipasvir/sofosbuvir (tablet) $1.25-$3.40 (Tier 1) PA, QLC1

Mavyret

MAVYRET (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Sofosbuvir/Velpatasvir sofosbuvir/velpatasvir (tablet) $1.25-$3.40 (Tier 1) PA, QLC1

Vosevi

VOSEVI (TABLET) $3.80-$8.50 (Tier 2) PA, QLB1

Antiherpetic AgentsC1

Acyclovir

acyclovir (200mg capsule, 200mg/5ml suspension,

400mg tablet, 800mg tablet)$1.25-$3.40 (Tier 1)

C1

Acyclovir Sodium acyclovir sodium (injection) $1.25-$3.40 (Tier 1) B/D, PAC1

Famciclovir

famciclovir (tablet) $1.25-$3.40 (Tier 1) QLC1

Trifluridine

trifluridine (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Valacyclovir HCl

valacyclovir hcl (tablet) $1.25-$3.40 (Tier 1) QLB1

Anti-HIV Agents, Integrase Inhibitors (INSTI) C1

Dovato

DOVATO (TABLET) $3.80-$8.50 (Tier 2) QL



43


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Genvoya

GENVOYA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Isentress

ISENTRESS (100MG PACKET, 100MG TABLET CHEWABLE, 25MG TABLET CHEWABLE, 400MG TABLET)

$3.80-$8.50 (Tier 2) QL

C1

Isentress HD ISENTRESS HD (TABLET) $3.80-$8.50 (Tier 2) QLC1

Stribild

STRIBILD (TABLET) $3.80-$8.50 (Tier 2) QLC1

Tivicay

TIVICAY (TABLET) $3.80-$8.50 (Tier 2) QLC1

Triumeq

TRIUMEQ (TABLET) $3.80-$8.50 (Tier 2) QLC1

Tybost

TYBOST (TABLET) $3.80-$8.50 (Tier 2) QLB1

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)C1

Atripla

ATRIPLA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Complera

COMPLERA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Delstrigo

DELSTRIGO (TABLET) $3.80-$8.50 (Tier 2) QLC1

Edurant

EDURANT (TABLET) $3.80-$8.50 (Tier 2) QLC1

Efavirenz

efavirenz (200mg capsule, 50mg capsule, 600mg

tablet)$1.25-$3.40 (Tier 1) QL

C1

Intelence

INTELENCE (TABLET) $3.80-$8.50 (Tier 2) QLC1

Juluca

JULUCA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Nevirapine

nevirapine (200mg tablet immediate-release, 50mg/

5ml suspension)$1.25-$3.40 (Tier 1) QL

C1

Nevirapine ER

nevirapine er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1) QLC1

Odefsey

ODEFSEY (TABLET) $3.80-$8.50 (Tier 2) QLC1

Pifeltro

PIFELTRO (TABLET) $3.80-$8.50 (Tier 2) QLC1

Rescriptor

RESCRIPTOR (TABLET) $3.80-$8.50 (Tier 2) QLC1

Symfi

SYMFI (TABLET) $3.80-$8.50 (Tier 2) QLC1

Symfi Lo

SYMFI LO (TABLET) $3.80-$8.50 (Tier 2) QLC1

Viramune

VIRAMUNE (50MG/5ML SUSPENSION) $3.80-$8.50 (Tier 2) QLB1

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)C1

Abacavir

abacavir (20mg/ml oral solution, 300mg tablet) $1.25-$3.40 (Tier 1) QL


44


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Abacavir Sulfate/Lamivudine abacavir sulfate/lamivudine (tablet) $1.25-$3.40 (Tier 1) QLC1

Abacavir Sulfate/Lamivudine/Zidovudine

abacavir sulfate/lamivudine/zidovudine (tablet) $1.25-$3.40 (Tier 1) QLC1

Biktarvy

BIKTARVY (TABLET) $3.80-$8.50 (Tier 2) QLC1

Cimduo

CIMDUO (TABLET) $3.80-$8.50 (Tier 2) QLC1

Descovy

DESCOVY (TABLET) $3.80-$8.50 (Tier 2) QLC1

Didanosine

didanosine (capsule delayed-release) $1.25-$3.40 (Tier 1) QLC1

Emtriva

EMTRIVA (10MG/ML ORAL SOLUTION, 200MG CAPSULE)

$3.80-$8.50 (Tier 2) QLC1

Lamivudine

lamivudine (10mg/ml oral solution, 150mg tablet,

300mg tablet)$1.25-$3.40 (Tier 1) QL

C1

Lamivudine/Zidovudine lamivudine/zidovudine (tablet) $1.25-$3.40 (Tier 1) QLC1

Stavudine

stavudine (capsule) $1.25-$3.40 (Tier 1) QLC1

Tenofovir Disoproxil Fumarate tenofovir disoproxil fumarate (tablet) $1.25-$3.40 (Tier 1) QLC1

Truvada

TRUVADA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Videx EC

VIDEX EC (125MG CAPSULE DELAYED-RELEASE) $3.80-$8.50 (Tier 2) QLC1

Videx Pediatric VIDEX PEDIATRIC (ORAL SOLUTION) $3.80-$8.50 (Tier 2) QLC1

Viread

VIREAD (150MG TABLET, 200MG TABLET, 250MG TABLET, 40MG/GM POWDER)

$3.80-$8.50 (Tier 2) QLC1

Zidovudine

zidovudine (100mg capsule, 300mg tablet, 50mg/

5ml syrup)$1.25-$3.40 (Tier 1) QL

B1

Anti-HIV Agents, OtherC1

Fuzeon

FUZEON (INJECTION) $3.80-$8.50 (Tier 2) QLC1

Selzentry

SELZENTRY (150MG TABLET, 25MG TABLET, 300MG TABLET, 75MG TABLET, 20MG/ML ORAL SOLUTION)

$3.80-$8.50 (Tier 2) QL

B1

Anti-HIV Agents, Protease InhibitorsC1

Aptivus

APTIVUS (100MG/ML ORAL SOLUTION, 250MG CAPSULE)

$3.80-$8.50 (Tier 2) QLC1

Atazanavir Sulfate atazanavir sulfate (capsule) $1.25-$3.40 (Tier 1) QLC1

Crixivan

CRIXIVAN (CAPSULE) $3.80-$8.50 (Tier 2) QLC1

Evotaz

EVOTAZ (TABLET) $3.80-$8.50 (Tier 2) QLC1

Fosamprenavir Calcium fosamprenavir calcium (tablet) $1.25-$3.40 (Tier 1) QLC1

Invirase

INVIRASE (TABLET) $3.80-$8.50 (Tier 2) QLC1

Kaletra

KALETRA (100MG-25MG TABLET, 200MG-50MG TABLET)

$3.80-$8.50 (Tier 2) QLC1

Lexiva

LEXIVA (50MG/ML SUSPENSION) $3.80-$8.50 (Tier 2) QLC1

Lopinavir/Ritonavir lopinavir/ritonavir (oral solution) $1.25-$3.40 (Tier 1) QL



45


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Norvir

NORVIR (100MG PACKET, 100MG TABLET, 80MG/ML ORAL SOLUTION)

$3.80-$8.50 (Tier 2) QLC1

Prezcobix

PREZCOBIX (TABLET) $3.80-$8.50 (Tier 2) QLC1

Prezista

PREZISTA (100MG/ML SUSPENSION, 150MG TABLET, 600MG TABLET, 75MG TABLET, 800MG TABLET)

$3.80-$8.50 (Tier 2) QLC1

Reyataz

REYATAZ (50MG PACKET) $3.80-$8.50 (Tier 2) QLC1

Ritonavir

ritonavir (tablet) $1.25-$3.40 (Tier 1) QLC1

Symtuza

SYMTUZA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Viracept

VIRACEPT (TABLET) $3.80-$8.50 (Tier 2) QLB1

Anti-influenza AgentsC1

Oseltamivir Phosphate oseltamivir phosphate (30mg capsule, 45mg

capsule, 75mg capsule, 6mg/ml suspension)$1.25-$3.40 (Tier 1) QL

C1

Relenza Diskhaler RELENZA DISKHALER (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1

Rimantadine HCl

rimantadine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Xofluza

XOFLUZA (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) QLA1

Anxiolytics

B1

Anxiolytics, OtherC1

Buspirone HCl

buspirone hcl (tablet) $1.25-$3.40 (Tier 1)C1

Hydroxyzine HCl

hydroxyzine hcl (10mg/5ml syrup) $1.25-$3.40 (Tier 1)C1

Hydroxyzine HCl

hydroxyzine hcl (tablet) $1.25-$3.40 (Tier 1)B1

Benzodiazepines C1

Alprazolam

alprazolam (tablet immediate-release) $1.25-$3.40 (Tier 1) QLC1

Chlordiazepoxide HCl chlordiazepoxide hcl (capsule) $1.25-$3.40 (Tier 1)C1

Clonazepam

clonazepam (tablet) $1.25-$3.40 (Tier 1) QLC1

Clonazepam ODT clonazepam odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1

Clorazepate Dipotassium clorazepate dipotassium (tablet) $1.25-$3.40 (Tier 1) QLC1

Diazepam

diazepam (10mg tablet, 2mg tablet, 5mg tablet) $1.25-$3.40 (Tier 1) QL


46


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Diazepam

diazepam (5mg/5ml oral solution) $1.25-$3.40 (Tier 1)C1

Diazepam Intensol diazepam intensol (5mg/ml concentrate) $1.25-$3.40 (Tier 1) QLC1

Lorazepam

lorazepam (0.5mg tablet, 1mg tablet, 2mg tablet,

2mg/ml concentrate)$1.25-$3.40 (Tier 1) QL

A1

Bipolar Agents

B1

Mood StabilizersC1

Divalproex Sodium divalproex sodium (capsule sprinkle delayed-release) $1.25-$3.40 (Tier 1)C1

Divalproex Sodium DR divalproex sodium dr (tablet delayed-release) $1.25-$3.40 (Tier 1)C1

Divalproex Sodium ER divalproex sodium er (tablet extended-release 24

hour)$1.25-$3.40 (Tier 1)

C1

Lithium

LITHIUM (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Lithium Carbonate lithium carbonate (150mg capsule, 300mg capsule,

600mg capsule, 300mg tablet immediate-release)$1.25-$3.40 (Tier 1)

C1

Lithium Carbonate ER lithium carbonate er (tablet extended-release) $1.25-$3.40 (Tier 1)

A1

Blood Glucose Regulators

B1

Antidiabetic AgentsC1

Acarbose

acarbose (tablet) $1.25-$3.40 (Tier 1) QLC1

Avandia

AVANDIA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Bydureon Bcise BYDUREON BCISE (AUTO INJECTOR) $3.80-$8.50 (Tier 2) QLC1

Bydureon Pen BYDUREON PEN (INJECTION) $3.80-$8.50 (Tier 2) QLC1

Byetta

BYETTA (INJECTION) $3.80-$8.50 (Tier 2) QLC1

Cycloset

CYCLOSET (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Farxiga

FARXIGA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Glimepiride

glimepiride (tablet) $1.25-$3.40 (Tier 1) QLC1

Glipizide

glipizide (tablet immediate-release) $1.25-$3.40 (Tier 1) QLC1

Glipizide ER

glipizide er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1) QLC1

Glipizide/Metformin HCl glipizide/metformin hcl (tablet) $1.25-$3.40 (Tier 1) QLC1

Glyxambi

GLYXAMBI (TABLET) $3.80-$8.50 (Tier 2) QLC1

Jardiance

JARDIANCE (TABLET) $3.80-$8.50 (Tier 2) QLC1

Jentadueto

JENTADUETO (TABLET) $3.80-$8.50 (Tier 2) QLC1

Jentadueto XR JENTADUETO XR (TABLET EXTENDED-RELEASE 24

HOUR)$3.80-$8.50 (Tier 2) QL

C1

Kombiglyze XR KOMBIGLYZE XR (TABLET EXTENDED-RELEASE 24

HOUR)$3.80-$8.50 (Tier 2) QL

C1

Metformin HCl

metformin hcl (tablet immediate-release) $1.25-$3.40 (Tier 1) QL



47


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Metformin HCl ER metformin hcl er (500mg tablet extended-release 24

hour, 750mg tablet extended-release 24 hour)

(generic glucophage xr)

$1.25-$3.40 (Tier 1) QL

C1

Nateglinide

nateglinide (tablet) $1.25-$3.40 (Tier 1) QLC1

Onglyza

ONGLYZA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Pioglitazone HCl

pioglitazone hcl (tablet) $1.25-$3.40 (Tier 1) QLC1

Pioglitazone HCl/Glimepiride pioglitazone hcl/glimepiride (tablet) $1.25-$3.40 (Tier 1) QLC1

Pioglitazone HCl/Metformin HCl pioglitazone hcl/metformin hcl (tablet) $1.25-$3.40 (Tier 1) QLC1

Repaglinide

repaglinide (tablet) $1.25-$3.40 (Tier 1) QLC1

Repaglinide/Metformin HCl repaglinide/metformin hcl (tablet) $1.25-$3.40 (Tier 1) QLC1

Riomet

RIOMET (ORAL SOLUTION) $3.80-$8.50 (Tier 2) QLC1

Soliqua 100/33 SOLIQUA 100/33 (INJECTION) $3.80-$8.50 (Tier 2) QLC1

SymlinPen 120 SYMLINPEN 120 (INJECTION) $3.80-$8.50 (Tier 2) PAC1

SymlinPen 60 SYMLINPEN 60 (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Synjardy

SYNJARDY (TABLET) $3.80-$8.50 (Tier 2) QLC1

Synjardy XR

SYNJARDY XR (TABLET EXTENDED-RELEASE 24 HOUR)

$3.80-$8.50 (Tier 2) QLC1

Tradjenta

TRADJENTA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Xigduo XR

XIGDUO XR (TABLET EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2) QLB1

Glycemic AgentsC1

GlucaGen HypoKit GLUCAGEN HYPOKIT (INJECTION) $3.80-$8.50 (Tier 2)C1

Glucagon Emergency Kit GLUCAGON EMERGENCY KIT (INJECTION) $3.80-$8.50 (Tier 2)C1

Proglycem

PROGLYCEM (SUSPENSION) $3.80-$8.50 (Tier 2)B1

InsulinsC1

Humalog Cartridge HUMALOG CARTRIDGE (INJECTION) $3.80-$8.50 (Tier 2)C1

Humalog Junior KwikPen HUMALOG JUNIOR KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1

Humalog KwikPen HUMALOG KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1

Humalog Mix 50/50 KwikPen HUMALOG MIX 50/50 KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)


48


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Humalog Mix 50/50 Vial HUMALOG MIX 50/50 VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1

Humalog Mix 75/25 KwikPen HUMALOG MIX 75/25 KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1

Humalog Mix 75/25 Vial HUMALOG MIX 75/25 VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1

Humalog Vial HUMALOG VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1

Humulin 70/30 KwikPen HUMULIN 70/30 KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1

Humulin 70/30 Vial HUMULIN 70/30 VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1

Humulin N KwikPen HUMULIN N KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1

Humulin N Vial HUMULIN N VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1

Humulin R U-500 KwikPen HUMULIN R U-500 KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1

Humulin R U-500 Vial HUMULIN R U-500 VIAL (CONCENTRATED) (INJECTION) $3.80-$8.50 (Tier 2)C1

Humulin R Vial HUMULIN R VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1

Insulin Lispro

insulin lispro (solution) $3.80-$8.50 (Tier 2)C1

Insulin Lispro KwikPen insulin lispro kwikpen (solution pen injector) $3.80-$8.50 (Tier 2)C1

Lantus SoloStar LANTUS SOLOSTAR (INJECTION) $3.80-$8.50 (Tier 2)C1

Lantus Vial

LANTUS VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1

Levemir FlexTouch LEVEMIR FLEXTOUCH (INJECTION) $3.80-$8.50 (Tier 2)C1

Levemir Vial

LEVEMIR VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1

Toujeo Max Solostar TOUJEO MAX SOLOSTAR (INJECTION) $3.80-$8.50 (Tier 2)C1

Toujeo SoloStar TOUJEO SOLOSTAR (INJECTION) $3.80-$8.50 (Tier 2)C1

Tresiba

TRESIBA (INJECTION) $3.80-$8.50 (Tier 2)C1

Tresiba FlexTouch TRESIBA FLEXTOUCH (INJECTION) $3.80-$8.50 (Tier 2)

A1

Blood Products/Modifiers/Volume Expanders

B1

AnticoagulantsC1

Coumadin

COUMADIN (TABLET) $3.80-$8.50 (Tier 2)C1

Eliquis

ELIQUIS (TABLET) $3.80-$8.50 (Tier 2) QLC1

Eliquis Starter Pack ELIQUIS STARTER PACK (TABLET) $3.80-$8.50 (Tier 2) QLC1

Enoxaparin Sodium enoxaparin sodium (injection) $1.25-$3.40 (Tier 1) QLC1

Fondaparinux Sodium fondaparinux sodium (injection) $1.25-$3.40 (Tier 1)C1

Heparin Sodium

heparin sodium (10000unit/ml injection, 20000unit/

ml injection, 5000unit/ml injection)$1.25-$3.40 (Tier 1)

C1

Heparin Sodium

heparin sodium (1000unit/ml injection) $1.25-$3.40 (Tier 1) B/D, PAC1

Jantoven

jantoven (tablet) $1.25-$3.40 (Tier 1)C1

Warfarin Sodium

warfarin sodium (tablet) $1.25-$3.40 (Tier 1)C1

Xarelto

XARELTO (10MG TABLET, 15MG TABLET, 20MG TABLET, 2.5MG TABLET)

$3.80-$8.50 (Tier 2) QLC1

Xarelto Starter Pack XARELTO STARTER PACK (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) QL



49


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useB1

Blood Formation ModifiersC1

Anagrelide HCl

anagrelide hcl (capsule) $1.25-$3.40 (Tier 1)C1

Aranesp Albumin Free ARANESP ALBUMIN FREE (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Leukine

LEUKINE (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Neulasta

NEULASTA (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Procrit

PROCRIT (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Promacta

PROMACTA (12.5MG PACKET, 12.5MG TABLET, 25MG TABLET, 50MG TABLET, 75MG TABLET)

$3.80-$8.50 (Tier 2) PA, QL, LAC1

Retacrit

RETACRIT (SOLUTION) $3.80-$8.50 (Tier 2) PAC1

Zarxio

ZARXIO (SOLUTION PREFILLED SYRINGE) $3.80-$8.50 (Tier 2)B1

Hemostasis AgentsC1

Tranexamic Acid

tranexamic acid (tablet) $1.25-$3.40 (Tier 1)B1

Platelet Modifying AgentsC1

Aspirin/Dipyridamole aspirin/dipyridamole (capsule extended-release 12

hour)$1.25-$3.40 (Tier 1) QL

C1

Brilinta

BRILINTA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Cablivi

CABLIVI (KIT) $3.80-$8.50 (Tier 2) PA, QLC1

Cilostazol

cilostazol (tablet) $1.25-$3.40 (Tier 1)C1

Clopidogrel

clopidogrel (75mg tablet) $1.25-$3.40 (Tier 1) QLC1

Prasugrel

prasugrel (tablet) $1.25-$3.40 (Tier 1) QLA1

Cardiovascular Agents

B1

Alpha-adrenergic AgonistsC1

Clonidine HCl

clonidine hcl (patch weekly) $1.25-$3.40 (Tier 1)C1

Clonidine HCl

clonidine hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)C1

Methyldopa

methyldopa (tablet) $1.25-$3.40 (Tier 1)C1

Midodrine HCl

midodrine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Northera

NORTHERA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LA


50


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useB1

Alpha-adrenergic Blocking AgentsC1

Doxazosin Mesylate doxazosin mesylate (tablet) $1.25-$3.40 (Tier 1)C1

Phenoxybenzamine HCl phenoxybenzamine hcl (capsule) $1.25-$3.40 (Tier 1)C1

Prazosin HCl

prazosin hcl (capsule) $1.25-$3.40 (Tier 1)B1

Angiotensin II Receptor AntagonistsC1

Candesartan Cilexetil candesartan cilexetil (tablet) $1.25-$3.40 (Tier 1) QLC1

Eprosartan Mesylate eprosartan mesylate (tablet) $1.25-$3.40 (Tier 1) QLC1

Irbesartan

irbesartan (tablet) $1.25-$3.40 (Tier 1) QLC1

Losartan Potassium losartan potassium (tablet) $1.25-$3.40 (Tier 1) QLC1

Olmesartan Medoxomil olmesartan medoxomil (tablet) $1.25-$3.40 (Tier 1) QLC1

Telmisartan

telmisartan (tablet) $1.25-$3.40 (Tier 1) QLC1

Valsartan

valsartan (tablet) $1.25-$3.40 (Tier 1) QLB1

Angiotensin-converting Enzyme (ACE) InhibitorsC1

Benazepril HCl

benazepril hcl (tablet) $1.25-$3.40 (Tier 1) QLC1

Captopril

captopril (tablet) $1.25-$3.40 (Tier 1) QLC1

Enalapril Maleate enalapril maleate (tablet) $1.25-$3.40 (Tier 1) QLC1

Fosinopril Sodium fosinopril sodium (tablet) $1.25-$3.40 (Tier 1) QLC1

Lisinopril

lisinopril (tablet) $1.25-$3.40 (Tier 1) QLC1

Moexipril HCl

moexipril hcl (tablet) $1.25-$3.40 (Tier 1) QLC1

Perindopril Erbumine perindopril erbumine (tablet) $1.25-$3.40 (Tier 1) QLC1

Quinapril HCl

quinapril hcl (tablet) $1.25-$3.40 (Tier 1) QLC1

Ramipril

ramipril (capsule) $1.25-$3.40 (Tier 1) QLC1

Trandolapril

trandolapril (tablet) $1.25-$3.40 (Tier 1) QLB1

AntiarrhythmicsC1

Amiodarone HCl

amiodarone hcl (200mg tablet) $1.25-$3.40 (Tier 1)C1

Dofetilide

dofetilide (capsule) $1.25-$3.40 (Tier 1)C1

Flecainide Acetate flecainide acetate (tablet) $1.25-$3.40 (Tier 1)C1

Mexiletine HCl

mexiletine hcl (capsule) $1.25-$3.40 (Tier 1)C1

Multaq

MULTAQ (TABLET) $3.80-$8.50 (Tier 2) QLC1

Pacerone

pacerone (200mg tablet) $1.25-$3.40 (Tier 1)C1

Propafenone HCl propafenone hcl (tablet) $1.25-$3.40 (Tier 1)C1

Propafenone HCl ER propafenone hcl er (capsule extended-release 12

hour)$1.25-$3.40 (Tier 1)

C1

Quinidine Gluconate CR quinidine gluconate cr (tablet extended-release) $1.25-$3.40 (Tier 1)



51


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Quinidine Sulfate quinidine sulfate (tablet) $1.25-$3.40 (Tier 1)C1

Sotalol HCl AF

sotalol hcl af (tablet) $1.25-$3.40 (Tier 1)C1

Sotalol HCl

sotalol hcl (tablet) $1.25-$3.40 (Tier 1)B1

Beta-adrenergic Blocking AgentsC1

Atenolol

atenolol (tablet) $1.25-$3.40 (Tier 1)C1

Bystolic

BYSTOLIC (TABLET) $3.80-$8.50 (Tier 2) QLC1

Carvedilol

carvedilol (tablet) $1.25-$3.40 (Tier 1)C1

Labetalol HCl

labetalol hcl (tablet) $1.25-$3.40 (Tier 1)C1

Metoprolol Succinate ER metoprolol succinate er (tablet extended-release 24

hour)$1.25-$3.40 (Tier 1)

C1

Metoprolol Tartrate metoprolol tartrate (100mg tablet immediate-release,


immediate-release)

$1.25-$3.40 (Tier 1)

C1

Nadolol

nadolol (tablet) $1.25-$3.40 (Tier 1)C1

Pindolol

pindolol (tablet) $1.25-$3.40 (Tier 1)C1

Propranolol HCl

propranolol hcl (20mg/5ml oral solution, 40mg/5ml

oral solution)$1.25-$3.40 (Tier 1)

C1

Propranolol HCl

propranolol hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)C1

Propranolol HCl ER propranolol hcl er (capsule extended-release 24

hour)$1.25-$3.40 (Tier 1)

C1

Timolol Maleate

timolol maleate (10mg tablet, 20mg tablet, 5mg

tablet)$1.25-$3.40 (Tier 1)

B1

Calcium Channel Blocking AgentsC1

Amlodipine Besylate amlodipine besylate (tablet) $1.25-$3.40 (Tier 1)C1

Cartia XT

cartia xt (capsule extended-release 24 hour) $1.25-$3.40 (Tier 1)C1

Dilt-XR

dilt-xr (capsule extended-release 24 hour) $1.25-$3.40 (Tier 1)C1

Diltiazem HCl

diltiazem hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)C1

Diltiazem HCl ER diltiazem hcl er (capsule extended-release 12 hour) $1.25-$3.40 (Tier 1)C1

Diltiazem HCl ER diltiazem hcl er (capsule extended-release 24 hour) $1.25-$3.40 (Tier 1)


52


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Matzim LA

matzim la (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1

Nicardipine HCl

nicardipine hcl (capsule) $1.25-$3.40 (Tier 1)C1

Nimodipine

nimodipine (capsule) $1.25-$3.40 (Tier 1)C1

Nymalize

NYMALIZE (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Taztia XT

taztia xt (capsule extended-release 24 hour) $1.25-$3.40 (Tier 1)C1

Verapamil HCl

verapamil hcl (120mg tablet immediate-release,


immediate-release)

$1.25-$3.40 (Tier 1)

C1

Verapamil HCl ER verapamil hcl er (120mg tablet extended-release,

180mg tablet extended-release, 240mg tablet

extended-release)

$1.25-$3.40 (Tier 1)

B1

Cardiovascular Agents, OtherC1

Amiloride/Hydrochlorothiazide amiloride/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1

Amlodipine Besylate/Atorvastatin Calcium

amlodipine besylate/atorvastatin calcium (tablet) $1.25-$3.40 (Tier 1) QLC1

Amlodipine Besylate/Benazepril HCl

amlodipine besylate/benazepril hcl (capsule) $1.25-$3.40 (Tier 1) QLC1

Atenolol/Chlorthalidone atenolol/chlorthalidone (tablet) $1.25-$3.40 (Tier 1)C1

Benazepril HCl/Hydrochlorothiazide benazepril hcl/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Candesartan Cilexetil/Hydrochlorothiazide

candesartan cilexetil/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Captopril/Hydrochlorothiazide captopril/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Corlanor

CORLANOR (5MG TABLET, 7.5MG TABLET, 5MG/5ML SOLUTION)

$3.80-$8.50 (Tier 2) PA, QLC1

Demser

DEMSER (CAPSULE) $3.80-$8.50 (Tier 2)C1

Digitek

digitek (tablet) $1.25-$3.40 (Tier 1)C1

Digox

digox (tablet) $1.25-$3.40 (Tier 1)C1

Digoxin

DIGOXIN (0.05MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Digoxin

digoxin (125mcg tablet, 250mcg tablet) $1.25-$3.40 (Tier 1)C1

Enalapril Maleate/Hydrochlorothiazide

enalapril maleate/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Entresto

ENTRESTO (TABLET) $3.80-$8.50 (Tier 2) QLC1

Fosinopril Sodium/Hydrochlorothiazide

fosinopril sodium/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Irbesartan/Hydrochlorothiazide irbesartan/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Lanoxin

LANOXIN (125MCG TABLET, 250MCG TABLET, 62.5MCG TABLET)

$3.80-$8.50 (Tier 2)C1

Lisinopril/Hydrochlorothiazide lisinopril/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Losartan Potassium/Hydrochlorothiazide

losartan potassium/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Methyldopa/Hydrochlorothiazide methyldopa/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1

Metoprolol/Hydrochlorothiazide metoprolol/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1

Olmesartan Medoxomil/Hydrochlorothiazide

olmesartan medoxomil/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QL



53


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Pentoxifylline ER

pentoxifylline er (tablet extended-release) $1.25-$3.40 (Tier 1)C1

Propranolol/Hydrochlorothiazide propranolol/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1

Quinapril/Hydrochlorothiazide quinapril/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Ranexa

RANEXA (TABLET EXTENDED-RELEASE 12 HOUR) $3.80-$8.50 (Tier 2) QLC1

Ranolazine ER

ranolazine er (tablet extended-release 12 hour) $1.25-$3.40 (Tier 1) QLC1

Spironolactone/Hydrochlorothiazide spironolactone/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1

Telmisartan/Amlodipine telmisartan/amlodipine (tablet) $1.25-$3.40 (Tier 1) QLC1

Telmisartan/Hydrochlorothiazide telmisartan/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Triamterene/Hydrochlorothiazide triamterene/hydrochlorothiazide (37.5mg-25mg

capsule, 37.5mg-25mg tablet, 75mg-50mg tablet)$1.25-$3.40 (Tier 1)

C1

Valsartan/Hydrochlorothiazide valsartan/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1

Vyndaqel

VYNDAQEL (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLB1

Diuretics, Carbonic Anhydrase InhibitorsC1

Acetazolamide

acetazolamide (tablet immediate-release) $1.25-$3.40 (Tier 1)C1

Acetazolamide ER acetazolamide er (capsule extended-release 12 hour) $1.25-$3.40 (Tier 1)C1

Methazolamide methazolamide (tablet) $1.25-$3.40 (Tier 1)

B1

Diuretics, LoopC1

Bumetanide

bumetanide (0.25mg/ml injection, 0.5mg tablet, 1mg

tablet, 2mg tablet)$1.25-$3.40 (Tier 1)

C1

Furosemide

furosemide (10mg/ml injection) $1.25-$3.40 (Tier 1) B/D, PAC1

Furosemide

furosemide (10mg/ml oral solution, 8mg/ml oral

solution, 20mg tablet, 40mg tablet, 80mg tablet)$1.25-$3.40 (Tier 1)

C1

Torsemide

torsemide (tablet) $1.25-$3.40 (Tier 1)B1

Diuretics, Potassium-sparingC1

Amiloride HCl

amiloride hcl (tablet) $1.25-$3.40 (Tier 1)C1

Eplerenone

eplerenone (tablet) $1.25-$3.40 (Tier 1)C1

Spironolactone

spironolactone (tablet) $1.25-$3.40 (Tier 1)


54


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useB1

Diuretics, ThiazideC1

Chlorothiazide

chlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1

Chlorthalidone

chlorthalidone (tablet) $1.25-$3.40 (Tier 1)C1

Diuril

DIURIL (SUSPENSION) $3.80-$8.50 (Tier 2)C1

Hydrochlorothiazide hydrochlorothiazide (12.5mg capsule, 12.5mg tablet,

25mg tablet, 50mg tablet)$1.25-$3.40 (Tier 1)

C1

Indapamide

indapamide (tablet) $1.25-$3.40 (Tier 1)C1

Metolazone

metolazone (tablet) $1.25-$3.40 (Tier 1)B1

Dyslipidemics, Fibric Acid DerivativesC1

Fenofibrate

fenofibrate (160mg tablet, 54mg tablet) $1.25-$3.40 (Tier 1)C1

Gemfibrozil

gemfibrozil (tablet) $1.25-$3.40 (Tier 1)B1

Dyslipidemics, HMG CoA Reductase InhibitorsC1

Atorvastatin Calcium atorvastatin calcium (tablet) $1.25-$3.40 (Tier 1) QLC1

Fluvastatin

fluvastatin (capsule immediate-release) $1.25-$3.40 (Tier 1) QLC1

Livalo

LIVALO (TABLET) $3.80-$8.50 (Tier 2) QLC1

Lovastatin

lovastatin (tablet) $1.25-$3.40 (Tier 1) QLC1

Pravastatin Sodium pravastatin sodium (tablet) $1.25-$3.40 (Tier 1) QLC1

Rosuvastatin Calcium rosuvastatin calcium (tablet) $1.25-$3.40 (Tier 1) QLC1

Simvastatin

simvastatin (tablet) $1.25-$3.40 (Tier 1) QLB1

Dyslipidemics, OtherC1

Cholestyramine

cholestyramine (packet) $1.25-$3.40 (Tier 1)C1

Cholestyramine Light cholestyramine light (powder) $1.25-$3.40 (Tier 1)C1

Colesevelam HCl

colesevelam hcl (3.75gm packet, 625mg tablet) $1.25-$3.40 (Tier 1)C1

Colestipol HCl

colestipol hcl (1gm tablet, 5gm packet) $1.25-$3.40 (Tier 1)C1

Ezetimibe

ezetimibe (tablet) $1.25-$3.40 (Tier 1) QLC1

Ezetimibe/Simvastatin ezetimibe/simvastatin (tablet) $1.25-$3.40 (Tier 1) QLC1

Juxtapid

JUXTAPID (CAPSULE) $3.80-$8.50 (Tier 2) PA, LAC1

Niacin ER

niacin er (rx only) (tablet extended-release) $1.25-$3.40 (Tier 1)C1

Niacor

niacor (tablet) $1.25-$3.40 (Tier 1)C1

Omega-3-Acid Ethyl Esters omega-3-acid ethyl esters (capsule) (generic lovaza) $1.25-$3.40 (Tier 1) QLC1

Praluent

PRALUENT (INJECTION) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Prevalite

prevalite (packet) $1.25-$3.40 (Tier 1)C1

Repatha

REPATHA (INJECTION) $3.80-$8.50 (Tier 2) PA, QLC1

Repatha Pushtronex System REPATHA PUSHTRONEX SYSTEM (INJECTION) $3.80-$8.50 (Tier 2) PA, QL



55


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Repatha SureClick REPATHA SURECLICK (INJECTION) $3.80-$8.50 (Tier 2) PA, QLC1

Vascepa

VASCEPA (CAPSULE) $3.80-$8.50 (Tier 2)B1

Vasodilators, Direct-acting ArterialC1

Hydralazine HCl

hydralazine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Minoxidil

minoxidil (tablet) $1.25-$3.40 (Tier 1)B1

Vasodilators, Direct-acting Arterial/VenousC1

Isosorbide Dinitrate isosorbide dinitrate (tablet immediate-release) $1.25-$3.40 (Tier 1)C1

Isosorbide Dinitrate ER isosorbide dinitrate er (tablet extended-release) $1.25-$3.40 (Tier 1)C1

Isosorbide Mononitrate isosorbide mononitrate (tablet immediate-release) $1.25-$3.40 (Tier 1)C1

Isosorbide Mononitrate ER isosorbide mononitrate er (tablet extended-release

24 hour)$1.25-$3.40 (Tier 1)

C1

Minitran

minitran (patch 24 hour) $1.25-$3.40 (Tier 1)C1

Nitro-Bid

nitro-bid (ointment) $1.25-$3.40 (Tier 1)C1

Nitroglycerin

nitroglycerin (tablet sublingual) $1.25-$3.40 (Tier 1)C1

Nitroglycerin Lingual nitroglycerin lingual (translingual solution) $1.25-$3.40 (Tier 1)C1

Nitroglycerin Transdermal nitroglycerin transdermal (patch 24 hour) $1.25-$3.40 (Tier 1)C1

Nitrostat

NITROSTAT (TABLET SUBLINGUAL) $3.80-$8.50 (Tier 2)A1

Central Nervous System Agents

B1

Attention Deficit Hyperactivity Disorder Agents, Amphetamines


56


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Amphetamine/Dextroamphetamine

amphetamine/dextroamphetamine (10mg capsule

extended-release 24 hour, 15mg capsule extended-

release 24 hour, 20mg capsule extended-release 24

hour, 25mg capsule extended-release 24 hour, 30mg

capsule extended-release 24 hour, 5mg capsule

extended-release 24 hour, 10mg tablet immediate-

release, 12.5mg tablet immediate-release, 15mg


release, 30mg tablet immediate-release, 5mg tablet

immediate-release, 7.5mg tablet immediate-release)

$1.25-$3.40 (Tier 1) QL

C1

Dextroamphetamine Sulfate dextroamphetamine sulfate (10mg tablet, 5mg tablet) $1.25-$3.40 (Tier 1) QL

B1

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesC1

Atomoxetine

atomoxetine (capsule) $1.25-$3.40 (Tier 1) QLC1

Clonidine HCl ER clonidine hcl er (tablet extended-release 12 hour) $1.25-$3.40 (Tier 1) PAC1

Dexmethylphenidate HCl dexmethylphenidate hcl (tablet immediate-release) $1.25-$3.40 (Tier 1) QLC1

Dexmethylphenidate HCl ER dexmethylphenidate hcl er (capsule extended-

release 24 hour)$1.25-$3.40 (Tier 1)

C1

Guanfacine ER

guanfacine er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1

Methylphenidate HCl methylphenidate hcl (10mg tablet immediate-release,


immediate-release) (generic ritalin), (10mg/5ml oral

solution, 5mg/5ml oral solution)

$1.25-$3.40 (Tier 1) QL

C1

Methylphenidate HCl ER methylphenidate hcl er (10mg tablet extended-

release, 20mg tablet extended-release)$1.25-$3.40 (Tier 1) QL

B1

Central Nervous System, OtherC1

Austedo

AUSTEDO (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Ingrezza

INGREZZA (CAPSULE THERAPY PACK, 40MG CAPSULE, 80MG CAPSULE)

$3.80-$8.50 (Tier 2) PA, QLC1

Namzaric

NAMZARIC (THERAPY PACK, CAPSULE EXTENDED-RELEASE 24 HOUR)

$3.80-$8.50 (Tier 2) PA, QLC1

Nuedexta

NUEDEXTA (CAPSULE) $3.80-$8.50 (Tier 2) PAC1

Riluzole

riluzole (tablet) $1.25-$3.40 (Tier 1)C1

Tetrabenazine

tetrabenazine (tablet) $1.25-$3.40 (Tier 1) PA, QL, LAB1

Fibromyalgia AgentsC1

Duloxetine HCl

duloxetine hcl (20mg capsule delayed-release, 30mg

capsule delayed-release, 60mg capsule delayed-

release)

$1.25-$3.40 (Tier 1) QL



57


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Pregabalin

pregabalin (100mg capsule, 150mg capsule, 200mg

capsule, 225mg capsule, 25mg capsule, 300mg

capsule, 50mg capsule, 75mg capsule, 20mg/ml

solution)

$1.25-$3.40 (Tier 1) QL

C1

Savella

SAVELLA (TABLET) $3.80-$8.50 (Tier 2)C1

Savella Titration Pack SAVELLA TITRATION PACK $3.80-$8.50 (Tier 2)

B1

Multiple Sclerosis AgentsC1

Ampyra

AMPYRA (TABLET EXTENDED-RELEASE 12 HOUR) $3.80-$8.50 (Tier 2) QL, LAC1

Aubagio

AUBAGIO (TABLET) $3.80-$8.50 (Tier 2) QL, LAC1

Avonex

AVONEX (INJECTION) $3.80-$8.50 (Tier 2)C1

Avonex Pen

AVONEX PEN (INJECTION) $3.80-$8.50 (Tier 2)C1

Betaseron

BETASERON (INJECTION) $3.80-$8.50 (Tier 2)C1

Dalfampridine ER dalfampridine er (tablet extended-release 12 hour) $1.25-$3.40 (Tier 1) QLC1

Gilenya

GILENYA (CAPSULE) $3.80-$8.50 (Tier 2) QLC1

Glatiramer Acetate glatiramer acetate (solution prefilled syringe) $1.25-$3.40 (Tier 1)C1

Glatopa

glatopa (injection) $1.25-$3.40 (Tier 1)C1

Mayzent

MAYZENT (TABLET) $3.80-$8.50 (Tier 2) QLC1

Rebif

REBIF (INJECTION) $3.80-$8.50 (Tier 2)C1

Rebif Rebidose REBIF REBIDOSE (INJECTION) $3.80-$8.50 (Tier 2)C1

Rebif Rebidose Titration Pack REBIF REBIDOSE TITRATION PACK (INJECTION) $3.80-$8.50 (Tier 2)C1

Rebif Titration Pack REBIF TITRATION PACK (INJECTION) $3.80-$8.50 (Tier 2)C1

Tecfidera

TECFIDERA (CAPSULE DELAYED-RELEASE) $3.80-$8.50 (Tier 2) QL, LAC1

Tecfidera Starter Pack TECFIDERA STARTER PACK $3.80-$8.50 (Tier 2) LA

A1

Dental and Oral Agents

B1

Dental and Oral AgentsC1

Chlorhexidine Gluconate Oral Rinse

chlorhexidine gluconate oral rinse (solution) $1.25-$3.40 (Tier 1)C1

Pilocarpine HCl

pilocarpine hcl (5mg tablet, 7.5mg tablet) $1.25-$3.40 (Tier 1)C1

Triamcinolone Acetonide Dental Paste

triamcinolone acetonide dental paste (paste) $1.25-$3.40 (Tier 1)


58


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useA1

Dermatological Agents

B1

Dermatological AgentsC1

Acitretin

acitretin (capsule) $1.25-$3.40 (Tier 1)C1

Acne Medication 10 acne medication 10 (otc only) (10% gel, 10% lotion)* $0 (Tier 3)C1

Acne Medication 5 acne medication 5 (5% gel, 5% lotion)* $0 (Tier 3)C1

Adapalene

adapalene (0.1% cream, 0.1% gel) $1.25-$3.40 (Tier 1)C1

Ammonium Lactate ammonium lactate (rx only) (12% cream, 12% lotion) $1.25-$3.40 (Tier 1)C1

Anu-Med

anu-med (suppository)* $0 (Tier 3)C1

Azelaic Acid

azelaic acid (gel) $1.25-$3.40 (Tier 1)C1

Benzoyl Peroxide benzoyl peroxide (otc only) (10% gel, 2.5% gel, 5%

gel, 5.3% foam, 9.8% foam)*$0 (Tier 3)

C1

Benzoyl Peroxide Wash benzoyl peroxide wash (liquid)* $0 (Tier 3)C1

Blue Gel

blue gel (gel)* $0 (Tier 3)C1

Calcipotriene

calcipotriene (0.005% cream, 0.005% external

solution, 0.005% ointment)$1.25-$3.40 (Tier 1)

C1

Calcitriol

CALCITRIOL (3MCG/GM OINTMENT) $3.80-$8.50 (Tier 2)C1

Capsaicin

capsaicin (cream)* $0 (Tier 3)C1

Claravis

claravis (capsule) $1.25-$3.40 (Tier 1) PAC1

Clindamycin Phosphate clindamycin phosphate (1% external solution, 1% gel,

1% lotion, 1% swab)$1.25-$3.40 (Tier 1)

C1

Clindamycin/Benzoyl Peroxide clindamycin/benzoyl peroxide (1%-5% gel) (generic

benzaclin)$1.25-$3.40 (Tier 1)

C1

Clotrimazole/Betamethasone Dipropionate

clotrimazole/betamethasone dipropionate (1%-0.05%

cream, 1%-0.05% lotion)$1.25-$3.40 (Tier 1)

C1

Coats Aloe Creme coats aloe creme (cream)* $0 (Tier 3)C1

Coats Aloe Gelly coats aloe gelly (gel)* $0 (Tier 3)C1

Coats Aloe Moisturizing Lotion coats aloe moisturizing lotion (lotion)* $0 (Tier 3)C1

Coleman Botanicals Insectrepellent

coleman botanicals insectrepellent (liquid)* $0 (Tier 3)C1

Coleman Insect Repellent/High & Dry

coleman insect repellent/high & dry (aerosol)* $0 (Tier 3)C1

Coleman Skinsmart Insect Repellent

coleman skinsmart insect repellent ( aerosol, liquid)* $0 (Tier 3)C1

Cosentyx

COSENTYX (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Cosentyx Sensoready Pen COSENTYX SENSOREADY PEN (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Cutter Backwoods cutter backwoods (25% aerosol, 25% liquid)* $0 (Tier 3)C1

Cutter Backwoods Dry cutter backwoods dry (aerosol)* $0 (Tier 3)C1

Cutter Lemon Eucalyptus cutter lemon eucalyptus (liquid)* $0 (Tier 3)C1

Dibucaine

dibucaine (ointment)* $0 (Tier 3)



59


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Diclofenac Sodium diclofenac sodium (3% gel) $1.25-$3.40 (Tier 1) PAC1

Doxepin HCl

doxepin hcl (5% cream) $1.25-$3.40 (Tier 1) PA, QLC1

Dr Smiths Diaper dr smiths diaper (ointment)* $0 (Tier 3)C1

Dr Smiths Diaper Rash Spray dr smiths diaper rash spray (aerosol)* $0 (Tier 3)C1

Elidel

ELIDEL (CREAM) $3.80-$8.50 (Tier 2) STC1

Ery

ery (2% pad) $1.25-$3.40 (Tier 1)C1

Erythromycin

erythromycin (2% external solution, 2% gel) $1.25-$3.40 (Tier 1)C1

Erythromycin/Benzoyl Peroxide erythromycin/benzoyl peroxide (gel) $1.25-$3.40 (Tier 1)C1

Finacea

FINACEA (15% FOAM, 15% GEL) $3.80-$8.50 (Tier 2)C1

Fluorouracil

fluorouracil (2% external solution, 5% external

solution, 5% cream)$1.25-$3.40 (Tier 1)

C1

Hemorrhoidal

hemorrhoidal (suppository)* $0 (Tier 3)C1

Hydrocortisone/Aloe hydrocortisone/aloe (cream)* $0 (Tier 3)C1

Imiquimod

imiquimod (cream) $1.25-$3.40 (Tier 1)C1

Imiquimod Pump imiquimod pump (cream) $1.25-$3.40 (Tier 1) PAC1

Isotretinoin

isotretinoin (capsule) $1.25-$3.40 (Tier 1) PAC1

Major-Prep Hemorrhoidal major-prep hemorrhoidal (ointment)* $0 (Tier 3)C1

Methoxsalen

methoxsalen (capsule) $1.25-$3.40 (Tier 1)C1

Mirvaso

MIRVASO (GEL) $3.80-$8.50 (Tier 2)C1

Moisturel Therapeutic moisturel therapeutic (lotion)* $0 (Tier 3)C1

Natrapel 12-Hour Tick & Insect Repellent Continuous Spray

natrapel 12-hour tick & insect repellent continuous

spray (aerosol)*$0 (Tier 3)

C1

Off Deep Woods off deep woods (25% aerosol, 25% liquid)* $0 (Tier 3)C1

Off Deep Woods Dry off deep woods dry (aerosol)* $0 (Tier 3)C1

Off Deep Woods Sportsmen off deep woods sportsmen (25% liquid, 30%

aerosol)*$0 (Tier 3)

C1

Oxsoralen Ultra OXSORALEN ULTRA (CAPSULE) $3.80-$8.50 (Tier 2)C1

Pain Relieving Cream pain relieving cream (cream)* $0 (Tier 3)C1

Picato

PICATO (GEL) $3.80-$8.50 (Tier 2)


60


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Pimecrolimus

pimecrolimus (cream) $1.25-$3.40 (Tier 1) STC1

Podofilox

podofilox (external solution) $1.25-$3.40 (Tier 1)C1

Prudoxin

PRUDOXIN (CREAM) $3.80-$8.50 (Tier 2) PA, QLC1

Regranex

REGRANEX (GEL) $3.80-$8.50 (Tier 2) PAC1

Repel Huniters Formula repel huniters formula (aerosol)* $0 (Tier 3)C1

Repel Lemon Eucalyptus Insect Repellent

repel lemon eucalyptus insect repellent (aerosol)* $0 (Tier 3)C1

Repel Sportsmen repel sportsmen (aerosol)* $0 (Tier 3)C1

Repel Sportsmen Dry repel sportsmen dry (aerosol)* $0 (Tier 3)C1

Repel Sportsmen Max repel sportsmen max (aerosol)* $0 (Tier 3)C1

Santyl

SANTYL (OINTMENT) $3.80-$8.50 (Tier 2)C1

Sawyer Premium Insect Repellent

sawyer premium insect repellent (liquid)* $0 (Tier 3)C1

Selenium Sulfide selenium sulfide (lotion) $1.25-$3.40 (Tier 1)C1

Stelara

STELARA (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Tacrolimus

tacrolimus (0.03% ointment, 0.1% ointment) $1.25-$3.40 (Tier 1) STC1

Tazarotene

tazarotene (cream) $1.25-$3.40 (Tier 1) PAC1

Tazorac

TAZORAC (0.05% CREAM) $3.80-$8.50 (Tier 2) PAC1

Tolak

TOLAK (CREAM) $3.80-$8.50 (Tier 2)C1

Tretinoin

tretinoin (0.01% gel, 0.025% gel, 0.025% cream,

0.05% cream, 0.1% cream)$1.25-$3.40 (Tier 1) PA

C1

Tretinoin Microsphere tretinoin microsphere (gel) $1.25-$3.40 (Tier 1) PAC1

Ultrathon Insect Repellent 8 ultrathon insect repellent 8 (aerosol)* $0 (Tier 3)C1

Vitamin A & D

vitamin a & d (ointment)* $0 (Tier 3)C1

Z-Bum

z-bum (cream)* $0 (Tier 3)C1

Zinc Oxide

zinc oxide (ointment)* $0 (Tier 3)C1

Zyclara Pump ZYCLARA PUMP (CREAM) $3.80-$8.50 (Tier 2) PA

A1

Electrolytes/Minerals/Metals/Vitamins

B1

Electrolyte/Mineral ReplacementC1

Advantage Care Oral Electrolyte Pediatric

advantage care oral electrolyte pediatric (solution)* $0 (Tier 3)C1

Aminosyn II

AMINOSYN II (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Aminosyn-PF AMINOSYN-PF (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Calcet Petites

calcet petites (tablet)* $0 (Tier 3)C1

Calci-Chew

calci-chew (tablet chewable)* $0 (Tier 3)C1

Calcitrate

calcitrate (tablet)* $0 (Tier 3)C1

Calcium

calcium (1250mg tablet, 600mg tablet, 500mg tablet,

600mg tablet)*$0 (Tier 3)

C1

Calcium + D3

calcium + d3 (tablet)* $0 (Tier 3)



61


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Calcium 500 + D

calcium 500 + d (tablet)* $0 (Tier 3)C1

Calcium 500 + D High Potency calcium 500 + d high potency (tablet)* $0 (Tier 3)C1

Calcium 500 + D3

calcium 500 + d3 (tablet)* $0 (Tier 3)C1

Calcium 500/D

calcium 500/d (200unit-500mg tablet,

400unit-500mg tablet chewable)*$0 (Tier 3)

C1

Calcium 500/Vitamin D3 calcium 500/vitamin d3 (tablet)* $0 (Tier 3)C1

Calcium 500+d

calcium 500+d (tablet)* $0 (Tier 3)C1

Calcium 500+d3

calcium 500+d3 (tablet)* $0 (Tier 3)C1

Calcium 600

calcium 600 (1500mg tablet, 600mg tablet, 600mg

tablet)*$0 (Tier 3)

C1

Calcium 600 + D

calcium 600 + d (tablet)* $0 (Tier 3)C1

Calcium 600 + D High Potency calcium 600 + d high potency (tablet)* $0 (Tier 3)C1

Calcium 600 + D Plus Minerals calcium 600 + d plus minerals

(600mg-400unit-1mg-50mg-1.8mg-250mcg-7.5mg

tablet,

600mg-400unit-1mg-50mg-1.8mg-250mcg-7.5mg

tablet chewable)*

$0 (Tier 3)

C1

Calcium 600 + D3

calcium 600 + d3 (tablet)* $0 (Tier 3)C1

Calcium 600 + D3 Plus Minerals calcium 600 + d3 plus minerals (tablet chewable)* $0 (Tier 3)C1

Calcium 600 High Potency calcium 600 high potency (tablet)* $0 (Tier 3)C1

Calcium 600 with Vitamin D calcium 600 with vitamin d (600mg-400unit tablet,

600mg-400unit tablet chewable)*$0 (Tier 3)

C1

Calcium 600/Vitamin D calcium 600/vitamin d (tablet)* $0 (Tier 3)C1

Calcium 600/Vitamin D3 calcium 600/vitamin d3 (tablet)* $0 (Tier 3)C1

Calcium 600+D

calcium 600+d (tablet)* $0 (Tier 3)C1

Calcium Carbonate calcium carbonate (1250mg tablet, 1250mg tablet,

600mg tablet, 1250mg/5ml suspension)*$0 (Tier 3)

C1

Calcium Carbonate/D3 calcium carbonate/d3 (tablet)* $0 (Tier 3)C1

Calcium Carbonate/Vitamin D calcium carbonate/vitamin d (tablet)* $0 (Tier 3)C1

Calcium Citrate

calcium citrate (tablet)* $0 (Tier 3)


62


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Calcium Citrate + D calcium citrate + d (tablet)* $0 (Tier 3)C1

Calcium Citrate + D3 calcium citrate + d3 (tablet)* $0 (Tier 3)C1

Calcium Citrate + D3 Max Imum calcium citrate + d3 max imum (tablet)* $0 (Tier 3)C1

Calcium Citrate + D3 Maximum calcium citrate + d3 maximum (tablet)* $0 (Tier 3)C1

Calcium Citrate Malate/Vitamin D calcium citrate malate/vitamin d (tablet)* $0 (Tier 3)C1

Calcium Citrate Plus/Magnesium calcium citrate plus/magnesium (tablet)* $0 (Tier 3)C1

Calcium Citrate w/D calcium citrate w/d (tablet)* $0 (Tier 3)C1

Calcium Citrate/Vitamin D calcium citrate/vitamin d (315mg-200unit tablet,

315mg-200unit tablet, 315mg-250unit tablet)*$0 (Tier 3)

C1

Calcium Citrate/Vitamin D3 calcium citrate/vitamin d3 (tablet)* $0 (Tier 3)C1

Calcium Extra D3

calcium extra d3 (tablet)* $0 (Tier 3)C1

Calcium for Women calcium for women (tablet chewable)* $0 (Tier 3)C1

Calcium Gluconate calcium gluconate (otc only) (tablet)* $0 (Tier 3)C1

Calcium High Potency calcium high potency (600mg tablet, 600mg-tablet)* $0 (Tier 3)C1

Calcium High Potency + Vitamin D calcium high potency + vitamin d (tablet)* $0 (Tier 3)C1

Calcium Oyster Shell calcium oyster shell (tablet)* $0 (Tier 3)C1

Calcium Plus Vitamin D3 calcium plus vitamin d3 (tablet)* $0 (Tier 3)C1

Calcium/C/D

calcium/c/d (tablet chewable)* $0 (Tier 3)C1

Calcium/Magnesium/Zinc calcium/magnesium/zinc (tablet)* $0 (Tier 3)C1

Calcium/Vitamin D calcium/vitamin d (200unit-500mg tablet,

500mg-400unit tablet, 600mg-400unit tablet,

500mg-200unit tablet, 600mg-200unit tablet,

600mg-400unit tablet, 600mg-400unit capsule)*

$0 (Tier 3)

C1

Calcium/Vitamin D3 calcium/vitamin d3 (tablet)* $0 (Tier 3)C1

Calcium+d3

calcium+d3 (tablet)* $0 (Tier 3)C1

Cal-Mag-Zinc-D cal-mag-zinc-d (tablet)* $0 (Tier 3)C1

Caltrate 600 + D

caltrate 600 + d (tablet)* $0 (Tier 3)C1

Caltrate 600 + D Plus Minerals caltrate 600 + d plus minerals (tablet)* $0 (Tier 3)C1

Caltrate 600 + D3 Soft Chews caltrate 600 + d3 soft chews (tablet chewable)* $0 (Tier 3)C1

Carbaglu

CARBAGLU (TABLET) $3.80-$8.50 (Tier 2) LAC1

Chewable Calcium chewable calcium (500mg tablet chewable,

500mg-200unit-40mcg tablet chewable)*$0 (Tier 3)

C1

Citracal + D3 Maximum citracal + d3 maximum (tablet)* $0 (Tier 3)C1

Citracal Maximum citracal maximum (tablet)* $0 (Tier 3)C1

Citrus Calcium + D citrus calcium + d (tablet)* $0 (Tier 3)C1

Coral Calcium

coral calcium (capsule)* $0 (Tier 3)C1

CVS Calcium

cvs calcium (tablet)* $0 (Tier 3)



63


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

CVS Calcium 600 & Vitamin D3 cvs calcium 600 & vitamin d3 (tablet)* $0 (Tier 3)C1

CVS Calcium 600 + D cvs calcium 600 + d (tablet)* $0 (Tier 3)C1

CVS Calcium Chewables 600plus cvs calcium chewables 600plus (tablet chewable)* $0 (Tier 3)C1

CVS Calcium Citrate + D cvs calcium citrate + d (tablet)* $0 (Tier 3)C1

CVS Calcium Citrate + D/Magnesium cvs calcium citrate + d/magnesium (tablet)* $0 (Tier 3)C1

CVS Calcium/Magnesium/Zinc cvs calcium/magnesium/zinc (tablet)* $0 (Tier 3)C1

CVS Electrolyte Solution cvs electrolyte solution (oral solution)* $0 (Tier 3)C1

CVS Iron

cvs iron (tablet)* $0 (Tier 3)C1

CVS Magnesium

cvs magnesium (tablet)* $0 (Tier 3)C1

CVS Pediatric Electrolyte cvs pediatric electrolyte (oral solution)* $0 (Tier 3)C1

CVS Pediatric Electrolyte Freezer Pops

cvs pediatric electrolyte freezer pops (oral solution)* $0 (Tier 3)C1

CVS Selenium

cvs selenium (tablet)* $0 (Tier 3)C1

CVS Slow Release Iron cvs slow release iron (tablet extended-release)* $0 (Tier 3)C1

CVS Zinc

cvs zinc (tablet)* $0 (Tier 3)C1

Dextrose 10% DEXTROSE 10% (INJECTION) $3.80-$8.50 (Tier 2)C1

Dextrose 10%/NaCl 0.2% DEXTROSE 10%/NACL 0.2% (INJECTION) $3.80-$8.50 (Tier 2)C1


Dextrose 2.5%/NaCl 0.45% DEXTROSE 2.5%/NACL 0.45% (INJECTION) $3.80-$8.50 (Tier 2)C1

Dextrose 5%

dextrose 5% (injection) $1.25-$3.40 (Tier 1) B/D, PAC1





Dextrose 5%/NaCl 0.9% DEXTROSE 5%/NACL 0.9% (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Enfamil Enfalyte

enfamil enfalyte (oral solution)* $0 (Tier 3)C1

Eq Calcium 500+d eq calcium 500+d (tablet)* $0 (Tier 3)C1

Eq Calcium 600+d eq calcium 600+d (tablet)* $0 (Tier 3)C1

Eq Calcium Citrate+d eq calcium citrate+d (tablet)* $0 (Tier 3)C1

Eq Slow-Release Iron eq slow-release iron (tablet extended-release)* $0 (Tier 3)


64


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

EQL Calcium 600mg/Vitamind3 eql calcium 600mg/vitamind3 (tablet)* $0 (Tier 3)C1

EQL Calcium Citrate with Vitamin D eql calcium citrate with vitamin d (tablet)* $0 (Tier 3)C1

EQL Calcium Citrate/ Vitamin D3 eql calcium citrate/ vitamin d3 (tablet)* $0 (Tier 3)C1

EQL Calcium/Vitamin D eql calcium/vitamin d (tablet)* $0 (Tier 3)C1

EZFE 200

ezfe 200 (capsule)* $0 (Tier 3)C1

FE C Tab

fe c tab (tablet)* $0 (Tier 3)C1

Feosol

feosol (tablet)* $0 (Tier 3)C1

Feosol Bifera

feosol bifera (tablet)* $0 (Tier 3)C1

Ferate

ferate (tablet)* $0 (Tier 3)C1

Fer-In-Sol

fer-in-sol (oral solution)* $0 (Tier 3)C1

Ferretts

ferretts (tablet)* $0 (Tier 3)C1

Ferretts IPS

ferretts ips (oral solution)* $0 (Tier 3)C1

Ferrex 150

ferrex 150 (capsule)* $0 (Tier 3)C1

Ferric X-150

ferric x-150 (capsule)* $0 (Tier 3)C1

Ferrimin 150

ferrimin 150 (tablet)* $0 (Tier 3)C1

Ferrous Drops

ferrous drops (oral solution)* $0 (Tier 3)C1

Ferrous Fumarate 324 ferrous fumarate 324 (tablet)* $0 (Tier 3)C1

Ferrous Gluconate ferrous gluconate (240mg tablet, 240mg tablet,


C1

Ferrous Sulfate

ferrous sulfate (140mg tablet extended-release,

15mg/ml oral solution, 220mg/5ml elixir, 220mg/5ml

liquid, 300mg/5ml syrup, 324mg tablet delayed-

release, 325mg tablet delayed-release, 325mg

tablet)*

$0 (Tier 3)

C1

Ferrousul

ferrousul (tablet)* $0 (Tier 3)C1

Folitab 500

folitab 500 (tablet extended-release)* $0 (Tier 3)C1

FreAmine HBC 6.9% FREAMINE HBC 6.9% (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Fusion

fusion (capsule)* $0 (Tier 3)C1

GNP Calcium

gnp calcium (tablet)* $0 (Tier 3)C1

GNP Calcium 1200 gnp calcium 1200 (tablet chewable)* $0 (Tier 3)C1

GNP Calcium 500 + D3 gnp calcium 500 + d3 (tablet)* $0 (Tier 3)C1

GNP Calcium 500/D gnp calcium 500/d (tablet)* $0 (Tier 3)C1

GNP Calcium 600 + D3 gnp calcium 600 + d3 (tablet)* $0 (Tier 3)C1

GNP Calcium 600/D gnp calcium 600/d (tablet)* $0 (Tier 3)C1

GNP Calcium Citrate + D Maximum

gnp calcium citrate + d maximum (tablet)* $0 (Tier 3)C1

GNP Calcium Citrate + D3 gnp calcium citrate + d3 (tablet)* $0 (Tier 3)C1

GNP Calcium Citrate + D3 Maximum

gnp calcium citrate + d3 maximum (tablet)* $0 (Tier 3)



65


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

GNP Calcium/Magnesium/Zinc gnp calcium/magnesium/zinc (tablet)* $0 (Tier 3)C1

GNP Calcuim/Vitamin D/Minerals

gnp calcuim/vitamin d/minerals (tablet chewable)* $0 (Tier 3)C1

GNP Iron

gnp iron (200mg tablet, 45mg tablet extended-

release)*$0 (Tier 3)

C1

GNP Magnesium gnp magnesium (tablet)* $0 (Tier 3)C1

GNP Pediatric Electrolyte gnp pediatric electrolyte (oral solution)* $0 (Tier 3)C1

GNP Zinc

gnp zinc (tablet)* $0 (Tier 3)C1

H-E-B Oral Electrolyte Solution h-e-b oral electrolyte solution (solution)* $0 (Tier 3)C1

Hemocyte

hemocyte (tablet)* $0 (Tier 3)C1

HepatAmine HEPATAMINE (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

HM Calcium 600 & Vitamin D3 hm calcium 600 & vitamin d3 (tablet)* $0 (Tier 3)C1

HM Calcium 600 + D Plus Minerals hm calcium 600 + d plus minerals (tablet chewable)* $0 (Tier 3)C1

HM Calcium 600 + Vitamin D3 hm calcium 600 + vitamin d3 (tablet)* $0 (Tier 3)C1

HM Calcium Citrate + Vitamin D hm calcium citrate + vitamin d (tablet)* $0 (Tier 3)C1

HM Calcium/Vitamin D hm calcium/vitamin d (tablet)* $0 (Tier 3)C1

HM Calcium/Vitamin D/Minerals hm calcium/vitamin d/minerals (tablet)* $0 (Tier 3)C1

HM Iron

hm iron (tablet)* $0 (Tier 3)C1

HM Iron Slow Release hm iron slow release (tablet extended-release)* $0 (Tier 3)C1

HM Pediatric Electrolyte hm pediatric electrolyte (solution)* $0 (Tier 3)C1

HM Selenium

hm selenium (tablet)* $0 (Tier 3)C1

HM Zinc

hm zinc (tablet)* $0 (Tier 3)C1

I.L.X. B-12

i.l.x. b-12 (elixir)* $0 (Tier 3)C1

ICAR Pediatric

icar pediatric (suspension)* $0 (Tier 3)C1

ICAR-C

icar-c (tablet)* $0 (Tier 3)C1

Iferex 150

iferex 150 (capsule)* $0 (Tier 3)C1

Infed

infed (injection)* $0 (Tier 3)C1

Integra

integra (capsule)* $0 (Tier 3)C1

Intralipid

INTRALIPID (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Ionosol-MB/Dextrose 5% IONOSOL-MB/DEXTROSE 5% (INJECTION) $3.80-$8.50 (Tier 2)


66


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Iron

iron (256mg tablet, 27mg tablet, 325mg tablet, 65mg

tablet, 27mg tablet, 325mg tablet)*$0 (Tier 3)

C1

Iron 100/C

iron 100/c (tablet)* $0 (Tier 3)C1

Iron 27

iron 27 (tablet)* $0 (Tier 3)C1

Iron High-Potency iron high-potency (tablet)* $0 (Tier 3)C1

Iron Slow Release iron slow release (tablet extended-release)* $0 (Tier 3)C1

Iron Supplement Childrens iron supplement childrens (oral solution)* $0 (Tier 3)C1

Isolyte-P/Dextrose 5% ISOLYTE-P/DEXTROSE 5% (INJECTION) $3.80-$8.50 (Tier 2)C1

Isolyte-S

ISOLYTE-S (INJECTION) $3.80-$8.50 (Tier 2)C1

KCl 0.075%/D5W/NaCl 0.45% KCL 0.075%/D5W/NACL 0.45% (INJECTION) $3.80-$8.50 (Tier 2)C1






Klor-Con

klor-con (packet) $1.25-$3.40 (Tier 1)C1

Klor-Con 10

KLOR-CON 10 (TABLET EXTENDED-RELEASE) $3.80-$8.50 (Tier 2)C1

Klor-Con 8

KLOR-CON 8 (TABLET EXTENDED-RELEASE) $3.80-$8.50 (Tier 2)C1

Klor-Con M10

klor-con m10 (tablet extended-release) $1.25-$3.40 (Tier 1)C1

Klor-Con M15


Klor-Con M20


Klor-Con Sprinkle

klor-con sprinkle (capsule extended-release) $1.25-$3.40 (Tier 1)C1

KP Calcium 600 + D kp calcium 600 + d (tablet)* $0 (Tier 3)C1

KP Calcium Citrate + D kp calcium citrate + d (tablet)* $0 (Tier 3)C1

KP Ferrous Gluconate kp ferrous gluconate (tablet)* $0 (Tier 3)C1

KP Ferrous Sulfate kp ferrous sulfate (tablet)* $0 (Tier 3)C1

Levocarnitine

levocarnitine (1gm/10ml oral solution) $1.25-$3.40 (Tier 1)C1

Levocarnitine LEVOCARNITINE (330MG TABLET) $3.80-$8.50 (Tier 2)C1

Liquid Calcium/Vitamin D liquid calcium/vitamin d (capsule)* $0 (Tier 3)C1

Magnesium

magnesium (250mg tablet, 500mg tablet)* $0 (Tier 3)C1

Magnesium 27

magnesium 27 (tablet)* $0 (Tier 3)C1

Magnesium Elemental magnesium elemental (otc only) (300mg capsule,


C1

Magnesium Oxide magnesium oxide (241.3mg tablet, 500mg capsule)* $0 (Tier 3)C1

Magnesium Sulfate MAGNESIUM SULFATE (1GM/2ML-50% INJECTION) $3.80-$8.50 (Tier 2)C1

Magnesium Sulfate magnesium sulfate (5gm/10ml-50% injection) $1.25-$3.40 (Tier 1)



67


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Mag-Tab SR

mag-tab sr (otc only) (tablet extended-release)* $0 (Tier 3)C1

Monocal

monocal (tablet)* $0 (Tier 3)C1

Myferon 150

myferon 150 (capsule)* $0 (Tier 3)C1

Nephramine NEPHRAMINE (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Normosol-M in D5W NORMOSOL-M IN D5W (INJECTION) $3.80-$8.50 (Tier 2)C1

Normosol-R

NORMOSOL-R (INJECTION) $3.80-$8.50 (Tier 2)C1

Normosol-R in D5W NORMOSOL-R IN D5W (INJECTION) $3.80-$8.50 (Tier 2)C1

Nu-Iron 150

nu-iron 150 (capsule)* $0 (Tier 3)C1

Nu-Mag

nu-mag (tablet delayed-release)* $0 (Tier 3)C1

Nutrilipid

NUTRILIPID (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Oceanic Selenium oceanic selenium (tablet)* $0 (Tier 3)C1

Oralyte

oralyte (oral solution)* $0 (Tier 3)C1

Oralyte Freezer Pops oralyte freezer pops (oral solution)* $0 (Tier 3)C1

Orazinc

orazinc (110mg tablet, 220mg capsule)* $0 (Tier 3)C1

OS-CAL

os-cal (tablet chewable)* $0 (Tier 3)C1

OS-CAL Calcium + D3 os-cal calcium + d3 (tablet)* $0 (Tier 3)C1

OS-CAL Extra D3

os-cal extra d3 (tablet)* $0 (Tier 3)C1

OS-CAL Ultra

os-cal ultra (tablet)* $0 (Tier 3)C1

Osteo-Poretical osteo-poretical (tablet)* $0 (Tier 3)C1

Oysco 500

oysco 500 (tablet)* $0 (Tier 3)C1

Oysco 500 + D

oysco 500 + d (tablet)* $0 (Tier 3)C1

Oyst-Cal-D 500

oyst-cal-d 500 (tablet)* $0 (Tier 3)C1

Oyster Calcium

oyster calcium (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium oyster shell calcium (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium + D3 oyster shell calcium + d3 (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium + Vitamin D

oyster shell calcium + vitamin d (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium 250 + D oyster shell calcium 250 + d (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium 500 oyster shell calcium 500 (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium 500 + D oyster shell calcium 500 + d (tablet chewable)* $0 (Tier 3)


68


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Oyster Shell Calcium 500 + D oyster shell calcium 500 + d (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium 500/D oyster shell calcium 500/d (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium Plus Vitamin D

oyster shell calcium plus vitamin d (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium/D oyster shell calcium/d (250mg-125unit tablet,

500mg-200unit tablet, 500mg-200unit tablet)*$0 (Tier 3)

C1

Oyster Shell Calcium/D3 oyster shell calcium/d3 (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium/Magnesium oyster shell calcium/magnesium (tablet)* $0 (Tier 3)C1

Oyster Shell Calcium/Vitamin D oyster shell calcium/vitamin d (200unit-500mg tablet,

250mg-125unit-tablet, 500mg-200unit tablet,

500mg-400unit tablet)*

$0 (Tier 3)

C1

Oyster Shell Calcium+d oyster shell calcium+d (tablet)* $0 (Tier 3)C1

Oystercal-D

oystercal-d (tablet)* $0 (Tier 3)C1

Pedialyte

pedialyte (2.1meq/59ml-1.5gm/59ml-1.2meq/

59ml-2.7meq/59ml-0.5mg/59ml solution, 35meq/

l-20gm/l-5gm/l-20meq/l-45meq/l solution, 35meq/

l-25gm/l-20meq/l-45meq/l-7.8mg/l solution, 35meq/

l-30meq/l-25gm/l-20meq/l-45meq/l solution, 35meq/

l-30meq/l-25gm/l-20meq/l-45meq/l oral solution)*

$0 (Tier 3)

C1

Pedialyte Advanced Care pedialyte advanced care (solution)* $0 (Tier 3)C1

Pedialyte Freezer Pops pedialyte freezer pops (35meq/l-30meq/l-25gm/

l-20meq/l-45meq/l oral solution, 35meq/l-30meq/

l-25gm/l-20meq/l-45meq/l solution)*

$0 (Tier 3)

C1

Pedialyte Singles pedialyte singles (7meq/200ml-5.3gm/200ml-4meq/

200ml-9meq/200ml-1.6mg/200ml solution, 8.3meq/

240ml-7.1meq/240ml-4.7gm/240ml-1.2gm/

240ml-4.7meq/240ml-10.6meq/240ml oral solution)*

$0 (Tier 3)

C1

Pediatric Electrolyte pediatric electrolyte (35meq/l-20gm/l-5gm/l-20meq/

l-45meq/l oral solution, 35meq/l-30meq/l-25gm/

l-20meq/l-45meq/l oral solution, 35meq/l-20gm/

l-5gm/l-20meq/l-45meq/l solution, 35meq/

l-25gm-20meq/l-45meq/l-7.8mg/l solution, 35meq/

l-25gm/l-20meq/l-45meq/l solution, 35meq/l-30meq/

l-20gm/l-5gm/l-20meq/l-45meq/l solution, 35meq/

l-30meq/l-25gm/l-20meq/l-45meq/l solution, 35meq/

l-30meq/l-25gm/l-5gm/l-20meq/l-45meq/l solution)*

$0 (Tier 3)

C1

Pediatric Electrolyte Freeze Pops

pediatric electrolyte freeze pops (solution)* $0 (Tier 3)C1

Pediatric Electrolyte Freezer Pops

pediatric electrolyte freezer pops (solution)* $0 (Tier 3)C1

Pediatric Electrolyte/Zinc pediatric electrolyte/zinc (solution)* $0 (Tier 3)C1

Plasma-Lyte A PLASMA-LYTE A (INJECTION) $3.80-$8.50 (Tier 2)



69


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Plasma-Lyte-148 PLASMA-LYTE-148 (INJECTION) $3.80-$8.50 (Tier 2)C1

Plenamine

plenamine (injection) $1.25-$3.40 (Tier 1) B/D, PAC1

Poly-Iron 150

poly-iron 150 (capsule)* $0 (Tier 3)C1

Potassium Chloride POTASSIUM CHLORIDE (10% ORAL SOLUTION, 20%

ORAL SOLUTION, 20MEQ PACKET)$3.80-$8.50 (Tier 2)

C1

Potassium Chloride POTASSIUM CHLORIDE (10MEQ/100ML INJECTION,

20MEQ/100ML INJECTION, 40MEQ/100ML INJECTION)$3.80-$8.50 (Tier 2) B/D, PA

C1

Potassium Chloride potassium chloride (2meq/ml injection) $1.25-$3.40 (Tier 1) B/D, PAC1

Potassium Chloride CR potassium chloride cr (tablet extended-release) $1.25-$3.40 (Tier 1)C1

Potassium Chloride ER potassium chloride er (10meq capsule extended-

release, 8meq capsule extended-release, 10meq

tablet extended-release, 20meq tablet extended-

release, 8meq tablet extended-release)

$1.25-$3.40 (Tier 1)

C1

Potassium Chloride/Dextrose POTASSIUM CHLORIDE/DEXTROSE (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Potassium Chloride/Dextrose/Lactated Ringers

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS (INJECTION)

$3.80-$8.50 (Tier 2)C1

Potassium Chloride/Dextrose/Sodium Chloride

POTASSIUM CHLORIDE/DEXTROSE/SODIUM CHLORIDE (INJECTION)

$3.80-$8.50 (Tier 2)C1

Potassium Chloride/Sodium Chloride

potassium chloride/sodium chloride (20meq/l-0.45%

injection)$1.25-$3.40 (Tier 1) B/D, PA

C1

Potassium Chloride/Sodium Chloride

POTASSIUM CHLORIDE/SODIUM CHLORIDE (20MEQ/L-0.9% INJECTION, 40MEQ/L-0.9% INJECTION)

$3.80-$8.50 (Tier 2) B/D, PAC1

Potassium Citrate ER potassium citrate er (tablet extended-release) $1.25-$3.40 (Tier 1)C1

Premasol

premasol (injection) $1.25-$3.40 (Tier 1) B/D, PAC1

Procalamine PROCALAMINE (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

ProFe

profe (capsule)* $0 (Tier 3)C1

Proferrin ES

proferrin es (tablet)* $0 (Tier 3)C1

Prosol

PROSOL (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

QC Calcium Fast Dissolution qc calcium fast dissolution (tablet)* $0 (Tier 3)C1

QC Calcium/Minerals/Vitamin D qc calcium/minerals/vitamin d (tablet)* $0 (Tier 3)C1

RA Calcium 600

ra calcium 600 (tablet)* $0 (Tier 3)


70


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

RA Calcium 600 Plus Vitamin D-3 ra calcium 600 plus vitamin d-3 (tablet)* $0 (Tier 3)C1

RA Calcium 600/Vitamin D/Minerals

ra calcium 600/vitamin d/minerals (tablet)* $0 (Tier 3)C1

RA Calcium Citrate Plus Vitamin D-3 ra calcium citrate plus vitamin d-3 (tablet)* $0 (Tier 3)C1

RA Calcium/Boron ra calcium/boron (tablet)* $0 (Tier 3)C1

RA Calcium/Magnesium/Zinc/Copper

ra calcium/magnesium/zinc/copper (tablet)* $0 (Tier 3)C1

RA Hi Cal

ra hi cal (tablet)* $0 (Tier 3)C1

RA High Potency Iron ra high potency iron (tablet)* $0 (Tier 3)C1

RA Iron

ra iron (tablet)* $0 (Tier 3)C1

RA Magnesium

ra magnesium (capsule)* $0 (Tier 3)C1

RA Natural Magnesium ra natural magnesium (tablet)* $0 (Tier 3)C1

RA Oyster Shell Calcium/Vitamin D

ra oyster shell calcium/vitamin d (tablet)* $0 (Tier 3)C1

RA Pediatric Electrolyte ra pediatric electrolyte (oral solution)* $0 (Tier 3)C1

RA Pediatric Electrolyte Freezer Pops

ra pediatric electrolyte freezer pops (oral solution)* $0 (Tier 3)C1

Ra Selenium

ra selenium (tablet)* $0 (Tier 3)C1

Ra Selenium Natural ra selenium natural (tablet)* $0 (Tier 3)C1

RA Slow Release Iron ra slow release iron (tablet extended-release)* $0 (Tier 3)C1

RA Zinc

ra zinc (tablet)* $0 (Tier 3)C1

Risacal-D

risacal-d (tablet)* $0 (Tier 3)C1

Selenium

selenium (200mcg tablet, 200mcg tablet extended-

release, 200mcg tablet, 50mcg tablet)*$0 (Tier 3)

C1

Slow Fe

slow fe (tablet extended-release)* $0 (Tier 3)C1

Slow Release Iron slow release iron (tablet extended-release)* $0 (Tier 3)C1

Slow-Mag

slow-mag (tablet delayed-release)* $0 (Tier 3)C1

Slow-Release Iron slow-release iron (tablet extended-release)* $0 (Tier 3)C1

SM Calcium 500/Vitamin D3 sm calcium 500/vitamin d3 (tablet)* $0 (Tier 3)C1

SM Calcium 600 + D3 sm calcium 600 + d3 (tablet)* $0 (Tier 3)C1

SM Calcium 600/Vitamin D sm calcium 600/vitamin d (tablet)* $0 (Tier 3)C1

SM Calcium Citrate + with Vitamin D sm calcium citrate + with vitamin d (tablet)* $0 (Tier 3)C1

SM Calcium Citrate with Vitamin D3 sm calcium citrate with vitamin d3 (tablet)* $0 (Tier 3)C1

SM Calcium Soft Chews sm calcium soft chews (tablet chewable)* $0 (Tier 3)C1

SM Calcium/Magnesium/Zinc sm calcium/magnesium/zinc (tablet)* $0 (Tier 3)C1

SM Calcium/Vitamin D sm calcium/vitamin d (tablet)* $0 (Tier 3)C1

SM Iron

sm iron (tablet)* $0 (Tier 3)C1

SM Iron Slow Release sm iron slow release (tablet extended-release)* $0 (Tier 3)C1

SM Magnesium

sm magnesium (tablet)* $0 (Tier 3)C1

SM Oyster Shell Calcium/Vitamin D

sm oyster shell calcium/vitamin d (tablet)* $0 (Tier 3)



71


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

SM Oyster Shell Calcium/Vitamin D3

sm oyster shell calcium/vitamin d3 (tablet)* $0 (Tier 3)C1

SM Pediatric Electrolyte sm pediatric electrolyte (oral solution)* $0 (Tier 3)C1

SM Selenium

sm selenium (tablet)* $0 (Tier 3)C1

SM Slow Release Iron sm slow release iron (142mg tablet extended-release,

143mg tablet extended-release)*$0 (Tier 3)

C1

SM Zinc

sm zinc (tablet)* $0 (Tier 3)C1

Sodium Chloride 0.9% SODIUM CHLORIDE 0.9% (IRRIGATION SOLUTION) $3.80-$8.50 (Tier 2)C1

Sodium Chloride SODIUM CHLORIDE (RX ONLY) (0.45% SOLUTION) $3.80-$8.50 (Tier 2)C1

Sodium Chloride

sodium chloride (rx only) (0.9% injection) $1.25-$3.40 (Tier 1) B/D, PAC1

Sodium Chloride SODIUM CHLORIDE (RX ONLY) (3% INJECTION, 5%

INJECTION)$3.80-$8.50 (Tier 2) B/D, PA

C1

Sodium Fluoride

sodium fluoride (tablet) $1.25-$3.40 (Tier 1)C1

Sodium Lactate SODIUM LACTATE (INJECTION) $3.80-$8.50 (Tier 2)C1

Super Calcium

super calcium (tablet)* $0 (Tier 3)C1

Super Calcium 600 + D 400 super calcium 600 + d 400 (tablet)* $0 (Tier 3)C1

Super Calcium 600 + D3 super calcium 600 + d3 (tablet)* $0 (Tier 3)C1

Super Calcium 600 + D3 400 super calcium 600 + d3 400 (tablet)* $0 (Tier 3)C1

Tandem

tandem (capsule)* $0 (Tier 3)C1

TGT Calcium + Vitamin D3 tgt calcium + vitamin d3 (tablet)* $0 (Tier 3)C1

TPN Electrolytes TPN ELECTROLYTES (INJECTION) $3.80-$8.50 (Tier 2)C1

Travasol

TRAVASOL (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Trophamine TROPHAMINE (10% INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Wee Care

wee care (suspension)* $0 (Tier 3)C1

Zinc

zinc (10mg lozenge, 30mg tablet, 50mg tablet, 50mg

tablet)*$0 (Tier 3)

C1

Zinc 15

zinc 15 (tablet)* $0 (Tier 3)C1

Zinc Chelated

zinc chelated (tablet)* $0 (Tier 3)C1

Zinc Gluconate

zinc gluconate (100mg tablet, 50mg tablet, 30mg

tablet)*$0 (Tier 3)


72


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Zinc Sulfate

zinc sulfate (220mg capsule, 220mg tablet)* $0 (Tier 3)C1

Zinc-220

zinc-220 (capsule)* $0 (Tier 3)B1

Electrolyte/Mineral/Metal ModifiersC1

Chemet

CHEMET (CAPSULE) $3.80-$8.50 (Tier 2)C1

Deferasirox

deferasirox (tablet soluble) $1.25-$3.40 (Tier 1) PAC1

Exjade

EXJADE (TABLET SOLUBLE) $3.80-$8.50 (Tier 2) PAC1

Ferriprox

FERRIPROX (1000MG TABLET, 100MG/ML ORAL SOLUTION, 500MG TABLET)

$3.80-$8.50 (Tier 2) PAC1

Jadenu

JADENU (TABLET) $3.80-$8.50 (Tier 2) PAC1

Jadenu Sprinkle JADENU SPRINKLE (PACKET) $3.80-$8.50 (Tier 2) PAC1

Kionex

kionex (suspension) $1.25-$3.40 (Tier 1)C1

Lokelma

LOKELMA (PACKET) $3.80-$8.50 (Tier 2) QLC1

Samsca

SAMSCA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Sodium Polystyrene Sulfonate sodium polystyrene sulfonate (powder) $1.25-$3.40 (Tier 1)C1

SPS

sps (suspension) $1.25-$3.40 (Tier 1)C1

Trientine HCl

trientine hcl (capsule) $1.25-$3.40 (Tier 1) PA, QLC1

Veltassa

VELTASSA (PACKET) $3.80-$8.50 (Tier 2) QLB1

Phosphate BindersC1

Auryxia

AURYXIA (TABLET) $3.80-$8.50 (Tier 2) PAC1

Calcium Acetate

calcium acetate (667mg capsule, 667mg tablet) $1.25-$3.40 (Tier 1)C1

Lanthanum Carbonate lanthanum carbonate (tablet chewable) $1.25-$3.40 (Tier 1)C1

Phoslyra

PHOSLYRA (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Sevelamer Carbonate sevelamer carbonate (0.8gm packet, 2.4gm packet,

800mg tablet)$1.25-$3.40 (Tier 1)

C1

Velphoro

VELPHORO (TABLET CHEWABLE) $3.80-$8.50 (Tier 2)B1

VitaminsC1

A Thru Z Advanced a thru z advanced (tablet)* $0 (Tier 3)C1

A Thru Z Select a thru z select (tablet)* $0 (Tier 3)C1

A Thru Z Select 50 + Advanced Formula

a thru z select 50 + advanced formula (tablet)* $0 (Tier 3)C1

A Thru Z Select Advanced a thru z select advanced (tablet)* $0 (Tier 3)C1

A Thru Z Select Ultimate Womens

a thru z select ultimate womens (tablet)* $0 (Tier 3)C1

A Thru Z Ultimate Mens a thru z ultimate mens (tablet)* $0 (Tier 3)C1

A-10000

a-10000 (capsule)* $0 (Tier 3)C1

Abc Plus Senior Adults 50+ abc plus senior adults 50+ (tablet)* $0 (Tier 3)C1

Acerola C 500

acerola c 500 (wafer)* $0 (Tier 3)



73


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Actical

actical (capsule)* $0 (Tier 3)C1

Advanced Stress Formula/Zinc advanced stress formula/zinc (tablet)* $0 (Tier 3)C1

Animal Chews

animal chews (tablet chewable)* $0 (Tier 3)C1

Animal Shapes

animal shapes (tablet chewable)* $0 (Tier 3)C1

Animal Shapes/Iron animal shapes/iron (tablet chewable)* $0 (Tier 3)C1

Apatate Forte

apatate forte (liquid)* $0 (Tier 3)C1

Apetex

apetex (elixir)* $0 (Tier 3)C1

Apetigen

apetigen (elixir)* $0 (Tier 3)C1

Apetigen-Plus

apetigen-plus

(225mg-6mcg-10mg-300mg-80mg-20mg-8mg-8.5mg-

15mg-30unit-18mg tablet, 25mcg/15ml-12.5mg/

15ml-790mg/15ml-200mg/15ml-20mg/15ml-2mg/

15ml-10mg/15ml-10mg/15ml-16.9mg/15ml oral

solution)*

$0 (Tier 3)

C1

AquADEKs

aquadeks (otc only) (tablet chewable, liquid)* $0 (Tier 3)C1

Aqueous Vitamin D Infants aqueous vitamin d infants (liquid)* $0 (Tier 3)C1

Aqueous Vitamin E aqueous vitamin e (oral solution)* $0 (Tier 3)C1

Ascorbic Acid

ascorbic acid (powder, 250mg tablet, 500mg tablet)* $0 (Tier 3)C1

B Complex

b complex

(100mg-1mg-70mg-10mg-100mcg-2mg-1.5mg

capsule,

5mg-1mcg-60mg-20mg-0.5mg-3mg-3mg-60mg

capsule, 6mcg-0.4mg-20mg-10mg-2mg-1.7mg-1.2mg

tablet)*

$0 (Tier 3)

C1

B Complex/C b complex/c (tablet)* $0 (Tier 3)C1

B Complex/Folic Acid b complex/folic acid (tablet)* $0 (Tier 3)C1

B-1

b-1 (tablet)* $0 (Tier 3)C1

B-12

b-12 (1000mcg tablet extended-release, 100mcg

tablet, 500mcg tablet, 50mcg tablet, 2500mcg tablet

sublingual)*

$0 (Tier 3)


74


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

B12

b12 (tablet extended-release)* $0 (Tier 3)C1

B-12 Dots

b-12 dots (tablet dispersible)* $0 (Tier 3)C1

B-12 TR

b-12 tr (tablet extended-release)* $0 (Tier 3)C1

B-2

b-2 (tablet)* $0 (Tier 3)C1

B-6

b-6 (100mg tablet, 100mg tablet, 50mg tablet)* $0 (Tier 3)C1

B6 Natural

b6 natural (tablet)* $0 (Tier 3)C1

Balance B-100

balance b-100 (tablet)* $0 (Tier 3)C1

Balance B-50

balance b-50 (tablet)* $0 (Tier 3)C1

Balanced B-100 balanced b-100 (tablet)* $0 (Tier 3)C1

Balanced B-50

balanced b-50 (tablet)* $0 (Tier 3)C1

Balanced B-50 Complex balanced b-50 complex (tablet)* $0 (Tier 3)C1

B-Complex

b-complex

(5mg-1mcg-400mcg-60mg-20mg-0.5mg-3mg-3mg-60

mg capsule,

5mg-1mcg-60mg-20mg-0.5mg-3mg-3mg-60mg

capsule, 6mcg-400mcg-20mg-2mg-1.7mg-1.5mg

tablet)*

$0 (Tier 3)

C1

B-Complex Formula 1 b-complex formula 1 (tablet)* $0 (Tier 3)C1

B-Complex Plus Vitamin C b-complex plus vitamin c (tablet)* $0 (Tier 3)C1

B-Complex w/C b-complex w/c (tablet)* $0 (Tier 3)C1

B-Complex with B-12 b-complex with b-12 (tablet)* $0 (Tier 3)C1

B-Complex/C b-complex/c (tablet)* $0 (Tier 3)C1

B-Complex/Vitamin C/High Potency

b-complex/vitamin c/high potency (tablet)* $0 (Tier 3)C1

Bee Zee

bee zee (tablet)* $0 (Tier 3)C1

Beta Carotene

beta carotene (capsule)* $0 (Tier 3)C1

Biocal

biocal (capsule)* $0 (Tier 3)C1

Biosupp

biosupp (liquid)* $0 (Tier 3)C1

Biotin

biotin (1000mcg tablet, 1000mcg tablet, 300mcg

tablet, 2500mcg capsule, 5000mcg capsule,

5000mcg capsule)*

$0 (Tier 3)

C1

Biotin 5000

biotin 5000 (capsule)* $0 (Tier 3)C1

Biotin/Maximum Strength biotin/maximum strength (capsule)* $0 (Tier 3)C1

Biovol

biovol (syrup)* $0 (Tier 3)C1

C 1000

c 1000 (tablet)* $0 (Tier 3)C1

C 1000/Bioflavonoids/Rosehips

c 1000/bioflavonoids/rosehips (capsule)* $0 (Tier 3)C1

C 250

c 250 (tablet)* $0 (Tier 3)C1

C 500

c 500 (tablet)* $0 (Tier 3)



75


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

C Complex

c complex (tablet extended-release)* $0 (Tier 3)C1

C-1000

c-1000 (tablet)* $0 (Tier 3)C1

C-1000 Prolonged Release c-1000 prolonged release (tablet extended-release)* $0 (Tier 3)C1

C-1000/Rose Hips c-1000/rose hips (tablet)* $0 (Tier 3)C1

C-250

c-250 (tablet)* $0 (Tier 3)C1

C-500

c-500 (500mg tablet, 500mg tablet chewable,

500mg-tablet chewable)*$0 (Tier 3)

C1

C-500 Prolonged Release c-500 prolonged release (tablet extended-release)* $0 (Tier 3)C1

C-500/Rose Hips c-500/rose hips (tablet)* $0 (Tier 3)C1

Calcidol

calcidol (oral solution)* $0 (Tier 3)C1

C-Chewable

c-chewable (tablet chewable)* $0 (Tier 3)C1

Centamin

centamin (liquid)* $0 (Tier 3)C1

Centravites

centravites (tablet)* $0 (Tier 3)C1

Centravites 50 Plus centravites 50 plus (tablet)* $0 (Tier 3)C1

Centrum

centrum (0-60mg/15ml-300mcg/15ml-400unit/

15ml-25mcg/15ml-6mcg/15ml-0-150mcg/15ml-9mg/

15ml-2mg/15ml-25mcg/15ml-20mg/15ml-10mg/

15ml-0-2mg/15ml-1.7mg/15ml-0-1.1mg/

15ml-1300unit/15ml-30unit/15ml-3mg/15ml liquid,

60mg-0-45mcg-108mg-10mg-20mcg-2mg-6mcg-400

unit-400mcg-18mg-40mg-1mg-20mg-50mg-10mcg-1

50mcg-2mg-1.7mg-20mcg-1.5mg-30unit-3500unit-15

mg tablet chewable)*

$0 (Tier 3)

C1

Centrum Adults centrum adults (tablet)* $0 (Tier 3)C1

Centrum Kids Complete centrum kids complete (tablet chewable)* $0 (Tier 3)C1

Centrum Silver centrum silver (tablet)* $0 (Tier 3)C1

Centrum Silver Adult 50+ centrum silver adult 50+ (tablet)* $0 (Tier 3)C1

Centrum Silver Ultra Womens centrum silver ultra womens (tablet)* $0 (Tier 3)C1

Centrum Specialist Heart centrum specialist heart (tablet)* $0 (Tier 3)C1

Centrum Ultra Mens centrum ultra mens (tablet)* $0 (Tier 3)


76


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Centrum Ultra Womens centrum ultra womens (tablet)* $0 (Tier 3)C1

Cerovite Advanced Formula cerovite advanced formula (tablet)* $0 (Tier 3)C1

Cerovite Jr

cerovite jr (tablet chewable)* $0 (Tier 3)C1

Certa Plus

certa plus (tablet)* $0 (Tier 3)C1

Certavite Senior/Antioxidant Nutrients

certavite senior/antioxidant nutrients (tablet)* $0 (Tier 3)C1

Certavite/Antioxidants certavite/antioxidants (tablet)* $0 (Tier 3)C1

Chewable Vitamin C chewable vitamin c (tablet chewable)* $0 (Tier 3)C1

Chewable Vite Childrens chewable vite childrens (tablet chewable)* $0 (Tier 3)C1

Chewable Vite with Iron/Childrens

chewable vite with iron/childrens (tablet chewable)* $0 (Tier 3)C1

Childrens Chewable Multivitamin childrens chewable multivitamin (tablet chewable)* $0 (Tier 3)C1

Childrens Chewable Vitamin childrens chewable vitamin (tablet chewable)* $0 (Tier 3)C1

Childrens Chewable Vitamins childrens chewable vitamins (tablet chewable)* $0 (Tier 3)C1

Childrens Chewable Vitamins/Iron

childrens chewable vitamins/iron (tablet chewable)* $0 (Tier 3)C1

Companion

companion (tablet)* $0 (Tier 3)C1

Compete

compete (tablet)* $0 (Tier 3)C1

Complete

complete (tablet)* $0 (Tier 3)C1

Complex B-100 complex b-100 (tablet extended-release)* $0 (Tier 3)C1

Cranberry Urinary Comfort cranberry urinary comfort (capsule)* $0 (Tier 3)C1

CVS B Complex Plus C cvs b complex plus c (tablet)* $0 (Tier 3)C1

CVS B-1

cvs b-1 (tablet)* $0 (Tier 3)C1

CVS B-12

cvs b-12 (1000mcg/15ml liquid, 500mcg tablet)* $0 (Tier 3)C1

CVS B6

cvs b6 (tablet)* $0 (Tier 3)C1

CVS Beta Carotene cvs beta carotene (capsule)* $0 (Tier 3)C1

CVS Biotin

cvs biotin (capsule)* $0 (Tier 3)C1

CVS Biotin High Potency cvs biotin high potency (tablet)* $0 (Tier 3)C1

CVS Childrens Chewable Complete

cvs childrens chewable complete (tablet chewable)* $0 (Tier 3)C1

CVS Childrens Chewable Multivitamin/Iron

cvs childrens chewable multivitamin/iron (tablet


C1

CVS Daily Multiple cvs daily multiple (tablet)* $0 (Tier 3)C1

CVS Daily Multiple for Men cvs daily multiple for men (tablet)* $0 (Tier 3)C1

CVS Daily Multiple for Women cvs daily multiple for women (tablet)* $0 (Tier 3)C1

CVS Daily Multiple for Women 50+ cvs daily multiple for women 50+ (tablet)* $0 (Tier 3)C1

CVS Daily Multiple Plus Iron/Calcium/Zinc

cvs daily multiple plus iron/calcium/zinc (tablet)* $0 (Tier 3)C1

CVS Gummy Dinos cvs gummy dinos (tablet chewable)* $0 (Tier 3)C1

CVS Hair/Skin/Nails cvs hair/skin/nails (tablet)* $0 (Tier 3)C1

CVS Spectravite Adult 50+ cvs spectravite adult 50+ (tablet)* $0 (Tier 3)



77


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

CVS Spectravite Advanced Formula

cvs spectravite advanced formula (tablet)* $0 (Tier 3)C1

CVS Spectravite Senior cvs spectravite senior (tablet)* $0 (Tier 3)C1

CVS Spectravite Ultra Health Mens cvs spectravite ultra health mens (tablet)* $0 (Tier 3)C1

CVS Spectravite Ultra Mens Health cvs spectravite ultra mens health (tablet)* $0 (Tier 3)C1

CVS Spectravite Ultra Women cvs spectravite ultra women (tablet)* $0 (Tier 3)C1

CVS Spectravite Ultra Womens Health

cvs spectravite ultra womens health (tablet)* $0 (Tier 3)C1

CVS Spectravite Ultra Womens Health Senior

cvs spectravite ultra womens health senior (tablet)* $0 (Tier 3)C1

CVS Super B Complex/C cvs super b complex/c (tablet)* $0 (Tier 3)C1

CVS Vitamin A

cvs vitamin a (capsule)* $0 (Tier 3)C1

CVS Vitamin B12

cvs vitamin b12 (tablet)* $0 (Tier 3)C1

CVS Vitamin B-12

cvs vitamin b-12 (tablet)* $0 (Tier 3)C1

CVS Vitamin B-12 TR cvs vitamin b-12 tr (tablet extended-release)* $0 (Tier 3)C1

CVS Vitamin B-2

cvs vitamin b-2 (tablet)* $0 (Tier 3)C1

CVS Vitamin C

cvs vitamin c (1000mg tablet, 250mg tablet, 500mg

tablet, 500mg-25mg-14mg tablet, 500mg-7.5mg-

tablet chewable)*

$0 (Tier 3)

C1

CVS Vitamin E

cvs vitamin e (capsule)* $0 (Tier 3)C1

Daily Combo Multi Vitamin daily combo multi vitamin (tablet)* $0 (Tier 3)C1

Daily Multiple Vitamin daily multiple vitamin (tablet)* $0 (Tier 3)C1

Daily Multiple Vitamin/Iron daily multiple vitamin/iron (tablet)* $0 (Tier 3)C1

Daily Multiple Vitamins daily multiple vitamins (tablet)* $0 (Tier 3)C1

Daily Value Multivitamin daily value multivitamin (tablet)* $0 (Tier 3)C1

Daily Vitamin

daily vitamin (tablet)* $0 (Tier 3)C1

Daily Vitamin Formula+ir On daily vitamin formula+ir on (tablet)* $0 (Tier 3)C1

Daily Vitamin Formula+iron daily vitamin formula+iron (tablet)* $0 (Tier 3)C1

Daily Vitamin Formula+minerals

daily vitamin formula+minerals (tablet)* $0 (Tier 3)C1

Daily Vite

daily vite (tablet)* $0 (Tier 3)C1

Daily Vite Multivitamin/Iron daily vite multivitamin/iron (tablet)* $0 (Tier 3)C1

Daily-Vite

daily-vite (tablet)* $0 (Tier 3)


78


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Daily-Vite/Iron/Beta-Carotene

daily-vite/iron/beta-carotene (tablet)* $0 (Tier 3)C1

Dekas Essential dekas essential (capsule)* $0 (Tier 3)C1

Dekas Plus

dekas plus

(0-100mcg-12mg-3000unit-10mg-12mcg-200mcg-10

mg-1000mcg-1.9mg-1.7mg-75mcg-75mg-1.5mg-0-15

0unit-0-18167unit-0-10mg capsule, 45mg/

ml-0-15mcg/ml-3mg/ml-750unit/ml-2mg/ml-6mg/

ml-500mcg/ml-0.6mg/ml-0.6mg/ml-0-10mcg/

ml-0.6mg/ml-0-50unit/ml-0-5751unit/ml-5mg/ml

liquid)*

$0 (Tier 3)

C1

Dialy vite 800

dialy vite 800 (tablet)* $0 (Tier 3)C1

Dino-Life

dino-life (tablet chewable)* $0 (Tier 3)C1

Dino-Life with Extra C dino-life with extra c (tablet chewable)* $0 (Tier 3)C1

Dino-Life with Iron & Zinc dino-life with iron & zinc (tablet chewable)* $0 (Tier 3)C1

D-Vi-Sol

d-vi-sol (liquid)* $0 (Tier 3)C1

E-400

e-400 (capsule)* $0 (Tier 3)C1

E400 Mixed

e400 mixed (capsule)* $0 (Tier 3)C1

Endur-Acin

endur-acin (tablet extended-release)* $0 (Tier 3)C1

Endur-C/Rose Hips endur-c/rose hips (tablet extended-release)* $0 (Tier 3)C1

E-Oil

e-oil (oil)* $0 (Tier 3)C1

EQ Complete Multivitamin Adults 50+

eq complete multivitamin adults 50+ (tablet)* $0 (Tier 3)C1

EQ Complete Multivitamin Adults Under 50

eq complete multivitamin adults under 50 (tablet)* $0 (Tier 3)C1

EQ One Daily Womens Health eq one daily womens health (tablet)* $0 (Tier 3)C1

EQL B Complex 50 eql b complex 50 (tablet)* $0 (Tier 3)C1

EQL B-6

eql b-6 (tablet)* $0 (Tier 3)C1

EQL One Daily Mens Health Formula

eql one daily mens health formula (tablet)* $0 (Tier 3)C1

EQL One Daily Womens eql one daily womens (tablet)* $0 (Tier 3)C1

EQL Vitamin B-12

eql vitamin b-12 (tablet)* $0 (Tier 3)C1

EQL Vitamin B-12 TR eql vitamin b-12 tr (tablet extended-release)* $0 (Tier 3)C1

EQL Vitamin C

eql vitamin c (tablet)* $0 (Tier 3)C1

EQL Vitamin C/Rose Hips eql vitamin c/rose hips (tablet)* $0 (Tier 3)C1

EQL Vitamin E

eql vitamin e (capsule)* $0 (Tier 3)C1

Ergocalciferol

ergocalciferol (oral solution)* $0 (Tier 3)C1

Essentia

essentia (tablet)* $0 (Tier 3)C1

Essential Balance essential balance (tablet)* $0 (Tier 3)C1

Flintstones Complete flintstones complete (tablet chewable)* $0 (Tier 3)C1

Flintstones Plus Extra C flintstones plus extra c (tablet chewable)* $0 (Tier 3)



79


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Flintstones/My First flintstones/my first (tablet chewable)* $0 (Tier 3)C1

Folic Acid

folic acid (1mg tablet, 5mg/ml injection)* $0 (Tier 3)C1

Foltabs 800

foltabs 800 (tablet)* $0 (Tier 3)C1

Fosfree

fosfree (tablet)* $0 (Tier 3)C1

Fruit C 500

fruit c 500 (tablet chewable)* $0 (Tier 3)C1

Fruity C

fruity c (tablet chewable)* $0 (Tier 3)C1

Fruity Chewables Multivitamin fruity chewables multivitamin (tablet chewable)* $0 (Tier 3)C1

Full Spectrum B/Vitamin C full spectrum b/vitamin c (tablet)* $0 (Tier 3)C1

GNP Animal Shapes gnp animal shapes (tablet chewable)* $0 (Tier 3)C1

GNP Animal Shapes Plus Extra C gnp animal shapes plus extra c (tablet chewable)* $0 (Tier 3)C1

GNP Animal Shapes Plus Iron gnp animal shapes plus iron (tablet chewable)* $0 (Tier 3)C1

GNP B-12

gnp b-12 (tablet sublingual)* $0 (Tier 3)C1

GNP B-50 Balanced gnp b-50 balanced (tablet)* $0 (Tier 3)C1

GNP Biotin

gnp biotin (capsule)* $0 (Tier 3)C1

GNP Century

gnp century

(60mg-0-30mcg-200mg-10mg-20mg-72mg-400unit-3

5mcg-0.5mg-6mcg-18mg-400mcg-50mg-2.3mg-20m

g-5mcg-25mcg-80mg-150mcg-2mg-1.7mg-2mg-75m

cg-10mcg-45mcg-55mcg-10mcg-1.5mg-30unit-3500u

nit-11mg tablet,

60mg-0-30mcg-200mg-10mg-72mg-400unit-35mcg-0.

5mg-6mcg-18mg-400mcg-50mg-2.3mg-20mg-5mcg-

20mg-25mcg-80mg-150mcg-2mg-1.7mg-2mg-75mcg

-10mcg-45mcg-55mcg-10mcg-1.5mg-30unit-3500unit

-11mg tablet)*

$0 (Tier 3)

C1

GNP Century Active Performance

gnp century active performance (tablet)* $0 (Tier 3)C1

GNP Century Adults 50+ Senior gnp century adults 50+ senior (tablet)* $0 (Tier 3)C1

GNP Century Cardio Healthformula

gnp century cardio healthformula (tablet)* $0 (Tier 3)C1

GNP Century Mature gnp century mature (tablet)* $0 (Tier 3)C1

GNP Century Ultimate Mens Complete

gnp century ultimate mens complete (tablet)* $0 (Tier 3)


80


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

GNP Century Ultimate Womens Complete

gnp century ultimate womens complete (tablet)* $0 (Tier 3)C1

GNP Century Ultimate Womens Senior Formula

gnp century ultimate womens senior formula

(tablet)*$0 (Tier 3)

C1

GNP Childrens Chewables w/Extra C

gnp childrens chewables w/extra c (tablet


C1

GNP Childrens Chewables/Extra C

gnp childrens chewables/extra c (tablet chewable)* $0 (Tier 3)C1

GNP Childrens Chewables/Iron gnp childrens chewables/iron (tablet chewable)* $0 (Tier 3)C1

GNP Essential One Daily gnp essential one daily (tablet)* $0 (Tier 3)C1

GNP Hair/Skin/Nails gnp hair/skin/nails (tablet)* $0 (Tier 3)C1

GNP Little Ones Childrens gnp little ones childrens (tablet chewable)* $0 (Tier 3)C1

GNP Mega Multi for Men gnp mega multi for men (tablet)* $0 (Tier 3)C1

GNP Mega Multi for Women gnp mega multi for women (tablet)* $0 (Tier 3)C1

GNP Niacin TR gnp niacin tr (tablet extended-release)* $0 (Tier 3)C1

GNP One Daily Maximum gnp one daily maximum (tablet)* $0 (Tier 3)C1

GNP One Daily Mens Health 50+

gnp one daily mens health 50+ (tablet)* $0 (Tier 3)C1

GNP One Daily Plus Iron gnp one daily plus iron (tablet)* $0 (Tier 3)C1

GNP One Daily Womens Health 50+

gnp one daily womens health 50+ (tablet)* $0 (Tier 3)C1

GNP Opti-Vitamins gnp opti-vitamins (tablet)* $0 (Tier 3)C1

GNP Therapeutic-M gnp therapeutic-m

(90mg-0-30mcg-150mcg-10mg-40mg-7.5mg-400unit-

50mcg-2mg-12mcg-9mg-400mcg-100mg-2mg-20mg-

5mcg-31mg-28mcg-7.5mg-150mcg-6mg-3.4mg-2mg-

10mcg-75mcg-70mcg-10mcg-3mg-60unit-5000unit-1

5mg tablet,

90mg-0-30mcg-150mcg-40mg-10mg-7.5mg-400unit-5

0mcg-2mg-12mcg-9mg-400mcg-100mg-2mg-20mg-5

mcg-31mg-28mcg-7.5mg-150mcg-6mg-3.4mg-2mg-1


mg tablet)*

$0 (Tier 3)

C1

GNP Vitamin A gnp vitamin a (10000unit capsule, 8000unit

capsule)*$0 (Tier 3)

C1

GNP Vitamin B-1 gnp vitamin b-1 (tablet)* $0 (Tier 3)C1

GNP Vitamin B-12 gnp vitamin b-12 (tablet)* $0 (Tier 3)C1

GNP Vitamin B-12 Prolonged Release

gnp vitamin b-12 prolonged release (tablet extended-


C1

GNP Vitamin B-12 TR gnp vitamin b-12 tr (tablet extended-release)* $0 (Tier 3)C1

GNP Vitamin B-6 gnp vitamin b-6 (tablet)* $0 (Tier 3)



81


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

GNP Vitamin C gnp vitamin c (1000mg tablet, 250mg tablet, 500mg

tablet, 500mg tablet chewable, 500mg-tablet

chewable, 500mg-tablet chewable)*

$0 (Tier 3)

C1

GNP Vitamin C Drops gnp vitamin c drops (60mg lozenge, 60mg-0

lozenge)*$0 (Tier 3)

C1

GNP Vitamin C Pr gnp vitamin c pr (tablet extended-release)* $0 (Tier 3)C1

GNP Vitamin C TR gnp vitamin c tr (tablet extended-release)* $0 (Tier 3)C1

GNP Vitamin C with Rose Hips gnp vitamin c with rose hips (500mg tablet,

500mg-37mg tablet)*$0 (Tier 3)

C1

GNP Vitamin C with Rose Hips TR

gnp vitamin c with rose hips tr (tablet extended-


C1

GNP Vitamin C/Rose Hips gnp vitamin c/rose hips (tablet)* $0 (Tier 3)C1

GNP Vitamin E gnp vitamin e (1000unit capsule, 200unit capsule,

400unit capsule, 200unit capsule, 400unit capsule)*$0 (Tier 3)

C1

GNP Vitamin E Water Dispersible

gnp vitamin e water dispersible (capsule)* $0 (Tier 3)C1

GNP Zoo Chews Gummies gnp zoo chews gummies (tablet chewable)* $0 (Tier 3)C1

Gummi Bear Multivitamin/Mineral gummi bear multivitamin/mineral (tablet chewable)* $0 (Tier 3)C1

Halls Defense Vitamin C Drops

halls defense vitamin c drops (lozenge)* $0 (Tier 3)C1

Hard Nails

hard nails (capsule)* $0 (Tier 3)C1

Healthy Kids Gummies healthy kids gummies (tablet chewable)* $0 (Tier 3)C1

HM Complete

hm complete (tablet)* $0 (Tier 3)C1

HM Complete 50+ hm complete 50+ (tablet)* $0 (Tier 3)C1

HM Complete 50+ Womens Ultimate

hm complete 50+ womens ultimate (tablet)* $0 (Tier 3)C1

HM Complete Women hm complete women (tablet)* $0 (Tier 3)C1

HM Hair/Skin/Nails hm hair/skin/nails (tablet)* $0 (Tier 3)C1

HM Niacin

hm niacin (tablet extended-release)* $0 (Tier 3)C1

HM Niacin TR

hm niacin tr (tablet extended-release)* $0 (Tier 3)C1

HM One Daily Essential hm one daily essential (tablet)* $0 (Tier 3)C1

HM One Daily Womens hm one daily womens (tablet)* $0 (Tier 3)C1

HM One Daily/Iron hm one daily/iron (tablet)* $0 (Tier 3)


82


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

HM Vitamin B Complex/Vitamin C

hm vitamin b complex/vitamin c (tablet)* $0 (Tier 3)C1

HM Vitamin B100 Complex hm vitamin b100 complex (tablet)* $0 (Tier 3)C1

HM Vitamin B12

hm vitamin b12 (1000mcg tablet extended-release,

500mcg tablet)*$0 (Tier 3)

C1

HM Vitamin B12 TR hm vitamin b12 tr (tablet extended-release)* $0 (Tier 3)C1

HM Vitamin B50 Complex hm vitamin b50 complex (tablet)* $0 (Tier 3)C1

HM Vitamin B6

hm vitamin b6 (tablet)* $0 (Tier 3)C1

HM Vitamin C

hm vitamin c (1000mg tablet, 500mg tablet, 500mg-

tablet chewable)*$0 (Tier 3)

C1

HM Vitamin C TR hm vitamin c tr (tablet extended-release)* $0 (Tier 3)C1

HM Vitamin C/Rose Hips hm vitamin c/rose hips (tablet)* $0 (Tier 3)C1

HM Vitamin E

hm vitamin e (capsule)* $0 (Tier 3)C1

Honey Bears

honey bears (tablet chewable)* $0 (Tier 3)C1

Honey Bears with Iron and Zinc honey bears with iron and zinc (tablet chewable)* $0 (Tier 3)C1

I-Caps Areds Formula i-caps areds formula (tablet)* $0 (Tier 3)C1

I-Caps Mv

i-caps mv (tablet)* $0 (Tier 3)C1

I-Caps Plus

i-caps plus (tablet)* $0 (Tier 3)C1

Just D

just d (liquid)* $0 (Tier 3)C1

Kobee

kobee (tablet)* $0 (Tier 3)C1

KP Adults 50+ Daily Formula kp adults 50+ daily formula (tablet)* $0 (Tier 3)C1

KP B Complex/C kp b complex/c (tablet)* $0 (Tier 3)C1

KP Niacin

kp niacin (tablet)* $0 (Tier 3)C1

KP Vitamin B-12

kp vitamin b-12 (tablet)* $0 (Tier 3)C1

KP Vitamin B-6

kp vitamin b-6 (tablet)* $0 (Tier 3)C1

KP Vitamin E

kp vitamin e (capsule)* $0 (Tier 3)C1

Land Before Time Multivitamin/Iron

land before time multivitamin/iron (tablet chewable)* $0 (Tier 3)C1

Life Pack Mens life pack mens* $0 (Tier 3)C1

Life Pack Womens life pack womens* $0 (Tier 3)C1

Liquid B12

liquid b12 (liquid)* $0 (Tier 3)C1

Lysiplex Plus

lysiplex plus (liquid)* $0 (Tier 3)C1

Mega Multiple with Chelated Minerals

mega multiple with chelated minerals (tablet)* $0 (Tier 3)C1

Mega Multivitamin for Men mega multivitamin for men (tablet)* $0 (Tier 3)C1

Mega Multivitamin for Women mega multivitamin for women (tablet)* $0 (Tier 3)C1

Meijer Advanced Formula meijer advanced formula (tablet)* $0 (Tier 3)C1

Meijer C

meijer c (tablet)* $0 (Tier 3)C1

Mephyton

mephyton (tablet)* $0 (Tier 3)



83


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Meribin

meribin (capsule)* $0 (Tier 3)C1

Mtx Support

mtx support (tablet)* $0 (Tier 3)C1

Multi Complete/Iron multi complete/iron (tablet)* $0 (Tier 3)C1

Multi Vitamin Daily multi vitamin daily (tablet)* $0 (Tier 3)C1

Multi-Day Plus Iron multi-day plus iron (tablet)* $0 (Tier 3)C1

Multi-Delyn/Iron multi-delyn/iron (liquid)* $0 (Tier 3)C1

Multilex

multilex (tablet)* $0 (Tier 3)C1

Multilex T&M

multilex t&m (tablet)* $0 (Tier 3)C1

Multiple Vitamin/Minerals/No Iron multiple vitamin/minerals/no iron (tablet)* $0 (Tier 3)C1

Multiple Vitamins multiple vitamins (tablet)* $0 (Tier 3)C1

Multiple Vitamins Plain multiple vitamins plain (tablet)* $0 (Tier 3)C1

Multiple Vitamins/Iron multiple vitamins/iron

(60mg-0-10mg-400unit-6mcg-18mg-400mcg-20mg-2

mg-1.7mg-1.5mg-30unit-5000unit tablet,

60mg-400unit-6mcg-18mg-400mcg-20mg-10mg-2mg

-1.7mg-1.5mg-30unit-5000unit tablet,

60mg-4.5mcg-400unit-15mg-0.3mg-13.5mg-1.04mg-1

.2mg-1.05mg-2500unit-15unit tablet chewable)*

$0 (Tier 3)

C1

Multivitamin & Mineral multivitamin & mineral (liquid)* $0 (Tier 3)C1

Multi-Vitamin

multi-vitamin (tablet)* $0 (Tier 3)C1

Multi-Vitamin Daily multi-vitamin daily (tablet)* $0 (Tier 3)C1

Multi-Vitamin HP/Minerals multi-vitamin hp/minerals (capsule)* $0 (Tier 3)C1

Multi-Vitamin/Minerals multi-vitamin/minerals (tablet)* $0 (Tier 3)C1

Multi-Vitamin/Multi-Mineral Adult/High Potency

multi-vitamin/multi-mineral adult/high potency

(liquid)*$0 (Tier 3)

C1

Multi-Vitamins multi-vitamins (tablet)* $0 (Tier 3)C1

My-Vitalife

my-vitalife (capsule)* $0 (Tier 3)C1

Natural C/Rose Hips natural c/rose hips (tablet)* $0 (Tier 3)C1

Natural Vitamin E natural vitamin e (capsule)* $0 (Tier 3)C1

Nephronex

nephronex (liquid)* $0 (Tier 3)


84


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Nephro-Vite

nephro-vite (tablet)* $0 (Tier 3)C1

Niacin

niacin (100mg tablet, 250mg tablet, 500mg tablet,

100mg tablet, 500mg tablet, 50mg tablet, 250mg

capsule extended-release, 500mg tablet extended-

release)*

$0 (Tier 3)

C1

Niacin ER

niacin er (otc only) (250mg capsule extended-

release, 500mg tablet extended-release)*$0 (Tier 3)

C1

Niacin SR

niacin sr (capsule extended-release)* $0 (Tier 3)C1

Niacin TR

niacin tr (250mg capsule extended-release, 250mg

tablet extended-release, 500mg tablet extended-

release)*

$0 (Tier 3)

C1

No Iron Multiple Vitamin/Minerals no iron multiple vitamin/minerals (tablet)* $0 (Tier 3)C1

Ocutabs

ocutabs (tablet)* $0 (Tier 3)C1

Ocutabs Vision Formula ocutabs vision formula (tablet)* $0 (Tier 3)C1

Ocutabs/Lutein ocutabs/lutein (tablet)* $0 (Tier 3)C1

Omnicap

omnicap (tablet)* $0 (Tier 3)C1

Once Daily

once daily (tablet)* $0 (Tier 3)C1

Once Daily/Iron once daily/iron (tablet)* $0 (Tier 3)C1

Oncovite

oncovite (tablet)* $0 (Tier 3)C1

One Daily

one daily (tablet)* $0 (Tier 3)C1

One Daily Complete one daily complete (tablet)* $0 (Tier 3)C1

One Daily for Men 50+ Advanced one daily for men 50+ advanced (tablet)* $0 (Tier 3)C1

One Daily for Women one daily for women (tablet)* $0 (Tier 3)C1

One Daily for Women 50+a Dvanced

one daily for women 50+a dvanced (tablet)* $0 (Tier 3)C1

One Daily Maximum one daily maximum (tablet)* $0 (Tier 3)C1

One Daily Mens one daily mens (tablet)* $0 (Tier 3)C1

One Daily Multivitamin Adult one daily multivitamin adult (tablet)* $0 (Tier 3)C1

One Daily Multivitamin/Iron one daily multivitamin/iron (tablet)* $0 (Tier 3)C1

One Daily Plus Iron one daily plus iron (tablet)* $0 (Tier 3)C1

One Daily Plus Minerals one daily plus minerals (tablet)* $0 (Tier 3)C1

One Daily Womens 50 Plus one daily womens 50 plus (tablet)* $0 (Tier 3)C1

One Daily Womens 50+ one daily womens 50+ (tablet)* $0 (Tier 3)C1

One Daily/Iron/Calcium one daily/iron/calcium (tablet)* $0 (Tier 3)C1

One Daily/Minerals one daily/minerals (tablet)* $0 (Tier 3)C1

One-A-Day Essential one-a-day essential (tablet)* $0 (Tier 3)C1

One-A-Day Mens 50+ Advantage one-a-day mens 50+ advantage (tablet)* $0 (Tier 3)C1

One-A-Day Teen Advantage for Her

one-a-day teen advantage for her (tablet)* $0 (Tier 3)



85


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

One-A-Day Teen Advantage for Him

one-a-day teen advantage for him (tablet)* $0 (Tier 3)C1

One-A-Day Womens Formula one-a-day womens formula (tablet)* $0 (Tier 3)C1

One-Daily Multi Vitamins one-daily multi vitamins (tablet)* $0 (Tier 3)C1

Pantothenic Acid

pantothenic acid (tablet)* $0 (Tier 3)C1

Peridin-C

peridin-c (tablet)* $0 (Tier 3)C1

Plain Niacin

plain niacin (tablet)* $0 (Tier 3)C1

Poly Vitamin

poly vitamin (tablet chewable)* $0 (Tier 3)C1

Polyvitamin

polyvitamin (oral solution)* $0 (Tier 3)C1

Polyvitamin/Iron

polyvitamin/iron (tablet chewable)* $0 (Tier 3)C1

Prevent

prevent (capsule)* $0 (Tier 3)C1

Pure C 500

pure c 500 (capsule extended-release)* $0 (Tier 3)C1

Pureway-C

pureway-c (tablet)* $0 (Tier 3)C1

Pyridoxine HCl

pyridoxine hcl (tablet)* $0 (Tier 3)C1

QC Childrens Chewable Vitamins/Extra C

qc childrens chewable vitamins/extra c (tablet


C1

QC Maximum Daily Multivitamin/Multimineral

qc maximum daily multivitamin/multimineral (tablet)* $0 (Tier 3)C1

QC Multi-Vite

qc multi-vite (tablet)* $0 (Tier 3)C1

QC Womens Daily Multivitamin qc womens daily multivitamin (tablet)* $0 (Tier 3)C1

Quintabs-M

quintabs-m (tablet)* $0 (Tier 3)C1

RA Balanced B-100 ra balanced b-100 (tablet)* $0 (Tier 3)C1

RA Balanced B-50 ra balanced b-50 (tablet)* $0 (Tier 3)C1

RA B-Complex ra b-complex (tablet)* $0 (Tier 3)C1

RA B-Complex with B-12 ra b-complex with b-12 (tablet)* $0 (Tier 3)C1

RA B-Complex/Vitamin C TR ra b-complex/vitamin c tr (tablet extended-release)* $0 (Tier 3)C1

RA Biotin

ra biotin (capsule)* $0 (Tier 3)C1

RA Central-Vite Cardio ra central-vite cardio (tablet)* $0 (Tier 3)C1

RA Central-Vite Select Mature ra central-vite select mature (tablet)* $0 (Tier 3)C1

RA Central-Vite Womens Mature ra central-vite womens mature (tablet)* $0 (Tier 3)C1

RA Central-Vite/Antioxidants ra central-vite/antioxidants (tablet)* $0 (Tier 3)


86


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

RA Niacin

ra niacin (tablet)* $0 (Tier 3)C1

RA One Daily Energy Formula ra one daily energy formula (tablet)* $0 (Tier 3)C1

RA One Daily Essential ra one daily essential (tablet)* $0 (Tier 3)C1

RA One Daily Maximum ra one daily maximum (tablet)* $0 (Tier 3)C1

RA One Daily Mens 50+ with Vitamin D-3

ra one daily mens 50+ with vitamin d-3 (tablet)* $0 (Tier 3)C1

RA Vitamin A

ra vitamin a (capsule)* $0 (Tier 3)C1

RA Vitamin B-1

ra vitamin b-1 (tablet)* $0 (Tier 3)C1

RA Vitamin B12

ra vitamin b12 (tablet extended-release)* $0 (Tier 3)C1

RA Vitamin B-12


RA Vitamin B-12 TR ra vitamin b-12 tr (tablet extended-release)* $0 (Tier 3)C1

RA Vitamin B-6


RA Vitamin C

ra vitamin c (250mg tablet, 500mg tablet, 500mg-

tablet chewable)*$0 (Tier 3)

C1

RA Vitamin C Drops ra vitamin c drops (lozenge)* $0 (Tier 3)C1

RA Vitamin C TR ra vitamin c tr (tablet extended-release)* $0 (Tier 3)C1

RA Vitamin C/Acerola ra vitamin c/acerola (tablet chewable)* $0 (Tier 3)C1

RA Vitamin C/Rose Hips ra vitamin c/rose hips (tablet)* $0 (Tier 3)C1

RA Vitamin C/Rose Hips TR ra vitamin c/rose hips tr (tablet extended-release)* $0 (Tier 3)C1

RA Vitamin E

ra vitamin e (capsule)* $0 (Tier 3)C1

Rabano Yodado

rabano yodado (liquid)* $0 (Tier 3)C1

Renal Vitamin

renal vitamin (tablet)* $0 (Tier 3)C1

Renal-Vite

renal-vite (tablet)* $0 (Tier 3)C1

Rena-Vite

rena-vite (tablet)* $0 (Tier 3)C1

SB Vitamin C

sb vitamin c (tablet)* $0 (Tier 3)C1

Scooby-Doo One A Day scooby-doo one a day (tablet chewable)* $0 (Tier 3)C1

Senior Tabs

senior tabs (tablet)* $0 (Tier 3)



87


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Sentry

sentry

(60mg-0-30mcg-75mcg-200mg-10mg-20mg-72mg-40

0unit-35mcg-0.5mg-6mcg-18mg-400mcg-50mg-2.3m

g-20mg-5mcg-25mcg-80mg-150mcg-2mg-1.7mg-2m

g-10mcg-45mcg-55mcg-10mcg-1.5mg-30unit-3500un

it-11mg tablet,

90mg-0-30mcg-150mcg-200mg-109mg-72mg-400uni

t-35mcg-0.9mg-6mcg-18mg-500mcg-250mcg-300mc

g-100mg-2.3mg-20mg-5mcg-10mg-25mcg-80mg-150

mcg-2mg-1.7mg-2mg-10mcg-45mcg-55mcg-10mcg-1

.5mg-30unit-3500unit-11mg tablet,

90mg-0-30mcg-150mcg-200mg-10mg-109mg-72mg-

400unit-35mcg-0.9mg-6mcg-18mg-500mcg-250mcg-

300mcg-100mg-2.3mg-20mg-5mcg-25mcg-80mg-15

0mcg-2mg-1.7mg-2mg-10mcg-45mcg-55mcg-10mcg-

1.5mg-30unit-3500unit-11mg tablet)*

$0 (Tier 3)

C1

Sentry Adults Under 50 sentry adults under 50 (tablet)* $0 (Tier 3)C1

Sentry Senior

sentry senior

(60mg-0-30mcg-150mcg-220mg-10mg-20mg-72mg-5

00unit-45mcg-0.5mg-25mcg-400mcg-250mcg-300mc

g-50mg-2.3mg-20mg-5mcg-30mcg-80mg-150mcg-3

mg-1.7mg-2mg-10mcg-45mcg-55mcg-1.5mg-50unit-2

500unit-11mg tablet,

60mg-0-30mcg-150mcg-220mg-10mg-20mg-72mg-5

00unit-45mcg-0.5mg-25mcg-400mcg-250mcg-300mc

g-50mg-2.3mg-20mg-5mcg-30mcg-80mg-150mcg-3



90mg-0-30mcg-150mcg-220mg-10mg-110mg-72mg-

500unit-45mcg-0.9mg-25mcg-500mcg-250mcg-300m

cg-50mg-2.3mg-20mg-5mcg-30mcg-80mg-150mcg-3


500unit-11mg tablet)*

$0 (Tier 3)


88


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Slo-Niacin

slo-niacin (tablet extended-release)* $0 (Tier 3)C1

SM Balanced B-50 sm balanced b-50 (tablet)* $0 (Tier 3)C1

SM B-Complex sm b-complex (tablet)* $0 (Tier 3)C1

SM B-Complex/Vitamin C sm b-complex/vitamin c (tablet)* $0 (Tier 3)C1

SM Chewable C

sm chewable c (tablet chewable)* $0 (Tier 3)C1

Sm Chewable Vitamin C sm chewable vitamin c (tablet chewable)* $0 (Tier 3)C1

SM Complete

sm complete

(120mg-0-40mcg-100mg-10mg-72mg-120mcg-2mg-1

6mcg-400unit-18mg-400mcg-60mg-40mg-4mg-40mg

-5mcg-50mg-48mg-25mcg-80mg-150mcg-6mg-5.1m

g-4mg-60mcg-10mcg-75mcg-70mcg-10mcg-4.5mg-6

0unit-3500unit-15mg tablet,

60mg-0-30mcg-200mg-10mg-72mg-400unit-35mcg-0.

5mg-6mcg-18mg-400mcg-50mg-2.3mg-20mg-5mcg-

20mg-25mcg-80mg-150mcg-2mg-1.7mg-2mg-75mcg

-10mcg-45mcg-55mcg-10mcg-1.5mg-30unit-3500unit

-11mg tablet)*

$0 (Tier 3)

C1

SM Complete 50+ sm complete 50+ (tablet)* $0 (Tier 3)C1

SM Complete 50+ Ultimate Womens

sm complete 50+ ultimate womens (tablet)* $0 (Tier 3)C1

SM Complete Advanced Formula

sm complete advanced formula (tablet)* $0 (Tier 3)C1

SM Complete Senior Formula sm complete senior formula (tablet)* $0 (Tier 3)C1

SM Hair/Skin/Nails sm hair/skin/nails (tablet)* $0 (Tier 3)C1

SM Multiple Vitamins Essential sm multiple vitamins essential (tablet)* $0 (Tier 3)C1

SM Multiple Vitamins/Iron sm multiple vitamins/iron (tablet)* $0 (Tier 3)C1

SM Niacin CR

sm niacin cr (tablet extended-release)* $0 (Tier 3)C1

SM One Daily Womens sm one daily womens (tablet)* $0 (Tier 3)C1

SM Super B Complex-Vitamin C sm super b complex-vitamin c (tablet)* $0 (Tier 3)C1

SM Vitamin B1

sm vitamin b1 (tablet)* $0 (Tier 3)C1

SM Vitamin B100 Complex sm vitamin b100 complex (tablet)* $0 (Tier 3)C1

SM Vitamin B12


SM Vitamin B-12

sm vitamin b-12 (tablet)* $0 (Tier 3)C1

SM Vitamin B12 TR sm vitamin b12 tr (tablet extended-release)* $0 (Tier 3)C1

SM Vitamin B6


SM Vitamin B-6

sm vitamin b-6 (tablet)* $0 (Tier 3)C1

SM Vitamin C

sm vitamin c (1000mg tablet, 250mg tablet, 1000mg

tablet, 500mg tablet, 500mg tablet chewable)*$0 (Tier 3)

C1

SM Vitamin C TR sm vitamin c tr (tablet extended-release)* $0 (Tier 3)C1

SM Vitamin C/Rose Hips sm vitamin c/rose hips (tablet)* $0 (Tier 3)



89


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

SM Vitamin E

sm vitamin e (1000unit capsule, 200unit capsule,

400unit capsule, 400unit capsule)*$0 (Tier 3)

C1

SM Vitamin E Blended sm vitamin e blended (capsule)* $0 (Tier 3)C1

Stress B/Zinc

stress b/zinc (tablet)* $0 (Tier 3)C1

Stress Formula stress formula

(500mg-45mcg-12mcg-400mcg-100mg-20mg-3mg-1

0mg-10mg-30unit tablet,

500mg-45mcg-12mcg-400mcg-100mg-20mg-5mg-10

mg-15mg-30unit tablet,

500mg-45mcg-12mcg-400mcg-100mg-20mg-5mg-10

mg-10mg-30unit tablet)*

$0 (Tier 3)

C1

Stress Formula with Iron stress formula with iron (tablet)* $0 (Tier 3)C1

Stress Formula/Iron stress formula/iron (tablet)* $0 (Tier 3)C1

Stress Formula/Zinc stress formula/zinc (tablet)* $0 (Tier 3)C1

Super B Complex Maxi super b complex maxi (tablet)* $0 (Tier 3)C1

Super B with C

super b with c (capsule)* $0 (Tier 3)C1

Super B-Complex/Vitamin C super b-complex/vitamin c (tablet)* $0 (Tier 3)C1

Super Biotin

super biotin (capsule)* $0 (Tier 3)C1

Super Quints B-50 super quints b-50 (tablet)* $0 (Tier 3)C1

Super Thera Vite M super thera vite m (tablet)* $0 (Tier 3)C1

Superplex-T

superplex-t (tablet)* $0 (Tier 3)C1

Suplevit

suplevit (liquid)* $0 (Tier 3)C1

TAB-A-VITE

tab-a-vite (tablet)* $0 (Tier 3)C1

TAB-A-VITE Maximum tab-a-vite maximum (tablet)* $0 (Tier 3)C1

TAB-A-VITE with Beta Carotene tab-a-vite with beta carotene (tablet)* $0 (Tier 3)C1

TAB-A-VITE/Iron tab-a-vite/iron (tablet)* $0 (Tier 3)C1

Thera

thera (tablet)* $0 (Tier 3)C1

Thera M Plus

thera m plus (tablet)* $0 (Tier 3)


90


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Thera-M

thera-m

(120mg-15mcg-44mg-10mg-7.5mg-400unit-15mcg-2

mg-9mcg-18mg-400mcg-100mg-5mg-30mg-31mg-7.

5mg-150mcg-3mg-3.4mg-15mcg-10mcg-3mg-30unit-


90mg-0-30mcg-150mcg-40mg-7.5mg-26mcg-2mg-9

mcg-400mcg-150mcg-18mg-100mg-3.5mg-32mcg-2

0mg-5mcg-10mg-31mg-7.5mg-3mg-3.4mg-21mcg-2

mg-3mg-10mcg-10mcg-5000unit-400unit-30unit-28m

cg-15mg tablet,

90mg-0-30mcg-30mg-10mg-50mcg-2mg-12mcg-400

unit-9mg-400mcg-100mg-2mg-20mg-5mcg-23mg-28

mcg-7.5mg-7mg-150mcg-6mg-3.4mg-6mg-150mcg-1


mg tablet)*

$0 (Tier 3)

C1

Therapeutic-M/Lutein therapeutic-m/lutein (tablet)* $0 (Tier 3)C1

Thera-Tabs

thera-tabs (tablet)* $0 (Tier 3)C1

Theratrum Complete theratrum complete

(60mg-0-30mcg-150mcg-162mg-0-10mg-0-400unit-12

0mcg-2mg-6mcg-18mg-400mcg-250mcg-300mcg-10

0mg-2mg-20mg-5mcg-109mg-25mcg-80mg-72mg-15

0mcg-2mg-1.7mg-2mg-0-10mcg-75mcg-20mcg-10mc

g-1.5mg-30unit-3500unit-15mg tablet,

60mg-0-30mcg-150mcg-162mg-10mg-72mg-400unit-

120mcg-2mg-6mcg-18mg-400mcg-150mcg-250mcg-

100mg-2mg-20mg-5mcg-108mg-80mg-2mg-1.7mg-2

mg-10mcg-75mcg-20mcg-10mcg-1.5mg-30unit-5000

unit-25mcg-15mg tablet)*

$0 (Tier 3)

C1

Theratrum Complete 50 Plus theratrum complete 50 plus (tablet)* $0 (Tier 3)C1

Therems

therems (tablet)* $0 (Tier 3)C1

Therems-H

therems-h (tablet)* $0 (Tier 3)C1

Therems-M

therems-m (tablet)* $0 (Tier 3)C1

Thiamine HCl

thiamine hcl (tablet)* $0 (Tier 3)C1

Total B/C

total b/c (tablet)* $0 (Tier 3)C1

Totalday Multiple

totalday multiple (tablet extended-release)* $0 (Tier 3)C1

Tri-Vi-Sol

tri-vi-sol (oral solution)* $0 (Tier 3)C1

Ultra Choice Multivitamin Kids ultra choice multivitamin kids (tablet chewable)* $0 (Tier 3)C1

Ultrachoice Advanced Formula ultrachoice advanced formula (tablet)* $0 (Tier 3)C1

Unicomplex-M

unicomplex-m (tablet)* $0 (Tier 3)



91


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Vita-Bee/C

vita-bee/c (tablet)* $0 (Tier 3)C1

Vitalee

vitalee (tablet)* $0 (Tier 3)C1

Vitalets

vitalets (tablet chewable)* $0 (Tier 3)C1

Vitalets Childrens vitalets childrens (tablet chewable)* $0 (Tier 3)C1

Vitamin A

vitamin a (10000unit capsule, 8000unit capsule,

8000unit capsule)*$0 (Tier 3)

C1

Vitamin B Complex vitamin b complex (10mg-10mg-0.2mg-2mg-1.5mg

tablet, 2mcg-15mg-5mg-2mg-2mg-2mg tablet)*$0 (Tier 3)

C1

Vitamin B Complex-C vitamin b complex-c (capsule)* $0 (Tier 3)C1

Vitamin B-1

vitamin b-1 (100mg tablet, 250mg tablet, 50mg


C1

Vitamin B1

vitamin b1 (tablet)* $0 (Tier 3)C1

Vitamin B-12

vitamin b-12 (1000mcg tablet, 100mcg tablet,

250mcg tablet, 500mcg tablet, 1000mcg tablet,

100mcg tablet, 500mcg tablet, 50mcg tablet,

2500mcg tablet sublingual)*

$0 (Tier 3)

C1

Vitamin B12


Vitamin B-12 CR

vitamin b-12 cr (tablet extended-release)* $0 (Tier 3)C1

Vitamin B-12 ER

vitamin b-12 er (tablet extended-release)* $0 (Tier 3)C1

Vitamin B12 TR

vitamin b12 tr (tablet extended-release)* $0 (Tier 3)C1

Vitamin B-12 TR

vitamin b-12 tr (tablet extended-release)* $0 (Tier 3)C1

Vitamin B-2

vitamin b-2 (100mg tablet, 25mg tablet, 100mg


C1

Vitamin B-6

vitamin b-6 (100mg tablet, 25mg tablet, 50mg tablet,

100mg tablet, 50mg tablet)*$0 (Tier 3)

C1

Vitamin B6


Vitamin B-Complex vitamin b-complex (tablet)* $0 (Tier 3)


92


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Vitamin C

vitamin c (powder, 0-500mg-0-0-0-tablet chewable,

250mg tablet chewable, 500mg tablet chewable,

1000mg tablet, 250mg tablet, 500mg tablet, 500mg

tablet chewable, 500mg-tablet chewable, 500mg

tablet extended-release, 500mg/5ml liquid)*

$0 (Tier 3)

C1

Vitamin C Drops vitamin c drops (lozenge)* $0 (Tier 3)C1

Vitamin C SR

vitamin c sr (capsule extended-release)* $0 (Tier 3)C1

Vitamin C TR

vitamin c tr (1500mg tablet extended-release, 500mg

capsule extended-release, 500mg tablet extended-

release)*

$0 (Tier 3)

C1

Vitamin C/Rose Hips vitamin c/rose hips (1000mg tablet, 1000mg-tablet,

500mg tablet, 500mg-tablet, 500mg-10mg tablet,

1000mg tablet, 500mg tablet)*

$0 (Tier 3)

C1

Vitamin C/Rose Hips TR vitamin c/rose hips tr (tablet extended-release)* $0 (Tier 3)C1

Vitamin D

vitamin d (capsule)* $0 (Tier 3)C1

Vitamin D3

vitamin d3 (liquid)* $0 (Tier 3)C1

Vitamin E

vitamin e (1000unit capsule, 100unit capsule, 200unit

capsule, 400unit capsule, 1000unit capsule, 200unit

capsule, 400unit capsule, 100unit/0.25ml oil)*

$0 (Tier 3)

C1

Vitamin E Blend vitamin e blend (capsule)* $0 (Tier 3)C1

Vitamin E Water Dispersible vitamin e water dispersible (capsule)* $0 (Tier 3)C1

Vitamin E Water Soluble vitamin e water soluble (1000unit capsule, 400unit

capsule, 400unit capsule)*$0 (Tier 3)

C1

Vitamin E/D-Alpha vitamin e/d-alpha (1000unit capsule, 200unit

capsule, 400unit capsule, 400unit capsule)*$0 (Tier 3)

C1

Vitamin E/D-Alpha Natural vitamin e/d-alpha natural (capsule)* $0 (Tier 3)C1

Vitamin E/Dl-Alpha vitamin e/dl-alpha (capsule)* $0 (Tier 3)C1

Vitamin E-400

vitamin e-400 (capsule)* $0 (Tier 3)C1

Vitamin K1

vitamin k1 (injection)* $0 (Tier 3)C1

Vitamins & Minerals vitamins & minerals (tablet)* $0 (Tier 3)C1

Vitamins for Hair

vitamins for hair (tablet)* $0 (Tier 3)



93


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Vitatrum

vitatrum

(60mg-0-45mcg-108mg-10mg-50mg-400unit-20mcg-

2mg-6mcg-18mg-400mcg-40mg-1mg-20mg-10unit-1

50mcg-2mg-1.7mg-20mg-1.5mg-60unit-3500unit-15m

g tablet chewable,

90mg-0-30mcg-200mg-10mg-109mg-72mg-400unit-3

5mcg-0.9mg-6mcg-18mg-500mcg-250mcg-300mcg-1

00mg-2.3mg-20mg-5mcg-25mcg-80mg-150mcg-2mg

-1.7mg-2mg-150mcg-10mcg-45mcg-55mcg-10mcg-1.

5mg-30unit-3500unit-11mg tablet)*

$0 (Tier 3)

C1

Vitrum 50+ Senior Multi vitrum 50+ senior multi (tablet)* $0 (Tier 3)C1

VP-PNV-DHA

vp-pnv-dha (capsule) $1.25-$3.40 (Tier 1)C1

Womens Daily Formula womens daily formula (tablet)* $0 (Tier 3)C1

Womens Daily Formula/Folic Acid/Calcium/Iron

womens daily formula/folic acid/calcium/iron


C1

Womens One Daily womens one daily (tablet)* $0 (Tier 3)C1

Yelets Teenage Formula yelets teenage formula (tablet)* $0 (Tier 3)C1

Zinc

zinc (100mg-50mg-500unit-15mg lozenge)* $0 (Tier 3)C1

Zoo Friends

zoo friends (tablet chewable)* $0 (Tier 3)A1

Gastrointestinal Agents

B1

Antispasmodics, GastrointestinalC1

Cuvposa

CUVPOSA (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Dicyclomine HCl dicyclomine hcl (10mg capsule, 20mg tablet) $1.25-$3.40 (Tier 1)C1

Dicyclomine HCl dicyclomine hcl (10mg/5ml oral solution) $1.25-$3.40 (Tier 1)C1

Methscopolamine Bromide methscopolamine bromide (tablet) $1.25-$3.40 (Tier 1)

B1

Gastrointestinal Agents, OtherC1

Acid Gone

acid gone (suspension)* $0 (Tier 3)C1

Actidose/Sorbitol actidose/sorbitol (liquid)* $0 (Tier 3)


94


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Almacone

almacone (200mg-200mg-25mg tablet chewable,

200mg/5ml-200mg/5ml-20mg/5ml suspension)*$0 (Tier 3)

C1

Almacone Double Strength almacone double strength (suspension)* $0 (Tier 3)C1

Aluminum Hydroxide aluminum hydroxide (suspension)* $0 (Tier 3)C1

Antacid Calcium Extra Strength antacid calcium extra strength (tablet chewable)* $0 (Tier 3)C1

Antacid Calcium Regular Strength antacid calcium regular strength (tablet chewable)* $0 (Tier 3)C1

Antacid Extra Strength antacid extra strength (tablet chewable)* $0 (Tier 3)C1

Antacid Maximum Strength antacid maximum strength (suspension)* $0 (Tier 3)C1

Antacid Plus Anti-Gas Relief antacid plus anti-gas relief (suspension)* $0 (Tier 3)C1

Anti-Diarrheal

anti-diarrheal (otc only) (tablet)* $0 (Tier 3)C1

Bismatrol

bismatrol (262mg tablet chewable, 262mg/15ml

suspension)*$0 (Tier 3)

C1

Bismatrol Maximum Strength bismatrol maximum strength (suspension)* $0 (Tier 3)C1

Calcium Antacid

calcium antacid (tablet chewable)* $0 (Tier 3)C1

Calcium Antacid Extra Strength calcium antacid extra strength (tablet chewable)* $0 (Tier 3)C1

Calcium Carbonate calcium carbonate (500mg tablet chewable)* $0 (Tier 3)C1

Cal-Gest Antacid

cal-gest antacid (tablet chewable)* $0 (Tier 3)C1

Chenodal

chenodal (tablet) $1.25-$3.40 (Tier 1)C1

Cromolyn Sodium cromolyn sodium (rx only) (100mg/5ml concentrate) $1.25-$3.40 (Tier 1)C1

Diphenoxylate/Atropine diphenoxylate/atropine (2.5mg-0.025mg tablet,

2.5mg-0.025mg/5ml liquid)$1.25-$3.40 (Tier 1)

C1

Gas Relief

gas relief (180mg capsule, 20mg/0.3ml suspension,

80mg tablet chewable)*$0 (Tier 3)

C1

Gas Relief Extra Strength gas relief extra strength (capsule)* $0 (Tier 3)C1

Gas Relief Maximum Strength gas relief maximum strength (tablet chewable)* $0 (Tier 3)C1

Gattex

GATTEX (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

GNP Antacid Anti-Gas gnp antacid anti-gas (suspension)* $0 (Tier 3)C1

GNP Masanti Maximum Strength gnp masanti maximum strength (suspension)* $0 (Tier 3)C1

GNP Masanti Regular Strength gnp masanti regular strength (suspension)* $0 (Tier 3)C1

HM Magnesium

hm magnesium (tablet)* $0 (Tier 3)C1

Infants Gas Relief infants gas relief (suspension)* $0 (Tier 3)C1

Infants Simethicone infants simethicone (suspension)* $0 (Tier 3)C1

Kao-Tin

kao-tin (suspension)* $0 (Tier 3)C1

Loperamide HCl loperamide hcl (otc only) (1mg/5ml liquid, 1mg/

7.5ml suspension)*$0 (Tier 3)

C1

Loperamide HCl loperamide hcl (rx only) (capsule) $1.25-$3.40 (Tier 1)C1

Magnesium

magnesium (500mg capsule)* $0 (Tier 3)



95


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Magnesium Oxide magnesium oxide (400mg tablet, 420mg tablet)* $0 (Tier 3)C1

Mi-Acid

mi-acid (suspension)* $0 (Tier 3)C1

Mi-Acid Gas Relief mi-acid gas relief (tablet chewable)* $0 (Tier 3)C1

Mi-Acid Maximum Strength mi-acid maximum strength (suspension)* $0 (Tier 3)C1

Mintox Maximum Strength mintox maximum strength (suspension)* $0 (Tier 3)C1

Myalept

MYALEPT (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Peptic Relief

peptic relief (tablet chewable)* $0 (Tier 3)C1

QC Anti-Diarrheal qc anti-diarrheal (otc only) (tablet)* $0 (Tier 3)C1

Relistor

RELISTOR (12MG/0.6ML INJECTION, 8MG/0.4ML INJECTION)

$3.80-$8.50 (Tier 2) PAC1

Relistor

RELISTOR (150MG TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Rulox

rulox (suspension)* $0 (Tier 3)C1

Serostim

SEROSTIM (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Simethicone

simethicone (capsule)* $0 (Tier 3)C1

SM Antacid Anti-Gas sm antacid anti-gas (suspension)* $0 (Tier 3)C1

SM Antacid/Anti-Gas sm antacid/anti-gas (suspension)* $0 (Tier 3)C1

SM Anti-Diarrheal sm anti-diarrheal (otc only) (tablet)* $0 (Tier 3)C1

Sodium Bicarbonate sodium bicarbonate (otc only) (tablet)* $0 (Tier 3)C1

Ursodiol

ursodiol (250mg tablet, 500mg tablet, 300mg

capsule)$1.25-$3.40 (Tier 1)

C1

Zorbtive

ZORBTIVE (INJECTION) $3.80-$8.50 (Tier 2) PA, LAB1

Histamine2 (H2) Receptor AntagonistsC1

Acid Reducer Maximum Strength acid reducer maximum strength (otc only) (tablet)* $0 (Tier 3)C1

Cimetidine

cimetidine (tablet) $1.25-$3.40 (Tier 1)C1

Cimetidine HCl

cimetidine hcl (rx only) (oral solution) $1.25-$3.40 (Tier 1)C1

Famotidine

famotidine (otc only) (tablet)* $0 (Tier 3)C1

Famotidine

famotidine (rx only) (20mg tablet, 40mg tablet) $1.25-$3.40 (Tier 1)C1

Ranitidine 150 Maximum Strength ranitidine 150 maximum strength (otc only) (tablet)* $0 (Tier 3)C1

Ranitidine 75

ranitidine 75 (tablet)* $0 (Tier 3)


96


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Ranitidine HCl

ranitidine hcl (150mg tablet, 300mg tablet) $1.25-$3.40 (Tier 1)C1

Ranitidine Maximum Strength ranitidine maximum strength (otc only) (tablet)* $0 (Tier 3)

B1

Irritable Bowel Syndrome AgentsC1

Alosetron HCl

alosetron hcl (tablet) $1.25-$3.40 (Tier 1) PAC1

Amitiza

AMITIZA (CAPSULE) $3.80-$8.50 (Tier 2) QLC1

Linzess

LINZESS (CAPSULE) $3.80-$8.50 (Tier 2) QLC1

Xifaxan

XIFAXAN (TABLET) $3.80-$8.50 (Tier 2) PAB1

LaxativesC1

Bisacodyl EC

bisacodyl ec (tablet delayed-release)* $0 (Tier 3)C1

Biscolax

biscolax (suppository)* $0 (Tier 3)C1

Clenpiq

CLENPIQ (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Constulose

constulose (oral solution) $1.25-$3.40 (Tier 1)C1

CVS Laxative Dietary Supplement cvs laxative dietary supplement (tablet)* $0 (Tier 3)C1

Doc-Q-Lace

doc-q-lace (capsule)* $0 (Tier 3)C1

Docusate Sodium & Senna Stimulant Laxative/Stool Softener

docusate sodium & senna stimulant laxative/stool

softener (tablet)*$0 (Tier 3)

C1

Docusol Kids

docusol kids (enema)* $0 (Tier 3)C1

Docusol Plus Mini-Enema docusol plus mini-enema* $0 (Tier 3)C1

DOK

dok (100mg capsule, 100mg tablet)* $0 (Tier 3)C1

DOK PLUS

dok plus (tablet)* $0 (Tier 3)C1

Enema Ready-To-Use enema ready-to-use* $0 (Tier 3)C1

Enemeez Mini

enemeez mini (enema)* $0 (Tier 3)C1

Enemeez Plus

enemeez plus (enema)* $0 (Tier 3)C1

Enulose

enulose (oral solution) $1.25-$3.40 (Tier 1)C1

Fiber Laxative

fiber laxative (capsule)* $0 (Tier 3)C1

Fiber Tabs

fiber tabs (tablet)* $0 (Tier 3)C1

Fiber-Lax

fiber-lax (tablet)* $0 (Tier 3)C1

Fleet Pediatric

fleet pediatric (enema)* $0 (Tier 3)C1

GaviLyte-C

gavilyte-c (oral solution) $1.25-$3.40 (Tier 1)C1

GaviLyte-G

gavilyte-g (oral solution) $1.25-$3.40 (Tier 1)C1

GaviLyte-N/Flavor Pack gavilyte-n/flavor pack (oral solution) $1.25-$3.40 (Tier 1)C1

Generlac

generlac (oral solution) $1.25-$3.40 (Tier 1)C1

Lactulose

lactulose (10gm/15ml oral solution) $1.25-$3.40 (Tier 1)C1

Laxative

laxative (suppository)* $0 (Tier 3)C1

Milk of Magnesia milk of magnesia (suspension)* $0 (Tier 3)



97


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Milk of Magnesia Concentrate milk of magnesia concentrate (suspension)* $0 (Tier 3)C1

Natural Fiber Therapy natural fiber therapy (powder)* $0 (Tier 3)C1

PEG 3350

peg 3350 (otc only) (packet)* $0 (Tier 3)C1

PEG 3350

peg 3350 (otc only) (powder)* $0 (Tier 3)C1

PEG 3350/Electrolytes peg 3350/electrolytes (oral solution) (generic colyte) $1.25-$3.40 (Tier 1)C1

PEG-3350/Electrolytes peg-3350/electrolytes (oral solution) (generic

golytely)$1.25-$3.40 (Tier 1)

C1

PEG-3350/NaCl/Na Bicarbonate/KCl peg-3350/nacl/na bicarbonate/kcl (oral solution)

(generic nulytely)$1.25-$3.40 (Tier 1)

C1

Phillips

phillips (tablet)* $0 (Tier 3)C1

Sani-Supp Adult sani-supp adult (suppository)* $0 (Tier 3)C1

Sani-Supp Pediatric sani-supp pediatric (suppository)* $0 (Tier 3)C1

Senexon

senexon (8.6mg tablet)* $0 (Tier 3)C1

Senexon-S

senexon-s (tablet)* $0 (Tier 3)C1

Senna

senna (8.6mg tablet, 8.8mg/5ml syrup)* $0 (Tier 3)C1

Senna Plus

senna plus (tablet)* $0 (Tier 3)C1

Senna-Lax

senna-lax (tablet)* $0 (Tier 3)C1

Stimulant Laxative stimulant laxative (tablet delayed-release)* $0 (Tier 3)C1

Stool Softener

stool softener (capsule)* $0 (Tier 3)C1

Suprep Bowel Prep Kit SUPREP BOWEL PREP KIT (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

TriLyte

trilyte (oral solution) $1.25-$3.40 (Tier 1)B1

ProtectantsC1

Carafate

CARAFATE (1GM/10ML SUSPENSION) $3.80-$8.50 (Tier 2)C1

Misoprostol

misoprostol (tablet) $1.25-$3.40 (Tier 1)C1

Sucralfate

sucralfate (tablet) $1.25-$3.40 (Tier 1)B1

Proton Pump InhibitorsC1

Esomeprazole Magnesium esomeprazole magnesium (otc only) (capsule

delayed-release)*$0 (Tier 3)


98


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Esomeprazole Magnesium esomeprazole magnesium (rx only) (capsule delayed-

release) (generic nexium)$1.25-$3.40 (Tier 1) QL

C1

GNP Omeprazole gnp omeprazole (otc only) (tablet delayed-release)* $0 (Tier 3)C1

Heartburn Treatment 24 Hour heartburn treatment 24 hour (otc only) (capsule

delayed-release)*$0 (Tier 3)

C1

Lansoprazole

lansoprazole (otc only) (capsule delayed-release)* $0 (Tier 3)C1

Lansoprazole

lansoprazole (rx only) (15mg capsule delayed-

release, 30mg capsule delayed-release)$1.25-$3.40 (Tier 1) QL

C1

Nexium

NEXIUM (10MG PACKET, 2.5MG PACKET, 20MG PACKET, 40MG PACKET, 5MG PACKET)

$3.80-$8.50 (Tier 2)C1

Nexium

NEXIUM (20MG CAPSULE DELAYED-RELEASE, 40MG CAPSULE DELAYED-RELEASE)

$3.80-$8.50 (Tier 2) QLC1

Omeprazole

omeprazole (otc only) (20mg tablet delayed-release)* $0 (Tier 3)C1

Omeprazole

omeprazole (rx only) (10mg capsule delayed-release) $1.25-$3.40 (Tier 1) QLC1

Omeprazole

omeprazole (rx only) (20mg capsule delayed-release,

40mg capsule delayed-release)$1.25-$3.40 (Tier 1)

C1

Omeprazole Magnesium omeprazole magnesium (capsule delayed-release)* $0 (Tier 3)C1

Pantoprazole Sodium pantoprazole sodium (20mg tablet delayed-release,

40mg tablet delayed-release)$1.25-$3.40 (Tier 1) QL

C1

Rabeprazole Sodium rabeprazole sodium (tablet delayed-release) $1.25-$3.40 (Tier 1)

A1

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

B1

Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentC1

Aralast NP

ARALAST NP (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Cholbam

CHOLBAM (CAPSULE) $3.80-$8.50 (Tier 2) PAC1

Creon

CREON (CAPSULE DELAYED-RELEASE) $3.80-$8.50 (Tier 2)C1

Cystadane

CYSTADANE (POWDER) $3.80-$8.50 (Tier 2)C1

Cystagon

CYSTAGON (CAPSULE) $3.80-$8.50 (Tier 2) LAC1

Glassia

GLASSIA (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Kuvan

KUVAN (100MG PACKET, 500MG PACKET, 100MG TABLET SOLUBLE)

$3.80-$8.50 (Tier 2) LAC1

Miglustat

miglustat (capsule) $1.25-$3.40 (Tier 1) PA, LAC1

Ocaliva

OCALIVA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Orfadin

ORFADIN (10MG CAPSULE, 20MG CAPSULE, 2MG CAPSULE, 5MG CAPSULE, 4MG/ML SUSPENSION)

$3.80-$8.50 (Tier 2) LAC1

Prolastin-C

PROLASTIN-C (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Ravicti

RAVICTI (LIQUID) $3.80-$8.50 (Tier 2) QL, LAC1

Sodium Phenylbutyrate sodium phenylbutyrate (powder, 500mg tablet) $1.25-$3.40 (Tier 1)



99


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Sucraid

SUCRAID (ORAL SOLUTION) $3.80-$8.50 (Tier 2) LAC1

Zemaira

ZEMAIRA (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Zenpep

ZENPEP (CAPSULE DELAYED-RELEASE) $3.80-$8.50 (Tier 2)A1

Genitourinary Agents

B1

Antispasmodics, UrinaryC1

Myrbetriq

MYRBETRIQ (TABLET EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2)C1

Oxybutynin Chloride oxybutynin chloride (5mg tablet immediate-release,

5mg/5ml syrup)$1.25-$3.40 (Tier 1)

C1

Oxybutynin Chloride ER oxybutynin chloride er (tablet extended-release 24

hour)$1.25-$3.40 (Tier 1) QL

C1

Solifenacin Succinate solifenacin succinate (tablet) $1.25-$3.40 (Tier 1) QLC1

Vesicare

VESICARE (TABLET) $3.80-$8.50 (Tier 2) QLB1

Benign Prostatic Hypertrophy AgentsC1

Alfuzosin HCl ER alfuzosin hcl er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1

Dutasteride

dutasteride (capsule) $1.25-$3.40 (Tier 1) QLC1

Finasteride

finasteride (5mg tablet) (generic proscar) $1.25-$3.40 (Tier 1)C1

Rapaflo

RAPAFLO (CAPSULE) $3.80-$8.50 (Tier 2) QLC1

Silodosin

silodosin (capsule) $1.25-$3.40 (Tier 1) QLC1

Tamsulosin HCl

tamsulosin hcl (capsule) $1.25-$3.40 (Tier 1)C1

Terazosin HCl

terazosin hcl (capsule) $1.25-$3.40 (Tier 1)B1

Genitourinary Agents, OtherC1

Bethanechol Chloride bethanechol chloride (tablet) $1.25-$3.40 (Tier 1)C1

Cuprimine

CUPRIMINE (CAPSULE) $3.80-$8.50 (Tier 2) PAC1

Depen Titratabs DEPEN TITRATABS (TABLET) $3.80-$8.50 (Tier 2)C1

Elmiron

ELMIRON (CAPSULE) $3.80-$8.50 (Tier 2)C1

Lithostat

LITHOSTAT (TABLET) $3.80-$8.50 (Tier 2)C1

Penicillamine

penicillamine (capsule) $1.25-$3.40 (Tier 1) PA


100


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useA1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

B1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)C1

Ala Cort

ala cort (rx only) (cream) $1.25-$3.40 (Tier 1)C1

Alclometasone Dipropionate alclometasone dipropionate (0.05% cream, 0.05%

ointment)$1.25-$3.40 (Tier 1)

C1

Augmented Betamethasone Dipropionate

augmented betamethasone dipropionate (0.05%

cream, 0.05% gel, 0.05% lotion, 0.05% ointment)$1.25-$3.40 (Tier 1)

C1

Betamethasone Dipropionate betamethasone dipropionate (0.05% cream, 0.05%

lotion, 0.05% ointment)$1.25-$3.40 (Tier 1)

C1

Betamethasone Valerate betamethasone valerate (0.1% cream, 0.1% lotion,

0.1% ointment)$1.25-$3.40 (Tier 1)

C1

Clobetasol Propionate clobetasol propionate (0.05% cream, 0.05% external

solution, 0.05% gel, 0.05% ointment, 0.05%

shampoo)

$1.25-$3.40 (Tier 1)

C1

Clobetasol Propionate Emollient clobetasol propionate emollient (0.05% cream) $1.25-$3.40 (Tier 1)C1

Cortisone Acetate cortisone acetate (tablet) $1.25-$3.40 (Tier 1)C1

Desonide

desonide (0.05% ointment) $1.25-$3.40 (Tier 1)C1

Desoximetasone desoximetasone (0.05% cream, 0.25% cream) $1.25-$3.40 (Tier 1)C1

Dexamethasone

dexamethasone (0.5mg tablet, 0.75mg tablet, 1.5mg

tablet, 1mg tablet, 2mg tablet, 4mg tablet, 6mg

tablet, 0.5mg/5ml elixir)

$1.25-$3.40 (Tier 1)

C1

Dexamethasone Intensol dexamethasone intensol (1mg/ml concentrate) $1.25-$3.40 (Tier 1)C1

Fludrocortisone Acetate fludrocortisone acetate (tablet) $1.25-$3.40 (Tier 1)C1

Fluocinolone Acetonide fluocinolone acetonide (0.01% cream, 0.01% external

solution, 0.025% cream, 0.025% ointment)$1.25-$3.40 (Tier 1)

C1

Fluocinonide

fluocinonide (0.05% external solution, 0.05% gel,

0.05% ointment)$1.25-$3.40 (Tier 1)

C1

Fluocinonide Emulsified Base fluocinonide emulsified base (cream) $1.25-$3.40 (Tier 1)C1

Fluticasone Propionate fluticasone propionate (rx only) (0.005% ointment,

0.05% cream)$1.25-$3.40 (Tier 1)

C1

Halobetasol Propionate halobetasol propionate (0.05% cream, 0.05%

ointment)$1.25-$3.40 (Tier 1)

C1

Hydrocortisone

hydrocortisone (otc only) (0.5% cream, 1% cream,

0.5% ointment, 1% ointment)*$0 (Tier 3)

C1

Hydrocortisone

hydrocortisone (rx only) (1% cream, 2.5% cream, 1%

ointment, 2.5% ointment, 10mg tablet, 20mg tablet,

5mg tablet, 2.5% lotion)

$1.25-$3.40 (Tier 1)

C1

Hydrocortisone Butyrate hydrocortisone butyrate (0.1% ointment) $1.25-$3.40 (Tier 1)



101


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Hydrocortisone Valerate hydrocortisone valerate (0.2% cream, 0.2% ointment) $1.25-$3.40 (Tier 1)C1

Methylprednisolone methylprednisolone (tablet) $1.25-$3.40 (Tier 1)C1

Methylprednisolone Dose Pack methylprednisolone dose pack (tablet therapy pack) $1.25-$3.40 (Tier 1)C1

Mometasone Furoate mometasone furoate (0.1% cream, 0.1% external

solution, 0.1% ointment)$1.25-$3.40 (Tier 1)

C1

Prednicarbate

prednicarbate (0.1% cream, 0.1% ointment) $1.25-$3.40 (Tier 1)C1

Prednisolone

prednisolone (15mg/5ml oral solution) $1.25-$3.40 (Tier 1)C1

Prednisolone Sodium Phosphate prednisolone sodium phosphate (25mg/5ml oral

solution, 5mg/5ml oral solution)$1.25-$3.40 (Tier 1)

C1

Prednisone

prednisone (10mg tablet therapy pack, 5mg tablet

therapy pack, 10mg tablet, 1mg tablet, 2.5mg tablet,

20mg tablet, 50mg tablet, 5mg tablet, 5mg/5ml oral

solution)

$1.25-$3.40 (Tier 1)

C1

Prednisone Intensol prednisone intensol (5mg/ml concentrate) $1.25-$3.40 (Tier 1)C1

Triamcinolone Acetonide triamcinolone acetonide (rx only) (0.025% cream,

0.1% cream, 0.5% cream, 0.025% lotion, 0.1% lotion,

0.025% ointment, 0.1% ointment, 0.5% ointment)

$1.25-$3.40 (Tier 1)

C1

Triderm

triderm (cream) $1.25-$3.40 (Tier 1)A1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

B1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)C1

Desmopressin Acetate desmopressin acetate (0.01% nasal spray solution,

0.1mg tablet, 0.2mg tablet)$1.25-$3.40 (Tier 1)

C1

Genotropin

GENOTROPIN (12MG INJECTION, 5MG INJECTION) $3.80-$8.50 (Tier 2) PAC1

Genotropin Miniquick GENOTROPIN MINIQUICK (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Humatrope

HUMATROPE (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Humatrope Combo Pack HUMATROPE COMBO PACK (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Increlex

INCRELEX (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Norditropin FlexPro NORDITROPIN FLEXPRO (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Nutropin AQ

NUTROPIN AQ (INJECTION) $3.80-$8.50 (Tier 2) PA


102


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Saizen

SAIZEN (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Saizenprep Reconstitution Kit SAIZENPREP RECONSTITUTION KIT (INJECTION) $3.80-$8.50 (Tier 2) PA, LA

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

B1

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)C1

Korlym

KORLYM (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAA1

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

B1

AndrogensC1

Anadrol-50

ANADROL-50 (TABLET) $3.80-$8.50 (Tier 2) PAC1

Androderm

ANDRODERM (PATCH 24 HOUR) $3.80-$8.50 (Tier 2) QLC1

Danazol

danazol (capsule) $1.25-$3.40 (Tier 1)C1

Oxandrolone

oxandrolone (tablet) $1.25-$3.40 (Tier 1) PA, QLC1

Testosterone

testosterone (20.25mg/1.25gm 1.62% gel, 40.5mg/

2.5gm 1.62% gel, 25mg/2.5gm 1% gel, 50mg/5gm

1% gel), testosterone pump (1.62% gel)

$1.25-$3.40 (Tier 1)

C1

Testosterone Cypionate testosterone cypionate (injection) $1.25-$3.40 (Tier 1)C1

Testosterone Enanthate testosterone enanthate (injection) $1.25-$3.40 (Tier 1)C1

Testosterone Pump testosterone pump (1% gel) $1.25-$3.40 (Tier 1)

B1

EstrogensC1

Altavera

altavera (tablet) $1.25-$3.40 (Tier 1)C1

Alyacen 1/35

alyacen 1/35 (tablet) $1.25-$3.40 (Tier 1)C1

Amethia

amethia (tablet) $1.25-$3.40 (Tier 1)C1

Amethia Lo

amethia lo (tablet) $1.25-$3.40 (Tier 1)C1

Apri

apri (tablet) $1.25-$3.40 (Tier 1)C1

Aranelle

aranelle (tablet) $1.25-$3.40 (Tier 1)C1

Ashlyna

ashlyna (tablet) $1.25-$3.40 (Tier 1)C1

Aubra

aubra (tablet) $1.25-$3.40 (Tier 1)C1

Aviane

aviane (tablet) $1.25-$3.40 (Tier 1)C1

Balziva

balziva (tablet) $1.25-$3.40 (Tier 1)C1

Blisovi 24 Fe

blisovi 24 fe (tablet) $1.25-$3.40 (Tier 1)C1

Blisovi Fe 1.5/30 blisovi fe 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1

Briellyn

briellyn (tablet) $1.25-$3.40 (Tier 1)C1

Camrese Lo

camrese lo (tablet) $1.25-$3.40 (Tier 1)C1

Caziant

caziant (tablet) $1.25-$3.40 (Tier 1)C1

Climara Pro

CLIMARA PRO (PATCH WEEKLY) $3.80-$8.50 (Tier 2)



103


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Cryselle-28

cryselle-28 (tablet) $1.25-$3.40 (Tier 1)C1

Cyclafem

cyclafem (tablet) $1.25-$3.40 (Tier 1)C1

Cyred Eq

cyred eq (tablet) $1.25-$3.40 (Tier 1)C1

Delyla

delyla (tablet) $1.25-$3.40 (Tier 1)C1

Desogestrel/Ethinyl Estradiol desogestrel/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1

Drospirenone/Ethinyl Estradiol drospirenone/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1

Duavee

DUAVEE (TABLET) $3.80-$8.50 (Tier 2)C1

Elestrin

ELESTRIN (GEL) $3.80-$8.50 (Tier 2)C1

Emoquette

emoquette (tablet) $1.25-$3.40 (Tier 1)C1

Enpresse-28

enpresse-28 (tablet) $1.25-$3.40 (Tier 1)C1

Enskyce

enskyce (tablet) $1.25-$3.40 (Tier 1)C1

Estarylla

estarylla (tablet) $1.25-$3.40 (Tier 1)C1

Estradiol

estradiol (0.025mg/24hr patch weekly, 0.05mg/24hr

patch weekly, 0.06mg/24hr patch weekly, 0.075mg/

24hr patch weekly, 0.1mg/24hr patch weekly,

37.5mcg/24hr patch weekly)

$1.25-$3.40 (Tier 1) QL

C1

Estradiol

estradiol (0.5mg tablet, 1mg tablet, 2mg tablet)

(generic estrace)$1.25-$3.40 (Tier 1)

C1

Estradiol Valerate estradiol valerate (injection) $1.25-$3.40 (Tier 1)C1

Estring

ESTRING (RING) $3.80-$8.50 (Tier 2)C1

Ethynodiol Diacetate/Ethinyl Estradiol

ethynodiol diacetate/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1

Falmina

falmina (tablet) $1.25-$3.40 (Tier 1)C1

Fayosim

fayosim (tablet) $1.25-$3.40 (Tier 1)C1

Femynor

femynor (tablet) $1.25-$3.40 (Tier 1)C1

Fyavolv

fyavolv (tablet) $1.25-$3.40 (Tier 1)C1

Gianvi

gianvi (tablet) $1.25-$3.40 (Tier 1)C1

Hailey 24 Fe

hailey 24 fe (tablet) $1.25-$3.40 (Tier 1)C1

Imvexxy Maintenance Pack IMVEXXY MAINTENANCE PACK (INSERT) $3.80-$8.50 (Tier 2) PA, QLC1

Imvexxy Starter Pack IMVEXXY STARTER PACK (INSERT) $3.80-$8.50 (Tier 2) PA, QL


104


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Introvale

introvale (tablet) $1.25-$3.40 (Tier 1)C1

Isibloom

isibloom (tablet) $1.25-$3.40 (Tier 1)C1

Jasmiel

jasmiel (tablet) $1.25-$3.40 (Tier 1)C1

Jinteli

jinteli (tablet) $1.25-$3.40 (Tier 1)C1

Juleber

juleber (tablet) $1.25-$3.40 (Tier 1)C1

Junel 1.5/30

junel 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1

Junel 1/20

junel 1/20 (tablet) $1.25-$3.40 (Tier 1)C1

Junel Fe 1.5/30 junel fe 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1

Junel Fe 1/20

junel fe 1/20 (tablet) $1.25-$3.40 (Tier 1)C1

Junel Fe 24

junel fe 24 (tablet) $1.25-$3.40 (Tier 1)C1

Kaitlib Fe

kaitlib fe (tablet chewable) $1.25-$3.40 (Tier 1)C1

Kariva

kariva (tablet) $1.25-$3.40 (Tier 1)C1

Kelnor 1/35

kelnor 1/35 (tablet) $1.25-$3.40 (Tier 1)C1

Kelnor 1/50

kelnor 1/50 (tablet) $1.25-$3.40 (Tier 1)C1

Kurvelo

kurvelo (tablet) $1.25-$3.40 (Tier 1)C1

LARIN 1.5/30

larin 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1

LARIN 1/20

larin 1/20 (tablet) $1.25-$3.40 (Tier 1)C1

LARIN Fe 1.5/30 larin fe 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1

LARIN Fe 1/20

larin fe 1/20 (tablet) $1.25-$3.40 (Tier 1)C1

Larissia

larissia (tablet) $1.25-$3.40 (Tier 1)C1

Layolis Fe

LAYOLIS FE (TABLET CHEWABLE) $3.80-$8.50 (Tier 2)C1

Leena

leena (tablet) $1.25-$3.40 (Tier 1)C1

Lessina

lessina (tablet) $1.25-$3.40 (Tier 1)C1

Levonest

levonest (tablet) $1.25-$3.40 (Tier 1)C1

Levonorgestrel and Ethinyl Estradiol

levonorgestrel and ethinyl estradiol (90mcg-20mcg

tablet)$1.25-$3.40 (Tier 1)

C1

Levonorgestrel/Ethinyl Estradiol levonorgestrel/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1

Levora 0.15/30-28 levora 0.15/30-28 (tablet) $1.25-$3.40 (Tier 1)C1

Loryna

loryna (tablet) $1.25-$3.40 (Tier 1)C1

Low-Ogestrel

low-ogestrel (tablet) $1.25-$3.40 (Tier 1)C1

Lutera

lutera (tablet) $1.25-$3.40 (Tier 1)C1

Marlissa

marlissa (tablet) $1.25-$3.40 (Tier 1)C1

Melodetta 24 Fe melodetta 24 fe (tablet chewable) $1.25-$3.40 (Tier 1)C1

Menest

menest (tablet) $1.25-$3.40 (Tier 1)C1

Mibelas 24 Fe

mibelas 24 fe (tablet chewable) $1.25-$3.40 (Tier 1)C1

Microgestin 1.5/30 microgestin 1.5/30 (tablet) $1.25-$3.40 (Tier 1)



105


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Microgestin 1/20

microgestin 1/20 (tablet) $1.25-$3.40 (Tier 1)C1

Microgestin Fe

microgestin fe (tablet) $1.25-$3.40 (Tier 1)C1

Microgestin Fe 1.5/30 microgestin fe 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1

Mili

mili (tablet) $1.25-$3.40 (Tier 1)C1

Necon 0.5/35-28 necon 0.5/35-28 (tablet) $1.25-$3.40 (Tier 1)C1

Nikki

nikki (tablet) $1.25-$3.40 (Tier 1)C1

Norethindrone Acetate/Ethinyl Estradiol

norethindrone acetate/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1

Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

norethindrone acetate/ethinyl estradiol/ferrous

fumarate (tablet)$1.25-$3.40 (Tier 1)

C1

Norethindrone/Ethinyl Estradiol/Ferrous Fumarate

norethindrone/ethinyl estradiol/ferrous fumarate

(tablet chewable)$1.25-$3.40 (Tier 1)

C1

Norgestimate/Ethinyl Estradiol norgestimate/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1

Nortrel 0.5/35

nortrel 0.5/35 (28) (tablet) $1.25-$3.40 (Tier 1)C1

Nortrel 1/35

nortrel 1/35 (tablet) $1.25-$3.40 (Tier 1)C1

Nortrel 7/7/7

nortrel 7/7/7 (tablet) $1.25-$3.40 (Tier 1)C1

NuvaRing

NUVARING (RING) $3.80-$8.50 (Tier 2)C1

Ocella

ocella (tablet) $1.25-$3.40 (Tier 1)C1

Ogestrel

ogestrel (tablet) $1.25-$3.40 (Tier 1)C1

Orsythia

orsythia (tablet) $1.25-$3.40 (Tier 1)C1

Pimtrea

pimtrea (tablet) $1.25-$3.40 (Tier 1)C1

Pirmella 1/35

pirmella 1/35 (tablet) $1.25-$3.40 (Tier 1)C1

Portia-28

portia-28 (tablet) $1.25-$3.40 (Tier 1)C1

Premarin

PREMARIN (0.3MG TABLET, 0.45MG TABLET, 0.625MG TABLET, 0.9MG TABLET, 1.25MG TABLET)

$3.80-$8.50 (Tier 2) QLC1

Premarin

PREMARIN (VAGINAL CREAM) $3.80-$8.50 (Tier 2)C1

Premphase

PREMPHASE (TABLET) $3.80-$8.50 (Tier 2) QLC1

Prempro

PREMPRO (TABLET) $3.80-$8.50 (Tier 2) QLC1

Previfem

previfem (tablet) $1.25-$3.40 (Tier 1)C1

Reclipsen

reclipsen (tablet) $1.25-$3.40 (Tier 1)


106


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Rivelsa

rivelsa (tablet) $1.25-$3.40 (Tier 1)C1

Setlakin

setlakin (tablet) $1.25-$3.40 (Tier 1)C1

Sprintec 28

sprintec 28 (tablet) $1.25-$3.40 (Tier 1)C1

Sronyx

sronyx (tablet) $1.25-$3.40 (Tier 1)C1

Syeda

syeda (tablet) $1.25-$3.40 (Tier 1)C1

Tarina 24 Fe

tarina 24 fe (tablet) $1.25-$3.40 (Tier 1)C1

Tarina Fe 1/20

tarina fe 1/20 (tablet) $1.25-$3.40 (Tier 1)C1

Tri-Estarylla

tri-estarylla (tablet) $1.25-$3.40 (Tier 1)C1

Tri-Legest Fe

tri-legest fe (tablet) $1.25-$3.40 (Tier 1)C1

Tri-Lo-Estarylla

tri-lo-estarylla (tablet) $1.25-$3.40 (Tier 1)C1

Tri-Lo-Sprintec

tri-lo-sprintec (tablet) $1.25-$3.40 (Tier 1)C1

Tri-Mili

tri-mili (tablet) $1.25-$3.40 (Tier 1)C1

Tri-Previfem

tri-previfem (tablet) $1.25-$3.40 (Tier 1)C1

Tri-Sprintec

tri-sprintec (tablet) $1.25-$3.40 (Tier 1)C1

Tri-VyLibra

tri-vylibra (tablet) $1.25-$3.40 (Tier 1)C1

Tri-VyLibra Lo

tri-vylibra lo (tablet) $1.25-$3.40 (Tier 1)C1

Trivora-28

trivora-28 (tablet) $1.25-$3.40 (Tier 1)C1

Velivet

velivet (tablet) $1.25-$3.40 (Tier 1)C1

Vienva

vienva (tablet) $1.25-$3.40 (Tier 1)C1

Vyfemla

vyfemla (tablet) $1.25-$3.40 (Tier 1)C1

VyLibra

vylibra (tablet) $1.25-$3.40 (Tier 1)C1

WYMZYA Fe

wymzya fe (tablet chewable) $1.25-$3.40 (Tier 1)C1

Zarah

zarah (tablet) $1.25-$3.40 (Tier 1)C1

Zovia 1/35E

zovia 1/35e (tablet) $1.25-$3.40 (Tier 1)B1

ProgestinsC1

Camila

camila (tablet) $1.25-$3.40 (Tier 1)C1

Crinone

CRINONE (GEL) $3.80-$8.50 (Tier 2) PAC1

Deblitane

deblitane (tablet) $1.25-$3.40 (Tier 1)C1

Depo-Provera DEPO-PROVERA (INJECTION) $3.80-$8.50 (Tier 2)C1

Econtra EZ

econtra ez (otc only) (tablet)* $0 (Tier 3)C1

Errin

errin (tablet) $1.25-$3.40 (Tier 1)C1

Incassia

incassia (tablet) $1.25-$3.40 (Tier 1)C1

Lyza

lyza (tablet) $1.25-$3.40 (Tier 1)C1

Medroxyprogesterone Acetate medroxyprogesterone acetate (10mg tablet, 2.5mg

tablet, 5mg tablet, 150mg/ml injection)$1.25-$3.40 (Tier 1)



107


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Megestrol Acetate megestrol acetate (20mg tablet, 40mg tablet, 40mg/

ml suspension, 625mg/5ml suspension)$1.25-$3.40 (Tier 1)

C1

My Way

my way (tablet)* $0 (Tier 3)C1

Nora-BE

nora-be (tablet) $1.25-$3.40 (Tier 1)C1

Norethindrone

norethindrone (0.35mg tablet) $1.25-$3.40 (Tier 1)C1

Norethindrone Acetate norethindrone acetate (5mg tablet) $1.25-$3.40 (Tier 1)C1

Norlyroc

norlyroc (tablet) $1.25-$3.40 (Tier 1)C1

Opcicon One-Step opcicon one-step (otc only) (tablet)* $0 (Tier 3)C1

Sharobel

sharobel (tablet) $1.25-$3.40 (Tier 1)B1

Selective Estrogen Receptor Modifying AgentsC1

Osphena

OSPHENA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Raloxifene HCl

raloxifene hcl (tablet) $1.25-$3.40 (Tier 1) QLA1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

B1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)C1

Levothyroxine Sodium levothyroxine sodium (tablet) $1.25-$3.40 (Tier 1)C1

Levoxyl

LEVOXYL (TABLET) $3.80-$8.50 (Tier 2)C1

Liothyronine Sodium liothyronine sodium (tablet) $1.25-$3.40 (Tier 1)C1

Synthroid

SYNTHROID (TABLET) $3.80-$8.50 (Tier 2)C1

Unithroid

UNITHROID (TABLET) $3.80-$8.50 (Tier 2)A1

Hormonal Agents, Suppressant (Adrenal)

B1

Hormonal Agents, Suppressant (Adrenal)C1

Lysodren

LYSODREN (TABLET) $3.80-$8.50 (Tier 2)A1

Hormonal Agents, Suppressant (Pituitary)

B1

Hormonal Agents, Suppressant (Pituitary)C1

Cabergoline

cabergoline (tablet) $1.25-$3.40 (Tier 1)


108


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Egrifta

EGRIFTA (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Firmagon

FIRMAGON (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Leuprolide Acetate leuprolide acetate (injection) $1.25-$3.40 (Tier 1) PAC1

Lupaneta Pack LUPANETA PACK (KIT) $3.80-$8.50 (Tier 2) PAC1

Lupron Depot LUPRON DEPOT (1-MONTH) (INJECTION) $3.80-$8.50 (Tier 2) PAC1




Octreotide Acetate octreotide acetate (injection) $1.25-$3.40 (Tier 1) PAC1

Signifor

SIGNIFOR (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Somatuline Depot SOMATULINE DEPOT (INJECTION) $3.80-$8.50 (Tier 2)C1

Somavert

SOMAVERT (INJECTION) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Synarel

SYNAREL (NASAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Trelstar Mixject TRELSTAR MIXJECT (INJECTION) $3.80-$8.50 (Tier 2) PA

A1

Hormonal Agents, Suppressant (Thyroid)

B1

Antithyroid AgentsC1

Methimazole

methimazole (tablet) $1.25-$3.40 (Tier 1)C1

Propylthiouracil

propylthiouracil (tablet) $1.25-$3.40 (Tier 1)A1

Immunological Agents

B1

Angioedema AgentsC1

Berinert

BERINERT (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Cinryze

CINRYZE (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Firazyr

FIRAZYR (INJECTION) $3.80-$8.50 (Tier 2) PA, QLC1

Haegarda

HAEGARDA (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Icatibant Acetate icatibant acetate (solution) $1.25-$3.40 (Tier 1) PA, QLC1

Ruconest

RUCONEST (INJECTION) $3.80-$8.50 (Tier 2) PA, LAB1

Immune SuppressantsC1

Azathioprine

azathioprine (tablet) $1.25-$3.40 (Tier 1) B/D, PAC1

Cimzia

CIMZIA (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Cyclosporine

cyclosporine (capsule) $1.25-$3.40 (Tier 1) B/D, PAC1

Cyclosporine Modified cyclosporine modified (100mg capsule, 25mg

capsule, 50mg capsule, 100mg/ml oral solution)$1.25-$3.40 (Tier 1) B/D, PA

C1

Enbrel

ENBREL (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Enbrel Mini

ENBREL MINI (INJECTION) $3.80-$8.50 (Tier 2) PA



109


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Enbrel SureClick ENBREL SURECLICK (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Envarsus XR

ENVARSUS XR (TABLET EXTENDED-RELEASE 24 HOUR)

$3.80-$8.50 (Tier 2) B/D, PAC1

Gengraf

gengraf (100mg capsule, 25mg capsule, 100mg/ml

oral solution)$1.25-$3.40 (Tier 1) B/D, PA

C1

Humira

HUMIRA (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Humira Pediatric Crohns Disease Starter Pack

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK (INJECTION)

$3.80-$8.50 (Tier 2) PAC1

Humira Pen

HUMIRA PEN (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Humira Pen Crohns Disease Starter Pack

HUMIRA PEN CROHNS DISEASE STARTER PACK (INJECTION)

$3.80-$8.50 (Tier 2) PAC1

Humira Pen-Psoriasis Starter HUMIRA PEN-PSORIASIS STARTER (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Kineret

KINERET (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Methotrexate

methotrexate (tablet) $1.25-$3.40 (Tier 1)C1

Methotrexate Sodium methotrexate sodium (injection) $1.25-$3.40 (Tier 1)C1

Mycophenolate Mofetil mycophenolate mofetil (200mg/ml suspension,

250mg capsule, 500mg tablet)$1.25-$3.40 (Tier 1) B/D, PA

C1

Mycophenolic Acid DR mycophenolic acid dr (tablet delayed-release) $1.25-$3.40 (Tier 1) B/D, PAC1

Orencia

ORENCIA (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Orencia Clickject ORENCIA CLICKJECT (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Prograf

PROGRAF (0.2MG PACKET, 1MG PACKET) $3.80-$8.50 (Tier 2) B/D, PAC1

Rapamune

RAPAMUNE (1MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Rasuvo

RASUVO (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Sandimmune SANDIMMUNE (100MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Simponi

SIMPONI (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Sirolimus

sirolimus (0.5mg tablet, 1mg tablet, 2mg tablet, 1mg/

ml solution)$1.25-$3.40 (Tier 1) B/D, PA

C1

Tacrolimus

tacrolimus (0.5mg capsule, 1mg capsule, 5mg

capsule)$1.25-$3.40 (Tier 1) B/D, PA

C1

Trexall

trexall (tablet) $1.25-$3.40 (Tier 1)


110


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Xatmep

XATMEP (ORAL SOLUTION) $3.80-$8.50 (Tier 2) PAC1

Xeljanz

XELJANZ (10MG TABLET, 5MG TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Xeljanz XR

XELJANZ XR (TABLET EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2) PA, QLC1

Zortress

ZORTRESS (0.25MG TABLET, 0.5MG TABLET, 0.75MG TABLET, 1MG TABLET)

$3.80-$8.50 (Tier 2) B/D, PA

B1

Immunizing Agents, PassiveC1

Flebogamma DIF FLEBOGAMMA DIF (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Gammagard Liquid GAMMAGARD LIQUID (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Gammagard S/D IGA Less Than 1 mcg/ml

GAMMAGARD S/D IGA LESS THAN 1 MCG/ML (INJECTION)

$3.80-$8.50 (Tier 2) PAC1

Gammaked GAMMAKED (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Gammaplex GAMMAPLEX (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Gamunex-C

GAMUNEX-C (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Octagam

OCTAGAM (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Panzyga

PANZYGA (SOLUTION) $3.80-$8.50 (Tier 2) PAC1

Privigen

PRIVIGEN (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Varizig

VARIZIG (INJECTION) $3.80-$8.50 (Tier 2)B1

ImmunomodulatorsC1

Actemra

ACTEMRA (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Actemra Actpen ACTEMRA ACTPEN (SOLUTION AUTO INJECTOR) $3.80-$8.50 (Tier 2) PAC1

Actimmune

ACTIMMUNE (INJECTION) $3.80-$8.50 (Tier 2) LAC1

Arcalyst

ARCALYST (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Benlysta

BENLYSTA (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Leflunomide

leflunomide (tablet) $1.25-$3.40 (Tier 1)C1

Otezla

OTEZLA (TABLET THERAPY PACK, 30MG TABLET) $3.80-$8.50 (Tier 2) PA, LAC1

Ridaura

RIDAURA (CAPSULE) $3.80-$8.50 (Tier 2)C1

Xolair

XOLAIR (150MG INJECTION, 150MG/ML SOLUTION PREFILLED SYRINGE, 75MG/0.5ML SOLUTION PREFILLED SYRINGE)

$3.80-$8.50 (Tier 2) PA, LA

B1

VaccinesC1

ActHIB

ACTHIB (INJECTION) $3.80-$8.50 (Tier 2)C1

Adacel

ADACEL (INJECTION) $3.80-$8.50 (Tier 2)C1

BCG Vaccine BCG VACCINE (INJECTION) $3.80-$8.50 (Tier 2)C1

Bexsero

BEXSERO (INJECTION) $3.80-$8.50 (Tier 2)C1

Boostrix

BOOSTRIX (INJECTION) $3.80-$8.50 (Tier 2)C1

Daptacel

DAPTACEL (INJECTION) $3.80-$8.50 (Tier 2)



111


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Diphtheria/Tetanus Toxoids Adsorbed Pediatric

DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC (INJECTION)

$3.80-$8.50 (Tier 2)C1

Engerix-B

ENGERIX-B (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Gardasil 9

GARDASIL 9 (INJECTION) $3.80-$8.50 (Tier 2)C1

Havrix

HAVRIX (INJECTION) $3.80-$8.50 (Tier 2)C1

Hiberix

HIBERIX (INJECTION) $3.80-$8.50 (Tier 2)C1

Imovax Rabies IMOVAX RABIES (H.D.C.V.) (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Infanrix

INFANRIX (INJECTION) $3.80-$8.50 (Tier 2)C1

IPOL Inactivated IPV IPOL INACTIVATED IPV (INJECTION) $3.80-$8.50 (Tier 2)C1

Ixiaro

IXIARO (INJECTION) $3.80-$8.50 (Tier 2)C1

Kinrix

KINRIX (INJECTION) $3.80-$8.50 (Tier 2)C1

M-M-R II

M-M-R II (INJECTION) $3.80-$8.50 (Tier 2)C1

Menactra

MENACTRA (INJECTION) $3.80-$8.50 (Tier 2)C1

Menveo

MENVEO (INJECTION) $3.80-$8.50 (Tier 2)C1

Pediarix

PEDIARIX (INJECTION) $3.80-$8.50 (Tier 2)C1

Pedvax HIB

PEDVAX HIB (INJECTION) $3.80-$8.50 (Tier 2)C1

ProQuad

PROQUAD (INJECTION) $3.80-$8.50 (Tier 2)C1

Quadracel

QUADRACEL (INJECTION) $3.80-$8.50 (Tier 2)C1

Rabavert

RABAVERT (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Recombivax HB RECOMBIVAX HB (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1

Rotarix

ROTARIX (SUSPENSION) $3.80-$8.50 (Tier 2)C1

RotaTeq

ROTATEQ (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1

Shingrix

SHINGRIX (INJECTION) $3.80-$8.50 (Tier 2) PAC1

Tenivac

TENIVAC (INJECTION) $3.80-$8.50 (Tier 2)C1

Tetanus/Diphtheria Toxoids-Adsorbed Adult

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT (INJECTION)

$3.80-$8.50 (Tier 2)C1

Trumenba

TRUMENBA (INJECTION) $3.80-$8.50 (Tier 2)C1

Twinrix

TWINRIX (INJECTION) $3.80-$8.50 (Tier 2)C1

Typhim Vi

TYPHIM VI (INJECTION) $3.80-$8.50 (Tier 2)


112


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Vaqta

VAQTA (INJECTION) $3.80-$8.50 (Tier 2)C1

Varivax

VARIVAX (INJECTION) $3.80-$8.50 (Tier 2)C1

YF-Vax

YF-VAX (INJECTION) $3.80-$8.50 (Tier 2)C1

Zostavax

ZOSTAVAX (INJECTION) $3.80-$8.50 (Tier 2) PAA1

Inflammatory Bowel Disease Agents

B1

AminosalicylatesC1

Apriso

APRISO (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2) QLC1

Balsalazide Disodium balsalazide disodium (capsule) $1.25-$3.40 (Tier 1)C1

Canasa

CANASA (SUPPOSITORY) $3.80-$8.50 (Tier 2)C1

Dipentum

DIPENTUM (CAPSULE) $3.80-$8.50 (Tier 2)C1

Lialda

LIALDA (TABLET DELAYED-RELEASE) $3.80-$8.50 (Tier 2) QLC1

Mesalamine

mesalamine (1000mg suppository) $1.25-$3.40 (Tier 1)C1

Mesalamine

mesalamine (4gm enema) $1.25-$3.40 (Tier 1) QLC1

Mesalamine DR mesalamine dr (1.2gm tablet delayed-release) $1.25-$3.40 (Tier 1) QL

B1

GlucocorticoidsC1

Budesonide

budesonide (3mg capsule delayed-release) $1.25-$3.40 (Tier 1)C1

Budesonide ER

budesonide er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1) STC1

Colocort

colocort (enema) $1.25-$3.40 (Tier 1)C1

Hydrocortisone

hydrocortisone (rx only) (100mg/60ml enema) $1.25-$3.40 (Tier 1)C1

Procto-Med HC

procto-med hc (cream) $1.25-$3.40 (Tier 1)C1

Procto-Pak

procto-pak (cream) $1.25-$3.40 (Tier 1)C1

Proctosol HC

proctosol hc (cream) $1.25-$3.40 (Tier 1)C1

Proctozone-HC

proctozone-hc (cream) $1.25-$3.40 (Tier 1)B1

SulfonamidesC1

Sulfasalazine

sulfasalazine (500mg tablet delayed-release, 500mg

tablet immediate-release)$1.25-$3.40 (Tier 1)

A1

Metabolic Bone Disease Agents

B1

Metabolic Bone Disease AgentsC1

Alendronate Sodium alendronate sodium (10mg tablet, 35mg tablet,

40mg tablet, 5mg tablet, 70mg tablet)$1.25-$3.40 (Tier 1) QL

C1

Alendronate Sodium alendronate sodium (70mg/75ml oral solution) $1.25-$3.40 (Tier 1)C1

Binosto

BINOSTO (TABLET EFFERVESCENT) $3.80-$8.50 (Tier 2) QLC1

Calcitonin-Salmon calcitonin-salmon (nasal solution) $1.25-$3.40 (Tier 1) QL



113


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Calcitriol

calcitriol (0.25mcg capsule, 0.5mcg capsule, 1mcg/

ml oral solution)$1.25-$3.40 (Tier 1) B/D, PA

C1

Cinacalcet HCl

cinacalcet hcl (tablet) $1.25-$3.40 (Tier 1) B/D, PA, QLC1

Doxercalciferol

doxercalciferol (capsule) $1.25-$3.40 (Tier 1) B/D, PA, QLC1

Etidronate Disodium etidronate disodium (tablet) $1.25-$3.40 (Tier 1)C1

Forteo

FORTEO (INJECTION) $3.80-$8.50 (Tier 2) PA, QLC1

Natpara

NATPARA (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1

Paricalcitol

paricalcitol (capsule) $1.25-$3.40 (Tier 1) B/D, PAC1

Prolia

PROLIA (INJECTION) $3.80-$8.50 (Tier 2) QLC1

Sensipar

SENSIPAR (TABLET) $3.80-$8.50 (Tier 2) B/D, PA, QLC1

Tymlos

TYMLOS (INJECTION) $3.80-$8.50 (Tier 2) PA, QLC1

Xgeva

XGEVA (INJECTION) $3.80-$8.50 (Tier 2) PAA1

Miscellaneous Therapeutic Agents

B1

Miscellaneous Therapeutic AgentsC1

1st Tier Unilet ComforTouch Lancets 28g

1st tier unilet comfortouch lancets 28g* $0 (Tier 3)C1

1st Tier Unilet ComforTouch Lancets 30g

1st tier unilet comfortouch lancets 30g* $0 (Tier 3)C1

Accu-Chek Aviva Plus accu-chek aviva plus (strip)* $0 (Tier 3)C1

Accu-Chek Compact Plus accu-chek compact plus (strip)* $0 (Tier 3)C1

Accu-Chek Fastclix Lancet Device Kit

accu-chek fastclix lancet device kit (kit)* $0 (Tier 3)C1

Accu-Chek Fastclix Lancets accu-chek fastclix lancets* $0 (Tier 3)C1

Accu-Chek Guide accu-chek guide (strip)* $0 (Tier 3)C1

Accu-Chek Multiclix Lancet Device Kit

accu-chek multiclix lancet device kit (kit)* $0 (Tier 3)C1

Accu-Chek Multiclix Lancets accu-chek multiclix lancets* $0 (Tier 3)C1

Accu-Chek Safe-T-Pro Lancets accu-chek safe-t-pro lancets* $0 (Tier 3)C1

Accu-Chek Safe-T-Pro Pluslancets

accu-chek safe-t-pro pluslancets* $0 (Tier 3)C1

Accu-Chek Smartview Strips accu-chek smartview strips (strip)* $0 (Tier 3)C1

Accu-Chek Soft Touch Lancets accu-chek soft touch lancets* $0 (Tier 3)C1

Accu-Chek Softclix Lancet Device Kit

accu-chek softclix lancet device kit (kit)* $0 (Tier 3)


114


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Accu-Chek Softclix Lancets accu-chek softclix lancets* $0 (Tier 3)C1

Accutrend Glucose accutrend glucose (strip)* $0 (Tier 3)C1

Acti-Lance Lancets 28g acti-lance lancets 28g* $0 (Tier 3)C1

Acti-Lance Lite Safety Lancets 28g acti-lance lite safety lancets 28g* $0 (Tier 3)C1

Acti-Lance Special Safety Lancets 17g

acti-lance special safety lancets 17g* $0 (Tier 3)C1

Acti-Lance Special Safetylancets 17g acti-lance special safetylancets 17g* $0 (Tier 3)C1

Acti-Lance Universal Safety Lancets 23g

acti-lance universal safety lancets 23g* $0 (Tier 3)C1

Active 1st Blood Lancets 30g/Easy Twist Cap

active 1st blood lancets 30g/easy twist cap* $0 (Tier 3)C1

Adjustable Lancing Device adjustable lancing device* $0 (Tier 3)C1

Advance Micro-Draw Test Strips

advance micro-draw test strips (strip)* $0 (Tier 3)C1

Advocate Lancets advocate lancets* $0 (Tier 3)C1

Advocate Lancets 30g advocate lancets 30g* $0 (Tier 3)C1

Advocate Lancing Device advocate lancing device* $0 (Tier 3)C1

Advocate Rapid-Safe Lancing Device

advocate rapid-safe lancing device* $0 (Tier 3)C1

Advocate Redi-Code advocate redi-code (strip)* $0 (Tier 3)C1

Advocate Redi-Code+ Test Strips

advocate redi-code+ test strips (strip)* $0 (Tier 3)C1

Advocate Safety Lancets advocate safety lancets* $0 (Tier 3)C1

Advocate Safety Lancets 26g advocate safety lancets 26g* $0 (Tier 3)C1

Advocate Test Strips advocate test strips (strip)* $0 (Tier 3)C1

Agamatrix Amp No Code Test Strips

agamatrix amp no code test strips (strip)* $0 (Tier 3)C1

Agamatrix Jazz Test Strips agamatrix jazz test strips (strip)* $0 (Tier 3)C1

Agamatrix Presto Test Strips agamatrix presto test strips (strip)* $0 (Tier 3)C1

Agamatrix Ultra-Thin Lancets 33g agamatrix ultra-thin lancets 33g* $0 (Tier 3)C1

Alba-Lybe NR alba-lybe nr (liquid)* $0 (Tier 3)C1

Alcohol Prep Pads alcohol prep pads (otc only) $1.25-$3.40 (Tier 1)C1

Alternate Site Lancing Device alternate site lancing device* $0 (Tier 3)C1

Aqua Lance Adjustable Lancing Device

aqua lance adjustable lancing device (device)* $0 (Tier 3)C1

Assure 4 Test Strips assure 4 test strips (strip)* $0 (Tier 3)C1

Assure Comfort Lancets Ultra Thin 28g

assure comfort lancets ultra thin 28g* $0 (Tier 3)C1

Assure Comfort Lancets Ultra Thin 30g

assure comfort lancets ultra thin 30g* $0 (Tier 3)C1

Assure Haemolance Plus High Flow 18g

assure haemolance plus high flow 18g* $0 (Tier 3)C1

Assure Haemolance Plus Low Flow 25g

assure haemolance plus low flow 25g* $0 (Tier 3)C1

Assure Haemolance Plus Micro Flow 28g

assure haemolance plus micro flow 28g* $0 (Tier 3)C1

Assure Haemolance Plus Normal Flow 21g

assure haemolance plus normal flow 21g* $0 (Tier 3)C1

Assure Haemolance Plus Pediatric Blade

assure haemolance plus pediatric blade* $0 (Tier 3)C1

Assure Lance Lancets assure lance lancets* $0 (Tier 3)



115


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Assure Lance Lancets 21g assure lance lancets 21g* $0 (Tier 3)C1

Assure Lance Plus Safety Lancets 25g

assure lance plus safety lancets 25g* $0 (Tier 3)C1

Assure Lance Plus Safety Lancets 30g

assure lance plus safety lancets 30g* $0 (Tier 3)C1

Assure Platinum Test Strips assure platinum test strips (strip)* $0 (Tier 3)C1

Assure Prism Multi Test Strips assure prism multi test strips (strip)* $0 (Tier 3)C1

Auto-Lancet Mini auto-lancet mini* $0 (Tier 3)C1

Autolet Impression Lancing Device

autolet impression lancing device* $0 (Tier 3)C1

Autolet Lancing Device autolet lancing device* $0 (Tier 3)C1

Autolet Plus

autolet plus* $0 (Tier 3)C1

Bayer Breeze 2 Test Disc bayer breeze 2 test disc (disk)* $0 (Tier 3)C1

Bayer Contour Blood Glucose Test Strips

bayer contour blood glucose test strips (strip)* $0 (Tier 3)C1

Bayer Microlet 2 Lancing Device

bayer microlet 2 lancing device* $0 (Tier 3)C1

Bayer Microlet Lancets bayer microlet lancets* $0 (Tier 3)C1

BD Lancet Ultrafine 30g bd lancet ultrafine 30g* $0 (Tier 3)C1

BD Lancet Ultrafine 33g bd lancet ultrafine 33g* $0 (Tier 3)C1

BD Microtainer Lancets bd microtainer lancets* $0 (Tier 3)C1

Blood Glucose Test Strips blood glucose test strips (strip)* $0 (Tier 3)C1

Blood Glucose Test Strips Premium

blood glucose test strips premium* $0 (Tier 3)C1

Bullseye Mini Safety Lancets bullseye mini safety lancets* $0 (Tier 3)C1

Careone Advanced Lancing Device

careone advanced lancing device* $0 (Tier 3)C1

Careone Blood Glucose Test Strips/Premium

careone blood glucose test strips/premium (strip)* $0 (Tier 3)C1

Careone Blood Glucose Test Strips/Value

careone blood glucose test strips/value (strip)* $0 (Tier 3)C1

Careone Lancet Ultra Thin careone lancet ultra thin* $0 (Tier 3)C1

Caresens N Blood Glucose Test Strips

caresens n blood glucose test strips (strip)* $0 (Tier 3)C1

Caretouch Blood Glucose Test Strips

caretouch blood glucose test strips (strip)* $0 (Tier 3)C1

Caretouch Lancing Device with Ejector

caretouch lancing device with ejector* $0 (Tier 3)C1

Caretouch Twist Lancets 28g caretouch twist lancets 28g* $0 (Tier 3)C1

Caretouch Twist Lancets 30g caretouch twist lancets 30g* $0 (Tier 3)C1

Caretouch Twist Lancets 33g caretouch twist lancets 33g* $0 (Tier 3)


116


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Clever Chek Auto-Code Test Strips

clever chek auto-code test strips (strip)* $0 (Tier 3)C1

Clever Chek Auto-Code Voice Test Strips

clever chek auto-code voice test strips (strip)* $0 (Tier 3)C1

Clever Chek Lancets Ultrathin clever chek lancets ultrathin* $0 (Tier 3)C1

Clever Chek Lancets Ultrathin 30g

clever chek lancets ultrathin 30g* $0 (Tier 3)C1

Clever Chek Test Strips clever chek test strips (strip)* $0 (Tier 3)C1

Clever Choice Auto-Code Pro Test Strips

clever choice auto-code pro test strips (strip)* $0 (Tier 3)C1

Clever Choice Comfort EZ Lancets 23g

clever choice comfort ez lancets 23g* $0 (Tier 3)C1

Clever Choice Comfort EZ Lancets 28g

clever choice comfort ez lancets 28g* $0 (Tier 3)C1

Clever Choice Micro Test Strips clever choice micro test strips (strip)* $0 (Tier 3)C1

Clever Choice No Coding Test Strips

clever choice no coding test strips (strip)* $0 (Tier 3)C1

Clever Choice Talk No Coding Test Strips

clever choice talk no coding test strips (strip)* $0 (Tier 3)C1

Coaguchek Lancets coaguchek lancets* $0 (Tier 3)C1

Comfort Assured Lancets Micro Thin 33g

comfort assured lancets micro thin 33g* $0 (Tier 3)C1

Comfort Assured Lancets Super Thin 28g

comfort assured lancets super thin 28g* $0 (Tier 3)C1

Comfort Lancets comfort lancets* $0 (Tier 3)C1

Contour Next Blood Glucose Test contour next blood glucose test (strip)* $0 (Tier 3)C1

Cool Blood Glucose Test Strips cool blood glucose test strips (strip)* $0 (Tier 3)C1

CVS Advanced Glucose Meter Test Strips

cvs advanced glucose meter test strips (strip)* $0 (Tier 3)C1

CVS Lancets Micro Thin 33g cvs lancets micro thin 33g* $0 (Tier 3)C1

CVS Lancets Micro-Thin 33g cvs lancets micro-thin 33g* $0 (Tier 3)C1

CVS Lancets Thin 26g cvs lancets thin 26g* $0 (Tier 3)C1

CVS Lancets Ultra Thin 30g cvs lancets ultra thin 30g* $0 (Tier 3)C1

CVS Lancets Ultra-Thin 30g cvs lancets ultra-thin 30g* $0 (Tier 3)C1

CVS Lancing Device cvs lancing device* $0 (Tier 3)C1

CVS Ultra Thin Lancets cvs ultra thin lancets* $0 (Tier 3)C1

Diatrue Plus Blood Glucose Test Strips

diatrue plus blood glucose test strips (strip)* $0 (Tier 3)C1

Droplet Lancets Ultra Thin 30g droplet lancets ultra thin 30g* $0 (Tier 3)C1

Droplet Lancing Device droplet lancing device* $0 (Tier 3)C1

Drug Mart Adjustable Lancing Device

drug mart adjustable lancing device* $0 (Tier 3)C1

Drug Mart On-The-Go Lancets Gentle 30g

drug mart on-the-go lancets gentle 30g* $0 (Tier 3)C1

Drug Mart Unilet Lancets Super Thin 30g

drug mart unilet lancets super thin 30g* $0 (Tier 3)C1

Drug Mart Unilet Lancets Ultra Thin 28g

drug mart unilet lancets ultra thin 28g* $0 (Tier 3)C1

Drug Mart Unilet Micro Thin Lancets 33g

drug mart unilet micro thin lancets 33g* $0 (Tier 3)C1

Easy Comfort Lancets easy comfort lancets* $0 (Tier 3)C1

Easy Comfort Lancets 30g/Pull Top

easy comfort lancets 30g/pull top* $0 (Tier 3)C1

Easy Comfort Lancets 30g/Thin Top

easy comfort lancets 30g/thin top* $0 (Tier 3)



117


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Easy Mini Eject Lancing Device

easy mini eject lancing device* $0 (Tier 3)C1

Easy Mini Lancing Device easy mini lancing device* $0 (Tier 3)C1

Easy Plus II Blood Glucose Test easy plus ii blood glucose test (strip)* $0 (Tier 3)C1

Easy Step Test Strips easy step test strips (strip)* $0 (Tier 3)C1

Easy Talk Blood Glucose Test Strips

easy talk blood glucose test strips (strip)* $0 (Tier 3)C1

Easy Touch Glucose Test Strips easy touch glucose test strips (strip)* $0 (Tier 3)C1

Easy Touch HealthPro Glucose Test Strips

easy touch healthpro glucose test strips (strip)* $0 (Tier 3)C1

Easy Touch Lancets 21g/Pressure Activated

easy touch lancets 21g/pressure activated* $0 (Tier 3)C1





Easy Touch Lancets 26g/Pull-Top

easy touch lancets 26g/pull-top* $0 (Tier 3)C1

Easy Touch Lancets 26g/Twist

easy touch lancets 26g/twist* $0 (Tier 3)C1







Easy Touch Lancets 30g/Button-Activated

easy touch lancets 30g/button-activated* $0 (Tier 3)C1















Easy Touch Lancing Device/Ejector

easy touch lancing device/ejector* $0 (Tier 3)C1

Easy Touch Safety Lancets21g/Pressure Activated

easy touch safety lancets21g/pressure activated* $0 (Tier 3)C1



Easy Touch Safety Lancets26g/Button Activated

easy touch safety lancets26g/button activated* $0 (Tier 3)C1



Easy Touch Safety Lancets28g/Button Activated

easy touch safety lancets28g/button activated* $0 (Tier 3)


118


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1



Easy Trak Blood Glucose Test Strips

easy trak blood glucose test strips (strip)* $0 (Tier 3)C1

Easy Twist & Cap Lancets easy twist & cap lancets* $0 (Tier 3)C1

EasyGluco

easygluco (strip)* $0 (Tier 3)C1

EasyGluco Plus

easygluco plus (strip)* $0 (Tier 3)C1

EASYMax 15 Test Strips easymax 15 test strips (strip)* $0 (Tier 3)C1

EASYMax Test Strips easymax test strips (strip)* $0 (Tier 3)C1

Element Compact Test Strips element compact test strips (strip)* $0 (Tier 3)C1

Element Test Strips element test strips (strip)* $0 (Tier 3)C1

Embrace Blood Glucose Test Strips

embrace blood glucose test strips (strip)* $0 (Tier 3)C1

Embrace Evo Blood Glucose Test Strips

embrace evo blood glucose test strips (strip)* $0 (Tier 3)C1

Embrace Lancets Ultra Thin 30g embrace lancets ultra thin 30g* $0 (Tier 3)C1

Embrace Pro Blood Glucose Test Strips

embrace pro blood glucose test strips (strip)* $0 (Tier 3)C1

EQ Blood Glucose Test Strips eq blood glucose test strips (strip)* $0 (Tier 3)C1

EQL Color Lancets Micro Thin 33g

eql color lancets micro thin 33g* $0 (Tier 3)C1

EvenCare G2 Test Strips evencare g2 test strips (strip)* $0 (Tier 3)C1

EvenCare G3 Test Strips evencare g3 test strips (strip)* $0 (Tier 3)C1

Evencare Mini Blood Glucose Test Strips

evencare mini blood glucose test strips (strip)* $0 (Tier 3)C1

Evolution Autocode evolution autocode (strip)* $0 (Tier 3)C1

E-Z Ject Lancets

e-z ject lancets* $0 (Tier 3)C1

E-Z Ject Lancets 21g e-z ject lancets 21g* $0 (Tier 3)C1

E-Z Ject Lancets Color e-z ject lancets color* $0 (Tier 3)C1

E-Z Ject Lancets Super Thin 30g e-z ject lancets super thin 30g* $0 (Tier 3)C1

E-Z Ject Lancets Thin 26g e-z ject lancets thin 26g* $0 (Tier 3)C1

EZ Smart Blood Glucose Lancets ez smart blood glucose lancets* $0 (Tier 3)C1

EZ Smart Blood Glucose Test Strips

ez smart blood glucose test strips (strip)* $0 (Tier 3)C1

EZ Smart Plus Blood Glucose Test Strips

ez smart plus blood glucose test strips (strip)* $0 (Tier 3)C1

E-Zject Lancets Micro-Thin 33g

e-zject lancets micro-thin 33g* $0 (Tier 3)C1

Fifty50 Glucose Test Strip 2.0 fifty50 glucose test strip 2.0 (strip)* $0 (Tier 3)C1

Fifty50 Lancing Device fifty50 lancing device* $0 (Tier 3)C1

Fifty50 Safety Seal Lancets 30g fifty50 safety seal lancets 30g* $0 (Tier 3)C1

Fifty50 Safety Seal Lancets 32g fifty50 safety seal lancets 32g* $0 (Tier 3)C1

Fifty50 Unilet Lancets 33g fifty50 unilet lancets 33g* $0 (Tier 3)C1

Fine 30

fine 30* $0 (Tier 3)C1

Fingerstix Lancets fingerstix lancets* $0 (Tier 3)C1

Fora Blood Glucose Test Strips fora blood glucose test strips (strip)* $0 (Tier 3)



119


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Fora D15g Blood Glucose Test Strips

fora d15g blood glucose test strips (strip)* $0 (Tier 3)C1

Fora D20 Blood Glucose Test Strips fora d20 blood glucose test strips (strip)* $0 (Tier 3)C1

Fora D40/G31 Blood Glucose Test Strips

fora d40/g31 blood glucose test strips (strip)* $0 (Tier 3)C1

Fora G20 Blood Glucose Test Strips fora g20 blood glucose test strips (strip)* $0 (Tier 3)C1

Fora G30/Premium V10 Blood Glucose Test Strips

fora g30/premium v10 blood glucose test strips

(strip)*$0 (Tier 3)

C1

Fora GD20 Test Strips fora gd20 test strips (strip)* $0 (Tier 3)C1

Fora GD50 Blood Glucose Test Strips

fora gd50 blood glucose test strips (strip)* $0 (Tier 3)C1

Fora Lancets

fora lancets* $0 (Tier 3)C1

Fora Lancing Device fora lancing device* $0 (Tier 3)C1

Fora Lancing Device/Clearcap fora lancing device/clearcap* $0 (Tier 3)C1

Fora Tn'g/Tn'g Voice Blood Glucose Test Strips

fora tn'g/tn'g voice blood glucose test strips (strip)* $0 (Tier 3)C1

Fora V10 Blood Glucose Test Strips fora v10 blood glucose test strips (strip)* $0 (Tier 3)C1



Fora V30a Blood Glucose Test Strips

fora v30a blood glucose test strips (strip)* $0 (Tier 3)C1

ForaCare GD40 foracare gd40 (strip)* $0 (Tier 3)C1

ForaCare Premium V10 Teststrips

foracare premium v10 teststrips (strip)* $0 (Tier 3)C1

ForaCare Test N Go Test Strips foracare test n go test strips (strip)* $0 (Tier 3)C1

Fortiscare Blood Glucose Test Strip fortiscare blood glucose test strip (strip)* $0 (Tier 3)C1

Freds Pharmacy Autolet Lancing Device

freds pharmacy autolet lancing device* $0 (Tier 3)C1

Freds Pharmacy Unilet Lancets Super Thin 30g

freds pharmacy unilet lancets super thin 30g* $0 (Tier 3)C1

Freds Pharmacy Unilet Lancets Ultra Thin 28g

freds pharmacy unilet lancets ultra thin 28g* $0 (Tier 3)C1

FreeStyle Insulinx Blood Glucose Test

freestyle insulinx blood glucose test (strip)* $0 (Tier 3)C1

FreeStyle Insulinx Blood Glucose Test Strips

freestyle insulinx blood glucose test strips (strip)* $0 (Tier 3)C1

FreeStyle Lancets freestyle lancets* $0 (Tier 3)C1

FreeStyle Lite Test Strips freestyle lite test strips (strip)* $0 (Tier 3)C1

FreeStyle Precision Neo Blood Glucose Test Strips

freestyle precision neo blood glucose test strips

(strip)*$0 (Tier 3)


120


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

FreeStyle Test Strips freestyle test strips (strip)* $0 (Tier 3)C1

FreeStyle Unistick II Lancets freestyle unistick ii lancets* $0 (Tier 3)C1

Gauze

gauze (non-medicated 2x2) $1.25-$3.40 (Tier 1)C1

GE100 Blood Glucose Test Strips ge100 blood glucose test strips (strip)* $0 (Tier 3)C1

Genstrip 50

genstrip 50 (strip)* $0 (Tier 3)C1

GHT Test Strips

ght test strips (strip)* $0 (Tier 3)C1

Global Inject Ease Lancets 28g global inject ease lancets 28g* $0 (Tier 3)C1

Global Inject Ease Lancets 30g global inject ease lancets 30g* $0 (Tier 3)C1

Global Lancing Device global lancing device* $0 (Tier 3)C1

Glucocard 01 Sensor Plus glucocard 01 sensor plus (strip)* $0 (Tier 3)C1

Glucocard 01 Sensor Plus Test Strips glucocard 01 sensor plus test strips (strip)* $0 (Tier 3)C1

Glucocard Expression Blood Glucose Test Strips

glucocard expression blood glucose test strips

(strip)*$0 (Tier 3)

C1

Glucocard Shine Test Strips glucocard shine test strips (strip)* $0 (Tier 3)C1

Glucocard Vital Test Strips glucocard vital test strips (strip)* $0 (Tier 3)C1

GlucoCom Lancets 28g glucocom lancets 28g* $0 (Tier 3)C1



GlucoCom Test Strips glucocom test strips (strip)* $0 (Tier 3)C1

GlucoNavii Blood Glucose Test Strips

gluconavii blood glucose test strips (strip)* $0 (Tier 3)C1

Glucose Meter Test Strips Advanced

glucose meter test strips advanced (strip)* $0 (Tier 3)C1

GNP Easy Touch Glucose Test Strips

gnp easy touch glucose test strips (strip)* $0 (Tier 3)C1

GNP Lancets

gnp lancets* $0 (Tier 3)C1

GNP Lancets 21g gnp lancets 21g* $0 (Tier 3)C1

GNP Lancets Micro Thin 33g gnp lancets micro thin 33g* $0 (Tier 3)C1

GNP Lancets Super Thin 30g gnp lancets super thin 30g* $0 (Tier 3)C1

GNP Lancets Thin gnp lancets thin* $0 (Tier 3)C1

GNP Lancets Thin 26g gnp lancets thin 26g* $0 (Tier 3)C1

GNP Micro Thin Lancets 33g gnp micro thin lancets 33g* $0 (Tier 3)C1

GNP Super Thin Lancets/30g gnp super thin lancets/30g* $0 (Tier 3)C1

Goodsense Lancets Micro-Thin 33g

goodsense lancets micro-thin 33g* $0 (Tier 3)C1

Goodsense Lancets Micro-Thin 33g Universal

goodsense lancets micro-thin 33g universal* $0 (Tier 3)C1

Goodsense Lancets Ultra-Thin 26g Universal

goodsense lancets ultra-thin 26g universal* $0 (Tier 3)C1

Goodsense Lancets Ultra-Thin 30g

goodsense lancets ultra-thin 30g* $0 (Tier 3)C1

Goodsense Lancing Device goodsense lancing device* $0 (Tier 3)



121


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Goodsense Premium Blood Glucose Test Strips

goodsense premium blood glucose test strips

(strip)*$0 (Tier 3)

C1

Health Care Lancing Device health care lancing device* $0 (Tier 3)C1

Healthy Accents Autolet Impression Lancing Device

healthy accents autolet impression lancing device* $0 (Tier 3)C1

Healthy Accents Unilet Lancets Super Thin 30g

healthy accents unilet lancets super thin 30g* $0 (Tier 3)C1

H-E-B Incontrol Advanced Lancing Device

h-e-b incontrol advanced lancing device* $0 (Tier 3)C1

H-E-B Incontrol Lancets Micro Thin 33g

h-e-b incontrol lancets micro thin 33g* $0 (Tier 3)C1

H-E-B Incontrol Lancets Super Thin 30g

h-e-b incontrol lancets super thin 30g* $0 (Tier 3)C1

H-E-B Incontrol Lancets Ultra Thin 28g

h-e-b incontrol lancets ultra thin 28g* $0 (Tier 3)C1

Hypolance AST Lancing Kit hypolance ast lancing kit (kit)* $0 (Tier 3)C1

Iglucose Blood Glucose Test Strips

iglucose blood glucose test strips (strip)* $0 (Tier 3)C1

Infinity Blood Glucose Test Strips infinity blood glucose test strips (strip)* $0 (Tier 3)C1

Infinity Voice

infinity voice (strip)* $0 (Tier 3)C1

Insulin Syringes, Needles insulin syringes, needles $1.25-$3.40 (Tier 1)C1

Iosat

iosat (tablet)* $0 (Tier 3)C1

Kroger Blood Glucose Teststrips kroger blood glucose teststrips (strip)* $0 (Tier 3)C1

Kroger Lancets 21g kroger lancets 21g* $0 (Tier 3)C1

Kroger Lancets Micro Thin33g kroger lancets micro thin33g* $0 (Tier 3)C1

Kroger Lancets Thin 26g kroger lancets thin 26g* $0 (Tier 3)C1

Kroger Lancets Ultrathin 30g kroger lancets ultrathin 30g* $0 (Tier 3)C1

Kroger Lancing Device kroger lancing device* $0 (Tier 3)C1

Kroger Premium Blood Glucose Test Strips

kroger premium blood glucose test strips (strip)* $0 (Tier 3)C1

Kroger Test Strips kroger test strips (strip)* $0 (Tier 3)C1

Lancet Device with Ejector lancet device with ejector* $0 (Tier 3)C1

Lancets

lancets* $0 (Tier 3)C1

Lancets 28g

lancets 28g* $0 (Tier 3)C1

Lancets 30g

lancets 30g* $0 (Tier 3)C1

Lancets 30g Twist Top lancets 30g twist top* $0 (Tier 3)C1

Lancets 30g/Twist Top lancets 30g/twist top* $0 (Tier 3)


122


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Lancets 33g Universal Design lancets 33g universal design* $0 (Tier 3)C1

Lancets Micro Thin 33g lancets micro thin 33g* $0 (Tier 3)C1

Lancets Safety Seal 28g lancets safety seal 28g* $0 (Tier 3)C1

Lancets Safety Seal 30g lancets safety seal 30g* $0 (Tier 3)C1

Lancets Super Thin 28g lancets super thin 28g* $0 (Tier 3)C1

Lancets Thin

lancets thin* $0 (Tier 3)C1

Lancets Twist Top lancets twist top* $0 (Tier 3)C1

Lancets Ultra Fine lancets ultra fine* $0 (Tier 3)C1

Lancets Ultra Thin lancets ultra thin* $0 (Tier 3)C1

Lancets Ultra Thin 30g lancets ultra thin 30g* $0 (Tier 3)C1

Lancing Device lancing device* $0 (Tier 3)C1

Lancing Device Adjustable lancing device adjustable* $0 (Tier 3)C1

Lanzo

lanzo* $0 (Tier 3)C1

Leader Advanced Lancing Device

leader advanced lancing device* $0 (Tier 3)C1

LiteTouch Lancets litetouch lancets* $0 (Tier 3)C1

LiteTouch Lancets Micro Thin 33g

litetouch lancets micro thin 33g* $0 (Tier 3)C1

LiteTouch Lancing Pen litetouch lancing pen* $0 (Tier 3)C1

Live Better Advanced Lancing Device

live better advanced lancing device* $0 (Tier 3)C1

Live Better Lancet Ultra Thin 28g live better lancet ultra thin 28g* $0 (Tier 3)C1

Longs Lancets Thin longs lancets thin* $0 (Tier 3)C1

Longs Lancets Ultra Thin longs lancets ultra thin* $0 (Tier 3)C1

Medisense Thin Lancets medisense thin lancets* $0 (Tier 3)C1

Medlance Plus Extra Lancets 21g medlance plus extra lancets 21g* $0 (Tier 3)C1

Medlance Plus Lancets medlance plus lancets* $0 (Tier 3)C1

Medlance Plus Lancets Lite 25g medlance plus lancets lite 25g* $0 (Tier 3)C1

Medlance Plus Lite Lancets 25g medlance plus lite lancets 25g* $0 (Tier 3)C1

Medlance Plus Special Lancets 0.8mm

medlance plus special lancets 0.8mm* $0 (Tier 3)C1

Medlance Plus SuperLite 30g medlance plus superlite 30g* $0 (Tier 3)C1

Medlance Plus SuperLite 30g/Comfort Max

medlance plus superlite 30g/comfort max* $0 (Tier 3)C1

Medlance Plus Universal Lancets 21g

medlance plus universal lancets 21g* $0 (Tier 3)C1

Medlance Plus/Lite 25g medlance plus/lite 25g* $0 (Tier 3)C1

Medlance/Lite

medlance/lite* $0 (Tier 3)C1

Medlance/Universal medlance/universal* $0 (Tier 3)C1

Meijer Blood Glucose Teststrips meijer blood glucose teststrips (strip)* $0 (Tier 3)C1

Meijer Lancets Thin meijer lancets thin* $0 (Tier 3)C1

Meijer Lancets Universal 33g meijer lancets universal 33g* $0 (Tier 3)



123


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Meijer Premium Blood Glucose Test Strips

meijer premium blood glucose test strips (strip)* $0 (Tier 3)C1

Meijer Super Thin Lancets meijer super thin lancets* $0 (Tier 3)C1

Microdot Test Strips microdot test strips (strip)* $0 (Tier 3)C1

Microlet Lancets

microlet lancets* $0 (Tier 3)C1

Microlet Next

microlet next* $0 (Tier 3)C1

Mini Lancing Device mini lancing device* $0 (Tier 3)C1

Mm Easy Touch Glucose Test Strips

mm easy touch glucose test strips (strip)* $0 (Tier 3)C1

Monolet Lancets

monolet lancets* $0 (Tier 3)C1

Multi-Lancet Device 2 multi-lancet device 2 (kit)* $0 (Tier 3)C1

MyGlucoHealth Blood Glucose Test myglucohealth blood glucose test (strip)* $0 (Tier 3)C1

MyGlucoHealth MGH Softlance Lancets 30g

myglucohealth mgh softlance lancets 30g* $0 (Tier 3)C1

Neutek 2Tek Test Strips neutek 2tek test strips (strip)* $0 (Tier 3)C1

Nova Max Glucose Test Strips nova max glucose test strips (strip)* $0 (Tier 3)C1

Nova Safety Lancets 23g nova safety lancets 23g* $0 (Tier 3)C1

Nova Safety Lancets 28g nova safety lancets 28g* $0 (Tier 3)C1

Nova Sureflex Lancets nova sureflex lancets* $0 (Tier 3)C1

Nova Sureflex Lancing Device nova sureflex lancing device* $0 (Tier 3)C1

On Call Express Blood Glucose Test Strips

on call express blood glucose test strips (strip)* $0 (Tier 3)C1

On Call Lancets

on call lancets* $0 (Tier 3)C1

On Call Lancing Device on call lancing device* $0 (Tier 3)C1

On Call Plus Blood Glucose Test on call plus blood glucose test (strip)* $0 (Tier 3)C1

On Call Plus Lancets on call plus lancets* $0 (Tier 3)C1

On Call Plus Lancing Device on call plus lancing device* $0 (Tier 3)C1

On Call Vivid Blood Glucose Test on call vivid blood glucose test (strip)* $0 (Tier 3)C1

On Call Vivid Blood Glucose Test Strips

on call vivid blood glucose test strips (strip)* $0 (Tier 3)C1

Onetouch Delica Lancets Extra Fine 33g

onetouch delica lancets extra fine 33g* $0 (Tier 3)C1

Onetouch Delica Lancets Fine 30g

onetouch delica lancets fine 30g* $0 (Tier 3)C1

Onetouch Delica Lancing Device

onetouch delica lancing device* $0 (Tier 3)C1

Onetouch Suresoft Lancing Device/18g

onetouch suresoft lancing device/18g* $0 (Tier 3)


124


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1


onetouch suresoft lancing device/21g* $0 (Tier 3)C1


onetouch suresoft lancing device/28g* $0 (Tier 3)C1

Onetouch Ultra Blue onetouch ultra blue (strip)* $0 (Tier 3)C1

Onetouch Ultrasoft Lancets onetouch ultrasoft lancets* $0 (Tier 3)C1

Onetouch Verio Test Strips onetouch verio test strips (strip)* $0 (Tier 3)C1

One-Way Valved Expiratory Mouthpiece/Disposable

one-way valved expiratory mouthpiece/disposable* $0 (Tier 3)C1

One-Way Valved Inspiratory Mouthpiece/Disposable

one-way valved inspiratory mouthpiece/disposable* $0 (Tier 3)C1

Optium Test Strips optium test strips (strip)* $0 (Tier 3)C1

OptiumEZ Test Strips optiumez test strips* $0 (Tier 3)C1

OptumRx Blood Glucose Test optumrx blood glucose test (strip)* $0 (Tier 3)C1

Panda Mask Large panda mask large* $0 (Tier 3)C1

Panda Mask Medium panda mask medium* $0 (Tier 3)C1

Panda Mask Small panda mask small* $0 (Tier 3)C1

PC Lancets Super Thin 30g pc lancets super thin 30g* $0 (Tier 3)C1

Pediatric Medium Mask pediatric medium mask* $0 (Tier 3)C1

Pediatric Mouthpiece/Disposable pediatric mouthpiece/disposable* $0 (Tier 3)C1

Pediatric Panda Mask pediatric panda mask* $0 (Tier 3)C1

Pediatric Small Mask pediatric small mask* $0 (Tier 3)C1

Pharmacist Choice Autocode Blood Glucose Test Strips

pharmacist choice autocode blood glucose test

strips (strip)*$0 (Tier 3)

C1

Pharmacist Choice No Coding Blood Glucose Test Strips

pharmacist choice no coding blood glucose test

strips (strip)*$0 (Tier 3)

C1

Pharmacist Choice Ultra Thin Lancets pharmacist choice ultra thin lancets* $0 (Tier 3)C1

Pharmacist Choice Ultra Thin Lancets 28g

pharmacist choice ultra thin lancets 28g* $0 (Tier 3)C1







Precision PCX

precision pcx (strip)* $0 (Tier 3)C1

Precision PCX Plus Test Strips precision pcx plus test strips (strip)* $0 (Tier 3)C1

Precision Point of Care Test Strips

precision point of care test strips (strip)* $0 (Tier 3)C1

Precision QID Test Strips precision qid test strips* $0 (Tier 3)C1

Precision XTra Blood Glucose Test Strips

precision xtra blood glucose test strips (strip)* $0 (Tier 3)C1

Preferred Plus Lancets Super Thin 30g

preferred plus lancets super thin 30g* $0 (Tier 3)C1

Preferred Plus Lancets Thin 26g preferred plus lancets thin 26g* $0 (Tier 3)C1

Premium Blood Glucose Test Strips

premium blood glucose test strips (strip)* $0 (Tier 3)C1

Pro Comfort Lancets 30g pro comfort lancets 30g* $0 (Tier 3)



125


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Pro Comfort Lancets 31g pro comfort lancets 31g* $0 (Tier 3)C1

Prodigy Lancing Device prodigy lancing device* $0 (Tier 3)C1

Prodigy No Coding Blood Glucose Test Strips

prodigy no coding blood glucose test strips (strip)* $0 (Tier 3)C1

Prodigy Pressure Activated Safety Lancets

prodigy pressure activated safety lancets* $0 (Tier 3)C1

Prodigy Safety Lancets prodigy safety lancets* $0 (Tier 3)C1

Prodigy Twist Top Lancets prodigy twist top lancets* $0 (Tier 3)C1

Push Button Safety Lancets 28g push button safety lancets 28g* $0 (Tier 3)C1

PX Advanced Lancing Device px advanced lancing device* $0 (Tier 3)C1

PX Lancets Ultra Thin px lancets ultra thin* $0 (Tier 3)C1

PX Lancets Ultra Thin 28g px lancets ultra thin 28g* $0 (Tier 3)C1

QC Advanced Lancing Device qc advanced lancing device* $0 (Tier 3)C1

QC Lancets Super Thin qc lancets super thin* $0 (Tier 3)C1

QC Unilet Lancets 28g/Ultra Thin

qc unilet lancets 28g/ultra thin* $0 (Tier 3)C1

QC Unilet Lancets 33g/Micro Thin

qc unilet lancets 33g/micro thin* $0 (Tier 3)C1

Quintet AC Blood Glucose Test Strips

quintet ac blood glucose test strips (strip)* $0 (Tier 3)C1

Quintet Blood Glucose Test Strips quintet blood glucose test strips (strip)* $0 (Tier 3)C1

RA E-Zject Lancets 28g ra e-zject lancets 28g* $0 (Tier 3)C1

RA E-Zject Lancets Thin 26g ra e-zject lancets thin 26g* $0 (Tier 3)C1

RA E-Zject Lancets Thin 28g ra e-zject lancets thin 28g* $0 (Tier 3)C1

RA E-Zject Lancets Ultra Thin 30g

ra e-zject lancets ultra thin 30g* $0 (Tier 3)C1

Readylance Safety Lancets/21g/2.2mm

readylance safety lancets/21g/2.2mm* $0 (Tier 3)C1









Refuah Plus Blood Glucose Test Strips

refuah plus blood glucose test strips (strip)* $0 (Tier 3)C1

Relion Confirm/Micro Test Strips

relion confirm/micro test strips (strip)* $0 (Tier 3)C1

Relion Lancets Thin 26g relion lancets thin 26g* $0 (Tier 3)C1

Relion Lancets Ultra-Thin30g relion lancets ultra-thin30g* $0 (Tier 3)


126


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Relion Lancing Device relion lancing device ( kit, misc)* $0 (Tier 3)C1

Relion Premier Blood Glucose Test Strips

relion premier blood glucose test strips (strip)* $0 (Tier 3)C1

Relion Prime Blood Glucose Test Strips

relion prime blood glucose test strips (strip)* $0 (Tier 3)C1

Relion Ultima Blood Glucose Test Strips

relion ultima blood glucose test strips (strip)* $0 (Tier 3)C1

Relion Ultra Thin Lancets30g relion ultra thin lancets30g* $0 (Tier 3)C1

Relion Ultra Thin Plus Lancets 32g relion ultra thin plus lancets 32g* $0 (Tier 3)C1

Relion Ultra Thin Plus Lancets 33g relion ultra thin plus lancets 33g* $0 (Tier 3)C1

Reveal Blood Glucose Test reveal blood glucose test (strip)* $0 (Tier 3)C1

Rexall Blood Glucose Test Strips rexall blood glucose test strips (strip)* $0 (Tier 3)C1

Rexall Lancets Ultra Thin rexall lancets ultra thin* $0 (Tier 3)C1

Rightest GD500 Lancing Device rightest gd500 lancing device* $0 (Tier 3)C1

Rightest GL300 Lancets rightest gl300 lancets* $0 (Tier 3)C1

Rightest GS100 Blood Glucose Test Strips

rightest gs100 blood glucose test strips (strip)* $0 (Tier 3)C1





Safety Lancet 21g/Pressure Activated

safety lancet 21g/pressure activated* $0 (Tier 3)C1

Safety Lancet 28g/Pressure Activated

safety lancet 28g/pressure activated* $0 (Tier 3)C1

Safety Lancets

safety lancets* $0 (Tier 3)C1

Safety Lancets 21g safety lancets 21g* $0 (Tier 3)C1

Safety Lancets 28g safety lancets 28g* $0 (Tier 3)C1

Safety Let Lancets safety let lancets* $0 (Tier 3)C1

Safety Seal Lancets 28g safety seal lancets 28g* $0 (Tier 3)C1

Safety Seal Lancets 30g safety seal lancets 30g* $0 (Tier 3)C1

Sapscare Twist Top Lancets 30g sapscare twist top lancets 30g* $0 (Tier 3)C1

Select-Lite Lancing Device select-lite lancing device* $0 (Tier 3)C1

Shopko Autolet Lancing Device shopko autolet lancing device* $0 (Tier 3)C1

Shopko On-The-Go Comfort Lancets 30g

shopko on-the-go comfort lancets 30g* $0 (Tier 3)C1

Shopko Unilet Lancets Super Thin 30g

shopko unilet lancets super thin 30g* $0 (Tier 3)C1

Shopko Unilet Lancets Ultra Thin 28g

shopko unilet lancets ultra thin 28g* $0 (Tier 3)C1

Sidekick Blood Glucose System sidekick blood glucose system (device)* $0 (Tier 3)C1

Sidestream Pediatric Face Mask/Tucker the Turtle

sidestream pediatric face mask/tucker the turtle* $0 (Tier 3)C1

Simple Diagnostics Lancing Device

simple diagnostics lancing device* $0 (Tier 3)C1

SM Micro Thin Lancets 33g sm micro thin lancets 33g* $0 (Tier 3)C1

Smart Diabetes Vantage Lancing Device

smart diabetes vantage lancing device* $0 (Tier 3)C1

Smart Sense Color Lancets Universal 33g

smart sense color lancets universal 33g* $0 (Tier 3)C1

Smart Sense Premium Bloodglucose Strips

smart sense premium bloodglucose strips (strip)* $0 (Tier 3)



127


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Smart Sense Standard Lancets Universal 21g

smart sense standard lancets universal 21g* $0 (Tier 3)C1

Smart Sense Super Thin Lancets Universal 30g

smart sense super thin lancets universal 30g* $0 (Tier 3)C1

Smart Sense Thin Lancets Universal 26g

smart sense thin lancets universal 26g* $0 (Tier 3)C1

Smart Sense Value Blood Glucose Strips

smart sense value blood glucose strips (strip)* $0 (Tier 3)C1

Smartest Blood Glucose Test Strips

smartest blood glucose test strips (strip)* $0 (Tier 3)C1

Smartest Lancets 28g smartest lancets 28g* $0 (Tier 3)C1

Solus V2 Audible Test solus v2 audible test (strip)* $0 (Tier 3)C1

Solus V2 Lancing Device solus v2 lancing device* $0 (Tier 3)C1

Solus V2 Pressure Activated Safety Lancets 28g

solus v2 pressure activated safety lancets 28g* $0 (Tier 3)C1

Solus V2 Twist Lancets 30g solus v2 twist lancets 30g* $0 (Tier 3)C1

Sterilance PA

sterilance pa* $0 (Tier 3)C1

Sterilance Tl

sterilance tl* $0 (Tier 3)C1

Sure Comfort Lancets 18g sure comfort lancets 18g* $0 (Tier 3)C1





Sure Comfort Lancing Pen sure comfort lancing pen* $0 (Tier 3)C1

Sure-Lance Flat Lancets sure-lance flat lancets* $0 (Tier 3)C1

Sure-Lance Thin Lancets 28g sure-lance thin lancets 28g* $0 (Tier 3)C1

Sure-Lance Ultra Thin Lancets sure-lance ultra thin lancets* $0 (Tier 3)C1

Sure-Test EasyPlus Mini Blood Glucose Test Strips

sure-test easyplus mini blood glucose test strips

(strip)*$0 (Tier 3)

C1

Sure-Touch Lancets Universal

sure-touch lancets universal* $0 (Tier 3)C1

Suspendol-S

suspendol-s (liquid)* $0 (Tier 3)C1

TechLite Lancets techlite lancets* $0 (Tier 3)C1

Techlite Lancets 30g techlite lancets 30g* $0 (Tier 3)C1

Telcare Blood Glucose Test Strips telcare blood glucose test strips (strip)* $0 (Tier 3)C1

TGT Blood Glucose Test Strips tgt blood glucose test strips (strip)* $0 (Tier 3)


128


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

TGT Blood Glucose Test Strips Premium

tgt blood glucose test strips premium* $0 (Tier 3)C1

TGT Lancet Micro Thin 33g tgt lancet micro thin 33g* $0 (Tier 3)C1

TGT Lancet Thin 26g tgt lancet thin 26g* $0 (Tier 3)C1

TGT Lancet Ultra Thin 30g tgt lancet ultra thin 30g* $0 (Tier 3)C1

TGT Lancing Device tgt lancing device* $0 (Tier 3)C1

ThyroSafe

thyrosafe (tablet)* $0 (Tier 3)C1

Topcare Lancets Micro-Thin 33g

topcare lancets micro-thin 33g* $0 (Tier 3)C1

Travel Lancets 30g travel lancets 30g* $0 (Tier 3)C1

Travel Lancets Advanced 28g travel lancets advanced 28g* $0 (Tier 3)C1

True Metrix Blood Glucose Test Strips

true metrix blood glucose test strips (strip)* $0 (Tier 3)C1

True Metrix Self Monitoring Blood Glucose Strips

true metrix self monitoring blood glucose strips

(strip)*$0 (Tier 3)

C1

TrueDraw Lancing Device truedraw lancing device* $0 (Tier 3)C1

TruePlus Lancets 26g trueplus lancets 26g* $0 (Tier 3)C1


Trueplus Lancets 28g Super Thin trueplus lancets 28g super thin* $0 (Tier 3)C1


Trueplus Lancets 30g Ultra Thin trueplus lancets 30g ultra thin* $0 (Tier 3)C1


Trueplus Lancets 33g Micro Thin trueplus lancets 33g micro thin* $0 (Tier 3)C1

Trueplus Safety Lancets 28g trueplus safety lancets 28g* $0 (Tier 3)C1

TrueTest Strips truetest strips* $0 (Tier 3)C1

TrueTrack Blood Glucose Test Strips

truetrack blood glucose test strips* $0 (Tier 3)C1

TrueTrack Test Strips truetrack test strips* $0 (Tier 3)C1

Ulti-Lance Automatic/ Clear Tip ulti-lance automatic/ clear tip* $0 (Tier 3)C1

Ultilet Classic Lancets ultilet classic lancets* $0 (Tier 3)C1

Ultilet Lancets

ultilet lancets* $0 (Tier 3)C1

Ultilet Lancets 33g ultilet lancets 33g* $0 (Tier 3)C1

Ultilet Safety Lancets 23g ultilet safety lancets 23g* $0 (Tier 3)C1

Ultima Test Strips ultima test strips (strip)* $0 (Tier 3)C1

Ultralance

ultralance* $0 (Tier 3)C1

Ultra-Thin II Lancets 28g ultra-thin ii lancets 28g* $0 (Tier 3)C1

Ultra-Thin II Lancets 30g ultra-thin ii lancets 30g* $0 (Tier 3)C1

Ultra-Thin II Safety Autolancets 26g

ultra-thin ii safety autolancets 26g* $0 (Tier 3)C1

Ultratrak Pro Test Strips ultratrak pro test strips (strip)* $0 (Tier 3)C1

Ultratrak Ultimate Test Strips ultratrak ultimate test strips (strip)* $0 (Tier 3)



129


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Unilet ComforTouch Lancet unilet comfortouch lancet* $0 (Tier 3)C1

Unilet Excelite

unilet excelite* $0 (Tier 3)C1

Unilet Excelite II unilet excelite ii* $0 (Tier 3)C1

Unilet G.P. SuperLite Lancet unilet g.p. superlite lancet* $0 (Tier 3)C1

Unilet GP 28 Ultra Thin unilet gp 28 ultra thin* $0 (Tier 3)C1

Unilet Lancets Micro-Thin33g unilet lancets micro-thin33g* $0 (Tier 3)C1

Unilet Lancets Super-Thin30g unilet lancets super-thin30g* $0 (Tier 3)C1

Unilet Lancets Ultra-Thin 28g unilet lancets ultra-thin 28g* $0 (Tier 3)C1

Unistik 2

unistik 2* $0 (Tier 3)C1

Unistik 2 Comfort unistik 2 comfort* $0 (Tier 3)C1

Unistik 2 Extra

unistik 2 extra* $0 (Tier 3)C1

Unistik 2 Normal

unistik 2 normal* $0 (Tier 3)C1

Unistik 2 Super

unistik 2 super* $0 (Tier 3)C1

Unistik 3 Comfort unistik 3 comfort* $0 (Tier 3)C1

Unistik 3 Extra

unistik 3 extra* $0 (Tier 3)C1

Unistik 3 Gentle

unistik 3 gentle* $0 (Tier 3)C1

Unistik 3 Neonatal unistik 3 neonatal* $0 (Tier 3)C1

Unistik 3 Normal

unistik 3 normal* $0 (Tier 3)C1

Unistik CZT Comfort unistik czt comfort* $0 (Tier 3)C1

Unistik CZT Normal unistik czt normal* $0 (Tier 3)C1

Unistik Safety Lancets 28g unistik safety lancets 28g* $0 (Tier 3)C1

Unistik Safety Lancets 30g unistik safety lancets 30g* $0 (Tier 3)C1

Unistik Touch Safety Lancets 21g unistik touch safety lancets 21g* $0 (Tier 3)C1

Unistik Touch Safety Lancets 23g unistik touch safety lancets 23g (misc)* $0 (Tier 3)C1



Unistrip1 Generic unistrip1 generic (strip)* $0 (Tier 3)C1

Universal 1 Lancets Thin 26g universal 1 lancets thin 26g* $0 (Tier 3)C1

Universal 1 Lancets Ultra Thin 30g universal 1 lancets ultra thin 30g* $0 (Tier 3)


130


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Value Plus Lancing Device value plus lancing device* $0 (Tier 3)C1

Valumark Lancet Super Thin 30g valumark lancet super thin 30g* $0 (Tier 3)C1

Valumark Lancet Ultra Thin 28g valumark lancet ultra thin 28g* $0 (Tier 3)C1

Verasens Blood Glucose Test Strips

verasens blood glucose test strips (strip)* $0 (Tier 3)C1

Vida Mia Autolet Lancing Device vida mia autolet lancing device* $0 (Tier 3)C1

Vida Mia Unilet Lancets Super Thin 30g

vida mia unilet lancets super thin 30g* $0 (Tier 3)C1

Vida Mia Unilet Lancets Ultra Thin 28g

vida mia unilet lancets ultra thin 28g* $0 (Tier 3)C1

Walgreens Advanced Travellancets 28g

walgreens advanced travellancets 28g* $0 (Tier 3)C1

Walgreens Comfort Assuredlancets Micro Thin/33g

walgreens comfort assuredlancets micro thin/33g* $0 (Tier 3)C1

Walgreens Comfort Assuredlancets Super Thin/28g

walgreens comfort assuredlancets super thin/28g* $0 (Tier 3)C1

Walgreens Thin Lancets walgreens thin lancets* $0 (Tier 3)C1

Walgreens Ultra Thin Lancets walgreens ultra thin lancets* $0 (Tier 3)C1

Wavesense Presto Test Strips wavesense presto test strips (strip)* $0 (Tier 3)C1

White Petrolatum white petrolatum (gel)* $0 (Tier 3)

A1

Ophthalmic Agents

B1

Ophthalmic Agents, OtherC1

Akwa Tears

akwa tears (ointment)* $0 (Tier 3)C1

Artificial Tears

artificial tears (otc only) (ophthalmic solution)* $0 (Tier 3)C1

Atropine Sulfate ATROPINE SULFATE (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Bacitracin/Polymyxin B bacitracin/polymyxin b (ophthalmic ointment) $1.25-$3.40 (Tier 1)C1

Blephamide

BLEPHAMIDE (SUSPENSION) $3.80-$8.50 (Tier 2)C1

Blephamide S.O.P. blephamide s.o.p. (ointment) $1.25-$3.40 (Tier 1)C1

Cystaran

CYSTARAN (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2) LAC1

Freshkote

freshkote (ophthalmic solution)* $0 (Tier 3)C1

Isopto Tears

isopto tears (ophthalmic solution)* $0 (Tier 3)C1

Lacrisert

LACRISERT (INSERT) $3.80-$8.50 (Tier 2)C1

Lastacaft

LASTACAFT (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Liquitears

liquitears (ophthalmic solution)* $0 (Tier 3)C1

Lubricant Eye Drops lubricant eye drops (ophthalmic solution)* $0 (Tier 3)C1

Lubricating Plus Eye Drops lubricating plus eye drops (ophthalmic solution)* $0 (Tier 3)C1

Lubrifresh P.M.

lubrifresh p.m. (ointment)* $0 (Tier 3)C1

Muro 128

muro 128 (ophthalmic solution)* $0 (Tier 3)C1

Natural Balance Tears natural balance tears (ophthalmic solution)* $0 (Tier 3)C1

Natures Tears natures tears (ophthalmic solution)* $0 (Tier 3)C1

Neomycin/Bacitracin/Polymyxin neomycin/bacitracin/polymyxin (ointment) $1.25-$3.40 (Tier 1)



131


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Neomycin/Polymyxin/Bacitracin/Hydrocortisone

neomycin/polymyxin/bacitracin/hydrocortisone

(ophthalmic ointment)$1.25-$3.40 (Tier 1)

C1

Neomycin/Polymyxin/Dexamethasone

neomycin/polymyxin/dexamethasone (0.1%

ophthalmic ointment, 0.1% ophthalmic suspension)$1.25-$3.40 (Tier 1)

C1

Neomycin/Polymyxin/Gramicidin neomycin/polymyxin/gramicidin (ophthalmic


C1

Neomycin/Polymyxin/Hydrocortisone

neomycin/polymyxin/hydrocortisone (1% ophthalmic


C1

Polymyxin B Sulfate/Trimethoprim Sulfate

polymyxin b sulfate/trimethoprim sulfate (ophthalmic


C1

Proparacaine HCl proparacaine hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Puralube

puralube (ointment)* $0 (Tier 3)C1

Refresh Celluvisc refresh celluvisc (ophthalmic solution)* $0 (Tier 3)C1

Refresh Lacri-Lube refresh lacri-lube (ointment)* $0 (Tier 3)C1

Refresh Optive Mega-3 refresh optive mega-3 (ophthalmic solution)* $0 (Tier 3)C1

Refresh Plus

refresh plus (ophthalmic solution)* $0 (Tier 3)C1

Restasis

RESTASIS (EMULSION) $3.80-$8.50 (Tier 2) QLC1

Rhopressa

RHOPRESSA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2) STC1

Sodium Chloride

sodium chloride (otc only) (5% ointment, 5%

ophthalmic solution)*$0 (Tier 3)

C1

Sulfacetamide Sodium/Prednisolone Sodium Phosphate

sulfacetamide sodium/prednisolone sodium

phosphate (ophthalmic solution)$1.25-$3.40 (Tier 1)

C1

Tobradex

TOBRADEX (0.3%-0.1% OPHTHALMIC OINTMENT) $3.80-$8.50 (Tier 2)C1

Tobradex ST

TOBRADEX ST (OPHTHALMIC SUSPENSION) $3.80-$8.50 (Tier 2)C1

Tobramycin/Dexamethasone tobramycin/dexamethasone (ophthalmic suspension) $1.25-$3.40 (Tier 1)C1

Ultra Lubricant Eye Drops ultra lubricant eye drops (ophthalmic solution)* $0 (Tier 3)C1

Xiidra

XIIDRA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2) QLB1

Ophthalmic Anti-allergy AgentsC1

Azelastine HCl

azelastine hcl (0.05% ophthalmic solution) $1.25-$3.40 (Tier 1)


132


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Bepreve

BEPREVE (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Cromolyn Sodium cromolyn sodium (rx only) (4% ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Epinastine HCl

epinastine hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Eye Drops

eye drops (ophthalmic solution)* $0 (Tier 3)C1

Olopatadine HCl

olopatadine hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Opti-Clear

opti-clear (ophthalmic solution)* $0 (Tier 3)C1

Pazeo

PAZEO (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)B1

Ophthalmic Antiglaucoma AgentsC1

Alphagan P

ALPHAGAN P (0.1% OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Apraclonidine

apraclonidine (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Betaxolol HCl

betaxolol hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Betimol

BETIMOL (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Brimonidine Tartrate brimonidine tartrate (0.2% ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Carteolol HCl

carteolol hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Combigan

COMBIGAN (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Cosopt PF

COSOPT PF (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Dorzolamide HCl dorzolamide hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Dorzolamide HCl/Timolol Maleate dorzolamide hcl/timolol maleate (ophthalmic


C1

Dorzolamide HCl/Timolol Maleate Preservative Free

dorzolamide hcl/timolol maleate preservative free

(solution)$1.25-$3.40 (Tier 1)

C1

Levobunolol HCl levobunolol hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Phospholine Iodide PHOSPHOLINE IODIDE (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Pilocarpine HCl

pilocarpine hcl (1% ophthalmic solution, 2%

ophthalmic solution, 4% ophthalmic solution)$1.25-$3.40 (Tier 1)

C1

Rocklatan

ROCKLATAN (SOLUTION) $3.80-$8.50 (Tier 2) STC1

Timolol Maleate

timolol maleate (0.25% ophthalmic solution, 0.5%

ophthalmic solution) (generic timoptic)$1.25-$3.40 (Tier 1)

C1

Timolol Maleate Ophthalmic Gel Forming

timolol maleate ophthalmic gel forming (solution)

(generic timoptic-xe)$3.80-$8.50 (Tier 2)

B1

Ophthalmic Anti-inflammatoriesC1

Dexamethasone Sodium Phosphate dexamethasone sodium phosphate (ophthalmic


C1

Diclofenac Sodium diclofenac sodium (0.1% ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Durezol

DUREZOL (EMULSION) $3.80-$8.50 (Tier 2)C1

Eye Itch Relief

eye itch relief (ophthalmic solution)* $0 (Tier 3)



133


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Fluorometholone

fluorometholone (ophthalmic suspension) $1.25-$3.40 (Tier 1)C1

Flurbiprofen Sodium flurbiprofen sodium (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Ilevro

ILEVRO (SUSPENSION) $3.80-$8.50 (Tier 2)C1

Ketorolac Tromethamine ketorolac tromethamine (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Lotemax

LOTEMAX (0.5% GEL, 0.5% OINTMENT, 0.5% SUSPENSION)

$3.80-$8.50 (Tier 2)C1

Lotemax SM

LOTEMAX SM (GEL) $3.80-$8.50 (Tier 2)C1

Loteprednol Etabonate loteprednol etabonate (ophthalmic suspension) $1.25-$3.40 (Tier 1)C1

Prednisolone Acetate prednisolone acetate (ophthalmic suspension) $1.25-$3.40 (Tier 1)C1

Prednisolone Sodium Phosphate prednisolone sodium phosphate (1% ophthalmic


C1

Prolensa

PROLENSA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)B1

Ophthalmic Prostaglandin and Prostamide AnalogsC1

Latanoprost

latanoprost (ophthalmic solution) $1.25-$3.40 (Tier 1)C1

Lumigan

LUMIGAN (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Travatan Z

TRAVATAN Z (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Vyzulta

VYZULTA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1

Zioptan

ZIOPTAN (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)A1

Otic Agents

B1

Otic AgentsC1

Acetic Acid

acetic acid (otic solution) $1.25-$3.40 (Tier 1)C1

Ear Drops

ear drops (otic solution)* $0 (Tier 3)C1

Earwax Treatment Drops earwax treatment drops (otic solution)* $0 (Tier 3)C1

Flac

flac (oil) $1.25-$3.40 (Tier 1)C1

Fluocinolone Acetonide fluocinolone acetonide (0.01% otic oil) $1.25-$3.40 (Tier 1)C1

Hydrocortisone/Acetic Acid hydrocortisone/acetic acid (otic solution) $1.25-$3.40 (Tier 1)C1

Neomycin/Polymyxin/Hydrocortisone

neomycin/polymyxin/hydrocortisone (1% otic

solution, 1% otic suspension)$1.25-$3.40 (Tier 1)


134


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useA1

Respiratory Tract/Pulmonary Agents

B1

AntihistaminesC1

Aceta-Gesic

aceta-gesic (tablet)* $0 (Tier 3)C1

Ala-Hist IR

ala-hist ir (tablet)* $0 (Tier 3)C1

Ala-Hist PE

ala-hist pe (tablet)* $0 (Tier 3)C1

All Day Allergy

all day allergy (tablet)* $0 (Tier 3)C1

All Day Allergy Childrens all day allergy childrens (10mg tablet chewable,

5mg/5ml oral solution)*$0 (Tier 3)

C1

All Day Allergy-D

all day allergy-d (tablet extended-release 12 hour)* $0 (Tier 3)C1

Aller-Chlor

aller-chlor (tablet)* $0 (Tier 3)C1

Allergy

allergy (tablet)* $0 (Tier 3)C1

Allergy Relief

allergy relief (tablet)* $0 (Tier 3)C1

Allergy Relief D-24 allergy relief d-24 (tablet extended-release 24 hour)* $0 (Tier 3)C1

Azelastine HCl

azelastine hcl (nasal solution) $1.25-$3.40 (Tier 1)C1

Banophen

banophen (otc only) (12.5mg/5ml liquid, 25mg

capsule, 50mg capsule)*$0 (Tier 3)

C1

Cetirizine HCl

cetirizine hcl (otc only) (10mg tablet chewable, 5mg

tablet chewable, 10mg tablet, 5mg tablet)*$0 (Tier 3)

C1

Cetirizine HCl

cetirizine hcl (rx only) (oral solution) $1.25-$3.40 (Tier 1)C1

Cetirizine HCl Allergy Childrens cetirizine hcl allergy childrens (otc only) (oral

solution)*$0 (Tier 3)

C1

Cetirizine HCl Childrens Allergy cetirizine hcl childrens allergy (otc only) (syrup)* $0 (Tier 3)C1

Cetirizine HCl/Pseudoephedrine HCl ER

cetirizine hcl/pseudoephedrine hcl er (otc only)

(tablet extended-release 12 hour)*$0 (Tier 3)

C1

Childrens Allergy childrens allergy (liquid)* $0 (Tier 3)C1

Childrens Loratadine childrens loratadine (5mg/5ml oral solution, 5mg/

5ml syrup)*$0 (Tier 3)

C1

Chlorphen SR

chlorphen sr (tablet extended-release)* $0 (Tier 3)C1

Complete Allergy Medicine complete allergy medicine (otc only) (capsule)* $0 (Tier 3)C1

Cyproheptadine HCl cyproheptadine hcl (2mg/5ml syrup, 4mg tablet) $1.25-$3.40 (Tier 1)C1

Dimaphen Childrens dimaphen childrens (elixir)* $0 (Tier 3)C1

Diphenhist

diphenhist (12.5mg/5ml liquid, 25mg capsule)* $0 (Tier 3)C1

Diphenhydramine HCl diphenhydramine hcl (otc only) (capsule)* $0 (Tier 3)C1

ED A-Hist

ed a-hist (liquid)* $0 (Tier 3)C1

ED Chlorped

ed chlorped (liquid)* $0 (Tier 3)C1

ED Chlorped D

ed chlorped d (liquid)* $0 (Tier 3)



135


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

ED Chlorped Jr

ed chlorped jr (syrup)* $0 (Tier 3)C1

Fexofenadine HCl fexofenadine hcl (tablet)* $0 (Tier 3)C1

Fexofenadine HCl Childrens Allergy

fexofenadine hcl childrens allergy (suspension)* $0 (Tier 3)C1

GNP All Day Allergy gnp all day allergy (tablet)* $0 (Tier 3)C1

GNP Allergy

gnp allergy (tablet)* $0 (Tier 3)C1

GNP Dayhist Allergy gnp dayhist allergy (tablet)* $0 (Tier 3)C1

GNP Loratadine gnp loratadine (10mg tablet, 5mg/5ml syrup)* $0 (Tier 3)C1

Histex

histex (syrup)* $0 (Tier 3)C1

Histex PD

histex pd (liquid)* $0 (Tier 3)C1

Levocetirizine Dihydrochloride levocetirizine dihydrochloride (5mg tablet) $1.25-$3.40 (Tier 1) QLC1

Lodrane D

lodrane d (capsule)* $0 (Tier 3)C1

LoHist-D

lohist-d (liquid)* $0 (Tier 3)C1

Loratadine

loratadine (tablet)* $0 (Tier 3)C1

Loratadine Childrens loratadine childrens (5mg/5ml oral solution, 5mg/

5ml syrup)*$0 (Tier 3)

C1

Loratadine-D 12hr

loratadine-d 12hr (tablet extended-release 12 hour)* $0 (Tier 3)C1

Loratadine-D 24hr

loratadine-d 24hr (tablet extended-release 24 hour)* $0 (Tier 3)C1

Lortuss LQ

lortuss lq (liquid)* $0 (Tier 3)C1

M-Hist PD

m-hist pd (liquid)* $0 (Tier 3)C1

Nasopen PE

nasopen pe (liquid)* $0 (Tier 3)C1

NoHist-LQ

nohist-lq (liquid)* $0 (Tier 3)C1

Phenadoz

phenadoz (suppository) $1.25-$3.40 (Tier 1)C1

Poly-Hist PD

poly-hist pd (liquid)* $0 (Tier 3)C1

Promethazine HCl promethazine hcl (12.5mg suppository, 25mg

suppository, 6.25mg/5ml syrup)$1.25-$3.40 (Tier 1)

C1

Promethazine HCl promethazine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Promethegan

promethegan (25mg suppository) $1.25-$3.40 (Tier 1)C1

QC Loratadine Allergy Relief qc loratadine allergy relief (tablet)* $0 (Tier 3)C1

QC Loratadine-D

qc loratadine-d (tablet extended-release 24 hour)* $0 (Tier 3)


136


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Rescon

rescon (tablet)* $0 (Tier 3)C1

Ru-Hist D

ru-hist d (tablet)* $0 (Tier 3)C1

Rymed

rymed (tablet)* $0 (Tier 3)C1

Rynex PE

rynex pe (elixir)* $0 (Tier 3)C1

Rynex PSE

rynex pse (liquid)* $0 (Tier 3)C1

Siladryl Allergy

siladryl allergy (liquid)* $0 (Tier 3)C1

SM Allergy 4 Hour sm allergy 4 hour (tablet)* $0 (Tier 3)C1

SM Allergy Relief sm allergy relief (1.34mg tablet, 12.5mg/5ml liquid)* $0 (Tier 3)C1

SM Loratadine

sm loratadine (syrup)* $0 (Tier 3)C1

SM Lorata-Dine D sm lorata-dine d (tablet extended-release 24 hour)* $0 (Tier 3)C1

Sudogest Sinus & Allergy sudogest sinus & allergy (tablet)* $0 (Tier 3)C1

Triprolidine HCl

triprolidine hcl (liquid)* $0 (Tier 3)C1

Vanaclear PD

vanaclear pd (liquid)* $0 (Tier 3)C1

Vanahist PD

vanahist pd (liquid)* $0 (Tier 3)C1

Vanamine PD

vanamine pd (liquid)* $0 (Tier 3)C1

Vanatab Ac

vanatab ac (tablet)* $0 (Tier 3)C1

Vanatab DM

vanatab dm (tablet)* $0 (Tier 3)B1

Anti-inflammatories, Inhaled CorticosteroidsC1

Arnuity Ellipta ARNUITY ELLIPTA (100MCG/ACT AEROSOL POWDER,

200MCG/ACT AEROSOL POWDER, 50MCG/ACT AEROSOL POWDER)

$3.80-$8.50 (Tier 2) QL

C1

Budesonide

budesonide (0.25mg/2ml suspension, 0.5mg/2ml

suspension, 1mg/2ml suspension)$1.25-$3.40 (Tier 1) B/D, PA

C1

Budesonide Nasal Spray budesonide nasal spray (otc only) (suspension)* $0 (Tier 3)C1

Flovent Diskus FLOVENT DISKUS (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1

Flovent HFA

FLOVENT HFA (AEROSOL) $3.80-$8.50 (Tier 2) QLC1

Flunisolide

flunisolide (nasal solution) $1.25-$3.40 (Tier 1)C1

Fluticasone Propionate fluticasone propionate (otc only) (suspension)* $0 (Tier 3)C1

Fluticasone Propionate fluticasone propionate (rx only) (50mcg/act


C1

Triamcinolone Acetonide triamcinolone acetonide (otc only) (aerosol)* $0 (Tier 3)

B1

AntileukotrienesC1

Montelukast Sodium montelukast sodium (10mg tablet, 4mg packet, 4mg

tablet chewable, 5mg tablet chewable)$1.25-$3.40 (Tier 1) QL

C1

Zafirlukast

zafirlukast (tablet) $1.25-$3.40 (Tier 1) QLC1

Zileuton ER

zileuton er (tablet extended-release 12 hour) $1.25-$3.40 (Tier 1) ST



137


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Zyflo

ZYFLO (TABLET) $3.80-$8.50 (Tier 2) STB1

Bronchodilators, AnticholinergicC1

Atrovent HFA ATROVENT HFA (AEROSOL SOLUTION) $3.80-$8.50 (Tier 2)C1

Incruse Ellipta INCRUSE ELLIPTA (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1

Ipratropium Bromide ipratropium bromide (0.02% inhalation solution) $1.25-$3.40 (Tier 1) B/D, PAC1

Ipratropium Bromide ipratropium bromide (0.03% nasal solution, 0.06%

nasal solution)$1.25-$3.40 (Tier 1)

C1

Lonhala Magnair Starter Kit LONHALA MAGNAIR STARTER KIT (INHALATION

SOLUTION)$3.80-$8.50 (Tier 2) QL

C1

Spiriva HandiHaler SPIRIVA HANDIHALER (CAPSULE) $3.80-$8.50 (Tier 2) QLC1

Spiriva Respimat SPIRIVA RESPIMAT (AEROSOL SOLUTION) $3.80-$8.50 (Tier 2) QL

B1

Bronchodilators, SympathomimeticC1

Albuterol Sulfate albuterol sulfate (0.083% nebulized solution, 0.5%

nebulized solution, 0.63mg/3ml nebulized solution,

1.25mg/3ml nebulized solution)

$1.25-$3.40 (Tier 1) B/D, PA

C1

Albuterol Sulfate albuterol sulfate (2mg tablet immediate-release, 4mg

tablet immediate-release)$1.25-$3.40 (Tier 1)

C1

Epinephrine

epinephrine (0.15mg/0.3ml injection) (brand

equivalent epipen jr), epinephrine (0.3mg/0.3ml

injection) (generic epipen)

$1.25-$3.40 (Tier 1) QL

C1

Levalbuterol HCl

levalbuterol hcl (nebulized solution) $1.25-$3.40 (Tier 1) B/D, PAC1

Perforomist

PERFOROMIST (NEBULIZED SOLUTION) $3.80-$8.50 (Tier 2) B/D, PA, QLC1

ProAir HFA

PROAIR HFA (AEROSOL SOLUTION) $3.80-$8.50 (Tier 2)C1

ProAir RespiClick PROAIR RESPICLICK (AEROSOL POWDER) $3.80-$8.50 (Tier 2)C1

S2

s2 (nebulized solution)* $0 (Tier 3)C1

Serevent Diskus SEREVENT DISKUS (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QL

B1

Cystic Fibrosis AgentsC1

Bethkis

BETHKIS (NEBULIZED SOLUTION) $3.80-$8.50 (Tier 2) B/D, PA, QL


138


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Cayston

CAYSTON (INHALATION SOLUTION) $3.80-$8.50 (Tier 2) PA, LAC1

Kalydeco

KALYDECO (150MG TABLET, 25MG PACKET, 50MG PACKET, 75MG PACKET)

$3.80-$8.50 (Tier 2) PA, QL, LAC1

Orkambi

ORKAMBI (PACKET, TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

TOBI Podhaler TOBI PODHALER (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1

Tobramycin

tobramycin (nebulized solution) $1.25-$3.40 (Tier 1) B/D, PA, QLB1

Mast Cell StabilizersC1

Cromolyn Sodium cromolyn sodium (otc only) (aerosol solution)* $0 (Tier 3)C1

Cromolyn Sodium cromolyn sodium (rx only) (20mg/2ml nebulized

solution)$1.25-$3.40 (Tier 1) B/D, PA

B1

Phosphodiesterase Inhibitors, Airways DiseaseC1

Daliresp

DALIRESP (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Theophylline

theophylline (oral solution) $1.25-$3.40 (Tier 1)C1

Theophylline ER theophylline er (300mg tablet extended-release 12



$1.25-$3.40 (Tier 1)

B1

Pulmonary AntihypertensivesC1

Adcirca

ADCIRCA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1

Adempas

ADEMPAS (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1

Alyq

alyq (tablet) $1.25-$3.40 (Tier 1) PA, QLC1

Ambrisentan

ambrisentan (tablet) $1.25-$3.40 (Tier 1) PA, QL, LAC1

Bosentan

bosentan (tablet) $1.25-$3.40 (Tier 1) PA, QL, LAC1

Letairis

LETAIRIS (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Opsumit

OPSUMIT (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1

Orenitram

ORENITRAM (TABLET EXTENDED-RELEASE) $3.80-$8.50 (Tier 2) PA, LAC1

Sildenafil

sildenafil (20mg tablet) (generic revatio) $1.25-$3.40 (Tier 1) PA, QLC1

Tadalafil

tadalafil (20mg tablet) $1.25-$3.40 (Tier 1) PA, QLC1

Tracleer

TRACLEER (125MG TABLET, 62.5MG TABLET, 32MG TABLET SOLUBLE)

$3.80-$8.50 (Tier 2) PA, QL, LAC1

Ventavis

VENTAVIS (INHALATION SOLUTION) $3.80-$8.50 (Tier 2) PA, QL, LAB1

Pulmonary Fibrosis AgentsC1

Esbriet

ESBRIET (267MG CAPSULE, 267MG TABLET, 801MG TABLET)

$3.80-$8.50 (Tier 2) PA, QL, LAC1

Ofev

OFEV (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAB1

Respiratory Tract Agents, Other



139


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

12 Hour Decongestant 12 hour decongestant (tablet extended-release)* $0 (Tier 3)C1

Acetylcysteine

acetylcysteine (inhalation solution) $1.25-$3.40 (Tier 1) B/D, PAC1

Advair Diskus ADVAIR DISKUS (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1

Advair HFA

ADVAIR HFA (AEROSOL) $3.80-$8.50 (Tier 2) QLC1

Alahist CF

alahist cf (tablet)* $0 (Tier 3)C1

Alahist DM

alahist dm (liquid)* $0 (Tier 3)C1

All-Nite Cold & Flu Nighttime Relief

all-nite cold & flu nighttime relief (liquid)* $0 (Tier 3)C1

Anoro Ellipta ANORO ELLIPTA (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1

AP-Hist DM

ap-hist dm (liquid)* $0 (Tier 3)C1

Aprodine

aprodine (tablet)* $0 (Tier 3)C1

Benzonatate

benzonatate (capsule)* $0 (Tier 3)C1

Bevespi Aerosphere BEVESPI AEROSPHERE (AEROSOL) $3.80-$8.50 (Tier 2) QLC1

Breo Ellipta BREO ELLIPTA (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1

Bromfed DM

bromfed dm (rx only) (syrup)* $0 (Tier 3)C1

Bromphen/Pseudoephedrine HCl/Dextromethorphan HBr

bromphen/pseudoephedrine hcl/dextromethorphan

hbr (rx only) (syrup)*$0 (Tier 3)

C1

Brotapp DM

brotapp dm (liquid)* $0 (Tier 3)C1

Cheratussin AC

cheratussin ac (syrup)* $0 (Tier 3)C1

Childrens Silfedrine childrens silfedrine (liquid)* $0 (Tier 3)C1

Chlo Tuss

chlo tuss (liquid)* $0 (Tier 3)C1

Codeine/Guaifenesin codeine/guaifenesin (oral solution)* $0 (Tier 3)C1

Combivent Respimat COMBIVENT RESPIMAT (AEROSOL SOLUTION) $3.80-$8.50 (Tier 2)C1

Cough DM

cough dm (suspension extended-release)* $0 (Tier 3)C1

Cough Syrup

cough syrup (syrup)* $0 (Tier 3)C1

Deconex DMX deconex dmx (tablet)* $0 (Tier 3)C1

Deconex IR

deconex ir (tablet)* $0 (Tier 3)C1

Deep Sea Nasal Spray deep sea nasal spray (nasal solution)* $0 (Tier 3)C1

Delsym

delsym (suspension extended-release)* $0 (Tier 3)C1

Delsym Cough + Chest Congestion DM

delsym cough + chest congestion dm (liquid)* $0 (Tier 3)


140


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Delsym Cough + Chest Congestion DM Childrens

delsym cough + chest congestion dm childrens


C1

Delsym Cough + Cold Daytime delsym cough + cold daytime (liquid)* $0 (Tier 3)C1

Delsym Cough + Cold Nighttime Childrens

delsym cough + cold nighttime childrens (liquid)* $0 (Tier 3)C1

Delsym Cough Childrens delsym cough childrens (suspension extended-


C1

Dextromethorphan Polistirex dextromethorphan polistirex (suspension extended-


C1

Dimaphen DM Cold & Cough dimaphen dm cold & cough (elixir)* $0 (Tier 3)C1

ED A-Hist

ed a-hist (4mg-10mg tablet)* $0 (Tier 3)C1

ED A-Hist DM

ed a-hist dm (4mg-10mg-10mg tablet, 4mg/

5ml-15mg/5ml-10mg/5ml liquid)*$0 (Tier 3)

C1

ED A-Hist PSE

ed a-hist pse (tablet)* $0 (Tier 3)C1

ED Bron GP

ed bron gp (liquid)* $0 (Tier 3)C1

EndaCof-DM

endacof-dm (liquid)* $0 (Tier 3)C1

Extra Action Cough extra action cough (syrup)* $0 (Tier 3)C1

Flowtuss

flowtuss (oral solution)* $0 (Tier 3)C1

Fluticasone Propionate/Salmeterol fluticasone propionate/salmeterol (aerosol powder)

(brand equivalent airduo)$1.25-$3.40 (Tier 1) QL

C1

Fluticasone Propionate/Salmeterol Diskus

fluticasone propionate/salmeterol diskus (aerosol

powder) (generic advair)$1.25-$3.40 (Tier 1) QL

C1

GNP Tussin DM gnp tussin dm (liquid)* $0 (Tier 3)C1

Guaifenesin AC

guaifenesin ac (syrup)* $0 (Tier 3)C1

Guaifenesin and Pseudoephedrine HCl

guaifenesin and pseudoephedrine hcl (otc only)

(tablet extended-release 12 hour)*$0 (Tier 3)

C1

Guaifenesin ER

guaifenesin er (tablet extended-release 12 hour)* $0 (Tier 3)C1

Guaifenesin/Codeine guaifenesin/codeine (oral solution)* $0 (Tier 3)C1

Histex-DM

histex-dm (syrup)* $0 (Tier 3)C1

Histex-PE

histex-pe (syrup)* $0 (Tier 3)C1

Hycofenix

hycofenix (oral solution)* $0 (Tier 3)C1

Hydrocodone Bitartrate/Chlorpheniramine Maleate/PSE

hydrocodone bitartrate/chlorpheniramine maleate/

pse (oral solution)*$0 (Tier 3)

C1

Hydrocodone Bitartrate/Homatropine Methylbromide

hydrocodone bitartrate/homatropine methylbromide

(1.5mg-5mg tablet, 1.5mg/5ml-5mg/5ml syrup)*$0 (Tier 3)

C1

Hydrocodone Polistirex/Chlorpheniramine Polistirex

hydrocodone polistirex/chlorpheniramine polistirex

(suspension extended-release)*$0 (Tier 3)

C1

Hydromet

hydromet (syrup)* $0 (Tier 3)



141


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Ipratropium Bromide/Albuterol Sulfate

ipratropium bromide/albuterol sulfate (inhalation

solution)$1.25-$3.40 (Tier 1) B/D, PA

C1

Kidkare Cough/Cold kidkare cough/cold (liquid)* $0 (Tier 3)C1

LoHist-DM

lohist-dm (syrup)* $0 (Tier 3)C1

Lortuss DM

lortuss dm (liquid)* $0 (Tier 3)C1

Lortuss EX

lortuss ex (liquid)* $0 (Tier 3)C1

Mapap Cold Formula Multi-Symptom

mapap cold formula multi-symptom (tablet)* $0 (Tier 3)C1

Mapap Sinus Maximum Strength Congestion and Pain

mapap sinus maximum strength congestion and pain


C1

M-END DMX

m-end dmx (liquid)* $0 (Tier 3)C1

M-Hist DM

m-hist dm (liquid)* $0 (Tier 3)C1

Mucinex

mucinex (otc only) (tablet extended-release 12 hour)* $0 (Tier 3)C1

Mucinex Chest Congestion Childrens

mucinex chest congestion childrens (liquid)* $0 (Tier 3)C1

Mucinex Childrens Cold Cough & Sore Throat

mucinex childrens cold cough & sore throat (liquid)* $0 (Tier 3)C1

Mucinex Childrens Multi-Symptom Cold & Fever

mucinex childrens multi-symptom cold & fever


C1

Mucinex Childrens Multi-Symptom Cold

mucinex childrens multi-symptom cold (liquid)* $0 (Tier 3)C1

Mucinex Congestion & Cough Childrens

mucinex congestion & cough childrens (liquid)* $0 (Tier 3)C1

Mucinex Cough Childrens mucinex cough childrens (liquid)* $0 (Tier 3)C1

Mucinex Cough for Kids mucinex cough for kids (packet)* $0 (Tier 3)C1

Mucinex D

mucinex d (otc only) (tablet extended-release 12

hour)*$0 (Tier 3)

C1

Mucinex D Maximum Strength mucinex d maximum strength (tablet extended-

release 12 hour)*$0 (Tier 3)

C1

Mucinex DM

mucinex dm (otc only) (tablet extended-release 12

hour)*$0 (Tier 3)

C1

Mucinex DM Maximum Strength mucinex dm maximum strength (tablet extended-

release 12 hour)*$0 (Tier 3)

C1

Mucinex Fast-Max Cold & Sinus mucinex fast-max cold & sinus (tablet)* $0 (Tier 3)


142


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Mucinex Fast-Max Cold Flu & Sore Throat

mucinex fast-max cold flu & sore throat

(325mg-10mg-200mg-5mg tablet, 650mg/

20ml-20mg/20ml-400mg/20ml-10mg/20ml liquid)*

$0 (Tier 3)

C1

Mucinex Fast-Max Day Time/Night Time

mucinex fast-max day time/night time (liquid)* $0 (Tier 3)C1

Mucinex Fast-Max Day/Night Maximum Strength

mucinex fast-max day/night maximum strength* $0 (Tier 3)C1

Mucinex Fast-Max DM Max mucinex fast-max dm max (liquid)* $0 (Tier 3)C1

Mucinex Fast-Max Night Time Cold & Flu

mucinex fast-max night time cold & flu (liquid)* $0 (Tier 3)C1

Mucinex Fast-Max Severe Cold mucinex fast-max severe cold

(325mg-10mg-200mg-5mg tablet, 325mg/

10ml-10mg/10ml-200mg/10ml-5mg/10ml liquid)*

$0 (Tier 3)

C1

Mucinex Fast-Max Severe Congestion & Cough

mucinex fast-max severe congestion & cough


C1

Mucinex for Kids

mucinex for kids (packet)* $0 (Tier 3)C1

Mucinex Maximum Strength mucinex maximum strength (tablet extended-release

12 hour)*$0 (Tier 3)

C1

Mucinex Multi-Symptom Cold Day/Night Pack

mucinex multi-symptom cold day/night pack (liquid)* $0 (Tier 3)C1

Mucinex Multi-Symptom Cold Night Time Childrens

mucinex multi-symptom cold night time childrens


C1

Mucinex Sinus-Max Pressure & Pain mucinex sinus-max pressure & pain (tablet)* $0 (Tier 3)C1

Mucinex Stuffy Nose & Cold Childrens

mucinex stuffy nose & cold childrens (liquid)* $0 (Tier 3)C1

Mucus Relief

mucus relief (tablet)* $0 (Tier 3)C1

Mucus Relief Sinus mucus relief sinus (tablet)* $0 (Tier 3)C1

Nasal Decongestant nasal decongestant (1% nasal solution, 30mg/5ml

syrup)*$0 (Tier 3)

C1

Nasal Decongestant Spray nasal decongestant spray (nasal solution)* $0 (Tier 3)C1

Night Time Multi-Symptom Cold/Flu Relief

night time multi-symptom cold/flu relief (capsule)* $0 (Tier 3)C1

NinjaCof

ninjacof (liquid)* $0 (Tier 3)C1

NinjaCof-A

ninjacof-a (liquid)* $0 (Tier 3)C1

NinjaCof-XG

ninjacof-xg (liquid)* $0 (Tier 3)C1

NoHist-DM

nohist-dm (liquid)* $0 (Tier 3)C1

Nucala

NUCALA (100MG INJECTION, 100MG/ML SOLUTION AUTO INJECTOR, 100MG/ML SOLUTION PREFILLED SYRINGE)

$3.80-$8.50 (Tier 2) PA, QL, LA

C1

Pain Relief Sinus PE Daytime pain relief sinus pe daytime (tablet)* $0 (Tier 3)C1

Pediatric Cough/Cold pediatric cough/cold (liquid)* $0 (Tier 3)C1

Phenylephrine HCl/Pyrilamine Maleate

phenylephrine hcl/pyrilamine maleate (tablet)* $0 (Tier 3)C1

Poly Hist Forte

poly hist forte (tablet)* $0 (Tier 3)C1

Poly-Hist DM

poly-hist dm (liquid)* $0 (Tier 3)



143


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Poly-Vent DM

poly-vent dm (tablet)* $0 (Tier 3)C1

Poly-Vent IR

poly-vent ir (tablet)* $0 (Tier 3)C1

Promethazine VC/Codeine promethazine vc/codeine (syrup)* $0 (Tier 3)C1

Promethazine/Codeine promethazine/codeine (syrup)* $0 (Tier 3)C1

Promethazine/Phenylephrine promethazine/phenylephrine (syrup) $1.25-$3.40 (Tier 1)C1

Promethazine-DM promethazine-dm (syrup)* $0 (Tier 3)C1

Pseudoephedrine HCl pseudoephedrine hcl (otc only) (tablet)* $0 (Tier 3)C1

Pulmosal

pulmosal (nebulized solution)* $0 (Tier 3)C1

Pulmozyme

PULMOZYME (INHALATION SOLUTION) $3.80-$8.50 (Tier 2) B/D, PA, QLC1

Respaire-30

respaire-30 (capsule)* $0 (Tier 3)C1

Robafen

robafen (syrup)* $0 (Tier 3)C1

Robafen CF Multi-Symptom Cold

robafen cf multi-symptom cold (liquid)* $0 (Tier 3)C1

Robafen Cough robafen cough (capsule)* $0 (Tier 3)C1

Robafen DM

robafen dm (syrup)* $0 (Tier 3)C1

Robafen DM Cough Clear robafen dm cough clear (syrup)* $0 (Tier 3)C1

Robafen DM Cough/Chest Congestion

robafen dm cough/chest congestion (liquid)* $0 (Tier 3)C1

Rynex DM

rynex dm (liquid)* $0 (Tier 3)C1

Siltussin DM DAS

siltussin dm das (liquid)* $0 (Tier 3)C1

Siltussin SA

siltussin sa (syrup)* $0 (Tier 3)C1

Siltussin-DM

siltussin-dm (syrup)* $0 (Tier 3)C1

SM Nasal Spray 12 Hour sm nasal spray 12 hour (nasal solution)* $0 (Tier 3)C1

SM Tussin DM

sm tussin dm (syrup)* $0 (Tier 3)C1

SM Tussin DM Cough/Chest Congestion

sm tussin dm cough/chest congestion (syrup)* $0 (Tier 3)C1

Sodium Chloride

sodium chloride (otc only) (3% nebulized solution,

7% nebulized solution)*$0 (Tier 3)

C1

Stahist AD

stahist ad (tablet, liquid)* $0 (Tier 3)C1

Stiolto Respimat STIOLTO RESPIMAT (AEROSOL SOLUTION) $3.80-$8.50 (Tier 2) QLC1

Sudogest

sudogest (otc only) (tablet)* $0 (Tier 3)C1

Sudogest 12 Hour sudogest 12 hour (tablet extended-release)* $0 (Tier 3)


144


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useC1

Sudogest PE

sudogest pe (tablet)* $0 (Tier 3)C1

Symbicort

SYMBICORT (AEROSOL) $3.80-$8.50 (Tier 2) QLC1

Trelegy Ellipta TRELEGY ELLIPTA (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1

Tussin DM

tussin dm (liquid)* $0 (Tier 3)C1

VanaCof

vanacof (liquid)* $0 (Tier 3)C1

VanaCof DM

vanacof dm (liquid)* $0 (Tier 3)C1

VanaCof-8

vanacof-8 (liquid)* $0 (Tier 3)C1

Virtussin A/C

virtussin a/c (oral solution)* $0 (Tier 3)C1

Virtussin DAC

virtussin dac (oral solution)* $0 (Tier 3)C1

Wixela Inhub

wixela inhub (aerosol powder) (generic advair) $1.25-$3.40 (Tier 1) QLC1

Zutripro

zutripro (oral solution)* $0 (Tier 3)A1

Skeletal Muscle Relaxants

B1

Skeletal Muscle RelaxantsC1

Baclofen

baclofen (10mg tablet, 20mg tablet, 5mg tablet) $1.25-$3.40 (Tier 1)C1

Chlorzoxazone

chlorzoxazone (500mg tablet) $1.25-$3.40 (Tier 1)C1

Cyclobenzaprine HCl cyclobenzaprine hcl (tablet) $1.25-$3.40 (Tier 1)C1

Dantrolene Sodium dantrolene sodium (capsule) $1.25-$3.40 (Tier 1)C1

Tizanidine HCl

tizanidine hcl (tablet) $1.25-$3.40 (Tier 1)A1

Sleep Disorder Agents

B1

GABA Receptor ModulatorsC1

Temazepam

temazepam (15mg capsule, 30mg capsule) $1.25-$3.40 (Tier 1) QLC1

Zaleplon

zaleplon (capsule) $1.25-$3.40 (Tier 1) QLC1

Zolpidem Tartrate zolpidem tartrate (10mg tablet immediate-release,

5mg tablet immediate-release)$1.25-$3.40 (Tier 1) QL

B1

Sleep Disorders, OtherC1

Belsomra

BELSOMRA (TABLET) $3.80-$8.50 (Tier 2) QLC1

Hetlioz

HETLIOZ (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1

Modafinil

modafinil (tablet) $1.25-$3.40 (Tier 1) PA, QLC1

Night Time Sleep Aid night time sleep aid (tablet)* $0 (Tier 3)C1

Ramelteon

ramelteon (tablet) $1.25-$3.40 (Tier 1) QLC1

Rozerem

ROZEREM (TABLET) $3.80-$8.50 (Tier 2) QLC1

SM Sleep Aid

sm sleep aid (tablet)* $0 (Tier 3)C1

Xyrem

XYREM (ORAL SOLUTION) $3.80-$8.50 (Tier 2) PA, QL, LA

145145

For Track Refered Purpose

E. Index of Covered Drugs

#

12 Hour Decongestant........139

1st Tier Unilet ComforTouch Lancets 28g....................... 113

1st Tier Unilet ComforTouch Lancets 30g....................... 113

A

A Thru Z Advanced................72

A Thru Z Select...................... 72

A Thru Z Select 50 + Advanced Formula................................ 72

A Thru Z Select Advanced....72

A Thru Z Select Ultimate Womens............................... 72

A Thru Z Ultimate Mens........ 72

A-10000.................................. 72

Abacavir..................................43

Abacavir Sulfate/Lamivudine44

Abacavir Sulfate/Lamivudine/Zidovudine........................... 44

Abc Plus Senior Adults 50+.. 72

Abelcet....................................30

Abilify Maintena..................... 40

Abiraterone Acetate...............34

Abstral.....................................16

Acamprosate Calcium DR.... 18

Acarbose................................ 46

Accu-Chek Aviva Plus......... 113

Accu-Chek Compact Plus...113

Accu-Chek Fastclix Lancet Device Kit...........................113

Accu-Chek Fastclix Lancets............................................ 113

Accu-Chek Guide................ 113

Accu-Chek Multiclix Lancet Device Kit...........................113

Accu-Chek Multiclix Lancets............................................ 113

Accu-Chek Safe-T-Pro Lancets............................................ 113

Accu-Chek Safe-T-Pro Pluslancets........................ 113

Accu-Chek Smartview Strips............................................ 113

Accu-Chek Soft Touch Lancets............................................ 113

Accu-Chek Softclix Lancet Device Kit...........................113

Accu-Chek Softclix Lancets114

Accutrend Glucose..............114

Acephen................................. 13

Acerola C 500........................ 72

Aceta-Gesic..........................134

Acetaminophen......................13

Acetaminophen/Codeine......16

Acetaminophen/Diphenhydramine................13

Acetazolamide....................... 53

Acetazolamide ER................. 53

Acetic Acid...........................133

Acetylcysteine......................139

Acid Gone.............................. 93

Acid Reducer Maximum Strength................................95

Acitretin.................................. 58

Acne Medication 10.............. 58

Acne Medication 5.................58

Actemra................................ 110

Actemra Actpen...................110

ActHIB.................................. 110

Acti-Lance Lancets 28g...... 114

Acti-Lance Lite Safety Lancets 28g..................................... 114

Acti-Lance Special Safety Lancets 17g....................... 114

Acti-Lance Special Safetylancets 17g..............114

Acti-Lance Universal Safety Lancets 23g....................... 114

Actical..................................... 73

Actidose/Sorbitol...................93

Actimmune...........................110

Active 1st Blood Lancets 30g/Easy Twist Cap.................. 114

Acyclovir................................. 42

Acyclovir Sodium...................42

Adacel...................................110

Adapalene.............................. 58

Adcirca................................. 138

Adempas.............................. 138

Adjustable Lancing Device. 114

Advair Diskus....................... 139

Advair HFA........................... 139

Advance Micro-Draw Test Strips.................................. 114

Advanced Stress Formula/Zinc.............................................. 73

Advantage Care Oral Electrolyte Pediatric............ 60

Advocate Lancets................114

Advocate Lancets 30g........ 114

146146

Advocate Lancing Device... 114

Advocate Rapid-Safe Lancing Device................................ 114

Advocate Redi-Code........... 114

Advocate Redi-Code+ Test Strips.................................. 114

Advocate Safety Lancets.... 114

Advocate Safety Lancets 26g............................................ 114

Advocate Test Strips........... 114

Afinitor.................................... 36

Afinitor Disperz...................... 36

Agamatrix Amp No Code Test Strips.................................. 114

Agamatrix Jazz Test Strips. 114

Agamatrix Presto Test Strips............................................ 114

Agamatrix Ultra-Thin Lancets 33g..................................... 114

Aimovig...................................32

Akwa Tears...........................130

Ala Cort.................................100

Ala-Hist IR.............................134

Ala-Hist PE............................134

Alahist CF............................. 139

Alahist DM............................139

Alba-Lybe NR....................... 114

Albendazole........................... 38

Albenza...................................38

Albuterol Sulfate.................. 137

Alclometasone Dipropionate............................................ 100

Alcohol Prep Pads...............114

Alecensa.................................36

Alendronate Sodium........... 112

Alfuzosin HCl ER....................99

Alinia....................................... 38

All Day Allergy......................134

All Day Allergy Childrens.... 134

All Day Allergy-D.................. 134

All Day Relief..........................14

All-Nite Cold & Flu Nighttime Relief.................................. 139

Aller-Chlor.............................134

Allergy...................................134

Allergy Relief........................134

Allergy Relief D-24............... 134

Allopurinol.............................. 32

Almacone............................... 94

Almacone Double Strength.. 94

Alosetron HCl.........................96

Alphagan P...........................132

Alprazolam............................. 45

Altavera.................................102

Alternate Site Lancing Device............................................ 114

Aluminum Hydroxide.............94

Alunbrig.................................. 36

Alyacen 1/35........................102

Alyq.......................................138

Amantadine HCl.....................39

AmBisome..............................30

Ambrisentan.........................138

Amethia................................ 102

Amethia Lo...........................102

Amikacin Sulfate....................19

Amiloride HCl.........................53

Amiloride/Hydrochlorothiazide.............................................. 52

Aminosyn II.............................60

Aminosyn-PF.......................... 60

Amiodarone HCl.................... 50

Amitiza.................................... 96

Amitriptyline HCl....................29

Amlodipine Besylate..............51

Amlodipine Besylate/Atorvastatin Calcium...........52

Amlodipine Besylate/Benazepril HCl.....................52

Ammonium Lactate............... 58

Amoxapine............................. 29

Amoxicillin.............................. 22

Amoxicillin/Clavulanate Potassium............................ 22

Amoxicillin/Clavulanate Potassium ER...................... 22

Amphetamine/Dextroamphetamine........... 56

Amphotericin B...................... 30

Ampicillin................................22

Ampicillin Sodium..................22

Ampicillin-Sulbactam.............22

Ampyra................................... 57

Anadrol-50............................102

Anagrelide HCl.......................49

Anastrozole............................ 36

Androderm........................... 102

Animal Chews........................ 73

Animal Shapes.......................73

Animal Shapes/Iron...............73

Anoro Ellipta.........................139

147147

Antacid Calcium Extra Strength................................94

Antacid Calcium Regular Strength................................94

Antacid Extra Strength.......... 94

Antacid Maximum Strength.. 94

Antacid Plus Anti-Gas Relief. 94

Anti-Diarrheal..........................94

Anti-Fungal Powder............... 30

Antifungal............................... 30

Anu-Med................................. 58

AP-Hist DM...........................139

Apatate Forte......................... 73

Apetex.....................................73

Apetigen................................. 73

Apetigen-Plus.........................73

Apokyn....................................39

Apraclonidine.......................132

Aprepitant...............................30

Apri....................................... 102

Apriso................................... 112

Aprodine...............................139

Aptiom.................................... 26

Aptivus....................................44

Aqua Lance Adjustable Lancing Device..................114

AquADEKs..............................73

Aqueous Vitamin D Infants... 73

Aqueous Vitamin E................ 73

Aralast NP...............................98

Aranelle................................ 102

Aranesp Albumin Free.......... 49

Arcalyst.................................110

Aripiprazole............................ 40

Aripiprazole ODT................... 40

Aristada.................................. 40

Aristada Initio......................... 40

Arnuity Ellipta.......................136

Artificial Tears...................... 130

Ascorbic Acid.........................73

Ashlyna.................................102

Aspir-Low................................14

Aspirin.....................................14

Aspirin EC...............................14

Aspirin Low Dose...................14

Aspirin/Dipyridamole............ 49

Assure 4 Test Strips............ 114

Assure Comfort Lancets Ultra Thin 28g............................. 114

Assure Comfort Lancets Ultra Thin 30g............................. 114

Assure Haemolance Plus High Flow 18g............................ 114

Assure Haemolance Plus Low Flow 25g............................ 114

Assure Haemolance Plus Micro Flow 28g..................114

Assure Haemolance Plus Normal Flow 21g............... 114

Assure Haemolance Plus Pediatric Blade.................. 114

Assure Lance Lancets.........114

Assure Lance Lancets 21g. 115

Assure Lance Plus Safety Lancets 25g....................... 115

Assure Lance Plus Safety Lancets 30g....................... 115

Assure Platinum Test Strips............................................ 115

Assure Prism Multi Test Strips............................................ 115

Atazanavir Sulfate.................. 44

Atenolol.................................. 51

Atenolol/Chlorthalidone........52

Atomoxetine........................... 56

Atorvastatin Calcium............. 54

Atovaquone............................ 38

Atovaquone/Proguanil HCl...38

Atripla..................................... 43

Atropine Sulfate................... 130

Atrovent HFA........................137

Aubagio.................................. 57

Aubra.................................... 102

Augmented Betamethasone Dipropionate......................100

Auryxia....................................72

Austedo.................................. 56

Auto-Lancet Mini..................115

Autolet Impression Lancing Device................................ 115

Autolet Lancing Device....... 115

Autolet Plus..........................115

Avandia...................................46

Aviane...................................102

Avonex....................................57

Avonex Pen............................ 57

Azathioprine......................... 108

Azelaic Acid............................58

Azelastine HCl............. 131, 134

Azithromycin.......................... 23

Aztreonam.............................. 22

B

B Complex..............................73

148148

B Complex/C......................... 73

B Complex/Folic Acid........... 73

B-1...........................................73

B-12.........................................73

B-12 Dots................................74

B-12 TR...................................74

B-2...........................................74

B-6...........................................74

B-Complex..............................74

B-Complex Formula 1............74

B-Complex Plus Vitamin C.... 74

B-Complex w/C......................74

B-Complex with B-12............. 74

B-Complex/C......................... 74

B-Complex/Vitamin C/High Potency................................ 74

B12..........................................74

B6 Natural.............................. 74

Bacitracin............................... 20

Bacitracin Zinc....................... 20

Bacitracin/Neomycin/Polymyxin.............................20

Bacitracin/Polymyxin B.......130

Baclofen............................... 144

Balance B-100........................74

Balance B-50..........................74

Balanced B-100......................74

Balanced B-50........................74

Balanced B-50 Complex....... 74

Balsalazide Disodium..........112

Balversa..................................36

Balziva.................................. 102

Banophen.............................134

Banzel..................................... 26

Baraclude............................... 42

Bayer Breeze 2 Test Disc....115

Bayer Contour Blood Glucose Test Strips..........................115

Bayer Microlet 2 Lancing Device................................ 115

Bayer Microlet Lancets....... 115

BCG Vaccine........................110

BD Lancet Ultrafine 30g......115

BD Lancet Ultrafine 33g......115

BD Microtainer Lancets...... 115

Bee Zee.................................. 74

Belsomra.............................. 144

Benazepril HCl....................... 50

Benazepril HCl/Hydrochlorothiazide............52

Benlysta................................110

Benznidazole..........................38

Benzonatate......................... 139

Benzoyl Peroxide...................58

Benzoyl Peroxide Wash........ 58

Benztropine Mesylate............39

Bepreve................................ 132

Berinert.................................108

Beta Carotene........................ 74

Betamethasone Dipropionate............................................ 100

Betamethasone Valerate.....100

Betaseron............................... 57

Betaxolol HCl....................... 132

Bethanechol Chloride............99

Bethkis..................................137

Betimol................................. 132

Bevespi Aerosphere............139

Bexarotene............................. 38

Bexsero................................ 110

Bicalutamide.......................... 34

Bicillin C-R.............................. 22

Bicillin L-A...............................23

Biktarvy................................... 44

Biltricide..................................38

Binosto................................. 112

Biocal......................................74

Biosupp.................................. 74

Biotin.......................................74

Biotin 5000............................. 74

Biotin/Maximum Strength.....74

Biovol...................................... 74

Bisacodyl EC..........................96

Biscolax.................................. 96

Bismatrol................................ 94

Bismatrol Maximum Strength.............................................. 94

Blephamide..........................130

Blephamide S.O.P............... 130

Blisovi 24 Fe.........................102

Blisovi Fe 1.5/30..................102

Blood Glucose Test Strips..115

Blood Glucose Test Strips Premium.............................115

Blue Gel..................................58

Boostrix................................ 110

Bosentan.............................. 138

Bosulif.....................................36

Braftovi................................... 36

Breo Ellipta...........................139

149149

Briellyn..................................102

Brilinta.....................................49

Brimonidine Tartrate........... 132

Briviact....................................25

Bromfed DM.........................139

Bromocriptine Mesylate........ 39

Bromphen/Pseudoephedrine HCl/Dextromethorphan HBr............................................ 139

Brotapp DM..........................139

Budesonide................. 112, 136

Budesonide ER....................112

Budesonide Nasal Spray.... 136

Bullseye Mini Safety Lancets............................................ 115

Bumetanide............................53

Buprenorphine.......................15

Buprenorphine HCl................18

Buprenorphine HCl/Naloxone HCl........................................18

Bupropion HCl....................... 27

Bupropion HCl SR...........18, 28

Bupropion HCl XL..................28

Buspirone HCl........................45

Butalbital/Acetaminophen....13

Butalbital/Acetaminophen/Caffeine 50mg-325mg-40mg Tablet, 50mg-325mg-40mg Capsule)...............................13

Butalbital/Aspirin/Caffeine... 13

Butorphanol Tartrate............. 16

Bydureon Bcise..................... 46

Bydureon Pen........................ 46

Byetta......................................46

Bystolic................................... 51

C

C 1000.................................... 74

C 1000/Bioflavonoids/Rosehips.............................. 74

C 250...................................... 74

C 500...................................... 74

C Complex..............................75

C-1000.................................... 75

C-1000 Prolonged Release...75

C-1000/Rose Hips................. 75

C-250...................................... 75

C-500...................................... 75

C-500 Prolonged Release..... 75

C-500/Rose Hips................... 75

C-Chewable............................75

Cabergoline..........................107

Cablivi..................................... 49

Cabometyx............................. 36

Cal-Gest Antacid.................... 94

Cal-Mag-Zinc-D.......................62

Calcet Petites......................... 60

Calci-Chew............................. 60

Calcidol...................................75

Calcipotriene..........................58

Calcitonin-Salmon............... 112

Calcitrate................................ 60

Calcitriol......................... 58, 113

Calcium...................................60

Calcium + D3..........................60

Calcium 500 + D.................... 61

Calcium 500 + D High Potency.............................................. 61

Calcium 500 + D3.................. 61

Calcium 500+d.......................61

Calcium 500+d3.....................61

Calcium 500/D.......................61

Calcium 500/Vitamin D3.......61

Calcium 600........................... 61

Calcium 600 + D.................... 61

Calcium 600 + D High Potency.............................................. 61

Calcium 600 + D Plus Minerals.............................................. 61

Calcium 600 + D3.................. 61

Calcium 600 + D3 Plus Minerals................................61

Calcium 600 High Potency... 61

Calcium 600 with Vitamin D..61

Calcium 600+D...................... 61

Calcium 600/Vitamin D......... 61

Calcium 600/Vitamin D3.......61

Calcium Acetate.....................72

Calcium Antacid.................... 94

Calcium Antacid Extra Strength................................94

Calcium Carbonate......... 61, 94

Calcium Carbonate/D3......... 61

Calcium Carbonate/Vitamin D.............................................. 61

Calcium Citrate...................... 61

Calcium Citrate + D............... 62

Calcium Citrate + D3............. 62

Calcium Citrate + D3 Max Imum.................................... 62

Calcium Citrate + D3 Maximum.............................................. 62

Calcium Citrate Malate/Vitamin D........................................... 62

150150

Calcium Citrate Plus/Magnesium.......................... 62

Calcium Citrate w/D.............. 62

Calcium Citrate/Vitamin D.... 62

Calcium Citrate/Vitamin D3.. 62

Calcium Extra D3................... 62

Calcium for Women...............62

Calcium Gluconate................ 62

Calcium High Potency...........62

Calcium High Potency + Vitamin D..............................62

Calcium Oyster Shell............. 62

Calcium Plus Vitamin D3.......62

Calcium+d3............................ 62

Calcium/C/D..........................62

Calcium/Magnesium/Zinc....62

Calcium/Vitamin D.................62

Calcium/Vitamin D3.............. 62

Calquence.............................. 36

Caltrate 600 + D.....................62

Caltrate 600 + D Plus Minerals.............................................. 62

Caltrate 600 + D3 Soft Chews.............................................. 62

Camila...................................106

Camrese Lo..........................102

Canasa..................................112

Candesartan Cilexetil............ 50

Candesartan Cilexetil/Hydrochlorothiazide............52

Caprelsa................................. 36

Capsaicin................................58

Captopril.................................50

Captopril/Hydrochlorothiazide.............................................. 52

Carafate.................................. 97

Carbaglu.................................62

Carbamazepine......................26

Carbamazepine ER................26

Carbidopa/Levodopa............39

Carbidopa/Levodopa ER......39

Carbidopa/Levodopa ODT... 39

Carbidopa/Levodopa/Entacapone..........................39

Careone Advanced Lancing Device................................ 115

Careone Blood Glucose Test Strips/Premium................. 115

Careone Blood Glucose Test Strips/Value....................... 115

Careone Lancet Ultra Thin..115

Caresens N Blood Glucose Test Strips..........................115

Caretouch Blood Glucose Test Strips.................................. 115

Caretouch Lancing Device with Ejector................................ 115

Caretouch Twist Lancets 28g............................................ 115



Carteolol HCl........................132

Cartia XT.................................51

Carvedilol................................51

Caspofungin Acetate.............30

Cayston................................ 138

Caziant..................................102

Cefaclor.................................. 21

Cefadroxil............................... 21

Cefazolin Sodium.................. 21

Cefdinir................................... 21

Cefepime................................ 21

Cefixime..................................21

Cefotaxime Sodium............... 21

Cefotetan................................21

Cefoxitin Sodium................... 21

Cefpodoxime Proxetil............21

Cefprozil................................. 21

Ceftazidime............................ 21

Ceftriaxone Sodium...............21

Cefuroxime Axetil.................. 21

Cefuroxime Sodium...............22

Celontin.................................. 25

Centamin................................ 75

Centravites............................. 75

Centravites 50 Plus................75

Centrum..................................75

Centrum Adults......................75

Centrum Kids Complete........75

Centrum Silver....................... 75

Centrum Silver Adult 50+......75

Centrum Silver Ultra Womens.............................................. 75

Centrum Specialist Heart......75

Centrum Ultra Mens.............. 75

Centrum Ultra Womens.........76

Cephalexin............................. 22

Cerovite Advanced Formula. 76

Cerovite Jr.............................. 76

151151

Certa Plus...............................76

Certavite Senior/Antioxidant Nutrients...............................76

Certavite/Antioxidants...........76

Cesamet................................. 30

Cetirizine HCl....................... 134

Cetirizine HCl Allergy Childrens............................................ 134

Cetirizine HCl Childrens Allergy............................................ 134

Cetirizine HCl/Pseudoephedrine HCl ER 134

Chantix....................................18

Chantix Continuing Month Pak.............................................. 18

Chantix Starting Month Pak..19

Chemet................................... 72

Chenodal................................ 94

Cheratussin AC....................139

Chewable Calcium.................62

Chewable Vitamin C.............. 76

Chewable Vite Childrens.......76

Chewable Vite with Iron/Childrens..............................76

Childrens Allergy................. 134

Childrens Aspirin................... 14

Childrens Chewable Multivitamin..........................76

Childrens Chewable Vitamin 76

Childrens Chewable Vitamins.............................................. 76

Childrens Chewable Vitamins/Iron........................................76

Childrens Ibuprofen...............14

Childrens Loratadine...........134

Childrens Silfedrine............. 139

Childs Ibuprofen.................... 14

Chlo Tuss............................. 139

Chlordiazepoxide HCl........... 45

Chlorhexidine Gluconate Oral Rinse.................................... 57

Chloroquine Phosphate........ 38

Chlorothiazide........................54

Chlorphen SR...................... 134

Chlorpromazine HCl.............. 40

Chlorthalidone....................... 54

Chlorzoxazone..................... 144

Cholbam................................. 98

Cholestyramine......................54

Cholestyramine Light............ 54

Ciclopirox............................... 30

Ciclopirox Nail Lacquer.........30

Ciclopirox Olamine................ 30

Cilostazol................................ 49

Cimduo................................... 44

Cimetidine.............................. 95

Cimetidine HCl.......................95

Cimzia...................................108

Cinacalcet HCl..................... 113

Cinryze..................................108

Ciprofloxacin.......................... 24

Ciprofloxacin HCl...................24

Ciprofloxacin I.V. in D5W...... 24

Citalopram HBr...................... 28

Citracal + D3 Maximum.........62

Citracal Maximum..................62

Citrus Calcium + D.................62

Claravis................................... 58

Clarithromycin........................23

Clarithromycin ER..................23

Clenpiq................................... 96

Clever Chek Auto-Code Test Strips.................................. 116

Clever Chek Auto-Code Voice Test Strips..........................116

Clever Chek Lancets Ultrathin............................................ 116

Clever Chek Lancets Ultrathin 30g..................................... 116

Clever Chek Test Strips...... 116

Clever Choice Auto-Code Pro Test Strips..........................116

Clever Choice Comfort EZ Lancets 23g....................... 116

Clever Choice Comfort EZ Lancets 28g....................... 116

Clever Choice Micro Test Strips.................................. 116

Clever Choice No Coding Test Strips.................................. 116

Clever Choice Talk No Coding Test Strips..........................116

Climara Pro.......................... 102

Clindamycin HCl.................... 20

Clindamycin Palmitate HCl... 20

Clindamycin Phosphate..20, 58

Clindamycin Phosphate in D5W......................................20

Clindamycin/Benzoyl Peroxide.............................................. 58

Clobazam............................... 25

Clobetasol Propionate........ 100

Clobetasol Propionate Emollient............................ 100

152152

Clomipramine HCl................. 29

Clonazepam........................... 45

Clonazepam ODT.................. 45

Clonidine HCl......................... 49

Clonidine HCl ER...................56

Clopidogrel.............................49

Clorazepate Dipotassium......45

Clotrimazole........................... 30

Clotrimazole Anti-Fungal.......30

Clotrimazole/Betamethasone Dipropionate........................ 58

Clozapine................................41

Clozapine ODT.......................41

Coaguchek Lancets............ 116

Coartem..................................38

Coats Aloe Creme................. 58

Coats Aloe Gelly.................... 58

Coats Aloe Moisturizing Lotion.............................................. 58

Codeine Sulfate..................... 16

Codeine/Guaifenesin.......... 139

Colchicine...............................32

Coleman Botanicals Insectrepellent..................... 58

Coleman Insect Repellent/High & Dry............................58

Coleman Skinsmart Insect Repellent..............................58

Colesevelam HCl................... 54

Colestipol HCl........................ 54

Colistimethate Sodium..........20

Colocort................................112

Combigan.............................132

Combivent Respimat...........139

Cometriq.................................36

Comfort Assured Lancets Micro Thin 33g.................. 116

Comfort Assured Lancets Super Thin 28g..................116

Comfort Lancets.................. 116

Companion.............................76

Compete.................................76

Complera................................43

Complete................................76

Complete Allergy Medicine 134

Complex B-100...................... 76

Compro...................................29

Constulose............................. 96

Contour Next Blood Glucose Test.....................................116

Cool Blood Glucose Test Strips.................................. 116

Copiktra.................................. 35

Coral Calcium........................ 62

Corlanor..................................52

Cortisone Acetate................100

Cosentyx.................................58

Cosentyx Sensoready Pen....58

Cosopt PF............................ 132

Cotellic....................................36

Cough DM............................139

Cough Syrup........................139

Coumadin...............................48

Cranberry Urinary Comfort... 76

Creon...................................... 98

Crinone.................................106

Crixivan...................................44

Cromolyn Sodium.94, 132, 138

Cryselle-28............................103

Cuprimine...............................99

Cutter Backwoods................. 58

Cutter Backwoods Dry.......... 58

Cutter Lemon Eucalyptus..... 58

Cuvposa..................................93

CVS Advanced Glucose Meter Test Strips..........................116

CVS B Complex Plus C......... 76

CVS B-1.................................. 76

CVS B-12................................ 76

CVS B6................................... 76

CVS Beta Carotene............... 76

CVS Biotin.............................. 76

CVS Biotin High Potency...... 76

CVS Calcium.......................... 62

CVS Calcium 600 & Vitamin D3.............................................. 63

CVS Calcium 600 + D............63

CVS Calcium Chewables 600plus.................................63

CVS Calcium Citrate + D.......63

CVS Calcium Citrate + D/Magnesium.......................... 63

CVS Calcium/Magnesium/Zinc.............................................. 63

CVS Childrens Chewable Complete..............................76

CVS Childrens Chewable Multivitamin/Iron................. 76

CVS Daily Multiple................. 76

CVS Daily Multiple for Men...76

CVS Daily Multiple for Women.............................................. 76

153153

CVS Daily Multiple for Women 50+........................................76

CVS Daily Multiple Plus Iron/Calcium/Zinc....................... 76

CVS Electrolyte Solution....... 63

CVS Gummy Dinos................76

CVS Hair/Skin/Nails..............76

CVS Iron................................. 63

CVS Lancets Micro Thin 33g............................................ 116

CVS Lancets Micro-Thin 33g............................................ 116

CVS Lancets Thin 26g........ 116

CVS Lancets Ultra Thin 30g............................................ 116

CVS Lancets Ultra-Thin 30g............................................ 116

CVS Lancing Device............116

CVS Laxative Dietary Supplement......................... 96

CVS Magnesium.................... 63

CVS Pediatric Electrolyte...... 63

CVS Pediatric Electrolyte Freezer Pops........................63

CVS Selenium........................ 63

CVS Slow Release Iron......... 63

CVS Spectravite Adult 50+... 76

CVS Spectravite Advanced Formula................................ 77

CVS Spectravite Senior.........77

CVS Spectravite Ultra Health Mens.....................................77

CVS Spectravite Ultra Mens Health................................... 77

CVS Spectravite Ultra Women.............................................. 77

CVS Spectravite Ultra Womens Health................................... 77

CVS Spectravite Ultra Womens Health Senior....................... 77

CVS Super B Complex/C......77

CVS Ultra Thin Lancets.......116

CVS Vitamin A........................77

CVS Vitamin B-12...................77

CVS Vitamin B-12 TR.............77

CVS Vitamin B-2.....................77

CVS Vitamin B12................... 77

CVS Vitamin C........................77

CVS Vitamin E........................ 77

CVS Zinc.................................63

Cyclafem.............................. 103

Cyclobenzaprine HCl.......... 144

Cyclophosphamide............... 34

Cycloset..................................46

Cyclosporine........................ 108

Cyclosporine Modified........ 108

Cyproheptadine HCl............134

Cyred Eq...............................103

Cystadane.............................. 98

Cystagon................................ 98

Cystaran............................... 130

D

D-Vi-Sol................................... 78

Daily Combo Multi Vitamin....77

Daily Multiple Vitamin............77

Daily Multiple Vitamin/Iron....77

Daily Multiple Vitamins.......... 77

Daily Value Multivitamin........ 77

Daily Vitamin.......................... 77

Daily Vitamin Formula+ir On. 77

Daily Vitamin Formula+iron...77

Daily Vitamin Formula+minerals..............................77

Daily Vite.................................77

Daily Vite Multivitamin/Iron... 77

Daily-Vite.................................77

Daily-Vite/Iron/Beta-Carotene.............................................. 78

Dalfampridine ER...................57

Daliresp................................ 138

Dalvance.................................20

Danazol.................................102

Dantrolene Sodium............. 144

Dapsone................................. 33

Daptacel............................... 110

Daptomycin............................ 20

Daraprim.................................38

Daurismo................................ 36

Deblitane.............................. 106

Deconex DMX...................... 139

Deconex IR...........................139

Deep Sea Nasal Spray........ 139

Deferasirox............................. 72

Dekas Essential......................78

Dekas Plus..............................78

Delstrigo................................. 43

Delsym..................................139

Delsym Cough + Chest Congestion DM................. 139

Delsym Cough + Chest Congestion DM Childrens 140

Delsym Cough + Cold Daytime............................................ 140

154154

Delsym Cough + Cold Nighttime Childrens.......... 140

Delsym Cough Childrens.... 140

Delyla.................................... 103

Demeclocycline HCl.............. 24

Demser................................... 52

Depen Titratabs..................... 99

Depo-Provera....................... 106

Descovy.................................. 44

Desipramine HCl....................29

Desmopressin Acetate........101

Desogestrel/Ethinyl Estradiol............................................ 103

Desonide.............................. 100

Desoximetasone.................. 100

Desvenlafaxine ER.................28

Dexamethasone...................100

Dexamethasone Intensol.... 100

Dexamethasone Sodium Phosphate..........................132

Dexmethylphenidate HCl...... 56

Dexmethylphenidate HCl ER 56

Dextroamphetamine Sulfate. 56

Dextromethorphan Polistirex............................................ 140

Dextrose 10%.........................63

Dextrose 10%/NaCl 0.2%..... 63

Dextrose 10%/NaCl 0.45%... 63

Dextrose 2.5%/NaCl 0.45%.. 63

Dextrose 5%........................... 63

Dextrose 5%/NaCl 0.2%........63

Dextrose 5%/NaCl 0.225%... 63



Dextrose 5%/NaCl 0.9%........63

Dialy vite 800..........................78

Diastat AcuDial.......................25

Diastat Pediatric.....................25

Diatrue Plus Blood Glucose Test Strips..........................116

Diazepam......................... 45, 46

Diazepam Intensol................. 46

Dibucaine............................... 58

Diclofenac Epolamine........... 14

Diclofenac Potassium............14

Diclofenac Sodium..14, 59, 132

Diclofenac Sodium DR..........14

Diclofenac Sodium ER.......... 14

Dicloxacillin Sodium.............. 23

Dicyclomine HCl.................... 93

Didanosine............................. 44

Dificid......................................23

Diflunisal.................................14

Digitek.....................................52

Digox.......................................52

Digoxin....................................52

Dihydroergotamine Mesylate32

Dilantin....................................27

Dilantin INFATABS................ 27

Dilt-XR..................................... 51

Diltiazem HCl..........................51

Diltiazem HCl ER....................51

Dimaphen Childrens............134

Dimaphen DM Cold & Cough............................................ 140

Dino-Life................................. 78

Dino-Life with Extra C............ 78

Dino-Life with Iron & Zinc......78

Dipentum..............................112

Diphenhist............................ 134

Diphenhydramine HCl.........134

Diphenoxylate/Atropine........ 94

Diphtheria/Tetanus Toxoids Adsorbed Pediatric........... 111

Disulfiram............................... 18

Diuril........................................54

Divalproex Sodium................ 46

Divalproex Sodium DR.......... 46

Divalproex Sodium ER.......... 46

Doc-Q-Lace.............................96

Docusate Sodium & Senna Stimulant Laxative/Stool Softener................................96

Docusol Kids.......................... 96

Docusol Plus Mini-Enema..... 96

Dofetilide................................ 50

DOK........................................ 96

DOK PLUS..............................96

Donepezil HCl........................ 27

Donepezil HCl ODT............... 27

Dorzolamide HCl................. 132

Dorzolamide HCl/Timolol Maleate.............................. 132

Dorzolamide HCl/Timolol Maleate Preservative Free 132

Dovato.....................................42

Doxazosin Mesylate...............50

Doxepin HCl.....................29, 59

Doxercalciferol.....................113

Doxy 100.................................24

Doxycycline............................ 24

155155

Doxycycline Hyclate.............. 24

Doxycycline Monohydrate.... 24

Dr Smiths Diaper....................59

Dr Smiths Diaper Rash Spray.............................................. 59

Dronabinol..............................30

Droplet Lancets Ultra Thin 30g............................................ 116

Droplet Lancing Device.......116

Drospirenone/Ethinyl Estradiol............................................ 103

Droxia......................................34

Drug Mart Adjustable Lancing Device................................ 116

Drug Mart On-The-Go Lancets Gentle 30g......................... 116

Drug Mart Unilet Lancets Super Thin 30g..................116

Drug Mart Unilet Lancets Ultra Thin 28g............................. 116

Drug Mart Unilet Micro Thin Lancets 33g....................... 116

Duavee..................................103

Duloxetine HCl....................... 56

Duramorph............................. 16

Durezol................................. 132

Dutasteride.............................99

E

E-400.......................................78

E-Oil.........................................78

E-Z Ject Lancets.................. 118

E-Z Ject Lancets 21g...........118

E-Z Ject Lancets Color........118

E-Z Ject Lancets Super Thin 30g..................................... 118

E-Z Ject Lancets Thin 26g.. 118

E-Zject Lancets Micro-Thin 33g............................................ 118

E.E.S. Granules...................... 23

E400 Mixed............................ 78

Ear Drops............................. 133

Earwax Treatment Drops.... 133

Easy Comfort Lancets.........116

Easy Comfort Lancets 30g/Pull Top..................................... 116

Easy Comfort Lancets 30g/Thin Top.............................116

Easy Mini Eject Lancing Device............................................ 117

Easy Mini Lancing Device...117

Easy Plus II Blood Glucose Test.....................................117

Easy Step Test Strips.......... 117

Easy Talk Blood Glucose Test Strips.................................. 117

Easy Touch Glucose Test Strips.................................. 117

Easy Touch HealthPro Glucose Test Strips..........................117

Easy Touch Lancets 21g/Pressure Activated............ 117



Easy Touch Lancets 26g/Pull-Top..................................... 117

Easy Touch Lancets 26g/Twist............................................ 117




Easy Touch Lancets 30g/Button-Activated................117








Easy Touch Lancing Device/Ejector................................ 117

Easy Touch Safety Lancets21g/Pressure Activated............................ 117


Easy Touch Safety Lancets26g/Button Activated............................................ 117


Easy Touch Safety Lancets28g/Button Activated............................................ 117

156156


Easy Trak Blood Glucose Test Strips.................................. 118

Easy Twist & Cap Lancets.. 118

EasyGluco............................ 118

EasyGluco Plus....................118

EASYMax 15 Test Strips..... 118

EASYMax Test Strips.......... 118

Econazole Nitrate...................30

Econtra EZ............................106

ED A-Hist......................134, 140

ED A-Hist DM....................... 140

ED A-Hist PSE...................... 140

ED Bron GP..........................140

ED Chlorped........................ 134

ED Chlorped D.....................134

ED Chlorped Jr.................... 135

ED-APAP.................................13

Edurant................................... 43

Efavirenz................................. 43

Egrifta................................... 108

Element Compact Test Strips............................................ 118

Element Test Strips............. 118

Elestrin..................................103

Elidel....................................... 59

Eliquis..................................... 48

Eliquis Starter Pack............... 48

Elmiron....................................99

Embeda.................................. 15

Embrace Blood Glucose Test Strips.................................. 118

Embrace Evo Blood Glucose Test Strips..........................118

Embrace Lancets Ultra Thin 30g..................................... 118

Embrace Pro Blood Glucose Test Strips..........................118

Emcyt......................................34

Emend.................................... 30

Emoquette............................103

Emsam....................................28

Emtriva....................................44

Enalapril Maleate................... 50

Enalapril Maleate/Hydrochlorothiazide............52

Enbrel................................... 108

Enbrel Mini........................... 108

Enbrel SureClick..................109

EndaCof-DM.........................140

Endocet.................................. 16

Endur-Acin..............................78

Endur-C/Rose Hips............... 78

Enema Ready-To-Use............96

Enemeez Mini.........................96

Enemeez Plus........................ 96

Enfamil Enfalyte..................... 63

Engerix-B.............................. 111

Enoxaparin Sodium............... 48

Enpresse-28......................... 103

Enskyce................................ 103

Entacapone............................ 39

Entecavir.................................42

Entresto.................................. 52

Enulose...................................96

Envarsus XR.........................109

Epclusa...................................42

Epidiolex.................................25

Epinastine HCl..................... 132

Epinephrine..........................137

Epitol.......................................27

Epivir HBV.............................. 42

Eplerenone............................. 53

Eprosartan Mesylate..............50

EQ Blood Glucose Test Strips............................................ 118

Eq Calcium 500+d................. 63

Eq Calcium 600+d................. 63

Eq Calcium Citrate+d............ 63

EQ Complete Multivitamin Adults 50+............................78

EQ Complete Multivitamin Adults Under 50.................. 78

EQ One Daily Womens Health.............................................. 78

Eq Slow-Release Iron............ 63

EQL B Complex 50................ 78

EQL B-6...................................78

EQL Calcium 600mg/Vitamind3............................. 64

EQL Calcium Citrate with Vitamin D..............................64

EQL Calcium Citrate/ Vitamin D3......................................... 64

EQL Calcium/Vitamin D........ 64

EQL Color Lancets Micro Thin 33g..................................... 118

EQL One Daily Mens Health Formula................................ 78

EQL One Daily Womens........78

EQL Vitamin B-12...................78

157157

EQL Vitamin B-12 TR.............78

EQL Vitamin C........................78

EQL Vitamin C/Rose Hips.....78

EQL Vitamin E........................ 78

Eraxis...................................... 31

Ergocalciferol......................... 78

Ergotamine Tartrate/Caffeine.............................................. 32

Erivedge..................................36

Erleada....................................34

Erlotinib HCl........................... 36

Errin...................................... 106

Ertapenem..............................22

Ery........................................... 59

Ery-Tab....................................23

EryPed 200.............................23

EryPed 400.............................23

Erythrocin Lactobionate........23

Erythromycin....................23, 59

Erythromycin Base.................23

Erythromycin DR....................24

Erythromycin Ethylsuccinate 24

Erythromycin/Benzoyl Peroxide............................... 59

Esbriet...................................138

Escitalopram Oxalate............ 28

Esomeprazole Magnesium.. 97, 98

Essentia.................................. 78

Essential Balance.................. 78

Estarylla................................ 103

Estradiol................................103

Estradiol Valerate.................103

Estring.................................. 103

Ethambutol HCl......................33

Ethosuximide......................... 25

Ethynodiol Diacetate/Ethinyl Estradiol............................. 103

Etidronate Disodium............113

Etodolac................................. 14

EvenCare G2 Test Strips.....118

EvenCare G3 Test Strips.....118

Evencare Mini Blood Glucose Test Strips..........................118

Evolution Autocode............. 118

Evotaz..................................... 44

Exemestane............................36

Exjade..................................... 72

Extra Action Cough............. 140

Eye Drops.............................132

Eye Itch Relief...................... 132

EZ Smart Blood Glucose Lancets...............................118

EZ Smart Blood Glucose Test Strips.................................. 118

EZ Smart Plus Blood Glucose Test Strips..........................118

Ezetimibe................................54

Ezetimibe/Simvastatin...........54

EZFE 200................................64

F

Falmina................................. 103

Famciclovir............................. 42

Famotidine............................. 95

Fanapt.....................................40

Fanapt Titration Pack............ 40

Fareston..................................34

Farxiga.................................... 46

Farydak...................................36

Fayosim................................ 103

FE C Tab.................................64

Febuxostat..............................32

Felbamate...............................26

Femynor............................... 103

Fenofibrate............................. 54

Fentanyl.................................. 15

Fentanyl Citrate Oral Transmucosal...................... 16

Feosol..................................... 64

Feosol Bifera.......................... 64

Fer-In-Sol.................................64

Ferate......................................64

Ferretts................................... 64

Ferretts IPS.............................64

Ferrex 150.............................. 64

Ferric X-150............................ 64

Ferrimin 150........................... 64

Ferriprox................................. 72

Ferrous Drops........................ 64

Ferrous Fumarate 324...........64

Ferrous Gluconate.................64

Ferrous Sulfate.......................64

Ferrousul................................ 64

Fetzima................................... 28

Fetzima Titration Pack...........28

Fexofenadine HCl................ 135

Fexofenadine HCl Childrens Allergy................................ 135

Fiber Laxative.........................96

Fiber Tabs.............................. 96

Fiber-Lax.................................96

158158

Fifty50 Glucose Test Strip 2.0............................................ 118

Fifty50 Lancing Device........118

Fifty50 Safety Seal Lancets 30g..................................... 118

Fifty50 Safety Seal Lancets 32g..................................... 118

Fifty50 Unilet Lancets 33g.. 118

Finacea................................... 59

Finasteride..............................99

Fine 30..................................118

Fingerstix Lancets............... 118

Firazyr................................... 108

Firmagon.............................. 108

Flac....................................... 133

Flebogamma DIF................. 110

Flecainide Acetate................. 50

Flector.....................................14

Fleet Pediatric........................ 96

Flintstones Complete............ 78

Flintstones Plus Extra C........ 78

Flintstones/My First............... 79

Flovent Diskus......................136

Flovent HFA..........................136

Flowtuss............................... 140

Fluconazole............................ 31

Fluconazole in NaCl...............31

Flucytosine............................. 31

Fludrocortisone Acetate......100

Flunisolide............................ 136

Fluocinolone Acetonide..... 100, 133

Fluocinonide........................ 100

Fluocinonide Emulsified Base............................................ 100

Fluorometholone................. 133

Fluorouracil............................ 59

Fluoxetine DR.........................28

Fluoxetine HCl........................28

Fluphenazine Decanoate...... 40

Fluphenazine HCl.................. 40

Flurbiprofen............................14

Flurbiprofen Sodium........... 133

Flutamide................................34

Fluticasone Propionate...... 100, 136

Fluticasone Propionate/Salmeterol..........................140

Fluticasone Propionate/Salmeterol Diskus............. 140

Fluvastatin.............................. 54

Fluvoxamine Maleate.............28

Folic Acid................................79

Folitab 500..............................64

Foltabs 800.............................79

Fondaparinux Sodium...........48

Fora Blood Glucose Test Strips............................................ 118

Fora D15g Blood Glucose Test Strips.................................. 119

Fora D20 Blood Glucose Test Strips.................................. 119

Fora D40/G31 Blood Glucose Test Strips..........................119

Fora G20 Blood Glucose Test Strips.................................. 119

Fora G30/Premium V10 Blood Glucose Test Strips...........119

Fora GD20 Test Strips.........119

Fora GD50 Blood Glucose Test Strips.................................. 119

Fora Lancets........................ 119

Fora Lancing Device........... 119

Fora Lancing Device/Clearcap............................................ 119

Fora Tn'g/Tn'g Voice Blood Glucose Test Strips...........119

Fora V10 Blood Glucose Test Strips.................................. 119



Fora V30a Blood Glucose Test Strips.................................. 119

ForaCare GD40....................119

ForaCare Premium V10 Teststrips........................... 119

ForaCare Test N Go Test Strips............................................ 119

Formula EM............................29

Forteo................................... 113

Fortiscare Blood Glucose Test Strip.................................... 119

Fosamprenavir Calcium........ 44

Fosfree....................................79

Fosinopril Sodium..................50

Fosinopril Sodium/Hydrochlorothiazide............52

FreAmine HBC 6.9%..............64

Freds Pharmacy Autolet Lancing Device..................119

Freds Pharmacy Unilet Lancets Super Thin 30g..................119

159159

Freds Pharmacy Unilet Lancets Ultra Thin 28g....................119

FreeStyle Insulinx Blood Glucose Test......................119

FreeStyle Insulinx Blood Glucose Test Strips...........119

FreeStyle Lancets................ 119

FreeStyle Lite Test Strips.... 119

FreeStyle Precision Neo Blood Glucose Test Strips...........119

FreeStyle Test Strips........... 120

FreeStyle Unistick II Lancets............................................ 120

Freshkote............................. 130

Fruit C 500..............................79

Fruity C................................... 79

Fruity Chewables Multivitamin.............................................. 79

Full Spectrum B/Vitamin C... 79

Fungoid Tincture................... 31

Furosemide............................ 53

Fusion..................................... 64

Fuzeon.................................... 44

Fyavolv..................................103

Fycompa.................................26

G

Gabapentin.............................25

Gammagard Liquid............. 110

Gammagard S/D IGA Less Than 1 mcg/ml..................110

Gammaked...........................110

Gammaplex..........................110

Gamunex-C.......................... 110

Gardasil 9............................. 111

Gas Relief............................... 94

Gas Relief Extra Strength......94

Gas Relief Maximum Strength.............................................. 94

Gattex..................................... 94

Gauze................................... 120

GaviLyte-C.............................. 96

GaviLyte-G.............................. 96

GaviLyte-N/Flavor Pack.........96

GE100 Blood Glucose Test Strips.................................. 120

Gemfibrozil............................. 54

Generlac................................. 96

Gengraf.................................109

Genotropin........................... 101

Genotropin Miniquick..........101

Genstrip 50...........................120

Gentak.................................... 19

Gentamicin Sulfate................ 19

Gentamicin Sulfate/0.9% Sodium Chloride................. 19

Genvoya..................................43

Geodon...................................40

GHT Test Strips................... 120

Gianvi....................................103

Gilenya....................................57

Gilotrif..................................... 36

Glassia.................................... 98

Glatiramer Acetate.................57

Glatopa................................... 57

Gleostine................................ 34

Glimepiride.............................46

Glipizide..................................46

Glipizide ER............................46

Glipizide/Metformin HCl....... 46

Global Inject Ease Lancets 28g............................................ 120

Global Inject Ease Lancets 30g............................................ 120

Global Lancing Device........ 120

GlucaGen HypoKit.................47

Glucagon Emergency Kit...... 47

Glucocard 01 Sensor Plus..120

Glucocard 01 Sensor Plus Test Strips.................................. 120

Glucocard Expression Blood Glucose Test Strips...........120

Glucocard Shine Test Strips............................................ 120

Glucocard Vital Test Strips. 120

GlucoCom Lancets 28g...... 120



GlucoCom Test Strips.........120

GlucoNavii Blood Glucose Test Strips.................................. 120

Glucose Meter Test Strips Advanced...........................120

Glyxambi.................................46

GNP All Day Allergy.............135

GNP Allergy..........................135

GNP Animal Shapes..............79

GNP Animal Shapes Plus Extra C........................................... 79

GNP Animal Shapes Plus Iron.............................................. 79

GNP Antacid Anti-Gas........... 94

GNP Arthritis Pain Relief....... 13

GNP B-12................................79

GNP B-50 Balanced...............79

160160

GNP Biotin..............................79

GNP Calcium......................... 64

GNP Calcium 1200................64

GNP Calcium 500 + D3......... 64

GNP Calcium 500/D..............64

GNP Calcium 600 + D3......... 64

GNP Calcium 600/D..............64

GNP Calcium Citrate + D Maximum............................. 64

GNP Calcium Citrate + D3.... 64

GNP Calcium Citrate + D3 Maximum............................. 64

GNP Calcium/Magnesium/Zinc.......................................65

GNP Calcuim/Vitamin D/Minerals................................65

GNP Century.......................... 79

GNP Century Active Performance........................ 79

GNP Century Adults 50+ Senior................................... 79

GNP Century Cardio Healthformula...................... 79

GNP Century Mature............. 79

GNP Century Ultimate Mens Complete..............................79

GNP Century Ultimate Womens Complete............. 80

GNP Century Ultimate Womens Senior Formula.... 80

GNP Childrens Chewables w/Extra C..................................80

GNP Childrens Chewables/Extra C..................................80

GNP Childrens Chewables/Iron........................................80

GNP Dayhist Allergy............ 135

GNP Easy Touch Glucose Test Strips.................................. 120

GNP Essential One Daily.......80

GNP Hair/Skin/Nails............. 80

GNP Ibuprofen.......................14

GNP Ibuprofen Junior Strength.............................................. 14

GNP Iron.................................65

GNP Lancets........................120

GNP Lancets 21g................ 120

GNP Lancets Micro Thin 33g............................................ 120

GNP Lancets Super Thin 30g............................................ 120

GNP Lancets Thin............... 120

GNP Lancets Thin 26g........120

GNP Lice Treatment..............38

GNP Little Ones Childrens....80

GNP Loratadine................... 135

GNP Magnesium................... 65

GNP Masanti Maximum Strength................................94

GNP Masanti Regular Strength.............................................. 94

GNP Mega Multi for Men...... 80

GNP Mega Multi for Women.80

GNP Micro Thin Lancets 33g............................................ 120

GNP Niacin TR.......................80

GNP Omeprazole...................98

GNP One Daily Maximum..... 80

GNP One Daily Mens Health 50+........................................80

GNP One Daily Plus Iron....... 80

GNP One Daily Womens Health 50+............................80

GNP Opti-Vitamins.................80

GNP Pediatric Electrolyte......65

GNP Super Thin Lancets/30g............................................ 120

GNP Therapeutic-M...............80

GNP Tussin DM................... 140

GNP Vitamin A....................... 80

GNP Vitamin B-1.................... 80

GNP Vitamin B-12..................80

GNP Vitamin B-12 Prolonged Release................................ 80

GNP Vitamin B-12 TR............ 80

GNP Vitamin B-6.................... 80

GNP Vitamin C....................... 81

GNP Vitamin C Drops............81

GNP Vitamin C Pr.................. 81

GNP Vitamin C TR................. 81

GNP Vitamin C with Rose Hips.............................................. 81

GNP Vitamin C with Rose Hips TR......................................... 81

GNP Vitamin C/Rose Hips....81

GNP Vitamin E....................... 81

GNP Vitamin E Water Dispersible........................... 81

GNP Zinc................................ 65

GNP Zoo Chews Gummies...81

Goodsense Ibuprofen........... 14

Goodsense Ibuprofen Childrens..............................14

Goodsense Ibuprofen Infants.............................................. 14

161161

Goodsense Ibuprofen Junior Strength................................14

Goodsense Lancets Micro-Thin 33g..................................... 120

Goodsense Lancets Micro-Thin 33g Universal.....................120

Goodsense Lancets Ultra-Thin 26g Universal.....................120

Goodsense Lancets Ultra-Thin 30g..................................... 120

Goodsense Lancing Device120

Goodsense Premium Blood Glucose Test Strips...........121

Granisetron HCl..................... 30

Griseofulvin Microsize........... 31

Griseofulvin Ultramicrosize... 31

Guaifenesin AC....................140

Guaifenesin and Pseudoephedrine HCl...... 140

Guaifenesin ER.................... 140

Guaifenesin/Codeine.......... 140

Guanfacine ER.......................56

Guanidine HCl........................33

Gummi Bear Multivitamin/Mineral................................. 81

H

H-E-B Incontrol Advanced Lancing Device..................121

H-E-B Incontrol Lancets Micro Thin 33g............................. 121

H-E-B Incontrol Lancets Super Thin 30g............................. 121

H-E-B Incontrol Lancets Ultra Thin 28g............................. 121

H-E-B Oral Electrolyte Solution.............................................. 65

Haegarda..............................108

Hailey 24 Fe......................... 103

Halls Defense Vitamin C Drops.............................................. 81

Halobetasol Propionate...... 100

Haloperidol.............................40

Haloperidol Decanoate......... 40

Haloperidol Lactate............... 40

Hard Nails...............................81

Harvoni................................... 42

Havrix....................................111

Health Care Lancing Device............................................ 121

Healthy Accents Autolet Impression Lancing Device............................................ 121

Healthy Accents Unilet Lancets Super Thin 30g..................121

Healthy Kids Gummies..........81

Heartburn Treatment 24 Hour.............................................. 98

Hemocyte............................... 65

Hemorrhoidal......................... 59

Heparin Sodium.....................48

HepatAmine........................... 65

Hetlioz...................................144

Hiberix.................................. 111

Histex....................................135

Histex PD..............................135

Histex-DM.............................140

Histex-PE.............................. 140

HM Calcium 600 & Vitamin D3.............................................. 65

HM Calcium 600 + D Plus Minerals................................65

HM Calcium 600 + Vitamin D3.............................................. 65

HM Calcium Citrate + Vitamin D........................................... 65

HM Calcium/Vitamin D......... 65

HM Calcium/Vitamin D/Minerals................................65

HM Complete.........................81

HM Complete 50+................. 81

HM Complete 50+ Womens Ultimate................................ 81

HM Complete Women...........81

HM Hair/Skin/Nails............... 81

HM Iron...................................65

HM Iron Slow Release...........65

HM Magnesium......................94

HM Niacin...............................81

HM Niacin TR.........................81

HM One Daily Essential.........81

HM One Daily Womens......... 81

HM One Daily/Iron.................81

HM Pediatric Electrolyte........65

HM Selenium..........................65

HM Vitamin B Complex/Vitamin C..............................82

HM Vitamin B100 Complex.. 82

HM Vitamin B12.....................82

HM Vitamin B12 TR...............82

HM Vitamin B50 Complex.....82

HM Vitamin B6....................... 82

HM Vitamin C......................... 82

HM Vitamin C TR................... 82

HM Vitamin C/Rose Hips......82

HM Vitamin E......................... 82

162162

HM Zinc.................................. 65

Honey Bears...........................82

Honey Bears with Iron and Zinc.......................................82

Humalog Cartridge................ 47

Humalog Junior KwikPen......47

Humalog KwikPen................. 47

Humalog Mix 50/50 KwikPen.............................................. 47

Humalog Mix 50/50 Vial........48

Humalog Mix 75/25 KwikPen.............................................. 48

Humalog Mix 75/25 Vial........48

Humalog Vial..........................48

Humatrope........................... 101

Humatrope Combo Pack.... 101

Humira.................................. 109

Humira Pediatric Crohns Disease Starter Pack.........109

Humira Pen.......................... 109

Humira Pen Crohns Disease Starter Pack....................... 109

Humira Pen-Psoriasis Starter............................................ 109

Humulin 70/30 KwikPen....... 48

Humulin 70/30 Vial................48

Humulin N KwikPen...............48

Humulin N Vial....................... 48

Humulin R U-500 KwikPen....48

Humulin R U-500 Vial............ 48

Humulin R Vial....................... 48

Hycofenix..............................140

Hydralazine HCl..................... 55

Hydrochlorothiazide.............. 54

Hydrocodone Bitartrate/Acetaminophen................... 16

Hydrocodone Bitartrate/Chlorpheniramine Maleate/PSE.....................................140

Hydrocodone Bitartrate/Homatropine Methylbromide............................................ 140

Hydrocodone Polistirex/Chlorpheniramine Polistirex............................................ 140

Hydrocodone/Acetaminophen.............................................. 16

Hydrocodone/Ibuprofen....... 17

Hydrocortisone............100, 112

Hydrocortisone Butyrate.....100

Hydrocortisone Valerate..... 101

Hydrocortisone/Acetic Acid............................................ 133

Hydrocortisone/Aloe............. 59

Hydromet..............................140

Hydromorphone HCl............. 17

Hydromorphone HCl ER....... 15

Hydroxychloroquine Sulfate. 38

Hydroxyurea...........................34

Hydroxyzine HCl.................... 45

Hydroxyzine Pamoate........... 29

Hypolance AST Lancing Kit121

Hysingla ER............................16

I

I-Caps Areds Formula............82

I-Caps Mv................................82

I-Caps Plus............................. 82

I.L.X. B-12............................... 65

Ibrance....................................36

Ibu........................................... 15

Ibu-200....................................15

Ibu-Drops Infants................... 15

Ibuprofen................................ 15

Ibuprofen Childrens...............15

ICAR Pediatric........................65

ICAR-C.................................... 65

Icatibant Acetate..................108

Iclusig......................................36

Idhifa....................................... 36

Iferex 150................................65

Iglucose Blood Glucose Test Strips.................................. 121

Ilevro..................................... 133

Imatinib Mesylate...................36

Imbruvica................................36

Imipenem/Cilastatin.............. 22

Imipramine HCl...................... 29

Imipramine Pamoate............. 29

Imiquimod.............................. 59

Imiquimod Pump................... 59

Imovax Rabies..................... 111

Imvexxy Maintenance Pack 103

Imvexxy Starter Pack...........103

Incassia.................................106

Increlex................................. 101

Incruse Ellipta...................... 137

Indapamide............................ 54

Indomethacin......................... 15

Infanrix..................................111

Infants Gas Relief...................94

Infants Ibuprofen....................15

Infants Simethicone...............94

163163

Infed........................................65

Infinity Blood Glucose Test Strips.................................. 121

Infinity Voice.........................121

Ingrezza.................................. 56

Inlyta........................................36

Inrebic.....................................35

Insulin Lispro..........................48

Insulin Lispro KwikPen.......... 48

Insulin Syringes, Needles....121

Integra.....................................65

Intelence.................................43

Intralipid..................................65

Intron A................................... 42

Introvale................................104

Invanz......................................22

Invega Sustenna.................... 40

Invega Trinza..........................41

Invirase................................... 44

Ionosol-MB/Dextrose 5%...... 65

Iosat...................................... 121

IPOL Inactivated IPV............111

Ipratropium Bromide........... 137

Ipratropium Bromide/Albuterol Sulfate................................ 141

Irbesartan............................... 50

Irbesartan/Hydrochlorothiazide.............................................. 52

Iressa...................................... 37

Iron..........................................66

Iron 100/C.............................. 66

Iron 27.....................................66

Iron High-Potency.................. 66

Iron Slow Release..................66

Iron Supplement Childrens...66

Isentress................................. 43

Isentress HD...........................43

Isibloom................................104

Isolyte-P/Dextrose 5%........... 66

Isolyte-S.................................. 66

Isoniazid..................................33

Isopto Tears......................... 130

Isosorbide Dinitrate............... 55

Isosorbide Dinitrate ER......... 55

Isosorbide Mononitrate......... 55

Isosorbide Mononitrate ER... 55

Isotonic Gentamicin...............19

Isotretinoin..............................59

Itraconazole............................31

Ivermectin...............................38

Ixiaro..................................... 111

J

Jadenu....................................72

Jadenu Sprinkle.....................72

Jakafi.......................................37

Jantoven................................. 48

Jardiance................................46

Jasmiel..................................104

Jentadueto............................. 46

Jentadueto XR....................... 46

Jinteli.................................... 104

Jublia...................................... 31

Juleber..................................104

Juluca..................................... 43

Junel 1.5/30......................... 104

Junel 1/20............................ 104

Junel Fe 1.5/30....................104

Junel Fe 1/20.......................104

Junel Fe 24...........................104

Just D......................................82

Juxtapid.................................. 54

K

Kaitlib Fe...............................104

Kaletra.....................................44

Kalydeco...............................138

Kao-Tin....................................94

Kariva....................................104

KCl 0.075%/D5W/NaCl 0.45%.............................................. 66

KCl 0.15%/D5W/NaCl 0.2%..66

KCl 0.15%/D5W/NaCl 0.45%.............................................. 66

KCl 0.15%/D5W/NaCl 0.9%..66

KCl 0.3%/D5W/NaCl 0.45%..66

KCl 0.3%/D5W/NaCl 0.9%....66

Kelnor 1/35.......................... 104

Kelnor 1/50.......................... 104

Ketoconazole......................... 31

Ketoprofen..............................15

Ketorolac Tromethamine.... 133

Kidkare Cough/Cold........... 141

Kineret.................................. 109

Kinrix.....................................111

Kionex.....................................72

Kisqali..................................... 35

Kisqali Femara 200 Dose...... 35



Klor-Con..................................66

Klor-Con 10............................ 66

Klor-Con 8...............................66

164164

Klor-Con M10......................... 66

Klor-Con M15......................... 66

Klor-Con M20......................... 66

Klor-Con Sprinkle...................66

Kobee..................................... 82

Kombiglyze XR.......................46

Korlym.................................. 102

KP Adults 50+ Daily Formula 82

KP B Complex/C................... 82

KP Calcium 600 + D.............. 66

KP Calcium Citrate + D..........66

KP Ferrous Gluconate........... 66

KP Ferrous Sulfate.................66

KP Niacin................................82

KP Vitamin B-12..................... 82

KP Vitamin B-6....................... 82

KP Vitamin E...........................82

Kroger Blood Glucose Teststrips........................... 121

Kroger Lancets 21g.............121

Kroger Lancets Micro Thin33g............................................ 121

Kroger Lancets Thin 26g.... 121

Kroger Lancets Ultrathin 30g............................................ 121

Kroger Lancing Device........121

Kroger Premium Blood Glucose Test Strips...........121

Kroger Test Strips................121

Kurvelo..................................104

Kuvan......................................98

L

Labetalol HCl..........................51

Lacrisert................................130

Lactulose................................ 96

Lamivudine.......................42, 44

Lamivudine/Zidovudine........ 44

Lamotrigine............................ 26

Lancet Device with Ejector. 121

Lancets.................................121

Lancets 28g......................... 121

Lancets 30g......................... 121

Lancets 30g Twist Top........121

Lancets 30g/Twist Top....... 121

Lancets 33g Universal Design............................................ 122

Lancets Micro Thin 33g...... 122

Lancets Safety Seal 28g..... 122

Lancets Safety Seal 30g..... 122

Lancets Super Thin 28g......122

Lancets Thin........................ 122

Lancets Twist Top............... 122

Lancets Ultra Fine................122

Lancets Ultra Thin............... 122

Lancets Ultra Thin 30g........122

Lancing Device.................... 122

Lancing Device Adjustable. 122

Land Before Time Multivitamin/Iron................. 82

Lanoxin................................... 52

Lansoprazole..........................98

Lanthanum Carbonate.......... 72

Lantus SoloStar..................... 48

Lantus Vial..............................48

Lanzo.................................... 122

LARIN 1.5/30....................... 104

LARIN 1/20.......................... 104

LARIN Fe 1.5/30..................104

LARIN Fe 1/20..................... 104

Larissia................................. 104

Lastacaft...............................130

Latanoprost..........................133

Latuda.....................................41

Laxative...................................96

Layolis Fe............................. 104

Leader Advanced Lancing Device................................ 122

Ledipasvir/Sofosbuvir........... 42

Leena....................................104

Leflunomide......................... 110

Lenvima.................................. 37

Lessina................................. 104

Letairis.................................. 138

Letrozole.................................36

Leucovorin Calcium...............35

Leukeran.................................34

Leukine................................... 49

Leuprolide Acetate.............. 108

Levalbuterol HCl.................. 137

Levemir FlexTouch................ 48

Levemir Vial............................48

Levetiracetam.........................25

Levetiracetam ER...................25

Levobunolol HCl.................. 132

Levocarnitine..........................66

Levocetirizine Dihydrochloride............................................ 135

Levofloxacin........................... 24

Levofloxacin in D5W..............24

Levonest...............................104

165165

Levonorgestrel and Ethinyl Estradiol............................. 104

Levonorgestrel/Ethinyl Estradiol............................. 104

Levora 0.15/30-28............... 104

Levorphanol Tartrate............. 16

Levothyroxine Sodium........ 107

Levoxyl..................................107

Lexiva......................................44

Lialda.................................... 112

Lidocaine................................18

Lidocaine HCl.........................18

Lidocaine Viscous................. 18

Lidocaine/Prilocaine............. 18

Life Pack Mens...................... 82

Life Pack Womens.................82

Lindane...................................39

Linezolid................................. 20

Linzess....................................96

Liothyronine Sodium........... 107

Liquid B12.............................. 82

Liquid Calcium/Vitamin D.....66

Liquitears..............................130

Lisinopril................................. 50

Lisinopril/Hydrochlorothiazide.............................................. 52

LiteTouch Lancets...............122

LiteTouch Lancets Micro Thin 33g..................................... 122

LiteTouch Lancing Pen....... 122

Lithium....................................46

Lithium Carbonate.................46

Lithium Carbonate ER...........46

Lithostat..................................99

Livalo.......................................54

Live Better Advanced Lancing Device................................ 122

Live Better Lancet Ultra Thin 28g..................................... 122

Lodrane D............................ 135

LoHist-D................................135

LoHist-DM.............................141

Lokelma..................................72

Longs Lancets Thin.............122

Longs Lancets Ultra Thin....122

Lonhala Magnair Starter Kit137

Lonsurf....................................35

Loperamide HCl.....................94

Lopinavir/Ritonavir................ 44

Loratadine............................ 135

Loratadine Childrens...........135

Loratadine-D 12hr................135

Loratadine-D 24hr................135

Lorazepam............................. 46

Lorbrena................................. 35

Lorcet......................................17

Lorcet HD............................... 17

Lorcet Plus............................. 17

Lortuss DM...........................141

Lortuss EX............................ 141

Lortuss LQ............................135

Loryna...................................104

Losartan Potassium...............50

Losartan Potassium/Hydrochlorothiazide............52

Lotemax................................133

Lotemax SM.........................133

Loteprednol Etabonate....... 133

Lovastatin............................... 54

Low-Ogestrel........................104

Loxapine Succinate...............40

Lubricant Eye Drops............130

Lubricating Plus Eye Drops 130

Lubrifresh P.M..................... 130

Lumigan............................... 133

Lupaneta Pack.....................108

Lupron Depot.......................108

Lutera....................................104

Lynparza.................................37

Lysiplex Plus.......................... 82

Lysodren...............................107

Lyza.......................................106

M

M-END DMX......................... 141

M-Hist DM.............................141

M-Hist PD............................. 135

M-M-R II................................ 111

Mag-Tab SR........................... 67

Magnesium...................... 66, 94

Magnesium 27....................... 66

Magnesium Elemental...........66

Magnesium Oxide........... 66, 95

Magnesium Sulfate................66

Major-Prep Hemorrhoidal......59

Malathion................................39

Mapap.....................................13

Mapap Acetaminophen Extra Strength................................13

Mapap Arthritis Pain..............13

Mapap Childrens................... 13

Mapap Cold Formula Multi-Symptom............................141

166166

Mapap PM..............................13

Mapap Sinus Maximum Strength Congestion and Pain.................................... 141

Maprotiline HCl...................... 28

Marlissa................................ 104

Marplan...................................28

Matulane.................................34

Matzim LA.............................. 52

Mavyret................................... 42

Mayzent.................................. 57

Meclizine HCl......................... 29

Medisense Thin Lancets.....122

Medlance Plus Extra Lancets 21g..................................... 122

Medlance Plus Lancets.......122

Medlance Plus Lancets Lite 25g..................................... 122

Medlance Plus Lite Lancets 25g..................................... 122

Medlance Plus Special Lancets 0.8mm................................ 122

Medlance Plus SuperLite 30g............................................ 122

Medlance Plus SuperLite 30g/Comfort Max......................122

Medlance Plus Universal Lancets 21g....................... 122

Medlance Plus/Lite 25g......122

Medlance/Lite......................122

Medlance/Universal............ 122

Medroxyprogesterone Acetate............................................ 106

Mefloquine HCl...................... 38

Mega Multiple with Chelated Minerals................................82

Mega Multivitamin for Men... 82

Mega Multivitamin for Women.............................................. 82

Megestrol Acetate............... 107

Meijer Advanced Formula.....82

Meijer Blood Glucose Teststrips........................... 122

Meijer C.................................. 82

Meijer Lancets Thin.............122

Meijer Lancets Universal 33g............................................ 122

Meijer Premium Blood Glucose Test Strips..........................123

Meijer Super Thin Lancets..123

Mekinist.................................. 37

Mektovi................................... 37

Melodetta 24 Fe...................104

Meloxicam.............................. 15

Memantine HCl...................... 27

Memantine HCl ER................ 27

Memantine HCl Titration Pak27

Menactra.............................. 111

Menest..................................104

Mentax.................................... 31

Menveo.................................111

Mephyton............................... 82

Mercaptopurine..................... 34

Meribin....................................83

Meropenem............................22

Mesalamine..........................112

Mesalamine DR................... 112

Mesnex................................... 38

Mestinon.................................33

Metformin HCl........................46

Metformin HCl ER..................47

Methadone HCl......................16

Methazolamide...................... 53

Methenamine Hippurate....... 20

Methimazole.........................108

Methotrexate........................109

Methotrexate Sodium..........109

Methoxsalen...........................59

Methscopolamine Bromide.. 93

Methyldopa............................ 49

Methyldopa/Hydrochlorothiazide............52

Methylphenidate HCl.............56

Methylphenidate HCl ER.......56

Methylprednisolone.............101

Methylprednisolone Dose Pack............................................ 101

Metoclopramide HCl....... 29, 30

Metolazone.............................54

Metoprolol Succinate ER...... 51

Metoprolol Tartrate................51

Metoprolol/Hydrochlorothiazide............52

Metronidazole........................ 20

Metronidazole in NaCl 0.79%.............................................. 20

Metronidazole Vaginal...........20

Mexiletine HCl........................50

Mi-Acid....................................95

Mi-Acid Gas Relief................. 95

Mi-Acid Maximum Strength.. 95

Mibelas 24 Fe.......................104

167167

Miconazole 3..........................31

Miconazole 7..........................31

Miconazole Nitrate.................31

Microdot Test Strips............123

Microgestin 1.5/30.............. 104

Microgestin 1/20................. 105

Microgestin Fe..................... 105

Microgestin Fe 1.5/30.........105

Microlet Lancets.................. 123

Microlet Next........................123

Midodrine HCl........................49

Migergot................................. 32

Miglustat.................................98

Migraine Formula...................13

Mili........................................ 105

Milk of Magnesia....................96

Milk of Magnesia Concentrate.............................................. 97

Mini Lancing Device............123

Minitran...................................55

Minocycline HCl.....................24

Minoxidil................................. 55

Mintox Maximum Strength....95

Mirtazapine.............................28

Mirtazapine ODT....................28

Mirvaso................................... 59

Misoprostol............................ 97

Mm Easy Touch Glucose Test Strips.................................. 123

Modafinil...............................144

Moexipril HCl..........................50

Moisturel Therapeutic........... 59

Molindone HCl....................... 40

Mometasone Furoate.......... 101

Monocal..................................67

Monolet Lancets.................. 123

Montelukast Sodium........... 136

Morphine Sulfate................... 17

Morphine Sulfate ER............. 16

Moxeza................................... 24

Moxifloxacin HCl/Sodium HCl.............................................. 24

Moxifloxacin HCl....................24

Mtx Support............................83

Mucinex................................141

Mucinex Chest Congestion Childrens............................141

Mucinex Childrens Cold Cough & Sore Throat........141

Mucinex Childrens Multi-Symptom Cold...................141

Mucinex Childrens Multi-Symptom Cold & Fever.....141

Mucinex Congestion & Cough Childrens............................141

Mucinex Cough Childrens.. 141

Mucinex Cough for Kids..... 141

Mucinex D............................ 141

Mucinex D Maximum Strength............................................ 141

Mucinex DM.........................141

Mucinex DM Maximum Strength............................. 141

Mucinex Fast-Max Cold & Sinus...................................141

Mucinex Fast-Max Cold Flu & Sore Throat........................142

Mucinex Fast-Max Day Time/Night Time......................... 142

Mucinex Fast-Max Day/Night Maximum Strength............142

Mucinex Fast-Max DM Max 142

Mucinex Fast-Max Night Time Cold & Flu.......................... 142

Mucinex Fast-Max Severe Cold............................................ 142

Mucinex Fast-Max Severe Congestion & Cough........ 142

Mucinex for Kids..................142

Mucinex Maximum Strength............................................ 142

Mucinex Multi-Symptom Cold Day/Night Pack................. 142

Mucinex Multi-Symptom Cold Night Time Childrens........ 142

Mucinex Sinus-Max Pressure & Pain.................................... 142

Mucinex Stuffy Nose & Cold Childrens............................142

Mucus Relief........................ 142

Mucus Relief Sinus..............142

Multaq.....................................50

Multi Complete/Iron.............. 83

Multi Vitamin Daily................. 83

Multi-Day Plus Iron.................83

Multi-Delyn/Iron..................... 83

Multi-Lancet Device 2..........123

Multi-Vitamin...........................83

Multi-Vitamin Daily................. 83

Multi-Vitamin HP/Minerals.... 83

Multi-Vitamin/Minerals.......... 83

168168

Multi-Vitamin/Multi-Mineral Adult/High Potency.............83

Multi-Vitamins.........................83

Multilex................................... 83

Multilex T&M.......................... 83

Multiple Vitamin/Minerals/No Iron........................................83

Multiple Vitamins................... 83

Multiple Vitamins Plain.......... 83

Multiple Vitamins/Iron........... 83

Multivitamin & Mineral...........83

Mupirocin............................... 20

Muro 128.............................. 130

My Way.................................107

My-Vitalife............................... 83

Myalept................................... 95

Mycamine...............................31

Mycophenolate Mofetil....... 109

Mycophenolic Acid DR....... 109

Myferon 150........................... 67

MyGlucoHealth Blood Glucose Test.....................................123

MyGlucoHealth MGH Softlance Lancets 30g....................... 123

Myrbetriq................................ 99

N

Nadolol................................... 51

Nafcillin Sodium.....................23

Naloxone HCl......................... 18

Naltrexone HCl.......................18

Namzaric................................ 56

Naproxen................................15

Naproxen DR......................... 15

Naratriptan HCl...................... 32

Narcan.................................... 18

Nasal Decongestant............ 142

Nasal Decongestant Spray. 142

Nasopen PE......................... 135

Natacyn...................................31

Nateglinide............................. 47

Natpara.................................113

Natrapel 12-Hour Tick & Insect Repellent Continuous Spray.............................................. 59

Natural Balance Tears.........130

Natural C/Rose Hips............. 83

Natural Fiber Therapy............97

Natural Vitamin E................... 83

Natures Tears.......................130

Nebupent................................38

Necon 0.5/35-28..................105

Nefazodone HCl.....................28

Neomycin Sulfate.................. 19

Neomycin/Bacitracin/Polymyxin...........................130

Neomycin/Polymyxin/Bacitracin/Hydrocortisone............................................ 131

Neomycin/Polymyxin/Dexamethasone................ 131

Neomycin/Polymyxin/Gramicidin......................... 131

Neomycin/Polymyxin/Hydrocortisone......... 131, 133

Nephramine............................67

Nephro-Vite............................ 84

Nephronex..............................83

Nerlynx....................................37

Neulasta..................................49

Neupro....................................39

Neutek 2Tek Test Strips..... 123

Nevirapine.............................. 43

Nevirapine ER........................ 43

Nexavar...................................37

Nexium....................................98

Niacin......................................84

Niacin ER......................... 54, 84

Niacin SR................................84

Niacin TR................................84

Niacor..................................... 54

Nicardipine HCl......................52

NicoDerm CQ.........................19

NICOrelief...............................19

Nicorette.................................19

Nicorette Mini.........................19

Nicorette Starter Kit............... 19

Nicotine Polacrilex.................19

Nicotine Transdermal System.............................................. 19

Nicotine Transdermal System Step 1................................... 19



Nicotrol................................... 19

Night Time Multi-Symptom Cold/Flu Relief.................. 142

Night Time Sleep Aid.......... 144

Nikki......................................105

Nilutamide.............................. 34

Nimodipine.............................52

NinjaCof................................142

169169

NinjaCof-A............................ 142

NinjaCof-XG..........................142

Ninlaro.................................... 35

Nitro-Bid..................................55

Nitrofurantoin......................... 20

Nitrofurantoin Macrocrystals 20

Nitrofurantoin Monohydrate. 20

Nitroglycerin...........................55

Nitroglycerin Lingual............. 55

Nitroglycerin Transdermal.... 55

Nitrostat.................................. 55

No Iron Multiple Vitamin/Minerals................................84

NoHist-DM............................142

NoHist-LQ.............................135

Nora-BE................................ 107

Norditropin FlexPro............. 101

Norethindrone......................107

Norethindrone Acetate........107

Norethindrone Acetate/Ethinyl Estradiol............................. 105

Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate............................................ 105

Norethindrone/Ethinyl Estradiol/Ferrous Fumarate............................................ 105

Norgestimate/Ethinyl Estradiol............................................ 105

Norlyroc................................107

Normosol-M in D5W.............. 67

Normosol-R............................ 67

Normosol-R in D5W...............67

Northera..................................49

Nortrel 0.5/35.......................105

Nortrel 1/35..........................105

Nortrel 7/7/7........................ 105

Nortriptyline HCl.................... 29

Norvir...................................... 45

Nova Max Glucose Test Strips............................................ 123

Nova Safety Lancets 23g.... 123

Nova Safety Lancets 28g.... 123

Nova Sureflex Lancets........ 123

Nova Sureflex Lancing Device............................................ 123

Noxafil.....................................31

Nu-Iron 150.............................67

Nu-Mag................................... 67

Nubeqa...................................34

Nucala.................................. 142

Nucynta ER............................ 16

Nuedexta................................ 56

Nuplazid................................. 41

Nutrilipid................................. 67

Nutropin AQ......................... 101

NuvaRing..............................105

Nyamyc...................................31

Nymalize................................. 52

Nystatin...................................31

Nystop.....................................31

O

Ocaliva.................................... 98

Oceanic Selenium................. 67

Ocella....................................105

Octagam...............................110

Octreotide Acetate.............. 108

Ocutabs.................................. 84

Ocutabs Vision Formula........84

Ocutabs/Lutein......................84

Odefsey.................................. 43

Odomzo..................................37

Ofev...................................... 138

Off Deep Woods.................... 59

Off Deep Woods Dry............. 59

Off Deep Woods Sportsmen.59

Ofloxacin................................ 24

Ogestrel................................105

Olanzapine............................. 41

Olanzapine ODT.................... 41

Olmesartan Medoxomil.........50

Olmesartan Medoxomil/Hydrochlorothiazide............52

Olopatadine HCl.................. 132

Omega-3-Acid Ethyl Esters... 54

Omeprazole............................98

Omeprazole Magnesium.......98

Omnicap.................................84

On Call Express Blood Glucose Test Strips...........123

On Call Lancets................... 123

On Call Lancing Device.......123

On Call Plus Blood Glucose Test.....................................123

On Call Plus Lancets........... 123

On Call Plus Lancing Device............................................ 123

On Call Vivid Blood Glucose Test.....................................123

On Call Vivid Blood Glucose Test Strips..........................123

Once Daily.............................. 84

170170

Once Daily/Iron......................84

Oncovite................................. 84

Ondansetron HCl...................30

Ondansetron ODT................. 30

One Daily................................ 84

One Daily Complete.............. 84

One Daily for Men 50+ Advanced.............................84

One Daily for Women............ 84

One Daily for Women 50+a Dvanced............................... 84

One Daily Maximum.............. 84

One Daily Mens......................84

One Daily Multivitamin Adult.84

One Daily Multivitamin/Iron.. 84

One Daily Plus Iron................ 84

One Daily Plus Minerals........ 84

One Daily Womens 50 Plus.. 84

One Daily Womens 50+.........84

One Daily/Iron/Calcium........ 84

One Daily/Minerals................84

One-A-Day Essential.............. 84

One-A-Day Mens 50+ Advantage............................84

One-A-Day Teen Advantage for Her........................................ 84

One-A-Day Teen Advantage for Him....................................... 85

One-A-Day Womens Formula.............................................. 85

One-Daily Multi Vitamins....... 85

One-Way Valved Expiratory Mouthpiece/Disposable... 124

One-Way Valved Inspiratory Mouthpiece/Disposable... 124

Onetouch Delica Lancets Extra Fine 33g............................. 123

Onetouch Delica Lancets Fine 30g..................................... 123

Onetouch Delica Lancing Device................................ 123

Onetouch Suresoft Lancing Device/18g........................ 123



Onetouch Ultra Blue............124

Onetouch Ultrasoft Lancets124

Onetouch Verio Test Strips.124

Onfi................................... 25, 26

Onglyza...................................47

Opcicon One-Step...............107

Opsumit................................138

Opti-Clear............................. 132

Optium Test Strips...............124

OptiumEZ Test Strips..........124

OptumRx Blood Glucose Test............................................ 124

Oralyte.................................... 67

Oralyte Freezer Pops.............67

Orazinc................................... 67

Orencia................................. 109

Orencia Clickject................. 109

Orenitram............................. 138

Orfadin....................................98

Orkambi................................138

Orsythia................................ 105

OS-CAL...................................67

OS-CAL Calcium + D3...........67

OS-CAL Extra D3................... 67

OS-CAL Ultra..........................67

Oseltamivir Phosphate.......... 45

Osphena...............................107

Osteo-Poretical...................... 67

Otezla....................................110

Oxacillin in Dextrose..............23

Oxacillin Sodium....................23

Oxandrolone........................ 102

Oxcarbazepine.......................27

Oxsoralen Ultra...................... 59

Oxybutynin Chloride..............99

Oxybutynin Chloride ER........99

Oxycodone HCl......................17

Oxycodone/Acetaminophen 17

Oxycodone/Aspirin............... 17

Oxycodone/Ibuprofen...........17

Oysco 500.............................. 67

Oysco 500 + D....................... 67

Oyst-Cal-D 500....................... 67

Oyster Calcium...................... 67

Oyster Shell Calcium............. 67

Oyster Shell Calcium + D3.... 67

Oyster Shell Calcium + Vitamin D........................................... 67

Oyster Shell Calcium 250 + D.............................................. 67

Oyster Shell Calcium 500......67

Oyster Shell Calcium 500 + D........................................67, 68

Oyster Shell Calcium 500/D. 68

Oyster Shell Calcium Plus Vitamin D..............................68

171171

Oyster Shell Calcium+d.........68

Oyster Shell Calcium/D.........68

Oyster Shell Calcium/D3.......68

Oyster Shell Calcium/Magnesium.......................... 68

Oyster Shell Calcium/Vitamin D........................................... 68

Oystercal-D.............................68

P

Pacerone................................ 50

Pain & Fever........................... 13

Pain & Fever Childrens..........13

Pain & Fever Extra Strength..14

Pain & Fever Infants...............14

Pain Relief Sinus PE Daytime............................................ 142

Pain Reliever PM Extra Strength................................14

Pain Relieving Cream............59

Paliperidone ER..................... 41

Panda Mask Large.............. 124

Panda Mask Medium.......... 124

Panda Mask Small...............124

Panretin.................................. 38

Pantoprazole Sodium............98

Pantothenic Acid................... 85

Panzyga................................110

Paricalcitol............................113

Paromomycin Sulfate............ 19

Paroxetine HCl....................... 28

Paser.......................................33

Paxil........................................ 28

Pazeo....................................132

PC Lancets Super Thin 30g124

Pedialyte.................................68

Pedialyte Advanced Care......68

Pedialyte Freezer Pops......... 68

Pedialyte Singles................... 68

Pediarix.................................111

Pediatric Cough/Cold......... 142

Pediatric Electrolyte...............68

Pediatric Electrolyte Freeze Pops..................................... 68

Pediatric Electrolyte Freezer Pops..................................... 68

Pediatric Electrolyte/Zinc......68

Pediatric Medium Mask...... 124

Pediatric Mouthpiece/Disposable.........................124

Pediatric Panda Mask......... 124

Pediatric Small Mask...........124

Pedvax HIB...........................111

PEG 3350............................... 97

PEG 3350/Electrolytes..........97

PEG-3350/Electrolytes.......... 97

PEG-3350/NaCl/Na Bicarbonate/KCl..................97

Peganone............................... 27

Pegasys.................................. 42

Pegasys ProClick...................42

Penicillamine..........................99

Penicillin G Potassium...........23

Penicillin G Procaine............. 23

Penicillin G Sodium............... 23

Penicillin V Potassium........... 23

Pentam 300............................ 38

Pentoxifylline ER....................53

Peptic Relief........................... 95

Perforomist...........................137

Peridin-C.................................85

Perindopril Erbumine............ 50

Permethrin..............................39

Perphenazine......................... 30

Perseris...................................41

Pharmacist Choice Autocode Blood Glucose Test Strips124

Pharmacist Choice No Coding Blood Glucose Test Strips124

Pharmacist Choice Ultra Thin Lancets...............................124

Pharmacist Choice Ultra Thin Lancets 28g....................... 124




Phenadoz............................. 135

Phenelzine Sulfate................. 28

Phenobarbital.........................26

Phenoxybenzamine HCl........50

Phenylephrine HCl/Pyrilamine Maleate.............................. 142

Phenytek.................................27

Phenytoin................................27

Phenytoin Sodium Extended 27

Phillips.................................... 97

Phoslyra..................................72

Phospholine Iodide............. 132

Picato......................................59

Pifeltro.....................................43

Pilocarpine HCl..............57, 132

172172

Pimecrolimus......................... 60

Pimozide.................................40

Pimtrea................................. 105

Pindolol...................................51

Pioglitazone HCl.................... 47

Pioglitazone HCl/Glimepiride.............................................. 47

Pioglitazone HCl/Metformin HCl........................................47

Piperacillin/Tazobactam....... 23

Piqray 200mg Daily Dose......35



Pirmella 1/35........................105

Plain Niacin............................ 85

Plasma-Lyte A........................ 68

Plasma-Lyte-148.....................69

Plenamine...............................69

Podofilox.................................60

Poly Hist Forte......................142

Poly Vitamin........................... 85

Poly-Hist DM.........................142

Poly-Hist PD......................... 135

Poly-Iron 150.......................... 69

Poly-Vent DM....................... 143

Poly-Vent IR..........................143

Polymyxin B Sulfate...............20

Polymyxin B Sulfate/Trimethoprim Sulfate........ 131

Polyvitamin............................. 85

Polyvitamin/Iron.....................85

Pomalyst.................................34

Portia-28............................... 105

Posaconazole DR.................. 31

Potassium Chloride............... 69

Potassium Chloride CR.........69

Potassium Chloride ER......... 69

Potassium Chloride/Dextrose.............................................. 69

Potassium Chloride/Dextrose/Lactated Ringers................. 69

Potassium Chloride/Dextrose/Sodium Chloride................. 69

Potassium Chloride/Sodium Chloride................................69

Potassium Citrate ER............ 69

Povidone-Iodine..................... 20

Praluent.................................. 54

Pramipexole Dihydrochloride.............................................. 39

Prasugrel................................ 49

Pravastatin Sodium................54

Praziquantel........................... 38

Prazosin HCl...........................50

Precision PCX...................... 124

Precision PCX Plus Test Strips............................................ 124

Precision Point of Care Test Strips.................................. 124

Precision QID Test Strips....124

Precision XTra Blood Glucose Test Strips..........................124

Prednicarbate...................... 101

Prednisolone........................101

Prednisolone Acetate..........133

Prednisolone Sodium Phosphate................. 101, 133

Prednisone........................... 101

Prednisone Intensol.............101

Preferred Plus Lancets Super Thin 30g............................. 124

Preferred Plus Lancets Thin 26g..................................... 124

Pregabalin.............................. 57

Premarin...............................105

Premasol................................ 69

Premium Blood Glucose Test Strips.................................. 124

Premphase...........................105

Prempro................................105

Prevalite..................................54

Prevent....................................85

Previfem............................... 105

Prezcobix................................45

Prezista................................... 45

Priftin.......................................33

Primaquine Phosphate..........38

Primidone............................... 26

Privigen.................................110

Pro Comfort Lancets 30g....124

Pro Comfort Lancets 31g....125

ProAir HFA........................... 137

ProAir RespiClick................ 137

Probenecid.............................32

Probenecid/Colchicine......... 32

Procalamine........................... 69

Prochlorperazine................... 30

Prochlorperazine Maleate.....30

Procrit..................................... 49

Procto-Med HC.................... 112

Procto-Pak............................112

Proctosol HC........................112

Proctozone-HC.....................112

173173

Prodigy Lancing Device...... 125

Prodigy No Coding Blood Glucose Test Strips...........125

Prodigy Pressure Activated Safety Lancets...................125

Prodigy Safety Lancets....... 125

Prodigy Twist Top Lancets. 125

ProFe...................................... 69

Proferrin ES............................ 69

Proglycem.............................. 47

Prograf..................................109

Prolastin-C.............................. 98

Prolensa............................... 133

Prolia.....................................113

Promacta................................ 49

Promethazine HCl................135

Promethazine VC/Codeine.143

Promethazine-DM................ 143

Promethazine/Codeine.......143

Promethazine/Phenylephrine............................................ 143

Promethegan....................... 135

Propafenone HCl................... 50

Propafenone HCl ER............. 50

Proparacaine HCl................ 131

Propranolol HCl..................... 51

Propranolol HCl ER............... 51

Propranolol/Hydrochlorothiazide............53

Propylthiouracil....................108

ProQuad............................... 111

Prosol......................................69

Protriptyline HCl.....................29

Prudoxin................................. 60

Pseudoephedrine HCl.........143

Pulmosal...............................143

Pulmozyme...........................143

Puralube............................... 131

Pure C 500............................. 85

Pureway-C.............................. 85

Purixan....................................34

Push Button Safety Lancets 28g..................................... 125

PX Advanced Lancing Device............................................ 125

PX Lancets Ultra Thin..........125

PX Lancets Ultra Thin 28g.. 125

Pyrazinamide..........................33

Pyridostigmine Bromide........33

Pyridostigmine Bromide ER..33

Pyridoxine HCl....................... 85

Q

QC Advanced Lancing Device............................................ 125

QC Anti-Diarrheal...................95

QC Arthritis Pain Relief..........14

QC Calcium Fast Dissolution69

QC Calcium/Minerals/Vitamin D........................................... 69

QC Childrens Chewable Vitamins/Extra C..................85

QC Lancets Super Thin.......125

QC Loratadine Allergy Relief............................................ 135

QC Loratadine-D..................135

QC Maximum Daily Multivitamin/Multimineral... 85

QC Multi-Vite.......................... 85

QC Naproxen Sodium........... 15

QC Tolnaftate.........................31

QC Unilet Lancets 28g/Ultra Thin.....................................125

QC Unilet Lancets 33g/Micro Thin.....................................125

QC Womens Daily Multivitamin.............................................. 85

Quadracel.............................111

Quetiapine Fumarate.............41

Quetiapine Fumarate ER.......41

Quinapril HCl..........................50

Quinapril/Hydrochlorothiazide.............................................. 53

Quinidine Gluconate CR....... 50

Quinidine Sulfate................... 51

Quinine Sulfate...................... 38

Quintabs-M.............................85

Quintet AC Blood Glucose Test Strips.................................. 125

Quintet Blood Glucose Test Strips.................................. 125

R

RA B-Complex........................85

RA B-Complex with B-12.......85

RA B-Complex/Vitamin C TR85

RA Balanced B-100............... 85

RA Balanced B-50................. 85

RA Biotin................................ 85

RA Calcium 600.....................69

RA Calcium 600 Plus Vitamin D-3........................................ 70

RA Calcium 600/Vitamin D/Minerals................................70

RA Calcium Citrate Plus Vitamin D-3...........................70

174174

RA Calcium/Boron................ 70

RA Calcium/Magnesium/Zinc/Copper................................. 70

RA Central-Vite Cardio.......... 85

RA Central-Vite Select Mature.............................................. 85

RA Central-Vite Womens Mature.................................. 85

RA Central-Vite/Antioxidants85

RA E-Zject Lancets 28g...... 125

RA E-Zject Lancets Thin 26g............................................ 125

RA E-Zject Lancets Thin 28g............................................ 125

RA E-Zject Lancets Ultra Thin 30g..................................... 125

RA Hi Cal................................ 70

RA High Potency Iron............70

RA Iron....................................70

RA Magnesium...................... 70

RA Natural Magnesium......... 70

RA Niacin................................86

RA One Daily Energy Formula.............................................. 86

RA One Daily Essential..........86

RA One Daily Maximum........ 86

RA One Daily Mens 50+ with Vitamin D-3...........................86

RA Oyster Shell Calcium/Vitamin D..............................70

RA Pediatric Electrolyte........ 70

RA Pediatric Electrolyte Freezer Pops........................70

Ra Selenium...........................70

Ra Selenium Natural..............70

RA Slow Release Iron............70

RA Vitamin A.......................... 86

RA Vitamin B-1.......................86

RA Vitamin B-12.....................86

RA Vitamin B-12 TR...............86

RA Vitamin B-6.......................86

RA Vitamin B12......................86

RA Vitamin C..........................86

RA Vitamin C Drops...............86

RA Vitamin C TR....................86

RA Vitamin C/Acerola........... 86

RA Vitamin C/Rose Hips.......86

RA Vitamin C/Rose Hips TR.86

RA Vitamin E.......................... 86

RA Zinc...................................70

Rabano Yodado.....................86

Rabavert............................... 111

Rabeprazole Sodium.............98

Raloxifene HCl..................... 107

Ramelteon............................144

Ramipril.................................. 50

Ranexa....................................53

Ranitidine 150 Maximum Strength................................95

Ranitidine 75.......................... 95

Ranitidine HCl........................ 96

Ranitidine Maximum Strength.............................................. 96

Ranolazine ER........................53

Rapaflo................................... 99

Rapamune............................109

Rasagiline Mesylate...............40

Rasuvo..................................109

Ravicti..................................... 98

Readylance Safety Lancets/21g/2.2mm........................ 125





Rebif....................................... 57

Rebif Rebidose...................... 57

Rebif Rebidose Titration Pack.............................................. 57

Rebif Titration Pack............... 57

Reclipsen............................. 105

Recombivax HB................... 111

Refresh Celluvisc.................131

Refresh Lacri-Lube.............. 131

Refresh Optive Mega-3....... 131

Refresh Plus.........................131

Refuah Plus Blood Glucose Test Strips..........................125

Regranex................................ 60

Relenza Diskhaler..................45

Relion Confirm/Micro Test Strips.................................. 125

Relion Lancets Thin 26g..... 125

Relion Lancets Ultra-Thin30g............................................ 125

Relion Lancing Device........ 126

Relion Premier Blood Glucose Test Strips..........................126

175175

Relion Prime Blood Glucose Test Strips..........................126

Relion Ultima Blood Glucose Test Strips..........................126

Relion Ultra Thin Lancets30g............................................ 126

Relion Ultra Thin Plus Lancets 32g..................................... 126

Relion Ultra Thin Plus Lancets 33g..................................... 126

Relistor....................................95

Rena-Vite................................ 86

Renal Vitamin.........................86

Renal-Vite............................... 86

Repaglinide............................ 47

Repaglinide/Metformin HCl..47

Repatha.................................. 54

Repatha Pushtronex System 54

Repatha SureClick.................55

Repel Huniters Formula........ 60

Repel Lemon Eucalyptus Insect Repellent...................60

Repel Sportsmen...................60

Repel Sportsmen Dry............ 60

Repel Sportsmen Max...........60

Rescon................................. 136

Rescriptor...............................43

Respaire-30.......................... 143

Restasis................................ 131

Retacrit................................... 49

Reveal Blood Glucose Test 126

Revlimid..................................34

Rexall Blood Glucose Test Strips.................................. 126

Rexall Lancets Ultra Thin....126

Rexulti.....................................41

Reyataz................................... 45

Rhopressa............................131

Ribavirin..................................42

Ridaura................................. 110

Rifabutin................................. 33

Rifampin................................. 33

Rifater..................................... 33

Rightest GD500 Lancing Device................................ 126

Rightest GL300 Lancets..... 126

Rightest GS100 Blood Glucose Test Strips..........................126



Riluzole................................... 56

Rimantadine HCl....................45

Riomet.................................... 47

Risacal-D.................................70

Risperdal Consta................... 41

Risperidone............................41

Risperidone ODT................... 41

Ritonavir................................. 45

Rivastigmine Tartrate............ 27

Rivastigmine Transdermal System..................................27

Rivelsa.................................. 106

Rizatriptan Benzoate............. 32

Rizatriptan Benzoate ODT.... 32

Robafen................................143

Robafen CF Multi-Symptom Cold....................................143

Robafen Cough................... 143

Robafen DM.........................143

Robafen DM Cough Clear.. 143

Robafen DM Cough/Chest Congestion........................ 143

Rocklatan............................. 132

Ropinirole HCl........................39

Rosuvastatin Calcium............54

Rotarix.................................. 111

RotaTeq................................111

Roweepra............................... 25

Roweepra XR......................... 25

Rozerem............................... 144

Rozlytrek.................................35

Ru-Hist D.............................. 136

Rubraca.................................. 36

Ruconest.............................. 108

Rulox.......................................95

Rydapt.................................... 37

Rymed.................................. 136

Rynex DM.............................143

Rynex PE.............................. 136

Rynex PSE............................136

Rytary......................................39

S

S2..........................................137

Sabril.......................................26

Safety Lancet 21g/Pressure Activated............................ 126

Safety Lancet 28g/Pressure Activated............................ 126

Safety Lancets..................... 126

176176

Safety Lancets 21g..............126

Safety Lancets 28g..............126

Safety Let Lancets...............126

Safety Seal Lancets 28g..... 126

Safety Seal Lancets 30g..... 126

Saizen................................... 102

Saizenprep Reconstitution Kit............................................ 102

Samsca...................................72

Sancuso..................................30

Sandimmune........................109

Sani-Supp Adult..................... 97

Sani-Supp Pediatric............... 97

Santyl...................................... 60

Saphris....................................41

Sapscare Twist Top Lancets 30g..................................... 126

Savella.................................... 57

Savella Titration Pack............57

Sawyer Premium Insect Repellent..............................60

SB Vitamin C.......................... 86

Scooby-Doo One A Day........ 86

Scopolamine.......................... 30

Select-Lite Lancing Device. 126

Selegiline HCl.........................40

Selenium.................................70

Selenium Sulfide....................60

Selzentry.................................44

Senexon..................................97

Senexon-S.............................. 97

Senior Tabs............................ 86

Senna......................................97

Senna Plus............................. 97

Senna-Lax...............................97

Sensipar............................... 113

Sentry......................................87

Sentry Adults Under 50......... 87

Sentry Senior..........................87

Serevent Diskus...................137

Serostim................................. 95

Sertraline HCl.........................28

Setlakin.................................106

Sevelamer Carbonate............72

Sharobel............................... 107

Shingrix.................................111

Shopko Autolet Lancing Device................................ 126

Shopko On-The-Go Comfort Lancets 30g....................... 126

Shopko Unilet Lancets Super Thin 30g............................. 126

Shopko Unilet Lancets Ultra Thin 28g............................. 126

Sidekick Blood Glucose System............................... 126

Sidestream Pediatric Face Mask/Tucker the Turtle.... 126

Signifor................................. 108

Siladryl Allergy..................... 136

Sildenafil...............................138

Silodosin.................................99

Siltussin DM DAS.................143

Siltussin SA.......................... 143

Siltussin-DM......................... 143

Silver Sulfadiazine................. 24

Simethicone........................... 95

Simple Diagnostics Lancing Device................................ 126

Simponi................................ 109

Simvastatin.............................54

Sirolimus...............................109

Sirturo..................................... 34

Slo-Niacin............................... 88

Slow Fe................................... 70

Slow Release Iron..................70

Slow-Mag................................70

Slow-Release Iron.................. 70

SM Allergy 4 Hour............... 136

SM Allergy Relief................. 136

SM Antacid Anti-Gas............. 95

SM Antacid/Anti-Gas.............95

SM Anti-Diarrheal...................95

SM B-Complex....................... 88

SM B-Complex/Vitamin C..... 88

SM Balanced B-50.................88

SM Calcium 500/Vitamin D3 70

SM Calcium 600 + D3........... 70

SM Calcium 600/Vitamin D.. 70

SM Calcium Citrate + with Vitamin D..............................70

SM Calcium Citrate with Vitamin D3............................70

SM Calcium Soft Chews....... 70

SM Calcium/Magnesium/Zinc.............................................. 70

SM Calcium/Vitamin D..........70

SM Chewable C..................... 88

Sm Chewable Vitamin C....... 88

SM Complete......................... 88

SM Complete 50+..................88

177177

SM Complete 50+ Ultimate Womens............................... 88

SM Complete Advanced Formula................................ 88

SM Complete Senior Formula.............................................. 88

SM Hair/Skin/Nails................88

SM Ibuprofen......................... 15

SM Iron................................... 70

SM Iron Slow Release........... 70

SM Lorata-Dine D................ 136

SM Loratadine..................... 136

SM Magnesium......................70

SM Miconazole 7................... 31

SM Micro Thin Lancets 33g126

SM Multiple Vitamins Essential.............................................. 88

SM Multiple Vitamins/Iron.... 88

SM Nasal Spray 12 Hour.....143

SM Niacin CR.........................88

SM One Daily Womens......... 88

SM Oyster Shell Calcium/Vitamin D..............................70

SM Oyster Shell Calcium/Vitamin D3............................71

SM Pediatric Electrolyte........71

SM Selenium..........................71

SM Sleep Aid....................... 144

SM Slow Release Iron........... 71

SM Super B Complex-Vitamin C........................................... 88

SM Tussin DM......................143

SM Tussin DM Cough/Chest Congestion........................ 143

SM Vitamin B-12.................... 88

SM Vitamin B-6...................... 88

SM Vitamin B1....................... 88

SM Vitamin B100 Complex...88

SM Vitamin B12..................... 88

SM Vitamin B12 TR............... 88

SM Vitamin B6....................... 88

SM Vitamin C......................... 88

SM Vitamin C TR................... 88

SM Vitamin C/Rose Hips...... 88

SM Vitamin E..........................89

SM Vitamin E Blended.......... 89

SM Zinc.................................. 71

Smart Diabetes Vantage Lancing Device..................126

Smart Sense Color Lancets Universal 33g.....................126

Smart Sense Premium Bloodglucose Strips..........126

Smart Sense Standard Lancets Universal 21g.....................127

Smart Sense Super Thin Lancets Universal 30g...... 127

Smart Sense Thin Lancets Universal 26g.....................127

Smart Sense Value Blood Glucose Strips................... 127

Smartest Blood Glucose Test Strips.................................. 127

Smartest Lancets 28g......... 127

Sodium Bicarbonate..............95

Sodium Chloride... 71, 131, 143

Sodium Chloride 0.9%......... 71

Sodium Fluoride.................... 71

Sodium Lactate......................71

Sodium Phenylbutyrate.........98

Sodium Polystyrene Sulfonate.............................................. 72

Sodium Sulfacetamide..........24

Sofosbuvir/Velpatasvir.......... 42

Solifenacin Succinate............99

Soliqua 100/33...................... 47

Soltamox.................................34

Solus V2 Audible Test.........127

Solus V2 Lancing Device.... 127

Solus V2 Pressure Activated Safety Lancets 28g........... 127

Solus V2 Twist Lancets 30g127

Somatuline Depot................108

Somavert.............................. 108

Sotalol HCl............................. 51

Sotalol HCl AF........................51

Spiriva HandiHaler...............137

Spiriva Respimat..................137

Spironolactone.......................53

Spironolactone/Hydrochlorothiazide............53

Sporanox................................ 32

Sprintec 28...........................106

Spritam................................... 25

Sprycel....................................37

SPS......................................... 72

Sronyx...................................106

SSD......................................... 24

Stahist AD.............................143

Stavudine................................44

Stelara.....................................60

Sterilance PA....................... 127

Sterilance Tl......................... 127

Stimulant Laxative..................97

178178

Stiolto Respimat.................. 143

Stivarga...................................37

Stool Softener........................ 97

Streptomycin Sulfate............. 19

Stress B/Zinc......................... 89

Stress Formula.......................89

Stress Formula with Iron....... 89

Stress Formula/Iron...............89

Stress Formula/Zinc..............89

Stribild.....................................43

Suboxone............................... 18

Sucraid................................... 99

Sucralfate............................... 97

Sudogest.............................. 143

Sudogest 12 Hour............... 143

Sudogest PE........................ 144

Sudogest Sinus & Allergy... 136

Sulfacetamide Sodium..........24

Sulfacetamide Sodium/Prednisolone Sodium Phosphate..........................131

Sulfadiazine............................24

Sulfamethoxazole/Trimethoprim....................... 24

Sulfamethoxazole/Trimethoprim DS................. 24

Sulfasalazine........................ 112

Sulindac..................................15

Sumatriptan............................32

Sumatriptan Succinate..........33

Sumatriptan Succinate Refill 33

Super B Complex Maxi......... 89

Super B with C....................... 89

Super B-Complex/Vitamin C 89

Super Biotin........................... 89

Super Calcium....................... 71

Super Calcium 600 + D 400..71

Super Calcium 600 + D3.......71

Super Calcium 600 + D3 400.............................................. 71

Super Quints B-50................. 89

Super Thera Vite M................89

Superplex-T............................ 89

Suplevit...................................89

Suprax.................................... 22

Suprep Bowel Prep Kit..........97

Sure Comfort Lancets 18g..127





Sure Comfort Lancing Pen. 127

Sure-Lance Flat Lancets..... 127

Sure-Lance Thin Lancets 28g............................................ 127

Sure-Lance Ultra Thin Lancets............................................ 127

Sure-Test EasyPlus Mini Blood Glucose Test Strips...........127

Sure-Touch Lancets Universal............................................ 127

Suspendol-S.........................127

Sutent..................................... 37

Syeda....................................106

Sylatron...................................42

Symbicort............................. 144

Symfi....................................... 43

Symfi Lo..................................43

SymlinPen 120....................... 47

SymlinPen 60......................... 47

Sympazan...............................26

Symtuza..................................45

Synarel..................................108

Synjardy..................................47

Synjardy XR............................47

Synribo................................... 35

Synthroid.............................. 107

T

TAB-A-VITE.............................89

TAB-A-VITE Maximum........... 89

TAB-A-VITE with Beta Carotene.............................................. 89

TAB-A-VITE/Iron.....................89

Tabloid....................................35

Tacrolimus..................... 60, 109

Tadalafil................................ 138

Tafinlar....................................37

Tagrisso..................................37

Talzenna................................. 36

Tamoxifen Citrate.................. 34

Tamsulosin HCl......................99

Tandem.................................. 71

Tarceva................................... 37

Targretin................................. 38

Tarina 24 Fe......................... 106

Tarina Fe 1/20..................... 106

Tasigna................................... 37

Tazarotene............................. 60

Tazicef.................................... 22

Tazorac...................................60

Taztia XT.................................52

179179

Tecfidera................................ 57

Tecfidera Starter Pack...........57

TechLite Lancets................. 127

Techlite Lancets 30g...........127

Telcare Blood Glucose Test Strips.................................. 127

Telmisartan.............................50

Telmisartan/Amlodipine........53

Telmisartan/Hydrochlorothiazide............53

Temazepam......................... 144

Tencon....................................14

Tenivac................................. 111

Tenofovir Disoproxil Fumarate.............................................. 44

Terazosin HCl.........................99

Terbinafine HCl......................32

Terconazole............................32

Testosterone........................ 102

Testosterone Cypionate......102

Testosterone Enanthate......102

Testosterone Pump.............102

Tetanus/Diphtheria Toxoids-Adsorbed Adult................. 111

Tetrabenazine........................ 56

Tetracycline HCl.................... 25

TGT Blood Glucose Test Strips............................................ 127

TGT Blood Glucose Test Strips Premium.............................128

TGT Calcium + Vitamin D3... 71

TGT Lancet Micro Thin 33g128

TGT Lancet Thin 26g.......... 128

TGT Lancet Ultra Thin 30g. 128

TGT Lancing Device............128

Thalomid.................................34

Theophylline.........................138

Theophylline ER...................138

Thera.......................................89

Thera M Plus.......................... 89

Thera-M.................................. 90

Thera-Tabs............................. 90

Therapeutic-M/Lutein............90

Theratrum Complete............. 90

Theratrum Complete 50 Plus90

Therems..................................90

Therems-H..............................90

Therems-M............................. 90

Thiamine HCl......................... 90

Thioridazine HCl.................... 40

Thiothixene.............................40

ThyroSafe............................. 128

Tiagabine HCl........................ 26

Tibsovo................................... 37

Tigecycline............................. 20

Timolol Maleate............. 51, 132

Timolol Maleate Ophthalmic Gel Forming.......................132

Tinidazole............................... 20

Tioconazole-1.........................32

Tivicay.....................................43

Tizanidine HCl......................144

TOBI Podhaler..................... 138

Tobradex.............................. 131

Tobradex ST........................ 131

Tobramycin.......................... 138

Tobramycin Sulfate............... 19

Tobramycin/Dexamethasone............................................ 131

Tobrex.....................................20

Tolak....................................... 60

Tolcapone.............................. 39

Tolnaftate............................... 32

Topcare Lancets Micro-Thin 33g..................................... 128

Topiramate............................. 26

Toremifene Citrate.................34

Torsemide.............................. 53

Total B/C................................ 90

Totalday Multiple................... 90

Toujeo Max Solostar..............48

Toujeo SoloStar..................... 48

TPN Electrolytes.................... 71

Tracleer................................ 138

Tradjenta................................ 47

Tramadol HCl.........................18

Tramadol HCl ER...................16

Tramadol HCl/Acetaminophen.............................................. 18

Trandolapril............................ 50

Tranexamic Acid....................49

Transderm-Scop.................... 30

Tranylcypromine Sulfate....... 28

Travasol.................................. 71

Travatan Z............................ 133

Travel Lancets 30g.............. 128

Travel Lancets Advanced 28g............................................ 128

Travel Sickness......................30

Trazodone HCl.......................28

Trecator.................................. 34

180180

Trelegy Ellipta...................... 144

Trelstar Mixject.................... 108

Tresiba....................................48

Tresiba FlexTouch................. 48

Tretinoin........................... 38, 60

Tretinoin Microsphere........... 60

Trexall................................... 109

Trezix...................................... 18

Tri-Estarylla...........................106

Tri-Legest Fe........................ 106

Tri-Lo-Estarylla..................... 106

Tri-Lo-Sprintec..................... 106

Tri-Mili................................... 106

Tri-Previfem.......................... 106

Tri-Sprintec...........................106

Tri-Vi-Sol..................................90

Tri-VyLibra............................ 106

Tri-VyLibra Lo.......................106

Triamcinolone Acetonide...101, 136

Triamcinolone Acetonide Dental Paste.........................57

Triamterene/Hydrochlorothiazide............53

Triderm................................. 101

Trientine HCl.......................... 72

Trifluoperazine HCl................40

Trifluridine.............................. 42

Trihexyphenidyl HCl.............. 39

TriLyte.....................................97

Trimethoprim..........................20

Trimipramine Maleate........... 29

Trintellix.................................. 28

Triple Antibiotic......................21

Triple Antibiotic Plus............. 21

Triprolidine HCl....................136

Triumeq.................................. 43

Trivora-28............................. 106

Trophamine............................71

True Metrix Blood Glucose Test Strips..........................128

True Metrix Self Monitoring Blood Glucose Strips........128

TrueDraw Lancing Device...128

TruePlus Lancets 26g......... 128


Trueplus Lancets 28g Super Thin.....................................128


Trueplus Lancets 30g Ultra Thin.....................................128


Trueplus Lancets 33g Micro Thin.....................................128

Trueplus Safety Lancets 28g............................................ 128

TrueTest Strips.................... 128

TrueTrack Blood Glucose Test Strips.................................. 128

TrueTrack Test Strips..........128

Trumenba.............................111

Truvada...................................44

Turalio.....................................37

Tussin DM............................ 144

Twinrix.................................. 111

Tybost..................................... 43

Tykerb.....................................37

Tymlos.................................. 113

Typhim Vi............................. 111

U

Ulti-Lance Automatic/ Clear Tip.......................................128

Ultilet Classic Lancets......... 128

Ultilet Lancets...................... 128

Ultilet Lancets 33g...............128

Ultilet Safety Lancets 23g... 128

Ultima Test Strips................ 128

Ultra Choice Multivitamin Kids.............................................. 90

Ultra Lubricant Eye Drops...131

Ultra-Thin II Lancets 28g..... 128

Ultra-Thin II Lancets 30g..... 128

Ultra-Thin II Safety Autolancets 26g..................................... 128

Ultrachoice Advanced Formula.............................................. 90

Ultralance............................. 128

Ultrathon Insect Repellent 8. 60

Ultratrak Pro Test Strips......128

Ultratrak Ultimate Test Strips............................................ 128

Unicomplex-M........................ 90

Unilet ComforTouch Lancet............................................ 129

Unilet Excelite...................... 129

Unilet Excelite II................... 129

Unilet G.P. SuperLite Lancet............................................ 129

Unilet GP 28 Ultra Thin....... 129

Unilet Lancets Micro-Thin33g............................................ 129

Unilet Lancets Super-Thin30g............................................ 129

181181

Unilet Lancets Ultra-Thin 28g............................................ 129

Unistik 2................................129

Unistik 2 Comfort.................129

Unistik 2 Extra...................... 129

Unistik 2 Normal.................. 129

Unistik 2 Super.................... 129

Unistik 3 Comfort.................129

Unistik 3 Extra...................... 129

Unistik 3 Gentle................... 129

Unistik 3 Neonatal............... 129

Unistik 3 Normal.................. 129

Unistik CZT Comfort............129

Unistik CZT Normal............. 129

Unistik Safety Lancets 28g. 129

Unistik Safety Lancets 30g. 129

Unistik Touch Safety Lancets 21g..................................... 129




Unistrip1 Generic.................129

Unithroid...............................107

Universal 1 Lancets Thin 26g............................................ 129

Universal 1 Lancets Ultra Thin 30g..................................... 129

Ursodiol.................................. 95

V

Valacyclovir HCl.....................42

Valchlor...................................34

Valganciclovir.........................42

Valganciclovir Hydrochlorde.42

Valproic Acid..........................26

Valsartan.................................50

Valsartan/Hydrochlorothiazide.............................................. 53

Value Plus Lancing Device. 130

Valumark Lancet Super Thin 30g..................................... 130

Valumark Lancet Ultra Thin 28g..................................... 130

Vanaclear PD....................... 136

VanaCof................................144

VanaCof DM.........................144

VanaCof-8.............................144

Vanahist PD..........................136

Vanamine PD....................... 136

Vanatab Ac...........................136

Vanatab DM......................... 136

Vancomycin HCl.................... 21

Vandazole...............................21

Vaqta.....................................112

Varivax.................................. 112

Varizig...................................110

Vascepa..................................55

Velivet................................... 106

Velphoro................................. 72

Veltassa.................................. 72

Vemlidy...................................42

Venclexta................................37

Venclexta Starting Pack........ 37

Venlafaxine HCl......................28

Venlafaxine HCl ER................29

Ventavis................................ 138

Verapamil HCl........................ 52

Verapamil HCl ER.................. 52

Verasens Blood Glucose Test Strips.................................. 130

Versacloz................................ 41

Verzenio..................................35

Vesicare..................................99

Vibramycin..............................25

Vida Mia Autolet Lancing Device................................ 130

Vida Mia Unilet Lancets Super Thin 30g............................. 130

Vida Mia Unilet Lancets Ultra Thin 28g............................. 130

Videx EC................................. 44

Videx Pediatric....................... 44

Vienva................................... 106

Vigabatrin............................... 26

Vigadrone............................... 26

Viibryd.....................................29

Viibryd Starter Pack...............29

Vimpat.....................................27

Viracept.................................. 45

Viramune................................ 43

Viread......................................44

Virtussin A/C........................144

Virtussin DAC.......................144

Vita-Bee/C.............................. 91

Vitalee..................................... 91

Vitalets.................................... 91

Vitalets Childrens...................91

Vitamin A................................ 91

Vitamin A & D......................... 60

Vitamin B Complex................91

Vitamin B Complex-C............ 91

182182

Vitamin B-1............................. 91

Vitamin B-12........................... 91

Vitamin B-12 CR.....................91

Vitamin B-12 ER..................... 91

Vitamin B-12 TR..................... 91

Vitamin B-2............................. 91

Vitamin B-6............................. 91

Vitamin B-Complex................ 91

Vitamin B1.............................. 91

Vitamin B12............................91

Vitamin B12 TR...................... 91

Vitamin B6.............................. 91

Vitamin C................................ 92

Vitamin C Drops.....................92

Vitamin C SR.......................... 92

Vitamin C TR.......................... 92

Vitamin C/Rose Hips.............92

Vitamin C/Rose Hips TR.......92

Vitamin D................................ 92

Vitamin D3.............................. 92

Vitamin E................................ 92

Vitamin E Blend..................... 92

Vitamin E Water Dispersible. 92

Vitamin E Water Soluble........92

Vitamin E-400......................... 92

Vitamin E/D-Alpha................. 92

Vitamin E/D-Alpha Natural.... 92

Vitamin E/Dl-Alpha................ 92

Vitamin K1.............................. 92

Vitamins & Minerals...............92

Vitamins for Hair.................... 92

Vitatrum.................................. 93

Vitrakvi.................................... 37

Vitrum 50+ Senior Multi.........93

Vivitrol..................................... 18

Vizimpro..................................37

Voriconazole.......................... 32

Vosevi..................................... 42

Votrient................................... 37

VP-PNV-DHA.......................... 93

Vraylar.....................................41

Vyfemla.................................106

VyLibra..................................106

Vyndaqel.................................53

Vyzulta.................................. 133

W

Walgreens Advanced Travellancets 28g..............130

Walgreens Comfort Assuredlancets Micro Thin/33g..................................... 130

Walgreens Comfort Assuredlancets Super Thin/28g..................................... 130

Walgreens Thin Lancets..... 130

Walgreens Ultra Thin Lancets............................................ 130

Warfarin Sodium.................... 48

Wavesense Presto Test Strips............................................ 130

Wee Care................................71

White Petrolatum................. 130

Wixela Inhub........................ 144

Womens Daily Formula......... 93

Womens Daily Formula/Folic Acid/Calcium/Iron...............93

Womens One Daily................ 93

WYMZYA Fe.........................106

X

Xalkori.....................................37

Xarelto.....................................48

Xarelto Starter Pack...............48

Xatmep................................. 110

Xeljanz.................................. 110

Xeljanz XR............................ 110

Xgeva....................................113

Xifaxan.................................... 96

Xigduo XR.............................. 47

Xiidra.....................................131

Xofluza.................................... 45

Xolair.....................................110

Xospata...................................37

Xpovio 100mg Once Weekly 35

Xpovio 60mg Once Weekly...35

Xpovio 80mg Once Weekly...35

Xpovio 80mg Twice Weekly..35

Xtampza ER............................16

Xtandi......................................34

Xyrem....................................144

Y

Yelets Teenage Formula....... 93

YF-Vax...................................112

Z

Z-Bum..................................... 60

Zafirlukast.............................136

Zaleplon................................144

Zarah.....................................106

Zarxio......................................49

Zeasorb-AF.............................32

Zebutal....................................14

Zejula...................................... 36

183183

Zelapar....................................40

Zelboraf.................................. 38

Zemaira...................................99

Zenpep................................... 99

Zerbaxa...................................22

Zidovudine..............................44

Zileuton ER...........................136

Zinc...................................71, 93

Zinc 15....................................71

Zinc Chelated.........................71

Zinc Gluconate.......................71

Zinc Oxide.............................. 60

Zinc Sulfate............................ 72

Zinc-220..................................72

Zioptan................................. 133

Ziprasidone HCl.....................41

Zirgan......................................42

Zolinza.................................... 35

Zolpidem Tartrate................144

Zonisamide.............................25

Zoo Friends............................ 93

Zorbtive...................................95

Zortress................................ 110

Zostavax............................... 112

Zovia 1/35E..........................106

Zutripro.................................144

Zyclara Pump.........................60

Zydelig.................................... 38

Zyflo...................................... 137

Zykadia................................... 38

Zyprexa Relprevv...................41

Zytiga...................................... 34

Formulary ID Number 00019088, Version 17

H7833_180629_022455_v01.13 ApprovedLast updated December 1, 2019UHTX19HM4307577_014

If you have questions, please call UnitedHealthcare Connected Member Services at:

Toll-free 1-800-256-6533, TTY 7-1-1

8 a.m. - 8 p.m. local time, Monday - Friday

www.UHCCommunityPlan.com

www.myuhc.com/CommunityPlan

2019 list of covered drugs (formulary) · 2 2 unitedhealthcare connected® (medicare-medicaid plan)...

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