Post on 14-Mar-2020
2019LIST OF COVERED DRUGS (FORMULARY)
UnitedHealthcare Connected® (Medicare-Medicaid Plan)
Toll-free 1-800-256-6533, TTY 7-1-18 a.m. - 8 p.m. local time, Monday - Friday
www.UHCCommunityPlan.comwww.myuhc.com/CommunityPlan
Formulary ID Number 00019088, Version 17H7833_180629_022455_v01.13 Approved Last updated December 1, 2019
Prescription drug list information
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UnitedHealthcare Connected® (Medicare-Medicaid Plan)
2019 List of Covered Drugs (Formulary)
IntroductionThis document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs are covered by UnitedHealthcare Connected. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UnitedHealthcare Connected. Key terms and their definitions appear in the last chapter of the Member Handbook.
Table of Contents
A. Disclaimers..............................................................................................................................................3
B. Frequently Asked Questions (FAQ)...................................................................................................... 4
B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.).................................................................................................... 4
B2. Does the Drug List ever change?...................................................................................................4
B3. What happens when there is a change to the Drug List?............................................................5
B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?..................................................................................................................................6
B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?............................................................................................................................... 7
B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?.....................................................7
B7. How can you find a drug on the Drug List?.................................................................................. 7
B8. What if the drug you want to take is not on the Drug List?..........................................................8
B9. What if you are a new UnitedHealthcare Connected member and can’t find your drug on the Drug List or have a problem getting your drug?...........................................................................8
B10. Can you ask for an exception to cover your drug?.................................................................... 9
B11. How can you ask for an exception?.............................................................................................9
B12. How long does it take to get an exception?................................................................................9
B13. What are generic drugs?............................................................................................................ 10
B14. What are OTC drugs?.................................................................................................................10
B15. What is your copay?................................................................................................................... 10
C. List of Covered Drugs.......................................................................................................................... 11
D. List of Drugs by Medical Condition.................................................................................................... 13
E. Index of Covered Drugs..................................................................................................................... 145
If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.
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A. Disclaimers
This is a list of drugs that members can get in UnitedHealthcare Connected.
v UnitedHealthcare Connected® (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.
v The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.
v Benefits and/or copays may change on January 1 of each year.
v You can always check UnitedHealthcare Connected’s up-to-date List of Covered Drugs online at www.UHCCommunityPlan.com.
v Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook.
v Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details.
v ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free.
v ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al 1-800-256-6533, TTY 7-1-1, de 8 a.m. a 8 p.m., hora local, de lunes a viernes. La llamada es gratuita.
v You can get this document for free in other formats, such as large print, braille, or audio. Call 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free.
v You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future.
If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.
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B. Frequently Asked Questions (FAQ)Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.
B1. What prescription drugs are on the List of Covered Drugs? (We call the List
of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 13 are the drugs covered by UnitedHealthcare Connected. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”· UnitedHealthcare Connected will cover all medically necessary drugs on the Drug List
if:
o Your doctor or other prescriber says you need them to get better or stay healthy, and
o You fill the prescription at a UnitedHealthcare Connected network pharmacy.
· UnitedHealthcare Connected may have additional steps to access certain drugs (see question B4 below).
You can also see an up-to-date list of drugs that we cover on our website at www.UHCCommunityPlan.com or call Member Services at 1-800-256-6533, TTY 7-1-1.
B2. Does the Drug List ever change?
Yes. UnitedHealthcare Connected may add or remove drugs on the Drug List during the year.
We may also change our rules about drugs. For example, we could:
· Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Connected before you can get a drug.)
· Add or change the amount of a drug you can get (called quantity limits).
· Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)
For more information on these drug rules, see question B4.
This section is continued on the next page.
If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.
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If you are taking a Medicare Part D drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:
· A new, cheaper drug comes along that works as well as a drug on the Drug List now, or
· We learn that a drug is not safe, or
· A drug is removed from the market.
Questions B3 and B6 below have more information on what happens when the Drug List changes.
· You can always check UnitedHealthcare Connected’s up-to-date Drug List online at www.UHCCommunityPlan.com.
· You can also call Member Services to check the current Drug List at 1-800-256-6533, TTY 7-1-1.
B3. What happens when there is a change to the Drug List?
Some changes to the Drug List will happen immediately. For example:
· A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits.
o We may not tell you before we make this change, but we will send you information about the specific change or changes we made.
o You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see questions B10 - B12 for more information on exceptions.
· A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Contact your doctor or other prescriber and ask about your other options.
This section is continued on the next page.
If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.
66We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:
· The FDA provides new guidance or there are new clinical guidelines about a drug.
· We add a generic drug that is not new to the market and
· Replace a brand name drug currently on the Drug List or
· Change the coverage rules or limits for the brand name drug.
When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can:
· Get at least a 30-day supply of the drug before the change to the Drug List is made, or
· Ask for an exception from these changes. Please see questions B10 - B12 for more information about exceptions.
B4. Are there any restrictions or limits on drug coverage or any required actions
to take to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you
or your doctor or other prescriber must do something before you can get the drug. For example:
· Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected before you fill your prescription. UnitedHealthcare Connected may not cover the drug if you do not get approval.
· Quantity limits: Sometimes UnitedHealthcare Connected limits the amount of a drug you can get.
· Step therapy: Sometimes UnitedHealthcare Connected requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on pages 13 - 144. You can also get more information by visiting our website at www.UHCCommunityPlan.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.
This section is continued on the next page.
If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.
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You can ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10 - B12 for more information about exceptions.
B5. How will you know if the drug you want has limitations or if there are
required actions to take to get the drug?
The List of Covered Drugs on pages 13 - 144 has a column labeled “Necessary actions, restrictions, or limits on use.”
B6. What happens if we change our rules about some drugs (for example, prior
authorization (approval), quantity limits, and/or step therapy restrictions)?
In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.
B7. How can you find a drug on the Drug List?
There are two ways to find a drug:
· You can search alphabetically (if you know how to spell the drug), or
· You can search by medical condition.
To search alphabetically, go to the Index of Covered Drugs section that begins on page 145. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information.
To search by medical condition, find the section labeled “List of drugs by medical condition” on pages 13 - 144. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.
If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.
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B8. What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services at 1-800-256-6533, TTY 7-1-1 and ask about it. If you learn that UnitedHealthcare Connected will not cover the drug, you can do one of these things:
· Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or
· You can ask the health plan to make an exception to cover your drug. Please see questions B10 – B12 for more information about exceptions.
B9. What if you are a new UnitedHealthcare Connected member and can’t find
your drug on the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Connected. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.
If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication.
We will cover a 30-day supply of your drug if:
· You are taking a drug that is not on our Drug List, or
· Health plan rules do not let you get the amount ordered by your prescriber, or
· The drug requires prior approval by UnitedHealthcare Connected, or
· You are taking a drug that is part of a step therapy restriction.
If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:
· We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Connected member.
· This is in addition to the temporary supply during the first 90 days you are a member of UnitedHealthcare Connected.
This section is continued on the next page.
If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.
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If you are going through a change in your level of care, such as being transferred from a hospital to a long-term care facility, any time during the year, we may cover a 31-day temporary supply of the Part D drug you need. This will give you time to talk to your doctor about other treatment options or to try to get an exception. Please see questions B10 - B12 for more information about exceptions.
We will not pay for more of your drug after you get a temporary or emergency supply unless you receive authorization from UnitedHealthcare Connected.
B10. Can you ask for an exception to cover your drug?
Yes. You can ask UnitedHealthcare Connected to make an exception to cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.
· For example, UnitedHealthcare Connected may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.
· Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.
B11. How can you ask for an exception?
To ask for an exception, call Member Services at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook to learn more about exceptions.
B12. How long does it take to get an exception?
First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.
B13. What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).
UnitedHealthcare Connected covers both brand name drugs and generic drugs.
B14. What are OTC drugs?
OTC stands for “over-the-counter.” UnitedHealthcare Connected covers some OTC drugs when they are written as prescriptions by your provider.
You can read the UnitedHealthcare Connected Drug List to see what OTC drugs are covered.
B15. What is your copay?
You can read the UnitedHealthcare Connected Drug List to learn about the copay for each drug. UnitedHealthcare Connected members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays.
Copays are listed by tiers. Tiers are groups of drugs with the same copay.
· Tier 1 drugs have the lowest copay. They are generic drugs. The copay is from $1.25 to $3.40, depending on your income.
· Tier 2 drugs have a higher copay. They are brand name drugs. The copay is from $3.80 to $8.50, depending on your income.
· Tier 3 drugs have $0 copay. They are OTC drugs.
If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.
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C. List of Covered Drugs
The following list of covered drugs gives you information about the drugs covered by UnitedHealthcare Connected. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 145. The index alphabetically lists all drugs covered by UnitedHealthcare Connected.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., simvastatin).
The information in the “Necessary actions, restrictions, or limits on use” column tells you if UnitedHealthcare Connected has any rules for covering your drug.
Coverage Rules and Limits
PA - Prior approval (or prior authorization)
For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected before you fill your prescription. UnitedHealthcare Connected may not cover the drug if you do not get approval.
QL - Quantity limits
Sometimes UnitedHealthcare Connected limits the amount of a drug you can get.
ST - Step therapy
Sometimes UnitedHealthcare Connected requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.
Other Special Coverage Rules
B/D - Medicare Part B or Part D
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.
LA - Limited access
Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.
MME - Morphine milligram equivalent
Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.
This section is continued on the next page.
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7D - 7-Day Limit
An opioid drug used for the treatment of acute pain may be limited to a 7 day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan.
DL - Dispensing limit
Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription.
Note: The asterisk (*) next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage).
· In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. For more information on Extra Help, please see the call-out box below.
· These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Texas Medicaid.
· If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at 1-800-256-6533, TTY 7-1-1. You can also read Chapter 9, of the Member Handbook to learn how to appeal a decision.
Extra Help
Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription drug costs, such as premiums, deductibles, and copays. Extra Help is also called the “Low-Income Subsidy,” or “LIS.”
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
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D. List of Drugs by Medical ConditionThe drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useA1
Analgesics
B1
AnalgesicsC1
Acephen
acephen (suppository)* $0 (Tier 3)C1
Acetaminophen
acetaminophen (tablet)* $0 (Tier 3)C1
Acetaminophen/Diphenhydramine acetaminophen/diphenhydramine (tablet)* $0 (Tier 3)C1
Butalbital/Acetaminophen butalbital/acetaminophen (50mg-325mg tablet) $1.25-$3.40 (Tier 1) QLC1
Butalbital/Acetaminophen/Caffeine 50mg-325mg-40mg Tablet, 50mg-325mg-40mg Capsule)
butalbital/acetaminophen/caffeine
50mg-325mg-40mg tablet, 50mg-325mg-40mg
capsule)
$1.25-$3.40 (Tier 1) QL
C1
Butalbital/Aspirin/Caffeine butalbital/aspirin/caffeine (50mg-325mg-40mg
capsule)$1.25-$3.40 (Tier 1) QL
C1
ED-APAP
ed-apap (liquid)* $0 (Tier 3)C1
GNP Arthritis Pain Relief gnp arthritis pain relief (tablet extended-release)* $0 (Tier 3)C1
Mapap
mapap (160mg/5ml liquid, 325mg tablet, 500mg
tablet, 500mg capsule, 80mg tablet chewable)*$0 (Tier 3)
C1
Mapap Acetaminophen Extra Strength
mapap acetaminophen extra strength (liquid)* $0 (Tier 3)C1
Mapap Arthritis Pain mapap arthritis pain (tablet extended-release)* $0 (Tier 3)C1
Mapap Childrens mapap childrens (160mg/5ml suspension, 80mg
tablet dispersible)*$0 (Tier 3)
C1
Mapap PM
mapap pm (tablet)* $0 (Tier 3)C1
Migraine Formula migraine formula (tablet)* $0 (Tier 3)C1
Pain & Fever
pain & fever (tablet)* $0 (Tier 3)C1
Pain & Fever Childrens pain & fever childrens (160mg/5ml oral solution,
80mg tablet chewable)*$0 (Tier 3)
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14
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Pain & Fever Extra Strength pain & fever extra strength (tablet)* $0 (Tier 3)C1
Pain & Fever Infants pain & fever infants (suspension)* $0 (Tier 3)C1
Pain Reliever PM Extra Strength pain reliever pm extra strength (tablet)* $0 (Tier 3)C1
QC Arthritis Pain Relief qc arthritis pain relief (tablet extended-release)* $0 (Tier 3)C1
Tencon
tencon (tablet) $1.25-$3.40 (Tier 1) QLC1
Zebutal
zebutal (capsule) $1.25-$3.40 (Tier 1) QLB1
Nonsteroidal Anti-inflammatory DrugsC1
All Day Relief
all day relief (tablet)* $0 (Tier 3)C1
Aspirin
aspirin (325mg tablet, 325mg tablet delayed-release,
81mg tablet delayed-release, 81mg tablet
chewable)*
$0 (Tier 3)
C1
Aspirin EC
aspirin ec (tablet delayed-release)* $0 (Tier 3)C1
Aspirin Low Dose aspirin low dose (tablet chewable)* $0 (Tier 3)C1
Aspir-Low
aspir-low (tablet delayed-release)* $0 (Tier 3)C1
Childrens Aspirin childrens aspirin (tablet chewable)* $0 (Tier 3)C1
Childrens Ibuprofen childrens ibuprofen (otc only) (suspension)* $0 (Tier 3)C1
Childs Ibuprofen childs ibuprofen (otc only) (suspension)* $0 (Tier 3)C1
Diclofenac Epolamine diclofenac epolamine (patch) $3.80-$8.50 (Tier 2) PA, QLC1
Diclofenac Potassium diclofenac potassium (tablet) $1.25-$3.40 (Tier 1)C1
Diclofenac Sodium diclofenac sodium (1% gel) $1.25-$3.40 (Tier 1)C1
Diclofenac Sodium DR diclofenac sodium dr (tablet delayed-release) $1.25-$3.40 (Tier 1)C1
Diclofenac Sodium ER diclofenac sodium er (tablet extended-release 24
hour)$1.25-$3.40 (Tier 1)
C1
Diflunisal
diflunisal (tablet) $1.25-$3.40 (Tier 1)C1
Etodolac
etodolac (200mg capsule, 300mg capsule, 400mg
tablet immediate-release, 500mg tablet immediate-
release)
$1.25-$3.40 (Tier 1)
C1
Flector
FLECTOR (PATCH) $3.80-$8.50 (Tier 2) PA, QLC1
Flurbiprofen
flurbiprofen (tablet) $1.25-$3.40 (Tier 1)C1
GNP Ibuprofen gnp ibuprofen (otc only) (tablet)* $0 (Tier 3)C1
GNP Ibuprofen Junior Strength gnp ibuprofen junior strength (otc only) (tablet
chewable)*$0 (Tier 3)
C1
Goodsense Ibuprofen goodsense ibuprofen (tablet)* $0 (Tier 3)C1
Goodsense Ibuprofen Childrens goodsense ibuprofen childrens (suspension)* $0 (Tier 3)C1
Goodsense Ibuprofen Infants goodsense ibuprofen infants (suspension)* $0 (Tier 3)C1
Goodsense Ibuprofen Junior Strength
goodsense ibuprofen junior strength (otc only) (tablet
chewable)*$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
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Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Ibu
ibu (rx only) (tablet) $1.25-$3.40 (Tier 1)C1
Ibu-200
ibu-200 (tablet)* $0 (Tier 3)C1
Ibu-Drops Infants ibu-drops infants (suspension)* $0 (Tier 3)C1
Ibuprofen
ibuprofen (otc only) (100mg/5ml suspension, 200mg
capsule, 200mg tablet)*$0 (Tier 3)
C1
Ibuprofen
ibuprofen (rx only) (100mg/5ml suspension, 400mg
tablet, 600mg tablet, 800mg tablet)$1.25-$3.40 (Tier 1)
C1
Ibuprofen Childrens ibuprofen childrens (suspension)* $0 (Tier 3)C1
Indomethacin
indomethacin (25mg capsule, 50mg capsule) $1.25-$3.40 (Tier 1)C1
Infants Ibuprofen infants ibuprofen (otc only) (suspension)* $0 (Tier 3)C1
Ketoprofen
ketoprofen (capsule) $1.25-$3.40 (Tier 1)C1
Meloxicam
meloxicam (tablet) $1.25-$3.40 (Tier 1)C1
Naproxen
naproxen (125mg/5ml suspension, 250mg tablet
immediate-release, 375mg tablet immediate-release,
500mg tablet immediate-release)
$1.25-$3.40 (Tier 1)
C1
Naproxen DR
naproxen dr (tablet delayed-release) (generic ec-
naprosyn)$1.25-$3.40 (Tier 1)
C1
QC Naproxen Sodium qc naproxen sodium (otc only) (tablet)* $0 (Tier 3)C1
SM Ibuprofen
sm ibuprofen (otc only) (tablet)* $0 (Tier 3)C1
Sulindac
sulindac (tablet) $1.25-$3.40 (Tier 1)B1
Opioid Analgesics, Long-actingC1
Buprenorphine
buprenorphine (patch weekly) $1.25-$3.40 (Tier 1) 7D, DL, QLC1
Embeda
EMBEDA (CAPSULE EXTENDED-RELEASE) $3.80-$8.50 (Tier 2)7D, DL, QL,
MMEC1
Fentanyl
fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch
72 hour, 25mcg/hr patch 72 hour, 50mcg/hr patch
72 hour, 75mcg/hr patch 72 hour)
$1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Hydromorphone HCl ER hydromorphone hcl er (tablet extended-release 24
hour abuse-deterrent)$1.25-$3.40 (Tier 1)
7D, DL, QL, MME
4For Track Refered Purpose164
16
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Hysingla ER
HYSINGLA ER (TABLET EXTENDED-RELEASE 24 HOUR ABUSE-DETERRENT)
$3.80-$8.50 (Tier 2)7D, DL, QL,
MMEC1
Levorphanol Tartrate
levorphanol tartrate (2mg tablet, 3mg tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Methadone HCl
methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml
oral solution, 5mg/5ml oral solution)$1.25-$3.40 (Tier 1)
7D, DL, QL, MME
C1
Morphine Sulfate ER morphine sulfate er (100mg tablet extended-release,
15mg tablet extended-release, 200mg tablet
extended-release, 30mg tablet extended-release,
60mg tablet extended-release) (generic ms contin)
$1.25-$3.40 (Tier 1)7D, DL, QL,
MME
C1
Nucynta ER
NUCYNTA ER (100MG TABLET EXTENDED-RELEASE 12 HOUR, 150MG TABLET EXTENDED-RELEASE 12 HOUR, 50MG TABLET EXTENDED-RELEASE 12 HOUR, 200MG TABLET EXTENDED-RELEASE 12 HOUR, 250MG TABLET EXTENDED-RELEASE 12 HOUR)
$3.80-$8.50 (Tier 2)7D, DL, QL,
MME
C1
Tramadol HCl ER tramadol hcl er (100mg tablet extended-release 24
hour, 200mg tablet extended-release 24 hour, 300mg
tablet extended-release 24 hour)
$1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Xtampza ER
XTAMPZA ER (CAPSULE EXTENDED-RELEASE 12 HOUR ABUSE-DETERRENT)
$3.80-$8.50 (Tier 2)7D, DL, QL,
MMEB1
Opioid Analgesics, Short-actingC1
Abstral
ABSTRAL (TABLET SUBLINGUAL) $3.80-$8.50 (Tier 2) DL, PA, QLC1
Acetaminophen/Codeine acetaminophen/codeine (120mg-12mg/5ml oral
solution, 300mg-15mg tablet, 300mg-30mg tablet,
300mg-60mg tablet)
$1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Butorphanol Tartrate
butorphanol tartrate (nasal solution) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Codeine Sulfate
codeine sulfate (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Duramorph
DURAMORPH (INJECTION) $3.80-$8.50 (Tier 2) DLC1
Endocet
endocet (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Fentanyl Citrate Oral Transmucosal fentanyl citrate oral transmucosal (lozenge on a
handle)$1.25-$3.40 (Tier 1) DL, PA, QL
C1
Hydrocodone Bitartrate/Acetaminophen
hydrocodone bitartrate/acetaminophen
(7.5mg-325mg/15ml oral solution)$1.25-$3.40 (Tier 1)
7D, DL, QL, MME
C1
Hydrocodone/Acetaminophen hydrocodone/acetaminophen (10mg-325mg tablet,
5mg-325mg tablet, 7.5mg-325mg tablet)$1.25-$3.40 (Tier 1)
7D, DL, QL, MME
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
5For Track Refered Purpose175
17
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Hydrocodone/Ibuprofen
hydrocodone/ibuprofen (7.5mg-200mg tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Hydromorphone HCl hydromorphone hcl (10mg/ml injection, 50mg/5ml
injection)$1.25-$3.40 (Tier 1) DL
C1
Hydromorphone HCl hydromorphone hcl (1mg/ml liquid, 2mg tablet
immediate-release, 4mg tablet immediate-release,
8mg tablet immediate-release)
$1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Hydromorphone HCl HYDROMORPHONE HCL (2MG/ML INJECTION) $3.80-$8.50 (Tier 2) DLC1
Lorcet
lorcet (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Lorcet HD
lorcet hd (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Lorcet Plus
lorcet plus (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Morphine Sulfate morphine sulfate (100mg/5ml oral solution, 10mg/
5ml oral solution, 20mg/5ml oral solution)$1.25-$3.40 (Tier 1)
7D, DL, QL, MME
C1
Morphine Sulfate MORPHINE SULFATE (15MG TABLET IMMEDIATE-
RELEASE, 30MG TABLET IMMEDIATE-RELEASE)$3.80-$8.50 (Tier 2)
7D, DL, QL, MME
C1
Oxycodone HCl
oxycodone hcl (100mg/5ml concentrate, 10mg tablet
immediate-release, 15mg tablet immediate-release,
20mg tablet immediate-release, 30mg tablet
immediate-release, 5mg tablet immediate-release,
5mg/5ml oral solution)
$1.25-$3.40 (Tier 1)7D, DL, QL,
MME
C1
Oxycodone/Acetaminophen oxycodone/acetaminophen (10mg-325mg tablet,
2.5mg-325mg tablet, 5mg-325mg tablet,
7.5mg-325mg tablet)
$1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Oxycodone/Aspirin
oxycodone/aspirin (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Oxycodone/Ibuprofen
oxycodone/ibuprofen (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,
MME
6For Track Refered Purpose186
18
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Tramadol HCl
tramadol hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Tramadol HCl/Acetaminophen
tramadol hcl/acetaminophen (tablet) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEC1
Trezix
trezix (capsule) $1.25-$3.40 (Tier 1)7D, DL, QL,
MMEA1
Anesthetics
B1
Local AnestheticsC1
Lidocaine
lidocaine (rx only) (5% ointment) $1.25-$3.40 (Tier 1) QLC1
Lidocaine
lidocaine (rx only) (5% patch) $1.25-$3.40 (Tier 1) PA, QLC1
Lidocaine HCl
lidocaine hcl (rx only) (4% external solution) $1.25-$3.40 (Tier 1)C1
Lidocaine HCl
lidocaine hcl (rx only) (2% gel) $1.25-$3.40 (Tier 1)C1
Lidocaine Viscous lidocaine viscous (rx only) (2% solution) $1.25-$3.40 (Tier 1)C1
Lidocaine/Prilocaine lidocaine/prilocaine (cream) $1.25-$3.40 (Tier 1)
A1
Anti-Addiction/Substance Abuse Treatment Agents
B1
Alcohol Deterrents/Anti-cravingC1
Acamprosate Calcium DR acamprosate calcium dr (tablet delayed-release) $1.25-$3.40 (Tier 1)C1
Disulfiram
disulfiram (tablet) $1.25-$3.40 (Tier 1)C1
Naltrexone HCl
naltrexone hcl (tablet) $1.25-$3.40 (Tier 1)C1
Vivitrol
VIVITROL (INJECTION) $3.80-$8.50 (Tier 2)B1
Opioid Dependence TreatmentsC1
Buprenorphine HCl buprenorphine hcl (tablet sublingual) $1.25-$3.40 (Tier 1) QLC1
Buprenorphine HCl/Naloxone HCl buprenorphine hcl/naloxone hcl (film) $1.25-$3.40 (Tier 1) QLC1
Buprenorphine HCl/Naloxone HCl buprenorphine hcl/naloxone hcl (tablet sublingual) $1.25-$3.40 (Tier 1) QLC1
Suboxone
SUBOXONE (FILM) $3.80-$8.50 (Tier 2) QLB1
Opioid Reversal Agents C1
Naloxone HCl
naloxone hcl (injection) $1.25-$3.40 (Tier 1)C1
Narcan
NARCAN (LIQUID) $3.80-$8.50 (Tier 2)B1
Smoking Cessation AgentsC1
Bupropion HCl SR bupropion hcl sr (150mg tablet extended-release 12
hour smoking-deterrent)$1.25-$3.40 (Tier 1)
C1
Chantix
CHANTIX (TABLET) $3.80-$8.50 (Tier 2)C1
Chantix Continuing Month Pak CHANTIX CONTINUING MONTH PAK (TABLET) $3.80-$8.50 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
7For Track Refered Purpose197
19
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Chantix Starting Month Pak CHANTIX STARTING MONTH PAK (TABLET) $3.80-$8.50 (Tier 2)C1
NicoDerm CQ
nicoderm cq (patch 24 hour)* $0 (Tier 3)C1
NICOrelief
nicorelief (gum)* $0 (Tier 3)C1
Nicorette
nicorette (2mg gum, 4mg gum, 2mg lozenge, 4mg
lozenge)*$0 (Tier 3)
C1
Nicorette Mini
nicorette mini (lozenge)* $0 (Tier 3)C1
Nicorette Starter Kit nicorette starter kit (gum)* $0 (Tier 3)C1
Nicotine Polacrilex nicotine polacrilex (2mg gum, 4mg gum, 2mg
lozenge, 4mg lozenge)*$0 (Tier 3)
C1
Nicotine Transdermal System nicotine transdermal system (kit, 14mg/24hr patch
24 hour, 21mg/24hr patch 24 hour, 7mg/24hr patch
24 hour)*
$0 (Tier 3)
C1
Nicotine Transdermal System Step 1 nicotine transdermal system step 1 (patch 24 hour)* $0 (Tier 3)C1
Nicotine Transdermal System Step 2 nicotine transdermal system step 2 (patch 24 hour)* $0 (Tier 3)C1
Nicotine Transdermal System Step 3 nicotine transdermal system step 3 (patch 24 hour)* $0 (Tier 3)C1
Nicotrol
NICOTROL (INHALER) $3.80-$8.50 (Tier 2)A1
Antibacterials
B1
AminoglycosidesC1
Amikacin Sulfate amikacin sulfate (injection) $1.25-$3.40 (Tier 1)C1
Gentak
gentak (ophthalmic ointment) $1.25-$3.40 (Tier 1)C1
Gentamicin Sulfate gentamicin sulfate (0.1% cream, 0.1% ointment,
0.3% ophthalmic solution, 40mg/ml injection)$1.25-$3.40 (Tier 1)
C1
Gentamicin Sulfate/0.9% Sodium Chloride
gentamicin sulfate/0.9% sodium chloride (injection) $1.25-$3.40 (Tier 1)C1
Isotonic Gentamicin isotonic gentamicin (injection) $1.25-$3.40 (Tier 1)C1
Neomycin Sulfate neomycin sulfate (tablet) $1.25-$3.40 (Tier 1)C1
Paromomycin Sulfate paromomycin sulfate (capsule) $1.25-$3.40 (Tier 1)C1
Streptomycin Sulfate streptomycin sulfate (injection) $1.25-$3.40 (Tier 1)C1
Tobramycin Sulfate tobramycin sulfate (0.3% ophthalmic solution, 10mg/
ml injection, 80mg/2ml injection)$1.25-$3.40 (Tier 1)
8For Track Refered Purpose208
20
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Tobrex
TOBREX (0.3% OPHTHALMIC OINTMENT) $3.80-$8.50 (Tier 2)B1
Antibacterials, OtherC1
Bacitracin
bacitracin (otc only) (ointment)* $0 (Tier 3)C1
Bacitracin
bacitracin (rx only) (ophthalmic ointment) $1.25-$3.40 (Tier 1)C1
Bacitracin Zinc
bacitracin zinc (ointment)* $0 (Tier 3)C1
Bacitracin/Neomycin/Polymyxin bacitracin/neomycin/polymyxin (otc only)
(ointment)*$0 (Tier 3)
C1
Clindamycin HCl
clindamycin hcl (capsule immediate-release) $1.25-$3.40 (Tier 1)C1
Clindamycin Palmitate HCl clindamycin palmitate hcl (oral solution) $1.25-$3.40 (Tier 1)C1
Clindamycin Phosphate clindamycin phosphate (2% cream, 300mg/2ml
injection, 600mg/4ml injection, 900mg/6ml injection)$1.25-$3.40 (Tier 1)
C1
Clindamycin Phosphate in D5W clindamycin phosphate in d5w (injection) $1.25-$3.40 (Tier 1)C1
Colistimethate Sodium colistimethate sodium (injection) $1.25-$3.40 (Tier 1)C1
Dalvance
DALVANCE (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Daptomycin
DAPTOMYCIN (350MG SOLUTION) $3.80-$8.50 (Tier 2)C1
Daptomycin
daptomycin (500mg injection) $1.25-$3.40 (Tier 1)C1
Linezolid
linezolid (100mg/5ml suspension, 600mg/300ml
injection)$1.25-$3.40 (Tier 1)
C1
Linezolid
linezolid (600mg tablet) $1.25-$3.40 (Tier 1) QLC1
Methenamine Hippurate methenamine hippurate (tablet) $1.25-$3.40 (Tier 1)C1
Metronidazole
metronidazole (0.75% cream, 0.75% gel, 1% gel,
0.75% lotion, 250mg tablet immediate-release,
500mg tablet immediate-release)
$1.25-$3.40 (Tier 1)
C1
Metronidazole in NaCl 0.79% metronidazole in nacl 0.79% (injection) $1.25-$3.40 (Tier 1)C1
Metronidazole Vaginal metronidazole vaginal (gel) $1.25-$3.40 (Tier 1)C1
Mupirocin
mupirocin (2% ointment) $1.25-$3.40 (Tier 1)C1
Nitrofurantoin
nitrofurantoin (suspension) $1.25-$3.40 (Tier 1)C1
Nitrofurantoin Macrocrystals nitrofurantoin macrocrystals (100mg capsule, 50mg
capsule) (generic macrodantin)$1.25-$3.40 (Tier 1)
C1
Nitrofurantoin Monohydrate nitrofurantoin monohydrate (100mg capsule)
(generic macrobid)$1.25-$3.40 (Tier 1)
C1
Polymyxin B Sulfate polymyxin b sulfate (injection) $1.25-$3.40 (Tier 1)C1
Povidone-Iodine povidone-iodine (10% external solution, 10%
ointment)*$0 (Tier 3)
C1
Tigecycline
tigecycline (injection) $1.25-$3.40 (Tier 1)C1
Tinidazole
tinidazole (tablet) $1.25-$3.40 (Tier 1)C1
Trimethoprim
trimethoprim (tablet) $1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
9For Track Refered Purpose219
21
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Triple Antibiotic triple antibiotic (ointment)* $0 (Tier 3)C1
Triple Antibiotic Plus triple antibiotic plus (ointment)* $0 (Tier 3)C1
Vancomycin HCl
vancomycin hcl (10gm injection, 1gm injection,
500mg injection, 750mg injection, 125mg capsule,
250mg capsule)
$1.25-$3.40 (Tier 1)
C1
Vancomycin HCl VANCOMYCIN HCL (250MG INJECTION) $3.80-$8.50 (Tier 2)C1
Vandazole
VANDAZOLE (GEL) $3.80-$8.50 (Tier 2)B1
Beta-lactam, CephalosporinsC1
Cefaclor
cefaclor (250mg capsule immediate-release, 500mg
capsule immediate-release)$1.25-$3.40 (Tier 1)
C1
Cefadroxil
cefadroxil (250mg/5ml suspension, 500mg/5ml
suspension, 500mg capsule)$1.25-$3.40 (Tier 1)
C1
Cefazolin Sodium cefazolin sodium (injection) $1.25-$3.40 (Tier 1)C1
Cefdinir
cefdinir (125mg/5ml suspension, 250mg/5ml
suspension, 300mg capsule)$1.25-$3.40 (Tier 1)
C1
Cefepime
cefepime (injection) $1.25-$3.40 (Tier 1)C1
Cefixime
cefixime (100mg/5ml suspension, 200mg/5ml
suspension, 400mg capsule)$1.25-$3.40 (Tier 1)
C1
Cefotaxime Sodium cefotaxime sodium (injection) $1.25-$3.40 (Tier 1)C1
Cefotetan
cefotetan (injection) $1.25-$3.40 (Tier 1)C1
Cefoxitin Sodium cefoxitin sodium (10gm injection, 1gm injection, 2gm
injection)$1.25-$3.40 (Tier 1)
C1
Cefpodoxime Proxetil cefpodoxime proxetil (100mg tablet, 200mg tablet,
100mg/5ml suspension, 50mg/5ml suspension)$1.25-$3.40 (Tier 1)
C1
Cefprozil
cefprozil (125mg/5ml suspension, 250mg/5ml
suspension, 250mg tablet, 500mg tablet)$1.25-$3.40 (Tier 1)
C1
Ceftazidime
ceftazidime (injection) $1.25-$3.40 (Tier 1)C1
Ceftriaxone Sodium ceftriaxone sodium (10gm injection, 1gm injection,
250mg injection, 2gm injection, 500mg injection)$1.25-$3.40 (Tier 1)
C1
Cefuroxime Axetil cefuroxime axetil (tablet) $1.25-$3.40 (Tier 1)
10For Track Refered Purpose2210
22
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Cefuroxime Sodium cefuroxime sodium (1.5gm injection, 7.5gm injection,
750mg injection)$1.25-$3.40 (Tier 1)
C1
Cephalexin
cephalexin (125mg/5ml suspension, 250mg/5ml
suspension, 250mg capsule, 500mg capsule, 750mg
capsule)
$1.25-$3.40 (Tier 1)
C1
Suprax
suprax (100mg tablet chewable, 200mg tablet
chewable)$1.25-$3.40 (Tier 1)
C1
Suprax
SUPRAX (400MG CAPSULE, 500MG/5ML SUSPENSION) $3.80-$8.50 (Tier 2)C1
Tazicef
tazicef (injection) $1.25-$3.40 (Tier 1)C1
Zerbaxa
ZERBAXA (INJECTION) $3.80-$8.50 (Tier 2) PAB1
Beta-lactam, OtherC1
Aztreonam
aztreonam (injection) $1.25-$3.40 (Tier 1)C1
Ertapenem
ertapenem (solution) $1.25-$3.40 (Tier 1)C1
Imipenem/Cilastatin imipenem/cilastatin (injection) $1.25-$3.40 (Tier 1)C1
Invanz
INVANZ (INJECTION) $3.80-$8.50 (Tier 2)C1
Meropenem
meropenem (injection) $1.25-$3.40 (Tier 1)B1
Beta-lactam, PenicillinsC1
Amoxicillin
amoxicillin (125mg tablet chewable, 250mg tablet
chewable, 125mg/5ml suspension, 200mg/5ml
suspension, 250mg/5ml suspension, 400mg/5ml
suspension, 250mg capsule, 500mg capsule, 500mg
tablet, 875mg tablet)
$1.25-$3.40 (Tier 1)
C1
Amoxicillin/Clavulanate Potassium amoxicillin/clavulanate potassium (200mg-28.5mg
tablet chewable, 400mg-57mg tablet chewable,
200mg/5ml-28.5mg/5ml suspension, 250mg/
5ml-62.5mg/5ml suspension, 400mg/5ml-57mg/5ml
suspension, 600mg/5ml-42.9mg/5ml suspension,
250mg-125mg tablet immediate-release,
500mg-125mg tablet immediate-release,
875mg-125mg tablet immediate-release) (generic
augmentin)
$1.25-$3.40 (Tier 1)
C1
Amoxicillin/Clavulanate Potassium ER
amoxicillin/clavulanate potassium er (tablet
extended-release 12 hour)$1.25-$3.40 (Tier 1)
C1
Ampicillin
ampicillin (capsule) $1.25-$3.40 (Tier 1)C1
Ampicillin Sodium ampicillin sodium (10gm injection, 125mg injection,
1gm injection)$1.25-$3.40 (Tier 1)
C1
Ampicillin-Sulbactam ampicillin-sulbactam (injection) $1.25-$3.40 (Tier 1)C1
Bicillin C-R
BICILLIN C-R (INJECTION) $3.80-$8.50 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
11For Track Refered Purpose2311
23
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Bicillin L-A
BICILLIN L-A (INJECTION) $3.80-$8.50 (Tier 2)C1
Dicloxacillin Sodium dicloxacillin sodium (capsule) $1.25-$3.40 (Tier 1)C1
Nafcillin Sodium
nafcillin sodium (10gm injection, 1gm injection, 2gm
injection)$1.25-$3.40 (Tier 1)
C1
Oxacillin in Dextrose OXACILLIN IN DEXTROSE (INJECTION) $3.80-$8.50 (Tier 2)C1
Oxacillin Sodium oxacillin sodium (injection) $1.25-$3.40 (Tier 1)C1
Penicillin G Potassium penicillin g potassium (injection) $1.25-$3.40 (Tier 1)C1
Penicillin G Procaine penicillin g procaine (injection) $1.25-$3.40 (Tier 1)C1
Penicillin G Sodium penicillin g sodium (injection) $1.25-$3.40 (Tier 1)C1
Penicillin V Potassium penicillin v potassium (125mg/5ml oral solution,
250mg/5ml oral solution, 250mg tablet, 500mg
tablet)
$1.25-$3.40 (Tier 1)
C1
Piperacillin/Tazobactam piperacillin/tazobactam (injection) $1.25-$3.40 (Tier 1)
B1
MacrolidesC1
Azithromycin
azithromycin (100mg/5ml suspension, 200mg/5ml
suspension, 250mg tablet, 500mg tablet, 600mg
tablet, 500mg injection)
$1.25-$3.40 (Tier 1)
C1
Clarithromycin
clarithromycin (125mg/5ml suspension, 250mg/5ml
suspension, 250mg tablet, 500mg tablet)$1.25-$3.40 (Tier 1)
C1
Clarithromycin ER clarithromycin er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1
Dificid
DIFICID (TABLET) $3.80-$8.50 (Tier 2)C1
E.E.S. Granules E.E.S. GRANULES (SUSPENSION) $3.80-$8.50 (Tier 2)C1
Ery-Tab
ery-tab (tablet delayed-release) $1.25-$3.40 (Tier 1)C1
EryPed 200
ERYPED 200 (SUSPENSION) $3.80-$8.50 (Tier 2)C1
EryPed 400
ERYPED 400 (SUSPENSION) $3.80-$8.50 (Tier 2)C1
Erythrocin Lactobionate erythrocin lactobionate (injection) $1.25-$3.40 (Tier 1)C1
Erythromycin
erythromycin (250mg capsule delayed-release, 5mg/
gm ophthalmic ointment)$1.25-$3.40 (Tier 1)
C1
Erythromycin Base erythromycin base (tablet) $1.25-$3.40 (Tier 1)
12For Track Refered Purpose2412
24
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Erythromycin DR erythromycin dr (tablet delayed-release) $1.25-$3.40 (Tier 1)C1
Erythromycin Ethylsuccinate erythromycin ethylsuccinate (200mg/5ml
suspension, 400mg tablet, 400mg/5ml suspension)$1.25-$3.40 (Tier 1)
B1
QuinolonesC1
Ciprofloxacin
ciprofloxacin (suspension) $1.25-$3.40 (Tier 1)C1
Ciprofloxacin HCl ciprofloxacin hcl (tablet immediate-release, 0.3%
ophthalmic solution)$1.25-$3.40 (Tier 1)
C1
Ciprofloxacin I.V. in D5W ciprofloxacin i.v. in d5w (injection) $1.25-$3.40 (Tier 1)C1
Levofloxacin
levofloxacin (0.5% ophthalmic solution, 250mg
tablet, 500mg tablet, 750mg tablet, 25mg/ml
injection, 25mg/ml oral solution)
$1.25-$3.40 (Tier 1)
C1
Levofloxacin in D5W levofloxacin in d5w (injection) $1.25-$3.40 (Tier 1)C1
Moxeza
MOXEZA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Moxifloxacin HCl/Sodium HCl moxifloxacin hcl/sodium hcl (injection) $1.25-$3.40 (Tier 1)C1
Moxifloxacin HCl
moxifloxacin hcl (0.5% ophthalmic solution, 400mg
tablet)$1.25-$3.40 (Tier 1)
C1
Ofloxacin
ofloxacin (0.3% ophthalmic solution, 0.3% otic
solution, 300mg tablet, 400mg tablet)$1.25-$3.40 (Tier 1)
B1
SulfonamidesC1
Silver Sulfadiazine silver sulfadiazine (cream) $3.80-$8.50 (Tier 2)C1
Sodium Sulfacetamide sodium sulfacetamide (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
SSD
SSD (CREAM) $3.80-$8.50 (Tier 2)C1
Sulfacetamide Sodium sulfacetamide sodium (ophthalmic ointment) $1.25-$3.40 (Tier 1)C1
Sulfadiazine
sulfadiazine (tablet) $1.25-$3.40 (Tier 1)C1
Sulfamethoxazole/Trimethoprim sulfamethoxazole/trimethoprim (200mg-40mg/5ml
suspension, 400mg-80mg tablet)$1.25-$3.40 (Tier 1)
C1
Sulfamethoxazole/Trimethoprim DS sulfamethoxazole/trimethoprim ds (tablet) $1.25-$3.40 (Tier 1)
B1
TetracyclinesC1
Demeclocycline HCl demeclocycline hcl (tablet) $1.25-$3.40 (Tier 1)C1
Doxy 100
doxy 100 (injection) $1.25-$3.40 (Tier 1)C1
Doxycycline
doxycycline (25mg/5ml suspension) $1.25-$3.40 (Tier 1)C1
Doxycycline Hyclate doxycycline hyclate (100mg capsule, 50mg capsule,
100mg tablet, 20mg tablet immediate-release)$1.25-$3.40 (Tier 1)
C1
Doxycycline Monohydrate doxycycline monohydrate (100mg capsule, 50mg
capsule, 100mg tablet, 50mg tablet, 75mg tablet)$1.25-$3.40 (Tier 1)
C1
Minocycline HCl
minocycline hcl (capsule) $1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
13For Track Refered Purpose2513
25
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Tetracycline HCl
tetracycline hcl (capsule) $1.25-$3.40 (Tier 1)C1
Vibramycin
VIBRAMYCIN (50MG/5ML SYRUP) $3.80-$8.50 (Tier 2)A1
Anticonvulsants
B1
Anticonvulsants, OtherC1
Briviact
BRIVIACT (100MG TABLET, 10MG TABLET, 25MG TABLET, 50MG TABLET, 75MG TABLET, 10MG/ML ORAL SOLUTION)
$3.80-$8.50 (Tier 2) QL
C1
Epidiolex
EPIDIOLEX (SOLUTION) $3.80-$8.50 (Tier 2) PAC1
Levetiracetam
levetiracetam (tablet immediate-release, 100mg/ml
oral solution)$1.25-$3.40 (Tier 1)
C1
Levetiracetam ER levetiracetam er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1
Roweepra
roweepra (tablet immediate-release) $1.25-$3.40 (Tier 1)C1
Roweepra XR
roweepra xr (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1
Spritam
SPRITAM (TABLET DISINTEGRATING SOLUBLE) $3.80-$8.50 (Tier 2)B1
Calcium Channel Modifying AgentsC1
Celontin
CELONTIN (CAPSULE) $3.80-$8.50 (Tier 2)C1
Ethosuximide
ethosuximide (250mg capsule, 250mg/5ml oral
solution)$1.25-$3.40 (Tier 1)
C1
Zonisamide
zonisamide (capsule) $1.25-$3.40 (Tier 1)B1
Gamma-aminobutyric Acid (GABA) Augmenting AgentsC1
Clobazam
clobazam (10mg tablet, 20mg tablet) $1.25-$3.40 (Tier 1) PA, QLC1
Clobazam
clobazam (2.5mg/ml suspension) $1.25-$3.40 (Tier 1) PAC1
Diastat AcuDial DIASTAT ACUDIAL (GEL) $3.80-$8.50 (Tier 2)C1
Diastat Pediatric DIASTAT PEDIATRIC (GEL) $3.80-$8.50 (Tier 2)C1
Gabapentin
gabapentin (100mg capsule, 300mg capsule, 400mg
capsule, 250mg/5ml oral solution, 600mg tablet,
800mg tablet)
$1.25-$3.40 (Tier 1)
C1
Onfi
ONFI (10MG TABLET, 20MG TABLET) $3.80-$8.50 (Tier 2) PA, QL
14For Track Refered Purpose2614
26
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Onfi
ONFI (2.5MG/ML SUSPENSION) $3.80-$8.50 (Tier 2) PAC1
Phenobarbital
phenobarbital (100mg tablet, 15mg tablet, 16.2mg
tablet, 30mg tablet, 32.4mg tablet, 60mg tablet,
64.8mg tablet, 97.2mg tablet, 20mg/5ml elixir)
$1.25-$3.40 (Tier 1)
C1
Primidone
primidone (tablet) $1.25-$3.40 (Tier 1)C1
Sabril
SABRIL (500MG TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Sympazan
SYMPAZAN (FILM) $3.80-$8.50 (Tier 2) PA, QLC1
Tiagabine HCl
tiagabine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Valproic Acid
valproic acid (250mg capsule, 250mg/5ml oral
solution)$1.25-$3.40 (Tier 1)
C1
Vigabatrin
vigabatrin (500mg packet, 500mg tablet) $1.25-$3.40 (Tier 1) PA, QL, LAC1
Vigadrone
vigadrone (packet) $1.25-$3.40 (Tier 1) PA, QL, LAB1
Glutamate Reducing AgentsC1
Felbamate
felbamate (400mg tablet, 600mg tablet, 600mg/5ml
suspension)$1.25-$3.40 (Tier 1)
C1
Fycompa
FYCOMPA (0.5MG/ML SUSPENSION, 10MG TABLET, 12MG TABLET, 2MG TABLET, 4MG TABLET, 6MG TABLET, 8MG TABLET)
$3.80-$8.50 (Tier 2)
C1
Lamotrigine
lamotrigine (100mg tablet immediate-release, 150mg
tablet immediate-release, 200mg tablet immediate-
release, 25mg tablet immediate-release, 25mg tablet
chewable, 5mg tablet chewable)
$1.25-$3.40 (Tier 1)
C1
Topiramate
topiramate (100mg tablet, 200mg tablet, 25mg
tablet, 50mg tablet, 15mg capsule sprinkle
immediate-release, 25mg capsule sprinkle
immediate-release)
$1.25-$3.40 (Tier 1)
B1
Sodium Channel AgentsC1
Aptiom
APTIOM (TABLET) $3.80-$8.50 (Tier 2) QLC1
Banzel
BANZEL (200MG TABLET, 400MG TABLET, 40MG/ML SUSPENSION)
$3.80-$8.50 (Tier 2)C1
Carbamazepine
carbamazepine (100mg tablet chewable, 100mg/5ml
suspension, 200mg tablet immediate-release)$1.25-$3.40 (Tier 1)
C1
Carbamazepine ER carbamazepine er (100mg capsule extended-release
12 hour, 200mg capsule extended-release 12 hour,
300mg capsule extended-release 12 hour, 100mg
tablet extended-release 12 hour, 200mg tablet
extended-release 12 hour, 400mg tablet extended-
release 12 hour)
$1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
15For Track Refered Purpose2715
27
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Dilantin
dilantin (capsule) $1.25-$3.40 (Tier 1)C1
Dilantin INFATABS dilantin infatabs (tablet chewable) $1.25-$3.40 (Tier 1)C1
Epitol
epitol (tablet) $1.25-$3.40 (Tier 1)C1
Oxcarbazepine
oxcarbazepine (150mg tablet, 300mg tablet, 600mg
tablet, 300mg/5ml suspension)$1.25-$3.40 (Tier 1)
C1
Peganone
PEGANONE (TABLET) $3.80-$8.50 (Tier 2)C1
Phenytek
phenytek (capsule) $1.25-$3.40 (Tier 1)C1
Phenytoin
phenytoin (125mg/5ml suspension, 50mg tablet
chewable)$1.25-$3.40 (Tier 1)
C1
Phenytoin Sodium Extended phenytoin sodium extended (capsule) $1.25-$3.40 (Tier 1)C1
Vimpat
VIMPAT (100MG TABLET, 150MG TABLET, 200MG TABLET, 50MG TABLET, 10MG/ML ORAL SOLUTION)
$3.80-$8.50 (Tier 2) QL
A1
Antidementia Agents
B1
Cholinesterase InhibitorsC1
Donepezil HCl
donepezil hcl (10mg tablet, 5mg tablet) $1.25-$3.40 (Tier 1) QLC1
Donepezil HCl ODT donepezil hcl odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1
Rivastigmine Tartrate rivastigmine tartrate (capsule) $1.25-$3.40 (Tier 1) QLC1
Rivastigmine Transdermal System rivastigmine transdermal system (patch 24 hour) $1.25-$3.40 (Tier 1) QL, ST
B1
N-methyl-D-aspartate (NMDA) Receptor AntagonistC1
Memantine HCl
memantine hcl (10mg tablet, 5mg tablet, 2mg/ml
oral solution)$1.25-$3.40 (Tier 1) PA, QL
C1
Memantine HCl ER memantine hcl er (capsule extended-release 24 hour) $1.25-$3.40 (Tier 1) PA, QLC1
Memantine HCl Titration Pak MEMANTINE HCL TITRATION PAK (TABLET) $3.80-$8.50 (Tier 2) PA
A1
Antidepressants
B1
Antidepressants, OtherC1
Bupropion HCl
bupropion hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)
16For Track Refered Purpose2816
28
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Bupropion HCl SR bupropion hcl sr (100mg tablet extended-release 12
hour, 150mg tablet extended-release 12 hour, 200mg
tablet extended-release 12 hour)
$1.25-$3.40 (Tier 1)
C1
Bupropion HCl XL bupropion hcl xl (150mg tablet extended-release 24
hour, 300mg tablet extended-release 24 hour)$1.25-$3.40 (Tier 1)
C1
Mirtazapine
mirtazapine (tablet) $1.25-$3.40 (Tier 1)C1
Mirtazapine ODT mirtazapine odt (tablet dispersible) $1.25-$3.40 (Tier 1)
B1
Monoamine Oxidase InhibitorsC1
Emsam
EMSAM (PATCH 24 HOUR) $3.80-$8.50 (Tier 2) QLC1
Marplan
MARPLAN (TABLET) $3.80-$8.50 (Tier 2)C1
Phenelzine Sulfate phenelzine sulfate (tablet) $1.25-$3.40 (Tier 1)C1
Tranylcypromine Sulfate tranylcypromine sulfate (tablet) $1.25-$3.40 (Tier 1)
B1
SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
C1
Citalopram HBr
citalopram hbr (10mg tablet, 20mg tablet, 40mg
tablet, 10mg/5ml oral solution)$1.25-$3.40 (Tier 1)
C1
Desvenlafaxine ER desvenlafaxine er (100mg tablet extended-release 24
hour, 25mg tablet extended-release 24 hour, 50mg
tablet extended-release 24 hour) (generic pristiq)
$1.25-$3.40 (Tier 1) QL
C1
Escitalopram Oxalate escitalopram oxalate (10mg tablet, 20mg tablet, 5mg
tablet, 5mg/5ml oral solution)$1.25-$3.40 (Tier 1)
C1
Fetzima
FETZIMA (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2) QL, STC1
Fetzima Titration Pack FETZIMA TITRATION PACK (CAPSULE EXTENDED-
RELEASE 24 HOUR THERAPY PACK)$3.80-$8.50 (Tier 2) ST
C1
Fluoxetine DR
fluoxetine dr (capsule delayed-release) $1.25-$3.40 (Tier 1)C1
Fluoxetine HCl
fluoxetine hcl (20mg/5ml oral solution) $1.25-$3.40 (Tier 1)C1
Fluoxetine HCl
fluoxetine hcl (capsule immediate-release) $1.25-$3.40 (Tier 1)C1
Fluvoxamine Maleate fluvoxamine maleate (tablet) $1.25-$3.40 (Tier 1)C1
Maprotiline HCl
maprotiline hcl (tablet) $1.25-$3.40 (Tier 1)C1
Nefazodone HCl nefazodone hcl (tablet) $1.25-$3.40 (Tier 1)C1
Paroxetine HCl
paroxetine hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)C1
Paxil
PAXIL (10MG/5ML SUSPENSION) $3.80-$8.50 (Tier 2)C1
Sertraline HCl
sertraline hcl (20mg/ml concentrate) $1.25-$3.40 (Tier 1)C1
Sertraline HCl
sertraline hcl (tablet) $1.25-$3.40 (Tier 1)C1
Trazodone HCl
trazodone hcl (tablet) $1.25-$3.40 (Tier 1)C1
Trintellix
TRINTELLIX (TABLET) $3.80-$8.50 (Tier 2) QLC1
Venlafaxine HCl
venlafaxine hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
17For Track Refered Purpose2917
29
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Venlafaxine HCl ER venlafaxine hcl er (150mg capsule extended-release
24 hour, 37.5mg capsule extended-release 24 hour,
75mg capsule extended-release 24 hour)
$1.25-$3.40 (Tier 1)
C1
Viibryd
VIIBRYD (TABLET) $3.80-$8.50 (Tier 2) QLC1
Viibryd Starter Pack VIIBRYD STARTER PACK (KIT) $3.80-$8.50 (Tier 2) QL
B1
TricyclicsC1
Amitriptyline HCl
amitriptyline hcl (tablet) $1.25-$3.40 (Tier 1)C1
Amoxapine
amoxapine (tablet) $1.25-$3.40 (Tier 1)C1
Clomipramine HCl clomipramine hcl (capsule) $1.25-$3.40 (Tier 1)C1
Desipramine HCl desipramine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Doxepin HCl
doxepin hcl (100mg capsule, 10mg capsule, 150mg
capsule, 50mg capsule, 75mg capsule, 10mg/ml
concentrate)
$1.25-$3.40 (Tier 1)
C1
Doxepin HCl
doxepin hcl (25mg capsule) $1.25-$3.40 (Tier 1)C1
Imipramine HCl
imipramine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Imipramine Pamoate imipramine pamoate (capsule) $1.25-$3.40 (Tier 1)C1
Nortriptyline HCl
nortriptyline hcl (10mg/5ml oral solution) $1.25-$3.40 (Tier 1)C1
Nortriptyline HCl
nortriptyline hcl (capsule) $1.25-$3.40 (Tier 1)C1
Protriptyline HCl
protriptyline hcl (tablet) $1.25-$3.40 (Tier 1)C1
Trimipramine Maleate trimipramine maleate (capsule) $1.25-$3.40 (Tier 1)
A1
Antiemetics
B1
Antiemetics, OtherC1
Compro
compro (suppository) $1.25-$3.40 (Tier 1)C1
Formula EM
formula em (oral solution)* $0 (Tier 3)C1
Hydroxyzine Pamoate hydroxyzine pamoate (capsule) $1.25-$3.40 (Tier 1)C1
Meclizine HCl
meclizine hcl (otc only) (tablet)* $0 (Tier 3)C1
Meclizine HCl
meclizine hcl (rx only) (tablet) $1.25-$3.40 (Tier 1)C1
Metoclopramide HCl metoclopramide hcl (5mg/5ml oral solution) $1.25-$3.40 (Tier 1)
18For Track Refered Purpose3018
30
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Metoclopramide HCl metoclopramide hcl (tablet) $1.25-$3.40 (Tier 1)C1
Perphenazine
perphenazine (tablet) $1.25-$3.40 (Tier 1)C1
Prochlorperazine
prochlorperazine (suppository) $1.25-$3.40 (Tier 1)C1
Prochlorperazine Maleate prochlorperazine maleate (tablet) $1.25-$3.40 (Tier 1)C1
Scopolamine
scopolamine (patch 72 hour) $1.25-$3.40 (Tier 1)C1
Transderm-Scop TRANSDERM-SCOP (PATCH 72 HOUR) $3.80-$8.50 (Tier 2)C1
Travel Sickness
travel sickness (otc only) (tablet)* $0 (Tier 3)B1
Emetogenic Therapy AdjunctsC1
Aprepitant
aprepitant (therapy pack, capsule) $1.25-$3.40 (Tier 1) PAC1
Cesamet
CESAMET (CAPSULE) $3.80-$8.50 (Tier 2) PAC1
Dronabinol
dronabinol (capsule) $1.25-$3.40 (Tier 1) PAC1
Emend
EMEND (125MG SUSPENSION) $3.80-$8.50 (Tier 2) PAC1
Granisetron HCl
granisetron hcl (tablet) $1.25-$3.40 (Tier 1) B/D, PA, QLC1
Ondansetron HCl ondansetron hcl (4mg/5ml oral solution) $1.25-$3.40 (Tier 1) B/D, PAC1
Ondansetron HCl ondansetron hcl (tablet) $1.25-$3.40 (Tier 1) B/D, PAC1
Ondansetron ODT ondansetron odt (tablet dispersible) $1.25-$3.40 (Tier 1) B/D, PAC1
Sancuso
SANCUSO (PATCH) $3.80-$8.50 (Tier 2)A1
Antifungals
B1
AntifungalsC1
Abelcet
ABELCET (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
AmBisome
AMBISOME (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Amphotericin B
amphotericin b (injection) $1.25-$3.40 (Tier 1) B/D, PAC1
Antifungal
antifungal (1% aerosol, 1% cream, 2% cream)* $0 (Tier 3)C1
Anti-Fungal Powder anti-fungal powder (otc only)* $0 (Tier 3)C1
Caspofungin Acetate caspofungin acetate (injection) $1.25-$3.40 (Tier 1)C1
Ciclopirox
ciclopirox (0.77% gel, 0.77% suspension, 1%
shampoo)$1.25-$3.40 (Tier 1)
C1
Ciclopirox Nail Lacquer ciclopirox nail lacquer (external solution) $1.25-$3.40 (Tier 1)C1
Ciclopirox Olamine ciclopirox olamine (cream) $1.25-$3.40 (Tier 1)C1
Clotrimazole
clotrimazole (otc only) (1% cream, 1% external
solution)*$0 (Tier 3)
C1
Clotrimazole
clotrimazole (rx only) (1% cream, 1% external
solution, 10mg lozenge)$1.25-$3.40 (Tier 1)
C1
Clotrimazole Anti-Fungal clotrimazole anti-fungal (otc only) (cream)* $0 (Tier 3)C1
Econazole Nitrate econazole nitrate (cream) $1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
19For Track Refered Purpose3119
31
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Eraxis
ERAXIS (INJECTION) $3.80-$8.50 (Tier 2)C1
Fluconazole
fluconazole (100mg tablet, 150mg tablet, 200mg
tablet, 50mg tablet, 10mg/ml suspension, 40mg/ml
suspension)
$1.25-$3.40 (Tier 1)
C1
Fluconazole in NaCl fluconazole in nacl (injection) $1.25-$3.40 (Tier 1)C1
Flucytosine
flucytosine (capsule) $1.25-$3.40 (Tier 1)C1
Fungoid Tincture fungoid tincture (external solution)* $0 (Tier 3)C1
Griseofulvin Microsize griseofulvin microsize (125mg/5ml suspension,
500mg tablet)$1.25-$3.40 (Tier 1)
C1
Griseofulvin Ultramicrosize griseofulvin ultramicrosize (tablet) $1.25-$3.40 (Tier 1)C1
Itraconazole
itraconazole (100mg capsule) $1.25-$3.40 (Tier 1) PA, QLC1
Itraconazole
itraconazole (10mg/ml solution) $1.25-$3.40 (Tier 1) PAC1
Jublia
JUBLIA (EXTERNAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Ketoconazole
ketoconazole (2% cream, 2% foam, 2% shampoo,
200mg tablet)$1.25-$3.40 (Tier 1)
C1
Mentax
MENTAX (RX ONLY) (CREAM) $3.80-$8.50 (Tier 2)C1
Miconazole 3
miconazole 3 (rx only) (suppository) $1.25-$3.40 (Tier 1)C1
Miconazole 7
miconazole 7 (suppository)* $0 (Tier 3)C1
Miconazole Nitrate miconazole nitrate (100mg suppository, 2% cream)* $0 (Tier 3)C1
Mycamine
MYCAMINE (INJECTION) $3.80-$8.50 (Tier 2)C1
Natacyn
NATACYN (SUSPENSION) $3.80-$8.50 (Tier 2)C1
Noxafil
NOXAFIL (100MG TABLET DELAYED-RELEASE) $3.80-$8.50 (Tier 2) PA, QLC1
Noxafil
NOXAFIL (40MG/ML SUSPENSION) $3.80-$8.50 (Tier 2) QLC1
Nyamyc
nyamyc (powder) $1.25-$3.40 (Tier 1)C1
Nystatin
nystatin (cream, ointment, powder, suspension,
tablet)$1.25-$3.40 (Tier 1)
C1
Nystop
nystop (powder) $1.25-$3.40 (Tier 1)C1
Posaconazole DR posaconazole dr (tablet delayed-release) $1.25-$3.40 (Tier 1) PA, QLC1
QC Tolnaftate
qc tolnaftate (cream)* $0 (Tier 3)C1
SM Miconazole 7 sm miconazole 7 (cream)* $0 (Tier 3)
20For Track Refered Purpose3220
32
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Sporanox
SPORANOX (10MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2) PAC1
Terbinafine HCl
terbinafine hcl (otc only) (cream)* $0 (Tier 3)C1
Terbinafine HCl
terbinafine hcl (rx only) (tablet) $1.25-$3.40 (Tier 1)C1
Terconazole
terconazole (0.4% cream, 0.8% cream, 80mg
suppository)$1.25-$3.40 (Tier 1)
C1
Tioconazole-1
tioconazole-1 (ointment)* $0 (Tier 3)C1
Tolnaftate
tolnaftate (1% cream, 1% powder)* $0 (Tier 3)C1
Voriconazole
voriconazole (200mg injection, 200mg tablet, 50mg
tablet, 40mg/ml suspension)$1.25-$3.40 (Tier 1)
C1
Zeasorb-AF
zeasorb-af (powder)* $0 (Tier 3)A1
Antigout Agents
B1
Antigout AgentsC1
Allopurinol
allopurinol (tablet) $1.25-$3.40 (Tier 1)C1
Colchicine
COLCHICINE (0.6MG CAPSULE) (BRAND EQUIVALENT MITIGARE)
$3.80-$8.50 (Tier 2) QLC1
Colchicine
colchicine (0.6mg tablet) (brand equivalent colcrys) $1.25-$3.40 (Tier 1) QLC1
Febuxostat
febuxostat (tablet) $1.25-$3.40 (Tier 1) STC1
Probenecid
probenecid (tablet) $1.25-$3.40 (Tier 1)C1
Probenecid/Colchicine probenecid/colchicine (tablet) $1.25-$3.40 (Tier 1)
A1
Antimigraine Agents
B1
Ergot AlkaloidsC1
Dihydroergotamine Mesylate dihydroergotamine mesylate (nasal solution) $1.25-$3.40 (Tier 1)C1
Ergotamine Tartrate/Caffeine ergotamine tartrate/caffeine (tablet) $1.25-$3.40 (Tier 1)C1
Migergot
migergot (suppository) $1.25-$3.40 (Tier 1)B1
ProphylacticC1
Aimovig
AIMOVIG (SOLUTION AUTO INJECTOR) $3.80-$8.50 (Tier 2) PA, QLB1
Serotonin (5-HT) 1b/1d Receptor AgonistsC1
Naratriptan HCl
naratriptan hcl (tablet) $1.25-$3.40 (Tier 1) QLC1
Rizatriptan Benzoate rizatriptan benzoate (10mg tablet, 5mg tablet) $1.25-$3.40 (Tier 1) QLC1
Rizatriptan Benzoate ODT rizatriptan benzoate odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1
Sumatriptan
sumatriptan (nasal solution) $1.25-$3.40 (Tier 1) QL
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
21For Track Refered Purpose3321
33
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Sumatriptan Succinate sumatriptan succinate (100mg tablet, 25mg tablet,
50mg tablet, 4mg/0.5ml injection, 6mg/0.5ml
solution prefilled syringe), sumatriptan succinate
(6mg/0.5ml injection) (generic imitrex)
$1.25-$3.40 (Tier 1) QL
C1
Sumatriptan Succinate SUMATRIPTAN SUCCINATE (6MG/0.5ML INJECTION) $3.80-$8.50 (Tier 2) QLC1
Sumatriptan Succinate Refill SUMATRIPTAN SUCCINATE REFILL (INJECTION) $3.80-$8.50 (Tier 2) QL
A1
Antimyasthenic Agents
B1
ParasympathomimeticsC1
Guanidine HCl GUANIDINE HCL (TABLET) $3.80-$8.50 (Tier 2)C1
Mestinon
MESTINON (60MG/5ML ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Pyridostigmine Bromide pyridostigmine bromide (tablet immediate-release,
60mg/5ml oral solution)$1.25-$3.40 (Tier 1)
C1
Pyridostigmine Bromide ER pyridostigmine bromide er (tablet extended-release) $1.25-$3.40 (Tier 1)
A1
Antimycobacterials
B1
Antimycobacterials, OtherC1
Dapsone
dapsone (tablet) $1.25-$3.40 (Tier 1)C1
Rifabutin
rifabutin (capsule) $1.25-$3.40 (Tier 1)B1
AntitubercularsC1
Ethambutol HCl
ethambutol hcl (tablet) $1.25-$3.40 (Tier 1)C1
Isoniazid
isoniazid (100mg tablet, 300mg tablet, 50mg/5ml
syrup)$1.25-$3.40 (Tier 1)
C1
Paser
paser (packet) $1.25-$3.40 (Tier 1)C1
Priftin
PRIFTIN (TABLET) $3.80-$8.50 (Tier 2)C1
Pyrazinamide
pyrazinamide (tablet) $1.25-$3.40 (Tier 1)C1
Rifampin
rifampin (150mg capsule, 300mg capsule, 600mg
injection)$1.25-$3.40 (Tier 1)
C1
Rifater
RIFATER (TABLET) $3.80-$8.50 (Tier 2)
22For Track Refered Purpose3422
34
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Sirturo
SIRTURO (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1
Trecator
TRECATOR (TABLET) $3.80-$8.50 (Tier 2)A1
Antineoplastics
B1
Alkylating AgentsC1
Cyclophosphamide cyclophosphamide (capsule) $1.25-$3.40 (Tier 1) B/D, PAC1
Gleostine
GLEOSTINE (CAPSULE) $3.80-$8.50 (Tier 2)C1
Leukeran
LEUKERAN (TABLET) $3.80-$8.50 (Tier 2)C1
Matulane
MATULANE (CAPSULE) $3.80-$8.50 (Tier 2) LAC1
Valchlor
VALCHLOR (GEL) $3.80-$8.50 (Tier 2) PA, LAB1
Antiandrogens C1
Abiraterone Acetate abiraterone acetate (tablet) $1.25-$3.40 (Tier 1) PA, QLC1
Bicalutamide
bicalutamide (tablet) $1.25-$3.40 (Tier 1)C1
Erleada
ERLEADA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Flutamide
flutamide (capsule) $1.25-$3.40 (Tier 1)C1
Nilutamide
nilutamide (tablet) $1.25-$3.40 (Tier 1)C1
Nubeqa
NUBEQA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Xtandi
XTANDI (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Zytiga
ZYTIGA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAB1
Antiangiogenic AgentsC1
Pomalyst
POMALYST (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Revlimid
REVLIMID (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Thalomid
THALOMID (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLB1
Antiestrogens/ModifiersC1
Emcyt
EMCYT (CAPSULE) $3.80-$8.50 (Tier 2)C1
Fareston
FARESTON (TABLET) $3.80-$8.50 (Tier 2)C1
Soltamox
SOLTAMOX (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Tamoxifen Citrate tamoxifen citrate (tablet) $1.25-$3.40 (Tier 1)C1
Toremifene Citrate toremifene citrate (tablet) $1.25-$3.40 (Tier 1)
B1
AntimetabolitesC1
Droxia
DROXIA (CAPSULE) $3.80-$8.50 (Tier 2)C1
Hydroxyurea
hydroxyurea (capsule) $1.25-$3.40 (Tier 1)C1
Mercaptopurine
mercaptopurine (tablet) $1.25-$3.40 (Tier 1)C1
Purixan
PURIXAN (SUSPENSION) $3.80-$8.50 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
23For Track Refered Purpose3523
35
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Tabloid
TABLOID (TABLET) $3.80-$8.50 (Tier 2) PAB1
AntineoplasticsC1
Xpovio 100mg Once Weekly XPOVIO 100MG ONCE WEEKLY (TABLET THERAPY
PACK)$3.80-$8.50 (Tier 2) PA, QL
C1
Xpovio 60mg Once Weekly XPOVIO 60MG ONCE WEEKLY (TABLET THERAPY
PACK)$3.80-$8.50 (Tier 2) PA, QL
C1
Xpovio 80mg Once Weekly XPOVIO 80MG ONCE WEEKLY (TABLET THERAPY
PACK)$3.80-$8.50 (Tier 2) PA, QL
C1
Xpovio 80mg Twice Weekly XPOVIO 80MG TWICE WEEKLY (TABLET THERAPY
PACK)$3.80-$8.50 (Tier 2) PA, QL
B1
Antineoplastics, OtherC1
Copiktra
COPIKTRA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Inrebic
INREBIC (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Kisqali
KISQALI (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Kisqali Femara 200 Dose KISQALI FEMARA 200 DOSE (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) PA, QLC1
Kisqali Femara 400 Dose KISQALI FEMARA 400 DOSE (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) PA, QLC1
Kisqali Femara 600 Dose KISQALI FEMARA 600 DOSE (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) PA, QLC1
Leucovorin Calcium leucovorin calcium (tablet) $1.25-$3.40 (Tier 1)C1
Lonsurf
LONSURF (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Lorbrena
LORBRENA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Ninlaro
NINLARO (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Piqray 200mg Daily Dose PIQRAY 200MG DAILY DOSE (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) PA, QLC1
Piqray 250mg Daily Dose PIQRAY 250MG DAILY DOSE (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) PA, QLC1
Piqray 300mg Daily Dose PIQRAY 300MG DAILY DOSE (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) PA, QLC1
Rozlytrek
ROZLYTREK (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Synribo
SYNRIBO (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Verzenio
VERZENIO (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Zolinza
ZOLINZA (CAPSULE) $3.80-$8.50 (Tier 2) PA
24For Track Refered Purpose3624
36
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useB1
Aromatase Inhibitors, 3rd GenerationC1
Anastrozole
anastrozole (tablet) $1.25-$3.40 (Tier 1)C1
Exemestane
exemestane (tablet) $1.25-$3.40 (Tier 1)C1
Letrozole
letrozole (tablet) $1.25-$3.40 (Tier 1)B1
Enzyme InhibitorsC1
Balversa
BALVERSA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Rubraca
RUBRACA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Talzenna
TALZENNA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Zejula
ZEJULA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAB1
Molecular Target InhibitorsC1
Afinitor
AFINITOR (TABLET) $3.80-$8.50 (Tier 2) PAC1
Afinitor Disperz AFINITOR DISPERZ (TABLET SOLUBLE) $3.80-$8.50 (Tier 2) PAC1
Alecensa
ALECENSA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Alunbrig
ALUNBRIG (TABLET THERAPY PACK, 180MG TABLET, 30MG TABLET, 90MG TABLET)
$3.80-$8.50 (Tier 2) PA, QL, LAC1
Bosulif
BOSULIF (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Braftovi
BRAFTOVI (CAPSULE) $3.80-$8.50 (Tier 2) PAC1
Cabometyx
CABOMETYX (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Calquence
CALQUENCE (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Caprelsa
CAPRELSA (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1
Cometriq
COMETRIQ (KIT) $3.80-$8.50 (Tier 2) PA, LAC1
Cotellic
COTELLIC (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Daurismo
DAURISMO (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Erivedge
ERIVEDGE (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Erlotinib HCl
erlotinib hcl (tablet) $1.25-$3.40 (Tier 1) PA, QLC1
Farydak
FARYDAK (CAPSULE) $3.80-$8.50 (Tier 2) PAC1
Gilotrif
GILOTRIF (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1
Ibrance
IBRANCE (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Iclusig
ICLUSIG (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Idhifa
IDHIFA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Imatinib Mesylate
imatinib mesylate (tablet) $1.25-$3.40 (Tier 1) PA, QLC1
Imbruvica
IMBRUVICA (140MG CAPSULE, 70MG CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Imbruvica
IMBRUVICA (140MG TABLET, 280MG TABLET, 420MG TABLET, 560MG TABLET)
$3.80-$8.50 (Tier 2) PA, QLC1
Inlyta
INLYTA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LA
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
25For Track Refered Purpose3725
37
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Iressa
IRESSA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Jakafi
JAKAFI (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Lenvima
LENVIMA (CAPSULE THERAPY PACK) $3.80-$8.50 (Tier 2) PA, LAC1
Lynparza
LYNPARZA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Mekinist
MEKINIST (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1
Mektovi
MEKTOVI (TABLET) $3.80-$8.50 (Tier 2) PAC1
Nerlynx
NERLYNX (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Nexavar
NEXAVAR (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1
Odomzo
ODOMZO (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Rydapt
RYDAPT (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Sprycel
SPRYCEL (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Stivarga
STIVARGA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Sutent
SUTENT (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Tafinlar
TAFINLAR (CAPSULE) $3.80-$8.50 (Tier 2) PA, LAC1
Tagrisso
TAGRISSO (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Tarceva
TARCEVA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Tasigna
TASIGNA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Tibsovo
TIBSOVO (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Turalio
TURALIO (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Tykerb
TYKERB (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1
Venclexta
VENCLEXTA (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Venclexta Starting Pack VENCLEXTA STARTING PACK (TABLET THERAPY
PACK)$3.80-$8.50 (Tier 2) PA, LA
C1
Vitrakvi
VITRAKVI (100MG CAPSULE, 25MG CAPSULE, 20MG/ML SOLUTION)
$3.80-$8.50 (Tier 2) PA, QLC1
Vizimpro
VIZIMPRO (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Votrient
VOTRIENT (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Xalkori
XALKORI (CAPSULE) $3.80-$8.50 (Tier 2) PA, LAC1
Xospata
XOSPATA (TABLET) $3.80-$8.50 (Tier 2) PA, QL
26For Track Refered Purpose3826
38
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Zelboraf
ZELBORAF (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Zydelig
ZYDELIG (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Zykadia
ZYKADIA (150MG CAPSULE, 150MG TABLET) $3.80-$8.50 (Tier 2) PA, QLB1
RetinoidsC1
Bexarotene
bexarotene (capsule) $1.25-$3.40 (Tier 1) PAC1
Panretin
PANRETIN (GEL) $3.80-$8.50 (Tier 2)C1
Targretin
TARGRETIN (1% GEL) $3.80-$8.50 (Tier 2) PAC1
Tretinoin
tretinoin (10mg capsule) $1.25-$3.40 (Tier 1)B1
Treatment AdjunctsC1
Mesnex
MESNEX (400MG TABLET) $3.80-$8.50 (Tier 2)A1
Antiparasitics
B1
AnthelminticsC1
Albendazole
albendazole (tablet) $1.25-$3.40 (Tier 1) QLC1
Albenza
ALBENZA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Biltricide
BILTRICIDE (TABLET) $3.80-$8.50 (Tier 2)C1
Ivermectin
ivermectin (tablet) $1.25-$3.40 (Tier 1)C1
Praziquantel
praziquantel (tablet) $1.25-$3.40 (Tier 1)B1
AntiprotozoalsC1
Alinia
ALINIA (100MG/5ML SUSPENSION, 500MG TABLET) $3.80-$8.50 (Tier 2)C1
Atovaquone
atovaquone (suspension) $1.25-$3.40 (Tier 1)C1
Atovaquone/Proguanil HCl atovaquone/proguanil hcl (tablet) (generic malarone) $1.25-$3.40 (Tier 1)C1
Benznidazole BENZNIDAZOLE (TABLET) $3.80-$8.50 (Tier 2)C1
Chloroquine Phosphate chloroquine phosphate (tablet) $1.25-$3.40 (Tier 1)C1
Coartem
COARTEM (TABLET) $3.80-$8.50 (Tier 2)C1
Daraprim
DARAPRIM (TABLET) $3.80-$8.50 (Tier 2)C1
Hydroxychloroquine Sulfate hydroxychloroquine sulfate (tablet) $1.25-$3.40 (Tier 1)C1
Mefloquine HCl
mefloquine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Nebupent
NEBUPENT (INHALATION SOLUTION) $3.80-$8.50 (Tier 2) B/D, PA, QLC1
Pentam 300
PENTAM 300 (INJECTION) $3.80-$8.50 (Tier 2)C1
Primaquine Phosphate primaquine phosphate (tablet) $1.25-$3.40 (Tier 1)C1
Quinine Sulfate
quinine sulfate (capsule) $1.25-$3.40 (Tier 1) PAB1
Pediculicides/ScabicidesC1
GNP Lice Treatment gnp lice treatment (liquid)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
27For Track Refered Purpose3927
39
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Lindane
lindane (shampoo) $1.25-$3.40 (Tier 1)C1
Malathion
malathion (lotion) $1.25-$3.40 (Tier 1)C1
Permethrin
permethrin (cream) $1.25-$3.40 (Tier 1)A1
Antiparkinson Agents
B1
AnticholinergicsC1
Benztropine Mesylate benztropine mesylate (tablet) $1.25-$3.40 (Tier 1)C1
Trihexyphenidyl HCl trihexyphenidyl hcl (oral solution) $1.25-$3.40 (Tier 1)C1
Trihexyphenidyl HCl trihexyphenidyl hcl (tablet) $1.25-$3.40 (Tier 1)
B1
Antiparkinson Agents, OtherC1
Amantadine HCl
amantadine hcl (100mg capsule, 100mg tablet,
50mg/5ml syrup)$1.25-$3.40 (Tier 1)
C1
Entacapone
entacapone (tablet) $1.25-$3.40 (Tier 1)C1
Tolcapone
tolcapone (tablet) $1.25-$3.40 (Tier 1) QLB1
Dopamine AgonistsC1
Apokyn
APOKYN (INJECTION) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Bromocriptine Mesylate bromocriptine mesylate (2.5mg tablet, 5mg capsule) $1.25-$3.40 (Tier 1)C1
Neupro
NEUPRO (PATCH 24 HOUR) $3.80-$8.50 (Tier 2)C1
Pramipexole Dihydrochloride pramipexole dihydrochloride (tablet immediate-
release)$1.25-$3.40 (Tier 1)
C1
Ropinirole HCl
ropinirole hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)B1
Dopamine Precursors/L-Amino Acid Decarboxylase InhibitorsC1
Carbidopa/Levodopa carbidopa/levodopa (tablet immediate-release) $1.25-$3.40 (Tier 1)C1
Carbidopa/Levodopa ER carbidopa/levodopa er (tablet extended-release) $1.25-$3.40 (Tier 1)C1
Carbidopa/Levodopa ODT carbidopa/levodopa odt (tablet dispersible) $1.25-$3.40 (Tier 1)C1
Carbidopa/Levodopa/Entacapone carbidopa/levodopa/entacapone (tablet) $1.25-$3.40 (Tier 1)C1
Rytary
RYTARY (CAPSULE EXTENDED-RELEASE) $3.80-$8.50 (Tier 2) ST
28For Track Refered Purpose4028
40
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useB1
Monoamine Oxidase B (MAO-B) InhibitorsC1
Rasagiline Mesylate rasagiline mesylate (0.5mg tablet, 1mg tablet) $1.25-$3.40 (Tier 1)C1
Selegiline HCl
selegiline hcl (5mg capsule, 5mg tablet) $1.25-$3.40 (Tier 1)C1
Zelapar
ZELAPAR (TABLET DISPERSIBLE) $3.80-$8.50 (Tier 2)A1
Antipsychotics
B1
1st Generation/TypicalC1
Chlorpromazine HCl chlorpromazine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Fluphenazine Decanoate fluphenazine decanoate (injection) $1.25-$3.40 (Tier 1)C1
Fluphenazine HCl fluphenazine hcl (10mg tablet, 1mg tablet, 2.5mg
tablet, 5mg tablet, 2.5mg/ml injection, 5mg/ml
concentrate)
$1.25-$3.40 (Tier 1)
C1
Fluphenazine HCl fluphenazine hcl (elixir) $1.25-$3.40 (Tier 1)C1
Haloperidol
haloperidol (0.5mg tablet, 10mg tablet, 1mg tablet,
20mg tablet, 2mg tablet, 5mg tablet, 2mg/ml
concentrate)
$1.25-$3.40 (Tier 1)
C1
Haloperidol Decanoate haloperidol decanoate (injection) $1.25-$3.40 (Tier 1)C1
Haloperidol Lactate haloperidol lactate (injection) $1.25-$3.40 (Tier 1)C1
Loxapine Succinate loxapine succinate (capsule) $1.25-$3.40 (Tier 1)C1
Molindone HCl
molindone hcl (tablet) $1.25-$3.40 (Tier 1)C1
Pimozide
pimozide (tablet) $1.25-$3.40 (Tier 1)C1
Thioridazine HCl
thioridazine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Thiothixene
thiothixene (capsule) $1.25-$3.40 (Tier 1)C1
Trifluoperazine HCl trifluoperazine hcl (tablet) $1.25-$3.40 (Tier 1)
B1
2nd Generation/AtypicalC1
Abilify Maintena ABILIFY MAINTENA (INJECTION) $3.80-$8.50 (Tier 2)C1
Aripiprazole
aripiprazole (10mg tablet, 15mg tablet, 20mg tablet,
2mg tablet, 30mg tablet, 5mg tablet, 1mg/ml oral
solution)
$1.25-$3.40 (Tier 1) QL
C1
Aripiprazole ODT
aripiprazole odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1
Aristada
ARISTADA (INJECTION) $3.80-$8.50 (Tier 2)C1
Aristada Initio ARISTADA INITIO (PREFILLED SYRINGE) $3.80-$8.50 (Tier 2)C1
Fanapt
FANAPT (TABLET) $3.80-$8.50 (Tier 2) QL, STC1
Fanapt Titration Pack FANAPT TITRATION PACK (TABLET) $3.80-$8.50 (Tier 2) STC1
Geodon
GEODON (20MG INJECTION) $3.80-$8.50 (Tier 2)C1
Invega Sustenna INVEGA SUSTENNA (INJECTION) $3.80-$8.50 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
29For Track Refered Purpose4129
41
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Invega Trinza INVEGA TRINZA (INJECTION) $3.80-$8.50 (Tier 2)C1
Latuda
LATUDA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Nuplazid
NUPLAZID (10MG TABLET, 34MG CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Olanzapine
olanzapine (10mg injection) $1.25-$3.40 (Tier 1)C1
Olanzapine
olanzapine (10mg tablet, 15mg tablet, 2.5mg tablet,
20mg tablet, 5mg tablet, 7.5mg tablet)$1.25-$3.40 (Tier 1) QL
C1
Olanzapine ODT
olanzapine odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1
Paliperidone ER paliperidone er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1) QLC1
Perseris
PERSERIS (PREFILLED SYRINGE) $3.80-$8.50 (Tier 2)C1
Quetiapine Fumarate quetiapine fumarate (tablet immediate-release) $1.25-$3.40 (Tier 1) QLC1
Quetiapine Fumarate ER quetiapine fumarate er (tablet extended-release 24
hour)$1.25-$3.40 (Tier 1) QL
C1
Rexulti
REXULTI (TABLET) $3.80-$8.50 (Tier 2) QLC1
Risperdal Consta RISPERDAL CONSTA (INJECTION) $3.80-$8.50 (Tier 2)C1
Risperidone
risperidone (0.25mg tablet, 0.5mg tablet, 1mg tablet,
2mg tablet, 3mg tablet, 4mg tablet, 1mg/ml oral
solution)
$1.25-$3.40 (Tier 1)
C1
Risperidone ODT
risperidone odt (tablet dispersible) $1.25-$3.40 (Tier 1)C1
Saphris
SAPHRIS (TABLET SUBLINGUAL) $3.80-$8.50 (Tier 2) QLC1
Vraylar
VRAYLAR (1.5MG CAPSULE, 3MG CAPSULE, 4.5MG CAPSULE, 6MG CAPSULE)
$3.80-$8.50 (Tier 2) QL, STC1
Vraylar
VRAYLAR (CAPSULE THERAPY PACK) $3.80-$8.50 (Tier 2) STC1
Ziprasidone HCl
ziprasidone hcl (capsule) $1.25-$3.40 (Tier 1) QLC1
Zyprexa Relprevv ZYPREXA RELPREVV (INJECTION) $3.80-$8.50 (Tier 2)
B1
Treatment-ResistantC1
Clozapine
clozapine (100mg tablet, 25mg tablet, 50mg tablet,
200mg tablet)$1.25-$3.40 (Tier 1)
C1
Clozapine ODT
clozapine odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1
Versacloz
VERSACLOZ (SUSPENSION) $3.80-$8.50 (Tier 2)
30For Track Refered Purpose4230
42
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useA1
Antivirals
B1
Anti-cytomegalovirus (CMV) AgentsC1
Valganciclovir
valganciclovir (tablet) $1.25-$3.40 (Tier 1) QLC1
Valganciclovir Hydrochlorde valganciclovir hydrochlorde (oral solution) $1.25-$3.40 (Tier 1) QLC1
Zirgan
ZIRGAN (GEL) $3.80-$8.50 (Tier 2)B1
Anti-hepatitis B (HBV) AgentsC1
Baraclude
BARACLUDE (0.05MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Entecavir
entecavir (tablet) $1.25-$3.40 (Tier 1)C1
Epivir HBV
EPIVIR HBV (5MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Lamivudine
lamivudine (100mg tablet) $1.25-$3.40 (Tier 1)C1
Vemlidy
VEMLIDY (TABLET) $3.80-$8.50 (Tier 2) QLB1
Anti-hepatitis C (HCV) Agents, OtherC1
Intron A
INTRON A (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Pegasys
PEGASYS (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Pegasys ProClick PEGASYS PROCLICK (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Ribavirin
ribavirin (200mg tablet) $1.25-$3.40 (Tier 1)C1
Sylatron
SYLATRON (INJECTION) $3.80-$8.50 (Tier 2) PAB1
Anti-hepatitis C (HCV) Direct Acting AgentsC1
Epclusa
EPCLUSA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Harvoni
HARVONI (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Ledipasvir/Sofosbuvir ledipasvir/sofosbuvir (tablet) $1.25-$3.40 (Tier 1) PA, QLC1
Mavyret
MAVYRET (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Sofosbuvir/Velpatasvir sofosbuvir/velpatasvir (tablet) $1.25-$3.40 (Tier 1) PA, QLC1
Vosevi
VOSEVI (TABLET) $3.80-$8.50 (Tier 2) PA, QLB1
Antiherpetic AgentsC1
Acyclovir
acyclovir (200mg capsule, 200mg/5ml suspension,
400mg tablet, 800mg tablet)$1.25-$3.40 (Tier 1)
C1
Acyclovir Sodium acyclovir sodium (injection) $1.25-$3.40 (Tier 1) B/D, PAC1
Famciclovir
famciclovir (tablet) $1.25-$3.40 (Tier 1) QLC1
Trifluridine
trifluridine (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Valacyclovir HCl
valacyclovir hcl (tablet) $1.25-$3.40 (Tier 1) QLB1
Anti-HIV Agents, Integrase Inhibitors (INSTI) C1
Dovato
DOVATO (TABLET) $3.80-$8.50 (Tier 2) QL
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
31For Track Refered Purpose4331
43
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Genvoya
GENVOYA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Isentress
ISENTRESS (100MG PACKET, 100MG TABLET CHEWABLE, 25MG TABLET CHEWABLE, 400MG TABLET)
$3.80-$8.50 (Tier 2) QL
C1
Isentress HD ISENTRESS HD (TABLET) $3.80-$8.50 (Tier 2) QLC1
Stribild
STRIBILD (TABLET) $3.80-$8.50 (Tier 2) QLC1
Tivicay
TIVICAY (TABLET) $3.80-$8.50 (Tier 2) QLC1
Triumeq
TRIUMEQ (TABLET) $3.80-$8.50 (Tier 2) QLC1
Tybost
TYBOST (TABLET) $3.80-$8.50 (Tier 2) QLB1
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)C1
Atripla
ATRIPLA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Complera
COMPLERA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Delstrigo
DELSTRIGO (TABLET) $3.80-$8.50 (Tier 2) QLC1
Edurant
EDURANT (TABLET) $3.80-$8.50 (Tier 2) QLC1
Efavirenz
efavirenz (200mg capsule, 50mg capsule, 600mg
tablet)$1.25-$3.40 (Tier 1) QL
C1
Intelence
INTELENCE (TABLET) $3.80-$8.50 (Tier 2) QLC1
Juluca
JULUCA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Nevirapine
nevirapine (200mg tablet immediate-release, 50mg/
5ml suspension)$1.25-$3.40 (Tier 1) QL
C1
Nevirapine ER
nevirapine er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1) QLC1
Odefsey
ODEFSEY (TABLET) $3.80-$8.50 (Tier 2) QLC1
Pifeltro
PIFELTRO (TABLET) $3.80-$8.50 (Tier 2) QLC1
Rescriptor
RESCRIPTOR (TABLET) $3.80-$8.50 (Tier 2) QLC1
Symfi
SYMFI (TABLET) $3.80-$8.50 (Tier 2) QLC1
Symfi Lo
SYMFI LO (TABLET) $3.80-$8.50 (Tier 2) QLC1
Viramune
VIRAMUNE (50MG/5ML SUSPENSION) $3.80-$8.50 (Tier 2) QLB1
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)C1
Abacavir
abacavir (20mg/ml oral solution, 300mg tablet) $1.25-$3.40 (Tier 1) QL
32For Track Refered Purpose4432
44
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Abacavir Sulfate/Lamivudine abacavir sulfate/lamivudine (tablet) $1.25-$3.40 (Tier 1) QLC1
Abacavir Sulfate/Lamivudine/Zidovudine
abacavir sulfate/lamivudine/zidovudine (tablet) $1.25-$3.40 (Tier 1) QLC1
Biktarvy
BIKTARVY (TABLET) $3.80-$8.50 (Tier 2) QLC1
Cimduo
CIMDUO (TABLET) $3.80-$8.50 (Tier 2) QLC1
Descovy
DESCOVY (TABLET) $3.80-$8.50 (Tier 2) QLC1
Didanosine
didanosine (capsule delayed-release) $1.25-$3.40 (Tier 1) QLC1
Emtriva
EMTRIVA (10MG/ML ORAL SOLUTION, 200MG CAPSULE)
$3.80-$8.50 (Tier 2) QLC1
Lamivudine
lamivudine (10mg/ml oral solution, 150mg tablet,
300mg tablet)$1.25-$3.40 (Tier 1) QL
C1
Lamivudine/Zidovudine lamivudine/zidovudine (tablet) $1.25-$3.40 (Tier 1) QLC1
Stavudine
stavudine (capsule) $1.25-$3.40 (Tier 1) QLC1
Tenofovir Disoproxil Fumarate tenofovir disoproxil fumarate (tablet) $1.25-$3.40 (Tier 1) QLC1
Truvada
TRUVADA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Videx EC
VIDEX EC (125MG CAPSULE DELAYED-RELEASE) $3.80-$8.50 (Tier 2) QLC1
Videx Pediatric VIDEX PEDIATRIC (ORAL SOLUTION) $3.80-$8.50 (Tier 2) QLC1
Viread
VIREAD (150MG TABLET, 200MG TABLET, 250MG TABLET, 40MG/GM POWDER)
$3.80-$8.50 (Tier 2) QLC1
Zidovudine
zidovudine (100mg capsule, 300mg tablet, 50mg/
5ml syrup)$1.25-$3.40 (Tier 1) QL
B1
Anti-HIV Agents, OtherC1
Fuzeon
FUZEON (INJECTION) $3.80-$8.50 (Tier 2) QLC1
Selzentry
SELZENTRY (150MG TABLET, 25MG TABLET, 300MG TABLET, 75MG TABLET, 20MG/ML ORAL SOLUTION)
$3.80-$8.50 (Tier 2) QL
B1
Anti-HIV Agents, Protease InhibitorsC1
Aptivus
APTIVUS (100MG/ML ORAL SOLUTION, 250MG CAPSULE)
$3.80-$8.50 (Tier 2) QLC1
Atazanavir Sulfate atazanavir sulfate (capsule) $1.25-$3.40 (Tier 1) QLC1
Crixivan
CRIXIVAN (CAPSULE) $3.80-$8.50 (Tier 2) QLC1
Evotaz
EVOTAZ (TABLET) $3.80-$8.50 (Tier 2) QLC1
Fosamprenavir Calcium fosamprenavir calcium (tablet) $1.25-$3.40 (Tier 1) QLC1
Invirase
INVIRASE (TABLET) $3.80-$8.50 (Tier 2) QLC1
Kaletra
KALETRA (100MG-25MG TABLET, 200MG-50MG TABLET)
$3.80-$8.50 (Tier 2) QLC1
Lexiva
LEXIVA (50MG/ML SUSPENSION) $3.80-$8.50 (Tier 2) QLC1
Lopinavir/Ritonavir lopinavir/ritonavir (oral solution) $1.25-$3.40 (Tier 1) QL
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
33For Track Refered Purpose4533
45
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Norvir
NORVIR (100MG PACKET, 100MG TABLET, 80MG/ML ORAL SOLUTION)
$3.80-$8.50 (Tier 2) QLC1
Prezcobix
PREZCOBIX (TABLET) $3.80-$8.50 (Tier 2) QLC1
Prezista
PREZISTA (100MG/ML SUSPENSION, 150MG TABLET, 600MG TABLET, 75MG TABLET, 800MG TABLET)
$3.80-$8.50 (Tier 2) QLC1
Reyataz
REYATAZ (50MG PACKET) $3.80-$8.50 (Tier 2) QLC1
Ritonavir
ritonavir (tablet) $1.25-$3.40 (Tier 1) QLC1
Symtuza
SYMTUZA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Viracept
VIRACEPT (TABLET) $3.80-$8.50 (Tier 2) QLB1
Anti-influenza AgentsC1
Oseltamivir Phosphate oseltamivir phosphate (30mg capsule, 45mg
capsule, 75mg capsule, 6mg/ml suspension)$1.25-$3.40 (Tier 1) QL
C1
Relenza Diskhaler RELENZA DISKHALER (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1
Rimantadine HCl
rimantadine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Xofluza
XOFLUZA (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) QLA1
Anxiolytics
B1
Anxiolytics, OtherC1
Buspirone HCl
buspirone hcl (tablet) $1.25-$3.40 (Tier 1)C1
Hydroxyzine HCl
hydroxyzine hcl (10mg/5ml syrup) $1.25-$3.40 (Tier 1)C1
Hydroxyzine HCl
hydroxyzine hcl (tablet) $1.25-$3.40 (Tier 1)B1
Benzodiazepines C1
Alprazolam
alprazolam (tablet immediate-release) $1.25-$3.40 (Tier 1) QLC1
Chlordiazepoxide HCl chlordiazepoxide hcl (capsule) $1.25-$3.40 (Tier 1)C1
Clonazepam
clonazepam (tablet) $1.25-$3.40 (Tier 1) QLC1
Clonazepam ODT clonazepam odt (tablet dispersible) $1.25-$3.40 (Tier 1) QLC1
Clorazepate Dipotassium clorazepate dipotassium (tablet) $1.25-$3.40 (Tier 1) QLC1
Diazepam
diazepam (10mg tablet, 2mg tablet, 5mg tablet) $1.25-$3.40 (Tier 1) QL
34For Track Refered Purpose4634
46
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Diazepam
diazepam (5mg/5ml oral solution) $1.25-$3.40 (Tier 1)C1
Diazepam Intensol diazepam intensol (5mg/ml concentrate) $1.25-$3.40 (Tier 1) QLC1
Lorazepam
lorazepam (0.5mg tablet, 1mg tablet, 2mg tablet,
2mg/ml concentrate)$1.25-$3.40 (Tier 1) QL
A1
Bipolar Agents
B1
Mood StabilizersC1
Divalproex Sodium divalproex sodium (capsule sprinkle delayed-release) $1.25-$3.40 (Tier 1)C1
Divalproex Sodium DR divalproex sodium dr (tablet delayed-release) $1.25-$3.40 (Tier 1)C1
Divalproex Sodium ER divalproex sodium er (tablet extended-release 24
hour)$1.25-$3.40 (Tier 1)
C1
Lithium
LITHIUM (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Lithium Carbonate lithium carbonate (150mg capsule, 300mg capsule,
600mg capsule, 300mg tablet immediate-release)$1.25-$3.40 (Tier 1)
C1
Lithium Carbonate ER lithium carbonate er (tablet extended-release) $1.25-$3.40 (Tier 1)
A1
Blood Glucose Regulators
B1
Antidiabetic AgentsC1
Acarbose
acarbose (tablet) $1.25-$3.40 (Tier 1) QLC1
Avandia
AVANDIA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Bydureon Bcise BYDUREON BCISE (AUTO INJECTOR) $3.80-$8.50 (Tier 2) QLC1
Bydureon Pen BYDUREON PEN (INJECTION) $3.80-$8.50 (Tier 2) QLC1
Byetta
BYETTA (INJECTION) $3.80-$8.50 (Tier 2) QLC1
Cycloset
CYCLOSET (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Farxiga
FARXIGA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Glimepiride
glimepiride (tablet) $1.25-$3.40 (Tier 1) QLC1
Glipizide
glipizide (tablet immediate-release) $1.25-$3.40 (Tier 1) QLC1
Glipizide ER
glipizide er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1) QLC1
Glipizide/Metformin HCl glipizide/metformin hcl (tablet) $1.25-$3.40 (Tier 1) QLC1
Glyxambi
GLYXAMBI (TABLET) $3.80-$8.50 (Tier 2) QLC1
Jardiance
JARDIANCE (TABLET) $3.80-$8.50 (Tier 2) QLC1
Jentadueto
JENTADUETO (TABLET) $3.80-$8.50 (Tier 2) QLC1
Jentadueto XR JENTADUETO XR (TABLET EXTENDED-RELEASE 24
HOUR)$3.80-$8.50 (Tier 2) QL
C1
Kombiglyze XR KOMBIGLYZE XR (TABLET EXTENDED-RELEASE 24
HOUR)$3.80-$8.50 (Tier 2) QL
C1
Metformin HCl
metformin hcl (tablet immediate-release) $1.25-$3.40 (Tier 1) QL
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
35For Track Refered Purpose4735
47
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Metformin HCl ER metformin hcl er (500mg tablet extended-release 24
hour, 750mg tablet extended-release 24 hour)
(generic glucophage xr)
$1.25-$3.40 (Tier 1) QL
C1
Nateglinide
nateglinide (tablet) $1.25-$3.40 (Tier 1) QLC1
Onglyza
ONGLYZA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Pioglitazone HCl
pioglitazone hcl (tablet) $1.25-$3.40 (Tier 1) QLC1
Pioglitazone HCl/Glimepiride pioglitazone hcl/glimepiride (tablet) $1.25-$3.40 (Tier 1) QLC1
Pioglitazone HCl/Metformin HCl pioglitazone hcl/metformin hcl (tablet) $1.25-$3.40 (Tier 1) QLC1
Repaglinide
repaglinide (tablet) $1.25-$3.40 (Tier 1) QLC1
Repaglinide/Metformin HCl repaglinide/metformin hcl (tablet) $1.25-$3.40 (Tier 1) QLC1
Riomet
RIOMET (ORAL SOLUTION) $3.80-$8.50 (Tier 2) QLC1
Soliqua 100/33 SOLIQUA 100/33 (INJECTION) $3.80-$8.50 (Tier 2) QLC1
SymlinPen 120 SYMLINPEN 120 (INJECTION) $3.80-$8.50 (Tier 2) PAC1
SymlinPen 60 SYMLINPEN 60 (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Synjardy
SYNJARDY (TABLET) $3.80-$8.50 (Tier 2) QLC1
Synjardy XR
SYNJARDY XR (TABLET EXTENDED-RELEASE 24 HOUR)
$3.80-$8.50 (Tier 2) QLC1
Tradjenta
TRADJENTA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Xigduo XR
XIGDUO XR (TABLET EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2) QLB1
Glycemic AgentsC1
GlucaGen HypoKit GLUCAGEN HYPOKIT (INJECTION) $3.80-$8.50 (Tier 2)C1
Glucagon Emergency Kit GLUCAGON EMERGENCY KIT (INJECTION) $3.80-$8.50 (Tier 2)C1
Proglycem
PROGLYCEM (SUSPENSION) $3.80-$8.50 (Tier 2)B1
InsulinsC1
Humalog Cartridge HUMALOG CARTRIDGE (INJECTION) $3.80-$8.50 (Tier 2)C1
Humalog Junior KwikPen HUMALOG JUNIOR KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1
Humalog KwikPen HUMALOG KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1
Humalog Mix 50/50 KwikPen HUMALOG MIX 50/50 KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)
36For Track Refered Purpose4836
48
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Humalog Mix 50/50 Vial HUMALOG MIX 50/50 VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1
Humalog Mix 75/25 KwikPen HUMALOG MIX 75/25 KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1
Humalog Mix 75/25 Vial HUMALOG MIX 75/25 VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1
Humalog Vial HUMALOG VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1
Humulin 70/30 KwikPen HUMULIN 70/30 KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1
Humulin 70/30 Vial HUMULIN 70/30 VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1
Humulin N KwikPen HUMULIN N KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1
Humulin N Vial HUMULIN N VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1
Humulin R U-500 KwikPen HUMULIN R U-500 KWIKPEN (INJECTION) $3.80-$8.50 (Tier 2)C1
Humulin R U-500 Vial HUMULIN R U-500 VIAL (CONCENTRATED) (INJECTION) $3.80-$8.50 (Tier 2)C1
Humulin R Vial HUMULIN R VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1
Insulin Lispro
insulin lispro (solution) $3.80-$8.50 (Tier 2)C1
Insulin Lispro KwikPen insulin lispro kwikpen (solution pen injector) $3.80-$8.50 (Tier 2)C1
Lantus SoloStar LANTUS SOLOSTAR (INJECTION) $3.80-$8.50 (Tier 2)C1
Lantus Vial
LANTUS VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1
Levemir FlexTouch LEVEMIR FLEXTOUCH (INJECTION) $3.80-$8.50 (Tier 2)C1
Levemir Vial
LEVEMIR VIAL (INJECTION) $3.80-$8.50 (Tier 2)C1
Toujeo Max Solostar TOUJEO MAX SOLOSTAR (INJECTION) $3.80-$8.50 (Tier 2)C1
Toujeo SoloStar TOUJEO SOLOSTAR (INJECTION) $3.80-$8.50 (Tier 2)C1
Tresiba
TRESIBA (INJECTION) $3.80-$8.50 (Tier 2)C1
Tresiba FlexTouch TRESIBA FLEXTOUCH (INJECTION) $3.80-$8.50 (Tier 2)
A1
Blood Products/Modifiers/Volume Expanders
B1
AnticoagulantsC1
Coumadin
COUMADIN (TABLET) $3.80-$8.50 (Tier 2)C1
Eliquis
ELIQUIS (TABLET) $3.80-$8.50 (Tier 2) QLC1
Eliquis Starter Pack ELIQUIS STARTER PACK (TABLET) $3.80-$8.50 (Tier 2) QLC1
Enoxaparin Sodium enoxaparin sodium (injection) $1.25-$3.40 (Tier 1) QLC1
Fondaparinux Sodium fondaparinux sodium (injection) $1.25-$3.40 (Tier 1)C1
Heparin Sodium
heparin sodium (10000unit/ml injection, 20000unit/
ml injection, 5000unit/ml injection)$1.25-$3.40 (Tier 1)
C1
Heparin Sodium
heparin sodium (1000unit/ml injection) $1.25-$3.40 (Tier 1) B/D, PAC1
Jantoven
jantoven (tablet) $1.25-$3.40 (Tier 1)C1
Warfarin Sodium
warfarin sodium (tablet) $1.25-$3.40 (Tier 1)C1
Xarelto
XARELTO (10MG TABLET, 15MG TABLET, 20MG TABLET, 2.5MG TABLET)
$3.80-$8.50 (Tier 2) QLC1
Xarelto Starter Pack XARELTO STARTER PACK (TABLET THERAPY PACK) $3.80-$8.50 (Tier 2) QL
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
37For Track Refered Purpose4937
49
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useB1
Blood Formation ModifiersC1
Anagrelide HCl
anagrelide hcl (capsule) $1.25-$3.40 (Tier 1)C1
Aranesp Albumin Free ARANESP ALBUMIN FREE (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Leukine
LEUKINE (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Neulasta
NEULASTA (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Procrit
PROCRIT (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Promacta
PROMACTA (12.5MG PACKET, 12.5MG TABLET, 25MG TABLET, 50MG TABLET, 75MG TABLET)
$3.80-$8.50 (Tier 2) PA, QL, LAC1
Retacrit
RETACRIT (SOLUTION) $3.80-$8.50 (Tier 2) PAC1
Zarxio
ZARXIO (SOLUTION PREFILLED SYRINGE) $3.80-$8.50 (Tier 2)B1
Hemostasis AgentsC1
Tranexamic Acid
tranexamic acid (tablet) $1.25-$3.40 (Tier 1)B1
Platelet Modifying AgentsC1
Aspirin/Dipyridamole aspirin/dipyridamole (capsule extended-release 12
hour)$1.25-$3.40 (Tier 1) QL
C1
Brilinta
BRILINTA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Cablivi
CABLIVI (KIT) $3.80-$8.50 (Tier 2) PA, QLC1
Cilostazol
cilostazol (tablet) $1.25-$3.40 (Tier 1)C1
Clopidogrel
clopidogrel (75mg tablet) $1.25-$3.40 (Tier 1) QLC1
Prasugrel
prasugrel (tablet) $1.25-$3.40 (Tier 1) QLA1
Cardiovascular Agents
B1
Alpha-adrenergic AgonistsC1
Clonidine HCl
clonidine hcl (patch weekly) $1.25-$3.40 (Tier 1)C1
Clonidine HCl
clonidine hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)C1
Methyldopa
methyldopa (tablet) $1.25-$3.40 (Tier 1)C1
Midodrine HCl
midodrine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Northera
NORTHERA (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LA
38For Track Refered Purpose5038
50
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useB1
Alpha-adrenergic Blocking AgentsC1
Doxazosin Mesylate doxazosin mesylate (tablet) $1.25-$3.40 (Tier 1)C1
Phenoxybenzamine HCl phenoxybenzamine hcl (capsule) $1.25-$3.40 (Tier 1)C1
Prazosin HCl
prazosin hcl (capsule) $1.25-$3.40 (Tier 1)B1
Angiotensin II Receptor AntagonistsC1
Candesartan Cilexetil candesartan cilexetil (tablet) $1.25-$3.40 (Tier 1) QLC1
Eprosartan Mesylate eprosartan mesylate (tablet) $1.25-$3.40 (Tier 1) QLC1
Irbesartan
irbesartan (tablet) $1.25-$3.40 (Tier 1) QLC1
Losartan Potassium losartan potassium (tablet) $1.25-$3.40 (Tier 1) QLC1
Olmesartan Medoxomil olmesartan medoxomil (tablet) $1.25-$3.40 (Tier 1) QLC1
Telmisartan
telmisartan (tablet) $1.25-$3.40 (Tier 1) QLC1
Valsartan
valsartan (tablet) $1.25-$3.40 (Tier 1) QLB1
Angiotensin-converting Enzyme (ACE) InhibitorsC1
Benazepril HCl
benazepril hcl (tablet) $1.25-$3.40 (Tier 1) QLC1
Captopril
captopril (tablet) $1.25-$3.40 (Tier 1) QLC1
Enalapril Maleate enalapril maleate (tablet) $1.25-$3.40 (Tier 1) QLC1
Fosinopril Sodium fosinopril sodium (tablet) $1.25-$3.40 (Tier 1) QLC1
Lisinopril
lisinopril (tablet) $1.25-$3.40 (Tier 1) QLC1
Moexipril HCl
moexipril hcl (tablet) $1.25-$3.40 (Tier 1) QLC1
Perindopril Erbumine perindopril erbumine (tablet) $1.25-$3.40 (Tier 1) QLC1
Quinapril HCl
quinapril hcl (tablet) $1.25-$3.40 (Tier 1) QLC1
Ramipril
ramipril (capsule) $1.25-$3.40 (Tier 1) QLC1
Trandolapril
trandolapril (tablet) $1.25-$3.40 (Tier 1) QLB1
AntiarrhythmicsC1
Amiodarone HCl
amiodarone hcl (200mg tablet) $1.25-$3.40 (Tier 1)C1
Dofetilide
dofetilide (capsule) $1.25-$3.40 (Tier 1)C1
Flecainide Acetate flecainide acetate (tablet) $1.25-$3.40 (Tier 1)C1
Mexiletine HCl
mexiletine hcl (capsule) $1.25-$3.40 (Tier 1)C1
Multaq
MULTAQ (TABLET) $3.80-$8.50 (Tier 2) QLC1
Pacerone
pacerone (200mg tablet) $1.25-$3.40 (Tier 1)C1
Propafenone HCl propafenone hcl (tablet) $1.25-$3.40 (Tier 1)C1
Propafenone HCl ER propafenone hcl er (capsule extended-release 12
hour)$1.25-$3.40 (Tier 1)
C1
Quinidine Gluconate CR quinidine gluconate cr (tablet extended-release) $1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
39For Track Refered Purpose5139
51
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Quinidine Sulfate quinidine sulfate (tablet) $1.25-$3.40 (Tier 1)C1
Sotalol HCl AF
sotalol hcl af (tablet) $1.25-$3.40 (Tier 1)C1
Sotalol HCl
sotalol hcl (tablet) $1.25-$3.40 (Tier 1)B1
Beta-adrenergic Blocking AgentsC1
Atenolol
atenolol (tablet) $1.25-$3.40 (Tier 1)C1
Bystolic
BYSTOLIC (TABLET) $3.80-$8.50 (Tier 2) QLC1
Carvedilol
carvedilol (tablet) $1.25-$3.40 (Tier 1)C1
Labetalol HCl
labetalol hcl (tablet) $1.25-$3.40 (Tier 1)C1
Metoprolol Succinate ER metoprolol succinate er (tablet extended-release 24
hour)$1.25-$3.40 (Tier 1)
C1
Metoprolol Tartrate metoprolol tartrate (100mg tablet immediate-release,
25mg tablet immediate-release, 50mg tablet
immediate-release)
$1.25-$3.40 (Tier 1)
C1
Nadolol
nadolol (tablet) $1.25-$3.40 (Tier 1)C1
Pindolol
pindolol (tablet) $1.25-$3.40 (Tier 1)C1
Propranolol HCl
propranolol hcl (20mg/5ml oral solution, 40mg/5ml
oral solution)$1.25-$3.40 (Tier 1)
C1
Propranolol HCl
propranolol hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)C1
Propranolol HCl ER propranolol hcl er (capsule extended-release 24
hour)$1.25-$3.40 (Tier 1)
C1
Timolol Maleate
timolol maleate (10mg tablet, 20mg tablet, 5mg
tablet)$1.25-$3.40 (Tier 1)
B1
Calcium Channel Blocking AgentsC1
Amlodipine Besylate amlodipine besylate (tablet) $1.25-$3.40 (Tier 1)C1
Cartia XT
cartia xt (capsule extended-release 24 hour) $1.25-$3.40 (Tier 1)C1
Dilt-XR
dilt-xr (capsule extended-release 24 hour) $1.25-$3.40 (Tier 1)C1
Diltiazem HCl
diltiazem hcl (tablet immediate-release) $1.25-$3.40 (Tier 1)C1
Diltiazem HCl ER diltiazem hcl er (capsule extended-release 12 hour) $1.25-$3.40 (Tier 1)C1
Diltiazem HCl ER diltiazem hcl er (capsule extended-release 24 hour) $1.25-$3.40 (Tier 1)
40For Track Refered Purpose5240
52
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Matzim LA
matzim la (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1
Nicardipine HCl
nicardipine hcl (capsule) $1.25-$3.40 (Tier 1)C1
Nimodipine
nimodipine (capsule) $1.25-$3.40 (Tier 1)C1
Nymalize
NYMALIZE (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Taztia XT
taztia xt (capsule extended-release 24 hour) $1.25-$3.40 (Tier 1)C1
Verapamil HCl
verapamil hcl (120mg tablet immediate-release,
40mg tablet immediate-release, 80mg tablet
immediate-release)
$1.25-$3.40 (Tier 1)
C1
Verapamil HCl ER verapamil hcl er (120mg tablet extended-release,
180mg tablet extended-release, 240mg tablet
extended-release)
$1.25-$3.40 (Tier 1)
B1
Cardiovascular Agents, OtherC1
Amiloride/Hydrochlorothiazide amiloride/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1
Amlodipine Besylate/Atorvastatin Calcium
amlodipine besylate/atorvastatin calcium (tablet) $1.25-$3.40 (Tier 1) QLC1
Amlodipine Besylate/Benazepril HCl
amlodipine besylate/benazepril hcl (capsule) $1.25-$3.40 (Tier 1) QLC1
Atenolol/Chlorthalidone atenolol/chlorthalidone (tablet) $1.25-$3.40 (Tier 1)C1
Benazepril HCl/Hydrochlorothiazide benazepril hcl/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Candesartan Cilexetil/Hydrochlorothiazide
candesartan cilexetil/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Captopril/Hydrochlorothiazide captopril/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Corlanor
CORLANOR (5MG TABLET, 7.5MG TABLET, 5MG/5ML SOLUTION)
$3.80-$8.50 (Tier 2) PA, QLC1
Demser
DEMSER (CAPSULE) $3.80-$8.50 (Tier 2)C1
Digitek
digitek (tablet) $1.25-$3.40 (Tier 1)C1
Digox
digox (tablet) $1.25-$3.40 (Tier 1)C1
Digoxin
DIGOXIN (0.05MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Digoxin
digoxin (125mcg tablet, 250mcg tablet) $1.25-$3.40 (Tier 1)C1
Enalapril Maleate/Hydrochlorothiazide
enalapril maleate/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Entresto
ENTRESTO (TABLET) $3.80-$8.50 (Tier 2) QLC1
Fosinopril Sodium/Hydrochlorothiazide
fosinopril sodium/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Irbesartan/Hydrochlorothiazide irbesartan/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Lanoxin
LANOXIN (125MCG TABLET, 250MCG TABLET, 62.5MCG TABLET)
$3.80-$8.50 (Tier 2)C1
Lisinopril/Hydrochlorothiazide lisinopril/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Losartan Potassium/Hydrochlorothiazide
losartan potassium/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Methyldopa/Hydrochlorothiazide methyldopa/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1
Metoprolol/Hydrochlorothiazide metoprolol/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1
Olmesartan Medoxomil/Hydrochlorothiazide
olmesartan medoxomil/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QL
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
41For Track Refered Purpose5341
53
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Pentoxifylline ER
pentoxifylline er (tablet extended-release) $1.25-$3.40 (Tier 1)C1
Propranolol/Hydrochlorothiazide propranolol/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1
Quinapril/Hydrochlorothiazide quinapril/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Ranexa
RANEXA (TABLET EXTENDED-RELEASE 12 HOUR) $3.80-$8.50 (Tier 2) QLC1
Ranolazine ER
ranolazine er (tablet extended-release 12 hour) $1.25-$3.40 (Tier 1) QLC1
Spironolactone/Hydrochlorothiazide spironolactone/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1
Telmisartan/Amlodipine telmisartan/amlodipine (tablet) $1.25-$3.40 (Tier 1) QLC1
Telmisartan/Hydrochlorothiazide telmisartan/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Triamterene/Hydrochlorothiazide triamterene/hydrochlorothiazide (37.5mg-25mg
capsule, 37.5mg-25mg tablet, 75mg-50mg tablet)$1.25-$3.40 (Tier 1)
C1
Valsartan/Hydrochlorothiazide valsartan/hydrochlorothiazide (tablet) $1.25-$3.40 (Tier 1) QLC1
Vyndaqel
VYNDAQEL (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLB1
Diuretics, Carbonic Anhydrase InhibitorsC1
Acetazolamide
acetazolamide (tablet immediate-release) $1.25-$3.40 (Tier 1)C1
Acetazolamide ER acetazolamide er (capsule extended-release 12 hour) $1.25-$3.40 (Tier 1)C1
Methazolamide methazolamide (tablet) $1.25-$3.40 (Tier 1)
B1
Diuretics, LoopC1
Bumetanide
bumetanide (0.25mg/ml injection, 0.5mg tablet, 1mg
tablet, 2mg tablet)$1.25-$3.40 (Tier 1)
C1
Furosemide
furosemide (10mg/ml injection) $1.25-$3.40 (Tier 1) B/D, PAC1
Furosemide
furosemide (10mg/ml oral solution, 8mg/ml oral
solution, 20mg tablet, 40mg tablet, 80mg tablet)$1.25-$3.40 (Tier 1)
C1
Torsemide
torsemide (tablet) $1.25-$3.40 (Tier 1)B1
Diuretics, Potassium-sparingC1
Amiloride HCl
amiloride hcl (tablet) $1.25-$3.40 (Tier 1)C1
Eplerenone
eplerenone (tablet) $1.25-$3.40 (Tier 1)C1
Spironolactone
spironolactone (tablet) $1.25-$3.40 (Tier 1)
42For Track Refered Purpose5442
54
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useB1
Diuretics, ThiazideC1
Chlorothiazide
chlorothiazide (tablet) $1.25-$3.40 (Tier 1)C1
Chlorthalidone
chlorthalidone (tablet) $1.25-$3.40 (Tier 1)C1
Diuril
DIURIL (SUSPENSION) $3.80-$8.50 (Tier 2)C1
Hydrochlorothiazide hydrochlorothiazide (12.5mg capsule, 12.5mg tablet,
25mg tablet, 50mg tablet)$1.25-$3.40 (Tier 1)
C1
Indapamide
indapamide (tablet) $1.25-$3.40 (Tier 1)C1
Metolazone
metolazone (tablet) $1.25-$3.40 (Tier 1)B1
Dyslipidemics, Fibric Acid DerivativesC1
Fenofibrate
fenofibrate (160mg tablet, 54mg tablet) $1.25-$3.40 (Tier 1)C1
Gemfibrozil
gemfibrozil (tablet) $1.25-$3.40 (Tier 1)B1
Dyslipidemics, HMG CoA Reductase InhibitorsC1
Atorvastatin Calcium atorvastatin calcium (tablet) $1.25-$3.40 (Tier 1) QLC1
Fluvastatin
fluvastatin (capsule immediate-release) $1.25-$3.40 (Tier 1) QLC1
Livalo
LIVALO (TABLET) $3.80-$8.50 (Tier 2) QLC1
Lovastatin
lovastatin (tablet) $1.25-$3.40 (Tier 1) QLC1
Pravastatin Sodium pravastatin sodium (tablet) $1.25-$3.40 (Tier 1) QLC1
Rosuvastatin Calcium rosuvastatin calcium (tablet) $1.25-$3.40 (Tier 1) QLC1
Simvastatin
simvastatin (tablet) $1.25-$3.40 (Tier 1) QLB1
Dyslipidemics, OtherC1
Cholestyramine
cholestyramine (packet) $1.25-$3.40 (Tier 1)C1
Cholestyramine Light cholestyramine light (powder) $1.25-$3.40 (Tier 1)C1
Colesevelam HCl
colesevelam hcl (3.75gm packet, 625mg tablet) $1.25-$3.40 (Tier 1)C1
Colestipol HCl
colestipol hcl (1gm tablet, 5gm packet) $1.25-$3.40 (Tier 1)C1
Ezetimibe
ezetimibe (tablet) $1.25-$3.40 (Tier 1) QLC1
Ezetimibe/Simvastatin ezetimibe/simvastatin (tablet) $1.25-$3.40 (Tier 1) QLC1
Juxtapid
JUXTAPID (CAPSULE) $3.80-$8.50 (Tier 2) PA, LAC1
Niacin ER
niacin er (rx only) (tablet extended-release) $1.25-$3.40 (Tier 1)C1
Niacor
niacor (tablet) $1.25-$3.40 (Tier 1)C1
Omega-3-Acid Ethyl Esters omega-3-acid ethyl esters (capsule) (generic lovaza) $1.25-$3.40 (Tier 1) QLC1
Praluent
PRALUENT (INJECTION) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Prevalite
prevalite (packet) $1.25-$3.40 (Tier 1)C1
Repatha
REPATHA (INJECTION) $3.80-$8.50 (Tier 2) PA, QLC1
Repatha Pushtronex System REPATHA PUSHTRONEX SYSTEM (INJECTION) $3.80-$8.50 (Tier 2) PA, QL
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
43For Track Refered Purpose5543
55
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Repatha SureClick REPATHA SURECLICK (INJECTION) $3.80-$8.50 (Tier 2) PA, QLC1
Vascepa
VASCEPA (CAPSULE) $3.80-$8.50 (Tier 2)B1
Vasodilators, Direct-acting ArterialC1
Hydralazine HCl
hydralazine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Minoxidil
minoxidil (tablet) $1.25-$3.40 (Tier 1)B1
Vasodilators, Direct-acting Arterial/VenousC1
Isosorbide Dinitrate isosorbide dinitrate (tablet immediate-release) $1.25-$3.40 (Tier 1)C1
Isosorbide Dinitrate ER isosorbide dinitrate er (tablet extended-release) $1.25-$3.40 (Tier 1)C1
Isosorbide Mononitrate isosorbide mononitrate (tablet immediate-release) $1.25-$3.40 (Tier 1)C1
Isosorbide Mononitrate ER isosorbide mononitrate er (tablet extended-release
24 hour)$1.25-$3.40 (Tier 1)
C1
Minitran
minitran (patch 24 hour) $1.25-$3.40 (Tier 1)C1
Nitro-Bid
nitro-bid (ointment) $1.25-$3.40 (Tier 1)C1
Nitroglycerin
nitroglycerin (tablet sublingual) $1.25-$3.40 (Tier 1)C1
Nitroglycerin Lingual nitroglycerin lingual (translingual solution) $1.25-$3.40 (Tier 1)C1
Nitroglycerin Transdermal nitroglycerin transdermal (patch 24 hour) $1.25-$3.40 (Tier 1)C1
Nitrostat
NITROSTAT (TABLET SUBLINGUAL) $3.80-$8.50 (Tier 2)A1
Central Nervous System Agents
B1
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
44For Track Refered Purpose5644
56
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Amphetamine/Dextroamphetamine
amphetamine/dextroamphetamine (10mg capsule
extended-release 24 hour, 15mg capsule extended-
release 24 hour, 20mg capsule extended-release 24
hour, 25mg capsule extended-release 24 hour, 30mg
capsule extended-release 24 hour, 5mg capsule
extended-release 24 hour, 10mg tablet immediate-
release, 12.5mg tablet immediate-release, 15mg
tablet immediate-release, 20mg tablet immediate-
release, 30mg tablet immediate-release, 5mg tablet
immediate-release, 7.5mg tablet immediate-release)
$1.25-$3.40 (Tier 1) QL
C1
Dextroamphetamine Sulfate dextroamphetamine sulfate (10mg tablet, 5mg tablet) $1.25-$3.40 (Tier 1) QL
B1
Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesC1
Atomoxetine
atomoxetine (capsule) $1.25-$3.40 (Tier 1) QLC1
Clonidine HCl ER clonidine hcl er (tablet extended-release 12 hour) $1.25-$3.40 (Tier 1) PAC1
Dexmethylphenidate HCl dexmethylphenidate hcl (tablet immediate-release) $1.25-$3.40 (Tier 1) QLC1
Dexmethylphenidate HCl ER dexmethylphenidate hcl er (capsule extended-
release 24 hour)$1.25-$3.40 (Tier 1)
C1
Guanfacine ER
guanfacine er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1
Methylphenidate HCl methylphenidate hcl (10mg tablet immediate-release,
20mg tablet immediate-release, 5mg tablet
immediate-release) (generic ritalin), (10mg/5ml oral
solution, 5mg/5ml oral solution)
$1.25-$3.40 (Tier 1) QL
C1
Methylphenidate HCl ER methylphenidate hcl er (10mg tablet extended-
release, 20mg tablet extended-release)$1.25-$3.40 (Tier 1) QL
B1
Central Nervous System, OtherC1
Austedo
AUSTEDO (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Ingrezza
INGREZZA (CAPSULE THERAPY PACK, 40MG CAPSULE, 80MG CAPSULE)
$3.80-$8.50 (Tier 2) PA, QLC1
Namzaric
NAMZARIC (THERAPY PACK, CAPSULE EXTENDED-RELEASE 24 HOUR)
$3.80-$8.50 (Tier 2) PA, QLC1
Nuedexta
NUEDEXTA (CAPSULE) $3.80-$8.50 (Tier 2) PAC1
Riluzole
riluzole (tablet) $1.25-$3.40 (Tier 1)C1
Tetrabenazine
tetrabenazine (tablet) $1.25-$3.40 (Tier 1) PA, QL, LAB1
Fibromyalgia AgentsC1
Duloxetine HCl
duloxetine hcl (20mg capsule delayed-release, 30mg
capsule delayed-release, 60mg capsule delayed-
release)
$1.25-$3.40 (Tier 1) QL
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
45For Track Refered Purpose5745
57
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Pregabalin
pregabalin (100mg capsule, 150mg capsule, 200mg
capsule, 225mg capsule, 25mg capsule, 300mg
capsule, 50mg capsule, 75mg capsule, 20mg/ml
solution)
$1.25-$3.40 (Tier 1) QL
C1
Savella
SAVELLA (TABLET) $3.80-$8.50 (Tier 2)C1
Savella Titration Pack SAVELLA TITRATION PACK $3.80-$8.50 (Tier 2)
B1
Multiple Sclerosis AgentsC1
Ampyra
AMPYRA (TABLET EXTENDED-RELEASE 12 HOUR) $3.80-$8.50 (Tier 2) QL, LAC1
Aubagio
AUBAGIO (TABLET) $3.80-$8.50 (Tier 2) QL, LAC1
Avonex
AVONEX (INJECTION) $3.80-$8.50 (Tier 2)C1
Avonex Pen
AVONEX PEN (INJECTION) $3.80-$8.50 (Tier 2)C1
Betaseron
BETASERON (INJECTION) $3.80-$8.50 (Tier 2)C1
Dalfampridine ER dalfampridine er (tablet extended-release 12 hour) $1.25-$3.40 (Tier 1) QLC1
Gilenya
GILENYA (CAPSULE) $3.80-$8.50 (Tier 2) QLC1
Glatiramer Acetate glatiramer acetate (solution prefilled syringe) $1.25-$3.40 (Tier 1)C1
Glatopa
glatopa (injection) $1.25-$3.40 (Tier 1)C1
Mayzent
MAYZENT (TABLET) $3.80-$8.50 (Tier 2) QLC1
Rebif
REBIF (INJECTION) $3.80-$8.50 (Tier 2)C1
Rebif Rebidose REBIF REBIDOSE (INJECTION) $3.80-$8.50 (Tier 2)C1
Rebif Rebidose Titration Pack REBIF REBIDOSE TITRATION PACK (INJECTION) $3.80-$8.50 (Tier 2)C1
Rebif Titration Pack REBIF TITRATION PACK (INJECTION) $3.80-$8.50 (Tier 2)C1
Tecfidera
TECFIDERA (CAPSULE DELAYED-RELEASE) $3.80-$8.50 (Tier 2) QL, LAC1
Tecfidera Starter Pack TECFIDERA STARTER PACK $3.80-$8.50 (Tier 2) LA
A1
Dental and Oral Agents
B1
Dental and Oral AgentsC1
Chlorhexidine Gluconate Oral Rinse
chlorhexidine gluconate oral rinse (solution) $1.25-$3.40 (Tier 1)C1
Pilocarpine HCl
pilocarpine hcl (5mg tablet, 7.5mg tablet) $1.25-$3.40 (Tier 1)C1
Triamcinolone Acetonide Dental Paste
triamcinolone acetonide dental paste (paste) $1.25-$3.40 (Tier 1)
46For Track Refered Purpose5846
58
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useA1
Dermatological Agents
B1
Dermatological AgentsC1
Acitretin
acitretin (capsule) $1.25-$3.40 (Tier 1)C1
Acne Medication 10 acne medication 10 (otc only) (10% gel, 10% lotion)* $0 (Tier 3)C1
Acne Medication 5 acne medication 5 (5% gel, 5% lotion)* $0 (Tier 3)C1
Adapalene
adapalene (0.1% cream, 0.1% gel) $1.25-$3.40 (Tier 1)C1
Ammonium Lactate ammonium lactate (rx only) (12% cream, 12% lotion) $1.25-$3.40 (Tier 1)C1
Anu-Med
anu-med (suppository)* $0 (Tier 3)C1
Azelaic Acid
azelaic acid (gel) $1.25-$3.40 (Tier 1)C1
Benzoyl Peroxide benzoyl peroxide (otc only) (10% gel, 2.5% gel, 5%
gel, 5.3% foam, 9.8% foam)*$0 (Tier 3)
C1
Benzoyl Peroxide Wash benzoyl peroxide wash (liquid)* $0 (Tier 3)C1
Blue Gel
blue gel (gel)* $0 (Tier 3)C1
Calcipotriene
calcipotriene (0.005% cream, 0.005% external
solution, 0.005% ointment)$1.25-$3.40 (Tier 1)
C1
Calcitriol
CALCITRIOL (3MCG/GM OINTMENT) $3.80-$8.50 (Tier 2)C1
Capsaicin
capsaicin (cream)* $0 (Tier 3)C1
Claravis
claravis (capsule) $1.25-$3.40 (Tier 1) PAC1
Clindamycin Phosphate clindamycin phosphate (1% external solution, 1% gel,
1% lotion, 1% swab)$1.25-$3.40 (Tier 1)
C1
Clindamycin/Benzoyl Peroxide clindamycin/benzoyl peroxide (1%-5% gel) (generic
benzaclin)$1.25-$3.40 (Tier 1)
C1
Clotrimazole/Betamethasone Dipropionate
clotrimazole/betamethasone dipropionate (1%-0.05%
cream, 1%-0.05% lotion)$1.25-$3.40 (Tier 1)
C1
Coats Aloe Creme coats aloe creme (cream)* $0 (Tier 3)C1
Coats Aloe Gelly coats aloe gelly (gel)* $0 (Tier 3)C1
Coats Aloe Moisturizing Lotion coats aloe moisturizing lotion (lotion)* $0 (Tier 3)C1
Coleman Botanicals Insectrepellent
coleman botanicals insectrepellent (liquid)* $0 (Tier 3)C1
Coleman Insect Repellent/High & Dry
coleman insect repellent/high & dry (aerosol)* $0 (Tier 3)C1
Coleman Skinsmart Insect Repellent
coleman skinsmart insect repellent ( aerosol, liquid)* $0 (Tier 3)C1
Cosentyx
COSENTYX (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Cosentyx Sensoready Pen COSENTYX SENSOREADY PEN (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Cutter Backwoods cutter backwoods (25% aerosol, 25% liquid)* $0 (Tier 3)C1
Cutter Backwoods Dry cutter backwoods dry (aerosol)* $0 (Tier 3)C1
Cutter Lemon Eucalyptus cutter lemon eucalyptus (liquid)* $0 (Tier 3)C1
Dibucaine
dibucaine (ointment)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
47For Track Refered Purpose5947
59
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Diclofenac Sodium diclofenac sodium (3% gel) $1.25-$3.40 (Tier 1) PAC1
Doxepin HCl
doxepin hcl (5% cream) $1.25-$3.40 (Tier 1) PA, QLC1
Dr Smiths Diaper dr smiths diaper (ointment)* $0 (Tier 3)C1
Dr Smiths Diaper Rash Spray dr smiths diaper rash spray (aerosol)* $0 (Tier 3)C1
Elidel
ELIDEL (CREAM) $3.80-$8.50 (Tier 2) STC1
Ery
ery (2% pad) $1.25-$3.40 (Tier 1)C1
Erythromycin
erythromycin (2% external solution, 2% gel) $1.25-$3.40 (Tier 1)C1
Erythromycin/Benzoyl Peroxide erythromycin/benzoyl peroxide (gel) $1.25-$3.40 (Tier 1)C1
Finacea
FINACEA (15% FOAM, 15% GEL) $3.80-$8.50 (Tier 2)C1
Fluorouracil
fluorouracil (2% external solution, 5% external
solution, 5% cream)$1.25-$3.40 (Tier 1)
C1
Hemorrhoidal
hemorrhoidal (suppository)* $0 (Tier 3)C1
Hydrocortisone/Aloe hydrocortisone/aloe (cream)* $0 (Tier 3)C1
Imiquimod
imiquimod (cream) $1.25-$3.40 (Tier 1)C1
Imiquimod Pump imiquimod pump (cream) $1.25-$3.40 (Tier 1) PAC1
Isotretinoin
isotretinoin (capsule) $1.25-$3.40 (Tier 1) PAC1
Major-Prep Hemorrhoidal major-prep hemorrhoidal (ointment)* $0 (Tier 3)C1
Methoxsalen
methoxsalen (capsule) $1.25-$3.40 (Tier 1)C1
Mirvaso
MIRVASO (GEL) $3.80-$8.50 (Tier 2)C1
Moisturel Therapeutic moisturel therapeutic (lotion)* $0 (Tier 3)C1
Natrapel 12-Hour Tick & Insect Repellent Continuous Spray
natrapel 12-hour tick & insect repellent continuous
spray (aerosol)*$0 (Tier 3)
C1
Off Deep Woods off deep woods (25% aerosol, 25% liquid)* $0 (Tier 3)C1
Off Deep Woods Dry off deep woods dry (aerosol)* $0 (Tier 3)C1
Off Deep Woods Sportsmen off deep woods sportsmen (25% liquid, 30%
aerosol)*$0 (Tier 3)
C1
Oxsoralen Ultra OXSORALEN ULTRA (CAPSULE) $3.80-$8.50 (Tier 2)C1
Pain Relieving Cream pain relieving cream (cream)* $0 (Tier 3)C1
Picato
PICATO (GEL) $3.80-$8.50 (Tier 2)
48For Track Refered Purpose6048
60
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Pimecrolimus
pimecrolimus (cream) $1.25-$3.40 (Tier 1) STC1
Podofilox
podofilox (external solution) $1.25-$3.40 (Tier 1)C1
Prudoxin
PRUDOXIN (CREAM) $3.80-$8.50 (Tier 2) PA, QLC1
Regranex
REGRANEX (GEL) $3.80-$8.50 (Tier 2) PAC1
Repel Huniters Formula repel huniters formula (aerosol)* $0 (Tier 3)C1
Repel Lemon Eucalyptus Insect Repellent
repel lemon eucalyptus insect repellent (aerosol)* $0 (Tier 3)C1
Repel Sportsmen repel sportsmen (aerosol)* $0 (Tier 3)C1
Repel Sportsmen Dry repel sportsmen dry (aerosol)* $0 (Tier 3)C1
Repel Sportsmen Max repel sportsmen max (aerosol)* $0 (Tier 3)C1
Santyl
SANTYL (OINTMENT) $3.80-$8.50 (Tier 2)C1
Sawyer Premium Insect Repellent
sawyer premium insect repellent (liquid)* $0 (Tier 3)C1
Selenium Sulfide selenium sulfide (lotion) $1.25-$3.40 (Tier 1)C1
Stelara
STELARA (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Tacrolimus
tacrolimus (0.03% ointment, 0.1% ointment) $1.25-$3.40 (Tier 1) STC1
Tazarotene
tazarotene (cream) $1.25-$3.40 (Tier 1) PAC1
Tazorac
TAZORAC (0.05% CREAM) $3.80-$8.50 (Tier 2) PAC1
Tolak
TOLAK (CREAM) $3.80-$8.50 (Tier 2)C1
Tretinoin
tretinoin (0.01% gel, 0.025% gel, 0.025% cream,
0.05% cream, 0.1% cream)$1.25-$3.40 (Tier 1) PA
C1
Tretinoin Microsphere tretinoin microsphere (gel) $1.25-$3.40 (Tier 1) PAC1
Ultrathon Insect Repellent 8 ultrathon insect repellent 8 (aerosol)* $0 (Tier 3)C1
Vitamin A & D
vitamin a & d (ointment)* $0 (Tier 3)C1
Z-Bum
z-bum (cream)* $0 (Tier 3)C1
Zinc Oxide
zinc oxide (ointment)* $0 (Tier 3)C1
Zyclara Pump ZYCLARA PUMP (CREAM) $3.80-$8.50 (Tier 2) PA
A1
Electrolytes/Minerals/Metals/Vitamins
B1
Electrolyte/Mineral ReplacementC1
Advantage Care Oral Electrolyte Pediatric
advantage care oral electrolyte pediatric (solution)* $0 (Tier 3)C1
Aminosyn II
AMINOSYN II (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Aminosyn-PF AMINOSYN-PF (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Calcet Petites
calcet petites (tablet)* $0 (Tier 3)C1
Calci-Chew
calci-chew (tablet chewable)* $0 (Tier 3)C1
Calcitrate
calcitrate (tablet)* $0 (Tier 3)C1
Calcium
calcium (1250mg tablet, 600mg tablet, 500mg tablet,
600mg tablet)*$0 (Tier 3)
C1
Calcium + D3
calcium + d3 (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
49For Track Refered Purpose6149
61
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Calcium 500 + D
calcium 500 + d (tablet)* $0 (Tier 3)C1
Calcium 500 + D High Potency calcium 500 + d high potency (tablet)* $0 (Tier 3)C1
Calcium 500 + D3
calcium 500 + d3 (tablet)* $0 (Tier 3)C1
Calcium 500/D
calcium 500/d (200unit-500mg tablet,
400unit-500mg tablet chewable)*$0 (Tier 3)
C1
Calcium 500/Vitamin D3 calcium 500/vitamin d3 (tablet)* $0 (Tier 3)C1
Calcium 500+d
calcium 500+d (tablet)* $0 (Tier 3)C1
Calcium 500+d3
calcium 500+d3 (tablet)* $0 (Tier 3)C1
Calcium 600
calcium 600 (1500mg tablet, 600mg tablet, 600mg
tablet)*$0 (Tier 3)
C1
Calcium 600 + D
calcium 600 + d (tablet)* $0 (Tier 3)C1
Calcium 600 + D High Potency calcium 600 + d high potency (tablet)* $0 (Tier 3)C1
Calcium 600 + D Plus Minerals calcium 600 + d plus minerals
(600mg-400unit-1mg-50mg-1.8mg-250mcg-7.5mg
tablet,
600mg-400unit-1mg-50mg-1.8mg-250mcg-7.5mg
tablet chewable)*
$0 (Tier 3)
C1
Calcium 600 + D3
calcium 600 + d3 (tablet)* $0 (Tier 3)C1
Calcium 600 + D3 Plus Minerals calcium 600 + d3 plus minerals (tablet chewable)* $0 (Tier 3)C1
Calcium 600 High Potency calcium 600 high potency (tablet)* $0 (Tier 3)C1
Calcium 600 with Vitamin D calcium 600 with vitamin d (600mg-400unit tablet,
600mg-400unit tablet chewable)*$0 (Tier 3)
C1
Calcium 600/Vitamin D calcium 600/vitamin d (tablet)* $0 (Tier 3)C1
Calcium 600/Vitamin D3 calcium 600/vitamin d3 (tablet)* $0 (Tier 3)C1
Calcium 600+D
calcium 600+d (tablet)* $0 (Tier 3)C1
Calcium Carbonate calcium carbonate (1250mg tablet, 1250mg tablet,
600mg tablet, 1250mg/5ml suspension)*$0 (Tier 3)
C1
Calcium Carbonate/D3 calcium carbonate/d3 (tablet)* $0 (Tier 3)C1
Calcium Carbonate/Vitamin D calcium carbonate/vitamin d (tablet)* $0 (Tier 3)C1
Calcium Citrate
calcium citrate (tablet)* $0 (Tier 3)
50For Track Refered Purpose6250
62
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Calcium Citrate + D calcium citrate + d (tablet)* $0 (Tier 3)C1
Calcium Citrate + D3 calcium citrate + d3 (tablet)* $0 (Tier 3)C1
Calcium Citrate + D3 Max Imum calcium citrate + d3 max imum (tablet)* $0 (Tier 3)C1
Calcium Citrate + D3 Maximum calcium citrate + d3 maximum (tablet)* $0 (Tier 3)C1
Calcium Citrate Malate/Vitamin D calcium citrate malate/vitamin d (tablet)* $0 (Tier 3)C1
Calcium Citrate Plus/Magnesium calcium citrate plus/magnesium (tablet)* $0 (Tier 3)C1
Calcium Citrate w/D calcium citrate w/d (tablet)* $0 (Tier 3)C1
Calcium Citrate/Vitamin D calcium citrate/vitamin d (315mg-200unit tablet,
315mg-200unit tablet, 315mg-250unit tablet)*$0 (Tier 3)
C1
Calcium Citrate/Vitamin D3 calcium citrate/vitamin d3 (tablet)* $0 (Tier 3)C1
Calcium Extra D3
calcium extra d3 (tablet)* $0 (Tier 3)C1
Calcium for Women calcium for women (tablet chewable)* $0 (Tier 3)C1
Calcium Gluconate calcium gluconate (otc only) (tablet)* $0 (Tier 3)C1
Calcium High Potency calcium high potency (600mg tablet, 600mg-tablet)* $0 (Tier 3)C1
Calcium High Potency + Vitamin D calcium high potency + vitamin d (tablet)* $0 (Tier 3)C1
Calcium Oyster Shell calcium oyster shell (tablet)* $0 (Tier 3)C1
Calcium Plus Vitamin D3 calcium plus vitamin d3 (tablet)* $0 (Tier 3)C1
Calcium/C/D
calcium/c/d (tablet chewable)* $0 (Tier 3)C1
Calcium/Magnesium/Zinc calcium/magnesium/zinc (tablet)* $0 (Tier 3)C1
Calcium/Vitamin D calcium/vitamin d (200unit-500mg tablet,
500mg-400unit tablet, 600mg-400unit tablet,
500mg-200unit tablet, 600mg-200unit tablet,
600mg-400unit tablet, 600mg-400unit capsule)*
$0 (Tier 3)
C1
Calcium/Vitamin D3 calcium/vitamin d3 (tablet)* $0 (Tier 3)C1
Calcium+d3
calcium+d3 (tablet)* $0 (Tier 3)C1
Cal-Mag-Zinc-D cal-mag-zinc-d (tablet)* $0 (Tier 3)C1
Caltrate 600 + D
caltrate 600 + d (tablet)* $0 (Tier 3)C1
Caltrate 600 + D Plus Minerals caltrate 600 + d plus minerals (tablet)* $0 (Tier 3)C1
Caltrate 600 + D3 Soft Chews caltrate 600 + d3 soft chews (tablet chewable)* $0 (Tier 3)C1
Carbaglu
CARBAGLU (TABLET) $3.80-$8.50 (Tier 2) LAC1
Chewable Calcium chewable calcium (500mg tablet chewable,
500mg-200unit-40mcg tablet chewable)*$0 (Tier 3)
C1
Citracal + D3 Maximum citracal + d3 maximum (tablet)* $0 (Tier 3)C1
Citracal Maximum citracal maximum (tablet)* $0 (Tier 3)C1
Citrus Calcium + D citrus calcium + d (tablet)* $0 (Tier 3)C1
Coral Calcium
coral calcium (capsule)* $0 (Tier 3)C1
CVS Calcium
cvs calcium (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
51For Track Refered Purpose6351
63
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
CVS Calcium 600 & Vitamin D3 cvs calcium 600 & vitamin d3 (tablet)* $0 (Tier 3)C1
CVS Calcium 600 + D cvs calcium 600 + d (tablet)* $0 (Tier 3)C1
CVS Calcium Chewables 600plus cvs calcium chewables 600plus (tablet chewable)* $0 (Tier 3)C1
CVS Calcium Citrate + D cvs calcium citrate + d (tablet)* $0 (Tier 3)C1
CVS Calcium Citrate + D/Magnesium cvs calcium citrate + d/magnesium (tablet)* $0 (Tier 3)C1
CVS Calcium/Magnesium/Zinc cvs calcium/magnesium/zinc (tablet)* $0 (Tier 3)C1
CVS Electrolyte Solution cvs electrolyte solution (oral solution)* $0 (Tier 3)C1
CVS Iron
cvs iron (tablet)* $0 (Tier 3)C1
CVS Magnesium
cvs magnesium (tablet)* $0 (Tier 3)C1
CVS Pediatric Electrolyte cvs pediatric electrolyte (oral solution)* $0 (Tier 3)C1
CVS Pediatric Electrolyte Freezer Pops
cvs pediatric electrolyte freezer pops (oral solution)* $0 (Tier 3)C1
CVS Selenium
cvs selenium (tablet)* $0 (Tier 3)C1
CVS Slow Release Iron cvs slow release iron (tablet extended-release)* $0 (Tier 3)C1
CVS Zinc
cvs zinc (tablet)* $0 (Tier 3)C1
Dextrose 10% DEXTROSE 10% (INJECTION) $3.80-$8.50 (Tier 2)C1
Dextrose 10%/NaCl 0.2% DEXTROSE 10%/NACL 0.2% (INJECTION) $3.80-$8.50 (Tier 2)C1
Dextrose 10%/NaCl 0.45% DEXTROSE 10%/NACL 0.45% (INJECTION) $3.80-$8.50 (Tier 2)C1
Dextrose 2.5%/NaCl 0.45% DEXTROSE 2.5%/NACL 0.45% (INJECTION) $3.80-$8.50 (Tier 2)C1
Dextrose 5%
dextrose 5% (injection) $1.25-$3.40 (Tier 1) B/D, PAC1
Dextrose 5%/NaCl 0.2% DEXTROSE 5%/NACL 0.2% (INJECTION) $3.80-$8.50 (Tier 2)C1
Dextrose 5%/NaCl 0.225% DEXTROSE 5%/NACL 0.225% (INJECTION) $3.80-$8.50 (Tier 2)C1
Dextrose 5%/NaCl 0.33% DEXTROSE 5%/NACL 0.33% (INJECTION) $3.80-$8.50 (Tier 2)C1
Dextrose 5%/NaCl 0.45% DEXTROSE 5%/NACL 0.45% (INJECTION) $3.80-$8.50 (Tier 2)C1
Dextrose 5%/NaCl 0.9% DEXTROSE 5%/NACL 0.9% (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Enfamil Enfalyte
enfamil enfalyte (oral solution)* $0 (Tier 3)C1
Eq Calcium 500+d eq calcium 500+d (tablet)* $0 (Tier 3)C1
Eq Calcium 600+d eq calcium 600+d (tablet)* $0 (Tier 3)C1
Eq Calcium Citrate+d eq calcium citrate+d (tablet)* $0 (Tier 3)C1
Eq Slow-Release Iron eq slow-release iron (tablet extended-release)* $0 (Tier 3)
52For Track Refered Purpose6452
64
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
EQL Calcium 600mg/Vitamind3 eql calcium 600mg/vitamind3 (tablet)* $0 (Tier 3)C1
EQL Calcium Citrate with Vitamin D eql calcium citrate with vitamin d (tablet)* $0 (Tier 3)C1
EQL Calcium Citrate/ Vitamin D3 eql calcium citrate/ vitamin d3 (tablet)* $0 (Tier 3)C1
EQL Calcium/Vitamin D eql calcium/vitamin d (tablet)* $0 (Tier 3)C1
EZFE 200
ezfe 200 (capsule)* $0 (Tier 3)C1
FE C Tab
fe c tab (tablet)* $0 (Tier 3)C1
Feosol
feosol (tablet)* $0 (Tier 3)C1
Feosol Bifera
feosol bifera (tablet)* $0 (Tier 3)C1
Ferate
ferate (tablet)* $0 (Tier 3)C1
Fer-In-Sol
fer-in-sol (oral solution)* $0 (Tier 3)C1
Ferretts
ferretts (tablet)* $0 (Tier 3)C1
Ferretts IPS
ferretts ips (oral solution)* $0 (Tier 3)C1
Ferrex 150
ferrex 150 (capsule)* $0 (Tier 3)C1
Ferric X-150
ferric x-150 (capsule)* $0 (Tier 3)C1
Ferrimin 150
ferrimin 150 (tablet)* $0 (Tier 3)C1
Ferrous Drops
ferrous drops (oral solution)* $0 (Tier 3)C1
Ferrous Fumarate 324 ferrous fumarate 324 (tablet)* $0 (Tier 3)C1
Ferrous Gluconate ferrous gluconate (240mg tablet, 240mg tablet,
324mg tablet)*$0 (Tier 3)
C1
Ferrous Sulfate
ferrous sulfate (140mg tablet extended-release,
15mg/ml oral solution, 220mg/5ml elixir, 220mg/5ml
liquid, 300mg/5ml syrup, 324mg tablet delayed-
release, 325mg tablet delayed-release, 325mg
tablet)*
$0 (Tier 3)
C1
Ferrousul
ferrousul (tablet)* $0 (Tier 3)C1
Folitab 500
folitab 500 (tablet extended-release)* $0 (Tier 3)C1
FreAmine HBC 6.9% FREAMINE HBC 6.9% (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Fusion
fusion (capsule)* $0 (Tier 3)C1
GNP Calcium
gnp calcium (tablet)* $0 (Tier 3)C1
GNP Calcium 1200 gnp calcium 1200 (tablet chewable)* $0 (Tier 3)C1
GNP Calcium 500 + D3 gnp calcium 500 + d3 (tablet)* $0 (Tier 3)C1
GNP Calcium 500/D gnp calcium 500/d (tablet)* $0 (Tier 3)C1
GNP Calcium 600 + D3 gnp calcium 600 + d3 (tablet)* $0 (Tier 3)C1
GNP Calcium 600/D gnp calcium 600/d (tablet)* $0 (Tier 3)C1
GNP Calcium Citrate + D Maximum
gnp calcium citrate + d maximum (tablet)* $0 (Tier 3)C1
GNP Calcium Citrate + D3 gnp calcium citrate + d3 (tablet)* $0 (Tier 3)C1
GNP Calcium Citrate + D3 Maximum
gnp calcium citrate + d3 maximum (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
53For Track Refered Purpose6553
65
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
GNP Calcium/Magnesium/Zinc gnp calcium/magnesium/zinc (tablet)* $0 (Tier 3)C1
GNP Calcuim/Vitamin D/Minerals
gnp calcuim/vitamin d/minerals (tablet chewable)* $0 (Tier 3)C1
GNP Iron
gnp iron (200mg tablet, 45mg tablet extended-
release)*$0 (Tier 3)
C1
GNP Magnesium gnp magnesium (tablet)* $0 (Tier 3)C1
GNP Pediatric Electrolyte gnp pediatric electrolyte (oral solution)* $0 (Tier 3)C1
GNP Zinc
gnp zinc (tablet)* $0 (Tier 3)C1
H-E-B Oral Electrolyte Solution h-e-b oral electrolyte solution (solution)* $0 (Tier 3)C1
Hemocyte
hemocyte (tablet)* $0 (Tier 3)C1
HepatAmine HEPATAMINE (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
HM Calcium 600 & Vitamin D3 hm calcium 600 & vitamin d3 (tablet)* $0 (Tier 3)C1
HM Calcium 600 + D Plus Minerals hm calcium 600 + d plus minerals (tablet chewable)* $0 (Tier 3)C1
HM Calcium 600 + Vitamin D3 hm calcium 600 + vitamin d3 (tablet)* $0 (Tier 3)C1
HM Calcium Citrate + Vitamin D hm calcium citrate + vitamin d (tablet)* $0 (Tier 3)C1
HM Calcium/Vitamin D hm calcium/vitamin d (tablet)* $0 (Tier 3)C1
HM Calcium/Vitamin D/Minerals hm calcium/vitamin d/minerals (tablet)* $0 (Tier 3)C1
HM Iron
hm iron (tablet)* $0 (Tier 3)C1
HM Iron Slow Release hm iron slow release (tablet extended-release)* $0 (Tier 3)C1
HM Pediatric Electrolyte hm pediatric electrolyte (solution)* $0 (Tier 3)C1
HM Selenium
hm selenium (tablet)* $0 (Tier 3)C1
HM Zinc
hm zinc (tablet)* $0 (Tier 3)C1
I.L.X. B-12
i.l.x. b-12 (elixir)* $0 (Tier 3)C1
ICAR Pediatric
icar pediatric (suspension)* $0 (Tier 3)C1
ICAR-C
icar-c (tablet)* $0 (Tier 3)C1
Iferex 150
iferex 150 (capsule)* $0 (Tier 3)C1
Infed
infed (injection)* $0 (Tier 3)C1
Integra
integra (capsule)* $0 (Tier 3)C1
Intralipid
INTRALIPID (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Ionosol-MB/Dextrose 5% IONOSOL-MB/DEXTROSE 5% (INJECTION) $3.80-$8.50 (Tier 2)
54For Track Refered Purpose6654
66
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Iron
iron (256mg tablet, 27mg tablet, 325mg tablet, 65mg
tablet, 27mg tablet, 325mg tablet)*$0 (Tier 3)
C1
Iron 100/C
iron 100/c (tablet)* $0 (Tier 3)C1
Iron 27
iron 27 (tablet)* $0 (Tier 3)C1
Iron High-Potency iron high-potency (tablet)* $0 (Tier 3)C1
Iron Slow Release iron slow release (tablet extended-release)* $0 (Tier 3)C1
Iron Supplement Childrens iron supplement childrens (oral solution)* $0 (Tier 3)C1
Isolyte-P/Dextrose 5% ISOLYTE-P/DEXTROSE 5% (INJECTION) $3.80-$8.50 (Tier 2)C1
Isolyte-S
ISOLYTE-S (INJECTION) $3.80-$8.50 (Tier 2)C1
KCl 0.075%/D5W/NaCl 0.45% KCL 0.075%/D5W/NACL 0.45% (INJECTION) $3.80-$8.50 (Tier 2)C1
KCl 0.15%/D5W/NaCl 0.2% KCL 0.15%/D5W/NACL 0.2% (INJECTION) $3.80-$8.50 (Tier 2)C1
KCl 0.15%/D5W/NaCl 0.45% KCL 0.15%/D5W/NACL 0.45% (INJECTION) $3.80-$8.50 (Tier 2)C1
KCl 0.15%/D5W/NaCl 0.9% KCL 0.15%/D5W/NACL 0.9% (INJECTION) $3.80-$8.50 (Tier 2)C1
KCl 0.3%/D5W/NaCl 0.45% KCL 0.3%/D5W/NACL 0.45% (INJECTION) $3.80-$8.50 (Tier 2)C1
KCl 0.3%/D5W/NaCl 0.9% KCL 0.3%/D5W/NACL 0.9% (INJECTION) $3.80-$8.50 (Tier 2)C1
Klor-Con
klor-con (packet) $1.25-$3.40 (Tier 1)C1
Klor-Con 10
KLOR-CON 10 (TABLET EXTENDED-RELEASE) $3.80-$8.50 (Tier 2)C1
Klor-Con 8
KLOR-CON 8 (TABLET EXTENDED-RELEASE) $3.80-$8.50 (Tier 2)C1
Klor-Con M10
klor-con m10 (tablet extended-release) $1.25-$3.40 (Tier 1)C1
Klor-Con M15
klor-con m15 (tablet extended-release) $1.25-$3.40 (Tier 1)C1
Klor-Con M20
klor-con m20 (tablet extended-release) $1.25-$3.40 (Tier 1)C1
Klor-Con Sprinkle
klor-con sprinkle (capsule extended-release) $1.25-$3.40 (Tier 1)C1
KP Calcium 600 + D kp calcium 600 + d (tablet)* $0 (Tier 3)C1
KP Calcium Citrate + D kp calcium citrate + d (tablet)* $0 (Tier 3)C1
KP Ferrous Gluconate kp ferrous gluconate (tablet)* $0 (Tier 3)C1
KP Ferrous Sulfate kp ferrous sulfate (tablet)* $0 (Tier 3)C1
Levocarnitine
levocarnitine (1gm/10ml oral solution) $1.25-$3.40 (Tier 1)C1
Levocarnitine LEVOCARNITINE (330MG TABLET) $3.80-$8.50 (Tier 2)C1
Liquid Calcium/Vitamin D liquid calcium/vitamin d (capsule)* $0 (Tier 3)C1
Magnesium
magnesium (250mg tablet, 500mg tablet)* $0 (Tier 3)C1
Magnesium 27
magnesium 27 (tablet)* $0 (Tier 3)C1
Magnesium Elemental magnesium elemental (otc only) (300mg capsule,
30mg tablet)*$0 (Tier 3)
C1
Magnesium Oxide magnesium oxide (241.3mg tablet, 500mg capsule)* $0 (Tier 3)C1
Magnesium Sulfate MAGNESIUM SULFATE (1GM/2ML-50% INJECTION) $3.80-$8.50 (Tier 2)C1
Magnesium Sulfate magnesium sulfate (5gm/10ml-50% injection) $1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
55For Track Refered Purpose6755
67
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Mag-Tab SR
mag-tab sr (otc only) (tablet extended-release)* $0 (Tier 3)C1
Monocal
monocal (tablet)* $0 (Tier 3)C1
Myferon 150
myferon 150 (capsule)* $0 (Tier 3)C1
Nephramine NEPHRAMINE (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Normosol-M in D5W NORMOSOL-M IN D5W (INJECTION) $3.80-$8.50 (Tier 2)C1
Normosol-R
NORMOSOL-R (INJECTION) $3.80-$8.50 (Tier 2)C1
Normosol-R in D5W NORMOSOL-R IN D5W (INJECTION) $3.80-$8.50 (Tier 2)C1
Nu-Iron 150
nu-iron 150 (capsule)* $0 (Tier 3)C1
Nu-Mag
nu-mag (tablet delayed-release)* $0 (Tier 3)C1
Nutrilipid
NUTRILIPID (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Oceanic Selenium oceanic selenium (tablet)* $0 (Tier 3)C1
Oralyte
oralyte (oral solution)* $0 (Tier 3)C1
Oralyte Freezer Pops oralyte freezer pops (oral solution)* $0 (Tier 3)C1
Orazinc
orazinc (110mg tablet, 220mg capsule)* $0 (Tier 3)C1
OS-CAL
os-cal (tablet chewable)* $0 (Tier 3)C1
OS-CAL Calcium + D3 os-cal calcium + d3 (tablet)* $0 (Tier 3)C1
OS-CAL Extra D3
os-cal extra d3 (tablet)* $0 (Tier 3)C1
OS-CAL Ultra
os-cal ultra (tablet)* $0 (Tier 3)C1
Osteo-Poretical osteo-poretical (tablet)* $0 (Tier 3)C1
Oysco 500
oysco 500 (tablet)* $0 (Tier 3)C1
Oysco 500 + D
oysco 500 + d (tablet)* $0 (Tier 3)C1
Oyst-Cal-D 500
oyst-cal-d 500 (tablet)* $0 (Tier 3)C1
Oyster Calcium
oyster calcium (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium oyster shell calcium (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium + D3 oyster shell calcium + d3 (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium + Vitamin D
oyster shell calcium + vitamin d (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium 250 + D oyster shell calcium 250 + d (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium 500 oyster shell calcium 500 (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium 500 + D oyster shell calcium 500 + d (tablet chewable)* $0 (Tier 3)
56For Track Refered Purpose6856
68
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Oyster Shell Calcium 500 + D oyster shell calcium 500 + d (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium 500/D oyster shell calcium 500/d (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium Plus Vitamin D
oyster shell calcium plus vitamin d (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium/D oyster shell calcium/d (250mg-125unit tablet,
500mg-200unit tablet, 500mg-200unit tablet)*$0 (Tier 3)
C1
Oyster Shell Calcium/D3 oyster shell calcium/d3 (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium/Magnesium oyster shell calcium/magnesium (tablet)* $0 (Tier 3)C1
Oyster Shell Calcium/Vitamin D oyster shell calcium/vitamin d (200unit-500mg tablet,
250mg-125unit-tablet, 500mg-200unit tablet,
500mg-400unit tablet)*
$0 (Tier 3)
C1
Oyster Shell Calcium+d oyster shell calcium+d (tablet)* $0 (Tier 3)C1
Oystercal-D
oystercal-d (tablet)* $0 (Tier 3)C1
Pedialyte
pedialyte (2.1meq/59ml-1.5gm/59ml-1.2meq/
59ml-2.7meq/59ml-0.5mg/59ml solution, 35meq/
l-20gm/l-5gm/l-20meq/l-45meq/l solution, 35meq/
l-25gm/l-20meq/l-45meq/l-7.8mg/l solution, 35meq/
l-30meq/l-25gm/l-20meq/l-45meq/l solution, 35meq/
l-30meq/l-25gm/l-20meq/l-45meq/l oral solution)*
$0 (Tier 3)
C1
Pedialyte Advanced Care pedialyte advanced care (solution)* $0 (Tier 3)C1
Pedialyte Freezer Pops pedialyte freezer pops (35meq/l-30meq/l-25gm/
l-20meq/l-45meq/l oral solution, 35meq/l-30meq/
l-25gm/l-20meq/l-45meq/l solution)*
$0 (Tier 3)
C1
Pedialyte Singles pedialyte singles (7meq/200ml-5.3gm/200ml-4meq/
200ml-9meq/200ml-1.6mg/200ml solution, 8.3meq/
240ml-7.1meq/240ml-4.7gm/240ml-1.2gm/
240ml-4.7meq/240ml-10.6meq/240ml oral solution)*
$0 (Tier 3)
C1
Pediatric Electrolyte pediatric electrolyte (35meq/l-20gm/l-5gm/l-20meq/
l-45meq/l oral solution, 35meq/l-30meq/l-25gm/
l-20meq/l-45meq/l oral solution, 35meq/l-20gm/
l-5gm/l-20meq/l-45meq/l solution, 35meq/
l-25gm-20meq/l-45meq/l-7.8mg/l solution, 35meq/
l-25gm/l-20meq/l-45meq/l solution, 35meq/l-30meq/
l-20gm/l-5gm/l-20meq/l-45meq/l solution, 35meq/
l-30meq/l-25gm/l-20meq/l-45meq/l solution, 35meq/
l-30meq/l-25gm/l-5gm/l-20meq/l-45meq/l solution)*
$0 (Tier 3)
C1
Pediatric Electrolyte Freeze Pops
pediatric electrolyte freeze pops (solution)* $0 (Tier 3)C1
Pediatric Electrolyte Freezer Pops
pediatric electrolyte freezer pops (solution)* $0 (Tier 3)C1
Pediatric Electrolyte/Zinc pediatric electrolyte/zinc (solution)* $0 (Tier 3)C1
Plasma-Lyte A PLASMA-LYTE A (INJECTION) $3.80-$8.50 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
57For Track Refered Purpose6957
69
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Plasma-Lyte-148 PLASMA-LYTE-148 (INJECTION) $3.80-$8.50 (Tier 2)C1
Plenamine
plenamine (injection) $1.25-$3.40 (Tier 1) B/D, PAC1
Poly-Iron 150
poly-iron 150 (capsule)* $0 (Tier 3)C1
Potassium Chloride POTASSIUM CHLORIDE (10% ORAL SOLUTION, 20%
ORAL SOLUTION, 20MEQ PACKET)$3.80-$8.50 (Tier 2)
C1
Potassium Chloride POTASSIUM CHLORIDE (10MEQ/100ML INJECTION,
20MEQ/100ML INJECTION, 40MEQ/100ML INJECTION)$3.80-$8.50 (Tier 2) B/D, PA
C1
Potassium Chloride potassium chloride (2meq/ml injection) $1.25-$3.40 (Tier 1) B/D, PAC1
Potassium Chloride CR potassium chloride cr (tablet extended-release) $1.25-$3.40 (Tier 1)C1
Potassium Chloride ER potassium chloride er (10meq capsule extended-
release, 8meq capsule extended-release, 10meq
tablet extended-release, 20meq tablet extended-
release, 8meq tablet extended-release)
$1.25-$3.40 (Tier 1)
C1
Potassium Chloride/Dextrose POTASSIUM CHLORIDE/DEXTROSE (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Potassium Chloride/Dextrose/Lactated Ringers
POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS (INJECTION)
$3.80-$8.50 (Tier 2)C1
Potassium Chloride/Dextrose/Sodium Chloride
POTASSIUM CHLORIDE/DEXTROSE/SODIUM CHLORIDE (INJECTION)
$3.80-$8.50 (Tier 2)C1
Potassium Chloride/Sodium Chloride
potassium chloride/sodium chloride (20meq/l-0.45%
injection)$1.25-$3.40 (Tier 1) B/D, PA
C1
Potassium Chloride/Sodium Chloride
POTASSIUM CHLORIDE/SODIUM CHLORIDE (20MEQ/L-0.9% INJECTION, 40MEQ/L-0.9% INJECTION)
$3.80-$8.50 (Tier 2) B/D, PAC1
Potassium Citrate ER potassium citrate er (tablet extended-release) $1.25-$3.40 (Tier 1)C1
Premasol
premasol (injection) $1.25-$3.40 (Tier 1) B/D, PAC1
Procalamine PROCALAMINE (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
ProFe
profe (capsule)* $0 (Tier 3)C1
Proferrin ES
proferrin es (tablet)* $0 (Tier 3)C1
Prosol
PROSOL (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
QC Calcium Fast Dissolution qc calcium fast dissolution (tablet)* $0 (Tier 3)C1
QC Calcium/Minerals/Vitamin D qc calcium/minerals/vitamin d (tablet)* $0 (Tier 3)C1
RA Calcium 600
ra calcium 600 (tablet)* $0 (Tier 3)
58For Track Refered Purpose7058
70
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
RA Calcium 600 Plus Vitamin D-3 ra calcium 600 plus vitamin d-3 (tablet)* $0 (Tier 3)C1
RA Calcium 600/Vitamin D/Minerals
ra calcium 600/vitamin d/minerals (tablet)* $0 (Tier 3)C1
RA Calcium Citrate Plus Vitamin D-3 ra calcium citrate plus vitamin d-3 (tablet)* $0 (Tier 3)C1
RA Calcium/Boron ra calcium/boron (tablet)* $0 (Tier 3)C1
RA Calcium/Magnesium/Zinc/Copper
ra calcium/magnesium/zinc/copper (tablet)* $0 (Tier 3)C1
RA Hi Cal
ra hi cal (tablet)* $0 (Tier 3)C1
RA High Potency Iron ra high potency iron (tablet)* $0 (Tier 3)C1
RA Iron
ra iron (tablet)* $0 (Tier 3)C1
RA Magnesium
ra magnesium (capsule)* $0 (Tier 3)C1
RA Natural Magnesium ra natural magnesium (tablet)* $0 (Tier 3)C1
RA Oyster Shell Calcium/Vitamin D
ra oyster shell calcium/vitamin d (tablet)* $0 (Tier 3)C1
RA Pediatric Electrolyte ra pediatric electrolyte (oral solution)* $0 (Tier 3)C1
RA Pediatric Electrolyte Freezer Pops
ra pediatric electrolyte freezer pops (oral solution)* $0 (Tier 3)C1
Ra Selenium
ra selenium (tablet)* $0 (Tier 3)C1
Ra Selenium Natural ra selenium natural (tablet)* $0 (Tier 3)C1
RA Slow Release Iron ra slow release iron (tablet extended-release)* $0 (Tier 3)C1
RA Zinc
ra zinc (tablet)* $0 (Tier 3)C1
Risacal-D
risacal-d (tablet)* $0 (Tier 3)C1
Selenium
selenium (200mcg tablet, 200mcg tablet extended-
release, 200mcg tablet, 50mcg tablet)*$0 (Tier 3)
C1
Slow Fe
slow fe (tablet extended-release)* $0 (Tier 3)C1
Slow Release Iron slow release iron (tablet extended-release)* $0 (Tier 3)C1
Slow-Mag
slow-mag (tablet delayed-release)* $0 (Tier 3)C1
Slow-Release Iron slow-release iron (tablet extended-release)* $0 (Tier 3)C1
SM Calcium 500/Vitamin D3 sm calcium 500/vitamin d3 (tablet)* $0 (Tier 3)C1
SM Calcium 600 + D3 sm calcium 600 + d3 (tablet)* $0 (Tier 3)C1
SM Calcium 600/Vitamin D sm calcium 600/vitamin d (tablet)* $0 (Tier 3)C1
SM Calcium Citrate + with Vitamin D sm calcium citrate + with vitamin d (tablet)* $0 (Tier 3)C1
SM Calcium Citrate with Vitamin D3 sm calcium citrate with vitamin d3 (tablet)* $0 (Tier 3)C1
SM Calcium Soft Chews sm calcium soft chews (tablet chewable)* $0 (Tier 3)C1
SM Calcium/Magnesium/Zinc sm calcium/magnesium/zinc (tablet)* $0 (Tier 3)C1
SM Calcium/Vitamin D sm calcium/vitamin d (tablet)* $0 (Tier 3)C1
SM Iron
sm iron (tablet)* $0 (Tier 3)C1
SM Iron Slow Release sm iron slow release (tablet extended-release)* $0 (Tier 3)C1
SM Magnesium
sm magnesium (tablet)* $0 (Tier 3)C1
SM Oyster Shell Calcium/Vitamin D
sm oyster shell calcium/vitamin d (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
59For Track Refered Purpose7159
71
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
SM Oyster Shell Calcium/Vitamin D3
sm oyster shell calcium/vitamin d3 (tablet)* $0 (Tier 3)C1
SM Pediatric Electrolyte sm pediatric electrolyte (oral solution)* $0 (Tier 3)C1
SM Selenium
sm selenium (tablet)* $0 (Tier 3)C1
SM Slow Release Iron sm slow release iron (142mg tablet extended-release,
143mg tablet extended-release)*$0 (Tier 3)
C1
SM Zinc
sm zinc (tablet)* $0 (Tier 3)C1
Sodium Chloride 0.9% SODIUM CHLORIDE 0.9% (IRRIGATION SOLUTION) $3.80-$8.50 (Tier 2)C1
Sodium Chloride SODIUM CHLORIDE (RX ONLY) (0.45% SOLUTION) $3.80-$8.50 (Tier 2)C1
Sodium Chloride
sodium chloride (rx only) (0.9% injection) $1.25-$3.40 (Tier 1) B/D, PAC1
Sodium Chloride SODIUM CHLORIDE (RX ONLY) (3% INJECTION, 5%
INJECTION)$3.80-$8.50 (Tier 2) B/D, PA
C1
Sodium Fluoride
sodium fluoride (tablet) $1.25-$3.40 (Tier 1)C1
Sodium Lactate SODIUM LACTATE (INJECTION) $3.80-$8.50 (Tier 2)C1
Super Calcium
super calcium (tablet)* $0 (Tier 3)C1
Super Calcium 600 + D 400 super calcium 600 + d 400 (tablet)* $0 (Tier 3)C1
Super Calcium 600 + D3 super calcium 600 + d3 (tablet)* $0 (Tier 3)C1
Super Calcium 600 + D3 400 super calcium 600 + d3 400 (tablet)* $0 (Tier 3)C1
Tandem
tandem (capsule)* $0 (Tier 3)C1
TGT Calcium + Vitamin D3 tgt calcium + vitamin d3 (tablet)* $0 (Tier 3)C1
TPN Electrolytes TPN ELECTROLYTES (INJECTION) $3.80-$8.50 (Tier 2)C1
Travasol
TRAVASOL (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Trophamine TROPHAMINE (10% INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Wee Care
wee care (suspension)* $0 (Tier 3)C1
Zinc
zinc (10mg lozenge, 30mg tablet, 50mg tablet, 50mg
tablet)*$0 (Tier 3)
C1
Zinc 15
zinc 15 (tablet)* $0 (Tier 3)C1
Zinc Chelated
zinc chelated (tablet)* $0 (Tier 3)C1
Zinc Gluconate
zinc gluconate (100mg tablet, 50mg tablet, 30mg
tablet)*$0 (Tier 3)
60For Track Refered Purpose7260
72
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Zinc Sulfate
zinc sulfate (220mg capsule, 220mg tablet)* $0 (Tier 3)C1
Zinc-220
zinc-220 (capsule)* $0 (Tier 3)B1
Electrolyte/Mineral/Metal ModifiersC1
Chemet
CHEMET (CAPSULE) $3.80-$8.50 (Tier 2)C1
Deferasirox
deferasirox (tablet soluble) $1.25-$3.40 (Tier 1) PAC1
Exjade
EXJADE (TABLET SOLUBLE) $3.80-$8.50 (Tier 2) PAC1
Ferriprox
FERRIPROX (1000MG TABLET, 100MG/ML ORAL SOLUTION, 500MG TABLET)
$3.80-$8.50 (Tier 2) PAC1
Jadenu
JADENU (TABLET) $3.80-$8.50 (Tier 2) PAC1
Jadenu Sprinkle JADENU SPRINKLE (PACKET) $3.80-$8.50 (Tier 2) PAC1
Kionex
kionex (suspension) $1.25-$3.40 (Tier 1)C1
Lokelma
LOKELMA (PACKET) $3.80-$8.50 (Tier 2) QLC1
Samsca
SAMSCA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Sodium Polystyrene Sulfonate sodium polystyrene sulfonate (powder) $1.25-$3.40 (Tier 1)C1
SPS
sps (suspension) $1.25-$3.40 (Tier 1)C1
Trientine HCl
trientine hcl (capsule) $1.25-$3.40 (Tier 1) PA, QLC1
Veltassa
VELTASSA (PACKET) $3.80-$8.50 (Tier 2) QLB1
Phosphate BindersC1
Auryxia
AURYXIA (TABLET) $3.80-$8.50 (Tier 2) PAC1
Calcium Acetate
calcium acetate (667mg capsule, 667mg tablet) $1.25-$3.40 (Tier 1)C1
Lanthanum Carbonate lanthanum carbonate (tablet chewable) $1.25-$3.40 (Tier 1)C1
Phoslyra
PHOSLYRA (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Sevelamer Carbonate sevelamer carbonate (0.8gm packet, 2.4gm packet,
800mg tablet)$1.25-$3.40 (Tier 1)
C1
Velphoro
VELPHORO (TABLET CHEWABLE) $3.80-$8.50 (Tier 2)B1
VitaminsC1
A Thru Z Advanced a thru z advanced (tablet)* $0 (Tier 3)C1
A Thru Z Select a thru z select (tablet)* $0 (Tier 3)C1
A Thru Z Select 50 + Advanced Formula
a thru z select 50 + advanced formula (tablet)* $0 (Tier 3)C1
A Thru Z Select Advanced a thru z select advanced (tablet)* $0 (Tier 3)C1
A Thru Z Select Ultimate Womens
a thru z select ultimate womens (tablet)* $0 (Tier 3)C1
A Thru Z Ultimate Mens a thru z ultimate mens (tablet)* $0 (Tier 3)C1
A-10000
a-10000 (capsule)* $0 (Tier 3)C1
Abc Plus Senior Adults 50+ abc plus senior adults 50+ (tablet)* $0 (Tier 3)C1
Acerola C 500
acerola c 500 (wafer)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
61For Track Refered Purpose7361
73
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Actical
actical (capsule)* $0 (Tier 3)C1
Advanced Stress Formula/Zinc advanced stress formula/zinc (tablet)* $0 (Tier 3)C1
Animal Chews
animal chews (tablet chewable)* $0 (Tier 3)C1
Animal Shapes
animal shapes (tablet chewable)* $0 (Tier 3)C1
Animal Shapes/Iron animal shapes/iron (tablet chewable)* $0 (Tier 3)C1
Apatate Forte
apatate forte (liquid)* $0 (Tier 3)C1
Apetex
apetex (elixir)* $0 (Tier 3)C1
Apetigen
apetigen (elixir)* $0 (Tier 3)C1
Apetigen-Plus
apetigen-plus
(225mg-6mcg-10mg-300mg-80mg-20mg-8mg-8.5mg-
15mg-30unit-18mg tablet, 25mcg/15ml-12.5mg/
15ml-790mg/15ml-200mg/15ml-20mg/15ml-2mg/
15ml-10mg/15ml-10mg/15ml-16.9mg/15ml oral
solution)*
$0 (Tier 3)
C1
AquADEKs
aquadeks (otc only) (tablet chewable, liquid)* $0 (Tier 3)C1
Aqueous Vitamin D Infants aqueous vitamin d infants (liquid)* $0 (Tier 3)C1
Aqueous Vitamin E aqueous vitamin e (oral solution)* $0 (Tier 3)C1
Ascorbic Acid
ascorbic acid (powder, 250mg tablet, 500mg tablet)* $0 (Tier 3)C1
B Complex
b complex
(100mg-1mg-70mg-10mg-100mcg-2mg-1.5mg
capsule,
5mg-1mcg-60mg-20mg-0.5mg-3mg-3mg-60mg
capsule, 6mcg-0.4mg-20mg-10mg-2mg-1.7mg-1.2mg
tablet)*
$0 (Tier 3)
C1
B Complex/C b complex/c (tablet)* $0 (Tier 3)C1
B Complex/Folic Acid b complex/folic acid (tablet)* $0 (Tier 3)C1
B-1
b-1 (tablet)* $0 (Tier 3)C1
B-12
b-12 (1000mcg tablet extended-release, 100mcg
tablet, 500mcg tablet, 50mcg tablet, 2500mcg tablet
sublingual)*
$0 (Tier 3)
62For Track Refered Purpose7462
74
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
B12
b12 (tablet extended-release)* $0 (Tier 3)C1
B-12 Dots
b-12 dots (tablet dispersible)* $0 (Tier 3)C1
B-12 TR
b-12 tr (tablet extended-release)* $0 (Tier 3)C1
B-2
b-2 (tablet)* $0 (Tier 3)C1
B-6
b-6 (100mg tablet, 100mg tablet, 50mg tablet)* $0 (Tier 3)C1
B6 Natural
b6 natural (tablet)* $0 (Tier 3)C1
Balance B-100
balance b-100 (tablet)* $0 (Tier 3)C1
Balance B-50
balance b-50 (tablet)* $0 (Tier 3)C1
Balanced B-100 balanced b-100 (tablet)* $0 (Tier 3)C1
Balanced B-50
balanced b-50 (tablet)* $0 (Tier 3)C1
Balanced B-50 Complex balanced b-50 complex (tablet)* $0 (Tier 3)C1
B-Complex
b-complex
(5mg-1mcg-400mcg-60mg-20mg-0.5mg-3mg-3mg-60
mg capsule,
5mg-1mcg-60mg-20mg-0.5mg-3mg-3mg-60mg
capsule, 6mcg-400mcg-20mg-2mg-1.7mg-1.5mg
tablet)*
$0 (Tier 3)
C1
B-Complex Formula 1 b-complex formula 1 (tablet)* $0 (Tier 3)C1
B-Complex Plus Vitamin C b-complex plus vitamin c (tablet)* $0 (Tier 3)C1
B-Complex w/C b-complex w/c (tablet)* $0 (Tier 3)C1
B-Complex with B-12 b-complex with b-12 (tablet)* $0 (Tier 3)C1
B-Complex/C b-complex/c (tablet)* $0 (Tier 3)C1
B-Complex/Vitamin C/High Potency
b-complex/vitamin c/high potency (tablet)* $0 (Tier 3)C1
Bee Zee
bee zee (tablet)* $0 (Tier 3)C1
Beta Carotene
beta carotene (capsule)* $0 (Tier 3)C1
Biocal
biocal (capsule)* $0 (Tier 3)C1
Biosupp
biosupp (liquid)* $0 (Tier 3)C1
Biotin
biotin (1000mcg tablet, 1000mcg tablet, 300mcg
tablet, 2500mcg capsule, 5000mcg capsule,
5000mcg capsule)*
$0 (Tier 3)
C1
Biotin 5000
biotin 5000 (capsule)* $0 (Tier 3)C1
Biotin/Maximum Strength biotin/maximum strength (capsule)* $0 (Tier 3)C1
Biovol
biovol (syrup)* $0 (Tier 3)C1
C 1000
c 1000 (tablet)* $0 (Tier 3)C1
C 1000/Bioflavonoids/Rosehips
c 1000/bioflavonoids/rosehips (capsule)* $0 (Tier 3)C1
C 250
c 250 (tablet)* $0 (Tier 3)C1
C 500
c 500 (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
63For Track Refered Purpose7563
75
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
C Complex
c complex (tablet extended-release)* $0 (Tier 3)C1
C-1000
c-1000 (tablet)* $0 (Tier 3)C1
C-1000 Prolonged Release c-1000 prolonged release (tablet extended-release)* $0 (Tier 3)C1
C-1000/Rose Hips c-1000/rose hips (tablet)* $0 (Tier 3)C1
C-250
c-250 (tablet)* $0 (Tier 3)C1
C-500
c-500 (500mg tablet, 500mg tablet chewable,
500mg-tablet chewable)*$0 (Tier 3)
C1
C-500 Prolonged Release c-500 prolonged release (tablet extended-release)* $0 (Tier 3)C1
C-500/Rose Hips c-500/rose hips (tablet)* $0 (Tier 3)C1
Calcidol
calcidol (oral solution)* $0 (Tier 3)C1
C-Chewable
c-chewable (tablet chewable)* $0 (Tier 3)C1
Centamin
centamin (liquid)* $0 (Tier 3)C1
Centravites
centravites (tablet)* $0 (Tier 3)C1
Centravites 50 Plus centravites 50 plus (tablet)* $0 (Tier 3)C1
Centrum
centrum (0-60mg/15ml-300mcg/15ml-400unit/
15ml-25mcg/15ml-6mcg/15ml-0-150mcg/15ml-9mg/
15ml-2mg/15ml-25mcg/15ml-20mg/15ml-10mg/
15ml-0-2mg/15ml-1.7mg/15ml-0-1.1mg/
15ml-1300unit/15ml-30unit/15ml-3mg/15ml liquid,
60mg-0-45mcg-108mg-10mg-20mcg-2mg-6mcg-400
unit-400mcg-18mg-40mg-1mg-20mg-50mg-10mcg-1
50mcg-2mg-1.7mg-20mcg-1.5mg-30unit-3500unit-15
mg tablet chewable)*
$0 (Tier 3)
C1
Centrum Adults centrum adults (tablet)* $0 (Tier 3)C1
Centrum Kids Complete centrum kids complete (tablet chewable)* $0 (Tier 3)C1
Centrum Silver centrum silver (tablet)* $0 (Tier 3)C1
Centrum Silver Adult 50+ centrum silver adult 50+ (tablet)* $0 (Tier 3)C1
Centrum Silver Ultra Womens centrum silver ultra womens (tablet)* $0 (Tier 3)C1
Centrum Specialist Heart centrum specialist heart (tablet)* $0 (Tier 3)C1
Centrum Ultra Mens centrum ultra mens (tablet)* $0 (Tier 3)
64For Track Refered Purpose7664
76
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Centrum Ultra Womens centrum ultra womens (tablet)* $0 (Tier 3)C1
Cerovite Advanced Formula cerovite advanced formula (tablet)* $0 (Tier 3)C1
Cerovite Jr
cerovite jr (tablet chewable)* $0 (Tier 3)C1
Certa Plus
certa plus (tablet)* $0 (Tier 3)C1
Certavite Senior/Antioxidant Nutrients
certavite senior/antioxidant nutrients (tablet)* $0 (Tier 3)C1
Certavite/Antioxidants certavite/antioxidants (tablet)* $0 (Tier 3)C1
Chewable Vitamin C chewable vitamin c (tablet chewable)* $0 (Tier 3)C1
Chewable Vite Childrens chewable vite childrens (tablet chewable)* $0 (Tier 3)C1
Chewable Vite with Iron/Childrens
chewable vite with iron/childrens (tablet chewable)* $0 (Tier 3)C1
Childrens Chewable Multivitamin childrens chewable multivitamin (tablet chewable)* $0 (Tier 3)C1
Childrens Chewable Vitamin childrens chewable vitamin (tablet chewable)* $0 (Tier 3)C1
Childrens Chewable Vitamins childrens chewable vitamins (tablet chewable)* $0 (Tier 3)C1
Childrens Chewable Vitamins/Iron
childrens chewable vitamins/iron (tablet chewable)* $0 (Tier 3)C1
Companion
companion (tablet)* $0 (Tier 3)C1
Compete
compete (tablet)* $0 (Tier 3)C1
Complete
complete (tablet)* $0 (Tier 3)C1
Complex B-100 complex b-100 (tablet extended-release)* $0 (Tier 3)C1
Cranberry Urinary Comfort cranberry urinary comfort (capsule)* $0 (Tier 3)C1
CVS B Complex Plus C cvs b complex plus c (tablet)* $0 (Tier 3)C1
CVS B-1
cvs b-1 (tablet)* $0 (Tier 3)C1
CVS B-12
cvs b-12 (1000mcg/15ml liquid, 500mcg tablet)* $0 (Tier 3)C1
CVS B6
cvs b6 (tablet)* $0 (Tier 3)C1
CVS Beta Carotene cvs beta carotene (capsule)* $0 (Tier 3)C1
CVS Biotin
cvs biotin (capsule)* $0 (Tier 3)C1
CVS Biotin High Potency cvs biotin high potency (tablet)* $0 (Tier 3)C1
CVS Childrens Chewable Complete
cvs childrens chewable complete (tablet chewable)* $0 (Tier 3)C1
CVS Childrens Chewable Multivitamin/Iron
cvs childrens chewable multivitamin/iron (tablet
chewable)*$0 (Tier 3)
C1
CVS Daily Multiple cvs daily multiple (tablet)* $0 (Tier 3)C1
CVS Daily Multiple for Men cvs daily multiple for men (tablet)* $0 (Tier 3)C1
CVS Daily Multiple for Women cvs daily multiple for women (tablet)* $0 (Tier 3)C1
CVS Daily Multiple for Women 50+ cvs daily multiple for women 50+ (tablet)* $0 (Tier 3)C1
CVS Daily Multiple Plus Iron/Calcium/Zinc
cvs daily multiple plus iron/calcium/zinc (tablet)* $0 (Tier 3)C1
CVS Gummy Dinos cvs gummy dinos (tablet chewable)* $0 (Tier 3)C1
CVS Hair/Skin/Nails cvs hair/skin/nails (tablet)* $0 (Tier 3)C1
CVS Spectravite Adult 50+ cvs spectravite adult 50+ (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
65For Track Refered Purpose7765
77
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
CVS Spectravite Advanced Formula
cvs spectravite advanced formula (tablet)* $0 (Tier 3)C1
CVS Spectravite Senior cvs spectravite senior (tablet)* $0 (Tier 3)C1
CVS Spectravite Ultra Health Mens cvs spectravite ultra health mens (tablet)* $0 (Tier 3)C1
CVS Spectravite Ultra Mens Health cvs spectravite ultra mens health (tablet)* $0 (Tier 3)C1
CVS Spectravite Ultra Women cvs spectravite ultra women (tablet)* $0 (Tier 3)C1
CVS Spectravite Ultra Womens Health
cvs spectravite ultra womens health (tablet)* $0 (Tier 3)C1
CVS Spectravite Ultra Womens Health Senior
cvs spectravite ultra womens health senior (tablet)* $0 (Tier 3)C1
CVS Super B Complex/C cvs super b complex/c (tablet)* $0 (Tier 3)C1
CVS Vitamin A
cvs vitamin a (capsule)* $0 (Tier 3)C1
CVS Vitamin B12
cvs vitamin b12 (tablet)* $0 (Tier 3)C1
CVS Vitamin B-12
cvs vitamin b-12 (tablet)* $0 (Tier 3)C1
CVS Vitamin B-12 TR cvs vitamin b-12 tr (tablet extended-release)* $0 (Tier 3)C1
CVS Vitamin B-2
cvs vitamin b-2 (tablet)* $0 (Tier 3)C1
CVS Vitamin C
cvs vitamin c (1000mg tablet, 250mg tablet, 500mg
tablet, 500mg-25mg-14mg tablet, 500mg-7.5mg-
tablet chewable)*
$0 (Tier 3)
C1
CVS Vitamin E
cvs vitamin e (capsule)* $0 (Tier 3)C1
Daily Combo Multi Vitamin daily combo multi vitamin (tablet)* $0 (Tier 3)C1
Daily Multiple Vitamin daily multiple vitamin (tablet)* $0 (Tier 3)C1
Daily Multiple Vitamin/Iron daily multiple vitamin/iron (tablet)* $0 (Tier 3)C1
Daily Multiple Vitamins daily multiple vitamins (tablet)* $0 (Tier 3)C1
Daily Value Multivitamin daily value multivitamin (tablet)* $0 (Tier 3)C1
Daily Vitamin
daily vitamin (tablet)* $0 (Tier 3)C1
Daily Vitamin Formula+ir On daily vitamin formula+ir on (tablet)* $0 (Tier 3)C1
Daily Vitamin Formula+iron daily vitamin formula+iron (tablet)* $0 (Tier 3)C1
Daily Vitamin Formula+minerals
daily vitamin formula+minerals (tablet)* $0 (Tier 3)C1
Daily Vite
daily vite (tablet)* $0 (Tier 3)C1
Daily Vite Multivitamin/Iron daily vite multivitamin/iron (tablet)* $0 (Tier 3)C1
Daily-Vite
daily-vite (tablet)* $0 (Tier 3)
66For Track Refered Purpose7866
78
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Daily-Vite/Iron/Beta-Carotene
daily-vite/iron/beta-carotene (tablet)* $0 (Tier 3)C1
Dekas Essential dekas essential (capsule)* $0 (Tier 3)C1
Dekas Plus
dekas plus
(0-100mcg-12mg-3000unit-10mg-12mcg-200mcg-10
mg-1000mcg-1.9mg-1.7mg-75mcg-75mg-1.5mg-0-15
0unit-0-18167unit-0-10mg capsule, 45mg/
ml-0-15mcg/ml-3mg/ml-750unit/ml-2mg/ml-6mg/
ml-500mcg/ml-0.6mg/ml-0.6mg/ml-0-10mcg/
ml-0.6mg/ml-0-50unit/ml-0-5751unit/ml-5mg/ml
liquid)*
$0 (Tier 3)
C1
Dialy vite 800
dialy vite 800 (tablet)* $0 (Tier 3)C1
Dino-Life
dino-life (tablet chewable)* $0 (Tier 3)C1
Dino-Life with Extra C dino-life with extra c (tablet chewable)* $0 (Tier 3)C1
Dino-Life with Iron & Zinc dino-life with iron & zinc (tablet chewable)* $0 (Tier 3)C1
D-Vi-Sol
d-vi-sol (liquid)* $0 (Tier 3)C1
E-400
e-400 (capsule)* $0 (Tier 3)C1
E400 Mixed
e400 mixed (capsule)* $0 (Tier 3)C1
Endur-Acin
endur-acin (tablet extended-release)* $0 (Tier 3)C1
Endur-C/Rose Hips endur-c/rose hips (tablet extended-release)* $0 (Tier 3)C1
E-Oil
e-oil (oil)* $0 (Tier 3)C1
EQ Complete Multivitamin Adults 50+
eq complete multivitamin adults 50+ (tablet)* $0 (Tier 3)C1
EQ Complete Multivitamin Adults Under 50
eq complete multivitamin adults under 50 (tablet)* $0 (Tier 3)C1
EQ One Daily Womens Health eq one daily womens health (tablet)* $0 (Tier 3)C1
EQL B Complex 50 eql b complex 50 (tablet)* $0 (Tier 3)C1
EQL B-6
eql b-6 (tablet)* $0 (Tier 3)C1
EQL One Daily Mens Health Formula
eql one daily mens health formula (tablet)* $0 (Tier 3)C1
EQL One Daily Womens eql one daily womens (tablet)* $0 (Tier 3)C1
EQL Vitamin B-12
eql vitamin b-12 (tablet)* $0 (Tier 3)C1
EQL Vitamin B-12 TR eql vitamin b-12 tr (tablet extended-release)* $0 (Tier 3)C1
EQL Vitamin C
eql vitamin c (tablet)* $0 (Tier 3)C1
EQL Vitamin C/Rose Hips eql vitamin c/rose hips (tablet)* $0 (Tier 3)C1
EQL Vitamin E
eql vitamin e (capsule)* $0 (Tier 3)C1
Ergocalciferol
ergocalciferol (oral solution)* $0 (Tier 3)C1
Essentia
essentia (tablet)* $0 (Tier 3)C1
Essential Balance essential balance (tablet)* $0 (Tier 3)C1
Flintstones Complete flintstones complete (tablet chewable)* $0 (Tier 3)C1
Flintstones Plus Extra C flintstones plus extra c (tablet chewable)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
67For Track Refered Purpose7967
79
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Flintstones/My First flintstones/my first (tablet chewable)* $0 (Tier 3)C1
Folic Acid
folic acid (1mg tablet, 5mg/ml injection)* $0 (Tier 3)C1
Foltabs 800
foltabs 800 (tablet)* $0 (Tier 3)C1
Fosfree
fosfree (tablet)* $0 (Tier 3)C1
Fruit C 500
fruit c 500 (tablet chewable)* $0 (Tier 3)C1
Fruity C
fruity c (tablet chewable)* $0 (Tier 3)C1
Fruity Chewables Multivitamin fruity chewables multivitamin (tablet chewable)* $0 (Tier 3)C1
Full Spectrum B/Vitamin C full spectrum b/vitamin c (tablet)* $0 (Tier 3)C1
GNP Animal Shapes gnp animal shapes (tablet chewable)* $0 (Tier 3)C1
GNP Animal Shapes Plus Extra C gnp animal shapes plus extra c (tablet chewable)* $0 (Tier 3)C1
GNP Animal Shapes Plus Iron gnp animal shapes plus iron (tablet chewable)* $0 (Tier 3)C1
GNP B-12
gnp b-12 (tablet sublingual)* $0 (Tier 3)C1
GNP B-50 Balanced gnp b-50 balanced (tablet)* $0 (Tier 3)C1
GNP Biotin
gnp biotin (capsule)* $0 (Tier 3)C1
GNP Century
gnp century
(60mg-0-30mcg-200mg-10mg-20mg-72mg-400unit-3
5mcg-0.5mg-6mcg-18mg-400mcg-50mg-2.3mg-20m
g-5mcg-25mcg-80mg-150mcg-2mg-1.7mg-2mg-75m
cg-10mcg-45mcg-55mcg-10mcg-1.5mg-30unit-3500u
nit-11mg tablet,
60mg-0-30mcg-200mg-10mg-72mg-400unit-35mcg-0.
5mg-6mcg-18mg-400mcg-50mg-2.3mg-20mg-5mcg-
20mg-25mcg-80mg-150mcg-2mg-1.7mg-2mg-75mcg
-10mcg-45mcg-55mcg-10mcg-1.5mg-30unit-3500unit
-11mg tablet)*
$0 (Tier 3)
C1
GNP Century Active Performance
gnp century active performance (tablet)* $0 (Tier 3)C1
GNP Century Adults 50+ Senior gnp century adults 50+ senior (tablet)* $0 (Tier 3)C1
GNP Century Cardio Healthformula
gnp century cardio healthformula (tablet)* $0 (Tier 3)C1
GNP Century Mature gnp century mature (tablet)* $0 (Tier 3)C1
GNP Century Ultimate Mens Complete
gnp century ultimate mens complete (tablet)* $0 (Tier 3)
68For Track Refered Purpose8068
80
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
GNP Century Ultimate Womens Complete
gnp century ultimate womens complete (tablet)* $0 (Tier 3)C1
GNP Century Ultimate Womens Senior Formula
gnp century ultimate womens senior formula
(tablet)*$0 (Tier 3)
C1
GNP Childrens Chewables w/Extra C
gnp childrens chewables w/extra c (tablet
chewable)*$0 (Tier 3)
C1
GNP Childrens Chewables/Extra C
gnp childrens chewables/extra c (tablet chewable)* $0 (Tier 3)C1
GNP Childrens Chewables/Iron gnp childrens chewables/iron (tablet chewable)* $0 (Tier 3)C1
GNP Essential One Daily gnp essential one daily (tablet)* $0 (Tier 3)C1
GNP Hair/Skin/Nails gnp hair/skin/nails (tablet)* $0 (Tier 3)C1
GNP Little Ones Childrens gnp little ones childrens (tablet chewable)* $0 (Tier 3)C1
GNP Mega Multi for Men gnp mega multi for men (tablet)* $0 (Tier 3)C1
GNP Mega Multi for Women gnp mega multi for women (tablet)* $0 (Tier 3)C1
GNP Niacin TR gnp niacin tr (tablet extended-release)* $0 (Tier 3)C1
GNP One Daily Maximum gnp one daily maximum (tablet)* $0 (Tier 3)C1
GNP One Daily Mens Health 50+
gnp one daily mens health 50+ (tablet)* $0 (Tier 3)C1
GNP One Daily Plus Iron gnp one daily plus iron (tablet)* $0 (Tier 3)C1
GNP One Daily Womens Health 50+
gnp one daily womens health 50+ (tablet)* $0 (Tier 3)C1
GNP Opti-Vitamins gnp opti-vitamins (tablet)* $0 (Tier 3)C1
GNP Therapeutic-M gnp therapeutic-m
(90mg-0-30mcg-150mcg-10mg-40mg-7.5mg-400unit-
50mcg-2mg-12mcg-9mg-400mcg-100mg-2mg-20mg-
5mcg-31mg-28mcg-7.5mg-150mcg-6mg-3.4mg-2mg-
10mcg-75mcg-70mcg-10mcg-3mg-60unit-5000unit-1
5mg tablet,
90mg-0-30mcg-150mcg-40mg-10mg-7.5mg-400unit-5
0mcg-2mg-12mcg-9mg-400mcg-100mg-2mg-20mg-5
mcg-31mg-28mcg-7.5mg-150mcg-6mg-3.4mg-2mg-1
0mcg-75mcg-70mcg-10mcg-3mg-60unit-5000unit-15
mg tablet)*
$0 (Tier 3)
C1
GNP Vitamin A gnp vitamin a (10000unit capsule, 8000unit
capsule)*$0 (Tier 3)
C1
GNP Vitamin B-1 gnp vitamin b-1 (tablet)* $0 (Tier 3)C1
GNP Vitamin B-12 gnp vitamin b-12 (tablet)* $0 (Tier 3)C1
GNP Vitamin B-12 Prolonged Release
gnp vitamin b-12 prolonged release (tablet extended-
release)*$0 (Tier 3)
C1
GNP Vitamin B-12 TR gnp vitamin b-12 tr (tablet extended-release)* $0 (Tier 3)C1
GNP Vitamin B-6 gnp vitamin b-6 (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
69For Track Refered Purpose8169
81
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
GNP Vitamin C gnp vitamin c (1000mg tablet, 250mg tablet, 500mg
tablet, 500mg tablet chewable, 500mg-tablet
chewable, 500mg-tablet chewable)*
$0 (Tier 3)
C1
GNP Vitamin C Drops gnp vitamin c drops (60mg lozenge, 60mg-0
lozenge)*$0 (Tier 3)
C1
GNP Vitamin C Pr gnp vitamin c pr (tablet extended-release)* $0 (Tier 3)C1
GNP Vitamin C TR gnp vitamin c tr (tablet extended-release)* $0 (Tier 3)C1
GNP Vitamin C with Rose Hips gnp vitamin c with rose hips (500mg tablet,
500mg-37mg tablet)*$0 (Tier 3)
C1
GNP Vitamin C with Rose Hips TR
gnp vitamin c with rose hips tr (tablet extended-
release)*$0 (Tier 3)
C1
GNP Vitamin C/Rose Hips gnp vitamin c/rose hips (tablet)* $0 (Tier 3)C1
GNP Vitamin E gnp vitamin e (1000unit capsule, 200unit capsule,
400unit capsule, 200unit capsule, 400unit capsule)*$0 (Tier 3)
C1
GNP Vitamin E Water Dispersible
gnp vitamin e water dispersible (capsule)* $0 (Tier 3)C1
GNP Zoo Chews Gummies gnp zoo chews gummies (tablet chewable)* $0 (Tier 3)C1
Gummi Bear Multivitamin/Mineral gummi bear multivitamin/mineral (tablet chewable)* $0 (Tier 3)C1
Halls Defense Vitamin C Drops
halls defense vitamin c drops (lozenge)* $0 (Tier 3)C1
Hard Nails
hard nails (capsule)* $0 (Tier 3)C1
Healthy Kids Gummies healthy kids gummies (tablet chewable)* $0 (Tier 3)C1
HM Complete
hm complete (tablet)* $0 (Tier 3)C1
HM Complete 50+ hm complete 50+ (tablet)* $0 (Tier 3)C1
HM Complete 50+ Womens Ultimate
hm complete 50+ womens ultimate (tablet)* $0 (Tier 3)C1
HM Complete Women hm complete women (tablet)* $0 (Tier 3)C1
HM Hair/Skin/Nails hm hair/skin/nails (tablet)* $0 (Tier 3)C1
HM Niacin
hm niacin (tablet extended-release)* $0 (Tier 3)C1
HM Niacin TR
hm niacin tr (tablet extended-release)* $0 (Tier 3)C1
HM One Daily Essential hm one daily essential (tablet)* $0 (Tier 3)C1
HM One Daily Womens hm one daily womens (tablet)* $0 (Tier 3)C1
HM One Daily/Iron hm one daily/iron (tablet)* $0 (Tier 3)
70For Track Refered Purpose8270
82
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
HM Vitamin B Complex/Vitamin C
hm vitamin b complex/vitamin c (tablet)* $0 (Tier 3)C1
HM Vitamin B100 Complex hm vitamin b100 complex (tablet)* $0 (Tier 3)C1
HM Vitamin B12
hm vitamin b12 (1000mcg tablet extended-release,
500mcg tablet)*$0 (Tier 3)
C1
HM Vitamin B12 TR hm vitamin b12 tr (tablet extended-release)* $0 (Tier 3)C1
HM Vitamin B50 Complex hm vitamin b50 complex (tablet)* $0 (Tier 3)C1
HM Vitamin B6
hm vitamin b6 (tablet)* $0 (Tier 3)C1
HM Vitamin C
hm vitamin c (1000mg tablet, 500mg tablet, 500mg-
tablet chewable)*$0 (Tier 3)
C1
HM Vitamin C TR hm vitamin c tr (tablet extended-release)* $0 (Tier 3)C1
HM Vitamin C/Rose Hips hm vitamin c/rose hips (tablet)* $0 (Tier 3)C1
HM Vitamin E
hm vitamin e (capsule)* $0 (Tier 3)C1
Honey Bears
honey bears (tablet chewable)* $0 (Tier 3)C1
Honey Bears with Iron and Zinc honey bears with iron and zinc (tablet chewable)* $0 (Tier 3)C1
I-Caps Areds Formula i-caps areds formula (tablet)* $0 (Tier 3)C1
I-Caps Mv
i-caps mv (tablet)* $0 (Tier 3)C1
I-Caps Plus
i-caps plus (tablet)* $0 (Tier 3)C1
Just D
just d (liquid)* $0 (Tier 3)C1
Kobee
kobee (tablet)* $0 (Tier 3)C1
KP Adults 50+ Daily Formula kp adults 50+ daily formula (tablet)* $0 (Tier 3)C1
KP B Complex/C kp b complex/c (tablet)* $0 (Tier 3)C1
KP Niacin
kp niacin (tablet)* $0 (Tier 3)C1
KP Vitamin B-12
kp vitamin b-12 (tablet)* $0 (Tier 3)C1
KP Vitamin B-6
kp vitamin b-6 (tablet)* $0 (Tier 3)C1
KP Vitamin E
kp vitamin e (capsule)* $0 (Tier 3)C1
Land Before Time Multivitamin/Iron
land before time multivitamin/iron (tablet chewable)* $0 (Tier 3)C1
Life Pack Mens life pack mens* $0 (Tier 3)C1
Life Pack Womens life pack womens* $0 (Tier 3)C1
Liquid B12
liquid b12 (liquid)* $0 (Tier 3)C1
Lysiplex Plus
lysiplex plus (liquid)* $0 (Tier 3)C1
Mega Multiple with Chelated Minerals
mega multiple with chelated minerals (tablet)* $0 (Tier 3)C1
Mega Multivitamin for Men mega multivitamin for men (tablet)* $0 (Tier 3)C1
Mega Multivitamin for Women mega multivitamin for women (tablet)* $0 (Tier 3)C1
Meijer Advanced Formula meijer advanced formula (tablet)* $0 (Tier 3)C1
Meijer C
meijer c (tablet)* $0 (Tier 3)C1
Mephyton
mephyton (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
71For Track Refered Purpose8371
83
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Meribin
meribin (capsule)* $0 (Tier 3)C1
Mtx Support
mtx support (tablet)* $0 (Tier 3)C1
Multi Complete/Iron multi complete/iron (tablet)* $0 (Tier 3)C1
Multi Vitamin Daily multi vitamin daily (tablet)* $0 (Tier 3)C1
Multi-Day Plus Iron multi-day plus iron (tablet)* $0 (Tier 3)C1
Multi-Delyn/Iron multi-delyn/iron (liquid)* $0 (Tier 3)C1
Multilex
multilex (tablet)* $0 (Tier 3)C1
Multilex T&M
multilex t&m (tablet)* $0 (Tier 3)C1
Multiple Vitamin/Minerals/No Iron multiple vitamin/minerals/no iron (tablet)* $0 (Tier 3)C1
Multiple Vitamins multiple vitamins (tablet)* $0 (Tier 3)C1
Multiple Vitamins Plain multiple vitamins plain (tablet)* $0 (Tier 3)C1
Multiple Vitamins/Iron multiple vitamins/iron
(60mg-0-10mg-400unit-6mcg-18mg-400mcg-20mg-2
mg-1.7mg-1.5mg-30unit-5000unit tablet,
60mg-400unit-6mcg-18mg-400mcg-20mg-10mg-2mg
-1.7mg-1.5mg-30unit-5000unit tablet,
60mg-4.5mcg-400unit-15mg-0.3mg-13.5mg-1.04mg-1
.2mg-1.05mg-2500unit-15unit tablet chewable)*
$0 (Tier 3)
C1
Multivitamin & Mineral multivitamin & mineral (liquid)* $0 (Tier 3)C1
Multi-Vitamin
multi-vitamin (tablet)* $0 (Tier 3)C1
Multi-Vitamin Daily multi-vitamin daily (tablet)* $0 (Tier 3)C1
Multi-Vitamin HP/Minerals multi-vitamin hp/minerals (capsule)* $0 (Tier 3)C1
Multi-Vitamin/Minerals multi-vitamin/minerals (tablet)* $0 (Tier 3)C1
Multi-Vitamin/Multi-Mineral Adult/High Potency
multi-vitamin/multi-mineral adult/high potency
(liquid)*$0 (Tier 3)
C1
Multi-Vitamins multi-vitamins (tablet)* $0 (Tier 3)C1
My-Vitalife
my-vitalife (capsule)* $0 (Tier 3)C1
Natural C/Rose Hips natural c/rose hips (tablet)* $0 (Tier 3)C1
Natural Vitamin E natural vitamin e (capsule)* $0 (Tier 3)C1
Nephronex
nephronex (liquid)* $0 (Tier 3)
72For Track Refered Purpose8472
84
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Nephro-Vite
nephro-vite (tablet)* $0 (Tier 3)C1
Niacin
niacin (100mg tablet, 250mg tablet, 500mg tablet,
100mg tablet, 500mg tablet, 50mg tablet, 250mg
capsule extended-release, 500mg tablet extended-
release)*
$0 (Tier 3)
C1
Niacin ER
niacin er (otc only) (250mg capsule extended-
release, 500mg tablet extended-release)*$0 (Tier 3)
C1
Niacin SR
niacin sr (capsule extended-release)* $0 (Tier 3)C1
Niacin TR
niacin tr (250mg capsule extended-release, 250mg
tablet extended-release, 500mg tablet extended-
release)*
$0 (Tier 3)
C1
No Iron Multiple Vitamin/Minerals no iron multiple vitamin/minerals (tablet)* $0 (Tier 3)C1
Ocutabs
ocutabs (tablet)* $0 (Tier 3)C1
Ocutabs Vision Formula ocutabs vision formula (tablet)* $0 (Tier 3)C1
Ocutabs/Lutein ocutabs/lutein (tablet)* $0 (Tier 3)C1
Omnicap
omnicap (tablet)* $0 (Tier 3)C1
Once Daily
once daily (tablet)* $0 (Tier 3)C1
Once Daily/Iron once daily/iron (tablet)* $0 (Tier 3)C1
Oncovite
oncovite (tablet)* $0 (Tier 3)C1
One Daily
one daily (tablet)* $0 (Tier 3)C1
One Daily Complete one daily complete (tablet)* $0 (Tier 3)C1
One Daily for Men 50+ Advanced one daily for men 50+ advanced (tablet)* $0 (Tier 3)C1
One Daily for Women one daily for women (tablet)* $0 (Tier 3)C1
One Daily for Women 50+a Dvanced
one daily for women 50+a dvanced (tablet)* $0 (Tier 3)C1
One Daily Maximum one daily maximum (tablet)* $0 (Tier 3)C1
One Daily Mens one daily mens (tablet)* $0 (Tier 3)C1
One Daily Multivitamin Adult one daily multivitamin adult (tablet)* $0 (Tier 3)C1
One Daily Multivitamin/Iron one daily multivitamin/iron (tablet)* $0 (Tier 3)C1
One Daily Plus Iron one daily plus iron (tablet)* $0 (Tier 3)C1
One Daily Plus Minerals one daily plus minerals (tablet)* $0 (Tier 3)C1
One Daily Womens 50 Plus one daily womens 50 plus (tablet)* $0 (Tier 3)C1
One Daily Womens 50+ one daily womens 50+ (tablet)* $0 (Tier 3)C1
One Daily/Iron/Calcium one daily/iron/calcium (tablet)* $0 (Tier 3)C1
One Daily/Minerals one daily/minerals (tablet)* $0 (Tier 3)C1
One-A-Day Essential one-a-day essential (tablet)* $0 (Tier 3)C1
One-A-Day Mens 50+ Advantage one-a-day mens 50+ advantage (tablet)* $0 (Tier 3)C1
One-A-Day Teen Advantage for Her
one-a-day teen advantage for her (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
73For Track Refered Purpose8573
85
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
One-A-Day Teen Advantage for Him
one-a-day teen advantage for him (tablet)* $0 (Tier 3)C1
One-A-Day Womens Formula one-a-day womens formula (tablet)* $0 (Tier 3)C1
One-Daily Multi Vitamins one-daily multi vitamins (tablet)* $0 (Tier 3)C1
Pantothenic Acid
pantothenic acid (tablet)* $0 (Tier 3)C1
Peridin-C
peridin-c (tablet)* $0 (Tier 3)C1
Plain Niacin
plain niacin (tablet)* $0 (Tier 3)C1
Poly Vitamin
poly vitamin (tablet chewable)* $0 (Tier 3)C1
Polyvitamin
polyvitamin (oral solution)* $0 (Tier 3)C1
Polyvitamin/Iron
polyvitamin/iron (tablet chewable)* $0 (Tier 3)C1
Prevent
prevent (capsule)* $0 (Tier 3)C1
Pure C 500
pure c 500 (capsule extended-release)* $0 (Tier 3)C1
Pureway-C
pureway-c (tablet)* $0 (Tier 3)C1
Pyridoxine HCl
pyridoxine hcl (tablet)* $0 (Tier 3)C1
QC Childrens Chewable Vitamins/Extra C
qc childrens chewable vitamins/extra c (tablet
chewable)*$0 (Tier 3)
C1
QC Maximum Daily Multivitamin/Multimineral
qc maximum daily multivitamin/multimineral (tablet)* $0 (Tier 3)C1
QC Multi-Vite
qc multi-vite (tablet)* $0 (Tier 3)C1
QC Womens Daily Multivitamin qc womens daily multivitamin (tablet)* $0 (Tier 3)C1
Quintabs-M
quintabs-m (tablet)* $0 (Tier 3)C1
RA Balanced B-100 ra balanced b-100 (tablet)* $0 (Tier 3)C1
RA Balanced B-50 ra balanced b-50 (tablet)* $0 (Tier 3)C1
RA B-Complex ra b-complex (tablet)* $0 (Tier 3)C1
RA B-Complex with B-12 ra b-complex with b-12 (tablet)* $0 (Tier 3)C1
RA B-Complex/Vitamin C TR ra b-complex/vitamin c tr (tablet extended-release)* $0 (Tier 3)C1
RA Biotin
ra biotin (capsule)* $0 (Tier 3)C1
RA Central-Vite Cardio ra central-vite cardio (tablet)* $0 (Tier 3)C1
RA Central-Vite Select Mature ra central-vite select mature (tablet)* $0 (Tier 3)C1
RA Central-Vite Womens Mature ra central-vite womens mature (tablet)* $0 (Tier 3)C1
RA Central-Vite/Antioxidants ra central-vite/antioxidants (tablet)* $0 (Tier 3)
74For Track Refered Purpose8674
86
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
RA Niacin
ra niacin (tablet)* $0 (Tier 3)C1
RA One Daily Energy Formula ra one daily energy formula (tablet)* $0 (Tier 3)C1
RA One Daily Essential ra one daily essential (tablet)* $0 (Tier 3)C1
RA One Daily Maximum ra one daily maximum (tablet)* $0 (Tier 3)C1
RA One Daily Mens 50+ with Vitamin D-3
ra one daily mens 50+ with vitamin d-3 (tablet)* $0 (Tier 3)C1
RA Vitamin A
ra vitamin a (capsule)* $0 (Tier 3)C1
RA Vitamin B-1
ra vitamin b-1 (tablet)* $0 (Tier 3)C1
RA Vitamin B12
ra vitamin b12 (tablet extended-release)* $0 (Tier 3)C1
RA Vitamin B-12
ra vitamin b-12 (tablet)* $0 (Tier 3)C1
RA Vitamin B-12 TR ra vitamin b-12 tr (tablet extended-release)* $0 (Tier 3)C1
RA Vitamin B-6
ra vitamin b-6 (tablet)* $0 (Tier 3)C1
RA Vitamin C
ra vitamin c (250mg tablet, 500mg tablet, 500mg-
tablet chewable)*$0 (Tier 3)
C1
RA Vitamin C Drops ra vitamin c drops (lozenge)* $0 (Tier 3)C1
RA Vitamin C TR ra vitamin c tr (tablet extended-release)* $0 (Tier 3)C1
RA Vitamin C/Acerola ra vitamin c/acerola (tablet chewable)* $0 (Tier 3)C1
RA Vitamin C/Rose Hips ra vitamin c/rose hips (tablet)* $0 (Tier 3)C1
RA Vitamin C/Rose Hips TR ra vitamin c/rose hips tr (tablet extended-release)* $0 (Tier 3)C1
RA Vitamin E
ra vitamin e (capsule)* $0 (Tier 3)C1
Rabano Yodado
rabano yodado (liquid)* $0 (Tier 3)C1
Renal Vitamin
renal vitamin (tablet)* $0 (Tier 3)C1
Renal-Vite
renal-vite (tablet)* $0 (Tier 3)C1
Rena-Vite
rena-vite (tablet)* $0 (Tier 3)C1
SB Vitamin C
sb vitamin c (tablet)* $0 (Tier 3)C1
Scooby-Doo One A Day scooby-doo one a day (tablet chewable)* $0 (Tier 3)C1
Senior Tabs
senior tabs (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
75For Track Refered Purpose8775
87
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Sentry
sentry
(60mg-0-30mcg-75mcg-200mg-10mg-20mg-72mg-40
0unit-35mcg-0.5mg-6mcg-18mg-400mcg-50mg-2.3m
g-20mg-5mcg-25mcg-80mg-150mcg-2mg-1.7mg-2m
g-10mcg-45mcg-55mcg-10mcg-1.5mg-30unit-3500un
it-11mg tablet,
90mg-0-30mcg-150mcg-200mg-109mg-72mg-400uni
t-35mcg-0.9mg-6mcg-18mg-500mcg-250mcg-300mc
g-100mg-2.3mg-20mg-5mcg-10mg-25mcg-80mg-150
mcg-2mg-1.7mg-2mg-10mcg-45mcg-55mcg-10mcg-1
.5mg-30unit-3500unit-11mg tablet,
90mg-0-30mcg-150mcg-200mg-10mg-109mg-72mg-
400unit-35mcg-0.9mg-6mcg-18mg-500mcg-250mcg-
300mcg-100mg-2.3mg-20mg-5mcg-25mcg-80mg-15
0mcg-2mg-1.7mg-2mg-10mcg-45mcg-55mcg-10mcg-
1.5mg-30unit-3500unit-11mg tablet)*
$0 (Tier 3)
C1
Sentry Adults Under 50 sentry adults under 50 (tablet)* $0 (Tier 3)C1
Sentry Senior
sentry senior
(60mg-0-30mcg-150mcg-220mg-10mg-20mg-72mg-5
00unit-45mcg-0.5mg-25mcg-400mcg-250mcg-300mc
g-50mg-2.3mg-20mg-5mcg-30mcg-80mg-150mcg-3
mg-1.7mg-2mg-10mcg-45mcg-55mcg-1.5mg-50unit-2
500unit-11mg tablet,
60mg-0-30mcg-150mcg-220mg-10mg-20mg-72mg-5
00unit-45mcg-0.5mg-25mcg-400mcg-250mcg-300mc
g-50mg-2.3mg-20mg-5mcg-30mcg-80mg-150mcg-3
mg-1.7mg-2mg-10mcg-45mcg-55mcg-1.5mg-50unit-2
500unit-11mg tablet,
90mg-0-30mcg-150mcg-220mg-10mg-110mg-72mg-
500unit-45mcg-0.9mg-25mcg-500mcg-250mcg-300m
cg-50mg-2.3mg-20mg-5mcg-30mcg-80mg-150mcg-3
mg-1.7mg-2mg-10mcg-45mcg-55mcg-1.5mg-50unit-2
500unit-11mg tablet)*
$0 (Tier 3)
76For Track Refered Purpose8876
88
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Slo-Niacin
slo-niacin (tablet extended-release)* $0 (Tier 3)C1
SM Balanced B-50 sm balanced b-50 (tablet)* $0 (Tier 3)C1
SM B-Complex sm b-complex (tablet)* $0 (Tier 3)C1
SM B-Complex/Vitamin C sm b-complex/vitamin c (tablet)* $0 (Tier 3)C1
SM Chewable C
sm chewable c (tablet chewable)* $0 (Tier 3)C1
Sm Chewable Vitamin C sm chewable vitamin c (tablet chewable)* $0 (Tier 3)C1
SM Complete
sm complete
(120mg-0-40mcg-100mg-10mg-72mg-120mcg-2mg-1
6mcg-400unit-18mg-400mcg-60mg-40mg-4mg-40mg
-5mcg-50mg-48mg-25mcg-80mg-150mcg-6mg-5.1m
g-4mg-60mcg-10mcg-75mcg-70mcg-10mcg-4.5mg-6
0unit-3500unit-15mg tablet,
60mg-0-30mcg-200mg-10mg-72mg-400unit-35mcg-0.
5mg-6mcg-18mg-400mcg-50mg-2.3mg-20mg-5mcg-
20mg-25mcg-80mg-150mcg-2mg-1.7mg-2mg-75mcg
-10mcg-45mcg-55mcg-10mcg-1.5mg-30unit-3500unit
-11mg tablet)*
$0 (Tier 3)
C1
SM Complete 50+ sm complete 50+ (tablet)* $0 (Tier 3)C1
SM Complete 50+ Ultimate Womens
sm complete 50+ ultimate womens (tablet)* $0 (Tier 3)C1
SM Complete Advanced Formula
sm complete advanced formula (tablet)* $0 (Tier 3)C1
SM Complete Senior Formula sm complete senior formula (tablet)* $0 (Tier 3)C1
SM Hair/Skin/Nails sm hair/skin/nails (tablet)* $0 (Tier 3)C1
SM Multiple Vitamins Essential sm multiple vitamins essential (tablet)* $0 (Tier 3)C1
SM Multiple Vitamins/Iron sm multiple vitamins/iron (tablet)* $0 (Tier 3)C1
SM Niacin CR
sm niacin cr (tablet extended-release)* $0 (Tier 3)C1
SM One Daily Womens sm one daily womens (tablet)* $0 (Tier 3)C1
SM Super B Complex-Vitamin C sm super b complex-vitamin c (tablet)* $0 (Tier 3)C1
SM Vitamin B1
sm vitamin b1 (tablet)* $0 (Tier 3)C1
SM Vitamin B100 Complex sm vitamin b100 complex (tablet)* $0 (Tier 3)C1
SM Vitamin B12
sm vitamin b12 (tablet)* $0 (Tier 3)C1
SM Vitamin B-12
sm vitamin b-12 (tablet)* $0 (Tier 3)C1
SM Vitamin B12 TR sm vitamin b12 tr (tablet extended-release)* $0 (Tier 3)C1
SM Vitamin B6
sm vitamin b6 (tablet)* $0 (Tier 3)C1
SM Vitamin B-6
sm vitamin b-6 (tablet)* $0 (Tier 3)C1
SM Vitamin C
sm vitamin c (1000mg tablet, 250mg tablet, 1000mg
tablet, 500mg tablet, 500mg tablet chewable)*$0 (Tier 3)
C1
SM Vitamin C TR sm vitamin c tr (tablet extended-release)* $0 (Tier 3)C1
SM Vitamin C/Rose Hips sm vitamin c/rose hips (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
77For Track Refered Purpose8977
89
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
SM Vitamin E
sm vitamin e (1000unit capsule, 200unit capsule,
400unit capsule, 400unit capsule)*$0 (Tier 3)
C1
SM Vitamin E Blended sm vitamin e blended (capsule)* $0 (Tier 3)C1
Stress B/Zinc
stress b/zinc (tablet)* $0 (Tier 3)C1
Stress Formula stress formula
(500mg-45mcg-12mcg-400mcg-100mg-20mg-3mg-1
0mg-10mg-30unit tablet,
500mg-45mcg-12mcg-400mcg-100mg-20mg-5mg-10
mg-15mg-30unit tablet,
500mg-45mcg-12mcg-400mcg-100mg-20mg-5mg-10
mg-10mg-30unit tablet)*
$0 (Tier 3)
C1
Stress Formula with Iron stress formula with iron (tablet)* $0 (Tier 3)C1
Stress Formula/Iron stress formula/iron (tablet)* $0 (Tier 3)C1
Stress Formula/Zinc stress formula/zinc (tablet)* $0 (Tier 3)C1
Super B Complex Maxi super b complex maxi (tablet)* $0 (Tier 3)C1
Super B with C
super b with c (capsule)* $0 (Tier 3)C1
Super B-Complex/Vitamin C super b-complex/vitamin c (tablet)* $0 (Tier 3)C1
Super Biotin
super biotin (capsule)* $0 (Tier 3)C1
Super Quints B-50 super quints b-50 (tablet)* $0 (Tier 3)C1
Super Thera Vite M super thera vite m (tablet)* $0 (Tier 3)C1
Superplex-T
superplex-t (tablet)* $0 (Tier 3)C1
Suplevit
suplevit (liquid)* $0 (Tier 3)C1
TAB-A-VITE
tab-a-vite (tablet)* $0 (Tier 3)C1
TAB-A-VITE Maximum tab-a-vite maximum (tablet)* $0 (Tier 3)C1
TAB-A-VITE with Beta Carotene tab-a-vite with beta carotene (tablet)* $0 (Tier 3)C1
TAB-A-VITE/Iron tab-a-vite/iron (tablet)* $0 (Tier 3)C1
Thera
thera (tablet)* $0 (Tier 3)C1
Thera M Plus
thera m plus (tablet)* $0 (Tier 3)
78For Track Refered Purpose9078
90
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Thera-M
thera-m
(120mg-15mcg-44mg-10mg-7.5mg-400unit-15mcg-2
mg-9mcg-18mg-400mcg-100mg-5mg-30mg-31mg-7.
5mg-150mcg-3mg-3.4mg-15mcg-10mcg-3mg-30unit-
5500unit-15mg tablet,
90mg-0-30mcg-150mcg-40mg-7.5mg-26mcg-2mg-9
mcg-400mcg-150mcg-18mg-100mg-3.5mg-32mcg-2
0mg-5mcg-10mg-31mg-7.5mg-3mg-3.4mg-21mcg-2
mg-3mg-10mcg-10mcg-5000unit-400unit-30unit-28m
cg-15mg tablet,
90mg-0-30mcg-30mg-10mg-50mcg-2mg-12mcg-400
unit-9mg-400mcg-100mg-2mg-20mg-5mcg-23mg-28
mcg-7.5mg-7mg-150mcg-6mg-3.4mg-6mg-150mcg-1
0mcg-75mcg-70mcg-10mcg-3mg-60unit-5000unit-15
mg tablet)*
$0 (Tier 3)
C1
Therapeutic-M/Lutein therapeutic-m/lutein (tablet)* $0 (Tier 3)C1
Thera-Tabs
thera-tabs (tablet)* $0 (Tier 3)C1
Theratrum Complete theratrum complete
(60mg-0-30mcg-150mcg-162mg-0-10mg-0-400unit-12
0mcg-2mg-6mcg-18mg-400mcg-250mcg-300mcg-10
0mg-2mg-20mg-5mcg-109mg-25mcg-80mg-72mg-15
0mcg-2mg-1.7mg-2mg-0-10mcg-75mcg-20mcg-10mc
g-1.5mg-30unit-3500unit-15mg tablet,
60mg-0-30mcg-150mcg-162mg-10mg-72mg-400unit-
120mcg-2mg-6mcg-18mg-400mcg-150mcg-250mcg-
100mg-2mg-20mg-5mcg-108mg-80mg-2mg-1.7mg-2
mg-10mcg-75mcg-20mcg-10mcg-1.5mg-30unit-5000
unit-25mcg-15mg tablet)*
$0 (Tier 3)
C1
Theratrum Complete 50 Plus theratrum complete 50 plus (tablet)* $0 (Tier 3)C1
Therems
therems (tablet)* $0 (Tier 3)C1
Therems-H
therems-h (tablet)* $0 (Tier 3)C1
Therems-M
therems-m (tablet)* $0 (Tier 3)C1
Thiamine HCl
thiamine hcl (tablet)* $0 (Tier 3)C1
Total B/C
total b/c (tablet)* $0 (Tier 3)C1
Totalday Multiple
totalday multiple (tablet extended-release)* $0 (Tier 3)C1
Tri-Vi-Sol
tri-vi-sol (oral solution)* $0 (Tier 3)C1
Ultra Choice Multivitamin Kids ultra choice multivitamin kids (tablet chewable)* $0 (Tier 3)C1
Ultrachoice Advanced Formula ultrachoice advanced formula (tablet)* $0 (Tier 3)C1
Unicomplex-M
unicomplex-m (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
79For Track Refered Purpose9179
91
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Vita-Bee/C
vita-bee/c (tablet)* $0 (Tier 3)C1
Vitalee
vitalee (tablet)* $0 (Tier 3)C1
Vitalets
vitalets (tablet chewable)* $0 (Tier 3)C1
Vitalets Childrens vitalets childrens (tablet chewable)* $0 (Tier 3)C1
Vitamin A
vitamin a (10000unit capsule, 8000unit capsule,
8000unit capsule)*$0 (Tier 3)
C1
Vitamin B Complex vitamin b complex (10mg-10mg-0.2mg-2mg-1.5mg
tablet, 2mcg-15mg-5mg-2mg-2mg-2mg tablet)*$0 (Tier 3)
C1
Vitamin B Complex-C vitamin b complex-c (capsule)* $0 (Tier 3)C1
Vitamin B-1
vitamin b-1 (100mg tablet, 250mg tablet, 50mg
tablet, 100mg tablet, 50mg tablet)*$0 (Tier 3)
C1
Vitamin B1
vitamin b1 (tablet)* $0 (Tier 3)C1
Vitamin B-12
vitamin b-12 (1000mcg tablet, 100mcg tablet,
250mcg tablet, 500mcg tablet, 1000mcg tablet,
100mcg tablet, 500mcg tablet, 50mcg tablet,
2500mcg tablet sublingual)*
$0 (Tier 3)
C1
Vitamin B12
vitamin b12 (tablet)* $0 (Tier 3)C1
Vitamin B-12 CR
vitamin b-12 cr (tablet extended-release)* $0 (Tier 3)C1
Vitamin B-12 ER
vitamin b-12 er (tablet extended-release)* $0 (Tier 3)C1
Vitamin B12 TR
vitamin b12 tr (tablet extended-release)* $0 (Tier 3)C1
Vitamin B-12 TR
vitamin b-12 tr (tablet extended-release)* $0 (Tier 3)C1
Vitamin B-2
vitamin b-2 (100mg tablet, 25mg tablet, 100mg
tablet, 25mg tablet, 50mg tablet)*$0 (Tier 3)
C1
Vitamin B-6
vitamin b-6 (100mg tablet, 25mg tablet, 50mg tablet,
100mg tablet, 50mg tablet)*$0 (Tier 3)
C1
Vitamin B6
vitamin b6 (tablet)* $0 (Tier 3)C1
Vitamin B-Complex vitamin b-complex (tablet)* $0 (Tier 3)
80For Track Refered Purpose9280
92
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Vitamin C
vitamin c (powder, 0-500mg-0-0-0-tablet chewable,
250mg tablet chewable, 500mg tablet chewable,
1000mg tablet, 250mg tablet, 500mg tablet, 500mg
tablet chewable, 500mg-tablet chewable, 500mg
tablet extended-release, 500mg/5ml liquid)*
$0 (Tier 3)
C1
Vitamin C Drops vitamin c drops (lozenge)* $0 (Tier 3)C1
Vitamin C SR
vitamin c sr (capsule extended-release)* $0 (Tier 3)C1
Vitamin C TR
vitamin c tr (1500mg tablet extended-release, 500mg
capsule extended-release, 500mg tablet extended-
release)*
$0 (Tier 3)
C1
Vitamin C/Rose Hips vitamin c/rose hips (1000mg tablet, 1000mg-tablet,
500mg tablet, 500mg-tablet, 500mg-10mg tablet,
1000mg tablet, 500mg tablet)*
$0 (Tier 3)
C1
Vitamin C/Rose Hips TR vitamin c/rose hips tr (tablet extended-release)* $0 (Tier 3)C1
Vitamin D
vitamin d (capsule)* $0 (Tier 3)C1
Vitamin D3
vitamin d3 (liquid)* $0 (Tier 3)C1
Vitamin E
vitamin e (1000unit capsule, 100unit capsule, 200unit
capsule, 400unit capsule, 1000unit capsule, 200unit
capsule, 400unit capsule, 100unit/0.25ml oil)*
$0 (Tier 3)
C1
Vitamin E Blend vitamin e blend (capsule)* $0 (Tier 3)C1
Vitamin E Water Dispersible vitamin e water dispersible (capsule)* $0 (Tier 3)C1
Vitamin E Water Soluble vitamin e water soluble (1000unit capsule, 400unit
capsule, 400unit capsule)*$0 (Tier 3)
C1
Vitamin E/D-Alpha vitamin e/d-alpha (1000unit capsule, 200unit
capsule, 400unit capsule, 400unit capsule)*$0 (Tier 3)
C1
Vitamin E/D-Alpha Natural vitamin e/d-alpha natural (capsule)* $0 (Tier 3)C1
Vitamin E/Dl-Alpha vitamin e/dl-alpha (capsule)* $0 (Tier 3)C1
Vitamin E-400
vitamin e-400 (capsule)* $0 (Tier 3)C1
Vitamin K1
vitamin k1 (injection)* $0 (Tier 3)C1
Vitamins & Minerals vitamins & minerals (tablet)* $0 (Tier 3)C1
Vitamins for Hair
vitamins for hair (tablet)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
81For Track Refered Purpose9381
93
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Vitatrum
vitatrum
(60mg-0-45mcg-108mg-10mg-50mg-400unit-20mcg-
2mg-6mcg-18mg-400mcg-40mg-1mg-20mg-10unit-1
50mcg-2mg-1.7mg-20mg-1.5mg-60unit-3500unit-15m
g tablet chewable,
90mg-0-30mcg-200mg-10mg-109mg-72mg-400unit-3
5mcg-0.9mg-6mcg-18mg-500mcg-250mcg-300mcg-1
00mg-2.3mg-20mg-5mcg-25mcg-80mg-150mcg-2mg
-1.7mg-2mg-150mcg-10mcg-45mcg-55mcg-10mcg-1.
5mg-30unit-3500unit-11mg tablet)*
$0 (Tier 3)
C1
Vitrum 50+ Senior Multi vitrum 50+ senior multi (tablet)* $0 (Tier 3)C1
VP-PNV-DHA
vp-pnv-dha (capsule) $1.25-$3.40 (Tier 1)C1
Womens Daily Formula womens daily formula (tablet)* $0 (Tier 3)C1
Womens Daily Formula/Folic Acid/Calcium/Iron
womens daily formula/folic acid/calcium/iron
(tablet)*$0 (Tier 3)
C1
Womens One Daily womens one daily (tablet)* $0 (Tier 3)C1
Yelets Teenage Formula yelets teenage formula (tablet)* $0 (Tier 3)C1
Zinc
zinc (100mg-50mg-500unit-15mg lozenge)* $0 (Tier 3)C1
Zoo Friends
zoo friends (tablet chewable)* $0 (Tier 3)A1
Gastrointestinal Agents
B1
Antispasmodics, GastrointestinalC1
Cuvposa
CUVPOSA (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Dicyclomine HCl dicyclomine hcl (10mg capsule, 20mg tablet) $1.25-$3.40 (Tier 1)C1
Dicyclomine HCl dicyclomine hcl (10mg/5ml oral solution) $1.25-$3.40 (Tier 1)C1
Methscopolamine Bromide methscopolamine bromide (tablet) $1.25-$3.40 (Tier 1)
B1
Gastrointestinal Agents, OtherC1
Acid Gone
acid gone (suspension)* $0 (Tier 3)C1
Actidose/Sorbitol actidose/sorbitol (liquid)* $0 (Tier 3)
82For Track Refered Purpose9482
94
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Almacone
almacone (200mg-200mg-25mg tablet chewable,
200mg/5ml-200mg/5ml-20mg/5ml suspension)*$0 (Tier 3)
C1
Almacone Double Strength almacone double strength (suspension)* $0 (Tier 3)C1
Aluminum Hydroxide aluminum hydroxide (suspension)* $0 (Tier 3)C1
Antacid Calcium Extra Strength antacid calcium extra strength (tablet chewable)* $0 (Tier 3)C1
Antacid Calcium Regular Strength antacid calcium regular strength (tablet chewable)* $0 (Tier 3)C1
Antacid Extra Strength antacid extra strength (tablet chewable)* $0 (Tier 3)C1
Antacid Maximum Strength antacid maximum strength (suspension)* $0 (Tier 3)C1
Antacid Plus Anti-Gas Relief antacid plus anti-gas relief (suspension)* $0 (Tier 3)C1
Anti-Diarrheal
anti-diarrheal (otc only) (tablet)* $0 (Tier 3)C1
Bismatrol
bismatrol (262mg tablet chewable, 262mg/15ml
suspension)*$0 (Tier 3)
C1
Bismatrol Maximum Strength bismatrol maximum strength (suspension)* $0 (Tier 3)C1
Calcium Antacid
calcium antacid (tablet chewable)* $0 (Tier 3)C1
Calcium Antacid Extra Strength calcium antacid extra strength (tablet chewable)* $0 (Tier 3)C1
Calcium Carbonate calcium carbonate (500mg tablet chewable)* $0 (Tier 3)C1
Cal-Gest Antacid
cal-gest antacid (tablet chewable)* $0 (Tier 3)C1
Chenodal
chenodal (tablet) $1.25-$3.40 (Tier 1)C1
Cromolyn Sodium cromolyn sodium (rx only) (100mg/5ml concentrate) $1.25-$3.40 (Tier 1)C1
Diphenoxylate/Atropine diphenoxylate/atropine (2.5mg-0.025mg tablet,
2.5mg-0.025mg/5ml liquid)$1.25-$3.40 (Tier 1)
C1
Gas Relief
gas relief (180mg capsule, 20mg/0.3ml suspension,
80mg tablet chewable)*$0 (Tier 3)
C1
Gas Relief Extra Strength gas relief extra strength (capsule)* $0 (Tier 3)C1
Gas Relief Maximum Strength gas relief maximum strength (tablet chewable)* $0 (Tier 3)C1
Gattex
GATTEX (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
GNP Antacid Anti-Gas gnp antacid anti-gas (suspension)* $0 (Tier 3)C1
GNP Masanti Maximum Strength gnp masanti maximum strength (suspension)* $0 (Tier 3)C1
GNP Masanti Regular Strength gnp masanti regular strength (suspension)* $0 (Tier 3)C1
HM Magnesium
hm magnesium (tablet)* $0 (Tier 3)C1
Infants Gas Relief infants gas relief (suspension)* $0 (Tier 3)C1
Infants Simethicone infants simethicone (suspension)* $0 (Tier 3)C1
Kao-Tin
kao-tin (suspension)* $0 (Tier 3)C1
Loperamide HCl loperamide hcl (otc only) (1mg/5ml liquid, 1mg/
7.5ml suspension)*$0 (Tier 3)
C1
Loperamide HCl loperamide hcl (rx only) (capsule) $1.25-$3.40 (Tier 1)C1
Magnesium
magnesium (500mg capsule)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
83For Track Refered Purpose9583
95
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Magnesium Oxide magnesium oxide (400mg tablet, 420mg tablet)* $0 (Tier 3)C1
Mi-Acid
mi-acid (suspension)* $0 (Tier 3)C1
Mi-Acid Gas Relief mi-acid gas relief (tablet chewable)* $0 (Tier 3)C1
Mi-Acid Maximum Strength mi-acid maximum strength (suspension)* $0 (Tier 3)C1
Mintox Maximum Strength mintox maximum strength (suspension)* $0 (Tier 3)C1
Myalept
MYALEPT (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Peptic Relief
peptic relief (tablet chewable)* $0 (Tier 3)C1
QC Anti-Diarrheal qc anti-diarrheal (otc only) (tablet)* $0 (Tier 3)C1
Relistor
RELISTOR (12MG/0.6ML INJECTION, 8MG/0.4ML INJECTION)
$3.80-$8.50 (Tier 2) PAC1
Relistor
RELISTOR (150MG TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Rulox
rulox (suspension)* $0 (Tier 3)C1
Serostim
SEROSTIM (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Simethicone
simethicone (capsule)* $0 (Tier 3)C1
SM Antacid Anti-Gas sm antacid anti-gas (suspension)* $0 (Tier 3)C1
SM Antacid/Anti-Gas sm antacid/anti-gas (suspension)* $0 (Tier 3)C1
SM Anti-Diarrheal sm anti-diarrheal (otc only) (tablet)* $0 (Tier 3)C1
Sodium Bicarbonate sodium bicarbonate (otc only) (tablet)* $0 (Tier 3)C1
Ursodiol
ursodiol (250mg tablet, 500mg tablet, 300mg
capsule)$1.25-$3.40 (Tier 1)
C1
Zorbtive
ZORBTIVE (INJECTION) $3.80-$8.50 (Tier 2) PA, LAB1
Histamine2 (H2) Receptor AntagonistsC1
Acid Reducer Maximum Strength acid reducer maximum strength (otc only) (tablet)* $0 (Tier 3)C1
Cimetidine
cimetidine (tablet) $1.25-$3.40 (Tier 1)C1
Cimetidine HCl
cimetidine hcl (rx only) (oral solution) $1.25-$3.40 (Tier 1)C1
Famotidine
famotidine (otc only) (tablet)* $0 (Tier 3)C1
Famotidine
famotidine (rx only) (20mg tablet, 40mg tablet) $1.25-$3.40 (Tier 1)C1
Ranitidine 150 Maximum Strength ranitidine 150 maximum strength (otc only) (tablet)* $0 (Tier 3)C1
Ranitidine 75
ranitidine 75 (tablet)* $0 (Tier 3)
84For Track Refered Purpose9684
96
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Ranitidine HCl
ranitidine hcl (150mg tablet, 300mg tablet) $1.25-$3.40 (Tier 1)C1
Ranitidine Maximum Strength ranitidine maximum strength (otc only) (tablet)* $0 (Tier 3)
B1
Irritable Bowel Syndrome AgentsC1
Alosetron HCl
alosetron hcl (tablet) $1.25-$3.40 (Tier 1) PAC1
Amitiza
AMITIZA (CAPSULE) $3.80-$8.50 (Tier 2) QLC1
Linzess
LINZESS (CAPSULE) $3.80-$8.50 (Tier 2) QLC1
Xifaxan
XIFAXAN (TABLET) $3.80-$8.50 (Tier 2) PAB1
LaxativesC1
Bisacodyl EC
bisacodyl ec (tablet delayed-release)* $0 (Tier 3)C1
Biscolax
biscolax (suppository)* $0 (Tier 3)C1
Clenpiq
CLENPIQ (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Constulose
constulose (oral solution) $1.25-$3.40 (Tier 1)C1
CVS Laxative Dietary Supplement cvs laxative dietary supplement (tablet)* $0 (Tier 3)C1
Doc-Q-Lace
doc-q-lace (capsule)* $0 (Tier 3)C1
Docusate Sodium & Senna Stimulant Laxative/Stool Softener
docusate sodium & senna stimulant laxative/stool
softener (tablet)*$0 (Tier 3)
C1
Docusol Kids
docusol kids (enema)* $0 (Tier 3)C1
Docusol Plus Mini-Enema docusol plus mini-enema* $0 (Tier 3)C1
DOK
dok (100mg capsule, 100mg tablet)* $0 (Tier 3)C1
DOK PLUS
dok plus (tablet)* $0 (Tier 3)C1
Enema Ready-To-Use enema ready-to-use* $0 (Tier 3)C1
Enemeez Mini
enemeez mini (enema)* $0 (Tier 3)C1
Enemeez Plus
enemeez plus (enema)* $0 (Tier 3)C1
Enulose
enulose (oral solution) $1.25-$3.40 (Tier 1)C1
Fiber Laxative
fiber laxative (capsule)* $0 (Tier 3)C1
Fiber Tabs
fiber tabs (tablet)* $0 (Tier 3)C1
Fiber-Lax
fiber-lax (tablet)* $0 (Tier 3)C1
Fleet Pediatric
fleet pediatric (enema)* $0 (Tier 3)C1
GaviLyte-C
gavilyte-c (oral solution) $1.25-$3.40 (Tier 1)C1
GaviLyte-G
gavilyte-g (oral solution) $1.25-$3.40 (Tier 1)C1
GaviLyte-N/Flavor Pack gavilyte-n/flavor pack (oral solution) $1.25-$3.40 (Tier 1)C1
Generlac
generlac (oral solution) $1.25-$3.40 (Tier 1)C1
Lactulose
lactulose (10gm/15ml oral solution) $1.25-$3.40 (Tier 1)C1
Laxative
laxative (suppository)* $0 (Tier 3)C1
Milk of Magnesia milk of magnesia (suspension)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
85For Track Refered Purpose9785
97
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Milk of Magnesia Concentrate milk of magnesia concentrate (suspension)* $0 (Tier 3)C1
Natural Fiber Therapy natural fiber therapy (powder)* $0 (Tier 3)C1
PEG 3350
peg 3350 (otc only) (packet)* $0 (Tier 3)C1
PEG 3350
peg 3350 (otc only) (powder)* $0 (Tier 3)C1
PEG 3350/Electrolytes peg 3350/electrolytes (oral solution) (generic colyte) $1.25-$3.40 (Tier 1)C1
PEG-3350/Electrolytes peg-3350/electrolytes (oral solution) (generic
golytely)$1.25-$3.40 (Tier 1)
C1
PEG-3350/NaCl/Na Bicarbonate/KCl peg-3350/nacl/na bicarbonate/kcl (oral solution)
(generic nulytely)$1.25-$3.40 (Tier 1)
C1
Phillips
phillips (tablet)* $0 (Tier 3)C1
Sani-Supp Adult sani-supp adult (suppository)* $0 (Tier 3)C1
Sani-Supp Pediatric sani-supp pediatric (suppository)* $0 (Tier 3)C1
Senexon
senexon (8.6mg tablet)* $0 (Tier 3)C1
Senexon-S
senexon-s (tablet)* $0 (Tier 3)C1
Senna
senna (8.6mg tablet, 8.8mg/5ml syrup)* $0 (Tier 3)C1
Senna Plus
senna plus (tablet)* $0 (Tier 3)C1
Senna-Lax
senna-lax (tablet)* $0 (Tier 3)C1
Stimulant Laxative stimulant laxative (tablet delayed-release)* $0 (Tier 3)C1
Stool Softener
stool softener (capsule)* $0 (Tier 3)C1
Suprep Bowel Prep Kit SUPREP BOWEL PREP KIT (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
TriLyte
trilyte (oral solution) $1.25-$3.40 (Tier 1)B1
ProtectantsC1
Carafate
CARAFATE (1GM/10ML SUSPENSION) $3.80-$8.50 (Tier 2)C1
Misoprostol
misoprostol (tablet) $1.25-$3.40 (Tier 1)C1
Sucralfate
sucralfate (tablet) $1.25-$3.40 (Tier 1)B1
Proton Pump InhibitorsC1
Esomeprazole Magnesium esomeprazole magnesium (otc only) (capsule
delayed-release)*$0 (Tier 3)
86For Track Refered Purpose9886
98
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Esomeprazole Magnesium esomeprazole magnesium (rx only) (capsule delayed-
release) (generic nexium)$1.25-$3.40 (Tier 1) QL
C1
GNP Omeprazole gnp omeprazole (otc only) (tablet delayed-release)* $0 (Tier 3)C1
Heartburn Treatment 24 Hour heartburn treatment 24 hour (otc only) (capsule
delayed-release)*$0 (Tier 3)
C1
Lansoprazole
lansoprazole (otc only) (capsule delayed-release)* $0 (Tier 3)C1
Lansoprazole
lansoprazole (rx only) (15mg capsule delayed-
release, 30mg capsule delayed-release)$1.25-$3.40 (Tier 1) QL
C1
Nexium
NEXIUM (10MG PACKET, 2.5MG PACKET, 20MG PACKET, 40MG PACKET, 5MG PACKET)
$3.80-$8.50 (Tier 2)C1
Nexium
NEXIUM (20MG CAPSULE DELAYED-RELEASE, 40MG CAPSULE DELAYED-RELEASE)
$3.80-$8.50 (Tier 2) QLC1
Omeprazole
omeprazole (otc only) (20mg tablet delayed-release)* $0 (Tier 3)C1
Omeprazole
omeprazole (rx only) (10mg capsule delayed-release) $1.25-$3.40 (Tier 1) QLC1
Omeprazole
omeprazole (rx only) (20mg capsule delayed-release,
40mg capsule delayed-release)$1.25-$3.40 (Tier 1)
C1
Omeprazole Magnesium omeprazole magnesium (capsule delayed-release)* $0 (Tier 3)C1
Pantoprazole Sodium pantoprazole sodium (20mg tablet delayed-release,
40mg tablet delayed-release)$1.25-$3.40 (Tier 1) QL
C1
Rabeprazole Sodium rabeprazole sodium (tablet delayed-release) $1.25-$3.40 (Tier 1)
A1
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
B1
Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentC1
Aralast NP
ARALAST NP (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Cholbam
CHOLBAM (CAPSULE) $3.80-$8.50 (Tier 2) PAC1
Creon
CREON (CAPSULE DELAYED-RELEASE) $3.80-$8.50 (Tier 2)C1
Cystadane
CYSTADANE (POWDER) $3.80-$8.50 (Tier 2)C1
Cystagon
CYSTAGON (CAPSULE) $3.80-$8.50 (Tier 2) LAC1
Glassia
GLASSIA (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Kuvan
KUVAN (100MG PACKET, 500MG PACKET, 100MG TABLET SOLUBLE)
$3.80-$8.50 (Tier 2) LAC1
Miglustat
miglustat (capsule) $1.25-$3.40 (Tier 1) PA, LAC1
Ocaliva
OCALIVA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Orfadin
ORFADIN (10MG CAPSULE, 20MG CAPSULE, 2MG CAPSULE, 5MG CAPSULE, 4MG/ML SUSPENSION)
$3.80-$8.50 (Tier 2) LAC1
Prolastin-C
PROLASTIN-C (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Ravicti
RAVICTI (LIQUID) $3.80-$8.50 (Tier 2) QL, LAC1
Sodium Phenylbutyrate sodium phenylbutyrate (powder, 500mg tablet) $1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
87For Track Refered Purpose9987
99
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Sucraid
SUCRAID (ORAL SOLUTION) $3.80-$8.50 (Tier 2) LAC1
Zemaira
ZEMAIRA (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Zenpep
ZENPEP (CAPSULE DELAYED-RELEASE) $3.80-$8.50 (Tier 2)A1
Genitourinary Agents
B1
Antispasmodics, UrinaryC1
Myrbetriq
MYRBETRIQ (TABLET EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2)C1
Oxybutynin Chloride oxybutynin chloride (5mg tablet immediate-release,
5mg/5ml syrup)$1.25-$3.40 (Tier 1)
C1
Oxybutynin Chloride ER oxybutynin chloride er (tablet extended-release 24
hour)$1.25-$3.40 (Tier 1) QL
C1
Solifenacin Succinate solifenacin succinate (tablet) $1.25-$3.40 (Tier 1) QLC1
Vesicare
VESICARE (TABLET) $3.80-$8.50 (Tier 2) QLB1
Benign Prostatic Hypertrophy AgentsC1
Alfuzosin HCl ER alfuzosin hcl er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1)C1
Dutasteride
dutasteride (capsule) $1.25-$3.40 (Tier 1) QLC1
Finasteride
finasteride (5mg tablet) (generic proscar) $1.25-$3.40 (Tier 1)C1
Rapaflo
RAPAFLO (CAPSULE) $3.80-$8.50 (Tier 2) QLC1
Silodosin
silodosin (capsule) $1.25-$3.40 (Tier 1) QLC1
Tamsulosin HCl
tamsulosin hcl (capsule) $1.25-$3.40 (Tier 1)C1
Terazosin HCl
terazosin hcl (capsule) $1.25-$3.40 (Tier 1)B1
Genitourinary Agents, OtherC1
Bethanechol Chloride bethanechol chloride (tablet) $1.25-$3.40 (Tier 1)C1
Cuprimine
CUPRIMINE (CAPSULE) $3.80-$8.50 (Tier 2) PAC1
Depen Titratabs DEPEN TITRATABS (TABLET) $3.80-$8.50 (Tier 2)C1
Elmiron
ELMIRON (CAPSULE) $3.80-$8.50 (Tier 2)C1
Lithostat
LITHOSTAT (TABLET) $3.80-$8.50 (Tier 2)C1
Penicillamine
penicillamine (capsule) $1.25-$3.40 (Tier 1) PA
88For Track Refered Purpose10088
100
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useA1
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
B1
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)C1
Ala Cort
ala cort (rx only) (cream) $1.25-$3.40 (Tier 1)C1
Alclometasone Dipropionate alclometasone dipropionate (0.05% cream, 0.05%
ointment)$1.25-$3.40 (Tier 1)
C1
Augmented Betamethasone Dipropionate
augmented betamethasone dipropionate (0.05%
cream, 0.05% gel, 0.05% lotion, 0.05% ointment)$1.25-$3.40 (Tier 1)
C1
Betamethasone Dipropionate betamethasone dipropionate (0.05% cream, 0.05%
lotion, 0.05% ointment)$1.25-$3.40 (Tier 1)
C1
Betamethasone Valerate betamethasone valerate (0.1% cream, 0.1% lotion,
0.1% ointment)$1.25-$3.40 (Tier 1)
C1
Clobetasol Propionate clobetasol propionate (0.05% cream, 0.05% external
solution, 0.05% gel, 0.05% ointment, 0.05%
shampoo)
$1.25-$3.40 (Tier 1)
C1
Clobetasol Propionate Emollient clobetasol propionate emollient (0.05% cream) $1.25-$3.40 (Tier 1)C1
Cortisone Acetate cortisone acetate (tablet) $1.25-$3.40 (Tier 1)C1
Desonide
desonide (0.05% ointment) $1.25-$3.40 (Tier 1)C1
Desoximetasone desoximetasone (0.05% cream, 0.25% cream) $1.25-$3.40 (Tier 1)C1
Dexamethasone
dexamethasone (0.5mg tablet, 0.75mg tablet, 1.5mg
tablet, 1mg tablet, 2mg tablet, 4mg tablet, 6mg
tablet, 0.5mg/5ml elixir)
$1.25-$3.40 (Tier 1)
C1
Dexamethasone Intensol dexamethasone intensol (1mg/ml concentrate) $1.25-$3.40 (Tier 1)C1
Fludrocortisone Acetate fludrocortisone acetate (tablet) $1.25-$3.40 (Tier 1)C1
Fluocinolone Acetonide fluocinolone acetonide (0.01% cream, 0.01% external
solution, 0.025% cream, 0.025% ointment)$1.25-$3.40 (Tier 1)
C1
Fluocinonide
fluocinonide (0.05% external solution, 0.05% gel,
0.05% ointment)$1.25-$3.40 (Tier 1)
C1
Fluocinonide Emulsified Base fluocinonide emulsified base (cream) $1.25-$3.40 (Tier 1)C1
Fluticasone Propionate fluticasone propionate (rx only) (0.005% ointment,
0.05% cream)$1.25-$3.40 (Tier 1)
C1
Halobetasol Propionate halobetasol propionate (0.05% cream, 0.05%
ointment)$1.25-$3.40 (Tier 1)
C1
Hydrocortisone
hydrocortisone (otc only) (0.5% cream, 1% cream,
0.5% ointment, 1% ointment)*$0 (Tier 3)
C1
Hydrocortisone
hydrocortisone (rx only) (1% cream, 2.5% cream, 1%
ointment, 2.5% ointment, 10mg tablet, 20mg tablet,
5mg tablet, 2.5% lotion)
$1.25-$3.40 (Tier 1)
C1
Hydrocortisone Butyrate hydrocortisone butyrate (0.1% ointment) $1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
89For Track Refered Purpose10189
101
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Hydrocortisone Valerate hydrocortisone valerate (0.2% cream, 0.2% ointment) $1.25-$3.40 (Tier 1)C1
Methylprednisolone methylprednisolone (tablet) $1.25-$3.40 (Tier 1)C1
Methylprednisolone Dose Pack methylprednisolone dose pack (tablet therapy pack) $1.25-$3.40 (Tier 1)C1
Mometasone Furoate mometasone furoate (0.1% cream, 0.1% external
solution, 0.1% ointment)$1.25-$3.40 (Tier 1)
C1
Prednicarbate
prednicarbate (0.1% cream, 0.1% ointment) $1.25-$3.40 (Tier 1)C1
Prednisolone
prednisolone (15mg/5ml oral solution) $1.25-$3.40 (Tier 1)C1
Prednisolone Sodium Phosphate prednisolone sodium phosphate (25mg/5ml oral
solution, 5mg/5ml oral solution)$1.25-$3.40 (Tier 1)
C1
Prednisone
prednisone (10mg tablet therapy pack, 5mg tablet
therapy pack, 10mg tablet, 1mg tablet, 2.5mg tablet,
20mg tablet, 50mg tablet, 5mg tablet, 5mg/5ml oral
solution)
$1.25-$3.40 (Tier 1)
C1
Prednisone Intensol prednisone intensol (5mg/ml concentrate) $1.25-$3.40 (Tier 1)C1
Triamcinolone Acetonide triamcinolone acetonide (rx only) (0.025% cream,
0.1% cream, 0.5% cream, 0.025% lotion, 0.1% lotion,
0.025% ointment, 0.1% ointment, 0.5% ointment)
$1.25-$3.40 (Tier 1)
C1
Triderm
triderm (cream) $1.25-$3.40 (Tier 1)A1
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
B1
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)C1
Desmopressin Acetate desmopressin acetate (0.01% nasal spray solution,
0.1mg tablet, 0.2mg tablet)$1.25-$3.40 (Tier 1)
C1
Genotropin
GENOTROPIN (12MG INJECTION, 5MG INJECTION) $3.80-$8.50 (Tier 2) PAC1
Genotropin Miniquick GENOTROPIN MINIQUICK (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Humatrope
HUMATROPE (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Humatrope Combo Pack HUMATROPE COMBO PACK (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Increlex
INCRELEX (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Norditropin FlexPro NORDITROPIN FLEXPRO (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Nutropin AQ
NUTROPIN AQ (INJECTION) $3.80-$8.50 (Tier 2) PA
90For Track Refered Purpose10290
102
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Saizen
SAIZEN (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Saizenprep Reconstitution Kit SAIZENPREP RECONSTITUTION KIT (INJECTION) $3.80-$8.50 (Tier 2) PA, LA
A1
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
B1
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)C1
Korlym
KORLYM (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAA1
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
B1
AndrogensC1
Anadrol-50
ANADROL-50 (TABLET) $3.80-$8.50 (Tier 2) PAC1
Androderm
ANDRODERM (PATCH 24 HOUR) $3.80-$8.50 (Tier 2) QLC1
Danazol
danazol (capsule) $1.25-$3.40 (Tier 1)C1
Oxandrolone
oxandrolone (tablet) $1.25-$3.40 (Tier 1) PA, QLC1
Testosterone
testosterone (20.25mg/1.25gm 1.62% gel, 40.5mg/
2.5gm 1.62% gel, 25mg/2.5gm 1% gel, 50mg/5gm
1% gel), testosterone pump (1.62% gel)
$1.25-$3.40 (Tier 1)
C1
Testosterone Cypionate testosterone cypionate (injection) $1.25-$3.40 (Tier 1)C1
Testosterone Enanthate testosterone enanthate (injection) $1.25-$3.40 (Tier 1)C1
Testosterone Pump testosterone pump (1% gel) $1.25-$3.40 (Tier 1)
B1
EstrogensC1
Altavera
altavera (tablet) $1.25-$3.40 (Tier 1)C1
Alyacen 1/35
alyacen 1/35 (tablet) $1.25-$3.40 (Tier 1)C1
Amethia
amethia (tablet) $1.25-$3.40 (Tier 1)C1
Amethia Lo
amethia lo (tablet) $1.25-$3.40 (Tier 1)C1
Apri
apri (tablet) $1.25-$3.40 (Tier 1)C1
Aranelle
aranelle (tablet) $1.25-$3.40 (Tier 1)C1
Ashlyna
ashlyna (tablet) $1.25-$3.40 (Tier 1)C1
Aubra
aubra (tablet) $1.25-$3.40 (Tier 1)C1
Aviane
aviane (tablet) $1.25-$3.40 (Tier 1)C1
Balziva
balziva (tablet) $1.25-$3.40 (Tier 1)C1
Blisovi 24 Fe
blisovi 24 fe (tablet) $1.25-$3.40 (Tier 1)C1
Blisovi Fe 1.5/30 blisovi fe 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1
Briellyn
briellyn (tablet) $1.25-$3.40 (Tier 1)C1
Camrese Lo
camrese lo (tablet) $1.25-$3.40 (Tier 1)C1
Caziant
caziant (tablet) $1.25-$3.40 (Tier 1)C1
Climara Pro
CLIMARA PRO (PATCH WEEKLY) $3.80-$8.50 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
91For Track Refered Purpose10391
103
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Cryselle-28
cryselle-28 (tablet) $1.25-$3.40 (Tier 1)C1
Cyclafem
cyclafem (tablet) $1.25-$3.40 (Tier 1)C1
Cyred Eq
cyred eq (tablet) $1.25-$3.40 (Tier 1)C1
Delyla
delyla (tablet) $1.25-$3.40 (Tier 1)C1
Desogestrel/Ethinyl Estradiol desogestrel/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1
Drospirenone/Ethinyl Estradiol drospirenone/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1
Duavee
DUAVEE (TABLET) $3.80-$8.50 (Tier 2)C1
Elestrin
ELESTRIN (GEL) $3.80-$8.50 (Tier 2)C1
Emoquette
emoquette (tablet) $1.25-$3.40 (Tier 1)C1
Enpresse-28
enpresse-28 (tablet) $1.25-$3.40 (Tier 1)C1
Enskyce
enskyce (tablet) $1.25-$3.40 (Tier 1)C1
Estarylla
estarylla (tablet) $1.25-$3.40 (Tier 1)C1
Estradiol
estradiol (0.025mg/24hr patch weekly, 0.05mg/24hr
patch weekly, 0.06mg/24hr patch weekly, 0.075mg/
24hr patch weekly, 0.1mg/24hr patch weekly,
37.5mcg/24hr patch weekly)
$1.25-$3.40 (Tier 1) QL
C1
Estradiol
estradiol (0.5mg tablet, 1mg tablet, 2mg tablet)
(generic estrace)$1.25-$3.40 (Tier 1)
C1
Estradiol Valerate estradiol valerate (injection) $1.25-$3.40 (Tier 1)C1
Estring
ESTRING (RING) $3.80-$8.50 (Tier 2)C1
Ethynodiol Diacetate/Ethinyl Estradiol
ethynodiol diacetate/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1
Falmina
falmina (tablet) $1.25-$3.40 (Tier 1)C1
Fayosim
fayosim (tablet) $1.25-$3.40 (Tier 1)C1
Femynor
femynor (tablet) $1.25-$3.40 (Tier 1)C1
Fyavolv
fyavolv (tablet) $1.25-$3.40 (Tier 1)C1
Gianvi
gianvi (tablet) $1.25-$3.40 (Tier 1)C1
Hailey 24 Fe
hailey 24 fe (tablet) $1.25-$3.40 (Tier 1)C1
Imvexxy Maintenance Pack IMVEXXY MAINTENANCE PACK (INSERT) $3.80-$8.50 (Tier 2) PA, QLC1
Imvexxy Starter Pack IMVEXXY STARTER PACK (INSERT) $3.80-$8.50 (Tier 2) PA, QL
92For Track Refered Purpose10492
104
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Introvale
introvale (tablet) $1.25-$3.40 (Tier 1)C1
Isibloom
isibloom (tablet) $1.25-$3.40 (Tier 1)C1
Jasmiel
jasmiel (tablet) $1.25-$3.40 (Tier 1)C1
Jinteli
jinteli (tablet) $1.25-$3.40 (Tier 1)C1
Juleber
juleber (tablet) $1.25-$3.40 (Tier 1)C1
Junel 1.5/30
junel 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1
Junel 1/20
junel 1/20 (tablet) $1.25-$3.40 (Tier 1)C1
Junel Fe 1.5/30 junel fe 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1
Junel Fe 1/20
junel fe 1/20 (tablet) $1.25-$3.40 (Tier 1)C1
Junel Fe 24
junel fe 24 (tablet) $1.25-$3.40 (Tier 1)C1
Kaitlib Fe
kaitlib fe (tablet chewable) $1.25-$3.40 (Tier 1)C1
Kariva
kariva (tablet) $1.25-$3.40 (Tier 1)C1
Kelnor 1/35
kelnor 1/35 (tablet) $1.25-$3.40 (Tier 1)C1
Kelnor 1/50
kelnor 1/50 (tablet) $1.25-$3.40 (Tier 1)C1
Kurvelo
kurvelo (tablet) $1.25-$3.40 (Tier 1)C1
LARIN 1.5/30
larin 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1
LARIN 1/20
larin 1/20 (tablet) $1.25-$3.40 (Tier 1)C1
LARIN Fe 1.5/30 larin fe 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1
LARIN Fe 1/20
larin fe 1/20 (tablet) $1.25-$3.40 (Tier 1)C1
Larissia
larissia (tablet) $1.25-$3.40 (Tier 1)C1
Layolis Fe
LAYOLIS FE (TABLET CHEWABLE) $3.80-$8.50 (Tier 2)C1
Leena
leena (tablet) $1.25-$3.40 (Tier 1)C1
Lessina
lessina (tablet) $1.25-$3.40 (Tier 1)C1
Levonest
levonest (tablet) $1.25-$3.40 (Tier 1)C1
Levonorgestrel and Ethinyl Estradiol
levonorgestrel and ethinyl estradiol (90mcg-20mcg
tablet)$1.25-$3.40 (Tier 1)
C1
Levonorgestrel/Ethinyl Estradiol levonorgestrel/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1
Levora 0.15/30-28 levora 0.15/30-28 (tablet) $1.25-$3.40 (Tier 1)C1
Loryna
loryna (tablet) $1.25-$3.40 (Tier 1)C1
Low-Ogestrel
low-ogestrel (tablet) $1.25-$3.40 (Tier 1)C1
Lutera
lutera (tablet) $1.25-$3.40 (Tier 1)C1
Marlissa
marlissa (tablet) $1.25-$3.40 (Tier 1)C1
Melodetta 24 Fe melodetta 24 fe (tablet chewable) $1.25-$3.40 (Tier 1)C1
Menest
menest (tablet) $1.25-$3.40 (Tier 1)C1
Mibelas 24 Fe
mibelas 24 fe (tablet chewable) $1.25-$3.40 (Tier 1)C1
Microgestin 1.5/30 microgestin 1.5/30 (tablet) $1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
93For Track Refered Purpose10593
105
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Microgestin 1/20
microgestin 1/20 (tablet) $1.25-$3.40 (Tier 1)C1
Microgestin Fe
microgestin fe (tablet) $1.25-$3.40 (Tier 1)C1
Microgestin Fe 1.5/30 microgestin fe 1.5/30 (tablet) $1.25-$3.40 (Tier 1)C1
Mili
mili (tablet) $1.25-$3.40 (Tier 1)C1
Necon 0.5/35-28 necon 0.5/35-28 (tablet) $1.25-$3.40 (Tier 1)C1
Nikki
nikki (tablet) $1.25-$3.40 (Tier 1)C1
Norethindrone Acetate/Ethinyl Estradiol
norethindrone acetate/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1
Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate
norethindrone acetate/ethinyl estradiol/ferrous
fumarate (tablet)$1.25-$3.40 (Tier 1)
C1
Norethindrone/Ethinyl Estradiol/Ferrous Fumarate
norethindrone/ethinyl estradiol/ferrous fumarate
(tablet chewable)$1.25-$3.40 (Tier 1)
C1
Norgestimate/Ethinyl Estradiol norgestimate/ethinyl estradiol (tablet) $1.25-$3.40 (Tier 1)C1
Nortrel 0.5/35
nortrel 0.5/35 (28) (tablet) $1.25-$3.40 (Tier 1)C1
Nortrel 1/35
nortrel 1/35 (tablet) $1.25-$3.40 (Tier 1)C1
Nortrel 7/7/7
nortrel 7/7/7 (tablet) $1.25-$3.40 (Tier 1)C1
NuvaRing
NUVARING (RING) $3.80-$8.50 (Tier 2)C1
Ocella
ocella (tablet) $1.25-$3.40 (Tier 1)C1
Ogestrel
ogestrel (tablet) $1.25-$3.40 (Tier 1)C1
Orsythia
orsythia (tablet) $1.25-$3.40 (Tier 1)C1
Pimtrea
pimtrea (tablet) $1.25-$3.40 (Tier 1)C1
Pirmella 1/35
pirmella 1/35 (tablet) $1.25-$3.40 (Tier 1)C1
Portia-28
portia-28 (tablet) $1.25-$3.40 (Tier 1)C1
Premarin
PREMARIN (0.3MG TABLET, 0.45MG TABLET, 0.625MG TABLET, 0.9MG TABLET, 1.25MG TABLET)
$3.80-$8.50 (Tier 2) QLC1
Premarin
PREMARIN (VAGINAL CREAM) $3.80-$8.50 (Tier 2)C1
Premphase
PREMPHASE (TABLET) $3.80-$8.50 (Tier 2) QLC1
Prempro
PREMPRO (TABLET) $3.80-$8.50 (Tier 2) QLC1
Previfem
previfem (tablet) $1.25-$3.40 (Tier 1)C1
Reclipsen
reclipsen (tablet) $1.25-$3.40 (Tier 1)
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Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Rivelsa
rivelsa (tablet) $1.25-$3.40 (Tier 1)C1
Setlakin
setlakin (tablet) $1.25-$3.40 (Tier 1)C1
Sprintec 28
sprintec 28 (tablet) $1.25-$3.40 (Tier 1)C1
Sronyx
sronyx (tablet) $1.25-$3.40 (Tier 1)C1
Syeda
syeda (tablet) $1.25-$3.40 (Tier 1)C1
Tarina 24 Fe
tarina 24 fe (tablet) $1.25-$3.40 (Tier 1)C1
Tarina Fe 1/20
tarina fe 1/20 (tablet) $1.25-$3.40 (Tier 1)C1
Tri-Estarylla
tri-estarylla (tablet) $1.25-$3.40 (Tier 1)C1
Tri-Legest Fe
tri-legest fe (tablet) $1.25-$3.40 (Tier 1)C1
Tri-Lo-Estarylla
tri-lo-estarylla (tablet) $1.25-$3.40 (Tier 1)C1
Tri-Lo-Sprintec
tri-lo-sprintec (tablet) $1.25-$3.40 (Tier 1)C1
Tri-Mili
tri-mili (tablet) $1.25-$3.40 (Tier 1)C1
Tri-Previfem
tri-previfem (tablet) $1.25-$3.40 (Tier 1)C1
Tri-Sprintec
tri-sprintec (tablet) $1.25-$3.40 (Tier 1)C1
Tri-VyLibra
tri-vylibra (tablet) $1.25-$3.40 (Tier 1)C1
Tri-VyLibra Lo
tri-vylibra lo (tablet) $1.25-$3.40 (Tier 1)C1
Trivora-28
trivora-28 (tablet) $1.25-$3.40 (Tier 1)C1
Velivet
velivet (tablet) $1.25-$3.40 (Tier 1)C1
Vienva
vienva (tablet) $1.25-$3.40 (Tier 1)C1
Vyfemla
vyfemla (tablet) $1.25-$3.40 (Tier 1)C1
VyLibra
vylibra (tablet) $1.25-$3.40 (Tier 1)C1
WYMZYA Fe
wymzya fe (tablet chewable) $1.25-$3.40 (Tier 1)C1
Zarah
zarah (tablet) $1.25-$3.40 (Tier 1)C1
Zovia 1/35E
zovia 1/35e (tablet) $1.25-$3.40 (Tier 1)B1
ProgestinsC1
Camila
camila (tablet) $1.25-$3.40 (Tier 1)C1
Crinone
CRINONE (GEL) $3.80-$8.50 (Tier 2) PAC1
Deblitane
deblitane (tablet) $1.25-$3.40 (Tier 1)C1
Depo-Provera DEPO-PROVERA (INJECTION) $3.80-$8.50 (Tier 2)C1
Econtra EZ
econtra ez (otc only) (tablet)* $0 (Tier 3)C1
Errin
errin (tablet) $1.25-$3.40 (Tier 1)C1
Incassia
incassia (tablet) $1.25-$3.40 (Tier 1)C1
Lyza
lyza (tablet) $1.25-$3.40 (Tier 1)C1
Medroxyprogesterone Acetate medroxyprogesterone acetate (10mg tablet, 2.5mg
tablet, 5mg tablet, 150mg/ml injection)$1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
95For Track Refered Purpose10795
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Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Megestrol Acetate megestrol acetate (20mg tablet, 40mg tablet, 40mg/
ml suspension, 625mg/5ml suspension)$1.25-$3.40 (Tier 1)
C1
My Way
my way (tablet)* $0 (Tier 3)C1
Nora-BE
nora-be (tablet) $1.25-$3.40 (Tier 1)C1
Norethindrone
norethindrone (0.35mg tablet) $1.25-$3.40 (Tier 1)C1
Norethindrone Acetate norethindrone acetate (5mg tablet) $1.25-$3.40 (Tier 1)C1
Norlyroc
norlyroc (tablet) $1.25-$3.40 (Tier 1)C1
Opcicon One-Step opcicon one-step (otc only) (tablet)* $0 (Tier 3)C1
Sharobel
sharobel (tablet) $1.25-$3.40 (Tier 1)B1
Selective Estrogen Receptor Modifying AgentsC1
Osphena
OSPHENA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Raloxifene HCl
raloxifene hcl (tablet) $1.25-$3.40 (Tier 1) QLA1
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
B1
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)C1
Levothyroxine Sodium levothyroxine sodium (tablet) $1.25-$3.40 (Tier 1)C1
Levoxyl
LEVOXYL (TABLET) $3.80-$8.50 (Tier 2)C1
Liothyronine Sodium liothyronine sodium (tablet) $1.25-$3.40 (Tier 1)C1
Synthroid
SYNTHROID (TABLET) $3.80-$8.50 (Tier 2)C1
Unithroid
UNITHROID (TABLET) $3.80-$8.50 (Tier 2)A1
Hormonal Agents, Suppressant (Adrenal)
B1
Hormonal Agents, Suppressant (Adrenal)C1
Lysodren
LYSODREN (TABLET) $3.80-$8.50 (Tier 2)A1
Hormonal Agents, Suppressant (Pituitary)
B1
Hormonal Agents, Suppressant (Pituitary)C1
Cabergoline
cabergoline (tablet) $1.25-$3.40 (Tier 1)
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108
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Egrifta
EGRIFTA (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Firmagon
FIRMAGON (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Leuprolide Acetate leuprolide acetate (injection) $1.25-$3.40 (Tier 1) PAC1
Lupaneta Pack LUPANETA PACK (KIT) $3.80-$8.50 (Tier 2) PAC1
Lupron Depot LUPRON DEPOT (1-MONTH) (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Lupron Depot LUPRON DEPOT (3-MONTH) (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Lupron Depot LUPRON DEPOT (4-MONTH) (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Lupron Depot LUPRON DEPOT (6-MONTH) (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Octreotide Acetate octreotide acetate (injection) $1.25-$3.40 (Tier 1) PAC1
Signifor
SIGNIFOR (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Somatuline Depot SOMATULINE DEPOT (INJECTION) $3.80-$8.50 (Tier 2)C1
Somavert
SOMAVERT (INJECTION) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Synarel
SYNAREL (NASAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Trelstar Mixject TRELSTAR MIXJECT (INJECTION) $3.80-$8.50 (Tier 2) PA
A1
Hormonal Agents, Suppressant (Thyroid)
B1
Antithyroid AgentsC1
Methimazole
methimazole (tablet) $1.25-$3.40 (Tier 1)C1
Propylthiouracil
propylthiouracil (tablet) $1.25-$3.40 (Tier 1)A1
Immunological Agents
B1
Angioedema AgentsC1
Berinert
BERINERT (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Cinryze
CINRYZE (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Firazyr
FIRAZYR (INJECTION) $3.80-$8.50 (Tier 2) PA, QLC1
Haegarda
HAEGARDA (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Icatibant Acetate icatibant acetate (solution) $1.25-$3.40 (Tier 1) PA, QLC1
Ruconest
RUCONEST (INJECTION) $3.80-$8.50 (Tier 2) PA, LAB1
Immune SuppressantsC1
Azathioprine
azathioprine (tablet) $1.25-$3.40 (Tier 1) B/D, PAC1
Cimzia
CIMZIA (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Cyclosporine
cyclosporine (capsule) $1.25-$3.40 (Tier 1) B/D, PAC1
Cyclosporine Modified cyclosporine modified (100mg capsule, 25mg
capsule, 50mg capsule, 100mg/ml oral solution)$1.25-$3.40 (Tier 1) B/D, PA
C1
Enbrel
ENBREL (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Enbrel Mini
ENBREL MINI (INJECTION) $3.80-$8.50 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
97For Track Refered Purpose10997
109
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Enbrel SureClick ENBREL SURECLICK (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Envarsus XR
ENVARSUS XR (TABLET EXTENDED-RELEASE 24 HOUR)
$3.80-$8.50 (Tier 2) B/D, PAC1
Gengraf
gengraf (100mg capsule, 25mg capsule, 100mg/ml
oral solution)$1.25-$3.40 (Tier 1) B/D, PA
C1
Humira
HUMIRA (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Humira Pediatric Crohns Disease Starter Pack
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK (INJECTION)
$3.80-$8.50 (Tier 2) PAC1
Humira Pen
HUMIRA PEN (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Humira Pen Crohns Disease Starter Pack
HUMIRA PEN CROHNS DISEASE STARTER PACK (INJECTION)
$3.80-$8.50 (Tier 2) PAC1
Humira Pen-Psoriasis Starter HUMIRA PEN-PSORIASIS STARTER (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Kineret
KINERET (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Methotrexate
methotrexate (tablet) $1.25-$3.40 (Tier 1)C1
Methotrexate Sodium methotrexate sodium (injection) $1.25-$3.40 (Tier 1)C1
Mycophenolate Mofetil mycophenolate mofetil (200mg/ml suspension,
250mg capsule, 500mg tablet)$1.25-$3.40 (Tier 1) B/D, PA
C1
Mycophenolic Acid DR mycophenolic acid dr (tablet delayed-release) $1.25-$3.40 (Tier 1) B/D, PAC1
Orencia
ORENCIA (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Orencia Clickject ORENCIA CLICKJECT (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Prograf
PROGRAF (0.2MG PACKET, 1MG PACKET) $3.80-$8.50 (Tier 2) B/D, PAC1
Rapamune
RAPAMUNE (1MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Rasuvo
RASUVO (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Sandimmune SANDIMMUNE (100MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Simponi
SIMPONI (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Sirolimus
sirolimus (0.5mg tablet, 1mg tablet, 2mg tablet, 1mg/
ml solution)$1.25-$3.40 (Tier 1) B/D, PA
C1
Tacrolimus
tacrolimus (0.5mg capsule, 1mg capsule, 5mg
capsule)$1.25-$3.40 (Tier 1) B/D, PA
C1
Trexall
trexall (tablet) $1.25-$3.40 (Tier 1)
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110
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Xatmep
XATMEP (ORAL SOLUTION) $3.80-$8.50 (Tier 2) PAC1
Xeljanz
XELJANZ (10MG TABLET, 5MG TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Xeljanz XR
XELJANZ XR (TABLET EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2) PA, QLC1
Zortress
ZORTRESS (0.25MG TABLET, 0.5MG TABLET, 0.75MG TABLET, 1MG TABLET)
$3.80-$8.50 (Tier 2) B/D, PA
B1
Immunizing Agents, PassiveC1
Flebogamma DIF FLEBOGAMMA DIF (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Gammagard Liquid GAMMAGARD LIQUID (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Gammagard S/D IGA Less Than 1 mcg/ml
GAMMAGARD S/D IGA LESS THAN 1 MCG/ML (INJECTION)
$3.80-$8.50 (Tier 2) PAC1
Gammaked GAMMAKED (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Gammaplex GAMMAPLEX (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Gamunex-C
GAMUNEX-C (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Octagam
OCTAGAM (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Panzyga
PANZYGA (SOLUTION) $3.80-$8.50 (Tier 2) PAC1
Privigen
PRIVIGEN (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Varizig
VARIZIG (INJECTION) $3.80-$8.50 (Tier 2)B1
ImmunomodulatorsC1
Actemra
ACTEMRA (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Actemra Actpen ACTEMRA ACTPEN (SOLUTION AUTO INJECTOR) $3.80-$8.50 (Tier 2) PAC1
Actimmune
ACTIMMUNE (INJECTION) $3.80-$8.50 (Tier 2) LAC1
Arcalyst
ARCALYST (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Benlysta
BENLYSTA (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Leflunomide
leflunomide (tablet) $1.25-$3.40 (Tier 1)C1
Otezla
OTEZLA (TABLET THERAPY PACK, 30MG TABLET) $3.80-$8.50 (Tier 2) PA, LAC1
Ridaura
RIDAURA (CAPSULE) $3.80-$8.50 (Tier 2)C1
Xolair
XOLAIR (150MG INJECTION, 150MG/ML SOLUTION PREFILLED SYRINGE, 75MG/0.5ML SOLUTION PREFILLED SYRINGE)
$3.80-$8.50 (Tier 2) PA, LA
B1
VaccinesC1
ActHIB
ACTHIB (INJECTION) $3.80-$8.50 (Tier 2)C1
Adacel
ADACEL (INJECTION) $3.80-$8.50 (Tier 2)C1
BCG Vaccine BCG VACCINE (INJECTION) $3.80-$8.50 (Tier 2)C1
Bexsero
BEXSERO (INJECTION) $3.80-$8.50 (Tier 2)C1
Boostrix
BOOSTRIX (INJECTION) $3.80-$8.50 (Tier 2)C1
Daptacel
DAPTACEL (INJECTION) $3.80-$8.50 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
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Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Diphtheria/Tetanus Toxoids Adsorbed Pediatric
DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC (INJECTION)
$3.80-$8.50 (Tier 2)C1
Engerix-B
ENGERIX-B (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Gardasil 9
GARDASIL 9 (INJECTION) $3.80-$8.50 (Tier 2)C1
Havrix
HAVRIX (INJECTION) $3.80-$8.50 (Tier 2)C1
Hiberix
HIBERIX (INJECTION) $3.80-$8.50 (Tier 2)C1
Imovax Rabies IMOVAX RABIES (H.D.C.V.) (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Infanrix
INFANRIX (INJECTION) $3.80-$8.50 (Tier 2)C1
IPOL Inactivated IPV IPOL INACTIVATED IPV (INJECTION) $3.80-$8.50 (Tier 2)C1
Ixiaro
IXIARO (INJECTION) $3.80-$8.50 (Tier 2)C1
Kinrix
KINRIX (INJECTION) $3.80-$8.50 (Tier 2)C1
M-M-R II
M-M-R II (INJECTION) $3.80-$8.50 (Tier 2)C1
Menactra
MENACTRA (INJECTION) $3.80-$8.50 (Tier 2)C1
Menveo
MENVEO (INJECTION) $3.80-$8.50 (Tier 2)C1
Pediarix
PEDIARIX (INJECTION) $3.80-$8.50 (Tier 2)C1
Pedvax HIB
PEDVAX HIB (INJECTION) $3.80-$8.50 (Tier 2)C1
ProQuad
PROQUAD (INJECTION) $3.80-$8.50 (Tier 2)C1
Quadracel
QUADRACEL (INJECTION) $3.80-$8.50 (Tier 2)C1
Rabavert
RABAVERT (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Recombivax HB RECOMBIVAX HB (INJECTION) $3.80-$8.50 (Tier 2) B/D, PAC1
Rotarix
ROTARIX (SUSPENSION) $3.80-$8.50 (Tier 2)C1
RotaTeq
ROTATEQ (ORAL SOLUTION) $3.80-$8.50 (Tier 2)C1
Shingrix
SHINGRIX (INJECTION) $3.80-$8.50 (Tier 2) PAC1
Tenivac
TENIVAC (INJECTION) $3.80-$8.50 (Tier 2)C1
Tetanus/Diphtheria Toxoids-Adsorbed Adult
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT (INJECTION)
$3.80-$8.50 (Tier 2)C1
Trumenba
TRUMENBA (INJECTION) $3.80-$8.50 (Tier 2)C1
Twinrix
TWINRIX (INJECTION) $3.80-$8.50 (Tier 2)C1
Typhim Vi
TYPHIM VI (INJECTION) $3.80-$8.50 (Tier 2)
100For Track Refered Purpose112100
112
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Vaqta
VAQTA (INJECTION) $3.80-$8.50 (Tier 2)C1
Varivax
VARIVAX (INJECTION) $3.80-$8.50 (Tier 2)C1
YF-Vax
YF-VAX (INJECTION) $3.80-$8.50 (Tier 2)C1
Zostavax
ZOSTAVAX (INJECTION) $3.80-$8.50 (Tier 2) PAA1
Inflammatory Bowel Disease Agents
B1
AminosalicylatesC1
Apriso
APRISO (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2) QLC1
Balsalazide Disodium balsalazide disodium (capsule) $1.25-$3.40 (Tier 1)C1
Canasa
CANASA (SUPPOSITORY) $3.80-$8.50 (Tier 2)C1
Dipentum
DIPENTUM (CAPSULE) $3.80-$8.50 (Tier 2)C1
Lialda
LIALDA (TABLET DELAYED-RELEASE) $3.80-$8.50 (Tier 2) QLC1
Mesalamine
mesalamine (1000mg suppository) $1.25-$3.40 (Tier 1)C1
Mesalamine
mesalamine (4gm enema) $1.25-$3.40 (Tier 1) QLC1
Mesalamine DR mesalamine dr (1.2gm tablet delayed-release) $1.25-$3.40 (Tier 1) QL
B1
GlucocorticoidsC1
Budesonide
budesonide (3mg capsule delayed-release) $1.25-$3.40 (Tier 1)C1
Budesonide ER
budesonide er (tablet extended-release 24 hour) $1.25-$3.40 (Tier 1) STC1
Colocort
colocort (enema) $1.25-$3.40 (Tier 1)C1
Hydrocortisone
hydrocortisone (rx only) (100mg/60ml enema) $1.25-$3.40 (Tier 1)C1
Procto-Med HC
procto-med hc (cream) $1.25-$3.40 (Tier 1)C1
Procto-Pak
procto-pak (cream) $1.25-$3.40 (Tier 1)C1
Proctosol HC
proctosol hc (cream) $1.25-$3.40 (Tier 1)C1
Proctozone-HC
proctozone-hc (cream) $1.25-$3.40 (Tier 1)B1
SulfonamidesC1
Sulfasalazine
sulfasalazine (500mg tablet delayed-release, 500mg
tablet immediate-release)$1.25-$3.40 (Tier 1)
A1
Metabolic Bone Disease Agents
B1
Metabolic Bone Disease AgentsC1
Alendronate Sodium alendronate sodium (10mg tablet, 35mg tablet,
40mg tablet, 5mg tablet, 70mg tablet)$1.25-$3.40 (Tier 1) QL
C1
Alendronate Sodium alendronate sodium (70mg/75ml oral solution) $1.25-$3.40 (Tier 1)C1
Binosto
BINOSTO (TABLET EFFERVESCENT) $3.80-$8.50 (Tier 2) QLC1
Calcitonin-Salmon calcitonin-salmon (nasal solution) $1.25-$3.40 (Tier 1) QL
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
101For Track Refered Purpose113101
113
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Calcitriol
calcitriol (0.25mcg capsule, 0.5mcg capsule, 1mcg/
ml oral solution)$1.25-$3.40 (Tier 1) B/D, PA
C1
Cinacalcet HCl
cinacalcet hcl (tablet) $1.25-$3.40 (Tier 1) B/D, PA, QLC1
Doxercalciferol
doxercalciferol (capsule) $1.25-$3.40 (Tier 1) B/D, PA, QLC1
Etidronate Disodium etidronate disodium (tablet) $1.25-$3.40 (Tier 1)C1
Forteo
FORTEO (INJECTION) $3.80-$8.50 (Tier 2) PA, QLC1
Natpara
NATPARA (INJECTION) $3.80-$8.50 (Tier 2) PA, LAC1
Paricalcitol
paricalcitol (capsule) $1.25-$3.40 (Tier 1) B/D, PAC1
Prolia
PROLIA (INJECTION) $3.80-$8.50 (Tier 2) QLC1
Sensipar
SENSIPAR (TABLET) $3.80-$8.50 (Tier 2) B/D, PA, QLC1
Tymlos
TYMLOS (INJECTION) $3.80-$8.50 (Tier 2) PA, QLC1
Xgeva
XGEVA (INJECTION) $3.80-$8.50 (Tier 2) PAA1
Miscellaneous Therapeutic Agents
B1
Miscellaneous Therapeutic AgentsC1
1st Tier Unilet ComforTouch Lancets 28g
1st tier unilet comfortouch lancets 28g* $0 (Tier 3)C1
1st Tier Unilet ComforTouch Lancets 30g
1st tier unilet comfortouch lancets 30g* $0 (Tier 3)C1
Accu-Chek Aviva Plus accu-chek aviva plus (strip)* $0 (Tier 3)C1
Accu-Chek Compact Plus accu-chek compact plus (strip)* $0 (Tier 3)C1
Accu-Chek Fastclix Lancet Device Kit
accu-chek fastclix lancet device kit (kit)* $0 (Tier 3)C1
Accu-Chek Fastclix Lancets accu-chek fastclix lancets* $0 (Tier 3)C1
Accu-Chek Guide accu-chek guide (strip)* $0 (Tier 3)C1
Accu-Chek Multiclix Lancet Device Kit
accu-chek multiclix lancet device kit (kit)* $0 (Tier 3)C1
Accu-Chek Multiclix Lancets accu-chek multiclix lancets* $0 (Tier 3)C1
Accu-Chek Safe-T-Pro Lancets accu-chek safe-t-pro lancets* $0 (Tier 3)C1
Accu-Chek Safe-T-Pro Pluslancets
accu-chek safe-t-pro pluslancets* $0 (Tier 3)C1
Accu-Chek Smartview Strips accu-chek smartview strips (strip)* $0 (Tier 3)C1
Accu-Chek Soft Touch Lancets accu-chek soft touch lancets* $0 (Tier 3)C1
Accu-Chek Softclix Lancet Device Kit
accu-chek softclix lancet device kit (kit)* $0 (Tier 3)
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114
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Accu-Chek Softclix Lancets accu-chek softclix lancets* $0 (Tier 3)C1
Accutrend Glucose accutrend glucose (strip)* $0 (Tier 3)C1
Acti-Lance Lancets 28g acti-lance lancets 28g* $0 (Tier 3)C1
Acti-Lance Lite Safety Lancets 28g acti-lance lite safety lancets 28g* $0 (Tier 3)C1
Acti-Lance Special Safety Lancets 17g
acti-lance special safety lancets 17g* $0 (Tier 3)C1
Acti-Lance Special Safetylancets 17g acti-lance special safetylancets 17g* $0 (Tier 3)C1
Acti-Lance Universal Safety Lancets 23g
acti-lance universal safety lancets 23g* $0 (Tier 3)C1
Active 1st Blood Lancets 30g/Easy Twist Cap
active 1st blood lancets 30g/easy twist cap* $0 (Tier 3)C1
Adjustable Lancing Device adjustable lancing device* $0 (Tier 3)C1
Advance Micro-Draw Test Strips
advance micro-draw test strips (strip)* $0 (Tier 3)C1
Advocate Lancets advocate lancets* $0 (Tier 3)C1
Advocate Lancets 30g advocate lancets 30g* $0 (Tier 3)C1
Advocate Lancing Device advocate lancing device* $0 (Tier 3)C1
Advocate Rapid-Safe Lancing Device
advocate rapid-safe lancing device* $0 (Tier 3)C1
Advocate Redi-Code advocate redi-code (strip)* $0 (Tier 3)C1
Advocate Redi-Code+ Test Strips
advocate redi-code+ test strips (strip)* $0 (Tier 3)C1
Advocate Safety Lancets advocate safety lancets* $0 (Tier 3)C1
Advocate Safety Lancets 26g advocate safety lancets 26g* $0 (Tier 3)C1
Advocate Test Strips advocate test strips (strip)* $0 (Tier 3)C1
Agamatrix Amp No Code Test Strips
agamatrix amp no code test strips (strip)* $0 (Tier 3)C1
Agamatrix Jazz Test Strips agamatrix jazz test strips (strip)* $0 (Tier 3)C1
Agamatrix Presto Test Strips agamatrix presto test strips (strip)* $0 (Tier 3)C1
Agamatrix Ultra-Thin Lancets 33g agamatrix ultra-thin lancets 33g* $0 (Tier 3)C1
Alba-Lybe NR alba-lybe nr (liquid)* $0 (Tier 3)C1
Alcohol Prep Pads alcohol prep pads (otc only) $1.25-$3.40 (Tier 1)C1
Alternate Site Lancing Device alternate site lancing device* $0 (Tier 3)C1
Aqua Lance Adjustable Lancing Device
aqua lance adjustable lancing device (device)* $0 (Tier 3)C1
Assure 4 Test Strips assure 4 test strips (strip)* $0 (Tier 3)C1
Assure Comfort Lancets Ultra Thin 28g
assure comfort lancets ultra thin 28g* $0 (Tier 3)C1
Assure Comfort Lancets Ultra Thin 30g
assure comfort lancets ultra thin 30g* $0 (Tier 3)C1
Assure Haemolance Plus High Flow 18g
assure haemolance plus high flow 18g* $0 (Tier 3)C1
Assure Haemolance Plus Low Flow 25g
assure haemolance plus low flow 25g* $0 (Tier 3)C1
Assure Haemolance Plus Micro Flow 28g
assure haemolance plus micro flow 28g* $0 (Tier 3)C1
Assure Haemolance Plus Normal Flow 21g
assure haemolance plus normal flow 21g* $0 (Tier 3)C1
Assure Haemolance Plus Pediatric Blade
assure haemolance plus pediatric blade* $0 (Tier 3)C1
Assure Lance Lancets assure lance lancets* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
103For Track Refered Purpose115103
115
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Assure Lance Lancets 21g assure lance lancets 21g* $0 (Tier 3)C1
Assure Lance Plus Safety Lancets 25g
assure lance plus safety lancets 25g* $0 (Tier 3)C1
Assure Lance Plus Safety Lancets 30g
assure lance plus safety lancets 30g* $0 (Tier 3)C1
Assure Platinum Test Strips assure platinum test strips (strip)* $0 (Tier 3)C1
Assure Prism Multi Test Strips assure prism multi test strips (strip)* $0 (Tier 3)C1
Auto-Lancet Mini auto-lancet mini* $0 (Tier 3)C1
Autolet Impression Lancing Device
autolet impression lancing device* $0 (Tier 3)C1
Autolet Lancing Device autolet lancing device* $0 (Tier 3)C1
Autolet Plus
autolet plus* $0 (Tier 3)C1
Bayer Breeze 2 Test Disc bayer breeze 2 test disc (disk)* $0 (Tier 3)C1
Bayer Contour Blood Glucose Test Strips
bayer contour blood glucose test strips (strip)* $0 (Tier 3)C1
Bayer Microlet 2 Lancing Device
bayer microlet 2 lancing device* $0 (Tier 3)C1
Bayer Microlet Lancets bayer microlet lancets* $0 (Tier 3)C1
BD Lancet Ultrafine 30g bd lancet ultrafine 30g* $0 (Tier 3)C1
BD Lancet Ultrafine 33g bd lancet ultrafine 33g* $0 (Tier 3)C1
BD Microtainer Lancets bd microtainer lancets* $0 (Tier 3)C1
Blood Glucose Test Strips blood glucose test strips (strip)* $0 (Tier 3)C1
Blood Glucose Test Strips Premium
blood glucose test strips premium* $0 (Tier 3)C1
Bullseye Mini Safety Lancets bullseye mini safety lancets* $0 (Tier 3)C1
Careone Advanced Lancing Device
careone advanced lancing device* $0 (Tier 3)C1
Careone Blood Glucose Test Strips/Premium
careone blood glucose test strips/premium (strip)* $0 (Tier 3)C1
Careone Blood Glucose Test Strips/Value
careone blood glucose test strips/value (strip)* $0 (Tier 3)C1
Careone Lancet Ultra Thin careone lancet ultra thin* $0 (Tier 3)C1
Caresens N Blood Glucose Test Strips
caresens n blood glucose test strips (strip)* $0 (Tier 3)C1
Caretouch Blood Glucose Test Strips
caretouch blood glucose test strips (strip)* $0 (Tier 3)C1
Caretouch Lancing Device with Ejector
caretouch lancing device with ejector* $0 (Tier 3)C1
Caretouch Twist Lancets 28g caretouch twist lancets 28g* $0 (Tier 3)C1
Caretouch Twist Lancets 30g caretouch twist lancets 30g* $0 (Tier 3)C1
Caretouch Twist Lancets 33g caretouch twist lancets 33g* $0 (Tier 3)
104For Track Refered Purpose116104
116
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Clever Chek Auto-Code Test Strips
clever chek auto-code test strips (strip)* $0 (Tier 3)C1
Clever Chek Auto-Code Voice Test Strips
clever chek auto-code voice test strips (strip)* $0 (Tier 3)C1
Clever Chek Lancets Ultrathin clever chek lancets ultrathin* $0 (Tier 3)C1
Clever Chek Lancets Ultrathin 30g
clever chek lancets ultrathin 30g* $0 (Tier 3)C1
Clever Chek Test Strips clever chek test strips (strip)* $0 (Tier 3)C1
Clever Choice Auto-Code Pro Test Strips
clever choice auto-code pro test strips (strip)* $0 (Tier 3)C1
Clever Choice Comfort EZ Lancets 23g
clever choice comfort ez lancets 23g* $0 (Tier 3)C1
Clever Choice Comfort EZ Lancets 28g
clever choice comfort ez lancets 28g* $0 (Tier 3)C1
Clever Choice Micro Test Strips clever choice micro test strips (strip)* $0 (Tier 3)C1
Clever Choice No Coding Test Strips
clever choice no coding test strips (strip)* $0 (Tier 3)C1
Clever Choice Talk No Coding Test Strips
clever choice talk no coding test strips (strip)* $0 (Tier 3)C1
Coaguchek Lancets coaguchek lancets* $0 (Tier 3)C1
Comfort Assured Lancets Micro Thin 33g
comfort assured lancets micro thin 33g* $0 (Tier 3)C1
Comfort Assured Lancets Super Thin 28g
comfort assured lancets super thin 28g* $0 (Tier 3)C1
Comfort Lancets comfort lancets* $0 (Tier 3)C1
Contour Next Blood Glucose Test contour next blood glucose test (strip)* $0 (Tier 3)C1
Cool Blood Glucose Test Strips cool blood glucose test strips (strip)* $0 (Tier 3)C1
CVS Advanced Glucose Meter Test Strips
cvs advanced glucose meter test strips (strip)* $0 (Tier 3)C1
CVS Lancets Micro Thin 33g cvs lancets micro thin 33g* $0 (Tier 3)C1
CVS Lancets Micro-Thin 33g cvs lancets micro-thin 33g* $0 (Tier 3)C1
CVS Lancets Thin 26g cvs lancets thin 26g* $0 (Tier 3)C1
CVS Lancets Ultra Thin 30g cvs lancets ultra thin 30g* $0 (Tier 3)C1
CVS Lancets Ultra-Thin 30g cvs lancets ultra-thin 30g* $0 (Tier 3)C1
CVS Lancing Device cvs lancing device* $0 (Tier 3)C1
CVS Ultra Thin Lancets cvs ultra thin lancets* $0 (Tier 3)C1
Diatrue Plus Blood Glucose Test Strips
diatrue plus blood glucose test strips (strip)* $0 (Tier 3)C1
Droplet Lancets Ultra Thin 30g droplet lancets ultra thin 30g* $0 (Tier 3)C1
Droplet Lancing Device droplet lancing device* $0 (Tier 3)C1
Drug Mart Adjustable Lancing Device
drug mart adjustable lancing device* $0 (Tier 3)C1
Drug Mart On-The-Go Lancets Gentle 30g
drug mart on-the-go lancets gentle 30g* $0 (Tier 3)C1
Drug Mart Unilet Lancets Super Thin 30g
drug mart unilet lancets super thin 30g* $0 (Tier 3)C1
Drug Mart Unilet Lancets Ultra Thin 28g
drug mart unilet lancets ultra thin 28g* $0 (Tier 3)C1
Drug Mart Unilet Micro Thin Lancets 33g
drug mart unilet micro thin lancets 33g* $0 (Tier 3)C1
Easy Comfort Lancets easy comfort lancets* $0 (Tier 3)C1
Easy Comfort Lancets 30g/Pull Top
easy comfort lancets 30g/pull top* $0 (Tier 3)C1
Easy Comfort Lancets 30g/Thin Top
easy comfort lancets 30g/thin top* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
105For Track Refered Purpose117105
117
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Easy Mini Eject Lancing Device
easy mini eject lancing device* $0 (Tier 3)C1
Easy Mini Lancing Device easy mini lancing device* $0 (Tier 3)C1
Easy Plus II Blood Glucose Test easy plus ii blood glucose test (strip)* $0 (Tier 3)C1
Easy Step Test Strips easy step test strips (strip)* $0 (Tier 3)C1
Easy Talk Blood Glucose Test Strips
easy talk blood glucose test strips (strip)* $0 (Tier 3)C1
Easy Touch Glucose Test Strips easy touch glucose test strips (strip)* $0 (Tier 3)C1
Easy Touch HealthPro Glucose Test Strips
easy touch healthpro glucose test strips (strip)* $0 (Tier 3)C1
Easy Touch Lancets 21g/Pressure Activated
easy touch lancets 21g/pressure activated* $0 (Tier 3)C1
Easy Touch Lancets 23g/Pressure Activated
easy touch lancets 23g/pressure activated* $0 (Tier 3)C1
Easy Touch Lancets 26g/Pressure Activated
easy touch lancets 26g/pressure activated* $0 (Tier 3)C1
Easy Touch Lancets 26g/Pull-Top
easy touch lancets 26g/pull-top* $0 (Tier 3)C1
Easy Touch Lancets 26g/Twist
easy touch lancets 26g/twist* $0 (Tier 3)C1
Easy Touch Lancets 28g/Pressure Activated
easy touch lancets 28g/pressure activated* $0 (Tier 3)C1
Easy Touch Lancets 28g/Pull-Top
easy touch lancets 28g/pull-top* $0 (Tier 3)C1
Easy Touch Lancets 28g/Twist
easy touch lancets 28g/twist* $0 (Tier 3)C1
Easy Touch Lancets 30g/Button-Activated
easy touch lancets 30g/button-activated* $0 (Tier 3)C1
Easy Touch Lancets 30g/Pressure Activated
easy touch lancets 30g/pressure activated* $0 (Tier 3)C1
Easy Touch Lancets 30g/Pull-Top
easy touch lancets 30g/pull-top* $0 (Tier 3)C1
Easy Touch Lancets 30g/Twist
easy touch lancets 30g/twist* $0 (Tier 3)C1
Easy Touch Lancets 32g/Pressure Activated
easy touch lancets 32g/pressure activated* $0 (Tier 3)C1
Easy Touch Lancets 32g/Pull-Top
easy touch lancets 32g/pull-top* $0 (Tier 3)C1
Easy Touch Lancets 32g/Twist
easy touch lancets 32g/twist* $0 (Tier 3)C1
Easy Touch Lancets 33g/Twist
easy touch lancets 33g/twist* $0 (Tier 3)C1
Easy Touch Lancing Device/Ejector
easy touch lancing device/ejector* $0 (Tier 3)C1
Easy Touch Safety Lancets21g/Pressure Activated
easy touch safety lancets21g/pressure activated* $0 (Tier 3)C1
Easy Touch Safety Lancets23g/Pressure Activated
easy touch safety lancets23g/pressure activated* $0 (Tier 3)C1
Easy Touch Safety Lancets26g/Button Activated
easy touch safety lancets26g/button activated* $0 (Tier 3)C1
Easy Touch Safety Lancets26g/Pressure Activated
easy touch safety lancets26g/pressure activated* $0 (Tier 3)C1
Easy Touch Safety Lancets28g/Button Activated
easy touch safety lancets28g/button activated* $0 (Tier 3)
106For Track Refered Purpose118106
118
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Easy Touch Safety Lancets28g/Pressure Activated
easy touch safety lancets28g/pressure activated* $0 (Tier 3)C1
Easy Trak Blood Glucose Test Strips
easy trak blood glucose test strips (strip)* $0 (Tier 3)C1
Easy Twist & Cap Lancets easy twist & cap lancets* $0 (Tier 3)C1
EasyGluco
easygluco (strip)* $0 (Tier 3)C1
EasyGluco Plus
easygluco plus (strip)* $0 (Tier 3)C1
EASYMax 15 Test Strips easymax 15 test strips (strip)* $0 (Tier 3)C1
EASYMax Test Strips easymax test strips (strip)* $0 (Tier 3)C1
Element Compact Test Strips element compact test strips (strip)* $0 (Tier 3)C1
Element Test Strips element test strips (strip)* $0 (Tier 3)C1
Embrace Blood Glucose Test Strips
embrace blood glucose test strips (strip)* $0 (Tier 3)C1
Embrace Evo Blood Glucose Test Strips
embrace evo blood glucose test strips (strip)* $0 (Tier 3)C1
Embrace Lancets Ultra Thin 30g embrace lancets ultra thin 30g* $0 (Tier 3)C1
Embrace Pro Blood Glucose Test Strips
embrace pro blood glucose test strips (strip)* $0 (Tier 3)C1
EQ Blood Glucose Test Strips eq blood glucose test strips (strip)* $0 (Tier 3)C1
EQL Color Lancets Micro Thin 33g
eql color lancets micro thin 33g* $0 (Tier 3)C1
EvenCare G2 Test Strips evencare g2 test strips (strip)* $0 (Tier 3)C1
EvenCare G3 Test Strips evencare g3 test strips (strip)* $0 (Tier 3)C1
Evencare Mini Blood Glucose Test Strips
evencare mini blood glucose test strips (strip)* $0 (Tier 3)C1
Evolution Autocode evolution autocode (strip)* $0 (Tier 3)C1
E-Z Ject Lancets
e-z ject lancets* $0 (Tier 3)C1
E-Z Ject Lancets 21g e-z ject lancets 21g* $0 (Tier 3)C1
E-Z Ject Lancets Color e-z ject lancets color* $0 (Tier 3)C1
E-Z Ject Lancets Super Thin 30g e-z ject lancets super thin 30g* $0 (Tier 3)C1
E-Z Ject Lancets Thin 26g e-z ject lancets thin 26g* $0 (Tier 3)C1
EZ Smart Blood Glucose Lancets ez smart blood glucose lancets* $0 (Tier 3)C1
EZ Smart Blood Glucose Test Strips
ez smart blood glucose test strips (strip)* $0 (Tier 3)C1
EZ Smart Plus Blood Glucose Test Strips
ez smart plus blood glucose test strips (strip)* $0 (Tier 3)C1
E-Zject Lancets Micro-Thin 33g
e-zject lancets micro-thin 33g* $0 (Tier 3)C1
Fifty50 Glucose Test Strip 2.0 fifty50 glucose test strip 2.0 (strip)* $0 (Tier 3)C1
Fifty50 Lancing Device fifty50 lancing device* $0 (Tier 3)C1
Fifty50 Safety Seal Lancets 30g fifty50 safety seal lancets 30g* $0 (Tier 3)C1
Fifty50 Safety Seal Lancets 32g fifty50 safety seal lancets 32g* $0 (Tier 3)C1
Fifty50 Unilet Lancets 33g fifty50 unilet lancets 33g* $0 (Tier 3)C1
Fine 30
fine 30* $0 (Tier 3)C1
Fingerstix Lancets fingerstix lancets* $0 (Tier 3)C1
Fora Blood Glucose Test Strips fora blood glucose test strips (strip)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
107For Track Refered Purpose119107
119
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Fora D15g Blood Glucose Test Strips
fora d15g blood glucose test strips (strip)* $0 (Tier 3)C1
Fora D20 Blood Glucose Test Strips fora d20 blood glucose test strips (strip)* $0 (Tier 3)C1
Fora D40/G31 Blood Glucose Test Strips
fora d40/g31 blood glucose test strips (strip)* $0 (Tier 3)C1
Fora G20 Blood Glucose Test Strips fora g20 blood glucose test strips (strip)* $0 (Tier 3)C1
Fora G30/Premium V10 Blood Glucose Test Strips
fora g30/premium v10 blood glucose test strips
(strip)*$0 (Tier 3)
C1
Fora GD20 Test Strips fora gd20 test strips (strip)* $0 (Tier 3)C1
Fora GD50 Blood Glucose Test Strips
fora gd50 blood glucose test strips (strip)* $0 (Tier 3)C1
Fora Lancets
fora lancets* $0 (Tier 3)C1
Fora Lancing Device fora lancing device* $0 (Tier 3)C1
Fora Lancing Device/Clearcap fora lancing device/clearcap* $0 (Tier 3)C1
Fora Tn'g/Tn'g Voice Blood Glucose Test Strips
fora tn'g/tn'g voice blood glucose test strips (strip)* $0 (Tier 3)C1
Fora V10 Blood Glucose Test Strips fora v10 blood glucose test strips (strip)* $0 (Tier 3)C1
Fora V12 Blood Glucose Test Strips fora v12 blood glucose test strips (strip)* $0 (Tier 3)C1
Fora V20 Blood Glucose Test Strips fora v20 blood glucose test strips (strip)* $0 (Tier 3)C1
Fora V30a Blood Glucose Test Strips
fora v30a blood glucose test strips (strip)* $0 (Tier 3)C1
ForaCare GD40 foracare gd40 (strip)* $0 (Tier 3)C1
ForaCare Premium V10 Teststrips
foracare premium v10 teststrips (strip)* $0 (Tier 3)C1
ForaCare Test N Go Test Strips foracare test n go test strips (strip)* $0 (Tier 3)C1
Fortiscare Blood Glucose Test Strip fortiscare blood glucose test strip (strip)* $0 (Tier 3)C1
Freds Pharmacy Autolet Lancing Device
freds pharmacy autolet lancing device* $0 (Tier 3)C1
Freds Pharmacy Unilet Lancets Super Thin 30g
freds pharmacy unilet lancets super thin 30g* $0 (Tier 3)C1
Freds Pharmacy Unilet Lancets Ultra Thin 28g
freds pharmacy unilet lancets ultra thin 28g* $0 (Tier 3)C1
FreeStyle Insulinx Blood Glucose Test
freestyle insulinx blood glucose test (strip)* $0 (Tier 3)C1
FreeStyle Insulinx Blood Glucose Test Strips
freestyle insulinx blood glucose test strips (strip)* $0 (Tier 3)C1
FreeStyle Lancets freestyle lancets* $0 (Tier 3)C1
FreeStyle Lite Test Strips freestyle lite test strips (strip)* $0 (Tier 3)C1
FreeStyle Precision Neo Blood Glucose Test Strips
freestyle precision neo blood glucose test strips
(strip)*$0 (Tier 3)
108For Track Refered Purpose120108
120
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
FreeStyle Test Strips freestyle test strips (strip)* $0 (Tier 3)C1
FreeStyle Unistick II Lancets freestyle unistick ii lancets* $0 (Tier 3)C1
Gauze
gauze (non-medicated 2x2) $1.25-$3.40 (Tier 1)C1
GE100 Blood Glucose Test Strips ge100 blood glucose test strips (strip)* $0 (Tier 3)C1
Genstrip 50
genstrip 50 (strip)* $0 (Tier 3)C1
GHT Test Strips
ght test strips (strip)* $0 (Tier 3)C1
Global Inject Ease Lancets 28g global inject ease lancets 28g* $0 (Tier 3)C1
Global Inject Ease Lancets 30g global inject ease lancets 30g* $0 (Tier 3)C1
Global Lancing Device global lancing device* $0 (Tier 3)C1
Glucocard 01 Sensor Plus glucocard 01 sensor plus (strip)* $0 (Tier 3)C1
Glucocard 01 Sensor Plus Test Strips glucocard 01 sensor plus test strips (strip)* $0 (Tier 3)C1
Glucocard Expression Blood Glucose Test Strips
glucocard expression blood glucose test strips
(strip)*$0 (Tier 3)
C1
Glucocard Shine Test Strips glucocard shine test strips (strip)* $0 (Tier 3)C1
Glucocard Vital Test Strips glucocard vital test strips (strip)* $0 (Tier 3)C1
GlucoCom Lancets 28g glucocom lancets 28g* $0 (Tier 3)C1
GlucoCom Lancets 30g glucocom lancets 30g* $0 (Tier 3)C1
GlucoCom Lancets 33g glucocom lancets 33g* $0 (Tier 3)C1
GlucoCom Test Strips glucocom test strips (strip)* $0 (Tier 3)C1
GlucoNavii Blood Glucose Test Strips
gluconavii blood glucose test strips (strip)* $0 (Tier 3)C1
Glucose Meter Test Strips Advanced
glucose meter test strips advanced (strip)* $0 (Tier 3)C1
GNP Easy Touch Glucose Test Strips
gnp easy touch glucose test strips (strip)* $0 (Tier 3)C1
GNP Lancets
gnp lancets* $0 (Tier 3)C1
GNP Lancets 21g gnp lancets 21g* $0 (Tier 3)C1
GNP Lancets Micro Thin 33g gnp lancets micro thin 33g* $0 (Tier 3)C1
GNP Lancets Super Thin 30g gnp lancets super thin 30g* $0 (Tier 3)C1
GNP Lancets Thin gnp lancets thin* $0 (Tier 3)C1
GNP Lancets Thin 26g gnp lancets thin 26g* $0 (Tier 3)C1
GNP Micro Thin Lancets 33g gnp micro thin lancets 33g* $0 (Tier 3)C1
GNP Super Thin Lancets/30g gnp super thin lancets/30g* $0 (Tier 3)C1
Goodsense Lancets Micro-Thin 33g
goodsense lancets micro-thin 33g* $0 (Tier 3)C1
Goodsense Lancets Micro-Thin 33g Universal
goodsense lancets micro-thin 33g universal* $0 (Tier 3)C1
Goodsense Lancets Ultra-Thin 26g Universal
goodsense lancets ultra-thin 26g universal* $0 (Tier 3)C1
Goodsense Lancets Ultra-Thin 30g
goodsense lancets ultra-thin 30g* $0 (Tier 3)C1
Goodsense Lancing Device goodsense lancing device* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
109For Track Refered Purpose121109
121
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Goodsense Premium Blood Glucose Test Strips
goodsense premium blood glucose test strips
(strip)*$0 (Tier 3)
C1
Health Care Lancing Device health care lancing device* $0 (Tier 3)C1
Healthy Accents Autolet Impression Lancing Device
healthy accents autolet impression lancing device* $0 (Tier 3)C1
Healthy Accents Unilet Lancets Super Thin 30g
healthy accents unilet lancets super thin 30g* $0 (Tier 3)C1
H-E-B Incontrol Advanced Lancing Device
h-e-b incontrol advanced lancing device* $0 (Tier 3)C1
H-E-B Incontrol Lancets Micro Thin 33g
h-e-b incontrol lancets micro thin 33g* $0 (Tier 3)C1
H-E-B Incontrol Lancets Super Thin 30g
h-e-b incontrol lancets super thin 30g* $0 (Tier 3)C1
H-E-B Incontrol Lancets Ultra Thin 28g
h-e-b incontrol lancets ultra thin 28g* $0 (Tier 3)C1
Hypolance AST Lancing Kit hypolance ast lancing kit (kit)* $0 (Tier 3)C1
Iglucose Blood Glucose Test Strips
iglucose blood glucose test strips (strip)* $0 (Tier 3)C1
Infinity Blood Glucose Test Strips infinity blood glucose test strips (strip)* $0 (Tier 3)C1
Infinity Voice
infinity voice (strip)* $0 (Tier 3)C1
Insulin Syringes, Needles insulin syringes, needles $1.25-$3.40 (Tier 1)C1
Iosat
iosat (tablet)* $0 (Tier 3)C1
Kroger Blood Glucose Teststrips kroger blood glucose teststrips (strip)* $0 (Tier 3)C1
Kroger Lancets 21g kroger lancets 21g* $0 (Tier 3)C1
Kroger Lancets Micro Thin33g kroger lancets micro thin33g* $0 (Tier 3)C1
Kroger Lancets Thin 26g kroger lancets thin 26g* $0 (Tier 3)C1
Kroger Lancets Ultrathin 30g kroger lancets ultrathin 30g* $0 (Tier 3)C1
Kroger Lancing Device kroger lancing device* $0 (Tier 3)C1
Kroger Premium Blood Glucose Test Strips
kroger premium blood glucose test strips (strip)* $0 (Tier 3)C1
Kroger Test Strips kroger test strips (strip)* $0 (Tier 3)C1
Lancet Device with Ejector lancet device with ejector* $0 (Tier 3)C1
Lancets
lancets* $0 (Tier 3)C1
Lancets 28g
lancets 28g* $0 (Tier 3)C1
Lancets 30g
lancets 30g* $0 (Tier 3)C1
Lancets 30g Twist Top lancets 30g twist top* $0 (Tier 3)C1
Lancets 30g/Twist Top lancets 30g/twist top* $0 (Tier 3)
110For Track Refered Purpose122110
122
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Lancets 33g Universal Design lancets 33g universal design* $0 (Tier 3)C1
Lancets Micro Thin 33g lancets micro thin 33g* $0 (Tier 3)C1
Lancets Safety Seal 28g lancets safety seal 28g* $0 (Tier 3)C1
Lancets Safety Seal 30g lancets safety seal 30g* $0 (Tier 3)C1
Lancets Super Thin 28g lancets super thin 28g* $0 (Tier 3)C1
Lancets Thin
lancets thin* $0 (Tier 3)C1
Lancets Twist Top lancets twist top* $0 (Tier 3)C1
Lancets Ultra Fine lancets ultra fine* $0 (Tier 3)C1
Lancets Ultra Thin lancets ultra thin* $0 (Tier 3)C1
Lancets Ultra Thin 30g lancets ultra thin 30g* $0 (Tier 3)C1
Lancing Device lancing device* $0 (Tier 3)C1
Lancing Device Adjustable lancing device adjustable* $0 (Tier 3)C1
Lanzo
lanzo* $0 (Tier 3)C1
Leader Advanced Lancing Device
leader advanced lancing device* $0 (Tier 3)C1
LiteTouch Lancets litetouch lancets* $0 (Tier 3)C1
LiteTouch Lancets Micro Thin 33g
litetouch lancets micro thin 33g* $0 (Tier 3)C1
LiteTouch Lancing Pen litetouch lancing pen* $0 (Tier 3)C1
Live Better Advanced Lancing Device
live better advanced lancing device* $0 (Tier 3)C1
Live Better Lancet Ultra Thin 28g live better lancet ultra thin 28g* $0 (Tier 3)C1
Longs Lancets Thin longs lancets thin* $0 (Tier 3)C1
Longs Lancets Ultra Thin longs lancets ultra thin* $0 (Tier 3)C1
Medisense Thin Lancets medisense thin lancets* $0 (Tier 3)C1
Medlance Plus Extra Lancets 21g medlance plus extra lancets 21g* $0 (Tier 3)C1
Medlance Plus Lancets medlance plus lancets* $0 (Tier 3)C1
Medlance Plus Lancets Lite 25g medlance plus lancets lite 25g* $0 (Tier 3)C1
Medlance Plus Lite Lancets 25g medlance plus lite lancets 25g* $0 (Tier 3)C1
Medlance Plus Special Lancets 0.8mm
medlance plus special lancets 0.8mm* $0 (Tier 3)C1
Medlance Plus SuperLite 30g medlance plus superlite 30g* $0 (Tier 3)C1
Medlance Plus SuperLite 30g/Comfort Max
medlance plus superlite 30g/comfort max* $0 (Tier 3)C1
Medlance Plus Universal Lancets 21g
medlance plus universal lancets 21g* $0 (Tier 3)C1
Medlance Plus/Lite 25g medlance plus/lite 25g* $0 (Tier 3)C1
Medlance/Lite
medlance/lite* $0 (Tier 3)C1
Medlance/Universal medlance/universal* $0 (Tier 3)C1
Meijer Blood Glucose Teststrips meijer blood glucose teststrips (strip)* $0 (Tier 3)C1
Meijer Lancets Thin meijer lancets thin* $0 (Tier 3)C1
Meijer Lancets Universal 33g meijer lancets universal 33g* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
111For Track Refered Purpose123111
123
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Meijer Premium Blood Glucose Test Strips
meijer premium blood glucose test strips (strip)* $0 (Tier 3)C1
Meijer Super Thin Lancets meijer super thin lancets* $0 (Tier 3)C1
Microdot Test Strips microdot test strips (strip)* $0 (Tier 3)C1
Microlet Lancets
microlet lancets* $0 (Tier 3)C1
Microlet Next
microlet next* $0 (Tier 3)C1
Mini Lancing Device mini lancing device* $0 (Tier 3)C1
Mm Easy Touch Glucose Test Strips
mm easy touch glucose test strips (strip)* $0 (Tier 3)C1
Monolet Lancets
monolet lancets* $0 (Tier 3)C1
Multi-Lancet Device 2 multi-lancet device 2 (kit)* $0 (Tier 3)C1
MyGlucoHealth Blood Glucose Test myglucohealth blood glucose test (strip)* $0 (Tier 3)C1
MyGlucoHealth MGH Softlance Lancets 30g
myglucohealth mgh softlance lancets 30g* $0 (Tier 3)C1
Neutek 2Tek Test Strips neutek 2tek test strips (strip)* $0 (Tier 3)C1
Nova Max Glucose Test Strips nova max glucose test strips (strip)* $0 (Tier 3)C1
Nova Safety Lancets 23g nova safety lancets 23g* $0 (Tier 3)C1
Nova Safety Lancets 28g nova safety lancets 28g* $0 (Tier 3)C1
Nova Sureflex Lancets nova sureflex lancets* $0 (Tier 3)C1
Nova Sureflex Lancing Device nova sureflex lancing device* $0 (Tier 3)C1
On Call Express Blood Glucose Test Strips
on call express blood glucose test strips (strip)* $0 (Tier 3)C1
On Call Lancets
on call lancets* $0 (Tier 3)C1
On Call Lancing Device on call lancing device* $0 (Tier 3)C1
On Call Plus Blood Glucose Test on call plus blood glucose test (strip)* $0 (Tier 3)C1
On Call Plus Lancets on call plus lancets* $0 (Tier 3)C1
On Call Plus Lancing Device on call plus lancing device* $0 (Tier 3)C1
On Call Vivid Blood Glucose Test on call vivid blood glucose test (strip)* $0 (Tier 3)C1
On Call Vivid Blood Glucose Test Strips
on call vivid blood glucose test strips (strip)* $0 (Tier 3)C1
Onetouch Delica Lancets Extra Fine 33g
onetouch delica lancets extra fine 33g* $0 (Tier 3)C1
Onetouch Delica Lancets Fine 30g
onetouch delica lancets fine 30g* $0 (Tier 3)C1
Onetouch Delica Lancing Device
onetouch delica lancing device* $0 (Tier 3)C1
Onetouch Suresoft Lancing Device/18g
onetouch suresoft lancing device/18g* $0 (Tier 3)
112For Track Refered Purpose124112
124
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Onetouch Suresoft Lancing Device/21g
onetouch suresoft lancing device/21g* $0 (Tier 3)C1
Onetouch Suresoft Lancing Device/28g
onetouch suresoft lancing device/28g* $0 (Tier 3)C1
Onetouch Ultra Blue onetouch ultra blue (strip)* $0 (Tier 3)C1
Onetouch Ultrasoft Lancets onetouch ultrasoft lancets* $0 (Tier 3)C1
Onetouch Verio Test Strips onetouch verio test strips (strip)* $0 (Tier 3)C1
One-Way Valved Expiratory Mouthpiece/Disposable
one-way valved expiratory mouthpiece/disposable* $0 (Tier 3)C1
One-Way Valved Inspiratory Mouthpiece/Disposable
one-way valved inspiratory mouthpiece/disposable* $0 (Tier 3)C1
Optium Test Strips optium test strips (strip)* $0 (Tier 3)C1
OptiumEZ Test Strips optiumez test strips* $0 (Tier 3)C1
OptumRx Blood Glucose Test optumrx blood glucose test (strip)* $0 (Tier 3)C1
Panda Mask Large panda mask large* $0 (Tier 3)C1
Panda Mask Medium panda mask medium* $0 (Tier 3)C1
Panda Mask Small panda mask small* $0 (Tier 3)C1
PC Lancets Super Thin 30g pc lancets super thin 30g* $0 (Tier 3)C1
Pediatric Medium Mask pediatric medium mask* $0 (Tier 3)C1
Pediatric Mouthpiece/Disposable pediatric mouthpiece/disposable* $0 (Tier 3)C1
Pediatric Panda Mask pediatric panda mask* $0 (Tier 3)C1
Pediatric Small Mask pediatric small mask* $0 (Tier 3)C1
Pharmacist Choice Autocode Blood Glucose Test Strips
pharmacist choice autocode blood glucose test
strips (strip)*$0 (Tier 3)
C1
Pharmacist Choice No Coding Blood Glucose Test Strips
pharmacist choice no coding blood glucose test
strips (strip)*$0 (Tier 3)
C1
Pharmacist Choice Ultra Thin Lancets pharmacist choice ultra thin lancets* $0 (Tier 3)C1
Pharmacist Choice Ultra Thin Lancets 28g
pharmacist choice ultra thin lancets 28g* $0 (Tier 3)C1
Pharmacist Choice Ultra Thin Lancets 30g
pharmacist choice ultra thin lancets 30g* $0 (Tier 3)C1
Pharmacist Choice Ultra Thin Lancets 31g
pharmacist choice ultra thin lancets 31g* $0 (Tier 3)C1
Pharmacist Choice Ultra Thin Lancets 33g
pharmacist choice ultra thin lancets 33g* $0 (Tier 3)C1
Precision PCX
precision pcx (strip)* $0 (Tier 3)C1
Precision PCX Plus Test Strips precision pcx plus test strips (strip)* $0 (Tier 3)C1
Precision Point of Care Test Strips
precision point of care test strips (strip)* $0 (Tier 3)C1
Precision QID Test Strips precision qid test strips* $0 (Tier 3)C1
Precision XTra Blood Glucose Test Strips
precision xtra blood glucose test strips (strip)* $0 (Tier 3)C1
Preferred Plus Lancets Super Thin 30g
preferred plus lancets super thin 30g* $0 (Tier 3)C1
Preferred Plus Lancets Thin 26g preferred plus lancets thin 26g* $0 (Tier 3)C1
Premium Blood Glucose Test Strips
premium blood glucose test strips (strip)* $0 (Tier 3)C1
Pro Comfort Lancets 30g pro comfort lancets 30g* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
113For Track Refered Purpose125113
125
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Pro Comfort Lancets 31g pro comfort lancets 31g* $0 (Tier 3)C1
Prodigy Lancing Device prodigy lancing device* $0 (Tier 3)C1
Prodigy No Coding Blood Glucose Test Strips
prodigy no coding blood glucose test strips (strip)* $0 (Tier 3)C1
Prodigy Pressure Activated Safety Lancets
prodigy pressure activated safety lancets* $0 (Tier 3)C1
Prodigy Safety Lancets prodigy safety lancets* $0 (Tier 3)C1
Prodigy Twist Top Lancets prodigy twist top lancets* $0 (Tier 3)C1
Push Button Safety Lancets 28g push button safety lancets 28g* $0 (Tier 3)C1
PX Advanced Lancing Device px advanced lancing device* $0 (Tier 3)C1
PX Lancets Ultra Thin px lancets ultra thin* $0 (Tier 3)C1
PX Lancets Ultra Thin 28g px lancets ultra thin 28g* $0 (Tier 3)C1
QC Advanced Lancing Device qc advanced lancing device* $0 (Tier 3)C1
QC Lancets Super Thin qc lancets super thin* $0 (Tier 3)C1
QC Unilet Lancets 28g/Ultra Thin
qc unilet lancets 28g/ultra thin* $0 (Tier 3)C1
QC Unilet Lancets 33g/Micro Thin
qc unilet lancets 33g/micro thin* $0 (Tier 3)C1
Quintet AC Blood Glucose Test Strips
quintet ac blood glucose test strips (strip)* $0 (Tier 3)C1
Quintet Blood Glucose Test Strips quintet blood glucose test strips (strip)* $0 (Tier 3)C1
RA E-Zject Lancets 28g ra e-zject lancets 28g* $0 (Tier 3)C1
RA E-Zject Lancets Thin 26g ra e-zject lancets thin 26g* $0 (Tier 3)C1
RA E-Zject Lancets Thin 28g ra e-zject lancets thin 28g* $0 (Tier 3)C1
RA E-Zject Lancets Ultra Thin 30g
ra e-zject lancets ultra thin 30g* $0 (Tier 3)C1
Readylance Safety Lancets/21g/2.2mm
readylance safety lancets/21g/2.2mm* $0 (Tier 3)C1
Readylance Safety Lancets/23g/1.8mm
readylance safety lancets/23g/1.8mm* $0 (Tier 3)C1
Readylance Safety Lancets/26g/1.8mm
readylance safety lancets/26g/1.8mm* $0 (Tier 3)C1
Readylance Safety Lancets/28g/1.8mm
readylance safety lancets/28g/1.8mm* $0 (Tier 3)C1
Readylance Safety Lancets/30g/1.6mm
readylance safety lancets/30g/1.6mm* $0 (Tier 3)C1
Refuah Plus Blood Glucose Test Strips
refuah plus blood glucose test strips (strip)* $0 (Tier 3)C1
Relion Confirm/Micro Test Strips
relion confirm/micro test strips (strip)* $0 (Tier 3)C1
Relion Lancets Thin 26g relion lancets thin 26g* $0 (Tier 3)C1
Relion Lancets Ultra-Thin30g relion lancets ultra-thin30g* $0 (Tier 3)
114For Track Refered Purpose126114
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Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Relion Lancing Device relion lancing device ( kit, misc)* $0 (Tier 3)C1
Relion Premier Blood Glucose Test Strips
relion premier blood glucose test strips (strip)* $0 (Tier 3)C1
Relion Prime Blood Glucose Test Strips
relion prime blood glucose test strips (strip)* $0 (Tier 3)C1
Relion Ultima Blood Glucose Test Strips
relion ultima blood glucose test strips (strip)* $0 (Tier 3)C1
Relion Ultra Thin Lancets30g relion ultra thin lancets30g* $0 (Tier 3)C1
Relion Ultra Thin Plus Lancets 32g relion ultra thin plus lancets 32g* $0 (Tier 3)C1
Relion Ultra Thin Plus Lancets 33g relion ultra thin plus lancets 33g* $0 (Tier 3)C1
Reveal Blood Glucose Test reveal blood glucose test (strip)* $0 (Tier 3)C1
Rexall Blood Glucose Test Strips rexall blood glucose test strips (strip)* $0 (Tier 3)C1
Rexall Lancets Ultra Thin rexall lancets ultra thin* $0 (Tier 3)C1
Rightest GD500 Lancing Device rightest gd500 lancing device* $0 (Tier 3)C1
Rightest GL300 Lancets rightest gl300 lancets* $0 (Tier 3)C1
Rightest GS100 Blood Glucose Test Strips
rightest gs100 blood glucose test strips (strip)* $0 (Tier 3)C1
Rightest GS300 Blood Glucose Test Strips
rightest gs300 blood glucose test strips (strip)* $0 (Tier 3)C1
Rightest GS550 Blood Glucose Test Strips
rightest gs550 blood glucose test strips (strip)* $0 (Tier 3)C1
Safety Lancet 21g/Pressure Activated
safety lancet 21g/pressure activated* $0 (Tier 3)C1
Safety Lancet 28g/Pressure Activated
safety lancet 28g/pressure activated* $0 (Tier 3)C1
Safety Lancets
safety lancets* $0 (Tier 3)C1
Safety Lancets 21g safety lancets 21g* $0 (Tier 3)C1
Safety Lancets 28g safety lancets 28g* $0 (Tier 3)C1
Safety Let Lancets safety let lancets* $0 (Tier 3)C1
Safety Seal Lancets 28g safety seal lancets 28g* $0 (Tier 3)C1
Safety Seal Lancets 30g safety seal lancets 30g* $0 (Tier 3)C1
Sapscare Twist Top Lancets 30g sapscare twist top lancets 30g* $0 (Tier 3)C1
Select-Lite Lancing Device select-lite lancing device* $0 (Tier 3)C1
Shopko Autolet Lancing Device shopko autolet lancing device* $0 (Tier 3)C1
Shopko On-The-Go Comfort Lancets 30g
shopko on-the-go comfort lancets 30g* $0 (Tier 3)C1
Shopko Unilet Lancets Super Thin 30g
shopko unilet lancets super thin 30g* $0 (Tier 3)C1
Shopko Unilet Lancets Ultra Thin 28g
shopko unilet lancets ultra thin 28g* $0 (Tier 3)C1
Sidekick Blood Glucose System sidekick blood glucose system (device)* $0 (Tier 3)C1
Sidestream Pediatric Face Mask/Tucker the Turtle
sidestream pediatric face mask/tucker the turtle* $0 (Tier 3)C1
Simple Diagnostics Lancing Device
simple diagnostics lancing device* $0 (Tier 3)C1
SM Micro Thin Lancets 33g sm micro thin lancets 33g* $0 (Tier 3)C1
Smart Diabetes Vantage Lancing Device
smart diabetes vantage lancing device* $0 (Tier 3)C1
Smart Sense Color Lancets Universal 33g
smart sense color lancets universal 33g* $0 (Tier 3)C1
Smart Sense Premium Bloodglucose Strips
smart sense premium bloodglucose strips (strip)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
115For Track Refered Purpose127115
127
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Smart Sense Standard Lancets Universal 21g
smart sense standard lancets universal 21g* $0 (Tier 3)C1
Smart Sense Super Thin Lancets Universal 30g
smart sense super thin lancets universal 30g* $0 (Tier 3)C1
Smart Sense Thin Lancets Universal 26g
smart sense thin lancets universal 26g* $0 (Tier 3)C1
Smart Sense Value Blood Glucose Strips
smart sense value blood glucose strips (strip)* $0 (Tier 3)C1
Smartest Blood Glucose Test Strips
smartest blood glucose test strips (strip)* $0 (Tier 3)C1
Smartest Lancets 28g smartest lancets 28g* $0 (Tier 3)C1
Solus V2 Audible Test solus v2 audible test (strip)* $0 (Tier 3)C1
Solus V2 Lancing Device solus v2 lancing device* $0 (Tier 3)C1
Solus V2 Pressure Activated Safety Lancets 28g
solus v2 pressure activated safety lancets 28g* $0 (Tier 3)C1
Solus V2 Twist Lancets 30g solus v2 twist lancets 30g* $0 (Tier 3)C1
Sterilance PA
sterilance pa* $0 (Tier 3)C1
Sterilance Tl
sterilance tl* $0 (Tier 3)C1
Sure Comfort Lancets 18g sure comfort lancets 18g* $0 (Tier 3)C1
Sure Comfort Lancets 21g sure comfort lancets 21g* $0 (Tier 3)C1
Sure Comfort Lancets 23g sure comfort lancets 23g* $0 (Tier 3)C1
Sure Comfort Lancets 28g sure comfort lancets 28g* $0 (Tier 3)C1
Sure Comfort Lancets 30g sure comfort lancets 30g* $0 (Tier 3)C1
Sure Comfort Lancing Pen sure comfort lancing pen* $0 (Tier 3)C1
Sure-Lance Flat Lancets sure-lance flat lancets* $0 (Tier 3)C1
Sure-Lance Thin Lancets 28g sure-lance thin lancets 28g* $0 (Tier 3)C1
Sure-Lance Ultra Thin Lancets sure-lance ultra thin lancets* $0 (Tier 3)C1
Sure-Test EasyPlus Mini Blood Glucose Test Strips
sure-test easyplus mini blood glucose test strips
(strip)*$0 (Tier 3)
C1
Sure-Touch Lancets Universal
sure-touch lancets universal* $0 (Tier 3)C1
Suspendol-S
suspendol-s (liquid)* $0 (Tier 3)C1
TechLite Lancets techlite lancets* $0 (Tier 3)C1
Techlite Lancets 30g techlite lancets 30g* $0 (Tier 3)C1
Telcare Blood Glucose Test Strips telcare blood glucose test strips (strip)* $0 (Tier 3)C1
TGT Blood Glucose Test Strips tgt blood glucose test strips (strip)* $0 (Tier 3)
116For Track Refered Purpose128116
128
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
TGT Blood Glucose Test Strips Premium
tgt blood glucose test strips premium* $0 (Tier 3)C1
TGT Lancet Micro Thin 33g tgt lancet micro thin 33g* $0 (Tier 3)C1
TGT Lancet Thin 26g tgt lancet thin 26g* $0 (Tier 3)C1
TGT Lancet Ultra Thin 30g tgt lancet ultra thin 30g* $0 (Tier 3)C1
TGT Lancing Device tgt lancing device* $0 (Tier 3)C1
ThyroSafe
thyrosafe (tablet)* $0 (Tier 3)C1
Topcare Lancets Micro-Thin 33g
topcare lancets micro-thin 33g* $0 (Tier 3)C1
Travel Lancets 30g travel lancets 30g* $0 (Tier 3)C1
Travel Lancets Advanced 28g travel lancets advanced 28g* $0 (Tier 3)C1
True Metrix Blood Glucose Test Strips
true metrix blood glucose test strips (strip)* $0 (Tier 3)C1
True Metrix Self Monitoring Blood Glucose Strips
true metrix self monitoring blood glucose strips
(strip)*$0 (Tier 3)
C1
TrueDraw Lancing Device truedraw lancing device* $0 (Tier 3)C1
TruePlus Lancets 26g trueplus lancets 26g* $0 (Tier 3)C1
TruePlus Lancets 28g trueplus lancets 28g* $0 (Tier 3)C1
Trueplus Lancets 28g Super Thin trueplus lancets 28g super thin* $0 (Tier 3)C1
TruePlus Lancets 30g trueplus lancets 30g* $0 (Tier 3)C1
Trueplus Lancets 30g Ultra Thin trueplus lancets 30g ultra thin* $0 (Tier 3)C1
TruePlus Lancets 33g trueplus lancets 33g* $0 (Tier 3)C1
Trueplus Lancets 33g Micro Thin trueplus lancets 33g micro thin* $0 (Tier 3)C1
Trueplus Safety Lancets 28g trueplus safety lancets 28g* $0 (Tier 3)C1
TrueTest Strips truetest strips* $0 (Tier 3)C1
TrueTrack Blood Glucose Test Strips
truetrack blood glucose test strips* $0 (Tier 3)C1
TrueTrack Test Strips truetrack test strips* $0 (Tier 3)C1
Ulti-Lance Automatic/ Clear Tip ulti-lance automatic/ clear tip* $0 (Tier 3)C1
Ultilet Classic Lancets ultilet classic lancets* $0 (Tier 3)C1
Ultilet Lancets
ultilet lancets* $0 (Tier 3)C1
Ultilet Lancets 33g ultilet lancets 33g* $0 (Tier 3)C1
Ultilet Safety Lancets 23g ultilet safety lancets 23g* $0 (Tier 3)C1
Ultima Test Strips ultima test strips (strip)* $0 (Tier 3)C1
Ultralance
ultralance* $0 (Tier 3)C1
Ultra-Thin II Lancets 28g ultra-thin ii lancets 28g* $0 (Tier 3)C1
Ultra-Thin II Lancets 30g ultra-thin ii lancets 30g* $0 (Tier 3)C1
Ultra-Thin II Safety Autolancets 26g
ultra-thin ii safety autolancets 26g* $0 (Tier 3)C1
Ultratrak Pro Test Strips ultratrak pro test strips (strip)* $0 (Tier 3)C1
Ultratrak Ultimate Test Strips ultratrak ultimate test strips (strip)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
117For Track Refered Purpose129117
129
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Unilet ComforTouch Lancet unilet comfortouch lancet* $0 (Tier 3)C1
Unilet Excelite
unilet excelite* $0 (Tier 3)C1
Unilet Excelite II unilet excelite ii* $0 (Tier 3)C1
Unilet G.P. SuperLite Lancet unilet g.p. superlite lancet* $0 (Tier 3)C1
Unilet GP 28 Ultra Thin unilet gp 28 ultra thin* $0 (Tier 3)C1
Unilet Lancets Micro-Thin33g unilet lancets micro-thin33g* $0 (Tier 3)C1
Unilet Lancets Super-Thin30g unilet lancets super-thin30g* $0 (Tier 3)C1
Unilet Lancets Ultra-Thin 28g unilet lancets ultra-thin 28g* $0 (Tier 3)C1
Unistik 2
unistik 2* $0 (Tier 3)C1
Unistik 2 Comfort unistik 2 comfort* $0 (Tier 3)C1
Unistik 2 Extra
unistik 2 extra* $0 (Tier 3)C1
Unistik 2 Normal
unistik 2 normal* $0 (Tier 3)C1
Unistik 2 Super
unistik 2 super* $0 (Tier 3)C1
Unistik 3 Comfort unistik 3 comfort* $0 (Tier 3)C1
Unistik 3 Extra
unistik 3 extra* $0 (Tier 3)C1
Unistik 3 Gentle
unistik 3 gentle* $0 (Tier 3)C1
Unistik 3 Neonatal unistik 3 neonatal* $0 (Tier 3)C1
Unistik 3 Normal
unistik 3 normal* $0 (Tier 3)C1
Unistik CZT Comfort unistik czt comfort* $0 (Tier 3)C1
Unistik CZT Normal unistik czt normal* $0 (Tier 3)C1
Unistik Safety Lancets 28g unistik safety lancets 28g* $0 (Tier 3)C1
Unistik Safety Lancets 30g unistik safety lancets 30g* $0 (Tier 3)C1
Unistik Touch Safety Lancets 21g unistik touch safety lancets 21g* $0 (Tier 3)C1
Unistik Touch Safety Lancets 23g unistik touch safety lancets 23g (misc)* $0 (Tier 3)C1
Unistik Touch Safety Lancets 28g unistik touch safety lancets 28g* $0 (Tier 3)C1
Unistik Touch Safety Lancets 30g unistik touch safety lancets 30g* $0 (Tier 3)C1
Unistrip1 Generic unistrip1 generic (strip)* $0 (Tier 3)C1
Universal 1 Lancets Thin 26g universal 1 lancets thin 26g* $0 (Tier 3)C1
Universal 1 Lancets Ultra Thin 30g universal 1 lancets ultra thin 30g* $0 (Tier 3)
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130
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Value Plus Lancing Device value plus lancing device* $0 (Tier 3)C1
Valumark Lancet Super Thin 30g valumark lancet super thin 30g* $0 (Tier 3)C1
Valumark Lancet Ultra Thin 28g valumark lancet ultra thin 28g* $0 (Tier 3)C1
Verasens Blood Glucose Test Strips
verasens blood glucose test strips (strip)* $0 (Tier 3)C1
Vida Mia Autolet Lancing Device vida mia autolet lancing device* $0 (Tier 3)C1
Vida Mia Unilet Lancets Super Thin 30g
vida mia unilet lancets super thin 30g* $0 (Tier 3)C1
Vida Mia Unilet Lancets Ultra Thin 28g
vida mia unilet lancets ultra thin 28g* $0 (Tier 3)C1
Walgreens Advanced Travellancets 28g
walgreens advanced travellancets 28g* $0 (Tier 3)C1
Walgreens Comfort Assuredlancets Micro Thin/33g
walgreens comfort assuredlancets micro thin/33g* $0 (Tier 3)C1
Walgreens Comfort Assuredlancets Super Thin/28g
walgreens comfort assuredlancets super thin/28g* $0 (Tier 3)C1
Walgreens Thin Lancets walgreens thin lancets* $0 (Tier 3)C1
Walgreens Ultra Thin Lancets walgreens ultra thin lancets* $0 (Tier 3)C1
Wavesense Presto Test Strips wavesense presto test strips (strip)* $0 (Tier 3)C1
White Petrolatum white petrolatum (gel)* $0 (Tier 3)
A1
Ophthalmic Agents
B1
Ophthalmic Agents, OtherC1
Akwa Tears
akwa tears (ointment)* $0 (Tier 3)C1
Artificial Tears
artificial tears (otc only) (ophthalmic solution)* $0 (Tier 3)C1
Atropine Sulfate ATROPINE SULFATE (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Bacitracin/Polymyxin B bacitracin/polymyxin b (ophthalmic ointment) $1.25-$3.40 (Tier 1)C1
Blephamide
BLEPHAMIDE (SUSPENSION) $3.80-$8.50 (Tier 2)C1
Blephamide S.O.P. blephamide s.o.p. (ointment) $1.25-$3.40 (Tier 1)C1
Cystaran
CYSTARAN (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2) LAC1
Freshkote
freshkote (ophthalmic solution)* $0 (Tier 3)C1
Isopto Tears
isopto tears (ophthalmic solution)* $0 (Tier 3)C1
Lacrisert
LACRISERT (INSERT) $3.80-$8.50 (Tier 2)C1
Lastacaft
LASTACAFT (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Liquitears
liquitears (ophthalmic solution)* $0 (Tier 3)C1
Lubricant Eye Drops lubricant eye drops (ophthalmic solution)* $0 (Tier 3)C1
Lubricating Plus Eye Drops lubricating plus eye drops (ophthalmic solution)* $0 (Tier 3)C1
Lubrifresh P.M.
lubrifresh p.m. (ointment)* $0 (Tier 3)C1
Muro 128
muro 128 (ophthalmic solution)* $0 (Tier 3)C1
Natural Balance Tears natural balance tears (ophthalmic solution)* $0 (Tier 3)C1
Natures Tears natures tears (ophthalmic solution)* $0 (Tier 3)C1
Neomycin/Bacitracin/Polymyxin neomycin/bacitracin/polymyxin (ointment) $1.25-$3.40 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
119For Track Refered Purpose131119
131
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Neomycin/Polymyxin/Bacitracin/Hydrocortisone
neomycin/polymyxin/bacitracin/hydrocortisone
(ophthalmic ointment)$1.25-$3.40 (Tier 1)
C1
Neomycin/Polymyxin/Dexamethasone
neomycin/polymyxin/dexamethasone (0.1%
ophthalmic ointment, 0.1% ophthalmic suspension)$1.25-$3.40 (Tier 1)
C1
Neomycin/Polymyxin/Gramicidin neomycin/polymyxin/gramicidin (ophthalmic
solution)$1.25-$3.40 (Tier 1)
C1
Neomycin/Polymyxin/Hydrocortisone
neomycin/polymyxin/hydrocortisone (1% ophthalmic
suspension)$1.25-$3.40 (Tier 1)
C1
Polymyxin B Sulfate/Trimethoprim Sulfate
polymyxin b sulfate/trimethoprim sulfate (ophthalmic
solution)$1.25-$3.40 (Tier 1)
C1
Proparacaine HCl proparacaine hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Puralube
puralube (ointment)* $0 (Tier 3)C1
Refresh Celluvisc refresh celluvisc (ophthalmic solution)* $0 (Tier 3)C1
Refresh Lacri-Lube refresh lacri-lube (ointment)* $0 (Tier 3)C1
Refresh Optive Mega-3 refresh optive mega-3 (ophthalmic solution)* $0 (Tier 3)C1
Refresh Plus
refresh plus (ophthalmic solution)* $0 (Tier 3)C1
Restasis
RESTASIS (EMULSION) $3.80-$8.50 (Tier 2) QLC1
Rhopressa
RHOPRESSA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2) STC1
Sodium Chloride
sodium chloride (otc only) (5% ointment, 5%
ophthalmic solution)*$0 (Tier 3)
C1
Sulfacetamide Sodium/Prednisolone Sodium Phosphate
sulfacetamide sodium/prednisolone sodium
phosphate (ophthalmic solution)$1.25-$3.40 (Tier 1)
C1
Tobradex
TOBRADEX (0.3%-0.1% OPHTHALMIC OINTMENT) $3.80-$8.50 (Tier 2)C1
Tobradex ST
TOBRADEX ST (OPHTHALMIC SUSPENSION) $3.80-$8.50 (Tier 2)C1
Tobramycin/Dexamethasone tobramycin/dexamethasone (ophthalmic suspension) $1.25-$3.40 (Tier 1)C1
Ultra Lubricant Eye Drops ultra lubricant eye drops (ophthalmic solution)* $0 (Tier 3)C1
Xiidra
XIIDRA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2) QLB1
Ophthalmic Anti-allergy AgentsC1
Azelastine HCl
azelastine hcl (0.05% ophthalmic solution) $1.25-$3.40 (Tier 1)
120For Track Refered Purpose132120
132
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Bepreve
BEPREVE (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Cromolyn Sodium cromolyn sodium (rx only) (4% ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Epinastine HCl
epinastine hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Eye Drops
eye drops (ophthalmic solution)* $0 (Tier 3)C1
Olopatadine HCl
olopatadine hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Opti-Clear
opti-clear (ophthalmic solution)* $0 (Tier 3)C1
Pazeo
PAZEO (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)B1
Ophthalmic Antiglaucoma AgentsC1
Alphagan P
ALPHAGAN P (0.1% OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Apraclonidine
apraclonidine (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Betaxolol HCl
betaxolol hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Betimol
BETIMOL (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Brimonidine Tartrate brimonidine tartrate (0.2% ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Carteolol HCl
carteolol hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Combigan
COMBIGAN (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Cosopt PF
COSOPT PF (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Dorzolamide HCl dorzolamide hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Dorzolamide HCl/Timolol Maleate dorzolamide hcl/timolol maleate (ophthalmic
solution)$1.25-$3.40 (Tier 1)
C1
Dorzolamide HCl/Timolol Maleate Preservative Free
dorzolamide hcl/timolol maleate preservative free
(solution)$1.25-$3.40 (Tier 1)
C1
Levobunolol HCl levobunolol hcl (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Phospholine Iodide PHOSPHOLINE IODIDE (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Pilocarpine HCl
pilocarpine hcl (1% ophthalmic solution, 2%
ophthalmic solution, 4% ophthalmic solution)$1.25-$3.40 (Tier 1)
C1
Rocklatan
ROCKLATAN (SOLUTION) $3.80-$8.50 (Tier 2) STC1
Timolol Maleate
timolol maleate (0.25% ophthalmic solution, 0.5%
ophthalmic solution) (generic timoptic)$1.25-$3.40 (Tier 1)
C1
Timolol Maleate Ophthalmic Gel Forming
timolol maleate ophthalmic gel forming (solution)
(generic timoptic-xe)$3.80-$8.50 (Tier 2)
B1
Ophthalmic Anti-inflammatoriesC1
Dexamethasone Sodium Phosphate dexamethasone sodium phosphate (ophthalmic
solution)$1.25-$3.40 (Tier 1)
C1
Diclofenac Sodium diclofenac sodium (0.1% ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Durezol
DUREZOL (EMULSION) $3.80-$8.50 (Tier 2)C1
Eye Itch Relief
eye itch relief (ophthalmic solution)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
121For Track Refered Purpose133121
133
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Fluorometholone
fluorometholone (ophthalmic suspension) $1.25-$3.40 (Tier 1)C1
Flurbiprofen Sodium flurbiprofen sodium (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Ilevro
ILEVRO (SUSPENSION) $3.80-$8.50 (Tier 2)C1
Ketorolac Tromethamine ketorolac tromethamine (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Lotemax
LOTEMAX (0.5% GEL, 0.5% OINTMENT, 0.5% SUSPENSION)
$3.80-$8.50 (Tier 2)C1
Lotemax SM
LOTEMAX SM (GEL) $3.80-$8.50 (Tier 2)C1
Loteprednol Etabonate loteprednol etabonate (ophthalmic suspension) $1.25-$3.40 (Tier 1)C1
Prednisolone Acetate prednisolone acetate (ophthalmic suspension) $1.25-$3.40 (Tier 1)C1
Prednisolone Sodium Phosphate prednisolone sodium phosphate (1% ophthalmic
solution)$1.25-$3.40 (Tier 1)
C1
Prolensa
PROLENSA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)B1
Ophthalmic Prostaglandin and Prostamide AnalogsC1
Latanoprost
latanoprost (ophthalmic solution) $1.25-$3.40 (Tier 1)C1
Lumigan
LUMIGAN (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Travatan Z
TRAVATAN Z (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Vyzulta
VYZULTA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)C1
Zioptan
ZIOPTAN (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2)A1
Otic Agents
B1
Otic AgentsC1
Acetic Acid
acetic acid (otic solution) $1.25-$3.40 (Tier 1)C1
Ear Drops
ear drops (otic solution)* $0 (Tier 3)C1
Earwax Treatment Drops earwax treatment drops (otic solution)* $0 (Tier 3)C1
Flac
flac (oil) $1.25-$3.40 (Tier 1)C1
Fluocinolone Acetonide fluocinolone acetonide (0.01% otic oil) $1.25-$3.40 (Tier 1)C1
Hydrocortisone/Acetic Acid hydrocortisone/acetic acid (otic solution) $1.25-$3.40 (Tier 1)C1
Neomycin/Polymyxin/Hydrocortisone
neomycin/polymyxin/hydrocortisone (1% otic
solution, 1% otic suspension)$1.25-$3.40 (Tier 1)
122For Track Refered Purpose134122
134
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useA1
Respiratory Tract/Pulmonary Agents
B1
AntihistaminesC1
Aceta-Gesic
aceta-gesic (tablet)* $0 (Tier 3)C1
Ala-Hist IR
ala-hist ir (tablet)* $0 (Tier 3)C1
Ala-Hist PE
ala-hist pe (tablet)* $0 (Tier 3)C1
All Day Allergy
all day allergy (tablet)* $0 (Tier 3)C1
All Day Allergy Childrens all day allergy childrens (10mg tablet chewable,
5mg/5ml oral solution)*$0 (Tier 3)
C1
All Day Allergy-D
all day allergy-d (tablet extended-release 12 hour)* $0 (Tier 3)C1
Aller-Chlor
aller-chlor (tablet)* $0 (Tier 3)C1
Allergy
allergy (tablet)* $0 (Tier 3)C1
Allergy Relief
allergy relief (tablet)* $0 (Tier 3)C1
Allergy Relief D-24 allergy relief d-24 (tablet extended-release 24 hour)* $0 (Tier 3)C1
Azelastine HCl
azelastine hcl (nasal solution) $1.25-$3.40 (Tier 1)C1
Banophen
banophen (otc only) (12.5mg/5ml liquid, 25mg
capsule, 50mg capsule)*$0 (Tier 3)
C1
Cetirizine HCl
cetirizine hcl (otc only) (10mg tablet chewable, 5mg
tablet chewable, 10mg tablet, 5mg tablet)*$0 (Tier 3)
C1
Cetirizine HCl
cetirizine hcl (rx only) (oral solution) $1.25-$3.40 (Tier 1)C1
Cetirizine HCl Allergy Childrens cetirizine hcl allergy childrens (otc only) (oral
solution)*$0 (Tier 3)
C1
Cetirizine HCl Childrens Allergy cetirizine hcl childrens allergy (otc only) (syrup)* $0 (Tier 3)C1
Cetirizine HCl/Pseudoephedrine HCl ER
cetirizine hcl/pseudoephedrine hcl er (otc only)
(tablet extended-release 12 hour)*$0 (Tier 3)
C1
Childrens Allergy childrens allergy (liquid)* $0 (Tier 3)C1
Childrens Loratadine childrens loratadine (5mg/5ml oral solution, 5mg/
5ml syrup)*$0 (Tier 3)
C1
Chlorphen SR
chlorphen sr (tablet extended-release)* $0 (Tier 3)C1
Complete Allergy Medicine complete allergy medicine (otc only) (capsule)* $0 (Tier 3)C1
Cyproheptadine HCl cyproheptadine hcl (2mg/5ml syrup, 4mg tablet) $1.25-$3.40 (Tier 1)C1
Dimaphen Childrens dimaphen childrens (elixir)* $0 (Tier 3)C1
Diphenhist
diphenhist (12.5mg/5ml liquid, 25mg capsule)* $0 (Tier 3)C1
Diphenhydramine HCl diphenhydramine hcl (otc only) (capsule)* $0 (Tier 3)C1
ED A-Hist
ed a-hist (liquid)* $0 (Tier 3)C1
ED Chlorped
ed chlorped (liquid)* $0 (Tier 3)C1
ED Chlorped D
ed chlorped d (liquid)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
123For Track Refered Purpose135123
135
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
ED Chlorped Jr
ed chlorped jr (syrup)* $0 (Tier 3)C1
Fexofenadine HCl fexofenadine hcl (tablet)* $0 (Tier 3)C1
Fexofenadine HCl Childrens Allergy
fexofenadine hcl childrens allergy (suspension)* $0 (Tier 3)C1
GNP All Day Allergy gnp all day allergy (tablet)* $0 (Tier 3)C1
GNP Allergy
gnp allergy (tablet)* $0 (Tier 3)C1
GNP Dayhist Allergy gnp dayhist allergy (tablet)* $0 (Tier 3)C1
GNP Loratadine gnp loratadine (10mg tablet, 5mg/5ml syrup)* $0 (Tier 3)C1
Histex
histex (syrup)* $0 (Tier 3)C1
Histex PD
histex pd (liquid)* $0 (Tier 3)C1
Levocetirizine Dihydrochloride levocetirizine dihydrochloride (5mg tablet) $1.25-$3.40 (Tier 1) QLC1
Lodrane D
lodrane d (capsule)* $0 (Tier 3)C1
LoHist-D
lohist-d (liquid)* $0 (Tier 3)C1
Loratadine
loratadine (tablet)* $0 (Tier 3)C1
Loratadine Childrens loratadine childrens (5mg/5ml oral solution, 5mg/
5ml syrup)*$0 (Tier 3)
C1
Loratadine-D 12hr
loratadine-d 12hr (tablet extended-release 12 hour)* $0 (Tier 3)C1
Loratadine-D 24hr
loratadine-d 24hr (tablet extended-release 24 hour)* $0 (Tier 3)C1
Lortuss LQ
lortuss lq (liquid)* $0 (Tier 3)C1
M-Hist PD
m-hist pd (liquid)* $0 (Tier 3)C1
Nasopen PE
nasopen pe (liquid)* $0 (Tier 3)C1
NoHist-LQ
nohist-lq (liquid)* $0 (Tier 3)C1
Phenadoz
phenadoz (suppository) $1.25-$3.40 (Tier 1)C1
Poly-Hist PD
poly-hist pd (liquid)* $0 (Tier 3)C1
Promethazine HCl promethazine hcl (12.5mg suppository, 25mg
suppository, 6.25mg/5ml syrup)$1.25-$3.40 (Tier 1)
C1
Promethazine HCl promethazine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Promethegan
promethegan (25mg suppository) $1.25-$3.40 (Tier 1)C1
QC Loratadine Allergy Relief qc loratadine allergy relief (tablet)* $0 (Tier 3)C1
QC Loratadine-D
qc loratadine-d (tablet extended-release 24 hour)* $0 (Tier 3)
124For Track Refered Purpose136124
136
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Rescon
rescon (tablet)* $0 (Tier 3)C1
Ru-Hist D
ru-hist d (tablet)* $0 (Tier 3)C1
Rymed
rymed (tablet)* $0 (Tier 3)C1
Rynex PE
rynex pe (elixir)* $0 (Tier 3)C1
Rynex PSE
rynex pse (liquid)* $0 (Tier 3)C1
Siladryl Allergy
siladryl allergy (liquid)* $0 (Tier 3)C1
SM Allergy 4 Hour sm allergy 4 hour (tablet)* $0 (Tier 3)C1
SM Allergy Relief sm allergy relief (1.34mg tablet, 12.5mg/5ml liquid)* $0 (Tier 3)C1
SM Loratadine
sm loratadine (syrup)* $0 (Tier 3)C1
SM Lorata-Dine D sm lorata-dine d (tablet extended-release 24 hour)* $0 (Tier 3)C1
Sudogest Sinus & Allergy sudogest sinus & allergy (tablet)* $0 (Tier 3)C1
Triprolidine HCl
triprolidine hcl (liquid)* $0 (Tier 3)C1
Vanaclear PD
vanaclear pd (liquid)* $0 (Tier 3)C1
Vanahist PD
vanahist pd (liquid)* $0 (Tier 3)C1
Vanamine PD
vanamine pd (liquid)* $0 (Tier 3)C1
Vanatab Ac
vanatab ac (tablet)* $0 (Tier 3)C1
Vanatab DM
vanatab dm (tablet)* $0 (Tier 3)B1
Anti-inflammatories, Inhaled CorticosteroidsC1
Arnuity Ellipta ARNUITY ELLIPTA (100MCG/ACT AEROSOL POWDER,
200MCG/ACT AEROSOL POWDER, 50MCG/ACT AEROSOL POWDER)
$3.80-$8.50 (Tier 2) QL
C1
Budesonide
budesonide (0.25mg/2ml suspension, 0.5mg/2ml
suspension, 1mg/2ml suspension)$1.25-$3.40 (Tier 1) B/D, PA
C1
Budesonide Nasal Spray budesonide nasal spray (otc only) (suspension)* $0 (Tier 3)C1
Flovent Diskus FLOVENT DISKUS (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1
Flovent HFA
FLOVENT HFA (AEROSOL) $3.80-$8.50 (Tier 2) QLC1
Flunisolide
flunisolide (nasal solution) $1.25-$3.40 (Tier 1)C1
Fluticasone Propionate fluticasone propionate (otc only) (suspension)* $0 (Tier 3)C1
Fluticasone Propionate fluticasone propionate (rx only) (50mcg/act
suspension)$1.25-$3.40 (Tier 1)
C1
Triamcinolone Acetonide triamcinolone acetonide (otc only) (aerosol)* $0 (Tier 3)
B1
AntileukotrienesC1
Montelukast Sodium montelukast sodium (10mg tablet, 4mg packet, 4mg
tablet chewable, 5mg tablet chewable)$1.25-$3.40 (Tier 1) QL
C1
Zafirlukast
zafirlukast (tablet) $1.25-$3.40 (Tier 1) QLC1
Zileuton ER
zileuton er (tablet extended-release 12 hour) $1.25-$3.40 (Tier 1) ST
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
125For Track Refered Purpose137125
137
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Zyflo
ZYFLO (TABLET) $3.80-$8.50 (Tier 2) STB1
Bronchodilators, AnticholinergicC1
Atrovent HFA ATROVENT HFA (AEROSOL SOLUTION) $3.80-$8.50 (Tier 2)C1
Incruse Ellipta INCRUSE ELLIPTA (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1
Ipratropium Bromide ipratropium bromide (0.02% inhalation solution) $1.25-$3.40 (Tier 1) B/D, PAC1
Ipratropium Bromide ipratropium bromide (0.03% nasal solution, 0.06%
nasal solution)$1.25-$3.40 (Tier 1)
C1
Lonhala Magnair Starter Kit LONHALA MAGNAIR STARTER KIT (INHALATION
SOLUTION)$3.80-$8.50 (Tier 2) QL
C1
Spiriva HandiHaler SPIRIVA HANDIHALER (CAPSULE) $3.80-$8.50 (Tier 2) QLC1
Spiriva Respimat SPIRIVA RESPIMAT (AEROSOL SOLUTION) $3.80-$8.50 (Tier 2) QL
B1
Bronchodilators, SympathomimeticC1
Albuterol Sulfate albuterol sulfate (0.083% nebulized solution, 0.5%
nebulized solution, 0.63mg/3ml nebulized solution,
1.25mg/3ml nebulized solution)
$1.25-$3.40 (Tier 1) B/D, PA
C1
Albuterol Sulfate albuterol sulfate (2mg tablet immediate-release, 4mg
tablet immediate-release)$1.25-$3.40 (Tier 1)
C1
Epinephrine
epinephrine (0.15mg/0.3ml injection) (brand
equivalent epipen jr), epinephrine (0.3mg/0.3ml
injection) (generic epipen)
$1.25-$3.40 (Tier 1) QL
C1
Levalbuterol HCl
levalbuterol hcl (nebulized solution) $1.25-$3.40 (Tier 1) B/D, PAC1
Perforomist
PERFOROMIST (NEBULIZED SOLUTION) $3.80-$8.50 (Tier 2) B/D, PA, QLC1
ProAir HFA
PROAIR HFA (AEROSOL SOLUTION) $3.80-$8.50 (Tier 2)C1
ProAir RespiClick PROAIR RESPICLICK (AEROSOL POWDER) $3.80-$8.50 (Tier 2)C1
S2
s2 (nebulized solution)* $0 (Tier 3)C1
Serevent Diskus SEREVENT DISKUS (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QL
B1
Cystic Fibrosis AgentsC1
Bethkis
BETHKIS (NEBULIZED SOLUTION) $3.80-$8.50 (Tier 2) B/D, PA, QL
126For Track Refered Purpose138126
138
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Cayston
CAYSTON (INHALATION SOLUTION) $3.80-$8.50 (Tier 2) PA, LAC1
Kalydeco
KALYDECO (150MG TABLET, 25MG PACKET, 50MG PACKET, 75MG PACKET)
$3.80-$8.50 (Tier 2) PA, QL, LAC1
Orkambi
ORKAMBI (PACKET, TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
TOBI Podhaler TOBI PODHALER (CAPSULE) $3.80-$8.50 (Tier 2) PA, QLC1
Tobramycin
tobramycin (nebulized solution) $1.25-$3.40 (Tier 1) B/D, PA, QLB1
Mast Cell StabilizersC1
Cromolyn Sodium cromolyn sodium (otc only) (aerosol solution)* $0 (Tier 3)C1
Cromolyn Sodium cromolyn sodium (rx only) (20mg/2ml nebulized
solution)$1.25-$3.40 (Tier 1) B/D, PA
B1
Phosphodiesterase Inhibitors, Airways DiseaseC1
Daliresp
DALIRESP (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Theophylline
theophylline (oral solution) $1.25-$3.40 (Tier 1)C1
Theophylline ER theophylline er (300mg tablet extended-release 12
hour, 400mg tablet extended-release 24 hour, 600mg
tablet extended-release 24 hour)
$1.25-$3.40 (Tier 1)
B1
Pulmonary AntihypertensivesC1
Adcirca
ADCIRCA (TABLET) $3.80-$8.50 (Tier 2) PA, QLC1
Adempas
ADEMPAS (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1
Alyq
alyq (tablet) $1.25-$3.40 (Tier 1) PA, QLC1
Ambrisentan
ambrisentan (tablet) $1.25-$3.40 (Tier 1) PA, QL, LAC1
Bosentan
bosentan (tablet) $1.25-$3.40 (Tier 1) PA, QL, LAC1
Letairis
LETAIRIS (TABLET) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Opsumit
OPSUMIT (TABLET) $3.80-$8.50 (Tier 2) PA, LAC1
Orenitram
ORENITRAM (TABLET EXTENDED-RELEASE) $3.80-$8.50 (Tier 2) PA, LAC1
Sildenafil
sildenafil (20mg tablet) (generic revatio) $1.25-$3.40 (Tier 1) PA, QLC1
Tadalafil
tadalafil (20mg tablet) $1.25-$3.40 (Tier 1) PA, QLC1
Tracleer
TRACLEER (125MG TABLET, 62.5MG TABLET, 32MG TABLET SOLUBLE)
$3.80-$8.50 (Tier 2) PA, QL, LAC1
Ventavis
VENTAVIS (INHALATION SOLUTION) $3.80-$8.50 (Tier 2) PA, QL, LAB1
Pulmonary Fibrosis AgentsC1
Esbriet
ESBRIET (267MG CAPSULE, 267MG TABLET, 801MG TABLET)
$3.80-$8.50 (Tier 2) PA, QL, LAC1
Ofev
OFEV (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAB1
Respiratory Tract Agents, Other
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
127For Track Refered Purpose139127
139
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
12 Hour Decongestant 12 hour decongestant (tablet extended-release)* $0 (Tier 3)C1
Acetylcysteine
acetylcysteine (inhalation solution) $1.25-$3.40 (Tier 1) B/D, PAC1
Advair Diskus ADVAIR DISKUS (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1
Advair HFA
ADVAIR HFA (AEROSOL) $3.80-$8.50 (Tier 2) QLC1
Alahist CF
alahist cf (tablet)* $0 (Tier 3)C1
Alahist DM
alahist dm (liquid)* $0 (Tier 3)C1
All-Nite Cold & Flu Nighttime Relief
all-nite cold & flu nighttime relief (liquid)* $0 (Tier 3)C1
Anoro Ellipta ANORO ELLIPTA (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1
AP-Hist DM
ap-hist dm (liquid)* $0 (Tier 3)C1
Aprodine
aprodine (tablet)* $0 (Tier 3)C1
Benzonatate
benzonatate (capsule)* $0 (Tier 3)C1
Bevespi Aerosphere BEVESPI AEROSPHERE (AEROSOL) $3.80-$8.50 (Tier 2) QLC1
Breo Ellipta BREO ELLIPTA (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1
Bromfed DM
bromfed dm (rx only) (syrup)* $0 (Tier 3)C1
Bromphen/Pseudoephedrine HCl/Dextromethorphan HBr
bromphen/pseudoephedrine hcl/dextromethorphan
hbr (rx only) (syrup)*$0 (Tier 3)
C1
Brotapp DM
brotapp dm (liquid)* $0 (Tier 3)C1
Cheratussin AC
cheratussin ac (syrup)* $0 (Tier 3)C1
Childrens Silfedrine childrens silfedrine (liquid)* $0 (Tier 3)C1
Chlo Tuss
chlo tuss (liquid)* $0 (Tier 3)C1
Codeine/Guaifenesin codeine/guaifenesin (oral solution)* $0 (Tier 3)C1
Combivent Respimat COMBIVENT RESPIMAT (AEROSOL SOLUTION) $3.80-$8.50 (Tier 2)C1
Cough DM
cough dm (suspension extended-release)* $0 (Tier 3)C1
Cough Syrup
cough syrup (syrup)* $0 (Tier 3)C1
Deconex DMX deconex dmx (tablet)* $0 (Tier 3)C1
Deconex IR
deconex ir (tablet)* $0 (Tier 3)C1
Deep Sea Nasal Spray deep sea nasal spray (nasal solution)* $0 (Tier 3)C1
Delsym
delsym (suspension extended-release)* $0 (Tier 3)C1
Delsym Cough + Chest Congestion DM
delsym cough + chest congestion dm (liquid)* $0 (Tier 3)
128For Track Refered Purpose140128
140
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Delsym Cough + Chest Congestion DM Childrens
delsym cough + chest congestion dm childrens
(liquid)*$0 (Tier 3)
C1
Delsym Cough + Cold Daytime delsym cough + cold daytime (liquid)* $0 (Tier 3)C1
Delsym Cough + Cold Nighttime Childrens
delsym cough + cold nighttime childrens (liquid)* $0 (Tier 3)C1
Delsym Cough Childrens delsym cough childrens (suspension extended-
release)*$0 (Tier 3)
C1
Dextromethorphan Polistirex dextromethorphan polistirex (suspension extended-
release)*$0 (Tier 3)
C1
Dimaphen DM Cold & Cough dimaphen dm cold & cough (elixir)* $0 (Tier 3)C1
ED A-Hist
ed a-hist (4mg-10mg tablet)* $0 (Tier 3)C1
ED A-Hist DM
ed a-hist dm (4mg-10mg-10mg tablet, 4mg/
5ml-15mg/5ml-10mg/5ml liquid)*$0 (Tier 3)
C1
ED A-Hist PSE
ed a-hist pse (tablet)* $0 (Tier 3)C1
ED Bron GP
ed bron gp (liquid)* $0 (Tier 3)C1
EndaCof-DM
endacof-dm (liquid)* $0 (Tier 3)C1
Extra Action Cough extra action cough (syrup)* $0 (Tier 3)C1
Flowtuss
flowtuss (oral solution)* $0 (Tier 3)C1
Fluticasone Propionate/Salmeterol fluticasone propionate/salmeterol (aerosol powder)
(brand equivalent airduo)$1.25-$3.40 (Tier 1) QL
C1
Fluticasone Propionate/Salmeterol Diskus
fluticasone propionate/salmeterol diskus (aerosol
powder) (generic advair)$1.25-$3.40 (Tier 1) QL
C1
GNP Tussin DM gnp tussin dm (liquid)* $0 (Tier 3)C1
Guaifenesin AC
guaifenesin ac (syrup)* $0 (Tier 3)C1
Guaifenesin and Pseudoephedrine HCl
guaifenesin and pseudoephedrine hcl (otc only)
(tablet extended-release 12 hour)*$0 (Tier 3)
C1
Guaifenesin ER
guaifenesin er (tablet extended-release 12 hour)* $0 (Tier 3)C1
Guaifenesin/Codeine guaifenesin/codeine (oral solution)* $0 (Tier 3)C1
Histex-DM
histex-dm (syrup)* $0 (Tier 3)C1
Histex-PE
histex-pe (syrup)* $0 (Tier 3)C1
Hycofenix
hycofenix (oral solution)* $0 (Tier 3)C1
Hydrocodone Bitartrate/Chlorpheniramine Maleate/PSE
hydrocodone bitartrate/chlorpheniramine maleate/
pse (oral solution)*$0 (Tier 3)
C1
Hydrocodone Bitartrate/Homatropine Methylbromide
hydrocodone bitartrate/homatropine methylbromide
(1.5mg-5mg tablet, 1.5mg/5ml-5mg/5ml syrup)*$0 (Tier 3)
C1
Hydrocodone Polistirex/Chlorpheniramine Polistirex
hydrocodone polistirex/chlorpheniramine polistirex
(suspension extended-release)*$0 (Tier 3)
C1
Hydromet
hydromet (syrup)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
129For Track Refered Purpose141129
141
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Ipratropium Bromide/Albuterol Sulfate
ipratropium bromide/albuterol sulfate (inhalation
solution)$1.25-$3.40 (Tier 1) B/D, PA
C1
Kidkare Cough/Cold kidkare cough/cold (liquid)* $0 (Tier 3)C1
LoHist-DM
lohist-dm (syrup)* $0 (Tier 3)C1
Lortuss DM
lortuss dm (liquid)* $0 (Tier 3)C1
Lortuss EX
lortuss ex (liquid)* $0 (Tier 3)C1
Mapap Cold Formula Multi-Symptom
mapap cold formula multi-symptom (tablet)* $0 (Tier 3)C1
Mapap Sinus Maximum Strength Congestion and Pain
mapap sinus maximum strength congestion and pain
(tablet)*$0 (Tier 3)
C1
M-END DMX
m-end dmx (liquid)* $0 (Tier 3)C1
M-Hist DM
m-hist dm (liquid)* $0 (Tier 3)C1
Mucinex
mucinex (otc only) (tablet extended-release 12 hour)* $0 (Tier 3)C1
Mucinex Chest Congestion Childrens
mucinex chest congestion childrens (liquid)* $0 (Tier 3)C1
Mucinex Childrens Cold Cough & Sore Throat
mucinex childrens cold cough & sore throat (liquid)* $0 (Tier 3)C1
Mucinex Childrens Multi-Symptom Cold & Fever
mucinex childrens multi-symptom cold & fever
(liquid)*$0 (Tier 3)
C1
Mucinex Childrens Multi-Symptom Cold
mucinex childrens multi-symptom cold (liquid)* $0 (Tier 3)C1
Mucinex Congestion & Cough Childrens
mucinex congestion & cough childrens (liquid)* $0 (Tier 3)C1
Mucinex Cough Childrens mucinex cough childrens (liquid)* $0 (Tier 3)C1
Mucinex Cough for Kids mucinex cough for kids (packet)* $0 (Tier 3)C1
Mucinex D
mucinex d (otc only) (tablet extended-release 12
hour)*$0 (Tier 3)
C1
Mucinex D Maximum Strength mucinex d maximum strength (tablet extended-
release 12 hour)*$0 (Tier 3)
C1
Mucinex DM
mucinex dm (otc only) (tablet extended-release 12
hour)*$0 (Tier 3)
C1
Mucinex DM Maximum Strength mucinex dm maximum strength (tablet extended-
release 12 hour)*$0 (Tier 3)
C1
Mucinex Fast-Max Cold & Sinus mucinex fast-max cold & sinus (tablet)* $0 (Tier 3)
130For Track Refered Purpose142130
142
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Mucinex Fast-Max Cold Flu & Sore Throat
mucinex fast-max cold flu & sore throat
(325mg-10mg-200mg-5mg tablet, 650mg/
20ml-20mg/20ml-400mg/20ml-10mg/20ml liquid)*
$0 (Tier 3)
C1
Mucinex Fast-Max Day Time/Night Time
mucinex fast-max day time/night time (liquid)* $0 (Tier 3)C1
Mucinex Fast-Max Day/Night Maximum Strength
mucinex fast-max day/night maximum strength* $0 (Tier 3)C1
Mucinex Fast-Max DM Max mucinex fast-max dm max (liquid)* $0 (Tier 3)C1
Mucinex Fast-Max Night Time Cold & Flu
mucinex fast-max night time cold & flu (liquid)* $0 (Tier 3)C1
Mucinex Fast-Max Severe Cold mucinex fast-max severe cold
(325mg-10mg-200mg-5mg tablet, 325mg/
10ml-10mg/10ml-200mg/10ml-5mg/10ml liquid)*
$0 (Tier 3)
C1
Mucinex Fast-Max Severe Congestion & Cough
mucinex fast-max severe congestion & cough
(tablet)*$0 (Tier 3)
C1
Mucinex for Kids
mucinex for kids (packet)* $0 (Tier 3)C1
Mucinex Maximum Strength mucinex maximum strength (tablet extended-release
12 hour)*$0 (Tier 3)
C1
Mucinex Multi-Symptom Cold Day/Night Pack
mucinex multi-symptom cold day/night pack (liquid)* $0 (Tier 3)C1
Mucinex Multi-Symptom Cold Night Time Childrens
mucinex multi-symptom cold night time childrens
(liquid)*$0 (Tier 3)
C1
Mucinex Sinus-Max Pressure & Pain mucinex sinus-max pressure & pain (tablet)* $0 (Tier 3)C1
Mucinex Stuffy Nose & Cold Childrens
mucinex stuffy nose & cold childrens (liquid)* $0 (Tier 3)C1
Mucus Relief
mucus relief (tablet)* $0 (Tier 3)C1
Mucus Relief Sinus mucus relief sinus (tablet)* $0 (Tier 3)C1
Nasal Decongestant nasal decongestant (1% nasal solution, 30mg/5ml
syrup)*$0 (Tier 3)
C1
Nasal Decongestant Spray nasal decongestant spray (nasal solution)* $0 (Tier 3)C1
Night Time Multi-Symptom Cold/Flu Relief
night time multi-symptom cold/flu relief (capsule)* $0 (Tier 3)C1
NinjaCof
ninjacof (liquid)* $0 (Tier 3)C1
NinjaCof-A
ninjacof-a (liquid)* $0 (Tier 3)C1
NinjaCof-XG
ninjacof-xg (liquid)* $0 (Tier 3)C1
NoHist-DM
nohist-dm (liquid)* $0 (Tier 3)C1
Nucala
NUCALA (100MG INJECTION, 100MG/ML SOLUTION AUTO INJECTOR, 100MG/ML SOLUTION PREFILLED SYRINGE)
$3.80-$8.50 (Tier 2) PA, QL, LA
C1
Pain Relief Sinus PE Daytime pain relief sinus pe daytime (tablet)* $0 (Tier 3)C1
Pediatric Cough/Cold pediatric cough/cold (liquid)* $0 (Tier 3)C1
Phenylephrine HCl/Pyrilamine Maleate
phenylephrine hcl/pyrilamine maleate (tablet)* $0 (Tier 3)C1
Poly Hist Forte
poly hist forte (tablet)* $0 (Tier 3)C1
Poly-Hist DM
poly-hist dm (liquid)* $0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12.CAPITALIZED = brand name drug lower-case italics = generic drug* OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.
131For Track Refered Purpose143131
143
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Poly-Vent DM
poly-vent dm (tablet)* $0 (Tier 3)C1
Poly-Vent IR
poly-vent ir (tablet)* $0 (Tier 3)C1
Promethazine VC/Codeine promethazine vc/codeine (syrup)* $0 (Tier 3)C1
Promethazine/Codeine promethazine/codeine (syrup)* $0 (Tier 3)C1
Promethazine/Phenylephrine promethazine/phenylephrine (syrup) $1.25-$3.40 (Tier 1)C1
Promethazine-DM promethazine-dm (syrup)* $0 (Tier 3)C1
Pseudoephedrine HCl pseudoephedrine hcl (otc only) (tablet)* $0 (Tier 3)C1
Pulmosal
pulmosal (nebulized solution)* $0 (Tier 3)C1
Pulmozyme
PULMOZYME (INHALATION SOLUTION) $3.80-$8.50 (Tier 2) B/D, PA, QLC1
Respaire-30
respaire-30 (capsule)* $0 (Tier 3)C1
Robafen
robafen (syrup)* $0 (Tier 3)C1
Robafen CF Multi-Symptom Cold
robafen cf multi-symptom cold (liquid)* $0 (Tier 3)C1
Robafen Cough robafen cough (capsule)* $0 (Tier 3)C1
Robafen DM
robafen dm (syrup)* $0 (Tier 3)C1
Robafen DM Cough Clear robafen dm cough clear (syrup)* $0 (Tier 3)C1
Robafen DM Cough/Chest Congestion
robafen dm cough/chest congestion (liquid)* $0 (Tier 3)C1
Rynex DM
rynex dm (liquid)* $0 (Tier 3)C1
Siltussin DM DAS
siltussin dm das (liquid)* $0 (Tier 3)C1
Siltussin SA
siltussin sa (syrup)* $0 (Tier 3)C1
Siltussin-DM
siltussin-dm (syrup)* $0 (Tier 3)C1
SM Nasal Spray 12 Hour sm nasal spray 12 hour (nasal solution)* $0 (Tier 3)C1
SM Tussin DM
sm tussin dm (syrup)* $0 (Tier 3)C1
SM Tussin DM Cough/Chest Congestion
sm tussin dm cough/chest congestion (syrup)* $0 (Tier 3)C1
Sodium Chloride
sodium chloride (otc only) (3% nebulized solution,
7% nebulized solution)*$0 (Tier 3)
C1
Stahist AD
stahist ad (tablet, liquid)* $0 (Tier 3)C1
Stiolto Respimat STIOLTO RESPIMAT (AEROSOL SOLUTION) $3.80-$8.50 (Tier 2) QLC1
Sudogest
sudogest (otc only) (tablet)* $0 (Tier 3)C1
Sudogest 12 Hour sudogest 12 hour (tablet extended-release)* $0 (Tier 3)
132For Track Refered Purpose144132
144
Name of DrugWhat the drug
will cost you
(tier level)
Necessary
actions,
restrictions, or
limits on useC1
Sudogest PE
sudogest pe (tablet)* $0 (Tier 3)C1
Symbicort
SYMBICORT (AEROSOL) $3.80-$8.50 (Tier 2) QLC1
Trelegy Ellipta TRELEGY ELLIPTA (AEROSOL POWDER) $3.80-$8.50 (Tier 2) QLC1
Tussin DM
tussin dm (liquid)* $0 (Tier 3)C1
VanaCof
vanacof (liquid)* $0 (Tier 3)C1
VanaCof DM
vanacof dm (liquid)* $0 (Tier 3)C1
VanaCof-8
vanacof-8 (liquid)* $0 (Tier 3)C1
Virtussin A/C
virtussin a/c (oral solution)* $0 (Tier 3)C1
Virtussin DAC
virtussin dac (oral solution)* $0 (Tier 3)C1
Wixela Inhub
wixela inhub (aerosol powder) (generic advair) $1.25-$3.40 (Tier 1) QLC1
Zutripro
zutripro (oral solution)* $0 (Tier 3)A1
Skeletal Muscle Relaxants
B1
Skeletal Muscle RelaxantsC1
Baclofen
baclofen (10mg tablet, 20mg tablet, 5mg tablet) $1.25-$3.40 (Tier 1)C1
Chlorzoxazone
chlorzoxazone (500mg tablet) $1.25-$3.40 (Tier 1)C1
Cyclobenzaprine HCl cyclobenzaprine hcl (tablet) $1.25-$3.40 (Tier 1)C1
Dantrolene Sodium dantrolene sodium (capsule) $1.25-$3.40 (Tier 1)C1
Tizanidine HCl
tizanidine hcl (tablet) $1.25-$3.40 (Tier 1)A1
Sleep Disorder Agents
B1
GABA Receptor ModulatorsC1
Temazepam
temazepam (15mg capsule, 30mg capsule) $1.25-$3.40 (Tier 1) QLC1
Zaleplon
zaleplon (capsule) $1.25-$3.40 (Tier 1) QLC1
Zolpidem Tartrate zolpidem tartrate (10mg tablet immediate-release,
5mg tablet immediate-release)$1.25-$3.40 (Tier 1) QL
B1
Sleep Disorders, OtherC1
Belsomra
BELSOMRA (TABLET) $3.80-$8.50 (Tier 2) QLC1
Hetlioz
HETLIOZ (CAPSULE) $3.80-$8.50 (Tier 2) PA, QL, LAC1
Modafinil
modafinil (tablet) $1.25-$3.40 (Tier 1) PA, QLC1
Night Time Sleep Aid night time sleep aid (tablet)* $0 (Tier 3)C1
Ramelteon
ramelteon (tablet) $1.25-$3.40 (Tier 1) QLC1
Rozerem
ROZEREM (TABLET) $3.80-$8.50 (Tier 2) QLC1
SM Sleep Aid
sm sleep aid (tablet)* $0 (Tier 3)C1
Xyrem
XYREM (ORAL SOLUTION) $3.80-$8.50 (Tier 2) PA, QL, LA
145145
For Track Refered Purpose
E. Index of Covered Drugs
#
12 Hour Decongestant........139
1st Tier Unilet ComforTouch Lancets 28g....................... 113
1st Tier Unilet ComforTouch Lancets 30g....................... 113
A
A Thru Z Advanced................72
A Thru Z Select...................... 72
A Thru Z Select 50 + Advanced Formula................................ 72
A Thru Z Select Advanced....72
A Thru Z Select Ultimate Womens............................... 72
A Thru Z Ultimate Mens........ 72
A-10000.................................. 72
Abacavir..................................43
Abacavir Sulfate/Lamivudine44
Abacavir Sulfate/Lamivudine/Zidovudine........................... 44
Abc Plus Senior Adults 50+.. 72
Abelcet....................................30
Abilify Maintena..................... 40
Abiraterone Acetate...............34
Abstral.....................................16
Acamprosate Calcium DR.... 18
Acarbose................................ 46
Accu-Chek Aviva Plus......... 113
Accu-Chek Compact Plus...113
Accu-Chek Fastclix Lancet Device Kit...........................113
Accu-Chek Fastclix Lancets............................................ 113
Accu-Chek Guide................ 113
Accu-Chek Multiclix Lancet Device Kit...........................113
Accu-Chek Multiclix Lancets............................................ 113
Accu-Chek Safe-T-Pro Lancets............................................ 113
Accu-Chek Safe-T-Pro Pluslancets........................ 113
Accu-Chek Smartview Strips............................................ 113
Accu-Chek Soft Touch Lancets............................................ 113
Accu-Chek Softclix Lancet Device Kit...........................113
Accu-Chek Softclix Lancets114
Accutrend Glucose..............114
Acephen................................. 13
Acerola C 500........................ 72
Aceta-Gesic..........................134
Acetaminophen......................13
Acetaminophen/Codeine......16
Acetaminophen/Diphenhydramine................13
Acetazolamide....................... 53
Acetazolamide ER................. 53
Acetic Acid...........................133
Acetylcysteine......................139
Acid Gone.............................. 93
Acid Reducer Maximum Strength................................95
Acitretin.................................. 58
Acne Medication 10.............. 58
Acne Medication 5.................58
Actemra................................ 110
Actemra Actpen...................110
ActHIB.................................. 110
Acti-Lance Lancets 28g...... 114
Acti-Lance Lite Safety Lancets 28g..................................... 114
Acti-Lance Special Safety Lancets 17g....................... 114
Acti-Lance Special Safetylancets 17g..............114
Acti-Lance Universal Safety Lancets 23g....................... 114
Actical..................................... 73
Actidose/Sorbitol...................93
Actimmune...........................110
Active 1st Blood Lancets 30g/Easy Twist Cap.................. 114
Acyclovir................................. 42
Acyclovir Sodium...................42
Adacel...................................110
Adapalene.............................. 58
Adcirca................................. 138
Adempas.............................. 138
Adjustable Lancing Device. 114
Advair Diskus....................... 139
Advair HFA........................... 139
Advance Micro-Draw Test Strips.................................. 114
Advanced Stress Formula/Zinc.............................................. 73
Advantage Care Oral Electrolyte Pediatric............ 60
Advocate Lancets................114
Advocate Lancets 30g........ 114
146146
Advocate Lancing Device... 114
Advocate Rapid-Safe Lancing Device................................ 114
Advocate Redi-Code........... 114
Advocate Redi-Code+ Test Strips.................................. 114
Advocate Safety Lancets.... 114
Advocate Safety Lancets 26g............................................ 114
Advocate Test Strips........... 114
Afinitor.................................... 36
Afinitor Disperz...................... 36
Agamatrix Amp No Code Test Strips.................................. 114
Agamatrix Jazz Test Strips. 114
Agamatrix Presto Test Strips............................................ 114
Agamatrix Ultra-Thin Lancets 33g..................................... 114
Aimovig...................................32
Akwa Tears...........................130
Ala Cort.................................100
Ala-Hist IR.............................134
Ala-Hist PE............................134
Alahist CF............................. 139
Alahist DM............................139
Alba-Lybe NR....................... 114
Albendazole........................... 38
Albenza...................................38
Albuterol Sulfate.................. 137
Alclometasone Dipropionate............................................ 100
Alcohol Prep Pads...............114
Alecensa.................................36
Alendronate Sodium........... 112
Alfuzosin HCl ER....................99
Alinia....................................... 38
All Day Allergy......................134
All Day Allergy Childrens.... 134
All Day Allergy-D.................. 134
All Day Relief..........................14
All-Nite Cold & Flu Nighttime Relief.................................. 139
Aller-Chlor.............................134
Allergy...................................134
Allergy Relief........................134
Allergy Relief D-24............... 134
Allopurinol.............................. 32
Almacone............................... 94
Almacone Double Strength.. 94
Alosetron HCl.........................96
Alphagan P...........................132
Alprazolam............................. 45
Altavera.................................102
Alternate Site Lancing Device............................................ 114
Aluminum Hydroxide.............94
Alunbrig.................................. 36
Alyacen 1/35........................102
Alyq.......................................138
Amantadine HCl.....................39
AmBisome..............................30
Ambrisentan.........................138
Amethia................................ 102
Amethia Lo...........................102
Amikacin Sulfate....................19
Amiloride HCl.........................53
Amiloride/Hydrochlorothiazide.............................................. 52
Aminosyn II.............................60
Aminosyn-PF.......................... 60
Amiodarone HCl.................... 50
Amitiza.................................... 96
Amitriptyline HCl....................29
Amlodipine Besylate..............51
Amlodipine Besylate/Atorvastatin Calcium...........52
Amlodipine Besylate/Benazepril HCl.....................52
Ammonium Lactate............... 58
Amoxapine............................. 29
Amoxicillin.............................. 22
Amoxicillin/Clavulanate Potassium............................ 22
Amoxicillin/Clavulanate Potassium ER...................... 22
Amphetamine/Dextroamphetamine........... 56
Amphotericin B...................... 30
Ampicillin................................22
Ampicillin Sodium..................22
Ampicillin-Sulbactam.............22
Ampyra................................... 57
Anadrol-50............................102
Anagrelide HCl.......................49
Anastrozole............................ 36
Androderm........................... 102
Animal Chews........................ 73
Animal Shapes.......................73
Animal Shapes/Iron...............73
Anoro Ellipta.........................139
147147
Antacid Calcium Extra Strength................................94
Antacid Calcium Regular Strength................................94
Antacid Extra Strength.......... 94
Antacid Maximum Strength.. 94
Antacid Plus Anti-Gas Relief. 94
Anti-Diarrheal..........................94
Anti-Fungal Powder............... 30
Antifungal............................... 30
Anu-Med................................. 58
AP-Hist DM...........................139
Apatate Forte......................... 73
Apetex.....................................73
Apetigen................................. 73
Apetigen-Plus.........................73
Apokyn....................................39
Apraclonidine.......................132
Aprepitant...............................30
Apri....................................... 102
Apriso................................... 112
Aprodine...............................139
Aptiom.................................... 26
Aptivus....................................44
Aqua Lance Adjustable Lancing Device..................114
AquADEKs..............................73
Aqueous Vitamin D Infants... 73
Aqueous Vitamin E................ 73
Aralast NP...............................98
Aranelle................................ 102
Aranesp Albumin Free.......... 49
Arcalyst.................................110
Aripiprazole............................ 40
Aripiprazole ODT................... 40
Aristada.................................. 40
Aristada Initio......................... 40
Arnuity Ellipta.......................136
Artificial Tears...................... 130
Ascorbic Acid.........................73
Ashlyna.................................102
Aspir-Low................................14
Aspirin.....................................14
Aspirin EC...............................14
Aspirin Low Dose...................14
Aspirin/Dipyridamole............ 49
Assure 4 Test Strips............ 114
Assure Comfort Lancets Ultra Thin 28g............................. 114
Assure Comfort Lancets Ultra Thin 30g............................. 114
Assure Haemolance Plus High Flow 18g............................ 114
Assure Haemolance Plus Low Flow 25g............................ 114
Assure Haemolance Plus Micro Flow 28g..................114
Assure Haemolance Plus Normal Flow 21g............... 114
Assure Haemolance Plus Pediatric Blade.................. 114
Assure Lance Lancets.........114
Assure Lance Lancets 21g. 115
Assure Lance Plus Safety Lancets 25g....................... 115
Assure Lance Plus Safety Lancets 30g....................... 115
Assure Platinum Test Strips............................................ 115
Assure Prism Multi Test Strips............................................ 115
Atazanavir Sulfate.................. 44
Atenolol.................................. 51
Atenolol/Chlorthalidone........52
Atomoxetine........................... 56
Atorvastatin Calcium............. 54
Atovaquone............................ 38
Atovaquone/Proguanil HCl...38
Atripla..................................... 43
Atropine Sulfate................... 130
Atrovent HFA........................137
Aubagio.................................. 57
Aubra.................................... 102
Augmented Betamethasone Dipropionate......................100
Auryxia....................................72
Austedo.................................. 56
Auto-Lancet Mini..................115
Autolet Impression Lancing Device................................ 115
Autolet Lancing Device....... 115
Autolet Plus..........................115
Avandia...................................46
Aviane...................................102
Avonex....................................57
Avonex Pen............................ 57
Azathioprine......................... 108
Azelaic Acid............................58
Azelastine HCl............. 131, 134
Azithromycin.......................... 23
Aztreonam.............................. 22
B
B Complex..............................73
148148
B Complex/C......................... 73
B Complex/Folic Acid........... 73
B-1...........................................73
B-12.........................................73
B-12 Dots................................74
B-12 TR...................................74
B-2...........................................74
B-6...........................................74
B-Complex..............................74
B-Complex Formula 1............74
B-Complex Plus Vitamin C.... 74
B-Complex w/C......................74
B-Complex with B-12............. 74
B-Complex/C......................... 74
B-Complex/Vitamin C/High Potency................................ 74
B12..........................................74
B6 Natural.............................. 74
Bacitracin............................... 20
Bacitracin Zinc....................... 20
Bacitracin/Neomycin/Polymyxin.............................20
Bacitracin/Polymyxin B.......130
Baclofen............................... 144
Balance B-100........................74
Balance B-50..........................74
Balanced B-100......................74
Balanced B-50........................74
Balanced B-50 Complex....... 74
Balsalazide Disodium..........112
Balversa..................................36
Balziva.................................. 102
Banophen.............................134
Banzel..................................... 26
Baraclude............................... 42
Bayer Breeze 2 Test Disc....115
Bayer Contour Blood Glucose Test Strips..........................115
Bayer Microlet 2 Lancing Device................................ 115
Bayer Microlet Lancets....... 115
BCG Vaccine........................110
BD Lancet Ultrafine 30g......115
BD Lancet Ultrafine 33g......115
BD Microtainer Lancets...... 115
Bee Zee.................................. 74
Belsomra.............................. 144
Benazepril HCl....................... 50
Benazepril HCl/Hydrochlorothiazide............52
Benlysta................................110
Benznidazole..........................38
Benzonatate......................... 139
Benzoyl Peroxide...................58
Benzoyl Peroxide Wash........ 58
Benztropine Mesylate............39
Bepreve................................ 132
Berinert.................................108
Beta Carotene........................ 74
Betamethasone Dipropionate............................................ 100
Betamethasone Valerate.....100
Betaseron............................... 57
Betaxolol HCl....................... 132
Bethanechol Chloride............99
Bethkis..................................137
Betimol................................. 132
Bevespi Aerosphere............139
Bexarotene............................. 38
Bexsero................................ 110
Bicalutamide.......................... 34
Bicillin C-R.............................. 22
Bicillin L-A...............................23
Biktarvy................................... 44
Biltricide..................................38
Binosto................................. 112
Biocal......................................74
Biosupp.................................. 74
Biotin.......................................74
Biotin 5000............................. 74
Biotin/Maximum Strength.....74
Biovol...................................... 74
Bisacodyl EC..........................96
Biscolax.................................. 96
Bismatrol................................ 94
Bismatrol Maximum Strength.............................................. 94
Blephamide..........................130
Blephamide S.O.P............... 130
Blisovi 24 Fe.........................102
Blisovi Fe 1.5/30..................102
Blood Glucose Test Strips..115
Blood Glucose Test Strips Premium.............................115
Blue Gel..................................58
Boostrix................................ 110
Bosentan.............................. 138
Bosulif.....................................36
Braftovi................................... 36
Breo Ellipta...........................139
149149
Briellyn..................................102
Brilinta.....................................49
Brimonidine Tartrate........... 132
Briviact....................................25
Bromfed DM.........................139
Bromocriptine Mesylate........ 39
Bromphen/Pseudoephedrine HCl/Dextromethorphan HBr............................................ 139
Brotapp DM..........................139
Budesonide................. 112, 136
Budesonide ER....................112
Budesonide Nasal Spray.... 136
Bullseye Mini Safety Lancets............................................ 115
Bumetanide............................53
Buprenorphine.......................15
Buprenorphine HCl................18
Buprenorphine HCl/Naloxone HCl........................................18
Bupropion HCl....................... 27
Bupropion HCl SR...........18, 28
Bupropion HCl XL..................28
Buspirone HCl........................45
Butalbital/Acetaminophen....13
Butalbital/Acetaminophen/Caffeine 50mg-325mg-40mg Tablet, 50mg-325mg-40mg Capsule)...............................13
Butalbital/Aspirin/Caffeine... 13
Butorphanol Tartrate............. 16
Bydureon Bcise..................... 46
Bydureon Pen........................ 46
Byetta......................................46
Bystolic................................... 51
C
C 1000.................................... 74
C 1000/Bioflavonoids/Rosehips.............................. 74
C 250...................................... 74
C 500...................................... 74
C Complex..............................75
C-1000.................................... 75
C-1000 Prolonged Release...75
C-1000/Rose Hips................. 75
C-250...................................... 75
C-500...................................... 75
C-500 Prolonged Release..... 75
C-500/Rose Hips................... 75
C-Chewable............................75
Cabergoline..........................107
Cablivi..................................... 49
Cabometyx............................. 36
Cal-Gest Antacid.................... 94
Cal-Mag-Zinc-D.......................62
Calcet Petites......................... 60
Calci-Chew............................. 60
Calcidol...................................75
Calcipotriene..........................58
Calcitonin-Salmon............... 112
Calcitrate................................ 60
Calcitriol......................... 58, 113
Calcium...................................60
Calcium + D3..........................60
Calcium 500 + D.................... 61
Calcium 500 + D High Potency.............................................. 61
Calcium 500 + D3.................. 61
Calcium 500+d.......................61
Calcium 500+d3.....................61
Calcium 500/D.......................61
Calcium 500/Vitamin D3.......61
Calcium 600........................... 61
Calcium 600 + D.................... 61
Calcium 600 + D High Potency.............................................. 61
Calcium 600 + D Plus Minerals.............................................. 61
Calcium 600 + D3.................. 61
Calcium 600 + D3 Plus Minerals................................61
Calcium 600 High Potency... 61
Calcium 600 with Vitamin D..61
Calcium 600+D...................... 61
Calcium 600/Vitamin D......... 61
Calcium 600/Vitamin D3.......61
Calcium Acetate.....................72
Calcium Antacid.................... 94
Calcium Antacid Extra Strength................................94
Calcium Carbonate......... 61, 94
Calcium Carbonate/D3......... 61
Calcium Carbonate/Vitamin D.............................................. 61
Calcium Citrate...................... 61
Calcium Citrate + D............... 62
Calcium Citrate + D3............. 62
Calcium Citrate + D3 Max Imum.................................... 62
Calcium Citrate + D3 Maximum.............................................. 62
Calcium Citrate Malate/Vitamin D........................................... 62
150150
Calcium Citrate Plus/Magnesium.......................... 62
Calcium Citrate w/D.............. 62
Calcium Citrate/Vitamin D.... 62
Calcium Citrate/Vitamin D3.. 62
Calcium Extra D3................... 62
Calcium for Women...............62
Calcium Gluconate................ 62
Calcium High Potency...........62
Calcium High Potency + Vitamin D..............................62
Calcium Oyster Shell............. 62
Calcium Plus Vitamin D3.......62
Calcium+d3............................ 62
Calcium/C/D..........................62
Calcium/Magnesium/Zinc....62
Calcium/Vitamin D.................62
Calcium/Vitamin D3.............. 62
Calquence.............................. 36
Caltrate 600 + D.....................62
Caltrate 600 + D Plus Minerals.............................................. 62
Caltrate 600 + D3 Soft Chews.............................................. 62
Camila...................................106
Camrese Lo..........................102
Canasa..................................112
Candesartan Cilexetil............ 50
Candesartan Cilexetil/Hydrochlorothiazide............52
Caprelsa................................. 36
Capsaicin................................58
Captopril.................................50
Captopril/Hydrochlorothiazide.............................................. 52
Carafate.................................. 97
Carbaglu.................................62
Carbamazepine......................26
Carbamazepine ER................26
Carbidopa/Levodopa............39
Carbidopa/Levodopa ER......39
Carbidopa/Levodopa ODT... 39
Carbidopa/Levodopa/Entacapone..........................39
Careone Advanced Lancing Device................................ 115
Careone Blood Glucose Test Strips/Premium................. 115
Careone Blood Glucose Test Strips/Value....................... 115
Careone Lancet Ultra Thin..115
Caresens N Blood Glucose Test Strips..........................115
Caretouch Blood Glucose Test Strips.................................. 115
Caretouch Lancing Device with Ejector................................ 115
Caretouch Twist Lancets 28g............................................ 115
Caretouch Twist Lancets 30g............................................ 115
Caretouch Twist Lancets 33g............................................ 115
Carteolol HCl........................132
Cartia XT.................................51
Carvedilol................................51
Caspofungin Acetate.............30
Cayston................................ 138
Caziant..................................102
Cefaclor.................................. 21
Cefadroxil............................... 21
Cefazolin Sodium.................. 21
Cefdinir................................... 21
Cefepime................................ 21
Cefixime..................................21
Cefotaxime Sodium............... 21
Cefotetan................................21
Cefoxitin Sodium................... 21
Cefpodoxime Proxetil............21
Cefprozil................................. 21
Ceftazidime............................ 21
Ceftriaxone Sodium...............21
Cefuroxime Axetil.................. 21
Cefuroxime Sodium...............22
Celontin.................................. 25
Centamin................................ 75
Centravites............................. 75
Centravites 50 Plus................75
Centrum..................................75
Centrum Adults......................75
Centrum Kids Complete........75
Centrum Silver....................... 75
Centrum Silver Adult 50+......75
Centrum Silver Ultra Womens.............................................. 75
Centrum Specialist Heart......75
Centrum Ultra Mens.............. 75
Centrum Ultra Womens.........76
Cephalexin............................. 22
Cerovite Advanced Formula. 76
Cerovite Jr.............................. 76
151151
Certa Plus...............................76
Certavite Senior/Antioxidant Nutrients...............................76
Certavite/Antioxidants...........76
Cesamet................................. 30
Cetirizine HCl....................... 134
Cetirizine HCl Allergy Childrens............................................ 134
Cetirizine HCl Childrens Allergy............................................ 134
Cetirizine HCl/Pseudoephedrine HCl ER 134
Chantix....................................18
Chantix Continuing Month Pak.............................................. 18
Chantix Starting Month Pak..19
Chemet................................... 72
Chenodal................................ 94
Cheratussin AC....................139
Chewable Calcium.................62
Chewable Vitamin C.............. 76
Chewable Vite Childrens.......76
Chewable Vite with Iron/Childrens..............................76
Childrens Allergy................. 134
Childrens Aspirin................... 14
Childrens Chewable Multivitamin..........................76
Childrens Chewable Vitamin 76
Childrens Chewable Vitamins.............................................. 76
Childrens Chewable Vitamins/Iron........................................76
Childrens Ibuprofen...............14
Childrens Loratadine...........134
Childrens Silfedrine............. 139
Childs Ibuprofen.................... 14
Chlo Tuss............................. 139
Chlordiazepoxide HCl........... 45
Chlorhexidine Gluconate Oral Rinse.................................... 57
Chloroquine Phosphate........ 38
Chlorothiazide........................54
Chlorphen SR...................... 134
Chlorpromazine HCl.............. 40
Chlorthalidone....................... 54
Chlorzoxazone..................... 144
Cholbam................................. 98
Cholestyramine......................54
Cholestyramine Light............ 54
Ciclopirox............................... 30
Ciclopirox Nail Lacquer.........30
Ciclopirox Olamine................ 30
Cilostazol................................ 49
Cimduo................................... 44
Cimetidine.............................. 95
Cimetidine HCl.......................95
Cimzia...................................108
Cinacalcet HCl..................... 113
Cinryze..................................108
Ciprofloxacin.......................... 24
Ciprofloxacin HCl...................24
Ciprofloxacin I.V. in D5W...... 24
Citalopram HBr...................... 28
Citracal + D3 Maximum.........62
Citracal Maximum..................62
Citrus Calcium + D.................62
Claravis................................... 58
Clarithromycin........................23
Clarithromycin ER..................23
Clenpiq................................... 96
Clever Chek Auto-Code Test Strips.................................. 116
Clever Chek Auto-Code Voice Test Strips..........................116
Clever Chek Lancets Ultrathin............................................ 116
Clever Chek Lancets Ultrathin 30g..................................... 116
Clever Chek Test Strips...... 116
Clever Choice Auto-Code Pro Test Strips..........................116
Clever Choice Comfort EZ Lancets 23g....................... 116
Clever Choice Comfort EZ Lancets 28g....................... 116
Clever Choice Micro Test Strips.................................. 116
Clever Choice No Coding Test Strips.................................. 116
Clever Choice Talk No Coding Test Strips..........................116
Climara Pro.......................... 102
Clindamycin HCl.................... 20
Clindamycin Palmitate HCl... 20
Clindamycin Phosphate..20, 58
Clindamycin Phosphate in D5W......................................20
Clindamycin/Benzoyl Peroxide.............................................. 58
Clobazam............................... 25
Clobetasol Propionate........ 100
Clobetasol Propionate Emollient............................ 100
152152
Clomipramine HCl................. 29
Clonazepam........................... 45
Clonazepam ODT.................. 45
Clonidine HCl......................... 49
Clonidine HCl ER...................56
Clopidogrel.............................49
Clorazepate Dipotassium......45
Clotrimazole........................... 30
Clotrimazole Anti-Fungal.......30
Clotrimazole/Betamethasone Dipropionate........................ 58
Clozapine................................41
Clozapine ODT.......................41
Coaguchek Lancets............ 116
Coartem..................................38
Coats Aloe Creme................. 58
Coats Aloe Gelly.................... 58
Coats Aloe Moisturizing Lotion.............................................. 58
Codeine Sulfate..................... 16
Codeine/Guaifenesin.......... 139
Colchicine...............................32
Coleman Botanicals Insectrepellent..................... 58
Coleman Insect Repellent/High & Dry............................58
Coleman Skinsmart Insect Repellent..............................58
Colesevelam HCl................... 54
Colestipol HCl........................ 54
Colistimethate Sodium..........20
Colocort................................112
Combigan.............................132
Combivent Respimat...........139
Cometriq.................................36
Comfort Assured Lancets Micro Thin 33g.................. 116
Comfort Assured Lancets Super Thin 28g..................116
Comfort Lancets.................. 116
Companion.............................76
Compete.................................76
Complera................................43
Complete................................76
Complete Allergy Medicine 134
Complex B-100...................... 76
Compro...................................29
Constulose............................. 96
Contour Next Blood Glucose Test.....................................116
Cool Blood Glucose Test Strips.................................. 116
Copiktra.................................. 35
Coral Calcium........................ 62
Corlanor..................................52
Cortisone Acetate................100
Cosentyx.................................58
Cosentyx Sensoready Pen....58
Cosopt PF............................ 132
Cotellic....................................36
Cough DM............................139
Cough Syrup........................139
Coumadin...............................48
Cranberry Urinary Comfort... 76
Creon...................................... 98
Crinone.................................106
Crixivan...................................44
Cromolyn Sodium.94, 132, 138
Cryselle-28............................103
Cuprimine...............................99
Cutter Backwoods................. 58
Cutter Backwoods Dry.......... 58
Cutter Lemon Eucalyptus..... 58
Cuvposa..................................93
CVS Advanced Glucose Meter Test Strips..........................116
CVS B Complex Plus C......... 76
CVS B-1.................................. 76
CVS B-12................................ 76
CVS B6................................... 76
CVS Beta Carotene............... 76
CVS Biotin.............................. 76
CVS Biotin High Potency...... 76
CVS Calcium.......................... 62
CVS Calcium 600 & Vitamin D3.............................................. 63
CVS Calcium 600 + D............63
CVS Calcium Chewables 600plus.................................63
CVS Calcium Citrate + D.......63
CVS Calcium Citrate + D/Magnesium.......................... 63
CVS Calcium/Magnesium/Zinc.............................................. 63
CVS Childrens Chewable Complete..............................76
CVS Childrens Chewable Multivitamin/Iron................. 76
CVS Daily Multiple................. 76
CVS Daily Multiple for Men...76
CVS Daily Multiple for Women.............................................. 76
153153
CVS Daily Multiple for Women 50+........................................76
CVS Daily Multiple Plus Iron/Calcium/Zinc....................... 76
CVS Electrolyte Solution....... 63
CVS Gummy Dinos................76
CVS Hair/Skin/Nails..............76
CVS Iron................................. 63
CVS Lancets Micro Thin 33g............................................ 116
CVS Lancets Micro-Thin 33g............................................ 116
CVS Lancets Thin 26g........ 116
CVS Lancets Ultra Thin 30g............................................ 116
CVS Lancets Ultra-Thin 30g............................................ 116
CVS Lancing Device............116
CVS Laxative Dietary Supplement......................... 96
CVS Magnesium.................... 63
CVS Pediatric Electrolyte...... 63
CVS Pediatric Electrolyte Freezer Pops........................63
CVS Selenium........................ 63
CVS Slow Release Iron......... 63
CVS Spectravite Adult 50+... 76
CVS Spectravite Advanced Formula................................ 77
CVS Spectravite Senior.........77
CVS Spectravite Ultra Health Mens.....................................77
CVS Spectravite Ultra Mens Health................................... 77
CVS Spectravite Ultra Women.............................................. 77
CVS Spectravite Ultra Womens Health................................... 77
CVS Spectravite Ultra Womens Health Senior....................... 77
CVS Super B Complex/C......77
CVS Ultra Thin Lancets.......116
CVS Vitamin A........................77
CVS Vitamin B-12...................77
CVS Vitamin B-12 TR.............77
CVS Vitamin B-2.....................77
CVS Vitamin B12................... 77
CVS Vitamin C........................77
CVS Vitamin E........................ 77
CVS Zinc.................................63
Cyclafem.............................. 103
Cyclobenzaprine HCl.......... 144
Cyclophosphamide............... 34
Cycloset..................................46
Cyclosporine........................ 108
Cyclosporine Modified........ 108
Cyproheptadine HCl............134
Cyred Eq...............................103
Cystadane.............................. 98
Cystagon................................ 98
Cystaran............................... 130
D
D-Vi-Sol................................... 78
Daily Combo Multi Vitamin....77
Daily Multiple Vitamin............77
Daily Multiple Vitamin/Iron....77
Daily Multiple Vitamins.......... 77
Daily Value Multivitamin........ 77
Daily Vitamin.......................... 77
Daily Vitamin Formula+ir On. 77
Daily Vitamin Formula+iron...77
Daily Vitamin Formula+minerals..............................77
Daily Vite.................................77
Daily Vite Multivitamin/Iron... 77
Daily-Vite.................................77
Daily-Vite/Iron/Beta-Carotene.............................................. 78
Dalfampridine ER...................57
Daliresp................................ 138
Dalvance.................................20
Danazol.................................102
Dantrolene Sodium............. 144
Dapsone................................. 33
Daptacel............................... 110
Daptomycin............................ 20
Daraprim.................................38
Daurismo................................ 36
Deblitane.............................. 106
Deconex DMX...................... 139
Deconex IR...........................139
Deep Sea Nasal Spray........ 139
Deferasirox............................. 72
Dekas Essential......................78
Dekas Plus..............................78
Delstrigo................................. 43
Delsym..................................139
Delsym Cough + Chest Congestion DM................. 139
Delsym Cough + Chest Congestion DM Childrens 140
Delsym Cough + Cold Daytime............................................ 140
154154
Delsym Cough + Cold Nighttime Childrens.......... 140
Delsym Cough Childrens.... 140
Delyla.................................... 103
Demeclocycline HCl.............. 24
Demser................................... 52
Depen Titratabs..................... 99
Depo-Provera....................... 106
Descovy.................................. 44
Desipramine HCl....................29
Desmopressin Acetate........101
Desogestrel/Ethinyl Estradiol............................................ 103
Desonide.............................. 100
Desoximetasone.................. 100
Desvenlafaxine ER.................28
Dexamethasone...................100
Dexamethasone Intensol.... 100
Dexamethasone Sodium Phosphate..........................132
Dexmethylphenidate HCl...... 56
Dexmethylphenidate HCl ER 56
Dextroamphetamine Sulfate. 56
Dextromethorphan Polistirex............................................ 140
Dextrose 10%.........................63
Dextrose 10%/NaCl 0.2%..... 63
Dextrose 10%/NaCl 0.45%... 63
Dextrose 2.5%/NaCl 0.45%.. 63
Dextrose 5%........................... 63
Dextrose 5%/NaCl 0.2%........63
Dextrose 5%/NaCl 0.225%... 63
Dextrose 5%/NaCl 0.33%..... 63
Dextrose 5%/NaCl 0.45%..... 63
Dextrose 5%/NaCl 0.9%........63
Dialy vite 800..........................78
Diastat AcuDial.......................25
Diastat Pediatric.....................25
Diatrue Plus Blood Glucose Test Strips..........................116
Diazepam......................... 45, 46
Diazepam Intensol................. 46
Dibucaine............................... 58
Diclofenac Epolamine........... 14
Diclofenac Potassium............14
Diclofenac Sodium..14, 59, 132
Diclofenac Sodium DR..........14
Diclofenac Sodium ER.......... 14
Dicloxacillin Sodium.............. 23
Dicyclomine HCl.................... 93
Didanosine............................. 44
Dificid......................................23
Diflunisal.................................14
Digitek.....................................52
Digox.......................................52
Digoxin....................................52
Dihydroergotamine Mesylate32
Dilantin....................................27
Dilantin INFATABS................ 27
Dilt-XR..................................... 51
Diltiazem HCl..........................51
Diltiazem HCl ER....................51
Dimaphen Childrens............134
Dimaphen DM Cold & Cough............................................ 140
Dino-Life................................. 78
Dino-Life with Extra C............ 78
Dino-Life with Iron & Zinc......78
Dipentum..............................112
Diphenhist............................ 134
Diphenhydramine HCl.........134
Diphenoxylate/Atropine........ 94
Diphtheria/Tetanus Toxoids Adsorbed Pediatric........... 111
Disulfiram............................... 18
Diuril........................................54
Divalproex Sodium................ 46
Divalproex Sodium DR.......... 46
Divalproex Sodium ER.......... 46
Doc-Q-Lace.............................96
Docusate Sodium & Senna Stimulant Laxative/Stool Softener................................96
Docusol Kids.......................... 96
Docusol Plus Mini-Enema..... 96
Dofetilide................................ 50
DOK........................................ 96
DOK PLUS..............................96
Donepezil HCl........................ 27
Donepezil HCl ODT............... 27
Dorzolamide HCl................. 132
Dorzolamide HCl/Timolol Maleate.............................. 132
Dorzolamide HCl/Timolol Maleate Preservative Free 132
Dovato.....................................42
Doxazosin Mesylate...............50
Doxepin HCl.....................29, 59
Doxercalciferol.....................113
Doxy 100.................................24
Doxycycline............................ 24
155155
Doxycycline Hyclate.............. 24
Doxycycline Monohydrate.... 24
Dr Smiths Diaper....................59
Dr Smiths Diaper Rash Spray.............................................. 59
Dronabinol..............................30
Droplet Lancets Ultra Thin 30g............................................ 116
Droplet Lancing Device.......116
Drospirenone/Ethinyl Estradiol............................................ 103
Droxia......................................34
Drug Mart Adjustable Lancing Device................................ 116
Drug Mart On-The-Go Lancets Gentle 30g......................... 116
Drug Mart Unilet Lancets Super Thin 30g..................116
Drug Mart Unilet Lancets Ultra Thin 28g............................. 116
Drug Mart Unilet Micro Thin Lancets 33g....................... 116
Duavee..................................103
Duloxetine HCl....................... 56
Duramorph............................. 16
Durezol................................. 132
Dutasteride.............................99
E
E-400.......................................78
E-Oil.........................................78
E-Z Ject Lancets.................. 118
E-Z Ject Lancets 21g...........118
E-Z Ject Lancets Color........118
E-Z Ject Lancets Super Thin 30g..................................... 118
E-Z Ject Lancets Thin 26g.. 118
E-Zject Lancets Micro-Thin 33g............................................ 118
E.E.S. Granules...................... 23
E400 Mixed............................ 78
Ear Drops............................. 133
Earwax Treatment Drops.... 133
Easy Comfort Lancets.........116
Easy Comfort Lancets 30g/Pull Top..................................... 116
Easy Comfort Lancets 30g/Thin Top.............................116
Easy Mini Eject Lancing Device............................................ 117
Easy Mini Lancing Device...117
Easy Plus II Blood Glucose Test.....................................117
Easy Step Test Strips.......... 117
Easy Talk Blood Glucose Test Strips.................................. 117
Easy Touch Glucose Test Strips.................................. 117
Easy Touch HealthPro Glucose Test Strips..........................117
Easy Touch Lancets 21g/Pressure Activated............ 117
Easy Touch Lancets 23g/Pressure Activated............ 117
Easy Touch Lancets 26g/Pressure Activated............ 117
Easy Touch Lancets 26g/Pull-Top..................................... 117
Easy Touch Lancets 26g/Twist............................................ 117
Easy Touch Lancets 28g/Pressure Activated............ 117
Easy Touch Lancets 28g/Pull-Top..................................... 117
Easy Touch Lancets 28g/Twist............................................ 117
Easy Touch Lancets 30g/Button-Activated................117
Easy Touch Lancets 30g/Pressure Activated............ 117
Easy Touch Lancets 30g/Pull-Top..................................... 117
Easy Touch Lancets 30g/Twist............................................ 117
Easy Touch Lancets 32g/Pressure Activated............ 117
Easy Touch Lancets 32g/Pull-Top..................................... 117
Easy Touch Lancets 32g/Twist............................................ 117
Easy Touch Lancets 33g/Twist............................................ 117
Easy Touch Lancing Device/Ejector................................ 117
Easy Touch Safety Lancets21g/Pressure Activated............................ 117
Easy Touch Safety Lancets23g/Pressure Activated............................ 117
Easy Touch Safety Lancets26g/Button Activated............................................ 117
Easy Touch Safety Lancets26g/Pressure Activated............................ 117
Easy Touch Safety Lancets28g/Button Activated............................................ 117
156156
Easy Touch Safety Lancets28g/Pressure Activated............................ 118
Easy Trak Blood Glucose Test Strips.................................. 118
Easy Twist & Cap Lancets.. 118
EasyGluco............................ 118
EasyGluco Plus....................118
EASYMax 15 Test Strips..... 118
EASYMax Test Strips.......... 118
Econazole Nitrate...................30
Econtra EZ............................106
ED A-Hist......................134, 140
ED A-Hist DM....................... 140
ED A-Hist PSE...................... 140
ED Bron GP..........................140
ED Chlorped........................ 134
ED Chlorped D.....................134
ED Chlorped Jr.................... 135
ED-APAP.................................13
Edurant................................... 43
Efavirenz................................. 43
Egrifta................................... 108
Element Compact Test Strips............................................ 118
Element Test Strips............. 118
Elestrin..................................103
Elidel....................................... 59
Eliquis..................................... 48
Eliquis Starter Pack............... 48
Elmiron....................................99
Embeda.................................. 15
Embrace Blood Glucose Test Strips.................................. 118
Embrace Evo Blood Glucose Test Strips..........................118
Embrace Lancets Ultra Thin 30g..................................... 118
Embrace Pro Blood Glucose Test Strips..........................118
Emcyt......................................34
Emend.................................... 30
Emoquette............................103
Emsam....................................28
Emtriva....................................44
Enalapril Maleate................... 50
Enalapril Maleate/Hydrochlorothiazide............52
Enbrel................................... 108
Enbrel Mini........................... 108
Enbrel SureClick..................109
EndaCof-DM.........................140
Endocet.................................. 16
Endur-Acin..............................78
Endur-C/Rose Hips............... 78
Enema Ready-To-Use............96
Enemeez Mini.........................96
Enemeez Plus........................ 96
Enfamil Enfalyte..................... 63
Engerix-B.............................. 111
Enoxaparin Sodium............... 48
Enpresse-28......................... 103
Enskyce................................ 103
Entacapone............................ 39
Entecavir.................................42
Entresto.................................. 52
Enulose...................................96
Envarsus XR.........................109
Epclusa...................................42
Epidiolex.................................25
Epinastine HCl..................... 132
Epinephrine..........................137
Epitol.......................................27
Epivir HBV.............................. 42
Eplerenone............................. 53
Eprosartan Mesylate..............50
EQ Blood Glucose Test Strips............................................ 118
Eq Calcium 500+d................. 63
Eq Calcium 600+d................. 63
Eq Calcium Citrate+d............ 63
EQ Complete Multivitamin Adults 50+............................78
EQ Complete Multivitamin Adults Under 50.................. 78
EQ One Daily Womens Health.............................................. 78
Eq Slow-Release Iron............ 63
EQL B Complex 50................ 78
EQL B-6...................................78
EQL Calcium 600mg/Vitamind3............................. 64
EQL Calcium Citrate with Vitamin D..............................64
EQL Calcium Citrate/ Vitamin D3......................................... 64
EQL Calcium/Vitamin D........ 64
EQL Color Lancets Micro Thin 33g..................................... 118
EQL One Daily Mens Health Formula................................ 78
EQL One Daily Womens........78
EQL Vitamin B-12...................78
157157
EQL Vitamin B-12 TR.............78
EQL Vitamin C........................78
EQL Vitamin C/Rose Hips.....78
EQL Vitamin E........................ 78
Eraxis...................................... 31
Ergocalciferol......................... 78
Ergotamine Tartrate/Caffeine.............................................. 32
Erivedge..................................36
Erleada....................................34
Erlotinib HCl........................... 36
Errin...................................... 106
Ertapenem..............................22
Ery........................................... 59
Ery-Tab....................................23
EryPed 200.............................23
EryPed 400.............................23
Erythrocin Lactobionate........23
Erythromycin....................23, 59
Erythromycin Base.................23
Erythromycin DR....................24
Erythromycin Ethylsuccinate 24
Erythromycin/Benzoyl Peroxide............................... 59
Esbriet...................................138
Escitalopram Oxalate............ 28
Esomeprazole Magnesium.. 97, 98
Essentia.................................. 78
Essential Balance.................. 78
Estarylla................................ 103
Estradiol................................103
Estradiol Valerate.................103
Estring.................................. 103
Ethambutol HCl......................33
Ethosuximide......................... 25
Ethynodiol Diacetate/Ethinyl Estradiol............................. 103
Etidronate Disodium............113
Etodolac................................. 14
EvenCare G2 Test Strips.....118
EvenCare G3 Test Strips.....118
Evencare Mini Blood Glucose Test Strips..........................118
Evolution Autocode............. 118
Evotaz..................................... 44
Exemestane............................36
Exjade..................................... 72
Extra Action Cough............. 140
Eye Drops.............................132
Eye Itch Relief...................... 132
EZ Smart Blood Glucose Lancets...............................118
EZ Smart Blood Glucose Test Strips.................................. 118
EZ Smart Plus Blood Glucose Test Strips..........................118
Ezetimibe................................54
Ezetimibe/Simvastatin...........54
EZFE 200................................64
F
Falmina................................. 103
Famciclovir............................. 42
Famotidine............................. 95
Fanapt.....................................40
Fanapt Titration Pack............ 40
Fareston..................................34
Farxiga.................................... 46
Farydak...................................36
Fayosim................................ 103
FE C Tab.................................64
Febuxostat..............................32
Felbamate...............................26
Femynor............................... 103
Fenofibrate............................. 54
Fentanyl.................................. 15
Fentanyl Citrate Oral Transmucosal...................... 16
Feosol..................................... 64
Feosol Bifera.......................... 64
Fer-In-Sol.................................64
Ferate......................................64
Ferretts................................... 64
Ferretts IPS.............................64
Ferrex 150.............................. 64
Ferric X-150............................ 64
Ferrimin 150........................... 64
Ferriprox................................. 72
Ferrous Drops........................ 64
Ferrous Fumarate 324...........64
Ferrous Gluconate.................64
Ferrous Sulfate.......................64
Ferrousul................................ 64
Fetzima................................... 28
Fetzima Titration Pack...........28
Fexofenadine HCl................ 135
Fexofenadine HCl Childrens Allergy................................ 135
Fiber Laxative.........................96
Fiber Tabs.............................. 96
Fiber-Lax.................................96
158158
Fifty50 Glucose Test Strip 2.0............................................ 118
Fifty50 Lancing Device........118
Fifty50 Safety Seal Lancets 30g..................................... 118
Fifty50 Safety Seal Lancets 32g..................................... 118
Fifty50 Unilet Lancets 33g.. 118
Finacea................................... 59
Finasteride..............................99
Fine 30..................................118
Fingerstix Lancets............... 118
Firazyr................................... 108
Firmagon.............................. 108
Flac....................................... 133
Flebogamma DIF................. 110
Flecainide Acetate................. 50
Flector.....................................14
Fleet Pediatric........................ 96
Flintstones Complete............ 78
Flintstones Plus Extra C........ 78
Flintstones/My First............... 79
Flovent Diskus......................136
Flovent HFA..........................136
Flowtuss............................... 140
Fluconazole............................ 31
Fluconazole in NaCl...............31
Flucytosine............................. 31
Fludrocortisone Acetate......100
Flunisolide............................ 136
Fluocinolone Acetonide..... 100, 133
Fluocinonide........................ 100
Fluocinonide Emulsified Base............................................ 100
Fluorometholone................. 133
Fluorouracil............................ 59
Fluoxetine DR.........................28
Fluoxetine HCl........................28
Fluphenazine Decanoate...... 40
Fluphenazine HCl.................. 40
Flurbiprofen............................14
Flurbiprofen Sodium........... 133
Flutamide................................34
Fluticasone Propionate...... 100, 136
Fluticasone Propionate/Salmeterol..........................140
Fluticasone Propionate/Salmeterol Diskus............. 140
Fluvastatin.............................. 54
Fluvoxamine Maleate.............28
Folic Acid................................79
Folitab 500..............................64
Foltabs 800.............................79
Fondaparinux Sodium...........48
Fora Blood Glucose Test Strips............................................ 118
Fora D15g Blood Glucose Test Strips.................................. 119
Fora D20 Blood Glucose Test Strips.................................. 119
Fora D40/G31 Blood Glucose Test Strips..........................119
Fora G20 Blood Glucose Test Strips.................................. 119
Fora G30/Premium V10 Blood Glucose Test Strips...........119
Fora GD20 Test Strips.........119
Fora GD50 Blood Glucose Test Strips.................................. 119
Fora Lancets........................ 119
Fora Lancing Device........... 119
Fora Lancing Device/Clearcap............................................ 119
Fora Tn'g/Tn'g Voice Blood Glucose Test Strips...........119
Fora V10 Blood Glucose Test Strips.................................. 119
Fora V12 Blood Glucose Test Strips.................................. 119
Fora V20 Blood Glucose Test Strips.................................. 119
Fora V30a Blood Glucose Test Strips.................................. 119
ForaCare GD40....................119
ForaCare Premium V10 Teststrips........................... 119
ForaCare Test N Go Test Strips............................................ 119
Formula EM............................29
Forteo................................... 113
Fortiscare Blood Glucose Test Strip.................................... 119
Fosamprenavir Calcium........ 44
Fosfree....................................79
Fosinopril Sodium..................50
Fosinopril Sodium/Hydrochlorothiazide............52
FreAmine HBC 6.9%..............64
Freds Pharmacy Autolet Lancing Device..................119
Freds Pharmacy Unilet Lancets Super Thin 30g..................119
159159
Freds Pharmacy Unilet Lancets Ultra Thin 28g....................119
FreeStyle Insulinx Blood Glucose Test......................119
FreeStyle Insulinx Blood Glucose Test Strips...........119
FreeStyle Lancets................ 119
FreeStyle Lite Test Strips.... 119
FreeStyle Precision Neo Blood Glucose Test Strips...........119
FreeStyle Test Strips........... 120
FreeStyle Unistick II Lancets............................................ 120
Freshkote............................. 130
Fruit C 500..............................79
Fruity C................................... 79
Fruity Chewables Multivitamin.............................................. 79
Full Spectrum B/Vitamin C... 79
Fungoid Tincture................... 31
Furosemide............................ 53
Fusion..................................... 64
Fuzeon.................................... 44
Fyavolv..................................103
Fycompa.................................26
G
Gabapentin.............................25
Gammagard Liquid............. 110
Gammagard S/D IGA Less Than 1 mcg/ml..................110
Gammaked...........................110
Gammaplex..........................110
Gamunex-C.......................... 110
Gardasil 9............................. 111
Gas Relief............................... 94
Gas Relief Extra Strength......94
Gas Relief Maximum Strength.............................................. 94
Gattex..................................... 94
Gauze................................... 120
GaviLyte-C.............................. 96
GaviLyte-G.............................. 96
GaviLyte-N/Flavor Pack.........96
GE100 Blood Glucose Test Strips.................................. 120
Gemfibrozil............................. 54
Generlac................................. 96
Gengraf.................................109
Genotropin........................... 101
Genotropin Miniquick..........101
Genstrip 50...........................120
Gentak.................................... 19
Gentamicin Sulfate................ 19
Gentamicin Sulfate/0.9% Sodium Chloride................. 19
Genvoya..................................43
Geodon...................................40
GHT Test Strips................... 120
Gianvi....................................103
Gilenya....................................57
Gilotrif..................................... 36
Glassia.................................... 98
Glatiramer Acetate.................57
Glatopa................................... 57
Gleostine................................ 34
Glimepiride.............................46
Glipizide..................................46
Glipizide ER............................46
Glipizide/Metformin HCl....... 46
Global Inject Ease Lancets 28g............................................ 120
Global Inject Ease Lancets 30g............................................ 120
Global Lancing Device........ 120
GlucaGen HypoKit.................47
Glucagon Emergency Kit...... 47
Glucocard 01 Sensor Plus..120
Glucocard 01 Sensor Plus Test Strips.................................. 120
Glucocard Expression Blood Glucose Test Strips...........120
Glucocard Shine Test Strips............................................ 120
Glucocard Vital Test Strips. 120
GlucoCom Lancets 28g...... 120
GlucoCom Lancets 30g...... 120
GlucoCom Lancets 33g...... 120
GlucoCom Test Strips.........120
GlucoNavii Blood Glucose Test Strips.................................. 120
Glucose Meter Test Strips Advanced...........................120
Glyxambi.................................46
GNP All Day Allergy.............135
GNP Allergy..........................135
GNP Animal Shapes..............79
GNP Animal Shapes Plus Extra C........................................... 79
GNP Animal Shapes Plus Iron.............................................. 79
GNP Antacid Anti-Gas........... 94
GNP Arthritis Pain Relief....... 13
GNP B-12................................79
GNP B-50 Balanced...............79
160160
GNP Biotin..............................79
GNP Calcium......................... 64
GNP Calcium 1200................64
GNP Calcium 500 + D3......... 64
GNP Calcium 500/D..............64
GNP Calcium 600 + D3......... 64
GNP Calcium 600/D..............64
GNP Calcium Citrate + D Maximum............................. 64
GNP Calcium Citrate + D3.... 64
GNP Calcium Citrate + D3 Maximum............................. 64
GNP Calcium/Magnesium/Zinc.......................................65
GNP Calcuim/Vitamin D/Minerals................................65
GNP Century.......................... 79
GNP Century Active Performance........................ 79
GNP Century Adults 50+ Senior................................... 79
GNP Century Cardio Healthformula...................... 79
GNP Century Mature............. 79
GNP Century Ultimate Mens Complete..............................79
GNP Century Ultimate Womens Complete............. 80
GNP Century Ultimate Womens Senior Formula.... 80
GNP Childrens Chewables w/Extra C..................................80
GNP Childrens Chewables/Extra C..................................80
GNP Childrens Chewables/Iron........................................80
GNP Dayhist Allergy............ 135
GNP Easy Touch Glucose Test Strips.................................. 120
GNP Essential One Daily.......80
GNP Hair/Skin/Nails............. 80
GNP Ibuprofen.......................14
GNP Ibuprofen Junior Strength.............................................. 14
GNP Iron.................................65
GNP Lancets........................120
GNP Lancets 21g................ 120
GNP Lancets Micro Thin 33g............................................ 120
GNP Lancets Super Thin 30g............................................ 120
GNP Lancets Thin............... 120
GNP Lancets Thin 26g........120
GNP Lice Treatment..............38
GNP Little Ones Childrens....80
GNP Loratadine................... 135
GNP Magnesium................... 65
GNP Masanti Maximum Strength................................94
GNP Masanti Regular Strength.............................................. 94
GNP Mega Multi for Men...... 80
GNP Mega Multi for Women.80
GNP Micro Thin Lancets 33g............................................ 120
GNP Niacin TR.......................80
GNP Omeprazole...................98
GNP One Daily Maximum..... 80
GNP One Daily Mens Health 50+........................................80
GNP One Daily Plus Iron....... 80
GNP One Daily Womens Health 50+............................80
GNP Opti-Vitamins.................80
GNP Pediatric Electrolyte......65
GNP Super Thin Lancets/30g............................................ 120
GNP Therapeutic-M...............80
GNP Tussin DM................... 140
GNP Vitamin A....................... 80
GNP Vitamin B-1.................... 80
GNP Vitamin B-12..................80
GNP Vitamin B-12 Prolonged Release................................ 80
GNP Vitamin B-12 TR............ 80
GNP Vitamin B-6.................... 80
GNP Vitamin C....................... 81
GNP Vitamin C Drops............81
GNP Vitamin C Pr.................. 81
GNP Vitamin C TR................. 81
GNP Vitamin C with Rose Hips.............................................. 81
GNP Vitamin C with Rose Hips TR......................................... 81
GNP Vitamin C/Rose Hips....81
GNP Vitamin E....................... 81
GNP Vitamin E Water Dispersible........................... 81
GNP Zinc................................ 65
GNP Zoo Chews Gummies...81
Goodsense Ibuprofen........... 14
Goodsense Ibuprofen Childrens..............................14
Goodsense Ibuprofen Infants.............................................. 14
161161
Goodsense Ibuprofen Junior Strength................................14
Goodsense Lancets Micro-Thin 33g..................................... 120
Goodsense Lancets Micro-Thin 33g Universal.....................120
Goodsense Lancets Ultra-Thin 26g Universal.....................120
Goodsense Lancets Ultra-Thin 30g..................................... 120
Goodsense Lancing Device120
Goodsense Premium Blood Glucose Test Strips...........121
Granisetron HCl..................... 30
Griseofulvin Microsize........... 31
Griseofulvin Ultramicrosize... 31
Guaifenesin AC....................140
Guaifenesin and Pseudoephedrine HCl...... 140
Guaifenesin ER.................... 140
Guaifenesin/Codeine.......... 140
Guanfacine ER.......................56
Guanidine HCl........................33
Gummi Bear Multivitamin/Mineral................................. 81
H
H-E-B Incontrol Advanced Lancing Device..................121
H-E-B Incontrol Lancets Micro Thin 33g............................. 121
H-E-B Incontrol Lancets Super Thin 30g............................. 121
H-E-B Incontrol Lancets Ultra Thin 28g............................. 121
H-E-B Oral Electrolyte Solution.............................................. 65
Haegarda..............................108
Hailey 24 Fe......................... 103
Halls Defense Vitamin C Drops.............................................. 81
Halobetasol Propionate...... 100
Haloperidol.............................40
Haloperidol Decanoate......... 40
Haloperidol Lactate............... 40
Hard Nails...............................81
Harvoni................................... 42
Havrix....................................111
Health Care Lancing Device............................................ 121
Healthy Accents Autolet Impression Lancing Device............................................ 121
Healthy Accents Unilet Lancets Super Thin 30g..................121
Healthy Kids Gummies..........81
Heartburn Treatment 24 Hour.............................................. 98
Hemocyte............................... 65
Hemorrhoidal......................... 59
Heparin Sodium.....................48
HepatAmine........................... 65
Hetlioz...................................144
Hiberix.................................. 111
Histex....................................135
Histex PD..............................135
Histex-DM.............................140
Histex-PE.............................. 140
HM Calcium 600 & Vitamin D3.............................................. 65
HM Calcium 600 + D Plus Minerals................................65
HM Calcium 600 + Vitamin D3.............................................. 65
HM Calcium Citrate + Vitamin D........................................... 65
HM Calcium/Vitamin D......... 65
HM Calcium/Vitamin D/Minerals................................65
HM Complete.........................81
HM Complete 50+................. 81
HM Complete 50+ Womens Ultimate................................ 81
HM Complete Women...........81
HM Hair/Skin/Nails............... 81
HM Iron...................................65
HM Iron Slow Release...........65
HM Magnesium......................94
HM Niacin...............................81
HM Niacin TR.........................81
HM One Daily Essential.........81
HM One Daily Womens......... 81
HM One Daily/Iron.................81
HM Pediatric Electrolyte........65
HM Selenium..........................65
HM Vitamin B Complex/Vitamin C..............................82
HM Vitamin B100 Complex.. 82
HM Vitamin B12.....................82
HM Vitamin B12 TR...............82
HM Vitamin B50 Complex.....82
HM Vitamin B6....................... 82
HM Vitamin C......................... 82
HM Vitamin C TR................... 82
HM Vitamin C/Rose Hips......82
HM Vitamin E......................... 82
162162
HM Zinc.................................. 65
Honey Bears...........................82
Honey Bears with Iron and Zinc.......................................82
Humalog Cartridge................ 47
Humalog Junior KwikPen......47
Humalog KwikPen................. 47
Humalog Mix 50/50 KwikPen.............................................. 47
Humalog Mix 50/50 Vial........48
Humalog Mix 75/25 KwikPen.............................................. 48
Humalog Mix 75/25 Vial........48
Humalog Vial..........................48
Humatrope........................... 101
Humatrope Combo Pack.... 101
Humira.................................. 109
Humira Pediatric Crohns Disease Starter Pack.........109
Humira Pen.......................... 109
Humira Pen Crohns Disease Starter Pack....................... 109
Humira Pen-Psoriasis Starter............................................ 109
Humulin 70/30 KwikPen....... 48
Humulin 70/30 Vial................48
Humulin N KwikPen...............48
Humulin N Vial....................... 48
Humulin R U-500 KwikPen....48
Humulin R U-500 Vial............ 48
Humulin R Vial....................... 48
Hycofenix..............................140
Hydralazine HCl..................... 55
Hydrochlorothiazide.............. 54
Hydrocodone Bitartrate/Acetaminophen................... 16
Hydrocodone Bitartrate/Chlorpheniramine Maleate/PSE.....................................140
Hydrocodone Bitartrate/Homatropine Methylbromide............................................ 140
Hydrocodone Polistirex/Chlorpheniramine Polistirex............................................ 140
Hydrocodone/Acetaminophen.............................................. 16
Hydrocodone/Ibuprofen....... 17
Hydrocortisone............100, 112
Hydrocortisone Butyrate.....100
Hydrocortisone Valerate..... 101
Hydrocortisone/Acetic Acid............................................ 133
Hydrocortisone/Aloe............. 59
Hydromet..............................140
Hydromorphone HCl............. 17
Hydromorphone HCl ER....... 15
Hydroxychloroquine Sulfate. 38
Hydroxyurea...........................34
Hydroxyzine HCl.................... 45
Hydroxyzine Pamoate........... 29
Hypolance AST Lancing Kit121
Hysingla ER............................16
I
I-Caps Areds Formula............82
I-Caps Mv................................82
I-Caps Plus............................. 82
I.L.X. B-12............................... 65
Ibrance....................................36
Ibu........................................... 15
Ibu-200....................................15
Ibu-Drops Infants................... 15
Ibuprofen................................ 15
Ibuprofen Childrens...............15
ICAR Pediatric........................65
ICAR-C.................................... 65
Icatibant Acetate..................108
Iclusig......................................36
Idhifa....................................... 36
Iferex 150................................65
Iglucose Blood Glucose Test Strips.................................. 121
Ilevro..................................... 133
Imatinib Mesylate...................36
Imbruvica................................36
Imipenem/Cilastatin.............. 22
Imipramine HCl...................... 29
Imipramine Pamoate............. 29
Imiquimod.............................. 59
Imiquimod Pump................... 59
Imovax Rabies..................... 111
Imvexxy Maintenance Pack 103
Imvexxy Starter Pack...........103
Incassia.................................106
Increlex................................. 101
Incruse Ellipta...................... 137
Indapamide............................ 54
Indomethacin......................... 15
Infanrix..................................111
Infants Gas Relief...................94
Infants Ibuprofen....................15
Infants Simethicone...............94
163163
Infed........................................65
Infinity Blood Glucose Test Strips.................................. 121
Infinity Voice.........................121
Ingrezza.................................. 56
Inlyta........................................36
Inrebic.....................................35
Insulin Lispro..........................48
Insulin Lispro KwikPen.......... 48
Insulin Syringes, Needles....121
Integra.....................................65
Intelence.................................43
Intralipid..................................65
Intron A................................... 42
Introvale................................104
Invanz......................................22
Invega Sustenna.................... 40
Invega Trinza..........................41
Invirase................................... 44
Ionosol-MB/Dextrose 5%...... 65
Iosat...................................... 121
IPOL Inactivated IPV............111
Ipratropium Bromide........... 137
Ipratropium Bromide/Albuterol Sulfate................................ 141
Irbesartan............................... 50
Irbesartan/Hydrochlorothiazide.............................................. 52
Iressa...................................... 37
Iron..........................................66
Iron 100/C.............................. 66
Iron 27.....................................66
Iron High-Potency.................. 66
Iron Slow Release..................66
Iron Supplement Childrens...66
Isentress................................. 43
Isentress HD...........................43
Isibloom................................104
Isolyte-P/Dextrose 5%........... 66
Isolyte-S.................................. 66
Isoniazid..................................33
Isopto Tears......................... 130
Isosorbide Dinitrate............... 55
Isosorbide Dinitrate ER......... 55
Isosorbide Mononitrate......... 55
Isosorbide Mononitrate ER... 55
Isotonic Gentamicin...............19
Isotretinoin..............................59
Itraconazole............................31
Ivermectin...............................38
Ixiaro..................................... 111
J
Jadenu....................................72
Jadenu Sprinkle.....................72
Jakafi.......................................37
Jantoven................................. 48
Jardiance................................46
Jasmiel..................................104
Jentadueto............................. 46
Jentadueto XR....................... 46
Jinteli.................................... 104
Jublia...................................... 31
Juleber..................................104
Juluca..................................... 43
Junel 1.5/30......................... 104
Junel 1/20............................ 104
Junel Fe 1.5/30....................104
Junel Fe 1/20.......................104
Junel Fe 24...........................104
Just D......................................82
Juxtapid.................................. 54
K
Kaitlib Fe...............................104
Kaletra.....................................44
Kalydeco...............................138
Kao-Tin....................................94
Kariva....................................104
KCl 0.075%/D5W/NaCl 0.45%.............................................. 66
KCl 0.15%/D5W/NaCl 0.2%..66
KCl 0.15%/D5W/NaCl 0.45%.............................................. 66
KCl 0.15%/D5W/NaCl 0.9%..66
KCl 0.3%/D5W/NaCl 0.45%..66
KCl 0.3%/D5W/NaCl 0.9%....66
Kelnor 1/35.......................... 104
Kelnor 1/50.......................... 104
Ketoconazole......................... 31
Ketoprofen..............................15
Ketorolac Tromethamine.... 133
Kidkare Cough/Cold........... 141
Kineret.................................. 109
Kinrix.....................................111
Kionex.....................................72
Kisqali..................................... 35
Kisqali Femara 200 Dose...... 35
Kisqali Femara 400 Dose...... 35
Kisqali Femara 600 Dose...... 35
Klor-Con..................................66
Klor-Con 10............................ 66
Klor-Con 8...............................66
164164
Klor-Con M10......................... 66
Klor-Con M15......................... 66
Klor-Con M20......................... 66
Klor-Con Sprinkle...................66
Kobee..................................... 82
Kombiglyze XR.......................46
Korlym.................................. 102
KP Adults 50+ Daily Formula 82
KP B Complex/C................... 82
KP Calcium 600 + D.............. 66
KP Calcium Citrate + D..........66
KP Ferrous Gluconate........... 66
KP Ferrous Sulfate.................66
KP Niacin................................82
KP Vitamin B-12..................... 82
KP Vitamin B-6....................... 82
KP Vitamin E...........................82
Kroger Blood Glucose Teststrips........................... 121
Kroger Lancets 21g.............121
Kroger Lancets Micro Thin33g............................................ 121
Kroger Lancets Thin 26g.... 121
Kroger Lancets Ultrathin 30g............................................ 121
Kroger Lancing Device........121
Kroger Premium Blood Glucose Test Strips...........121
Kroger Test Strips................121
Kurvelo..................................104
Kuvan......................................98
L
Labetalol HCl..........................51
Lacrisert................................130
Lactulose................................ 96
Lamivudine.......................42, 44
Lamivudine/Zidovudine........ 44
Lamotrigine............................ 26
Lancet Device with Ejector. 121
Lancets.................................121
Lancets 28g......................... 121
Lancets 30g......................... 121
Lancets 30g Twist Top........121
Lancets 30g/Twist Top....... 121
Lancets 33g Universal Design............................................ 122
Lancets Micro Thin 33g...... 122
Lancets Safety Seal 28g..... 122
Lancets Safety Seal 30g..... 122
Lancets Super Thin 28g......122
Lancets Thin........................ 122
Lancets Twist Top............... 122
Lancets Ultra Fine................122
Lancets Ultra Thin............... 122
Lancets Ultra Thin 30g........122
Lancing Device.................... 122
Lancing Device Adjustable. 122
Land Before Time Multivitamin/Iron................. 82
Lanoxin................................... 52
Lansoprazole..........................98
Lanthanum Carbonate.......... 72
Lantus SoloStar..................... 48
Lantus Vial..............................48
Lanzo.................................... 122
LARIN 1.5/30....................... 104
LARIN 1/20.......................... 104
LARIN Fe 1.5/30..................104
LARIN Fe 1/20..................... 104
Larissia................................. 104
Lastacaft...............................130
Latanoprost..........................133
Latuda.....................................41
Laxative...................................96
Layolis Fe............................. 104
Leader Advanced Lancing Device................................ 122
Ledipasvir/Sofosbuvir........... 42
Leena....................................104
Leflunomide......................... 110
Lenvima.................................. 37
Lessina................................. 104
Letairis.................................. 138
Letrozole.................................36
Leucovorin Calcium...............35
Leukeran.................................34
Leukine................................... 49
Leuprolide Acetate.............. 108
Levalbuterol HCl.................. 137
Levemir FlexTouch................ 48
Levemir Vial............................48
Levetiracetam.........................25
Levetiracetam ER...................25
Levobunolol HCl.................. 132
Levocarnitine..........................66
Levocetirizine Dihydrochloride............................................ 135
Levofloxacin........................... 24
Levofloxacin in D5W..............24
Levonest...............................104
165165
Levonorgestrel and Ethinyl Estradiol............................. 104
Levonorgestrel/Ethinyl Estradiol............................. 104
Levora 0.15/30-28............... 104
Levorphanol Tartrate............. 16
Levothyroxine Sodium........ 107
Levoxyl..................................107
Lexiva......................................44
Lialda.................................... 112
Lidocaine................................18
Lidocaine HCl.........................18
Lidocaine Viscous................. 18
Lidocaine/Prilocaine............. 18
Life Pack Mens...................... 82
Life Pack Womens.................82
Lindane...................................39
Linezolid................................. 20
Linzess....................................96
Liothyronine Sodium........... 107
Liquid B12.............................. 82
Liquid Calcium/Vitamin D.....66
Liquitears..............................130
Lisinopril................................. 50
Lisinopril/Hydrochlorothiazide.............................................. 52
LiteTouch Lancets...............122
LiteTouch Lancets Micro Thin 33g..................................... 122
LiteTouch Lancing Pen....... 122
Lithium....................................46
Lithium Carbonate.................46
Lithium Carbonate ER...........46
Lithostat..................................99
Livalo.......................................54
Live Better Advanced Lancing Device................................ 122
Live Better Lancet Ultra Thin 28g..................................... 122
Lodrane D............................ 135
LoHist-D................................135
LoHist-DM.............................141
Lokelma..................................72
Longs Lancets Thin.............122
Longs Lancets Ultra Thin....122
Lonhala Magnair Starter Kit137
Lonsurf....................................35
Loperamide HCl.....................94
Lopinavir/Ritonavir................ 44
Loratadine............................ 135
Loratadine Childrens...........135
Loratadine-D 12hr................135
Loratadine-D 24hr................135
Lorazepam............................. 46
Lorbrena................................. 35
Lorcet......................................17
Lorcet HD............................... 17
Lorcet Plus............................. 17
Lortuss DM...........................141
Lortuss EX............................ 141
Lortuss LQ............................135
Loryna...................................104
Losartan Potassium...............50
Losartan Potassium/Hydrochlorothiazide............52
Lotemax................................133
Lotemax SM.........................133
Loteprednol Etabonate....... 133
Lovastatin............................... 54
Low-Ogestrel........................104
Loxapine Succinate...............40
Lubricant Eye Drops............130
Lubricating Plus Eye Drops 130
Lubrifresh P.M..................... 130
Lumigan............................... 133
Lupaneta Pack.....................108
Lupron Depot.......................108
Lutera....................................104
Lynparza.................................37
Lysiplex Plus.......................... 82
Lysodren...............................107
Lyza.......................................106
M
M-END DMX......................... 141
M-Hist DM.............................141
M-Hist PD............................. 135
M-M-R II................................ 111
Mag-Tab SR........................... 67
Magnesium...................... 66, 94
Magnesium 27....................... 66
Magnesium Elemental...........66
Magnesium Oxide........... 66, 95
Magnesium Sulfate................66
Major-Prep Hemorrhoidal......59
Malathion................................39
Mapap.....................................13
Mapap Acetaminophen Extra Strength................................13
Mapap Arthritis Pain..............13
Mapap Childrens................... 13
Mapap Cold Formula Multi-Symptom............................141
166166
Mapap PM..............................13
Mapap Sinus Maximum Strength Congestion and Pain.................................... 141
Maprotiline HCl...................... 28
Marlissa................................ 104
Marplan...................................28
Matulane.................................34
Matzim LA.............................. 52
Mavyret................................... 42
Mayzent.................................. 57
Meclizine HCl......................... 29
Medisense Thin Lancets.....122
Medlance Plus Extra Lancets 21g..................................... 122
Medlance Plus Lancets.......122
Medlance Plus Lancets Lite 25g..................................... 122
Medlance Plus Lite Lancets 25g..................................... 122
Medlance Plus Special Lancets 0.8mm................................ 122
Medlance Plus SuperLite 30g............................................ 122
Medlance Plus SuperLite 30g/Comfort Max......................122
Medlance Plus Universal Lancets 21g....................... 122
Medlance Plus/Lite 25g......122
Medlance/Lite......................122
Medlance/Universal............ 122
Medroxyprogesterone Acetate............................................ 106
Mefloquine HCl...................... 38
Mega Multiple with Chelated Minerals................................82
Mega Multivitamin for Men... 82
Mega Multivitamin for Women.............................................. 82
Megestrol Acetate............... 107
Meijer Advanced Formula.....82
Meijer Blood Glucose Teststrips........................... 122
Meijer C.................................. 82
Meijer Lancets Thin.............122
Meijer Lancets Universal 33g............................................ 122
Meijer Premium Blood Glucose Test Strips..........................123
Meijer Super Thin Lancets..123
Mekinist.................................. 37
Mektovi................................... 37
Melodetta 24 Fe...................104
Meloxicam.............................. 15
Memantine HCl...................... 27
Memantine HCl ER................ 27
Memantine HCl Titration Pak27
Menactra.............................. 111
Menest..................................104
Mentax.................................... 31
Menveo.................................111
Mephyton............................... 82
Mercaptopurine..................... 34
Meribin....................................83
Meropenem............................22
Mesalamine..........................112
Mesalamine DR................... 112
Mesnex................................... 38
Mestinon.................................33
Metformin HCl........................46
Metformin HCl ER..................47
Methadone HCl......................16
Methazolamide...................... 53
Methenamine Hippurate....... 20
Methimazole.........................108
Methotrexate........................109
Methotrexate Sodium..........109
Methoxsalen...........................59
Methscopolamine Bromide.. 93
Methyldopa............................ 49
Methyldopa/Hydrochlorothiazide............52
Methylphenidate HCl.............56
Methylphenidate HCl ER.......56
Methylprednisolone.............101
Methylprednisolone Dose Pack............................................ 101
Metoclopramide HCl....... 29, 30
Metolazone.............................54
Metoprolol Succinate ER...... 51
Metoprolol Tartrate................51
Metoprolol/Hydrochlorothiazide............52
Metronidazole........................ 20
Metronidazole in NaCl 0.79%.............................................. 20
Metronidazole Vaginal...........20
Mexiletine HCl........................50
Mi-Acid....................................95
Mi-Acid Gas Relief................. 95
Mi-Acid Maximum Strength.. 95
Mibelas 24 Fe.......................104
167167
Miconazole 3..........................31
Miconazole 7..........................31
Miconazole Nitrate.................31
Microdot Test Strips............123
Microgestin 1.5/30.............. 104
Microgestin 1/20................. 105
Microgestin Fe..................... 105
Microgestin Fe 1.5/30.........105
Microlet Lancets.................. 123
Microlet Next........................123
Midodrine HCl........................49
Migergot................................. 32
Miglustat.................................98
Migraine Formula...................13
Mili........................................ 105
Milk of Magnesia....................96
Milk of Magnesia Concentrate.............................................. 97
Mini Lancing Device............123
Minitran...................................55
Minocycline HCl.....................24
Minoxidil................................. 55
Mintox Maximum Strength....95
Mirtazapine.............................28
Mirtazapine ODT....................28
Mirvaso................................... 59
Misoprostol............................ 97
Mm Easy Touch Glucose Test Strips.................................. 123
Modafinil...............................144
Moexipril HCl..........................50
Moisturel Therapeutic........... 59
Molindone HCl....................... 40
Mometasone Furoate.......... 101
Monocal..................................67
Monolet Lancets.................. 123
Montelukast Sodium........... 136
Morphine Sulfate................... 17
Morphine Sulfate ER............. 16
Moxeza................................... 24
Moxifloxacin HCl/Sodium HCl.............................................. 24
Moxifloxacin HCl....................24
Mtx Support............................83
Mucinex................................141
Mucinex Chest Congestion Childrens............................141
Mucinex Childrens Cold Cough & Sore Throat........141
Mucinex Childrens Multi-Symptom Cold...................141
Mucinex Childrens Multi-Symptom Cold & Fever.....141
Mucinex Congestion & Cough Childrens............................141
Mucinex Cough Childrens.. 141
Mucinex Cough for Kids..... 141
Mucinex D............................ 141
Mucinex D Maximum Strength............................................ 141
Mucinex DM.........................141
Mucinex DM Maximum Strength............................. 141
Mucinex Fast-Max Cold & Sinus...................................141
Mucinex Fast-Max Cold Flu & Sore Throat........................142
Mucinex Fast-Max Day Time/Night Time......................... 142
Mucinex Fast-Max Day/Night Maximum Strength............142
Mucinex Fast-Max DM Max 142
Mucinex Fast-Max Night Time Cold & Flu.......................... 142
Mucinex Fast-Max Severe Cold............................................ 142
Mucinex Fast-Max Severe Congestion & Cough........ 142
Mucinex for Kids..................142
Mucinex Maximum Strength............................................ 142
Mucinex Multi-Symptom Cold Day/Night Pack................. 142
Mucinex Multi-Symptom Cold Night Time Childrens........ 142
Mucinex Sinus-Max Pressure & Pain.................................... 142
Mucinex Stuffy Nose & Cold Childrens............................142
Mucus Relief........................ 142
Mucus Relief Sinus..............142
Multaq.....................................50
Multi Complete/Iron.............. 83
Multi Vitamin Daily................. 83
Multi-Day Plus Iron.................83
Multi-Delyn/Iron..................... 83
Multi-Lancet Device 2..........123
Multi-Vitamin...........................83
Multi-Vitamin Daily................. 83
Multi-Vitamin HP/Minerals.... 83
Multi-Vitamin/Minerals.......... 83
168168
Multi-Vitamin/Multi-Mineral Adult/High Potency.............83
Multi-Vitamins.........................83
Multilex................................... 83
Multilex T&M.......................... 83
Multiple Vitamin/Minerals/No Iron........................................83
Multiple Vitamins................... 83
Multiple Vitamins Plain.......... 83
Multiple Vitamins/Iron........... 83
Multivitamin & Mineral...........83
Mupirocin............................... 20
Muro 128.............................. 130
My Way.................................107
My-Vitalife............................... 83
Myalept................................... 95
Mycamine...............................31
Mycophenolate Mofetil....... 109
Mycophenolic Acid DR....... 109
Myferon 150........................... 67
MyGlucoHealth Blood Glucose Test.....................................123
MyGlucoHealth MGH Softlance Lancets 30g....................... 123
Myrbetriq................................ 99
N
Nadolol................................... 51
Nafcillin Sodium.....................23
Naloxone HCl......................... 18
Naltrexone HCl.......................18
Namzaric................................ 56
Naproxen................................15
Naproxen DR......................... 15
Naratriptan HCl...................... 32
Narcan.................................... 18
Nasal Decongestant............ 142
Nasal Decongestant Spray. 142
Nasopen PE......................... 135
Natacyn...................................31
Nateglinide............................. 47
Natpara.................................113
Natrapel 12-Hour Tick & Insect Repellent Continuous Spray.............................................. 59
Natural Balance Tears.........130
Natural C/Rose Hips............. 83
Natural Fiber Therapy............97
Natural Vitamin E................... 83
Natures Tears.......................130
Nebupent................................38
Necon 0.5/35-28..................105
Nefazodone HCl.....................28
Neomycin Sulfate.................. 19
Neomycin/Bacitracin/Polymyxin...........................130
Neomycin/Polymyxin/Bacitracin/Hydrocortisone............................................ 131
Neomycin/Polymyxin/Dexamethasone................ 131
Neomycin/Polymyxin/Gramicidin......................... 131
Neomycin/Polymyxin/Hydrocortisone......... 131, 133
Nephramine............................67
Nephro-Vite............................ 84
Nephronex..............................83
Nerlynx....................................37
Neulasta..................................49
Neupro....................................39
Neutek 2Tek Test Strips..... 123
Nevirapine.............................. 43
Nevirapine ER........................ 43
Nexavar...................................37
Nexium....................................98
Niacin......................................84
Niacin ER......................... 54, 84
Niacin SR................................84
Niacin TR................................84
Niacor..................................... 54
Nicardipine HCl......................52
NicoDerm CQ.........................19
NICOrelief...............................19
Nicorette.................................19
Nicorette Mini.........................19
Nicorette Starter Kit............... 19
Nicotine Polacrilex.................19
Nicotine Transdermal System.............................................. 19
Nicotine Transdermal System Step 1................................... 19
Nicotine Transdermal System Step 2................................... 19
Nicotine Transdermal System Step 3................................... 19
Nicotrol................................... 19
Night Time Multi-Symptom Cold/Flu Relief.................. 142
Night Time Sleep Aid.......... 144
Nikki......................................105
Nilutamide.............................. 34
Nimodipine.............................52
NinjaCof................................142
169169
NinjaCof-A............................ 142
NinjaCof-XG..........................142
Ninlaro.................................... 35
Nitro-Bid..................................55
Nitrofurantoin......................... 20
Nitrofurantoin Macrocrystals 20
Nitrofurantoin Monohydrate. 20
Nitroglycerin...........................55
Nitroglycerin Lingual............. 55
Nitroglycerin Transdermal.... 55
Nitrostat.................................. 55
No Iron Multiple Vitamin/Minerals................................84
NoHist-DM............................142
NoHist-LQ.............................135
Nora-BE................................ 107
Norditropin FlexPro............. 101
Norethindrone......................107
Norethindrone Acetate........107
Norethindrone Acetate/Ethinyl Estradiol............................. 105
Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate............................................ 105
Norethindrone/Ethinyl Estradiol/Ferrous Fumarate............................................ 105
Norgestimate/Ethinyl Estradiol............................................ 105
Norlyroc................................107
Normosol-M in D5W.............. 67
Normosol-R............................ 67
Normosol-R in D5W...............67
Northera..................................49
Nortrel 0.5/35.......................105
Nortrel 1/35..........................105
Nortrel 7/7/7........................ 105
Nortriptyline HCl.................... 29
Norvir...................................... 45
Nova Max Glucose Test Strips............................................ 123
Nova Safety Lancets 23g.... 123
Nova Safety Lancets 28g.... 123
Nova Sureflex Lancets........ 123
Nova Sureflex Lancing Device............................................ 123
Noxafil.....................................31
Nu-Iron 150.............................67
Nu-Mag................................... 67
Nubeqa...................................34
Nucala.................................. 142
Nucynta ER............................ 16
Nuedexta................................ 56
Nuplazid................................. 41
Nutrilipid................................. 67
Nutropin AQ......................... 101
NuvaRing..............................105
Nyamyc...................................31
Nymalize................................. 52
Nystatin...................................31
Nystop.....................................31
O
Ocaliva.................................... 98
Oceanic Selenium................. 67
Ocella....................................105
Octagam...............................110
Octreotide Acetate.............. 108
Ocutabs.................................. 84
Ocutabs Vision Formula........84
Ocutabs/Lutein......................84
Odefsey.................................. 43
Odomzo..................................37
Ofev...................................... 138
Off Deep Woods.................... 59
Off Deep Woods Dry............. 59
Off Deep Woods Sportsmen.59
Ofloxacin................................ 24
Ogestrel................................105
Olanzapine............................. 41
Olanzapine ODT.................... 41
Olmesartan Medoxomil.........50
Olmesartan Medoxomil/Hydrochlorothiazide............52
Olopatadine HCl.................. 132
Omega-3-Acid Ethyl Esters... 54
Omeprazole............................98
Omeprazole Magnesium.......98
Omnicap.................................84
On Call Express Blood Glucose Test Strips...........123
On Call Lancets................... 123
On Call Lancing Device.......123
On Call Plus Blood Glucose Test.....................................123
On Call Plus Lancets........... 123
On Call Plus Lancing Device............................................ 123
On Call Vivid Blood Glucose Test.....................................123
On Call Vivid Blood Glucose Test Strips..........................123
Once Daily.............................. 84
170170
Once Daily/Iron......................84
Oncovite................................. 84
Ondansetron HCl...................30
Ondansetron ODT................. 30
One Daily................................ 84
One Daily Complete.............. 84
One Daily for Men 50+ Advanced.............................84
One Daily for Women............ 84
One Daily for Women 50+a Dvanced............................... 84
One Daily Maximum.............. 84
One Daily Mens......................84
One Daily Multivitamin Adult.84
One Daily Multivitamin/Iron.. 84
One Daily Plus Iron................ 84
One Daily Plus Minerals........ 84
One Daily Womens 50 Plus.. 84
One Daily Womens 50+.........84
One Daily/Iron/Calcium........ 84
One Daily/Minerals................84
One-A-Day Essential.............. 84
One-A-Day Mens 50+ Advantage............................84
One-A-Day Teen Advantage for Her........................................ 84
One-A-Day Teen Advantage for Him....................................... 85
One-A-Day Womens Formula.............................................. 85
One-Daily Multi Vitamins....... 85
One-Way Valved Expiratory Mouthpiece/Disposable... 124
One-Way Valved Inspiratory Mouthpiece/Disposable... 124
Onetouch Delica Lancets Extra Fine 33g............................. 123
Onetouch Delica Lancets Fine 30g..................................... 123
Onetouch Delica Lancing Device................................ 123
Onetouch Suresoft Lancing Device/18g........................ 123
Onetouch Suresoft Lancing Device/21g........................ 124
Onetouch Suresoft Lancing Device/28g........................ 124
Onetouch Ultra Blue............124
Onetouch Ultrasoft Lancets124
Onetouch Verio Test Strips.124
Onfi................................... 25, 26
Onglyza...................................47
Opcicon One-Step...............107
Opsumit................................138
Opti-Clear............................. 132
Optium Test Strips...............124
OptiumEZ Test Strips..........124
OptumRx Blood Glucose Test............................................ 124
Oralyte.................................... 67
Oralyte Freezer Pops.............67
Orazinc................................... 67
Orencia................................. 109
Orencia Clickject................. 109
Orenitram............................. 138
Orfadin....................................98
Orkambi................................138
Orsythia................................ 105
OS-CAL...................................67
OS-CAL Calcium + D3...........67
OS-CAL Extra D3................... 67
OS-CAL Ultra..........................67
Oseltamivir Phosphate.......... 45
Osphena...............................107
Osteo-Poretical...................... 67
Otezla....................................110
Oxacillin in Dextrose..............23
Oxacillin Sodium....................23
Oxandrolone........................ 102
Oxcarbazepine.......................27
Oxsoralen Ultra...................... 59
Oxybutynin Chloride..............99
Oxybutynin Chloride ER........99
Oxycodone HCl......................17
Oxycodone/Acetaminophen 17
Oxycodone/Aspirin............... 17
Oxycodone/Ibuprofen...........17
Oysco 500.............................. 67
Oysco 500 + D....................... 67
Oyst-Cal-D 500....................... 67
Oyster Calcium...................... 67
Oyster Shell Calcium............. 67
Oyster Shell Calcium + D3.... 67
Oyster Shell Calcium + Vitamin D........................................... 67
Oyster Shell Calcium 250 + D.............................................. 67
Oyster Shell Calcium 500......67
Oyster Shell Calcium 500 + D........................................67, 68
Oyster Shell Calcium 500/D. 68
Oyster Shell Calcium Plus Vitamin D..............................68
171171
Oyster Shell Calcium+d.........68
Oyster Shell Calcium/D.........68
Oyster Shell Calcium/D3.......68
Oyster Shell Calcium/Magnesium.......................... 68
Oyster Shell Calcium/Vitamin D........................................... 68
Oystercal-D.............................68
P
Pacerone................................ 50
Pain & Fever........................... 13
Pain & Fever Childrens..........13
Pain & Fever Extra Strength..14
Pain & Fever Infants...............14
Pain Relief Sinus PE Daytime............................................ 142
Pain Reliever PM Extra Strength................................14
Pain Relieving Cream............59
Paliperidone ER..................... 41
Panda Mask Large.............. 124
Panda Mask Medium.......... 124
Panda Mask Small...............124
Panretin.................................. 38
Pantoprazole Sodium............98
Pantothenic Acid................... 85
Panzyga................................110
Paricalcitol............................113
Paromomycin Sulfate............ 19
Paroxetine HCl....................... 28
Paser.......................................33
Paxil........................................ 28
Pazeo....................................132
PC Lancets Super Thin 30g124
Pedialyte.................................68
Pedialyte Advanced Care......68
Pedialyte Freezer Pops......... 68
Pedialyte Singles................... 68
Pediarix.................................111
Pediatric Cough/Cold......... 142
Pediatric Electrolyte...............68
Pediatric Electrolyte Freeze Pops..................................... 68
Pediatric Electrolyte Freezer Pops..................................... 68
Pediatric Electrolyte/Zinc......68
Pediatric Medium Mask...... 124
Pediatric Mouthpiece/Disposable.........................124
Pediatric Panda Mask......... 124
Pediatric Small Mask...........124
Pedvax HIB...........................111
PEG 3350............................... 97
PEG 3350/Electrolytes..........97
PEG-3350/Electrolytes.......... 97
PEG-3350/NaCl/Na Bicarbonate/KCl..................97
Peganone............................... 27
Pegasys.................................. 42
Pegasys ProClick...................42
Penicillamine..........................99
Penicillin G Potassium...........23
Penicillin G Procaine............. 23
Penicillin G Sodium............... 23
Penicillin V Potassium........... 23
Pentam 300............................ 38
Pentoxifylline ER....................53
Peptic Relief........................... 95
Perforomist...........................137
Peridin-C.................................85
Perindopril Erbumine............ 50
Permethrin..............................39
Perphenazine......................... 30
Perseris...................................41
Pharmacist Choice Autocode Blood Glucose Test Strips124
Pharmacist Choice No Coding Blood Glucose Test Strips124
Pharmacist Choice Ultra Thin Lancets...............................124
Pharmacist Choice Ultra Thin Lancets 28g....................... 124
Pharmacist Choice Ultra Thin Lancets 30g....................... 124
Pharmacist Choice Ultra Thin Lancets 31g....................... 124
Pharmacist Choice Ultra Thin Lancets 33g....................... 124
Phenadoz............................. 135
Phenelzine Sulfate................. 28
Phenobarbital.........................26
Phenoxybenzamine HCl........50
Phenylephrine HCl/Pyrilamine Maleate.............................. 142
Phenytek.................................27
Phenytoin................................27
Phenytoin Sodium Extended 27
Phillips.................................... 97
Phoslyra..................................72
Phospholine Iodide............. 132
Picato......................................59
Pifeltro.....................................43
Pilocarpine HCl..............57, 132
172172
Pimecrolimus......................... 60
Pimozide.................................40
Pimtrea................................. 105
Pindolol...................................51
Pioglitazone HCl.................... 47
Pioglitazone HCl/Glimepiride.............................................. 47
Pioglitazone HCl/Metformin HCl........................................47
Piperacillin/Tazobactam....... 23
Piqray 200mg Daily Dose......35
Piqray 250mg Daily Dose......35
Piqray 300mg Daily Dose......35
Pirmella 1/35........................105
Plain Niacin............................ 85
Plasma-Lyte A........................ 68
Plasma-Lyte-148.....................69
Plenamine...............................69
Podofilox.................................60
Poly Hist Forte......................142
Poly Vitamin........................... 85
Poly-Hist DM.........................142
Poly-Hist PD......................... 135
Poly-Iron 150.......................... 69
Poly-Vent DM....................... 143
Poly-Vent IR..........................143
Polymyxin B Sulfate...............20
Polymyxin B Sulfate/Trimethoprim Sulfate........ 131
Polyvitamin............................. 85
Polyvitamin/Iron.....................85
Pomalyst.................................34
Portia-28............................... 105
Posaconazole DR.................. 31
Potassium Chloride............... 69
Potassium Chloride CR.........69
Potassium Chloride ER......... 69
Potassium Chloride/Dextrose.............................................. 69
Potassium Chloride/Dextrose/Lactated Ringers................. 69
Potassium Chloride/Dextrose/Sodium Chloride................. 69
Potassium Chloride/Sodium Chloride................................69
Potassium Citrate ER............ 69
Povidone-Iodine..................... 20
Praluent.................................. 54
Pramipexole Dihydrochloride.............................................. 39
Prasugrel................................ 49
Pravastatin Sodium................54
Praziquantel........................... 38
Prazosin HCl...........................50
Precision PCX...................... 124
Precision PCX Plus Test Strips............................................ 124
Precision Point of Care Test Strips.................................. 124
Precision QID Test Strips....124
Precision XTra Blood Glucose Test Strips..........................124
Prednicarbate...................... 101
Prednisolone........................101
Prednisolone Acetate..........133
Prednisolone Sodium Phosphate................. 101, 133
Prednisone........................... 101
Prednisone Intensol.............101
Preferred Plus Lancets Super Thin 30g............................. 124
Preferred Plus Lancets Thin 26g..................................... 124
Pregabalin.............................. 57
Premarin...............................105
Premasol................................ 69
Premium Blood Glucose Test Strips.................................. 124
Premphase...........................105
Prempro................................105
Prevalite..................................54
Prevent....................................85
Previfem............................... 105
Prezcobix................................45
Prezista................................... 45
Priftin.......................................33
Primaquine Phosphate..........38
Primidone............................... 26
Privigen.................................110
Pro Comfort Lancets 30g....124
Pro Comfort Lancets 31g....125
ProAir HFA........................... 137
ProAir RespiClick................ 137
Probenecid.............................32
Probenecid/Colchicine......... 32
Procalamine........................... 69
Prochlorperazine................... 30
Prochlorperazine Maleate.....30
Procrit..................................... 49
Procto-Med HC.................... 112
Procto-Pak............................112
Proctosol HC........................112
Proctozone-HC.....................112
173173
Prodigy Lancing Device...... 125
Prodigy No Coding Blood Glucose Test Strips...........125
Prodigy Pressure Activated Safety Lancets...................125
Prodigy Safety Lancets....... 125
Prodigy Twist Top Lancets. 125
ProFe...................................... 69
Proferrin ES............................ 69
Proglycem.............................. 47
Prograf..................................109
Prolastin-C.............................. 98
Prolensa............................... 133
Prolia.....................................113
Promacta................................ 49
Promethazine HCl................135
Promethazine VC/Codeine.143
Promethazine-DM................ 143
Promethazine/Codeine.......143
Promethazine/Phenylephrine............................................ 143
Promethegan....................... 135
Propafenone HCl................... 50
Propafenone HCl ER............. 50
Proparacaine HCl................ 131
Propranolol HCl..................... 51
Propranolol HCl ER............... 51
Propranolol/Hydrochlorothiazide............53
Propylthiouracil....................108
ProQuad............................... 111
Prosol......................................69
Protriptyline HCl.....................29
Prudoxin................................. 60
Pseudoephedrine HCl.........143
Pulmosal...............................143
Pulmozyme...........................143
Puralube............................... 131
Pure C 500............................. 85
Pureway-C.............................. 85
Purixan....................................34
Push Button Safety Lancets 28g..................................... 125
PX Advanced Lancing Device............................................ 125
PX Lancets Ultra Thin..........125
PX Lancets Ultra Thin 28g.. 125
Pyrazinamide..........................33
Pyridostigmine Bromide........33
Pyridostigmine Bromide ER..33
Pyridoxine HCl....................... 85
Q
QC Advanced Lancing Device............................................ 125
QC Anti-Diarrheal...................95
QC Arthritis Pain Relief..........14
QC Calcium Fast Dissolution69
QC Calcium/Minerals/Vitamin D........................................... 69
QC Childrens Chewable Vitamins/Extra C..................85
QC Lancets Super Thin.......125
QC Loratadine Allergy Relief............................................ 135
QC Loratadine-D..................135
QC Maximum Daily Multivitamin/Multimineral... 85
QC Multi-Vite.......................... 85
QC Naproxen Sodium........... 15
QC Tolnaftate.........................31
QC Unilet Lancets 28g/Ultra Thin.....................................125
QC Unilet Lancets 33g/Micro Thin.....................................125
QC Womens Daily Multivitamin.............................................. 85
Quadracel.............................111
Quetiapine Fumarate.............41
Quetiapine Fumarate ER.......41
Quinapril HCl..........................50
Quinapril/Hydrochlorothiazide.............................................. 53
Quinidine Gluconate CR....... 50
Quinidine Sulfate................... 51
Quinine Sulfate...................... 38
Quintabs-M.............................85
Quintet AC Blood Glucose Test Strips.................................. 125
Quintet Blood Glucose Test Strips.................................. 125
R
RA B-Complex........................85
RA B-Complex with B-12.......85
RA B-Complex/Vitamin C TR85
RA Balanced B-100............... 85
RA Balanced B-50................. 85
RA Biotin................................ 85
RA Calcium 600.....................69
RA Calcium 600 Plus Vitamin D-3........................................ 70
RA Calcium 600/Vitamin D/Minerals................................70
RA Calcium Citrate Plus Vitamin D-3...........................70
174174
RA Calcium/Boron................ 70
RA Calcium/Magnesium/Zinc/Copper................................. 70
RA Central-Vite Cardio.......... 85
RA Central-Vite Select Mature.............................................. 85
RA Central-Vite Womens Mature.................................. 85
RA Central-Vite/Antioxidants85
RA E-Zject Lancets 28g...... 125
RA E-Zject Lancets Thin 26g............................................ 125
RA E-Zject Lancets Thin 28g............................................ 125
RA E-Zject Lancets Ultra Thin 30g..................................... 125
RA Hi Cal................................ 70
RA High Potency Iron............70
RA Iron....................................70
RA Magnesium...................... 70
RA Natural Magnesium......... 70
RA Niacin................................86
RA One Daily Energy Formula.............................................. 86
RA One Daily Essential..........86
RA One Daily Maximum........ 86
RA One Daily Mens 50+ with Vitamin D-3...........................86
RA Oyster Shell Calcium/Vitamin D..............................70
RA Pediatric Electrolyte........ 70
RA Pediatric Electrolyte Freezer Pops........................70
Ra Selenium...........................70
Ra Selenium Natural..............70
RA Slow Release Iron............70
RA Vitamin A.......................... 86
RA Vitamin B-1.......................86
RA Vitamin B-12.....................86
RA Vitamin B-12 TR...............86
RA Vitamin B-6.......................86
RA Vitamin B12......................86
RA Vitamin C..........................86
RA Vitamin C Drops...............86
RA Vitamin C TR....................86
RA Vitamin C/Acerola........... 86
RA Vitamin C/Rose Hips.......86
RA Vitamin C/Rose Hips TR.86
RA Vitamin E.......................... 86
RA Zinc...................................70
Rabano Yodado.....................86
Rabavert............................... 111
Rabeprazole Sodium.............98
Raloxifene HCl..................... 107
Ramelteon............................144
Ramipril.................................. 50
Ranexa....................................53
Ranitidine 150 Maximum Strength................................95
Ranitidine 75.......................... 95
Ranitidine HCl........................ 96
Ranitidine Maximum Strength.............................................. 96
Ranolazine ER........................53
Rapaflo................................... 99
Rapamune............................109
Rasagiline Mesylate...............40
Rasuvo..................................109
Ravicti..................................... 98
Readylance Safety Lancets/21g/2.2mm........................ 125
Readylance Safety Lancets/23g/1.8mm........................ 125
Readylance Safety Lancets/26g/1.8mm........................ 125
Readylance Safety Lancets/28g/1.8mm........................ 125
Readylance Safety Lancets/30g/1.6mm........................ 125
Rebif....................................... 57
Rebif Rebidose...................... 57
Rebif Rebidose Titration Pack.............................................. 57
Rebif Titration Pack............... 57
Reclipsen............................. 105
Recombivax HB................... 111
Refresh Celluvisc.................131
Refresh Lacri-Lube.............. 131
Refresh Optive Mega-3....... 131
Refresh Plus.........................131
Refuah Plus Blood Glucose Test Strips..........................125
Regranex................................ 60
Relenza Diskhaler..................45
Relion Confirm/Micro Test Strips.................................. 125
Relion Lancets Thin 26g..... 125
Relion Lancets Ultra-Thin30g............................................ 125
Relion Lancing Device........ 126
Relion Premier Blood Glucose Test Strips..........................126
175175
Relion Prime Blood Glucose Test Strips..........................126
Relion Ultima Blood Glucose Test Strips..........................126
Relion Ultra Thin Lancets30g............................................ 126
Relion Ultra Thin Plus Lancets 32g..................................... 126
Relion Ultra Thin Plus Lancets 33g..................................... 126
Relistor....................................95
Rena-Vite................................ 86
Renal Vitamin.........................86
Renal-Vite............................... 86
Repaglinide............................ 47
Repaglinide/Metformin HCl..47
Repatha.................................. 54
Repatha Pushtronex System 54
Repatha SureClick.................55
Repel Huniters Formula........ 60
Repel Lemon Eucalyptus Insect Repellent...................60
Repel Sportsmen...................60
Repel Sportsmen Dry............ 60
Repel Sportsmen Max...........60
Rescon................................. 136
Rescriptor...............................43
Respaire-30.......................... 143
Restasis................................ 131
Retacrit................................... 49
Reveal Blood Glucose Test 126
Revlimid..................................34
Rexall Blood Glucose Test Strips.................................. 126
Rexall Lancets Ultra Thin....126
Rexulti.....................................41
Reyataz................................... 45
Rhopressa............................131
Ribavirin..................................42
Ridaura................................. 110
Rifabutin................................. 33
Rifampin................................. 33
Rifater..................................... 33
Rightest GD500 Lancing Device................................ 126
Rightest GL300 Lancets..... 126
Rightest GS100 Blood Glucose Test Strips..........................126
Rightest GS300 Blood Glucose Test Strips..........................126
Rightest GS550 Blood Glucose Test Strips..........................126
Riluzole................................... 56
Rimantadine HCl....................45
Riomet.................................... 47
Risacal-D.................................70
Risperdal Consta................... 41
Risperidone............................41
Risperidone ODT................... 41
Ritonavir................................. 45
Rivastigmine Tartrate............ 27
Rivastigmine Transdermal System..................................27
Rivelsa.................................. 106
Rizatriptan Benzoate............. 32
Rizatriptan Benzoate ODT.... 32
Robafen................................143
Robafen CF Multi-Symptom Cold....................................143
Robafen Cough................... 143
Robafen DM.........................143
Robafen DM Cough Clear.. 143
Robafen DM Cough/Chest Congestion........................ 143
Rocklatan............................. 132
Ropinirole HCl........................39
Rosuvastatin Calcium............54
Rotarix.................................. 111
RotaTeq................................111
Roweepra............................... 25
Roweepra XR......................... 25
Rozerem............................... 144
Rozlytrek.................................35
Ru-Hist D.............................. 136
Rubraca.................................. 36
Ruconest.............................. 108
Rulox.......................................95
Rydapt.................................... 37
Rymed.................................. 136
Rynex DM.............................143
Rynex PE.............................. 136
Rynex PSE............................136
Rytary......................................39
S
S2..........................................137
Sabril.......................................26
Safety Lancet 21g/Pressure Activated............................ 126
Safety Lancet 28g/Pressure Activated............................ 126
Safety Lancets..................... 126
176176
Safety Lancets 21g..............126
Safety Lancets 28g..............126
Safety Let Lancets...............126
Safety Seal Lancets 28g..... 126
Safety Seal Lancets 30g..... 126
Saizen................................... 102
Saizenprep Reconstitution Kit............................................ 102
Samsca...................................72
Sancuso..................................30
Sandimmune........................109
Sani-Supp Adult..................... 97
Sani-Supp Pediatric............... 97
Santyl...................................... 60
Saphris....................................41
Sapscare Twist Top Lancets 30g..................................... 126
Savella.................................... 57
Savella Titration Pack............57
Sawyer Premium Insect Repellent..............................60
SB Vitamin C.......................... 86
Scooby-Doo One A Day........ 86
Scopolamine.......................... 30
Select-Lite Lancing Device. 126
Selegiline HCl.........................40
Selenium.................................70
Selenium Sulfide....................60
Selzentry.................................44
Senexon..................................97
Senexon-S.............................. 97
Senior Tabs............................ 86
Senna......................................97
Senna Plus............................. 97
Senna-Lax...............................97
Sensipar............................... 113
Sentry......................................87
Sentry Adults Under 50......... 87
Sentry Senior..........................87
Serevent Diskus...................137
Serostim................................. 95
Sertraline HCl.........................28
Setlakin.................................106
Sevelamer Carbonate............72
Sharobel............................... 107
Shingrix.................................111
Shopko Autolet Lancing Device................................ 126
Shopko On-The-Go Comfort Lancets 30g....................... 126
Shopko Unilet Lancets Super Thin 30g............................. 126
Shopko Unilet Lancets Ultra Thin 28g............................. 126
Sidekick Blood Glucose System............................... 126
Sidestream Pediatric Face Mask/Tucker the Turtle.... 126
Signifor................................. 108
Siladryl Allergy..................... 136
Sildenafil...............................138
Silodosin.................................99
Siltussin DM DAS.................143
Siltussin SA.......................... 143
Siltussin-DM......................... 143
Silver Sulfadiazine................. 24
Simethicone........................... 95
Simple Diagnostics Lancing Device................................ 126
Simponi................................ 109
Simvastatin.............................54
Sirolimus...............................109
Sirturo..................................... 34
Slo-Niacin............................... 88
Slow Fe................................... 70
Slow Release Iron..................70
Slow-Mag................................70
Slow-Release Iron.................. 70
SM Allergy 4 Hour............... 136
SM Allergy Relief................. 136
SM Antacid Anti-Gas............. 95
SM Antacid/Anti-Gas.............95
SM Anti-Diarrheal...................95
SM B-Complex....................... 88
SM B-Complex/Vitamin C..... 88
SM Balanced B-50.................88
SM Calcium 500/Vitamin D3 70
SM Calcium 600 + D3........... 70
SM Calcium 600/Vitamin D.. 70
SM Calcium Citrate + with Vitamin D..............................70
SM Calcium Citrate with Vitamin D3............................70
SM Calcium Soft Chews....... 70
SM Calcium/Magnesium/Zinc.............................................. 70
SM Calcium/Vitamin D..........70
SM Chewable C..................... 88
Sm Chewable Vitamin C....... 88
SM Complete......................... 88
SM Complete 50+..................88
177177
SM Complete 50+ Ultimate Womens............................... 88
SM Complete Advanced Formula................................ 88
SM Complete Senior Formula.............................................. 88
SM Hair/Skin/Nails................88
SM Ibuprofen......................... 15
SM Iron................................... 70
SM Iron Slow Release........... 70
SM Lorata-Dine D................ 136
SM Loratadine..................... 136
SM Magnesium......................70
SM Miconazole 7................... 31
SM Micro Thin Lancets 33g126
SM Multiple Vitamins Essential.............................................. 88
SM Multiple Vitamins/Iron.... 88
SM Nasal Spray 12 Hour.....143
SM Niacin CR.........................88
SM One Daily Womens......... 88
SM Oyster Shell Calcium/Vitamin D..............................70
SM Oyster Shell Calcium/Vitamin D3............................71
SM Pediatric Electrolyte........71
SM Selenium..........................71
SM Sleep Aid....................... 144
SM Slow Release Iron........... 71
SM Super B Complex-Vitamin C........................................... 88
SM Tussin DM......................143
SM Tussin DM Cough/Chest Congestion........................ 143
SM Vitamin B-12.................... 88
SM Vitamin B-6...................... 88
SM Vitamin B1....................... 88
SM Vitamin B100 Complex...88
SM Vitamin B12..................... 88
SM Vitamin B12 TR............... 88
SM Vitamin B6....................... 88
SM Vitamin C......................... 88
SM Vitamin C TR................... 88
SM Vitamin C/Rose Hips...... 88
SM Vitamin E..........................89
SM Vitamin E Blended.......... 89
SM Zinc.................................. 71
Smart Diabetes Vantage Lancing Device..................126
Smart Sense Color Lancets Universal 33g.....................126
Smart Sense Premium Bloodglucose Strips..........126
Smart Sense Standard Lancets Universal 21g.....................127
Smart Sense Super Thin Lancets Universal 30g...... 127
Smart Sense Thin Lancets Universal 26g.....................127
Smart Sense Value Blood Glucose Strips................... 127
Smartest Blood Glucose Test Strips.................................. 127
Smartest Lancets 28g......... 127
Sodium Bicarbonate..............95
Sodium Chloride... 71, 131, 143
Sodium Chloride 0.9%......... 71
Sodium Fluoride.................... 71
Sodium Lactate......................71
Sodium Phenylbutyrate.........98
Sodium Polystyrene Sulfonate.............................................. 72
Sodium Sulfacetamide..........24
Sofosbuvir/Velpatasvir.......... 42
Solifenacin Succinate............99
Soliqua 100/33...................... 47
Soltamox.................................34
Solus V2 Audible Test.........127
Solus V2 Lancing Device.... 127
Solus V2 Pressure Activated Safety Lancets 28g........... 127
Solus V2 Twist Lancets 30g127
Somatuline Depot................108
Somavert.............................. 108
Sotalol HCl............................. 51
Sotalol HCl AF........................51
Spiriva HandiHaler...............137
Spiriva Respimat..................137
Spironolactone.......................53
Spironolactone/Hydrochlorothiazide............53
Sporanox................................ 32
Sprintec 28...........................106
Spritam................................... 25
Sprycel....................................37
SPS......................................... 72
Sronyx...................................106
SSD......................................... 24
Stahist AD.............................143
Stavudine................................44
Stelara.....................................60
Sterilance PA....................... 127
Sterilance Tl......................... 127
Stimulant Laxative..................97
178178
Stiolto Respimat.................. 143
Stivarga...................................37
Stool Softener........................ 97
Streptomycin Sulfate............. 19
Stress B/Zinc......................... 89
Stress Formula.......................89
Stress Formula with Iron....... 89
Stress Formula/Iron...............89
Stress Formula/Zinc..............89
Stribild.....................................43
Suboxone............................... 18
Sucraid................................... 99
Sucralfate............................... 97
Sudogest.............................. 143
Sudogest 12 Hour............... 143
Sudogest PE........................ 144
Sudogest Sinus & Allergy... 136
Sulfacetamide Sodium..........24
Sulfacetamide Sodium/Prednisolone Sodium Phosphate..........................131
Sulfadiazine............................24
Sulfamethoxazole/Trimethoprim....................... 24
Sulfamethoxazole/Trimethoprim DS................. 24
Sulfasalazine........................ 112
Sulindac..................................15
Sumatriptan............................32
Sumatriptan Succinate..........33
Sumatriptan Succinate Refill 33
Super B Complex Maxi......... 89
Super B with C....................... 89
Super B-Complex/Vitamin C 89
Super Biotin........................... 89
Super Calcium....................... 71
Super Calcium 600 + D 400..71
Super Calcium 600 + D3.......71
Super Calcium 600 + D3 400.............................................. 71
Super Quints B-50................. 89
Super Thera Vite M................89
Superplex-T............................ 89
Suplevit...................................89
Suprax.................................... 22
Suprep Bowel Prep Kit..........97
Sure Comfort Lancets 18g..127
Sure Comfort Lancets 21g..127
Sure Comfort Lancets 23g..127
Sure Comfort Lancets 28g..127
Sure Comfort Lancets 30g..127
Sure Comfort Lancing Pen. 127
Sure-Lance Flat Lancets..... 127
Sure-Lance Thin Lancets 28g............................................ 127
Sure-Lance Ultra Thin Lancets............................................ 127
Sure-Test EasyPlus Mini Blood Glucose Test Strips...........127
Sure-Touch Lancets Universal............................................ 127
Suspendol-S.........................127
Sutent..................................... 37
Syeda....................................106
Sylatron...................................42
Symbicort............................. 144
Symfi....................................... 43
Symfi Lo..................................43
SymlinPen 120....................... 47
SymlinPen 60......................... 47
Sympazan...............................26
Symtuza..................................45
Synarel..................................108
Synjardy..................................47
Synjardy XR............................47
Synribo................................... 35
Synthroid.............................. 107
T
TAB-A-VITE.............................89
TAB-A-VITE Maximum........... 89
TAB-A-VITE with Beta Carotene.............................................. 89
TAB-A-VITE/Iron.....................89
Tabloid....................................35
Tacrolimus..................... 60, 109
Tadalafil................................ 138
Tafinlar....................................37
Tagrisso..................................37
Talzenna................................. 36
Tamoxifen Citrate.................. 34
Tamsulosin HCl......................99
Tandem.................................. 71
Tarceva................................... 37
Targretin................................. 38
Tarina 24 Fe......................... 106
Tarina Fe 1/20..................... 106
Tasigna................................... 37
Tazarotene............................. 60
Tazicef.................................... 22
Tazorac...................................60
Taztia XT.................................52
179179
Tecfidera................................ 57
Tecfidera Starter Pack...........57
TechLite Lancets................. 127
Techlite Lancets 30g...........127
Telcare Blood Glucose Test Strips.................................. 127
Telmisartan.............................50
Telmisartan/Amlodipine........53
Telmisartan/Hydrochlorothiazide............53
Temazepam......................... 144
Tencon....................................14
Tenivac................................. 111
Tenofovir Disoproxil Fumarate.............................................. 44
Terazosin HCl.........................99
Terbinafine HCl......................32
Terconazole............................32
Testosterone........................ 102
Testosterone Cypionate......102
Testosterone Enanthate......102
Testosterone Pump.............102
Tetanus/Diphtheria Toxoids-Adsorbed Adult................. 111
Tetrabenazine........................ 56
Tetracycline HCl.................... 25
TGT Blood Glucose Test Strips............................................ 127
TGT Blood Glucose Test Strips Premium.............................128
TGT Calcium + Vitamin D3... 71
TGT Lancet Micro Thin 33g128
TGT Lancet Thin 26g.......... 128
TGT Lancet Ultra Thin 30g. 128
TGT Lancing Device............128
Thalomid.................................34
Theophylline.........................138
Theophylline ER...................138
Thera.......................................89
Thera M Plus.......................... 89
Thera-M.................................. 90
Thera-Tabs............................. 90
Therapeutic-M/Lutein............90
Theratrum Complete............. 90
Theratrum Complete 50 Plus90
Therems..................................90
Therems-H..............................90
Therems-M............................. 90
Thiamine HCl......................... 90
Thioridazine HCl.................... 40
Thiothixene.............................40
ThyroSafe............................. 128
Tiagabine HCl........................ 26
Tibsovo................................... 37
Tigecycline............................. 20
Timolol Maleate............. 51, 132
Timolol Maleate Ophthalmic Gel Forming.......................132
Tinidazole............................... 20
Tioconazole-1.........................32
Tivicay.....................................43
Tizanidine HCl......................144
TOBI Podhaler..................... 138
Tobradex.............................. 131
Tobradex ST........................ 131
Tobramycin.......................... 138
Tobramycin Sulfate............... 19
Tobramycin/Dexamethasone............................................ 131
Tobrex.....................................20
Tolak....................................... 60
Tolcapone.............................. 39
Tolnaftate............................... 32
Topcare Lancets Micro-Thin 33g..................................... 128
Topiramate............................. 26
Toremifene Citrate.................34
Torsemide.............................. 53
Total B/C................................ 90
Totalday Multiple................... 90
Toujeo Max Solostar..............48
Toujeo SoloStar..................... 48
TPN Electrolytes.................... 71
Tracleer................................ 138
Tradjenta................................ 47
Tramadol HCl.........................18
Tramadol HCl ER...................16
Tramadol HCl/Acetaminophen.............................................. 18
Trandolapril............................ 50
Tranexamic Acid....................49
Transderm-Scop.................... 30
Tranylcypromine Sulfate....... 28
Travasol.................................. 71
Travatan Z............................ 133
Travel Lancets 30g.............. 128
Travel Lancets Advanced 28g............................................ 128
Travel Sickness......................30
Trazodone HCl.......................28
Trecator.................................. 34
180180
Trelegy Ellipta...................... 144
Trelstar Mixject.................... 108
Tresiba....................................48
Tresiba FlexTouch................. 48
Tretinoin........................... 38, 60
Tretinoin Microsphere........... 60
Trexall................................... 109
Trezix...................................... 18
Tri-Estarylla...........................106
Tri-Legest Fe........................ 106
Tri-Lo-Estarylla..................... 106
Tri-Lo-Sprintec..................... 106
Tri-Mili................................... 106
Tri-Previfem.......................... 106
Tri-Sprintec...........................106
Tri-Vi-Sol..................................90
Tri-VyLibra............................ 106
Tri-VyLibra Lo.......................106
Triamcinolone Acetonide...101, 136
Triamcinolone Acetonide Dental Paste.........................57
Triamterene/Hydrochlorothiazide............53
Triderm................................. 101
Trientine HCl.......................... 72
Trifluoperazine HCl................40
Trifluridine.............................. 42
Trihexyphenidyl HCl.............. 39
TriLyte.....................................97
Trimethoprim..........................20
Trimipramine Maleate........... 29
Trintellix.................................. 28
Triple Antibiotic......................21
Triple Antibiotic Plus............. 21
Triprolidine HCl....................136
Triumeq.................................. 43
Trivora-28............................. 106
Trophamine............................71
True Metrix Blood Glucose Test Strips..........................128
True Metrix Self Monitoring Blood Glucose Strips........128
TrueDraw Lancing Device...128
TruePlus Lancets 26g......... 128
TruePlus Lancets 28g......... 128
Trueplus Lancets 28g Super Thin.....................................128
TruePlus Lancets 30g......... 128
Trueplus Lancets 30g Ultra Thin.....................................128
TruePlus Lancets 33g......... 128
Trueplus Lancets 33g Micro Thin.....................................128
Trueplus Safety Lancets 28g............................................ 128
TrueTest Strips.................... 128
TrueTrack Blood Glucose Test Strips.................................. 128
TrueTrack Test Strips..........128
Trumenba.............................111
Truvada...................................44
Turalio.....................................37
Tussin DM............................ 144
Twinrix.................................. 111
Tybost..................................... 43
Tykerb.....................................37
Tymlos.................................. 113
Typhim Vi............................. 111
U
Ulti-Lance Automatic/ Clear Tip.......................................128
Ultilet Classic Lancets......... 128
Ultilet Lancets...................... 128
Ultilet Lancets 33g...............128
Ultilet Safety Lancets 23g... 128
Ultima Test Strips................ 128
Ultra Choice Multivitamin Kids.............................................. 90
Ultra Lubricant Eye Drops...131
Ultra-Thin II Lancets 28g..... 128
Ultra-Thin II Lancets 30g..... 128
Ultra-Thin II Safety Autolancets 26g..................................... 128
Ultrachoice Advanced Formula.............................................. 90
Ultralance............................. 128
Ultrathon Insect Repellent 8. 60
Ultratrak Pro Test Strips......128
Ultratrak Ultimate Test Strips............................................ 128
Unicomplex-M........................ 90
Unilet ComforTouch Lancet............................................ 129
Unilet Excelite...................... 129
Unilet Excelite II................... 129
Unilet G.P. SuperLite Lancet............................................ 129
Unilet GP 28 Ultra Thin....... 129
Unilet Lancets Micro-Thin33g............................................ 129
Unilet Lancets Super-Thin30g............................................ 129
181181
Unilet Lancets Ultra-Thin 28g............................................ 129
Unistik 2................................129
Unistik 2 Comfort.................129
Unistik 2 Extra...................... 129
Unistik 2 Normal.................. 129
Unistik 2 Super.................... 129
Unistik 3 Comfort.................129
Unistik 3 Extra...................... 129
Unistik 3 Gentle................... 129
Unistik 3 Neonatal............... 129
Unistik 3 Normal.................. 129
Unistik CZT Comfort............129
Unistik CZT Normal............. 129
Unistik Safety Lancets 28g. 129
Unistik Safety Lancets 30g. 129
Unistik Touch Safety Lancets 21g..................................... 129
Unistik Touch Safety Lancets 23g..................................... 129
Unistik Touch Safety Lancets 28g..................................... 129
Unistik Touch Safety Lancets 30g..................................... 129
Unistrip1 Generic.................129
Unithroid...............................107
Universal 1 Lancets Thin 26g............................................ 129
Universal 1 Lancets Ultra Thin 30g..................................... 129
Ursodiol.................................. 95
V
Valacyclovir HCl.....................42
Valchlor...................................34
Valganciclovir.........................42
Valganciclovir Hydrochlorde.42
Valproic Acid..........................26
Valsartan.................................50
Valsartan/Hydrochlorothiazide.............................................. 53
Value Plus Lancing Device. 130
Valumark Lancet Super Thin 30g..................................... 130
Valumark Lancet Ultra Thin 28g..................................... 130
Vanaclear PD....................... 136
VanaCof................................144
VanaCof DM.........................144
VanaCof-8.............................144
Vanahist PD..........................136
Vanamine PD....................... 136
Vanatab Ac...........................136
Vanatab DM......................... 136
Vancomycin HCl.................... 21
Vandazole...............................21
Vaqta.....................................112
Varivax.................................. 112
Varizig...................................110
Vascepa..................................55
Velivet................................... 106
Velphoro................................. 72
Veltassa.................................. 72
Vemlidy...................................42
Venclexta................................37
Venclexta Starting Pack........ 37
Venlafaxine HCl......................28
Venlafaxine HCl ER................29
Ventavis................................ 138
Verapamil HCl........................ 52
Verapamil HCl ER.................. 52
Verasens Blood Glucose Test Strips.................................. 130
Versacloz................................ 41
Verzenio..................................35
Vesicare..................................99
Vibramycin..............................25
Vida Mia Autolet Lancing Device................................ 130
Vida Mia Unilet Lancets Super Thin 30g............................. 130
Vida Mia Unilet Lancets Ultra Thin 28g............................. 130
Videx EC................................. 44
Videx Pediatric....................... 44
Vienva................................... 106
Vigabatrin............................... 26
Vigadrone............................... 26
Viibryd.....................................29
Viibryd Starter Pack...............29
Vimpat.....................................27
Viracept.................................. 45
Viramune................................ 43
Viread......................................44
Virtussin A/C........................144
Virtussin DAC.......................144
Vita-Bee/C.............................. 91
Vitalee..................................... 91
Vitalets.................................... 91
Vitalets Childrens...................91
Vitamin A................................ 91
Vitamin A & D......................... 60
Vitamin B Complex................91
Vitamin B Complex-C............ 91
182182
Vitamin B-1............................. 91
Vitamin B-12........................... 91
Vitamin B-12 CR.....................91
Vitamin B-12 ER..................... 91
Vitamin B-12 TR..................... 91
Vitamin B-2............................. 91
Vitamin B-6............................. 91
Vitamin B-Complex................ 91
Vitamin B1.............................. 91
Vitamin B12............................91
Vitamin B12 TR...................... 91
Vitamin B6.............................. 91
Vitamin C................................ 92
Vitamin C Drops.....................92
Vitamin C SR.......................... 92
Vitamin C TR.......................... 92
Vitamin C/Rose Hips.............92
Vitamin C/Rose Hips TR.......92
Vitamin D................................ 92
Vitamin D3.............................. 92
Vitamin E................................ 92
Vitamin E Blend..................... 92
Vitamin E Water Dispersible. 92
Vitamin E Water Soluble........92
Vitamin E-400......................... 92
Vitamin E/D-Alpha................. 92
Vitamin E/D-Alpha Natural.... 92
Vitamin E/Dl-Alpha................ 92
Vitamin K1.............................. 92
Vitamins & Minerals...............92
Vitamins for Hair.................... 92
Vitatrum.................................. 93
Vitrakvi.................................... 37
Vitrum 50+ Senior Multi.........93
Vivitrol..................................... 18
Vizimpro..................................37
Voriconazole.......................... 32
Vosevi..................................... 42
Votrient................................... 37
VP-PNV-DHA.......................... 93
Vraylar.....................................41
Vyfemla.................................106
VyLibra..................................106
Vyndaqel.................................53
Vyzulta.................................. 133
W
Walgreens Advanced Travellancets 28g..............130
Walgreens Comfort Assuredlancets Micro Thin/33g..................................... 130
Walgreens Comfort Assuredlancets Super Thin/28g..................................... 130
Walgreens Thin Lancets..... 130
Walgreens Ultra Thin Lancets............................................ 130
Warfarin Sodium.................... 48
Wavesense Presto Test Strips............................................ 130
Wee Care................................71
White Petrolatum................. 130
Wixela Inhub........................ 144
Womens Daily Formula......... 93
Womens Daily Formula/Folic Acid/Calcium/Iron...............93
Womens One Daily................ 93
WYMZYA Fe.........................106
X
Xalkori.....................................37
Xarelto.....................................48
Xarelto Starter Pack...............48
Xatmep................................. 110
Xeljanz.................................. 110
Xeljanz XR............................ 110
Xgeva....................................113
Xifaxan.................................... 96
Xigduo XR.............................. 47
Xiidra.....................................131
Xofluza.................................... 45
Xolair.....................................110
Xospata...................................37
Xpovio 100mg Once Weekly 35
Xpovio 60mg Once Weekly...35
Xpovio 80mg Once Weekly...35
Xpovio 80mg Twice Weekly..35
Xtampza ER............................16
Xtandi......................................34
Xyrem....................................144
Y
Yelets Teenage Formula....... 93
YF-Vax...................................112
Z
Z-Bum..................................... 60
Zafirlukast.............................136
Zaleplon................................144
Zarah.....................................106
Zarxio......................................49
Zeasorb-AF.............................32
Zebutal....................................14
Zejula...................................... 36
183183
Zelapar....................................40
Zelboraf.................................. 38
Zemaira...................................99
Zenpep................................... 99
Zerbaxa...................................22
Zidovudine..............................44
Zileuton ER...........................136
Zinc...................................71, 93
Zinc 15....................................71
Zinc Chelated.........................71
Zinc Gluconate.......................71
Zinc Oxide.............................. 60
Zinc Sulfate............................ 72
Zinc-220..................................72
Zioptan................................. 133
Ziprasidone HCl.....................41
Zirgan......................................42
Zolinza.................................... 35
Zolpidem Tartrate................144
Zonisamide.............................25
Zoo Friends............................ 93
Zorbtive...................................95
Zortress................................ 110
Zostavax............................... 112
Zovia 1/35E..........................106
Zutripro.................................144
Zyclara Pump.........................60
Zydelig.................................... 38
Zyflo...................................... 137
Zykadia................................... 38
Zyprexa Relprevv...................41
Zytiga...................................... 34
Formulary ID Number 00019088, Version 17
H7833_180629_022455_v01.13 ApprovedLast updated December 1, 2019UHTX19HM4307577_014
If you have questions, please call UnitedHealthcare Connected Member Services at:
Toll-free 1-800-256-6533, TTY 7-1-1
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www.UHCCommunityPlan.com
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