FORMULARY (LIST OF COVERED DRUGS)

Buckeye Health Plan - MyCare Ohio (MMP)

NOTE TO EXISTING MEMBERS:

This formulary has changed since last

year.Please review this document to

make sure that it still contains the

drugs you take.

PLEASE READ: THIS DOCUMENT

CONTAINS INFORMATION ABOUT THE

DRUGS WE COVERIN THIS PLAN.

For more recent information or other questions,

please contact Buckeye Health Plan Member

Services at 1-866-549-8289, TTY:711. Member

Service hours are from 8 a.m. to 8 p.m., Monday

through Friday.

After hours, on weekends and on holidays, you

may beasked to leave a message. Your call will be

returned within the next business day. Or visit:

http://mmp.BuckeyeHealthPlan.com.

BHP – MMP - 020921

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVERIN THIS PLAN.

00017408, Version 17

Buckeye Health Plan Member Services at 1-

866-549-8289, TTY:711. Member Service

hoursare from 8 a.m. to 8 p m., Monday

through Friday.

After hours, on weekends and on holidays,

you may be asked to leave a message.

Yourcall will be returned within the next

business day. Or visit:

http://mmp.BuckeyeHealthPlan.c.om

? If you have questions, please call Buckeye at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m.,

Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a

message. Your call will be returned within the next business day. TTY users call 711. The call is free. For

more information, visit http://mmp.buckeyehealthplan.com.

email OH_MMP_EmailRequests@centene.com.

H0022_LOD17_Approved_020921

Buckeye Health Plan – MyCare Ohio | 2020 List of Covered Drugs (Formulary)

This is a list of drugs that members can get in Buckeye Health Plan – MyCare Ohio (Buckeye).

• Buckeye Health Plan – MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid

to provide benefits of both programs to enrollees.

• The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We

will send you a notice before we make a change that affects you.

• Benefits may change on January 1 of each year.

• You can always check Buckeye’s up-to-date List of Covered Drugs online

at http://mmp.buckeyehealthplan.com.

• Limitations and restrictions may apply. For more information, call Buckeye Member Services or read

the Buckeye Member Handbook.

• You can get this information for free in other languages. Call 1-866-549-8289. Hours are from 8 a.m. to

8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a

message. Your call will be returned within the next business day. The call is free.

• Puede obtener esta información en otros idiomas gratis. Llame al 1-866-549-8289. El horario de atención

es de 8 a. m. a 8 p. m., de lunes a viernes. Luego del horario de atención, los fines de semana y los días

feriado, es posible que se le pida que deje un mensaje. Le devolveremos la llamada el próximo día hábil. Los

usuarios de TTY deben llamar al 711. La llamada es gratuita.

• You can get this information for free in other formats, such as large print, braille, or audio. Call 1-

866-549-8289 from 8 a.m. to 8 p.m., Monday through Friday. TTY users call 711. The call is free.

• If you would like this information in a format other than English or in an alternate format, please call 1-

866549-8289. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on

holidays, you may be asked to leave a message. Your call will be returned within the next business day.

The call is free. You can also

? If you have questions, please call Buckeye at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m.,

Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a

message. Your call will be returned within the next business day. TTY users call 711. The call is free. For

more information, visit http://mmp.buckeyehealthplan.com.

Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn

more, or look for a question and answer.

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

Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 10 are the drugs covered by Buckeye. These

drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement

with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

□ Buckeye will cover all medically necessary drugs on the Drug List if:

• your doctor or other prescriber says you need them to get better or stay healthy, and

• you fill the prescription at a Buckeye network pharmacy.

□ Buckeye may have additional steps to access certain drugs (see question #5 below).

You can also see an up-to-date list of drugs that we cover on our website at http://mmp.buckeyehealthplan.com

or call Member Services at 1-866-549-8289 (TTY: 711).

2. Does the Drug List ever change?

Yes. Buckeye may add or remove drugs on the Drug List during the year. Generally,

the Drug List will only change if:

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

• we learn that a drug is not safe.

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

• Decide to require or not require prior approval for a drug. (Prior approval is permission from Buckeye

before you can get a drug.)

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

• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before

we will cover another drug.)

(For more information on these drug rules, see page 3.)

We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we

change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens

when the Drug List changes.

? If you have questions, please call Buckeye at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m.,

Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a

message. Your call will be returned within the next business day. TTY users call 711. The call is free. For

more information, visit http://mmp.buckeyehealthplan.com.

You can always check Buckeye’s up to date Drug List online at http://mmp.buckeyehealthplan.com.

You can also call Member Services to check the current Drug List at 1-866-549-8289 (TTY: 711).

3. What happens when a cheaper drug comes along that works as well as a

drug on the Drug List now?

If you are taking a drug that is removed because a cheaper drug that works just as well comes

along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or

when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the

Drug List is made.

We will mail you a notice if you are taking a drug, and we change our rules for covering it. You will

receive the notice by mail at least 60 days before we remove the drug from our List of Covered Drugs.

Or, we have to tell you when you request a refill of the drug. If we tell you when you refill your drug, you

will receive a 60-day supply of the drug. For more information on these drug rules, see below. If you

have questions about the notice you receive from Buckeye, call Member Services at 1-866-549-8289.

TTY Users should call 711. Hours are from 8 a.m. to 8 p.m., Monday through Friday.

4. What happens when we find out a drug is not safe?

If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the

Drug List right away. We will also send you a letter telling you that. If you have any questions after being

notified of the change, you should contact the doctor who prescribed the drug for you.

5. Are there any restrictions or limits on drug coverage? Or are there

any required actions to take in order to get certain drugs?

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

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

• Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber

must get approval from Buckeye before you fill your prescription. If you don’t get approval,

Buckeye may not cover the drug.

• Quantity limits: Sometimes Buckeye limits the amount of a drug you can get.

• Step therapy: Sometimes Buckeye requires you to do step therapy. This means you will have

to try drugs in a certain order for your medical condition. You might have to try one drug before

we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will

cover the second.

If you have questions, please call Buckeye at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m.,

Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a

message. Your call will be returned within the next business day. TTY users call 711. The call is

free. For more information, visit http://mmp.buckeyehealthplan.com.

?

You can find out if your drug has any additional requirements or limits by looking in the tables on pages

8. You can also get more information by visiting our web site at http://mmp.buckeyehealthplan.com. We

have posted online documents that explain our prior authorization and step therapy restrictions. You

may also ask us to send you a copy.

You can ask for an “exception” from these limits. Please see question 11 for more information on exceptions.

□ If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List,

or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of

the drug you need (unless you have a prescription for fewer days), whether or not you are a new

Buckeye member. This will give you time to talk to your doctor or other prescriber. He or she can help

you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an

exception. Please see question 11 for more information about exceptions.

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

required actions to take to get the drug?

The List of Covered Drugs on page 10 has a column labeled “Necessary actions, restrictions, or limits on use.”

7. What happens if we change our rules on how we cover some drugs?

For example, if we add prior authorization (approval), quantity limits,

and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We

will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you

can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to

talk to your doctor or other prescriber about what to do next.

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

There are two ways to find a drug:

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

• You can search by medical condition.

To search alphabetically, go to the Alphabetical Listing section. You can find it by reviewing the

index of drugs that begins on page 147.

If you have questions, please call Buckeye at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m.,

Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a

message. Your call will be returned within the next business day. TTY users call 711. The call is

free. For more information, visit http://mmp.buckeyehealthplan.com.

?

To search by medical condition, find the section labeled “List of drugs by medical condition” on page

10. The drugs in this section are grouped into categories depending on the type of medical conditions

they are used to treat. For example, if you have a heart condition, you should look in the category,

Cardiovascular Agents. That is where you will find drugs that treat heart conditions.

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

If you don’t see your drug on the Drug List, call Member Services at 1-866-549-8289 (TTY: 711)

and ask about it. If you learn that Buckeye will not cover the drug, you can do one of these things:

• Ask Member Services for a list of drugs like the one you want to take. Then show the list to your

doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you

want to take. Or

• You can ask the health plan to make an exception to cover your drug. Please see question

11 for more information about exceptions.

10. What if you are a new Buckeye member and can’t find your drug on the Drug

List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a

member of Buckeye. This will give you time to talk to your doctor or other prescriber. He or she can help you

decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.

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

• you are taking a drug that is not on our Drug List, or

• health plan rules do not let you get the amount ordered by your prescriber, or

• the drug requires prior approval by Buckeye, or

• you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as

long as 91 to 98 days. You may refill the drug multiple times during your first 90 days in the plan.

This gives your prescriber time to change your drugs to ones on the Drug List or ask for an

exception.

Throughout the plan year, you may have a change in your treatment setting (the place where you get and

take your medicine) because of the level of care you require. Such transitions may include, but are not

limited to:

• Members who are discharged from a hospital or skilled-nursing facility to a home setting

• Members who are admitted to a hospital or skilled-nursing facility from a home setting

If you have questions, please call Buckeye at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m.,

Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a

message. Your call will be returned within the next business day. TTY users call 711. The call is

free. For more information, visit http://mmp.buckeyehealthplan.com.

?

• Members who transfer from one skilled-nursing facility to another and are served by a different pharmacy

• Members who end their skilled-nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who now need to use their Part D plan benefit

• Members who give up Hospice Status and go back to standard Medicare Part A and B coverage

• Members discharged from psychiatric hospitals with highly individualized drug regimens

For these changes in treatment settings, Buckeye will cover as much as a 31-day temporary supply of a Part D-

covered drug when you fill your prescription at a network pharmacy. If you change treatment settings multiple

times within the same month, you may have to request an exception or prior authorization and get approval for

continued coverage of your drug. We will review these requests for continuation of therapy on a case-by-case

basis when you are on a stabilized drug regimen that, if changed, is known to have risks. To ask for a temporary

supply of a drug, call Member Services.

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

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

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

• For example, Buckeye may limit the amount of a drug we will cover. If your drug has a limit, you can

ask us to change the limit and cover more.

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

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

First, we must get a statement from your prescriber supporting your request for an

exception. After we get the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask

for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a

decision within 24 hours of getting your prescriber’s supporting statement.

13. How can you ask for an exception?

To ask for an exception, call Member Services. A Member Services representative will work with you and

your provider to help you ask for an exception.

OH Buckeye MMP Opt-Out Formulary August 1, 2021 9

Drug Name Tier Drug

Restriction

PRESERVISION

AREDS-2 250 MG-

90 MG-40 MG-1 MG

CAPSULE

$0 (Tier 3)

Prosight 5,000 unit-

60 mg-30 unit tablet

$0 (Tier 3)

Vision Formula-2

250 mg-90 mg-40

mg-1 mg capsule

$0 (Tier 3)

ALTERNATIVE THERAPY - UNCLASSIFIED

AIRBORNE

(ASCORBATE

SODIUM) 250 MG-

1.25 MG

LOZENGES

$0 (Tier 3)

AIRBORNE

(ASCORBATE

SODIUM) 333 MG-

1.7 MG

CHEWABLE

TABLET

$0 (Tier 3)

AIRBORNE

(ASCORBIC ACID)

1,000 MG-350 MG

ORAL

EFFERVESCENT

POWDER PACK

$0 (Tier 3)

AIRBORNE (WITH

LYSINE ACETATE)

250 MG-12.5 MG

CHEWABLE

TABLET

$0 (Tier 3)

AIRBORNE 1,000

MG-50 MG

EFFERVESCENT

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction ALTERNATIVE THERAPY

ALTERNATIVE THERAPY - ANTIARTHRITICS

GLUCOTEN 375

MG-300 MG-25

MG-0.5 MG

TABLET

$0 (Tier 3)

ALTERNATIVE THERAPY - ANTIOXIDANT

alpha lipoic acid 100

mg capsule

$0 (Tier 3)

alpha lipoic acid 200

mg capsule

$0 (Tier 3)

alpha lipoic acid 300

mg capsule

$0 (Tier 3)

alpha lipoic acid 50

mg capsule

$0 (Tier 3)

alpha lipoic acid 600

mg capsule

$0 (Tier 3)

Macuvite With

Lutein 5,000 unit-60

mg-30 unit-2 mg

tablet

$0 (Tier 3)

OCUVITE EYE

HEALTH 50 MG-15

UNIT-4.5 MG-2.5

MG CHEWABLE

TABLET

$0 (Tier 3)

OCUVITE LUTEIN

AND

ZEAXANTHIN 60

MG-13.5 MG-15

MG-2 MG-6 MG

CAPSULE

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 10

Drug Name Tier Drug

Restriction

Co Q-10 200 mg

capsule

$0 (Tier 3)

Co Q-10 30 mg

capsule

$0 (Tier 3)

Co Q-10 300 mg

capsule

$0 (Tier 3)

coenzyme Q10 400

mg capsule

$0 (Tier 3)

coenzyme Q10 50

mg capsule

$0 (Tier 3)

coenzyme Q10 60

mg capsule

$0 (Tier 3)

coenzyme Q10 75

mg capsule

$0 (Tier 3)

coenzyme Q10 10 mg

capsule

$0 (Tier 3)

coenzyme Q10 100

mg capsule

$0 (Tier 3)

coenzyme Q10 100

mg-vitamin E 20 mg-

vitamin E mixed 15

mg capsule

$0 (Tier 3)

coenzyme Q10 150

mg capsule

$0 (Tier 3)

coenzyme Q10 200

mg capsule

$0 (Tier 3)

coenzyme Q10 30 mg

capsule

$0 (Tier 3)

coenzyme Q10-

vitamin E 100 mg-5

unit capsule

$0 (Tier 3)

Drug Name Tier Drug

Restriction

AIRBORNE

EVERYDAY

STRESS AWAY

1,000 MG-200 MG-

360 MG ORAL

POWDER PACKT

$0 (Tier 3)

Airshield 1,000 mg-

50 mg effervescent

tablet

$0 (Tier 3)

Airshield 250 mg-

1.25 mg chewable

tablet

$0 (Tier 3)

AZO HORMONAL

HEALTH CYCLE

CARE 100 MG-50

MG-50 MG-15 MG

TABLET

$0 (Tier 3)

Co Q-10 400 mg

capsule

$0 (Tier 3)

Co Q-10 50 mg

capsule

$0 (Tier 3)

Co Q-10 75 mg

capsule

$0 (Tier 3)

Co Q-10 (with Vit E)

100 mg-5 unit

capsule

$0 (Tier 3)

Co Q-10 (with Vit E)

50 mg-5 unit capsule

$0 (Tier 3)

Co Q-10 10 mg

capsule

$0 (Tier 3)

Co Q-10 100 mg

capsule

$0 (Tier 3)

Co Q-10 150 mg

capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 11

Drug Name Tier Drug

Restriction

Q-GEL 15 mg-3 unit

capsule

$0 (Tier 3)

Q-Gel Forte 30 mg-6

unit capsule

$0 (Tier 3)

Q-Gel Mega 100 mg-

150 unit capsule

$0 (Tier 3)

Q-Gel Ultra 60 mg-

150 unit capsule

$0 (Tier 3)

Q-Sorb Co Q-10 100

mg capsule

$0 (Tier 3)

Q-Sorb Co Q-10 150

mg capsule

$0 (Tier 3)

Q-Sorb Co Q-10 200

mg capsule

$0 (Tier 3)

Q-Sorb Co Q-10 Plus

100 mg-20 mg

capsule

$0 (Tier 3)

VITAMENT 0.5

MG-270 MG-200

MG-25 MG ORAL

POWDER PACKET

$0 (Tier 3)

ANALGESIC, ANTI-INFLAMMATORY OR ANTIPYRETIC

ANALGESIC OR ANTIPYRETIC NON-OPIOID

8 Hour Pain Reliever

650 mg

tablet,extended

release

$0 (Tier 3)

8HR Muscle Aches-

Pain 650 mg

tablet,extended

release

$0 (Tier 3)

ACEPHEN 120 MG

RECTAL

SUPPOSITORY

$0 (Tier 3)

Drug Name Tier Drug

Restriction

CONCEPTIONXR

MOTILITY 250 MG-

500 UNIT-200 UNIT

ORAL PACK

$0 (Tier 3)

CoQ-10 100 mg

capsule

$0 (Tier 3)

CoQ-10 30 mg

capsule

$0 (Tier 3)

CYTO-Q 80 MG/10

ML ORAL LIQUID

$0 (Tier 3)

CYTO-Q MAX 100

MG/ML ORAL

LIQUID

$0 (Tier 3)

CYTO-Q T-F 8

MG/ML ORAL

LIQUID

$0 (Tier 3)

H2Q 100 mg capsule $0 (Tier 3)

Immune Support 250

mg-12.5 mg

chewable tablet

$0 (Tier 3)

Liq-10 50 mg-15

unit/5 mL oral syrup

$0 (Tier 3)

LiQ-10 100 mg/5 mL

oral syrup

$0 (Tier 3)

MEMORY

COMPLEX 60 MG-

30 UNIT-70 MCG-

40 MG TABLET

$0 (Tier 3)

NEOQ10 125 MG

CAPSULE

$0 (Tier 3)

PHYTOMULTI 3

MG-3 MG-200 MG

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 12

Drug Name Tier Drug

Restriction

acetaminophen 500

mg capsule

$0 (Tier 3)

acetaminophen 500

mg tablet

$0 (Tier 3)

acetaminophen 500

mg/15 mL oral liquid

$0 (Tier 3)

acetaminophen 650

mg rectal suppository

$0 (Tier 3)

acetaminophen 650

mg/20.3 mL oral

solution

$0 (Tier 3)

acetaminophen 650

mg/20.3 mL oral

suspension

$0 (Tier 3)

acetaminophen 80

mg chewable tablet

$0 (Tier

3)

acetaminophen 80

mg disintegrating

tablet

$0 (Tier 3)

acetaminophen 80

mg/0.8 mL oral

drops,suspension

$0 (Tier 3)

acetaminophen ER

650 mg

tablet,extended

release

$0 (Tier 3)

Acetaminophen Extra

Strength 500 mg

tablet

$0 (Tier 3)

Acetaminophen Pain

Relief 500 mg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ACEPHEN 325 MG

RECTAL

SUPPOSITORY

$0 (Tier 3)

Acephen 650 mg

rectal suppository

$0 (Tier 3)

acetaminophen 120

mg rectal suppository

$0 (Tier 3)

acetaminophen 160

mg chewable tablet

$0 (Tier 3)

acetaminophen 160

mg disintegrating

tablet

$0 (Tier 3)

acetaminophen 160

mg/5 mL (5 mL) oral

solution

$0 (Tier 3)

acetaminophen 160

mg/5 mL (5 mL) oral

suspension

$0 (Tier 3)

acetaminophen 160

mg/5 mL oral elixir

$0 (Tier 3)

acetaminophen 160

mg/5 mL oral liquid

$0 (Tier 3)

acetaminophen 160

mg/5 mL oral

suspension

$0 (Tier 3)

acetaminophen 325

mg tablet

$0 (Tier 3)

acetaminophen 325

mg/10.15 mL oral

solution

$0 (Tier 3)

acetaminophen 325

mg/10.15 mL oral

suspension

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 13

Drug Name Tier Drug

Restriction

Children's Fever

Reducing 120 mg

rectal suppository

$0 (Tier 3)

Children's Mapap

160 mg chewable

tablet

$0 (Tier 3)

Children's Mapap 80

mg chewable tablet

$0 (Tier 3)

Children's Mapap 80

mg disintegrating

tablet

$0 (Tier 3)

CHILDREN'S NON-

ASPIRIN 160 MG/5

ML ORAL

SUSPENSION

$0 (Tier 3)

CHILDREN'S NON-

ASPIRIN 80 MG

CHEWABLE

TABLET

$0 (Tier 3)

Children's Pain and

Fever Relief 160 mg

chewable tablet

$0 (Tier 3)

Children's Pain and

Fever Relief 160 mg

disintegrating tablet

$0 (Tier 3)

Children's Pain and

Fever Relief 160

mg/5 mL oral liquid

$0 (Tier 3)

Children's Pain and

Fever Relief 160

mg/5 mL oral

suspension

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Arthritis Pain Relief

(acetaminophen) ER

650 mg tablet,extend

release

$0 (Tier 3)

ARTHRITIS PAIN

RELIEVER 650 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

Athenol 325 mg

tablet

$0 (Tier 3)

BETATEMP 160

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

Children's

Acetaminophen 160

mg chewable tablet

$0 (Tier 3)

Children's

Acetaminophen 160

mg/5 mL (5 mL) oral

suspension

$0 (Tier 3)

Children's

Acetaminophen 160

mg/5 mL oral liquid

$0 (Tier 3)

Children's

Acetaminophen 160

mg/5 mL oral

suspension

$0 (Tier 3)

CHILDREN'S

ACETAMINOPHEN

80 MG CHEWABLE

TABLET

$0 (Tier 3)

Children's Fever

Reducer-Pain

Reliever 160 mg/5

mL oral suspension

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 14

Drug Name Tier Drug

Restriction

Fever Reducer 120

mg rectal suppository

$0 (Tier 3)

FEVERALL 120 MG

RECTAL

SUPPOSITORY

$0 (Tier 3)

Feverall 325 mg

rectal suppository

$0 (Tier 3)

Feverall 650 mg

rectal suppository

$0 (Tier 3)

Feverall 80 mg rectal

suppository

$0 (Tier 3)

Infant Fever

Reducer-Pain Relief

160 mg/5 mL oral

suspension

$0 (Tier 3)

Infant Pain Reliever

160 mg/5 mL oral

suspension

$0 (Tier 3)

Infant's

Acetaminophen 160

mg/5 mL oral

suspension

$0 (Tier 3)

Infants' Pain and

Fever 160 mg/5 mL

oral suspension

$0 (Tier 3)

Infants' Pain Relief

160 mg/5 mL oral

suspension

$0 (Tier 3)

INFANT'S PAIN

RELIEF 160 MG/5

ML ORAL

SUSPENSION

$0 (Tier 3)

Infant's Pain Reliever

80 mg/0.8 mL oral

drops,suspension

$0 (Tier 3)

Drug Name Tier Drug

Restriction

CHILDREN'S PAIN

AND FEVER

RELIEF 80 MG

CHEWABLE

TABLET

$0 (Tier 3)

Children's Pain Relief

160 mg chewable

tablet

$0 (Tier 3)

Children's Pain Relief

160 mg/5 mL oral

suspension

$0 (Tier 3)

Children's Pain

Reliever 160 mg/5

mL oral suspension

$0 (Tier 3)

Children's Pain

Reliever 80 mg

disintegrating tablet

$0 (Tier 3)

Children's Pain

Reliever and Fever

Reducer 120 mg

rectal suppository

$0 (Tier 3)

Children's Q-PAP

160 mg/5 mL oral

suspension

$0 (Tier 3)

CHILDREN'S

SILAPAP 160 MG/5

ML ORAL LIQUID

$0 (Tier 3)

Children's Tactinal

80 mg chewable

tablet

$0 (Tier 3)

CHILDREN'S

TYLENOL 160

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

Ed-APAP 160 mg/5

mL oral liquid

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 15

Drug Name Tier Drug

Restriction

Mapap

(acetaminophen) 500

mg/15 mL oral liquid

$0 (Tier 3)

Mapap Arthritis Pain

650 mg

tablet,extended

release

$0 (Tier 3)

MAPAP EXTRA

STRENGTH 500

MG TABLET

$0 (Tier 3)

M-PAP 160 mg/5 mL

oral liquid

$0 (Tier 3)

NON-ASPIRIN 160

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

NON-ASPIRIN 325

MG TABLET

$0 (Tier 3)

NON-ASPIRIN 80

MG CHEWABLE

TABLET

$0 (Tier 3)

NON-ASPIRIN

CHILDREN'S 80

MG CHEWABLE

TABLET

$0 (Tier 3)

NON-ASPIRIN

EXTRA STRENGTH

500 MG TABLET

$0 (Tier 3)

NON-ASPIRIN

PAIN RELIEF 500

MG TABLET

$0 (Tier 3)

Nortemp 160 mg/5

mL oral suspension

$0 (Tier 3)

Nortemp 80 mg/0.8

mL oral drops

$0 (Tier 3)

Drug Name Tier Drug

Restriction

INFANT'S

TYLENOL 160

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

Jr. Acetaminophen

160 mg disintegrating

tablet

$0 (Tier 3)

Jr. Str Non-Aspirin

Pain 160 mg

disintegrating tablet

$0 (Tier 3)

JR. STRENGTH

PAIN RELIEVER

160 MG

DISINTEGRATING

TABLET

$0 (Tier 3)

Junior Mapap 160 mg

disintegrating tablet

$0 (Tier 3)

Little Remedies

Fever and Pain

Reliever 160 mg/5

mL oral liquid

$0 (Tier 3)

Mapap

(acetaminophen) 160

mg/5 mL oral liquid

$0 (Tier 3)

Mapap

(acetaminophen) 160

mg/5 mL oral

suspension

$0 (Tier 3)

MAPAP

(ACETAMINOPHE

N) 325 MG TABLET

$0 (Tier 3)

MAPAP

(ACETAMINOPHE

N) 500 MG

CAPSULE

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 16

Drug Name Tier Drug

Restriction

Pain Reliever Extra

Strength 500 mg

tablet

$0 (Tier 3)

PEDIACARE

FEVER REDUCER

160 MG/5 ML

ORAL

SUSPENSION

$0 (Tier 3)

Pharbetol 325 mg

tablet

$0 (Tier 3)

Pharbetol 500 mg

tablet

$0 (Tier 3)

Q-PAP 325 mg tablet $0 (Tier 3)

Q-PAP 500 mg tablet $0 (Tier 3)

Q-PAP Extra

Strength 500 mg

tablet

$0 (Tier 3)

Shake That Ache 500

mg tablet

$0 (Tier 3)

Silapap 160 mg/5 mL

oral liquid

$0 (Tier 3)

TACTINAL 325 MG

TABLET

$0 (Tier 3)

TACTINAL EXTRA

STRENGTH 500

MG TABLET

$0 (Tier 3)

TYLENOL 325 MG

TABLET

$0 (Tier 3)

TYLENOL EXTRA

STRENGTH 500

MG TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Pain and Fever 325

mg tablet

$0 (Tier 3)

Pain and Fever 500

mg tablet

$0 (Tier 3)

Pain Relief

(acetaminophen) 160

mg/5 mL oral liquid

$0 (Tier 3)

Pain Relief

(acetaminophen) 500

mg tablet

$0 (Tier 3)

Pain Relief

(acetaminophen) 650

mg tablet,extended

release

$0 (Tier 3)

Pain Relief 8HR 650

mg tablet,extended

release

$0 (Tier 3)

Pain Relief Adult 500

mg/15 mL oral liquid

$0 (Tier 3)

PAIN RELIEF

EXTRA STRENGTH

500 MG TABLET

$0 (Tier 3)

Pain Relief Regular

Strength 325 mg

tablet

$0 (Tier 3)

Pain Reliever

(acetaminophen) 325

mg tablet

$0 (Tier 3)

Pain Reliever

(acetaminophen) 500

mg capsule

$0 (Tier 3)

Pain Reliever

(acetaminophen) 500

mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 17

Drug Name Tier Drug

Restriction

ADVIL 100 MG

TABLET

$0 (Tier 3)

ADVIL LIQUI-GEL

200 MG CAPSULE

$0 (Tier 3)

ADVIL MIGRAINE

200 MG CAPSULE

$0 (Tier 3)

ALEVE 220 MG

CAPSULE

$0 (Tier 3)

ALEVE 220 MG

TABLET

$0 (Tier 3)

All Day Pain Relief

220 mg tablet

$0 (Tier 3)

All Day Relief 220

mg tablet

$0 (Tier 3)

Children's Ibuprofen

100 mg/5 mL oral

suspension

$0 (Tier 3)

Children's Profen IB

100 mg/5 mL oral

suspension

$0 (Tier 3)

Flanax (naproxen)

220 mg tablet

$0 (Tier 3)

IBU-200 200 mg

tablet

$0 (Tier 3)

Ibu-Drops 50

mg/1.25 mL oral

drops,suspension

$0 (Tier 3)

ibuprofen 100 mg

chewable tablet

$0 (Tier 3)

ibuprofen 100 mg

tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction ANALGESIC OR ANTIPYRETIC NON- OPIOID/SEDATIVE COMBINATIONS

HISTAFLEX 325

MG-25 MG

TABLET

$0 (Tier 3)

ANALGESIC,NON-SALICYLATE AND 1ST GENERATION ANTIHISTAMINE COMBINATIONS

ACETA-GESIC 12.5

MG-325 MG

TABLET

$0 (Tier 3)

Acetaminophen PM

25 mg-500 mg tablet

$0 (Tier 3)

diphenhydramine 25

mg-acetaminophen

500 mg tablet

$0 (Tier 3)

Non-Aspirin

Nightime 25 mg-500

mg tablet

$0 (Tier 3)

Pain Relief PM 25

mg-500 mg tablet

$0 (Tier 3)

Pain Reliever PM Ex-

Strength 25 mg-500

mg tablet

$0 (Tier 3)

Percogesic 12.5 mg-

325 mg tablet

$0 (Tier 3)

STAFLEX

(BROMPHENIRAM

INE-

ACETAMINOPHEN

) 2 MG-250 MG

TABLET

$0 (Tier 3)

NSAID ANALGESICS (COX NON-SPECIFIC) - PROPIONIC ACID DERIVATIVES

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 18

Drug Name Tier Drug

Restriction

I-PRIN 200 MG

TABLET

$0 (Tier 3)

Mediproxen 220 mg

tablet

$0 (Tier 3)

Motrin IB 200 mg

capsule

$0 (Tier 3)

MOTRIN IB 200 MG

TABLET

$0 (Tier 3)

naproxen sodium 220

mg capsule

$0 (Tier 3)

naproxen sodium 220

mg tablet

$0 (Tier 3)

PROVIL 200 MG

TABLET

$0 (Tier 3)

Wal-Profen 200 mg

capsule

$0 (Tier 3)

WAL-PROFEN 200

MG TABLET

$0 (Tier 3)

WAL-PROXEN 220

MG TABLET

$0 (Tier 3)

SALICYLATE ANALGESIC COMBINATIONS

Headache Relief

(ASA-acetaminophn-

caffeine) 250 mg-250

mg-65 mg tablet

$0 (Tier 3)

Migraine Formula

250 mg-250 mg-65

mg tablet

$0 (Tier 3)

Migraine Relief 250

mg-250 mg-65 mg

tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ibuprofen 100 mg/5

mL oral suspension

$0 (Tier 3)

ibuprofen 200 mg

capsule

$0 (Tier 3)

ibuprofen 200 mg

tablet

$0 (Tier 3)

ibuprofen 50 mg/1.25

mL oral

drops,suspension

$0 (Tier 3)

Ibuprofen IB 100 mg

chewable tablet

$0 (Tier

3)

Ibuprofen IB 200 mg

tablet

$0 (Tier 3)

Ibuprofen Jr Strength

100 mg chewable

tablet

$0 (Tier 3)

INFANT'S ADVIL

50 MG/1.25 ML

ORAL

DROPS,SUSPENSIO

N

$0 (Tier 3)

Infants Ibu-Drops 50

mg/1.25 mL oral

drops,suspension

$0 (Tier 3)

Infant's Ibuprofen 50

mg/1.25 mL oral

drops,suspension

$0 (Tier 3)

INFANT'S MOTRIN

50 MG/1.25 ML

ORAL

DROPS,SUSPENSIO

N

$0 (Tier 3)

Infants ProfenIB 50

mg/1.25 mL oral

drops,suspension

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 19

Drug Name Tier Drug

Restriction

Hemorrhoidal(phenyl

eph-min oil-

petrolat)0.25 %-14

%-74.9 % rectal oint

$0 (Tier 3)

Major-Prep

Hemorrhoidal 0.25

%-14 %-74.9 %

ointment

$0 (Tier 3)

PREPARATION H

0.25 %-14 %-74.9 %

OINTMENT

$0 (Tier 3)

PREPARATION

H(PHENYLEPH,CO

COA BUTTR) 0.25

%-88.44 % RECTAL

SUPPOSITORY

$0 (Tier 3)

ANORECTAL - HEMORRHOIDAL SINGLE AGENTS OTHER

HEMORRHOIDAL

SUPPOSITORY 0.25

% RECTAL

$0 (Tier 3)

ANTIDOTES AND OTHER REVERSAL AGENTS

ANTIDOTE OTHERS

GALZIN 25 MG

(ZINC) CAPSULE

$0 (Tier 3)

GALZIN 50 MG

(ZINC) CAPSULE

$0 (Tier 3)

WILZIN 25 MG

(ZINC) CAPSULE

$0 (Tier 3)

ANTI-INFECTIVE AGENTS

ANTHELMINTIC AGENTS OTHER

Pinworm Treatment

50 mg/mL oral

suspension

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Pain Relief

(acetaminophen-

aspirin-caff) 250 mg-

250 mg-65 mg tablet

$0 (Tier 3)

Pain Reliever Plus

250 mg-250 mg-65

mg tablet

$0 (Tier 3)

SALICYLATE ANALGESICS

aspirin 300 mg rectal

suppository

$0 (Tier 3)

aspirin 325 mg tablet $0 (Tier 3)

aspirin 325 mg

tablet,delayed release

$0 (Tier 3)

aspirin 600 mg rectal

suppository

$0 (Tier 3)

BAYER ASPIRIN

325 MG TABLET

$0 (Tier 3)

E.C. Prin 325 mg

tablet,delayed release

$0 (Tier 3)

Ecotrin 325 mg

tablet,enteric coated

$0 (Tier 3)

Lite Coat Aspirin 325

mg tablet

$0 (Tier 3)

ANORECTAL PREPARATIONS

ANORECTAL - HEMORRHOIDAL COMBINATIONS OTHER

Hemorrhoidal

(phenyleph-cocoa)

0.25 %-88.44 %

rectal suppository

$0 (Tier 3)

Hemorrhoidal

ointment

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 20

Drug Name Tier Drug

Restriction

SUPER TWIN EPA-

DHA 1,250 MG

CAPSULE

$0 (Tier 3)

ANTIHYPERLIPIDEMIC AGENTS - DIETARY SOURCE COMBINATIONS

$0 (Tier 3)

COROMEGA 2,000

MG-650 MG-12

MG/2.5 GRAM

ORAL PACKET

$0 (Tier 3)

COROMEGA 284

MG-850 MG/2.5

GRAM ORAL

PACKET

$0 (Tier 3)

Fish Oil 1,000 mg

(120 mg-180 mg)

capsule

$0 (Tier 3)

Fish Oil 1,200 mg

(144 mg-216 mg)

capsule

$0 (Tier 3)

Fish Oil 1,600 mg-

500 mg-800 mg/5 mL

oral liquid

$0 (Tier 3)

Fish Oil 100 mg-160

mg-1,000 mg capsule

$0 (Tier 3)

Fish Oil 120 mg-180

mg-500 mg capsule

$0 (Tier 3)

Fish Oil 120 mg-180

mg-60 mg-1,200 mg

capsule,delayed

release

$0 (Tier 3)

Fish Oil 150 mg-217

mg-840 mg

capsule,delayed

release

$0 (Tier 3)

Drug Name Tier Drug

Restriction

REESE'S

PINWORM

MEDICINE 50

MG/ML ORAL

SUSPENSION

$0 (Tier 3)

ANTISEPTICS AND DISINFECTANTS

ANTISEPTIC - PHENOL DERIVATIVES

CASTELLANI

PAINT 1.5 %

TOPICAL LIQUID

$0 (Tier 3)

Castellani Paint

Modified 1.5 %

topical liquid

$0 (Tier 3)

ANTISEPTIC - QUATERNARY AMMONIUM

New Skin

(benzethonium) 0.2

% topical film-

forming liquid

$0 (Tier 3)

CARDIOVASCULAR THERAPY AGENTS

ANTIHYPERLIPIDEMIC - NICOTINIC ACID DERIVATIVES

niacin 500 mg tablet $0 (Tier 3)

ANTIHYPERLIPIDEMIC AGENTS - DIETARY SOURCE

Fish Oil 120 mg-180

mg capsule

$0 (Tier 3)

Fish Oil Concentrate

1,000 mg capsule

$0 (Tier 3)

omega-3 fatty acids

1,000 mg capsule

$0 (Tier 3)

omega-3 fatty acids

100 mg chewable

tablet

$0 (Tier 3)

Super Omega-3 1,000

mg capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 21

Drug Name Tier Drug

Restriction

Fish Oil 900 mg-

1,400 mg

capsule,delayed

release

$0 (Tier 3)

Fish Oil 900 mg-360

mg-455 mg-1,000 mg

capsule

$0 (Tier 3)

Fish Oil Extra

Strength 435 mg-880

mg capsule

$0 (Tier 3)

Fish Oil Pearls 150

mg-400 mg capsule

$0 (Tier 3)

Fish Oil Pearls 180

mg-400 mg capsule

$0 (Tier 3)

Fish Oil Pearls 300

mg-400 mg capsule

$0 (Tier 3)

fish oil-dha-epa 1,200

mg-144 mg-216 mg

capsule

$0 (Tier 3)

omega 3 600 mg-dha

216 mg-epa 324 mg-

fish oil 1,200 mg

capsule,del rel

$0 (Tier 3)

omega 3-dha-epa-fish

oil 1,000 mg (120

mg-180 mg) capsule

$0 (Tier 3)

omega 3-dha-epa-fish

oil 1,200 mg (144

mg-216 mg) capsule

$0 (Tier 3)

omega 3-dha-epa-fish

oil 100 mg-150 mg-

750 mg capsule

$0 (Tier 3)

omega 3-dha-epa-fish

oil 250 mg-500 mg-

1,000 mg capsule

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Fish Oil 183.3 mg-75

mg-91.6 mg-306 mg

capsule

$0 (Tier 3)

Fish Oil 300 mg-

1,000 mg capsule

$0 (Tier 3)

Fish Oil 300 mg-

1,000 mg

capsule,delayed

release

$0 (Tier 3)

Fish Oil 300 mg-108

mg-162 mg-600 mg

capsule,delayed

release

$0 (Tier 3)

Fish Oil 300 mg-500

mg capsule

$0 (Tier 3)

Fish Oil 340 mg-

1,000 mg capsule

$0 (Tier 3)

Fish Oil 360 mg-

1,200 mg capsule

$0 (Tier 3)

Fish Oil 360 mg-

1,200 mg

capsule,delayed

release

$0 (Tier 3)

Fish Oil 360 mg-144

mg-216 mg-1,200 mg

capsule,delayed

release

$0 (Tier 3)

Fish Oil 60 mg-90

mg-500 mg capsule

$0 (Tier 3)

Fish Oil 60 mg-90

mg-500 mg

capsule,delayed

release

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 22

Drug Name Tier Drug

Restriction

omega-3 28.5 mg-dha

23.75 mg-epa 4.75

mg-fish oil 113.5 mg

chew tablet

$0 (Tier 3)

omega3 300 mg-

dha,epa 250 mg-other

omega 3s-fish oil

1,000 mg capsule

$0 (Tier 3)

Omega-3 350 mg-

235 mg-90 mg-597

mg capsule,delayed

release

$0 (Tier 3)

omega-3 360 mg-

dha-epa-fish oil 1,200

mg capsule,delayed

release

$0 (Tier 3)

omega3 720 mg-dha-

epa-other om3s-fish

oil 1,200 mg

capsule,delay rel

$0 (Tier 3)

omega-3 fatty acids-

fish oil 340 mg-1,000

mg capsule

$0 (Tier 3)

omega-3 fatty acids-

fish oil 360 mg-1,200

mg capsule

$0 (Tier 3)

omega-3 fatty acids-

fish oil 440 mg-880

mg capsule

$0 (Tier 3)

Omega-3 Fish Oil

910 mg-1,400 mg

capsule

$0 (Tier 3)

omega-3s 600 mg-

dha-epa-other

omega3s-fish oil

1,200 mg capsule

$0 (Tier 3)

Drug Name Tier Drug

Restriction

omega 3-dha-epa-fish

oil 300 mg-1,000 mg

capsule

$0 (Tier 3)

omega 3-dha-epa-fish

oil 300 mg-1,000 mg

capsule,delayed

release

$0 (Tier 3)

omega 3-dha-epa-fish

oil 356 mg (100 mg-

256 mg)-554 mg

capsule

$0 (Tier 3)

omega 3-dha-epa-fish

oil 500 mg (200mg-

300mg)-1,000 mg

capsule

$0 (Tier 3)

omega 3-dha-epa-fish

oil 60 mg-90 mg-500

mg capsule

$0 (Tier 3)

omega 3s 300 mg-

dha-epa-fish oil 1,000

mg capsule,delayed

release

$0 (Tier 3)

OMEGA

ESSENTIALS

BASIC 1,400 MG/5

ML ORAL LIQUID

$0 (Tier 3)

Omega-3 (with

docosapentaenoic

acid) 1,050 mg-1,200

mg capsule

$0 (Tier 3)

omega3 1,000 mg-

dha-epa-other om3s-

fish oil 1,400 mg

capsule,delay rel

$0 (Tier 3)

Omega-3 2100 1,050

mg-1,200 mg capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 23

Drug Name Tier Drug

Restriction

Ultra Omega-3 500

mg (200mg-300mg)-

1,000 mg capsule

$0 (Tier 3)

CENTRAL NERVOUS SYSTEM AGENTS

SEDATIVE-HYPNOTIC - ANTIHISTAMINES

ALKA-SELTZER

PLUS ALLERGY 25

MG TABLET

$0 (Tier 3)

Nightime Sleep 50

mg capsule

$0 (Tier 3)

NIGHTTIME SLEEP

AID

(DIPHENHYDRAMI

NE) 25 MG

TABLET

$0 (Tier 3)

NightTime Sleep Aid

(diphenhydramine)

50 mg capsule

$0 (Tier 3)

ORMIR 50 MG

CAPSULE

$0 (Tier 3)

SIMPLY SLEEP 25

MG TABLET

$0 (Tier 3)

SLEEP 25 MG

TABLET

$0 (Tier 3)

Sleep Aid

(diphenhydramine)

25 mg tablet

$0 (Tier 3)

Sleep Aid

(diphenhydramine)

50 mg capsule

$0 (Tier 3)

Sleep Aid Max

Strength

(diphenhydramine)

50 mg capsule

$0 (Tier 3)

Drug Name Tier Drug

Restriction

omega-3s 980 mg-

dha 253 mg-epa 647

mg-fish oil

capsule,delayed

release

$0 (Tier 3)

OMEGAPURE 780

EC 910 MG-330

MG-450 MG-1,400

MG

CAPSULE,DELAYE

D RELEASE

$0 (Tier 3)

Omera 300 mg-400

mg-1,000 mg capsule

$0 (Tier 3)

One-Per-Day Omega-

3 684 mg-1,200 mg

capsule,delayed

release

$0 (Tier 3)

OVEGA-3 500 MG-

270 MG-135 MG

CAPSULE

$0 (Tier 3)

OVEGA-3 500 MG-

320 MG-130 MG

CAPSULE

$0 (Tier 3)

salmon oil 1,000 mg-

omega-3 fatty acids

210 mg capsule

$0 (Tier 3)

Super DHA Gems

500 mg-100 mg-

1,000 mg capsule

$0 (Tier 3)

THEROMEGA 250

MG-350 MG-1,000

MG CAPSULE

$0 (Tier 3)

THEROMEGA

SPORT 250 MG-350

MG-1,000 MG

CAPSULE

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 24

Drug Name Tier Drug

Restriction

NICORETTE 2 MG

BUCCAL MINI

LOZENGE

$0 (Tier 3)

NICORETTE 2 MG

GUM

$0 (Tier 3)

NICORETTE 4 MG

BUCCAL

LOZENGE

$0 (Tier 3)

NICORETTE 4 MG

BUCCAL MINI

LOZENGE

$0 (Tier 3)

Nicorette 4 mg gum $0 (Tier 3)

nicotine (polacrilex)

2 mg buccal lozenge

$0 (Tier 3)

nicotine (polacrilex)

2 mg buccal mini

lozenge

$0 (Tier 3)

nicotine (polacrilex)

2 mg gum

$0 (Tier 3)

nicotine (polacrilex)

4 mg buccal lozenge

$0 (Tier 3)

nicotine (polacrilex)

4 mg buccal mini

lozenge

$0 (Tier 3)

nicotine (polacrilex)

4 mg gum

$0 (Tier 3)

nicotine 14 mg/24 hr

daily transdermal

patch

$0 (Tier 3)

nicotine 21 mg/24 hr

daily transdermal

patch

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Sleep II 25 mg tablet $0 (Tier 3)

SLEEP TABLET

(DIPHENHYDRAMI

NE) 25 MG

TABLET

$0 (Tier 3)

SLEEP-TABS 25

MG TABLET

$0 (Tier 3)

UNISOM

SLEEPGELS 50 MG

CAPSULE

$0 (Tier 3)

Wal-Som

(diphenhydramine)

50 mg capsule

$0 (Tier 3)

CHEMICAL DEPENDENCY, AGENTS TO TREAT

SMOKING DETERRENTS - NICOTINE-TYPE

Nicoderm CQ 14

mg/24 hr daily

transdermal patch

$0 (Tier 3)

Nicoderm CQ 21

mg/24 hr daily

transdermal patch

$0 (Tier 3)

NICODERM CQ 7

MG/24 HR DAILY

TRANSDERMAL

PATCH

$0 (Tier 3)

Nicorelief 2 mg gum $0 (Tier 3)

NICORELIEF 4 MG

GUM

$0 (Tier 3)

NICORETTE 2 MG

BUCCAL

LOZENGE

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 25

Drug Name Tier Drug

Restriction

AlpaWash ointment $0 (Tier 3)

Altaderm Cream

Base topical

$0 (Tier 3)

Apothesar 2 cream $0 (Tier 3)

Apothesar Plus cream $0 (Tier 3)

Apothesil Base

topical cream

$0 (Tier 3)

ARBEM H-Cosmetic

cream

$0 (Tier 3)

ARBEM LipoPen

cream

$0 (Tier 3)

arginine (L-arginine)

(bulk) 100 % crystals

$0 (Tier 3)

arginine (L-arginine)

(bulk) 100 % powder

$0 (Tier 3)

Atrevis Hydrogel

cream

$0 (Tier 3)

Auxipro Vanishing

Cream topical

$0 (Tier 3)

AZ topical cream $0 (Tier 3)

Base 7542

transdermal cream

$0 (Tier 3)

Base W301 cream $0 (Tier 3)

Base, PCCA Polypeg

wax

$0 (Tier 3)

Drug Name Tier Drug

Restriction

nicotine 21mg/24hr-

14mg/24hr-7mg/24hr

daily transderm

patches,sequentl

$0 (Tier 3)

nicotine 7 mg/24 hr

daily transdermal

patch

$0 (Tier 3)

NTS Step 1 21 mg/24

hr transdermal 24

hour patch

$0 (Tier 3)

Quit 2 mg buccal

lozenge

$0 (Tier 3)

Quit 2 mg gum $0 (Tier 3)

Quit 4 mg buccal

lozenge

$0 (Tier 3)

Quit 4 mg gum $0 (Tier 3)

STOP SMOKING

AID 2 MG BUCCAL

LOZENGE

$0 (Tier 3)

STOP SMOKING

AID 4 MG BUCCAL

LOZENGE

$0 (Tier 3)

CHEMICALS-PHARMACEUTICAL ADJUVANTS

BULK CHEMICALS

1st Base cream $0 (Tier 3)

acetaminophen (bulk)

100 % powder

$0 (Tier 3)

Alba-Derm cream $0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 26

Drug Name Tier Drug

Restriction

Chrysaderm Night

Cream topical

$0 (Tier 3)

citrulline (bulk)

powder

$0 (Tier 3)

coenzyme Q10 (bulk)

100 % powder

$0 (Tier 3)

coenzyme Q10 (bulk)

powder

$0 (Tier 3)

cream base no.64

(bulk) topical

$0 (Tier 3)

Custom Base Pcca

Lipoderm topical

cream

$0 (Tier 3)

Cutis Plus cream $0 (Tier 3)

cyanocobalamin

(vitamin B-12) (bulk)

powder

$0 (Tier 3)

dextromethorphan

HBr (bulk) powder

$0 (Tier 3)

Durabase Advanced

topical cream

$0 (Tier 3)

Durabase topical

cream

$0 (Tier 3)

Emolivan topical

cream

$0 (Tier 3)

emollient

combination no.112

(bulk) topical cream

$0 (Tier 3)

Epsom Salt 100 %

crystals

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Base, PCCA

Vanishing Cream-

Lotion topical

$0 (Tier 3)

Base, PCCA Vanpen

topical cream

$0 (Tier 3)

Base, PCCA

Xematop topical

cream

$0 (Tier 3)

benzoin (bulk)

topical tincture

$0 (Tier 3)

benzoin compound

(bulk) tincture

$0 (Tier 3)

benzyl alcohol (bulk)

liquid

$0 (Tier 3)

benzyl benzoate

(bulk) liquid

$0 (Tier 3)

Biopeptide

Biocosmetic Base

cream

$0 (Tier 3)

biotin (bulk) 100 %

powder

$0 (Tier 3)

caffeine (bulk) 100 %

powder

$0 (Tier 3)

Cela Cream Base $0 (Tier 3)

cholesterol (bulk)

100 % powder

$0 (Tier 3)

cholesterol (bulk)

powder

$0 (Tier 3)

Chrysaderm Day

Cream topical

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 27

Drug Name Tier Drug

Restriction

Humco Base, Pain

Mgmt topical cream

$0 (Tier 3)

Hydrous Emulsified

Base cream

$0 (Tier 3)

hydroxocobalamin

(bulk) powder

$0 (Tier 3)

hypromellose (bulk)

23 % and 10 %

powder

$0 (Tier 3)

IdealBase cream $0 (Tier

3)

isoleucine (bulk) 100

% crystals

$0 (Tier 3)

isoleucine (bulk)

powder

$0 (Tier 3)

lactose (bulk) powder $0 (Tier 3)

L-Citrulline powder $0 (Tier 3)

L-Glutamine powder $0 (Tier 3)

Lip Balm Base

(Bulk) 1.3 gm/3 mL

$0 (Tier 3)

Lipo Cream Base $0 (Tier 3)

Lipobase Heavy

topical cream

$0 (Tier 3)

Lipobase Regular

transdermal cream

$0 (Tier 3)

Lipocream Base $0 (Tier 3)

Drug Name Tier Drug

Restriction

Fagron LS Plus

topical cream

$0 (Tier 3)

Fagron LS Ultra

cream

$0 (Tier 3)

Fagron Natural

Cream transdermal

cream

$0 (Tier 3)

Fagron Supreme

Cream transdermal

cream

$0 (Tier 3)

FattiBASE wax $0 (Tier 3)

ferrous sulfate, dried

(bulk) 100 % powder

$0 (Tier 3)

Fitalite Cream Base $0 (Tier 3)

folic acid (bulk) 100

% powder

$0 (Tier 3)

fructose (bulk)

granules

$0 (Tier 3)

glutamine (bulk)

powder

$0 (Tier 3)

glutathione (bulk)

100 % powder

$0 (Tier 3)

glycerin (bulk) 100 %

liquid

$0 (Tier 3)

glycerol formal

(bulk) 100 % liquid

$0 (Tier 3)

grape flavor (bulk)

liquid

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 28

Drug Name Tier Drug

Restriction

Microderm Base

Cream

$0 (Tier 3)

Microsome Base

Cream

$0 (Tier 3)

MultiBase topical

cream

$0 (Tier 3)

MultiUse Base cream $0 (Tier 3)

Nourilite topical

emulsion

$0 (Tier 3)

Nourivan Antioxidant

topical cream

$0 (Tier 3)

Noxi-K topical cream $0 (Tier 3)

Omnibase cream $0 (Tier 3)

PCCA Aladerm Base

ointment

$0 (Tier 3)

PCCA Anhydrous

Lipoderma cream

$0 (Tier 3)

PCCA Cosmetic

HRT Base cream

$0 (Tier 3)

PCCA Lipoderm

Base cream

$0 (Tier 3)

PCCA MVC Cream $0 (Tier 3)

PCCA Natacream $0 (Tier 3)

PCCA Vanishing

Base cream

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Lipopen Absorption

Enhancing Base

cream

$0 (Tier 3)

Lipopen Ultra Base

cream

$0 (Tier 3)

Liposomal Heavy

topical cream

$0 (Tier 3)

L-Isoleucine powder $0 (Tier 3)

Lollibase powder $0 (Tier 3)

lysine HCl (bulk) 100

% powder

$0 (Tier 3)

magnesium chloride

(bulk) crystals

$0 (Tier 3)

Mediderm cream $0 (Tier 3)

Medium Cream

topical

$0 (Tier 3)

Methocel K 100 M

23 % and 10 %

powder

$0 (Tier 3)

methylcellulose

1500cps (bulk) 27.5

% to 31.5 % (USP)

powder

$0 (Tier 3)

methylcellulose

4000cps (bulk) 30 %

powder

$0 (Tier 3)

methylcellulose

400cps (bulk) 30 %

powder

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 29

Drug Name Tier Drug

Restriction

Picoderm topical

cream

$0 (Tier 3)

PNA-HRT Base

Cream

$0 (Tier 3)

polyethylene glycol

1000 (bulk) powder

$0 (Tier 3)

polyethylene glycol

3350 (bulk) powder

$0 (Tier 3)

polyethylene glycol

8000 (bulk) 100 %

wax

$0 (Tier 3)

polyethylene glycol

8000 (bulk) powder

$0 (Tier 3)

potassium bromide

(bulk) crystals

$0 (Tier 3)

Pracasil TM-Plus gel $0 (Tier 3)

propylene glycol

(bulk) 99.5 % (not

less than, USP) liquid

$0 (Tier 3)

pyridoxine (bulk) 100

% powder

$0 (Tier 3)

pyridoxine (bulk)

crystals

$0 (Tier 3)

Q-Derm cream $0 (Tier 3)

Rejuvacare Plus

transdermal cream

$0 (Tier 3)

Sa3derm cream $0 (Tier 3)

Drug Name Tier Drug

Restriction

Peg Ointment Base

(Bulk) 40 %-60 %

$0 (Tier 3)

Pegblend 59 %-39 %-

2 % wax

$0 (Tier 3)

PENcream

Compounding Agent

$0 (Tier 3)

PenDerm transdermal

cream

$0 (Tier 3)

PenSomal

transdermal cream

$0 (Tier 3)

Pentravan Plus

topical cream

$0 (Tier 3)

Pentravan

transdermal cream

$0 (Tier 3)

PFCB cream $0 (Tier 3)

Pharmabase

Cosmetic topical

cream

$0 (Tier 3)

Pharmabase Heavy

topical cream

$0 (Tier 3)

Pharmabase Light

topical cream

$0 (Tier 3)

Pharmabase Natural

topical cream

$0 (Tier 3)

Pharmabase topical

cream

$0 (Tier 3)

Pharmabase Vaginal

cream

$0 (Tier 3)

Phytobase cream $0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 30

Drug Name Tier Drug

Restriction

Vanibase topical

cream

$0 (Tier 3)

Vanibase Traditional

Formula topical

cream

$0 (Tier 3)

Vanishing Cream $0 (Tier 3)

Vanishing Cream

topical

$0 (Tier 3)

Vanish-Pen Cream

Base topical

$0 (Tier 3)

Versapro Cream Base

topical

$0 (Tier 3)

Versatile Rich topical

cream

$0 (Tier 3)

Versatile topical

cream

$0 (Tier 3)

Versigel cream $0 (Tier 3)

V-Max cream $0 (Tier 3)

Xcel 100 cream $0 (Tier 3)

zinc sulfate (bulk)

100 % powder

$0 (Tier 3)

zinc sulfate (bulk)

powder

$0 (Tier 3)

zinc sulfate

heptahydrate (bulk)

100 % powder

$0 (Tier 3)

CHEMICALS - FIXED OILS

Drug Name Tier Drug

Restriction

salicylic acid (bulk)

powder

$0 (Tier 3)

Salt Durable topical

cream

$0 (Tier 3)

SaltStable LO cream

base

$0 (Tier 3)

SaltStable LS cream $0 (Tier 3)

Sanare Advanced

Scar Therapy Base

topical gel

$0 (Tier 3)

Sedanare cream $0 (Tier 3)

SkyyDerm Cream

Base

$0 (Tier 3)

sodium benzoate

(bulk) powder

$0 (Tier 3)

sodium bromide

(bulk) granules

$0 (Tier 3)

sodium chloride

(bulk) granules

$0 (Tier 3)

Stera Base cream $0 (Tier 3)

theophylline (bulk)

powder

$0 (Tier 3)

thiamine HCl (bulk)

powder

$0 (Tier 3)

U-Base topical cream $0 (Tier 3)

Ultraderm Base

cream

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 31

Drug Name Tier Drug

Restriction

MX-Sol Blend oral

suspension

$0 (Tier 3)

MX-Sol Blend SF

oral suspension

$0 (Tier 3)

MX-Sol oral syrup $0 (Tier 3)

MX-Sol SF oral

liquid

$0 (Tier 3)

MX-Sol Suspend oral $0 (Tier 3)

Ora-Blend oral

suspension

$0 (Tier 3)

Ora-Blend SF oral

suspension

$0 (Tier 3)

Oral Mix oral

suspension

$0 (Tier 3)

Oral Mix SF oral

suspension

$0 (Tier 3)

Oral Suspend oral $0 (Tier 3)

Oral Suspending

Compound Plus oral

$0 (Tier 3)

Oral Syrup oral liquid $0 (Tier 3)

Oral Syrup SF oral

liquid

$0 (Tier 3)

Ora-Plus oral

suspension

$0 (Tier 3)

Ora-Sweet oral syrup $0 (Tier 3)

Drug Name Tier Drug

Restriction

castor oil $0 (Tier 3)

CHEMICALS - SOLVENTS

$0 (Tier 3)

sesame oil $0 (Tier 3)

PHARMACEUTICAL ADJUVANT - CREAM/OINTMENT VEHICLES

Aquabase topical

ointment

$0 (Tier 3)

DermaFix topical

ointment

$0 (Tier 3)

Hydrophilic

Petrolatum topical

ointment

$0 (Tier 3)

PHARMACEUTICAL ADJUVANT - ORAL VEHICLES

Base, PCCA Syrup

Vehicle oral liquid

$0 (Tier 3)

Blended Suspending

Compound oral

$0 (Tier 3)

compounding vehicle

suspension sugar-free

no.12 oral

$0 (Tier 3)

Flavor Blend 2 in 1

oral suspension

$0 (Tier 3)

Flavor Plus oral

suspension

$0 (Tier 3)

Flavor Sweet oral

syrup

$0 (Tier 3)

Flavor Sweet-SF oral

liquid

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 32

Drug Name Tier Drug

Restriction

Syrspend SF PH4

oral powder for

suspension

$0 (Tier 3)

Syrup Vehicle SF

oral solution

$0 (Tier 3)

Versa Free oral

solution

$0 (Tier 3)

Versa Plus oral

suspension

$0 (Tier 3)

PHARMACEUTICAL ADJUVANT - SUSPENDING AGENTS

hypromellose powder $0 (Tier 3)

Methocel E 4 M

granules

$0 (Tier 3)

Methocel E 4 M

powder

$0 (Tier 3)

CONTRACEPTIVES

EMERGENCY CONTRACEPTIVES

Aftera 1.5 mg tablet $0 (Tier 3)

EContra EZ 1.5 mg

tablet

$0 (Tier 3)

Econtra One-Step 1.5

mg tablet

$0 (Tier 3)

Fallback Solo 1.5 mg

tablet

$0 (Tier 3)

levonorgestrel 1.5 mg

tablet

$0 (Tier 3)

My Choice 1.5 mg

tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Ora-Sweet SF oral

liquid

$0 (Tier 3)

PCCA-Plus Base oral

suspension

$0 (Tier 3)

simple syrup $0 (Tier 3)

sorbitol 70 %

solution

$0 (Tier 3)

SoSweet Syrup

Vehicle

$0 (Tier 3)

SuspendRx

Anhydrous

Sweetened oral

$0 (Tier 3)

SuspendRx

Anhydrous

Unsweetened oral

$0 (Tier 3)

Sweetening

Suspending

Compounding

Vehicle oral syrup

$0 (Tier 3)

Sweet-SF oral liquid $0 (Tier 3)

SyrPalta Vehicle oral

syrup

$0 (Tier 3)

SyrSpend SF Alka

oral powder for

suspension

$0 (Tier 3)

SyrSpend SF Liquid

oral suspension

$0 (Tier 3)

Syrspend SF oral

powder for

suspension

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 33

Drug Name Tier Drug

Restriction

Acne-Clear 10 %

topical gel

$0 (Tier 3)

Advanced Exfoliating

Cleanser 5 % topical

$0 (Tier 3)

BenzePrO 5.3 %

topical foam

$0 (Tier 3)

BENZEPRO 6 %

TOWELETTE

$0 (Tier 3)

benzoyl peroxide 10

% topical cleanser

$0 (Tier 3)

benzoyl peroxide 10

% topical gel

$0 (Tier 3)

benzoyl peroxide 2.5

% topical gel

$0 (Tier 3)

benzoyl peroxide 3 %

topical cleanser

$0 (Tier 3)

benzoyl peroxide 5 %

topical cleanser

$0 (Tier 3)

benzoyl peroxide 5 %

topical gel

$0 (Tier 3)

benzoyl peroxide 5.3

% topical foam

$0 (Tier 3)

benzoyl peroxide 6 %

topical cleanser

$0 (Tier 3)

benzoyl peroxide 9 %

topical cleanser

$0 (Tier 3)

benzoyl peroxide 9.8

% topical foam

$0 (Tier 3)

BP 10 % topical gel $0 (Tier 3)

Drug Name Tier Drug

Restriction

My Way 1.5 mg

tablet

$0 (Tier 3)

New Day 1.5 mg

tablet

$0 (Tier 3)

NEXT CHOICE

ONE DOSE 1.5 MG

TABLET

$0 (Tier 3)

Opcicon One-Step

1.5 mg tablet

$0 (Tier 3)

Option-2 1.5 mg

tablet

$0 (Tier 3)

Plan B One-Step 1.5

mg tablet

$0 (Tier 3)

Take Action 1.5 mg

tablet

$0 (Tier 3)

DERMATOLOGICAL

ACNE THERAPY TOPICAL - KERATOLYTIC

Acne Foaming Wash

10 % topical cleanser

$0 (Tier 3)

Acne Medication 10

% lotion

$0 (Tier 3)

Acne Medication 10

% topical gel

$0 (Tier 3)

Acne Medication 2.5

% topical gel

$0 (Tier 3)

Acne Medication 5 %

lotion

$0 (Tier 3)

Acne Medication 5 %

topical gel

$0 (Tier 3)

Acne Treatment

(benzoyl peroxide)

10 % topical gel

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 34

Drug Name Tier Drug

Restriction

adapalene 0.1 %

topical gel

$0 (Tier 3)

DIFFERIN 0.1 %

TOPICAL GEL

$0 (Tier 3)

DERMATOLOGICAL - ANTIBACTERIAL MIXTURES

$0 (Tier 3)

Antibiotic(neomy-

bacit-polym) 3.5 mg-

400 unit-5,000

unit/gram top oint

$0 (Tier 3)

bacitracin 500 unit-

polymyxin B 10,000

unit/gram topical

ointment

$0 (Tier

3)

bacitracin-polymyxin

B 500 unit-10,000

unit/gram topical

packet

$0 (Tier 3)

Double Antibiotic

(bacitrcn zn) 500

unit-10,000 unit/gram

top ointment

$0 (Tier 3)

First Aid Antibiotic

3.5 mg-400 unit-

5,000 unit/gram

topical ointment

$0 (Tier 3)

First Aid Antibiotic

3.5 mg-500 unit-

10,000 unit topical

ointment

$0 (Tier 3)

NEOSPORIN (NEO-

BAC-POLYM) 3.5

MG-400 UNIT-5,000

UNIT/GRAM TOP

OINTMENT

$0 (Tier 3)

Drug Name Tier Drug

Restriction

BP 5 % topical gel $0 (Tier 3)

BP Foam 5.3 %

topical

$0 (Tier 3)

BP WASH 10 %

TOPICAL

CLEANSER

$0 (Tier 3)

BP Wash 5 % topical

cleanser

$0 (Tier 3)

BPO 6 % towelette $0 (Tier 3)

BPO CREAMY

WASH PACK 4 %-5

% TOPICAL

$0 (Tier 3)

BPO CREAMY

WASH PACK 8 %-5

% TOPICAL

$0 (Tier 3)

Creamy Acne Face 4

% topical cleanser

$0 (Tier 3)

FOAMING ACNE

FACE WASH 10 %

TOPICAL

CLEANSER

$0 (Tier 3)

PANOXYL 10 %

TOPICAL

CLEANSER

$0 (Tier 3)

PANOXYL-4 4 %

TOPICAL

CLEANSER

$0 (Tier 3)

PERSA-GEL 10 %

TOPICAL

$0 (Tier 3)

ACNE THERAPY TOPICAL - RETINOIDS AND DERIVATIVES

OH Buckeye MMP Opt-Out Formulary August 1, 2021 35

Drug Name Tier Drug

Restriction

bacitracin 500

unit/gram topical

packet

$0 (Tier 3)

bacitracin zinc 500

unit/gram topical

ointment

$0 (Tier 3)

bacitracin zinc 500

unit/gram topical

ointment in packet

$0 (Tier 3)

BACITRAYCIN

PLUS 500

UNIT/GRAM

TOPICAL

OINTMENT

$0 (Tier 3)

DERMATOLOGICAL - ANTIBACTERIAL POVIDONE- IODINE PREPARATIONS

ANTISEPTIC 10 %

TOPICAL

SOLUTION

$0 (Tier 3)

BETADINE 5 %

TOPICAL SPRAY

$0 (Tier 3)

BETADINE SKIN

CLEANSER 7.5 %

$0 (Tier 3)

BETADINE

SURGICAL SCRUB

7.5 % TOPICAL

SOLUTION

$0 (Tier 3)

BETADINE

SWABSTICKS 10 %

$0 (Tier 3)

First Aid Antiseptic

(povidone-iodine) 10

% topical solution

$0 (Tier 3)

Nasal Antiseptic

Swabs 10 %

$0 (Tier 3)

Drug Name Tier Drug

Restriction

NEOSPORIN(NEO-

BAC-POLYM) 3.5

MG-400 UNIT-5,000

UNIT TOP

OINTMENT PACKT

$0 (Tier 3)

Poly Bacitracin (zinc)

500 unit-10,000

unit/gram topical

ointment

$0 (Tier 3)

Poly Bacitracin 500

unit-10,000 unit/gram

topical ointment

$0 (Tier 3)

POLYSPORIN 500

UNIT-10,000

UNIT/GRAM

TOPICAL PACKET

$0 (Tier 3)

Triple Antibiotic 3.5

mg-400 unit-5,000

unit topical ointment

packet

$0 (Tier 3)

Triple Antibiotic 3.5

mg-400 unit-5,000

unit/gram topical

ointment

$0 (Tier 3)

Wal-Sporin 500 unit-

10,000 unit/gram

topical ointment

$0 (Tier 3)

DERMATOLOGICAL - ANTIBACTERIAL POLYMYXINS AND DERIVATIVES

ANTIBIOTIC

(BACITRACIN

ZINC) 500

UNIT/GRAM

TOPICAL

OINTMENT

$0 (Tier 3)

bacitracin 500

unit/gram topical

ointment

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 36

Drug Name Tier Drug

Restriction

Multi Antibiotic Plus

3.5 mg-10,000 unit-

10 mg/gram topical

cream

$0 (Tier 3)

NEOSPORIN PLUS

PAIN RELIEF 3.5

MG-10,000 UNIT-10

MG/GRAM

TOPICAL CREAM

$0 (Tier 3)

NEOSPORIN-PAIN

ITCH SCAR 3.5

MG-500 UNIT-

10,000 UNIT/GRAM

TOPICAL OINT

$0 (Tier 3)

TRI-BIOZENE 3.5

MG-500 UNIT-

10,000 UNIT/GRAM

TOPICAL

OINTMENT

$0 (Tier 3)

Triple Antibiotic

(pram) Extra 3.5 mg-

500 unit-10,000

unit/g Top Oint

$0 (Tier 3)

Triple Antibiotic Plus

3.5 mg-500 unit-

10,000 unit/gram top

ointment

$0 (Tier 3)

Triple Antibiotic-

Pain Relief 3.5 mg-

500 unit-10,000

unit/gram ointmnt

$0 (Tier 3)

DERMATOLOGICAL - ANTIFUNGAL ALLYLAMINES

Antifungal

(terbinafine) 1 %

topical cream

$0 (Tier 3)

Athlete's Foot

(terbinafine) 1 %

topical cream

$0 (Tier 3)

Drug Name Tier Drug

Restriction

povidone-iodine 10

% sponge

$0 (Tier 3)

povidone-iodine 10

% topical liquid

packet

$0 (Tier 3)

povidone-iodine 10

% topical ointment

$0 (Tier 3)

povidone-iodine 10

% topical solution

$0 (Tier 3)

povidone-iodine 10

% topical spray

$0 (Tier 3)

povidone-iodine 10

% topical swab

$0 (Tier 3)

povidone-iodine 7.5

% topical solution

$0 (Tier 3)

DERMATOLOGICAL - ANTIBACTERIAL-LOCAL ANESTHETIC COMBINATIONS

Antibiotic Plus

(pramoxine) 3.5 mg-

10,000 unit-10

mg/gram top cream

$0 (Tier 3)

Antibiotic-Pain

Relief(bacit)3.5 mg-

500 unit-10,000

unit/gram ointment

$0 (Tier 3)

First Aid ABX Pain

Relief 3.5 mg-10,000

unit-10 mg/gram

topical cream

$0 (Tier 3)

First Aid Antibiotic-

Pain Rlf 3.5 mg-500

unit-10,000 unit/g top

oint

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 37

Drug Name Tier Drug

Restriction

Athlete's Foot

(clotrimazole) 1 %

topical cream

$0 (Tier 3)

ATHLETE'S FOOT

2 % POWDER

$0 (Tier 3)

Athlete's Foot 2 %

topical spray powder

$0 (Tier 3)

Athletic Foot Cream

1 % topical

$0 (Tier 3)

AZOLEN

TINCTURE 2 %

TOPICAL

$0 (Tier 3)

Baza Antifungal 2 %

topical cream

$0 (Tier 3)

clotrimazole 1 %

topical cream

$0 (Tier 3)

clotrimazole 1 %

topical solution

$0 (Tier 3)

Clotrimazole AF 1 %

topical cream

$0 (Tier 3)

Critic-Aid Clear AF

(miconazole) 2 %

topical ointment

$0 (Tier 3)

DESENEX 2 %

TOPICAL POWDER

$0 (Tier 3)

Fungi Cure 1 %

topical spray

$0 (Tier 3)

FUNGOID

TINCTURE 2 %

TOPICAL

$0 (Tier 3)

Fungoid Tincture 2 %

topical kit

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Athlete's Foot AF 1

% topical cream

$0 (Tier 3)

Jock Itch

(terbinafine) 1 %

topical cream

$0 (Tier 3)

LAMISIL

(AEROSOL) 1 %

TOPICAL SPRAY

$0 (Tier 3)

LAMISIL AT 1 %

TOPICAL CREAM

$0 (Tier 3)

LAMISIL AT 1 %

TOPICAL GEL

$0 (Tier 3)

terbinafine HCl 1 %

topical cream

$0 (Tier 3)

DERMATOLOGICAL - ANTIFUNGAL BENZYLAMINES

butenafine 1 %

topical cream

$0 (Tier 3)

DERMATOLOGICAL - ANTIFUNGAL IMIDAZOLE AND RELATED AGENTS

$0 (Tier 3)

Alevazol 1 % topical

ointment

$0 (Tier 3)

ALOE VESTA

ANTIFUNGAL

(MICONAZOLE) 2

% TOPICAL

OINTMENT

$0 (Tier 3)

Anti-Fungal 2 %

topical powder

$0 (Tier 3)

Antifungal Cream

(miconazole) 2 %

topical

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 38

Drug Name Tier Drug

Restriction

Remedy Antifungal 2

% topical cream

$0 (Tier 3)

Remedy Antifungal 2

% topical powder

$0 (Tier 3)

Remedy Phytoplex

Antifungal 2 %

topical ointment

$0 (Tier 3)

Remedy Phytoplex

Antifungal 2 %

topical powder

$0 (Tier 3)

Ringworm 1 %

topical cream

$0 (Tier 3)

SECURA

ANTIFUNGAL 2 %

TOPICAL CREAM

$0 (Tier 3)

SECURA

ANTIFUNGAL

EXTRA THICK 2 %

TOPICAL CREAM

$0 (Tier 3)

TRIPLE PASTE AF

2 % TOPICAL

OINTMENT

$0 (Tier 3)

ZEASORB

(MICONAZOLE) 2

% TOPICAL

POWDER

$0 (Tier 3)

ZEASORB AF 2 %

TOPICAL POWDER

$0 (Tier 3)

DERMATOLOGICAL - ANTIFUNGAL THIOCARBAMATE

AF 1 % topical spray

powder

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Inzo Antifungal 2 %

topical cream

$0 (Tier 3)

Itch Relief

(clotrimazole) 1 %

topical cream

$0 (Tier 3)

Jock Itch

(clotrimazole) 1 %

topical cream

$0 (Tier 3)

LOTRIMIN AF

(CLOTRIMAZOLE)

1 % TOPICAL

CREAM

$0 (Tier 3)

LOTRIMIN AF 2 %

TOPICAL POWDER

$0 (Tier 3)

LOTRIMIN AF

JOCK ITCH

POWDER 2 %

TOPICAL SPRAY

$0 (Tier 3)

LOTRIMIN AF

POWDER 2 %

TOPICAL SPRAY

$0 (Tier 3)

MICATIN 2 %

TOPICAL CREAM

$0 (Tier 3)

miconazole nitrate 2

% topical cream

$0 (Tier 3)

miconazole nitrate 2

% topical spray

powder

$0 (Tier 3)

Miconazorb AF 2 %

topical powder

$0 (Tier 3)

MICRO-GUARD 2

% TOPICAL

POWDER

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 39

Drug Name Tier Drug

Restriction

Medi-First Anti-

Fungal 1 % topical

packet

$0 (Tier 3)

Odor Control Foot-

Sneaker 1 % topical

spray powder

$0 (Tier 3)

TINACTIN 1 %

TOPICAL CREAM

$0 (Tier 3)

TINACTIN 1 %

TOPICAL POWDER

$0 (Tier 3)

TINACTIN 1 %

TOPICAL SPRAY

$0 (Tier 3)

TINACTIN 1 %

TOPICAL SPRAY

POWDER

$0 (Tier 3)

tolnaftate 1 % topical

cream

$0 (Tier 3)

tolnaftate 1 % topical

powder

$0 (Tier 3)

tolnaftate 1 % topical

solution

$0 (Tier 3)

tolnaftate 1 % topical

spray powder

$0 (Tier 3)

DERMATOLOGICAL - ANTIPERSPIRANTS

XERAC AC 6.25 %

TOPICAL

SOLUTION

$0 (Tier 3)

DERMATOLOGICAL - ANTIPRURITICS COMBINATIONS

Anti-Itch

(diphenhydramine)

with Zinc 2 %-0.1 %

topical cream

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ANTIFUNGAL

(TOLNAFTATE) 1

% TOPICAL

CREAM

$0 (Tier 3)

ANTIFUNGAL

(TOLNAFTATE) 1

% TOPICAL

POWDER

$0 (Tier 3)

ANTIFUNGAL

(TOLNAFTATE) 1

% TOPICAL SPRAY

$0 (Tier 3)

Antifungal Spray 1 %

topical powder

$0 (Tier 3)

Athlete's Foot

(tolnaftate) 1 %

topical cream

$0 (Tier 3)

Athlete's Foot

(tolnaftate) 1 %

topical spray

$0 (Tier 3)

Athlete's Foot

(tolnaftate) 1 %

topical spray powder

$0 (Tier 3)

Foot and Sneaker 1

% topical spray

powder

$0 (Tier 3)

Formula 3 1 %

topical solution

$0 (Tier 3)

FUNGOID-D 1 %

TOPICAL CREAM

$0 (Tier 3)

Jock Itch 1 % topical

spray powder

$0 (Tier 3)

LAMISIL AF 1 %

TOPICAL SPRAY

POWDER

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 40

Drug Name Tier Drug

Restriction

DHS Zinc 2 %

shampoo

$0 (Tier 3)

NOBLE FORMULA

2 % SHAMPOO

$0 (Tier 3)

SELSUN BLUE 1 %

SHAMPOO

$0 (Tier 3)

DERMATOLOGICAL - ANTISEBORRHEIC COMBINATIONS

Anti-Dandruff With

Menthol 1 %

shampoo

$0 (Tier 3)

Dandruff Shampoo

(selenium sulfide-

aloe) 1 %

$0 (Tier 3)

Dandruff Shampoo-

Menthol 1 %

$0 (Tier 3)

SELSUN BLUE

MOISTURIZING 1

% SHAMPOO

$0 (Tier

3)

DERMATOLOGICAL - ASTRINGENT COMBINATIONS

PEDI-BORO SOAK

839 MG-1,191 MG

TOPICAL POWDER

IN PACKET

$0 (Tier 3)

DERMATOLOGICAL - EMOLLIENT COMBINATIONS

CERAVE TOPICAL

CREAM

$0 (Tier 3)

RENEWAL

MOISTURIZING

CREAM TOPICAL

$0 (Tier 3)

DERMATOLOGICAL - EMOLLIENT COMBINATIONS OTHER

DML FORTE

TOPICAL CREAM

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ANTI-ITCH

(DIPHENHYDRAMI

NE) WITH ZINC 2

%-0.1 % TOPICAL

SPRAY

$0 (Tier 3)

Banophen Anti-Itch 2

%-0.1 % topical

cream

$0 (Tier 3)

BENADRYL

EXTRA STRENGTH

2 %-0.1 % TOPICAL

CREAM

$0 (Tier 3)

BENADRYL ITCH

COOLING 2 %-0.1

% TOPICAL SPRAY

$0 (Tier 3)

Itch Relief 2 %-0.1 %

topical cream

$0 (Tier 3)

Itch Relief 2 %-0.1 %

topical spray

$0 (Tier 3)

Wal-Dryl

(diphenhydramine-Zn

acetate) 2 %-0.1 %

topical cream

$0 (Tier 3)

Wal-Dryl

(diphenhydramine-Zn

acetate) 2 %-0.1 %

topical spray

$0 (Tier 3)

DERMATOLOGICAL - ANTISEBORRHEIC

ANTI-DANDRUFF

1 % SHAMPOO

$0 (Tier 3)

BETA MED 2 %

SHAMPOO

$0 (Tier 3)

DermaZinc Shampoo

2 %

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 41

Drug Name Tier Drug

Restriction

EUCERIN

INTENSIVE

REPAIR CREME

TOPICAL

$0 (Tier 3)

EUCERIN SKIN

CALMING CREAM

$0 (Tier 3)

EUCERIN TOPICAL

CREAM

$0 (Tier 3)

HYDRASYN25 25

%-6 % TOPICAL

CREAM

$0 (Tier 3)

HYDRATING

HEALING

TOPICAL

OINTMENT

$0 (Tier 3)

Hydrocerin (with

petrolatum) topical

cream

$0 (Tier 3)

HYDRO-LAN

TOPICAL CREAM

$0 (Tier 3)

KERADAN

TOPICAL CREAM

$0 (Tier 3)

Kerodex 51 Dry or

Oily topical cream

$0 (Tier 3)

Minerin Creme

topical

$0 (Tier 3)

Moisturizing Cream

topical

$0 (Tier 3)

NIVEA SOFT

TOPICAL CREAM

$0 (Tier 3)

NIVEA TOPICAL

CREAM

$0 (Tier 3)

Drug Name Tier Drug

Restriction

vit E-wheat germ-

aloe vera topical

ointment

$0 (Tier 3)

DERMATOLOGICAL - EMOLLIENT MIXTURES

ABSORBASE

TOPICAL

OINTMENT

$0 (Tier 3)

AmeriPhor topical

ointment

$0 (Tier 3)

AmLactin topical

cream

$0 (Tier 3)

BETA CARE

TOPICAL CREAM

$0 (Tier 3)

CERAMAX

TOPICAL CREAM

$0 (Tier 3)

Cetaphil Hand topical

cream

$0 (Tier 3)

Cetaphil Moisturizing

topical cream

$0 (Tier 3)

CETAPHIL

TOPICAL CREAM

$0 (Tier 3)

Coconut Oil Cream

topical

$0 (Tier 3)

Dermacerin topical

cream

$0 (Tier 3)

DERMAPHOR

TOPICAL

OINTMENT

$0 (Tier 3)

Dry Skin Therapy

cream

$0 (Tier 3)

EMOLLIA

TOPICAL CREAM

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 42

Drug Name Tier Drug

Restriction

Aqua Glycolic Face

topical cream

$0 (Tier 3)

Dermabase topical

cream

$0 (Tier 3)

emollient topical

cream

$0 (Tier 3)

Finger Cream topical $0 (Tier 3)

GERI-HYDROLAC

12 % LOTION

$0 (Tier 3)

Geri-Hydrolac 12 %

topical cream

$0 (Tier 3)

glycerin 99.5 %

topical solution

$0 (Tier 3)

glycerin topical

liquid

$0 (Tier 3)

GORMEL TEN 10 %

LOTION

$0 (Tier 3)

LACTINOL HX

TOPICAL CREAM

$0 (Tier 3)

LANTISEPTIC DRY

SKIN THERAPY 30

% CREAM

$0 (Tier 3)

LANTISEPTIC

SKIN

PROTECTANT 50

% CREAM

$0 (Tier 3)

NEUTROGENA

HAND TOPICAL

CREAM

$0 (Tier 3)

Drug Name Tier Drug

Restriction

NUTRASEB

TOPICAL CREAM

$0 (Tier 3)

PEN-KERA

TOPICAL CREAM

$0 (Tier 3)

PETROLATUM

TOPICAL

OINTMENT

$0 (Tier 3)

SOOTHE AND

COOL SKIN

CREAM WITH

ALOE

$0 (Tier 3)

SORBOLENE

TOPICAL CREAM

$0 (Tier 3)

Special Care Lotion

topical

$0 (Tier 3)

Studio 35

Moisturizing Skin

cream

$0 (Tier 3)

Therapeutic

Moisturizing topical

cream

$0 (Tier 3)

Triple Cream topical $0 (Tier 3)

VELVACHOL

TOPICAL CREAM

$0 (Tier 3)

DERMATOLOGICAL - EMOLLIENTS

AMLACTIN 12 %

LOTION

$0 (Tier 3)

ammonium lactate 12

% lotion

$0 (Tier 3)

ammonium lactate 12

% topical cream

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 43

Drug Name Tier Drug

Restriction

Anti-Itch

(hydrocortisone) 1 %

topical ointment

$0 (Tier 3)

Anti-Itch

(hydrocortisone) 1 %

topical spray

$0 (Tier 3)

Cortisone

(hydrocortisone) 1 %

topical cream

$0 (Tier 3)

Cortisone

(hydrocortisone) 1 %

topical ointment

$0 (Tier 3)

CORTIZONE-10 1

% TOPICAL

CREAM

$0 (Tier 3)

CORTIZONE-10 1

% TOPICAL

OINTMENT

$0 (Tier 3)

CORTIZONE-10

PLUS 1 % TOPICAL

CREAM

$0 (Tier 3)

Eczema Anti-Itch 1

% topical cream

$0 (Tier 3)

hydrocortisone 0.5 %

topical cream

$0 (Tier 3)

hydrocortisone 0.5 %

topical ointment

$0 (Tier 3)

hydrocortisone 1 %

lotion

$0 (Tier 3)

hydrocortisone 1 %

topical cream

$0 (Tier 3)

hydrocortisone 1 %

topical cream packet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

NEUTROGENA

NORWEGIAN

FORMULA

TOPICAL CREAM

$0 (Tier 3)

PCCA Emollient

Base topical cream

$0 (Tier 3)

Pretty Feet Hands

topical cream

$0 (Tier 3)

Skin Treatment 12 %

lotion

$0 (Tier 3)

Soothe and Cool

Medseptic 50 %

topical ointment

$0 (Tier 3)

Soothe-Cool Protect

Medseptic 50 %

topical ointment

$0 (Tier 3)

Sorbidon Hydrate

topical cream

$0 (Tier 3)

TENDER CARE

LANOLIN

TOPICAL CREAM

$0 (Tier 3)

urea 10 % lotion $0 (Tier 3)

UREACIN-10 10 %

LOTION

$0 (Tier 3)

Vanicream topical $0 (Tier 3)

DERMATOLOGICAL - GLUCOCORTICOID

Anti-Itch

(hydrocortisone) 1 %

topical cream

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 44

Drug Name Tier Drug

Restriction

SCALPICIN ANTI-

ITCH 1 % TOPICAL

SOLUTION

$0 (Tier 3)

Soothing Care

(hydrocortisone) 1 %

topical cream

$0 (Tier 3)

DERMATOLOGICAL - GLUCOCORTICOID- EMOLLIENT COMBINATIONS

Anti-Itch (HC) with

Aloe and Vitamin E 1

% topical cream

$0 (Tier 3)

Anti-Itch Plus 1 %

topical cream

$0 (Tier 3)

AVEENO ANTI-

ITCH

(HYDROCORTISO

NE) 1 % TOPICAL

CREAM

$0 (Tier 3)

Cortisone with Aloe

1 % topical cream

$0 (Tier 3)

CORTIZONE-10

WITH ALOE 1 %

TOPICAL CREAM

$0 (Tier 3)

hydrocortisone-aloe

vera 0.5 % topical

cream

$0 (Tier 3)

hydrocortisone-aloe

vera 1 % topical

cream

$0 (Tier 3)

hydrocortisone-

mineral oil-white

petrolatum 1 %

topical ointment

$0 (Tier 3)

Hydroskin with Aloe

1 % cream

$0 (Tier 3)

DERMATOLOGICAL - INSECT REPELLENTS

Drug Name Tier Drug

Restriction

hydrocortisone 1 %

topical ointment

$0 (Tier 3)

hydrocortisone

acetate 0.5 % topical

cream

$0 (Tier 3)

hydrocortisone

acetate 1 % topical

cream

$0 (Tier 3)

hydrocortisone

acetate 1 % topical

ointment

$0 (Tier 3)

Hydrocortisone Plus

1 % topical cream

$0 (Tier 3)

Hydrocream 1 %

topical

$0 (Tier 3)

HYDROSKIN 1 %

LOTION

$0 (Tier 3)

NEOSPORIN ANTI-

ITCH 1 % TOPICAL

CREAM

$0 (Tier 3)

NOBLE FORMULA

HC 1 % TOPICAL

CREAM

$0 (Tier 3)

NOBLE FORMULA

HC 1 % TOPICAL

SPRAY

$0 (Tier 3)

PREPARATION H

HYDROCORTISON

E 1 % TOPICAL

CREAM

$0 (Tier 3)

RECORT PLUS 1 %

TOPICAL CREAM

$0 (Tier 3)

Scalp Relief 1 %

topical solution

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 45

Drug Name Tier Drug

Restriction

Cutter Natural Insect

Repellent 5 %-2 %-

0.4 %-0.1 % topical

spray

$0 (Tier 3)

Cutter Natural Insect

Repellent2 5 %-2 %

topical spray

$0 (Tier 3)

Cutter Skinsations 7

% topical spray

$0 (Tier 3)

Insect Repellent

(DEET) 15 % topical

spray

$0 (Tier 3)

Insect Repellent

(picaridin) 20 %

topical spray with

pump

$0 (Tier 3)

Natrapel 20 % topical

spray

$0 (Tier 3)

Off Active 15 %

topical spray

$0 (Tier 3)

Off Deep Woods 25

% topical pump spray

$0 (Tier 3)

Off Deep Woods 25

% topical spray

$0 (Tier 3)

Off Deep Woods Dry

25 % topical spray

powder

$0 (Tier 3)

Off Deep Woods

Sportsmen 25 %

topical spray pump

$0 (Tier 3)

Off Deep Woods

Sportsmen 30 %

topical spray

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Coleman 100 Max

Insect Repellent

98.11 % topical

pump spray

$0 (Tier 3)

Coleman 100 Max

Insect Repellent

98.11 % topical spray

$0 (Tier 3)

Coleman Botanicals

Insect Repellent 30 %

topical spray

$0 (Tier 3)

Coleman High and

Dry Insect Repellent

25 % topical spray

powder

$0 (Tier 3)

Coleman SkinSmart

Insect Repellent 20 %

topical pump spray

$0 (Tier 3)

Coleman SkinSmart

Insect Repellent 20 %

topical spray

$0 (Tier 3)

Coleman Sportsmen

Insect Repellent 40 %

topical spray

$0 (Tier 3)

Cutter Backwoods 25

% topical pump spray

$0 (Tier 3)

Cutter Backwoods 25

% topical spray

$0 (Tier 3)

Cutter Backwoods

Dry 25 % topical

spray

$0 (Tier 3)

Cutter Lemon

Eucalyptus 30 %

topical spray

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 46

Drug Name Tier Drug

Restriction

Repel Sportsmen

Max 40 % lotion

$0 (Tier 3)

Repel Sportsmen

Max 40 % topical

pump spray

$0 (Tier 3)

Repel Sportsmen

Max 40 % topical

spray

$0 (Tier 3)

Repel Tick Defense

15 % topical spray

$0 (Tier 3)

Total Home Insect

Repellent 30 %

topical spray

$0 (Tier 3)

ULTRATHON 25 %

TOPICAL SPRAY

$0 (Tier 3)

ULTRATHON 34.34

% LOTION

$0 (Tier 3)

DERMATOLOGICAL - KERATOLYTIC-ANTIMITOTIC COMBINATIONS

ALA-SEB 2 %-2 %

SHAMPOO

$0 (Tier 3)

Sebex 2 %-2 %

shampoo

$0 (Tier 3)

DERMATOLOGICAL - KERATOLYTIC-ANTIMITOTIC SINGLE AGENTS

BETASAL 3 %

SHAMPOO

$0 (Tier 3)

Callus Removers 40

% topical patch

$0 (Tier 3)

Compound W 17 %

topical gel

$0 (Tier 3)

Compound W 17 %

topical liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Off Deep Woods

Sportsmen 98.25 %

topical spray pump

$0 (Tier 3)

Off FamilyCare (with

DEET) 15 % topical

spray powder

$0 (Tier 3)

Off FamilyCare (with

DEET) 5 % topical

spray

$0 (Tier 3)

Off FamilyCare (with

DEET) 7 % topical

spray

$0 (Tier 3)

Off FamilyCare (with

picaridin) 5 % topical

spray with pump

$0 (Tier 3)

Ranger Ready

Repellent 20 %

topical spray with

pump

$0 (Tier 3)

Repel 100 98.11 %

topical pump spray

$0 (Tier 3)

Repel Family 10 %

topical spray

$0 (Tier 3)

Repel Family 15 %

topical spray powder

$0 (Tier 3)

Repel Hunter's 25 %

topical spray

$0 (Tier 3)

Repel Lemon

Eucalyptus 30 %

topical spray

$0 (Tier 3)

Repel Sportsmen 25

% topical spray

$0 (Tier 3)

Repel Sportsmen Dry

25 % topical spray

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 47

Drug Name Tier Drug

Restriction

SALACTIC FILM 17

% TOPICAL

LIQUID

$0 (Tier 3)

SAL-PLANT 17 %

TOPICAL GEL

$0 (Tier 3)

SCALP ITCH-

DANDRUFF

RELIEF 3 %

TOPICAL LIQUID

$0 (Tier 3)

SCALP RELIEF 3 %

TOPICAL LIQUID

$0 (Tier 3)

SELSUN BLUE

(SALICYLIC ACID)

3 % SHAMPOO

$0 (Tier 3)

SELSUN BLUE

NATURALS 3 %

SHAMPOO

$0 (Tier 3)

Therapeutic Dandruff

Shampoo 3 %

$0 (Tier 3)

Therapeutic T Plus 3

% shampoo

$0 (Tier 3)

Wart Remover 17 %

topical gel

$0 (Tier 3)

WART REMOVER

17 % TOPICAL

LIQUID

$0 (Tier 3)

Wart Remover 40 %

topical patch

$0 (Tier 3)

Wart Remover 40 %

topical plaster

$0 (Tier 3)

DERMATOLOGICAL - KERATOPLASTIC TAR PRODUCTS

Drug Name Tier Drug

Restriction

Compound W 40 %

topical patch

$0 (Tier 3)

Corn Remover 40 %

topical patch

$0 (Tier 3)

Corn-Callus Remover

17 % topical liquid

$0 (Tier 3)

Dermarest Psoriasis

Medicated 3 %

shampoo

$0 (Tier 3)

DHS SAL 3 %

SHAMPOO

$0 (Tier 3)

LIQUID CORN

AND CALLUS

REMOVER 17 %

TOPICAL

$0 (Tier 3)

MEDICATED

CORN REMOVERS

40 % TOPICAL

PATCH

$0 (Tier 3)

Mediplast Corn-

Callus-Wart Remover

40 % topical patch

$0 (Tier 3)

Mosco Corn

Remover 40 %

topical patch

$0 (Tier 3)

NEUTROGENA

T/SAL 3 %

SHAMPOO

$0 (Tier 3)

Plantar Wart

Remover 40 %

topical patch

$0 (Tier 3)

Psoriasis Medicated 3

% shampoo

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 48

Drug Name Tier Drug

Restriction

BETA XMA

TOPICAL CREAM

$0 (Tier 3)

Carrington Moist

Barrier-Zinc 10 %-78

% topical cream

$0 (Tier 3)

PeriShield topical

ointment

$0 (Tier 3)

Sensi-Care Body

Cream 1 %-30 %

topical

$0 (Tier 3)

Soothe and Cool

Moisture Barrier 92.8

% topical ointment

$0 (Tier 3)

Soothe and Cool

Moisture Barrier 98.3

% topical ointment

$0 (Tier 3)

Soothe and Cool Skin

Paste topical

ointment

$0 (Tier 3)

DERMATOLOGICAL - PROTECTANTS

4-N-1 No Rinse

Wash 1 % topical

$0 (Tier 3)

4-N-1 No Rinse

Wash 1 % topical

cream

$0 (Tier 3)

Advanced Healing

(Petrolatum) 41 %

topical ointment

$0 (Tier 3)

ALOE VESTA

PROTECTANT

OINTMENT 43 %

$0 (Tier 3)

AmeriCerin topical

cream

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ANTI-DANDRUFF

(COAL TAR) 0.5 %

SHAMPOO

$0 (Tier 3)

DHS TAR 0.5 %

SHAMPOO

$0 (Tier 3)

DHS TAR GEL 0.5

% SHAMPOO

$0 (Tier 3)

IONIL T 1 %

SHAMPOO

$0 (Tier 3)

NEUTROGENA T-

GEL 0.5 %

SHAMPOO

$0 (Tier 3)

PC-Tar 1 % shampoo $0 (Tier 3)

Tera-Gel Tar

Shampoo 0.5 %

$0 (Tier 3)

Thera-Gel 0.5 %

shampoo

$0 (Tier 3)

Therapeutic Shampoo

0.5 %

$0 (Tier 3)

Therapeutic Shampoo

1 %

$0 (Tier 3)

T-Plus 0.5 %

shampoo

$0 (Tier 3)

DERMATOLOGICAL - MISCELLANEOUS COMBINATIONS

NAIL SCRUB

LOTION

$0 (Tier 3)

DERMATOLOGICAL - PROTECTANT COMBINATIONS

Baza Protect topical

cream

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 49

Drug Name Tier Drug

Restriction

DERMAMED

TOPICAL

OINTMENT

$0 (Tier 3)

DermaPhor 44 %

topical ointment

$0 (Tier 3)

Hydrolatum topical

ointment

$0 (Tier 3)

Hydrophor 42 %

topical ointment

$0 (Tier 3)

Kerodex-71 Wet

topical cream

$0 (Tier 3)

Lip Treatment topical

jelly

$0 (Tier 3)

Moisturel

Therapeutic 3 %

lotion

$0 (Tier 3)

NEUTRAPHOR 1 %

TOPICAL CREAM

$0 (Tier 3)

PeriGuard topical

ointment

$0 (Tier 3)

PeriShield 3.8 %

topical ointment

$0 (Tier 3)

PROSHIELD PLUS

1 % TOPICAL

OINTMENT

$0 (Tier 3)

Remedy Clear-Aid

Protect 50 % topical

ointment

$0 (Tier 3)

Remedy Dimethicone

Cream 5 % topical

$0 (Tier 3)

Remedy Nutrashield

Skin Protec 1 %

cream

$0 (Tier 3)

Drug Name Tier Drug

Restriction

AQUAPHOR

HEALING 41 %

TOPICAL

OINTMENT

$0 (Tier 3)

AQUAPHOR

ORIGINAL 41 %

TOPICAL

OINTMENT

$0 (Tier 3)

benzoin compound

10 %-2 %-8 %-4 %

topical tincture

$0 (Tier 3)

benzoin topical

tincture

$0 (Tier 3)

Carrington Moisture

Barrier Cr 61 %

topical cream

$0 (Tier 3)

COOL BOTTOMS 1

% TOPICAL

CREAM

$0 (Tier 3)

Critic-Aid Clear 71.5

% topical ointment

$0 (Tier 3)

Daylogic Advanced

Healing 41 % topical

ointment

$0 (Tier 3)

DermacinRx Skin

Repair Complex 5 %

cream

$0 (Tier 3)

Dermadrox 1.2 %

topical ointment

$0 (Tier 3)

DERMAGRAN

(ALUMINUM

HYDROXIDE) 0.275

% TOPICAL

OINTMENT

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 50

Drug Name Tier Drug

Restriction

LMX 4 PLUS 4 %

TOPICAL KIT

$0 (Tier 3)

DERMATOLOGICAL ANTIPRURITICS - ANTIHISTAMINES

diphenhydramine 2

% topical cream

$0 (Tier 3)

Itch Relief

(diphenhydramine) 2

% topical spray

$0 (Tier 3)

Wal-Dryl

(diphenhydramine) 2

% topical spray

$0 (Tier 3)

DERMATOLOGICAL IRRITANTS-COUNTER- IRRITANT COMBINATIONS

FLANDERS

BUTTOCKS

TOPICAL

OINTMENT

$0 (Tier 3)

Ziks Arthritis Pain

Relief 0.025 %-12 %-

1 % topical cream

$0 (Tier 3)

DERMATOLOGICAL IRRITANTS-COUNTER- IRRITANT SINGLE AGENTS

Arthritis Pain Relief

(capsaicin) 0.075 %

topical cream

$0 (Tier 3)

capsaicin 0.025 %

topical cream

$0 (Tier 3)

capsaicin 0.1 %

topical cream

$0 (Tier 3)

capsaicin 0.15 %

topical liquid

$0 (Tier 3)

CAPZASIN 0.15 %

TOPICAL LIQUID

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Remedy Skin Repair

1.5 % cream

$0 (Tier 3)

SECURA

DIMETHICONE 5 %

TOPICAL CREAM

$0 (Tier 3)

SWEEN 24 6 %

topical cream

$0 (Tier 3)

Walgreens Dry Skin

Treatment 41 %

topical ointment

$0 (Tier 3)

DERMATOLOGICAL - TOPICAL LOCAL ANESTHETIC AMIDES

Anecream (with

dressings) 4 %

topical kit

$0 (Tier 3)

Anecream 4 %

topical

$0 (Tier 3)

LC-4 4 % TOPICAL

CREAM

$0 (Tier 3)

lidocaine 4 % topical

cream

$0 (Tier 3)

lidocaine HCl 4 %

topical cream

$0 (Tier 3)

lidocaine-transparent

dressing 4 % topical

kit

$0 (Tier 3)

LIDOCREAM 4 %

TOPICAL

$0 (Tier 3)

LMX 4 4 %

TOPICAL CREAM

$0 (Tier 3)

LMX 4 4 %

TOPICAL KIT

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 51

Drug Name Tier Drug

Restriction SCABICIDE AND PEDICULICIDE SINGLE AGENTS

LICE KILLING

(PERMETHRIN) 1

% TOPICAL

LIQUID

$0 (Tier 3)

LICE TREATMENT

(PERMETHRIN) 1

% TOPICAL

LIQUID

$0 (Tier 3)

Lice Treatment 1 %

topical liquid

$0 (Tier 3)

Nix Creme Rinse 1 %

topical liquid

$0 (Tier 3)

permethrin 1 %

topical liquid

$0 (Tier 3)

DIAGNOSTIC AGENTS

DIAGNOSTIC - MULTIPLE URINE TESTS

Chemstrip 10 MD $0 (Tier 3)

Chemstrip 10/SG $0 (Tier 3)

Chemstrip 2 GP $0 (Tier 3)

Chemstrip 50B $0 (Tier 3)

Chemstrip 7 $0 (Tier 3)

Chemstrip 9 $0 (Tier 3)

Combistix Reagent

strips

$0 (Tier 3)

Hema-Combistix

strips

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Zostrix-HP 0.1 %

topical cream

$0 (Tier 3)

Zostrix-HP Foot 0.1

% topical cream

$0 (Tier 3)

NAIL PROTECTIVES

GENADUR

TOPICAL LIQUID

$0 (Tier 3)

SCABICIDE AND PEDICULICIDE COMBINATIONS

Complete Lice

Treatment 4 %-0.33

%-0.5 % topical kit

$0 (Tier

3)

Lice Complete Kit 1-

2-3 4 %-0.33 %-0.5

% topical kit

$0 (Tier 3)

Lice Killing 0.33 %-4

% shampoo

$0 (Tier 3)

Lice Pyrinyl

Shampoo 0.33 %-4 %

$0 (Tier 3)

LICE SOLUTION 4

%-0.33 %-0.5 %

TOPICAL KIT

$0 (Tier 3)

Lice Treatment 0.33

%-4 % shampoo

$0 (Tier 3)

RID COMPLETE

LICE

ELIMINATION KIT

4 %-0.33 %-0.5 %

TOPICAL

$0 (Tier 3)

RID LICE KILLING

0.33 %-4 %

SHAMPOO

$0 (Tier 3)

VANALICE 0.3 %-

3.5 % TOPICAL

GEL

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 52

Drug Name Tier Drug

Restriction

arginine (L-arginine)

500 mg tablet

$0 (Tier 3)

arginine (L-arginine)

oral powder

$0 (Tier 3)

arginine HCl (L-

arginine) 1,000 mg

tablet

$0 (Tier 3)

arginine HCl (L-

arginine) 500 mg

capsule

$0 (Tier 3)

CYTO ARG 70

GRAM/100 GRAM

ORAL POWDER

$0 (Tier 3)

isoleucine oral

powder

$0 (Tier 3)

Pure L-Citrulline 600

mg capsule

$0 (Tier 3)

B-COMPLEX VITAMIN COMBINATIONS

Activite 1 mg tablet $0 (Tier 3)

B Complex Plus

Vitamin C 15 mg-10

mg-50 mg-5 mg-300

mg capsule

$0 (Tier 3)

B complex-vitamin

C-folic acid ER 400

mcg tablet,extended

release

$0 (Tier 3)

B-Complex Plus

Vitamin C (and

calcium) 300 mg-150

mg calcium tablet

$0 (Tier 3)

B-complex with

vitamin C 400 mcg-

500 mg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Labstix Reagent

strips

$0 (Tier 3)

Multistix 10 SG

strips

$0 (Tier 3)

Multistix 5 strips $0 (Tier 3)

Multistix 7 strips $0 (Tier 3)

Multistix 8 SG strips $0 (Tier 3)

Multistix 9 SG strips $0 (Tier 3)

Multistix 9 strips $0 (Tier 3)

Multistix strips $0 (Tier 3)

Uristix 4 strips $0 (Tier 3)

Uristix Reagent strips $0 (Tier 3)

ELECTROLYTE BALANCE-NUTRITIONAL PRODUCTS

AMINO ACIDS, SINGLE INGREDIENT, ORAL (NON- INJECTABLE)

arginine (L-arginine)

2,000 mg oral

powder packet

$0 (Tier 3)

arginine (L-arginine)

500 mg capsule

$0 (Tier 3)

arginine (L-arginine)

500 mg oral powder

packet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 53

Drug Name Tier Drug

Restriction

Lorid 1 mg-200 mg-

300 mcg tablet

$0 (Tier 3)

Lysiplex Plus tablet $0 (Tier 3)

Mynephrocaps 1 mg

capsule

$0 (Tier 3)

Mynephron 1 mg

capsule

$0 (Tier 3)

NEPHRON FA 66

MG IRON-1,000

MCG TABLET

$0 (Tier 3)

NEPHRONEX 900

MCG/5 ML ORAL

LIQUID

$0 (Tier 3)

NEPHRONEX-SL

800 MCG-2,000

UNIT

DISINTEGRATING

TABLET

$0 (Tier 3)

NEPHRO-VITE 0.8

MG TABLET

$0 (Tier 3)

PRORENAL 8 MG

IRON-800 MCG-

1,000 UNIT

TABLET

$0 (Tier 3)

Quin B Strong 500

mg-400 mcg-15 mg

tablet

$0 (Tier 3)

RENAL CAPS 1 MG

CAPSULE

$0 (Tier 3)

Renal Vitamin 0.8

mg tablet

$0 (Tier 3)

Renal-Vite 0.8 mg

tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

B-complex with

vitamin C capsule

$0 (Tier 3)

B-complex with

vitamin C ER

tablet,extended

release

$0 (Tier 3)

B-complex with

vitamin C tablet

$0 (Tier 3)

DIALYVITE 100

MG-1 MG TABLET

$0 (Tier 3)

DIALYVITE 3000 3

MG-70 MCG-15 MG

TABLET

$0 (Tier 3)

Dialyvite 800 800

mcg chewable tablet

$0 (Tier 3)

Dialyvite 800 0.8 mg

tablet

$0 (Tier 3)

Dialyvite 800-Ultra

D 0.8 mg-2,000 unit

tablet

$0 (Tier 3)

DIALYVITE

SUPREME D 3 MG-

2,000 UNIT

TABLET

$0 (Tier 3)

Folika-T 1 mg-100

mg-300 mcg tablet

$0 (Tier 3)

Full Spectrum B-

Vitamin C 0.8 mg

tablet

$0 (Tier 3)

GENICIN VITA-S 1

MG-100 MG-300

MCG TABLET

$0 (Tier 3)

Hylavite 1 mg tablet $0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 54

Drug Name Tier Drug

Restriction

TOTAL B/C

TABLET

$0 (Tier 3)

TRIPHROCAPS 1

MG CAPSULE

$0 (Tier 3)

TRONVite 1 mg-100

mg-300 mcg tablet

$0 (Tier 3)

VIRT-CAPS 1 MG

CAPSULE

$0 (Tier 3)

Virt-Vite Plus 5 mg

tablet

$0 (Tier 3)

Vita-Bee with C 400

mcg tablet

$0 (Tier 3)

vitamin B complex-

vitamin C-folic acid

400 mcg tablet

$0 (Tier 3)

Vitasure 1 mg-100

mg-300 mcg tablet

$0 (Tier 3)

Xvite 1 mg-100 mg-

300 mcg tablet

$0 (Tier 3)

B-COMPLEX VITAMINS

Folgard 2,000 unit-

800 mcg-0.32 mg

tablet

$0 (Tier 3)

B-COMPLEX VITAMINS AND COMBINATIONS

DIALYVITE 1 MG-

100 MG-300 MCG-

50 MG TABLET

$0 (Tier 3)

NEPHPLEX RX 1

MG-60 MG-300

MCG-12.5 MG

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

RenaPlex 800 mcg-

12.5 mg tablet

$0 (Tier 3)

RenaPlex-D 800

mcg-12.5 mg-2,000

unit tablet

$0 (Tier 3)

RENA-VITE 0.8 MG

TABLET

$0 (Tier 3)

Reno Caps 1 mg

capsule

$0 (Tier 3)

STRESS B PLUS

ZINC TABLET

$0 (Tier 3)

Stress B With Zinc

tablet

$0 (Tier 3)

Stress Formula with

Iron 500 mg-400

mcg-18 mg iron

tablet

$0 (Tier 3)

Stress Formula With

Iron(sulf) 500 mg-

400 mcg-27 mg iron

tablet

$0 (Tier 3)

STRESS FORMULA

WITH ZINC

TABLET

$0 (Tier 3)

Super B Complex +

C 150 mg tablet

$0 (Tier 3)

SUPER B

COMPLEX-

VITAMIN C

TABLET

$0 (Tier 3)

Super B/C capsule $0 (Tier 3)

SUPERPLEX-T

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 55

Drug Name Tier Drug

Restriction

Megavite 18 mg iron-

800 mcg-150 mg

tablet

$0 (Tier 3)

Megavite Golden

Years 55+ 800 mcg-

150 mg-25 mg tablet

$0 (Tier 3)

NICADAN 800 MG-

10 MG-100 MG-500

MCG TABLET

$0 (Tier 3)

NICADAN ZX 400

MG-5 MG-250

MCG-10 MG

TABLET

$0 (Tier 3)

Nicazel 600 mg-5

mg-10 mg-5 mg-1.5

mg tablet

$0 (Tier 3)

NICAZEL FORTE

700 MG-500 MCG-8

MG-12 MG

TABLET

$0 (Tier 3)

Omega-3 Fish Oil

300 mg-1,000 mg

capsule

$0 (Tier 3)

One Daily 300 mg-18

mg-400 mcg-50 mg

tablet

$0 (Tier 3)

One Daily Women's

Metabolism 300 mg-

18 mg-400 mcg-50

mg tablet

$0 (Tier 3)

PHLEXY-VITS

ORAL PACKET

$0 (Tier 3)

Proxeed Plus 200

mcg-1 gram-0.5

gram-50 mg oral

powder packet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

RABANO YODADO

50 MG/15 ML

ORAL LIQUID

$0 (Tier 3)

RENA-VITE RX 1

MG-60 MG-300

MCG TABLET

$0 (Tier 3)

Vol-Care Rx 1 mg-60

mg-300 mcg tablet

$0 (Tier 3)

VP-VITE RX 1 MG-

60 MG-300 MCG

TABLET

$0 (Tier 3)

DIETARY PRODUCT - DIETARY SUPPLEMENTS

CHLOROCAPS 10

MG-30 MCG-30

MCG CAPSULE

$0 (Tier 3)

Diabetic Support

Formula 167 mcg-

100 mcg-83 mcg

tablet

$0 (Tier 3)

DRY EYE

FORMULA 133

MG-167 MG-170

MG CAPSULE

$0 (Tier 3)

Hair, Skin and Nails

Advanced 3.3 mg

iron-25 mcg tablet

$0 (Tier 3)

Hair-Skin-Nail (vit

A,C-biotin-Zn-Cu)

2,500 unit-100 mg-

2,500 mcg cap

$0 (Tier 3)

Kids Omega-3 with

DHA 25 mg-5 mg-

113.5 mg chewable

tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 56

Drug Name Tier Drug

Restriction

Eldertonic 0.5 mg-0.6

mg-7 mg-0.7 mg oral

elixir

$0 (Tier 3)

ELLIS TONIC

ORAL ELIXIR

$0 (Tier 3)

GERAVIM ORAL

LIQUID

$0 (Tier 3)

GERIATON ORAL

LIQUID

$0 (Tier 3)

Milltrium Senior

tablet

$0 (Tier 3)

Multivitamin 50 Plus

tablet

$0 (Tier 3)

multivitamin with

minerals tablet

$0 (Tier 3)

Spectravite Senior

tablet

$0 (Tier 3)

Theratrum Complete

50 Plus with Lutein

tablet

$0 (Tier 3)

Vision Plus Lutein

tablet

$0 (Tier 3)

VITRUM SENIOR

TABLET

$0 (Tier 3)

MINERALS AND ELECTROLYTES - CALCIUM REPLACEMENT

CALCI-CHEW 500

MG CALCIUM

(1,250 MG)

TABLET

$0 (Tier 3)

Calci-Mix 500 mg

calcium (1,250 mg)

capsule

$0 (Tier 3)

Drug Name Tier Drug

Restriction

REPHRESH PRO-B

2.5 BILLION CELL

CAPSULE

$0 (Tier 3)

Sea-Omega 200 mg-

300 mg-100 mg-

1,000 mg capsule

$0 (Tier 3)

Taliva 1 mg-12.5 mg-

0.5 mg-500 mg

capsule

$0 (Tier 3)

Ultra Men's Pack 200

mcg-1,600 unit-300

mg oral pack

$0 (Tier 3)

ULTRA OMEGA-3

200 MG-300 MG-

100 MG-1,000 MG

CAPSULE

$0 (Tier 3)

Vitamin D3

Complete 18 mg

iron-800 mcg-150 mg

tablet

$0 (Tier 3)

VP-ZEL 600 MG-5

MG-10 MG-5 MG-

1.5 MG TABLET

$0 (Tier 3)

GERIATRIC VITAMINS

A Thru Z High

Potency tablet

$0 (Tier 3)

A Thru Z Select

tablet

$0 (Tier 3)

Centravites 50 Plus

tablet

$0 (Tier 3)

Cerovite Senior tablet $0 (Tier 3)

Complete Senior

tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 57

Drug Name Tier Drug

Restriction

calcium citrate 200

mg (950 mg) tablet

$0 (Tier 3)

calcium citrate 250

mg tablet

$0 (Tier 3)

calcium citrate 760

mg calcium/3.5 gram

oral granules

$0 (Tier 3)

calcium lactate 100

mg calcium tablet

$0 (Tier 3)

calcium lactate 84 mg

(648 mg) tablet

$0 (Tier 3)

Cal-Mint 260 mg

calcium (650 mg)

chewable tablet

$0 (Tier 3)

OYSCO-500 500

MG CALCIUM

(1,250 MG)

TABLET

$0 (Tier 3)

Oyster Shell Calcium

500 500 mg calcium

(1,250 mg) tablet

$0 (Tier 3)

Oyster Shell Calcium

500 mg calcium

(1,250 mg) tablet

$0 (Tier 3)

MINERALS AND ELECTROLYTES - CALCIUM REPLACEMENT COMBINATIONS

BIOCAL 500 MG-

100 UNIT-45 MG-

800 MCG CAPSULE

$0 (Tier 3)

Ca 600 mg-D3 20

mcg-mag oxide 50

mg-Zn-copper-

manganese-boron

tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Calcionate 115 mg/5

mL (1.8 gram/5 mL)

oral syrup

$0 (Tier 3)

CALCITRATE 200

MG (950 MG)

TABLET

$0 (Tier 3)

Calcium 600 mg

calcium (1,500 mg)

tablet

$0 (Tier 3)

calcium carbonate

260 mg calcium (650

mg) chewable tablet

$0 (Tier 3)

calcium carbonate

500 mg calcium

(1,250 mg) chewable

tablet

$0 (Tier 3)

calcium carbonate

500 mg calcium

(1,250 mg) tablet

$0 (Tier 3)

calcium carbonate

500 mg/5 mL

calcium (1,250 mg/5

mL) oral suspension

$0 (Tier 3)

calcium carbonate

600 mg calcium

(1,500 mg) tablet

$0 (Tier 3)

calcium carbonate

800 mg calcium/2

gram oral powder

$0 (Tier 3)

calcium chloride 100

mg/mL (10 %)

intravenous solution

$0 (Tier 3)

calcium chloride 100

mg/mL (10 %)

intravenous syringe

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 58

Drug Name Tier Drug

Restriction

Calcium-Folic Acid-

Vitamin D 500 mg-

50 mg-300 unit-1 mg

oral wafer

$0 (Tier 3)

calcium-magnesium-

zinc 333 mg-133 mg-

5 mg tablet

$0 (Tier 3)

CALTRATE + D3

PLUS MINERALS

300 MG-800 UNIT-

25 MG-0.5 MG

TABLET

$0 (Tier 3)

CALTRATE 600-D

PLUS MINERALS

600 MG CALCIUM-

800 UNIT-40 MG

CHEW TABLET

$0 (Tier 3)

CALTRATE 600-D

PLUS MINERALS

600 MG CALCIUM-

800 UNIT-50 MG

TABLET

$0 (Tier 3)

CITRACAL PLUS

BONE DENSITY

BUILDER 300 MG-

200 UNIT-13.5 MG

TABLET

$0 (Tier 3)

CITRACAL-D3

MAXIMUM PLUS

325 MG-12.5 MCG-

2.75 MG TABLET

$0 (Tier 3)

CITRACAL-D3

PLUS

MAGNESIUM 250

MG-40 MG-125

UNIT TABLET

$0 (Tier 3)

Fem-Cal Citrate 200

mg-80 mg-80 unit-

0.8 mg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Ca 600 mg-D3 400

unit-mag ox 40 mg-

Zn-copper-Mn-boron

chewable tablet

$0 (Tier 3)

Ca 600 mg-D3 800

unit-mag ox 40 mg-

Zn-copper-Mn-boron

chewable tablet

$0 (Tier 3)

Cal Mag Zinc Plus

D3 333 mg-133 unit-

133 mg-5 mg tablet

$0 (Tier 3)

calcium 250 mg-D3

400 unit-magnesium

40 mg-B6-Zn-

copper-mangan tablet

$0 (Tier 3)

Calcium 600 +

Minerals 600 mg

calcium-200 unit

tablet

$0 (Tier 3)

Calcium 600 +

Minerals 600 mg

calcium-400 unit

tablet

$0 (Tier 3)

Calcium 600-D3 Plus

(mag-zinc) 600 mg

calcium-20 mcg-50

mg tablet

$0 (Tier 3)

calcium carb-vit D3-

magnesium-zinc 333

mg-200 unit-133 mg-

5 mg tablet

$0 (Tier 3)

calcium carb-vit D3-

minerals 600 mg

calcium-400 unit

tablet

$0 (Tier 3)

Calcium Citrate Plus

250 mg-40 mg-125

unit-3.75 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 59

Drug Name Tier Drug

Restriction

Calcium 600 + D(3)

600 mg (1,500 mg)-

400 unit tablet

$0 (Tier 3)

Calcium 600 + D(3)

600 mg calcium-200

unit capsule

$0 (Tier 3)

Calcium 600 with

Vitamin D3 600 mg

(1,500 mg)-400 unit

capsule

$0 (Tier 3)

Calcium 600 with

Vitamin D3 600 mg

(1,500 mg)-500 unit

capsule

$0 (Tier 3)

Calcium 600 with

Vitamin D3 600

mg(1,500 mg)-400

unit chewable tablet

$0 (Tier 3)

calcium carb-

ergocalciferol (vit

D2) 250 mg (625

mg)-125 unit tablet

$0 (Tier 3)

calcium carbonate

500 mg (1,250 mg)-

vitamin D3 125 unit

tablet

$0 (Tier 3)

calcium carbonate

500 mg (1,250 mg)-

vitamin D3 200 unit

tablet

$0 (Tier 3)

calcium carbonate

500 mg (1,250 mg)-

vitamin D3 400 unit

tablet

$0 (Tier 3)

calcium carbonate

500 mg(1,250 mg)-

vitamin D3 400 unit

chewable tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ORTHO-TABS 500

MG CALCIUM-400

UNIT-15 MCG

TABLET

$0 (Tier 3)

PRO-CAL 187.5

MG-40 MG-7.5 MG

TABLET

$0 (Tier 3)

MINERALS AND ELECTROLYTES - CALCIUM REPLACEMENT/VITAMIN D COMBINATIONS

$0 (Tier 3)

Cal-Citrate 250 mg

calcium-2.5 mcg (100

unit) tablet

$0 (Tier 3)

Calcitrate 315 mg

calcium-6.25 mcg

(250 unit) tablet

$0 (Tier 3)

Calcium 500 + D 500

mg (1,250 mg)-200

unit tablet

$0 (Tier 3)

Calcium 500 + D 500

mg (1,250 mg)-400

unit tablet

$0 (Tier 3)

Calcium 500 + D 500

mg(1,250 mg)-400

unit chewable tablet

$0 (Tier 3)

Calcium 500 mg

(1,250 mg) + D3 125

unit tablet

$0 (Tier 3)

Calcium 500 With D

500 mg (1,250 mg)-

400 unit tablet

$0 (Tier 3)

Calcium 600 + D(3)

600 mg (1,500 mg)-

200 unit tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 60

Drug Name Tier Drug

Restriction

calcium carbonate-

vitamin D3 600 mg

(1,500 mg)-800 unit

tablet

$0 (Tier 3)

calcium cit 1,000 mg

calcium-vit D3 10

mcg(400 unit)/30 mL

oral liquid

$0 (Tier 3)

Calcium Citrate + D

315 mg-5 mcg (200

unit) tablet

$0 (Tier 3)

calcium citrate 200

mg calcium-vitamin

D3 3.125 mcg (125

unit) tablet

$0 (Tier 3)

calcium citrate 200

mg calcium-vitamin

D3 6.25 mcg (250

unit) tablet

$0 (Tier 3)

calcium citrate 250

mg calcium-vitamin

D3 5 mcg (200 unit)

tablet

$0 (Tier 3)

calcium citrate 315

mg calcium-vitamin

D3 6.25 mcg (250

unit) tablet

$0 (Tier 3)

calcium citrate 315

mg-vitamin D3 5

mcg (200 unit) tablet

$0 (Tier 3)

calcium phosphate

250 mg-vit D3 12.5

mcg (500 unit)

chewable tablet

$0 (Tier 3)

calcium phosphate

250 mg-vitamin D3 5

mcg (200 unit)

chewable tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

calcium carbonate

600 mg (1,500 mg)-

vitamin D3 2,500

unit capsule

$0 (Tier 3)

calcium carbonate

600 mg (1,500 mg)-

vitamin D3 200 unit

tablet

$0 (Tier 3)

calcium carbonate

600 mg (1,500 mg)-

vitamin D3 500 unit

capsule

$0 (Tier 3)

calcium carbonate

600 mg calcium

(1,500 mg)-vit D3

1,000 unit capsule

$0 (Tier 3)

calcium carbonate-

vitamin D3 1,000 mg

(2,500 mg)-800 unit

tablet

$0 (Tier 3)

calcium carbonate-

vitamin D3 250 mg-

125 unit tablet

$0 (Tier 3)

calcium carbonate-

vitamin D3 500 mg

(1,250 mg)-600 unit

tablet

$0 (Tier 3)

calcium carbonate-

vitamin D3 500 mg-

100 unit chewable

tablet

$0 (Tier 3)

calcium carbonate-

vitamin D3 600 mg

(1,500 mg)-400 unit

capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 61

Drug Name Tier Drug

Restriction

Liquid Calcium with

Vitamin D 600 mg

calcium-200 unit

capsule

$0 (Tier 3)

OS-CAL 500 + D3

500 MG (1,250 MG)-

200 UNIT TABLET

$0 (Tier 3)

OS-CAL 500 + D3

500 MG (1,250 MG)-

600 UNIT TABLET

$0 (Tier 3)

OSTEO-

PORETICAL 600

MG (1,500 MG)-

1,000 UNIT

TABLET

$0 (Tier 3)

Oysco 500/D 500 mg

(1,250 mg)-200 unit

tablet

$0 (Tier 3)

Oyster Shell + D3

250 mg-125 unit

tablet

$0 (Tier 3)

Oyster Shell

Calcium-Vitamin D3

250 mg-125 unit

tablet

$0 (Tier 3)

Oyster Shell

Calcium-Vitamin D3

500 mg (1,250 mg)-

200 unit tablet

$0 (Tier 3)

Oyster Shell

Calcium-Vitamin D3

500 mg (1,250 mg)-

400 unit tablet

$0 (Tier 3)

Oyster Shell

Calcium-Vitamin D3

500 mg(1,250 mg)-

200 unit powder

packt

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Calcium with

Vitamin D 600 mg

(1,500 mg)-400 unit

tablet

$0 (Tier 3)

CAL-QUICK 500

MG CALCIUM-400

UNIT/5 ML ORAL

LIQUID

$0 (Tier 3)

CALTRATE 600

PLUS D 600 MG

(1,500 MG)-800

UNIT CHEWABLE

TABLET

$0 (Tier 3)

CALTRATE WITH

VITAMIN D3 600

MG (1,500 MG)-800

UNIT TABLET

$0 (Tier 3)

CITRACAL-D3

GUMMIES 250 MG-

12.5 MCG (500

UNIT) CHEWABLE

TABLET

$0 (Tier 3)

CITRACAL-D3

PETITES 200 MG

CALCIUM-6.25

MCG (250 UNIT)

TABLET

$0 (Tier 3)

Citrus Calcium-

Vitamin D3 200 mg

calcium-6.25 mcg

(250 unit) tablet

$0 (Tier 3)

Citrus Calcium-

Vitamin D3 315 mg

calcium-6.25 mcg

(250 unit) tablet

$0 (Tier 3)

Hi-Cal Plus Vit D

500 mg (1,250 mg)-

200 unit tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 62

Drug Name Tier Drug

Restriction

FEOSOL 45 MG

TABLET

$0 (Tier 3)

FERAHEME 510

MG/17 ML (30

MG/ML)

INTRAVENOUS

SOLUTION

$0 (Tier 3)

Ferate 240 mg (27

mg iron) tablet

$0 (Tier 3)

Fergon 270 mg (27

mg iron) tablet

$0 (Tier 3)

FER-IN-SOL 15 MG

IRON (75 MG)/ML

ORAL DROPS

$0 (Tier 3)

Fer-Iron 15 mg iron

(75 mg)/mL oral

drops

$0 (Tier 3)

FeroSul 220 mg (44

mg iron)/5 mL oral

elixir

$0 (Tier 3)

FEROSUL 325 MG

(65 MG IRON)

TABLET

$0 (Tier 3)

Ferrex 150 mg iron

capsule

$0 (Tier 3)

Ferric x-150 150 mg

iron capsule

$0 (Tier 3)

FERRLECIT 62.5

MG/5 ML

INTRAVENOUS

SOLUTION

$0 (Tier 3)

Ferro-Time 325 mg

(65 mg iron) tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Oystercal-D 500 mg

(1,250 mg)-400 unit

tablet

$0 (Tier 3)

PROSTEON 250 MG

CALCIUM-500

UNIT TABLET

$0 (Tier 3)

THERACAL 250

MG CALCIUM-500

UNIT TABLET

$0 (Tier 3)

THERACAL D2000

250 MG CALCIUM-

500 UNIT TABLET

$0 (Tier 3)

THERACAL D4000

250 MG CALCIUM-

1,000 UNIT

TABLET

$0 (Tier 3)

Upcal D 500 mg

calcium-12.5 mcg

(500 unit)/5 gram

oral powder

$0 (Tier 3)

Upcal D 500 mg

calcium-12.5 mcg

(500 unit)/5 gram

oral powder packet

$0 (Tier 3)

MINERALS AND ELECTROLYTES - IRON

$0 (Tier 3)

CHILDREN'S IRON

15 MG IRON (75

MG)/ML ORAL

DROPS

$0 (Tier 3)

EZFE 200 200 mg

iron capsule

$0 (Tier 3)

FEOSOL 325 MG

(65 MG IRON)

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 63

Drug Name Tier Drug

Restriction

ferrous sulfate 325

mg (65 mg iron)

tablet

$0 (Tier 3)

ferrous sulfate 325

mg (65 mg iron)

tablet,delayed release

$0 (Tier 3)

FERROUSUL 325

MG (65 MG IRON)

TABLET

$0 (Tier 3)

HEMATEX 100 MG

IRON/5 ML ORAL

LIQUID

$0 (Tier 3)

High Potency Iron

134 mg (27 mg iron)

tablet

$0 (Tier 3)

High Potency Iron 27

mg iron tablet

$0 (Tier 3)

Icar 15 mg/1.25 mL

oral suspension

$0 (Tier 3)

IFEREX 150 150

MG IRON

CAPSULE

$0 (Tier 3)

INFED 50 MG/ML

INJECTION

SOLUTION

$0 (Tier 3)

INJECTAFER 50

MG IRON/ML

INTRAVENOUS

SOLUTION

$0 (Tier 3)

IRON (DRIED) 160

MG (50 MG IRON)

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ferrous gluconate 236

mg (27 mg iron)

tablet

$0 (Tier 3)

ferrous gluconate 240

mg (27 mg iron)

tablet

$0 (Tier 3)

ferrous gluconate 256

mg (28 mg iron)

tablet

$0 (Tier 3)

ferrous gluconate 324

mg (37.5 mg iron)

tablet

$0 (Tier 3)

ferrous gluconate 324

mg (38 mg iron)

tablet

$0 (Tier 3)

ferrous sulfate 15 mg

iron (75 mg)/mL oral

drops

$0 (Tier 3)

ferrous sulfate 15 mg

iron (75 mg)/mL oral

syringe (ORAL USE)

$0 (Tier 3)

ferrous sulfate 220

mg (44 mg iron)/5

mL oral elixir

$0 (Tier 3)

ferrous sulfate 220

mg (44 mg iron)/5

mL oral solution

$0 (Tier 3)

ferrous sulfate 300

mg (60 mg iron)/5

mL oral liquid

$0 (Tier 3)

ferrous sulfate 324

mg (65 mg iron)

tablet,delayed release

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 64

Drug Name Tier Drug

Restriction

Perfect Iron 25 mg

tablet

$0 (Tier 3)

POLY-IRON 150

MG IRON

CAPSULE

$0 (Tier 3)

polysaccharide iron

complex 150 mg iron

capsule

$0 (Tier 3)

PRO FE 180 MG

IRON CAPSULE

$0 (Tier 3)

SLOW FE 142 MG

(45 MG IRON)

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

Slow Release Iron

140 mg (45 mg iron)

tablet,extended

release

$0 (Tier 3)

Slow Release Iron

142 mg (45 mg iron)

tablet,extended

release

$0 (Tier 3)

Slow Release Iron

143 mg (45 mg iron)

tablet,extended

release

$0 (Tier 3)

Slow Release Iron

144 mg (45 mg iron)

tablet,extended

release

$0 (Tier 3)

Slow Release Iron

159 mg (45 mg iron)

tablet,extended

release

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Iron (ferrous sulfate)

325 mg (65 mg iron)

tablet

$0 (Tier 3)

iron 18 mg tablet $0 (Tier 3)

iron 325 mg (65 mg

iron) tablet

$0 (Tier 3)

Iron Chews 15 mg

tablet

$0 (Tier 3)

iron ER 159 mg (45

mg iron)

tablet,extended

release

$0 (Tier 3)

Iron High Potency

240 mg (27 mg iron)

tablet

$0 (Tier 3)

iron, carbonyl 45 mg

tablet

$0 (Tier 3)

IronUp 15 mg

iron/0.5 mL oral

drops

$0 (Tier 3)

Myferon 150 150 mg

iron capsule

$0 (Tier 3)

NOVAFERRUM 15

MG IRON/ML

ORAL DROPS

$0 (Tier 3)

NOVAFERRUM 50

50 MG IRON

CAPSULE

$0 (Tier 3)

Nu-Iron 150 mg iron

capsule

$0 (Tier 3)

Pedia Iron 15 mg iron

(75 mg)/mL oral

drops

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 65

Drug Name Tier Drug

Restriction

Abatron AF 150 mg

iron-1 mg-500 mg

tablet

$0 (Tier 3)

ACTIVE FE 75 MG

IRON-1,250 MCG

TABLET

$0 (Tier 3)

Apetigen Plus 10 mg-

300 mg-30 unit tablet

$0 (Tier 3)

CENTRATEX 106

MG IRON-1 MG

CAPSULE

$0 (Tier 3)

CORVITE 150 150

MG IRON-1 MG

TABLET

$0 (Tier 3)

CORVITE FE 150

MG IRON-1 MG

TABLET

$0 (Tier 3)

FEOSOL BIFERA

28 MG TABLET

$0 (Tier 3)

FERIVA 21-7 75

MG IRON-175 MG-

1 MG-12 MCG

TABLET

$0 (Tier 3)

FERIVA FA (WITH

SUMALATE) 110

MG-175 MG-1 MG-

12 MCG CAPSULE

$0 (Tier 3)

FEROCON 110 MG-

0.5 MG CAPSULE

$0 (Tier 3)

FERREX 150 PLUS

150 MG-50 MG-50

MG CAPSULE

$0 (Tier 3)

Drug Name Tier Drug

Restriction

SLOW RELEASE

IRON 160 MG (50

MG IRON)

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

Slow Release Iron

168 mg (50 mg iron)

tablet,extended

release

$0 (Tier 3)

Slow Release Iron

250 mg (50 mg iron)

tablet,extended

release

$0 (Tier 3)

sodium ferric

gluconate complex in

sucrose 62.5 mg/5

mL intravenous

$0 (Tier 3)

TRIFERIC 272 MG

IRON POWDER

CONC. FOR

HEMODIALYSIS

$0 (Tier 3)

VENOFER 100 MG

IRON/5 ML

INTRAVENOUS

SOLUTION

$0 (Tier 3)

VENOFER 200 MG

IRON/10 ML

INTRAVENOUS

SOLUTION

$0 (Tier 3)

VENOFER 50 MG

IRON/2.5 ML

INTRAVENOUS

SOLUTION

$0 (Tier 3)

Wee Care 15 mg/1.25

mL oral suspension

$0 (Tier 3)

MINERALS AND ELECTROLYTES - IRON COMBINATIONS

OH Buckeye MMP Opt-Out Formulary August 1, 2021 66

Drug Name Tier Drug

Restriction

HEMOCYTE-PLUS

106 MG IRON-1 MG

CAPSULE

$0 (Tier 3)

IFEREX 150 FORTE

150 MG-25 MCG-1

MG CAPSULE

$0 (Tier 3)

INTEGRA F 125

MG-1 MG-40 MG-3

MG CAPSULE

$0 (Tier 3)

INTEGRA PLUS

125 MG IRON-1 MG

CAPSULE

$0 (Tier 3)

IROSPAN 24/6 65

MG-65 MG-1,000

MCG (24) TABLET

$0 (Tier 3)

Myferon 150 Forte

150 mg-25 mcg-1 mg

capsule

$0 (Tier 3)

NIFEREX

(SUMALATE-

QUATREFOLIC)

150 MG IRON-60

MG-1 MG TABLET

$0 (Tier 3)

NUFERA 125 MG-1

MG-170 MG-1,000

UNIT TABLET

$0 (Tier 3)

Parvlex 29 mg iron-

400 mcg tablet

$0 (Tier 3)

POLY-IRON 150

FORTE 150 MG-25

MCG-1 MG

CAPSULE

$0 (Tier 3)

Siderol tablet $0 (Tier 3)

Drug Name Tier Drug

Restriction

Folitab 105 mg iron-

500 mg-800 mcg

tablet,extended

release

$0 (Tier 3)

FOLIVANE-F 125

MG-1 MG-40 MG-3

MG CAPSULE

$0 (Tier 3)

FOLIVANE-PLUS

125 MG IRON-1 MG

CAPSULE

$0 (Tier 3)

FUSION PLUS 130

MG IRON-1,250

MCG CAPSULE

$0 (Tier 3)

FUSION

SPRINKLES 7 MG

IRON-250 MCG

ORAL POWDER

PACKET

$0 (Tier 3)

HEMATINIC/FOLIC

ACID 324 MG (106

MG IRON)-1 MG

TABLET

$0 (Tier 3)

HEMATOGEN FA

200 MG-250 MG-

0.01 MG-1 MG

CAPSULE

$0 (Tier 3)

HEMATOGEN

FORTE 460 MG-60

MG-0.01 MG-1 MG

CAPSULE

$0 (Tier 3)

HEMAX 150 MG

IRON-1 MG-500

MG TABLET

$0 (Tier 3)

HEMOCYTE-F 324

MG (106 MG

IRON)-1 MG

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 67

Drug Name Tier Drug

Restriction

magnesium 240 mg

(as magnesium

oxide) oral powder

packet

$0 (Tier 3)

magnesium 250 mg

(as magnesium

oxide) tablet

$0 (Tier 3)

magnesium 250 mg

tablet

$0 (Tier 3)

magnesium 400 mg

(as magnesium

oxide) capsule

$0 (Tier 3)

magnesium 400 mg

(as magnesium

oxide) tablet

$0 (Tier 3)

magnesium 64 mg

(magnesium chloride)

tablet,delayed release

$0 (Tier 3)

magnesium 70 mg

(magnesium chloride)

tablet,delayed release

$0 (Tier 3)

magnesium amino

acid chelate 27 mg

tablet

$0 (Tier 3)

magnesium citrate

100 mg tablet

$0 (Tier 3)

magnesium gluconate

27 mg magnesium

(500 mg) tablet

$0 (Tier 3)

magnesium gluconate

27.5 mg magnesium

(500 mg) tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

STRESS FORMULA

TABLET

$0 (Tier 3)

TARON FORTE 150

MG-60 MG-25

MCG-1 MG

CAPSULE

$0 (Tier 3)

TL-Hem 150 150

mg-1 mg-50 mg

tablet,extended

release

$0 (Tier 3)

TRICON 110 MG-

0.5 MG CAPSULE

$0 (Tier 3)

TRIGELS-F FORTE

460 MG-60 MG-0.01

MG-1 MG

CAPSULE

$0 (Tier 3)

Virt-FeFA Plus 125

mg iron-1 mg capsule

$0 (Tier 3)

VITAFOL 65 MG-1

MG TABLET

$0 (Tier 3)

MINERALS AND ELECTROLYTES - MAGNESIUM

Mag 64 64 mg

tablet,delayed release

$0 (Tier 3)

Mag-Delay 64 mg

tablet,delayed release

$0 (Tier 3)

Mag-Delay 70 mg

tablet,delayed release

$0 (Tier 3)

MAG-G 27 MG

MAGNESIUM (500

MG) TABLET

$0 (Tier 3)

magnesium 200 mg

(as magnesium

oxide) tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 68

Drug Name Tier Drug

Restriction

MAGONATE

(MAGNESIUM

CARB) 54 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

MagOx 400 mg

(241.3 mg

magnesium) tablet

$0 (Tier 3)

MAGTAB 84 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

MgO 400 mg (241.3

mg magnesium)

tablet

$0 (Tier 3)

Nu-Mag 71.5 mg

tablet,delayed release

$0 (Tier 3)

SLOW-MAG 71.5

MG

TABLET,DELAYED

RELEASE

$0 (Tier 3)

Triple Magnesium

Complex 400 mg

magnesium capsule

$0 (Tier 3)

MINERALS AND ELECTROLYTES - MANGANESE

manganese chloride

0.1 mg/mL

intravenous solution

$0 (Tier 3)

MINERALS AND ELECTROLYTES - MULTIPLE MINERAL COMBINATIONS

Medi-Lyte 40 mg-18

mg-9 mg tablet

$0 (Tier 3)

MINERALS AND ELECTROLYTES - ORAL ELECTROLYTES

CeraLyte-70 70

mEq-60 mEq-20

mEq-30 mEq/L oral

solution

$0 (Tier 3)

Drug Name Tier Drug

Restriction

magnesium L-lactate

ER 84 mg

tablet,extended

release

$0 (Tier 3)

magnesium oxide

400 mg (241.3 mg

magnesium) tablet

$0 (Tier 3)

magnesium oxide

420 mg tablet

$0 (Tier 3)

magnesium oxide

500 mg capsule

$0 (Tier 3)

magnesium oxide

500 mg tablet

$0 (Tier 3)

magnesium sulfate 2

gram/50 mL (4 %) in

water intravenous

piggyback

$0 (Tier 3)

magnesium sulfate 20

gram/500 mL (4 %)

in water intravenous

solution

$0 (Tier 3)

magnesium sulfate 4

gram/100 mL (4 %)

in water intravenous

piggyback

$0 (Tier 3)

magnesium sulfate 4

gram/50 mL (8 %) in

water intravenous

piggyback

$0 (Tier 3)

magnesium sulfate 40

gram/1,000 mL (4 %)

in water intravenous

solution

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 69

Drug Name Tier Drug

Restriction

Phosphorous

Supplement 280 mg-

160 mg-250 mg oral

powder packet

$0 (Tier 3)

potassium, sodium

phosphates 280 mg-

160 mg-250 mg oral

powder packet

$0 (Tier 3)

MINERALS AND ELECTROLYTES - SODIUM CHLORIDE, ORAL

sodium chloride

1,000 mg soluble

tablet

$0 (Tier 3)

MINERALS AND ELECTROLYTES - TRACE MINERALS

chromium chloride 4

mcg/mL intravenous

solution

$0 (Tier 3)

Copper Chloride 0.4

mg/mL intravenous

solution

$0 (Tier 3)

MINERALS AND ELECTROLYTES - ZINC

ORAZINC 50 MG

ZINC (220 MG)

CAPSULE

$0 (Tier 3)

Zinc (with Vitamins

A and C) Lozenges

$0 (Tier 3)

zinc chloride 1

mg/mL intravenous

solution

$0 (Tier 3)

zinc sulfate 50 mg

zinc (220 mg)

capsule

$0 (Tier 3)

ZINC-220 50 MG

ZINC (220 MG)

CAPSULE

$0 (Tier 3)

MULTIVITAMIN AND MINERAL COMBINATIONS

Drug Name Tier Drug

Restriction

electrolytes-dextrose

oral solution

$0 (Tier 3)

ENFAMIL

ENFALYTE ORAL

SOLUTION

$0 (Tier 3)

Oralyte oral solution $0 (Tier 3)

PEDIALYTE

ADVANCED CARE

ORAL SOLUTION

$0 (Tier 3)

PEDIALYTE

FREEZER POPS

ORAL SOLUTION

$0 (Tier 3)

PEDIALYTE ORAL

SOLUTION

$0 (Tier 3)

PEDIALYTE

SINGLES ORAL

SOLUTION

$0 (Tier 3)

Pediatric Electrolyte

oral solution

$0 (Tier 3)

Pediatric Freezer

Pops oral solution

$0 (Tier 3)

PEDIAVANCE 5.3

MEQ-2.35 MEQ-

4.15 MEQ ORAL

CONCENTRATE IN

PACKET

$0 (Tier 3)

THERMOTABS 287

MG-180 MG-15 MG

TABLET

$0 (Tier 3)

MINERALS AND ELECTROLYTES - PHOSPHATE

Phos-NaK 280 mg-

160 mg-250 mg oral

powder packet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 70

Drug Name Tier Drug

Restriction

Adult Multivitamin

Extra Vitamin D3

200 mcg chewable

tablet

$0 (Tier 3)

Adult Multivitamin

Gummies 200 mcg

chewable tablet

$0 (Tier 3)

Adult One Daily

Gummies 200 mcg

chewable tablet

$0 (Tier 3)

Adult One Daily

Multivitamin 0.4 mg

tablet

$0 (Tier 3)

Adults 50 Plus 0.4

mg-300 mcg-250

mcg tablet

$0 (Tier 3)

Adults' Daily

Formula 18 mg iron-

25 mcg tablet

$0 (Tier 3)

Adults Multivitamin

18 mg iron-400 mcg-

25 mcg tablet

$0 (Tier 3)

ADVANCED

MULTI EA 22.5

MG-400 MCG-150

MCG-10 MG

CHEWABLE

TABLET

$0 (Tier 3)

Alive Once Daily

Women 50 Plus 800

mcg-100 mcg tablet

$0 (Tier 3)

Alive Women's

Energy 18 mg-400

mcg-80 mcg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction $0 (Tier

3)

50 Plus Adult Eye

Health 250 mg-5 mg-

1 mg capsule

$0 (Tier 3)

A THRU Z 18 MG-

500 MCG-300 MCG-

250 MCG TABLET

$0 (Tier 3)

A Thru Z Men's

Ultimate 8 mg iron-

200 mcg-600 mcg

tablet

$0 (Tier 3)

A Thru Z Select 300

mcg-600 mcg-300

mcg tablet

$0 (Tier 3)

A Thru Z Select 50

Plus Formula 0.4 mg-

300 mcg-250 mcg

tablet

$0 (Tier 3)

A Thru Z Select 500

mcg-300 mcg-250

mcg tablet

$0 (Tier 3)

A Thru Z Select

Women's tablet

$0 (Tier 3)

ABC Plus 0.4 mg-

300 mcg-250 mcg

tablet

$0 (Tier 3)

Actical capsule $0 (Tier 3)

Adult Multi plus

Omega-3 200 mcg-

1,000 unit-25 mg

chewable tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 71

Drug Name Tier Drug

Restriction

BIO-35, GLUTEN

FREE 3 MG-133

MCG-33 MCG-33

MCG CAPSULE

$0 (Tier 3)

BIOCEL (WITH

LUTEIN) 800 MCG-

250 MCG-750 MCG

TABLET

$0 (Tier 3)

BIOSUPP ORAL

LIQUID

$0 (Tier 3)

BIOTECT PLUS

ORAL LIQUID

$0 (Tier 3)

Biotin Plus-Calcium

and Vit D3 200 mg-

450 mcg-400 unit

tablet

$0 (Tier 3)

BIOVOL ORAL

SYRUP

$0 (Tier 3)

Body, Hair, Skin and

Nails 3 mg-133 mcg

capsule

$0 (Tier 3)

Calcium Citrate Plus

(pyridoxine) 250 mg-

40 mg-5 mg-125 unit

tablet

$0 (Tier 3)

Centamin 9 mg

iron/15 mL oral

liquid

$0 (Tier 3)

CENTRAL-VITE

SENIOR 0.4 MG-300

MCG-250 MCG

TABLET

$0 (Tier 3)

Central-Vite

Women's Mature 8

mg iron-400 mcg-300

mcg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Antioxidant

A/C/E/Selenium

capsule

$0 (Tier 3)

Antioxidant Formula

(selenium yeast)

8,333 unit-167 mg-

133 unit tablet

$0 (Tier 3)

Antioxidant Vitamins

1,000 unit-200 mg-60

unit-2mg tablet

$0 (Tier 3)

Apatate Forte oral

liquid

$0 (Tier 3)

AQUADEKS 100

MCG-350 MCG-5

MG CHEWABLE

TABLET

$0 (Tier 3)

AQUADEKS 100

MCG-700 MCG-10

MG CAPSULE

$0 (Tier 3)

BACMIN 27 MG

IRON-1 MG

TABLET

$0 (Tier 3)

BARIATRIC

MULTIVITAMINS

45 MG IRON-800

MCG-120 MCG

CAPSULE

$0 (Tier 3)

Bee-Zee tablet $0 (Tier 3)

BEROCCA (FA-

GUARANA-CAFF)

400 MCG-89.45 MG-

44 MG

EFFERVESCENT

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 72

Drug Name Tier Drug

Restriction

CENTRUM SILVER

MEN 300 MCG-600

MCG-300 MCG

TABLET

$0 (Tier 3)

CENTRUM SILVER

ULTRA MEN'S 300

MCG-600 MCG-300

MCG TABLET

$0 (Tier 3)

CENTRUM SILVER

WOMEN 8 MG

IRON-400 MCG-300

MCG TABLET

$0 (Tier 3)

CENTRUM

SPECIALIST

HEART 3 MG-200

MCG-400 MG

TABLET

$0 (Tier 3)

CENTRUM ULTRA

MEN'S 8 MG IRON-

200 MCG-600 MCG

TABLET

$0 (Tier 3)

Century Adults 50

Plus 0.4 mg-300

mcg-250 mcg tablet

$0 (Tier 3)

Century Cardio 3 mg-

200 mcg-400 mg

tablet

$0 (Tier 3)

CENTURY

ENERGY

METABOLISM 18

MG IRON-400

MCG-50 MG

TABLET

$0 (Tier 3)

Century Mature 0.4

mg-300 mcg-250

mcg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Centram-Care 9 mg

iron/15 mL oral

liquid

$0 (Tier 3)

Centravites 0.4 mg-

162 mg-18 mg tablet

$0 (Tier 3)

Centravites Adults 18

mg iron-400 mcg-25

mcg tablet

$0 (Tier 3)

CENTRUM 3,500

UNIT-18 MG-0.4

MG CHEWABLE

TABLET

$0 (Tier 3)

CENTRUM 9 MG

IRON/15 ML ORAL

LIQUID

$0 (Tier 3)

CENTRUM

CHEWABLES 8 MG

IRON-400 MCG-10

MCG TABLET

$0 (Tier 3)

CENTRUM

FLAVOR BURST

KIDS CHEWABLE

TABLET

$0 (Tier 3)

CENTRUM MEN 8

MG IRON-200

MCG-600 MCG

TABLET

$0 (Tier 3)

CENTRUM SILVER

0.4 MG-300 MCG-

250 MCG TABLET

$0 (Tier 3)

CENTRUM SILVER

400 MCG-250 MCG

CHEWABLE

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 73

Drug Name Tier Drug

Restriction

Complete Men 50

Plus 300 mcg-600

mcg-300 mcg tablet

$0 (Tier 3)

Complete Men 8 mg

iron-200 mcg-600

mcg tablet

$0 (Tier 3)

Complete

Multivitamin Adult

50 Plus 0.4 mg-300

mcg-250 mcg tablet

$0 (Tier 3)

Complete

Multivitamin tablet

$0 (Tier 3)

Complete

Multivitamin-

Multimineral 9 mg

iron/15 mL oral

liquid

$0 (Tier 3)

COMPLETE

PREMIUM

VITAMIN TABLET

$0 (Tier 3)

COMPLETE

SENIOR 0.4 MG-300

MCG-250 MCG

TABLET

$0 (Tier 3)

CORVITA 1.25 MG-

2.5 MG-7 MG

TABLET

$0 (Tier 3)

CORVITE 1.25 MG-

2.5 MG-7 MG

TABLET

$0 (Tier 3)

CORVITE FREE

1.25 MG-400 MCG-

125 MCG-35 MG

TABLET

$0 (Tier 3)

Daily Gummies 200

mcg chewable tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Century Mature 400

mcg-30 mcg tablet

$0 (Tier 3)

Century Men's 8 mg

iron-200 mcg-60 mcg

tablet

$0 (Tier 3)

Century Ultimate

Men's 300 mcg-600

mcg-300 mcg tablet

$0 (Tier 3)

Century Ultimate

Men's 8 mg iron-200

mcg-600 mcg tablet

$0 (Tier 3)

Century Ultimate

Women's 8 mg iron-

400 mcg-300 mcg

tablet

$0 (Tier 3)

Cerovite 9 mg

iron/15 mL oral

liquid

$0 (Tier 3)

Certa Plus 18 mg-0.4

mg-250 mcg tablet

$0 (Tier 3)

CertaVite Senior 0.4

mg-300 mcg-250

mcg tablet

$0 (Tier 3)

CertaVite-

Antioxidants (iron

gluc) 9 mg iron/15

mL oral liquid

$0 (Tier 3)

COMPETE TABLET $0 (Tier 3)

COMPLETE 18 MG-

500 MCG-300 MCG-

250 MCG TABLET

$0 (Tier 3)

Complete 50 Plus 0.4

mg-300 mcg-250

mcg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 74

Drug Name Tier Drug

Restriction

DEKAs Plus (folic

acid) 200 mcg-1,000

mcg-10 mg capsule

$0 (Tier 3)

DEKAs Plus (folic

acid) 200 mcg-1,000

mcg-10 mg chewable

tablet

$0 (Tier 3)

DermacinRx Folitin-

Z 9 mg iron-500 mcg

tablet

$0 (Tier 3)

DermacinRx Venexa

1,000 mcg tablet

$0 (Tier 3)

DermacinRx Venexa

FE 27 mg iron-1 mg

tablet

$0 (Tier 3)

DermacinRx Vitranol

FE 27 mg iron-1 mg

tablet

$0 (Tier 3)

Diabetes Health 0.8

mg-250 mg-50 mg

oral pack

$0 (Tier 3)

Diabetes Health

Formula 500 mcg-

250 mcg tablet

$0 (Tier 3)

DIALYVITE 5000 5

MG TABLET

$0 (Tier 3)

Endur-VM Iron-Free

400 mcg

tablet,extended

release

$0 (Tier 3)

Endur-VM with Iron

18 mg iron-400 mcg

tablet,extended

release

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Daily Multiple 400

mcg-120 mg tablet

$0 (Tier 3)

Daily Multiple For

Men 0.4 mg tablet

$0 (Tier 3)

Daily Multiple For

Women 18 mg iron-

400 mcg-500 mg Ca

tablet

$0 (Tier 3)

Daily Multiple For

Women 50+ 0.4 mg

tablet

$0 (Tier 3)

DAILY MULTIPLE

TABLET

$0 (Tier 3)

Daily Multivitamin

200 mcg-100 mcg-

500 mcg capsule

$0 (Tier 3)

DAILY VITAMIN

FORMULA-

MINERALS tablet

$0 (Tier 3)

Daily Vitamin with

Iron and CA tablet

$0 (Tier 3)

DAILY VITAMIN

WITH IRON

TABLET

$0 (Tier 3)

Daily Vites/Iron

tablet

$0 (Tier 3)

Daily-Vite tablet $0 (Tier 3)

DEKAs Bariatric

22.5 mg-400 mcg-

500 mcg-10 mg

chewable tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 75

Drug Name Tier Drug

Restriction

GERITOL

COMPLETE 16 MG

IRON-0.38 MG

TABLET

$0 (Tier 3)

Hair Formula 400

mcg-100 mcg tablet

$0 (Tier 3)

Hair, Skin and Nails-

Argan Oil 66.7 mcg-

1,666.7 mcg capsule

$0 (Tier 3)

Hair,Skin and Nails

(folic acid-biotin)

66.7 mcg-1,000 mcg

tablet

$0 (Tier 3)

Hair,Skin and Nails

(folic acid-biotin)

66.7 mcg-1,666.7

mcg tablet

$0 (Tier 3)

Hair,Skin and Nails 1

mg iron-66.7 mcg-

1,000 mcg tablet

$0 (Tier 3)

HAIR,SKIN AND

NAILS TABLET

$0 (Tier 3)

Hair-Skin-Nails

(PABA) 3 mg-133

mcg capsule

$0 (Tier 3)

Healthy Eyes 1,000

unit-200 mg-60 unit-

2mg tablet

$0 (Tier 3)

Healthy Eyes

SuperVision 14,320

unit-226 mg-200 unit

capsule

$0 (Tier 3)

High Potency

Multivitamin (w-

iron) 9 mg iron-400

mcg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ESSENTIAL DAILY

18 MG-0.4 MG

TABLET

$0 (Tier 3)

ESSENTIAL Man

0.4 mg-2 mg-250

mcg tablet

$0 (Tier 3)

ESSENTIAL Man

50+ 0.4 mg-2 mg-250

mcg tablet

$0 (Tier 3)

Essential Woman

50+ 0.4 mg-250 mcg

tablet

$0 (Tier 3)

ESTROVEN

MENOPAUSE 400

MCG-40 MG-40

MG-100 MG

TABLET

$0 (Tier 3)

Eye Health Plus

Lutein 1,000 unit-200

mg-60 unit-2mg

tablet

$0 (Tier 3)

Eye Vitamin and

Minerals 7,160 unit-

113 mg-100 unit

tablet

$0 (Tier 3)

EyeProtect 7,160

unit-113 mg-100 unit

tablet

$0 (Tier 3)

FOSFREE 175.5

MG-14.5 MG

TABLET

$0 (Tier 3)

Freedavite 1.8 mg

iron-400 mcg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 76

Drug Name Tier Drug

Restriction

LIFE-PACK

WOMEN'S 0.8 MG

ORAL PACK

$0 (Tier 3)

MACULAR

BENEFITS 550 MG-

2.5 MG-50 MCG

ORAL PACK

$0 (Tier 3)

MACULAR

HEALTH

FORMULA 5 MG-1

MG-7.5 MG

CAPSULE

$0 (Tier 3)

Macuvite Eye Care

7,160 unit-113 mg-1

mg tablet

$0 (Tier 3)

Maximin Pack 0.8

mg-250 mcg oral

pack

$0 (Tier 3)

MAXIMUM DAILY

GREEN 5 MG-133

MCG TABLET

$0 (Tier 3)

Maximum Daily

Multivitamin 18 mg-

0.4 mg tablet

$0 (Tier 3)

Mega Multi for

Women 13.5 mg-200

mcg-250 mcg tablet

$0 (Tier 3)

Mega Multivitamin

For Men 200 mcg-

175 mcg-250 mcg

tablet

$0 (Tier 3)

Mega Multivitamin

with Minerals 13.5

mg-200 mcg-250

mcg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

I-CAPS 280 MG-10

MG-2 MG

CAPSULE

$0 (Tier 3)

ICAPS AREDS

14,320 UNIT-226

MG-200 UNIT

CAPSULE

$0 (Tier 3)

ICAPS AREDS2 250

MG-200 UNIT-12.5

MG-1 MG

CAPSULE

$0 (Tier 3)

ICAPS MV 100

MCG-1.66 MG-0.83

MG

TABLET,DELAYED

RELEASE

$0 (Tier 3)

I-Vite 1,000 unit-200

mg-60 unit-2mg

tablet

$0 (Tier 3)

I-Vite Protect 7,160

unit-113 mg-100 unit

tablet

$0 (Tier 3)

K-PAX 4.5 MG

IRON-200 MCG

CAPSULE

$0 (Tier 3)

K-PAX 9 MG IRON-

400 MCG CAPSULE

$0 (Tier 3)

K-PAX IMMUNE

SUPPORT 2.25 MG

IRON-100 MCG

TABLET

$0 (Tier 3)

LIFE-PACK MEN'S

0.8 MG ORAL

PACK

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 77

Drug Name Tier Drug

Restriction

Men's Pack 0.4 mg-

250 mcg oral pack

$0 (Tier 3)

MONOCAPS 14 MG

IRON-400 MCG

TABLET

$0 (Tier 3)

Multi For Her 18 mg

iron-600 mcg-40 mcg

capsule

$0 (Tier 3)

Multi For Her 18 mg

iron-600 mcg-80 mcg

tablet

$0 (Tier 3)

Multi For Her 50

Plus 400 mcg-80 mcg

capsule

$0 (Tier 3)

Multi Vitamin 9 mg

iron/15 mL oral

liquid

$0 (Tier 3)

Multi-Day Plus

Minerals 18 mg iron-

400 mcg-25 mcg

tablet

$0 (Tier 3)

Multi-Delyn with

Iron 10 mg iron/5 mL

oral liquid

$0 (Tier 3)

Multilex 15 mg iron

tablet

$0 (Tier 3)

Multilex-T and M 15

mg iron tablet

$0 (Tier 3)

MULTILEX-T AND

M TABLET

$0 (Tier 3)

Multiple Vitamin,

Womens tablet

$0 (Tier 3)

Multiple Vitamin-

Minerals tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Men 50 Plus

Advanced One Daily

400 mcg-20 mcg-370

mcg tablet

$0 (Tier 3)

Men 50 Plus

Multivitamin 300

mcg-600 mcg-300

mcg tablet

$0 (Tier 3)

Men's 50 Plus Daily

Formula 400 mcg-20

mcg-370 mcg tablet

$0 (Tier 3)

Men's Daily 0.4 mg-

600 mcg capsule

$0 (Tier 3)

Men's Daily Formula

400 mcg-20 mcg-300

mcg tablet

$0 (Tier 3)

Men's Daily

Gummies 200 mcg

chewable tablet

$0 (Tier 3)

Men's Multivitamin

400 mcg-20 mcg-300

mcg tablet

$0 (Tier 3)

Men's Multivitamin

Gummies 200 mcg

chewable tablet

$0 (Tier 3)

Mens Multivitamin

High Potency 200

mcg-175 mcg-250

mcg tablet

$0 (Tier 3)

Men's One Daily 400

mcg-20 mcg-300

mcg tablet

$0 (Tier 3)

MEN'S ONE DAILY

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 78

Drug Name Tier Drug

Restriction

NICOMIDE

(SELENIUM-

CHROMIUM) 500

MCG-750 MG

TABLET

$0 (Tier 3)

Nicotinamide (with

chromium) 500 mcg-

750 mg tablet

$0 (Tier 3)

NUTRICAP 1 MG

TABLET

$0 (Tier 3)

Ocular Vitamins

7,160 unit-113 mg-

0.5 mg tablet

$0 (Tier 3)

Ocutabs tablet $0 (Tier 3)

OCUVITE ADULT

50 PLUS 250 MG-5

MG-1 MG

CAPSULE

$0 (Tier 3)

OCUVITE EYE

PLUS MULTI 200

MCG-15 MCG-150

MCG TABLET

$0 (Tier 3)

OCUVITE WITH

LUTEIN 1,000

UNIT-200 MG-60

UNIT-2MG

TABLET

$0 (Tier 3)

Omnicap 0.4 mg

tablet

$0 (Tier 3)

One Daily 0.4 mg-

600 mcg tablet

$0 (Tier 3)

One Daily

Calcium/Iron tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

multivit and

minerals-ferrous

gluconate 9 mg

iron/15 mL oral

liquid

$0 (Tier 3)

multivit with min-

folic acid-lutein 200

mcg-137.5 mcg

chewable tablet

$0 (Tier 3)

MULTIVITAMIN

WITH IRON

TABLET

$0 (Tier 3)

multivitamin with

minerals 9 mg

iron/15 mL oral

liquid

$0 (Tier 3)

multivitamin with

minerals-ferrous

fumarate 15 mg iron

tablet

$0 (Tier 3)

Multivitamin Women

50 Plus 8 mg iron-

400 mcg-300 mcg

tablet

$0 (Tier 3)

multivitamin-

minerals-iron

fumarate 7.5 mg-folic

acid 400 mcg tablet

$0 (Tier 3)

Multi-Vite 9 mg

iron/15 mL oral

liquid

$0 (Tier 3)

My-Vitalife capsule $0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 79

Drug Name Tier Drug

Restriction

One Daily

Multivitamins with

Minerals 4.5 mg iron

oral powder packet

$0 (Tier 3)

One Daily

Multivitamins with

Minerals 4.5 mg iron

tablet

$0 (Tier 3)

ONE DAILY PLUS

MINERALS

TABLET

$0 (Tier 3)

ONE DAILY WITH

IRON TABLET

$0 (Tier 3)

One Daily Women 50

Plus 400 mcg-120 mg

tablet

$0 (Tier 3)

One Daily Women 50

Plus(Vit K) 400 mcg-

500 mg calcium-20

mcg tablet

$0 (Tier 3)

One Daily Women's

18 mg iron-400 mcg-

25 mcg tablet

$0 (Tier 3)

One Daily Women's

18 mg iron-400 mcg-

450 mg Ca tablet

$0 (Tier 3)

ONE DAILY

WOMENS 50 PLUS

0.4 MG TABLET

$0 (Tier 3)

ONE-A-DAY

ENERGY 9 MG

IRON-400 MCG-200

MG TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

One Daily Complete

18 mg-0.4 mg tablet

$0 (Tier 3)

One Daily Complete

tablet

$0 (Tier 3)

One Daily Energy

tablet

$0 (Tier 3)

One Daily Essential

0.4 mg tablet

$0 (Tier 3)

One Daily For Men

0.4 mg-600 mcg

tablet

$0 (Tier 3)

One Daily For

Women 18 mg-0.4

mg tablet

$0 (Tier

3)

ONE DAILY

GUMMY VITES 200

MCG CHEWABLE

TABLET

$0 (Tier 3)

One Daily Healthy

Weight 200 mg-18

mg-0.4 mg tablet

$0 (Tier 3)

One Daily Maximum

18 mg-0.4 mg tablet

$0 (Tier 3)

One Daily Men's 50

Plus Advanced 400

mcg-20 mcg tablet

$0 (Tier 3)

One Daily Men's 50

Plus with D3 400

mcg-20 mcg-370

mcg tablet

$0 (Tier 3)

One Daily

Multivitamin with

Iron 18 mg iron tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 80

Drug Name Tier Drug

Restriction

ONE-A-DAY

WEIGHTSMART

200 MG-18 MG-0.4

MG TABLET

$0 (Tier 3)

ONE-A-DAY

WOMEN

VITACRAVES 200

MCG CHEWABLE

TABLET

$0 (Tier 3)

ONE-A-DAY

WOMEN'S 50 PLUS

400 MCG-20 MCG

TABLET

$0 (Tier 3)

ONE-A-DAY

WOMEN'S ACTIVE

18 MG IRON-400

MCG-180 MG

TABLET

$0 (Tier 3)

ONE-A-DAY

WOMEN'S

HEALTHY SKIN 18

MG IRON-400

MCG-6 MG

TABLET

$0 (Tier 3)

ONE-A-DAY

WOMEN'S PETITES

9 MG IRON-200

MCG TABLET

$0 (Tier 3)

Optisource 9 mg

iron-200 mcg-40 mcg

chewable tablet

$0 (Tier 3)

OPTI-VITAMINS

1,000 UNIT-200

MG-60 UNIT-2MG

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ONE-A-DAY MEN

VITACRAVES 200

MCG CHEWABLE

TABLET

$0 (Tier 3)

ONE-A-DAY

MENOPAUSE

FORMULA 400

MCG-60 MG

TABLET

$0 (Tier 3)

ONE-A-DAY

MEN'S 50 PLUS 400

MCG-20 MCG-370

MCG TABLET

$0 (Tier 3)

ONE-A-DAY

MEN'S

MULTIVITAMIN

400 MCG-20 MCG-

300 MCG TABLET

$0 (Tier 3)

ONE-A-DAY

PROACTIVE 65

PLUS 200 MCG

TABLET

$0 (Tier 3)

ONE-A-DAY

VITACRAVES 200

MCG CHEWABLE

TABLET

$0 (Tier 3)

ONE-A-DAY

VITACRAVES

IMMUNITY 200

MCG CHEWABLE

TABLET

$0 (Tier 3)

ONE-A-DAY

VITACRAVES

OMEGA-3 200

MCG-16 MG

CHEWABLE

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 81

Drug Name Tier Drug

Restriction

PROTECT PLUS NF

10 MG IRON-1

MG/15 ML ORAL

LIQUID

$0 (Tier 3)

PROTECT PLUS SO

0.5 MG-15 MG

CAPSULE

$0 (Tier 3)

PUREFE PLUS 106

MG IRON-1 MG

CAPSULE

$0 (Tier 3)

QUINTABS-M 10

MG IRON-400 MCG

TABLET

$0 (Tier 3)

Quintabs-M Iron Free

0.4 mg tablet

$0 (Tier 3)

REQ49+ 200 MCG-

1.5 MG-1.5 MG

TABLET

$0 (Tier 3)

SAVision tablet $0 (Tier 3)

Senior Tabs 0.4 mg-

300 mcg-250 mcg

tablet

$0 (Tier 3)

SENTRY (WITH

LUTEIN) 18 MG-

500 MCG-300 MCG-

250 MCG TABLET

$0 (Tier 3)

Sentry Senior 0.4

mg-300 mcg-250

mcg tablet

$0 (Tier 3)

SENTRY SENIOR

500 MCG-300 MCG-

250 MCG TABLET

$0 (Tier 3)

SOLO 400 MCG-80

MCG TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

OPURITY

MULTIVITAMIN 30

MG IRON-800 MCG

CHEWABLE

TABLET

$0 (Tier 3)

Polyvitamin with

Iron(with Vit K) 18

mg iron-0.4 mg-55

mcg chew tablet

$0 (Tier 3)

PRESERVISION

AREDS 14,320

UNIT-226 MG-200

UNIT CAPSULE

$0 (Tier 3)

PRESERVISION

AREDS 7,160 UNIT-

113 MG-100 UNIT

TABLET

$0 (Tier 3)

PRESERVISION

LUTEIN 226 MG-

200 UNIT-5 MG-0.8

MG CAPSULE

$0 (Tier 3)

Prevent capsule $0 (Tier 3)

PROCERV HP 9 MG

IRON-300 MCG-50

MCG TABLET

$0 (Tier 3)

PRORENAL QD 400

MCG-500 UNIT

CAPSULE

$0 (Tier 3)

Prosight with Lutein

60 mg-30 unit-6 mg

capsule

$0 (Tier 3)

PROTECT CARDIO

AF 0.5 MG-30 MG-

60 MG-90 MG

CAPSULE

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 82

Drug Name Tier Drug

Restriction

Stress B-Complex

500 mg-400 mcg-

23.9 mg-3 mg tablet

$0 (Tier 3)

Stress B-Complex

500 mg-400 mcg-24

mg-3 mg tablet

$0 (Tier 3)

STROVITE FORTE

10 MG-1 MG

TABLET

$0 (Tier 3)

STROVITE ONE 1

MG-1,000 UNIT-15

MG-5 MG TABLET

$0 (Tier 3)

Sunvite 18 mg iron-

400 mcg-25 mcg

tablet

$0 (Tier 3)

Super Antioxidant

capsule

$0 (Tier 3)

Super Multiple - Low

Iron 400 mcg tablet

$0 (Tier 3)

Super Multiple 0.4

mg capsule

$0 (Tier 3)

Super Multiple tablet $0 (Tier 3)

SUPER THERA

VITE M TABLET

$0 (Tier 3)

Support oral liquid $0 (Tier 3)

Tab-A-Vite

Multivitamin w-iron

15 mg iron-400 mcg

tablet

$0 (Tier 3)

TAB-A-VITE/IRON

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Spectravite Adult 200

mcg chewable tablet

$0 (Tier 3)

Spectravite Adult 50

Plus 0.4 mg-300

mcg-250 mcg tablet

$0 (Tier 3)

Spectravite Adult 50

Plus(with lutein) 500

mcg-250 mcg

chewable tablet

$0 (Tier 3)

Spectravite Men 50

Plus 300 mcg-600

mcg-300 mcg tablet

$0 (Tier 3)

Spectravite Men's 8

mg iron-200 mcg-600

mcg tablet

$0 (Tier 3)

Spectravite Senior

500 mcg-300 mcg-

250 mcg tablet

$0 (Tier 3)

Spectravite Ultra

Men 50+ 300 mcg-

600 mcg-300 mcg

tablet

$0 (Tier 3)

Spectravite Ultra

Men's Senior 300

mcg-600 mcg-300

mcg tablet

$0 (Tier 3)

Spectravite Ultra

Women's Senior 8

mg iron-400 mcg-300

mcg tablet

$0 (Tier 3)

Spectravite Women

50 Plus 8 mg iron-

400 mcg-300 mcg

tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 83

Drug Name Tier Drug

Restriction

THERATRUM

COMPLETE WITH

LUTEIN TABLET

$0 (Tier 3)

Therems tablet $0 (Tier 3)

Therems-H 27 mg-

0.33 mg tablet

$0 (Tier 3)

THEREMS-M 27

MG-0.4 MG

TABLET

$0 (Tier 3)

Totalday Multiple

tablet,extended

release

$0 (Tier 3)

TRUEplus Diabetic

Multivitamin 500

mcg-10 mcg tablet

$0 (Tier 3)

ULTIMATE MEN'S

COMPLETE 50+

300 MCG-600 MCG-

300 MCG TABLET

$0 (Tier 3)

Ultimate Women's

Complete 50+ 8 mg

iron-400 mcg-300

mcg tablet

$0 (Tier 3)

Ultra Freeda 267 mcg

tablet

$0 (Tier 3)

Ultra Freeda 6 mg

iron-267 mcg tablet

$0 (Tier 3)

Unicomplex-M tablet $0 (Tier 3)

V-C FORTE 1 MG

CAPSULE

$0 (Tier 3)

VIC-Forte 1 mg

capsule

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Tab-A-Vite-Minerals

tablet

$0 (Tier 3)

Thera M Plus

(ferrous fumarate) 9

mg iron-400 mcg

tablet

$0 (Tier 3)

Theragran-M Premier

50 Plus 400 mcg-250

mcg-375 mcg tablet

$0 (Tier 3)

THERALOGIX

COMPANION 0.4

MG TABLET

$0 (Tier 3)

Thera-M 27 mg-0.4

mg tablet

$0 (Tier 3)

Thera-M 9 mg iron-

400 mcg tablet

$0 (Tier 3)

THERA-M TABLET $0 (Tier 3)

THERANATAL 9

MG IRON-400

MCG-90 MCG

ORAL PACK

$0 (Tier 3)

THERAPEUTIC-M

VITAMIN/MINERA

LS 27 MG-0.4 MG

TABLET

$0 (Tier 3)

Thera-Tabs M 27 mg

iron-400 mcg tablet

$0 (Tier 3)

Theratrum Complete

50

Plus(lycopene,lutein)

0.4 mg-300 mcg-250

mcg tab

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 84

Drug Name Tier Drug

Restriction

Women's 50 Plus

Daily Formula 400

mcg-500 mg

calcium-20 mcg

tablet

$0 (Tier 3)

Women's Active 18

mg iron-400 mcg-180

mg tablet

$0 (Tier 3)

Women's Daily

Formula 18 mg iron-

400 mcg-500 mg Ca

tablet

$0 (Tier 3)

Women's Daily

Formula 18 mg iron-

400 mcg-500 mg

tablet

$0 (Tier 3)

Women's Daily

Formula 27 mg-0.4

mg tablet

$0 (Tier 3)

Womens Daily

Gummies 200 mcg

chewable tablet

$0 (Tier 3)

Women's Daily Pack

400 mcg-800 mg-10

mcg tablet

$0 (Tier 3)

Women's

Multivitamin 18 mg

iron-400 mcg-500 mg

tablet

$0 (Tier 3)

Women's

Multivitamin 18 mg-

400 mcg-500 mg-50

mcg tablet

$0 (Tier 3)

Women's

Multivitamin

Gummies 200 mcg

chewable tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Vision Formula (A-

C-E-zinc-copper)

14,320 unit-226 mg-

200 unit capsule

$0 (Tier 3)

Vision Formula (with

lutein) 1,000 unit-200

mg-60 unit-2mg

tablet

$0 (Tier 3)

Vision Formula(A-C-

E-Zn-Se-Cu) 1,000

unit-60 mg-30 unit

tablet

$0 (Tier 3)

VISION-VITE +

ZINC TABLET

$0 (Tier 3)

Vitabex Plus 500

mcg-25 mg-10 mg

capsule

$0 (Tier 3)

Vitacel (with Lutein)

800 mcg-250 mcg-

750 mcg tablet

$0 (Tier 3)

Vitalee 0.4 mg tablet $0 (Tier 3)

Vitamins A-D-E with

selenium 10,000 unit-

400 unit tablet

$0 (Tier 3)

Vitamins and

Minerals tablet

$0 (Tier 3)

Vitatrum 18 mg-500

mcg-300 mcg-250

mcg tablet

$0 (Tier 3)

Vitrexyl 1,000 mcg

tablet

$0 (Tier 3)

Vitrexyl Plus Iron 27

mg iron-1 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 85

Drug Name Tier Drug

Restriction

Complete

Multivitamin-

Multimineral 18 mg-

400 mcg tablet

$0 (Tier 3)

Complete Women 18

mg-400 mcg tablet

$0 (Tier 3)

DAILY MULTIPLE

FOR MEN 50+ 400

MCG-600 MCG-120

MG TABLET

$0 (Tier 3)

DAILY MULTI-

VITAMIN TABLET

$0 (Tier 3)

Daily Multivitamin

with Iron 18 mg-400

mcg tablet

$0 (Tier 3)

Daily Value tablet $0 (Tier 3)

Daily Vitamin

Formula tablet

$0 (Tier 3)

Daily Vitamin

Formula-Iron 18 mg-

400 mcg tablet

$0 (Tier 3)

DECUBI VITE 400

MCG-50 MG-500

MG CAPSULE

$0 (Tier 3)

DEKAs Essential

2,000 unit-2,000

mcg/mL oral liquid

$0 (Tier 3)

Diabetes Health

Support 800 mcg oral

pack

$0 (Tier 3)

E-400 C-500 and

Beta Carotene tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Womens

Multivitamin High

Potency 13.5 mg-200

mcg-250 mcg tablet

$0 (Tier 3)

Women's One Daily

18 mg iron-400 mcg-

500 mg Ca tablet

$0 (Tier 3)

Zyvana 6 mg-263.5

mg-20.5 mcg-11.5mg

capsule

$0 (Tier 3)

MULTIVITAMINS

A Thru Z Advanced

Formula 18 mg-400

mcg tablet

$0 (Tier 3)

CENTRAL-VITE 18

MG-400 MCG

TABLET

$0 (Tier 3)

CENTRUM

COMPLETE 18 MG-

400 MCG TABLET

$0 (Tier 3)

CENTRUM

WOMEN 18 MG-

400 MCG TABLET

$0 (Tier 3)

Century 18 mg-400

mcg tablet

$0 (Tier 3)

Century Ultimate

Women's 18 mg-400

mcg tablet

$0 (Tier 3)

Cerovite Advanced

Formula 18 mg-400

mcg tablet

$0 (Tier 3)

Certavite-Antioxidant

18 mg-400 mcg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 86

Drug Name Tier Drug

Restriction

Multi-Day with Iron

18 mg-400 mcg tablet

$0 (Tier 3)

Multiple Vitamins

tablet

$0 (Tier 3)

multivitamin capsule $0 (Tier 3)

multivitamin tablet $0 (Tier 3)

Once Daily tablet $0 (Tier 3)

ONCOVITE

TABLET

$0 (Tier 3)

One Daily Essential

400 mcg tablet

$0 (Tier 3)

One Daily Essential

tablet

$0 (Tier 3)

One Daily For Men

50+ Advanced 400

mcg-600 mcg-120

mg tablet

$0 (Tier 3)

One Daily Men's 50

Plus Memory

Support 400 mcg-600

mcg-120 mg tablet

$0 (Tier 3)

One Daily

Multivitamin oral

powder packet

$0 (Tier 3)

ONE DAILY

MULTIVITAMIN

TABLET

$0 (Tier 3)

One Daily

Multivitamin with

Iron (folic acid) 18

mg-400 mcg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ESSENTIA 18 MG-

400 MCG TABLET

$0 (Tier 3)

ESSENTIAL

BALANCE WITH

LUTEIN TABLET

$0 (Tier 3)

FORTAVIT

CAPSULE

$0 (Tier 3)

Hair-Skin-Nails

(multivit-folic-biotin)

400 mcg-2,000 mcg

tablet

$0 (Tier 3)

High Potency

Multivitamin (w-

iron) 18 mg-400 mcg

tablet

$0 (Tier 3)

INFUVITE ADULT

3300 UNIT-150

MCG/10 ML

INTRAVENOUS

SOLUTION

$0 (Tier 3)

M.V.I. ADULT

3,300 UNIT-150

MCG/10 ML

INTRAVENOUS

SOLUTION

$0 (Tier 3)

M.V.I.-12

(WITHOUT VIT K)

3,300 UNIT-200

UNIT/10 ML

INTRAVENOUS

SOLN

$0 (Tier 3)

Men's Multi-Vitamin

tablet

$0 (Tier 3)

Multi Complete with

Iron 18 mg-400 mcg

tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 87

Drug Name Tier Drug

Restriction

Spectravite Ultra

Women 18 mg-400

mcg tablet

$0 (Tier 3)

Tandem Plus 162

mg-115.2 mg (106

mg)-1 mg capsule

$0 (Tier 3)

THERA TABLET $0 (Tier 3)

Thera-Tabs tablet $0 (Tier 3)

VIT 3 500 MG-500

MCG-1 MG-12.5

MG CAPSULE

$0 (Tier 3)

Wellesse Multi

Vitamin Plus 400

mcg-200 mg/30 mL

oral liquid

$0 (Tier 3)

Yelets 18 mg-400

mcg tablet

$0 (Tier 3)

PEDIATRIC VITAMINS

ABDEK

Multivitamin 1,000

unit-800 mcg

chewable tablet

$0 (Tier 3)

ABDEK

Multivitamin 500

unit-400 mcg/mL

oral drops

$0 (Tier 3)

ANIMAL CHEWS

tablet

$0 (Tier 3)

Animal Shapes

chewable tablet

$0 (Tier 3)

CHEWABLE-VITE

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

One Daily Plus Iron

18 mg-400 mcg tablet

$0 (Tier 3)

ONE DAILY

TABLET

$0 (Tier 3)

ONE-A-DAY

ESSENTIAL

TABLET

$0 (Tier 3)

ONE-A-DAY

MEN'S 50 PLUS

(WITH GINKGO)

400 MCG-300 MCG-

120 MG TABLET

$0 (Tier 3)

ONE-A-DAY TEEN

ADVANTAGE 18

MG-400 MCG

TABLET

$0 (Tier 3)

PUREVIT DUALFE

PLUS 162 MG-115.2

MG (106 MG)-1 MG

CAPSULE

$0 (Tier 3)

Quintabs 400 mcg

tablet

$0 (Tier 3)

Sentry 18 mg-400

mcg tablet

$0 (Tier 3)

SE-TAN PLUS 162

MG-115.2 MG (106

MG)-1 MG

CAPSULE

$0 (Tier 3)

Spectravite Adult 18

mg-400 mcg tablet

$0 (Tier 3)

Spectravite Advanced

Formula 18 mg-400

mcg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 88

Drug Name Tier Drug

Restriction

FLINTSTONES

COMPLETE

CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES

GUMMIES

CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES

GUMMIES

OMEGA-3 DHA 16

MG CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES

MULTIVITAMIN

300 MCG

CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES

MULTIVITAMIN

CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES

MULTI-VITAMINS

GUMMIES 200

MCG CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES

SOUR GUMMIES

COMPLETE

CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES/EX

TRA C 100 MCG

CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES/EX

TRA C CHEWABLE

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Children

Multivitamin

chewable tablet

$0 (Tier 3)

Children's Chewable

Multivitamin 300

mcg tablet

$0 (Tier 3)

Children's Chewable

Vitamin tablet

$0 (Tier 3)

Children's Chewables

300 mcg tablet

$0 (Tier 3)

Children's Chewables

Extra C 300 mcg

tablet

$0 (Tier 3)

Children's Chewables

with Iron 15 mg

tablet

$0 (Tier 3)

Children's

Multivitamin

chewable tablet

$0 (Tier 3)

Children's Multi-

Vitamin Gummies

200 mcg chewable

tablet

$0 (Tier 3)

CHILDS CHEW

VITE TABLET

$0 (Tier 3)

Child's Omega-3

DHA Multivitamin

250 unit-3 mg-50 unit

chewable tablet

$0 (Tier 3)

DEKAs Plus Liquid

500 mcg/mL oral

$0 (Tier 3)

Dino-Life with Iron-

Zinc 4.5 mg

chewable tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 89

Drug Name Tier Drug

Restriction

Little Animals-Iron

15 mg chewable

tablet

$0 (Tier 3)

M.V.I. PEDIATRIC

80 MG-400 UNIT-

200 MCG

INTRAVENOUS

SOLUTION

$0 (Tier 3)

MVW COMPLETE

FORMULATION

D3000 3,000 UNIT-

1,000 MCG

CHEWABLE

TABLET

$0 (Tier 3)

MVW COMPLETE

FORMULATION

D5000 5,000 UNIT-

1,000 MCG

CHEWABLE

TABLET

$0 (Tier 3)

MVW COMPLETE

FORMULATION

MULTIVITAMIN

1,500 UNIT-1,000

MCG CHEW

TABLET

$0 (Tier 3)

MVW COMPLETE

FORMULATION

PEDIATRIC 750

UNIT-500 MCG/0.5

ML ORAL DROPS

$0 (Tier 3)

NANO VM 1-3 3.5

MG-75 MCG ORAL

POWDER

$0 (Tier 3)

NANO VM 4-8 5

MG-100 MCG

ORAL POWDER

$0 (Tier 3)

Drug Name Tier Drug

Restriction

GUMMI BEAR

MULTIVITAMIN

CHEWABLE

TABLET

$0 (Tier 3)

Gummies Children

Multivitamin

chewable tablet

$0 (Tier 3)

Gummy Dinos 200

mcg chewable tablet

$0 (Tier 3)

Gummy Dinos

chewable tablet

$0 (Tier 3)

HONEY BEARS

CHEWABLE

TABLET

$0 (Tier 3)

Honey Bears with

Iron-Zinc 4.5 mg

chewable tablet

$0 (Tier 3)

Infant-Toddler

Multivitamin oral

drops

$0 (Tier 3)

Infant-Toddler Tri-

Vitamin 500 mcg-50

mg-10 mcg/mL oral

drops

$0 (Tier 3)

INFUVITE

PEDIATRIC 80 MG-

400 UNIT-200

MCG/5 ML

INTRAVENOUS

SOLUTION

$0 (Tier 3)

Kids' Gummy

chewable tablet

$0 (Tier 3)

Kids Multivitamin-

Minerals 200 mcg

chewable tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 90

Drug Name Tier Drug

Restriction

Poly-Vitamin 1,500

unit-35 mg-400

unit/mL oral drops

$0 (Tier 3)

Poly-Vitamins

chewable tablet

$0 (Tier 3)

SCOOBY-DOO

ONE A DAY KIDS

CHEWABLE

TABLET

$0 (Tier 3)

Tri-Vita 1,500 unit-

35 mg-400 unit/mL

oral drops

$0 (Tier 3)

Tropical Liquid

Nutrition oral

$0 (Tier 3)

vit A palmitate 750

unit-vit C 35 mg-vit

D3 400 unit/mL oral

drops

$0 (Tier 3)

ZOO CHEWS

TABLET

$0 (Tier 3)

Zoo Friends

chewable tablet

$0 (Tier 3)

ZOO FRIENDS

ORIGINAL 300

MCG CHEWABLE

TABLET

$0 (Tier 3)

PEDIATRIC VITAMINS AND MINERAL COMBINATIONS

Animal Shapes

Complete 18 mg iron

chewable tablet

$0 (Tier 3)

AQUADEKS

PEDIATRIC 400

MCG/ML ORAL

DROPS

$0 (Tier 3)

Drug Name Tier Drug

Restriction

NovaMV 750 unit-35

mg-400 unit/mL oral

drops

$0 (Tier 3)

ONE-A-DAY KID'S

CHEWABLE

TABLET

$0 (Tier 3)

ONE-A-DAY TEEN

FOR HER

VITACRAVES 300

UNIT-37.5 MCG

CHEWABLE

TABLET

$0 (Tier 3)

ONE-A-DAY TEEN

FOR HIM

VITACRAVES 300

UNIT-37.5 MCG

CHEWABLE

TABLET

$0 (Tier 3)

Pedia Poly-Vite 750

unit-35 mg-400

unit/mL oral drops

$0 (Tier 3)

Pedia Tri-Vite 750

unit-35 mg-400

unit/mL oral drops

$0 (Tier 3)

pediatric

multivitamin no.171

750 unit-35 mg-400

unit/mL oral drops

$0 (Tier 3)

POLY-VI-SOL 250

MCG-50 MG-10

MCG/ML ORAL

DROPS

$0 (Tier 3)

Poly-Vita 1,500 unit-

35 mg-400 unit/mL

oral drops

$0 (Tier 3)

Poly-Vita Drops 750

unit-35 mg-400

unit/mL oral

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 91

Drug Name Tier Drug

Restriction

Children's Chewable

Complete 9 mg iron-

200 mcg tablet

$0 (Tier 3)

Children's Chewable

Vitamin Complete 18

mg iron tablet

$0 (Tier 3)

CHILD'S VITAMIN

WITH IRON

CHEWABLE

TABLET

$0 (Tier 3)

Childs/Iron chewable

tablet

$0 (Tier 3)

EMERGEN-C KIDZ

ORAL

EFFERVESCENT

POWDER PACKET

$0 (Tier 3)

FLINTSTONES

COMPLETE (IRON)

18 MG IRON

CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES

COMPLETE (IRON)

CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES

MULTI-VITAMINS

GUMMIES 100

MCG CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES

PLUS CALCIUM

CHEWABLE

TABLET

$0 (Tier 3)

FLINTSTONES

TAB CHEW 100

MCG TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Baby Iron-

Multivitamin 10

mg/mL oral drops

$0 (Tier 3)

CENTRUM KIDS 18

MG IRON

CHEWABLE

TABLET

$0 (Tier 3)

Cerovite Jr 18 mg

iron-10 mcg

chewable tablet

$0 (Tier 3)

CEROVITE JR

CHEWABLE

TABLET

$0 (Tier 3)

Chewable-Vite with

Iron tablet

$0 (Tier 3)

Child Chewable

Vitamins with Iron

15 mg tablet

$0 (Tier 3)

CHILD

CHEWABLE

VITAMINS WITH

IRON TABLET

$0 (Tier 3)

Child Complete

Multivitamin 18 mg

iron chewable tablet

$0 (Tier 3)

Child Multivitamin

Plus Iron 18 mg

chewable tablet

$0 (Tier 3)

Child Vitamin with

Minerals chewable

tablet

$0 (Tier 3)

Children's Chew

Multivit with Iron 15

mg iron tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 92

Drug Name Tier Drug

Restriction

Poly-Vitamin with

Iron 1,500 unit-400

unit-10 mg/mL oral

drops

$0 (Tier 3)

POLYVITAMIN

WITH IRON 12 MG

CHEWABLE

TABLET

$0 (Tier 3)

SCOOBY-DOO

ONE A DAY

CHEWABLE

TABLET

$0 (Tier 3)

Vitalets 10 mg iron

chewable tablet

$0 (Tier 3)

VITALETS

CHEWABLE

TABLET

$0 (Tier 3)

Zoo Friends

Complete 9 mg iron

chewable tablet

$0 (Tier 3)

Zoo Friends

Gummies chewable

tablet

$0 (Tier 3)

PRENATAL VITAMINS AND MINERALS

CENTRUM

SPECIALIST

PRENATAL 27 MG

IRON-800 MCG-200

MG ORAL PACK

$0 (Tier 3)

EXPECTA

PRENATAL 28 MG

IRON-800 MCG-200

MG ORAL PACK

$0 (Tier 3)

ONE DAILY

PRENATAL 28 MG

IRON-800 MCG

ORAL PACK

$0 (Tier 3)

Drug Name Tier Drug

Restriction

FLINTSTONES

WITH IRON 18 MG

IRON CHEWABLE

TABLET

$0 (Tier 3)

Infant-Toddler

Multivitamin-Iron 11

mg/mL oral drops

$0 (Tier 3)

Lysiplex Plus oral

liquid

$0 (Tier 3)

NANOVM 9-18 2

MG IRON/2.6

GRAM ORAL

POWDER

$0 (Tier 3)

NANOVM T-F 2.75

MG IRON/5.4

GRAM POWDER

ADDITIVE FOR

TUBE FEED

$0 (Tier 3)

NOVAFERRUM

PEDIATRIC

MULTIVITAMIN-

IRON 10 MG

IRON/ML ORAL

DROPS

$0 (Tier 3)

Pedia Poly-Vite with

Iron 10 mg/mL oral

drops

$0 (Tier 3)

pediatric

multivitamin no.194-

ferrous sulfate 10 mg

iron/mL oral drops

$0 (Tier 3)

Poly-Vita (iron)

1,500 unit-400 unit-

10 mg/mL oral drops

$0 (Tier 3)

Poly-Vita With Iron

10 mg/mL oral drops

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 93

Drug Name Tier Drug

Restriction

EMERGEN-C 1,000

MG ORAL

EFFERVESCENT

POWDER PACKET

$0 (Tier 3)

EMERGEN-C

IMMUNE PLUS

1,000 MG ORAL

EFFERVESCENT

POWDER PACKET

$0 (Tier 3)

EMERGEN-C MSM

LITE 1,000 MG-

1,000 MG ORAL

EFFERVESCENT

POWDER PACKET

$0 (Tier 3)

Essence C 1,000 mg

oral effervescent

powder packet

$0 (Tier 3)

Vitamin C Energy

Booster 1,000 mg

oral effervescent

powder packet

$0 (Tier 3)

Vitamin C Fizzy

Drink 1,000 mg oral

effervescent powder

packet

$0 (Tier 3)

VITAMIN D AND FOLIC ACID COMBINATIONS

DermacinRx

Folixapure 125 mcg

(5,000 unit)-1 mg

tablet

$0 (Tier 3)

DermacinRx

Foltrexyl 125 mcg

(5,000 unit)-1 mg

tablet

$0 (Tier 3)

DermacinRx

PureFolix 125 mcg

(5,000 unit)-1 mg

tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

One Daily Prenatal

28 mg-800 mcg-440

mg oral pack

$0 (Tier 3)

prenatal vit no.95-

ferrous fumarate 28

mg-folic acid 800

mcg tablet

$0 (Tier 3)

Prenatal Vitamin 27

mg iron-0.8 mg tablet

$0 (Tier 3)

Prenatal Vitamin

tablet

$0 (Tier 3)

prenatal vitamin-

ferrous fumarate 28

mg iron-folic acid

800 mcg tablet

$0 (Tier 3)

Prenatal Vitamins

with Minerals 28 mg

iron-800 mcg tablet

$0 (Tier 3)

prenatal vits 96-

ferrous fumarate 27

mg iron-folic acid

800 mcg tablet

$0 (Tier 3)

RIGHT STEP

PRENATAL

VITAMINS 27 MG

IRON-0.8 MG

TABLET

$0 (Tier 3)

SIMILAC

PRENATAL 27 MG

IRON-800 MCG-200

MG ORAL PACK

$0 (Tier 3)

Stuart One 27 mg

iron-800 mcg-200 mg

capsule

$0 (Tier 3)

VITAMIN C COMBINATIONS

OH Buckeye MMP Opt-Out Formulary August 1, 2021 94

Drug Name Tier Drug

Restriction

Virt-Vite Forte 2.5

mg-25 mg-2 mg

tablet

$0 (Tier 3)

VITAMINS - B-1, THIAMINE AND DERIVATIVES

thiamine HCl

(vitamin B1) 100

mg/mL injection

solution

$0 (Tier 3)

Vitamin B-1 100 mg

tablet

$0 (Tier 3)

Vitamin B-1 50 mg

tablet

$0 (Tier 3)

VITAMINS - B-12 AND FOLIC ACID COMBINATIONS

FOLTRATE 0.5 MG-

1 MG TABLET

$0 (Tier 3)

MTX SUPPORT 0.5

MG-1 MG TABLET

$0 (Tier 3)

OPURITY 1,000

MCG-200 MCG

SUBLINGUAL

TABLET

$0 (Tier 3)

vitamin B12 500

mcg-folic acid 400

mcg tablet

$0 (Tier 3)

VITAMINS - B-12, CYANOCOBALAMIN AND DERIVATIVES

cyanocobalamin (vit

B-12) 1,000 mcg

tablet

$0 (Tier 3)

cyanocobalamin (vit

B-12) 1,000 mcg/mL

injection solution

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Folixapure 125 mcg

(5,000 unit)-1 mg

tablet

$0 (Tier 3)

VITAMINS - A

AQUASOL A 50,000

UNIT/ML

INTRAMUSCULAR

SOLUTION

$0 (Tier 3)

beta carotene 25,000

unit capsule

$0 (Tier 3)

vitamin A 10,000

unit capsule

$0 (Tier 3)

vitamin A 2,400 mcg

capsule

$0 (Tier 3)

vitamin A palmitate

10,000 unit capsule

$0 (Tier 3)

vitamin A palmitate

10,000 unit tablet

$0 (Tier 3)

vitamin A palmitate

15,000 unit tablet

$0 (Tier 3)

VITAMINS - B PREPARATION COMBINATIONS

Av-Vite FB 2.5 mg-

25 mg-1 mg tablet

$0 (Tier 3)

B Complex w-Vit C

18 mg-10 mg-45 mg-

5 mg-250 mg tablet

$0 (Tier 3)

FOLBEE 2.5 MG-25

MG-1 MG TABLET

$0 (Tier 3)

folic acid-vit B6-vit

B12 2.2 mg-25 mg-

0.5 mg tablet

$0 (Tier 3)

Virt-Vite 2.5 mg-25

mg-1 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 95

Drug Name Tier Drug

Restriction

niacin 100 mg tablet $0 (Tier 3)

niacin 250 mg tablet $0 (Tier 3)

niacin 400 mg

(inositol niacinate

500 mg) capsule

$0 (Tier 3)

niacin 455 mg

(inositol niacinate

500 mg) capsule

$0 (Tier 3)

niacin 50 mg tablet $0 (Tier 3)

niacin ER 1,000 mg

tablet,extended

release

$0 (Tier 3)

niacin ER 250 mg

capsule,extended

release

$0 (Tier 3)

niacin ER 250 mg

tablet,extended

release

$0 (Tier 3)

niacin ER 500 mg

capsule,extended

release

$0 (Tier 3)

niacin ER 500 mg

tablet,extended

release

$0 (Tier 3)

niacin ER 750 mg

tablet,extended

release

$0 (Tier 3)

SLO-NIACIN 250

MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

Drug Name Tier Drug

Restriction

cyanocobalamin (vit

B-12) ER 1,000 mcg

tablet,extended

release

$0 (Tier 3)

cyanocobalamin (vit

B-12) ER 2,000 mcg

tablet,extended

release

$0 (Tier 3)

hydroxocobalamin

1,000 mcg/mL

intramuscular

solution

$0 (Tier 3)

NASCOBAL 500

MCG/SPRAY

NASAL SPRAY

$0 (Tier 3)

Vitamin B-12 ER

1,000 mcg

tablet,extended

release

$0 (Tier 3)

VITAMINS - B-3, NIACIN AND DERIVATIVES

Endur-Acin 250 mg

tablet,extended

release

$0 (Tier 3)

Endur-Acin 500 mg

tablet,extended

release

$0 (Tier 3)

Endur-Acin 750 mg

tablet,extended

release

$0 (Tier 3)

niacin (inositol

niacinate) 500 mg

capsule

$0 (Tier 3)

niacin (inositol

niacinate) 500 mg

tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 96

Drug Name Tier Drug

Restriction VITAMINS - C, ASCORBIC ACID AND DERIVATIVES

Acerola C-500 500

mg oral wafer

$0 (Tier 3)

ASCOR 500 MG/ML

INTRAVENOUS

SOLUTION

$0 (Tier 3)

ascorbic acid

(vitamin C) 1,000 mg

tablet

$0 (Tier 3)

ascorbic acid

(vitamin C) 100 mg

tablet

$0 (Tier 3)

ascorbic acid

(vitamin C) 250 mg

tablet

$0 (Tier 3)

ascorbic acid

(vitamin C) 500 mg

tablet

$0 (Tier 3)

ascorbic acid

(vitamin C) 500 mg/5

mL oral syrup

$0 (Tier 3)

ascorbic acid

(vitamin C) ER 1,000

mg tablet,extended

release

$0 (Tier 3)

C-1000 1,000 mg

tablet

$0 (Tier 3)

C-1000 with Rose

Hips 1,000 mg tablet

$0 (Tier 3)

C-500 500 mg tablet $0 (Tier 3)

Soothing PureWay-C

500 mg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Slo-Niacin 500 mg

tablet,extended

release

$0 (Tier 3)

VITAMINS - B-6, PYRIDOXINE AND DERIVATIVES

pyridoxine (vitamin

B6) 100 mg tablet

$0 (Tier 3)

pyridoxine (vitamin

B6) 100 mg/mL

injection solution

$0 (Tier 3)

pyridoxine (vitamin

B6) 25 mg tablet

$0 (Tier 3)

pyridoxine (vitamin

B6) 50 mg tablet

$0 (Tier 3)

Vitamin B-6 100 mg

tablet

$0 (Tier 3)

Vitamin B-6 50 mg

tablet

$0 (Tier 3)

VITAMINS - BIOTIN

biotin 1 mg capsule $0 (Tier 3)

biotin 10,000 mcg

capsule

$0 (Tier 3)

biotin 2,500 mcg

capsule

$0 (Tier 3)

biotin 300 mcg tablet $0 (Tier 3)

biotin 5 mg capsule $0 (Tier 3)

HARD NAILS 2,500

MCG CAPSULE

$0 (Tier 3)

MERIBIN 5 MG

CAPSULE

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 97

Drug Name Tier Drug

Restriction

BIO-D-MULSION

FORTE 50

MCG/DROP (2,000

UNIT/DROP) ORAL

DROPS

$0 (Tier 3)

CALCIDOL 200

MCG/ML (8,000

UNIT/ML) ORAL

DROPS

$0 (Tier 3)

cholecalciferol

(vitamin D3) 1,250

mcg (50,000 unit)

capsule

$0 (Tier 3)

cholecalciferol

(vitamin D3) 10 mcg

(400 unit) capsule

$0 (Tier 3)

cholecalciferol

(vitamin D3) 10 mcg

(400 unit) chewable

tablet

$0 (Tier 3)

cholecalciferol

(vitamin D3) 10 mcg

(400 unit) tablet

$0 (Tier 3)

cholecalciferol

(vitamin D3) 10

mcg/5 mL (400 unit/5

mL) oral liquid

$0 (Tier 3)

cholecalciferol

(vitamin D3) 10

mcg/drop (400

unit/drop) oral drops

$0 (Tier 3)

cholecalciferol

(vitamin D3) 10

mcg/mL (400

unit/mL) oral drops

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Vitamin C 1,000 mg

tablet

$0 (Tier 3)

Vitamin C 100 mg

tablet

$0 (Tier 3)

Vitamin C 250 mg

tablet

$0 (Tier 3)

Vitamin C 500 mg

chewable tablet

$0 (Tier 3)

Vitamin C 500 mg

tablet

$0 (Tier 3)

Vitamin C ER 1,000

mg tablet,extended

release

$0 (Tier 3)

Vitamin C With Rose

Hips 1,000 mg tablet

$0 (Tier 3)

Vitamin C With Rose

Hips 500 mg tablet

$0 (Tier 3)

VITAMINS - D DERIVATIVES

Baby Ddrops 10

mcg/drop (400

unit/drop) oral

$0 (Tier 3)

Baby Vitamin D3 10

mcg/drop (400

unit/drop) oral drops

$0 (Tier 3)

Baby's Super Daily

D3 10 mcg/drop (400

unit/drop) oral drops

$0 (Tier 3)

BIO-D-MULSION

10 MCG/DROP (400

UNIT/DROP) ORAL

DROPS

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 98

Drug Name Tier Drug

Restriction

cholecalciferol

(vitamin D3) 50 mcg

(2,000 unit) chewable

tablet

$0 (Tier 3)

cholecalciferol

(vitamin D3) 50 mcg

(2,000 unit) tablet

$0 (Tier 3)

cholecalciferol

(vitamin D3) 75 mcg

(3,000 unit) tablet

$0 (Tier 3)

cholecalciferol(D3)

25 mcg/spray(1,000

unit/spray) subling

spray, susp

$0 (Tier 3)

cholecalciferol(vitam

in D3) 125 mcg

(5,000 unit)

disintegrating tablet

$0 (Tier 3)

D3-2000 50 mcg

(2,000 unit) capsule

$0 (Tier 3)

D3-50

Cholecalciferol 1,250

mcg (50,000 unit)

capsule

$0 (Tier 3)

Ddrops 25 mcg/drop

(1,000 unit/drop) oral

$0 (Tier 3)

Ddrops 50 mcg/drop

(2,000 unit/drop) oral

$0 (Tier 3)

DECARA 1,250

MCG (50,000 UNIT)

CAPSULE

$0 (Tier 3)

DECARA 625 MCG

(25,000 UNIT)

CAPSULE

$0 (Tier 3)

Drug Name Tier Drug

Restriction

cholecalciferol

(vitamin D3) 12.5

mcg/5 mL (500 unit/5

mL) oral liquid

$0 (Tier 3)

cholecalciferol

(vitamin D3) 125

mcg (5,000 unit)

capsule

$0 (Tier 3)

cholecalciferol

(vitamin D3) 125

mcg (5,000 unit)

tablet

$0 (Tier 3)

cholecalciferol

(vitamin D3) 125

mcg/mL (5,000

unit/mL) oral drops

$0 (Tier 3)

cholecalciferol

(vitamin D3) 25 mcg

(1,000 unit) capsule

$0 (Tier 3)

cholecalciferol

(vitamin D3) 25 mcg

(1,000 unit) chewable

tablet

$0 (Tier 3)

cholecalciferol

(vitamin D3) 25 mcg

(1,000 unit) tablet

$0 (Tier 3)

cholecalciferol

(vitamin D3) 250

mcg (10,000 unit)

capsule

$0 (Tier 3)

cholecalciferol

(vitamin D3) 250

mcg (10,000 unit)

tablet

$0 (Tier 3)

cholecalciferol

(vitamin D3) 50 mcg

(2,000 unit) capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 99

Drug Name Tier Drug

Restriction

Just D 10 mcg/mL

(400 unit/mL) oral

drops

$0 (Tier 3)

Kids First Vitamin

D3 25 mcg (1,000

unit) chewable tablet

$0 (Tier 3)

Kids Vitamin D3 10

mcg (400 unit)

chewable tablet

$0 (Tier 3)

Optimal D3 1,250

mcg (50,000 unit)

capsule

$0 (Tier 3)

Optimal D3 M 350

mcg (14,000 unit)

capsule

$0 (Tier 3)

Pedia D-Vite 10

mcg/mL (400

unit/mL) oral drops

$0 (Tier 3)

REPLESTA 1,250

MCG (50,000 UNIT)

ORAL WAFER

$0 (Tier 3)

REPLESTA NX 350

MCG (14,000 UNIT)

ORAL WAFER

$0 (Tier 3)

Super Daily D3 25

mcg/drop (1,000

unit/drop) oral drops

$0 (Tier 3)

Super Daily D3 50

mcg/drop (2,000

unit/drop) oral drops

$0 (Tier 3)

THERA-D 4000 100

MCG (4,000 UNIT)

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Delta D3 10 mcg

(400 unit) tablet

$0 (Tier 3)

Dialyvite Vitamin D

125 mcg (5,000 unit)

capsule

$0 (Tier 3)

Dialyvite Vitamin D3

Max 1,250 mcg

(50,000 unit) tablet

$0 (Tier 3)

DRISDOL 1,250

MCG (50,000 UNIT)

CAPSULE

$0 (Tier 3)

Use Generic Products

D-VI-SOL 10

MCG/ML (400

UNIT/ML) ORAL

DROPS

$0 (Tier 3)

D-Vita 10 mcg/mL

(400 unit/mL) oral

drops

$0 (Tier 3)

ergocalciferol

(vitamin D2) 1,250

mcg (50,000 unit)

capsule

$0 (Tier 3)

ergocalciferol

(vitamin D2) 10 mcg

(400 unit) tablet

$0 (Tier 3)

ergocalciferol

(vitamin D2) 200

mcg/mL (8,000

unit/mL) oral drops

$0 (Tier 3)

ergocalciferol

(vitamin D2) 50 mcg

(2,000 unit) capsule

$0 (Tier 3)

ergocalciferol

(vitamin D2) 50 mcg

(2,000 unit) tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 100

Drug Name Tier Drug

Restriction

Vitamin D3 50 mcg

(2,000 unit) tablet

$0 (Tier 3)

VITAMINS - E

Aqua-E Concentrate

75 unit/mL oral drops

$0 (Tier 3)

E-200 90 mg (200

unit) capsule

$0 (Tier 3)

SOLUVITA-E 22.5

MG (50 UNIT)/ML

ORAL DROPS

$0 (Tier 3)

vitamin E (dl,

acetate) 22.5 mg (50

unit)/mL oral drops

$0 (Tier 3)

vitamin E (dl,

acetate) 400 unit

capsule

$0 (Tier 3)

vitamin E (dl,

acetate) 45 mg (100

unit) capsule

$0 (Tier 3)

vitamin E (dl,

acetate) 45 mg/0.25

mL (100 unit/0.25

mL) oral drops

$0 (Tier 3)

vitamin E (dl,

acetate) 450 mg

(1,000 unit) capsule

$0 (Tier 3)

vitamin E (dl,

acetate) 90 mg (200

unit) capsule

$0 (Tier 3)

vitamin E 1,000 unit

capsule

$0 (Tier 3)

vitamin E 100 unit

capsule

$0 (Tier 3)

Drug Name Tier Drug

Restriction

THERA-D 50 MCG

(2,000 UNIT)

TABLET

$0 (Tier 3)

VitaJoy Daily D 25

mcg (1,000 unit)

chewable tablet

$0 (Tier 3)

VITAL-D RX 1,750

UNIT-60 MG-1 MG-

12.5 MG TABLET

$0 (Tier 3)

Vitamin D2 1,250

mcg (50,000 unit)

capsule

$0 (Tier 3)

Vitamin D3 10 mcg

(400 unit) capsule

$0 (Tier 3)

Vitamin D3 10 mcg

(400 unit) chewable

tablet

$0 (Tier 3)

Vitamin D3 10 mcg

(400 unit) tablet

$0 (Tier 3)

Vitamin D3 100 mcg

(4,000 unit) capsule

$0 (Tier 3)

Vitamin D3 125 mcg

(5,000 unit) tablet

$0 (Tier 3)

Vitamin D3 25 mcg

(1,000 unit) capsule

$0 (Tier 3)

Vitamin D3 25 mcg

(1,000 unit) chewable

tablet

$0 (Tier 3)

Vitamin D3 25 mcg

(1,000 unit) tablet

$0 (Tier 3)

Vitamin D3 50 mcg

(2,000 unit) capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 101

Drug Name Tier Drug

Restriction

folic acid 5 mg/mL

injection solution

$0 (Tier 3)

folic acid 800 mcg

tablet

$0 (Tier 3)

Hylazinc 1 mg-1.5

mg-1.7 mg-50 mg

tablet

$0 (Tier 3)

VITAMINS - FOLIC ACID COMBINATIONS

FOLITE 1 MG-200

MG-50 MCG-100

MG TABLET

$0 (Tier 3)

VITAMINS - K, PHYTONADIONE AND DERIVATIVES

MEPHYTON 5 MG

TABLET

$0 (Tier 3)

phytonadione

(vitamin K1) 1

mg/0.5 mL injection

syringe

$0 (Tier 3)

phytonadione

(vitamin K1) 10

mg/mL injection

solution

$0 (Tier 3)

phytonadione

(vitamin K1) 5 mg

tablet

$0 (Tier 3)

vitamin K 1 mg/0.5

mL injection solution

$0 (Tier 3)

Vitamin K1 10

mg/mL injection

solution

$0 (Tier 3)

ENDOCRINE

AGENTS TO TREAT HYPOGLYCEMIA (HYPERGLYCEMICS)

Drug Name Tier Drug

Restriction

vitamin E 100

unit/0.25 mL oral

drops

$0 (Tier 3)

vitamin E 200 unit

capsule

$0 (Tier 3)

vitamin E 400 unit

capsule

$0 (Tier 3)

vitamin E 50 unit/mL

oral drops

$0 (Tier 3)

vitamin E acetate 200

unit capsule

$0 (Tier 3)

vitamin E mixed

1,000 unit capsule

$0 (Tier 3)

vitamin E mixed 100

unit tablet

$0 (Tier 3)

vitamin E mixed 400

unit capsule

$0 (Tier 3)

vitamin E succinate

100 unit tablet

$0 (Tier 3)

VITAMINS - FOLIC ACID AND DERIVATIVES

FA-8 0.8 mg capsule $0 (Tier 3)

folic acid 0.8 mg

capsule

$0 (Tier 3)

folic acid 1 mg tablet $0 (Tier 3)

folic acid 20 mg

capsule

$0 (Tier 3)

folic acid 400 mcg

tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 102

Drug Name Tier Drug

Restriction

TRUEplus Glucose

15 gram/32 mL oral

gel packet

$0 (Tier 3)

HUMAN CHORIONIC GONADOTROPIN (HCG)

OVIDREL 250

MCG/0.5 ML

SUBCUTANEOUS

SYRINGE

$0 (Tier 3)

GASTROINTESTINAL THERAPY AGENTS

ANTACID - ALGINATE COMBINATIONS

FOAMING

ANTACID 80 MG-

20 MG CHEWABLE

TABLET

$0 (Tier 3)

GAVISCON 80 MG-

14.2 MG

CHEWABLE

TABLET

$0 (Tier 3)

ANTACID - ALUMINUM

aluminum hydroxide

gel 320 mg/5 mL oral

suspension

$0 (Tier 3)

ANTACID - ANTACID COMBINATIONS

Acid Gone Antacid

95 mg-358 mg/15 mL

oral suspension

$0 (Tier 3)

Acid Gone Antacid

Extra Strength 160

mg-105 mg chewable

tablet

$0 (Tier 3)

Antacid Extra

Strength (calcium-

mag hyd) 675 mg-

135 mg chewable

tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Dex4 Glucose 15

gram/33 gram oral

gel packet

$0 (Tier 3)

Dex4 Glucose 4 gram

chewable tablet

$0 (Tier 3)

Dex4 Glucose Pouch

Pack 4 gram

chewable tablet

$0 (Tier 3)

Dex4 Glucose Quick

Dissolve 4 gram

chewable tablet

$0 (Tier 3)

dextrose 15 gram/59

mL oral liquid

$0 (Tier 3)

dextrose 40 % oral

gel

$0 (Tier 3)

Gluco Burst 40 %

oral gel

$0 (Tier 3)

glucose 4 gram

chewable tablet

$0 (Tier 3)

Glucose Gel 40 %

oral gel

$0 (Tier 3)

Glutose-15 40 % oral

gel

$0 (Tier 3)

Glutose-45 40 % oral

gel

$0 (Tier 3)

Glutose-5 40 % oral

gel

$0 (Tier 3)

INSTA-GLUCOSE

(WITH DEXTRIN)

24 GRAM/31 GRAM

ORAL GEL

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 103

Drug Name Tier Drug

Restriction

Mi-Acid (calcium

carb-magnesium

hydroxide) 700 mg-

300 mg chew tablet

$0 (Tier 3)

ROLAIDS 550 MG-

110 MG

CHEWABLE

TABLET

$0 (Tier 3)

ANTACID - BICARBONATE

sodium bicarbonate

325 mg tablet

$0 (Tier 3)

sodium bicarbonate

650 mg tablet

$0 (Tier 3)

ANTACID - CALCIUM

Antacid (calcium

carbonate) 200 mg

calcium (500 mg)

chewable tablet

$0 (Tier 3)

Antacid (calcium

carbonate) 215 mg

calcium (500 mg)

chewable tablet

$0 (Tier 3)

Antacid (calcium

carbonate) 320 mg

calcium (750 mg)

chewable tablet

$0 (Tier 3)

Antacid Calcium 215

mg calcium (500 mg)

chewable tablet

$0 (Tier 3)

Antacid Extra

Strength (calcium

carb) 300 mg (750

mg) chewable tablet

$0 (Tier 3)

Antacid Extra-

Strength 300 mg (750

mg) chewable tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Antacid Extra

Strength (mag carb-

Al hyd) 160 mg-105

mg chewable tablet

$0 (Tier 3)

Foaming Antacid 95

mg-358 mg/15 mL

oral suspension

$0 (Tier 3)

GAVISCON 95 MG-

358 MG/15 ML

ORAL

SUSPENSION

$0 (Tier 3)

GAVISCON EXTRA

STRENGTH 160

MG-105 MG

CHEWABLE

TABLET

$0 (Tier 3)

GAVISCON EXTRA

STRENGTH 254

MG-237.5 MG/5 ML

ORAL

SUSPENSION

$0 (Tier 3)

Heartburn Antacid

160 mg-105 mg

chewable tablet

$0 (Tier 3)

HEARTBURN

RELIEF 160 MG-

105 MG

CHEWABLE

TABLET

$0 (Tier 3)

Heartburn Relief 254

mg-237.5 mg/5 mL

oral suspension

$0 (Tier 3)

MAG-AL 200 mg-

200 mg/5 mL oral

suspension

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 104

Drug Name Tier Drug

Restriction

calcium carbonate

260 mg calcium (648

mg) tablet

$0 (Tier 3)

calcium carbonate

300 mg (750 mg)

chewable tablet

$0 (Tier 3)

calcium carbonate

320 mg calcium (750

mg) chewable tablet

$0 (Tier 3)

calcium carbonate

400 mg calcium

(1,000 mg) chewable

tablet

$0 (Tier 3)

CAL-GEST

ANTACID 200 MG

CALCIUM (500

MG) CHEWABLE

TABLET

$0 (Tier 3)

Flavor Chews

Antacid 300 mg (750

mg) tablet

$0 (Tier 3)

SMOOTH

ANTACID 300 MG

(750 MG)

CHEWABLE

TABLET

$0 (Tier 3)

Tame The Flame 195

mg calcium (500 mg)

chewable tablet

$0 (Tier 3)

TUMS 200 MG

CALCIUM (500

MG) CHEWABLE

TABLET

$0 (Tier 3)

TUMS 300 MG (750

MG) CHEWABLE

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Antacid Ultra

Strength 400 mg

calcium (1,000 mg)

chewable tablet

$0 (Tier 3)

Antacid Ultra

Strength 430 mg

calcium (1,000 mg)

chewable tablet

$0 (Tier 3)

Antacid Ultra

Strength 470 mg

calcium (1,177 mg)

chewable tablet

$0 (Tier 3)

CALCIUM

ANTACID 200 MG

CALCIUM (500

MG) CHEWABLE

TABLET

$0 (Tier 3)

Calcium Antacid 300

mg (750 mg)

chewable tablet

$0 (Tier 3)

Calcium Antacid 320

mg calcium (750 mg)

chewable tablet

$0 (Tier 3)

Calcium Antacid 400

mg calcium (1,000

mg) chewable tablet

$0 (Tier 3)

Calcium Antacid 430

mg calcium (1,000

mg) chewable tablet

$0 (Tier 3)

Calcium Antacid

Ultra Max St 400 mg

calcium (1,000 mg)

chewable tablet

$0 (Tier 3)

calcium carbonate

200 mg calcium (500

mg) chewable tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 105

Drug Name Tier Drug

Restriction

Advanced Antacid-

Antigas 400 mg-400

mg-40 mg/5 mL oral

suspension

$0 (Tier 3)

Almacone 200 mg-

200 mg-20 mg/5 mL

oral suspension

$0 (Tier 3)

Almacone 200 mg-

200 mg-25 mg

chewable tablet

$0 (Tier 3)

ALMACONE-2 400

MG-400 MG-40

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

aluminum-mag

hydroxide-

simethicone 200 mg-

200 mg-20 mg/5 mL

oral susp

$0 (Tier 3)

aluminum-mag

hydroxide-

simethicone 400 mg-

400 mg-40 mg/5 mL

oral susp

$0 (Tier 3)

Antacid 200 mg-200

mg-20 mg/5 mL oral

suspension

$0 (Tier 3)

Antacid Anti-Gas

(calcium carb-simeth)

1,000 mg-60 mg

chewable tablet

$0 (Tier 3)

Antacid Anti-Gas

200 mg-200 mg-20

mg/5 mL oral

suspension

$0 (Tier 3)

Drug Name Tier Drug

Restriction

TUMS E-X 300 MG

(750 MG)

CHEWABLE

TABLET

$0 (Tier 3)

TUMS EXTRA

STRENGTH

SMOOTHIES 300

MG (750 MG)

CHEWABLE

TABLET

$0 (Tier 3)

TUMS FRESHERS

200 MG CALCIUM

(500 MG)

CHEWABLE

TABLET

$0 (Tier 3)

TUMS ULTRA 400

MG CALCIUM

(1,000 MG)

CHEWABLE

TABLET

$0 (Tier 3)

TUMS ULTRA 470

MG CALCIUM

(1,177 MG)

CHEWABLE

TABLET

$0 (Tier 3)

Ultra Strength

Antacid 400 mg

calcium (1,000 mg)

chewable tablet

$0 (Tier 3)

ANTACID - SIMETHICONE COMBINATIONS

ADVANCED

ANTACID-

ANTIGAS 200 MG-

200 MG-20 MG/5

ML ORAL

SUSPENSION

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 106

Drug Name Tier Drug

Restriction

ANTACID WITH

SIMETHICONE 200

MG-200 MG-20

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

Antacid-Antigas 200

mg-200 mg-20 mg/5

mL oral suspension

$0 (Tier 3)

Antacid-Antigas 400

mg-400 mg-40 mg/5

mL oral suspension

$0 (Tier 3)

ANTACID-

SIMETHICONE 400

MG-400 MG-40

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

Comfort Gel 200 mg-

200 mg-20 mg/5 mL

oral suspension

$0 (Tier 3)

Comfort Gel Extra

Strength 400 mg-400

mg-40 mg/5 mL oral

suspension

$0 (Tier 3)

Flanax Antacid 200

mg-200 mg-20 mg/5

mL oral suspension

$0 (Tier 3)

GELUSIL

ANTACID AND

ANTI-GAS 200 MG-

200 MG-25 MG

CHEWABLE

TABLET

$0 (Tier 3)

Geri-Lanta 200 mg-

200 mg-20 mg/5 mL

oral suspension

$0 (Tier 3)

Geri-Lanta 400 mg-

400 mg-40 mg/5 mL

oral suspension

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Antacid Anti-Gas

400 mg-400 mg-40

mg/5 mL oral

suspension

$0 (Tier 3)

ANTACID ANTI-

GAS DOUBLE STR

400 MG-400 MG-40

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

Antacid Extra-

Strength 200 mg-200

mg-20 mg/5 mL oral

suspension

$0 (Tier 3)

ANTACID LIQUID

200 MG-200 MG-20

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

ANTACID M 200

MG-200 MG-20

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

Antacid Maximum

Strength 400 mg-400

mg-40 mg/5 mL oral

suspension

$0 (Tier 3)

ANTACID PLUS

ANTI-GAS 200 MG-

200 MG-20 MG/5

ML ORAL

SUSPENSION

$0 (Tier 3)

ANTACID PLUS

ANTI-GAS 400 MG-

400 MG-40 MG/5

ML ORAL

SUSPENSION

$0 (Tier 3)

Antacid Regular

Strength 200 mg-200

mg-20 mg/5 mL oral

suspension

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 107

Drug Name Tier Drug

Restriction

Mintox Plus 200 mg-

200 mg-25 mg

chewable tablet

$0 (Tier 3)

Mylanta Maximum

Strength 400 mg-400

mg-40 mg/5 mL oral

suspension

$0 (Tier 3)

Rulox 200 mg-200

mg-20 mg/5 mL oral

suspension

$0 (Tier 3)

ANTIDIARRHEAL - ANTIPERISTALTIC AGENTS

ANTI-DIARRHEA 2

MG TABLET

$0 (Tier 3)

Anti-Diarrheal

(loperamide) 1 mg/5

mL oral liquid

$0 (Tier 3)

Anti-Diarrheal

(loperamide) 1

mg/7.5 mL oral

liquid

$0 (Tier 3)

Anti-Diarrheal

(loperamide) 2 mg

capsule

$0 (Tier 3)

Anti-Diarrheal

(loperamide) 2 mg

tablet

$0 (Tier 3)

DIAMODE 2 MG

TABLET

$0 (Tier 3)

IMODIUM A-D 1

MG/7.5 ML ORAL

LIQUID

$0 (Tier 3)

loperamide 1 mg/5

mL oral liquid

$0 (Tier 3)

loperamide 1 mg/7.5

mL oral liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

GERI-MOX

ANTACID-

ANTIGAS 200 MG-

200 MG-20 MG/5

ML ORAL

SUSPENSION

$0 (Tier 3)

Liquid Antacid 200

mg-200 mg-20 mg/5

mL oral suspension

$0 (Tier 3)

MAALOX

ADVANCED 1,000

MG-60 MG

CHEWABLE

TABLET

$0 (Tier 3)

Mag-Al Plus 200 mg-

200 mg-20 mg/5 mL

oral suspension

$0 (Tier 3)

Mag-Al Plus Extra

Strength 400 mg-400

mg-40 mg/5 mL oral

suspension

$0 (Tier 3)

Masanti Double

Strength 400 mg-400

mg-40 mg/5 mL oral

suspension

$0 (Tier 3)

Mi-Acid 200 mg-200

mg-20 mg/5 mL oral

suspension

$0 (Tier 3)

Mi-Acid 400 mg-400

mg-40 mg/5 mL oral

suspension

$0 (Tier 3)

Mintox 200 mg-200

mg-20 mg/5 mL oral

suspension

$0 (Tier 3)

Mintox Maximum

Strength 400 mg-400

mg-40 mg/5 mL oral

suspension

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 108

Drug Name Tier Drug

Restriction

Diarrhea Relief

(bismuth

subsalicylate) 262

mg/15 mL oral

suspension

$0 (Tier 3)

Digestive Relief 262

mg tablet

$0 (Tier 3)

Diotame 262 mg

chewable tablet

$0 (Tier 3)

Geri-Pectate 262

mg/15 mL oral

suspension

$0 (Tier 3)

KAOPECTATE

(BISMUTH

SUBSALICYLATE)

262 MG TABLET

$0 (Tier 3)

KAOPECTATE

(BISMUTH

SUBSALICYLATE)

262 MG/15 ML

ORAL

SUSPENSION

$0 (Tier 3)

KAOPECTATE EX

STR (BISMUTH SS)

525 MG/15 ML

ORAL

SUSPENSION

$0 (Tier 3)

Kao-Tin (bismuth

subsalicylate) 262

mg/15 mL oral

suspension

$0 (Tier 3)

K-PEC

ANTIDIARRHEAL

(BISM SUB) 262

MG/15 ML ORAL

SUSPENSION

$0 (Tier 3)

Drug Name Tier Drug

Restriction

loperamide 2 mg

capsule

$0 (Tier 3)

ANTIDIARRHEAL - BISMUTH AGENTS

Anti-Diarrheal 262

mg/15 mL oral

suspension

$0 (Tier 3)

BISMATROL 262

MG CHEWABLE

TABLET

$0 (Tier 3)

Bismatrol 262 mg/15

mL oral suspension

$0 (Tier 3)

Bismatrol 525 mg/15

mL oral suspension

$0 (Tier 3)

Bismuth 262 mg

chewable tablet

$0 (Tier 3)

Bismuth 262 mg

tablet

$0 (Tier 3)

BISMUTH 262

MG/15 ML ORAL

SUSPENSION

$0 (Tier 3)

BISMUTH

MAXIMUM

STRENGTH 525

MG/15 ML ORAL

SUSPENSION

$0 (Tier 3)

bismuth subsalicylate

262 mg chewable

tablet

$0 (Tier 3)

bismuth subsalicylate

262 mg/15 mL oral

suspension

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 109

Drug Name Tier Drug

Restriction

PINK BISMUTH

MAXIMUM

STRENGTH 525

MG/15 ML ORAL

SUSPENSION

$0 (Tier 3)

Soothe (bismuth

subsalicylate) 262 mg

chewable tablet

$0 (Tier 3)

Soothe (bismuth

subsalicylate) 262 mg

tablet

$0 (Tier 3)

Soothe Regular

Strength 262 mg/15

mL oral suspension

$0 (Tier 3)

Stomach Relief 262

mg chewable tablet

$0 (Tier 3)

Stomach Relief 262

mg tablet

$0 (Tier 3)

Stomach Relief 262

mg/15 mL oral

suspension

$0 (Tier 3)

STOMACH RELIEF

525 MG/15 ML

ORAL

SUSPENSION

$0 (Tier 3)

Stomach Relief Max

Strength 525 mg/15

mL oral suspension

$0 (Tier 3)

STOMACH RELIEF

ORIGINAL 262

MG/15 ML ORAL

SUSPENSION

$0 (Tier 3)

ANTIDIARRHEAL GI ADSORBENT-INTESTINAL FLORA MODIFIERS COMBINATIONS

Drug Name Tier Drug

Restriction

PEPTIC RELIEF 262

MG CHEWABLE

TABLET

$0 (Tier 3)

PEPTIC RELIEF 262

MG/15 ML ORAL

SUSPENSION

$0 (Tier 3)

Pepto-Bismol 262 mg

chewable tablet

$0 (Tier 3)

PEPTO-BISMOL

262 MG TABLET

$0 (Tier 3)

PEPTO-BISMOL

262 MG/15 ML

ORAL

SUSPENSION

$0 (Tier 3)

PEPTO-BISMOL

MAX ST 525 MG/15

ML ORAL

SUSPENSION

$0 (Tier 3)

PEPTO-BISMOL

TO-GO 262 MG

CHEWABLE

TABLET

$0 (Tier 3)

PINK BISMUTH

262 MG

CHEWABLE

TABLET

$0 (Tier 3)

PINK BISMUTH

262 MG TABLET

$0 (Tier 3)

PINK BISMUTH

262 MG/15 ML

ORAL

SUSPENSION

$0 (Tier 3)

PINK BISMUTH

525 MG/15 ML

ORAL

SUSPENSION

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 110

Drug Name Tier Drug

Restriction

Motion Sickness

Relief (meclizine) 25

mg chewable tablet

$0 (Tier 3)

Motion Sickness

Relief (meclizine) 25

mg tablet

$0 (Tier 3)

Motion Sickness

Relief 50 mg tablet

$0 (Tier 3)

Motion-Time 25 mg

chewable tablet

$0 (Tier 3)

TRAVEL

SICKNESS

(MECLIZINE) 25

MG CHEWABLE

TABLET

$0 (Tier 3)

TRAVEL

SICKNESS 50 MG

TABLET

$0 (Tier 3)

Travel-Ease

(meclizine) 25 mg

tablet

$0 (Tier 3)

Wal-Dram 2 25 mg

tablet

$0 (Tier 3)

Wal-Dram 50 mg

tablet

$0 (Tier 3)

ANTIEMETIC - PHOSPHORATED CARBOHYDRATES

FORMULA EM

ORAL SOLUTION

$0 (Tier 3)

NAUSEA

CONTROL ORAL

SOLUTION

$0 (Tier 3)

Nausea Relief oral

solution

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Acidophilus-Pectin

75 million cell-100

mg capsule

$0 (Tier 3)

Kala 30 mg-20 mg

tablet

$0 (Tier 3)

ANTIEMETIC - ANTIHISTAMINES

dimenhydrinate 50

mg tablet

$0 (Tier 3)

DRAMAMINE 50

MG TABLET

$0 (Tier 3)

DRAMAMINE

LESS DROWSY 25

MG TABLET

$0 (Tier 3)

Driminate 50 mg

tablet

$0 (Tier 3)

meclizine 12.5 mg

tablet

$0 (Tier 3)

meclizine 25 mg

chewable tablet

$0 (Tier 3)

meclizine 25 mg

tablet

$0 (Tier 3)

Motion Relief

(meclizine) 25 mg

tablet

$0 (Tier 3)

MOTION

SICKNESS

(MECLIZINE) 25

MG TABLET

$0 (Tier 3)

MOTION

SICKNESS 50 MG

TABLET

$0 (Tier 3)

Motion Sickness II

25 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 111

Drug Name Tier Drug

Restriction

Heartburn Relief

(famotidine) 20 mg

tablet

$0 (Tier 3)

PEPCID 20 MG

TABLET

$0 (Tier 3)

Use Generic Products

PEPCID AC 10 MG

TABLET

$0 (Tier 3)

PEPCID AC 20 MG

TABLET

$0 (Tier 3)

ranitidine 150 mg

tablet

$0 (Tier 3)

Tagamet HB 200 mg

tablet

$0 (Tier 3)

GASTRIC ACID SECRETION REDUCING AGENTS - PROTON PUMP INHIBITORS (PPIS)

Acid Reducer

(omeprazole) 20 mg

capsule,delayed

release

$0 (Tier 3)

esomeprazole

magnesium 20 mg

capsule,delayed

release

$0 (Tier 3)

Heartburn Treatment

20 mg

capsule,delayed

release

$0 (Tier 3)

Heartburn Treatment

24 Hour 15 mg

capsule,delayed

release

$0 (Tier 3)

lansoprazole 15 mg

capsule,delayed

release

$0 (Tier 3)

Drug Name Tier Drug

Restriction GASTRIC ACID SECRETION REDUCERS - HISTAMINE H2-RECEPTOR ANTAGONISTS

ACID

CONTROLLER 10

MG TABLET

$0 (Tier 3)

Acid Controller 20

mg tablet

$0 (Tier 3)

Acid Reducer

(cimetidine) 200 mg

tablet

$0 (Tier 3)

Acid Reducer

(famotidine) 10 mg

tablet

$0 (Tier 3)

Acid Reducer

(famotidine) 20 mg

tablet

$0 (Tier 3)

cimetidine 200 mg

tablet

$0 (Tier 3)

famotidine 10 mg

tablet

$0 (Tier 3)

famotidine 20 mg

tablet

$0 (Tier 3)

Heartburn Prevention

10 mg tablet

$0 (Tier 3)

HEARTBURN

PREVENTION 20

MG TABLET

$0 (Tier 3)

HEARTBURN

RELIEF

(CIMETIDINE) 200

MG TABLET

$0 (Tier 3)

Heartburn Relief

(famotidine) 10 mg

tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 112

Drug Name Tier Drug

Restriction

GAS RELIEF

(SIMETHICONE)

180 MG CAPSULE

$0 (Tier 3)

GAS RELIEF

(SIMETHICONE) 40

MG/0.6 ML ORAL

DROPS,SUSPENSIO

N

$0 (Tier 3)

Gas Relief

(simethicone) 80 mg

chewable tablet

$0 (Tier 3)

GAS RELIEF 80

(SIMETHICONE) 80

MG CHEWABLE

TABLET

$0 (Tier 3)

Gas Relief Extra

Strength 125 mg

capsule

$0 (Tier 3)

Gas Relief Extra

Strength 125 mg

chewable tablet

$0 (Tier 3)

Gas Relief Ultra

Strength 180 mg

capsule

$0 (Tier 3)

GAS-X EXTRA

STRENGTH 125

MG CAPSULE

$0 (Tier 3)

GAS-X EXTRA

STRENGTH 125

MG CHEWABLE

TABLET

$0 (Tier 3)

GAS-X ULTRA-

STRENGTH 180

MG CAPSULE

$0 (Tier 3)

Drug Name Tier Drug

Restriction

NEXIUM 20 MG

CAPSULE,DELAYE

D RELEASE

$0 (Tier 3)

Use Generic Products

Nexium 24HR 20 mg

capsule,delayed

release

$0 (Tier 3)

omeprazole 20 mg

tablet,delayed release

$0 (Tier 3)

omeprazole

magnesium 20 mg

capsule,delayed

release

$0 (Tier 3)

PREVACID 15 MG

CAPSULE,DELAYE

D RELEASE

$0 (Tier 3)

Use Generic Products

PREVACID 24HR

15 MG

CAPSULE,DELAYE

D RELEASE

$0 (Tier 3)

PRILOSEC OTC 20

MG

TABLET,DELAYED

RELEASE

$0 (Tier 3)

GASTROINTESTINAL ANTIFLATULENTS

ANTI-GAS ULTRA

STRENGTH 180

MG CAPSULE

$0 (Tier 3)

GAS RELIEF

(SIMETHICONE)

125 MG CAPSULE

$0 (Tier 3)

GAS RELIEF

(SIMETHICONE)

125 MG

CHEWABLE

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 113

Drug Name Tier Drug

Restriction

acidophilus 100

million cell-pectin,

citrus 10 mg capsule

$0 (Tier 3)

acidophilus 25

million cell-pectin,

citrus 100 mg tablet

$0 (Tier 3)

Acidophilus capsule $0 (Tier 3)

Acidophilus Ex Str

(L. sporog) 35

million-25 million

cell tablet

$0 (Tier 3)

AZO COMPLETE

FEMININE

BALANCE 5

BILLION CELL

CAPSULE

$0 (Tier 3)

Digestive Health

Probiotic 10 billion

cell capsule

$0 (Tier 3)

Digestive Probiotic

10 billion cell capsule

$0 (Tier 3)

Flora Assist 100

million cell oral

powder packet

$0 (Tier 3)

Florajen Acidophilus

20 billion cell capsule

$0 (Tier 3)

Floranex 1 million

cell tablet

$0 (Tier 3)

Floranex 100 million

cell oral granules in

packet

$0 (Tier 3)

Freeze Dried

Acidophilus capsule

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Infants Gas Relief 40

mg/0.6 mL oral

drops,suspension

$0 (Tier 3)

Little Remedies Gas

Relief 40 mg/0.6 mL

oral drops,suspension

$0 (Tier 3)

Mi-Acid Gas Relief

(simethicone) 80 mg

chewable tablet

$0 (Tier 3)

Mytab Gas

(simethicone) 80 mg

chewable tablet

$0 (Tier 3)

Mytab Gas

Maximum Strength

125 mg chewable

tablet

$0 (Tier 3)

PHAZYME 180 MG

CAPSULE

$0 (Tier 3)

SIMETHICONE 125

MG CAPSULE

$0 (Tier 3)

simethicone 125 mg

chewable tablet

$0 (Tier 3)

simethicone 180 mg

capsule

$0 (Tier 3)

simethicone 40

mg/0.6 mL oral

drops,suspension

$0 (Tier 3)

simethicone 80 mg

chewable tablet

$0 (Tier 3)

INTESTINAL FLORA MODIFIERS

Abatinex 680 mg

(750 million cell)

capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 114

Drug Name Tier Drug

Restriction

Lactobacillus

acidophilus 500

million cell tablet

$0 (Tier 3)

Lactobacillus

acidophilus capsule

$0 (Tier 3)

Lactobacillus

acidoph-L.bulgaricus

1 million cell tablet

$0 (Tier 3)

Lactobacillus

acidoph-L.bulgaricus

100 million cell oral

powder packet

$0 (Tier 3)

More-Dophilus oral

powder

$0 (Tier 3)

Probiotic 10 billion

cell capsule

$0 (Tier 3)

Probiotic 3 billion

cell chewable tablet

$0 (Tier 3)

Probiotic Acidophilus

1.5 mg (250 million

cell) capsule

$0 (Tier 3)

Probiotic

Acidophilus-Pectin

100 million cell-10

mg capsule

$0 (Tier 3)

Probiotic Gold

Acidophilus 1 billion

cell capsule

$0 (Tier 3)

LAXATIVE - BULK FORMING

calcium

polycarbophil 625

mg tablet

$0 (Tier 3)

CITRUCEL

(SUCROSE) ORAL

POWDER

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Intestinex 680 mg

(750 million cell)

capsule

$0 (Tier 3)

L.acidophilus-

Bifido.longum 16 mg

capsule,delayed

release

$0 (Tier 3)

LACTINEX 1

MILLION CELL

CHEWABLE

TABLET

$0 (Tier 3)

Lactobacillus

acidophilus 0.5 mg

(100 million cell)

tablet

$0 (Tier 3)

Lactobacillus

acidophilus 1 billion

cell tablet

$0 (Tier 3)

Lactobacillus

acidophilus 1 mg (10

million) oral wafer

$0 (Tier 3)

Lactobacillus

acidophilus 100 mg

(1 billion cell)

capsule

$0 (Tier 3)

Lactobacillus

acidophilus 100

million cell capsule

$0 (Tier 3)

Lactobacillus

acidophilus 2 billion

cell tablet

$0 (Tier 3)

Lactobacillus

acidophilus 500

million cell capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 115

Drug Name Tier Drug

Restriction

FIBER LAXATIVE

(CALCIUM

POLYCARBOPHIL)

625 MG TABLET

$0 (Tier 3)

Fiber Laxative

(methylcellulose) 500

mg tablet

$0 (Tier 3)

Fiber Laxative

(psyllium husk) 0.52

gram capsule

$0 (Tier 3)

FIBER ORAL

POWDER

$0 (Tier 3)

FIBER SMOOTH (

WITH SUCROSE)

ORAL POWDER

$0 (Tier 3)

FIBER SMOOTH

ORAL POWDER

$0 (Tier 3)

Fiber Therapy (ca

polycarbophil) 625

mg tablet

$0 (Tier 3)

FIBER THERAPY

(METHYLCELLUL

OSE) 500 MG

TABLET

$0 (Tier 3)

Fiber Therapy

(methylcellulose-

sugar) 2 gram/19

gram oral powder

$0 (Tier 3)

Fiber Therapy

(psyllium husk-

sucrose) 3 gram/12

gram oral powder

$0 (Tier 3)

Drug Name Tier Drug

Restriction

CITRUCEL 500 MG

TABLET

$0 (Tier 3)

CITRUCEL SUGAR

FREE ORAL

POWDER

$0 (Tier 3)

Daily Fiber

(psyllium-sucrose)

3.4 gram/12 gram

oral powder

$0 (Tier 3)

Daily Fiber

(psyllium-sucrose)

3.4 gram/7 gram oral

powder

$0 (Tier 3)

Evac 3 gram/3 gram

oral powder

$0 (Tier 3)

Fiber (calcium

polycarbophil) 625

mg tablet

$0 (Tier 3)

FIBER (PSYLLIUM

HUSK) 0.52 GRAM

CAPSULE

$0 (Tier 3)

Fiber (psyllium husk-

sugar) 3.4 gram/11

gram oral powder

$0 (Tier 3)

Fiber (psyllium husk-

sugar) 3.4 gram/12

gram oral powder

$0 (Tier 3)

Fiber (psyllium husk-

sugar) 3.4 gram/7

gram oral powder

$0 (Tier 3)

Fiber (with

aspartame) 3.4

gram/5.8 gram oral

powder

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 116

Drug Name Tier Drug

Restriction

Konsyl Fiber 625 mg

tablet

$0 (Tier 3)

Konsyl Formula-D

3.4 gram/6.5 gram

oral powder

$0 (Tier 3)

Konsyl Sugar-Free

(aspartame) 3.5

gram/5.8 gram oral

powder

$0 (Tier 3)

Konsyl Sugar-Free

0.52 gram capsule

$0 (Tier 3)

KONSYL SUGAR-

FREE 6 GRAM

ORAL POWDER

PACKET

$0 (Tier 3)

Konsyl Sugar-Free 6

gram/6 gram oral

powder

$0 (Tier 3)

METAMUCIL

(SUGAR) ORAL

POWDER

$0 (Tier 3)

METAMUCIL

(WITH SUGAR) 3.4

GRAM/12 GRAM

ORAL POWDER

$0 (Tier 3)

METAMUCIL 0.4

GRAM CAPSULE

$0 (Tier 3)

METAMUCIL

MULTIHEALTH

FIBER 3.4

GRAM/5.8 GRAM

ORAL POWDER

$0 (Tier 3)

Drug Name Tier Drug

Restriction

FIBER THERAPY

(PSYLLIUM SEED)

3.4 GRAM/5.8

GRAM ORAL

POWDER

$0 (Tier 3)

Fiber Therapy

Laxative (psyllium

husk) 0.52 gram

capsule

$0 (Tier 3)

Fiber-Caps (ca

polycarbophil) 625

mg tablet

$0 (Tier 3)

Fiber-Caps (psyllium

husk) 0.52 gram

capsule

$0 (Tier 3)

FIBERCON 625 MG

TABLET

$0 (Tier 3)

FIBER-LAX 625

MG TABLET

$0 (Tier 3)

Fiber-Tabs 625 mg

tablet

$0 (Tier 3)

HYDROCIL ORAL

POWDER

$0 (Tier 3)

Konsyl (sugar) 3.4

gram oral powder

packet

$0 (Tier 3)

Konsyl (sugar) 3.4

gram/11 gram oral

powder

$0 (Tier 3)

Konsyl (sugar) 3.4

gram/12 gram oral

powder

$0 (Tier 3)

Konsyl Easy Mix 4.3

gram/6 gram oral

powder

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 117

Drug Name Tier Drug

Restriction

NATURAL FIBER

LAXATIVE

THERAPY ORAL

POWDER

$0 (Tier 3)

Natural Psyllium

Fiber 3.4 gram/5.8

gram oral powder

$0 (Tier 3)

Natural Vegetable

(psyllium) oral

powder

$0 (Tier 3)

NATURAL

VEGETABLE

ORAL POWDER

$0 (Tier 3)

Natural Vegetable

Powder 3.4 gram/12

gram oral

$0 (Tier 3)

psyllium husk 0.52

gram capsule

$0 (Tier 3)

psyllium husk 2.6

gram/4.1 gram oral

powder

$0 (Tier 3)

Reguloid (psyllium

husk) 0.52 gram

capsule

$0 (Tier 3)

Reguloid (psyllium

husk-sucrose) 3

gram/12 gram oral

powder

$0 (Tier 3)

Reguloid, Sugar Free

oral powder

$0 (Tier 3)

SOLUBLE FIBER

500 MG TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

METAMUCIL

SUGAR-FREE

(ASPARTAME) 3.4

GRAM/5.8 GRAM

ORAL POWDER

$0 (Tier 3)

Multihealth Fiber

(sugar) 3.4 gram/7

gram oral powder

$0 (Tier 3)

Multihealth Fiber 3.4

gram/5.8 gram oral

powder

$0 (Tier 3)

Natural Daily Fiber

3.4 gram/5.8 gram

oral powder

$0 (Tier 3)

Natural Fiber

Laxative (aspartame)

3.4 gram/5.8 gram

oral powder

$0 (Tier 3)

NATURAL FIBER

LAXATIVE

(ASPARTAME)

ORAL POWDER

$0 (Tier 3)

Natural Fiber

Laxative (sugar) 3.4

gram/12 gram oral

powder

$0 (Tier 3)

Natural Fiber

Laxative (sugar) 3.4

gram/7 gram oral

powder

$0 (Tier 3)

Natural Fiber

Laxative (sugar) oral

powder

$0 (Tier 3)

Natural Fiber

Laxative 0.52 gram

capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 118

Drug Name Tier Drug

Restriction

ClearLax 17

gram/dose oral

powder

$0 (Tier 3)

Epsom Salt (laxative)

495 mg/5 gram oral

granules

$0 (Tier 3)

Gavilax 17

gram/dose oral

powder

$0 (Tier 3)

GentleLax 17

gram/dose oral

powder

$0 (Tier 3)

GLYCOLAX 17

GRAM/DOSE

ORAL POWDER

$0 (Tier 3)

HealthyLax 17 gram

oral powder packet

$0 (Tier 3)

LaxaClear 17

gram/dose oral

powder

$0 (Tier 3)

Laxative PEG 3350

17 gram/dose oral

powder

$0 (Tier 3)

magnesium citrate

oral solution

$0 (Tier 3)

magnesium

hydroxide 2,400

mg/10 mL oral

suspension

$0 (Tier 3)

magnesium

hydroxide 400 mg/5

mL oral suspension

$0 (Tier 3)

Milk of Magnesia

400 mg/5 mL oral

suspension

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Wal-Mucil Fiber

(aspartame) 3.4

gram/5.8 gram oral

powder

$0 (Tier 3)

Wal-Mucil Fiber

(sugar) 3.4 gram/7

gram oral powder

$0 (Tier 3)

Wal-Mucil Fiber 0.52

gram capsule

$0 (Tier 3)

Wal-Mucil Natural

Fiber Laxative 3.4

gram/12 gram oral

powder

$0 (Tier 3)

LAXATIVE - LUBRICANT

FLEET MINERAL

OIL ENEMA

$0 (Tier 3)

mineral oil enema $0 (Tier 3)

Mineral Oil Extra

Heavy oral

$0 (Tier 3)

Mineral Oil Heavy

oral

$0 (Tier 3)

mineral oil oral $0 (Tier 3)

Ready-To-Use

Enema (mineral oil)

$0 (Tier 3)

LAXATIVE - SALINE AND OSMOTIC

Citrate of Magnesia

oral

$0 (Tier 3)

Citroma oral solution $0 (Tier 3)

ClearLax 17 gram

oral powder packet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 119

Drug Name Tier Drug

Restriction

Purelax 17 gram/dose

oral powder

$0 (Tier 3)

SmoothLax 17 gram

oral powder packet

$0 (Tier 3)

SmoothLax 17

gram/dose oral

powder

$0 (Tier 3)

LAXATIVE - SALINE/OSMOTIC MIXTURES

Enema 19 gram-7

gram/118 mL

$0 (Tier 3)

Enema Disposable 19

gram-7 gram/118 mL

$0 (Tier 3)

FLEET ENEMA 19

GRAM-7

GRAM/118 ML

$0 (Tier 3)

FLEET PEDIATRIC

9.5 GRAM-3.5

GRAM/59 ML

ENEMA

$0 (Tier 3)

ORAL SALINE

LAXATIVE 7.2

GRAM-2.7

GRAM/15 ML

ORAL LIQUID

$0 (Tier 3)

Pediatric Enema 9.5

gram-3.5 gram/59

mL

$0 (Tier 3)

PHOSPHATE

LAXATIVE 7.2

GRAM-2.7

GRAM/15 ML

ORAL LIQUID

$0 (Tier 3)

READY-TO-USE

ENEMA 19 GRAM-

7 GRAM/118 ML

$0 (Tier 3)

LAXATIVE - STIMULANT

Drug Name Tier Drug

Restriction

Milk Of Magnesia

Concentrated 2,400

mg/10 mL oral

suspension

$0 (Tier 3)

MIRALAX 17

GRAM ORAL

POWDER PACKET

$0 (Tier 3)

Use Generic Products

MIRALAX 17

GRAM/DOSE

ORAL POWDER

$0 (Tier 3)

Use Generic Products

Natura-LAX 17

gram/dose oral

powder

$0 (Tier 3)

PEDIA-LAX 400

MG (170 MG

MAGNESIUM)

CHEWABLE

TABLET

$0 (Tier 3)

PHILLIPS MILK OF

MAGNESIA 400

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

polyethylene glycol

3350 17 gram oral

powder packet

$0 (Tier 3)

polyethylene glycol

3350 17 gram/dose

oral powder

$0 (Tier 3)

Powderlax 17 gram

oral powder packet

$0 (Tier 3)

Powderlax 17

gram/dose oral

$0 (Tier 3)

PURELAX 17

GRAM ORAL

POWDER PACKET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 120

Drug Name Tier Drug

Restriction

DULCOLAX

(BISACODYL) 5

MG

TABLET,DELAYED

RELEASE

$0 (Tier 3)

Evac-U-Gen

(sennosides) 8.6 mg

tablet

$0 (Tier 3)

EX-LAX

(SENNOSIDES) 15

MG CHEWABLE

TABLET

$0 (Tier 3)

EX-LAX

(SENNOSIDES) 15

MG TABLET

$0 (Tier 3)

EX-LAX

MAXIMUM

STRENGTH 25 MG

TABLET

$0 (Tier 3)

FLEET

BISACODYL 10

MG/30 ML ENEMA

$0 (Tier 3)

FLEET LAXATIVE

(BISACODYL) 5

MG

TABLET,DELAYED

RELEASE

$0 (Tier 3)

Gentle Laxative

(bisacodyl) 10 mg

rectal suppository

$0 (Tier 3)

GENTLE

LAXATIVE

(BISACODYL) 5

MG

TABLET,DELAYED

RELEASE

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ALOPHEN

(BISACODYL) 5

MG

TABLET,DELAYED

RELEASE

$0 (Tier 3)

Bisac-Evac 10 mg

rectal suppository

$0 (Tier 3)

bisacodyl 10 mg

rectal suppository

$0 (Tier 3)

bisacodyl 5 mg

tablet,delayed release

$0 (Tier 3)

BISA-LAX

(BISACODYL) 5

MG

TABLET,DELAYED

RELEASE

$0 (Tier 3)

BISCOLAX 10 MG

RECTAL

SUPPOSITORY

$0 (Tier 3)

castor oil 100 % oral $0 (Tier 3)

castor oil oral $0 (Tier 3)

Chocolate Laxative

15 mg chewable

tablet

$0 (Tier 3)

CORRECTOL 5 MG

TABLET

$0 (Tier 3)

Ducodyl (bisacodyl)

5 mg tablet,delayed

release

$0 (Tier 3)

DULCOLAX

(BISACODYL) 10

MG RECTAL

SUPPOSITORY

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 121

Drug Name Tier Drug

Restriction

Natural Vegetable

Laxative (sennosides)

8.6 mg tablet

$0 (Tier 3)

PERDIEM

OVERNIGHT

RELIEF 15 MG

TABLET

$0 (Tier 3)

Senexon 8.6 mg

tablet

$0 (Tier 3)

SENEXON 8.8 MG/5

ML ORAL SYRUP

$0 (Tier 3)

senna 8.6 mg capsule $0 (Tier 3)

SENNA 8.6 MG

TABLET

$0 (Tier 3)

senna 8.8 mg/5 mL

oral syrup

$0 (Tier 3)

Senna Lax 8.6 mg

tablet

$0 (Tier 3)

SENNA LAXATIVE

25 MG TABLET

$0 (Tier 3)

Senna Laxative 8.6

mg tablet

$0 (Tier 3)

Senna-Extra 17.2 mg

tablet

$0 (Tier 3)

Senno 8.6 mg tablet $0 (Tier 3)

sennosides 8.8 mg/5

mL oral syrup

$0 (Tier 3)

SENOKOT 8.6 MG

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Geri-kot 8.6 mg

tablet

$0 (Tier 3)

LAXATIVE

(BISACODYL) 10

MG RECTAL

SUPPOSITORY

$0 (Tier 3)

LAXATIVE

(BISACODYL) 5

MG TABLET

$0 (Tier 3)

Laxative (bisacodyl)

5 mg tablet,delayed

release

$0 (Tier 3)

LAXATIVE

(SENNOSIDES) 15

MG CHEWABLE

TABLET

$0 (Tier 3)

Laxative (sennosides)

15 mg tablet

$0 (Tier 3)

Laxative (sennosides)

25 mg tablet

$0 (Tier 3)

Laxative Feminine 5

mg tablet

$0 (Tier 3)

LAXATIVE

MAXIMUM

STRENGTH 25 MG

TABLET

$0 (Tier 3)

Laxative Pills 25 mg

tablet

$0 (Tier 3)

LAXATIVE PILLS

REGULAR 15 MG

TABLET

$0 (Tier 3)

NATURAL

LAXATIVE 25 MG

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 122

Drug Name Tier Drug

Restriction

DOC-Q-LAX 8.6

MG-50 MG

TABLET

$0 (Tier 3)

Docuzen 8.6 mg-50

mg tablet

$0 (Tier 3)

DOK Plus 8.6 mg-50

mg tablet

$0 (Tier 3)

LAXACIN 8.6 MG-

50 MG TABLET

$0 (Tier 3)

LAXATIVE PLUS

STOOL SOFTENER

8.6 MG-50 MG

TABLET

$0 (Tier 3)

P-COL RITE 8.6

MG-50 MG

TABLET

$0 (Tier 3)

PERI-COLACE 8.6

MG-50 MG

TABLET

$0 (Tier 3)

Senexon-S 8.6 mg-50

mg tablet

$0 (Tier 3)

SENNA

LAXATIVE-STOOL

SOFTENER 8.6 MG-

50 MG TABLET

$0 (Tier 3)

Senna Plus 8.6 mg-50

mg capsule

$0 (Tier 3)

SENNA PLUS 8.6

MG-50 MG

TABLET

$0 (Tier 3)

Senna with Docusate

Sodium 8.6 mg-50

mg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

SENOKOT EXTRA

STRENGTH 17.2

MG TABLET

$0 (Tier 3)

THE MAGIC

BULLET 10 MG

RECTAL

SUPPOSITORY

$0 (Tier 3)

VEGETABLE

LAXATIVE 8.6 MG

TABLET

$0 (Tier 3)

WOMAN'S

LAXATIVE

(BISACODYL) 5

MG TABLET

$0 (Tier 3)

Woman's Laxative

(bisacodyl) 5 mg

tablet,delayed release

$0 (Tier 3)

Women's Gentle

Laxative (bisacodyl)

5 mg tablet,delayed

release

$0 (Tier 3)

WOMEN'S

LAXATIVE

(BISACODYL) 5

MG TABLET

$0 (Tier 3)

Women's Laxative

(bisacodyl) 5 mg

tablet,delayed release

$0 (Tier 3)

LAXATIVE - STIMULANT AND BULK FORMING COMBINATIONS

SENNA PROMPT 9

MG-500 MG

CAPSULE

$0 (Tier 3)

LAXATIVE - STIMULANT AND SURFACTANT COMBINATIONS

COLACE 2-IN-1 8.6

MG-50 MG

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 123

Drug Name Tier Drug

Restriction

COL-RITE 100 MG

CAPSULE

$0 (Tier 3)

Col-Rite 250 mg

capsule

$0 (Tier 3)

Diocto 50 mg/5 mL

oral liquid

$0 (Tier 3)

Diocto 60 mg/15 mL

oral syrup

$0 (Tier 3)

Doc-Q-Lace 100 mg

capsule

$0 (Tier 3)

Docu 50 mg/5 mL

oral liquid

$0 (Tier 3)

DOCUPRENE 100

MG TABLET

$0 (Tier 3)

docusate calcium 240

mg capsule

$0 (Tier 3)

docusate sodium 100

mg capsule

$0 (Tier 3)

docusate sodium 100

mg tablet

$0 (Tier 3)

docusate sodium 250

mg capsule

$0 (Tier 3)

docusate sodium 283

mg/5 mL enema

$0 (Tier 3)

docusate sodium 50

mg/5 mL oral liquid

$0 (Tier 3)

Docusil 100 mg

capsule

$0 (Tier 3)

DOCUSOL 283 MG

ENEMA

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Sennalax-S 8.6 mg-

50 mg tablet

$0 (Tier 3)

Senna-S 8.6 mg-50

mg tablet

$0 (Tier 3)

Senna-Time S 8.6

mg-50 mg tablet

$0 (Tier 3)

sennosides 8.6 mg-

docusate sodium 50

mg tablet

$0 (Tier 3)

SENOKOT-S 8.6

MG-50 MG

TABLET

$0 (Tier 3)

Stimulant Laxative

Plus 8.6 mg-50 mg

tablet

$0 (Tier 3)

STOOL

SOFTENER-

LAXATIVE 8.6 MG-

50 MG TABLET

$0 (Tier 3)

Stool Softener-

Stimulant Laxative

8.6 mg-50 mg

capsule

$0 (Tier 3)

Stool Softener-

Stimulant Laxative

8.6 mg-50 mg tablet

$0 (Tier 3)

Vegetable Laxative-

Stool Softener 8.6

mg-50 mg tablet

$0 (Tier 3)

LAXATIVE - SURFACTANT

COLACE 100 MG

CAPSULE

$0 (Tier 3)

COLACE CLEAR 50

MG CAPSULE

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 124

Drug Name Tier Drug

Restriction

Move It Along 100

mg tablet

$0 (Tier 3)

PEDIA-LAX STOOL

SOFTENER 50

MG/15 ML ORAL

SYRUP

$0 (Tier 3)

PHILLIPS' LIQUI-

GELS 100 MG

CAPSULE

$0 (Tier 3)

PROMOLAXIN 100

MG TABLET

$0 (Tier 3)

Silace 50 mg/5 mL

oral liquid

$0 (Tier 3)

Silace 60 mg/15 mL

oral syrup

$0 (Tier 3)

SOF-LAX 100 MG

CAPSULE

$0 (Tier 3)

STOOL SOFTENER

(DOCUSATE

CALCIUM) 240 MG

CAPSULE

$0 (Tier 3)

Stool Softener 100

mg capsule

$0 (Tier 3)

Stool Softener 100

mg tablet

$0 (Tier 3)

Stool Softener 250

mg capsule

$0 (Tier 3)

STOOL SOFTENER

50 MG CAPSULE

$0 (Tier 3)

Stool Softener 50

mg/5 mL oral liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

DOCUSOL KIDS

100 MG/5 ML

ENEMA

$0 (Tier 3)

DOCUSOL PLUS

283 MG-20 MG/5

ML ENEMA

$0 (Tier 3)

DOK 100 mg capsule $0 (Tier 3)

DOK 100 mg tablet $0 (Tier 3)

DOK 250 MG

CAPSULE

$0 (Tier 3)

DSS 250 MG

CAPSULE

$0 (Tier 3)

DULCOEASE 100

MG CAPSULE

$0 (Tier 3)

DULCOLAX

STOOL SOFTENER

(DOCUSATE) 100

MG CAPSULE

$0 (Tier 3)

ENEMEEZ 283

MG/5 ML ENEMA

$0 (Tier 3)

ENEMEEZ PLUS

283 MG-20 MG/5

ML ENEMA

$0 (Tier 3)

Kao-Tin (docusate

calcium) 240 mg

capsule

$0 (Tier 3)

Kids Mini Enema

100 mg/5 mL

$0 (Tier 3)

Laxa Basic 100 mg

capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 125

Drug Name Tier Drug

Restriction

Urinary Pain Relief

97.5 mg tablet

$0 (Tier 3)

Uristat 95 mg tablet $0 (Tier 3)

URINARY ANTISPASMODIC - SMOOTH MUSCLE RELAXANTS

OXYTROL 3.9

MG/24 HR

TRANSDERMAL

PATCH

$0 (Tier 3)

OXYTROL FOR

WOMEN 3.9 MG/24

HOUR

TRANSDERMAL

PATCH

$0 (Tier 3)

HEMATOLOGICAL AGENTS

PLATELET AGGREGATION INHIBITORS - SALICYLATES

Adult Aspirin

Regimen 81 mg

tablet,delayed release

$0 (Tier 3)

Aspir-81 mg

tablet,delayed release

$0 (Tier 3)

aspirin 81 mg

chewable tablet

$0 (Tier 3)

aspirin 81 mg

tablet,delayed release

$0 (Tier 3)

Aspirin Childrens 81

mg chewable tablet

$0 (Tier 3)

Aspirin Low Dose 81

mg tablet,delayed

release

$0 (Tier 3)

ASPIR-LOW 81 MG

TABLET,DELAYED

RELEASE

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Stool Softener 60

mg/15 mL oral syrup

$0 (Tier 3)

SURFAK 240 MG

CAPSULE

$0 (Tier 3)

GENITOURINARY THERAPY

PHOSPHATE BINDERS

$0 (Tier 3)

ELIPHOS 667 MG

TABLET

$0 (Tier 3)

MAGNEBIND 300

250 MG-300 MG

TABLET

$0 (Tier 3)

URINARY ALKALINIZER - CITRATES

Cytra-2 500 mg-334

mg/5 mL oral

solution

$0 (Tier 3)

sodium citrate-citric

acid 500 mg-334

mg/5 mL oral

solution

$0 (Tier 3)

Virtrate-2 500 mg-

334 mg/5 mL oral

solution

$0 (Tier 3)

URINARY ANALGESICS

AZO URINARY

PAIN RELIEF 95

MG TABLET

$0 (Tier 3)

AZO URINARY

PAIN RELIEF 97.5

MG TABLET

$0 (Tier 3)

Urinary Pain Relief

95 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 126

Drug Name Tier Drug

Restriction

Durex Avanti Bare

Real Feel Condom

$0 (Tier 3)

Fantasy Condom $0 (Tier 3)

Kimono

Condoms(Non-

lubricated)

$0 (Tier 3)

Kimono Maxx

Condoms

$0 (Tier 3)

Kimono MicroThin

Aqua Lube Condom

$0 (Tier 3)

Kimono MicroThin

Condoms

$0 (Tier 3)

Kimono MicroThin

Large Condoms

$0 (Tier 3)

Kimono Textured

Condoms

$0 (Tier 3)

Trustex Latex

Condom

$0 (Tier 3)

Trustex Lubricated

Condoms

$0 (Tier 3)

Trustex Non-

Lubricated Condoms

$0 (Tier 3)

Trustex-RIA

Lubricated Condoms

$0 (Tier 3)

Trustex-RIA

Lubricated/Spermicid

e Condom

$0 (Tier 3)

Trustex-RIA Non-

Lubricated Condoms

$0 (Tier 3)

MEDICAL SUPPLIES AND DME - PEAK FLOW METERS

Drug Name Tier Drug

Restriction

BAYER

CHEWABLE LOW

DOSE ASPIRIN 81

MG TABLET

$0 (Tier 3)

Children's Aspirin 81

mg chewable tablet

$0 (Tier 3)

ECOTRIN LOW

STRENGTH 81 MG

TABLET,ENTERIC

COATED

$0 (Tier 3)

ST JOSEPH

ASPIRIN 81 MG

CHEWABLE

TABLET

$0 (Tier 3)

St. Joseph Aspirin 81

mg tablet,delayed

release

$0 (Tier 3)

MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT (DME)

MEDICAL SUPPLIES AND DME - FACIAL MASKS

Face Mask,Earloop-

Style

$0 (Tier 3)

Nexcare All Purpose

Mask

$0 (Tier 3)

Procedural Face

Masks

$0 (Tier 3)

MEDICAL SUPPLIES AND DME - FEMALE CONDOMS

FC2 Female Condom $0 (Tier 3)

MEDICAL SUPPLIES AND DME - MALE CONDOMS

Aimsco Latex

Condom

$0 (Tier 3)

Condoms-Prem

Lubricated

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 127

Drug Name Tier Drug

Restriction

Truzone Peak Flow

Meter

$0 (Tier 3)

MEDICAL SUPPLIES AND DME - RESPIRATORY THERAPY SUPPLIES

Aerochamber Mini $0 (Tier 3)

Aerochamber MV

spacer

$0 (Tier 3)

Aerochamber Plus

Flow-Vu

$0 (Tier 3)

Aerochamber Plus

Flow-Vu,Large Mask

$0 (Tier 3)

Aerochamber Plus

Flow-Vu,Medium

Mask

$0 (Tier 3)

Aerochamber Plus

Flow-Vu,Small Mask

$0 (Tier 3)

Aerochamber Plus Z

Stat Large Mask

$0 (Tier 3)

AeroChamber Plus Z

Stat Medium Mask

$0 (Tier 3)

AeroChamber Plus Z

Stat Small Mask

$0 (Tier 3)

Aerochamber Plus Z

Stat spacer

$0 (Tier 3)

Aerochamber with

Flowsignal

$0 (Tier 3)

AeroChamber Z-Stat

Plus-Flow Signal

$0 (Tier 3)

Aerovent Plus spacer $0 (Tier 3)

Drug Name Tier Drug

Restriction

Aerogear Action

Asthma Kit

$0 (Tier 3)

Airzone Peak Flow

Meter

$0 (Tier 3)

Assess Full Range

Peak Meter

$0 (Tier 3)

Asthma Check Meter $0 (Tier 3)

AsthmaMentOr Peak

Flow Meter

$0 (Tier 3)

Asthmapack

Children's kit

$0 (Tier 3)

Clever Choice Peak

Flow Meter

$0 (Tier 3)

Microlife Peak Flow

Meter

$0 (Tier 3)

Mini Wright Peak

Flow Meter

$0 (Tier 3)

Peak Air Peak Flow

Meter

$0 (Tier 3)

Personal Best Full

Range device

$0 (Tier 3)

Personal Best Low

Range device

$0 (Tier 3)

Piko 1 device $0 (Tier 3)

Pocket Peak Flow

Meter

$0 (Tier 3)

PureComfort Peak

Flow Meter

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 128

Drug Name Tier Drug

Restriction

EasiVent Mask Large $0 (Tier 3)

EasiVent Mask

Medium

$0 (Tier 3)

EasiVent Mask Small $0 (Tier 3)

Flexichamber spacer $0 (Tier 3)

Flexichamber-Large

Child Mask

$0 (Tier 3)

Flexichamber-Small

Adult Mask

$0 (Tier 3)

Flexichamber-Small

Child Mask

$0 (Tier 3)

InspiraChamber

spacer

$0 (Tier 3)

InspiraChamber with

Mask-Large

$0 (Tier 3)

InspiraChamber with

Mask-Med

$0 (Tier 3)

InspiraChamber with

Mask-Small

$0 (Tier 3)

LiteAire MDI

Chamber

$0 (Tier 3)

Microchamber spacer $0 (Tier 3)

Microspacer $0 (Tier 3)

OptiChamber

Diamond VHC

spacer

$0 (Tier 3)

Drug Name Tier Drug

Restriction

BreatheRite MDI

Spacer

$0 (Tier 3)

BreatheRite Spacer

and Mask, Adult

$0 (Tier 3)

BreatheRite Spacer

and Mask, Child

$0 (Tier 3)

BreatheRite Spacer

and Mask, Infant

$0 (Tier 3)

BreatheRite Spacer

and Mask, Neonate

$0 (Tier 3)

BreatheRite Spacer

and Mask, Small

Child

$0 (Tier 3)

Clever Choice

Holding Chamber-

Large Mask

$0 (Tier 3)

Clever Choice

Holding Chamber-

Medium Mask

$0 (Tier 3)

Clever Choice

Holding Chamber-

Small Mask

$0 (Tier 3)

Compact Space

Chamber

$0 (Tier 3)

Compact Space

Chamber-Lrg Mask

$0 (Tier 3)

Compact Space

Chamber-Med Mask

$0 (Tier 3)

Compact Space

Chamber-Sm Mask

$0 (Tier 3)

EasiVent Holding

Chamber

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 129

Drug Name Tier Drug

Restriction

Space Chamber $0 (Tier 3)

Space Chamber with

Large Mask

$0 (Tier 3)

Space Chamber with

Medium Mask

$0 (Tier 3)

Space Chamber with

Small Mask

$0 (Tier 3)

Vortex Holding

Chamber

$0 (Tier 3)

Vortex VHC Frog

Mask-Child

$0 (Tier 3)

MEDICAL SUPPLIES AND DME - URINE GLUCOSE- ACETONE COMBINATION TESTS

Keto-Diastix strips $0 (Tier 3)

MEDICAL SUPPLIES AND DME - URINE KETONE TESTS

Ketone Care strips $0 (Tier 3)

MISCELLANEOUS

OTHER

$0 (Tier 3)

$0 (Tier 3)

$0 (Tier 3)

$0 (Tier 3)

$0 (Tier 3)

Drug Name Tier Drug

Restriction

OptiChamber

Diamond VHC with

Large Mask

$0 (Tier 3)

OptiChamber

Diamond VHC with

Medium Mask

$0 (Tier 3)

OptiChamber

Diamond VHC with

Small Mask

$0 (Tier 3)

Panda Mask $0 (Tier 3)

Pediatric Medium

Mask

$0 (Tier 3)

Pediatric Panda Mask $0 (Tier 3)

Pediatric Small Mask $0 (Tier 3)

POCKET

CHAMBER spacer

$0 (Tier 3)

Pro Comfort Spacer-

Adult Mask

$0 (Tier 3)

Pro Comfort Spacer-

Child Mask

$0 (Tier 3)

Procare Spacer With

Adult Mask

$0 (Tier 3)

Procare Spacer With

Child Mask

$0 (Tier 3)

ProChamber $0 (Tier 3)

RiteFlo Aerochamber $0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 130

Drug Name Tier Drug

Restriction

Artificial Tears

(petrolatum/mineral

oil) 83 %-15 % eye

ointment

$0 (Tier 3)

Artificial Tears (PF)

0.1 %-0.3 % drops in

a dropperette

$0 (Tier 3)

ARTIFICIAL

TEARS (PF) DROPS

IN A

DROPPERETTE

$0 (Tier 3)

Artificial Tears

(pg400-hypromell-

glycerin) 1 %-0.2 %-

0.2 % eye drops

$0 (Tier 3)

Artificial Tears

(polyvinyl

alcohol/povidone) 0.5

%-0.6 % eye drops

$0 (Tier 3)

Clear Eyes Natural

Tears 0.5 %-0.6 %

drops

$0 (Tier 3)

Dry Eye Relief 1 %-

0.2 %-0.2 % drops

$0 (Tier 3)

For Sty Relief eye

ointment

$0 (Tier 3)

FRESHKOTE 2 %-

0.9 %-1.8 % EYE

DROPS

$0 (Tier 3)

GENTEAL GEL 0.25

%-0.3 % EYE

LIQUID GEL

DROPS

$0 (Tier 3)

GenTeal Tears Mild

0.1 %-0.3 % eye

drops

$0 (Tier 3)

Drug Name Tier Drug

Restriction $0 (Tier

3)

$0 (Tier 3)

$0 (Tier 3)

$0 (Tier 3)

$0 (Tier 3)

$0 (Tier 3)

$0 (Tier 3)

$0 (Tier 3)

MOUTH-THROAT-DENTAL - PREPARATIONS

MOUTH AND THROAT - LOZENGES

Zinc with Vitamins A

and C 15 mg

lozenges

$0 (Tier 3)

OPHTHALMIC AGENTS

ARTIFICIAL TEARS AND LUBRICANT COMBINATIONS

Artificial Tears

(dextran 70-

hypromellose) 0.1 %-

0.3 % eye drops

$0 (Tier 3)

ARTIFICIAL

TEARS (DEXTRAN

70-

HYPROMELLOSE)

EYE DROPS

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 131

Drug Name Tier Drug

Restriction

LUBRICANT EYE

83 %-15 %

OINTMENT

$0 (Tier 3)

Lubricant Gel 0.25

%-0.3 % eye liquid

gel drops

$0 (Tier 3)

Lubricating Drops

0.5 %-0.9 % eye

drops

$0 (Tier 3)

Lubricating Relief

0.4 %-0.3 % eye

drops

$0 (Tier 3)

LUBRIFRESH PM

83 %-15 % EYE

OINTMENT

$0 (Tier 3)

Natural Balance

Tears 0.1 %-0.3 %

eye drops

$0 (Tier 3)

Natural Tears (PF)

0.1 %-0.3 % drops in

a dropperette

$0 (Tier 3)

Nature's Tears 0.1 %-

0.3 % eye drops

$0 (Tier 3)

Nighttime Dry-Eye

Relief 57.3 %-42.5 %

ointment

$0 (Tier 3)

Overnight

Lubricating Eye 94

%-3 % ointment

$0 (Tier 3)

PURALUBE 85 %-

15 % EYE

OINTMENT

$0 (Tier 3)

Drug Name Tier Drug

Restriction

GENTEAL TEARS

MODERATE (PF)

0.1 %-0.3 % DROPS

IN A

DROPPERETTE

$0 (Tier 3)

GENTEAL TEARS

MODERATE 0.1 %-

0.3 %-0.2 % EYE

DROPS

$0 (Tier 3)

GENTEAL TEARS

SEVERE

(PETROLATUM-

MINERAL OIL) 94

%-3 % EYE

OINTMENT

$0 (Tier 3)

GENTEAL TEARS

SEVERE GEL

DROPS 0.4 %-0.3 %

EYE DROPS

$0 (Tier 3)

Lubricant Eye (cmc-

glycerin) 0.5 %-0.9

% drops

$0 (Tier 3)

Lubricant Eye (PG-

PEG 400) (PF) 0.4

%-0.3 % drops in a

dropperette

$0 (Tier 3)

Lubricant Eye (PG-

PEG 400) 0.4 %-0.3

% drops

$0 (Tier 3)

Lubricant Eye 56.8

%-41.5 % ointment

$0 (Tier 3)

Lubricant Eye 57.3

%-42.5 % ointment

$0 (Tier 3)

Lubricant Eye 57.7

%-31.9 % ointment

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 132

Drug Name Tier Drug

Restriction

REFRESH P.M. 57.3

%-42.5 % EYE

OINTMENT

$0 (Tier 3)

REFRESH

RELIEVA PF 0.5 %-

0.9 % EYE DROPS

$0 (Tier 3)

REFRESH REPAIR

0.5 %-0.9 % EYE

DROPS

$0 (Tier 3)

Restore PM 57.3 %-

42.5 % eye ointment

$0 (Tier 3)

Retaine PM 80 %-20

% eye ointment

$0 (Tier 3)

SOOTHE NIGHT

TIME LUBRICANT

80 %-20 % EYE

OINTMENT

$0 (Tier 3)

Stye Lubricant 57.7

%-31.9 % eye

ointment

$0 (Tier 3)

SYSTANE (PF) 0.4

%-0.3 % EYE

DROPS IN A

DROPPERETTE

$0 (Tier 3)

SYSTANE

(PROPYLENE

GLYCOL) 0.4 %-0.3

% EYE DROPS

$0 (Tier 3)

SYSTANE GEL 0.4

%-0.3 % EYE

DROPS

$0 (Tier 3)

SYSTANE

HYDRATION PF 0.4

%-0.3 % EYE

DROPS

$0 (Tier 3)

Drug Name Tier Drug

Restriction

REFRESH CLASSIC

(PF) 1.4 %-0.6 %

EYE DROPS IN A

DROPPERETTE

$0 (Tier 3)

REFRESH DIGITAL

0.5 %-1 %-0.5 %

EYE DROPS

$0 (Tier 3)

REFRESH DIGITAL

PF 0.5 %-1 %-0.5 %

EYE DROPS IN A

DROPPERETTE

$0 (Tier 3)

REFRESH LACRI-

LUBE 56.8 %-42.5

% EYE OINTMENT

$0 (Tier 3)

REFRESH OPTIVE

1 %-0.9 % EYE GEL

DROPS

$0 (Tier 3)

REFRESH OPTIVE

ADVANCED (PF)

0.5 %-1 %-0.5 %

EYE DROPS IN

DROPPERETTE

$0 (Tier 3)

REFRESH OPTIVE

ADVANCED 0.5 %-

1 %-0.5 % EYE

DROPS

$0 (Tier 3)

REFRESH OPTIVE

MEGA-3 (PF) 0.5 %-

1 %-0.5 % EYE

DROPS IN A

DROPPERETTE

$0 (Tier 3)

REFRESH OPTIVE

SENSITIVE (PF) 0.5

%-0.9 % EYE

DROPS IN A

DROPPERETTE

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 133

Drug Name Tier Drug

Restriction

GENTEAL SEVERE

0.3 % EYE GEL

$0 (Tier 3)

GENTEAL TEARS

SEVERE 0.3 % EYE

GEL

$0 (Tier 3)

ISOPTO TEARS 0.5

% EYE DROPS

$0 (Tier 3)

LiquiTears 1.4 % eye

drops

$0 (Tier 3)

Lubricant Dry Eye

Relief 1 % eye liquid

gel drops

$0 (Tier 3)

Lubricant Eye

(propylene glycol)

0.6 % drops

$0 (Tier 3)

Lubricant Eye Drops

0.5 %

$0 (Tier 3)

Lubricant Eye Drops

0.5 % drops in a

dropperette

$0 (Tier 3)

Lubricating Plus 0.5

% eye drops in a

dropperette

$0 (Tier 3)

polyvinyl alcohol 1.4

% eye drops

$0 (Tier 3)

PURE AND

GENTLE EYE 0.3 %

DROPS

$0 (Tier 3)

REFRESH

CELLUVISC 1 %

EYE GEL IN A

DROPPERETTE

$0 (Tier 3)

Drug Name Tier Drug

Restriction

SYSTANE

HYDRATION PF 0.4

%-0.3 % EYE

DROPS IN A

DROPPERETTE

$0 (Tier 3)

SYSTANE

NIGHTTIME 94 %-3

% EYE OINTMENT

$0 (Tier 3)

SYSTANE ULTRA

(PF) 0.4 %-0.3 %

EYE DROPS IN A

DROPPERETTE

$0 (Tier 3)

Systane Ultra 0.4 %-

0.3 % eye drops

$0 (Tier 3)

TEARS NATURALE

PM 94 %-3 % EYE

OINTMENT

$0 (Tier 3)

Ultra Fresh PM eye

ointment

$0 (Tier 3)

Ultra Lubricant Eye

0.4 %-0.3 % drops

$0 (Tier 3)

ARTIFICIAL TEARS AND LUBRICANT SINGLE AGENTS

ARTIFICIAL

TEARS

(POLYVINYL

ALCOHOL) 1.4 %

EYE DROPS

$0 (Tier 3)

carboxymethylcellulo

se sodium 0.5 % eye

drops

$0 (Tier 3)

GENTEAL MILD

TO MODERATE 0.3

% EYE DROPS

$0 (Tier 3)

GENTEAL MILD

0.2 % EYE DROPS

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 134

Drug Name Tier Drug

Restriction

ULTRA FRESH 0.5

% EYE DROPS

$0 (Tier 3)

VISTA GEL 0.3 %

EYE GEL

$0 (Tier 3)

VISTA MEIBO

TEARS 0.6 % EYE

DROPS

$0 (Tier 3)

CONTACT LENS PREPARATION - HARD/SOFT/GAS PERMEABLE PRODUCTS

Systane Contacts eye

drops

$0 (Tier 3)

OPHTHALMIC - ANTIHISTAMINES

Alaway 0.025 %

(0.035 %) eye drops

$0 (Tier 3)

ALLERGY EYE

(KETOTIFEN) 0.025

% (0.035 %) DROPS

$0 (Tier 3)

CHILDREN'S

ALAWAY 0.025 %

(0.035 %) EYE

DROPS

$0 (Tier 3)

EYE ITCH RELIEF

0.025 % (0.035 %)

DROPS

$0 (Tier 3)

ITCHY EYE DROPS

0.025 % (0.035 %)

$0 (Tier 3)

ketotifen 0.025 %

(0.035 %) eye drops

$0 (Tier 3)

Wal-Zyr (ketotifen)

0.025 % (0.035 %)

eye drops

$0 (Tier 3)

ZADITOR 0.025 %

(0.035 %) EYE

DROPS

$0 (Tier 3)

Drug Name Tier Drug

Restriction

REFRESH

LIQUIGEL 1 % EYE

LIQUID GEL

DROPS

$0 (Tier 3)

REFRESH PLUS 0.5

% EYE DROPS IN A

DROPPERETTE

$0 (Tier 3)

REFRESH TEARS

0.5 % EYE DROPS

$0 (Tier 3)

Restore Plus

(carboxymethylcellul

ose) 0.5 % eye drops

in a dropperette

$0 (Tier 3)

Restore Tears 0.5 %

eye drops

$0 (Tier 3)

Retaine CMC 0.5 %

eye drops in a

dropperette

$0 (Tier 3)

Revive Plus 0.5 %

eye drops in a

dropperette

$0 (Tier 3)

SOOTHE

HYDRATION 1.25

% EYE DROPS

$0 (Tier 3)

SYSTANE

BALANCE 0.6 %

EYE DROPS

$0 (Tier 3)

SYSTANE

COMPLETE 0.6 %

EYE DROPS

$0 (Tier 3)

SYSTANE GEL 0.3

% EYE GEL

$0 (Tier 3)

Tears Again (PVA)

1.4 % eye drops

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 135

Drug Name Tier Drug

Restriction

Altachlore 5 % eye

drops

$0 (Tier 3)

Altachlore 5 % eye

ointment

$0 (Tier 3)

MURO 128 2 % EYE

DROPS

$0 (Tier 3)

Sochlor 5 % eye

drops

$0 (Tier 3)

Sochlor 5 % eye

ointment

$0 (Tier 3)

sodium chloride 5 %

eye drops

$0 (Tier 3)

sodium chloride 5 %

eye ointment

$0 (Tier 3)

OPHTHALMIC OTHERS

SOOTHE XP 1 %-

4.5 % EYE DROPS

$0 (Tier 3)

OTIC (EAR)

OTIC (EAR) - WAX REMOVERS-SOFTENERS

Debrox 6.5 % ear

drops

$0 (Tier 3)

EAR DROPS

(CARBAMIDE

PEROXIDE) 6.5 %

$0 (Tier 3)

Ear Drops Otc 6.5 % $0 (Tier 3)

EAR WAX

REMOVAL DROPS

6.5 %

$0 (Tier 3)

Ear Wax Removal

Kit 6.5 % drops

$0 (Tier 3)

Drug Name Tier Drug

Restriction OPHTHALMIC - DECONGESTANT-ARTIFICIAL TEAR COMBINATIONS

Advanced Formula

Eye Drops 0.05 %-

0.1 %-1 %-1 %

$0 (Tier 3)

VISINE

ADVANCED

REDNESS RELIEF

0.05 %-0.1 %-1 %-1

% EYE DROPS

$0 (Tier 3)

OPHTHALMIC - DECONGESTANT-ASTRINGENT COMBINATIONS

EYE DROPS

(TETRAHYDROZO

LINE-ZINC

SULFATE) 0.05 %-

0.25 %

$0 (Tier 3)

EYE DROPS

ALLERGY RELIEF

0.05 %-0.25 %

$0 (Tier 3)

VISINE-AC 0.05 %-

0.25 % EYE DROPS

$0 (Tier 3)

OPHTHALMIC - DECONGESTANTS

EYE DROPS

(TETRAHYDROZO

LINE) 0.05 %

$0 (Tier 3)

Opti-Clear 0.05 %

eye drops

$0 (Tier 3)

Redness Reliever Eye

Drops 0.05 %

$0 (Tier 3)

Sterile Eye Drops

0.05 %

$0 (Tier 3)

VISINE 0.05 % EYE

DROPS

$0 (Tier 3)

OPHTHALMIC - HYPEROSMOLAR AGENTS

OH Buckeye MMP Opt-Out Formulary August 1, 2021 136

Drug Name Tier Drug

Restriction

BROHIST D 4 MG-

10 MG TABLET

$0 (Tier 3)

Brotapp 1 mg-15

mg/5 mL oral liquid

$0 (Tier 3)

Children Night Time

Cold-Cough 6.25 mg-

2.5 mg/5 mL oral

liquid

$0 (Tier 3)

Children's Cold-

Allergy

(phenylephrine) 1

mg-2.5 mg/5 mL oral

solution

$0 (Tier 3)

Children's Dibromm

Cold and Allergy 1

mg-2.5 mg/5 mL oral

solution

$0 (Tier 3)

Children's Wal-Tap

Cold-Allergy 1 mg-

2.5 mg/5 mL oral

solution

$0 (Tier 3)

CHILDS

TRIACTING COLD

AND COUGH 6.25

MG-2.5 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

COLD AND

ALLERGY

(BROMPHEN-PE) 1

MG-2.5 MG/5 ML

ORAL SOLUTION

$0 (Tier 3)

COLD AND

ALLERGY 4 MG-10

MG TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

EAR WAX

REMOVAL

SYSTEM 6.5 %

DROPS

$0 (Tier 3)

EAR WAX

TREATMENT 6.5 %

DROPS

$0 (Tier 3)

Murine Ear 6.5 %

drops

$0 (Tier 3)

MURINE EAR

WAX REMOVAL

SYSTEM 6.5 %

DROPS

$0 (Tier 3)

RESPIRATORY THERAPY AGENTS

1ST GENERATION ANTIHISTAMINE- DECONGESTANT COMBINATIONS

Acticon

(dexbrompheniramin

e-pseudoephed) 1

mg-30 mg/5 mL oral

solution

$0 (Tier 3)

Acticon

(dexbrompheniramin

e-pseudoephedrine) 2

mg-60 mg tablet

$0 (Tier 3)

Allerfed Cold and

Allergy 4 mg-10 mg

tablet

$0 (Tier 3)

AMBI 10PEH-4CPM

4 MG-10 MG

TABLET

$0 (Tier 3)

AMBI 60PSE-4CPM

4 MG-60 MG

TABLET

$0 (Tier 3)

Aprodine 2.5 mg-60

mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 137

Drug Name Tier Drug

Restriction

doxylamine 7.5 mg-

phenylephrine 10 mg

tablet

$0 (Tier 3)

Dr Manzanilla PE 10

mg-2.5 mg/5 mL oral

liquid

$0 (Tier 3)

ED A-HIST 4 MG-10

MG TABLET

$0 (Tier 3)

Ed A-Hist PSE 2.5

mg-60 mg tablet

$0 (Tier 3)

Ed Chlorped D 2 mg-

5 mg/mL oral drops

$0 (Tier 3)

Glenmax PEB 4 mg-

10 mg/5 mL oral

liquid

$0 (Tier 3)

HISTEX PE 10 MG-

2.5 MG/5 ML ORAL

LIQUID

$0 (Tier 3)

LODRANE D 4 MG-

60 MG CAPSULE

$0 (Tier 3)

LoHist - D 2 mg-30

mg/5 mL oral liquid

$0 (Tier 3)

Lortuss LQ 6.25 mg-

30 mg/5 mL oral

liquid

$0 (Tier 3)

NASOPEN PE 50

MG-10 MG/15 ML

ORAL LIQUID

$0 (Tier 3)

NoHist-LQ 4 mg-10

mg/5 mL oral liquid

$0 (Tier 3)

POLY HIST FORTE

(DOXYLAMINE)

7.5 MG-10 MG

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Cold and Cough

(diphenhydr-pe) 6.25

mg-2.5 mg/5 mL oral

liquid

$0 (Tier 3)

CONEX 1 MG-30

MG/5 ML ORAL

SOLUTION

$0 (Tier 3)

CONEX 2 MG-60

MG TABLET

$0 (Tier 3)

Dallergy

(chlorpheniramine-

phenylephrine) 1 mg-

2.5 mg/mL oral drops

$0 (Tier 3)

Dallergy

(dexbrompheniramin

e-PE) 1 mg-5 mg

tablet

$0 (Tier 3)

Dallergy

(dexbrompheniramin

e-PE) 1 mg-5 mg/5

mL oral liquid

$0 (Tier 3)

dexbrompheniramine

-phenylephrine 2 mg-

10 mg tablet

$0 (Tier 3)

Dimaphen (PE) 1

mg-2.5 mg/5 mL oral

solution

$0 (Tier 3)

Dimetapp Cold-

Allergy (PE) 1 mg-

2.5 mg/5 mL oral

solution

$0 (Tier 3)

Dimetapp Cold-

Congestion 6.25 mg-

2.5 mg/5 mL oral

liquid

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 138

Drug Name Tier Drug

Restriction

Stahist AD 25 mg-60

mg/5 mL oral liquid

$0 (Tier 3)

SudoGest Cold and

Allergy 4 mg-60 mg

tablet

$0 (Tier 3)

SudoGest Sinus and

Allergy 4 mg-60 mg

tablet

$0 (Tier 3)

SUPHEDRINE PE

COLD AND

ALLERGY 4 MG-10

MG TABLET

$0 (Tier 3)

Suphedrine PE Sinus

and Allergy 4 mg-10

mg tablet

$0 (Tier 3)

TRIAMINIC COLD

AND COUGH

NIGHT

TIME(PE)6.25 MG-

2.5 MG/5 ML ORAL

LIQUID

$0 (Tier 3)

VAZOTAB

(PYRILAMINE) 25

MG-10 MG

TABLET

$0 (Tier 3)

Wal-Act D Cold and

Allergy 2.5 mg-60

mg tablet

$0 (Tier 3)

Wal-Finate-D 4 mg-

60 mg tablet

$0 (Tier 3)

Wal-phed 4 mg-60

mg tablet

$0 (Tier 3)

Wal-Phed PE Sinus

and Allergy 4 mg-10

mg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

POLY HIST FORTE

10.5 MG-10 MG

TABLET

$0 (Tier 3)

pyrilamine-

phenylephrine 25

mg-10 mg tablet

$0 (Tier 3)

Q-TAPP 1 MG-15

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

Relhist BP 4 mg-10

mg tablet

$0 (Tier 3)

Rescon 2 mg-60 mg

tablet

$0 (Tier 3)

RU-HIST D 4 MG-

10 MG TABLET

$0 (Tier 3)

Rymed

(dexchlorpheniramin

e-phenylephrine) 2

mg-10 mg tablet

$0 (Tier 3)

Rynex PE 1 mg-2.5

mg/5 mL oral

solution

$0 (Tier 3)

Rynex PSE 1 mg-15

mg/5 mL oral liquid

$0 (Tier 3)

SINUS AND

ALLERGY

(PHENYLEPHRINE

) 4 MG-10 MG

TABLET

$0 (Tier 3)

SINUS AND

ALLERGY PE 4

MG-10 MG

TABLET

$0 (Tier 3)

Stahist AD 25 mg-60

mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 139

Drug Name Tier Drug

Restriction

Cough and Severe

Cold 25 mg-10 mg-

650 mg oral powder

packet

$0 (Tier 3)

DELSYM COUGH-

COLD NIGHTTIME

12.5 MG-5 MG-325

MG/10 ML ORAL

LIQUID

$0 (Tier 3)

DRISTAN COLD 2

MG-5 MG-325 MG

TABLET

$0 (Tier 3)

Flu and Severe Cold-

Nighttime 25 mg-10

mg-650 mg/30 mL

oral liquid

$0 (Tier 3)

Flu Relief Therapy

Nighttime 25 mg-10

mg-650 mg/30 mL

oral liquid

$0 (Tier 3)

FLU-SEVERE

COLD-COUGH

NIGHTTIME 25

MG-10 MG-650 MG

ORAL POWDER

PACKET

$0 (Tier 3)

HerbioMed Allergy

Cold-Sinus Night

12.5 mg-5 mg-325

mg/10 mL oral liq

$0 (Tier 3)

Medicidin-D 2 mg-5

mg-325 mg tablet

$0 (Tier 3)

MUCINEX FAST-

MAX NITE COLD-

FLU 12.5 MG-5 MG-

325 MG/10 ML

ORAL LIQUID

$0 (Tier 3)

Drug Name Tier Drug

Restriction 1ST GENERATION ANTIHISTAMINE- DECONGESTANT-ANALGESIC, NON-SALICYLATE

Allergy and Cold PE

12.5 mg-5 mg-325

mg tablet

$0 (Tier 3)

Allergy Multi-

Symptom 2 mg-5

mg-325 mg tablet

$0 (Tier 3)

ALLERGY MULTI-

SYMPTOM

NIGHTTIME 25

MG-5 MG-325 MG

TABLET

$0 (Tier 3)

Allergy Relief Multi-

Symptom 2 mg-5

mg-325 mg tablet

$0 (Tier 3)

Allergy Sinus

Headache (PE) 12.5

mg-5 mg-325 mg

tablet

$0 (Tier 3)

Allergy Sinus PE 2

mg-5 mg-325 mg

tablet

$0 (Tier 3)

CHILD DELSYM

COUGH-COLD 12.5

MG-5 MG-325

MG/10 ML ORAL

LIQUID

$0 (Tier 3)

CHILDREN'S

MUCINEX NIGHT

TIME 12.5 MG-5

MG-325 MG/10 ML

ORAL LIQUID

$0 (Tier 3)

Cold and Flu Relief

(diphen-pe) 12.5 mg-

5 mg-325 mg/10 mL

oral liquid

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 140

Drug Name Tier Drug

Restriction

Sinus Daytime-

Nightime 5-325

mg(dy)/6.25-5-

325mg(nt) tablets

$0 (Tier 3)

THERAFLU

EXPRESSMAX

COLD-COUGH

NIGHT 12.5 MG-5

MG-325 MG

TABLET

$0 (Tier 3)

THERAFLU FLU-

SORE THROAT 20

MG-10 MG-650 MG

ORAL POWDER

PACKET

$0 (Tier 3)

THERAFLU

NIGHTTIME

POWERPOD 25

MG-10 MG-650 MG

ORAL POWDER IN

POD

$0 (Tier 3)

THERAFLU

NIGHTTIME

SEVERE COLD-

COUGH 25 MG-10

MG-650 MG

POWDER PACKET

$0 (Tier 3)

Wal-Dryl Severe

Allergy-Sinus 25 mg-

5 mg-325 mg tablet

$0 (Tier 3)

Wal-Flu Night

Severe Cold 25 mg-

10 mg-650 mg/30 mL

oral liquid

$0 (Tier 3)

Wal-Flu Night Time

20 mg-10 mg-650 mg

oral powder packet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

MUCINEX SINUS-

MAX NITE

CONGESTION-

COUGH 12.5-5-325

MG/10 ML ORAL

LIQ

$0 (Tier 3)

Norel AD 4 mg-10

mg-325 mg tablet

$0 (Tier 3)

Pain Relief Allergy

Sinus 2 mg-5 mg-325

mg tablet

$0 (Tier 3)

ROBITUSSIN

COLD-FLU NIGHT

(PE) 12.5 MG-5 MG-

325 MG/10 ML

ORAL LIQUID

$0 (Tier 3)

Severe Allergy-Sinus

Headache 25 mg-5

mg-325 mg tablet

$0 (Tier 3)

Severe Cold Cough-

Flu 25 mg-10 mg-650

mg oral powder

packet

$0 (Tier 3)

SEVERE COLD PE

12.5 MG-5 MG-325

MG TABLET

$0 (Tier 3)

Sinus Congestion and

Pain

(chlorpheniramine) 2

mg-5 mg-325 mg

tablet

$0 (Tier 3)

Sinus Congestion and

Pain Day-Night 2

mg-5 mg-325 mg

tablets

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 141

Drug Name Tier Drug

Restriction

ALAVERT D-12

ALLERGY-SINUS 5

MG-120 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

All Day Allergy-D 5

mg-120 mg

tablet,extended

release

$0 (Tier 3)

ALLEGRA-D 12

HOUR 60 MG-120

MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

Use Generic Products

AllerClear D-12hr 5

mg-120 mg

tablet,extended

release

$0 (Tier 3)

AllerClear D-24hr 10

mg-240 mg

tablet,extended

release

$0 (Tier 3)

Allergy and

Congestion Relief 10

mg-240 mg

tablet,extend release

24 hr

$0 (Tier 3)

Allergy and

Congestion Relief 5

mg-120 mg

tablet,extend release

12 hr

$0 (Tier 3)

Allergy Complete-D

5 mg-120 mg

tablet,extended

release

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Wal-Flu Severe Cold

and Cough 25 mg-10

mg-650 mg oral

powder packet

$0 (Tier 3)

Wal-Phed PE

Nighttime Cold 25

mg-5 mg-325 mg

tablet

$0 (Tier 3)

Wal-phed PE Severe

Cold 12.5 mg-5 mg-

325 mg tablet

$0 (Tier 3)

1ST GENERATION ANTIHISTAMINE- DECONGESTANT-ANALGESIC, SALICYLATE COMB

ALKA-SELTZER

PLUS COLD (PE) 2

MG-7.8 MG-325 MG

EFFERVESCENT

TABLET

$0 (Tier 3)

Cold Relief 2 mg-7.8

mg-325 mg

effervescent tablet

$0 (Tier 3)

Cold Relief Plus 2

mg-7.8 mg-325 mg

effervescent tablet

$0 (Tier 3)

1ST GENERATION ANTIHISTAMINE- DECONGESTANT-ANALGESIC-EXPECTORANT COMB.

MUCINEX SINUS-

MAX DAY-

NT(DIPHEN) 5-325-

200 MG(D)/25-5-

325MG(N)

TABLETS

$0 (Tier 3)

Sinus Relief Max Str

Day-Night 5-325-200

mg(d)/25-5-325

mg(n) tablets

$0 (Tier 3)

2ND GENERATION ANTIHISTAMINE- DECONGESTANT COMBINATIONS

OH Buckeye MMP Opt-Out Formulary August 1, 2021 142

Drug Name Tier Drug

Restriction

Allergy-Congestion

Relief-D 10 mg-240

mg tablet,extended

release 24 hr

$0 (Tier 3)

Aller-Tec D 5 mg-

120 mg

tablet,extended

release

$0 (Tier 3)

Cetiri-D 5 mg-120

mg tablet,extended

release

$0 (Tier 3)

cetirizine 5 mg-

pseudoephedrine ER

120 mg

tablet,extended

release,12hr

$0 (Tier 3)

CLARITIN-D 12

HOUR 5 MG-120

MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

CLARITIN-D 24

HOUR 10 MG-240

MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

fexofenadine 60 mg-

pseudoephedrine ER

120 mg

tablet,ext.release,12

hr

$0 (Tier 3)

Lorata-D 10 mg-240

mg tablet,extended

release

$0 (Tier 3)

lorata-dine D 10 mg-

240 mg

tablet,extended

release

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Allergy D-12 5 mg-

120 mg

tablet,extended

release

$0 (Tier 3)

Allergy plus

Congestn Relief-

D(cetiriz) 5 mg-120

mg tablet,ext.release

$0 (Tier 3)

ALLERGY RELIEF

AND NASAL

DECONGESTANT

10 MG-240 MG

TABLET,EXTENDE

D REL

$0 (Tier 3)

ALLERGY RELIEF

D12 5 MG-120 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

Allergy Relief D-

24hr 10 mg-240 mg

tablet,extended

release

$0 (Tier 3)

Allergy Relief-D

(cetirizine) 5 mg-120

mg tablet,extended

release

$0 (Tier 3)

Allergy Relief-D

(fexofenadine) 60

mg-120 mg

tablet,extended

release

$0 (Tier 3)

Allergy Relief-D

(loratadine) 5 mg-120

mg tablet,extended

release

$0 (Tier 3)

Allergy-Congestion

Relief-D (fexo) 60

mg-120 mg

tablet,extend release

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 143

Drug Name Tier Drug

Restriction

Aller-G-Time 25 mg

tablet

$0 (Tier 3)

Allergy

(chlorpheniramine) 4

mg tablet

$0 (Tier 3)

ALLERGY

(DIPHENHYDRAMI

NE) 12.5 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Allergy

(diphenhydramine)

25 mg capsule

$0 (Tier 3)

Allergy

(diphenhydramine)

25 mg tablet

$0 (Tier 3)

Allergy 4-Hour 4 mg

tablet

$0 (Tier 3)

ALLERGY

MEDICATION 25

MG CAPSULE

$0 (Tier 3)

ALLERGY

MEDICINE 12.5

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

ALLERGY

MEDICINE 25 MG

CAPSULE

$0 (Tier 3)

Allergy Medicine 25

mg tablet

$0 (Tier 3)

Allergy Relief

(chlorpheniramine) 4

mg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

LORATADINE-D 10

MG-240 MG

TABLET,EXTENDE

D RELEASE 24 HR

$0 (Tier 3)

Loratadine-D 5 mg-

120 mg

tablet,extended

release 12 hr

$0 (Tier 3)

Wal-Fex D 12 Hour

60 mg-120 mg

tablet,extended

release

$0 (Tier 3)

Wal-itin D 10 mg-

240 mg

tablet,extended

release

$0 (Tier 3)

Wal-Itin D 12 Hour 5

mg-120 mg

tablet,extended

release

$0 (Tier 3)

Wal-Zyr D 5 mg-120

mg tablet,extended

release

$0 (Tier 3)

ZYRTEC-D 5 MG-

120 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

ANTIHISTAMINES - 1ST GENERATION

ALA-HIST IR 2 MG

TABLET

$0 (Tier 3)

Aler-Cap 25 mg

capsule

$0 (Tier 3)

Aller-Chlor 2 mg/5

mL oral syrup

$0 (Tier 3)

Aller-Chlor 4 mg

tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 144

Drug Name Tier Drug

Restriction

BANOPHEN

ALLERGY 12.5

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

BENADRYL 25 MG

CAPSULE

$0 (Tier 3)

Use Generic Products

BENADRYL

ALLERGY 12.5

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

BENADRYL

ALLERGY 25 MG

TABLET

$0 (Tier 3)

CHILDREN'S

ALLERGY

(DIPHENHYDRAMI

NE) 12.5 MG/5 ML

ORAL ELIXIR

$0 (Tier 3)

Children's Allergy

(diphenhydramine)

12.5 mg/5 mL oral

liquid

$0 (Tier 3)

Children's

Diphenhydramine

12.5 mg/5 mL oral

liquid

$0 (Tier 3)

Children's Wal-Dryl

Allergy 12.5 mg/5

mL oral liquid

$0 (Tier 3)

Children's Wal-Dryl

Allergy 12.5 mg/5

mL prefilled spoon

$0 (Tier 3)

CHLORHIST 4 MG

TABLET

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Allergy Relief

(chlorpheniramine)

ER 12 mg

tablet,extended

release

$0 (Tier 3)

Allergy Relief

(clemastine) 1.34 mg

tablet

$0 (Tier 3)

ALLERGY RELIEF

(DIPHENHYDRAMI

NE) 12.5 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

ALLERGY RELIEF

(DIPHENHYDRAMI

NE) 25 MG

CAPSULE

$0 (Tier 3)

Allergy Relief

(diphenhydramine)

25 mg tablet

$0 (Tier 3)

Allergy-Time 4 mg

tablet

$0 (Tier 3)

Allerhist (clemastine)

1.34 mg tablet

$0 (Tier 3)

ALLERHIST-1 1.34

MG TABLET

$0 (Tier 3)

BANOPHEN 12.5

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

Banophen 25 mg

capsule

$0 (Tier 3)

Banophen 25 mg

tablet

$0 (Tier 3)

Banophen 50 mg

capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 145

Drug Name Tier Drug

Restriction

DIPHEDRYL 12.5

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

DIPHEDRYL 25 MG

CAPSULE

$0 (Tier 3)

DIPHEDRYL 25 MG

TABLET

$0 (Tier 3)

Diphedryl Allergy

12.5 mg/5 mL oral

liquid

$0 (Tier 3)

Diphen 25 mg tablet $0 (Tier 3)

DIPHENHIST 12.5

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

DIPHENHIST 25

MG CAPSULE

$0 (Tier 3)

DIPHENHIST 25

MG TABLET

$0 (Tier 3)

diphenhydramine

12.5 mg/5 mL oral

liquid

$0 (Tier 3)

diphenhydramine 25

mg capsule

$0 (Tier 3)

diphenhydramine 25

mg tablet

$0 (Tier 3)

diphenhydramine 50

mg capsule

$0 (Tier 3)

diphenhydramine

6.25 mg/mL oral

drops

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Chlorphen SR 12 mg

tablet,extended

release

$0 (Tier 3)

chlorpheniramine 4

mg tablet

$0 (Tier 3)

chlorpheniramine ER

12 mg

tablet,extended

release

$0 (Tier 3)

ChlorTabs 4 mg

tablet

$0 (Tier 3)

CHLOR-

TRIMETON 4 MG

TABLET

$0 (Tier 3)

COMPLETE

ALLERGY 12.5

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

COMPLETE

ALLERGY 25 MG

CAPSULE

$0 (Tier 3)

COMPLETE

ALLERGY 25 MG

TABLET

$0 (Tier 3)

COMPLETE

ALLERGY

MEDICINE 25 MG

CAPSULE

$0 (Tier 3)

COMPLETE

ALLERGY

MEDICINE 25 MG

TABLET

$0 (Tier 3)

Dayhist Allergy 1.34

mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 146

Drug Name Tier Drug

Restriction

PEDIACLEAR

ALLERGY 0.313

MG/ML ORAL

DROPS

$0 (Tier 3)

PEDIACLEAR

COUGH 6.25

MG/ML ORAL

DROPS

$0 (Tier 3)

PEDIACLEAR PD

0.625 MG/ML

ORAL DROPS

$0 (Tier 3)

Pediavent 2 mg/5 mL

oral liquid

$0 (Tier 3)

Pharbechlor 4 mg

tablet

$0 (Tier 3)

Pharbedryl 25 mg

capsule

$0 (Tier 3)

Pharbedryl 50 mg

capsule

$0 (Tier 3)

Q-Dryl 12.5 mg/5

mL oral liquid

$0 (Tier 3)

Q-Dryl 25 mg

capsule

$0 (Tier 3)

Siladryl SA 12.5

mg/5 mL oral liquid

$0 (Tier 3)

Silphen Cough 12.5

mg/5 mL oral syrup

$0 (Tier 3)

TOTAL ALLERGY

MEDICINE 25 MG

TABLET

$0 (Tier 3)

triprolidine HCl

0.313 mg/mL oral

drops

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Dr Manzanilla Infant

0.938 mg/mL oral

drops

$0 (Tier 3)

Dr Manzanilla

Pediatric

(triprolidine) 2.5

mg/5 mL oral liquid

$0 (Tier 3)

ED Chlorped Jr 2

mg/5 mL oral syrup

$0 (Tier 3)

Ed-ChlorPed 2

mg/mL oral drops

$0 (Tier 3)

ED-CHLORTAN 4

MG TABLET

$0 (Tier 3)

Geri-Dryl 12.5 mg/5

mL oral liquid

$0 (Tier 3)

Geri-Dryl 25 mg

tablet

$0 (Tier 3)

HISTEX

(TRIPROLIDINE)

2.5 MG/5 ML ORAL

LIQUID

$0 (Tier 3)

HISTEX PD 0.938

MG/ML ORAL

DROPS

$0 (Tier 3)

M-Dryl 12.5 mg/5

mL oral liquid

$0 (Tier 3)

M-Hist PD 0.625

mg/mL oral drops

$0 (Tier 3)

Naramin 12.5 mg/5

mL oral liquid in

packet

$0 (Tier 3)

Nighttime Allergy

Relief 25 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 147

Drug Name Tier Drug

Restriction

ALAVERT 10 MG

DISINTEGRATING

TABLET

$0 (Tier 3)

ALL DAY

ALLERGY

(CETIRIZINE) 1

MG/ML ORAL

SOLUTION

$0 (Tier 3)

ALL DAY

ALLERGY

(CETIRIZINE) 10

MG CHEWABLE

TABLET

$0 (Tier 3)

All Day Allergy

(cetirizine) 10 mg

tablet

$0 (Tier 3)

ALL DAY

ALLERGY RELIEF

(CETIRIZINE) 10

MG TABLET

$0 (Tier 3)

Allegra Allergy 180

mg tablet

$0 (Tier 3)

Allegra Allergy 60

mg tablet

$0 (Tier 3)

Allerclear 10 mg

tablet

$0 (Tier 3)

Aller-ease 180 mg

tablet

$0 (Tier 3)

Aller-ease 30 mg/5

mL oral suspension

$0 (Tier 3)

Aller-ease 60 mg

tablet

$0 (Tier 3)

Aller-Fex 180 mg

tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

triprolidine HCl

0.625 mg/mL oral

drops

$0 (Tier 3)

triprolidine HCl

0.938 mg/mL oral

drops

$0 (Tier 3)

VALU-DRYL

ALLERGY 25 MG

CAPSULE

$0 (Tier 3)

VANACLEAR PD

0.313 MG/ML

ORAL DROPS

$0 (Tier 3)

VANAHIST PD

0.625 MG/ML

ORAL DROPS

$0 (Tier 3)

VANAMINE PD

6.25 MG/ML ORAL

DROPS

$0 (Tier 3)

Wal-Dryl Allergy

12.5 mg/5 mL oral

liquid

$0 (Tier 3)

Wal-Dryl Allergy 25

mg capsule

$0 (Tier 3)

Wal-Dryl Allergy 25

mg tablet

$0 (Tier 3)

Wal-Finate 4 mg

tablet

$0 (Tier 3)

ANTIHISTAMINES - 2ND GENERATION

24Hour Allergy 10

mg tablet

$0 (Tier 3)

24HR Allergy Relief

5 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 148

Drug Name Tier Drug

Restriction

cetirizine 10 mg

chewable tablet

$0 (Tier 3)

cetirizine 10 mg

tablet

$0 (Tier 3)

cetirizine 5 mg

chewable tablet

$0 (Tier 3)

cetirizine 5 mg tablet $0 (Tier 3)

cetirizine 5 mg/5 mL

oral solution

$0 (Tier 3)

Children's All Day

Allergy (cetirizine) 1

mg/mL oral solution

$0 (Tier 3)

Children's Allergy

(cetirizine) 1 mg/mL

oral solution

$0 (Tier 3)

Children's Allergy

Complete 1 mg/mL

oral solution

$0 (Tier 3)

Children's Allergy

Relief (cetirizine) 1

mg/mL oral solution

$0 (Tier 3)

Children's Allergy

Relief (cetirizine) 10

mg chewable tablet

$0 (Tier 3)

Children's Allergy

Relief (loratadine) 5

mg chewable tablet

$0 (Tier 3)

Children's Allergy

Relief (loratadine) 5

mg/5 mL oral

solution

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Allergy Relief

(cetirizine) 1 mg/mL

oral solution

$0 (Tier 3)

Allergy Relief

(cetirizine) 10 mg

capsule

$0 (Tier 3)

Allergy Relief

(cetirizine) 10 mg

tablet

$0 (Tier 3)

Allergy Relief

(fexofenadine) 180

mg tablet

$0 (Tier 3)

Allergy Relief

(fexofenadine) 60 mg

tablet

$0 (Tier 3)

Allergy Relief

(levocetirizine) 5 mg

tablet

$0 (Tier 3)

ALLERGY RELIEF

(LORATADINE) 10

MG

DISINTEGRATING

TABLET

$0 (Tier 3)

Allergy Relief

(loratadine) 10 mg

tablet

$0 (Tier 3)

ALLERGY RELIEF

(LORATADINE) 5

MG/5 ML ORAL

SOLUTION

$0 (Tier 3)

Aller-Tec 10 mg

tablet

$0 (Tier 3)

cetirizine 1 mg/mL

oral solution

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 149

Drug Name Tier Drug

Restriction

Loradamed 10 mg

tablet

$0 (Tier 3)

loratadine 10 mg

capsule

$0 (Tier 3)

loratadine 10 mg

disintegrating tablet

$0 (Tier 3)

loratadine 10 mg

tablet

$0 (Tier 3)

loratadine 5 mg/5 mL

oral solution

$0 (Tier 3)

NON-DROWSY

ALLERGY 10 MG

TABLET

$0 (Tier 3)

Wal-Fex Allergy 180

mg tablet

$0 (Tier 3)

Wal-Fex Allergy 60

mg tablet

$0 (Tier 3)

WAL-ITIN 10 MG

DISINTEGRATING

TABLET

$0 (Tier 3)

Wal-itin 10 mg tablet $0 (Tier 3)

Wal-itin 5 mg/5 mL

oral solution

$0 (Tier 3)

Wal-Zyr (cetirizine)

1 mg/mL oral

solution

$0 (Tier 3)

Wal-Zyr (cetirizine)

10 mg capsule

$0 (Tier 3)

Wal-Zyr (cetirizine)

10 mg tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Children's Aller-Tec

1 mg/mL oral

solution

$0 (Tier 3)

Children's Cetirizine

1 mg/mL oral

solution

$0 (Tier 3)

Children's Cetirizine

10 mg chewable

tablet

$0 (Tier 3)

Children's Cetirizine

5 mg chewable tablet

$0 (Tier 3)

CHILDREN'S

CLARITIN 5 MG/5

ML ORAL

SOLUTION

$0 (Tier 3)

Children's Loratadine

5 mg chewable tablet

$0 (Tier 3)

Children's Wal-Zyr 1

mg/mL oral solution

$0 (Tier 3)

Children's Wal-Zyr

10 mg chewable

tablet

$0 (Tier 3)

CLARITIN 10 MG

TABLET

$0 (Tier 3)

Use Generic Products

CLARITIN

REDITABS 10 MG

DISINTEGRATING

TABLET

$0 (Tier 3)

fexofenadine 180 mg

tablet

$0 (Tier 3)

fexofenadine 60 mg

tablet

$0 (Tier 3)

levocetirizine 5 mg

tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 150

Drug Name Tier Drug

Restriction

dextromethorphan

polistirex ER 30

mg/5 mL oral susp

ext.release 12hr

$0 (Tier 3)

Father John's Cough

Suppressant 10 mg/5

mL oral liquid

$0 (Tier 3)

ROBAFEN COUGH

15 MG CAPSULE

$0 (Tier 3)

ROBITUSSIN

COUGHGEL 15 MG

CAPSULE

$0 (Tier 3)

ROBITUSSIN

PEDIATRIC 7.5

MG/5 ML ORAL

SYRUP

$0 (Tier 3)

TESSALON

PERLES 100 MG

CAPSULE

$0 (Tier 3)

TUSSIN COUGH

(DM ONLY) 15 MG

CAPSULE

$0 (Tier 3)

Tussin Cough (DM

only) 15 mg/5 mL

oral liquid

$0 (Tier 3)

Tussin Long-Acting

15 mg/5 mL oral

liquid

$0 (Tier 3)

TUSSIN

MAXIMUM

STRENGTH 15

MG/5 ML ORAL

SYRUP

$0 (Tier 3)

Drug Name Tier Drug

Restriction

ZYRTEC 10 MG

TABLET

$0 (Tier 3)

ANTITUSSIVES - NON-OPIOID

benzonatate 100 mg

capsule

$0 (Tier 3)

benzonatate 150 mg

capsule

$0 (Tier 3)

benzonatate 200 mg

capsule

$0 (Tier 3)

Children's Cough

DM ER 30 mg/5 mL

oral

suspension,extended

release

$0 (Tier 3)

CHILDREN'S

DELSYM COUGH

30 MG/5 ML ORAL

SUSPENSION,EXT

ENDED RELEASE

$0 (Tier 3)

Children's Robitussin

ER 30 mg/5 mL oral

suspension,extended

release

$0 (Tier 3)

Cough Control

(dextromethorphan)

15 mg capsule

$0 (Tier 3)

Cough DM ER 30

mg/5 mL oral

suspension,extended

release

$0 (Tier 3)

Delsym 12 hour 30

mg/5 mL oral

suspension,extended

release

$0 (Tier 3)

dextromethorphan

HBr 15 mg capsule

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 151

Drug Name Tier Drug

Restriction

Sinus Pain Relief 5

mg-325 mg tablet

$0 (Tier 3)

Sinus Pain-Pressure

(PE) 5 mg-325 mg

tablet

$0 (Tier 3)

Sinus Relief (Non-

Drowsy) 5 mg-325

mg tablet

$0 (Tier 3)

Suphedrine PE Sinus

Headache 5 mg-325

mg tablet

$0 (Tier 3)

VICKS SINEX

DAYTIME 5 MG-

325 MG CAPSULE

$0 (Tier 3)

Wal-Phed PE Sinus

Headache 5 mg-325

mg tablet

$0 (Tier 3)

DECONGESTANT-ANALGESIC, NON-SALICYLATE- EXPECTORANT COMBINATIONS

MUCINEX FAST-

MAX COLD-SINUS

5 MG-325 MG-200

MG TABLET

$0 (Tier 3)

MUCINEX SINUS-

MAX PRESSURE-

PAIN 5 MG-325

MG-200 MG

TABLET

$0 (Tier 3)

MUCINEX SINUS-

MAX SEV

CONGEST RLF 10

MG-650 MG-400

MG/20 ML ORAL

LIQ

$0 (Tier 3)

Drug Name Tier Drug

Restriction

TUSSIN

MAXIMUM

STRENGTH

COUGH 15 MG/5

ML ORAL SYRUP

$0 (Tier 3)

Wal-Tussin Cough

15 mg capsule

$0 (Tier 3)

Wal-Tussin Cough

15 mg/5 mL oral

liquid

$0 (Tier 3)

Wal-Tussin Max

Strength Cough 15

mg/5 mL oral syrup

$0 (Tier 3)

ASTHMA THERAPY - ALPHA/BETA ADRENERGIC- EXPECTORANT COMBINATIONS

Bronkaid Dual

Action 25 mg-400

mg tablet

$0 (Tier 3)

DECONGESTANT-ANALGESIC, NON-SALICYLATE COMBINATIONS

Acetaminophen

Congestion-Pain 5

mg-325 mg tablet

$0 (Tier 3)

Mapap Sinus

Maximum Strength

(PE) 5 mg-325 mg

tablet

$0 (Tier 3)

Pain Relief Sinus PE

5 mg-325 mg tablet

$0 (Tier 3)

SINUS

CONGESTION AND

PAIN 5 MG-325 MG

TABLET

$0 (Tier 3)

Sinus Headache PE 5

mg-325 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 152

Drug Name Tier Drug

Restriction

Sinus Relief Severe

Congestion 5 mg-325

mg-200 mg tablet

$0 (Tier 3)

Wal-Phed PE Triple

Relief 5 mg-325 mg-

200 mg tablet

$0 (Tier 3)

DECONGESTANT-ANALGESIC, NSAID COX NON- SPECIFIC

ADVIL COLD AND

SINUS 30 MG-200

MG TABLET

$0 (Tier 3)

ALEVE-D SINUS

AND HEADACHE

220 MG-120 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

All Day Pain Relief

Sinus and Cold 220

mg-120 mg

tablet,extend release

$0 (Tier 3)

Cold and Sinus Pain

Relief 30 mg-200 mg

tablet

$0 (Tier 3)

Cold-Sinus Relief 30

mg-200 mg tablet

$0 (Tier 3)

Ibuprofen Cold-Sinus

(with

pseudoephedrine) 30

mg-200 mg tablet

$0 (Tier 3)

Sinus and Cold-D

220 mg-120 mg

tablet,extended

release

$0 (Tier 3)

Wal-Profen Cold-

Sinus 30 mg-200 mg

tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

MUCINEX SINUS-

MAX SEVERE

CONGESTION

RELIEF 5 MG-325

MG-200 MG

TABLET

$0 (Tier 3)

Mucus Relief Cold

and Sinus 10 mg-650

mg-400 mg/20 mL

oral liquid

$0 (Tier 3)

Mucus Relief Cold

and Sinus 5 mg-325

mg-200 mg tablet

$0 (Tier 3)

MUCUS RELIEF

SEVERE SINUS

CONGESTION 5

MG-325 MG-200

MG TABLET

$0 (Tier 3)

Mucus Relief Sinus

Pressure and Pain 5

mg-325 mg-200 mg

tablet

$0 (Tier 3)

Pressure-Pain PE

Plus Mucus 5 mg-325

mg-200 mg tablet

$0 (Tier 3)

Severe Congestion

Relief 10 mg-650

mg-400 mg/20 mL

oral liquid

$0 (Tier 3)

Sinus Congestion and

Pain (guaifenesin) 5

mg-325 mg-200 mg

tablet

$0 (Tier 3)

Sinus Relief Pressure

and Pain 5 mg-325

mg-200 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 153

Drug Name Tier Drug

Restriction

ED Bron GP 5 mg-

100 mg/5 mL oral

liquid

$0 (Tier 3)

Fenesin PE IR 10

mg-400 mg tablet

$0 (Tier 3)

MAXIFED 60 MG-

360 MG TABLET

$0 (Tier 3)

MAXI-TUSS PE

MAX 5 MG-100

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

MUCAPHED 10

MG-400 MG

TABLET

$0 (Tier 3)

MUCINEX D 60

MG-600 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

MUCINEX D

MAXIMUM

STRENGTH 120

MG-1,200 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

Mucus D 60 mg-600

mg tablet,extended

release

$0 (Tier 3)

Mucus Relief D

(pseudoephed) 120

mg-1,200 mg

tablet,extended

release

$0 (Tier 3)

Mucus Relief D

(pseudoephed) 60

mg-600 mg

tablet,extended

release

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Wal-Profen D Cold

and Sinus 30 mg-200

mg tablet

$0 (Tier 3)

DECONGESTANT-EXPECTORANT COMBINATIONS

AMBI 60PSE-

400GFN 60 MG-400

MG TABLET

$0 (Tier 3)

Chest Congestion

Relief PE 10 mg-400

mg tablet

$0 (Tier 3)

CHEST-SINUS

CONGESTION

RELIEF 10 MG-400

MG TABLET

$0 (Tier 3)

CHILDREN'S

MUCINEX STUFFY

NOSE AND COLD

2.5 MG-100 MG/5

ML ORAL LIQUID

$0 (Tier 3)

CHILDREN'S

MUCINEX STUFFY

NOSE-CHEST 2.5

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Children's Stuffy

Nose-Cold 2.5 mg-

100 mg/5 mL oral

liquid

$0 (Tier 3)

CONGESTAC 60

MG-400 MG

TABLET

$0 (Tier 3)

DECONEX IR 10

MG-380 MG

TABLET

$0 (Tier 3)

DECONEX IR 10

MG-385 MG

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 154

Drug Name Tier Drug

Restriction

ADULT TUSSIN

CHEST

CONGESTION 100

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

Adult Wal-Tussin

100 mg/5 mL oral

liquid

$0 (Tier 3)

Chest Congestion

Relief 400 mg tablet

$0 (Tier 3)

CHILD MUCINEX

CHEST CONGEST

MINI-MELTS 100

MG ORAL

GRANULES IN

PACKET

$0 (Tier 3)

CHILD MUCUS

RELIEF

EXPECTORANT

100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Children's Chest

Congestion 100 mg/5

mL oral liquid

$0 (Tier 3)

CHILDREN'S

MUCINEX CHEST

CONGESTION 100

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

COUGH CONTROL

(GUAIFENESIN)

100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Cough Syrup 100

mg/5 mL oral liquid

$0 (Tier 3)

Coughtab 200 mg

tablet

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Mucus Relief PE 10

mg-400 mg tablet

$0 (Tier 3)

Mucus Relief Sinus

10 mg-400 mg tablet

$0 (Tier 3)

POLY-VENT IR 60

MG-380 MG

TABLET

$0 (Tier 3)

pseudoephedrine-

guaifenesin ER 120

mg-1,200 mg

tab,extend release

12hr

$0 (Tier 3)

pseudoephedrine-

guaifenesin ER 60

mg-600 mg

tablet,extend release

12hr

$0 (Tier 3)

REFENESEN PE 10

MG-400 MG

TABLET

$0 (Tier 3)

RelCof IR 10 mg-380

mg tablet

$0 (Tier 3)

RESCON-GG 5 MG-

100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Respaire-30 30 mg-

150 mg capsule

$0 (Tier 3)

TUSNEL

PEDIATRIC 7.5

MG-50 MG/ML

ORAL DROPS

$0 (Tier 3)

EXPECTORANTS - SINGLE AGENTS, GENERAL

OH Buckeye MMP Opt-Out Formulary August 1, 2021 155

Drug Name Tier Drug

Restriction

MUCINEX 600 MG

TABLET,

EXTENDED

RELEASE

$0 (Tier 3)

Mucosa 400 mg

tablet

$0 (Tier 3)

Mucus Relief 200 mg

tablet

$0 (Tier 3)

Mucus Relief 400 mg

tablet

$0 (Tier 3)

Mucus Relief Chest

400 mg tablet

$0 (Tier 3)

Mucus Relief ER

1,200 mg tablet,

extended release

$0 (Tier 3)

MUCUS RELIEF ER

600 MG TABLET,

EXTENDED

RELEASE

$0 (Tier 3)

Mucus-Chest

Congestion 100 mg/5

mL oral liquid

$0 (Tier 3)

Mucus-ER MAX

1,200 mg tablet,

extended release

$0 (Tier 3)

ORGAN-I NR 200

MG TABLET

$0 (Tier 3)

Q-TUSSIN 100

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

REFENESEN 400

MG TABLET

$0 (Tier 3)

Robafen 100 mg/5

mL oral liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Diabetic Siltussin

DAS-Na 100 mg/5

mL oral liquid

$0 (Tier 3)

Expectorant 100

mg/5 mL oral liquid

$0 (Tier 3)

Expectorant Cough

Syrup 100 mg/5 mL

oral liquid

$0 (Tier 3)

Fenesin IR 400 mg

tablet

$0 (Tier 3)

Geri-Tussin 100

mg/5 mL oral liquid

$0 (Tier 3)

guaifenesin 100 mg/5

mL oral liquid

$0 (Tier 3)

guaifenesin 200 mg

tablet

$0 (Tier 3)

guaifenesin 400 mg

tablet

$0 (Tier 3)

guaifenesin ER 1,200

mg tablet, extended

release 12 hr

$0 (Tier 3)

guaifenesin ER 600

mg tablet, extended

release 12 hr

$0 (Tier 3)

IOPHEN-NR 100

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

MUCINEX 1,200

MG TABLET,

EXTENDED

RELEASE

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 156

Drug Name Tier Drug

Restriction

CHILDREN'S

FLONASE

ALLERGY RELIEF

50

MCG/ACTUATION

NASAL

SPRAY,SUSP

$0 (Tier 3)

ClariSpray 50

mcg/actuation nasal

spray,suspension

$0 (Tier 3)

FLONASE

ALLERGY RELIEF

50

MCG/ACTUATION

NASAL

SPRAY,SUSPENSIO

N

$0 (Tier 3)

fluticasone

propionate 50

mcg/actuation nasal

spray,suspension

$0 (Tier 3)

NASACORT 55

MCG NASAL

SPRAY AEROSOL

$0 (Tier 3)

Nasal Allergy 55 mcg

spray aerosol

$0 (Tier 3)

triamcinolone

acetonide 55 mcg

nasal spray aerosol

$0 (Tier 3)

NASAL MAST CELL STABILIZERS

cromolyn 5.2

mg/spray (4 %) nasal

spray

$0 (Tier 3)

NASALCROM 5.2

MG/SPRAY (4 %)

SPRAY

$0 (Tier 3)

NASAL MOISTURIZER COMBINATIONS

Drug Name Tier Drug

Restriction

Scot-Tussin

Expectorant 100

mg/5 mL oral liquid

$0 (Tier 3)

Siltussin SA 100

mg/5 mL oral liquid

$0 (Tier 3)

Tab Tussin 400 mg

tablet

$0 (Tier 3)

TUSSIN 100 MG/5

ML ORAL LIQUID

$0 (Tier 3)

Tussin 400 mg tablet $0 (Tier 3)

Tussin Chest

Congestion 100 mg/5

mL oral liquid

$0 (Tier 3)

Tussin Expectorant

100 mg/5 mL oral

liquid

$0 (Tier 3)

Tussin Mucus-Chest

Congestion 100 mg/5

mL oral liquid

$0 (Tier 3)

NASAL CORTICOSTEROIDS

24 Hour Allergy

Relief 50

mcg/actuation nasal

spray,suspension

$0 (Tier 3)

Aller-Flo 50

mcg/actuation nasal

spray,suspension

$0 (Tier 3)

Allergy Relief

(fluticasone) 50

mcg/actuation nasal

spray,suspension

$0 (Tier 3)

budesonide 32

mcg/actuation nasal

spray

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 157

Drug Name Tier Drug

Restriction

Little Remedies

Saline Mist 0.9 %

nasal spray aerosol

$0 (Tier 3)

NASADROPS 0.9 %

NASAL SOLUTION

$0 (Tier 3)

Nasal Mist 0.9 %

spray aerosol

$0 (Tier 3)

Nasal Moisturizing

0.65 % spray aerosol

$0 (Tier 3)

NASAL SPRAY

(SODIUM

CHLORIDE) 0.65 %

AEROSOL

$0 (Tier 3)

OCEAN NASAL

0.65 % SPRAY

AEROSOL

$0 (Tier 3)

RHINARIS 0.2 %

NASAL SPRAY

$0 (Tier 3)

Saline Mist 0.65 %

nasal spray aerosol

$0 (Tier 3)

Saline Nasal (aloe

vera) gel

$0 (Tier 3)

Saline Nasal 0.65 %

spray aerosol

$0 (Tier 3)

Saline Nasal Mist

0.65 % spray aerosol

$0 (Tier 3)

Saline Nose 0.65 %

spray aerosol

$0 (Tier 3)

SEA SOFT NASAL

MIST 0.65 %

SPRAY AEROSOL

$0 (Tier 3)

Drug Name Tier Drug

Restriction

NASOGEL 0.9 %

NASAL GEL

$0 (Tier 3)

NASOGEL 0.9 %

NASAL SPRAY

GEL

$0 (Tier 3)

NASAL MOISTURIZERS

Altamist 0.65 %

nasal spray aerosol

$0 (Tier 3)

AYR ALLERGY

AND SINUS 2.65 %

NASAL SPRAY

AEROSOL

$0 (Tier 3)

Ayr Saline 0.65 %

nasal drops

$0 (Tier 3)

AYR SALINE 0.65

% NASAL SPRAY

AEROSOL

$0 (Tier 3)

AYR SALINE GEL

NASAL SPRAY

$0 (Tier 3)

AYR SALINE

NASAL GEL

$0 (Tier 3)

BABY AYR

SALINE 0.65 %

NASAL DROPS

$0 (Tier 3)

Children's Saline

Nasal Spray 0.65 %

aerosol

$0 (Tier 3)

Deep Sea Nasal 0.65

% spray aerosol

$0 (Tier 3)

Little Remedies 0.65

% nasal spray aerosol

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 158

Drug Name Tier Drug

Restriction

Ephrine 1 % nasal

drops

$0 (Tier 3)

Fast Acting Nasal 1

% spray

$0 (Tier 3)

MUCINEX SINUS-

MAX 0.05 %

NASAL SPRAY

$0 (Tier 3)

Nasal Decongestant

(oxymetazoline) 0.05

% spray

$0 (Tier 3)

Nasal Four 1 % spray $0 (Tier 3)

NASAL SPRAY

(OXYMETAZOLIN

E) 0.05 %

$0 (Tier 3)

Nasal Spray 12 Hour

(oxymetazoline) 0.05

%

$0 (Tier 3)

Nasal Spray 12 Hour

(oxymetazoline) 0.05

% mist

$0 (Tier 3)

Nasal Spray Extra

Moisturizing 0.05 %

$0 (Tier 3)

NASAL SPRAY

SINUS 0.05 %

$0 (Tier 3)

Neo-Synephrine

(phenylephrine) 1 %

nasal spray

$0 (Tier 3)

NEO-SYNEPHRINE

12 HOUR NASAL

SPRAY

(OXYMETAZOLIN

E) 0.05 %

$0 (Tier 3)

Drug Name Tier Drug

Restriction

sodium chloride 0.65

% nasal spray aerosol

$0 (Tier 3)

SOOTHING

SALINE-ALOE

NASAL SPRAY

$0 (Tier 3)

Sterile Saline 0.9 %

nasal spray aerosol

$0 (Tier 3)

NASAL SYMPATHOMIMETIC DECONGESTANTS (INTRANASAL)

12 HOUR NASAL

RELIEF SPRAY

0.05 %

$0 (Tier 3)

12 HOUR NASAL

SPRAY 0.05 %

$0 (Tier 3)

4 WAY 1 % NASAL

SPRAY

$0 (Tier 3)

AFRIN

(OXYMETAZOLIN

E) 0.05 % NASAL

SPRAY

$0 (Tier 3)

AFRIN NO DRIP

(OXYMETAZOLIN

E) 0.05 % NASAL

MIST

$0 (Tier 3)

AFRIN SINUS

(OXYMETAZOLIN

E) 0.05 % NASAL

SPRAY

$0 (Tier 3)

ANEFRIN 0.05 %

NASAL SPRAY

$0 (Tier 3)

BENZEDREX

NASAL INHALER

$0 (Tier 3)

DRISTAN LONG

LASTING 0.05 %

NASAL MIST

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 159

Drug Name Tier Drug

Restriction

VICKS SINEX

ULTRA FINE MIST

12-HOUR 0.05 %

NASAL SPRAY

$0 (Tier 3)

Wal-Four 1 % nasal

spray

$0 (Tier 3)

NON-OPIOID ANTITUS-1ST GEN ANTIHIST.- DECONGEST-ANALGESIC,NON-SALICYLAT

Children's Flu Relief

1 mg-2.5 mg-5 mg-

160 mg/5 mL oral

suspension

$0 (Tier 3)

Children's Plus Flu 1

mg-2.5 mg-5 mg-160

mg/5 mL oral

suspension

$0 (Tier 3)

Children's Plus

Multi-Symp Cold 1

mg-2.5 mg-5 mg-160

mg/5 mL oral susp

$0 (Tier 3)

CHILDREN'S

TRIAMINIC MS

FEVCOLD 1 MG-2.5

MG-5 MG-160 MG/5

ML ORAL SUSP

$0 (Tier 3)

Cold Head

Congestion Day/Nite

2 mg-5 mg-10 mg-

325 mg tablets

$0 (Tier 3)

Cold Multi-Symptom

Day/Night 2 mg-5

mg-10 mg-325 mg

tablets

$0 (Tier 3)

Cold MultiSymptom

NighTime 6.25 mg-5

mg-10 mg-325 mg/15

mL oral liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

No Drip 0.05 % nasal

spray

$0 (Tier 3)

No Drip Nasal Mist

0.05 %

$0 (Tier 3)

Nose Drops 1 % $0 (Tier 3)

NOSE DROPS

EXTRA STRENGTH

1 %

$0 (Tier 3)

NRS NASAL

RELIEF 0.05 %

SPRAY

$0 (Tier 3)

ORIGINAL NASAL

SPRAY 0.05 %

$0 (Tier 3)

oxymetazoline 0.05

% nasal spray

$0 (Tier 3)

Sinus Nasal Spray

0.05 %

$0 (Tier 3)

SINUS RELIEF

(OXYMETAZOLIN

E) 0.05 % NASAL

MIST

$0 (Tier 3)

Sinus Relief

(oxymetazoline) 0.05

% nasal spray

$0 (Tier 3)

Sinus Relief

(phenylephrine) 1 %

nasal spray

$0 (Tier 3)

VICKS

QLEARQUIL 0.05 %

NASAL MIST

$0 (Tier 3)

VICKS SINEX 12-

HOUR 0.05 %

NASAL SPRAY

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 160

Drug Name Tier Drug

Restriction

CHILD MUCINEX

M-S COLD DAY-

NITE 325 MG-12.5

MG-5

MG/10ML(NT)

ORAL LIQS

$0 (Tier 3)

Children Mult-Sympt

Cold Day-Nite 325

mg-12.5 mg-5 mg/10

mL(nt) liquid

$0 (Tier 3)

Day-Cold Night-

Cold-

Flu(doxylamine) 6.25

mg-5 mg-10 mg-325

mg(nt) caps

$0 (Tier 3)

Daytime-Cold

Nighttime-Cold-Flu

10 mg-650 mg/20

mL(dy-nt) oral

liquids

$0 (Tier 3)

MUCINEX FAST-

MAX DAY COLD-

NT COLD-

FLU(DOXYLAM)6.

25-5-10-325MG(NT)

CAPS

$0 (Tier 3)

MUCINEX FAST-

MAX DAY

CONGES-COUGH-

NT COLD-FLU 25-

10-650MG/20ML

LIQUIDS

$0 (Tier 3)

MUCINEX FAST-

MAX DAY SEV

COLD-NITE COLD-

FLU 10 MG-650

MG/20 ML

LIQUIDS

$0 (Tier 3)

Drug Name Tier Drug

Restriction

COLD RELIEF

MULTI-SYMPTOM

DAY/NIGHT 2 MG-

5 MG-10 MG-325

MG TABLETS

$0 (Tier 3)

Daytime and

Nighttime Cold 2

mg-5 mg-10 mg-325

mg tablets

$0 (Tier 3)

Daytime-Nighttime

10-5-325mg(d)/15-

325-6.25mg capsules

$0 (Tier 3)

MUCINEX FAST-

MAX NITE COLD

AND

FLU(DOXYLAMIN

E)6.25-5-10-325 MG

CAPSULE

$0 (Tier 3)

MULTI-SYMPTOM

COLD (PE-CPM) 1

MG-2.5 MG-5 MG-

160 MG/5 ML

ORAL SUSP

$0 (Tier 3)

MULTI-SYMPTOM

COLD NIGHT TIME

2 MG-5 MG-10 MG-

325 MG TABLET

$0 (Tier 3)

Severe Cold-Flu

Nighttime 6.25 mg-5

mg-10 mg-325 mg/15

mL oral liquid

$0 (Tier 3)

VICKS NYQUIL

SEVERE COLD-

FLU 6.25 MG-5 MG-

10 MG-

325MG/15ML

ORAL LIQUID

$0 (Tier 3)

NON-OPIOID ANTITUS-1ST GEN.ANTIHISTAMINE-DECONGESTANT- ANALGESIC-EXPECT

OH Buckeye MMP Opt-Out Formulary August 1, 2021 161

Drug Name Tier Drug

Restriction

CHILDREN'S

MUCINEX COLD-

FEVER 5 MG-10

MG-325 MG/10 ML

ORAL LIQUID

$0 (Tier 3)

COLD AND FLU

SEVERE 5 MG-10

MG-325 MG-200

MG TABLET

$0 (Tier 3)

Cold Head

Congestion Severe

Daytime 5 mg-10

mg-325 mg-200 mg

tablet

$0 (Tier 3)

Cold Severe

Congestion 5 mg-10

mg-325 mg-200 mg

tablet

$0 (Tier 3)

Cold-Flu-Sore Throat

10 mg-20 mg-650

mg/20 mL oral liquid

$0 (Tier 3)

DELSYM COUGH-

COLD DAYTIME

10 MG-20 MG-650

MG/20 ML ORAL

LIQUID

$0 (Tier 3)

DURAFLU 60 MG-

20 MG-200 MG-325

MG TABLET

$0 (Tier 3)

HerbioMed Severe

Cold-Flu Multi-Symp

10 mg-20 mg-650

mg/20 mL oral liq

$0 (Tier 3)

MUCINEX

COLD,FLU AND

SORE THROAT 10

MG-20 MG-650

MG/20 ML ORAL

LIQUID

$0 (Tier 3)

Drug Name Tier Drug

Restriction

MUCINEX FAST-

MAX DAY SEV

COLD-NITE COLD-

FLU 5 MG-325 MG-

200 MG TABLETS

$0 (Tier 3)

MUCINEX FAST-

MAX

DAYCONGES-

COUGH-

NITECOLD-FLU

5MG/12.5-5-

325MG(N) TABS

$0 (Tier 3)

MUCINEX FAST-

MAX

DAYCONGEST-

COUGH-

NITECOLD-FLU

5MG/25-5-

325MG(NT) TABS

$0 (Tier 3)

MUCINEX FAST-

MAX DAY-NITE

COLD 325

MG(D)/12.5 MG-

325MG (N)

TABLETS

$0 (Tier 3)

MUCINEX SINUS-

MAX DAY-

NIGHT(DOXYLAM

) 6.25 MG-5 MG-10

MG-325MG(NT)

CAPS

$0 (Tier 3)

Wal-Phed PE Day-

Night 5 mg-10 mg-

325 mg tablets

$0 (Tier 3)

NON-OPIOID ANTITUSS-DECONGESTANT- ANALGESIC,NON-SALICYLATE-EXPECTORANT

Children's Cold-

Cough-Sore Throat 5

mg-10 mg-325 mg/10

mL oral liquid

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 162

Drug Name Tier Drug

Restriction

Mucus Relief Cold-

Flu-Sore Throat 5

mg-10 mg-325 mg-

200 mg tablet

$0 (Tier 3)

Mucus Relief Sev

Congest-Cold 5 mg-

10 mg-325 mg-200

mg tablet

$0 (Tier 3)

Mucus Relief Severe

Cold 10 mg-20 mg-

650 mg/20 mL oral

liquid

$0 (Tier 3)

Mucus Relief Severe

Cold 5 mg-10 mg-

325 mg-200 mg

tablet

$0 (Tier 3)

MULTI-SYMPTOM

COLD(WITH

PHENYLEPHRINE)

5 MG-10 MG-325

MG-200 MG

TABLET

$0 (Tier 3)

Severe Cold 5 mg-10

mg-325 mg-200 mg

tablet

$0 (Tier 3)

Severe Cold and Flu

(phenylephrine) 5

mg-10 mg-325 mg-

200 mg tablet

$0 (Tier 3)

Severe Cold Multi-

Symptom 5 mg-10

mg-325 mg-200 mg

tablet

$0 (Tier 3)

Severe Cold-Flu

(phenylephrine) 5

mg-10 mg-325 mg-

200 mg/15 mL liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

MUCINEX FAST-

MAX COLD-FLU 5

MG-10 MG-325

MG-200 MG

CAPSULE

$0 (Tier 3)

MUCINEX FAST-

MAX COLD-FLU-

SORE THROAT 5

MG-10 MG-325

MG-200 MG

CAPSULE

$0 (Tier 3)

MUCINEX FAST-

MAX COLD-FLU-

SORE THROAT 5

MG-10 MG-325

MG-200 MG

TABLET

$0 (Tier 3)

MUCINEX FAST-

MAX SEVERE

COLD 5 MG-10

MG-325 MG-200

MG TABLET

$0 (Tier 3)

MUCINEX SINUS-

MAX PRESSURE-

PAIN-COUGH 5

MG-10 MG-325

MG-200 MG

CAPSULE

$0 (Tier 3)

MUCINEX SINUS-

MAX PRESSURE-

PAIN-COUGH 5

MG-10 MG-325

MG-200 MG

TABLET

$0 (Tier 3)

Mucus Relief Cold-

Flu-Sore Throat 10

mg-20 mg-650 mg/20

mL oral liquid

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 163

Drug Name Tier Drug

Restriction

Cough-Sore Throat

Night 12.5 mg-30

mg-1,000 mg/30 mL

oral liquid

$0 (Tier 3)

Flu HBP 2 mg-15

mg-500 mg tablet

$0 (Tier 3)

MAXIMUM

STRENGTH FLU 2

MG-15 MG-500 MG

TABLET

$0 (Tier 3)

NIGHT TIME 6.25

MG-15 MG-325 MG

CAPSULE

$0 (Tier 3)

Night Time Cold and

Flu Relief 6.25 mg-

15 mg-325 mg/15 mL

oral liquid

$0 (Tier 3)

Nighttime Cold-Flu

6.25 mg-15 mg-325

mg capsule

$0 (Tier 3)

Nighttime Cold-Flu

Relief 6.25 mg-15

mg-325 mg/15 mL

oral liquid

$0 (Tier 3)

Ninjacof-A 12.5 mg-

12.5 mg-160 mg/5

mL oral liquid

$0 (Tier 3)

Nite Time Cold-Flu

6.25 mg-15 mg-325

mg/15 mL oral liquid

$0 (Tier 3)

NITE TIME COLD-

FLU RELIEF 12.5

MG-30 MG-1,000

MG/30 ML ORAL

LIQUID

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Tussin CF Max

Severe M-S Cold 10

mg-20 mg-650 mg/20

mL oral liquid

$0 (Tier 3)

VICKS DAYQUIL

SEVERE COLD-

FLU 5 MG-10 MG-

325 MG-200 MG

TABLET

$0 (Tier 3)

VICKS DAYQUIL

SEVERE COLD-

FLU 5 MG-10 MG-

325 MG-200 MG/15

ML LIQUID

$0 (Tier 3)

NON-OPIOID ANTITUSSIVE-1ST GEN ANTIHISTAMINE-ANALGESIC, NON-SALICYLATE

All-Nite Cold-Flu

6.25 mg-15 mg-325

mg/15 mL oral liquid

$0 (Tier 3)

COLD-FLU RELIEF

12.5 MG-30 MG-

1,000 MG/30 ML

ORAL LIQUID

$0 (Tier 3)

CONTAC COLD-

FLU NIGHT 12.5

MG-30 MG-1,000

MG/30 ML ORAL

LIQUID

$0 (Tier 3)

CORICIDIN HBP

COLD-MULTI

SYMPTOM 6.25

MG-15 MG-325

MG/15 ML ORAL

LIQD

$0 (Tier 3)

CORICIDIN HBP

FLU 2 MG-15 MG-

500 MG TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 164

Drug Name Tier Drug

Restriction

Brotapp DM 1 mg-15

mg-5 mg/5 mL oral

elixir

$0 (Tier 3)

Children's Cold and

Cough (PE) 1 mg-2.5

mg-5 mg/5 mL oral

solution

$0 (Tier 3)

Children's Cold and

Cough DM 1 mg-2.5

mg-5 mg/5 mL oral

solution

$0 (Tier 3)

Children's Dibromm

DM Cold-Cough 1

mg-2.5 mg-5 mg/5

mL oral solution

$0 (Tier 3)

Chlo Tuss 1 mg-30

mg-12.5 mg/5 mL

oral liquid

$0 (Tier 3)

Cold and Cough DM

1 mg-2.5 mg-5 mg/5

mL oral solution

$0 (Tier 3)

Cold and Cough

Elixir 1 mg-2.5 mg-5

mg/5 mL oral

solution

$0 (Tier 3)

dexchlorphen-p-

phed-chlophedianol 1

mg-30 mg-12.5 mg/5

mL oral liquid

$0 (Tier 3)

Dimaphen DM 1 mg-

2.5 mg-5 mg/5 mL

oral solution

$0 (Tier 3)

Dimetapp DM Cold-

Cough (PE) 1 mg-2.5

mg-5 mg/5 mL oral

solution

$0 (Tier 3)

Drug Name Tier Drug

Restriction

NITE TIME COLD-

FLU RELIEF 6.25

MG-15 MG-325 MG

CAPSULE

$0 (Tier 3)

Nitetime Multi-

Symptom 12.5 mg-30

mg-1,000 mg/30 mL

oral liquid

$0 (Tier 3)

VICKS NYQUIL

COLD/FLU

LIQUICAP 6.25

MG-15 MG-325 MG

CAPSULE

$0 (Tier 3)

VICKS NYQUIL

NIGHTTIME

RELIEF 6.25 MG-15

MG-325 MG/15 ML

ORAL LIQUID

$0 (Tier 3)

NON-OPIOID ANTITUSSIVE-1ST GEN.ANTIHISTAMINE-DECONGESTANT COMBINATIONS

ALAHIST CF 2 MG-

10 MG-20 MG

TABLET

$0 (Tier 3)

ALAHIST DM 2

MG-7.5 MG-15

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

ALA-HIST DM 4

MG-7.5 MG-15

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

BROMFED DM 2

MG-30 MG-10 MG/5

ML ORAL SYRUP

$0 (Tier 3)

Use Generic Products

brompheniramine-

pseudoephedrine-DM

2 mg-30 mg-10 mg/5

mL oral syrup

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 165

Drug Name Tier Drug

Restriction

M-Hist DM 4 mg-7.5

mg-15 mg/5 mL oral

liquid

$0 (Tier 3)

Niva-Hist DM 4 mg-

7.5 mg-15 mg/5 mL

oral liquid

$0 (Tier 3)

NoHist-DM 4 mg-10

mg-15 mg/5 mL oral

liquid

$0 (Tier 3)

PEDIA RELIEF

COUGH-COLD 1

MG-15 MG-5 MG/5

ML ORAL LIQUID

$0 (Tier 3)

PEDIATRIC

COUGH AND

COLD 1 MG-15

MG-5 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

POLY-HIST DM

(THONZYLAMINE)

25 MG-5 MG-10

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

POLYTUSSIN DM 1

MG-5 MG-10 MG/5

ML ORAL SYRUP

$0 (Tier 3)

Q-TAPP DM 1 MG-

15 MG-5 MG/5 ML

ORAL ELIXIR

$0 (Tier 3)

RelCof DM 4 mg-7.5

mg-15 mg/5 mL oral

liquid

$0 (Tier 3)

Rescon-DM 2 mg-30

mg-10 mg/5 mL oral

liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Donatussin 4 mg-10

mg-20 mg/5 mL oral

liquid

$0 (Tier 3)

Dr Manzanilla DM

2.5 mg-10 mg-20

mg/5 mL oral liquid

$0 (Tier 3)

Ed A-Hist DM 4 mg-

10 mg-10 mg tablet

$0 (Tier 3)

Ed A-Hist DM 4 mg-

10 mg-15 mg/5 mL

oral liquid

$0 (Tier 3)

EndaCof - DM 1 mg-

2.5 mg-5 mg/5 mL

oral solution

$0 (Tier 3)

Glentuss 6.25 mg-30

mg-15 mg/5 mL oral

liquid

$0 (Tier 3)

HISTEX DM 2.5

MG-10 MG-20 MG/5

ML ORAL LIQUID

$0 (Tier 3)

Kidkare Cough/Cold

1 mg-15 mg-5 mg/5

mL oral liquid

$0 (Tier 3)

LoHist-DM 2 mg-5

mg-10 mg/5 mL oral

liquid

$0 (Tier 3)

Lortuss DM 6.25 mg-

30 mg-15 mg/5 mL

oral liquid

$0 (Tier 3)

MAXICHLOR PEH

DM 4 MG-10 MG-18

MG TABLET

$0 (Tier 3)

M-End DMX 0.667

mg-20 mg-10 mg/5

mL oral liquid

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 166

Drug Name Tier Drug

Restriction

COUGH AND

COLD

(CHLORPHENIRA

MINE-DM) 4 MG-30

MG TABLET

$0 (Tier 3)

Cough and Cold BP 4

mg-30 mg tablet

$0 (Tier 3)

Cough-Cold Relief

HBP 4 mg-30 mg

tablet

$0 (Tier 3)

DAYCLEAR

ALLERGY RELIEF

50 MG-25 MG

TABLET

$0 (Tier 3)

DIMETAPP LONG-

ACTING(CHLORPH

ENIRAMINE-DM) 1

MG-7.5 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

MAXI-TUSS DM

(WITH

CHLORPHENIRAM

INE) 4 MG-18 MG/5

ML ORAL LIQUID

$0 (Tier 3)

NightTime Cough

6.25 mg-15 mg/15

mL oral solution

$0 (Tier 3)

Ninjacof 12.5 mg-

12.5 mg/5 mL oral

liquid

$0 (Tier 3)

Nite Time Cough

6.25 mg-15 mg/15

mL oral solution

$0 (Tier 3)

POLY HIST PD 6.25

MG-6.25 MG/ML

ORAL DROPS

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Rynex DM 1 mg-2.5

mg-5 mg/5 mL oral

solution

$0 (Tier 3)

VANACOF 1 MG-30

MG-12.5 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Wal-tap DM 1 mg-

2.5 mg-5 mg/5 mL

oral solution

$0 (Tier 3)

NON-OPIOID ANTITUSSIVE-ANALGESIC, NON- SALICYLATE COMBINATIONS

CHILD TRIAMINIC

COUGH-SORE

THROAT 160 MG-5

MG/5 ML ORAL

SUSPENSION

$0 (Tier 3)

Pain Relief Cold and

Cough 1,000 mg-30

mg/30 mL oral liquid

$0 (Tier 3)

NON-OPIOID ANTITUSSIVE-ANTIHISTAMINE COMBINATIONS

Capron DM 7.5 mg-

7.5 mg/5 mL oral

liquid

$0 (Tier 3)

Capron DMT 30 mg-

30 mg tablet

$0 (Tier 3)

Chlo Hist 1 mg-12.5

mg/5 mL oral

solution

$0 (Tier 3)

CORICIDIN HBP

COUGH AND

COLD 4 MG-30 MG

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 167

Drug Name Tier Drug

Restriction

ALKA-SELTZER

PLUS DAY 5 MG-10

MG-325 MG

CAPSULE

$0 (Tier 3)

ALKA-SELTZER

PLUS SINUS-

COUGH 5 MG-10

MG-325 MG

CAPSULE

$0 (Tier 3)

Cold Head

Congestion Daytime

5 mg-10 mg-325 mg

tablet

$0 (Tier 3)

COLD MULTI-

SYMPTOM 5 MG-

10 MG-325 MG

TABLET

$0 (Tier 3)

COLD-FLU RELIEF

5 MG-10 MG-325

MG/15 ML ORAL

LIQUID

$0 (Tier 3)

Day Multi-Symptom

Flu-Severe Cold 10

mg-20 mg-500 mg

oral powder packt

$0 (Tier 3)

DAY TIME PE 5

MG-10 MG-325 MG

CAPSULE

$0 (Tier 3)

DAYTIME 5 MG-10

MG-325 MG

CAPSULE

$0 (Tier 3)

Daytime Cold 5 mg-

10 mg-325 mg tablet

$0 (Tier 3)

Daytime Cold and

Flu Relief (PE) 5 mg-

10 mg-325 mg/15 mL

oral liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

promethazine-DM

6.25 mg-15 mg/5 mL

oral syrup

$0 (Tier 3)

ROBITUSSIN

LONG-ACTING 1

MG-7.5 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

VANACOF AC 25

MG-12.5 MG/30 ML

ORAL LIQUID

$0 (Tier 3)

VANACOF-8 50

MG-25 MG/15 ML

ORAL LIQUID

$0 (Tier 3)

VANATAB AC 25

MG-12.5 MG

TABLET

$0 (Tier 3)

VICKS NYQUIL

COUGH 6.25 MG-15

MG/15 ML ORAL

SOLUTION

$0 (Tier 3)

NON-OPIOID ANTITUSSIVE-DECONGESTANT COMBINATIONS

PEDIACARE

MULTI-SYMPTOM

COLD 2.5 MG-5

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

Rondec-D 30 mg-

12.5 mg/5 mL oral

liquid

$0 (Tier 3)

TRIAMINIC COLD

AND COUGH (PE)

2.5 MG-5 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

NON-OPIOID ANTITUSSIVE-DECONGESTANT- ANALGESIC, NON-SALICYLATE COMB

OH Buckeye MMP Opt-Out Formulary August 1, 2021 168

Drug Name Tier Drug

Restriction

THERAFLU

EXPRESSMAX

COLD-COUGH

DAY 5 MG-10 MG-

325 MG TABLET

$0 (Tier 3)

THERAFLU

EXPRESSMAX

COLD-COUGH

DAY 5 MG-10 MG-

325 MG/15 ML

ORAL LIQUID

$0 (Tier 3)

VICKS DAYQUIL

COLD AND FLU

RELIEF 5 MG-10

MG-325 MG

CAPSULE

$0 (Tier 3)

VICKS DAYQUIL

COLD AND FLU

RELIEF 5 MG-10

MG-325 MG/15 ML

ORAL LIQUID

$0 (Tier 3)

Wal-Flu Severe

Cold-Cough 10 mg-

20 mg-650 mg oral

powder packet

$0 (Tier 3)

NON-OPIOID ANTITUSSIVE-DECONGESTANT- EXPECTORANT COMBINATIONS

Actinel 30 mg-15

mg-200 mg/5 mL

oral solution

$0 (Tier 3)

Actinel Pediatric 15

mg-5 mg-50 mg/5

mL oral liquid

$0 (Tier 3)

ADULT

ROBITUSSIN PEAK

COLD M-S 5 MG-10

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Daytime Cold and

Flu Relief

(phenylephrine) 5

mg-10 mg-325 mg

capsule

$0 (Tier 3)

Daytime Cold-Flu 5

mg-10 mg-325 mg/15

mL oral liquid

$0 (Tier 3)

Flu Relief Therapy

Daytime 5 mg-10

mg-325 mg/15 mL

oral liquid

$0 (Tier 3)

Flu-Severe Cold-

Cough Daytime 10

mg-20 mg-650 mg

oral powder packet

$0 (Tier 3)

Mapap Cold Formula

5 mg-10 mg-325 mg

tablet

$0 (Tier 3)

MUCINEX FAST-

MAX

CONGESTION-

HEADACHE (DM) 5

MG-10 MG-325 MG

CAPSULE

$0 (Tier 3)

MUCINEX SINUS-

MAX SEVERE

CONGESTION-

PAIN(DM) 5 MG-10

MG-325 MG

CAPSULE

$0 (Tier 3)

MULTI-SYMPTOM

COLD DAYTIME 5

MG-10 MG-325 MG

TABLET

$0 (Tier 3)

Severe Cold and Flu-

Daytime (DM) 5 mg-

10 mg-325 mg/15 mL

oral liquid

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 169

Drug Name Tier Drug

Restriction

Child's Mucus Relief

M-S Cold 2.5 mg-5

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

COUGH AND

COLD 5 MG-10

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Cough and Cold

Mucus Relief CF 5

mg-10 mg-200 mg/5

mL oral liquid

$0 (Tier 3)

COUGH CONTROL

CF

(PHENYLEPHRINE

) 5 MG-10 MG-100

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

DECONEX DMX 10

MG-15 MG-380 MG

TABLET

$0 (Tier 3)

DECONEX DMX 10

MG-17.5 MG-385

MG TABLET

$0 (Tier 3)

DECONEX DMX 10

MG-17.5 MG-400

MG TABLET

$0 (Tier 3)

Desgen DM 5 mg-10

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

Despec DM-G 5 mg-

10 mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

Despec-DM

(phenylephrine-DM-

guaif) 5 mg-10 mg-

100 mg/5 mL oral

liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Adult Tussin Multi-

Symptom Cold 5 mg-

10 mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

Aquanaz 10 mg-15

mg-400 mg tablet

$0 (Tier 3)

BIO T PRES 5 MG-

10 MG-200 MG/5

ML ORAL LIQUID

$0 (Tier 3)

BIONEL 30 MG-15

MG-200 MG/5 ML

ORAL SOLUTION

$0 (Tier 3)

BIONEL

PEDIATRIC 15 MG-

5 MG-50 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Capmist DM 60 mg-

15 mg-400 mg tablet

$0 (Tier 3)

CHILD MULTI-

SYMPTOM

COLD/COUGH 2.5

MG-5 MG-100 MG/5

ML ORAL LIQUID

$0 (Tier 3)

CHILDREN

MUCINEX

CONGESTION-

COUGH 2.5 MG-5

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

CHILDREN'S

MUCINEX MULTI-

SYMPTOM 2.5 MG-

5 MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 170

Drug Name Tier Drug

Restriction

Robafen CF

(phenylephrine) 5

mg-10 mg-100 mg/5

mL oral liquid

$0 (Tier 3)

ROBITUSSIN

COUGH AND

COLD CF 2.5 MG-5

MG-50 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Severe Cough-

Congestion 2.5 mg-5

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

TUSNEL DM

PEDIATRIC(PSEUD

OEPHEDRINE) 7.5

MG-2.5 MG-25

MG/ML ORAL

DROPS

$0 (Tier 3)

TUSNEL NEW

FORMULA 30 MG-

15 MG-200 MG/5

ML ORAL

SOLUTION

$0 (Tier 3)

TUSNEL NEW

FORMULA 60 MG-

30 MG-400 MG

TABLET

$0 (Tier 3)

TUSNEL

PEDIATRIC 15 MG-

5 MG-50 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Tussin CF (PE-DM-

guaif) 5 mg-10 mg-

100 mg/5 mL oral

liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

MUCINEX FAST-

MAX

CONGESTION-

COUGH 2.5 MG-5

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

MUCINEX FAST-

MAX

CONGESTION-

COUGH 5 MG-10

MG-200 MG

TABLET

$0 (Tier 3)

MUCUS RELIEF

CONGESTION-

COUGH 2.5 MG-5

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Nivanex DMX 10

mg-15 mg-380 mg

tablet

$0 (Tier 3)

phenylephrine 10

mg-

dextromethorphan

17.5 mg-guaifenesin

385 mg tablet

$0 (Tier 3)

phenylephrine 10

mg-DM 18 mg-

guaifenesin 200

mg/15 mL oral liquid

$0 (Tier 3)

POLY-VENT DM 60

MG-20 MG-380 MG

TABLET

$0 (Tier 3)

Pres Gen 5 mg-10

mg-200 mg/5 mL

oral liquid

$0 (Tier 3)

Relhist DMX 10 mg-

15 mg-380 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 171

Drug Name Tier Drug

Restriction

ADULT

ROBITUSSIN PEAK

COLD DM MAX 10

MG-200 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Adult Tussin Cough

Congestion DM 10

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

Adult Tussin DM 10

mg-100 mg/5 mL

oral syrup

$0 (Tier 3)

Adult Wal-Tussin

DM Max 10 mg-200

mg/5 mL oral liquid

$0 (Tier 3)

ANTITUSSIVE DM

10 MG-100 MG/5

ML ORAL SYRUP

$0 (Tier 3)

BIOCOTRON 10

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Chest Congestion

Relief DM 20 mg-

400 mg tablet

$0 (Tier 3)

CHEST

CONGESTION-

COUGH RELIEF 20

MG-400 MG

TABLET

$0 (Tier 3)

Child Chest

Congestion-Cough 5

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Tussin CF Cough-

Cold 5 mg-10 mg-

100 mg/5 mL oral

liquid

$0 (Tier 3)

Tussin CF MAX 5

mg-10 mg-200 mg/5

mL oral liquid

$0 (Tier 3)

Tussi-Pres 5 mg-10

mg-200 mg/5 mL

(10mL) oral liquid in

packet

$0 (Tier 3)

Tussi-Pres 5 mg-10

mg-200 mg/5 mL

oral liquid

$0 (Tier 3)

VANACOF DM 10

MG-18 MG-200

MG/15 ML ORAL

LIQUID

$0 (Tier 3)

VANATAB DM 5

MG-9 MG-198 MG

TABLET

$0 (Tier 3)

WAL-TUSSIN

COUGH AND

COLD CF 5 MG-10

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

NON-OPIOID ANTITUSSIVE-EXPECTORANT COMBINATIONS

Adult Cough

Formula DM Max 10

mg-200 mg/5 mL

oral liquid

$0 (Tier 3)

ADULT

ROBITUSSIN PEAK

COLD DM 10 MG-

100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 172

Drug Name Tier Drug

Restriction

COUGH

SUPPRESSANT-

EXPECTORANT 10

MG-100 MG/5 ML

ORAL SYRUP

$0 (Tier 3)

COUGH SYRUP

DM 10 MG-100

MG/5 ML

$0 (Tier 3)

Cough-Chest

Congestion DM 5

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

DELSYM COUGH-

CHEST

CONGESTION DM

5 MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

dextromethorphan-

guaifenesin 10 mg-

100 mg/5 mL oral

liquid

$0 (Tier 3)

dextromethorphan-

guaifenesin 10 mg-

100 mg/5 mL oral

syrup

$0 (Tier 3)

dextromethorphan-

guaifenesin 20 mg-

400 mg tablet

$0 (Tier 3)

dextromethorphan-

guaifenesin ER 60

mg-1,200 mg

tab,extend

release,12hr

$0 (Tier 3)

Diabetic Siltussin-

DM 10 mg-100 mg/5

mL oral liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

CHILD MUCINEX

COUGH MINI-

MELTS 5 MG-100

MG ORAL

GRANULES IN

PACKET

$0 (Tier 3)

Child Mucus Relief

Cough 5 mg-100

mg/5 mL oral liquid

$0 (Tier 3)

CHILD TRIAMINIC

COUGH-

CONGESTION 5

MG-100 MG/5 ML

ORAL SYRUP

$0 (Tier 3)

CHILDREN

DELSYM COUGH-

CHEST

CONGESTION DM

5 MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Children's Cough 5

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

Children's Cough-

Chest Congestion

DM 5 mg-100 mg/5

mL oral liquid

$0 (Tier 3)

CHILDREN'S

MUCINEX COUGH

5 MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

COUGH CONTROL

DM 10 MG-100

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 173

Drug Name Tier Drug

Restriction

MUCINEX DM 60

MG-1,200 MG

TABLET,EXTENDE

D RELEASE 12 HR

$0 (Tier 3)

MUCINEX FAST-

MAX DM MAX 5

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Mucosa DM 20 mg-

400 mg tablet

$0 (Tier 3)

Mucus and Cough

Relief 20 mg-400 mg

tablet

$0 (Tier 3)

MUCUS DM 30

MG-600 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

Mucus DM Max ER

60 mg-1,200 mg

tablet,extended

release

$0 (Tier 3)

MUCUS RELIEF

COUGH 5 MG-100

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

MUCUS RELIEF

DM 20 MG-400 MG

TABLET

$0 (Tier 3)

Mucus Relief DM

Cough 20 mg-400 mg

tablet

$0 (Tier 3)

Mucus Relief DM

Max 5 mg-100 mg/5

mL oral liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Diabetic Siltussin-

DM Max Str 10 mg-

200 mg/5 mL oral

liquid

$0 (Tier 3)

Diabetic Tussin DM

10 mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

DM MAX 5 MG-100

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

Fenesin DM IR 20

mg-400 mg tablet

$0 (Tier 3)

Geri-Tussin DM 10

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

Geri-Tussin DM 10

mg-100 mg/5 mL

oral syrup

$0 (Tier 3)

G-Tron 10 mg-100

mg/5 mL oral liquid

$0 (Tier 3)

Guaiasorb DM 10

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

Guaicon DMS 20

mg-200 mg/10 mL

oral liquid in packet

$0 (Tier 3)

IOPHEN DM-NR 10

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

MUCINEX DM 30

MG-600 MG

TABLET,EXTENDE

D RELEASE 12 HR

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 174

Drug Name Tier Drug

Restriction

TUSNEL DIABETIC

10 MG-100 MG/5

ML ORAL LIQUID

$0 (Tier 3)

TUSSIN COUGH

AND CHEST

CONGESTION 10

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Tussin DM 10 mg-

100 mg/5 mL oral

liquid

$0 (Tier 3)

TUSSIN DM 10 MG-

100 MG/5 ML

ORAL SYRUP

$0 (Tier 3)

Tussin DM 20 mg-

400 mg tablet

$0 (Tier 3)

TUSSIN DM

CLEAR 10 MG-100

MG/5 ML ORAL

SYRUP

$0 (Tier 3)

TUSSIN DM

COUGH 10 MG-100

MG/5 ML ORAL

SYRUP

$0 (Tier 3)

Tussin DM Cough

and Chest 10 mg-100

mg/5 mL oral syrup

$0 (Tier 3)

Tussin DM Cough

and Chest 10 mg-200

mg/5 mL oral liquid

$0 (Tier 3)

Tussin DM Cough

and Chest 5 mg-100

mg/5 mL oral liquid

$0 (Tier 3)

TUSSIN DM MAX

10 MG-200 MG/5

ML ORAL LIQUID

$0 (Tier 3)

Drug Name Tier Drug

Restriction

Q-TUSSIN DM 10

MG-100 MG/5 ML

ORAL SYRUP

$0 (Tier 3)

REFENESEN DM 20

MG-400 MG

TABLET

$0 (Tier 3)

Robafen DM 10 mg-

100 mg/5 mL oral

syrup

$0 (Tier 3)

Robafen DM Cough

10 mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

Robafen DM Cough-

Chest Congestion 10

mg-100 mg/5 mL

oral syrup

$0 (Tier 3)

ROBITUSSIN

COUGH-CHEST

CONGESTION DM

5 MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

SAFE TUSSIN DM

10 MG-100 MG/5

ML ORAL LIQUID

$0 (Tier 3)

SILTUSSIN DM

DAS 10 MG-100

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

Siltussin-DM 10 mg-

100 mg/5 mL oral

syrup

$0 (Tier 3)

Sorbugen NR 10 mg-

100 mg/5 mL oral

liquid

$0 (Tier 3)

Tab Tussin DM 20

mg-400 mg tablet

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 175

Drug Name Tier Drug

Restriction

HISTEX-AC 2.5

MG-10 MG-10 MG/5

ML ORAL SYRUP

$0 (Tier 3)

hydrocodone 5 mg-

cpm 4 mg-

pseudoephedrine 60

mg/5 mL oral

solution

$0 (Tier 3)

Mar-Cof BP 2 mg-30

mg-7.5 mg/5 mL oral

liquid

$0 (Tier 3)

MAXI-TUSS CD 4

MG-10 MG-10 MG/5

ML ORAL LIQUID

$0 (Tier 3)

M-END PE 1.33 mg-

3.33 mg-6.33 mg/5

mL oral liquid

$0 (Tier 3)

PHENYLHISTINE

DH 2 MG-30 MG-10

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

POLY-TUSSIN AC

4 MG-10 MG-10

MG/5 ML ORAL

LIQUID

$0 (Tier 3)

Promethazine VC-

Codeine 6.25 mg-5

mg-10 mg/5 mL oral

syrup

$0 (Tier 3)

promethazine-

phenylephrine-

codeine 6.25 mg-5

mg-10 mg/5 mL oral

syrup

$0 (Tier 3)

Drug Name Tier Drug

Restriction

VICKS DAYQUIL

MUCUS CONTROL

DM 10 MG-200

MG/15 ML ORAL

LIQUID

$0 (Tier 3)

Wal-Tussin DM 10

mg-100 mg/5 mL

oral syrup

$0 (Tier 3)

Zyncof 20 mg-400

mg tablet

$0 (Tier 3)

OPIOID ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE COMBINATIONS

hydrocodone 10 mg-

chlorpheniramine 8

mg/5 mL oral susp

extend.rel 12hr

$0 (Tier 3)

promethazine 6.25

mg-codeine 10 mg/5

mL syrup

$0 (Tier 3)

TUSSICAPS 10 MG-

8 MG

CAPSULE,EXTEND

ED RELEASE

$0 (Tier 3)

TUSSIONEX

PENNKINETIC ER

10 MG-8 MG/5 ML

SUSPENSION,EXT

ENDED RELEASE

$0 (Tier 3)

Use Generic Products

Z-Tuss AC 2 mg-9

mg/5 mL oral liquid

$0 (Tier 3)

OPIOID ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE-DECONGESTANT COMB.

CapCof 2 mg-5 mg-

10 mg/5 mL oral

liquid

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 176

Drug Name Tier Drug

Restriction

REZIRA 60 MG-5

MG/5 ML ORAL

SOLUTION

$0 (Tier 3)

OPIOID ANTITUSSIVE-DECONGESTANT- EXPECTORANT COMBINATIONS

CHERATUSSIN

DAC 30 MG-10 MG-

100 MG/5 ML

ORAL SYRUP

$0 (Tier 3)

Guaifenesin DAC 30

mg-10 mg-100 mg/5

mL oral syrup

$0 (Tier 3)

HYCOFENIX 2.5

MG-30 MG-200

MG/5 ML ORAL

SOLUTION

$0 (Tier 3)

Lortuss EX 30 mg-10

mg-100 mg/5 mL

oral syrup

$0 (Tier 3)

TUSNEL C 30 MG-

10 MG-100 MG/5

ML ORAL SYRUP

$0 (Tier 3)

VIRTUSSIN DAC

30 MG-10 MG-100

MG/5 ML ORAL

SYRUP

$0 (Tier 3)

OPIOID ANTITUSSIVE-EXPECTORANT COMBINATIONS

CHERATUSSIN AC

10 MG-100 MG/5

ML ORAL LIQUID

$0 (Tier 3)

codeine 10 mg-

guaifenesin 100 mg/5

mL oral liquid

$0 (Tier 3)

FLOWTUSS 2.5

MG-200 MG/5 ML

ORAL SOLUTION

$0 (Tier 3)

Drug Name Tier Drug

Restriction

PRO-RED AC

(WITH

DEXCHLORPHENI

RAMINE) 1 MG-5

MG-9 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Rydex 1.3 mg-10

mg-6.3 mg/5 mL oral

liquid

$0 (Tier 3)

ZUTRIPRO 5 MG-4

MG-60 MG/5 ML

ORAL SOLUTION

$0 (Tier 3)

OPIOID ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONS

HYCODAN (WITH

HOMATROPINE) 5

MG-1.5 MG/5 ML

ORAL SYRUP

$0 (Tier 3)

hydrocodone-

homatropine 5 mg-

1.5 mg tablet

$0 (Tier 3)

hydrocodone-

homatropine 5 mg-

1.5 mg/5 mL (5 mL)

oral syrup

$0 (Tier 3)

hydrocodone-

homatropine 5 mg-

1.5 mg/5 mL oral

syrup

$0 (Tier 3)

HYDROMET 5 MG-

1.5 MG/5 ML ORAL

SYRUP

$0 (Tier 3)

TUSSIGON 5 MG-

1.5 MG TABLET

$0 (Tier 3)

Use Generic Products

OPIOID ANTITUSSIVE-DECONGESTANT COMBINATIONS

OH Buckeye MMP Opt-Out Formulary August 1, 2021 177

Drug Name Tier Drug

Restriction $0 (Tier

3)

12 HOUR COLD

RELIEF 120 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

12 HOUR

DECONGESTANT

ER 120 MG

TABLET,EXTENDE

D RELEASE

$0 (Tier 3)

12 Hour Nasal

Decongestant (PSE)

120 mg

tablet,extended

release

$0 (Tier 3)

Children's Silfedrine

15 mg/5 mL oral

liquid

$0 (Tier 3)

CHILDREN'S

SUDAFED 15 MG/5

ML ORAL LIQUID

$0 (Tier 3)

Nasal Decongestant

(phenylephrine) 10

mg tablet

$0 (Tier 3)

Nasal Decongestant

(pseudoephedrine)

120 mg

tablet,extended

release

$0 (Tier 3)

Nasal Decongestant

(pseudoephedrine) 30

mg tablet

$0 (Tier 3)

Nasal Decongestant

(pseudoephedrine) 30

mg/5 mL oral liquid

$0 (Tier 3)

Drug Name Tier Drug

Restriction

G Tussin AC 10 mg-

100 mg/5 mL oral

liquid

$0 (Tier 3)

Guaiatussin AC 10

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

Guaifenesin AC 10

mg-100 mg/5 mL

oral liquid

$0 (Tier 3)

IOPHEN C-NR 10

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

Mar-Cof CG 7.5 mg-

225 mg/5 mL oral

liquid

$0 (Tier 3)

M-Clear WC 6.3 mg-

100 mg/5 mL oral

liquid

$0 (Tier 3)

Ninjacof-XG 8 mg-

200 mg/5 mL oral

liquid

$0 (Tier 3)

OBREDON 2.5 MG-

200 MG/5 ML

ORAL SOLUTION

$0 (Tier 3)

RelCof C 6.3 mg-100

mg/5 mL oral liquid

$0 (Tier 3)

ROBAFEN AC 10

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

VIRTUSSIN AC 10

MG-100 MG/5 ML

ORAL LIQUID

$0 (Tier 3)

SYSTEMIC SYMPATHOMIMETIC DECONGESTANTS

OH Buckeye MMP Opt-Out Formulary August 1, 2021 178

Drug Name Tier Drug

Restriction

Sudogest PE 10 mg

tablet

$0 (Tier 3)

Suphedrin 15 mg/5

mL oral liquid

$0 (Tier 3)

SUPHEDRIN 30 MG

TABLET

$0 (Tier 3)

Suphedrine 12 Hour

120 mg

tablet,extended

release

$0 (Tier 3)

Suphedrine 30 mg

tablet

$0 (Tier 3)

SUPHEDRINE PE

10 MG TABLET

$0 (Tier 3)

Wal-phed 12 hour

120 mg

tablet,extended

release

$0 (Tier 3)

Wal-phed 30 mg

tablet

$0 (Tier 3)

Wal-Phed D 120 mg

tablet,extended

release

$0 (Tier 3)

Wal-phed PE 10 mg

tablet

$0 (Tier 3)

VAGINAL PRODUCTS

VAGINAL ANTIFUNGAL - IMIDAZOLES

3 Day Vaginal 200

mg/5 gram (4 %)

cream

$0 (Tier 3)

3-DAY VAGINAL 2

% CREAM

$0 (Tier 3)

Drug Name Tier Drug

Restriction

phenylephrine 10 mg

tablet

$0 (Tier 3)

pseudoephedrine 30

mg tablet

$0 (Tier 3)

pseudoephedrine 30

mg/5 mL oral liquid

$0 (Tier 3)

pseudoephedrine 60

mg tablet

$0 (Tier 3)

pseudoephedrine ER

120 mg

tablet,extended

release

$0 (Tier 3)

Sinus 12 Hour 120

mg tablet,extended

release

$0 (Tier 3)

Sinus Decongestant

(PE) 10 mg tablet

$0 (Tier 3)

Sinus PE

Decongestant 10 mg

tablet

$0 (Tier 3)

Sudafed 12 Hour 120

mg tablet,extended

release

$0 (Tier 3)

SUDAFED 30 MG

TABLET

$0 (Tier 3)

Sudogest 12-hour

120 mg

tablet,extended

release

$0 (Tier 3)

Sudogest 30 mg

tablet

$0 (Tier 3)

SUDOGEST 60 MG

TABLET

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 179

Drug Name Tier Drug

Restriction

Miconazole-3 4 %

(200 mg)-2 % (9

gram) vaginal

pack,prefil appl,

cream

$0 (Tier 3)

Miconazole-3

prefilled,cream,wipes

4 %(200 mg)-2 %(9

gram) vaginal kit

$0 (Tier 3)

Miconazole-7 100

mg vaginal

suppository

$0 (Tier 3)

Miconazole-7 2 %

vaginal cream

$0 (Tier 3)

miconazole-skin

cleanser #17 4 %

(200 mg)-2 % (9

gram) vaginal kit

$0 (Tier 3)

MONISTAT 1

COMBO PACK

1,200 MG-2 %

VAGINAL OVULE

AND CREAM

$0 (Tier 3)

MONISTAT 3 4 %

(200 MG)-2 %(9

GRAM)VAGINAL

PACK,PREFIL

APPL AND CREAM

$0 (Tier 3)

Monistat 3 200 mg/5

gram (4 %) vaginal

cream

$0 (Tier 3)

MONISTAT 3 200

MG-2 % (9 GRAM)

VAGINAL KIT

$0 (Tier 3)

MONISTAT 7 2 %

VAGINAL CREAM

$0 (Tier 3)

Drug Name Tier Drug

Restriction

clotrimazole 1 %

vaginal cream

$0 (Tier 3)

clotrimazole 2 %

vaginal cream

$0 (Tier 3)

Clotrimazole 3 Day 2

% vaginal cream

$0 (Tier 3)

Clotrimazole-3 2 %

vaginal cream

$0 (Tier 3)

Clotrimazole-7 1 %

vaginal cream

$0 (Tier 3)

GYNE-LOTRIMIN 2

% VAGINAL

CREAM

$0 (Tier 3)

miconazole nitrate

1,200 mg-2 %

vaginal kit

$0 (Tier 3)

miconazole nitrate

100 mg vaginal

suppository

$0 (Tier 3)

miconazole nitrate 2

% vaginal cream

$0 (Tier 3)

miconazole nitrate

200 mg-2 % (9 gram)

vaginal kit

$0 (Tier 3)

miconazole nitrate 4

% (200 mg)-2 % (9

gram)vaginal,prefill

appl,cream

$0 (Tier 3)

Miconazole-3 200

mg-2 % (9 gram)

vaginal kit

$0 (Tier 3)

Miconazole-3 200

mg/5 gram (4 %)

vaginal cream

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 180

Drug Name Tier Drug

Restriction

tioconazole 6.5 %

vaginal ointment

$0 (Tier 3)

Tioconazole-1 6.5 %

vaginal ointment

$0 (Tier 3)

VAGISTAT-3 200

MG-2 % (9 GRAM)

VAGINAL KIT

$0 (Tier 3)

OH Buckeye MMP Opt-Out Formulary August 1, 2021 181

Index

1

12 HOUR COLD RELIEF 120 MG

TABLET,EXTENDED RELEASE ............177

12 HOUR DECONGESTANT ER 120 MG

TABLET,EXTENDED RELEASE ............177

12 Hour Nasal Decongestant (PSE) 120 mg

tablet,extended release ...................177

12 HOUR NASAL RELIEF SPRAY 0.05 % 158

12 HOUR NASAL SPRAY 0.05 % .............158

1st Base cream........................................25

2

24 Hour Allergy Relief 50 mcg/actuation

nasal spray,suspension ....................156

24Hour Allergy 10 mg tablet .................147

24HR Allergy Relief 5 mg tablet ............147

3

3 Day Vaginal 200 mg/5 gram (4 %) cream

.........................................................178

3-DAY VAGINAL 2 % CREAM .................178

4

4 WAY 1 % NASAL SPRAY ......................158

4-N-1 No Rinse Wash 1 % topical ............48

4-N-1 No Rinse Wash 1 % topical cream 48

5

50 Plus Adult Eye Health 250 mg-5 mg-1

mg capsule .........................................70

8

8 Hour Pain Reliever 650 mg

tablet,extended release .....................11

8HR Muscle Aches-Pain 650 mg

tablet,extended release .....................11

A

A THRU Z 18 MG-500 MCG-300 MCG-250

MCG TABLET ......................................70

A Thru Z Advanced Formula 18 mg-400

mcg tablet ..........................................85

A Thru Z High Potency tablet ..................56

A Thru Z Men's Ultimate 8 mg iron-200

mcg-600 mcg tablet ...........................70

A Thru Z Select 300 mcg-600 mcg-300 mcg

tablet .................................................70

A Thru Z Select 50 Plus Formula 0.4 mg-

300 mcg-250 mcg tablet ....................70

A Thru Z Select 500 mcg-300 mcg-250 mcg

tablet ................................................. 70

A Thru Z Select tablet ............................. 56

A Thru Z Select Women's tablet ............. 70

Abatinex 680 mg (750 million cell) capsule

.........................................................113

Abatron AF 150 mg iron-1 mg-500 mg

tablet ................................................. 65

ABC Plus 0.4 mg-300 mcg-250 mcg tablet

...........................................................70

ABDEK Multivitamin 1,000 unit-800 mcg

chewable tablet ................................. 87

ABDEK Multivitamin 500 unit-400 mcg/mL

oral drops .......................................... 87

ABSORBASE TOPICAL OINTMENT ........... 41

ACEPHEN 120 MG RECTAL SUPPOSITORY

...........................................................11

ACEPHEN 325 MG RECTAL SUPPOSITORY

...........................................................12

Acephen 650 mg rectal suppository ....... 12

Acerola C-500 500 mg oral wafer .......... 96

ACETA-GESIC 12.5 MG-325 MG TABLET .17

acetaminophen (bulk) 100 % powder .... 25

acetaminophen 120 mg rectal suppository

...........................................................12

acetaminophen 160 mg chewable tablet

...........................................................12

acetaminophen 160 mg disintegrating

tablet ................................................. 12

acetaminophen 160 mg/5 mL (5 mL) oral

solution .............................................. 12

acetaminophen 160 mg/5 mL (5 mL) oral

suspension ......................................... 12

acetaminophen 160 mg/5 mL oral elixir.12

acetaminophen 160 mg/5 mL oral liquid12

acetaminophen 160 mg/5 mL oral

suspension ......................................... 12

acetaminophen 325 mg tablet ............... 12

acetaminophen 325 mg/10.15 mL oral

solution .............................................. 12

acetaminophen 325 mg/10.15 mL oral

suspension ......................................... 12

acetaminophen 500 mg capsule ............. 12

acetaminophen 500 mg tablet ............... 12

acetaminophen 500 mg/15 mL oral liquid

...........................................................12

acetaminophen 650 mg rectal suppository

...........................................................12

acetaminophen 650 mg/20.3 mL oral

solution .............................................. 12

acetaminophen 650 mg/20.3 mL oral

suspension ......................................... 12

acetaminophen 80 mg chewable tablet .12

acetaminophen 80 mg disintegrating

tablet ................................................. 12

acetaminophen 80 mg/0.8 mL oral

drops,suspension .............................. 12

Acetaminophen Congestion-Pain 5 mg-

325 mg tablet .................................. 151

acetaminophen ER 650 mg

tablet,extended release .................... 12

Acetaminophen Extra Strength 500 mg

tablet ................................................. 12

Acetaminophen Pain Relief 500 mg tablet

...........................................................12

Acetaminophen PM 25 mg-500 mg tablet

...........................................................17

ACID CONTROLLER 10 MG TABLET ....... 111

Acid Controller 20 mg tablet ................ 111

Acid Gone Antacid 95 mg-358 mg/15 mL

oral suspension................................ 102

Acid Gone Antacid Extra Strength 160 mg-

105 mg chewable tablet .................. 102

Acid Reducer (cimetidine) 200 mg tablet

.........................................................111

Acid Reducer (famotidine) 10 mg tablet

.........................................................111

Acid Reducer (famotidine) 20 mg tablet

.........................................................111

Acid Reducer (omeprazole) 20 mg

capsule,delayed release .................. 111

acidophilus 100 million cell-pectin, citrus

10 mg capsule .................................. 113

acidophilus 25 million cell-pectin, citrus

100 mg tablet .................................. 113

Acidophilus capsule .............................. 113

Acidophilus Ex Str (L. sporog) 35 million-25

million cell tablet ............................. 113

Acidophilus-Pectin 75 million cell-100 mg

capsule ............................................ 110

Acne Foaming Wash 10 % topical cleanser

...........................................................33

Acne Medication 10 % lotion ................. 33

Acne Medication 10 % topical gel .......... 33

Acne Medication 2.5 % topical gel ......... 33

Acne Medication 5 % lotion ................... 33

Acne Medication 5 % topical gel ............ 33

Acne Treatment (benzoyl peroxide) 10 %

topical gel .......................................... 33

Acne-Clear 10 % topical gel .................... 33

Actical capsule ........................................ 70

Acticon (dexbrompheniramine-

pseudoephed) 1 mg-30 mg/5 mL oral

solution ........................................... 136

Acticon (dexbrompheniramine-

pseudoephedrine) 2 mg-60 mg tablet

.........................................................136

Actinel 30 mg-15 mg-200 mg/5 mL oral

solution ........................................... 168

OH Buckeye MMP Opt-Out Formulary August 1, 2021 182

Actinel Pediatric 15 mg-5 mg-50 mg/5 mL

oral liquid .........................................168

ACTIVE FE 75 MG IRON-1,250 MCG

TABLET ...............................................65

Activite 1 mg tablet ................................52

adapalene 0.1 % topical gel ....................34

Adult Aspirin Regimen 81 mg

tablet,delayed release .....................125

Adult Cough Formula DM Max 10 mg-200

mg/5 mL oral liquid ..........................171

Adult Multi plus Omega-3 200 mcg-1,000

unit-25 mg chewable tablet ...............70

Adult Multivitamin Extra Vitamin D3 200

mcg chewable tablet ..........................70

Adult Multivitamin Gummies 200 mcg

chewable tablet .................................70

Adult One Daily Gummies 200 mcg

chewable tablet .................................70

Adult One Daily Multivitamin 0.4 mg

tablet .................................................70

ADULT ROBITUSSIN PEAK COLD DM 10

MG-100 MG/5 ML ORAL LIQUID ......171

ADULT ROBITUSSIN PEAK COLD DM MAX

10 MG-200 MG/5 ML ORAL LIQUID .171

ADULT ROBITUSSIN PEAK COLD M-S 5 MG-

10 MG-100 MG/5 ML ORAL LIQUID .168

ADULT TUSSIN CHEST CONGESTION 100

MG/5 ML ORAL LIQUID ....................154

Adult Tussin Cough Congestion DM 10 mg-

100 mg/5 mL oral liquid ...................171

Adult Tussin DM 10 mg-100 mg/5 mL oral

syrup ................................................171

Adult Tussin Multi-Symptom Cold 5 mg-10

mg-100 mg/5 mL oral liquid .............169

Adult Wal-Tussin 100 mg/5 mL oral liquid

.........................................................154

Adult Wal-Tussin DM Max 10 mg-200

mg/5 mL oral liquid ..........................171

Adults 50 Plus 0.4 mg-300 mcg-250 mcg

tablet .................................................70

Adults' Daily Formula 18 mg iron-25 mcg

tablet .................................................70

Adults Multivitamin 18 mg iron-400 mcg-

25 mcg tablet .....................................70

ADVANCED ANTACID-ANTIGAS 200 MG-

200 MG-20 MG/5 ML ORAL

SUSPENSION ....................................105

Advanced Antacid-Antigas 400 mg-400

mg-40 mg/5 mL oral suspension ......105

Advanced Exfoliating Cleanser 5 % topical

...........................................................33

Advanced Formula Eye Drops 0.05 %-0.1

%-1 %-1 % ........................................135

Advanced Healing (Petrolatum) 41 %

topical ointment ................................48

ADVANCED MULTI EA 22.5 MG-400 MCG-

150 MCG-10 MG CHEWABLE TABLET 70

ADVIL 100 MG TABLET ............................ 17

ADVIL COLD AND SINUS 30 MG-200 MG

TABLET ............................................. 152

ADVIL LIQUI-GEL 200 MG CAPSULE ........ 17

ADVIL MIGRAINE 200 MG CAPSULE ....... 17

Aerochamber Mini................................ 127

Aerochamber MV spacer ...................... 127

Aerochamber Plus Flow-Vu .................. 127

Aerochamber Plus Flow-Vu,Large Mask

.........................................................127

Aerochamber Plus Flow-Vu,Medium Mask

.........................................................127

Aerochamber Plus Flow-Vu,Small Mask

.........................................................127

Aerochamber Plus Z Stat Large Mask ... 127

AeroChamber Plus Z Stat Medium Mask

.........................................................127

AeroChamber Plus Z Stat Small Mask ... 127

Aerochamber Plus Z Stat spacer ........... 127

Aerochamber with Flowsignal .............. 127

AeroChamber Z-Stat Plus-Flow Signal .. 127

Aerogear Action Asthma Kit ................. 127

Aerovent Plus spacer ............................ 127

AF 1 % topical spray powder .................. 38

AFRIN (OXYMETAZOLINE) 0.05 % NASAL

SPRAY .............................................. 158

AFRIN NO DRIP (OXYMETAZOLINE) 0.05 %

NASAL MIST ..................................... 158

AFRIN SINUS (OXYMETAZOLINE) 0.05 %

NASAL SPRAY ................................... 158

Aftera 1.5 mg tablet ............................... 32

Aimsco Latex Condom .......................... 126

AIRBORNE (ASCORBATE SODIUM) 250

MG-1.25 MG LOZENGES ...................... 9

AIRBORNE (ASCORBATE SODIUM) 333

MG-1.7 MG CHEWABLE TABLET .......... 9

AIRBORNE (ASCORBIC ACID) 1,000 MG-

350 MG ORAL EFFERVESCENT POWDER

PACK .................................................... 9

AIRBORNE (WITH LYSINE ACETATE) 250

MG-12.5 MG CHEWABLE TABLET ........ 9

AIRBORNE 1,000 MG-50 MG

EFFERVESCENT TABLET ........................ 9

AIRBORNE EVERYDAY STRESS AWAY 1,000

MG-200 MG-360 MG ORAL POWDER

PACKT ................................................ 10

Airshield 1,000 mg-50 mg effervescent

tablet ................................................. 10

Airshield 250 mg-1.25 mg chewable tablet

...........................................................10

Airzone Peak Flow Meter ..................... 127

ALAHIST CF 2 MG-10 MG-20 MG TABLET

.........................................................164

ALAHIST DM 2 MG-7.5 MG-15 MG/5 ML

ORAL LIQUID .................................... 164

ALA-HIST DM 4 MG-7.5 MG-15 MG/5 ML

ORAL LIQUID .................................... 164

ALA-HIST IR 2 MG TABLET .................... 143

ALA-SEB 2 %-2 % SHAMPOO .................. 46

ALAVERT 10 MG DISINTEGRATING TABLET

.........................................................147

ALAVERT D-12 ALLERGY-SINUS 5 MG-120

MG TABLET,EXTENDED RELEASE ..... 141

Alaway 0.025 % (0.035 %) eye drops .... 134

Alba-Derm cream ................................... 25

Aler-Cap 25 mg capsule ........................ 143

Alevazol 1 % topical ointment ................ 37

ALEVE 220 MG CAPSULE ........................ 17

ALEVE 220 MG TABLET ........................... 17

ALEVE-D SINUS AND HEADACHE 220 MG-

120 MG TABLET,EXTENDED RELEASE

.........................................................152

Alive Once Daily Women 50 Plus 800 mcg-

100 mcg tablet ................................... 70

Alive Women's Energy 18 mg-400 mcg-80

mcg tablet ......................................... 70

ALKA-SELTZER PLUS ALLERGY 25 MG

TABLET ............................................... 23

ALKA-SELTZER PLUS COLD (PE) 2 MG-7.8

MG-325 MG EFFERVESCENT TABLET141

ALKA-SELTZER PLUS DAY 5 MG-10 MG-325

MG CAPSULE ................................... 167

ALKA-SELTZER PLUS SINUS-COUGH 5 MG-

10 MG-325 MG CAPSULE ................. 167

ALL DAY ALLERGY (CETIRIZINE) 1 MG/ML

ORAL SOLUTION .............................. 147

ALL DAY ALLERGY (CETIRIZINE) 10 MG

CHEWABLE TABLET .......................... 147

All Day Allergy (cetirizine) 10 mg tablet147

ALL DAY ALLERGY RELIEF (CETIRIZINE) 10

MG TABLET ...................................... 147

All Day Allergy-D 5 mg-120 mg

tablet,extended release .................. 141

All Day Pain Relief 220 mg tablet ........... 17

All Day Pain Relief Sinus and Cold 220 mg-

120 mg tablet,extend release .......... 152

All Day Relief 220 mg tablet ................... 17

Allegra Allergy 180 mg tablet ............... 147

Allegra Allergy 60 mg tablet ................. 147

ALLEGRA-D 12 HOUR 60 MG-120 MG

TABLET,EXTENDED RELEASE ............ 141

Aller-Chlor 2 mg/5 mL oral syrup ......... 143

Aller-Chlor 4 mg tablet ......................... 143

Allerclear 10 mg tablet ......................... 147

AllerClear D-12hr 5 mg-120 mg

tablet,extended release .................. 141

AllerClear D-24hr 10 mg-240 mg

tablet,extended release .................. 141

Aller-ease 180 mg tablet ...................... 147

OH Buckeye MMP Opt-Out Formulary August 1, 2021 183

Aller-ease 30 mg/5 mL oral suspension147

Aller-ease 60 mg tablet .........................147

Allerfed Cold and Allergy 4 mg-10 mg

tablet ...............................................136

Aller-Fex 180 mg tablet.........................147

Aller-Flo 50 mcg/actuation nasal

spray,suspension .............................156

Aller-G-Time 25 mg tablet ....................143

Allergy (chlorpheniramine) 4 mg tablet143

ALLERGY (DIPHENHYDRAMINE) 12.5 MG/5

ML ORAL LIQUID .............................. 143

Allergy (diphenhydramine) 25 mg capsule

.........................................................143

Allergy (diphenhydramine) 25 mg tablet

.........................................................143

Allergy 4-Hour 4 mg tablet....................143

Allergy and Cold PE 12.5 mg-5 mg-325 mg

tablet ...............................................139

Allergy and Congestion Relief 10 mg-240

mg tablet,extend release 24 hr ........141

Allergy and Congestion Relief 5 mg-120

mg tablet,extend release 12 hr ........141

Allergy Complete-D 5 mg-120 mg

tablet,extended release ...................141

Allergy D-12 5 mg-120 mg tablet,extended

release .............................................142

ALLERGY EYE (KETOTIFEN) 0.025 % (0.035

%) DROPS .........................................134

ALLERGY MEDICATION 25 MG CAPSULE

.........................................................143

ALLERGY MEDICINE 12.5 MG/5 ML ORAL

LIQUID ..............................................143

ALLERGY MEDICINE 25 MG CAPSULE ....143

Allergy Medicine 25 mg tablet ..............143

Allergy Multi-Symptom 2 mg-5 mg-325 mg

tablet ...............................................139

ALLERGY MULTI-SYMPTOM NIGHTTIME 25

MG-5 MG-325 MG TABLET ..............139

Allergy plus Congestn Relief-D(cetiriz) 5

mg-120 mg tablet,ext.release ..........142

Allergy Relief (cetirizine) 1 mg/mL oral

solution ............................................148

Allergy Relief (cetirizine) 10 mg capsule

.........................................................148

Allergy Relief (cetirizine) 10 mg tablet 148

Allergy Relief (chlorpheniramine) 4 mg

tablet ...............................................143

Allergy Relief (chlorpheniramine) ER 12

mg tablet,extended release .............144

Allergy Relief (clemastine) 1.34 mg tablet

.........................................................144

ALLERGY RELIEF (DIPHENHYDRAMINE)

12.5 MG/5 ML ORAL LIQUID ............144

ALLERGY RELIEF (DIPHENHYDRAMINE) 25

MG CAPSULE ....................................144

Allergy Relief (diphenhydramine) 25 mg

tablet ............................................... 144

Allergy Relief (fexofenadine) 180 mg

tablet ............................................... 148

Allergy Relief (fexofenadine) 60 mg tablet

.........................................................148

Allergy Relief (fluticasone) 50

mcg/actuation nasal spray,suspension

.........................................................156

Allergy Relief (levocetirizine) 5 mg tablet

.........................................................148

ALLERGY RELIEF (LORATADINE) 10 MG

DISINTEGRATING TABLET................. 148

Allergy Relief (loratadine) 10 mg tablet148

ALLERGY RELIEF (LORATADINE) 5 MG/5

ML ORAL SOLUTION ......................... 148

ALLERGY RELIEF AND NASAL

DECONGESTANT 10 MG-240 MG

TABLET,EXTENDED REL .................... 142

ALLERGY RELIEF D12 5 MG-120 MG

TABLET,EXTENDED RELEASE ............ 142

Allergy Relief D-24hr 10 mg-240 mg

tablet,extended release ................... 142

Allergy Relief Multi-Symptom 2 mg-5 mg-

325 mg tablet .................................. 139

Allergy Relief-D (cetirizine) 5 mg-120 mg

tablet,extended release ................... 142

Allergy Relief-D (fexofenadine) 60 mg-120

mg tablet,extended release ............. 142

Allergy Relief-D (loratadine) 5 mg-120 mg

tablet,extended release ................... 142

Allergy Sinus Headache (PE) 12.5 mg-5

mg-325 mg tablet ............................ 139

Allergy Sinus PE 2 mg-5 mg-325 mg tablet

.........................................................139

Allergy-Congestion Relief-D (fexo) 60 mg-

120 mg tablet,extend release .......... 142

Allergy-Congestion Relief-D 10 mg-240 mg

tablet,extended release 24 hr ......... 142

Allergy-Time 4 mg tablet ...................... 144

Allerhist (clemastine) 1.34 mg tablet.... 144

ALLERHIST-1 1.34 MG TABLET .............. 144

Aller-Tec 10 mg tablet .......................... 148

Aller-Tec D 5 mg-120 mg tablet,extended

release ............................................. 142

All-Nite Cold-Flu 6.25 mg-15 mg-325

mg/15 mL oral liquid ........................ 163

Almacone 200 mg-200 mg-20 mg/5 mL

oral suspension ................................ 105

Almacone 200 mg-200 mg-25 mg

chewable tablet ............................... 105

ALMACONE-2 400 MG-400 MG-40 MG/5

ML ORAL SUSPENSION ..................... 105

ALOE VESTA ANTIFUNGAL (MICONAZOLE)

2 % TOPICAL OINTMENT .................... 37

ALOE VESTA PROTECTANT OINTMENT 43

% ........................................................48

ALOPHEN (BISACODYL) 5 MG

TABLET,DELAYED RELEASE ............... 120

AlpaWash ointment ............................... 25

alpha lipoic acid 100 mg capsule .............. 9

alpha lipoic acid 200 mg capsule .............. 9

alpha lipoic acid 300 mg capsule .............. 9

alpha lipoic acid 50 mg capsule ................ 9

alpha lipoic acid 600 mg capsule .............. 9

Altachlore 5 % eye drops ...................... 135

Altachlore 5 % eye ointment ................ 135

Altaderm Cream Base topical ................. 25

Altamist 0.65 % nasal spray aerosol ..... 157

aluminum hydroxide gel 320 mg/5 mL oral

suspension ....................................... 102

aluminum-mag hydroxide-simethicone

200 mg-200 mg-20 mg/5 mL oral susp

.........................................................105

aluminum-mag hydroxide-simethicone

400 mg-400 mg-40 mg/5 mL oral susp

.........................................................105

AMBI 10PEH-4CPM 4 MG-10 MG TABLET

.........................................................136

AMBI 60PSE-400GFN 60 MG-400 MG

TABLET ............................................. 153

AMBI 60PSE-4CPM 4 MG-60 MG TABLET

.........................................................136

AmeriCerin topical cream ....................... 48

AmeriPhor topical ointment ................... 41

AMLACTIN 12 % LOTION ........................ 42

AmLactin topical cream .......................... 41

ammonium lactate 12 % lotion .............. 42

ammonium lactate 12 % topical cream .. 42

Anecream (with dressings) 4 % topical kit

...........................................................50

Anecream 4 % topical ............................. 50

ANEFRIN 0.05 % NASAL SPRAY ............. 158

ANIMAL CHEWS tablet ........................... 87

Animal Shapes chewable tablet ............. 87

Animal Shapes Complete 18 mg iron

chewable tablet ................................. 90

Antacid (calcium carbonate) 200 mg

calcium (500 mg) chewable tablet... 103

Antacid (calcium carbonate) 215 mg

calcium (500 mg) chewable tablet... 103

Antacid (calcium carbonate) 320 mg

calcium (750 mg) chewable tablet... 103

Antacid 200 mg-200 mg-20 mg/5 mL oral

suspension ....................................... 105

Antacid Anti-Gas (calcium carb-simeth)

1,000 mg-60 mg chewable tablet .... 105

Antacid Anti-Gas 200 mg-200 mg-20 mg/5

mL oral suspension .......................... 105

Antacid Anti-Gas 400 mg-400 mg-40 mg/5

mL oral suspension .......................... 106

OH Buckeye MMP Opt-Out Formulary August 1, 2021 184

ANTACID ANTI-GAS DOUBLE STR 400 MG-

400 MG-40 MG/5 ML ORAL

SUSPENSION ....................................106

Antacid Calcium 215 mg calcium (500 mg)

chewable tablet ...............................103

Antacid Extra Strength (calcium carb) 300

mg (750 mg) chewable tablet ..........103

Antacid Extra Strength (calcium-mag hyd)

675 mg-135 mg chewable tablet .....102

Antacid Extra Strength (mag carb-Al hyd)

160 mg-105 mg chewable tablet .....103

Antacid Extra-Strength 200 mg-200 mg-20

mg/5 mL oral suspension .................106

Antacid Extra-Strength 300 mg (750 mg)

chewable tablet ...............................103

ANTACID LIQUID 200 MG-200 MG-20

MG/5 ML ORAL SUSPENSION...........106

ANTACID M 200 MG-200 MG-20 MG/5 ML

ORAL SUSPENSION ...........................106

Antacid Maximum Strength 400 mg-400

mg-40 mg/5 mL oral suspension ......106

ANTACID PLUS ANTI-GAS 200 MG-200

MG-20 MG/5 ML ORAL SUSPENSION

.........................................................106

ANTACID PLUS ANTI-GAS 400 MG-400

MG-40 MG/5 ML ORAL SUSPENSION

.........................................................106

Antacid Regular Strength 200 mg-200 mg-

20 mg/5 mL oral suspension ............106

Antacid Ultra Strength 400 mg calcium

(1,000 mg) chewable tablet .............104

Antacid Ultra Strength 430 mg calcium

(1,000 mg) chewable tablet .............104

Antacid Ultra Strength 470 mg calcium

(1,177 mg) chewable tablet .............104

ANTACID WITH SIMETHICONE 200 MG-

200 MG-20 MG/5 ML ORAL

SUSPENSION ....................................106

Antacid-Antigas 200 mg-200 mg-20 mg/5

mL oral suspension ..........................106

Antacid-Antigas 400 mg-400 mg-40 mg/5

mL oral suspension ..........................106

ANTACID-SIMETHICONE 400 MG-400 MG-

40 MG/5 ML ORAL SUSPENSION ......106

ANTIBIOTIC (BACITRACIN ZINC) 500

UNIT/GRAM TOPICAL OINTMENT ......35

Antibiotic Plus (pramoxine) 3.5 mg-10,000

unit-10 mg/gram top cream ..............36

Antibiotic(neomy-bacit-polym) 3.5 mg-400

unit-5,000 unit/gram top oint ............34

Antibiotic-Pain Relief(bacit)3.5 mg-500

unit-10,000 unit/gram ointment........36

ANTI-DANDRUFF (COAL TAR) 0.5 %

SHAMPOO ..........................................48

ANTI-DANDRUFF 1 % SHAMPOO ............40

Anti-Dandruff With Menthol 1 % shampoo

...........................................................40

ANTI-DIARRHEA 2 MG TABLET .............. 107

Anti-Diarrheal (loperamide) 1 mg/5 mL

oral liquid ......................................... 107

Anti-Diarrheal (loperamide) 1 mg/7.5 mL

oral liquid ......................................... 107

Anti-Diarrheal (loperamide) 2 mg capsule

.........................................................107

Anti-Diarrheal (loperamide) 2 mg tablet

.........................................................107

Anti-Diarrheal 262 mg/15 mL oral

suspension ....................................... 108

Antifungal (terbinafine) 1 % topical cream

...........................................................36

ANTIFUNGAL (TOLNAFTATE) 1 % TOPICAL

CREAM ............................................... 39

ANTIFUNGAL (TOLNAFTATE) 1 % TOPICAL

POWDER ............................................ 39

ANTIFUNGAL (TOLNAFTATE) 1 % TOPICAL

SPRAY ................................................ 39

Anti-Fungal 2 % topical powder .............. 37

Antifungal Cream (miconazole) 2 % topical

...........................................................37

Antifungal Spray 1 % topical powder ...... 39

ANTI-GAS ULTRA STRENGTH 180 MG

CAPSULE .......................................... 112

Anti-Itch (diphenhydramine) with Zinc 2

%-0.1 % topical cream ....................... 39

ANTI-ITCH (DIPHENHYDRAMINE) WITH

ZINC 2 %-0.1 % TOPICAL SPRAY ......... 40

Anti-Itch (HC) with Aloe and Vitamin E 1 %

topical cream ..................................... 44

Anti-Itch (hydrocortisone) 1 % topical

cream ................................................. 43

Anti-Itch (hydrocortisone) 1 % topical

ointment ............................................ 43

Anti-Itch (hydrocortisone) 1 % topical

spray .................................................. 43

Anti-Itch Plus 1 % topical cream ............. 44

Antioxidant A/C/E/Selenium capsule ..... 71

Antioxidant Formula (selenium yeast)

8,333 unit-167 mg-133 unit tablet ..... 71

Antioxidant Vitamins 1,000 unit-200 mg-

60 unit-2mg tablet ............................. 71

ANTISEPTIC 10 % TOPICAL SOLUTION..... 35

ANTITUSSIVE DM 10 MG-100 MG/5 ML

ORAL SYRUP ..................................... 171

Apatate Forte oral liquid ........................ 71

Apetigen Plus 10 mg-300 mg-30 unit

tablet ................................................. 65

Apothesar 2 cream ................................. 25

Apothesar Plus cream ............................. 25

Apothesil Base topical cream ................. 25

Aprodine 2.5 mg-60 mg tablet.............. 136

Aqua Glycolic Face topical cream ........... 42

Aquabase topical ointment .................... 31

AQUADEKS 100 MCG-350 MCG-5 MG

CHEWABLE TABLET ............................ 71

AQUADEKS 100 MCG-700 MCG-10 MG

CAPSULE ............................................ 71

AQUADEKS PEDIATRIC 400 MCG/ML ORAL

DROPS ............................................... 90

Aqua-E Concentrate 75 unit/mL oral drops

.........................................................100

Aquanaz 10 mg-15 mg-400 mg tablet .. 169

AQUAPHOR HEALING 41 % TOPICAL

OINTMENT ......................................... 49

AQUAPHOR ORIGINAL 41 % TOPICAL

OINTMENT ......................................... 49

AQUASOL A 50,000 UNIT/ML

INTRAMUSCULAR SOLUTION ............. 94

ARBEM H-Cosmetic cream ..................... 25

ARBEM LipoPen cream ........................... 25

arginine (L-arginine) (bulk) 100 % crystals

...........................................................25

arginine (L-arginine) (bulk) 100 % powder

...........................................................25

arginine (L-arginine) 2,000 mg oral

powder packet................................... 52

arginine (L-arginine) 500 mg capsule ..... 52

arginine (L-arginine) 500 mg oral powder

packet ................................................ 52

arginine (L-arginine) 500 mg tablet ........ 52

arginine (L-arginine) oral powder ........... 52

arginine HCl (L-arginine) 1,000 mg tablet

...........................................................52

arginine HCl (L-arginine) 500 mg capsule

...........................................................52

Arthritis Pain Relief (acetaminophen) ER

650 mg tablet,extend release ............ 13

Arthritis Pain Relief (capsaicin) 0.075 %

topical cream ..................................... 50

ARTHRITIS PAIN RELIEVER 650 MG

TABLET,EXTENDED RELEASE .............. 13

Artificial Tears (dextran 70-hypromellose)

0.1 %-0.3 % eye drops ..................... 130

ARTIFICIAL TEARS (DEXTRAN 70-

HYPROMELLOSE) EYE DROPS ........... 130

Artificial Tears (petrolatum/mineral oil) 83

%-15 % eye ointment ...................... 130

Artificial Tears (PF) 0.1 %-0.3 % drops in a

dropperette ..................................... 130

ARTIFICIAL TEARS (PF) DROPS IN A

DROPPERETTE ................................. 130

Artificial Tears (pg400-hypromell-glycerin)

1 %-0.2 %-0.2 % eye drops .............. 130

ARTIFICIAL TEARS (POLYVINYL ALCOHOL)

1.4 % EYE DROPS ............................. 133

Artificial Tears (polyvinyl

alcohol/povidone) 0.5 %-0.6 % eye

drops ............................................... 130

OH Buckeye MMP Opt-Out Formulary August 1, 2021 185

ASCOR 500 MG/ML INTRAVENOUS

SOLUTION ..........................................96

ascorbic acid (vitamin C) 1,000 mg tablet

...........................................................96

ascorbic acid (vitamin C) 100 mg tablet 96

ascorbic acid (vitamin C) 250 mg tablet 96

ascorbic acid (vitamin C) 500 mg tablet 96

ascorbic acid (vitamin C) 500 mg/5 mL oral

syrup ..................................................96

ascorbic acid (vitamin C) ER 1,000 mg

tablet,extended release .....................96

Aspir-81 mg tablet,delayed release ......125

aspirin 300 mg rectal suppository ...........19

aspirin 325 mg tablet ..............................19

aspirin 325 mg tablet,delayed release ....19

aspirin 600 mg rectal suppository ...........19

aspirin 81 mg chewable tablet ..............125

aspirin 81 mg tablet,delayed release ....125

Aspirin Childrens 81 mg chewable tablet

.........................................................125

Aspirin Low Dose 81 mg tablet,delayed

release .............................................125

ASPIR-LOW 81 MG TABLET,DELAYED

RELEASE ...........................................125

Assess Full Range Peak Meter...............127

Asthma Check Meter ............................127

AsthmaMentOr Peak Flow Meter .........127

Asthmapack Children's kit ....................127

Athenol 325 mg tablet ............................13

Athlete's Foot (clotrimazole) 1 % topical

cream .................................................37

Athlete's Foot (terbinafine) 1 % topical

cream .................................................36

Athlete's Foot (tolnaftate) 1 % topical

cream .................................................39

Athlete's Foot (tolnaftate) 1 % topical

spray ..................................................39

Athlete's Foot (tolnaftate) 1 % topical

spray powder .....................................39

ATHLETE'S FOOT 2 % POWDER ...............37

Athlete's Foot 2 % topical spray powder 37

Athlete's Foot AF 1 % topical cream .......37

Athletic Foot Cream 1 % topical..............37

Atrevis Hydrogel cream ..........................25

Auxipro Vanishing Cream topical ............25

AVEENO ANTI-ITCH (HYDROCORTISONE) 1

% TOPICAL CREAM .............................44

Av-Vite FB 2.5 mg-25 mg-1 mg tablet .....94

AYR ALLERGY AND SINUS 2.65 % NASAL

SPRAY AEROSOL ...............................157

Ayr Saline 0.65 % nasal drops ...............157

AYR SALINE 0.65 % NASAL SPRAY

AEROSOL ..........................................157

AYR SALINE GEL NASAL SPRAY ..............157

AYR SALINE NASAL GEL .........................157

AZ topical cream .....................................25

AZO COMPLETE FEMININE BALANCE 5

BILLION CELL CAPSULE ..................... 113

AZO HORMONAL HEALTH CYCLE CARE 100

MG-50 MG-50 MG-15 MG TABLET .... 10

AZO URINARY PAIN RELIEF 95 MG TABLET

.........................................................125

AZO URINARY PAIN RELIEF 97.5 MG

TABLET ............................................. 125

AZOLEN TINCTURE 2 % TOPICAL ............. 37

B

B Complex Plus Vitamin C 15 mg-10 mg-50

mg-5 mg-300 mg capsule .................. 52

B Complex w-Vit C 18 mg-10 mg-45 mg-5

mg-250 mg tablet .............................. 94

B complex-vitamin C-folic acid ER 400 mcg

tablet,extended release ..................... 52

BABY AYR SALINE 0.65 % NASAL DROPS

.........................................................157

Baby Ddrops 10 mcg/drop (400 unit/drop)

oral .................................................... 97

Baby Iron-Multivitamin 10 mg/mL oral

drops.................................................. 91

Baby Vitamin D3 10 mcg/drop (400

unit/drop) oral drops ......................... 97

Baby's Super Daily D3 10 mcg/drop (400

unit/drop) oral drops ......................... 97

bacitracin 500 unit/gram topical ointment

...........................................................35

bacitracin 500 unit/gram topical packet.35

bacitracin 500 unit-polymyxin B 10,000

unit/gram topical ointment ............... 34

bacitracin zinc 500 unit/gram topical

ointment ............................................ 35

bacitracin zinc 500 unit/gram topical

ointment in packet ............................ 35

bacitracin-polymyxin B 500 unit-10,000

unit/gram topical packet ................... 34

BACITRAYCIN PLUS 500 UNIT/GRAM

TOPICAL OINTMENT .......................... 35

BACMIN 27 MG IRON-1 MG TABLET ....... 71

BANOPHEN 12.5 MG/5 ML ORAL LIQUID

.........................................................144

Banophen 25 mg capsule ..................... 144

Banophen 25 mg tablet ........................ 144

Banophen 50 mg capsule ..................... 144

BANOPHEN ALLERGY 12.5 MG/5 ML ORAL

LIQUID ............................................. 144

Banophen Anti-Itch 2 %-0.1 % topical

cream ................................................. 40

BARIATRIC MULTIVITAMINS 45 MG IRON-

800 MCG-120 MCG CAPSULE ............. 71

Base 7542 transdermal cream ................ 25

Base W301 cream ................................... 25

Base, PCCA Polypeg wax ......................... 25

Base, PCCA Syrup Vehicle oral liquid ...... 31

Base, PCCA Vanishing Cream-Lotion

topical ................................................ 26

Base, PCCA Vanpen topical cream .......... 26

Base, PCCA Xematop topical cream ....... 26

BAYER ASPIRIN 325 MG TABLET ............. 19

BAYER CHEWABLE LOW DOSE ASPIRIN 81

MG TABLET ...................................... 126

Baza Antifungal 2 % topical cream ......... 37

Baza Protect topical cream ..................... 48

B-Complex Plus Vitamin C (and calcium)

300 mg-150 mg calcium tablet .......... 52

B-complex with vitamin C 400 mcg-500

mg tablet ........................................... 52

B-complex with vitamin C capsule .......... 53

B-complex with vitamin C ER

tablet,extended release .................... 53

B-complex with vitamin C tablet ............ 53

Bee-Zee tablet ........................................ 71

BENADRYL 25 MG CAPSULE ................. 144

BENADRYL ALLERGY 12.5 MG/5 ML ORAL

LIQUID ............................................. 144

BENADRYL ALLERGY 25 MG TABLET ..... 144

BENADRYL EXTRA STRENGTH 2 %-0.1 %

TOPICAL CREAM ................................ 40

BENADRYL ITCH COOLING 2 %-0.1 %

TOPICAL SPRAY .................................. 40

BENZEDREX NASAL INHALER ................ 158

BenzePrO 5.3 % topical foam ................. 33

BENZEPRO 6 % TOWELETTE ................... 33

benzoin (bulk) topical tincture ............... 26

benzoin compound (bulk) tincture ......... 26

benzoin compound 10 %-2 %-8 %-4 %

topical tincture .................................. 49

benzoin topical tincture ......................... 49

benzonatate 100 mg capsule ............... 150

benzonatate 150 mg capsule ............... 150

benzonatate 200 mg capsule ............... 150

benzoyl peroxide 10 % topical cleanser 33

benzoyl peroxide 10 % topical gel .......... 33

benzoyl peroxide 2.5 % topical gel ......... 33

benzoyl peroxide 3 % topical cleanser ... 33

benzoyl peroxide 5 % topical cleanser ... 33

benzoyl peroxide 5 % topical gel ............ 33

benzoyl peroxide 5.3 % topical foam ..... 33

benzoyl peroxide 6 % topical cleanser ... 33

benzoyl peroxide 9 % topical cleanser ... 33

benzoyl peroxide 9.8 % topical foam ..... 33

benzyl alcohol (bulk) liquid ..................... 26

benzyl benzoate (bulk) liquid ................. 26

BEROCCA (FA-GUARANA-CAFF) 400 MCG-

89.45 MG-44 MG EFFERVESCENT

TABLET ............................................... 71

BETA CARE TOPICAL CREAM ................... 41

beta carotene 25,000 unit capsule ......... 94

BETA MED 2 % SHAMPOO ...................... 40

OH Buckeye MMP Opt-Out Formulary August 1, 2021 186

BETA XMA TOPICAL CREAM ....................48

BETADINE 5 % TOPICAL SPRAY................35

BETADINE SKIN CLEANSER 7.5 %.............35

BETADINE SURGICAL SCRUB 7.5 %

TOPICAL SOLUTION ............................35

BETADINE SWABSTICKS 10 % ..................35

BETASAL 3 % SHAMPOO .........................46

BETATEMP 160 MG/5 ML ORAL

SUSPENSION ......................................13

BIO T PRES 5 MG-10 MG-200 MG/5 ML

ORAL LIQUID ....................................169

BIO-35, GLUTEN FREE 3 MG-133 MCG-33

MCG-33 MCG CAPSULE ......................71

BIOCAL 500 MG-100 UNIT-45 MG-800

MCG CAPSULE ....................................57

BIOCEL (WITH LUTEIN) 800 MCG-250

MCG-750 MCG TABLET ......................71

BIOCOTRON 10 MG-100 MG/5 ML ORAL

LIQUID ..............................................171

BIO-D-MULSION 10 MCG/DROP (400

UNIT/DROP) ORAL DROPS ..................97

BIO-D-MULSION FORTE 50 MCG/DROP

(2,000 UNIT/DROP) ORAL DROPS.......97

BIONEL 30 MG-15 MG-200 MG/5 ML

ORAL SOLUTION ...............................169

BIONEL PEDIATRIC 15 MG-5 MG-50 MG/5

ML ORAL LIQUID ..............................169

Biopeptide Biocosmetic Base cream .......26

BIOSUPP ORAL LIQUID ............................71

BIOTECT PLUS ORAL LIQUID ....................71

biotin (bulk) 100 % powder ....................26

biotin 1 mg capsule .................................96

biotin 10,000 mcg capsule ......................96

biotin 2,500 mcg capsule ........................96

biotin 300 mcg tablet ..............................96

biotin 5 mg capsule .................................96

Biotin Plus-Calcium and Vit D3 200 mg-

450 mcg-400 unit tablet .....................71

BIOVOL ORAL SYRUP ...............................71

Bisac-Evac 10 mg rectal suppository .....120

bisacodyl 10 mg rectal suppository ......120

bisacodyl 5 mg tablet,delayed release .120

BISA-LAX (BISACODYL) 5 MG

TABLET,DELAYED RELEASE ...............120

BISCOLAX 10 MG RECTAL SUPPOSITORY

.........................................................120

BISMATROL 262 MG CHEWABLE TABLET

.........................................................108

Bismatrol 262 mg/15 mL oral suspension

.........................................................108

Bismatrol 525 mg/15 mL oral suspension

.........................................................108

Bismuth 262 mg chewable tablet .........108

Bismuth 262 mg tablet .........................108

BISMUTH 262 MG/15 ML ORAL

SUSPENSION ....................................108

BISMUTH MAXIMUM STRENGTH 525

MG/15 ML ORAL SUSPENSION ........ 108

bismuth subsalicylate 262 mg chewable

tablet ............................................... 108

bismuth subsalicylate 262 mg/15 mL oral

suspension ....................................... 108

Blended Suspending Compound oral ..... 31

Body, Hair, Skin and Nails 3 mg-133 mcg

capsule ............................................... 71

BP 10 % topical gel ................................. 33

BP 5 % topical gel ................................... 34

BP Foam 5.3 % topical ............................ 34

BP WASH 10 % TOPICAL CLEANSER ........ 34

BP Wash 5 % topical cleanser ................. 34

BPO 6 % towelette .................................. 34

BPO CREAMY WASH PACK 4 %-5 %

TOPICAL ............................................. 34

BPO CREAMY WASH PACK 8 %-5 %

TOPICAL ............................................. 34

BreatheRite MDI Spacer ....................... 128

BreatheRite Spacer and Mask, Adult .... 128

BreatheRite Spacer and Mask, Child .... 128

BreatheRite Spacer and Mask, Infant ... 128

BreatheRite Spacer and Mask, Neonate

.........................................................128

BreatheRite Spacer and Mask, Small Child

.........................................................128

BROHIST D 4 MG-10 MG TABLET .......... 136

BROMFED DM 2 MG-30 MG-10 MG/5 ML

ORAL SYRUP ..................................... 164

brompheniramine-pseudoephedrine-DM

2 mg-30 mg-10 mg/5 mL oral syrup.164

Bronkaid Dual Action 25 mg-400 mg tablet

.........................................................151

Brotapp 1 mg-15 mg/5 mL oral liquid ... 136

Brotapp DM 1 mg-15 mg-5 mg/5 mL oral

elixir ................................................. 164

budesonide 32 mcg/actuation nasal spray

.........................................................156

butenafine 1 % topical cream ................. 37

C

C-1000 1,000 mg tablet .......................... 96

C-1000 with Rose Hips 1,000 mg tablet 96

C-500 500 mg tablet .............................. 96

Ca 600 mg-D3 20 mcg-mag oxide 50 mg-

Zn-copper-manganese-boron tablet 57

Ca 600 mg-D3 400 unit-mag ox 40 mg-Zn-

copper-Mn-boron chewable tablet ... 58

Ca 600 mg-D3 800 unit-mag ox 40 mg-Zn-

copper-Mn-boron chewable tablet ... 58

caffeine (bulk) 100 % powder ................. 26

Cal Mag Zinc Plus D3 333 mg-133 unit-133

mg-5 mg tablet .................................. 58

CALCI-CHEW 500 MG CALCIUM (1,250

MG) TABLET ....................................... 56

CALCIDOL 200 MCG/ML (8,000 UNIT/ML)

ORAL DROPS ...................................... 97

Calci-Mix 500 mg calcium (1,250 mg)

capsule .............................................. 56

Calcionate 115 mg/5 mL (1.8 gram/5 mL)

oral syrup........................................... 57

CALCITRATE 200 MG (950 MG) TABLET .. 57

Cal-Citrate 250 mg calcium-2.5 mcg (100

unit) tablet ......................................... 59

Calcitrate 315 mg calcium-6.25 mcg (250

unit) tablet ......................................... 59

calcium 250 mg-D3 400 unit-magnesium

40 mg-B6-Zn-copper-mangan tablet 58

Calcium 500 + D 500 mg (1,250 mg)-200

unit tablet .......................................... 59

Calcium 500 + D 500 mg (1,250 mg)-400

unit tablet .......................................... 59

Calcium 500 + D 500 mg(1,250 mg)-400

unit chewable tablet.......................... 59

Calcium 500 mg (1,250 mg) + D3 125 unit

tablet ................................................. 59

Calcium 500 With D 500 mg (1,250 mg)-

400 unit tablet ................................... 59

Calcium 600 + D(3) 600 mg (1,500 mg)-200

unit tablet .......................................... 59

Calcium 600 + D(3) 600 mg (1,500 mg)-400

unit tablet .......................................... 59

Calcium 600 + D(3) 600 mg calcium-200

unit capsule ....................................... 59

Calcium 600 + Minerals 600 mg calcium-

200 unit tablet ................................... 58

Calcium 600 + Minerals 600 mg calcium-

400 unit tablet ................................... 58

Calcium 600 mg calcium (1,500 mg) tablet

...........................................................57

Calcium 600 with Vitamin D3 600 mg

(1,500 mg)-400 unit capsule .............. 59

Calcium 600 with Vitamin D3 600 mg

(1,500 mg)-500 unit capsule .............. 59

Calcium 600 with Vitamin D3 600

mg(1,500 mg)-400 unit chewable tablet

...........................................................59

Calcium 600-D3 Plus (mag-zinc) 600 mg

calcium-20 mcg-50 mg tablet ............ 58

CALCIUM ANTACID 200 MG CALCIUM (500

MG) CHEWABLE TABLET .................. 104

Calcium Antacid 300 mg (750 mg)

chewable tablet ............................... 104

Calcium Antacid 320 mg calcium (750 mg)

chewable tablet ............................... 104

Calcium Antacid 400 mg calcium (1,000

mg) chewable tablet ........................ 104

Calcium Antacid 430 mg calcium (1,000

mg) chewable tablet ........................ 104

OH Buckeye MMP Opt-Out Formulary August 1, 2021 187

Calcium Antacid Ultra Max St 400 mg

calcium (1,000 mg) chewable tablet104

calcium carb-ergocalciferol (vit D2) 250

mg (625 mg)-125 unit tablet ..............59

calcium carbonate 200 mg calcium (500

mg) chewable tablet ........................104

calcium carbonate 260 mg calcium (648

mg) tablet ........................................104

calcium carbonate 260 mg calcium (650

mg) chewable tablet ..........................57

calcium carbonate 300 mg (750 mg)

chewable tablet ...............................104

calcium carbonate 320 mg calcium (750

mg) chewable tablet ........................104

calcium carbonate 400 mg calcium (1,000

mg) chewable tablet ........................104

calcium carbonate 500 mg (1,250 mg)-

vitamin D3 125 unit tablet .................59

calcium carbonate 500 mg (1,250 mg)-

vitamin D3 200 unit tablet .................59

calcium carbonate 500 mg (1,250 mg)-

vitamin D3 400 unit tablet .................59

calcium carbonate 500 mg calcium (1,250

mg) chewable tablet ..........................57

calcium carbonate 500 mg calcium (1,250

mg) tablet ..........................................57

calcium carbonate 500 mg(1,250 mg)-

vitamin D3 400 unit chewable tablet.59

calcium carbonate 500 mg/5 mL calcium

(1,250 mg/5 mL) oral suspension .......57

calcium carbonate 600 mg (1,500 mg)-

vitamin D3 2,500 unit capsule ...........60

calcium carbonate 600 mg (1,500 mg)-

vitamin D3 200 unit tablet .................60

calcium carbonate 600 mg (1,500 mg)-

vitamin D3 500 unit capsule ..............60

calcium carbonate 600 mg calcium (1,500

mg) tablet ..........................................57

calcium carbonate 600 mg calcium (1,500

mg)-vit D3 1,000 unit capsule ............60

calcium carbonate 800 mg calcium/2 gram

oral powder .......................................57

calcium carbonate-vitamin D3 1,000 mg

(2,500 mg)-800 unit tablet .................60

calcium carbonate-vitamin D3 250 mg-125

unit tablet ..........................................60

calcium carbonate-vitamin D3 500 mg

(1,250 mg)-600 unit tablet .................60

calcium carbonate-vitamin D3 500 mg-100

unit chewable tablet ..........................60

calcium carbonate-vitamin D3 600 mg

(1,500 mg)-400 unit capsule ..............60

calcium carbonate-vitamin D3 600 mg

(1,500 mg)-800 unit tablet .................60

calcium carb-vit D3-magnesium-zinc 333

mg-200 unit-133 mg-5 mg tablet .......58

calcium carb-vit D3-minerals 600 mg

calcium-400 unit tablet ...................... 58

calcium chloride 100 mg/mL (10 %)

intravenous solution .......................... 57

calcium chloride 100 mg/mL (10 %)

intravenous syringe ........................... 57

calcium cit 1,000 mg calcium-vit D3 10

mcg(400 unit)/30 mL oral liquid ........ 60

Calcium Citrate + D 315 mg-5 mcg (200

unit) tablet ......................................... 60

calcium citrate 200 mg (950 mg) tablet 57

calcium citrate 200 mg calcium-vitamin D3

3.125 mcg (125 unit) tablet ............... 60

calcium citrate 200 mg calcium-vitamin D3

6.25 mcg (250 unit) tablet ................. 60

calcium citrate 250 mg calcium-vitamin D3

5 mcg (200 unit) tablet ...................... 60

calcium citrate 250 mg tablet ................. 57

calcium citrate 315 mg calcium-vitamin D3

6.25 mcg (250 unit) tablet ................. 60

calcium citrate 315 mg-vitamin D3 5 mcg

(200 unit) tablet ................................. 60

calcium citrate 760 mg calcium/3.5 gram

oral granules ...................................... 57

Calcium Citrate Plus (pyridoxine) 250 mg-

40 mg-5 mg-125 unit tablet ............... 71

Calcium Citrate Plus 250 mg-40 mg-125

unit-3.75 mg tablet ............................ 58

calcium lactate 100 mg calcium tablet ... 57

calcium lactate 84 mg (648 mg) tablet ... 57

calcium phosphate 250 mg-vit D3 12.5

mcg (500 unit) chewable tablet ......... 60

calcium phosphate 250 mg-vitamin D3 5

mcg (200 unit) chewable tablet ......... 60

calcium polycarbophil 625 mg tablet ... 114

Calcium with Vitamin D 600 mg (1,500

mg)-400 unit tablet ............................ 61

Calcium-Folic Acid-Vitamin D 500 mg-50

mg-300 unit-1 mg oral wafer ............. 58

calcium-magnesium-zinc 333 mg-133 mg-

5 mg tablet ........................................ 58

CAL-GEST ANTACID 200 MG CALCIUM

(500 MG) CHEWABLE TABLET .......... 104

Callus Removers 40 % topical patch ....... 46

Cal-Mint 260 mg calcium (650 mg)

chewable tablet ................................. 57

CAL-QUICK 500 MG CALCIUM-400 UNIT/5

ML ORAL LIQUID ................................ 61

CALTRATE + D3 PLUS MINERALS 300 MG-

800 UNIT-25 MG-0.5 MG TABLET ...... 58

CALTRATE 600 PLUS D 600 MG (1,500

MG)-800 UNIT CHEWABLE TABLET .... 61

CALTRATE 600-D PLUS MINERALS 600 MG

CALCIUM-800 UNIT-40 MG CHEW

TABLET ............................................... 58

CALTRATE 600-D PLUS MINERALS 600 MG

CALCIUM-800 UNIT-50 MG TABLET ...58

CALTRATE WITH VITAMIN D3 600 MG

(1,500 MG)-800 UNIT TABLET ............ 61

CapCof 2 mg-5 mg-10 mg/5 mL oral liquid

.........................................................175

Capmist DM 60 mg-15 mg-400 mg tablet

.........................................................169

Capron DM 7.5 mg-7.5 mg/5 mL oral liquid

.........................................................166

Capron DMT 30 mg-30 mg tablet ......... 166

capsaicin 0.025 % topical cream............. 50

capsaicin 0.1 % topical cream................. 50

capsaicin 0.15 % topical liquid ................ 50

CAPZASIN 0.15 % TOPICAL LIQUID ......... 50

carboxymethylcellulose sodium 0.5 % eye

drops ............................................... 133

Carrington Moist Barrier-Zinc 10 %-78 %

topical cream ..................................... 48

Carrington Moisture Barrier Cr 61 %

topical cream ..................................... 49

CASTELLANI PAINT 1.5 % TOPICAL LIQUID

...........................................................20

Castellani Paint Modified 1.5 % topical

liquid.................................................. 20

castor oil ................................................. 31

castor oil 100 % oral ............................. 120

castor oil oral ........................................ 120

Cela Cream Base ..................................... 26

Centamin 9 mg iron/15 mL oral liquid .... 71

CENTRAL-VITE 18 MG-400 MCG TABLET 85

CENTRAL-VITE SENIOR 0.4 MG-300 MCG-

250 MCG TABLET ............................... 71

Central-Vite Women's Mature 8 mg iron-

400 mcg-300 mcg tablet .................... 71

Centram-Care 9 mg iron/15 mL oral liquid

...........................................................72

CENTRATEX 106 MG IRON-1 MG CAPSULE

...........................................................65

Centravites 0.4 mg-162 mg-18 mg tablet

...........................................................72

Centravites 50 Plus tablet ...................... 56

Centravites Adults 18 mg iron-400 mcg-25

mcg tablet ......................................... 72

CENTRUM 3,500 UNIT-18 MG-0.4 MG

CHEWABLE TABLET ............................ 72

CENTRUM 9 MG IRON/15 ML ORAL

LIQUID ............................................... 72

CENTRUM CHEWABLES 8 MG IRON-400

MCG-10 MCG TABLET ........................ 72

CENTRUM COMPLETE 18 MG-400 MCG

TABLET ............................................... 85

CENTRUM FLAVOR BURST KIDS

CHEWABLE TABLET ............................ 72

CENTRUM KIDS 18 MG IRON CHEWABLE

TABLET ............................................... 91

OH Buckeye MMP Opt-Out Formulary August 1, 2021 188

CENTRUM MEN 8 MG IRON-200 MCG-600

MCG TABLET ......................................72

CENTRUM SILVER 0.4 MG-300 MCG-250

MCG TABLET ......................................72

CENTRUM SILVER 400 MCG-250 MCG

CHEWABLE TABLET ............................72

CENTRUM SILVER MEN 300 MCG-600

MCG-300 MCG TABLET ......................72

CENTRUM SILVER ULTRA MEN'S 300 MCG-

600 MCG-300 MCG TABLET ...............72

CENTRUM SILVER WOMEN 8 MG IRON-

400 MCG-300 MCG TABLET ...............72

CENTRUM SPECIALIST HEART 3 MG-200

MCG-400 MG TABLET ........................72

CENTRUM SPECIALIST PRENATAL 27 MG

IRON-800 MCG-200 MG ORAL PACK 92

CENTRUM ULTRA MEN'S 8 MG IRON-200

MCG-600 MCG TABLET ......................72

CENTRUM WOMEN 18 MG-400 MCG

TABLET ...............................................85

Century 18 mg-400 mcg tablet ...............85

Century Adults 50 Plus 0.4 mg-300 mcg-

250 mcg tablet ...................................72

Century Cardio 3 mg-200 mcg-400 mg

tablet .................................................72

CENTURY ENERGY METABOLISM 18 MG

IRON-400 MCG-50 MG TABLET ..........72

Century Mature 0.4 mg-300 mcg-250 mcg

tablet .................................................72

Century Mature 400 mcg-30 mcg tablet 73

Century Men's 8 mg iron-200 mcg-60 mcg

tablet ................................................. 73

Century Ultimate Men's 300 mcg-600

mcg-300 mcg tablet ...........................73

Century Ultimate Men's 8 mg iron-200

mcg-600 mcg tablet ...........................73

Century Ultimate Women's 18 mg-400

mcg tablet ..........................................85

Century Ultimate Women's 8 mg iron-400

mcg-300 mcg tablet ...........................73

CeraLyte-70 70 mEq-60 mEq-20 mEq-30

mEq/L oral solution ............................68

CERAMAX TOPICAL CREAM.....................41

CERAVE TOPICAL CREAM ........................40

Cerovite 9 mg iron/15 mL oral liquid ......73

Cerovite Advanced Formula 18 mg-400

mcg tablet ..........................................85

Cerovite Jr 18 mg iron-10 mcg chewable

tablet .................................................91

CEROVITE JR CHEWABLE TABLET ............91

Cerovite Senior tablet .............................56

Certa Plus 18 mg-0.4 mg-250 mcg tablet73

CertaVite Senior 0.4 mg-300 mcg-250 mcg

tablet ................................................. 73

Certavite-Antioxidant 18 mg-400 mcg

tablet .................................................85

CertaVite-Antioxidants (iron gluc) 9 mg

iron/15 mL oral liquid ........................ 73

Cetaphil Hand topical cream .................. 41

Cetaphil Moisturizing topical cream ....... 41

CETAPHIL TOPICAL CREAM ..................... 41

Cetiri-D 5 mg-120 mg tablet,extended

release ............................................. 142

cetirizine 1 mg/mL oral solution ........... 148

cetirizine 10 mg chewable tablet .......... 148

cetirizine 10 mg tablet .......................... 148

cetirizine 5 mg chewable tablet ............ 148

cetirizine 5 mg tablet ............................ 148

cetirizine 5 mg/5 mL oral solution ........ 148

cetirizine 5 mg-pseudoephedrine ER 120

mg tablet,extended release,12hr .... 142

Chemstrip 10 MD ................................... 51

Chemstrip 10/SG .................................... 51

Chemstrip 2 GP ....................................... 51

Chemstrip 50B ........................................ 51

Chemstrip 7 ............................................ 51

Chemstrip 9 ............................................ 51

CHERATUSSIN AC 10 MG-100 MG/5 ML

ORAL LIQUID .................................... 176

CHERATUSSIN DAC 30 MG-10 MG-100

MG/5 ML ORAL SYRUP .................... 176

Chest Congestion Relief 400 mg tablet.154

Chest Congestion Relief DM 20 mg-400

mg tablet ......................................... 171

Chest Congestion Relief PE 10 mg-400 mg

tablet ............................................... 153

CHEST CONGESTION-COUGH RELIEF 20

MG-400 MG TABLET ........................ 171

CHEST-SINUS CONGESTION RELIEF 10 MG-

400 MG TABLET ............................... 153

CHEWABLE-VITE TABLET......................... 87

Chewable-Vite with Iron tablet .............. 91

Child Chest Congestion-Cough 5 mg-100

mg/5 mL oral liquid .......................... 171

Child Chewable Vitamins with Iron 15 mg

tablet ................................................. 91

CHILD CHEWABLE VITAMINS WITH IRON

TABLET ............................................... 91

Child Complete Multivitamin 18 mg iron

chewable tablet ................................. 91

CHILD DELSYM COUGH-COLD 12.5 MG-5

MG-325 MG/10 ML ORAL LIQUID .... 139

CHILD MUCINEX CHEST CONGEST MINI-

MELTS 100 MG ORAL GRANULES IN

PACKET ............................................ 154

CHILD MUCINEX COUGH MINI-MELTS 5

MG-100 MG ORAL GRANULES IN

PACKET ............................................ 172

CHILD MUCINEX M-S COLD DAY-NITE 325

MG-12.5 MG-5 MG/10ML(NT) ORAL

LIQS .................................................. 160

Child Mucus Relief Cough 5 mg-100 mg/5

mL oral liquid ................................... 172

CHILD MUCUS RELIEF EXPECTORANT 100

MG/5 ML ORAL LIQUID.................... 154

CHILD MULTI-SYMPTOM COLD/COUGH

2.5 MG-5 MG-100 MG/5 ML ORAL

LIQUID ............................................. 169

Child Multivitamin Plus Iron 18 mg

chewable tablet ................................. 91

CHILD TRIAMINIC COUGH-CONGESTION 5

MG-100 MG/5 ML ORAL SYRUP ...... 172

CHILD TRIAMINIC COUGH-SORE THROAT

160 MG-5 MG/5 ML ORAL SUSPENSION

.........................................................166

Child Vitamin with Minerals chewable

tablet ................................................. 91

CHILDREN DELSYM COUGH-CHEST

CONGESTION DM 5 MG-100 MG/5 ML

ORAL LIQUID .................................... 172

CHILDREN MUCINEX CONGESTION-

COUGH 2.5 MG-5 MG-100 MG/5 ML

ORAL LIQUID .................................... 169

Children Multivitamin chewable tablet .. 88

Children Mult-Sympt Cold Day-Nite 325

mg-12.5 mg-5 mg/10 mL(nt) liquid .. 160

Children Night Time Cold-Cough 6.25 mg-

2.5 mg/5 mL oral liquid.................... 136

Children's Acetaminophen 160 mg

chewable tablet ................................. 13

Children's Acetaminophen 160 mg/5 mL

(5 mL) oral suspension ....................... 13

Children's Acetaminophen 160 mg/5 mL

oral liquid .......................................... 13

Children's Acetaminophen 160 mg/5 mL

oral suspension.................................. 13

CHILDREN'S ACETAMINOPHEN 80 MG

CHEWABLE TABLET ............................ 13

CHILDREN'S ALAWAY 0.025 % (0.035 %)

EYE DROPS ....................................... 134

Children's All Day Allergy (cetirizine) 1

mg/mL oral solution ........................ 148

Children's Allergy (cetirizine) 1 mg/mL oral

solution ........................................... 148

CHILDREN'S ALLERGY

(DIPHENHYDRAMINE) 12.5 MG/5 ML

ORAL ELIXIR ..................................... 144

Children's Allergy (diphenhydramine) 12.5

mg/5 mL oral liquid ......................... 144

Children's Allergy Complete 1 mg/mL oral

solution ........................................... 148

Children's Allergy Relief (cetirizine) 1

mg/mL oral solution ........................ 148

Children's Allergy Relief (cetirizine) 10 mg

chewable tablet ............................... 148

Children's Allergy Relief (loratadine) 5 mg

chewable tablet ............................... 148

OH Buckeye MMP Opt-Out Formulary August 1, 2021 189

Children's Allergy Relief (loratadine) 5

mg/5 mL oral solution ......................148

Children's Aller-Tec 1 mg/mL oral solution

.........................................................149

Children's Aspirin 81 mg chewable tablet

.........................................................126

Children's Cetirizine 1 mg/mL oral solution

.........................................................149

Children's Cetirizine 10 mg chewable

tablet ...............................................149

Children's Cetirizine 5 mg chewable tablet

.........................................................149

Children's Chest Congestion 100 mg/5 mL

oral liquid .........................................154

Children's Chew Multivit with Iron 15 mg

iron tablet ..........................................91

Children's Chewable Complete 9 mg iron-

200 mcg tablet ...................................91

Children's Chewable Multivitamin 300

mcg tablet ..........................................88

Children's Chewable Vitamin Complete 18

mg iron tablet ....................................91

Children's Chewable Vitamin tablet ........88

Children's Chewables 300 mcg tablet .....88

Children's Chewables Extra C 300 mcg

tablet .................................................88

Children's Chewables with Iron 15 mg

tablet .................................................88

CHILDREN'S CLARITIN 5 MG/5 ML ORAL

SOLUTION ........................................149

Children's Cold and Cough (PE) 1 mg-2.5

mg-5 mg/5 mL oral solution .............164

Children's Cold and Cough DM 1 mg-2.5

mg-5 mg/5 mL oral solution .............164

Children's Cold-Allergy (phenylephrine) 1

mg-2.5 mg/5 mL oral solution ..........136

Children's Cold-Cough-Sore Throat 5 mg-

10 mg-325 mg/10 mL oral liquid ......161

Children's Cough 5 mg-100 mg/5 mL oral

liquid ................................................172

Children's Cough DM ER 30 mg/5 mL oral

suspension,extended release ..........150

Children's Cough-Chest Congestion DM 5

mg-100 mg/5 mL oral liquid .............172

CHILDREN'S DELSYM COUGH 30 MG/5 ML

ORAL SUSPENSION,EXTENDED RELEASE

.........................................................150

Children's Dibromm Cold and Allergy 1

mg-2.5 mg/5 mL oral solution ..........136

Children's Dibromm DM Cold-Cough 1 mg-

2.5 mg-5 mg/5 mL oral solution .......164

Children's Diphenhydramine 12.5 mg/5

mL oral liquid ...................................144

Children's Fever Reducer-Pain Reliever

160 mg/5 mL oral suspension ............13

Children's Fever Reducing 120 mg rectal

suppository ........................................ 13

CHILDREN'S FLONASE ALLERGY RELIEF 50

MCG/ACTUATION NASAL SPRAY,SUSP

.........................................................156

Children's Flu Relief 1 mg-2.5 mg-5 mg-

160 mg/5 mL oral suspension .......... 159

Children's Ibuprofen 100 mg/5 mL oral

suspension ......................................... 17

CHILDREN'S IRON 15 MG IRON (75

MG)/ML ORAL DROPS ........................ 62

Children's Loratadine 5 mg chewable

tablet ............................................... 149

Children's Mapap 160 mg chewable tablet

...........................................................13

Children's Mapap 80 mg chewable tablet

...........................................................13

Children's Mapap 80 mg disintegrating

tablet ................................................. 13

CHILDREN'S MUCINEX CHEST

CONGESTION 100 MG/5 ML ORAL

LIQUID ............................................. 154

CHILDREN'S MUCINEX COLD-FEVER 5 MG-

10 MG-325 MG/10 ML ORAL LIQUID

.........................................................161

CHILDREN'S MUCINEX COUGH 5 MG-100

MG/5 ML ORAL LIQUID .................... 172

CHILDREN'S MUCINEX MULTI-SYMPTOM

2.5 MG-5 MG-100 MG/5 ML ORAL

LIQUID ............................................. 169

CHILDREN'S MUCINEX NIGHT TIME 12.5

MG-5 MG-325 MG/10 ML ORAL LIQUID

.........................................................139

CHILDREN'S MUCINEX STUFFY NOSE AND

COLD 2.5 MG-100 MG/5 ML ORAL

LIQUID ............................................. 153

CHILDREN'S MUCINEX STUFFY NOSE-

CHEST 2.5 MG-100 MG/5 ML ORAL

LIQUID ............................................. 153

Children's Multivitamin chewable tablet88

Children's Multi-Vitamin Gummies 200

mcg chewable tablet ......................... 88

CHILDREN'S NON-ASPIRIN 160 MG/5 ML

ORAL SUSPENSION ............................ 13

CHILDREN'S NON-ASPIRIN 80 MG

CHEWABLE TABLET ............................ 13

Children's Pain and Fever Relief 160 mg

chewable tablet ................................. 13

Children's Pain and Fever Relief 160 mg

disintegrating tablet .......................... 13

Children's Pain and Fever Relief 160 mg/5

mL oral liquid ..................................... 13

Children's Pain and Fever Relief 160 mg/5

mL oral suspension ............................ 13

CHILDREN'S PAIN AND FEVER RELIEF 80

MG CHEWABLE TABLET ..................... 14

Children's Pain Relief 160 mg chewable

tablet ................................................. 14

Children's Pain Relief 160 mg/5 mL oral

suspension ......................................... 14

Children's Pain Reliever 160 mg/5 mL oral

suspension ......................................... 14

Children's Pain Reliever 80 mg

disintegrating tablet .......................... 14

Children's Pain Reliever and Fever

Reducer 120 mg rectal suppository ... 14

Children's Plus Flu 1 mg-2.5 mg-5 mg-160

mg/5 mL oral suspension ................ 159

Children's Plus Multi-Symp Cold 1 mg-2.5

mg-5 mg-160 mg/5 mL oral susp ..... 159

Children's Profen IB 100 mg/5 mL oral

suspension ......................................... 17

Children's Q-PAP 160 mg/5 mL oral

suspension ......................................... 14

Children's Robitussin ER 30 mg/5 mL oral

suspension,extended release .......... 150

Children's Saline Nasal Spray 0.65 %

aerosol ............................................. 157

CHILDREN'S SILAPAP 160 MG/5 ML ORAL

LIQUID ............................................... 14

Children's Silfedrine 15 mg/5 mL oral

liquid................................................ 177

Children's Stuffy Nose-Cold 2.5 mg-100

mg/5 mL oral liquid ......................... 153

CHILDREN'S SUDAFED 15 MG/5 ML ORAL

LIQUID ............................................. 177

Children's Tactinal 80 mg chewable tablet

...........................................................14

CHILDREN'S TRIAMINIC MS FEVCOLD 1

MG-2.5 MG-5 MG-160 MG/5 ML ORAL

SUSP ................................................ 159

CHILDREN'S TYLENOL 160 MG/5 ML ORAL

SUSPENSION ...................................... 14

Children's Wal-Dryl Allergy 12.5 mg/5 mL

oral liquid ........................................ 144

Children's Wal-Dryl Allergy 12.5 mg/5 mL

prefilled spoon ................................ 144

Children's Wal-Tap Cold-Allergy 1 mg-2.5

mg/5 mL oral solution ..................... 136

Children's Wal-Zyr 1 mg/mL oral solution

.........................................................149

Children's Wal-Zyr 10 mg chewable tablet

.........................................................149

CHILDS CHEW VITE TABLET .................... 88

Child's Mucus Relief M-S Cold 2.5 mg-5

mg-100 mg/5 mL oral liquid ............ 169

Child's Omega-3 DHA Multivitamin 250

unit-3 mg-50 unit chewable tablet .... 88

CHILDS TRIACTING COLD AND COUGH

6.25 MG-2.5 MG/5 ML ORAL LIQUID

.........................................................136

OH Buckeye MMP Opt-Out Formulary August 1, 2021 190

CHILD'S VITAMIN WITH IRON CHEWABLE

TABLET ...............................................91

Childs/Iron chewable tablet ....................91

Chlo Hist 1 mg-12.5 mg/5 mL oral solution

.........................................................166

Chlo Tuss 1 mg-30 mg-12.5 mg/5 mL oral

liquid ................................................164

CHLORHIST 4 MG TABLET .....................144

CHLOROCAPS 10 MG-30 MCG-30 MCG

CAPSULE.............................................55

Chlorphen SR 12 mg tablet,extended

release .............................................145

chlorpheniramine 4 mg tablet ..............145

chlorpheniramine ER 12 mg

tablet,extended release ...................145

ChlorTabs 4 mg tablet ...........................145

CHLOR-TRIMETON 4 MG TABLET ..........145

Chocolate Laxative 15 mg chewable tablet

.........................................................120

cholecalciferol (vitamin D3) 1,250 mcg

(50,000 unit) capsule .........................97

cholecalciferol (vitamin D3) 10 mcg (400

unit) capsule ......................................97

cholecalciferol (vitamin D3) 10 mcg (400

unit) chewable tablet .........................97

cholecalciferol (vitamin D3) 10 mcg (400

unit) tablet .........................................97

cholecalciferol (vitamin D3) 10 mcg/5 mL

(400 unit/5 mL) oral liquid .................97

cholecalciferol (vitamin D3) 10 mcg/drop

(400 unit/drop) oral drops .................97

cholecalciferol (vitamin D3) 10 mcg/mL

(400 unit/mL) oral drops ....................97

cholecalciferol (vitamin D3) 12.5 mcg/5

mL (500 unit/5 mL) oral liquid ............98

cholecalciferol (vitamin D3) 125 mcg

(5,000 unit) capsule ...........................98

cholecalciferol (vitamin D3) 125 mcg

(5,000 unit) tablet ..............................98

cholecalciferol (vitamin D3) 125 mcg/mL

(5,000 unit/mL) oral drops .................98

cholecalciferol (vitamin D3) 25 mcg (1,000

unit) capsule ......................................98

cholecalciferol (vitamin D3) 25 mcg (1,000

unit) chewable tablet .........................98

cholecalciferol (vitamin D3) 25 mcg (1,000

unit) tablet .........................................98

cholecalciferol (vitamin D3) 250 mcg

(10,000 unit) capsule .........................98

cholecalciferol (vitamin D3) 250 mcg

(10,000 unit) tablet ............................98

cholecalciferol (vitamin D3) 50 mcg (2,000

unit) capsule ......................................98

cholecalciferol (vitamin D3) 50 mcg (2,000

unit) chewable tablet .........................98

cholecalciferol (vitamin D3) 50 mcg (2,000

unit) tablet ......................................... 98

cholecalciferol (vitamin D3) 75 mcg (3,000

unit) tablet ......................................... 98

cholecalciferol(D3) 25 mcg/spray(1,000

unit/spray) subling spray, susp .......... 98

cholecalciferol(vitamin D3) 125 mcg

(5,000 unit) disintegrating tablet ....... 98

cholesterol (bulk) 100 % powder ............ 26

cholesterol (bulk) powder ...................... 26

chromium chloride 4 mcg/mL intravenous

solution .............................................. 69

Chrysaderm Day Cream topical .............. 26

Chrysaderm Night Cream topical ............ 26

cimetidine 200 mg tablet...................... 111

CITRACAL PLUS BONE DENSITY BUILDER

300 MG-200 UNIT-13.5 MG TABLET .. 58

CITRACAL-D3 GUMMIES 250 MG-12.5

MCG (500 UNIT) CHEWABLE TABLET .61

CITRACAL-D3 MAXIMUM PLUS 325 MG-

12.5 MCG-2.75 MG TABLET ............... 58

CITRACAL-D3 PETITES 200 MG CALCIUM-

6.25 MCG (250 UNIT) TABLET ............ 61

CITRACAL-D3 PLUS MAGNESIUM 250 MG-

40 MG-125 UNIT TABLET ................... 58

Citrate of Magnesia oral ....................... 118

Citroma oral solution ............................ 118

CITRUCEL (SUCROSE) ORAL POWDER ... 114

CITRUCEL 500 MG TABLET .................... 115

CITRUCEL SUGAR FREE ORAL POWDER 115

citrulline (bulk) powder .......................... 26

Citrus Calcium-Vitamin D3 200 mg

calcium-6.25 mcg (250 unit) tablet .... 61

Citrus Calcium-Vitamin D3 315 mg

calcium-6.25 mcg (250 unit) tablet .... 61

ClariSpray 50 mcg/actuation nasal

spray,suspension ............................. 156

CLARITIN 10 MG TABLET ....................... 149

CLARITIN REDITABS 10 MG

DISINTEGRATING TABLET................. 149

CLARITIN-D 12 HOUR 5 MG-120 MG

TABLET,EXTENDED RELEASE ............ 142

CLARITIN-D 24 HOUR 10 MG-240 MG

TABLET,EXTENDED RELEASE ............ 142

Clear Eyes Natural Tears 0.5 %-0.6 % drops

.........................................................130

ClearLax 17 gram oral powder packet .. 118

ClearLax 17 gram/dose oral powder..... 118

Clever Choice Holding Chamber-Large

Mask ................................................ 128

Clever Choice Holding Chamber-Medium

Mask ................................................ 128

Clever Choice Holding Chamber-Small

Mask ................................................ 128

Clever Choice Peak Flow Meter ............ 127

clotrimazole 1 % topical cream .............. 37

clotrimazole 1 % topical solution ........... 37

clotrimazole 1 % vaginal cream ............ 179

clotrimazole 2 % vaginal cream ............ 179

Clotrimazole 3 Day 2 % vaginal cream .. 179

Clotrimazole AF 1 % topical cream ......... 37

Clotrimazole-3 2 % vaginal cream ........ 179

Clotrimazole-7 1 % vaginal cream ........ 179

Co Q-10 400 mg capsule ........................ 10

Co Q-10 50 mg capsule .......................... 10

Co Q-10 75 mg capsule .......................... 10

Co Q-10 (with Vit E) 100 mg-5 unit capsule

...........................................................10

Co Q-10 (with Vit E) 50 mg-5 unit capsule

...........................................................10

Co Q-10 10 mg capsule ........................... 10

Co Q-10 100 mg capsule ......................... 10

Co Q-10 150 mg capsule ......................... 10

Co Q-10 200 mg capsule ......................... 10

Co Q-10 30 mg capsule ........................... 10

Co Q-10 300 mg capsule ......................... 10

Coconut Oil Cream topical ...................... 41

codeine 10 mg-guaifenesin 100 mg/5 mL

oral liquid ........................................ 176

coenzyme Q10 400 mg capsule ............. 10

coenzyme Q10 50 mg capsule ............... 10

coenzyme Q10 60 mg capsule ............... 10

coenzyme Q10 75 mg capsule ............... 10

coenzyme Q10 (bulk) 100 % powder ...... 26

coenzyme Q10 (bulk) powder ................ 26

coenzyme Q10 10 mg capsule ................ 10

coenzyme Q10 100 mg capsule .............. 10

coenzyme Q10 100 mg-vitamin E 20 mg-

vitamin E mixed 15 mg capsule ......... 10

coenzyme Q10 150 mg capsule .............. 10

coenzyme Q10 200 mg capsule .............. 10

coenzyme Q10 30 mg capsule ................ 10

coenzyme Q10-vitamin E 100 mg-5 unit

capsule .............................................. 10

COLACE 100 MG CAPSULE .................... 123

COLACE 2-IN-1 8.6 MG-50 MG TABLET.122

COLACE CLEAR 50 MG CAPSULE ........... 123

COLD AND ALLERGY (BROMPHEN-PE) 1

MG-2.5 MG/5 ML ORAL SOLUTION .136

COLD AND ALLERGY 4 MG-10 MG TABLET

.........................................................136

Cold and Cough (diphenhydr-pe) 6.25 mg-

2.5 mg/5 mL oral liquid ................... 137

Cold and Cough DM 1 mg-2.5 mg-5 mg/5

mL oral solution ............................... 164

Cold and Cough Elixir 1 mg-2.5 mg-5 mg/5

mL oral solution ............................... 164

Cold and Flu Relief (diphen-pe) 12.5 mg-5

mg-325 mg/10 mL oral liquid .......... 139

COLD AND FLU SEVERE 5 MG-10 MG-325

MG-200 MG TABLET ........................ 161

OH Buckeye MMP Opt-Out Formulary August 1, 2021 191

Cold and Sinus Pain Relief 30 mg-200 mg

tablet ...............................................152

Cold Head Congestion Day/Nite 2 mg-5

mg-10 mg-325 mg tablets ................159

Cold Head Congestion Daytime 5 mg-10

mg-325 mg tablet ............................167

Cold Head Congestion Severe Daytime 5

mg-10 mg-325 mg-200 mg tablet ....161

COLD MULTI-SYMPTOM 5 MG-10 MG-325

MG TABLET ......................................167

Cold Multi-Symptom Day/Night 2 mg-5

mg-10 mg-325 mg tablets ................159

Cold MultiSymptom NighTime 6.25 mg-5

mg-10 mg-325 mg/15 mL oral liquid159

Cold Relief 2 mg-7.8 mg-325 mg

effervescent tablet ...........................141

COLD RELIEF MULTI-SYMPTOM

DAY/NIGHT 2 MG-5 MG-10 MG-325

MG TABLETS.....................................160

Cold Relief Plus 2 mg-7.8 mg-325 mg

effervescent tablet ...........................141

Cold Severe Congestion 5 mg-10 mg-325

mg-200 mg tablet ............................161

COLD-FLU RELIEF 12.5 MG-30 MG-1,000

MG/30 ML ORAL LIQUID ..................163

COLD-FLU RELIEF 5 MG-10 MG-325

MG/15 ML ORAL LIQUID ..................167

Cold-Flu-Sore Throat 10 mg-20 mg-650

mg/20 mL oral liquid ........................161

Cold-Sinus Relief 30 mg-200 mg tablet.152

Coleman 100 Max Insect Repellent 98.11

% topical pump spray .........................45

Coleman 100 Max Insect Repellent 98.11

% topical spray ...................................45

Coleman Botanicals Insect Repellent 30 %

topical spray.......................................45

Coleman High and Dry Insect Repellent 25

% topical spray powder ......................45

Coleman SkinSmart Insect Repellent 20 %

topical pump spray ............................45

Coleman SkinSmart Insect Repellent 20 %

topical spray.......................................45

Coleman Sportsmen Insect Repellent 40 %

topical spray.......................................45

COL-RITE 100 MG CAPSULE ..................123

Col-Rite 250 mg capsule .......................123

Combistix Reagent strips ........................51

Comfort Gel 200 mg-200 mg-20 mg/5 mL

oral suspension ................................106

Comfort Gel Extra Strength 400 mg-400

mg-40 mg/5 mL oral suspension ......106

Compact Space Chamber ......................128

Compact Space Chamber-Lrg Mask ......128

Compact Space Chamber-Med Mask ....128

Compact Space Chamber-Sm Mask ......128

COMPETE TABLET ...................................73

COMPLETE 18 MG-500 MCG-300 MCG-

250 MCG TABLET ............................... 73

Complete 50 Plus 0.4 mg-300 mcg-250

mcg tablet .......................................... 73

COMPLETE ALLERGY 12.5 MG/5 ML ORAL

LIQUID ............................................. 145

COMPLETE ALLERGY 25 MG CAPSULE .. 145

COMPLETE ALLERGY 25 MG TABLET ..... 145

COMPLETE ALLERGY MEDICINE 25 MG

CAPSULE .......................................... 145

COMPLETE ALLERGY MEDICINE 25 MG

TABLET ............................................. 145

Complete Lice Treatment 4 %-0.33 %-0.5

% topical kit ....................................... 51

Complete Men 50 Plus 300 mcg-600 mcg-

300 mcg tablet ................................... 73

Complete Men 8 mg iron-200 mcg-600

mcg tablet .......................................... 73

Complete Multivitamin Adult 50 Plus 0.4

mg-300 mcg-250 mcg tablet .............. 73

Complete Multivitamin tablet ................ 73

Complete Multivitamin-Multimineral 18

mg-400 mcg tablet ............................. 85

Complete Multivitamin-Multimineral 9 mg

iron/15 mL oral liquid ........................ 73

COMPLETE PREMIUM VITAMIN TABLET.73

COMPLETE SENIOR 0.4 MG-300 MCG-250

MCG TABLET ...................................... 73

Complete Senior tablet ........................... 56

Complete Women 18 mg-400 mcg tablet

...........................................................85

Compound W 17 % topical gel ................ 46

Compound W 17 % topical liquid ........... 46

Compound W 40 % topical patch ........... 47

compounding vehicle suspension sugar-

free no.12 oral ................................... 31

CONCEPTIONXR MOTILITY 250 MG-500

UNIT-200 UNIT ORAL PACK ................ 11

Condoms-Prem Lubricated ................... 126

CONEX 1 MG-30 MG/5 ML ORAL

SOLUTION ........................................ 137

CONEX 2 MG-60 MG TABLET ................ 137

CONGESTAC 60 MG-400 MG TABLET.... 153

CONTAC COLD-FLU NIGHT 12.5 MG-30

MG-1,000 MG/30 ML ORAL LIQUID .163

COOL BOTTOMS 1 % TOPICAL CREAM .... 49

Copper Chloride 0.4 mg/mL intravenous

solution .............................................. 69

CoQ-10 100 mg capsule .......................... 11

CoQ-10 30 mg capsule ............................ 11

CORICIDIN HBP COLD-MULTI SYMPTOM

6.25 MG-15 MG-325 MG/15 ML ORAL

LIQD ................................................. 163

CORICIDIN HBP COUGH AND COLD 4 MG-

30 MG TABLET ................................. 166

CORICIDIN HBP FLU 2 MG-15 MG-500 MG

TABLET ............................................. 163

Corn Remover 40 % topical patch .......... 47

Corn-Callus Remover 17 % topical liquid 47

COROMEGA 2,000 MG-650 MG-12

MG/2.5 GRAM ORAL PACKET ............ 20

COROMEGA 284 MG-850 MG/2.5 GRAM

ORAL PACKET ..................................... 20

CORRECTOL 5 MG TABLET .................... 120

Cortisone (hydrocortisone) 1 % topical

cream ................................................ 43

Cortisone (hydrocortisone) 1 % topical

ointment ............................................ 43

Cortisone with Aloe 1 % topical cream ... 44

CORTIZONE-10 1 % TOPICAL CREAM ...... 43

CORTIZONE-10 1 % TOPICAL OINTMENT 43

CORTIZONE-10 PLUS 1 % TOPICAL CREAM

...........................................................43

CORTIZONE-10 WITH ALOE 1 % TOPICAL

CREAM ............................................... 44

CORVITA 1.25 MG-2.5 MG-7 MG TABLET

...........................................................73

CORVITE 1.25 MG-2.5 MG-7 MG TABLET73

CORVITE 150 150 MG IRON-1 MG TABLET

...........................................................65

CORVITE FE 150 MG IRON-1 MG TABLET65

CORVITE FREE 1.25 MG-400 MCG-125

MCG-35 MG TABLET .......................... 73

COUGH AND COLD (CHLORPHENIRAMINE-

DM) 4 MG-30 MG TABLET ............... 166

COUGH AND COLD 5 MG-10 MG-100

MG/5 ML ORAL LIQUID.................... 169

Cough and Cold BP 4 mg-30 mg tablet .166

Cough and Cold Mucus Relief CF 5 mg-10

mg-200 mg/5 mL oral liquid ............ 169

Cough and Severe Cold 25 mg-10 mg-650

mg oral powder packet .................... 139

Cough Control (dextromethorphan) 15 mg

capsule ............................................ 150

COUGH CONTROL (GUAIFENESIN) 100

MG/5 ML ORAL LIQUID.................... 154

COUGH CONTROL CF (PHENYLEPHRINE) 5

MG-10 MG-100 MG/5 ML ORAL LIQUID

.........................................................169

COUGH CONTROL DM 10 MG-100 MG/5

ML ORAL LIQUID .............................. 172

Cough DM ER 30 mg/5 mL oral

suspension,extended release .......... 150

COUGH SUPPRESSANT-EXPECTORANT 10

MG-100 MG/5 ML ORAL SYRUP ...... 172

Cough Syrup 100 mg/5 mL oral liquid .. 154

COUGH SYRUP DM 10 MG-100 MG/5 ML

.........................................................172

Cough-Chest Congestion DM 5 mg-100

mg/5 mL oral liquid ......................... 172

OH Buckeye MMP Opt-Out Formulary August 1, 2021 192

Cough-Cold Relief HBP 4 mg-30 mg tablet

.........................................................166

Cough-Sore Throat Night 12.5 mg-30 mg-

1,000 mg/30 mL oral liquid ..............163

Coughtab 200 mg tablet .......................154

cream base no.64 (bulk) topical ..............26

Creamy Acne Face 4 % topical cleanser 34

Critic-Aid Clear 71.5 % topical ointment.49

Critic-Aid Clear AF (miconazole) 2 %

topical ointment ................................37

cromolyn 5.2 mg/spray (4 %) nasal spray

.........................................................156

Custom Base Pcca Lipoderm topical cream

...........................................................26

Cutis Plus cream .....................................26

Cutter Backwoods 25 % topical pump

spray ..................................................45

Cutter Backwoods 25 % topical spray .....45

Cutter Backwoods Dry 25 % topical spray

...........................................................45

Cutter Lemon Eucalyptus 30 % topical

spray ..................................................45

Cutter Natural Insect Repellent 5 %-2 %-

0.4 %-0.1 % topical spray ...................45

Cutter Natural Insect Repellent2 5 %-2 %

topical spray.......................................45

Cutter Skinsations 7 % topical spray .......45

cyanocobalamin (vit B-12) 1,000 mcg

tablet .................................................94

cyanocobalamin (vit B-12) 1,000 mcg/mL

injection solution ...............................94

cyanocobalamin (vit B-12) ER 1,000 mcg

tablet,extended release .....................95

cyanocobalamin (vit B-12) ER 2,000 mcg

tablet,extended release .....................95

cyanocobalamin (vitamin B-12) (bulk)

powder...............................................26

CYTO ARG 70 GRAM/100 GRAM ORAL

POWDER ............................................52

CYTO-Q 80 MG/10 ML ORAL LIQUID .......11

CYTO-Q MAX 100 MG/ML ORAL LIQUID.11

CYTO-Q T-F 8 MG/ML ORAL LIQUID ........11

Cytra-2 500 mg-334 mg/5 mL oral solution

.........................................................125

D

D3-2000 50 mcg (2,000 unit) capsule .....98

D3-50 Cholecalciferol 1,250 mcg (50,000

unit) capsule ......................................98

Daily Fiber (psyllium-sucrose) 3.4 gram/12

gram oral powder ............................115

Daily Fiber (psyllium-sucrose) 3.4 gram/7

gram oral powder ............................115

Daily Gummies 200 mcg chewable tablet

...........................................................73

Daily Multiple 400 mcg-120 mg tablet ...74

Daily Multiple For Men 0.4 mg tablet ..... 74

DAILY MULTIPLE FOR MEN 50+ 400 MCG-

600 MCG-120 MG TABLET ................. 85

Daily Multiple For Women 18 mg iron-400

mcg-500 mg Ca tablet ........................ 74

Daily Multiple For Women 50+ 0.4 mg

tablet ................................................. 74

DAILY MULTIPLE TABLET ......................... 74

Daily Multivitamin 200 mcg-100 mcg-500

mcg capsule ....................................... 74

DAILY MULTI-VITAMIN TABLET ............... 85

Daily Multivitamin with Iron 18 mg-400

mcg tablet .......................................... 85

Daily Value tablet ................................... 85

Daily Vitamin Formula tablet .................. 85

Daily Vitamin Formula-Iron 18 mg-400

mcg tablet .......................................... 85

DAILY VITAMIN FORMULA-MINERALS

tablet ................................................. 74

Daily Vitamin with Iron and CA tablet .... 74

DAILY VITAMIN WITH IRON TABLET ....... 74

Daily Vites/Iron tablet ............................ 74

Daily-Vite tablet ...................................... 74

Dallergy (chlorpheniramine-

phenylephrine) 1 mg-2.5 mg/mL oral

drops................................................ 137

Dallergy (dexbrompheniramine-PE) 1 mg-

5 mg tablet ...................................... 137

Dallergy (dexbrompheniramine-PE) 1 mg-

5 mg/5 mL oral liquid ....................... 137

Dandruff Shampoo (selenium sulfide-aloe)

1 % ..................................................... 40

Dandruff Shampoo-Menthol 1 % ............ 40

Day Multi-Symptom Flu-Severe Cold 10

mg-20 mg-500 mg oral powder packt

.........................................................167

DAY TIME PE 5 MG-10 MG-325 MG

CAPSULE .......................................... 167

DAYCLEAR ALLERGY RELIEF 50 MG-25 MG

TABLET ............................................. 166

Day-Cold Night-Cold-Flu(doxylamine) 6.25

mg-5 mg-10 mg-325 mg(nt) caps ..... 160

Dayhist Allergy 1.34 mg tablet .............. 145

Daylogic Advanced Healing 41 % topical

ointment ............................................ 49

DAYTIME 5 MG-10 MG-325 MG CAPSULE

.........................................................167

Daytime and Nighttime Cold 2 mg-5 mg-

10 mg-325 mg tablets ...................... 160

Daytime Cold 5 mg-10 mg-325 mg tablet

.........................................................167

Daytime Cold and Flu Relief (PE) 5 mg-10

mg-325 mg/15 mL oral liquid .......... 167

Daytime Cold and Flu Relief

(phenylephrine) 5 mg-10 mg-325 mg

capsule ............................................ 168

Daytime Cold-Flu 5 mg-10 mg-325 mg/15

mL oral liquid ................................... 168

Daytime-Cold Nighttime-Cold-Flu 10 mg-

650 mg/20 mL(dy-nt) oral liquids .... 160

Daytime-Nighttime 10 5-325mg(d)/15-

325-6.25mg capsules ....................... 160

Ddrops 25 mcg/drop (1,000 unit/drop)

oral .................................................... 98

Ddrops 50 mcg/drop (2,000 unit/drop)

oral .................................................... 98

Debrox 6.5 % ear drops ........................ 135

DECARA 1,250 MCG (50,000 UNIT)

CAPSULE ............................................ 98

DECARA 625 MCG (25,000 UNIT) CAPSULE

...........................................................98

DECONEX DMX 10 MG-15 MG-380 MG

TABLET ............................................. 169

DECONEX DMX 10 MG-17.5 MG-385 MG

TABLET ............................................. 169

DECONEX DMX 10 MG-17.5 MG-400 MG

TABLET ............................................. 169

DECONEX IR 10 MG-380 MG TABLET ... 153

DECONEX IR 10 MG-385 MG TABLET ... 153

DECUBI VITE 400 MCG-50 MG-500 MG

CAPSULE ............................................ 85

Deep Sea Nasal 0.65 % spray aerosol ... 157

DEKAs Bariatric 22.5 mg-400 mcg-500

mcg-10 mg chewable tablet .............. 74

DEKAs Essential 2,000 unit-2,000 mcg/mL

oral liquid .......................................... 85

DEKAs Plus (folic acid) 200 mcg-1,000

mcg-10 mg capsule ............................ 74

DEKAs Plus (folic acid) 200 mcg-1,000

mcg-10 mg chewable tablet .............. 74

DEKAs Plus Liquid 500 mcg/mL oral ....... 88

Delsym 12 hour 30 mg/5 mL oral

suspension,extended release .......... 150

DELSYM COUGH-CHEST CONGESTION DM

5 MG-100 MG/5 ML ORAL LIQUID ... 172

DELSYM COUGH-COLD DAYTIME 10 MG-

20 MG-650 MG/20 ML ORAL LIQUID

.........................................................161

DELSYM COUGH-COLD NIGHTTIME 12.5

MG-5 MG-325 MG/10 ML ORAL LIQUID

.........................................................139

Delta D3 10 mcg (400 unit) tablet .......... 99

Dermabase topical cream ...................... 42

Dermacerin topical cream ...................... 41

DermacinRx Folitin-Z 9 mg iron-500 mcg

tablet ................................................. 74

DermacinRx Folixapure 125 mcg (5,000

unit)-1 mg tablet................................ 93

OH Buckeye MMP Opt-Out Formulary August 1, 2021 193

DermacinRx Foltrexyl 125 mcg (5,000

unit)-1 mg tablet ................................93

DermacinRx PureFolix 125 mcg (5,000

unit)-1 mg tablet ................................93

DermacinRx Skin Repair Complex 5 %

cream .................................................49

DermacinRx Venexa 1,000 mcg tablet ....74

DermacinRx Venexa FE 27 mg iron-1 mg

tablet .................................................74

DermacinRx Vitranol FE 27 mg iron-1 mg

tablet .................................................74

Dermadrox 1.2 % topical ointment .........49

DermaFix topical ointment .....................31

DERMAGRAN (ALUMINUM HYDROXIDE)

0.275 % TOPICAL OINTMENT .............49

DERMAMED TOPICAL OINTMENT ...........49

DermaPhor 44 % topical ointment .........49

DERMAPHOR TOPICAL OINTMENT .........41

Dermarest Psoriasis Medicated 3 %

shampoo ............................................47

DermaZinc Shampoo 2 % ........................40

DESENEX 2 % TOPICAL POWDER .............37

Desgen DM 5 mg-10 mg-100 mg/5 mL oral

liquid ................................................169

Despec DM-G 5 mg-10 mg-100 mg/5 mL

oral liquid .........................................169

Despec-DM (phenylephrine-DM-guaif) 5

mg-10 mg-100 mg/5 mL oral liquid .169

Dex4 Glucose 15 gram/33 gram oral gel

packet ..............................................102

Dex4 Glucose 4 gram chewable tablet .102

Dex4 Glucose Pouch Pack 4 gram

chewable tablet ...............................102

Dex4 Glucose Quick Dissolve 4 gram

chewable tablet ...............................102

dexbrompheniramine-phenylephrine 2

mg-10 mg tablet ..............................137

dexchlorphen-p-phed-chlophedianol 1

mg-30 mg-12.5 mg/5 mL oral liquid 164

dextromethorphan HBr (bulk) powder ...26

dextromethorphan HBr 15 mg capsule 150

dextromethorphan polistirex ER 30 mg/5

mL oral susp ext.release 12hr ..........150

dextromethorphan-guaifenesin 10 mg-100

mg/5 mL oral liquid ..........................172

dextromethorphan-guaifenesin 10 mg-100

mg/5 mL oral syrup ..........................172

dextromethorphan-guaifenesin 20 mg-400

mg tablet ..........................................172

dextromethorphan-guaifenesin ER 60 mg-

1,200 mg tab,extend release,12hr ...172

dextrose 15 gram/59 mL oral liquid ......102

dextrose 40 % oral gel ..........................102

DHS SAL 3 % SHAMPOO ..........................47

DHS TAR 0.5 % SHAMPOO ......................48

DHS TAR GEL 0.5 % SHAMPOO ...............48

DHS Zinc 2 % shampoo ........................... 40

Diabetes Health 0.8 mg-250 mg-50 mg

oral pack ............................................ 74

Diabetes Health Formula 500 mcg-250

mcg tablet .......................................... 74

Diabetes Health Support 800 mcg oral

pack ................................................... 85

Diabetic Siltussin DAS-Na 100 mg/5 mL

oral liquid ......................................... 155

Diabetic Siltussin-DM 10 mg-100 mg/5 mL

oral liquid ......................................... 172

Diabetic Siltussin-DM Max Str 10 mg-200

mg/5 mL oral liquid .......................... 173

Diabetic Support Formula 167 mcg-100

mcg-83 mcg tablet ............................. 55

Diabetic Tussin DM 10 mg-100 mg/5 mL

oral liquid ......................................... 173

DIALYVITE 1 MG-100 MG-300 MCG-50 MG

TABLET ............................................... 54

DIALYVITE 100 MG-1 MG TABLET ........... 53

DIALYVITE 3000 3 MG-70 MCG-15 MG

TABLET ............................................... 53

DIALYVITE 5000 5 MG TABLET ............... 74

Dialyvite 800 800 mcg chewable tablet.53

Dialyvite 800 0.8 mg tablet ..................... 53

Dialyvite 800-Ultra D 0.8 mg-2,000 unit

tablet ................................................. 53

DIALYVITE SUPREME D 3 MG-2,000 UNIT

TABLET ............................................... 53

Dialyvite Vitamin D 125 mcg (5,000 unit)

capsule ............................................... 99

Dialyvite Vitamin D3 Max 1,250 mcg

(50,000 unit) tablet ............................ 99

DIAMODE 2 MG TABLET ....................... 107

Diarrhea Relief (bismuth subsalicylate)

262 mg/15 mL oral suspension ........ 108

DIFFERIN 0.1 % TOPICAL GEL .................. 34

Digestive Health Probiotic 10 billion cell

capsule ............................................. 113

Digestive Probiotic 10 billion cell capsule

.........................................................113

Digestive Relief 262 mg tablet .............. 108

Dimaphen (PE) 1 mg-2.5 mg/5 mL oral

solution ............................................ 137

Dimaphen DM 1 mg-2.5 mg-5 mg/5 mL

oral solution ..................................... 164

dimenhydrinate 50 mg tablet ............... 110

Dimetapp Cold-Allergy (PE) 1 mg-2.5 mg/5

mL oral solution ............................... 137

Dimetapp Cold-Congestion 6.25 mg-2.5

mg/5 mL oral liquid .......................... 137

Dimetapp DM Cold-Cough (PE) 1 mg-2.5

mg-5 mg/5 mL oral solution ............ 164

DIMETAPP LONG-

ACTING(CHLORPHENIRAMINE-DM) 1

MG-7.5 MG/5 ML ORAL LIQUID ....... 166

Dino-Life with Iron-Zinc 4.5 mg chewable

tablet ................................................. 88

Diocto 50 mg/5 mL oral liquid .............. 123

Diocto 60 mg/15 mL oral syrup ............ 123

Diotame 262 mg chewable tablet ........ 108

DIPHEDRYL 12.5 MG/5 ML ORAL LIQUID

.........................................................145

DIPHEDRYL 25 MG CAPSULE ................. 145

DIPHEDRYL 25 MG TABLET ................... 145

Diphedryl Allergy 12.5 mg/5 mL oral liquid

.........................................................145

Diphen 25 mg tablet ............................. 145

DIPHENHIST 12.5 MG/5 ML ORAL LIQUID

.........................................................145

DIPHENHIST 25 MG CAPSULE ............... 145

DIPHENHIST 25 MG TABLET ................. 145

diphenhydramine 12.5 mg/5 mL oral

liquid................................................ 145

diphenhydramine 2 % topical cream ...... 50

diphenhydramine 25 mg capsule ......... 145

diphenhydramine 25 mg tablet ............ 145

diphenhydramine 25 mg-acetaminophen

500 mg tablet .................................... 17

diphenhydramine 50 mg capsule ......... 145

diphenhydramine 6.25 mg/mL oral drops

.........................................................145

DM MAX 5 MG-100 MG/5 ML ORAL

LIQUID ............................................. 173

DML FORTE TOPICAL CREAM ................. 40

Doc-Q-Lace 100 mg capsule ................. 123

DOC-Q-LAX 8.6 MG-50 MG TABLET ...... 122

Docu 50 mg/5 mL oral liquid ................ 123

DOCUPRENE 100 MG TABLET ............... 123

docusate calcium 240 mg capsule ........ 123

docusate sodium 100 mg capsule ........ 123

docusate sodium 100 mg tablet ........... 123

docusate sodium 250 mg capsule ........ 123

docusate sodium 283 mg/5 mL enema 123

docusate sodium 50 mg/5 mL oral liquid

.........................................................123

Docusil 100 mg capsule ........................ 123

DOCUSOL 283 MG ENEMA ................... 123

DOCUSOL KIDS 100 MG/5 ML ENEMA 124

DOCUSOL PLUS 283 MG-20 MG/5 ML

ENEMA ............................................ 124

Docuzen 8.6 mg-50 mg tablet .............. 122

DOK 100 mg capsule............................. 124

DOK 100 mg tablet ............................... 124

DOK 250 MG CAPSULE ......................... 124

DOK Plus 8.6 mg-50 mg tablet .............. 122

Donatussin 4 mg-10 mg-20 mg/5 mL oral

liquid................................................ 165

Double Antibiotic (bacitrcn zn) 500 unit-

10,000 unit/gram top ointment ........ 34

doxylamine 7.5 mg-phenylephrine 10 mg

tablet ............................................... 137

OH Buckeye MMP Opt-Out Formulary August 1, 2021 194

Dr Manzanilla DM 2.5 mg-10 mg-20 mg/5

mL oral liquid ...................................165

Dr Manzanilla Infant 0.938 mg/mL oral

drops ................................................146

Dr Manzanilla PE 10 mg-2.5 mg/5 mL oral

liquid ................................................137

Dr Manzanilla Pediatric (triprolidine) 2.5

mg/5 mL oral liquid ..........................146

DRAMAMINE 50 MG TABLET ................110

DRAMAMINE LESS DROWSY 25 MG

TABLET .............................................110

Driminate 50 mg tablet .........................110

DRISDOL 1,250 MCG (50,000 UNIT)

CAPSULE.............................................99

DRISTAN COLD 2 MG-5 MG-325 MG

TABLET .............................................139

DRISTAN LONG LASTING 0.05 % NASAL

MIST .................................................158

DRY EYE FORMULA 133 MG-167 MG-170

MG CAPSULE ......................................55

Dry Eye Relief 1 %-0.2 %-0.2 % drops ...130

Dry Skin Therapy cream ..........................41

DSS 250 MG CAPSULE ...........................124

Ducodyl (bisacodyl) 5 mg tablet,delayed

release .............................................120

DULCOEASE 100 MG CAPSULE ..............124

DULCOLAX (BISACODYL) 10 MG RECTAL

SUPPOSITORY ..................................120

DULCOLAX (BISACODYL) 5 MG

TABLET,DELAYED RELEASE ...............120

DULCOLAX STOOL SOFTENER (DOCUSATE)

100 MG CAPSULE .............................124

Durabase Advanced topical cream .........26

Durabase topical cream ..........................26

DURAFLU 60 MG-20 MG-200 MG-325 MG

TABLET .............................................161

Durex Avanti Bare Real Feel Condom ...126

D-VI-SOL 10 MCG/ML (400 UNIT/ML)

ORAL DROPS ......................................99

D-Vita 10 mcg/mL (400 unit/mL) oral

drops ..................................................99

E

E.C. Prin 325 mg tablet,delayed release .19

E-200 90 mg (200 unit) capsule ............100

E-400 C-500 and Beta Carotene tablet ...85

EAR DROPS (CARBAMIDE PEROXIDE) 6.5 %

.........................................................135

Ear Drops Otc 6.5 % ..............................135

EAR WAX REMOVAL DROPS 6.5 % ........135

Ear Wax Removal Kit 6.5 % drops .........135

EAR WAX REMOVAL SYSTEM 6.5 % DROPS

.........................................................136

EAR WAX TREATMENT 6.5 % DROPS ....136

EasiVent Holding Chamber ...................128

EasiVent Mask Large............................. 128

EasiVent Mask Medium ........................ 128

EasiVent Mask Small ............................. 128

EContra EZ 1.5 mg tablet ........................ 32

Econtra One-Step 1.5 mg tablet ............. 32

Ecotrin 325 mg tablet,enteric coated ..... 19

ECOTRIN LOW STRENGTH 81 MG

TABLET,ENTERIC COATED ................ 126

Eczema Anti-Itch 1 % topical cream ....... 43

ED A-HIST 4 MG-10 MG TABLET ........... 137

Ed A-Hist DM 4 mg-10 mg-10 mg tablet

.........................................................165

Ed A-Hist DM 4 mg-10 mg-15 mg/5 mL

oral liquid ......................................... 165

Ed A-Hist PSE 2.5 mg-60 mg tablet ....... 137

ED Bron GP 5 mg-100 mg/5 mL oral liquid

.........................................................153

Ed Chlorped D 2 mg-5 mg/mL oral drops

.........................................................137

ED Chlorped Jr 2 mg/5 mL oral syrup ... 146

Ed-APAP 160 mg/5 mL oral liquid ........... 14

Ed-ChlorPed 2 mg/mL oral drops .......... 146

ED-CHLORTAN 4 MG TABLET ................ 146

Eldertonic 0.5 mg-0.6 mg-7 mg-0.7 mg

oral elixir ............................................ 56

electrolytes-dextrose oral solution ......... 69

ELIPHOS 667 MG TABLET ...................... 125

ELLIS TONIC ORAL ELIXIR ........................ 56

EMERGEN-C 1,000 MG ORAL

EFFERVESCENT POWDER PACKET ...... 93

EMERGEN-C IMMUNE PLUS 1,000 MG

ORAL EFFERVESCENT POWDER PACKET

...........................................................93

EMERGEN-C KIDZ ORAL EFFERVESCENT

POWDER PACKET ............................... 91

EMERGEN-C MSM LITE 1,000 MG-1,000

MG ORAL EFFERVESCENT POWDER

PACKET .............................................. 93

Emolivan topical cream .......................... 26

EMOLLIA TOPICAL CREAM ...................... 41

emollient combination no.112 (bulk)

topical cream ..................................... 26

emollient topical cream .......................... 42

EndaCof - DM 1 mg-2.5 mg-5 mg/5 mL

oral solution ..................................... 165

Endur-Acin 250 mg tablet,extended

release ............................................... 95

Endur-Acin 500 mg tablet,extended

release ............................................... 95

Endur-Acin 750 mg tablet,extended

release ............................................... 95

Endur-VM Iron-Free 400 mcg

tablet,extended release ..................... 74

Endur-VM with Iron 18 mg iron-400 mcg

tablet,extended release ..................... 74

Enema 19 gram-7 gram/118 mL ........... 119

Enema Disposable 19 gram-7 gram/118

mL .................................................... 119

ENEMEEZ 283 MG/5 ML ENEMA .......... 124

ENEMEEZ PLUS 283 MG-20 MG/5 ML

ENEMA ............................................ 124

ENFAMIL ENFALYTE ORAL SOLUTION ..... 69

Ephrine 1 % nasal drops ....................... 158

Epsom Salt (laxative) 495 mg/5 gram oral

granules ........................................... 118

Epsom Salt 100 % crystals ...................... 26

ergocalciferol (vitamin D2) 1,250 mcg

(50,000 unit) capsule ......................... 99

ergocalciferol (vitamin D2) 10 mcg (400

unit) tablet ......................................... 99

ergocalciferol (vitamin D2) 200 mcg/mL

(8,000 unit/mL) oral drops ................ 99

ergocalciferol (vitamin D2) 50 mcg (2,000

unit) capsule ...................................... 99

ergocalciferol (vitamin D2) 50 mcg (2,000

unit) tablet ......................................... 99

esomeprazole magnesium 20 mg

capsule,delayed release .................. 111

Essence C 1,000 mg oral effervescent

powder packet................................... 93

ESSENTIA 18 MG-400 MCG TABLET ........ 86

ESSENTIAL BALANCE WITH LUTEIN TABLET

...........................................................86

ESSENTIAL DAILY 18 MG-0.4 MG TABLET

...........................................................75

ESSENTIAL Man 0.4 mg-2 mg-250 mcg

tablet ................................................. 75

ESSENTIAL Man 50+ 0.4 mg-2 mg-250 mcg

tablet ................................................. 75

Essential Woman 50+ 0.4 mg-250 mcg

tablet ................................................. 75

ESTROVEN MENOPAUSE 400 MCG-40 MG-

40 MG-100 MG TABLET ..................... 75

EUCERIN INTENSIVE REPAIR CREME

TOPICAL ............................................. 41

EUCERIN SKIN CALMING CREAM ............ 41

EUCERIN TOPICAL CREAM ...................... 41

Evac 3 gram/3 gram oral powder ......... 115

Evac-U-Gen (sennosides) 8.6 mg tablet120

EX-LAX (SENNOSIDES) 15 MG CHEWABLE

TABLET ............................................. 120

EX-LAX (SENNOSIDES) 15 MG TABLET .. 120

EX-LAX MAXIMUM STRENGTH 25 MG

TABLET ............................................. 120

EXPECTA PRENATAL 28 MG IRON-800

MCG-200 MG ORAL PACK .................. 92

Expectorant 100 mg/5 mL oral liquid ... 155

Expectorant Cough Syrup 100 mg/5 mL

oral liquid ........................................ 155

EYE DROPS (TETRAHYDROZOLINE) 0.05 %

.........................................................135

OH Buckeye MMP Opt-Out Formulary August 1, 2021 195

EYE DROPS (TETRAHYDROZOLINE-ZINC

SULFATE) 0.05 %-0.25 % ..................135

EYE DROPS ALLERGY RELIEF 0.05 %-0.25 %

.........................................................135

Eye Health Plus Lutein 1,000 unit-200 mg-

60 unit-2mg tablet .............................75

EYE ITCH RELIEF 0.025 % (0.035 %) DROPS

.........................................................134

Eye Vitamin and Minerals 7,160 unit-113

mg-100 unit tablet .............................75

EyeProtect 7,160 unit-113 mg-100 unit

tablet .................................................75

EZFE 200 200 mg iron capsule ................62

F

FA-8 0.8 mg capsule .............................101

Face Mask,Earloop-Style .......................126

Fagron LS Plus topical cream ..................27

Fagron LS Ultra cream.............................27

Fagron Natural Cream transdermal cream

...........................................................27

Fagron Supreme Cream transdermal

cream .................................................27

Fallback Solo 1.5 mg tablet .....................32

famotidine 10 mg tablet .......................111

famotidine 20 mg tablet .......................111

Fantasy Condom ...................................126

Fast Acting Nasal 1 % spray ..................158

Father John's Cough Suppressant 10 mg/5

mL oral liquid ...................................150

FattiBASE wax .........................................27

FC2 Female Condom .............................126

Fem-Cal Citrate 200 mg-80 mg-80 unit-0.8

mg tablet ............................................58

Fenesin DM IR 20 mg-400 mg tablet.....173

Fenesin IR 400 mg tablet ......................155

Fenesin PE IR 10 mg-400 mg tablet ......153

FEOSOL 325 MG (65 MG IRON) TABLET 62

FEOSOL 45 MG TABLET ...........................62

FEOSOL BIFERA 28 MG TABLET ...............65

FERAHEME 510 MG/17 ML (30 MG/ML)

INTRAVENOUS SOLUTION ..................62

Ferate 240 mg (27 mg iron) tablet ..........62

Fergon 270 mg (27 mg iron) tablet .........62

FER-IN-SOL 15 MG IRON (75 MG)/ML

ORAL DROPS ......................................62

Fer-Iron 15 mg iron (75 mg)/mL oral drops

...........................................................62

FERIVA 21-7 75 MG IRON-175 MG-1 MG-

12 MCG TABLET .................................65

FERIVA FA (WITH SUMALATE) 110 MG-175

MG-1 MG-12 MCG CAPSULE ..............65

FEROCON 110 MG-0.5 MG CAPSULE ......65

FeroSul 220 mg (44 mg iron)/5 mL oral

elixir ...................................................62

FEROSUL 325 MG (65 MG IRON) TABLET62

Ferrex 150 mg iron capsule .................... 62

FERREX 150 PLUS 150 MG-50 MG-50 MG

CAPSULE ............................................ 65

Ferric x-150 150 mg iron capsule ............ 62

FERRLECIT 62.5 MG/5 ML INTRAVENOUS

SOLUTION .......................................... 62

Ferro-Time 325 mg (65 mg iron) tablet .. 62

ferrous gluconate 236 mg (27 mg iron)

tablet ................................................. 63

ferrous gluconate 240 mg (27 mg iron)

tablet ................................................. 63

ferrous gluconate 256 mg (28 mg iron)

tablet ................................................. 63

ferrous gluconate 324 mg (37.5 mg iron)

tablet ................................................. 63

ferrous gluconate 324 mg (38 mg iron)

tablet ................................................. 63

ferrous sulfate 15 mg iron (75 mg)/mL oral

drops.................................................. 63

ferrous sulfate 15 mg iron (75 mg)/mL oral

syringe (ORAL USE) ............................ 63

ferrous sulfate 220 mg (44 mg iron)/5 mL

oral elixir ............................................ 63

ferrous sulfate 220 mg (44 mg iron)/5 mL

oral solution ....................................... 63

ferrous sulfate 300 mg (60 mg iron)/5 mL

oral liquid ........................................... 63

ferrous sulfate 324 mg (65 mg iron)

tablet,delayed release ....................... 63

ferrous sulfate 325 mg (65 mg iron) tablet

...........................................................63

ferrous sulfate 325 mg (65 mg iron)

tablet,delayed release ....................... 63

ferrous sulfate, dried (bulk) 100 % powder

...........................................................27

FERROUSUL 325 MG (65 MG IRON)

TABLET ............................................... 63

Fever Reducer 120 mg rectal suppository

...........................................................14

FEVERALL 120 MG RECTAL SUPPOSITORY

...........................................................14

Feverall 325 mg rectal suppository ......... 14

Feverall 650 mg rectal suppository ......... 14

Feverall 80 mg rectal suppository ........... 14

fexofenadine 180 mg tablet ................. 149

fexofenadine 60 mg tablet ................... 149

fexofenadine 60 mg-pseudoephedrine ER

120 mg tablet,ext.release,12 hr ....... 142

Fiber (calcium polycarbophil) 625 mg

tablet ............................................... 115

FIBER (PSYLLIUM HUSK) 0.52 GRAM

CAPSULE .......................................... 115

Fiber (psyllium husk-sugar) 3.4 gram/11

gram oral powder ............................ 115

Fiber (psyllium husk-sugar) 3.4 gram/12

gram oral powder ............................ 115

Fiber (psyllium husk-sugar) 3.4 gram/7

gram oral powder ............................ 115

Fiber (with aspartame) 3.4 gram/5.8 gram

oral powder ..................................... 115

FIBER LAXATIVE (CALCIUM

POLYCARBOPHIL) 625 MG TABLET .. 115

Fiber Laxative (methylcellulose) 500 mg

tablet ............................................... 115

Fiber Laxative (psyllium husk) 0.52 gram

capsule ............................................ 115

FIBER ORAL POWDER ........................... 115

FIBER SMOOTH ( WITH SUCROSE) ORAL

POWDER .......................................... 115

FIBER SMOOTH ORAL POWDER ............ 115

Fiber Therapy (ca polycarbophil) 625 mg

tablet ............................................... 115

FIBER THERAPY (METHYLCELLULOSE) 500

MG TABLET ...................................... 115

Fiber Therapy (methylcellulose-sugar) 2

gram/19 gram oral powder ............. 115

Fiber Therapy (psyllium husk-sucrose) 3

gram/12 gram oral powder ............. 115

FIBER THERAPY (PSYLLIUM SEED) 3.4

GRAM/5.8 GRAM ORAL POWDER ... 116

Fiber Therapy Laxative (psyllium husk)

0.52 gram capsule ........................... 116

Fiber-Caps (ca polycarbophil) 625 mg

tablet ............................................... 116

Fiber-Caps (psyllium husk) 0.52 gram

capsule ............................................ 116

FIBERCON 625 MG TABLET ................... 116

FIBER-LAX 625 MG TABLET ................... 116

Fiber-Tabs 625 mg tablet...................... 116

Finger Cream topical .............................. 42

First Aid ABX Pain Relief 3.5 mg-10,000

unit-10 mg/gram topical cream ......... 36

First Aid Antibiotic 3.5 mg-400 unit-5,000

unit/gram topical ointment ............... 34

First Aid Antibiotic 3.5 mg-500 unit-10,000

unit topical ointment ......................... 34

First Aid Antibiotic-Pain Rlf 3.5 mg-500

unit-10,000 unit/g top oint ................ 36

First Aid Antiseptic (povidone-iodine) 10 %

topical solution .................................. 35

Fish Oil 1,000 mg (120 mg-180 mg)

capsule .............................................. 20

Fish Oil 1,200 mg (144 mg-216 mg)

capsule .............................................. 20

Fish Oil 1,600 mg-500 mg-800 mg/5 mL

oral liquid .......................................... 20

Fish Oil 100 mg-160 mg-1,000 mg capsule

...........................................................20

Fish Oil 120 mg-180 mg capsule ............. 20

Fish Oil 120 mg-180 mg-500 mg capsule 20

OH Buckeye MMP Opt-Out Formulary August 1, 2021 196

Fish Oil 120 mg-180 mg-60 mg-1,200 mg

capsule,delayed release .....................20

Fish Oil 150 mg-217 mg-840 mg

capsule,delayed release .....................20

Fish Oil 183.3 mg-75 mg-91.6 mg-306 mg

capsule ...............................................21

Fish Oil 300 mg-1,000 mg capsule ..........21

Fish Oil 300 mg-1,000 mg capsule,delayed

release ...............................................21

Fish Oil 300 mg-108 mg-162 mg-600 mg

capsule,delayed release .....................21

Fish Oil 300 mg-500 mg capsule .............21

Fish Oil 340 mg-1,000 mg capsule ..........21

Fish Oil 360 mg-1,200 mg capsule ..........21

Fish Oil 360 mg-1,200 mg capsule,delayed

release ...............................................21

Fish Oil 360 mg-144 mg-216 mg-1,200 mg

capsule,delayed release .....................21

Fish Oil 60 mg-90 mg-500 mg capsule ....21

Fish Oil 60 mg-90 mg-500 mg

capsule,delayed release .....................21

Fish Oil 900 mg-1,400 mg capsule,delayed

release ...............................................21

Fish Oil 900 mg-360 mg-455 mg-1,000 mg

capsule ...............................................21

Fish Oil Concentrate 1,000 mg capsule ...20

Fish Oil Extra Strength 435 mg-880 mg

capsule ...............................................21

Fish Oil Pearls 150 mg-400 mg capsule ...21

Fish Oil Pearls 180 mg-400 mg capsule ...21

Fish Oil Pearls 300 mg-400 mg capsule ...21

fish oil-dha-epa 1,200 mg-144 mg-216 mg

capsule ...............................................21

Fitalite Cream Base .................................27

Flanax (naproxen) 220 mg tablet ............17

Flanax Antacid 200 mg-200 mg-20 mg/5

mL oral suspension ..........................106

FLANDERS BUTTOCKS TOPICAL OINTMENT

...........................................................50

Flavor Blend 2 in 1 oral suspension.........31

Flavor Chews Antacid 300 mg (750 mg)

tablet ...............................................104

Flavor Plus oral suspension .....................31

Flavor Sweet oral syrup ..........................31

Flavor Sweet-SF oral liquid .....................31

FLEET BISACODYL 10 MG/30 ML ENEMA

.........................................................120

FLEET ENEMA 19 GRAM-7 GRAM/118 ML

.........................................................119

FLEET LAXATIVE (BISACODYL) 5 MG

TABLET,DELAYED RELEASE ...............120

FLEET MINERAL OIL ENEMA ..................118

FLEET PEDIATRIC 9.5 GRAM-3.5 GRAM/59

ML ENEMA .......................................119

Flexichamber spacer .............................128

Flexichamber-Large Child Mask ............128

Flexichamber-Small Adult Mask ........... 128

Flexichamber-Small Child Mask ............ 128

FLINTSTONES COMPLETE (IRON) 18 MG

IRON CHEWABLE TABLET ................... 91

FLINTSTONES COMPLETE (IRON)

CHEWABLE TABLET ............................ 91

FLINTSTONES COMPLETE CHEWABLE

TABLET ............................................... 88

FLINTSTONES GUMMIES CHEWABLE

TABLET ............................................... 88

FLINTSTONES GUMMIES OMEGA-3 DHA

16 MG CHEWABLE TABLET ................ 88

FLINTSTONES MULTIVITAMIN 300 MCG

CHEWABLE TABLET ............................ 88

FLINTSTONES MULTIVITAMIN CHEWABLE

TABLET ............................................... 88

FLINTSTONES MULTI-VITAMINS GUMMIES

100 MCG CHEWABLE TABLET ............ 91

FLINTSTONES MULTI-VITAMINS GUMMIES

200 MCG CHEWABLE TABLET ............ 88

FLINTSTONES PLUS CALCIUM CHEWABLE

TABLET ............................................... 91

FLINTSTONES SOUR GUMMIES COMPLETE

CHEWABLE TABLET ............................ 88

FLINTSTONES TAB CHEW 100 MCG TABLET

...........................................................91

FLINTSTONES WITH IRON 18 MG IRON

CHEWABLE TABLET ............................ 92

FLINTSTONES/EXTRA C 100 MCG

CHEWABLE TABLET ............................ 88

FLINTSTONES/EXTRA C CHEWABLE TABLET

...........................................................88

FLONASE ALLERGY RELIEF 50

MCG/ACTUATION NASAL

SPRAY,SUSPENSION ......................... 156

Flora Assist 100 million cell oral powder

packet .............................................. 113

Florajen Acidophilus 20 billion cell capsule

.........................................................113

Floranex 1 million cell tablet ................ 113

Floranex 100 million cell oral granules in

packet .............................................. 113

FLOWTUSS 2.5 MG-200 MG/5 ML ORAL

SOLUTION ........................................ 176

Flu and Severe Cold-Nighttime 25 mg-10

mg-650 mg/30 mL oral liquid .......... 139

Flu HBP 2 mg-15 mg-500 mg tablet ...... 163

Flu Relief Therapy Daytime 5 mg-10 mg-

325 mg/15 mL oral liquid ................. 168

Flu Relief Therapy Nighttime 25 mg-10

mg-650 mg/30 mL oral liquid .......... 139

Flu-Severe Cold-Cough Daytime 10 mg-20

mg-650 mg oral powder packet ....... 168

FLU-SEVERE COLD-COUGH NIGHTTIME 25

MG-10 MG-650 MG ORAL POWDER

PACKET ............................................ 139

fluticasone propionate 50 mcg/actuation

nasal spray,suspension .................... 156

FOAMING ACNE FACE WASH 10 %

TOPICAL CLEANSER ............................ 34

FOAMING ANTACID 80 MG-20 MG

CHEWABLE TABLET .......................... 102

Foaming Antacid 95 mg-358 mg/15 mL

oral suspension................................ 103

FOLBEE 2.5 MG-25 MG-1 MG TABLET .... 94

Folgard 2,000 unit-800 mcg-0.32 mg tablet

...........................................................54

folic acid (bulk) 100 % powder ............... 27

folic acid 0.8 mg capsule ...................... 101

folic acid 1 mg tablet ............................ 101

folic acid 20 mg capsule ....................... 101

folic acid 400 mcg tablet ...................... 101

folic acid 5 mg/mL injection solution ... 101

folic acid 800 mcg tablet ...................... 101

folic acid-vit B6-vit B12 2.2 mg-25 mg-0.5

mg tablet ........................................... 94

Folika-T 1 mg-100 mg-300 mcg tablet .... 53

Folitab 105 mg iron-500 mg-800 mcg

tablet,extended release .................... 66

FOLITE 1 MG-200 MG-50 MCG-100 MG

TABLET ............................................. 101

FOLIVANE-F 125 MG-1 MG-40 MG-3 MG

CAPSULE ............................................ 66

FOLIVANE-PLUS 125 MG IRON-1 MG

CAPSULE ............................................ 66

Folixapure 125 mcg (5,000 unit)-1 mg

tablet ................................................. 94

FOLTRATE 0.5 MG-1 MG TABLET ............ 94

Foot and Sneaker 1 % topical spray

powder .............................................. 39

For Sty Relief eye ointment .................. 130

Formula 3 1 % topical solution ............... 39

FORMULA EM ORAL SOLUTION ............ 110

FORTAVIT CAPSULE ................................ 86

FOSFREE 175.5 MG-14.5 MG TABLET ..... 75

Freedavite 1.8 mg iron-400 mcg tablet .. 75

Freeze Dried Acidophilus capsule ......... 113

FRESHKOTE 2 %-0.9 %-1.8 % EYE DROPS

.........................................................130

fructose (bulk) granules ......................... 27

Full Spectrum B-Vitamin C 0.8 mg tablet53

Fungi Cure 1 % topical spray .................. 37

FUNGOID TINCTURE 2 % TOPICAL .......... 37

Fungoid Tincture 2 % topical kit ............. 37

FUNGOID-D 1 % TOPICAL CREAM ........... 39

FUSION PLUS 130 MG IRON-1,250 MCG

CAPSULE ............................................ 66

FUSION SPRINKLES 7 MG IRON-250 MCG

ORAL POWDER PACKET ..................... 66

OH Buckeye MMP Opt-Out Formulary August 1, 2021 197

G

G Tussin AC 10 mg-100 mg/5 mL oral

liquid ................................................177

GALZIN 25 MG (ZINC) CAPSULE ..............19

GALZIN 50 MG (ZINC) CAPSULE ..............19

GAS RELIEF (SIMETHICONE) 125 MG

CAPSULE...........................................112

GAS RELIEF (SIMETHICONE) 125 MG

CHEWABLE TABLET ..........................112

GAS RELIEF (SIMETHICONE) 180 MG

CAPSULE...........................................112

GAS RELIEF (SIMETHICONE) 40 MG/0.6 ML

ORAL DROPS,SUSPENSION ...............112

Gas Relief (simethicone) 80 mg chewable

tablet ...............................................112

GAS RELIEF 80 (SIMETHICONE) 80 MG

CHEWABLE TABLET ..........................112

Gas Relief Extra Strength 125 mg capsule

.........................................................112

Gas Relief Extra Strength 125 mg

chewable tablet ...............................112

Gas Relief Ultra Strength 180 mg capsule

.........................................................112

GAS-X EXTRA STRENGTH 125 MG CAPSULE

.........................................................112

GAS-X EXTRA STRENGTH 125 MG

CHEWABLE TABLET ..........................112

GAS-X ULTRA-STRENGTH 180 MG

CAPSULE...........................................112

Gavilax 17 gram/dose oral powder .......118

GAVISCON 80 MG-14.2 MG CHEWABLE

TABLET .............................................102

GAVISCON 95 MG-358 MG/15 ML ORAL

SUSPENSION ....................................103

GAVISCON EXTRA STRENGTH 160 MG-105

MG CHEWABLE TABLET ...................103

GAVISCON EXTRA STRENGTH 254 MG-

237.5 MG/5 ML ORAL SUSPENSION.103

GELUSIL ANTACID AND ANTI-GAS 200 MG-

200 MG-25 MG CHEWABLE TABLET 106

GENADUR TOPICAL LIQUID .....................51

GENICIN VITA-S 1 MG-100 MG-300 MCG

TABLET ...............................................53

GENTEAL MILD TO MODERATE 0.3 % EYE

DROPS ..............................................133

GENTEAL GEL 0.25 %-0.3 % EYE LIQUID

GEL DROPS .......................................130

GENTEAL MILD 0.2 % EYE DROPS ..........133

GENTEAL SEVERE 0.3 % EYE GEL ...........133

GenTeal Tears Mild 0.1 %-0.3 % eye drops

.........................................................130

GENTEAL TEARS MODERATE (PF) 0.1 %-0.3

% DROPS IN A DROPPERETTE ...........131

GENTEAL TEARS MODERATE 0.1 %-0.3 %-

0.2 % EYE DROPS ..............................131

GENTEAL TEARS SEVERE (PETROLATUM-

MINERAL OIL) 94 %-3 % EYE OINTMENT

.........................................................131

GENTEAL TEARS SEVERE 0.3 % EYE GEL133

GENTEAL TEARS SEVERE GEL DROPS 0.4 %-

0.3 % EYE DROPS ............................. 131

Gentle Laxative (bisacodyl) 10 mg rectal

suppository ...................................... 120

GENTLE LAXATIVE (BISACODYL) 5 MG

TABLET,DELAYED RELEASE ............... 120

GentleLax 17 gram/dose oral powder .. 118

GERAVIM ORAL LIQUID .......................... 56

GERIATON ORAL LIQUID ......................... 56

Geri-Dryl 12.5 mg/5 mL oral liquid ....... 146

Geri-Dryl 25 mg tablet .......................... 146

GERI-HYDROLAC 12 % LOTION ............... 42

Geri-Hydrolac 12 % topical cream .......... 42

Geri-kot 8.6 mg tablet .......................... 121

Geri-Lanta 200 mg-200 mg-20 mg/5 mL

oral suspension ................................ 106

Geri-Lanta 400 mg-400 mg-40 mg/5 mL

oral suspension ................................ 106

GERI-MOX ANTACID-ANTIGAS 200 MG-

200 MG-20 MG/5 ML ORAL

SUSPENSION .................................... 107

Geri-Pectate 262 mg/15 mL oral

suspension ....................................... 108

GERITOL COMPLETE 16 MG IRON-0.38 MG

TABLET ............................................... 75

Geri-Tussin 100 mg/5 mL oral liquid ..... 155

Geri-Tussin DM 10 mg-100 mg/5 mL oral

liquid ................................................ 173

Geri-Tussin DM 10 mg-100 mg/5 mL oral

syrup ................................................ 173

Glenmax PEB 4 mg-10 mg/5 mL oral liquid

.........................................................137

Glentuss 6.25 mg-30 mg-15 mg/5 mL oral

liquid ................................................ 165

Gluco Burst 40 % oral gel ...................... 102

glucose 4 gram chewable tablet ........... 102

Glucose Gel 40 % oral gel ..................... 102

GLUCOTEN 375 MG-300 MG-25 MG-0.5

MG TABLET .......................................... 9

glutamine (bulk) powder ........................ 27

glutathione (bulk) 100 % powder ........... 27

Glutose-15 40 % oral gel ....................... 102

Glutose-45 40 % oral gel ....................... 102

Glutose-5 40 % oral gel ......................... 102

glycerin (bulk) 100 % liquid ..................... 27

glycerin 99.5 % topical solution .............. 42

glycerin topical liquid.............................. 42

glycerol formal (bulk) 100 % liquid ......... 27

GLYCOLAX 17 GRAM/DOSE ORAL POWDER

.........................................................118

GORMEL TEN 10 % LOTION .................... 42

grape flavor (bulk) liquid ........................ 27

G-Tron 10 mg-100 mg/5 mL oral liquid 173

Guaiasorb DM 10 mg-100 mg/5 mL oral

liquid................................................ 173

Guaiatussin AC 10 mg-100 mg/5 mL oral

liquid................................................ 177

Guaicon DMS 20 mg-200 mg/10 mL oral

liquid in packet ................................ 173

guaifenesin 100 mg/5 mL oral liquid .... 155

guaifenesin 200 mg tablet .................... 155

guaifenesin 400 mg tablet .................... 155

Guaifenesin AC 10 mg-100 mg/5 mL oral

liquid................................................ 177

Guaifenesin DAC 30 mg-10 mg-100 mg/5

mL oral syrup ................................... 176

guaifenesin ER 1,200 mg tablet, extended

release 12 hr .................................... 155

guaifenesin ER 600 mg tablet, extended

release 12 hr .................................... 155

GUMMI BEAR MULTIVITAMIN CHEWABLE

TABLET ............................................... 89

Gummies Children Multivitamin chewable

tablet ................................................. 89

Gummy Dinos 200 mcg chewable tablet 89

Gummy Dinos chewable tablet .............. 89

GYNE-LOTRIMIN 2 % VAGINAL CREAM.179

H

H2Q 100 mg capsule .............................. 11

Hair Formula 400 mcg-100 mcg tablet ... 75

Hair, Skin and Nails Advanced 3.3 mg iron-

25 mcg tablet ..................................... 55

Hair, Skin and Nails-Argan Oil 66.7 mcg-

1,666.7 mcg capsule .......................... 75

Hair,Skin and Nails (folic acid-biotin) 66.7

mcg-1,000 mcg tablet ........................ 75

Hair,Skin and Nails (folic acid-biotin) 66.7

mcg-1,666.7 mcg tablet ..................... 75

Hair,Skin and Nails 1 mg iron-66.7 mcg-

1,000 mcg tablet ................................ 75

HAIR,SKIN AND NAILS TABLET ................ 75

Hair-Skin-Nail (vit A,C-biotin-Zn-Cu) 2,500

unit-100 mg-2,500 mcg cap ............... 55

Hair-Skin-Nails (multivit-folic-biotin) 400

mcg-2,000 mcg tablet ........................ 86

Hair-Skin-Nails (PABA) 3 mg-133 mcg

capsule .............................................. 75

HARD NAILS 2,500 MCG CAPSULE .......... 96

Headache Relief (ASA-acetaminophn-

caffeine) 250 mg-250 mg-65 mg tablet

...........................................................18

Healthy Eyes 1,000 unit-200 mg-60 unit-

2mg tablet ......................................... 75

Healthy Eyes SuperVision 14,320 unit-226

mg-200 unit capsule .......................... 75

OH Buckeye MMP Opt-Out Formulary August 1, 2021 198

HealthyLax 17 gram oral powder packet

.........................................................118

Heartburn Antacid 160 mg-105 mg

chewable tablet ...............................103

Heartburn Prevention 10 mg tablet ......111

HEARTBURN PREVENTION 20 MG TABLET

.........................................................111

HEARTBURN RELIEF (CIMETIDINE) 200 MG

TABLET .............................................111

Heartburn Relief (famotidine) 10 mg

tablet ...............................................111

Heartburn Relief (famotidine) 20 mg

tablet ...............................................111

HEARTBURN RELIEF 160 MG-105 MG

CHEWABLE TABLET ..........................103

Heartburn Relief 254 mg-237.5 mg/5 mL

oral suspension ................................103

Heartburn Treatment 20 mg

capsule,delayed release ...................111

Heartburn Treatment 24 Hour 15 mg

capsule,delayed release ...................111

Hema-Combistix strips ............................51

HEMATEX 100 MG IRON/5 ML ORAL

LIQUID ................................................63

HEMATINIC/FOLIC ACID 324 MG (106 MG

IRON)-1 MG TABLET ...........................66

HEMATOGEN FA 200 MG-250 MG-0.01

MG-1 MG CAPSULE ............................66

HEMATOGEN FORTE 460 MG-60 MG-0.01

MG-1 MG CAPSULE ............................66

HEMAX 150 MG IRON-1 MG-500 MG

TABLET ...............................................66

HEMOCYTE-F 324 MG (106 MG IRON)-1

MG TABLET ........................................66

HEMOCYTE-PLUS 106 MG IRON-1 MG

CAPSULE.............................................66

Hemorrhoidal (phenyleph-cocoa) 0.25 %-

88.44 % rectal suppository .................19

Hemorrhoidal ointment ..........................19

HEMORRHOIDAL SUPPOSITORY 0.25 %

RECTAL ...............................................19

Hemorrhoidal(phenyleph-min oil-

petrolat)0.25 %-14 %-74.9 % rectal oint

...........................................................19

HerbioMed Allergy Cold-Sinus Night 12.5

mg-5 mg-325 mg/10 mL oral liq .......139

HerbioMed Severe Cold-Flu Multi-Symp

10 mg-20 mg-650 mg/20 mL oral liq161

Hi-Cal Plus Vit D 500 mg (1,250 mg)-200

unit tablet ..........................................61

High Potency Iron 134 mg (27 mg iron)

tablet .................................................63

High Potency Iron 27 mg iron tablet .......63

High Potency Multivitamin (w-iron) 18 mg-

400 mcg tablet ...................................86

High Potency Multivitamin (w-iron) 9 mg

iron-400 mcg tablet ........................... 75

HISTAFLEX 325 MG-25 MG TABLET ........ 17

HISTEX (TRIPROLIDINE) 2.5 MG/5 ML

ORAL LIQUID .................................... 146

HISTEX DM 2.5 MG-10 MG-20 MG/5 ML

ORAL LIQUID .................................... 165

HISTEX PD 0.938 MG/ML ORAL DROPS 146

HISTEX PE 10 MG-2.5 MG/5 ML ORAL

LIQUID ............................................. 137

HISTEX-AC 2.5 MG-10 MG-10 MG/5 ML

ORAL SYRUP ..................................... 175

HONEY BEARS CHEWABLE TABLET ......... 89

Honey Bears with Iron-Zinc 4.5 mg

chewable tablet ................................. 89

Humco Base, Pain Mgmt topical cream .. 27

HYCODAN (WITH HOMATROPINE) 5 MG-

1.5 MG/5 ML ORAL SYRUP ............... 176

HYCOFENIX 2.5 MG-30 MG-200 MG/5 ML

ORAL SOLUTION .............................. 176

HYDRASYN25 25 %-6 % TOPICAL CREAM41

HYDRATING HEALING TOPICAL OINTMENT

...........................................................41

Hydrocerin (with petrolatum) topical

cream ................................................. 41

HYDROCIL ORAL POWDER .................... 116

hydrocodone 10 mg-chlorpheniramine 8

mg/5 mL oral susp extend.rel 12hr .. 175

hydrocodone 5 mg-cpm 4 mg-

pseudoephedrine 60 mg/5 mL oral

solution ............................................ 175

hydrocodone-homatropine 5 mg-1.5 mg

tablet ............................................... 176

hydrocodone-homatropine 5 mg-1.5 mg/5

mL (5 mL) oral syrup ........................ 176

hydrocodone-homatropine 5 mg-1.5 mg/5

mL oral syrup ................................... 176

hydrocortisone 0.5 % topical cream ....... 43

hydrocortisone 0.5 % topical ointment .. 43

hydrocortisone 1 % lotion ...................... 43

hydrocortisone 1 % topical cream .......... 43

hydrocortisone 1 % topical cream packet

...........................................................43

hydrocortisone 1 % topical ointment ..... 44

hydrocortisone acetate 0.5 % topical

cream ................................................. 44

hydrocortisone acetate 1 % topical cream

...........................................................44

hydrocortisone acetate 1 % topical

ointment ............................................ 44

Hydrocortisone Plus 1 % topical cream .. 44

hydrocortisone-aloe vera 0.5 % topical

cream ................................................. 44

hydrocortisone-aloe vera 1 % topical

cream ................................................. 44

hydrocortisone-mineral oil-white

petrolatum 1 % topical ointment ...... 44

Hydrocream 1 % topical ......................... 44

HYDRO-LAN TOPICAL CREAM ................. 41

Hydrolatum topical ointment ................. 49

HYDROMET 5 MG-1.5 MG/5 ML ORAL

SYRUP .............................................. 176

Hydrophilic Petrolatum topical ointment

...........................................................31

Hydrophor 42 % topical ointment .......... 49

HYDROSKIN 1 % LOTION......................... 44

Hydroskin with Aloe 1 % cream .............. 44

Hydrous Emulsified Base cream ............. 27

hydroxocobalamin (bulk) powder .......... 27

hydroxocobalamin 1,000 mcg/mL

intramuscular solution ...................... 95

Hylavite 1 mg tablet ............................... 53

Hylazinc 1 mg-1.5 mg-1.7 mg-50 mg tablet

.........................................................101

hypromellose (bulk) 23 % and 10 %

powder .............................................. 27

hypromellose powder ............................ 32

I

IBU-200 200 mg tablet ........................... 17

Ibu-Drops 50 mg/1.25 mL oral

drops,suspension .............................. 17

ibuprofen 100 mg chewable tablet ........ 17

ibuprofen 100 mg tablet ........................ 17

ibuprofen 100 mg/5 mL oral suspension 18

ibuprofen 200 mg capsule ...................... 18

ibuprofen 200 mg tablet ........................ 18

ibuprofen 50 mg/1.25 mL oral

drops,suspension .............................. 18

Ibuprofen Cold-Sinus (with

pseudoephedrine) 30 mg-200 mg

tablet ............................................... 152

Ibuprofen IB 100 mg chewable tablet .... 18

Ibuprofen IB 200 mg tablet .................... 18

Ibuprofen Jr Strength 100 mg chewable

tablet ................................................. 18

I-CAPS 280 MG-10 MG-2 MG CAPSULE .. 76

ICAPS AREDS 14,320 UNIT-226 MG-200

UNIT CAPSULE ................................... 76

ICAPS AREDS2 250 MG-200 UNIT-12.5

MG-1 MG CAPSULE ........................... 76

ICAPS MV 100 MCG-1.66 MG-0.83 MG

TABLET,DELAYED RELEASE ................. 76

Icar 15 mg/1.25 mL oral suspension ....... 63

IdealBase cream ..................................... 27

IFEREX 150 150 MG IRON CAPSULE ........ 63

IFEREX 150 FORTE 150 MG-25 MCG-1 MG

CAPSULE ............................................ 66

Immune Support 250 mg-12.5 mg

chewable tablet ................................. 11

OH Buckeye MMP Opt-Out Formulary August 1, 2021 199

IMODIUM A-D 1 MG/7.5 ML ORAL LIQUID

.........................................................107

Infant Fever Reducer-Pain Relief 160 mg/5

mL oral suspension ............................14

Infant Pain Reliever 160 mg/5 mL oral

suspension .........................................14

Infant's Acetaminophen 160 mg/5 mL oral

suspension .........................................14

INFANT'S ADVIL 50 MG/1.25 ML ORAL

DROPS,SUSPENSION ..........................18

Infants Gas Relief 40 mg/0.6 mL oral

drops,suspension .............................113

Infants Ibu-Drops 50 mg/1.25 mL oral

drops,suspension ...............................18

Infant's Ibuprofen 50 mg/1.25 mL oral

drops,suspension ...............................18

INFANT'S MOTRIN 50 MG/1.25 ML ORAL

DROPS,SUSPENSION ..........................18

Infants' Pain and Fever 160 mg/5 mL oral

suspension .........................................14

Infants' Pain Relief 160 mg/5 mL oral

suspension .........................................14

INFANT'S PAIN RELIEF 160 MG/5 ML ORAL

SUSPENSION ......................................14

Infant's Pain Reliever 80 mg/0.8 mL oral

drops,suspension ...............................14

Infants ProfenIB 50 mg/1.25 mL oral

drops,suspension ...............................18

INFANT'S TYLENOL 160 MG/5 ML ORAL

SUSPENSION ......................................15

Infant-Toddler Multivitamin oral drops ..89

Infant-Toddler Multivitamin-Iron 11

mg/mL oral drops ..............................92

Infant-Toddler Tri-Vitamin 500 mcg-50

mg-10 mcg/mL oral drops ..................89

INFED 50 MG/ML INJECTION SOLUTION 63

INFUVITE ADULT 3300 UNIT-150 MCG/10

ML INTRAVENOUS SOLUTION ............86

INFUVITE PEDIATRIC 80 MG-400 UNIT-200

MCG/5 ML INTRAVENOUS SOLUTION89

INJECTAFER 50 MG IRON/ML

INTRAVENOUS SOLUTION ..................63

Insect Repellent (DEET) 15 % topical spray

...........................................................45

Insect Repellent (picaridin) 20 % topical

spray with pump ................................45

InspiraChamber spacer .........................128

InspiraChamber with Mask-Large .........128

InspiraChamber with Mask-Med ..........128

InspiraChamber with Mask-Small .........128

INSTA-GLUCOSE (WITH DEXTRIN) 24

GRAM/31 GRAM ORAL GEL .............102

INTEGRA F 125 MG-1 MG-40 MG-3 MG

CAPSULE.............................................66

INTEGRA PLUS 125 MG IRON-1 MG

CAPSULE.............................................66

Intestinex 680 mg (750 million cell)

capsule ............................................. 114

Inzo Antifungal 2 % topical cream .......... 38

IONIL T 1 % SHAMPOO ........................... 48

IOPHEN C-NR 10 MG-100 MG/5 ML ORAL

LIQUID ............................................. 177

IOPHEN DM-NR 10 MG-100 MG/5 ML

ORAL LIQUID .................................... 173

IOPHEN-NR 100 MG/5 ML ORAL LIQUID

.........................................................155

I-PRIN 200 MG TABLET ........................... 18

IRON (DRIED) 160 MG (50 MG IRON)

TABLET,EXTENDED RELEASE .............. 63

Iron (ferrous sulfate) 325 mg (65 mg iron)

tablet ................................................. 64

iron 18 mg tablet .................................... 64

iron 325 mg (65 mg iron) tablet .............. 64

Iron Chews 15 mg tablet ......................... 64

iron ER 159 mg (45 mg iron)

tablet,extended release ..................... 64

Iron High Potency 240 mg (27 mg iron)

tablet ................................................. 64

iron, carbonyl 45 mg tablet .................... 64

IronUp 15 mg iron/0.5 mL oral drops ..... 64

IROSPAN 24/6 65 MG-65 MG-1,000 MCG

(24) TABLET ........................................ 66

isoleucine (bulk) 100 % crystals .............. 27

isoleucine (bulk) powder ........................ 27

isoleucine oral powder ........................... 52

ISOPTO TEARS 0.5 % EYE DROPS ........... 133

Itch Relief (clotrimazole) 1 % topical

cream ................................................. 38

Itch Relief (diphenhydramine) 2 % topical

spray .................................................. 50

Itch Relief 2 %-0.1 % topical cream ........ 40

Itch Relief 2 %-0.1 % topical spray .......... 40

ITCHY EYE DROPS 0.025 % (0.035 %) .... 134

I-Vite 1,000 unit-200 mg-60 unit-2mg

tablet ................................................. 76

I-Vite Protect 7,160 unit-113 mg-100 unit

tablet ................................................. 76

J

Jock Itch (clotrimazole) 1 % topical cream

...........................................................38

Jock Itch (terbinafine) 1 % topical cream37

Jock Itch 1 % topical spray powder ......... 39

Jr. Acetaminophen 160 mg disintegrating

tablet ................................................. 15

Jr. Str Non-Aspirin Pain 160 mg

disintegrating tablet .......................... 15

JR. STRENGTH PAIN RELIEVER 160 MG

DISINTEGRATING TABLET................... 15

Junior Mapap 160 mg disintegrating tablet

...........................................................15

Just D 10 mcg/mL (400 unit/mL) oral drops

...........................................................99

K

Kala 30 mg-20 mg tablet ...................... 110

KAOPECTATE (BISMUTH SUBSALICYLATE)

262 MG TABLET ............................... 108

KAOPECTATE (BISMUTH SUBSALICYLATE)

262 MG/15 ML ORAL SUSPENSION 108

KAOPECTATE EX STR (BISMUTH SS) 525

MG/15 ML ORAL SUSPENSION ........ 108

Kao-Tin (bismuth subsalicylate) 262 mg/15

mL oral suspension .......................... 108

Kao-Tin (docusate calcium) 240 mg

capsule ............................................ 124

KERADAN TOPICAL CREAM ..................... 41

Kerodex 51 Dry or Oily topical cream ..... 41

Kerodex-71 Wet topical cream ............... 49

Keto-Diastix strips ................................ 129

Ketone Care strips ................................ 129

ketotifen 0.025 % (0.035 %) eye drops.134

Kidkare Cough/Cold 1 mg-15 mg-5 mg/5

mL oral liquid ................................... 165

Kids First Vitamin D3 25 mcg (1,000 unit)

chewable tablet ................................. 99

Kids' Gummy chewable tablet ................ 89

Kids Mini Enema 100 mg/5 mL ............. 124

Kids Multivitamin-Minerals 200 mcg

chewable tablet ................................. 89

Kids Omega-3 with DHA 25 mg-5 mg-113.5

mg chewable tablet ........................... 55

Kids Vitamin D3 10 mcg (400 unit)

chewable tablet ................................. 99

Kimono Condoms(Non-lubricated) ...... 126

Kimono Maxx Condoms ....................... 126

Kimono MicroThin Aqua Lube Condom126

Kimono MicroThin Condoms ................ 126

Kimono MicroThin Large Condoms ...... 126

Kimono Textured Condoms .................. 126

Konsyl (sugar) 3.4 gram oral powder

packet .............................................. 116

Konsyl (sugar) 3.4 gram/11 gram oral

powder ............................................ 116

Konsyl (sugar) 3.4 gram/12 gram oral

powder ............................................ 116

Konsyl Easy Mix 4.3 gram/6 gram oral

powder ............................................ 116

Konsyl Fiber 625 mg tablet ................... 116

Konsyl Formula-D 3.4 gram/6.5 gram oral

powder ............................................ 116

Konsyl Sugar-Free (aspartame) 3.5

gram/5.8 gram oral powder ............ 116

Konsyl Sugar-Free 0.52 gram capsule ... 116

KONSYL SUGAR-FREE 6 GRAM ORAL

POWDER PACKET ............................. 116

OH Buckeye MMP Opt-Out Formulary August 1, 2021 200

Konsyl Sugar-Free 6 gram/6 gram oral

powder.............................................116

K-PAX 4.5 MG IRON-200 MCG CAPSULE .76

K-PAX 9 MG IRON-400 MCG CAPSULE ....76

K-PAX IMMUNE SUPPORT 2.25 MG IRON-

100 MCG TABLET ...............................76

K-PEC ANTIDIARRHEAL (BISM SUB) 262

MG/15 ML ORAL SUSPENSION .........108

L

L.acidophilus-Bifido.longum 16 mg

capsule,delayed release ...................114

Labstix Reagent strips .............................52

LACTINEX 1 MILLION CELL CHEWABLE

TABLET .............................................114

LACTINOL HX TOPICAL CREAM ...............42

Lactobacillus acidophilus 0.5 mg (100

million cell) tablet ............................114

Lactobacillus acidophilus 1 billion cell

tablet ...............................................114

Lactobacillus acidophilus 1 mg (10 million)

oral wafer.........................................114

Lactobacillus acidophilus 100 mg (1 billion

cell) capsule .....................................114

Lactobacillus acidophilus 100 million cell

capsule .............................................114

Lactobacillus acidophilus 2 billion cell

tablet ...............................................114

Lactobacillus acidophilus 500 million cell

capsule .............................................114

Lactobacillus acidophilus 500 million cell

tablet ...............................................114

Lactobacillus acidophilus capsule .........114

Lactobacillus acidoph-L.bulgaricus 1

million cell tablet .............................114

Lactobacillus acidoph-L.bulgaricus 100

million cell oral powder packet ........114

lactose (bulk) powder .............................27

LAMISIL (AEROSOL) 1 % TOPICAL SPRAY 37

LAMISIL AF 1 % TOPICAL SPRAY POWDER

...........................................................39

LAMISIL AT 1 % TOPICAL CREAM ............37

LAMISIL AT 1 % TOPICAL GEL ..................37

lansoprazole 15 mg capsule,delayed

release .............................................111

LANTISEPTIC DRY SKIN THERAPY 30 %

CREAM ...............................................42

LANTISEPTIC SKIN PROTECTANT 50 %

CREAM ...............................................42

Laxa Basic 100 mg capsule ....................124

LAXACIN 8.6 MG-50 MG TABLET ...........122

LaxaClear 17 gram/dose oral powder ...118

LAXATIVE (BISACODYL) 10 MG RECTAL

SUPPOSITORY ..................................121

LAXATIVE (BISACODYL) 5 MG TABLET ...121

Laxative (bisacodyl) 5 mg tablet,delayed

release ............................................. 121

LAXATIVE (SENNOSIDES) 15 MG

CHEWABLE TABLET .......................... 121

Laxative (sennosides) 15 mg tablet ...... 121

Laxative (sennosides) 25 mg tablet ...... 121

Laxative Feminine 5 mg tablet .............. 121

LAXATIVE MAXIMUM STRENGTH 25 MG

TABLET ............................................. 121

Laxative PEG 3350 17 gram/dose oral

powder ............................................ 118

Laxative Pills 25 mg tablet .................... 121

LAXATIVE PILLS REGULAR 15 MG TABLET

.........................................................121

LAXATIVE PLUS STOOL SOFTENER 8.6 MG-

50 MG TABLET ................................. 122

LC-4 4 % TOPICAL CREAM ....................... 50

L-Citrulline powder ................................. 27

levocetirizine 5 mg tablet ..................... 149

levonorgestrel 1.5 mg tablet .................. 32

L-Glutamine powder ............................... 27

Lice Complete Kit 1-2-3 4 %-0.33 %-0.5 %

topical kit ........................................... 51

LICE KILLING (PERMETHRIN) 1 % TOPICAL

LIQUID ............................................... 51

Lice Killing 0.33 %-4 % shampoo ............. 51

Lice Pyrinyl Shampoo 0.33 %-4 % ........... 51

LICE SOLUTION 4 %-0.33 %-0.5 % TOPICAL

KIT ...................................................... 51

LICE TREATMENT (PERMETHRIN) 1 %

TOPICAL LIQUID ................................. 51

Lice Treatment 0.33 %-4 % shampoo ..... 51

Lice Treatment 1 % topical liquid ........... 51

lidocaine 4 % topical cream .................... 50

lidocaine HCl 4 % topical cream.............. 50

lidocaine-transparent dressing 4 % topical

kit ....................................................... 50

LIDOCREAM 4 % TOPICAL ....................... 50

LIFE-PACK MEN'S 0.8 MG ORAL PACK ..... 76

LIFE-PACK WOMEN'S 0.8 MG ORAL PACK

...........................................................76

Lip Balm Base (Bulk) 1.3 gm/3 mL .......... 27

Lip Treatment topical jelly ...................... 49

Lipo Cream Base ..................................... 27

Lipobase Heavy topical cream ................ 27

Lipobase Regular transdermal cream ..... 27

Lipocream Base ...................................... 27

Lipopen Absorption Enhancing Base cream

...........................................................28

Lipopen Ultra Base cream ...................... 28

Liposomal Heavy topical cream .............. 28

Liq-10 50 mg-15 unit/5 mL oral syrup .... 11

LiQ-10 100 mg/5 mL oral syrup .............. 11

Liquid Antacid 200 mg-200 mg-20 mg/5

mL oral suspension .......................... 107

Liquid Calcium with Vitamin D 600 mg

calcium-200 unit capsule ................... 61

LIQUID CORN AND CALLUS REMOVER 17

% TOPICAL ......................................... 47

LiquiTears 1.4 % eye drops ................... 133

L-Isoleucine powder ............................... 28

Lite Coat Aspirin 325 mg tablet .............. 19

LiteAire MDI Chamber .......................... 128

Little Animals-Iron 15 mg chewable tablet

...........................................................89

Little Remedies 0.65 % nasal spray aerosol

.........................................................157

Little Remedies Fever and Pain Reliever

160 mg/5 mL oral liquid..................... 15

Little Remedies Gas Relief 40 mg/0.6 mL

oral drops,suspension ..................... 113

Little Remedies Saline Mist 0.9 % nasal

spray aerosol ................................... 157

LMX 4 4 % TOPICAL CREAM .................... 50

LMX 4 4 % TOPICAL KIT .......................... 50

LMX 4 PLUS 4 % TOPICAL KIT .................. 50

LODRANE D 4 MG-60 MG CAPSULE ...... 137

LoHist - D 2 mg-30 mg/5 mL oral liquid 137

LoHist-DM 2 mg-5 mg-10 mg/5 mL oral

liquid................................................ 165

Lollibase powder .................................... 28

loperamide 1 mg/5 mL oral liquid ........ 107

loperamide 1 mg/7.5 mL oral liquid ..... 107

loperamide 2 mg capsule ..................... 108

Loradamed 10 mg tablet ...................... 149

Lorata-D 10 mg-240 mg tablet,extended

release ............................................. 142

loratadine 10 mg capsule ..................... 149

loratadine 10 mg disintegrating tablet .149

loratadine 10 mg tablet ........................ 149

loratadine 5 mg/5 mL oral solution ...... 149

lorata-dine D 10 mg-240 mg

tablet,extended release .................. 142

LORATADINE-D 10 MG-240 MG

TABLET,EXTENDED RELEASE 24 HR .. 143

Loratadine-D 5 mg-120 mg

tablet,extended release 12 hr ......... 143

Lorid 1 mg-200 mg-300 mcg tablet ........ 53

Lortuss DM 6.25 mg-30 mg-15 mg/5 mL

oral liquid ........................................ 165

Lortuss EX 30 mg-10 mg-100 mg/5 mL oral

syrup ................................................ 176

Lortuss LQ 6.25 mg-30 mg/5 mL oral liquid

.........................................................137

LOTRIMIN AF (CLOTRIMAZOLE) 1 %

TOPICAL CREAM ................................ 38

LOTRIMIN AF 2 % TOPICAL POWDER ...... 38

LOTRIMIN AF JOCK ITCH POWDER 2 %

TOPICAL SPRAY .................................. 38

LOTRIMIN AF POWDER 2 % TOPICAL

SPRAY ................................................ 38

OH Buckeye MMP Opt-Out Formulary August 1, 2021 201

Lubricant Dry Eye Relief 1 % eye liquid gel

drops ................................................133

Lubricant Eye (cmc-glycerin) 0.5 %-0.9 %

drops ................................................131

Lubricant Eye (PG-PEG 400) (PF) 0.4 %-0.3

% drops in a dropperette .................131

Lubricant Eye (PG-PEG 400) 0.4 %-0.3 %

drops ................................................131

Lubricant Eye (propylene glycol) 0.6 %

drops ................................................133

Lubricant Eye 56.8 %-41.5 % ointment.131

Lubricant Eye 57.3 %-42.5 % ointment.131

Lubricant Eye 57.7 %-31.9 % ointment.131

LUBRICANT EYE 83 %-15 % OINTMENT 131

Lubricant Eye Drops 0.5 % ....................133

Lubricant Eye Drops 0.5 % drops in a

dropperette .....................................133

Lubricant Gel 0.25 %-0.3 % eye liquid gel

drops ................................................131

Lubricating Drops 0.5 %-0.9 % eye drops

.........................................................131

Lubricating Plus 0.5 % eye drops in a

dropperette .....................................133

Lubricating Relief 0.4 %-0.3 % eye drops

.........................................................131

LUBRIFRESH PM 83 %-15 % EYE

OINTMENT .......................................131

lysine HCl (bulk) 100 % powder ..............28

Lysiplex Plus oral liquid ...........................92

Lysiplex Plus tablet .................................53

M

M.V.I. ADULT 3,300 UNIT-150 MCG/10 ML

INTRAVENOUS SOLUTION ..................86

M.V.I. PEDIATRIC 80 MG-400 UNIT-200

MCG INTRAVENOUS SOLUTION .........89

M.V.I.-12 (WITHOUT VIT K) 3,300 UNIT-

200 UNIT/10 ML INTRAVENOUS SOLN

...........................................................86

MAALOX ADVANCED 1,000 MG-60 MG

CHEWABLE TABLET ..........................107

MACULAR BENEFITS 550 MG-2.5 MG-50

MCG ORAL PACK ................................76

MACULAR HEALTH FORMULA 5 MG-1 MG-

7.5 MG CAPSULE ................................76

Macuvite Eye Care 7,160 unit-113 mg-1

mg tablet ............................................76

Macuvite With Lutein 5,000 unit-60 mg-30

unit-2 mg tablet ...................................9

Mag 64 64 mg tablet,delayed release.....67

MAG-AL 200 mg-200 mg/5 mL oral

suspension .......................................103

Mag-Al Plus 200 mg-200 mg-20 mg/5 mL

oral suspension ................................107

Mag-Al Plus Extra Strength 400 mg-400

mg-40 mg/5 mL oral suspension ...... 107

Mag-Delay 64 mg tablet,delayed release

...........................................................67

Mag-Delay 70 mg tablet,delayed release

...........................................................67

MAG-G 27 MG MAGNESIUM (500 MG)

TABLET ............................................... 67

MAGNEBIND 300 250 MG-300 MG TABLET

.........................................................125

magnesium 200 mg (as magnesium oxide)

tablet ................................................. 67

magnesium 240 mg (as magnesium oxide)

oral powder packet ............................ 67

magnesium 250 mg (as magnesium oxide)

tablet ................................................. 67

magnesium 250 mg tablet ...................... 67

magnesium 400 mg (as magnesium oxide)

capsule ............................................... 67

magnesium 400 mg (as magnesium oxide)

tablet ................................................. 67

magnesium 64 mg (magnesium chloride)

tablet,delayed release ....................... 67

magnesium 70 mg (magnesium chloride)

tablet,delayed release ....................... 67

magnesium amino acid chelate 27 mg

tablet ................................................. 67

magnesium chloride (bulk) crystals ........ 28

magnesium citrate 100 mg tablet........... 67

magnesium citrate oral solution ........... 118

magnesium gluconate 27 mg magnesium

(500 mg) tablet .................................. 67

magnesium gluconate 27.5 mg

magnesium (500 mg) tablet ............... 67

magnesium hydroxide 2,400 mg/10 mL

oral suspension ................................ 118

magnesium hydroxide 400 mg/5 mL oral

suspension ....................................... 118

magnesium L-lactate ER 84 mg

tablet,extended release ..................... 68

magnesium oxide 400 mg (241.3 mg

magnesium) tablet............................. 68

magnesium oxide 420 mg tablet ............ 68

magnesium oxide 500 mg capsule .......... 68

magnesium oxide 500 mg tablet ............ 68

magnesium sulfate 2 gram/50 mL (4 %) in

water intravenous piggyback ............. 68

magnesium sulfate 20 gram/500 mL (4 %)

in water intravenous solution ............ 68

magnesium sulfate 4 gram/100 mL (4 %)

in water intravenous piggyback ......... 68

magnesium sulfate 4 gram/50 mL (8 %) in

water intravenous piggyback ............. 68

magnesium sulfate 40 gram/1,000 mL (4

%) in water intravenous solution ....... 68

MAGONATE (MAGNESIUM CARB) 54

MG/5 ML ORAL LIQUID...................... 68

MagOx 400 mg (241.3 mg magnesium)

tablet ................................................. 68

MAGTAB 84 MG TABLET,EXTENDED

RELEASE ............................................. 68

Major-Prep Hemorrhoidal 0.25 %-14 %-

74.9 % ointment ................................ 19

manganese chloride 0.1 mg/mL

intravenous solution .......................... 68

Mapap (acetaminophen) 160 mg/5 mL

oral liquid .......................................... 15

Mapap (acetaminophen) 160 mg/5 mL

oral suspension.................................. 15

MAPAP (ACETAMINOPHEN) 325 MG

TABLET ............................................... 15

MAPAP (ACETAMINOPHEN) 500 MG

CAPSULE ............................................ 15

Mapap (acetaminophen) 500 mg/15 mL

oral liquid .......................................... 15

Mapap Arthritis Pain 650 mg

tablet,extended release .................... 15

Mapap Cold Formula 5 mg-10 mg-325 mg

tablet ............................................... 168

MAPAP EXTRA STRENGTH 500 MG TABLET

...........................................................15

Mapap Sinus Maximum Strength (PE) 5

mg-325 mg tablet ............................ 151

Mar-Cof BP 2 mg-30 mg-7.5 mg/5 mL oral

liquid................................................ 175

Mar-Cof CG 7.5 mg-225 mg/5 mL oral

liquid................................................ 177

Masanti Double Strength 400 mg-400 mg-

40 mg/5 mL oral suspension ............ 107

MAXICHLOR PEH DM 4 MG-10 MG-18 MG

TABLET ............................................. 165

MAXIFED 60 MG-360 MG TABLET ........ 153

Maximin Pack 0.8 mg-250 mcg oral pack76

MAXIMUM DAILY GREEN 5 MG-133 MCG

TABLET ............................................... 76

Maximum Daily Multivitamin 18 mg-0.4

mg tablet ........................................... 76

MAXIMUM STRENGTH FLU 2 MG-15 MG-

500 MG TABLET ............................... 163

MAXI-TUSS CD 4 MG-10 MG-10 MG/5 ML

ORAL LIQUID .................................... 175

MAXI-TUSS DM (WITH

CHLORPHENIRAMINE) 4 MG-18 MG/5

ML ORAL LIQUID .............................. 166

MAXI-TUSS PE MAX 5 MG-100 MG/5 ML

ORAL LIQUID .................................... 153

M-Clear WC 6.3 mg-100 mg/5 mL oral

liquid................................................ 177

M-Dryl 12.5 mg/5 mL oral liquid .......... 146

meclizine 12.5 mg tablet ...................... 110

meclizine 25 mg chewable tablet ......... 110

OH Buckeye MMP Opt-Out Formulary August 1, 2021 202

meclizine 25 mg tablet..........................110

MEDICATED CORN REMOVERS 40 %

TOPICAL PATCH ..................................47

Medicidin-D 2 mg-5 mg-325 mg tablet.139

Mediderm cream ....................................28

Medi-First Anti-Fungal 1 % topical packet

...........................................................39

Medi-Lyte 40 mg-18 mg-9 mg tablet ......68

Mediplast Corn-Callus-Wart Remover 40

% topical patch ..................................47

Mediproxen 220 mg tablet .....................18

Medium Cream topical ...........................28

Mega Multi for Women 13.5 mg-200 mcg-

250 mcg tablet ...................................76

Mega Multivitamin For Men 200 mcg-175

mcg-250 mcg tablet ...........................76

Mega Multivitamin with Minerals 13.5

mg-200 mcg-250 mcg tablet ..............76

Megavite 18 mg iron-800 mcg-150 mg

tablet .................................................55

Megavite Golden Years 55+ 800 mcg-150

mg-25 mg tablet ................................55

MEMORY COMPLEX 60 MG-30 UNIT-70

MCG-40 MG TABLET ..........................11

Men 50 Plus Advanced One Daily 400

mcg-20 mcg-370 mcg tablet ..............77

Men 50 Plus Multivitamin 300 mcg-600

mcg-300 mcg tablet ...........................77

M-End DMX 0.667 mg-20 mg-10 mg/5 mL

oral liquid .........................................165

M-END PE 1.33 mg-3.33 mg-6.33 mg/5 mL

oral liquid .........................................175

Men's 50 Plus Daily Formula 400 mcg-20

mcg-370 mcg tablet ...........................77

Men's Daily 0.4 mg-600 mcg capsule ......77

Men's Daily Formula 400 mcg-20 mcg-300

mcg tablet ..........................................77

Men's Daily Gummies 200 mcg chewable

tablet .................................................77

Men's Multivitamin 400 mcg-20 mcg-300

mcg tablet ..........................................77

Men's Multivitamin Gummies 200 mcg

chewable tablet .................................77

Mens Multivitamin High Potency 200 mcg-

175 mcg-250 mcg tablet ....................77

Men's Multi-Vitamin tablet ....................86

Men's One Daily 400 mcg-20 mcg-300 mcg

tablet .................................................77

MEN'S ONE DAILY TABLET ......................77

Men's Pack 0.4 mg-250 mcg oral pack ....77

MEPHYTON 5 MG TABLET .....................101

MERIBIN 5 MG CAPSULE .........................96

METAMUCIL (SUGAR) ORAL POWDER ..116

METAMUCIL (WITH SUGAR) 3.4 GRAM/12

GRAM ORAL POWDER......................116

METAMUCIL 0.4 GRAM CAPSULE .........116

METAMUCIL MULTIHEALTH FIBER 3.4

GRAM/5.8 GRAM ORAL POWDER .... 116

METAMUCIL SUGAR-FREE (ASPARTAME)

3.4 GRAM/5.8 GRAM ORAL POWDER

.........................................................117

Methocel E 4 M granules ........................ 32

Methocel E 4 M powder ......................... 32

Methocel K 100 M 23 % and 10 % powder

...........................................................28

methylcellulose 1500cps (bulk) 27.5 % to

31.5 % (USP) powder ......................... 28

methylcellulose 4000cps (bulk) 30 %

powder .............................................. 28

methylcellulose 400cps (bulk) 30 %

powder .............................................. 28

MgO 400 mg (241.3 mg magnesium)

tablet ................................................. 68

M-Hist DM 4 mg-7.5 mg-15 mg/5 mL oral

liquid ................................................ 165

M-Hist PD 0.625 mg/mL oral drops ...... 146

Mi-Acid (calcium carb-magnesium

hydroxide) 700 mg-300 mg chew tablet

.........................................................103

Mi-Acid 200 mg-200 mg-20 mg/5 mL oral

suspension ....................................... 107

Mi-Acid 400 mg-400 mg-40 mg/5 mL oral

suspension ....................................... 107

Mi-Acid Gas Relief (simethicone) 80 mg

chewable tablet ............................... 113

MICATIN 2 % TOPICAL CREAM ................ 38

miconazole nitrate 1,200 mg-2 % vaginal

kit ..................................................... 179

miconazole nitrate 100 mg vaginal

suppository ...................................... 179

miconazole nitrate 2 % topical cream .... 38

miconazole nitrate 2 % topical spray

powder .............................................. 38

miconazole nitrate 2 % vaginal cream .. 179

miconazole nitrate 200 mg-2 % (9 gram)

vaginal kit ........................................ 179

miconazole nitrate 4 % (200 mg)-2 % (9

gram)vaginal,prefill appl,cream ....... 179

Miconazole-3 200 mg-2 % (9 gram)

vaginal kit ........................................ 179

Miconazole-3 200 mg/5 gram (4 %) vaginal

cream ............................................... 179

Miconazole-3 4 % (200 mg)-2 % (9 gram)

vaginal pack,prefil appl, cream ........ 179

Miconazole-3 prefilled,cream,wipes 4

%(200 mg)-2 %(9 gram) vaginal kit .. 179

Miconazole-7 100 mg vaginal suppository

.........................................................179

Miconazole-7 2 % vaginal cream ......... 179

miconazole-skin cleanser #17 4 % (200

mg)-2 % (9 gram) vaginal kit ............ 179

Miconazorb AF 2 % topical powder ........ 38

Microchamber spacer .......................... 128

Microderm Base Cream .......................... 28

MICRO-GUARD 2 % TOPICAL POWDER .. 38

Microlife Peak Flow Meter ................... 127

Microsome Base Cream ......................... 28

Microspacer ......................................... 128

Migraine Formula 250 mg-250 mg-65 mg

tablet ................................................. 18

Migraine Relief 250 mg-250 mg-65 mg

tablet ................................................. 18

Milk of Magnesia 400 mg/5 mL oral

suspension ....................................... 118

Milk Of Magnesia Concentrated 2,400

mg/10 mL oral suspension .............. 119

Milltrium Senior tablet ........................... 56

mineral oil enema ................................ 118

Mineral Oil Extra Heavy oral ................. 118

Mineral Oil Heavy oral .......................... 118

mineral oil oral ..................................... 118

Minerin Creme topical............................ 41

Mini Wright Peak Flow Meter .............. 127

Mintox 200 mg-200 mg-20 mg/5 mL oral

suspension ....................................... 107

Mintox Maximum Strength 400 mg-400

mg-40 mg/5 mL oral suspension ..... 107

Mintox Plus 200 mg-200 mg-25 mg

chewable tablet ............................... 107

MIRALAX 17 GRAM ORAL POWDER

PACKET ............................................ 119

MIRALAX 17 GRAM/DOSE ORAL POWDER

.........................................................119

Moisturel Therapeutic 3 % lotion ........... 49

Moisturizing Cream topical .................... 41

MONISTAT 1 COMBO PACK 1,200 MG-2 %

VAGINAL OVULE AND CREAM ......... 179

MONISTAT 3 4 % (200 MG)-2 %(9

GRAM)VAGINAL PACK,PREFIL APPL

AND CREAM..................................... 179

Monistat 3 200 mg/5 gram (4 %) vaginal

cream .............................................. 179

MONISTAT 3 200 MG-2 % (9 GRAM)

VAGINAL KIT .................................... 179

MONISTAT 7 2 % VAGINAL CREAM ...... 179

MONOCAPS 14 MG IRON-400 MCG

TABLET ............................................... 77

More-Dophilus oral powder ................. 114

Mosco Corn Remover 40 % topical patch

...........................................................47

Motion Relief (meclizine) 25 mg tablet 110

MOTION SICKNESS (MECLIZINE) 25 MG

TABLET ............................................. 110

MOTION SICKNESS 50 MG TABLET ....... 110

Motion Sickness II 25 mg tablet ........... 110

Motion Sickness Relief (meclizine) 25 mg

chewable tablet ............................... 110

OH Buckeye MMP Opt-Out Formulary August 1, 2021 203

Motion Sickness Relief (meclizine) 25 mg

tablet ...............................................110

Motion Sickness Relief 50 mg tablet .....110

Motion-Time 25 mg chewable tablet ...110

Motrin IB 200 mg capsule .......................18

MOTRIN IB 200 MG TABLET ....................18

Move It Along 100 mg tablet ................124

M-PAP 160 mg/5 mL oral liquid ..............15

MTX SUPPORT 0.5 MG-1 MG TABLET .....94

MUCAPHED 10 MG-400 MG TABLET ....153

MUCINEX 1,200 MG TABLET, EXTENDED

RELEASE ...........................................155

MUCINEX 600 MG TABLET, EXTENDED

RELEASE ...........................................155

MUCINEX COLD,FLU AND SORE THROAT

10 MG-20 MG-650 MG/20 ML ORAL

LIQUID ..............................................161

MUCINEX D 60 MG-600 MG

TABLET,EXTENDED RELEASE ............153

MUCINEX D MAXIMUM STRENGTH 120

MG-1,200 MG TABLET,EXTENDED

RELEASE ...........................................153

MUCINEX DM 30 MG-600 MG

TABLET,EXTENDED RELEASE 12 HR ..173

MUCINEX DM 60 MG-1,200 MG

TABLET,EXTENDED RELEASE 12 HR ..173

MUCINEX FAST-MAX COLD-FLU 5 MG-10

MG-325 MG-200 MG CAPSULE ........162

MUCINEX FAST-MAX COLD-FLU-SORE

THROAT 5 MG-10 MG-325 MG-200 MG

CAPSULE...........................................162

MUCINEX FAST-MAX COLD-FLU-SORE

THROAT 5 MG-10 MG-325 MG-200 MG

TABLET .............................................162

MUCINEX FAST-MAX COLD-SINUS 5 MG-

325 MG-200 MG TABLET .................151

MUCINEX FAST-MAX CONGESTION-

COUGH 2.5 MG-5 MG-100 MG/5 ML

ORAL LIQUID ....................................170

MUCINEX FAST-MAX CONGESTION-

COUGH 5 MG-10 MG-200 MG TABLET

.........................................................170

MUCINEX FAST-MAX CONGESTION-

HEADACHE (DM) 5 MG-10 MG-325 MG

CAPSULE...........................................168

MUCINEX FAST-MAX DAY COLD-NT COLD-

FLU(DOXYLAM)6.25-5-10-325MG(NT)

CAPS .................................................160

MUCINEX FAST-MAX DAY CONGES-

COUGH-NT COLD-FLU 25-10-

650MG/20ML LIQUIDS.....................160

MUCINEX FAST-MAX DAY SEV COLD-NITE

COLD-FLU 10 MG-650 MG/20 ML

LIQUIDS ............................................160

MUCINEX FAST-MAX DAY SEV COLD-NITE

COLD-FLU 5 MG-325 MG-200 MG

TABLETS ........................................... 161

MUCINEX FAST-MAX DAYCONGES-

COUGH-NITECOLD-FLU 5MG/12.5-5-

325MG(N) TABS ............................... 161

MUCINEX FAST-MAX DAYCONGEST-

COUGH-NITECOLD-FLU 5MG/25-5-

325MG(NT) TABS ............................. 161

MUCINEX FAST-MAX DAY-NITE COLD 325

MG(D)/12.5 MG-325MG (N) TABLETS

.........................................................161

MUCINEX FAST-MAX DM MAX 5 MG-100

MG/5 ML ORAL LIQUID .................... 173

MUCINEX FAST-MAX NITE COLD AND

FLU(DOXYLAMINE)6.25-5-10-325 MG

CAPSULE .......................................... 160

MUCINEX FAST-MAX NITE COLD-FLU 12.5

MG-5 MG-325 MG/10 ML ORAL LIQUID

.........................................................139

MUCINEX FAST-MAX SEVERE COLD 5 MG-

10 MG-325 MG-200 MG TABLET ..... 162

MUCINEX SINUS-MAX 0.05 % NASAL

SPRAY .............................................. 158

MUCINEX SINUS-MAX DAY-

NIGHT(DOXYLAM) 6.25 MG-5 MG-10

MG-325MG(NT) CAPS ...................... 161

MUCINEX SINUS-MAX DAY-NT(DIPHEN) 5-

325-200 MG(D)/25-5-325MG(N)

TABLETS ........................................... 141

MUCINEX SINUS-MAX NITE CONGESTION-

COUGH 12.5-5-325 MG/10 ML ORAL

LIQ ................................................... 140

MUCINEX SINUS-MAX PRESSURE-PAIN 5

MG-325 MG-200 MG TABLET .......... 151

MUCINEX SINUS-MAX PRESSURE-PAIN-

COUGH 5 MG-10 MG-325 MG-200 MG

CAPSULE .......................................... 162

MUCINEX SINUS-MAX PRESSURE-PAIN-

COUGH 5 MG-10 MG-325 MG-200 MG

TABLET ............................................. 162

MUCINEX SINUS-MAX SEV CONGEST RLF

10 MG-650 MG-400 MG/20 ML ORAL

LIQ ................................................... 151

MUCINEX SINUS-MAX SEVERE

CONGESTION RELIEF 5 MG-325 MG-

200 MG TABLET ............................... 152

MUCINEX SINUS-MAX SEVERE

CONGESTION-PAIN(DM) 5 MG-10 MG-

325 MG CAPSULE ............................. 168

Mucosa 400 mg tablet .......................... 155

Mucosa DM 20 mg-400 mg tablet ........ 173

Mucus and Cough Relief 20 mg-400 mg

tablet ............................................... 173

Mucus D 60 mg-600 mg tablet,extended

release ............................................. 153

MUCUS DM 30 MG-600 MG

TABLET,EXTENDED RELEASE ............ 173

Mucus DM Max ER 60 mg-1,200 mg

tablet,extended release .................. 173

Mucus Relief 200 mg tablet .................. 155

Mucus Relief 400 mg tablet .................. 155

Mucus Relief Chest 400 mg tablet ........ 155

Mucus Relief Cold and Sinus 10 mg-650

mg-400 mg/20 mL oral liquid .......... 152

Mucus Relief Cold and Sinus 5 mg-325 mg-

200 mg tablet .................................. 152

Mucus Relief Cold-Flu-Sore Throat 10 mg-

20 mg-650 mg/20 mL oral liquid ..... 162

Mucus Relief Cold-Flu-Sore Throat 5 mg-

10 mg-325 mg-200 mg tablet .......... 162

MUCUS RELIEF CONGESTION-COUGH 2.5

MG-5 MG-100 MG/5 ML ORAL LIQUID

.........................................................170

MUCUS RELIEF COUGH 5 MG-100 MG/5

ML ORAL LIQUID .............................. 173

Mucus Relief D (pseudoephed) 120 mg-

1,200 mg tablet,extended release ... 153

Mucus Relief D (pseudoephed) 60 mg-600

mg tablet,extended release............. 153

MUCUS RELIEF DM 20 MG-400 MG

TABLET ............................................. 173

Mucus Relief DM Cough 20 mg-400 mg

tablet ............................................... 173

Mucus Relief DM Max 5 mg-100 mg/5 mL

oral liquid ........................................ 173

Mucus Relief ER 1,200 mg tablet,

extended release ............................. 155

MUCUS RELIEF ER 600 MG TABLET,

EXTENDED RELEASE ......................... 155

Mucus Relief PE 10 mg-400 mg tablet .. 154

Mucus Relief Sev Congest-Cold 5 mg-10

mg-325 mg-200 mg tablet ............... 162

Mucus Relief Severe Cold 10 mg-20 mg-

650 mg/20 mL oral liquid................. 162

Mucus Relief Severe Cold 5 mg-10 mg-325

mg-200 mg tablet ............................ 162

MUCUS RELIEF SEVERE SINUS

CONGESTION 5 MG-325 MG-200 MG

TABLET ............................................. 152

Mucus Relief Sinus 10 mg-400 mg tablet

.........................................................154

Mucus Relief Sinus Pressure and Pain 5

mg-325 mg-200 mg tablet ............... 152

Mucus-Chest Congestion 100 mg/5 mL

oral liquid ........................................ 155

Mucus-ER MAX 1,200 mg tablet, extended

release ............................................. 155

Multi Antibiotic Plus 3.5 mg-10,000 unit-

10 mg/gram topical cream ................ 36

Multi Complete with Iron 18 mg-400 mcg

tablet ................................................. 86

OH Buckeye MMP Opt-Out Formulary August 1, 2021 204

Multi For Her 18 mg iron-600 mcg-40 mcg

capsule ...............................................77

Multi For Her 18 mg iron-600 mcg-80 mcg

tablet .................................................77

Multi For Her 50 Plus 400 mcg-80 mcg

capsule ...............................................77

Multi Vitamin 9 mg iron/15 mL oral liquid

...........................................................77

MultiBase topical cream .........................28

Multi-Day Plus Minerals 18 mg iron-400

mcg-25 mcg tablet .............................77

Multi-Day with Iron 18 mg-400 mcg tablet

...........................................................86

Multi-Delyn with Iron 10 mg iron/5 mL

oral liquid ...........................................77

Multihealth Fiber (sugar) 3.4 gram/7 gram

oral powder .....................................117

Multihealth Fiber 3.4 gram/5.8 gram oral

powder.............................................117

Multilex 15 mg iron tablet ......................77

Multilex-T and M 15 mg iron tablet ........77

MULTILEX-T AND M TABLET ...................77

Multiple Vitamin, Womens tablet ..........77

Multiple Vitamin-Minerals tablet ...........77

Multiple Vitamins tablet .........................86

Multistix 10 SG strips ..............................52

Multistix 5 strips .....................................52

Multistix 7 strips .....................................52

Multistix 8 SG strips ................................52

Multistix 9 SG strips ................................52

Multistix 9 strips .....................................52

Multistix strips ........................................52

MULTI-SYMPTOM COLD (PE-CPM) 1 MG-

2.5 MG-5 MG-160 MG/5 ML ORAL

SUSP .................................................160

MULTI-SYMPTOM COLD DAYTIME 5 MG-

10 MG-325 MG TABLET....................168

MULTI-SYMPTOM COLD NIGHT TIME 2

MG-5 MG-10 MG-325 MG TABLET ..160

MULTI-SYMPTOM COLD(WITH

PHENYLEPHRINE) 5 MG-10 MG-325

MG-200 MG TABLET ........................162

MultiUse Base cream ..............................28

multivit and minerals-ferrous gluconate 9

mg iron/15 mL oral liquid ...................78

multivit with min-folic acid-lutein 200

mcg-137.5 mcg chewable tablet ........78

Multivitamin 50 Plus tablet ....................56

multivitamin capsule ..............................86

multivitamin tablet .................................86

MULTIVITAMIN WITH IRON TABLET .......78

multivitamin with minerals 9 mg iron/15

mL oral liquid .....................................78

multivitamin with minerals tablet ..........56

multivitamin with minerals-ferrous

fumarate 15 mg iron tablet ................78

Multivitamin Women 50 Plus 8 mg iron-

400 mcg-300 mcg tablet .................... 78

multivitamin-minerals-iron fumarate 7.5

mg-folic acid 400 mcg tablet.............. 78

Multi-Vite 9 mg iron/15 mL oral liquid ... 78

Murine Ear 6.5 % drops ........................ 136

MURINE EAR WAX REMOVAL SYSTEM 6.5

% DROPS .......................................... 136

MURO 128 2 % EYE DROPS ................... 135

MVW COMPLETE FORMULATION D3000

3,000 UNIT-1,000 MCG CHEWABLE

TABLET ............................................... 89

MVW COMPLETE FORMULATION D5000

5,000 UNIT-1,000 MCG CHEWABLE

TABLET ............................................... 89

MVW COMPLETE FORMULATION

MULTIVITAMIN 1,500 UNIT-1,000 MCG

CHEW TABLET .................................... 89

MVW COMPLETE FORMULATION

PEDIATRIC 750 UNIT-500 MCG/0.5 ML

ORAL DROPS ...................................... 89

MX-Sol Blend oral suspension ................ 31

MX-Sol Blend SF oral suspension ............ 31

MX-Sol oral syrup ................................... 31

MX-Sol SF oral liquid ............................... 31

MX-Sol Suspend oral ............................... 31

My Choice 1.5 mg tablet ......................... 32

My Way 1.5 mg tablet ............................ 33

Myferon 150 150 mg iron capsule .......... 64

Myferon 150 Forte 150 mg-25 mcg-1 mg

capsule ............................................... 66

Mylanta Maximum Strength 400 mg-400

mg-40 mg/5 mL oral suspension ...... 107

Mynephrocaps 1 mg capsule .................. 53

Mynephron 1 mg capsule ....................... 53

Mytab Gas (simethicone) 80 mg chewable

tablet ............................................... 113

Mytab Gas Maximum Strength 125 mg

chewable tablet ............................... 113

My-Vitalife capsule ................................. 78

N

NAIL SCRUB LOTION ............................... 48

NANO VM 1-3 3.5 MG-75 MCG ORAL

POWDER ............................................ 89

NANO VM 4-8 5 MG-100 MCG ORAL

POWDER ............................................ 89

NANOVM 9-18 2 MG IRON/2.6 GRAM

ORAL POWDER .................................. 92

NANOVM T-F 2.75 MG IRON/5.4 GRAM

POWDER ADDITIVE FOR TUBE FEED .. 92

naproxen sodium 220 mg capsule .......... 18

naproxen sodium 220 mg tablet ............. 18

Naramin 12.5 mg/5 mL oral liquid in

packet .............................................. 146

NASACORT 55 MCG NASAL SPRAY

AEROSOL ......................................... 156

NASADROPS 0.9 % NASAL SOLUTION ... 157

Nasal Allergy 55 mcg spray aerosol ...... 156

Nasal Antiseptic Swabs 10 % .................. 35

Nasal Decongestant (oxymetazoline) 0.05

% spray ............................................ 158

Nasal Decongestant (phenylephrine) 10

mg tablet ......................................... 177

Nasal Decongestant (pseudoephedrine)

120 mg tablet,extended release ...... 177

Nasal Decongestant (pseudoephedrine) 30

mg tablet ......................................... 177

Nasal Decongestant (pseudoephedrine) 30

mg/5 mL oral liquid ......................... 177

Nasal Four 1 % spray ............................ 158

Nasal Mist 0.9 % spray aerosol ............. 157

Nasal Moisturizing 0.65 % spray aerosol

.........................................................157

NASAL SPRAY (OXYMETAZOLINE) 0.05 %

.........................................................158

NASAL SPRAY (SODIUM CHLORIDE) 0.65 %

AEROSOL ......................................... 157

Nasal Spray 12 Hour (oxymetazoline) 0.05

% ......................................................158

Nasal Spray 12 Hour (oxymetazoline) 0.05

% mist .............................................. 158

Nasal Spray Extra Moisturizing 0.05 % .158

NASAL SPRAY SINUS 0.05 % .................. 158

NASALCROM 5.2 MG/SPRAY (4 %) SPRAY

.........................................................156

NASCOBAL 500 MCG/SPRAY NASAL SPRAY

...........................................................95

NASOGEL 0.9 % NASAL GEL .................. 157

NASOGEL 0.9 % NASAL SPRAY GEL ....... 157

NASOPEN PE 50 MG-10 MG/15 ML ORAL

LIQUID ............................................. 137

Natrapel 20 % topical spray .................... 45

Natural Balance Tears 0.1 %-0.3 % eye

drops ............................................... 131

Natural Daily Fiber 3.4 gram/5.8 gram oral

powder ............................................ 117

Natural Fiber Laxative (aspartame) 3.4

gram/5.8 gram oral powder ............ 117

NATURAL FIBER LAXATIVE (ASPARTAME)

ORAL POWDER ................................ 117

Natural Fiber Laxative (sugar) 3.4 gram/12

gram oral powder ............................ 117

Natural Fiber Laxative (sugar) 3.4 gram/7

gram oral powder ............................ 117

Natural Fiber Laxative (sugar) oral powder

.........................................................117

Natural Fiber Laxative 0.52 gram capsule

.........................................................117

NATURAL FIBER LAXATIVE THERAPY ORAL

POWDER .......................................... 117

OH Buckeye MMP Opt-Out Formulary August 1, 2021 205

NATURAL LAXATIVE 25 MG TABLET ......121

Natural Psyllium Fiber 3.4 gram/5.8 gram

oral powder .....................................117

Natural Tears (PF) 0.1 %-0.3 % drops in a

dropperette .....................................131

Natural Vegetable (psyllium) oral powder

.........................................................117

Natural Vegetable Laxative (sennosides)

8.6 mg tablet ....................................121

NATURAL VEGETABLE ORAL POWDER ..117

Natural Vegetable Powder 3.4 gram/12

gram oral..........................................117

Natura-LAX 17 gram/dose oral powder119

Nature's Tears 0.1 %-0.3 % eye drops ...131

NAUSEA CONTROL ORAL SOLUTION .....110

Nausea Relief oral solution ...................110

NEOQ10 125 MG CAPSULE .....................11

NEOSPORIN (NEO-BAC-POLYM) 3.5 MG-

400 UNIT-5,000 UNIT/GRAM TOP

OINTMENT .........................................34

NEOSPORIN ANTI-ITCH 1 % TOPICAL

CREAM ...............................................44

NEOSPORIN PLUS PAIN RELIEF 3.5 MG-

10,000 UNIT-10 MG/GRAM TOPICAL

CREAM ...............................................36

NEOSPORIN(NEO-BAC-POLYM) 3.5 MG-

400 UNIT-5,000 UNIT TOP OINTMENT

PACKT ................................................35

NEOSPORIN-PAIN ITCH SCAR 3.5 MG-500

UNIT-10,000 UNIT/GRAM TOPICAL

OINT ...................................................36

Neo-Synephrine (phenylephrine) 1 % nasal

spray ................................................158

NEO-SYNEPHRINE 12 HOUR NASAL SPRAY

(OXYMETAZOLINE) 0.05 % ...............158

NEPHPLEX RX 1 MG-60 MG-300 MCG-12.5

MG TABLET ........................................54

NEPHRON FA 66 MG IRON-1,000 MCG

TABLET ...............................................53

NEPHRONEX 900 MCG/5 ML ORAL LIQUID

...........................................................53

NEPHRONEX-SL 800 MCG-2,000 UNIT

DISINTEGRATING TABLET ...................53

NEPHRO-VITE 0.8 MG TABLET ................53

NEUTRAPHOR 1 % TOPICAL CREAM .......49

NEUTROGENA HAND TOPICAL CREAM ...42

NEUTROGENA NORWEGIAN FORMULA

TOPICAL CREAM .................................43

NEUTROGENA T/SAL 3 % SHAMPOO ......47

NEUTROGENA T-GEL 0.5 % SHAMPOO ...48

New Day 1.5 mg tablet ...........................33

New Skin (benzethonium) 0.2 % topical

film-forming liquid .............................20

Nexcare All Purpose Mask ....................126

NEXIUM 20 MG CAPSULE,DELAYED

RELEASE ...........................................112

Nexium 24HR 20 mg capsule,delayed

release ............................................. 112

NEXT CHOICE ONE DOSE 1.5 MG TABLET

...........................................................33

niacin (inositol niacinate) 500 mg capsule

...........................................................95

niacin (inositol niacinate) 500 mg tablet 95

niacin 100 mg tablet ............................... 95

niacin 250 mg tablet ............................... 95

niacin 400 mg (inositol niacinate 500 mg)

capsule ............................................... 95

niacin 455 mg (inositol niacinate 500 mg)

capsule ............................................... 95

niacin 50 mg tablet ................................. 95

niacin 500 mg tablet ............................... 20

niacin ER 1,000 mg tablet,extended

release ............................................... 95

niacin ER 250 mg capsule,extended

release ............................................... 95

niacin ER 250 mg tablet,extended release

...........................................................95

niacin ER 500 mg capsule,extended

release ............................................... 95

niacin ER 500 mg tablet,extended release

...........................................................95

niacin ER 750 mg tablet,extended release

...........................................................95

NICADAN 800 MG-10 MG-100 MG-500

MCG TABLET ...................................... 55

NICADAN ZX 400 MG-5 MG-250 MCG-10

MG TABLET ........................................ 55

Nicazel 600 mg-5 mg-10 mg-5 mg-1.5 mg

tablet ................................................. 55

NICAZEL FORTE 700 MG-500 MCG-8 MG-

12 MG TABLET ................................... 55

Nicoderm CQ 14 mg/24 hr daily

transdermal patch ............................. 24

Nicoderm CQ 21 mg/24 hr daily

transdermal patch ............................. 24

NICODERM CQ 7 MG/24 HR DAILY

TRANSDERMAL PATCH....................... 24

NICOMIDE (SELENIUM-CHROMIUM) 500

MCG-750 MG TABLET ........................ 78

Nicorelief 2 mg gum ............................... 24

NICORELIEF 4 MG GUM .......................... 24

NICORETTE 2 MG BUCCAL LOZENGE ...... 24

NICORETTE 2 MG BUCCAL MINI LOZENGE

...........................................................24

NICORETTE 2 MG GUM ........................... 24

NICORETTE 4 MG BUCCAL LOZENGE ...... 24

NICORETTE 4 MG BUCCAL MINI LOZENGE

...........................................................24

Nicorette 4 mg gum ................................ 24

Nicotinamide (with chromium) 500 mcg-

750 mg tablet .................................... 78

nicotine (polacrilex) 2 mg buccal lozenge

...........................................................24

nicotine (polacrilex) 2 mg buccal mini

lozenge .............................................. 24

nicotine (polacrilex) 2 mg gum ............... 24

nicotine (polacrilex) 4 mg buccal lozenge

...........................................................24

nicotine (polacrilex) 4 mg buccal mini

lozenge .............................................. 24

nicotine (polacrilex) 4 mg gum ............... 24

nicotine 14 mg/24 hr daily transdermal

patch ................................................. 24

nicotine 21 mg/24 hr daily transdermal

patch ................................................. 24

nicotine 21mg/24hr-14mg/24hr-7mg/24hr

daily transderm patches,sequentl ..... 25

nicotine 7 mg/24 hr daily transdermal

patch ................................................. 25

NIFEREX (SUMALATE-QUATREFOLIC) 150

MG IRON-60 MG-1 MG TABLET ......... 66

NIGHT TIME 6.25 MG-15 MG-325 MG

CAPSULE .......................................... 163

Night Time Cold and Flu Relief 6.25 mg-15

mg-325 mg/15 mL oral liquid .......... 163

Nightime Sleep 50 mg capsule ............... 23

Nighttime Allergy Relief 25 mg tablet .. 146

Nighttime Cold-Flu 6.25 mg-15 mg-325 mg

capsule ............................................ 163

Nighttime Cold-Flu Relief 6.25 mg-15 mg-

325 mg/15 mL oral liquid................. 163

NightTime Cough 6.25 mg-15 mg/15 mL

oral solution .................................... 166

Nighttime Dry-Eye Relief 57.3 %-42.5 %

ointment .......................................... 131

NIGHTTIME SLEEP AID

(DIPHENHYDRAMINE) 25 MG TABLET23

NightTime Sleep Aid (diphenhydramine)

50 mg capsule .................................... 23

Ninjacof 12.5 mg-12.5 mg/5 mL oral liquid

.........................................................166

Ninjacof-A 12.5 mg-12.5 mg-160 mg/5 mL

oral liquid ........................................ 163

Ninjacof-XG 8 mg-200 mg/5 mL oral liquid

.........................................................177

Nite Time Cold-Flu 6.25 mg-15 mg-325

mg/15 mL oral liquid ....................... 163

NITE TIME COLD-FLU RELIEF 12.5 MG-30

MG-1,000 MG/30 ML ORAL LIQUID .163

NITE TIME COLD-FLU RELIEF 6.25 MG-15

MG-325 MG CAPSULE ..................... 164

Nite Time Cough 6.25 mg-15 mg/15 mL

oral solution .................................... 166

Nitetime Multi-Symptom 12.5 mg-30 mg-

1,000 mg/30 mL oral liquid.............. 164

Niva-Hist DM 4 mg-7.5 mg-15 mg/5 mL

oral liquid ........................................ 165

OH Buckeye MMP Opt-Out Formulary August 1, 2021 206

Nivanex DMX 10 mg-15 mg-380 mg tablet

.........................................................170

NIVEA SOFT TOPICAL CREAM..................41

NIVEA TOPICAL CREAM...........................41

Nix Creme Rinse 1 % topical liquid ..........51

No Drip 0.05 % nasal spray ...................159

No Drip Nasal Mist 0.05 % ....................159

NOBLE FORMULA 2 % SHAMPOO ...........40

NOBLE FORMULA HC 1 % TOPICAL CREAM

...........................................................44

NOBLE FORMULA HC 1 % TOPICAL SPRAY

...........................................................44

NoHist-DM 4 mg-10 mg-15 mg/5 mL oral

liquid ................................................165

NoHist-LQ 4 mg-10 mg/5 mL oral liquid

.........................................................137

NON-ASPIRIN 160 MG/5 ML ORAL

SUSPENSION ......................................15

NON-ASPIRIN 325 MG TABLET ................15

NON-ASPIRIN 80 MG CHEWABLE TABLET

...........................................................15

NON-ASPIRIN CHILDREN'S 80 MG

CHEWABLE TABLET ............................15

NON-ASPIRIN EXTRA STRENGTH 500 MG

TABLET ...............................................15

Non-Aspirin Nightime 25 mg-500 mg

tablet .................................................17

NON-ASPIRIN PAIN RELIEF 500 MG TABLET

...........................................................15

NON-DROWSY ALLERGY 10 MG TABLET

.........................................................149

Norel AD 4 mg-10 mg-325 mg tablet ....140

Nortemp 160 mg/5 mL oral suspension .15

Nortemp 80 mg/0.8 mL oral drops .........15

Nose Drops 1 % .....................................159

NOSE DROPS EXTRA STRENGTH 1 % .....159

Nourilite topical emulsion ......................28

Nourivan Antioxidant topical cream .......28

NOVAFERRUM 15 MG IRON/ML ORAL

DROPS ................................................64

NOVAFERRUM 50 50 MG IRON CAPSULE

...........................................................64

NOVAFERRUM PEDIATRIC MULTIVITAMIN-

IRON 10 MG IRON/ML ORAL DROPS 92

NovaMV 750 unit-35 mg-400 unit/mL oral

drops ..................................................90

Noxi-K topical cream ...............................28

NRS NASAL RELIEF 0.05 % SPRAY ..........159

NTS Step 1 21 mg/24 hr transdermal 24

hour patch .........................................25

NUFERA 125 MG-1 MG-170 MG-1,000

UNIT TABLET ......................................66

Nu-Iron 150 mg iron capsule ..................64

Nu-Mag 71.5 mg tablet,delayed release 68

NUTRASEB TOPICAL CREAM ...................42

NUTRICAP 1 MG TABLET .........................78

O

OBREDON 2.5 MG-200 MG/5 ML ORAL

SOLUTION ........................................ 177

OCEAN NASAL 0.65 % SPRAY AEROSOL 157

Ocular Vitamins 7,160 unit-113 mg-0.5 mg

tablet ................................................. 78

Ocutabs tablet ........................................ 78

OCUVITE ADULT 50 PLUS 250 MG-5 MG-1

MG CAPSULE ...................................... 78

OCUVITE EYE HEALTH 50 MG-15 UNIT-4.5

MG-2.5 MG CHEWABLE TABLET .......... 9

OCUVITE EYE PLUS MULTI 200 MCG-15

MCG-150 MCG TABLET ...................... 78

OCUVITE LUTEIN AND ZEAXANTHIN 60

MG-13.5 MG-15 MG-2 MG-6 MG

CAPSULE .............................................. 9

OCUVITE WITH LUTEIN 1,000 UNIT-200

MG-60 UNIT-2MG TABLET ................. 78

Odor Control Foot-Sneaker 1 % topical

spray powder ..................................... 39

Off Active 15 % topical spray .................. 45

Off Deep Woods 25 % topical pump spray

...........................................................45

Off Deep Woods 25 % topical spray ....... 45

Off Deep Woods Dry 25 % topical spray

powder .............................................. 45

Off Deep Woods Sportsmen 25 % topical

spray pump ........................................ 45

Off Deep Woods Sportsmen 30 % topical

spray .................................................. 45

Off Deep Woods Sportsmen 98.25 %

topical spray pump ............................ 46

Off FamilyCare (with DEET) 15 % topical

spray powder ..................................... 46

Off FamilyCare (with DEET) 5 % topical

spray .................................................. 46

Off FamilyCare (with DEET) 7 % topical

spray .................................................. 46

Off FamilyCare (with picaridin) 5 % topical

spray with pump ................................ 46

omega 3 600 mg-dha 216 mg-epa 324 mg-

fish oil 1,200 mg capsule,del rel ........ 21

omega 3-dha-epa-fish oil 1,000 mg (120

mg-180 mg) capsule .......................... 21

omega 3-dha-epa-fish oil 1,200 mg (144

mg-216 mg) capsule .......................... 21

omega 3-dha-epa-fish oil 100 mg-150 mg-

750 mg capsule .................................. 21

omega 3-dha-epa-fish oil 250 mg-500 mg-

1,000 mg capsule ............................... 21

omega 3-dha-epa-fish oil 300 mg-1,000

mg capsule ......................................... 22

omega 3-dha-epa-fish oil 300 mg-1,000

mg capsule,delayed release ............... 22

omega 3-dha-epa-fish oil 356 mg (100 mg-

256 mg)-554 mg capsule ................... 22

omega 3-dha-epa-fish oil 500 mg (200mg-

300mg)-1,000 mg capsule ................. 22

omega 3-dha-epa-fish oil 60 mg-90 mg-

500 mg capsule .................................. 22

omega 3s 300 mg-dha-epa-fish oil 1,000

mg capsule,delayed release .............. 22

OMEGA ESSENTIALS BASIC 1,400 MG/5

ML ORAL LIQUID ................................ 22

Omega-3 (with docosapentaenoic acid)

1,050 mg-1,200 mg capsule ............... 22

omega3 1,000 mg-dha-epa-other om3s-

fish oil 1,400 mg capsule,delay rel ..... 22

Omega-3 2100 1,050 mg-1,200 mg

capsule .............................................. 22

omega-3 28.5 mg-dha 23.75 mg-epa 4.75

mg-fish oil 113.5 mg chew tablet ...... 22

omega3 300 mg-dha,epa 250 mg-other

omega 3s-fish oil 1,000 mg capsule ... 22

Omega-3 350 mg-235 mg-90 mg-597 mg

capsule,delayed release .................... 22

omega-3 360 mg-dha-epa-fish oil 1,200

mg capsule,delayed release .............. 22

omega3 720 mg-dha-epa-other om3s-fish

oil 1,200 mg capsule,delay rel ........... 22

omega-3 fatty acids 1,000 mg capsule ... 20

omega-3 fatty acids 100 mg chewable

tablet ................................................. 20

omega-3 fatty acids-fish oil 340 mg-1,000

mg capsule ........................................ 22

omega-3 fatty acids-fish oil 360 mg-1,200

mg capsule ........................................ 22

omega-3 fatty acids-fish oil 440 mg-880

mg capsule ........................................ 22

Omega-3 Fish Oil 300 mg-1,000 mg

capsule .............................................. 55

Omega-3 Fish Oil 910 mg-1,400 mg

capsule .............................................. 22

omega-3s 600 mg-dha-epa-other

omega3s-fish oil 1,200 mg capsule .... 22

omega-3s 980 mg-dha 253 mg-epa 647

mg-fish oil capsule,delayed release ... 23

OMEGAPURE 780 EC 910 MG-330 MG-450

MG-1,400 MG CAPSULE,DELAYED

RELEASE ............................................. 23

omeprazole 20 mg tablet,delayed release

.........................................................112

omeprazole magnesium 20 mg

capsule,delayed release .................. 112

Omera 300 mg-400 mg-1,000 mg capsule

...........................................................23

Omnibase cream .................................... 28

Omnicap 0.4 mg tablet ........................... 78

Once Daily tablet .................................... 86

ONCOVITE TABLET .................................. 86

OH Buckeye MMP Opt-Out Formulary August 1, 2021 207

One Daily 0.4 mg-600 mcg tablet ...........78

One Daily 300 mg-18 mg-400 mcg-50 mg

tablet .................................................55

One Daily Calcium/Iron tablet ................78

One Daily Complete 18 mg-0.4 mg tablet

...........................................................79

One Daily Complete tablet .....................79

One Daily Energy tablet ..........................79

One Daily Essential 0.4 mg tablet ...........79

One Daily Essential 400 mcg tablet .........86

One Daily Essential tablet .......................86

One Daily For Men 0.4 mg-600 mcg tablet

...........................................................79

One Daily For Men 50+ Advanced 400

mcg-600 mcg-120 mg tablet ..............86

One Daily For Women 18 mg-0.4 mg

tablet .................................................79

ONE DAILY GUMMY VITES 200 MCG

CHEWABLE TABLET ............................79

One Daily Healthy Weight 200 mg-18 mg-

0.4 mg tablet ......................................79

One Daily Maximum 18 mg-0.4 mg tablet

...........................................................79

One Daily Men's 50 Plus Advanced 400

mcg-20 mcg tablet .............................79

One Daily Men's 50 Plus Memory Support

400 mcg-600 mcg-120 mg tablet .......86

One Daily Men's 50 Plus with D3 400 mcg-

20 mcg-370 mcg tablet ......................79

One Daily Multivitamin oral powder

packet ................................................86

ONE DAILY MULTIVITAMIN TABLET ........86

One Daily Multivitamin with Iron (folic

acid) 18 mg-400 mcg tablet ...............86

One Daily Multivitamin with Iron 18 mg

iron tablet ..........................................79

One Daily Multivitamins with Minerals 4.5

mg iron oral powder packet ...............79

One Daily Multivitamins with Minerals 4.5

mg iron tablet ....................................79

One Daily Plus Iron 18 mg-400 mcg tablet

...........................................................87

ONE DAILY PLUS MINERALS TABLET .......79

ONE DAILY PRENATAL 28 MG IRON-800

MCG ORAL PACK ................................92

One Daily Prenatal 28 mg-800 mcg-440

mg oral pack.......................................93

ONE DAILY TABLET ..................................87

ONE DAILY WITH IRON TABLET ...............79

One Daily Women 50 Plus 400 mcg-120

mg tablet ............................................79

One Daily Women 50 Plus(Vit K) 400 mcg-

500 mg calcium-20 mcg tablet ...........79

One Daily Women's 18 mg iron-400 mcg-

25 mcg tablet .....................................79

One Daily Women's 18 mg iron-400 mcg-

450 mg Ca tablet ................................ 79

ONE DAILY WOMENS 50 PLUS 0.4 MG

TABLET ............................................... 79

One Daily Women's Metabolism 300 mg-

18 mg-400 mcg-50 mg tablet ............. 55

ONE-A-DAY ENERGY 9 MG IRON-400 MCG-

200 MG TABLET ................................. 79

ONE-A-DAY ESSENTIAL TABLET ............... 87

ONE-A-DAY KID'S CHEWABLE TABLET ..... 90

ONE-A-DAY MEN VITACRAVES 200 MCG

CHEWABLE TABLET ............................ 80

ONE-A-DAY MENOPAUSE FORMULA 400

MCG-60 MG TABLET .......................... 80

ONE-A-DAY MEN'S 50 PLUS (WITH

GINKGO) 400 MCG-300 MCG-120 MG

TABLET ............................................... 87

ONE-A-DAY MEN'S 50 PLUS 400 MCG-20

MCG-370 MCG TABLET ...................... 80

ONE-A-DAY MEN'S MULTIVITAMIN 400

MCG-20 MCG-300 MCG TABLET ........ 80

ONE-A-DAY PROACTIVE 65 PLUS 200 MCG

TABLET ............................................... 80

ONE-A-DAY TEEN ADVANTAGE 18 MG-400

MCG TABLET ...................................... 87

ONE-A-DAY TEEN FOR HER VITACRAVES

300 UNIT-37.5 MCG CHEWABLE

TABLET ............................................... 90

ONE-A-DAY TEEN FOR HIM VITACRAVES

300 UNIT-37.5 MCG CHEWABLE

TABLET ............................................... 90

ONE-A-DAY VITACRAVES 200 MCG

CHEWABLE TABLET ............................ 80

ONE-A-DAY VITACRAVES IMMUNITY 200

MCG CHEWABLE TABLET ................... 80

ONE-A-DAY VITACRAVES OMEGA-3 200

MCG-16 MG CHEWABLE TABLET ....... 80

ONE-A-DAY WEIGHTSMART 200 MG-18

MG-0.4 MG TABLET ........................... 80

ONE-A-DAY WOMEN VITACRAVES 200

MCG CHEWABLE TABLET ................... 80

ONE-A-DAY WOMEN'S 50 PLUS 400 MCG-

20 MCG TABLET ................................. 80

ONE-A-DAY WOMEN'S ACTIVE 18 MG

IRON-400 MCG-180 MG TABLET ........ 80

ONE-A-DAY WOMEN'S HEALTHY SKIN 18

MG IRON-400 MCG-6 MG TABLET ..... 80

ONE-A-DAY WOMEN'S PETITES 9 MG

IRON-200 MCG TABLET ...................... 80

One-Per-Day Omega-3 684 mg-1,200 mg

capsule,delayed release .................... 23

Opcicon One-Step 1.5 mg tablet............. 33

OptiChamber Diamond VHC spacer ...... 128

OptiChamber Diamond VHC with Large

Mask ................................................ 129

OptiChamber Diamond VHC with Medium

Mask ................................................ 129

OptiChamber Diamond VHC with Small

Mask ................................................ 129

Opti-Clear 0.05 % eye drops ................. 135

Optimal D3 1,250 mcg (50,000 unit)

capsule .............................................. 99

Optimal D3 M 350 mcg (14,000 unit)

capsule .............................................. 99

Option-2 1.5 mg tablet .......................... 33

Optisource 9 mg iron-200 mcg-40 mcg

chewable tablet ................................. 80

OPTI-VITAMINS 1,000 UNIT-200 MG-60

UNIT-2MG TABLET ............................. 80

OPURITY 1,000 MCG-200 MCG

SUBLINGUAL TABLET ......................... 94

OPURITY MULTIVITAMIN 30 MG IRON-800

MCG CHEWABLE TABLET ................... 81

Ora-Blend oral suspension ..................... 31

Ora-Blend SF oral suspension ................. 31

Oral Mix oral suspension ........................ 31

Oral Mix SF oral suspension ................... 31

ORAL SALINE LAXATIVE 7.2 GRAM-2.7

GRAM/15 ML ORAL LIQUID ............. 119

Oral Suspend oral ................................... 31

Oral Suspending Compound Plus oral .... 31

Oral Syrup oral liquid .............................. 31

Oral Syrup SF oral liquid ......................... 31

Oralyte oral solution .............................. 69

Ora-Plus oral suspension ........................ 31

Ora-Sweet oral syrup .............................. 31

Ora-Sweet SF oral liquid ......................... 32

ORAZINC 50 MG ZINC (220 MG) CAPSULE

...........................................................69

ORGAN-I NR 200 MG TABLET ............... 155

ORIGINAL NASAL SPRAY 0.05 % ........... 159

ORMIR 50 MG CAPSULE ......................... 23

ORTHO-TABS 500 MG CALCIUM-400 UNIT-

15 MCG TABLET ................................. 59

OS-CAL 500 + D3 500 MG (1,250 MG)-200

UNIT TABLET ...................................... 61

OS-CAL 500 + D3 500 MG (1,250 MG)-600

UNIT TABLET ...................................... 61

OSTEO-PORETICAL 600 MG (1,500 MG)-

1,000 UNIT TABLET ............................ 61

OVEGA-3 500 MG-270 MG-135 MG

CAPSULE ............................................ 23

OVEGA-3 500 MG-320 MG-130 MG

CAPSULE ............................................ 23

Overnight Lubricating Eye 94 %-3 %

ointment .......................................... 131

OVIDREL 250 MCG/0.5 ML

SUBCUTANEOUS SYRINGE ............... 102

oxymetazoline 0.05 % nasal spray ........ 159

OXYTROL 3.9 MG/24 HR TRANSDERMAL

PATCH .............................................. 125

OH Buckeye MMP Opt-Out Formulary August 1, 2021 208

OXYTROL FOR WOMEN 3.9 MG/24 HOUR

TRANSDERMAL PATCH .....................125

Oysco 500/D 500 mg (1,250 mg)-200 unit

tablet .................................................61

OYSCO-500 500 MG CALCIUM (1,250 MG)

TABLET ...............................................57

Oyster Shell + D3 250 mg-125 unit tablet

...........................................................61

Oyster Shell Calcium 500 500 mg calcium

(1,250 mg) tablet ...............................57

Oyster Shell Calcium 500 mg calcium

(1,250 mg) tablet ...............................57

Oyster Shell Calcium-Vitamin D3 250 mg-

125 unit tablet ...................................61

Oyster Shell Calcium-Vitamin D3 500 mg

(1,250 mg)-200 unit tablet .................61

Oyster Shell Calcium-Vitamin D3 500 mg

(1,250 mg)-400 unit tablet .................61

Oyster Shell Calcium-Vitamin D3 500

mg(1,250 mg)-200 unit powder packt

...........................................................61

Oystercal-D 500 mg (1,250 mg)-400 unit

tablet .................................................62

P

Pain and Fever 325 mg tablet .................16

Pain and Fever 500 mg tablet .................16

Pain Relief (acetaminophen) 160 mg/5 mL

oral liquid ...........................................16

Pain Relief (acetaminophen) 500 mg

tablet .................................................16

Pain Relief (acetaminophen) 650 mg

tablet,extended release .....................16

Pain Relief (acetaminophen-aspirin-caff)

250 mg-250 mg-65 mg tablet ............19

Pain Relief 8HR 650 mg tablet,extended

release ...............................................16

Pain Relief Adult 500 mg/15 mL oral liquid

...........................................................16

Pain Relief Allergy Sinus 2 mg-5 mg-325

mg tablet ..........................................140

Pain Relief Cold and Cough 1,000 mg-30

mg/30 mL oral liquid ........................166

PAIN RELIEF EXTRA STRENGTH 500 MG

TABLET ...............................................16

Pain Relief PM 25 mg-500 mg tablet ......17

Pain Relief Regular Strength 325 mg tablet

...........................................................16

Pain Relief Sinus PE 5 mg-325 mg tablet

.........................................................151

Pain Reliever (acetaminophen) 325 mg

tablet .................................................16

Pain Reliever (acetaminophen) 500 mg

capsule ...............................................16

Pain Reliever (acetaminophen) 500 mg

tablet ................................................. 16

Pain Reliever Extra Strength 500 mg tablet

...........................................................16

Pain Reliever Plus 250 mg-250 mg-65 mg

tablet ................................................. 19

Pain Reliever PM Ex-Strength 25 mg-500

mg tablet ........................................... 17

Panda Mask .......................................... 129

PANOXYL 10 % TOPICAL CLEANSER ........ 34

PANOXYL-4 4 % TOPICAL CLEANSER ....... 34

Parvlex 29 mg iron-400 mcg tablet ......... 66

PCCA Aladerm Base ointment ................ 28

PCCA Anhydrous Lipoderma cream ........ 28

PCCA Cosmetic HRT Base cream ............. 28

PCCA Emollient Base topical cream ........ 43

PCCA Lipoderm Base cream .................... 28

PCCA MVC Cream ................................... 28

PCCA Natacream .................................... 28

PCCA Vanishing Base cream ................... 28

PCCA-Plus Base oral suspension ............. 32

P-COL RITE 8.6 MG-50 MG TABLET ....... 122

PC-Tar 1 % shampoo ............................... 48

Peak Air Peak Flow Meter .................... 127

Pedia D-Vite 10 mcg/mL (400 unit/mL)

oral drops .......................................... 99

Pedia Iron 15 mg iron (75 mg)/mL oral

drops.................................................. 64

Pedia Poly-Vite 750 unit-35 mg-400

unit/mL oral drops ............................. 90

Pedia Poly-Vite with Iron 10 mg/mL oral

drops.................................................. 92

PEDIA RELIEF COUGH-COLD 1 MG-15 MG-

5 MG/5 ML ORAL LIQUID ................. 165

Pedia Tri-Vite 750 unit-35 mg-400 unit/mL

oral drops .......................................... 90

PEDIACARE FEVER REDUCER 160 MG/5 ML

ORAL SUSPENSION............................. 16

PEDIACARE MULTI-SYMPTOM COLD 2.5

MG-5 MG/5 ML ORAL LIQUID .......... 167

PEDIACLEAR ALLERGY 0.313 MG/ML ORAL

DROPS .............................................. 146

PEDIACLEAR COUGH 6.25 MG/ML ORAL

DROPS .............................................. 146

PEDIACLEAR PD 0.625 MG/ML ORAL

DROPS .............................................. 146

PEDIA-LAX 400 MG (170 MG

MAGNESIUM) CHEWABLE TABLET ... 119

PEDIA-LAX STOOL SOFTENER 50 MG/15

ML ORAL SYRUP ............................... 124

PEDIALYTE ADVANCED CARE ORAL

SOLUTION .......................................... 69

PEDIALYTE FREEZER POPS ORAL SOLUTION

...........................................................69

PEDIALYTE ORAL SOLUTION ................... 69

PEDIALYTE SINGLES ORAL SOLUTION ..... 69

PEDIATRIC COUGH AND COLD 1 MG-15

MG-5 MG/5 ML ORAL LIQUID.......... 165

Pediatric Electrolyte oral solution .......... 69

Pediatric Enema 9.5 gram-3.5 gram/59 mL

.........................................................119

Pediatric Freezer Pops oral solution ....... 69

Pediatric Medium Mask ....................... 129

pediatric multivitamin no.171 750 unit-35

mg-400 unit/mL oral drops ................ 90

pediatric multivitamin no.194-ferrous

sulfate 10 mg iron/mL oral drops ...... 92

Pediatric Panda Mask ........................... 129

Pediatric Small Mask ............................ 129

PEDIAVANCE 5.3 MEQ-2.35 MEQ-4.15

MEQ ORAL CONCENTRATE IN PACKET

...........................................................69

Pediavent 2 mg/5 mL oral liquid........... 146

PEDI-BORO SOAK 839 MG-1,191 MG

TOPICAL POWDER IN PACKET ............ 40

Peg Ointment Base (Bulk) 40 %-60 % ..... 29

Pegblend 59 %-39 %-2 % wax ................. 29

PENcream Compounding Agent ............. 29

PenDerm transdermal cream ................. 29

PEN-KERA TOPICAL CREAM .................... 42

PenSomal transdermal cream ................ 29

Pentravan Plus topical cream ................. 29

Pentravan transdermal cream ................ 29

PEPCID 20 MG TABLET ......................... 111

PEPCID AC 10 MG TABLET .................... 111

PEPCID AC 20 MG TABLET .................... 111

PEPTIC RELIEF 262 MG CHEWABLE TABLET

.........................................................109

PEPTIC RELIEF 262 MG/15 ML ORAL

SUSPENSION .................................... 109

Pepto-Bismol 262 mg chewable tablet.109

PEPTO-BISMOL 262 MG TABLET ........... 109

PEPTO-BISMOL 262 MG/15 ML ORAL

SUSPENSION .................................... 109

PEPTO-BISMOL MAX ST 525 MG/15 ML

ORAL SUSPENSION .......................... 109

PEPTO-BISMOL TO-GO 262 MG

CHEWABLE TABLET .......................... 109

Percogesic 12.5 mg-325 mg tablet ......... 17

PERDIEM OVERNIGHT RELIEF 15 MG

TABLET ............................................. 121

Perfect Iron 25 mg tablet ....................... 64

PERI-COLACE 8.6 MG-50 MG TABLET ... 122

PeriGuard topical ointment .................... 49

PeriShield 3.8 % topical ointment .......... 49

PeriShield topical ointment .................... 48

permethrin 1 % topical liquid ................. 51

PERSA-GEL 10 % TOPICAL ....................... 34

Personal Best Full Range device ........... 127

Personal Best Low Range device .......... 127

PETROLATUM TOPICAL OINTMENT ........ 42

PFCB cream ............................................ 29

OH Buckeye MMP Opt-Out Formulary August 1, 2021 209

Pharbechlor 4 mg tablet .......................146

Pharbedryl 25 mg capsule ....................146

Pharbedryl 50 mg capsule ....................146

Pharbetol 325 mg tablet .........................16

Pharbetol 500 mg tablet .........................16

Pharmabase Cosmetic topical cream ......29

Pharmabase Heavy topical cream ..........29

Pharmabase Light topical cream.............29

Pharmabase Natural topical cream ........29

Pharmabase topical cream .....................29

Pharmabase Vaginal cream ....................29

PHAZYME 180 MG CAPSULE .................113

phenylephrine 10 mg tablet .................178

phenylephrine 10 mg-dextromethorphan

17.5 mg-guaifenesin 385 mg tablet .170

phenylephrine 10 mg-DM 18 mg-

guaifenesin 200 mg/15 mL oral liquid

.........................................................170

PHENYLHISTINE DH 2 MG-30 MG-10 MG/5

ML ORAL LIQUID ..............................175

PHILLIPS' LIQUI-GELS 100 MG CAPSULE124

PHILLIPS MILK OF MAGNESIA 400 MG/5

ML ORAL SUSPENSION .....................119

PHLEXY-VITS ORAL PACKET .....................55

Phos-NaK 280 mg-160 mg-250 mg oral

powder packet ...................................69

PHOSPHATE LAXATIVE 7.2 GRAM-2.7

GRAM/15 ML ORAL LIQUID..............119

Phosphorous Supplement 280 mg-160

mg-250 mg oral powder packet .........69

Phytobase cream ....................................29

PHYTOMULTI 3 MG-3 MG-200 MG TABLET

...........................................................11

phytonadione (vitamin K1) 1 mg/0.5 mL

injection syringe ...............................101

phytonadione (vitamin K1) 10 mg/mL

injection solution .............................101

phytonadione (vitamin K1) 5 mg tablet 101

Picoderm topical cream ..........................29

Piko 1 device .........................................127

PINK BISMUTH 262 MG CHEWABLE

TABLET .............................................109

PINK BISMUTH 262 MG TABLET ............109

PINK BISMUTH 262 MG/15 ML ORAL

SUSPENSION ....................................109

PINK BISMUTH 525 MG/15 ML ORAL

SUSPENSION ....................................109

PINK BISMUTH MAXIMUM STRENGTH 525

MG/15 ML ORAL SUSPENSION .........109

Pinworm Treatment 50 mg/mL oral

suspension .........................................19

Plan B One-Step 1.5 mg tablet ................33

Plantar Wart Remover 40 % topical patch

...........................................................47

PNA-HRT Base Cream .............................29

POCKET CHAMBER spacer ....................129

Pocket Peak Flow Meter ....................... 127

Poly Bacitracin (zinc) 500 unit-10,000

unit/gram topical ointment ............... 35

Poly Bacitracin 500 unit-10,000 unit/gram

topical ointment ................................ 35

POLY HIST FORTE (DOXYLAMINE) 7.5 MG-

10 MG TABLET ................................. 137

POLY HIST FORTE 10.5 MG-10 MG TABLET

.........................................................138

POLY HIST PD 6.25 MG-6.25 MG/ML ORAL

DROPS .............................................. 166

polyethylene glycol 1000 (bulk) powder 29

polyethylene glycol 3350 (bulk) powder 29

polyethylene glycol 3350 17 gram oral

powder packet ................................. 119

polyethylene glycol 3350 17 gram/dose

oral powder ..................................... 119

polyethylene glycol 8000 (bulk) 100 % wax

...........................................................29

polyethylene glycol 8000 (bulk) powder 29

POLY-HIST DM (THONZYLAMINE) 25 MG-5

MG-10 MG/5 ML ORAL LIQUID ........ 165

POLY-IRON 150 FORTE 150 MG-25 MCG-1

MG CAPSULE ...................................... 66

POLY-IRON 150 MG IRON CAPSULE ........ 64

polysaccharide iron complex 150 mg iron

capsule ............................................... 64

POLYSPORIN 500 UNIT-10,000

UNIT/GRAM TOPICAL PACKET ........... 35

POLY-TUSSIN AC 4 MG-10 MG-10 MG/5

ML ORAL LIQUID .............................. 175

POLYTUSSIN DM 1 MG-5 MG-10 MG/5 ML

ORAL SYRUP ..................................... 165

POLY-VENT DM 60 MG-20 MG-380 MG

TABLET ............................................. 170

POLY-VENT IR 60 MG-380 MG TABLET .154

polyvinyl alcohol 1.4 % eye drops ......... 133

POLY-VI-SOL 250 MCG-50 MG-10 MCG/ML

ORAL DROPS ...................................... 90

Poly-Vita (iron) 1,500 unit-400 unit-10

mg/mL oral drops .............................. 92

Poly-Vita 1,500 unit-35 mg-400 unit/mL

oral drops .......................................... 90

Poly-Vita Drops 750 unit-35 mg-400

unit/mL oral ....................................... 90

Poly-Vita With Iron 10 mg/mL oral drops

...........................................................92

Poly-Vitamin 1,500 unit-35 mg-400

unit/mL oral drops ............................. 90

Poly-Vitamin with Iron 1,500 unit-400

unit-10 mg/mL oral drops .................. 92

POLYVITAMIN WITH IRON 12 MG

CHEWABLE TABLET ............................ 92

Polyvitamin with Iron(with Vit K) 18 mg

iron-0.4 mg-55 mcg chew tablet ........ 81

Poly-Vitamins chewable tablet ............... 90

potassium bromide (bulk) crystals ......... 29

potassium, sodium phosphates 280 mg-

160 mg-250 mg oral powder packet .. 69

povidone-iodine 10 % sponge ................ 36

povidone-iodine 10 % topical liquid packet

...........................................................36

povidone-iodine 10 % topical ointment .36

povidone-iodine 10 % topical solution ... 36

povidone-iodine 10 % topical spray ....... 36

povidone-iodine 10 % topical swab ........ 36

povidone-iodine 7.5 % topical solution .. 36

Powderlax 17 gram oral powder packet

.........................................................119

Powderlax 17 gram/dose oral .............. 119

Pracasil TM-Plus gel ................................ 29

prenatal vit no.95-ferrous fumarate 28

mg-folic acid 800 mcg tablet ............. 93

Prenatal Vitamin 27 mg iron-0.8 mg tablet

...........................................................93

Prenatal Vitamin tablet .......................... 93

prenatal vitamin-ferrous fumarate 28 mg

iron-folic acid 800 mcg tablet ............ 93

Prenatal Vitamins with Minerals 28 mg

iron-800 mcg tablet ........................... 93

prenatal vits 96-ferrous fumarate 27 mg

iron-folic acid 800 mcg tablet ............ 93

PREPARATION H 0.25 %-14 %-74.9 %

OINTMENT ......................................... 19

PREPARATION H HYDROCORTISONE 1 %

TOPICAL CREAM ................................ 44

PREPARATION H(PHENYLEPH,COCOA

BUTTR) 0.25 %-88.44 % RECTAL

SUPPOSITORY .................................... 19

Pres Gen 5 mg-10 mg-200 mg/5 mL oral

liquid................................................ 170

PRESERVISION AREDS 14,320 UNIT-226

MG-200 UNIT CAPSULE ..................... 81

PRESERVISION AREDS 7,160 UNIT-113

MG-100 UNIT TABLET ........................ 81

PRESERVISION AREDS-2 250 MG-90 MG-

40 MG-1 MG CAPSULE ......................... 9

PRESERVISION LUTEIN 226 MG-200 UNIT-

5 MG-0.8 MG CAPSULE ...................... 81

Pressure-Pain PE Plus Mucus 5 mg-325

mg-200 mg tablet ............................ 152

Pretty Feet Hands topical cream ............ 43

PREVACID 15 MG CAPSULE,DELAYED

RELEASE ........................................... 112

PREVACID 24HR 15 MG CAPSULE,DELAYED

RELEASE ........................................... 112

Prevent capsule ...................................... 81

PRILOSEC OTC 20 MG TABLET,DELAYED

RELEASE ........................................... 112

Pro Comfort Spacer-Adult Mask ........... 129

Pro Comfort Spacer-Child Mask ........... 129

PRO FE 180 MG IRON CAPSULE .............. 64

OH Buckeye MMP Opt-Out Formulary August 1, 2021 210

Probiotic 10 billion cell capsule ............114

Probiotic 3 billion cell chewable tablet.114

Probiotic Acidophilus 1.5 mg (250 million

cell) capsule .....................................114

Probiotic Acidophilus-Pectin 100 million

cell-10 mg capsule ...........................114

Probiotic Gold Acidophilus 1 billion cell

capsule .............................................114

PRO-CAL 187.5 MG-40 MG-7.5 MG TABLET

...........................................................59

Procare Spacer With Adult Mask ..........129

Procare Spacer With Child Mask ...........129

Procedural Face Masks .........................126

PROCERV HP 9 MG IRON-300 MCG-50

MCG TABLET ......................................81

ProChamber ..........................................129

promethazine 6.25 mg-codeine 10 mg/5

mL syrup ..........................................175

Promethazine VC-Codeine 6.25 mg-5 mg-

10 mg/5 mL oral syrup .....................175

promethazine-DM 6.25 mg-15 mg/5 mL

oral syrup .........................................167

promethazine-phenylephrine-codeine

6.25 mg-5 mg-10 mg/5 mL oral syrup

.........................................................175

PROMOLAXIN 100 MG TABLET .............124

propylene glycol (bulk) 99.5 % (not less

than, USP) liquid ................................29

PRO-RED AC (WITH

DEXCHLORPHENIRAMINE) 1 MG-5 MG-

9 MG/5 ML ORAL LIQUID .................176

PRORENAL 8 MG IRON-800 MCG-1,000

UNIT TABLET ......................................53

PRORENAL QD 400 MCG-500 UNIT

CAPSULE.............................................81

PROSHIELD PLUS 1 % TOPICAL OINTMENT

...........................................................49

Prosight 5,000 unit-60 mg-30 unit tablet .9

Prosight with Lutein 60 mg-30 unit-6 mg

capsule ...............................................81

PROSTEON 250 MG CALCIUM-500 UNIT

TABLET ...............................................62

PROTECT CARDIO AF 0.5 MG-30 MG-60

MG-90 MG CAPSULE ..........................81

PROTECT PLUS NF 10 MG IRON-1 MG/15

ML ORAL LIQUID ................................81

PROTECT PLUS SO 0.5 MG-15 MG

CAPSULE.............................................81

PROVIL 200 MG TABLET ..........................18

Proxeed Plus 200 mcg-1 gram-0.5 gram-50

mg oral powder packet ......................55

pseudoephedrine 30 mg tablet ............178

pseudoephedrine 30 mg/5 mL oral liquid

.........................................................178

pseudoephedrine 60 mg tablet ............178

pseudoephedrine ER 120 mg

tablet,extended release ................... 178

pseudoephedrine-guaifenesin ER 120 mg-

1,200 mg tab,extend release 12hr ... 154

pseudoephedrine-guaifenesin ER 60 mg-

600 mg tablet,extend release 12hr 154

Psoriasis Medicated 3 % shampoo ......... 47

psyllium husk 0.52 gram capsule .......... 117

psyllium husk 2.6 gram/4.1 gram oral

powder ............................................ 117

PURALUBE 85 %-15 % EYE OINTMENT .131

PURE AND GENTLE EYE 0.3 % DROPS ... 133

Pure L-Citrulline 600 mg capsule ............ 52

PureComfort Peak Flow Meter ............. 127

PUREFE PLUS 106 MG IRON-1 MG

CAPSULE ............................................ 81

PURELAX 17 GRAM ORAL POWDER

PACKET ............................................ 119

Purelax 17 gram/dose oral powder ...... 119

PUREVIT DUALFE PLUS 162 MG-115.2 MG

(106 MG)-1 MG CAPSULE .................. 87

pyridoxine (bulk) 100 % powder ............. 29

pyridoxine (bulk) crystals ........................ 29

pyridoxine (vitamin B6) 100 mg tablet ... 96

pyridoxine (vitamin B6) 100 mg/mL

injection solution ............................... 96

pyridoxine (vitamin B6) 25 mg tablet ..... 96

pyridoxine (vitamin B6) 50 mg tablet ..... 96

pyrilamine-phenylephrine 25 mg-10 mg

tablet ............................................... 138

Q

Q-Derm cream ........................................ 29

Q-Dryl 12.5 mg/5 mL oral liquid ........... 146

Q-Dryl 25 mg capsule ........................... 146

Q-GEL 15 mg-3 unit capsule ................... 11

Q-Gel Forte 30 mg-6 unit capsule ........... 11

Q-Gel Mega 100 mg-150 unit capsule .... 11

Q-Gel Ultra 60 mg-150 unit capsule ....... 11

Q-PAP 325 mg tablet .............................. 16

Q-PAP 500 mg tablet .............................. 16

Q-PAP Extra Strength 500 mg tablet ....... 16

Q-Sorb Co Q-10 100 mg capsule ............. 11

Q-Sorb Co Q-10 150 mg capsule ............. 11

Q-Sorb Co Q-10 200 mg capsule ............. 11

Q-Sorb Co Q-10 Plus 100 mg-20 mg

capsule ............................................... 11

Q-TAPP 1 MG-15 MG/5 ML ORAL LIQUID

.........................................................138

Q-TAPP DM 1 MG-15 MG-5 MG/5 ML

ORAL ELIXIR ..................................... 165

Q-TUSSIN 100 MG/5 ML ORAL LIQUID .155

Q-TUSSIN DM 10 MG-100 MG/5 ML ORAL

SYRUP .............................................. 174

Quin B Strong 500 mg-400 mcg-15 mg

tablet ................................................. 53

Quintabs 400 mcg tablet ........................ 87

QUINTABS-M 10 MG IRON-400 MCG

TABLET ............................................... 81

Quintabs-M Iron Free 0.4 mg tablet ....... 81

Quit 2 mg buccal lozenge ....................... 25

Quit 2 mg gum ........................................ 25

Quit 4 mg buccal lozenge ....................... 25

Quit 4 mg gum ........................................ 25

R

RABANO YODADO 50 MG/15 ML ORAL

LIQUID ............................................... 55

Ranger Ready Repellent 20 % topical spray

with pump ......................................... 46

ranitidine 150 mg tablet ....................... 111

Ready-To-Use Enema (mineral oil) ....... 118

READY-TO-USE ENEMA 19 GRAM-7

GRAM/118 ML ................................. 119

RECORT PLUS 1 % TOPICAL CREAM ........ 44

Redness Reliever Eye Drops 0.05 % ...... 135

REESE'S PINWORM MEDICINE 50 MG/ML

ORAL SUSPENSION ............................ 20

REFENESEN 400 MG TABLET ................ 155

REFENESEN DM 20 MG-400 MG TABLET

.........................................................174

REFENESEN PE 10 MG-400 MG TABLET 154

REFRESH CELLUVISC 1 % EYE GEL IN A

DROPPERETTE ................................. 133

REFRESH CLASSIC (PF) 1.4 %-0.6 % EYE

DROPS IN A DROPPERETTE .............. 132

REFRESH DIGITAL 0.5 %-1 %-0.5 % EYE

DROPS ............................................. 132

REFRESH DIGITAL PF 0.5 %-1 %-0.5 % EYE

DROPS IN A DROPPERETTE .............. 132

REFRESH LACRI-LUBE 56.8 %-42.5 % EYE

OINTMENT ....................................... 132

REFRESH LIQUIGEL 1 % EYE LIQUID GEL

DROPS ............................................. 134

REFRESH OPTIVE 1 %-0.9 % EYE GEL

DROPS ............................................. 132

REFRESH OPTIVE ADVANCED (PF) 0.5 %-1

%-0.5 % EYE DROPS IN DROPPERETTE

.........................................................132

REFRESH OPTIVE ADVANCED 0.5 %-1 %-

0.5 % EYE DROPS ............................. 132

REFRESH OPTIVE MEGA-3 (PF) 0.5 %-1 %-

0.5 % EYE DROPS IN A DROPPERETTE

.........................................................132

REFRESH OPTIVE SENSITIVE (PF) 0.5 %-0.9

% EYE DROPS IN A DROPPERETTE .... 132

REFRESH P.M. 57.3 %-42.5 % EYE

OINTMENT ....................................... 132

OH Buckeye MMP Opt-Out Formulary August 1, 2021 211

REFRESH PLUS 0.5 % EYE DROPS IN A

DROPPERETTE ..................................134

REFRESH RELIEVA PF 0.5 %-0.9 % EYE

DROPS ..............................................132

REFRESH REPAIR 0.5 %-0.9 % EYE DROPS

.........................................................132

REFRESH TEARS 0.5 % EYE DROPS.........134

Reguloid (psyllium husk) 0.52 gram

capsule .............................................117

Reguloid (psyllium husk-sucrose) 3

gram/12 gram oral powder ..............117

Reguloid, Sugar Free oral powder .........117

Rejuvacare Plus transdermal cream .......29

RelCof C 6.3 mg-100 mg/5 mL oral liquid

.........................................................177

RelCof DM 4 mg-7.5 mg-15 mg/5 mL oral

liquid ................................................165

RelCof IR 10 mg-380 mg tablet .............154

Relhist BP 4 mg-10 mg tablet ................138

Relhist DMX 10 mg-15 mg-380 mg tablet

.........................................................170

Remedy Antifungal 2 % topical cream ....38

Remedy Antifungal 2 % topical powder 38

Remedy Clear-Aid Protect 50 % topical

ointment ............................................49

Remedy Dimethicone Cream 5 % topical49

Remedy Nutrashield Skin Protec 1 %

cream .................................................49

Remedy Phytoplex Antifungal 2 % topical

ointment ............................................38

Remedy Phytoplex Antifungal 2 % topical

powder...............................................38

Remedy Skin Repair 1.5 % cream ...........50

RENAL CAPS 1 MG CAPSULE ...................53

Renal Vitamin 0.8 mg tablet ...................53

Renal-Vite 0.8 mg tablet .........................53

RenaPlex 800 mcg-12.5 mg tablet ..........54

RenaPlex-D 800 mcg-12.5 mg-2,000 unit

tablet .................................................54

RENA-VITE 0.8 MG TABLET .....................54

RENA-VITE RX 1 MG-60 MG-300 MCG

TABLET ...............................................55

RENEWAL MOISTURIZING CREAM TOPICAL

...........................................................40

Reno Caps 1 mg capsule .........................54

Repel 100 98.11 % topical pump spray 46

Repel Family 10 % topical spray ..............46

Repel Family 15 % topical spray powder 46

Repel Hunter's 25 % topical spray ..........46

Repel Lemon Eucalyptus 30 % topical

spray ..................................................46

Repel Sportsmen 25 % topical spray .......46

Repel Sportsmen Dry 25 % topical spray 46

Repel Sportsmen Max 40 % lotion ..........46

Repel Sportsmen Max 40 % topical pump

spray ..................................................46

Repel Sportsmen Max 40 % topical spray

...........................................................46

Repel Tick Defense 15 % topical spray .... 46

REPHRESH PRO-B 2.5 BILLION CELL

CAPSULE ............................................ 56

REPLESTA 1,250 MCG (50,000 UNIT) ORAL

WAFER ............................................... 99

REPLESTA NX 350 MCG (14,000 UNIT)

ORAL WAFER ..................................... 99

REQ49+ 200 MCG-1.5 MG-1.5 MG TABLET

...........................................................81

Rescon 2 mg-60 mg tablet .................... 138

Rescon-DM 2 mg-30 mg-10 mg/5 mL oral

liquid ................................................ 165

RESCON-GG 5 MG-100 MG/5 ML ORAL

LIQUID ............................................. 154

Respaire-30 30 mg-150 mg capsule ...... 154

Restore Plus (carboxymethylcellulose) 0.5

% eye drops in a dropperette .......... 134

Restore PM 57.3 %-42.5 % eye ointment

.........................................................132

Restore Tears 0.5 % eye drops ............. 134

Retaine CMC 0.5 % eye drops in a

dropperette ..................................... 134

Retaine PM 80 %-20 % eye ointment ... 132

Revive Plus 0.5 % eye drops in a

dropperette ..................................... 134

REZIRA 60 MG-5 MG/5 ML ORAL

SOLUTION ........................................ 176

RHINARIS 0.2 % NASAL SPRAY .............. 157

RID COMPLETE LICE ELIMINATION KIT 4 %-

0.33 %-0.5 % TOPICAL ........................ 51

RID LICE KILLING 0.33 %-4 % SHAMPOO.51

RIGHT STEP PRENATAL VITAMINS 27 MG

IRON-0.8 MG TABLET ......................... 93

Ringworm 1 % topical cream .................. 38

RiteFlo Aerochamber ............................ 129

Robafen 100 mg/5 mL oral liquid ......... 155

ROBAFEN AC 10 MG-100 MG/5 ML ORAL

LIQUID ............................................. 177

Robafen CF (phenylephrine) 5 mg-10 mg-

100 mg/5 mL oral liquid ................... 170

ROBAFEN COUGH 15 MG CAPSULE ...... 150

Robafen DM 10 mg-100 mg/5 mL oral

syrup ................................................ 174

Robafen DM Cough 10 mg-100 mg/5 mL

oral liquid ......................................... 174

Robafen DM Cough-Chest Congestion 10

mg-100 mg/5 mL oral syrup ............. 174

ROBITUSSIN COLD-FLU NIGHT (PE) 12.5

MG-5 MG-325 MG/10 ML ORAL LIQUID

.........................................................140

ROBITUSSIN COUGH AND COLD CF 2.5

MG-5 MG-50 MG/5 ML ORAL LIQUID

.........................................................170

ROBITUSSIN COUGH-CHEST CONGESTION

DM 5 MG-100 MG/5 ML ORAL LIQUID

.........................................................174

ROBITUSSIN COUGHGEL 15 MG CAPSULE

.........................................................150

ROBITUSSIN LONG-ACTING 1 MG-7.5

MG/5 ML ORAL LIQUID.................... 167

ROBITUSSIN PEDIATRIC 7.5 MG/5 ML

ORAL SYRUP .................................... 150

ROLAIDS 550 MG-110 MG CHEWABLE

TABLET ............................................. 103

Rondec-D 30 mg-12.5 mg/5 mL oral liquid

.........................................................167

RU-HIST D 4 MG-10 MG TABLET ........... 138

Rulox 200 mg-200 mg-20 mg/5 mL oral

suspension ....................................... 107

Rydex 1.3 mg-10 mg-6.3 mg/5 mL oral

liquid................................................ 176

Rymed (dexchlorpheniramine-

phenylephrine) 2 mg-10 mg tablet .. 138

Rynex DM 1 mg-2.5 mg-5 mg/5 mL oral

solution ........................................... 166

Rynex PE 1 mg-2.5 mg/5 mL oral solution

.........................................................138

Rynex PSE 1 mg-15 mg/5 mL oral liquid

.........................................................138

S

Sa3derm cream ...................................... 29

SAFE TUSSIN DM 10 MG-100 MG/5 ML

ORAL LIQUID .................................... 174

SALACTIC FILM 17 % TOPICAL LIQUID .... 47

salicylic acid (bulk) powder .................... 30

Saline Mist 0.65 % nasal spray aerosol .157

Saline Nasal (aloe vera) gel ................... 157

Saline Nasal 0.65 % spray aerosol ........ 157

Saline Nasal Mist 0.65 % spray aerosol.157

Saline Nose 0.65 % spray aerosol ......... 157

salmon oil 1,000 mg-omega-3 fatty acids

210 mg capsule .................................. 23

SAL-PLANT 17 % TOPICAL GEL ................ 47

Salt Durable topical cream ..................... 30

SaltStable LO cream base ....................... 30

SaltStable LS cream ................................ 30

Sanare Advanced Scar Therapy Base

topical gel .......................................... 30

SAVision tablet ....................................... 81

SCALP ITCH-DANDRUFF RELIEF 3 %

TOPICAL LIQUID ................................. 47

Scalp Relief 1 % topical solution ............. 44

SCALP RELIEF 3 % TOPICAL LIQUID ......... 47

SCALPICIN ANTI-ITCH 1 % TOPICAL

SOLUTION .......................................... 44

SCOOBY-DOO ONE A DAY CHEWABLE

TABLET ............................................... 92

OH Buckeye MMP Opt-Out Formulary August 1, 2021 212

SCOOBY-DOO ONE A DAY KIDS CHEWABLE

TABLET ...............................................90

Scot-Tussin Expectorant 100 mg/5 mL oral

liquid ................................................156

SEA SOFT NASAL MIST 0.65 % SPRAY

AEROSOL ..........................................157

Sea-Omega 200 mg-300 mg-100 mg-1,000

mg capsule .........................................56

Sebex 2 %-2 % shampoo .........................46

SECURA ANTIFUNGAL 2 % TOPICAL

CREAM ...............................................38

SECURA ANTIFUNGAL EXTRA THICK 2 %

TOPICAL CREAM .................................38

SECURA DIMETHICONE 5 % TOPICAL

CREAM ...............................................50

Sedanare cream ......................................30

SELSUN BLUE (SALICYLIC ACID) 3 %

SHAMPOO ..........................................47

SELSUN BLUE 1 % SHAMPOO ..................40

SELSUN BLUE MOISTURIZING 1 %

SHAMPOO ..........................................40

SELSUN BLUE NATURALS 3 % SHAMPOO47

Senexon 8.6 mg tablet ..........................121

SENEXON 8.8 MG/5 ML ORAL SYRUP ...121

Senexon-S 8.6 mg-50 mg tablet ............122

Senior Tabs 0.4 mg-300 mcg-250 mcg

tablet .................................................81

senna 8.6 mg capsule............................121

SENNA 8.6 MG TABLET .........................121

senna 8.8 mg/5 mL oral syrup ..............121

Senna Lax 8.6 mg tablet ........................121

SENNA LAXATIVE 25 MG TABLET ..........121

Senna Laxative 8.6 mg tablet ................121

SENNA LAXATIVE-STOOL SOFTENER 8.6

MG-50 MG TABLET ..........................122

Senna Plus 8.6 mg-50 mg capsule .........122

SENNA PLUS 8.6 MG-50 MG TABLET ....122

SENNA PROMPT 9 MG-500 MG CAPSULE

.........................................................122

Senna with Docusate Sodium 8.6 mg-50

mg tablet ..........................................122

Senna-Extra 17.2 mg tablet ..................121

Sennalax-S 8.6 mg-50 mg tablet ...........123

Senna-S 8.6 mg-50 mg tablet ................123

Senna-Time S 8.6 mg-50 mg tablet .......123

Senno 8.6 mg tablet ..............................121

sennosides 8.6 mg-docusate sodium 50

mg tablet ..........................................123

sennosides 8.8 mg/5 mL oral syrup ......121

SENOKOT 8.6 MG TABLET .....................121

SENOKOT EXTRA STRENGTH 17.2 MG

TABLET .............................................122

SENOKOT-S 8.6 MG-50 MG TABLET ......123

Sensi-Care Body Cream 1 %-30 % topical

...........................................................48

SENTRY (WITH LUTEIN) 18 MG-500 MCG-

300 MCG-250 MCG TABLET ............... 81

Sentry 18 mg-400 mcg tablet ................. 87

Sentry Senior 0.4 mg-300 mcg-250 mcg

tablet ................................................. 81

SENTRY SENIOR 500 MCG-300 MCG-250

MCG TABLET ...................................... 81

sesame oil ............................................... 31

SE-TAN PLUS 162 MG-115.2 MG (106

MG)-1 MG CAPSULE .......................... 87

Severe Allergy-Sinus Headache 25 mg-5

mg-325 mg tablet ............................ 140

Severe Cold 5 mg-10 mg-325 mg-200 mg

tablet ............................................... 162

Severe Cold and Flu (phenylephrine) 5 mg-

10 mg-325 mg-200 mg tablet .......... 162

Severe Cold and Flu-Daytime (DM) 5 mg-

10 mg-325 mg/15 mL oral liquid ...... 168

Severe Cold Cough-Flu 25 mg-10 mg-650

mg oral powder packet .................... 140

Severe Cold Multi-Symptom 5 mg-10 mg-

325 mg-200 mg tablet ..................... 162

SEVERE COLD PE 12.5 MG-5 MG-325 MG

TABLET ............................................. 140

Severe Cold-Flu (phenylephrine) 5 mg-10

mg-325 mg-200 mg/15 mL liquid..... 162

Severe Cold-Flu Nighttime 6.25 mg-5 mg-

10 mg-325 mg/15 mL oral liquid ...... 160

Severe Congestion Relief 10 mg-650 mg-

400 mg/20 mL oral liquid ................. 152

Severe Cough-Congestion 2.5 mg-5 mg-

100 mg/5 mL oral liquid ................... 170

Shake That Ache 500 mg tablet .............. 16

Siderol tablet .......................................... 66

Silace 50 mg/5 mL oral liquid ................ 124

Silace 60 mg/15 mL oral syrup .............. 124

Siladryl SA 12.5 mg/5 mL oral liquid ..... 146

Silapap 160 mg/5 mL oral liquid ............. 16

Silphen Cough 12.5 mg/5 mL oral syrup

.........................................................146

SILTUSSIN DM DAS 10 MG-100 MG/5 ML

ORAL LIQUID .................................... 174

Siltussin SA 100 mg/5 mL oral liquid ..... 156

Siltussin-DM 10 mg-100 mg/5 mL oral

syrup ................................................ 174

SIMETHICONE 125 MG CAPSULE .......... 113

simethicone 125 mg chewable tablet ... 113

simethicone 180 mg capsule ................ 113

simethicone 40 mg/0.6 mL oral

drops,suspension ............................. 113

simethicone 80 mg chewable tablet ..... 113

SIMILAC PRENATAL 27 MG IRON-800

MCG-200 MG ORAL PACK .................. 93

simple syrup ........................................... 32

SIMPLY SLEEP 25 MG TABLET ................. 23

Sinus 12 Hour 120 mg tablet,extended

release ............................................. 178

SINUS AND ALLERGY (PHENYLEPHRINE) 4

MG-10 MG TABLET .......................... 138

SINUS AND ALLERGY PE 4 MG-10 MG

TABLET ............................................. 138

Sinus and Cold-D 220 mg-120 mg

tablet,extended release .................. 152

Sinus Congestion and Pain

(chlorpheniramine) 2 mg-5 mg-325 mg

tablet ............................................... 140

Sinus Congestion and Pain (guaifenesin) 5

mg-325 mg-200 mg tablet ............... 152

SINUS CONGESTION AND PAIN 5 MG-325

MG TABLET ...................................... 151

Sinus Congestion and Pain Day-Night 2

mg-5 mg-325 mg tablets ................. 140

Sinus Daytime-Nightime 5-325

mg(dy)/6.25-5-325mg(nt) tablets .... 140

Sinus Decongestant (PE) 10 mg tablet .. 178

Sinus Headache PE 5 mg-325 mg tablet

.........................................................151

Sinus Nasal Spray 0.05 % ...................... 159

Sinus Pain Relief 5 mg-325 mg tablet ... 151

Sinus Pain-Pressure (PE) 5 mg-325 mg

tablet ............................................... 151

Sinus PE Decongestant 10 mg tablet .... 178

Sinus Relief (Non-Drowsy) 5 mg-325 mg

tablet ............................................... 151

SINUS RELIEF (OXYMETAZOLINE) 0.05 %

NASAL MIST ..................................... 159

Sinus Relief (oxymetazoline) 0.05 % nasal

spray ................................................ 159

Sinus Relief (phenylephrine) 1 % nasal

spray ................................................ 159

Sinus Relief Max Str Day-Night 5-325-200

mg(d)/25-5-325 mg(n) tablets ......... 141

Sinus Relief Pressure and Pain 5 mg-325

mg-200 mg tablet ............................ 152

Sinus Relief Severe Congestion 5 mg-325

mg-200 mg tablet ............................ 152

Skin Treatment 12 % lotion .................... 43

SkyyDerm Cream Base ........................... 30

SLEEP 25 MG TABLET .............................. 23

Sleep Aid (diphenhydramine) 25 mg tablet

...........................................................23

Sleep Aid (diphenhydramine) 50 mg

capsule .............................................. 23

Sleep Aid Max Strength

(diphenhydramine) 50 mg capsule .... 23

Sleep II 25 mg tablet ............................... 24

SLEEP TABLET (DIPHENHYDRAMINE) 25

MG TABLET ........................................ 24

SLEEP-TABS 25 MG TABLET .................... 24

SLO-NIACIN 250 MG TABLET,EXTENDED

RELEASE ............................................. 95

OH Buckeye MMP Opt-Out Formulary August 1, 2021 213

Slo-Niacin 500 mg tablet,extended release

...........................................................96

SLOW FE 142 MG (45 MG IRON)

TABLET,EXTENDED RELEASE ..............64

Slow Release Iron 140 mg (45 mg iron)

tablet,extended release .....................64

Slow Release Iron 142 mg (45 mg iron)

tablet,extended release .....................64

Slow Release Iron 143 mg (45 mg iron)

tablet,extended release .....................64

Slow Release Iron 144 mg (45 mg iron)

tablet,extended release .....................64

Slow Release Iron 159 mg (45 mg iron)

tablet,extended release .....................64

SLOW RELEASE IRON 160 MG (50 MG

IRON) TABLET,EXTENDED RELEASE ....65

Slow Release Iron 168 mg (50 mg iron)

tablet,extended release .....................65

Slow Release Iron 250 mg (50 mg iron)

tablet,extended release .....................65

SLOW-MAG 71.5 MG TABLET,DELAYED

RELEASE .............................................68

SMOOTH ANTACID 300 MG (750 MG)

CHEWABLE TABLET ..........................104

SmoothLax 17 gram oral powder packet

.........................................................119

SmoothLax 17 gram/dose oral powder 119

Sochlor 5 % eye drops ...........................135

Sochlor 5 % eye ointment .....................135

sodium benzoate (bulk) powder .............30

sodium bicarbonate 325 mg tablet .......103

sodium bicarbonate 650 mg tablet .......103

sodium bromide (bulk) granules .............30

sodium chloride (bulk) granules .............30

sodium chloride 0.65 % nasal spray

aerosol .............................................158

sodium chloride 1,000 mg soluble tablet69

sodium chloride 5 % eye drops .............135

sodium chloride 5 % eye ointment .......135

sodium citrate-citric acid 500 mg-334

mg/5 mL oral solution ......................125

sodium ferric gluconate complex in

sucrose 62.5 mg/5 mL intravenous ....65

SOF-LAX 100 MG CAPSULE....................124

SOLO 400 MCG-80 MCG TABLET .............81

SOLUBLE FIBER 500 MG TABLET ...........117

SOLUVITA-E 22.5 MG (50 UNIT)/ML ORAL

DROPS ..............................................100

Soothe (bismuth subsalicylate) 262 mg

chewable tablet ...............................109

Soothe (bismuth subsalicylate) 262 mg

tablet ...............................................109

Soothe and Cool Medseptic 50 % topical

ointment ............................................43

Soothe and Cool Moisture Barrier 92.8 %

topical ointment ................................48

Soothe and Cool Moisture Barrier 98.3 %

topical ointment ................................ 48

SOOTHE AND COOL SKIN CREAM WITH

ALOE .................................................. 42

Soothe and Cool Skin Paste topical

ointment ............................................ 48

SOOTHE HYDRATION 1.25 % EYE DROPS

.........................................................134

SOOTHE NIGHT TIME LUBRICANT 80 %-20

% EYE OINTMENT ............................. 132

Soothe Regular Strength 262 mg/15 mL

oral suspension ................................ 109

SOOTHE XP 1 %-4.5 % EYE DROPS ........ 135

Soothe-Cool Protect Medseptic 50 %

topical ointment ................................ 43

Soothing Care (hydrocortisone) 1 %

topical cream ..................................... 44

Soothing PureWay-C 500 mg tablet ....... 96

SOOTHING SALINE-ALOE NASAL SPRAY 158

Sorbidon Hydrate topical cream ............. 43

sorbitol 70 % solution ............................. 32

SORBOLENE TOPICAL CREAM ................. 42

Sorbugen NR 10 mg-100 mg/5 mL oral

liquid ................................................ 174

SoSweet Syrup Vehicle ........................... 32

Space Chamber ..................................... 129

Space Chamber with Large Mask .......... 129

Space Chamber with Medium Mask ..... 129

Space Chamber with Small Mask .......... 129

Special Care Lotion topical ..................... 42

Spectravite Adult 18 mg-400 mcg tablet 87

Spectravite Adult 200 mcg chewable

tablet ................................................. 82

Spectravite Adult 50 Plus 0.4 mg-300 mcg-

250 mcg tablet ................................... 82

Spectravite Adult 50 Plus(with lutein) 500

mcg-250 mcg chewable tablet ........... 82

Spectravite Advanced Formula 18 mg-400

mcg tablet .......................................... 87

Spectravite Men 50 Plus 300 mcg-600

mcg-300 mcg tablet ........................... 82

Spectravite Men's 8 mg iron-200 mcg-600

mcg tablet .......................................... 82

Spectravite Senior 500 mcg-300 mcg-250

mcg tablet .......................................... 82

Spectravite Senior tablet ........................ 56

Spectravite Ultra Men 50+ 300 mcg-600

mcg-300 mcg tablet ........................... 82

Spectravite Ultra Men's Senior 300 mcg-

600 mcg-300 mcg tablet .................... 82

Spectravite Ultra Women 18 mg-400 mcg

tablet ................................................. 87

Spectravite Ultra Women's Senior 8 mg

iron-400 mcg-300 mcg tablet ............ 82

Spectravite Women 50 Plus 8 mg iron-400

mcg-300 mcg tablet ........................... 82

ST JOSEPH ASPIRIN 81 MG CHEWABLE

TABLET ............................................. 126

St. Joseph Aspirin 81 mg tablet,delayed

release ............................................. 126

STAFLEX (BROMPHENIRAMINE-

ACETAMINOPHEN) 2 MG-250 MG

TABLET ............................................... 17

Stahist AD 25 mg-60 mg tablet ............. 138

Stahist AD 25 mg-60 mg/5 mL oral liquid

.........................................................138

Stera Base cream .................................... 30

Sterile Eye Drops 0.05 % ....................... 135

Sterile Saline 0.9 % nasal spray aerosol 158

Stimulant Laxative Plus 8.6 mg-50 mg

tablet ............................................... 123

Stomach Relief 262 mg chewable tablet

.........................................................109

Stomach Relief 262 mg tablet .............. 109

Stomach Relief 262 mg/15 mL oral

suspension ....................................... 109

STOMACH RELIEF 525 MG/15 ML ORAL

SUSPENSION .................................... 109

Stomach Relief Max Strength 525 mg/15

mL oral suspension .......................... 109

STOMACH RELIEF ORIGINAL 262 MG/15

ML ORAL SUSPENSION .................... 109

STOOL SOFTENER (DOCUSATE CALCIUM)

240 MG CAPSULE............................. 124

Stool Softener 100 mg capsule ............. 124

Stool Softener 100 mg tablet ............... 124

Stool Softener 250 mg capsule ............. 124

STOOL SOFTENER 50 MG CAPSULE ...... 124

Stool Softener 50 mg/5 mL oral liquid .. 124

Stool Softener 60 mg/15 mL oral syrup 125

STOOL SOFTENER-LAXATIVE 8.6 MG-50

MG TABLET ...................................... 123

Stool Softener-Stimulant Laxative 8.6 mg-

50 mg capsule .................................. 123

Stool Softener-Stimulant Laxative 8.6 mg-

50 mg tablet .................................... 123

STOP SMOKING AID 2 MG BUCCAL

LOZENGE ........................................... 25

STOP SMOKING AID 4 MG BUCCAL

LOZENGE ........................................... 25

STRESS B PLUS ZINC TABLET ................... 54

Stress B With Zinc tablet ........................ 54

Stress B-Complex 500 mg-400 mcg-23.9

mg-3 mg tablet .................................. 82

Stress B-Complex 500 mg-400 mcg-24 mg-

3 mg tablet ........................................ 82

STRESS FORMULA TABLET ...................... 67

Stress Formula with Iron 500 mg-400 mcg-

18 mg iron tablet ............................... 54

Stress Formula With Iron(sulf) 500 mg-400

mcg-27 mg iron tablet ....................... 54

STRESS FORMULA WITH ZINC TABLET .... 54

OH Buckeye MMP Opt-Out Formulary August 1, 2021 214

STROVITE FORTE 10 MG-1 MG TABLET ..82

STROVITE ONE 1 MG-1,000 UNIT-15 MG-5

MG TABLET ........................................ 82

Stuart One 27 mg iron-800 mcg-200 mg

capsule ...............................................93

Studio 35 Moisturizing Skin cream .........42

Stye Lubricant 57.7 %-31.9 % eye

ointment ..........................................132

Sudafed 12 Hour 120 mg tablet,extended

release .............................................178

SUDAFED 30 MG TABLET ......................178

Sudogest 12-hour 120 mg tablet,extended

release .............................................178

Sudogest 30 mg tablet ..........................178

SUDOGEST 60 MG TABLET ....................178

SudoGest Cold and Allergy 4 mg-60 mg

tablet ...............................................138

Sudogest PE 10 mg tablet .....................178

SudoGest Sinus and Allergy 4 mg-60 mg

tablet ...............................................138

Sunvite 18 mg iron-400 mcg-25 mcg tablet

...........................................................82

Super Antioxidant capsule ......................82

Super B Complex + C 150 mg tablet ........54

SUPER B COMPLEX-VITAMIN C TABLET ..54

Super B/C capsule ...................................54

Super Daily D3 25 mcg/drop (1,000

unit/drop) oral drops .........................99

Super Daily D3 50 mcg/drop (2,000

unit/drop) oral drops .........................99

Super DHA Gems 500 mg-100 mg-1,000

mg capsule .........................................23

Super Multiple - Low Iron 400 mcg tablet

...........................................................82

Super Multiple 0.4 mg capsule ...............82

Super Multiple tablet ..............................82

Super Omega-3 1,000 mg capsule ..........20

SUPER THERA VITE M TABLET .................82

SUPER TWIN EPA-DHA 1,250 MG CAPSULE

...........................................................20

SUPERPLEX-T TABLET ..............................54

Suphedrin 15 mg/5 mL oral liquid .........178

SUPHEDRIN 30 MG TABLET ...................178

Suphedrine 12 Hour 120 mg

tablet,extended release ...................178

Suphedrine 30 mg tablet ......................178

SUPHEDRINE PE 10 MG TABLET ............178

SUPHEDRINE PE COLD AND ALLERGY 4

MG-10 MG TABLET ..........................138

Suphedrine PE Sinus and Allergy 4 mg-10

mg tablet ..........................................138

Suphedrine PE Sinus Headache 5 mg-325

mg tablet ..........................................151

Support oral liquid ..................................82

SURFAK 240 MG CAPSULE ....................125

SuspendRx Anhydrous Sweetened oral ..32

SuspendRx Anhydrous Unsweetened oral

...........................................................32

SWEEN 24 6 % topical cream .................. 50

Sweetening Suspending Compounding

Vehicle oral syrup .............................. 32

Sweet-SF oral liquid ................................ 32

SyrPalta Vehicle oral syrup ..................... 32

SyrSpend SF Alka oral powder for

suspension ......................................... 32

SyrSpend SF Liquid oral suspension ........ 32

Syrspend SF oral powder for suspension32

Syrspend SF PH4 oral powder for

suspension ......................................... 32

Syrup Vehicle SF oral solution ................ 32

SYSTANE (PF) 0.4 %-0.3 % EYE DROPS IN A

DROPPERETTE .................................. 132

SYSTANE (PROPYLENE GLYCOL) 0.4 %-0.3

% EYE DROPS ................................... 132

SYSTANE BALANCE 0.6 % EYE DROPS ... 134

SYSTANE COMPLETE 0.6 % EYE DROPS.134

Systane Contacts eye drops .................. 134

SYSTANE GEL 0.3 % EYE GEL ................. 134

SYSTANE GEL 0.4 %-0.3 % EYE DROPS .. 132

SYSTANE HYDRATION PF 0.4 %-0.3 % EYE

DROPS .............................................. 132

SYSTANE HYDRATION PF 0.4 %-0.3 % EYE

DROPS IN A DROPPERETTE .............. 133

SYSTANE NIGHTTIME 94 %-3 % EYE

OINTMENT ....................................... 133

SYSTANE ULTRA (PF) 0.4 %-0.3 % EYE

DROPS IN A DROPPERETTE .............. 133

Systane Ultra 0.4 %-0.3 % eye drops .... 133

T

Tab Tussin 400 mg tablet ...................... 156

Tab Tussin DM 20 mg-400 mg tablet .... 174

Tab-A-Vite Multivitamin w-iron 15 mg

iron-400 mcg tablet ........................... 82

TAB-A-VITE/IRON TABLET ....................... 82

Tab-A-Vite-Minerals tablet ..................... 83

TACTINAL 325 MG TABLET...................... 16

TACTINAL EXTRA STRENGTH 500 MG

TABLET ............................................... 16

Tagamet HB 200 mg tablet ................... 111

Take Action 1.5 mg tablet ....................... 33

Taliva 1 mg-12.5 mg-0.5 mg-500 mg

capsule ............................................... 56

Tame The Flame 195 mg calcium (500 mg)

chewable tablet ............................... 104

Tandem Plus 162 mg-115.2 mg (106 mg)-1

mg capsule ......................................... 87

TARON FORTE 150 MG-60 MG-25 MCG-1

MG CAPSULE ...................................... 67

Tears Again (PVA) 1.4 % eye drops ....... 134

TEARS NATURALE PM 94 %-3 % EYE

OINTMENT ....................................... 133

TENDER CARE LANOLIN TOPICAL CREAM

...........................................................43

Tera-Gel Tar Shampoo 0.5 % .................. 48

terbinafine HCl 1 % topical cream .......... 37

TESSALON PERLES 100 MG CAPSULE .... 150

THE MAGIC BULLET 10 MG RECTAL

SUPPOSITORY .................................. 122

theophylline (bulk) powder .................... 30

Thera M Plus (ferrous fumarate) 9 mg

iron-400 mcg tablet ........................... 83

THERA TABLET ........................................ 87

THERACAL 250 MG CALCIUM-500 UNIT

TABLET ............................................... 62

THERACAL D2000 250 MG CALCIUM-500

UNIT TABLET ...................................... 62

THERACAL D4000 250 MG CALCIUM-1,000

UNIT TABLET ...................................... 62

THERA-D 4000 100 MCG (4,000 UNIT)

TABLET ............................................... 99

THERA-D 50 MCG (2,000 UNIT) TABLET100

THERAFLU EXPRESSMAX COLD-COUGH

DAY 5 MG-10 MG-325 MG TABLET .. 168

THERAFLU EXPRESSMAX COLD-COUGH

DAY 5 MG-10 MG-325 MG/15 ML ORAL

LIQUID ............................................. 168

THERAFLU EXPRESSMAX COLD-COUGH

NIGHT 12.5 MG-5 MG-325 MG TABLET

.........................................................140

THERAFLU FLU-SORE THROAT 20 MG-10

MG-650 MG ORAL POWDER PACKET

.........................................................140

THERAFLU NIGHTTIME POWERPOD 25

MG-10 MG-650 MG ORAL POWDER IN

POD ................................................. 140

THERAFLU NIGHTTIME SEVERE COLD-

COUGH 25 MG-10 MG-650 MG

POWDER PACKET ............................. 140

Thera-Gel 0.5 % shampoo ...................... 48

Theragran-M Premier 50 Plus 400 mcg-

250 mcg-375 mcg tablet .................... 83

THERALOGIX COMPANION 0.4 MG TABLET

...........................................................83

Thera-M 27 mg-0.4 mg tablet ................ 83

Thera-M 9 mg iron-400 mcg tablet ........ 83

THERA-M TABLET ................................... 83

THERANATAL 9 MG IRON-400 MCG-90

MCG ORAL PACK ................................ 83

Therapeutic Dandruff Shampoo 3 % ...... 47

Therapeutic Moisturizing topical cream.42

Therapeutic Shampoo 0.5 % .................. 48

Therapeutic Shampoo 1 % ..................... 48

Therapeutic T Plus 3 % shampoo............ 47

THERAPEUTIC-M VITAMIN/MINERALS 27

MG-0.4 MG TABLET ........................... 83

OH Buckeye MMP Opt-Out Formulary August 1, 2021 215

Thera-Tabs M 27 mg iron-400 mcg tablet

...........................................................83

Thera-Tabs tablet....................................87

Theratrum Complete 50 Plus with Lutein

tablet .................................................56

Theratrum Complete 50

Plus(lycopene,lutein) 0.4 mg-300 mcg-

250 mcg tab .......................................83

THERATRUM COMPLETE WITH LUTEIN

TABLET ...............................................83

Therems tablet .......................................83

Therems-H 27 mg-0.33 mg tablet ...........83

THEREMS-M 27 MG-0.4 MG TABLET ......83

THERMOTABS 287 MG-180 MG-15 MG

TABLET ...............................................69

THEROMEGA 250 MG-350 MG-1,000 MG

CAPSULE.............................................23

THEROMEGA SPORT 250 MG-350 MG-

1,000 MG CAPSULE ............................23

thiamine HCl (bulk) powder ....................30

thiamine HCl (vitamin B1) 100 mg/mL

injection solution ...............................94

TINACTIN 1 % TOPICAL CREAM ...............39

TINACTIN 1 % TOPICAL POWDER ............39

TINACTIN 1 % TOPICAL SPRAY ................39

TINACTIN 1 % TOPICAL SPRAY POWDER.39

tioconazole 6.5 % vaginal ointment ......180

Tioconazole-1 6.5 % vaginal ointment ..180

TL-Hem 150 150 mg-1 mg-50 mg

tablet,extended release .....................67

tolnaftate 1 % topical cream ...................39

tolnaftate 1 % topical powder ................39

tolnaftate 1 % topical solution ................39

tolnaftate 1 % topical spray powder .......39

TOTAL ALLERGY MEDICINE 25 MG TABLET

.........................................................146

TOTAL B/C TABLET ..................................54

Total Home Insect Repellent 30 % topical

spray ..................................................46

Totalday Multiple tablet,extended release

...........................................................83

T-Plus 0.5 % shampoo .............................48

TRAVEL SICKNESS (MECLIZINE) 25 MG

CHEWABLE TABLET ..........................110

TRAVEL SICKNESS 50 MG TABLET .........110

Travel-Ease (meclizine) 25 mg tablet ....110

triamcinolone acetonide 55 mcg nasal

spray aerosol....................................156

TRIAMINIC COLD AND COUGH (PE) 2.5

MG-5 MG/5 ML ORAL LIQUID ..........167

TRIAMINIC COLD AND COUGH NIGHT

TIME(PE)6.25 MG-2.5 MG/5 ML ORAL

LIQUID ..............................................138

TRI-BIOZENE 3.5 MG-500 UNIT-10,000

UNIT/GRAM TOPICAL OINTMENT ......36

TRICON 110 MG-0.5 MG CAPSULE ..........67

TRIFERIC 272 MG IRON POWDER CONC.

FOR HEMODIALYSIS ........................... 65

TRIGELS-F FORTE 460 MG-60 MG-0.01

MG-1 MG CAPSULE ............................ 67

TRIPHROCAPS 1 MG CAPSULE ................ 54

Triple Antibiotic (pram) Extra 3.5 mg-500

unit-10,000 unit/g Top Oint ............... 36

Triple Antibiotic 3.5 mg-400 unit-5,000

unit topical ointment packet ............. 35

Triple Antibiotic 3.5 mg-400 unit-5,000

unit/gram topical ointment ............... 35

Triple Antibiotic Plus 3.5 mg-500 unit-

10,000 unit/gram top ointment ......... 36

Triple Antibiotic-Pain Relief 3.5 mg-500

unit-10,000 unit/gram ointmnt ......... 36

Triple Cream topical ............................... 42

Triple Magnesium Complex 400 mg

magnesium capsule ........................... 68

TRIPLE PASTE AF 2 % TOPICAL OINTMENT

...........................................................38

triprolidine HCl 0.313 mg/mL oral drops

.........................................................146

triprolidine HCl 0.625 mg/mL oral drops

.........................................................147

triprolidine HCl 0.938 mg/mL oral drops

.........................................................147

Tri-Vita 1,500 unit-35 mg-400 unit/mL oral

drops.................................................. 90

TRONVite 1 mg-100 mg-300 mcg tablet .54

Tropical Liquid Nutrition oral .................. 90

TRUEplus Diabetic Multivitamin 500 mcg-

10 mcg tablet ..................................... 83

TRUEplus Glucose 15 gram/32 mL oral gel

packet .............................................. 102

Trustex Latex Condom .......................... 126

Trustex Lubricated Condoms ................ 126

Trustex Non-Lubricated Condoms ........ 126

Trustex-RIA Lubricated Condoms ......... 126

Trustex-RIA Lubricated/Spermicide

Condom ........................................... 126

Trustex-RIA Non-Lubricated Condoms .126

Truzone Peak Flow Meter ..................... 127

TUMS 200 MG CALCIUM (500 MG)

CHEWABLE TABLET .......................... 104

TUMS 300 MG (750 MG) CHEWABLE

TABLET ............................................. 104

TUMS E-X 300 MG (750 MG) CHEWABLE

TABLET ............................................. 105

TUMS EXTRA STRENGTH SMOOTHIES 300

MG (750 MG) CHEWABLE TABLET ... 105

TUMS FRESHERS 200 MG CALCIUM (500

MG) CHEWABLE TABLET .................. 105

TUMS ULTRA 400 MG CALCIUM (1,000

MG) CHEWABLE TABLET .................. 105

TUMS ULTRA 470 MG CALCIUM (1,177

MG) CHEWABLE TABLET .................. 105

TUSNEL C 30 MG-10 MG-100 MG/5 ML

ORAL SYRUP .................................... 176

TUSNEL DIABETIC 10 MG-100 MG/5 ML

ORAL LIQUID .................................... 174

TUSNEL DM

PEDIATRIC(PSEUDOEPHEDRINE) 7.5

MG-2.5 MG-25 MG/ML ORAL DROPS

.........................................................170

TUSNEL NEW FORMULA 30 MG-15 MG-

200 MG/5 ML ORAL SOLUTION ....... 170

TUSNEL NEW FORMULA 60 MG-30 MG-

400 MG TABLET ............................... 170

TUSNEL PEDIATRIC 15 MG-5 MG-50 MG/5

ML ORAL LIQUID .............................. 170

TUSNEL PEDIATRIC 7.5 MG-50 MG/ML

ORAL DROPS .................................... 154

TUSSICAPS 10 MG-8 MG

CAPSULE,EXTENDED RELEASE ......... 175

TUSSIGON 5 MG-1.5 MG TABLET ......... 176

TUSSIN 100 MG/5 ML ORAL LIQUID ..... 156

Tussin 400 mg tablet ............................ 156

Tussin CF (PE-DM-guaif) 5 mg-10 mg-100

mg/5 mL oral liquid ......................... 170

Tussin CF Cough-Cold 5 mg-10 mg-100

mg/5 mL oral liquid ......................... 171

Tussin CF MAX 5 mg-10 mg-200 mg/5 mL

oral liquid ........................................ 171

Tussin CF Max Severe M-S Cold 10 mg-20

mg-650 mg/20 mL oral liquid .......... 163

Tussin Chest Congestion 100 mg/5 mL oral

liquid................................................ 156

TUSSIN COUGH (DM ONLY) 15 MG

CAPSULE .......................................... 150

Tussin Cough (DM only) 15 mg/5 mL oral

liquid................................................ 150

TUSSIN COUGH AND CHEST CONGESTION

10 MG-100 MG/5 ML ORAL LIQUID .174

Tussin DM 10 mg-100 mg/5 mL oral liquid

.........................................................174

TUSSIN DM 10 MG-100 MG/5 ML ORAL

SYRUP .............................................. 174

Tussin DM 20 mg-400 mg tablet .......... 174

TUSSIN DM CLEAR 10 MG-100 MG/5 ML

ORAL SYRUP .................................... 174

TUSSIN DM COUGH 10 MG-100 MG/5 ML

ORAL SYRUP .................................... 174

Tussin DM Cough and Chest 10 mg-100

mg/5 mL oral syrup ......................... 174

Tussin DM Cough and Chest 10 mg-200

mg/5 mL oral liquid ......................... 174

Tussin DM Cough and Chest 5 mg-100

mg/5 mL oral liquid ......................... 174

TUSSIN DM MAX 10 MG-200 MG/5 ML

ORAL LIQUID .................................... 174

Tussin Expectorant 100 mg/5 mL oral

liquid................................................ 156

OH Buckeye MMP Opt-Out Formulary August 1, 2021 216

Tussin Long-Acting 15 mg/5 mL oral liquid

.........................................................150

TUSSIN MAXIMUM STRENGTH 15 MG/5

ML ORAL SYRUP ...............................150

TUSSIN MAXIMUM STRENGTH COUGH 15

MG/5 ML ORAL SYRUP .....................151

Tussin Mucus-Chest Congestion 100 mg/5

mL oral liquid ...................................156

TUSSIONEX PENNKINETIC ER 10 MG-8

MG/5 ML SUSPENSION,EXTENDED

RELEASE ...........................................175

Tussi-Pres 5 mg-10 mg-200 mg/5 mL

(10mL) oral liquid in packet .............171

Tussi-Pres 5 mg-10 mg-200 mg/5 mL oral

liquid ................................................171

TYLENOL 325 MG TABLET .......................16

TYLENOL EXTRA STRENGTH 500 MG

TABLET ...............................................16

U

U-Base topical cream ..............................30

ULTIMATE MEN'S COMPLETE 50+ 300

MCG-600 MCG-300 MCG TABLET ......83

Ultimate Women's Complete 50+ 8 mg

iron-400 mcg-300 mcg tablet .............83

Ultra Freeda 267 mcg tablet ...................83

Ultra Freeda 6 mg iron-267 mcg tablet ...83

ULTRA FRESH 0.5 % EYE DROPS ............134

Ultra Fresh PM eye ointment ................133

Ultra Lubricant Eye 0.4 %-0.3 % drops 133

Ultra Men's Pack 200 mcg-1,600 unit-300

mg oral pack.......................................56

ULTRA OMEGA-3 200 MG-300 MG-100

MG-1,000 MG CAPSULE .....................56

Ultra Omega-3 500 mg (200mg-300mg)-

1,000 mg capsule ...............................23

Ultra Strength Antacid 400 mg calcium

(1,000 mg) chewable tablet .............105

Ultraderm Base cream ............................30

ULTRATHON 25 % TOPICAL SPRAY ..........46

ULTRATHON 34.34 % LOTION .................46

Unicomplex-M tablet ..............................83

UNISOM SLEEPGELS 50 MG CAPSULE .....24

Upcal D 500 mg calcium-12.5 mcg (500

unit)/5 gram oral powder ..................62

Upcal D 500 mg calcium-12.5 mcg (500

unit)/5 gram oral powder packet .......62

urea 10 % lotion ......................................43

UREACIN-10 10 % LOTION ......................43

Urinary Pain Relief 95 mg tablet ...........125

Urinary Pain Relief 97.5 mg tablet ........125

Uristat 95 mg tablet ..............................125

Uristix 4 strips .........................................52

Uristix Reagent strips ..............................52

V

VAGISTAT-3 200 MG-2 % (9 GRAM)

VAGINAL KIT .................................... 180

VALU-DRYL ALLERGY 25 MG CAPSULE .. 147

VANACLEAR PD 0.313 MG/ML ORAL

DROPS .............................................. 147

VANACOF 1 MG-30 MG-12.5 MG/5 ML

ORAL LIQUID .................................... 166

VANACOF AC 25 MG-12.5 MG/30 ML

ORAL LIQUID .................................... 167

VANACOF DM 10 MG-18 MG-200 MG/15

ML ORAL LIQUID .............................. 171

VANACOF-8 50 MG-25 MG/15 ML ORAL

LIQUID ............................................. 167

VANAHIST PD 0.625 MG/ML ORAL DROPS

.........................................................147

VANALICE 0.3 %-3.5 % TOPICAL GEL ....... 51

VANAMINE PD 6.25 MG/ML ORAL DROPS

.........................................................147

VANATAB AC 25 MG-12.5 MG TABLET .167

VANATAB DM 5 MG-9 MG-198 MG

TABLET ............................................. 171

Vanibase topical cream .......................... 30

Vanibase Traditional Formula topical

cream ................................................. 30

Vanicream topical ................................... 43

Vanishing Cream ..................................... 30

Vanishing Cream topical ......................... 30

Vanish-Pen Cream Base topical .............. 30

VAZOTAB (PYRILAMINE) 25 MG-10 MG

TABLET ............................................. 138

V-C FORTE 1 MG CAPSULE ...................... 83

VEGETABLE LAXATIVE 8.6 MG TABLET 122

Vegetable Laxative-Stool Softener 8.6 mg-

50 mg tablet .................................... 123

VELVACHOL TOPICAL CREAM ................. 42

VENOFER 100 MG IRON/5 ML

INTRAVENOUS SOLUTION .................. 65

VENOFER 200 MG IRON/10 ML

INTRAVENOUS SOLUTION .................. 65

VENOFER 50 MG IRON/2.5 ML

INTRAVENOUS SOLUTION .................. 65

Versa Free oral solution .......................... 32

Versa Plus oral suspension ..................... 32

Versapro Cream Base topical .................. 30

Versatile Rich topical cream ................... 30

Versatile topical cream ........................... 30

Versigel cream ........................................ 30

VIC-Forte 1 mg capsule ........................... 83

VICKS DAYQUIL COLD AND FLU RELIEF 5

MG-10 MG-325 MG CAPSULE .......... 168

VICKS DAYQUIL COLD AND FLU RELIEF 5

MG-10 MG-325 MG/15 ML ORAL

LIQUID ............................................. 168

VICKS DAYQUIL MUCUS CONTROL DM 10

MG-200 MG/15 ML ORAL LIQUID.... 175

VICKS DAYQUIL SEVERE COLD-FLU 5 MG-

10 MG-325 MG-200 MG TABLET ..... 163

VICKS DAYQUIL SEVERE COLD-FLU 5 MG-

10 MG-325 MG-200 MG/15 ML LIQUID

.........................................................163

VICKS NYQUIL COLD/FLU LIQUICAP 6.25

MG-15 MG-325 MG CAPSULE.......... 164

VICKS NYQUIL COUGH 6.25 MG-15 MG/15

ML ORAL SOLUTION ........................ 167

VICKS NYQUIL NIGHTTIME RELIEF 6.25

MG-15 MG-325 MG/15 ML ORAL

LIQUID ............................................. 164

VICKS NYQUIL SEVERE COLD-FLU 6.25 MG-

5 MG-10 MG-325MG/15ML ORAL

LIQUID ............................................. 160

VICKS QLEARQUIL 0.05 % NASAL MIST .159

VICKS SINEX 12-HOUR 0.05 % NASAL

SPRAY .............................................. 159

VICKS SINEX DAYTIME 5 MG-325 MG

CAPSULE .......................................... 151

VICKS SINEX ULTRA FINE MIST 12-HOUR

0.05 % NASAL SPRAY ....................... 159

VIRT-CAPS 1 MG CAPSULE ...................... 54

Virt-FeFA Plus 125 mg iron-1 mg capsule

...........................................................67

Virtrate-2 500 mg-334 mg/5 mL oral

solution ........................................... 125

VIRTUSSIN AC 10 MG-100 MG/5 ML ORAL

LIQUID ............................................. 177

VIRTUSSIN DAC 30 MG-10 MG-100 MG/5

ML ORAL SYRUP ............................... 176

Virt-Vite 2.5 mg-25 mg-1 mg tablet ........ 94

Virt-Vite Forte 2.5 mg-25 mg-2 mg tablet

...........................................................94

Virt-Vite Plus 5 mg tablet ....................... 54

VISINE 0.05 % EYE DROPS ..................... 135

VISINE ADVANCED REDNESS RELIEF 0.05

%-0.1 %-1 %-1 % EYE DROPS ........... 135

VISINE-AC 0.05 %-0.25 % EYE DROPS ... 135

Vision Formula (A-C-E-zinc-copper) 14,320

unit-226 mg-200 unit capsule ............ 84

Vision Formula (with lutein) 1,000 unit-

200 mg-60 unit-2mg tablet ................ 84

Vision Formula(A-C-E-Zn-Se-Cu) 1,000

unit-60 mg-30 unit tablet .................. 84

Vision Formula-2 250 mg-90 mg-40 mg-1

mg capsule .......................................... 9

Vision Plus Lutein tablet ......................... 56

VISION-VITE + ZINC TABLET .................... 84

VISTA GEL 0.3 % EYE GEL ...................... 134

VISTA MEIBO TEARS 0.6 % EYE DROPS .134

VIT 3 500 MG-500 MCG-1 MG-12.5 MG

CAPSULE ............................................ 87

OH Buckeye MMP Opt-Out Formulary August 1, 2021 217

vit A palmitate 750 unit-vit C 35 mg-vit D3

400 unit/mL oral drops ......................90

vit E-wheat germ-aloe vera topical

ointment ............................................41

Vita-Bee with C 400 mcg tablet ..............54

Vitabex Plus 500 mcg-25 mg-10 mg

capsule ...............................................84

Vitacel (with Lutein) 800 mcg-250 mcg-

750 mcg tablet ...................................84

VITAFOL 65 MG-1 MG TABLET ................67

VitaJoy Daily D 25 mcg (1,000 unit)

chewable tablet ...............................100

VITAL-D RX 1,750 UNIT-60 MG-1 MG-12.5

MG TABLET ......................................100

Vitalee 0.4 mg tablet ..............................84

Vitalets 10 mg iron chewable tablet .......92

VITALETS CHEWABLE TABLET .................92

VITAMENT 0.5 MG-270 MG-200 MG-25

MG ORAL POWDER PACKET ...............11

vitamin A 10,000 unit capsule ................94

vitamin A 2,400 mcg capsule ..................94

vitamin A palmitate 10,000 unit capsule 94

vitamin A palmitate 10,000 unit tablet ...94

vitamin A palmitate 15,000 unit tablet ...94

vitamin B complex-vitamin C-folic acid 400

mcg tablet ..........................................54

Vitamin B-1 100 mg tablet ......................94

Vitamin B-1 50 mg tablet ........................94

vitamin B12 500 mcg-folic acid 400 mcg

tablet .................................................94

Vitamin B-12 ER 1,000 mcg

tablet,extended release .....................95

Vitamin B-6 100 mg tablet ......................96

Vitamin B-6 50 mg tablet ........................96

Vitamin C 1,000 mg tablet ......................97

Vitamin C 100 mg tablet .........................97

Vitamin C 250 mg tablet .........................97

Vitamin C 500 mg chewable tablet .........97

Vitamin C 500 mg tablet .........................97

Vitamin C Energy Booster 1,000 mg oral

effervescent powder packet ..............93

Vitamin C ER 1,000 mg tablet,extended

release ...............................................97

Vitamin C Fizzy Drink 1,000 mg oral

effervescent powder packet ..............93

Vitamin C With Rose Hips 1,000 mg tablet

...........................................................97

Vitamin C With Rose Hips 500 mg tablet97

Vitamin D2 1,250 mcg (50,000 unit)

capsule .............................................100

Vitamin D3 10 mcg (400 unit) capsule ..100

Vitamin D3 10 mcg (400 unit) chewable

tablet ...............................................100

Vitamin D3 10 mcg (400 unit) tablet .....100

Vitamin D3 100 mcg (4,000 unit) capsule

.........................................................100

Vitamin D3 125 mcg (5,000 unit) tablet100

Vitamin D3 25 mcg (1,000 unit) capsule

.........................................................100

Vitamin D3 25 mcg (1,000 unit) chewable

tablet ............................................... 100

Vitamin D3 25 mcg (1,000 unit) tablet 100

Vitamin D3 50 mcg (2,000 unit) capsule

.........................................................100

Vitamin D3 50 mcg (2,000 unit) tablet 100

Vitamin D3 Complete 18 mg iron-800 mcg-

150 mg tablet .................................... 56

vitamin E (dl, acetate) 22.5 mg (50

unit)/mL oral drops .......................... 100

vitamin E (dl, acetate) 400 unit capsule100

vitamin E (dl, acetate) 45 mg (100 unit)

capsule ............................................. 100

vitamin E (dl, acetate) 45 mg/0.25 mL (100

unit/0.25 mL) oral drops .................. 100

vitamin E (dl, acetate) 450 mg (1,000 unit)

capsule ............................................. 100

vitamin E (dl, acetate) 90 mg (200 unit)

capsule ............................................. 100

vitamin E 1,000 unit capsule ................. 100

vitamin E 100 unit capsule .................... 100

vitamin E 100 unit/0.25 mL oral drops .101

vitamin E 200 unit capsule .................... 101

vitamin E 400 unit capsule .................... 101

vitamin E 50 unit/mL oral drops ........... 101

vitamin E acetate 200 unit capsule ....... 101

vitamin E mixed 1,000 unit capsule ...... 101

vitamin E mixed 100 unit tablet............ 101

vitamin E mixed 400 unit capsule ......... 101

vitamin E succinate 100 unit tablet ...... 101

vitamin K 1 mg/0.5 mL injection solution

.........................................................101

Vitamin K1 10 mg/mL injection solution

.........................................................101

Vitamins A-D-E with selenium 10,000 unit-

400 unit tablet ................................... 84

Vitamins and Minerals tablet ................. 84

Vitasure 1 mg-100 mg-300 mcg tablet ... 54

Vitatrum 18 mg-500 mcg-300 mcg-250

mcg tablet .......................................... 84

Vitrexyl 1,000 mcg tablet ........................ 84

Vitrexyl Plus Iron 27 mg iron-1 mg tablet

...........................................................84

VITRUM SENIOR TABLET ......................... 56

V-Max cream .......................................... 30

Vol-Care Rx 1 mg-60 mg-300 mcg tablet 55

Vortex Holding Chamber ...................... 129

Vortex VHC Frog Mask-Child ................ 129

VP-VITE RX 1 MG-60 MG-300 MCG TABLET

...........................................................55

VP-ZEL 600 MG-5 MG-10 MG-5 MG-1.5

MG TABLET ........................................ 56

W

Wal-Act D Cold and Allergy 2.5 mg-60 mg

tablet ............................................... 138

Wal-Dram 2 25 mg tablet ..................... 110

Wal-Dram 50 mg tablet ........................ 110

Wal-Dryl (diphenhydramine) 2 % topical

spray .................................................. 50

Wal-Dryl (diphenhydramine-Zn acetate) 2

%-0.1 % topical cream ....................... 40

Wal-Dryl (diphenhydramine-Zn acetate) 2

%-0.1 % topical spray......................... 40

Wal-Dryl Allergy 12.5 mg/5 mL oral liquid

.........................................................147

Wal-Dryl Allergy 25 mg capsule ............ 147

Wal-Dryl Allergy 25 mg tablet .............. 147

Wal-Dryl Severe Allergy-Sinus 25 mg-5

mg-325 mg tablet ............................ 140

Wal-Fex Allergy 180 mg tablet ............. 149

Wal-Fex Allergy 60 mg tablet ............... 149

Wal-Fex D 12 Hour 60 mg-120 mg

tablet,extended release .................. 143

Wal-Finate 4 mg tablet ......................... 147

Wal-Finate-D 4 mg-60 mg tablet .......... 138

Wal-Flu Night Severe Cold 25 mg-10 mg-

650 mg/30 mL oral liquid................. 140

Wal-Flu Night Time 20 mg-10 mg-650 mg

oral powder packet ......................... 140

Wal-Flu Severe Cold and Cough 25 mg-10

mg-650 mg oral powder packet ...... 141

Wal-Flu Severe Cold-Cough 10 mg-20 mg-

650 mg oral powder packet ............. 168

Wal-Four 1 % nasal spray ..................... 159

Walgreens Dry Skin Treatment 41 %

topical ointment ................................ 50

WAL-ITIN 10 MG DISINTEGRATING TABLET

.........................................................149

Wal-itin 10 mg tablet............................ 149

Wal-itin 5 mg/5 mL oral solution .......... 149

Wal-itin D 10 mg-240 mg tablet,extended

release ............................................. 143

Wal-Itin D 12 Hour 5 mg-120 mg

tablet,extended release .................. 143

Wal-Mucil Fiber (aspartame) 3.4 gram/5.8

gram oral powder ............................ 118

Wal-Mucil Fiber (sugar) 3.4 gram/7 gram

oral powder ..................................... 118

Wal-Mucil Fiber 0.52 gram capsule ...... 118

Wal-Mucil Natural Fiber Laxative 3.4

gram/12 gram oral powder ............. 118

Wal-phed 12 hour 120 mg tablet,extended

release ............................................. 178

Wal-phed 30 mg tablet......................... 178

Wal-phed 4 mg-60 mg tablet ............... 138

Wal-Phed D 120 mg tablet,extended

release ............................................. 178

OH Buckeye MMP Opt-Out Formulary August 1, 2021 218

Wal-phed PE 10 mg tablet ....................178

Wal-Phed PE Day-Night 5 mg-10 mg-325

mg tablets ........................................161

Wal-Phed PE Nighttime Cold 25 mg-5 mg-

325 mg tablet ...................................141

Wal-phed PE Severe Cold 12.5 mg-5 mg-

325 mg tablet ...................................141

Wal-Phed PE Sinus and Allergy 4 mg-10

mg tablet ..........................................138

Wal-Phed PE Sinus Headache 5 mg-325

mg tablet ..........................................151

Wal-Phed PE Triple Relief 5 mg-325 mg-

200 mg tablet ...................................152

Wal-Profen 200 mg capsule ....................18

WAL-PROFEN 200 MG TABLET ................18

Wal-Profen Cold-Sinus 30 mg-200 mg

tablet ...............................................152

Wal-Profen D Cold and Sinus 30 mg-200

mg tablet ..........................................153

WAL-PROXEN 220 MG TABLET ...............18

Wal-Som (diphenhydramine) 50 mg

capsule ...............................................24

Wal-Sporin 500 unit-10,000 unit/gram

topical ointment ................................35

Wal-tap DM 1 mg-2.5 mg-5 mg/5 mL oral

solution ............................................166

Wal-Tussin Cough 15 mg capsule .........151

Wal-Tussin Cough 15 mg/5 mL oral liquid

.........................................................151

WAL-TUSSIN COUGH AND COLD CF 5 MG-

10 MG-100 MG/5 ML ORAL LIQUID .171

Wal-Tussin DM 10 mg-100 mg/5 mL oral

syrup ................................................175

Wal-Tussin Max Strength Cough 15 mg/5

mL oral syrup ...................................151

Wal-Zyr (cetirizine) 1 mg/mL oral solution

.........................................................149

Wal-Zyr (cetirizine) 10 mg capsule ........149

Wal-Zyr (cetirizine) 10 mg tablet ..........149

Wal-Zyr (ketotifen) 0.025 % (0.035 %) eye

drops ................................................134

Wal-Zyr D 5 mg-120 mg tablet,extended

release .............................................143

Wart Remover 17 % topical gel ..............47

WART REMOVER 17 % TOPICAL LIQUID .47

Wart Remover 40 % topical patch .......... 47

Wart Remover 40 % topical plaster ........ 47

Wee Care 15 mg/1.25 mL oral suspension

...........................................................65

Wellesse Multi Vitamin Plus 400 mcg-200

mg/30 mL oral liquid .......................... 87

WILZIN 25 MG (ZINC) CAPSULE .............. 19

WOMAN'S LAXATIVE (BISACODYL) 5 MG

TABLET ............................................. 122

Woman's Laxative (bisacodyl) 5 mg

tablet,delayed release ..................... 122

Women's 50 Plus Daily Formula 400 mcg-

500 mg calcium-20 mcg tablet ........... 84

Women's Active 18 mg iron-400 mcg-180

mg tablet ........................................... 84

Women's Daily Formula 18 mg iron-400

mcg-500 mg Ca tablet ........................ 84

Women's Daily Formula 18 mg iron-400

mcg-500 mg tablet ............................. 84

Women's Daily Formula 27 mg-0.4 mg

tablet ................................................. 84

Womens Daily Gummies 200 mcg

chewable tablet ................................. 84

Women's Daily Pack 400 mcg-800 mg-10

mcg tablet .......................................... 84

Women's Gentle Laxative (bisacodyl) 5 mg

tablet,delayed release ..................... 122

WOMEN'S LAXATIVE (BISACODYL) 5 MG

TABLET ............................................. 122

Women's Laxative (bisacodyl) 5 mg

tablet,delayed release ..................... 122

Women's Multivitamin 18 mg iron-400

mcg-500 mg tablet ............................. 84

Women's Multivitamin 18 mg-400 mcg-

500 mg-50 mcg tablet ........................ 84

Women's Multivitamin Gummies 200 mcg

chewable tablet ................................. 84

Womens Multivitamin High Potency 13.5

mg-200 mcg-250 mcg tablet .............. 85

Women's One Daily 18 mg iron-400 mcg-

500 mg Ca tablet ................................ 85

X

Xcel 100 cream ....................................... 30

XERAC AC 6.25 % TOPICAL SOLUTION .... 39

Xvite 1 mg-100 mg-300 mcg tablet ........ 54

Y

Yelets 18 mg-400 mcg tablet .................. 87

Z

ZADITOR 0.025 % (0.035 %) EYE DROPS

.........................................................134

ZEASORB (MICONAZOLE) 2 % TOPICAL

POWDER ............................................ 38

ZEASORB AF 2 % TOPICAL POWDER ....... 38

Ziks Arthritis Pain Relief 0.025 %-12 %-1 %

topical cream ..................................... 50

Zinc (with Vitamins A and C) Lozenges ... 69

zinc chloride 1 mg/mL intravenous

solution ............................................. 69

zinc sulfate (bulk) 100 % powder ........... 30

zinc sulfate (bulk) powder ...................... 30

zinc sulfate 50 mg zinc (220 mg) capsule69

zinc sulfate heptahydrate (bulk) 100 %

powder .............................................. 30

Zinc with Vitamins A and C 15 mg lozenges

.........................................................130

ZINC-220 50 MG ZINC (220 MG) CAPSULE

...........................................................69

ZOO CHEWS TABLET ............................... 90

Zoo Friends chewable tablet .................. 90

Zoo Friends Complete 9 mg iron chewable

tablet ................................................. 92

Zoo Friends Gummies chewable tablet .. 92

ZOO FRIENDS ORIGINAL 300 MCG

CHEWABLE TABLET ............................ 90

Zostrix-HP 0.1 % topical cream ............... 51

Zostrix-HP Foot 0.1 % topical cream....... 51

Z-Tuss AC 2 mg-9 mg/5 mL oral liquid .. 175

ZUTRIPRO 5 MG-4 MG-60 MG/5 ML ORAL

SOLUTION ........................................ 176

Zyncof 20 mg-400 mg tablet................. 175

ZYRTEC 10 MG TABLET ......................... 150

ZYRTEC-D 5 MG-120 MG

TABLET,EXTENDED RELEASE ............ 143

Zyvana 6 mg-263.5 mg-20.5 mcg-11.5mg

capsule .............................................. 85