HNMC CV Formulary PDF

CalViva Health Medi-Cal
Recommended Drug List
The CalViva Health Medi-Cal Recommended Drug List (RDL) includes drugs covered by CalViva
Health. The drug list is updated often and may change. To get the most up-to-date information, call
Member Services at 1-888-893-1569 (TTY: 711).
PLEASE DISCARD ALL PREVIOUS VERSIONS OF THE DRUG LIST
CV_Drug List Front Matter_ENG_3.7.17

Welcome to CalViva Health
What is the CalViva Health Medi-Cal Recommended Drug List?
The drug list includes drugs used to treat common diseases or health problems. A team of doctors
and pharmacists meets regularly to decide which drugs should be on the drug list. The team reviews
new and existing drugs and chooses drugs that work best and are safe. This drug list is updated
monthly.
How do I use the CalViva Health Medi-Cal Recommended Drug List?

Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug
list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will
see the page number where you can find your drug.
The table below has descriptions of the limits that may appear on the drug list:
Abbreviation Term What it means

AL Age Limit Some drugs are only covered for certain ages.
These drugs are carved out by the Department of Health
Care Services. This means these drugs are covered by the
CO Carve Out
Medi-Cal Fee-for-Service program and can be billed to the
State by the pharmacy.
F Formulary These drugs are covered on the Drug List.
These drugs are not covered on the Drug List. If your
NF Non-formulary doctor feels you need a drug that is not covered, he or she
can ask us to make an exception.
Your doctor must ask for approval from CalViva Health
PA Prior Authorization
before some drugs will be covered.
QL Quantity Limit Some drugs are only covered for a certain amount.
These drugs are made in both prescription form and Over-
RX/OTC Prescription and OTC
the-counter (OTC) form.
In some cases, you must first try certain drugs before
CalViva Health covers another drug for your medical
condition.
ST Step Therapy
For example, if Drug A and Drug B both treat your
medical condition, CalViva Health may not cover Drug B
unless you try Drug A first.
These drugs are specialty drugs. You can only get these
Specialty Pharmacy drugs through the specialty pharmacy vendor. All
SP
Program prescriptions must be filled by the listed specialty
pharmacy.
What if my drug is not on the CalViva Health Medi-Cal Recommended Drug List?
If your drug is not on the drug list, call Member Services at 1-888-893-1569 and ask if your drug is
covered. If your drug is not covered, you can ask your doctor if there is another drug that works in
the same way that is covered. If your doctor feels you need to have the drug that is not covered, your
doctor can ask us to make an exception.
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Can I go to any pharmacy?
Members must use pharmacies that are in the network. These pharmacies have a contract with
CalViva Health. To find a pharmacy, call Member Services at 1-888-893-1569.
Some drugs are only covered when supplied by a specialty pharmacy. Specialty drugs are those used
to treat ongoing or complex conditions and may need special handling or training. Specialty
pharmacies will mail drugs to you. You may choose to have your drugs sent to your home, work, your
doctor’s office or another address. Specialty drugs that must be supplied by a specific specialty
pharmacy are listed in the Requirements/Limits column on the Drug List. Drugs that do not have a
specialty pharmacy listed in the Requirements/Limits column on the Drug List can be filled at any
network pharmacy.
If your doctor does not want you to get your drugs from a specialty pharmacy, he/she must submit a
prior authorization request to ask for an exception to this rule.
You or your pharmacy can ask for an exception to have a specialty drug filled at a retail network
pharmacy. For example, if:
 Your dose or directions for how to take your drug has changed and you need to fill the drug
immediately.
 Your drugs arrive late or your drugs are going to arrive late.
 You have an urgent need for the drug and did not understand how to get the order placed with the
specialty pharmacy.
 You need the drug urgently to treat a life-threatening condition or you have an emergency need
for the drug and cannot wait for the drug to arrive from the specialty pharmacy.
If you cannot use a specialty pharmacy, you can request an exception to get all your drugs filled at a
retail network pharmacy. For example, if you:
 Do not have a mailing address or other way to get your drugs by mail
 If your doctor’s office provides the drugs to you
 If using a specialty pharmacy is a hardship for you
If you need an exception, you, your doctor or your pharmacy must ask for an exception. To ask for
an exception, please call CalViva Health Member Services at 1-888-893-1569 (TTY: 711), 24 hours
a day, seven days a week.
Are there any limits on my drug coverage?

Some drugs have limits on coverage. If a drug has limits, it will be noted in the Requirements/Limits
column on the Drug List.
How can I get an exception to the rules for drug coverage?

Your doctor can ask for an exception to our rules for drug coverage.
 Your doctor can ask us to cover your drug even if it is not on the drug list.
 Your doctor can ask us to make an exception for limits on your drug. For example, if your drug
has a quantity limit of 1 tablet per day, your doctor can ask us to cover more.
To ask for an exception, your doctor can fax a prior authorization request to us at
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1-800-977-8226. After we receive your doctor’s request, we usually make our decision within one
business day. If we deny the request, we will send you and your doctor a letter and tell you how to
file an appeal.
What if I’m a new member?

If you are a new member in our plan, you may be taking drugs that are not on our drug list. You may
also be taking a drug that is on our drug list, but the drug may have some limits. In these cases, you
should talk to your doctor to see if you should change to drugs that we cover. Your doctor may
request an exception so that we could cover the drug you have been taking. See the section, “How
do I get an exception to the rules for the drug coverage?” for more information.
What are over-the-counter drugs?

Over-the-counter (OTC) drugs are drugs you can buy without a prescription. The CalViva Health
Medi-Cal Recommended Drug List covers similar OTC drugs as those listed on the State Medi-Cal
List of Contract Drugs. However, if you want CalViva Health to cover an OTC drug on the drug list,
your doctor must write a prescription for that drug.
Are brand name drugs covered?

Your pharmacy benefit does not cover brand name drugs when generic drugs are available. Brand
name drugs may be covered when generic drugs are not available or if your doctor requests an
exception because the brand name drug is medically necessary.
What is a generic drug?

A generic drug contains the same active ingredient and works the same way as the brand name drug.
Generic drugs must be safe and effective.
Will the pharmacist give me a generic drug if one is available?

Yes. Pharmacies may give you a generic drug, unless your doctor says that you must take the brand
name drug.
Are there any excluded or carve-out drugs?

Excluded drugs
The CalViva Health Medi-Cal Recommended Drug List is similar to the State Medi-Cal List of
Contract Drugs and does not include certain drugs. The following types of drugs are not included on
the drug list because they are excluded from coverage:
 multivitamins
 erectile or sexual dysfunction drugs
 drugs used for cosmetic reasons or hair growth
 drugs that are considered experimental
 drugs used to treat infertility
 OTC cough and cold products
 OTC adult acetaminophen products
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Carve-out drugs
Some drugs are carved out by the Department of Health Care Services. This means that these drugs
are covered by the Medi-Cal Fee-for-Service program and can be billed to the State by the pharmacy.
The following types of drugs are carved out:
 certain psychotherapeutic drugs
 HIV-related drugs
 treatment drugs for alcohol and heroin detoxification and dependency
 certain drugs to treat hemophilia.
What is California Children’s Services?

California Children’s Services (CCS) is a state program for children (up to 21 years old) with certain
diseases or health problems. Some drugs for CCS-covered diseases or health problems are not
covered by CalViva Health.
Only doctors approved by CCS can write prescriptions for drugs used to treat CCS-covered
conditions. Pharmacies must bill CCS, and not CalViva Health, for these drugs. If you are at the
pharmacy and you are not yet in the CCS system, call Member Services at 1-888-893-1569. Member
Services can help you register with CCS. They may also help you get an emergency supply of your
drug.
Need more information?

For more information about your pharmacy benefits, please review your Evidence of Coverage or
call Member Services at 1-888-893-1569.
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Lista de Medicamentos
Recomendados
La Lista de Medicamentos Recomendados de CalViva Health Medi-Cal (RDL) incluye
medicamentos cubiertos por CalViva Health. Esta lista de medicamentos se actualiza a menudo y
puede variar. Para obtener la información más actualizada, llame al Departamento de Servicios al
Afiliado al 1-888-893-1569 (TTY: 711).
DESECHE TODAS LAS VERSIONES ANTERIORES DE LA LISTA DE
MEDICAMENTOS
CV_Drug List Front Matter_SPN_3.7.17

Bienvenido a CalViva Health
¿Qué es la Lista de Medicamentos Recomendados de CalViva Health Medi-Cal?
La lista de medicamentos incluye medicamentos usados para tratar enfermedades o problemas de
salud comunes. Un equipo de médicos y farmacéuticos se reúne regularmente para decidir qué
medicamentos deben estar en la lista de medicamentos. El equipo revisa los medicamentos nuevos y
los ya existentes, y elije los medicamentos que mejor funcionan y son seguros. Esta lista de
medicamentos se actualiza mensualmente.
¿Cómo uso la Lista de Medicamentos Recomendados de CalViva Health Medi-Cal?

Busque su medicamento en el índice que se encuentra al final de este folleto. El índice enumera
todos los medicamentos de la lista de medicamentos. Tanto los medicamentos de marca como los
medicamentos genéricos están enumerados en el índice. Junto a su medicamento, verá el número de
página en la que puede encontrar este medicamento.
La tabla que figura a continuación contiene descripciones de los límites que pueden aparecer en la
lista de medicamentos:
Abreviatura Término Lo que significa

Algunos medicamentos solo se cubren para determinadas
AL Age Limit
edades.
Estos medicamentos son excluidos por el Departamento de
Servicios de Cuidado de la Salud. Esto significa que estos
CO Carve Out medicamentos están cubiertos por el Programa de Pago
por Servicio de Medi-Cal y la farmacia puede
facturárselos al Estado.
Estos medicamentos están cubiertos en la Lista de
F Formulary
Medicamentos.
Estos medicamentos no están cubiertos en la Lista de
Medicamentos. Si su médico considera que usted necesita
NF Non-formulary
un medicamento que no está cubierto, el médico puede
pedirnos que hagamos una excepción.
Su médico debe solicitar aprobación de CalViva Health
antes de que se cubran algunos medicamentos.
Algunos medicamentos solo se cubren por determinada
QL Quantity Limit
cantidad.
Estos medicamentos pueden ser recetados o de venta libre
RX/OTC Prescription and OTC
(por sus siglas en inglés, OTC).
En algunos casos, usted primero debe probar ciertos
medicamentos antes de que CalViva Health cubra otro
medicamento para su condición médica.
ST Step Therapy
Por ejemplo, si tanto el Medicamento A como el
Medicamento B tratan su condición médica,
CalViva Health posiblemente no cubra el Medicamento B,
a menos que usted pruebe primero el Medicamento A.
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Abreviatura Término Lo que significa
Estos medicamentos son de especialidades. Solo puede
Specialty Pharmacy obtenerlos a través de un proveedor de especialidades
SP
Program farmacéuticas. Todas las recetas deben ser surtidas por la
farmacia de especialidades indicada.
¿Qué sucede si mi medicamento no está en la Lista de Medicamentos Recomendados de

CalViva Health Medi-Cal?
Si su medicamento no está en la lista de medicamentos, llame al Departamento de Servicios al
Afiliado al 1-888-893-1569 y pregunte si su medicamento está cubierto. Si su medicamento no está
cubierto, puede preguntarle a su médico si hay otro medicamento que actúe de la misma manera y
que esté cubierto. Si su médico considera que usted necesita el medicamento que no está cubierto, el
médico puede solicitarnos que hagamos una excepción.
¿Puedo ir a cualquier farmacia?

Los afiliados deben usar las farmacias que están en la red. Estas farmacias tienen un contrato con
CalViva Health. Para encontrar una farmacia, llame al Departamento de Servicios al Afiliado al
1-888-893-1569.
Algunos medicamentos solo están cubiertos cuando los suministra una farmacia de especialidades.
Los medicamentos de especialidades son aquellos usados para tratar afecciones complejas o
permanentes y pueden requerir de una capacitación o un manejo especial. Las farmacias de
especialidades le enviarán los medicamentos por correo. Puede elegir que le envíen los medicamentos a
su casa, al trabajo, al consultorio de su médico o a otra dirección. Los medicamentos de especialidades que
deben ser suministrados por una farmacia de especialidades específica se enumeran en la columna
Requisitos/Límites de la Lista de Medicamentos. Los medicamentos que no tienen una farmacia de
especialidades indicada en la columna Requisitos/Límites de la Lista de Medicamentos pueden
surtirse en cualquier farmacia de la red.
Si su médico no quiere que usted obtenga sus medicamentos a través de una farmacia de
especialidades, debe presentar una solicitud de autorización previa para pedir una excepción a esta
regla.
Usted o su farmacia pueden pedir una excepción para surtir un medicamento de especialidades en
una farmacia de venta minorista de la red. Por ejemplo, en estos casos:
 Su dosis o las indicaciones sobre la forma de tomar su medicamento cambiaron y usted necesita
surtir el medicamento de inmediato.
 Sus medicamentos llegan o llegarán tarde.
 Tiene una necesidad urgente de obtener el medicamento y no comprendió como hacerlo a través
de la farmacia de especialidades.
 Necesita el medicamento con urgencia para tratar una afección de riesgo vital o tiene una
necesidad de emergencia para obtener el medicamento y no puede esperar que este llegue de la
farmacia de especialidades.
Si no puede usar una farmacia de especialidades, puede solicitar una excepción para surtir todos los
medicamentos en una farmacia de venta minorista de la red. Por ejemplo, en estos casos:
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 No tiene una dirección de correo ni otra manera de recibir los medicamentos por correo.
 Si el consultorio de su médico le proporciona los medicamentos.
 Si el uso de una farmacia de especialidades es una dificultad para usted.
Si necesita que se haga una excepción, usted, su médico o su farmacia deben pedir una. Para pedir
una excepción, llame al Departamento de Servicios al Afiliado de CalViva Health al
1-888-893-1569 (TTY: 711), las 24 horas del día, los siete días de la semana.
¿Existe algún límite sobre la cobertura de mis medicamentos?

Algunos medicamentos tienen límites sobre la cobertura. Si un medicamento tiene límites, aparecerá
en la columna Requisitos/Límites de la Lista de Medicamentos.
¿Cómo puedo obtener una excepción a las reglas para la cobertura de medicamentos?
Su médico puede solicitar una excepción a nuestras reglas para la cobertura de medicamentos.
 Su médico puede solicitarnos que cubramos su medicamento incluso si este no se encuentra en la
lista de medicamentos.
 Su médico puede pedirnos que hagamos una excepción para los límites sobre su medicamento.
Por ejemplo, si su medicamento tiene un límite de cantidad de 1 comprimido por día, su médico
puede pedirnos que cubramos más cantidad.
Para pedir una excepción, su médico puede enviarnos una solicitud de autorización previa por fax al
1-800-977-8226. Luego de recibir la solicitud de su médico, usualmente tomamos nuestra decisión
en el lapso de un día hábil. Si denegamos la solicitud, les enviaremos a usted y a su médico una carta
y les informaremos cómo presentar una apelación.
¿Qué sucede si soy un afiliado nuevo?

Si usted es un afiliado nuevo a nuestro plan, es posible que esté tomando medicamentos que no están
en nuestra lista de medicamentos. También puede estar tomando un medicamento que esté en nuestra
lista de medicamentos, pero que pueda tener algunos límites. En estos casos, usted puede hablar con
su médico para ver si debe cambiar a otros medicamentos que cubramos. Su médico puede solicitar
una excepción para que podamos cubrir el medicamento que usted ha estado tomando. Consulte la
sección "¿Cómo puedo obtener una excepción a las reglas para la cobertura de medicamentos?", para
obtener más información.
¿Qué son los medicamentos de venta libre?

Los medicamentos de venta libre (OTC) son medicamentos que usted puede comprar sin receta. La
Lista de Medicamentos Recomendados de CalViva Health Medi-Cal cubre medicamentos OTC
similares a los que se enumeran en la Lista de Medi-Cal Estatal de Medicamentos por Contrato. Sin
embargo, si desea que CalViva Health cubra un medicamento OTC de la lista de medicamentos, su
médico debe hacer una receta para ese medicamento.
¿Están cubiertos los medicamentos de marca?

Su beneficio de farmacia no cubre medicamentos de marca cuando se encuentran disponibles
medicamentos genéricos. Los medicamentos de marca pueden estar cubiertos cuando los
medicamentos genéricos no están disponibles o si su médico solicita una excepción porque el
medicamento de marca es médicamente necesario.
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¿Qué es un medicamento genérico?
Un medicamento genérico contiene los mismos principios activos y funciona de la misma forma que
el medicamento de marca. Los medicamentos genéricos deben ser seguros y efectivos.
¿El farmacéutico me dará un medicamento genérico si está disponible?

Sí. Las farmacias pueden darle un medicamento genérico, a menos que su médico indique que usted
debe tomar el medicamento de marca.
¿Existe algún medicamento excluido o no incluido?

Medicamentos Excluidos
La Lista de Medicamentos Recomendados de CalViva Health Medi-Cal es similar a la Lista de
Medi-Cal Estatal de Medicamentos por Contrato y no incluye ciertos medicamentos. Los siguientes
tipos de medicamentos no están incluidos en la lista de medicamentos debido a que están excluidos
de la cobertura:
 multivitaminas
 medicamentos para la disfunción sexual o eréctil
 medicamentos para uso cosmético o para el crecimiento del cabello
 medicamentos que se consideran experimentales
 medicamentos utilizados para tratar la infertilidad
 productos OTC para la tos y el resfrío
 productos con acetaminofeno OTC para adultos
Medicamentos no incluidos
Algunos medicamentos son excluidos por el Departamento de Servicios de Cuidado de la Salud. Esto
significa que estos medicamentos están cubiertos por el Programa de Pago por Servicio de Medi-Cal
y la farmacia puede facturárselos al Estado. Los siguientes tipos de medicamentos no están incluidos:
 ciertos medicamentos psicoterapéuticos
 medicamentos relacionados con el VIH
 medicamentos de tratamiento para la desintoxicación y la dependencia del alcohol y la heroína
 ciertos medicamentos para tratar la hemofilia
¿Qué es Servicios Infantiles de California?

Servicios Infantiles de California (CCS) es un programa estatal para niños (hasta 21 años de edad)
con ciertas enfermedades o problemas de salud. Algunos medicamentos para las enfermedades o
problemas de salud cubiertos por los CCS no están cubiertos por CalViva Health.
Solo los médicos aprobados por los CCS pueden hacer recetas para los medicamentos usados para
tratar las condiciones cubiertas por los CCS. Las farmacias deben facturar a los CCS, y no a
CalViva Health, por esos medicamentos. Si usted está en la farmacia y no se encuentra aún en el
sistema de los CCS, llame al Departamento de Servicios al Afiliado al 1-888-893-1569. El
Departamento de Servicios al Afiliado puede ayudarlo a registrarse en los CCS. También puede
ayudarlo a conseguir un suministro de emergencia de su medicamento.
¿Necesita más información?

Para obtener más información sobre sus beneficios de farmacia, revise su Evidencia de Cobertura o
llame al Departamento de Servicios al Afiliado al 1-888-893-1569.
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Daim Ntawv Teev Cov
Npe Tshuaj Pom Zoo
Kom Muab
CalViva Health Medi-Cal Daim Ntawv Teev Cov Npe Tshuaj Pom Zoo Kom Muab (Recommended
Drug List, RDL) muaj cov tshuaj uas CalViva Health them rau. Yuav muab daim ntawv teev cov npe
tshuaj no kho tshiab tsis so thiab yuav muaj pauv. Yog xav tau daim uas muab kho tshiab los no, hu
rau tus xov tooj Pab Cov Tswv Cuab ntawm 1-888-893-1569 (TTY: 711).
THOV KOJ MUAB TAS NRHO COV NTAWV TEEV COV NPE TSHUAJ ZAUM TAS
LOS POV TSEG
CV_Drug List Front Matter_HMG_3.7.17

Zoo Siab Txais Tos Koj rau hauv CalViva Health
CalViva Health Medi-Cal Daim Ntawv Teev Cov Npe Tshuaj Pom Zoo Kom Muab yog dab
tsi?
Daim ntawv teev cov tshuaj muaj cov tshuaj uas muab siv los kho cov mob kheev pom muaj los yog
cov teeb meem kev mob nkeeg. Ib pab neeg ntawm cov kws kho mob thiab cov kws muab tshuaj
muaj sib ntsib tsis so los mus txiav txim seb yuav muab hom tshuaj twg tso rau ntawm daim ntawv
teev cov npe tshuaj. Pab neeg no yuav xyuas cov tshuaj tshiab thiab cov twb muaj tam sim no lawm
uas ua hauj lwm zoo tshaj thiab tsis muaj teeb meem dab tsi. Daim ntawv teev cov npe tshuaj no
yuav raug muab hloov kho dua tshiab txhua hli.
Kuv yuav siv CalViva Health Medi-Cal Daim Ntawv Teev Cov Npe Tshuaj Pom Zoo Kom
Muab li cas?
Saib kom pom koj cov tshuaj hauv daim ntawv teev cov npe nyob nram qab kawg ntawm phau me
nyuam ntawv no. Daim ntawv teev tag nrho cov tshuaj uas muaj nyob rau ntawm daim teev cov npe
tshuaj. Muaj yam tshuaj muaj npe cim (brand name) thiab tsis muaj npe cim (generic) teev rau
ntawm daim ntawv. Nyob tom ntej ntawm koj qhov tshuaj, koj yuav pom phab ntawv tus naj npawb
uas koj mus nrhiav tau koj qhov tshuaj.
Lub voj ntawv muaj kab (table) hauv qab no muaj cov lus piav txog qhov txwv them tsis pub tshaj
uas tej zaum yuav muaj tso rau ntawm koj daim ntawv teev cov npe tshuaj:
Tsiaj ntawv Lo lus sau kom tas Nws txhais li cas

sau kom luv nrho
AL Age Limit Muaj ib co tshuaj tsuas them rau qee lub hnub nyoog xwb.
Cov tshuaj no raug muab tshem tawm los ntawm
Department of Health Care Services. Qhov no txhais hais
CO Carve Out tias Medi-Cal Fee-for-Service them rau cov tshuaj no
thiab lub khw muag tshuaj xa tau cov nqi mus rau lub
Xeev them.
Cov tshuaj no muaj nyob rau hauv Daim Ntawv Teev Cov
F Formulary
Npe Tshuaj.
Cov tshuaj no tsis muaj nyob rau hauv Daim Ntawv Teev
Cov Npe Tshuaj. Yog koj tus kws kho mob xav tias koj
NF Non-formulary yuav tsum tau noj qhov tshuaj uas peb tsis them rau
ntawd, koj tus kws kho mob yuav tau thov peb kom muab
ib qho kev zam.
Koj tus kws kho mob yuav tsum thov kev tso cai los
ntawm CalViva Health ua ntej yuav them rau ib co tshuaj.
QL Quantity Limit Muaj ib co tshuaj tsuas them txog ntau npaum cas xwb.
Cov tshuaj no yog muab raws li daim ntawv kws kho mob
RX/OTC Prescription and OTC sau qhia qhov tshuaj kom mus yuav thiab mus yuav tau
qhov tshuaj Nyob-ntawm-txee (OTC) ob yam tib si.
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Tsiaj ntawv Lo lus sau kom tas Nws txhais li cas
sau kom luv nrho
Muaj tej qhov, koj yuav tsum tau xub sim qee hom tshuaj
ua ntej CalViva Health yuav them rau lwm yam tshuaj rau
koj tus mob.
ST Step Therapy
Piv txwv, yog tias qhov Tshuaj A thiab Tshuaj B ob qho
yeej kho tau koj tus mob, tej zaum CalViva Health yuav
tsis them rau qhov Tshuaj B tshwj tias yog koj xub sim
qhov Tshuaj A ua ntej lawm.
Cov tshuaj no yog ib co tshuaj tshwj xeeb. Koj tsuas yuav
tau cov tshuaj no nyob rau ntawm lub khw muag tshuaj
Specialty Pharmacy
SP tshwj xeeb xwb. Yuav tsum yog lub khw muag tshuaj
Program
tshwj xeeb uas muaj npe teev tseg xwb mas thiaj muaj cai
muab tau cov tshuaj uas kws kho mob ua ntawv yuav.
Yog hais tias kuv qhov tshuaj tsis nyob ntawm CalViva Health Medi-Cal Daim Ntawv Teev
Cov Npe Tshuaj Pom Zoo Kom Muab ne yuav ua li cas?
Yog koj qhov tshuaj tsis nyob ntawm daim ntawv teev cov npe tshuaj, hu rau tus xov tooj Pab Cov
Tswv Cuab ntawm 1-888-893-1569 thiab nug seb lawv puas them rau koj qhov tshuaj. Yog tias tsis
them rau koj qhov tshuaj ntawd, koj yuav tsum nug koj tus kws kho mob seb puas muaj lwm hom
tshuaj uas siv kho tau ib yam li hom ntawd uas them rau. Yog koj tus kws kho mob xav tias koj yuav
tsum tau noj qhov tshuaj uas peb tsis them rau ntawd, koj tus kws kho mob yuav thov tau peb kom
muab ib qho kev zam.
Kuv puas mus tau rau ntawm ib lub khw muag tshuaj tsis hais lub twg?
Cov tswv cuab yuav tsum mus rau ntawm cov khw muag tshuaj uas koom hauj lwm ua ke (network).
Cov khw muag tshuaj no muaj ib daim ntawv cog lus nrog rau CalViva Health. Yog koj xav nrhiav
kom tau ib lub khw muag tshuaj, hu rau tus xov tooj Pab Cov Tswv Cuab ntawm 1-888-893-1569.
Ib txhia tshuaj tsuas them thaum muaj ib lub khw muag tshuaj tshwj xeeb muab rau xwb. Cov tshuaj
tshwj xeeb yog cov tshuaj uas siv kho cov mob tsis tu ncua los yog cov mob uas muaj ntau yam mob
nyuaj heev thiab tej zaum yuav tsum tau muaj kev kawm paub los yog kev cob qhia txog kev khaws
qhov tshuaj cia. Cov khw muag tshuaj tshwj xeeb mam li xa cov tshuaj tuaj rau koj. Koj muaj cai
xaiv tau kom xa koj cov tshuaj tuaj rau ntawm koj tsev, koj qhov chaw ua hauj lwm, koj tus kws kho
mob qhov chaw ua hauj lwm los yog lwm qhov chaw nyob. Cov tshuaj tshwj xeeb uas yuav tsum
yog ib lub khw muag tshuaj tshwj xeeb nkaus xwb thiaj muaj cai muab rau koj muaj npe teev tseg
nyob rau hauv kem qhia txog Txhua yam yuav tsum muaj/Cov ciaj ciam tsis pub tshaj hauv Daim
Ntawv Teev Cov Npe Tshuaj. Cov tshuaj uas tsis muaj ib lub khw muag tshuaj tshwj xeeb npe teev
tseg nyob hauv kem qhia txog Txhua yam yuav tsum muaj/Cov ciaj ciam tsis pub tshaj ntawm Daim
Ntawv Teev Cov Npe Tshuaj yuav mus nqa tau qhov tshuaj nyob rau ntawm ib lub khw muag tshuaj
koom hauj lwm ua ke lub twg los tau.
Yog tias koj tus kws kho mob tsis xav kom koj mus yuav tshuaj tom ib lub khw muag tshuaj tshwj
xeeb, nws yuav tsum tau xa ib daim ntawv thov kev tso cai ua ntej mus thov ib qho kev zam txog
ntawm txoj cai no tso.
iii
Koj los yog koj lub khw muag tshuaj muaj cai thov ib qho kev zam mus nqa tau qhov tshuaj tshwj
xeeb nyob rau ntawm ib lub khw muag tshuaj uas koom hauj lwm ua ke. Piv txiv, yog tias:
 Koj qhov tshuaj uas yuav tsum noj ntau tsawg li cas tauj ib zaug los yog cov lus qhia txog kev
yuav noj koj cov tshuaj li cas tau hloov pauv lawm thiab koj yuav tsum tau mus nqa qhov tshuaj
tam sim ntawd los noj.
 Koj cov tshuaj tuaj txog qeeb los yog koj cov tshuaj yuav tuaj txog qeeb.
 Koj xav tau qhov tshuaj ntawd noj sai sai thiab koj tsis nkag siab zoo tias yuav ua li cas thiaj
yuav tau tshuaj los ntawm lub khw muag tshuaj tshwj xeeb.
 Koj xav tau qhov tshuaj ntawd noj sai sai txhawm rau kho tus mob hnyav txog-lub neej txoj sia
los yog koj xav tau qhov tshuaj ntawd ceev heev thiab koj tsis muaj peev xwm yuav tos taus txog
thaum lub khw muag tshuaj tshwj xeeb xa qhov tshuaj tuaj txog koj.
Yog tias koj tsis muaj peev xwm siv tau ib lub khw muag tshuaj tshwj xeeb, koj muaj cai thov ib qho
kev zam txhawm rau kom mus nqa tau koj txhua yam tshuaj nyob rau ntawm ib lub khw muag tshuaj
koom hauj lwm ua ke. Piv txwv, yog tias:
 Koj tsis muaj ib qho chaw nyob xa ntawv los yog tsis muaj lwm txoj hau kev kom lub khw xa tau
koj cov tshuaj tuaj rau koj
 Yog tias koj tus kws kho mob lub chaw ua hauj lwm muab cov tshuaj ntawd rau koj
 Yog tias kev siv ib lub khw muag tshuaj tshwj xeeb yog ib qho kev nyuaj rau koj
Yog tias koj xav tau ib qho kev zam, koj, koj tus kws kho mob los yog koj lub khw muag tshuaj yuav
tsum tau thov ib qho kev zam. Yog yuav thov ib qho kev zam, hu rau CalViva Health tus xov tooj
Pab Cov Tswv Cuab ntawm 1-888-893-1569 (TTY: 711), 24 teev tauj ib hnub, xya hnub txhua lim
piam.
Puas muaj qhov txwv tsis pub tshaj rau ntawm qhov them rau kuv qhov tshuaj?
Ib co tshuaj muaj qhov txwv them tsis pub tshaj. Yog tias hom tshuaj twg muaj ciaj ciam tsis pub
tshaj, nws yuav muaj lus sau qhia tseg nyob rau kem qhia txog Txhua yam yuav tsum muaj/Cov ciaj
ciam tsis pub tshaj nyob hauv Daim Ntawv Teev Cov Npe Tshuaj.
Kuv yuav tau txais ib qho kev zam rau ntawm cov cai hais txog kev them nyiaj rau cov tshuaj
li cas?
Koj tus kws kho mob yuav thov tau kom muaj ib qho kev zam ntawm peb cov cai rau qhov them cov
tshuaj.
 Koj tus kws kho mob yuav thov tau peb kom them rau koj qhov tshuaj tab txawm qhov tshuaj tsis
nyob ntawm daim ntawv teev cov npe tshuaj.
 Koj tus kws kho mob yuav thov tau kom muaj ib qho kev zam rau ntawm cov kev txwv tsis pub
tshaj rau ntawm koj cov tshuaj. Piv txwv, yog tias koj qhov tshuaj muaj qhov txwv tsis pub tshaj
1 ntsia tauj ib hnub, koj tus kws kho mob yuav thov tau peb kom them rau ntau tshaj qhov ntawd.
Yog yuav thov kom peb muab ib qho kev zam, koj tus kws kho mob yuav tsum tau fax (fev) ib daim
ntawv thov kev tso cai ua ntej mus rau peb ntawm 1-800-977-8226. Tom qab peb txais tau koj tus
kws kho mob daim ntawv thov lawm, peb yeej kheev muab peb qhov kev txiav txim siab tsis dhau ib
hnub hauv cov hnub ua hauj lwm. Yog tias peb tsis kam zam raws li daim ntawv thov, peb yuav xa
ib tsab ntawv tuaj rau koj thiab koj tus kws kho mob thiab yuav qhia rau koj seb yuav sau ib tsab
ntawv tsis txaus siab kom muab qhov no los xyuas dua li cas.
iv
Yog tias kuv yog ib tug tswv cuab tshiab ne yuav ua li cas?
Yog tias koj yob ib tug tswv cuab tshiab hauv peb daim phiaj npaj kho mob (plan), tej zaum koj yuav
noj cov tshuaj uas tsis nyob ntawm peb daim ntawv teev cov npe tshuaj. Tej zaum kuj yog koj noj ib
qho tshuaj uas nyob ntawm peb daim ntawv teev cov npe tshuaj, tab sis qhov tshuaj muaj cov kev
txwv tsis pub tshaj. Yog thaum zoo li no, koj yuav tau nug koj tus kws kho mob saib seb koj puas
yuav tau pauv mus rau cov tshuaj uas peb them. Koj tus kws kho mob yuav tau ua ib daim ntawv
thov kom zam xwv peb thiaj li yuav them rau cov tshuaj uas koj noj. Saib nqe lus, “Kuv yuav tau
txais ib qho kev zam rau ntawm cov cai hais txog kev them nyiaj rau cov tshuaj li cas?” kom paub
ntau ntxiv.
Cov tshuaj nyob-ntawm-txee yog dab tsi?

Cov tshuaj nyob–ntawm-txee (over-the-counter, OTC) yog cov tshuaj koj yuav tau tsis tas kom kws
kho mob sau daim ntawv qhia tshuaj rau koj mus yuav. CalViva Health Medi-Cal Daim Ntawv Teev
Cov Npe Tshuaj Pom Zoo Kom Muab them rau cov OTC tshuaj ib yam li cov muab teev rau ntawm
lub Xeev Medi-Cal Daim Ntawv Teev Cov Tshuaj Muaj Ntawv Cog Lus. Tab sis li cas los xij, yog
tias koj xav kom CalViva Health them rau ib qho tshuaj OTC uas muaj nyob rau ntawm daim ntawv
teev cov npe tshuaj, koj tus kws kho mob yuav tsum tau sau ib daim ntawv qhia qhov tshuaj ntawd
rau koj mus yuav.
Cov tshuaj muaj npe cim (brand name) puas yog cov tshuaj them rau?
Koj lub khw muag tshuaj qhov kev pab tsis them rau cov tshuaj muaj npe cim (brand name) thaum
muaj cov tshuaj tsis muaj npe cim (generic). Kuj yuav them rau cov tshuaj muaj npe cim (brand
name) yog thaum tsis muaj cov tshuaj uas tsis muaj npe cim (generic) los yog tias koj tus kws kho
mob thov kom peb muab ib qho kev zam yeeb vim hais tias qhov tshuaj muaj npe cim (brand name)
yog qhov tshuaj yuav tsum tau muab los kho koj tus mob.
Tshuaj tsis muaj npe cim (generic) yog dab tsi?

Ib hom tshuaj tsis muaj npe cim (generic) muaj cov khoom nyob hauv zoo ib yam thiab ua hauj lwm
tau ib yam li ib hom tshuaj muaj npe cim (brand name). Cov tshuaj tsis muaj npe cim (generic) yuav
tsum muab kev kaj huv thiab ua tau hauj lwm zoo.
Tus kws muab tshuaj puas yuav muab ib qho tshuaj tsis muaj npe cim (generic) rau kuv yog muaj ib
qho?
Muab. Cov khw muag tshuaj yuav muab ib qho tshuaj tsis muaj npe cim (generic) rau koj, tshwj tias
ntshe koj tus kws kho mob hais tias koj yuav tsum tau noj hom tshuaj muaj npe cim (brand name) no
xwb.
Puas muaj cov tshuaj uas tsis muab xam rau hauv los yog muab tshem tawm?
Cov tshuaj tsis muab xam rau hauv
CalViva Health Medi-Cal Daim Ntawv Teev Cov Npe Tshuaj Pom Zoo Kom Muab zoo ib yam li
lub Xeev Medi-Cal Daim Ntawv Teev Cov Npe Tshuaj Muaj Ntawv Cog Lus thiab tsis muaj qee
yam tshuaj nyob hauv. Hom tshuaj nram qab no tsis muaj nyob hauv daim ntawv teev cov npe tshuaj
vim tau muab lawv tshem tawm tsis them rau lawm:
 cov tshuaj qab los multivitamins
 cov tshuaj siv zoo rau chaw mos los yog chaw mos muaj qhov txawv txav tsis ua hauj lwm
 cov tshuaj siv kom zoo nkauj los yog kom plaub hau tuaj zoo
 cov tshuaj sim
v
 cov tshuaj siv kom tsis muaj me nyuam
 cov tshuaj OTC zoo hnoos thiab tshuaj zoo khaub thuas
 cov tshuaj OTC zoo ua npaws rau cov neeg muaj hnub nyoog
Cov tshuaj muab tshem tawm

Muaj ib cov tshuaj muab tshem tawm los ntawm Department of Health Care Services. Qhov no
txhais hais tias Medi-Cal Fee-for-Service them rau cov tshuaj no thiab lub khw muag tshuaj xa tau
cov nqi mus rau lub Xeev them. Hom tshuaj nram qab no yog cov muab tshem tawm:
 qee hom tshuaj kho kev nyuaj siab mob hlwb
 cov tshuaj kho ncig txog tus mob HIV
 cov tshuaj kho quav yeeb quav tshuaj thiab yeeb dawb thiab tshuaj muaj yees
 qee yam tshuaj uas kho zoo ntshav los tsis tu
California Children’s Services yog dab tsi?

California Children’s Services (CCS) yog lub xeev ib qho kev pab cuam rau cov me nyuam (hnub
nyoog siab mus txog 21 xyoos) uas muaj mob los yog muaj teeb meem kev mob nkeeg. Ib txhia
tshuaj uas CCS them kho cov mob los yog teeb meem mob CalViva Health tsis them.
Tsuas yog cov kws kho mob uas pom zoo los ntawm CCS xwb thiaj muaj cai sau tau cov ntawv qhia
mus yuav cov tshuaj siv kho cov mob uas CCS them. Cov khw muag tshuaj yuav tsum xa cov nqi
mus rau CCS them rau cov tshuaj no, tsis yog xa mus rau CalViva Health them. Yog koj nyob rau
ntawm lub khw muag tshuaj es koj tseem tsis tau nyob hauv CCS txoj kev khiav hauj lwm, hu rau tus
xov tooj Pab Cov Tswv Cuab ntawm 1-888-893-1569. Qhov Chaw Pab Cov Tswv Cuab yuav pab
tau koj sau npe nrog rau CCS. Lawv kuj tseem pab tau koj kom tau tshuaj thaum muaj xwm txheej
ceev.
Xav paub ntxiv?

Yog xav paub ntxiv txog koj lub khw muag tshuaj cov kev pab, thov saib koj Phau Ntawv Pov
Thawj Them Rau (Evidence of Coverage) los yog hu rau tus xov tooj Pab Cov Tswv Cuab ntawm
1-888-893-1569.
vi
Nondiscrimination Notice
CalViva Health complies with applicable federal civil rights laws and does not discriminate, exclude
people or treat them differently on the basis of race, color, national origin, ancestry, religion,
marital status, gender, gender identity, sexual orientation, age, disability, or sex.
CalViva Health:
• Provides free aids and services to people with disabilities to
communicate effectively with us, such as qualified sign language
interpreters and written information in other formats (large
print, accessible electronic formats, other formats).
• Provides free language services to people whose primary
language is not English, such as qualified interpreters and
information written in other languages.
If you need these services, contact CalViva Health’s Member
Services Department at 1-888-893-1569 (TTY: 711).
If you believe that CalViva Health has failed to provide these services or discriminated in another
way, you can file a grievance by calling the number above and telling them you need help filing a
grievance; CalViva Health’s Member Services Department is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health
and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC
20201, 1-800-368-1019 (TDD: 1-800-537-7697) if there is a concern of discrimination based on race,
color, national origin, age, disability, or sex.
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
FLY017666EW00 (12/17)
English: If you, or someone you’re helping, has questions about CalViva Health, you have
the right to get help and information in your language at no cost. To talk to an interpreter, call
1-888-893-1569 (TTY: 711).
Arabic:c ‫ لديك الحق في تلقي‬,CalViva Health ‫إذا كان لديك أو شخص ما تساعده أية استفسارات عن‬
‫ اتصل على الرقم‬،‫ للتحدث إلى مترجم فوري‬.ً‫المساعدة والمعلومات بلغتك مجانا‬
.)TTY: 711( 1-888-893-1569
Armenian: Եթե դուք կամ որևէ մեկը, ում դուք օգնում եք, հարցեր CalViva
Health-ի մասին, դուք իրավունք ունեք ստանալ օգնություն և ձեր լեզվով անվճար
տեղեկություններ: Թարգմանչի հետ խոսելու համար զանգահարեք
1-888-893-1569 հեռախոսահամարով (TTY: 711)
Cambodian (Khmer): ប ស ើ ិ នបោកអ្នក ឬនរណាម្កដែលបោកអ្ន

្ន ់ កកំពុងជួយម្នសំ ណួរអំពី
CalViva Health បោកអ្នកម្នសិទ្ិ ទទួលបានជនួ ំ យ នងព ័ ម្នជាភាសារ
ិ ត ៌ ស់បោកអ្នកបោយឥត
គតថ្លៃ
ិ ។ បែម្ប
ើ ី រឹកសាជាមួយអ្នក កដប សមបៅទរសព្ទ
ូ ូ ័ បៅបលខ 1-888-893-1569 (TTY: 711)។
Chinese (Traditional): 如果您或您協助的人士對 CalViva Health 有疑問，您有權免費

取得以您的語言提供的協助及資訊。如欲取得口譯員協助，請致電
1-888-893-1569 (TTY: 711)。
Hindi: यदि आप, या कोई वयक्ति जिसकी आप मिि कर रहे हैं , के CalViva Health के
बारे में प्रश्न हैं , तो आपको अपनी भाषा में नन:शुलक मिि प्राप्त करने और िानकारी प्राप्त
करने का अनिकार है । एक अनुवािक से बात करने के निए,
1-888-893-1569 (TTY: 711) पर कॉि करें ।
Hmong (White): Yog koj, lossis lwm tus koj pab, muaj lus nug txog CalViva Health, koj
muaj txoj cai tau kev pab thiab ntaub ntawv ua koj hom lus tsis muaj nqi them. Xav nrog ib
tug neeg txhais lus, hu 1-888-893-1569 (TTY: 711).
Japanese: あなたご自身またはあなたが援助している方がCalViva Healthに関する質

問をお持ちの場合、あなたには無料で日本語によるサポートと情報を得る権利があ
ります。通訳とお話になるには、1-888-893-1569（TTY：711）までお電話くだ
さい。
Korean: 귀하 또는 귀하가 도와드리고 있는 분이 CalViva Health에 관한 질문이

있을 경우, 귀하에게는 무료로 본인이 구사하는 언어로 도움과 정보를 받을 권리가
있습니다. 통역사와 통화하려면 1-888-893-1569 (TTY: 711) 번으로 전화해 주십시오.
Laotian: ຖ້າທ່ານ ຫຼື ຜູ້ໃດໜຶ່ງທີ່ທ່ານກຳລັງຊ່ວຍເຫຼືອມີຄຳຖາມກ່ຽວກັບ CalViva Health,

ທ່ານມີສິດໃນການຮັບການຊ່ວຍເຫຼືອ ແລະ ຮັບຂໍ້ມູນເປັນພາສາຂອງທ່ານໂດຍບໍ່ຕ້ອງເສຍຄ່າໃດໆ.
ລົມກັບລ່າມພາສາ, ໂທ 1-888-893-1569 (TTY: 711).
Persian (Farsi):i،‫ داريد‬CalViva Health ‫ سؤاالتی در مورد‬،‫اگر شما يا شخصی که به وی کمک می کنيد‬
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.‫) تماس بگيريد‬TTY: 711( 1-888-893-1569 ‫ با شماره‬،‫شفاهی‬
Panjabi (Punjabi): ਜੇ ਤੁਹਾਡੇ, ਜਾਂ ਕਿਸੇ ਅਕਜਹੇ ਕਿਅਿਤੀ, ਕਜਸਦੀ ਤੁਸੀਂ ਮਦਦ ਿਰ ਰਹੇ ਹੋ, ਦੇ
CalViva Health ਹੈਲਥ) ਬਾਰੇ ਿੋਈ ਸਿਾਲ ਹਨ, ਤਾਂ ਤੁਹਾਨੰੂ ਮੁਫ਼ਤ ਕਿੱਚ ਆਪਣੀ ਭਾਸਾ ਕਿੱਚ ਮਦਦ
ਪ੍ਾਪਤ ਿਰਨ ਅਤੇ ਜਾਣਿਾਰੀ ਪ੍ਾਪਤ ਿਰਨ ਦਾ ਹੱਿ ਹੈ। ਇੱਿ ਦੁਭਾਕਸਏ ਨਾਲ ਗੱਲ ਿਰਨ ਲਈ
1-888-893-1569 )TTY: 711( ‘ਤੇ ਫ਼ੋਨ ਿਰੋ।
Russian: Если у Вас или у кого-то, кому Вы помогаете, есть вопросы о плане CalViva
Health, Вы имеет право бесплатно получить необходимые сведения в переводе на Ваш
язык. Для того чтобы воспользоваться помощью устного переводчика, позвоните по
телефону 1-888-893-1569 (TTY:711).
Spanish: Si usted, o alguna persona a la que asiste, tiene preguntas sobre CalViva Health,
tiene derecho a obtener ayuda e información en su idioma sin cargo. Para hablar con un
intérprete, llame al 1-888-893-1569 (TTY: 711).
Tagalog: Kung ikaw o ang isang taong tinutulungan mo ay mayroong mga tanong tungkol
sa CalViva Health, mayroon kang karapatang makakuha ng tulong at impormasyon na
nasa wika mo nang walang babayaran. Para makipag-usap sa isang interpreter, tumawag sa
1-888-893-1569 (TTY: 711).
Thai: หากคุณ หรือคนที่คุณกำาลังให้ความช่วยเหลือ มีคำาถามเกี่ยวกับ CalViva Health คุณมี

สิทธิที่จะขอรับความช่วยเหลือและข้อมูลเป็นภาษาของคุณได้โดยไม่มีค่าใช้จ่าย หากต้องการคุย
กับล่าม โทร 1-888-893-1569 (TTY: 711).
Vietnamese: Nếu quý vị, hoặc một người nào đó quý vị đang giúp đỡ, có thắc mắc về
CalViva Health, quý vị có quyền nhận được trợ giúp và thông tin bằng ngôn ngữ của quý vị
miễn phí. Để trao đổi với phiên dịch viên, hãy gọi số 1-888-893-1569 (TTY: 711).
CA CalViva Notice of Language Assistance FLY017908ZO00 (12/17)

Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ADHD/ANTI-NARCOLEPSY/ANTI- benzphetamine hcl tabs 25 F PA
OBESITY/ANOREXIANTS - Drugs to Treat mg
ADHD, Sleep and Eating Disorders diethylpropion hcl tabs 25 F PA
Amphetamines
mg
ADDERALL TABS (Use DIETHYLPROPION HCL PA
Amphetamine- NF TABS 25 MG (Use NF
Dextroamphetamine) Diethylpropion HCl)
ADDERALL XR CP24 (Use QL(1 ea daily) diethylpropion hcl tb24 75 F PA
Amphetamine- NF mg
Dextroamphetamine) LOMAIRA TABS F PA
amphetamine- QL(1 ea daily)
dextroamphetamine cp24 phentermine hcl caps F PA
5mg-5mg-5mg-5mg,
2.5mg-2.5mg-2.5mg- phentermine hcl tabs F PA
2.5mg, 7.5mg-7.5mg- F
7.5mg-7.5mg, 1.25mg- QSYMIA CP24 F PA
1.25mg-1.25mg-1.25mg,
3.75mg-3.75mg-3.75mg- REGIMEX TABS (Use NF PA
3.75mg, 6.25mg-6.25mg- Benzphetamine HCl)
6.25mg-6.25mg PA
SUPRENZA TBDP F
amphetamine-
dextroamphetamine tabs Anti-Obesity Agents
5mg-5mg-5mg-5mg, PA
2.5mg-2.5mg-2.5mg- ALLI CAPS F
2.5mg, 7.5mg-7.5mg-
7.5mg-7.5mg, 1.25mg- BELVIQ TABS F PA
1.25mg-1.25mg-1.25mg, F
3.75mg-3.75mg-3.75mg- BELVIQ XR TB24 F PA
3.75mg, 1.875mg-
1.875mg-1.875mg- CONTRAVE TB12 F PA
1.875mg, 3.125mg-
3.125mg-3.125mg- SAXENDA SOPN F PA
3.125mg
DEXEDRINE CP24 (Use XENICAL CAPS F PA
Dextroamphetamine NF
Sulfate) Attention-Deficit/Hyperactivity Disorder (ADHD)
dextroamphetamine sulfate F atomoxetine hcl caps F QL(2 ea daily)
cp24 5 mg, 10 mg, 15 mg
dextroamphetamine sulfate F QL(3 ea daily) clonidine hcl (adhd) tb12 F
tabs 10 mg
dextroamphetamine sulfate guanfacine hcl (adhd) tb24 F QL(1 ea daily)
F
tabs 5 mg
INTUNIV TB24 (Use NF QL(1 ea daily)
Anorexiants Non-Amphetamine Guanfacine HCl (ADHD))
ADIPEX-P CAPS (Use NF PA KAPVAY TB12 (Use
Phentermine HCl) NF
Clonidine HCl (ADHD))
ADIPEX-P TABS (Use NF PA STRATTERA CAPS (Use
Phentermine HCl) NF QL(2 ea daily)
Atomoxetine HCl)
To learn what the symbols and abbreviations on this table mean, go to page ii.
Last Updated: April 1, 2018
www.calvivahealth.org
1
Stimulants - Misc. paromomycin sulfate caps F QL(160 ea per
PA fill retail)
armodafinil tabs F SP-
CONCERTA TBCR 27 MG, QL(1 ea daily) TOBI NEBU (Use NF AcariaHealth;A
54 MG (Use NF Tobramycin) L; At least 21
Methylphenidate HCl) yrs old
CONCERTA TBCR 36 MG SP-
NF QL(2 ea daily)
(Use Methylphenidate HCl) TOBI PODHALER CAPS F AcariaHealth;A
L; At least 21
METHYLPHENIDATE HCL F QL(2 ea daily) yrs old
ER TB24
SP-
methylphenidate hcl tabs 5
mg, 10 mg, 20 mg F tobramycin nebu F AcariaHealth;A
L; At least 21
methylphenidate hcl tbcr 10 F yrs old
mg, 20 mg SP-
methylphenidate hcl tbcr 18 QL(1 ea daily)
mg, 27 mg, 54 mg F TOBRAMYCIN NEBU F AcariaHealth;A
L; At least 21
methylphenidate hcl tbcr 36 QL(2 ea daily) yrs old
F
mg ANALGESICS - ANTI-INFLAMMATORY - Drugs
modafinil tabs F PA; QL(1 ea to Treat Pain, Swelling, Muscle and Joint
daily) Conditions
NUVIGIL TABS (Use NF PA Anti-TNF-alpha - Monoclonal Antibodies
Armodafinil)
HUMIRA PEDIATRIC PA; SP-
PROVIGIL TABS (Use NF PA; QL(1 ea CROHNS DISEASE F AcariaHealth
Modafinil) daily) STARTER PACK PSKT
RITALIN TABS (Use
Methylphenidate HCl) NF HUMIRA PEN PNKT F PA; SP-
AcariaHealth
AMINOGLYCOSIDES - Drugs to Treat Bacterial HUMIRA PEN-CROHNS
Infections F PA; SP-
DISEASESTARTER PNKT AcariaHealth
Aminoglycosides HUMIRA PEN-PSORIASIS F PA; SP-
SP- STARTER PNKT AcariaHealth
BETHKIS NEBU F AcariaHealth;A HUMIRA PSKT F PA; SP-
L; At least 21 AcariaHealth
yrs old
SIMPONI ARIA SOLN F PA; SP-
PA AcariaHealth
gentamicin in saline soln F
Antirheumatic - Enzyme Inhibitors
GENTAMICIN PA
SULFATE/0.9% SODIUM F PA; SP-
XELJANZ TABS F
CHLORIDE SOLN AcariaHealth
ISOTONIC GENTAMICIN PA PA; SP-
F XELJANZ XR TB24 F
SOLN AcariaHealth
SP- Antirheumatic Antimetabolites
AcariaHealth;A RHEUMATREX TABS F
KITABIS PAK NEBU F
L; At least 21
yrs old Gold Compounds
neomycin sulfate tabs F RIDAURA CAPS F
2
Interleukin-1beta Blockers fenoprofen calcium tabs F
PA; SP-
600 mg
ILARIS SOLN F
Caremark ibuprofen caps 200 mg F
PA; SP-
ILARIS SOLR F ibuprofen chew 100 mg F
Caremark
Interleukin-6 Receptor Inhibitors RX/OTC
ibuprofen susp 100 mg/5ml F
ACTEMRA SOLN IV 80 PA; SP-
MG/4ML, 200 MG/10ML, F AcariaHealth ibuprofen susp 40 mg/ml, F
400 MG/20ML 50 mg/1.25ml
Nonsteroidal Anti-inflammatory Agents (NSAIDs) ibuprofen tabs 100 mg, 200
mg, 400 mg, 600 mg, 800 F
ADVIL CAPS (Use NF mg
Ibuprofen)
ADVIL MIGRAINE CAPS INDOCIN SUPP F
NF
(Use Ibuprofen)
ADVIL TABS (Use INDOCIN SUSP F
NF
Ibuprofen)
ALEVE CAPS (Use indomethacin caps F
NF
Naproxen Sodium)
indomethacin cpcr F
ANAPROX DS TABS (Use NF
Naproxen Sodium) INFANTS ADVIL SUSP NF
CELEBREX CAPS (Use (Use Ibuprofen)
NF
Celecoxib) KETOPROFEN CAPS 50 F
MG, 75 MG
celecoxib caps F
ketoprofen caps 50 mg, 75 F
CHILDRENS ADVIL SUSP mg
NF RX/OTC
(Use Ibuprofen) LODINE TABS (Use NF
CHILDRENS MOTRIN Etodolac)
NF RX/OTC
SUSP (Use Ibuprofen) MECLOFENAMATE F
DAYPRO TABS (Use SODIUM CAPS
NF
Oxaprozin) QL(1 ea daily)
meloxicam tabs F
diclofenac potassium tabs F
MOBIC TABS 15 MG, 7.5 NF QL(1 ea daily)
diclofenac sodium tb24 or MG (Use Meloxicam)
F
100 mg MOTRIN INFANTS
diclofenac sodium tbec or DROPS SUSP (Use NF
F Ibuprofen)
25 mg, 50 mg, 75 mg
EC-NAPROSYN TBEC NF nabumetone tabs F
(Use Naproxen)
NAPROSYN SUSP (Use NF
etodolac caps F Naproxen)
etodolac tabs F NAPROSYN TABS (Use NF
Naproxen)
etodolac tb24 F naproxen sodium caps 220 F
mg
FELDENE CAPS (Use NF
Piroxicam)
3
naproxen sodium tabs 275 F ENBREL SOSY F PA; SP-
mg, 550 mg AcariaHealth
naproxen susp 125 mg/5ml F ENBREL SURECLICK F PA; SP-
SOAJ AcariaHealth
NAPROXEN SUSP 125 F ANALGESICS - NonNarcotic - Drugs to Treat
MG/5ML Pain, Muscle and Joint Conditions
naproxen tabs 250 mg, 375 F
mg, 500 mg Analgesic Combinations
naproxen tbec 375 mg, 500 butalbital-acetaminophen F
F tabs 325mg-50mg
mg
butalbital-acetaminophen-
oxaprozin tabs F caffeine caps 325mg- F
50mg-40mg
piroxicam caps F butalbital-acetaminophen-
caffeine tabs 325mg-50mg- F
sulindac tabs F 40mg
tolmetin sodium caps 400 butalbital-aspirin-caffeine F
F caps
mg
TOLMETIN SODIUM BUTALBITAL/ASPIRIN/CA F
F FFEINE TABS
CAPS 400 MG
TOLMETIN SODIUM TABS F ESGIC TABS (Use
200 MG, 600 MG Butalbital-Acetaminophen- NF
Caffeine)
Phosphodiesterase 4 (PDE4) Inhibitors
FIORINAL CAPS (Use NF
OTEZLA TABS F PA; SP- Butalbital-Aspirin-Caffeine)
AcariaHealth
TENCON TABS F
OTEZLA TBPK F PA; SP-
AcariaHealth
Analgesics Other
Pyrimidine Synthesis Inhibitors
acetaminophen chew or 80 F AL; Up to 21
ARAVA TABS (Use NF SP-Caremark mg, 160 mg yrs old
Leflunomide)
acetaminophen elix or 160 F AL; Up to 21
leflunomide tabs F SP-Caremark mg/5ml, 80 mg/2.5ml yrs old
acetaminophen liqd or 160 F AL; Up to 21
Selective Costimulation Modulators mg/5ml yrs old
ORENCIA CLICKJECT F PA; SP- acetaminophen soln or 160 AL; Up to 21
SOAJ AcariaHealth mg/5ml, 650 mg/20.3ml, F yrs old
325 mg/10.15ml
ORENCIA SOLR F PA; SP-
AcariaHealth acetaminophen supp re AL; Up to 21
F
120 mg yrs old
ORENCIA SOSY F PA; SP-
AcariaHealth acetaminophen susp or AL; Up to 21
Soluble Tumor Necrosis Factor Receptor Agents 160 mg/5ml, 80 mg/0.8ml, F yrs old
80 mg/2.5ml
ENBREL MINI SOCT F PA; SP-Acaria acetaminophen tbdp or 80 AL; Up to 21
Health F
mg, 160 mg yrs old
ENBREL SOLR F PA; SP- FEVERALL INFANTS AL; Up to 21
AcariaHealth F
SUPP yrs old
4
NORTEMP INFANTS F AL; Up to 21 ANALGESICS - OPIOID - Drugs to Treat Pain,
SUSP yrs old Muscle and Joint Conditions
TYLENOL CHILDRENS AL; Up to 21
Opioid Agonists
SUSP (Use NF yrs old
Acetaminophen) CODEINE SULFATE TABS F
15 MG
TYLENOL INFANTS AL; Up to 21
PAIN+FEVER SUSP (Use NF yrs old codeine sulfate tabs 15 mg, F
Acetaminophen) 30 mg, 60 mg
TYLENOL INFANTS SUSP DEMEROL TABS OR 50
NF AL; Up to 21 MG, 100 MG (Use NF
(Use Acetaminophen) yrs old
Meperidine HCl)
Salicylates DILAUDID LIQD OR 1
aspirin buffered (cal carb- F MG/ML (Use NF
mag carb-mag oxide) tabs Hydromorphone HCl)
aspirin chew or 81 mg F DILAUDID TABS OR 2
MG, 4 MG, 8 MG (Use NF
ASPIRIN LOW DOSE F Hydromorphone HCl)
TABS QL(240 ea per
ASPIRIN SUPP RE 120 DOLOPHINE TABS 10 MG
MG, 200 MG, 300 MG, 600 F NF fill retail,720 ea
(Use Methadone HCl) per 75 days
MG retail)
aspirin supp re 300 mg, F QL(120 ea per
600 mg DOLOPHINE TABS 5 MG NF fill retail,360 ea
(Use Methadone HCl) per 75 days
aspirin tabs or 325 mg F retail)
aspirin tbec or 81 mg, 324 F EXALGO T24A 8 MG, 12 QL(1 ea daily)
mg, 325 mg, 500 mg MG, 16 MG (Use NF
BUFFERIN EXTRA Hydromorphone HCl)
F
STRENGTH TABS hydromorphone hcl liqd or F
BUFFERIN LOW DOSE 1 mg/ml
F
TABS HYDROMORPHONE HCL F
BUFFERIN TABS (Use SUPP RE 3 MG
Aspirin Buffered (Cal Carb- NF hydromorphone hcl t24a or QL(1 ea daily)
Mag Carb-Mag Oxide)) F
8mg, 8 mg, 12 mg, 16 mg
choline & mag salicylate F hydromorphone hcl tabs or
liqd F
2 mg, 4 mg, 8 mg
DISALCID TABS (Use NF KADIAN CP24 10 MG, 20 QL(2 ea daily)
Salsalate) MG, 30 MG, 50 MG, 60 NF
ECOTRIN MAXIMUM MG, 80 MG, 100 MG (Use
STRENGTH TBEC (Use NF Morphine Sulfate)
Aspirin) KADIAN CP24 200 MG F QL(2 ea daily)
ECOTRIN REGULAR
STRENGTH TBEC (Use NF MEPERIDINE HCL SOLN F
Aspirin) OR 50 MG/5ML
salsalate tabs F
meperidine hcl tabs or 50 F
mg, 100 mg
5
QL(240 ml per QL(90 ea per
methadone hcl conc or 10 F fill retail,720 ml MORPHINE SULFATE F fill retail,270 ea
mg/ml per 75 days TABS OR 15 MG, 30 MG per 75 days
retail) retail)
methadone hcl soln or 10 morphine sulfate tbcr or 15
F fill retail,3600 mg, 30 mg, 60 mg, 100 mg, F fill retail,270 ea
mg/5ml ml per 75 days
200 mg per 75 days
retail) retail)
methadone hcl soln or 5 F fill retail,1800 MS CONTIN TBCR (Use NF fill retail,270 ea
mg/5ml ml per 75 days Morphine Sulfate) per 75 days
retail) retail)
QL(240 ea per NUCYNTA ER TB12 F PA
methadone hcl tabs or 10 F fill retail,720 ea
mg per 75 days QL(90 ea per
retail) fill retail,270 ea
oxycodone hcl caps 5 mg F
per 75 days
QL(120 ea per
methadone hcl tabs or 5 retail)
F fill retail,360 ea
mg per 75 days QL(1000 ml per
retail) oxycodone hcl conc 100 fill retail,3000
F
QL(60 ea per mg/5ml ml per 75 days
methadone hcl tbso or 40 retail)
F fill retail,180 ea
mg per 75 days OXYCODONE HCL ER PA
retail) F
T12A
QL(240 ml per QL(1000 ml per
METHADOSE CONC (Use NF fill retail,720 ml oxycodone hcl soln 5 fill retail,3000
Methadone HCl) per 75 days F
mg/5ml ml per 75 days
retail) retail)
METHADOSE SUGAR- oxycodone hcl tabs 5 mg,
FREE CONC (Use NF fill retail,720 ml 10 mg, 15 mg, 20 mg, 30 F fill retail,270 ea
per 75 days per 75 days
Methadone HCl) retail) mg retail)
morphine sulfate cp24 or QL(2 ea daily) OXYCONTIN T12A F PA
10 mg, 20 mg, 30 mg, 50 F
mg, 60 mg, 80 mg, 100 mg QL(90 ea per
MORPHINE SULFATE ER ROXICODONE TABS (Use NF fill retail,270 ea
F QL(1 ea daily) Oxycodone HCl) per 75 days
CP24
MORPHINE SULFATE retail)
F PA
SOLN IV 25 MG/ML tramadol hcl tabs 50 mg F
QL(120 ml per
morphine sulfate soln or 20 ULTRAM TABS (Use
mg/ml, 10 mg/5ml, 20 F fill retail,360 ml Tramadol HCl) NF
per 75 days
mg/5ml, 100 mg/5ml retail) Opioid Combinations
MORPHINE SULFATE acetaminophen w/ codeine
SUPP RE 5 MG, 10 MG, F F
soln 120mg/5ml-12mg/5ml
20 MG, 30 MG
6
QL(60 ea per QL(1000 ml per
acetaminophen w/ codeine
tabs 300mg-15mg, 300mg- F fill retail,180 ea OXYCODONE/ACETAMIN F fill retail,3000
per 75 days OPHEN SOLN ml per 75 days
60mg retail) retail)
QL(45 ea per PERCOCET TABS 10MG- QL(90 ea per
acetaminophen w/ codeine F fill retail,135 ea 325MG, 7.5MG-325MG NF fill retail,270 ea
tabs 300mg-30mg per 75 days (Use Oxycodone w/ per 75 days
retail) Acetaminophen) retail)
butalbital-acetaminophen- F PERCOCET TABS 5MG-
QL(120 ea per
caffeine w/ codeine caps 325MG (Use Oxycodone w/ NF fill retail,360 ea
butalbital-aspirin-caffeine per 75 days
F Acetaminophen) retail)
w/cod caps
QL(45 ea per
CAPITAL/CODEINE SUSP F TYLENOL/CODEINE #3
TABS (Use Acetaminophen NF fill retail,135 ea
FIORICET/CODEINE per 75 days
w/ Codeine) retail)
CAPS (Use Butalbital- NF
Acetaminophen-Caffeine QL(60 ea per
TYLENOL/CODEINE #4
w/ Codeine) TABS (Use Acetaminophen NF fill retail,180 ea
FIORINAL/CODEINE #3 per 75 days
w/ Codeine) retail)
CAPS (Use Butalbital- NF
Aspirin-Caffeine w/Cod) XODOL TABS (Use QL(45 ea per
HYCET SOLN (Use QL(1000 ml per Hydrocodone- NF fill retail,135 ea
per 75 days
Hydrocodone- NF fill retail,3000 Acetaminophen) retail)
ml per 75 days
Acetaminophen) retail) Opioid Partial Agonists
hydrocodone- QL(1000 ml per
acetaminophen soln fill retail,3000 BELBUCA FILM CO
2.5mg/5ml-108mg/5ml, F ml per 75 days
5mg/10ml-217mg/10ml, retail) BUNAVAIL FILM CO
7.5mg/15ml-325mg/15ml BUPRENEX SOLN (Use
hydrocodone- QL(45 ea per CO
Buprenorphine HCl)
acetaminophen tabs 5mg- fill retail,135 ea
300mg, 5mg-325mg, per 75 days buprenorphine hcl soln CO
F
10mg-300mg, 10mg- retail)
325mg, 7.5mg-300mg, buprenorphine hcl subl CO
7.5mg-325mg buprenorphine hcl-
QL(45 ea per CO
NORCO TABS (Use naloxone hcl dihydrate subl
Hydrocodone- NF fill retail,135 ea BUPRENORPHINE PTWK CO
per 75 days
Acetaminophen) retail)
QL(90 ea per BUTRANS PTWK CO
oxycodone w/
acetaminophen tabs 10mg- F fill retail,270 ea PROBUPHINE IMPLANT CO
per 75 days KIT IMPL
325mg, 7.5mg-325mg retail)
QL(120 ea per SUBLOCADE SOSY CO
oxycodone w/
acetaminophen tabs 5mg- F fill retail,360 ea SUBOXONE FILM CO
per 75 days
325mg retail)
7
ZUBSOLV SUBL CO CORTENEMA ENEM (Use
Hydrocortisone NF
ANDROGENS-ANABOLIC - Drugs to Regulate (Intrarectal))
Hormones CORTIFOAM FOAM F
Anabolic Steroids hydrocortisone (intrarectal)
OXANDRIN TABS (Use F
NF enem
Oxandrolone)
Rectal Combinations
oxandrolone tabs F ANALPRAM-HC CREA
1%-1% (Use NF
Androgens Hydrocortisone Acetate w/
ANDROGEL GEL 40.5 Pramoxine)
MG/2.5GM, 20.25 F ANALPRAM-HC LOTN 1%-
MG/1.25GM F
2.5%
ANDROGEL GEL 50 hydrocortisone acetate w/
MG/5GM, 25 MG/2.5GM NF F
pramoxine crea 1%-1%
(Use Testosterone)
lidocaine-hydrocortisone
ANDROGEL PUMP GEL F acetate (rectal) crea 3%- F
0.5%
ANDROID CAPS (Use NF
Methyltestosterone) lidocaine-hydrocortisone QL(2 ea per fill
acetate (rectal) kit 3%-1%, F retail)
ANDROXY TABS F 3%-0.5%, 3%-2.5%
danazol caps F PROCTOFOAM HC FOAM F

Rectal Steroids
METHITEST TABS F
ANUSOL-HC CREA (Use NF
methyltestosterone caps F Hydrocortisone (Rectal))
TESTIM GEL (Use hydrocortisone (rectal) crea F

NF
Testosterone) PROCTOCORT CREA 1 %
testosterone gel 1 %, 50 (Use Hydrocortisone NF
F (Rectal))
mg/5gm, 25 mg/2.5gm
TESTOSTERONE GEL 1 Vasodilating Agents
%, 50 MG/5GM, 25 F
MG/2.5GM RECTIV OINT F
TESTOSTERONE PUMP F
GEL ANTACIDS - Ulcer and Stomach Acid Drugs
TESTRED CAPS (Use NF Antacid Combinations
Methyltestosterone)
alum & mag hydrox- F
VOGELXO GEL F simethicone chew
VOGELXO PUMP GEL F simethicone liqd
ANORECTAL AGENTS - Rectal Drugs to Treat simethicone susp
Pain, Swelling and Itching
aluminum hydroxide-mag F
Intrarectal Steroids trisil chew
8
GELUSIL CHEW 200MG- ALBENZA TABS F QL(12 ea per
25MG-200MG (Use Alum & NF fill retail)
Mag Hydrox-Simethicone)
BILTRICIDE TABS F QL(20 ea per
HYVEE ADVANCED fill retail)
ANTACID MAXIMUM
STRENGTH SUSP (Use NF EMVERM CHEW F QL(2 ea per fill
retail)
Alum & Mag Hydrox-
Simethicone) pyrantel pamoate susp F
Antacids - Aluminum Salts ANTI-INFECTIVE AGENTS - MISC. - Drugs to
ALUMINUM HYDROXIDE F Treat Bacterial Infections
SUSP OR
Anti-infective Agents - Misc.
Antacids - Calcium Salts SP-Acaria
calcium carbonate CAYSTON SOLR F Health;AL; At
(antacid) chew 500 mg, F least 21 yrs old
600 mg, 750 mg FLAGYL CAPS (Use
calcium carbonate NF
F Metronidazole)
(antacid) tabs 648 mg FLAGYL TABS (Use
CALCIUM CARBONATE NF
F Metronidazole)
TABS 648 MG
IMPAVIDO CAPS F
MAALOX CHEW F
METRO IV SOLN F PA
TUMS CHEW (Use
Calcium Carbonate NF metronidazole caps or 375
(Antacid)) F
mg
TUMS CHEWY BITES PA
CHEW (Use Calcium NF metronidazole in nacl soln F
Carbonate (Antacid)) METRONIDAZOLE SOLN PA
F
TUMS E-X 750 CHEW IV 5 MG/ML
(Use Calcium Carbonate NF metronidazole tabs or 250
(Antacid)) F
mg, 500 mg
TUMS EXTRA STRENGTH
750 CHEW (Use Calcium NF trimethoprim tabs F
Carbonate (Antacid)) vancomycin hcl solr iv 10 PA
TUMS KIDS CHEW (Use gm, 500 mg, 750 mg, 1000 F
Calcium Carbonate NF mg, 5000 mg
(Antacid)) VANCOMYCIN HCL SOLR
TUMS LASTING EFFECTS F PA
IV 100 GM
CHEW (Use Calcium NF
Carbonate (Antacid)) Anti-infective Misc. - Combinations
TUMS SMOOTHIES BACTRIM DS TABS (Use
CHEW (Use Calcium NF Sulfamethoxazole- NF
Carbonate (Antacid)) Trimethoprim)
BACTRIM TABS (Use
ANTHELMINTICS - Drugs to Treat Worm Sulfamethoxazole- NF
Infections Trimethoprim)
Anthelmintics
9
sulfamethoxazole- PA ANTIANGINAL AGENTS - Drugs to Treat Chest
trimethoprim soln iv F Pain
80mg/5ml-400mg/5ml
sulfamethoxazole- Nitrates
trimethoprim susp or F DILATRATE SR CPCR F
40mg/5ml-200mg/5ml
sulfamethoxazole- ISORDIL TITRADOSE F
trimethoprim tabs or 80mg- F TABS 40 MG
400mg, 160mg-800mg ISORDIL TITRADOSE
TABS 5 MG (Use NF
Antiprotozoal Agents Isosorbide Dinitrate)
atovaquone susp F ISOSORBIDE DINITRATE F
ER TBCR
MEPRON SUSP (Use NF
Atovaquone) isosorbide dinitrate tabs F
Chloramphenicols isosorbide mononitrate tabs F
CHLORAMPHENICOL PA
SODIUM SUCCINATE F isosorbide mononitrate F
SOLR tb24
Leprostatics NITRO-BID OINT F
dapsone tabs F NITRO-DUR PT24 0.1
MG/HR, 0.2 MG/HR, 0.4 NF
Lincosamides MG/HR, 0.6 MG/HR (Use
CLEOCIN CAPS OR 75 Nitroglycerin)
MG, 150 MG, 300 MG (Use NF NITRO-DUR PT24 0.3
Clindamycin HCl) F
MG/HR, 0.8 MG/HR
CLEOCIN PEDIATRIC nitroglycerin cpcr or 9 mg,
GRANULES SOLR (Use F
NF 2.5 mg, 6.5 mg
Clindamycin Palmitate nitroglycerin pt24 td 0.1
Hydrochloride) mg/hr, 0.2 mg/hr, 0.4 F
CLEOCIN PHOSPHATE PA mg/hr, 0.6 mg/hr
SOLN IJ 300 MG/2ML, 600 nitroglycerin subl sl 0.3 mg,
MG/4ML, 900 MG/6ML NF F
0.4 mg, 0.6 mg
(Use Clindamycin
Phosphate) NITROSTAT SUBL (Use NF
Nitroglycerin)
CLEOCIN PHOSPHATE PA
SOLN IV 300 MG/2ML, 600 ANTIANXIETY AGENTS - Drugs to Treat Anxiety
MG/4ML, 900 MG/6ML NF
(Use Clindamycin Antianxiety Agents - Misc.
Phosphate)
buspirone hcl tabs F
CLIN SINGLE USE KIT KIT F PA
hydroxyzine hcl syrp or 10 F
clindamycin hcl caps F mg/5ml
hydroxyzine hcl tabs or 10 F
clindamycin palmitate F mg, 25 mg, 50 mg
hydrochloride solr HYDROXYZINE
clindamycin phosphate PA F
F PAMOATE CAPS 100 MG
soln
10
hydroxyzine pamoate caps F QUINIDINE SULFATE F
25 mg, 50 mg TABS
meprobamate tabs F Antiarrhythmics Type I-B
VISTARIL CAPS (Use mexiletine hcl caps F
NF
Hydroxyzine Pamoate)
Antiarrhythmics Type I-C
Benzodiazepines
alprazolam tabs 0.25 mg, flecainide acetate tabs F
F
0.5 mg, 1 mg, 2 mg
propafenone hcl cp12 F
ATIVAN TABS OR 0.5 MG,
1 MG, 2 MG (Use NF
Lorazepam) propafenone hcl tabs F
chlordiazepoxide hcl caps F RYTHMOL SR CP12 (Use NF

Propafenone HCl)
clorazepate dipotassium F RYTHMOL TABS (Use
tabs NF
Propafenone HCl)
DIAZEPAM SOLN OR 1 F Antiarrhythmics Type III
MG/ML
diazepam tabs or 2 mg, 5 amiodarone hcl tabs F
F
mg, 10 mg
lorazepam tabs or 0.5 mg, dofetilide caps F
F
1 mg, 2 mg
MULTAQ TABS F
oxazepam caps F
TIKOSYN CAPS (Use NF
TRANXENE T TABS (Use Dofetilide)
NF
Clorazepate Dipotassium) ANTIASTHMATIC AND BRONCHODILATOR
VALIUM TABS (Use NF AGENTS - Drugs to Treat Lung Conditions
Diazepam)
Anti-Inflammatory Agents
XANAX TABS (Use NF
Alprazolam) cromolyn sodium nebu F
ANTIARRHYTHMICS - Drugs to treat abnormal
heart rhythms Antiasthmatic - Monoclonal Antibodies
Antiarrhythmics Type I-A CINQAIR SOLN F PA
disopyramide phosphate F PA; SP-
caps NUCALA SOLR F
AcariaHealth
NORPACE CAPS (Use NF PA; SP-
Disopyramide Phosphate) XOLAIR SOLR F
AcariaHealth
NORPACE CR CP12 F Asthma and Bronchodilator Agent Combinations
procainamide hcl soln F PA dyphylline-guaifenesin liqd F
quinidine gluconate tbcr or Bronchodilators - Anticholinergics

F
324 mg Limit 2 inhalers
QUINIDINE SULFATE ER per
F ATROVENT HFA AERS F
TBCR month;QL(0.86
gm daily)
11
INCRUSE ELLIPTA AEPB F QL(1 ea daily) ASMANEX TWISTHALER Limit 1 per
60 METERED DOSES F month;QL(0.03
ipratropium bromide soln F AEPB 4 ea daily)
ASMANEX TWISTHALER Limit 1 per
SPIRIVA HANDIHALER F QL(1 ea daily) 7 METERED DOSES F month;QL(0.03
CAPS AEPB 4 ea daily)
Limit 1 Inhaler budesonide (inhalation) QL(8 ml daily)
SPIRIVA RESPIMAT per F
F susp 0.25 mg/2ml
AERS month;QL(0.14 budesonide (inhalation) QL(4 ml daily)
gm daily) F
susp 0.5 mg/2ml
Limit 1 Inhaler budesonide (inhalation) QL(2 ml daily)
TUDORZA PRESSAIR per F
F susp 1 mg/2ml
AEPB month;QL(0.04
ea daily) FLOVENT DISKUS AEPB F QL(20 ea daily)
100 MCG/BLIST
Leukotriene Modulators FLOVENT DISKUS AEPB QL(8 ea daily)
QL(1 ea daily) F
montelukast sodium chew F 250 MCG/BLIST
FLOVENT DISKUS AEPB F QL(40 ea daily)
montelukast sodium pack F QL(1 ea daily) 50 MCG/BLIST
QL(1 ea daily) Limit 2 inhalers
montelukast sodium tabs F FLOVENT HFA AERO 110 per
F
MCG/ACT, 220 MCG/ACT month;QL(0.8
SINGULAIR CHEW (Use NF QL(1 ea daily) gm daily)
Montelukast Sodium)
Limit 1 Inhaler
SINGULAIR PACK (Use NF QL(1 ea daily) FLOVENT HFA AERO 44 per
Montelukast Sodium) F
MCG/ACT month;QL(0.36
SINGULAIR TABS (Use NF QL(1 ea daily) gm daily)
Montelukast Sodium) Limit 2 inhalers
Steroid Inhalants PULMICORT FLEXHALER F per
Limit 2 inhalers AEPB 180 MCG/ACT month;QL(0.07
per ea daily)
AEROSPAN AERS F Limit 8 Inhalers
month;QL(0.6
gm daily) PULMICORT FLEXHALER F per
QL(1 ea daily) AEPB 90 MCG/ACT Month;QL(0.27
ARNUITY ELLIPTA AEPB F ea daily)
Limit 1 Inhaler PULMICORT SUSP 0.25 QL(8 ml daily)
per MG/2ML (Use Budesonide NF
ASMANEX HFA AERO F (Inhalation))
month;QL(0.44
gm daily) PULMICORT SUSP 0.5 QL(4 ml daily)
ASMANEX TWISTHALER Limit 1 per MG/2ML (Use Budesonide NF
120 METERED DOSES F month;QL(0.03 (Inhalation))
AEPB 4 ea daily) PULMICORT SUSP 1 QL(2 ml daily)
ASMANEX TWISTHALER Limit 1 per MG/2ML (Use Budesonide NF
14 METERED DOSES F month;QL(0.03 (Inhalation))
AEPB 4 ea daily) Limit 2 inhalers
ASMANEX TWISTHALER Limit 1 per per
QVAR AERS 40 MCG/ACT F
30 METERED DOSES F month;QL(0.03 month;QL(0.58
AEPB 4 ea daily) gm daily)
12
Limit 1 Inhaler METAPROTERENOL F
QVAR AERS 80 MCG/ACT F per SULFATE TABS
month;QL(0.29 SEREVENT DISKUS QL(2 ea daily)
gm daily) F
AEPB
QVAR REDIHALER AERB F QL(0.36 gm Limit 1 Inhaler
40 MCG/ACT daily) STIOLTO RESPIMAT per
F
QVAR REDIHALER AERB F QL(0.72 gm AERS month;QL(0.14
80 MCG/ACT daily) gm daily)
Sympathomimetics Limit 1 Inhaler
STRIVERDI RESPIMAT per
ADVAIR DISKUS AEPB F QL(2 ea daily) AERS
F
month;QL(0.14
gm daily)
Limit 1 Inhaler
per Limit 1 Inhaler
ADVAIR HFA AERO F per
month;QL(0.4 SYMBICORT AERO F
gm daily) month;QL(0.34
gm daily)
ALBUTEROL SULFATE F
ER TB12 terbutaline sulfate tabs or 5 F
mg, 2.5 mg
albuterol sulfate nebu F Limit 2 inhalers
per
albuterol sulfate syrp F VENTOLIN HFA AERS F
month;QL(1.2
gm daily)
albuterol sulfate tabs F VOSPIRE ER TB12 (Use NF
Albuterol Sulfate)
albuterol sulfate tb12 F
Xanthines
ANORO ELLIPTA AEPB F QL(2 ea daily) PA
aminophylline soln F
BEVESPI AEROSPHERE F QL(0.36 gm
AERO daily) ELIXOPHYLLIN ELIX F
BREO ELLIPTA AEPB F QL(2 ea daily) THEO-24 CP24 100MG, F
200 MG, 300 MG
Limit 1 Inhaler theophylline tb12 100 mg,
COMBIVENT RESPIMAT per F
F 200 mg, 300 mg, 450 mg
AERS month;QL(0.2
gm daily) theophylline tb24 400 mg, F
600 mg
Limit 1 Inhaler
per ANTICOAGULANTS - Blood Thinners
DULERA AERO F
month;QL(0.45
gm daily) Coumarin Anticoagulants
EPHEDRINE HCL TABS F COUMADIN TABS F
FLUTICASONE QL(0.04 ea warfarin sodium tabs F
PROPIONATE/SALMETER F daily)
OL AEPB Direct Factor Xa Inhibitors
ipratropium-albuterol soln F ELIQUIS STARTER PACK F
TABS
METAPROTERENOL F
SULFATE SYRP ELIQUIS TABS F
13
XARELTO STARTER F HEPARIN SODIUM/D5W F PA
PACK TBPK SOLN
XARELTO TABS 10 MG F QL(1 ea daily) SP-
AccariaHealth
XARELTO TABS 15 MG, only after
F LOVENOX SOLN SC 100 Quantity Limit
20 MG MG/ML, 150 MG/ML (Use NF
has been
Heparins And Heparinoid-Like Agents Enoxaparin Sodium) exceeded;QL(1
SP- 0 ml per 180
AccariaHealth days retail)
only after SP-
enoxaparin sodium soln sc F Quantity Limit AccariaHealth
100 mg/ml, 150 mg/ml has been only after
exceeded;QL(1 LOVENOX SOLN SC 30 Quantity Limit
0 ml per 180 MG/0.3ML (Use NF
has been
days retail) Enoxaparin Sodium) exceeded;QL(3
SP- ml per 180
only after SP-
30 mg/0.3ml has been only after
ml per 180 MG/0.4ML (Use NF
has been
SP- ml per 180
only after SP-
ml per 180 MG/0.6ML (Use NF
has been
SP- ml per 180
only after SP-
ml per 180 MG/0.8ML, 120 MG/0.8ML NF
has been
days retail) (Use Enoxaparin Sodium) exceeded;QL(8
SP- ml per 180
only after
enoxaparin sodium soln sc Quantity Limit Thrombin Inhibitors
80 mg/0.8ml, 120 mg/0.8ml F has been PRADAXA CAPS F
exceeded;QL(8
ml per 180
days retail) ANTICONVULSANTS - Drugs to Treat Seizures
heparin sod (porcine) in F PA AMPA Glutamate Receptor Antagonists
d5w soln
14
FYCOMPA SUSP F KEPPRA TABS OR 250
MG, 500 MG, 750 MG, NF
FYCOMPA TABS F 1000 MG (Use
Levetiracetam)
Anticonvulsants - Benzodiazepines LAMICTAL CHEWABLE
DISPERSIBLE CHEW (Use NF
clonazepam tabs F Lamotrigine)
LAMICTAL TABS (Use NF
clonazepam tbdp F Lamotrigine)
DIASTAT ACUDIAL GEL QL(4 ea per 30 lamotrigine chew 5 mg, 25 F
(Use Diazepam NF days retail) mg
(Anticonvulsant)) lamotrigine tabs 25 mg, F
DIASTAT PEDIATRIC GEL QL(4 ea per 30 100 mg, 150 mg, 200 mg
(Use Diazepam NF days retail) levetiracetam soln or 100
(Anticonvulsant)) F
mg/ml, 500 mg/5ml
diazepam (anticonvulsant) F QL(4 ea per 30 levetiracetam tabs or 250
gel days retail) mg, 500 mg, 750 mg, 1000 F
DIAZEPAM RECTAL GEL QL(4 ea per 30 mg
F
GEL days retail) MYSOLINE TABS (Use NF
KLONOPIN TABS (Use Primidone)
NF
Clonazepam) NEURONTIN CAPS 100
Anticonvulsants - Misc. MG, 300 MG, 400 MG (Use NF
Gabapentin)
BANZEL SUSP F NEURONTIN TABS 600
MG, 800 MG (Use NF
BANZEL TABS F Gabapentin)
carbamazepine chew F oxcarbazepine susp F
carbamazepine cp12 F oxcarbazepine tabs F
carbamazepine susp F POTIGA TABS F
carbamazepine tabs F primidone tabs F
carbamazepine tb12 F TEGRETOL SUSP F

CARBATROL CP12 (Use NF TEGRETOL TABS F
Carbamazepine)
gabapentin caps 100 mg, TEGRETOL-XR TB12 (Use NF
F Carbamazepine)
300 mg, 400 mg
gabapentin tabs 600 mg, TOPAMAX SPRINKLE NF
F CPSP (Use Topiramate)
800 mg
KEPPRA SOLN OR 100 TOPAMAX TABS (Use NF
MG/ML (Use NF Topiramate)
Levetiracetam) topiramate cpsp F
topiramate tabs F
15
TRILEPTAL SUSP (Use NF phenytoin sodium extended F
Oxcarbazepine) caps
TRILEPTAL TABS (Use NF phenytoin susp F
Oxcarbazepine)
VIMPAT SOLN OR 10 F Succinimides
MG/ML
CELONTIN CAPS F
VIMPAT TABS OR 50 MG, F
100 MG, 150 MG, 200 MG
ethosuximide caps F
ZONEGRAN CAPS (Use NF
Zonisamide) ethosuximide soln F
zonisamide caps F ZARONTIN CAPS (Use NF
Ethosuximide)
Carbamates
ZARONTIN SOLN (Use NF
felbamate susp F Ethosuximide)
Valproic Acid
felbamate tabs F
DEPAKENE CAPS F
FELBATOL SUSP (Use NF
Felbamate)
DEPAKENE SOLN F
FELBATOL TABS (Use NF
Felbamate) DEPAKOTE ER TB24 (Use NF
Divalproex Sodium)
GABA Modulators
DEPAKOTE SPRINKLES
GABITRIL TABS 2 MG NF CSDR (Use Divalproex NF
(Use Tiagabine HCl) Sodium)
GABITRIL TABS 4 MG, 12 F DEPAKOTE TBEC (Use
MG, 16 MG NF
Divalproex Sodium)
SABRIL PACK (Use NF SP-Caremark
Vigabatrin) divalproex sodium csdr F
SABRIL TABS F SP-Caremark
divalproex sodium tb24 F
tiagabine hcl tabs F divalproex sodium tbec F
vigabatrin pack F SP-Caremark valproate sodium soln or F
250 mg/5ml
Hydantoins
valproic acid caps F
DILANTIN CAPS F
ANTIDEPRESSANTS - Drugs to Treat Depression
DILANTIN INFATABS NF
CHEW (Use Phenytoin) Alpha-2 Receptor Antagonists (Tetracyclics)
DILANTIN-125 SUSP (Use NF
Phenytoin) mirtazapine tabs F
PHENYTEK CAPS (Use mirtazapine tbdp F
Phenytoin Sodium NF
Extended) REMERON SOLTAB TBDP NF
(Use Mirtazapine)
phenytoin chew F
16
REMERON TABS (Use NF citalopram hydrobromide F QL(4 ea daily)
Mirtazapine) tabs 10 mg
Antidepressants - Misc. citalopram hydrobromide F QL(2 ea daily)
bupropion hcl tabs 75 mg, tabs 20 mg
F citalopram hydrobromide QL(1 ea daily)
100 mg F
bupropion hcl tb12 100 mg, tabs 40 mg
F
150 mg escitalopram oxalate soln F
bupropion hcl tb12 200 mg F QL(2 ea daily)
escitalopram oxalate tabs F
bupropion hcl tb24 150 mg, F QL(1 ea daily)
300 mg fluoxetine hcl caps 10 mg, F
20 mg, 40 mg
WELLBUTRIN SR TB12
100 MG, 150 MG (Use NF fluoxetine hcl soln 20 F
Bupropion HCl) mg/5ml
WELLBUTRIN SR TB12 QL(2 ea daily) fluoxetine hcl tabs 10 mg, F
200 MG (Use Bupropion NF 20 mg
HCl) fluvoxamine maleate cp24 F
WELLBUTRIN TABS (Use NF
Bupropion HCl) fluvoxamine maleate tabs F
WELLBUTRIN XL TB24 NF QL(1 ea daily) LEXAPRO SOLN (Use
(Use Bupropion HCl) Escitalopram Oxalate) NF
Monoamine Oxidase Inhibitors (MAOIs) LEXAPRO TABS (Use NF
EMSAM PT24 CO Escitalopram Oxalate)
paroxetine hcl tabs F
MARPLAN TABS CO
NARDIL TABS (Use paroxetine hcl tb24 F
CO
Phenelzine Sulfate) PAXIL CR TB24 (Use NF
PARNATE TABS (Use Paroxetine HCl)
CO
Tranylcypromine Sulfate)
PAXIL SUSP 10 MG/5ML F
phenelzine sulfate tabs CO
PAXIL TABS 10 MG, 20
tranylcypromine sulfate MG, 30 MG, 40 MG (Use NF
CO Paroxetine HCl)
tabs
Selective Serotonin Reuptake Inhibitors (SSRIs) PROZAC CAPS (Use NF
Fluoxetine HCl)
CELEXA TABS 10 MG QL(4 ea daily)
(Use Citalopram NF sertraline hcl conc F
Hydrobromide)
CELEXA TABS 20 MG QL(2 ea daily) sertraline hcl tabs F
(Use Citalopram NF
Hydrobromide) ZOLOFT CONC (Use NF
Sertraline HCl)
CELEXA TABS 40 MG QL(1 ea daily)
(Use Citalopram NF ZOLOFT TABS (Use NF
Hydrobromide) Sertraline HCl)
citalopram hydrobromide Serotonin Modulators
F QL(20 ml daily)
soln 10 mg/5ml
17
NEFAZODONE HCL TABS F NORPRAMIN TABS (Use NF
100 MG, 150 MG, 200 MG Desipramine HCl)
nefazodone hcl tabs 50 F nortriptyline hcl caps 10 F
mg, 250 mg mg, 25 mg, 50 mg, 75 mg
trazodone hcl tabs F NORTRIPTYLINE HCL F
SOLN 10 MG/5ML
Serotonin-Norepinephrine Reuptake Inhibitors PAMELOR CAPS (Use NF
CYMBALTA CPEP (Use Nortriptyline HCl)
NF QL(2 ea daily)
Duloxetine HCl) protriptyline hcl tabs F
DESVENLAFAXINE ER F ST
TB24 50 MG, 100 MG TOFRANIL TABS (Use NF
desvenlafaxine succinate Imipramine HCl)
F
tb24 ANTIDIABETICS - Drugs to Regulate Blood Sugar
duloxetine hcl cpep 20 mg, F QL(2 ea daily)
30 mg, 60 mg Alpha-Glucosidase Inhibitors
EFFEXOR XR CP24 (Use NF acarbose tabs F
Venlafaxine HCl)
PRECOSE TABS (Use
KHEDEZLA TB24 F ST Acarbose) NF
PRISTIQ TB24 (Use NF Antidiabetic - Amylin Analogs
Desvenlafaxine Succinate) PA
SYMLINPEN 120 SOPN F
venlafaxine hcl cp24 F
SYMLINPEN 60 SOPN F PA
VENLAFAXINE HCL ER F
TB24 Antidiabetic Combinations
venlafaxine hcl tabs F ACTOPLUS MET TABS
(Use Pioglitazone HCl- NF
venlafaxine hcl tb24 F Metformin HCl)
ALOGLIPTIN/METFORMIN F
Tricyclic Agents HCL TABS
amitriptyline hcl tabs F ALOGLIPTIN/PIOGLITAZO F
NE TABS
ANAFRANIL CAPS (Use NF DUETACT TABS (Use QL(1 ea daily)
Clomipramine HCl) Pioglitazone HCl- NF
clomipramine hcl caps F Glimepiride)
glipizide-metformin hcl tabs F QL(2 ea daily)
desipramine hcl tabs F
GLUCOVANCE TABS (Use NF
doxepin hcl caps F Glyburide-Metformin)
doxepin hcl conc F glyburide-metformin tabs F
ELAVIL TABS (Use INVOKAMET TABS F

NF
Amitriptyline HCl)
INVOKAMET XR TB24 F
imipramine hcl tabs F
JANUMET TABS F QL(2 ea daily)
18
JANUMET XR TB24 F TRADJENTA TABS F
JENTADUETO TABS F Dopamine Receptor Agonists - Antidiabetic

CYCLOSET TABS F
KAZANO TABS F
Incretin Mimetic Agents (GLP-1 Receptor
KOMBIGLYZE XR TB24 F
ADLYXIN SOPN F PA
OSENI TABS F
ADLYXIN STARTER PACK F PA
pioglitazone hcl-glimepiride QL(1 ea daily) PNKT
F
tabs BYDUREON BCISE AUIJ F PA
pioglitazone hcl-metformin F
hcl tabs BYDUREON PEN PEN F PA
SOLIQUA 100/33 SOPN F PA
BYDUREON SRER F PA
SYNJARDY TABS F PA
BYETTA SOPN F
SYNJARDY XR TB24 F PA
TANZEUM PEN F
XULTOPHY 100/3.6 SOPN F PA
TRULICITY SOPN F PA
Biguanides PA
FORTAMET TB24 (Use VICTOZA SOPN F
NF
Metformin HCl)
Insulin Sensitizing Agents
GLUCOPHAGE TABS NF
(Use Metformin HCl) ACTOS TABS (Use NF
Pioglitazone HCl)
GLUCOPHAGE XR TB24 NF
(Use Metformin HCl) AVANDIA TABS F
metformin hcl tabs 500 mg, F
850 mg, 1000 mg pioglitazone hcl tabs F
metformin hcl tb24 500 mg, F Insulin
750 mg, 1000 mg
Limit 50mls per
Diabetic Other ADMELOG SOLN F month;QL(1.67
GLUCAGON AL; At least 21 ml daily)
F
EMERGENCY KIT KIT yrs old Limit 50mls per
ADMELOG SOLOSTAR
PA F month;QL(1.67
KORLYM TABS F SOPN ml daily)
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors PA; Limit 50mls
per
ALOGLIPTIN TABS F APIDRA SOLN F
month;QL(1.67
ml daily)
JANUVIA TABS F PA; Limit 50mls
APIDRA SOLOSTAR F per
NESINA TABS F SOPN month;QL(1.67
ml daily)
ONGLYZA TABS F
19
Limit 50mls per Limit 20 per
BASAGLAR KWIKPEN F month;QL(1.67 HUMULIN R U-500 F month;QL(0.67
SOPN KWIKPEN SOPN
ml daily) ml daily)
Limit 50mls per Meglitinide Analogues
HUMALOG JUNIOR F month;QL(1.67
KWIKPEN SOPN nateglinide tabs F
ml daily)
Limit 50mls per STARLIX TABS (Use
HUMALOG KWIKPEN F month;QL(1.67 NF
SOPN 100 UNIT/ML Nateglinide)
ml daily)
Limit 24mls per Sodium-Glucose Co-Transporter 2 (SGLT2)
HUMALOG KWIKPEN F Month;QL(0.8
SOPN 200 UNIT/ML INVOKANA TABS F
ml daily)
Limit 50mls per JARDIANCE TABS F
HUMALOG MIX 50/50 F month;QL(1.67
KWIKPEN SUPN Sulfonylureas
ml daily)
Limit 50mls per AMARYL TABS (Use NF
HUMALOG MIX 50/50 F month;QL(1.67 Glimepiride)
SUSP ml daily)
glimepiride tabs F
Limit 50mls per
KWIKPEN SUPN glipizide tabs F
ml daily)
Limit 50mls per glipizide tb24 F
SUSP GLUCOTROL TABS (Use
ml daily) NF
Limit 50mls per Glipizide)
HUMALOG SOCT F month;QL(1.67 GLUCOTROL XL TB24 NF
ml daily) (Use Glipizide)
Limit 50mls per glyburide micronized tabs F
HUMALOG SOLN F month;QL(1.67
ml daily) glyburide tabs F
HUMULIN 70/30 KWIKPEN F Limit 50mls per
month;QL(1.67 GLYNASE TABS (Use NF
SUPN Glyburide Micronized)
ml daily)
Limit 50mls per TOLAZAMIDE TABS F
HUMULIN 70/30 SUSP F month;QL(1.67
ml daily) TOLBUTAMIDE TABS F
Limit 50mls per
HUMULIN N KWIKPEN F month;QL(1.67
SUPN ANTIDIARRHEALS - Drugs to Treat Diarrhea
ml daily)
Limit 50mls per Antidiarrheal Agents - Misc.
HUMULIN N SUSP F month;QL(1.67 bismuth subsalicylate chew F
ml daily)
Limit 50mls per bismuth subsalicylate susp F
HUMULIN R SOLN F month;QL(1.67
ml daily) bismuth subsalicylate tabs F
Limit 20 per
HUMULIN R U-500 F month;QL(0.67
(CONCENTRATED) SOLN ml daily)
20
PEPTO BISMOL TABS NARCAN LIQD CO
(Use Bismuth NF
Subsalicylate) VIVITROL SUSR CO
PEPTO-BISMOL CHEW
262 MG (Use Bismuth NF ANTIEMETICS - Drugs to Treat Nausea and
Subsalicylate) Vomiting
PEPTO-BISMOL 5-HT3 Receptor Antagonists
INSTACOOL CHEW (Use NF
Bismuth Subsalicylate) GRANISETRON HCL F PA; SP-
SOLN IV 0.1 MG/ML AcariaHealth
PEPTO-BISMOL MAX
STRENGTH SUSP (Use NF granisetron hcl soln iv 0.1 F PA; SP-
Bismuth Subsalicylate) mg/ml, 1 mg/ml, 4 mg/4ml AcariaHealth
PEPTO-BISMOL SUSP granisetron hcl tabs or 1 F PA
262 MG/15ML (Use NF mg
Bismuth Subsalicylate) QL(50 ml per
PEPTO-BISMOL TO-GO ondansetron hcl soln 4 F fill retail,50 ml
CHEW (Use Bismuth NF mg/5ml per 30 days
Subsalicylate) retail)
QL(20 ea per
Antiperistaltic Agents ondansetron hcl tabs 4 mg,
diphenoxylate w/ atropine F fill retail,20 ea
F 8 mg per 30 days
tabs retail)
DIPHENOXYLATE/ATROP F QL(20 ea per
INE LIQD
ondansetron tbdp F fill retail,20 ea
LOMOTIL TABS (Use per 30 days
NF retail)
Diphenoxylate w/ Atropine)
QL(20 ea per
ANTIDOTES AND SPECIFIC ANTAGONISTS ZOFRAN ODT TBDP (Use NF fill retail,20 ea
Antidotes - Chelating Agents Ondansetron) per 30 days
retail)
CHEMET CAPS F QL(50 ml per
ZOFRAN SOLN 4 MG/5ML NF fill retail,50 ml
PA; SP- (Use Ondansetron HCl) per 30 days
JADENU SPRINKLE PACK F
AcariaHealth retail)
PA; SP- QL(20 ea per
JADENU TABS F ZOFRAN TABS 4 MG, 8
AcariaHealth
MG (Use Ondansetron NF fill retail,20 ea
Antidotes and Specific Antagonists HCl) per 30 days
retail)
VISTOGARD PACK F
Antiemetics - Anticholinergic
Opioid Antagonists
meclizine hcl chew 25 mg F
NALOXONE HCL SOCT CO
0.4 MG/ML meclizine hcl tabs 25 mg, F RX/OTC
naloxone hcl soln 0.4 12.5 mg
CO TIGAN CAPS OR 300 MG
mg/ml, 4 mg/10ml
NALOXONE HCL SOSY 2 (Use Trimethobenzamide NF
CO HCl)
MG/2ML
trimethobenzamide hcl F
naltrexone hcl tabs CO caps
21
Antiemetics - Miscellaneous Imidazole-Related Antifungals
Limit 2 fills per DIFLUCAN SUSR (Use NF
DICLEGIS TBEC F year;QL(2 ea Fluconazole)
daily) DIFLUCAN TABS (Use NF
dronabinol caps F PA Fluconazole)
fluconazole in dextrose F PA
MARINOL CAPS (Use NF PA soln
Dronabinol)
fluconazole susr F
Substance P/Neurokinin 1 (NK1) Receptor
QL(3 ea per fill fluconazole tabs F
aprepitant caps F retail,3 ea per
30 days retail) itraconazole caps F PA
aprepitant caps 40 mg F QL(2 ea per 30
days retail) ketoconazole tabs F
aprepitant caps 80 mg, 125 F QL(1 ea per fill
retail,1 ea per
SPORANOX CAPS 100 NF PA
mg MG (Use Itraconazole)
30 days retail)
SPORANOX PULSEPAK NF PA
EMEND CAPS 40 MG (Use NF QL(2 ea per 30 CAPS (Use Itraconazole)
Aprepitant) days retail)
VFEND SUSR (Use NF
QL(1 ea per fill Voriconazole)
EMEND CAPS 80 MG, 125 NF retail,1 ea per
MG (Use Aprepitant) 30 days retail) VFEND TABS (Use NF
Voriconazole)
QL(3 ea per fill
EMEND TRIPACK CAPS NF retail,3 ea per voriconazole susr or 40
(Use Aprepitant) F
30 days retail) mg/ml
voriconazole tabs or 50 mg, F
ANTIFUNGALS - Drugs to Treat Fungal Infections 200 mg
Antifungals ANTIHISTAMINES - Drugs to Treat Allergies
BIO-STATIN CAPS F Antihistamines - Alkylamines
GRIS-PEG TABS (Use CHLOR-TRIMETON SYRP
NF (Use Chlorpheniramine NF
Griseofulvin Ultramicrosize)
Maleate)
griseofulvin microsize susp F
CHLOR-TRIMETON TABS
(Use Chlorpheniramine NF
griseofulvin microsize tabs F Maleate)
griseofulvin ultramicrosize F chlorpheniramine maleate
tabs F
syrp 2 mg/5ml
LAMISIL PACK 125 MG, F PA chlorpheniramine maleate
187.5 MG F
tabs 4 mg
LAMISIL TABS 250 MG NF QL(90 ea per ED CHLORPED LIQD F
(Use Terbinafine HCl) 365 days retail)
nystatin tabs F Antihistamines - Ethanolamines
QL(90 ea per ALER-DRYL TABS F
terbinafine hcl tabs F
365 days retail)
22
BENADRYL ALLERGY CLARITIN REDITABS F
CAPS (Use NF TBDP 5 MG
Diphenhydramine HCl) CLARITIN SYRP 5 NF QL(10 ml daily)
BENADRYL ALLERGY MG/5ML (Use Loratadine)
CHILDRENS CHEW 12.5 F CLARITIN TABS 10 MG
MG NF QL(1 ea daily)
(Use Loratadine)
BENADRYL ALLERGY QL(10 ml daily)
CHILDRENS LIQD 12.5 loratadine soln 5 mg/5ml F
NF
MG/5ML (Use QL(10 ml daily)
Diphenhydramine HCl) loratadine syrp 5 mg/5ml F
BENADRYL ALLERGY QL(1 ea daily)
TABS (Use NF loratadine tabs 10 mg F
Diphenhydramine HCl) QL(1 ea daily)
loratadine tbdp 10 mg F
clemastine fumarate tabs F
2.68 mg ZYRTEC ALLERGY TABS NF QL(1 ea daily)
CLEMASTINE FUMARATE (Use Cetirizine HCl)
F
TABS 2.68 MG Antihistamines - Phenothiazines
diphenhydramine hcl caps F promethazine hcl soln or
or 25 mg F
6.25 mg/5ml
diphenhydramine hcl caps F RX/OTC promethazine hcl supp re
or 50 mg F
25 mg, 50 mg, 12.5 mg
diphenhydramine hcl chew F promethazine hcl syrp or
or 12.5 mg F
6.25 mg/5ml
diphenhydramine hcl elix or F RX/OTC promethazine hcl tabs or
12.5 mg/5ml F
25 mg, 50 mg, 12.5 mg
diphenhydramine hcl liqd or
25 mg/10ml, 50 mg/20ml, F Antihistamines - Piperidines
12.5 mg/5ml cyproheptadine hcl syrp F
diphenhydramine hcl syrp F
or 12.5 mg/5ml cyproheptadine hcl tabs F
diphenhydramine hcl tabs F
or 25 mg ANTIHYPERLIPIDEMICS - Drugs to Treat High
Cholesterol
SILPHEN COUGH SYRP F
Bile Acid Sequestrants
TRIAMINIC COUGH & F cholestyramine light powd
RUNNY NOSE STRP F
4 gm/dose
Antihistamines - Non-Sedating cholestyramine powd 4 F
cetirizine hcl chew 5 mg, QL(1 ea daily) gm/dose
F COLESTID FLAVORED
10 mg
cetirizine hcl tabs 5 mg, 10 QL(1 ea daily) GRAN 5 GM (Use NF
F Colestipol HCl)
mg
CLARITIN ALLERGY QL(10 ml daily) COLESTID GRAN 5 GM NF
CHILDRENS SYRP (Use NF (Use Colestipol HCl)
Loratadine) COLESTID TABS 1 GM NF
CLARITIN REDITABS QL(1 ea daily) (Use Colestipol HCl)
TBDP 10 MG (Use NF colestipol hcl gran 5 gm F
Loratadine)
23
colestipol hcl tabs 1 gm F niacin (antihyperlipidemic) F
tbcr
QUESTRAN LIGHT POWD NF
(Use Cholestyramine Light) NIACOR TABS F
QUESTRAN POWD 4 NIASPAN TBCR (Use NF
GM/DOSE (Use NF Niacin (Antihyperlipidemic))
Cholestyramine)
ANTIHYPERTENSIVES - Drugs to Treat High
Fibric Acid Derivatives Blood Pressure
fenofibrate micronized caps F ACE Inhibitors
43 mg, 130 mg
ACCUPRIL TABS (Use NF
gemfibrozil tabs F Quinapril HCl)
ALTACE CAPS 10 MG NF QL(2 ea daily)
LOPID TABS (Use NF (Use Ramipril)
Gemfibrozil)
ALTACE CAPS 5 MG, 2.5 QL(1 ea daily)
HMG CoA Reductase Inhibitors MG, 1.25 MG (Use NF
atorvastatin calcium tabs F QL(1 ea daily) Ramipril)
QL(1 ea daily) benazepril hcl tabs F

fluvastatin sodium caps F
QL(1 ea daily) captopril tabs F
fluvastatin sodium tb24 F
LESCOL XL TB24 (Use enalapril maleate tabs F
NF QL(1 ea daily)
Fluvastatin Sodium)
fosinopril sodium tabs F
LIPITOR TABS (Use NF QL(1 ea daily)
Atorvastatin Calcium) lisinopril tabs F
Limit 45 per
lovastatin tabs 10 mg, 20 F month;QL(1.5 LOTENSIN TABS (Use
mg NF
ea daily) Benazepril HCl)
lovastatin tabs 40 mg F QL(2 ea daily) moexipril hcl tabs F
MEVACOR TABS (Use PRINIVIL TABS (Use
NF QL(2 ea daily) Lisinopril) NF
Lovastatin)
PRAVACHOL TABS (Use NF QL(1 ea daily) quinapril hcl tabs F
Pravastatin Sodium)
QL(1 ea daily) ramipril caps 10 mg F QL(2 ea daily)
pravastatin sodium tabs F
QL(1 ea daily) ramipril caps 5 mg, 2.5 mg, F QL(1 ea daily)
simvastatin tabs F 1.25 mg
ZOCOR TABS (Use VASOTEC TABS (Use
NF QL(1 ea daily) Enalapril Maleate) NF
Simvastatin)
Intestinal Cholesterol Absorption Inhibitors ZESTRIL TABS (Use NF
Lisinopril)
ezetimibe tabs F ST Agents for Pheochromocytoma
ZETIA TABS (Use NF ST DEMSER CAPS F
Ezetimibe)
Nicotinic Acid Derivatives DIBENZYLINE CAPS (Use NF
Phenoxybenzamine HCl)
24
phenoxybenzamine hcl F ATACAND HCT TABS
caps (Use Candesartan Cilexetil- NF
Hydrochlorothiazide)
Angiotensin II Receptor Antagonists
ATACAND TABS (Use atenolol & chlorthalidone F
Candesartan Cilexetil) NF tabs
AVALIDE TABS (Use
AVAPRO TABS (Use
Irbesartan) NF Irbesartan- NF
candesartan cilexetil tabs F benazepril & F
hydrochlorothiazide tabs
COZAAR TABS (Use NF
Losartan Potassium) bisoprolol & F
irbesartan tabs F candesartan cilexetil- F
losartan potassium tabs F CAPTOPRIL/HYDROCHL F
MICARDIS TABS (Use OROTHIAZIDE TABS
NF
Telmisartan) enalapril maleate & F
telmisartan tabs F
fosinopril sodium & F
Antiadrenergic Antihypertensives hydrochlorothiazide tabs
CARDURA TABS (Use HYZAAR TABS (Use
NF QL(1 ea daily) Losartan Potassium & NF
Doxazosin Mesylate)
CATAPRES TABS (Use NF
Clonidine HCl) irbesartan- F
clonidine hcl tabs or 0.1 F
mg, 0.2 mg, 0.3 mg lisinopril & F
doxazosin mesylate tabs F QL(1 ea daily) LOPRESSOR HCT TABS
(Use Metoprolol & NF
guanfacine hcl tabs F Hydrochlorothiazide)
losartan potassium & F
methyldopa tabs F hydrochlorothiazide tabs
MINIPRESS CAPS (Use NF LOTENSIN HCT TABS
Prazosin HCl) (Use Benazepril & NF
prazosin hcl caps F
METHYLDOPA/HYDROCH F
TENEX TABS (Use LOROTHIAZIDE TABS
NF
Guanfacine HCl) metoprolol & F
terazosin hcl caps F QL(1 ea daily) hydrochlorothiazide tabs
METOPROLOL/HYDROCH F
Antihypertensive Combinations LOROTHIAZIDE TABS
ACCURETIC TABS (Use MICARDIS HCT TABS
Quinapril- NF (Use Telmisartan- NF
Hydrochlorothiazide) Hydrochlorothiazide)
moexipril- F
25
PROPRANOLOL/HYDROC F PLAQUENIL TABS (Use
HLOROTHIAZIDE TABS Hydroxychloroquine NF
quinapril- Sulfate)
F
ANTIMYASTHENIC/CHOLINERGIC AGENTS
TARKA TBCR (Use
Trandolapril-Verapamil NF Antimyasthenic/Cholinergic Agents
HCl) MESTINON TABS 60 MG
telmisartan-amlodipine tabs F (Use Pyridostigmine NF
Bromide)
telmisartan- F MESTINON TIMESPAN
hydrochlorothiazide tabs TBCR (Use Pyridostigmine NF
TENORETIC 100 TABS Bromide)
(Use Atenolol & NF pyridostigmine bromide
Chlorthalidone) F
tabs
TENORETIC 50 TABS
(Use Atenolol & NF pyridostigmine bromide tbcr F
Chlorthalidone)
ANTIMYCOBACTERIAL AGENTS - Drugs to
trandolapril-verapamil hcl F Treat Tuberculosis (Bacterial Infections)
tbcr
TWYNSTA TABS (Use Antimycobacterial Agents
NF
Telmisartan-Amlodipine) ethambutol hcl tabs F
VASERETIC TABS (Use
Enalapril Maleate & NF ISONIAZID SYRP OR 50 F
Hydrochlorothiazide) MG/5ML
ZESTORETIC TABS (Use isoniazid tabs or 100 mg, F
Lisinopril & NF 300 mg
Hydrochlorothiazide) MYAMBUTOL TABS (Use NF
ZIAC TABS (Use Bisoprolol Ethambutol HCl)
NF MYCOBUTIN CAPS (Use
& Hydrochlorothiazide) NF
Rifabutin)
Vasodilators
hydralazine hcl tabs or 10 PRIFTIN TABS F
F
mg, 25 mg, 50 mg, 100 mg
pyrazinamide tabs F
minoxidil tabs F
rifabutin caps F
ANTIMALARIALS - Drugs to Treat Malaria
(Parasitic Infections) RIFADIN CAPS OR 150
MG, 300 MG (Use NF
Antimalarial Combinations Rifampin)
atovaquone-proguanil hcl QL(1 ea daily)
tabs F rifampin caps or 150 mg, F
300 mg
MALARONE TABS (Use NF QL(1 ea daily)
Atovaquone-Proguanil HCl) ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES - Drugs to Treat Cancer
Antimalarials
hydroxychloroquine sulfate Alkylating Agents
F ALKERAN TABS OR 2 MG
tabs NF
(Use Melphalan)
26
GLEOSTINE CAPS 10 MG, F SP- DARZALEX SOLN F PA; SP-
40 MG, 100 MG AcariaHealth AcariaHealth
GLEOSTINE CAPS 5 MG F EMPLICITI SOLR F PA; SP-
AcariaHealth
HEXALEN CAPS F HERCEPTIN SOLR F PA; SP-
AcariaHealth
LEUKERAN TABS F KADCYLA SOLR F PA; SP-
AcariaHealth
melphalan tabs F
LARTRUVO SOLN F PA
MYLERAN TABS F OPDIVO SOLN 240 PA; SP- Acaria
F
MG/24ML Health
TEMODAR CAPS OR 5
MG, 20 MG, 100 MG, 140 OPDIVO SOLN 40 F PA; SP-
NF MG/4ML, 100 MG/10ML AcariaHealth
MG, 180 MG, 250 MG (Use
Temozolomide) PA; SP-
RITUXAN SOLN F
AcariaHealth
temozolomide caps F
Antineoplastic - BCL-2 Inhibitors
YONDELIS SOLR F PA VENCLEXTA STARTING PA
F
PACK TBPK
Antimetabolites PA
VENCLEXTA TABS F
capecitabine tabs F
Antineoplastic - Cellular Immunotherapy
DACOGEN SOLR (Use NF PA; SP-
Decitabine) AcariaHealth KYMRIAH SUSP F PA
decitabine solr F PA; SP- PROVENGE SUSP F PA
AcariaHealth
mercaptopurine tabs F Antineoplastic - Hedgehog Pathway Inhibitors
methotrexate sodium tabs F ERIVEDGE CAPS F SP-
or 2.5 mg AcariaHealth
PURIXAN SUSP F ODOMZO CAPS F SP-

AcariaHealth
TABLOID TABS F Antineoplastic - Hormonal and Related Agents
anastrozole tabs F
TREXALL TABS F
ARIMIDEX TABS (Use NF
XATMEP SOLN F PA Anastrozole)
AROMASIN TABS (Use NF
XELODA TABS (Use NF Exemestane)
Capecitabine)
Antineoplastic - Angiogenesis Inhibitors bicalutamide tabs F
CYRAMZA SOLN F PA CASODEX TABS (Use NF

Bicalutamide)
PA; SP-
ZALTRAP SOLN F EMCYT CAPS F
Caremark
Antineoplastic - Antibodies exemestane tabs F
27
FARESTON TABS F ALUNBRIG TABS F PA; SP-
Caremark
FEMARA TABS (Use
Letrozole) NF ALUNBRIG TBPK F PA; SP-
Caremark
flutamide caps F CABOMETYX TABS F PA; SP-
Caremark
HYDROXYPROGESTERO F PA
NE CAPROATE SOLN CAPRELSA TABS F
letrozole tabs F COMETRIQ KIT F
LYSODREN TABS F PA; SP-
COTELLIC TABS F
Caremark
MEGACE ORAL SUSP NF PA; SP-
(Use Megestrol Acetate) FARYDAK CAPS F
Caremark
megestrol acetate susp F GILOTRIF TABS F PA
megestrol acetate tabs F SP-

GLEEVEC TABS (Use NF AcariaHealth:
tamoxifen citrate tabs F Imatinib Mesylate) Brand;AL; At
least 21 yrs old
PA; SP-
ZYTIGA TABS F
AcariaHealth IBRANCE CAPS F SP-
AcariaHealth
Antineoplastic - Immunomodulators
IDHIFA TABS F PA
POMALYST CAPS F SP-Caremark
SP-
Antineoplastic Antibiotics AcariaHealth:
imatinib mesylate tabs F
Brand;AL; At
doxorubicin hcl soln 2 F PA least 21 yrs old
mg/ml
IMBRUVICA CAPS F PA
PA; SP-
mitoxantrone hcl conc F
AcariaHealth
IMBRUVICA TABS F PA
Antineoplastic Combinations
KISQALI FEMARA 200 PA; SP-Acaria IRESSA TABS F SP-Caremark
F
DOSE TBPK Health
KISQALI FEMARA 400 PA; SP-Acaria JAKAFI TABS F SP-Caremark
F
DOSE TBPK Health
PA; SP-
KISQALI FEMARA 600 PA; SP-Acaria KISQALI TABS F
F AcariaHealth
DOSE TBPK Health
LENVIMA 10 MG DAILY PA
PA; SP- DOSE CPPK
F
LONSURF TABS F
Caremark
LENVIMA 14 MG DAILY PA
PA; SP- DOSE CPPK
F
RITUXAN HYCELA SOLN F
AcariaHealth
LENVIMA 18 MG DAILY F PA
Antineoplastic Enzyme Inhibitors DOSE CPPK
AFINITOR TABS 5 MG, 10 F PA; SP- LENVIMA 20 MG DAILY PA
MG, 2.5 MG AcariaHealth F
DOSE CPPK
ALECENSA CAPS F PA LENVIMA 24 MG DAILY F PA
DOSE CPPK
28
LENVIMA 8 MG DAILY F PA ZYDELIG TABS F PA
DOSE CPPK
LYNPARZA CAPS F PA Antineoplastics Misc.
SP-
PA bexarotene caps F
AcariaHealth
LYNPARZA TABS F
HYDREA CAPS (Use NF
PA; SP- Hydroxyurea)
MEKINIST TABS F
AcariaHealth
PA; SP- hydroxyurea caps F
NERLYNX TABS F
AcariaHealth
SP- MATULANE CAPS F
NEXAVAR TABS F
AcariaHealth PA; SP-
PA SYLATRON KIT F
NINLARO CAPS F AcariaHealth
TARGRETIN CAPS OR 75 NF SP-
PA; SP- MG (Use Bexarotene) AcariaHealth
RUBRACA TABS F
Caremark
tretinoin (chemotherapy) F
PA; SP- caps
RYDAPT CAPS F
AcariaHealth
Chemotherapy Rescue/Antidote Agents
SPRYCEL TABS 20 MG, SP-
50 MG, 70 MG, 100 MG, F AcariaHealth LEUCOVORIN CALCIUM F
140 MG TABS OR 10 MG, 15 MG
SP-Acaria leucovorin calcium tabs or F
SPRYCEL TABS 80 MG F 5 mg, 25 mg
Health
SP- Mitotic Inhibitors
SUTENT CAPS F
AcariaHealth PA
DOCEFREZ SOLR F
PA; SP-
TAFINLAR CAPS F
AcariaHealth DOCETAXEL (NON- PA; SP-
PA ALCOHOL FORMULA) F AcariaHealth
TAGRISSO TABS F SOLN
PA; SP- DOCETAXEL CONC 20 PA; SP-
TARCEVA TABS F MG/ML, 80 MG/2ML, 80 AcariaHealth
AcariaHealth
PA; SP- MG/4ML, 140 MG/7ML, F
TASIGNA CAPS F 160 MG/8ML, 20
AcariaHealth
MG/0.5ML, 200 MG/10ML
SP-
TYKERB TABS F docetaxel conc 20 mg/ml, PA; SP-
AcariaHealth F
80 mg/4ml AcariaHealth
SP-
AcariaHealth;A DOCETAXEL SOLN 20 PA; SP-
VOTRIENT TABS F MG/2ML, 80 MG/8ML, 160 F AcariaHealth
L; At least 21
yrs old MG/16ML, 200 MG/20ML
PA; SP- SP-
XALKORI CAPS F ETOPOSIDE CAPS F
AcariaHealth AcariaHealth
ZEJULA CAPS F PA HALAVEN SOLN F PA; SP-
AcariaHealth
ZELBORAF TABS F PA; SP- IXEMPRA KIT SOLR F PA; SP-
Caremark Caremark
PA; SP- TAXOTERE CONC (Use NF PA; SP-
ZOLINZA CAPS F Docetaxel) AcariaHealth
AcariaHealth
29
vincristine sulfate soln F PA carbidopa-levodopa tbcr
25mg-100mg, 50mg- F
Topoisomerase I Inhibitors 200mg
CAMPTOSAR SOLN 300 F PA GOCOVRI CP24 CO
MG/15ML
CAMPTOSAR SOLN 40 MIRAPEX TABS (Use
PA
MG/2ML, 100 MG/5ML NF Pramipexole NF
(Use Irinotecan HCl) Dihydrochloride)
PA PARLODEL CAPS (Use NF
irinotecan hcl soln F Bromocriptine Mesylate)
PA; SP- PARLODEL TABS (Use NF
IRINOTECAN SOLN F Bromocriptine Mesylate)
AcariaHealth
pramipexole
ANTIPARKINSON AGENTS - Drugs to Treat dihydrochloride tabs 0.125
Parkinson's Disease F
mg, 0.25 mg, 0.75 mg, 0.5
Antiparkinson Anticholinergics mg, 1 mg, 1.5 mg
benztropine mesylate soln CO REQUIP TABS (Use NF
Ropinirole Hydrochloride)
benztropine mesylate tabs CO REQUIP XL TB24 (Use NF
Ropinirole Hydrochloride)
COGENTIN SOLN (Use CO ropinirole hydrochloride
Benztropine Mesylate) F
tabs
trihexyphenidyl hcl elix CO ropinirole hydrochloride F
tb24
trihexyphenidyl hcl tabs CO SINEMET CR TBCR (Use NF
Carbidopa-Levodopa)
Antiparkinson COMT Inhibitors SINEMET TABS (Use
COMTAN TABS (Use NF
NF Carbidopa-Levodopa)
Entacapone)
Antiparkinson Monoamine Oxidase Inhibitors
entacapone tabs F ELDEPRYL CAPS (Use NF
Selegiline HCl)
Antiparkinson Dopaminergics
selegiline hcl caps F
amantadine hcl caps CO
selegiline hcl tabs F
amantadine hcl syrp CO
ANTIPSYCHOTICS/ANTIMANIC AGENTS -
amantadine hcl tabs CO Drugs to Treat Mood Disorders
bromocriptine mesylate F Antimanic Agents
caps lithium carbonate caps 150
bromocriptine mesylate CO
F mg, 300 mg, 600 mg
tabs LITHIUM CARBONATE
carbidopa-levodopa tabs CAPS 150 MG, 600 MG CO
10mg-100mg, 25mg- F (Use Lithium Carbonate)
100mg, 25mg-250mg lithium carbonate tabs 300 CO
mg
30
lithium carbonate tbcr 300 CO risperidone tabs CO
mg, 450 mg
LITHIUM SOLN CO risperidone tbdp CO
LITHOBID TBCR (Use CO Butyrophenones
Lithium Carbonate) HALDOL DECANOATE
Antipsychotics - Misc. 100 SOLN (Use CO
GEODON CAPS OR 20 Haloperidol Decanoate)
MG, 40 MG, 60 MG, 80 MG CO HALDOL DECANOATE 50
(Use Ziprasidone HCl) SOLN (Use Haloperidol CO
Decanoate)
GEODON SOLR IM 20 MG CO HALDOL SOLN (Use CO
Haloperidol Lactate)
LATUDA TABS CO
haloperidol decanoate soln CO
NUPLAZID TABS CO
haloperidol lactate conc CO
VRAYLAR CAPS CO
haloperidol lactate soln CO
VRAYLAR CPPK CO
haloperidol tabs or 0.5 mg,
ziprasidone hcl caps CO 1 mg, 2 mg, 5 mg, 10 mg, CO
20 mg
Benzisoxazoles Dibenzapines
FANAPT TABS CO ADASUVE AEPB CO
FANAPT TITRATION CO
PACK TABS CLOZAPINE ODT TBDP CO
INVEGA SUSTENNA CO clozapine tabs CO
SUSP
INVEGA TB24 (Use CO clozapine tbdp CO
Paliperidone)
CLOZARIL TABS (Use CO
INVEGA TRINZA SUSP CO Clozapine)
FAZACLO TBDP 150 MG, CO
paliperidone tb24 CO 200 MG, 12.5 MG
RISPERDAL CONSTA FAZACLO TBDP 25 MG, CO
CO 100 MG (Use Clozapine)
SUSR
RISPERDAL M-TAB TBDP CO loxapine succinate caps CO
(Use Risperidone)
RISPERDAL SOLN (Use CO olanzapine solr CO
Risperidone)
RISPERDAL TABS (Use olanzapine tabs CO
CO
Risperidone)
olanzapine tbdp CO
RISPERIDONE ODT TBDP CO
quetiapine fumarate tabs CO
risperidone soln CO
31
quetiapine fumarate tb24 CO trifluoperazine hcl tabs CO
SAPHRIS SUBL CO Quinolinone Derivatives

SEROQUEL TABS (Use ABILIFY MAINTENA PRSY CO
CO
Quetiapine Fumarate)
SEROQUEL XR TB24 (Use CO ABILIFY MAINTENA SRER CO
Quetiapine Fumarate) ABILIFY TABS (Use CO
VERSACLOZ SUSP CO Aripiprazole)
ZYPREXA RELPREVV aripiprazole soln CO
CO
SUSR
aripiprazole tabs CO
ZYPREXA SOLR (Use CO
Olanzapine)
aripiprazole tbdp CO
ZYPREXA TABS (Use CO
Olanzapine) ARISTADA PRSY CO
ZYPREXA ZYDIS TBDP CO
(Use Olanzapine) REXULTI TABS CO
Dihydroindolones
Thioxanthenes
MOLINDONE CO
HYDROCHLORIDE TABS thiothixene caps CO
Phenothiazines
ANTIVIRALS - Drugs to Treat Viral Infections
CHLORPROMAZINE HCL
SOLN IJ 25 MG/ML, 50 CO Antiretrovirals
MG/2ML
chlorpromazine hcl tabs or abacavir sulfate soln CO
10 mg, 25 mg, 50 mg, 100 CO
mg, 200 mg abacavir sulfate tabs CO
fluphenazine decanoate CO abacavir sulfate-lamivudine
soln CO
tabs
FLUPHENAZINE HCL CO abacavir sulfate-
CONC OR 5 MG/ML CO
lamivudine-zidovudine tabs
FLUPHENAZINE HCL CO APTIVUS CAPS CO
ELIX OR 2.5 MG/5ML
FLUPHENAZINE HCL CO APTIVUS SOLN CO
SOLN IJ 2.5 MG/ML
fluphenazine hcl tabs or 1 CO atazanavir sulfate caps CO
mg, 5 mg, 10 mg, 2.5 mg
perphenazine tabs CO ATRIPLA TABS CO
prochlorperazine maleate BIKTARVY TABS CO

F
tabs
COMBIVIR TABS (Use CO
prochlorperazine supp F Lamivudine-Zidovudine)
thioridazine hcl tabs CO COMPLERA TABS CO
32
CRIXIVAN CAPS CO KALETRA SOLN
400MG/5ML-100MG/5ML CO
DESCOVY TABS CO (Use Lopinavir-Ritonavir)
KALETRA TABS 100MG- CO
didanosine cpdr F 25MG, 200MG-50MG
lamivudine soln CO
EDURANT TABS CO
lamivudine tabs CO
efavirenz caps CO
lamivudine-zidovudine tabs CO
efavirenz tabs CO
LEXIVA SUSP 50 MG/ML CO
EMTRIVA CAPS CO
LEXIVA TABS 700 MG
EMTRIVA SOLN CO (Use Fosamprenavir CO
Calcium)
EPIVIR SOLN (Use CO
Lamivudine) lopinavir-ritonavir soln CO
EPIVIR TABS (Use CO NEVIRAPINE SUSP 50
Lamivudine) CO
MG/5ML
EPZICOM TABS (Use
Abacavir Sulfate- CO nevirapine tabs 200 mg CO
Lamivudine) nevirapine tb24 100 mg, CO
EVOTAZ TABS CO 400 mg
NORVIR CAPS CO
fosamprenavir calcium tabs CO
NORVIR SOLN CO
FUZEON SOLR CO
NORVIR TABS CO
GENVOYA TABS CO
ODEFSEY TABS CO
INTELENCE TABS CO
PREZCOBIX TABS CO
INVIRASE CAPS CO
PREZISTA SUSP CO
INVIRASE TABS CO
PREZISTA TABS CO
ISENTRESS CHEW CO
RESCRIPTOR TABS CO
ISENTRESS HD TABS CO
RETROVIR CAPS (Use NF
ISENTRESS PACK CO Zidovudine)
RETROVIR SYRP (Use NF
ISENTRESS TABS CO Zidovudine)
REYATAZ CAPS 150 MG,
JULUCA TABS CO 200 MG, 300 MG (Use CO
Atazanavir Sulfate)
REYATAZ PACK 50 MG CO
33
SELZENTRY SOLN CO VITEKTA TABS CO
SELZENTRY TABS CO ZERIT CAPS 15 MG, 20

MG, 30 MG, 40 MG (Use CO
stavudine caps CO Stavudine)
ZERIT SOLR 1 MG/ML CO
STRIBILD TABS CO
ZIAGEN SOLN (Use CO
SUSTIVA CAPS (Use CO Abacavir Sulfate)
Efavirenz) ZIAGEN TABS (Use
SUSTIVA TABS (Use CO
CO Abacavir Sulfate)
Efavirenz)
tenofovir disoproxil zidovudine caps F
CO
fumarate tabs
zidovudine syrp F
TIVICAY TABS CO
zidovudine tabs F
TRIUMEQ TABS CO
CMV Agents
TRIZIVIR TABS (Use PA
Abacavir Sulfate- CO cidofovir soln F
Lamivudine-Zidovudine) SP-
TRUVADA TABS CO VALCYTE SOLR 50 Caremark;QL(2
MG/ML (Use Valganciclovir NF 1 ml daily); AL;
TYBOST TABS CO HCl) At least 21 yrs
old
VIDEX EC CPDR 125 MG F VALCYTE TABS 450 MG NF SP-Caremark
(Use Valganciclovir HCl)
VIDEX EC CPDR 200 MG,
250 MG, 400 MG (Use NF SP-
Didanosine) Caremark;QL(2
valganciclovir hcl solr 50 F 1 ml daily); AL;
mg/ml At least 21 yrs
VIDEXPEDIATRIC SOLR F
old
VIRACEPT TABS CO valganciclovir hcl tabs 450 SP-Caremark
F
mg
VIRAMUNE SUSP 50 CO
MG/5ML Hepatitis Agents
VIRAMUNE TABS 200 MG Brand: SP-
CO adefovir dipivoxil tabs F
AcariaHealth
(Use Nevirapine)
VIRAMUNE XR TB24 (Use BARACLUDE SOLN 0.05 F Brand: SP-
CO MG/ML AcariaHealth
Nevirapine)
BARACLUDE TABS 0.5 NF Brand: SP-
VIREAD POWD 40 MG/GM CO MG, 1 MG (Use Entecavir) AcariaHealth
VIREAD TABS 150 MG, COPEGUS TABS (Use
200 MG, 250 MG
CO NF PA; SP-
Ribavirin (Hepatitis C)) AcariaHealth
VIREAD TABS 300 MG
(Use Tenofovir Disoproxil CO DAKLINZA TABS F PA; SP-
AcariaHealth
Fumarate)
entecavir tabs F Brand: SP-
AcariaHealth
34
EPCLUSA TABS F PA; SP- SOVALDI TABS F PA; SP-
AcariaHealth AcariaHealth
EPIVIR HBV SOLN 5 CO TECHNIVIE TABS F PA; SP-
MG/ML AcariaHealth
EPIVIR HBV TABS 100 VEMLIDY TABS CO
MG (Use Lamivudine CO
(HBV)) PA; SP-
ZEPATIER TABS F
AcariaHealth
HARVONI TABS F PA; SP-
AcariaHealth Herpes Agents
HEPSERA TABS (Use NF Brand: SP-
Adefovir Dipivoxil) AcariaHealth acyclovir caps F
lamivudine (hbv) tabs CO acyclovir susp F
PA; SP-
MAVYRET TABS F acyclovir tabs F
AcariaHealth
MODERIBA 1200 DOSE F PA; SP- famciclovir tabs F
PACK TABS AcariaHealth
MODERIBA 800 DOSE FAMVIR TABS (Use
F PA; SP- Famciclovir) NF
PACK TABS AcariaHealth
MODERIBA TBPK F PA; SP- valacyclovir hcl tabs F
AcariaHealth
PEG-INTRON REDIPEN VALTREX TABS (Use
F PA; SP- Valacyclovir HCl) NF
KIT AcariaHealth
PEG-INTRON REDIPEN ZOVIRAX CAPS OR 200
F PA; SP- MG (Use Acyclovir)
NF
PAK 4 KIT AcariaHealth
PEGASYS PROCLICK ZOVIRAX SUSP OR 200
F PA; SP- MG/5ML (Use Acyclovir)
NF
SOLN AcariaHealth
ZOVIRAX TABS OR 400
PEGASYS SOLN F PA; SP- MG, 800 MG (Use NF
AcariaHealth
Acyclovir)
PEGINTRON KIT F PA; SP- Influenza Agents
AcariaHealth
REBETOL CAPS 200 MG PA; SP- FLUMADINE TABS (Use
(Use Ribavirin (Hepatitis NF AcariaHealth Rimantadine NF
C)) Hydrochloride)
REBETOL SOLN 40 PA; SP- oseltamivir phosphate caps F QL(10 ea per
F 30 mg, 45 mg, 75 mg fill retail)
MG/ML AcariaHealth
RIBASPHERE RIBAPAK PA; SP- oseltamivir phosphate susr F QL(120 ml per
F 6 mg/ml fill retail)
TABS AcariaHealth
RIBASPHERE RIBAPAK PA; SP- Limit 20 per
F RELENZA DISKHALER
TBPK AcariaHealth F month;QL(0.67
AEPB
PA; SP- ea daily)
RIBASPHERE TABS F rimantadine hydrochloride
AcariaHealth F
PA; SP- tabs
ribavirin (hepatitis c) caps F TAMIFLU CAPS (Use
AcariaHealth NF QL(10 ea per
PA; SP- Oseltamivir Phosphate) fill retail)
ribavirin (hepatitis c) tabs F
AcariaHealth
35
BETA BLOCKERS - Drugs to Treat High Blood propranolol hcl soln iv 1 F PA
Pressure mg/ml
PROPRANOLOL HCL
Alpha-Beta Blockers SOLN OR 20 MG/5ML
F
carvedilol tabs F propranolol hcl tabs or 10
mg, 20 mg, 40 mg, 60 mg, F
COREG TABS (Use NF 80 mg
Carvedilol)
labetalol hcl tabs or 100 sotalol hcl (afib/afl) tabs F
F
mg, 200 mg, 300 mg
sotalol hcl tabs F
Beta Blockers Cardio-Selective
acebutolol hcl caps F SOTYLIZE SOLN F
atenolol tabs F TIMOLOL MALEATE TABS F
bisoprolol fumarate tabs F CALCIUM CHANNEL BLOCKERS - Drugs to

Treat High Blood Pressure
LOPRESSOR TABS (Use NF
Metoprolol Tartrate) Calcium Channel Blockers
ADALAT CC TB24 (Use NF QL(1 ea daily)
metoprolol succinate tb24 F Nifedipine)
metoprolol tartrate tabs or amlodipine besylate tabs F QL(1 ea daily)
F
25 mg, 50 mg, 100 mg
CALAN SR TBCR (Use
SECTRAL CAPS (Use NF
Acebutolol HCl) NF Verapamil HCl)
CALAN TABS (Use
TENORMIN TABS (Use NF
Atenolol) NF Verapamil HCl)
CARDIZEM CD CP24 (Use
TOPROL XL TB24 (Use
Metoprolol Succinate) NF Diltiazem HCl Coated NF
Beads)
ZEBETA TABS (Use NF CARDIZEM TABS (Use
Bisoprolol Fumarate) Diltiazem HCl) NF
Beta Blockers Non-Selective diltiazem hcl coated beads
BETAPACE AF TABS (Use NF cp24 120 mg, 180 mg, 240 F
Sotalol HCl (AFIB/AFL)) mg, 300 mg, 360 mg
BETAPACE TABS (Use NF diltiazem hcl cp12 or 60 F
Sotalol HCl) mg, 90 mg, 120 mg
CORGARD TABS (Use NF diltiazem hcl cp24 or 120 F
Nadolol) mg, 180 mg, 240 mg
HEMANGEOL SOLN F AL; Up to 1 yrs diltiazem hcl extended F
old release beads cp24
INDERAL LA CP24 (Use NF diltiazem hcl tabs or 30 mg, F
Propranolol HCl) 60 mg, 90 mg, 120 mg
nadolol tabs F felodipine tb24 F
propranolol hcl cp24 or 60 nifedipine caps 10 mg, 20 F
mg, 80 mg, 120 mg, 160 F mg
mg
36
nifedipine tb24 30 mg, 60 F QL(1 ea daily) DIGOXIN SOLN OR 0.05 F
mg, 90 mg MG/ML
nifedipine tb24 60 mg F QL(2 ea daily) digoxin tabs or 0.125 mg,
0.25 mg, 125 mcg, 250 F
QL(12 ea mcg
daily,21 day(s) LANOXIN TABS OR 125
nimodipine caps F
limit,252 ea per F
MCG, 250 MCG
21 days retail)
CARDIOVASCULAR AGENTS - MISC. - Drugs to
NISOLDIPINE ER TB24 F Treat Heart and Circulation Conditions
25.5 MG
nisoldipine tb24 17 mg, 34 Prostaglandin Vasodilators
F PA; SP-
mg, 8.5 mg REMODULIN SOLN F
NORVASC TABS (Use Caremark
NF QL(1 ea daily) PA; SP-
Amlodipine Besylate) VENTAVIS SOLN F
Caremark
NYMALIZE SOLN F
Pulmonary Hypertension - Endothelin Receptor
PROCARDIA CAPS (Use
Nifedipine) NF LETAIRIS TABS F SP-Caremark
PROCARDIA XL TB24 30 QL(1 ea daily) SP-Caremark
MG, 90 MG (Use NF TRACLEER TABS F
Nifedipine) SP-Caremark
TRACLEER TBSO F
PROCARDIA XL TB24 60 NF QL(2 ea daily)
MG (Use Nifedipine) Pulmonary Hypertension - Phosphodiesterase
SULAR TB24 (Use
Nisoldipine) NF ADCIRCA TABS F PA; SP-
AcariaHealth
TIAZAC CP24 (Use
Diltiazem HCl Extended NF CEPHALOSPORINS - Drugs to Treat Bacterial
Release Beads) Infections
verapamil hcl cp24 or 100 Cephalosporins - 1st Generation
mg, 120 mg, 180 mg, 200 F cefadroxil caps F
mg, 240 mg, 300 mg, 360
mg
cefadroxil susr F
verapamil hcl soln iv 2.5 F PA
mg/ml cefadroxil tabs F
verapamil hcl tabs or 40 F
mg, 80 mg, 120 mg CEFAZOLIN PA
SODIUM/SODIUM F
verapamil hcl tbcr or 120 F CHLORIDE SOLN
mg, 180 mg, 240 mg
CEFAZOLIN PA
VERELAN CP24 (Use NF SODIUM/SODIUM F
Verapamil HCl) CHLORIDE SOSY
VERELAN PM CP24 (Use NF CEFAZOLIN/SODIUM PA
Verapamil HCl) F
CHLORIDE SOLN
CARDIOTONICS - Drugs to Treat Heart Failure cephalexin caps 250 mg,
and Abnormal Heart Rhythm F
500 mg
Cardiac Glycosides cephalexin susr 125 F
mg/5ml, 250 mg/5ml
37
CEPHALEXIN TABS 250 F BREVICON-28 TABS (Use
MG, 500 MG Norethindrone & Eth NF
KEFLEX CAPS 250 MG, Estradiol)
NF
500 MG (Use Cephalexin) CYCLESSA TABS (Use
Desogestrel-Ethinyl NF
Cephalosporins - 2nd Generation Estradiol (Triphasic))
cefaclor caps 250 mg, 500 F DESOGEN TABS (Use
mg Desogestrel & Ethinyl NF
CEFACLOR SUSR 125 Estradiol)
MG/5ML, 250 MG/5ML, F
375 MG/5ML desogestrel & ethinyl F
estradiol tabs
cefprozil susr F desogestrel-ethinyl F
estradiol (biphasic) tabs
cefprozil tabs F desogestrel-ethinyl F
CEFTIN SUSR 125 estradiol (triphasic) tabs
F drospirenone-ethinyl
MG/5ML, 250 MG/5ML F
CEFTIN TABS 250 MG, estradiol tabs
500 MG (Use Cefuroxime NF ESTROSTEP FE TABS
Axetil) (Use Norethindrone NF
Acetate-Ethinyl Estradiol-
cefuroxime axetil tabs F Fe)
Cephalosporins - 3rd Generation ethynodiol diacet & eth F
estrad tabs
cefdinir caps F FEMCON FE CHEW (Use
Norethindrone & Ethinyl NF
cefdinir susr F Estradiol-Fe)
GENERESS FE CHEW
cefpodoxime proxetil susr F (Use Norethindrone & NF
Ethinyl Estradiol-Fe)
cefpodoxime proxetil tabs F levonorgestrel & eth F
ceftriaxone sodium solr ij 1 PA estradiol tabs
F
gm, 2 gm, 250 mg, 500 mg levonorgestrel-eth estradiol F
CEFTRIAXONE SODIUM PA (triphasic) tabs
F
SOLR IJ 100 GM levonorgestrel-ethinyl F
ceftriaxone sodium solr iv 1 PA estradiol (91-day) tabs
F
gm, 2 gm, 10 gm LOESTRIN 1.5/30-21
TABS (Use Norethindrone NF
CHEMICALS Acet & Eth Estra)
Bulk Chemicals - H's LOESTRIN FE 1.5/30
TABS (Use Norethin Acet & NF
HALOPERIDOL POWD XX CO Estrad-Fe)
LOESTRIN FE 1/20 TABS
CONTRACEPTIVES - Drugs to Prevent (Use Norethin Acet & NF
Pregnancy Estrad-Fe)
Combination Contraceptives - Oral LOSEASONIQUE TABS
(Use Levonorgestrel- NF
Ethinyl Estradiol (91-Day))
38
MIRCETTE TABS (Use ORTHO-CYCLEN TABS
Desogestrel-Ethinyl NF (Use Norgestimate-Ethinyl NF
Estradiol (Biphasic)) Estradiol)
MODICON TABS (Use ORTHO-NOVUM 1/35
Norethindrone & Eth NF TABS (Use Norethindrone NF
Estradiol) & Eth Estradiol)
NECON 10/11-28 TABS F ORTHO-NOVUM 7/7/7
TABS (Use Norethindrone- NF
norethin acet & estrad-fe Eth Estradiol (Triphasic))
tabs 75mg-20mcg-1mg, F OVCON-35 TABS (Use
75mg-30mcg-1.5mg Norethindrone & Eth NF
norethindrone & eth Estradiol)
F
estradiol tabs SEASONIQUE TABS (Use
norethindrone & ethinyl Levonorgestrel-Ethinyl NF
F Estradiol (91-Day))
estradiol-fe chew
norethindrone & mestranol TRI-NORINYL 28 TABS
F (Use Norethindrone-Eth NF
tabs
norethindrone acet & eth Estradiol (Triphasic))
F YASMIN 28 TABS (Use
estra tabs 30mcg-1.5mg
norethindrone acetate- Drospirenone-Ethinyl NF
F Estradiol)
ethinyl estradiol-fe tabs
norethindrone-eth estradiol YAZ TABS (Use
F Drospirenone-Ethinyl NF
(triphasic) tabs
Estradiol)
norgestimate-ethinyl F
estradiol (triphasic) tabs Combination Contraceptives - Transdermal
norgestimate-ethinyl Limit 1 box of 3
F
estradiol tabs XULANE PTWK F per
norgestrel & ethinyl month;QL(0.10
F 8 ea daily)
estradiol tabs
NORINYL 1+35 TABS (Use Combination Contraceptives - Vaginal
Norethindrone & Eth NF 1 per
Estradiol) NUVARING RING F month;QL(0.03
NORINYL 1+50 TABS (Use 6 ea daily)
Norethindrone & NF Emergency Contraceptives
Mestranol)
QL(1 ea per fill
OGESTREL TABS F ELLA TABS F retail,6 ea per
365 days retail)
ORTHO TRI-CYCLEN LO
TABS (Use Norgestimate- QL(1 ea per fill
NF levonorgestrel (emergency F retail,6 ea per
Ethinyl Estradiol oc) tabs
(Triphasic)) 365 days retail)
ORTHO TRI-CYCLEN PLAN B ONE-STEP TABS QL(1 ea per fill
TABS (Use Norgestimate- (Use Levonorgestrel NF retail,6 ea per
Ethinyl Estradiol NF (Emergency OC)) 365 days retail)
(Triphasic)) Progestin Contraceptives - Injectable
39
DEPO-PROVERA QL(1 ml per 90 ENTOCORT EC CPEP NF
CONTRACEPTIVE SUSP NF days retail) (Use Budesonide)
(Use Medroxyprogesterone
Acetate (Contraceptive)) hydrocortisone tabs F
DEPO-PROVERA QL(1 ml per 90 MEDROL DOSEPAK TBPK
CONTRACEPTIVE SUSY NF
NF days retail) (Use Methylprednisolone)
(Use Medroxyprogesterone
Acetate (Contraceptive)) MEDROL TABS 2 MG F
DEPO-SUBQ PROVERA F QL(1 ml per 90 MEDROL TABS 4 MG, 8
104 SUSY days retail) MG, 16 MG, 32 MG (Use NF
medroxyprogesterone QL(1 ml per 90 Methylprednisolone)
acetate (contraceptive) F days retail)
susp methylprednisolone tabs F
medroxyprogesterone QL(1 ml per 90 methylprednisolone tbpk F
acetate (contraceptive) F days retail)
susy MILLIPRED TABS 5 MG F
Progestin Contraceptives - Oral
prednisolone sodium
NOR-QD TABS (Use phosphate soln or 15 F
Norethindrone NF mg/5ml
(Contraceptive))
norethindrone prednisolone soln F
F
(contraceptive) tabs
ORTHO MICRONOR prednisolone syrp F
TABS (Use Norethindrone NF PREDNISONE INTENSOL
(Contraceptive)) F
CONC
CORTICOSTEROIDS - Steroid Hormone Drugs to PREDNISONE SOLN 5
Treat Systemic Swelling Conditions F
MG/5ML
Glucocorticosteroids prednisone tabs 1 mg, 5 F
mg, 10 mg, 20 mg, 2.5 mg
budesonide cpep F PREDNISONE TABS 50 F
CORTEF TABS (Use MG
NF PREDNISONE TBPK 5
Hydrocortisone) F
CORTISONE ACETATE MG, 10 MG
F
TABS Mineralocorticoids
dexamethasone elix 0.5 F
mg/5ml fludrocortisone acetate tabs F
DEXAMETHASONE F COUGH/COLD/ALLERGY - Drugs to Treat
INTENSOL CONC Cough, Cold and Allergy Symptoms
DEXAMETHASONE SOLN F
0.5 MG/5ML Antitussives
dexamethasone tabs 0.75 benzonatate caps 100 mg, F
mg, 0.5 mg, 4 mg, 6 mg, F 200 mg
1.5 mg hydrocodone w/ F
DEXAMETHASONE TABS
homatropine syrp
F hydrocodone w/
1 MG, 2 MG F
homatropine tabs
40
TESSALON PERLES NF diphenhydramine-
CAPS (Use Benzonatate) phenylephrine tabs 25mg- F
10mg
Cough/Cold/Allergy Combinations
ADVIL ALLERGY & diphenhydramine-
CONGESTION TABS
F phenylephrine-
acetaminophen tabs F
BENADRYL-D ALLERGY & F 12.5mg-325mg-5mg,
SINUS CHILDRENS SOLN 12.5mg-12.5mg-325mg-
brompheniramine & 325mg-5mg-5mg
phenyleph elix 1mg/5ml- DRIXORAL
2.5mg/5ml, 1mg/5ml- F F
COLD/ALLERGY TB12
1mg/5ml-2.5mg/5ml-
2.5mg/5ml ED CHLORPED D LIQD F
brompheniramine & F
pseudoeph elix ENTRE-HIST PSE LIQD F
brompheniramine & F EQ TRIACTING
pseudoeph liqd F
COLD/ALLERGY SYRP
cetirizine-pseudoephedrine F QL(2 ea daily) guaifenesin-codeine liqd
tb12 F
100mg/5ml-10mg/5ml
chlorpheniramine & guaifenesin-codeine soln
phenylephrine tabs 4mg- F F
100mg/5ml-10mg/5ml
10mg guaifenesin-codeine syrp
chlorpheniramine & F
100mg/5ml-10mg/5ml
pseudoeph syrp 15mg/5ml- F hydrocodone polistirex- QL(10 ml
1mg/5ml chlorpheniramine polistirex F daily); AL; At
CLARITIN-D 12 HOUR suer least 6 yrs old
TB12 (Use Loratadine & NF
Pseudoephedrine) LEXUSS 210 LIQD F
CLARITIN-D 24 HOUR loratadine &
TB24 (Use Loratadine & NF F
pseudoephedrine tb12
Pseudoephedrine) loratadine &
DECON-A ELIX 2MG/5ML- F
F pseudoephedrine tb24
5MG/5ML NEXAFED SINUS
dexbrompheniramine & F
F PRESSURE +PAIN TABS
pseudoephedrine tb12 promethazine &
DIMETAPP COLD & F
phenylephrine soln
ALLERGY ELIX 1MG/5ML- promethazine &
2.5MG/5ML (Use NF phenylephrine syrp F
Brompheniramine &
Phenyleph) promethazine w/codeine F
syrp
diphenhydramine-
phenylephrine liqd F promethazine-dm syrp F
12.5mg/5ml-5mg/5ml
diphenhydramine- promethazine- F
phenylephrine soln F phenylephrine-codeine syrp
12.5mg/5ml-5mg/5ml PROMETHAZINE/PHENYL F
EPHRINE SYRP
41
RYMED TABS F BENZAMYCIN GEL (Use
Benzoyl Peroxide- NF
triprolidine & Erythromycin)
F
pseudoephedrine tabs
BENZIQ WASH LIQD F
TUSSIONEX QL(10 ml
PENNKINETIC daily); AL; At benzoyl peroxide bar 10 % F
EXTENDED RELEASE least 6 yrs old
SUER (Use Hydrocodone NF benzoyl peroxide gel 10 % F RX/OTC
Polistirex-
Chlorpheniramine BENZOYL PEROXIDE
Polistirex) F
GEL 2.5 %
ZYRTEC-D QL(2 ea daily)
ALLERGY/CONGESTION benzoyl peroxide gel 5 % F
NF
TB12 (Use Cetirizine- benzoyl peroxide liqd 4 %,
Pseudoephedrine) F
7%
Misc. Respiratory Inhalants benzoyl peroxide liqd 5 %, F RX/OTC
10 %, 2.5 %
HYPERSAL NEBU 3.5 % F
benzoyl peroxide lotn 6 % F RX/OTC
sodium chloride (inhalant) F
aers 0.9 % benzoyl peroxide- F
sodium chloride (inhalant) erythromycin gel
F
nebu 0.9 %, 3 % CLEOCIN-T GEL (Use
Mucolytics Clindamycin Phosphate NF
(Topical))
acetylcysteine soln F CLEOCIN-T LOTN (Use
Clindamycin Phosphate NF
DERMATOLOGICALS - Drugs to Treat Skin (Topical))
Conditions CLEOCIN-T SOLN (Use
Acne Products Clindamycin Phosphate NF
ACNE MEDICATION 10 (Topical))
F CLINDAGEL GEL (Use
LOTN
Limit 45gms Clindamycin Phosphate NF
(Topical))
adapalene crea 0.1 % F per clindamycin phosphate
month;QL(1.5 F
gm daily) (topical) gel
Limit 45gms clindamycin phosphate F
per (topical) lotn
adapalene gel 0.1 % F month;QL(1.5 clindamycin phosphate
gm daily); F
(topical) soln
RX/OTC
DESQUAM-X WASH LIQD NF RX/OTC
Limit 45gms (Use Benzoyl Peroxide)
adapalene gel 0.3 % F per Limit 45gms
month;QL(1.5
gm daily) DIFFERIN CREA 0.1 % NF per
(Use Adapalene) month;QL(1.5
BENZAC AC WASH LIQD NF RX/OTC gm daily)
(Use Benzoyl Peroxide)
42
Limit 45gms Limit 45gms
per
DIFFERIN GEL 0.1 % (Use NF month;QL(1.5 RETIN-A GEL (Use NF per
Adapalene) Tretinoin) month;QL(1.5
gm daily); gm daily)
RX/OTC Limit 50gms
Limit 45gms RETIN-A MICRO GEL 0.04
%, 0.1 % (Use Tretinoin NF per
DIFFERIN GEL 0.3 % (Use NF per Microsphere) month;QL(1.67
Adapalene) month;QL(1.5 gm daily)
gm daily) Limit 50gms
RETIN-A MICRO PUMP
ERYGEL GEL (Use NF per
Erythromycin (Acne Aid)) NF GEL 0.04 %, 0.1 % (Use month;QL(1.67
Tretinoin Microsphere) gm daily)
erythromycin (acne aid) gel F
SODIUM
erythromycin (acne aid) SULFACETAMIDE/SULFU F
F R LOTN
pads
erythromycin (acne aid) sulfacetamide sodium F
F (acne) lotn
soln
isotretinoin caps 10 mg F QL(4 ea daily) sulfacetamide sodium F
(acne) susp
QL(4 ea sulfacetamide sodium w/
daily,600 ea F
isotretinoin caps 10 mg F sulfur lotn 5%-10%
per 150 days Limit 45gms
retail) tretinoin crea 0.025 %, 0.05 F per
isotretinoin caps 20 mg F QL(5 ea daily) %, 0.1 % month;QL(1.5
gm daily)
isotretinoin caps 30 mg F QL(3 ea daily) Limit 45gms
tretinoin gel 0.025 %, 0.01 F per
QL(2 ea % month;QL(1.5
daily,300 ea gm daily)
isotretinoin caps 40 mg F
per 150 days Limit 50gms
retail)
QL(2 ea daily) tretinoin microsphere gel F per
isotretinoin caps 40 mg F month;QL(1.67
gm daily)
KLARON LOTN (Use
Sulfacetamide Sodium NF Anti-inflammatory Agents - Topical
(Acne)) diclofenac sodium (topical) F QL(6.68 gm
PANOXYL LIQD 2.5 % gel 1 % daily)
NF RX/OTC VOLTAREN GEL (Use QL(6.68 gm
(Use Benzoyl Peroxide)
PANOXYL-4 CREAMY Diclofenac Sodium NF daily)
WASH LIQD (Use Benzoyl NF (Topical))
Peroxide) Antibiotics - Topical
Limit 45gms BACIGUENT OINT (Use
RETIN-A CREA (Use NF
NF per Bacitracin (Topical))
Tretinoin) month;QL(1.5
gm daily) bacitracin (topical) oint F
bacitracin zinc oint F
43
bacitracin-polymyxin b oint F LOTRIMIN AF FOR HER RX/OTC
CREA (Use Clotrimazole NF
BACTROBAN CREA (Use (Topical))
Mupirocin Calcium NF LOTRIMIN AF JOCK ITCH RX/OTC
(Topical)) CREA (Use Clotrimazole NF
BACTROBAN OINT (Use (Topical))
NF
Mupirocin) LOTRISONE CREA (Use
CORTISPORIN CREA F Clotrimazole w/ NF
Betamethasone)
CORTISPORIN OINT F MICATIN CREA (Use
Miconazole Nitrate NF
gentamicin sulfate (topical) F (Topical))
crea miconazole nitrate (topical)
gentamicin sulfate (topical) F
F crea
oint
naftifine hcl crea F
mupirocin calcium (topical) F
crea NAFTIN CREA 2 % (Use NF
Naftifine HCl)
mupirocin oint F
NAFTIN GEL 1 %, 2 % F
POLYSPORIN OINT (Use NF
Bacitracin-Polymyxin B) NIZORAL SHAM (Use NF
Antifungals - Topical Ketoconazole (Topical))
ALEVAZOL OINT F nystatin (topical) crea F
clotrimazole (topical) crea F RX/OTC nystatin (topical) oint F
clotrimazole (topical) soln F RX/OTC nystatin-triamcinolone crea F
clotrimazole w/ F nystatin-triamcinolone oint F

betamethasone crea
terbinafine hcl (topical) crea F
econazole nitrate crea F
TINACTIN CREA (Use NF
EXELDERM SOLN F Tolnaftate)
TINACTIN JOCK ITCH NF
ketoconazole (topical) crea F CREA (Use Tolnaftate)
ketoconazole (topical) F tolnaftate crea F
sham
LAMISIL AT CREA (Use NF tolnaftate liqd F
Terbinafine HCl (Topical))
LAMISIL AT JOCK ITCH tolnaftate soln F
CREA (Use Terbinafine NF
HCl (Topical)) Antineoplastic or Premalignant Lesion Agents -
LAMISIL AT SPRAY SOLN F CARAC CREA F
LOTRIMIN AF CREA 1 % RX/OTC EFUDEX CREA (Use NF
(Use Clotrimazole NF Fluorouracil (Topical))
(Topical))
44
FLUOROPLEX CREA F TAZORAC CREA 0.1 % NF QL(1 gm daily)
(Use Tazarotene)
fluorouracil (topical) crea 5 F TAZORAC GEL 0.05 %, QL(1 gm daily)
% F
0.1 %
FLUOROURACIL CREA F Antiseborrheic Products
0.5 %
selenium sulfide lotn 2.5 % F
PANRETIN GEL F
Antivirals - Topical
PICATO GEL F
acyclovir topical oint F QL(1 gm daily)
Antipruritics - Topical
ZOVIRAX OINT EX 5 % NF QL(1 gm daily)
doxepin hcl (antipruritic) F (Use Acyclovir Topical)
crea
Burn Products
PRUDOXIN CREA F
SILVADENE CREA (Use NF
ZONALON CREA (Use Silver Sulfadiazine)
NF
Doxepin HCl (Antipruritic)) silver sulfadiazine crea F
Antipsoriatics
SULFAMYLON CREA 85 F
calcipotriene crea F MG/GM
Corticosteroids - Topical
calcipotriene oint F
APEXICON E CREA F
calcipotriene soln F
AUGMENTED
Limit 100gms BETAMETHASONE F
per DIPROPIONATE GEL
month;QL(3.4 betamethasone
calcitriol (topical) oint F
gm daily,100 F
dipropionate (topical) crea
gm per fill
retail) betamethasone F
dipropionate (topical) lotn
COSENTYX F PA; SP-
SENSOREADY PEN SOAJ AcariaHealth betamethasone F
dipropionate (topical) oint
PA; SP-
COSENTYX SOSY F betamethasone
AcariaHealth
dipropionate augmented F
DOVONEX CREA (Use NF gel
Calcipotriene)
betamethasone
DRITHO-CREME HP F dipropionate augmented F
CREA lotn
PA; SP- betamethasone
STELARA SOLN F
AcariaHealth dipropionate augmented F
PA; SP- oint
STELARA SOSY F
AcariaHealth betamethasone valerate
QL(1 gm daily) F
tazarotene crea F crea 0.1 %
betamethasone valerate F
TAZORAC CREA 0.05 % F QL(1 gm daily) lotn 0.1 %
betamethasone valerate F
oint 0.1 %
45
CAPEX SHAM F fluocinolone acetonide crea F
clobetasol propionate crea F fluocinolone acetonide oil F

clobetasol propionate F fluocinolone acetonide oint F
emollient base crea
clobetasol propionate foam F fluocinolone acetonide soln F
clobetasol propionate gel F fluocinonide crea 0.05 % F

fluocinonide emulsified F
clobetasol propionate oint F base crea
clobetasol propionate soln F fluocinonide gel 0.05 % F
CVS HDYROCORTISONE F fluocinonide oint 0.05 % F
ACETATE CREA
DERMA-SMOOTHE/FS fluocinonide soln 0.05 % F
BODY OIL (Use NF
Fluocinolone Acetonide) halobetasol propionate F
DERMA-SMOOTHE/FS crea
SCALP OIL (Use NF hydrocortisone (topical) F
Fluocinolone Acetonide) crea 0.5 %, 2.5 %
desonide crea F
hydrocortisone (topical) F RX/OTC
crea 1%, 1 %
desonide oint F hydrocortisone (topical) lotn F
1 %, 2.5 %
DESOWEN CREA (Use NF hydrocortisone (topical) oint
Desonide) F
0.5 %, 2.5 %
desoximetasone crea 0.05 F hydrocortisone (topical) oint RX/OTC
%, 0.25 % F
1%
desoximetasone gel 0.05 F hydrocortisone (topical)
% F
soln 1 %
desoximetasone oint 0.25 F hydrocortisone acetate
% F
(topical) crea
DIFLORASONE F hydrocortisone valerate
DIACETATE CREA F
crea
DIFLORASONE F
DIACETATE OINT hydrocortisone valerate oint F
DIPROLENE LOTN (Use hydrocortisone-aloe vera
Betamethasone NF F
crea
Dipropionate Augmented) KENALOG AERS (Use
DIPROLENE OINT (Use Triamcinolone Acetonide NF
Betamethasone NF (Topical))
Dipropionate Augmented)
ELOCON CREA (Use
mometasone furoate crea F
NF
Mometasone Furoate)
mometasone furoate oint F
ELOCON OINT (Use NF
Mometasone Furoate)
46
MONISTAT SOOTHING RX/OTC ULTRAVATE CREA (Use NF
CARE ITCH RELIEF CREA NF Halobetasol Propionate)
(Use Hydrocortisone WESTCORT OINT (Use
(Topical)) NF
Hydrocortisone Valerate)
OLUX FOAM (Use NF
Clobetasol Propionate) Eczema Agents
PA; SP-Acaria
PRAMOSONE CREA 1%- DUPIXENT SOSY F
F Health
1%
PRAMOSONE LOTN 1%- Emollients
F
1%, 1%-2.5% LAC-HYDRIN CREA (Use RX/OTC
Lactic Acid (Ammonium NF
PSORCON CREA F Lactate))
SYNALAR CREA (Use LAC-HYDRIN LOTN (Use RX/OTC
NF Lactic Acid (Ammonium NF
Fluocinolone Acetonide)
SYNALAR OINT (Use Lactate))
NF LAC-HYDRIN TWELVE RX/OTC
SYNALAR SOLN (Use LOTN (Use Lactic Acid NF
NF (Ammonium Lactate))
TEMOVATE CREA (Use lactic acid (ammonium F RX/OTC
NF lactate) crea 12 %
Clobetasol Propionate)
TEMOVATE E CREA (Use lactic acid (ammonium F RX/OTC
Clobetasol Propionate NF lactate) lotn 12 %
Emollient Base) lactic acid w/ vitamin e crea F
TEMOVATE GEL (Use NF
Clobetasol Propionate) Enzymes - Topical
TEMOVATE OINT (Use NF SANTYL OINT F
Clobetasol Propionate)
TEMOVATE SOLN (Use NF Immunomodulating Agents - Topical
Clobetasol Propionate) ALDARA CREA (Use NF
TOPICORT CREA 0.05 %, Imiquimod)
0.25 % (Use NF
Desoximetasone) imiquimod crea F
TOPICORT GEL 0.05 % NF Keratolytic/Antimitotic Agents
(Use Desoximetasone)
TOPICORT OINT 0.25 % CONDYLOX GEL F
NF
(Use Desoximetasone) CONDYLOX SOLN (Use
triamcinolone acetonide NF
F Podofilox)
(topical) aers
triamcinolone acetonide podofilox soln F
F
(topical) crea Local Anesthetics - Topical
triamcinolone acetonide F EMLA CREA (Use
(topical) lotn NF
Lidocaine-Prilocaine)
triamcinolone acetonide F
(topical) oint ETHYL CHLORIDE AERO F
TRIDESILON CREA (Use NF ETHYL CHLORIDE/FINE
Desonide) F
PINPOINT AERO
47
ETHYL CHLORIDE/FINE F RA CALAMINE LOTN F
STREAM AERO 6.971%-6.971%
ETHYL SM CALAMINE LOTN F
CHLORIDE/MEDIUM JET F
STREAM AERO SM CALAMINE F
ETHYL PHENOLATED LOTN
CHLORIDE/MEDIUM F Rosacea Agents
STREAM AERO
Limit 50gms
ETHYL CHLORIDE/MIST
AERO
F FINACEA GEL F per
month;QL(1.67
lidocaine crea 4 % F gm daily)
Limit 45gms
RX/OTC METROCREAM CREA
lidocaine hcl gel ex 2 % F (Use Metronidazole NF per
month;QL(1.5
(Topical)) gm daily)
lidocaine hcl soln ex 4 % F
METROGEL GEL (Use NF QL(2 gm daily)
lidocaine-prilocaine crea F Metronidazole (Topical))
LMX 4 CREA (Use METROLOTION LOTN QL(2 ml daily)
Lidocaine) NF (Use Metronidazole NF
(Topical))
REGENECARE HA LIQD F Limit 45gms
metronidazole (topical) F per
XYLOCAINE SOLN EX 4 NF crea 0.75 % month;QL(1.5
% (Use Lidocaine HCl) gm daily)
Misc. Topical Limit 45gms
aluminum sulfate & calcium metronidazole (topical) gel F per
F 0.75 % month;QL(1.5
acetate pack
gm daily)
CALAMINE LOTN F
metronidazole (topical) gel F QL(2 gm daily)
CALAMINE PHENOLATED 1%
F
LOTN metronidazole (topical) lotn QL(2 ml daily)
F
DOMEBORO PACK (Use 0.75 %
Aluminum Sulfate & NF Scabicides & Pediculicides
Calcium Acetate)
ELIMITE CREA (Use NF
DRYSOL SOLN F Permethrin)
GNP CALAMINE LOTN F EURAX CREA F
GNP CALAMINE EURAX LOTN F

F
PHENOLATED LOTN
LICE B GONE SHAM F
HM CALAMINE LOTN F
malathion lotn F
MEIJER CALAMINE LOTN F
NIX CREME RINSE LIQD NF
PX CALAMINE LOTN F (Use Permethrin)
OVIDE LOTN (Use NF
QC CALAMINE LOTN F Malathion)
48
permethrin crea ex 5 % F FREESTYLE INSULINX QL(10 ea
BLOODGLUCOSE TEST F daily); RX/OTC
permethrin liqd ex 1 % F STRIPS STRP
FREESTYLE INSULINX QL(10 ea
permethrin lotn ex 1 % F BLOODGLUCOSE TEST F daily); RX/OTC
STRP
pyrethrins-piperonyl F FREESTYLE LITE TEST QL(10 ea
butoxide liqd F
STRIPS STRP daily); RX/OTC
pyrethrins-piperonyl F FREESTYLE PRECISION QL(10 ea
butoxide sham NEO BLOOD GLUCOSE F daily); RX/OTC
RID LIQD EX 0.33%-4% TEST STRIPS STRP
(Use Pyrethrins-Piperonyl NF FREESTYLE TEST QL(10 ea
Butoxide) F
STRIPS STRP daily); RX/OTC
Tar Products HEMA-COMBISTIX STRP F
COAL TAR SOLN F
KETOCARE STRP F
ELTA TAR CREA F KETONE TEST STRIPS F
STRP
DIAGNOSTIC PRODUCTS
KETOSTIX STRP F
Diagnostic Tests
Available to LABSTIX STRP F
members in
ASSURE PLATINUM TEST F LTC/SNF MULTISTIX 10 SG STRP F
STRIPS STRP only;QL(10 ea
daily); RX/OTC MULTISTIX 5 STRP F
CHEK-STIX COMBO PAK
URINALYSIS CONTROL F MULTISTIX 7 STRP F
STRP
CHEK-STIX CONTROL MULTISTIX 8 SG STRP F
F
STRP
CHEMSTRIP -10 WITH SG MULTISTIX 9 SG STRP F
F
STRP
MULTISTIX 9 STRP F
CHEMSTRIP 10 MD STRP F
MULTISTIX STRP F
CHEMSTRIP 2 GP F
STRIPS STRP PRECISION XTRA BLOOD QL(10 ea
GLUCOSE TEST STRIPS F daily); RX/OTC
CHEMSTRIP 7 STRP F STRP
CHEMSTRIP 9 STRIPS PRECISION XTRA STRP F
F VI
STRP
CHEMSTRIP-K STRP F RELION KETONE STRP F
COMBISTIX STRP F RELION KETONE TEST F

STRIPS STRP
DIASTIX STRP F URISTIX 4 STRP F
49
URISTIX STRP F MAXZIDE TABS (Use
Triamterene & NF
DIGESTIVE AIDS - Drugs to Treat Low Digestive Hydrochlorothiazide)
Enzymes MAXZIDE-25 TABS (Use
Triamterene & NF
Digestive Enzymes Hydrochlorothiazide)
CREON CPEP spironolactone &
19000UNIT-6000UNIT- F
30000UNIT, 38000UNIT-
12000UNIT-60000UNIT, F triamterene & F
76000UNIT-24000UNIT- hydrochlorothiazide caps
120000UNIT, 114000UNIT- triamterene & F
36000UNIT-180000UNIT hydrochlorothiazide tabs
ZENPEP CPEP TRIAMTERENE/HYDROC F
10000UNIT-3000UNIT- HLOROTHIAZIDE CAPS
16000UNIT, 17000UNIT-
5000UNIT-27000UNIT, Loop Diuretics
34000UNIT-10000UNIT- bumetanide tabs or 0.5 mg, F
55000UNIT, 51000UNIT- 1 mg, 2 mg
F
15000UNIT-82000UNIT, BUMEX TABS (Use
68000UNIT-20000UNIT- NF
Bumetanide)
109000UNIT, 85000UNIT- furosemide soln or 10
25000UNIT-136000UNIT, F
mg/ml
136000UNIT-40000UNIT-
218000UNIT furosemide tabs or 20 mg, F
40 mg, 80 mg
DIURETICS - Drugs to Treat Heart, Circulation LASIX TABS (Use
Conditions and Blood Pressure NF
Furosemide)
Carbonic Anhydrase Inhibitors Potassium Sparing Diuretics
acetazolamide cp12 F ALDACTONE TABS (Use NF
Spironolactone)
acetazolamide tabs F
amiloride hcl tabs F
DIAMOX CP12 (Use NF
Acetazolamide) spironolactone tabs F
methazolamide tabs F Thiazides and Thiazide-Like Diuretics
NEPTAZANE TABS (Use NF chlorthalidone tabs F
Methazolamide)
Diuretic Combinations hydrochlorothiazide caps F
ALDACTAZIDE TABS
25MG-25MG (Use hydrochlorothiazide tabs F
NF
Spironolactone &
Hydrochlorothiazide) indapamide tabs F
DYAZIDE CAPS (Use METHYCLOTHIAZIDE
Triamterene & NF F
TABS
metolazone tabs F
50
MICROZIDE CAPS (Use F PA; SP-
Hydrochlorothiazide) NF H.P. ACTHAR GEL Caremark
ENDOCRINE AND METABOLIC AGENTS - Growth Hormones
MISC. - Drugs to Treat Bone Disease and HUMATROPE COMBO PA; SP-
Regulate Hormones F
PACK SOLR AcariaHealth
Bone Density Regulators PA; SP-
HUMATROPE SOLR F
Limit 4 per AcariaHealth
alendronate sodium tabs F month;QL(0.15
35 mg, 70 mg NORDITROPIN FLEXPRO F PA; SP-
ea daily) SOLN AcariaHealth
ALENDRONATE SODIUM F QL(1 ea daily) Hormone Receptor Modulators
TABS 40 MG
EVISTA TABS (Use NF PA
alendronate sodium tabs 5 F QL(1 ea daily) Raloxifene HCl)
mg, 10 mg
raloxifene hcl tabs F PA
calcitonin (salmon) soln F
LHRH/GnRH Agonist Analog Pituitary
ETIDRONATE DISODIUM F
TABS 200 MG SYNAREL SOLN F
etidronate disodium tabs F
400 mg Metabolic Modifiers
PA; SP-
FORTICAL SOLN F ALDURAZYME SOLN F
AcariaHealth
Limit 4 per BRINEURA SOLN F PA
FOSAMAX PLUS D TABS F month;QL(0.15
ea daily) calcitriol caps or 0.25 mcg, F
Limit 4 per 0.5 mcg
FOSAMAX TABS (Use NF month;QL(0.15
Alendronate Sodium) calcitriol soln or 1 mcg/ml F
ea daily)
MIACALCIN SOLN NA 200 CARBAGLU TABS F
UNIT/ACT (Use Calcitonin NF
(Salmon)) CARNITOR SF SOLN (Use
RECLAST SOLN (Use Levocarnitine (Metabolic NF
NF PA; SP- Modifiers))
Zoledronic Acid) AcariaHealth
zoledronic acid conc 4 CARNITOR SOLN OR 1
F PA; SP- GM/10ML (Use
mg/5ml AcariaHealth NF
Levocarnitine (Metabolic
ZOLEDRONIC ACID SOLN F PA Modifiers))
4 MG/100ML
CARNITOR TABS OR 330 RX/OTC
zoledronic acid soln 5 F PA; SP- MG (Use Levocarnitine NF
mg/100ml AcariaHealth (Metabolic Modifiers))
ZOLEDRONIC ACID SOLR F PA; SP- PA; SP-
4 MG AcariaHealth FABRAZYME SOLR F
AcariaHealth
ZOMETA CONC 4 PA; SP- SP-Caremark
MG/5ML (Use Zoledronic NF AcariaHealth KUVAN PACK F
Acid) SP-Caremark
ZOMETA SOLN 4 PA KUVAN TBSO F
F
MG/100ML levocarnitine (metabolic F
Corticotropin modifiers) soln 1 gm/10ml
51
levocarnitine (metabolic F RX/OTC ESTROGENS - Hormone Replacement/Modifying
modifiers) tabs 330 mg Drugs
PA; SP-
LUMIZYME SOLR F Estrogen Combinations
Caremark
Limit 4 per 28
PA; SP- CLIMARA PRO PTWK F days;QL(0.15
NAGLAZYME SOLN F
Caremark ea daily)
paricalcitol caps or 1 mcg, F FEMHRT LOW DOSE
2 mcg, 4 mcg TABS (Use Norethindrone NF
ROCALTROL CAPS (Use NF Acetate-Ethinyl Estradiol)
Calcitriol) norethindrone acetate-
ROCALTROL SOLN (Use F
NF ethinyl estradiol tabs
Calcitriol)
SP- PREMPHASE TABS F
SENSIPAR TABS F
AcariaHealth
PREMPRO TABS F
AL; At least 21
XURIDEN PACK F
yrs old Estrogens
ZEMPLAR CAPS OR 1 Limit 8 per
MCG, 2 MCG (Use NF ALORA PTTW F month;QL(0.29
Paricalcitol) ea daily)
Posterior Pituitary Hormones Limit 4 patches
DDAVP SOLN NA 0.01 % PA CLIMARA PTWK (Use NF per
(Use Desmopressin NF Estradiol) month;QL(0.14
Acetate Refrigerated) ea daily)
DDAVP SOLN NA 0.01 % PA ESTRACE TABS (Use NF
(Use Desmopressin NF Estradiol)
Acetate Spray) estradiol pttw td 0.0375 Limit 8 per
DDAVP TABS OR 0.1 MG, PA mg/24hr, 0.025 mg/24hr, F month;QL(0.29
0.2 MG (Use NF 0.075 mg/24hr, 0.05 ea daily)
Desmopressin Acetate) mg/24hr, 0.1 mg/24hr
desmopressin acetate PA estradiol ptwk td 0.025 Limit 4 patches
F mg/24hr, 0.075 mg/24hr, per
refrigerated soln
desmopressin acetate PA 0.05 mg/24hr, 0.06 F month;QL(0.14
F mg/24hr, 0.1 mg/24hr, 37.5 ea daily)
spray refrigerated soln
mcg/24hr
desmopressin acetate F PA
spray soln estradiol tabs or 0.5 mg, 1 F
mg, 2 mg
desmopressin acetate tabs F PA
or 0.1 mg, 0.2 mg ESTROPIPATE TABS F
PA; SP-
STIMATE SOLN F MENEST TABS F
AcariaHealth
Prolactin Inhibitors Limit 8 per
MINIVELLE PTTW F month;QL(0.29
cabergoline tabs F ea daily)
Vasopressin Receptor Antagonists PREMARIN TABS OR
0.625 MG, 0.45 MG, 0.3 F
SP- MG, 0.9 MG, 1.25 MG
SAMSCA TABS F Caremark;QL(1
ea daily)
52
Limit 8 per Gallstone Solubilizing Agents
VIVELLE-DOT PTTW (Use NF month;QL(0.29
Estradiol) ea daily) ACTIGALL CAPS (Use NF
Ursodiol)
FLUOROQUINOLONES - Drugs to Treat Bacterial URSO 250 TABS (Use
Infections NF
Ursodiol)
Fluoroquinolones ursodiol caps 300 mg F
CIPRO SUSR 5 F
GM/100ML ursodiol tabs 250 mg F
CIPRO SUSR 500
MG/5ML (Use NF Gastrointestinal Antiallergy Agents
Ciprofloxacin) cromolyn sodium F
CIPRO TABS 250 MG, 500 QL(56 ea per (mastocytosis) conc
MG (Use Ciprofloxacin NF 90 days retail) GASTROCROM CONC
HCl) (Use Cromolyn Sodium NF
CIPRO XR TB24 (Use QL(14 ea per (Mastocytosis))
Ciprofloxacin-Ciprofloxacin NF fill retail) Gastrointestinal Stimulants
HCl)
metoclopramide hcl soln or F
CIPROFLOXACIN HCL F 5 mg/5ml, 10 mg/10ml
TABS 100 MG
metoclopramide hcl tabs or F
ciprofloxacin hcl tabs 250 F QL(56 ea per 5 mg, 10 mg
mg, 500 mg, 750 mg 90 days retail)
REGLAN TABS (Use NF
ciprofloxacin susr or 250 F Metoclopramide HCl)
mg/5ml, 500 mg/5ml
ciprofloxacin-ciprofloxacin QL(14 ea per Inflammatory Bowel Agents
F AZULFIDINE EN-TABS
hcl tb24 fill retail) NF
LEVAQUIN TABS (Use TBEC (Use Sulfasalazine)
NF QL(14 ea per AZULFIDINE TABS (Use
Levofloxacin) fill retail) NF
LEVOFLOXACIN SOLN Sulfasalazine)
F
OR 25 MG/ML balsalazide disodium caps F
levofloxacin soln or 25 F
mg/ml COLAZAL CAPS (Use NF
Balsalazide Disodium)
levofloxacin tabs or 250 F QL(14 ea per
mg, 500 mg, 750 mg fill retail) PA; SP-
ENTYVIO SOLR F
AcariaHealth
OFLOXACIN TABS 300 F
MG INFLECTRA SOLR F PA
GASTROINTESTINAL AGENTS - MISC. - LIALDA TBEC (Use
Miscellaneous Gastrointestinal Drugs NF
Mesalamine)
Antiflatulents mesalamine enem F
GAS-X EXTRA
STRENGTH CHEW 125 NF mesalamine tbec F
MG (Use Simethicone)
simethicone caps 125mg, Limit 4 kits
F (4X7) per 28
125 mg
mesalamine w/ cleanser kit F days;QL(4 ea
simethicone chew 125 mg F per 28 days
retail)
53
REMICADE SOLR F PA; SP- acetic acid soln F
AcariaHealth
RENFLEXIS SOLR F PA Interstitial Cystitis Agents
ELMIRON CAPS F QL(3 ea daily)
Limit 4 kits
ROWASA KIT (Use (4X7) per 28
NF days;QL(4 ea Prostatic Hypertrophy Agents
Mesalamine w/ Cleanser) per 28 days alfuzosin hcl tb24 F
retail)
dutasteride-tamsulosin hcl F
SFROWASA ENEM F caps
PA; SP- finasteride tabs F
STELARA SOLN F
AcariaHealth
FLOMAX CAPS (Use NF
sulfasalazine tabs F Tamsulosin HCl)
JALYN CAPS (Use
sulfasalazine tbec F Dutasteride-Tamsulosin NF
HCl)
Intestinal Acidifiers
PROSCAR TABS (Use
lactulose (encephalopathy) F Finasteride) NF
soln
Phosphate Binder Agents tamsulosin hcl caps F
calcium acetate (phosphate F UROXATRAL TB24 (Use
binder) caps NF
Alfuzosin HCl)
GENITOURINARY AGENTS - MISCELLANEOUS Urinary Analgesics
- Miscellaneous Drugs to Treat Reproductive phenazopyridine hcl tabs
Organs and Urinary System F
100 mg, 200 mg
Alkalinizers PYRIDIUM TABS (Use NF
Phenazopyridine HCl)
ORACIT SOLN F
Urinary Stone Agents
potassium citrate
(alkalinizer) tbcr 540 mg, F THIOLA TABS F
1080 mg
SHOHLS SOLUTION RX/OTC GOUT AGENTS - Drugs to Treat Gout
MODIFIED SOLN (Use NF
Sodium Citrate & Citric Gout Agent Combinations
Acid) colchicine w/ probenecid F
sodium citrate & citric acid RX/OTC tabs
F
soln Gout Agents
UROCIT-K 10 TBCR (Use
Potassium Citrate NF allopurinol tabs F
(Alkalinizer))
COLCHICINE TABS F
UROCIT-K 5 TBCR (Use
Potassium Citrate NF COLCRYS TABS F
(Alkalinizer))
Genitourinary Irrigants PA; SP-
KRYSTEXXA SOLN F
AcariaHealth
54
ZYLOPRIM TABS (Use NF KOGENATE FS BIO-SET CO
Allopurinol) KIT
Uricosurics KOGENATE FS KIT CO
probenecid tabs F
KOVALTRY SOLR CO
HEMATOLOGICAL AGENTS - MISC. - Drugs to
Treat Blood Disorders MONOCLATE-P KIT CO
Antihemophilic Products MONONINE SOLR CO
ADVATE SOLR CO
NOVOEIGHT SOLR CO
ADYNOVATE SOLR CO
NOVOSEVEN RT SOLR CO
AFSTYLA KIT CO
NUWIQ KIT CO
ALPHANATE/VON
WILLEBRANDFACTOR CO NUWIQ SOLR CO
COMPLEX/HUMAN SOLR
ALPHANINE SD SOLR CO OBIZUR SOLR CO
ALPROLIX SOLR CO PROFILNINE SD SOLR CO
BEBULIN SOLR CO PROFILNINE SOLR CO
BENEFIX KIT CO REBINYN SOLR CO
COAGADEX SOLR CO RECOMBINATE SOLR CO
CORIFACT KIT CO RIXUBIS SOLR CO
ELOCTATE SOLR CO TRETTEN SOLR CO
FEIBA SOLR CO VONVENDI SOLR CO
HELIXATE FS KIT CO WILATE KIT CO
HEMOFIL M SOLR CO WILATE SOLR CO
HUMATE-P SOLR CO XYNTHA KIT CO
IDELVION SOLR CO XYNTHA SOLOFUSE KIT CO

Complement Inhibitors
IXINITY SOLR CO
PA; SP-
CINRYZE SOLR F
KOATE SOLR CO Caremark
PA; SP-
SOLIRIS SOLN F
KOATE-DVI SOLR CO AcariaHealth
Hematorheologic Agents
55
pentoxifylline tbcr F FOLIC ACID CAPS OR 5 F
MG, 20 MG
Platelet Aggregation Inhibitors folic acid tabs or 1 mg F RX/OTC
AGRYLIN CAPS (Use NF
Anagrelide HCl) folic acid tabs or 400 mcg, F
800 mcg
anagrelide hcl caps 0.5 mg F
Hematopoietic Growth Factors
BRILINTA TABS F ARANESP ALBUMIN F PA; SP-
FREE SOLN AcariaHealth
cilostazol tabs F ARANESP ALBUMIN F PA; SP-
FREE SOSY AcariaHealth
clopidogrel bisulfate tabs F
300 mg PA; SP-
NPLATE SOLR F
AcariaHealth
clopidogrel bisulfate tabs F QL(1 ea daily)
75 mg PA; SP-
AcariaHealth;A
dipyridamole tabs or 25 PROMACTA TABS F
F L; At least 21
mg, 50 mg, 75 mg yrs old
EFFIENT TABS (Use NF
Prasugrel HCl) Hematopoietic Mixtures
PERSANTINE TABS (Use iron combinations caps F RX/OTC
NF
Dipyridamole)
PLAVIX TABS 300 MG Iron
NF FER-IN-SOL SOLN (Use
(Use Clopidogrel Bisulfate) NF
PLAVIX TABS 75 MG (Use Ferrous Sulfate)
NF QL(1 ea daily) FERROUS GLUCONATE
Clopidogrel Bisulfate) F
TABS 225 MG
prasugrel hcl tabs F ferrous sulfate elix 220 F
mg/5ml
ZONTIVITY TABS F
FERROUS SULFATE LIQD F
HEMATOPOIETIC AGENTS - Drugs to Treat 220 MG/5ML
Blood Disorders ferrous sulfate soln 15 F
mg/ml
Agents for Gaucher Disease
FERROUS SULFATE F
PA; SP- SYRP 300 MG/5ML
CEREZYME SOLR F
AcariaHealth
ferrous sulfate tabs 28 mg, F
PA; SP- 65 mg, 325 mg
VPRIV SOLR F
AcariaHealth
Agents for Sickle Cell Anemia ferrous sulfate tbcr 50 mg F
DROXIA CAPS F FERROUS SULFATE F

TBEC 324 MG
Cobalamins ferrous sulfate tbec 325 mg F
cyanocobalamin tabs or F
250 mcg IRON CHEWS PEDIATRIC F
CHEW
Folic Acid/Folates
polysaccharide iron F
folic acid caps or 0.8 mg, F complex caps 150 mg
800 mcg
56
HEMOSTATICS - Drugs to Stop Bleeding/Treat temazepam caps F
Blood Disorders
TRIAZOLAM TABS 0.125 F
Hemostatics - Systemic MG
AMICAR SOLN 0.25 F
GM/ML triazolam tabs 0.25 mg F
AMICAR TABS 500 MG F zolpidem tartrate tabs or 5 F QL(1 ea daily)
mg, 10 mg
LYSTEDA TABS (Use NF QL(6 ea daily,5
Tranexamic Acid) day(s) limit) LAXATIVES - Bowel Treatment Drugs
tranexamic acid tabs F QL(6 ea daily,5 Bulk Laxatives
day(s) limit)
HYPNOTICS/SEDATIVES/SLEEP DISORDER calcium polycarbophil tabs F
AGENTS CITRUCEL FIBER
Barbiturate Hypnotics LAXATIVE POWD (Use NF
Methylcellulose (Laxative))
phenobarbital elix 20 F
mg/5ml CVS NATURAL FIBER F
SUPPLEMENT PACK
phenobarbital soln 20 F
mg/5ml EQL NATURAL FIBER F
POWD
PHENOBARBITAL TABS
15 MG, 30 MG, 60 MG, F EQUALACTIN CHEW F
100 MG
phenobarbital tabs 16.2 EVAC POWD (Use NF
mg, 32.4 mg, 64.8 mg, 97.2 F Psyllium)
mg FIBERCON TABS (Use NF
Calcium Polycarbophil)
Non-Barbiturate Hypnotics
AMBIEN TABS (Use HM FIBER POWD F
NF QL(1 ea daily)
Zolpidem Tartrate) HM FIBER POWDER F
estazolam tabs F POWD
HYDROCIL INSTANT F
eszopiclone tabs 1 mg, 2 F ST; QL(1 ea PACK
mg daily)
HYDROCIL INSTANT NF
ST; QL(1 ea POWD (Use Psyllium)
eszopiclone tabs 3 mg F daily); AL; Up
to 64 yrs old KONSYL PACK 100 %, F
28.3 %, 60.3 %
FLURAZEPAM HCL CAPS F KONSYL POWD 100 % NF
(Use Psyllium)
HALCION TABS (Use NF
Triazolam) KONSYL POWD 60.3 %, F
71.67 %
LUNESTA TABS 1 MG, 2 NF ST; QL(1 ea
MG (Use Eszopiclone) daily) KONSYL-D POWD F
ST; QL(1 ea
LUNESTA TABS 3 MG NF daily); AL; Up METAMUCIL CAPS 0.52
(Use Eszopiclone) NF
to 64 yrs old GM (Use Psyllium)
RESTORIL CAPS (Use METAMUCIL FIBER PACK F
NF
Temazepam)
57
METAMUCIL peg 3350-kcl-sod bicarb-
MULTIHEALTH FIBER F sod chloride-sod sulfate F
POWD 55.46 % solr
METAMUCIL ORIGINAL peg 3350-potassium
TEXTURE POWD (Use NF chloride-sod bicarbonate- F
Psyllium) sod chloride solr
METAMUCIL POWD 48.57 NF Laxatives - Miscellaneous
% (Use Psyllium) FLEET LIQUID GLYCERIN F
METAMUCIL SMOOTH SUPPOSITORIES ENEM
TEXTUREFIBER SINGLES F
PACK lactulose soln F
METAMUCIL WAFR F MIRALAX PACK (Use NF QL(1 ea daily);
Polyethylene Glycol 3350) RX/OTC
methylcellulose (laxative) Limit 527gms
powd 2 gm/19gm, 2 F
per
gm/10.2gm, MIRALAX POWD (Use NF month;QL(17.6
psyllium caps 0.52 gm, 520 Polyethylene Glycol 3350) gm daily);
F
mg RX/OTC
psyllium powd 30 %, 33 %, polyethylene glycol 3350
49 %, 68 %, 95 %, 100 %, F QL(1 ea daily);
F pack RX/OTC
28.3 %, 30.9 %, 58.6 %, Limit 527gms
48.57 %, per
polyethylene glycol 3350 F month;QL(17.6
SM FIBER POWD F powd gm daily);
SM FIBER POWDER F RX/OTC
POWD
Saline Laxatives
UNIFIBER POWD F magnesium hydroxide F
chew 311 mg
Laxative Combinations
MILK OF MAGNESIA F
COLYTE-FLAVOR PACKS CONCENTRATE SUSP
SOLR (Use PEG 3350- NF
KCl-Sod Bicarb-Sod PHILLIPS MILK OF
Chloride-Sod Sulfate) MAGNESIA CHEWABLE F
CHEW
GOLYTELY SOLR
227.1GM-21.5GM-5.53GM- F PHILLIPS MILK OF
2.82GM-6.36GM MAGNESIA F
CONCENTRATED SUSP
GOLYTELY SOLR 236GM-
22.74GM-5.86GM-2.97GM- PHILLIPS MILK OF F
6.74GM (Use PEG 3350- NF MAGNESIA SUSP
KCl-Sod Bicarb-Sod Stimulant Laxatives
Chloride-Sod Sulfate)
NULYTELY/FLAVOR bisacodyl supp F
PACKS SOLR (Use PEG
3350-Potassium Chloride- NF bisacodyl tbec F
Sod Bicarbonate-Sod DULCOLAX SUPP (Use
Chloride) NF
Bisacodyl)
58
DULCOLAX TBEC (Use NF azithromycin tabs or 600 F QL(10 ea per
Bisacodyl) mg 30 days retail)
EX-LAX TABS (Use NF ZITHROMAX PACK OR 1 NF QL(1 ea per 30
Sennosides) GM (Use Azithromycin) days retail)
FLEET BISACODYL ENEM F ZITHROMAX SUSR OR QL(45 ml per
100 MG/5ML, 200 MG/5ML NF 30 days retail)
sennosides tabs 15 mg F (Use Azithromycin)
ZITHROMAX TABS OR NF QL(6 ea per 30
Surfactant Laxatives 250 MG (Use Azithromycin) days retail)
COLACE CAPS (Use ZITHROMAX TABS OR NF QL(3 ea per 30
NF 500 MG (Use Azithromycin) days retail)
Docusate Sodium)
COLACE CLEAR CAPS ZITHROMAX TABS OR NF QL(10 ea per
NF 600 MG (Use Azithromycin) 30 days retail)
(Use Docusate Sodium)
ZITHROMAX TRI-PAK NF QL(3 ea per 30
docusate calcium caps F TABS (Use Azithromycin) days retail)
docusate sodium caps F ZITHROMAX Z-PAK TABS NF QL(6 ea per 30
(Use Azithromycin) days retail)
docusate sodium enem F ZMAX SUSR F QL(1 ea per 30
days retail)
docusate sodium liqd F Clarithromycin
BIAXIN SUSR 250 QL(150 ml per
docusate sodium syrp F MG/5ML (Use NF 30 days retail)
Clarithromycin)
docusate sodium tabs F
BIAXIN TABS 250 MG NF QL(28 ea per
DOCUSOL KIDS ENEM (Use Clarithromycin) 30 days retail)
NF
(Use Docusate Sodium)
BIAXIN TABS 500 MG F QL(28 ea per
DOCUSOL MINI ENEM F 30 days retail)
CLARITHROMYCIN SUSR F QL(150 ml per
DOCUSOL PLUS MINI- F 125 MG/5ML, 250 MG/5ML 30 days retail)
ENEMA ENEM clarithromycin susr 125 F QL(150 ml per
ENEMEEZ MINI ENEM F mg/5ml, 250 mg/5ml 30 days retail)
clarithromycin tabs 250 mg, F QL(28 ea per
ENEMEEZ PLUS ENEM F 500 mg 30 days retail)
MACROLIDES - Drugs to Treat Bacterial clarithromycin tb24 500 mg F QL(14 ea per
30 days retail)
Infections
Erythromycins
Azithromycin
QL(1 ea per 30 E.E.S. 400 TABS F
azithromycin pack or 1 gm F
days retail) E.E.S. GRANULES SUSR
azithromycin susr or 100 F QL(45 ml per (Use Erythromycin NF
mg/5ml, 200 mg/5ml 30 days retail) Ethylsuccinate)
azithromycin tabs or 250 F QL(6 ea per 30 ERY-TAB TBEC F
mg days retail)
azithromycin tabs or 500 QL(3 ea per 30 ERYPED 200 SUSR (Use
F Erythromycin NF
mg days retail)
Ethylsuccinate)
59
ERYPED 400 SUSR F FANTASY
LUBRICATED/SPERMICID F
ERYTHROCIN STEARATE E MISC
F
TABS FC FEMALE CONDOM F
erythromycin base cpep MISC
F
250 mg FC2 FEMALE CONDOM F
ERYTHROMYCIN BASE MISC
F
TABS 250 MG, 500 MG QL(1 ea per
FEMCAP DEVI F
erythromycin 365 days retail)
ethylsuccinate susr 200 F HIGH SENSATION
mg/5ml F
SPERMICIDAL DEVI
ERYTHROMYCIN INTENSE SENSATION
ETHYLSUCCINATE TABS F F
DEVI
400 MG KAMELEON LUBRICATED F
PCE TBEC F MISC
KIMONO COLORS DEVI F
MEDICAL DEVICES AND SUPPLIES
KIMONO LUBRICATED F
Contraceptives MISC
AIMSCO LUBRICATED F KIMONO MICRO THIN
MISC PLUS SPERMICIDE F
ATLAS COLORED LUBRICATED MISC
LUBRICATEDCONDOM F KIMONO PLUS
DEVI SPERMICIDE F
ATLAS LUBRICATED LUBRICATED MISC
F
CONDOM DEVI KIMONO PLUS
ATLAS LUBRICATED SPERMICIDE/LUBRICATE F
CONDOM/SPERMICIDE F D MISC
DEVI KIMONO PS LUBRICATED F
QL(1 ea per MISC
CAYA DPRH F
365 days retail) KIMONO PS PLUS
CLASS ACT LUBRICATED SPERMICIDE/LUBRICATE F
F D MISC
MISC
DUREX EXTRA KIMONO SENSATION F
F LUBRICATED MISC
SENSITIVE DEVI
ELEXA NATURAL FEEL KIMONO SENSATION
F PLUS SPERMICIDE F
MISC
ELEXA STIMULATING LUBRICATED MISC
F
MISC KIMONO SPECIAL DEVI F
ELEXA ULTRA SENSITIVE F
MISC LATEX CONDOMS F
EXTRA SENSITIVE F
SPERMICIDAL DEVI MAXX LUBRICATED MISC F
FANTASY LUBRICATED F MAXX PLUS SPERMICIDE
MISC F
LUBRICATED MISC
60
OMNIFLEX DIAPHRAGM F QL(1 ea per TROJAN-ENZ LUBRICANT F
DPRH 365 days retail) MISC
PREMIUM CONDOMS F TROJAN-ENZ F
LUBRICATED MISC LUBRICATED MISC
REALITY LATEX TROJAN-ENZ F
CONDOMS/LUBRICATED F W/SPERMICIDAL MISC
MISC TRUSTEX COLOR F
REALITY LATEX/ULTRA F CONDOMS + LUBE MISC
TEXTURED DEVI TRUSTEX LUBRICATED F
REALITY LATEX/ULTRA F EXTRALARGE MISC
THIN DEVI TRUSTEX LUBRICATED F
TROJAN EXTENDED EXTRASTRENGTH MISC
PLEASURE/LUBRICATED F TRUSTEX LUBRICATED
DEVI F
MISC
TROJAN MAGNUM MISC F TRUSTEX
LUBRICATED/RIBBED/ST F
TROJAN MAGNUM WARM F UDDED MISC
SENSATIONS DEVI TRUSTEX
TROJAN MAGNUM XL F LUBRICATED/SPERMICID F
LUBRICATED DEVI E EXTRA LARGE MISC
TROJAN PLEASURE TRUSTEX
MESH/SPERMICIDAL F LUBRICATED/SPERMICID
DEVI F
E EXTRA STRENGTH
TROJAN RIBBED MISC
F
W/SPERMICIDAL MISC TRUSTEX
TROJAN SHARED LUBRICATED/SPERMICID F
SENSATION/LUBRICATE F E MISC
D DEVI TRUSTEX NATURAL
TROJAN SUPRAS CONDOMS F
F +LUBE/LUBRICATED
SPERMICIDAL DEVI
TROJAN TWISTED MISC
F TRUSTEX WITH
PLEASURE DEVI
TROJAN ULTRA NONOXYNOL- F
PLEASURE/LUBRICATED F 9/RIBBED/STUDDED
DEVI MISC
TROJAN VERY TRUSTEX/RIA F
SENSITIVE LUBRICATED F LUBRICATED MISC
MISC TRUSTEX/RIA
TROJAN VERY LUBRICATED F
SENSITIVE SPERMICIDAL F SPERMICIDE MISC
LUBRICANT MISC TRUSTEX/RIA
TROJAN VERY THIN LUBRICATED/SPERMICID F
F E MISC
LUBRICATED MISC
TROJAN VERY THIN ULTIMATE FEELING DEVI F
SPERMICIDAL F
LUBRICANT MISC Diabetic Supplies
61
ASSURE COMFORT Available to FREESTYLE INSULINX QL(1 ea per
LANCETS ULTRA THIN F members in BLOODGLUCOSE F 365 days
28G MISC LTC/SNF only MONITORING SYSTEM retail); RX/OTC
ASSURE COMFORT Available to KIT
LANCETS ULTRA THIN F members in FREESTYLE LITE BLOOD QL(1 ea per
30G MISC LTC/SNF only GLUCOSE MONITORING F 365 days retail)
ASSURE HAEMOLANCE Available to SYSTEM DEVI
PLUS HIGH FLOW 18G F members in FREESTYLE PRECISION QL(1 ea per
MISC LTC/SNF only NEO BOOD GLUCOSE F 365 days
ASSURE HAEMOLANCE Available to MONITORING SYSTEM retail); RX/OTC
PLUS LOW FLOW 25G F members in KIT
MISC LTC/SNF only FREESTYLE SYSTEM KIT F QL(1 ea per
ASSURE HAEMOLANCE Available to KIT 365 days retail)
PLUS MICRO FLOW 28G F members in GOODSENSE
MISC LTC/SNF only UNIVERSAL 1 MICRO F
ASSURE HAEMOLANCE Available to THIN 33G MISC
PLUS NORMAL FLOW F members in GOODSENSE
21G MISC LTC/SNF only UNIVERSAL 1 MICRO- F
ASSURE HAEMOLANCE Available to THIN 33G MISC
PLUS PEDIATRIC BLADE F members in GOODSENSE
MISC LTC/SNF only UNIVERSAL 1THIN 26G F
Available to MISC
ASSURE LANCE F members in Available to
LANCETS 21G MISC HAEMOLANCE LOW
LTC/SNF only F members in
FLOW LANCETS MISC
Available to LTC/SNF only
ASSURE LANCE F members in Available to
LANCETS MISC HAEMOLANCE MISC members in
LTC/SNF only F
ASSURE LANCE PLUS Available to LTC/SNF only
SAFETYLANCETS 25G F members in Available to
HAEMOLANCE PLUS
MISC LTC/SNF only F members in
HIGH FLOW MISC
ASSURE LANCE PLUS Available to LTC/SNF only
SAFETYLANCETS 30G F members in Available to
HAEMOLANCE PLUS
MISC LTC/SNF only F members in
LOW FLOW MISC
DRUG MART UNILET LTC/SNF only
MICRO THIN LANCETS F Available to
HAEMOLANCE PLUS
33G MISC F members in
MAX FLOW MISC
FREESTYLE CONTROL LTC/SNF only
SOLUTION HIGH/LOW F Available to
LIQD HAEMOLANCE PLUS F members in
MISC
FREESTYLE CONTROL LTC/SNF only
F
SOLUTION LIQD Available to
HAEMOLANCE PLUS
FREESTYLE FLASH QL(1 ea per F members in
F PEDIATRIC FLOW MISC
SYSTEM KIT 365 days retail) LTC/SNF only
QL(1 ea per LANCETS AND LANCET F Use Preferred
FREESTYLE FREEDOM DEVICES Abbott
F 365 days
LITE KIT retail); RX/OTC PRECISION GLUCOSE F
CONTROL LIQD
62
PRECISION GLUCOSE INSULIN SYRINGES AND F
CONTROLSOLUTION PEN NEEDLES
(TRI- F
LEVEL/HI/LO/NORMAL) INSUPEN 33GX4MM MISC F
SOLN TECHLITE PEN NEEDLES
PRECISION GLUCOSE F
29GX 10MM MISC
KETONECONTROL F
SOLUTION 1-LOW, 1- Respiratory Therapy Supplies
HIGH LIQD QL(2 ea per
AIRZONE PEAK FLOW
PRECISION F 365 days
METER DEVI
GLUCOSE/KETONECONT retail); RX/OTC
F QL(2 ea per
ROL SOLUTIONS 1-HI 1- ASSESS FULL RANGE
LO LIQD F 365 days
PEAK FLOW METER DEVI
PRECISION XTRA DEVI QL(1 ea per retail); RX/OTC
F QL(2 ea per
XX 365 days retail) ASSESS LOW RANGE
QL(1 ea per F 365 days
PRECISION XTRA KIT XX F PEAK FLOW METER DEVI
365 days retail) retail); RX/OTC
ASSESS PEAK FLOW QL(2 ea per
Parenteral Therapy Supplies METER FULL RANGE F 365 days
ADVOCATE INSULIN PEN F DEVI retail); RX/OTC
NEEDLES MISC ASSESS PEAK FLOW QL(2 ea per
BD INSULIN SYRINGE/U- METER LOW RANGE F 365 days
500/0.5ML/31G X 15/64" F DEVI retail); RX/OTC
MISC QL(2 ea per
CLEVER CHOICE ASTHMA CHECK METER- F 365 days
COMFORT EZINSULIN ZONE SYSTEM DEVI
F retail); RX/OTC
PEN NEEDLES 33GX4MM QL(2 ea per
MISC ASTHMAMENTOR DEVI F 365 days
CLEVER CHOICE retail); RX/OTC
COMFORT EZPEN F QL(2 ea per
NEEDLES 33GX4MM LUNG PERFORMANCE F 365 days
MISC PEAK FLOW METER DEVI retail); RX/OTC
CLEVER CHOICE QL(2 ea per
COMFORT EZPEN MICROLIFE DIGITAL
F F 365 days
NEEDLES 33GX5MM PEAK FLOW METER DEVI retail); RX/OTC
MISC
MINI WRIGHT AFS PEAK QL(2 ea per
CLEVER CHOICE FLOWMETER LOW F 365 days
COMFORT EZPEN F RANGE DEVI retail); RX/OTC
NEEDLES 33GX6MM
MISC QL(2 ea per
MINI WRIGHT PEAK F 365 days
CLEVER CHOICE FLOW METER DEVI retail); RX/OTC
COMFORT EZPEN F
NEEDLES 33GX8MM PEAK AIR PEAK FLOW QL(2 ea per
MISC METERADULT/PEDIATRI F 365 days
C DEVI retail); RX/OTC
DROPLET PEN NEEDLES F
29GX10MM MISC QL(2 ea per
PERSONAL BEST FULL F 365 days
EXCEL COMFORT POINT RANGE DEVI retail); RX/OTC
INSULIN PEN NEEDLES F
31G X 4MM MISC
63
QL(2 ea per IMITREX STATDOSE Limit 2 per 7
PERSONAL BEST LOW F 365 days REFILL SOCT 4 MG/0.5ML NF days;QL(0.29
RANGE DEVI retail); RX/OTC (Use Sumatriptan ml daily,7
QL(2 ea per Succinate) day(s) limit)
PIKO 1 ELECTRONIC F 365 days IMITREX STATDOSE QL(2 ml per 7
DEVI REFILL SOCT 6 MG/0.5ML NF days retail)
retail); RX/OTC
QL(2 ea per (Use Sumatriptan
POCKET PEAK FLOW F 365 days Succinate)
METER DEVI IMITREX STATDOSE Limit 2 per 7
retail); RX/OTC
POCKETPEAK PEAK QL(2 ea per SYSTEM SOAJ 4 NF days;QL(0.29
FLOW METER LOW F 365 days MG/0.5ML (Use ml daily,7
RANGE DEVI retail); RX/OTC Sumatriptan Succinate) day(s) limit)
POCKETPEAK PEAK QL(2 ea per IMITREX STATDOSE QL(2 ml per 7
FLOW SYSTEM SOAJ 6 NF days retail)
F 365 days MG/0.5ML (Use
METER/UNIVERSAL retail); RX/OTC
RANGE 50-720 LPM DEVI Sumatriptan Succinate)
QL(2 ea per IMITREX TABS OR 25 MG, QL(9 ea per fill
SPACER/AEROSOL- 50 MG, 100 MG (Use NF retail)
F 365 days
HOLDING CHAMBERS Sumatriptan Succinate)
retail); RX/OTC
QL(2 ea per Limit 9 per
TRUZONE PEAK FLOW naratriptan hcl tabs F month;QL(0.3
F 365 days
METER DEVI ea daily)
retail); RX/OTC
Limit 2 per 7
MIGRAINE PRODUCTS - Drugs to Treat Migraine sumatriptan succinate soaj
Headaches F days;QL(0.29
sc 4 mg/0.5ml ml daily,7
Migraine Combinations day(s) limit)
CAFERGOT TABS (Use sumatriptan succinate soaj F QL(2 ml per 7
NF sc 6 mg/0.5ml days retail)
Ergotamine w/ Caffeine)
ergotamine w/ caffeine tabs F Limit 2 per 7
sumatriptan succinate soct F days;QL(0.29
MIGERGOT SUPP F
sc 4 mg/0.5ml ml daily,7
day(s) limit)
Migraine Products sumatriptan succinate soct F QL(2 ml per 7
sc 6 mg/0.5ml days retail)
ERGOMAR SUBL F sumatriptan succinate soln F QL(2 ml per 7
Serotonin Agonists sc 6 mg/0.5ml days retail)
QL(6 ea per 30 SUMATRIPTAN QL(2 ml per 7
almotriptan malate tabs F
days retail) SUCCINATE SOSY SC 6 F days retail)
MG/0.5ML
AMERGE TABS (Use Limit 9 per
NF month;QL(0.3 sumatriptan succinate tabs F QL(9 ea per fill
Naratriptan HCl) ea daily) or 25 mg, 50 mg, 100 mg retail)
AXERT TABS (Use NF QL(6 ea per 30 MINERALS & ELECTROLYTES
Almotriptan Malate) days retail)
IMITREX SOLN SC 6 QL(2 ml per 7 Calcium
MG/0.5ML (Use NF days retail) CALCI-CHEW CHEW F
Sumatriptan Succinate)
64
calcium carbonate tabs RA OYSTER SHELL
600mg, 500 mg, 600 mg, F CALCIUM/VITAMIN D F
1250 mg TABS
calcium carbonate- RISACAL-D TABS F
cholecalciferol caps F
600mg-500unit Electrolyte Mixtures
calcium carbonate-
cholecalciferol chew CERASPORT EX1 SOLN F
F
500mg-100unit, 500mg- CERASPORT SOLN
400unit 4MEQ/L-18MEQ/L- F
calcium carbonate- 20MEQ/L-6MEQ/L
cholecalciferol tabs 500mg- F DEXTROSE 10%/NACL PA
200unit, 500mg-600unit F
0.45% SOLN
calcium carbonate- F DEXTROSE PA
ergocalciferol tabs 5%/ELECTROLYTE #48 F
calcium carbonate-vitamin VIAFLEX SOLN
d tabs 125unit-250mg, DEXTROSE 10%/NACL PA
125unit-500mg, 200unit- F
0.2% SOLN
500mg, 250mg-125unit, F
400unit-600mg, 500mg- DEXTROSE 10%/NACL F PA
125unit, 500mg-200unit, 0.225% SOLN
600mg-400unit, 500mg- DEXTROSE 2.5%/NACL F PA
500mg-200unit-200unit 0.45% SOLN
CALCIUM CITRATE DEXTROSE 5%/NACL F PA
F 0.225% SOLN
MALATE/VITAMIN D TABS
calcium citrate tabs 200 DEXTROSE 5%/NACL F PA
F 0.3% SOLN
mg, 950 mg
calcium citrate-vitamin d dextrose w/ sodium F PA
tabs 250mg-200unit, F chloride soln
315mg-200unit ENFAMIL ENFALYTE F
CALCIUM GLUCONATE SOLN
F
TABS OR 500 MG IONOSOL-B/DEXTROSE PA
F
CALCIUM LACTATE TABS 5% SOLN
F
648 MG, 750 MG IONOSOL-MB/DEXTROSE PA
F
CALCIUM TABS 600MG- 5% SOLN
F
200UNIT ISOLYTE-P/DEXTROSE PA
F
calcium w/ vitamin d tabs F 5% SOLN
ISOLYTE-S PH 7.4 SOLN F PA
CALCIUM/VITAMIN D F
CAPS PA
ISOLYTE-S SOLN F
EQL CALCIUM/VITAMIN D F
CAPS KCL 0.15%/D5W/NACL PA
F
0.225% SOLN
oyster shell tabs F
KCL 0.3%/D5W/NACL F PA
PARVA-CAL TABS F 0.9% SOLN
lactated ringer's soln F PA
RA CALCIUM HI- F
CAL/VITAMIND TABS
65
NORMOSOL -R SOLN F PA POTASSIUM PA
CHLORIDE/SODIUMCHLO F
NORMOSOL-M IN D5W PA RIDE SOLN
F
SOLN
ringer's soln F PA
NORMOSOL-R SOLN F PA
Fluoride
oral electrolytes soln F FLURA-DROPS SOLN F
PEDIALYTE FREEZER
POPS SOLN (Use Oral NF LOZI-FLUR LOZG F
Electrolytes) Limit 50 per
PEDIALYTE SOLN LURIDE SOLN (Use NF month;QL(1.67
20MEQ/L-45MEQ/L- Sodium Fluoride) ml daily)
35MEQ/L-5GM/L-20GM/L,
20MEQ/L-45MEQ/L- NF MONOCAL TABS F
35MEQ/L-30MEQ/L-
25GM/L (Use Oral sodium fluoride chew 0.25
Electrolytes) mg, 0.5 mg, 1 mg, 1.1 mg, F
2.2 mg
PLASMA-LYTE A SOLN F PA
sodium fluoride soln 0.125 F
PA mg/drop
PLASMA-LYTE-148 SOLN F Limit 50 per
sodium fluoride soln 0.5 F month;QL(1.67
PLASMA-LYTE-56/D5W F PA mg/ml
SOLN ml daily)
POTASSIUM CHLORIDE PA SODIUM FLUORIDE TABS F
/SODIUM CHLORIDE F 0.5 MG, 1 MG
SOLN Iodine Products
potassium chloride in PA POTASSIUM IODIDE
dextrose & sodium chloride F F
TABS 32.5 MG
soln
potassium chloride in PA SSKI SOLN F
F
dextrose soln
Magnesium
potassium chloride in nacl F PA
soln MAG64 TBCR F
POTASSIUM PA
CHLORIDE/DEXTROSE F MAGDELAY TBEC F
SOLN
Phosphate
POTASSIUM PA
CHLORIDE/DEXTROSE/L K-PHOS NEUTRAL TABS
F (Use Pot Phosphate
ACTATED RINGERS
SOLN Monobasic w/ Sod NF
Phosphate Dibasic &
POTASSIUM PA Monobasic)
CHLORIDE/LIDOCAINE F
HYDROCHLORIDE/SODIU K-PHOS TABS F
M CHLORIDE SOLN
pot phosphate monobasic
POTASSIUM PA w/ sod phosphate dibasic & F
CHLORIDE/SODIUM F monobasic tabs
CHLORIDE SOLN
66
Potassium XIAFLEX SOLR F PA
K-TAB TBCR 10 MEQ (Use NF
Potassium Chloride) Immunosuppressive Agents
AL; At least 21
K-TAB TBCR 8 MEQ F AZASAN TABS F
yrs old
MICRO-K CPCR 10 MEQ AL; At least 21
(Use Potassium Chloride)
NF azathioprine tabs or 50 mg F
yrs old
potassium bicarb & F CELLCEPT CAPS (Use NF AL; At least 21
chloride tbef Mycophenolate Mofetil) yrs old
potassium bicarbonate tbef F CELLCEPT SUSR (Use NF AL; At least 21
Mycophenolate Mofetil) yrs old
potassium chloride cpcr or F CELLCEPT TABS (Use AL; At least 21
10 meq NF
Mycophenolate Mofetil) yrs old
POTASSIUM CHLORIDE F cyclosporine caps or 25 AL; At least 21
ER TBCR 8 MEQ F
mg, 100 mg yrs old
potassium chloride cyclosporine modified (for AL; At least 21
microencapsulated crystals F F
microemulsion) caps yrs old
er tbcr cyclosporine modified (for AL; At least 21
potassium chloride pack or F
F microemulsion) soln yrs old
20 meq CYCLOSPORINE AL; At least 21
potassium chloride soln iv PA MODIFIED CAPS (Use yrs old
0.4 meq/ml, 2 meq/ml, 20 NF
Cyclosporine Modified (For
meq/50ml, 10 meq/100ml, F Microemulsion))
20 meq/100ml, 40 IMURAN TABS (Use
meq/100ml NF AL; At least 21
Azathioprine) yrs old
POTASSIUM CHLORIDE PA mycophenolate mofetil
SOLN IV 10 MEQ/50ML
F F AL; At least 21
caps yrs old
potassium chloride soln or
10 %, 20 % F mycophenolate mofetil susr F AL; At least 21
yrs old
POTASSIUM CHLORIDE
SOLN OR 20 %
F mycophenolate mofetil tabs F AL; At least 21
yrs old
potassium chloride tbcr or mycophenolate sodium
8 meq, 10 meq F F AL; At least 21
tbec yrs old
Sodium MYFORTIC TBEC (Use NF AL; At least 21
sodium chloride soln ij 0.9 PA Mycophenolate Sodium) yrs old
F
%, 2.5 meq/ml NEORAL CAPS (Use AL; At least 21
sodium chloride soln iv PA Cyclosporine Modified (For NF yrs old
0.45 %, 0.9 %, 3 %, 5 %, 4 F Microemulsion))
meq/ml NEORAL SOLN (Use AL; At least 21
Cyclosporine Modified (For NF yrs old
MISCELLANEOUS THERAPEUTIC CLASSES Microemulsion))
Chelating Agents PROGRAF CAPS OR 0.5 AL; At least 21
MG, 1 MG, 5 MG (Use NF yrs old
DEPEN TITRATABS TABS F Tacrolimus)
Enzymes RAPAMUNE SOLN 1 F AL; At least 21
MG/ML yrs old
67
RAPAMUNE TABS 0.5 AL; At least 21 SALAGEN TABS (Use NF
MG, 1 MG, 2 MG (Use NF yrs old Pilocarpine HCl (Oral))
Sirolimus)
SANDIMMUNE CAPS OR AL; At least 21 MULTIVITAMINS
25 MG, 100 MG (Use NF yrs old B-Complex w/ Folic Acid
Cyclosporine)
b-complex w/ c & folic acid RX/OTC
SANDIMMUNE SOLN OR F AL; At least 21 caps 1.5mg-5mg-20mg-
100 MG/ML yrs old 1.7mg-6mcg-1mg-150mcg-
AL; At least 21 F
sirolimus tabs F 10mg-100mg, 5mg-1.7mg-
yrs old 6mcg-20mg-1.5mg-1mg-
AL; At least 21 150mcg-10mg-100mg
tacrolimus caps F
yrs old Ped MV w/ Fluoride
AL; At least 21 AL; Up to 5 yrs
ZORTRESS TABS F FLORIVA PLUS SOLN F
yrs old old
Potassium Removing Agents MULTIVITAMIN/FLUORID AL; Up to 5 yrs
F
KAYEXALATE POWD (Use E CHEW old
Sodium Polystyrene NF pediatric multivitamins w/fl AL; Up to 5 yrs
Sulfonate) F
chew old
sodium polystyrene F pediatric multivitamins w/fl AL; Up to 5 yrs
sulfonate powd F
soln old
sodium polystyrene F pediatric vitamins acd w/ AL; Up to 5 yrs
sulfonate susp F
fluoride soln old
Systemic Lupus Erythematosus Agents POLY-VI-FLOR CHEW AL; Up to 5 yrs
BENLYSTA SOLR IV 120 200MCG-1MG-15UNIT- old
F PA; SP- 400UNIT, 200MCG-0.5MG-
MG, 400 MG AcariaHealth F
15UNIT-400UNIT,
MOUTH/THROAT/DENTAL AGENTS 200MCG-0.25MG-15UNIT-
400UNIT
Anesthetics Topical Oral QUFLORA PEDIATRIC AL; Up to 5 yrs
F
FIRST-MOUTHWASH BLM CHEW old
F
SUSP QUFLORA PEDIATRIC AL; Up to 5 yrs
F
lidocaine hcl (mouth-throat) SOLN old
F
soln Ped MV w/ Iron
Anti-infectives - Throat pediatric multiple vitamins AL; Up to 5 yrs
clotrimazole lozg F w/ iron soln 0.6mg/ml- old
10mg/ml-5unit/ml-8mg/ml- F
1500unit/ml-400unit/ml-
clotrimazole troc F 0.5mg/ml-0.4mg/ml-
nystatin (mouth-throat) 35mg/ml
F
susp Ped Multi Vitamins w/Fl & FE
Steroids - Mouth/Throat ped multivitamins w/fl & AL; Up to 5 yrs
F
triamcinolone acetonide iron soln old
F
(mouth) pste POLY-VI-FLOR/IRON AL; Up to 5 yrs
Throat Products - Misc. CHEW 200MCG-0.5MG- F old
10MG-15UNIT-400UNIT
pilocarpine hcl (oral) tabs F
68
TRI-VIT/FLUORIDE/IRON F AL; Up to 5 yrs ENFAMIL EXPECTA MISC F
SOLN old
Pediatric Multiple Vitamins EQL PRENATAL F
FORMULA TABS
pediatric multiple vitamin w/ F AL; Up to 5 yrs
c soln old EZFE FORTE CAPS F
Pediatric Vitamins GNP DAILY PRENATAL F
BPROTECTED PEDIA AL; Up to 5 yrs MISC
F
TRI-VITE SOLN old
GNP PRENATAL TABS F
AL; Up to 5 yrs
pediatric vitamins adc soln F
old GOODSENSE PRENATAL F
AL; Up to 5 yrs VITAMINS TABS
TRI-VI-SOL SOLN F
old HEALTHY MAMA BE F
WELL ROUNDED THPK
Prenatal Vitamins
HM ONE DAILY F
ALIVE PRENATAL MULTI- PRENATAL COMBO MISC
VITAMIN/PLANT DHA F
CHEW HM PRENATAL TABS F
ATABEX EC TBEC F
INATAL ADVANCE TABS F
ATABEX PRENATAL F
CHEW INATAL GT TABS F
BRAINSTRONG F
PRENATAL MISC INATAL ULTRA TABS F
CALNA TABS F KP PRENATAL F
MULTIVITAMINS TABS
CENTRUM SPECIALIST F
PRENATAL MISC KPN PRENATAL TABS F
CLASSIC PRENATAL F RX/OTC
TABS M-VIT TABS F
CLINICAL NUTRIENTS MARNATAL-F CAPS F
PRENATAL FORMULA F
TABS MULTI PRENATAL TABS F
CO-NATAL FA TABS F MYNATAL ADVANCE F
COMPLETE NATAL DHA TABS
F
MISC MYNATAL CAPS F
COMPLETENATE CHEW F
MYNATAL PLUS TABS F
CVS PRENATAL
GUMMY/DHA/FOLIC ACID F MYNATAL ULTRACAPLET F
CHEW TABS
CVS PRENATAL F MYNATAL-Z TABS F
MULTI+DHA CAPS
CVS PRENATAL TABS F MYNATE 90 PLUS TBCR F
CVS WOMENS NAT-RUL PRENATAL F
F VITAMINS TABS
PRENATAL+DHA MISC
69
NATALVIT TABS F PRENATAL 19 TABS F
NIVA-PLUS TABS F RX/OTC PRENATAL ADULT

GUMMY/DHA/FOLIC ACID F
NUTRICION PORVIDA CHEW
F
TABS PRENATAL AND IRON F
O-CAL FA TABS F RX/OTC TABS
PRENATAL COMPLETE F
O-CAL PRENATAL TABS F TABS
PRENATAL FORMULA A- F
OBSTETRIX EC TABS F RX/OTC FREE TABS
PRENATAL FORMULA F
OBTREX TABS F RX/OTC CAPS
ONE A DAY WOMENS PRENATAL FORMULA F
F TABS
PRENATAL/DHA MISC
ONE A DAY WOMENS F PRENATAL FORTE TABS F
PRENATAL1 CAPS
PRENATAL
ONE-A-DAY WOMENS F GUMMIES/DHA & FOLIC F
PRENATAL MISC ACID CHEW
PA PRENATAL FORMULA F PRENATAL LOW IRON
TABS F
TABS
PERRY PRENATAL CAPS F PRENATAL MULTI + DHA F
CAPS
PNV FERROUS
FUMARATE/DOCUSATE/F F PRENATAL MULTI +DHA F
OLIC ACID TABS CAPS
PNV FOLIC ACID + IRON RX/OTC PRENATAL
F MULTIVITAMIN + DHA F
MULTIVITAMIN TABS
MISC
PNV PRENATAL PLUS
MULTIVITAMIN + DHA F PRENATAL
MISC MULTIVITAMIN PLUS F
DHA CAPS
PNV PRENATAL PLUS F RX/OTC
MULTIVITAMIN TABS PRENATAL
MULTIVITAMIN PLUS F
PNV TABS 29-1 TABS F DHA MISC
PRENATAL F
PNV-VP-U CAPS F MULTIVITAMIN TABS
PRE-NATAL FORMULA PRENATAL ONE DAILY F
F TABS
TABS
PRENATAL PLUS DHA F
PRENATA CHEW F TABS
PRENATABS FA TABS F PRENATAL PLUS IRON F
TABS
PRENATABS RX TABS F PRENATAL PLUS TABS F RX/OTC
PRENATAL 19 CHEW F
70
PRENATAL TABS 11UNIT- PRENATAL VITAMIN & F
263MG-25MG-1.5MG- MINERAL TABS
27MG-4000UNIT-18MG- PRENATAL VITAMIN
1.7MG-4MCG-400UNIT- F
TABS
0.8MG-2.6MG-100MG,
30UNIT-4000UNIT-25MG- PRENATAL F
1.8MG-200MG-28MG- VITAMIN/IRON TABS
20MG-1.7MG-8MCG- PRENATAL VITAMINS F RX/OTC
400UNIT-0.8MG-2.6MG- PLUS LOW IRON TABS
120MG, 30UNIT-25MG- PRENATAL VITAMINS
1.8MG-200MG-28MG- F
TABS
20MG-1.7MG-4000UNIT-
8MCG-400UNIT-800MCG- PRENATAL+DHA MISC F
2.6MG-120MG, 30UNIT-
4000UNIT-25MG-1.8MG- PRENATAL-U CAPS F
200MG-28MG-20MG-
1.7MG-8MCG-400UNIT- PRENATAL/OMEGA- F
800MCG-2.6MG-120MG, 3/FOLIC ACID/IRON CAPS
4000UNIT-30UNIT- PREPLUS TABS F RX/OTC
F
200MG-25MG-1.8MG-
28MG-20MG-1.7MG- PRETAB TABS F
8MCG-400UNIT-800MCG-
2.6MG-120MG, 4000UNIT- PROFE FORTE CAPS F
30UNIT-25MG-1.8MG-
200MG-28MG-20MG- PUREFE OB PLUS CAPS F
1.7MG-8MCG-400UNIT-
800MCG-2.6MG-120MG, PX PRENATAL
160MG-11UNIT-200MG- F
MULTIVITAMINS TABS
25MG-1.84MG-27MG-
4000UNIT-18MG-1.7MG- QC PRENATAL TABS F
4MCG-400UNIT-800MCG-
2.6MG-100MG, 3.75UNIT- RA ONE DAILY MISC F
0.5MG-50MG-0.5MG-
25MG-15MG-3.75MG- RA PRENATAL
6.75MG-2.5MG-5MG- FORMULA/FOLICACID F
0.75MG-500UNIT- TABS
2.5MCG-0.5MG-200MCG- RA PRENATAL TABS F
25MCG-0.75MG-100UNIT
PRENATAL TABS 22MG- RX/OTC RIGHT STEP PRENATAL F
2MG-25MG-1.84MG- TABS
200MG-27MG-4000UNIT- F SE-NATAL 19 CHEW F
20MG-3MG-12MCG-
400UNIT-1MG-10MG- SE-NATAL 19 TABS F
120MG
PRENATAL TABS SIMILAC PRENATAL F
4000UNIT-200MG- EARLY SHIELD MISC
11UNIT-27MG-25MG- F SM ONE DAILY
1.84MG-18MG-1.7MG- F
PRENATAL MISC
4MCG-400UNIT-0.8MG- SM PRENATAL VITAMINS
2.6MG-100MG F
TABS
71
STUART ONE CAPS F YOUR LIFE MULTI F
PRENATAL CAPS
TARON-BC MISC F MUSCULOSKELETAL THERAPY AGENTS -
Drugs to Treat Spasms
THERANATAL F
COMPLETE MISC Central Muscle Relaxants
THERANATAL CORE F RX/OTC baclofen tabs F
NUTRITION TABS
THRIVITE 19 TABS F carisoprodol tabs 350 mg F
THRIVITE RX TABS F cyclobenzaprine hcl tabs F

FEXMID TABS (Use NF
TL FOLATE TABS F Cyclobenzaprine HCl)
methocarbamol tabs or 500 F
TRIADVANCE TABS F mg, 750 mg
TRICARE TABS F RX/OTC ROBAXIN TABS OR 500 NF
MG (Use Methocarbamol)
TRINATAL GT TABS F ROBAXIN-750 TABS (Use NF
Methocarbamol)
TRINATAL RX 1 TABS F SOMA TABS 350 MG (Use NF
Carisoprodol)
TRINATE TABS F tizanidine hcl tabs 2 mg, 4 F
mg
VINATE II TABS F ZANAFLEX TABS 4 MG NF
(Use Tizanidine HCl)
VINATE M TABS F
Direct Muscle Relaxants
VINATE ONE TABS F DANTRIUM CAPS (Use NF
Dantrolene Sodium)
VIRT NATE TABS F dantrolene sodium caps or F
25 mg, 50 mg, 100 mg
VIRT-ADVANCE TABS F
NASAL AGENTS - SYSTEMIC AND TOPICAL -
VIRT-VITE GT TABS F Drugs to treat the Nose or Sinus
Nasal Agents - Misc.
VITA-PREN TABS F OCEAN NASAL SPRAY NF
SOLN (Use Saline)
VITAFOL-OB TABS F saline soln na 0.65%- F
0.002%, 0.65 %, 0.65%
VOL-NATE TABS F
Nasal Antiallergy
VOL-PLUS TABS F RX/OTC ASTEPRO SOLN (Use NF QL(2 ml daily)
Azelastine HCl)
VOL-TAB RX TABS F
azelastine hcl soln F QL(2 ml daily)
WEGMANS COMPLETE F
PRENATAL+DHA MISC Nasal Anticholinergics
72
ATROVENT SOLN (Use SUDAFED NASAL
Ipratropium Bromide NF DECONGESTANT
(Nasal)) MAXIMUM STRENGTH NF
ipratropium bromide (nasal) TABS (Use
F Pseudoephedrine HCl)
soln
SUDAFED PE
Nasal Steroids CHILDRENS NASAL F
budesonide (nasal) susp F RX/OTC DECONGESTANT SOLN
Limit 2 inhalers NEUROMUSCULAR AGENTS - Drugs to
FLONASE ALLERGY Relax/Paralyze Muscles
RELIEF CHILDRENS per
NF month;QL(1.07 ALS Agents
SUSP (Use Fluticasone
ml daily); PA
Propionate (Nasal)) RX/OTC RADICAVA SOLN F
Limit 2 inhalers RILUTEK TABS (Use
FLONASE ALLERGY per NF
RELIEF SUSP (Use Riluzole)
NF month;QL(1.07
Fluticasone Propionate ml daily); riluzole tabs F
(Nasal)) RX/OTC
Limit 2 inhalers Neuromuscular Blocking Agent - Neurotoxins
FLUNISOLIDE SOLN F per BOTOX SOLR F PA; SP-
month;QL(1.67 AcariaHealth
ml daily)
DYSPORT SOLR F PA; SP-
Limit 2 inhalers AcariaHealth
per
fluticasone propionate F month;QL(1.07 MYOBLOC SOLN F PA; SP-
(nasal) susp AcariaHealth
ml daily);
RX/OTC XEOMIN SOLR F PA; SP-
AcariaHealth
RHINOCORT AQUA SUSP NF RX/OTC
(Use Budesonide (Nasal)) NUTRIENTS
Sympathomimetic Decongestants Carbohydrates
NASAL DECONGESTANT F PA
LIQD DEXTROSE 20% SOLN F
NASAL DECONGESTANT F DEXTROSE 25% SOLN F PA
SYRP
pseudoephedrine hcl liqd DEXTROSE 30% SOLN F PA
F
15 mg/5ml
pseudoephedrine hcl tabs DEXTROSE 40% SOLN F PA
F
30 mg, 60 mg
dextrose soln F PA
SUDAFED CHILDRENS
LIQD (Use NF
Pseudoephedrine HCl) Lipids
SUDAFED CONGESTION fat emulsion emul F PA
TABS (Use NF
Pseudoephedrine HCl) INTRALIPID EMUL F PA
Misc. Nutritional Substances
73
ATABEX DHA CAPS F AMINOSYN II SOLN PA
31.3MEQ/L-
docosahexaenoic acid F 505MG/100ML-
caps 200 mg 517MG/100ML-
713MG/100ML-
Protein-Carbohydrate-Lipid Combinations 462MG/100ML-
KABIVEN EMUL F PA 140MG/100ML-
280MG/100ML-
PERIKABIVEN EMUL F PA 350MG/100ML-
50.3MEQ/L-
total parenteral nutrition F PA 210MG/100ML-
209MG/100ML-
Proteins 120MG/100ML-
700MG/100ML-
amino acid infusion soln F PA 189MG/100ML-
735MG/100ML-
490MG/100ML-
371MG/100ML-
695MG/100ML-
350MG/100ML,
33.3MEQ/L-
614MG/100ML-
627MG/100ML-
865MG/100ML-
561MG/100ML-
170MG/100ML- F
340MG/100ML-
425MG/100ML-
61.1MEQ/L-
255MG/100ML-
253MG/100ML-
146MG/100ML-
850MG/100ML-
230MG/100ML-
893MG/100ML-
595MG/100ML-
450MG/100ML-
844MG/100ML-
425MG/100ML, 38MEQ/L-
722MG/100ML-
738MG/100ML-
1018MG/100ML-
660MG/100ML-
200MG/100ML-
400MG/100ML-
500MG/100ML-
71.8MEQ/L-
300MG/100ML-
298MG/100ML-
172MG/100ML-
1000MG/100ML-
270MG/100ML-
74
1050MG/100ML- CLINIMIX 5%/DEXTROSE F PA
700MG/100ML- 15% SOLN
530MG/100ML- CLINIMIX 5%/DEXTROSE PA
993MG/100ML- F
20% SOLN
500MG/100ML,
45.3MEQ/L- CLINIMIX 5%/DEXTROSE F PA
722MG/100ML- 25% SOLN
738MG/100ML- CLINIMIX E PA
1018MG/100ML- 2.75%/DEXTROSE 10% F
660MG/100ML- SOLN
400MG/100ML- 2.75%/DEXTROSE 5% F
500MG/100ML- SOLN
71.8MEQ/L- CLINIMIX E PA
300MG/100ML- 4.25%/DEXTROSE 10% F
298MG/100ML- SOLN
172MG/100ML-
270MG/100ML- 4.25%/DEXTROSE 5% F
1050MG/100ML- SOLN
700MG/100ML- CLINIMIX N9G20E SOLN F PA
530MG/100ML-
993MG/100ML- FREAMINE HBC 6.9% F PA
500MG/100ML SOLN
AMINOSYN SOLN F PA FREAMINE III SOLN F PA
AMINOSYN-HBC SOLN F PA HEPATAMINE SOLN F PA
AMINOSYN-PF 7% SOLN F PA NEPHRAMINE SOLN F PA
AMINOSYN-PF SOLN F PA PREMASOL SOLN F PA
AMINOSYN-RF SOLN F PA PROSOL SOLN F PA
CLINIMIX PA SYNTHAMIN 17 SOLN F PA

2.75%/DEXTROSE 5% F
SOLN TRAVASOL SOLN F PA
CLINIMIX PA
4.25%/DEXTROSE 10% F
SOLN
CLINIMIX PA
SOLN
CLINIMIX PA
SOLN
CLINIMIX PA
4.25%/DEXTROSE 5% F
SOLN
75
TROPHAMINE SOLN PA timolol maleate (ophth) soln F
1.2GM/100ML-5MEQ/L-
0.5GM/100ML- TIMOLOL MALEATE
0.68GM/100ML- OPHTHALMIC GEL F
0.025GM/100ML- FORMING SOLG
1.2GM/100ML- TIMOPTIC OCUDOSE
0.82GM/100ML- F
SOLN
0.2GM/100ML-
0.42GM/100ML- TIMOPTIC SOLN (Use NF
0.78GM/100ML-97MEQ/L- F Timolol Maleate (Ophth))
0.48GM/100ML- TIMOPTIC-XE SOLG 0.25
0.48GM/100ML- % (Use Timolol Maleate NF
0.34GM/100ML- (Ophth))
1.4GM/100ML- TIMOPTIC-XE SOLG 0.25
0.24GM/100ML- F
%, 0.5 %
0.32GM/100ML-
0.38GM/100ML- Cycloplegic Mydriatics
0.54GM/100ML- ATROPINE SULFATE F
0.36GM/100ML OINT OP 1 %
ATROPINE SULFATE F
OPHTHALMIC AGENTS - Drugs to Treat the Eye SOLN OP 1 %
Artificial Tears and Lubricants CYCLOGYL SOLN (Use NF
Cyclopentolate HCl)
NUTRATEAR SOLN F
CYCLOMYDRIL SOLN F
polyvinyl alcohol soln F
cyclopentolate hcl soln F
Beta-blockers - Ophthalmic
BETAGAN SOLN (Use homatropine hbr soln F
NF
Levobunolol HCl) MYDRIACYL SOLN (Use NF
betaxolol hcl (ophth) soln F Tropicamide)
tropicamide soln F
BETOPTIC-S SUSP F
COSOPT SOLN (Use Miotics
Dorzolamide HCl-Timolol NF ISOPTO CARPINE SOLN NF
Maleate) (Use Pilocarpine HCl)
dorzolamide hcl-timolol PHOSPHOLINE IODIDE F
F SOLR
maleate soln
ISTALOL SOLN F pilocarpine hcl soln F
ISTALOL SOLN (Use NF Ophthalmic - Angiogenesis Inhibitors
Timolol Maleate (Ophth))
LUCENTIS SOLN F PA; SP-
levobunolol hcl soln F AcariaHealth
LUCENTIS SOSY F PA; SP-
METIPRANOLOL SOLN F AcariaHealth
timolol maleate (ophth) Ophthalmic Adrenergic Agents
F
solg ALPHAGAN P SOLN 0.1 % F
76
ALPHAGAN P SOLN 0.15 ofloxacin (ophth) soln F
% (Use Brimonidine NF
Tartrate) polymyxin b-trimethoprim F
soln
apraclonidine hcl soln F
POLYTRIM SOLN (Use NF
brimonidine tartrate soln F Polymyxin B-Trimethoprim)
sulfacetamide sodium F
IOPIDINE SOLN 0.5 % NF (ophth) soln
(Use Apraclonidine HCl) SULFACETAMIDE F
IOPIDINE SOLN 1 % F SODIUM OINT OP
Ophthalmic Anti-infectives tobramycin (ophth) soln F

BACITRACIN OINT OP F TOBREX OINT F
500 UNIT/GM
bacitracin-polymyxin b TOBREX SOLN (Use NF
F Tobramycin (Ophth))
(ophth) oint
BLEPH-10 SOLN (Use trifluridine soln F
Sulfacetamide Sodium NF
(Ophth)) VIROPTIC SOLN (Use NF
Trifluridine)
CILOXAN OINT F ZYMAXID SOLN (Use NF
CILOXAN SOLN (Use Gatifloxacin (Ophth))
NF
Ciprofloxacin HCl (Ophth)) Ophthalmic Decongestants
ciprofloxacin hcl (ophth) F NAPHAZOLINE HCL
soln F
SOLN
erythromycin (ophth) oint F naphazoline w/
pheniramine soln 0.025%- F
gatifloxacin (ophth) soln F 0.3%
NAPHCON-A SOLN (Use
GENTAK OINT F Naphazoline w/ NF
Pheniramine)
gentamicin sulfate (ophth) F
oint phenylephrine hcl (ophth) F
soln 2.5 %
gentamicin sulfate (ophth) F
soln Ophthalmic Immunomodulators
RESTASIS EMUL F PA
NATACYN SUSP F
neomycin-bacitracin zn- RESTASIS MULTIDOSE F PA
F EMUL
polymyxin oint
neomycin-polymyxin- F Ophthalmic Local Anesthetics
gramicidin soln ALCAINE SOLN (Use
NEOSPORIN SOLN (Use NF
Proparacaine HCl)
Neomycin-Polymyxin- NF
Gramicidin) proparacaine hcl soln F
OCUFLOX SOLN (Use
Ofloxacin (Ophth)) NF tetracaine hcl (ophth) soln F
Ophthalmic Steroids
77
bacitracin-poly-neomycin- F PREDNISOLONE SODIUM
hc oint PHOSPHATE SOLN OP 1 F
BLEPHAMIDE S.O.P. %
F
OINT sulfacetamide sod- F
prednisolone soln
BLEPHAMIDE SUSP F
TOBRADEX SUSP (Use
DEXAMETHASONE Tobramycin- NF
SODIUM PHOSPHATE F Dexamethasone)
SOLN OP 0.1 % tobramycin- F
fluorometholone (ophth) dexamethasone susp
F
susp Ophthalmics - Misc.
FML FORTE SUSP F ACULAR LS SOLN (Use
Ketorolac Tromethamine NF
FML LIQUIFILM SUSP (Ophth))
(Use Fluorometholone NF
(Ophth)) ACULAR SOLN (Use
Ketorolac Tromethamine NF
FML OINT F (Ophth))
MAXIDEX SUSP F azelastine hcl (ophth) soln F
MAXITROL OINT (Use bromfenac sodium (ophth) F

Neomycin-Polymy- NF soln
Dexameth) BROMFENAC SOLN F
MAXITROL SUSP (Use
Neomycin-Polymy- NF Limit 4 bottles
Dexameth) per
CYSTARAN SOLN F
month;QL(2.15
neomycin-polymy- F ml daily)
dexameth oint
neomycin-polymy- dorzolamide hcl soln F
F
dexameth susp FLURBIPROFEN SODIUM
NEOMYCIN/POLYMYXIN/ F
SOLN
HYDROCORTISONE F
SUSP flurbiprofen sodium soln F
OMNIPRED SUSP (Use ketorolac tromethamine
Prednisolone Acetate NF F
(ophth) soln
(Ophth)) ketotifen fumarate (ophth)
PRED FORTE SUSP (Use F
soln
Prednisolone Acetate NF
MURO 128 OINT 5 % (Use
(Ophth)) Sodium Chloride NF
PRED MILD SUSP F Hypertonic)
MURO 128 SOLN 2 % F
PRED-G S.O.P. OINT F
MURO 128 SOLN 5 %
PRED-G SUSP F (Use Sodium Chloride NF
Hypertonic)
prednisolone acetate F
(ophth) susp OCUFEN SOLN (Use NF
Flurbiprofen Sodium)
78
sodium chloride hypertonic F neomycin-polymyxin-hc F
oint (otic) soln
sodium chloride hypertonic F neomycin-polymyxin-hc F
soln (otic) susp
TRUSOPT SOLN (Use NF OXYTOCICS - Drugs to Prevent/Control Uterine
Dorzolamide HCl) Bleeding
ZADITOR SOLN (Use
Ketotifen Fumarate NF Oxytocics
(Ophth)) METHERGINE TABS F
Prostaglandins - Ophthalmic methylergonovine maleate
Limit 2.5mls F
tabs or 0.2 mg
BIMATOPROST SOLN F per PASSIVE IMMUNIZING AGENTS - Antibody
month;QL(0.09
ml daily) Drugs to Treat Low Immune System
Limit 2.5mls Monoclonal Antibodies
latanoprost soln F per SYNAGIS SOLN F PA; SP-
month;QL(0.09 AcariaHealth
ml daily)
Limit 2.5mls PENICILLINS - Drugs to Treat Bacterial Infections
LUMIGAN SOLN F per Aminopenicillins
month;QL(0.09
ml daily) amoxicillin caps 250 mg, F
500 mg
Limit 2.5mls
XALATAN SOLN (Use AMOXICILLIN CHEW 125
NF per MG, 250 MG
F
Latanoprost) month;QL(0.09
ml daily) amoxicillin susr 125
mg/5ml, 200 mg/5ml, 250 F
OTIC AGENTS - Drugs to Treat the Ear mg/5ml, 400 mg/5ml
Otic Agents - Miscellaneous amoxicillin tabs 500 mg F
acetic acid (otic) soln F ampicillin caps 250 mg, F
500 mg
ACETIC ACID/ALUMINUM F
ACETATE SOLN AMPICILLIN CAPS 500 F
MG
carbamide peroxide (otic) F
soln AMPICILLIN SUSR 125 F
MG/5ML, 250 MG/5ML
DEBROX SOLN (Use NF
Carbamide Peroxide (Otic)) Natural Penicillins
Otic Anti-infectives PENICILLIN V
POTASSIUM SOLR 125 F
CIPROFLOXACIN SOLN F MG/5ML, 250 MG/5ML
OT 0.2 %
penicillin v potassium solr F
FLOXIN OTIC SOLN (Use NF 125 mg/5ml, 250 mg/5ml
Ofloxacin (Otic))
penicillin v potassium tabs F
ofloxacin (otic) soln F 250 mg, 500 mg
Otic Combinations Penicillin Combinations
79
amoxicillin & pot F PROVERA TABS (Use
clavulanate susr Medroxyprogesterone NF
amoxicillin & pot Acetate)
F
clavulanate tabs PSYCHOTHERAPEUTIC AND NEUROLOGICAL
amoxicillin & pot AGENTS - MISC. - Drugs to Treat Mental and
F Emotional Conditions
clavulanate tb12
AMOXICILLIN/CLAVULAN F Agents for Chemical Dependency
ATE POTASSIUM CHEW
AUGMENTIN ES-600 acamprosate calcium tbec CO
SUSR (Use Amoxicillin & NF ANTABUSE TABS (Use
Pot Clavulanate) NF
Disulfiram)
AUGMENTIN SUSR F
125MG/5ML-31.25MG/5ML disulfiram tabs F
AUGMENTIN SUSR Antidementia Agents
250MG/5ML-62.5MG/5ML NF
(Use Amoxicillin & Pot ARICEPT TABS (Use NF
Clavulanate) Donepezil Hydrochloride)
AUGMENTIN TABS donepezil hydrochloride F
500MG-125MG, 875MG- tabs
NF donepezil hydrochloride
125MG (Use Amoxicillin & F
Pot Clavulanate) tbdp
AUGMENTIN XR TB12 EXELON CAPS (Use NF
(Use Amoxicillin & Pot NF Rivastigmine Tartrate)
Clavulanate) EXELON PT24 (Use NF
Penicillinase-Resistant Penicillins Rivastigmine)
galantamine hydrobromide F
dicloxacillin sodium caps F cp24 8 mg, 16 mg, 24 mg
nafcillin sodium solr ij 1 gm, F PA GALANTAMINE
2 gm, 10 gm HYDROBROMIDE SOLN 4 F
NAFCILLIN SODIUM MG/ML
F PA galantamine hydrobromide
SOLR IV 1 GM, 2 GM F
tabs 4 mg, 8 mg, 12 mg
PROGESTINS - Hormone Replacement/Modifying
Drugs memantine hcl cp24 7 mg, F PA
14 mg, 21 mg, 28 mg
Progestins memantine hcl soln 2
AYGESTIN TABS (Use F
NF mg/ml
Norethindrone Acetate) memantine hcl tabs 5 mg,
MAKENA OIL IM 250 F
F PA; SP- 10 mg,
MG/ML AcariaHealth NAMENDA TABS 5 MG, 10
MAKENA SOAJ SC 275 NF
F PA; SP- Acaria MG (Use Memantine HCl)
MG/1.1ML Health NAMENDA TITRATION
medroxyprogesterone F PAK TABS (Use NF
acetate tabs Memantine HCl)
norethindrone acetate tabs F NAMENDA XR CP24 (Use NF PA
Memantine HCl)
NAMENDA XR TITRATION F PA
PACK CP24
80
RAZADYNE ER CP24 (Use GILENYA CAPS F PA; SP-
Galantamine NF AcariaHealth
Hydrobromide)
glatiramer acetate sosy F PA; SP-
RAZADYNE TABS (Use AcariaHealth
Galantamine NF
Hydrobromide) LEMTRADA SOLN F PA; SP-
Caremark
rivastigmine pt24 F OCREVUS SOLN F PA; SP-
AcariaHealth
rivastigmine tartrate caps F
PLEGRIDY SOPN F PA; SP-
AcariaHealth
Combination Psychotherapeutics
CHLORDIAZEPOXIDE/AMI F PLEGRIDY SOSY F PA; SP-
AcariaHealth
TRIPTYLINE TABS PLEGRIDY STARTER
olanzapine-fluoxetine hcl F PA; SP-
CO PACK SOPN AcariaHealth
caps PLEGRIDY STARTER
PERPHENAZINE/AMITRIP F PA; SP-
F PACK SOSY AcariaHealth
TYLINE TABS
SYMBYAX CAPS (Use REBIF REBIDOSE SOAJ F PA; SP-
AcariaHealth
Olanzapine-Fluoxetine CO REBIF REBIDOSE
HCl) F PA; SP-
TITRATIONPACK SOAJ AcariaHealth
Movement Disorder Drug Therapy
REBIF SOSY F PA; SP-
SP- AcariaHealth
tetrabenazine tabs F Caremark;AL; REBIF TITRATION PACK F PA; SP-
At least 21 yrs SOSY AcariaHealth
old TECFIDERA CPDR 120
SP- F PA; SP-Acaria
MG Health
XENAZINE TABS (Use NF Caremark;AL; TECFIDERA CPDR 240
Tetrabenazine) At least 21 yrs F PA; SP-
MG AcariaHealth
old
TECFIDERA STARTER F PA; SP-
Multiple Sclerosis Agents PACK MISC AcariaHealth
PA; SP-
AMPYRA TB12 F
Caremark TYSABRI CONC F PA; SP-
AcariaHealth
AUBAGIO TABS F PA; SP- ZINBRYTA SOSY F PA
AcariaHealth
AVONEX KIT F PA; SP- Premenstrual Dysphoric Disorder (PMDD) Agents
AcariaHealth
FLUOXETINE CAPS 10 F QL(1 ea daily)
AVONEX PEN AJKT F PA; SP- MG
AcariaHealth
FLUOXETINE CAPS 20 F QL(2 ea daily)
AVONEX PSKT F PA; SP- MG
AcariaHealth
Pseudobulbar Affect (PBA) Agents
BETASERON KIT F PA; SP-
AcariaHealth NUEDEXTA CAPS F
COPAXONE SOSY (Use NF PA; SP-
Glatiramer Acetate) AcariaHealth Psychotherapeutic and Neurological Agents -
ERGOLOID MESYLATES
EXTAVIA KIT F PA; SP- TABS
F
AcariaHealth
81
ORAP TABS (Use CO RESPIRATORY AGENTS - MISC. - Drugs to
Pimozide) Treat Lung Conditions
pimozide tabs CO Alpha-Proteinase Inhibitor (Human)
Smoking Deterrents ARALAST NP SOLR F PA; SP-
Caremark
bupropion hcl (smoking QL(2 ea daily)
deterrent) tb12 F GLASSIA SOLN F PA; SP-
Caremark
QL(2 ea
CHANTIX CONTINUING daily,90 day(s)
F PROLASTIN-C SOLN F PA; SP-
MONTHPAK TABS Caremark
limit)
QL(2 ea PROLASTIN-C SOLR F PA; SP-
CHANTIX STARTING Caremark
F daily,90 day(s)
MONTH PAK TABS limit) ZEMAIRA SOLR F PA; SP-
Caremark
QL(2 ea
CHANTIX TABS F daily,90 day(s) Cystic Fibrosis Agents
limit) PA; SP-
KALYDECO PACK F
NICODERM CQ PT24 (Use NF QL(1 ea daily) AcariaHealth
Nicotine) PA; SP-
KALYDECO TABS F
NICORETTE GUM 2 MG, 4 QL(24 ea daily) AcariaHealth
MG (Use Nicotine NF PA; SP-Acaria
Polacrilex) ORKAMBI TABS F
Health
NICORETTE LOZG 2 MG, QL(20 ea daily) SP-
4 MG (Use Nicotine NF PULMOZYME SOLN F
AcariaHealth
Polacrilex)
SULFONAMIDES - Drugs to Treat Bacterial
NICORETTE MINI LOZG NF QL(20 ea daily) Infections
(Use Nicotine Polacrilex)
NICORETTE STARTER QL(24 ea daily) Sulfonamides
KIT GUM (Use Nicotine NF SULFADIAZINE TABS F
Polacrilex)
nicotine polacrilex gum 2 F QL(24 ea daily) TETRACYCLINES - Drugs to Treat Bacterial
mg, 4 mg Infections
nicotine polacrilex lozg 2 F QL(20 ea daily) Tetracyclines
mg, 4 mg
doxycycline (monohydrate) F
nicotine pt24 F QL(1 ea daily) susr 25 mg/5ml
doxycycline hyclate caps or F
NICOTINE QL(1 ea daily) 50 mg, 100 mg
TRANSDERMAL SYSTEM F
KIT doxycycline hyclate tabs or F
20 mg, 100 mg
NICOTROL INHALER F
INHA MINOCIN CAPS (Use NF
Minocycline HCl)
QL(360 ml per
NICOTROL NS SOLN F minocycline hcl caps 50
90 days retail) F
mg, 75 mg, 100 mg
ZYBAN TB12 (Use QL(2 ea daily)
Bupropion HCl (Smoking NF tetracycline hcl caps 250 F
Deterrent)) mg, 500 mg
82
TETRACYCLINE HCL THYROLAR-2 TABS F
CAPS 250 MG, 500 MG NF
(Use Tetracycline HCl) THYROLAR-3 TABS F
VIBRAMYCIN CAPS 100
MG (Use Doxycycline NF WESTHROID TABS 65
Hyclate) MG, 130 MG, 195 MG, F
VIBRAMYCIN SUSR 25 32.5 MG
MG/5ML (Use Doxycycline NF WP THYROID TABS 65
(Monohydrate)) MG, 130 MG, 32.5 MG, F
VIBRAMYCIN SYRP 50 16.25 MG
F
MG/5ML TOXOIDS
THYROID AGENTS - Drugs to Regulate Thyroid
Hormones Toxoid Combinations
Limit 1 dose
Antithyroid Agents per 10
methimazole tabs F years;QL(1 ml
ADACEL SUSP F
per 999 days
propylthiouracil tabs F retail); AL; At
least 19 yrs old
TAPAZOLE TABS (Use NF Limit 1 dose
Methimazole) per 10
Thyroid Hormones years;QL(1 ml
BOOSTRIX SUSP F
per 999 days
ARMOUR THYROID TABS F retail); AL; At
least 19 yrs old
CYTOMEL TABS 25 MCG,
50 MCG (Use Liothyronine NF Limit 1 dose
Sodium) per 10
years;QL(1 ml
CYTOMEL TABS 5 MCG F TENIVAC INJ F
per 999 days
retail); AL; At
levothyroxine sodium tabs F least 19 yrs old
liothyronine sodium tabs or Limit 1 dose
F per 10
5 mcg, 25 mcg, 50 mcg TETANUS/DIPHTHERIA years;QL(1 ml
NATURE-THROID NT-2.5 TOXOIDS-ADSORBED F
F per 999 days
TABS SUSP retail); AL; At
NATURE-THROID TABS least 19 yrs old
65 MG, 130 MG, 195 MG, F
32.5 MG, 16.25 MG ULCER DRUGS - Drugs to Treat Bowel, Intestine
and Stomach Conditions
SYNTHROID TABS F Antispasmodics
thyroid tabs F ANASPAZ TBDP (Use NF
Hyoscyamine Sulfate)
THYROLAR-1 TABS F BENTYL CAPS OR 10 MG NF
(Use Dicyclomine HCl)
THYROLAR-1/2 TABS F BENTYL TABS OR 20 MG NF
(Use Dicyclomine HCl)
THYROLAR-1/4 TABS F
83
chlordiazepoxide hcl- F cimetidine tabs 300 mg, F QL(4 ea daily)
clidinium bromide caps 400 mg
CUVPOSA SOLN F cimetidine tabs 800 mg F QL(2 ea daily)
dicyclomine hcl caps or 10 F famotidine susr 40 mg/5ml F

mg
dicyclomine hcl soln or 10 famotidine tabs 10 mg, 40 F
F mg
mg/5ml
dicyclomine hcl tabs or 20 famotidine tabs 20 mg F RX/OTC
F
mg
glycopyrrolate tabs or 1 PEPCID AC EZ CHEWS
F MAXIMUM STRENGTH F
mg, 2 mg
CHEW
hyoscyamine sulfate elix F PEPCID AC MAXIMUM RX/OTC
STRENGTH TABS (Use NF
hyoscyamine sulfate soln F Famotidine)
PEPCID AC TABS (Use NF
hyoscyamine sulfate subl F Famotidine)
hyoscyamine sulfate tabs F PEPCID SUSR 40 MG/5ML NF
(Use Famotidine)
hyoscyamine sulfate tb12 F PEPCID TABS 20 MG (Use NF RX/OTC
Famotidine)
hyoscyamine sulfate tbdp F PEPCID TABS 40 MG (Use NF
Famotidine)
LEVBID TB12 (Use NF ranitidine hcl caps or 150 QL(2 ea daily)
Hyoscyamine Sulfate) mg, 300 mg F
LEVSIN TABS OR 0.125 ranitidine hcl syrp or 15
MG (Use Hyoscyamine NF mg/ml, 75 mg/5ml, 150 F
Sulfate) mg/10ml
LEVSIN/SL SUBL (Use NF ranitidine hcl tabs or 150 RX/OTC
Hyoscyamine Sulfate) mg F
LIBRAX CAPS (Use ranitidine hcl tabs or 300
Chlordiazepoxide HCl- NF mg F
Clidinium Bromide)
ranitidine hcl tabs or 75 mg F QL(2 ea daily)
PROPANTHELINE F
BROMIDE TABS
TAGAMET HB TABS (Use NF RX/OTC
ROBINUL FORTE TABS NF Cimetidine)
(Use Glycopyrrolate)
ZANTAC 150 MAXIMUM RX/OTC
ROBINUL TABS OR 1 MG NF STRENGTH TABS (Use NF
(Use Glycopyrrolate) Ranitidine HCl)
SYMAX DUOTAB TBCR F ZANTAC 75 TABS (Use NF QL(2 ea daily)
Ranitidine HCl)
H-2 Antagonists ZANTAC TABS OR 150 NF RX/OTC
CIMETIDINE HCL SOLN F MG (Use Ranitidine HCl)
ZANTAC TABS OR 300 NF
cimetidine tabs 200 mg F RX/OTC MG (Use Ranitidine HCl)
Misc. Anti-Ulcer
84
CARAFATE SUSP 1 F PRILOSEC CPDR 10 MG, NF QL(1 ea daily)
GM/10ML 40 MG (Use Omeprazole)
CARAFATE TABS 1 GM NF PRILOSEC CPDR 20 MG NF QL(1 ea daily);
(Use Sucralfate) (Use Omeprazole) RX/OTC
sucralfate tabs F PRILOSEC OTC TBEC F QL(1 ea daily)
Proton Pump Inhibitors PROTONIX TBEC OR 20 QL(1 ea daily)
MG, 40 MG (Use NF
CVS OMEPRAZOLE TBEC F QL(1 ea daily) Pantoprazole Sodium)
QL(1 ea daily) PX OMEPRAZOLE TBEC F QL(1 ea daily)
EQ OMEPRAZOLE TBEC F
QL(1 ea daily) RA OMEPRAZOLE TBEC F QL(1 ea daily)
EQL OMEPRAZOLE TBEC F
FIRST-LANSOPRAZOLE SB OMEPRAZOLE TBEC F QL(1 ea daily)
F
SUSP
SM OMEPRAZOLE TBEC F QL(1 ea daily)
AL; At least 1
FIRST-OMEPRAZOLE F yrs old - Up to
SUSP SW OMEPRAZOLE TBEC F QL(1 ea daily)
16 yrs old
GNP OMEPRAZOLE F QL(1 ea daily) QL(1 ea daily)
TBEC TGT OMEPRAZOLE TBEC F
HM OMEPRAZOLE TBEC F QL(1 ea daily) Ulcer Drugs - Prostaglandins
QL(1 ea daily) CYTOTEC TABS (Use NF
KLS OMEPRAZOLE TBEC F Misoprostol)
QL(1 ea daily); misoprostol tabs F
lansoprazole cpdr 15 mg F
RX/OTC
QL(1 ea daily) Ulcer Therapy Combinations
lansoprazole cpdr 30 mg F
amoxicillin-clarithromycin F QL(112 ea per
OMEPRAZOLE + AL; At least 1 w/ lansoprazole misc fill retail)
SYRSPEND SFALKA F yrs old - Up to PREVPAC MISC (Use QL(112 ea per
SUSP 16 yrs old Amoxicillin-Clarithromycin NF fill retail)
omeprazole cpdr 10 mg, 40 F QL(1 ea daily) w/ Lansoprazole)
mg
URINARY ANTI-INFECTIVES - Drugs to Treat
QL(1 ea daily); Bladder/Kidney Infections
omeprazole cpdr 20 mg F
RX/OTC
OMEPRAZOLE TBEC 20 QL(1 ea daily) Urinary Anti-infective Combinations
F methenamine-hyosc-
MG
pantoprazole sodium tbec QL(1 ea daily) methylene blue-sod phos-
or 20 mg, 40 mg F phenyl sal tabs 40.8mg- F
0.12mg-36.2mg-81.6mg-
PREVACID 24HR CPDR NF QL(1 ea daily); 10.8mg, 40.8mg-36.2mg-
(Use Lansoprazole) RX/OTC 0.12mg-81.6mg-10.8mg
PREVACID CPDR 15 MG NF QL(1 ea daily); Urinary Anti-infectives
(Use Lansoprazole) RX/OTC
FURADANTIN SUSP (Use NF
PREVACID CPDR 30 MG NF QL(1 ea daily) Nitrofurantoin)
(Use Lansoprazole)
PREVACID SOLUTAB F ST; QL(1 ea
TBDP daily)
85
MACROBID CAPS (Use Limit 2 doses
Nitrofurantoin Monohyd NF per
Macro) BEXSERO SUSY F lifetime;QL(1 ml
MACRODANTIN CAPS per 999 days
(Use Nitrofurantoin NF retail); AL; At
Macrocrystal) least 19 yrs old
nitrofurantoin macrocrystal F MENACTRA INJ F AL; At least 19
caps yrs old
nitrofurantoin monohyd MENOMUNE-A/C/Y/W-135 F AL; At least 19
F INJ yrs old
macro caps
nitrofurantoin susp F MENVEO SOLR F AL; At least 19
yrs old
URINARY ANTISPASMODICS - Drugs to Treat Limit 2 doses
Miscellaneous Bladder Spasms per
Urinary Antispasmodic - Antimuscarinics PNEUMOVAX 23 INJ F lifetime;QL(1 ml
per 999 days
DETROL LA CP24 (Use retail); AL; At
NF QL(1 ea daily) least 19 yrs old
Tolterodine Tartrate)
DETROL TABS (Use Limit 2 doses
NF per
Tolterodine Tartrate)
DITROPAN XL TB24 (Use PNEUMOVAX 23/1 DOSE F lifetime;QL(1 ml
NF INJ per 999 days
Oxybutynin Chloride)
retail); AL; At
oxybutynin chloride syrp F least 19 yrs old
Limit 1 dose
oxybutynin chloride tabs F per
oxybutynin chloride tb24 F PREVNAR 13 SUSP F lifetime;QL(1 ml
per 999 days
retail); AL; At
tolterodine tartrate cp24 2 F QL(1 ea daily) least 19 yrs old
mg, 4 mg
Limit 3 doses
tolterodine tartrate tabs 1 F per
mg, 2 mg
TRUMENBA SUSY F lifetime;QL(2 ml
trospium chloride cp24 F per 999 days
retail); AL; At
trospium chloride tabs F least 19 yrs old
Viral Vaccines
Urinary Antispasmodics - Cholinergic Agonists QL(1 ml per
bethanechol chloride tabs F AFLURIA PF 2017-2018 F 180 days
SUSY retail); AL; At
URECHOLINE TABS (Use NF least 19 yrs old
Bethanechol Chloride) Limit 3 doses
VACCINES per
lifetime;QL(2 ml
Bacterial Vaccines per 999 days
CERVARIX SUSP F
retail); AL; At
least 19 yrs old
- Up to 26 yrs
old
86
Limit 3 doses Limit 2 doses
per per
ENGERIX-B INJ IM 10 F lifetime;QL(2 ml HAVRIX SUSP 1440 F lifetime;QL(2 ml
MCG/0.5ML per 999 days ELU/ML per 999 days
retail); AL; At retail); AL; At
least 19 yrs old least 19 yrs old
per per
ENGERIX-B INJ IM 20 F lifetime;QL(3 ml HAVRIX SUSP 720 F lifetime;QL(1 ml
MCG/ML per 999 days ELU/0.5ML per 999 days
retail); AL; At retail); AL; At
per per lifetime; AL;
ENGERIX-B SUSP IJ 10 F lifetime;QL(2 ml At least 19 yrs
MCG/0.5ML per 999 days HEPLISAV-B SOLN F old; AGE
retail); AL; At QL(Age 19 and
least 19 yrs old up, 1 ml per
Limit 3 doses 999 retail,)
per IMOVAX RABIES F AL; At least 19
ENGERIX-B SUSP IJ 20 F lifetime;QL(3 ml (H.D.C.V.) INJ yrs old
MCG/ML per 999 days Limit 1 dose
retail); AL; At influenza virus vaccine F every 6
least 19 yrs old injection (2017-2018) months; AL
per per
lifetime;QL(2 ml lifetime;QL(2
GARDASIL 9 SUSP F per 999 days M-M-R II INJ F ea per 999
retail); AL; At days retail); AL;
least 19 yrs old At least 19 yrs
- Up to 26 yrs old
old
Limit 3 doses RABAVERT SUSR F AL; At least 19
yrs old
per
lifetime;QL(2 ml Limit 3 doses
per
GARDASIL 9 SUSY F per 999 days RECOMBIVAX HB SUSP
retail); AL; At F lifetime;QL(3 ml
least 19 yrs old 10 MCG/ML, 40 MCG/ML per 999 days
- Up to 26 yrs retail); AL; At
old least 19 yrs old
per per
lifetime;QL(2 ml RECOMBIVAX HB SUSP 5 F lifetime;QL(2 ml
MCG/0.5ML per 999 days
GARDASIL SUSP F per 999 days retail); AL; At
retail); AL; At
- Up to 26 yrs
old
87
Limit 2 doses OPTIONS GYNOL II
per VAGINALCONTRACEPTIV F
lifetime;QL(2 E GEL
SHINGRIX SUSR F ea per 999
days retail); AL; SHUR-SEAL GEL F
At least 50 yrs
old TODAY SPONGE MISC F
Limit 3 doses VCF VAGINAL
per CONTRACEPTIVE FILM F
TWINRIX SUSP F lifetime;QL(3 ml FILM
per 999 days VCF VAGINAL
retail); AL; At CONTRACEPTIVE FOAM F
least 19 yrs old FOAM
Limit 2 doses
per Vaginal Anti-infectives
VAQTA SUSP 25 F lifetime;QL(1 ml AVC CREA F
UNIT/0.5ML per 999 days
retail); AL; At CLEOCIN CREA VA 2 %
least 19 yrs old (Use Clindamycin NF
Limit 2 doses Phosphate Vaginal)
per clindamycin phosphate F
VAQTA SUSP 50 UNIT/ML F lifetime;QL(2 ml vaginal crea
per 999 days
retail); AL; At CLINDESSE CREA F
least 19 yrs old clotrimazole vaginal crea 1
Limit 2 doses F
%
per GYNE-LOTRIMIN CREA
lifetime;QL(2 NF
(Use Clotrimazole Vaginal)
VARIVAX INJ F ea per 999
days retail); AL; METROGEL-VAGINAL
At least 19 yrs GEL (Use Metronidazole NF
old Vaginal)
QL(1 ea per metronidazole vaginal gel F
ZOSTAVAX SUSR F 999 days miconazole nitrate vaginal
retail); AL; At F
least 60 yrs old crea 2 %, 4 %
miconazole nitrate vaginal F
VAGINAL PRODUCTS - Drugs to Treat Vaginal kit
Infections and Low Hormones
miconazole nitrate vaginal F
Spermicides supp 100 mg
ENCARE SUPP F MONISTAT 3
COMBINATION PACK KIT NF
nonoxynol-9 gel F (Use Miconazole Nitrate
Vaginal)
OPTIONS CONCEPTROL MONISTAT 3 CREA (Use
VAGINAL NF
NF Miconazole Nitrate Vaginal)
CONTRACEPTIVE GEL
(Use Nonoxynol-9) MONISTAT 7 SIMPLY
CURE CREA (Use NF
Miconazole Nitrate Vaginal)
88
tioconazole vaginal oint F Water Soluble Vitamins
VAGISTAT-1 OINT (Use B-1 TABS F
NF
Tioconazole Vaginal)
niacin cpcr 250 mg F
Vaginal Estrogens
ESTRACE CREA (Use niacin tabs 50 mg, 100 mg, F
NF 500 mg
Estradiol Vaginal)
estradiol vaginal crea 0.1 F niacin tbcr 500 mg F
mg/gm
PREMARIN CREA VA pyridoxine hcl tabs or 25 F
F mg, 50 mg, 100 mg
0.625 MG/GM
SLO-NIACIN TBCR 500 NF
VASOPRESSORS - Drugs to Treat Heart and MG (Use Niacin)
Circulation Conditions
thiamine hcl tabs or 50 mg, F
Anaphylaxis Therapy Agents 100 mg, 250 mg
epinephrine (anaphylaxis) QL(2 ea per fill
soaj 0.15 mg/0.15ml, 0.15 2 retail)
mg/0.3ml, 0.3 mg/0.3ml
epinephrine (anaphylaxis) QL(2 ea per fill
soaj 0.15 mg/0.3ml, 0.3 F retail)
mg/0.3ml
Vasopressors
midodrine hcl tabs F
VITAMINS
Oil Soluble Vitamins
BABY DDROPS LIQD (Use NF
Cholecalciferol)
cholecalciferol caps 1000 F
unit, 2000 unit, 5000 unit
cholecalciferol liqd 400 F
unt/0.03ml
cholecalciferol tabs 400
unit, 1000 unit, 2000 unit, F
5000 unit
DRISDOL CAPS 50000 NF
UNIT (Use Ergocalciferol)
ergocalciferol caps 50000 F
unit
MEPHYTON TABS F
phytonadione tabs or 100 F
mcg
VITAMIN A TABS F
10000UNIT-1000UNIT
89
Index
abacavir sulfate 32 ADVIL MIGRAINE 3 alum & mag hydrox-
abacavir sulfate-lamivudine 32 ADVOCATE INSULIN PEN simethicone 8
abacavir sulfate-lamivudine- NEEDLES 63 ALUMINUM HYDROXIDE 9
zidovudine 32 ADYNOVATE 55 aluminum hydroxide-mag trisil 8
ABILIFY 32 AEROSPAN 12 aluminum sulfate & calcium
ABILIFY MAINTENA 32 AFINITOR 28 acetate 48
ALUNBRIG 28
acamprosate calcium 80 AFLURIA PF 2017-2018 86
amantadine hcl 30
acarbose 18 AFSTYLA 55
AMARYL 20
ACCUPRIL 24 AGRYLIN 56
AMBIEN 57
ACCURETIC 25 AIMSCO LUBRICATED 60
AIRZONE PEAK FLOW AMERGE 64
acebutolol hcl 36
METER 63 AMICAR 57
acetaminophen 4
ALBENZA 9 amiloride hcl 50
acetaminophen w/ codeine 6,7
albuterol sulfate 13 amino acid infusion 74
acetazolamide 50
ALBUTEROL SULFATE aminophylline 13
acetic acid 54 ER 13 AMINOSYN 75
acetic acid (otic) 79 ALCAINE 77
ACETIC ACID/ALUMINUM AMINOSYN II 74
ALDACTAZIDE 50
ACETATE 79 AMINOSYN-HBC 75
ALDACTONE 50
acetylcysteine 42 AMINOSYN-PF 75
ALDARA 47
ACNE MEDICATION 10 42 AMINOSYN-PF 7% 75
ALDURAZYME 51
ACTEMRA 3 AMINOSYN-RF 75
ALECENSA 28
ACTIGALL 53 amiodarone hcl 11
alendronate sodium 51
ACTOPLUS MET 18 amitriptyline hcl 18
ALENDRONATE SODIUM 51
ACTOS 19 amlodipine besylate 36
alendronate sodium 51
ACULAR 78 amoxicillin 79
ALER-DRYL 22
ACULAR LS 78 AMOXICILLIN 79
ALEVAZOL 44
acyclovir 35 amoxicillin 79
ALEVE 3
acyclovir topical 45 amoxicillin & pot clavulanate 80
alfuzosin hcl 54 amoxicillin-clarithromycin w/
ADACEL 83
ALIVE PRENATAL MULTI- lansoprazole 85
ADALAT CC 36 VITAMIN/PLANT DHA 69 AMOXICILLIN/CLAVULANATE
adapalene 42 ALKERAN 26 POTASSIUM 80
ADASUVE 31 ALLI 1 amphetamine-
ADCIRCA 37 allopurinol 54 dextroamphetamine 1
ADDERALL 1 ampicillin 79
almotriptan malate 64
ADDERALL XR 1 AMPICILLIN 79
ALOGLIPTIN 19
adefovir dipivoxil 34 ALOGLIPTIN/METFORMIN AMPYRA 81
ADIPEX-P 1 HCL 18 ANAFRANIL 18
ALOGLIPTIN/PIOGLITAZONE anagrelide hcl 56
ADLYXIN 19 18
ADLYXIN STARTER PACK 19 ANALPRAM-HC 8
ALORA 52
ADMELOG 19 ANAPROX DS 3
ALPHAGAN P 76,77
ADMELOG SOLOSTAR 19 ANASPAZ 83
ALPHANATE/VON
ADVAIR DISKUS 13 WILLEBRANDFACTOR anastrozole 27
ADVAIR HFA 13 COMPLEX/HUMAN 55 ANDROGEL 8
ALPHANINE SD 55 ANDROGEL PUMP 8
ADVATE 55
alprazolam 11 ANDROID 8
ADVIL 3
ADVIL ALLERGY & ALPROLIX 55 ANDROXY 8
CONGESTION 41 ALTACE 24 ANORO ELLIPTA 13
Index 1
ANTABUSE 80 ASSURE HAEMOLANCE AVANDIA 19
ANUSOL-HC 8 PLUS MICRO FLOW 28G 62 AVAPRO 25
ASSURE HAEMOLANCE
APEXICON E 45 PLUS NORMAL FLOW AVC 88
APIDRA 19 21G 62 AVONEX 81
APIDRA SOLOSTAR 19 ASSURE HAEMOLANCE AVONEX PEN 81
PLUS PEDIATRIC BLADE 62
apraclonidine hcl 77 ASSURE LANCE AXERT 64
aprepitant 22 LANCETS 62 AYGESTIN 80
APTIVUS 32 ASSURE LANCE LANCETS AZASAN 67
ARALAST NP 82 21G 62 azathioprine 67
ASSURE LANCE PLUS
ARANESP ALBUMIN FREE 56 SAFETYLANCETS 25G 62 azelastine hcl 72
ARAVA 4 ASSURE LANCE PLUS azelastine hcl (ophth) 78
ARICEPT 80 SAFETYLANCETS 30G 62 azithromycin 59
ASSURE PLATINUM TEST
ARIMIDEX 27 STRIPS 49 AZULFIDINE 53
aripiprazole 32 ASTEPRO 72 AZULFIDINE EN-TABS 53
ARISTADA 32 ASTHMA CHECK METER- B-1 89
armodafinil 2 ZONE SYSTEM 63 b-complex w/ c & folic acid 68
ARMOUR THYROID 83 ASTHMAMENTOR 63 BABY DDROPS 89
ARNUITY ELLIPTA 12 ATABEX DHA 74 BACIGUENT 43
AROMASIN 27 ATABEX EC 69 BACITRACIN 77
ASMANEX HFA 12 ATABEX PRENATAL 69 bacitracin (topical) 43
ASMANEX TWISTHALER 120 ATACAND 25 bacitracin zinc 43
METERED DOSES 12 ATACAND HCT 25 bacitracin-poly-neomycin-hc 78
ASMANEX TWISTHALER 14 atazanavir sulfate 32
METERED DOSES 12 bacitracin-polymyxin b 44
ASMANEX TWISTHALER 30 atenolol 36 bacitracin-polymyxin b
METERED DOSES 12 atenolol & chlorthalidone 25 (ophth) 77
ASMANEX TWISTHALER 60 ATIVAN 11 baclofen 72
METERED DOSES 12 ATLAS COLORED BACTRIM 9
ASMANEX TWISTHALER 7 LUBRICATEDCONDOM 60
METERED DOSES 12 BACTRIM DS 9
ATLAS LUBRICATED BACTROBAN 44
aspirin 5 CONDOM 60
ASPIRIN 5 ATLAS LUBRICATED balsalazide disodium 53
aspirin 5 CONDOM/SPERMICIDE 60 BANZEL 15
aspirin buffered (cal carb-mag atomoxetine hcl 1 BARACLUDE 34
carb-mag oxide) 5 atorvastatin calcium 24 BASAGLAR KWIKPEN 20
ASPIRIN LOW DOSE 5 atovaquone 10 BD INSULIN SYRINGE/U-
ASSESS FULL RANGE PEAK atovaquone-proguanil hcl 26 500/0.5ML/31G X 15/64" 63
FLOW METER 63 BEBULIN 55
ASSESS LOW RANGE PEAK ATRIPLA 32
ATROPINE SULFATE 76 BELBUCA 7
FLOW METER 63
ASSESS PEAK FLOW METER ATROVENT 73 BELVIQ 1
FULL RANGE 63 ATROVENT HFA 11 BELVIQ XR 1
ASSESS PEAK FLOW METER BENADRYL ALLERGY 23
LOW RANGE 63 AUBAGIO 81
AUGMENTED BENADRYL ALLERGY
ASSURE COMFORT LANCETS CHILDRENS 23
ULTRA THIN 28G 62 BETAMETHASONE
DIPROPIONATE 45 BENADRYL-D ALLERGY &
ASSURE COMFORT LANCETS SINUS CHILDRENS 41
ULTRA THIN 30G 62 AUGMENTIN 80 benazepril &
ASSURE HAEMOLANCE PLUS AUGMENTIN ES-600 80 hydrochlorothiazide 25
HIGH FLOW 18G 62
ASSURE HAEMOLANCE PLUS AUGMENTIN XR 80 benazepril hcl 24
LOW FLOW 25G 62 AVALIDE 25 BENEFIX 55
Index 2
BENLYSTA 68 BREO ELLIPTA 13 CALAMINE PHENOLATED 48
BENTYL 83 BREVICON-28 38 CALAN 36
BENZAC AC WASH 42 BRILINTA 56 CALAN SR 36
BENZAMYCIN 42 brimonidine tartrate 77 CALCI-CHEW 64
BENZIQ WASH 42 BRINEURA 51 calcipotriene 45
benzonatate 40 BROMFENAC 78 calcitonin (salmon) 51
benzoyl peroxide 42 bromfenac sodium (ophth) 78 calcitriol 51
BENZOYL PEROXIDE 42 bromocriptine mesylate 30 calcitriol (topical) 45
benzoyl peroxide 42 brompheniramine & CALCIUM 65
benzoyl peroxide- phenyleph 41 calcium acetate (phosphate
erythromycin 42 brompheniramine & binder) 54
benzphetamine hcl 1 pseudoeph 41 CALCIUM CARBONATE 9
budesonide 40
benztropine mesylate 30 calcium carbonate 65
budesonide (inhalation) 12
BETAGAN 76 calcium carbonate (antacid) 9
betamethasone dipropionate budesonide (nasal) 73 calcium carbonate-
(topical) 45 BUFFERIN 5 cholecalciferol 65
betamethasone dipropionate BUFFERIN EXTRA calcium carbonate-
augmented 45 STRENGTH 5 ergocalciferol 65
betamethasone valerate 45 BUFFERIN LOW DOSE 5 calcium carbonate-vitamin d 65
BETAPACE 36 bumetanide 50 calcium citrate 65
BETAPACE AF 36 BUMEX 50 CALCIUM CITRATE
BETASERON 81 BUNAVAIL 7 MALATE/VITAMIN D 65
calcium citrate-vitamin d 65
betaxolol hcl (ophth) 76 BUPRENEX 7
CALCIUM GLUCONATE 65
bethanechol chloride 86 BUPRENORPHINE 7
CALCIUM LACTATE 65
BETHKIS 2 buprenorphine hcl 7
buprenorphine hcl-naloxone hcl calcium polycarbophil 57
BETOPTIC-S 76
dihydrate 7 calcium w/ vitamin d 65
BEVESPI AEROSPHERE 13
bupropion hcl 17 CALCIUM/VITAMIN D 65
bexarotene 29
bupropion hcl (smoking CALNA 69
BEXSERO 86 deterrent) 82 CAMPTOSAR 30
BIAXIN 59 buspirone hcl 10
candesartan cilexetil 25
bicalutamide 27 butalbital-acetaminophen 4 candesartan cilexetil-
BIKTARVY 32 butalbital-acetaminophen- hydrochlorothiazide 25
BILTRICIDE 9 caffeine 4 capecitabine 27
butalbital-acetaminophen-
BIMATOPROST 79 caffeine w/ codeine 7 CAPEX 46
BIO-STATIN 22 butalbital-aspirin-caffeine 4 CAPITAL/CODEINE 7
bisacodyl 58 butalbital-aspirin-caffeine CAPRELSA 28
bismuth subsalicylate 20 w/cod 7 captopril 24
bisoprolol & BUTALBITAL/ASPIRIN/CAFFEI CAPTOPRIL/HYDROCHLOROT
hydrochlorothiazide 25 NE 4 HIAZIDE 25
bisoprolol fumarate 36 BUTRANS 7 CARAC 44
BLEPH-10 77 BYDUREON 19 CARAFATE 85
BLEPHAMIDE 78 BYDUREON BCISE 19 CARBAGLU 51
BLEPHAMIDE S.O.P. 78 BYDUREON PEN 19 carbamazepine 15
BOOSTRIX 83 BYETTA 19 carbamide peroxide (otic) 79
BOTOX 73 cabergoline 52 CARBATROL 15
BPROTECTED PEDIA TRI- CABOMETYX 28 carbidopa-levodopa 30
VITE 69 CAFERGOT 64 CARDIZEM 36
BRAINSTRONG PRENATAL69 CALAMINE 48 CARDIZEM CD 36
Index 3
CARDURA 25 CHEMSTRIP 10 MD 49 CLARITIN ALLERGY

carisoprodol 72 CHEMSTRIP 2 GP CHILDRENS 23
STRIPS 49 CLARITIN REDITABS 23
CARNITOR 51
CHEMSTRIP 7 49 CLARITIN-D 12 HOUR 41
CARNITOR SF 51
CHEMSTRIP 9 STRIPS 49 CLARITIN-D 24 HOUR 41
carvedilol 36
CHEMSTRIP-K 49 CLASS ACT LUBRICATED 60
CASODEX 27
CHILDRENS ADVIL 3 CLASSIC PRENATAL 69
CATAPRES 25
CHILDRENS MOTRIN 3 clemastine fumarate 23
CAYA 60
CHLOR-TRIMETON 22 CLEMASTINE FUMARATE 23
CAYSTON 9
CHLORAMPHENICOL CLEOCIN 10,88
cefaclor 38 SODIUM SUCCINATE 10 CLEOCIN PEDIATRIC
CEFACLOR 38 chlordiazepoxide hcl 11 GRANULES 10
cefadroxil 37 chlordiazepoxide hcl-clidinium CLEOCIN PHOSPHATE 10
CEFAZOLIN SODIUM/SODIUM bromide 84 CLEOCIN-T 42
CHLORIDE 37 CHLORDIAZEPOXIDE/AMITRI
PTYLINE 81 CLEVER CHOICE COMFORT
CEFAZOLIN/SODIUM EZINSULIN PEN NEEDLES
CHLORIDE 37 chlorpheniramine &
phenylephrine 41 33GX4MM 63
cefdinir 38 CLEVER CHOICE COMFORT
chlorpheniramine &
cefpodoxime proxetil 38 pseudoeph 41 EZPEN NEEDLES
cefprozil 38 chlorpheniramine maleate 22 33GX4MM 63
CLEVER CHOICE COMFORT
CEFTIN 38 CHLORPROMAZINE HCL 32 EZPEN NEEDLES
ceftriaxone sodium 38 chlorpromazine hcl 32 33GX5MM 63
CEFTRIAXONE SODIUM 38 chlorthalidone 50 CLEVER CHOICE COMFORT
ceftriaxone sodium 38 EZPEN NEEDLES
cholecalciferol 89 33GX6MM 63
cefuroxime axetil 38 cholestyramine 23 CLEVER CHOICE COMFORT
CELEBREX 3 cholestyramine light 23 EZPEN NEEDLES
celecoxib 3 choline & mag salicylate 5 33GX8MM 63
CELEXA 17 CLIMARA 52
cidofovir 34
CELLCEPT 67 CLIMARA PRO 52
cilostazol 56
CELONTIN 16 CLIN SINGLE USE KIT 10
CILOXAN 77
CENTRUM SPECIALIST CLINDAGEL 42
cimetidine 84
PRENATAL 69 clindamycin hcl 10
cephalexin 37 CIMETIDINE HCL 84
clindamycin palmitate
CEPHALEXIN 38 CINQAIR 11 hydrochloride 10
CERASPORT 65 CINRYZE 55 clindamycin phosphate 10
CERASPORT EX1 65 CIPRO 53 clindamycin phosphate
CIPRO XR 53 (topical) 42
CEREZYME 56 clindamycin phosphate
CERVARIX 86 ciprofloxacin 53 vaginal 88
cetirizine hcl 23 CIPROFLOXACIN 79 CLINDESSE 88
cetirizine-pseudoephedrine 41 CIPROFLOXACIN HCL 53 CLINICAL NUTRIENTS
ciprofloxacin hcl 53 PRENATAL FORMULA 69
CHANTIX 82 CLINIMIX 2.75%/DEXTROSE
CHANTIX CONTINUING ciprofloxacin hcl (ophth) 77
5% 75
MONTHPAK 82 ciprofloxacin-ciprofloxacin CLINIMIX 4.25%/DEXTROSE
CHANTIX STARTING MONTH hcl 53 10% 75
PAK 82 citalopram hydrobromide 17 CLINIMIX 4.25%/DEXTROSE
CHEK-STIX COMBO PAK CITRUCEL FIBER 20% 75
URINALYSIS CONTROL 49 LAXATIVE 57 CLINIMIX 4.25%/DEXTROSE
CHEK-STIX CONTROL 49 CLARITHROMYCIN 59 25% 75
CHEMET 21 clarithromycin 59 CLINIMIX 4.25%/DEXTROSE
CHEMSTRIP -10 WITH SG 49 5% 75
CLARITIN 23
Index 4
CLINIMIX 5%/DEXTROSE COMBIVIR 32 CYCLOMYDRIL 76
15% 75 COMETRIQ 28 cyclopentolate hcl 76
CLINIMIX 5%/DEXTROSE
20% 75 COMPLERA 32 CYCLOSET 19
CLINIMIX 5%/DEXTROSE COMPLETE NATAL DHA 69 cyclosporine 67
25% 75 COMPLETENATE 69 CYCLOSPORINE
CLINIMIX E 2.75%/DEXTROSE MODIFIED 67
10% 75 COMTAN 30
cyclosporine modified (for
CLINIMIX E 2.75%/DEXTROSE CONCERTA 2 microemulsion) 67
5% 75 CONDYLOX 47 CYMBALTA 18
CLINIMIX E 4.25%/DEXTROSE CONTRAVE 1
10% 75 cyproheptadine hcl 23
CLINIMIX E 4.25%/DEXTROSE COPAXONE 81 CYRAMZA 27
5% 75 COPEGUS 34 CYSTARAN 78
CLINIMIX N9G20E 75 COREG 36 CYTOMEL 83
clobetasol propionate 46 CORGARD 36 CYTOTEC 85
clobetasol propionate emollient CORIFACT 55 DACOGEN 27
base 46
CORTEF 40 DAKLINZA 34
clomipramine hcl 18
CORTENEMA 8 danazol 8
clonazepam 15
CORTIFOAM 8 DANTRIUM 72
clonidine hcl 25
CORTISONE ACETATE 40 dantrolene sodium 72
clonidine hcl (adhd) 1
CORTISPORIN 44 dapsone 10
clopidogrel bisulfate 56
COSENTYX 45 DARZALEX 27
clorazepate dipotassium 11
COSENTYX SENSOREADY DAYPRO 3
clotrimazole 68 PEN 45
clotrimazole (topical) 44 DDAVP 52
COSOPT 76
clotrimazole vaginal 88 DEBROX 79
COTELLIC 28
clotrimazole w/ decitabine 27
COUMADIN 13
betamethasone 44 DECON-A 41
COZAAR 25
clozapine 31 DEMEROL 5
CREON 50
CLOZAPINE ODT 31 DEMSER 24
CRIXIVAN 33
CLOZARIL 31 DEPAKENE 16
cromolyn sodium 11
CO-NATAL FA 69 DEPAKOTE 16
cromolyn sodium
COAGADEX 55 (mastocytosis) 53 DEPAKOTE ER 16
COAL TAR 49 CUVPOSA 84 DEPAKOTE SPRINKLES 16
CODEINE SULFATE 5 CVS HDYROCORTISONE DEPEN TITRATABS 67
codeine sulfate 5 ACETATE 46 DEPO-PROVERA
CVS NATURAL FIBER CONTRACEPTIVE 40
COGENTIN 30 SUPPLEMENT 57 DEPO-SUBQ PROVERA
COLACE 59 CVS OMEPRAZOLE 85 104 40
COLACE CLEAR 59 CVS PRENATAL 69 DERMA-SMOOTHE/FS
COLAZAL 53 CVS PRENATAL BODY 46
COLCHICINE 54 GUMMY/DHA/FOLIC DERMA-SMOOTHE/FS
ACID 69 SCALP 46
colchicine w/ probenecid 54 DESCOVY 33
CVS PRENATAL
COLCRYS 54 MULTI+DHA 69 desipramine hcl 18
COLESTID 23 CVS WOMENS desmopressin acetate 52
COLESTID FLAVORED 23 PRENATAL+DHA 69 desmopressin acetate
colestipol hcl 23,24 cyanocobalamin 56 refrigerated 52
COLYTE-FLAVOR PACKS 58 CYCLESSA 38 desmopressin acetate spray 52
COMBISTIX 49 cyclobenzaprine hcl 72 desmopressin acetate spray
CYCLOGYL 76 refrigerated 52
COMBIVENT RESPIMAT 13
DESOGEN 38
Index 5
desogestrel & ethinyl diazepam (anticonvulsant) 15 DOCETAXEL 29
estradiol 38 DIAZEPAM RECTAL GEL 15 DOCETAXEL (NON-ALCOHOL
desogestrel-ethinyl estradiol FORMULA) 29
(biphasic) 38 DIBENZYLINE 24
docosahexaenoic acid 74
desogestrel-ethinyl estradiol DICLEGIS 22
(triphasic) 38 docusate calcium 59
diclofenac potassium 3
desonide 46 docusate sodium 59
diclofenac sodium 3
DESOWEN 46 DOCUSOL KIDS 59
diclofenac sodium (topical) 43
desoximetasone 46 DOCUSOL MINI 59
dicloxacillin sodium 80
DESQUAM-X WASH 42 DOCUSOL PLUS MINI-
dicyclomine hcl 84 ENEMA 59
DESVENLAFAXINE ER 18 didanosine 33 dofetilide 11
desvenlafaxine succinate 18 diethylpropion hcl 1 DOLOPHINE 5
DETROL 86 DIETHYLPROPION HCL 1 DOMEBORO 48
DETROL LA 86 diethylpropion hcl 1 donepezil hydrochloride 80
dexamethasone 40 DIFFERIN 42,43 dorzolamide hcl 78
DEXAMETHASONE 40 DIFLORASONE dorzolamide hcl-timolol
dexamethasone 40 DIACETATE 46 maleate 76
DEXAMETHASONE 40 DIFLUCAN 22 DOVONEX 45
DEXAMETHASONE DIGOXIN 37 doxazosin mesylate 25
INTENSOL 40 digoxin 37 doxepin hcl 18
DEXAMETHASONE SODIUM
PHOSPHATE 78 DILANTIN 16 doxepin hcl (antipruritic) 45
dexbrompheniramine & DILANTIN INFATABS 16 doxorubicin hcl 28
pseudoephedrine 41 DILANTIN-125 16 doxycycline (monohydrate) 82
DEXEDRINE 1 DILATRATE SR 10 doxycycline hyclate 82
dextroamphetamine sulfate 1 DILAUDID 5 DRISDOL 89
dextrose 73 diltiazem hcl 36 DRITHO-CREME HP 45
DEXTROSE 10%/NACL diltiazem hcl coated beads 36 DRIXORAL
0.45% 65 COLD/ALLERGY 41
DEXTROSE 5%/ELECTROLYTE diltiazem hcl extended release
#48 VIAFLEX 65 beads 36 dronabinol 22
DEXTROSE 10%/NACL DIMETAPP COLD & DROPLET PEN NEEDLES
0.2% 65 ALLERGY 41 29GX10MM 63
DEXTROSE 10%/NACL diphenhydramine hcl 23 drospirenone-ethinyl
0.225% 65 diphenhydramine- estradiol 38
DEXTROSE 2.5%/NACL phenylephrine 41 DROXIA 56
0.45% 65 diphenhydramine- DRUG MART UNILET MICRO
DEXTROSE 20% 73 phenylephrine-acetaminophen THIN LANCETS 33G 62
DEXTROSE 25% 73 41 DRYSOL 48
diphenoxylate w/ atropine 21 DUETACT 18
DEXTROSE 30% 73 DIPHENOXYLATE/ATROPINE
DEXTROSE 40% 73 21 DULCOLAX 58
DEXTROSE 5%/NACL DIPROLENE 46 DULERA 13
0.225% 65 dipyridamole 56 duloxetine hcl 18
DEXTROSE 5%/NACL 0.3% 65 DUPIXENT 47
DISALCID 5
dextrose w/ sodium chloride 65 DUREX EXTRA SENSITIVE 60
disopyramide phosphate 11
DIAMOX 50 dutasteride-tamsulosin hcl 54
disulfiram 80
DIASTAT ACUDIAL 15 DYAZIDE 50
DITROPAN XL 86
DIASTAT PEDIATRIC 15 dyphylline-guaifenesin 11
divalproex sodium 16
DIASTIX 49 DYSPORT 73
DOCEFREZ 29
DIAZEPAM 11 E.E.S. 400 59
DOCETAXEL 29
diazepam 11 E.E.S. GRANULES 59
docetaxel 29
Index 6
EC-NAPROSYN 3 enoxaparin sodium 14 eszopiclone 57
econazole nitrate 44 entacapone 30 ethambutol hcl 26
ECOTRIN MAXIMUM entecavir 34 ethosuximide 16
STRENGTH 5 ENTOCORT EC 40 ETHYL CHLORIDE 47
ECOTRIN REGULAR
STRENGTH 5 ENTRE-HIST PSE 41 ETHYL CHLORIDE/FINE
ENTYVIO 53 PINPOINT 47
ED CHLORPED 22 ETHYL CHLORIDE/FINE
ED CHLORPED D 41 EPCLUSA 35 STREAM 48
EDURANT 33 EPHEDRINE HCL 13 ETHYL CHLORIDE/MEDIUM
efavirenz 33 epinephrine (anaphylaxis) 89 JET STREAM 48
ETHYL CHLORIDE/MEDIUM
EFFEXOR XR 18 EPIVIR 33 STREAM 48
EFFIENT 56 EPIVIR HBV 35 ETHYL CHLORIDE/MIST 48
EFUDEX 44 EPZICOM 33 ethynodiol diacet & eth
ELAVIL 18 EQ OMEPRAZOLE 85 estrad 38
ELDEPRYL 30 EQ TRIACTING ETIDRONATE DISODIUM 51
COLD/ALLERGY 41 etidronate disodium 51
ELEXA NATURAL FEEL 60 EQL CALCIUM/VITAMIN
ELEXA STIMULATING 60 etodolac 3
D 65
ELEXA ULTRA SENSITIVE 60 EQL NATURAL FIBER 57 ETOPOSIDE 29
ELIMITE 48 EQL OMEPRAZOLE 85 EURAX 48
ELIQUIS 13 EQL PRENATAL EVAC 57
ELIQUIS STARTER PACK 13 FORMULA 69 EVISTA 51
EQUALACTIN 57 EVOTAZ 33
ELIXOPHYLLIN 13
ergocalciferol 89 EX-LAX 59
ELLA 39
ERGOLOID MESYLATES 81 EXALGO 5
ELMIRON 54
ERGOMAR 64 EXCEL COMFORT POINT
ELOCON 46 INSULIN PEN NEEDLES 31G X
ergotamine w/ caffeine 64
ELOCTATE 55 4MM 63
ERIVEDGE 27
ELTA TAR 49 EXELDERM 44
ERY-TAB 59
EMCYT 27 EXELON 80
ERYGEL 43
EMEND 22 exemestane 27
ERYPED 200 59
EMEND TRIPACK 22 EXTAVIA 81
ERYPED 400 60 EXTRA SENSITIVE
EMLA 47
ERYTHROCIN SPERMICIDAL 60
EMPLICITI 27 STEARATE 60 ezetimibe 24
EMSAM 17 erythromycin (acne aid) 43
EZFE FORTE 69
EMTRIVA 33 erythromycin (ophth) 77
FABRAZYME 51
EMVERM 9 erythromycin base 60
famciclovir 35
enalapril maleate 24 ERYTHROMYCIN BASE 60
enalapril maleate & famotidine 84
erythromycin
hydrochlorothiazide 25 ethylsuccinate 60 FAMVIR 35
ENBREL 4 ERYTHROMYCIN FANAPT 31
ENBREL MINI 4 ETHYLSUCCINATE 60 FANAPT TITRATION PACK 31
ENBREL SURECLICK 4 escitalopram oxalate 17 FANTASY LUBRICATED 60
ENCARE 88 ESGIC 4 FANTASY
ENEMEEZ MINI 59 estazolam 57 LUBRICATED/SPERMICIDE
ESTRACE 52 60
ENEMEEZ PLUS 59 FARESTON 28
ENFAMIL ENFALYTE 65 estradiol 52
estradiol vaginal 89 FARYDAK 28
ENFAMIL EXPECTA 69 fat emulsion 73
ENGERIX-B 87 ESTROPIPATE 52
ESTROSTEP FE 38 FAZACLO 31
Index 7
FC FEMALE CONDOM 60 fluconazole 22 FREESTYLE CONTROL
FC2 FEMALE CONDOM 60 fluconazole in dextrose 22 SOLUTION HIGH/LOW 62
FREESTYLE FLASH
FEIBA 55 fludrocortisone acetate 40 SYSTEM 62
felbamate 16 FLUMADINE 35 FREESTYLE FREEDOM
FELBATOL 16 FLUNISOLIDE 73 LITE 62
FREESTYLE INSULINX
FELDENE 3 fluocinolone acetonide 46 BLOODGLUCOSE
felodipine 36 fluocinonide 46 MONITORING SYSTEM 62
FEMARA 28 fluocinonide emulsified FREESTYLE INSULINX
FEMCAP 60 base 46 BLOODGLUCOSE TEST 49
fluorometholone (ophth) 78 FREESTYLE INSULINX
FEMCON FE 38 BLOODGLUCOSE TEST
FLUOROPLEX 45
FEMHRT LOW DOSE 52 STRIPS 49
FLUOROURACIL 45 FREESTYLE LITE BLOOD
fenofibrate micronized 24
fluorouracil (topical) 45 GLUCOSE MONITORING
fenoprofen calcium 3 SYSTEM 62
FLUOXETINE 81
FER-IN-SOL 56 FREESTYLE LITE TEST
fluoxetine hcl 17 STRIPS 49
FERROUS GLUCONATE 56
fluphenazine decanoate 32 FREESTYLE PRECISION NEO
ferrous sulfate 56
FLUPHENAZINE HCL 32 BLOOD GLUCOSE TEST
FERROUS SULFATE 56 STRIPS 49
fluphenazine hcl 32
ferrous sulfate 56 FREESTYLE PRECISION NEO
FLURA-DROPS 66 BOOD GLUCOSE MONITORING
FERROUS SULFATE 56
FLURAZEPAM HCL 57 SYSTEM 62
ferrous sulfate 56
FLURBIPROFEN SODIUM78 FREESTYLE SYSTEM KIT 62
FERROUS SULFATE 56
flurbiprofen sodium 78 FREESTYLE TEST STRIPS 49
ferrous sulfate 56
flutamide 28 FURADANTIN 85
FEVERALL INFANTS 4
fluticasone propionate furosemide 50
FEXMID 72 (nasal) 73 FUZEON 33
FIBERCON 57 FLUTICASONE
PROPIONATE/SALMETEROL FYCOMPA 15
FINACEA 48
13 gabapentin 15
finasteride 54
fluvastatin sodium 24 GABITRIL 16
FIORICET/CODEINE 7
fluvoxamine maleate 17 galantamine hydrobromide 80
FIORINAL 4 GALANTAMINE
FML 78
FIORINAL/CODEINE #3 7 HYDROBROMIDE 80
FML FORTE 78
FIRST-LANSOPRAZOLE 85 galantamine hydrobromide 80
FML LIQUIFILM 78
FIRST-MOUTHWASH BLM 68 GARDASIL 87
folic acid 56
FIRST-OMEPRAZOLE 85 GARDASIL 9 87
FOLIC ACID 56
FLAGYL 9 GAS-X EXTRA STRENGTH 53
folic acid 56
flecainide acetate 11 GASTROCROM 53
FORTAMET 19
FLEET BISACODYL 59 gatifloxacin (ophth) 77
FORTICAL 51
FLEET LIQUID GLYCERIN GELUSIL 9
SUPPOSITORIES 58 FOSAMAX 51
FOSAMAX PLUS D 51 gemfibrozil 24
FLOMAX 54
FLONASE ALLERGY fosamprenavir calcium 33 GENERESS FE 38
RELIEF 73 fosinopril sodium 24 GENTAK 77
FLONASE ALLERGY RELIEF fosinopril sodium & gentamicin in saline 2
CHILDRENS 73 hydrochlorothiazide 25 gentamicin sulfate (ophth) 77
FLORIVA PLUS 68 FREAMINE HBC 6.9% 75 gentamicin sulfate (topical) 44
FLOVENT DISKUS 12 FREAMINE III 75 GENTAMICIN SULFATE/0.9%
FLOVENT HFA 12 FREESTYLE CONTROL SODIUM CHLORIDE 2
FLOXIN OTIC 79 SOLUTION 62 GENVOYA 33
Index 8
GEODON 31 HAEMOLANCE LOW FLOW HUMALOG KWIKPEN 20
GILENYA 81 LANCETS 62 HUMALOG MIX 50/50 20
HAEMOLANCE PLUS 62 HUMALOG MIX 50/50
GILOTRIF 28
HAEMOLANCE PLUS HIGH KWIKPEN 20
GLASSIA 82 FLOW 62 HUMALOG MIX 75/25 20
glatiramer acetate 81 HAEMOLANCE PLUS LOW
FLOW 62 HUMALOG MIX 75/25
GLEEVEC 28 KWIKPEN 20
HAEMOLANCE PLUS MAX
GLEOSTINE 27 FLOW 62 HUMATE-P 55
glimepiride 20 HAEMOLANCE PLUS HUMATROPE 51
glipizide 20 PEDIATRIC FLOW 62 HUMATROPE COMBO
glipizide-metformin hcl 18 HALAVEN 29 PACK 51
GLUCAGON EMERGENCY HALCION 57 HUMIRA 2
KIT 19 HALDOL 31 HUMIRA PEDIATRIC CROHNS
GLUCOPHAGE 19 HALDOL DECANOATE DISEASE STARTER PACK 2
GLUCOPHAGE XR 19 100 31 HUMIRA PEN 2
HALDOL DECANOATE 50 31 HUMIRA PEN-CROHNS
GLUCOTROL 20 DISEASESTARTER 2
GLUCOTROL XL 20 halobetasol propionate 46 HUMIRA PEN-PSORIASIS
GLUCOVANCE 18 haloperidol 31 STARTER 2
glyburide 20 HALOPERIDOL 38 HUMULIN 70/30 20
glyburide micronized 20 haloperidol decanoate 31 HUMULIN 70/30 KWIKPEN 20
glyburide-metformin 18 haloperidol lactate 31 HUMULIN N 20
glycopyrrolate 84 HARVONI 35 HUMULIN N KWIKPEN 20
GLYNASE 20 HAVRIX 87 HUMULIN R 20
GNP CALAMINE 48 HEALTHY MAMA BE WELL HUMULIN R U-500
ROUNDED 69 (CONCENTRATED) 20
GNP CALAMINE HUMULIN R U-500
PHENOLATED 48 HELIXATE FS 55
HEMA-COMBISTIX 49 KWIKPEN 20
GNP DAILY PRENATAL 69 HYCET 7
GNP OMEPRAZOLE 85 HEMANGEOL 36
hydralazine hcl 26
GNP PRENATAL 69 HEMOFIL M 55
heparin sod (porcine) in HYDREA 29
GOCOVRI 30 hydrochlorothiazide 50
d5w 14
GOLYTELY 58 HEPARIN SODIUM/D5W 14 HYDROCIL INSTANT 57
GOODSENSE PRENATAL hydrocodone polistirex-
VITAMINS 69 HEPATAMINE 75
HEPLISAV-B 87 chlorpheniramine polistirex 41
GOODSENSE UNIVERSAL 1 hydrocodone w/
MICRO THIN 33G 62 HEPSERA 35 homatropine 40
GOODSENSE UNIVERSAL 1 HERCEPTIN 27
MICRO-THIN 33G 62 hydrocodone-acetaminophen 7
GOODSENSE UNIVERSAL HEXALEN 27 hydrocortisone 40
1THIN 26G 62 HIGH SENSATION hydrocortisone (intrarectal) 8
GRANISETRON HCL 21 SPERMICIDAL 60
hydrocortisone (rectal) 8
granisetron hcl 21 HM CALAMINE 48
hydrocortisone (topical) 46
GRIS-PEG 22 HM FIBER 57
hydrocortisone acetate
griseofulvin microsize 22 HM FIBER POWDER 57 (topical) 46
griseofulvin ultramicrosize 22 HM OMEPRAZOLE 85 hydrocortisone acetate w/
HM ONE DAILY PRENATAL pramoxine 8
guaifenesin-codeine 41 COMBO 69 hydrocortisone valerate 46
guanfacine hcl 25 HM PRENATAL 69 hydrocortisone-aloe vera 46
guanfacine hcl (adhd) 1 homatropine hbr 76 hydromorphone hcl 5
GYNE-LOTRIMIN 88 HUMALOG 20 HYDROMORPHONE HCL 5
H.P. ACTHAR 51 HUMALOG JUNIOR hydromorphone hcl 5
HAEMOLANCE 62 KWIKPEN 20
Index 9
hydroxychloroquine sulfate 26 INVEGA SUSTENNA 31 JANUMET XR 19
HYDROXYPROGESTERONE INVEGA TRINZA 31 JANUVIA 19
CAPROATE 28 INVIRASE 33 JARDIANCE 20
hydroxyurea 29
INVOKAMET 18 JENTADUETO 19
hydroxyzine hcl 10
INVOKAMET XR 18 JULUCA 33
HYDROXYZINE PAMOATE 10
INVOKANA 20 K-PHOS 66
hydroxyzine pamoate 11 IONOSOL-B/DEXTROSE K-PHOS NEUTRAL 66
hyoscyamine sulfate 84 5% 65 K-TAB 67
HYPERSAL 42 IONOSOL-MB/DEXTROSE
5% 65 KABIVEN 74
HYVEE ADVANCED ANTACID
MAXIMUM STRENGTH 9 IOPIDINE 77 KADCYLA 27
HYZAAR 25 ipratropium bromide 12 KADIAN 5
IBRANCE 28 ipratropium bromide KALETRA 33
ibuprofen 3 (nasal) 73 KALYDECO 82
ipratropium-albuterol 13 KAMELEON LUBRICATED 60
IDELVION 55
irbesartan 25 KAPVAY 1
IDHIFA 28
irbesartan-hydrochlorothiazide
ILARIS 3 25 KAYEXALATE 68
imatinib mesylate 28 IRESSA 28 KAZANO 19
IMBRUVICA 28 IRINOTECAN 30 KCL 0.15%/D5W/NACL
0.225% 65
imipramine hcl 18 irinotecan hcl 30 KCL 0.3%/D5W/NACL 0.9% 65
imiquimod 47 IRON CHEWS
PEDIATRIC 56 KEFLEX 38
IMITREX 64
iron combinations 56 KENALOG 46
IMITREX STATDOSE
REFILL 64 ISENTRESS 33 KEPPRA 15
IMITREX STATDOSE ISENTRESS HD 33 KETOCARE 49
SYSTEM 64 ISOLYTE-P/DEXTROSE ketoconazole 22
IMOVAX RABIES (H.D.C.V.) 87 5% 65 ketoconazole (topical) 44
IMPAVIDO 9 ISOLYTE-S 65 KETONE TEST STRIPS 49
IMURAN 67 ISOLYTE-S PH 7.4 65 KETOPROFEN 3
INATAL ADVANCE 69 ISONIAZID 26 ketoprofen 3
INATAL GT 69 isoniazid 26 ketorolac tromethamine
INATAL ULTRA 69 ISOPTO CARPINE 76 (ophth) 78
INCRUSE ELLIPTA 12 ISORDIL TITRADOSE 10 KETOSTIX 49
indapamide 50 isosorbide dinitrate 10 ketotifen fumarate (ophth) 78
INDERAL LA 36 ISOSORBIDE DINITRATE KHEDEZLA 18
INDOCIN 3 ER 10 KIMONO COLORS 60
indomethacin 3 isosorbide mononitrate 10 KIMONO LUBRICATED 60
INFANTS ADVIL 3 ISOTONIC GENTAMICIN 2 KIMONO MICRO THIN PLUS
isotretinoin 43 SPERMICIDE LUBRICATED60
INFLECTRA 53 KIMONO PLUS SPERMICIDE
influenza virus vaccine injection ISTALOL 76
LUBRICATED 60
(2017-2018) 87 itraconazole 22 KIMONO PLUS
INSULIN SYRINGES AND PEN IXEMPRA KIT 29 SPERMICIDE/LUBRICATED
NEEDLES 63 60
IXINITY 55
INSUPEN 33GX4MM 63 KIMONO PS LUBRICATED 60
JADENU 21
INTELENCE 33 KIMONO PS PLUS
JADENU SPRINKLE 21 SPERMICIDE/LUBRICATED
INTENSE SENSATION 60
JAKAFI 28 60
INTRALIPID 73
JALYN 54 KIMONO SENSATION
INTUNIV 1 LUBRICATED 60
JANUMET 18
INVEGA 31
Index 10
KIMONO SENSATION PLUS
lamotrigine 15
LEXUSS 210 41
SPERMICIDE LUBRICATED60
LANCETS AND LANCET
LIALDA 53
KIMONO SPECIAL 60
DEVICES 62
LIBRAX 84
KISQALI 28
LANOXIN 37
LICE B GONE 48
KISQALI FEMARA 200

lansoprazole 85
DOSE 28
lidocaine 48
LARTRUVO 27
KISQALI FEMARA 400

lidocaine hcl 48
DOSE 28
LASIX 50
lidocaine hcl (mouth-throat) 68
KISQALI FEMARA 600

latanoprost 79
lidocaine-hydrocortisone acetate
DOSE 28
LATEX CONDOMS 60
(rectal) 8
KITABIS PAK 2
LATUDA 31
lidocaine-prilocaine 48
KLARON 43
leflunomide 4
liothyronine sodium 83
KLONOPIN 15
LEMTRADA 81
LIPITOR 24
KLS OMEPRAZOLE 85
LENVIMA 10 MG DAILY
lisinopril 24
KOATE 55
DOSE 28
lisinopril &
KOATE-DVI 55
LENVIMA 14 MG DAILY
hydrochlorothiazide 25
DOSE 28
LITHIUM 31
KOGENATE FS 55
LENVIMA 18 MG DAILY

KOGENATE FS BIO-SET 55
DOSE 28
lithium carbonate 30
KOMBIGLYZE XR 19
LENVIMA 20 MG DAILY
LITHIUM CARBONATE 30
KONSYL 57
DOSE 28
lithium carbonate 30,31
LENVIMA 24 MG DAILY

KONSYL-D 57
DOSE 28
LITHOBID 31
KORLYM 19
LENVIMA 8 MG DAILY
LMX 4 48
KOVALTRY 55
DOSE 29
LODINE 3
KP PRENATAL
LESCOL XL 24
LOESTRIN 1.5/30-21 38
MULTIVITAMINS 69
LETAIRIS 37
LOESTRIN FE 1.5/30 38
KPN PRENATAL 69
letrozole 28
LOESTRIN FE 1/20 38
KRYSTEXXA 54
LEUCOVORIN CALCIUM 29
LOMAIRA 1
KUVAN 51
leucovorin calcium 29
LOMOTIL 21
KYMRIAH 27
LEUKERAN 27
LONSURF 28
labetalol hcl 36
LEVAQUIN 53
LOPID 24
LABSTIX 49
LEVBID 84
lopinavir-ritonavir 33
LAC-HYDRIN 47
levetiracetam 15
LOPRESSOR 36
LAC-HYDRIN TWELVE 47
levobunolol hcl 76
LOPRESSOR HCT 25
lactated ringer's 65
levocarnitine (metabolic
loratadine 23
lactic acid (ammonium

modifiers) 51,52
loratadine &

lactate) 47
LEVOFLOXACIN 53
pseudoephedrine 41
lactic acid w/ vitamin e 47

levofloxacin 53
lorazepam 11
lactulose 58
levonorgestrel & eth
losartan potassium 25
lactulose (encephalopathy) 54
estradiol 38
levonorgestrel (emergency
losartan potassium &
LAMICTAL 15
oc) 39
hydrochlorothiazide 25
LAMICTAL CHEWABLE
levonorgestrel-eth estradiol
LOSEASONIQUE 38
DISPERSIBLE 15
(triphasic) 38
LOTENSIN 24
LAMISIL 22
levonorgestrel-ethinyl estradiol
LOTENSIN HCT 25
LAMISIL AT 44
(91-day) 38
LOTRIMIN AF 44
LAMISIL AT JOCK ITCH 44

levothyroxine sodium 83
LOTRIMIN AF FOR HER 44
LAMISIL AT SPRAY 44
LEVSIN 84
LOTRIMIN AF JOCK ITCH 44
lamivudine 33
LEVSIN/SL 84
LOTRISONE 44
lamivudine (hbv) 35
LEXAPRO 17
lovastatin 24
lamivudine-zidovudine 33
LEXIVA 33
LOVENOX 14
Index 11
loxapine succinate 31 melphalan 27 methylprednisolone 40

LOZI-FLUR 66 memantine hcl 80 methyltestosterone 8
LUCENTIS 76 MENACTRA 86 METIPRANOLOL 76
LUMIGAN 79 MENEST 52 metoclopramide hcl 53
LUMIZYME 52 MENOMUNE-A/C/Y/W-135 metolazone 50
LUNESTA 57 86 metoprolol &
LUNG PERFORMANCE PEAK MENVEO 86 hydrochlorothiazide 25
FLOW METER 63 MEPERIDINE HCL 5 metoprolol succinate 36
LURIDE 66 meperidine hcl 5 metoprolol tartrate 36
LYNPARZA 29 MEPHYTON 89 METOPROLOL/HYDROCHLOR
LYSODREN 28 meprobamate 11 OTHIAZIDE 25
METRO IV 9
LYSTEDA 57 MEPRON 10
METROCREAM 48
M-M-R II 87 mercaptopurine 27
METROGEL 48
M-VIT 69 mesalamine 53
METROGEL-VAGINAL 88
MAALOX 9 mesalamine w/ cleanser 53
METROLOTION 48
MACROBID 86 MESTINON 26
metronidazole 9
MACRODANTIN 86 MESTINON TIMESPAN 26
METRONIDAZOLE 9
MAG64 66 METAMUCIL 57,58
metronidazole 9
MAGDELAY 66 METAMUCIL FIBER 57
METAMUCIL MULTIHEALTH metronidazole (topical) 48
magnesium hydroxide 58
FIBER 58 metronidazole in nacl 9
MAKENA 80
METAMUCIL ORIGINAL metronidazole vaginal 88
MALARONE 26 TEXTURE 58 MEVACOR 24
malathion 48 METAMUCIL SMOOTH
TEXTUREFIBER mexiletine hcl 11
MARINOL 22
SINGLES 58 MIACALCIN 51
MARNATAL-F 69 METAPROTERENOL MICARDIS 25
MARPLAN 17 SULFATE 13
MICARDIS HCT 25
MATULANE 29 metformin hcl 19
MICATIN 44
MAVYRET 35 methadone hcl 6
miconazole nitrate (topical) 44
MAXIDEX 78 METHADOSE 6
METHADOSE SUGAR- miconazole nitrate vaginal 88
MAXITROL 78
FREE 6 MICRO-K 67
MAXX LUBRICATED 60
methazolamide 50 MICROLIFE DIGITAL PEAK
MAXX PLUS SPERMICIDE FLOW METER 63
LUBRICATED 60 methenamine-hyosc-methylene
blue-sod phos-phenyl sal 85 MICROZIDE 51
MAXZIDE 50
METHERGINE 79 midodrine hcl 89
MAXZIDE-25 50
methimazole 83 MIGERGOT 64
meclizine hcl 21
METHITEST 8 MILK OF MAGNESIA
MECLOFENAMATE SODIUM 3 CONCENTRATE 58
methocarbamol 72
MEDROL 40 MILLIPRED 40
methotrexate sodium 27
MEDROL DOSEPAK 40 MINI WRIGHT AFS PEAK
medroxyprogesterone METHYCLOTHIAZIDE 50 FLOWMETER LOW RANGE 63
acetate 80 methylcellulose (laxative) 58 MINI WRIGHT PEAK FLOW
medroxyprogesterone acetate methyldopa 25 METER 63
(contraceptive) 40 METHYLDOPA/HYDROCHLO MINIPRESS 25
MEGACE ORAL 28 ROTHIAZIDE 25 MINIVELLE 52
megestrol acetate 28 methylergonovine maleate 79 MINOCIN 82
MEIJER CALAMINE 48 methylphenidate hcl 2 minocycline hcl 82
MEKINIST 29 METHYLPHENIDATE HCL minoxidil 26
meloxicam 3 ER 2
MIRALAX 58
Index 12
MIRAPEX 30 mupirocin calcium (topical) 44 NAT-RUL PRENATAL
MIRCETTE 39 MURO 128 78 VITAMINS 69
NATACYN 77
mirtazapine 16 MYAMBUTOL 26
NATALVIT 70
misoprostol 85 MYCOBUTIN 26
nateglinide 20
mitoxantrone hcl 28 mycophenolate mofetil 67
NATURE-THROID 83
MOBIC 3 mycophenolate sodium 67
NATURE-THROID NT-2.5 83
modafinil 2 MYDRIACYL 76
NECON 10/11-28 39
MODERIBA 35 MYFORTIC 67
MODERIBA 1200 DOSE NEFAZODONE HCL 18
MYLERAN 27
PACK 35 nefazodone hcl 18
MYNATAL 69
MODERIBA 800 DOSE neomycin sulfate 2
PACK 35 MYNATAL ADVANCE 69
neomycin-bacitracin zn-
MODICON 39 MYNATAL PLUS 69 polymyxin 77
moexipril hcl 24 MYNATAL neomycin-polymy-dexameth 78
moexipril-hydrochlorothiazide ULTRACAPLET 69 neomycin-polymyxin-gramicidin
25 MYNATAL-Z 69 77
MOLINDONE MYNATE 90 PLUS 69 neomycin-polymyxin-hc
HYDROCHLORIDE 32 MYOBLOC 73 (otic) 79
mometasone furoate 46 NEOMYCIN/POLYMYXIN/HYDR
MYSOLINE 15 OCORTISONE 78
MONISTAT 3 88 nabumetone 3
MONISTAT 3 COMBINATION NEORAL 67
PACK 88 nadolol 36 NEOSPORIN 77
MONISTAT 7 SIMPLY nafcillin sodium 80 NEPHRAMINE 75
CURE 88 NAFCILLIN SODIUM 80 NEPTAZANE 50
MONISTAT SOOTHING CARE naftifine hcl 44
ITCH RELIEF 47 NERLYNX 29
MONOCAL 66 NAFTIN 44 NESINA 19
MONOCLATE-P 55 NAGLAZYME 52 NEURONTIN 15
MONONINE 55 NALOXONE HCL 21 NEVIRAPINE 33
montelukast sodium 12 naloxone hcl 21 nevirapine 33
morphine sulfate 6 NALOXONE HCL 21 NEXAFED SINUS PRESSURE
naltrexone hcl 21 +PAIN 41
MORPHINE SULFATE 6
NAMENDA 80 NEXAVAR 29
morphine sulfate 6
NAMENDA TITRATION niacin 89
MORPHINE SULFATE 6 PAK 80 niacin (antihyperlipidemic) 24
morphine sulfate 6 NAMENDA XR 80 NIACOR 24
MORPHINE SULFATE ER 6 NAMENDA XR TITRATION NIASPAN 24
MOTRIN INFANTS DROPS 3 PACK 80
NAPHAZOLINE HCL 77 NICODERM CQ 82
MS CONTIN 6
naphazoline w/ NICORETTE 82
MULTAQ 11
pheniramine 77 NICORETTE MINI 82
MULTI PRENATAL 69 NAPHCON-A 77 NICORETTE STARTER KIT 82
MULTISTIX 49 NAPROSYN 3 nicotine 82
MULTISTIX 10 SG 49 naproxen 4 nicotine polacrilex 82
MULTISTIX 5 49 NAPROXEN 4 NICOTINE TRANSDERMAL
MULTISTIX 7 49 naproxen 4 SYSTEM 82
MULTISTIX 8 SG 49 naproxen sodium 3,4 NICOTROL INHALER 82
MULTISTIX 9 49 naratriptan hcl 64 NICOTROL NS 82
MULTISTIX 9 SG 49 NARCAN 21 nifedipine 36,37
MULTIVITAMIN/FLUORIDE 68 NARDIL 17 nimodipine 37
mupirocin 44 NASAL DECONGESTANT 73 NINLARO 29
Index 13
nisoldipine 37 NORVIR 33 ONE A DAY WOMENS
NISOLDIPINE ER 37 NOVOEIGHT 55 PRENATAL/DHA 70
ONE A DAY WOMENS
NITRO-BID 10 NOVOSEVEN RT 55 PRENATAL1 70
NITRO-DUR 10 NPLATE 56 ONE-A-DAY WOMENS
nitrofurantoin 86 NUCALA 11 PRENATAL 70
nitrofurantoin macrocrystal 86 NUCYNTA ER 6 ONGLYZA 19
nitrofurantoin monohyd NUEDEXTA 81 OPDIVO 27
macro 86 NULYTELY/FLAVOR OPTIONS CONCEPTROL
nitroglycerin 10 PACKS 58 VAGINAL
CONTRACEPTIVE 88
NITROSTAT 10 NUPLAZID 31 OPTIONS GYNOL II
NIVA-PLUS 70 NUTRATEAR 76 VAGINALCONTRACEPTIVE
NIX CREME RINSE 48 NUTRICION PORVIDA 70 88
NIZORAL 44 NUVARING 39 ORACIT 54
nonoxynol-9 88 NUVIGIL 2 oral electrolytes 66
NOR-QD 40 NUWIQ 55 ORAP 82
NORCO 7 NYMALIZE 37 ORENCIA 4
NORDITROPIN FLEXPRO 51 nystatin 22 ORENCIA CLICKJECT 4
norethin acet & estrad-fe 39 nystatin (mouth-throat) 68 ORKAMBI 82
norethindrone & eth estradiol39 nystatin (topical) 44 ORTHO MICRONOR 40
norethindrone & ethinyl estradiol- nystatin-triamcinolone 44 ORTHO TRI-CYCLEN 39
fe 39 O-CAL FA 70 ORTHO TRI-CYCLEN LO 39
norethindrone & mestranol 39 ORTHO-CYCLEN 39
O-CAL PRENATAL 70
norethindrone ORTHO-NOVUM 1/35 39
(contraceptive) 40 OBIZUR 55
norethindrone acet & eth OBSTETRIX EC 70 ORTHO-NOVUM 7/7/7 39
estra 39 OBTREX 70 oseltamivir phosphate 35
norethindrone acetate 80 OCEAN NASAL SPRAY 72 OSENI 19
norethindrone acetate-ethinyl OTEZLA 4
estradiol 52 OCREVUS 81
norethindrone acetate-ethinyl OCUFEN 78 OVCON-35 39
estradiol-fe 39 OCUFLOX 77 OVIDE 48
norethindrone-eth estradiol ODEFSEY 33 OXANDRIN 8
(triphasic) 39 oxandrolone 8
norgestimate-ethinyl ODOMZO 27
estradiol 39 OFLOXACIN 53 oxaprozin 4
norgestimate-ethinyl estradiol ofloxacin (ophth) 77 oxazepam 11
(triphasic) 39 oxcarbazepine 15
ofloxacin (otic) 79
norgestrel & ethinyl estradiol 39 oxybutynin chloride 86
OGESTREL 39
NORINYL 1+35 39 oxycodone hcl 6
olanzapine 31
NORINYL 1+50 39 OXYCODONE HCL ER 6
olanzapine-fluoxetine hcl 81
NORMOSOL -R 66 oxycodone w/ acetaminophen 7
OLUX 47
NORMOSOL-M IN D5W 66 OXYCODONE/ACETAMINOPHE
omeprazole 85
NORMOSOL-R 66 N 7
OMEPRAZOLE 85 OXYCONTIN 6
NORPACE 11
OMEPRAZOLE + SYRSPEND
NORPACE CR 11 SFALKA 85 oyster shell 65
NORPRAMIN 18 OMNIFLEX DIAPHRAGM 61 PA PRENATAL FORMULA 70
NORTEMP INFANTS 5 OMNIPRED 78 paliperidone 31
nortriptyline hcl 18 ondansetron 21 PAMELOR 18
NORTRIPTYLINE HCL 18 ondansetron hcl 21 PANOXYL 43
NORVASC 37 PANOXYL-4 CREAMY
WASH 43
Index 14
PANRETIN 45 PERCOCET 7 PLEGRIDY 81
pantoprazole sodium 85 PERIKABIVEN 74 PLEGRIDY STARTER

paricalcitol 52 permethrin 49 PACK 81
PNEUMOVAX 23 86
PARLODEL 30 perphenazine 32
PERPHENAZINE/AMITRIPTYL PNEUMOVAX 23/1 DOSE 86
PARNATE 17
INE 81 PNV FERROUS
paromomycin sulfate 2 FUMARATE/DOCUSATE/FOLIC
PERRY PRENATAL 70
paroxetine hcl 17 ACID 70
PERSANTINE 56 PNV FOLIC ACID + IRON
PARVA-CAL 65
PERSONAL BEST FULL MULTIVITAMIN 70
PAXIL 17 RANGE 63 PNV PRENATAL PLUS
PAXIL CR 17 PERSONAL BEST LOW MULTIVITAMIN 70
PCE 60 RANGE 64 PNV PRENATAL PLUS
PEAK AIR PEAK FLOW phenazopyridine hcl 54 MULTIVITAMIN + DHA 70
METERADULT/PEDIATRIC 63 phenelzine sulfate 17 PNV TABS 29-1 70
ped multivitamins w/fl & iron 68 phenobarbital 57 PNV-VP-U 70
PEDIALYTE 66 PHENOBARBITAL 57 POCKET PEAK FLOW
PEDIALYTE FREEZER METER 64
phenobarbital 57 POCKETPEAK PEAK FLOW
POPS 66
pediatric multiple vitamin w/ phenoxybenzamine hcl 25 METER LOW RANGE 64
c 69 phentermine hcl 1 POCKETPEAK PEAK FLOW
pediatric multiple vitamins w/ phenylephrine hcl (ophth) 77 METER/UNIVERSAL RANGE 50-
iron 68 720 LPM 64
PHENYTEK 16 podofilox 47
pediatric multivitamins w/fl 68
phenytoin 16 POLY-VI-FLOR 68
pediatric vitamins acd w/
fluoride 68 phenytoin sodium
extended 16 POLY-VI-FLOR/IRON 68
pediatric vitamins adc 69 PHILLIPS MILK OF polyethylene glycol 3350 58
peg 3350-kcl-sod bicarb-sod MAGNESIA 58 polymyxin b-trimethoprim 77
chloride-sod sulfate 58 PHILLIPS MILK OF
peg 3350-potassium chloride-sod polysaccharide iron complex 56
MAGNESIA CHEWABLE 58
bicarbonate-sod chloride 58 PHILLIPS MILK OF POLYSPORIN 44
PEG-INTRON REDIPEN 35 MAGNESIA POLYTRIM 77
PEG-INTRON REDIPEN PAK CONCENTRATED 58 polyvinyl alcohol 76
4 35 PHOSPHOLINE IODIDE 76 POMALYST 28
PEGASYS 35 phytonadione 89 pot phosphate monobasic w/ sod
PEGASYS PROCLICK 35 PICATO 45 phosphate dibasic &
PEGINTRON 35 PIKO 1 ELECTRONIC 64 monobasic 66
PENICILLIN V POTASSIUM 79 pilocarpine hcl 76 potassium bicarb & chloride 67
penicillin v potassium 79 pilocarpine hcl (oral) 68 potassium bicarbonate 67
pentoxifylline 56 pimozide 82 potassium chloride 67
PEPCID 84 pioglitazone hcl 19 POTASSIUM CHLORIDE 67
PEPCID AC 84 pioglitazone hcl- potassium chloride 67
PEPCID AC EZ CHEWS glimepiride 19 POTASSIUM CHLORIDE 67
MAXIMUM STRENGTH 84 pioglitazone hcl-metformin potassium chloride 67
PEPCID AC MAXIMUM hcl 19 POTASSIUM CHLORIDE
STRENGTH 84 piroxicam 4 /SODIUM CHLORIDE 66
PEPTO BISMOL 21 PLAN B ONE-STEP 39 POTASSIUM CHLORIDE
PEPTO-BISMOL 21 PLAQUENIL 26 ER 67
PEPTO-BISMOL potassium chloride in
PLASMA-LYTE A 66 dextrose 66
INSTACOOL 21
PEPTO-BISMOL MAX PLASMA-LYTE-148 66 potassium chloride in dextrose &
STRENGTH 21 PLASMA-LYTE-56/D5W 66 sodium chloride 66
PEPTO-BISMOL TO-GO 21 PLAVIX 56 potassium chloride in nacl 66
Index 15
potassium chloride PREDNISOLONE SODIUM PRENATAL/OMEGA-3/FOLIC
microencapsulated crystals PHOSPHATE 78 ACID/IRON 71
er 67 PREDNISONE 40 PREPLUS 71
POTASSIUM prednisone 40 PRETAB 71
CHLORIDE/DEXTROSE 66
POTASSIUM PREDNISONE 40 PREVACID 85
CHLORIDE/DEXTROSE/LACTA PREDNISONE INTENSOL 40 PREVACID 24HR 85
TED RINGERS 66 PREMARIN 52,89 PREVACID SOLUTAB 85
POTASSIUM
CHLORIDE/LIDOCAINE PREMASOL 75 PREVNAR 13 86
HYDROCHLORIDE/SODIUM PREMIUM CONDOMS PREVPAC 85
CHLORIDE 66 LUBRICATED 61 PREZCOBIX 33
POTASSIUM PREMPHASE 52
PREZISTA 33
CHLORIDE/SODIUM PREMPRO 52
CHLORIDE 66 PRIFTIN 26
PRENATA 70
POTASSIUM PRILOSEC 85
CHLORIDE/SODIUMCHLORIDE PRENATABS FA 70
PRILOSEC OTC 85
66 PRENATABS RX 70
primidone 15
potassium citrate PRENATAL 71
(alkalinizer) 54 PRINIVIL 24
PRENATAL 19 70
POTASSIUM IODIDE 66 PRISTIQ 18
PRENATAL ADULT
POTIGA 15 GUMMY/DHA/FOLIC probenecid 55
PRADAXA 14 ACID 70 PROBUPHINE IMPLANT KIT 7
pramipexole dihydrochloride 30 PRENATAL AND IRON 70 procainamide hcl 11
PRAMOSONE 47 PRENATAL COMPLETE 70 PROCARDIA 37
prasugrel hcl 56 PRENATAL FORMULA 70 PROCARDIA XL 37
PRAVACHOL 24 PRENATAL FORMULA A- prochlorperazine 32
FREE 70
pravastatin sodium 24 prochlorperazine maleate 32
PRENATAL FORTE 70
prazosin hcl 25 PRENATAL GUMMIES/DHA & PROCTOCORT 8
PRE-NATAL FORMULA 70 FOLIC ACID 70 PROCTOFOAM HC 8
PRECISION GLUCOSE PRENATAL LOW IRON 70 PROFE FORTE 71
CONTROL 62 PRENATAL MULTI + DHA 70 PROFILNINE 55
PRECISION GLUCOSE
CONTROLSOLUTION (TRI- PRENATAL MULTI +DHA 70 PROFILNINE SD 55
LEVEL/HI/LO/NORMAL) 63 PRENATAL PROGRAF 67
PRECISION GLUCOSE MULTIVITAMIN 70 PROLASTIN-C 82
KETONECONTROL SOLUTION PRENATAL MULTIVITAMIN +
DHA 70 PROMACTA 56
1-LOW, 1-HIGH 63 promethazine &
PRECISION PRENATAL MULTIVITAMIN
GLUCOSE/KETONECONTROL PLUS DHA 70 phenylephrine 41
SOLUTIONS 1-HI 1-LO 63 PRENATAL ONE DAILY 70 promethazine hcl 23
PRECISION XTRA 49 PRENATAL PLUS 70 promethazine w/codeine 41
PRECISION XTRA BLOOD PRENATAL PLUS DHA 70 promethazine-dm 41
GLUCOSE TEST STRIPS 49 PRENATAL PLUS IRON 70 promethazine-phenylephrine-
PRECOSE 18 codeine 41
PRENATAL VITAMIN 71 PROMETHAZINE/PHENYLEPHR
PRED FORTE 78 PRENATAL VITAMIN & INE 41
PRED MILD 78 MINERAL 71 propafenone hcl 11
PRED-G 78 PRENATAL
VITAMIN/IRON 71 PROPANTHELINE
PRED-G S.O.P. 78 BROMIDE 84
PRENATAL VITAMINS 71
prednisolone 40 proparacaine hcl 77
PRENATAL VITAMINS PLUS
prednisolone acetate (ophth) 78 LOW IRON 71 propranolol hcl 36
prednisolone sodium PRENATAL+DHA 71 PROPRANOLOL HCL 36
phosphate 40 PRENATAL-U 71 propranolol hcl 36
Index 16
PROPRANOLOL/HYDROCHLOR RA OMEPRAZOLE 85 RESTORIL 57
OTHIAZIDE 26 RA ONE DAILY 71 RETIN-A 43
propylthiouracil 83 RA OYSTER SHELL RETIN-A MICRO 43
PROSCAR 54 CALCIUM/VITAMIN D 65 RETIN-A MICRO PUMP 43
PROSOL 75 RA PRENATAL 71
RETROVIR 33
PROTONIX 85 RA PRENATAL
FORMULA/FOLICACID 71 REXULTI 32
protriptyline hcl 18
RABAVERT 87 REYATAZ 33
PROVENGE 27
RADICAVA 73 RHEUMATREX 2
PROVERA 80
raloxifene hcl 51 RHINOCORT AQUA 73
PROVIGIL 2
ramipril 24 RIBASPHERE 35
PROZAC 17
ranitidine hcl 84 RIBASPHERE RIBAPAK 35
PRUDOXIN 45
RAPAMUNE 67,68 ribavirin (hepatitis c) 35
pseudoephedrine hcl 73
RAZADYNE 81 RID 49
PSORCON 47
RAZADYNE ER 81 RIDAURA 2
psyllium 58
REALITY LATEX rifabutin 26
PULMICORT 12 CONDOMS/LUBRICATED 61 RIFADIN 26
PULMICORT FLEXHALER 12 REALITY LATEX/ULTRA
TEXTURED 61 rifampin 26
PULMOZYME 82
REALITY LATEX/ULTRA RIGHT STEP PRENATAL 71
PUREFE OB PLUS 71 THIN 61 RILUTEK 73
PURIXAN 27 REBETOL 35 riluzole 73
PX CALAMINE 48 REBIF 81 rimantadine hydrochloride 35
PX OMEPRAZOLE 85 REBIF REBIDOSE 81 ringer's 66
PX PRENATAL REBIF REBIDOSE
MULTIVITAMINS 71 RISACAL-D 65
TITRATIONPACK 81
pyrantel pamoate 9 REBIF TITRATION PACK 81 RISPERDAL 31
pyrazinamide 26 REBINYN 55 RISPERDAL CONSTA 31
pyrethrins-piperonyl butoxide49 RECLAST 51 RISPERDAL M-TAB 31
PYRIDIUM 54 RECOMBINATE 55 risperidone 31
pyridostigmine bromide 26 RECOMBIVAX HB 87 RISPERIDONE ODT 31
pyridoxine hcl 89 RECTIV 8 RITALIN 2
QC CALAMINE 48 REGENECARE HA 48 RITUXAN 27
QC PRENATAL 71 REGIMEX 1 RITUXAN HYCELA 28
QSYMIA 1 REGLAN 53 rivastigmine 81
QUESTRAN 24 RELENZA DISKHALER 35 rivastigmine tartrate 81
QUESTRAN LIGHT 24 RELION KETONE 49 RIXUBIS 55
quetiapine fumarate 31 RELION KETONE TEST ROBAXIN 72
QUFLORA PEDIATRIC 68 STRIPS 49 ROBAXIN-750 72
quinapril hcl 24 REMERON 17 ROBINUL 84
quinapril-hydrochlorothiazide REMERON SOLTAB 16 ROBINUL FORTE 84
26 REMICADE 54 ROCALTROL 52
quinidine gluconate 11 REMODULIN 37 ropinirole hydrochloride 30
QUINIDINE SULFATE 11 RENFLEXIS 54 ROWASA 54
QUINIDINE SULFATE ER 11 REQUIP 30 ROXICODONE 6
QVAR 12,13 REQUIP XL 30 RUBRACA 29
QVAR REDIHALER 13 RESCRIPTOR 33 RYDAPT 29
RA CALAMINE 48 RESTASIS 77 RYMED 42
RA CALCIUM HI- RESTASIS MULTIDOSE 77
CAL/VITAMIND 65 RYTHMOL 11
Index 17
RYTHMOL SR 11 SM ONE DAILY SUDAFED PE CHILDRENS
SABRIL 16 PRENATAL 71 NASAL DECONGESTANT 73
SM PRENATAL VITAMINS71 SULAR 37
SALAGEN 68
sodium chloride 67 sulfacetamide sod-
saline 72 prednisolone 78
sodium chloride (inhalant) 42
salsalate 5 SULFACETAMIDE SODIUM 77
sodium chloride hypertonic 79
SAMSCA 52 sulfacetamide sodium (acne) 43
sodium citrate & citric acid 54
SANDIMMUNE 68 sulfacetamide sodium
sodium fluoride 66 (ophth) 77
SANTYL 47
SODIUM FLUORIDE 66 sulfacetamide sodium w/
SAPHRIS 32 sulfur 43
sodium polystyrene
SAXENDA 1 sulfonate 68 SULFADIAZINE 82
SB OMEPRAZOLE 85 SODIUM sulfamethoxazole-trimethoprim
SE-NATAL 19 71 SULFACETAMIDE/SULFUR 10
43 SULFAMYLON 45
SEASONIQUE 39
SOLIQUA 100/33 19 sulfasalazine 54
SECTRAL 36
SOLIRIS 55 sulindac 4
selegiline hcl 30
SOMA 72 sumatriptan succinate 64
selenium sulfide 45
sotalol hcl 36 SUMATRIPTAN
SELZENTRY 34
sotalol hcl (afib/afl) 36 SUCCINATE 64
sennosides 59 sumatriptan succinate 64
SOTYLIZE 36
SENSIPAR 52 SUPRENZA 1
SOVALDI 35
SEREVENT DISKUS 13 SPACER/AEROSOL-HOLDING SUSTIVA 34
SEROQUEL 32 CHAMBERS 64 SUTENT 29
SEROQUEL XR 32 SPIRIVA HANDIHALER 12 SW OMEPRAZOLE 85
sertraline hcl 17 SPIRIVA RESPIMAT 12 SYLATRON 29
SFROWASA 54 spironolactone 50 SYMAX DUOTAB 84
SHINGRIX 88 spironolactone &
hydrochlorothiazide 50 SYMBICORT 13
SHOHLS SOLUTION
MODIFIED 54 SPORANOX 22 SYMBYAX 81
SHUR-SEAL 88 SPORANOX PULSEPAK 22 SYMLINPEN 120 18
SILPHEN COUGH 23 SPRYCEL 29 SYMLINPEN 60 18
SILVADENE 45 SSKI 66 SYNAGIS 79
silver sulfadiazine 45 STARLIX 20 SYNALAR 47
simethicone 53 stavudine 34 SYNAREL 51
SIMILAC PRENATAL EARLY STELARA 45 SYNJARDY 19
SHIELD 71 STIMATE 52 SYNJARDY XR 19
SIMPONI ARIA 2 SYNTHAMIN 17 75
STIOLTO RESPIMAT 13
simvastatin 24 SYNTHROID 83
STRATTERA 1
SINEMET 30 TABLOID 27
STRIBILD 34
SINEMET CR 30 tacrolimus 68
STRIVERDI RESPIMAT 13
SINGULAIR 12 TAFINLAR 29
STUART ONE 72
sirolimus 68 TAGAMET HB 84
SUBLOCADE 7
SLO-NIACIN 89 TAGRISSO 29
SUBOXONE 7
SM CALAMINE 48 TAMIFLU 35
sucralfate 85
SM CALAMINE tamoxifen citrate 28
PHENOLATED 48 SUDAFED CHILDRENS 73
SM FIBER 58 SUDAFED CONGESTION 73 tamsulosin hcl 54
SM FIBER POWDER 58 SUDAFED NASAL TANZEUM 19
DECONGESTANT MAXIMUM TAPAZOLE 83
SM OMEPRAZOLE 85 STRENGTH 73 TARCEVA 29
Index 18
TARGRETIN 29 THEO-24 13 TOLBUTAMIDE 20
TARKA 26 theophylline 13 tolmetin sodium 4
TARON-BC 72 THERANATAL TOLMETIN SODIUM 4
TASIGNA 29 COMPLETE 72 tolnaftate 44
THERANATAL CORE
TAXOTERE 29 NUTRITION 72 tolterodine tartrate 86
tazarotene 45 thiamine hcl 89 TOPAMAX 15
TAZORAC 45 THIOLA 54 TOPAMAX SPRINKLE 15
TECFIDERA 81 thioridazine hcl 32 TOPICORT 47
TECFIDERA STARTER thiothixene 32 topiramate 15
PACK 81 TOPROL XL 36
TECHLITE PEN NEEDLES 29GX THRIVITE 19 72
10MM 63 THRIVITE RX 72 total parenteral nutrition 74
TECHNIVIE 35 thyroid 83 TRACLEER 37
TEGRETOL 15 THYROLAR-1 83 TRADJENTA 19
TEGRETOL-XR 15 THYROLAR-1/2 83 tramadol hcl 6
telmisartan 25 THYROLAR-1/4 83 trandolapril-verapamil hcl 26
telmisartan-amlodipine 26 THYROLAR-2 83 tranexamic acid 57
telmisartan-hydrochlorothiazide THYROLAR-3 83 TRANXENE T 11
26 tiagabine hcl 16 tranylcypromine sulfate 17
temazepam 57 TRAVASOL 75
TIAZAC 37
TEMODAR 27 trazodone hcl 18
TIGAN 21
TEMOVATE 47 tretinoin 43
TIKOSYN 11
TEMOVATE E 47 tretinoin (chemotherapy) 29
TIMOLOL MALEATE 36
temozolomide 27 tretinoin microsphere 43
timolol maleate (ophth) 76
TENCON 4 TIMOLOL MALEATE TRETTEN 55
TENEX 25 OPHTHALMIC GEL TREXALL 27
TENIVAC 83 FORMING 76
TRI-NORINYL 28 39
tenofovir disoproxil fumarate 34 TIMOPTIC 76
TRI-VI-SOL 69
TENORETIC 100 26 TIMOPTIC OCUDOSE 76
TRI-VIT/FLUORIDE/IRON 69
TENORETIC 50 26 TIMOPTIC-XE 76
TRIADVANCE 72
TENORMIN 36 TINACTIN 44
triamcinolone acetonide
terazosin hcl 25 TINACTIN JOCK ITCH 44 (mouth) 68
terbinafine hcl 22 tioconazole vaginal 89 triamcinolone acetonide
TIVICAY 34 (topical) 47
terbinafine hcl (topical) 44 TRIAMINIC COUGH & RUNNY
terbutaline sulfate 13 tizanidine hcl 72 NOSE 23
TESSALON PERLES 41 TL FOLATE 72 triamterene &
TESTIM 8 TOBI 2 hydrochlorothiazide 50
TOBI PODHALER 2 TRIAMTERENE/HYDROCHLOR
testosterone 8 OTHIAZIDE 50
TESTOSTERONE 8 TOBRADEX 78 TRIAZOLAM 57
TESTOSTERONE PUMP 8 tobramycin 2 triazolam 57
TESTRED 8 TOBRAMYCIN 2 TRICARE 72
TETANUS/DIPHTHERIA tobramycin (ophth) 77 TRIDESILON 47
TOXOIDS-ADSORBED 83 tobramycin-
dexamethasone 78 trifluoperazine hcl 32
tetrabenazine 81
TOBREX 77 trifluridine 77
tetracaine hcl (ophth) 77
TODAY SPONGE 88 trihexyphenidyl hcl 30
tetracycline hcl 82
TOFRANIL 18 TRILEPTAL 16
TETRACYCLINE HCL 83
TOLAZAMIDE 20 trimethobenzamide hcl 21
TGT OMEPRAZOLE 85
Index 19
trimethoprim 9 TRUSTEX UNIFIBER 58
TRINATAL GT 72 LUBRICATED/RIBBED/STUDD URECHOLINE 86
ED 61
TRINATAL RX 1 72 TRUSTEX URISTIX 50
TRINATE 72 LUBRICATED/SPERMICIDE URISTIX 4 49
triprolidine & 61 UROCIT-K 10 54
pseudoephedrine 42 TRUSTEX
LUBRICATED/SPERMICIDE UROCIT-K 5 54
TRIUMEQ 34
EXTRA LARGE 61 UROXATRAL 54
TRIZIVIR 34 TRUSTEX URSO 250 53
TROJAN EXTENDED LUBRICATED/SPERMICIDE
PLEASURE/LUBRICATED 61 ursodiol 53
EXTRA STRENGTH 61
TROJAN MAGNUM 61 TRUSTEX NATURAL VAGISTAT-1 89
TROJAN MAGNUM WARM CONDOMS valacyclovir hcl 35
SENSATIONS 61 +LUBE/LUBRICATED 61 VALCYTE 34
TROJAN MAGNUM XL TRUSTEX WITH
LUBRICATED 61 valganciclovir hcl 34
NONOXYNOL-
TROJAN PLEASURE 9/RIBBED/STUDDED 61 VALIUM 11
MESH/SPERMICIDAL 61 TRUSTEX/RIA valproate sodium 16
TROJAN RIBBED LUBRICATED 61 valproic acid 16
W/SPERMICIDAL 61 TRUSTEX/RIA LUBRICATED
TROJAN SHARED SPERMICIDE 61 VALTREX 35
SENSATION/LUBRICATED 61 TRUSTEX/RIA vancomycin hcl 9
TROJAN SUPRAS LUBRICATED/SPERMICIDE VANCOMYCIN HCL 9
SPERMICIDAL 61 61
TROJAN TWISTED VAQTA 88
TRUVADA 34
PLEASURE 61 VARIVAX 88
TRUZONE PEAK FLOW
TROJAN ULTRA METER 64 VASERETIC 26
PLEASURE/LUBRICATED 61 VASOTEC 24
TROJAN VERY SENSITIVE TUDORZA PRESSAIR 12
LUBRICATED 61 TUMS 9 VCF VAGINAL
TROJAN VERY SENSITIVE CONTRACEPTIVE FILM 88
TUMS CHEWY BITES 9 VCF VAGINAL
SPERMICIDAL LUBRICANT 61 TUMS E-X 750 9
TROJAN VERY THIN CONTRACEPTIVE FOAM 88
LUBRICATED 61 TUMS EXTRA STRENGTH VEMLIDY 35
TROJAN VERY THIN 750 9 VENCLEXTA 27
SPERMICIDAL LUBRICANT 61 TUMS KIDS 9 VENCLEXTA STARTING
TROJAN-ENZ LUBRICANT 61 TUMS LASTING EFFECTS 9 PACK 27
TROJAN-ENZ TUMS SMOOTHIES 9 venlafaxine hcl 18
LUBRICATED 61 TUSSIONEX PENNKINETIC VENLAFAXINE HCL ER 18
TROJAN-ENZ EXTENDED RELEASE 42
W/SPERMICIDAL 61 VENTAVIS 37
TWINRIX 88
TROPHAMINE 76 VENTOLIN HFA 13
TWYNSTA 26
tropicamide 76 verapamil hcl 37
TYBOST 34
trospium chloride 86 VERELAN 37
TYKERB 29
TRULICITY 19 VERELAN PM 37
TYLENOL CHILDRENS 5
TRUMENBA 86 VERSACLOZ 32
TYLENOL INFANTS 5
TRUSOPT 79 VFEND 22
TYLENOL INFANTS
TRUSTEX COLOR CONDOMS + PAIN+FEVER 5 VIBRAMYCIN 83
LUBE 61 TYLENOL/CODEINE #3 7 VICTOZA 19
TRUSTEX LUBRICATED 61 TYLENOL/CODEINE #4 7 VIDEX EC 34
TRUSTEX LUBRICATED
EXTRALARGE 61 TYSABRI 81 VIDEXPEDIATRIC 34
TRUSTEX LUBRICATED ULTIMATE FEELING 61 vigabatrin 16
EXTRASTRENGTH 61 ULTRAM 6 VIMPAT 16
ULTRAVATE 47 VINATE II 72
Index 20
VINATE M 72 XATMEP 27 ZITHROMAX Z-PAK 59
VINATE ONE 72 XELJANZ 2 ZMAX 59
vincristine sulfate 30 XELJANZ XR 2 ZOCOR 24
VIRACEPT 34 XELODA 27 ZOFRAN 21
VIRAMUNE 34 XENAZINE 81 ZOFRAN ODT 21
VIRAMUNE XR 34 XENICAL 1 zoledronic acid 51
VIREAD 34 XEOMIN 73 ZOLEDRONIC ACID 51
VIROPTIC 77 XIAFLEX 67 zoledronic acid 51
VIRT NATE 72 XODOL 7 ZOLEDRONIC ACID 51
VIRT-ADVANCE 72 XOLAIR 11 ZOLINZA 29
VIRT-VITE GT 72 XULANE 39 ZOLOFT 17
VISTARIL 11 XULTOPHY 100/3.6 19 zolpidem tartrate 57
VISTOGARD 21 XURIDEN 52 ZOMETA 51
VITA-PREN 72 XYLOCAINE 48 ZONALON 45
VITAFOL-OB 72 XYNTHA 55 ZONEGRAN 16
VITAMIN A 89 XYNTHA SOLOFUSE 55 zonisamide 16
VITEKTA 34 YASMIN 28 39 ZONTIVITY 56
VIVELLE-DOT 53 YAZ 39 ZORTRESS 68
VIVITROL 21 YONDELIS 27 ZOSTAVAX 88
VOGELXO 8 YOUR LIFE MULTI ZOVIRAX 35,45
VOGELXO PUMP 8 PRENATAL 72 ZUBSOLV 8
ZADITOR 79
VOL-NATE 72 ZYBAN 82
ZALTRAP 27
VOL-PLUS 72 ZYDELIG 29
ZANAFLEX 72
VOL-TAB RX 72 ZYLOPRIM 55
ZANTAC 84
VOLTAREN 43 ZYMAXID 77
ZANTAC 150 MAXIMUM
VONVENDI 55 STRENGTH 84 ZYPREXA 32
voriconazole 22 ZANTAC 75 84 ZYPREXA RELPREVV 32
VOSPIRE ER 13 ZARONTIN 16 ZYPREXA ZYDIS 32
VOTRIENT 29 ZEBETA 36 ZYRTEC ALLERGY 23
VPRIV 56 ZEJULA 29 ZYRTEC-D
VRAYLAR 31 ALLERGY/CONGESTION 42
ZELBORAF 29
ZYTIGA 28
warfarin sodium 13 ZEMAIRA 82
WEGMANS COMPLETE ZEMPLAR 52
PRENATAL+DHA 72
ZENPEP 50
WELLBUTRIN 17
ZEPATIER 35
WELLBUTRIN SR 17
ZERIT 34
WELLBUTRIN XL 17
ZESTORETIC 26
WESTCORT 47
ZESTRIL 24
WESTHROID 83
ZETIA 24
WILATE 55
ZIAC 26
WP THYROID 83
ZIAGEN 34
XALATAN 79
zidovudine 34
XALKORI 29
ZINBRYTA 81
XANAX 11
ziprasidone hcl 31
XARELTO 14
ZITHROMAX 59
XARELTO STARTER PACK 14
ZITHROMAX TRI-PAK 59
Index 21

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CalViva Health Medi-Cal

Recommended Drug List

PLEASE DISCARD ALL PREVIOUS VERSIONS OF THE DRUG LIST

CV_Drug List Front Matter_ENG_3.7.17

How do I use the CalViva Health Medi-Cal Recommended Drug List?

Abbreviation Term What it means

Are there any limits on my drug coverage?

How can I get an exception to the rules for drug coverage?

What if I’m a new member?

What are over-the-counter drugs?

Are brand name drugs covered?

What is a generic drug?

Will the pharmacist give me a generic drug if one is available?

Are there any excluded or carve-out drugs?

What is California Children’s Services?

Need more information?

DESECHE TODAS LAS VERSIONES ANTERIORES DE LA LISTA DE

CV_Drug List Front Matter_SPN_3.7.17

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Abreviatura Término Lo que significa

¿Qué sucede si mi medicamento no está en la Lista de Medicamentos Recomendados de

¿Puedo ir a cualquier farmacia?

 Si el consultorio de su médico le proporciona los medicamentos.

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una excepción, llame al Departamento de Servicios al Afiliado de CalViva Health al

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¿Qué es Servicios Infantiles de California?

¿Necesita más información?

LOS POV TSEG

CV_Drug List Front Matter_HMG_3.7.17

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California Children’s Services yog dab tsi?

Xav paub ntxiv?

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Cambodian (Khmer): ប ស ើ ិ នបោកអ្នក ឬនរណាម្កដែលបោកអ្ន

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danazol caps F PROCTOFOAM HC FOAM F

TESTIM GEL (Use hydrocortisone (rectal) crea F

chlordiazepoxide hcl caps F RYTHMOL SR CP12 (Use NF

procainamide hcl soln F PA dyphylline-guaifenesin liqd F

quinidine gluconate tbcr or Bronchodilators - Anticholinergics

carbamazepine cp12 F oxcarbazepine tabs F

carbamazepine susp F POTIGA TABS F

carbamazepine tabs F primidone tabs F

carbamazepine tb12 F TEGRETOL SUSP F

doxepin hcl conc F glyburide-metformin tabs F

ELAVIL TABS (Use INVOKAMET TABS F

JENTADUETO TABS F Dopamine Receptor Agonists - Antidiabetic

QL(1 ea daily) benazepril hcl tabs F

PURIXAN SUSP F ODOMZO CAPS F SP-