2021 member formulary - geisinger health system

GHP FAMILY

2021 member formulary List of covered drugs

¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document

Geisinger Family 2021 Supplemental Formulary of 84

Effective Date: 12/01/2021

What is the Statewide PDL and GHP Family Formulary? Geisinger Health Plan, like other Medicaid Managed Care Organizations follows the Statewide Preferred Drug List (PDL). The Statewide PDL is developed by the Department of Human Services’ (DHS) Pharmacy and Therapeutics Committee. A formulary is a list of drugs selected by GHP Family, which represents medications believed to be a necessary part of a quality treatment program. Only medications that are not part of the PDL may be included in the GHP Family formulary.

This formulary is up to date at the time of print. For the most up to date information, please go to our website at https://www.geisinger.org/health-plan/plans/ghp-family and visit https://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Preferred-Drug-List.aspx for information on the Statewide PDL.

Can the Formulary change? The plan may add or remove drugs from the formulary. If we remove drugs from our formulary or add restrictions on a drug such as a requirement for prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective. See section, “Are there any requirements or limits on my drugs?” for more information.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Drug Class The formulary begins on page 14. The drugs in this formulary are grouped into the class of drugs they belong to. If you know what class your drug belongs to, look for the class name in the list that begins on page 11. Then look under the class name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that is included at the end of this document. The Index provides an alphabetical list of all the drugs included in this document.

The first column of the formulary lists the formulary drug. Brand drugs are printed in all upper-case letters (e.g. DIURIL ORAL SUSPENSION). Generic drugs are printed in all lower-case italic letters (e.g. furosemide). Drug names that appear in the third column for generic covered drugs are the name of the brand medication. The brand name in the third column appears for reference only to assist in identifying the generic medication and does NOT indicate that the brand name drug is on the formulary.

https://www.geisinger.org/health-plan/plans/ghp-family

https://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Preferred-Drug-List.aspx




The second column of the formulary lists the tier the drug is covered on. Tier 1 contains generic medications. Tier 2 contains brand name medications. Drugs listed as OTC are over-the-counter medications.

The fourth and final column of the formulary lists any requirements or limits that may apply to the drug. See the section titled “Are there any requirements or limits on my drugs” below.

Sometimes a drug comes in multiple forms (e.g., drops, liquid, tablet, syrup, etc.). If this column lists a specific drug form, then only that form is included in the formulary.

What are generic drugs? GHP Family covers both brand name drugs and generic drugs. If your doctor prescribes a brand name drug and a generic is available, your pharmacist will give you the generic version of that drug. A generic drug is approved by the Federal Food & Drug Administration (FDA) as having the same active ingredient as the brand name drug and is just as safe and effective. Generally, generic drugs cost less than brand name drugs. Prescriptions written as “brand medically necessary” by your doctor will require prior authorization.

Are Over-the-Counter (OTC) drugs covered? Certain OTC medications are listed on the Statewide PDL or formulary. OTC drugs will require a prescription from your doctor.

Dispensing Limits GHP Family will cover up to a 34-day supply of your medication unless the prescription is written for less by your physician or the medication is subject to a quantity limit restriction. If there are medications you take on a regular basis, such as blood pressure medications or medications to treat cholesterol (maintenance medications), you have the option to obtain a 90-day supply from a participating retail pharmacy or mail order pharmacy. Please call GHP Family Pharmacy services at (855) 552-6028 or (570) 214–3554 for assistance in finding a participating pharmacy. Certain medications such as controlled substances and specialty medications are excluded from this 90-day supply program. If you have questions about which medications are considered maintenance medications you can check online at https://healthplan.geisinger.org/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger or call GHP Family Pharmacy services at (855) 552-6028 or (570) 214–3554. A medication may be refilled when 85% has been used. Controlled medications, which may cause addiction, such as those used for pain or anxiety, may be refilled when 90% has been used. If for some reason you need a refill

https://healthplan.geisinger.org/pharmacy/pharmacy.aspx?strip=true&amp%3Bstyle=OneGeisinger




before 85% or 90% of the medication has been used please call GHP Family Pharmacy Services at (855) 552-6028 or (570) 214-3554 for assistance.

GHP Family will grant one early refill if you are traveling outside of Pennsylvania and will run out of medication before you return home. GHP Family will allow this once per medication per member per year. Your pharmacy should contact GHP Family Pharmacy Services at (855) 552-6028 or (570) 214-3554 to obtain a vacation supply. Any additional requests for a vacation supply will require prior authorization.

Requests to replace medications that are lost, stolen, or destroyed must be reviewed by GHP Family Pharmacy Services. Members should contact GHP Family Pharmacy Services at (855) 552-6028 or (570) 214-3554 for more information.

Blood Glucose Monitors and Strips Members are entitled to receive one new blood glucose monitor every two years and 200 strips every month. You can also receive a new monitor if you switch to a different one that is preferred on the PDL. Medical Benefit Drugs Medical benefit drugs are drugs dispensed and administered in a physician’s office and are not included in the formulary. For some Medical Benefit Drugs, your provider must first obtain prior authorization. Your provider can find a list of medical benefit drugs that require prior authorization here: https://www.geisinger.org/health-plan/providers/pharmacy-forms. Any questions regarding the coverage of medical benefit drugs should be directed to GHP Family Pharmacy Services at (855) 552-6028. Vaccines The vaccines included in the formulary are available to members at a retail pharmacy without a prescription. The typhoid vaccine (Vivotif) is also available at retail pharmacies but requires a prescription. Other vaccines are considered a medical benefit and should be administered by your physician.

Are there any requirements or limits on my drugs? Some drugs may have additional requirements or limits. These requirements and limits may include:

• Prior Authorization: GHP Family requires your physician to get prior approval for certain

drugs. This means that your prescriber will need to get approval from GHP Family before you fill prescriptions for these drugs. Without this approval, GHP Family will not pay for the drug. If GHP denies the prior authorization request, you can appeal the decision. Please see the GHP

https://www.geisinger.org/health-plan/providers/pharmacy-forms




member handbook, section 15, Complaint, Appeal and Fair Hearing Processes, for information about filing an appeal.

• Quantity Limits: For certain drugs, there are limits to the amount of the drug that you can get.

GHP Family follows DHS’ quantity limits except for blood glucose meters and strips, condoms, spacers (OptiChamber), injectable anticoagulants (Lovenox), vaccines, and medications used to treat low blood sugar (glucagon, GVOKE, etc.). Quantity limits are available at www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Quantity-Limits-and-Daily-Dose- Limits.aspx or https://healthplan.geisinger.org/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger If your prescriber wants you to have more than the limit, your prescriber must request prior authorization.

• Step Therapy: In some cases, GHP Family requires you to first try certain drugs to treat your

medical condition before we will approve another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, GHP Family may not approve Drug B unless you try Drug A first. If Drug A does not work for you, GHP Family will then approve Drug B. Your prescriber may request prior authorization if Drug A does not work for you or if you cannot take Drug A.

• Specialty Pharmacy: Specialty medications can only be filled by certain pharmacies in the GHP Family

network. Specialty drugs are medications used to treat complex diseases. These medications usually require specialized handling and monitoring. If you are taking a specialty medicine or if you have a question about finding a specialty pharmacy, please call PerformRx at (844) 399-0477. Specialty medications that are included in this formulary have the initials SP next to them. A complete list of specialty medications and pharmacies that can fill them can be found here: https://www.geisinger.org/health-plan/plans/ghp-family/pharmacy-coverage Any Specialty Medication that is also a Medical Benefit Drug can either be dispensed by a contracted specialty pharmacy or a prescriber can obtain, administer and bill GHP Family for the cost of the medications.

The following abbreviations are found within column three of this formulary and indicate the requirements and limits listed above:

ABBREVIATION DESCRIPTION EXPLANATION

Utilization Management Restrictions

PA

Prior Authorization Restriction

Your physician is required to get prior authorization from GHP Family before you fill your prescription for this drug. Without prior approval, GHP Family will not pay for this drug.

http://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Quantity-Limits-and-Daily-Dose-Limits.aspx



https://healthplan.geisinger.org/pharmacy/pharmacy.aspx?strip=true&amp%3Bstyle=OneGeisinger

https://www.geisinger.org/health-plan/plans/ghp-family/pharmacy-coverage




ABBREVIATION DESCRIPTION EXPLANATION

QL Quantity Limit

Restriction

GHP Family limits the amount of this drug that can be obtained per prescription, or within a specific time frame.

ST

Step Therapy Restriction

Before GHP Family will approve this drug, you must first try another drug(s) to treat your medical condition. This drug may only be approved if the other drug(s) does not work for you.

SP

Specialty Pharmacy

Some drugs are not available at your retail pharmacy. These drugs are called specialty drugs and can be obtained at specialty pharmacies. To find out how and where to obtain a specialty drug, please contact PerformRx at (844) 399-0477.

PA-NSO

Prior Authorization Restriction for New Starts Only

If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from GHP Family before you fill your prescription for this drug. Without prior approval, GHP Family will not pay for this drug.

How much will I pay for my drugs? Pharmacy copays will apply to members 18 years of age and older unless otherwise listed below. Brand name prescription drugs have a $3 copayment. Generic prescription and over-the-counter drugs have a $1 copayment. Services cannot be denied if the member is unable to afford the copay.

There are no copays for: • Pregnant women (including the postpartum period which ends 60 days after delivery) • Children under 18 years of age • Medical benefit drugs • Members in a nursing home • Members in an Intermediate Care Facility for Mental Retardation or Intermediate Care Facility for Other

Related Conditions • Family planning drugs or supplies • Drugs, including immunizations, when dispensed and/or administered by a physician • Title IV-B Foster Care and IV-E Foster Care and Adoption Assistance • Members eligible under the Breast and Cervical Cancer Prevention and Treatment Programs • There is no copay for the following groups of medications:




o Antihypertensives (high blood pressure) o Antidiabetes (high blood sugar) o Anticonvulsants (seizure) o Cardiovascular preparations (heart disease) o Antipsychotics (except those that are controlled substance antianxiety drugs) o Antineoplastics (cancer drugs) o Antiglaucoma drugs o Anti-Parkinson’s drugs o HIV/AIDS drugs o Preferred naloxone injection/nasal spray for drug overdose

Non-covered medications The following medications are not eligible for coverage under the Medical Assistance Program:

• Drugs that are designated by the FDA as less than effective (DESI) drugs • Any drug marketed by a drug company that does not participate in the Medicaid Rebate Program • Drugs used for weight loss • Drugs used for cosmetic purposes or hair growth • Drugs used for fertility • Drugs used for erectile dysfunction • Cough and cold medications for members over 21 years of age • Drugs and devices classified as experimental • Drugs ordered by a prescriber who has been barred or suspended from participating the MA program

What if my drug requires prior authorization? If you learn that GHP Family requires prior authorization of your drug, you have two options:

• You can ask GHP Family Pharmacy Services for a list of similar drugs that are on the GHP Family formulary. You can call GHP Family Pharmacy Services at (855) 552-6028 or (570) 214-3554. When you receive the list, show it to your doctor and ask him or her if one of these drugs will work for you.

• Your physician can ask GHP Family for approval of your drug through a prior authorization. See below for information about how your physician can request a prior authorization.

What if I need a drug that is not listed on the Statewide PDL or GHP Family Formulary?

• Please check the PDL (https://www.dhs.pa.gov/providers/Pharmacy- Services/Pages/Preferred-Drug-List.aspx) and formulary to see if there is a preferred alternative or formulary alternative that you can ask your physician to switch you to

• Your physician can ask us to approve your drug even if it is not on our formulary or the PDL







Generally, GHP Family will only approve your physician’s request if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have a negative medical effect. We must make our decision within 24 hours of getting your prescriber’s request.

If the pharmacy cannot fill your prescription because of the medication being non-formulary or requiring prior authorization, GHP Family will authorize a temporary supply of the medication. If your prescription is for an ongoing medication, a 15-day temporary supply will be authorized. If your prescription is for a new medication, a 5-day temporary supply of medication will be authorized. Members are limited to one emergency supply per medication every 180 days.

A member whose prescription rejects for prior authorization or other utilization management criteria should not be turned away at the pharmacy without receiving a temporary supply of medication unless the dispensing pharmacist feels that dispensing the medication would jeopardize the health and safety of the member.


Geisinger Family Supplemental Formulary of 84


Table of Contents

ADRENALS ................................................................................................................................................14

ALCOHOL DETERRENTS .......................................................................................................................14

ALKALINIZING AGENTS .........................................................................................................................14

AMMONIA DETOXICANTS ......................................................................................................................14

ANALGESICS AND ANTIPYRETICS......................................................................................................15

ANDROGENS ............................................................................................................................................16

ANOREXIGENIC AGENTS AND RESPIRATORY AND CNS STIMULANTS ....................................16

ANTACIDS AND ADSORBENTS ............................................................................................................16

ANTHELMINTICS ......................................................................................................................................17

ANTIANEMIA DRUGS ..............................................................................................................................18

ANTIBACTERIALS ....................................................................................................................................18

ANTICHOLINERGIC AGENTS ................................................................................................................18

ANTIDIARRHEA AGENTS .......................................................................................................................18

ANTIDOTES ...............................................................................................................................................19

ANTIEMETICS ...........................................................................................................................................19

ANTIFLATULENTS ...................................................................................................................................20

ANTIFUNGALS ..........................................................................................................................................20

ANTIGLAUCOMA AGENTS .....................................................................................................................20

ANTIHEMORRHAGIC AGENTS ..............................................................................................................20

ANTIHYPOGLYCEMIC AGENTS ............................................................................................................20

ANTI-INFECTIVES ....................................................................................................................................20

ANTI-INFLAMMATORY AGENTS ...........................................................................................................22

ANTIMANIC AGENTS ...............................................................................................................................23

ANTIMYCOBACTERIALS ........................................................................................................................23

ANTINEOPLASTIC AGENTS...................................................................................................................24

ANTIPARKINSONIAN AGENTS ..............................................................................................................25

ANTIPROTOZOALS ..................................................................................................................................25

ANTIPRURITICS AND LOCAL ANESTHETICS ....................................................................................25

ANTISENSE OLIGONUCLEOTIDES ......................................................................................................25




ANTITHROMBOTIC AGENTS .................................................................................................................25

ANTITOXINS AND IMMUNE GLOBULINS ............................................................................................26

ANTITUSSIVES .........................................................................................................................................26

ANTIULCER AGENTS AND ACID SUPPRESSANTS ..........................................................................26

ANXIOLYTICS, SEDATIVES, AND HYPNOTICS ..................................................................................27

ASTRINGENTS ..........................................................................................................................................27

AUTONOMIC DRUGS, MISCELLANEOUS ...........................................................................................27

CARDIAC DRUGS .....................................................................................................................................27

CARIOSTATIC AGENTS ..........................................................................................................................28

CATHARTICS AND LAXATIVES ............................................................................................................28

CENTRAL NERVOUS SYSTEM AGENTS, MISC .................................................................................30

CONTRACEPTIVES ..................................................................................................................................30

CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR MODULATORS ..........30

DENTAL AGENTS .....................................................................................................................................31

DEVICES ....................................................................................................................................................31

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS..............................................................................51

DIURETICS.................................................................................................................................................51

EENT DRUGS, MISCELLANEOUS .........................................................................................................53

EMOLLIENTS, DEMULCENTS, AND PROTECTANTS ........................................................................53

ENZYMES ...................................................................................................................................................53

EXPECTORANTS ......................................................................................................................................53

FIRST GENERATION ANTIHISTAMINES ..............................................................................................53

GOLD COMPOUNDS ................................................................................................................................54

HEMORRHEOLOGIC AGENTS ...............................................................................................................54

HYPOTENSIVE AGENTS .........................................................................................................................54

IMMUNOMODULATORY AGENTS .........................................................................................................55

IMMUNOSUPPRESSIVE AGENTS .........................................................................................................55

ION-REMOVING AGENTS .......................................................................................................................55

IRRIGATING SOLUTIONS .......................................................................................................................55

KERATOLYTIC AGENTS .........................................................................................................................55

MOUTHWASHES AND GARGLES .........................................................................................................56




MUCOLYTIC AGENTS .............................................................................................................................56

MULTIVITAMIN PREPARATIONS ..........................................................................................................56

MYDRIATICS .............................................................................................................................................59

NON-AHFS SUBCLASS ...........................................................................................................................59

OTHER MISCELLANEOUS THERAPEUTIC AGENTS ........................................................................59

OXYTOCICS ...............................................................................................................................................60

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS .....................................................................60

PARATHYROID AND ANTIPARATHYROID AGENTS .........................................................................61

PITUITARY .................................................................................................................................................61

PROGESTINS ............................................................................................................................................61

PSYCHOTHERAPEUTIC AGENTS .........................................................................................................61

RENIN-ANGIOTENSIN-ALDOSTERONE SYS INHIB...........................................................................61

REPLACEMENT PREPARATIONS .........................................................................................................61

RESPIRATORY SMOOTH MUSCLE RELAXANTS ..............................................................................63

SECOND GENERATION ANTIHISTAMINES .........................................................................................64

SKIN AND MUCOUS MEMBRANE AGENTS, MISC ............................................................................64

SOMATOSTATIN AGONISTS AND ANTAGONISTS ...........................................................................64

SYMPATHOMIMETIC (ADRENERGIC) AGENTS .................................................................................64

THYROID AND ANTITHYROID AGENTS ..............................................................................................65

TOXOIDS ....................................................................................................................................................65

URINARY ANTI-INFECTIVES ..................................................................................................................65

URINE AND FECES CONTENTS ............................................................................................................65

VACCINES .................................................................................................................................................65

VASOCONSTRICTORS ............................................................................................................................67

VASODILATING AGENTS .......................................................................................................................67

VITAMIN B COMPLEX ..............................................................................................................................68

VITAMIN C ..................................................................................................................................................68

VITAMIN D ..................................................................................................................................................68

VITAMIN E ..................................................................................................................................................68

VITAMIN K ACTIVITY ...............................................................................................................................68




F o rmu la ry D ru g L is t

Drug Name

Drug Tier

Reference Name

Requirements/Limits1

THERAPEUTIC CATEGORY Therapeutic Class ADRENALS Adrenals

methylprednisolone acetate 40 mg/ml Injection Suspension, 80 mg/ml Injection Suspension 1 DEPO-MEDROL methylprednisolone sodium succ 1000 mg Injection Solution Reconstituted, 125 mg Injection Solution Reconstituted, 40 mg Injection Solution Reconstituted, 500 mg Injection Solution Reconstituted 1 SOLU-MEDROL READYSHARP DEXAMETHASONE 1 SOLU-CORTEF 2 SOLU-MEDROL 1000 mg Injection Solution Reconstituted, 125 mg Injection Solution Reconstituted, 40 mg Injection Solution Reconstituted, 500 mg Injection Solution Reconstituted 2 ALCOHOL DETERRENTS Alcohol Deterrents

disulfiram 250 mg Oral Tablet, 500 mg Oral Tablet 1 ANTABUSE ALKALINIZING AGENTS Alkalinizing Agents

cytra-2 OTC potassium citrate er 1 UROCIT-K sod citrate-citric acid 500-334 mg/5ml Oral Solution OTC AMMONIA DETOXICANTS Ammonia Detoxicants

constulose 1 CONSTULOSE enulose 1 CONSTULOSE generlac 1 CONSTULOSE




Drug Name

Drug Tier

Reference Name


lactulose 10 gm/15ml Oral Solution, 20 gm/30ml Oral Solution 1 CONSTULOSE lactulose encephalopathy 1 CONSTULOSE ANALGESICS AND ANTIPYRETICS Analgesics And Antipyretics, Misc

ACEPHEN OTC QL(20 EA per 1 days) acetaminophen 650 mg Rectal Suppository OTC QL(6 EA per 1 days) acetaminophen 325 mg Oral Tablet OTC QL(10 EA per 1 days) acetaminophen 120 mg Rectal Suppository, 160 mg Oral Tablet Chewable OTC QL(20 EA per 1 days) acetaminophen 80 mg Oral Tablet Chewable OTC QL(30 EA per 1 days) acetaminophen 160 mg/5ml Oral Liquid, 160 mg/5ml Oral Solution OTC QL(75 ML per 1 days) acetaminophen 650 mg/20.3ml Oral Solution, 650 mg/20.3ml Oral Suspension OTC QL(100 ML per 1 days) acetaminophen extra strength OTC QL(6 EA per 1 days) childrens acetaminophen 80 mg tab disint OTC QL(30 EA per 1 days) childrens acetaminophen 160 mg/5ml Oral Suspension OTC QL(75 ML per 1 days) childrens apap OTC QL(30 EA per 1 days) childrens silapap OTC QL(75 ML per 1 days) childrens tactinal OTC QL(30 EA per 1 days) HEALTHY MAMA SHAKE THAT ACHE OTC QL(6 EA per 1 days) mapap 500 mg Oral Capsule OTC QL(6 EA per 1 days) MAPAP CHILDRENS 80 mg Oral Tablet Chewable OTC QL(30 EA per 1 days) m-pap OTC QL(75 ML per 1 days) non-aspirin extra strength OTC QL(6 EA per 1 days) pain & fever childrens 160 mg Oral Tablet Chewable OTC QL(20 EA per 1 days) pain & fever childrens 160 mg/5ml Oral Solution OTC QL(75 ML per 1 days) pain & fever extra strength OTC QL(6 EA per 1 days) pain reliever extra strength 500 mg Oral Tablet OTC QL(6 EA per 1 days)




Drug Name

Drug Tier

Reference Name


Nonsteroidal Anti-inflammatory Agents

aspirin 81 mg Oral Tablet Chewable OTC aspirin 325 mg Oral Tablet, 81 mg Oral Tablet Delayed Release OTC QL(12 EA per 1 days) aspirin adult OTC QL(12 EA per 1 days) salsalate 500 mg Oral Tablet, 750 mg Oral Tablet 1 QL(4 EA per 1 days) ANDROGENS Androgens

danazol 100 mg Oral Capsule, 200 mg Oral Capsule, 50 mg Oral Capsule 1 DANOCRINE testosterone cypionate 50 mg/ml Injection Solution 1 PA ANOREXIGENIC AGENTS AND RESPIRATORY AND CNS STIMULANTS Respiratory And Cns Stimulants

caffeine citrate 20 mg/ml Oral Solution, 60 mg/3ml Oral Solution 1 AL(Max 2 years) ANTACIDS AND ADSORBENTS Antacids And Adsorbents

ACID GONE 160-105 mg Oral Tablet Chewable OTC ACID GONE 95-358 mg/15ml Oral Suspension OTC alumina-magnesia-simethicone OTC aluminum hydroxide gel 320 mg/5ml Oral Suspension OTC antacid 500 mg Oral Tablet Chewable OTC antacid 200-200-20 mg/5ml Oral Suspension OTC antacid anti-gas OTC antacid anti-gas reg strength OTC antacid calcium OTC antacid calcium extra strength OTC antacid calcium rich OTC antacid extra strength 750 mg Oral Tablet Chewable OTC antacid fast acting OTC antacid fast relief OTC




Drug Name

Drug Tier

Reference Name


antacid liquid OTC antacid m OTC antacid maximum OTC antacid plus anti-gas fast act OTC antacid plus anti-gas relief 200-200-20 mg/5ml Oral Suspension OTC antacid regular strength 500 mg Oral Tablet Chewable OTC antacid regular strength 200-200-20 mg/5ml Oral Suspension OTC antacid ultra strength 1000 mg Oral Tablet Chewable OTC calcium antacid OTC calcium antacid ultra max st OTC calcium antacid ultra strength OTC calcium carbonate antacid 500 mg Oral Tablet Chewable, 750 mg Oral Tablet Chewable OTC calcium carbonate antacid 1250 mg/5ml Oral Suspension OTC geri-lanta OTC geri-mox OTC goodsense antacid 500 mg Oral Tablet Chewable OTC hm antacid OTC hm antacid/antigas OTC hm calcium antacid 500 mg Oral Tablet Chewable OTC hm calcium antacid ultra st OTC mag-al plus OTC magnesium oxide 400 mg Oral Tablet OTC rulox OTC sodium bicarbonate 325 mg Oral Tablet, 650 mg Oral Tablet OTC ANTHELMINTICS Anthelmintics

albendazole 200 mg Oral Tablet 1 ALBENZA QL(4 EA per 1 days)

EMVERM 2 PA, QL(2 EA per 1

days) praziquantel 600 mg Oral Tablet 1 BILTRICIDE




Drug Name

Drug Tier

Reference Name


ANTIANEMIA DRUGS Iron Preparations

EZFE 200 OTC FERREX 150 OTC ferrous gluconate 324 (37.5 Fe) mg Oral Tablet OTC ICAR-C PLUS 1 IFEREX 150 OTC pc pediatric iron drops OTC POLY-IRON 150 OTC purefe plus 1 ANTIBACTERIALS Antibacterials, Miscellaneous

clindamycin hcl 150 mg Oral Capsule, 300 mg Oral Capsule, 75 mg Oral Capsule 1 CLEOCIN clindamycin palmitate hcl 1 CLEOCIN linezolid 600 mg Oral Tablet 1 ZYVOX linezolid 100 mg/5ml Oral Suspension Reconstituted 1 ZYVOX PA

SIVEXTRO 200 mg Oral Tablet 2 PA, QL(1 EA per 1

days) XENLETA 600 mg Oral Tablet 2 PA Sulfonamides

sulfamethoxazole-trimethoprim 400-80 mg Oral Tablet, 800-160 mg Oral Tablet 1 SEPTRA sulfamethoxazole-trimethoprim 200-40 mg/5ml Oral Suspension 1 SEPTRA SULFATRIM PEDIATRIC 1 ANTICHOLINERGIC AGENTS Antimuscarinics/antispasmodics

dicyclomine hcl 10 mg Oral Capsule, 20 mg Oral Tablet 1 BENTYL dicyclomine hcl 10 mg/5ml Oral Solution 1 BENTYL glycopyrrolate 1 mg Oral Tablet, 2 mg Oral Tablet 1 ROBINUL propantheline bromide 15 mg Oral Tablet 1 PRO-BANTHINE ANTIDIARRHEA AGENTS




Drug Name

Drug Tier

Reference Name


Antidiarrhea Agents

ALIGN OTC ALIGN JR FOR KIDS OTC bismatrol 262 mg Oral Tablet Chewable OTC bismatrol 262 mg/15ml Oral Suspension OTC SOOTHE bismatrol maximum strength OTC diphenoxylate-atropine 2.5-0.025 mg Oral Tablet 1 LOMOTIL diphenoxylate-atropine 2.5-0.025 mg/5ml Oral Liquid 1 LOMOTIL geri-pectate OTC SOOTHE hm loperamide hcl OTC IMODIUM QL(8 EA per 1 days) IMODIUM A-D 2 mg Oral Capsule OTC QL(8 EA per 1 days) KAOPECTATE 262 mg/15ml Oral Suspension OTC KAOPECTATE EXTRA STRENGTH OTC KAO-TIN 262 mg/15ml Oral Suspension OTC loperamide hcl 2 mg Oral Capsule 1 IMODIUM QL(8 EA per 1 days) peptic relief OTC SOOTHE 262 mg Oral Tablet, 262 mg Oral Tablet Chewable OTC SOOTHE 262 mg/15ml Oral Suspension OTC stomach relief 262 mg Oral Tablet Chewable OTC

XERMELO 2 SP, PA, QL(3 EA per 1

days) ANTIDOTES Antidotes

acetylcysteine 200 mg/ml Intravenous Solution 1 ACETADOTE acetylcysteine 10 % Inhalation Solution, 20 % Inhalation Solution 1 MUCOMYST leucovorin calcium 10 mg Oral Tablet, 15 mg Oral Tablet, 25 mg Oral Tablet, 5 mg Oral Tablet 1 ANTIEMETICS




Drug Name

Drug Tier

Reference Name


5-ht3 Receptor Antagonists

ondansetron hcl 24 mg Oral Tablet 1 ZOFRAN QL(1 EA per 1 days) Antiemetics, Miscellaneous

TRANSDERM SCOP (1.5 MG) 1 QL(0.4 EA per 1 days) ANTIFLATULENTS Antiflatulents

gas relief 180 mg Oral Capsule, 250 mg Oral Capsule OTC gas relief extra strength 125 mg Oral Capsule OTC gas relief ultra strength OTC simethicone 125 mg Oral Capsule, 180 mg Oral Capsule OTC ANTIFUNGALS Polyenes

nystatin Powder 1 ANTIGLAUCOMA AGENTS Carbonic Anhydrase Inhibitors

acetazolamide 125 mg Oral Tablet, 250 mg Oral Tablet 1 DIAMOX acetazolamide er 1 DIAMOX methazolamide 25 mg Oral Tablet, 50 mg Oral Tablet 1 NEPTAZANE ANTIHEMORRHAGIC AGENTS Hemostatics

KOATE-DVI 250 unit Intravenous Solution Reconstituted, 500 unit Intravenous Solution Reconstituted 2 SP, PA ANTIHYPOGLYCEMIC AGENTS Antihypoglycemic Agents, Miscellaneous

glucose 4 gm Oral Tablet Chewable 2 Glycogenolytic Agents

GLUCAGEN DIAGNOSTIC 2 QL(2 EA per 30 days) glucagon emergency 1 mg/ml Injection Solution Reconstituted 2 QL(2 EA per 30 days) ANTI-INFECTIVES Antibacterials

bacitracin-neomycin-polymyxin OTC bacitracin-neomycin-polymyxin OTC




Drug Name

Drug Tier

Reference Name


kp bacitracin zinc OTC metronidazole 0.75 % External Cream 1 METROCREAM metronidazole 0.75 % External Gel, 1 % External Gel 1 METROGEL metronidazole 0.75 % External Lotion 1 METROLOTION NEOSPORIN + PAIN/ITCH/SCAR OTC Antifungals

antifungal 1 % External Aerosol OTC athletes foot 2 % External Powder OTC GYNE-LOTRIMIN OTC jock itch spray powder OTC kp miconazole nitrate OTC kp terbinafine hydrochloride OTC kp tolnaftate OTC LOTRIMIN AF DEODORANT POWDER OTC LOTRIMIN AF JOCK ITCH POWDER OTC LOTRIMIN ULTRA OTC miconazole antifungal OTC Antivirals

trifluridine 1 VIROPTIC Eent Anti-infectives, Miscellaneous

chlorhexidine gluconate 0.12 % Mouth/Throat Solution 1 PERIOGARD Local Anti-infectives, Miscellaneous

acne treatment 10 % External Gel OTC bp gel OTC bp wash 5 % External Liquid OTC kp benzoyl peroxide OTC kp benzoyl peroxide wash OTC selenium sulfide 2.25 % External Shampoo, 2.3 % External Shampoo 1 selenium sulfide 2.5 % External Lotion 1 SELSUN silver sulfadiazine 1 % External Cream 1 SILVADENE SSD 1




Drug Name

Drug Tier

Reference Name


Scabicides And Pediculicides

complete lice treatment OTC lice treatment 1 % External Liquid OTC stop lice complete treatment OTC ANTI-INFLAMMATORY AGENTS Anti-inflammatory Agents

hydrocortisone 1 % External Lotion OTC hydrocortisone 100 mg/60ml Rectal Enema 1 CORTENEMA Corticosteroids

ANTI-ITCH INTENSIVE HEALING OTC beta hc OTC COLOCORT 1 CORTIZONE-10 OTC CORTIZONE-10 DIABETICS SKIN OTC CORTIZONE-10 ECZEMA OTC CORTIZONE-10 PLUS OTC CORTIZONE-10/ALOE 1 % External Cream OTC DERMAREST ECZEMA OTC fluocinolone acetonide 0.01 % Otic Oil 1 DERMOTIC hydrocortisone 1 % External Lotion OTC hydrocortisone 1 % External Lotion OTC hydrocortisone 100 mg/60ml Rectal Enema 1 CORTENEMA hydrocortisone (perianal) 2.5 % External Cream 1 ANUSOL HC hydrocortisone anti-itch OTC ALA-CORT hydrocortisone intensive heal OTC ALA-CORT hydrocortisone plus OTC ALA-CORT hydrocortisone-acetic acid 1 ACETASOL HC kls hydrocortisone plus OTC CORTIZONE 10 kp hydrocortisone OTC ALA-CORT kp hydrocortisone-aloe OTC MONISTAT SOOTHING CARE ITCH OTC NOBLE FORMULA HC 1 % External Cream OTC

ORALONE 1 QL(0.72 GM per 1

days)




Drug Name

Drug Tier

Reference Name


prednisolone acetate p-f 1 PRED FORTE PREPARATION H 1 % External Cream OTC PROCTO-MED HC 2.5 % External Cream 1 PROCTO-PAK 1 % External Cream 1 PROCTOSOL HC 2.5 % External Cream 1 PROCTOZONE-HC 2.5 % External Cream 1 scalp relief maximum strength OTC triamcinolone acetonide 0.1 % Mouth/Throat Paste 1

KENALOG IN ORABASE

QL(0.72 GM per 1 days)

TRIDESILON 1 VANICREAM HC MAXIMUM STRENGTH OTC Eent Anti-inflammatory Agents, Misc

RESTASIS MULTIDOSE 2 QL(0.19 ML per 1

days) Mast-cell Stabilizers

cromolyn sodium 100 mg/5ml Oral Concentrate 1 GASTROCROM cromolyn sodium 20 mg/2ml Inhalation Nebulization Solution 1 INTAL ANTIMANIC AGENTS Antimanic Agents

lithium 1 lithium carbonate 150 mg Oral Capsule, 600 mg Oral Capsule 1 lithium carbonate 300 mg Oral Capsule 1 ESKALITH lithium carbonate 300 mg Oral Tablet 1 LITHOBID lithium carbonate er 450 mg Oral Tablet Extended Release 1 ESKALITH CR lithium carbonate er 300 mg Oral Tablet Extended Release 1 LITHOBID ANTIMYCOBACTERIALS Antimycobacterials, Miscellaneous

dapsone 100 mg Oral Tablet, 25 mg Oral Tablet 1




Drug Name

Drug Tier

Reference Name


Antituberculosis Agents

ethambutol hcl 100 mg Oral Tablet, 400 mg Oral Tablet 1 MYAMBUTOL isoniazid 100 mg Oral Tablet, 300 mg Oral Tablet 1 isoniazid 50 mg/5ml Oral Syrup 1 pretomanid 2 PA pyrazinamide 500 mg Oral Tablet 1 rifabutin 1 MYCOBUTIN rifampin 150 mg Oral Capsule, 300 mg Oral Capsule 1 RIFADIN ANTINEOPLASTIC AGENTS Antineoplastic Agents

ALKERAN 2 mg Oral Tablet 2 bexarotene 75 mg Oral Capsule 1 TARGRETIN SP, PA carboplatin 150 mg/15ml Intravenous Solution, 50 mg/5ml Intravenous Solution, 600 mg/60ml Intravenous Solution 2 PARAPLATIN carboplatin 450 mg/45ml Intravenous Solution 2 PARAPLATIN SP cyclophosphamide 25 mg Oral Capsule, 50 mg Oral Capsule 1 SP EMCYT 2 SP etoposide 50 mg Oral Capsule 1 SP flutamide 1 EULEXIN QL(6 EA per 1 days) HYCAMTIN 0.25 mg Oral Capsule, 1 mg Oral Capsule 2 SP INQOVI 2 PA INTRON A 10000000 unit Injection Solution Reconstituted, 18000000 unit Injection Solution Reconstituted, 50000000 unit Injection Solution Reconstituted 2 SP INTRON A 10000000 unit/ml Injection Solution, 6000000 unit/ml Injection Solution 2 SP LEUKERAN 2 SP LYSODREN 2 SP MATULANE 2 SP




Drug Name

Drug Tier

Reference Name


megestrol acetate 40 mg Oral Tablet 1 MEGACE megestrol acetate 40 mg/ml Oral Suspension, 400 mg/10ml Oral Suspension 1 MEGACE melphalan 1 ALKERAN mercaptopurine 50 mg Oral Tablet 1 PURINETHOL MYLERAN 2 SP

NILANDRON 2 SP, QL(2 EA per 1

days)

nilutamide 1 NILANDRON SP, QL(2 EA per 1

days) SYLATRON 2 SP, PA ANTIPARKINSONIAN AGENTS Dopamine Receptor Agonists

cabergoline 1 DOSTINEX ANTIPROTOZOALS Antiprotozoals, Miscellaneous

atovaquone 750 mg/5ml Oral Suspension 1 MEPRON QL(20 ML per 1 days) MEPRON 2 QL(20 ML per 1 days) ANTIPRURITICS AND LOCAL ANESTHETICS Antipruritics And Local Anesthetics

hemorrhoidal relief 1 lidocaine-hydrocortisone ace 2-2 % Rectal Kit, 3-1 % Rectal Kit, 3-2.5 % Rectal Kit 1 lidopac 1 lidopin 3 % External Cream 1 phenazopyridine hcl 100 mg Oral Tablet, 200 mg Oral Tablet 1 pramoxine hcl (perianal) OTC PRIZOTRAL-II 1 PROCTOFOAM HC 1-1 % External Foam 2 ANTISENSE OLIGONUCLEOTIDES Antisense Oligonucleotides

TEGSEDI 2 SP, PA ANTITHROMBOTIC AGENTS Anticoagulants




Drug Name

Drug Tier

Reference Name


BEVYXXA 80 mg Oral Capsule 2 PA heparin sodium (porcine) 1000 unit/ml Injection Solution, 10000 unit/ml Injection Solution, 20000 unit/ml Injection Solution, 5000 unit/0.5ml Injection Solution Prefilled Syringe, 5000 unit/ml Injection Solution 1 heparin sodium (porcine) pf 1 Antithrombotic Agents, Misc

CABLIVI 2 SP, PA Platelet-aggregation Inhibitors

cilostazol 1 PLETAL QL(2 EA per 1 days) Platelet-reducing Agents

anagrelide hcl 1 mg Oral Capsule 1 AGRYLIN anagrelide hcl 0.5 mg Oral Capsule 1 AGRYLIN SP ANTITOXINS AND IMMUNE GLOBULINS Antitoxins And Immune Globulins

WINRHO SDF 2 SP ANTITUSSIVES Antitussives

benzonatate 100 mg Oral Capsule, 200 mg Oral Capsule 1

HYCODAN 1 QL(30 ML per 1 days),

AL(Max 20 years) hydrocod polst-cpm polst er 10-8 mg/5ml Oral Suspension Extended Release 1

TUSSIONEX PENNKINETIC EXT

QL(10 ML per 1 days), AL(Max 20 years)

hydrocodone-homatropine 5-1.5 mg Oral Tablet 1

QL(6 EA per 1 days), AL(Max 20 years)

hydrocodone-homatropine 5-1.5 mg/5ml Oral Syrup 1

QL(30 ML per 1 days), AL(Max 20 years)

hydromet 1 QL(30 ML per 1 days),

AL(Max 20 years)

promethazine-codeine 1 QL(30 ML per 1 days),

AL(Min 18 years) ANTIULCER AGENTS AND ACID SUPPRESSANTS Histamine H2-antagonists

cimetidine 200 OTC TAGAMET Prostaglandins




Drug Name

Drug Tier

Reference Name


misoprostol 100 mcg Oral Tablet, 200 mcg Oral Tablet 1 CYTOTEC Protectants

sucralfate 1 gm/10ml Oral Suspension 1 sucralfate 1 gm Oral Tablet 1 CARAFATE ANXIOLYTICS, SEDATIVES, AND HYPNOTICS Anxiolytics, Sedatives, & Hypnotics Misc

sleep tabs OTC ASTRINGENTS Astringents

DRYSOL 2 XERAC AC 2 zinc oxide 20 % External Ointment, 25 % External Paste OTC zinc oxide 25 % External Ointment OTC DELAZINC AUTONOMIC DRUGS, MISCELLANEOUS Autonomic Drugs, Miscellaneous

KLS QUIT2 2 mg Mouth/Throat Gum OTC QL(24 EA per 1 days) CARDIAC DRUGS Antiarrhythmic Agents

amiodarone hcl 200 mg Oral Tablet 1 CORDARONE amiodarone hcl 100 mg Oral Tablet, 400 mg Oral Tablet 1 PACERONE disopyramide phosphate 1 NORPACE dofetilide 1 TIKOSYN QL(2 EA per 1 days) flecainide acetate 1 TAMBOCOR mexiletine hcl 150 mg Oral Capsule, 200 mg Oral Capsule, 250 mg Oral Capsule 1 MEXITIL PACERONE 1 propafenone hcl 1 RYTHMOL quinidine sulfate 200 mg Oral Tablet, 300 mg Oral Tablet 1 Cardiotonic Agents

DIGITEK 1 digox 1 LANOXIN digoxin 125 mcg Oral Tablet, 250 mcg Oral Tablet 1 LANOXIN




Drug Name

Drug Tier

Reference Name


digoxin 0.05 mg/ml Oral Solution 1 LANOXIN CARIOSTATIC AGENTS Cariostatic Agents

DENTA 5000 PLUS 1 DENTAGEL 1 FLORIVA 0.25-400 mg-unit/ml Oral Liquid OTC FLUORABON OTC fluoritab 1.1 (0.5 F) mg Oral Tablet Chewable, 2.2 (1 F) mg Oral Tablet Chewable OTC FLURA-DROPS OTC LUDENT 0.55 (0.25 F) mg Oral Tablet Chewable, 1.1 (0.5 F) mg Oral Tablet Chewable, 2.2 (1 F) mg Oral Tablet Chewable OTC sf 1 sf 5000 plus 1 sodium fluoride 1.1 % Dental Cream, 1.1 % Dental Gel 1 sodium fluoride 0.55 (0.25 F) mg Oral Tablet Chewable, 1.1 (0.5 F) mg Oral Tablet Chewable, 2.2 (1 F) mg Oral Tablet Chewable OTC sodium fluoride 1.1 (0.5 F) mg/ml Oral Solution OTC sodium fluoride 5000 plus 1 sodium fluoride 5000 ppm 1.1 % Dental Cream 1 sodium fluoride 5000 ppm 1.1 % Dental Gel, 1.1 % Dental Paste 1 CATHARTICS AND LAXATIVES Cathartics And Laxatives

bisacodyl 10 mg Rectal Suppository OTC bisacodyl ec OTC bisacodyl laxative OTC calcium polycarbophil 625 mg Oral Tablet OTC citrate of magnesia Oral Solution, 1.745 gm/30ml Oral Solution OTC




Drug Name

Drug Tier

Reference Name


CLENPIQ 2 diocto 60 mg/15ml Oral Syrup OTC docuzen OTC DOK PLUS OTC ducodyl OTC easy-lax plus OTC fiber laxative 0.52 gm Oral Capsule, 625 mg Oral Tablet OTC fiber-lax OTC GAVILYTE-C 1 GAVILYTE-G 1 GAVILYTE-N WITH FLAVOR PACK 1 gentle laxative OTC glycerin (adult) 2 gm Rectal Suppository OTC glycerin (child) OTC glycerin adult OTC goodsense magnesium citrate OTC goodsense stimulant laxative OTC hm fiber 0.52 gm Oral Capsule, 500 mg Oral Tablet OTC hm magnesium citrate OTC hm senna-s OTC hm stool softener/laxative OTC kls fiber-tabs OTC laxacin OTC laxative 10 mg Rectal Suppository OTC magnesium citrate 1.745 gm/30ml Oral Solution OTC milk of magnesia 7.75 % Oral Suspension OTC milk of magnesia concentrate OTC PEDIA-LAX 1 gm Rectal Suppository OTC peg 3350/electrolytes 1 peg 3350-kcl-na bicarb-nacl 1 NULYTELY peg-3350/electrolytes 1 GOLYTELY polyethylene glycol 3350 17 gm Oral Packet 1 MIRALAX




Drug Name

Drug Tier

Reference Name


polyethylene glycol 3350 17 gm/scoop Oral Powder 1 MIRALAX senexon-s OTC SENEXON-S OTC senna 8.8 mg/5ml Oral Liquid OTC senna plus 8.6-50 mg Oral Tablet OTC senna s OTC senna-docusate sodium OTC senna-plus OTC senna-s OTC senna-time s OTC sennosides-docusate sodium 8.6-50 mg Oral Tablet OTC silace 60 mg/15ml Oral Syrup OTC SOLUBLE FIBER THERAPY OTC stimulant laxative 8.6-50 mg Oral Tablet OTC stool softener plus laxative OTC stool softener/laxative 50-8.6 mg Oral Tablet OTC TRILYTE 1 vegetable lax+stool softener OTC CENTRAL NERVOUS SYSTEM AGENTS, MISC Central Nervous System Agents, Misc

acamprosate calcium 1 CAMPRAL riluzole 50 mg Oral Tablet 1 RILUTEK QL(2 EA per 1 days)

TIGLUTIK 2 SP, PA, QL(20 ML per

1 days) CONTRACEPTIVES Contraceptives

ECONTRA EZ OTC ECONTRA ONE-STEP OTC levonorgestrel 1.5 mg Oral Tablet OTC MY WAY OTC NEXT CHOICE ONE DOSE OTC OPCICON ONE-STEP OTC OPTION 2 OTC CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR MODULATORS Cystic Fibrosis Transmembrane Conductance Regulator (cftr) Correctors

ORKAMBI 100-125 mg Oral Packet, 150-188 mg Oral Packet 2

SP, PA, QL(2 EA per 1 days)




Drug Name

Drug Tier

Reference Name


ORKAMBI 100-125 mg Oral Tablet, 200-125 mg Oral Tablet 2


SYMDEKO 2 SP, PA, QL(2 EA per 1

days) TRIKAFTA 50-25-37.5 & 75 mg Oral Tablet Therapy Pack 2 PA TRIKAFTA 100-50-75 & 150 mg Oral Tablet Therapy Pack 2


Cystic Fibrosis Transmembrane Conductance Regulator (cftr) Potentiators

KALYDECO 2 SP, PA, QL(2 EA per 1

days) DENTAL AGENTS Dental Agents

sodium fluoride 5000 sensitive 1.1-5 % Dental Gel 1 DEVICES Devices

1st tier unifine pentips 2 1st tier unifine pentips plus 2 1st tier unilet comfortouch 2 ABOUTTIME PEN NEEDLE 2 ACCU-CHEK FASTCLIX LANCET 2 ACCU-CHEK FASTCLIX LANCETS 2 ACCU-CHEK MULTICLIX LANCET DEV 2 ACCU-CHEK MULTICLIX LANCETS 2 ACCU-CHEK SAFE-T PRO LANCETS 2 ACCU-CHEK SOFT TOUCH LANCETS 2 ACCU-CHEK SOFTCLIX LANCET DEV 2 ACCU-CHEK SOFTCLIX LANCETS 2 acti-lance 28g 2 acti-lance lite lancets 28g 2 acti-lance special lancets 17g 2 acti-lance universal 23g 2 adjustable lancing device 2 QL(1 EA per 1 days)




Drug Name

Drug Tier

Reference Name


adult mask large 2 QL(2 EA per 365 days) advanced mobile lancet 2 ADVOCATE INSULIN PEN NEEDLES 2 ADVOCATE INSULIN SYRINGE 2 ADVOCATE LANCETS 2 ADVOCATE LANCETS 30G 2 ADVOCATE LANCING DEVICE 2 QL(1 EA per 1 days) ADVOCATE RAPID-SAFE LANCING 2 QL(1 EA per 1 days) ADVOCATE SAFETY LANCETS 2 ADVOCATE SAFETY LANCETS 26G 2 AGAMATRIX ULTRA-THIN LANCETS 2 aimsco twist lancets 32g 2 AIMSCO TWIST LANCETS 33G 2 alternate site lancing device 2 QL(1 EA per 1 days) aqua lance adjustable lancing 2 QL(1 EA per 1 days) AQUALANCE LANCETS 30G 2 assure comfort lancets 28g 2 ASSURE HAEMOLANCE PLUS HIGH 2 ASSURE HAEMOLANCE PLUS LOW 2 ASSURE HAEMOLANCE PLUS MICRO 2 ASSURE HAEMOLANCE PLUS NORMAL 2 ASSURE HAEMOLANCE PLUS PED 2 ASSURE ID INSULIN SAFETY SYR 2 ASSURE ID SAFETY PEN NEEDLES 2 ASSURE LANCE LANCETS 2 ASSURE LANCE LANCETS 21G 2 ASSURE LANCE PLUS SAFETY 25G 2 ASSURE LANCE PLUS SAFETY 30G 2




Drug Name

Drug Tier

Reference Name


ASSURE LANCE SAFETY LANCET 28G 2 ASSURE LANCETS 2 aurora lancet super thin 30g 2 aurora lancet thin 23g 2 aurora pen needles 2 aurora unifine pentips 2 AUTO-LANCET 2 QL(1 EA per 1 days) AUTO-LANCET MINI 2 QL(1 EA per 1 days) AUTOLET LANCING DEVICE 2 QL(1 EA per 1 days) BD AUTOSHIELD 2 BD AUTOSHIELD DUO 2 BD ECLIPSE SYRINGE 30G X 1/2" 1 ml Miscellaneous 2 BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.3 ml Miscellaneous, 31G X 5/16" 0.5 ml Miscellaneous, 31G X 5/16" 1 ml Miscellaneous 2 BD INSULIN SYRINGE 2 BD INSULIN SYRINGE HALF-UNIT 2 BD INSULIN SYRINGE MICROFINE 2 BD INSULIN SYRINGE U/F 2 BD INSULIN SYRINGE U/F 1/2UNIT 2 BD INSULIN SYRINGE U-500 2 BD INSULIN SYRINGE ULTRAFINE 2 BD LANCET ULTRAFINE 30G 2 BD LANCET ULTRAFINE 33G 2 BD LUER-LOK SYRINGE 20G X 1" 1 ml Miscellaneous 2 BD MICROTAINER LANCETS 2 BD PEN NEEDLE MICRO U/F 2 BD PEN NEEDLE MINI U/F 2 BD PEN NEEDLE NANO 2ND GEN 2 BD PEN NEEDLE NANO U/F 2 BD PEN NEEDLE ORIGINAL U/F 2 BD PEN NEEDLE SHORT U/F 2




Drug Name

Drug Tier

Reference Name


BD SAFETYGLIDE INSULIN SYRINGE 2 BD SAFETYGLIDE NEEDLE 27G X 5/8" Miscellaneous 2 BD SAFETYGLIDE SYRINGE/NEEDLE 27G X 5/8" 1 ml Miscellaneous 2 BD SAFETY-LOK INSULIN SYRINGE 2 BD SYRINGE 50 ML Miscellaneous 2 BD VEO INSULIN SYR U/F 1/2UNIT 2 BD VEO INSULIN SYRINGE U/F 2 CARDIOCOM LANCING DEVICE 2 QL(1 EA per 1 days) CAREFINE PEN NEEDLES 2 careone advanced lancing dev 2 QL(1 EA per 1 days) careone insulin syringe 2 CAREONE LANCET SUPER THIN 30G 2 careone lancet thin 23g 2 careone unifine pentips 2 careone unifine pentips plus 29G X 12MM Miscellaneous, 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous, 31G X 8 MM Miscellaneous, 32G X 4 MM Miscellaneous 2 CARESENS LANCETS 2 CARETOUCH HYPODERMIC NEEDLE 26G X 1" Miscellaneous 2 CARETOUCH INSULIN SYRINGE 2 CARETOUCH LANCING/EJECTOR 2 QL(1 EA per 1 days) CARETOUCH PEN NEEDLES 2 CARETOUCH SAFETY LANCETS 2 CARETOUCH SAFETY LANCETS 26G 2 CARETOUCH TWIST LANCETS 28G 2 CARETOUCH TWIST LANCETS 30G 2




Drug Name

Drug Tier

Reference Name


CARETOUCH TWIST LANCETS 33G 2 CLEANLET LANCETS 28G 2 CLEVER CHEK LANCETS 2 CLEVER CHOICE COMFORT EZ 2 CLEVER CHOICE LANCETS 21G 2 CLEVER CHOICE LANCETS 23G 2 CLEVER CHOICE LANCETS 28G 2 clickfine pen needles 31G X 6 MM Miscellaneous, 31G X 8 MM Miscellaneous, 32G X 4 MM Miscellaneous 2 CLICKFINE PEN NEEDLES 2 COAGUCHEK LANCETS 2 COMFORT ASSIST INSULIN SYRINGE 2 comfort assured lancets 28g 2 comfort assured lancets 33g 2 COMFORT EZ INSULIN SYRINGE 2 COMFORT EZ MICRO PEN NEEDLES 2 COMFORT EZ PEN NEEDLES 2 COMFORT EZ SHORT PEN NEEDLES 2 comfort lancets 2 COMFORT TOUCH INSULIN PEN NEED 31G X 4 MM Miscellaneous, 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous, 31G X 8 MM Miscellaneous, 32G X 4 MM Miscellaneous, 32G X 5 MM Miscellaneous, 32G X 6 MM Miscellaneous, 32G X 8 MM Miscellaneous 2 CONTOUR CONTROL Normal In Vitro Liquid 2 CONTOUR NEXT CONTROL Normal In Vitro Solution 2 DIATHRIVE LANCET ULTRA THIN 30 2 DIATHRIVE LANCETS 2 DIATHRIVE LANCING DEVICE 2 QL(1 EA per 1 days)




Drug Name

Drug Tier

Reference Name


DIATHRIVE PEN NEEDLE 2 DROPLET INSULIN SYRINGE 2 DROPLET LANCETS ULTRA THIN 30G 2 DROPLET LANCING DEVICE 2 QL(1 EA per 1 days) DROPLET MICRON 2 DROPLET PEN NEEDLES 2 dropsafe safety pen needles 2 easy comfort insulin syringe 2 easy comfort lancets 2 easy comfort lancets twist top 2 easy comfort pen needles 2 easy glide pen needles 2 easy mini eject lancing device 2 QL(1 EA per 1 days) easy mini lancing device 2 QL(1 EA per 1 days) EASY TOUCH FLIPLOCK INSULIN SY 2 EASY TOUCH INSULIN BARRELS 1ML 2 EASY TOUCH INSULIN SAFETY SYR 2 EASY TOUCH INSULIN SYRINGE 2 EASY TOUCH LANCETS 21G 2 EASY TOUCH LANCETS 23G 2 EASY TOUCH LANCETS 26G 2 EASY TOUCH LANCETS 28G 2 EASY TOUCH LANCETS 28G/TWIST 2 EASY TOUCH LANCETS 30G 2 EASY TOUCH LANCETS 30G/TWIST 2 EASY TOUCH LANCETS 32G 2 EASY TOUCH LANCETS 32G/TWIST 2 EASY TOUCH LANCETS 33G/TWIST 2 EASY TOUCH LANCING DEVICE 2 QL(1 EA per 1 days) EASY TOUCH PEN NEEDLES 2 EASY TOUCH SAFETY LANCETS 21G 2




Drug Name

Drug Tier

Reference Name


EASY TOUCH SAFETY LANCETS 23G 2 EASY TOUCH SAFETY LANCETS 26G 2 EASY TOUCH SAFETY LANCETS 28G 2 EASY TOUCH SAFETY PEN NEEDLES 2 EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 ml Miscellaneous, 30G X 1/2" 1 ml Miscellaneous, 30G X 5/16" 1 ml Miscellaneous, 31G X 5/16" 1 ml Miscellaneous 2 EASY TWIST & CAP LANCETS 2 elite-thin insulin syringe 2 EMBRACE LANCETS ULTRA THIN 30G 2 EXEL COMFORT POINT INSULIN SYR 2 EXEL COMFORT POINT PEN NEEDLE 2 E-Z JECT LANCET MICRO-THIN 33G 2 E-Z JECT LANCET SUPER THIN 30G 2 E-Z JECT LANCETS 2 E-Z JECT LANCETS 21G 2 E-Z JECT LANCETS THIN 26G 2 EZ SMART BLOOD GLUCOSE LANCETS 2 EZ-LETS LANCETS 21G 2 EZ-LETS LANCETS 26G 2 EZ-LETS LANCETS 28G 2 EZ-LETS LANCETS 30G 2 FIFTY50 PEN NEEDLES 2 FIFTY50 SAFETY SEAL LANCETS 2 FIFTY50 SUPERIOR COMFORT SYR 2 FIFTY50 UNILET LANCETS 33G 2 FINE 30 2




Drug Name

Drug Tier

Reference Name


FINGERSTIX LANCETS 2 FORA LANCETS 2 FORA LANCING DEVICE 2 QL(1 EA per 1 days) FORA V10/V12/D10/D20 TEST 2 FREESTYLE LANCETS 2 FREESTYLE LIBRE 14 DAY READER 2 PA FREESTYLE LIBRE 14 DAY SENSOR 2

PA, QL(0.15 EA per 1 days)

FREESTYLE LIBRE 2 READER 2 PA

FREESTYLE LIBRE 2 SENSOR 2 PA, QL(0.15 EA per 1

days) FREESTYLE LIBRE READER 2 PA FREESTYLE LIBRE SENSOR SYSTEM 2

PA, QL(0.15 EA per 1 days)

FREESTYLE PRECISION INS SYR 2 FREESTYLE UNISTICK II LANCETS 2 GENTEEL BUTTERFLY TOUCH LANCET 2 GENTEEL LANCING DEVICE (GOLD) 2 QL(1 EA per 1 days) GENTEEL LANCING DEVICE(PLATNM) 2 QL(1 EA per 1 days) GENTEEL LANCING DEVICE(SILVER) 2 QL(1 EA per 1 days) GENTEEL LANCING KIT (BLUE) 2 GENTLE-LET GP LANCETS 2 GENTLE-LET LANCETS 2 global ease inject pen needles 2 global easy glide insulin syr 2 global easy glide pen needles 2 global inject ease insulin syr 2 global inject ease lancets 28g 2 global inject ease lancets 30g 2 global insulin syringes 2 global lancing device 2 QL(1 EA per 1 days) GLUCOCOM LANCETS 28G 2 GLUCOCOM LANCETS 30G 2 GLUCOCOM LANCETS 33G 2




Drug Name

Drug Tier

Reference Name


GLUCOPRO INSULIN SYRINGE 2 gnp insulin syringes 2 gnp insulin syringes 28gx1/2" 2 gnp insulin syringes 29gx1/2" 2 gnp insulin syringes 30gx5/16" 2 gnp insulin syringes 31gx5/16" 2 gnp sterile lancets 28g 2 gnp sterile lancets 30g 2 gnp sterile lancets 33g 2 GOJJI LANCING DEVICE/CLEAR CAP 2 QL(1 EA per 1 days) GOJJI STERILE LANCETS 2 goodsense clickfine pen needle 2 goodsense color lancets 33g 2 goodsense lancets 26g univ 2 goodsense lancets 30g 2 goodsense lancets 30g univ 2 goodsense lancets 33g 2 goodsense lancets 33g univ 2 goodsense lancing device 2 QL(1 EA per 1 days) GOODSENSE PEN NEEDLE PENFINE 2 HEALTH CARE LANCING DEVICE 2 QL(1 EA per 1 days) healthwise insulin syr/needle 2 healthwise micron pen needles 2 healthwise mini pen needles 2 healthwise pen needles 2 healthwise short pen needles 2 healthwise unifine pentips 2 healthy accents lancing device 2 QL(1 EA per 1 days) healthy accents unifine pentip 2 healthy accents unilet lancets 2 HM ULTICARE INSULIN SYRINGE 2 HM ULTICARE SHORT PEN NEEDLES 2 HYPOLANCE AST LANCING 2 HY-VEE LANCETS 2 hy-vee thin lancets 2 IN TOUCH LANCING DEVICE 2 QL(1 EA per 1 days) IN TOUCH STERILE LANCETS 30G 2




Drug Name

Drug Tier

Reference Name


insulin syringe 2 insulin syringe/needle 2 insulin syringe-needle u-100 29G X 1/2" 0.5 ml Miscellaneous, 29G X 1/2" 1 ml Miscellaneous, 30G X 5/16" 0.3 ml Miscellaneous, 30G X 5/16" 0.5 ml Miscellaneous, 30G X 5/16" 1 ml Miscellaneous, 31G X 1/4" 0.3 ml Miscellaneous, 31G X 1/4" 0.5 ml Miscellaneous, 31G X 1/4" 1 ml Miscellaneous, 31G X 5/16" 0.3 ml Miscellaneous, 31G X 5/16" 0.5 ml Miscellaneous, 31G X 5/16" 1 ml Miscellaneous 2 insupen pen needles 2 INSUPEN SENSITIVE 2 INSUPEN ULTRAFIN 2 kinney lancets 2 kinney thin lancets 2 kinray insulin syringe 2 kmart valu insulin syringe 29g 2 kmart valu insulin syringe 30g 2 lancet device 2 QL(1 EA per 1 days) lancet device with ejector 2 QL(1 EA per 1 days) lancet transporter case 2 QL(1 EA per 1 days) lancets 2 lancets 28g 2 lancets 30g 2 lancets 33g 2 lancets micro thin 33g 2 lancets super thin 28g 2 lancets thin 2 LANCETS ULTRA FINE 2 LANCETS ULTRA THIN 2 lancets ultra thin 30g 2 lancing device 2 QL(1 EA per 1 days) LANZO 2 QL(1 EA per 1 days) leader advanced lancing device 2 QL(1 EA per 1 days) leader insulin syringe 2 LEADER UNIFINE PENTIPS 2 LEADER UNIFINE PENTIPS PLUS 2




Drug Name

Drug Tier

Reference Name


LIBERTY MEDICAL LANCETS 2 LIBERTY MINI LANCING DEVICE 2 QL(1 EA per 1 days) LIFESCAN UNISTIK 2 2 LIFESCAN UNISTIK II LANCETS 2 lite touch lancets 2 LITE TOUCH LANCING PEN 2 QL(1 EA per 1 days) LITETOUCH INSULIN SYRINGE 2 LITETOUCH LANCETS 2 LITETOUCH PEN NEEDLES 2 live better adv lancing device 2 QL(1 EA per 1 days) live better lancet super thin 2 live better lancet ultra thin 2 longs insulin syringe 2 longs lancets standard 2 longs lancets thin 2 longs lancets ultra thin 2 MAGELLAN INSULIN SAFETY SYR 2 MARATHON MEDICAL PENTIPS 2 MAXICOMFORT II PEN NEEDLE 2 MAXI-COMFORT INSULIN SYRINGE 2 MAXI-COMFORT SAFETY PEN NEEDLE 2 MAXICOMFORT SYR 27G X 1/2" 2 medic insulin syringe 2 medichoice safety lancet 2 medichoice safety lancet extra 2 medichoice safety lancet norm 2 medicine shoppe pen needles 2 MEDISENSE THIN LANCETS 2 MEDLANCE EXTRA 21G 2 MEDLANCE LITE 25G 2 MEDLANCE PLUS EXTRA 21G 2 MEDLANCE PLUS LANCETS 2 MEDLANCE PLUS LITE 25G 2 MEDLANCE PLUS SPECIAL 0.8MM 2 MEDLANCE PLUS SUPERLITE 30G 2




Drug Name

Drug Tier

Reference Name


MEDLANCE PLUS UNIVERSAL 21G 2 MEDLANCE UNIVERSAL 21G 2 MEIJER LANCETS 2 MEIJER LANCETS THIN 2 MEIJER LANCETS UNIVERSAL 21G 2 MEIJER LANCETS UNIVERSAL 30G 2 MEIJER LANCETS UNIVERSAL 33G 2 MEIJER SUPER THIN LANCETS 2 MICRODOT PEN NEEDLE 2 MICROLET LANCETS 2 MICROLET NEXT LANCING DEVICE 2 QL(1 EA per 1 days) mini lancing device 2 QL(1 EA per 1 days) mm insulin syringe/needle 2 MM LANCING DEVICE 2 QL(1 EA per 1 days) MM PEN NEEDLES 2 MM TWIST LANCETS 2 MONOJECT INSULIN SYRINGE 2 MONOJECT ULTRA COMFORT SYRINGE 2 MONOLET LANCETS 2 MONOLET OPD LANCETS 2 MONOLETTOR SAFETY LANCETS 2 mpd safety lancet 21g 2 mpd safety lancet 23g 2 mpd safety lancet 28g 2 ms insulin syringe 2 multi-lancet device 2 QL(1 EA per 1 days) MULTI-LANCET DEVICE 2 2 MYGLUCOHEALTH LANCETS 30G 2 NOVA SAFETY LANCETS 23G 2 NOVA SAFETY LANCETS 28G 2 NOVA SUREFLEX LANCETS 2 NOVA SUREFLEX LANCING DEVICE 2 QL(1 EA per 1 days)




Drug Name

Drug Tier

Reference Name


NOVOFINE AUTOCOVER PEN NEEDLE 2 NOVOFINE PEN NEEDLE 2 NOVOFINE PLUS PEN NEEDLE 2 NOVOTWIST PEN NEEDLE 2 OMNIPOD 5 PACK 2 OMNIPOD DASH 5 PACK PODS 2 ON CALL LANCETS 2 ON CALL LANCING DEVICE 2 QL(1 EA per 1 days) ON CALL PLUS LANCETS 2 ON CALL PLUS LANCING DEVICE 2 QL(1 EA per 1 days) ONETOUCH CLUB LANCETS FINE PT 2 ONETOUCH DELICA LANCETS 30G 2 ONETOUCH DELICA LANCETS 33G 2 ONETOUCH DELICA LANCETS FINE 2 ONETOUCH DELICA LANCING DEV 2 QL(1 EA per 1 days) ONETOUCH DELICA PLUS LANCET30G 2 ONETOUCH DELICA PLUS LANCET33G 2 ONETOUCH DELICA PLUS LANCING 2 QL(1 EA per 1 days) ONETOUCH DELICA SAFETY LANCING 2 QL(1 EA per 1 days) ONETOUCH FINEPOINT LANCETS 2 ONETOUCH SURESOFT LANCING DEV 2 QL(1 EA per 1 days) ONETOUCH ULTRA CONTROL 2 ONETOUCH ULTRASOFT LANCETS 2 ONETOUCH VERIO In Vitro Solution, High In Vitro Solution 2 OPTICHAMBER DIAMOND 2 QL(2 EA per 365 days)




Drug Name

Drug Tier

Reference Name


OPTICHAMBER DIAMOND-LG MASK 2 QL(2 EA per 365 days) OPTICHAMBER DIAMOND-MD MASK 2 QL(2 EA per 365 days) OPTICHAMBER DIAMOND-SM MASK 2 QL(2 EA per 365 days) pc lancets super thin 30g 2 pc unifine pentips 29G X 12MM Miscellaneous 2 pediatric medium mask 2 pediatric small mask 2 pen needles 2 pen needles 1/2" 2 pen needles 3/16" 2 pen needles 5/16" 2 PENTIPS 2 PERFECT LANCETS 28G 2 PERFECT LANCETS 30G 2 PHARMACIST CHOICE LANCETS 2 PHARMACY COUNTER LANCETS 2 pip lancets 28g 2 pip lancets 30g 2 PRECISION SUREDOSE PLUS SYR 2 PRECISION SURE-DOSE SYRINGE 2 PRECISION THINS GP LANCETS 2 preferred plus insulin syringe 2 preferred plus lancets colored 2 preferred plus lancets thin 2 preferred plus unifine pentips 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous, 31G X 8 MM Miscellaneous, 32G X 4 MM Miscellaneous 2 pressure activat safety lancet 2 PREVENT DROPSAFE PEN NEEDLES 2 PREVENT SAFETY PEN NEEDLES 2




Drug Name

Drug Tier

Reference Name


PRO COMFORT INSULIN SYRINGE 2 pro comfort lancets 30g 2 pro comfort lancets 31g 2 pro comfort pen needles 2 PRODIGY INSULIN SYRINGE 2 PRODIGY LANCETS 28G 2 PRODIGY LANCING DEVICE 2 QL(1 EA per 1 days) PRODIGY SAFETY LANCETS 26G 2 PRODIGY TWIST TOP LANCETS 28G 2 PSS SELECT GP LANCETS 2 PSS SELECT SAFETY LANCETS 2 pure comfort pen needle 2 push button safety lancets 2 push button safety lancets 28g 2 px lancets microthin 33g 2 READYLANCE SAFETY LANCETS 2 reality insulin syringe 2 reality lancets 2 reality trigger lancets 2 RELION INSULIN SYRINGE 29G X 1/2" 0.3 ml Miscellaneous, 29G X 1/2" 0.5 ml Miscellaneous, 29G X 1/2" 1 ml Miscellaneous, 30G X 5/16" 0.3 ml Miscellaneous, 30G X 5/16" 0.5 ml Miscellaneous, 30G X 5/16" 1 ml Miscellaneous, 31G X 15/64" 0.3 ml Miscellaneous, 31G X 15/64" 0.5 ml Miscellaneous, 31G X 15/64" 1 ml Miscellaneous, 31G X 5/16" 0.3 ml Miscellaneous, 31G X 5/16" 0.5 ml Miscellaneous, 31G X 5/16" 1 ml Miscellaneous 2 RELI-ON INSULIN SYRINGE 2 RELION LANCET DEVICES 30G 2 QL(1 EA per 1 days) RELION LANCETS MICRO-THIN 33G 2 RELION LANCETS STANDARD 21G 2 RELION LANCETS THIN 26G 2




Drug Name

Drug Tier

Reference Name


RELION LANCETS ULTRA-THIN 30G 2 RELION LANCING DEVICE Kit 2 RELION LANCING DEVICE Miscellaneous 2 QL(1 EA per 1 days) RELION MINI PEN NEEDLES 2 RELION PEN NEEDLES 2 RELION SHORT PEN NEEDLES 2 RELION ULTRA THIN LANCETS 30G 2 RELION ULTRA THIN PLUS LANCETS 2 REXALL LANCETS ULTRA THIN 30G 2 RIGHTEST GD500 LANCING DEVICE 2 QL(1 EA per 1 days) RIGHTEST GL300 LANCETS 2 SAFESNAP INSULIN SYRINGE 2 SAFE-T-LANCE 2 safety insulin syringes 2 safety lancet 21g/pressure act 2 safety lancet 23g/pressure act 2 safety lancet 28g/pressure act 2 safety lancet 30g/pressure act 2 SAFETY LANCETS 2 SAFETY LANCETS 21G 2 safety lancets 28g 2 SAFETY LET LANCETS 2 SAFETY SEAL LANCETS 2 saps health twist top lancets 2 saps twist top lancets 2 sapscare twist top lancets 2 SECURESAFE INSULIN SYRINGE 2 select-lite device/lancets 2 select-lite lancing device 2 QL(1 EA per 1 days) SHOPKO AUTOLET LANCING DEVICE 2 QL(1 EA per 1 days) SHOPKO ON-THE-GO LANCETS 30G 2 SHOPKO UNIFINE PENTIPS 2




Drug Name

Drug Tier

Reference Name


SHOPKO UNIFINE PENTIPS PLUS 2 SHOPKO UNILET LANCETS 28G 2 SHOPKO UNILET LANCETS 30G 2 side button safety lancet 2 SIMPLE DIAGNOSTICS LANCING DEV 2 QL(1 EA per 1 days) SMART DIABETES VANTAGE LANCING 2 QL(1 EA per 1 days) SMART SENSE COLOR LANCETS 33G 2 SMART SENSE STANDARD LANCETS 2 SMART SENSE SUPER THIN LANCETS 2 SMART SENSE THIN LANCETS 26G 2 SMARTEST LANCETS 28G 2 SOLUS V2 LANCETS 28G 2 SOLUS V2 LANCING DEVICE 2 QL(1 EA per 1 days) SOLUS V2 TWIST LANCETS 30G 2 STERILANCE PA 2 QL(1 EA per 1 days) STERILANCE TL 2 super thin lancets 2 sure comfort insulin syringe 2 sure comfort lancets 18g 2 sure comfort lancets 21g 2 sure comfort lancets 23g 2 sure comfort lancets 28g 2 sure comfort lancets 30g 2 sure comfort lancing pen 2 QL(1 EA per 1 days) sure comfort pen needles 2 SURE-FINE PEN NEEDLES 2 SURE-JECT INSULIN SYRINGE 2 SURE-LANCE FLAT LANCETS 2 SURE-LANCE LANCETS 26G 2 SURE-LANCE THIN LANCETS 28G 2 SURE-LANCE ULTRA THIN LANCETS 2 SURELITE LANCETS 2




Drug Name

Drug Tier

Reference Name


SURE-TOUCH LANCETS UNIVERSAL 2 TECHLITE AST LANCETS 2 techlite insulin syringe 2 TECHLITE LANCETS 2 TECHLITE LANCETS 30G 2 TECHLITE PEN NEEDLES 2 THINLETS GP LANCETS 2 todays health lancing device 2 QL(1 EA per 1 days) todays health mini pen needles 2 todays health thin lancets 28g 2 todays health thin lancets 30g 2 topcare clickfine pen needles 2 topcare lancets micro-thin 33g 2 topcare ultra comfort ins syr 2 travel lancets 2 TRAVEL LANCETS ADVANCED 28G 2 true comfort insulin syringe 2 true comfort pen needles 2 true comfort pro insulin syr 30G X 1/2" 0.5 ml Miscellaneous, 30G X 1/2" 1 ml Miscellaneous, 30G X 5/16" 0.5 ml Miscellaneous, 30G X 5/16" 1 ml Miscellaneous, 32G X 5/16" 1 ml Miscellaneous 2 true comfort twist top lancets 2 TRUEDRAW LANCING DEVICE 2 QL(1 EA per 1 days) TRUEPLUS 5-BEVEL PEN NEEDLES 2 TRUEPLUS INSULIN SYRINGE 2 TRUEPLUS LANCETS 26G 2 TRUEPLUS LANCETS 28G 2 TRUEPLUS LANCETS 30G 2 TRUEPLUS LANCETS 33G 2 TRUEPLUS PEN NEEDLES 2 TRUEPLUS SAFETY LANCETS 28G 2 ULTICARE INSULIN SAFETY SYR 2 ULTICARE INSULIN SYRINGE 2 ULTICARE MICRO PEN NEEDLES 2




Drug Name

Drug Tier

Reference Name


ULTICARE MINI PEN NEEDLES 31G X 6 MM Miscellaneous, 32G X 6 MM Miscellaneous 2 ULTICARE PEN NEEDLES 29G X 12.7MM Miscellaneous, 31G X 5 MM Miscellaneous 2 ULTICARE SAFETY SYRINGE 2 ULTICARE SHORT PEN NEEDLES 31G X 8 MM Miscellaneous 2 ultiguard safepack pen needle 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous, 31G X 8 MM Miscellaneous, 32G X 4 MM Miscellaneous, 32G X 6 MM Miscellaneous 2 ULTI-LANCE AUTOMATIC 2 QL(1 EA per 1 days) ULTILET CLASSIC LANCETS 2 ULTILET INSULIN SYRINGE 2 ULTILET INSULIN SYRINGE SHORT 2 ULTILET LANCETS 2 ULTILET PEN NEEDLE 2 ULTILET SAFETY LANCETS 2 ULTILET SAFETY LANCETS 23G 2 ultra comfort insulin syringe 2 ULTRA FLO INSULIN PEN NEEDLES 29G X 12MM Miscellaneous 2 ULTRA FLO INSULIN SYRINGE 29G X 1/2" 0.3 ml Miscellaneous 2 ultra thin lancets 31g 2 ULTRA THIN PEN NEEDLES 2 ultracare insulin syringe 2 ultra-care lancets 30g 2 ultracare pen needles 2 ultra-comfort insulin syringe 2 ULTRALANCE 2 QL(1 EA per 1 days) ULTRA-THIN II AUTO LANCET 2 ULTRA-THIN II INS SYR SHORT 2 ULTRA-THIN II INSULIN SYRINGE 2




Drug Name

Drug Tier

Reference Name


ULTRA-THIN II LANCETS 2 ULTRA-THIN II MINI PEN NEEDLE 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous 2 ULTRA-THIN II PEN NEEDLE SHORT 2 ULTRA-THIN II PEN NEEDLES 2 UNIFINE PENTIPS 2 UNIFINE PENTIPS PLUS 2 UNIFINE SAFECONTROL PEN NEEDLE 2 UNIFINE ULTRA PEN NEEDLE 2 UNILET COMFORTOUCH LANCET 2 UNILET EXCELITE 2 UNILET EXCELITE II 2 UNILET G.P. LANCET 2 UNILET G.P. SUPERLITE LANCET 2 UNILET GP 28 ULTRA THIN 2 UNILET LANCET 2 UNILET MICRO-THIN 33G 2 UNILET SUPERLITE LANCET 2 UNILET SUPER-THIN 30G 2 UNILET ULTRA-THIN 28G 2 UNISTIK 1 2 QL(1 EA per 1 days) UNISTIK 2 2 QL(1 EA per 1 days) UNISTIK 2 COMFORT 2 QL(1 EA per 1 days) UNISTIK 2 EXTRA 2 QL(1 EA per 1 days) UNISTIK 2 NEONATAL 2 QL(1 EA per 1 days) UNISTIK 2 NORMAL 2 QL(1 EA per 1 days) UNISTIK 2 SUPER 2 QL(1 EA per 1 days) UNISTIK 3 2 QL(1 EA per 1 days) UNISTIK 3 COMFORT 2 QL(1 EA per 1 days) UNISTIK 3 EXTRA 2 QL(1 EA per 1 days) UNISTIK 3 GENTLE 2 UNISTIK 3 NEONATAL 2 QL(1 EA per 1 days) UNISTIK 3 NORMAL 2 QL(1 EA per 1 days) UNISTIK CZT COMFORT 2 QL(1 EA per 1 days) UNISTIK CZT NORMAL 2 QL(1 EA per 1 days) UNISTIK NORMAL 2 QL(1 EA per 1 days)




Drug Name

Drug Tier

Reference Name


UNISTIK PRO SAFETY LANCET 2 UNISTIK SAFETY LANCETS 28G 2 UNISTIK SAFETY LANCETS 30G 2 UNISTIK TOUCH SAFETY LANC 21G 2 UNISTIK TOUCH SAFETY LANC 23G 2 UNISTIK TOUCH SAFETY LANC 28G 2 UNISTIK TOUCH SAFETY LANC 30G 2 UNIVERSAL 1 LANCETS THIN 26G 2 UNIVERSAL 1 LANCETS THIN 33G 2 UNIVERSAL 1 LANCETS ULTRA THIN 2 value health insulin syringe 2 value plus lancet standard 21g 2 value plus lancets super thin 2 value plus lancets thin 26g 2 value plus lancing device 2 QL(1 EA per 1 days) valumark lancet super thin 30g 2 valumark lancet ultra thin 28g 2 valumark pen needles 2 VANISHPOINT INSULIN SYRINGE 2 VIDA MIA AUTOLET LANCING DEV 2 QL(1 EA per 1 days) VIDA MIA UNIFINE PENTIPS 2 VIDA MIA UNILET LANCETS 28G 2 VIDA MIA UNILET LANCETS 30G 2 VIVAGUARD LANCETS 2 VIVAGUARD LANCING DEVICE 2 QL(1 EA per 1 days) vp insulin syringe 2 zevrx insulin syringe 2 zevrx twist top lancets 30g 2 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS Disease-modifying Antirheumatic Drugs

leflunomide 10 mg Oral Tablet, 20 mg Oral Tablet 1 ARAVA DIURETICS




Drug Name

Drug Tier

Reference Name


Loop Diuretics

bumetanide 0.5 mg Oral Tablet, 1 mg Oral Tablet, 2 mg Oral Tablet 1 BUMEX furosemide 20 mg Oral Tablet, 40 mg Oral Tablet, 80 mg Oral Tablet 1 LASIX furosemide 10 mg/ml Injection Solution, 10 mg/ml Oral Solution, 8 mg/ml Oral Solution 1 LASIX torsemide 1 DEMADEX Potassium-sparing Diuretics

amiloride hcl 5 mg Oral Tablet 1 MIDAMOR amiloride-hydrochlorothiazide 1 MODURETIC triamterene-hctz 37.5-25 mg Oral Capsule 1 DYAZIDE triamterene-hctz 37.5-25 mg Oral Tablet, 75-50 mg Oral Tablet 1 MAXZIDE Thiazide Diuretics

chlorothiazide 250 mg Oral Tablet, 500 mg Oral Tablet 1 DIURIL DIURIL 2 AL(Max 2 years) hydrochlorothiazide 25 mg Oral Tablet, 50 mg Oral Tablet 1 HYDRODIURIL hydrochlorothiazide 12.5 mg Oral Capsule, 12.5 mg Oral Tablet 1 MICROZIDE Thiazide-like Diuretics

chlorthalidone 25 mg Oral Tablet, 50 mg Oral Tablet 1 HYGROTON indapamide 1 LOZOL metolazone 1 ZAROXOLYN Vasopressin Antagonists

JYNARQUE 15 mg Oral Tablet Therapy Pack, 30 & 15 mg Oral Tablet Therapy Pack, 45 & 15 mg Oral Tablet Therapy Pack, 60 & 30 mg Oral Tablet Therapy Pack, 90 & 30 mg Oral Tablet Therapy Pack 2 SP, PA

JYNARQUE 15 mg Oral Tablet 2 SP, PA, QL(1 EA per 1

days)

JYNARQUE 30 mg Oral Tablet 2 SP, PA, QL(2 EA per 1

days)

tolvaptan 15 mg Oral Tablet 1 SP, PA, QL(1 EA per 1

days)




Drug Name

Drug Tier

Reference Name


tolvaptan 30 mg Oral Tablet 1 SAMSCA SP, PA, QL(2 EA per 1

days) EENT DRUGS, MISCELLANEOUS Eent Drugs, Miscellaneous

acetic acid 2 % Otic Solution 1 VOSOL ALTACHLORE 5 % Ophthalmic Ointment OTC ALTACHLORE 5 % Ophthalmic Solution OTC hm saline nasal spray OTC nasal moisturizing spray OTC REFRESH PLUS OTC saline mist spray OTC saline nasal spray OTC sodium chloride (hypertonic) 5 % Ophthalmic Ointment OTC sodium chloride (hypertonic) 5 % Ophthalmic Solution OTC EMOLLIENTS, DEMULCENTS, AND PROTECTANTS Basic Lotions And Liniments

ammonium lactate 12 % External Cream, 12 % External Lotion 1 LAC-HYDRIN ENZYMES Enzymes

PALYNZIQ 2.5 mg/0.5ml Subcutaneous Solution Prefilled Syringe 2

SP, PA, QL(0.15 ML per 1 days)

PALYNZIQ 10 mg/0.5ml Subcutaneous Solution Prefilled Syringe 2

SP, PA, QL(0.5 ML per 1 days)

PALYNZIQ 20 mg/ml Subcutaneous Solution Prefilled Syringe 2

SP, PA, QL(3 ML per 1 days)

STRENSIQ 2 SP, PA EXPECTORANTS Expectorants

iodine strong 5 % Oral Solution 1 FIRST GENERATION ANTIHISTAMINES Derivatives, Miscellaneous




Drug Name

Drug Tier

Reference Name


cyproheptadine hcl 4 mg Oral Tablet 1 PERIACTIN cyproheptadine hcl 2 mg/5ml Oral Syrup 1 PERIACTIN Ethanolamine Derivatives

ALKA-SELTZER PLUS ALLERGY OTC allergy 25 mg Oral Capsule OTC allergy childrens 12.5 mg/5ml Oral Liquid OTC complete allergy medicine 25 mg Oral Capsule OTC complete allergy relief OTC DAYHIST ALLERGY 12 HOUR RELIEF OTC diphen 12.5 mg/5ml Oral Elixir 1 BENADRYL diphenhydramine hcl 25 mg Oral Capsule, 25 mg Oral Tablet, 50 mg Oral Capsule OTC diphenhydramine hcl 12.5 mg/5ml Oral Liquid OTC diphenhydramine hcl 12.5 mg/5ml Oral Elixir 1 BENADRYL geri-dryl 25 mg Oral Tablet OTC NARAMIN OTC pharbedryl 50 mg Oral Capsule OTC total allergy OTC Propylamine Derivatives

allergy 12 mg Oral Tablet Extended Release OTC CHLORPHEN SR OTC chlorpheniramine maleate er OTC GOLD COMPOUNDS Gold Compounds

RIDAURA 2 HEMORRHEOLOGIC AGENTS Hemorrheologic Agents

pentoxifylline er 1 TRENTAL HYPOTENSIVE AGENTS Direct Vasodilators




Drug Name

Drug Tier

Reference Name


hydralazine hcl 10 mg Oral Tablet, 100 mg Oral Tablet, 25 mg Oral Tablet, 50 mg Oral Tablet 1 APRESOLINE minoxidil 10 mg Oral Tablet, 2.5 mg Oral Tablet 1 LONITEN IMMUNOMODULATORY AGENTS Immunomodulatory Agents

ENSPRYNG 2 PA IMMUNOSUPPRESSIVE AGENTS Immunosuppressive Agents

BENLYSTA 200 mg/ml Subcutaneous Solution Auto-injector, 200 mg/ml Subcutaneous Solution Prefilled Syringe 2 SP, PA ION-REMOVING AGENTS Potassium-removing Agents

KIONEX 1 sodium polystyrene sulfonate Oral Powder 1 KAYEXALATE sodium polystyrene sulfonate 15 gm/60ml Oral Suspension, 30 gm/120ml Rectal Suspension, 50 gm/200ml Rectal Suspension 1 SPS SPS 1 IRRIGATING SOLUTIONS Irrigating Solutions

sterile water for irrigation 1 KERATOLYTIC AGENTS Keratolytic Agents

CEM-UREA 1 METOPIC 1 salicylic acid 6 % External Lotion 1 salicylic acid 6 % External Lotion, 6 % External Shampoo 1 salicylic acid-cleanser 6 % lotion External Kit 1 SULFACLEANSE 8/4 1 urea 39 % External Cream, 40 % External Cream, 40 % External Lotion, 41 % External Cream 1




Drug Name

Drug Tier

Reference Name


urea 40 % External Lotion 1 urea hydrating 1 urea nail 1 xurea 1 MOUTHWASHES AND GARGLES Mouthwashes And Gargles

goodsense sore throat spray OTC hm sore throat spray OTC oral relief OTC phenaseptic OTC sore throat Mouth/Throat Liquid, 1.4 % Mouth/Throat Liquid OTC sore throat spray OTC MUCOLYTIC AGENTS Mucolytic Agents

NEBUSAL 3 % Inhalation Nebulization Solution 1 PULMOZYME 2.5 mg/2.5ml Inhalation Solution 2

SP, PA, QL(5 ML per 1 days)

sodium chloride 0.9 % Inhalation Nebulization Solution, 10 % Inhalation Nebulization Solution, 3 % Inhalation Nebulization Solution, 7 % Inhalation Nebulization Solution 1 MULTIVITAMIN PREPARATIONS Multivitamin Preparations

ATABEX EC 1 azesco 1 BAL-CARE DHA 1 cadeau dha 1 CEROVITE SENIOR OTC CERTAVITE/ANTIOXIDANTS OTC dothelle dha 1 DUET DHA 400 1 DUET DHA BALANCED 1 FLORIVA 0.25 mg Oral Tablet Chewable, 0.5 mg Oral Tablet Chewable, 1 mg Oral Tablet Chewable OTC FOLET ONE 1




Drug Name

Drug Tier

Reference Name


hemenatal ob + dha 1 kosher prenatal plus iron 1 MARNATAL-F 1 multi-vit/iron/fluoride OTC multivitamin + fluoride OTC multivitamin select/fluoride OTC multivitamin/fluoride 0.25 mg Oral Tablet Chewable, 0.5 mg Oral Tablet Chewable, 1 mg Oral Tablet Chewable OTC multivitamin/fluoride 0.25 mg/ml Oral Solution, 0.5 mg/ml Oral Solution OTC multivitamin/fluoride/iron OTC multi-vitamin/fluoride/iron OTC MVC-FLUORIDE OTC MYNATAL Oral Capsule, 90-1 mg Oral Tablet 1 MYNATAL ADVANCE 1 mynatal plus 1 mynatal-z 1 mynate 90 plus 1 mynephrocaps OTC MYNEPHRON OTC NATACHEW 1 NATELLE ONE 1 NEEVO DHA 1 NESTABS ABC 1 NEXA PLUS 1 OBSTETRIX DHA 1 OBSTETRIX EC 1 OBSTETRIX ONE 1 OBTREX DHA 1 pnv ob+dha 1 POLY-VI-FLOR 0.25 mg Oral Tablet Chewable, 0.5 mg Oral Tablet Chewable, 1 mg Oral Tablet Chewable OTC POLY-VI-FLOR 0.25 mg/ml Oral Suspension OTC




Drug Name

Drug Tier

Reference Name


POLY-VI-FLOR/IRON 0.5-10 mg Oral Tablet Chewable OTC POLY-VI-FLOR/IRON 0.25-7 mg/ml Oral Suspension OTC POLY-VI-SOL/IRON OTC PR NATAL 400 1 PR NATAL 400 EC 1 PR NATAL 430 1 PR NATAL 430 EC 1 prena 1 true 1 prena1 1 prenatabs fa 1 PRENATABS RX 1 prenatal 19 29-1 mg Oral Tablet, 29-1 mg Oral Tablet Chewable 1 prenatal 19 Oral Tablet OTC prenatal low iron 27-1 mg Oral Tablet 1 prenatal multi +dha 27-0.8-228 mg Oral Capsule OTC prenatal plus iron 1 PRENATAL-U 1 QUFLORA FE OTC QUFLORA FE PEDIATRIC OTC QUFLORA PEDIATRIC 0.25 mg Oral Tablet Chewable, 0.5 mg Oral Tablet Chewable, 1 mg Oral Tablet Chewable OTC QUFLORA PEDIATRIC 0.25 mg/ml Oral Solution, 0.5 mg/ml Oral Solution OTC relnate dha 1 RENAL OTC reno caps OTC R-NATAL OB 1 therapeutic-m OTC TRICARE PRENATAL DHA ONE 1 TRINATE 1 triphrocaps OTC TRI-VI-FLOR 0.25 mg/ml Oral Suspension OTC




Drug Name

Drug Tier

Reference Name


tri-vitamin/fluoride 0.25 mg/ml Oral Solution, 0.5 mg/ml Oral Solution OTC ultimatecare one 1 vena-bal dha 1 VINATE CARE 1 VINATE II 1 VINATE M 1 VINATE ONE 1 virt-caps OTC vision vitamins OTC VITAMEDMD ONE RX/QUATREFOLIC 1 VITAMEDMD REDICHEW RX 1 vitamins acd-fluoride OTC VITAPEARL 1 VITATRUE 1 VIVA DHA 1 vol-nate 1 vol-tab rx 1 MYDRIATICS Mydriatics

atropine sulfate 1 % Ophthalmic Ointment 1 atropine sulfate 1 % Ophthalmic Solution 1 cyclopentolate hcl 0.5 % Ophthalmic Solution, 1 % Ophthalmic Solution, 2 % Ophthalmic Solution 1 HOMATROPAIRE 1 homatropine hbr 1 NON-AHFS SUBCLASS Unknown Therapeutic Class

INQOVI 2 PA OTHER MISCELLANEOUS THERAPEUTIC AGENTS Other Miscellaneous Therapeutic Agents

CYSTAGON 2 SP EVRYSDI 2 PA FIRDAPSE 2 SP, PA fish oil 1000 mg Oral Capsule OTC




Drug Name

Drug Tier

Reference Name


KUVAN 100 mg Oral Packet, 100 mg Oral Tablet, 500 mg Oral Packet 2 SP, PA levocarnitine 330 mg Oral Tablet 1 CARNITOR levocarnitine 1 gm/10ml Oral Solution 1 CARNITOR levocarnitine sf 1 CARNITOR l-methylfolate 15 mg Oral Tablet, 7.5 mg Oral Tablet OTC melatonin 3 mg Oral Tablet OTC melatonin/vitamin b-6 ex st 3-1 mg Oral Tablet OTC melatonin-pyridoxine 5-10 mg Oral Tablet OTC NITYR 2 SP, PA octreotide acetate 500 mcg/ml Injection Solution 1 SANDOSTATIN SP omega 3 1000 mg Oral Capsule OTC omega iii epa+dha OTC omega-3 1000 mg Oral Capsule OTC omega-3 fish oil 1000 mg Oral Capsule, 500 mg Oral Capsule OTC sapropterin dihydrochloride 100 mg Oral Packet, 100 mg Oral Tablet, 500 mg Oral Packet 1 SP, PA SUPER OMEGA-3 1000 mg Oral Capsule OTC ZOKINVY 2 PA OXYTOCICS Oxytocics

methylergonovine maleate 0.2 mg Oral Tablet 1 METHERGINE PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS Parasympathomimetic (cholinergic) Agents

bethanechol chloride 10 mg Oral Tablet, 25 mg Oral Tablet, 5 mg Oral Tablet, 50 mg Oral Tablet 1 URECHOLINE pilocarpine hcl 5 mg Oral Tablet, 7.5 mg Oral Tablet 1 SALAGEN pyridostigmine bromide 30 mg Oral Tablet 1




Drug Name

Drug Tier

Reference Name


pyridostigmine bromide 60 mg Oral Tablet 1 MESTINON PARATHYROID AND ANTIPARATHYROID AGENTS Antiparathyroid Agents

cinacalcet hcl 1 SENSIPAR SP, PA, QL(4 EA per 1

days) PITUITARY Pituitary

desmopressin acetate 0.1 mg Oral Tablet, 0.2 mg Oral Tablet 1 DDAVP desmopressin acetate spray 1 DDVAP QL(0.4 ML per 1 days) PROGESTINS Progestins

megestrol acetate 20 mg Oral Tablet, 40 mg Oral Tablet 1 MEGACE megestrol acetate 40 mg/ml Oral Suspension, 400 mg/10ml Oral Suspension 1 MEGACE PSYCHOTHERAPEUTIC AGENTS Antidepressants

chlordiazepoxide-amitriptyline 1 LIMBITROL Antipsychotics

prochlorperazine edisylate 50 mg/10ml Injection Solution 1 RENIN-ANGIOTENSIN-ALDOSTERONE SYS INHIB Mineralocorticoid (aldost) Recept Antag

eplerenone 50 mg Oral Tablet 1 INSPRA QL(2 EA per 1 days) eplerenone 25 mg Oral Tablet 1 INSPRA QL(4 EA per 1 days) spironolactone 100 mg Oral Tablet, 25 mg Oral Tablet, 50 mg Oral Tablet 1 ALDACTONE spironolactone-hctz 25-25 mg Oral Tablet 1 ALDACTAZIDE REPLACEMENT PREPARATIONS Replacement Preparations

CALCITRATE 315-250 mg-unit Oral Tablet OTC calcium + vitamin d3 500-400 mg-unit Oral Tablet Chewable, 600-10 mg-mcg Oral Tablet OTC




Drug Name

Drug Tier

Reference Name


calcium 500/d 500-400 mg-unit Oral Tablet Chewable OTC calcium 600 +d high potency OTC calcium 600+d 600-400 mg-unit Oral Tablet OTC calcium 600+d high potency OTC calcium 600+d3 600-400 mg-unit Oral Tablet OTC calcium 600-d OTC calcium carb-cholecalciferol 500-10 mg-mcg Oral Tablet Chewable, 600-400 mg-unit Oral Tablet OTC calcium carbonate 1250 (500 Ca) mg Oral Tablet Chewable OTC calcium carbonate w/vitamin d OTC calcium carbonate-vitamin d 600-400 mg-unit Oral Tablet OTC calcium carbonate-vitamin d3 OTC calcium citrate + d 250-200 mg-unit Oral Tablet, 315-200 mg-unit Oral Tablet OTC calcium citrate + d3 315-5 mg-mcg Oral Tablet OTC calcium citrate + d3 maximum OTC calcium citrate-vitamin d 315-200 mg-unit Oral Tablet OTC calcium citrate-vitamin d3 315-6.25 mg-mcg Oral Tablet OTC calcium-vitamin d 600-400 mg-unit Oral Tablet OTC citrus calcium +d OTC hm calcium citrate+vitamin d OTC KLOR-CON 1 KLOR-CON 10 1 KLOR-CON M10 1 KLOR-CON M15 1 KLOR-CON M20 1 KLOR-CON SPRINKLE 1 kp mag-oxide magnesium OTC K-PHOS 2 magnesium 400 mg Oral Tablet OTC




Drug Name

Drug Tier

Reference Name


magnesium oxide 400 (240 Mg) mg Oral Tablet OTC MAGNESIUM-OXIDE OTC MAGOX 400 OTC oyster shell calcium 500+d OTC PHOSPHA 250 NEUTRAL OTC potassium chloride 20 meq Oral Packet 1 potassium chloride 20 MEQ/15ML (10%) Oral Solution, 40 MEQ/15ML (20%) Oral Solution 1 K-SOL potassium chloride crys er 10 meq Oral Tablet Extended Release, 15 meq Oral Tablet Extended Release 1 potassium chloride crys er 20 meq Oral Tablet Extended Release 1 KLOR-CON potassium chloride er 20 meq Oral Tablet Extended Release 1 K-TAB potassium chloride er 10 meq Oral Tablet Extended Release, 8 meq Oral Tablet Extended Release 1 KLOR-CON potassium chloride er 10 meq Oral Capsule Extended Release, 8 meq Oral Capsule Extended Release 1 MICRO-K super calcium 600 + d 400 OTC RESPIRATORY SMOOTH MUSCLE RELAXANTS Respiratory Smooth Muscle Relaxants

ELIXOPHYLLIN 1 theophylline 80 mg/15ml Oral Solution 1 theophylline er 100 mg Oral Tablet Extended Release 12 Hour, 200 mg Oral Tablet Extended Release 12 Hour, 300 mg Oral Tablet Extended Release 12 Hour, 450 mg Oral Tablet Extended Release 12 Hour 1 THEO-DUR theophylline er 400 mg Oral Tablet Extended Release 24 Hour, 600 mg Oral Tablet Extended Release 24 Hour 1 UNIPHYL




Drug Name

Drug Tier

Reference Name


SECOND GENERATION ANTIHISTAMINES Second Generation Antihistamines

cetirizine hcl 5 mg/5ml Oral Solution 1 ZYRTEC SKIN AND MUCOUS MEMBRANE AGENTS, MISC Skin And Mucous Membrane Agents, Misc

azelaic acid 15 % External Gel 1 FINACEA CUTTER BACKWOODS External Aerosol OTC QL(31 GM per 1 days) CUTTER BACKWOODS External Liquid OTC QL(31 ML per 1 days) fluorouracil 0.5 % External Cream 1 CARAC fluorouracil 5 % External Cream 1 EFUDEX fluorouracil 2 % External Solution, 5 % External Solution 1 EFUDEX OFF DEEP WOODS DRY OTC QL(31 GM per 1 days) podofilox 0.5 % External Solution 1 CONDYLOX QBREXZA 2 PA REPEL SPORTSMEN MAX 40 % External Aerosol OTC QL(31 GM per 1 days) REPEL SPORTSMEN MAX 40 % External Liquid OTC QL(31 ML per 1 days) SOMATOSTATIN AGONISTS AND ANTAGONISTS Somatostatin Agonists

octreotide acetate 100 mcg/ml Subcutaneous Solution Prefilled Syringe, 50 mcg/ml Subcutaneous Solution Prefilled Syringe, 500 mcg/ml Subcutaneous Solution Prefilled Syringe 1 SP octreotide acetate 100 mcg/ml Injection Solution, 1000 mcg/ml Injection Solution, 200 mcg/ml Injection Solution, 50 mcg/ml Injection Solution, 500 mcg/ml Injection Solution 1 SANDOSTATIN SP SYMPATHOMIMETIC (ADRENERGIC) AGENTS Alpha-adrenergic Agonists

midodrine hcl 1 PROAMATINE VICKS SINEX DAYTIME OTC




Drug Name

Drug Tier

Reference Name


THYROID AND ANTITHYROID AGENTS Antithyroid Agents

methimazole 10 mg Oral Tablet, 5 mg Oral Tablet 1 TAPAZOLE propylthiouracil 50 mg Oral Tablet 1 TOXOIDS Toxoids

ADACEL 2 AL(Min 19 years and

Max 64 years) BOOSTRIX 2 AL(Min 19 years) TDVAX 2 AL(Min 19 years) TENIVAC 2 AL(Min 19 years) tetanus-diphtheria toxoids td 2-2 lf/0.5ml Intramuscular Suspension 2 AL(Min 19 years) URINARY ANTI-INFECTIVES Urinary Anti-infectives

trimethoprim 100 mg Oral Tablet 1 PROLOPRIM URINE AND FECES CONTENTS Ketones

KETOSTIX OTC VACCINES Vaccines

AFLURIA 2 AFLURIA PRESERVATIVE FREE 2 AFLURIA QUADRIVALENT 2 astrazeneca covid-19 vaccine 2

BEXSERO 2 AL(Min 19 years and

Max 25 years) ENGERIX-B 10 mcg/0.5ml Injection Suspension 2

AL(Min 19 years and Max 19 years)

ENGERIX-B 20 mcg/ml Injection Suspension 2 AL(Min 20 years) EZ FLU SHOT-FLUCELVAX QUAD 2 FLUAD 2 FLUAD QUADRIVALENT 2 FLUARIX QUADRIVALENT 2 FLUBLOK QUADRIVALENT 2 FLUCELVAX QUADRIVALENT 2 FLULAVAL QUADRIVALENT 2 FLUMIST QUADRIVALENT 2




Drug Name

Drug Tier

Reference Name


FLUZONE HIGH-DOSE 2 FLUZONE HIGH-DOSE QUADRIVALENT 2 FLUZONE QUADRIVALENT 2

GARDASIL 9 2 AL(Min 19 years and

Max 45 years) HAVRIX 1440 el u/ml Intramuscular Suspension 2 AL(Min 19 years) HEPLISAV-B 20 mcg/0.5ml Intramuscular Solution, 20 mcg/0.5ml Intramuscular Solution Prefilled Syringe 2 AL(Min 19 years) janssen covid-19 vaccine 2 MENACTRA 2 AL(Min 19 years) MENQUADFI Intramuscular Solution 2 AL(Min 19 years)

MENVEO 2 AL(Min 19 years and

Max 55 years) M-M-R II 2 AL(Min 19 years) novavax covid-19 vaccine 2 pfizer covid-19 vac-tris 5-11y 2 pfizer-biont covid-19 vac-tris 2 PNEUMOVAX 23 2 AL(Min 19 years) PREVNAR 13 2 AL(Min 19 years) PREVNAR 20 2 AL(Min 19 years) PROQUAD 2 AL(Min 19 years) RECOMBIVAX HB 5 mcg/0.5ml Injection Suspension 2

AL(Min 19 years and Max 19 years)

RECOMBIVAX HB 40 mcg/ml Injection Suspension 2 AL(Min 19 years) RECOMBIVAX HB 10 mcg/ml Injection Suspension 2 AL(Min 20 years)

SHINGRIX 2 QL(2 EA per 365 days),

AL(Min 19 years)

TRUMENBA 2 AL(Min 19 years and

Max 25 years) TWINRIX 2 AL(Min 19 years) VAQTA 50 unit/ml Intramuscular Suspension 2 AL(Min 19 years) VARIVAX 2 AL(Min 19 years) VAXNEUVANCE 2 AL(Min 19 years)




Drug Name

Drug Tier

Reference Name


VIVOTIF 2 QL(0.58 EA per 1 days) ZOSTAVAX 2 AL(Min 49 years) VASOCONSTRICTORS Vasoconstrictors

12 hour decongestant 0.05 % Nasal Solution OTC 12 hour nasal decongestant 0.05 % Nasal Solution OTC 12 hour nasal relief spray OTC 12 hour nasal spray OTC anefrin spray OTC hm nasal spray OTC hm sinus nasal spray OTC kls nasal decongestant spray OTC MUCINEX SINUS-MAX CLEAR & COOL OTC MUCINEX SINUS-MAX FULL FORCE OTC nasal decongestant spray OTC nasal four OTC nasal relief OTC nasal spray OTC nasal spray 12 hour OTC nasal spray extra moisturizing OTC nasal spray no drip OTC nasal spray sinus OTC no drip nasal spray OTC phenylephrine hcl 2.5 % Ophthalmic Solution 1 phenylephrine hcl 10 % Ophthalmic Solution, 2.5 % Ophthalmic Solution 1 sinus nasal spray OTC sinus relief 0.05 % Nasal Solution OTC sinus relief extra strength OTC VASODILATING AGENTS Vasodilating Agents

treprostinil 100 mg/20ml Injection Solution, 20 mg/20ml Injection Solution, 200 mg/20ml Injection 1 REMODULIN SP, PA




Drug Name

Drug Tier

Reference Name


Solution, 50 mg/20ml Injection Solution VITAMIN B COMPLEX Vitamin B Complex

b-2 50 mg Oral Tablet OTC cyanocobalamin 1000 mcg/ml Injection Solution 1 folic acid 1 mg Oral Tablet 1 folic acid 0.8 mg Oral Capsule, 1 mg Oral Tablet, 800 mcg Oral Tablet OTC FOLTANX OTC kp folic acid 1 mg Oral Tablet OTC vitamin b1 50 mg Oral Tablet OTC vitamin b12 100 mcg Oral Tablet OTC vitamin b-12 500 mcg Oral Tablet OTC vitamin b-2 25 mg Oral Tablet OTC vitamin b-6 100 mg Oral Tablet OTC VITAMIN C Vitamin C

vitamin c 250 mg Oral Tablet OTC VITAMIN D Vitamin D

d 400 10 MCG (400 unit) Oral Tablet OTC d-400 OTC ergocalciferol 200 mcg/ml Oral Solution OTC vitamin d (ergocalciferol) 1.25 MG (50000 ut) Oral Capsule 1 vitamin d3 10 MCG (400 unit) Oral Tablet OTC VITAMIN E Vitamin E

e200 90 MG (200 unit) Oral Capsule OTC vitamin e 200 unit Oral Capsule, 90 MG (200 unit) Oral Capsule OTC vitamin e-200 OTC VITAMIN K ACTIVITY




Drug Name

Drug Tier

Reference Name


Vitamin K Activity

MEPHYTON 2 phytonadione 5 mg Oral Tablet 1




I n d e x

1 12 hour decongestant ...................................... 67 12 hour nasal decongestant............................ 67 12 hour nasal relief spray ................................ 68 12 hour nasal spray ......................................... 68 1st tier unifine pentips ..................................... 32 1st tier unifine pentips plus ............................. 32 1st tier unilet comfortouch ............................... 32 A ABOUTTIME PEN NEEDLE ........................... 32 acamprosate calcium....................................... 31 ACCU-CHEK FASTCLIX LANCET ................. 32 ACCU-CHEK FASTCLIX LANCETS .............. 32 ACCU-CHEK MULTICLIX LANCET DEV ...... 32 ACCU-CHEK MULTICLIX LANCETS ............ 32 ACCU-CHEK SAFE-T PRO LANCETS.......... 32 ACCU-CHEK SOFT TOUCH LANCETS ........ 32 ACCU-CHEK SOFTCLIX LANCET DEV ....... 32 ACCU-CHEK SOFTCLIX LANCETS .............. 32 ACEPHEN ........................................................ 16 acetaminophen ................................................ 16 acetaminophen extra strength ........................ 16 acetazolamide .................................................. 21 acetazolamide er ............................................. 21 acetic acid ........................................................ 54 acetylcysteine .................................................. 20 ACID GONE ..................................................... 17 acne treatment ................................................. 22 acti-lance 28g ................................................... 32 acti-lance lite lancets 28g ................................ 32 acti-lance special lancets 17g ......................... 32 acti-lance universal 23g................................... 32 ADACEL ........................................................... 66 adjustable lancing device ................................ 32 adult mask large .............................................. 32 advanced mobile lancet................................... 32 ADVOCATE INSULIN PEN NEEDLES .......... 33 ADVOCATE INSULIN SYRINGE ................... 33 ADVOCATE LANCETS ................................... 33 ADVOCATE LANCETS 30G ........................... 33 ADVOCATE LANCING DEVICE .................... 33 ADVOCATE RAPID-SAFE LANCING ............ 33 ADVOCATE SAFETY LANCETS ................... 33 ADVOCATE SAFETY LANCETS 26G ........... 33

AFLURIA...........................................................66 AFLURIA PRESERVATIVE FREE .................66 AFLURIA QUADRIVALENT ............................66 AGAMATRIX ULTRA-THIN LANCETS ..........33 aimsco twist lancets 32g..................................33 AIMSCO TWIST LANCETS 33G ....................33 albendazole ......................................................18 ALIGN ...............................................................20 ALIGN JR FOR KIDS .......................................20 ALKA-SELTZER PLUS ALLERGY .................54 ALKERAN .........................................................25 allergy ...............................................................55 allergy childrens ...............................................55 ALTACHLORE .................................................54 alternate site lancing device ............................33 alumina-magnesia-simethicone ......................17 aluminum hydroxide gel ...................................17 amiloride hcl .....................................................53 amiloride-hydrochlorothiazide .........................53 amiodarone hcl .................................................28 ammonium lactate ............................................54 anagrelide hcl ...................................................27 anefrin spray .....................................................68 antacid ..............................................................17 antacid anti-gas ................................................17 antacid anti-gas reg strength ...........................17 antacid calcium.................................................17 antacid calcium extra strength ........................17 antacid calcium rich .........................................17 antacid extra strength ......................................17 antacid fast acting ............................................17 antacid fast relief ..............................................17 antacid liquid ....................................................17 antacid m ..........................................................18 antacid maximum .............................................18 antacid plus anti-gas fast act ...........................18 antacid plus anti-gas relief ...............................18 antacid regular strength ...................................18 antacid ultra strength .......................................18 antifungal ..........................................................22 ANTI-ITCH INTENSIVE HEALING .................23 aqua lance adjustable lancing .........................33 AQUALANCE LANCETS 30G.........................33 aspirin ...............................................................17 aspirin adult ......................................................17




assure comfort lancets 28g ............................. 33 ASSURE HAEMOLANCE PLUS HIGH .......... 33 ASSURE HAEMOLANCE PLUS LOW........... 33 ASSURE HAEMOLANCE PLUS MICRO ....... 33 ASSURE HAEMOLANCE PLUS NORMAL ... 33 ASSURE HAEMOLANCE PLUS PED ........... 33 ASSURE ID INSULIN SAFETY SYR ............. 33 ASSURE ID SAFETY PEN NEEDLES........... 33 ASSURE LANCE LANCETS........................... 33 ASSURE LANCE LANCETS 21G .................. 33 ASSURE LANCE PLUS SAFETY 25G .......... 33 ASSURE LANCE PLUS SAFETY 30G .......... 33 ASSURE LANCE SAFETY LANCET 28G ..... 33 ASSURE LANCETS ........................................ 34 astrazeneca covid-19 vaccine ........................ 66 ATABEX EC ..................................................... 57 athletes foot ...................................................... 22 atovaquone ...................................................... 26 atropine sulfate ................................................ 60 aurora lancet super thin 30g ........................... 34 aurora lancet thin 23g ...................................... 34 aurora pen needles .......................................... 34 aurora unifine pentips ...................................... 34 AUTO-LANCET................................................ 34 AUTO-LANCET MINI....................................... 34 AUTOLET LANCING DEVICE ........................ 34 azelaic acid ...................................................... 64 azesco .............................................................. 57 B b-2 ..................................................................... 68 bacitracin-neomycin-polymyxin....................... 21 BAL-CARE DHA .............................................. 57 BD AUTOSHIELD ............................................ 34 BD AUTOSHIELD DUO .................................. 34 BD ECLIPSE SYRINGE .................................. 34 BD INSULIN SYR ULTRAFINE II ................... 34 BD INSULIN SYRINGE ................................... 34 BD INSULIN SYRINGE HALF-UNIT .............. 34 BD INSULIN SYRINGE MICROFINE ............. 34 BD INSULIN SYRINGE U/F ............................ 34 BD INSULIN SYRINGE U/F 1/2UNIT ............. 34 BD INSULIN SYRINGE U-500 ........................ 34 BD INSULIN SYRINGE ULTRAFINE ............. 34 BD LANCET ULTRAFINE 30G ....................... 34 BD LANCET ULTRAFINE 33G ....................... 34 BD LUER-LOK SYRINGE ............................... 34

BD MICROTAINER LANCETS .......................34 BD PEN NEEDLE MICRO U/F........................34 BD PEN NEEDLE MINI U/F ............................34 BD PEN NEEDLE NANO 2ND GEN...............34 BD PEN NEEDLE NANO U/F .........................34 BD PEN NEEDLE ORIGINAL U/F ..................34 BD PEN NEEDLE SHORT U/F .......................34 BD SAFETYGLIDE INSULIN SYRINGE ........34 BD SAFETYGLIDE NEEDLE ..........................35 BD SAFETYGLIDE SYRINGE/NEEDLE ........35 BD SAFETY-LOK INSULIN SYRINGE ...........35 BD SYRINGE ...................................................35 BD VEO INSULIN SYR U/F 1/2UNIT .............35 BD VEO INSULIN SYRINGE U/F ...................35 BENLYSTA .......................................................56 benzonatate ......................................................27 beta hc ..............................................................23 bethanechol chloride ........................................61 BEVYXXA .........................................................26 bexarotene ........................................................25 BEXSERO ........................................................66 bisacodyl ...........................................................29 bisacodyl ec ......................................................29 bisacodyl laxative .............................................29 bismatrol ...........................................................20 bismatrol maximum strength ...........................20 BOOSTRIX .......................................................66 bp gel ................................................................22 bp wash ............................................................22 bumetanide .......................................................52 C cabergoline .......................................................26 CABLIVI ............................................................27 cadeau dha .......................................................57 caffeine citrate ..................................................17 CALCITRATE ...................................................62 calcium + vitamin d3 ........................................62 calcium 500/d ...................................................62 calcium 600 +d high potency...........................62 calcium 600+d ..................................................62 calcium 600+d high potency............................62 calcium 600+d3 ................................................62 calcium 600-d ...................................................63 calcium antacid.................................................18 calcium antacid ultra max st ............................18 calcium antacid ultra strength .........................18




calcium carb-cholecalciferol ............................ 63 calcium carbonate............................................ 63 calcium carbonate antacid .............................. 18 calcium carbonate w/vitamin d........................ 63 calcium carbonate-vitamin d ........................... 63 calcium carbonate-vitamin d3 ......................... 63 calcium citrate + d ............................................ 63 calcium citrate + d3.......................................... 63 calcium citrate + d3 maximum ........................ 63 calcium citrate-vitamin d .................................. 63 calcium citrate-vitamin d3................................ 63 calcium polycarbophil ...................................... 29 calcium-vitamin d ............................................. 63 carboplatin ........................................................ 25 CARDIOCOM LANCING DEVICE .................. 35 CAREFINE PEN NEEDLES............................ 35 careone advanced lancing dev ....................... 35 careone insulin syringe.................................... 35 CAREONE LANCET SUPER THIN 30G ....... 35 careone lancet thin 23g ................................... 35 careone unifine pentips ................................... 35 careone unifine pentips plus ........................... 35 CARESENS LANCETS ................................... 35 CARETOUCH HYPODERMIC NEEDLE ....... 35 CARETOUCH INSULIN SYRINGE ................ 35 CARETOUCH LANCING/EJECTOR .............. 35 CARETOUCH PEN NEEDLES ....................... 35 CARETOUCH SAFETY LANCETS ................ 35 CARETOUCH SAFETY LANCETS 26G ........ 35 CARETOUCH TWIST LANCETS 28G ........... 35 CARETOUCH TWIST LANCETS 30G ........... 35 CARETOUCH TWIST LANCETS 33G ........... 35 CEM-UREA ...................................................... 56 CEROVITE SENIOR ....................................... 57 CERTAVITE/ANTIOXIDANTS ........................ 57 cetirizine hcl ..................................................... 64 childrens acetaminophen ................................ 16 childrens apap .................................................. 16 childrens silapap .............................................. 16 childrens tactinal .............................................. 16 chlordiazepoxide-amitriptyline ........................ 62 chlorhexidine gluconate................................... 22 chlorothiazide ................................................... 53 CHLORPHEN SR ............................................ 55 chlorpheniramine maleate er .......................... 55 chlorthalidone ................................................... 53

cilostazol ...........................................................27 cimetidine 200 ..................................................27 cinacalcet hcl ....................................................61 citrate of magnesia ...........................................29 citrus calcium +d ..............................................63 CLEANLET LANCETS 28G ............................35 CLENPIQ ..........................................................29 CLEVER CHEK LANCETS .............................36 CLEVER CHOICE COMFORT EZ ..................36 CLEVER CHOICE LANCETS 21G .................36 CLEVER CHOICE LANCETS 23G .................36 CLEVER CHOICE LANCETS 28G .................36 clickfine pen needles .......................................36 CLICKFINE PEN NEEDLES ...........................36 clindamycin hcl .................................................19 clindamycin palmitate hcl.................................19 COAGUCHEK LANCETS ................................36 COLOCORT .....................................................23 COMFORT ASSIST INSULIN SYRINGE .......36 comfort assured lancets 28g ...........................36 comfort assured lancets 33g ...........................36 COMFORT EZ INSULIN SYRINGE................36 COMFORT EZ MICRO PEN NEEDLES ........36 COMFORT EZ PEN NEEDLES ......................36 COMFORT EZ SHORT PEN NEEDLES ........36 comfort lancets .................................................36 COMFORT TOUCH INSULIN PEN NEED .....36 complete allergy medicine ...............................55 complete allergy relief ......................................55 complete lice treatment ...................................23 constulose ........................................................15 CONTOUR CONTROL ....................................36 CONTOUR NEXT CONTROL .........................36 CORTIZONE-10 ...............................................23 CORTIZONE-10 DIABETICS SKIN ................23 CORTIZONE-10 ECZEMA ..............................23 CORTIZONE-10 PLUS ....................................23 CORTIZONE-10/ALOE ....................................23 cromolyn sodium ..............................................24 CUTTER BACKWOODS .................................65 cyanocobalamin ...............................................68 cyclopentolate hcl.............................................60 cyclophosphamide ...........................................25 cyproheptadine hcl ...........................................54 CYSTAGON .....................................................60 cytra-2 ...............................................................15




D d 400 ................................................................. 69 d-400................................................................. 69 danazol ............................................................. 17 dapsone ............................................................ 24 DAYHIST ALLERGY 12 HOUR RELIEF ........ 55 DENTA 5000 PLUS ......................................... 29 DENTAGEL ...................................................... 29 DERMAREST ECZEMA .................................. 23 desmopressin acetate ..................................... 62 desmopressin acetate spray ........................... 62 DIATHRIVE LANCET ULTRA THIN 30.......... 36 DIATHRIVE LANCETS.................................... 36 DIATHRIVE LANCING DEVICE ..................... 36 DIATHRIVE PEN NEEDLE ............................. 36 dicyclomine hcl................................................. 19 DIGITEK ........................................................... 28 digox ................................................................. 28 digoxin .............................................................. 28 diocto ................................................................ 29 diphen ............................................................... 55 diphenhydramine hcl ....................................... 55 diphenoxylate-atropine .................................... 20 disopyramide phosphate ................................. 28 disulfiram .......................................................... 15 DIURIL .............................................................. 53 docuzen ............................................................ 30 dofetilide ........................................................... 28 DOK PLUS ....................................................... 30 dothelle dha ...................................................... 57 DROPLET INSULIN SYRINGE ...................... 36 DROPLET LANCETS ULTRA THIN 30G ...... 37 DROPLET LANCING DEVICE ....................... 37 DROPLET MICRON ........................................ 37 DROPLET PEN NEEDLES ............................. 37 dropsafe safety pen needles ........................... 37 DRYSOL ........................................................... 28 ducodyl ............................................................. 30 DUET DHA 400................................................ 57 DUET DHA BALANCED ................................. 57 E e200 .................................................................. 69 easy comfort insulin syringe............................ 37 easy comfort lancets........................................ 37 easy comfort lancets twist top ......................... 37 easy comfort pen needles ............................... 37

easy glide pen needles ....................................37 easy mini eject lancing device.........................37 easy mini lancing device..................................37 EASY TOUCH FLIPLOCK INSULIN SY .........37 EASY TOUCH INSULIN BARRELS 1ML .......37 EASY TOUCH INSULIN SAFETY SYR .........37 EASY TOUCH INSULIN SYRINGE ................37 EASY TOUCH LANCETS 21G .......................37 EASY TOUCH LANCETS 23G .......................37 EASY TOUCH LANCETS 26G .......................37 EASY TOUCH LANCETS 28G .......................37 EASY TOUCH LANCETS 28G/TWIST...........37 EASY TOUCH LANCETS 30G .......................37 EASY TOUCH LANCETS 30G/TWIST...........37 EASY TOUCH LANCETS 32G .......................37 EASY TOUCH LANCETS 32G/TWIST...........37 EASY TOUCH LANCETS 33G/TWIST...........37 EASY TOUCH LANCING DEVICE .................37 EASY TOUCH PEN NEEDLES ......................37 EASY TOUCH SAFETY LANCETS 21G........37 EASY TOUCH SAFETY LANCETS 23G........37 EASY TOUCH SAFETY LANCETS 26G........38 EASY TOUCH SAFETY LANCETS 28G........38 EASY TOUCH SAFETY PEN NEEDLES .......38 EASY TOUCH SHEATHLOCK SYRINGE .....38 EASY TWIST & CAP LANCETS .....................38 easy-lax plus.....................................................30 ECONTRA EZ ..................................................31 ECONTRA ONE-STEP ....................................31 elite-thin insulin syringe ...................................38 ELIXOPHYLLIN ................................................64 EMBRACE LANCETS ULTRA THIN 30G ......38 EMCYT .............................................................25 EMVERM ..........................................................18 ENGERIX-B ......................................................66 ENSPRYNG .....................................................56 enulose .............................................................15 eplerenone ........................................................62 ergocalciferol ....................................................69 ethambutol hcl ..................................................25 etoposide ..........................................................25 EVRYSDI ..........................................................60 EXEL COMFORT POINT INSULIN SYR .......38 EXEL COMFORT POINT PEN NEEDLE .......38 EZ FLU SHOT-FLUCELVAX QUAD ...............66 E-Z JECT LANCET MICRO-THIN 33G ..........38




E-Z JECT LANCET SUPER THIN 30G.......... 38 E-Z JECT LANCETS ....................................... 38 E-Z JECT LANCETS 21G ............................... 38 E-Z JECT LANCETS THIN 26G ..................... 38 EZ SMART BLOOD GLUCOSE LANCETS ... 38 EZFE 200 ......................................................... 19 EZ-LETS LANCETS 21G ................................ 38 EZ-LETS LANCETS 26G ................................ 38 EZ-LETS LANCETS 28G ................................ 38 EZ-LETS LANCETS 30G ................................ 38 F FERREX 150.................................................... 19 ferrous gluconate ............................................. 19 fiber laxative ..................................................... 30 fiber-lax ............................................................. 30 FIFTY50 PEN NEEDLES ................................ 38 FIFTY50 SAFETY SEAL LANCETS............... 38 FIFTY50 SUPERIOR COMFORT SYR .......... 38 FIFTY50 UNILET LANCETS 33G .................. 38 FINE 30 ............................................................ 38 FINGERSTIX LANCETS ................................. 38 FIRDAPSE ....................................................... 60 fish oil................................................................ 60 flecainide acetate ............................................. 28 FLORIVA ....................................................29, 57 FLUAD .............................................................. 66 FLUAD QUADRIVALENT ............................... 66 FLUARIX QUADRIVALENT ............................ 66 FLUBLOK QUADRIVALENT........................... 66 FLUCELVAX QUADRIVALENT ...................... 66 FLULAVAL QUADRIVALENT ......................... 66 FLUMIST QUADRIVALENT ............................ 66 fluocinolone acetonide ..................................... 23 FLUORABON ................................................... 29 fluoritab ............................................................. 29 fluorouracil ........................................................ 65 FLURA-DROPS ............................................... 29 flutamide ........................................................... 25 FLUZONE HIGH-DOSE .................................. 66 FLUZONE HIGH-DOSE QUADRIVALENT .... 66 FLUZONE QUADRIVALENT .......................... 66 FOLET ONE ..................................................... 57 folic acid......................................................68, 69 FOLTANX ......................................................... 69 FORA LANCETS ............................................. 38 FORA LANCING DEVICE ............................... 39

FORA V10/V12/D10/D20 TEST ......................39 FREESTYLE LANCETS ..................................39 FREESTYLE LIBRE 14 DAY READER ..........39 FREESTYLE LIBRE 14 DAY SENSOR .........39 FREESTYLE LIBRE 2 READER.....................39 FREESTYLE LIBRE 2 SENSOR ....................39 FREESTYLE LIBRE READER ........................39 FREESTYLE LIBRE SENSOR SYSTEM .......39 FREESTYLE PRECISION INS SYR...............39 FREESTYLE UNISTICK II LANCETS ............39 furosemide ................................................. 52, 53 G GARDASIL 9 ....................................................66 gas relief ...........................................................21 gas relief extra strength ...................................21 gas relief ultra strength ....................................21 GAVILYTE-C ....................................................30 GAVILYTE-G ....................................................30 GAVILYTE-N WITH FLAVOR PACK ..............30 generlac ............................................................15 GENTEEL BUTTERFLY TOUCH LANCET ...39 GENTEEL LANCING DEVICE (GOLD) ..........39 GENTEEL LANCING DEVICE(PLATNM) ......39 GENTEEL LANCING DEVICE(SILVER) ........39 GENTEEL LANCING KIT (BLUE) ...................39 gentle laxative ..................................................30 GENTLE-LET GP LANCETS ..........................39 GENTLE-LET LANCETS .................................39 geri-dryl .............................................................55 geri-lanta ...........................................................18 geri-mox ............................................................18 geri-pectate.......................................................20 global ease inject pen needles ........................39 global easy glide insulin syr.............................39 global easy glide pen needles .........................39 global inject ease insulin syr............................39 global inject ease lancets 28g .........................39 global inject ease lancets 30g .........................39 global insulin syringes......................................39 global lancing device .......................................39 GLUCAGEN DIAGNOSTIC .............................21 glucagon emergency .......................................21 GLUCOCOM LANCETS 28G ..........................39 GLUCOCOM LANCETS 30G ..........................39 GLUCOCOM LANCETS 33G ..........................39 GLUCOPRO INSULIN SYRINGE ...................39




glucose ............................................................. 21 glycerin (adult) ................................................. 30 glycerin (child) .................................................. 30 glycerin adult .................................................... 30 glycopyrrolate ................................................... 19 gnp insulin syringes ......................................... 39 gnp insulin syringes 28gx1/2........................... 40 gnp insulin syringes 29gx1/2........................... 40 gnp insulin syringes 30gx5/16 ........................ 40 gnp insulin syringes 31gx5/16 ........................ 40 gnp sterile lancets 28g .................................... 40 gnp sterile lancets 30g .................................... 40 gnp sterile lancets 33g .................................... 40 GOJJI LANCING DEVICE/CLEAR CAP ........ 40 GOJJI STERILE LANCETS ............................ 40 goodsense antacid .......................................... 18 goodsense clickfine pen needle ..................... 40 goodsense color lancets 33g .......................... 40 goodsense lancets 26g univ ........................... 40 goodsense lancets 30g ................................... 40 goodsense lancets 30g univ ........................... 40 goodsense lancets 33g ................................... 40 goodsense lancets 33g univ ........................... 40 goodsense lancing device ............................... 40 goodsense magnesium citrate ........................ 30 GOODSENSE PEN NEEDLE PENFINE ....... 40 goodsense sore throat spray .......................... 56 goodsense stimulant laxative .......................... 30 GYNE-LOTRIMIN ............................................ 22 H HAVRIX ............................................................ 66 HEALTH CARE LANCING DEVICE ............... 40 healthwise insulin syr/needle .......................... 40 healthwise micron pen needles ...................... 40 healthwise mini pen needles ........................... 40 healthwise pen needles ................................... 40 healthwise short pen needles ......................... 40 healthwise unifine pentips ............................... 40 healthy accents lancing device ....................... 40 healthy accents unifine pentip ........................ 40 healthy accents unilet lancets ......................... 40 HEALTHY MAMA SHAKE THAT ACHE ........ 16 hemenatal ob + dha ......................................... 57 hemorrhoidal relief ........................................... 26 heparin sodium (porcine) ................................ 27 heparin sodium (porcine) pf ............................ 27

HEPLISAV-B ....................................................67 hm antacid ........................................................18 hm antacid/antigas ...........................................18 hm calcium antacid ..........................................18 hm calcium antacid ultra st ..............................18 hm calcium citrate+vitamin d ...........................63 hm fiber .............................................................30 hm loperamide hcl ............................................20 hm magnesium citrate .....................................30 hm nasal spray .................................................68 hm saline nasal spray ......................................54 hm senna-s .......................................................30 hm sinus nasal spray .......................................68 hm sore throat spray ........................................57 hm stool softener/laxative ................................30 HM ULTICARE INSULIN SYRINGE ...............40 HM ULTICARE SHORT PEN NEEDLES .......40 HOMATROPAIRE ............................................60 homatropine hbr ...............................................60 HYCAMTIN .......................................................25 HYCODAN ........................................................27 hydralazine hcl .................................................55 hydrochlorothiazide ..........................................53 hydrocod polst-cpm polst er ............................27 hydrocodone-homatropine ..............................27 hydrocortisone ..................................................23 hydrocortisone (perianal) .................................23 hydrocortisone anti-itch ...................................23 hydrocortisone intensive heal ..........................23 hydrocortisone plus ..........................................23 hydrocortisone-acetic acid ...............................23 hydromet ...........................................................27 HYPOLANCE AST LANCING .........................40 HY-VEE LANCETS ..........................................40 hy-vee thin lancets ...........................................40 I ICAR-C PLUS ...................................................19 IFEREX 150......................................................19 IMODIUM A-D ..................................................20 IN TOUCH LANCING DEVICE .......................40 IN TOUCH STERILE LANCETS 30G .............40 indapamide .......................................................53 INQOVI ...................................................... 25, 60 insulin syringe ...................................................40 insulin syringe/needle ......................................40 insulin syringe-needle u-100 ...........................41




insupen pen needles ....................................... 41 INSUPEN SENSITIVE ..................................... 41 INSUPEN ULTRAFIN ...................................... 41 INTRON A ........................................................ 25 iodine strong..................................................... 54 isoniazid............................................................ 25 J janssen covid-19 vaccine ................................ 67 jock itch spray powder ..................................... 22 JYNARQUE ...................................................... 53 K KALYDECO ...................................................... 32 KAOPECTATE ................................................. 20 KAOPECTATE EXTRA STRENGTH ............. 20 KAO-TIN ........................................................... 20 KETOSTIX........................................................ 66 kinney lancets .................................................. 41 kinney thin lancets ........................................... 41 kinray insulin syringe ....................................... 41 KIONEX ............................................................ 56 KLOR-CON ...................................................... 63 KLOR-CON 10 ................................................. 63 KLOR-CON M10 .............................................. 63 KLOR-CON M15 .............................................. 63 KLOR-CON M20 .............................................. 63 KLOR-CON SPRINKLE................................... 63 kls fiber-tabs ..................................................... 30 kls hydrocortisone plus .................................... 23 kls nasal decongestant spray ......................... 68 KLS QUIT2 ....................................................... 28 kmart valu insulin syringe 29g ........................ 41 kmart valu insulin syringe 30g ........................ 41 KOATE-DVI ...................................................... 21 kosher prenatal plus iron ................................. 57 kp bacitracin zinc ............................................. 21 kp benzoyl peroxide ......................................... 22 kp benzoyl peroxide wash ............................... 22 kp folic acid ...................................................... 69 kp hydrocortisone ............................................ 23 kp hydrocortisone-aloe .................................... 23 kp mag-oxide magnesium ............................... 63 kp miconazole nitrate....................................... 22 kp terbinafine hydrochloride ............................ 22 kp tolnaftate ...................................................... 22 K-PHOS ............................................................ 63

KUVAN..............................................................60 L lactulose ............................................................15 lactulose encephalopathy ................................16 lancet device ....................................................41 lancet device with ejector ................................41 lancet transporter case ....................................41 lancets...............................................................41 lancets 28g .......................................................41 lancets 30g .......................................................41 lancets 33g .......................................................41 lancets micro thin 33g ......................................41 lancets super thin 28g......................................41 lancets thin .......................................................41 LANCETS ULTRA FINE ..................................41 LANCETS ULTRA THIN ..................................41 lancets ultra thin 30g ........................................41 lancing device...................................................41 LANZO ..............................................................41 laxacin ...............................................................30 laxative ..............................................................30 leader advanced lancing device ......................41 leader insulin syringe .......................................41 LEADER UNIFINE PENTIPS ..........................41 LEADER UNIFINE PENTIPS PLUS ...............41 leflunomide .......................................................52 leucovorin calcium ...........................................20 LEUKERAN ......................................................25 levocarnitine .....................................................60 levocarnitine sf .................................................60 levonorgestrel ...................................................31 LIBERTY MEDICAL LANCETS ......................41 LIBERTY MINI LANCING DEVICE .................41 lice treatment ....................................................23 lidocaine-hydrocortisone ace ..........................26 lidopac...............................................................26 lidopin ................................................................26 LIFESCAN UNISTIK 2 .....................................42 LIFESCAN UNISTIK II LANCETS ..................42 linezolid .............................................................19 lite touch lancets ..............................................42 LITE TOUCH LANCING PEN .........................42 LITETOUCH INSULIN SYRINGE ...................42 LITETOUCH LANCETS ...................................42 LITETOUCH PEN NEEDLES ..........................42 lithium ................................................................24




lithium carbonate ............................................. 24 lithium carbonate er ......................................... 24 live better adv lancing device .......................... 42 live better lancet super thin ............................. 42 live better lancet ultra thin ............................... 42 l-methylfolate .................................................... 61 longs insulin syringe ........................................ 42 longs lancets standard .................................... 42 longs lancets thin ............................................. 42 longs lancets ultra thin ..................................... 42 loperamide hcl .................................................. 20 LOTRIMIN AF DEODORANT POWDER ....... 22 LOTRIMIN AF JOCK ITCH POWDER ........... 22 LOTRIMIN ULTRA ........................................... 22 LUDENT ........................................................... 29 LYSODREN ..................................................... 25 M mag-al plus ....................................................... 18 MAGELLAN INSULIN SAFETY SYR ............. 42 magnesium ....................................................... 63 magnesium citrate ........................................... 30 magnesium oxide.......................................18, 63 MAGNESIUM-OXIDE ...................................... 63 MAGOX 400 ..................................................... 63 mapap ............................................................... 16 MAPAP CHILDRENS ...................................... 16 MARATHON MEDICAL PENTIPS.................. 42 MARNATAL-F .................................................. 57 MATULANE ...................................................... 25 MAXICOMFORT II PEN NEEDLE .................. 42 MAXI-COMFORT INSULIN SYRINGE........... 42 MAXI-COMFORT SAFETY PEN NEEDLE .... 42 MAXICOMFORT SYR 27G X 1/2 ................... 42 medic insulin syringe ....................................... 42 medichoice safety lancet ................................. 42 medichoice safety lancet extra ....................... 42 medichoice safety lancet norm ....................... 42 medicine shoppe pen needles ........................ 42 MEDISENSE THIN LANCETS ........................ 42 MEDLANCE EXTRA 21G ............................... 42 MEDLANCE LITE 25G .................................... 42 MEDLANCE PLUS EXTRA 21G .................... 42 MEDLANCE PLUS LANCETS ........................ 42 MEDLANCE PLUS LITE 25G ......................... 42 MEDLANCE PLUS SPECIAL 0.8MM ............. 42 MEDLANCE PLUS SUPERLITE 30G ............ 42

MEDLANCE PLUS UNIVERSAL 21G ............42 MEDLANCE UNIVERSAL 21G .......................42 megestrol acetate................................ 25, 26, 62 MEIJER LANCETS ..........................................43 MEIJER LANCETS THIN ................................43 MEIJER LANCETS UNIVERSAL 21G............43 MEIJER LANCETS UNIVERSAL 30G............43 MEIJER LANCETS UNIVERSAL 33G............43 MEIJER SUPER THIN LANCETS ..................43 melatonin ..........................................................61 melatonin/vitamin b-6 ex st ..............................61 melatonin-pyridoxine ........................................61 melphalan .........................................................26 MENACTRA .....................................................67 MENQUADFI ....................................................67 MENVEO ..........................................................67 MEPHYTON .....................................................69 MEPRON ..........................................................26 mercaptopurine ................................................26 methazolamide .................................................21 methimazole .....................................................65 methylergonovine maleate ..............................61 methylprednisolone acetate ............................15 methylprednisolone sodium succ ....................15 metolazone .......................................................53 METOPIC .........................................................56 metronidazole ...................................................22 mexiletine hcl ....................................................28 miconazole antifungal ......................................22 MICRODOT PEN NEEDLE .............................43 MICROLET LANCETS.....................................43 MICROLET NEXT LANCING DEVICE ...........43 midodrine hcl ....................................................65 milk of magnesia ..............................................30 milk of magnesia concentrate .........................30 mini lancing device ...........................................43 minoxidil ............................................................55 misoprostol .......................................................27 mm insulin syringe/needle ...............................43 MM LANCING DEVICE ...................................43 MM PEN NEEDLES .........................................43 MM TWIST LANCETS .....................................43 M-M-R II ............................................................67 MONISTAT SOOTHING CARE ITCH ............23 MONOJECT INSULIN SYRINGE ...................43 MONOJECT ULTRA COMFORT SYRINGE ..43




MONOLET LANCETS ..................................... 43 MONOLET OPD LANCETS ............................ 43 MONOLETTOR SAFETY LANCETS ............. 43 m-pap................................................................ 16 mpd safety lancet 21g ..................................... 43 mpd safety lancet 23g ..................................... 43 mpd safety lancet 28g ..................................... 43 ms insulin syringe ............................................ 43 MUCINEX SINUS-MAX CLEAR & COOL ...... 68 MUCINEX SINUS-MAX FULL FORCE .......... 68 multi-lancet device ........................................... 43 MULTI-LANCET DEVICE 2 ............................ 43 multi-vit/iron/fluoride ........................................ 57 multivitamin + fluoride...................................... 57 multivitamin select/fluoride .............................. 57 multivitamin/fluoride ......................................... 58 multivitamin/fluoride/iron ................................. 58 multi-vitamin/fluoride/iron ................................ 58 MVC-FLUORIDE ............................................. 58 MY WAY ........................................................... 31 MYGLUCOHEALTH LANCETS 30G.............. 43 MYLERAN ........................................................ 26 MYNATAL ........................................................ 58 MYNATAL ADVANCE ..................................... 58 mynatal plus ..................................................... 58 mynatal-z .......................................................... 58 mynate 90 plus................................................. 58 mynephrocaps ................................................. 58 MYNEPHRON .................................................. 58 N NARAMIN ......................................................... 55 nasal decongestant spray ............................... 68 nasal four .......................................................... 68 nasal moisturizing spray .................................. 54 nasal relief ........................................................ 68 nasal spray ....................................................... 68 nasal spray 12 hour ......................................... 68 nasal spray extra moisturizing ........................ 68 nasal spray no drip .......................................... 68 nasal spray sinus ............................................. 68 NATACHEW..................................................... 58 NATELLE ONE ................................................ 58 NEBUSAL......................................................... 57 NEEVO DHA .................................................... 58 NEOSPORIN + PAIN/ITCH/SCAR ................. 22 NESTABS ABC ................................................ 58

NEXA PLUS .....................................................58 NEXT CHOICE ONE DOSE ............................31 NILANDRON ....................................................26 nilutamide .........................................................26 NITYR ...............................................................61 no drip nasal spray ...........................................68 NOBLE FORMULA HC ....................................23 non-aspirin extra strength ................................16 NOVA SAFETY LANCETS 23G .....................43 NOVA SAFETY LANCETS 28G .....................43 NOVA SUREFLEX LANCETS ........................43 NOVA SUREFLEX LANCING DEVICE ..........43 novavax covid-19 vaccine ...............................67 NOVOFINE AUTOCOVER PEN NEEDLE .....43 NOVOFINE PEN NEEDLE ..............................43 NOVOFINE PLUS PEN NEEDLE ...................44 NOVOTWIST PEN NEEDLE ...........................44 nystatin..............................................................21 O OBSTETRIX DHA ............................................58 OBSTETRIX EC ...............................................58 OBSTETRIX ONE ............................................58 OBTREX DHA ..................................................58 octreotide acetate...................................... 61, 65 OFF DEEP WOODS DRY ...............................65 omega 3 ............................................................61 omega iii epa+dha............................................61 omega-3 ............................................................61 omega-3 fish oil ................................................61 OMNIPOD 5 PACK ..........................................44 OMNIPOD DASH 5 PACK PODS ...................44 ON CALL LANCETS ........................................44 ON CALL LANCING DEVICE .........................44 ON CALL PLUS LANCETS .............................44 ON CALL PLUS LANCING DEVICE ..............44 ondansetron hcl ................................................21 ONETOUCH CLUB LANCETS FINE PT ........44 ONETOUCH DELICA LANCETS 30G............44 ONETOUCH DELICA LANCETS 33G............44 ONETOUCH DELICA LANCETS FINE ..........44 ONETOUCH DELICA LANCING DEV............44 ONETOUCH DELICA PLUS LANCET30G ....44 ONETOUCH DELICA PLUS LANCET33G ....44 ONETOUCH DELICA PLUS LANCING .........44 ONETOUCH DELICA SAFETY LANCING .....44 ONETOUCH FINEPOINT LANCETS .............44




ONETOUCH SURESOFT LANCING DEV .... 44 ONETOUCH ULTRA CONTROL .................... 44 ONETOUCH ULTRASOFT LANCETS........... 44 ONETOUCH VERIO ........................................ 44 OPCICON ONE-STEP .................................... 31 OPTICHAMBER DIAMOND ............................ 44 OPTICHAMBER DIAMOND-LG MASK.......... 44 OPTICHAMBER DIAMOND-MD MASK ......... 44 OPTICHAMBER DIAMOND-SM MASK ......... 45 OPTION 2......................................................... 31 oral relief ........................................................... 57 ORALONE ........................................................ 23 ORKAMBI ......................................................... 31 oyster shell calcium 500+d.............................. 63 P PACERONE ..................................................... 28 pain & fever childrens ...................................... 16 pain & fever extra strength .............................. 16 pain reliever extra strength ............................. 16 PALYNZIQ........................................................ 54 pc lancets super thin 30g ................................ 45 pc pediatric iron drops ..................................... 19 pc unifine pentips ............................................. 45 PEDIA-LAX ...................................................... 30 pediatric medium mask ................................... 45 pediatric small mask ........................................ 45 peg 3350/electrolytes ...................................... 30 peg 3350-kcl-na bicarb-nacl............................ 30 peg-3350/electrolytes ...................................... 30 pen needles ...................................................... 45 pen needles 1/2 ............................................... 45 pen needles 3/16 ............................................. 45 pen needles 5/16 ............................................. 45 PENTIPS .......................................................... 45 pentoxifylline er ................................................ 55 peptic relief ....................................................... 20 PERFECT LANCETS 28G .............................. 45 PERFECT LANCETS 30G .............................. 45 pfizer covid-19 vac-tris 5-11y .......................... 67 pfizer-biont covid-19 vac-tris ........................... 67 pharbedryl ........................................................ 55 PHARMACIST CHOICE LANCETS ............... 45 PHARMACY COUNTER LANCETS............... 45 phenaseptic ...................................................... 57 phenazopyridine hcl......................................... 26 phenylephrine hcl............................................. 68

PHOSPHA 250 NEUTRAL ..............................63 phytonadione ....................................................69 pilocarpine hcl ..................................................61 pip lancets 28g .................................................45 pip lancets 30g .................................................45 PNEUMOVAX 23 .............................................67 pnv ob+dha .......................................................58 podofilox ...........................................................65 polyethylene glycol 3350 .................................30 POLY-IRON 150 ..............................................19 POLY-VI-FLOR ................................................58 POLY-VI-FLOR/IRON ......................................58 POLY-VI-SOL/IRON ........................................58 potassium chloride .................................... 63, 64 potassium chloride crys er ...............................64 potassium chloride er .......................................64 potassium citrate er..........................................15 PR NATAL 400 .................................................58 PR NATAL 400 EC ..........................................58 PR NATAL 430 .................................................59 PR NATAL 430 EC ..........................................59 pramoxine hcl (perianal) ..................................26 praziquantel ......................................................18 PRECISION SUREDOSE PLUS SYR ............45 PRECISION SURE-DOSE SYRINGE ............45 PRECISION THINS GP LANCETS ................45 prednisolone acetate p-f ..................................23 preferred plus insulin syringe ..........................45 preferred plus lancets colored .........................45 preferred plus lancets thin ...............................45 preferred plus unifine pentips ..........................45 prena 1 true ......................................................59 prena1 ...............................................................59 prenatabs fa......................................................59 PRENATABS RX .............................................59 prenatal 19 ........................................................59 prenatal low iron ...............................................59 prenatal multi +dha ..........................................59 prenatal plus iron..............................................59 PRENATAL-U ...................................................59 PREPARATION H ............................................24 pressure activat safety lancet ..........................45 pretomanid ........................................................25 PREVENT DROPSAFE PEN NEEDLES .......45 PREVENT SAFETY PEN NEEDLES .............45 PREVNAR 13 ...................................................67




PREVNAR 20 ................................................... 67 PRIZOTRAL-II .................................................. 26 PRO COMFORT INSULIN SYRINGE ............ 45 pro comfort lancets 30g ................................... 45 pro comfort lancets 31g ................................... 45 pro comfort pen needles ................................. 45 prochlorperazine edisylate .............................. 62 PROCTOFOAM HC ......................................... 26 PROCTO-MED HC .......................................... 24 PROCTO-PAK ................................................. 24 PROCTOSOL HC ............................................ 24 PROCTOZONE-HC ......................................... 24 PRODIGY INSULIN SYRINGE ....................... 46 PRODIGY LANCETS 28G .............................. 46 PRODIGY LANCING DEVICE ........................ 46 PRODIGY SAFETY LANCETS 26G .............. 46 PRODIGY TWIST TOP LANCETS 28G......... 46 promethazine-codeine ..................................... 27 propafenone hcl ............................................... 28 propantheline bromide ..................................... 19 propylthiouracil ................................................. 65 PROQUAD ....................................................... 67 PSS SELECT GP LANCETS .......................... 46 PSS SELECT SAFETY LANCETS ................. 46 PULMOZYME .................................................. 57 pure comfort pen needle ................................. 46 purefe plus........................................................ 19 push button safety lancets .............................. 46 push button safety lancets 28g ....................... 46 px lancets microthin 33g ................................. 46 pyrazinamide .................................................... 25 pyridostigmine bromide ................................... 61 Q QBREXZA ........................................................ 65 QUFLORA FE .................................................. 59 QUFLORA FE PEDIATRIC ............................. 59 QUFLORA PEDIATRIC ................................... 59 quinidine sulfate ............................................... 28 R READYLANCE SAFETY LANCETS .............. 46 READYSHARP DEXAMETHASONE ............. 15 reality insulin syringe ....................................... 46 reality lancets ................................................... 46 reality trigger lancets ....................................... 46 RECOMBIVAX HB ........................................... 67

REFRESH PLUS..............................................54 RELION INSULIN SYRINGE ..........................46 RELI-ON INSULIN SYRINGE .........................46 RELION LANCET DEVICES 30G ...................46 RELION LANCETS MICRO-THIN 33G ..........46 RELION LANCETS STANDARD 21G ............46 RELION LANCETS THIN 26G ........................46 RELION LANCETS ULTRA-THIN 30G ..........46 RELION LANCING DEVICE............................46 RELION MINI PEN NEEDLES ........................46 RELION PEN NEEDLES .................................47 RELION SHORT PEN NEEDLES ...................47 RELION ULTRA THIN LANCETS 30G...........47 RELION ULTRA THIN PLUS LANCETS ........47 relnate dha ........................................................59 RENAL ..............................................................59 reno caps ..........................................................59 REPEL SPORTSMEN MAX ............................65 RESTASIS MULTIDOSE .................................24 REXALL LANCETS ULTRA THIN 30G ..........47 RIDAURA..........................................................55 rifabutin .............................................................25 rifampin .............................................................25 RIGHTEST GD500 LANCING DEVICE .........47 RIGHTEST GL300 LANCETS.........................47 riluzole...............................................................31 R-NATAL OB ....................................................59 rulox ..................................................................18 S SAFESNAP INSULIN SYRINGE ....................47 SAFE-T-LANCE ...............................................47 safety insulin syringes......................................47 safety lancet 21g/pressure act ........................47 safety lancet 23g/pressure act ........................47 safety lancet 28g/pressure act ........................47 safety lancet 30g/pressure act ........................47 SAFETY LANCETS .........................................47 SAFETY LANCETS 21G .................................47 safety lancets 28g ............................................47 SAFETY LET LANCETS .................................47 SAFETY SEAL LANCETS ...............................47 salicylic acid......................................................56 salicylic acid-cleanser ......................................56 saline mist spray ..............................................54 saline nasal spray ............................................54 salsalate ............................................................17




sapropterin dihydrochloride ............................. 61 saps health twist top lancets ........................... 47 saps twist top lancets ...................................... 47 sapscare twist top lancets ............................... 47 scalp relief maximum strength ........................ 24 SECURESAFE INSULIN SYRINGE............... 47 select-lite device/lancets ................................. 47 select-lite lancing device ................................. 47 selenium sulfide ............................................... 22 senexon-s ......................................................... 30 SENEXON-S .................................................... 31 senna ................................................................ 31 senna plus ........................................................ 31 senna s ............................................................. 31 senna-docusate sodium .................................. 31 senna-plus ........................................................ 31 senna-s ............................................................. 31 senna-time s..................................................... 31 sennosides-docusate sodium ......................... 31 sf 29 sf 5000 plus ...................................................... 29 SHINGRIX ........................................................ 67 SHOPKO AUTOLET LANCING DEVICE ....... 47 SHOPKO ON-THE-GO LANCETS 30G ......... 47 SHOPKO UNIFINE PENTIPS ......................... 47 SHOPKO UNIFINE PENTIPS PLUS .............. 47 SHOPKO UNILET LANCETS 28G ................. 47 SHOPKO UNILET LANCETS 30G ................. 47 side button safety lancet ................................. 47 silace................................................................. 31 silver sulfadiazine ............................................ 22 simethicone ...................................................... 21 SIMPLE DIAGNOSTICS LANCING DEV ....... 47 sinus nasal spray ............................................. 68 sinus relief ........................................................ 68 sinus relief extra strength ................................ 68 SIVEXTRO ....................................................... 19 sleep tabs ......................................................... 28 SMART DIABETES VANTAGE LANCING .... 48 SMART SENSE COLOR LANCETS 33G ...... 48 SMART SENSE STANDARD LANCETS ....... 48 SMART SENSE SUPER THIN LANCETS ..... 48 SMART SENSE THIN LANCETS 26G........... 48 SMARTEST LANCETS 28G ........................... 48 sod citrate-citric acid ........................................ 15 sodium bicarbonate ......................................... 18

sodium chloride ................................................57 sodium chloride (hypertonic) ...........................54 sodium fluoride .................................................29 sodium fluoride 5000 plus ...............................29 sodium fluoride 5000 ppm ...............................29 sodium fluoride 5000 sensitive ........................32 sodium polystyrene sulfonate ..........................56 SOLUBLE FIBER THERAPY ..........................31 SOLU-CORTEF ...............................................15 SOLU-MEDROL ...............................................15 SOLUS V2 LANCETS 28G .............................48 SOLUS V2 LANCING DEVICE .......................48 SOLUS V2 TWIST LANCETS 30G.................48 SOOTHE...........................................................20 sore throat ........................................................57 sore throat spray ..............................................57 spironolactone ..................................................62 spironolactone-hctz ..........................................62 SPS ...................................................................56 SSD ...................................................................22 STERILANCE PA .............................................48 STERILANCE TL .............................................48 sterile water for irrigation .................................56 stimulant laxative..............................................31 stomach relief ...................................................20 stool softener plus laxative ..............................31 stool softener/laxative ......................................31 stop lice complete treatment ...........................23 STRENSIQ .......................................................54 sucralfate ..........................................................28 SULFACLEANSE 8/4 ......................................56 sulfamethoxazole-trimethoprim .......................19 SULFATRIM PEDIATRIC ................................19 super calcium 600 + d 400 ..............................64 SUPER OMEGA-3 ...........................................61 super thin lancets .............................................48 sure comfort insulin syringe.............................48 sure comfort lancets 18g .................................48 sure comfort lancets 21g .................................48 sure comfort lancets 23g .................................48 sure comfort lancets 28g .................................48 sure comfort lancets 30g .................................48 sure comfort lancing pen .................................48 sure comfort pen needles ................................48 SURE-FINE PEN NEEDLES ...........................48 SURE-JECT INSULIN SYRINGE ...................48




SURE-LANCE FLAT LANCETS ..................... 48 SURE-LANCE LANCETS 26G ....................... 48 SURE-LANCE THIN LANCETS 28G ............. 48 SURE-LANCE ULTRA THIN LANCETS ........ 48 SURELITE LANCETS ..................................... 48 SURE-TOUCH LANCETS UNIVERSAL ........ 48 SYLATRON ...................................................... 26 SYMDEKO ....................................................... 32 T TDVAX .............................................................. 66 TECHLITE AST LANCETS ............................. 48 techlite insulin syringe ..................................... 48 TECHLITE LANCETS ..................................... 48 TECHLITE LANCETS 30G ............................. 48 TECHLITE PEN NEEDLES ............................ 48 TEGSEDI .......................................................... 26 TENIVAC .......................................................... 66 testosterone cypionate .................................... 17 tetanus-diphtheria toxoids td ........................... 66 theophylline ...................................................... 64 theophylline er .................................................. 64 therapeutic-m ................................................... 59 THINLETS GP LANCETS ............................... 49 TIGLUTIK ......................................................... 31 todays health lancing device ........................... 49 todays health mini pen needles ...................... 49 todays health thin lancets 28g ........................ 49 todays health thin lancets 30g ........................ 49 tolvaptan ........................................................... 53 topcare clickfine pen needles ......................... 49 topcare lancets micro-thin 33g........................ 49 topcare ultra comfort ins syr............................ 49 torsemide .......................................................... 53 total allergy ....................................................... 55 TRANSDERM SCOP (1.5 MG)....................... 21 travel lancets .................................................... 49 TRAVEL LANCETS ADVANCED 28G ........... 49 treprostinil ......................................................... 68 triamcinolone acetonide .................................. 24 triamterene-hctz ............................................... 53 TRICARE PRENATAL DHA ONE .................. 59 TRIDESILON.................................................... 24 trifluridine .......................................................... 22 TRIKAFTA ........................................................ 32 TRILYTE ........................................................... 31 trimethoprim ..................................................... 66

TRINATE ..........................................................59 triphrocaps ........................................................59 TRI-VI-FLOR ....................................................59 tri-vitamin/fluoride .............................................59 true comfort insulin syringe .............................49 true comfort pen needles .................................49 true comfort pro insulin syr ..............................49 true comfort twist top lancets ..........................49 TRUEDRAW LANCING DEVICE ....................49 TRUEPLUS 5-BEVEL PEN NEEDLES ..........49 TRUEPLUS INSULIN SYRINGE ....................49 TRUEPLUS LANCETS 26G ............................49 TRUEPLUS LANCETS 28G ............................49 TRUEPLUS LANCETS 30G ............................49 TRUEPLUS LANCETS 33G ............................49 TRUEPLUS PEN NEEDLES ...........................49 TRUEPLUS SAFETY LANCETS 28G ............49 TRUMENBA .....................................................67 TWINRIX...........................................................67 U ULTICARE INSULIN SAFETY SYR ...............49 ULTICARE INSULIN SYRINGE ......................49 ULTICARE MICRO PEN NEEDLES ...............49 ULTICARE MINI PEN NEEDLES ...................49 ULTICARE PEN NEEDLES ............................49 ULTICARE SAFETY SYRINGE ......................49 ULTICARE SHORT PEN NEEDLES ..............50 ultiguard safepack pen needle ........................50 ULTI-LANCE AUTOMATIC .............................50 ULTILET CLASSIC LANCETS ........................50 ULTILET INSULIN SYRINGE .........................50 ULTILET INSULIN SYRINGE SHORT ...........50 ULTILET LANCETS .........................................50 ULTILET PEN NEEDLE ..................................50 ULTILET SAFETY LANCETS .........................50 ULTILET SAFETY LANCETS 23G .................50 ultimatecare one ...............................................59 ultra comfort insulin syringe.............................50 ULTRA FLO INSULIN PEN NEEDLES ..........50 ULTRA FLO INSULIN SYRINGE ....................50 ultra thin lancets 31g ........................................50 ULTRA THIN PEN NEEDLES .........................50 ultracare insulin syringe ...................................50 ultra-care lancets 30g ......................................50 ultracare pen needles ......................................50 ultra-comfort insulin syringe ............................50




ULTRALANCE ................................................. 50 ULTRA-THIN II AUTO LANCET ..................... 50 ULTRA-THIN II INS SYR SHORT .................. 50 ULTRA-THIN II INSULIN SYRINGE............... 50 ULTRA-THIN II LANCETS .............................. 50 ULTRA-THIN II MINI PEN NEEDLE............... 50 ULTRA-THIN II PEN NEEDLE SHORT ......... 50 ULTRA-THIN II PEN NEEDLES ..................... 50 UNIFINE PENTIPS .......................................... 51 UNIFINE PENTIPS PLUS ............................... 51 UNIFINE SAFECONTROL PEN NEEDLE ..... 51 UNIFINE ULTRA PEN NEEDLE ..................... 51 UNILET COMFORTOUCH LANCET.............. 51 UNILET EXCELITE ......................................... 51 UNILET EXCELITE II ...................................... 51 UNILET G.P. LANCET .................................... 51 UNILET G.P. SUPERLITE LANCET .............. 51 UNILET GP 28 ULTRA THIN .......................... 51 UNILET LANCET ............................................. 51 UNILET MICRO-THIN 33G ............................. 51 UNILET SUPERLITE LANCET ....................... 51 UNILET SUPER-THIN 30G ............................ 51 UNILET ULTRA-THIN 28G ............................. 51 UNISTIK 1 ........................................................ 51 UNISTIK 2 ........................................................ 51 UNISTIK 2 COMFORT .................................... 51 UNISTIK 2 EXTRA........................................... 51 UNISTIK 2 NEONATAL ................................... 51 UNISTIK 2 NORMAL ....................................... 51 UNISTIK 2 SUPER .......................................... 51 UNISTIK 3 ........................................................ 51 UNISTIK 3 COMFORT .................................... 51 UNISTIK 3 EXTRA........................................... 51 UNISTIK 3 GENTLE ........................................ 51 UNISTIK 3 NEONATAL ................................... 51 UNISTIK 3 NORMAL ....................................... 51 UNISTIK CZT COMFORT ............................... 51 UNISTIK CZT NORMAL .................................. 51 UNISTIK NORMAL .......................................... 51 UNISTIK PRO SAFETY LANCET .................. 51 UNISTIK SAFETY LANCETS 28G ................. 51 UNISTIK SAFETY LANCETS 30G ................. 51 UNISTIK TOUCH SAFETY LANC 21G .......... 51 UNISTIK TOUCH SAFETY LANC 23G .......... 51 UNISTIK TOUCH SAFETY LANC 28G .......... 52 UNISTIK TOUCH SAFETY LANC 30G .......... 52

UNIVERSAL 1 LANCETS THIN 26G .............52 UNIVERSAL 1 LANCETS THIN 33G .............52 UNIVERSAL 1 LANCETS ULTRA THIN ........52 urea ...................................................................56 urea hydrating ..................................................56 urea nail ............................................................56 V value health insulin syringe .............................52 value plus lancet standard 21g .......................52 value plus lancets super thin ...........................52 value plus lancets thin 26g ..............................52 value plus lancing device.................................52 valumark lancet super thin 30g .......................52 valumark lancet ultra thin 28g .........................52 valumark pen needles......................................52 VANICREAM HC MAXIMUM STRENGTH ....24 VANISHPOINT INSULIN SYRINGE ...............52 VAQTA ..............................................................67 VARIVAX ..........................................................67 VAXNEUVANCE ..............................................67 vegetable lax+stool softener ...........................31 vena-bal dha .....................................................59 VICKS SINEX DAYTIME .................................65 VIDA MIA AUTOLET LANCING DEV .............52 VIDA MIA UNIFINE PENTIPS.........................52 VIDA MIA UNILET LANCETS 28G .................52 VIDA MIA UNILET LANCETS 30G .................52 VINATE CARE .................................................59 VINATE II ..........................................................59 VINATE M .........................................................59 VINATE ONE ....................................................60 virt-caps ............................................................60 vision vitamins ..................................................60 VITAMEDMD ONE RX/QUATREFOLIC ........60 VITAMEDMD REDICHEW RX ........................60 vitamin b1 .........................................................69 vitamin b12 .......................................................69 vitamin b-12 ......................................................69 vitamin b-2 ........................................................69 vitamin b-6 ........................................................69 vitamin c ............................................................69 vitamin d (ergocalciferol) .................................69 vitamin d3 .........................................................69 vitamin e ...........................................................69 vitamin e-200 ....................................................69 vitamins acd-fluoride ........................................60




VITAPEARL ..................................................... 60 VITATRUE........................................................ 60 VIVA DHA......................................................... 60 VIVAGUARD LANCETS ................................. 52 VIVAGUARD LANCING DEVICE ................... 52 VIVOTIF............................................................ 67 vol-nate ............................................................. 60 vol-tab rx ........................................................... 60 vp insulin syringe ............................................. 52 W WINRHO SDF .................................................. 27

X XENLETA .........................................................19 XERAC AC .......................................................28 XERMELO ........................................................20 xurea .................................................................56 Z zevrx insulin syringe.........................................52 zevrx twist top lancets 30g ..............................52 zinc oxide ..........................................................28 ZOKINVY ..........................................................61 ZOSTAVAX ......................................................67

2021 member formulary - geisinger health system

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