mnscha.org · 2020. 8. 31. · 2020 List of Covered Drugs (Formulary) SeniorCare Complete (HMO SNP)...

2020 List of Covered Drugs (Formulary) SeniorCare Complete (HMO SNP) and AbilityCare (HMO SNP)

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 SeniorCare Complete and AbilityCare. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by SeniorCare Complete and AbilityCare. Key terms and their definitions appear in the last chapter of the Member Handbook or Evidence of Coverage.

This List of Covered Drugs was updated on 08/2020. For more recent information or other questions, please contact us at 1-866-567-7242, TTY users call 1-800-627-3529 or 711.Hours of Operation: October – March, 7 days a week, 8 a.m. – 8 p.m.,April – September, Monday – Friday, 8 a.m. – 8 p.m.

or visit www.mnscha.org

H2419, H5703_4899_FINAL_5343_C Formulary ID 20507 Version 18

Effective Date: 09/01/2020

SCHA Member Services 1-866-567-7242, TTY 1-800-627-3529 or 711Attention. If you need free help interpreting this document, call the above number.

SCHA Member Services 1-866-567-7242, TTY 1-800-627-3529 or 711Attention. If you need free help interpreting this document, call the above number.ያስተውሉ፡ ካለምንም ክፍያ ይህንን ዶኩመንት የሚተረጉምሎ አስተርጓሚ ከፈለጉ ከላይ ወደተጻፈው የስልክ ቁጥር ይደውሉ።

مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اتصل على الرقم أعاله.

သတ ိ။ ဤစာရြက္စာတမ္းအားအခမဲ့ဘာသာျပန္ေပးျခင္း အကူအညီလုုိအပ္ပါက၊အထက္ပါဖုုန္းနံပါတ္ကုုိေခၚဆုုိပါ။kMNt’sMKal’ . ebIG~k¨tUvkarCMnYyk~¬gkarbkE¨bäksarenHeday²tKit«fÂ sUmehATUrs&BÍtamelxxagelI .請注意，如果您需要免費協助傳譯這份文件，請撥打上面的電話號碼。Attention. Si vous avez besoin d’une aide gratuite pour interpréter le présent document, veuillez appeler au numéro ci-dessus.Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb, ces hu rau tus najnpawb xov tooj saum toj no.ymol.ymo;b.wuh>I zJerh>vd.b.w>rRpXRuvDvXw>uusd;xH0J'.vHm wDvHmrDwcgtHRM.<

ud;b.vDwJpdeD>*H>vXx;tHRM.wuh>I

알려드립니다. 이 문서에 대한 이해를 돕기 위해 무료로 제공되는 도움을 받으시려면 위의 전화번호로 연락하십시오.

ໂປຣດຊາບ. ຖາ້ຫາກ ທ່ານຕອ້ງການການຊວ່ຍເຫືຼອໃນການແປເອກະສານນີຟ້ຣ,ີ ຈ ົ່ ງໂທຣໄປທ່ີໝາຍເລກຂາ້ງເທີງນີ.້Hubachiisa. Dokumentiin kun tola akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bilbili.Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по указанному выше телефону.Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.

LB2 (8-16)

CB5 (MCOs) (5-2020)

Civil Rights Notice

Discrimination is against the law. South Country Health Alliance (SCHA) does not discriminate on the basis of any of the following:

• race• color• national origin• creed• religion• sexual orientation• public assistance status• age

• disability (including physicalor mental impairment)

• sex (including sexstereotypes and genderidentity)

• marital status• political beliefs• medical condition

• health status• receipt of health care

services• claims experience• medical history• genetic information

Auxiliary Aids and Services: SCHA provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner to ensure an equal opportunity to participate in our health care programs. Contact SCHA Member Services at [email protected] or call 1-866-567-7242 (toll free), TTY 1-800-627-3529 or 711.

Language Assistance Services: SCHA provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact SCHA Member Services at [email protected] or call 1-866-567-7242 (toll free), TTY 1-800-627-3529 or 711.

Civil Rights ComplaintsYou have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by SCHA. You may contact any of the following four agencies directly to file a discrimination complaint.

U.S. Department of Health and Human Services’ Office for Civil Rights (OCR)You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following:

• race• color• national origin• age

• disability• sex• religion (in some cases)

Contact the OCR directly to file a complaint:

U.S. Department of Health and Human Services’ Office for Civil Rights200 Independence Avenue SWRoom 515FHHH BuildingWashington, DC 20201Customer Response Center: Toll-free: 800-368-1019TDD 800-537-7697Email: [email protected]

Minnesota Department of Human Rights (MDHR)In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following:

• race• color• national origin• religion

• creed• sex• sexual orientation• marital status

• public assistance status• disability

Contact the MDHR directly to file a complaint:Minnesota Department of Human Rights540 Fairview Avenue North, Suite 201St. Paul, MN 55104651-539-1100 (voice)800-657-3704 (toll free)711 or 800-627-3529 (MN Relay)651-296-9042 (fax)[email protected] (email)

Minnesota Department of Human Services (DHS)You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following:

• race• color• national origin• creed• religion• sexual orientation• public assistance status• age

Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint.

DHS will notify you in writing of the investigation’s outcome. You have the right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome. Be brief and state why you disagree with the decision. Include additional information you think is important.

If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administrative actions.

Contact DHS directly to file a discrimination complaint:Civil Rights CoordinatorMinnesota Department of Human ServicesEqual Opportunity and Access DivisionP.O. Box 64997St. Paul, MN 55164-0997651-431-3040 (voice) or use your preferred relay service

• disability (including physicalor mental impairment)

• sex (including sexstereotypes and genderidentity)

• marital status• political beliefs• medical condition

• health status• receipt of health care

services• claims experience• medical history• genetic information

SCHA Complaint Notice

You have the right to file a complaint with SCHA if you believe you have been discriminated against because of any of the following:

• medical condition• health status• receipt of health care services• claims experience• medical history• genetic information• disability (including mental or physical

impairment)• marital status• age

• sex (including sex stereotypes and genderidentity)

• sexual orientation• national origin• race• color• religion• creed• public assistance status• political beliefs

You can file a complaint and ask for help in filing a complaint in person or by mail, phone, fax, or email at:

Attn: Civil Rights CoordinatorSouth Country Health Alliance2300 Park Drive, Suite 100Owatonna, MN 55060Toll Free: 866-567-7242TTY: 800-627-3529 or 711Fax: 507-444-7774Email: [email protected]

American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral.

SCHA LB/CB-5287 DHS Approved 06/25/2020

This Page Intentionally left blank

1

If you have questions, please call South Country Health Alliance Member Services at 1-866-567-7242, TTY 1-800-627-3529 or 711. Hours of Operation: October – March, 7 days a week, 8 a.m. – 8 p.m., April – September, Monday – Friday, 8 a.m. – 8 p.m. The call is free. For more information, visit www.mnscha.org.

Table of ContentsA. Disclaimers 2

B. Frequently Asked Questions (FAQ) ....................................................................................2B1. What prescription drugs are on the List of Covered Drugs? (We call the List

of Covered Drugs the “Drug List” for short.)...........................................................2B2. Does the Drug List ever change? ...................................................................................2B3. What happens when there is a change to the Drug List? ...............................................3B4. Are there any restrictions or limits on drug coverage or any required actions to

take to get certain drugs? ......................................................................................4B5. How will you know if the drug you want has limitations or if there are any actions

required to get the drug?........................................................................................4B6. What happens if we change our rules about how we cover some drugs (prior

authorization, quantity limits, and/or step therapy restrictions)? ............................5B7. How can you find a drug on the Drug List? ....................................................................5B8. What if the drug you want to take is not on the Drug List? .............................................5B9. What if you are a new SeniorCare Complete or AbilityCare member and can’t

find your drug on the Drug List or have a problem getting your drug? ..................5B10. Can you ask for an exception to cover your drug? .......................................................6B11. How can you ask for an exception? ..............................................................................6B12. How long does it take to get an exception? ..................................................................6B13. What are generic drugs? ..............................................................................................6B14. What are over-the-counter (OTC) drugs? ....................................................................7B15. Does SeniorCare Complete and AbilityCare cover non-drug OTC products? .............7B16. Can I get my drugs through Long-Term Supply? ..........................................................7B17. What is your copay? .....................................................................................................7

C. Overview of the List of Covered Drugs ..............................................................................7C1. List of Drugs by Drug Type ............................................................................................8

D. Index of Covered Drugs .....................................................................................................68

E. List of Over-The-Counter (OTC) Drugs by Drug Type .....................................................81

2


A. Disclaimers

� SeniorCare Complete (HMO SNP) and AbilityCare (HMO SNP) are health plans that contract with bothMedicare and the Minnesota Medical Assistance (Medicaid) programs to provide benefits of both programsto enrollees. Enrollment in SeniorCare Complete and AbilityCare depends on contract renewal.

� You can always check SeniorCare Complete’s and AbilityCare’s up-to-date List of Covered Drugs online atwww.mnscha.org or call Member Services at the number listed at the bottom of this page.

� You can get this document for free in other formats, such as large print, braille, or audio. Call MemberServices at the number listed at the bottom of this page.

� To make or change a standing request to get this document, now and in the future, in a language otherthan English or in an alternate format, call Member Services at the number at the bottom of this page.

B. Frequently Asked Questions (FAQ)

Find answers 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 Drug List in Section C, that starts on page 9 are the drugs covered by SeniorCare Complete and AbilityCare. 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.”

● SeniorCare Complete and AbilityCare will cover all medically necessary drugs on the Drug List if:

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

○ you fill the prescription at a SeniorCare Complete and AbilityCare network pharmacy.

○ SeniorCare Complete and AbilityCare may have additional steps to access certain drugs. Seequestion B4 for more information.

You can also see an up-to-date list of drugs we cover on our website at www.mnscha.org or call Member Services at the number listed at the bottom of this page.

B2. Does the Drug List ever change?

Yes, and SeniorCare Complete and AbilityCare must follow Medicare and Medicaid rules when making chang-es. We 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 authorization for a drug. (Prior authorization is permission fromSeniorCare Complete and AbilityCare before you can get a drug.)

3


● 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 beforewe will cover another drug.)

For more information on these drug rules, see question B4.

If you are taking a drug that is 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 on the market 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 have more information on what happens when the Drug List changes.

● You can always check SeniorCare Complete and AbilityCare’s current Drug List online atwww.mnscha.org.

● You can also call Member Services at the number listed at the bottom of this page to check the currentDrug List.

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 generic drug comes on the market thatworks as well as a brand name drug on the Drug List now. When that happens, we may remove the thebrand name drug and add the new generic drug, but your cost for the new drug will stay the same orwill be lower. When we add the new generic drug, we may also decide to keep the brand name drug onthe list but change its coverage rules or limits.

○ We may not tell you before we make this change, but we will send you information about thespecific change or we made once it happens.

○ You or your provider can ask for an exception from these changes. We will send you a notice withthe steps you can take to ask for an exception. Please see questions B10-B12 for more informationon exceptions.

● A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are takingis not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If youare taking the drug, we will let you know. We will also send you a letter telling you that. Show the letterto your doctor or other prescriber and ask them about your next steps.

We 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.

4


When these changes happen, we will

● Tell you at least 30 days before we make the change to the Drug List or● Let you know and give you a 30-day supply of the drug after 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 from these changes. Please see questions B10-B12 for moreinformation 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, your doc-tor, or other prescriber must do something before you can get the drug. For example:

● Prior authorization: For some drugs, you, your doctor, or other prescriber must get authorizationfrom SeniorCare Complete and AbilityCare before you fill your prescription. Prior authorization meansan approval from SeniorCare Complete and AbilityCare to seek services outside of our network or toget services not routinely covered by our network before you get the services. Prior authorization isdifferent from a referral. SeniorCare Complete and AbilityCare may not cover the drug if you do not getauthorization.

● Quantity limits: Sometimes SeniorCare Complete and AbilityCare limits the amount of a drug you canget.

● Step therapy: Sometimes SeniorCare Complete and AbilityCare requires you to do step therapy. Thismeans you will have to try drugs in a certain order for your medical condition. You might have to try onedrug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’twork 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 table in Section C1 that starts on page 8. You can also get more information by visiting our website at www.mnscha.org. We have posted online documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an exception to these limits. You should 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 excep-tion. 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 any actions required to get the drug?

The Drug List in Section C1, that starts on page 4, has a column labeled “Necessary actions, restrictions, or limits on use.” Please see question B4 for more information about restrictions, limits, or actions to take.

B6. What happens if we change our rules about how we cover some drugs (prior authorization, quantity limits, and/or step therapy restrictions)?

5


In some cases, we will tell you in advance if we add or change prior authorization, 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 drug type.

To search alphabetically, go to the Index of Covered Drugs section. You can find it on page 68. The Index of Covered Drugs is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed in the index.

To search by drug type, find the section labeled “List of Drugs by Drug Type” on page 9. The drugs in this sec-tion are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the “Antimigraine Agents” category. That is where you will find drugs that treat migraines.

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 the number listed at the bottom of this page and ask about it. If you learn that SeniorCare Complete and AbilityCare 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 doctoror other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want totake. Or

● You can ask the health plan to make an exception to cover your drug. See questions B10-B12 for moreinformation about exceptions.

B9. What if you are a new SeniorCare Complete or AbilityCare 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 SeniorCare Complete or AbilityCare. 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 refills 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 authorization by SeniorCare Complete and AbilityCare, 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

6


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 SeniorCare Complete and AbilityCare member.

● This is in addition to the temporary supply during the first 90 days you are a member of SeniorCareComplete or AbilityCare.

South Country Health Alliance will not apply early refill edits that would limit appropriate and necessary actions to Part D Drugs by enrollees who experience a Level of Care Change. These enrollees will be allowed to obtain a refill of their prescription(s) upon admission to or discharge from a long term care facility.

B10. Can you ask for an exception to cover your drug?

Yes. You can ask SeniorCare Complete or AbilityCare 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, SeniorCare Complete or AbilityCare may limit the amount of a drug we will cover. If yourdrug 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 authorization requirements.

B11. How can you ask for an exception?

To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook or Evidence of Coverage 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).

SeniorCare Complete and AbilityCare covers both brand name drugs and generic drugs.

B14. What are over-the-counter (OTC) drugs?

7


OTC stands for “over-the-counter.” SeniorCare Complete and AbilityCare offers some OTC drugs through Medical Assistance (Medicaid) at no cost to you. You need a prescription for OTC drugs to be covered. These OTC drugs are listed in this Drug List starting on page 81.

B15. Does SeniorCare Complete and AbilityCare cover non-drug OTC products?

SeniorCare Complete and AbilityCare covers some non-drug OTC products through Medical Assistance (Medicaid). These non-drug OTC products are listed in this Drug List starting on page 81.

Examples of non-drug OTC products include Diafoods Thick-It oral powder and DuoDERM dressings.

B16. Can I get my drugs through Long-Term Supply?

We offer a way to get a long-term supply of “maintenance” drugs on our plan’s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)

For more information about getting drugs for a long-term supply, please call Member Services at the number listed at the bottom of this page.

B17. What is your copay?

You can read the SeniorCare Complete and AbilityCare Drug List to learn about the copay for each drug.

A copay is an amount you may be required to pay as your share of the cost of a prescription drug. A copay is usually a set amount, rather than a percentage. For example, you might pay $0 to $8.95 for a prescription drug.

SeniorCare Complete and AbilityCare 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.

The Drug List includes copays listed by tiers.

● Tier 1 Generic drugs have the lowest copay. The copay is from $0 to $3.60, depending on your incomeand level of Medical Assistance (Medicaid) eligibility.

● Tier 1 Brand drugs have a higher copay. The copay is from $0 to $8.95, depending on your income andlevel of Medical Assistance (Medicaid) eligibility.

● OTCs have a $0 copay.

If you have questions, call Member Services at the number at the bottom of this page. We can help you under-stand what your copays will be.

C. Overview of the List of Covered DrugsThe List of Covered Drugs gives you information about the drugs covered by SeniorCare Complete and AbilityCare. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 68. The index alphabetically lists all drugs covered by SeniorCare Complete and AbilityCare.

8


C1. List of Drugs by Drug Type

The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the “Antimigraine Agents” category. That is where you will find drugs that treat migraines.

Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on use” column:

B/D = This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

QL = Quantity Limit. For certain drugs, SeniorCare Complete and AbilityCare limits the amount of the drug that we will cover. For example, the plan provides twelve tablets per 30-day supply.

ST = Step Therapy. In some cases, SeniorCare Complete and AbilityCare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For ex-ample, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

PA = Prior Authorization. SeniorCare Complete and AbilityCare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don’t get approval, the plan may not cover the drug.

LA = Limited Availability. This prescription may be available only at certain pharmacies. For more informa-tion, please contact Member Services at the number listed at the bottom of this page.

The first column of the table lists the name of the drug. Generic drugs are listed in lower-case italics (e.g., warfarin), brand name drugs are capitalized (e.g., COUMADIN), and OTC drugs and products are listed in lower case (e.g., aspirin). The information in the “Necessary actions, restrictions, or limits on use” column tells you if SeniorCare Complete and AbilityCare has any rules for covering your drug.

LIST OF DRUGS BY DRUG TYPE

You can find information on what the symbols and abbreviations in this table mean by going to page 8. 9

Name of Drug What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Analgesics Analgesics, Other acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml

$0-$3.60 (Tier 1-Generic)

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg $0-$3.60 (Tier 1-Generic)

ascomp with codeine oral capsule 30-50-325-40 mg $0-$3.60 (Tier 1-Generic) PA butalbital compound w/codeine oral capsule 30-50-325-40 mg $0-$3.60 (Tier 1-Generic) PA butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg $0-$3.60 (Tier 1-Generic) PA butalbital-acetaminophen oral tablet 50-325 mg $0-$3.60 (Tier 1-Generic) PA butalbital-acetaminophen-caff oral capsule 50-325-40 mg $0-$3.60 (Tier 1-Generic) PA butalbital-acetaminophen-caff oral tablet 50-325-40 mg $0-$3.60 (Tier 1-Generic) PA butalbital-aspirin-caffeine oral capsule 50-325-40 mg $0-$3.60 (Tier 1-Generic) PA carisoprodol-aspirin oral tablet 200-325 mg $0-$3.60 (Tier 1-Generic) PA carisoprodol-aspirin-codeine oral tablet 200-325-16 mg $0-$3.60 (Tier 1-Generic) PA codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg $0-$3.60 (Tier 1-Generic) PA hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg $0-$3.60 (Tier 1-Generic)

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg $0-$3.60 (Tier 1-Generic)

ibu oral tablet 600 mg, 800 mg $0-$3.60 (Tier 1-Generic) ibuprofen-oxycodone oral tablet 400-5 mg $0-$3.60 (Tier 1-Generic) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg $0-$3.60 (Tier 1-Generic)

oxycodone-aspirin oral tablet 4.8355-325 mg $0-$3.60 (Tier 1-Generic) pentazocine-naloxone oral tablet 50-0.5 mg $0-$3.60 (Tier 1-Generic) PA tramadol-acetaminophen oral tablet 37.5-325 mg $0-$3.60 (Tier 1-Generic) Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg $0-$3.60 (Tier 1-Generic) comfort pac-ibuprofen kit 800 mg $0-$3.60 (Tier 1-Generic) comfort pac-meloxicam kit 15 mg $0-$3.60 (Tier 1-Generic) comfort pac-naproxen kit 500 mg $0-$3.60 (Tier 1-Generic) diclofenac potassium oral tablet 50 mg $0-$3.60 (Tier 1-Generic) diclofenac sodium oral tablet extended release 24 hr 100 mg $0-$3.60 (Tier 1-Generic) diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic)

DICLOZOR TOPICAL KIT 1 % $0-$8.95 (Tier 1-Brand) diflunisal oral tablet 500 mg $0-$3.60 (Tier 1-Generic) ec-naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg $0-$3.60 (Tier 1-Generic) etodolac oral capsule 200 mg, 300 mg $0-$3.60 (Tier 1-Generic) etodolac oral tablet 400 mg, 500 mg $0-$3.60 (Tier 1-Generic) etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg $0-$3.60 (Tier 1-Generic)

flurbiprofen oral tablet 100 mg, 50 mg $0-$3.60 (Tier 1-Generic) ibuprofen oral suspension 100 mg/5 ml $0-$3.60 (Tier 1-Generic) ibuprofen oral tablet 400 mg, 600 mg, 800 mg $0-$3.60 (Tier 1-Generic) indomethacin oral capsule 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) PA indomethacin oral capsule, extended release 75 mg $0-$3.60 (Tier 1-Generic) PA ketoprofen oral capsule 75 mg $0-$3.60 (Tier 1-Generic)





ketorolac oral tablet 10 mg $0-$3.60 (Tier 1-Generic) PA; QL (20 EA per 30 days) meclofenamate oral capsule 100 mg, 50 mg $0-$3.60 (Tier 1-Generic) meloxicam oral tablet 15 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) nabumetone oral tablet 500 mg, 750 mg $0-$3.60 (Tier 1-Generic) naproxen oral suspension 125 mg/5 ml $0-$3.60 (Tier 1-Generic) naproxen oral tablet 250 mg, 375 mg, 500 mg $0-$3.60 (Tier 1-Generic) naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg $0-$3.60 (Tier 1-Generic) naproxen sodium oral tablet 275 mg, 550 mg $0-$3.60 (Tier 1-Generic) piroxicam oral capsule 10 mg, 20 mg $0-$3.60 (Tier 1-Generic) sulindac oral tablet 150 mg, 200 mg $0-$3.60 (Tier 1-Generic) Opioid Analgesics, Long-Acting buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour $0-$3.60 (Tier 1-Generic) QL (4 EA per 28 days)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour

$0-$3.60 (Tier 1-Generic) QL (10 EA per 30 days)

methadone oral solution 10 mg/5 ml $0-$3.60 (Tier 1-Generic) QL (1200 ML per 30 days) methadone oral solution 5 mg/5 ml $0-$3.60 (Tier 1-Generic) QL (2400 ML per 30 days) methadone oral tablet 10 mg $0-$3.60 (Tier 1-Generic) QL (240 EA per 30 days) methadone oral tablet 5 mg $0-$3.60 (Tier 1-Generic) QL (180 EA per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days)

oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg $0-$3.60 (Tier 1-Generic) PA

Opioid Analgesics, Short-Acting butorphanol nasal spray,non-aerosol 10 mg/ml $0-$3.60 (Tier 1-Generic) QL (5 ML per 30 days) DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML $0-$8.95 (Tier 1-Brand) B/D

fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg $0-$3.60 (Tier 1-Generic) PA; QL (120 EA per 30 days)

hydromorphone (pf) injection solution 1 mg/ml, 10 (mg/ml) (5 ml), 10 mg/ml, 4 mg/ml $0-$3.60 (Tier 1-Generic)

hydromorphone oral tablet 2 mg, 4 mg, 8 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY $0-$8.95 (Tier 1-Brand) PA; QL (600 EA per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY, 400 MCG/SPRAY $0-$8.95 (Tier 1-Brand) PA; QL (150 EA per 30 days)

meperidine oral solution 50 mg/5 ml $0-$3.60 (Tier 1-Generic) PA; QL (900 ML per 30 days) meperidine oral tablet 100 mg, 50 mg $0-$3.60 (Tier 1-Generic) PA; QL (180 EA per 30 days) morphine oral tablet 15 mg, 30 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) nalbuphine injection solution 10 mg/ml $0-$3.60 (Tier 1-Generic) B/D oxycodone oral solution 5 mg/5 ml $0-$3.60 (Tier 1-Generic) QL (5400 ML per 30 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) tramadol oral tablet 50 mg $0-$3.60 (Tier 1-Generic) QL (240 EA per 30 days) Anesthetics Local Anesthetics anodyne lpt topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) dermacinrx empricaine topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) diclofenac sodium topical gel 1 % $0-$3.60 (Tier 1-Generic) leva set topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) lidocaine hcl laryngotracheal solution 4 % $0-$3.60 (Tier 1-Generic)





lidocaine hcl mucous membrane jelly 2 % $0-$3.60 (Tier 1-Generic) lidocaine hcl mucous membrane jelly in applicator 2 % $0-$3.60 (Tier 1-Generic) lidocaine hcl mucous membrane solution 4 % (40 mg/ml) $0-$3.60 (Tier 1-Generic) lidocaine topical adhesive patch,medicated 5 % $0-$3.60 (Tier 1-Generic) PA; QL (90 EA per 30 days) lidocaine topical ointment 5 % $0-$3.60 (Tier 1-Generic) lidocaine viscous mucous membrane solution 2 % $0-$3.60 (Tier 1-Generic) lidocaine-prilocaine topical cream 2.5-2.5 % $0-$3.60 (Tier 1-Generic) lidocaine-prilocaine topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) lidopac topical kit 5 % $0-$3.60 (Tier 1-Generic) lidopril topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) lidopril xr topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) lido-prilo caine pack topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) liprozonepak topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) livixil pak topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) medolor pak topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) prilolid topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) prilovix lite plus topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) prilovix lite topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) prilovix ultralite plus topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) prilovix ultralite topical kit 2.5-2.5 % $0-$3.60 (Tier 1-Generic) ZTLIDO TOPICAL ADHESIVE PATCH,MEDICATED 1.8 % $0-$8.95 (Tier 1-Brand) PA Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/ Anti-Craving acamprosate oral tablet,delayed release (dr/ec) 333 mg $0-$3.60 (Tier 1-Generic) disulfiram oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) Opioid Dependence Treatments buprenorphine hcl sublingual tablet 2 mg, 8 mg $0-$3.60 (Tier 1-Generic) buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg $0-$3.60 (Tier 1-Generic) LUCEMYRA ORAL TABLET 0.18 MG $0-$8.95 (Tier 1-Brand) PA; QL (224 EA per 14 days) naltrexone oral tablet 50 mg $0-$3.60 (Tier 1-Generic) Opioid Reversal Agents naloxone injection solution 0.4 mg/ml $0-$3.60 (Tier 1-Generic) naloxone injection syringe 0.4 mg/ml, 1 mg/ml $0-$3.60 (Tier 1-Generic) NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION $0-$8.95 (Tier 1-Brand) Smoking Cessation Agents bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg $0-$3.60 (Tier 1-Generic)

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG $0-$8.95 (Tier 1-Brand) QL (336 EA per 365 days) CHANTIX ORAL TABLET 0.5 MG, 1 MG $0-$8.95 (Tier 1-Brand) QL (336 EA per 365 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) $0-$8.95 (Tier 1-Brand) QL (106 EA per 365 days)

NICOTROL INHALATION CARTRIDGE 10 MG $0-$8.95 (Tier 1-Brand) NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML $0-$8.95 (Tier 1-Brand) Antibacterials Aminoglycosides amikacin injection solution 500 mg/2 ml $0-$3.60 (Tier 1-Generic) gentak ophthalmic (eye) ointment 0.3 % (3 mg/gram) $0-$3.60 (Tier 1-Generic) gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml $0-$3.60 (Tier 1-Generic)

gentamicin injection solution 40 mg/ml $0-$3.60 (Tier 1-Generic)





gentamicin ophthalmic (eye) drops 0.3 % $0-$3.60 (Tier 1-Generic) gentamicin topical cream 0.1 % $0-$3.60 (Tier 1-Generic) gentamicin topical ointment 0.1 % $0-$3.60 (Tier 1-Generic) neomycin oral tablet 500 mg $0-$3.60 (Tier 1-Generic) paromomycin oral capsule 250 mg $0-$3.60 (Tier 1-Generic) streptomycin intramuscular recon soln 1 gram $0-$3.60 (Tier 1-Generic) TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 % $0-$8.95 (Tier 1-Brand) tobramycin ophthalmic (eye) drops 0.3 % $0-$3.60 (Tier 1-Generic) tobramycin sulfate injection recon soln 1.2 gram $0-$3.60 (Tier 1-Generic) tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml $0-$3.60 (Tier 1-Generic) tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 % $0-$3.60 (Tier 1-Generic)

Antibacterials, Other ak-poly-bac ophthalmic (eye) ointment 500-10,000 unit/gram $0-$3.60 (Tier 1-Generic) bacitracin ophthalmic (eye) ointment 500 unit/gram $0-$3.60 (Tier 1-Generic) bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram $0-$3.60 (Tier 1-Generic)

BACTROBAN NASAL NASAL OINTMENT 2 % $0-$8.95 (Tier 1-Brand) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg $0-$3.60 (Tier 1-Generic) clindamycin in 0.9 % sod chlor intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml $0-$3.60 (Tier 1-Generic)

clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml $0-$3.60 (Tier 1-Generic)

clindamycin palmitate hcl oral recon soln 75 mg/5 ml $0-$3.60 (Tier 1-Generic) clindamycin pediatric oral recon soln 75 mg/5 ml $0-$3.60 (Tier 1-Generic) clindamycin phosphate injection solution 150 (mg/ml) (6 ml), 150 mg/ml $0-$3.60 (Tier 1-Generic)

clindamycin phosphate intravenous solution 300 mg/2 ml, 600 mg/4 ml, 900 mg/6 ml $0-$3.60 (Tier 1-Generic)

clindamycin phosphate topical gel 1 % $0-$3.60 (Tier 1-Generic) clindamycin phosphate topical gel, once daily 1 % $0-$3.60 (Tier 1-Generic) clindamycin phosphate topical lotion 1 % $0-$3.60 (Tier 1-Generic) clindamycin phosphate topical solution 1 % $0-$3.60 (Tier 1-Generic) clindamycin phosphate topical swab 1 % $0-$3.60 (Tier 1-Generic) clindamycin phosphate vaginal cream 2 % $0-$3.60 (Tier 1-Generic) colistin (colistimethate na) injection recon soln 150 mg $0-$3.60 (Tier 1-Generic) daptomycin intravenous recon soln 350 mg, 500 mg $0-$3.60 (Tier 1-Generic) PA linezolid in dextrose 5% intravenous piggyback 600 mg/300 ml $0-$3.60 (Tier 1-Generic) B/D linezolid oral suspension for reconstitution 100 mg/5 ml $0-$3.60 (Tier 1-Generic) linezolid oral tablet 600 mg $0-$3.60 (Tier 1-Generic) linezolid-0.9% sodium chloride intravenous parenteral solution 600 mg/300 ml $0-$3.60 (Tier 1-Generic) B/D

methenamine hippurate oral tablet 1 gram $0-$3.60 (Tier 1-Generic) metro i.v. intravenous piggyback 500 mg/100 ml $0-$3.60 (Tier 1-Generic) metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml $0-$3.60 (Tier 1-Generic)

metronidazole oral capsule 375 mg $0-$3.60 (Tier 1-Generic) metronidazole oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) metronidazole topical cream 0.75 % $0-$3.60 (Tier 1-Generic) metronidazole topical gel 0.75 %, 1 % $0-$3.60 (Tier 1-Generic)





metronidazole topical gel with pump 1 % $0-$3.60 (Tier 1-Generic) metronidazole topical lotion 0.75 % $0-$3.60 (Tier 1-Generic) metronidazole vaginal gel 0.75 % $0-$3.60 (Tier 1-Generic) mupirocin topical ointment 2 % $0-$3.60 (Tier 1-Generic) neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1% $0-$3.60 (Tier 1-Generic)

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g $0-$3.60 (Tier 1-Generic)

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % $0-$3.60 (Tier 1-Generic)

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 % $0-$3.60 (Tier 1-Generic)

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml $0-$3.60 (Tier 1-Generic)

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 mg-unit-mg/ml $0-$3.60 (Tier 1-Generic)

nitrofurantoin macrocrystal oral capsule 100 mg $0-$3.60 (Tier 1-Generic) QL (360 EA per 365 days) nitrofurantoin macrocrystal oral capsule 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) nitrofurantoin monohyd/m-cryst oral capsule 100 mg $0-$3.60 (Tier 1-Generic) QL (180 EA per 365 days) polymyxin b sulfate injection recon soln 500,000 unit $0-$3.60 (Tier 1-Generic) polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml $0-$3.60 (Tier 1-Generic)

tinidazole oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) trimethoprim oral tablet 100 mg $0-$3.60 (Tier 1-Generic) vancomycin injection recon soln 100 gram $0-$3.60 (Tier 1-Generic) vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg $0-$3.60 (Tier 1-Generic)

vancomycin oral capsule 125 mg, 250 mg $0-$3.60 (Tier 1-Generic) Beta-Lactam, Cephalosporins cefaclor oral capsule 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) cefaclor oral tablet extended release 12 hr 500 mg $0-$3.60 (Tier 1-Generic) cefadroxil oral capsule 500 mg $0-$3.60 (Tier 1-Generic) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml $0-$3.60 (Tier 1-Generic)

cefadroxil oral tablet 1 gram $0-$3.60 (Tier 1-Generic) cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml $0-$3.60 (Tier 1-Generic)

cefazolin injection recon soln 1 gram, 500 mg $0-$3.60 (Tier 1-Generic) cefazolin intravenous recon soln 1 gram $0-$3.60 (Tier 1-Generic) cefdinir oral capsule 300 mg $0-$3.60 (Tier 1-Generic) cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml $0-$3.60 (Tier 1-Generic)

cefepime in dextrose 5 % intravenous piggyback 1 gram/50 ml, 2 gram/50 ml $0-$3.60 (Tier 1-Generic)

cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/100 ml $0-$3.60 (Tier 1-Generic)

cefepime injection recon soln 1 gram, 2 gram $0-$3.60 (Tier 1-Generic) cefixime oral capsule 400 mg $0-$3.60 (Tier 1-Generic) cefotaxime injection recon soln 1 gram $0-$3.60 (Tier 1-Generic) cefoxitin in dextrose, iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/50 ml $0-$3.60 (Tier 1-Generic)





cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram $0-$3.60 (Tier 1-Generic) cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml $0-$3.60 (Tier 1-Generic)

cefpodoxime oral tablet 100 mg, 200 mg $0-$3.60 (Tier 1-Generic) cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml $0-$3.60 (Tier 1-Generic)

cefprozil oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) ceftazidime in d5w intravenous piggyback 1 gram/50 ml, 2 gram/50 ml $0-$3.60 (Tier 1-Generic)

ceftazidime injection recon soln 1 gram, 2 gram, 6 gram $0-$3.60 (Tier 1-Generic) ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml, 2 gram/50 ml $0-$3.60 (Tier 1-Generic)

ceftriaxone injection recon soln 1 gram, 10 gram, 100 gram, 2 gram, 250 mg, 500 mg $0-$3.60 (Tier 1-Generic)

ceftriaxone intravenous recon soln 1 gram, 2 gram $0-$3.60 (Tier 1-Generic) cefuroxime axetil oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) cefuroxime sodium injection recon soln 750 mg $0-$3.60 (Tier 1-Generic) cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram $0-$3.60 (Tier 1-Generic) cephalexin oral capsule 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml $0-$3.60 (Tier 1-Generic)

cephalexin oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) tazicef injection recon soln 1 gram, 2 gram, 6 gram $0-$3.60 (Tier 1-Generic) tazicef intravenous recon soln 1 gram, 2 gram $0-$3.60 (Tier 1-Generic) TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG $0-$8.95 (Tier 1-Brand) PA Beta-Lactam, Other aztreonam injection recon soln 1 gram $0-$3.60 (Tier 1-Generic) ertapenem injection recon soln 1 gram $0-$3.60 (Tier 1-Generic) PA imipenem-cilastatin intravenous recon soln 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) B/D meropenem intravenous recon soln 1 gram, 500 mg $0-$3.60 (Tier 1-Generic) meropenem-0.9% sodium chloride intravenous piggyback 1 gram/50 ml, 500 mg/50 ml $0-$3.60 (Tier 1-Generic)

VABOMERE INTRAVENOUS RECON SOLN 2 GRAM $0-$8.95 (Tier 1-Brand) PA Beta-Lactam, Penicillins amoxicillin oral capsule 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml $0-$3.60 (Tier 1-Generic)

amoxicillin oral tablet 500 mg, 875 mg $0-$3.60 (Tier 1-Generic) amoxicillin oral tablet,chewable 125 mg, 250 mg $0-$3.60 (Tier 1-Generic) amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml


amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg $0-$3.60 (Tier 1-Generic)

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg $0-$3.60 (Tier 1-Generic)

amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg $0-$3.60 (Tier 1-Generic)

ampicillin oral capsule 500 mg $0-$3.60 (Tier 1-Generic) ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg $0-$3.60 (Tier 1-Generic)





ampicillin sodium intravenous recon soln 1 gram $0-$3.60 (Tier 1-Generic) ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram $0-$3.60 (Tier 1-Generic)

ampicillin-sulbactam intravenous recon soln 1.5 gram, 3 gram $0-$3.60 (Tier 1-Generic) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML $0-$8.95 (Tier 1-Brand)

dicloxacillin oral capsule 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml $0-$3.60 (Tier 1-Generic) nafcillin injection recon soln 1 gram $0-$3.60 (Tier 1-Generic) nafcillin intravenous recon soln 1 gram, 2 gram $0-$3.60 (Tier 1-Generic) penicillin g procaine intramuscular syringe 1.2 million unit/2 ml $0-$3.60 (Tier 1-Generic) penicillin g sodium injection recon soln 5 million unit $0-$3.60 (Tier 1-Generic) penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml $0-$3.60 (Tier 1-Generic) penicillin v potassium oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) piperacillin-tazobactam intravenous recon soln 13.5 gram, 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram $0-$3.60 (Tier 1-Generic)

Macrolides azithromycin intravenous recon soln 500 mg $0-$3.60 (Tier 1-Generic) azithromycin oral packet 1 gram $0-$3.60 (Tier 1-Generic) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml $0-$3.60 (Tier 1-Generic)

azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg $0-$3.60 (Tier 1-Generic)

clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml $0-$3.60 (Tier 1-Generic)

clarithromycin oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) clarithromycin oral tablet extended release 24 hr 500 mg $0-$3.60 (Tier 1-Generic) DIFICID ORAL TABLET 200 MG $0-$8.95 (Tier 1-Brand) PA ery pads topical swab 2 % $0-$3.60 (Tier 1-Generic) ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG $0-$8.95 (Tier 1-Brand) ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG $0-$8.95 (Tier 1-Brand) erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml $0-$3.60 (Tier 1-Generic)

erythromycin ethylsuccinate oral tablet 400 mg $0-$3.60 (Tier 1-Generic) erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) $0-$3.60 (Tier 1-Generic) erythromycin oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) erythromycin with ethanol topical gel 2 % $0-$3.60 (Tier 1-Generic) erythromycin with ethanol topical solution 2 % $0-$3.60 (Tier 1-Generic) Quinolones ciprofloxacin hcl ophthalmic (eye) drops 0.3 % $0-$3.60 (Tier 1-Generic) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg $0-$3.60 (Tier 1-Generic) ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml $0-$3.60 (Tier 1-Generic)

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml $0-$3.60 (Tier 1-Generic) levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml $0-$3.60 (Tier 1-Generic)

levofloxacin intravenous solution 25 mg/ml $0-$3.60 (Tier 1-Generic) levofloxacin oral solution 250 mg/10 ml $0-$3.60 (Tier 1-Generic) levofloxacin oral tablet 250 mg, 500 mg, 750 mg $0-$3.60 (Tier 1-Generic) moxifloxacin ophthalmic (eye) drops 0.5 % $0-$3.60 (Tier 1-Generic)





moxifloxacin ophthalmic (eye) drops, viscous 0.5 % $0-$3.60 (Tier 1-Generic) moxifloxacin oral tablet 400 mg $0-$3.60 (Tier 1-Generic) moxifloxacin-sod.ace,sul-water intravenous piggyback 400 mg/250 ml $0-$3.60 (Tier 1-Generic)

moxifloxacin-sod.chloride(iso) intravenous piggyback 400 mg/250 ml $0-$3.60 (Tier 1-Generic)

ofloxacin ophthalmic (eye) drops 0.3 % $0-$3.60 (Tier 1-Generic) ofloxacin oral tablet 300 mg, 400 mg $0-$3.60 (Tier 1-Generic) Sulfonamides silver sulfadiazine topical cream 1 % $0-$3.60 (Tier 1-Generic) SSD TOPICAL CREAM 1 % $0-$8.95 (Tier 1-Brand) sulfacetamide sodium (acne) topical suspension 10 % $0-$3.60 (Tier 1-Generic) sulfacetamide sodium ophthalmic (eye) drops 10 % $0-$3.60 (Tier 1-Generic) sulfacetamide sodium ophthalmic (eye) ointment 10 % $0-$3.60 (Tier 1-Generic) sulfadiazine oral tablet 500 mg $0-$3.60 (Tier 1-Generic) sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml $0-$3.60 (Tier 1-Generic) sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg $0-$3.60 (Tier 1-Generic)

Tetracyclines doxy-100 intravenous recon soln 100 mg $0-$3.60 (Tier 1-Generic) doxycycline hyclate oral capsule 100 mg, 50 mg $0-$3.60 (Tier 1-Generic) doxycycline hyclate oral tablet 100 mg, 20 mg $0-$3.60 (Tier 1-Generic) doxycycline monohydrate oral capsule 100 mg, 50 mg $0-$3.60 (Tier 1-Generic) doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic)

minocycline oral capsule 100 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic) minocycline oral tablet 100 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic) morgidox 1x 50 kit 50 mg $0-$3.60 (Tier 1-Generic) tetracycline oral capsule 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) Anticonvulsants Anticonvulsants, Other BRIVIACT ORAL SOLUTION 10 MG/ML $0-$8.95 (Tier 1-Brand) ST BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG $0-$8.95 (Tier 1-Brand) ST

DIACOMIT ORAL CAPSULE 250 MG, 500 MG $0-$8.95 (Tier 1-Brand) PA DIACOMIT ORAL POWDER IN PACKET 250 MG, 500 MG $0-$8.95 (Tier 1-Brand) PA EPIDIOLEX ORAL SOLUTION 100 MG/ML $0-$8.95 (Tier 1-Brand) PA levetiracetam oral solution 100 mg/ml, 500 mg/5 ml (5 ml) $0-$3.60 (Tier 1-Generic) levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg $0-$3.60 (Tier 1-Generic) levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg $0-$3.60 (Tier 1-Generic) roweepra oral tablet 1,000 mg, 500 mg, 750 mg $0-$3.60 (Tier 1-Generic) roweepra xr oral tablet extended release 24 hr 500 mg, 750 mg $0-$3.60 (Tier 1-Generic) SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG $0-$8.95 (Tier 1-Brand) ST; QL (60 EA per 30 days)

SPRITAM ORAL TABLET FOR SUSPENSION 750 MG $0-$8.95 (Tier 1-Brand) ST; QL (120 EA per 30 days) Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 300 MG $0-$8.95 (Tier 1-Brand) ethosuximide oral capsule 250 mg $0-$3.60 (Tier 1-Generic) ethosuximide oral solution 250 mg/5 ml $0-$3.60 (Tier 1-Generic)





pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic)

pregabalin oral solution 20 mg/ml $0-$3.60 (Tier 1-Generic) zonisamide oral capsule 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) Gamma-Aminobutyric Acid (Gaba) Augmenting Agents clobazam oral suspension 2.5 mg/ml $0-$3.60 (Tier 1-Generic) PA; QL (480 ML per 30 days) clobazam oral tablet 10 mg, 20 mg $0-$3.60 (Tier 1-Generic) PA; QL (60 EA per 30 days) DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG, 5-7.5-10 MG $0-$8.95 (Tier 1-Brand)

DIASTAT RECTAL KIT 2.5 MG $0-$8.95 (Tier 1-Brand) diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg $0-$3.60 (Tier 1-Generic) divalproex oral capsule, delayed rel sprinkle 125 mg $0-$3.60 (Tier 1-Generic) divalproex oral tablet extended release 24 hr 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg $0-$3.60 (Tier 1-Generic)

gabapentin oral capsule 100 mg, 300 mg, 400 mg $0-$3.60 (Tier 1-Generic) gabapentin oral solution 250 mg/5 ml, 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) $0-$3.60 (Tier 1-Generic)

gabapentin oral tablet 600 mg, 800 mg $0-$3.60 (Tier 1-Generic) NAYZILAM NASAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML) $0-$8.95 (Tier 1-Brand)

phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) $0-$3.60 (Tier 1-Generic) PA phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg $0-$3.60 (Tier 1-Generic) PA

primidone oral tablet 250 mg, 50 mg $0-$3.60 (Tier 1-Generic) SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG $0-$8.95 (Tier 1-Brand) PA; QL (60 EA per 30 days) tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg $0-$3.60 (Tier 1-Generic) valproic acid (as sodium salt) oral solution 250 mg/5 ml, 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) $0-$3.60 (Tier 1-Generic)

valproic acid oral capsule 250 mg $0-$3.60 (Tier 1-Generic) VALTOCO NASAL SPRAY,NON-AEROSOL 10 MG/SPRAY (0.1 ML), 15 MG/2 SPRAY (7.5/0.1ML X 2), 20 MG/2 SPRAY (10MG/0.1ML X2), 5 MG/SPRAY (0.1 ML)

$0-$8.95 (Tier 1-Brand) PA

vigabatrin oral powder in packet 500 mg $0-$3.60 (Tier 1-Generic) PA; QL (180 EA per 30 days) vigabatrin oral tablet 500 mg $0-$3.60 (Tier 1-Generic) PA; QL (180 EA per 30 days) VIGADRONE ORAL POWDER IN PACKET 500 MG $0-$8.95 (Tier 1-Brand) PA; QL (180 EA per 30 days) XCOPRI MAINTENANCE PACK ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 350 MG/DAY (200 MG X1-150MG X1) $0-$8.95 (Tier 1-Brand) ST

XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG $0-$8.95 (Tier 1-Brand) ST XCOPRI TITRATION PACK ORAL TABLETS,DOSE PACK 12.5 MG (14)- 25 MG (14), 150 MG (14)- 200 MG (14), 50 MG (14)- 100 MG (14)

$0-$8.95 (Tier 1-Brand) ST

Glutamate Reducing Agents felbamate oral suspension 600 mg/5 ml $0-$3.60 (Tier 1-Generic) felbamate oral tablet 400 mg, 600 mg $0-$3.60 (Tier 1-Generic) FYCOMPA ORAL SUSPENSION 0.5 MG/ML $0-$8.95 (Tier 1-Brand) ST FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG $0-$8.95 (Tier 1-Brand) ST; QL (30 EA per 30 days)

lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg $0-$3.60 (Tier 1-Generic)

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg $0-$3.60 (Tier 1-Generic)





topiramate oral capsule, sprinkle 15 mg, 25 mg $0-$3.60 (Tier 1-Generic) topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) Sodium Channel Agents APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG $0-$8.95 (Tier 1-Brand) ST; QL (30 EA per 30 days) APTIOM ORAL TABLET 600 MG $0-$8.95 (Tier 1-Brand) ST; QL (60 EA per 30 days)

BANZEL ORAL SUSPENSION 40 MG/ML $0-$8.95 (Tier 1-Brand) PA; QL (2400 ML per 30 days)

BANZEL ORAL TABLET 200 MG, 400 MG $0-$8.95 (Tier 1-Brand) PA; QL (240 EA per 30 days) carbamazepine oral suspension 100 mg/5 ml, 100 mg/5 ml (5 ml), 200 mg/10 ml $0-$3.60 (Tier 1-Generic)

carbamazepine oral tablet 200 mg $0-$3.60 (Tier 1-Generic) carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg $0-$3.60 (Tier 1-Generic)

carbamazepine oral tablet,chewable 100 mg $0-$3.60 (Tier 1-Generic) DILANTIN ORAL CAPSULE 30 MG $0-$8.95 (Tier 1-Brand) epitol oral tablet 200 mg $0-$3.60 (Tier 1-Generic) oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) $0-$3.60 (Tier 1-Generic) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg $0-$3.60 (Tier 1-Generic) PEGANONE ORAL TABLET 250 MG $0-$8.95 (Tier 1-Brand) PHENYTEK ORAL CAPSULE 200 MG, 300 MG $0-$8.95 (Tier 1-Brand) phenytoin oral suspension 100 mg/4 ml, 125 mg/5 ml $0-$3.60 (Tier 1-Generic) phenytoin oral tablet,chewable 50 mg $0-$3.60 (Tier 1-Generic) phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg $0-$3.60 (Tier 1-Generic)

VIMPAT ORAL SOLUTION 10 MG/ML $0-$8.95 (Tier 1-Brand) ST; QL (1200 ML per 30 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG $0-$8.95 (Tier 1-Brand) ST; QL (60 EA per 30 days) Antidementia Agents Antidementia Agents, Other ergoloid oral tablet 1 mg $0-$3.60 (Tier 1-Generic) PA Cholinesterase Inhibitors donepezil oral tablet 10 mg, 23 mg, 5 mg $0-$3.60 (Tier 1-Generic) donepezil oral tablet,disintegrating 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg $0-$3.60 (Tier 1-Generic)

galantamine oral tablet 12 mg, 4 mg, 8 mg $0-$3.60 (Tier 1-Generic) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg $0-$3.60 (Tier 1-Generic) rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr $0-$3.60 (Tier 1-Generic)

N-Methyl-D-Aspartate (Nmda) Receptor Antagonist memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, 28 mg, 7 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days)

memantine oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) memantine oral tablets,dose pack 5-10 mg $0-$3.60 (Tier 1-Generic) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG $0-$8.95 (Tier 1-Brand)

Antidepressants Antidepressants, Other bupropion hcl oral tablet 100 mg, 75 mg $0-$3.60 (Tier 1-Generic) bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg, 450 mg $0-$3.60 (Tier 1-Generic)





bupropion hcl oral tablet sustained-release 12 hr 100 mg, 150 mg, 200 mg $0-$3.60 (Tier 1-Generic)

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG $0-$8.95 (Tier 1-Brand)

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg $0-$3.60 (Tier 1-Generic) nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg $0-$3.60 (Tier 1-Generic) perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg $0-$3.60 (Tier 1-Generic) PA

SPRAVATO NASAL SPRAY,NON-AEROSOL 56 MG (28 MG X 2), 84 MG (28 MG X 3) $0-$8.95 (Tier 1-Brand) PA

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg $0-$3.60 (Tier 1-Generic) Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR $0-$8.95 (Tier 1-Brand)

MARPLAN ORAL TABLET 10 MG $0-$8.95 (Tier 1-Brand) phenelzine oral tablet 15 mg $0-$3.60 (Tier 1-Generic) tranylcypromine oral tablet 10 mg $0-$3.60 (Tier 1-Generic) Ssris/ Snris citalopram oral solution 10 mg/5 ml $0-$3.60 (Tier 1-Generic) citalopram oral tablet 10 mg, 20 mg, 40 mg $0-$3.60 (Tier 1-Generic) desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 40 MG, 60 MG $0-$8.95 (Tier 1-Brand) PA

escitalopram oxalate oral solution 5 mg/5 ml $0-$3.60 (Tier 1-Generic) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg $0-$3.60 (Tier 1-Generic) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) $0-$8.95 (Tier 1-Brand) ST

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG $0-$8.95 (Tier 1-Brand) ST

fluoxetine oral capsule 10 mg, 20 mg, 40 mg $0-$3.60 (Tier 1-Generic) fluoxetine oral capsule,delayed release(dr/ec) 90 mg $0-$3.60 (Tier 1-Generic) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) $0-$3.60 (Tier 1-Generic) fluoxetine oral tablet 10 mg, 20 mg $0-$3.60 (Tier 1-Generic) fluvoxamine oral tablet 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) maprotiline oral tablet 25 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic) paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg $0-$3.60 (Tier 1-Generic) paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg $0-$3.60 (Tier 1-Generic)

PAXIL ORAL SUSPENSION 10 MG/5 ML $0-$8.95 (Tier 1-Brand) sertraline oral concentrate 20 mg/ml $0-$3.60 (Tier 1-Generic) sertraline oral tablet 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG $0-$8.95 (Tier 1-Brand) ST venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg $0-$3.60 (Tier 1-Generic)

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic) venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg $0-$3.60 (Tier 1-Generic)

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG $0-$8.95 (Tier 1-Brand) ST





VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) $0-$8.95 (Tier 1-Brand) ST Tricyclics amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic) PA

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) clomipramine oral capsule 25 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic) PA desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic)

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic) PA

doxepin oral concentrate 10 mg/ml $0-$3.60 (Tier 1-Generic) PA imipramine hcl oral tablet 10 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) PA imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg $0-$3.60 (Tier 1-Generic) PA

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic) nortriptyline oral solution 10 mg/5 ml $0-$3.60 (Tier 1-Generic) protriptyline oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) trimipramine oral capsule 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) PA Antiemetics Antiemetics, Other chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic)

meclizine oral tablet 12.5 mg, 25 mg $0-$3.60 (Tier 1-Generic) metoclopramide hcl oral solution 5 mg/5 ml $0-$3.60 (Tier 1-Generic) metoclopramide hcl oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg $0-$3.60 (Tier 1-Generic) prochlorperazine maleate oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) prochlorperazine rectal suppository 25 mg $0-$3.60 (Tier 1-Generic) promethazine oral tablet 12.5 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) PA promethazine rectal suppository 12.5 mg, 25 mg $0-$3.60 (Tier 1-Generic) PA promethegan rectal suppository 50 mg $0-$3.60 (Tier 1-Generic) PA scopolamine base transdermal patch 3 day 1 mg over 3 days $0-$3.60 (Tier 1-Generic) trimethobenzamide oral capsule 300 mg $0-$3.60 (Tier 1-Generic) PA Emetogenic Therapy Adjuncts aprepitant oral capsule 125 mg, 40 mg, 80 mg $0-$3.60 (Tier 1-Generic) B/D aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) $0-$3.60 (Tier 1-Generic) B/D dronabinol oral capsule 10 mg, 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) B/D EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) $0-$8.95 (Tier 1-Brand) B/D

granisetron hcl oral tablet 1 mg $0-$3.60 (Tier 1-Generic) B/D ondansetron hcl oral solution 4 mg/5 ml $0-$3.60 (Tier 1-Generic) B/D ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg $0-$3.60 (Tier 1-Generic) B/D ondansetron oral tablet,disintegrating 4 mg, 8 mg $0-$3.60 (Tier 1-Generic) B/D SYNDROS ORAL SOLUTION 5 MG/ML $0-$8.95 (Tier 1-Brand) PA Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML $0-$8.95 (Tier 1-Brand) B/D AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG $0-$8.95 (Tier 1-Brand) B/D

amphotericin b injection recon soln 50 mg $0-$3.60 (Tier 1-Generic) B/D





caspofungin intravenous recon soln 50 mg, 70 mg $0-$3.60 (Tier 1-Generic) PA ciclopirox topical cream 0.77 % $0-$3.60 (Tier 1-Generic) ciclopirox topical solution 8 % $0-$3.60 (Tier 1-Generic) ciclopirox topical suspension 0.77 % $0-$3.60 (Tier 1-Generic) ciclopirox-ure-camph-menth-euc topical solution 8 % $0-$3.60 (Tier 1-Generic) clotrimazole mucous membrane troche 10 mg $0-$3.60 (Tier 1-Generic) clotrimazole topical cream 1 % $0-$3.60 (Tier 1-Generic) clotrimazole topical solution 1 % $0-$3.60 (Tier 1-Generic) econazole topical cream 1 % $0-$3.60 (Tier 1-Generic) ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG, 50 MG $0-$8.95 (Tier 1-Brand) PA

fluconazole in dextrose(iso-o) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml $0-$3.60 (Tier 1-Generic)

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml $0-$3.60 (Tier 1-Generic)

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml $0-$3.60 (Tier 1-Generic)

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg $0-$3.60 (Tier 1-Generic) flucytosine oral capsule 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) griseofulvin microsize oral suspension 125 mg/5 ml $0-$3.60 (Tier 1-Generic) itraconazole oral capsule 100 mg $0-$3.60 (Tier 1-Generic) itraconazole oral solution 10 mg/ml $0-$3.60 (Tier 1-Generic) ketoconazole oral tablet 200 mg $0-$3.60 (Tier 1-Generic) ketoconazole topical cream 2 % $0-$3.60 (Tier 1-Generic) ketoconazole topical shampoo 2 % $0-$3.60 (Tier 1-Generic) MENTAX TOPICAL CREAM 1 % $0-$8.95 (Tier 1-Brand) micafungin intravenous recon soln 100 mg, 50 mg $0-$3.60 (Tier 1-Generic) PA NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) $0-$8.95 (Tier 1-Brand) PA nyamyc topical powder 100,000 unit/gram $0-$3.60 (Tier 1-Generic) nystatin oral suspension 100,000 unit/ml $0-$3.60 (Tier 1-Generic) nystatin oral tablet 500,000 unit $0-$3.60 (Tier 1-Generic) nystatin topical cream 100,000 unit/gram $0-$3.60 (Tier 1-Generic) nystatin topical ointment 100,000 unit/gram $0-$3.60 (Tier 1-Generic) nystatin topical powder 100,000 unit/gram $0-$3.60 (Tier 1-Generic) nystop topical powder 100,000 unit/gram $0-$3.60 (Tier 1-Generic) posaconazole oral suspension 200 mg/5 ml (40 mg/ml) $0-$3.60 (Tier 1-Generic) PA posaconazole oral tablet,delayed release (dr/ec) 100 mg $0-$3.60 (Tier 1-Generic) PA terbinafine hcl oral tablet 250 mg $0-$3.60 (Tier 1-Generic) terconazole vaginal cream 0.4 %, 0.8 % $0-$3.60 (Tier 1-Generic) terconazole vaginal suppository 80 mg $0-$3.60 (Tier 1-Generic) voriconazole intravenous recon soln 200 mg $0-$3.60 (Tier 1-Generic) voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) $0-$3.60 (Tier 1-Generic)

voriconazole oral tablet 200 mg, 50 mg $0-$3.60 (Tier 1-Generic) Antigout Agents Antigout Agents allopurinol oral tablet 100 mg, 300 mg $0-$3.60 (Tier 1-Generic) colchicine oral capsule 0.6 mg $0-$3.60 (Tier 1-Generic) colchicine oral tablet 0.6 mg $0-$3.60 (Tier 1-Generic) febuxostat oral tablet 40 mg, 80 mg $0-$3.60 (Tier 1-Generic) ST





probenecid oral tablet 500 mg $0-$3.60 (Tier 1-Generic) probenecid-colchicine oral tablet 500-0.5 mg $0-$3.60 (Tier 1-Generic) Anti-Inflammatory Agents Glucocorticoids ALA-CORT TOPICAL CREAM 1 % $0-$8.95 (Tier 1-Brand) alclometasone topical cream 0.05 % $0-$3.60 (Tier 1-Generic) alclometasone topical ointment 0.05 % $0-$3.60 (Tier 1-Generic) betamethasone dipropionate topical cream 0.05 % $0-$3.60 (Tier 1-Generic) betamethasone dipropionate topical lotion 0.05 % $0-$3.60 (Tier 1-Generic) betamethasone dipropionate topical ointment 0.05 % $0-$3.60 (Tier 1-Generic) betamethasone valerate topical cream 0.1 % $0-$3.60 (Tier 1-Generic) betamethasone valerate topical lotion 0.1 % $0-$3.60 (Tier 1-Generic) betamethasone valerate topical ointment 0.1 % $0-$3.60 (Tier 1-Generic) betamethasone, augmented topical cream 0.05 % $0-$3.60 (Tier 1-Generic) betamethasone, augmented topical gel 0.05 % $0-$3.60 (Tier 1-Generic) betamethasone, augmented topical lotion 0.05 % $0-$3.60 (Tier 1-Generic) betamethasone, augmented topical ointment 0.05 % $0-$3.60 (Tier 1-Generic) clobetasol scalp solution 0.05 % $0-$3.60 (Tier 1-Generic) clobetasol topical cream 0.05 % $0-$3.60 (Tier 1-Generic) clobetasol topical gel 0.05 % $0-$3.60 (Tier 1-Generic) clobetasol topical ointment 0.05 % $0-$3.60 (Tier 1-Generic) clobetasol-emollient topical cream 0.05 % $0-$3.60 (Tier 1-Generic) desonide topical cream 0.05 % $0-$3.60 (Tier 1-Generic) desonide topical lotion 0.05 % $0-$3.60 (Tier 1-Generic) desonide topical ointment 0.05 % $0-$3.60 (Tier 1-Generic) desoximetasone topical cream 0.05 %, 0.25 % $0-$3.60 (Tier 1-Generic) desoximetasone topical gel 0.05 % $0-$3.60 (Tier 1-Generic) desoximetasone topical ointment 0.05 %, 0.25 % $0-$3.60 (Tier 1-Generic) dexamethasone intensol oral drops 1 mg/ml $0-$3.60 (Tier 1-Generic) dexamethasone oral elixir 0.5 mg/5 ml $0-$3.60 (Tier 1-Generic) dexamethasone oral solution 0.5 mg/5 ml $0-$3.60 (Tier 1-Generic) dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg $0-$3.60 (Tier 1-Generic)

fluocinolone topical cream 0.01 %, 0.025 % $0-$3.60 (Tier 1-Generic) fluocinolone topical ointment 0.025 % $0-$3.60 (Tier 1-Generic) fluocinolone topical solution 0.01 % $0-$3.60 (Tier 1-Generic) fluocinonide topical gel 0.05 % $0-$3.60 (Tier 1-Generic) fluocinonide topical ointment 0.05 % $0-$3.60 (Tier 1-Generic) fluocinonide topical solution 0.05 % $0-$3.60 (Tier 1-Generic) fluocinonide-e topical cream 0.05 % $0-$3.60 (Tier 1-Generic) fluocinonide-emollient topical cream 0.05 % $0-$3.60 (Tier 1-Generic) fluticasone propionate topical cream 0.05 % $0-$3.60 (Tier 1-Generic) fluticasone propionate topical lotion 0.05 % $0-$3.60 (Tier 1-Generic) fluticasone propionate topical ointment 0.005 % $0-$3.60 (Tier 1-Generic) halobetasol propionate topical cream 0.05 % $0-$3.60 (Tier 1-Generic) halobetasol propionate topical ointment 0.05 % $0-$3.60 (Tier 1-Generic) hydrocortisone butyrate topical cream 0.1 % $0-$3.60 (Tier 1-Generic) hydrocortisone butyrate topical ointment 0.1 % $0-$3.60 (Tier 1-Generic) hydrocortisone butyrate topical solution 0.1 % $0-$3.60 (Tier 1-Generic) hydrocortisone butyr-emollient topical cream 0.1 % $0-$3.60 (Tier 1-Generic)





hydrocortisone topical cream 1 %, 2.5 % $0-$3.60 (Tier 1-Generic) hydrocortisone topical cream with perineal applicator 1 % $0-$3.60 (Tier 1-Generic) hydrocortisone topical lotion 2.5 % $0-$3.60 (Tier 1-Generic) hydrocortisone topical ointment 2.5 % $0-$3.60 (Tier 1-Generic) hydrocortisone valerate topical cream 0.2 % $0-$3.60 (Tier 1-Generic) hydrocortisone valerate topical ointment 0.2 % $0-$3.60 (Tier 1-Generic) methylpred dp oral tablets,dose pack 4 mg $0-$3.60 (Tier 1-Generic) methylprednisolone oral tablets,dose pack 4 mg $0-$3.60 (Tier 1-Generic) mometasone topical cream 0.1 % $0-$3.60 (Tier 1-Generic) mometasone topical ointment 0.1 % $0-$3.60 (Tier 1-Generic) mometasone topical solution 0.1 % $0-$3.60 (Tier 1-Generic) prednisolone oral solution 15 mg/5 ml $0-$3.60 (Tier 1-Generic) prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)


prednisone oral solution 5 mg/5 ml $0-$3.60 (Tier 1-Generic) prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg $0-$3.60 (Tier 1-Generic) prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack) $0-$3.60 (Tier 1-Generic)

triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 % $0-$3.60 (Tier 1-Generic) triamcinolone acetonide topical lotion 0.025 %, 0.1 % $0-$3.60 (Tier 1-Generic) triamcinolone acetonide topical ointment 0.025 %, 0.05 %, 0.1 %, 0.5 % $0-$3.60 (Tier 1-Generic)

triderm topical cream 0.1 % $0-$3.60 (Tier 1-Generic) Antimigraine Agents Ergot Alkaloids dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml) $0-$3.60 (Tier 1-Generic) QL (8 ML per 30 days)

ergotamine-caffeine oral tablet 1-100 mg $0-$3.60 (Tier 1-Generic) Prophylactic AIMOVIG AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML $0-$8.95 (Tier 1-Brand) PA

AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML, 70 MG/ML $0-$8.95 (Tier 1-Brand) PA

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML $0-$8.95 (Tier 1-Brand) PA

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML, 300 MG/3 ML (100 MG/ML X 3) $0-$8.95 (Tier 1-Brand) PA

Serotonin (5-Ht) 1B/1D Receptor Agonists rizatriptan oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) QL (12 EA per 30 days) rizatriptan oral tablet,disintegrating 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) QL (12 EA per 30 days) sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation $0-$3.60 (Tier 1-Generic) QL (12 EA per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) QL (9 EA per 30 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml $0-$3.60 (Tier 1-Generic) QL (4 ML per 30 days)

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml $0-$3.60 (Tier 1-Generic) QL (4 ML per 30 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5 ml $0-$3.60 (Tier 1-Generic) QL (4 ML per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml $0-$3.60 (Tier 1-Generic) QL (4 ML per 30 days)





Antimyasthenic Agents Parasympathomimetics guanidine oral tablet 125 mg $0-$3.60 (Tier 1-Generic) pyridostigmine bromide oral tablet 30 mg, 60 mg $0-$3.60 (Tier 1-Generic) pyridostigmine bromide oral tablet extended release 180 mg $0-$3.60 (Tier 1-Generic) Antimycobacterials Antimycobacterials, Other dapsone oral tablet 100 mg, 25 mg $0-$3.60 (Tier 1-Generic) rifabutin oral capsule 150 mg $0-$3.60 (Tier 1-Generic) Antituberculars ethambutol oral tablet 100 mg, 400 mg $0-$3.60 (Tier 1-Generic) isoniazid oral tablet 100 mg, 300 mg $0-$3.60 (Tier 1-Generic) PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM $0-$8.95 (Tier 1-Brand)

PRETOMANID ORAL TABLET 200 MG $0-$8.95 (Tier 1-Brand) PA PRIFTIN ORAL TABLET 150 MG $0-$8.95 (Tier 1-Brand) pyrazinamide oral tablet 500 mg $0-$3.60 (Tier 1-Generic) rifampin intravenous recon soln 600 mg $0-$3.60 (Tier 1-Generic) rifampin oral capsule 150 mg, 300 mg $0-$3.60 (Tier 1-Generic) SIRTURO ORAL TABLET 100 MG, 20 MG $0-$8.95 (Tier 1-Brand) PA TRECATOR ORAL TABLET 250 MG $0-$8.95 (Tier 1-Brand) Antineoplastics Alkylating Agents cyclophosphamide oral capsule 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) B/D GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG $0-$8.95 (Tier 1-Brand) PA HEXALEN ORAL CAPSULE 50 MG $0-$8.95 (Tier 1-Brand) LEUKERAN ORAL TABLET 2 MG $0-$8.95 (Tier 1-Brand) MATULANE ORAL CAPSULE 50 MG $0-$8.95 (Tier 1-Brand) VALCHLOR TOPICAL GEL 0.016 % $0-$8.95 (Tier 1-Brand) Antiandrogens abiraterone oral tablet 250 mg $0-$3.60 (Tier 1-Generic) PA bicalutamide oral tablet 50 mg $0-$3.60 (Tier 1-Generic) ERLEADA ORAL TABLET 60 MG $0-$8.95 (Tier 1-Brand) PA flutamide oral capsule 125 mg $0-$3.60 (Tier 1-Generic) nilutamide oral tablet 150 mg $0-$3.60 (Tier 1-Generic) NUBEQA ORAL TABLET 300 MG $0-$8.95 (Tier 1-Brand) PA XTANDI ORAL CAPSULE 40 MG $0-$8.95 (Tier 1-Brand) PA YONSA ORAL TABLET 125 MG $0-$8.95 (Tier 1-Brand) PA ZYTIGA ORAL TABLET 500 MG $0-$8.95 (Tier 1-Brand) PA Antiangiogenic Agents POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG $0-$8.95 (Tier 1-Brand) PA REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG $0-$8.95 (Tier 1-Brand) PA; LA

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG $0-$8.95 (Tier 1-Brand)

Antiestrogens/Modifiers DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML $0-$8.95 (Tier 1-Brand) PA

EMCYT ORAL CAPSULE 140 MG $0-$8.95 (Tier 1-Brand) SOLTAMOX ORAL SOLUTION 20 MG/10 ML $0-$8.95 (Tier 1-Brand)





tamoxifen oral tablet 10 mg, 20 mg $0-$3.60 (Tier 1-Generic) toremifene oral tablet 60 mg $0-$3.60 (Tier 1-Generic) PA Antimetabolites DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG $0-$8.95 (Tier 1-Brand) fluorouracil topical cream 0.5 %, 5 % $0-$3.60 (Tier 1-Generic) fluorouracil topical solution 2 %, 5 % $0-$3.60 (Tier 1-Generic) hydroxyurea oral capsule 500 mg $0-$3.60 (Tier 1-Generic) mercaptopurine oral tablet 50 mg $0-$3.60 (Tier 1-Generic) PURIXAN ORAL SUSPENSION 20 MG/ML $0-$8.95 (Tier 1-Brand) TABLOID ORAL TABLET 40 MG $0-$8.95 (Tier 1-Brand) PA Antineoplastics, Other diclofenac sodium topical gel 3 % $0-$3.60 (Tier 1-Generic) leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg $0-$3.60 (Tier 1-Generic) LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG $0-$8.95 (Tier 1-Brand) PA LYNPARZA ORAL CAPSULE 50 MG $0-$8.95 (Tier 1-Brand) PA LYNPARZA ORAL TABLET 100 MG, 150 MG $0-$8.95 (Tier 1-Brand) PA MESNEX ORAL TABLET 400 MG $0-$8.95 (Tier 1-Brand) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG $0-$8.95 (Tier 1-Brand) PA ODOMZO ORAL CAPSULE 200 MG $0-$8.95 (Tier 1-Brand) PA SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG $0-$8.95 (Tier 1-Brand) PA

SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG $0-$8.95 (Tier 1-Brand) PA TAZVERIK ORAL TABLET 200 MG $0-$8.95 (Tier 1-Brand) PA VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG $0-$8.95 (Tier 1-Brand) PA VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG $0-$8.95 (Tier 1-Brand) PA

XPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5), 40 MG/WEEK (20 MG X 2), 40MG TWICE WEEK (80 MG/WEEK), 60 MG/WEEK (20 MG X 3), 60MG TWICE WEEK (120 MG/WEEK), 80 MG/WEEK (20 MG X 4), 80MG TWICE WEEK (160 MG/WEEK)


ZOLINZA ORAL CAPSULE 100 MG $0-$8.95 (Tier 1-Brand) PA ZYDELIG ORAL TABLET 100 MG, 150 MG $0-$8.95 (Tier 1-Brand) PA Aromatase Inhibitors, 3Rd Generation anastrozole oral tablet 1 mg $0-$3.60 (Tier 1-Generic) exemestane oral tablet 25 mg $0-$3.60 (Tier 1-Generic) letrozole oral tablet 2.5 mg $0-$3.60 (Tier 1-Generic) Enzyme Inhibitors COPIKTRA ORAL CAPSULE 15 MG, 25 MG $0-$8.95 (Tier 1-Brand) PA PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1), 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2) $0-$8.95 (Tier 1-Brand) PA

TALZENNA ORAL CAPSULE 0.25 MG, 1 MG $0-$8.95 (Tier 1-Brand) PA VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG $0-$8.95 (Tier 1-Brand) PA Molecular Target Inhibitors AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG $0-$8.95 (Tier 1-Brand) PA

AFINITOR ORAL TABLET 10 MG $0-$8.95 (Tier 1-Brand) PA ALECENSA ORAL CAPSULE 150 MG $0-$8.95 (Tier 1-Brand) PA ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG $0-$8.95 (Tier 1-Brand) PA





ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23) $0-$8.95 (Tier 1-Brand) PA

AYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG $0-$8.95 (Tier 1-Brand) PA BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG $0-$8.95 (Tier 1-Brand) PA BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG $0-$8.95 (Tier 1-Brand) PA BRAFTOVI ORAL CAPSULE 75 MG $0-$8.95 (Tier 1-Brand) PA BRUKINSA ORAL CAPSULE 80 MG $0-$8.95 (Tier 1-Brand) PA CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG $0-$8.95 (Tier 1-Brand) PA CALQUENCE ORAL CAPSULE 100 MG $0-$8.95 (Tier 1-Brand) PA CAPRELSA ORAL TABLET 100 MG, 300 MG $0-$8.95 (Tier 1-Brand) PA COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)


COTELLIC ORAL TABLET 20 MG $0-$8.95 (Tier 1-Brand) PA DAURISMO ORAL TABLET 100 MG, 25 MG $0-$8.95 (Tier 1-Brand) PA ERIVEDGE ORAL CAPSULE 150 MG $0-$8.95 (Tier 1-Brand) PA erlotinib oral tablet 100 mg, 150 mg, 25 mg $0-$3.60 (Tier 1-Generic) PA everolimus (antineoplastic) oral tablet 2.5 mg, 5 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) PA FARYDAK ORAL CAPSULE 10 MG, 20 MG $0-$8.95 (Tier 1-Brand) PA GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG $0-$8.95 (Tier 1-Brand) PA IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG $0-$8.95 (Tier 1-Brand) PA IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG $0-$8.95 (Tier 1-Brand) PA ICLUSIG ORAL TABLET 15 MG, 45 MG $0-$8.95 (Tier 1-Brand) PA IDHIFA ORAL TABLET 100 MG, 50 MG $0-$8.95 (Tier 1-Brand) PA imatinib oral tablet 100 mg, 400 mg $0-$3.60 (Tier 1-Generic) PA IMBRUVICA ORAL CAPSULE 140 MG, 70 MG $0-$8.95 (Tier 1-Brand) PA IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG $0-$8.95 (Tier 1-Brand) PA

INLYTA ORAL TABLET 1 MG, 5 MG $0-$8.95 (Tier 1-Brand) PA INREBIC ORAL CAPSULE 100 MG $0-$8.95 (Tier 1-Brand) PA IRESSA ORAL TABLET 250 MG $0-$8.95 (Tier 1-Brand) PA JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG $0-$8.95 (Tier 1-Brand) PA KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG


KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) $0-$8.95 (Tier 1-Brand) PA

KOSELUGO ORAL CAPSULE 10 MG, 25 MG $0-$8.95 (Tier 1-Brand) PA LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2)


LORBRENA ORAL TABLET 100 MG, 25 MG $0-$8.95 (Tier 1-Brand) PA MEKINIST ORAL TABLET 0.5 MG, 2 MG $0-$8.95 (Tier 1-Brand) PA MEKTOVI ORAL TABLET 15 MG $0-$8.95 (Tier 1-Brand) PA NERLYNX ORAL TABLET 40 MG $0-$8.95 (Tier 1-Brand) PA NEXAVAR ORAL TABLET 200 MG $0-$8.95 (Tier 1-Brand) PA PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG $0-$8.95 (Tier 1-Brand) PA QINLOCK ORAL TABLET 50 MG $0-$8.95 (Tier 1-Brand) PA RETEVMO ORAL CAPSULE 40 MG, 80 MG $0-$8.95 (Tier 1-Brand) PA





ROZLYTREK ORAL CAPSULE 100 MG, 200 MG $0-$8.95 (Tier 1-Brand) PA RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG $0-$8.95 (Tier 1-Brand) PA RYDAPT ORAL CAPSULE 25 MG $0-$8.95 (Tier 1-Brand) PA SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG $0-$8.95 (Tier 1-Brand) PA

STIVARGA ORAL TABLET 40 MG $0-$8.95 (Tier 1-Brand) PA SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG $0-$8.95 (Tier 1-Brand) PA TABRECTA ORAL TABLET 150 MG, 200 MG $0-$8.95 (Tier 1-Brand) PA TAFINLAR ORAL CAPSULE 50 MG, 75 MG $0-$8.95 (Tier 1-Brand) PA TAGRISSO ORAL TABLET 40 MG, 80 MG $0-$8.95 (Tier 1-Brand) PA TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG $0-$8.95 (Tier 1-Brand) PA TIBSOVO ORAL TABLET 250 MG $0-$8.95 (Tier 1-Brand) PA TUKYSA ORAL TABLET 150 MG, 50 MG $0-$8.95 (Tier 1-Brand) PA TURALIO ORAL CAPSULE 200 MG $0-$8.95 (Tier 1-Brand) PA TYKERB ORAL TABLET 250 MG $0-$8.95 (Tier 1-Brand) PA VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG $0-$8.95 (Tier 1-Brand) PA VITRAKVI ORAL CAPSULE 100 MG, 25 MG $0-$8.95 (Tier 1-Brand) PA VITRAKVI ORAL SOLUTION 20 MG/ML $0-$8.95 (Tier 1-Brand) PA VOTRIENT ORAL TABLET 200 MG $0-$8.95 (Tier 1-Brand) PA XALKORI ORAL CAPSULE 200 MG, 250 MG $0-$8.95 (Tier 1-Brand) PA XOSPATA ORAL TABLET 40 MG $0-$8.95 (Tier 1-Brand) PA ZEJULA ORAL CAPSULE 100 MG $0-$8.95 (Tier 1-Brand) PA ZELBORAF ORAL TABLET 240 MG $0-$8.95 (Tier 1-Brand) PA ZYKADIA ORAL CAPSULE 150 MG $0-$8.95 (Tier 1-Brand) PA ZYKADIA ORAL TABLET 150 MG $0-$8.95 (Tier 1-Brand) PA Retinoids bexarotene oral capsule 75 mg $0-$3.60 (Tier 1-Generic) PANRETIN TOPICAL GEL 0.1 % $0-$8.95 (Tier 1-Brand) PA TARGRETIN TOPICAL GEL 1 % $0-$8.95 (Tier 1-Brand) PA tretinoin (antineoplastic) oral capsule 10 mg $0-$3.60 (Tier 1-Generic) Treatment Adjuncts LYSODREN ORAL TABLET 500 MG $0-$8.95 (Tier 1-Brand) Antiparasitics Anthelmintics albendazole oral tablet 200 mg $0-$3.60 (Tier 1-Generic) ivermectin oral tablet 3 mg $0-$3.60 (Tier 1-Generic) praziquantel oral tablet 600 mg $0-$3.60 (Tier 1-Generic) Antiprotozoals ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML $0-$8.95 (Tier 1-Brand)

ALINIA ORAL TABLET 500 MG $0-$8.95 (Tier 1-Brand) atovaquone oral suspension 750 mg/5 ml $0-$3.60 (Tier 1-Generic) atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg $0-$3.60 (Tier 1-Generic) BENZNIDAZOLE ORAL TABLET 100 MG, 12.5 MG $0-$8.95 (Tier 1-Brand) PA chloroquine phosphate oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) COARTEM ORAL TABLET 20-120 MG $0-$8.95 (Tier 1-Brand) hydroxychloroquine oral tablet 200 mg $0-$3.60 (Tier 1-Generic) mefloquine oral tablet 250 mg $0-$3.60 (Tier 1-Generic) pentamidine inhalation recon soln 300 mg $0-$3.60 (Tier 1-Generic) B/D pentamidine injection recon soln 300 mg $0-$3.60 (Tier 1-Generic) PA





primaquine oral tablet 26.3 mg $0-$3.60 (Tier 1-Generic) pyrimethamine oral tablet 25 mg $0-$3.60 (Tier 1-Generic) quinine sulfate oral capsule 324 mg $0-$3.60 (Tier 1-Generic) Pediculicides/ Scabicides lindane topical shampoo 1 % $0-$3.60 (Tier 1-Generic) malathion topical lotion 0.5 % $0-$3.60 (Tier 1-Generic) permethrin topical cream 5 % $0-$3.60 (Tier 1-Generic) Antiparkinson Agents Anticholinergics benztropine oral tablet 0.5 mg, 1 mg, 2 mg $0-$3.60 (Tier 1-Generic) trihexyphenidyl oral elixir 0.4 mg/ml $0-$3.60 (Tier 1-Generic) PA trihexyphenidyl oral tablet 2 mg, 5 mg $0-$3.60 (Tier 1-Generic) PA Antiparkinson Agents, Other amantadine hcl oral capsule 100 mg $0-$3.60 (Tier 1-Generic) amantadine hcl oral solution 50 mg/5 ml $0-$3.60 (Tier 1-Generic) amantadine hcl oral tablet 100 mg $0-$3.60 (Tier 1-Generic) entacapone oral tablet 200 mg $0-$3.60 (Tier 1-Generic) GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 137 MG, 68.5 MG $0-$8.95 (Tier 1-Brand) PA

tolcapone oral tablet 100 mg $0-$3.60 (Tier 1-Generic) Dopamine Agonists APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML $0-$8.95 (Tier 1-Brand) PA bromocriptine oral capsule 5 mg $0-$3.60 (Tier 1-Generic) bromocriptine oral tablet 2.5 mg $0-$3.60 (Tier 1-Generic) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR

$0-$8.95 (Tier 1-Brand)

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg $0-$3.60 (Tier 1-Generic)

pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg $0-$3.60 (Tier 1-Generic)

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg $0-$3.60 (Tier 1-Generic)

ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg $0-$3.60 (Tier 1-Generic)

Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg $0-$3.60 (Tier 1-Generic)

carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg $0-$3.60 (Tier 1-Generic)

carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg $0-$3.60 (Tier 1-Generic)

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg


Monoamine Oxidase B (Mao-B) Inhibitors rasagiline oral tablet 0.5 mg, 1 mg $0-$3.60 (Tier 1-Generic) selegiline hcl oral capsule 5 mg $0-$3.60 (Tier 1-Generic) selegiline hcl oral tablet 5 mg $0-$3.60 (Tier 1-Generic)





Antipsychotics 1St Generation/ Typical fluphenazine decanoate injection solution 25 mg/ml $0-$3.60 (Tier 1-Generic) fluphenazine hcl injection solution 2.5 mg/ml $0-$3.60 (Tier 1-Generic) fluphenazine hcl oral concentrate 5 mg/ml $0-$3.60 (Tier 1-Generic) fluphenazine hcl oral elixir 2.5 mg/5 ml $0-$3.60 (Tier 1-Generic) fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml, 50 mg/ml(1ml) $0-$3.60 (Tier 1-Generic)

haloperidol lactate injection solution 5 mg/ml $0-$3.60 (Tier 1-Generic) haloperidol lactate intramuscular syringe 5 mg/ml $0-$3.60 (Tier 1-Generic) haloperidol lactate oral concentrate 2 mg/ml $0-$3.60 (Tier 1-Generic) haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg $0-$3.60 (Tier 1-Generic) loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg $0-$3.60 (Tier 1-Generic) molindone oral tablet 10 mg, 25 mg, 5 mg $0-$3.60 (Tier 1-Generic) pimozide oral tablet 1 mg, 2 mg $0-$3.60 (Tier 1-Generic) thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) PA thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg $0-$3.60 (Tier 1-Generic) trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg $0-$3.60 (Tier 1-Generic) 2Nd Generation/ Atypical ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG $0-$8.95 (Tier 1-Brand) PA; QL (1 EA per 28 days)

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG $0-$8.95 (Tier 1-Brand) PA; QL (1 EA per 28 days)

aripiprazole oral solution 1 mg/ml $0-$3.60 (Tier 1-Generic) QL (900 ML per 30 days) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) aripiprazole oral tablet,disintegrating 10 mg, 15 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML $0-$8.95 (Tier 1-Brand) PA

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML $0-$8.95 (Tier 1-Brand) PA; QL (3.9 ML per 56 days)

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML $0-$8.95 (Tier 1-Brand) PA; QL (1.6 ML per 28 days)



CAPLYTA ORAL CAPSULE 42 MG $0-$8.95 (Tier 1-Brand) PA FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG $0-$8.95 (Tier 1-Brand) PA; QL (60 EA per 30 days)

FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2) $0-$8.95 (Tier 1-Brand) PA

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML $0-$8.95 (Tier 1-Brand) PA; QL (0.75 ML per 28 days)

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML $0-$8.95 (Tier 1-Brand) PA; QL (1 ML per 28 days)








INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML $0-$8.95 (Tier 1-Brand) PA; QL (0.875 ML per 84

days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML $0-$8.95 (Tier 1-Brand) PA; QL (1.315 ML per 84

days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML $0-$8.95 (Tier 1-Brand) PA; QL (1.75 ML per 84 days)

INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML $0-$8.95 (Tier 1-Brand) PA; QL (2.625 ML per 84

days) LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG $0-$8.95 (Tier 1-Brand) PA; QL (30 EA per 30 days) LATUDA ORAL TABLET 80 MG $0-$8.95 (Tier 1-Brand) PA; QL (60 EA per 30 days) NUPLAZID ORAL CAPSULE 34 MG $0-$8.95 (Tier 1-Brand) PA; QL (30 EA per 30 days) NUPLAZID ORAL TABLET 10 MG $0-$8.95 (Tier 1-Brand) PA; QL (30 EA per 30 days) NUPLAZID ORAL TABLET 17 MG $0-$8.95 (Tier 1-Brand) PA; QL (60 EA per 30 days) olanzapine intramuscular recon soln 10 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days)

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg $0-$3.60 (Tier 1-Generic) PA; QL (30 EA per 30 days)

paliperidone oral tablet extended release 24hr 6 mg $0-$3.60 (Tier 1-Generic) PA; QL (60 EA per 30 days) PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSION,EXTEND REL SYR KIT 120 MG, 90 MG $0-$8.95 (Tier 1-Brand) PA; QL (1 EA per 28 days)

quetiapine oral tablet 100 mg, 200 mg, 300 mg, 400 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) quetiapine oral tablet 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) quetiapine oral tablet extended release 24 hr 150 mg, 200 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days)

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG $0-$8.95 (Tier 1-Brand) PA; QL (30 EA per 30 days)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML

$0-$8.95 (Tier 1-Brand) PA; QL (2 EA per 28 days)

risperidone oral solution 1 mg/ml $0-$3.60 (Tier 1-Generic) QL (240 ML per 30 days) risperidone oral syringe 1 mg/ml $0-$3.60 (Tier 1-Generic) QL (240 ML per 30 days) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) risperidone oral tablet 4 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days)

risperidone oral tablet,disintegrating 4 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) SAPHRIS SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24 HOUR, 5.7 MG/24 HOUR, 7.6 MG/24 HOUR $0-$8.95 (Tier 1-Brand) PA; QL (30 EA per 30 days)

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG $0-$8.95 (Tier 1-Brand) PA; QL (30 EA per 30 days) VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) $0-$8.95 (Tier 1-Brand) PA; QL (28 EA per 28 days) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) ziprasidone mesylate intramuscular recon soln 20 mg/ml (final conc.) $0-$3.60 (Tier 1-Generic) B/D; QL (6 EA per 3 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG $0-$8.95 (Tier 1-Brand) PA; QL (2 EA per 28 days)





ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG $0-$8.95 (Tier 1-Brand) PA; QL (1 EA per 28 days)

Treatment-Resistant clozapine oral tablet 100 mg $0-$3.60 (Tier 1-Generic) QL (270 EA per 30 days) clozapine oral tablet 200 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) clozapine oral tablet 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) clozapine oral tablet,disintegrating 100 mg $0-$3.60 (Tier 1-Generic) QL (270 EA per 30 days) clozapine oral tablet,disintegrating 12.5 mg, 25 mg $0-$3.60 (Tier 1-Generic) clozapine oral tablet,disintegrating 150 mg $0-$3.60 (Tier 1-Generic) QL (180 EA per 30 days) clozapine oral tablet,disintegrating 200 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) VERSACLOZ ORAL SUSPENSION 50 MG/ML $0-$8.95 (Tier 1-Brand) QL (540 ML per 30 days) Antispasticity Agents Antispasticity Agents baclofen oral tablet 10 mg, 20 mg, 5 mg $0-$3.60 (Tier 1-Generic) COMFORT PAC-TIZANIDINE KIT 4 MG $0-$8.95 (Tier 1-Brand) dantrolene oral capsule 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) tizanidine oral tablet 2 mg, 4 mg $0-$3.60 (Tier 1-Generic) Antivirals Anti-Cytomegalovirus (Cmv) Agents PREVYMIS ORAL TABLET 240 MG, 480 MG $0-$8.95 (Tier 1-Brand) PA valganciclovir oral recon soln 50 mg/ml $0-$3.60 (Tier 1-Generic) valganciclovir oral tablet 450 mg $0-$3.60 (Tier 1-Generic) ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % $0-$8.95 (Tier 1-Brand) ST Anti-Hepatitis B (Hbv) Agents adefovir oral tablet 10 mg $0-$3.60 (Tier 1-Generic) PA BARACLUDE ORAL SOLUTION 0.05 MG/ML $0-$8.95 (Tier 1-Brand) entecavir oral tablet 0.5 mg, 1 mg $0-$3.60 (Tier 1-Generic) EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) $0-$8.95 (Tier 1-Brand) lamivudine oral solution 10 mg/ml $0-$3.60 (Tier 1-Generic) lamivudine oral tablet 100 mg, 300 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) lamivudine oral tablet 150 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) PA

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML $0-$8.95 (Tier 1-Brand) PA PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) PA tenofovir disoproxil fumarate oral tablet 300 mg $0-$3.60 (Tier 1-Generic) VEMLIDY ORAL TABLET 25 MG $0-$8.95 (Tier 1-Brand) VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) $0-$8.95 (Tier 1-Brand) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) Anti-Hepatitis C (Hcv) Agents, Direct Acting Agents MAVYRET ORAL TABLET 100-40 MG $0-$8.95 (Tier 1-Brand) PA sofosbuvir-velpatasvir oral tablet 400-100 mg $0-$3.60 (Tier 1-Generic) PA VOSEVI ORAL TABLET 400-100-100 MG $0-$8.95 (Tier 1-Brand) PA Anti-Hepatitis C (Hcv) Agents, Other INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) $0-$8.95 (Tier 1-Brand) PA

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML $0-$8.95 (Tier 1-Brand) PA

ribavirin oral capsule 200 mg $0-$3.60 (Tier 1-Generic) ribavirin oral tablet 200 mg $0-$3.60 (Tier 1-Generic)





Antiherpetic Agents acyclovir oral capsule 200 mg $0-$3.60 (Tier 1-Generic) acyclovir oral suspension 200 mg/5 ml, 200 mg/5 ml (5 ml) $0-$3.60 (Tier 1-Generic) acyclovir oral tablet 400 mg, 800 mg $0-$3.60 (Tier 1-Generic) acyclovir sodium intravenous solution 50 mg/ml $0-$3.60 (Tier 1-Generic) B/D acyclovir topical cream 5 % $0-$3.60 (Tier 1-Generic) acyclovir topical ointment 5 % $0-$3.60 (Tier 1-Generic) DENAVIR TOPICAL CREAM 1 % $0-$8.95 (Tier 1-Brand) famciclovir oral tablet 125 mg, 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) trifluridine ophthalmic (eye) drops 1 % $0-$3.60 (Tier 1-Generic) valacyclovir oral tablet 1 gram, 500 mg $0-$3.60 (Tier 1-Generic) Anti-Hiv Agents, Integrase Inhibitors (Insti) DOVATO ORAL TABLET 50-300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) GENVOYA ORAL TABLET 150-150-200-10 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) ISENTRESS HD ORAL TABLET 600 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) ISENTRESS ORAL POWDER IN PACKET 100 MG $0-$8.95 (Tier 1-Brand) QL (180 EA per 30 days) ISENTRESS ORAL TABLET 400 MG $0-$8.95 (Tier 1-Brand) QL (120 EA per 30 days) ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG $0-$8.95 (Tier 1-Brand) QL (180 EA per 30 days) JULUCA ORAL TABLET 50-25 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) STRIBILD ORAL TABLET 150-150-200-300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) TIVICAY ORAL TABLET 10 MG $0-$8.95 (Tier 1-Brand) QL (300 EA per 30 days) TIVICAY ORAL TABLET 25 MG $0-$8.95 (Tier 1-Brand) QL (120 EA per 30 days) TIVICAY ORAL TABLET 50 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG $0-$8.95 (Tier 1-Brand) TRIUMEQ ORAL TABLET 600-50-300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Nnrti)

ATRIPLA ORAL TABLET 600-200-300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) COMPLERA ORAL TABLET 200-25-300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) DELSTRIGO ORAL TABLET 100-300-300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) EDURANT ORAL TABLET 25 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) efavirenz oral capsule 200 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) efavirenz oral capsule 50 mg $0-$3.60 (Tier 1-Generic) QL (360 EA per 30 days) efavirenz oral tablet 600 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) INTELENCE ORAL TABLET 100 MG, 25 MG $0-$8.95 (Tier 1-Brand) QL (120 EA per 30 days) INTELENCE ORAL TABLET 200 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) nevirapine oral suspension 50 mg/5 ml $0-$3.60 (Tier 1-Generic) nevirapine oral tablet 200 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) nevirapine oral tablet extended release 24 hr 100 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) nevirapine oral tablet extended release 24 hr 400 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) ODEFSEY ORAL TABLET 200-25-25 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) PIFELTRO ORAL TABLET 100 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) RESCRIPTOR ORAL TABLET 200 MG $0-$8.95 (Tier 1-Brand) QL (180 EA per 30 days) RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG $0-$8.95 (Tier 1-Brand) QL (360 EA per 30 days) SYMFI LO ORAL TABLET 400-300-300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti)

abacavir oral solution 20 mg/ml $0-$3.60 (Tier 1-Generic) abacavir oral tablet 300 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) abacavir-lamivudine oral tablet 600-300 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days)





abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) CIMDUO ORAL TABLET 300-300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) DESCOVY ORAL TABLET 200-25 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) didanosine oral capsule,delayed release(dr/ec) 125 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) didanosine oral capsule,delayed release(dr/ec) 200 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) EMTRIVA ORAL CAPSULE 200 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) EMTRIVA ORAL SOLUTION 10 MG/ML $0-$8.95 (Tier 1-Brand) lamivudine-zidovudine oral tablet 150-300 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) stavudine oral capsule 15 mg, 20 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) stavudine oral capsule 30 mg, 40 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days)

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) $0-$8.95 (Tier 1-Brand)

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) $0-$8.95 (Tier 1-Brand)

VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG $0-$8.95 (Tier 1-Brand) QL (90 EA per 30 days)

ZERIT ORAL RECON SOLN 1 MG/ML $0-$8.95 (Tier 1-Brand) zidovudine oral capsule 100 mg $0-$3.60 (Tier 1-Generic) QL (180 EA per 30 days) zidovudine oral syrup 10 mg/ml $0-$3.60 (Tier 1-Generic) zidovudine oral tablet 300 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) Anti-Hiv Agents, Other BIKTARVY ORAL TABLET 50-200-25 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) FUZEON SUBCUTANEOUS RECON SOLN 90 MG $0-$8.95 (Tier 1-Brand) SELZENTRY ORAL SOLUTION 20 MG/ML $0-$8.95 (Tier 1-Brand) SELZENTRY ORAL TABLET 150 MG, 75 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) SELZENTRY ORAL TABLET 25 MG, 300 MG $0-$8.95 (Tier 1-Brand) QL (120 EA per 30 days) SYMFI ORAL TABLET 600-300-300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) SYMTUZA ORAL TABLET 800-150-200-10 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) TYBOST ORAL TABLET 150 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) Anti-Hiv Agents, Protease Inhibitors APTIVUS (WITH VITAMIN E) ORAL SOLUTION 100 MG/ML $0-$8.95 (Tier 1-Brand) APTIVUS ORAL CAPSULE 250 MG $0-$8.95 (Tier 1-Brand) QL (120 EA per 30 days) atazanavir oral capsule 150 mg, 300 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) atazanavir oral capsule 200 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) CRIXIVAN ORAL CAPSULE 200 MG $0-$8.95 (Tier 1-Brand) QL (360 EA per 30 days) CRIXIVAN ORAL CAPSULE 400 MG $0-$8.95 (Tier 1-Brand) QL (180 EA per 30 days) EVOTAZ ORAL TABLET 300-150 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) fosamprenavir oral tablet 700 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) INVIRASE ORAL TABLET 500 MG $0-$8.95 (Tier 1-Brand) QL (120 EA per 30 days) KALETRA ORAL TABLET 100-25 MG $0-$8.95 (Tier 1-Brand) QL (240 EA per 30 days) KALETRA ORAL TABLET 200-50 MG $0-$8.95 (Tier 1-Brand) QL (120 EA per 30 days) LEXIVA ORAL SUSPENSION 50 MG/ML $0-$8.95 (Tier 1-Brand) lopinavir-ritonavir oral solution 400-100 mg/5 ml $0-$3.60 (Tier 1-Generic) NORVIR ORAL POWDER IN PACKET 100 MG $0-$8.95 (Tier 1-Brand) QL (360 EA per 30 days) NORVIR ORAL SOLUTION 80 MG/ML $0-$8.95 (Tier 1-Brand) PREZCOBIX ORAL TABLET 800-150 MG-MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) PREZISTA ORAL SUSPENSION 100 MG/ML $0-$8.95 (Tier 1-Brand)





PREZISTA ORAL TABLET 150 MG $0-$8.95 (Tier 1-Brand) QL (180 EA per 30 days) PREZISTA ORAL TABLET 600 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) PREZISTA ORAL TABLET 75 MG $0-$8.95 (Tier 1-Brand) QL (300 EA per 30 days) PREZISTA ORAL TABLET 800 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) REYATAZ ORAL POWDER IN PACKET 50 MG $0-$8.95 (Tier 1-Brand) ritonavir oral tablet 100 mg $0-$3.60 (Tier 1-Generic) QL (360 EA per 30 days) VIRACEPT ORAL TABLET 250 MG $0-$8.95 (Tier 1-Brand) QL (300 EA per 30 days) VIRACEPT ORAL TABLET 625 MG $0-$8.95 (Tier 1-Brand) QL (120 EA per 30 days) Anti-Influenza Agents oseltamivir oral capsule 30 mg $0-$3.60 (Tier 1-Generic) QL (84 EA per 180 days) oseltamivir oral capsule 45 mg, 75 mg $0-$3.60 (Tier 1-Generic) QL (42 EA per 180 days) oseltamivir oral suspension for reconstitution 6 mg/ml $0-$3.60 (Tier 1-Generic) QL (540 ML per 180 days) RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION $0-$8.95 (Tier 1-Brand) QL (60 EA per 180 days)

rimantadine oral tablet 100 mg $0-$3.60 (Tier 1-Generic) Anxiolytics Anxiolytics, Other buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) PA Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) alprazolam oral tablet 2 mg $0-$3.60 (Tier 1-Generic) QL (150 EA per 30 days) clonazepam oral tablet 0.5 mg, 1 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) clonazepam oral tablet 2 mg $0-$3.60 (Tier 1-Generic) QL (300 EA per 30 days) clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days)

clonazepam oral tablet,disintegrating 2 mg $0-$3.60 (Tier 1-Generic) QL (300 EA per 30 days) clorazepate dipotassium oral tablet 15 mg $0-$3.60 (Tier 1-Generic) PA; QL (180 EA per 30 days) clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) PA; QL (90 EA per 30 days) diazepam intensol oral concentrate 5 mg/ml $0-$3.60 (Tier 1-Generic) PA; QL (240 ML per 30 days) diazepam oral concentrate 5 mg/ml $0-$3.60 (Tier 1-Generic) PA; QL (240 ML per 30 days) diazepam oral solution 5 mg/5 ml (1 mg/ml), 5 mg/5 ml (1 mg/ml, 5 ml) $0-$3.60 (Tier 1-Generic) PA; QL (1200 ML per 30

days) diazepam oral tablet 10 mg, 2 mg, 5 mg $0-$3.60 (Tier 1-Generic) PA; QL (120 EA per 30 days) lorazepam intensol oral concentrate 2 mg/ml $0-$3.60 (Tier 1-Generic) QL (150 ML per 30 days) lorazepam oral concentrate 2 mg/ml $0-$3.60 (Tier 1-Generic) QL (150 ML per 30 days) lorazepam oral tablet 0.5 mg, 1 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) lorazepam oral tablet 2 mg $0-$3.60 (Tier 1-Generic) QL (150 EA per 30 days) Bipolar Agents Mood Stabilizers carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg $0-$3.60 (Tier 1-Generic)

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG $0-$8.95 (Tier 1-Brand)

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg $0-$3.60 (Tier 1-Generic) lithium carbonate oral capsule 150 mg, 300 mg, 600 mg $0-$3.60 (Tier 1-Generic) lithium carbonate oral tablet 300 mg $0-$3.60 (Tier 1-Generic) lithium carbonate oral tablet extended release 300 mg, 450 mg $0-$3.60 (Tier 1-Generic) lithium citrate oral solution 8 meq/5 ml, 8 meq/5 ml (5 ml) $0-$3.60 (Tier 1-Generic) Blood Glucose Regulators





Antidiabetic Agents acarbose oral tablet 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) AVANDIA ORAL TABLET 2 MG, 4 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) dm2 combo pack, tablet and strip 500 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) glimepiride oral tablet 1 mg $0-$3.60 (Tier 1-Generic) QL (240 EA per 30 days) glimepiride oral tablet 2 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) glimepiride oral tablet 4 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) glipizide oral tablet 10 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) glipizide oral tablet 5 mg $0-$3.60 (Tier 1-Generic) QL (240 EA per 30 days) glipizide oral tablet extended release 24hr 10 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) glipizide oral tablet extended release 24hr 2.5 mg $0-$3.60 (Tier 1-Generic) QL (240 EA per 30 days) glipizide oral tablet extended release 24hr 5 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) glipizide-metformin oral tablet 2.5-250 mg $0-$3.60 (Tier 1-Generic) QL (240 EA per 30 days) glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) glyburide micronized oral tablet 1.5 mg, 3 mg $0-$3.60 (Tier 1-Generic) PA; QL (90 EA per 30 days) glyburide micronized oral tablet 6 mg $0-$3.60 (Tier 1-Generic) PA; QL (60 EA per 30 days) glyburide oral tablet 1.25 mg, 2.5 mg $0-$3.60 (Tier 1-Generic) PA; QL (60 EA per 30 days) glyburide oral tablet 5 mg $0-$3.60 (Tier 1-Generic) PA; QL (120 EA per 30 days) glyburide-metformin oral tablet 1.25-250 mg $0-$3.60 (Tier 1-Generic) PA; QL (240 EA per 30 days) glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg $0-$3.60 (Tier 1-Generic) PA; QL (120 EA per 30 days) INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days)

INVOKAMET ORAL TABLET 50-500 MG $0-$8.95 (Tier 1-Brand) QL (120 EA per 30 days) INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days)

INVOKANA ORAL TABLET 100 MG, 300 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) JARDIANCE ORAL TABLET 10 MG, 25 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days)

KORLYM ORAL TABLET 300 MG $0-$8.95 (Tier 1-Brand) PA metformin oral tablet 1,000 mg $0-$3.60 (Tier 1-Generic) QL (75 EA per 30 days) metformin oral tablet 500 mg $0-$3.60 (Tier 1-Generic) QL (150 EA per 30 days) metformin oral tablet 850 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) metformin oral tablet extended release 24 hr 500 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) metformin oral tablet extended release 24 hr 750 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) nateglinide oral tablet 120 mg, 60 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/DOSE (2 MG/1.5 ML) $0-$8.95 (Tier 1-Brand) QL (3 ML per 28 days)

pioglitazone oral tablet 15 mg, 30 mg, 45 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days)





repaglinide oral tablet 0.5 mg, 1 mg, 2 mg $0-$3.60 (Tier 1-Generic) RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) SEGLUROMET ORAL TABLET 2.5-1,000 MG, 7.5-1,000 MG, 7.5-500 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days)

SEGLUROMET ORAL TABLET 2.5-500 MG $0-$8.95 (Tier 1-Brand) QL (120 EA per 30 days) STEGLATRO ORAL TABLET 15 MG, 5 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML $0-$8.95 (Tier 1-Brand) PA

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML $0-$8.95 (Tier 1-Brand) PA

SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days)

TRADJENTA ORAL TABLET 5 MG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML $0-$8.95 (Tier 1-Brand) QL (2 ML per 28 days)

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) $0-$8.95 (Tier 1-Brand) QL (9 ML per 30 days)

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) $0-$8.95 (Tier 1-Brand) QL (9 ML per 30 days)

Blood Glucose Regulators alcohol pads topical pads, medicated $0-$3.60 (Tier 1-Generic) assure id insulin safety syringe 1 ml 29 gauge x 1/2" $0-$3.60 (Tier 1-Generic) gauze pad topical bandage 2 x 2 " $0-$3.60 (Tier 1-Generic) insulin syringe-needle u-100 syringe 0.3 ml 29 gauge, 1 ml 29 gauge x 1/2", 1/2 ml 28 gauge $0-$3.60 (Tier 1-Generic)

pen needle, diabetic needle 29 gauge x 1/2" $0-$3.60 (Tier 1-Generic) Glycemic Agents BAQSIMI NASAL SPRAY,NON-AEROSOL 3 MG/ACTUATION $0-$8.95 (Tier 1-Brand) QL (4 EA per 30 days) diazoxide oral suspension 50 mg/ml $0-$3.60 (Tier 1-Generic) GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MG/ML $0-$8.95 (Tier 1-Brand) QL (4 EA per 30 days)

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG $0-$8.95 (Tier 1-Brand) QL (4 EA per 30 days) GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG $0-$8.95 (Tier 1-Brand) QL (4 EA per 30 days)

GLUCAGON HCL INJECTION RECON SOLN 1 MG/ML $0-$8.95 (Tier 1-Brand) QL (2 EA per 30 days) Insulins HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML $0-$8.95 (Tier 1-Brand)

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) $0-$8.95 (Tier 1-Brand)

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) $0-$8.95 (Tier 1-Brand)

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) $0-$8.95 (Tier 1-Brand)

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) $0-$8.95 (Tier 1-Brand)





HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) $0-$8.95 (Tier 1-Brand)

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML $0-$8.95 (Tier 1-Brand)

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) $0-$8.95 (Tier 1-Brand)

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML $0-$8.95 (Tier 1-Brand)

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML $0-$8.95 (Tier 1-Brand)

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML $0-$8.95 (Tier 1-Brand)

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) $0-$8.95 (Tier 1-Brand)

insulin asp prt-insulin aspart subcutaneous insulin pen 100 unit/ml (70-30) $0-$3.60 (Tier 1-Generic)

insulin asp prt-insulin aspart subcutaneous solution 100 unit/ml (70-30) $0-$3.60 (Tier 1-Generic)

insulin aspart u-100 subcutaneous cartridge 100 unit/ml $0-$3.60 (Tier 1-Generic) insulin aspart u-100 subcutaneous insulin pen 100 unit/ml (3 ml) $0-$3.60 (Tier 1-Generic) insulin aspart u-100 subcutaneous solution 100 unit/ml $0-$3.60 (Tier 1-Generic) insulin lispro protamin-lispro subcutaneous insulin pen 100 unit/ml (75-25) $0-$3.60 (Tier 1-Generic)

insulin lispro subcutaneous insulin pen 100 unit/ml $0-$3.60 (Tier 1-Generic) insulin lispro subcutaneous insulin pen, half-unit 100 unit/ml $0-$3.60 (Tier 1-Generic) insulin lispro subcutaneous solution 100 unit/ml $0-$3.60 (Tier 1-Generic) LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) $0-$8.95 (Tier 1-Brand)

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML $0-$8.95 (Tier 1-Brand)

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) $0-$8.95 (Tier 1-Brand)

LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML $0-$8.95 (Tier 1-Brand)

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) $0-$8.95 (Tier 1-Brand)

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML $0-$8.95 (Tier 1-Brand)

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML $0-$8.95 (Tier 1-Brand)

TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) $0-$8.95 (Tier 1-Brand)

TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) $0-$8.95 (Tier 1-Brand)

Blood Products/ Modifiers/ Volume Expanders Anticoagulants COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG $0-$8.95 (Tier 1-Brand)

ELIQUIS DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 5 MG (74 TABS) $0-$8.95 (Tier 1-Brand)

ELIQUIS ORAL TABLET 2.5 MG, 5 MG $0-$8.95 (Tier 1-Brand)





enoxaparin subcutaneous solution 300 mg/3 ml $0-$3.60 (Tier 1-Generic) enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml


fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml $0-$3.60 (Tier 1-Generic)

FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA UNIT/ML $0-$8.95 (Tier 1-Brand)

FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML

$0-$8.95 (Tier 1-Brand)

heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) $0-$3.60 (Tier 1-Generic) heparin (porcine) injection solution 1,000 unit/ml $0-$3.60 (Tier 1-Generic) heparin (porcine) injection solution 10,000 unit/ml, 5,000 unit/ml $0-$3.60 (Tier 1-Generic) B/D heparin, porcine (pf) injection solution 1,000 unit/ml, 5,000 unit/0.5 ml $0-$3.60 (Tier 1-Generic)

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg $0-$3.60 (Tier 1-Generic)

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG $0-$8.95 (Tier 1-Brand) warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg $0-$3.60 (Tier 1-Generic)

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG $0-$8.95 (Tier 1-Brand) XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) $0-$8.95 (Tier 1-Brand)

Blood Formation Modifiers anagrelide oral capsule 0.5 mg, 1 mg $0-$3.60 (Tier 1-Generic) ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML


ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML


DOPTELET (10 TAB PACK) ORAL TABLET 20 MG $0-$8.95 (Tier 1-Brand) PA DOPTELET (15 TAB PACK) ORAL TABLET 20 MG $0-$8.95 (Tier 1-Brand) PA DOPTELET (30 TAB PACK) ORAL TABLET 20 MG $0-$8.95 (Tier 1-Brand) PA EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML


GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6 ML $0-$8.95 (Tier 1-Brand) PA

GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML $0-$8.95 (Tier 1-Brand) PA

LEUKINE INJECTION RECON SOLN 250 MCG $0-$8.95 (Tier 1-Brand) PA NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML $0-$8.95 (Tier 1-Brand) PA NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML $0-$8.95 (Tier 1-Brand) PA

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML $0-$8.95 (Tier 1-Brand) PA





NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML $0-$8.95 (Tier 1-Brand) PA

NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML $0-$8.95 (Tier 1-Brand) PA

OXBRYTA ORAL TABLET 500 MG $0-$8.95 (Tier 1-Brand) PA PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML


PROMACTA ORAL POWDER IN PACKET 12.5 MG $0-$8.95 (Tier 1-Brand) PA PROMACTA ORAL POWDER IN PACKET 25 MG $0-$8.95 (Tier 1-Brand) PA; QL (30 EA per 30 days) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG $0-$8.95 (Tier 1-Brand) PA; QL (30 EA per 30 days) RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML $0-$8.95 (Tier 1-Brand) PA

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML $0-$8.95 (Tier 1-Brand) PA

ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG/0.6 ML $0-$8.95 (Tier 1-Brand) PA Hemostasis Agents tranexamic acid oral tablet 650 mg $0-$3.60 (Tier 1-Generic) Platelet Modifying Agents aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg $0-$3.60 (Tier 1-Generic)

BRILINTA ORAL TABLET 60 MG, 90 MG $0-$8.95 (Tier 1-Brand) cilostazol oral tablet 100 mg, 50 mg $0-$3.60 (Tier 1-Generic) clopidogrel oral tablet 300 mg, 75 mg $0-$3.60 (Tier 1-Generic) dipyridamole oral tablet 25 mg, 50 mg, 75 mg $0-$3.60 (Tier 1-Generic) PA prasugrel oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) Cardiovascular Agents Alpha-Adrenergic Agonists clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg $0-$3.60 (Tier 1-Generic) clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr $0-$3.60 (Tier 1-Generic)

guanfacine oral tablet 1 mg, 2 mg $0-$3.60 (Tier 1-Generic) PA methyldopa oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) PA midodrine oral tablet 10 mg, 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG $0-$8.95 (Tier 1-Brand) Alpha-Adrenergic Blocking Agents doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg $0-$3.60 (Tier 1-Generic) phenoxybenzamine oral capsule 10 mg $0-$3.60 (Tier 1-Generic) PA prazosin oral capsule 1 mg, 2 mg, 5 mg $0-$3.60 (Tier 1-Generic) terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg $0-$3.60 (Tier 1-Generic) Angiotensin Ii Receptor Antagonists irbesartan oral tablet 150 mg, 300 mg, 75 mg $0-$3.60 (Tier 1-Generic) losartan oral tablet 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) olmesartan oral tablet 20 mg, 40 mg, 5 mg $0-$3.60 (Tier 1-Generic) valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg $0-$3.60 (Tier 1-Generic) Angiotensin-Converting Enzyme (Ace) Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg $0-$3.60 (Tier 1-Generic) captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg $0-$3.60 (Tier 1-Generic) fosinopril oral tablet 10 mg, 20 mg, 40 mg $0-$3.60 (Tier 1-Generic)





lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg $0-$3.60 (Tier 1-Generic) moexipril oral tablet 15 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg $0-$3.60 (Tier 1-Generic) ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) trandolapril oral tablet 1 mg, 2 mg, 4 mg $0-$3.60 (Tier 1-Generic) Antiarrhythmics amiodarone oral tablet 100 mg, 200 mg, 400 mg $0-$3.60 (Tier 1-Generic) disopyramide phosphate oral capsule 100 mg, 150 mg $0-$3.60 (Tier 1-Generic) PA dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg $0-$3.60 (Tier 1-Generic) flecainide oral tablet 100 mg, 150 mg, 50 mg $0-$3.60 (Tier 1-Generic) mexiletine oral capsule 150 mg, 200 mg, 250 mg $0-$3.60 (Tier 1-Generic) MULTAQ ORAL TABLET 400 MG $0-$8.95 (Tier 1-Brand) NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 100 MG, 150 MG $0-$8.95 (Tier 1-Brand) PA

propafenone oral tablet 150 mg, 225 mg, 300 mg $0-$3.60 (Tier 1-Generic) quinidine gluconate oral tablet extended release 324 mg $0-$3.60 (Tier 1-Generic) quinidine sulfate oral tablet 200 mg, 300 mg $0-$3.60 (Tier 1-Generic) sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg $0-$3.60 (Tier 1-Generic) sotalol af oral tablet 120 mg $0-$3.60 (Tier 1-Generic) SOTALOL AF ORAL TABLET 160 MG, 80 MG $0-$8.95 (Tier 1-Brand) sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg $0-$3.60 (Tier 1-Generic) Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg $0-$3.60 (Tier 1-Generic) atenolol oral tablet 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) betaxolol oral tablet 10 mg, 20 mg $0-$3.60 (Tier 1-Generic) bisoprolol fumarate oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG $0-$8.95 (Tier 1-Brand) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg $0-$3.60 (Tier 1-Generic) labetalol oral tablet 100 mg, 200 mg, 300 mg $0-$3.60 (Tier 1-Generic) metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic)

metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg, 50-25 mg $0-$3.60 (Tier 1-Generic)

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) nadolol oral tablet 20 mg, 40 mg, 80 mg $0-$3.60 (Tier 1-Generic) pindolol oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg $0-$3.60 (Tier 1-Generic)

propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) $0-$3.60 (Tier 1-Generic)

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg $0-$3.60 (Tier 1-Generic) timolol maleate oral tablet 10 mg, 20 mg, 5 mg $0-$3.60 (Tier 1-Generic) Calcium Channel Blocking Agents amlodipine oral tablet 10 mg, 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg $0-$3.60 (Tier 1-Generic)

diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg $0-$3.60 (Tier 1-Generic)

diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg $0-$3.60 (Tier 1-Generic)





diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg $0-$3.60 (Tier 1-Generic)

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg $0-$3.60 (Tier 1-Generic)

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg $0-$3.60 (Tier 1-Generic) dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg $0-$3.60 (Tier 1-Generic)

felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic)

isradipine oral capsule 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) nifedipine oral capsule 10 mg, 20 mg $0-$3.60 (Tier 1-Generic) PA nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg $0-$3.60 (Tier 1-Generic)

nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg $0-$3.60 (Tier 1-Generic) nimodipine oral capsule 30 mg $0-$3.60 (Tier 1-Generic) taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg $0-$3.60 (Tier 1-Generic)

verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg $0-$3.60 (Tier 1-Generic)

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg $0-$3.60 (Tier 1-Generic)

verapamil oral tablet 120 mg, 40 mg, 80 mg $0-$3.60 (Tier 1-Generic) verapamil oral tablet extended release 120 mg, 180 mg, 240 mg $0-$3.60 (Tier 1-Generic) Cardiovascular Agents, Other aliskiren oral tablet 150 mg, 300 mg $0-$3.60 (Tier 1-Generic) amiloride-hydrochlorothiazide oral tablet 5-50 mg $0-$3.60 (Tier 1-Generic) amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg $0-$3.60 (Tier 1-Generic)

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg $0-$3.60 (Tier 1-Generic)

amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg $0-$3.60 (Tier 1-Generic)

amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg $0-$3.60 (Tier 1-Generic)

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg $0-$3.60 (Tier 1-Generic) benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg $0-$3.60 (Tier 1-Generic)

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg $0-$3.60 (Tier 1-Generic)

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg $0-$3.60 (Tier 1-Generic)

CORLANOR ORAL SOLUTION 5 MG/5 ML $0-$8.95 (Tier 1-Brand) PA CORLANOR ORAL TABLET 5 MG, 7.5 MG $0-$8.95 (Tier 1-Brand) PA DEMSER ORAL CAPSULE 250 MG $0-$8.95 (Tier 1-Brand) PA digitek oral tablet 125 mcg (0.125 mg) $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) digitek oral tablet 250 mcg (0.25 mg) $0-$3.60 (Tier 1-Generic) PA digox oral tablet 125 mcg (0.125 mg) $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) digox oral tablet 250 mcg (0.25 mg) $0-$3.60 (Tier 1-Generic) PA digoxin oral solution 50 mcg/ml (0.05 mg/ml) $0-$3.60 (Tier 1-Generic) PA digoxin oral tablet 125 mcg (0.125 mg) $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days) digoxin oral tablet 250 mcg (0.25 mg) $0-$3.60 (Tier 1-Generic) PA





enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg $0-$3.60 (Tier 1-Generic) ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG $0-$8.95 (Tier 1-Brand) fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg $0-$3.60 (Tier 1-Generic) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg $0-$3.60 (Tier 1-Generic)

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg $0-$3.60 (Tier 1-Generic)

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg $0-$3.60 (Tier 1-Generic)

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg $0-$3.60 (Tier 1-Generic) PA

olmesartan-amlodipin-hcthiazid oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg $0-$3.60 (Tier 1-Generic)

olmesartan-hydrochlorothiazide oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg $0-$3.60 (Tier 1-Generic)

pentoxifylline oral tablet extended release 400 mg $0-$3.60 (Tier 1-Generic) propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80-25 mg $0-$3.60 (Tier 1-Generic) quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg $0-$3.60 (Tier 1-Generic)

ranolazine oral tablet extended release 12 hr 1,000 mg, 500 mg $0-$3.60 (Tier 1-Generic) ST spironolacton-hydrochlorothiaz oral tablet 25-25 mg $0-$3.60 (Tier 1-Generic) TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG $0-$8.95 (Tier 1-Brand)

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg $0-$3.60 (Tier 1-Generic) triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg $0-$3.60 (Tier 1-Generic) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg $0-$3.60 (Tier 1-Generic)

Diuretics, Carbonic Anhydrase Inhibitors acetazolamide oral capsule, extended release 500 mg $0-$3.60 (Tier 1-Generic) acetazolamide oral tablet 125 mg, 250 mg $0-$3.60 (Tier 1-Generic) KEVEYIS ORAL TABLET 50 MG $0-$8.95 (Tier 1-Brand) PA methazolamide oral tablet 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) Diuretics, Loop bumetanide oral tablet 0.5 mg, 1 mg, 2 mg $0-$3.60 (Tier 1-Generic) furosemide injection solution 10 mg/ml $0-$3.60 (Tier 1-Generic) furosemide injection syringe 10 mg/ml $0-$3.60 (Tier 1-Generic) furosemide oral solution 10 mg/ml, 40 mg/4 ml, 40 mg/5 ml (8 mg/ml) $0-$3.60 (Tier 1-Generic)

furosemide oral tablet 20 mg, 40 mg, 80 mg $0-$3.60 (Tier 1-Generic) torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg $0-$3.60 (Tier 1-Generic) Diuretics, Potassium-Sparing amiloride oral tablet 5 mg $0-$3.60 (Tier 1-Generic) eplerenone oral tablet 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) spironolactone oral tablet 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) Diuretics, Thiazide chlorothiazide oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) chlorthalidone oral tablet 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) hydrochlorothiazide oral capsule 12.5 mg $0-$3.60 (Tier 1-Generic) hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) indapamide oral tablet 1.25 mg, 2.5 mg $0-$3.60 (Tier 1-Generic)





methyclothiazide oral tablet 5 mg $0-$3.60 (Tier 1-Generic) metolazone oral tablet 10 mg, 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized oral capsule 134 mg, 200 mg, 43 mg, 67 mg $0-$3.60 (Tier 1-Generic)

fenofibrate nanocrystallized oral tablet 145 mg, 160 mg, 48 mg $0-$3.60 (Tier 1-Generic) fenofibrate oral tablet 160 mg, 54 mg $0-$3.60 (Tier 1-Generic) fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg $0-$3.60 (Tier 1-Generic)

fenofibric acid oral tablet 35 mg $0-$3.60 (Tier 1-Generic) gemfibrozil oral tablet 600 mg $0-$3.60 (Tier 1-Generic) Dyslipidemics, Hmg Coa Reductase Inhibitors atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg $0-$3.60 (Tier 1-Generic) lovastatin oral tablet 10 mg, 20 mg, 40 mg $0-$3.60 (Tier 1-Generic) pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg $0-$3.60 (Tier 1-Generic) rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg $0-$3.60 (Tier 1-Generic) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg $0-$3.60 (Tier 1-Generic) Dyslipidemics, Other cholestyramine (with sugar) oral powder 4 gram $0-$3.60 (Tier 1-Generic) cholestyramine (with sugar) oral powder in packet 4 gram $0-$3.60 (Tier 1-Generic) cholestyramine light oral powder 4 gram $0-$3.60 (Tier 1-Generic) cholestyramine light oral powder in packet 4 gram $0-$3.60 (Tier 1-Generic) colesevelam oral powder in packet 3.75 gram $0-$3.60 (Tier 1-Generic) colesevelam oral tablet 625 mg $0-$3.60 (Tier 1-Generic) colestipol oral granules 5 gram $0-$3.60 (Tier 1-Generic) colestipol oral packet 5 gram $0-$3.60 (Tier 1-Generic) colestipol oral tablet 1 gram $0-$3.60 (Tier 1-Generic) ezetimibe oral tablet 10 mg $0-$3.60 (Tier 1-Generic) ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg $0-$3.60 (Tier 1-Generic)

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG $0-$8.95 (Tier 1-Brand) PA

NEXLETOL ORAL TABLET 180 MG $0-$8.95 (Tier 1-Brand) PA niacin oral tablet extended release 1,000 mg $0-$3.60 (Tier 1-Generic) niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg $0-$3.60 (Tier 1-Generic)

omega-3 acid ethyl esters oral capsule 1 gram $0-$3.60 (Tier 1-Generic) PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML $0-$8.95 (Tier 1-Brand) PA

prevalite oral powder 4 gram $0-$3.60 (Tier 1-Generic) prevalite oral powder in packet 4 gram $0-$3.60 (Tier 1-Generic) REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML $0-$8.95 (Tier 1-Brand) PA

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML $0-$8.95 (Tier 1-Brand) PA

REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML $0-$8.95 (Tier 1-Brand) PA triklo oral capsule 1 gram $0-$3.60 (Tier 1-Generic) Vasodilators, Direct-Acting Arterial hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) minoxidil oral tablet 10 mg, 2.5 mg $0-$3.60 (Tier 1-Generic)





Vasodilators, Direct-Acting Arterial/ Venous isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg $0-$3.60 (Tier 1-Generic) isosorbide mononitrate oral tablet 10 mg, 20 mg $0-$3.60 (Tier 1-Generic) isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg $0-$3.60 (Tier 1-Generic)

NITRO-BID TRANSDERMAL OINTMENT 2 % $0-$8.95 (Tier 1-Brand) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR $0-$8.95 (Tier 1-Brand)

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg $0-$3.60 (Tier 1-Generic) nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr $0-$3.60 (Tier 1-Generic)

nitroglycerin translingual aerosol,spray 400 mcg/spray $0-$3.60 (Tier 1-Generic) nitroglycerin translingual spray,non-aerosol 400 mcg/spray $0-$3.60 (Tier 1-Generic) Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines

dextroamphetamine oral capsule, extended release 10 mg $0-$3.60 (Tier 1-Generic) QL (150 EA per 30 days) dextroamphetamine oral capsule, extended release 15 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) dextroamphetamine oral capsule, extended release 5 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) dextroamphetamine oral tablet 10 mg $0-$3.60 (Tier 1-Generic) QL (180 EA per 30 days) dextroamphetamine oral tablet 5 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days)

dextroamphetamine-amphetamine oral tablet 10 mg, 20 mg, 30 mg, 5 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days)

dextroamphetamine-amphetamine oral tablet 12.5 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) dextroamphetamine-amphetamine oral tablet 15 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 30 days) Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines

atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg $0-$3.60 (Tier 1-Generic)

clonidine hcl oral tablet extended release 12 hr 0.1 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg $0-$3.60 (Tier 1-Generic) PA

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) PA guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg $0-$3.60 (Tier 1-Generic)

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg $0-$3.60 (Tier 1-Generic) PA

methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 30 mg, 40 mg, 60 mg $0-$3.60 (Tier 1-Generic) PA

methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml $0-$3.60 (Tier 1-Generic) PA methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg $0-$3.60 (Tier 1-Generic) PA methylphenidate hcl oral tablet extended release 10 mg $0-$3.60 (Tier 1-Generic) PA methylphenidate hcl oral tablet extended release 20 mg $0-$3.60 (Tier 1-Generic) PA; QL (90 EA per 30 days) methylphenidate hcl oral tablet extended release 24hr 18 mg $0-$3.60 (Tier 1-Generic) PA; QL (120 EA per 30 days) methylphenidate hcl oral tablet extended release 24hr 27 mg $0-$3.60 (Tier 1-Generic) PA; QL (90 EA per 30 days) methylphenidate hcl oral tablet extended release 24hr 36 mg $0-$3.60 (Tier 1-Generic) PA; QL (60 EA per 30 days) methylphenidate hcl oral tablet extended release 24hr 54 mg $0-$3.60 (Tier 1-Generic) PA; QL (30 EA per 30 days) methylphenidate hcl oral tablet,chewable 10 mg, 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) PA





Central Nervous System, Other AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG $0-$8.95 (Tier 1-Brand) PA FIRDAPSE ORAL TABLET 10 MG $0-$8.95 (Tier 1-Brand) PA INGREZZA INITIATION PACK ORAL CAPSULE,DOSE PACK 40 MG (7)- 80 MG (21) $0-$8.95 (Tier 1-Brand) PA

INGREZZA ORAL CAPSULE 40 MG, 80 MG $0-$8.95 (Tier 1-Brand) PA NUEDEXTA ORAL CAPSULE 20-10 MG $0-$8.95 (Tier 1-Brand) PA riluzole oral tablet 50 mg $0-$3.60 (Tier 1-Generic) tetrabenazine oral tablet 12.5 mg, 25 mg $0-$3.60 (Tier 1-Generic) PA Fibromyalgia Agents duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg $0-$3.60 (Tier 1-Generic)

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG $0-$8.95 (Tier 1-Brand) SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) $0-$8.95 (Tier 1-Brand)

Multiple Sclerosis Agents AUBAGIO ORAL TABLET 14 MG, 7 MG $0-$8.95 (Tier 1-Brand) PA BETASERON SUBCUTANEOUS KIT 0.3 MG $0-$8.95 (Tier 1-Brand) PA BETASERON SUBCUTANEOUS RECON SOLN 0.3 MG $0-$8.95 (Tier 1-Brand) PA dalfampridine oral tablet extended release 12 hr 10 mg $0-$3.60 (Tier 1-Generic) PA EXTAVIA SUBCUTANEOUS RECON SOLN 0.3 MG $0-$8.95 (Tier 1-Brand) PA GILENYA ORAL CAPSULE 0.5 MG $0-$8.95 (Tier 1-Brand) PA glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml $0-$3.60 (Tier 1-Generic) PA glatopa subcutaneous syringe 20 mg/ml, 40 mg/ml $0-$3.60 (Tier 1-Generic) PA MAYZENT ORAL TABLET 0.25 MG, 2 MG $0-$8.95 (Tier 1-Brand) PA REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) PA

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)


REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) $0-$8.95 (Tier 1-Brand) PA

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG $0-$8.95 (Tier 1-Brand) PA

Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg $0-$3.60 (Tier 1-Generic) chlorhexidine gluconate mucous membrane mouthwash 0.12 % $0-$3.60 (Tier 1-Generic) PERIOGARD MUCOUS MEMBRANE MOUTHWASH 0.12 % $0-$8.95 (Tier 1-Brand) pilocarpine hcl oral tablet 5 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) triamcinolone acetonide dental paste 0.1 % $0-$3.60 (Tier 1-Generic) Dermatological Agents Dermatological Agents acitretin oral capsule 10 mg, 17.5 mg, 25 mg $0-$3.60 (Tier 1-Generic) PA adapalene topical gel 0.1 % $0-$3.60 (Tier 1-Generic) adapalene-benzoyl peroxide topical gel with pump 0.1-2.5 % $0-$3.60 (Tier 1-Generic) ammonium lactate topical cream 12 % $0-$3.60 (Tier 1-Generic) ammonium lactate topical lotion 12 % $0-$3.60 (Tier 1-Generic) amnesteem oral capsule 10 mg, 20 mg, 40 mg $0-$3.60 (Tier 1-Generic) calcipotriene scalp solution 0.005 % $0-$3.60 (Tier 1-Generic)





calcipotriene topical cream 0.005 % $0-$3.60 (Tier 1-Generic) calcipotriene topical ointment 0.005 % $0-$3.60 (Tier 1-Generic) claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg $0-$3.60 (Tier 1-Generic) clindamycin-benzoyl peroxide topical gel 1-5 %, 1.2 %(1 % base) -5 % $0-$3.60 (Tier 1-Generic)

clindamycin-benzoyl peroxide topical gel with pump 1-5 %, 1.2-2.5 % $0-$3.60 (Tier 1-Generic)

clotrimazole-betamethasone topical cream 1-0.05 % $0-$3.60 (Tier 1-Generic) clotrimazole-betamethasone topical lotion 1-0.05 % $0-$3.60 (Tier 1-Generic) COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML $0-$8.95 (Tier 1-Brand) PA

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML $0-$8.95 (Tier 1-Brand) PA

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML $0-$8.95 (Tier 1-Brand) PA

COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML $0-$8.95 (Tier 1-Brand) PA doxepin topical cream 5 % $0-$3.60 (Tier 1-Generic) DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG/1.14 ML, 300 MG/2 ML $0-$8.95 (Tier 1-Brand) PA

erythromycin-benzoyl peroxide topical gel 3-5 % $0-$3.60 (Tier 1-Generic) EUCRISA TOPICAL OINTMENT 2 % $0-$8.95 (Tier 1-Brand) PA hydrocortisone topical ointment 1 % $0-$3.60 (Tier 1-Generic) hydrocortisone-min oil-wht pet topical ointment 1 % $0-$3.60 (Tier 1-Generic) imiquimod topical cream in packet 5 % $0-$3.60 (Tier 1-Generic) isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg $0-$3.60 (Tier 1-Generic) methoxsalen oral capsule,liqd-filled,rapid rel 10 mg $0-$3.60 (Tier 1-Generic) PA myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg $0-$3.60 (Tier 1-Generic) nystatin-triamcinolone topical cream 100,000-0.1 unit/g-% $0-$3.60 (Tier 1-Generic) nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-% $0-$3.60 (Tier 1-Generic) pimecrolimus topical cream 1 % $0-$3.60 (Tier 1-Generic) ST podofilox topical solution 0.5 % $0-$3.60 (Tier 1-Generic) prednicarbate topical cream 0.1 % $0-$3.60 (Tier 1-Generic) prednicarbate topical ointment 0.1 % $0-$3.60 (Tier 1-Generic) REGRANEX TOPICAL GEL 0.01 % $0-$8.95 (Tier 1-Brand) PA; QL (15 GM per 30 days) SANTYL TOPICAL OINTMENT 250 UNIT/GRAM $0-$8.95 (Tier 1-Brand) selenium sulfide topical lotion 2.5 % $0-$3.60 (Tier 1-Generic) STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML $0-$8.95 (Tier 1-Brand) PA STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML $0-$8.95 (Tier 1-Brand) PA

tacrolimus topical ointment 0.03 %, 0.1 % $0-$3.60 (Tier 1-Generic) ST tazarotene topical cream 0.1 % $0-$3.60 (Tier 1-Generic) TAZORAC TOPICAL CREAM 0.05 % $0-$8.95 (Tier 1-Brand) TAZORAC TOPICAL GEL 0.05 %, 0.1 % $0-$8.95 (Tier 1-Brand) TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML $0-$8.95 (Tier 1-Brand) PA TREMFYA SUBCUTANEOUS SYRINGE 100 MG/ML $0-$8.95 (Tier 1-Brand) PA tretinoin (emollient) topical cream 0.05 % $0-$3.60 (Tier 1-Generic) tretinoin topical cream 0.025 %, 0.05 %, 0.1 % $0-$3.60 (Tier 1-Generic) tretinoin topical gel 0.01 %, 0.025 % $0-$3.60 (Tier 1-Generic) zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg $0-$3.60 (Tier 1-Generic) Electrolytes/Minerals/ Metals/ Vitamins





Electrolyte/Mineral Replacement AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % $0-$8.95 (Tier 1-Brand) B/D

AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % $0-$8.95 (Tier 1-Brand) B/D

AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % $0-$8.95 (Tier 1-Brand) B/D

CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG $0-$8.95 (Tier 1-Brand) PA CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % $0-$8.95 (Tier 1-Brand) B/D

CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % $0-$8.95 (Tier 1-Brand) B/D

d10 %-0.45 % sodium chloride intravenous parenteral solution $0-$3.60 (Tier 1-Generic) d2.5 %-0.45 % sodium chloride intravenous parenteral solution $0-$3.60 (Tier 1-Generic) d5 % and 0.9 % sodium chloride intravenous parenteral solution $0-$3.60 (Tier 1-Generic) d5 %-0.45 % sodium chloride intravenous parenteral solution $0-$3.60 (Tier 1-Generic) dextrose 10 % and 0.2 % nacl intravenous parenteral solution $0-$3.60 (Tier 1-Generic) dextrose 10 % in water (d10w) intravenous parenteral solution 10 % $0-$3.60 (Tier 1-Generic)

dextrose 5 % in water (d5w) intravenous parenteral solution $0-$3.60 (Tier 1-Generic) dextrose 5 % in water (d5w) intravenous piggyback 5 % $0-$3.60 (Tier 1-Generic) dextrose 5%-0.2 % sod chloride intravenous parenteral solution $0-$3.60 (Tier 1-Generic) dextrose 5%-0.3 % sod.chloride intravenous parenteral solution $0-$3.60 (Tier 1-Generic) dextrose with sodium chloride intravenous parenteral solution 5-0.2 % $0-$3.60 (Tier 1-Generic)

ENDARI ORAL POWDER IN PACKET 5 GRAM $0-$8.95 (Tier 1-Brand) PA fluoride (sodium) oral tablet 1 mg (2.2 mg sod. fluoride) $0-$3.60 (Tier 1-Generic) INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % $0-$8.95 (Tier 1-Brand) B/D ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION $0-$8.95 (Tier 1-Brand) ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % $0-$8.95 (Tier 1-Brand)

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION $0-$8.95 (Tier 1-Brand) KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ $0-$8.95 (Tier 1-Brand) KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ $0-$8.95 (Tier 1-Brand) klor-con m10 oral tablet,er particles/crystals 10 meq $0-$3.60 (Tier 1-Generic) KLOR-CON M15 ORAL TABLET,ER PARTICLES/CRYSTALS 15 MEQ $0-$8.95 (Tier 1-Brand)

klor-con m20 oral tablet,er particles/crystals 20 meq $0-$3.60 (Tier 1-Generic) KLOR-CON SPRINKLE ORAL CAPSULE, EXTENDED RELEASE 10 MEQ $0-$8.95 (Tier 1-Brand)

klor-con sprinkle oral capsule, extended release 8 meq $0-$3.60 (Tier 1-Generic) k-sol oral liquid 20 meq/15 ml $0-$3.60 (Tier 1-Generic) levocarnitine (with sugar) oral solution 100 mg/ml $0-$3.60 (Tier 1-Generic) levocarnitine oral solution 1 gram/10 ml, 100 mg/ml $0-$3.60 (Tier 1-Generic) levocarnitine oral tablet 330 mg $0-$3.60 (Tier 1-Generic) magnesium sulfate injection solution 4 meq/ml (50 %) $0-$3.60 (Tier 1-Generic) NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION $0-$8.95 (Tier 1-Brand) NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION $0-$8.95 (Tier 1-Brand)

plenamine intravenous parenteral solution 15 % $0-$3.60 (Tier 1-Generic) B/D





potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l $0-$3.60 (Tier 1-Generic)

potassium chloride in water intravenous piggyback 40 meq/100 ml $0-$3.60 (Tier 1-Generic)

potassium chloride oral capsule, extended release 10 meq, 8 meq $0-$3.60 (Tier 1-Generic)

potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml $0-$3.60 (Tier 1-Generic) potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq $0-$3.60 (Tier 1-Generic)

potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq $0-$3.60 (Tier 1-Generic)

potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) $0-$3.60 (Tier 1-Generic)

sodium chloride 0.45 % intravenous parenteral solution 0.45 % $0-$3.60 (Tier 1-Generic) sodium chloride 0.9 % injection solution $0-$3.60 (Tier 1-Generic) sodium chloride 0.9 % intravenous parenteral solution $0-$3.60 (Tier 1-Generic) sodium chloride 0.9 % intravenous piggyback $0-$3.60 (Tier 1-Generic) sodium chloride 3 % intravenous parenteral solution 3 % $0-$3.60 (Tier 1-Generic) sodium chloride irrigation solution 0.9 % $0-$3.60 (Tier 1-Generic) Electrolyte/Mineral/Metal Modifiers deferasirox oral tablet 180 mg, 360 mg, 90 mg $0-$3.60 (Tier 1-Generic) PA deferasirox oral tablet, dispersible 125 mg, 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) PA FERRIPROX (2 TIMES A DAY) ORAL TABLET 1,000 MG $0-$8.95 (Tier 1-Brand) PA FERRIPROX ORAL TABLET 1,000 MG, 500 MG $0-$8.95 (Tier 1-Brand) PA JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG, 360 MG, 90 MG $0-$8.95 (Tier 1-Brand) PA

JYNARQUE ORAL TABLET 15 MG, 30 MG $0-$8.95 (Tier 1-Brand) PA JYNARQUE ORAL TABLETS, SEQUENTIAL 15 MG (AM)/ 15 MG (PM), 30 MG (AM)/ 15 MG (PM), 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM)


kionex (with sorbitol) oral suspension 15-19.3 gram/60 ml $0-$3.60 (Tier 1-Generic) SAMSCA ORAL TABLET 15 MG, 30 MG $0-$8.95 (Tier 1-Brand) sodium polystyrene (sorb free) oral suspension 15 gram/60 ml $0-$3.60 (Tier 1-Generic) sodium polystyrene sulfonate oral powder $0-$3.60 (Tier 1-Generic) sodium polystyrene sulfonate oral suspension 15 gram/60 ml $0-$3.60 (Tier 1-Generic) sodium polystyrene sulfonate rectal enema 30 gram/120 ml, 50 gram/200 ml $0-$3.60 (Tier 1-Generic)

SPS (WITH SORBITOL) ORAL SUSPENSION 15-20 GRAM/60 ML $0-$8.95 (Tier 1-Brand)

SPS (WITH SORBITOL) RECTAL ENEMA 30-40 GRAM/120 ML $0-$8.95 (Tier 1-Brand) tolvaptan oral tablet 30 mg $0-$3.60 (Tier 1-Generic) trientine oral capsule 250 mg $0-$3.60 (Tier 1-Generic) PA Phosphate Binders calcium acetate(phosphat bind) oral capsule 667 mg $0-$3.60 (Tier 1-Generic) FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 MG $0-$8.95 (Tier 1-Brand) lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg $0-$3.60 (Tier 1-Generic) sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram $0-$3.60 (Tier 1-Generic) sevelamer carbonate oral tablet 800 mg $0-$3.60 (Tier 1-Generic) VELPHORO ORAL TABLET,CHEWABLE 500 MG $0-$8.95 (Tier 1-Brand) Vitamins





calcitriol oral capsule 0.25 mcg, 0.5 mcg $0-$3.60 (Tier 1-Generic) calcitriol oral solution 1 mcg/ml $0-$3.60 (Tier 1-Generic) calcitriol topical ointment 3 mcg/gram $0-$3.60 (Tier 1-Generic) paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg $0-$3.60 (Tier 1-Generic) PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET 27 MG IRON- 1 MG $0-$3.60 (Tier 1-Generic)

Gastrointestinal Agents Antispasmodics, Gastrointestinal dicyclomine oral capsule 10 mg $0-$3.60 (Tier 1-Generic) dicyclomine oral solution 10 mg/5 ml $0-$3.60 (Tier 1-Generic) dicyclomine oral tablet 20 mg $0-$3.60 (Tier 1-Generic) diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml $0-$3.60 (Tier 1-Generic) diphenoxylate-atropine oral tablet 2.5-0.025 mg $0-$3.60 (Tier 1-Generic) glycopyrrolate oral tablet 1 mg, 2 mg $0-$3.60 (Tier 1-Generic) Gastrointestinal Agents, Other enulose oral solution 10 gram/15 ml $0-$3.60 (Tier 1-Generic) GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG $0-$8.95 (Tier 1-Brand) PA GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG $0-$8.95 (Tier 1-Brand) PA gavilyte-c oral recon soln 240-22.72-6.72 -5.84 gram $0-$3.60 (Tier 1-Generic) generlac oral solution 10 gram/15 ml $0-$3.60 (Tier 1-Generic) loperamide oral capsule 2 mg $0-$3.60 (Tier 1-Generic) OCALIVA ORAL TABLET 10 MG, 5 MG $0-$8.95 (Tier 1-Brand) PA RECTIV RECTAL OINTMENT 0.4 % (W/W) $0-$8.95 (Tier 1-Brand) RELISTOR ORAL TABLET 150 MG $0-$8.95 (Tier 1-Brand) PA RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML $0-$8.95 (Tier 1-Brand) PA RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML $0-$8.95 (Tier 1-Brand) PA

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG $0-$8.95 (Tier 1-Brand) PA

ursodiol oral capsule 300 mg $0-$3.60 (Tier 1-Generic) ursodiol oral tablet 250 mg, 500 mg $0-$3.60 (Tier 1-Generic) XERMELO ORAL TABLET 250 MG $0-$8.95 (Tier 1-Brand) PA Histamine2 (H2) Receptor Antagonists cimetidine hcl oral solution 300 mg/5 ml $0-$3.60 (Tier 1-Generic) cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg $0-$3.60 (Tier 1-Generic) famotidine oral tablet 20 mg, 40 mg $0-$3.60 (Tier 1-Generic) Irritable Bowel Syndrome Agents alosetron oral tablet 0.5 mg, 1 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) AMITIZA ORAL CAPSULE 24 MCG, 8 MCG $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG $0-$8.95 (Tier 1-Brand) QL (30 EA per 30 days) XIFAXAN ORAL TABLET 200 MG, 550 MG $0-$8.95 (Tier 1-Brand) PA Laxatives constulose oral solution 10 gram/15 ml $0-$3.60 (Tier 1-Generic) gavilyte-g oral recon soln 236-22.74-6.74 -5.86 gram $0-$3.60 (Tier 1-Generic) gavilyte-n oral recon soln 420 gram $0-$3.60 (Tier 1-Generic) KRISTALOSE ORAL PACKET 20 GRAM $0-$8.95 (Tier 1-Brand) ST lactulose oral packet 10 gram $0-$3.60 (Tier 1-Generic) ST lactulose oral solution 10 gram/15 ml, 10 gram/15 ml (15 ml), 20 gram/30 ml $0-$3.60 (Tier 1-Generic)

peg 3350-electrolytes oral recon soln 240-22.72-6.72 -5.84 gram $0-$3.60 (Tier 1-Generic)





peg-electrolyte soln oral recon soln 420 gram $0-$3.60 (Tier 1-Generic) trilyte with flavor packets oral recon soln 420 gram $0-$3.60 (Tier 1-Generic) Protectants misoprostol oral tablet 100 mcg, 200 mcg $0-$3.60 (Tier 1-Generic) sucralfate oral tablet 1 gram $0-$3.60 (Tier 1-Generic) Proton Pump Inhibitors lansoprazole oral capsule,delayed release(dr/ec) 15 mg, 30 mg $0-$3.60 (Tier 1-Generic) omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg $0-$3.60 (Tier 1-Generic)

pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg $0-$3.60 (Tier 1-Generic) Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment

Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment

ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, 500 MG $0-$8.95 (Tier 1-Brand) PA

CERDELGA ORAL CAPSULE 84 MG $0-$8.95 (Tier 1-Brand) PA CHOLBAM ORAL CAPSULE 250 MG, 50 MG $0-$8.95 (Tier 1-Brand) PA CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

$0-$8.95 (Tier 1-Brand)

CYSTADANE ORAL POWDER 1 GRAM/1.7 ML $0-$8.95 (Tier 1-Brand) CYSTAGON ORAL CAPSULE 150 MG, 50 MG $0-$8.95 (Tier 1-Brand) PA GALAFOLD ORAL CAPSULE 123 MG $0-$8.95 (Tier 1-Brand) PA GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %) $0-$8.95 (Tier 1-Brand) PA KUVAN ORAL POWDER IN PACKET 100 MG, 500 MG $0-$8.95 (Tier 1-Brand) PA KUVAN ORAL TABLET,SOLUBLE 100 MG $0-$8.95 (Tier 1-Brand) PA nitisinone oral capsule 10 mg, 2 mg, 5 mg $0-$3.60 (Tier 1-Generic) PA NITYR ORAL TABLET 10 MG, 2 MG, 5 MG $0-$8.95 (Tier 1-Brand) PA ORFADIN ORAL CAPSULE 20 MG $0-$8.95 (Tier 1-Brand) PA ORFADIN ORAL SUSPENSION 4 MG/ML $0-$8.95 (Tier 1-Brand) PA PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG $0-$8.95 (Tier 1-Brand) PA PROLASTIN-C INTRAVENOUS SOLUTION 1,000 MG (+/-)/20 ML $0-$8.95 (Tier 1-Brand) PA

RAVICTI ORAL LIQUID 1.1 GRAM/ML $0-$8.95 (Tier 1-Brand) PA sodium phenylbutyrate oral powder 0.94 gram/gram $0-$3.60 (Tier 1-Generic) PA sodium phenylbutyrate oral tablet 500 mg $0-$3.60 (Tier 1-Generic) PA SUCRAID ORAL SOLUTION 8,500 UNIT/ML $0-$8.95 (Tier 1-Brand) PA XURIDEN ORAL GRANULES IN PACKET 2 GRAM $0-$8.95 (Tier 1-Brand) PA ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG $0-$8.95 (Tier 1-Brand) PA ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

$0-$8.95 (Tier 1-Brand)

Genitourinary Agents Antispasmodics, Urinary darifenacin oral tablet extended release 24 hr 15 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) ST flavoxate oral tablet 100 mg $0-$3.60 (Tier 1-Generic)





MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG $0-$8.95 (Tier 1-Brand) ST; QL (30 EA per 30 days)

oxybutynin chloride oral syrup 5 mg/5 ml $0-$3.60 (Tier 1-Generic) oxybutynin chloride oral tablet 5 mg $0-$3.60 (Tier 1-Generic) oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg $0-$3.60 (Tier 1-Generic)

tolterodine oral capsule,extended release 24hr 2 mg, 4 mg $0-$3.60 (Tier 1-Generic) tolterodine oral tablet 1 mg, 2 mg $0-$3.60 (Tier 1-Generic) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG $0-$8.95 (Tier 1-Brand)

trospium oral capsule,extended release 24hr 60 mg $0-$3.60 (Tier 1-Generic) ST trospium oral tablet 20 mg $0-$3.60 (Tier 1-Generic) ST Benign Prostatic Hypertrophy Agents alfuzosin oral tablet extended release 24 hr 10 mg $0-$3.60 (Tier 1-Generic) dutasteride oral capsule 0.5 mg $0-$3.60 (Tier 1-Generic) finasteride oral tablet 5 mg $0-$3.60 (Tier 1-Generic) tamsulosin oral capsule 0.4 mg $0-$3.60 (Tier 1-Generic) Genitourinary Agents, Other bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg $0-$3.60 (Tier 1-Generic) ELMIRON ORAL CAPSULE 100 MG $0-$8.95 (Tier 1-Brand) THIOLA EC ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG, 300 MG $0-$8.95 (Tier 1-Brand) PA

THIOLA ORAL TABLET 100 MG $0-$8.95 (Tier 1-Brand) PA Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

ACTHAR INJECTION GEL 80 UNIT/ML $0-$8.95 (Tier 1-Brand) PA cortisone oral tablet 25 mg $0-$3.60 (Tier 1-Generic) dexamethasone sodium phosphate injection solution 4 mg/ml $0-$3.60 (Tier 1-Generic) B/D fludrocortisone oral tablet 0.1 mg $0-$3.60 (Tier 1-Generic) hydrocortisone oral tablet 10 mg, 20 mg, 5 mg $0-$3.60 (Tier 1-Generic) hydrocortisone topical cream with perineal applicator 2.5 % $0-$3.60 (Tier 1-Generic) methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml $0-$3.60 (Tier 1-Generic)

prednisone intensol oral concentrate 5 mg/ml $0-$3.60 (Tier 1-Generic) procto-med hc topical cream with perineal applicator 2.5 % $0-$3.60 (Tier 1-Generic) procto-pak topical cream with perineal applicator 1 % $0-$3.60 (Tier 1-Generic) proctosol hc topical cream with perineal applicator 2.5 % $0-$3.60 (Tier 1-Generic) proctozone-hc topical cream with perineal applicator 2.5 % $0-$3.60 (Tier 1-Generic) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)

Anabolic Steroids ANADROL-50 ORAL TABLET 50 MG $0-$8.95 (Tier 1-Brand) PA oxandrolone oral tablet 10 mg, 2.5 mg $0-$3.60 (Tier 1-Generic) Androgens danazol oral capsule 100 mg, 200 mg, 50 mg $0-$3.60 (Tier 1-Generic) methyltestosterone oral capsule 10 mg $0-$3.60 (Tier 1-Generic) PA testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml $0-$3.60 (Tier 1-Generic) testosterone enanthate intramuscular oil 200 mg/ml $0-$3.60 (Tier 1-Generic)





testosterone transdermal gel 50 mg/5 gram (1 %) $0-$3.60 (Tier 1-Generic) PA testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) $0-$3.60 (Tier 1-Generic) PA

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram), 1.62 % (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)

$0-$3.60 (Tier 1-Generic) PA

testosterone transdermal solution in metered pump w/app 30 mg/actuation (1.5 ml) $0-$3.60 (Tier 1-Generic) PA

Estrogens estradiol oral tablet 0.5 mg, 1 mg, 2 mg $0-$3.60 (Tier 1-Generic) estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr $0-$3.60 (Tier 1-Generic)

estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr


estradiol vaginal cream 0.01 % (0.1 mg/gram) $0-$3.60 (Tier 1-Generic) estradiol vaginal tablet 10 mcg $0-$3.60 (Tier 1-Generic) estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml $0-$3.60 (Tier 1-Generic) ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR) $0-$8.95 (Tier 1-Brand) estropipate oral tablet 0.75 mg, 1.5 mg $0-$3.60 (Tier 1-Generic) PA MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG $0-$8.95 (Tier 1-Brand) PA PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG $0-$8.95 (Tier 1-Brand)

PREMARIN VAGINAL CREAM 0.625 MG/GRAM $0-$8.95 (Tier 1-Brand) yuvafem vaginal tablet 10 mcg $0-$3.60 (Tier 1-Generic) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)

afirmelle oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) altavera (28) oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) alyacen 1/35 (28) oral tablet 1-35 mg-mcg $0-$3.60 (Tier 1-Generic) amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg $0-$3.60 (Tier 1-Generic) apri oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg $0-$3.60 (Tier 1-Generic) aubra eq oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) aubra oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) aurovela 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0-$3.60 (Tier 1-Generic) aurovela fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) aviane oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) ayuna oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) balziva (28) oral tablet 0.4-35 mg-mcg $0-$3.60 (Tier 1-Generic) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) briellyn oral tablet 0.4-35 mg-mcg $0-$3.60 (Tier 1-Generic) caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg $0-$3.60 (Tier 1-Generic) chateal eq (28) oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR $0-$8.95 (Tier 1-Brand)

cryselle (28) oral tablet 0.3-30 mg-mcg $0-$3.60 (Tier 1-Generic) cyclafem 1/35 (28) oral tablet 1-35 mg-mcg $0-$3.60 (Tier 1-Generic)





cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg $0-$3.60 (Tier 1-Generic) cyred eq oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) cyred oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) delyla (28) oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 $0-$3.60 (Tier 1-Generic)

desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) drospirenone-ethinyl estradiol oral tablet 3-0.03 mg $0-$3.60 (Tier 1-Generic) eluryng vaginal ring 0.12-0.015 mg/24 hr $0-$3.60 (Tier 1-Generic) emoquette oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10) $0-$3.60 (Tier 1-Generic) enskyce oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) estarylla oral tablet 0.25-35 mg-mcg $0-$3.60 (Tier 1-Generic) estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg $0-$3.60 (Tier 1-Generic) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg $0-$3.60 (Tier 1-Generic)

etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24 hr $0-$3.60 (Tier 1-Generic) falmina (28) oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) femynor oral tablet 0.25-35 mg-mcg $0-$3.60 (Tier 1-Generic) fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg $0-$3.60 (Tier 1-Generic) hailey 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) $0-$3.60 (Tier 1-Generic) hailey fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) hailey fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) hailey oral tablet 1.5-30 mg-mcg $0-$3.60 (Tier 1-Generic) introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) $0-$3.60 (Tier 1-Generic) isibloom oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) jinteli oral tablet 1-5 mg-mcg $0-$3.60 (Tier 1-Generic) juleber oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0-$3.60 (Tier 1-Generic) junel 1/20 (21) oral tablet 1-20 mg-mcg $0-$3.60 (Tier 1-Generic) junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) kalliga oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 $0-$3.60 (Tier 1-Generic) kelnor 1/35 (28) oral tablet 1-35 mg-mcg $0-$3.60 (Tier 1-Generic) kelnor 1-50 oral tablet 1-50 mg-mcg $0-$3.60 (Tier 1-Generic) kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 $0-$3.60 (Tier 1-Generic) kurvelo (28) oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0-$3.60 (Tier 1-Generic) larin 1/20 (21) oral tablet 1-20 mg-mcg $0-$3.60 (Tier 1-Generic) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) larissia oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) leena 28 oral tablet 0.5/1/0.5-35 mg-mcg $0-$3.60 (Tier 1-Generic) lessina oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) $0-$3.60 (Tier 1-Generic) levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg $0-$3.60 (Tier 1-Generic)

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) $0-$3.60 (Tier 1-Generic)





levonorg-eth estrad triphasic oral tablet 50-30 (6)/75-40 (5)/125-30(10) $0-$3.60 (Tier 1-Generic)

levora-28 oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) lillow (28) oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG $0-$8.95 (Tier 1-Brand) lopreeza oral tablet 1-0.5 mg $0-$3.60 (Tier 1-Generic) low-ogestrel (28) oral tablet 0.3-30 mg-mcg $0-$3.60 (Tier 1-Generic) lutera (28) oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) marlissa (28) oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0-$3.60 (Tier 1-Generic) microgestin 1/20 (21) oral tablet 1-20 mg-mcg $0-$3.60 (Tier 1-Generic) microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic)

microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) mili oral tablet 0.25-35 mg-mcg $0-$3.60 (Tier 1-Generic) mimvey oral tablet 1-0.5 mg $0-$3.60 (Tier 1-Generic) mononessa (28) oral tablet 0.25-35 mg-mcg $0-$3.60 (Tier 1-Generic) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg $0-$3.60 (Tier 1-Generic) necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg $0-$3.60 (Tier 1-Generic) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1-5 mg-mcg, 1.5-30 mg-mcg $0-$3.60 (Tier 1-Generic)

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4), 1.5 mg-30 mcg (21)/75 mg (7)


norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg $0-$3.60 (Tier 1-Generic)

norlyda oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg $0-$3.60 (Tier 1-Generic) nortrel 1/35 (21) oral tablet 1-35 mg-mcg (21) $0-$3.60 (Tier 1-Generic) nortrel 1/35 (28) oral tablet 1-35 mg-mcg $0-$3.60 (Tier 1-Generic) nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg $0-$3.60 (Tier 1-Generic) ocella oral tablet 3-0.03 mg $0-$3.60 (Tier 1-Generic) orsythia oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 $0-$3.60 (Tier 1-Generic) pirmella oral tablet 1-35 mg-mcg $0-$3.60 (Tier 1-Generic) portia 28 oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14) $0-$8.95 (Tier 1-Brand)

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG $0-$8.95 (Tier 1-Brand)

previfem oral tablet 0.25-35 mg-mcg $0-$3.60 (Tier 1-Generic) quasense oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) $0-$3.60 (Tier 1-Generic) reclipsen (28) oral tablet 0.15-0.03 mg $0-$3.60 (Tier 1-Generic) setlakin oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) $0-$3.60 (Tier 1-Generic) simliya (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 $0-$3.60 (Tier 1-Generic) sprintec (28) oral tablet 0.25-35 mg-mcg $0-$3.60 (Tier 1-Generic) sronyx oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) tarina fe 1-20 eq (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) $0-$3.60 (Tier 1-Generic) tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg (28) $0-$3.60 (Tier 1-Generic)





tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) $0-$3.60 (Tier 1-Generic) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) $0-$3.60 (Tier 1-Generic) tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg (28) $0-$3.60 (Tier 1-Generic) trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) $0-$3.60 (Tier 1-Generic) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) $0-$3.60 (Tier 1-Generic) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) $0-$3.60 (Tier 1-Generic) trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) $0-$3.60 (Tier 1-Generic) tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg (28) $0-$3.60 (Tier 1-Generic) velivet triphasic regimen (28) oral tablet 0.1/.125/.15-25 mg-mcg $0-$3.60 (Tier 1-Generic) vienva oral tablet 0.1-20 mg-mcg $0-$3.60 (Tier 1-Generic) volnea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 $0-$3.60 (Tier 1-Generic) vyfemla (28) oral tablet 0.4-35 mg-mcg $0-$3.60 (Tier 1-Generic) vylibra oral tablet 0.25-35 mg-mcg $0-$3.60 (Tier 1-Generic) xulane transdermal patch weekly 150-35 mcg/24 hr $0-$3.60 (Tier 1-Generic) zarah oral tablet 3-0.03 mg $0-$3.60 (Tier 1-Generic) zovia 1/35e (28) oral tablet 1-35 mg-mcg $0-$3.60 (Tier 1-Generic) Progestins camila oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) deblitane oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG/0.65 ML $0-$8.95 (Tier 1-Brand)

errin oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) incassia oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) jolivette oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) lyza oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) medroxyprogesterone intramuscular suspension 150 mg/ml $0-$3.60 (Tier 1-Generic) medroxyprogesterone intramuscular syringe 150 mg/ml $0-$3.60 (Tier 1-Generic) medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 625 mg/5 ml (125 mg/ml), 800 mg/20 ml (20 ml) $0-$3.60 (Tier 1-Generic) PA

megestrol oral tablet 20 mg, 40 mg $0-$3.60 (Tier 1-Generic) PA nora-be oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) norethindrone (contraceptive) oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) norethindrone acetate oral tablet 5 mg $0-$3.60 (Tier 1-Generic) norlyroc oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) progesterone micronized oral capsule 100 mg, 200 mg $0-$3.60 (Tier 1-Generic) sharobel oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) tulana oral tablet 0.35 mg $0-$3.60 (Tier 1-Generic) Selective Estrogen Receptor Modifying Agents DUAVEE ORAL TABLET 0.45-20 MG $0-$8.95 (Tier 1-Brand) raloxifene oral tablet 60 mg $0-$3.60 (Tier 1-Generic) Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)

desmopressin nasal spray with pump 10 mcg/spray (0.1 ml) $0-$3.60 (Tier 1-Generic) desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) $0-$3.60 (Tier 1-Generic) desmopressin oral tablet 0.1 mg, 0.2 mg $0-$3.60 (Tier 1-Generic) EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG, 2 MG $0-$8.95 (Tier 1-Brand) PA EGRIFTA SV SUBCUTANEOUS RECON SOLN 2 MG $0-$8.95 (Tier 1-Brand) PA





GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML


GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) $0-$8.95 (Tier 1-Brand) PA

HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT) $0-$8.95 (Tier 1-Brand) PA

HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG $0-$8.95 (Tier 1-Brand) PA INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML $0-$8.95 (Tier 1-Brand) PA NOCTIVA NASAL SPRAY,NON-AEROSOL 0.83 MCG/SPRAY (0.1 ML), 1.66 MCG/SPRAY (0.1 ML) $0-$8.95 (Tier 1-Brand) PA

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)


NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML)


OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) $0-$8.95 (Tier 1-Brand) PA

OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG $0-$8.95 (Tier 1-Brand) PA Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)

LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

$0-$8.95 (Tier 1-Brand)

levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg


LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

$0-$8.95 (Tier 1-Brand)

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg $0-$3.60 (Tier 1-Generic) SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

$0-$8.95 (Tier 1-Brand)

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

$0-$8.95 (Tier 1-Brand)

Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline oral tablet 0.5 mg $0-$3.60 (Tier 1-Generic) ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG $0-$8.95 (Tier 1-Brand) PA ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG $0-$8.95 (Tier 1-Brand) PA ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG $0-$8.95 (Tier 1-Brand) PA ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) $0-$8.95 (Tier 1-Brand) PA FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG, 80 MG $0-$8.95 (Tier 1-Brand) PA

FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG $0-$8.95 (Tier 1-Brand) PA





leuprolide subcutaneous kit 1 mg/0.2 ml $0-$3.60 (Tier 1-Generic) leuprolide subcutaneous solution 1 mg/0.2 ml $0-$3.60 (Tier 1-Generic) LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG $0-$8.95 (Tier 1-Brand) PA

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG $0-$8.95 (Tier 1-Brand) PA

LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG $0-$8.95 (Tier 1-Brand) PA

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG $0-$8.95 (Tier 1-Brand) PA

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG $0-$8.95 (Tier 1-Brand) PA

LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) $0-$8.95 (Tier 1-Brand) PA octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml $0-$3.60 (Tier 1-Generic) PA

ORILISSA ORAL TABLET 150 MG, 200 MG $0-$8.95 (Tier 1-Brand) PA SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) $0-$8.95 (Tier 1-Brand) PA

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML $0-$8.95 (Tier 1-Brand) PA

SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG $0-$8.95 (Tier 1-Brand) PA

SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML $0-$8.95 (Tier 1-Brand) PA TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG, 22.5 MG, 3.75 MG $0-$8.95 (Tier 1-Brand) PA

Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) propylthiouracil oral tablet 50 mg $0-$3.60 (Tier 1-Generic) Immunological Agents Angioedema Agents CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) $0-$8.95 (Tier 1-Brand) PA HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT $0-$8.95 (Tier 1-Brand) PA

icatibant subcutaneous syringe 30 mg/3 ml $0-$3.60 (Tier 1-Generic) PA Immune Suppressants ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG $0-$8.95 (Tier 1-Brand) B/D

azathioprine oral tablet 50 mg $0-$3.60 (Tier 1-Generic) B/D CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) $0-$8.95 (Tier 1-Brand) PA

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) $0-$8.95 (Tier 1-Brand) PA

CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) $0-$8.95 (Tier 1-Brand) PA

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) B/D cyclosporine modified oral solution 100 mg/ml $0-$3.60 (Tier 1-Generic) B/D cyclosporine oral capsule 100 mg, 25 mg $0-$3.60 (Tier 1-Generic) B/D ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML) $0-$8.95 (Tier 1-Brand) PA

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) $0-$8.95 (Tier 1-Brand) PA





ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5), 50 MG/ML (1 ML) $0-$8.95 (Tier 1-Brand) PA

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) $0-$8.95 (Tier 1-Brand) PA

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG $0-$8.95 (Tier 1-Brand) B/D

everolimus (immunosuppressive) oral tablet 0.25 mg, 0.5 mg, 0.75 mg $0-$3.60 (Tier 1-Generic) B/D

gengraf oral capsule 100 mg, 25 mg $0-$3.60 (Tier 1-Generic) B/D gengraf oral solution 100 mg/ml $0-$3.60 (Tier 1-Generic) B/D HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML $0-$8.95 (Tier 1-Brand) PA

HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML $0-$8.95 (Tier 1-Brand) PA

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML $0-$8.95 (Tier 1-Brand) PA

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML $0-$8.95 (Tier 1-Brand) PA

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML $0-$8.95 (Tier 1-Brand) PA

HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML $0-$8.95 (Tier 1-Brand) PA

HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML $0-$8.95 (Tier 1-Brand) PA

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 80 MG/0.8 ML $0-$8.95 (Tier 1-Brand) PA

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4 ML $0-$8.95 (Tier 1-Brand) PA

KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML $0-$8.95 (Tier 1-Brand) PA methotrexate sodium (pf) injection solution 25 mg/ml $0-$3.60 (Tier 1-Generic) methotrexate sodium injection solution 25 mg/ml $0-$3.60 (Tier 1-Generic) methotrexate sodium oral tablet 2.5 mg $0-$3.60 (Tier 1-Generic) mycophenolate mofetil oral capsule 250 mg $0-$3.60 (Tier 1-Generic) B/D mycophenolate mofetil oral suspension for reconstitution 200 mg/ml $0-$3.60 (Tier 1-Generic) B/D

mycophenolate mofetil oral tablet 500 mg $0-$3.60 (Tier 1-Generic) B/D mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg $0-$3.60 (Tier 1-Generic) B/D

NULOJIX INTRAVENOUS RECON SOLN 250 MG $0-$8.95 (Tier 1-Brand) B/D ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG $0-$8.95 (Tier 1-Brand) PA

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML $0-$8.95 (Tier 1-Brand) PA

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML $0-$8.95 (Tier 1-Brand) PA

penicillamine oral tablet 250 mg $0-$3.60 (Tier 1-Generic) PA PROGRAF ORAL GRANULES IN PACKET 0.2 MG, 1 MG $0-$8.95 (Tier 1-Brand) B/D SANDIMMUNE ORAL SOLUTION 100 MG/ML $0-$8.95 (Tier 1-Brand) B/D SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML $0-$8.95 (Tier 1-Brand) PA





SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML $0-$8.95 (Tier 1-Brand) PA

sirolimus oral solution 1 mg/ml $0-$3.60 (Tier 1-Generic) B/D sirolimus oral tablet 0.5 mg, 1 mg, 2 mg $0-$3.60 (Tier 1-Generic) B/D tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg $0-$3.60 (Tier 1-Generic) B/D TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG $0-$8.95 (Tier 1-Brand) ST XATMEP ORAL SOLUTION 2.5 MG/ML $0-$8.95 (Tier 1-Brand) PA ZORTRESS ORAL TABLET 1 MG $0-$8.95 (Tier 1-Brand) B/D Immunizing Agents, Passive FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 % $0-$8.95 (Tier 1-Brand) B/D GAMMAGARD LIQUID INJECTION SOLUTION 10 % $0-$8.95 (Tier 1-Brand) B/D GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM $0-$8.95 (Tier 1-Brand) B/D

GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %) $0-$8.95 (Tier 1-Brand) B/D GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % $0-$8.95 (Tier 1-Brand) B/D

GAMMAPLEX INTRAVENOUS SOLUTION 10 %, 10 % (100 ML), 10 % (200 ML) $0-$8.95 (Tier 1-Brand) B/D

GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %) $0-$8.95 (Tier 1-Brand) B/D HYPERRAB (PF) INTRAMUSCULAR SOLUTION 300 UNIT/ML $0-$8.95 (Tier 1-Brand) HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML $0-$8.95 (Tier 1-Brand)

PRIVIGEN INTRAVENOUS SOLUTION 10 % $0-$8.95 (Tier 1-Brand) B/D Immunomodulators ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML $0-$8.95 (Tier 1-Brand) PA

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML $0-$8.95 (Tier 1-Brand) PA ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) PA ARCALYST SUBCUTANEOUS RECON SOLN 220 MG $0-$8.95 (Tier 1-Brand) PA BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML $0-$8.95 (Tier 1-Brand) PA BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML $0-$8.95 (Tier 1-Brand) PA leflunomide oral tablet 10 mg, 20 mg $0-$3.60 (Tier 1-Generic) NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML $0-$8.95 (Tier 1-Brand) PA NUCALA SUBCUTANEOUS RECON SOLN 100 MG $0-$8.95 (Tier 1-Brand) PA NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML $0-$8.95 (Tier 1-Brand) PA OTEZLA ORAL TABLET 30 MG $0-$8.95 (Tier 1-Brand) PA OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) $0-$8.95 (Tier 1-Brand) PA

XELJANZ ORAL TABLET 10 MG, 5 MG $0-$8.95 (Tier 1-Brand) PA XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG, 22 MG $0-$8.95 (Tier 1-Brand) PA

XOLAIR SUBCUTANEOUS RECON SOLN 150 MG $0-$8.95 (Tier 1-Brand) PA XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/0.5 ML $0-$8.95 (Tier 1-Brand) PA

Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML $0-$8.95 (Tier 1-Brand)

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML $0-$8.95 (Tier 1-Brand)





ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML $0-$8.95 (Tier 1-Brand)

BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG $0-$8.95 (Tier 1-Brand)

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML $0-$8.95 (Tier 1-Brand)

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML $0-$8.95 (Tier 1-Brand)

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML $0-$8.95 (Tier 1-Brand)

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML $0-$8.95 (Tier 1-Brand)

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML $0-$8.95 (Tier 1-Brand) B/D ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) B/D

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML $0-$8.95 (Tier 1-Brand) GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML $0-$8.95 (Tier 1-Brand) HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML $0-$8.95 (Tier 1-Brand)

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML $0-$8.95 (Tier 1-Brand)

HEPLISAV-B (PF) INTRAMUSCULAR SOLUTION 20 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) B/D

HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) B/D

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML $0-$8.95 (Tier 1-Brand)

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT $0-$8.95 (Tier 1-Brand)

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML $0-$8.95 (Tier 1-Brand)

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF/0.5ML $0-$8.95 (Tier 1-Brand)

IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML $0-$8.95 (Tier 1-Brand) IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) KEDRAB (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML $0-$8.95 (Tier 1-Brand) KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML $0-$8.95 (Tier 1-Brand)

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML $0-$8.95 (Tier 1-Brand)

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML $0-$8.95 (Tier 1-Brand)

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML $0-$8.95 (Tier 1-Brand)

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML $0-$8.95 (Tier 1-Brand)

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML $0-$8.95 (Tier 1-Brand)

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML $0-$8.95 (Tier 1-Brand)





PENTACEL (PF) INTRAMUSCULAR KIT 15LF-48MCG-62DU -10 MCG/0.5ML $0-$8.95 (Tier 1-Brand)

PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML $0-$8.95 (Tier 1-Brand)

PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 62 DU/0.5 ML $0-$8.95 (Tier 1-Brand)

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5 $0-$8.95 (Tier 1-Brand)

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML $0-$8.95 (Tier 1-Brand)

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT $0-$8.95 (Tier 1-Brand)

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML $0-$8.95 (Tier 1-Brand) B/D

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) B/D

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML $0-$8.95 (Tier 1-Brand)

ROTATEQ VACCINE ORAL SOLUTION 2 ML $0-$8.95 (Tier 1-Brand) SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) QL (2 EA per 999 days)

SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG $0-$8.95 (Tier 1-Brand)

tdvax intramuscular suspension 2-2 lf unit/0.5 ml $0-$3.60 (Tier 1-Generic) TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML $0-$8.95 (Tier 1-Brand)

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML $0-$8.95 (Tier 1-Brand)

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML $0-$8.95 (Tier 1-Brand)

TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG $0-$8.95 (Tier 1-Brand)

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML $0-$8.95 (Tier 1-Brand)

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML $0-$8.95 (Tier 1-Brand) VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML $0-$8.95 (Tier 1-Brand)

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML $0-$8.95 (Tier 1-Brand)

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML $0-$8.95 (Tier 1-Brand)

VARIZIG INTRAMUSCULAR RECON SOLN 125 UNIT $0-$8.95 (Tier 1-Brand) VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2 ML $0-$8.95 (Tier 1-Brand) VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF UNIT $0-$8.95 (Tier 1-Brand)

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML $0-$8.95 (Tier 1-Brand)

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML $0-$8.95 (Tier 1-Brand) QL (1 EA per 999 days)





Inflammatory Bowel Disease Agents Aminosalicylates balsalazide oral capsule 750 mg $0-$3.60 (Tier 1-Generic) DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG $0-$8.95 (Tier 1-Brand)

DIPENTUM ORAL CAPSULE 250 MG $0-$8.95 (Tier 1-Brand) mesalamine oral capsule (with del rel tablets) 400 mg $0-$3.60 (Tier 1-Generic) mesalamine oral tablet,delayed release (dr/ec) 1.2 gram $0-$3.60 (Tier 1-Generic) mesalamine rectal enema 4 gram/60 ml $0-$3.60 (Tier 1-Generic) mesalamine rectal suppository 1,000 mg $0-$3.60 (Tier 1-Generic) mesalamine with cleansing wipe rectal enema kit 4 gram/60 ml $0-$3.60 (Tier 1-Generic) PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG $0-$8.95 (Tier 1-Brand)

sulfasalazine oral tablet 500 mg $0-$3.60 (Tier 1-Generic) sulfasalazine oral tablet,delayed release (dr/ec) 500 mg $0-$3.60 (Tier 1-Generic) Glucocorticoids budesonide oral capsule,delayed,extend.release 3 mg $0-$3.60 (Tier 1-Generic) hydrocortisone rectal enema 100 mg/60 ml $0-$3.60 (Tier 1-Generic) methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg $0-$3.60 (Tier 1-Generic) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg $0-$3.60 (Tier 1-Generic) calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation $0-$3.60 (Tier 1-Generic) cinacalcet oral tablet 30 mg, 60 mg $0-$3.60 (Tier 1-Generic) QL (60 EA per 30 days) cinacalcet oral tablet 90 mg $0-$3.60 (Tier 1-Generic) QL (120 EA per 30 days) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg $0-$3.60 (Tier 1-Generic) FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML $0-$8.95 (Tier 1-Brand) PA

ibandronate oral tablet 150 mg $0-$3.60 (Tier 1-Generic) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE $0-$8.95 (Tier 1-Brand) PA

PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML $0-$8.95 (Tier 1-Brand) PA risedronate oral tablet 150 mg, 30 mg, 35 mg, 35 mg (12 pack), 35 mg (4 pack), 5 mg $0-$3.60 (Tier 1-Generic)

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) $0-$8.95 (Tier 1-Brand) PA

XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7 ML (70 MG/ML) $0-$8.95 (Tier 1-Brand) PA

Ophthalmic Agents Ophthalmic Prostaglandin And Prostamide Analogs latanoprost (pf) ophthalmic (eye) drops 0.005 % $0-$3.60 (Tier 1-Generic) latanoprost ophthalmic (eye) drops 0.005 % $0-$3.60 (Tier 1-Generic) LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % $0-$8.95 (Tier 1-Brand) travoprost (benzalkonium) ophthalmic (eye) drops 0.004 % $0-$3.60 (Tier 1-Generic) travoprost ophthalmic (eye) drops 0.004 % $0-$3.60 (Tier 1-Generic) Ophthalmic Agents, Other CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % $0-$8.95 (Tier 1-Brand) NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % $0-$8.95 (Tier 1-Brand) OXERVATE OPHTHALMIC (EYE) DROPS 0.002 % $0-$8.95 (Tier 1-Brand) PA proparacaine ophthalmic (eye) drops 0.5 % $0-$3.60 (Tier 1-Generic)





RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS 0.05 % $0-$8.95 (Tier 1-Brand) QL (60 ML per 30 days) RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) $0-$3.60 (Tier 1-Generic)

XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % $0-$8.95 (Tier 1-Brand) QL (60 EA per 30 days) Ophthalmic Anti-Allergy Agents azelastine ophthalmic (eye) drops 0.05 % $0-$3.60 (Tier 1-Generic) cromolyn ophthalmic (eye) drops 4 % $0-$3.60 (Tier 1-Generic) epinastine ophthalmic (eye) drops 0.05 % $0-$3.60 (Tier 1-Generic) olopatadine ophthalmic (eye) drops 0.1 % $0-$3.60 (Tier 1-Generic) Ophthalmic Antiglaucoma Agents ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % $0-$8.95 (Tier 1-Brand) atropine ophthalmic (eye) drops 1 % $0-$3.60 (Tier 1-Generic) AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % $0-$8.95 (Tier 1-Brand) ST brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % $0-$3.60 (Tier 1-Generic) carteolol ophthalmic (eye) drops 1 % $0-$3.60 (Tier 1-Generic) COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-0.5 % $0-$8.95 (Tier 1-Brand) dorzolamide ophthalmic (eye) drops 2 % $0-$3.60 (Tier 1-Generic) dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml $0-$3.60 (Tier 1-Generic) FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % $0-$8.95 (Tier 1-Brand)

levobunolol ophthalmic (eye) drops 0.5 % $0-$3.60 (Tier 1-Generic) PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 % $0-$8.95 (Tier 1-Brand) pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % $0-$3.60 (Tier 1-Generic) SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION 1-0.2 % $0-$8.95 (Tier 1-Brand)

timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % $0-$3.60 (Tier 1-Generic) timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % $0-$3.60 (Tier 1-Generic)

Ophthalmic Anti-Inflammatories dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % $0-$3.60 (Tier 1-Generic)

diclofenac sodium ophthalmic (eye) drops 0.1 % $0-$3.60 (Tier 1-Generic) DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % $0-$8.95 (Tier 1-Brand) fluorometholone ophthalmic (eye) drops,suspension 0.1 % $0-$3.60 (Tier 1-Generic) flurbiprofen sodium ophthalmic (eye) drops 0.03 % $0-$3.60 (Tier 1-Generic) ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % $0-$3.60 (Tier 1-Generic) prednisolone acetate ophthalmic (eye) drops,suspension 1 % $0-$3.60 (Tier 1-Generic) prednisolone sodium phosphate ophthalmic (eye) drops 1 % $0-$3.60 (Tier 1-Generic) Otic Agents Otic Agents acetic acid otic (ear) solution 2 % $0-$3.60 (Tier 1-Generic) acetic acid-aluminum acetate otic (ear) drops 2 % $0-$3.60 (Tier 1-Generic) CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 % $0-$8.95 (Tier 1-Brand) hydrocortisone-acetic acid otic (ear) drops 1-2 % $0-$3.60 (Tier 1-Generic) neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-% $0-$3.60 (Tier 1-Generic)

neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-% $0-$3.60 (Tier 1-Generic)

ofloxacin otic (ear) drops 0.3 % $0-$3.60 (Tier 1-Generic)





Respiratory Tract/ Pulmonary Agents Antihistamines azelastine nasal aerosol,spray 137 mcg (0.1 %) $0-$3.60 (Tier 1-Generic) azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg) $0-$3.60 (Tier 1-Generic) cetirizine oral solution 1 mg/ml $0-$3.60 (Tier 1-Generic) clemastine oral tablet 2.68 mg $0-$3.60 (Tier 1-Generic) PA cyproheptadine oral syrup 2 mg/5 ml $0-$3.60 (Tier 1-Generic) PA cyproheptadine oral tablet 4 mg $0-$3.60 (Tier 1-Generic) PA diphenhydramine hcl injection solution 50 mg/ml $0-$3.60 (Tier 1-Generic) B/D hydroxyzine hcl oral solution 10 mg/5 ml, 10 mg/5 ml (5 ml) $0-$3.60 (Tier 1-Generic) PA hydroxyzine hcl oral tablet 10 mg $0-$3.60 (Tier 1-Generic) hydroxyzine hcl oral tablet 25 mg, 50 mg $0-$3.60 (Tier 1-Generic) PA levocetirizine oral solution 2.5 mg/5 ml $0-$3.60 (Tier 1-Generic) levocetirizine oral tablet 5 mg $0-$3.60 (Tier 1-Generic) promethazine oral syrup 6.25 mg/5 ml $0-$3.60 (Tier 1-Generic) PA Anti-Inflammatories, Inhaled Corticosteroids ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION

$0-$8.95 (Tier 1-Brand)

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml $0-$3.60 (Tier 1-Generic) B/D

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION

$0-$8.95 (Tier 1-Brand)

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION

$0-$8.95 (Tier 1-Brand)

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) $0-$3.60 (Tier 1-Generic) fluticasone propionate nasal spray,suspension 50 mcg/actuation $0-$3.60 (Tier 1-Generic) mometasone nasal spray,non-aerosol 50 mcg/actuation $0-$3.60 (Tier 1-Generic) QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION $0-$8.95 (Tier 1-Brand)

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION $0-$8.95 (Tier 1-Brand)

Antileukotrienes montelukast oral granules in packet 4 mg $0-$3.60 (Tier 1-Generic) montelukast oral tablet 10 mg $0-$3.60 (Tier 1-Generic) montelukast oral tablet,chewable 4 mg, 5 mg $0-$3.60 (Tier 1-Generic) XYREM ORAL SOLUTION 500 MG/ML $0-$8.95 (Tier 1-Brand) PA; LA zafirlukast oral tablet 10 mg, 20 mg $0-$3.60 (Tier 1-Generic) ST Bronchodilators, Anticholinergic INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION $0-$8.95 (Tier 1-Brand)

ipratropium bromide inhalation solution 0.02 % $0-$3.60 (Tier 1-Generic) B/D SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION $0-$8.95 (Tier 1-Brand)

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG $0-$8.95 (Tier 1-Brand)

Bronchodilators, Sympathomimetic





albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation, 90 mcg/actuation (nda020503), 90 mcg/actuation (nda020983) $0-$3.60 (Tier 1-Generic)

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

$0-$3.60 (Tier 1-Generic) B/D

albuterol sulfate oral syrup 2 mg/5 ml $0-$3.60 (Tier 1-Generic) albuterol sulfate oral tablet 2 mg, 4 mg $0-$3.60 (Tier 1-Generic) albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg $0-$3.60 (Tier 1-Generic) epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml $0-$3.60 (Tier 1-Generic) QL (2 EA per 30 days)

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/3 ml $0-$3.60 (Tier 1-Generic) B/D

metaproterenol oral syrup 10 mg/5 ml $0-$3.60 (Tier 1-Generic) metaproterenol oral tablet 10 mg, 20 mg $0-$3.60 (Tier 1-Generic) PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML $0-$8.95 (Tier 1-Brand) B/D

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE $0-$8.95 (Tier 1-Brand)

STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION $0-$8.95 (Tier 1-Brand)

terbutaline oral tablet 2.5 mg, 5 mg $0-$3.60 (Tier 1-Generic) VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION $0-$8.95 (Tier 1-Brand)

Cystic Fibrosis Agents KALYDECO ORAL GRANULES IN PACKET 25 MG, 50 MG, 75 MG $0-$8.95 (Tier 1-Brand) PA

KALYDECO ORAL TABLET 150 MG $0-$8.95 (Tier 1-Brand) PA ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG $0-$8.95 (Tier 1-Brand) PA

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG $0-$8.95 (Tier 1-Brand) PA PULMOZYME INHALATION SOLUTION 1 MG/ML $0-$8.95 (Tier 1-Brand) B/D SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N) $0-$8.95 (Tier 1-Brand) PA

tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml $0-$3.60 (Tier 1-Generic) B/D

tobramycin with nebulizer inhalation solution for nebulization 300 mg/5 ml $0-$3.60 (Tier 1-Generic) B/D

TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 MG(D) /150 MG (N) $0-$8.95 (Tier 1-Brand) PA

Mast Cell Stabilizers cromolyn inhalation solution for nebulization 20 mg/2 ml $0-$3.60 (Tier 1-Generic) B/D cromolyn oral concentrate 100 mg/5 ml $0-$3.60 (Tier 1-Generic) Phosphodiesterase Inhibitors, Airways Disease DALIRESP ORAL TABLET 250 MCG, 500 MCG $0-$8.95 (Tier 1-Brand) theophylline oral elixir 80 mg/15 ml $0-$3.60 (Tier 1-Generic) theophylline oral solution 80 mg/15 ml $0-$3.60 (Tier 1-Generic) theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg $0-$3.60 (Tier 1-Generic)

theophylline oral tablet extended release 24 hr 400 mg, 600 mg $0-$3.60 (Tier 1-Generic) Pulmonary Antihypertensives





ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG $0-$8.95 (Tier 1-Brand) PA

ambrisentan oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) PA sildenafil (pulm.hypertension) oral suspension for reconstitution 10 mg/ml $0-$3.60 (Tier 1-Generic) PA

sildenafil (pulm.hypertension) oral tablet 20 mg $0-$3.60 (Tier 1-Generic) PA VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML $0-$8.95 (Tier 1-Brand) PA

Pulmonary Fibrosis Agents ESBRIET ORAL CAPSULE 267 MG $0-$8.95 (Tier 1-Brand) PA ESBRIET ORAL TABLET 267 MG, 801 MG $0-$8.95 (Tier 1-Brand) PA OFEV ORAL CAPSULE 100 MG, 150 MG $0-$8.95 (Tier 1-Brand) PA Respiratory Tract Agents, Other acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) $0-$3.60 (Tier 1-Generic) B/D ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION

$0-$8.95 (Tier 1-Brand)

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION $0-$8.95 (Tier 1-Brand)

BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE $0-$8.95 (Tier 1-Brand)

budesonide-formoterol inhalation hfa aerosol inhaler 160-4.5 mcg/actuation, 80-4.5 mcg/actuation $0-$3.60 (Tier 1-Generic)

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION $0-$8.95 (Tier 1-Brand) ST

CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2 MG/ML) $0-$8.95 (Tier 1-Brand) DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION, 50-5 MCG/ACTUATION

$0-$8.95 (Tier 1-Brand)

fluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation


fluticasone propion-salmeterol inhalation blister with device 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose $0-$3.60 (Tier 1-Generic)

ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 mcg (0.06 %) $0-$3.60 (Tier 1-Generic)

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml $0-$3.60 (Tier 1-Generic) B/D

promethazine vc oral syrup 6.25-5 mg/5 ml $0-$3.60 (Tier 1-Generic) PA promethazine-phenylephrine oral syrup 6.25-5 mg/5 ml $0-$3.60 (Tier 1-Generic) PA STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION $0-$8.95 (Tier 1-Brand)

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG $0-$8.95 (Tier 1-Brand)

wixela inhub inhalation blister with device 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose $0-$3.60 (Tier 1-Generic)

Skeletal Muscle Relaxants Skeletal Muscle Relaxants carisoprodol oral tablet 250 mg, 350 mg $0-$3.60 (Tier 1-Generic) PA chlorzoxazone oral tablet 500 mg $0-$3.60 (Tier 1-Generic) PA cyclobenzaprine oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) PA





cyclotens refill combo pack 10 mg $0-$3.60 (Tier 1-Generic) PA cyclotens starter combo pack 10 mg $0-$3.60 (Tier 1-Generic) PA metaxall oral tablet 800 mg $0-$3.60 (Tier 1-Generic) metaxalone oral tablet 800 mg $0-$3.60 (Tier 1-Generic) methocarbamol oral tablet 500 mg, 750 mg $0-$3.60 (Tier 1-Generic) PA orphenadrine citrate oral tablet extended release 100 mg $0-$3.60 (Tier 1-Generic) PA Sleep Disorder Agents Gaba Receptor Modulators eszopiclone oral tablet 1 mg, 2 mg, 3 mg $0-$3.60 (Tier 1-Generic) PA; QL (30 EA per 30 days) temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 365 days) zaleplon oral capsule 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) QL (90 EA per 365 days) zolpidem oral tablet 10 mg, 5 mg $0-$3.60 (Tier 1-Generic) PA; QL (30 EA per 30 days) zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg $0-$3.60 (Tier 1-Generic) PA; QL (30 EA per 30 days) Sleep Disorders, Other armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg $0-$3.60 (Tier 1-Generic) PA doxepin oral tablet 3 mg, 6 mg $0-$3.60 (Tier 1-Generic) HETLIOZ ORAL CAPSULE 20 MG $0-$8.95 (Tier 1-Brand) PA modafinil oral tablet 100 mg, 200 mg $0-$3.60 (Tier 1-Generic) PA ramelteon oral tablet 8 mg $0-$3.60 (Tier 1-Generic) QL (30 EA per 30 days)

INDEX

68

Index A abacavir ................................. 32 abacavir-lamivudine ............ 32 abacavir-lamivudine-

zidovudine ......................... 33 ABELCET .............................. 20 ABILIFY MAINTENA ........... 29 abiraterone ............................ 24 acamprosate ......................... 11 acarbose ............................... 35 acebutolol .............................. 40 acetaminophen-codeine ....... 9 acetazolamide ...................... 42 acetic acid ............................. 63 acetic acid-aluminum acetate

............................................ 63 acetylcysteine ....................... 66 acitretin .................................. 45 ACTEMRA ............................ 59 ACTEMRA ACTPEN ........... 59 ACTHAR ............................... 51 ACTHIB (PF) ........................ 59 ACTIMMUNE ........................ 59 acyclovir ................................ 32 acyclovir sodium .................. 32 ADACEL(TDAP

ADOLESN/ADULT)(PF) 59, 60

adapalene ............................. 45 adapalene-benzoyl peroxide

............................................ 45 adefovir .................................. 31 ADEMPAS ............................ 66 ADVAIR HFA ........................ 66 AFINITOR ............................. 25 AFINITOR DISPERZ ........... 25 afirmelle ................................. 52 AIMOVIG AUTOINJECTOR

............................................ 23 AIMOVIG AUTOINJECTOR

(2 PACK) ........................... 23 ak-poly-bac ........................... 12 ALA-CORT ............................ 22 albendazole .......................... 27 albuterol sulfate .................... 65 alclometasone ...................... 22 alcohol pads ......................... 36 ALECENSA .......................... 25

alendronate ........................... 62 alfuzosin ................................ 51 ALINIA ................................... 27 aliskiren ................................. 41 allopurinol .............................. 21 alosetron................................ 49 ALPHAGAN P ...................... 63 alprazolam ............................ 34 altavera (28).......................... 52 ALUNBRIG...................... 25, 26 alyacen 1/35 (28) ................. 52 amabelz ................................. 52 amantadine hcl ..................... 28 AMBISOME .......................... 20 ambrisentan .......................... 66 amikacin ................................ 11 amiloride ................................ 42 amiloride-hydrochlorothiazide

............................................ 41 AMINOSYN II 10 % ............. 47 AMINOSYN II 15 % ............. 47 AMINOSYN-PF 7 %

(SULFITE-FREE) ............. 47 amiodarone ........................... 40 AMITIZA ................................ 49 amitriptyline ........................... 20 amlodipine ............................. 40 amlodipine-benazepril ......... 41 amlodipine-olmesartan ....... 41 amlodipine-valsartan ........... 41 amlodipine-valsartan-

hcthiazid ............................ 41 ammonium lactate ............... 45 amnesteem ........................... 45 amoxapine ............................ 20 amoxicillin.............................. 14 amoxicillin-pot clavulanate . 14 amphotericin b ...................... 20 ampicillin................................ 14 ampicillin sodium............ 14, 15 ampicillin-sulbactam ............ 15 ANADROL-50 ....................... 51 anagrelide ............................. 38 anastrozole ........................... 25 anodyne lpt ........................... 10 ANORO ELLIPTA ................ 66 APOKYN ............................... 28 aprepitant .............................. 20

apri ......................................... 52 APTIOM ................................. 18 APTIVUS ............................... 33 APTIVUS (WITH VITAMIN E)

............................................ 33 ARALAST NP ....................... 50 aranelle (28) .......................... 52 ARANESP (IN

POLYSORBATE) ............. 38 ARCALYST ........................... 59 aripiprazole ........................... 29 ARISTADA ............................ 29 ARISTADA INITIO ............... 29 armodafinil............................. 67 ARNUITY ELLIPTA ............. 64 ascomp with codeine ............. 9 aspirin-dipyridamole ............ 39 assure id insulin safety ........ 36 ASTAGRAF XL..................... 57 atazanavir .............................. 33 atenolol .................................. 40 atenolol-chlorthalidone ........ 41 atomoxetine .......................... 44 atorvastatin ........................... 43 atovaquone ........................... 27 atovaquone-proguanil ......... 27 ATRIPLA ............................... 32 atropine .................................. 63 AUBAGIO .............................. 45 aubra ...................................... 52 aubra eq ................................ 52 aurovela 1.5/30 (21) ............ 52 aurovela fe 1.5/30 (28) ........ 52 aurovela fe 1-20 (28) ........... 52 AUSTEDO ............................. 45 AVANDIA............................... 35 aviane .................................... 52 ayuna ..................................... 52 AYVAKIT ............................... 26 azathioprine .......................... 57 azelastine ........................ 63, 64 azithromycin .......................... 15 AZOPT ................................... 63 aztreonam ............................. 14 B bacitracin ............................... 12 bacitracin-polymyxin b......... 12 baclofen ................................. 31

INDEX

69

BACTROBAN NASAL ......... 12 balsalazide ............................ 62 BALVERSA ........................... 26 balziva (28) ........................... 52 BANZEL ................................ 18 BAQSIMI ............................... 36 BARACLUDE ....................... 31 BCG VACCINE, LIVE (PF) 60 benazepril ............................. 39 benazepril-

hydrochlorothiazide ......... 41 BENLYSTA ........................... 59 BENZNIDAZOLE ................. 27 benztropine ........................... 28 betamethasone dipropionate

............................................ 22 betamethasone valerate ..... 22 betamethasone, augmented

............................................ 22 BETASERON ....................... 45 betaxolol ................................ 40 bethanechol chloride ........... 51 bexarotene ............................ 27 BEXSERO ............................ 60 bicalutamide ......................... 24 BICILLIN L-A ........................ 15 BIKTARVY ............................ 33 bisoprolol fumarate .............. 40 bisoprolol-

hydrochlorothiazide ......... 41 blisovi fe 1.5/30 (28) ............ 52 blisovi fe 1/20 (28) ............... 52 BOOSTRIX TDAP ............... 60 BOSULIF ............................... 26 BRAFTOVI ............................ 26 BREO ELLIPTA ................... 66 briellyn ................................... 52 BRILINTA .............................. 39 brimonidine ........................... 63 BRIVIACT ............................. 16 bromocriptine ........................ 28 BRUKINSA ........................... 26 budesonide ..................... 62, 64 budesonide-formoterol ........ 66 bumetanide ........................... 42 buprenorphine ...................... 10 buprenorphine hcl ................ 11 buprenorphine-naloxone .... 11 bupropion hcl .................. 18, 19

bupropion hcl (smoking deter).................................. 11

buspirone .............................. 34 butalbital compound

w/codeine ............................ 9 butalbital-acetaminop-caf-cod

.............................................. 9 butalbital-acetaminophen ..... 9 butalbital-acetaminophen-caff

.............................................. 9 butalbital-aspirin-caffeine ..... 9 butorphanol ........................... 10 BYSTOLIC ............................ 40 C cabergoline ........................... 56 CABOMETYX ....................... 26 calcipotriene.................... 45, 46 calcitonin (salmon) ............... 62 calcitriol.................................. 49 calcium acetate(phosphat

bind) ................................... 48 CALQUENCE ....................... 26 camila .................................... 55 CAPLYTA .............................. 29 CAPRELSA ........................... 26 captopril ................................. 39 captopril-hydrochlorothiazide

............................................ 41 CARBAGLU .......................... 47 carbamazepine ............... 18, 34 carbidopa-levodopa ............. 28 carbidopa-levodopa-

entacapone ....................... 28 carisoprodol .......................... 66 carisoprodol-aspirin ............... 9 carisoprodol-aspirin-codeine 9 carteolol ................................. 63 cartia xt .................................. 40 carvedilol ............................... 40 caspofungin .......................... 21 caziant (28) ........................... 52 cefaclor .................................. 13 cefadroxil ............................... 13 cefazolin ................................ 13 cefazolin in dextrose (iso-os)

............................................ 13 cefdinir ................................... 13 cefepime ................................ 13 cefepime in dextrose 5 % ... 13

cefepime in dextrose,iso-osm ............................................ 13

cefixime ................................. 13 cefotaxime ............................. 13 cefoxitin ................................. 14 cefoxitin in dextrose, iso-osm

............................................ 13 cefpodoxime ......................... 14 cefprozil ................................. 14 ceftazidime ............................ 14 ceftazidime in d5w ............... 14 ceftriaxone............................. 14 ceftriaxone in dextrose,iso-os

............................................ 14 cefuroxime axetil .................. 14 cefuroxime sodium............... 14 celecoxib ................................. 9 CELONTIN ............................ 16 cephalexin ............................. 14 CERDELGA .......................... 50 cetirizine ................................ 64 cevimeline ............................. 45 CHANTIX............................... 11 CHANTIX CONTINUING

MONTH BOX .................... 11 CHANTIX STARTING

MONTH BOX .................... 11 chateal eq (28) ..................... 52 chlorhexidine gluconate ...... 45 chloroquine phosphate ........ 27 chlorothiazide ....................... 42 chlorpromazine ..................... 20 chlorthalidone ....................... 42 chlorzoxazone ...................... 66 CHOLBAM ............................ 50 cholestyramine (with sugar)

............................................ 43 cholestyramine light ............. 43 ciclopirox ............................... 21 ciclopirox-ure-camph-menth-

euc ...................................... 21 cilostazol ................................ 39 CIMDUO ................................ 33 cimetidine .............................. 49 cimetidine hcl ........................ 49 CIMZIA................................... 57 CIMZIA POWDER FOR

RECONST......................... 57 CIMZIA STARTER KIT ....... 57

INDEX

70

cinacalcet .............................. 62 CINRYZE .............................. 57 CIPRODEX ........................... 63 ciprofloxacin .......................... 15 ciprofloxacin hcl ................... 15 ciprofloxacin in 5 % dextrose

............................................ 15 citalopram ............................. 19 claravis .................................. 46 clarithromycin ....................... 15 clemastine ............................. 64 clindamycin hcl ..................... 12 clindamycin in 0.9 % sod

chlor ................................... 12 clindamycin in 5 % dextrose

............................................ 12 clindamycin palmitate hcl ... 12 clindamycin pediatric ........... 12 clindamycin phosphate ....... 12 clindamycin-benzoyl peroxide

............................................ 46 CLINIMIX 4.25%/D10W

SULF FREE ...................... 47 CLINISOL SF 15 % ............. 47 clobazam ............................... 17 clobetasol .............................. 22 clobetasol-emollient ............ 22 clomipramine ........................ 20 clonazepam .......................... 34 clonidine ................................ 39 clonidine hcl .................... 39, 44 clopidogrel ............................ 39 clorazepate dipotassium ..... 34 clotrimazole .......................... 21 clotrimazole-betamethasone

............................................ 46 clozapine ............................... 31 COARTEM ............................ 27 codeine-butalbital-asa-caff ... 9 colchicine .............................. 21 colesevelam .......................... 43 colestipol ............................... 43 colistin (colistimethate na) .. 12 COMBIGAN .......................... 63 COMBIPATCH ..................... 52 COMBIVENT RESPIMAT .. 66 COMETRIQ .......................... 26 comfort pac-ibuprofen ........... 9 comfort pac-meloxicam......... 9

comfort pac-naproxen ........... 9 COMFORT PAC-

TIZANIDINE ...................... 31 COMPLERA.......................... 32 constulose ............................. 49 COPIKTRA............................ 25 CORLANOR ......................... 41 cortisone ................................ 51 COSENTYX .......................... 46 COSENTYX (2 SYRINGES)

............................................ 46 COSENTYX PEN ................. 46 COSENTYX PEN (2 PENS)

............................................ 46 COTELLIC ............................ 26 COUMADIN .......................... 37 CREON.................................. 50 CRIXIVAN ............................. 33 cromolyn .......................... 63, 65 cryselle (28) .......................... 52 CUVPOSA ............................ 66 cyclafem 1/35 (28) ............... 52 cyclafem 7/7/7 (28) .............. 53 cyclobenzaprine ................... 66 cyclophosphamide ............... 24 cyclosporine .......................... 57 cyclosporine modified ......... 57 cyclotens refill ....................... 67 cyclotens starter ................... 67 cyproheptadine ..................... 64 cyred ...................................... 53 cyred eq ................................. 53 CYSTADANE........................ 50 CYSTAGON.......................... 50 CYSTARAN .......................... 62 D d10 %-0.45 % sodium

chloride .............................. 47 d2.5 %-0.45 % sodium

chloride .............................. 47 d5 % and 0.9 % sodium

chloride .............................. 47 d5 %-0.45 % sodium chloride

............................................ 47 dalfampridine ........................ 45 DALIRESP ............................ 65 danazol .................................. 51 dantrolene ............................. 31 dapsone ................................. 24

DAPTACEL (DTAP PEDIATRIC) (PF)............. 60

daptomycin ............................ 12 darifenacin............................. 50 DAURISMO........................... 26 deblitane ................................ 55 deferasirox ............................ 48 DELSTRIGO ......................... 32 delyla (28) ............................. 53 DELZICOL............................. 62 DEMSER ............................... 41 DENAVIR .............................. 32 DEPO-PROVERA ................ 24 DEPO-SUBQ PROVERA 104

............................................ 55 dermacinrx empricaine ........ 10 DESCOVY............................. 33 desipramine .......................... 20 desmopressin ....................... 55 desog-e.estradiol/e.estradiol

............................................ 53 desogestrel-ethinyl estradiol

............................................ 53 desonide ................................ 22 desoximetasone ................... 22 desvenlafaxine succinate ... 19 dexamethasone .................... 22 dexamethasone intensol ..... 22 dexamethasone sodium

phosphate ................... 51, 63 dexmethylphenidate ............ 44 dextroamphetamine ............. 44 dextroamphetamine-

amphetamine .................... 44 dextrose 10 % and 0.2 %

nacl ..................................... 47 dextrose 10 % in water

(d10w) ................................ 47 dextrose 5 % in water (d5w)

............................................ 47 dextrose 5%-0.2 % sod

chloride .............................. 47 dextrose 5%-0.3 %

sod.chloride....................... 47 dextrose with sodium chloride

............................................ 47 DIACOMIT............................. 16 DIASTAT ............................... 17 DIASTAT ACUDIAL ............. 17

INDEX

71

diazepam ........................ 17, 34 diazepam intensol ................ 34 diazoxide ............................... 36 diclofenac potassium ............ 9 diclofenac sodium 9, 10, 25, 63 dicloxacillin ............................ 15 DICLOZOR ............................. 9 dicyclomine ........................... 49 didanosine ............................ 33 DIFICID ................................. 15 diflunisal .................................. 9 digitek .................................... 41 digox ...................................... 41 digoxin ................................... 41 dihydroergotamine ............... 23 DILANTIN .............................. 18 diltiazem hcl .................... 40, 41 dilt-xr ...................................... 41 DIPENTUM ........................... 62 diphenhydramine hcl ........... 64 diphenoxylate-atropine ....... 49 dipyridamole ......................... 39 disopyramide phosphate .... 40 disulfiram ............................... 11 divalproex .............................. 17 dm2 ........................................ 35 dofetilide ................................ 40 donepezil ............................... 18 DOPTELET (10 TAB PACK)

............................................ 38 DOPTELET (15 TAB PACK)

............................................ 38 DOPTELET (30 TAB PACK)

............................................ 38 dorzolamide .......................... 63 dorzolamide-timolol ............. 63 DOVATO ............................... 32 doxazosin .............................. 39 doxepin ...................... 20, 46, 67 doxercalciferol ...................... 62 doxy-100 ............................... 16 doxycycline hyclate ............. 16 doxycycline monohydrate ... 16 DRIZALMA SPRINKLE ....... 19 dronabinol ............................. 20 drospirenone-ethinyl estradiol

............................................ 53 DROXIA................................. 25 DUAVEE ............................... 55

DULERA ................................ 66 duloxetine .............................. 45 DUPIXENT SYRINGE ......... 46 DURAMORPH (PF) ............. 10 DUREZOL ............................. 63 dutasteride ............................ 51 E ec-naproxen ............................ 9 econazole .............................. 21 EDURANT ............................. 32 efavirenz ................................ 32 EGRIFTA ............................... 55 EGRIFTA SV ........................ 55 ELIGARD .............................. 56 ELIGARD (3 MONTH) ......... 56 ELIGARD (4 MONTH) ......... 56 ELIGARD (6 MONTH) ......... 56 ELIQUIS ................................ 37 ELIQUIS DVT-PE TREAT

30D START ...................... 37 ELMIRON .............................. 51 eluryng ................................... 53 EMCYT .................................. 24 EMEND.................................. 20 EMGALITY PEN .................. 23 EMGALITY SYRINGE ......... 23 emoquette ............................. 53 EMSAM ................................. 19 EMTRIVA .............................. 33 enalapril maleate ................. 39 enalapril-hydrochlorothiazide

............................................ 42 ENBREL .......................... 57, 58 ENBREL MINI ...................... 57 ENBREL SURECLICK ........ 58 ENDARI ................................. 47 ENGERIX-B (PF) ................. 60 ENGERIX-B PEDIATRIC

(PF) .................................... 60 enoxaparin ............................ 38 enpresse................................ 53 enskyce ................................. 53 entacapone ........................... 28 entecavir ................................ 31 ENTRESTO .......................... 42 enulose .................................. 49 ENVARSUS XR ................... 58 EPIDIOLEX ........................... 16 epinastine .............................. 63

epinephrine ........................... 65 epitol....................................... 18 EPIVIR HBV .......................... 31 eplerenone ............................ 42 EPOGEN ............................... 38 EQUETRO ............................ 34 ERAXIS(WATER DILUENT)

............................................ 21 ergoloid .................................. 18 ergotamine-caffeine ............. 23 ERIVEDGE ........................... 26 ERLEADA ............................. 24 erlotinib .................................. 26 errin ........................................ 55 ertapenem ............................. 14 ery pads ................................. 15 ERYTHROCIN ...................... 15 ERYTHROCIN (AS

STEARATE) ...................... 15 erythromycin ......................... 15 erythromycin ethylsuccinate

............................................ 15 erythromycin with ethanol ... 15 erythromycin-benzoyl

peroxide ............................. 46 ESBRIET ............................... 66 escitalopram oxalate ........... 19 estarylla ................................. 53 estradiol ................................. 52 estradiol valerate .................. 52 estradiol-norethindrone acet

............................................ 53 ESTRING .............................. 52 estropipate ............................ 52 eszopiclone ........................... 67 ethambutol ............................ 24 ethosuximide......................... 16 ethynodiol diac-eth estradiol

............................................ 53 etodolac ................................... 9 etonogestrel-ethinyl estradiol

............................................ 53 EUCRISA .............................. 46 everolimus (antineoplastic). 26 everolimus

(immunosuppressive) ...... 58 EVOTAZ ................................ 33 exemestane .......................... 25 EXTAVIA ............................... 45

INDEX

72

ezetimibe ............................... 43 ezetimibe-simvastatin ......... 43 F falmina (28) ........................... 53 famciclovir ............................. 32 famotidine ............................. 49 FANAPT ................................ 29 FARYDAK ............................. 26 febuxostat ............................. 21 felbamate .............................. 17 felodipine ............................... 41 femynor ................................. 53 fenofibrate ............................. 43 fenofibrate micronized ........ 43 fenofibrate nanocrystallized43 fenofibric acid ....................... 43 fenofibric acid (choline) ....... 43 fentanyl .................................. 10 fentanyl citrate ...................... 10 FERRIPROX......................... 48 FERRIPROX (2 TIMES A

DAY) .................................. 48 FETZIMA ............................... 19 finasteride ............................. 51 FIRDAPSE ............................ 45 FIRMAGON .......................... 56 FIRMAGON KIT W DILUENT

SYRINGE .......................... 56 flavoxate ................................ 50 FLEBOGAMMA DIF ............ 59 flecainide ............................... 40 FLOVENT DISKUS ............. 64 FLOVENT HFA .................... 64 fluconazole ............................ 21 fluconazole in dextrose(iso-o)

............................................ 21 fluconazole in nacl (iso-osm)

............................................ 21 flucytosine ............................. 21 fludrocortisone ...................... 51 flunisolide .............................. 64 fluocinolone .......................... 22 fluocinonide .......................... 22 fluocinonide-e ....................... 22 fluocinonide-emollient ......... 22 fluoride (sodium) .................. 47 fluorometholone ................... 63 fluorouracil ............................ 25 fluoxetine ............................... 19

fluphenazine decanoate ..... 29 fluphenazine hcl ................... 29 flurbiprofen .............................. 9 flurbiprofen sodium .............. 63 flutamide ................................ 24 fluticasone propionate ... 22, 64 fluticasone propion-

salmeterol.......................... 66 fluvoxamine ........................... 19 FML FORTE ......................... 63 fondaparinux ......................... 38 FORFIVO XL ........................ 19 FORTEO ............................... 62 fosamprenavir ....................... 33 fosinopril ................................ 39 fosinopril-hydrochlorothiazide

............................................ 42 FOSRENOL .......................... 48 FRAGMIN.............................. 38 furosemide ............................ 42 FUZEON................................ 33 fyavolv.................................... 53 FYCOMPA ............................ 17 G gabapentin ............................ 17 GALAFOLD ........................... 50 galantamine .......................... 18 GAMMAGARD LIQUID ....... 59 GAMMAGARD S-D (IGA < 1

MCG/ML) ........................... 59 GAMMAKED ......................... 59 GAMMAPLEX ....................... 59 GAMMAPLEX (WITH

SORBITOL) ...................... 59 GAMUNEX-C........................ 59 GARDASIL 9 (PF)................ 60 GATTEX 30-VIAL ................ 49 GATTEX ONE-VIAL ............ 49 gauze pad ............................. 36 gavilyte-c ............................... 49 gavilyte-g ............................... 49 gavilyte-n ............................... 49 gemfibrozil ............................. 43 generlac ................................. 49 gengraf .................................. 58 GENOTROPIN ..................... 56 GENOTROPIN MINIQUICK

............................................ 56 gentak .................................... 11

gentamicin ....................... 11, 12 gentamicin in nacl (iso-osm)

............................................ 11 GENVOYA ............................ 32 GILENYA ............................... 45 GILOTRIF .............................. 26 GLASSIA ............................... 50 glatiramer .............................. 45 glatopa ................................... 45 GLEOSTINE ......................... 24 glimepiride ............................. 35 glipizide .................................. 35 glipizide-metformin............... 35 GLUCAGEN DIAGNOSTIC

KIT ...................................... 36 GLUCAGEN HYPOKIT ....... 36 GLUCAGON EMERGENCY

KIT (HUMAN) ................... 36 GLUCAGON HCL ................ 36 glyburide ................................ 35 glyburide micronized ........... 35 glyburide-metformin ............. 35 glycopyrrolate ....................... 49 GOCOVRI ............................. 28 granisetron hcl ...................... 20 GRANIX ................................. 38 griseofulvin microsize .......... 21 guanfacine....................... 39, 44 guanidine ............................... 24 H HAEGARDA .......................... 57 hailey ...................................... 53 hailey 24 fe ............................ 53 hailey fe 1.5/30 (28) ............. 53 hailey fe 1/20 (28) ................ 53 halobetasol propionate ........ 22 haloperidol............................. 29 haloperidol decanoate ......... 29 haloperidol lactate ................ 29 HAVRIX (PF) ........................ 60 heparin (porcine) .................. 38 heparin, porcine (pf) ............ 38 HEPLISAV-B (PF) ................ 60 HETLIOZ ............................... 67 HEXALEN ............................. 24 HIBERIX (PF) ....................... 60 HUMALOG JUNIOR

KWIKPEN U-100 .............. 36

INDEX

73

HUMALOG KWIKPEN INSULIN ............................ 36

HUMALOG MIX 50-50 INSULN U-100 ................. 36

HUMALOG MIX 50-50 KWIKPEN ......................... 36

HUMALOG MIX 75-25 KWIKPEN ......................... 36

HUMALOG MIX 75-25(U-100)INSULN ..................... 37

HUMALOG U-100 INSULIN ............................................ 37

HUMATROPE ...................... 56 HUMIRA ................................ 58 HUMIRA PEN ....................... 58 HUMIRA PEN CROHNS-UC-

HS START ........................ 58 HUMIRA PEN PSOR-

UVEITS-ADOL HS .......... 58 HUMIRA(CF) ........................ 58 HUMIRA(CF) PEDI CROHNS

STARTER ......................... 58 HUMIRA(CF) PEN ............... 58 HUMIRA(CF) PEN

CROHNS-UC-HS............. 58 HUMIRA(CF) PEN PSOR-

UV-ADOL HS ................... 58 HUMULIN 70/30 U-100

INSULIN ............................ 37 HUMULIN N NPH U-100

INSULIN ............................ 37 HUMULIN R REGULAR U-

100 INSULN ..................... 37 HUMULIN R U-500 (CONC)

INSULIN ............................ 37 HUMULIN R U-500 (CONC)

KWIKPEN ......................... 37 hydralazine ........................... 43 hydrochlorothiazide ............. 42 hydrocodone-acetaminophen

.............................................. 9 hydrocodone-ibuprofen ......... 9 hydrocortisone .... 23, 46, 51, 62 hydrocortisone butyrate ...... 22 hydrocortisone butyr-

emollient ............................ 22 hydrocortisone valerate ...... 23 hydrocortisone-acetic acid . 63

hydrocortisone-min oil-wht pet ...................................... 46

hydromorphone .................... 10 hydromorphone (pf) ............. 10 hydroxychloroquine ............. 27 hydroxyurea .......................... 25 hydroxyzine hcl .................... 64 hydroxyzine pamoate .......... 34 HYPERRAB (PF) ................. 59 HYPERRAB S/D (PF) ......... 59 I ibandronate ........................... 62 IBRANCE .............................. 26 ibu ............................................. 9 ibuprofen ................................. 9 ibuprofen-oxycodone ............. 9 icatibant ................................. 57 ICLUSIG ................................ 26 IDHIFA ................................... 26 imatinib .................................. 26 IMBRUVICA .......................... 26 imipenem-cilastatin .............. 14 imipramine hcl ...................... 20 imipramine pamoate ............ 20 imiquimod .............................. 46 IMOVAX RABIES VACCINE

(PF) .................................... 60 incassia.................................. 55 INCRELEX ............................ 56 INCRUSE ELLIPTA ............. 64 indapamide ........................... 42 indomethacin .......................... 9 INFANRIX (DTAP) (PF) ...... 60 INGREZZA ............................ 45 INGREZZA INITIATION

PACK ................................. 45 INLYTA .................................. 26 INREBIC ................................ 26 insulin asp prt-insulin aspart

............................................ 37 insulin aspart u-100 ............. 37 insulin lispro .......................... 37 insulin lispro protamin-lispro

............................................ 37 insulin syringe-needle u-100

............................................ 36 INTELENCE.......................... 32 INTRALIPID .......................... 47 INTRON A ............................. 31

introvale ................................. 53 INVEGA SUSTENNA .... 29, 30 INVEGA TRINZA ................. 30 INVIRASE ............................. 33 INVOKAMET......................... 35 INVOKAMET XR .................. 35 INVOKANA ........................... 35 IPOL ....................................... 60 ipratropium bromide....... 64, 66 ipratropium-albuterol ........... 66 irbesartan .............................. 39 irbesartan-

hydrochlorothiazide ......... 42 IRESSA ................................. 26 ISENTRESS ......................... 32 ISENTRESS HD................... 32 isibloom ................................. 53 ISOLYTE S PH 7.4 .............. 47 ISOLYTE-P IN 5 %

DEXTROSE ...................... 47 ISOLYTE-S ........................... 47 isoniazid................................. 24 isosorbide dinitrate............... 44 isosorbide mononitrate ........ 44 isotretinoin ............................. 46 isradipine ............................... 41 itraconazole........................... 21 ivermectin .............................. 27 IXIARO (PF) .......................... 60 J JADENU SPRINKLE ........... 48 JAKAFI................................... 26 jantoven ................................. 38 JANUMET ............................. 35 JANUMET XR....................... 35 JANUVIA ............................... 35 JARDIANCE ......................... 35 JENTADUETO ..................... 35 JENTADUETO XR ............... 35 jinteli ....................................... 53 jolivette................................... 55 juleber .................................... 53 JULUCA................................. 32 junel 1.5/30 (21) ................... 53 junel 1/20 (21)....................... 53 junel fe 1.5/30 (28) ............... 53 junel fe 1/20 (28) .................. 53 JUXTAPID ............................. 43 JYNARQUE .......................... 48

INDEX

74

K KALETRA .............................. 33 kalliga .................................... 53 KALYDECO .......................... 65 kariva (28) ............................. 53 KEDRAB (PF)....................... 60 kelnor 1/35 (28) .................... 53 kelnor 1-50 ............................ 53 ketoconazole ........................ 21 ketoprofen ............................... 9 ketorolac .......................... 10, 63 KEVEYIS ............................... 42 kimidess (28) ........................ 53 KINERET............................... 58 KINRIX (PF) .......................... 60 kionex (with sorbitol) ........... 48 KISQALI ................................ 26 KISQALI FEMARA CO-PACK

............................................ 26 KLOR-CON 10 ..................... 47 KLOR-CON 8 ....................... 47 klor-con m10 ......................... 47 KLOR-CON M15 .................. 47 klor-con m20 ......................... 47 klor-con sprinkle ................... 47 KLOR-CON SPRINKLE ...... 47 KORLYM ............................... 35 KOSELUGO ......................... 26 KRISTALOSE ....................... 49 k-sol ....................................... 47 kurvelo (28) ........................... 53 KUVAN .................................. 50 L labetalol ................................. 40 lactulose ................................ 49 lamivudine ............................. 31 lamivudine-zidovudine ........ 33 lamotrigine ...................... 17, 34 lansoprazole ......................... 50 lanthanum ............................. 48 LANTUS SOLOSTAR U-100

INSULIN ............................ 37 LANTUS U-100 INSULIN ... 37 larin 1.5/30 (21) .................... 53 larin 1/20 (21) ....................... 53 larin fe 1.5/30 (28) ............... 53 larin fe 1/20 (28) ................... 53 larissia ................................... 53 latanoprost ............................ 62

latanoprost (pf) ..................... 62 LATUDA ................................ 30 LAZANDA.............................. 10 leena 28 ................................. 53 leflunomide............................ 59 LENVIMA .............................. 26 lessina.................................... 53 letrozole ................................. 25 leucovorin calcium ............... 25 LEUKERAN .......................... 24 LEUKINE ............................... 38 leuprolide ............................... 57 leva set .................................. 10 levalbuterol hcl ..................... 65 LEVEMIR FLEXTOUCH U-

100 INSULN...................... 37 LEVEMIR U-100 INSULIN . 37 levetiracetam ........................ 16 levobunolol ............................ 63 levocarnitine.......................... 47 levocarnitine (with sugar).... 47 levocetirizine ......................... 64 levofloxacin ........................... 15 levofloxacin in d5w .............. 15 levonest (28) ......................... 53 levonorgestrel-ethinyl estrad

............................................ 53 levonorg-eth estrad triphasic

............................................ 54 levora-28 ............................... 54 LEVO-T.................................. 56 levothyroxine ........................ 56 LEVOXYL .............................. 56 LEXIVA .................................. 33 lidocaine ................................ 11 lidocaine hcl .................... 10, 11 lidocaine viscous .................. 11 lidocaine-prilocaine .............. 11 lidopac ................................... 11 lidopril .................................... 11 lidopril xr ................................ 11 lido-prilo caine pack ............. 11 lillow (28) ............................... 54 lindane ................................... 28 linezolid.................................. 12 linezolid in dextrose 5% ...... 12 linezolid-0.9% sodium

chloride .............................. 12 LINZESS ............................... 49

liothyronine ............................ 56 liprozonepak ......................... 11 lisinopril .................................. 40 lisinopril-hydrochlorothiazide

............................................ 42 lithium carbonate .................. 34 lithium citrate......................... 34 livixil pak ................................ 11 LOESTRIN 1.5/30 (21) ........ 54 LONSURF ............................. 25 loperamide ............................ 49 lopinavir-ritonavir .................. 33 lopreeza ................................. 54 lorazepam ............................. 34 lorazepam intensol............... 34 LORBRENA .......................... 26 losartan .................................. 39 losartan-hydrochlorothiazide

............................................ 42 lovastatin ............................... 43 low-ogestrel (28) .................. 54 loxapine succinate ............... 29 LUCEMYRA .......................... 11 LUMIGAN .............................. 62 LUPRON DEPOT................. 57 LUPRON DEPOT (3

MONTH) ............................ 57 LUPRON DEPOT (4

MONTH) ............................ 57 LUPRON DEPOT (6

MONTH) ............................ 57 LUPRON DEPOT-PED ....... 57 LUPRON DEPOT-PED (3

MONTH) ............................ 57 lutera (28) .............................. 54 LYNPARZA ........................... 25 LYSODREN .......................... 27 lyza ......................................... 55 M magnesium sulfate............... 47 malathion ............................... 28 maprotiline............................. 19 marlissa (28) ......................... 54 MARPLAN ............................. 19 MATULANE .......................... 24 MAVYRET ............................. 31 MAYZENT ............................. 45 meclizine ............................... 20 meclofenamate ..................... 10

INDEX

75

medolor pak .......................... 11 medroxyprogesterone ......... 55 mefloquine ............................ 27 megestrol .............................. 55 MEKINIST ............................. 26 MEKTOVI .............................. 26 meloxicam ............................. 10 memantine ............................ 18 MENACTRA (PF)................. 60 MENEST ............................... 52 MENTAX ............................... 21 MENVEO A-C-Y-W-135-DIP

(PF) .................................... 60 meperidine ............................ 10 mercaptopurine .................... 25 meropenem .......................... 14 meropenem-0.9% sodium

chloride .............................. 14 mesalamine .......................... 62 mesalamine with cleansing

wipe .................................... 62 MESNEX ............................... 25 metaproterenol ..................... 65 metaxall ................................. 67 metaxalone ........................... 67 metformin .............................. 35 methadone ............................ 10 methazolamide ..................... 42 methenamine hippurate ...... 12 methimazole ......................... 57 methocarbamol .................... 67 methotrexate sodium .......... 58 methotrexate sodium (pf) ... 58 methoxsalen ......................... 46 methyclothiazide .................. 43 methyldopa ........................... 39 methyldopa-

hydrochlorothiazide ......... 42 methylphenidate hcl ............ 44 methylpred dp ...................... 23 methylprednisolone ....... 23, 62 methylprednisolone acetate

............................................ 51 methyltestosterone .............. 51 metoclopramide hcl ............. 20 metolazone ........................... 43 metoprolol succinate ........... 40 metoprolol ta-

hydrochlorothiaz .............. 40

metoprolol tartrate ............... 40 metro i.v................................. 12 metronidazole ................. 12, 13 metronidazole in nacl (iso-os)

............................................ 12 mexiletine .............................. 40 micafungin ............................. 21 microgestin 1.5/30 (21) ....... 54 microgestin 1/20 (21) .......... 54 microgestin fe 1.5/30 (28) ... 54 microgestin fe 1/20 (28) ...... 54 midodrine .............................. 39 mili .......................................... 54 mimvey .................................. 54 minocycline ........................... 16 minoxidil ................................ 43 mirtazapine ........................... 19 misoprostol............................ 50 M-M-R II (PF)........................ 60 modafinil ................................ 67 moexipril ................................ 40 molindone.............................. 29 mometasone ................... 23, 64 mononessa (28) ................... 54 montelukast .......................... 64 morgidox 1x 50 ..................... 16 morphine ............................... 10 moxifloxacin .................... 15, 16 moxifloxacin-sod.ace,sul-

water .................................. 16 moxifloxacin-sod.chloride(iso)

............................................ 16 MULTAQ ............................... 40 mupirocin ............................... 13 mycophenolate mofetil ........ 58 mycophenolate sodium ....... 58 myorisan ................................ 46 MYRBETRIQ ........................ 51 N nabumetone .......................... 10 nadolol ................................... 40 nafcillin ................................... 15 nafcillin in dextrose iso-osm

............................................ 15 nalbuphine ............................ 10 naloxone ................................ 11 naltrexone ............................. 11 NAMENDA XR ..................... 18 naproxen ............................... 10

naproxen sodium ................. 10 NARCAN ............................... 11 NATACYN ............................. 62 nateglinide ............................. 35 NATPARA ............................. 62 NAYZILAM ............................ 17 necon 0.5/35 (28) ................. 54 necon 7/7/7 (28) ................... 54 nefazodone ........................... 19 neomycin ............................... 12 neomycin-bacitracin-poly-hc

............................................ 13 neomycin-bacitracin-

polymyxin .......................... 13 neomycin-polymyxin b-

dexameth........................... 13 neomycin-polymyxin-

gramicidin .......................... 13 neomycin-polymyxin-hc 13, 63 NERLYNX ............................. 26 NEULASTA ........................... 38 NEUPOGEN ................... 38, 39 NEUPRO ............................... 28 nevirapine .............................. 32 NEXAVAR ............................. 26 NEXLETOL ........................... 43 niacin ...................................... 43 NICOTROL ........................... 11 NICOTROL NS ..................... 11 nifedipine ............................... 41 nilutamide .............................. 24 nimodipine ............................. 41 NINLARO .............................. 25 nitisinone ............................... 50 NITRO-BID ............................ 44 NITRO-DUR .......................... 44 nitrofurantoin macrocrystal . 13 nitrofurantoin monohyd/m-

cryst .................................... 13 nitroglycerin........................... 44 NITYR .................................... 50 NIVESTYM ............................ 39 NOCTIVA .............................. 56 nora-be .................................. 55 NORDITROPIN FLEXPRO 56 norethindrone (contraceptive)

............................................ 55 norethindrone acetate ......... 55

INDEX

76

norethindrone ac-eth estradiol ............................. 54

norethindrone-e.estradiol-iron ............................................ 54

norgestimate-ethinyl estradiol ............................................ 54

norlyda ................................... 54 norlyroc .................................. 55 NORMOSOL-R .................... 47 NORMOSOL-R PH 7.4 ....... 47 NORPACE CR ..................... 40 NORTHERA ......................... 39 nortrel 0.5/35 (28) ................ 54 nortrel 1/35 (21) ................... 54 nortrel 1/35 (28) ................... 54 nortrel 7/7/7 (28) .................. 54 nortriptyline ........................... 20 NORVIR ................................ 33 NOVOLIN 70/30 U-100

INSULIN ............................ 37 NOVOLIN N NPH U-100

INSULIN ............................ 37 NOVOLIN R REGULAR U-

100 INSULN ..................... 37 NOXAFIL ............................... 21 NUBEQA ............................... 24 NUCALA ................................ 59 NUEDEXTA .......................... 45 NULOJIX ............................... 58 NUPLAZID ............................ 30 NUTROPIN AQ NUSPIN .... 56 nyamyc .................................. 21 nystatin .................................. 21 nystatin-triamcinolone ......... 46 nystop .................................... 21 O OCALIVA .............................. 49 ocella ..................................... 54 octreotide acetate ................ 57 ODEFSEY ............................. 32 ODOMZO .............................. 25 OFEV ..................................... 66 ofloxacin .......................... 16, 63 olanzapine ............................ 30 olmesartan ............................ 39 olmesartan-amlodipin-

hcthiazid ............................ 42 olmesartan-

hydrochlorothiazide ......... 42

olopatadine ........................... 63 omega-3 acid ethyl esters .. 43 omeprazole ........................... 50 OMNITROPE ........................ 56 ondansetron .......................... 20 ondansetron hcl ................... 20 ORENCIA .............................. 58 ORENCIA (WITH MALTOSE)

............................................ 58 ORENCIA CLICKJECT ....... 58 ORFADIN .............................. 50 ORILISSA.............................. 57 ORKAMBI.............................. 65 orphenadrine citrate ............ 67 orsythia .................................. 54 oseltamivir ............................. 34 OTEZLA ................................ 59 OTEZLA STARTER ............. 59 oxandrolone .......................... 51 OXBRYTA ............................. 39 oxcarbazepine ...................... 18 OXERVATE .......................... 62 oxybutynin chloride .............. 51 oxycodone ............................. 10 oxycodone-acetaminophen .. 9 oxycodone-aspirin ................. 9 OZEMPIC .............................. 35 P paliperidone .......................... 30 PANRETIN ............................ 27 pantoprazole ......................... 50 paricalcitol ............................. 49 paromomycin ........................ 12 paroxetine hcl ....................... 19 PASER .................................. 24 PAXIL ..................................... 19 PEDIARIX (PF) .................... 60 PEDVAX HIB (PF) ............... 60 peg 3350-electrolytes .......... 49 PEGANONE ......................... 18 PEGASYS ............................. 31 PEGASYS PROCLICK ....... 31 peg-electrolyte soln ............. 50 PEMAZYRE .......................... 26 pen needle, diabetic ............ 36 penicillamine ......................... 58 penicillin g procaine ............. 15 penicillin g sodium ............... 15 penicillin v potassium .......... 15

PENTACEL (PF) .................. 61 PENTACEL ACTHIB

COMPONENT (PF) ......... 61 PENTACEL DTAP-IPV

COMPNT (PF) .................. 61 pentamidine .......................... 27 PENTASA ............................. 62 pentazocine-naloxone ........... 9 pentoxifylline ......................... 42 PERFOROMIST ................... 65 PERIOGARD ........................ 45 permethrin ............................. 28 perphenazine ........................ 20 perphenazine-amitriptyline . 19 PERSERIS ............................ 30 phenelzine ............................. 19 phenobarbital ........................ 17 phenoxybenzamine ............. 39 PHENYTEK........................... 18 phenytoin ............................... 18 phenytoin sodium extended

............................................ 18 PHOSPHOLINE IODIDE .... 63 PIFELTRO............................. 32 pilocarpine hcl................. 45, 63 pimecrolimus......................... 46 pimozide ................................ 29 pimtrea (28)........................... 54 pindolol .................................. 40 pioglitazone ........................... 35 pioglitazone-metformin ........ 35 piperacillin-tazobactam ....... 15 PIQRAY ................................. 25 pirmella .................................. 54 piroxicam ............................... 10 plenamine .............................. 47 podofilox ................................ 46 polymyxin b sulfate .............. 13 polymyxin b sulf-trimethoprim

............................................ 13 POMALYST .......................... 24 portia 28................................. 54 posaconazole ....................... 21 potassium chlorid-d5-

0.45%nacl ......................... 48 potassium chloride ............... 48 potassium chloride in water 48 potassium citrate .................. 48 PRADAXA ............................. 38

INDEX

77

PRALUENT PEN ................. 43 pramipexole .......................... 28 prasugrel ............................... 39 pravastatin ............................ 43 praziquantel .......................... 27 prazosin ................................. 39 prednicarbate ....................... 46 prednisolone ......................... 23 prednisolone acetate ........... 63 prednisolone sodium

phosphate ................... 23, 63 prednisone ............................ 23 prednisone intensol ............. 51 pregabalin ............................. 17 PREMARIN ........................... 52 PREMPHASE ....................... 54 PREMPRO ............................ 54 PRENATAL VITAMIN PLUS

LOW IRON ........................ 49 PRETOMANID ..................... 24 prevalite ................................. 43 previfem................................. 54 PREVYMIS ........................... 31 PREZCOBIX ......................... 33 PREZISTA ...................... 33, 34 PRIFTIN ................................ 24 prilolid .................................... 11 prilovix lite ............................. 11 prilovix lite plus ..................... 11 prilovix ultralite ..................... 11 prilovix ultralite plus ............. 11 primaquine ............................ 28 primidone .............................. 17 PRIVIGEN ............................. 59 probenecid ............................ 22 probenecid-colchicine ......... 22 prochlorperazine .................. 20 prochlorperazine maleate ... 20 PROCRIT .............................. 39 procto-med hc ...................... 51 procto-pak ............................. 51 proctosol hc .......................... 51 proctozone-hc ...................... 51 progesterone micronized .... 55 PROGRAF ............................ 58 PROLASTIN-C ..................... 50 PROLIA ................................. 62 PROMACTA ......................... 39 promethazine .................. 20, 64

promethazine vc ................... 66 promethazine-phenylephrine

............................................ 66 promethegan ........................ 20 propafenone ......................... 40 proparacaine ......................... 62 propranolol ............................ 40 propranolol-

hydrochlorothiazid ........... 42 propylthiouracil ..................... 57 PROQUAD (PF) ................... 61 protriptyline ........................... 20 PULMOZYME ....................... 65 PURIXAN .............................. 25 pyrazinamide ........................ 24 pyridostigmine bromide ....... 24 pyrimethamine ...................... 28 Q QINLOCK .............................. 26 QUADRACEL (PF) .............. 61 quasense ............................... 54 quetiapine ............................. 30 quinapril ................................. 40 quinapril-hydrochlorothiazide

............................................ 42 quinidine gluconate ............. 40 quinidine sulfate ................... 40 quinine sulfate ...................... 28 QVAR ..................................... 64 QVAR REDIHALER ............. 64 R RABAVERT (PF).................. 61 raloxifene ............................... 55 ramelteon .............................. 67 ramipril ................................... 40 ranolazine.............................. 42 rasagiline ............................... 28 RAVICTI ................................ 50 REBIF (WITH ALBUMIN) ... 45 REBIF REBIDOSE .............. 45 REBIF TITRATION PACK .. 45 reclipsen (28) ........................ 54 RECOMBIVAX HB (PF) ...... 61 RECTIV ................................. 49 REGRANEX.......................... 46 RELENZA DISKHALER ...... 34 RELISTOR ............................ 49 repaglinide ............................ 36 REPATHA PUSHTRONEX 43

REPATHA SURECLICK ..... 43 REPATHA SYRINGE .......... 43 RESCRIPTOR ...................... 32 RESTASIS ............................ 63 RESTASIS MULTIDOSE .... 63 RETACRIT ............................ 39 RETEVMO ............................ 26 REVLIMID ............................. 24 REXULTI ............................... 30 REYATAZ .............................. 34 ribavirin .................................. 31 rifabutin .................................. 24 rifampin .................................. 24 riluzole ................................... 45 rimantadine ........................... 34 risedronate ............................ 62 RISPERDAL CONSTA ........ 30 risperidone ............................ 30 ritonavir .................................. 34 rivastigmine ........................... 18 rivastigmine tartrate ............. 18 rizatriptan............................... 23 ropinirole ................................ 28 rosuvastatin........................... 43 ROTARIX .............................. 61 ROTATEQ VACCINE .......... 61 roweepra ............................... 16 roweepra xr ........................... 16 ROZLYTREK ........................ 27 RUBRACA............................. 27 RYBELSUS ........................... 36 RYDAPT ................................ 27 S SAMSCA ............................... 48 SANDIMMUNE ..................... 58 SANTYL................................. 46 SAPHRIS............................... 30 SAVELLA .............................. 45 scopolamine base ................ 20 SECUADO ............................ 30 SEGLUROMET .................... 36 selegiline hcl ......................... 28 selenium sulfide ................... 46 SELZENTRY......................... 33 SEREVENT DISKUS........... 65 SEROSTIM ........................... 49 sertraline ................................ 19 setlakin................................... 54 sevelamer carbonate ........... 48

INDEX

78

sharobel ................................ 55 SHINGRIX (PF) .................... 61 SHINGRIX GE ANTIGEN

COMPONENT .................. 61 SIGNIFOR............................. 57 sildenafil (pulm.hypertension)

............................................ 66 silver sulfadiazine ................ 16 SIMBRINZA .......................... 63 simliya (28) ........................... 54 SIMPONI ......................... 58, 59 simvastatin ............................ 43 sirolimus ................................ 59 SIRTURO .............................. 24 sodium chloride .................... 48 sodium chloride 0.45 % ...... 48 sodium chloride 0.9 % ........ 48 sodium chloride 3 % ............ 48 sodium phenylbutyrate ........ 50 sodium polystyrene (sorb

free) .................................... 48 sodium polystyrene sulfonate

............................................ 48 sofosbuvir-velpatasvir ......... 31 SOLTAMOX .......................... 24 SOMATULINE DEPOT ....... 57 SOMAVERT ......................... 57 sorine ..................................... 40 sotalol .................................... 40 sotalol af ................................ 40 SOTALOL AF ....................... 40 SPIRIVA RESPIMAT .......... 64 SPIRIVA WITH

HANDIHALER .................. 64 spironolactone ...................... 42 spironolacton-

hydrochlorothiaz .............. 42 SPRAVATO .......................... 19 sprintec (28) .......................... 54 SPRITAM .............................. 16 SPRYCEL ............................. 27 SPS (WITH SORBITOL) .... 48 sronyx .................................... 54 SSD ........................................ 16 stavudine ............................... 33 STEGLATRO ........................ 36 STEGLUJAN ........................ 36 STELARA .............................. 46 STIOLTO RESPIMAT ......... 66

STIVARGA ............................ 27 streptomycin ......................... 12 STRIBILD .............................. 32 STRIVERDI RESPIMAT ..... 65 SUCRAID .............................. 50 sucralfate ............................... 50 sulfacetamide sodium ......... 16 sulfacetamide sodium (acne)

............................................ 16 sulfacetamide-prednisolone

............................................ 63 sulfadiazine ........................... 16 sulfamethoxazole-

trimethoprim ...................... 16 sulfasalazine ......................... 62 sulindac ................................. 10 sumatriptan ........................... 23 sumatriptan succinate ......... 23 SUTENT ................................ 27 SYLATRON .......................... 25 SYMDEKO ............................ 65 SYMFI .................................... 33 SYMFI LO ............................. 32 SYMLINPEN 120 ................. 36 SYMLINPEN 60 ................... 36 SYMPAZAN .......................... 17 SYMTUZA ............................. 33 SYNAREL ............................. 57 SYNDROS ............................ 20 SYNJARDY ........................... 36 SYNJARDY XR .................... 36 SYNRIBO .............................. 25 SYNTHROID ........................ 56 T TABLOID ............................... 25 TABRECTA ........................... 27 tacrolimus ........................ 46, 59 TAFINLAR ............................. 27 TAGRISSO ........................... 27 TALZENNA ........................... 25 tamoxifen ............................... 25 tamsulosin ............................. 51 TARGRETIN ......................... 27 tarina fe 1/20 (28) ................ 54 tarina fe 1-20 eq (28) ........... 54 TASIGNA .............................. 27 tazarotene ............................. 46 tazicef .................................... 14 TAZORAC ............................. 46

taztia xt .................................. 41 TAZVERIK............................. 25 tdvax....................................... 61 TECFIDERA ......................... 45 TEFLARO .............................. 14 TEKTURNA HCT ................. 42 temazepam ........................... 67 TENIVAC (PF) ...................... 61 tenofovir disoproxil fumarate

............................................ 31 terazosin ................................ 39 terbinafine hcl ....................... 21 terbutaline ............................. 65 terconazole ........................... 21 testosterone .......................... 52 testosterone cypionate ........ 51 testosterone enanthate ....... 51 TETANUS,DIPHTHERIA

TOX PED(PF) ................... 61 tetrabenazine ........................ 45 tetracycline ............................ 16 THALOMID ........................... 24 theophylline ........................... 65 THIOLA .................................. 51 THIOLA EC ........................... 51 thioridazine ............................ 29 thiothixene ............................. 29 tiagabine ................................ 17 TIBSOVO .............................. 27 TICE BCG ............................. 61 timolol maleate ............... 40, 63 tinidazole ............................... 13 TIVICAY................................. 32 TIVICAY PD .......................... 32 tizanidine ............................... 31 TOBRADEX .......................... 12 tobramycin............................. 12 tobramycin in 0.225 % nacl 65 tobramycin sulfate ................ 12 tobramycin with nebulizer ... 65 tobramycin-dexamethasone

............................................ 12 tolcapone ............................... 28 tolterodine ............................. 51 tolvaptan ................................ 48 topiramate ............................. 18 toremifene ............................. 25 torsemide............................... 42

INDEX

79

TOUJEO MAX U-300 SOLOSTAR ...................... 37

TOUJEO SOLOSTAR U-300 INSULIN ............................ 37

TOVIAZ ................................. 51 TRADJENTA ........................ 36 tramadol ................................ 10 tramadol-acetaminophen ...... 9 trandolapril ............................ 40 tranexamic acid .................... 39 tranylcypromine .................... 19 travoprost .............................. 62 travoprost (benzalkonium) .. 62 trazodone .............................. 19 TRECATOR .......................... 24 TRELEGY ELLIPTA ............ 66 TRELSTAR ........................... 57 TREMFYA ............................. 46 tretinoin .................................. 46 tretinoin (antineoplastic) ..... 27 tretinoin (emollient) .............. 46 TREXALL .............................. 59 tri femynor ............................. 54 triamcinolone acetonide 23, 45 triamterene-

hydrochlorothiazid ........... 42 triderm ................................... 23 trientine .................................. 48 tri-estarylla ............................ 55 trifluoperazine ....................... 29 trifluridine .............................. 32 trihexyphenidyl ..................... 28 TRIKAFTA............................. 65 triklo ....................................... 43 tri-legest fe ............................ 55 trilyte with flavor packets .... 50 trimethobenzamide .............. 20 trimethoprim .......................... 13 tri-mili ..................................... 55 trimipramine .......................... 20 trinessa (28) .......................... 55 TRINTELLIX ......................... 19 tri-previfem (28) .................... 55 tri-sprintec (28) ..................... 55 TRIUMEQ ............................. 32 trivora (28)............................. 55 tri-vylibra ................................ 55 trospium................................. 51 TRULICITY ........................... 36

TRUMENBA.......................... 61 TRUVADA ............................. 33 TUKYSA ................................ 27 tulana ..................................... 55 TURALIO ............................... 27 TWINRIX (PF) ...................... 61 TYBOST ................................ 33 TYKERB ................................ 27 TYMLOS................................ 62 TYPHIM VI ............................ 61 U UNITHROID .......................... 56 ursodiol .................................. 49 V VABOMERE ......................... 14 valacyclovir ........................... 32 VALCHLOR .......................... 24 valganciclovir ........................ 31 valproic acid .......................... 17 valproic acid (as sodium salt)

............................................ 17 valsartan ................................ 39 valsartan-hydrochlorothiazide

............................................ 42 VALTOCO ............................. 17 vancomycin ........................... 13 VAQTA (PF).......................... 61 VARIVAX (PF) ...................... 61 VARIZIG ................................ 61 VAXCHORA VACCINE ....... 61 velivet triphasic regimen (28)

............................................ 55 VELPHORO .......................... 48 VEMLIDY .............................. 31 VENCLEXTA ........................ 25 VENCLEXTA STARTING

PACK ................................. 25 venlafaxine ............................ 19 VENTAVIS ............................ 66 VENTOLIN HFA ................... 65 verapamil ............................... 41 VERSACLOZ ........................ 31 VERZENIO............................ 27 VICTOZA 2-PAK .................. 36 VICTOZA 3-PAK .................. 36 VIDEX 2 GRAM PEDIATRIC

............................................ 33 VIDEX 4 GRAM PEDIATRIC

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

VIDEX EC ............................. 33 vienva..................................... 55 vigabatrin ............................... 17 VIGADRONE ........................ 17 VIIBRYD .......................... 19, 20 VIMPAT ................................. 18 VIRACEPT ............................ 34 VIREAD ................................. 31 VITRAKVI .............................. 27 VIZIMPRO ............................. 25 volnea (28) ............................ 55 voriconazole .......................... 21 VOSEVI ................................. 31 VOTRIENT ............................ 27 VRAYLAR ............................. 30 vyfemla (28) .......................... 55 vylibra..................................... 55 W warfarin .................................. 38 wixela inhub .......................... 66 X XALKORI ............................... 27 XARELTO ............................. 38 XATMEP ................................ 59 XCOPRI ................................. 17 XCOPRI MAINTENANCE

PACK ................................. 17 XCOPRI TITRATION PACK

............................................ 17 XELJANZ............................... 59 XELJANZ XR ........................ 59 XERMELO............................. 49 XGEVA .................................. 62 XIFAXAN ............................... 49 XIIDRA ................................... 63 XOLAIR ................................. 59 XOSPATA ............................. 27 XPOVIO ................................. 25 XTANDI ................................. 24 xulane .................................... 55 XURIDEN .............................. 50 XYREM .................................. 64 Y YF-VAX (PF) ......................... 61 YONSA .................................. 24 yuvafem ................................. 52 Z zafirlukast .............................. 64 zaleplon ................................. 67

INDEX

80

zarah ...................................... 55 ZARXIO ................................. 39 ZEJULA ................................. 27 ZELBORAF ........................... 27 ZEMAIRA .............................. 50 zenatane ............................... 46 ZENPEP ................................ 50 ZERIT .................................... 33

zidovudine ............................. 33 ZIEXTENZO.......................... 39 ziprasidone hcl ..................... 30 ziprasidone mesylate .......... 30 ZIRGAN ................................. 31 ZOLINZA ............................... 25 zolpidem ................................ 67 zonisamide ............................ 17

ZORTRESS .......................... 59 ZOSTAVAX (PF) .................. 61 zovia 1/35e (28) ................... 55 ZTLIDO .................................. 11 ZYDELIG ............................... 25 ZYKADIA ............................... 27 ZYPREXA RELPREVV . 30, 31 ZYTIGA .................................. 24

All drugs listed as over-the-counter (OTC) drugs have no prior authorization, quantity limit, or step therapy requirements. 81

E. List of Over-the-Counter (OTC) Drugs by Drug Type

Antihistamine Drugs ......................................................................................................... 82

Autonomic Drugs .............................................................................................................. 86

Blood Formation, Coagulation, Thrombosis .................................................................. 87

Cardiovascular Drugs ...................................................................................................... 92

Central Nervous System Agents ..................................................................................... 93

Contraceptives (E.G. Foams, Devices) ........................................................................... 97

Devices .............................................................................................................................. 98

Electrolytic, Caloric, And Water Balance ........................................................................ 98

Eye, Ear, Nose And Throat (Eent) Preps. ...................................................................... 101

Gastrointestinal Drugs ................................................................................................... 103

Hormones And Synthetic Substitutes .......................................................................... 110

Miscellaneous Therapeutic Agents ............................................................................... 110

Pharmaceutical Aids ...................................................................................................... 111

Respiratory Tract Agents ............................................................................................... 111

Skin And Mucous Membrane Agents ............................................................................ 117

Vitamins ........................................................................................................................... 123

LIST OF OVER-THE-COUNTER (OTC) DRUGS BY DRUG TYPE


Drug What the drug will cost you (tier level)

Notes

Antihistamine Drugs Ethanolamine Derivatives Acetadryl $0 (OTC) Acetaminophen PM $0 (OTC) Acetaminophen PM Extra Str $0 (OTC) Aler-Cap $0 (OTC) Alka-Seltzer Plus Allergy $0 (OTC) Aller-G-Time $0 (OTC) Allergy (diphenhydramine) $0 (OTC) Allergy Medication $0 (OTC) Allergy Medicine oral tablet $0 (OTC) Allergy oral tablet $0 (OTC) Allergy Relief (clemastine) $0 (OTC) Allergy Relief(diphenhydramin) $0 (OTC) Banophen oral capsule $0 (OTC) Banophen oral tablet $0 (OTC) Benadryl Allergy $0 (OTC) Children's Allergy (diphenhyd) oral liquid $0 (OTC) Children's Benadryl Allergy oral tablet,chewable $0 (OTC) Children's Wal-Dryl Allergy oral liquid $0 (OTC) Children's Wal-Dryl Allergy oral prefilled spoon $0 (OTC) Complete Allergy Medicine $0 (OTC) Complete Allergy oral capsule $0 (OTC) Complete Allergy oral tablet $0 (OTC) Compoz $0 (OTC) Dayhist Allergy $0 (OTC) Diphedryl $0 (OTC) Diphedryl Allergy $0 (OTC) Diphen oral tablet $0 (OTC) diphenhydramine HCl oral capsule $0 (OTC) diphenhydramine HCl oral elixir $0 (OTC) diphenhydramine HCl oral liquid $0 (OTC) diphenhydramine HCl oral syrup $0 (OTC) diphenhydramine HCl oral tablet 25 mg $0 (OTC) diphenhydramine-acetaminophen $0 (OTC) EaZZZe The Pain $0 (OTC) Geri-Dryl oral liquid $0 (OTC) Geri-Dryl oral tablet $0 (OTC) Headache PM $0 (OTC) Mapap PM $0 (OTC) Night Time Pain Medicine $0 (OTC) Nighttime Allergy Relief $0 (OTC) NightTime Sleep Aid (diphen) oral tablet $0 (OTC) Non-Aspirin PM $0 (OTC) Nytol $0 (OTC) Pain and Sleep $0 (OTC) Pain Relief PM $0 (OTC) Pain Relief PM Rapid Release $0 (OTC) Pain Reliever PM Ex-Strength $0 (OTC) Pain Reliever PM oral tablet 25-500 mg $0 (OTC) Pharbedryl $0 (OTC)




Notes

Siladryl SA $0 (OTC) Simply Sleep $0 (OTC) Sleep Aid (diphenhydramine) oral tablet $0 (OTC) Sleep II $0 (OTC) Sleep Tablet (diphenhydramine) $0 (OTC) Total Allergy Medicine $0 (OTC) Tylenol PM Extra Strength $0 (OTC) Valu-Dryl Allergy oral capsule $0 (OTC) Wal-Dryl Allergy $0 (OTC) Wal-Nadol PM $0 (OTC) Ethylenediamine Derivatives Menstrual Relief $0 (OTC) First Generation Antihistamines Aler-Cap $0 (OTC) Alka-Seltzer Plus Allergy $0 (OTC) Aller-G-Time $0 (OTC) Allergy (chlorpheniramine) $0 (OTC) Allergy (diphenhydramine) $0 (OTC) Allergy 4-Hour $0 (OTC) Allergy Medication $0 (OTC) Allergy Medicine oral tablet $0 (OTC) Allergy oral tablet $0 (OTC) Allergy Relief (clemastine) $0 (OTC) Allergy Relief(chlorpheniramn) oral tablet $0 (OTC) Allergy Relief(diphenhydramin) $0 (OTC) Allergy-Time $0 (OTC) Banophen oral capsule $0 (OTC) Banophen oral tablet $0 (OTC) Benadryl Allergy $0 (OTC) Children's Allergy (diphenhyd) oral liquid $0 (OTC) Children's Wal-Dryl Allergy oral liquid $0 (OTC) ChlorHist $0 (OTC) chlorpheniramine maleate oral tablet $0 (OTC) ChlorTabs $0 (OTC) Complete Allergy Medicine $0 (OTC) Complete Allergy oral capsule $0 (OTC) Complete Allergy oral tablet $0 (OTC) Compoz $0 (OTC) Dayhist Allergy $0 (OTC) Diphedryl $0 (OTC) Diphedryl Allergy $0 (OTC) Diphen oral tablet $0 (OTC) diphenhydramine HCl oral capsule $0 (OTC) diphenhydramine HCl oral elixir $0 (OTC) diphenhydramine HCl oral liquid $0 (OTC) diphenhydramine HCl oral syrup $0 (OTC) diphenhydramine HCl oral tablet 25 mg $0 (OTC) ED Chlorped Jr $0 (OTC) Geri-Dryl oral liquid $0 (OTC) Geri-Dryl oral tablet $0 (OTC) Nighttime Allergy Relief $0 (OTC)




Notes

NightTime Sleep Aid (diphen) oral tablet $0 (OTC) Nytol $0 (OTC) Pharbechlor $0 (OTC) Pharbedryl $0 (OTC) Siladryl SA $0 (OTC) Simply Sleep $0 (OTC) Sleep Aid (diphenhydramine) oral tablet $0 (OTC) Sleep II $0 (OTC) Sleep Tablet (diphenhydramine) $0 (OTC) Total Allergy Medicine $0 (OTC) Valu-Dryl Allergy oral capsule $0 (OTC) Wal-Dryl Allergy $0 (OTC) Wal-Finate $0 (OTC) Piperazine Derivatives Dramamine Less Drowsy $0 (OTC) meclizine oral tablet 12.5 mg, 25 mg $0 (OTC) meclizine oral tablet,chewable $0 (OTC) Medi-Meclizine $0 (OTC) Motion Relief (meclizine) $0 (OTC) Motion Sickness (meclizine) $0 (OTC) Motion Sickness II $0 (OTC) Motion Sickness Relief(mecliz) $0 (OTC) Motion-Time $0 (OTC) Travel-Ease (meclizine) $0 (OTC) VertiCalm $0 (OTC) Wal-Dram 2 $0 (OTC) Propylamine Derivatives Allergy (chlorpheniramine) $0 (OTC) Allergy 4-Hour $0 (OTC) Allergy Relief(chlorpheniramn) oral tablet $0 (OTC) Allergy-Time $0 (OTC) Child Triaminic Cold-Allergy $0 (OTC) Child Wal-Tap Cold-Allergy $0 (OTC) Children's Cold and Cough (PE) $0 (OTC) Children's Cold-Allergy (PE) $0 (OTC) Children's Dibromm Cold-Allerg $0 (OTC) Children's Dibromm DM Cold-Cou $0 (OTC) ChlorHist $0 (OTC) chlorpheniramine maleate oral tablet $0 (OTC) ChlorTabs $0 (OTC) Cold and Allergy (bromphen-PE) $0 (OTC) Cold and Cough DM $0 (OTC) Cold and Cough Elixir $0 (OTC) Dimaphen (PE) $0 (OTC) Dimaphen DM $0 (OTC) Dimetapp Cold-Allergy (PE) $0 (OTC) Dimetapp DM Cold-Cough (PE) $0 (OTC) ED Chlorped Jr $0 (OTC) EndaCof - DM $0 (OTC) LoHist - D $0 (OTC) Pharbechlor $0 (OTC)




Notes

Rynex DM $0 (OTC) Rynex PE $0 (OTC) Rynex PSE $0 (OTC) SudoGest Cold and Allergy $0 (OTC) SudoGest Sinus and Allergy $0 (OTC) Valu-Tapp $0 (OTC) Wal-Finate $0 (OTC) Wal-Finate-D $0 (OTC) Wal-phed oral tablet 4-60 mg $0 (OTC) Wal-Tap $0 (OTC) Wal-tap DM $0 (OTC) Second Generation Antihistamines 24Hour Allergy $0 (OTC) Alavert $0 (OTC) Alavert D-12 Allergy-Sinus $0 (OTC) All Day Allergy (cetirizine) oral solution $0 (OTC) All Day Allergy (cetirizine) oral tablet $0 (OTC) All Day Allergy-D $0 (OTC) Allerclear $0 (OTC) AllerClear D-12hr $0 (OTC) AllerClear D-24hr $0 (OTC) Allergy and Congestion Relief $0 (OTC) Allergy Complete-D $0 (OTC) Allergy Relief (cetirizine) oral solution $0 (OTC) Allergy Relief (cetirizine) oral tablet $0 (OTC) Allergy Relief (loratadine) $0 (OTC) Allergy Relief D12 $0 (OTC) Allergy Relief D-24hr $0 (OTC) Allergy Relief,Nasal Decongest $0 (OTC) Allergy Relief-D (cetirizine) $0 (OTC) Allergy Relief-D (loratadine) $0 (OTC) Allergy-Congestion Relief-D oral tablet extended release 24 hr $0 (OTC) Aller-Tec $0 (OTC) Aller-Tec D $0 (OTC) Cetiri-D $0 (OTC) cetirizine $0 (OTC) cetirizine-pseudoephedrine $0 (OTC) Child Allergy Relf(cetirizine) oral solution $0 (OTC) Children's Allergy Relief(lor) $0 (OTC) Children's Allergy(cetirizine) $0 (OTC) Children's Cetirizine $0 (OTC) Children's Loratadine $0 (OTC) Children's Wal-Zyr $0 (OTC) Children's Zyrtec Allergy oral solution $0 (OTC) Child's All Day Allergy(cetir) $0 (OTC) Claritin RediTabs oral tablet,disintegrating 5 mg $0 (OTC) Loradamed $0 (OTC) Lorata-D $0 (OTC) lorata-dine D $0 (OTC) loratadine oral solution $0 (OTC) loratadine oral tablet $0 (OTC)




Notes

loratadine oral tablet,disintegrating $0 (OTC) Loratadine-D $0 (OTC) Wal-itin D $0 (OTC) Wal-Itin D 12 Hour $0 (OTC) Wal-itin oral solution $0 (OTC) Wal-itin oral tablet $0 (OTC) Wal-Zyr (cetirizine) oral solution $0 (OTC) Wal-Zyr (cetirizine) oral tablet $0 (OTC) Wal-Zyr D $0 (OTC) Autonomic Drugs Alpha- And Beta-Adrenergic Agonists 12 Hour Decongestant $0 (OTC) 12 Hour Nasal Decongest (PSE) $0 (OTC) Adult Nasal Decongestant $0 (OTC) Alavert D-12 Allergy-Sinus $0 (OTC) All Day Allergy-D $0 (OTC) AllerClear D-12hr $0 (OTC) AllerClear D-24hr $0 (OTC) Allergy and Congestion Relief $0 (OTC) Allergy Complete-D $0 (OTC) Allergy Relief D12 $0 (OTC) Allergy Relief D-24hr $0 (OTC) Allergy Relief,Nasal Decongest $0 (OTC) Allergy Relief-D (cetirizine) $0 (OTC) Allergy Relief-D (loratadine) $0 (OTC) Allergy-Congestion Relief-D oral tablet extended release 24 hr $0 (OTC) Aller-Tec D $0 (OTC) Cetiri-D $0 (OTC) cetirizine-pseudoephedrine $0 (OTC) Children's Silfedrine $0 (OTC) Children's Sudafed $0 (OTC) LoHist - D $0 (OTC) Long Acting Nasal Decong (PSE) $0 (OTC) Lorata-D $0 (OTC) lorata-dine D $0 (OTC) Loratadine-D $0 (OTC) Mucus D oral tablet extended release 12 hr 60-600 mg $0 (OTC) Mucus Relief D (pseudoephed) oral tablet extended release 12 hr $0 (OTC) Nasal Decongestant (pseudoeph) oral tablet $0 (OTC) Nasal Decongestant (pseudoeph) oral tablet extended release $0 (OTC) pseudoephedrine HCl oral tablet $0 (OTC) pseudoephedrine HCl oral tablet extended release $0 (OTC) pseudoephedrine-guaifenesin oral tablet extended release 12 hr 60-600 mg $0 (OTC) Rynex PSE $0 (OTC) Sinus 12 Hour $0 (OTC) Sudafed 24 Hour $0 (OTC) Sudogest $0 (OTC) Sudogest 12-hour $0 (OTC) SudoGest Cold and Allergy $0 (OTC) SudoGest Sinus and Allergy $0 (OTC) Suphedrin $0 (OTC)




Notes

Suphedrine $0 (OTC) Suphedrine 12 Hour $0 (OTC) Valu-Tapp $0 (OTC) Wal-Finate-D $0 (OTC) Wal-itin D $0 (OTC) Wal-Itin D 12 Hour $0 (OTC) Wal-phed $0 (OTC) Wal-phed 12 hour $0 (OTC) Wal-Phed D $0 (OTC) Wal-Zyr D $0 (OTC) Alpha-Adrenergic Agonists Child Triaminic Cold-Allergy $0 (OTC) Child Wal-Tap Cold-Allergy $0 (OTC) Children's Cold and Cough (PE) $0 (OTC) Children's Cold-Allergy (PE) $0 (OTC) Children's Dibromm Cold-Allerg $0 (OTC) Children's Dibromm DM Cold-Cou $0 (OTC) Cold and Allergy (bromphen-PE) $0 (OTC) Cold and Cough DM $0 (OTC) Cold and Cough Elixir $0 (OTC) Dimaphen (PE) $0 (OTC) Dimaphen DM $0 (OTC) Dimetapp Cold-Allergy (PE) $0 (OTC) Dimetapp DM Cold-Cough (PE) $0 (OTC) ED Bron GP $0 (OTC) EndaCof - DM $0 (OTC) Nasal Decongestant (PE) oral tablet 10 mg $0 (OTC) Rynex DM $0 (OTC) Rynex PE $0 (OTC) Sinus Decongestant (PE) $0 (OTC) Sinus PE Decongestant $0 (OTC) Sinus Pressure-Cong Relief PE $0 (OTC) Sudogest PE $0 (OTC) Suphedrine PE $0 (OTC) Wal-phed PE $0 (OTC) Wal-Tap $0 (OTC) Wal-tap DM $0 (OTC) Autonomic Drugs, Miscellaneous nicotine (polacrilex) $0 (OTC) nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr $0 (OTC) nicotine transdermal patch, TD daily, sequential $0 (OTC) Blood Formation, Coagulation, Thrombosis Iron Preparations A Thru Z Advanced Formula $0 (OTC) A Thru Z Men's Ultimate $0 (OTC) A Thru Z Select Women's $0 (OTC) Adults Multivitamin $0 (OTC) Animal Shapes Complete oral tablet,chewable 18 mg iron $0 (OTC) Bacmin $0 (OTC) Bio-35, Gluten Free $0 (OTC) Biotect Plus $0 (OTC)




Notes

Centamin $0 (OTC) Central-Vite oral tablet , 18 mg iron-400 mcg-25 mcg $0 (OTC) Central-Vite Women's Mature $0 (OTC) Centram-Care $0 (OTC) Centravites Adults $0 (OTC) Centrum Complete $0 (OTC) Centrum oral liquid 9 mg iron/15 mL $0 (OTC) Centrum oral tablet $0 (OTC) Centrum Women $0 (OTC) Century oral tablet 18-400 mg-mcg $0 (OTC) Century Ultimate Men's oral tablet 8 mg iron- 200 mcg-600 mcg $0 (OTC) Century Ultimate Women's $0 (OTC) Certa Plus $0 (OTC) Certavite-Antioxidant $0 (OTC) Children's Iron $0 (OTC) Classic Prenatal $0 (OTC) Complete Men $0 (OTC) Complete Multivitamin oral tablet $0 (OTC) Complete Multivitamin-Mineral $0 (OTC) Complete Premium Vitamin $0 (OTC) Complete Women $0 (OTC) CompleteNate $0 (OTC) Daily Multiple For Women $0 (OTC) Daily Multiple oral tablet 18-400 mg-mcg $0 (OTC) Daily Multiple Vitamins/Iron $0 (OTC) Daily Multivitamin with Iron $0 (OTC) Daily Vitamin Formula-Iron $0 (OTC) Daily Vitamin with Iron $0 (OTC) Dino-Life with Iron-Zinc $0 (OTC) Essentia $0 (OTC) EZFE 200 $0 (OTC) Feosol oral tablet 325 mg (65 mg iron) $0 (OTC) Ferate oral tablet 240 mg (27 mg iron) $0 (OTC) Fergon oral tablet 240 mg (27 mg iron) $0 (OTC) FeroSul oral tablet $0 (OTC) Ferretts $0 (OTC) Ferrex 150 $0 (OTC) Ferric x-150 $0 (OTC) Ferrocite $0 (OTC) Ferro-Time $0 (OTC) ferrous fumarate oral tablet 324 mg (106 mg iron) $0 (OTC) ferrous gluconate oral tablet 236 mg (27 mg iron), 240 mg (27 mg iron), 324 mg (38 mg iron) $0 (OTC)

ferrous sulfate oral drops $0 (OTC) ferrous sulfate oral elixir $0 (OTC) ferrous sulfate oral solution $0 (OTC) ferrous sulfate oral tablet 325 mg (65 mg iron) $0 (OTC) ferrous sulfate oral tablet,delayed release (DR/EC) $0 (OTC) FerrouSul $0 (OTC) Fortavit $0 (OTC) Freedavite $0 (OTC)




Notes

Hair Vitamins $0 (OTC) Hair, Skin and Nails Advanced $0 (OTC) Hemocyte $0 (OTC) Honey Bears with Iron-Zinc $0 (OTC) iFerex 150 $0 (OTC) Iron (dried) $0 (OTC) Iron (ferrous sulfate) $0 (OTC) iron oral tablet 325 mg (65 mg iron) $0 (OTC) iron oral tablet extended release 159 mg (45 mg iron) $0 (OTC) K-Pax Immune Support $0 (OTC) Maximum Daily Multivitamin $0 (OTC) Mega Multi for Women $0 (OTC) Mega Multivitamin with Mineral oral tablet 13.5-200-250 mg-mcg-mcg $0 (OTC) Megavite $0 (OTC) Men Under 50 Multivitamin $0 (OTC) Mini Prenatal $0 (OTC) Monocaps $0 (OTC) Multi Complete with Iron $0 (OTC) Multi For Her oral capsule $0 (OTC) Multi Vitamin $0 (OTC) Multi-Day with Iron $0 (OTC) Multilex $0 (OTC) Multilex-T and M $0 (OTC) Multiple Vitamin, Womens $0 (OTC) Multi-Vit with Fluoride-Iron $0 (OTC) multivitamin with iron $0 (OTC) multivitamin with minerals oral liquid $0 (OTC) Multi-Vite $0 (OTC) Myferon 150 $0 (OTC) Mynatal Advance $0 (OTC) Niva-Plus $0 (OTC) One Daily Calcium/Iron $0 (OTC) One Daily Energy oral tablet 9 mg iron-400 mcg-200 mg $0 (OTC) One Daily For Women $0 (OTC) One Daily Maximum $0 (OTC) One Daily Multi-Vit w-Mineral oral tablet $0 (OTC) One Daily Multivit-Iron(folic) $0 (OTC) One Daily Plus Iron oral tablet 18-400 mg-mcg $0 (OTC) One Daily Prenatal $0 (OTC) One Daily With Iron $0 (OTC) One Daily Women's Health $0 (OTC) One Daily Women's oral tablet 18 mg iron-400 mcg-450 mg Ca, 27-0.4 mg $0 (OTC) One-A-Day Teen Advantage $0 (OTC) One-A-Day Women's Healthy Skin $0 (OTC) One-A-Day Women's Petites $0 (OTC) Parvlex $0 (OTC) Pedia Iron $0 (OTC) Perry Prenatal $0 (OTC) PNV cmb#95-ferrous fumarate-FA $0 (OTC) Poly-Iron $0 (OTC) polysaccharide iron complex $0 (OTC)




Notes

PreNata $0 (OTC) Prenatal + DHA oral combo pack 28 mg iron-800 mcg-200 mg $0 (OTC) Prenatal Complete $0 (OTC) Prenatal Formula oral tablet 28 mg iron- 800 mcg $0 (OTC) Prenatal Low Iron $0 (OTC) Prenatal Multi $0 (OTC) Prenatal Multi-DHA (algal oil) $0 (OTC) Prenatal Multi-DHA(with vit K) $0 (OTC) Prenatal Multivitamins $0 (OTC) Prenatal One Daily $0 (OTC) Prenatal oral tablet $0 (OTC) Prenatal Plus (calcium carb) $0 (OTC) Prenatal Tablet $0 (OTC) Prenatal Vitamin oral tablet 27 mg iron- 0.8 mg, 27 mg iron- 800 mcg $0 (OTC) Prenatal Vitamin Plus Low Iron $0 (OTC) Prenatal Vitamin with Minerals $0 (OTC) prenatal vit-iron fum-folic ac $0 (OTC) prenatal vits96-iron fum-folic $0 (OTC) PrePlus $0 (OTC) ProRenal $0 (OTC) ProRenal QD $0 (OTC) Quintabs-M $0 (OTC) Sentry $0 (OTC) Siderol oral tablet $0 (OTC) Slow Release Iron oral tablet extended release 142 mg (45 mg iron), 160 mg (50 mg iron) $0 (OTC)

Spectravite Advanced Formula oral tablet 18-400 mg-mcg $0 (OTC) Spectravite Men's $0 (OTC) Spectravite Ultra Women $0 (OTC) Spectravite Ultra Women's Sr $0 (OTC) Stress Formula with Iron $0 (OTC) Stress Formula With Iron(sulf) $0 (OTC) Strovite Forte $0 (OTC) Super Multiple oral tablet $0 (OTC) Tab-A-Vite/Iron $0 (OTC) Theradex M $0 (OTC) Thera-M oral tablet , 9 mg iron-400 mcg $0 (OTC) Therapeutic-M oral tablet 9 mg iron-400 mcg $0 (OTC) Therapeutic-M Vitamin/Minerals $0 (OTC) Theratrum Complete with Lutein $0 (OTC) Therems-M $0 (OTC) TYR Cooler oral liquid $0 (OTC) Ultimate Women's Complete 50+ $0 (OTC) Ultra Freeda oral tablet 6 mg iron-267 mcg $0 (OTC) Vitamin D3 Complete $0 (OTC) Vitamins B Complex oral tablet 500 mg-400 mcg- 18 mg iron $0 (OTC) Women's Daily Caplet $0 (OTC) Women's Daily Formula oral tablet 18 mg iron-400 mcg-500 mg Ca, 27-0.4 mg $0 (OTC) Women's One Daily $0 (OTC) Yelets $0 (OTC) Zoo Friends Plus Iron $0 (OTC)




Notes

Platelet-Aggregation Inhibitors Added Strength Headache Relief $0 (OTC) Adult Aspirin Regimen $0 (OTC) Adult Low Dose Aspirin $0 (OTC) Aspir-81 $0 (OTC) Aspirin Childrens $0 (OTC) Aspirin Low Dose $0 (OTC) aspirin oral tablet $0 (OTC) aspirin oral tablet,chewable $0 (OTC) aspirin oral tablet,delayed release (DR/EC) 325 mg, 81 mg $0 (OTC) aspirin rectal $0 (OTC) aspirin,buffd-calcium carb-mag $0 (OTC) Aspir-Trin $0 (OTC) Bayer Aspirin $0 (OTC) Buffered Aspirin $0 (OTC) Bufferin $0 (OTC) Children's Aspirin $0 (OTC) E.C. Prin $0 (OTC) Ecotrin Low Strength $0 (OTC) Enteric Coated Aspirin $0 (OTC) Excedrin Extra Strength $0 (OTC) Excedrin Migraine $0 (OTC) Extra Pain Relief $0 (OTC) Extraprin $0 (OTC) Headache Relief (ASA-acet-caf) $0 (OTC) Lite Coat Aspirin $0 (OTC) Lo-Dose Aspirin $0 (OTC) Migraine Formula $0 (OTC) Migraine Relief $0 (OTC) Pain Reliever (acetam-aspirin) $0 (OTC) Pain Reliever Plus $0 (OTC) Pain-Off $0 (OTC) St Joseph Aspirin $0 (OTC) St. Joseph Aspirin $0 (OTC) Tri-Buffered Aspirin $0 (OTC) Thrombolytic Agents Added Strength Headache Relief $0 (OTC) Adult Aspirin Regimen $0 (OTC) Adult Low Dose Aspirin $0 (OTC) Aspir-81 $0 (OTC) Aspirin Childrens $0 (OTC) Aspirin Low Dose $0 (OTC) aspirin oral tablet $0 (OTC) aspirin oral tablet,chewable $0 (OTC) aspirin oral tablet,delayed release (DR/EC) 325 mg, 81 mg $0 (OTC) aspirin rectal $0 (OTC) aspirin,buffd-calcium carb-mag $0 (OTC) Aspir-Trin $0 (OTC) Bayer Aspirin $0 (OTC) Buffered Aspirin $0 (OTC) Bufferin $0 (OTC)




Notes

Children's Aspirin $0 (OTC) E.C. Prin $0 (OTC) Ecotrin Low Strength $0 (OTC) Enteric Coated Aspirin $0 (OTC) Excedrin Extra Strength $0 (OTC) Excedrin Migraine $0 (OTC) Extra Pain Relief $0 (OTC) Extraprin $0 (OTC) Headache Relief (ASA-acet-caf) $0 (OTC) Lite Coat Aspirin $0 (OTC) Lo-Dose Aspirin $0 (OTC) Migraine Formula $0 (OTC) Migraine Relief $0 (OTC) Pain Reliever (acetam-aspirin) $0 (OTC) Pain Reliever Plus $0 (OTC) Pain-Off $0 (OTC) St Joseph Aspirin $0 (OTC) St. Joseph Aspirin $0 (OTC) Tri-Buffered Aspirin $0 (OTC) Cardiovascular Drugs Antilipemic Agents, Miscellaneous Endur-Acin $0 (OTC) Fish Oil Concentrate $0 (OTC) Fish Oil oral capsule 1,000 mg (120 mg-180 mg), 100-160-1,000 mg, 300-1,000 mg, 300-500 mg, 340-1,000 mg $0 (OTC)

Fish Oil oral capsule,delayed release(DR/EC) 300-1,000 mg, 60-90-500 mg $0 (OTC) niacin (inositol niacinate) oral tablet $0 (OTC) niacin oral capsule, extended release 250 mg, 500 mg $0 (OTC) niacin oral tablet $0 (OTC) niacin oral tablet extended release $0 (OTC) omega 3-dha-epa-fish oil oral capsule 1,000 mg (120 mg-180 mg), 250-500-1,000 mg, 300-1,000 mg, 500-1,000 mg $0 (OTC)

omega 3-dha-epa-fish oil oral capsule,delayed release(DR/EC) 300-1,000 mg $0 (OTC) omega-3 fatty acids oral capsule $0 (OTC) omega-3 fatty acids-fish oil oral capsule 300-1,000 mg $0 (OTC) Slo-Niacin oral tablet extended release 500 mg $0 (OTC) Super Omega-3 oral capsule 1,000 mg $0 (OTC) TherOmega $0 (OTC) TherOmega Sport $0 (OTC) Ultra Omega-3 oral capsule 500-1,000 mg $0 (OTC) Calcium-Channel Block.Agt,Misc(Hypoten) diltiazem HCl oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) DILT-XR oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) Calcium-Channel Blocking Agents diltiazem HCl oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) DILT-XR oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) Calcium-Channel Blocking Agents(Hypoten) diltiazem HCl oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) DILT-XR oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) Calcium-Channel Blocking Agents, Misc. diltiazem HCl oral capsule,ext.rel 24h degradable 120 mg $0 (OTC)




Notes

DILT-XR oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) Class Iv Antiarrhythmics diltiazem HCl oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) DILT-XR oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) Vasodilating Agents, Miscellaneous diltiazem HCl oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) DILT-XR oral capsule,ext.rel 24h degradable 120 mg $0 (OTC) Central Nervous System Agents Analgesics And Antipyretics, Misc. 8 Hour Pain Reliever $0 (OTC) 8HR Muscle Aches-Pain $0 (OTC) Acetadryl $0 (OTC) Acetaminophen Extra Strength $0 (OTC) acetaminophen oral elixir $0 (OTC) acetaminophen oral liquid 160 mg/5 mL, 500 mg/15 mL $0 (OTC) acetaminophen oral solution $0 (OTC) acetaminophen oral suspension 160 mg/5 mL $0 (OTC) acetaminophen oral tablet $0 (OTC) acetaminophen oral tablet extended release $0 (OTC) acetaminophen oral tablet,disintegrating $0 (OTC) Acetaminophen Pain Relief $0 (OTC) Acetaminophen PM $0 (OTC) Acetaminophen PM Extra Str $0 (OTC) acetaminophen rectal $0 (OTC) Added Strength Headache Relief $0 (OTC) Arthritis Pain Relief (acetam) $0 (OTC) Arthritis Pain Reliever $0 (OTC) Athenol $0 (OTC) BetaTemp $0 (OTC) Child Fever Reducer-Pain Relvr $0 (OTC) Child Pain Rel-Fever Reducer $0 (OTC) Children's Acetaminophen oral suspension $0 (OTC) Children's Acetaminophen oral tablet,chewable $0 (OTC) Children's Acetaminophen oral tablet,disintegrating $0 (OTC) Children's Easy-Melts $0 (OTC) Children's Fever Reducing $0 (OTC) Children's Mapap oral tablet,chewable $0 (OTC) Children's Non-Aspirin oral suspension $0 (OTC) Children's Pain Relief oral suspension $0 (OTC) Children's Pain Relief oral tablet,chewable $0 (OTC) Children's Pain Reliever oral suspension $0 (OTC) Children's Pain-Fever Relief oral suspension $0 (OTC) Children's Pain-Fever Relief oral tablet,chewable 160 mg $0 (OTC) Children's Pain-Fever Relief oral tablet,disintegrating $0 (OTC) Children's Silapap $0 (OTC) Children's Tactinal $0 (OTC) Children's Tylenol oral tablet,chewable $0 (OTC) diphenhydramine-acetaminophen $0 (OTC) EaZZZe The Pain $0 (OTC) Ed-APAP $0 (OTC) Excedrin Extra Strength $0 (OTC)




Notes

Excedrin Migraine $0 (OTC) Extra Pain Relief $0 (OTC) Extraprin $0 (OTC) Fever Reducer $0 (OTC) Feverall rectal suppository 80 mg $0 (OTC) Headache PM $0 (OTC) Headache Relief (ASA-acet-caf) $0 (OTC) Infant Fever Reducer-Pain Relf $0 (OTC) Infant Pain Reliever $0 (OTC) Infant's Acetaminophen $0 (OTC) Infants' Pain and Fever $0 (OTC) Infants' Pain Relief $0 (OTC) Infant's Pain Relief oral drops,suspension 80 mg/0.8 mL $0 (OTC) Infant's Pain Relief oral suspension $0 (OTC) Infant's Pain Reliever $0 (OTC) Jr. Acetaminophen $0 (OTC) Jr. Str Non-Aspirin Pain $0 (OTC) Jr. Strength Pain Reliever $0 (OTC) Little Remedies Fever and Pain $0 (OTC) Mapap (acetaminophen) oral capsule $0 (OTC) Mapap (acetaminophen) oral liquid 500 mg/15 mL $0 (OTC) Mapap (acetaminophen) oral tablet $0 (OTC) Mapap Arthritis Pain $0 (OTC) Mapap Extra Strength $0 (OTC) Mapap PM $0 (OTC) Masophen $0 (OTC) Menstrual Relief $0 (OTC) Migraine Formula $0 (OTC) Migraine Relief $0 (OTC) Night Time Pain Medicine $0 (OTC) Non-Aspirin Childrens $0 (OTC) Non-Aspirin Extra Strength oral liquid $0 (OTC) Non-Aspirin Extra Strength oral tablet $0 (OTC) Non-Aspirin oral elixir $0 (OTC) Non-Aspirin oral suspension $0 (OTC) Non-Aspirin oral tablet $0 (OTC) Non-Aspirin oral tablet,chewable 80 mg $0 (OTC) Non-Aspirin Pain Relief $0 (OTC) Non-Aspirin PM $0 (OTC) Nortemp $0 (OTC) Pain and Sleep $0 (OTC) Pain Relief Adult $0 (OTC) Pain Relief Extra Strength $0 (OTC) Pain Relief oral liquid $0 (OTC) Pain Relief oral tablet $0 (OTC) Pain Relief oral tablet extended release $0 (OTC) Pain Relief PM $0 (OTC) Pain Relief PM Rapid Release $0 (OTC) Pain Relief Regular Strength $0 (OTC) Pain Reliever (acetam-aspirin) $0 (OTC) Pain Reliever Extra Strength $0 (OTC)




Notes

Pain Reliever Jr Strength $0 (OTC) Pain Reliever oral tablet $0 (OTC) Pain Reliever Plus $0 (OTC) Pain Reliever PM Ex-Strength $0 (OTC) Pain Reliever PM oral tablet 25-500 mg $0 (OTC) Pain-Off $0 (OTC) PediaCare Fever Reducer $0 (OTC) Pharbetol $0 (OTC) Shake That Ache $0 (OTC) Tactinal $0 (OTC) Tactinal Extra Strength $0 (OTC) Tylenol PM Extra Strength $0 (OTC) Tylophen $0 (OTC) Wal-Nadol PM $0 (OTC) Antimigraine Agents, Miscellaneous Added Strength Headache Relief $0 (OTC) Adult Aspirin Regimen $0 (OTC) Adult Low Dose Aspirin $0 (OTC) Aspir-81 $0 (OTC) Aspirin Childrens $0 (OTC) Aspirin Low Dose $0 (OTC) aspirin oral tablet $0 (OTC) aspirin oral tablet,chewable $0 (OTC) aspirin oral tablet,delayed release (DR/EC) 325 mg, 81 mg $0 (OTC) aspirin rectal $0 (OTC) aspirin,buffd-calcium carb-mag $0 (OTC) Aspir-Trin $0 (OTC) Bayer Aspirin $0 (OTC) Buffered Aspirin $0 (OTC) Bufferin $0 (OTC) Children's Aspirin $0 (OTC) E.C. Prin $0 (OTC) Ecotrin Low Strength $0 (OTC) Enteric Coated Aspirin $0 (OTC) Excedrin Extra Strength $0 (OTC) Excedrin Migraine $0 (OTC) Extra Pain Relief $0 (OTC) Extraprin $0 (OTC) Headache Relief (ASA-acet-caf) $0 (OTC) Lite Coat Aspirin $0 (OTC) Lo-Dose Aspirin $0 (OTC) Migraine Formula $0 (OTC) Migraine Relief $0 (OTC) Pain Reliever (acetam-aspirin) $0 (OTC) Pain Reliever Plus $0 (OTC) Pain-Off $0 (OTC) St Joseph Aspirin $0 (OTC) St. Joseph Aspirin $0 (OTC) Tri-Buffered Aspirin $0 (OTC) Anxiolytics,Sedatives,And Hypnotics,Misc Alka-Seltzer Plus Allergy $0 (OTC)




Notes

Compoz $0 (OTC) NightTime Sleep Aid (diphen) oral tablet $0 (OTC) Nytol $0 (OTC) Simply Sleep $0 (OTC) Sleep Aid (diphenhydramine) oral tablet $0 (OTC) Sleep II $0 (OTC) Sleep Tablet (diphenhydramine) $0 (OTC) Opiate Agonists codeine-guaifenesin $0 (OTC) G Tussin AC $0 (OTC) Guaiatussin AC $0 (OTC) Guaifenesin AC $0 (OTC) Virtussin AC $0 (OTC) Other Nonsteroidal Anti-Inflam. Agents Advil oral tablet,chewable $0 (OTC) All Day Pain Relief $0 (OTC) All Day Relief $0 (OTC) Children's Advil $0 (OTC) Children's Ibuprofen $0 (OTC) Children's Motrin $0 (OTC) Children's Profen IB $0 (OTC) Flanax (naproxen) $0 (OTC) IBU-200 $0 (OTC) Ibuprofen IB $0 (OTC) Ibuprofen Jr Strength $0 (OTC) ibuprofen oral drops,suspension $0 (OTC) ibuprofen oral suspension $0 (OTC) ibuprofen oral tablet 200 mg $0 (OTC) ibuprofen oral tablet,chewable $0 (OTC) Infant's Advil $0 (OTC) Infant's Ibuprofen $0 (OTC) Infants ProfenIB $0 (OTC) I-Prin $0 (OTC) Mediproxen $0 (OTC) Motrin IB oral tablet $0 (OTC) naproxen sodium oral tablet 220 mg $0 (OTC) Provil $0 (OTC) Wal-Profen oral tablet $0 (OTC) Wal-Proxen $0 (OTC) Respiratory And Cns Stimulants Added Strength Headache Relief $0 (OTC) Excedrin Extra Strength $0 (OTC) Excedrin Migraine $0 (OTC) Extra Pain Relief $0 (OTC) Extraprin $0 (OTC) Headache Relief (ASA-acet-caf) $0 (OTC) Menstrual Relief $0 (OTC) Migraine Formula $0 (OTC) Migraine Relief $0 (OTC) Pain Reliever (acetam-aspirin) $0 (OTC) Pain Reliever Plus $0 (OTC)




Notes

Pain-Off $0 (OTC) Salicylates Added Strength Headache Relief $0 (OTC) Adult Aspirin Regimen $0 (OTC) Adult Low Dose Aspirin $0 (OTC) Aspir-81 $0 (OTC) Aspirin Childrens $0 (OTC) Aspirin Low Dose $0 (OTC) aspirin oral tablet $0 (OTC) aspirin oral tablet,chewable $0 (OTC) aspirin oral tablet,delayed release (DR/EC) 325 mg, 81 mg $0 (OTC) aspirin rectal $0 (OTC) aspirin,buffd-calcium carb-mag $0 (OTC) Aspir-Trin $0 (OTC) Bayer Aspirin $0 (OTC) Buffered Aspirin $0 (OTC) Bufferin $0 (OTC) Children's Aspirin $0 (OTC) E.C. Prin $0 (OTC) Ecotrin Low Strength $0 (OTC) Enteric Coated Aspirin $0 (OTC) Excedrin Extra Strength $0 (OTC) Excedrin Migraine $0 (OTC) Extra Pain Relief $0 (OTC) Extraprin $0 (OTC) Headache Relief (ASA-acet-caf) $0 (OTC) Lite Coat Aspirin $0 (OTC) Lo-Dose Aspirin $0 (OTC) Migraine Formula $0 (OTC) Migraine Relief $0 (OTC) Pain Reliever (acetam-aspirin) $0 (OTC) Pain Reliever Plus $0 (OTC) Pain-Off $0 (OTC) St Joseph Aspirin $0 (OTC) St. Joseph Aspirin $0 (OTC) Tri-Buffered Aspirin $0 (OTC) Contraceptives (E.G. Foams, Devices) Contraceptives (E.G. Foams, Devices) Aimsco Latex Condom $0 (OTC) Condoms-Prem Lubricated $0 (OTC) Durex Avanti Bare Real Feel $0 (OTC) Fantasy Condom $0 (OTC) FC2 Female Condom $0 (OTC) Gynol II $0 (OTC) Kimono Condoms(Non-lubricated) $0 (OTC) Kimono Maxx Condoms $0 (OTC) Kimono MicroThin Aqua Lube Con $0 (OTC) Kimono MicroThin Condoms $0 (OTC) Kimono MicroThin Large Condoms $0 (OTC) Kimono Textured Condoms $0 (OTC) Trustex Latex Condom $0 (OTC)




Notes

Trustex Lubricated Condoms $0 (OTC) Trustex Non-Lub Condoms $0 (OTC) Trustex-RIA Lub/Spermicide $0 (OTC) Trustex-RIA Lubricated Condoms $0 (OTC) Trustex-RIA Non-Lub Condoms $0 (OTC) Vaginal Contraceptive Film $0 (OTC) Vaginal Contraceptive Foam $0 (OTC) VCF Contraceptive Film $0 (OTC) VCF Contraceptive Gel $0 (OTC) Devices Devices BD PosiFlush Normal Saline 0.9 $0 (OTC) BD Pre-Filled Normal Saline $0 (OTC) BD Pre-Filled Saline Blunt Can $0 (OTC) Blood Glucose Monitoring $0 (OTC) blood-glucose meter $0 (OTC) DuoDERM CGF Dressing topical bandage 4 X 4 ", 6 X 6 ", 6 X 8 " $0 (OTC) DuoDERM CGF Extra Thin topical bandage 2 X 4 ", 3 X 3 ", 4 X 6 ", 6 X 7 " $0 (OTC) DuoDERM Hydroactive topical bandage $0 (OTC) Monoject 0.9% Sodium Chloride $0 (OTC) Monoject Prefill Advanced NS $0 (OTC) Normal Saline Flush $0 (OTC) sodium chloride 0.9 % (flush) injection syringe $0 (OTC) sodium chloride inhalation solution for nebulization 0.9 % $0 (OTC) Electrolytic, Caloric, And Water Balance Caloric Agents Dex4 Glucose oral gel $0 (OTC) Dex4 Glucose oral tablet,chewable $0 (OTC) Dex4 Glucose Pouch Pack $0 (OTC) Dex4 Glucose Quick Dissolve $0 (OTC) dextrose oral gel $0 (OTC) Gluco Burst $0 (OTC) Glucose Gel $0 (OTC) glucose oral tablet,chewable 4 gram $0 (OTC) Glutose-15 $0 (OTC) Glutose-45 $0 (OTC) L-Carnitine (tartrate) oral capsule 500 mg $0 (OTC) L-Carnitine oral tablet $0 (OTC) levocarnitine tartrate oral capsule 500 mg $0 (OTC) Lysiplex Plus oral tablet $0 (OTC) TRUEplus Glucose oral tablet,chewable $0 (OTC) Replacement Preparations Actical $0 (OTC) Alcalak $0 (OTC) Antacid (calcium carbonate) $0 (OTC) Antacid Calcium oral tablet,chewable 215 mg calcium (500 mg) $0 (OTC) Antacid Ext Str (calcium carb) $0 (OTC) Antacid Extra-Strength oral tablet,chewable 168 mg calcium (420 mg), 300 mg (750 mg) $0 (OTC)

Antacid Ultra Strength oral tablet,chewable 1,177 mg, 400 mg calcium (1,000 mg) $0 (OTC) Ban-Acid $0 (OTC)




Notes

BD PosiFlush Normal Saline 0.9 $0 (OTC) BD Pre-Filled Normal Saline $0 (OTC) BD Pre-Filled Saline Blunt Can $0 (OTC) Bio-35, Gluten Free $0 (OTC) Biocal $0 (OTC) Ca-D3-mag ox-zinc-cop-mang-bor oral tablet,chewable 600 mg calcium- 800 unit-40 mg $0 (OTC)

Calcitrate $0 (OTC) Cal-Citrate $0 (OTC) Calcium 500 $0 (OTC) Calcium 500 + D oral tablet $0 (OTC) Calcium 500 With D $0 (OTC) Calcium 600 $0 (OTC) Calcium 600 + D(3) oral tablet $0 (OTC) Calcium 600 with Vitamin D3 oral tablet,chewable $0 (OTC) Calcium Antacid oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg), 320 mg calcium (750 mg), 400 mg calcium (1,000 mg) $0 (OTC)

Calcium Antacid Tropical $0 (OTC) Calcium Antacid Ultra Max St $0 (OTC) calcium carbonate oral suspension $0 (OTC) calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg calcium (1,500 mg) $0 (OTC)

calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg), 400 mg calcium (1,000 mg), 500 mg calcium (1,250 mg) $0 (OTC)

calcium carbonate-vitamin D3 oral tablet 1,000 mg(2,500 mg)-800 unit, 250-125 mg-unit, 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit

$0 (OTC)

calcium carbonate-vitamin D3 oral tablet,chewable 500-100 mg-unit $0 (OTC) Calcium Citrate + D $0 (OTC) calcium citrate oral tablet 200 mg (950 mg) $0 (OTC) calcium citrate-vitamin D3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit, 315 mg- 250 unit, 315-200 mg-unit $0 (OTC)

Calcium with Vitamin D $0 (OTC) Cal-Gest Antacid $0 (OTC) Children's Pepto $0 (OTC) Children's Soothe $0 (OTC) Citracal + D Maximum $0 (OTC) Citracal Regular $0 (OTC) Citrus Calcium-Vitamin D3 oral tablet 200 mg calcium -250 unit $0 (OTC) Daily Multiple For Women $0 (OTC) electrolytes-dextrose $0 (OTC) Flavor Chews Antacid $0 (OTC) Flintstones Plus Calcium $0 (OTC) Fosfree $0 (OTC) Hi-Cal Plus Vit D $0 (OTC) Mag-G $0 (OTC) Magnesium (oxide/AA chelate) $0 (OTC) magnesium chloride oral tablet,delayed release (DR/EC) 64 mg $0 (OTC) magnesium gluconate oral tablet 27 mg magnesium (500 mg), 27.5 mg magnesium (500 mg) $0 (OTC)




Notes

magnesium L-lactate $0 (OTC) magnesium oral tablet 250 mg $0 (OTC) Mega Multi for Women $0 (OTC) Mega Multivitamin with Mineral oral tablet 13.5-200-250 mg-mcg-mcg $0 (OTC) Monoject 0.9% Sodium Chloride $0 (OTC) Monoject Prefill Advanced NS $0 (OTC) Mynatal Advance $0 (OTC) Natural Calcium $0 (OTC) Normal Saline Flush $0 (OTC) One Daily Energy oral tablet 9 mg iron-400 mcg-200 mg $0 (OTC) One Daily Prenatal $0 (OTC) One Daily Women 50 Plus(Vit K) $0 (OTC) One Daily Women's Health $0 (OTC) One Daily Women's oral tablet 18 mg iron-400 mcg-450 mg Ca $0 (OTC) One-A-Day Menopause Formula $0 (OTC) One-A-Day Teen Advantage oral tablet 9 mg iron-400 mcg $0 (OTC) One-A-Day Women's Healthy Skin $0 (OTC) One-A-Day Women's Petites $0 (OTC) Oralyte $0 (OTC) Os-Cal 500 + D3 oral tablet 500 mg(1,250mg) -200 unit $0 (OTC) Oysco 500/D oral tablet $0 (OTC) Oysco-500 $0 (OTC) Oyster Shell + D3 $0 (OTC) Oyster Shell Calcium $0 (OTC) Oyster Shell Calcium 500 $0 (OTC) Oyster Shell Calcium-Vit D2 oral tablet 250 (625)-125 mg-unit $0 (OTC) Oyster Shell Calcium-Vit D3 oral tablet $0 (OTC) Oystercal-D $0 (OTC) Pediatric Electrolyte oral solution $0 (OTC) Pediatric Freezer Pops $0 (OTC) Perry Prenatal $0 (OTC) Prenatal Complete $0 (OTC) Prenatal Low Iron $0 (OTC) Prenatal One Daily $0 (OTC) Prenatal Plus (calcium carb) $0 (OTC) Prenatal Tablet $0 (OTC) Prenatal Vitamin oral tablet 27 mg iron- 0.8 mg $0 (OTC) Prenatal Vitamin Plus Low Iron $0 (OTC) Prenatal Vitamin with Minerals $0 (OTC) prenatal vit-iron fum-folic ac $0 (OTC) prenatal vits96-iron fum-folic $0 (OTC) PrePlus $0 (OTC) Pro-Cal oral tablet $0 (OTC) Quintabs-M $0 (OTC) selenium oral capsule $0 (OTC) selenium oral tablet 100 mcg, 50 mcg $0 (OTC) Smooth Antacid $0 (OTC) sodium chloride 0.9 % (flush) injection syringe $0 (OTC) sodium chloride inhalation solution for nebulization 0.9 % $0 (OTC) sodium chloride oral $0 (OTC) Super Calcium $0 (OTC)




Notes

Thera-M oral tablet 9 mg iron-400 mcg $0 (OTC) Therapeutic-M oral tablet 9 mg iron-400 mcg $0 (OTC) Tums Ultra oral tablet,chewable 1,177 mg $0 (OTC) Ultra Freeda $0 (OTC) Ultra Strength Antacid $0 (OTC) Ultra Strength Calcium Antacid $0 (OTC) Women's 50 Plus Daily Formula $0 (OTC) Women's 50 Plus Multivitamin $0 (OTC) Women's Daily Caplet $0 (OTC) Women's Daily Formula oral tablet 18 mg iron-400 mcg-500 mg Ca $0 (OTC) Women's One Daily $0 (OTC) zinc gluconate oral tablet $0 (OTC) zinc sulfate oral capsule $0 (OTC) Eye, Ear, Nose And Throat (Eent) Preps. Antiallergic Agents Allergy Eye (ketotifen) $0 (OTC) cromolyn nasal $0 (OTC) Eye Itch Relief $0 (OTC) Itchy Eye Drops $0 (OTC) ketotifen fumarate $0 (OTC) Nasal Allergy Symptom Control $0 (OTC) Wal-Zyr (ketotifen) $0 (OTC) Contact Lens Solutions Bio true $0 (OTC) Boston Cleaner $0 (OTC) Boston Conditioning $0 (OTC) Boston One Step (PF) $0 (OTC) Boston Rewetting $0 (OTC) Boston Simplus $0 (OTC) Disinfecting Solution $0 (OTC) Multipurpose Contact Lens $0 (OTC) Multi-Purpose Soft Contact Len $0 (OTC) Opti-Free Replenish $0 (OTC) Renu Disinfecting $0 (OTC) ReNu MultiPlus $0 (OTC) Renu Rewetting Drops $0 (OTC) Rewetting Drops $0 (OTC) Saline Sensitive Eyes $0 (OTC) Saline Solution $0 (OTC) Saline Solution,Sterile Presrv $0 (OTC) Sensitive Eyes $0 (OTC) Sensitive Eyes Daily Cleaner $0 (OTC) Sensitive Eyes Plus Saline $0 (OTC) Systane Contacts $0 (OTC) Visine For Contacts $0 (OTC) Corticosteroids (Eent) 24 Hour Nasal Allergy $0 (OTC) Nasal Allergy $0 (OTC) triamcinolone acetonide nasal $0 (OTC) Eent Anti-Infectives, Miscellaneous Carbamoxide Ear Drops $0 (OTC)




Notes

Ear Drops (carbamide peroxide) $0 (OTC) Ear Drops Otc $0 (OTC) Ear Wax Removal Drops $0 (OTC) Ear Wax Removal Kit $0 (OTC) Murine Ear Wax Removal System $0 (OTC) Eent Drugs, Miscellaneous Altachlore $0 (OTC) Altamist $0 (OTC) Artificial Tears (PF) $0 (OTC) Artificial Tears(dext70-hypro) ophthalmic (eye) drops $0 (OTC) Artificial Tears(pvalch-povid) $0 (OTC) Ayr Saline nasal drops $0 (OTC) Baby Ayr Saline $0 (OTC) Children's Saline Nasal Spray $0 (OTC) Deep Sea Nasal $0 (OTC) EQ Gentle $0 (OTC) For Sty Relief $0 (OTC) GenTeal Tears Moderate $0 (OTC) Little Remedies $0 (OTC) Lubricant Eye (PG-PEG 400) $0 (OTC) Lubricant Eye (PG-PEG 400)(PF) $0 (OTC) Lubricant Eye Drops ophthalmic (eye) dropperette $0 (OTC) Lubricant Eye Drops ophthalmic (eye) drops 0.5 % $0 (OTC) Lubricant Eye ophthalmic (eye) ointment 57.3-42.5 % $0 (OTC) Lubricating Plus $0 (OTC) Lubricating Relief $0 (OTC) Lubrifresh PM $0 (OTC) Muro 128 ophthalmic (eye) drops 2 % $0 (OTC) Muro 128 ophthalmic (eye) ointment $0 (OTC) Nasal Moisturizing $0 (OTC) Nasal Spray (sodium chloride) $0 (OTC) Natural Tears (PF) $0 (OTC) polyvinyl alcohol $0 (OTC) Pure and Gentle Eye $0 (OTC) Refresh Classic (PF) $0 (OTC) Refresh Lacri-Lube $0 (OTC) Restore Plus (cmcellulose) $0 (OTC) Restore PM $0 (OTC) Restore Tears $0 (OTC) Retaine PM $0 (OTC) Revive Plus $0 (OTC) Saline Mist $0 (OTC) Saline Nasal $0 (OTC) Saline Nasal Mist nasal aerosol,spray $0 (OTC) Saline Nose $0 (OTC) sodium chloride ophthalmic (eye) $0 (OTC) Soothe Hydration $0 (OTC) Soothe XP $0 (OTC) Ultra Fresh $0 (OTC) Ultra Fresh PM $0 (OTC) Ultra Lubricant Eye $0 (OTC)




Notes

Local Anesthetics (Eent) Anbesol (benzocaine) Max Str $0 (OTC) Anesthetic Oral Gel $0 (OTC) Benz-O-Sthetic mucous membrane gel $0 (OTC) Intense Toothache Pain Relief $0 (OTC) Oral Analgesic mucous membrane gel $0 (OTC) Oral Anesthetic mucous membrane gel $0 (OTC) Oral Pain Relief mucous membrane gel $0 (OTC) Mouthwashes And Gargles hydrogen peroxide $0 (OTC) Vasoconstrictors 12 Hour Nasal Relief Spray $0 (OTC) 12 Hour Nasal Spray $0 (OTC) 4 Way $0 (OTC) Afrin No Drip(oxymetazolin) $0 (OTC) Anefrin $0 (OTC) Ephrine $0 (OTC) Fast Acting Nasal $0 (OTC) Long Acting Nasal Spray $0 (OTC) Mucinex Sinus-Max $0 (OTC) Nasal Decongestant (oxymetazl) $0 (OTC) Nasal Four $0 (OTC) Nasal Relief $0 (OTC) Nasal Spray (oxymetazoline) $0 (OTC) Nasal Spray 12Hr(oxymetazoline $0 (OTC) Nasal Spray Extra Moisturizing $0 (OTC) Nasal Spray Long Acting $0 (OTC) Nasal Spray Sinus $0 (OTC) Neo-Synephrine (phenylephrine) nasal spray,non-aerosol 0.25 %, 1 % $0 (OTC) No Drip $0 (OTC) Nose Drops $0 (OTC) Nose Drops Extra Strength $0 (OTC) Original Nasal Spray $0 (OTC) oxymetazoline $0 (OTC) Sinus Nasal Spray $0 (OTC) Sinus Relief (oxymetazoline) $0 (OTC) Sinus Relief (phenylephrine) $0 (OTC) Vicks QlearQuil(oxymetazoline) $0 (OTC) Vicks Sinex 12-Hour $0 (OTC) Vicks Sinex Ultra Fine Mist 12 $0 (OTC) Wal-Four $0 (OTC) Gastrointestinal Drugs Antacids And Adsorbents Actidose-Aqua oral suspension 15 g/72 mL $0 (OTC) activated charcoal oral capsule $0 (OTC) Advanced Antacid-Antigas $0 (OTC) Alcalak $0 (OTC) Almacone-2 $0 (OTC) aluminum hydroxide gel $0 (OTC) alum-mag hydroxide-simeth oral suspension 200-200-20 mg/5 mL $0 (OTC) Antacid $0 (OTC)




Notes

Antacid (calcium carbonate) $0 (OTC) Antacid Anti-Gas $0 (OTC) Antacid Calcium oral tablet,chewable 215 mg calcium (500 mg) $0 (OTC) Antacid Ext Str (calcium carb) $0 (OTC) Antacid Extra-Strength oral suspension 200-200-20 mg/5 mL $0 (OTC) Antacid Extra-Strength oral tablet,chewable 168 mg calcium (420 mg), 300 mg (750 mg) $0 (OTC)

Antacid Liquid $0 (OTC) Antacid M $0 (OTC) Antacid Maximum Strength $0 (OTC) Antacid Plus Anti-Gas $0 (OTC) Antacid Regular Strength $0 (OTC) Antacid Ultra Strength oral tablet,chewable 1,177 mg, 400 mg calcium (1,000 mg) $0 (OTC) Antacid-Antigas $0 (OTC) Antacid-Simethicone $0 (OTC) Anti-Diarrheal $0 (OTC) Ban-Acid $0 (OTC) Bismatrol oral suspension $0 (OTC) bismuth subsalicylate oral suspension $0 (OTC) Calcium Antacid oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg), 320 mg calcium (750 mg), 400 mg calcium (1,000 mg) $0 (OTC)

Calcium Antacid Tropical $0 (OTC) Calcium Antacid Ultra Max St $0 (OTC) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg), 400 mg calcium (1,000 mg) $0 (OTC)

Cal-Gest Antacid $0 (OTC) Children's Pepto $0 (OTC) Children's Soothe $0 (OTC) Comfort Gel $0 (OTC) Comfort Gel Extra Strength $0 (OTC) Diarrhea Relief (bismuth subs) $0 (OTC) Digestive Relief oral suspension $0 (OTC) EZ Char $0 (OTC) Flavor Chews Antacid $0 (OTC) Foaming Antacid oral tablet,chewable $0 (OTC) Geri-Lanta oral suspension 200-200-20 mg/5 mL $0 (OTC) Geri-Mox Antacid-Antigas $0 (OTC) Geri-Pectate $0 (OTC) Insta-Char $0 (OTC) Kaopectate (bismuth subsalicy) oral suspension $0 (OTC) Kaopectate Ex Str (bismuth ss) $0 (OTC) K-Pec Antidiarrheal (bism sub) $0 (OTC) Liquid Antacid $0 (OTC) Maalox Maximum Strength $0 (OTC) Mag-Al Plus Extra Strength $0 (OTC) Maglox $0 (OTC) magnesium oxide oral capsule 500 mg $0 (OTC) magnesium oxide oral tablet 200 mg magnesium, 250 mg magnesium, 400 mg magnesium, 500 mg $0 (OTC)

magnesium oxide oral tablet 400 mg (241.3 mg magnesium) NP Masanti Double Strength $0 (OTC)




Notes

MgO $0 (OTC) Mi-Acid $0 (OTC) Mintox $0 (OTC) Mintox Maximum Strength $0 (OTC) Phillips $0 (OTC) Phillips Milk of Magnesia oral tablet,chewable $0 (OTC) Pink Bismuth Maximum Strength $0 (OTC) Pink Bismuth oral suspension $0 (OTC) Ri-Gel $0 (OTC) Ri-Gel II $0 (OTC) Ri-Mox $0 (OTC) Smooth Antacid $0 (OTC) sodium bicarbonate oral tablet 650 mg $0 (OTC) Soothe Regular Strength $0 (OTC) Stomach Relief Max Strength $0 (OTC) Stomach Relief oral suspension $0 (OTC) Stomach Relief Original $0 (OTC) Tums Ultra oral tablet,chewable 1,177 mg $0 (OTC) Ultra Strength Antacid $0 (OTC) Ultra Strength Calcium Antacid $0 (OTC) Uro-Mag $0 (OTC) Antidiarrhea Agents Anti-Diarrheal $0 (OTC) Anti-Diarrheal (loperamide) oral capsule $0 (OTC) Anti-Diarrheal (loperamide) oral liquid 1 mg/5 mL $0 (OTC) Anti-Diarrheal (loperamide) oral tablet $0 (OTC) Bismatrol oral suspension $0 (OTC) bismuth subsalicylate oral suspension $0 (OTC) Diamode $0 (OTC) Diarrhea Relief (bismuth subs) $0 (OTC) Digestive Relief oral suspension $0 (OTC) Geri-Pectate $0 (OTC) Imodium A-D oral capsule $0 (OTC) Kaopectate (bismuth subsalicy) oral suspension $0 (OTC) Kaopectate Ex Str (bismuth ss) $0 (OTC) K-Pec Antidiarrheal (bism sub) $0 (OTC) loperamide oral capsule $0 (OTC) loperamide oral tablet $0 (OTC) Pink Bismuth Maximum Strength $0 (OTC) Pink Bismuth oral suspension $0 (OTC) Soothe Regular Strength $0 (OTC) Stomach Relief Max Strength $0 (OTC) Stomach Relief oral suspension $0 (OTC) Stomach Relief Original $0 (OTC) Ultra A-D $0 (OTC) Antiflatulents Advanced Antacid-Antigas $0 (OTC) Almacone-2 $0 (OTC) alum-mag hydroxide-simeth oral suspension 200-200-20 mg/5 mL $0 (OTC) Antacid $0 (OTC) Antacid Anti-Gas $0 (OTC)




Notes

Antacid Extra-Strength oral suspension 200-200-20 mg/5 mL $0 (OTC) Antacid Liquid $0 (OTC) Antacid M $0 (OTC) Antacid Maximum Strength $0 (OTC) Antacid Plus Anti-Gas $0 (OTC) Antacid Regular Strength $0 (OTC) Antacid-Antigas $0 (OTC) Antacid-Simethicone $0 (OTC) Anti-Gas Ultra Strength $0 (OTC) Comfort Gel $0 (OTC) Comfort Gel Extra Strength $0 (OTC) Gas Relief (simethicone) oral capsule 180 mg $0 (OTC) Gas Relief (simethicone) oral drops,suspension $0 (OTC) Gas Relief (simethicone) oral tablet,chewable $0 (OTC) Gas Relief 80 (simethicone) $0 (OTC) Gas Relief Extra Strength oral tablet,chewable $0 (OTC) Gas Relief Ultra Strength $0 (OTC) Gas-X oral strip $0 (OTC) Geri-Lanta oral suspension 200-200-20 mg/5 mL $0 (OTC) Geri-Mox Antacid-Antigas $0 (OTC) Infants Gas Relief $0 (OTC) Liquid Antacid $0 (OTC) Little Remedies Gas Relief $0 (OTC) Maalox Maximum Strength $0 (OTC) Mag-Al Plus Extra Strength $0 (OTC) Maglox $0 (OTC) Masanti Double Strength $0 (OTC) Mi-Acid $0 (OTC) Mi-Acid Gas Relief(simethicon) $0 (OTC) Mintox $0 (OTC) Mintox Maximum Strength $0 (OTC) Ri-Gel $0 (OTC) Ri-Gel II $0 (OTC) Ri-Mox $0 (OTC) simethicone oral capsule 180 mg $0 (OTC) simethicone oral drops,suspension $0 (OTC) simethicone oral tablet,chewable $0 (OTC) Antihistamines (Gi Drugs) Dramamine Less Drowsy $0 (OTC) meclizine oral tablet 12.5 mg, 25 mg $0 (OTC) meclizine oral tablet,chewable $0 (OTC) Medi-Meclizine $0 (OTC) Motion Relief (meclizine) $0 (OTC) Motion Sickness (meclizine) $0 (OTC) Motion Sickness II $0 (OTC) Motion Sickness Relief(mecliz) $0 (OTC) Motion-Time $0 (OTC) Travel-Ease (meclizine) $0 (OTC) VertiCalm $0 (OTC) Wal-Dram 2 $0 (OTC) Cathartics And Laxatives




Notes

Alophen (bisacodyl) $0 (OTC) bisacodyl $0 (OTC) Bisa-Lax (bisacodyl) $0 (OTC) calcium polycarbophil $0 (OTC) Chocolate Laxative $0 (OTC) Citrate of Magnesia $0 (OTC) Citrucel $0 (OTC) Citrucel (sucrose) $0 (OTC) Citrucel Sugar Free $0 (OTC) C-Lax Laxative (bisacodyl) $0 (OTC) ClearLax $0 (OTC) Col-Rite oral capsule 100 mg, 250 mg $0 (OTC) Daily Fiber (psyllium-sucrose) oral powder 3.4 gram/12 gram, 3.4 gram/7 gram $0 (OTC) Daily Fiber oral capsule 0.52 gram $0 (OTC) Dioctyl $0 (OTC) Docu $0 (OTC) docusate sodium oral capsule $0 (OTC) docusate sodium oral liquid $0 (OTC) docusate sodium oral syrup $0 (OTC) Docusil $0 (OTC) Docusol $0 (OTC) DOK Plus $0 (OTC) DSS $0 (OTC) Ducodyl (bisacodyl) $0 (OTC) DulcoEase $0 (OTC) Dulcolax Stool Softener (dss) $0 (OTC) Enema Disposable $0 (OTC) Enema rectal enema 19-7 gram/118 mL $0 (OTC) Enemeez $0 (OTC) Evac-U-Gen (sennosides) $0 (OTC) Ex-Lax (sennosides) oral tablet,chewable $0 (OTC) Fiber (calcium polycarbophil) $0 (OTC) Fiber (psyllium husk) oral capsule 0.52 gram $0 (OTC) Fiber (psyllium husk/sugar) $0 (OTC) Fiber (with aspartame) oral powder 3.4 gram/5.8 gram $0 (OTC) Fiber Laxative (ca polycarbo) $0 (OTC) Fiber Laxative (methylcellulo) $0 (OTC) Fiber Laxative (psyllium husk) $0 (OTC) fiber oral powder $0 (OTC) Fiber Smooth $0 (OTC) Fiber Smooth (sucrose) $0 (OTC) Fiber Therapy (ca polycarboph) $0 (OTC) Fiber Therapy (m-cell/sugar) oral powder 2 gram/19 gram $0 (OTC) Fiber Therapy (m-cellulose) $0 (OTC) Fiber Therapy Laxative (husk) $0 (OTC) Fiber Therapy(psyl seed-sugar) $0 (OTC) Fiber-Caps (psyllium husk) $0 (OTC) Fiber-Lax $0 (OTC) Fiber-Tabs $0 (OTC) Fleet Bisacodyl $0 (OTC) Fleet Glycerin (Adult) $0 (OTC)




Notes

Fleet Glycerin (Child) $0 (OTC) Fleet Glycerin Laxative $0 (OTC) Fleet Laxative (bisacodyl) $0 (OTC) Gavilax oral powder $0 (OTC) Gentle Laxative (bisacodyl) $0 (OTC) GentleLax $0 (OTC) Geri-kot $0 (OTC) Geri-Mucil (aspartame) $0 (OTC) Geri-Mucil (sugar) $0 (OTC) glycerin (adult) $0 (OTC) glycerin (child) $0 (OTC) GlycoLax oral powder $0 (OTC) HealthyLax $0 (OTC) Konsyl (sugar) oral powder 3.4 gram/12 gram $0 (OTC) Lax Stool Softener With Senna $0 (OTC) Laxa Basic $0 (OTC) Laxacin $0 (OTC) LaxaClear $0 (OTC) Laxative (bisacodyl) $0 (OTC) Laxative (glycerin-pediatric) $0 (OTC) Laxative (sennosides) oral tablet 25 mg $0 (OTC) Laxative (sennosides) oral tablet,chewable $0 (OTC) Laxative PEG 3350 oral powder $0 (OTC) Laxative Pills $0 (OTC) Laxative Plus Stool Softener $0 (OTC) magnesium citrate oral solution $0 (OTC) magnesium hydroxide oral suspension 400 mg/5 mL $0 (OTC) Metamucil (sugar) $0 (OTC) Metamucil Sunrise $0 (OTC) Milk of Magnesia $0 (OTC) Mineral Oil Extra Heavy $0 (OTC) Mineral Oil Heavy oral $0 (OTC) mineral oil oral $0 (OTC) Multihealth Fiber $0 (OTC) Multihealth Fiber (sugar) $0 (OTC) Natural Daily Fiber $0 (OTC) Natural Fiber Laxative $0 (OTC) Natural Fiber Laxative (sugar) oral powder , 3.4 gram/12 gram, 3.4 gram/7 gram $0 (OTC) Natural Fiber Laxative Therapy $0 (OTC) Natural Fiber Laxative(aspart) oral powder $0 (OTC) Natural Psyllium Fiber $0 (OTC) Natural Veg Laxative(sennosid) $0 (OTC) Natural Vegetable $0 (OTC) Natural Vegetable (psyllium) $0 (OTC) Natural Vegetable Powder $0 (OTC) Natura-LAX $0 (OTC) Oral Saline Laxative oral solution $0 (OTC) P-COL RITE $0 (OTC) Pedia-Lax oral $0 (OTC) Pedia-Lax Stool Softener $0 (OTC) Pediatric Enema $0 (OTC)




Notes

Phillips' Liqui-Gels $0 (OTC) Phillips Milk of Magnesia oral tablet,chewable $0 (OTC) polyethylene glycol 3350 $0 (OTC) Powderlax oral powder $0 (OTC) psyllium husk oral capsule 0.52 gram $0 (OTC) psyllium husk oral powder $0 (OTC) Pure and Gentle Disposable $0 (OTC) Purelax $0 (OTC) Ready-To-Use Enema $0 (OTC) Reguloid, Sugar Free $0 (OTC) Senexon-S $0 (OTC) Senna Lax $0 (OTC) Senna Laxative oral tablet 8.6 mg $0 (OTC) senna oral syrup $0 (OTC) senna oral tablet $0 (OTC) Senna Plus oral tablet $0 (OTC) Senna with Docusate Sodium $0 (OTC) Senna-S $0 (OTC) Senna-Time S $0 (OTC) Senno $0 (OTC) sennosides oral syrup $0 (OTC) sennosides-docusate sodium $0 (OTC) Sen-O-Tab $0 (OTC) SmoothLax $0 (OTC) Sof-Lax $0 (OTC) sorbitol solution 70 % $0 (OTC) Stimulant Laxative Plus $0 (OTC) Stool Softener oral capsule $0 (OTC) Stool Softener oral liquid $0 (OTC) Stool Softener oral syrup $0 (OTC) Stool Softener-Laxative $0 (OTC) Stool Softener-Stimulant Laxat oral tablet $0 (OTC) The Magic Bullet $0 (OTC) Unifiber $0 (OTC) Vegetable Laxative $0 (OTC) Wal-Mucil Fiber $0 (OTC) Wal-Mucil Fiber (aspartame) $0 (OTC) Wal-Mucil Fiber (sugar) $0 (OTC) Wal-Mucil Natural Fiber Lax $0 (OTC) Woman's Laxative (bisacodyl) oral tablet $0 (OTC) Women's Gentle Laxative(bisac) $0 (OTC) Women's Laxative (bisacodyl) $0 (OTC) Digestants Dairy Aid $0 (OTC) Dairy Digestive $0 (OTC) Dairy Digestive Supplement $0 (OTC) Dairy Relief $0 (OTC) Lac-Dose $0 (OTC) lactase $0 (OTC) Lactase Enzyme $0 (OTC) Lactase Fast Acting $0 (OTC)




Notes

Lactose Fast Acting Relief $0 (OTC) Ultra Dairy Digestive $0 (OTC) Emetics ipecac $0 (OTC) Histamine H2-Antagonists Acid Controller $0 (OTC) Acid Reducer (famotidine) $0 (OTC) famotidine oral tablet 10 mg, 20 mg $0 (OTC) Heartburn Prevention $0 (OTC) Heartburn Relief (famotidine) $0 (OTC) Proton-Pump Inhibitors Acid Reducer (omeprazole) $0 (OTC) omeprazole magnesium oral capsule,delayed release(DR/EC) $0 (OTC) Prilosec OTC $0 (OTC) Hormones And Synthetic Substitutes Contraceptives Aftera $0 (OTC) EContra EZ $0 (OTC) Econtra One-Step $0 (OTC) levonorgestrel oral tablet 1.5 mg $0 (OTC) My Choice $0 (OTC) My Way $0 (OTC) New Day $0 (OTC) Opcicon One-Step $0 (OTC) Option-2 $0 (OTC) Miscellaneous Therapeutic Agents Antigout Agents All Day Pain Relief $0 (OTC) All Day Relief $0 (OTC) Flanax (naproxen) $0 (OTC) Mediproxen $0 (OTC) naproxen sodium oral tablet 220 mg $0 (OTC) Wal-Proxen $0 (OTC) Cariostatic Agents fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid) $0 (OTC)

Fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid) $0 (OTC) Flura-Drops $0 (OTC) Gel-Kam $0 (OTC) Ludent Fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid) $0 (OTC)

Multi-Vit with Fluoride-Iron $0 (OTC) Multivitamin With Fluoride $0 (OTC) Multi-Vitamin With Fluoride oral drops 0.5 mg/mL $0 (OTC) Multi-Vitamin With Fluoride oral tablet,chewable 0.25 mg $0 (OTC) Multivitamins With Fluoride oral tablet,chewable 0.25 mg, 0.5 mg $0 (OTC) Mvc-Fluoride oral tablet,chewable 0.25 mg, 0.5 mg $0 (OTC) Triple Vitamin with Fluoride $0 (OTC) Tri-Vitamin With Fluoride $0 (OTC) Other Miscellaneous Therapeutic Agents Cidatrine $0 (OTC)




Notes

Diafoods Thick-It #2 oral powder $0 (OTC) Diafoods Thick-It oral powder $0 (OTC) Dona oral tablet $0 (OTC) Genicin $0 (OTC) Glucosamine $0 (OTC) glucosamine sulfate $0 (OTC) glucosamine sulfate 2KCl oral capsule 750 mg $0 (OTC) Healthy Eyes SuperVision $0 (OTC) HyProst $0 (OTC) ICaps AREDS oral capsule $0 (OTC) Instant Food Thickener oral powder $0 (OTC) I-Vite Protect $0 (OTC) Macuvite With Lutein $0 (OTC) MAXIMUM DAILY GREEN $0 (OTC) Ocuvite Lutein and Zeaxanthin $0 (OTC) PreserVision Lutein $0 (OTC) Prosight with Lutein $0 (OTC) Synovacin $0 (OTC) Thick Now $0 (OTC) Thicken Up Clear oral powder $0 (OTC) Thick-It #2 oral powder $0 (OTC) Thick-It oral powder $0 (OTC) Pharmaceutical Aids Pharmaceutical Aids DuoDERM Hydroactive topical gel $0 (OTC) Lip Treatment $0 (OTC) Petroleum Jelly $0 (OTC) Petroleum Jelly, White $0 (OTC) polyethylene glycol 3350(bulk) powder $0 (OTC) white petrolatum (bulk) gel $0 (OTC) white petrolatum topical gel $0 (OTC) White Petroleum Jelly $0 (OTC) Respiratory Tract Agents Alpha And Beta Adrenergic Agonist(Respr) 12 Hour Decongestant $0 (OTC) 12 Hour Nasal Decongest (PSE) $0 (OTC) Adult Nasal Decongestant $0 (OTC) Alavert D-12 Allergy-Sinus $0 (OTC) All Day Allergy-D $0 (OTC) AllerClear D-12hr $0 (OTC) AllerClear D-24hr $0 (OTC) Allergy and Congestion Relief $0 (OTC) Allergy Complete-D $0 (OTC) Allergy Relief D12 $0 (OTC) Allergy Relief D-24hr $0 (OTC) Allergy Relief,Nasal Decongest $0 (OTC) Allergy Relief-D (cetirizine) $0 (OTC) Allergy Relief-D (loratadine) $0 (OTC) Allergy-Congestion Relief-D oral tablet extended release 24 hr $0 (OTC) Aller-Tec D $0 (OTC) Cetiri-D $0 (OTC)




Notes

cetirizine-pseudoephedrine $0 (OTC) Children's Silfedrine $0 (OTC) Children's Sudafed $0 (OTC) LoHist - D $0 (OTC) Long Acting Nasal Decong (PSE) $0 (OTC) Lorata-D $0 (OTC) lorata-dine D $0 (OTC) Loratadine-D $0 (OTC) Mucus D oral tablet extended release 12 hr 60-600 mg $0 (OTC) Mucus Relief D (pseudoephed) oral tablet extended release 12 hr $0 (OTC) Nasal Decongestant (pseudoeph) oral tablet $0 (OTC) Nasal Decongestant (pseudoeph) oral tablet extended release $0 (OTC) pseudoephedrine HCl oral tablet $0 (OTC) pseudoephedrine HCl oral tablet extended release $0 (OTC) pseudoephedrine-guaifenesin oral tablet extended release 12 hr 60-600 mg $0 (OTC) Rynex PSE $0 (OTC) Sinus 12 Hour $0 (OTC) Sudafed 24 Hour $0 (OTC) Sudogest $0 (OTC) Sudogest 12-hour $0 (OTC) SudoGest Cold and Allergy $0 (OTC) SudoGest Sinus and Allergy $0 (OTC) Suphedrin $0 (OTC) Suphedrine $0 (OTC) Suphedrine 12 Hour $0 (OTC) Valu-Tapp $0 (OTC) Wal-Finate-D $0 (OTC) Wal-itin D $0 (OTC) Wal-Itin D 12 Hour $0 (OTC) Wal-phed $0 (OTC) Wal-phed 12 hour $0 (OTC) Wal-Phed D $0 (OTC) Wal-Zyr D $0 (OTC) Antitussives 12-Hour Cough Relief $0 (OTC) Adult Tussin Cough Congest DM $0 (OTC) Adult Tussin DM $0 (OTC) Antitussive DM $0 (OTC) Biocotron $0 (OTC) Children's Cold and Cough (PE) $0 (OTC) Children's Cough DM ER $0 (OTC) Children's Dibromm DM Cold-Cou $0 (OTC) codeine-guaifenesin $0 (OTC) Cold and Cough DM $0 (OTC) Cold and Cough Elixir $0 (OTC) Cough DM ER $0 (OTC) Cough Formula DM $0 (OTC) Cough Syrup DM $0 (OTC) dextromethorphan polistirex $0 (OTC) dextromethorphan-guaifenesin oral syrup $0 (OTC) dextromethorphan-guaifenesin oral tablet extended release 12 hr $0 (OTC)




Notes

Diabetic Tussin DM oral liquid 10-100 mg/5 mL $0 (OTC) Dimaphen DM $0 (OTC) Dimetapp DM Cold-Cough (PE) $0 (OTC) EndaCof - DM $0 (OTC) Expectorant DM oral syrup $0 (OTC) G Tussin AC $0 (OTC) Guaiasorb DM $0 (OTC) Guaiatussin AC $0 (OTC) Guaicon DMS $0 (OTC) Guaifenesin AC $0 (OTC) Mucus DM $0 (OTC) Mucus DM Max ER $0 (OTC) Ri-Tussin DM $0 (OTC) Robafen DM Cough $0 (OTC) Robafen DM Cough-Chest Congest $0 (OTC) Rynex DM $0 (OTC) Safe Tussin DM $0 (OTC) Siltussin DM DAS $0 (OTC) Siltussin-DM $0 (OTC) Sorbugen NR $0 (OTC) Tusnel Diabetic $0 (OTC) Tussin Cough-Chest Congestion $0 (OTC) Tussin DM Clear $0 (OTC) Tussin DM Cough and Chest oral syrup $0 (OTC) Tussin DM oral liquid $0 (OTC) Tussin DM oral syrup 10-100 mg/5 mL $0 (OTC) Ultra DM Free and Clear $0 (OTC) Ultra Tuss Safe $0 (OTC) Virtussin AC $0 (OTC) Wal-tap DM $0 (OTC) Wal-Tussin DM $0 (OTC) Wal-Tussin DM Clear $0 (OTC) Expectorants Adult Tussin Chest Congestion $0 (OTC) Adult Tussin Cough Congest DM $0 (OTC) Adult Tussin DM $0 (OTC) Adult Wal-Tussin $0 (OTC) Antitussive DM $0 (OTC) Biocotron $0 (OTC) Chest Congestion Relief $0 (OTC) Child Mucinex Chest Mini-Melts oral granules in packet 100 mg $0 (OTC) Child Mucus Relief Expectorant $0 (OTC) Children's Chest Congestion $0 (OTC) codeine-guaifenesin $0 (OTC) Cough Formula DM $0 (OTC) Cough Syrup $0 (OTC) Cough Syrup DM $0 (OTC) dextromethorphan-guaifenesin oral syrup $0 (OTC) dextromethorphan-guaifenesin oral tablet extended release 12 hr $0 (OTC) Diabetic Tussin DM oral liquid 10-100 mg/5 mL $0 (OTC) Diabetic Tussin EX $0 (OTC)




Notes

ED Bron GP $0 (OTC) Expectorant $0 (OTC) Expectorant Cough Syrup $0 (OTC) Expectorant DM oral syrup $0 (OTC) Fenesin IR $0 (OTC) G Tussin AC $0 (OTC) Geri-Tussin $0 (OTC) G-Fenesin $0 (OTC) Guaiasorb DM $0 (OTC) Guaiatussin AC $0 (OTC) Guaicon DMS $0 (OTC) Guaifenesin AC $0 (OTC) guaifenesin oral liquid $0 (OTC) guaifenesin oral tablet $0 (OTC) Mucosa $0 (OTC) Mucus D oral tablet extended release 12 hr 60-600 mg $0 (OTC) Mucus DM $0 (OTC) Mucus DM Max ER $0 (OTC) Mucus Relief $0 (OTC) Mucus Relief Chest $0 (OTC) Mucus Relief D (pseudoephed) oral tablet extended release 12 hr $0 (OTC) Mucus Relief ER oral tablet extended release 12hr $0 (OTC) Mucus-ER MAX $0 (OTC) pseudoephedrine-guaifenesin oral tablet extended release 12 hr 60-600 mg $0 (OTC) Refenesen oral tablet 400 mg $0 (OTC) Ri-Tussin $0 (OTC) Ri-Tussin DM $0 (OTC) Robafen $0 (OTC) Robafen DM Cough $0 (OTC) Robafen DM Cough-Chest Congest $0 (OTC) Safe Tussin DM $0 (OTC) Siltussin DM DAS $0 (OTC) Siltussin SA $0 (OTC) Siltussin-DM $0 (OTC) Sorbugen NR $0 (OTC) Tusnel Diabetic $0 (OTC) Tussin $0 (OTC) Tussin Chest Congestion $0 (OTC) Tussin Cough-Chest Congestion $0 (OTC) Tussin DM Clear $0 (OTC) Tussin DM Cough and Chest oral syrup $0 (OTC) Tussin DM oral liquid $0 (OTC) Tussin DM oral syrup 10-100 mg/5 mL $0 (OTC) Tussin Expectorant $0 (OTC) Tussin Honey $0 (OTC) Tussin Mucus-Chest Congestion $0 (OTC) Ultra DM Free and Clear $0 (OTC) Ultra Tuss Safe $0 (OTC) Virtussin AC $0 (OTC) Wal-Tussin $0 (OTC) Wal-Tussin DM $0 (OTC)




Notes

Wal-Tussin DM Clear $0 (OTC) First Generation Antihist.(Respir Tract) Acetadryl $0 (OTC) Acetaminophen PM $0 (OTC) Acetaminophen PM Extra Str $0 (OTC) Aler-Cap $0 (OTC) Alka-Seltzer Plus Allergy $0 (OTC) Aller-G-Time $0 (OTC) Allergy (chlorpheniramine) $0 (OTC) Allergy (diphenhydramine) $0 (OTC) Allergy 4-Hour $0 (OTC) Allergy Medication $0 (OTC) Allergy Medicine oral tablet $0 (OTC) Allergy oral tablet $0 (OTC) Allergy Relief (clemastine) $0 (OTC) Allergy Relief(chlorpheniramn) oral tablet $0 (OTC) Allergy Relief(diphenhydramin) $0 (OTC) Allergy-Time $0 (OTC) Banophen oral capsule $0 (OTC) Banophen oral tablet $0 (OTC) Benadryl Allergy $0 (OTC) Child Triaminic Cold-Allergy $0 (OTC) Child Wal-Tap Cold-Allergy $0 (OTC) Children's Allergy (diphenhyd) oral liquid $0 (OTC) Children's Benadryl Allergy oral tablet,chewable $0 (OTC) Children's Cold and Cough (PE) $0 (OTC) Children's Cold-Allergy (PE) $0 (OTC) Children's Dibromm Cold-Allerg $0 (OTC) Children's Dibromm DM Cold-Cou $0 (OTC) Children's Wal-Dryl Allergy oral liquid $0 (OTC) Children's Wal-Dryl Allergy oral prefilled spoon $0 (OTC) ChlorHist $0 (OTC) chlorpheniramine maleate oral tablet $0 (OTC) ChlorTabs $0 (OTC) Cold and Allergy (bromphen-PE) $0 (OTC) Cold and Cough DM $0 (OTC) Cold and Cough Elixir $0 (OTC) Complete Allergy Medicine $0 (OTC) Complete Allergy oral capsule $0 (OTC) Complete Allergy oral tablet $0 (OTC) Compoz $0 (OTC) Dayhist Allergy $0 (OTC) Dimaphen (PE) $0 (OTC) Dimaphen DM $0 (OTC) Dimetapp Cold-Allergy (PE) $0 (OTC) Dimetapp DM Cold-Cough (PE) $0 (OTC) Diphedryl $0 (OTC) Diphedryl Allergy $0 (OTC) Diphen oral tablet $0 (OTC) diphenhydramine HCl oral capsule $0 (OTC) diphenhydramine HCl oral elixir $0 (OTC)




Notes

diphenhydramine HCl oral liquid $0 (OTC) diphenhydramine HCl oral syrup $0 (OTC) diphenhydramine HCl oral tablet 25 mg $0 (OTC) diphenhydramine-acetaminophen $0 (OTC) EaZZZe The Pain $0 (OTC) ED Chlorped Jr $0 (OTC) EndaCof - DM $0 (OTC) Geri-Dryl oral liquid $0 (OTC) Geri-Dryl oral tablet $0 (OTC) Headache PM $0 (OTC) LoHist - D $0 (OTC) Mapap PM $0 (OTC) Night Time Pain Medicine $0 (OTC) Nighttime Allergy Relief $0 (OTC) NightTime Sleep Aid (diphen) oral tablet $0 (OTC) Non-Aspirin PM $0 (OTC) Nytol $0 (OTC) Pain and Sleep $0 (OTC) Pain Relief PM $0 (OTC) Pain Relief PM Rapid Release $0 (OTC) Pain Reliever PM Ex-Strength $0 (OTC) Pain Reliever PM oral tablet 25-500 mg $0 (OTC) Pharbechlor $0 (OTC) Pharbedryl $0 (OTC) Rynex DM $0 (OTC) Rynex PE $0 (OTC) Rynex PSE $0 (OTC) Siladryl SA $0 (OTC) Simply Sleep $0 (OTC) Sleep Aid (diphenhydramine) oral tablet $0 (OTC) Sleep II $0 (OTC) Sleep Tablet (diphenhydramine) $0 (OTC) SudoGest Cold and Allergy $0 (OTC) SudoGest Sinus and Allergy $0 (OTC) Total Allergy Medicine $0 (OTC) Tylenol PM Extra Strength $0 (OTC) Valu-Dryl Allergy oral capsule $0 (OTC) Valu-Tapp $0 (OTC) Wal-Dryl Allergy $0 (OTC) Wal-Finate $0 (OTC) Wal-Finate-D $0 (OTC) Wal-Nadol PM $0 (OTC) Wal-phed oral tablet 4-60 mg $0 (OTC) Wal-Tap $0 (OTC) Wal-tap DM $0 (OTC) Mast-Cell Stabilizers cromolyn nasal $0 (OTC) Nasal Allergy Symptom Control $0 (OTC) Nasal Preparations (Steroids) 24 Hour Nasal Allergy $0 (OTC) Nasal Allergy $0 (OTC)




Notes

triamcinolone acetonide nasal $0 (OTC) Second Generation Antihist(Respir Tract) 24Hour Allergy $0 (OTC) Alavert $0 (OTC) Alavert D-12 Allergy-Sinus $0 (OTC) All Day Allergy (cetirizine) oral solution $0 (OTC) All Day Allergy (cetirizine) oral tablet $0 (OTC) All Day Allergy-D $0 (OTC) Allerclear $0 (OTC) AllerClear D-12hr $0 (OTC) AllerClear D-24hr $0 (OTC) Allergy and Congestion Relief $0 (OTC) Allergy Complete-D $0 (OTC) Allergy Relief (cetirizine) oral solution $0 (OTC) Allergy Relief (cetirizine) oral tablet $0 (OTC) Allergy Relief (loratadine) $0 (OTC) Allergy Relief D12 $0 (OTC) Allergy Relief D-24hr $0 (OTC) Allergy Relief,Nasal Decongest $0 (OTC) Allergy Relief-D (cetirizine) $0 (OTC) Allergy Relief-D (loratadine) $0 (OTC) Allergy-Congestion Relief-D oral tablet extended release 24 hr $0 (OTC) Aller-Tec $0 (OTC) Aller-Tec D $0 (OTC) Cetiri-D $0 (OTC) cetirizine $0 (OTC) cetirizine-pseudoephedrine $0 (OTC) Child Allergy Relf(cetirizine) oral solution $0 (OTC) Children's Allergy Relief(lor) $0 (OTC) Children's Allergy(cetirizine) $0 (OTC) Children's Cetirizine $0 (OTC) Children's Loratadine $0 (OTC) Children's Wal-Zyr $0 (OTC) Children's Zyrtec Allergy oral solution $0 (OTC) Child's All Day Allergy(cetir) $0 (OTC) Claritin RediTabs oral tablet,disintegrating 5 mg $0 (OTC) Loradamed $0 (OTC) Lorata-D $0 (OTC) lorata-dine D $0 (OTC) loratadine oral solution $0 (OTC) loratadine oral tablet $0 (OTC) loratadine oral tablet,disintegrating $0 (OTC) Loratadine-D $0 (OTC) Wal-itin D $0 (OTC) Wal-Itin D 12 Hour $0 (OTC) Wal-itin oral solution $0 (OTC) Wal-itin oral tablet $0 (OTC) Wal-Zyr (cetirizine) oral solution $0 (OTC) Wal-Zyr (cetirizine) oral tablet $0 (OTC) Wal-Zyr D $0 (OTC) Skin And Mucous Membrane Agents




Notes

Allylamines (Skin And Mucous Membrane) Antifungal (terbinafine) $0 (OTC) Athlete's Foot (terbinafine) $0 (OTC) Jock Itch (terbinafine) $0 (OTC) Lamisil AT topical cream $0 (OTC) terbinafine HCl topical $0 (OTC) Antibacterials (Skin, Mucous Membrane) Antibiotic (bacitracin zinc) $0 (OTC) Antibiotic (neomy-bacit-polym) $0 (OTC) Antibiotic-Pain Relief (bacit) $0 (OTC) bacitracin topical $0 (OTC) bacitracin zinc $0 (OTC) Bacitraycin Plus topical ointment 500 unit/gram $0 (OTC) Double Antibiotic (b.tracn Zn) topical ointment $0 (OTC) First Aid Antibiotic topical ointment 3.5mg-400 unit- 5,000 unit/gram $0 (OTC) First Aid Antibiotic-Pain Rlf $0 (OTC) Neosporin (neo-bac-polym) topical ointment in packet $0 (OTC) Triple Antibiotic Plus $0 (OTC) Triple Antibiotic topical ointment $0 (OTC) Triple Antibiotic topical ointment in packet $0 (OTC) Triple Antibiotic-Pain Relief $0 (OTC) Wal-Sporin $0 (OTC) Anti-Inflammatory Agents (Skin, Mucous) Anti-Itch (HC) topical cream $0 (OTC) Anti-Itch (HC) topical lotion $0 (OTC) Anti-Itch (HC) topical ointment $0 (OTC) Aquanil HC $0 (OTC) Aveeno Anti-Itch (hydrocortsn) $0 (OTC) Beta-HC $0 (OTC) Cortaid $0 (OTC) Cortisone (hydrocortisone) topical cream $0 (OTC) Cortisone (hydrocortisone) topical lotion $0 (OTC) Cortisone with Aloe $0 (OTC) Cortizone-10 Plus $0 (OTC) Cortizone-10 topical cream $0 (OTC) Cortizone-10 topical lotion $0 (OTC) Cortizone-10 topical ointment $0 (OTC) Cortizone-10 with aloe $0 (OTC) Dermarest Eczema (hydrocort) $0 (OTC) hydrocortisone acetate topical cream $0 (OTC) hydrocortisone acetate topical ointment $0 (OTC) Hydrocortisone Plus $0 (OTC) hydrocortisone topical cream 0.5 %, 1 % $0 (OTC) hydrocortisone topical cream in packet $0 (OTC) hydrocortisone topical lotion 1 % $0 (OTC) hydrocortisone topical ointment 0.5 %, 1 % $0 (OTC) hydrocortisone-aloe vera topical cream 1 % $0 (OTC) Hydrocream $0 (OTC) Noble Formula HC topical cream $0 (OTC) Preparation H Hydrocortisone $0 (OTC) Soothing Care (hydrocortisone) $0 (OTC)




Notes

Antipruritics And Local Anesthetics Nupercainal $0 (OTC) Antivirals (Skin And Mucous Membrane) Abreva $0 (OTC) Azoles (Skin And Mucous Membrane) 3 Day Vaginal $0 (OTC) 3-Day Vaginal $0 (OTC) Antifungal (clotrimazole) $0 (OTC) Antifungal Cream (miconazole) $0 (OTC) Antifungal Ringworm $0 (OTC) Anti-Fungal topical powder $0 (OTC) Athlete's Foot $0 (OTC) Athlete's Foot (clotrimazole) $0 (OTC) Athletic Foot Cream $0 (OTC) Azolen Tincture $0 (OTC) Baza Antifungal $0 (OTC) Clotrimazole 3 Day $0 (OTC) Clotrimazole AF $0 (OTC) clotrimazole topical $0 (OTC) clotrimazole vaginal cream $0 (OTC) Clotrimazole-3 $0 (OTC) Clotrimazole-7 $0 (OTC) Desenex topical powder $0 (OTC) Fungi Cure $0 (OTC) Gyne-Lotrimin $0 (OTC) Gyne-Lotrimin 7 $0 (OTC) Inzo Antifungal $0 (OTC) Itch Relief (clotrimazole) $0 (OTC) Jock Itch (clotrimazole) $0 (OTC) Lotrimin AF $0 (OTC) Lotrimin AF (clotrimazole) topical cream $0 (OTC) Lotrimin AF Jock Itch Powder $0 (OTC) Lotrimin AF Powder $0 (OTC) Micatin $0 (OTC) Miconazole 7 $0 (OTC) miconazole nitrate topical $0 (OTC) miconazole nitrate vaginal comb pack,prefill appl, cream $0 (OTC) miconazole nitrate vaginal cream $0 (OTC) miconazole nitrate vaginal kit 1,200-2 mg-% $0 (OTC) Miconazole-3 prefil,cream,wipe $0 (OTC) Miconazole-3 vaginal comb pack,prefill appl, cream $0 (OTC) Miconazole-3 vaginal cream $0 (OTC) Miconazole-3 vaginal kit $0 (OTC) miconazole-skin clnsr17 vaginal kit 4 % (200 mg)- 2 % (9 gram) $0 (OTC) Miconazorb AF $0 (OTC) Micro-Guard $0 (OTC) Monistat 3 vaginal cream $0 (OTC) Nizoral A-D $0 (OTC) Remedy Antifungal $0 (OTC) Remedy Phytoplex Antifungal topical powder $0 (OTC) Ringworm $0 (OTC)




Notes

Secura Antifungal $0 (OTC) Secura Antifungal Extra Thick $0 (OTC) Zeasorb AF $0 (OTC) Basic Lotions And Liniments AmLactin topical lotion $0 (OTC) ammonium lactate topical lotion $0 (OTC) calamine-zinc oxide topical lotion 8-8 % $0 (OTC) Geri-Hydrolac topical lotion 12 % $0 (OTC) Lac-Hydrin Five $0 (OTC) Skin Treatment $0 (OTC) Basic Oils And Other Solvents Lobana Bath $0 (OTC) Mapo Bath $0 (OTC) mineral oil $0 (OTC) Mineral Oil Heavy $0 (OTC) Mineral Oil Light $0 (OTC) mineral oil topical $0 (OTC) Basic Ointments And Protectants 4-N-1 No Rinse Wash topical cream $0 (OTC) Cool Bottoms $0 (OTC) Diaper Rash topical ointment $0 (OTC) Diaper Rash topical paste $0 (OTC) Neutraphor $0 (OTC) Remedy Nutrashield Skin Protec $0 (OTC) TheraSeal $0 (OTC) Triple Paste topical ointment 12.8 % $0 (OTC) white petrolatum topical ointment in packet $0 (OTC) zinc oxide topical ointment , 20 %, 40 % $0 (OTC) Basic Powders And Demulcents Natural Oatmeal Bath Treatment $0 (OTC) Oatmeal Bath Regular $0 (OTC) Renewal Bath Treatment $0 (OTC) Soothing Bath Treatment $0 (OTC) Corticosteroids (Skin, Mucous Membrane) Anti-Itch (HC) topical cream $0 (OTC) Anti-Itch (HC) topical lotion $0 (OTC) Anti-Itch (HC) topical ointment $0 (OTC) Aquanil HC $0 (OTC) Aveeno Anti-Itch (hydrocortsn) $0 (OTC) Beta-HC $0 (OTC) Cortaid $0 (OTC) Cortisone (hydrocortisone) topical cream $0 (OTC) Cortisone (hydrocortisone) topical lotion $0 (OTC) Cortisone with Aloe $0 (OTC) Cortizone-10 Plus $0 (OTC) Cortizone-10 topical cream $0 (OTC) Cortizone-10 topical lotion $0 (OTC) Cortizone-10 topical ointment $0 (OTC) Cortizone-10 with aloe $0 (OTC) Dermarest Eczema (hydrocort) $0 (OTC) hydrocortisone acetate topical cream $0 (OTC)




Notes

hydrocortisone acetate topical ointment $0 (OTC) Hydrocortisone Plus $0 (OTC) hydrocortisone topical cream 0.5 %, 1 % $0 (OTC) hydrocortisone topical cream in packet $0 (OTC) hydrocortisone topical lotion 1 % $0 (OTC) hydrocortisone topical ointment 0.5 %, 1 % $0 (OTC) hydrocortisone-aloe vera topical cream 1 % $0 (OTC) Hydrocream $0 (OTC) Noble Formula HC topical cream $0 (OTC) Preparation H Hydrocortisone $0 (OTC) Soothing Care (hydrocortisone) $0 (OTC) Keratolytic Agents Acne Cleanser $0 (OTC) Acne Foaming Wash $0 (OTC) Acne Medication topical lotion 5 % $0 (OTC) Acne Pads $0 (OTC) Acne Vanishing $0 (OTC) Advanced Exfoliating Cleanser $0 (OTC) BenzePrO (microspheres) $0 (OTC) benzoyl peroxide topical cleanser 10 %, 5 % $0 (OTC) benzoyl peroxide topical gel 2.5 %, 5 % $0 (OTC) BP topical gel 5 % $0 (OTC) BP Wash $0 (OTC) BPO topical gel $0 (OTC) Callus Remover $0 (OTC) Callus Removers $0 (OTC) Clean-Clear Continuous Control $0 (OTC) Clear Away $0 (OTC) Clearasil Daily Clear(benzoyl) $0 (OTC) Clearasil Ultra $0 (OTC) Compound W topical adhesive patch,medicated $0 (OTC) Compound W topical liquid $0 (OTC) Corn Remover $0 (OTC) Corn-Callus Remover topical kit $0 (OTC) Corn-Callus Remover topical liquid 17 % $0 (OTC) Creamy Acne Face $0 (OTC) Daily Face Wash $0 (OTC) Daylogic Acne Foaming Wash $0 (OTC) Dr Scholl's Clear Away $0 (OTC) Duofilm $0 (OTC) Foaming Acne Face Wash $0 (OTC) Keralyt $0 (OTC) Liquid Corn and Callus Remover topical liquid 17 % $0 (OTC) Medicated Corn Removers $0 (OTC) Mediplast Corn-Callus-Wart $0 (OTC) Mosco Corn Remover $0 (OTC) Panoxyl topical cleanser 10 % $0 (OTC) Plantar Wart Remover $0 (OTC) PR Benzoyl Peroxide $0 (OTC) Rapid Clear Treatment Pads $0 (OTC) Sal-Plant $0 (OTC)




Notes

Scalp Relief topical liquid $0 (OTC) Wart Remover $0 (OTC) Keratoplastic Agents Anti-Dandruff (coal tar) $0 (OTC) Ionil T $0 (OTC) Oxipor VHC $0 (OTC) Tarsum Professional $0 (OTC) Tera-Gel Tar Shampoo $0 (OTC) Thera-Gel $0 (OTC) Therapeutic Shampoo topical shampoo 0.5 %, 1 % $0 (OTC) T-Plus $0 (OTC) X-Seb T Plus $0 (OTC) Local Anti-Infectives, Miscellaneous Alcohol, Rubbing $0 (OTC) Antiseptic Skin Clnsr(chlorhe) $0 (OTC) Antiseptic topical solution $0 (OTC) Betasept Surgical Scrub $0 (OTC) chlorhexidine gluconate topical liquid 4 % $0 (OTC) First Aid Antiseptic topical solution $0 (OTC) isopropyl alcohol solution 70 % $0 (OTC) povidone-iodine topical liquid in packet $0 (OTC) povidone-iodine topical ointment $0 (OTC) povidone-iodine topical pads, medicated $0 (OTC) povidone-iodine topical solution 10 % $0 (OTC) povidone-iodine topical spray,non-aerosol $0 (OTC) Scabicides And Pediculicides Complete Lice Treatment $0 (OTC) Lice Complete Kit 1-2-3 $0 (OTC) Lice Killing $0 (OTC) Lice Killing (permethrin) $0 (OTC) Lice Pyrinyl Shampoo $0 (OTC) Lice Solution $0 (OTC) Lice Treatment (permethrin) $0 (OTC) Lice Treatment topical liquid 1 % $0 (OTC) Lice Treatment topical shampoo $0 (OTC) RID Complete Lice Elim Kit topical $0 (OTC) RID Lice Killing $0 (OTC) Skin And Mucous Membrane Agents, Misc. Arthritis Pain Relief(capsaic) $0 (OTC) capsaicin topical cream 0.025 %, 0.1 % $0 (OTC) Hemorrhoid rectal ointment $0 (OTC) Hemorrhoidal Cooling $0 (OTC) Hemorrhoidal H $0 (OTC) Hemorrhoidal rectal ointment $0 (OTC) Hemorrhoidal rectal suppository 0.25-3 % $0 (OTC) High Potency Capsaicin $0 (OTC) Rectiv $0 (OTC) Zostrix-HP $0 (OTC) Zostrix-HP Foot $0 (OTC) Thiocarbamates(Skin And Mucous Membrane) AF $0 (OTC)




Notes

Antifungal (tolnaftate) $0 (OTC) Antifungal Spray $0 (OTC) Athlete's Foot (tolnaftate) $0 (OTC) Blis-To-Sol (tolnaftate) $0 (OTC) Foot and Sneaker $0 (OTC) Formula 3 $0 (OTC) Fungoid-D $0 (OTC) Jock Itch $0 (OTC) Lamisil AF $0 (OTC) Odor Control Foot-Sneaker $0 (OTC) Tinactin topical aerosol powder $0 (OTC) tolnaftate topical aerosol powder $0 (OTC) tolnaftate topical cream $0 (OTC) tolnaftate topical powder $0 (OTC) Vitamins Multivitamin Preparations 50 Plus Adult Eye Health $0 (OTC) A Thru Z $0 (OTC) A Thru Z Advanced Formula $0 (OTC) A Thru Z High Potency $0 (OTC) A Thru Z Men's Ultimate $0 (OTC) A Thru Z Select $0 (OTC) A Thru Z Select 50Plus Formula $0 (OTC) A Thru Z Select Women's $0 (OTC) ABC Plus $0 (OTC) Adult One Daily Multivitamin $0 (OTC) Adults 50 plus $0 (OTC) Adults Multivitamin $0 (OTC) ANIMAL CHEWS $0 (OTC) Animal Shape Vitamins $0 (OTC) Animal Shapes Complete $0 (OTC) Animal Shapes Plus Iron $0 (OTC) Antioxidant A/C/E/Selenium $0 (OTC) Antioxidant Vitamins oral tablet 1,000 unit-200 mg-60 unit-2 mg $0 (OTC) Bacmin $0 (OTC) Bio-35, Gluten Free $0 (OTC) Biosupp $0 (OTC) Biotect Plus $0 (OTC) Biotin Plus-Calcium and Vit D3 $0 (OTC) Body, Hair, Skin and Nails $0 (OTC) Centamin $0 (OTC) Central-Vite oral tablet , 18 mg iron-400 mcg-25 mcg $0 (OTC) Central-Vite Women's Mature $0 (OTC) Centram-Care $0 (OTC) Centravites $0 (OTC) Centravites 50 Plus $0 (OTC) Centravites Adults $0 (OTC) Centrum Complete $0 (OTC) Centrum oral liquid 9 mg iron/15 mL $0 (OTC) Centrum oral tablet $0 (OTC) Centrum Silver oral tablet $0 (OTC)




Notes

Centrum Specialist Heart $0 (OTC) Centrum Women $0 (OTC) Century Adults 50 Plus $0 (OTC) Century Cardio $0 (OTC) Century Mature oral tablet 0.4-300-250 mg-mcg-mcg $0 (OTC) Century oral tablet 18-400 mg-mcg $0 (OTC) Century Ultimate Men's $0 (OTC) Century Ultimate Women's $0 (OTC) Cerovite Jr oral tablet,chewable $0 (OTC) Certa Plus $0 (OTC) Certavite-Antioxidant $0 (OTC) Chewable-Vite $0 (OTC) Child Multivitamins $0 (OTC) Children's Chew Multivitamin $0 (OTC) Children's Chewable Multivitmn $0 (OTC) Children's Chewable Vitamin $0 (OTC) Children's Chewables $0 (OTC) Children's Multivitamin $0 (OTC) Child's Chewable Vitamins/Iron oral tablet,chewable $0 (OTC) Childs/Iron $0 (OTC) Classic Prenatal $0 (OTC) Complete 50 Plus $0 (OTC) Complete Men $0 (OTC) Complete Multi $0 (OTC) Complete Multi 50+ $0 (OTC) Complete Multivitamin oral tablet $0 (OTC) Complete Multivitamin-Mineral $0 (OTC) Complete MV Adult 50 Plus $0 (OTC) Complete oral tablet 18-500-300-250 mg-mcg-mcg-mcg $0 (OTC) Complete Premium Vitamin $0 (OTC) Complete Senior $0 (OTC) Complete Women $0 (OTC) CompleteNate $0 (OTC) Corvite Free $0 (OTC) Daily Multiple $0 (OTC) Daily Multiple For Men $0 (OTC) Daily Multiple For Women $0 (OTC) Daily Multiple Vitamins/Iron $0 (OTC) Daily Multi-Vitamin $0 (OTC) Daily Multivitamin with Iron $0 (OTC) Daily Multivitamin-Minerals $0 (OTC) Daily Value $0 (OTC) Daily Vitamin Formula $0 (OTC) Daily Vitamin Formula-Iron $0 (OTC) DAILY VITAMIN FORMULA-MINERALS $0 (OTC) Daily Vitamin with Iron $0 (OTC) Decubi Vite $0 (OTC) Diabetes Health Formula $0 (OTC) Diabetic Support Formula $0 (OTC) Dino-Life with Iron-Zinc $0 (OTC) E-400 C-500 and Beta Carotene $0 (OTC)




Notes

Essentia $0 (OTC) ESSENTIAL Man $0 (OTC) ESSENTIAL Man 50+ $0 (OTC) Essential Woman 50+ $0 (OTC) Eye Health Plus Lutein $0 (OTC) Flintstones Complete (iron) oral tablet,chewable $0 (OTC) Flintstones Multi-Vit Gummies oral tablet,chewable 100 mcg $0 (OTC) Flintstones Multivitamin oral tablet,chewable $0 (OTC) Flintstones Plus Calcium $0 (OTC) Flintstones Tab Chew $0 (OTC) Flintstones/Extra C $0 (OTC) Fortavit $0 (OTC) Freedavite $0 (OTC) Gummi Bear Multivitamin $0 (OTC) Gummy Dinos oral tablet,chewable 200 mcg $0 (OTC) Hair Vitamins $0 (OTC) Hair, Skin and Nails Advanced $0 (OTC) Hair,Skin and Nails oral tablet $0 (OTC) Healthy Eyes $0 (OTC) Honey Bears $0 (OTC) Honey Bears with Iron-Zinc $0 (OTC) I-Caps $0 (OTC) Icaps MV $0 (OTC) K-Pax Immune Support $0 (OTC) KPN oral tablet $0 (OTC) Little Animals-Iron oral tablet,chewable $0 (OTC) Lysiplex Plus oral liquid $0 (OTC) Maximum Daily Multivitamin $0 (OTC) Mega Multi for Women $0 (OTC) Mega Multiple/Chelated Mineral $0 (OTC) Mega Multivitamin For Men $0 (OTC) Mega Multivitamin with Mineral oral tablet 13.5-200-250 mg-mcg-mcg $0 (OTC) Megavite $0 (OTC) Men 50 Plus Multivitamin $0 (OTC) Men Under 50 Multivitamin $0 (OTC) Men's Daily $0 (OTC) Men's Daily Formula oral tablet 400-20-300 mcg $0 (OTC) Men's Daily Multivit-Mineral $0 (OTC) Men's Multivitamin $0 (OTC) Men's One Daily $0 (OTC) Milltrium Senior $0 (OTC) Mini Prenatal $0 (OTC) Monocaps $0 (OTC) Multi Complete with Iron $0 (OTC) Multi For Her 50 Plus $0 (OTC) Multi For Her oral capsule $0 (OTC) Multi Vitamin $0 (OTC) Multi-Betic $0 (OTC) Multi-Day with Iron $0 (OTC) Multilex $0 (OTC) Multilex-T and M $0 (OTC)




Notes

Multiple Vitamin, Womens $0 (OTC) Multiple Vitamin-Minerals $0 (OTC) Multiple Vitamins $0 (OTC) Multi-Vit with Fluoride-Iron $0 (OTC) multivitamin $0 (OTC) Multivitamin 50 Plus $0 (OTC) Multi-Vitamin HP/Minerals $0 (OTC) Multivitamin With Fluoride $0 (OTC) Multi-Vitamin With Fluoride oral drops 0.5 mg/mL $0 (OTC) Multi-Vitamin With Fluoride oral tablet,chewable 0.25 mg $0 (OTC) multivitamin with iron $0 (OTC) multivitamin with minerals oral liquid $0 (OTC) multivitamin with minerals oral tablet $0 (OTC) Multivitamins With Fluoride oral tablet,chewable 0.25 mg, 0.5 mg $0 (OTC) Multi-Vitamins with Iron $0 (OTC) Multi-Vite $0 (OTC) Mvc-Fluoride oral tablet,chewable 0.25 mg, 0.5 mg $0 (OTC) My Favorite Multiple $0 (OTC) Mynatal Advance $0 (OTC) My-Vitalife $0 (OTC) Niva-Plus $0 (OTC) Ocutabs $0 (OTC) Ocuvite with Lutein $0 (OTC) Omnicap $0 (OTC) Once Daily $0 (OTC) Oncovite $0 (OTC) One Daily Calcium/Iron $0 (OTC) One Daily Energy oral tablet , 9 mg iron-400 mcg-200 mg $0 (OTC) One Daily Essential $0 (OTC) One Daily For Men $0 (OTC) One Daily For Men 50+ Advanced $0 (OTC) One Daily For Women $0 (OTC) One Daily Maximum $0 (OTC) One Daily Men's 50 Plus Memory $0 (OTC) One Daily Multi-Vit w-Mineral oral tablet $0 (OTC) One Daily Multivitamin oral tablet $0 (OTC) One Daily Multivit-Iron(folic) $0 (OTC) One Daily oral tablet 0.4-600 mg-mcg, 300-18-400-50 mg-mg-mcg-mg $0 (OTC) One Daily Plus Iron oral tablet 18-400 mg-mcg $0 (OTC) One Daily Plus Minerals $0 (OTC) One Daily Prenatal $0 (OTC) One Daily With Iron $0 (OTC) One Daily Women 50 Plus $0 (OTC) One Daily Women 50 Plus(Vit K) $0 (OTC) One Daily Womens 50 Plus $0 (OTC) One Daily Women's Health $0 (OTC) One Daily Women's Metabolism $0 (OTC) One Daily Women's oral tablet 18 mg iron-400 mcg-450 mg Ca, 27-0.4 mg $0 (OTC) One-A-Day Essential $0 (OTC) One-A-Day Maximum Formula $0 (OTC) One-A-Day Men 50 Plus (ginkgo) $0 (OTC)




Notes

One-A-Day Menopause Formula $0 (OTC) One-A-Day Teen Advantage $0 (OTC) One-A-Day Vitacraves Omega-3 $0 (OTC) One-A-Day Women's Healthy Skin $0 (OTC) One-A-Day Women's Petites $0 (OTC) Opti-Vitamins $0 (OTC) Perry Prenatal $0 (OTC) PNV cmb#95-ferrous fumarate-FA $0 (OTC) PreNata $0 (OTC) Prenatal + DHA oral combo pack 28 mg iron-800 mcg-200 mg $0 (OTC) Prenatal Complete $0 (OTC) Prenatal Formula oral tablet 28 mg iron- 800 mcg $0 (OTC) Prenatal Gummy $0 (OTC) Prenatal Low Iron $0 (OTC) Prenatal Multi $0 (OTC) Prenatal Multi-DHA (algal oil) $0 (OTC) Prenatal Multi-DHA(with vit K) $0 (OTC) Prenatal Multivitamins $0 (OTC) Prenatal One Daily $0 (OTC) Prenatal oral tablet $0 (OTC) Prenatal Plus (calcium carb) $0 (OTC) Prenatal Tablet $0 (OTC) Prenatal Vitamin oral tablet 27 mg iron- 0.8 mg, 27 mg iron- 800 mcg $0 (OTC) Prenatal Vitamin Plus Low Iron $0 (OTC) Prenatal Vitamin with Minerals $0 (OTC) prenatal vit-iron fum-folic ac $0 (OTC) prenatal vits96-iron fum-folic $0 (OTC) Prenatal with DHA-Folic Acid $0 (OTC) PrePlus $0 (OTC) ProRenal QD $0 (OTC) Quintabs $0 (OTC) Quintabs-M $0 (OTC) Quintabs-M Iron Free $0 (OTC) REQ49+ $0 (OTC) SAVision $0 (OTC) Scooby-Doo One A Day $0 (OTC) Senior Tabs $0 (OTC) Sentry $0 (OTC) Sentry Senior $0 (OTC) Spectravite Adult 50 Plus $0 (OTC) Spectravite Advanced Formula oral tablet 18-400 mg-mcg $0 (OTC) Spectravite Men's $0 (OTC) Spectravite Senior oral tablet 500-300-250 mcg $0 (OTC) Spectravite Ultra Men 50+ $0 (OTC) Spectravite Ultra Men's Sr $0 (OTC) Spectravite Ultra Women $0 (OTC) Spectravite Ultra Women's Sr $0 (OTC) Stress B With Zinc $0 (OTC) Stress Formula $0 (OTC) Stress Formula 600 C $0 (OTC) Stress Formula with Zinc $0 (OTC)




Notes

Strovite Forte $0 (OTC) Strovite One $0 (OTC) Super Antioxidant $0 (OTC) Super Multiple $0 (OTC) Super Multiple - Low Iron $0 (OTC) Super Thera Vite M $0 (OTC) Support $0 (OTC) Tab-A-Vite $0 (OTC) Tab-A-Vite/Iron $0 (OTC) Thera $0 (OTC) Theradex M $0 (OTC) Theragran-M Premier 50 Plus $0 (OTC) Theralogix Companion $0 (OTC) Thera-M oral tablet , 9 mg iron-400 mcg $0 (OTC) Therapeutic Liquid $0 (OTC) Therapeutic-M oral tablet 9 mg iron-400 mcg $0 (OTC) Therapeutic-M Vitamin/Minerals $0 (OTC) Thera-Tabs $0 (OTC) Theratrum Complete 50 Plus/Lut $0 (OTC) Theratrum Complete 50 Plus-lyc $0 (OTC) Theratrum Complete with Lutein $0 (OTC) Therems-M $0 (OTC) Triple Vitamin with Fluoride $0 (OTC) Tri-Vitamin With Fluoride $0 (OTC) TYR Cooler oral liquid $0 (OTC) Ultimate Men's Complete 50+ $0 (OTC) Ultimate Women's Complete 50+ $0 (OTC) Ultra Antioxidant Formula $0 (OTC) Ultra Freeda $0 (OTC) V-C Forte $0 (OTC) VIC-Forte $0 (OTC) Vision $0 (OTC) Vision Formula (with lutein) $0 (OTC) Vision Plus Lutein $0 (OTC) Vitalee $0 (OTC) Vitalets oral tablet,chewable $0 (OTC) Vitamin D3 Complete $0 (OTC) Vitamins A-D-E selenium $0 (OTC) Vitamins and Minerals $0 (OTC) Vitrum Senior oral tablet $0 (OTC) Women's 50 Plus Daily Formula $0 (OTC) Women's 50 Plus Multivitamin $0 (OTC) Women's Daily Caplet $0 (OTC) Women's Daily Formula oral tablet 18 mg iron-400 mcg-500 mg Ca, 27-0.4 mg $0 (OTC) Women's One Daily $0 (OTC) Yelets $0 (OTC) Zoo Chews $0 (OTC) Zoo Friends Plus Iron $0 (OTC) Vitamin A beta carotene $0 (OTC) Child Multivitamins $0 (OTC)




Notes

Prevent $0 (OTC) Triple Vitamin with Fluoride $0 (OTC) Tri-Vitamin With Fluoride $0 (OTC) vitamin A oral capsule 10,000 unit, 8,000 unit $0 (OTC) Vitamins A-D-E selenium $0 (OTC) Vitamin B Complex A Thru Z Advanced Formula $0 (OTC) A Thru Z Men's Ultimate $0 (OTC) A Thru Z Select 50Plus Formula $0 (OTC) A Thru Z Select oral tablet 300-600-300 mcg, 500-300-250 mcg $0 (OTC) ABC Plus $0 (OTC) Adult One Daily Multivitamin $0 (OTC) Adults 50 plus $0 (OTC) Adults Multivitamin $0 (OTC) B Complex w-Vit C $0 (OTC) B complex-vitamin C-folic acid oral tablet $0 (OTC) B-12 DOTS $0 (OTC) Bacmin $0 (OTC) B-complex with vitamin C oral tablet $0 (OTC) Bio-35, Gluten Free $0 (OTC) Biocal $0 (OTC) Central-Vite oral tablet 18 mg iron-400 mcg-25 mcg $0 (OTC) Central-Vite Women's Mature $0 (OTC) Centravites 50 Plus oral tablet 0.4-300-250 mg-mcg-mcg $0 (OTC) Centravites Adults $0 (OTC) Centrum Complete $0 (OTC) Centrum oral tablet $0 (OTC) Centrum Silver oral tablet $0 (OTC) Centrum Women $0 (OTC) Century Adults 50 Plus $0 (OTC) Century Mature oral tablet 0.4-300-250 mg-mcg-mcg $0 (OTC) Century oral tablet 18-400 mg-mcg $0 (OTC) Century Ultimate Men's $0 (OTC) Century Ultimate Women's $0 (OTC) Certa Plus $0 (OTC) Certavite-Antioxidant $0 (OTC) Child Multivitamins $0 (OTC) Children's Chewable Multivitmn $0 (OTC) Children's Chewables $0 (OTC) Classic Prenatal $0 (OTC) Complete 50 Plus $0 (OTC) Complete Men $0 (OTC) Complete Multi 50+ $0 (OTC) Complete Multivitamin-Mineral oral tablet $0 (OTC) Complete MV Adult 50 Plus $0 (OTC) Complete Senior oral tablet 0.4-300-250 mg-mcg-mcg $0 (OTC) Complete Women $0 (OTC) CompleteNate $0 (OTC) Corvite Free $0 (OTC) cyanocobalamin (vitamin B-12) injection $0 (OTC) cyanocobalamin (vitamin B-12) oral tablet 1,000 mcg, 100 mcg, 500 mcg $0 (OTC)




Notes

cyanocobalamin (vitamin B-12) oral tablet extended release 1,000 mcg $0 (OTC) Daily Multiple For Men $0 (OTC) Daily Multiple For Women $0 (OTC) Daily Multiple oral tablet 18-400 mg-mcg, 400-120 mcg-mg $0 (OTC) Daily Multivitamin with Iron $0 (OTC) Daily Vitamin Formula-Iron $0 (OTC) Decubi Vite $0 (OTC) Diabetes Health Formula $0 (OTC) Diabetic Support Formula $0 (OTC) Dialyvite 800 oral tablet $0 (OTC) Dialyvite 800-Ultra D $0 (OTC) Dialyvite oral tablet 100-1 mg $0 (OTC) Essentia $0 (OTC) ESSENTIAL Man $0 (OTC) ESSENTIAL Man 50+ $0 (OTC) Essential Woman 50+ $0 (OTC) FA-8 $0 (OTC) Flintstones Multi-Vit Gummies oral tablet,chewable 100 mcg $0 (OTC) Flintstones Tab Chew $0 (OTC) Flintstones/Extra C oral tablet,chewable 100 mcg $0 (OTC) folic acid oral $0 (OTC) Freedavite $0 (OTC) Full Spectrum B-Vitamin C $0 (OTC) Gummy Dinos oral tablet,chewable 200 mcg $0 (OTC) Hair, Skin and Nails Advanced $0 (OTC) Icaps MV $0 (OTC) K-Pax Immune Support $0 (OTC) Mega Multi for Women $0 (OTC) Mega Multivitamin For Men $0 (OTC) Mega Multivitamin with Mineral oral tablet 13.5-200-250 mg-mcg-mcg $0 (OTC) Megavite $0 (OTC) Men 50 Plus Multivitamin $0 (OTC) Men Under 50 Multivitamin $0 (OTC) Men's Daily $0 (OTC) Men's Daily Formula oral tablet 400-20-300 mcg $0 (OTC) Men's Daily Multivit-Mineral $0 (OTC) Men's Multivitamin $0 (OTC) Men's One Daily oral tablet 400-20-300 mcg $0 (OTC) Mini Prenatal $0 (OTC) Monocaps $0 (OTC) Multi Complete with Iron $0 (OTC) Multi For Her 50 Plus $0 (OTC) Multi For Her oral capsule $0 (OTC) Multi-Betic $0 (OTC) Multi-Day with Iron $0 (OTC) Mynatal Advance $0 (OTC) Mynephrocaps $0 (OTC) Mynephron $0 (OTC) Nephro-Vite Rx $0 (OTC) Niva-Plus $0 (OTC) Omnicap $0 (OTC)




Notes

One Daily Energy oral tablet 9 mg iron-400 mcg-200 mg $0 (OTC) One Daily Essential oral tablet 0.4 mg, 400 mcg $0 (OTC) One Daily For Men $0 (OTC) One Daily For Men 50+ Advanced $0 (OTC) One Daily For Women $0 (OTC) One Daily Maximum $0 (OTC) One Daily Men's 50 Plus Memory $0 (OTC) One Daily Multivitamin oral tablet 400 mcg $0 (OTC) One Daily Multivit-Iron(folic) $0 (OTC) One Daily oral tablet 0.4-600 mg-mcg $0 (OTC) One Daily Plus Iron oral tablet 18-400 mg-mcg $0 (OTC) One Daily Prenatal $0 (OTC) One Daily Women 50 Plus $0 (OTC) One Daily Women 50 Plus(Vit K) $0 (OTC) One Daily Womens 50 Plus $0 (OTC) One Daily Women's Health $0 (OTC) One Daily Women's oral tablet 18 mg iron-400 mcg-450 mg Ca $0 (OTC) One-A-Day Men 50 Plus (ginkgo) $0 (OTC) One-A-Day Menopause Formula $0 (OTC) One-A-Day Teen Advantage $0 (OTC) One-A-Day Vitacraves Omega-3 $0 (OTC) One-A-Day Women's Healthy Skin $0 (OTC) One-A-Day Women's Petites $0 (OTC) Parvlex $0 (OTC) Perry Prenatal $0 (OTC) PNV cmb#95-ferrous fumarate-FA $0 (OTC) PreNata $0 (OTC) Prenatal + DHA oral combo pack 28 mg iron-800 mcg-200 mg $0 (OTC) Prenatal Complete $0 (OTC) Prenatal Formula oral tablet 28 mg iron- 800 mcg $0 (OTC) Prenatal Gummy $0 (OTC) Prenatal Low Iron $0 (OTC) Prenatal Multi $0 (OTC) Prenatal Multi-DHA (algal oil) $0 (OTC) Prenatal Multi-DHA(with vit K) $0 (OTC) Prenatal Multivitamins $0 (OTC) Prenatal One Daily $0 (OTC) Prenatal oral tablet $0 (OTC) Prenatal Plus (calcium carb) $0 (OTC) Prenatal Tablet $0 (OTC) Prenatal Vitamin oral tablet 27 mg iron- 0.8 mg, 27 mg iron- 800 mcg $0 (OTC) Prenatal Vitamin Plus Low Iron $0 (OTC) Prenatal Vitamin with Minerals $0 (OTC) prenatal vit-iron fum-folic ac $0 (OTC) prenatal vits96-iron fum-folic $0 (OTC) Prenatal with DHA-Folic Acid $0 (OTC) PrePlus $0 (OTC) ProRenal $0 (OTC) ProRenal QD $0 (OTC) pyridoxine (vitamin B6) oral tablet 100 mg, 25 mg, 50 mg $0 (OTC) Quin B Strong $0 (OTC)




Notes

Quintabs $0 (OTC) Quintabs-M $0 (OTC) Quintabs-M Iron Free $0 (OTC) Renal Caps $0 (OTC) Renal Vitamin $0 (OTC) Renal-Vite $0 (OTC) Rena-Vite $0 (OTC) Rena-Vite Rx $0 (OTC) Reno Caps $0 (OTC) riboflavin (vitamin B2) oral tablet 100 mg $0 (OTC) Senior Tabs $0 (OTC) Sentry $0 (OTC) Sentry Senior $0 (OTC) Siderol oral tablet $0 (OTC) Spectravite Adult 50 Plus $0 (OTC) Spectravite Advanced Formula oral tablet 18-400 mg-mcg $0 (OTC) Spectravite Men's $0 (OTC) Spectravite Senior oral tablet 500-300-250 mcg $0 (OTC) Spectravite Ultra Men 50+ $0 (OTC) Spectravite Ultra Men's Sr $0 (OTC) Spectravite Ultra Women $0 (OTC) Spectravite Ultra Women's Sr $0 (OTC) Stress B Plus Zinc $0 (OTC) Stress B-Complex oral tablet 500-400-23.9-3 mg-mcg-mg-mg $0 (OTC) Stress Formula with Iron $0 (OTC) Stress Formula With Iron(sulf) $0 (OTC) Strovite Forte $0 (OTC) Strovite One $0 (OTC) Super B Complex-Vitamin C $0 (OTC) Super Multiple - Low Iron $0 (OTC) Super Multiple oral capsule $0 (OTC) Thera oral tablet 400 mcg $0 (OTC) Theradex M $0 (OTC) Theragran-M Premier 50 Plus $0 (OTC) Theralogix Companion $0 (OTC) Thera-M oral tablet 9 mg iron-400 mcg $0 (OTC) Therapeutic-M oral tablet 9 mg iron-400 mcg $0 (OTC) Therapeutic-M Vitamin/Minerals $0 (OTC) Theratrum Complete 50 Plus-lyc $0 (OTC) thiamine HCl (vitamin B1) oral tablet 100 mg, 250 mg $0 (OTC) Total B/C $0 (OTC) Triphrocaps $0 (OTC) Ultimate Men's Complete 50+ $0 (OTC) Ultimate Women's Complete 50+ $0 (OTC) Ultra Freeda $0 (OTC) V-C Forte $0 (OTC) VIC-Forte $0 (OTC) Virt-Caps $0 (OTC) Vitalee $0 (OTC) Vitamin B-1 $0 (OTC) Vitamin B-12 oral tablet 1,000 mcg, 100 mcg, 250 mcg, 500 mcg $0 (OTC)




Notes

Vitamin B-12 oral tablet extended release 1,000 mcg $0 (OTC) Vitamin B-2 oral tablet 100 mg $0 (OTC) Vitamin B-6 oral tablet 100 mg, 25 mg, 50 mg $0 (OTC) Vitamin D3 Complete $0 (OTC) Vitamins B Complex oral tablet 500 mg-400 mcg- 18 mg iron $0 (OTC) VP-Vite Rx $0 (OTC) Women's 50 Plus Daily Formula $0 (OTC) Women's 50 Plus Multivitamin $0 (OTC) Women's Daily Caplet $0 (OTC) Women's Daily Formula oral tablet 18 mg iron-400 mcg-500 mg Ca $0 (OTC) Women's One Daily $0 (OTC) Yelets $0 (OTC) Vitamin C Acerola C $0 (OTC) Acerola C-500 $0 (OTC) ascorbic acid (vitamin C) oral tablet $0 (OTC) ascorbic acid (vitamin C) oral tablet,chewable 500 mg $0 (OTC) ascorbic acid-ascorbate sodium oral wafer $0 (OTC) B Complex w-Vit C $0 (OTC) B complex-vitamin C-folic acid oral tablet $0 (OTC) B-complex with vitamin C oral tablet $0 (OTC) C Complex oral tablet extended release 1,000 mg $0 (OTC) C-1000 $0 (OTC) C-1000 with Rose Hips $0 (OTC) C-500 oral tablet $0 (OTC) C-500 oral tablet,chewable $0 (OTC) Decubi Vite $0 (OTC) Dialyvite 800 oral tablet $0 (OTC) Dialyvite 800-Ultra D $0 (OTC) Dialyvite oral tablet 100-1 mg $0 (OTC) Endur-C with rose hips oral tablet extended release 1,000 mg $0 (OTC) Fruit C-500 $0 (OTC) Full Spectrum B-Vitamin C $0 (OTC) Mynephrocaps $0 (OTC) Mynephron $0 (OTC) Nephro-Vite Rx $0 (OTC) Parvlex $0 (OTC) Prevent $0 (OTC) ProRenal $0 (OTC) Quin B Strong $0 (OTC) Renal Caps $0 (OTC) Renal Vitamin $0 (OTC) Renal-Vite $0 (OTC) Rena-Vite $0 (OTC) Rena-Vite Rx $0 (OTC) Reno Caps $0 (OTC) Siderol oral tablet $0 (OTC) Soothing PureWay-C $0 (OTC) Strawberry C $0 (OTC) Stress B-Complex oral tablet 500-400-23.9-3 mg-mcg-mg-mg $0 (OTC) Stress Formula with Iron $0 (OTC)




Notes

Stress Formula With Iron(sulf) $0 (OTC) Super B Complex-Vitamin C $0 (OTC) Total B/C $0 (OTC) Triphrocaps $0 (OTC) Triple Vitamin with Fluoride $0 (OTC) Tri-Vitamin With Fluoride $0 (OTC) Virt-Caps $0 (OTC) Vitamin C oral tablet 1,000 mg, 250 mg, 500 mg $0 (OTC) Vitamin C oral tablet extended release 1,000 mg $0 (OTC) Vitamin C oral tablet,chewable 500 mg $0 (OTC) Vitamin C With Rose Hips oral tablet $0 (OTC) Vitamin C With Rose Hips oral tablet extended release 1,000 mg $0 (OTC) Vitamin C With Rose Hips oral tablet,chewable $0 (OTC) Vitamins B Complex oral tablet 500 mg-400 mcg- 18 mg iron $0 (OTC) VP-Vite Rx $0 (OTC) Vitamin D Actical $0 (OTC) Biocal $0 (OTC) Ca-D3-mag ox-zinc-cop-mang-bor oral tablet,chewable 600 mg calcium- 800 unit-40 mg $0 (OTC)

Calcidol $0 (OTC) Cal-Citrate $0 (OTC) Calcium 500 + D oral tablet $0 (OTC) Calcium 500 With D $0 (OTC) Calcium 600 + D(3) oral tablet $0 (OTC) Calcium 600 with Vitamin D3 oral tablet,chewable $0 (OTC) calcium carbonate-vitamin D3 oral tablet 1,000 mg(2,500 mg)-800 unit, 250-125 mg-unit, 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit

$0 (OTC)

calcium carbonate-vitamin D3 oral tablet,chewable 500-100 mg-unit $0 (OTC) Calcium Citrate + D $0 (OTC) calcium citrate-vitamin D3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit, 315 mg- 250 unit, 315-200 mg-unit $0 (OTC)

Calcium with Vitamin D $0 (OTC) Child Multivitamins $0 (OTC) cholecalciferol (vitamin D3) oral capsule 1,250 mcg (50,000 unit), 10 mcg (400 unit), 125 mcg (5,000 unit), 25 mcg (1,000 unit), 50 mcg (2,000 unit) $0 (OTC)

cholecalciferol (vitamin D3) oral drops 10 mcg/mL (400 unit/mL) $0 (OTC) cholecalciferol (vitamin D3) oral tablet 10 mcg (400 unit), 25 mcg (1,000 unit) $0 (OTC) Citracal + D Maximum $0 (OTC) Citracal Regular $0 (OTC) Citrus Calcium-Vitamin D3 oral tablet 200 mg calcium -250 unit $0 (OTC) D3-2000 $0 (OTC) Decara oral capsule 1,250 mcg (50,000 unit) $0 (OTC) Delta D3 $0 (OTC) Dialyvite 800-Ultra D $0 (OTC) Dialyvite Vitamin D $0 (OTC) D-Vi-Sol $0 (OTC) ergocalciferol (vitamin D2) oral capsule 1,250 mcg (50,000 unit) $0 (OTC) ergocalciferol (vitamin D2) oral drops $0 (OTC)




Notes

ergocalciferol (vitamin D2) oral tablet 10 mcg (400 unit) $0 (OTC) Hi-Cal Plus Vit D $0 (OTC) Optimal D3 $0 (OTC) Os-Cal 500 + D3 oral tablet 500 mg(1,250mg) -200 unit $0 (OTC) Oysco 500/D oral tablet $0 (OTC) Oyster Shell + D3 $0 (OTC) Oyster Shell Calcium-Vit D2 oral tablet 250 (625)-125 mg-unit $0 (OTC) Oyster Shell Calcium-Vit D3 oral tablet $0 (OTC) Oystercal-D $0 (OTC) Pedia D-Vite oral drops $0 (OTC) ProRenal $0 (OTC) ProRenal QD $0 (OTC) Strovite One $0 (OTC) Triple Vitamin with Fluoride $0 (OTC) Tri-Vitamin With Fluoride $0 (OTC) Vitamin D2 $0 (OTC) Vitamin D3 oral capsule 10 mcg (400 unit), 25 mcg (1,000 unit), 50 mcg (2,000 unit) $0 (OTC)

Vitamin D3 oral tablet 10 mcg (400 unit), 25 mcg (1,000 unit) $0 (OTC) Vitamins A-D-E selenium $0 (OTC) Vitamin E Child Multivitamins $0 (OTC) E-200 $0 (OTC) Prevent $0 (OTC) Stress Formula with Iron $0 (OTC) Stress Formula With Iron(sulf) $0 (OTC) vitamin E (dl, acetate) oral capsule 200 unit, 400 unit, 450 mg (1,000 unit) $0 (OTC) vitamin E mixed oral capsule $0 (OTC) vitamin E oral capsule 1,000 unit, 100 unit, 200 unit, 400 unit $0 (OTC) Vitamins A-D-E selenium $0 (OTC) Vitamins B Complex oral tablet 500 mg-400 mcg- 18 mg iron $0 (OTC) Vitamin K Activity Adults Multivitamin $0 (OTC) Biocal $0 (OTC) Central-Vite oral tablet 18 mg iron-400 mcg-25 mcg $0 (OTC) Centravites Adults $0 (OTC) Men's Daily Formula oral tablet 400-20-300 mcg $0 (OTC) Men's Multivitamin $0 (OTC) Men's One Daily oral tablet 400-20-300 mcg $0 (OTC) Multi For Her 50 Plus $0 (OTC) Multi For Her oral capsule $0 (OTC) One Daily Women 50 Plus(Vit K) $0 (OTC) Women's 50 Plus Daily Formula $0 (OTC) Women's 50 Plus Multivitamin $0 (OTC)

Questions?This formulary was updated on 08/2020. For more recent information or other questions, please call South Country Health Alliance Member Services at 1-866-567-7242, TTY users call 1-800-627-3529 or 711.

Hours of Operation: October – March, 7 days a week, 8 a.m. – 8 p.m., April – September, Monday – Friday, 8 a.m. – 8 p.m., or visit http://www.mnscha.org

mnscha.org · 2020. 8. 31. · 2020 List of Covered Drugs (Formulary) SeniorCare Complete (HMO SNP)...

Documents

Transcript of mnscha.org · 2020. 8. 31. · 2020 List of Covered Drugs (Formulary) SeniorCare Complete (HMO SNP)...