over-the-counter (otc) drugs added...4-way fast acting a thru z advanced a thru z high potency a...

Key: PA – Prior Authorization; ST – Step Therapy; QL – Quantity Limit

Updated 05/2017

May 2017 Formulary Updates

Generics Added DESVENLAFAXINE ER 10MG, 25MG, 100MG TABS (generic Pristiq®)—PA, QL PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION 10 MG/5ML; 20MG/5ML TACROLIMUS OINT 0.03%; 0.1%—QL

Brands Added GLEOSTINE 10MG, 40MG, 100MG CAPS ILARIS INJ 150MG/ML—PA, QL KISQALI —PA, QL

Over-the-Counter (OTC) Drugs Added 4-WAY FAST ACTING A THRU Z ADVANCED A THRU Z HIGH POTENCY A THRU Z SELECT A THRU Z SELECT 50+ MENS A THRU Z SELECT ADVANCED A THRU Z SELECT ULTIMATE A THRU Z ULTIMATE MENS ABC PLUS ABC PLUS SENIOR ADULTS 50 ACETA-GESIC ACETAMINOPHEN ACETAMINOPHEN EXTRA STREN ACID REDUCER ACIDOPHILUS PLUS PECTIN ACIDOPHILUS/CITRUS PECTIN ACIDOPHILUS/PECTIN ACTICAL ADULT ONE DAILY GUMMIES AFRIN SALINE NASAL MIST AIRBORNE AIRBORNE GUMMIES ALAHIST DM ALA-HIST PE ALIVE WOMENS ENERGY ALIVE WOMENS GUMMY VITAMI ALL DAY ALLERGY CHILDRENS ALL DAY ALLERGY D ALL DAY PAIN RELIEF ALLERGY 24-HR ALLERGY RELIEF


Updated 05/2017

ALLERGY RELIEF CHILDRENS ALMACONE ALOE VESTA PROTECTIVE ALTAMIST AMERICERIN ANTACID FAST ACTING ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI-GAS REL ANTI-DIARRHEAL ANTIFUNGAL ANTIOXIDANT ANTI-OXIDANT ANTIOXIDANT FORMULA ANTIOXIDANT FORMULA SG ANTIOXIDANT VITAMINS APATATE FORTE AP-HIST DM AQUADEKS ASPIRIN ASPIRIN ADULT LOW STRENGT ASPIRIN EC ASPIRIN LOW STRENGTH ATHLETES FOOT SPRAY AYR AYR NASAL DROPS AYR NASAL MIST ALLERGY & AYR SALINE NASAL AYR SALINE NASAL NO-DRIP BABY AYR SALINE BABY DARLINGS PEDIATRIC E BACITRACIN BACITRACIN ZINC BACITRACIN/NEOMYCIN/POLYM BANOPHEN BENZONATATE BEROCCA BETADINE BETADINE SKIN CLEANSER BIO-35 GLUTEN-FREE BIOCAL BIOSUPP BIOTECT PLUS BIOTIN PLUS/CALCIUM/VIT D BISACODYL EC


Updated 05/2017

BISCOLAX BODY/HAIR/SKIN/NAILS CALCARB 600 CAL-CARB FORTE CALCET PLUS CALCI-CHEW CHERRY CALCIDOL CALCIFEROL CALCI-MIX CALCIONATE CALCITRATE CAL-CITRATE PLUS VITAMIN CALCIUM CALCIUM + D3 CALCIUM 1000 + D CALCIUM 1200 CALCIUM 500 + D CALCIUM 500 +D CALCIUM 500/D CALCIUM 500/VITAMIN D CALCIUM 500/VITAMIN D3 CALCIUM 500+D CALCIUM 500+D HIGH POTENC CALCIUM 600 CALCIUM 600 + D CALCIUM 600 HIGH POTENCY CALCIUM 600 WITH VITAMIN CALCIUM 600/VITAMIN D CALCIUM 600/VITAMIN D3 CALCIUM 600+D CALCIUM 600+D HIGH POTENC CALCIUM 600+D PLUS MINERA CALCIUM 600+D3 CALCIUM 600+D3 PLUS MINER CALCIUM 600-D CALCIUM CARBONATE CALCIUM CARBONATE/D3 CALCIUM CARBONATE/VITAMIN CALCIUM CITRATE CALCIUM CITRATE + D CALCIUM CITRATE + D3 CALCIUM CITRATE + D3 MAXI CALCIUM CITRATE +D CALCIUM CITRATE MAXIMUM/V

Updated 05/2017

CALCIUM CITRATE PETITE/VI CALCIUM CITRATE W/D CALCIUM CITRATE/VITAMIN D CALCIUM CITRATE+ D CALCIUM CITRATE+D CALCIUM CITRATE+D3 CALCIUM CITRATE+D3 PETITE CALCIUM GUMMIES CALCIUM HIGH POTENCY CALCIUM HIGH POTENCY + VI CALCIUM LACTATE CALCIUM OYSTER SHELL CALCIUM PLUS VITAMIN D3 CALCIUM POLYCARBOPHIL CALCIUM/D CALCIUM/D3 LIQUID CALCIUM/VITAMIN D CALCIUM/VITAMIN D/MINERAL CALCIUM/VITAMIN D3 CALCIUM+D3 CAL-MINT CAL-QUICK CALTRATE 600 CALTRATE 600+D CALTRATE 600+D PLUS MINER CALTRATE 600+D SOFT CHEWS CALTRATE 600+D3 SOFT CHEW CALTRATE MINIS PLUS MIN CAPSAICIN CARDENZ CARRAVITE CARRINGTON MOISTURE BARRI CASTOR OIL STIMULANT LAXA CENTAMIN CENTAVITE CENTAVITE A-Z COMPLETE MU CENTRAVITES CENTRAVITES 50 PLUS CENTRUM CENTRUM ADULTS CENTRUM CARDIO CENTRUM FLAVOR BURST ADUL CENTRUM FLAVOR BURST KIDS CENTRUM SILVER


Updated 05/2017

CENTRUM SILVER ADULT 50+ CENTRUM SILVER ULTRA MENS CENTRUM SILVER ULTRA WOME CENTRUM SPECIALIST HEART CENTRUM SPECIALIST VISION CENTRUM ULTRA MENS CENTRUM ULTRA WOMENS CENTURY CENTURY MATURE CERALYTE 70 CEROVITE ADVANCED FORMULA CEROVITE SENIOR CERTA PLUS CERTAGEN CERTA-VITE CERTAVITE SENIOR/ANTIOXID CERTAVITE/ANTIOXIDANTS CHEST CONGESTION RELIEF P CHEWABLE CALCIUM CHILDRENS ALLERGY CHILDRENS COLD & ALLERGY CHILDRENS IBUPROFEN CHLORPHENIRAMINE MALEATE CITRACAL + D3 MAXIMUM CITRACAL CALCIUM GUMMIES CITRACAL MAXIMUM CITRACAL PETITES/VITAMIN CITRACAL/VITAMIN D CITRACAL+D3 CITRUCEL CITRUS CALCIUM +D CITRUS CALCIUM/VITAMIN D CLEARLAX COLACE COLACE CLEAR COLD & ALLERGY COMPANION COMPETE COMPLETE COMPLETE FORMULATION MULT COMPLETE MULTIVITAMIN/MUL COMPLETE SENIOR CONCEPTIONXR MOTILITY SUP CONEX COLD/ALLERGY


Updated 05/2017

COUGH & COLD COUGH DM CRITIC-AID CLEAR AF CRITIC-AID CLEAR MOISTURE CVS CALCIUM CVS CALCIUM 600 & VITAMIN CVS CALCIUM 600 + D/MINER CVS CALCIUM 600+D CVS CALCIUM CARBONATE CVS CALCIUM CITRATE CVS CALCIUM CITRATE + D CVS CALCIUM CITRATE +D3 M CVS D3 CVS DAILY ENERGY CVS DAILY GUMMIES CVS DAILY MULTIPLE CVS DAILY MULTIPLE FOR ME CVS DAILY MULTIPLE FOR WO CVS DAILY MULTIPLE PLUS I CVS DIABETES HEALTH SUPPO CVS ELECTROLYTE SOLUTION CVS FISH OIL CVS FOLIC ACID CVS GLUCOSE CVS IRON CVS MAGNESIUM CVS MENS DAILY GUMMIES CVS NASAL MIST CVS NATURAL FISH OIL CVS OMEGA-3 GUMMY FISH/DH CVS OYSTER SHELL CALCIUM CVS PEDIATRIC ELECTROLYTE CVS SALINE NASAL SPRAY CVS SALINE NOSE SPRAY CVS SLOW RELEASE IRON CVS SPECTRAVITE ADULT 50+ CVS SPECTRAVITE ADULT GUM CVS SPECTRAVITE ADVANCED CVS SPECTRAVITE PERFORMAN CVS SPECTRAVITE SENIOR CVS SPECTRAVITE ULTRA HEA CVS SPECTRAVITE ULTRA MEN CVS SPECTRAVITE ULTRA WOM CVS VISION FORMULA


Updated 05/2017

CVS VITAMIN D 5000 HIGH-P CVS VITAMIN D3 CVS WOMENS ACTIVE DAILY CVS WOMENS DAILY GUMMIES D 1000 D 10000 D 2000 D 400 D 5000 D-1000 EXTRA STRENGTH D-1000 MAXIMUM ST D-2000 MAXIMUM STRENGTH D2000 ULTRA STRENGTH D3 D3 ADULT D3 HIGH POTENCY D3 KIDS D3 SUPER STRENGTH D3 ULTRA STRENGTH D3-1000 D-3-5 D3-50 D-400 D-5000 DAILY COMBO MULTI VITAMIN DAILY MULTI DAILY MULTIPLE VITAMIN DAILY MULTIPLE VITAMIN/IR DAILY MULTIPLE VITAMINS DAILY MULTIPLE VITAMINS W DAILY MULTIPLE VITAMINS/I DAILY MULTIPLE VITAMINS/M DAILY MULTIPLE WEIGHT LOS DAILY MULTIVITAMIN DAILY VALUE MULTIVITAMIN DAILY VITAMIN DAILY VITAMIN FORMULA+IR DAILY VITAMIN FORMULA+IRO DAILY VITAMIN FORMULA+MIN DAILY VITAMINS DAILY VITE DAILY-VITE DAILY-VITE/IRON/BETA-CARO DALLERGY


Updated 05/2017

DAY TIME COLD/FLU RELIEF DAY TIME COUGH DAYHIST ALLERGY 12 HOUR R DAYTIME PE MULTI-SYMPTOM DECARA DECONEX DMX DECONEX IR DECUBI-VITE DEKAS ESSENTIAL DEKAS PLUS DELSYM DELSYM COUGH CHILDRENS DELTA D3 DERMACERIN DERMAGRAN DERMAGRAN BC DERMAMED DEX4 QUICK DISSOLVE GLUCO DIABETES HEALTH FORMULA DIABETES HEALTH PACK DIALYVITE 800/ULTRA D DIALYVITE VITAMIN D 5000 DIALYVITE VITAMIN D3 MAX DIMAPHEN CHILDRENS DIPHENHYDRAMINE HCL DISNEY CALCIUM + VITAMIN DOCUSATE SODIUM DOCUSATE SODIUM & SENNA S DOCUSOL KIDS DOCUSOL PLUS MINI-ENEMA DONATUSSIN DOUBLE ANTIBIOTIC DRISDOL DURAVENT DM ED A-HIST ED A-HIST DM ED-APAP ELDERTONIC ENDUR-ACIN ENFAMIL ENFALYTE ENVIRO-STRESS EPA EQ ASPIRIN EC EQ CALCIUM 500+D


Updated 05/2017

EQ CALCIUM 600+D EQ CALCIUM 600+D+MINERALS EQ CALCIUM CITRATE+D EQ COMPLETE MULTIVITAMIN EQ ONE DAILY MENS HEALTH EQ ONE DAILY WOMENS HEALT EQ ONE DAILY WOMENS PRO-A EQ SALINE NASAL SPRAY EQ SLOW-RELEASE IRON EQL CALCIUM EQL CALCIUM CITRATE W/VIT EQL CALCIUM/VITAMIN D EQL CALCIUM/VITAMIN D EQL CALCIUM/VITAMIN D/MIN EQL CENTRAL-VITE EQL CENTRAL-VITE PERFORMA EQL CENTRAL-VITE SELECT EQL CENTURY EQL CENTURY CARDIO HEALTH EQL CENTURY MATURE EQL CHILDRENS CALCIUM GUM EQL FISH OIL EQL FOLIC ACID EQL IRON SUPPLEMENT EQL IRON SUPPLEMENT THERA EQL NIACIN EQL OMEGA 3 FISH OIL EQL OMEGA-3 GUMMIES CHILD EQL ONE DAILY 50 PLUS EQL ONE DAILY DIET SUPPOR EQL ONE DAILY DIETERS SUP EQL ONE DAILY ESSENTIAL EQL ONE DAILY MAXIMUM EQL ONE DAILY MENS HEALTH EQL OYSTER SHELL CALCIUM/ EQL PEDIATRIC ELECTROLYTE EQL SALINE NASAL SPRAY EQL SLOW RELEASE IRON EQL ULTIMATE WOMENS CENTU EQL VISION FORMULA EQL VITAMIN D3 EQUALYTE ERGOCALCIFEROL ESSENTIA


Updated 05/2017

ESSENTIAL BALANCE EUCERIN EX-LAX EX-LAX MAXIMUM STRENGTH EXTRA STRENGTH PAIN RELIE EYE VITAMINS & MINERALS EYEPROTECT EYE-VITE EXTRA PLUS LUTEI EZFE 200 FA-8 FA-8 FAST ACTING ANTACID PLUS FEOSOL FERAHEME FERGON FERREX 150 FERRIC GLUCONATE COMPLEX FERRIC X-150 FERRLECIT FERRO-BOB FERROUS GLUCONATE FERROUS SULFATE FERROUSUL FEXOFENADINE HCL FIBER LAXATIVE FIBER-CAPS FISH OIL FISH OIL BURP-LESS FISH OIL CONCENTRATE FISH OIL DOUBLE STRENGTH FISH OIL EXTRA STRENGTH FISH OIL MAXIMUM STRENGTH FISH OIL PEARLS FISH OIL/SUPER POTENT/NO FLU & SORE THROAT FLU/SEVERE COLD & COUGH D FLUTICASONE PROPIONATE FOLIC ACID FOSFREE FREEDAVITE FUNGOID TINCTURE NAIL KIT GAS RELIEF GAS RELIEF ANTIFLATUEN SM GAS RELIEF EXTRA STRENGTH


Updated 05/2017

GAS RELIEF ULTRA STRENGTH GAS-X GAS-X EXTRA STRENGTH GAS-X ULTRA STRENGTH GENTEAL GENTEAL SEVERE GERIVITE COMPLETE GLUCO BURST GLUCOSE GLUCOTEN GNP 12 HOUR NASAL SPRAY GNP ACID REDUCER GNP ALL DAY PAIN RELIEF GNP ALLERGY GNP ALLERGY PLUS SEVERE S GNP ALLERGY PLUS SINUS HE GNP ALLERGY RELIEF GNP ANTI-GAS GNP BISA-LAX GNP CALCIUM GNP CALCIUM 1200 GNP CALCIUM 500 +D3 GNP CALCIUM 500/D GNP CALCIUM 600 +D/MINERA GNP CALCIUM 600 +D3 GNP CALCIUM 600 +D3/MINER GNP CALCIUM 600/D GNP CALCIUM CITRATE +D3 GNP CALCIUM CITRATE+D MAX GNP CALCIUM CITRATE+D3 MA GNP CALCIUM PLUS 600 +D GNP CALCUIM/VITAMIN D/MIN GNP CASTOR OIL GNP CENTURY GNP CENTURY ACTIVE PERFOR GNP CENTURY ADULTS 50+ SE GNP CENTURY CARDIO HEALTH GNP CENTURY MATURE GNP CENTURY ULTIMATE MENS GNP CENTURY ULTIMATE WOME GNP CHILDRENS PAIN RELIEF GNP COLD & ALLERGY CHILDR GNP COLD HEAD CONGESTION GNP COLD RELIEF HEAD CONG


Updated 05/2017

GNP COLD RELIEF MULTI-SYM GNP DIABETIC SUPPORT FORM GNP DOCUSATE CALCIUM GNP ENEMA GNP ESSENTIAL ONE DAILY GNP FIBER THERAPY GNP FIBER-CAPS GNP FISH OIL GNP FISH OIL MAXIMUM STRE GNP FOLIC ACID GNP GAS RELIEF GNP GAS RELIEF EXTRA STRE GNP HAIR/SKIN/NAILS GNP HEALTHY EYES GNP HEALTHY EYES SUPERVIS GNP HYDROCORTISONE MAXIMUM GNP HYDRO-LOTION GNP IBUPROFEN GNP IBUPROFEN COLD/SINUS GNP IBUPROFEN INFANTS GNP INFANTS PAIN/FEVER GNP IRON GNP ITCH RELIEF EXTRA STR GNP LAXATIVE PILLS GNP LICE TREATMENT GNP LORATADINE GNP LUBRICANT PM GNP MAGNESIUM CITRATE GNP MAXIMUM ONE DAILY GNP MEGA MULTI FOR MEN GNP MEGA MULTI FOR WOMEN GNP MICONAZOLE 3 COMBINAT GNP MICONAZOLE 7 GNP MOTION SICKNESS RELIE GNP MUCUS RELIEF CHILDREN GNP MUCUS RELIEF COUGH CH GNP MUCUS RELIEF PE GNP NAPROXEN SODIUM GNP NASAL MOISTURIZING GNP NASAL SPRAY FAST ACTI GNP NATURAL FIBER GNP NIACIN GNP NIACIN TR GNP NICOTINE POLACRILEX


Updated 05/2017

GNP ONE DAILY MAXIMUM GNP ONE DAILY MENS 50+ AD GNP ONE DAILY MENS HEALTH GNP ONE DAILY PLUS IRON GNP ONE DAILY WOMENS 50+ GNP ONE DAILY WOMENS HEAL GNP ONE DAILY WOMENS META GNP OPTI-VITAMINS GNP PAIN & FEVER CHILDREN GNP PAIN RELIEF GNP PEDIATRIC ELECTROLYTE GNP POVIDONE-IODINE GNP QUICK DISSOLVE GLUCOS GNP SCALP RELIEF GNP SINUS & ALLERGY PE GNP SINUS RELIEF CONGESTI GNP SLOW RELEASE IRON GNP STOMACH RELIEF GNP STOOL SOFTENER/STIMUL GNP THERAPEUTIC-M GNP TRIPLE ANTIBIOTIC GNP TUSSIN DM MAX GNP TUSSIN DM MAX COUGH & GNP VITAMIN D GNP VITAMIN D MAXIMUM STR GNP VITAMIN D SUPER STREN GNP VITAMIN D3 EXTRA STRE GNP VITAMIN D-400 GNP WART REMOVER GNP WOMENS LAXATIVE GNP WOMENS ONE DAILY GUAIATUSSIN AC GUAIFENESIN ER GUAIFENESIN/CODEINE HAIR FORMULA EXTRA STRENG HAIR/SKIN/NAILS HAIR/SKIN/NAILS/BIOTIN HEALTHY EYES HEALTHY KIDS GUMMIES OMEG HEALTHY KIDS VITAMIN D3 HEARTBURN RELIEF H-E-B ORAL ELECTROLYTE SO HIGH POTENCY CALCIUM HISTEX


Updated 05/2017

HM ACID REDUCER HM ANTIOXIDANT VITAMINS HM ASPIRIN EC HM CALCIUM 600 + D PLUS M HM CALCIUM CITRATE + VITA HM CALCIUM CITRATE+D3 PET HM CALCIUM/VITAMIN D HM CALCIUM/VITAMIN D/MINE HM COMPLETE HM COMPLETE 50+ HM COMPLETE 50+ MENS ULTI HM COMPLETE 50+ WOMENS UL HM DAY TIME HM FISH OIL HM FOLIC ACID HM HAIR/SKIN/NAILS HM IRON HM IRON SLOW RELEASE HM LUBRICATING TEARS HM NAPROXEN SODIUM HM NASAL SPRAY HM NIACIN HM NICOTINE POLACRILEX HM NIGHT TIME MULTI-SYMPT HM ONE DAILY MENS HM ONE DAILY WOMENS HM ONE DAILY/IRON HM PAIN RELIEF EXTRA STRE HM PEDIATRIC ELECTROLYTE HM SALINE NASAL SPRAY HM SEVERE COLD/COUGH/FLU HM TRIPLE ANTIBIOTIC PLUS HM VITAMIN D HM VITAMIN D3 HUMIST HYALEX HYDROCERIN HYDROCERIN PLUS HYDROCODONE BITARTRATE/HO HYDROCODONE/HOMATROPINE HYDROCORTISONE HYDROCORTISONE/ALOE IBUPROFEN IBUPROFEN CHILDRENS


Updated 05/2017

IBUPROFEN COLD & SINUS ICAPS ICAPS AREDS FORMULA ICAPS LUTEIN & OMEGA-3 ICAPS MV ICAPS PLUS ICAR PEDIATRIC INFANTS SILAPAP INSTA-GLUCOSE IRON IRON SLOW RELEASE IRON SUPPLEMENT IRON UP I-VITE PROTECT J-MAX J-TAN PD KALA KERODEX-51 DRY/OILY KERODEX-71 WET KONSYL KONSYL FIBER KONSYL-D KP ADULTS 50+ DAILY FORMU KP ADULTS DAILY FORMULA KP CALCIUM 600+D KP FERROUS GLUCONATE KP FERROUS SULFATE KP FISH OIL KP FOLIC ACID KP MENS 50+ DAILY FORMULA KP MENS DAILY FORMULA KP OMEGA-3 FISH OIL KP VITAMIN D KP WOMENS 50+ DAILY FORMU KP WOMENS DAILY FORMULA K-PAX IMMUNE SUPPORT FORM LACRI-LUBE LANSOPRAZOLE L-ARGININE LAXATIVE LEADER QUICK DISSOLVE GLU LICE KILLING MAXIMUM STRE LIFE PACK MENS LIFE PACK WOMENS


Updated 05/2017

LIQUID CALCIUM WITH D3 MA LIQUID CALCIUM/VITAMIN D LIQUITEARS LITTLE NOSES SALINE LITTLE NOSES STUFFY NOSE LODRANE D LORATADINE LORTUSS LQ LYSIPLEX PLUS MACULAR VITAMIN BENEFIT MACUVITE MACUVITE EYE CARE MACUVITE/LUTEIN MAG64 MAG-AL MAG-AL PLUS MAG-AL PLUS XS MAG-G MAGNESIUM MAGNESIUM 27 MAGNESIUM GLUCONATE MAGNESIUM OXIDE MAGNESIUM-OXIDE MAGONATE MAGOX 400 MAG-OXIDE MAG-SR PLUS CALCIUM MAG-TAB SR MAPAP COLD FORMULA MULTI-MAXIMUM DAILY GREEN MAXIMUM BLUE LABEL MAXIMUM D3 MAXIMUM EPA MAXIMUM GREEN LABEL MAXIMUM RED LABEL MECLIZINE HCL MEDIPLEX PLUS MEGA MULTIVITAMIN FOR MEN MEGA MULTIVITAMIN FOR WOM MEGA VM-80 MEGAVITE FRUITS & VEGGIES MEGAVITE GOLDEN YEARS 55+ MEIJER SALINE NASAL SPRAY MENS 50+ ADVANCED


Updated 05/2017

MENS DAILY FORMULA/LYCOPE MENS PACK MGO MH MACULAR HEALTH MICONAZOLE 3 COMBINATION MICONAZOLE 3 COMBO PACK MILK OF MAGNESIA MILK OF MAGNESIA CONCENTR MILLTRIUM SENIOR MINERIN MINTOX PLUS MOTION-TIME MS QUICK DISSOLVE GLUCOSE MUCINEX MUCINEX ALLERGY MUCINEX COUGH FOR KIDS MUCINEX DM MUCINEX FAST-MAX COLD & S MUCINEX FAST-MAX COLD FLU MUCINEX FAST-MAX COLD/FLU MUCINEX FAST-MAX DAY TIME MUCINEX FAST-MAX DAY TIME MUCINEX FAST-MAX DAY/NIGH MUCINEX FAST-MAX NIGHT TI MUCINEX FAST-MAX SEVERE C MUCINEX MAXIMUM STRENGTH MUCINEX SINUS-MAX DAY/NIG MUCINEX SINUS-MAX FULL FO MUCINEX SINUS-MAX PRESSUR MUCINEX SINUS-MAX SEVERE MUCOSA MUCUSRELIEF SINUS MULTI ADULT GUMMIES MULTI COMPLETE/IRON MULTI FOR HER MULTI FOR HER 50+ MULTI FOR HIM MULTI FOR HIM 50+ MULTI VITAMIN DAILY MULTI VITAMIN MENS MULTI-BETIC MULTI-DAY MULTI-DAY VITAMINS MULTILEX-T&M


Updated 05/2017

MULTIMINERAL PLUS MULTIPLE VITAMIN MULTIPLE VITAMIN/MINERALS MULTIPLE VITAMINS MULTIPLE VITAMINS ESSENTI MULTIPLE VITAMINS PLAIN MULTIPLE VITAMINS/IRON MULTIPLE VITAMINS/WOMENS MULTIVITAL MULTIVITAL PERFORMANCE MULTIVITAL PLATINUM MULTIVITAL PLATINUM SILVE MULTIVITAMIN MULTI-VITAMIN MULTIVITAMIN & MINERAL MULTI-VITAMIN DAILY MULTI-VITAMIN GUMMIES MULTIVITAMIN GUMMIES ADUL MULTIVITAMIN GUMMIES MENS MULTIVITAMIN GUMMIES WOME MULTI-VITAMIN MONOCAPS MULTI-VITAMIN/MINERALS MULTIVITAMINS MULTI-VITAMINS MULTI-VITAMINS/IRON MURO 128 MYAMULTI MYFERON 150 MYKIDZ IRON 10 MY-VITALIFE NASAL DECONGESTANT NASAL FOUR NASAL MIST NASAL MOIST NASAL MOISTURIZING SPRAY NASAL RELIEF NASAL SPRAY 12 HOUR NASAL SPRAY EXTRA MOISTUR NASOGEL NATURAL BALANCE TEARS NATURAL VITAMIN D-3 NATURALYTE NATURES TEARS NA-ZONE


Updated 05/2017

NIACIN NIACIN ER NIACIN SR NIACIN TD NIACIN TR NIACIN-50 NICORETTE NICOTINE POLACRILEX NITE TIME COUGH NITE TIME MULTI-SYMPTOM NITE TIME MULTI-SYMPTOM C NITE-TIME MULTI-SYMPTOM NIVA-HIST DM NIVANEX DMX NO DRIP NASAL SPRAY NO IRON MULTIPLE VITAMIN/ NON-ASPIRIN NOREL AD NORWEGIAN SALMON OIL NOSE DROPS EXTRA STRENGTH NOVAFERRUM 50 NU-IRON 150 NU-MAG OCEAN FOR KIDS OCEAN NASAL SPRAY OCUTABS OCUTABS/LUTEIN OCUVITE OCUVITE ADULT 50+ OCUVITE ADULT FORMULA OCUVITE EXTRA OCUVITE EYE + MULTI OCUVITE LUTEIN OMEGA 3 OMEGA 3 500 OMEGA III EPA+DHA OMEGA-3 OMEGA-3 FISH OIL OMEGA-3 FISH OIL MAXIMUM OMEGA-3 FISH OIL NO BURP OMEPRAZOLE OMERA OMNICAP ONCE DAILY


Updated 05/2017

ONCE DAILY/IRON ONCOVITE ONE DAILY ONE DAILY ADULTS 50+ ONE DAILY COMPLETE ONE DAILY FOR MEN 50+ ADV ONE DAILY FOR MEN/LYCOPEN ONE DAILY FOR WOMEN ONE DAILY FOR WOMEN 50+A ONE DAILY HEALTHY WEIGHT ONE DAILY MAXIMUM ONE DAILY MENS ONE DAILY MENS HEALTH/LYC ONE DAILY MULTIVITAMIN/IR ONE DAILY PLUS IRON ONE DAILY PLUS MINERALS ONE DAILY WOMENS 50 PLUS ONE DAILY WOMENS 50+ ONE DAILY/IRON/CALCIUM ONE DAILY/MINERALS ONE-A-DAY ADULT VITACRAVE ONE-A-DAY ENERGY ONE-A-DAY ESSENTIAL ONE-A-DAY FOR HER VITACRA ONE-A-DAY FOR HIM/VITACRA ONE-A-DAY MENOPAUSE FORMU ONE-A-DAY MENS ONE-A-DAY MENS 50+ ADVANT ONE-A-DAY MENS HEALTH FOR ONE-A-DAY MENS VITACRAVES ONE-A-DAY TEEN ADVANTAGE ONE-A-DAY VITACRAVES ONE-A-DAY VITACRAVES GUMM ONE-A-DAY VITACRAVES SOUR ONE-A-DAY VITACRAVES WOME ONE-A-DAY WEIGHT SMART AD ONE-A-DAY WOMENS 50+ ADVA ONE-A-DAY WOMENS ACTIVE M ONE-A-DAY WOMENS PETITES ONE-A-DAY WOMENS PLUS HEA ONE-A-DAY WOMENS VITACRAV ONE-DAILY MULTI VITAMINS ONE-DAILY/IRON OPTIC-VITES


Updated 05/2017

OPTIMAL-D OPTIMAL-D PACK OPTIMUM PMS OPTISOURCE POST BARIATRIC OPTIVE REFRESH OPTIVE SENSITIVE REFRESH OPTIVITE P.M.T. OPURITY/BYPASS OPTIMIZED ORALYTE ORALYTE FREEZER POPS ORAZINC ORTHOVITE OS-CAL OS-CAL CALCIUM + D3 OS-CAL EXTRA D3 OSTEO-PORETICAL OVEGA-3 OYSCO 500 OYSCO 500+D OYSCO D OYST-CAL D OYST-CAL-D 500 OYSTER CALCIUM OYSTER CALCIUM/VITAMIN D OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM + D OYSTER SHELL CALCIUM + D3 OYSTER SHELL CALCIUM + VI OYSTER SHELL CALCIUM 250+ OYSTER SHELL CALCIUM 500 OYSTER SHELL CALCIUM 500/ OYSTER SHELL CALCIUM 500+ OYSTER SHELL CALCIUM PLUS OYSTER SHELL CALCIUM/ OYSTER SHELL CALCIUM/D OYSTER SHELL CALCIUM/D3 OYSTER SHELL CALCIUM/VITA OYSTER SHELL CALCIUM+D OYSTER SHELL/VITAMIN D OYSTERCAL OYSTERCAL-D PA FISH OIL PA MENS 50 PLUS VITAPAK PA MENS VITAPAK


Updated 05/2017

PA OYSTER SHELL CALCIUM PA VITAMIN D-3 PA VITAMIN D-3 GUMMY PA WOMENS 50 PLUS VITAPAK PA WOMENS VITAPAK PAIN & FEVER CHILDRENS PAIN & FEVER INFANTS PAIN RELIEF CHILDRENS PAIN RELIEF EXTRA STRENGT PARVLEX PC PEDIATRIC ELECTROLYTE PEDIA VANCE PEDIA-LAX PEDIALYTE PEDIALYTE ADVANCED CARE PEDIALYTE FREEZER POPS PEDIALYTE SINGLES PEDIATRIC ELECTROLYTE PEDIATRIC ELECTROLYTE FRE PEDIATRIC ELECTROLYTE/ZIN PERDIEM OVERNIGHT RELIEF PERFECT IRON PERI-COLACE PHARBETOL PHARBETOL EXTRA STRENGTH PIC 200 PIN-X POLY HIST FORTE POLY-IRON 150 POLY-TUSSIN AC POVIDONE-IODINE PRESERVISION AREDS PRESERVISION AREDS 2 PRESERVISION/LUTEIN PREVENT PRO-CAL PROCERV HP PROFE PRONUTRIENTS CALCIUM+D3 PRORENAL+D PRORENAL+D/OMEGA-3 PROSHIELD PLUS SKIN PROTE PROSIGHT PROSIGHT W/LUTEIN


Updated 05/2017

PROTECT CARDIO AF PROTECT PLUS NF PROTECT PLUS SO PROVIL PURPOSE PX CALCIUM&D PX COMPLETE SENIOR MULTIV PX FISH OIL PX FOLIC ACID PX IRON PX MENS MULTIVITAMINS PX NIACIN PX SALINE NASAL SPRAY QC ACID CONTROLLER MAXIMU QC ALLERGY/SINUS HEADACHE QC ANTI-ITCH EXTRA STRENG QC ASPIRIN QC CALCIUM 600 +D3 QC CALCIUM FAST DISSOLUTI QC CALCIUM/MINERALS/VITAM QC CHILDRENS IBUPROFEN QC COLD RELIEF PLUS QC DAILY MULTIVITAMINS/IR QC ENEMA QC FERROUS SULFATE QC IBUPROFEN QC IBUPROFEN COLD/SINUS QC IBUPROFEN IB QC MAXIMUM DAILY MULTIVIT QC MENS DAILY MULTIVITAMI QC MULTI-VITE QC MULTI-VITE 50 & OVER QC NON-ASPIRIN EXTRA STRE QC POVIDONE IODINE QC THERIN-M QC WOMENS DAILY MULTIVITA Q-DRYL QUIN B STRONG QUINTABS QUINTABS-M RA CALCIUM 600 RA CALCIUM 600 PLUS VITAM RA CALCIUM 600/VIT D/MINE RA CALCIUM CITRATE PLUS V


Updated 05/2017

RA CALCIUM CITRATE/VITAMI RA CALCIUM PLUS VITAMIN D RA CALCIUM/MINERALS/VITAM RA CENTRAL-VITE RA CENTRAL-VITE ENERGY RA CENTRAL-VITE SELECT RA CENTRAL-VITE SELECT MA RA CENTRAL-VITE SENIOR RA CENTRAL-VITE UNDER 50 RA CENTRAL-VITE WOMENS MA RA CENTRAL-VITE/ANTIOXIDA RA FISH OIL RA FOLIC ACID RA GLUCOSE RA HI CAL RA HI-CAL RA HI-CAL PLUS VITAMIN D RA HIGH POTENCY IRON RA IRON RA MAGNESIUM RA NIACIN RA NO FLUSH NIACIN 500 RA ONE DAILY ENERGY FORMU RA ONE DAILY ESSENTIAL RA ONE DAILY GUMMY VITES RA ONE DAILY MAXIMUM RA ONE DAILY MENS 50+ WIT RA ONE DAILY MENS/VITAMIN RA ONE DAILY MULTI-VITAMI RA ONE DAILY WOMENS/VITAM RA OYSTER SHELL CALCIUM RA PEDIATRIC ELECTROLYTE RA SALINE NASAL SPRAY RA SLOW RELEASE IRON RA STRESS FORMULA ADVANCE RA STRESS FORMULA ENERGY RA THERAPEUTIC M PLUS BET RA VITAMIN D-3 RA WHOLE SOURCE COMPLETE RA WHOLE SOURCE DIETARY RA WHOLE SOURCE DIETARY F RA WHOLE SOURCE DIETARY M RAGUS RANITIDINE 75


Updated 05/2017

REESES PINWORM MEDICINE REFRESH REFRESH LIQUIGEL REFRESH OPTIVE REFRESH OPTIVE ADVANCED REFRESH OPTIVE ADVANCED S REFRESH OPTIVE SENSITIVE REFRESH TEARS REGULOID REHYDRALYTE RELCOF IR RELHIST BP RELHIST DMX REMEDY DIMETHICONE MOISTU RENAL MULTIVITAMIN FORMUL RENAL-TAB RESCON REVITAL FREEZER POPS REVITAL JELL CUPS REVITAL LIQUID SQUEEZERS RHINARIS RISACAL-D ROBAFEN DM RU-HIST D RYMED SALINE MIST SALINE NASAL GEL SALINE NASAL SPRAY SALINE NASAL SPRAY INFANT SAVISION SB 12HR NASAL SPRAY SB ACID REDUCER SB ALLERGY SB ALLERGY & COLD PE SB ALLERGY MEDICINE SB ANTACID ANTI-GAS DOUBL SB ANTACID/ANTIGAS SB ANTI-DIARRHEA SB ASPIRIN SB BISACODYL LAXATIVE EC SB BISMUTH MAXIMUM STRENG SB CALCIUM + D SB CHILDRENS ASPIRIN SB CHLORPHENIRAMINE


Updated 05/2017

SB COUGH CONTROL SB DOCUSATE SODIUM SB EAR WAX REMOVER SB IBUPROFEN SB LORATADINE SB MILK OF MAGNESIA SB MOTION SICKNESS SB NAPROXEN SODIUM SB OMEGA-3 FISH OIL SB OYSTER SHELL CALCIUM SB PEDIATRIC ELECTROLYTE SB POVIDONE-IODINE SB SALINE NOSE SB SEVERE COLD PE SCALPICIN MAXIMUM STRENGT SCLEREX SEA SOFT NASAL MIST SEA-OMEGA SEA-OMEGA 30 SECURA ANTIFUNGAL SECURA ANTIFUNGAL EXTRA T SECURA DIMETHICONE PROTEC SENIOR TABS SENNA-PLUS SENNA-S SENOKOT SENOKOT S SENOKOT XTRA SENSI-CARE MOISTURIZING SENTRY SENTRY ADULTS UNDER 50 SENTRY SENIOR SILPHEN COUGH SILPHEN DM COUGH SILTUSSIN DAS SILTUSSIN DM DAS SIMETHICONE SIMPLY SALINE SINUS & ALLERGY PE MAXIMU SINUS RELIEF NASAL SPRAY SLO-NIACIN SLOW FE SLOW IRON SLOW MAGNESIUM CHLORIDE/


Updated 05/2017

SLOW RELEASE IRON SLOW-MAG SM ACID REDUCER SM ANTIBIOTIC PLUS PAIN R SM ANTI-DIARRHEAL SM ANTIOXIDANT VITAMINS SM ASPIRIN SM CALCIUM 500/VITAMIN D3 SM CALCIUM 600/VITAMIN D SM CALCIUM CITRATE W/VITA SM CALCIUM CITRATE/VITAMI SM CALCIUM CITRATE+ W/VIT SM CALCIUM/VITAMIN D SM CALCIUM/VITAMIN D3 SM CHEST CONGESTION RELIE SM COMPLETE SM COMPLETE 50+ SM COMPLETE 50+ ULTIMATE SM COMPLETE ADVANCED FORM SM COMPLETE SENIOR FORMUL SM FIBER SM FIRST AID ANTIBIOTIC SM FISH OIL SM FOLIC ACID SM GENTLE LAXATIVE SM HAIR/SKIN/NAILS SM HYDROCORTISONE PLUS SM IBUPROFEN SM IBUPROFEN IB SM IRON SM IRON SLOW RELEASE SM LUBRICANT EYE DROPS SM MAGNESIUM SM MAGNESIUM CITRATE SM MICONAZOLE 3 SM MOTION SICKNESS SM MOTION SICKNESS RELIEF SM MULTIPLE VITAMINS ESSE SM MULTIPLE VITAMINS/IRON SM NASAL SPRAY 12 HOUR SM NASAL SPRAY SALINE SM NIACIN CR SM ONE DAILY MENS SM ONE DAILY WOMENS


Updated 05/2017

SM OPTI-VITAMINS SM OYSTER SHELL CALCIUM/V SM PEDIATRIC ELECTROLYTE SM POVIDONE-IODINE SM SENNA LAXATIVE MAXIMUM SM SLOW RELEASE IRON SM STOOL SOFTENER SM STOOL SOFTENER PLUS LA SM TRIPLE ANTIBIOTIC PLUS SM VITAMIN D SM VITAMIN D3 SODIUM BICARBONATE SODIUM CHLORIDE SOF-LAX SOLO SOOTHE & COOL FREE MEDSEP SOOTHE & COOL FREE SKIN P SORBIDON HYDRATE SORBITOL STOMACH RELIEF MAXIMUM ST STOOL SOFTENER STRESS 500 B-COMPLEX/ZINC STRESS FORMULA STRESS FORMULA W/IRON STRESS FORMULA/IRON SUDOGEST SUNVITE ADVANCED SUPER ANTIOXIDANT/A/C/E/S SUPER CALCIUM SUPER CALCIUM 600 + D3 SUPER CALCIUM 600+D 400 SUPER CALCIUM 600+D3 400 SUPER DHA GEMS SUPER MULTIPLE SUPER NU-THERA SUPER OMEGA-3 SUPER THERA VITE M SUPER TWIN EPA/DHA SUPER VIKAPS SUPER VITA-MINS SYSTANE PRESERVATIVE FREE SYSTANE ULTRA PRESERVATIV TAB-A-VITE TAB-A-VITE MAXIMUM


Updated 05/2017

TAB-A-VITE W/BETA CAROTEN TAB-A-VITE/IRON TGT CALCIUM + VITAMIN D3 TGT NASAL SPRAY TGT SALINE NASAL SPRAY TH B COMPLEX/IRON/VITAMIN TH CALCIUM TH CALCIUM 600 WITH VITAM TH CALCIUM 600/VITAMIN D TH CALCIUM CITRATE/VITAMI TH CALCIUM/VITAMIN D/MINE TH COMPLETE MULTI TH COMPLETE MULTI 50+ TH DAILY MULTIPLE VITAMIN TH FISH OIL EXTRA STRENGT TH IRON TH OMEGA-3 FISH OIL TH OYSTER SHELL CALCIUM/V TH PREMIUM DAILY MULTIPLE TH THERADEX-M TH VISION VITAMINS/LUTEIN TH VITAMIN D3 TH WOMENS DAILY THERA THERA M PLUS THERA VITAL M THERA/BETA-CAROTENE THERABASIC-M THERA-D 2000 THERA-D 4000 THERA-D RAPID REPLETION THERA-D SPORT THERAFLU FLU & SORE THROA THERAFLU SEVERE COLD & CO THERAGRAN-M THERAGRAN-M ADVANCED THERAGRAN-M ADVANCED 50 P THERAGRAN-M FISH OIL CONC THERAGRAN-M PREMIER THERAGRAN-M PREMIER 50 PL THERA-M THERAMILL FORTE THERANATAL LACTATION SUPP THERAPEUTIC


Updated 05/2017

THERAPEUTIC LIQUID THERAPEUTIC M THERAPEUTIC MULTI VITAMIN THERAPEUTIC-M THERAPEUTIC-M/LUTEIN THERA-TABS THERA-TABS M THERATRUM COMPLETE THERATRUM COMPLETE 50 PLU THERAVIM THEREMS THEREMS-H THEREMS-M THEROMEGA THEROMEGA SPORT TOLNAFTATE TOTAL FORMULA TOTAL FORMULA 2 TOTAL FORMULA 3 TRIACTING DAY TIME COLD/C TRIAMINIC FEVER & COLD MU TRIFERIC TRIPLE ANTIBIOTIC TRIPLE ANTIBIOTIC PLUS TRUEPLUS DIABETIC MULTIVI TUSNEL TUSNEL C TUSNEL DIABETIC TUSSICAPS TUSSIN CF COUGH & COLD TUSSIN CF MAX MULTI-SYMPT TUSSIN DM TUSSIN DM CLEAR ULTRA FREEDA ULTRA FREEDA/IRON ULTRA MENS PACK UPCAL D VALUE PLUS GLUCOSE VISION FORMULA/LUTEIN VISION VITAMINS VITA HAIR VITABASIC COMPLETE VITABASIC SENIOR VITALEE


Updated 05/2017

VITAMIN D VITAMIN D 400 VITAMIN D HIGH POTENCY VITAMIN D2 VITAMIN D3 VITAMIN D-3 VITAMIN D3 - 50 VITAMIN D3 1000 VITAMIN D3 400 VITAMIN D3 5000 VITAMIN D3 ADULT GUMMIES VITAMIN D3 COMPLETE VITAMIN D3 MAXIMUM STR VITAMIN D3 MAXIMUM STRENG VITAMIN D3 SUPER STRENGTH VITAMIN E/VITAMIN C/BETA VITAMINS & MINERALS VITAMINS A-D-E/SELENIUM VITASANA VITATRUM VITATRUM COMPLETE VITRUM 50+ SENIOR MULTI VITRUM SENIOR WALGREENS GLUCOSE WEE CARE WOMENS 50+ ADVANCED WOMENS BIOMULTIPLE WOMENS DAILY FORMULA WOMENS DAILY FORMULA/FOLI WOMENS MULTI WOMENS ONE DAILY WOMENS PACK YELETS TEENAGE FORMULA YL FOLIC ACID YOUR LIFE MULTI ADULT GUM ZANTAC 150 MAXIMUM STRENG ZANTAC 75 ZEASORB-AF ZINC SULFATE ZINC-220

Prior Authorization Updates ADEMPAS—Criteria Revised


Updated 05/2017

Quantity Limit Updates NONE

Step Therapy Updates ELIDEL—Criteria Revised

Medications Removed from Formulary NONE


Updated 05/2017

April 2017 Formulary Updates

Generics Added DAPTOMYCIN INJ 500MG DEXMETHYLPHENIDATE HCL ER CAP 5MG, 10MG, 15MG, 20MG, 30MG, 40MG—PA, QL LEVOLEUCOVOR INJ 175MG METHYLPHENIDATE HCL ER (LA) CAPS —PA, QL MIGERGOT—QL PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM INJ 12-1.5GM

Brands Added LINZESS CAP 72MCG—QL POLY-VI-FLOR CHEW POLY-VI-FLOR SUSP POLY-VI-FLOR/IRON CHEW POLY-VI-FLOR/IRON SUSP SELZENTRY TAB 25MG, 75MG TRI-VI-FLOR SUSP VIBERZI TAB —QL

Prior Authorization Updates EXONDYS 51—Criteria Revised


Step Therapy Updates TRAVATAN Z—Criteria Revised



Updated 05/2017

March 2017 Formulary Updates

Generics Added AMABELZ TABS—PA APREPITANT CAPS-PA, QL DEXMETHYLPHENIDATE ER CAP 25 MG, 35 MG—PA, QL LOPINAVIR/RITONAVIR SOLN 80-20/ML—QL MOMETASONE FUROATE SUSP 50 MCG/ACT—QL NIFEDICAL XL TABS NORETHINDRONE/ETHINYL ESTRADIOL/FERROUS FUMARATE TABS NORGESTIMATE/ETHINYL ESTRADIOL TABS 0.215MG; 0.035 MG RASAGILINE TABS—QL RIBAVIRIN SOLR 6 GM

Brands Added CAMPATH INJ—PA MITIGARE CAP ONIVYDE INJ—PA PRIMACARE CAP PRENATAL PLS RUBRACA TABS—PA ZERIT SOLN 1MG/ML

Prior Authorization Updates ASCOMP/CODEINE—Criteria Revised BUTALBITAL COMPOUND/CODEINE CAPS— Criteria Revised BUTALBITAL/ACETAMINOPHENE/CAFFEINE CAPS—Criteria Revised BUTALBITAL/ACETAMINOPHEN/CAFFIENE TABS—Criteria Revised BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE—Criteria Revised BUTALBITAL/ASPIRIN/CAFFEINE CAPS—Criteria Revised BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE—Criteria Revised CAPACET—Criteria Revised DEXTROSE 10%—PA Removal ESGIC CAPS—Criteria Revised GAMASTAN S/D—Criteria Revised FANAPT—Criteria Revised FAZACLO TABS—Criteria Revised LATUDA—Criteria Revised MARGESIC—Criteria Revised REXULTI—Criteria Revised SAPHRIS—Criteria Revised


Updated 05/2017

VERSACLOZ—Criteria Revised VRAYLAR CAPS—Criteria Revised XTANDI—Criteria Revised ZEBUTAL CAPS—Criteria Revised ZYTIGA—Criteria Revised


Step Therapy Updates ASACOL HD TABS—Criteria Revised DELZICOL HD CAPS— Criteria Revised LIALDA TABS— Criteria Revised PENTASA CAPS— Criteria Revised



Updated 05/2017

February 2017 Formulary Updates

Generics Added CHLORDIAZEPOXIDE HCL-CLIDINIUM BROMIDE CAP 5-2.5 MG—PA, QL EPINEPHRINE INJ 0.3MG/0.3ML, 0.15MG/0.3ML —QL ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL EZETIMIBE TAB —QL NIFEDICAL XL TAB 30MG

Brands Added EVZIO INJ 2MG/0.4ML KYPROLIS —PA

Prior Authorization Updates NONE


Step Therapy Updates NONE



over-the-counter (otc) drugs added...4-way fast acting a thru z advanced a thru z high potency a...

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