2020 LIST OF COVERED DRUGS (FORMULARY)€¦ · 01-07-2020 · UnitedHealthcare® Senior Care...

2020 LIST OF COVERED DRUGS (FORMULARY)

Prescription drug list information

UnitedHealthcare® Senior Care Options (HMO D-SNP)

UnitedHealthcare® Senior Care Options NHC (HMO D-SNP)

Important Notes: This document has information about the drugs covered by this plan. For more recent information or if you have questions, please call Customer Service at:

Toll-free 1-888-867-5511, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week

www.UHCCommunityPlan.com

Formulary ID Number 00020047, Version 19 H2226_190701_012345_C v01.10 UHCSCO 190701_012345 Last updated October 1, 2020


UnitedHealthcare® Senior Care Options (HMO D-SNP)

UnitedHealthcare® Senior Care Options NHC (HMO D-SNP)

2020 List of Covered Drugs (Formulary)

IntroductionThis document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs are covered by UnitedHealthcare Senior Care Options. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UnitedHealthcare Senior Care Options. Key terms and their definitions appear in the last chapter of the Evidence of Coverage.

Our contact information, along with the date we last updated the Drug List, appears on the front and back cover pages.

Table of Contents

A. Disclaimers..............................................................................................................................................4

B. Frequently Asked Questions (FAQ)...................................................................................................... 5

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of CoveredDrugs the �“Drug List” for short.)................................................................................................ 5

B2. Does the Drug List ever change?...............................................................................................5

B3. What happens when there is a change to the Drug List?........................................................ 6

B4. Are there any restrictions or limits on drug coverage or any required actions to take to getcertain drugs?.............................................................................................................................. 7

B5. How will you know if the drug you want has limitations or if there are any actions requiredto get the drug?........................................................................................................................... 7

B6. What happens if we change our rules about how we cover some drugs (for example, priorauthorization (approval), quantity limits, and/or step therapy restrictions)?.......................... 8

B7. How can you find a drug on the Drug List?...............................................................................8

B8. What if the drug you want to take is not on the Drug List?...................................................... 8

B9. What if you are a new UnitedHealthcare Senior Care Options member and can’t find yourdrug on the Drug List or have a problem getting your drug?.................................................. 8

B10. Can you ask for an exception to cover your drug?...................................................................9

B11. How can you ask for an exception?.........................................................................................10

B12. How long does it take to get an exception?............................................................................10

B13. What are generic drugs?.......................................................................................................... 10

This section is continued on the next page.

B14. What are over-the-counter (OTC) drugs?................................................................................ 10

B15. Does UnitedHealthcare Senior Care Options cover non-drug OTC products?................... 10

B16. Can you get a long-term supply of drugs?.............................................................................. 10

B17. What is your copay?..................................................................................................................11

C. Overview of the List of Covered Drugs...............................................................................................12

C1. List of Drugs by Medical Condition......................................................................................... 12

C2. Covered drugs with a quantity limit (QL).................................................................................91

C3. Over-the-counter (OTC) Drug List.......................................................................................... 119

D. Index of Covered Drugs.....................................................................................................................189

If you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more

information, visit www.UHCCommunityPlan.com.


A. Disclaimers

This is a list of drugs that members can get in UnitedHealthcare Senior Care Options.

v UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare.

v The Drug List (formulary) may change on January 1 of each year, and from time to time during the plan year. You will receive notice when necessary.

v You can always check UnitedHealthcare Senior Care Options’ up-to-date List of Covered Drugs online at www.UHCCommunityPlan.com or by calling Customer Service toll-free at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.

v ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free.

v ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame a Servicio al Cliente de UnitedHealthcare Senior Care Options al 1-888-867-5511, TTY 711, de 8 a.m. a 8 p.m., hora local, los 7 días de la semana. La llamada es gratuita.

v You can get this document for free in other formats, such as large print, braille, or audio. Call Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.

v You can call Customer Service and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future.

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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 that starts on page 12 are the drugs covered by UnitedHealthcare Senior Care Options. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

· UnitedHealthcare Senior Care Options will cover all medically necessary drugs on the Drug List if:

o Your doctor or other prescriber says you need them to get better or stay healthy,

o The plan agrees that the drug is medically necessary for you, and

o You fill the prescription at a UnitedHealthcare Senior Care Options network pharmacy.

· UnitedHealthcare Senior Care Options may have additional steps to access certain drugs. See question B4 for more information.

You can also see an up-to-date list of drugs we cover on our website at www.UHCCommunityPlan.com or call Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.

B2. Does the Drug List ever change?

Yes. UnitedHealthcare Senior Care Options may add or remove drugs on the Drug List during the year. We must follow Medicare rules in making these changes.

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

· Decide to require or not require prior authorization (approval) for a drug. (Prior authorization (approval) is permission from UnitedHealthcare Senior Care Options before you can get a drug.)

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

· Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

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

If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:




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· 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 UnitedHealthcare Senior Care Options’ current Drug List online at www.UHCCommunityPlan.com.

· You can also call Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week to check the current Drug 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 that works as well as a brand name drug on the Drug List now. When that happens, we may remove the brand name drug and add the new generic drug. When we add the new generic drug, we may also decide to keep the brand name drug on the list but change its coverage rules or limits.

o We may not tell you before we make this change, but we will send you information about the specific change we made once it happens.

o You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see questions B10 - B12 for more information on exceptions.

· A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Contact your doctor or other prescriber and ask about your other options.

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 new to the market and

· Replace a brand name drug currently on the Drug List or

· Change the coverage rules or limits for the brand name drug.

When these changes happen, we will:

· Tell you at least 30 days before we make the change to the Drug List or

· Let you know and give you a 30-day supply of the drug after you ask for a refill.


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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. To learn more about exceptions, see questions B10 - B12 for more information about exceptions.

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?

Yes. Some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example:

· Prior authorization (approval): For some drugs, you, your doctor or other prescriber must get authorization (approval) from UnitedHealthcare Senior Care Options before you fill your prescription. Prior authorization is different from a referral. UnitedHealthcare Senior Care Options may not cover the drug if you don’t get authorization (approval).

· Quantity limits: Sometimes UnitedHealthcare Senior Care Options limits the amount of a drug you can get.

· Step therapy: Sometimes UnitedHealthcare Senior Care Options requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 14 - 90. You can also get more information by visiting our website at www.UHCCommunityPlan.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an exception to these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10 - B12 for more information about exceptions.

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

The Drug List on pages 14 - 90 has a column labeled “Necessary actions, restrictions, or limits on use.”




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B6. What happens if we change our rules about how we cover some drugs (for

example, prior authorization (approval), quantity limits, and/or step therapy

restrictions)?

In some cases, we will tell you in advance if we add or change prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.

B7. How can you find a drug on the Drug List?

There are two ways to find a drug:

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

· You can search by medical condition.

To search alphabetically, go to the Index of Covered Drugs section that begins on page 189. The Index is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. To search by medical condition, find the section labeled “List of Drugs by Medical Condition” on page 12. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.

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 Customer Service at 1-888-867-5511, TTY 711 and ask about it. If you learn that UnitedHealthcare Senior Care Options will not cover the drug, you can do one of these things:

· Ask Customer Service for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

· You can ask the health plan to make an exception to cover your drug. Please see questions B10 - B12 for more information about exceptions.

B9. What if you are a new UnitedHealthcare Senior Care Options member and can’t find your drug on the Drug List or have a problem getting your drug?

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


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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 temporary 30-day supply of your drug if:

.

If

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in

· 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 (approval) by UnitedHealthcare Senior Care Options, or

· You are taking a drug that is part of a step therapy restriction.

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:

· We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Senior Care Options member.

· This is in addition to the temporary supply during the first 90 days you are a member of UnitedHealthcare Senior Care Options.

If you are going through a change in your level of care, such as being transferred from a hospital to a long-term care facility, any time during the year, we may cover a temporary 31-day supply of the drug you need. This will give you time to talk to your doctor or other prescriber about other treatment options or to try to get an exception. Please see questions B10 - B12 for more information about exceptions.

We will not pay for more of your drug after you get a temporary supply unless you receive authorization from the plan.

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

Yes. You can ask UnitedHealthcare Senior Care Options to make an exception to cover a drug that is not on the Drug List.

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

· For example, UnitedHealthcare Senior Care Options may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

· Other examples: You can ask us to drop step therapy restrictions or prior authorization (approval) requirements.

This section is continued on the next page

you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more

formation, visit www.UHCCommunityPlan.com.

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

OTC stands for “over-the-counter.” UnitedHealthcare Senior Care Options covers some OTC drugs when they are written as prescriptions by your provider. These OTC drugs are listed in this Drug List starting on page 119.

B15. Does UnitedHealthcare Senior Care Options cover non-drug OTC products?

Yes. UnitedHealthcare Senior Care Options covers some non-drug OTC products when they are written as prescriptions by your provider. These non-drug OTC products are listed in the Drug List.

B16. Can you get a long-term supply of drugs?

Yes. UnitedHealthcare Senior Care Options offers two ways 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.)

· Retail pharmacy. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Pharmacy Directory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs.

B11. How can you ask for an exception?

To ask for an exception, call Customer Service. A Customer Service representative will work with you and your provider to help you ask for an exception. You can also read Chapter 8 of the 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).

UnitedHealthcare Senior Care Options covers both brand name drugs and generic drugs.

· Mail-order. For certain kinds of drugs, you can use the plan’s network mail-order services. Our plan’s mail-order service allows you to get up to a 90-day supply. To get order forms and information about filling your prescriptions by mail, please reference your Pharmacy

Directory to find the mail service pharmacies in our network.


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For more information about getting a long-term supply of drugs, call Customer Service at 1-888-867-5511, TTY 711.

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B17. What is your copay?

UnitedHealthcare Senior Care Options members have no copays for prescription and over-the-counter (OTC) drugs and non-drug products as long as the member follows the plan’s rules. See questions B14 and B15 for more information about OTC drugs and non-drug products.

Tiers are groups of drugs on our Drug List. Your plan has 1 tier named “Covered Drugs.” All covered drugs are in this tier.

· Tier 1 Generic drugs have $0 copay.

· Tier 1 Brand name drugs have $0 copay.

OTCs have $0 copay.

f you have questions, call Customer Service at 1-888-867-5511, TTY 711.

f you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more

nformation, visit www.UHCCommunityPlan.com.

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C. Overview of the List of Covered Drugs

The List of Covered Drugs gives you information about the drugs covered by UnitedHealthcare Senior Care Options. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 189. The index alphabetically lists all drugs covered by UnitedHealthcare Senior Care Options.

C1. List of Drugs by Medical Condition

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.

The first column of the table lists the name of the drug. Generic drugs are listed in plain type (e.g., Simvastatin) and brand name drugs are in bold type (e.g., Humalog).

The second column lists the Medicare Part D drug tier. Your plan has 1 tier named “Covered Drugs.” All covered drugs are in this tier. As a member of this plan, you have no copays for

covered, prescribed drugs when obtained from network pharmacies.

The information in the “Necessary actions, restrictions, or limits on use” column tells you if UnitedHealthcare Senior Care Options has any rules for covering your drug.

Coverage Rules and Limits

PA – Prior authorization (approval)

For some drugs, you, your doctor or other prescriber must get authorization (approval) from UnitedHealthcare Senior Care Options before you fill your prescription. Prior authorization is different from a referral. UnitedHealthcare Senior Care Options may not cover the drug if you don’t get authorization (approval).

QL – Quantity limits

Sometimes UnitedHealthcare Senior Care Options limits the amount of a drug you can get.

ST – Step therapy

Sometimes UnitedHealthcare Senior Care Options requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’t work for you, then we will cover the second.

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2Other Special Coverage Rules

B/D – Medicare Part B or Part D

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.

LA – Limited access

Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.

MME – Morphine milligram equivalent

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

7D – 7-Day limit

An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan.

DL – Dispensing limit

Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription.

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You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13.

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A1

B1

C1Butalbital-Acetaminophen-Caffeine

C1Butalbital-Aspirin-Caffeine

B1

C1Celecoxib

C1Diclofenac Epolamine

C1Diclofenac Potassium

C1Diclofenac Sodium ER

C1Diclofenac Sodium

C1Diclofenac Sodium

C1Diflunisal

C1Etodolac ER

C1Etodolac

C1Etodolac

C1Flector

C1Flurbiprofen

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Ibu

C1Ibuprofen

C1Ibuprofen

C1Indomethacin

C1Ketoprofen

C1Meloxicam

C1Nabumetone

C1Naproxen DR

C1Naproxen

C1Naproxen

C1Piroxicam

C1Sulindac

B1

C1Buprenorphine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Analgesics

Analgesics

Butalbital-Acetaminophen-Caffeine (Oral Tablet)

1 QL

Butalbital-Aspirin-Caffeine (Oral Capsule)

1 QL

Nonsteroidal Anti-inflammatory Drugs

Celecoxib (Oral Capsule)

1 QL

Diclofenac Epolamine (Transdermal Patch)

1 PA; QL

Diclofenac Potassium (Oral Tablet)

1

Diclofenac Sodium ER (Oral Tablet Extended Release 24 Hour)

1

Diclofenac Sodium (Oral Tablet Delayed Release)

1

Diclofenac Sodium (1% Transdermal Gel)

1

Diflunisal (Oral Tablet) 1

Etodolac ER (Oral Tablet Extended Release 24 Hour)

1

Etodolac (Oral Capsule)

1

Etodolac (Oral Tablet Immediate Release)

1

Flector (Transdermal

Patch)1 PA; QL

Flurbiprofen (100MG Oral Tablet)

1

Ibu (600MG Oral Tablet, 800MG Oral Tablet)

1

Ibuprofen (Oral Suspension)

1

Ibuprofen (400MG Oral Tablet, 600MG Oral Tablet, 800MG Oral Tablet)

1

Indomethacin (25MG Oral Capsule Immediate Release, 50MG Oral Capsule Immediate Release)

1

Ketoprofen (Oral Capsule Immediate Release)

1

Meloxicam (Oral Tablet)

1

Nabumetone (Oral Tablet)

1

Naproxen DR (Oral Tablet Delayed Release) (Generic EC-Naprosyn)

1

Naproxen (Oral Suspension)

1

Naproxen (Oral Tablet Immediate Release)

1

Piroxicam (Oral Capsule)

1

Sulindac (Oral Tablet) 1

Opioid Analgesics, Long-acting

Buprenorphine (Transdermal Patch Weekly)

1 7D; DL; QL

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4

Bold type = Brand name drug Plain type = Generic drug

C1Fentanyl

C1Hydromorphone HCl ER

C1Hysingla ER

C1Levorphanol Tartrate

C1Methadone HCl

C1Methadone HCl

C1Morphine Sulfate ER

C1Morphine Sulfate ER

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Nucynta ER

C1Tramadol HCl ER

C1Tramadol HCl ER

C1Xtampza ER

B1

C1Acetaminophen-Codeine

C1Acetaminophen-Codeine

C1Butorphanol Tartrate

C1Codeine Sulfate

C1Codeine Sulfate

C1Endocet

C1Fentanyl Citrate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)

17D; MME;

DL; QL

Hydromorphone HCl ER (Oral Tablet ER 24 Hour Abuse-Deterrent)

17D; MME;

DL; QL

Hysingla ER (Oral

Tablet ER 24 Hour

Abuse-Deterrent)

17D; MME;

DL; QL

Levorphanol Tartrate (Oral Tablet)

17D; MME;

DL; QL

Methadone HCl (Oral Solution)

17D; MME;

DL; QL

Methadone HCl (Oral Tablet)

17D; MME;

DL; QL

Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release, 30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)

17D; MME;

DL; QL

Morphine Sulfate ER (200MG Oral Tablet Extended Release) (Generic MS Contin)

17D; MME;

DL; QL

Nucynta ER (Oral

Tablet Extended

Release 12 Hour)

17D; MME;

DL; QL

Tramadol HCl ER (Biphasic) (Oral Tablet Extended Release 24 Hour)

17D; MME;

DL; QL

Tramadol HCl ER (Oral Tablet Extended Release 24 Hour)

17D; MME;

DL; QL

Xtampza ER (Oral

Capsule ER 12 Hour

Abuse-Deterrent)

17D; MME;

DL; QL

Opioid Analgesics, Short-acting

Acetaminophen-Codeine (120-12MG/ 5ML Oral Solution)

17D; MME;

DL; QL

Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Tablet)

17D; MME;

DL; QL

Butorphanol Tartrate (Nasal Solution)

17D; MME;

DL; QL

Codeine Sulfate

(15MG Oral Tablet)1

7D; MME; DL; QL

Codeine Sulfate (30MG Oral Tablet, 60MG Oral Tablet)

17D; MME;

DL; QL

Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)

17D; MME;

DL; QL

Fentanyl Citrate (Buccal Lozenge On A Handle)

1 PA; DL; QL

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C1Hydrocodone-Acetaminophen

C1Hydrocodone-Acetaminophen

C1Hydrocodone-Ibuprofen

C1Hydromorphone HCl

C1Hydromorphone HCl

C1Hydromorphone HCl Preservative Free

C1Lorcet HD

C1Lorcet

C1Morphine Sulfate

C1Morphine Sulfate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Oxycodone HCl

C1Oxycodone HCl

C1Oxycodone HCl

C1Oxycodone-Acetaminophen

C1Oxycodone-Aspirin

C1Tramadol HCl

C1Tramadol-Acetaminophen

C1Trezix

A1

B1

C1Lidocaine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral Solution)

17D; MME;

DL; QL

Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)

17D; MME;

DL; QL

Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet)

17D; MME;

DL; QL

Hydromorphone HCl (1MG/ML Oral Liquid)

17D; MME;

DL; QL

Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release, 8MG Oral Tablet Immediate Release)

17D; MME;

DL; QL

Hydromorphone HCl Preservative Free (10MG/ML Injection Solution, 50MG/5ML Injection Solution)

1 DL

Lorcet HD (Oral Tablet) 17D; MME;

DL; QL

Lorcet (Oral Tablet) 17D; MME;

DL; QL

Morphine Sulfate (Oral Solution)

17D; MME;

DL; QL

Morphine Sulfate

(Oral Tablet

Immediate Release)

17D; MME;

DL; QL

Oxycodone HCl (100MG/5ML Oral Concentrate)

17D; MME;

DL; QL

Oxycodone HCl (5MG/ 5ML Oral Solution)

17D; MME;

DL; QL

Oxycodone HCl (10MG Oral Tablet Immediate Release, 15MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)

17D; MME;

DL; QL

Oxycodone-Acetaminophen (10-325MG Oral Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)

17D; MME;

DL; QL

Oxycodone-Aspirin (Oral Tablet)

17D; MME;

DL; QL

Tramadol HCl (50MG Oral Tablet Immediate Release)

17D; MME;

DL; QL

Tramadol-Acetaminophen (Oral Tablet)

17D; MME;

DL; QL

Trezix (Oral Capsule) 17D; MME;

DL; QL

Anesthetics

Local Anesthetics

Lidocaine (5% External Ointment)

1 QL

tRACK16

6


C1Lidocaine

C1Lidocaine HCl

C1Lidocaine HCl

C1Lidocaine Viscous

C1Lidocaine-Prilocaine

A1

B1

C1Acamprosate Calcium

C1Disulfiram

C1Naltrexone HCl

C1Vivitrol

B1

C1Buprenorphine HCl

C1Buprenorphine HCl-Naloxone HCl

C1Buprenorphine HCl-Naloxone HCl

C1Suboxone

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Naloxone HCl

C1Naloxone HCl

C1Naloxone HCl

C1Narcan

B1

C1Bupropion HCl SR

C1Chantix Continuing Month Pak

C1Chantix

C1Chantix Starting Month Pak

C1Nicotrol

C1Nicotrol NS

A1

B1

C1Amikacin Sulfate

C1Gentak

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Lidocaine (5% External Patch)

1 PA; QL

Lidocaine HCl (4% External Solution)

1

Lidocaine HCl (External Gel)

1

Lidocaine Viscous (2% Mouth/Throat Solution)

1

Lidocaine-Prilocaine (External Cream)

1

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

Acamprosate Calcium (Oral Tablet Delayed Release)

1

Disulfiram (Oral Tablet) 1

Naltrexone HCl (Oral Tablet)

1

Vivitrol (Intramuscular

Suspension

Reconstituted)

1

Opioid Dependence Treatments

Buprenorphine HCl (Tablet Sublingual)

1 QL

Buprenorphine HCl-Naloxone HCl (Sublingual Film)

1 QL

Buprenorphine HCl-Naloxone HCl (Tablet Sublingual)

1 QL

Suboxone (Sublingual

Film)1 QL

Opioid Reversal Agents

Naloxone HCl (0.4MG/ ML Injection Solution)

1

Naloxone HCl (Injection Solution Cartridge)

1

Naloxone HCl (Injection Solution Prefilled Syringe)

1

Narcan (Nasal Liquid) 1

Smoking Cessation Agents

Bupropion HCl SR (150MG Oral Tablet Extended Release 12 Hour Smoking-Deterrent)

1

Chantix Continuing

Month Pak (Oral

Tablet)

1

Chantix (Oral Tablet) 1

Chantix Starting

Month Pak (Oral

Tablet)

1

Nicotrol (Inhalation

Inhaler)1

Nicotrol NS (Nasal

Solution)1

Antibacterials

Aminoglycosides

Amikacin Sulfate (500MG/2ML Injection Solution)

1

Gentak (Ophthalmic Ointment)

1

tRACK 17

7


C1Gentamicin Sulfate-0.9% Sodium Chloride

C1Gentamicin Sulfate




C1Neomycin Sulfate

C1Paromomycin Sulfate

C1Streptomycin Sulfate

C1Tobramycin

C1Tobramycin Sulfate

C1Tobrex

B1

C1Bacitracin

C1Clindamycin HCl

C1Clindamycin Palmitate HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Clindamycin Phosphate in D5W

C1Clindamycin Phosphate


C1Colistimethate Sodium

C1Dalvance

C1Daptomycin

C1Daptomycin

C1Linezolid

C1Linezolid

C1Linezolid

C1Methenamine Hippurate

C1Metronidazole

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Gentamicin Sulfate-0.9% Sodium Chloride (Intravenous Solution)

1

Gentamicin Sulfate (External Cream)

1

Gentamicin Sulfate (External Ointment)

1

Gentamicin Sulfate (40MG/ML Injection Solution)

1

Gentamicin Sulfate (Ophthalmic Solution)

1

Neomycin Sulfate (Oral Tablet)

1

Paromomycin Sulfate (Oral Capsule)

1

Streptomycin Sulfate (Intramuscular Solution Reconstituted)

1

Tobramycin (Ophthalmic Solution)

1

Tobramycin Sulfate (10MG/ML Injection Solution, 80MG/2ML Injection Solution)

1

Tobrex (Ophthalmic

Ointment)1

Antibacterials, Other

Bacitracin (Ophthalmic Ointment)

1

Clindamycin HCl (Oral Capsule)

1

Clindamycin Palmitate HCl (Oral Solution Reconstituted)

1

Clindamycin Phosphate in D5W (Intravenous Solution)

1

Clindamycin Phosphate (300MG/ 2ML Injection Solution, 600MG/4ML Injection Solution, 900MG/6ML Injection Solution)

1

Clindamycin Phosphate (Vaginal Cream)

1

Colistimethate Sodium (CBA) (Injection Solution Reconstituted)

1

Dalvance (Intravenous

Solution

Reconstituted)

1 PA

Daptomycin (350MG

Intravenous Solution

Reconstituted)

1

Daptomycin (500MG Intravenous Solution Reconstituted)

1

Linezolid (Intravenous Solution)

1

Linezolid (Oral Suspension Reconstituted)

1

Linezolid (Oral Tablet) 1 QL

Methenamine Hippurate (Oral Tablet)

1

Metronidazole (0.75% External Cream)

1

tRACK18

8


C1Metronidazole

C1Metronidazole

C1Metronidazole in NaCl 0.79%

C1Metronidazole

C1Metronidazole

C1Mupirocin Calcium

C1Mupirocin

C1Nitrofurantoin Macrocrystal

C1Nitrofurantoin Monohydrate

C1Nitrofurantoin

C1Polymyxin B Sulfate

C1Sulfamylon

C1Tigecycline

C1Tinidazole

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Trimethoprim

C1Vancomycin HCl

C1Vancomycin HCl

C1Vancomycin HCl

C1Vandazole

B1

C1Cefaclor

C1Cefadroxil

C1Cefadroxil

C1Cefazolin Sodium

C1Cefdinir

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Metronidazole (0.75% External Gel, 1% External Gel)

1

Metronidazole (0.75% External Lotion)

1

Metronidazole in NaCl 0.79% (Intravenous Solution)

1

Metronidazole (250MG Oral Tablet, 500MG Oral Tablet)

1

Metronidazole (0.75% Vaginal Gel)

1

Mupirocin Calcium (External Cream)

1

Mupirocin (External Ointment)

1

Nitrofurantoin Macrocrystal (100MG Oral Capsule, 50MG Oral Capsule) (Generic Macrodantin)

1

Nitrofurantoin Monohydrate (Generic Macrobid)

1

Nitrofurantoin (Oral Suspension)

1

Polymyxin B Sulfate (Injection Solution Reconstituted)

1

Sulfamylon (External

Cream)1

Tigecycline (Intravenous Solution Reconstituted)

1

Tinidazole (Oral Tablet) 1

Trimethoprim (Oral Tablet)

1

Vancomycin HCl (10GM Intravenous Solution Reconstituted, 1GM Intravenous Solution Reconstituted, 500MG Intravenous Solution Reconstituted, 750MG Intravenous Solution Reconstituted)

1

Vancomycin HCl

(250MG Intravenous

Solution

Reconstituted)

1

Vancomycin HCl (Oral Capsule)

1 QL

Vandazole (Vaginal

Gel)1

Beta-lactam, Cephalosporins

Cefaclor (Oral Capsule)

1

Cefadroxil (Oral Capsule)

1

Cefadroxil (Oral Suspension Reconstituted)

1

Cefazolin Sodium (10GM Injection Solution Reconstituted, 1GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)

1

Cefdinir (Oral Capsule) 1

tRACK 19

9


C1Cefdinir

C1Cefepime HCl

C1Cefixime

C1Cefixime

C1Cefotetan Disodium

C1Cefoxitin Sodium

C1Cefoxitin Sodium

C1Cefpodoxime Proxetil

C1Cefpodoxime Proxetil

C1Cefprozil

C1Cefprozil

C1Ceftazidime

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Ceftriaxone Sodium

C1Ceftriaxone Sodium

C1Cefuroxime Axetil

C1Cefuroxime Sodium

C1Cefuroxime Sodium

C1Cephalexin

C1Cephalexin

C1Suprax

C1Suprax

C1Suprax

C1Tazicef

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Cefdinir (Oral Suspension Reconstituted)

1

Cefepime HCl (Injection Solution Reconstituted)

1

Cefixime (Oral Capsule)

1

Cefixime (Oral Suspension Reconstituted)

1

Cefotetan Disodium (Injection Solution Reconstituted)

1

Cefoxitin Sodium (Injection Solution Reconstituted)

1

Cefoxitin Sodium (Intravenous Solution Reconstituted)

1

Cefpodoxime Proxetil (Oral Suspension Reconstituted)

1

Cefpodoxime Proxetil (Oral Tablet)

1

Cefprozil (Oral Suspension Reconstituted)

1

Cefprozil (Oral Tablet) 1

Ceftazidime (Injection Solution Reconstituted)

1

Ceftriaxone Sodium (1GM Injection Solution Reconstituted, 250MG Injection Solution Reconstituted, 2GM Injection Solution Reconstituted, 500MG Injection Solution Reconstituted)

1

Ceftriaxone Sodium (10GM Intravenous Solution Reconstituted)

1

Cefuroxime Axetil (Oral Tablet)

1

Cefuroxime Sodium (Injection Solution Reconstituted)

1

Cefuroxime Sodium (Intravenous Solution Reconstituted)

1

Cephalexin (Oral Capsule)

1

Cephalexin (Oral Suspension Reconstituted)

1

Suprax (Oral Capsule) 1

Suprax (500MG/5ML

Oral Suspension

Reconstituted)

1

Suprax (Oral Tablet Chewable)

1

Tazicef (Injection Solution Reconstituted)

1

tRACK20

10


C1Zerbaxa

B1

C1Aztreonam

C1Ertapenem Sodium

C1Imipenem-Cilastatin

C1Meropenem

B1

C1Amoxicillin

C1Amoxicillin

C1Amoxicillin

C1Amoxicillin

C1Amoxicillin-Potassium Clavulanate ER

C1Amoxicillin-Potassium Clavulanate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Amoxicillin-Potassium Clavulanate

C1Amoxicillin-Potassium Clavulanate

C1Ampicillin

C1Ampicillin Sodium

C1Ampicillin Sodium

C1Ampicillin-Sulbactam Sodium

C1Ampicillin-Sulbactam Sodium

C1Bicillin C-R 900/300

C1Bicillin C-R

C1Bicillin L-A

C1Dicloxacillin Sodium

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Zerbaxa (Intravenous

Solution

Reconstituted)

1 PA

Beta-lactam, Other

Aztreonam (1GM Injection Solution Reconstituted)

1

Ertapenem Sodium (Injection Solution Reconstituted)

1

Imipenem-Cilastatin (Intravenous Solution Reconstituted)

1

Meropenem (Intravenous Solution Reconstituted)

1

Beta-lactam, Penicillins

Amoxicillin (Oral Capsule)

1

Amoxicillin (Oral Suspension Reconstituted)

1

Amoxicillin (Oral Tablet Immediate Release)

1

Amoxicillin (Oral Tablet Chewable)

1

Amoxicillin-Potassium Clavulanate ER (Oral Tablet Extended Release 12 Hour)

1

Amoxicillin-Potassium Clavulanate (Oral Suspension Reconstituted)

1

Amoxicillin-Potassium Clavulanate (Oral Tablet Immediate Release)

1

Amoxicillin-Potassium Clavulanate (Oral Tablet Chewable)

1

Ampicillin (Oral Capsule)

1

Ampicillin Sodium (125MG Injection Solution Reconstituted, 1GM Injection Solution Reconstituted)

1

Ampicillin Sodium (10GM Intravenous Solution Reconstituted)

1

Ampicillin-Sulbactam Sodium (Injection Solution Reconstituted)

1

Ampicillin-Sulbactam Sodium (15 (10-5)GM Intravenous Solution Reconstituted)

1

Bicillin C-R 900/300

(Intramuscular

Suspension)

1

Bicillin C-R

(Intramuscular

Suspension)

1

Bicillin L-A

(Intramuscular

Suspension)

1

Dicloxacillin Sodium (Oral Capsule)

1

tRACK 21

11


C1Nafcillin Sodium

C1Nafcillin Sodium

C1Oxacillin Sodium in Dextrose

C1Oxacillin Sodium

C1Oxacillin Sodium

C1Penicillin G Potassium

C1Penicillin G Procaine

C1Penicillin G Sodium

C1Penicillin V Potassium

C1Penicillin V Potassium

C1Piperacillin-Tazobactam

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Azasite

C1Azithromycin

C1Azithromycin

C1Azithromycin

C1Clarithromycin ER

C1Clarithromycin

C1Clarithromycin

C1Dificid

C1E.E.S. Granules

C1Erythrocin Lactobionate

C1Erythromycin Base

C1Erythromycin Base

C1Erythromycin Base

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Nafcillin Sodium (1GM Injection Solution Reconstituted, 2GM Injection Solution Reconstituted)

1

Nafcillin Sodium (10GM Intravenous Solution Reconstituted)

1

Oxacillin Sodium in

Dextrose (Intravenous

Solution)

1

Oxacillin Sodium (Injection Solution Reconstituted)

1

Oxacillin Sodium (Intravenous Solution Reconstituted)

1

Penicillin G Potassium (20000000UNIT Injection Solution Reconstituted)

1

Penicillin G Procaine (Intramuscular Suspension)

1

Penicillin G Sodium (Injection Solution Reconstituted)

1

Penicillin V Potassium (Oral Solution Reconstituted)

1

Penicillin V Potassium (Oral Tablet)

1

Piperacillin-Tazobactam (Intravenous Solution Reconstituted)

1

Macrolides

Azasite (Ophthalmic

Solution)1

Azithromycin (Intravenous Solution Reconstituted)

1

Azithromycin (Oral Suspension Reconstituted)

1

Azithromycin (Oral Tablet)

1

Clarithromycin ER (Oral Tablet Extended Release 24 Hour)

1

Clarithromycin (Oral Suspension Reconstituted)

1

Clarithromycin (Oral Tablet Immediate Release)

1

Dificid (Oral Tablet) 1

E.E.S. Granules (Oral

Suspension

Reconstituted)

1

Erythrocin Lactobionate (Intravenous Solution Reconstituted)

1

Erythromycin Base (Oral Capsule Delayed Release Particles)

1

Erythromycin Base (Oral Tablet Immediate Release)

1

Erythromycin Base (Oral Tablet Delayed Release)

1

tRACK22

12


C1Erythromycin Ethylsuccinate

C1Erythromycin Ethylsuccinate

C1Erythromycin

B1

C1Besivance

C1Ciloxan

C1Ciprofloxacin HCl

C1Ciprofloxacin HCl

C1Ciprofloxacin HCl

C1Ciprofloxacin in D5W

C1Gatifloxacin

C1Levofloxacin in D5W

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Levofloxacin

C1Levofloxacin

C1Levofloxacin

C1Levofloxacin

C1Moxifloxacin HCl in NaCl

C1Moxifloxacin HCl

C1Moxifloxacin HCl

C1Ofloxacin

C1Ofloxacin

C1Ofloxacin

B1

C1Silver Sulfadiazine

C1SSD

C1Sulfacetamide Sodium

C1Sulfacetamide Sodium

C1Sulfadiazine

C1Sulfamethoxazole-Trimethoprim

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Erythromycin Ethylsuccinate (200MG/5ML Oral Suspension Reconstituted)

1

Erythromycin Ethylsuccinate (Oral Tablet)

1

Erythromycin (Ophthalmic Ointment)

1

Quinolones

Besivance

(Ophthalmic

Suspension)

1

Ciloxan (Ophthalmic

Ointment)1

Ciprofloxacin HCl (Ophthalmic Solution)

1

Ciprofloxacin HCl (100MG Oral Tablet Immediate Release)

1

Ciprofloxacin HCl (250MG Oral Tablet Immediate Release, 500MG Oral Tablet Immediate Release, 750MG Oral Tablet Immediate Release)

1

Ciprofloxacin in D5W (200MG/100ML Intravenous Solution)

1

Gatifloxacin (Ophthalmic Solution)

1

Levofloxacin in D5W (500MG/100ML Intravenous Solution, 750MG/150ML Intravenous Solution)

1

Levofloxacin (25MG/ ML Intravenous Solution)

1

Levofloxacin (0.5% Ophthalmic Solution)

1

Levofloxacin (25MG/ ML Oral Solution)

1

Levofloxacin (250MG Oral Tablet, 500MG Oral Tablet, 750MG Oral Tablet)

1

Moxifloxacin HCl in NaCl (Intravenous Solution)

1

Moxifloxacin HCl (Ophthalmic Solution) (Generic Vigamox)

1

Moxifloxacin HCl (Oral Tablet)

1

Ofloxacin (Ophthalmic Solution)

1

Ofloxacin (Oral Tablet) 1

Ofloxacin (Otic Solution)

1

Sulfonamides

Silver Sulfadiazine (External Cream)

1

SSD (External Cream) 1

Sulfacetamide Sodium (Ophthalmic Ointment)

1

Sulfacetamide Sodium (Ophthalmic Solution)

1

Sulfadiazine (Oral Tablet)

1

Sulfamethoxazole-Trimethoprim (Oral Suspension)

1

tRACK 23

13


C1Sulfamethoxazole-Trimethoprim

B1

C1Demeclocycline HCl

C1Doxy 100

C1Doxycycline Hyclate

C1Doxycycline Hyclate

C1Doxycycline Monohydrate



C1Minocycline HCl

C1Minocycline HCl

C1Tetracycline HCl

C1Vibramycin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useA1

B1

C1BRIVIACT

C1BRIVIACT

C1Epidiolex

C1Fintepla

C1Levetiracetam ER

C1Levetiracetam

C1Levetiracetam

C1Nayzilam

C1Roweepra

C1Roweepra XR

C1Spritam ODT

C1Xcopri

C1Xcopri

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Sulfamethoxazole-Trimethoprim (Oral Tablet)

1

Tetracyclines

Demeclocycline HCl (Oral Tablet)

1

Doxy 100 (Intravenous Solution Reconstituted)

1

Doxycycline Hyclate (Oral Capsule)

1

Doxycycline Hyclate (100MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release)

1

Doxycycline Monohydrate (100MG Oral Capsule, 50MG Oral Capsule)

1

Doxycycline Monohydrate (Oral Suspension Reconstituted)

1

Doxycycline Monohydrate (100MG Oral Tablet, 50MG Oral Tablet, 75MG Oral Tablet)

1

Minocycline HCl (Oral Capsule)

1

Minocycline HCl (Oral Tablet Immediate Release)

1

Tetracycline HCl (Oral Capsule)

1

Vibramycin (50MG/

5ML Oral Syrup)1

Anticonvulsants

Anticonvulsants, Other

BRIVIACT (Oral

Solution)1 PA; QL

BRIVIACT (Oral

Tablet)1 PA; QL

Epidiolex (Oral

Solution)1 PA

Fintepla (Oral

Solution)1 PA; QL

Levetiracetam ER (Oral Tablet Extended Release 24 Hour)

1

Levetiracetam (Oral Solution)

1

Levetiracetam (Oral Tablet Immediate Release)

1

Nayzilam (Nasal

Solution)1

Roweepra (Oral Tablet Immediate Release)

1

Roweepra XR (Oral Tablet Extended Release 24 Hour)

1

Spritam ODT (Oral

Tablet Disintegrating

Soluble)

1

Xcopri (250 MG Daily

Dose) (Oral Tablet

Therapy Pack)

1 PA; QL

Xcopri (350 MG Daily

Dose) (Oral Tablet

Therapy Pack)

1 PA; QL

tRACK24

14


C1Xcopri

C1Xcopri

C1Xcopri

C1Xcopri

B1

C1Celontin

C1Ethosuximide

C1Ethosuximide

C1Zonisamide

B1

C1Clobazam

C1Clobazam

C1Clobazam

C1Diastat AcuDial

C1Diastat Pediatric

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Diazepam

C1Gabapentin

C1Gabapentin

C1Gabapentin

C1Phenobarbital

C1Phenobarbital

C1Primidone

C1Sympazan

C1Tiagabine HCl

C1Valproic Acid

C1Valproic Acid

C1Valtoco 10 MG Dose



C1Valtoco 5 MG Dose

C1Vigabatrin

C1Vigabatrin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Xcopri (100MG Oral

Tablet, 150MG Oral

Tablet, 50MG Oral

Tablet)

1 PA; QL

Xcopri (200MG Oral

Tablet)1 PA; QL

Xcopri (14x12.5MG &

14x25MG Oral Tablet

Therapy Pack)

1 PA; QL

Xcopri (14x150MG &

14x200MG Oral

Tablet Therapy Pack,

14x50MG &

14x100MG Oral

Tablet Therapy Pack)

1 PA; QL

Calcium Channel Modifying Agents

Celontin (Oral

Capsule)1

Ethosuximide (Oral Capsule)

1

Ethosuximide (Oral Solution)

1

Zonisamide (Oral Capsule)

1

Gamma-aminobutyric Acid (GABA) Augmenting Agents

Clobazam (2.5MG/ML Oral Suspension)

1 PA; QL

Clobazam (10MG Oral Tablet)

1 PA; QL

Clobazam (20MG Oral Tablet)

1 PA; QL

Diastat AcuDial

(Rectal Gel)1

Diastat Pediatric

(Rectal Gel)1

Diazepam (10MG Rectal Gel, 2.5MG Rectal Gel, 20MG Rectal Gel)

1

Gabapentin (Oral Capsule)

1

Gabapentin (250MG/ 5ML Oral Solution)

1

Gabapentin (Oral Tablet)

1

Phenobarbital (Oral Elixir)

1

Phenobarbital (Oral Tablet)

1

Primidone (Oral Tablet) 1

Sympazan (Oral Film) 1 PA; QL

Tiagabine HCl (Oral Tablet)

1

Valproic Acid (Oral Capsule)

1

Valproic Acid (Oral Solution)

1

Valtoco 10 MG Dose

(Nasal Liquid)1 QL

Valtoco 15 MG Dose

(Nasal Liquid Therapy

Pack)

1 QL

Valtoco 20 MG Dose

(Nasal Liquid Therapy

Pack)

1 QL

Valtoco 5 MG Dose

(Nasal Liquid)1 QL

Vigabatrin (Oral Packet)

1 PA; LA; QL

Vigabatrin (Oral Tablet) 1 PA; LA; QL

tRACK 25

15


C1Vigadrone

B1

C1Felbamate

C1Felbamate

C1Fycompa

C1Fycompa

C1Lamotrigine

C1Lamotrigine

C1Topiramate

C1Topiramate

B1

C1Aptiom

C1Banzel

C1Banzel

C1Carbamazepine ER

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Carbamazepine ER

C1Carbamazepine

C1Carbamazepine

C1Carbamazepine

C1Dilantin INFATABS

C1Dilantin

C1Epitol

C1Oxcarbazepine

C1Oxcarbazepine

C1Peganone

C1Phenytek

C1Phenytoin

C1Phenytoin

C1Phenytoin Sodium Extended

C1Vimpat

C1Vimpat

A1

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Vigadrone (Oral Packet)

1 PA; LA; QL

Glutamate Reducing Agents

Felbamate (Oral Suspension)

1

Felbamate (Oral Tablet)

1

Fycompa (Oral

Suspension)1

Fycompa (Oral Tablet) 1

Lamotrigine (100MG Oral Tablet Immediate Release, 150MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 25MG Oral Tablet Immediate Release)

1

Lamotrigine (25MG Oral Tablet Chewable, 5MG Oral Tablet Chewable)

1

Topiramate (Oral Capsule Sprinkle Immediate Release)

1

Topiramate (Oral Tablet)

1

Sodium Channel Agents

Aptiom (Oral Tablet) 1 QL

Banzel (Oral

Suspension)1

Banzel (Oral Tablet) 1

Carbamazepine ER (Oral Capsule Extended Release 12 Hour)

1

Carbamazepine ER (Oral Tablet Extended Release 12 Hour)

1

Carbamazepine (Oral Suspension)

1

Carbamazepine (Oral Tablet Immediate Release)

1

Carbamazepine (Oral Tablet Chewable)

1

Dilantin INFATABS (Oral Tablet Chewable)

1

Dilantin (Oral Capsule) 1

Epitol (Oral Tablet) 1

Oxcarbazepine (300MG/5ML Oral Suspension)

1

Oxcarbazepine (150MG Oral Tablet, 300MG Oral Tablet, 600MG Oral Tablet)

1

Peganone (Oral

Tablet)1

Phenytek (Oral Capsule)

1

Phenytoin (125MG/ 5ML Oral Suspension)

1

Phenytoin (Oral Tablet Chewable)

1

Phenytoin Sodium Extended (Oral Capsule)

1

Vimpat (Oral Solution) 1 QL

Vimpat (Oral Tablet) 1 QL

Antidementia Agents

Cholinesterase Inhibitors

tRACK26

16


C1Donepezil HCl

C1Donepezil HCl ODT

C1Galantamine Hydrobromide ER

C1Galantamine Hydrobromide

C1Galantamine Hydrobromide

C1Rivastigmine Tartrate

C1Rivastigmine

B1

C1Memantine HCl ER

C1Memantine HCl

C1Memantine HCl

C1Memantine HCl Titration Pak

A1

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Bupropion HCl SR

C1Bupropion HCl XL

C1Bupropion HCl

C1Mirtazapine

C1Mirtazapine ODT

B1

C1Emsam

C1Marplan

C1Phenelzine Sulfate

C1Tranylcypromine Sulfate

B1

C1Citalopram Hydrobromide

C1Citalopram Hydrobromide

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Donepezil HCl (Oral Tablet)

1 QL

Donepezil HCl ODT (Oral Tablet Dispersible)

1 QL

Galantamine Hydrobromide ER (Oral Capsule Extended Release 24 Hour)

1 QL

Galantamine Hydrobromide (Oral Solution)

1 QL

Galantamine Hydrobromide (Oral Tablet)

1 QL

Rivastigmine Tartrate (Oral Capsule)

1 QL

Rivastigmine (Transdermal Patch 24 Hour)

1 ST; QL

N-methyl-D-aspartate (NMDA) Receptor Antagonist

Memantine HCl ER (Oral Capsule Extended Release 24 Hour)

1 PA; QL

Memantine HCl (2MG/ ML Oral Solution)

1 PA; QL

Memantine HCl (10MG Oral Tablet, 5MG Oral Tablet)

1 PA; QL

Memantine HCl

Titration Pak (Oral

Tablet)

1 PA

Antidepressants

Antidepressants, Other

Bupropion HCl SR (Oral Tablet Extended Release 12 Hour)

1

Bupropion HCl XL (150MG Oral Tablet Extended Release 24 Hour, 300MG Oral Tablet Extended Release 24 Hour)

1

Bupropion HCl (Oral Tablet Immediate Release)

1

Mirtazapine (Oral Tablet)

1

Mirtazapine ODT (Oral Tablet Dispersible)

1

Monoamine Oxidase Inhibitors

Emsam (Transdermal

Patch 24 Hour)1 QL

Marplan (Oral Tablet) 1

Phenelzine Sulfate (Oral Tablet)

1

Tranylcypromine Sulfate (Oral Tablet)

1

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)

Citalopram Hydrobromide (Oral Solution)

1

Citalopram Hydrobromide (Oral Tablet)

1

tRACK 27

17


C1Desvenlafaxine Succinate ER

C1Escitalopram Oxalate

C1Escitalopram Oxalate

C1Fetzima

C1Fetzima Titration

C1Fluoxetine HCl

C1Fluoxetine HCl

C1Fluoxetine HCl

C1Fluvoxamine Maleate

C1Maprotiline HCl

C1Nefazodone HCl

C1Paroxetine HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Paxil

C1Sertraline HCl

C1Sertraline HCl

C1Trazodone HCl

C1Trazodone HCl

C1Trintellix

C1Venlafaxine HCl ER

C1Venlafaxine HCl

C1Viibryd

C1Viibryd Starter Pack

B1

C1Amitriptyline HCl

C1Amoxapine

C1Clomipramine HCl

C1Desipramine HCl

C1Doxepin HCl

C1Doxepin HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Desvenlafaxine Succinate ER (Oral Tablet Extended Release 24 Hour) (Generic Pristiq)

1 QL

Escitalopram Oxalate (Oral Solution)

1

Escitalopram Oxalate (Oral Tablet)

1

Fetzima (Oral Capsule

Extended Release 24

Hour)

1 ST; QL

Fetzima Titration

(Oral Capsule ER 24

Hour Therapy Pack)

1 ST

Fluoxetine HCl (10MG Oral Capsule Immediate Release, 20MG Oral Capsule Immediate Release, 40MG Oral Capsule Immediate Release)

1

Fluoxetine HCl (90MG Oral Capsule Delayed Release)

1

Fluoxetine HCl (20MG/ 5ML Oral Solution)

1

Fluvoxamine Maleate (Oral Tablet)

1

Maprotiline HCl (Oral Tablet)

1

Nefazodone HCl (Oral Tablet)

1

Paroxetine HCl (Oral Tablet Immediate Release)

1

Paxil (Oral

Suspension)1

Sertraline HCl (Oral Concentrate)

1

Sertraline HCl (Oral Tablet)

1

Trazodone HCl (100MG Oral Tablet, 150MG Oral Tablet, 50MG Oral Tablet)

1

Trazodone HCl (300MG Oral Tablet)

1

Trintellix (Oral Tablet) 1 QL

Venlafaxine HCl ER (Oral Capsule Extended Release 24 Hour)

1

Venlafaxine HCl (Oral Tablet Immediate Release)

1

Viibryd (Oral Tablet) 1 QL

Viibryd Starter Pack

(Oral Kit)1 QL

Tricyclics

Amitriptyline HCl (Oral Tablet)

1

Amoxapine (Oral Tablet)

1

Clomipramine HCl (Oral Capsule)

1

Desipramine HCl (Oral Tablet)

1

Doxepin HCl (Oral Capsule)

1

Doxepin HCl (Oral Concentrate)

1

tRACK28

18


C1Imipramine HCl

C1Imipramine Pamoate

C1Nortriptyline HCl

C1Nortriptyline HCl

C1Protriptyline HCl

C1Trimipramine Maleate

A1

B1

C1Compro

C1Hydroxyzine Pamoate

C1Meclizine HCl

C1Metoclopramide HCl

C1Metoclopramide HCl

C1Perphenazine

C1Prochlorperazine Maleate

C1Prochlorperazine

C1Scopolamine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Transderm-Scop

B1

C1Aprepitant

C1Dronabinol

C1Granisetron HCl

C1Ondansetron HCl

C1Ondansetron HCl

C1Ondansetron ODT

C1Sancuso

A1

B1

C1Abelcet

C1AmBisome

C1Amphotericin B

C1Ciclopirox

C1Ciclopirox

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Imipramine HCl (Oral Tablet)

1

Imipramine Pamoate (Oral Capsule)

1

Nortriptyline HCl (Oral Capsule)

1

Nortriptyline HCl (Oral Solution)

1

Protriptyline HCl (Oral Tablet)

1

Trimipramine Maleate (Oral Capsule)

1

Antiemetics

Antiemetics, Other

Compro (Rectal Suppository)

1

Hydroxyzine Pamoate (Oral Capsule)

1

Meclizine HCl (Oral Tablet)

1

Metoclopramide HCl (10MG/10ML Oral Solution)

1

Metoclopramide HCl (Oral Tablet)

1

Perphenazine (Oral Tablet)

1

Prochlorperazine Maleate (Oral Tablet)

1

Prochlorperazine (Rectal Suppository)

1

Scopolamine (Transdermal Patch 72 Hour)

1

Transderm-Scop

(1.5MG) (Transdermal

Patch 72 Hour)

1

Emetogenic Therapy Adjuncts

Aprepitant (Oral Therapy Pack, Oral Capsule)

1 PA

Dronabinol (Oral Capsule)

1 PA

Granisetron HCl (Oral Tablet)

1 B/D, PA; QL

Ondansetron HCl (Oral Solution)

1 B/D, PA

Ondansetron HCl (Oral Tablet)

1 B/D, PA

Ondansetron ODT (Oral Tablet Dispersible)

1 B/D, PA

Sancuso

(Transdermal Patch)1

Antifungals

Antifungals

Abelcet (Intravenous

Suspension)1 B/D, PA

AmBisome

(Intravenous

Suspension

Reconstituted)

1 B/D, PA

Amphotericin B (Intravenous Solution Reconstituted)

1 B/D, PA

Ciclopirox (External Gel)

1

Ciclopirox (External Shampoo)

1

tRACK 29

19


C1Ciclopirox

C1Ciclopirox Olamine

C1Ciclopirox Olamine

C1Clotrimazole

C1Clotrimazole

C1Clotrimazole

C1Econazole Nitrate

C1Eraxis

C1Eraxis

C1Fluconazole in Sodium Chloride

C1Fluconazole

C1Fluconazole

C1Flucytosine

C1Griseofulvin Microsize

C1Griseofulvin Microsize

C1Griseofulvin Ultramicrosize

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Itraconazole

C1Itraconazole

C1Jublia

C1Ketoconazole

C1Ketoconazole

C1Ketoconazole

C1Mentax

C1Micafungin Sodium

C1Miconazole 3

C1Mycamine

C1Naftifine HCl

C1Naftin

C1Natacyn

C1Noxafil

C1Noxafil

C1Nyamyc

C1Nystatin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Ciclopirox (External Solution)

1

Ciclopirox Olamine (External Cream)

1

Ciclopirox Olamine (External Suspension)

1

Clotrimazole (External Cream)

1

Clotrimazole (External Solution)

1

Clotrimazole (Mouth/ Throat Troche)

1

Econazole Nitrate (External Cream)

1 QL

Eraxis (100MG


Reconstituted)

1

Eraxis (50MG


Reconstituted)

1

Fluconazole in Sodium Chloride (Intravenous Solution)

1

Fluconazole (Oral Suspension Reconstituted)

1

Fluconazole (Oral Tablet)

1

Flucytosine (Oral Capsule)

1

Griseofulvin Microsize (Oral Suspension)

1

Griseofulvin Microsize (Oral Tablet)

1

Griseofulvin Ultramicrosize (Oral Tablet)

1

Itraconazole (Oral Capsule)

1 PA; QL

Itraconazole (Oral Solution)

1 PA

Jublia (External

Solution)1

Ketoconazole (External Cream)

1 QL

Ketoconazole (External Shampoo)

1

Ketoconazole (Oral Tablet)

1

Mentax (External

Cream)1

Micafungin Sodium (Intravenous Solution Reconstituted)

1

Miconazole 3 (Vaginal Suppository)

1

Mycamine

(Intravenous Solution

Reconstituted)

1

Naftifine HCl (External Cream)

1

Naftin (External Gel) 1

Natacyn (Ophthalmic

Suspension)1

Noxafil (Oral

Suspension)1 QL

Noxafil (Oral Tablet

Delayed Release)1 PA; QL

Nyamyc (External Powder)

1

Nystatin (External Cream)

1

tRACK30

20


C1Nystatin

C1Nystatin

C1Nystatin

C1Nystatin

C1Nystop

C1Posaconazole

C1Terbinafine HCl

C1Terconazole

C1Terconazole

C1Voriconazole

C1Voriconazole

C1Voriconazole

A1

B1

C1Allopurinol

C1Colchicine

C1Colchicine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Colcrys

C1Febuxostat

C1Probenecid

C1Probenecid-Colchicine

A1

B1

C1Dihydroergotamine Mesylate

C1Ergotamine-Caffeine

C1Migergot

B1

C1Aimovig

C1Emgality

C1Emgality

C1Emgality

C1Timolol Maleate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Nystatin (External Ointment)

1

Nystatin (External Powder)

1

Nystatin (Mouth/Throat Suspension)

1

Nystatin (Oral Tablet) 1

Nystop (External Powder)

1

Posaconazole (Oral Tablet Delayed Release)

1 PA; QL

Terbinafine HCl (Oral Tablet)

1

Terconazole (Vaginal Cream)

1

Terconazole (Vaginal Suppository)

1

Voriconazole (Intravenous Solution Reconstituted)

1

Voriconazole (Oral Suspension Reconstituted)

1

Voriconazole (Oral Tablet)

1

Antigout Agents

Antigout Agents

Allopurinol (Oral Tablet)

1

Colchicine (0.6MG

Oral Capsule) (Brand

Equivalent Mitigare)

1 QL

Colchicine (0.6MG Oral Tablet) (Generic Colcrys)

1 QL

Colcrys (Oral Tablet) 1 QL

Febuxostat (Oral Tablet)

1 ST

Probenecid (Oral Tablet)

1

Probenecid-Colchicine (Oral Tablet)

1

Antimigraine Agents

Ergot Alkaloids

Dihydroergotamine Mesylate (Nasal Solution)

1

Ergotamine-Caffeine (Oral Tablet)

1

Migergot (Rectal Suppository)

1

Prophylactic

Aimovig

(Subcutaneous

Solution Auto-

Injector)

1 PA; QL

Emgality (300MG

Dose) (100MG/ML

Subcutaneous

Solution Prefilled

Syringe)

1 PA; QL

Emgality

(Subcutaneous

Solution Auto-

Injector)

1 PA; QL

Emgality (120MG/ML

Subcutaneous

Solution Prefilled

Syringe)

1 PA; QL

Timolol Maleate (Oral Tablet)

1

tRACK 31

21


B1

C1Naratriptan HCl

C1Rizatriptan Benzoate

C1Rizatriptan Benzoate ODT

C1Sumatriptan

C1Sumatriptan Succinate

C1Sumatriptan Succinate Refill





Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useA1

B1

C1Guanidine HCl

C1Pyridostigmine Bromide ER

C1Pyridostigmine Bromide

C1Pyridostigmine Bromide

A1

B1

C1Dapsone

C1Rifabutin

B1

C1Ethambutol HCl

C1Isoniazid

C1Isoniazid

C1Paser

C1Priftin

C1Pyrazinamide

C1Rifampin

C1Rifampin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Serotonin (5-HT) 1b/1d Receptor Agonists

Naratriptan HCl (Oral Tablet)

1 QL

Rizatriptan Benzoate (Oral Tablet)

1 QL

Rizatriptan Benzoate ODT (Oral Tablet Dispersible)

1 QL

Sumatriptan (Nasal Solution)

1 QL

Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)

1 QL

Sumatriptan

Succinate Refill

(Subcutaneous

Solution Cartridge)

1 QL

Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution)

1 QL

Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/ 0.5ML Subcutaneous Solution Auto-Injector)

1 QL

Sumatriptan

Succinate (6MG/

0.5ML Subcutaneous

Solution Auto-

Injector) (Generic

Imitrex STATdose)

1 QL

Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Prefilled Syringe)

1 QL

Antimyasthenic Agents

Parasympathomimetics

Guanidine HCl (Oral

Tablet)1

Pyridostigmine Bromide ER (Oral Tablet Extended Release)

1

Pyridostigmine Bromide (Oral Solution)

1

Pyridostigmine Bromide (60MG Oral Tablet Immediate Release)

1

Antimycobacterials

Antimycobacterials, Other

Dapsone (Oral Tablet) 1

Rifabutin (Oral Capsule)

1

Antituberculars

Ethambutol HCl (Oral Tablet)

1

Isoniazid (Oral Syrup) 1

Isoniazid (Oral Tablet) 1

Paser (Oral Packet) 1

Priftin (Oral Tablet) 1

Pyrazinamide (Oral Tablet)

1

Rifampin (600MG Intravenous Solution Reconstituted)

1

Rifampin (150MG Oral Capsule, 300MG Oral Capsule)

1

tRACK32

22


C1Sirturo

C1Trecator

A1

B1

C1Cyclophosphamide

C1Gleostine

C1Gleostine

C1Leukeran

C1Matulane

C1Valchlor

B1

C1Abiraterone Acetate

C1Bicalutamide

C1Erleada

C1Flutamide

C1Nilutamide

C1Nubeqa

C1Xtandi

B1

C1Pomalyst

C1Revlimid

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Tabrecta

C1Thalomid

B1

C1Emcyt

C1Soltamox

C1Tamoxifen Citrate

C1Toremifene Citrate

B1

C1Droxia

C1Hydroxyurea

C1Mercaptopurine

C1Purixan

C1Tabloid

B1

C1Xpovio

C1Xpovio

C1Xpovio

C1Xpovio

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Sirturo (Oral Tablet) 1 PA; LA

Trecator (Oral Tablet) 1

Antineoplastics

Alkylating Agents

Cyclophosphamide (Oral Capsule)

1 B/D, PA

Gleostine (100MG

Oral Capsule)1

Gleostine (10MG Oral

Capsule, 40MG Oral

Capsule)

1

Leukeran (Oral

Tablet)1

Matulane (Oral

Capsule)1 LA

Valchlor (External

Gel)1 PA; LA

Antiandrogens

Abiraterone Acetate (Oral Tablet)

1 PA; QL

Bicalutamide (Oral Tablet)

1

Erleada (Oral Tablet) 1 PA; QL

Flutamide (Oral Capsule)

1

Nilutamide (Oral Tablet)

1

Nubeqa (Oral Tablet) 1 PA; QL

Xtandi (Oral Capsule) 1 PA; LA; QL

Antiangiogenic Agents

Pomalyst (Oral

Capsule)1 PA; QL

Revlimid (Oral

Capsule)1 PA; LA; QL

Tabrecta (Oral Tablet) 1 PA; QL

Thalomid (Oral

Capsule)1 PA; QL

Antiestrogens/Modifiers

Emcyt (Oral Capsule) 1

Soltamox (Oral

Solution)1

Tamoxifen Citrate (Oral Tablet)

1

Toremifene Citrate (Oral Tablet)

1

Antimetabolites

Droxia (Oral Capsule) 1

Hydroxyurea (Oral Capsule)

1

Mercaptopurine (Oral Tablet)

1

Purixan (Oral

Suspension)1 PA

Tabloid (Oral Tablet) 1 PA

Antineoplastics

Xpovio (100MG Once

Weekly) (Oral Tablet

Therapy Pack)

1 PA; QL

Xpovio (40 MG Once


Therapy Pack)

1 PA; QL

Xpovio (40 MG Twice


Therapy Pack)

1 PA; QL

Xpovio (60MG Once


Therapy Pack)

1 PA; QL

tRACK 33

23


C1Xpovio

C1Xpovio

C1Xpovio

B1

C1Copiktra

C1Inrebic

C1Kisqali

C1Kisqali

C1Kisqali

C1Kisqali Femara

C1Kisqali Femara

C1Kisqali Femara

C1Leucovorin Calcium

C1Leucovorin Calcium

C1Lonsurf

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Lorbrena

C1Ninlaro

C1Pemazyre

C1Piqray

C1Piqray

C1Piqray

C1Qinlock

C1Retevmo

C1Rozlytrek

C1Synribo

C1Tazverik

C1Tukysa

C1Verzenio

C1Zolinza

B1

C1Anastrozole

C1Exemestane

C1Letrozole

B1

C1Balversa

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Xpovio (60 MG Twice


Therapy Pack)

1 PA; QL

Xpovio (80MG Once


Therapy Pack)

1 PA; QL

Xpovio (80MG Twice


Therapy Pack)

1 PA; QL

Antineoplastics, Other

Copiktra (Oral

Capsule)1 PA; QL

Inrebic (Oral Capsule) 1 PA; QL

Kisqali (200MG Dose)

(Oral Tablet)1 PA; QL





Kisqali Femara

(400MG Dose) (Oral


1 PA; QL

Kisqali Femara

(600MG Dose) (Oral


1 PA; QL

Kisqali Femara

(200MG Dose) (Oral


1 PA; QL

Leucovorin Calcium (10MG Oral Tablet, 15MG Oral Tablet, 5MG Oral Tablet)

1

Leucovorin Calcium (25MG Oral Tablet)

1

Lonsurf (Oral Tablet) 1 PA; LA; QL

Lorbrena (Oral Tablet) 1 PA; QL

Ninlaro (Oral Capsule) 1 PA; QL

Pemazyre (Oral

Tablet)1 PA; QL

Piqray (200MG Daily

Dose) (Oral Tablet

Therapy Pack)

1 PA; QL

Piqray (250MG Daily

Dose) (Oral Tablet

Therapy Pack)

1 PA; QL

Piqray (300MG Daily

Dose) (Oral Tablet

Therapy Pack)

1 PA; QL

Qinlock (Oral Tablet) 1 PA; QL

Retevmo (Oral

Capsule)1 PA; QL

Rozlytrek (Oral

Capsule)1 PA; QL

Synribo

(Subcutaneous

Solution

Reconstituted)

1 PA

Tazverik (Oral Tablet) 1 PA; QL

Tukysa (Oral Tablet) 1 PA; QL

Verzenio (Oral Tablet) 1 PA; LA; QL

Zolinza (Oral Capsule) 1 PA

Aromatase Inhibitors, 3rd Generation

Anastrozole (Oral Tablet)

1

Exemestane (Oral Tablet)

1

Letrozole (Oral Tablet) 1

Enzyme Inhibitors

Balversa (Oral Tablet) 1 PA; QL

tRACK34

24


C1Rubraca

C1Talzenna

C1Zejula

B1

C1Afinitor Disperz

C1Afinitor

C1Alecensa

C1Alunbrig

C1Alunbrig

C1Ayvakit

C1Bosulif

C1Braftovi

C1Brukinsa

C1Cabometyx

C1Calquence

C1Caprelsa

C1Cometriq

C1Cometriq

C1Cometriq

C1Cotellic

C1Daurismo

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Erivedge

C1Erlotinib HCl

C1Everolimus

C1Farydak

C1Gilotrif

C1Ibrance

C1Ibrance

C1Iclusig

C1IDHIFA

C1Imatinib Mesylate

C1Imbruvica

C1Imbruvica

C1Inlyta

C1Iressa

C1Jakafi

C1Koselugo

C1Lenvima 10MG Daily Dose


Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Rubraca (Oral Tablet) 1 PA; LA; QL

Talzenna (Oral


Zejula (Oral Capsule) 1 PA; LA; QL

Molecular Target Inhibitors

Afinitor Disperz (Oral

Tablet Soluble)1 PA

Afinitor (Oral Tablet) 1 PA

Alecensa (Oral


Alunbrig (Oral Tablet) 1 PA; LA; QL

Alunbrig (Oral Tablet

Therapy Pack)1 PA; LA; QL

Ayvakit (Oral Tablet) 1 PA; LA; QL

Bosulif (Oral Tablet) 1 PA; QL

Braftovi (Oral

Capsule)1 PA

Brukinsa (Oral


Cabometyx (Oral

Tablet)1 PA; LA; QL

Calquence (Oral

Capsule)1 PA; QL

Caprelsa (Oral Tablet) 1 PA; LA

Cometriq (100MG

Daily Dose) (Oral Kit)1 PA; LA

Cometriq (140MG

Daily Dose) (Oral Kit)1 PA; LA

Cometriq (60MG Daily

Dose) (Oral Kit)1 PA; LA

Cotellic (Oral Tablet) 1 PA; LA; QL

Daurismo (Oral

Tablet)1 PA; LA; QL

Erivedge (Oral


Erlotinib HCl (Oral Tablet)

1 PA; QL

Everolimus (2.5MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)

1 PA

Farydak (Oral

Capsule)1 PA

Gilotrif (Oral Tablet) 1 PA; LA

Ibrance (Oral


Ibrance (Oral Tablet) 1 PA; LA; QL

Iclusig (Oral Tablet) 1 PA; LA; QL

IDHIFA (Oral Tablet) 1 PA; LA; QL

Imatinib Mesylate (Oral Tablet)

1 PA; QL

Imbruvica (Oral


Imbruvica (Oral

Tablet)1 PA; QL

Inlyta (Oral Tablet) 1 PA; LA; QL

Iressa (Oral Tablet) 1 PA; LA; QL

Jakafi (Oral Tablet) 1 PA; LA; QL

Koselugo (Oral

Capsule)1 PA; QL

Lenvima 10MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 12MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

tRACK 35

25








C1Lynparza

C1Mekinist

C1Mektovi

C1Nerlynx

C1Nexavar

C1Odomzo

C1Rydapt

C1Sprycel

C1Stivarga

C1Sutent

C1Tafinlar

C1Tagrisso

C1Tasigna

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Tibsovo

C1Turalio

C1Tykerb

C1Venclexta

C1Venclexta

C1Venclexta Starting Pack

C1Vitrakvi

C1Vitrakvi

C1Vizimpro

C1Votrient

C1Xalkori

C1Xospata

C1Zelboraf

C1Zydelig

C1Zykadia

B1

C1Bexarotene

C1Panretin

C1Targretin

C1Tretinoin

B1

C1Mesnex

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Lenvima 14MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 18MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 20MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 24MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 4MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lenvima 8MG Daily

Dose (Oral Capsule

Therapy Pack)

1 PA; LA

Lynparza (Oral Tablet) 1 PA; LA; QL

Mekinist (Oral Tablet) 1 PA; LA

Mektovi (Oral Tablet) 1 PA

Nerlynx (Oral Tablet) 1 PA; LA; QL

Nexavar (Oral Tablet) 1 PA; LA

Odomzo (Oral


Rydapt (Oral Capsule) 1 PA; QL

Sprycel (Oral Tablet) 1 PA; QL

Stivarga (Oral Tablet) 1 PA; LA; QL

Sutent (Oral Capsule) 1 PA; QL

Tafinlar (Oral

Capsule)1 PA; LA

Tagrisso (Oral Tablet) 1 PA; LA; QL

Tasigna (Oral

Capsule)1 PA; QL

Tibsovo (Oral Tablet) 1 PA; QL

Turalio (Oral Capsule) 1 PA; LA; QL

Tykerb (Oral Tablet) 1 PA; LA

Venclexta (100MG

Oral Tablet, 50MG

Oral Tablet)

1 PA; LA; QL

Venclexta (10MG Oral

Tablet)1 PA; LA; QL

Venclexta Starting

Pack (Oral Tablet

Therapy Pack)

1 PA; LA

Vitrakvi (Oral


Vitrakvi (Oral

Solution)1 PA; LA; QL

Vizimpro (Oral Tablet) 1 PA; LA; QL

Votrient (Oral Tablet) 1 PA; LA; QL

Xalkori (Oral Capsule) 1 PA; LA

Xospata (Oral Tablet) 1 PA; QL

Zelboraf (Oral Tablet) 1 PA; LA; QL

Zydelig (Oral Tablet) 1 PA; LA; QL

Zykadia (Oral Tablet) 1 PA; QL

Retinoids

Bexarotene (Oral Capsule)

1 PA

Panretin (External

Gel)1

Targretin (External

Gel)1 PA

Tretinoin (Oral Capsule)

1

Treatment Adjuncts

Mesnex (Oral Tablet) 1

tRACK36

26


A1

B1

C1Albendazole

C1Ivermectin

C1Praziquantel

B1

C1Alinia

C1Alinia

C1Atovaquone

C1Atovaquone-Proguanil HCl

C1Benznidazole

C1Chloroquine Phosphate

C1Coartem

C1DARAPRIM

C1Hydroxychloroquine Sulfate

C1Mefloquine HCl

C1Nebupent

C1PENTAM 300

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Pentamidine Isethionate

C1Pentamidine Isethionate

C1Primaquine Phosphate

C1Pyrimethamine

C1Quinine Sulfate

B1

C1Lindane

C1Malathion

C1Permethrin

A1

B1

C1Benztropine Mesylate

C1Trihexyphenidyl HCl

C1Trihexyphenidyl HCl

B1

C1Amantadine HCl

C1Amantadine HCl

C1Amantadine HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Antiparasitics

Anthelmintics

Albendazole (Oral Tablet)

1 QL

Ivermectin (Oral Tablet)

1

Praziquantel (Oral Tablet)

1

Antiprotozoals

Alinia (Oral

Suspension

Reconstituted)

1

Alinia (Oral Tablet) 1

Atovaquone (Oral Suspension)

1

Atovaquone-Proguanil HCl (Oral Tablet)

1

Benznidazole (Oral

Tablet)1

Chloroquine Phosphate (Oral Tablet)

1

Coartem (Oral Tablet) 1

DARAPRIM (Oral

Tablet)1

Hydroxychloroquine Sulfate (Oral Tablet)

1

Mefloquine HCl (Oral Tablet)

1

Nebupent (Inhalation

Solution

Reconstituted)

1 B/D, PA; QL

PENTAM 300

(Injection Solution

Reconstituted)

1

Pentamidine Isethionate (Inhalation Solution Reconstituted)

1 B/D, PA; QL

Pentamidine Isethionate (Injection Solution Reconstituted)

1

Primaquine Phosphate (Oral Tablet)

1

Pyrimethamine (Oral Tablet)

1

Quinine Sulfate (Oral Capsule)

1 PA

Pediculicides/Scabicides

Lindane (External Shampoo)

1

Malathion (External Lotion)

1

Permethrin (External Cream)

1

Antiparkinson Agents

Anticholinergics

Benztropine Mesylate (Oral Tablet)

1

Trihexyphenidyl HCl (Oral Solution)

1

Trihexyphenidyl HCl (Oral Tablet)

1

Antiparkinson Agents, Other

Amantadine HCl (Oral Capsule)

1

Amantadine HCl (Oral Syrup)

1

Amantadine HCl (Oral Tablet)

1

tRACK 37

27


C1Entacapone

C1Tolcapone

B1

C1Apokyn

C1Bromocriptine Mesylate

C1Bromocriptine Mesylate

C1Neupro

C1Pramipexole Dihydrochloride

C1Ropinirole HCl

B1

C1Carbidopa

C1Carbidopa-Levodopa ER

C1Carbidopa-Levodopa

C1Carbidopa-Levodopa ODT

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Carbidopa-Levodopa-Entacapone

C1Rytary

B1

C1Rasagiline Mesylate

C1Selegiline HCl

C1Selegiline HCl

C1Zelapar ODT

A1

B1

C1Chlorpromazine HCl

C1Fluphenazine Decanoate

C1Fluphenazine HCl

C1Fluphenazine HCl

C1Fluphenazine HCl

C1Fluphenazine HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Entacapone (Oral Tablet)

1

Tolcapone (Oral Tablet)

1 QL

Dopamine Agonists

Apokyn

(Subcutaneous

Solution Cartridge)

1 PA; LA; QL

Bromocriptine Mesylate (Oral Capsule)

1

Bromocriptine Mesylate (Oral Tablet)

1

Neupro (Transdermal

Patch 24 Hour)1

Pramipexole Dihydrochloride (Oral Tablet Immediate Release)

1

Ropinirole HCl (Oral Tablet Immediate Release)

1

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors

Carbidopa (Oral Tablet)

1

Carbidopa-Levodopa ER (Oral Tablet Extended Release)

1

Carbidopa-Levodopa (Oral Tablet Immediate Release)

1

Carbidopa-Levodopa ODT (Oral Tablet Dispersible)

1

Carbidopa-Levodopa-Entacapone (Oral Tablet)

1

Rytary (Oral Capsule

Extended Release)1 ST

Monoamine Oxidase B (MAO-B) Inhibitors

Rasagiline Mesylate (Oral Tablet)

1

Selegiline HCl (Oral Capsule)

1

Selegiline HCl (Oral Tablet)

1

Zelapar ODT (Oral

Tablet Dispersible)1

Antipsychotics

1st Generation/Typical

Chlorpromazine HCl (Oral Tablet)

1

Fluphenazine Decanoate (Injection Solution)

1

Fluphenazine HCl (2.5MG/ML Injection Solution)

1

Fluphenazine HCl (5MG/ML Oral Concentrate)

1

Fluphenazine HCl (2.5MG/5ML Oral Elixir)

1

Fluphenazine HCl (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 5MG Oral Tablet)

1

tRACK38

28


C1Haloperidol Decanoate

C1Haloperidol Lactate

C1Haloperidol Lactate

C1Haloperidol

C1Loxapine Succinate

C1Molindone HCl

C1Pimozide

C1Thioridazine HCl

C1Thiothixene

C1Trifluoperazine HCl

B1

C1Abilify Maintena

C1Abilify Maintena

C1Aripiprazole

C1Aripiprazole

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Aripiprazole ODT

C1Aristada Initio

C1Aristada

C1Caplyta

C1Fanapt

C1Fanapt

C1Fanapt Titration Pack

C1Geodon

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Haloperidol Decanoate (Intramuscular Solution)

1

Haloperidol Lactate (Injection Solution)

1

Haloperidol Lactate (Oral Concentrate)

1

Haloperidol (Oral Tablet)

1

Loxapine Succinate (Oral Capsule)

1

Molindone HCl (Oral Tablet)

1

Pimozide (Oral Tablet) 1

Thioridazine HCl (Oral Tablet)

1

Thiothixene (Oral Capsule)

1

Trifluoperazine HCl (Oral Tablet)

1

2nd Generation/Atypical

Abilify Maintena

(Intramuscular

Prefilled Syringe)

1

Abilify Maintena

(Intramuscular

Suspension

Reconstituted ER)

1

Aripiprazole (1MG/ML Oral Solution)

1 QL

Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)

1 QL

Aripiprazole ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible)

1 QL

Aristada Initio

(Intramuscular

Prefilled Syringe)

1

Aristada

(Intramuscular

Prefilled Syringe)

1

Caplyta (Oral

Capsule)1 ST; QL

Fanapt (10MG Oral

Tablet, 12MG Oral

Tablet, 4MG Oral

Tablet, 6MG Oral

Tablet, 8MG Oral

Tablet)

1 ST; QL

Fanapt (1MG Oral

Tablet, 2MG Oral

Tablet)

1 ST; QL

Fanapt Titration Pack

(Oral Tablet)1 ST

Geodon

(Intramuscular

Solution

Reconstituted)

1

tRACK 39

29


C1Invega Sustenna

C1Invega Sustenna

C1Invega Trinza

C1Latuda

C1Nuplazid

C1Nuplazid

C1Olanzapine

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Olanzapine

C1Olanzapine ODT

C1Paliperidone ER

C1Perseris

C1Quetiapine Fumarate ER

C1Quetiapine Fumarate

C1Rexulti

C1Risperdal Consta

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Invega Sustenna

(117MG/0.75ML

Intramuscular

Suspension Prefilled

Syringe, 156MG/ML

Intramuscular


Syringe, 234MG/

1.5ML Intramuscular


Syringe, 78MG/0.5ML

Intramuscular


Syringe)

1

Invega Sustenna

(39MG/0.25ML

Intramuscular


Syringe)

1

Invega Trinza

(Intramuscular


Syringe)

1

Latuda (Oral Tablet) 1 QL

Nuplazid (Oral

Capsule)1 PA; QL

Nuplazid (10MG Oral

Tablet)1 PA; QL

Olanzapine (10MG Intramuscular Solution Reconstituted)

1

Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)

1 QL

Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)

1 QL

Paliperidone ER (Oral Tablet Extended Release 24 Hour)

1 QL

Perseris

(Subcutaneous

Prefilled Syringe)

1

Quetiapine Fumarate ER (Oral Tablet Extended Release 24 Hour)

1 QL

Quetiapine Fumarate (Oral Tablet Immediate Release)

1 QL

Rexulti (Oral Tablet) 1 QL

Risperdal Consta

(12.5MG

Intramuscular

Suspension

Reconstituted ER,

25MG Intramuscular

Suspension

Reconstituted ER)

1

tRACK40

30


C1Risperdal Consta

C1Risperidone

C1Risperidone

C1Risperidone ODT

C1Saphris

C1Secuado

C1Vraylar

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Vraylar

C1Ziprasidone HCl

C1Ziprasidone Mesylate

C1Zyprexa Relprevv

B1

C1Clozapine

C1Clozapine ODT

C1Versacloz

A1

B1

C1Valganciclovir HCl

C1Valganciclovir HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Risperdal Consta

(37.5MG

Intramuscular

Suspension

Reconstituted ER,

50MG Intramuscular

Suspension

Reconstituted ER)

1

Risperidone (1MG/ML Oral Solution)

1

Risperidone (0.25MG Oral Tablet, 0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet, 3MG Oral Tablet, 4MG Oral Tablet)

1

Risperidone ODT (0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible, 3MG Oral Tablet Dispersible, 4MG Oral Tablet Dispersible)

1

Saphris (Tablet

Sublingual)1 QL

Secuado

(Transdermal Patch

24 Hour)

1 PA; QL

Vraylar (1.5MG Oral

Capsule, 3MG Oral

Capsule, 4.5MG Oral

Capsule, 6MG Oral

Capsule)

1 ST; QL

Vraylar (Oral Capsule

Therapy Pack)1 ST

Ziprasidone HCl (Oral Capsule)

1 QL

Ziprasidone Mesylate (Intramuscular Solution Reconstituted)

1

Zyprexa Relprevv

(210MG

Intramuscular

Suspension

Reconstituted)

1

Treatment-Resistant

Clozapine (100MG Oral Tablet, 200MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)

1

Clozapine ODT (100MG Oral Tablet Dispersible, 12.5MG Oral Tablet Dispersible, 150MG Oral Tablet Dispersible, 200MG Oral Tablet Dispersible, 25MG Oral Tablet Dispersible)

1 QL

Versacloz (Oral

Suspension)1

Antivirals

Anti-cytomegalovirus (CMV) Agents

Valganciclovir HCl (Oral Solution Reconstituted)

1 QL

Valganciclovir HCl (Oral Tablet)

1 QL

tRACK 41

31


C1Zirgan

B1

C1Adefovir Dipivoxil

C1Baraclude

C1Entecavir

C1Epivir HBV

C1Lamivudine

C1Vemlidy

B1

C1Intron A

C1Intron A

C1Pegasys ProClick

C1Pegasys

C1Ribavirin

B1

C1Epclusa

C1Mavyret

C1Sofosbuvir-Velpatasvir

C1Sovaldi

C1Sovaldi

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Vosevi

B1

C1Acyclovir

C1Acyclovir

C1Acyclovir

C1Acyclovir

C1Acyclovir Sodium

C1Denavir

C1Famciclovir

C1Trifluridine

C1Valacyclovir HCl

B1

C1Dovato

C1Genvoya

C1Isentress HD

C1Isentress

C1Isentress

C1Isentress

C1Isentress

C1Stribild

C1Tivicay

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Zirgan (Ophthalmic

Gel)1

Anti-hepatitis B (HBV) Agents

Adefovir Dipivoxil (Oral Tablet)

1

Baraclude (Oral

Solution)1

Entecavir (Oral Tablet) 1

Epivir HBV (Oral

Solution)1

Lamivudine (100MG Oral Tablet)

1

Vemlidy (Oral Tablet) 1 QL

Anti-hepatitis C (HCV) Agents, Other

Intron A (Injection

Solution)1 PA; LA

Intron A (Injection

Solution

Reconstituted)

1 PA; LA

Pegasys ProClick

(Subcutaneous

Solution)

1 PA

Pegasys

(Subcutaneous

Solution)

1 PA

Ribavirin (Oral Tablet) 1

Anti-hepatitis C (HCV) Direct Acting Agents

Epclusa (Oral Tablet) 1 PA; QL

Mavyret (Oral Tablet) 1 PA; QL

Sofosbuvir-Velpatasvir (Oral Tablet)

1 PA; QL

Sovaldi (Oral Packet) 1 PA; QL

Sovaldi (400MG Oral

Tablet)1 PA; QL

Vosevi (Oral Tablet) 1 PA; QL

Antiherpetic Agents

Acyclovir (External Ointment)

1 QL

Acyclovir (Oral Capsule)

1

Acyclovir (Oral Suspension)

1

Acyclovir (Oral Tablet) 1

Acyclovir Sodium (Intravenous Solution)

1 B/D, PA

Denavir (External

Cream)1 QL

Famciclovir (Oral Tablet)

1 QL

Trifluridine (Ophthalmic Solution)

1

Valacyclovir HCl (Oral Tablet)

1 QL

Anti-HIV Agents, Integrase Inhibitors (INSTI)

Dovato (Oral Tablet) 1 QL

Genvoya (Oral Tablet) 1 QL

Isentress HD (Oral

Tablet)1 QL

Isentress (Oral

Packet)1 QL

Isentress (Oral Tablet) 1 QL

Isentress (100MG

Oral Tablet Chewable)1 QL

Isentress (25MG Oral

Tablet Chewable)1 QL

Stribild (Oral Tablet) 1 QL

Tivicay (10MG Oral

Tablet)1 QL

tRACK42

32


C1Tivicay

C1Tivicay PD

C1Triumeq

C1Tybost

B1

C1Atripla

C1Complera

C1Delstrigo

C1Edurant

C1Efavirenz

C1Efavirenz

C1Intelence

C1Intelence

C1Juluca

C1Nevirapine ER

C1Nevirapine

C1Nevirapine

C1Odefsey

C1Pifeltro

C1Symfi Lo

C1Symfi

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useB1

C1Abacavir Sulfate

C1Abacavir Sulfate

C1Abacavir Sulfate-Lamivudine

C1Abacavir-Lamivudine-Zidovudine

C1Biktarvy

C1Cimduo

C1Descovy

C1Didanosine

C1Emtriva

C1Emtriva

C1Lamivudine

C1Lamivudine

C1Lamivudine-Zidovudine

C1Stavudine

C1Tenofovir Disoproxil Fumarate

C1Truvada

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Tivicay (25MG Oral

Tablet, 50MG Oral

Tablet)

1 QL

Tivicay PD (Oral

Tablet Soluble)1 QL

Triumeq (Oral Tablet) 1 QL

Tybost (Oral Tablet) 1 QL

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

Atripla (Oral Tablet) 1 QL

Complera (Oral

Tablet)1 QL

Delstrigo (Oral Tablet) 1 QL

Edurant (Oral Tablet) 1 QL

Efavirenz (Oral Capsule)

1 QL

Efavirenz (Oral Tablet) 1 QL

Intelence (100MG

Oral Tablet, 200MG

Oral Tablet)

1 QL

Intelence (25MG Oral

Tablet)1 QL

Juluca (Oral Tablet) 1 QL

Nevirapine ER (Oral Tablet Extended Release 24 Hour)

1 QL

Nevirapine (Oral Suspension)

1 QL

Nevirapine (Oral Tablet Immediate Release)

1 QL

Odefsey (Oral Tablet) 1 QL

Pifeltro (Oral Tablet) 1 QL

Symfi Lo (Oral Tablet) 1 QL

Symfi (Oral Tablet) 1 QL

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

Abacavir Sulfate (Oral Solution)

1 QL

Abacavir Sulfate (Oral Tablet)

1 QL

Abacavir Sulfate-Lamivudine (Oral Tablet)

1 QL

Abacavir-Lamivudine-Zidovudine (Oral Tablet)

1 QL

Biktarvy (Oral Tablet) 1 QL

Cimduo (Oral Tablet) 1 QL

Descovy (Oral Tablet) 1 QL

Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Release)

1 QL

Emtriva (Oral

Capsule)1 QL

Emtriva (Oral

Solution)1 QL

Lamivudine (10MG/ML Oral Solution)

1 QL

Lamivudine (150MG Oral Tablet, 300MG Oral Tablet)

1 QL

Lamivudine-Zidovudine (Oral Tablet)

1 QL

Stavudine (Oral Capsule)

1 QL

Tenofovir Disoproxil Fumarate (Oral Tablet)

1 QL

Truvada (Oral Tablet) 1 QL

tRACK 43

33


C1Viread

C1Viread

C1Zidovudine

C1Zidovudine

C1Zidovudine

B1

C1Fuzeon

C1Rukobia

C1Selzentry

C1Selzentry

C1Selzentry

B1

C1Aptivus

C1Aptivus

C1Atazanavir Sulfate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Crixivan

C1Evotaz

C1Fosamprenavir Calcium

C1Invirase

C1Kaletra

C1Kaletra

C1Lexiva

C1Lopinavir-Ritonavir

C1Norvir

C1Norvir

C1Prezcobix

C1Prezista

C1Prezista

C1Prezista

C1Reyataz

C1Ritonavir

C1Symtuza

C1Viracept

B1

C1Oseltamivir Phosphate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Viread (Oral Powder) 1 QL

Viread (150MG Oral

Tablet, 200MG Oral

Tablet, 250MG Oral

Tablet)

1 QL

Zidovudine (Oral Capsule)

1 QL

Zidovudine (Oral Syrup)

1 QL

Zidovudine (Oral Tablet)

1 QL

Anti-HIV Agents, Other

Fuzeon

(Subcutaneous

Solution

Reconstituted)

1 QL

Rukobia (Oral Tablet

Extended Release 12

Hour)

1 QL

Selzentry (Oral

Solution)1 QL

Selzentry (150MG

Oral Tablet, 300MG

Oral Tablet, 75MG

Oral Tablet)

1 QL

Selzentry (25MG Oral

Tablet)1 QL

Anti-HIV Agents, Protease Inhibitors

Aptivus (Oral

Capsule)1 QL

Aptivus (Oral

Solution)1 QL

Atazanavir Sulfate (Oral Capsule)

1 QL

Crixivan (Oral

Capsule)1 QL

Evotaz (Oral Tablet) 1 QL

Fosamprenavir Calcium (Oral Tablet)

1 QL

Invirase (Oral Tablet) 1 QL

Kaletra (100-25MG

Oral Tablet)1 QL

Kaletra (200-50MG

Oral Tablet)1 QL

Lexiva (Oral

Suspension)1 QL

Lopinavir-Ritonavir (Oral Solution)

1 QL

Norvir (Oral Packet) 1 QL

Norvir (Oral Solution) 1 QL

Prezcobix (Oral

Tablet)1 QL

Prezista (Oral

Suspension)1 QL

Prezista (150MG Oral

Tablet, 75MG Oral

Tablet)

1 QL

Prezista (600MG Oral

Tablet, 800MG Oral

Tablet)

1 QL

Reyataz (Oral Packet) 1 QL

Ritonavir (Oral Tablet) 1 QL

Symtuza (Oral Tablet) 1 QL

Viracept (Oral Tablet) 1 QL

Anti-influenza Agents

Oseltamivir Phosphate (Oral Capsule)

1 QL

tRACK44

34


C1Oseltamivir Phosphate

C1Relenza Diskhaler

C1Rimantadine HCl

C1Xofluza

C1Xofluza

A1

B1

C1Buspirone HCl

C1Hydroxyzine HCl

C1Hydroxyzine HCl

B1

C1Alprazolam

C1Chlordiazepoxide HCl

C1Clonazepam

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Clonazepam ODT

C1Clorazepate Dipotassium

C1Diazepam Intensol

C1Diazepam

C1Diazepam

C1Lorazepam

C1Lorazepam

A1

B1

C1Divalproex Sodium ER

C1Divalproex Sodium

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Oseltamivir Phosphate (Oral Suspension Reconstituted)

1 QL

Relenza Diskhaler

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Rimantadine HCl (Oral Tablet)

1

Xofluza (40 MG Dose)

(Oral Tablet Therapy

Pack)

1 QL

Xofluza (80 MG Dose)


Pack)

1 QL

Anxiolytics

Anxiolytics, Other

Buspirone HCl (Oral Tablet)

1

Hydroxyzine HCl (Oral Syrup)

1

Hydroxyzine HCl (Oral Tablet)

1

Benzodiazepines

Alprazolam (Oral Tablet Immediate Release)

1 QL

Chlordiazepoxide HCl (Oral Capsule)

1

Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)

1 QL

Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible, 2MG Oral Tablet Dispersible)

1 QL

Clorazepate Dipotassium (Oral Tablet)

1 QL

Diazepam Intensol (5MG/ML Oral Concentrate)

1 QL

Diazepam (5MG/5ML Oral Solution)

1

Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)

1 QL

Lorazepam (2MG/ML Oral Concentrate)

1 QL

Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet)

1 QL

Bipolar Agents

Mood Stabilizers

Divalproex Sodium ER (Oral Tablet Extended Release 24 Hour)

1

Divalproex Sodium (Oral Capsule Delayed Release Sprinkle)

1

tRACK 45

35


C1Divalproex Sodium

C1Lithium Carbonate ER

C1Lithium Carbonate

C1Lithium Carbonate

C1Lithium

A1

B1

C1Acarbose

C1Bydureon BCise

C1Bydureon

C1Byetta 10MCG Pen

C1Byetta 5MCG Pen

C1Cycloset

C1Glimepiride

C1Glipizide ER

C1Glipizide

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Glipizide-Metformin HCl

C1Glyxambi

C1Invokamet

C1Invokamet XR

C1Invokana

C1Janumet

C1Janumet XR

C1Januvia

C1Jardiance

C1Jentadueto

C1Jentadueto XR

C1Metformin HCl ER

C1Metformin HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Divalproex Sodium (Oral Tablet Delayed Release)

1

Lithium Carbonate ER (Oral Tablet Extended Release)

1

Lithium Carbonate (Oral Capsule)

1

Lithium Carbonate (Oral Tablet Immediate Release)

1

Lithium (Oral

Solution)1

Blood Glucose Regulators

Antidiabetic Agents

Acarbose (Oral Tablet) 1 QL

Bydureon BCise

(Subcutaneous Auto-

Injector)

1 QL

Bydureon

(Subcutaneous Pen-

Injector)

1 QL

Byetta 10MCG Pen

(Subcutaneous

Solution Pen-Injector)

1 QL

Byetta 5MCG Pen

(Subcutaneous


1 QL

Cycloset (Oral Tablet) 1 PA; QL

Glimepiride (Oral Tablet)

1 QL

Glipizide ER (Oral Tablet Extended Release 24 Hour)

1 QL

Glipizide (Oral Tablet Immediate Release)

1 QL

Glipizide-Metformin HCl (Oral Tablet)

1 QL

Glyxambi (Oral

Tablet)1 QL

Invokamet (Oral

Tablet Immediate

Release)

1 QL

Invokamet XR (Oral

Tablet Extended

Release 24 Hour)

1 QL

Invokana (Oral Tablet) 1 QL

Janumet (Oral Tablet

Immediate Release)1 QL

Janumet XR (Oral

Tablet Extended

Release 24 Hour)

1 QL

Januvia (Oral Tablet) 1 QL

Jardiance (Oral

Tablet)1 QL

Jentadueto (Oral

Tablet Immediate

Release)

1 QL

Jentadueto XR (Oral

Tablet Extended

Release 24 Hour)

1 QL

Metformin HCl ER (Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)

1 QL

Metformin HCl (500MG/5ML Oral Solution)

1 QL

tRACK46

36


C1Metformin HCl

C1Miglitol

C1Nateglinide

C1Ozempic

C1Ozempic

C1Pioglitazone HCl

C1Pioglitazone HCl-Glimepiride

C1Pioglitazone HCl-Metformin HCl

C1Repaglinide

C1Riomet ER

C1Riomet

C1Rybelsus

C1Soliqua

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1SymlinPen 120

C1SymlinPen 60

C1Synjardy

C1Synjardy XR

C1Tradjenta

C1Trulicity

C1Victoza

B1

C1Baqsimi Two Pack

C1Diazoxide

C1GlucaGen HypoKit

C1Glucagon

C1Gvoke HypoPen 2-Pack

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Metformin HCl (1000MG Oral Tablet Immediate Release, 500MG Oral Tablet Immediate Release, 850MG Oral Tablet Immediate Release)

1 QL

Miglitol (Oral Tablet) 1 QL

Nateglinide (Oral Tablet)

1 QL

Ozempic (0.25 or

0.5MG/DOSE)

(Subcutaneous


1 QL

Ozempic (1MG/

DOSE)

(Subcutaneous


1 QL

Pioglitazone HCl (Oral Tablet)

1 QL

Pioglitazone HCl-Glimepiride (Oral Tablet)

1 QL

Pioglitazone HCl-Metformin HCl (Oral Tablet)

1 QL

Repaglinide (Oral Tablet)

1 QL

Riomet ER (Oral

Suspension

Reconstituted ER)

1 QL

Riomet (Oral Solution) 1 QL

Rybelsus (Oral Tablet) 1 QL

Soliqua

(Subcutaneous


1 QL

SymlinPen 120

(Subcutaneous


1 PA

SymlinPen 60

(Subcutaneous


1 PA

Synjardy (Oral Tablet

Immediate Release)1 QL

Synjardy XR (Oral

Tablet Extended

Release 24 Hour)

1 QL

Tradjenta (Oral

Tablet)1 QL

Trulicity

(Subcutaneous


1 QL

Victoza

(Subcutaneous


1 QL

Glycemic Agents

Baqsimi Two Pack

(Nasal Powder)1

Diazoxide (Oral Suspension)

1

GlucaGen HypoKit

(Injection Solution

Reconstituted)

1

Glucagon (Injection

Kit) (Lilly)1

Gvoke HypoPen 2-

Pack (Subcutaneous

Solution Auto-

Injector)

1

tRACK 47

37


C1Gvoke PFS

C1Proglycem

B1

C1Humalog Junior KwikPen

C1Humalog KwikPen

C1Humalog Mix 50/50 KwikPen

C1Humalog Mix 50/50

C1Humalog Mix 75/25 KwikPen

C1Humalog Mix 75/25

C1Humalog

C1Humalog

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Humulin 70/30 KwikPen

C1Humulin 70/30

C1Humulin N KwikPen

C1Humulin N

C1Humulin R

C1Humulin R U-500

C1Humulin R U-500 KwikPen

C1Insulin Lispro

C1Insulin Lispro Junior KwikPen

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Gvoke PFS

(Subcutaneous

Solution Prefilled

Syringe)

1

Proglycem (Oral

Suspension)1

Insulins

Humalog Junior

KwikPen

(Subcutaneous


1

Humalog KwikPen

(Subcutaneous


1

Humalog Mix 50/50

KwikPen

(Subcutaneous

Suspension Pen-

Injector)

1

Humalog Mix 50/50

(Subcutaneous

Suspension)

1

Humalog Mix 75/25

KwikPen

(Subcutaneous

Suspension Pen-

Injector)

1

Humalog Mix 75/25

(Subcutaneous

Suspension)

1

Humalog

(Subcutaneous

Solution)

1

Humalog

(Subcutaneous

Solution Cartridge)

1

Humulin 70/30

KwikPen

(Subcutaneous

Suspension Pen-

Injector)

1

Humulin 70/30

(Subcutaneous

Suspension)

1

Humulin N KwikPen

(Subcutaneous

Suspension Pen-

Injector)

1

Humulin N

(Subcutaneous

Suspension)

1

Humulin R (Injection

Solution)1

Humulin R U-500

(Concentrated)

(Subcutaneous

Solution)

1

Humulin R U-500

KwikPen

(Subcutaneous


1

Insulin Lispro (1 Unit

Dial) (Subcutaneous


(Brand Equivalent

Humalog)

1

Insulin Lispro Junior

KwikPen

(Subcutaneous


(Brand Equivalent

Humalog)

1

tRACK48

38


C1Insulin Lispro Prot & Lispro

C1Insulin Lispro

C1Lantus SoloStar

C1Lantus

C1Levemir FlexTouch

C1Levemir

C1Toujeo Max SoloStar

C1Toujeo SoloStar

C1Tresiba FlexTouch

C1Tresiba

A1

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Eliquis Starter Pack

C1Eliquis

C1Enoxaparin Sodium

C1Fondaparinux Sodium

C1Fondaparinux Sodium

C1Heparin Sodium

C1Heparin Sodium

C1Jantoven

C1Warfarin Sodium

C1Xarelto

C1Xarelto Starter Pack

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Insulin Lispro Prot &

Lispro (Subcutaneous

Suspension Pen-

Injector) (Brand

Equivalent Humalog)

1

Insulin Lispro

(Subcutaneous

Solution) (Brand

Equivalent Humalog)

1

Lantus SoloStar

(Subcutaneous


1

Lantus

(Subcutaneous

Solution)

1

Levemir FlexTouch

(Subcutaneous


1

Levemir

(Subcutaneous

Solution)

1

Toujeo Max SoloStar

(Subcutaneous


1

Toujeo SoloStar

(Subcutaneous


1

Tresiba FlexTouch

(Subcutaneous


1

Tresiba

(Subcutaneous

Solution)

1

Blood Products/Modifiers/Volume Expanders

Anticoagulants

Eliquis Starter Pack

(Oral Tablet)1 QL

Eliquis (Oral Tablet) 1 QL

Enoxaparin Sodium (Subcutaneous Solution)

1 QL

Fondaparinux Sodium (10MG/0.8ML Subcutaneous Solution, 5MG/0.4ML Subcutaneous Solution, 7.5MG/ 0.6ML Subcutaneous Solution)

1

Fondaparinux Sodium (2.5MG/0.5ML Subcutaneous Solution)

1

Heparin Sodium (10000UNIT/ML Injection Solution, 20000UNIT/ML Injection Solution, 5000UNIT/ML Injection Solution)

1

Heparin Sodium (1000UNIT/ML Injection Solution)

1 B/D, PA

Jantoven (Oral Tablet) 1

Warfarin Sodium (Oral Tablet)

1

Xarelto (Oral Tablet) 1 QL

Xarelto Starter Pack


Pack)

1 QL

Blood Formation Modifiers

tRACK 49

39


C1Anagrelide HCl

C1Aranesp

C1Aranesp

C1Aranesp

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Aranesp

C1Granix

C1Granix

C1Leukine

C1Neulasta

C1Neupogen

C1Neupogen

C1Procrit

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Anagrelide HCl (Oral Capsule)

1

Aranesp (Albumin

Free) (100MCG/ML

Injection Solution,

200MCG/ML

Injection Solution,

300MCG/ML

Injection Solution,

60MCG/ML Injection

Solution)

1 PA

Aranesp (Albumin

Free) (25MCG/ML

Injection Solution,

40MCG/ML Injection

Solution)

1 PA

Aranesp (Albumin

Free) (100MCG/

0.5ML Injection

Solution Prefilled

Syringe, 150MCG/

0.3ML Injection

Solution Prefilled

Syringe, 200MCG/

0.4ML Injection

Solution Prefilled

Syringe, 300MCG/

0.6ML Injection

Solution Prefilled

Syringe, 500MCG/ML

Injection Solution

Prefilled Syringe,

60MCG/0.3ML

Injection Solution

Prefilled Syringe)

1 PA

Aranesp (Albumin

Free) (10MCG/0.4ML

Injection Solution

Prefilled Syringe,

25MCG/0.42ML

Injection Solution

Prefilled Syringe,

40MCG/0.4ML

Injection Solution

Prefilled Syringe)

1 PA

Granix (Subcutaneous

Solution)1 ST

Granix (Subcutaneous

Solution Prefilled

Syringe)

1 ST

Leukine (Injection

Solution

Reconstituted)

1 PA

Neulasta

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Neupogen (Injection

Solution)1 ST

Neupogen (Injection

Solution Prefilled

Syringe)

1 ST

Procrit (10000UNIT/

ML Injection Solution,

2000UNIT/ML

Injection Solution,

3000UNIT/ML

Injection Solution,

4000UNIT/ML

Injection Solution)

1 PA

tRACK50

40


C1Procrit

C1Promacta

C1Promacta

C1Retacrit

C1Retacrit

C1Udenyca

C1Zarxio

B1

C1Tranexamic Acid

B1

C1Aspirin-Dipyridamole ER

C1Brilinta

C1Cablivi

C1Cilostazol

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Clopidogrel Bisulfate

C1Prasugrel HCl

A1

B1

C1Clonidine HCl

C1Clonidine

C1Methyldopa

C1Midodrine HCl

C1Northera

B1

C1Doxazosin Mesylate

C1Phenoxybenzamine HCl

C1Prazosin HCl

B1

C1Candesartan Cilexetil

C1Edarbi

C1Irbesartan

C1Losartan Potassium

C1Olmesartan Medoxomil

C1Telmisartan

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Procrit (20000UNIT/


40000UNIT/ML

Injection Solution)

1 PA

Promacta (Oral

Packet)1 PA; LA; QL

Promacta (Oral

Tablet)1 PA; LA; QL

Retacrit (10000UNIT/


2000UNIT/ML

Injection Solution,

3000UNIT/ML

Injection Solution,

4000UNIT/ML

Injection Solution)

1 PA

Retacrit (40000UNIT/

ML Injection Solution)1 PA

Udenyca

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Zarxio (Injection

Solution Prefilled

Syringe)

1

Hemostasis Agents

Tranexamic Acid (Oral Tablet)

1

Platelet Modifying Agents

Aspirin-Dipyridamole ER (Oral Capsule Extended Release 12 Hour)

1 QL

Brilinta (Oral Tablet) 1 QL

Cablivi (Injection Kit) 1 PA; QL

Cilostazol (Oral Tablet) 1

Clopidogrel Bisulfate (75MG Oral Tablet)

1 QL

Prasugrel HCl (Oral Tablet)

1 QL

Cardiovascular Agents

Alpha-adrenergic Agonists

Clonidine HCl (Oral Tablet Immediate Release)

1

Clonidine (Transdermal Patch Weekly)

1

Methyldopa (Oral Tablet)

1

Midodrine HCl (Oral Tablet)

1

Northera (Oral


Alpha-adrenergic Blocking Agents

Doxazosin Mesylate (Oral Tablet)

1

Phenoxybenzamine HCl (Oral Capsule)

1

Prazosin HCl (Oral Capsule)

1

Angiotensin II Receptor Antagonists

Candesartan Cilexetil (Oral Tablet)

1 QL

Edarbi (Oral Tablet) 1 QL

Irbesartan (Oral Tablet) 1 QL

Losartan Potassium (Oral Tablet)

1 QL

Olmesartan Medoxomil (Oral Tablet)

1 QL

Telmisartan (Oral Tablet)

1 QL

tRACK 51

41


C1Valsartan

B1

C1Benazepril HCl

C1Captopril

C1Enalapril Maleate

C1Fosinopril Sodium

C1Lisinopril

C1Moexipril HCl

C1Perindopril Erbumine

C1Quinapril HCl

C1Ramipril

C1Trandolapril

B1

C1Amiodarone HCl

C1Dofetilide

C1Flecainide Acetate

C1Mexiletine HCl

C1Multaq

C1Pacerone

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Propafenone HCl ER

C1Propafenone HCl

C1Quinidine Gluconate ER

C1Quinidine Sulfate

C1Sotalol HCl AF

C1Sotalol HCl

B1

C1Acebutolol HCl

C1Atenolol

C1Betaxolol HCl

C1Bisoprolol Fumarate

C1Bystolic

C1Carvedilol

C1Labetalol HCl

C1Metoprolol Succinate ER

C1Metoprolol Tartrate

C1Nadolol

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Valsartan (Oral Tablet) 1 QL

Angiotensin-converting Enzyme (ACE) Inhibitors

Benazepril HCl (Oral Tablet)

1 QL

Captopril (Oral Tablet) 1 QL

Enalapril Maleate (Oral Tablet)

1 QL

Fosinopril Sodium (Oral Tablet)

1 QL

Lisinopril (Oral Tablet) 1 QL

Moexipril HCl (Oral Tablet)

1 QL

Perindopril Erbumine (Oral Tablet)

1 QL

Quinapril HCl (Oral Tablet)

1 QL

Ramipril (Oral Capsule) 1 QL

Trandolapril (Oral Tablet)

1 QL

Antiarrhythmics

Amiodarone HCl (200MG Oral Tablet)

1

Dofetilide (Oral Capsule)

1

Flecainide Acetate (Oral Tablet)

1

Mexiletine HCl (Oral Capsule)

1

Multaq (Oral Tablet) 1 QL

Pacerone (200MG Oral Tablet)

1

Propafenone HCl ER (Oral Capsule Extended Release 12 Hour)

1

Propafenone HCl (Oral Tablet)

1

Quinidine Gluconate ER (Oral Tablet Extended Release)

1

Quinidine Sulfate (Oral Tablet)

1

Sotalol HCl AF (Oral Tablet)

1

Sotalol HCl (Oral Tablet)

1

Beta-adrenergic Blocking Agents

Acebutolol HCl (Oral Capsule)

1

Atenolol (Oral Tablet) 1

Betaxolol HCl (Oral Tablet)

1

Bisoprolol Fumarate (Oral Tablet)

1

Bystolic (Oral Tablet) 1 QL

Carvedilol (Oral Tablet) 1

Labetalol HCl (Oral Tablet)

1

Metoprolol Succinate ER (Oral Tablet Extended Release 24 Hour)

1

Metoprolol Tartrate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)

1

Nadolol (Oral Tablet) 1

tRACK52

42


C1Pindolol

C1Propranolol HCl ER

C1Propranolol HCl

C1Propranolol HCl

B1

C1Amlodipine Besylate

C1Cartia XT

C1Diltiazem HCl ER Beads

C1Diltiazem HCl ER Coated Beads

C1Diltiazem HCl ER

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Diltiazem HCl

C1Dilt-XR

C1Felodipine ER

C1Matzim LA

C1Nicardipine HCl

C1Nifedipine ER

C1Nifedipine ER Osmotic Release

C1Nimodipine

C1Nymalize

C1Taztia XT

C1Tiadylt ER

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Pindolol (Oral Tablet) 1

Propranolol HCl ER (Oral Capsule Extended Release 24 Hour)

1

Propranolol HCl (Oral Solution)

1

Propranolol HCl (Oral Tablet)

1

Calcium Channel Blocking Agents

Amlodipine Besylate (Oral Tablet)

1

Cartia XT (Oral Capsule Extended Release 24 Hour)

1

Diltiazem HCl ER Beads (360MG Oral Capsule Extended Release 24 Hour, 420MG Oral Capsule Extended Release 24 Hour)

1

Diltiazem HCl ER Coated Beads (120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)

1

Diltiazem HCl ER (Oral Capsule Extended Release 12 Hour)

1

Diltiazem HCl (Oral Tablet Immediate Release)

1

Dilt-XR (Oral Capsule Extended Release 24 Hour)

1

Felodipine ER (Oral Tablet Extended Release 24 Hour)

1

Matzim LA (Oral Tablet Extended Release 24 Hour)

1

Nicardipine HCl (Oral Capsule)

1

Nifedipine ER (Oral Tablet Extended Release 24 Hour)

1 QL

Nifedipine ER Osmotic Release (Oral Tablet Extended Release 24 Hour)

1 QL

Nimodipine (Oral Capsule)

1

Nymalize (6MG/ML

Oral Solution)1

Taztia XT (Oral Capsule Extended Release 24 Hour)

1

Tiadylt ER (Oral Capsule Extended Release 24 Hour)

1

tRACK 53

43


C1Verapamil HCl ER

C1Verapamil HCl ER

C1Verapamil HCl ER

C1Verapamil HCl

B1

C1Aliskiren Fumarate

C1Amiloride-Hydrochlorothiazide

C1Amlodipine-Atorvastatin

C1Amlodipine-Benazepril

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Amlodipine-Olmesartan

C1Amlodipine-Valsartan

C1Amlodipine-Valsartan-HCTZ

C1Atenolol-Chlorthalidone

C1Benazepril-Hydrochlorothiazide

C1BiDil

C1Bisoprolol-Hydrochlorothiazide

C1Candesartan Cilexetil-HCTZ

C1Captopril-Hydrochlorothiazide

C1Corlanor

C1Corlanor

C1Demser

C1Digitek

C1Digox

C1Digoxin

C1Digoxin

C1Edarbyclor

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Verapamil HCl ER (100MG Oral Capsule Extended Release 24 Hour, 120MG Oral Capsule Extended Release 24 Hour, 180MG Oral Capsule Extended Release 24 Hour, 200MG Oral Capsule Extended Release 24 Hour, 240MG Oral Capsule Extended Release 24 Hour, 300MG Oral Capsule Extended Release 24 Hour)

1

Verapamil HCl ER

(360MG Oral Capsule

Extended Release 24

Hour)

1

Verapamil HCl ER (Oral Tablet Extended Release)

1

Verapamil HCl (Oral Tablet Immediate Release)

1

Cardiovascular Agents, Other

Aliskiren Fumarate (Oral Tablet)

1 QL

Amiloride-Hydrochlorothiazide (Oral Tablet)

1

Amlodipine-Atorvastatin (Oral Tablet)

1 QL

Amlodipine-Benazepril (Oral Capsule)

1 QL

Amlodipine-Olmesartan (Oral Tablet)

1 QL

Amlodipine-Valsartan (Oral Tablet)

1 QL

Amlodipine-Valsartan-HCTZ (Oral Tablet)

1 QL

Atenolol-Chlorthalidone (Oral Tablet)

1

Benazepril-Hydrochlorothiazide (Oral Tablet)

1 QL

BiDil (Oral Tablet) 1 QL

Bisoprolol-Hydrochlorothiazide (Oral Tablet)

1 QL

Candesartan Cilexetil-HCTZ (Oral Tablet)

1 QL

Captopril-Hydrochlorothiazide (Oral Tablet)

1 QL

Corlanor (Oral

Solution)1 PA; QL

Corlanor (Oral Tablet) 1 PA; QL

Demser (Oral

Capsule)1

Digitek (Oral Tablet) 1

Digox (Oral Tablet) 1

Digoxin (Oral

Solution)1

Digoxin (Oral Tablet) 1

Edarbyclor (Oral

Tablet)1 QL

tRACK54

44


C1Enalapril-Hydrochlorothiazide

C1Entresto

C1Fosinopril Sodium-HCTZ

C1Irbesartan-Hydrochlorothiazide

C1Lanoxin

C1Lisinopril-Hydrochlorothiazide

C1Losartan Potassium-HCTZ

C1Methyldopa-Hydrochlorothiazide

C1Metoprolol-Hydrochlorothiazide

C1Olmesartan Medoxomil-HCTZ

C1Olmesartan-Amlodipine-HCTZ

C1Pentoxifylline ER

C1Propranolol-HCTZ

C1Quinapril-Hydrochlorothiazide

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Ranolazine ER

C1Spironolactone-HCTZ

C1Telmisartan-Amlodipine

C1Telmisartan-HCTZ

C1Triamterene-HCTZ

C1Triamterene-HCTZ

C1Valsartan-Hydrochlorothiazide

C1Vyndamax

C1Vyndaqel

B1

C1Acetazolamide ER

C1Acetazolamide

C1Methazolamide

B1

C1Bumetanide

C1Bumetanide

C1Ethacrynic Acid

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Enalapril-Hydrochlorothiazide (Oral Tablet)

1 QL

Entresto (Oral Tablet) 1 QL

Fosinopril Sodium-HCTZ (Oral Tablet)

1 QL

Irbesartan-Hydrochlorothiazide (Oral Tablet)

1 QL

Lanoxin (Oral Tablet) 1

Lisinopril-Hydrochlorothiazide (Oral Tablet)

1 QL

Losartan Potassium-HCTZ (Oral Tablet)

1 QL

Methyldopa-Hydrochlorothiazide (Oral Tablet)

1

Metoprolol-Hydrochlorothiazide (Oral Tablet)

1

Olmesartan Medoxomil-HCTZ (Oral Tablet)

1 QL

Olmesartan-Amlodipine-HCTZ (Oral Tablet)

1 QL

Pentoxifylline ER (Oral Tablet Extended Release)

1

Propranolol-HCTZ (Oral Tablet)

1

Quinapril-Hydrochlorothiazide (Oral Tablet)

1 QL

Ranolazine ER (Oral Tablet Extended Release 12 Hour)

1 QL

Spironolactone-HCTZ (Oral Tablet)

1

Telmisartan-Amlodipine (Oral Tablet)

1 QL

Telmisartan-HCTZ (Oral Tablet)

1 QL

Triamterene-HCTZ (Oral Capsule)

1

Triamterene-HCTZ (Oral Tablet)

1

Valsartan-Hydrochlorothiazide (Oral Tablet)

1 QL

Vyndamax (Oral

Capsule)1 PA; QL

Vyndaqel (Oral

Capsule)1 PA; QL

Diuretics, Carbonic Anhydrase Inhibitors

Acetazolamide ER (Oral Capsule Extended Release 12 Hour)

1

Acetazolamide (Oral Tablet)

1

Methazolamide (Oral Tablet)

1

Diuretics, Loop

Bumetanide (Injection Solution)

1

Bumetanide (Oral Tablet)

1

Ethacrynic Acid (Oral Tablet)

1

tRACK 55

45


C1Furosemide

C1Furosemide

C1Furosemide

C1Torsemide

B1

C1Amiloride HCl

C1Eplerenone

C1Spironolactone

C1Triamterene

B1

C1Chlorthalidone

C1Diuril

C1Hydrochlorothiazide

C1Hydrochlorothiazide

C1Indapamide

C1Metolazone

B1

C1Fenofibrate Micronized

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Fenofibrate

C1Fenofibrate

C1Fenofibric Acid

C1Gemfibrozil

B1

C1Atorvastatin Calcium

C1Fluvastatin Sodium

C1Livalo

C1Lovastatin

C1Pravastatin Sodium

C1Rosuvastatin Calcium

C1Simvastatin

B1

C1Cholestyramine Light

C1Cholestyramine

C1Colesevelam HCl

C1Colesevelam HCl

C1Colestipol HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Furosemide (Injection Solution)

1 B/D, PA

Furosemide (Oral Solution)

1

Furosemide (Oral Tablet)

1

Torsemide (Oral Tablet)

1

Diuretics, Potassium-sparing

Amiloride HCl (Oral Tablet)

1

Eplerenone (Oral Tablet)

1

Spironolactone (Oral Tablet)

1

Triamterene (Oral Capsule)

1

Diuretics, Thiazide

Chlorthalidone (Oral Tablet)

1

Diuril (Oral

Suspension)1

Hydrochlorothiazide (Oral Capsule)

1

Hydrochlorothiazide (Oral Tablet)

1

Indapamide (Oral Tablet)

1

Metolazone (Oral Tablet)

1

Dyslipidemics, Fibric Acid Derivatives

Fenofibrate Micronized (134MG Oral Capsule, 200MG Oral Capsule, 67MG Oral Capsule)

1

Fenofibrate (145MG Oral Tablet, 48MG Oral Tablet)

1

Fenofibrate (160MG Oral Tablet, 54MG Oral Tablet)

1

Fenofibric Acid (Oral Capsule Delayed Release)

1

Gemfibrozil (Oral Tablet)

1

Dyslipidemics, HMG CoA Reductase Inhibitors

Atorvastatin Calcium (Oral Tablet)

1 QL

Fluvastatin Sodium (Oral Capsule)

1 QL

Livalo (Oral Tablet) 1 QL

Lovastatin (Oral Tablet) 1 QL

Pravastatin Sodium (Oral Tablet)

1 QL

Rosuvastatin Calcium (Oral Tablet)

1 QL

Simvastatin (Oral Tablet)

1 QL

Dyslipidemics, Other

Cholestyramine Light (Oral Powder)

1

Cholestyramine (Oral Packet)

1

Colesevelam HCl (Oral Packet)

1

Colesevelam HCl (Oral Tablet)

1

Colestipol HCl (Oral Packet)

1

tRACK56

46


C1Colestipol HCl

C1Ezetimibe

C1Ezetimibe-Simvastatin

C1Juxtapid

C1Niacin ER

C1Niacor

C1Omega-3-Acid Ethyl Esters

C1Praluent

C1Prevalite

C1Repatha Pushtronex System

C1Repatha

C1Repatha SureClick

C1Vascepa

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Hydralazine HCl

C1Minoxidil

B1

C1Isosorbide Dinitrate

C1Isosorbide Mononitrate ER

C1Isosorbide Mononitrate

C1Minitran

C1Nitro-Bid

C1Nitroglycerin

C1Nitroglycerin

C1Nitroglycerin

C1Nitrostat

C1Rectiv

A1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Colestipol HCl (Oral Tablet)

1

Ezetimibe (Oral Tablet) 1 QL

Ezetimibe-Simvastatin (Oral Tablet)

1 QL

Juxtapid (Oral

Capsule)1 PA; LA

Niacin ER (Antihyperlipidemic) (Oral Tablet Extended Release)

1

Niacor (Oral Tablet) 1

Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic Lovaza)

1 QL

Praluent

(Subcutaneous

Solution Auto-

Injector)

1 PA; LA; QL

Prevalite (Oral Packet) 1

Repatha Pushtronex

System

(Subcutaneous

Solution Cartridge)

1 PA; QL

Repatha

(Subcutaneous

Solution Prefilled

Syringe)

1 PA; QL

Repatha SureClick

(Subcutaneous

Solution Auto-

Injector)

1 PA; QL

Vascepa (Oral

Capsule)1

Vasodilators, Direct-acting Arterial

Hydralazine HCl (Oral Tablet)

1

Minoxidil (Oral Tablet) 1

Vasodilators, Direct-acting Arterial/Venous

Isosorbide Dinitrate (10MG Oral Tablet Immediate Release, 20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)

1

Isosorbide Mononitrate ER (Oral Tablet Extended Release 24 Hour)

1

Isosorbide Mononitrate (Oral Tablet Immediate Release)

1

Minitran (Transdermal Patch 24 Hour)

1

Nitro-Bid (Transdermal Ointment)

1

Nitroglycerin (Tablet Sublingual)

1

Nitroglycerin (Transdermal Patch 24 Hour)

1

Nitroglycerin (Translingual Solution)

1

Nitrostat (Tablet

Sublingual)1

Rectiv (Rectal

Ointment)1

Central Nervous System Agents

tRACK 57

47


B1

C1Amphetamine-Dextroamphetamine ER

C1Amphetamine-Dextroamphetamine

C1Dextroamphetamine Sulfate ER

C1Dextroamphetamine Sulfate

C1Vyvanse

C1Vyvanse

B1

C1Atomoxetine HCl

C1Clonidine HCl ER

C1Dexmethylphenidate HCl ER

C1Dexmethylphenidate HCl

C1Guanfacine HCl ER

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Methylphenidate HCl ER

C1Methylphenidate HCl

C1Methylphenidate HCl

B1

C1Austedo

C1Ingrezza

C1Ingrezza

C1Namzaric

C1Namzaric

C1Nuedexta

C1Riluzole

C1Tetrabenazine

B1

C1Drizalma Sprinkle

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)

1 QL

Amphetamine-Dextroamphetamine (Oral Tablet)

1 QL

Dextroamphetamine Sulfate ER (Oral Capsule Extended Release 24 Hour)

1 QL

Dextroamphetamine Sulfate (Oral Tablet)

1 QL

Vyvanse (Oral

Capsule)1

Vyvanse (Oral Tablet

Chewable)1

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

Atomoxetine HCl (Oral Capsule)

1 QL

Clonidine HCl ER (Oral Tablet Extended Release 12 Hour)

1 PA

Dexmethylphenidate HCl ER (Oral Capsule Extended Release 24 Hour)

1

Dexmethylphenidate HCl (Oral Tablet)

1 QL

Guanfacine HCl ER (Oral Tablet Extended Release 24 Hour)

1

Methylphenidate HCl ER (10MG Oral Tablet Extended Release, 20MG Oral Tablet Extended Release)

1 QL

Methylphenidate HCl (Oral Solution)

1 QL

Methylphenidate HCl (Oral Tablet Immediate Release) (Generic Ritalin)

1 QL

Central Nervous System, Other

Austedo (Oral Tablet) 1 PA; LA; QL

Ingrezza (Oral

Capsule)1 PA; QL

Ingrezza (Oral

Capsule Therapy

Pack)

1 PA; QL

Namzaric (Oral

Capsule ER 24 Hour

Therapy Pack)

1 PA; QL

Namzaric (Oral

Capsule Extended

Release 24 Hour)

1 PA; QL

Nuedexta (Oral

Capsule)1 PA

Riluzole (Oral Tablet) 1

Tetrabenazine (Oral Tablet)

1 PA; LA; QL

Fibromyalgia Agents

Drizalma Sprinkle

(Oral Capsule

Delayed Release

Sprinkle)

1 ST; QL

tRACK58

48


C1Duloxetine HCl

C1Pregabalin

C1Pregabalin

C1Savella

C1Savella Titration Pack

B1

C1Ampyra

C1Aubagio

C1Avonex Pen

C1Avonex Prefilled

C1Betaseron

C1Dalfampridine ER

C1Gilenya

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Glatiramer Acetate

C1Glatopa

C1Mayzent

C1Rebif Rebidose

C1Rebif Rebidose Titration Pack

C1Rebif

C1Rebif Titration Pack

C1Tecfidera Starter Pack

C1Tecfidera

A1

B1

C1Chlorhexidine Gluconate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule Delayed Release Particles)

1 QL

Pregabalin (Oral Capsule)

1 QL

Pregabalin (Oral Solution)

1 QL

Savella (Oral Tablet) 1

Savella Titration Pack

(Oral Tablet)1

Multiple Sclerosis Agents

Ampyra (Oral Tablet

Extended Release 12

Hour)

1 QL

Aubagio (Oral Tablet) 1 LA; QL

Avonex Pen

(Intramuscular Auto-

Injector Kit)

1 QL

Avonex Prefilled

(Intramuscular

Prefilled Syringe Kit)

1 QL

Betaseron

(Subcutaneous Kit)1 QL

Dalfampridine ER (Oral Tablet Extended Release 12 Hour)

1 QL

Gilenya (0.5MG Oral

Capsule)1 QL

Glatiramer Acetate (Subcutaneous Solution Prefilled Syringe)

1 QL

Glatopa (Subcutaneous Solution Prefilled Syringe)

1 QL

Mayzent (Oral Tablet) 1 QL

Rebif Rebidose

(Subcutaneous

Solution Auto-

Injector)

1 QL

Rebif Rebidose

Titration Pack

(Subcutaneous

Solution Auto-

Injector)

1 QL

Rebif (Subcutaneous

Solution Prefilled

Syringe)

1 QL

Rebif Titration Pack

(Subcutaneous

Solution Prefilled

Syringe)

1 QL

Tecfidera Starter

Pack (Oral)1 LA

Tecfidera (Oral

Capsule Delayed

Release)

1 LA; QL

Dental and Oral Agents

Dental and Oral Agents

Chlorhexidine Gluconate (Mouth Solution)

1

tRACK 59

49


C1Pilocarpine HCl

C1Triamcinolone Acetonide

A1

B1

C1Acitretin

C1Adapalene

C1Adapalene

C1Ammonium Lactate

C1Ammonium Lactate

C1Azelaic Acid

C1Benzoyl Peroxide-Erythromycin

C1Calcipotriene

C1Calcipotriene

C1Calcipotriene

C1Calcitriol

C1Carac

C1Claravis


Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Clindamycin Phosphate



C1Clindamycin Phosphate-Benzoyl Peroxide

C1Clotrimazole-Betamethasone

C1Clotrimazole-Betamethasone

C1Cortisporin

C1Cortisporin

C1Cosentyx

C1Cosentyx Sensoready

C1Diclofenac Sodium

C1Doxepin HCl

C1Ery

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Pilocarpine HCl (Oral Tablet)

1

Triamcinolone Acetonide (Dental Paste)

1

Dermatological Agents

Dermatological Agents

Acitretin (Oral Capsule) 1

Adapalene (External Cream)

1

Adapalene (0.1% External Gel)

1

Ammonium Lactate (External Cream)

1

Ammonium Lactate (External Lotion)

1

Azelaic Acid (External Gel)

1

Benzoyl Peroxide-Erythromycin (External Gel)

1

Calcipotriene (External Cream)

1

Calcipotriene (External Ointment)

1

Calcipotriene (External Solution)

1

Calcitriol (External

Ointment)1

Carac (External

Cream)1 PA

Claravis (Oral Capsule) 1 PA

Clindamycin Phosphate (External Gel)

1

Clindamycin Phosphate (External Lotion)

1

Clindamycin Phosphate (External Solution)

1

Clindamycin Phosphate (External Swab)

1

Clindamycin Phosphate-Benzoyl Peroxide (1-5% External Gel)

1

Clotrimazole-Betamethasone (External Cream)

1

Clotrimazole-Betamethasone (External Lotion)

1

Cortisporin (External

Cream)1

Cortisporin (External

Ointment)1

Cosentyx (300 MG

Dose) (Subcutaneous

Solution Prefilled

Syringe)

1 PA; LA

Cosentyx Sensoready

(300 MG)

(Subcutaneous

Solution Auto-

Injector)

1 PA; LA

Diclofenac Sodium (3% Transdermal Gel)

1 PA

Doxepin HCl (External Cream)

1 PA; QL

Ery (External Pad) 1

tRACK60

50


C1Erythromycin

C1Erythromycin

C1Finacea

C1Fluorouracil

C1Fluorouracil

C1Fluorouracil

C1Imiquimod

C1Imiquimod Pump

C1Isotretinoin

C1Methoxsalen Rapid

C1Mirvaso

C1Oxsoralen Ultra

C1Picato

C1Pimecrolimus

C1Podofilox

C1Regranex

C1Santyl

C1Selenium Sulfide

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Stelara

C1Stelara

C1Tacrolimus

C1Tazarotene

C1Tazorac

C1Tazorac

C1Tazorac

C1Tolak

C1Tretinoin

C1Tretinoin

C1Tretinoin Microsphere

C1Zyclara Pump

A1

B1

C1Aminosyn II

C1Aminosyn-PF

C1Carbaglu

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Erythromycin (External Gel)

1

Erythromycin (External Solution)

1

Finacea (External

Foam)1

Fluorouracil (0.5% External Cream)

1

Fluorouracil (5% External Cream)

1

Fluorouracil (External Solution)

1

Imiquimod (5% External Cream)

1

Imiquimod Pump (3.75% External Cream)

1 PA

Isotretinoin (Oral Capsule)

1 PA

Methoxsalen Rapid (Oral Capsule)

1

Mirvaso (External Gel) 1

Oxsoralen Ultra (Oral

Capsule)1

Picato (External Gel) 1

Pimecrolimus (External Cream)

1 ST

Podofilox (External Solution)

1

Regranex (External

Gel)1 PA

Santyl (External

Ointment)1

Selenium Sulfide (External Lotion)

1

Stelara

(Subcutaneous

Solution)

1 PA

Stelara

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Tacrolimus (External Ointment)

1 ST

Tazarotene (External Cream)

1 PA

Tazorac (0.05%

External Cream)1 PA

Tazorac (0.05%

External Gel)1 PA

Tazorac (0.1%

External Gel)1 PA

Tolak (External

Cream)1

Tretinoin (External Cream)

1 PA

Tretinoin (0.01% External Gel, 0.025% External Gel)

1 PA

Tretinoin Microsphere (External Gel)

1 PA

Zyclara Pump

(External Cream)1 PA

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

Aminosyn II

(Intravenous Solution)1 B/D, PA

Aminosyn-PF (7%

Intravenous Solution)1 B/D, PA

Carbaglu (Oral Tablet) 1 LA

tRACK 61

51


C1Dextrose

C1Dextrose

C1Dextrose-NaCl

C1Dextrose-NaCl

C1FreAmine HBC

C1HepatAmine

C1Intralipid

C1Isolyte-P in D5W

C1Isolyte-S

C1KCl in Dextrose-NaCl

C1KCl-Lactated Ringers-D5W

C1Klor-Con 10

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Klor-Con M10

C1Klor-Con M15

C1Klor-Con M20

C1Klor-Con

C1Klor-Con 8

C1Levocarnitine

C1Levocarnitine

C1Magnesium Sulfate

C1Magnesium Sulfate

C1NephrAmine

C1Normosol-M in D5W

C1Normosol-R pH 7.4

C1Nutrilipid

C1Plasma-Lyte 148

C1Plasma-Lyte A

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Dextrose (10%

Intravenous Solution)1

Dextrose (5% Intravenous Solution)

1 B/D, PA

Dextrose-NaCl

(10-0.2% Intravenous

Solution, 10-0.45%

Intravenous Solution,

2.5-0.45%


5-0.2% Intravenous

Solution, 5-0.45%

Intravenous Solution)

1

Dextrose-NaCl

(5-0.9% Intravenous

Solution)

1 B/D, PA

FreAmine HBC


HepatAmine


Intralipid (Intravenous

Emulsion)1 B/D, PA

Isolyte-P in D5W

(Intravenous Solution)1

Isolyte-S (Intravenous

Solution)1

KCl in Dextrose-NaCl


KCl-Lactated Ringers-

D5W (Intravenous

Solution)

1

Klor-Con 10 (Oral

Tablet Extended

Release)

1

Klor-Con M10 (Oral Tablet Extended Release)

1


1


1

Klor-Con (Oral Packet) 1

Klor-Con 8 (Oral

Tablet Extended

Release)

1

Levocarnitine (1GM/ 10ML Oral Solution)

1

Levocarnitine (330MG

Oral Tablet)1

Magnesium Sulfate

(50% Injection

Solution)

1

Magnesium Sulfate (50% (10ML Syringe) Injection Solution)

1

NephrAmine


Normosol-M in D5W


Normosol-R pH 7.4


Nutrilipid

(Intravenous

Emulsion)

1 B/D, PA

Plasma-Lyte 148


Plasma-Lyte A


tRACK62

52


C1Plenamine

C1Potassium Chloride CR

C1Potassium Chloride ER

C1Potassium Chloride in Dextrose

C1Potassium Chloride in NaCl

C1Potassium Chloride in NaCl

C1Potassium Chloride




Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Potassium Citrate ER

C1Premasol

C1Procalamine

C1Prosol

C1Sodium Chloride

C1Sodium Chloride

C1Sodium Chloride

C1Sodium Chloride

C1Sodium Fluoride

C1TPN Electrolytes

C1Travasol

C1TrophAmine

B1

C1Chemet

C1Clovique

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Plenamine (Intravenous Solution)

1 B/D, PA

Potassium Chloride CR (Oral Tablet Extended Release)

1

Potassium Chloride ER (Oral Capsule Extended Release)

1

Potassium Chloride in

Dextrose (20MEQ/L


1 B/D, PA

Potassium Chloride in NaCl (20-0.45MEQ/L-% Intravenous Solution)

1 B/D, PA

Potassium Chloride in

NaCl (20-0.9MEQ/L-%


40-0.9MEQ/L-%


1 B/D, PA

Potassium Chloride

(10MEQ/100ML


20MEQ/100ML


40MEQ/100ML


1 B/D, PA

Potassium Chloride (2MEQ/ML Intravenous Solution, 2MEQ/ML (20ML) Intravenous Solution)

1 B/D, PA

Potassium Chloride (Oral Packet)

1

Potassium Chloride (Oral Solution)

1

Potassium Citrate ER (Oral Tablet Extended Release)

1

Premasol (Intravenous Solution)

1 B/D, PA

Procalamine


Prosol (Intravenous

Solution)1 B/D, PA

Sodium Chloride

(0.45% Intravenous

Solution)

1

Sodium Chloride (0.9% Intravenous Solution)

1 B/D, PA

Sodium Chloride (3%


5% Intravenous

Solution)

1 B/D, PA

Sodium Chloride

(Irrigation Solution)1

Sodium Fluoride (Oral Tablet)

1

TPN Electrolytes

(Intravenous

Concentrate)

1

Travasol (Intravenous

Solution)1 B/D, PA

TrophAmine (10%

Intravenous Solution)1 B/D, PA

Electrolyte/Mineral/Metal Modifiers

Chemet (Oral

Capsule)1

Clovique (Oral Capsule)

1 PA; QL

tRACK 63

53


C1Deferasirox

C1Deferasirox

C1Ferriprox

C1Ferriprox

C1Jadenu

C1Jadenu Sprinkle

C1Kionex

C1Lokelma

C1Sodium Polystyrene Sulfonate

C1Sodium Polystyrene Sulfonate

C1SPS

C1Trientine HCl

C1Veltassa

B1

C1Auryxia

C1Calcium Acetate

C1Calcium Acetate

C1Lanthanum Carbonate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Phoslyra

C1Sevelamer Carbonate

C1Sevelamer Carbonate

C1Velphoro

B1

C1VP-PNV-DHA

A1

B1

C1Cuvposa

C1Dicyclomine HCl

C1Dicyclomine HCl

C1Dicyclomine HCl

C1Methscopolamine Bromide

B1

C1Chenodal

C1Cromolyn Sodium

C1Diphenoxylate-Atropine

C1Diphenoxylate-Atropine

C1Gattex

C1Loperamide HCl

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Deferasirox (Oral Tablet) (Generic Jadenu)

1 PA

Deferasirox (Oral Tablet Soluble) (Generic Exjade)

1 PA

Ferriprox (Oral

Solution)1 PA

Ferriprox (Oral Tablet) 1 PA

Jadenu (Oral Tablet) 1 PA

Jadenu Sprinkle (Oral

Packet)1 PA

Kionex (Oral Suspension)

1

Lokelma (Oral Packet) 1 QL

Sodium Polystyrene Sulfonate (Oral Powder)

1

Sodium Polystyrene Sulfonate (Oral Suspension)

1

SPS (Oral Suspension) 1

Trientine HCl (Oral Capsule)

1 PA; QL

Veltassa (Oral Packet) 1 QL

Phosphate Binders

Auryxia (Oral Tablet) 1 PA

Calcium Acetate (Phosphate Binder) (Oral Capsule)

1

Calcium Acetate (Phosphate Binder) (Oral Tablet)

1

Lanthanum Carbonate (Oral Tablet Chewable)

1

Phoslyra (Oral

Solution)1

Sevelamer Carbonate (Oral Packet)

1

Sevelamer Carbonate (Oral Tablet) (Generic Renvela)

1

Velphoro (Oral Tablet

Chewable)1

Vitamins

VP-PNV-DHA (Oral Capsule)

1

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

Cuvposa (Oral

Solution)1 PA

Dicyclomine HCl (Oral Capsule)

1

Dicyclomine HCl (Oral Solution)

1

Dicyclomine HCl (Oral Tablet)

1

Methscopolamine Bromide (Oral Tablet)

1

Gastrointestinal Agents, Other

Chenodal (Oral Tablet) 1

Cromolyn Sodium (Oral Concentrate)

1

Diphenoxylate-Atropine (Oral Liquid)

1

Diphenoxylate-Atropine (Oral Tablet)

1

Gattex (Subcutaneous

Kit)1 PA; LA

Loperamide HCl (Oral Capsule)

1

tRACK64

54


C1Myalept

C1Relistor

C1Relistor

C1Serostim

C1Ursodiol

C1Ursodiol

C1Zorbtive

B1

C1Cimetidine HCl

C1Cimetidine

C1Famotidine

C1Famotidine

B1

C1Alosetron HCl

C1Amitiza

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Linzess

C1Xifaxan

B1

C1Clenpiq

C1Constulose

C1Enulose

C1GaviLyte-C

C1GaviLyte-G

C1GaviLyte-N with Flavor Pack

C1Generlac

C1Lactulose

C1PEG-3350-NaCl-Na Bicarbonate-KCl

C1PEG-3350-Electrolytes

C1Suprep Bowel Prep Kit

C1TriLyte

B1

C1Carafate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Myalept

(Subcutaneous

Solution

Reconstituted)

1 PA; LA

Relistor (Oral Tablet) 1 PA; QL

Relistor

(Subcutaneous

Solution)

1 PA

Serostim

(Subcutaneous

Solution

Reconstituted)

1 PA; LA

Ursodiol (Oral Capsule)

1

Ursodiol (Oral Tablet) 1

Zorbtive

(Subcutaneous

Solution

Reconstituted)

1 PA; LA

Histamine2 (H2) receptor Antagonists

Cimetidine HCl (Oral Solution)

1

Cimetidine (Oral Tablet)

1

Famotidine (Oral Suspension Reconstituted)

1

Famotidine (20MG Oral Tablet, 40MG Oral Tablet)

1

Irritable Bowel Syndrome Agents

Alosetron HCl (Oral Tablet)

1 PA

Amitiza (Oral

Capsule)1 QL

Linzess (Oral

Capsule)1 QL

Xifaxan (Oral Tablet) 1 PA

Laxatives

Clenpiq (Oral

Solution)1

Constulose (Oral Solution)

1

Enulose (Oral Solution) 1

GaviLyte-C (Oral Solution Reconstituted)

1

GaviLyte-G (Oral Solution Reconstituted)

1

GaviLyte-N with Flavor Pack (Oral Solution Reconstituted)

1

Generlac (Oral Solution)

1

Lactulose (10GM/ 15ML Oral Solution)

1

PEG-3350-NaCl-Na Bicarbonate-KCl (Oral Solution) (Generic NuLYTELY)

1

PEG-3350-Electrolytes (Oral Solution) (Generic GoLYTELY)

1

Suprep Bowel Prep

Kit (Oral Solution)1

TriLyte (Oral Solution Reconstituted)

1

Protectants

Carafate (Oral

Suspension)1

tRACK 65

55


C1Misoprostol

C1Sucralfate

C1Sucralfate

B1

C1Dexilant

C1Esomeprazole Magnesium

C1Lansoprazole

C1Omeprazole

C1Pantoprazole Sodium

C1Prilosec

C1Rabeprazole Sodium

A1

B1

C1Aralast NP

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Cholbam

C1Creon

C1Cystadane

C1Cystagon

C1Glassia

C1Kuvan

C1Kuvan

C1Miglustat

C1Nitisinone

C1Ocaliva

C1Orfadin

C1Orfadin

C1Procysbi

C1Prolastin-C

C1RAVICTI

C1Sodium Phenylbutyrate

C1Sodium Phenylbutyrate

C1Sucraid

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Misoprostol (Oral Tablet)

1

Sucralfate (Oral Suspension)

1

Sucralfate (Oral Tablet) 1

Proton Pump Inhibitors

Dexilant (Oral

Capsule Delayed

Release)

1 QL

Esomeprazole Magnesium (Oral Capsule Delayed Release) (Generic Nexium)

1 QL

Lansoprazole (Oral Capsule Delayed Release)

1 QL

Omeprazole (20MG Oral Capsule Delayed Release, 40MG Oral Capsule Delayed Release)

1

Pantoprazole Sodium (Oral Tablet Delayed Release)

1 QL

Prilosec (Oral Packet) 1 PA

Rabeprazole Sodium (Oral Tablet Delayed Release)

1

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Aralast NP (1000MG


Reconstituted)

1 PA; LA

Cholbam (Oral

Capsule)1 PA

Creon (Oral Capsule

Delayed Release

Particles)

1

Cystadane (Oral

Powder)1

Cystagon (Oral

Capsule)1 LA

Glassia (Intravenous

Solution)1 PA; LA

Kuvan (Oral Packet) 1 LA

Kuvan (Oral Tablet

Soluble)1 LA

Miglustat (Oral Capsule)

1 PA; LA

Nitisinone (Oral Capsule)

1

Ocaliva (Oral Tablet) 1 PA; QL

Orfadin (Oral

Capsule)1 LA

Orfadin (Oral

Suspension)1 LA

Procysbi (Oral

Packet)1 LA

Prolastin-C


Reconstituted)

1 PA; LA

RAVICTI (Oral Liquid) 1 LA; QL

Sodium Phenylbutyrate (Oral Powder)

1

Sodium Phenylbutyrate (Oral Tablet)

1

Sucraid (Oral

Solution)1 LA

tRACK66

56


C1Tegsedi

C1Zemaira

C1Zenpep

A1

B1

C1Myrbetriq

C1Oxybutynin Chloride ER

C1Oxybutynin Chloride

C1Oxybutynin Chloride

C1Solifenacin Succinate

B1

C1Alfuzosin HCl ER

C1Dutasteride

C1Finasteride

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Silodosin

C1Tamsulosin HCl

C1Terazosin HCl

B1

C1Bethanechol Chloride

C1Depen Titratabs

C1Elmiron

C1Lithostat

C1Penicillamine

C1Penicillamine

A1

B1

C1Ala-Cort

C1Alclometasone Dipropionate

C1Alclometasone Dipropionate

C1Betamethasone Dipropionate Aug


Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Tegsedi

(Subcutaneous

Solution Prefilled

Syringe)

1 PA; LA

Zemaira (Intravenous

Solution

Reconstituted)

1 PA; LA

Zenpep (Oral Capsule

Delayed Release

Particles)

1

Genitourinary Agents

Antispasmodics, Urinary

Myrbetriq (Oral Tablet

Extended Release 24

Hour)

1

Oxybutynin Chloride ER (Oral Tablet Extended Release 24 Hour)

1 QL

Oxybutynin Chloride (Oral Syrup)

1

Oxybutynin Chloride (Oral Tablet Immediate Release)

1

Solifenacin Succinate (Oral Tablet)

1 QL

Benign Prostatic Hypertrophy Agents

Alfuzosin HCl ER (Oral Tablet Extended Release 24 Hour)

1

Dutasteride (Oral Capsule)

1 QL

Finasteride (5MG Oral Tablet) (Generic Proscar)

1

Silodosin (Oral Capsule)

1 QL

Tamsulosin HCl (Oral Capsule)

1

Terazosin HCl (Oral Capsule)

1

Genitourinary Agents, Other

Bethanechol Chloride (Oral Tablet)

1

Depen Titratabs (Oral

Tablet)1

Elmiron (Oral

Capsule)1

Lithostat (Oral Tablet) 1

Penicillamine (250MG Oral Capsule)

1 PA

Penicillamine (250MG Oral Tablet)

1

Hormonal Agents, Stimulant/Replacement/ Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Ala-Cort (1% External Cream)

1

Alclometasone Dipropionate (External Cream)

1

Alclometasone Dipropionate (External Ointment)

1

Betamethasone Dipropionate Aug (External Cream)

1

Betamethasone Dipropionate Aug (External Gel)

1

tRACK 67

57




C1Betamethasone Dipropionate



C1Betamethasone Valerate



C1Clobetasol Propionate Emollient Base

C1Clobetasol Propionate





Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Cordran

C1Cortisone Acetate

C1Desonide

C1Desoximetasone

C1Dexamethasone Intensol

C1Dexamethasone

C1Dexamethasone

C1Fludrocortisone Acetate

C1Fluocinolone Acetonide



C1Fluocinolone Acetonide Scalp

C1Fluocinonide Emulsified Base

C1Fluocinonide

C1Fluocinonide

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Betamethasone Dipropionate Aug (External Lotion)

1

Betamethasone Dipropionate Aug (External Ointment)

1

Betamethasone Dipropionate (External Cream)

1

Betamethasone Dipropionate (External Lotion)

1

Betamethasone Dipropionate (External Ointment)

1

Betamethasone Valerate (External Cream)

1

Betamethasone Valerate (External Lotion)

1

Betamethasone Valerate (External Ointment)

1

Clobetasol Propionate Emollient Base (External Cream)

1

Clobetasol Propionate (External Cream)

1

Clobetasol Propionate (External Gel)

1

Clobetasol Propionate (External Ointment)

1

Clobetasol Propionate (External Shampoo)

1

Clobetasol Propionate (External Solution)

1

Cordran (External

Tape)1

Cortisone Acetate (Oral Tablet)

1

Desonide (External Ointment)

1

Desoximetasone (External Cream)

1

Dexamethasone Intensol (Oral Concentrate)

1

Dexamethasone (Oral Elixir)

1

Dexamethasone (Oral Tablet)

1

Fludrocortisone Acetate (Oral Tablet)

1

Fluocinolone Acetonide (External Cream)

1

Fluocinolone Acetonide (External Ointment)

1

Fluocinolone Acetonide (External Solution)

1

Fluocinolone Acetonide Scalp (External Oil)

1

Fluocinonide Emulsified Base (External Cream)

1

Fluocinonide (External Gel)

1

Fluocinonide (External Ointment)

1

tRACK68

58


C1Fluocinonide

C1Fluticasone Propionate


C1Halobetasol Propionate

C1Halobetasol Propionate

C1Hydrocortisone Butyrate

C1Hydrocortisone

C1Hydrocortisone

C1Hydrocortisone

C1Hydrocortisone

C1Hydrocortisone Valerate

C1Hydrocortisone Valerate

C1Methylprednisolone

C1Methylprednisolone

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Mometasone Furoate

C1Mometasone Furoate


C1Prednicarbate

C1Prednicarbate

C1Prednisolone

C1Prednisolone Sodium Phosphate

C1Prednisone Intensol

C1Prednisone

C1Prednisone

C1Prednisone

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Fluocinonide (External Solution)

1

Fluticasone Propionate (External Cream)

1

Fluticasone Propionate (External Ointment)

1

Halobetasol Propionate (External Cream)

1

Halobetasol Propionate (External Ointment)

1

Hydrocortisone Butyrate (External Ointment)

1

Hydrocortisone (1% External Cream, 2.5% External Cream)

1

Hydrocortisone (2.5% External Lotion)

1

Hydrocortisone (1% External Ointment, 2.5% External Ointment)

1

Hydrocortisone (Oral Tablet)

1

Hydrocortisone Valerate (External Cream)

1

Hydrocortisone Valerate (External Ointment)

1

Methylprednisolone (Oral Tablet)

1

Methylprednisolone (Oral Tablet Therapy Pack)

1

Mometasone Furoate (External Cream)

1

Mometasone Furoate (External Ointment)

1

Mometasone Furoate (External Solution)

1

Prednicarbate (External Cream)

1

Prednicarbate (External Ointment)

1

Prednisolone (Oral Solution)

1

Prednisolone Sodium Phosphate (25MG/ 5ML Oral Solution, 6.7MG/5ML Oral Solution)

1

Prednisone Intensol (Oral Concentrate)

1

Prednisone (5MG/5ML Oral Solution)

1

Prednisone (10MG Oral Tablet, 1MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 50MG Oral Tablet, 5MG Oral Tablet)

1

Prednisone (10MG (21) Oral Tablet Therapy Pack, 10MG (48) Oral Tablet Therapy Pack, 5MG (21) Oral Tablet Therapy Pack, 5MG (48) Oral Tablet Therapy Pack)

1

tRACK 69

59





C1Triderm

A1

B1

C1Desmopressin Acetate

C1Desmopressin Acetate Spray

C1Genotropin MiniQuick

C1Genotropin

C1Humatrope

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Increlex

C1Norditropin FlexPro

C1Nutropin AQ NuSpin 10



C1Saizen

C1Saizenprep

A1

B1

C1Korlym

A1

B1

C1Anadrol-50

C1Androderm

C1Danazol

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Triamcinolone Acetonide (External Cream)

1

Triamcinolone Acetonide (External Lotion)

1

Triamcinolone Acetonide (0.025% External Ointment, 0.1% External Ointment, 0.5% External Ointment)

1

Triderm (0.1% External Cream)

1

Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Desmopressin Acetate (Oral Tablet)

1

Desmopressin Acetate Spray (Nasal Solution)

1

Genotropin MiniQuick

(Subcutaneous

Solution

Reconstituted)

1 PA

Genotropin

(Subcutaneous

Solution

Reconstituted)

1 PA

Humatrope (Injection

Solution

Renconstituted),

Humatrope Combo

Pack (Injection)

1 PA

Increlex

(Subcutaneous

Solution)

1 PA; LA

Norditropin FlexPro

(Subcutaneous

Solution)

1 PA

Nutropin AQ NuSpin

10 (Subcutaneous

Solution)

1 PA

Nutropin AQ NuSpin

20 (Subcutaneous

Solution)

1 PA

Nutropin AQ NuSpin 5

(Subcutaneous

Solution)

1 PA

Saizen (Injection

Solution

Reconstituted)

1 PA; LA

Saizenprep (Injection

Solution

Reconstituted)

1 PA; LA

Hormonal Agents, Stimulant/Replacement/ Modifying (Prostaglandins)

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

Korlym (Oral Tablet) 1 PA; LA; QL

Hormonal Agents, Stimulant/Replacement/ Modifying (Sex Hormones/Modifiers)

Androgens

Anadrol-50 (Oral

Tablet)1 PA

Androderm

(Transdermal Patch

24 Hour)

1 QL

Danazol (Oral Capsule) 1

tRACK70

60


C1Oxandrolone

C1Oxandrolone

C1Testosterone Cypionate

C1Testosterone Enanthate

C1Testosterone

C1Testosterone

B1

C1Altavera

C1Alyacen 1/35

C1Amethia Lo

C1Amethia

C1Apri

C1Aranelle

C1Ashlyna

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Aubra

C1Aviane

C1Balziva

C1Blisovi 24 Fe

C1Blisovi Fe 1.5/30

C1Briellyn

C1Camrese Lo

C1Caziant

C1Climara Pro

C1Cryselle-28

C1Cyclafem 1/35

C1Cyclafem 7/7/7

C1Cyred

C1Depo-Estradiol

C1Desogestrel-Ethinyl Estradiol

C1Drospirenone-Ethinyl Estradiol

C1Duavee

C1Elestrin

C1EluRyng

C1Emoquette

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Oxandrolone (10MG Oral Tablet)

1 PA; QL

Oxandrolone (2.5MG Oral Tablet)

1 PA; QL

Testosterone Cypionate (Intramuscular Solution)

1

Testosterone Enanthate (Intramuscular Solution)

1

Testosterone (25MG/ 2.5GM 1% Transdermal Gel, 50MG/5GM 1% Transdermal Gel), Testosterone Pump (1% Transdermal Gel)

1

Testosterone (20.25MG/1.25GM 1.62% Transdermal Gel, 40.5MG/2.5GM 1.62% Transdermal Gel), Testosterone Pump (1.62% Transdermal Gel)

1

Estrogens

Altavera (Oral Tablet) 1

Alyacen 1/35 (Oral Tablet)

1

Amethia Lo (Oral Tablet)

1

Amethia (Oral Tablet) 1

Apri (Oral Tablet) 1

Aranelle (Oral Tablet) 1

Ashlyna (Oral Tablet) 1

Aubra (Oral Tablet) 1

Aviane (Oral Tablet) 1

Balziva (Oral Tablet) 1

Blisovi 24 Fe (Oral Tablet)

1

Blisovi Fe 1.5/30 (Oral Tablet)

1

Briellyn (Oral Tablet) 1

Camrese Lo (Oral Tablet)

1

Caziant (Oral Tablet) 1

Climara Pro

(Transdermal Patch

Weekly)

1

Cryselle-28 (Oral Tablet)

1

Cyclafem 1/35 (Oral Tablet)

1

Cyclafem 7/7/7 (Oral Tablet)

1

Cyred (Oral Tablet) 1

Depo-Estradiol (Intramuscular Oil)

1

Desogestrel-Ethinyl Estradiol (0.15-0.02/0.01MG (21/5) Oral Tablet)

1

Drospirenone-Ethinyl Estradiol (Oral Tablet)

1

Duavee (Oral Tablet) 1

Elestrin (Transdermal

Gel)1

EluRyng (Vaginal Ring) 1

Emoquette (Oral Tablet)

1

tRACK 71

61


C1Enpresse-28

C1Enskyce

C1Estarylla

C1Estradiol

C1Estradiol

C1Estradiol

C1Estradiol

C1Estradiol Valerate

C1Estring

C1Ethynodiol Diacetate-Ethinyl Estradiol

C1Etonogestrel-Ethinyl Estradiol

C1Falmina

C1Fayosim

C1Femring

C1Femynor

C1Fyavolv

C1Gianvi

C1Hailey 24 Fe

C1Imvexxy Maintenance Pack

C1Imvexxy Starter Pack

C1Introvale

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Isibloom

C1Jasmiel

C1Jinteli

C1Juleber

C1Junel 1.5/30

C1Junel 1/20

C1Junel Fe 1.5/30

C1Junel Fe 1/20

C1Junel Fe 24

C1Kaitlib Fe

C1Kariva

C1Kelnor 1/35

C1Kelnor 1/50

C1Kurvelo

C1LARIN 1.5/30

C1LARIN 1/20

C1LARIN Fe 1.5/30

C1LARIN Fe 1/20

C1Larissia

C1Layolis Fe

C1Leena

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Enpresse-28 (Oral Tablet)

1

Enskyce (Oral Tablet) 1

Estarylla (Oral Tablet) 1

Estradiol (Oral Tablet) 1

Estradiol (Transdermal Patch Weekly)

1 QL

Estradiol (Vaginal Cream)

1

Estradiol (Vaginal Tablet)

1 QL

Estradiol Valerate (Intramuscular Oil)

1

Estring (Vaginal Ring) 1

Ethynodiol Diacetate-Ethinyl Estradiol (Oral Tablet)

1

Etonogestrel-Ethinyl Estradiol (Vaginal Ring)

1

Falmina (Oral Tablet) 1

Fayosim (Oral Tablet) 1

Femring (Vaginal

Ring)1

Femynor (Oral Tablet) 1

Fyavolv (Oral Tablet) 1

Gianvi (Oral Tablet) 1

Hailey 24 Fe (Oral Tablet)

1

Imvexxy Maintenance

Pack (Vaginal Insert)1 PA; QL

Imvexxy Starter Pack

(Vaginal Insert)1 PA; QL

Introvale (Oral Tablet) 1

Isibloom (Oral Tablet) 1

Jasmiel (Oral Tablet) 1

Jinteli (Oral Tablet) 1

Juleber (Oral Tablet) 1

Junel 1.5/30 (Oral Tablet)

1

Junel 1/20 (Oral Tablet)

1

Junel Fe 1.5/30 (Oral Tablet)

1

Junel Fe 1/20 (Oral Tablet)

1

Junel Fe 24 (Oral Tablet)

1

Kaitlib Fe (Oral Tablet Chewable)

1

Kariva (Oral Tablet) 1

Kelnor 1/35 (Oral Tablet)

1

Kelnor 1/50 (Oral Tablet)

1

Kurvelo (Oral Tablet) 1

LARIN 1.5/30 (Oral Tablet)

1

LARIN 1/20 (Oral Tablet)

1

LARIN Fe 1.5/30 (Oral Tablet)

1

LARIN Fe 1/20 (Oral Tablet)

1

Larissia (Oral Tablet) 1

Layolis Fe (Oral

Tablet Chewable)1

Leena (Oral Tablet) 1

tRACK72

62


C1Lessina

C1Levonest

C1Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol

C1Levonorgestrel-Ethinyl Estradiol 91-Day

C1Levonorgestrel-Ethinyl Estradiol

C1Levora 0.15/30

C1Loryna

C1Low-Ogestrel

C1Lutera

C1Marlissa

C1Melodetta 24 Fe

C1Menest

C1Mibelas 24 Fe

C1Microgestin 1.5/30

C1Microgestin 1/20

C1Microgestin Fe 1.5/30

C1Microgestin Fe 1/20

C1Mili

C1Necon 0.5/35

C1Nikki

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Norethindrone Acetate-Ethinyl Estradiol

C1Norethindrone Acetate-Ethinyl Estradiol

C1Norethindrone Acetate-Ethinyl Estradiol-Fe

C1Norgestimate-Ethinyl Estradiol

C1Norgestimate-Ethinyl Estradiol Triphasic

C1Nortrel 0.5/35

C1Nortrel 1/35

C1Nortrel 1/35

C1Nortrel 7/7/7

C1Ocella

C1Orsythia

C1Pimtrea

C1Pirmella 1/35

C1Portia-28

C1Premarin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Lessina (Oral Tablet) 1

Levonest (Oral Tablet) 1

Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol (Oral Tablet)

1

Levonorgestrel-Ethinyl Estradiol 91-Day (Oral Tablet)

1

Levonorgestrel-Ethinyl Estradiol (Oral Tablet)

1

Levora 0.15/30 (28) (Oral Tablet)

1

Loryna (Oral Tablet) 1

Low-Ogestrel (Oral Tablet)

1

Lutera (Oral Tablet) 1

Marlissa (Oral Tablet) 1

Melodetta 24 Fe (Oral Tablet Chewable)

1

Menest (Oral Tablet) 1

Mibelas 24 Fe (Oral Tablet Chewable)

1

Microgestin 1.5/30 (Oral Tablet)

1

Microgestin 1/20 (Oral Tablet)

1

Microgestin Fe 1.5/30 (Oral Tablet)

1

Microgestin Fe 1/20 (Oral Tablet)

1

Mili (Oral Tablet) 1

Necon 0.5/35 (28) (Oral Tablet)

1

Nikki (Oral Tablet) 1

Norethindrone Acetate-Ethinyl Estradiol (0.5-2.5MG-MCG Oral Tablet, 1-5MG-MCG Oral Tablet)

1

Norethindrone Acetate-Ethinyl Estradiol (1-20MG-MCG Oral Tablet)

1

Norethindrone Acetate-Ethinyl Estradiol-Fe (0.4-35MG-MCG Oral Tablet Chewable, 0.8-25MG-MCG Oral Tablet Chewable, 1-20MG-MCG(24) Oral Tablet Chewable)

1

Norgestimate-Ethinyl Estradiol (Oral Tablet)

1

Norgestimate-Ethinyl Estradiol Triphasic (Oral Tablet)

1

Nortrel 0.5/35 (28) (Oral Tablet)

1

Nortrel 1/35 (21) (Oral Tablet)

1

Nortrel 1/35 (28) (Oral Tablet)

1

Nortrel 7/7/7 (Oral Tablet)

1

Ocella (Oral Tablet) 1

Orsythia (Oral Tablet) 1

Pimtrea (Oral Tablet) 1

Pirmella 1/35 (Oral Tablet)

1

Portia-28 (Oral Tablet) 1

Premarin (Oral Tablet) 1 QL

tRACK 73

63


C1Premarin

C1Premphase

C1Prempro

C1Previfem

C1Reclipsen

C1Rivelsa

C1Setlakin

C1Sprintec 28

C1Sronyx

C1Syeda

C1Tarina 24 Fe

C1Tarina Fe 1/20

C1Tri-Estarylla

C1Tri-Legest Fe

C1Tri-Lo-Estarylla

C1Tri-Lo-Sprintec

C1Tri-Mili

C1Tri-Previfem

C1Tri-Sprintec

C1Trivora

C1Tri-VyLibra Lo

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Tri-VyLibra

C1Velivet

C1Vienva

C1Vyfemla

C1VyLibra

C1WYMZYA Fe

C1Xulane

C1Yuvafem

C1Zarah

C1Zovia 1/35E

B1

C1Camila

C1Crinone

C1Deblitane

C1Depo-Provera

C1Errin

C1Incassia

C1Lyza

C1Medroxyprogesterone Acetate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Premarin (Vaginal

Cream)1

Premphase (Oral

Tablet)1 QL

Prempro (Oral Tablet) 1 QL

Previfem (Oral Tablet) 1

Reclipsen (Oral Tablet) 1

Rivelsa (Oral Tablet) 1

Setlakin (Oral Tablet) 1

Sprintec 28 (Oral Tablet)

1

Sronyx (Oral Tablet) 1

Syeda (Oral Tablet) 1

Tarina 24 Fe (Oral Tablet)

1

Tarina Fe 1/20 (Oral Tablet)

1

Tri-Estarylla (Oral Tablet)

1

Tri-Legest Fe (Oral Tablet)

1

Tri-Lo-Estarylla (Oral Tablet)

1

Tri-Lo-Sprintec (Oral Tablet)

1

Tri-Mili (Oral Tablet) 1

Tri-Previfem (Oral Tablet)

1

Tri-Sprintec (Oral Tablet)

1

Trivora (28) (Oral Tablet)

1

Tri-VyLibra Lo (Oral Tablet)

1

Tri-VyLibra (Oral Tablet)

1

Velivet (Oral Tablet) 1

Vienva (Oral Tablet) 1

Vyfemla (Oral Tablet) 1

VyLibra (Oral Tablet) 1

WYMZYA Fe (Oral Tablet Chewable)

1

Xulane (Transdermal Patch Weekly)

1

Yuvafem (Vaginal Tablet)

1 QL

Zarah (Oral Tablet) 1

Zovia 1/35E (28) (Oral Tablet)

1

Progestins

Camila (Oral Tablet) 1

Crinone (Vaginal Gel) 1 PA

Deblitane (Oral Tablet) 1

Depo-Provera

(400MG/ML

Intramuscular

Suspension)

1

Errin (Oral Tablet) 1

Incassia (Oral Tablet) 1

Lyza (Oral Tablet) 1

Medroxyprogesterone Acetate (150MG/ML Intramuscular Suspension)

1

tRACK74

64




C1Megestrol Acetate

C1Megestrol Acetate

C1Megestrol Acetate

C1Nora-BE

C1Norethindrone Acetate

C1Norethindrone

C1Progesterone Micronized

C1Sharobel

B1

C1Osphena

C1Raloxifene HCl

A1

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Euthyrox

C1Levo-T

C1Levothyroxine Sodium

C1Levoxyl

C1Liothyronine Sodium

C1Synthroid

C1Unithroid

A1

B1

C1Lysodren

A1

B1

C1Cabergoline

C1Firmagon

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Medroxyprogesterone Acetate (150MG/ML Intramuscular Suspension Prefilled Syringe)

1

Medroxyprogesterone Acetate (10MG Oral Tablet, 2.5MG Oral Tablet, 5MG Oral Tablet)

1

Megestrol Acetate (40MG/ML Oral Suspension)

1

Megestrol Acetate (625MG/5ML Oral Suspension)

1

Megestrol Acetate (Oral Tablet)

1

Nora-BE (Oral Tablet) 1

Norethindrone Acetate (5MG Oral Tablet)

1

Norethindrone (0.35MG Oral Tablet)

1

Progesterone Micronized (Oral Capsule)

1

Sharobel (Oral Tablet) 1

Selective Estrogen Receptor Modifying Agents

Osphena (Oral Tablet) 1 PA; QL

Raloxifene HCl (Oral Tablet)

1 QL

Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Euthyrox (Oral Tablet) 1

Levo-T (Oral Tablet) 1

Levothyroxine Sodium (Oral Tablet)

1

Levoxyl (Oral Tablet) 1

Liothyronine Sodium (Oral Tablet)

1

Synthroid (Oral

Tablet)1

Unithroid (100MCG

Oral Tablet, 112MCG

Oral Tablet, 125MCG

Oral Tablet, 150MCG

Oral Tablet, 175MCG

Oral Tablet, 200MCG

Oral Tablet, 25MCG

Oral Tablet, 300MCG

Oral Tablet, 50MCG

Oral Tablet, 75MCG

Oral Tablet, 88MCG

Oral Tablet)

1

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)

Lysodren (Oral

Tablet)1

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)

Cabergoline (Oral Tablet)

1

Firmagon (240MG

Dose) (120MG/Vial

Subcutaneous

Solution

Reconstituted)

1 PA

tRACK 75

65


C1Firmagon

C1Leuprolide Acetate

C1Lupaneta Pack

C1Lupron Depot

C1Lupron Depot

C1Lupron Depot

C1Lupron Depot

C1Octreotide Acetate

C1Octreotide Acetate

C1Signifor

C1Somatuline Depot

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Somavert

C1Synarel

C1Trelstar Mixject

A1

B1

C1Methimazole

C1Propylthiouracil

A1

B1

C1Berinert

C1Cinryze

C1Firazyr

C1Haegarda

C1Icatibant Acetate

C1Ruconest

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Firmagon (80MG

Subcutaneous

Solution

Reconstituted)

1 PA

Leuprolide Acetate (Injection Kit)

1 PA

Lupaneta Pack

(Combination Kit)1 PA

Lupron Depot (1-

Month)

(Intramuscular Kit)

1 PA

Lupron Depot (3-

Month)

(Intramuscular Kit)

1 PA

Lupron Depot (4-

Month)

(Intramuscular Kit)

1 PA

Lupron Depot (6-

Month)

(Intramuscular Kit)

1 PA

Octreotide Acetate (1000MCG/ML Injection Solution, 500MCG/ML Injection Solution)

1 PA

Octreotide Acetate (100MCG/ML Injection Solution, 200MCG/ML Injection Solution, 50MCG/ML Injection Solution)

1 PA

Signifor

(Subcutaneous

Solution)

1 PA; LA

Somatuline Depot

(Subcutaneous

Solution)

1

Somavert

(Subcutaneous

Solution

Reconstituted)

1 PA; LA; QL

Synarel (Nasal

Solution)1

Trelstar Mixject

(Intramuscular

Suspension

Reconstituted)

1 PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

Methimazole (Oral Tablet)

1

Propylthiouracil (Oral Tablet)

1

Immunological Agents

Angioedema Agents

Berinert (Intravenous

Kit)1 PA; LA

Cinryze (Intravenous

Solution

Reconstituted)

1 PA; LA

Firazyr

(Subcutaneous

Solution)

1 PA; QL

Haegarda

(Subcutaneous

Solution

Reconstituted)

1 PA; LA

Icatibant Acetate (Subcutaneous Solution)

1 PA; QL

Ruconest


Reconstituted)

1 PA; LA

tRACK76

66


B1

C1Azathioprine

C1Cimzia Prefilled

C1Cimzia

C1Cyclosporine Modified

C1Cyclosporine Modified

C1Cyclosporine

C1Enbrel Mini

C1Enbrel

C1Enbrel

C1Enbrel SureClick

C1Envarsus XR

C1Everolimus

C1Gengraf

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Gengraf

C1Humira Pediatric Crohns Start

C1Humira Pen

C1Humira Pen Crohns Disease Starter

C1Humira Pen Psoriasis Starter

C1Humira

C1Kineret

C1Methotrexate

C1Methotrexate Sodium

C1Methotrexate Sodium

C1Mycophenolate Mofetil

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Immune Suppressants

Azathioprine (Oral Tablet)

1 B/D, PA

Cimzia Prefilled

(Subcutaneous Kit)1 PA

Cimzia

(Subcutaneous Kit)1 PA

Cyclosporine Modified (Oral Capsule)

1 B/D, PA

Cyclosporine Modified (Oral Solution)

1 B/D, PA

Cyclosporine (Oral Capsule)

1 B/D, PA

Enbrel Mini

(Subcutaneous

Solution Cartridge)

1 PA

Enbrel

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Enbrel

(Subcutaneous

Solution

Reconstituted)

1 PA

Enbrel SureClick

(Subcutaneous

Solution Auto-

Injector)

1 PA

Envarsus XR (Oral

Tablet Extended

Release 24 Hour)

1 B/D, PA

Everolimus (0.25MG Oral Tablet, 0.5MG Oral Tablet, 0.75MG Oral Tablet)

1 B/D, PA

Gengraf (Oral Capsule) 1 B/D, PA

Gengraf (Oral Solution) 1 B/D, PA

Humira Pediatric

Crohns Start

(Subcutaneous


1 PA

Humira Pen

(Subcutaneous Pen-

Injector Kit)

1 PA

Humira Pen Crohns

Disease Starter

(Subcutaneous Pen-

Injector Kit)

1 PA

Humira Pen Psoriasis

Starter

(Subcutaneous Pen-

Injector Kit)

1 PA

Humira

(Subcutaneous


1 PA

Kineret

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Methotrexate (Oral Tablet)

1

Methotrexate Sodium (50MG/2ML Injection Solution Prefilled Syringe)

1

Methotrexate Sodium (50MG/2ML Injection Solution)

1

Mycophenolate Mofetil (Oral Capsule)

1 B/D, PA

tRACK 77

67




C1Mycophenolate Sodium

C1Orencia ClickJect

C1Orencia

C1Prograf

C1Rasuvo

C1Sandimmune

C1Simponi

C1Simponi

C1Sirolimus

C1Sirolimus

C1Tacrolimus

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Trexall

C1Xatmep

C1Xeljanz

C1Xeljanz XR

C1Zortress

B1

C1BIVIGAM

C1Flebogamma DIF

C1Gammagard

C1Gammagard S/D Less IgA

C1Gammaked

C1Gammaplex

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Mycophenolate Mofetil (Oral Suspension Reconstituted)

1 B/D, PA

Mycophenolate Mofetil (Oral Tablet)

1 B/D, PA

Mycophenolate Sodium (Oral Tablet Delayed Release)

1 B/D, PA

Orencia ClickJect

(Subcutaneous

Solution Auto-

Injector)

1 PA

Orencia

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Prograf (Oral Packet) 1 B/D, PA

Rasuvo

(Subcutaneous

Solution Auto-

Injector)

1 PA

Sandimmune (Oral

Solution)1 B/D, PA

Simponi

(Subcutaneous

Solution Auto-

Injector)

1 PA

Simponi

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Sirolimus (Oral Solution)

1 B/D, PA

Sirolimus (Oral Tablet) 1 B/D, PA

Tacrolimus (Oral Capsule)

1 B/D, PA

Trexall (Oral Tablet) 1

Xatmep (Oral

Solution)1 PA

Xeljanz (Oral Tablet

Immediate Release)1 PA; QL

Xeljanz XR (Oral

Tablet Extended

Release 24 Hour)

1 PA; QL

Zortress (Oral Tablet) 1 B/D, PA

Immunizing Agents, Passive

BIVIGAM (Intravenous

Solution)1 PA

Flebogamma DIF

(5GM/50ML


1 PA

Gammagard (2.5GM/

25ML Injection

Solution)

1 PA

Gammagard S/D Less

IgA (Intravenous

Solution

Reconstituted)

1 PA

Gammaked (1GM/

10ML Injection

Solution)

1 PA

Gammaplex (10GM/

100ML Intravenous

Solution, 10GM/

200ML Intravenous

Solution, 20GM/

200ML Intravenous

Solution, 5GM/50ML


1 PA

tRACK78

68


C1Gamunex-C

C1Octagam

C1Panzyga

C1Privigen

C1Varizig

B1

C1Actemra ACTPen

C1Actemra

C1Actimmune

C1Arcalyst

C1Benlysta

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Benlysta

C1Leflunomide

C1Otezla

C1Otezla

C1Ridaura

C1Xolair

C1Xolair

B1

C1ActHIB

C1Adacel

C1BCG Vaccine

C1Bexsero

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Gamunex-C (1GM/

10ML Injection

Solution)

1 PA

Octagam (1GM/20ML


2GM/20ML


1 PA

Panzyga (Intravenous

Solution)1 PA

Privigen (20GM/

200ML Intravenous

Solution)

1 PA

Varizig (Intramuscular

Solution)1

Immunomodulators

Actemra ACTPen

(Subcutaneous

Solution Auto-

Injector)

1 PA

Actemra

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Actimmune

(Subcutaneous

Solution)

1 LA

Arcalyst

(Subcutaneous

Solution

Reconstituted)

1 PA; LA

Benlysta

(Subcutaneous

Solution Auto-

Injector)

1 PA

Benlysta

(Subcutaneous

Solution Prefilled

Syringe)

1 PA

Leflunomide (Oral Tablet)

1

Otezla (Oral Tablet) 1 PA; LA

Otezla (Oral Tablet

Therapy Pack)1 PA; LA

Ridaura (Oral

Capsule)1

Xolair (Subcutaneous

Solution Prefilled

Syringe)

1 PA; LA

Xolair (Subcutaneous

Solution

Reconstituted)

1 PA; LA

Vaccines

ActHIB

(Intramuscular

Solution

Reconstituted)

1

Adacel (Intramuscular

Suspension)1

BCG Vaccine

(Injection)1

Bexsero

(Intramuscular


Syringe)

1

tRACK 79

69


C1Boostrix

C1Daptacel

C1Diphtheria-Tetanus Toxoids DT

C1Engerix-B

C1Gardasil 9

C1Gardasil 9

C1Havrix

C1Hiberix

C1Imovax Rabies

C1Infanrix

C1IPOL

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Ixiaro

C1Kinrix

C1Menactra

C1Menveo

C1M-M-R II

C1Pediarix

C1Pedvax HIB

C1ProQuad

C1Quadracel

C1RabAvert

C1Recombivax HB

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Boostrix (5-2.5-18.5

Intramuscular

Suspension,

5-2.5-18.5 (0.5ML

Syringe)

Intramuscular

Suspension)

1

Daptacel

(Intramuscular

Suspension)

1

Diphtheria-Tetanus

Toxoids DT

(Intramuscular

Suspension)

1

Engerix-B (Injection

Suspension)1 B/D, PA

Gardasil 9

(Intramuscular

Suspension)

1

Gardasil 9

(Intramuscular


Syringe)

1

Havrix (Intramuscular

Suspension)1 PA

Hiberix (Injection

Solution

Reconstituted)

1

Imovax Rabies

(Intramuscular

Injectable)

1 B/D, PA

Infanrix

(Intramuscular

Suspension)

1

IPOL (Injection) 1

Ixiaro (Intramuscular

Suspension)1

Kinrix (Intramuscular

Suspension)1

Menactra

(Intramuscular

Injectable)

1

Menveo

(Intramuscular

Solution

Reconstituted)

1

M-M-R II (Injection

Solution

Reconstituted)

1

Pediarix

(Intramuscular

Suspension)

1

Pedvax HIB

(Intramuscular

Suspension)

1

ProQuad

(Subcutaneous

Suspension

Reconstituted)

1

Quadracel

(Intramuscular

Suspension)

1

RabAvert

(Intramuscular

Suspension

Reconstituted)

1 B/D, PA

Recombivax HB

(Injection

Suspension)

1 B/D, PA

tRACK80

70


C1Rotarix

C1RotaTeq

C1Shingrix

C1TDVAX

C1Tenivac

C1Trumenba

C1Twinrix

C1Typhim Vi

C1VAQTA

C1Varivax

C1YF-Vax

A1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useB1

C1Apriso

C1Balsalazide Disodium

C1Canasa

C1Dipentum

C1Mesalamine ER

C1Mesalamine

C1Mesalamine

C1Mesalamine

C1Pentasa

B1

C1Budesonide ER

C1Budesonide

C1Hydrocortisone

C1Procto-Med HC

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Rotarix (Oral

Suspension

Reconstituted)

1

RotaTeq (Oral

Solution)1

Shingrix

(Intramuscular

Suspension

Reconstituted)

1 PA

TDVAX

(Intramuscular

Suspension)

1

Tenivac

(Intramuscular

Injectable)

1

Trumenba

(Intramuscular


Syringe)

1

Twinrix

(Intramuscular


Syringe)

1

Typhim Vi

(Intramuscular

Solution)

1

VAQTA

(Intramuscular

Suspension)

1 PA

Varivax

(Subcutaneous

Injectable)

1

YF-Vax

(Subcutaneous

Injectable)

1

Inflammatory Bowel Disease Agents

Aminosalicylates

Apriso (Oral Capsule

Extended Release 24

Hour)

1 QL

Balsalazide Disodium (Oral Capsule)

1

Canasa (Rectal

Suppository)1

Dipentum (Oral

Capsule)1

Mesalamine ER (0.375MG Oral Capsule Extended Release 24 Hour) (Generic Apriso)

1 QL

Mesalamine (1.2GM Oral Tablet Delayed Release) (Generic Lialda)

1 QL

Mesalamine (Rectal Enema)

1 QL

Mesalamine (Rectal Suppository)

1

Pentasa (Oral

Capsule Extended

Release)

1 QL

Glucocorticoids

Budesonide ER (Oral Tablet Extended Release 24 Hour)

1 ST

Budesonide (Oral Capsule Delayed Release Particles)

1

Hydrocortisone (Rectal Enema)

1

Procto-Med HC (External Cream)

1

tRACK 81

71


C1Procto-Pak

C1Proctosol HC

C1Proctozone-HC

B1

C1Sulfasalazine

C1Sulfasalazine

A1

B1

C1Alendronate Sodium

C1Alendronate Sodium

C1Binosto

C1Calcitonin Salmon

C1Calcitriol

C1Calcitriol

C1Cinacalcet HCl

C1Cinacalcet HCl

C1Doxercalciferol

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Forteo

C1Ibandronate Sodium

C1Natpara

C1Paricalcitol

C1Prolia

C1Rayaldee

C1Risedronate Sodium

C1Teriparatide

C1Tymlos

C1Xgeva

A1

B1

C1Alcohol Prep Pads

C1Gauze

C1Insulin Syringes, Needles

A1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Procto-Pak (External Cream)

1

Proctosol HC (External Cream)

1

Proctozone-HC (External Cream)

1

Sulfonamides

Sulfasalazine (Oral Tablet Immediate Release)

1

Sulfasalazine (Oral Tablet Delayed Release)

1

Metabolic Bone Disease Agents

Metabolic Bone Disease Agents

Alendronate Sodium (Oral Solution)

1

Alendronate Sodium (10MG Oral Tablet, 35MG Oral Tablet, 70MG Oral Tablet)

1 QL

Binosto (Oral Tablet

Effervescent)1 QL

Calcitonin Salmon (Nasal Solution)

1 QL

Calcitriol (Oral Capsule)

1 B/D, PA

Calcitriol (Oral Solution)

1 B/D, PA

Cinacalcet HCl (30MG Oral Tablet)

1 B/D, PA; QL

Cinacalcet HCl (60MG Oral Tablet, 90MG Oral Tablet)

1 B/D, PA; QL

Doxercalciferol (Oral Capsule)

1 B/D, PA; QL

Forteo (Subcutaneous

Solution Pen-Injector)1 PA; QL

Ibandronate Sodium (Oral Tablet)

1 QL

Natpara

(Subcutaneous

Cartridge)

1 PA; LA

Paricalcitol (Oral Capsule)

1 B/D, PA

Prolia (Subcutaneous

Solution Prefilled

Syringe)

1 QL

Rayaldee (Oral

Capsule Extended

Release)

1 QL

Risedronate Sodium (Oral Tablet Immediate Release)

1 QL

Teriparatide

(Recombinant)

(Subcutaneous


1 PA; QL

Tymlos

(Subcutaneous


1 PA; QL

Xgeva (Subcutaneous

Solution)1 PA

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents

Alcohol Prep Pads 1

Gauze (Non-medicated 2X2 Pad)

1

Insulin Syringes, Needles

1

Ophthalmic Agents

tRACK82

72


B1

C1Atropine Sulfate

C1Bacitracin-Polymyxin B

C1Neomycin-Polymyxin-Bacitracin-Hydrocortisone

C1Blephamide

C1Blephamide S.O.P.

C1Cystaran

C1Lacrisert

C1Lastacaft

C1Neomycin-Bacitracin-Polymyxin

C1Neomycin-Polymyxin-Dexamethasone

C1Neomycin-Polymyxin-Dexamethasone

C1Neomycin-Polymyxin-Gramicidin

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Neomycin-Polymyxin-HC

C1Polymyxin B-Trimethoprim

C1Pred-G

C1Pred-G S.O.P.

C1Proparacaine HCl

C1Restasis Single-Use Vials

C1Rhopressa

C1Sulfacetamide-Prednisolone

C1TobraDex

C1TobraDex ST

C1Tobramycin-Dexamethasone

C1Xiidra

B1

C1Alocril

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Ophthalmic Agents, Other

Atropine Sulfate (1%

Ophthalmic Solution)1

Bacitracin-Polymyxin B (Ophthalmic Ointment)

1

Neomycin-Polymyxin-Bacitracin-Hydrocortisone (Ophthalmic Ointment)

1

Blephamide

(Ophthalmic

Suspension)

1

Blephamide S.O.P. (Ophthalmic Ointment)

1

Cystaran (Ophthalmic

Solution)1 LA

Lacrisert (Ophthalmic

Insert)1

Lastacaft (Ophthalmic

Solution)1

Neomycin-Bacitracin-Polymyxin (5-400-10000 Ophthalmic Ointment)

1

Neomycin-Polymyxin-Dexamethasone (Ophthalmic Ointment)

1

Neomycin-Polymyxin-Dexamethasone (3.5-10000-0.1 Ophthalmic Suspension)

1

Neomycin-Polymyxin-Gramicidin (Ophthalmic Solution)

1

Neomycin-Polymyxin-HC (Ophthalmic Suspension)

1

Polymyxin B-Trimethoprim (Ophthalmic Solution)

1

Pred-G (Ophthalmic

Suspension)1

Pred-G S.O.P.

(Ophthalmic

Ointment)

1

Proparacaine HCl (Ophthalmic Solution)

1

Restasis Single-Use

Vials (Ophthalmic

Emulsion)

1 QL

Rhopressa

(Ophthalmic Solution)1 ST

Sulfacetamide-Prednisolone (Ophthalmic Solution)

1

TobraDex

(Ophthalmic

Ointment)

1

TobraDex ST

(Ophthalmic

Suspension)

1

Tobramycin-Dexamethasone (Ophthalmic Suspension)

1

Xiidra (Ophthalmic

Solution)1 QL

Ophthalmic Anti-allergy Agents

Alocril (Ophthalmic

Solution)1

tRACK 83

73


C1Alomide

C1Azelastine HCl

C1Bepreve

C1Cromolyn Sodium

C1Epinastine HCl

C1Olopatadine HCl

C1Pazeo

B1

C1Alphagan P

C1Apraclonidine HCl

C1Azopt

C1Betaxolol HCl

C1Betimol

C1Brimonidine Tartrate

C1Brimonidine Tartrate

C1Carteolol HCl

C1Combigan

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Cosopt PF

C1Dorzolamide HCl

C1Dorzolamide HCl-Timolol Maleate

C1Dorzolamide HCl-Timolol Maleate Preservative Free

C1Levobunolol HCl

C1Phospholine Iodide

C1Pilocarpine HCl

C1Rocklatan

C1Simbrinza

C1Timolol Maleate Ophthalmic Gel Forming

C1Timolol Maleate

B1

C1Dexamethasone Sodium Phosphate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Alomide (Ophthalmic

Solution)1

Azelastine HCl (Ophthalmic Solution)

1

Bepreve (Ophthalmic

Solution)1

Cromolyn Sodium (Ophthalmic Solution)

1

Epinastine HCl (Ophthalmic Solution)

1

Olopatadine HCl (Ophthalmic Solution)

1

Pazeo (Ophthalmic

Solution)1

Ophthalmic Antiglaucoma Agents

Alphagan P (0.1%

Ophthalmic Solution)1

Apraclonidine HCl (Ophthalmic Solution)

1

Azopt (Ophthalmic

Suspension)1

Betaxolol HCl (Ophthalmic Solution)

1

Betimol (Ophthalmic

Solution)1

Brimonidine Tartrate

(0.15% Ophthalmic

Solution)

1

Brimonidine Tartrate (0.2% Ophthalmic Solution)

1

Carteolol HCl (Ophthalmic Solution)

1

Combigan

(Ophthalmic Solution)1

Cosopt PF

(Ophthalmic Solution)1

Dorzolamide HCl (Ophthalmic Solution)

1

Dorzolamide HCl-Timolol Maleate (Ophthalmic Solution)

1

Dorzolamide HCl-Timolol Maleate Preservative Free (Ophthalmic Solution)

1

Levobunolol HCl (Ophthalmic Solution)

1

Phospholine Iodide

(Ophthalmic Solution

Reconstituted)

1

Pilocarpine HCl (Ophthalmic Solution)

1

Rocklatan

(Ophthalmic Solution)1 ST

Simbrinza

(Ophthalmic

Suspension)

1

Timolol Maleate Ophthalmic Gel Forming (Ophthalmic Solution) (Generic Timoptic-XE)

1

Timolol Maleate (0.25% Ophthalmic Solution, 0.5% Ophthalmic Solution) (Generic Timoptic)

1

Ophthalmic Anti-inflammatories

Dexamethasone Sodium Phosphate (Ophthalmic Solution)

1

tRACK84

74


C1Diclofenac Sodium

C1Durezol

C1Flarex

C1Fluorometholone

C1Flurbiprofen Sodium

C1FML Forte

C1FML

C1Ilevro

C1Ketorolac Tromethamine

C1Lotemax

C1Lotemax

C1Lotemax

C1Lotemax SM

C1Loteprednol Etabonate

C1Pred Mild

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Prednisolone Acetate

C1Prednisolone Sodium Phosphate

C1Prolensa

B1

C1Latanoprost

C1Lumigan

C1Travoprost

C1Vyzulta

C1Zioptan

A1

B1

C1Acetic Acid

C1Cipro HC

C1Ciprodex

C1Flac


C1Hydrocortisone-Acetic Acid

C1Neomycin-Polymyxin-HC

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Diclofenac Sodium (Ophthalmic Solution)

1

Durezol (Ophthalmic

Emulsion)1

Flarex (Ophthalmic

Suspension)1

Fluorometholone (Ophthalmic Suspension)

1

Flurbiprofen Sodium (Ophthalmic Solution)

1

FML Forte

(Ophthalmic

Suspension)

1

FML (Ophthalmic

Ointment)1

Ilevro (Ophthalmic

Suspension)1

Ketorolac Tromethamine (Ophthalmic Solution)

1

Lotemax (Ophthalmic

Gel)1

Lotemax (Ophthalmic

Ointment)1

Lotemax (Ophthalmic

Suspension)1

Lotemax SM

(Ophthalmic Gel)1

Loteprednol Etabonate (Ophthalmic Suspension)

1

Pred Mild

(Ophthalmic

Suspension)

1

Prednisolone Acetate (Ophthalmic Suspension)

1

Prednisolone Sodium Phosphate (1% Ophthalmic Solution)

1

Prolensa (Ophthalmic

Solution)1

Ophthalmic Prostaglandin and Prostamide Analogs

Latanoprost (Ophthalmic Solution)

1

Lumigan (Ophthalmic

Solution)1

Travoprost (BAK Free) (Ophthalmic Solution)

1

Vyzulta (Ophthalmic

Solution)1

Zioptan (Ophthalmic

Solution)1

Otic Agents

Otic Agents

Acetic Acid (Otic Solution)

1

Cipro HC (Otic

Suspension)1

Ciprodex (Otic

Suspension)1

Flac (Otic Oil) 1

Fluocinolone Acetonide (Otic Oil)

1

Hydrocortisone-Acetic Acid (Otic Solution)

1

Neomycin-Polymyxin-HC (1% Otic Solution)

1

tRACK 85

75


C1Neomycin-Polymyxin-HC

A1

B1

C1Azelastine HCl

C1Cetirizine HCl

C1Cyproheptadine HCl

C1Cyproheptadine HCl

C1Levocetirizine Dihydrochloride

C1Promethazine HCl

C1Promethazine HCl

C1Promethazine HCl

C1Promethegan

B1

C1Arnuity Ellipta

C1Budesonide

C1Flovent Diskus

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Flovent HFA

C1Flunisolide



B1

C1Montelukast Sodium



C1Zafirlukast

C1Zileuton ER

C1Zyflo

B1

C1Atrovent HFA

C1Incruse Ellipta

C1Ipratropium Bromide

C1Ipratropium Bromide

C1Lonhala Magnair

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Neomycin-Polymyxin-HC (Otic Suspension)

1

Respiratory Tract/Pulmonary Agents

Antihistamines

Azelastine HCl (0.1% Nasal Solution, 0.15% Nasal Solution)

1

Cetirizine HCl (1MG/ ML Oral Solution)

1

Cyproheptadine HCl (Oral Syrup)

1

Cyproheptadine HCl (Oral Tablet)

1

Levocetirizine Dihydrochloride (Oral Tablet)

1 QL

Promethazine HCl (Oral Syrup)

1

Promethazine HCl (Oral Tablet)

1

Promethazine HCl (Rectal Suppository)

1

Promethegan (25MG Rectal Suppository)

1

Anti-inflammatories, Inhaled Corticosteroids

Arnuity Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Budesonide (Inhalation Suspension)

1 B/D, PA

Flovent Diskus

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Flovent HFA

(Inhalation Aerosol)1 QL

Flunisolide (Nasal Solution)

1

Fluticasone Propionate (Nasal Suspension)

1

Mometasone Furoate (Nasal Suspension)

1

Antileukotrienes

Montelukast Sodium (Oral Packet)

1 QL

Montelukast Sodium (Oral Tablet)

1 QL

Montelukast Sodium (Oral Tablet Chewable)

1 QL

Zafirlukast (Oral Tablet)

1 QL

Zileuton ER (Oral Tablet Extended Release 12 Hour)

1 ST

Zyflo (Oral Tablet

Immediate Release)1 ST

Bronchodilators, Anticholinergic

Atrovent HFA

(Inhalation Aerosol

Solution)

1

Incruse Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Ipratropium Bromide (Inhalation Solution)

1 B/D, PA

Ipratropium Bromide (Nasal Solution)

1

Lonhala Magnair

(Inhalation Solution)1 QL

tRACK86

76


C1Spiriva HandiHaler

C1Spiriva Respimat

B1

C1Albuterol Sulfate HFA

C1Albuterol Sulfate

C1Albuterol Sulfate

C1Albuterol Sulfate

C1Epinephrine

C1EpiPen 2-Pak

C1EpiPen Jr 2-Pak

C1Levalbuterol HCl

C1Metaproterenol Sulfate

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Perforomist

C1ProAir HFA

C1ProAir RespiClick

C1Serevent Diskus

B1

C1Bethkis

C1Cayston

C1Orkambi

C1Orkambi

C1TOBI Podhaler

C1Tobramycin

B1

C1Cromolyn Sodium

B1

C1Daliresp

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Spiriva HandiHaler

(Inhalation Capsule)1 QL

Spiriva Respimat

(Inhalation Aerosol

Solution)

1 QL

Bronchodilators, Sympathomimetic

Albuterol Sulfate HFA (108 (90 Base)MCG/ ACT Inhalation Aerosol Solution (Generic Proair), 108 (90 Base)MCG/ACT Inhalation Aerosol Solution) (Generic Proventil)

1

Albuterol Sulfate (Inhalation Nebulization Solution)

1 B/D, PA

Albuterol Sulfate (Oral Syrup)

1

Albuterol Sulfate (Oral Tablet Immediate Release)

1

Epinephrine (Injection Solution Auto-Injector)

1 QL

EpiPen 2-Pak

(Injection Solution

Auto-Injector)

1 QL

EpiPen Jr 2-Pak

(Injection Solution

Auto-Injector)

1 QL

Levalbuterol HCl (Inhalation Nebulization Solution)

1 B/D, PA

Metaproterenol Sulfate (Oral Syrup)

1

Perforomist

(Inhalation

Nebulization Solution)

1 B/D, PA; QL

ProAir HFA

(Inhalation Aerosol

Solution)

1

ProAir RespiClick

(Inhalation Aerosol

Powder Breath

Activated)

1

Serevent Diskus

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Cystic Fibrosis Agents

Bethkis (Inhalation

Nebulization Solution)1 B/D, PA; QL

Cayston (Inhalation

Solution

Reconstituted)

1 PA; LA

Orkambi (Oral Packet) 1 PA; LA; QL

Orkambi (Oral Tablet) 1 PA; LA; QL

TOBI Podhaler

(Inhalation Capsule)1 PA; QL

Tobramycin (Inhalation Nebulization Solution)

1 B/D, PA; QL

Mast Cell Stabilizers

Cromolyn Sodium (Inhalation Nebulization Solution)

1 B/D, PA

Phosphodiesterase Inhibitors, Airways Disease

Daliresp (Oral Tablet) 1 PA; QL

tRACK 87

77


C1Theophylline ER

C1Theophylline ER

C1Theophylline

B1

C1Adempas

C1Alyq

C1Ambrisentan

C1Bosentan

C1Opsumit

C1Orenitram

C1Orenitram

C1Sildenafil Citrate

C1Tadalafil

C1Tracleer

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Ventavis

B1

C1Esbriet

C1Esbriet

C1Ofev

B1

C1Acetylcysteine

C1Advair Diskus

C1Advair HFA

C1Anoro Ellipta

C1Azelastine-Fluticasone

C1Bevespi Aerosphere

C1Breo Ellipta

C1Combivent Respimat

C1Dulera

C1Dymista

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Theophylline ER (300MG Oral Tablet Extended Release 12 Hour)

1

Theophylline ER (Oral Tablet Extended Release 24 Hour)

1

Theophylline (Oral Solution)

1

Pulmonary Antihypertensives

Adempas (Oral

Tablet)1 PA; LA

Alyq (Oral Tablet) 1 PA; QL

Ambrisentan (Oral Tablet)

1 PA; LA; QL

Bosentan (Oral Tablet) 1 PA; LA; QL

Opsumit (Oral Tablet) 1 PA; LA

Orenitram (0.125MG

Oral Tablet Extended

Release)

1 PA; LA

Orenitram (0.25MG

Oral Tablet Extended

Release, 1MG Oral

Tablet Extended

Release, 2.5MG Oral

Tablet Extended

Release, 5MG Oral

Tablet Extended

Release)

1 PA; LA

Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio)

1 PA; QL

Tadalafil (PAH) (20MG Oral Tablet)

1 PA; QL

Tracleer (Oral Tablet

Soluble)1 PA; LA; QL

Ventavis (Inhalation

Solution)1 PA; LA; QL

Pulmonary Fibrosis Agents

Esbriet (Oral Capsule) 1 PA; LA; QL

Esbriet (Oral Tablet) 1 PA; LA; QL

Ofev (Oral Capsule) 1 PA; LA; QL

Respiratory Tract Agents, Other

Acetylcysteine (Inhalation Solution)

1 B/D, PA

Advair Diskus

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Advair HFA


Anoro Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Azelastine-Fluticasone (Nasal Suspension)

1

Bevespi Aerosphere


Breo Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Combivent Respimat

(Inhalation Aerosol

Solution)

1 QL

Dulera (Inhalation

Aerosol)1 QL

Dymista (Nasal

Suspension)1

tRACK88

78


C1Fasenra Pen

C1Fasenra

C1Fluticasone-Salmeterol

C1Ipratropium-Albuterol

C1Kalydeco

C1Kalydeco

C1Nucala

C1Nucala

C1Nucala

C1Pulmozyme

C1Stiolto Respimat

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Symbicort

C1Trelegy Ellipta

C1Wixela Inhub

A1

B1

C1Baclofen

C1Chlorzoxazone

C1Cyclobenzaprine HCl

C1Cyclobenzaprine HCl

C1Dantrolene Sodium

C1Tizanidine HCl

A1

B1

C1Temazepam

C1Zaleplon

C1Zolpidem Tartrate

B1

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Fasenra Pen

(Subcutaneous

Solution Auto-

Injector)

1 PA; LA

Fasenra

(Subcutaneous

Solution Prefilled

Syringe)

1 PA; LA

Fluticasone-Salmeterol (Inhalation Aerosol Powder Breath Activated)

1 QL

Ipratropium-Albuterol (Inhalation Solution)

1 B/D, PA

Kalydeco (Oral

Packet)1 PA; LA; QL

Kalydeco (Oral

Tablet)1 PA; LA; QL

Nucala

(Subcutaneous

Solution Auto-

Injector)

1 PA; LA; QL

Nucala

(Subcutaneous

Solution Prefilled

Syringe)

1 PA; LA; QL

Nucala

(Subcutaneous

Solution

Reconstituted)

1 PA; LA; QL

Pulmozyme

(Inhalation Solution)1 B/D, PA; QL

Stiolto Respimat

(Inhalation Aerosol

Solution)

1 QL

Symbicort (Inhalation

Aerosol)1 QL

Trelegy Ellipta

(Inhalation Aerosol

Powder Breath

Activated)

1 QL

Wixela Inhub (Inhalation Aerosol Powder Breath Activated) (Generic Advair)

1 QL

Skeletal Muscle Relaxants

Skeletal Muscle Relaxants

Baclofen (Oral Tablet) 1

Chlorzoxazone (500MG Oral Tablet)

1

Cyclobenzaprine HCl (10MG Oral Tablet, 5MG Oral Tablet)

1

Cyclobenzaprine HCl (7.5MG Oral Tablet)

1

Dantrolene Sodium (Oral Capsule)

1

Tizanidine HCl (Oral Tablet)

1

Sleep Disorder Agents

GABA Receptor Modulators

Temazepam (15MG Oral Capsule, 30MG Oral Capsule)

1 QL

Zaleplon (Oral Capsule)

1 QL

Zolpidem Tartrate (Oral Tablet Immediate Release)

1 QL

Sleep Disorders, Other

tRACK 89

79


C1Belsomra

C1Hetlioz

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

useC1Modafinil

C1Ramelteon

C1Xyrem

tRACK

Drug NameDrug

Tier

Necessary

actions,

restriction,

or limits on

use

Belsomra (Oral

Tablet)1 QL

Hetlioz (Oral Capsule) 1 PA; LA; QL

Modafinil (Oral Tablet) 1 PA; QL

Ramelteon (Oral Tablet)

1 QL

Xyrem (Oral Solution) 1 PA; LA; QL

tRACK90


C2. Covered drugs with a quantity limit (QL)

This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. These limits may be in place to ensure your safety.

Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain number of days. For more information about quantity limits, talk with your doctor or pharmacist. You can also call Customer Service. Our contact information is on the cover.

Drugs are listed in alphabetical order in the tables below.

Drug Name Quantity Limit

Abacavir Sulfate (Oral Solution) Maximum of 32 ml per day

Abacavir Sulfate (Oral Tablet) Maximum of 2 tablets per day

Abacavir Sulfate-Lamivudine (Oral Tablet) Maximum of 1 tablet per day

Abacavir-Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day

Abiraterone Acetate (Oral Tablet) Maximum of 4 tablets per day

Acarbose (100MG Oral Tablet) Maximum of 3 tablets per day



Acetaminophen-Codeine (120-12MG/5ML Oral Solution)

Maximum of 150 ml per day

Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Tablet)

Maximum of 13 tablets per day

Acyclovir (External Ointment) Maximum of 1 tube (30 grams) per 30 days

Advair Diskus (Inhalation Aerosol Powder

Breath Activated)Maximum of 1 inhaler (60 blisters) per 30 days

Advair HFA (Inhalation Aerosol) Maximum of 1 inhaler (12 grams) per 30 days

Aimovig (140MG/ML Subcutaneous Solution

Auto-Injector)Maximum of 1 pen (1 ml) per 30 days

Aimovig (70MG/ML Subcutaneous Solution

Auto-Injector)Maximum of 2 pens (2 ml) per 30 days

Albendazole (Oral Tablet) Maximum of 16 tablets per day

Alecensa (Oral Capsule) Maximum of 8 capsules per day

Alendronate Sodium (10MG Oral Tablet) Maximum of 1 tablet per day

Alendronate Sodium (35MG Oral Tablet) Maximum of 8 tablets per 28 days

Alendronate Sodium (70MG Oral Tablet) Maximum of 4 tablets per 28 days

Aliskiren Fumarate (Oral Tablet) Maximum of 1 tablet per day

91



Alprazolam (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate Release, 1MG Oral Tablet Immediate Release)


Alprazolam (2MG Oral Tablet Immediate Release)


Alunbrig (180MG Oral Tablet, 90MG Oral

Tablet)Maximum of 1 tablet per day

Alunbrig (30MG Oral Tablet) Maximum of 4 tablets per day

Alunbrig (Oral Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days

Alyq (Oral Tablet) Maximum of 2 tablets per day

Ambrisentan (Oral Tablet) Maximum of 1 tablet per day

Amitiza (Oral Capsule) Maximum of 2 capsules per day

Amlodipine-Atorvastatin (Oral Tablet) Maximum of 1 tablet per day

Amlodipine-Benazepril (Oral Capsule) Maximum of 1 capsule per day

Amlodipine-Olmesartan (Oral Tablet) Maximum of 1 tablet per day

Amlodipine-Valsartan (Oral Tablet) Maximum of 1 tablet per day

Amlodipine-Valsartan-HCTZ (Oral Tablet) Maximum of 1 tablet per day

Amphetamine-Dextroamphetamine ER (Oral Capsule Extended Release 24 Hour)

Maximum of 2 capsules per day

Amphetamine-Dextroamphetamine (10MG Oral Tablet, 12.5MG Oral Tablet, 15MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)


Amphetamine-Dextroamphetamine (20MG Oral Tablet)


Ampyra (Oral Tablet Extended Release 12

Hour)Maximum of 2 tablets per day

Androderm (Transdermal Patch 24 Hour) Maximum of 1 patch per day

Anoro Ellipta (Inhalation Aerosol Powder


Apokyn (Subcutaneous Solution Cartridge) Maximum of 3 ml per day

Apriso (Oral Capsule Extended Release 24

Hour)Maximum of 4 capsules per day

Aptiom (200MG Oral Tablet, 400MG Oral


Aptiom (600MG Oral Tablet, 800MG Oral

Tablet)Maximum of 2 tablets per day

Aptivus (Oral Capsule) Maximum of 4 capsules per day

Aptivus (Oral Solution) Maximum of 4 bottles (380 ml) per 30 days

Aripiprazole (1MG/ML Oral Solution) Maximum of 25 ml per day

92



Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, 30MG Oral Tablet, 5MG Oral Tablet)

Maximum of 1 tablet per day

Aripiprazole ODT (10MG Oral Tablet Dispersible)


Aripiprazole ODT (15MG Oral Tablet Dispersible)


Arnuity Ellipta (Inhalation Aerosol Powder


Aspirin-Dipyridamole ER (Oral Capsule Extended Release 12 Hour)


Atazanavir Sulfate (150MG Oral Capsule, 300MG Oral Capsule)

Maximum of 1 capsule per day

Atazanavir Sulfate (200MG Oral Capsule) Maximum of 2 capsules per day

Atomoxetine HCl (100MG Oral Capsule, 60MG Oral Capsule, 80MG Oral Capsule)


Atomoxetine HCl (10MG Oral Capsule, 18MG Oral Capsule, 25MG Oral Capsule, 40MG Oral Capsule)


Atorvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day

Atripla (Oral Tablet) Maximum of 1 tablet per day

Aubagio (Oral Tablet) Maximum of 1 tablet per day

Austedo (Oral Tablet) Maximum of 4 tablets per day

Avonex Pen (Intramuscular Auto-Injector Kit) Maximum of 1 kit per 28 days

Avonex Prefilled (Intramuscular Prefilled

Syringe Kit)Maximum of 1 kit per 28 days

Ayvakit (Oral Tablet) Maximum of 1 tablet per day

Balversa (3MG Oral Tablet) Maximum of 3 tablets per day

Balversa (4MG Oral Tablet) Maximum of 2 tablets per day

Balversa (5MG Oral Tablet) Maximum of 1 tablet per day

Belsomra (Oral Tablet) Maximum of 1 tablet per day

Benazepril HCl (Oral Tablet) Maximum of 2 tablets per day

Benazepril-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day

Betaseron (Subcutaneous Kit) Maximum of 1 kit (15 vials) per 30 days

Bethkis (Inhalation Nebulization Solution) Maximum of 2 ampules (8 ml) per day

Bevespi Aerosphere (Inhalation Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days

BiDil (Oral Tablet) Maximum of 6 tablets per day

Biktarvy (Oral Tablet) Maximum of 1 tablet per day

Binosto (Oral Tablet Effervescent) Maximum of 4 tablets per 28 days

93



Bisoprolol-Hydrochlorothiazide (Oral Tablet) Maximum of 2 tablets per day

Bosentan (Oral Tablet) Maximum of 2 tablets per day

Bosulif (100MG Oral Tablet) Maximum of 6 tablets per day

Bosulif (400MG Oral Tablet, 500MG Oral


Breo Ellipta (Inhalation Aerosol Powder


Brilinta (Oral Tablet) Maximum of 2 tablets per day

BRIVIACT (10MG/ML Oral Solution) Maximum of 20 ml per day

BRIVIACT (100MG Oral Tablet, 10MG Oral

Tablet, 25MG Oral Tablet, 50MG Oral Tablet,

75MG Oral Tablet)


Brukinsa (Oral Capsule) Maximum of 4 capsules per day

Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day

Buprenorphine HCl-Naloxone HCl (12-3MG Sublingual Film, 4-1MG Sublingual Film)

Maximum of 2 films per day

Buprenorphine HCl-Naloxone HCl (2-0.5MG Sublingual Film, 8-2MG Sublingual Film)

Maximum of 3 films per day

Buprenorphine HCl-Naloxone HCl (Tablet Sublingual)


Buprenorphine (Transdermal Patch Weekly) Maximum of 4 patches per 28 days

Butalbital-Acetaminophen-Caffeine (Oral Tablet)


Butalbital-Aspirin-Caffeine (Oral Capsule) Maximum of 6 capsules per day

Butorphanol Tartrate (Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days

Bydureon BCise (Subcutaneous Auto-

Injector)Maximum of 4 pens (3.4 ml) per 28 days

Bydureon (Subcutaneous Pen-Injector) Maximum of 4 pens per 28 days

Byetta 10MCG Pen (Subcutaneous Solution

Pen-Injector)Maximum of 1 pen (2.4 ml) per 30 days

Byetta 5MCG Pen (Subcutaneous Solution

Pen-Injector)Maximum of 1 pen (1.2 ml) per 30 days

Bystolic (10MG Oral Tablet, 2.5MG Oral

Tablet, 5MG Oral Tablet)Maximum of 1 tablet per day

Bystolic (20MG Oral Tablet) Maximum of 2 tablets per day

Cablivi (Injection Kit) Maximum of 1 kit per day

Cabometyx (20MG Oral Tablet, 60MG Oral


Cabometyx (40MG Oral Tablet) Maximum of 2 tablets per day

Calcitonin Salmon (Nasal Solution) Maximum of 1 bottle per 28 days

94



Calquence (Oral Capsule) Maximum of 2 capsules per day

Candesartan Cilexetil (16MG Oral Tablet, 32MG Oral Tablet, 4MG Oral Tablet)


Candesartan Cilexetil (8MG Oral Tablet) Maximum of 3 tablets per day

Candesartan Cilexetil-HCTZ (Oral Tablet) Maximum of 1 tablet per day

Caplyta (Oral Capsule) Maximum of 1 capsule per day

Captopril (100MG Oral Tablet) Maximum of 4 tablets per day

Captopril (12.5MG Oral Tablet, 25MG Oral Tablet)


Captopril (50MG Oral Tablet) Maximum of 9 tablets per day

Captopril-Hydrochlorothiazide (25-15MG Oral Tablet, 50-15MG Oral Tablet)


Captopril-Hydrochlorothiazide (25-25MG Oral Tablet, 50-25MG Oral Tablet)


Celecoxib (Oral Capsule) Maximum of 2 capsules per day

Cimduo (Oral Tablet) Maximum of 1 tablet per day

Cinacalcet HCl (30MG Oral Tablet, 60MG Oral Tablet)


Cinacalcet HCl (90MG Oral Tablet) Maximum of 4 tablets per day

Clobazam (2.5MG/ML Oral Suspension) Maximum of 16 ml per day

Clobazam (10MG Oral Tablet, 20MG Oral Tablet)


Clonazepam (0.5MG Oral Tablet, 1MG Oral Tablet)


Clonazepam (2MG Oral Tablet) Maximum of 10 tablets per day

Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible)


Clonazepam ODT (2MG Oral Tablet Dispersible)


Clopidogrel Bisulfate (75MG Oral Tablet) Maximum of 4 tablets per day

Clorazepate Dipotassium (15MG Oral Tablet) Maximum of 6 tablets per day

Clorazepate Dipotassium (3.75MG Oral Tablet) Maximum of 24 tablets per day

Clorazepate Dipotassium (7.5MG Oral Tablet) Maximum of 12 tablets per day

Clovique (Oral Capsule) Maximum of 8 capsules per day

Clozapine ODT (100MG Oral Tablet Dispersible)


Clozapine ODT (12.5MG Oral Tablet Dispersible)


95







Clozapine ODT (25MG Oral Tablet Dispersible) Maximum of 3 tablets per day

Codeine Sulfate (15MG Oral Tablet) Maximum of 6 tablets per day

Codeine Sulfate (30MG Oral Tablet, 60MG Oral Tablet)


Colchicine (0.6MG Oral Capsule) (Brand

Equivalent Mitigare)Maximum of 4 capsules per day

Colchicine (0.6MG Oral Tablet) (Generic Colcrys)


Colcrys (Oral Tablet) Maximum of 4 tablets per day

Combivent Respimat (Inhalation Aerosol

Solution)Maximum of 1 inhaler (4 grams) per 20 days

Complera (Oral Tablet) Maximum of 1 tablet per day

Copiktra (Oral Capsule) Maximum of 2 capsules per day

Corlanor (Oral Solution) Maximum of 15 ml per day

Corlanor (Oral Tablet) Maximum of 2 tablets per day

Cotellic (Oral Tablet) Maximum of 3 tablets per day

Crixivan (200MG Oral Capsule) Maximum of 9 capsules per day

Crixivan (400MG Oral Capsule) Maximum of 6 capsules per day

Cycloset (Oral Tablet) Maximum of 6 tablets per day

Dalfampridine ER (Oral Tablet Extended Release 12 Hour)


Daliresp (Oral Tablet) Maximum of 1 tablet per day

Daurismo (100MG Oral Tablet) Maximum of 1 tablet per day

Daurismo (25MG Oral Tablet) Maximum of 2 tablets per day

Delstrigo (Oral Tablet) Maximum of 1 tablet per day

Denavir (External Cream) Maximum of 1 tube (5 grams) per 30 days

Descovy (Oral Tablet) Maximum of 1 tablet per day

Desvenlafaxine Succinate ER (100MG Oral Tablet Extended Release 24 Hour) (Generic Pristiq)


Desvenlafaxine Succinate ER (25MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) (Generic Pristiq)


Dexilant (Oral Capsule Delayed Release) Maximum of 1 capsule per day

96



Dexmethylphenidate HCl (Oral Tablet) Maximum of 2 tablets per day

Dextroamphetamine Sulfate ER (10MG Oral Capsule Extended Release 24 Hour)






Dextroamphetamine Sulfate (Oral Tablet) Maximum of 6 tablets per day

Diazepam Intensol (5MG/ML Oral Concentrate) Maximum of 8 ml per day

Diazepam (10MG Oral Tablet, 2MG Oral Tablet, 5MG Oral Tablet)


Diclofenac Epolamine (Transdermal Patch) Maximum of 2 patches per day

Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Release)


Donepezil HCl (10MG Oral Tablet) Maximum of 2 tablets per day

Donepezil HCl (23MG Oral Tablet, 5MG Oral Tablet)


Donepezil HCl ODT (10MG Oral Tablet Dispersible)


Donepezil HCl ODT (5MG Oral Tablet Dispersible)


Dovato (Oral Tablet) Maximum of 1 tablet per day

Doxepin HCl (External Cream) Maximum of 90 grams per 30 days

Doxercalciferol (0.5MCG Oral Capsule) Maximum of 3 capsules per day

Doxercalciferol (1MCG Oral Capsule, 2.5MCG Oral Capsule)


Drizalma Sprinkle (20MG Oral Capsule

Delayed Release Sprinkle, 30MG Oral

Capsule Delayed Release Sprinkle, 60MG

Oral Capsule Delayed Release Sprinkle)


Drizalma Sprinkle (40MG Oral Capsule

Delayed Release Sprinkle)Maximum of 3 capsules per day

Dulera (120 Inhalation Aerosol) Maximum of 1 inhaler (13 grams) per 30 days

Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Release Particles, 60MG Oral Capsule Delayed Release Particles)


Dutasteride (Oral Capsule) Maximum of 1 capsule per day

Econazole Nitrate (External Cream) Maximum of 90 grams per 30 days

97



Edarbi (Oral Tablet) Maximum of 1 tablet per day

Edarbyclor (Oral Tablet) Maximum of 1 tablet per day

Edurant (Oral Tablet) Maximum of 1 tablet per day

Efavirenz (Oral Capsule) Maximum of 3 capsules per day

Efavirenz (Oral Tablet) Maximum of 1 tablet per day

Eliquis Starter Pack (Oral Tablet) Maximum of 1 pack (74 tablets) per 30 days

Eliquis (Oral Tablet) Maximum of 2 tablets per day

Emgality (300MG Dose) (100MG/ML

Subcutaneous Solution Prefilled Syringe)

Maximum of 3 syringes or pens (3 ml) per 30 days

Emgality (Subcutaneous Solution Auto-

Injector)


Emgality (120MG/ML Subcutaneous

Solution Prefilled Syringe)


Emsam (Transdermal Patch 24 Hour) Maximum of 1 patch per day

Emtriva (Oral Capsule) Maximum of 1 capsule per day

Emtriva (Oral Solution) Maximum of 5 bottles (850 ml) per 30 days

Enalapril Maleate (Oral Tablet) Maximum of 2 tablets per day

Enalapril-Hydrochlorothiazide (10-25MG Oral Tablet)


Enalapril-Hydrochlorothiazide (5-12.5MG Oral Tablet)


Endocet (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)


Enoxaparin Sodium (100MG/ML Subcutaneous Solution, 150MG/ML Subcutaneous Solution)

Maximum of 2 syringes (2 ml) per day

Enoxaparin Sodium (120MG/0.8ML Subcutaneous Solution, 80MG/0.8ML Subcutaneous Solution)

Maximum of 2 syringes (1.6 ml) per day

Enoxaparin Sodium (30MG/0.3ML Subcutaneous Solution)






Entresto (Oral Tablet) Maximum of 2 tablets per day

Epclusa (Oral Tablet) Maximum of 1 tablet per day

Epinephrine (Injection Solution Auto-Injector) Maximum of 4 pens (2 boxes) per 30 days

EpiPen 2-Pak (Injection Solution Auto-

Injector)Maximum of 4 pens (2 boxes) per 30 days

98



EpiPen Jr 2-Pak (Injection Solution Auto-

Injector)Maximum of 4 pens (2 boxes) per 30 days

Erivedge (Oral Capsule) Maximum of 1 capsule per day

Erleada (Oral Tablet) Maximum of 4 tablets per day

Erlotinib HCl (100MG Oral Tablet, 150MG Oral Tablet)


Erlotinib HCl (25MG Oral Tablet) Maximum of 3 tablets per day

Esbriet (Oral Capsule) Maximum of 9 capsules per day

Esbriet (267MG Oral Tablet) Maximum of 9 tablets per day

Esbriet (801MG Oral Tablet) Maximum of 3 tablets per day

Esomeprazole Magnesium (20MG Oral Capsule Delayed Release) (Generic Nexium)


Esomeprazole Magnesium (40MG Oral Capsule Delayed Release) (Generic Nexium)


Estradiol (Transdermal Patch Weekly) Maximum of 4 patches per 28 days

Estradiol (Vaginal Tablet) Maximum of 1 tablet per day

Evotaz (Oral Tablet) Maximum of 1 tablet per day

Ezetimibe (Oral Tablet) Maximum of 1 tablet per day

Ezetimibe-Simvastatin (Oral Tablet) Maximum of 1 tablet per day

Famciclovir (125MG Oral Tablet, 250MG Oral Tablet)


Famciclovir (500MG Oral Tablet) Maximum of 3 tablets per day

Fanapt (10MG Oral Tablet, 12MG Oral

Tablet, 1MG Oral Tablet, 2MG Oral Tablet,

4MG Oral Tablet, 6MG Oral Tablet, 8MG Oral

Tablet)


Fentanyl Citrate (Buccal Lozenge On A Handle) Maximum of 4 lozenges per day

Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour)

Maximum of 15 patches per 30 days

Fetzima (Oral Capsule Extended Release 24

Hour)Maximum of 1 capsule per day

Fintepla (Oral Solution) Maximum of 12 ml per day

Firazyr (Subcutaneous Solution) Maximum of 3 syringes (9 ml) per day

Flector (Transdermal Patch) Maximum of 2 patches per day

Flovent Diskus (Inhalation Aerosol Powder

Breath Activated)

Maximum of 2 inhalers (120 blisters) per 30 days

99



Flovent HFA (110MCG/ACT Inhalation

Aerosol)Maximum of 1 inhaler (12 grams) per 30 days


Aerosol)Maximum of 2 inhalers (24 grams) per 30 days


Aerosol)Maximum of 1 inhaler (10.6 grams) per 30 days

Fluticasone-Salmeterol (100-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 250-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 500-50MCG/DOSE Inhalation Aerosol Powder Breath Activated) (Generic Advair)

Maximum of 1 inhaler (60 blisters) per 30 days

Fluticasone-Salmeterol (113-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 232-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 55-14MCG/ACT Inhalation Aerosol Powder Breath Activated) (Brand Equivalent AirDuo)

Maximum of 1 inhaler per 30 days

Fluvastatin Sodium (20MG Oral Capsule) Maximum of 1 capsule per day

Fluvastatin Sodium (40MG Oral Capsule) Maximum of 2 capsules per day

Forteo (Subcutaneous Solution Pen-Injector) Maximum of 1 pen (2.4 ml) per 28 days

Fosamprenavir Calcium (Oral Tablet) Maximum of 4 tablets per day

Fosinopril Sodium (Oral Tablet) Maximum of 2 tablets per day

Fosinopril Sodium-HCTZ (Oral Tablet) Maximum of 4 tablets per day

Fuzeon (Subcutaneous Solution

Reconstituted)Maximum of 2 vials per day

Galantamine Hydrobromide ER (Oral Capsule Extended Release 24 Hour)


Galantamine Hydrobromide (Oral Solution) Maximum of 2 bottles (200 ml) per 30 days

Galantamine Hydrobromide (Oral Tablet) Maximum of 2 tablets per day

Genvoya (Oral Tablet) Maximum of 1 tablet per day

Gilenya (0.5MG Oral Capsule) Maximum of 1 pack (30 capsules) per 30 days

Glatiramer Acetate (20MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 1 syringe (1 ml) per day

Glatiramer Acetate (40MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 12 syringes (12 ml) per 28 days

Glatopa (20MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 1 syringe (1 ml) per day

Glatopa (40MG/ML Subcutaneous Solution Prefilled Syringe)

Maximum of 12 syringes (12 ml) per 28 days

100



Glimepiride (1MG Oral Tablet) Maximum of 8 tablets per day



Glipizide ER (10MG Oral Tablet Extended Release 24 Hour)


Glipizide ER (2.5MG Oral Tablet Extended Release 24 Hour)


Glipizide ER (5MG Oral Tablet Extended Release 24 Hour)


Glipizide (10MG Oral Tablet Immediate Release)


Glipizide (5MG Oral Tablet Immediate Release) Maximum of 8 tablets per day

Glipizide-Metformin HCl (2.5-250MG Oral Tablet)


Glipizide-Metformin HCl (2.5-500MG Oral Tablet, 5-500MG Oral Tablet)


Glyxambi (Oral Tablet) Maximum of 1 tablet per day

Granisetron HCl (Oral Tablet) Maximum of 2 tablets per day

Hetlioz (Oral Capsule) Maximum of 1 capsule per day

Hydrocodone-Acetaminophen (7.5-325MG/15ML Oral Solution)


Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)


Hydrocodone-Ibuprofen (7.5-200MG Oral Tablet)


Hydromorphone HCl ER (Oral Tablet ER 24 Hour Abuse-Deterrent)


Hydromorphone HCl (1MG/ML Oral Liquid) Maximum of 50 ml per day

Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Immediate Release)


Hydromorphone HCl (8MG Oral Tablet Immediate Release)


Hysingla ER (Oral Tablet ER 24 Hour Abuse-

Deterrent)Maximum of 1 tablet per day

Ibandronate Sodium (Oral Tablet) Maximum of 1 tablet per 28 days

Ibrance (Oral Capsule) Maximum of 1 capsule per day

Ibrance (Oral Tablet) Maximum of 1 tablet per day

Icatibant Acetate (Subcutaneous Solution) Maximum of 3 syringes (9 ml) per day

101



Iclusig (15MG Oral Tablet) Maximum of 2 tablets per day

Iclusig (45MG Oral Tablet) Maximum of 1 tablet per day

IDHIFA (Oral Tablet) Maximum of 1 tablet per day

Imatinib Mesylate (Oral Tablet) Maximum of 3 tablets per day

Imbruvica (140MG Oral Capsule) Maximum of 4 capsules per day

Imbruvica (70MG Oral Capsule) Maximum of 1 capsule per day

Imbruvica (Oral Tablet) Maximum of 1 tablet per day

Imvexxy Maintenance Pack (Vaginal Insert) Maximum of 1 vaginal insert per day

Imvexxy Starter Pack (Vaginal Insert) Maximum of 1 vaginal insert per day

Incruse Ellipta (Inhalation Aerosol Powder


Ingrezza (Oral Capsule) Maximum of 1 capsule per day

Ingrezza (Oral Capsule Therapy Pack) Maximum of 1 pack (28 capsules) per 28 days

Inlyta (Oral Tablet) Maximum of 4 tablets per day

Inrebic (Oral Capsule) Maximum of 4 capsules per day

Intelence (100MG Oral Tablet, 200MG Oral


Intelence (25MG Oral Tablet) Maximum of 4 tablets per day

Invirase (Oral Tablet) Maximum of 4 tablets per day

Invokamet (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Invokamet XR (Oral Tablet Extended Release

24 Hour)Maximum of 2 tablets per day

Invokana (Oral Tablet) Maximum of 1 tablet per day

Irbesartan (150MG Oral Tablet, 300MG Oral Tablet)


Irbesartan (75MG Oral Tablet) Maximum of 3 tablets per day

Irbesartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day

Iressa (Oral Tablet) Maximum of 2 tablets per day

Isentress HD (Oral Tablet) Maximum of 2 tablets per day

Isentress (Oral Packet) Maximum of 2 packets per day

Isentress (Oral Tablet) Maximum of 2 tablets per day

Isentress (Oral Tablet Chewable) Maximum of 6 tablets per day

Itraconazole (Oral Capsule) Maximum of 4 capsules per day

Jakafi (Oral Tablet) Maximum of 2 tablets per day

Janumet (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Janumet XR (100-1000MG Oral Tablet

Extended Release 24 Hour)Maximum of 1 tablet per day

102



Janumet XR (50-1000MG Oral Tablet

Extended Release 24 Hour, 50-500MG Oral

Tablet Extended Release 24 Hour)


Januvia (Oral Tablet) Maximum of 1 tablet per day

Jardiance (Oral Tablet) Maximum of 1 tablet per day

Jentadueto (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Jentadueto XR (2.5-1000MG Oral Tablet

Extended Release 24 Hour)Maximum of 2 tablets per day

Jentadueto XR (5-1000MG Oral Tablet

Extended Release 24 Hour)Maximum of 1 tablet per day

Juluca (Oral Tablet) Maximum of 1 tablet per day

Kaletra (100-25MG Oral Tablet) Maximum of 8 tablets per day

Kaletra (200-50MG Oral Tablet) Maximum of 4 tablets per day

Kalydeco (Oral Packet) Maximum of 2 packets per day

Kalydeco (Oral Tablet) Maximum of 2 tablets per day

Ketoconazole (External Cream) Maximum of 90 grams per 30 days

Kisqali (200MG Dose) (Oral Tablet) Maximum of 3 tablets per day



Kisqali Femara (400MG Dose) (Oral Tablet

Therapy Pack)Maximum of 1 pack (91 tablets) per 28 days





Korlym (Oral Tablet) Maximum of 4 tablets per day

Koselugo (10MG Oral Capsule) Maximum of 8 capsules per day

Koselugo (25MG Oral Capsule) Maximum of 4 capsules per day

Lamivudine (10MG/ML Oral Solution) Maximum of 32 ml per day

Lamivudine (150MG Oral Tablet) Maximum of 2 tablets per day

Lamivudine (300MG Oral Tablet) Maximum of 1 tablet per day

Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day

Lansoprazole (Oral Capsule Delayed Release) Maximum of 2 capsules per day

Latuda (120MG Oral Tablet, 20MG Oral

Tablet, 40MG Oral Tablet, 60MG Oral Tablet)Maximum of 1 tablet per day

Latuda (80MG Oral Tablet) Maximum of 2 tablets per day

Levocetirizine Dihydrochloride (Oral Tablet) Maximum of 1 tablet per day

Levorphanol Tartrate (Oral Tablet) Maximum of 6 tablets per day

Lexiva (Oral Suspension) Maximum of 60 ml per day

103



Lidocaine (5% External Ointment) Maximum of 152 grams per 30 days

Lidocaine (5% External Patch) Maximum of 3 patches per day

Linezolid (Oral Tablet) Maximum of 2 tablets per day

Linzess (Oral Capsule) Maximum of 1 capsule per day

Lisinopril (Oral Tablet) Maximum of 2 tablets per day

Lisinopril-Hydrochlorothiazide (10-12.5MG Oral Tablet)


Lisinopril-Hydrochlorothiazide (20-12.5MG Oral Tablet)


Lisinopril-Hydrochlorothiazide (20-25MG Oral Tablet)


Livalo (Oral Tablet) Maximum of 1 tablet per day

Lokelma (Oral Packet) Maximum of 90 packets per 30 days

Lonhala Magnair (Inhalation Solution) Maximum of 2 vials (2 ml) per day

Lonsurf (15-6.14MG Oral Tablet) Maximum of 10 tablets per day

Lonsurf (20-8.19MG Oral Tablet) Maximum of 8 tablets per day

Lopinavir-Ritonavir (Oral Solution) Maximum of 2 bottles (320 ml) per 30 days

Lorazepam (2MG/ML Oral Concentrate) Maximum of 5 ml per day

Lorazepam (0.5MG Oral Tablet, 1MG Oral Tablet)


Lorazepam (2MG Oral Tablet) Maximum of 5 tablets per day

Lorbrena (100MG Oral Tablet) Maximum of 1 tablet per day

Lorbrena (25MG Oral Tablet) Maximum of 3 tablets per day

Lorcet HD (Oral Tablet) Maximum of 12 tablets per day

Lorcet (Oral Tablet) Maximum of 12 tablets per day

Losartan Potassium (100MG Oral Tablet) Maximum of 1 tablet per day

Losartan Potassium (25MG Oral Tablet, 50MG Oral Tablet)


Losartan Potassium-HCTZ (100-12.5MG Oral Tablet, 100-25MG Oral Tablet)


Losartan Potassium-HCTZ (50-12.5MG Oral Tablet)


Lovastatin (10MG Oral Tablet, 20MG Oral Tablet)


Lovastatin (40MG Oral Tablet) Maximum of 2 tablets per day

Lynparza (Oral Tablet) Maximum of 4 tablets per day

Mavyret (Oral Tablet) Maximum of 3 tablets per day

Mayzent (0.25MG Oral Tablet) Maximum of 8 tablets per day

Mayzent (2MG Oral Tablet) Maximum of 1 tablet per day

104



Memantine HCl ER (Oral Capsule Extended Release 24 Hour)


Memantine HCl (2MG/ML Oral Solution) Maximum of 10 ml per day

Memantine HCl (10MG Oral Tablet) Maximum of 2 tablets per day

Memantine HCl (5MG Oral Tablet) Maximum of 3 tablets per day

Mesalamine ER (0.375MG Oral Capsule Extended Release 24 Hour) (Generic Apriso)


Mesalamine (1.2GM Oral Tablet Delayed Release) (Generic Lialda)


Mesalamine (Rectal Enema) Maximum of 1 bottle (60 ml) per day

Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)


Metformin HCl ER (750MG Oral Tablet Extended Release 24 Hour) (Generic Glucophage XR)


Metformin HCl (500MG/5ML Oral Solution) Maximum of 25.5 ml per day

Metformin HCl (1000MG Oral Tablet Immediate Release)

Maximum of 2.5 tablets per day





Methadone HCl (10MG/5ML Oral Solution) Maximum of 60 ml per day

Methadone HCl (5MG/5ML Oral Solution) Maximum of 120 ml per day

Methadone HCl (10MG Oral Tablet) Maximum of 12 tablets per day

Methadone HCl (5MG Oral Tablet) Maximum of 8 tablets per day

Methylphenidate HCl ER (10MG Oral Tablet Extended Release)


Methylphenidate HCl ER (20MG Oral Tablet Extended Release)


Methylphenidate HCl (10MG/5ML Oral Solution)


Methylphenidate HCl (5MG/5ML Oral Solution) Maximum of 60 ml per day

Methylphenidate HCl (Oral Tablet Immediate Release) (Generic Ritalin)


Miglitol (100MG Oral Tablet) Maximum of 3 tablets per day



Modafinil (100MG Oral Tablet) Maximum of 1 tablet per day

105



Modafinil (200MG Oral Tablet) Maximum of 2 tablets per day

Moexipril HCl (Oral Tablet) Maximum of 2 tablets per day

Montelukast Sodium (Oral Packet) Maximum of 1 packet per day

Montelukast Sodium (Oral Tablet) Maximum of 1 tablet per day

Montelukast Sodium (Oral Tablet Chewable) Maximum of 1 tablet per day

Morphine Sulfate (100MG/5ML Oral Solution) Maximum of 10 ml per day

Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Release) (Generic MS Contin)


Morphine Sulfate ER (200MG Oral Tablet Extended Release) (Generic MS Contin)


Morphine Sulfate ER (30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Release) (Generic MS Contin)




Morphine Sulfate (15MG Oral Tablet

Immediate Release)Maximum of 8 tablets per day

Morphine Sulfate (30MG Oral Tablet

Immediate Release)Maximum of 6 tablets per day

Multaq (Oral Tablet) Maximum of 2 tablets per day

Namzaric (Oral Capsule ER 24 Hour Therapy

Pack)Maximum of 1 capsule per day

Namzaric (Oral Capsule Extended Release

24 Hour)Maximum of 1 capsule per day

Naratriptan HCl (Oral Tablet) Maximum of 12 tablets per 30 days

Nateglinide (120MG Oral Tablet) Maximum of 3 tablets per day

Nateglinide (60MG Oral Tablet) Maximum of 6 tablets per day

Nebupent (Inhalation Solution Reconstituted) Maximum of 1 vial (300 mg) per 28 days

Nerlynx (Oral Tablet) Maximum of 6 tablets per day

Nevirapine ER (100MG Oral Tablet Extended Release 24 Hour)


Nevirapine ER (400MG Oral Tablet Extended Release 24 Hour)


Nevirapine (Oral Suspension) Maximum of 40 ml per day

Nevirapine (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Nifedipine ER (Oral Tablet Extended Release 24 Hour)


Nifedipine ER Osmotic Release (Oral Tablet Extended Release 24 Hour)


106



Ninlaro (Oral Capsule) Maximum of 3 capsules per 28 days

Northera (100MG Oral Capsule) Maximum of 3 capsules per day

Northera (200MG Oral Capsule, 300MG Oral

Capsule)Maximum of 6 capsules per day

Norvir (Oral Packet) Maximum of 12 packets per day

Norvir (Oral Solution) Maximum of 16 ml per day

Noxafil (Oral Suspension) Maximum of 20 ml per day

Noxafil (Oral Tablet Delayed Release) Maximum of 6 tablets per day

Nubeqa (Oral Tablet) Maximum of 4 tablets per day

Nucala (Subcutaneous Solution Auto-

Injector)Maximum of 3 ml per 28 days

Nucala (Subcutaneous Solution Prefilled

Syringe)Maximum of 3 ml per 28 days

Nucala (Subcutaneous Solution

Reconstituted)Maximum of 3 vials per 28 days

Nucynta ER (Oral Tablet Extended Release

12 Hour)Maximum of 2 tablets per day

Nuplazid (Oral Capsule) Maximum of 1 capsule per day

Nuplazid (10MG Oral Tablet) Maximum of 1 tablet per day

Ocaliva (Oral Tablet) Maximum of 1 tablet per day

Odefsey (Oral Tablet) Maximum of 1 tablet per day

Odomzo (Oral Capsule) Maximum of 1 capsule per day

Ofev (Oral Capsule) Maximum of 2 capsules per day

Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet)


Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible)


Olmesartan Medoxomil (20MG Oral Tablet, 40MG Oral Tablet)


Olmesartan Medoxomil (5MG Oral Tablet) Maximum of 2 tablets per day

Olmesartan Medoxomil-HCTZ (Oral Tablet) Maximum of 1 tablet per day

Olmesartan-Amlodipine-HCTZ (Oral Tablet) Maximum of 1 tablet per day

Omega-3-Acid Ethyl Esters (Oral Capsule) (Generic Lovaza)


Orkambi (Oral Packet) Maximum of 56 packets per 28 days

Orkambi (Oral Tablet) Maximum of 112 tablets per 28 days

107



Oseltamivir Phosphate (Oral Capsule) Maximum of 2 capsules per day

Oseltamivir Phosphate (Oral Suspension Reconstituted)


Osphena (Oral Tablet) Maximum of 1 tablet per day

Oxandrolone (10MG Oral Tablet) Maximum of 2 tablets per day

Oxandrolone (2.5MG Oral Tablet) Maximum of 4 tablets per day

Oxybutynin Chloride ER (10MG Oral Tablet Extended Release 24 Hour)






Oxycodone HCl (100MG/5ML Oral Concentrate)


Oxycodone HCl (5MG/5ML Oral Solution) Maximum of 130 ml per day

Oxycodone HCl (10MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)


Oxycodone HCl (15MG Oral Tablet Immediate Release)


Oxycodone HCl (20MG Oral Tablet Immediate Release, 30MG Oral Tablet Immediate Release)


Oxycodone-Acetaminophen (10-325MG Oral Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Tablet)


Oxycodone-Aspirin (Oral Tablet) Maximum of 12 tablets per day

Ozempic (0.25 or 0.5MG/DOSE)

(Subcutaneous Solution Pen-Injector)Maximum of 1 pen (1.5 ml) per 28 days

Ozempic (1MG/DOSE) (Subcutaneous

Solution Pen-Injector)Maximum of 2 pens (3 ml) per 28 days

Paliperidone ER (1.5MG Oral Tablet Extended Release 24 Hour, 3MG Oral Tablet Extended Release 24 Hour, 9MG Oral Tablet Extended Release 24 Hour)


Paliperidone ER (6MG Oral Tablet Extended Release 24 Hour)


Pantoprazole Sodium (20MG Oral Tablet Delayed Release)


Pantoprazole Sodium (40MG Oral Tablet Delayed Release)


Pemazyre (Oral Tablet) Maximum of 1 tablet per day

108



Pentamidine Isethionate (Inhalation Solution Reconstituted)

Maximum of 1 vial (300 mg) per 28 days

Pentasa (250MG Oral Capsule Extended

Release)Maximum of 12 capsules per day

Pentasa (500MG Oral Capsule Extended

Release)Maximum of 8 capsules per day

Perforomist (Inhalation Nebulization

Solution)Maximum of 2 vials (4 ml) per day

Perindopril Erbumine (Oral Tablet) Maximum of 2 tablets per day

Pifeltro (Oral Tablet) Maximum of 1 tablet per day

Pioglitazone HCl (15MG Oral Tablet) Maximum of 3 tablets per day

Pioglitazone HCl (30MG Oral Tablet, 45MG Oral Tablet)


Pioglitazone HCl-Glimepiride (Oral Tablet) Maximum of 1 tablet per day

Pioglitazone HCl-Metformin HCl (Oral Tablet) Maximum of 3 tablets per day

Piqray (200MG Daily Dose) (Oral Tablet

Therapy Pack)Maximum of 1 tablet per day


Therapy Pack)Maximum of 2 tablets per day


Therapy Pack)Maximum of 2 tablets per day

Pomalyst (Oral Capsule) Maximum of 1 capsule per day

Posaconazole (Oral Tablet Delayed Release) Maximum of 6 tablets per day

Praluent (Subcutaneous Solution Auto-

Injector)Maximum of 2 pens (2 ml) per 28 days

Prasugrel HCl (Oral Tablet) Maximum of 1 tablet per day

Pravastatin Sodium (Oral Tablet) Maximum of 1 tablet per day

Pregabalin (100MG Oral Capsule, 150MG Oral Capsule, 200MG Oral Capsule, 25MG Oral Capsule, 50MG Oral Capsule, 75MG Oral Capsule)


Pregabalin (225MG Oral Capsule, 300MG Oral Capsule)


Pregabalin (Oral Solution) Maximum of 30 ml per day

Premarin (Oral Tablet) Maximum of 1 tablet per day

Premphase (Oral Tablet) Maximum of 1 tablet per day

Prempro (Oral Tablet) Maximum of 1 tablet per day

Prezcobix (Oral Tablet) Maximum of 1 tablet per day

Prezista (Oral Suspension) Maximum of 2 bottles (400 ml) per 30 days

Prezista (150MG Oral Tablet) Maximum of 6 tablets per day

109



Prezista (600MG Oral Tablet, 75MG Oral


Prezista (800MG Oral Tablet) Maximum of 1 tablet per day

Prolia (Subcutaneous Solution Prefilled

Syringe)Maximum of 1 syringe per 180 days

Promacta (Oral Packet) Maximum of 6 packets per day

Promacta (12.5MG Oral Tablet, 25MG Oral


Promacta (50MG Oral Tablet, 75MG Oral


Pulmozyme (Inhalation Solution) Maximum of 2 ampules (5 ml) per day

Qinlock (Oral Tablet) Maximum of 3 tablets per day

Quetiapine Fumarate ER (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Extended Release 24 Hour)


Quetiapine Fumarate ER (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour)


Quetiapine Fumarate (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Immediate Release, 50MG Oral Tablet Immediate Release)


Quetiapine Fumarate (25MG Oral Tablet Immediate Release)


Quetiapine Fumarate (300MG Oral Tablet Immediate Release, 400MG Oral Tablet Immediate Release)


Quinapril HCl (Oral Tablet) Maximum of 2 tablets per day

Quinapril-Hydrochlorothiazide (10-12.5MG Oral Tablet)


Quinapril-Hydrochlorothiazide (20-12.5MG Oral Tablet, 20-25MG Oral Tablet)


Raloxifene HCl (Oral Tablet) Maximum of 1 tablet per day

Ramelteon (Oral Tablet) Maximum of 1 tablet per day

Ramipril (Oral Capsule) Maximum of 2 capsules per day

Ranolazine ER (Oral Tablet Extended Release 12 Hour)


RAVICTI (Oral Liquid) Maximum of 17.5 ml per day

Rayaldee (Oral Capsule Extended Release) Maximum of 2 capsules per day

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Rebif Rebidose (Subcutaneous Solution


Rebif Rebidose Titration Pack

(Subcutaneous Solution Auto-Injector)Maximum of 1 pack (4.2 ml) per 28 days

Rebif (Subcutaneous Solution Prefilled

Syringe)Maximum of 12 syringes (6 ml) per 28 days

Rebif Titration Pack (Subcutaneous Solution

Prefilled Syringe)Maximum of 1 pack (4.2 ml) per 28 days

Relenza Diskhaler (Inhalation Aerosol

Powder Breath Activated)Maximum of 3 inhalers (60 blisters) per 30 days

Relistor (Oral Tablet) Maximum of 3 tablets per day

Repaglinide (0.5MG Oral Tablet) Maximum of 32 tablets per day

Repaglinide (1MG Oral Tablet) Maximum of 16 tablets per day

Repaglinide (2MG Oral Tablet) Maximum of 8 tablets per day

Repatha Pushtronex System (Subcutaneous

Solution Cartridge)Maximum of 1 cartridge (3.5 ml) per 28 days

Repatha (Subcutaneous Solution Prefilled

Syringe)Maximum of 3 syringes (3 ml) per 28 days

Repatha SureClick (Subcutaneous Solution


Restasis Single-Use Vials (Ophthalmic

Emulsion)Maximum of 2 vials per day

Retevmo (40MG Oral Capsule) Maximum of 6 capsules per day

Retevmo (80MG Oral Capsule) Maximum of 4 capsules per day

Revlimid (Oral Capsule) Maximum of 1 capsule per day

Rexulti (Oral Tablet) Maximum of 1 tablet per day

Reyataz (Oral Packet) Maximum of 6 packets per day

Riomet ER (Oral Suspension Reconstituted

ER)Maximum of 20 ml per day

Riomet (Oral Solution) Maximum of 25.5 ml per day

Risedronate Sodium (150MG Oral Tablet Immediate Release)

Maximum of 1 tablet per 30 days

Risedronate Sodium (30MG Oral Tablet Immediate Release, 5MG Oral Tablet Immediate Release)


Risedronate Sodium (35MG Oral Tablet Immediate Release, 35MG (12 PACK) Oral Tablet Immediate Release, 35MG (4 PACK) Oral Tablet Immediate Release)

Maximum of 4 tablets per 28 days

Ritonavir (Oral Tablet) Maximum of 12 tablets per day

111



Rivastigmine Tartrate (Oral Capsule) Maximum of 2 capsules per day

Rivastigmine (Transdermal Patch 24 Hour) Maximum of 1 patch per day

Rizatriptan Benzoate (Oral Tablet) Maximum of 12 tablets per 30 days

Rizatriptan Benzoate ODT (Oral Tablet Dispersible)


Rosuvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day

Rozlytrek (100MG Oral Capsule) Maximum of 5 capsules per day

Rozlytrek (200MG Oral Capsule) Maximum of 3 capsules per day

Rubraca (Oral Tablet) Maximum of 4 tablets per day

Rukobia (Oral Tablet Extended Release 12

Hour)Maximum of 2 tablets per day

Rybelsus (Oral Tablet) Maximum of 1 tablet per day

Rydapt (Oral Capsule) Maximum of 8 capsules per day

Saphris (Tablet Sublingual) Maximum of 2 tablets per day

Secuado (Transdermal Patch 24 Hour) Maximum of 1 patch per day

Selzentry (Oral Solution) Maximum of 8 bottles (1840 ml) per 30 days

Selzentry (150MG Oral Tablet, 75MG Oral


Selzentry (25MG Oral Tablet, 300MG Oral


Serevent Diskus (Inhalation Aerosol Powder

Breath Activated)

Maximum of 1 inhaler (60 inhalations) per 30 days

Sildenafil Citrate (20MG Oral Tablet) (Generic Revatio)


Silodosin (Oral Capsule) Maximum of 1 capsule per day

Simvastatin (Oral Tablet) Maximum of 1 tablet per day

Sofosbuvir-Velpatasvir (Oral Tablet) Maximum of 1 tablet per day

Solifenacin Succinate (Oral Tablet) Maximum of 1 tablet per day

Soliqua (Subcutaneous Solution Pen-


Somavert (Subcutaneous Solution

Reconstituted)Maximum of 1 vial per day

Sovaldi (150MG Oral Packet) Maximum of 1 carton (28 packets) per 28 days

Sovaldi (200MG Oral Packet) Maximum of 2 cartons (56 packets) per 28 days

Sovaldi (400MG Oral Tablet) Maximum of 1 tablet per day

Spiriva HandiHaler (Inhalation Capsule) Maximum of 1 capsule per day

Spiriva Respimat (Inhalation Aerosol


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Sprycel (100MG Oral Tablet, 140MG Oral


Sprycel (20MG Oral Tablet, 50MG Oral


Sprycel (80MG Oral Tablet) Maximum of 2 tablets per day

Stavudine (Oral Capsule) Maximum of 2 capsules per day

Stiolto Respimat (Inhalation Aerosol


Stivarga (Oral Tablet) Maximum of 4 tablets per day

Stribild (Oral Tablet) Maximum of 1 tablet per day

Suboxone (12-3MG Sublingual Film, 4-1MG

Sublingual Film)Maximum of 2 films per day

Suboxone (2-0.5MG Sublingual Film, 8-2MG

Sublingual Film)Maximum of 3 films per day

Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days

Sumatriptan Succinate (100MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet)


Sumatriptan Succinate Refill (Subcutaneous

Solution Cartridge)Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution)

Maximum of 12 injections (6 ml) per 30 days

Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/0.5ML Subcutaneous Solution Auto-Injector)


Sumatriptan Succinate (6MG/0.5ML

Subcutaneous Solution Auto-Injector)

(Generic Imitrex STATdose)


Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Prefilled Syringe)


Sutent (12.5MG Oral Capsule, 25MG Oral

Capsule, 50MG Oral Capsule)Maximum of 1 capsule per day

Sutent (37.5MG Oral Capsule) Maximum of 2 capsules per day

Symbicort (120 Inhalation Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days

Symfi Lo (Oral Tablet) Maximum of 1 tablet per day

Symfi (Oral Tablet) Maximum of 1 tablet per day

Sympazan (Oral Film) Maximum of 2 films per day

Symtuza (Oral Tablet) Maximum of 1 tablet per day

Synjardy (Oral Tablet Immediate Release) Maximum of 2 tablets per day

113



Synjardy XR (10-1000MG Oral Tablet




Synjardy XR (12.5-1000MG Oral Tablet




Tabrecta (Oral Tablet) Maximum of 4 tablets per day

Tadalafil (PAH) (20MG Oral Tablet) Maximum of 2 tablets per day

Tagrisso (Oral Tablet) Maximum of 1 tablet per day

Talzenna (0.25MG Oral Capsule) Maximum of 3 capsules per day

Talzenna (1MG Oral Capsule) Maximum of 1 capsule per day

Tasigna (150MG Oral Capsule) Maximum of 5 capsules per day



Tazverik (Oral Tablet) Maximum of 8 tablets per day

Tecfidera (Oral Capsule Delayed Release) Maximum of 2 capsules per day

Telmisartan (Oral Tablet) Maximum of 1 tablet per day

Telmisartan-Amlodipine (Oral Tablet) Maximum of 1 tablet per day

Telmisartan-HCTZ (40-12.5MG Oral Tablet, 80-25MG Oral Tablet)


Telmisartan-HCTZ (80-12.5MG Oral Tablet) Maximum of 2 tablets per day

Temazepam (15MG Oral Capsule, 30MG Oral Capsule)


Tenofovir Disoproxil Fumarate (Oral Tablet) Maximum of 1 tablet per day

Teriparatide (Recombinant) (Subcutaneous

Solution Pen-Injector)Maximum of 1 pen (2.48 ml) per 28 days

Tetrabenazine (12.5MG Oral Tablet) Maximum of 3 tablets per day

Tetrabenazine (25MG Oral Tablet) Maximum of 4 tablets per day

Thalomid (100MG Oral Capsule, 50MG Oral

Capsule)Maximum of 1 capsule per day

Thalomid (150MG Oral Capsule, 200MG Oral

Capsule)Maximum of 2 capsules per day

Tibsovo (Oral Tablet) Maximum of 2 tablets per day

Tivicay (10MG Oral Tablet, 25MG Oral


Tivicay (50MG Oral Tablet) Maximum of 2 tablets per day

Tivicay PD (Oral Tablet Soluble) Maximum of 6 tablets per day

TOBI Podhaler (Inhalation Capsule) Maximum of 8 capsules per day

Tobramycin (Inhalation Nebulization Solution) Maximum of 2 ampules (10 ml) per day

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Tolcapone (Oral Tablet) Maximum of 6 tablets per day

Tracleer (Oral Tablet Soluble) Maximum of 8 tablets per day

Tradjenta (Oral Tablet) Maximum of 1 tablet per day

Tramadol HCl ER (Biphasic) (Oral Tablet Extended Release 24 Hour)


Tramadol HCl ER (Oral Tablet Extended Release 24 Hour)


Tramadol HCl (50MG Oral Tablet Immediate Release)


Tramadol-Acetaminophen (Oral Tablet) Maximum of 8 tablets per day

Trandolapril (1MG Oral Tablet, 2MG Oral Tablet)


Trandolapril (4MG Oral Tablet) Maximum of 2 tablets per day

Trelegy Ellipta (Inhalation Aerosol Powder


Trezix (Oral Capsule) Maximum of 10 capsules per day

Trientine HCl (Oral Capsule) Maximum of 8 capsules per day

Trintellix (Oral Tablet) Maximum of 1 tablet per day

Triumeq (Oral Tablet) Maximum of 1 tablet per day

Trulicity (Subcutaneous Solution Pen-


Truvada (Oral Tablet) Maximum of 1 tablet per day

Tukysa (150MG Oral Tablet) Maximum of 4 tablets per day

Tukysa (50MG Oral Tablet) Maximum of 12 tablets per day

Turalio (Oral Capsule) Maximum of 4 capsules per day

Tybost (Oral Tablet) Maximum of 1 tablet per day

Tymlos (Subcutaneous Solution Pen-Injector) Maximum of 1.56 ml per 30 days

Valacyclovir HCl (1GM Oral Tablet) Maximum of 4 tablets per day

Valacyclovir HCl (500MG Oral Tablet) Maximum of 2 tablets per day

Valganciclovir HCl (50MG/ML Oral Solution Reconstituted)


Valganciclovir HCl (450MG Oral Tablet) Maximum of 4 tablets per day

Valsartan (160MG Oral Tablet, 40MG Oral Tablet, 80MG Oral Tablet)


Valsartan (320MG Oral Tablet) Maximum of 1 tablet per day

Valsartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day

Valtoco 10 MG Dose (Nasal Liquid)Maximum of 10 blister packs (10 spray devices) per 30 days

115



Valtoco 15 MG Dose (Nasal Liquid Therapy

Pack)

Maximum of 10 blister packs (20 spray devices) per 30 days

Valtoco 20 MG Dose (Nasal Liquid Therapy

Pack)

Maximum of 10 blister packs (20 spray devices) per 30 days

Valtoco 5 MG Dose (Nasal Liquid)Maximum of 10 blister packs (10 spray devices) per 30 days

Vancomycin HCl (125MG Oral Capsule) Maximum of 4 capsules per day

Vancomycin HCl (250MG Oral Capsule) Maximum of 8 capsules per day

Veltassa (Oral Packet) Maximum of 1 packet per day

Vemlidy (Oral Tablet) Maximum of 1 tablet per day

Venclexta (100MG Oral Tablet) Maximum of 6 tablets per day

Venclexta (10MG Oral Tablet) Maximum of 2 tablets per day

Venclexta (50MG Oral Tablet) Maximum of 1 tablet per day

Ventavis (10MCG/ML Inhalation Solution) Maximum of 7 ml per day

Ventavis (20MCG/ML Inhalation Solution) Maximum of 3 ml per day

Verzenio (Oral Tablet) Maximum of 2 tablets per day

Victoza (Subcutaneous Solution Pen-Injector) Maximum of 3 pens (9 ml) per 30 days

Vigabatrin (Oral Packet) Maximum of 6 packets per day

Vigabatrin (Oral Tablet) Maximum of 6 tablets per day

Vigadrone (Oral Packet) Maximum of 6 packets per day

Viibryd (Oral Tablet) Maximum of 1 tablet per day

Viibryd Starter Pack (Oral Kit) Maximum of 1 pack (30 tablets) per 30 days

Vimpat (Oral Solution) Maximum of 40 ml per day

Vimpat (Oral Tablet) Maximum of 2 tablets per day

Viracept (250MG Oral Tablet) Maximum of 10 tablets per day

Viracept (625MG Oral Tablet) Maximum of 4 tablets per day

Viread (Oral Powder) Maximum of 4 bottles (240 grams) per 30 days

Viread (150MG Oral Tablet, 200MG Oral


Vitrakvi (100MG Oral Capsule) Maximum of 4 capsules per day

Vitrakvi (25MG Oral Capsule) Maximum of 6 capsules per day

Vitrakvi (Oral Solution) Maximum of 20 ml per day

Vizimpro (Oral Tablet) Maximum of 1 tablet per day

Vosevi (Oral Tablet) Maximum of 1 tablet per day

Votrient (Oral Tablet) Maximum of 4 tablets per day

Vraylar (1.5MG Oral Capsule, 3MG Oral

Capsule, 4.5MG Oral Capsule, 6MG Oral

Capsule)


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Vyndamax (Oral Capsule) Maximum of 1 capsule per day

Vyndaqel (Oral Capsule) Maximum of 4 capsules per day

Wixela Inhub (Inhalation Aerosol Powder Breath Activated) (Generic Advair)

Maximum of 1 inhaler (60 blisters) per 30 days

Xarelto (10MG Oral Tablet, 20MG Oral


Xarelto (15MG Oral Tablet, 2.5MG Oral


Xarelto Starter Pack (Oral Tablet Therapy

Pack)Maximum of 1 pack (51 tablets) per 30 days

Xcopri (250 MG Daily Dose) (Oral Tablet


Xcopri (350 MG Daily Dose) (Oral Tablet


Xcopri (100MG Oral Tablet, 50MG Oral


Xcopri (150MG Oral Tablet, 200MG Oral


Xcopri (Oral Tablet Titration Therapy Pack) Maximum of 1 pack (28 tablets) per 28 days

Xeljanz (Oral Tablet Immediate Release) Maximum of 2 tablets per day

Xeljanz XR (Oral Tablet Extended Release 24

Hour)Maximum of 1 tablet per day

Xiidra (Ophthalmic Solution) Maximum of 2 vials per day

Xofluza (40 MG Dose) (Oral Tablet Therapy

Pack)Maximum of 2 tablets per 30 days

Xofluza (80 MG Dose) (Oral Tablet Therapy

Pack)Maximum of 2 tablets per 30 days

Xospata (Oral Tablet) Maximum of 3 tablets per day

Xpovio (100MG Once Weekly) (Oral Tablet

Therapy Pack)Maximum of 20 tablets per 28 days

Xpovio (40 MG Once Weekly) (Oral Tablet


Xpovio (40 MG Twice Weekly) (Oral Tablet




Xpovio (60 MG Twice Weekly) (Oral Tablet




117



Xpovio (80MG Twice Weekly) (Oral Tablet


Xtampza ER (13.5MG Oral Capsule ER 12

Hour Abuse-Deterrent, 18MG Oral Capsule

ER 12 Hour Abuse-Deterrent, 9MG Oral

Capsule ER 12 Hour Abuse-Deterrent)


Xtampza ER (27MG Oral Capsule ER 12 Hour

Abuse-Deterrent, 36MG Oral Capsule ER 12

Hour Abuse-Deterrent)


Xtandi (Oral Capsule) Maximum of 4 capsules per day

Xyrem (Oral Solution) Maximum of 18 ml per day

Yuvafem (Vaginal Tablet) Maximum of 1 tablet per day

Zafirlukast (Oral Tablet) Maximum of 2 tablets per day

Zaleplon (10MG Oral Capsule) Maximum of 2 capsules per day

Zaleplon (5MG Oral Capsule) Maximum of 1 capsule per day

Zejula (Oral Capsule) Maximum of 3 capsules per day

Zelboraf (Oral Tablet) Maximum of 8 tablets per day

Zidovudine (Oral Capsule) Maximum of 6 capsules per day

Zidovudine (Oral Syrup) Maximum of 64 ml per day

Zidovudine (Oral Tablet) Maximum of 2 tablets per day

Ziprasidone HCl (Oral Capsule) Maximum of 2 capsules per day

Zolpidem Tartrate (Oral Tablet Immediate Release)


Zydelig (Oral Tablet) Maximum of 2 tablets per day

Zykadia (Oral Tablet) Maximum of 3 tablets per day

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C3. Over-the-counter (OTC) Drug List

UnitedHealthcare Senior Care Options covers some prescription OTC drugs that aren’t normally covered under our Medicare Part D benefit.

You need a prescription from your doctor to have drugs on this list covered. If your prescription is for a brand name drug, you will get the generic version of the drug if it’s available. Your doctor should write “no substitution” on the prescription to get the brand name drug.

Some of these drugs may need prior authorization. Please check with your doctor and the plan. If the drug requires a prior authorization, you or your doctor will need to get approval from the plan before the drug may be covered.

The list below shows the prescription OTC drugs covered by the plan.

tRACK

OTC Drug Name OTC Drug Name C1

Analgesics Acetaminophen/Extra Strength (Tablet) C1

Analgesics Aminofen (Tablet) C1

8 Hour Arthritis Pain Reliever (Tablet Apap (Elixir) C1 Extended-Release)

Apra (Elixir) C1 8 Hour Pain Relief (Tablet Extended-

Arthritis Pain (Tablet Extended-Release) Release) C1

Arthritis Pain Relief (Tablet Extended-8 Hour Pain Reliever (Tablet Extended-Release) Release) C1

Arthritis Pain Reliever (Tablet Extended-8 Hr Arthritis Pain Relief (Tablet Extended-Release) Release) C1

Betatemp Children's (Suspension) 8Hr Muscle Aches & Pain (Tablet C1

Chewable Acetaminophen Children's Extended-Release) (Tablet Chewable) Acephen (Suppository)

C1

Children's Acetaminophen (Suspension) Acetaminophen (160mg/5ml Liquid, C1

Children's Apap (Tablet Chewable) 160mg/5ml Solution, 120mg Suppository, C1

650mg Suppository, 325mg Tablet) Children's Chewable Acetaminophen (Tablet Chewable) Acetaminophen Children's (Suspension)

C1

Children's Medi-Tabs (Tablet Chewable) Acetaminophen ER (Tablet Extended-C1

Release) Children's Pain Reliever (Tablet Chewable) C1

Acetaminophen Extra Strength (Tablet) Children's Pain Reliever (Tablet Disintegrating) Acetaminophen Infants (Suspension)

C1

Children's Silapap (Liquid) Acetaminophen Junior Strength (Tablet C1

Disintegrating) Children's Tactinal (Tablet Chewable) C1

Acetaminophen Rapid Tabs Children's Chloraseptic Sore Throat (Liquid) (Tablet Disintegrating)


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OTC Drug NameC1

CVS 8Hr Arthritis Pain Relief (Tablet Extended-Release)

C1

CVS 8Hr Muscle Aches & Pain (Tablet Extended-Release)

C1

CVS Acetaminophen (Liquid)C1

CVS Acetaminophen Extra Strength (Tablet)

C1

CVS Arthritis Pain Relief (Tablet Extended-Release)

C1

CVS Children's Pain Relief (Suspension)C1

CVS Fever Reducing Children's (Suppository)

C1

CVS Infants Pain Relief (Suspension)C1

CVS Pain & Fever Children's (Suspension)C1

CVS Pain & Fever Infants (Suspension)C1

CVS Pain Relief 8 Hour (Tablet Extended-Release)

C1

CVS Pain Relief Adult/Rapid Burst (Liquid)C1

CVS Pain Relief Children's (Suspension)C1

CVS Pain Relief Children's (Tablet Chewable)

C1

CVS Pain Relief Extra Strength (Tablet)C1

CVS Pain Relief Regular Strength (Capsule)

C1

CVS Pain Relief Regular Strength (Tablet)C1

ED-Apap (Liquid)C1

EQ 8Hr Arthritis Pain Relief (Tablet Extended-Release)

C1

EQ Acetaminophen (Tablet)C1

EQ Acetaminophen Children's (Suspension)

C1

EQ Acetaminophen Children's (Tablet Disintegrating)

C1

EQ Acetaminophen Extra Strength (Tablet)C1

EQ Acetaminophen Junior (Tablet Disintegrating)

OTC Drug NameC1

EQ Arthritis Pain (Tablet Extended-Release)

C1

EQ Children's Pain Reliever (Tablet Chewable)

C1

EQ Pain & Fever Children's (Suspension)C1

EQ Pain & Fever Children's (Tablet Chewable)

C1

EQ Pain & Fever Infants (Suspension)C1

EQ Pain Relief Adult/Rapid Burst (Liquid)C1

EQ Pain Reliever (Tablet)C1

EQ Pain Reliever Junior (Tablet Chewable)C1

EQL Acetaminophen (Tablet Disintegrating)

C1

EQL Acetaminophen (Tablet)C1

EQL Acetaminophen Children's (Suspension)

C1

EQL Acetaminophen Extra Strength (Tablet)

C1

EQL Acetaminophen Infants (Suspension)C1

EQL Acetaminophen Rapid Tabs (Tablet Disintegrating)

C1

EQL Arthritis Pain Relief (Tablet Extended-Release)

C1

Extra Strength Pain Relief (Tablet)C1

Fever Reducer Children's (Suppository)C1

Feverall Adults (Suppository)C1

Feverall Children's (Suppository)C1

Feverall Infants (Suppository)C1

Feverall Junior Strength (Suppository)C1

GNP 8 Hour Pain Reliever (Tablet Extended-Release)

C1

GNP Acetaminophen (Tablet)C1

GNP Acetaminophen Extra Strength (Capsule)

C1

GNP All Day Pain Relief (Tablet)C1

GNP Arthritis Pain Relief (Tablet Extended-Release)

120


OTC Drug NameC1

GNP Children's Easy-Melts (Tablet Disintegrating)

C1

GNP Children's Pain Relief (Suspension)C1

GNP Infants Pain Relief (Suspension)C1

GNP Infants Pain/Fever (Suspension)C1

GNP Pain & Fever Children's (Suspension)C1

GNP Pain Relief (160mg Tablet Chewable, 325mg Tablet)

C1

GNP Pain Relief Extra Strength (167mg/5ml Liquid, 500mg Tablet)

C1

GNP Pain Reliever Extra Strength (Tablet)C1

Goodsense Arthritis Pain (Tablet Extended-Release)

C1

Goodsense Pain & Fever Children's (Suspension)

C1

Goodsense Pain & Fever Infants (Suspension)

C1

Goodsense Pain Relief (Tablet Extended-Release)

C1

Goodsense Pain Relief Extra Strength (Tablet)

C1

Healthy Mama Shake That Ache (Tablet)C1

HM Acetaminophen Children's (Tablet Chewable)

C1

HM Arthritis Pain Relief (Tablet Extended-Release)

C1

HM Pain & Fever Children's (Suspension)C1

HM Pain & Fever Infants (Suspension)C1

HM Pain Relief (Tablet Extended-Release)C1

HM Pain Relief Extra Strength (Tablet)C1

HM Pain Reliever (Tablet)C1

HM Rapid Melts Junior (Tablet)C1

Infants Pain & Fever (Suspension)C1

KLS Acetaminophen Extra Strength (Tablet)

C1

KLS Rapid Release Pain Reliever (Tablet)C1

Liquid Pain Relief (Liquid)

OTC Drug NameC1

Little Remedies Fever/Pain Reliever Children's (Liquid)

C1

Little Remedies For Fevers Fever/Pain Reliever Children's (Liquid)

C1

Little Remedies For Fevers Fever/Pain Reliever Infant (Liquid)

C1

Mapap (500mg Capsule, 80mg Tablet Chewable, 160mg/5ml Liquid, 325mg Tablet, 500mg Tablet)

C1

Mapap Acetaminophen Extra Strength (Liquid)

C1

Mapap Arthritis Pain (Tablet Extended-Release)

C1

Mapap Children's (Suspension)C1

Mapap Children's (Tablet Chewable)C1

Mapap Children's (Tablet)C1

Mapap Extra Strength (Tablet)C1

Maxapap Maximum Strength (Tablet)C1

Maxapap Regular Strength (Tablet)C1

Medi-Tabs Children's (Elixir)C1

Medi-Tabs Extra Strength (Tablet)C1

Medi-Tabs Junor Strength (Tablet Chewable)

C1

Midol (Tablet Extended-Release)C1

Non-Aspirin Children's (Suspension)C1

Nortemp (Suspension)C1

Nortemp Infants (Suspension)C1

Pain & Fever (Tablet)C1

Pain & Fever Children's (Solution)C1

Pain & Fever Children's (Suspension)C1

Pain & Fever Children's (Tablet Chewable)C1

Pain & Fever Children's Dye-Free (Suspension)

C1

Pain & Fever Children's/Dye-Free (Suspension)

C1

Pain & Fever Extra Strength (Tablet)

121


OTC Drug NameC1

Pain & Fever Infants (Suspension)C1

Pain Relief (325mg Tablet, 500mg Tablet)C1

Pain Relief 8 Hour (Tablet Extended-Release)

C1

Pain Relief Children's (Suspension)C1

Pain Relief Extra Strength (Tablet)C1

Pain Relief Regular Strength (Tablet)C1

Pain Reliever (Liquid)C1

Pain Reliever (Tablet)C1

Pain Reliever Extra Strength (Tablet)C1

Pain Reliever/Fever Reducer Children's (Suppository)

C1

Pediacare Children (Suspension)C1

Pediacare Fever Reducer/Pain Reliever/Infant (Suspension)

C1

Pediacare Infants (Suspension)C1

Pharbetol (Tablet)C1

Pharbetol Extra Strength (Tablet)C1

PX Arthritis Pain Relief (Tablet Extended-Release)

C1

PX Children's Pain Relief (Suspension)C1

PX Pain Relief Extra Strength (Tablet)C1

QC Acetaminophen 8 Hours (Tablet Extended-Release)

C1

QC Arthritis Pain Relief (Tablet Extended-Release)

C1

QC Non-Aspirin Children's (Suspension)C1

QC Non-Aspirin Extra Strength (Tablet)C1

QC Non-Aspirin Jr Strength (Tablet)C1

QC Pain Relief (Tablet)C1

QC Pain Relief Children's (Suspension)C1

QC Pain Relief Extra Strength (Tablet)C1

QC Pain Relief Infants (Suspension)C1

RA 8 Hour Pain Relief (Tablet Extended-Release)

C1

RA Acetaminophen (Tablet)

OTC Drug NameC1

RA Acetaminophen Children's (Tablet Chewable)

C1

RA Acetaminophen ER (Tablet Extended-Release)

C1

RA Acetaminophen Extra Strength (Tablet)C1

RA Acetaminophen Rapid Melts Children's (Tablet Disintegrating)

C1

RA Acetaminophen Rapid Melts Junior (Tablet Disintegrating)

C1

RA Arthritis Pain Relief (Tablet Extended-Release)

C1

RA Arthritis Pain Relief Acetaminophen (Tablet Extended-Release)

C1

RA Fever Reducer & Pain Reliever Infants (Suspension)

C1

RA Fever Reducer/Pain Reliever Children's (Suspension)

C1

RA Fever Reducer/Pain Reliever Infants (Suspension)

C1

RA Pain Relief Acetaminophen (Tablet)C1

RA Pain Reliever Extra Strength Adult (Liquid)

C1

SB Arthritis Pain Relief (Tablet Extended-Release)

C1

SB Pain Reliever Children's (Suspension)C1

SB Pain Reliever Extra Strength (Tablet)C1

SM 8 Hour Pain Relief (Tablet Extended-Release)

C1

SM Arthritis Pain Relief (Tablet Extended-Release)

C1

SM Arthritis Pain Reliever (Tablet Extended-Release)

C1

SM Pain & Fever Children's (Suspension)C1

SM Pain & Fever Infants (Suspension)C1

SM Pain Relief Extra Strength (Tablet)C1

SM Pain Reliever (Tablet)

122


OTC Drug NameC1

SM Pain Reliever Extra Strength (500mg Capsule, 500mg Tablet, 650mg Tablet Extended-Release)

C1

SM Rapid Melts Junior (Tablet)C1

Tactinal (Tablet)C1

Tactinal Extra Strength (Tablet)C1

TGT Acetaminophen Children's (Suspension)

C1

TGT Acetaminophen Extra Strength (Tablet)

C1

TGT Acetaminophen Extra Strength Quick Release (Tablet)

C1

TGT Acetaminophen Melts Children's (Tablet Disintegrating)

C1

TGT Arthritis Pain Relief (Tablet Extended-Release)

C1

TGT Children's Acetaminophen (Suspension)

C1

TGT Pain Reliever Jr Strength Melts (Tablet Disintegrating)

B1

Analgesics, TopicalC1

Arthritis Pain Relieving (Cream)C1

Aspercreme Warming Pain Relief Patch (Pad)

C1

Capsagel (Gel)C1

Capsagel Extra Strength (Gel)C1

Capsagel Maximum Strength (Gel)C1

Capsaicin (Cream)C1

Capsaicin Hot Patch (Pad)C1

Capsaicin HP (Cream)C1

Capzasin-HP (Cream)C1

Capzasin-P (Cream)C1

Castiva Warming (Lotion)C1

CVS Capsaicin HP (Cream)C1

CVS Medicated Heat Patch (Pad)C1

GNP Capsaicin (0.1% Cream)

OTC Drug NameC1

GNP Capsaicin (0.15% Liquid)C1

RA Capsicum Hot Patch (Pad)C1

Sure Result Sr Relief (Cream)C1

Zostrix High Potency (Cream)C1

Zostrix High Potency Footpain Relief (Cream)

C1

Zostrix Natural Pain Relief (Cream)C1

Zostrix-HPB1

Non-Steroidal Anti Inflammatory Drugs (NSAIDs)

C1

Adult Aspirin Regimen (Tablet)C1

Addaprin (Tablet)C1

Adult Aspirin EC Low Strength (Tablet Delayed-Release)

C1

Advil Junior Strength (Tablet)C1

All Day Pain Relief (Tablet)C1

All Day Relief (Tablet)C1

Aspirin (120mg Suppository, 200mg Suppository, 300mg Suppository, 600mg Suppository, 325mg Tablet, 325mg Tablet Delayed-Release, 81mg Tablet Delayed-Release)

C1

Aspirin (81mg Tablet Chewable)C1

Aspirin 81 (Tablet Delayed-Release)C1

Aspirin 81 Low Dose (Tablet Chewable)C1

Aspirin Adult (Tablet)C1

Aspirin Adult Low Dose (81mg Tablet Chewable, 81mg Tablet Delayed-Release)

C1

Aspirin Adult Low Strength (Tablet Chewable)

C1

Aspirin Children's (Tablet Chewable)C1

Aspirin DR (Tablet Delayed-Release)C1

Aspirin EC (Tablet Delayed-Release)C1

Aspirin EC Low Dose (Tablet Delayed-Release)

C1

Aspirin Enteric Coated Adult Low Strength (Tablet Delayed-Release)

123


OTC Drug NameC1

Aspirin Low Dose (Tablet Chewable)C1

Aspirin Low Dose (Tablet Delayed-Release)C1

Aspirin Low Strength (Tablet Chewable)C1

Aspirin Regimen Low Dose/Adult (Tablet Delayed-Release)

C1

Aspirin Regular Strength (Tablet Delayed-Release)

C1

Aspir-Low (Tablet Delayed-Release)C1

Aspirtab (Tablet Delayed-Release)C1

Aspirtab Maximum Strength (Tablet)C1

Bayer Advanced Aspirin Extra Strength

(Tablet)C1

Bayer Advanced Aspirin Regular Strength (Tablet)

C1

Bayer Aspirin (Tablet Delayed-Release)C1

Bayer Aspirin (Tablet)C1

Bayer Aspirin EC Low Dose (Tablet Delayed-Release)

C1

Bayer Aspirin Extra Strength (Tablet)C1

Bayer Low Dose (Tablet Delayed-Release)C1

Bayer Plus (Tablet)C1

Careall Aspirin (Tablet Chewable)C1

Children's Aspirin (Tablet Chewable)C1

Children's Aspirin Free (Elixir)C1

Children's Aspirin Low Strength (Tablet Chewable)

C1

Children's Non-Aspirin (Suspension)C1

Children's Non-Aspirin (Tablet Chewable)C1

CVS All Day Pain Relief (Tablet)C1

CVS Aspirin (Tablet Delayed-Release)C1

CVS Aspirin (Tablet)C1

CVS Aspirin Adult Low Dose (Tablet Chewable)

C1

CVS Aspirin Adult Low Strength (Tablet Delayed-Release)

C1

CVS Aspirin Ec (Tablet Delayed-Release)

OTC Drug NameC1

CVS Aspirin Low Dose (Tablet Delayed-Release)

C1

CVS Aspirin Low Strength (Tablet Delayed-Release)

C1

CVS Childs Non-Aspirin (Tablet Chewable)C1

CVS Ibuprofen (Capsule)C1

CVS Ibuprofen (Tablet)C1

CVS Ibuprofen IB (Tablet)C1

CVS Ibuprofen Infants (Suspension)C1

CVS Ibuprofen Junior Strength (Tablet Chewable)

C1

CVS Ibuprofen Liquid Filled (Capsule)C1

CVS Naproxen Sodium (Capsule)C1

CVS Naproxen Sodium (Tablet)C1

CVS Non-Aspirin Children's (Tablet Chewable)

C1

CVS Non-Aspirin Extra Strength (Tablet)C1

Dyspel (Tablet)C1

EC-81 Aspirin (Tablet Delayed-Release)C1

Ecotrin (Tablet Delayed-Release)C1

Ecotrin Low Strength (Tablet Delayed-Release)

C1

Ecotrin Maximum Strength (Tablet

Delayed-Release)C1

Ecpirin (Tablet Delayed-Release)C1

Enovarx-Ibuprofen (Cream)C1

Enteric Coated Aspirin (Tablet Delayed-Release)

C1

EQ Adult Aspirin Low Strength (Tablet Delayed-Release)

C1

EQ All Day Pain Relief (Tablet)C1

EQ Aspirin (Tablet Delayed-Release)C1

EQ Aspirin Adult Low Dose (Tablet Delayed-Release)

C1

EQ Aspirin EC (Tablet Delayed-Release)C1

EQ Aspirin Low Dose (Tablet Chewable)

124


OTC Drug NameC1

EQ Aspirin Low Dose (Tablet Delayed-Release)

C1

EQ Children's Aspirin (Tablet Chewable)C1

EQ Ibuprofen (Capsule)C1

EQ Ibuprofen (Tablet)C1

EQ Ibuprofen Infants (Suspension)C1

EQ Ibuprofen Junior Strength (Tablet Chewable)

C1

EQ Naproxen Sodium (Capsule)C1

EQ Naproxen Sodium (Tablet)C1

EQL Aspirin (Tablet)C1

EQL Aspirin EC (Tablet Delayed-Release)C1

EQL Aspirin Low Dose (Tablet Chewable)C1

EQL Aspirin Low Dose (Tablet Delayed-Release)

C1

EQL Ibuprofen (Capsule)C1

EQL Ibuprofen (Tablet)C1

EQL Ibuprofen Infants (Suspension)C1

EQL Ibuprofen Junior Strength (Tablet Chewable)

C1

EQL Naproxen Sodium (Capsule)C1

EQL Naproxen Sodium (Tablet)C1

Flanax Pain Relief (Tablet)C1

Genpril (Tablet)C1

GNP Adult Aspirin Low Strength (Tablet Chewable)

C1

GNP Aspirin (325mg Tablet, 81mg Tablet Delayed-Release, 325mg Delayed-Release)

C1

GNP Aspirin Low Dose (Tablet Delayed-Release)

C1

GNP Ibuprofen (200mg Capsule, 200mg Tablet)

C1

GNP Ibuprofen Infants (Suspension)C1

GNP Ibuprofen Junior Strength (Tablet Chewable)

C1

GNP Naproxen (Tablet)

OTC Drug NameC1

GNP Naproxen Sodium (220mg Capsule, 220mg Tablet)

C1

Goodsense Aspirin (81mg Tablet Chewable, 325mg Tablet)

C1

Goodsense Aspirin Adult Low Strength (Tablet Chewable)

C1

Goodsense Aspirin Low Dose (Tablet Delayed-Release)

C1

Goodsense Ibuprofen (Tablet)C1

Goodsense Ibuprofen Infants (Suspension)C1

Goodsense Ibuprofen Junior Strength (Tablet Chewable)

C1

Goodsense Naproxen Sodium (Tablet)C1

H-E-B Aspirin (Tablet Delayed-Release)C1

HM Aspirin (81mg Tablet Chewable, 325mg Tablet)

C1

HM Aspirin EC (Tablet Delayed-Release)C1

HM Aspirin EC Low Dose (Tablet Delayed-Release)

C1

HM Ibuprofen (Capsule)C1

HM Ibuprofen (Tablet Chewable)C1

HM Ibuprofen (Tablet)C1

HM Ibuprofen IB (Tablet)C1

HM Ibuprofen IB/Junior Strength (Tablet Chewable)

C1

HM Ibuprofen Infants (Suspension)C1

HM Naproxen Sodium (220mg Capsule, 220mg Tablet)

C1

Hy-Vee All Day Relief (Tablet)C1

Ibu-200 (Tablet)C1

Ibu-Drops Infants (Suspension)C1

Ibuprofen (200mg Capsule, 200mg Tablet)C1

Ibuprofen 100 Junior Strength (Tablet Chewable)

C1

Ibuprofen 200 (Tablet)C1

Ibuprofen Infants (Suspension)

125


OTC Drug NameC1

Ibuprofen Infants Drops (Suspension)C1

Ibuprofen Junior Strength (Tablet Chewable)

C1

Ibuprofen Lysine (Solution)C1

Infants Ibuprofen (Suspension)C1

I-Prin (Tablet)C1

KLS Aspirin EC (Tablet Delayed-Release)C1

KLS Aspirin Low Dose (Tablet Delayed-Release)

C1

KLS Ibuprofen (Tablet)C1

KLS Naproxen Sodium (Tablet)C1

KP Aspirin (Tablet Delayed-Release)C1

KS Ibuprofen (Capsule)C1

Medi-Profen (Capsule)C1

Medi-Profen (Suspension)C1

Medi-Profen (Tablet)C1

Mediproxen (Tablet)C1

Medique Aspirin (Tablet)C1

Meijer Aspirin EC (Tablet Delayed-Release)C1

Meijer Aspirin Free (Tablet)C1

Meijer Ibuprofen (Tablet)C1

Meijer Jr Strength Aspirin Free (Tablet Chewable)

C1

Miniprin Low Dose (Tablet Delayed-Release)

C1

MM Aspirin (Tablet)C1

Motrin IB (Capsule)C1

Naproxen Sodium (Capsule)C1

Naproxen Sodium (Tablet)C1

Naproxen Sodium CR (Tablet Extended-Release)

C1

Naproxen Sodium ER (Tablet Extended-Release)

C1

Non-Aspirin (Tablet)C1

Non-Aspirin Extra Strength (Tablet)

OTC Drug NameC1

Non-Aspirin Junior Strength (Tablet Chewable)

C1

Non-Aspirin Pain Relief (Tablet)C1

Non-Aspirin Pain Relief Extra Strength (Tablet)

C1

Norwich Aspirin (Tablet)C1

Pamprin All Day Maximum Strength (Tablet)

C1

Provil (Tablet)C1

PX All Day Relief (Tablet)C1

PX Aspirin (Tablet Chewable)C1

PX Aspirin (Tablet)C1

PX Enteric Aspirin (Tablet Delayed-Release)

C1

PX Ibuprofen (Tablet)C1

PX Ibuprofen Junior Strength (Tablet Chewable)

C1

PX Infants Profen IB (Suspension)C1

QC Aspirin (Tablet)C1

QC Aspirin Low Dose (Tablet Delayed-Release)

C1

QC Chewable Aspirin Low Dose (Tablet Chewable)

C1

QC Children's Aspirin (Tablet Chewable)C1

QC Enteric Aspirin (Tablet Delayed-Release)

C1

QC Ibuprofen (Tablet)C1

QC Ibuprofen IB (Tablet)C1

QC Ibuprofen Infants (Suspension)C1

QC Naproxen Sodium (Tablet)C1

QC Non-Aspirin 8 Hour (Tablet Extended-Release)

C1

RA Aspirin (Tablet)C1

RA Aspirin Adult Low Dose (Tablet Chewable)

C1

RA Aspirin Adult Low Strength (Tablet Chewable)

126


OTC Drug NameC1

RA Aspirin Children's (Tablet Chewable)C1

RA Aspirin EC (Tablet Delayed-Release)C1

RA Aspirin EC Adult Low Strength (Tablet Delayed-Release)

C1

RA Children's Aspirin (Tablet Chewable)C1

RA Children's Non-Aspirin (Suspension)C1

RA Ibuprofen (Capsule)C1

RA Ibuprofen (Tablet)C1

RA Ibuprofen Infants (Suspension)C1

RA Ibuprofen Junior Strength (Tablet Chewable)

C1

RA Naproxen Sodium (Capsule)C1

RA Naproxen Sodium (Tablet)C1

RA Pain Relief Aspirin (Tablet)C1

RA Pain Relief Ibuprofen (Tablet)C1

SB Aspirin (Tablet)C1

SB Aspirin Adult Low Strength (Tablet Delayed-Release)

C1

SB Aspirin EC (Tablet Delayed-Release)C1

SB Children's Aspirin (Tablet Chewable)C1

SB Children's Non-Aspirin (Tablet Disintegrating)

C1

SB Ibuprofen (Tablet)C1

SB Infants Ibuprofen (Suspension)C1

SB Low Dose ASA EC (Tablet Delayed-Release)

C1

SB Naproxen Sodium (Tablet)C1

SB Non-Aspirin (Tablet Chewable)C1

SB Non-Aspirin (Tablet)C1

SB Non-Aspirin Extra Strength (Tablet)C1

SB Non-Aspirin Jr Strength (Tablet Disintegrating)

C1

SM Aspirin (Tablet)C1

SM Aspirin Adult Low Strength (81mg Tablet Chewable, 81mg Tablet Delayed-Release)

OTC Drug NameC1

SM Aspirin EC Low Strength (Tablet Delayed-Release)

C1

SM Aspirin Enteric Coated (Tablet Delayed-Release)

C1

SM Aspirin Low Dose (Tablet Chewable)C1

SM Children's Aspirin (Tablet Chewable)C1

SM Ibuprofen (200mg Capsule, 200mg Tablet)

C1

SM Ibuprofen IB (100mg Tablet Chewable, 200mg Tablet)

C1

SM Ibuprofen Jr (Tablet)C1

SM Infants Ibuprofen (Suspension)C1

SM Naproxen Sodium (Tablet)C1

St Joseph Aspirin (Tablet Delayed-Release)C1

St Joseph Low Dose Aspirin (Tablet Chewable)

C1

TGT Aspirin (Tablet Chewable)C1

TGT Aspirin (Tablet Delayed-Release)C1

TGT Aspirin (Tablet)C1

TGT Aspirin Low Dose (Tablet Delayed-Release)

C1

TGT Children's Aspirin (Tablet Chewable)C1

TGT Enteric-Coated Aspirin (Tablet Delayed-Release)

C1

TGT Ibuprofen (Capsule)C1

TGT Ibuprofen (Tablet)C1

TGT Ibuprofen Junior Strength (Tablet Chewable)

C1

TGT Infants Ibuprofen (Suspension)C1

TGT Naproxen Sodium (Capsule)C1

TGT Naproxen Sodium (Tablet)C1

Wal-Profen (Capsule)C1

Wal-Profen (Tablet)A1

Anti-Addiction/Substance Abuse Treatment Agents

B1

Smoking Cessation Agents

127


OTC Drug NameC1

CVS Nicotine (Gum)C1

CVS Nicotine Lozenge (Lozenge)C1

CVS Nicotine Polacrilex (Gum)C1

CVS Nicotine Polacrilex (Lozenge)C1

CVS Nicotine Polacrilex Starter (Gum)C1

CVS Nicotine Transdermal System (Patch)C1

CVS Nicotine Transdermal System Step 1 (Patch)

C1

CVS Nicotine Transdermal System Step 2 (Patch)

C1

CVS Nicotine Transdermal System/Step 3 (Patch)

C1

EQ Nicotine (Lozenge)C1

EQ Nicotine (Patch)C1

EQ Nicotine Gum Refill (Gum)C1

EQ Nicotine Gum Starter (Gum)C1

EQ Nicotine Lozenges (Lozenge)C1

EQ Nicotine Polacrilex (Gum)C1

EQ Nicotine Polacrilex (Lozenge)C1

EQ Nicotine Step 3 (Patch)C1

EQL Nicotine Polacrilex (Gum)C1

EQL Nicotine Polacrilex (Lozenge)C1

GNP Nicotine Gum (Gum)C1

GNP Nicotine Mini Lozenge (Lozenge)C1

GNP Nicotine Polacrilex (Gum)C1

GNP Nicotine Polacrilex (Lozenge)C1

GNP Nicotine Polacrilex Mini (Lozenge)C1

GNP Nicotine Transdermal System (Patch)C1

GNP Nicotine Transdermal System Step 2 (Patch)

C1

Goodsense Nicotine (Lozenge)C1

Goodsense Nicotine Gum (Gum)C1

Goodsense Nicotine Polacrilex (Lozenge)C1

HM Nicotine Polacrilex (Gum)C1

HM Nicotine Polacrilex (Lozenge)

OTC Drug NameC1

HM Nicotine Transdermal System (Patch)C1

HM Nicotine Transdermal System Step 1 (Patch)

C1


C1


C1

KLS Quit2 (Gum)C1

KLS Quit2 (Lozenge)C1

KLS Quit4 (Gum)C1

KLS Quit4 (Lozenge)C1

Nicorelief (Gum)C1

Nicotine (Gum)C1

Nicotine (Lozenge)C1

Nicotine (Patch)C1

Nicotine Mini Lozenge (Lozenge)C1

Nicotine Polacrilex (Gum)C1

Nicotine Polacrilex (Lozenge)C1

Nicotine Polacrilex Refill (Gum)C1

Nicotine Polacrilex Starter Kit (Gum)C1

Nicotine Step 1 (Patch)C1



Nicotine Transdermal System (Patch)C1

Nicotine Transdermal System Step 1 (Patch)

C1


C1


C1

PX Stop Smoking Aid (Gum)C1

PX Stop Smoking Aid (Lozenge)C1

RA Mini Nicotine (Lozenge)C1

RA Nicotine (Gum)C1

RA Nicotine (Patch)

128


OTC Drug NameC1

RA Nicotine Gum (Gum)C1

RA Nicotine Polacrilex (Gum)C1

RA Nicotine Polacrilex (Lozenge)C1

RA Nicotine Transdermal System (Patch)C1

RA Nicotine Transdermal System Step 3 (Patch)

C1

SM Nicotine (Gum)C1

SM Nicotine (Lozenge)C1

SM Nicotine Polacrilex (Gum)C1

SM Nicotine Polacrilex (Lozenge)C1

SM Nicotine Transdermal System (Patch)C1

SM Nicotine Transdermal System/Step 1/Clear (Patch)

C1


C1


C1

Sr Nicotine Gum (Gum)C1

TGT Nicotine Gum (Gum)C1

TGT Nicotine Polacrilex (Gum)C1

TGT Nicotine Polacrilex (Lozenge)C1

TGT Nicotine Step One (Patch)C1

TGT Nicotine Step Three (Patch)C1

TGT Nicotine Step Two (Patch)C1

Thrive (Gum)A1

Antimicrobial AgentsB1

Antimicrobials, TopicalC1

Alevazol (Ointment)C1

Aloe Vesta Clear Antifungal (Ointment)C1

Antibiotic + Pain Relief Maximum Strength (Cream)

C1

Antifungal (1% Aerosol, 1% Cream, 2% Cream)

C1

Anti-Fungal Powder (Powder)C1

Antiseptic Skin Cleanser (Solution)C1

Aplicare Povidone/Iodine (Solution)

OTC Drug NameC1

Aplicare Povidone-Iodine Scrub (Solution)C1

Athletes Foot Antifungal Powder Spray (Aerosol Powder)

C1

Athletes Foot Powder (Powder)C1

Athletes Foot Powder Spray (Aerosol Powder)

C1

Athletes Foot Spray (Aerosol)C1

Bacitracin (Ointment)C1

Bacitracin Zinc (Ointment)C1

Bacitracin/Neomycin/Polymyxin (Ointment)

C1

Bacitracin/Polymyxin (Ointment)C1

Bacitraycin Plus (Ointment)C1

Band-Aid Plus Antibiotic (Pad)C1

Band-Aid Plus Antibiotic/Extra Large

(Pad)C1

Baza Antifungal (Cream)C1

Betadine (Solution)C1

Betadine Surgical Scrub (Solution)C1

Betadine Swabsticks (Swab)C1

Betasept Surgical Scrub (Liquid)C1

Biopatch Antimicrobial Dressing/1"

Disk/4Mm Hole C1

Biopatch Antimicrobial Dressing/1"

Disk/7Mm Hole C1

Biopatch Antimicrobial Dressing/3/4"

Disk/1.5Mm Hole C1

Biopatch Protective Disk With Chg/

1"Disk/4Mm Hole C1

Blis-To-Sol (Solution)C1

Carrington Antifungal (Cream)C1

Cavilon (Cream)C1

Chlorhexidine Gluconate (2% Liquid,

20% Solution)C1

Chlorhexidine Gluconate Cloth (Pad)C1

Clorox Nasal Antiseptic Swabs (Swabs)

129


OTC Drug NameC1

Clotrimazole-7 (Cream)C1

Critic-Aid Clear AF (Ointment)C1

Cruex Prescription Strength (Aerosol Powder)

C1

Curad Triple Antibiotic (Ointment)C1

CVS 3-Day Vaginal Cream (Cream)C1

CVS Af Spray Powder (Aerosol Powder)C1

CVS Antibiotic (Ointment)C1

CVS Antibiotic Plus (Cream)C1

CVS Antifungal (Cream)C1

CVS Anti-Fungal Powder (Powder)C1

CVS Antiseptic Skin Cleanser (Solution)C1

CVS Athletes Foot Powder Spray (Aerosol Powder)

C1

CVS Bacitracin (Ointment)C1

CVS Clotrimazole 3 (Cream)C1

CVS Foot & Sneaker Powder Spray (Aerosol Powder)

C1

CVS Hand Wash Advanced Antibacterial (Solution)

C1

CVS Hydrogen Peroxide (Solution)C1

CVS Peroxide Sore Mouth Cleanser (Solution)

C1

CVS Poly Bacitracin (Ointment)C1

CVS Povidone-Iodine (Solution)C1

CVS Triple Antibiotic (Ointment)C1

Dermafungal (Ointment)C1

Desenex (Powder)C1

Desenex Jock Itch Spray Powder (Aerosol Powder)

C1

Desenex Shake Powder (Powder)C1

Double Antibiotic (Ointment)C1

Dr G's Clear Nail (Solution)C1

Dyna-Hex 2 (Solution)C1

Dyna-Hex 4 (Solution)

OTC Drug NameC1

Ear Dry (Liquid)C1

EQ Antibiotic + Pain Relief Maximum Strength (Cream)

C1

EQ Athletes Foot (Aerosol Powder)C1

EQ Athletes Foot (Cream)C1

EQ Athletes Foot Powder Spray (Aerosol Powder)

C1

EQ Bacitracin Zinc (Ointment)C1

EQ First Aid Antiseptic (Solution)C1

EQ Hydrogen Peroxide (Solution)C1

EQ Povidone-Iodine (Solution)C1

EQ Tolnaftate (Aerosol)C1

EQ Triple Antibiotic (Ointment)C1

EQL Antibiotic + Pain Relief Maximum Strength (Cream)

C1

EQL Antifungal (Cream)C1

EQL Bacitracin Zinc (Ointment)C1

EQL First Aid Antibiotic (Ointment)C1

EQL Hydrogen Peroxide (Solution)C1

First Aid Antibiotic (Ointment)C1

Foot Repair Serum (Solution)C1

Fungal Nail Eraser (Solution)C1

Fungi-Guard (Cream)C1

Fungoid Tincture (2% Kit, 2% Solution)C1

Fungoid-D (Cream)C1

GNP Antibiotic Plus Pramoxine (Cream)C1

GNP Antiseptic Skin Cleanser (Solution)C1

GNP Athlete's Foot Relief (Aerosol Powder)C1

GNP Bacitracin Zinc (Ointment)C1

GNP Hydrogen Peroxide (Solution)C1

GNP Hydrogen Peroxide Wipes C1

GNP Iodides Tincture (Tincture)C1

GNP Iodine Tincture (Tincture)C1

GNP Miconazole Nitrate (Aerosol Powder)

130


OTC Drug NameC1

GNP Miconazorb AF (Powder)C1

GNP Povidone-Iodine (Solution)C1

GNP Tolnaftate (Cream)C1

GNP Triple Antibiotic (Ointment)C1

Goodsense Hydrogen Peroxide (Solution)C1

HM Antiseptic Skin Cleanser (Solution)C1

HM Bacitracin (Ointment)C1

HM Double Antibiotic (Ointment)C1

HM Hydrogen Peroxide (Solution)C1

HM Iodides Tincture (Tincture)C1

HM Iodine Tincture (Tincture)C1

HM Povidone-Iodine (Solution)C1

HM Triple Antibiotic (Ointment)C1

Hydrogen Peroxide (Solution)C1

Hydrogen Peroxide Spray (Solution)C1

Hylamend First Aid Antiseptic (Gel)C1

Instaclean (Liquid)C1

Iodex (Ointment)C1

Iodides Tincture (Tincture)C1

Iodine Tincture (Tincture)C1

Iodine Tincture Mild (Tincture)C1

Iodine Tincture Strong (Tincture)C1

Iodine Tincture Strong Decolorized

(Tincture)C1

Iso-Blu (Liquid)C1

Isopropyl Alcohol Spray C1

Jock Itch Spray (Aerosol Powder)C1

Jock Itch Spray Powder (Aerosol Powder)C1

Kelp (Tablet)C1

KP Bacitracin Zinc (Ointment)C1

KP Double Antibiotic (Ointment)C1

KP Miconazole Nitrate (Cream)C1

KP Tolnaftate (Cream)C1

Lamisil AF Defense (Aerosol Powder)

OTC Drug NameC1

Lanabiotic (Ointment)C1

Lotrimin AF (Aerosol)C1

Lotrimin AF Deodorant Powder (Aerosol Powder)

C1

Lotrimin AF Jock Itch Powder (Aerosol Powder)

C1

Lotrimin AF Powder (Aerosol Powder)C1

Lugols Strong Iodine (Tincture)C1

Medicated Anti-Fungal (Solution)C1

Medi-First Triple Antibiotic (Ointment)C1

Meijer Hydrogen Peroxide (Solution)C1

Meijer Triple Antibiotic (Ointment)C1

Micaderm (Cream)C1

Miconazole (Cream)C1

Miconazole Antifungal (Cream)C1

Miconazole Nitrate (Cream)C1

Micro Guard (Powder)C1

Multi Antibiotic Plus (Cream)C1

Mycocide Clinical NS Antifungal Treatment (Solution)

C1

Odor Control Foot & Sneaker Spray (Aerosol Powder)

C1

Odor Eaters Antifungal (Powder)C1

Odor Eaters Foot & Sneaker Spray (Aerosol Powder)

C1

Operand Chlorhexidine Gluconate (Liquid)C1

Perox-A-Mint (Solution)C1

Peroxyl Oral Spot Treatment (Gel)C1

Podactin (Cream)C1

Podactin Powder (Powder)C1

Poly Bacitracin (Ointment)C1

Polysporin (Ointment)C1

Povidone Iodine (Solution)C1

Povidone/Iodine Swabsticks (Swabs)

131


OTC Drug NameC1

Povidone-Iodine (10% Ointment, 10% Solution)

C1

Povidone-Iodine Antiseptic (Swabs)C1

Povidone-Iodine Antiseptic Swabsticks (Swabs)

C1

Povidone-Iodine Paint Sponge Swabstick (Swabs)

C1

PVP Prep (Solution)C1

PX Hydrogen Peroxide (Solution)C1

PX Triple Ointment (Ointment)C1

QC Bacitracin (Ointment)C1

QC Hydrogen Peroxide (Solution)C1

QC Iodides Tincture (Tincture)C1

QC Iodine Tincture (Tincture)C1

QC Povidone Iodine (Solution)C1

QC Tolnaftate (Cream)C1

RA Antibiotic Plus (Cream)C1

RA Antifungal (Cream)C1

RA Antifungal Spray (Aerosol)C1

RA Antiseptic (Solution)C1

RA Antiseptic Skin Cleanser (Solution)C1

RA Athletes Foot (Cream)C1

RA Athletes Foot Powder Spray (Aerosol Powder)

C1

RA Bacitracin (Ointment)C1

RA Bacitracin Zinc First Aid (Ointment)C1

RA Clotrimazole 3 (Cream)C1

RA Clotrimazole 7 (Cream)C1

RA Double Antibiotic (Ointment)C1

RA First Aid Iodine (Tincture)C1

RA Foot Care Antifungal (Cream)C1

RA Hydrogen Peroxide (Solution)C1

Ra Hydrogen Peroxide Wipes C1

RA Jock Itch Maximum Strength Powder (Aerosol Powder)

OTC Drug NameC1

RA Povidone Iodine (Ointment)C1

RA Triple Antibiotic (Ointment)C1

RA Triple Antibiotic Spray (Aerosol)C1

Remedy Antifungal (Cream)C1

Remedy Antifungal Clear/Phytoplex (Ointment)

C1

Remedy Phytoplex Antifungal (Powder)C1

SB Anti-Fungal (Cream)C1

SB Bacitracin (Ointment)C1

SB Povidone-Iodine (Solution)C1

SB Triple Antibiotic (Ointment)C1

Secura Antifungal (Cream)C1

Secura Antifungal Extra Thick (Cream)C1

SM Antibiotic (Ointment)C1

SM Antibiotic Plus Pain Relief Maximum Strength (Cream)

C1

SM Antifungal Miconazole (Cream)C1

SM Antifungal Tolnaftate (Cream)C1

SM Double Antibiotic (Ointment)C1

SM Hydrogen Peroxide (Solution)C1

SM Iodides Tincture (Tincture)C1

SM Iodine Tincture (Tincture)C1

SM Povidone-Iodine (Solution)C1

SM Swimmers Ear Drops (Otic Solution)C1

SM Triple Antibiotic (Ointment)C1

SM Triple Antibiotic Original Strength (Ointment)

C1

Soothe & Cool Inzo Antifungal Cream (Cream)

C1

Soothe (Tablet Chewable)C1

Swim Ear (Liquid)C1

Swimmers Ear Drops (Otic Solution)C1

Swimmers Instant Ear Dry (Otic Solution)C1

Tegaderm Chg Dressing/2-3/4"X3-3/8" C1

Tegaderm Chg Dressing/3-1/2"X4-1/2"

132


OTC Drug NameC1

Tegaderm Chg Dressing/4"X4-3/4" C1

Tegaderm Chg Dressing/4"X6-1/8" C1

Tetterine (Ointment)C1

TGT Antifungal (Cream)C1

TGT Antifungal Spray Powder (Aerosol Powder)

C1

TGT First Aid Antibiotic Maximum Strength (Cream)

C1

TGT Hydrogen Peroxide (Solution)C1

The Treatment Formula 3 (Solution)C1

Tinaspore (Solution)C1

Tineacide (Cream)C1

Tolnaftate (1% Cream, 1% Powder)C1

Triple Antibiotic (Ointment)C1

Triple Antibiotic First Aid (Ointment)C1

Triple Paste AF (Ointment)C1

Wal-Sporin (Ointment)C1

Zeasorb-AF (Powder)B1

Antimicrobials, VaginalC1

3 Day Vaginal (Cream)C1

Clotrimazole (Cream)C1

Clotrimazole 3 (Cream)C1

GNP Clotrimazole 3 (Cream)C1

SM 3-Day Vaginal (Cream)C1

SM Clotrimazole Vaginal (Cream)A1

AntiparasiticsB1

Anthelmintic AgentsC1

CVS Pinworm Treatment (Suspension)C1

Pinworm Medicine (Suspension)C1

Reeses Pinworm Medicine (144mg/ml Suspension)

C1

Reeses Pinworm Medicine (180mg

Tablet)B1

Pediculicides/ScabicidesC1

Bedding Spray Lice Treat Ment (Aerosol)

OTC Drug NameC1

Bedding Spray Lice Treatment Step 3 (Aerosol)

C1

CVS Bedding Spray Lice Treatment (Aerosol)

C1

CVS Lice Killing (Shampoo)C1

CVS Lice Treatment (Rinse)C1

EQ Lice Killing Maximum Strength (Shampoo)

C1

EQL Lice Killing Maximum Strength (Shampoo)

C1

GNP Lice Bedding (Aerosol)C1

GNP Lice Treatment (1% Rinse, 0.33-4% Shampoo)

C1

HM Lice Killing Maximum Strength (Shampoo)

C1

HM Lice Treatment (Rinse)C1

Lice Killing Maximum Strength (Shampoo)C1

Lice Killing Shampoo (Shampoo)C1

Lice Treatment (Lotion)C1

Lice Treatment Creme Rinse (Liquid)C1

LiceMD Complete Kit (Gel)C1

Licide (Aerosol)C1

Licide Maximum Strength (Liquid)C1

RA Lice Bedding (Aerosol)C1

RA Lice Maximum Strength (Shampoo)C1

RA Lice Treatment (Lotion)C1

Rid Lice Killing Shampoo (Shampoo)C1

SB Lice Killing Maximum Strength (Shampoo)

C1

SB Lice Treatment (Liquid)C1

SB Lice Treatment (Rinse)C1

SM Bedding Lice Treatment (Aerosol)C1

SM Lice Killing (Liquid)C1

SM Lice Killing Maximum Strength (Shampoo)

C1

SM Lice Treatment (Lotion)

133


OTC Drug NameC1

Stop Lice (Aerosol)C1

Stop Lice Maximum Strength (Liquid)C1

Stop Lice Step 3 (Aerosol)C1

TGT Lice Killing Maximum Strength (Shampoo)

C1

Vanalice (Gel)A1

Dermatological AgentsB1

Dermatologic Agents, TopicalC1

Acne Maximum Strength (Cream)C1

Acne Foaming Wash (Liquid)C1

Acne Medication 10 (Gel)C1

Acne Medication 10 (Lotion)C1

Acne Medication 5 (Gel)C1

Acne Medication 5 (Lotion)C1

Acne Treatment Cleansing Bar Maximum Strength

C1

Acne Treatment Gel (Gel)C1

Acne-Clear (Gel)C1

Acnefree 24 Hour Acne Clearing System C1

Acnefree Severe 24 Hour Clearing

System C1

Advanced Acne Wash (Liquid)C1

Anti-Dandruff Shampoo (Lotion)C1

Anti-Itch Intensive Healing (Lotion)C1

Aquanil HC (Lotion)C1

Baby Diaper Rash Cream (Cream)C1

Baby Ease (Ointment)C1

Baby Vitamin A & D (Ointment)C1

Baza Clear (Ointment)C1

Benzefoam (Foam)C1

Benzefoam Ultra (Foam)C1

Benzefoamultra (Foam)C1

Benzepro (Foam)C1

Benzepro Creamy Wash (Liquid)C1

Benzepro Foaming Cloths (Cloth)

OTC Drug NameC1

Benzepro Short Contact (Foam)C1

Benziq (Gel)C1

Benziq LS (Gel)C1

Benziq Wash (Liquid)C1

Benzoyl Peroxide (5% Gel)C1

Benzoyl Peroxide (5.3% Foam, 9.8% Foam, 10% Gel, 2.5% Gel, 6.5% Gel)

C1

Benzoyl Peroxide Cleanser (3% Lotion,

9% Lotion)C1

Benzoyl Peroxide Cleanser (Liquid)C1

Benzoyl Peroxide Wash (10% Liquid, 5% Liquid)

C1

Beta HC (Lotion)C1

Boudreauxs Butt Paste Maximum Strength (Ointment)

C1

BP Foam (5.3% Foam, 9.8% Foam)C1

BP Foaming Wash (Liquid)C1

BP Gel (Gel)C1

BP Wash (2.5% Liquid, 7% Liquid)C1

BPO (4% Gel, 8% Gel)C1

BPO 6% Foaming Cloths C1

BPO Creamy Wash Complete Pack (Cream)

C1

BPO Foaming Cloths C1

Calamine (Lotion)C1

Clean & Clear Continuous Control Acne Cleanser (Cream)

C1

Clearasil Daily Clear Vanishing Acne Treatment (Cream)

C1

Clearskin (Cream)C1

Corticool (Gel)C1

Cortizone-10 (Gel)C1

Cortizone-10 Diabetics Skin (Lotion)C1

Cortizone-10 Eczema (Lotion)C1

Cortizone-10 Hydratensivehealing (Lotion)

134


OTC Drug NameC1

Cortizone-10 Hydratensivesoothing (Lotion)

C1

Cottontails Diaper Rash (Ointment)C1

Cottontails Diaper Rash Creamy W/Vitamin E (Ointment)

C1

Curad Vitamin A & D (Ointment)C1

CVS Acne (Cream)C1

CVS Acne Cleansing Bar C1

CVS Acne Control Cleanser (Cream)C1

CVS Acne Foaming Face Wash (Liquid)C1

CVS Acne Treatment/Maximum Strength (Gel)

C1

CVS Advanced 3-In-1 Exfoliating Cleanser (Liquid)

C1

CVS Anti-Dandruff (Lotion)C1

CVS Cortisone Maximum Strength (Gel)C1

CVS Creamy Acne Face Wash (Liquid)C1

CVS Diaper Rash (Ointment)C1

CVS Eczema Relief (Cream)C1

CVS Foaming Acne Face Wash (Liquid)C1

CVS Hydrocortisone Anti-Itch (Cream)C1

CVS Medicated Pads (Pad)C1

CVS Medicated Wipes (Pad)C1

CVS Petroleum Jelly (Gel)C1

CVS Quick Relief Diaper Rash Cream (Cream)

C1

CVS Targeted Acne Spot Treatment (Cream)

C1

CVS Vitamin A&D Ointment (Ointment)C1

CVS Witch Hazel (Liquid)C1

CVS Zinc Oxide (Ointment)C1

Daily Care Skin Protectant (Ointment)C1

Dandruff Shampoo (Lotion)C1

Delbase Compounding (Ointment)C1

Dermarest Eczema (Lotion)

OTC Drug NameC1

Desitin (Cream)C1

Desitin Rapid Relief (Cream)C1

Diaper Rash (Ointment)C1

Diaper Rash Paste (Paste)C1

Dickinsons Witch Hazel (Liquid)C1

Effaclar Duo (Solution)C1

EQ Diaper Rash (Ointment)C1

EQ Hemorrhoidal Pads (Pad)C1

EQ Hygienic Cleansing Wipes (Pad)C1

EQ Petroleum Jelly (Gel)C1

EQ Vitamins A & D (Ointment)C1

EQL Baby Basics Diaper Rash (Ointment)C1

EQL Medicated Dandruff (Lotion)C1

EQL Witch Hazel (Solution)C1

Eucerin Eczema Relief (Cream)C1

GNP Acne Treatment Maximum Strength (Cream)

C1

GNP Diaper Rash (Cream)C1

GNP Diaper Rash Creamy (Ointment)C1

GNP Hydrocortisone (Cream)C1

GNP Hydro-Lotion (Lotion)C1

GNP Hygienic Cleansing (Pad)C1

GNP Hygienic Cleansing Pads (Pad)C1

GNP Medicated Wipes (Pad)C1

GNP Petroleum Jelly (Gel)C1

GNP Soothing Bath Treatment (Packet)C1

GNP Zinc Oxide (Ointment)C1

Goodsense Petroleum Jelly (Gel)C1

Gynecort 10 (Cream)C1

Hemorrhoidal (Pad)C1

Hemorrhoidal Hygiene Pads (Pad)C1

HM Medicated Cooling Pads (Pad)C1

HM Petroleum Jelly (Gel)C1

HM Witch Hazel (Liquid)

135


OTC Drug NameC1

Hydrocortisone (0.5% Cream, 0.5% Ointment)

C1

Hydrocortisone Acetate (Cream)C1

Hydrophilic (Ointment)C1

Hydroskin (Lotion)C1

Instacort 5 (Cream)C1

Invisible Acne Treatment (Cream)C1

KP Benzoyl Peroxide (Gel)C1

KP Benzoyl Peroxide Wash (Liquid)C1

Lanacort 10 (Cream)C1

Lanolin Hydrous-GRX (Ointment)C1

Lan-O-Soothe (Cream)C1

Medicated Cleansing Pads (Pad)C1

Medicated Wipes Pre-Moistened (Pad)C1

Medi-First Hydrocortisone (Cream)C1

Medi-Pads (Pad)C1

Meijer Calamine (Lotion)C1

Meijer Zinc Oxide (Ointment)C1

MG217 Psoriasis Anti-Itch (Gel)C1

Natural Oatmeal Bath Treatment (Packet)C1

Neutrogena Clear Pore Cleanser/Mask C1

Neutrogena On-The-Spot Acne

Treatment (Cream)C1

Noble Formula HC (Solution)C1

OC8 (Gel)C1

Occluvan (Ointment)C1

Panoxyl (Liquid)C1

Panoxyl Creamy Wash (Liquid)C1

Panoxyl Foaming Wash (Liquid)C1

Panoxyl Wash (Liquid)C1

Panoxyl-4 Creamy Wash (Liquid)C1

Petrolatum (Ointment)C1

Petrolatum White (Gel)C1

Petroleum Jelly (Gel)

OTC Drug NameC1

Pinxav (Ointment)C1

PR Benzoyl Peroxide Wash (Liquid)C1

Pre-Moistened Witch Hazel (Pad)C1

Preparation H (Pad)C1

Preparation H For Women (Pad)C1

Preparation H Totables (Pad)C1

QC Calamine (Lotion)C1

QC Medicated Pads Pre-Moistened (Pad)C1

QC Witch Hazel (Liquid)C1

RA Acne Treatment (Cream)C1

RA Baby Care Vitamins A&D to Go (Ointment)

C1

RA Dandruff Shampoo (Lotion)C1

RA Daylogic Acne Foaming Wash Maximum Strength (Foam)

C1

RA Diaper Rash (Ointment)C1

RA First Aid Anti-Itch Spray (Solution)C1

RA Hemorrhoid Relief Medicated Wipes Maximum Strength (Pad)

C1

RA Medicated Wipes Pre-Moistened (Pad)C1

RA Petroleum Jelly (Gel)C1

RA Renewal Dandruff Shampoo (Lotion)C1

RA Renewal Dandruff Shampoo Clinical (Lotion)

C1

RA Renewal Eczema Moisturizing Cream (Cream)

C1

RA Renewal Soothing Bath Treatment (Packet)

C1

RA Tugaboos Creamy Petroleum Jelly/Shea Butter (Gel)

C1

RA Tugaboos Petroleum Jelly (Gel)C1

RA Vanishing Acne Treatment/Maximum Strength (Cream)

C1

RA Vitamin A & D (Ointment)C1

RA Vitamins A & D (Ointment)C1

RA Witch Hazel (Solution)

136


OTC Drug NameC1

RA Zinc Oxide (Ointment)C1

Riax (5.5% Foam, 9.5% Foam)C1

Sarnol-HC (Lotion)C1

Scalp Relief Maximum Strength (Solution)C1

Scalpicin Maximum Strength (Solution)C1

Secura Protective (Cream)C1

Selenium Sulfide (Shampoo)C1

Selenium Sulfide Shampoo (Shampoo)C1

Skin Protectant Moisture Barrier (Cream)C1

SM Calamine (Lotion)C1

SM Hydrocortisone (Cream)C1

SM Hydrocortisone (Ointment)C1

SM Medicated Wipes (Pad)C1

SM Oatmeal Bath (Packet)C1

SM Petroleum Jelly (Gel)C1

SM Witch Hazel (Liquid)C1

SM Witch Hazel (Solution)C1

Spot Acne Treatment (Cream)C1

TGT Medicated Hemorrhoidal Pads (Pad)C1

TGT Medicated Wipe/Witch Hazel/Aloe (Pad)

C1

Tippy Toes Diaper Rash (Ointment)C1

TN Dickinsons Witch Hazel (Liquid)C1

TN Dickinsons Witch Hazel Cleansing Pads (Pad)

C1

TN Dickinsons Witch Hazel Hemorrhoidal (Pad)

C1

Vagisil (Cream)C1

Vaseline (Gel)C1

Vaseline Pure Ultra White Petroleum Jelly (Gel)

C1

Vitamin A (Tablet)C1

White Petrolatum (Gel)C1

White Petrolatum (Ointment)C1

White Petroleum Jelly (Gel)

OTC Drug NameC1

Witch Hazel (Solution)C1

Zaclir Cleansing (Lotion)C1

Zinc Oxide (Ointment)A1

Gastrointestinal AgentsB1

AntacidsC1

Acid Controller (Tablet)C1

Acid Controller Original Strength (Tablet)C1

Acid Reducer (10mg Tablet, 75mg Tablet)C1

Acidophilus (Capsule)C1

Acidophilus (Tablet Chewable)C1

Acidophilus (Tablet)C1

Acidophilus (Wafer)C1

Acidophilus Extra Strength (Capsule)C1

Acidophilus Lactobacilli (Capsule)C1

Acidophilus Probiotic (Capsule)C1

Acidophilus Probiotic (Tablet)C1

Acidophilus Probiotic Formula (Tablet)C1

Acidophilus With Bifidus (Tablet Chewable)

C1

Acidophilus/Bifidus (Wafer)C1

Acidophilus/L-Sporogenes Extra Strength (Tablet)

C1

Acidophilus/Pectin (Capsule)C1

Align (Capsule)C1

Aluminum Hydroxide C1

Antacid (Tablet Chewable)C1

Antacid Calcium Extra Strength (Tablet Chewable)

C1

Antacid Calcium Regular Strength (Tablet Chewable)

C1

Antacid Extra Strength (Tablet Chewable)C1

Antacid Flavor Chews (Tablet Chewable)C1

Antacid Maximum (Tablet Chewable)C1

Antacid Ultra Strength (Tablet Chewable)C1

Calcium Antacid (Tablet Chewable)

137


OTC Drug NameC1

Calcium Antacid Extra Strength (Tablet Chewable)

C1

Calcium Antacid Ultra Maximum Strength (Tablet Chewable)

C1

Calcium Antacid Ultra Strength (Tablet Chewable)

C1

Calcium Carbonate (Suspension)C1

Calcium Carbonate (Tablet Chewable)C1

Calcium Carbonate (Tablet)C1

Calcium Carbonate Extra Strength (Tablet Chewable)

C1

Cal-Gest Antacid (Tablet Chewable)C1

Children's Pepto (Tablet Chewable)C1

Children's Soothe (Tablet Chewable)C1

CVS Acid Controller (Tablet)C1

CVS Acid Reducer (Tablet)C1

CVS Acidophilus (Capsule)C1

CVS Acidophilus Probioticformula (Tablet)C1

CVS Antacid & Anti-Gas Fast Relief (Tablet Chewable)

C1

CVS Antacid Extra (Tablet Chewable)C1

CVS Antacid Extra Strength (Tablet Chewable)

C1

CVS Antacid Kids (Tablet Chewable)C1

CVS Antacid Maximum Strength (Tablet Chewable)

C1

CVS Antacid Supreme (Suspension)C1

CVS Antacid Ultra Strength (Tablet Chewable)

C1

CVS Chewy Not Chalky Flavor Chews (Tablet Chewable)

C1

CVS Probiotic Acidophilus (Capsule)C1

CVS Smooth Antacid Extra Strength (Tablet Chewable)

C1

EQ Acid Reducer (Tablet)C1

EQ Antacid (Tablet Chewable)

OTC Drug NameC1

EQ Antacid Extra Strength (Tablet Chewable)

C1

EQ Antacid Ultra Strength (Tablet Chewable)

C1

EQL Acid Reducer (Tablet)C1

EQL Antacid (Tablet Chewable)C1

EQL Antacid Extra Strength (Tablet Chewable)

C1

EQL Antacid Ultra Strength (Tablet Chewable)

C1

Famotidine (Tablet)C1

Florajen Acidophilus (Capsule)C1

Freeze Dried Acidophilus (Capsule)C1

Geri-Lanta Supreme (Suspension)C1

GNP Acid Reducer (10mg Tablet, 75mg Tablet)

C1

GNP Antacid & Anti-Gas Maximum Strength (Tablet Chewable)

C1

GNP Antacid (Tablet Chewable)C1

GNP Antacid Extra Strength (Tablet Chewable)

C1

GNP Antacid Ultra Strength (Tablet Chewable)

C1

GNP Heartburn Relief (Tablet)C1

Goodsense Acid Reducer (Tablet)C1

Healthy Mama Tame The Flame (Tablet Chewable)

C1

Heartburn Relief (10mg Tablet, 75mg Tablet, 200mg Tablet)

C1

HM Acid Reducer (Tablet)C1

HM Acidophilus Probiotic Formula (Tablet)C1

HM Calcium Antacid (Tablet Chewable)C1

HM Calcium Antacid Extra Strength (Tablet Chewable)

C1

HM Calcium Antacid Smooth Dissolve (Tablet Chewable)

138


OTC Drug NameC1

HM Calcium Antacid Smooth Dissolve Extra Strength (Tablet Chewable)

C1

HM Calcium Antacid Ultra Strength (Tablet Chewable)

C1

HM Famotidine (Tablet)C1

KLS Acid Reducer (Tablet)C1

Long Lasting Antacid (Tablet Chewable)C1

Maalox Children's (Tablet Chewable)C1

Mi-Acid (Tablet Chewable)C1

More-Dophilus Acidophilus (Powder)C1

Probiotic Acidophilus (Capsule)C1

Probiotic Acidophilus Super Strength (Tablet)

C1

PX Acid Reducer (Tablet)C1

PX Antacid Extra Strength (Tablet Chewable)

C1

PX Antacid Maximum Strength (Tablet Chewable)

C1

PX Calcium Antacid Regular Strength (Tablet Chewable)

C1

QC Acid Controller (Tablet)C1

QC Antacid (Tablet Chewable)C1

QC Antacid Extra Strength (Tablet Chewable)

C1

RA Acid Reducer (Tablet)C1

RA Acidophilus (Capsule)C1

RA Antacid (Tablet Chewable)C1

RA Antacid Extra Strength (Tablet Chewable)

C1

RA Antacid Ultra Strength (Tablet Chewable)

C1

RA Multihealth Fiber Supplement (Powder)C1

RA Probiotic Digestive Care (Capsule)C1

RA Probiotic Gummies (Tablet Chewable)C1

RA Saline Enema (Enema)C1

RA Senna (Capsule)

OTC Drug NameC1

RA Senna (Tablet)C1

RA Smooth Antacid Extra Strength (Tablet Chewable)

C1

RA Stomach Relief Kids (Tablet Chewable)C1

Ranitidine 75 (Tablet)C1

Ranitidine Acid Reducer (Tablet)C1

Rolaids (Tablet Chewable)C1

SB Acid Controller (Tablet)C1

SB Acid Reducer (Tablet)C1

SB Acid Reducer Ranitidine 75 (Tablet)C1

SB Antacid (Tablet Chewable)C1

SB Antacid Extra Strength (Tablet Chewable)

C1

SM Acid Reducer (10mg Tablet, 75mg Tablet, 200mg Tablet)

C1

SM Acidophilus (Capsule)C1

SM Calcium Antacid (Tablet Chewable)C1

SM Calcium Antacid Extra Strength (Tablet Chewable)

C1

SM Calcium Antacid Ultra Strength (Tablet Chewable)

C1

SM Smooth Antacid Extra Strength (Tablet Chewable)

C1

Sodium Bicarbonate (325mg Tablet, 650mg Tablet)

C1

Sodium Bicarbonate (Powder)C1

TGT Acid Reducer (Tablet)C1

TGT Antacid (Tablet Chewable)C1

TGT Antacid Extra Strength (Tablet Chewable)

C1

Titralac (Tablet Chewable)C1

Tums Freshers (Tablet Chewable)C1

Tums Gas Relief Chewy Bites (Tablet Chewable)

C1

Zantac 75 (Tablet)B1

Gastrointestinal Agents, Other

139


OTC Drug NameC1

Align (Tablet Chewable)C1

Align Extra Strength (Capsule)C1

Align Jr For Kids (Tablet Chewable)C1

Anti-Diarrheal (1mg/7.5ml Liquid, 2mg Tablet)

C1

Bismatrol (262mg/15ml Suspension, 262mg Tablet Chewable)

C1

Bismatrol Maximum Strength (Suspension)C1

Bismuth (Tablet Chewable)C1

Bismuth Subsalicylate (Tablet Chewable)C1

Culturelle (Capsule)C1

Culturelle Immunity Support Formula

(Capsule)C1

Culturelle Kids (Packet)C1

Culturelle Kids (Tablet Chewable)C1

Culturelle Kids Regularity (Packet)C1

Culturelle Probiotics Kids (Packet)C1

CVS Bismuth (Tablet Chewable)C1

CVS Dairy Relief (Chewable Tablet)C1

CVS Dairy Relief Fast Acting (Tablet)C1

CVS Easy Fiber/Calcium (Tablet Chewable)

C1

CVS Lactase (Tablet)C1

CVS Lactase Enzyme Ultra Strength (Tablet)

C1

CVS Stomach Relief (Tablet Chewable)C1

Dairy Digest Ultra (Tablet)C1

Dairy Digestive Supplement Fast Acting (Tablet)

C1

Dairy Digestive Ultra (Tablet)C1

Dairy Relief (Tablet)C1

Dairy-Digestive (Chewable Tablet)C1

EQ Dairy Digestive Supplement Fast Acting (Chewable Tablet)

C1

EQ Dairy Digestive Supplement Fast Acting (Tablet)

OTC Drug NameC1

EQ Pink-Bismuth (Tablet Chewable)C1

EQ Stomach Relief (Tablet Chewable)C1

EQL Dairy Digest Fast Acting (Tablet)C1

EQL Stomach Relief (Tablet Chewable)C1

Fast Acting Dairy Aid (Tablet)C1

Florastor (Capsule)C1

Florastor Kids (Packet)C1

Florastormax (Packet)C1

Gas Relief (40mg/0.6ml Suspension, 80mg Tablet Chewable)

C1

Gas Relief Extra Strength (Capsule)C1

Gas Relief Maximum Strength (Tablet Chewable)

C1

Gas Relief Ultra Strength (Capsule)C1

Gas-X Extra Strength (Capsule)C1

Gas-X Ultra Strength (Capsule)C1

GNP Anti-Diarrheal (Tablet)C1

GNP Anti-Gas (Capsule)C1

GNP Dairy Relief (Tablet)C1

GNP Fast Acting Dairy Relief (Chewable Tablet)

C1

GNP Gas Relief (Tablet Chewable)C1

GNP Gas Relief Extra Strength (125mg Capsule, 125mg Tablet Chewable)

C1

GNP Infants Gas Relief (Suspension)C1

GNP Loperamide HCL (Liquid)C1

GNP Pink Bismuth (262mg Tablet Chewable, 262mg Tablet)

C1

GNP Stomach Relief (Suspension)C1

GNP Stomach Relief Maximum Strength (Suspension)

C1

Goodsense Stomach Relief (Tablet Chewable)

C1

HM Anti-Diarrheal (Tablet)C1

HM Gas Relief (80mg Tablet Chewable, 125mg Tablet Chewable)

140


OTC Drug NameC1

HM Gas Relief Extra Strength (Capsule)C1

HM Gas Relief Infants (Suspension)C1

HM Loperamide HCL (Liquid)C1

HM Stomach Relief (262mg Tablet Chewable, 262mg/15ml Suspension)

C1

HM Stomach Relief Maximum Strength (Suspension)

C1

Infants Gas Relief (Suspension)C1

Infants Simethicone (Suspension)C1

Kao-Tin (Suspension)C1

KLS Fast Acting Lactase (Tablet)C1

Lac-Dose (Tablet)C1

Lactase (Tablet)C1

Lactase Enzyme (Tablet)C1

Lactase Fast Acting (Tablet)C1

Lactinex (Tablet Chewable)C1

Lactobacillus (Packet)C1

Lactobacillus (Tablet)C1

Lactobacillus Extra Strength (Capsule)C1

Lacto-Key-100 (Capsule)C1

Lacto-Key-600 (Capsule)C1

Lactose Fast Acting Relief (Chewable Tablet)

C1

Lactose Fast Acting Relief (Tablet)C1

Little Remedies For Tummys Gas Relief (Suspension)

C1

Little Tummys Gas Relief (Suspension)C1

Loperamide A-D (Tablet)C1

Loperamide HCL (1mg/5ml Liquid, 1mg/7.5ml Liquid)

C1

Loperamide Hydrochloride (Tablet)C1

Meclizine (Tablet Chewable)C1

Meclizine HCL (Tablet Chewable)C1

Meclizine Hydrochloride (Tablet Chewable)C1

Medi-Bismuth (Tablet Chewable)

OTC Drug NameC1

Medi-Lax (Tablet)C1

Medi-Mucil (Capsule)C1

Medi-Natural (Tablet)C1

Meijer Anti-Diarrheal (Tablet)C1

Meta Biotic/Bio-Active 12 (Capsule)C1

Metamucil (Powder)C1

Metamucil Smooth Texture (Powder)C1

Metamucil Smooth Texture Sugar Free (Powder)

C1

Mi-Acid Gas Relief (Tablet Chewable)C1

Mineral Oil (Enema)C1

Mineral Oil (Oil)C1

Mineral Oil Heavy (Oil)C1

MM Anti-Diarrheal (Tablet)C1

MM Stool Softener (Capsule)C1

Mommys Bliss Gas Relief Drops (Suspension)

C1

Motion Sickness Relief (Tablet Chewable)C1

Motion-Time (Tablet Chewable)C1

Mytab Gas (Tablet Chewable)C1

Natural Psyllium Seed Indian Husks (Powder)

C1

Natural Vegetable Fiber (Powder)C1

Pediacare Gas Relief Drops Infants (Suspension)

C1

Pediatric Enema (Enema)C1

Peptic Relief (Suspension)C1

Peptic Relief (Tablet Chewable)C1

Pepto-Bismol (Tablet Chewable)C1

Pepto-Bismol Instacool (Tablet

Chewable)C1

Pepto-Bismol To-Go (Tablet Chewable)C1

Phazyme (Tablet Chewable)C1

Phillips Stool Softener (Capsule)C1

Pink Bismuth (Tablet Chewable)

141


OTC Drug NameC1

Pink Bismuth Maximum Strength (Suspension)

C1

Primadophilus (Capsule)C1

Probiotic (Capsule)C1

Probiotic Chewable Children's (Tablet Chewable)

C1

Probiotic Choclate Bears Children's (Tablet Chewable)

C1

Probiotic Gold Extra Strength (Capsule)C1

Probiotic Packets Children's (Packet)C1

Probiotic-10 Chewable (Tablet Chewable)C1

Promolaxin (Tablet)C1

Psyldex (Powder)C1

Psyllium Fiber (Capsule)C1

Psyllium Husk (Powder)C1

Pure & Gentle Enema (Enema)C1

PX Anti-Diarrheal (Tablet)C1

PX Dairy Digestive (Tablet)C1

PX Docusate Sodium (Capsule)C1

PX Fiber (Capsule)C1

PX Gas Relief Extra Strength (Capsule)C1

PX Gas Relief Infants (Suspension)C1

PX Gas Relief Ultra Strength (Capsule)C1

PX Ranitidine (Tablet)C1

PX Stomach Relief (Tablet Chewable)C1

PX Stomach Relief Maximum Strength (Suspension)

C1

QC Anti-Diarrheal (Tablet)C1

QC Anti-Gas Ultra Strength (Capsule)C1

QC Diarrhea Relief (Suspension)C1

QC Gas Relief (Capsule)C1

QC Gas Relief (Tablet Chewable)C1

QC Gas Relief Extra Strength (Tablet Chewable)

C1

QC Natural Vegetable (Powder)

OTC Drug NameC1

QC Pink Bismuth (Tablet Chewable)C1

QC Senna (Tablet)C1

RA Anti-Diarrheal (Liquid)C1

RA Anti-Diarrheal (Tablet)C1

RA Col-Rite (Capsule)C1

RA Dairy Aid (Tablet)C1

RA Dairy Relief Fast Acting (Chewable Tablet)

C1

RA Dairy Relief Fast Acting (Tablet)C1

RA Digestive Health (Capsule)C1

RA Enema (Enema)C1

RA Fiber (Capsule)C1

RA Fiber (Powder)C1

RA Fiber Supplement (Powder)C1

RA Fiber Therapy (Capsule)C1

RA Gas Relief (Capsule)C1

RA Gas Relief (Suspension)C1

RA Gas Relief (Tablet Chewable)C1

RA Gas Relief Extra Strength (Capsule)C1

RA Gas Relief Extra Strength (Tablet Chewable)

C1

RA Gas Relief Maximum Strength (Tablet Chewable)

C1

RA Gas Relief Ultra Strength (Capsule)C1

RA Gas Relief/Infants (Suspension)C1

RA K-Pec (Suspension)C1

RA Loperamide HCl (Liquid)C1

RA Mineral Oil (Oil)C1

RA Motion Sickness Relief (Tablet Chewable)

C1

RA Pink Bismuth (Tablet Chewable)C1

RA Soluble Fiber (Tablet)C1

RA Stomach Relief (Tablet Chewable)C1

RA Stomach Relief Maximum Strength (Suspension)

142


OTC Drug NameC1

RA Stool Softener (Capsule)C1

Ranitidine HCl (Tablet)C1

Reliable-1 Psyllium (Capsule)C1

SB Anti-Diarrhea (Tablet)C1

SB Anti-Gas (Capsule)C1

SB Bismuth (Tablet)C1

SB Docusate Sodium (Capsule)C1

SB Fib Lax Orange (Powder)C1

SB Gas Relief (Suspension)C1

SB Gas Relief (Tablet Chewable)C1

SB Gentle Lax-Women (Tablet Delayed-Release)

C1

SB Senna-Lax (Tablet)C1

Senna Lax (Tablet)C1

Senna Regular Strength (Tablet)C1

Senna Smooth (Tablet)C1

Sennacon (Tablet)C1

Senna-GRX (Syrup)C1

Sennazon (Syrup)C1

Sennosides (Senna) (Tablet)C1

Sennosides (Tablet)C1

Simeped (Suspension)C1

Simethicone (180mg Capsule, 40mg/0.6ml Suspension)

C1

Simethicone Extra Strength (Capsule)C1

SM Anti-Diarrheal (Tablet)C1

SM Fiber Powder (Powder)C1

SM Gas Relief (80mg Tablet Chewable, 125mg Tablet Chewable)

C1

SM Gas Relief Antiflatuent (Capsule)C1

SM Gas Relief Drops Infants (Suspension)C1

SM Gas Relief Extra Strength (Capsule)C1

SM Gas Relief Infants Drops (Suspension)C1

SM Loperamide HCL (Liquid)

OTC Drug NameC1

SM Mineral Oil (Enema)C1

SM Mineral Oil (Oil)C1

SM Probiotic (Capsule)C1

SM Stomach Relief (262mg/15ml Suspension, 262mg Tablet Chewable, 262mg Tablet)

C1

SM Stomach Relief Liquid (Suspension)C1

SM Stomach Relief Maximum Strength (Suspension)

C1

SM Ultra Dairy Digestive (Tablet)C1

Smarty Pants Kids Probiotic Complete (Tablet Chewable)

C1

Sodium Bicarbonate Partial Fill (Solution)C1

Soluble Fiber/Probiotics (Tablet Chewable)C1

Soothe Maximum Strength (Suspension)C1

Sorbulax (Powder)C1

SR Anti-Diarrheal (Tablet)C1

Stablegi (Capsule)C1

Stomach Relief (262mg/15ml Suspension, 262mg Tablet Chewable)

C1

Stomach Relief Maximum Strength (Suspension)

C1

Stomach Relief Plus (Suspension)C1

Surelac (Tablet)C1

TGT Anti-Diarrheal (Tablet)C1

TGT Dairy Digestive Aid (Tablet)C1

TGT Fiber Therapy (Powder)C1

TGT Gas Relief Extra Strength (Capsule)C1

TGT Gas Relief Extra Strength (Tablet Chewable)

C1

TGT Gas Relief Infants Drops (Liquid)C1

TGT Psyllium Fiber (Capsule)C1

TGT Senna (Tablet)C1

TGT Stomach Relief (Tablet)C1

The Magic Bullet (Suppository)C1

Travel Sickness (Tablet Chewable)

143


OTC Drug NameC1

Trunature Probiotic For Kids (Tablet Chewable)

C1

Ultimate Probiotic Formula (Capsule)C1

Veracolate (Tablet Delayed-Release)C1

Wal-Mucil (Capsule)C1

Wal-Mucil (Powder)C1

Wal-Mucil Plus Calcium (Capsule)C1

Wal-Zan 75 (Tablet)B1

LaxativesC1

Abatinex (Capsule)C1

Alophen (Tablet Delayed-Release)C1

AZO Complete Feminine Balance (Capsule)

C1

Benefiber On The Go (Powder)C1

Biohm Children's Probiotic Supplement (Tablet Chewable)

C1

Biotinex (Capsule)C1

Bisac-Evac (Suppository)C1

Bisacodyl (Suppository)C1

Bisacodyl EC (Tablet Delayed-Release)C1

Bisacodyl Laxative (Suppository)C1

Biscolax (Suppository)C1

Bonine (Tablet Chewable)C1

Carters Little Pills (Tablet Delayed-Release)C1

Children's Probiotic (Tablet Chewable)C1

Chocolated Laxative (Tablet Chewable)C1

Citrucel (Tablet)C1

Citrucel Fiber Laxative (Powder)C1

Clear Soluble Fiber (Powder)C1

Clearlax (Powder)C1

Colace (Capsule)C1

Colace Clear (Capsule)C1

Correct (Tablet Delayed-Release)C1

Correctol (Tablet Delayed-Release)C1

Correctol Extra Gentle (Capsule)

OTC Drug NameC1

CVS Advanced Probiotic Gummies (Tablet Chewable)

C1

CVS Anti-Diarrheal (Suspension)C1

CVS Anti-Diarrheal (Tablet)C1

CVS Bisacodyl (Suppository)C1

CVS Bisacodyl (Tablet Delayed-Release)C1

CVS Bismuth Maximum Strength (Suspension)

C1

CVS Chocolate Laxative Pieces (Tablet Chewable)

C1

CVS C-Lax Laxative (Tablet Delayed-Release)

C1

CVS Daily Fiber (Capsule)C1

CVS Digestive Probiotic (Capsule)C1

CVS Easy Fiber (Powder)C1

CVS Enema Disposable (Enema)C1

CVS Enema Ready-To-Use (Enema)C1

CVS Fiber (Capsule)C1

CVS Gas Relief (Capsule)C1

CVS Gas Relief (Tablet Chewable)C1

CVS Gas Relief Drops Extra Strength (Liquid)

C1

CVS Gas Relief Extra Strength (Capsule)C1

CVS Gas Relief Extra Strength (Tablet Chewable)

C1

CVS Gas Relief Infants (Suspension)C1

CVS Gas Relief Ultra Strength (Capsule)C1

CVS Gentle Laxative (Suppository)C1

CVS Gentle Laxative (Tablet Delayed-Release)

C1

CVS Gentle Laxative Womens (Tablet Delayed-Release)

C1

CVS Glycerin Adult (Suppository)C1

CVS Glycerin Child (Suppository)C1

CVS Infants Gas Relief (Suspension)C1

CVS Laxative Pills (Tablet)

144


OTC Drug NameC1

CVS Loperamide HCl (Liquid)C1

CVS Loperamide Hydrochloride (Liquid)C1

CVS Mineral Oil (Oil)C1

CVS Mineral Oil Enema (Enema)C1

CVS Mini Enema Kids (Enema)C1

CVS Motion Sickness Relief (Tablet Chewable)

C1

CVS Natural Daily Fiber (Powder)C1

CVS Natural Fiber Supplement (Powder)C1

CVS Probiotic (Capsule)C1

CVS Probiotic (Tablet Chewable)C1

CVS Probiotic Children's (Tablet Chewable)

C1

CVS Ranitidine (Tablet)C1

CVS Senna (Tablet)C1

CVS Senna-Extra (Tablet)C1

CVS Soluble Fiber Therapy (Tablet)C1

CVS Stomach Relief Maximum Strength (Suspension)

C1

CVS Stool Softener (Capsule)C1

Dialyvite Chewable Probiotic (Tablet Chewable)

C1

Diamode (Tablet)C1

Diarrhea (Suspension)C1

Digestive Advantage Probiotic Gummies (Tablet Chewable)

C1

Digestive Health Probiotic (Capsule)C1

Diocto (Liquid)C1

Diocto (Syrup)C1

Docqlace (Capsule)C1

Docu (Liquid)C1

Docu Soft (Capsule)C1

Docuprene (Tablet)C1

Docusate Sodium (100mg Capsule, 150mg/15ml Liquid)

OTC Drug NameC1

Docusate Sodium Extra Strength (Capsule)C1

Docusil (Capsule)C1

Docusol Kids (Enema)C1

Docusol Mini (Enema)C1

Dofus (Capsule)C1

DOK (100mg Capsule, 250mg Capsule, 100mg Tablet)

C1

Dr Edwards Olive Laxative (Tablet)C1

DRx Choice Gas Relief (Tablet Chewable)C1

DSS (Capsule)C1

Ducodyl (Tablet Delayed-Release)C1

Dulcolax Pink Stool Softener (Capsule)C1

Dulcolax Stool Softener (Capsule)C1

Easy Fiber (Powder)C1

Easy-Lax (Capsule)C1

Enema (Enema)C1

Enema Disposable (Enema)C1

Enema Mineral Oil (Enema)C1

Enema Mineral Oil Ready-To-Use (Enema)C1

Enema Ready-To-Use (Enema)C1

Enemeez Mini (Enema)C1

EQ Anti-Diarrheal (Liquid)C1

EQ Anti-Diarrheal (Tablet)C1

EQ Daily Fiber (Capsule)C1

EQ Enema (Enema)C1

EQ Fiber Powder (Powder)C1

EQ Fiber Therapy (Capsule)C1

EQ Fiber Therapy (Powder)C1

EQ Fiber Therapy (Tablet)C1

EQ Gas Relief (Capsule)C1

EQ Gas Relief (Tablet Chewable)C1

EQ Gas Relief Extra Strength (Tablet Chewable)

145


OTC Drug NameC1

EQ Gentle Laxative (Tablet Delayed-Release)

C1

EQ Infants Gas Relief (Suspension)C1

EQ Laxative (Tablet Chewable)C1

EQ Laxative Maximum Strength (Tablet)C1

EQ Loperamide HCl (Liquid)C1

EQ Mineral Oil (Oil)C1

EQ Natural Fiber Laxative (Powder)C1

EQ Natural Laxative (Tablet)C1

EQ Natural Vegetable Laxative (Tablet)C1

EQ Probiotic Digestive System Support (Capsule)

C1

EQ Ranitidine (Tablet)C1

EQ Stool Softener (Capsule)C1

EQ Vegetable Laxative (Tablet)C1

EQ Womans Laxative (Tablet Delayed-Release)

C1

EQ Womens Laxative (Tablet Delayed-Release)

C1

EQL Anti-Diarrheal (Tablet)C1

EQL Digestive Probiotic (Capsule)C1

EQL Fiber Supplement (Powder)C1

EQL Fiber Therapy (Powder)C1

EQL Fiber Therapy (Tablet)C1

EQL Gas Gone Extra Strength (Tablet Chewable)

C1

EQL Gas Relief (Capsule)C1

EQL Gas Relief Extra Strength (Capsule)C1

EQL Gas Relief Ultra Strength (Capsule)C1

EQL Gentle Laxative (Tablet Delayed-Release)

C1

EQL Heartburn Prevention (Tablet)C1

EQL Infants Gas Relief (Suspension)C1

EQL Laxative (Tablet Delayed-Release)C1

EQL Laxative EQL Laxative (Tablet Chewable)

OTC Drug NameC1

EQL Laxative Maximum Strength (Tablet)C1

EQL Loperamide HCl (Liquid)C1

EQL Natural Fiber (Powder)C1

EQL Ready-To-Use Enema (Enema)C1

EQL Senna Laxative (Tablet)C1

EQL Stomach Relief Maximum Strength (Suspension)

C1

EQL Stool Softener (Capsule)C1

Evac-U-Gen (Tablet)C1

Ex-Lax (15mg Tablet Chewable, 15mg

Tablet)C1

Ex-Lax Ultra (Tablet Delayed-Release)C1

Feenamint (Tablet Delayed-Release)C1

Fiber Laxative (Capsule)C1

Fiber Powder (Powder)C1

Fiber Therapy (Powder)C1

Fiber Therapy (Tablet)C1

Fleet Bisacodyl (Enema)C1

Fleet Enema (Enema)C1

Fleet Liquid Glycerin Suppositories

(Enema)C1

Fleet Oil (Enema)C1

Fleet Pediatric (Enema)C1

Flora Assist (Packet)C1

Floranex (Packet)C1

Floranex (Tablet)C1

Gas Relief Drops Infants (Suspension)C1

Gas Relief Infants (Liquid)C1

Gas Relief Infants (Suspension)C1

Gas-X Infant Drops (Liquid)C1

Gavilax (Powder)C1

Gentle Laxative (Suppository)C1

Gentle Laxative (Tablet Delayed-Release)C1

Gentle Laxative For Women (Tablet Delayed-Release)

146


OTC Drug NameC1

Gentle Laxative Overnight Relief (Tablet Delayed-Release)

C1

Geri-Kot (Tablet)C1

Geri-Mucil (Powder)C1

Geri-Pectate (Suspension)C1

Glycerin Adult (2gm Suppository, 2.1gm Suppository)

C1

Glycerin Adult (Suppository)C1

Glycerin Children (Suppository)C1

Glycerin Children's (Suppository)C1

Glycerin Infants & Children (Suppository)C1

Glycerin Pediatric (Suppository)C1

Glycolax (Powder)C1

GNP Best Fiber (Powder)C1

GNP Bisa-Lax (Tablet Delayed-Release)C1

GNP Clearlax (Packet)C1

GNP Clearlax (Powder)C1

GNP Enema (Enema)C1

GNP Enema Mineral Oil Laxative (Enema)C1

GNP Fiber Therapy (Tablet)C1

GNP Gas Relief Maximum Strength (Tablet Chewable)

C1

GNP Gentle Laxative (Suppository)C1

GNP Glycerin Adult (Suppository)C1

GNP Glycerin Child (Suppository)C1

GNP Glycerin Infant (Suppository)C1

GNP K-Pec (Suspension)C1

GNP Laxative (Tablet Delayed-Release)C1

GNP Laxative Pills (Tablet)C1

GNP Loperamide Hydrochloride (Liquid)C1

GNP Mineral Oil (Oil)C1

GNP Mineral Oil Heavy (Oil)C1

GNP Natural Fiber (Powder)C1

GNP Senna-Lax (Tablet)

OTC Drug NameC1

GNP Stool Softener (100mg Capsule, 250mg Capsule, 150mg/15ml Liquid, 60mg/15ml Syrup)

C1

GNP Stool Softener Extra Strength (Capsule)

C1

GNP Womens Gentle Laxative (Tablet Delayed-Release)

C1

GNP Womens Laxative (Tablet Delayed-Release)

C1

Goodsense Best Fiber (Powder)C1

Goodsense Bisacodyl Ec (Tablet Delayed-Release)

C1

Goodsense Clearlax (Powder)C1

Goodsense Fiber (Tablet)C1

Goodsense Gas Relief Extra Strength (Tablet Chewable)

C1

Goodsense Laxative Pills (Tablet)C1

Goodsense Mineral Oil Lubricant Laxative (Oil)

C1

Goodsense Natural Fiber (Powder)C1

Goodsense Psyllium Fiber (Powder)C1

Goodsense Senna Laxative (Tablet)C1

Healthy Mama Move It Along (Tablet)C1

Healthylax (Packet)C1

HM Clear Fiber (Powder)C1

HM Clearlax (Packet)C1

HM Clearlax (Powder)C1

HM Enema (Enema)C1

HM Enema Mineral Oil (Enema)C1

HM Enema Ready-To-Use (Enema)C1

HM Enema Saline Laxative (Enema)C1

HM Fiber (0.52gm Capsule, 500mg Tablet, 28.3% Powder, 30.9% Powder, 48.57% Powder, 58.6% Powder)

C1

HM Fiber Powder (Powder)C1

HM Gas Relief Infants Drops (Suspension)

147


OTC Drug NameC1

HM Laxative (Tablet Delayed-Release)C1

HM Mineral Oil (Oil)C1

HM Probiotic Digestive Health (Capsule)C1

HM Senna (Tablet)C1

HM Stomach Relief Ultra (Suspension)C1

HM Stool Softener (100mg Capsule, 100mg Tablet)

C1

HM Stool Softener Maximum Strength (Capsule)

C1

Intestinex (Capsule)C1

Kaopectate (Suspension)C1

Kaopectate (Tablet)C1

Kaopectate Extra Strength (Suspension)C1

KLS Anti-Diarrheal (Tablet)C1

KLS Natural Psyllium Fiber (Powder)C1

KLS Stool Softener (Capsule)C1

Kondremul (Oil)C1

Konsyl (Capsule)C1

Konsyl (Powder)C1

Konsyl Daily Fiber (100% Powder)C1

Konsyl Daily Fiber (28.3% Powder, 28.3% Powder Packet, 100% Powder Packet)

C1

Konsyl Original Formula Daily Fiber

(Powder)C1

Konsyl-D (Powder)C1

KP Bisacodyl (Tablet Delayed-Release)C1

KP Senna (Tablet)C1

KS Stool Softener (Capsule)C1

Laxa Basic (Capsule)C1

Laxative (10mg Suppository, 5mg Tablet Delayed-Release, 25mg Tablet)

C1

Laxative Feminine (Tablet Delayed-Release)

C1

Laxative Maximum Strength (Tablet)C1

Laxative Pills Maximum Strength (Tablet)

OTC Drug NameC1

Laxative Pills Regular Strength (Tablet)C1

Laxative With Senna (Tablet)C1

Natural Fiber (Powder)C1

Natural Fiber Laxative (48.57% Powder, 58.6% Powder)

C1

Natural Fiber Therapy (28.3% Powder, 48.57% Powder)

C1

Natural Senna Laxative (Tablet)C1

Oral Saline Laxative (Solution)C1

Pedia-Lax (1gm Suppository, 2.8gm

Suppository)C1

Peg 3350 (Packet)C1

Peg 3350 (Powder)C1

Perdiem Overnight Relief (Tablet)C1

Polyethylene Glycol 3350 (Packet)C1

Polyethylene Glycol 3350 (Powder)C1

PX Glycerin (Suppository)C1

PX Laxative (Tablet Delayed-Release)C1

PX Vegetable Laxative (Tablet)C1

QC Enema (Enema)C1

QC Fiber Laxative (Capsule)C1

QC Gentle Laxative (Suppository)C1

QC Laxative (Tablet)C1

QC Mineral Oil Heavy (Oil)C1

QC Natural Vegetable Laxative (Tablet)C1

QC Natura-Lax (Powder)C1

QC Stool Softener (Capsule)C1

RA Fast Relief Laxative (Suppository)C1

RA Fiber Laxative (Powder)C1

RA Glycerin Adult (Suppository)C1

RA Glycerin Child (Suppository)C1

RA Laxative (Tablet Chewable)C1

RA Laxative (Tablet Delayed-Release)C1

RA Laxative (Tablet)

148


OTC Drug NameC1

RA Laxative Extra Strength (Tablet)C1

RA Laxative Maximum Strength (Tablet)C1

RA Stimulant Laxative (Suppository)C1

RA Womens Laxative (Tablet Delayed-Release)

C1

Reguloid (28.3% Powder, 48.57% Powder, 58.6% Powder)

C1

SB Bisacodyl Laxative EC (Tablet Delayed-Release)

C1

SB Fiber Laxative (Powder)C1

SB Gentle Laxative Womens (Tablet Delayed-Release)

C1

SB Glycerin Adult (Suppository)C1

SB Glycerin Pediatric (Suppository)C1

SB Laxative (Suppository)C1

SB Natural Fiber Laxative (Powder)C1

Senexon (Tablet)C1

Senna (Tablet)C1

Senna Laxative (Tablet)C1

Senna-Lax (Tablet)C1

Senna-Tabs (Tablet)C1

Senna-Time (Tablet)C1

Senno (Tablet)C1

Senokot (Tablet)C1

Senokot Extra Strength (Tablet)C1

Silace (150mg/15ml Liquid, 60mg/15ml Syrup)

C1

SM Clearlax (Powder)C1

SM Enema (Enema)C1

SM Fiber (28.3% Powder, 48.57% Powder, 58.6% Powder)

C1

SM Fiber Laxative (Tablet)C1

SM Gentle Laxative (Tablet Delayed-Release)

C1

SM Glycerin Laxative Pediatric (Suppository)

OTC Drug NameC1

SM Glycerin Pediatric (Suppository)C1

SM Laxative (Suppository)C1

SM Laxative Maximum Strength (Tablet)C1

SM Senna Laxative (Tablet)C1

SM Senna Laxative Maximum Strength (Tablet)

C1

SM Stool Softener (Capsule)C1

SM Womans Laxative (Tablet Delayed-Release)

C1

Soluble Fiber (Powder)C1

Stimulant Laxative (Tablet Delayed-Release)

C1

Stool Softener (Capsule)C1

Stool Softener Extra Strength (Capsule)C1

Stool Softener Laxative (Capsule)C1

Stool Softener Laxative Extra Strength (Capsule)

C1

TGT Gentle Laxative (Tablet Delayed-Release)

C1

TGT Laxative Pills Maximum Strength (Tablet)

C1

TGT Natural Laxative Pills Maximum Strength (Tablet)

C1

TGT Saline Laxative (Enema)C1

TGT Senna Laxative (Tablet)C1

TGT Womens Laxative (Tablet Delayed-Release)

C1

Total Fiber (Powder)C1

Womans Laxative (Tablet Delayed-Release)C1

Womens Laxative (Tablet Delayed-Release)

A1

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

B1

Contraceptives, OralC1

Aftera (Tablet)C1

Econtra EZ (Tablet)C1

Econtra One-Step (Tablet)

149


OTC Drug NameC1

Levonorgestrel (Tablet)C1

My Choice (Tablet)C1

My Way (Tablet)C1

New Day (Tablet)C1

Next Choice One Dose (Tablet)C1

Opcicon One-Step (Tablet)C1

Option 2 (Tablet)C1

Preventeza (Tablet)C1

React (Tablet)C1

Take Action (Tablet)B1

Contraceptives, TopicalC1

Encare (Suppository)C1

Options Conceptrol Vaginal

Contraceptive (Gel)C1

Options Gynol II Vaginal Contraceptive

(Gel)C1

Shur-Seal (Gel)C1

Today Sponge C1

VCF Vaginal Contraceptive Film C1

VCF Vaginal Contraceptive Foam (Foam)C1

VCF Vaginal Contraceptive Gel (Gel)A1

Miscellaneous Therapeutic AgentsB1

Devices / Other Therapeutic AgentsC1

Aerochamber Mini Aerosol Chamber

(Device)C1

Aerochamber MV (Device)C1

Aerochamber Plus (Device)C1

Aerochamber Plus Flow Vu (Device)C1

Aerochamber Plus Flow-Vu (Device)C1

Aerochamber Plus Flow-Vu/Large Mask

(Device)C1

Aerochamber Plus Flow-Vu/Mask

(Device)C1

Aerochamber Plus Flow-Vu/Medium

Mask (Device)

OTC Drug NameC1

Aerochamber Plus Flow-Vu/Small Mask

(Device)C1

Aerochamber Plus/Small Mask (Device)C1

Aerochamber Z-Stat Plus Valved Holding

Chamber W/Flow Vu (Device)C1

Aerochamber Z-Stat Plus/Flowsignal

(Device)C1

Aerochamber Z-Stat Plus/Large Mask

(Device)C1

Aerochamber Z-Stat Plus/Medium Mask

(Device)C1

Aerochamber Z-Stat Plus/Small Mask

(Device)C1

Aerochamber/Flowsignal (Device)C1

Aerovent Plus Holding Chamber/

Collapsible (Device)C1

Arial Chamber (Device)C1

Breathe Ease/Large Mask (Device)C1

Breathe Ease/Medium Mask (Device)C1

Breathe Ease/Small Mask (Device)C1

Breatherite (Device)C1

Breatherite Collapsible Adult Spacer W/

Mask (Device)C1

Breatherite Collapsible Child Spacer W/

Mask (Device)C1

Breatherite Collapsible Infant Spacer W/

Mask (Device)C1

Breatherite Collapsible Small Child

Spacer W/Mask (Device)C1

Breatherite Collapsible Spacer W/

Neonate Mask (Device)C1

Breatherite Rigid Spacer W/Mask

(Device)C1

Breatherite W/Large Mask (Device)C1

Breatherite W/Medium Mask (Device)C1

Breatherite W/Small Mask (Device)C1

Clever Choice Anti-Staticvalved Holding

Chamber/Adult Large (Device)

150


OTC Drug NameC1


Chamber/Medium (Device)C1


Chamber/Small (Device)C1

Compact Space Chamber/Anti-Static

(Device)C1

Compact Space Chamber/Anti-Static/

Large Mask (Device)C1


Medium Mask (Device)C1


Small Mask (Device)C1

Easivent (Device)C1

Easivent/Mask-Large (Device)C1

Easivent/Mask-Medium (Device)C1

Easivent/Mask-Small (Device)C1

Flexichamber (Device)C1

Flexichamber Adult Mask/Small (Mask)C1

Flexichamber Child Mask/Large (Mask)C1

Flexichamber Child Mask/Small (Mask)C1

Hyper-Sal (3.5% Solution, 7% Solution)C1

Inspirachamber/Anti-Static Valved/

Mouthpiece (Device)C1

Inspirachamber/Large (Device)C1

Inspirachamber/Soothermask/

Inspiramask/Medium (Device)C1

Inspirachamber/Soothermask/

Inspiramask/Small (Device)C1

Inspirease Drug Delivery System

(Device)C1

Inspirease Reservoir Bags (Aerosol)C1

Liteaire (Device)C1

Lma Mad Nasal (Device)C1

Mask Vortex/Baby Whirl Duckling (Mask)C1

Mask Vortex/Child/Frog (Mask)C1

Mask Vortex/Spinner The Duck (Mask)

OTC Drug NameC1

Mask Vortex/Toddler/Lady Bug (Mask)C1

Microchamber (Device)C1

Microspacer (Device)C1

Nebusal (3% Solution)C1

Nebusal (6% Solution)C1

Optichamber Advantage/Large Mask

(Device)C1

Optichamber Advantage/Medium Face

Mask (Device)C1

Optichamber Advantage/Small Face

Mask (Device)C1

Optichamber Diamond (Device)C1

Optichamber Diamond/Largeface Mask

(Device)C1

Optichamber Diamond/Medium Face

Mask (Device)C1

Optichamber Diamond/Smallface Mask

(Device)C1

Optichamber Face Mask/Large (Device)C1

Optichamber Face Mask/Medium

(Device)C1

Optichamber Face Mask/Small (Device)C1

Optihaler (Device)C1

Optihaler MDI Drug Delivery System

(Device)C1

Panda Mask Large (Mask)C1

Panda Mask Medium (Mask)C1

Panda Mask Small (Mask)C1

Pediatric Panda Mask (Mask)C1

Pocket Chamber (Device)C1

Pocket Spacer (Device)C1

Pro Comfort Inhaler Spacer Chamber

Adult (Device)C1

Pro Comfort Inhaler Spacer Chamber

Child (Device)C1

Riteflo (Device)

151


OTC Drug NameC1

Valved Holding Chamber (Device)C1

Vortex Valved Holding Chamber (Device)C1

Watchhaler (Device)B1

Saliva Replacement AgentsC1

Act Dry Mouth (Lozenge)C1

Biotene Dry Mouth (Lozenge)C1

Oral Relief For Dry Mouth (Lozenge)C1

Oral Relief For Dry Mouth& Discomfort (Kit)C1

Oral Relief For Dry Mouth& Discomfort (Lozenge)

C1

Salese/Xylitol (Lozenge)C1

Salivasure (Lozenge)C1

Therabreath Dry Mouth (Lozenge)A1

Ophthalmic AgentsB1

Allergy Agents, OphthalmicC1

Alaway (Ophthalmic Solution)C1

Alaway (Ophthalmic Solution)C1

Alaway Children's Allergy Eye Itch Relief

(Ophthalmic Solution)C1

Allergy Eye Drops (Ophthalmic Solution)C1

Clear Eyes Pure Relief For Dry Eyes

(Solution)C1

Computer Eye Drops (Solution)C1

CVS Allergy Eye Drops (Ophthalmic Solution)

C1

CVS Eye Allergy Relief (Ophthalmic Solution)

C1

CVS Eye Itch Relief (Ophthalmic Solution)C1

EQ Eye Allergy Relief (Ophthalmic Solution)

C1

Eye Allergy Relief (Ophthalmic Solution)C1

Eye Itch Relief (Ophthalmic Solution)C1

GNP Eye Itch Relief (Ophthalmic Solution)C1

GNP Itchy Eye (Ophthalmic Solution)C1

Goodsense Itchy Eye (Ophthalmic Solution)

OTC Drug NameC1

HM Eye Itch Relief (Ophthalmic Solution)C1

Ketotifen Fumarate (Ophthalmic Solution)C1

Ketotifen Fumarate (Solution)C1

KP Ketotifen Fumarate (Solution)C1

Naphcon-A (Ophthalmic Solution)C1

Opcon-A (Ophthalmic Solution)C1

RA Antihistamine Eye Drops (Ophthalmic Solution)

C1

RA Eye Allergy Relief (Ophthalmic Solution)

C1

RA Eye Itch Relief (Ophthalmic Solution)C1

SM Eye Itch Relief (Ophthalmic Solution)C1

TGT Eye Allergy Relief (Ophthalmic Solution)

C1

Theratears Allergy Eye Itch Relief (Ophthalmic Solution)

C1

Visine-A (Ophthalmic Solution)C1

Zaditor (Ophthalmic Solution)B1

Ophthalmic Agents, OtherC1

Akwa Tears (Ointment)C1

Artificial Tears (Ophthalmic Solution)C1

CVS Artificial Tears (Ophthalmic Solution)C1

EQ Artificial Tears (Ophthalmic Solution)C1

Genteal Tears Liquid Drops Moderate (Solution)

C1

RA Artificial Tears Eye Care (Ophthalmic Solution)

C1

RA Lubricant Eye Drops (Ophthalmic Solution)

C1

TGT Lubricant Eye Drops/Mild To Moderate (Ophthalmic Solution)

A1

Otic AgentsB1

Otic AgentsC1

Auraphene-B (Otic Solution)C1

Clearcanal Earwax Softener (Otic Solution)C1

CVS Ear Drops (Otic Solution)

152


OTC Drug NameC1

CVS Ear Wax Removal Kit (Otic Solution)C1

CVS Earwax Removal Kit (Otic Solution)C1

CVS Earwax Removal System (Otic Solution)

C1

Ear Drops (Solution)C1

Ear Drops Earwax Removal Aid (Otic Solution)

C1

Ear Wax Cleansing (Otic Solution)C1

Ear Wax Cleansing Kit (Solution)C1

Ear Wax Drops (Otic Solution)C1

Ear Wax Removal Drops (Otic Solution)C1

Ear Wax Removal Kit (Otic Solution)C1

Ear Wax Removal System (Otic Solution)C1

Earwax Removal (Otic Solution)C1

Earwax Removal Aid (Otic Solution)C1

Earwax Removal Kit (Solution)C1

Earwax Treatment Drops (Solution)C1

EQ Ear Wax Removal Aid (Otic Solution)C1

GNP Ear Drops (Otic Solution)C1

GNP Ear Systems (Solution)C1

GNP Earwax Removal Drops (Otic Solution)

C1

GNP Earwax Removal Kit (Otic Solution)C1

Goodsense Ear Wax Removal (Otic Solution)

C1

HM Earwax Removal Aid (Solution)C1

HM Earwax Removal Kit (Solution)C1

Murine Ear (Otic Solution)C1

Murine For Ear Wax Removal System (Otic Solution)

C1

Otix (Otic Solution)C1

QC Ear Wax Removal Drops (Otic Solution)C1

QC Earwax Removal (Otic Solution)C1

RA Ear Drops (Otic Solution)

OTC Drug NameC1

RA Ear Wax Cleansing System (Otic Solution)

C1

RA Earwax Removal Kit (Otic Solution)C1

SB Ear Wax Remover (Otic Solution)C1

SM Ear Drops (Solution)A1

Respiratory Tract/Pulmonary AgentsB1

Antihistamines / DecongestantsC1

12 Hour Decongestant (Tablet Extended-Release)

C1

12 Hour Allergy-D (Tablet Extended-Release)

C1

12 Hour Nasal Decongestant/Maximum Strength (Tablet Extended-Release)

C1

Alavert (Tablet Disintegrating)C1

Aler-Cap (Capsule)C1

Aler-Dryl (Tablet)C1

Alertab (Tablet)C1

Alka-Seltzer Plus Allergy Fast Relief Formula (Tablet)

C1

All Day Allergy (Tablet)C1

All Day Allergy D-12 (Tablet Extended-Release)

C1

All Day Allergy-D (Tablet Extended-Release)

C1

Aller-Chlor (Tablet)C1

Allergy & Congestion Relief (Tablet Extended-Release)

C1

Allergy (12mg Tablet Extended-Release, 4mg Tablet, 10mg Tablet)

C1

Allergy 24 Hour Indoor/Outdoor (Tablet)C1

Allergy Children's (Syrup)C1

Allergy D-12 (Tablet Extended-Release)C1

Allergy Medication (Capsule)C1

Allergy Medication (Tablet)C1

Allergy Medication Children's (Liquid)C1

Allergy Non-Drowsy (Tablet)

153


OTC Drug NameC1

Allergy Relief (4mg Tablet, 25mg Tablet, 10mg Tablet Disintegrating, 10mg Tablet)

C1

Allergy Relief Child (Syrup)C1

Allergy Relief Children's (12.5mg/5ml Liquid, 12.5mg Tablet Disintegrating)

C1

Allergy Relief D (Tablet Extended-Release)C1

Allergy Relief D-24 (Tablet Extended-Release)

C1

Allergy Relief Loratadine (Tablet)C1

Allergy Relief Nasal Decongestant (Tablet Extended-Release)

C1

Allergy Relief Nighttime (Tablet)C1

Allergy Relief/Indoor/Outdoor (Tablet)C1

Allergy Relief/Nasal Decongestant (Tablet Extended-Release)

C1

Allergy Relief-D (Tablet Extended-Release)C1

Allergy Tablets (Tablet)C1

Allergy-Relief-D (Tablet Extended-Release)C1

Allergy-Time (Tablet)C1

Anti-Hist Allergy (Tablet)C1

Banophen (Liquid)C1

Banophen (Tablet)C1

Cetirizine HCL (10mg Tablet Chewable, 5mg Tablet Chewable, 5mg Tablet)

C1

Cetirizine HCL Children's (10mg Tablet Chewable, 5mg Tablet Chewable)

C1

Cetirizine HCL/Pseudoephedrine HCL ER (Tablet Extended-Release)

C1

Cetirizine Hydrochloride (Tablet)C1

Children's Allergy (Liquid)C1

Children's Loratadine (Syrup)C1

Children's Silfedrine (Liquid)C1

Chlorhist (Tablet)C1

Chlorphen SR (Tablet Extended-Release)C1

Chlorpheniramine Maleate (Tablet Extended-Release)

OTC Drug NameC1

Claritin Allergy Children's (Syrup)C1

Complete Allergy Medication (Tablet)C1

Complete Allergy Medicine (Capsule)C1

Complete Allergy Medicine (Tablet)C1

Complete Allergy Relief (Tablet)C1

Cough Daytime/Nighttime (Liquid)C1

CVS 12 Hour Nasal Decongestant (Tablet Extended-Release)

C1

CVS Allergy (Capsule)C1

CVS Allergy (Tablet)C1

CVS Allergy Relief (Tablet Extended-Release)

C1

CVS Allergy Relief Adult Maximum Strength (Liquid)

C1

CVS Allergy Relief Children's (Tablet)C1

CVS Allergy Relief Nighttime (Tablet)C1

CVS Allergy Relief-D (Tablet Extended-Release)

C1

CVS Allergy Relief-D12 (Tablet Extended-Release)

C1

CVS Children's Allergy (Liquid)C1

CVS Children's Allergy Relief (Liquid)C1

CVS Daytime/Nighttime Cough Relief (Liquid)

C1

CVS Dye-Free Allergy (Tablet)C1

CVS Indoor/Outdoor Allergy Relief (Tablet)C1

CVS Indoor/Outdoor Allergy Relief Children's (Tablet Chewable)

C1

CVS Loratadine (Tablet)C1

CVS Nasal Decongestant (Tablet)C1

CVS Nighttime Cough (Liquid)C1

CVS Nighttime Tussin DM (Liquid)C1

CVS Sleep-Aid Nighttime (Tablet)C1

CVS Ultra Sleep (Tablet)C1

Decongestant (Tablet)

154


OTC Drug NameC1

Decongestant 12Hour Maximum Strength (Tablet Extended-Release)

C1

Diabetic Tussin Allergy (Syrup)C1

Diphen (Tablet)C1

Diphenhist (12.5mg/5ml Liquid, 25mg Tablet)

C1

Diphenhydramine HCL (Tablet)C1

Diphenhydramine Hydrochloride (Liquid)C1

Diphenhydramine Hydrochloride Children's Dye Free (Liquid)

C1

Dye-Free Allergy Relief Children's (Liquid)C1

ED Chlorped Jr (Syrup)C1

EQ Allergy & Congestion Relief (Tablet Extended-Release)

C1

EQ Allergy (Capsule)C1

EQ Allergy Children's (Syrup)C1

EQ Allergy Relief (Capsule)C1

EQ Allergy Relief (Tablet)C1

EQ Allergy Relief Children's (Tablet)C1

EQ Allergy Relief D 24 Hour (Tablet Extended-Release)

C1

EQ Cetirizine Hydrochloride Children's (Tablet Chewable)

C1

EQ Children's Loratadine (Syrup)C1

EQ Chlortabs (Tablet)C1

EQ Loratadine (Tablet Disintegrating)C1

EQ Loratadine (Tablet)C1

EQ Loratadine Children's (Tablet Chewable)

C1

EQ Night Time Cough (Liquid)C1

EQ Suphedrine (Tablet)C1

EQL All Day Allergy (Tablet)C1

EQL All Day Allergy-D (Tablet Extended-Release)

C1

EQL Allergy (Tablet)C1

EQL Allergy Relief (Capsule)

OTC Drug NameC1

EQL Allergy Relief (Tablet)C1

EQL Allergy Relief Children's (Tablet)C1

EQL Allergy/Congestion Relief (Tablet Extended-Release)

C1

EQL Children's Allergy (Liquid)C1

EQL Nasal Decongestant (Tablet)C1

EQL Nasal Decongestant Maximum Strength (Tablet)

C1

EQL Nighttime Cough Relief (Liquid)C1

EQL Nighttime Sleep Aid (Tablet)C1

Genahist (Capsule)C1

Genaphed (Tablet)C1

Geri-Dryl (Capsule)C1

Geri-Dryl (Liquid)C1

Geri-Dryl Allergy Relief (Tablet)C1

GNP All Day Allergy (Tablet)C1

GNP All Day Allergy-D (Tablet Extended-Release)

C1

GNP Allergy & Congestion Relief (Tablet Extended-Release)

C1

GNP Allergy (4mg Tablet, 25mg Tablet)C1

GNP Allergy AntihistamineChildren's (Liquid)

C1

GNP Allergy Relief (12.5mg Tablet Chewable, 10mg Tablet)

C1

GNP Allergy Relief For Kids (Tablet)C1

GNP Children's Allergy (Liquid)C1

GNP Loratadine (5mg/5ml Syrup, 10mg Tablet)

C1

GNP Loratadine Children's (Syrup)C1

GNP Loratadine-D 12Hr (Tablet Extended-Release)

C1

GNP Loratadine-D 24 Hour (Tablet Extended-Release)

C1

GNP Nasal Decongestant (Tablet)

155


OTC Drug NameC1

GNP Nasal Decongestant/Maximum Strength (Tablet)

C1

GNP Night Time Cough (Liquid)C1

GNP Pseudoephedrine HCL 12 Hour (Tablet Extended-Release)

C1

GNP Pseudoephedrine HCL ER (Tablet Extended-Release)

C1

GNP Sleep Aid (Tablet)C1

GNP Suphedrin (Liquid)C1

GNP Tussin DM Max (Liquid)C1

Goodsense All Day Allergy (Tablet)C1

Goodsense Allergy Relief (Tablet)C1

HM All Day Allergy (Tablet)C1

HM Allergy & Congestion (Tablet Extended-Release)

C1

HM Allergy (Tablet)C1

HM Allergy Children's (Liquid)C1

HM Allergy Complete-D (Tablet Extended-Release)

C1

HM Allergy Relief & Nasal Decongestant (Tablet Extended-Release)

C1

HM Allergy Relief (4mg Tablet, 25mg Tablet)

C1

HM Allergy Relief Children's (Liquid)C1

HM Allgery Multi Symptom (Capsule)C1

HM Cetirizine Hydrochloride (Tablet)C1

HM Loratadine (Tablet)C1

HM Loratadine Children's (Syrup)C1

HM Nasal Decongestant (Tablet)C1

HM Nasal Decongestant 12 Hour (Tablet Extended-Release)

C1

HM Sleep Aid (Tablet)C1

KLS Allerclear (Tablet)C1

KLS Allerclear D-12 Hr (Tablet Extended-Release)

OTC Drug NameC1

KLS Allerclear D-12Hr (Tablet Extended-Release)

C1

KLS Allerclear D-24Hr (Tablet Extended-Release)

C1

KLS Allerclear-D 24Hr (Tablet Extended-Release)

C1

KLS Allergy Medicine (Tablet)C1

KLS Aller-Tec (Tablet)C1

KLS Aller-Tec D (Tablet Extended-Release)C1

KP Cetirizine HCl (Tablet)C1

KP Cetirizine Hydrochloride (Tablet)C1

KP Diphenhydramine HCl (Capsule)C1

KP Loratadine (Tablet)C1

KP Pseudoephedrine HCl (Tablet)C1

Loradamed (Tablet)C1

Loratadine (Tablet)C1

Loratadine Children's (5mg/ml Syrup, 5mg Tablet Chewable)

C1

Loratadine Hives Relief (Syrup)C1

Loratadine/Pseudoephedrine (Tablet Extended-Release)

C1

Loratadine-D 12Hr (Tablet Extended-Release)

C1

Loratadine-D 24Hr (Tablet Extended-Release)

C1

Medi-Phedryl (Capsule)C1

Meijer Allergy Relief (Tablet Disintegrating)C1

Meijer Allergy Relief (Tablet)C1

Meijer Allergy Relief-D (Tablet Extended-Release)

C1

Meijer Allergy/Congestion Relief (Tablet Extended-Release)

C1

Meijer Antihistamine Allergy (Capsule)C1

Meijer Loratadine (Syrup)C1

Meijer Nasal Decongestant (Tablet)C1

MM Cetirizine Hydrochloride (Tablet)

156


OTC Drug NameC1

MM Loratadine-D 24 Hour (Tablet Extended-Release)

C1

Naramin (Liquid)C1

Nasal Decongestant (30mg/5ml Liquid, 30mg/5ml Syrup, 30mg Tablet)

C1

Nasal Decongestant 12 Hour Sinus (Tablet Extended-Release)

C1

Nasal Decongestant Maximum Strength (Tablet)

C1

Nighttime Cough (Liquid)C1

Nite Time Cough (Liquid)C1

Pediacare Children's Allergy (Liquid)C1

Pediaclear Cough Children's (Liquid)C1

Pharbechlor (Tablet)C1

Pharbedryl (Capsule)C1

Pseudoephedrine (Syrup)C1

Pseudoephedrine HCL (Tablet)C1

Pseudoephedrine HCL ER (Tablet Extended-Release)

C1

Pseudoephedrine Hydrochloride (Tablet)C1

PX Allergy (Capsule)C1

PX Allergy (Liquid)C1

PX Allergy (Tablet)C1

PX Allergy Relief (Tablet Disintegrating)C1

PX Allergy Relief (Tablet)C1

PX Allergy Relief D (Tablet Extended-Release)

C1

PX Nasal Decongestant (Tablet Extended-Release)

C1

PX Nasal Decongestant (Tablet)C1

PX Nitetime Cough (Liquid)C1

QC All Day Allergy (Tablet)C1

QC Allergy Relief (Tablet Disintegrating)C1

QC Allergy Relief (Tablet)C1

QC Allergy Relief Children's (Syrup)C1

QC Chlor-Pheniramine (Tablet)

OTC Drug NameC1

QC Complete Allergy Medicine (Tablet)C1

QC Loratadine Allergy Relief (Tablet)C1

QC Loratadine-D (Tablet Extended-Release)

C1

QC Nighttime Cough (Liquid)C1

QC Suphedrine (Tablet)C1

QC Suphedrine Maximum Strength (Tablet Extended-Release)

C1

RA Allergy (Liquid)C1

RA Allergy (Tablet)C1

RA Allergy Medication (Capsule)C1

RA Allergy Medication (Tablet)C1

RA Allergy Medication Children's (Liquid)C1

RA Allergy Relief (Capsule)C1

RA Allergy Relief (Tablet Disintegrating)C1

RA Allergy Relief (Tablet)C1

RA Allergy Relief 24 Hour (Tablet)C1

RA Allergy Relief Children's (Tablet)C1

RA Allergy/Congestion Relief (Tablet Extended-Release)

C1

RA Cetiri-D (Tablet Extended-Release)C1

RA Cetirizine (Tablet)C1

RA Cetirizine Children's (Tablet Chewable)C1

RA Chlorpheniramine Maleate (Tablet)C1

RA Complete Allergy (Tablet)C1

RA Diphedryl Allergy (Liquid)C1

RA Lorata-D (Tablet Extended-Release)C1

RA Loratadine (Syrup)C1

RA Loratadine (Tablet Disintegrating)C1

RA Loratadine (Tablet)C1

RA Loratadine Children's (Syrup)C1

RA Night Sleep Aid (Tablet)C1

RA Nighttime Cough Relief (Liquid)C1

RA Nite Time Cough (Liquid)

157


OTC Drug NameC1

RA Sleep Aid (Tablet)C1

RA Suphedrine (Tablet Extended-Release)C1

RA Suphedrine (Tablet)C1

RA Tussin Nighttime Cough DM/Maximum Strength/Adult (Liquid)

C1

Robitussin Nightime Cough DM Maximum Strength (Liquid)

C1

Robitussin Nighttime Cough DM (Liquid)C1

Safe Tussin PM (Liquid)C1

SB Allergy (Capsule)C1

SB Allergy (Tablet)C1

SB Allergy Medicine (Liquid)C1

SB Allergy Medicine (Tablet)C1

SB Allergy Relief (Tablet Disintegrating)C1

SB Allergy Relief/Nasal Decongestant (Tablet Extended-Release)

C1

SB Chlorpheniramine (Tablet)C1

SB Loratadine (Syrup)C1

SB Loratadine (Tablet)C1

SB Loratadine Allergy Relief (Tablet)C1

SB Nighttime Cough (Liquid)C1

Shopko Allergy Relief-D (Tablet Extended-Release)

C1

Shopko Nasal Decongestant (Tablet Extended-Release)

C1

Shopko Nasal Decongestant Maximum Strength (Tablet)

C1

Siladryl Allergy (Liquid)C1

Silphen Cough (Syrup)C1

Sleep Aid (Tablet)C1

SM 12 Hour Sinus Decongestant (Tablet Extended-Release)

C1

SM All Day Allergy (Tablet)C1

SM All Day Allergy-D (Tablet Extended-Release)

C1

SM Allergy 4 Hour (Tablet)

OTC Drug NameC1

SM Allergy Children's (Syrup)C1

SM Allergy Relief (12.5mg/ml Liquid, 25mg Tablet)

C1

SM Allergy Relief Children's (Liquid)C1

SM Children's Loratadine (Syrup)C1

SM Loratadine (Syrup)C1

SM Loratadine (Tablet)C1

SM Loratadine Allergy Relief (Tablet Disintegrating)

C1

SM Lorata-Dine D (Tablet Extended-Release)

C1

SM Loratadine D 12Hr (Tablet Extended-Release)

C1

SM Nasal Decongestant Maximum Strength (Tablet)

C1

SM Sleep Aid (Tablet)C1

Sudafed 12 Hour (Tablet Extended-Release)

C1

Sudafed Sinus Congestion 12 Hour (Tablet Extended-Release)

C1

Sudogest (30mg Tablet, 60mg Tablet)C1

Sudogest 12 Hour (Tablet Extended-Release)

C1

Sudogest Maximum Strength (Tablet)C1

SW Allergy Relief-D (Tablet Extended-Release)

C1

TGT All Day Allergy Relief (Tablet)C1

TGT All Day Allergy-D (Tablet Extended-Release)

C1

TGT Allergy & Congestion Relief (Tablet Extended-Release)

C1

TGT Allergy Melts Children's (Tablet)C1

TGT Allergy Relief (Capsule)C1

TGT Allergy Relief (Tablet Disintegrating)C1

TGT Allergy Relief (Tablet)C1

TGT Allergy Relief Children's (Liquid)

158


OTC Drug NameC1

TGT Allergy Relief Children's Dye Free (Liquid)

C1

TGT Allergy+ Congestion Relief-D (Tablet Extended-Release)

C1

TGT Loratadine Children's (Syrup)C1

TGT Sinus 12 Hour (Tablet Extended-Release)

C1

Total Allergy (Tablet)C1

Total Allergy Medicine (Liquid)C1

Triaminic Allerchews (Tablet Disintegrating)

C1

Vicks Dayquil/Nyquil Cough (Liquid)C1

Wal-Dryl Allergy (Capsule)C1

Wal-Dryl Allergy (Liquid)C1

Wal-Dryl Allergy (Tablet)C1

Wal-Dryl Allergy Children's (Liquid)C1

Wal-Dryl Allergy Dye-FreeChildren's (Liquid)

C1

Wal-Dryl Allergy Relief Children's (Tablet)C1

Wal-Finate (Tablet)C1

Wal-Itin (Syrup)C1

Wal-Itin (Tablet Disintegrating)C1

Wal-Itin (Tablet)C1

Wal-Itin Allergy Relief Reditabs (Tablet Disintegrating)

C1

Wal-Itin Aller-Melts (Tablet Disintegrating)C1

Wal-Itin Children's (Syrup)C1

Wal-Itin D (Tablet Extended-Release)C1

Wal-Itin D 24 Hour (Tablet Extended-Release)

C1

Wal-Phed (Tablet)C1

Wal-Phed 12 Hour (Tablet Extended-Release)

C1

Wal-Phed D (Tablet Extended-Release)C1

Wal-Som (Tablet)C1

Wal-Vert (Tablet Disintegrating)

OTC Drug NameC1

Wal-Zyr (Tablet)C1

Wal-Zyr Children's (Tablet Chewable)C1

Wal-Zyr D (Tablet Extended-Release)C1

Zephrex-D (Tablet)B1

Intranasal SpraysC1

Allergy Nasal Spray 24 Hour (Suspension)C1

Budesonide Nasal Spray (Suspension)C1

CVS Budesonide Nasal Spray (Suspension)

C1

CVS Nasal Allergy Spray (Suspension)C1

EQ Budesonide Nasal Spray (Suspension)C1

EQ Nasal Allergy Spray (Suspension)C1

GNP 24 Hour Nasal Allergy Spray (Suspension)

C1

GNP Budesonide Nasal Spray (Suspension)

C1

Goodsense Nasal Allergy Spray (Suspension)

C1

Nasacort Allergy 24Hr (Suspension)C1

Nasacort Allergy 24Hr Children's

(Suspension)C1

Nasal Allergy 24 Hour (Suspension)C1

Nasal Allergy 24 Hour Multi-Symptom (Suspension)

C1

RA Budesonide Nasal Spray (Suspension)C1

RA Nasal Allergy Spray (Suspension)C1

Rhinocort Allergy (Suspension)B1

Respiratory AgentsC1

Nasal Mist (Solution)C1

Pulmosal (Solution)C1

Simply Saline Baby (Solution)C1

Sodium Chloride (0.9% Solution, 10%, Solution, 3% Solution, 7% Solution)

C1

Triamcinolone Acetonide (Suspension)A1

Therapeutic Nutrients/Minerals/ElectrolytesB1

Vitamins / Nutrients / Supplements

159


OTC Drug NameC1

600+D3 Plus Minerals (Tablet Chewable)C1

50+ Adult Eye Health (Capsule)C1

A Thru Z Advanced (Tablet)C1

A Thru Z Advanced Adult Formula (Tablet)C1

A Thru Z High Potency (Tablet)C1

A Thru Z Select (Tablet Chewable)C1

A Thru Z Select (Tablet)C1

A Thru Z Select 50+ Advanced Formula (Tablet)

C1

A Thru Z Select 50+ Mens (Tablet)C1

A Thru Z Select Advanced (Tablet)C1

A Thru Z Select Ultimate Womens (Tablet)C1

A Thru Z Ultimate Mens (Tablet)C1

A-10000 (Capsule)C1

A-25 (Capsule)C1

ABC Plus (Tablet)C1

ABC Plus Senior (Tablet)C1

ABC Plus Senior Adults 50+ (Tablet)C1

Abdek (Tablet Chewable)C1

Abdek Pediatric (Drops)C1

Acerola C-500 (Tablet Chewable)C1

Act Anticavity Fluoride Rinse (Rinse)C1

Act Anticavity Fluoride Rinse Kids (Rinse)C1

Act Restoring Fluoride Rinse (Rinse)C1

Act Total Care (Rinse)C1

Act Total Care Dry Mouth (Rinse)C1

Actical (Capsule)C1

ADC/Fluoride (Solution)C1

Adult Gummy (Tablet Chewable)C1

Advanced Calcium Formula (Tablet)C1

Advanced Eye Health (Capsule)C1

Advanced Multi EA (Tablet Chewable)C1

Advantage Care Oral Electrolyte Pediatric (Oral Solution)

OTC Drug NameC1

Airborne (Tablet Chewable)C1

Airborne (Tablet)C1

Airborne Gummies (Tablet Chewable)C1

Airborne Immune System (Tablet Chewable)

C1

Alive Gummies For Children (Tablet Chewable)

C1

Alive Multi-Vitamin Children's Chewable (Tablet Chewable)

C1

Alph-E (Capsule)C1

Alph-E-Mixed (200unit Capsule, 400unit Capsule)

C1

Alph-E-Mixed 1000 (Capsule)C1

Amoryn Mood Booster (Capsule)C1

Animal Chews (Tablet Chewable)C1

Animal Shapes (Tablet Chewable)C1

Animal Shapes/Iron (Tablet Chewable)C1

Antioxidant (Capsule)C1

Anti-Oxidant (Tablet)C1

Anti-Oxidant Formula (Capsule)C1

Antioxidant Formula/Minerals (Capsule)C1

Antioxidant Protection Formula (Tablet)C1

Antioxidant Vitamins (Tablet)C1

Antioxin 4000 (Capsule)C1

Aqueous Vitamin D Infants (Liquid)C1

Aqueous Vitamin E (Solution)C1

Ascocid-Iso-Ph (Powder)C1

Ascorbic Acid (250mg Tablet Chewable, 250mg Tablet, 500mg Tablet, 1000mg Tablet)

C1

Asco-Tabs-1000 (Tablet)C1

Avoria Cal+D (Packet)C1

B Complex (Capsule)C1

B-1 (100mg, 250mg Tablet)C1

B-1 (Tablet)

160


OTC Drug NameC1

B-1 High Potency (Tablet)C1

B-1 Natural (Tablet)C1

B-12 (Capsule)C1

B-12 (Lozenge)C1

B-12 (Tablet Extended-Release)C1

B-12 (Tablet)C1

B-12 Fast Dissolve (Tablet)C1

B-12 Super Strength (Liquid)C1

B-12 TR (Tablet Extended-Release)C1

B-12-Sl (Tablet)C1

B-2 (Tablet)C1

B-6 (Tablet)C1

B-6 Natural (Tablet)C1

Baby Super Daily D3 (Drops)C1

Baby Vitamin D3 Drops (Drops)C1

B-Complex (Capsule)C1

B-Complex 50 (Tablet)C1

B-Complex 50 TR (Tablet Extended-Release)

C1

B-Complex High Potency (Tablet Extended-Release)

C1

B-Complex Plus Vitamin C (Tablet)C1

B-Complex With B-12 (Tablet)C1

B-Complex/B-12 (Liquid)C1

B-Complex/B-12 (Tablet)C1

BD Posiflush (Solution)C1

Berocca (Tablet)C1

Biocel (Tablet)C1

Bio-D-Mulsion (Drops)C1

Bio-D-Mulsion Forte (Drops)C1

Biosupp (Liquid)C1

Biotin Plus/Calcium/Vit D3 (Tablet)C1

Bite-A-Mins (Tablet Chewable)C1

Bite-A-Mins/Iron (Tablet Chewable)

OTC Drug NameC1

Body/Hair/Skin/Nails (Capsule)C1

Bone Density (Tablet)C1

Bone Meal (Tablet)C1

Bounty Bears/C (Tablet Chewable)C1

BP Multinatal Plus (Tablet Chewable)C1

BP Multinatal Plus (Tablet)C1

B-Plex Plus (Tablet)C1

BProtected Multi-Vite (Liquid)C1

Bprotected Pedia D-Vite (Liquid)C1

Bprotected Pedia Iron (Solution)C1

Bprotected Pedia Poly-Vite (Solution)C1

Bprotected Pedia Poly-Vite/Iron (Drops)C1

Bprotected Pedia Tri-Vite (Drops)C1

Bprotected Vitamin C/Rosehips (Liquid)C1

B-Redi/Red Hearts/Red Roosters (Tablet)C1

Brewers Yeast (Tablet)C1

Buffered Vitamin C (Capsule)C1

C 1000 (Tablet)C1

C 250 (Tablet Chewable)C1

C 250 (Tablet)C1

C 500 (Tablet Chewable)C1

C 500 (Tablet)C1

C 500/Rose Hips (Tablet)C1

C-1000 (Tablet)C1

C-1000 Prolonged Release (Tablet Extended-Release)

C1

C-1000 SR (Tablet Extended-Release)C1

C-1000/Rose Hips (Tablet)C1

C-1000/Rose Hips SR (Tablet Extended-Release)

C1

C-1500/Rose Hips SR (Tablet Extended-Release)

C1

C-250 (Tablet Chewable)C1

C-250 (Tablet)

161


OTC Drug NameC1

C-500 (Tablet Chewable)C1

C-500 (Tablet)C1

C-500 Non-Acid (Tablet)C1

C-500 Prolonged Release (Tablet Extended-Release)

C1

C-500 SR (Capsule)C1

C-500 SR (Tablet Extended-Release)C1

C-500/Rose Hips (Tablet)C1

Cal/Mag (Tablet)C1

Cal/Mag Citrate (Tablet)C1

Cal-Carb Forte (Tablet)C1

Calcet Creamy Bites (Tablet Chewable)C1

Calcet Petites (Tablet)C1

Calcidol (Solution)C1

Calciferol (Solution)C1

Calcifol (Wafer)C1

Calci-Max (Capsule)C1

Calcitrate (Tablet)C1

Calcitrate Plus D (Tablet)C1

Cal-Citrate Plus Vitamin D (Tablet)C1

Calcium & Magnesium + Zinc (Tablet)C1

Calcium (Capsule)C1

Calcium (Tablet Chewable)C1

Calcium (Tablet)C1

Calcium + D (Tablet Chewable)C1

Calcium + D + K (Tablet)C1

Calcium + D3 (Tablet)C1

Calcium 1000 + D (Tablet)C1

Calcium 1200 (Tablet Chewable)C1

Calcium 500 (Tablet)C1


Calcium 500 + D3 (Tablet Chewable)C1

Calcium 500 +D (Tablet)C1

Calcium 500 +D3 (Tablet)

OTC Drug NameC1

Calcium 500/D (Tablet Chewable)C1

Calcium 500/D (Tablet)C1

Calcium 500/Vitamin D (Tablet)C1

Calcium 500/Vitamin D3 (Tablet)C1

Calcium 500+D (Tablet)C1

Calcium 500+D High Potency (Tablet)C1

Calcium 500+D3 (Tablet)C1

Calcium 600 (Tablet)C1


Calcium 600 + Minerals (Tablet)C1

Calcium 600 High Potency (Tablet)C1

Calcium 600 With Vitamin D (Tablet Chewable)

C1

Calcium 600 With Vitamin D (Tablet)C1

Calcium 600/Magnesium 300/Vitamin D

(Capsule)C1

Calcium 600/Vitamin D (Tablet)C1

Calcium 600/Vitamin D3 (Tablet)C1

Calcium 600+D (Tablet)C1

Calcium 600+D High Potency (Tablet)C1

Calcium 600+D Plus Minerals (Tablet Chewable)

C1

Calcium 600+D Plus Minerals (Tablet)C1

Calcium 600+D3 (Tablet)C1

Calcium 600+D3 Plus Minerals (Tablet Chewable)

C1

Calcium 600+D3 Plus Minerals (Tablet)C1

Calcium 600-D (Tablet)C1

Calcium Acetate (Tablet)C1

Calcium Ascorbate (Tablet)C1

Calcium Aspartate (Tablet)C1

Calcium Carbonate (Tablet)C1

Calcium Carbonate (Wafer)C1

Calcium Carbonate/D3 (Tablet)C1

Calcium Carbonate/Vitamin D (Tablet)

162


OTC Drug NameC1

Calcium Chews (Tablet Chewable)C1

Calcium Citrate (Oral Granules)C1

Calcium Citrate (Tablet)C1

Calcium Citrate + (Tablet)C1

Calcium Citrate + D (Tablet)C1

Calcium Citrate + D3 (Tablet)C1

Calcium Citrate + D3 Maximum (Tablet)C1

Calcium Citrate +D (Tablet)C1

Calcium Citrate Chewy Bite (Tablet Chewable)

C1

Calcium Citrate Malate/Vitamin D (Tablet)C1

Calcium Citrate Petite/Vitamin D (Tablet)C1

Calcium Citrate W/D (Tablet)C1

Calcium Citrate W/Vitamin D (Tablet)C1

Calcium Citrate/D3 (Tablet)C1

Calcium Citrate/Magnesium/Vitamin D

Chewable Wafers (Wafer)C1

Calcium Citrate/Vitamin D (Tablet)C1

Calcium Citrate/Vitamin D3 (Liquid)C1

Calcium Citrate/Vitamin D3 (Tablet)C1

Calcium Citrate+D (Tablet)C1

Calcium Citrate+D3 (Tablet)C1

Calcium Citrate+D3 Petites (Tablet)C1

Calcium Creamies (Tablet Chewable)C1

Calcium Extra D3 (Tablet)C1

Calcium For Women (Tablet Chewable)C1

Calcium Gluconate (Tablet)C1

Calcium Gluconate/Dextrose (Solution)C1

Calcium Gluconate/Sodium Chloride

(Solution)C1

Calcium Gummies (Tablet Chewable)C1

Calcium High Potency (Tablet)C1

Calcium High Potency + Vitamin D (Tablet)C1

Calcium Lactate (Tablet)

OTC Drug NameC1

Calcium Magnesium & Zinc (Tablet)C1

Calcium Magnesium 750 (Tablet)C1

Calcium Oyster Shell (Tablet)C1

Calcium Plus D3 Absorbable (Capsule)C1

Calcium Plus Vitamin D (Capsule)C1

Calcium Plus Vitamin D3 (Capsule)C1

Calcium Plus Vitamin D3 (Tablet)C1

Calcium Soft Chews (Tablet Chewable)C1

Calcium Soft Chews (Tablet Chewable)C1

Calcium/C/D (Tablet Chewable)C1

Calcium/D (Wafer)C1

Calcium/D3 Adult Gummies (Tablet Chewable)

C1

Calcium/Magnesium (Tablet)C1

Calcium/Magnesium (Tablet)C1

Calcium/Magnesium Citrate (Tablet)C1

Calcium/Magnesium/Vitamind (Tablet)C1

Calcium/Magnesium/Zinc (Tablet)C1

Calcium/Vitamin D (Capsule)C1

Calcium/Vitamin D (Tablet)C1

Calcium/Vitamin D/Minerals (Tablet Chewable)

C1

Calcium/Vitamin D3 (Capsule)C1

Calcium/Vitamin D-3 (Tablet Chewable)C1

Calcium/Vitamin D3 (Tablet)C1

Calcium/Vitamin D3 Gummies (Tablet

Chewable)C1

Calcium/Vitamin D3 Gummies (Tablet Chewable)

C1

Calcium/Vitamin D3/Adult Gummy (Tablet Chewable)

C1

Calcium+D3 (Tablet)C1

Calcium+D3 Gradual Release (Tablet Extended-Release)

C1

Calcium+Menaq7 (Tablet)

163


OTC Drug NameC1

Calcium-Folic Acid Plus D (Wafer)C1

Calciumvitamin D3 Plus Minerals (Tablet Chewable)

C1

Cal-Mag (Tablet)C1

Cal-Mag Aspartate (Tablet)C1

Cal-Mag Chela-Max (Capsule)C1

Cal-Mag Complex (Tablet)C1

Calmag Thins (Tablet)C1

Cal-Quick (Liquid)C1

Caltrate 600 (Tablet)C1

Caltrate 600+D Plus Minerals (Tablet

Chewable)C1

Caltrate 600+D Plus Minerals (Tablet)C1

Caltrate 600+D3 (Tablet)C1

Caltrate 600+D3 Soft Chews (Tablet

Chewable)C1

Caltrate Gummy Bites (Tablet Chewable)C1

Caltrate Minis Plus Minerals (Tablet)C1

Carravite (Tablet)C1

C-Chewable (Tablet Chewable)C1

Celebrate Calcium Citrate (Tablet Chewable)

C1

Celebrate Calcium Plus 500 (Tablet

Chewable)C1

Cemill (Tablet Extended-Release)C1

Cemill SR (Tablet Extended-Release)C1

Centamin (Liquid)C1

Centavite (Liquid)C1

Centavite A-Z Complete Multivitamin/Minerals (Tablet)

C1

Centravites (Tablet)C1

Centravites 50 Plus (Tablet)C1

Centrum Kids Complete (Tablet Chewable)C1

Century (Tablet)C1

Century Mature (Tablet)

OTC Drug NameC1

Ceralyte 70 (Oral Solution)C1

Cerovite Advanced Formula (Tablet)C1

Cerovite Jr (Tablet Chewable)C1

Cerovite Senior (Tablet)C1

Certa Plus (Tablet)C1

Certagen (Tablet)C1

Certavite/Antioxidants (Tablet)C1

Chelated Calcium (Tablet)C1

Chelated Magnesium (Tablet)C1

Chelated Potassium (Tablet)C1

Chewable Calcium (Tablet Chewable)C1

Chewable Vitamin C (Tablet Chewable)C1

Chewable Vitamins Children's (Tablet Chewable)

C1

Chewable Vite Children's (Tablet Chewable)

C1

Chewable Vite With Iron/Children's (Tablet Chewable)

C1

Chew-C (Tablet Chewable)C1

Children's Animal Shapes Complete (Tablet Chewable)

C1

Children's Chewable Multivitamin (Tablet Chewable)

C1

Children's Chewable Multivitamin With Iron (Tablet Chewable)

C1

Children's Chewable Vitamin (Tablet Chewable)

C1

Children's Chewable Vitamins (Tablet Chewable)

C1

Children's Chewable Vitamins/Iron (Tablet Chewable)

C1

Children's Gummies (Tablet Chewable)C1

Children's Multivitamin (Tablet Chewable)C1

Chlorocaps (Capsule)C1

Citracal + D3 Maximum (Tablet)

164


OTC Drug NameC1

Citracal Calcium Gummies (Tablet

Chewable)C1

Citracal Calcium+D Slow Release (Tablet

Extended-Release)C1

Citracal Maximum (Tablet)C1

Citracal Petites/Vitamin D (Tablet)C1

Citracal+D3 (Tablet Chewable)C1

Citrate Of Magnesia (Solution)C1

Citroma (Solution)C1

Citrus Calcium +D (Tablet)C1

Citrus Calcium/Vitamin D (Tablet)C1

Classic Prenatal (Tablet)C1

Co Q-10 (Capsule)C1

Co Q-10 Maximum Strength (Capsule)C1

Cod Liver Oil (Capsule)C1

Cod Liver Oil W/Vitamins A&D (Capsule)C1

Cod Liver Oil/Low Vitamin A (Capsule)C1

Cod Liver Oil/Vitamins A & D (Capsule)C1

Co-Enzyme Q-10 (Capsule)C1

Coenzyme Q10 (Liquid)C1

Co-Enzyme Q-10 (Tablet)C1

Coenzyme Q-10 High Potency (Capsule)C1

Companion (Tablet)C1

Compete (Tablet)C1

Complere (Tablet)C1

Complete (Tablet)C1

Complete Daily With Lutein (Tablet)C1

Complete Energy (Tablet)C1

Complete Multi-Vitamin Gummies (Tablet Chewable)

C1

Complete Multivitamin/Multimineral Supplement (Liquid)

C1

Complete PMS Support Complex (Capsule)

C1

Complete Womens (Tablet)

OTC Drug NameC1

Coq-10 (Capsule)C1

Coq-10 Fast Dissolve (Tablet)C1

Coq10 Gummies Adult (Tablet Chewable)C1

Coq10 Maximum Strength (Capsule)C1

Coral Calcium (Capsule)C1

Coral Calcium (Capsule)C1

Coral Calcium Plus (Capsule)C1

Coral Calcium Plus (Capsule)C1

Corvite Free (Tablet)C1

Crest Complete (Paste)C1

Crest Pro-Health Complete (Rinse)C1

Crush Vitamin C Drops (Lozenge)C1

C-Time SR (Capsule)C1

CVS Airshield (Tablet)C1

CVS B-1 (Tablet)C1

CVS B-12 (Liquid)C1

CVS B-12 (Tablet Chewable)C1

CVS B-12 (Tablet)C1

CVS B-12 Gummies (Tablet Chewable)C1

CVS B-6 (Tablet)C1

CVS Balanced B100 (Tablet Extended-Release)

C1

CVS Calcium (Tablet Chewable)C1

CVS Calcium (Tablet)C1

CVS Calcium 600 & Vitamind3 (Tablet)C1

CVS Calcium 600 + D Plus Minerals (Tablet Chewable)

C1

CVS Calcium 600 + D Plus Minerals (Tablet)

C1

CVS Calcium 600+D (Tablet)C1

CVS Calcium Carbonate (Tablet)C1

CVS Calcium Citrate + D (Tablet)C1

CVS Calcium Citrate +D3 Miniatures (Tablet)

165


OTC Drug NameC1

CVS Calcium Soft Chews (Tablet Chewable)

C1

CVS Calcium/Magnesium/Zinc (Tablet)C1

CVS Chewable Children's Vitamin (Tablet Chewable)

C1

CVS Children's Chewable Complete (Tablet Chewable)

C1

CVS Citrate Of Magnesia (Solution)C1

CVS Cod Liver Oil (Capsule)C1

CVS Coenzyme Q-10 (Capsule)C1

CVS Coq-10 (Capsule)C1

CVS D3 (Capsule)C1

CVS D3 (Tablet Chewable)C1

CVS Daily Gummies (Tablet Chewable)C1

CVS Daily Multiple (Tablet)C1

CVS Daily Multiple For Men (Tablet)C1

CVS Daily Multiple For Women (Tablet)C1

CVS Daily Multiple For Women 50+ (Tablet)

C1

CVS Daily Multiple Plus Iron/Calcium/Zinc (Tablet)

C1

CVS Diabetes Health Support (Pack)C1

CVS E (Capsule)C1

CVS Electrolyte Solution (Oral Solution)C1

CVS Eye Health & Lutein (Tablet)C1

CVS Folic Acid (Tablet)C1

CVS Glucose (Gel)C1

CVS Glucose Liquid Shot (Liquid)C1

CVS Glucose Shot (Liquid)C1

CVS Gummy Dinos (Tablet Chewable)C1

CVS Gummy Dinos Children's (Tablet Chewable)

C1

CVS Gummy Multivitamin Kids (Tablet Chewable)

C1

CVS Iron (Tablet)C1

CVS Magnesium (Tablet)

OTC Drug NameC1

CVS Magnesium Citrate (Capsule)C1

CVS Melatonin (Capsule)C1

CVS Melatonin (Liquid)C1

CVS Melatonin (Tablet)C1

CVS Melatonin Extra Strength (Liquid)C1

CVS Melatonin Gummies (Tablet Chewable)

C1

CVS Melatonin Instant Dissolving (Tablet)C1

CVS Melatonin Quick Dissolve (Tablet)C1

CVS Melatonin TR (Tablet Extended-Release)

C1

CVS Mens Daily Gummies (Tablet Chewable)

C1

CVS One Daily Essential (Tablet)C1

CVS One Daily Womens Formula (Tablet)C1

CVS Oyster Shell Calcium +Vitamin D (Tablet)

C1

CVS Pediatric Electrolyte (Oral Solution)C1

CVS Pediatric Electrolyte Freezer Pops (Oral Solution)

C1

CVS Prenatal (Tablet)C1

CVS Prenatal Gummies (Tablet Chewable)C1

CVS Prenatal Gummy/DHA/Folic Acid (Tablet Chewable)

C1

CVS Prenatal Multi+DHA (Capsule)C1

CVS Quality Sleep (Capsule)C1

CVS Slow Release Iron (Tablet Extended-Release)

C1

CVS Spectravite Adult 50+ (Tablet)C1

CVS Spectravite Advanced Formula (Tablet)

C1

CVS Spectravite Senior (Tablet)C1

CVS Spectravite Ultra Health Mens (Tablet)C1

CVS Spectravite Ultra Men50+ (Tablet)C1

CVS Spectravite Ultra Mens Health Senior (Tablet)

166


OTC Drug NameC1

CVS Spectravite Ultra Women (Tablet)C1

CVS Spectravite Ultra Womens Health Senior (Tablet)

C1

CVS Vision Formula (Tablet)C1

CVS Vitamin A (Capsule)C1

CVS Vitamin B-12 (Tablet Extended-Release)

C1

CVS Vitamin B12 (Tablet)C1

CVS Vitamin B-12 (Tablet)C1

CVS Vitamin B-12 TR (Tablet Extended-Release)

C1

CVS Vitamin B-2 (Tablet)C1

CVS Vitamin C (Tablet)C1

CVS Vitamin C/Rose Hips (Tablet)C1

CVS Vitamin D Children's Gummies (Tablet Chewable)

C1

CVS Vitamin D3 (Capsule)C1

CVS Vitamin D3 (Tablet Chewable)C1

CVS Vitamin D3 Drops/Infants (Drops)C1

CVS Vitamin E (Capsule)C1

CVS Womens Active Daily (Tablet)C1

CVS Womens Daily Gummies (Tablet Chewable)

C1

CVS Womens Prenatal+DHA (Capsule)C1

CVS Yogurt+Calcium Gummies (Tablet

Chewable)C1

Cyanocobalamin (Injection)C1

D 1000 (Capsule)C1

D 1000 (Tablet Chewable)C1

D 1000 (Tablet)C1

D 10000 (Capsule)C1

D 2000 (Tablet)C1

D 400 (Tablet Chewable)C1

D 400 (Tablet)C1

D 5000 (Capsule)

OTC Drug NameC1

D 5000 (Tablet)C1

D-1000 Extra Strength (Tablet)C1

D-2000 Maximum Strength (Tablet)C1

D2000 Ultra Strength (Capsule)C1

D3 (Capsule)C1

D3 (Tablet Chewable)C1

D3 (Tablet)C1

D3 2000 (Tablet)C1

D3 Adult (Tablet Chewable)C1

D3 Adult Gummy (Tablet Chewable)C1

D3 High Potency (Capsule)C1

D3 High Potency (Tablet)C1

D3 Kids (Tablet Chewable)C1

D3 Maximum Strength (Capsule)C1

D3 Maximum Strength (Drops)C1

D3 Super Strength (Capsule)C1

D3 Ultra Strength (Capsule)C1

D3 Vitamin (Liquid)C1

D3-1000 (Capsule)C1

D3-1000 (Tablet)C1

D-3-5 (Capsule)C1

D3-50 (Capsule)C1

D-400 (Tablet)C1

D-5000 (Tablet)C1

Daily Betic (Tablet)C1

Daily Combo Multi Vitamin (Tablet)C1

Daily Heart Health Support (Pack)C1

Daily Mens Health Formula (Tablet)C1

Daily Multi (Tablet)C1

Daily Multi 50+ (Tablet)C1

Daily Multiple Vitamins (Tablet)C1

Daily Multiple Vitamins/Minerals (Tablet)C1

Daily Multivitamin (Capsule)C1

Daily Value Multivitamin (Tablet)

167


OTC Drug NameC1

Daily Vitamin Plus (Capsule)C1

Daily Vitamins (Tablet)C1

Daily Womens Health Formula (Tablet)C1

Daily-Vitamin (Tablet)C1

Daily-Vitamin Maximum Formula (Tablet)C1

Daily-Vite (Tablet)C1

Decara (Capsule)C1

Dekas Plus (Liquid)C1

Delta D3 (Tablet)C1

Diabetes Health Formula (Tablet)C1

Dialyvite 800/Ultra D (Tablet)C1

Dialyvite Vitamin D 5000 (Capsule)C1

Dialyvite Vitamin D3 Max (Tablet)C1

Dino-Life (Tablet Chewable)C1

Dino-Life W Extra C (Tablet Chewable)C1

Disney Calcium + Vitamin D3 Gummies

(Tablet Chewable)C1

Disney Cars Gummies (Tablet Chewable)C1

Disney Princess Gummies (Tablet Chewable)

C1

Doctors Choice Multivitamins Men (Tablet)C1

Dolomite (Tablet)C1

Dry Eye Formula (Capsule)C1

E-1000 (Capsule)C1

E-200 (Capsule)C1

E-400 (Capsule)C1

E-400-Clear (Capsule)C1

E-400-Mixed (Capsule)C1

E600 (Capsule)C1

Electrolyte Solution (Oral Solution)C1

Elite Ca/Mg (Tablet)C1

Elite Calcium (Tablet)C1

Elite Magnesium (Tablet)C1

E-Max-1000 (Capsule)

OTC Drug NameC1

Endur-Acin (Tablet Extended-Release)C1

Endur-Amide (Tablet Extended-Release)C1

Endur-C/Rose Hips (Tablet Extended-Release)

C1

Enviro-Stress (Tablet)C1

E-Oil (Oil)C1

E-Pherol (Tablet)C1

EQ Calcium 500+D (Tablet)C1

EQ Calcium 600+D (Tablet)C1

EQ Calcium 600+D+Minerals (Tablet)C1

EQ Calcium Citrate+D (Tablet)C1

EQ Calcium Citrate+D3 (Tablet)C1

EQ Calcium Citrate+D3/Petites (Tablet)C1

EQ Complete Chewable Multivitamin Children's (Tablet Chewable)

C1

EQ Complete Multivitamin Adults 50+ (Tablet)

C1

EQ Complete Multivitamin Adults Under 50 (Tablet)

C1

EQ Magnesium Citrate (Solution)C1

EQ Multivitamin Gummies Children's (Tablet Chewable)

C1

EQ Multivitamins Children's Gummy (Tablet Chewable)

C1

EQ One Daily Womens Health (Tablet)C1

EQ One Daily Womens Pro-Active (Tablet)C1

EQ Slow-Release Iron (Tablet Extended-Release)

C1

EQ Vision Formula 50+ (Capsule)C1

EQL Air Protector (Tablet)C1

EQL Anticavity Fluoride Rinse Kids (Rinse)C1

EQL Anticavity Mouthwash/Multiple Benefit (Rinse)

C1

EQL B-12 (Tablet)C1

EQL B-6 (Tablet)C1

EQL Calcium 600mg/Vitamin D3 (Tablet)

168


OTC Drug NameC1

EQL Calcium Citrate W/Vitamin D (Tablet)C1

EQL Calcium Citrate/ Vitamin D3 (Tablet)C1

EQL Calcium Gummies (Tablet Chewable)C1

EQL Calcium Soft Chews (Tablet Chewable)

C1

EQL Calcium/Vitamin D (Capsule)C1

EQL Calcium/Vitamin D (Tablet)C1

EQL Century (Tablet)C1

EQL Century Mature (Tablet)C1

EQL Century Mature Men 50+ (Tablet)C1

EQL Century Mature Women 50+ (Tablet)C1

EQL Children's Multivitamins/Minerals (Tablet Chewable)

C1

EQL Coq10 (Capsule)C1

EQL Dental Travel Pack (Paste)C1

EQL Gummies Children's (Tablet Chewable)

C1

EQL Iron Supplement Therapy (Tablet)C1

EQL Magnesium Citrate (Solution)C1

EQL Melatonin/Vitamin B-6 (Tablet)C1

EQL One Daily Mens 50+ Advanced (Tablet)

C1

EQL One Daily Mens Health Formula (Tablet)

C1

EQL One Daily Womens (Tablet)C1

EQL One Daily Womens 50+ Advanced (Tablet)

C1

EQL Prenatal Formula (Tablet)C1

EQL Slow Release Iron (Tablet Extended-Release)

C1

EQL Vision Formula (Tablet)C1

EQL Vitamin B-12 (Tablet)C1

EQL Vitamin B-12 TR (Tablet Extended-Release)

C1

EQL Vitamin C (Tablet)

OTC Drug NameC1

EQL Vitamin C Gummies (Tablet Chewable)

C1

EQL Vitamin C/Rose Hips (Tablet)C1

EQL Vitamin D3 (Capsule)C1

EQL Vitamin D3 Gummies (Tablet Chewable)

C1

EQL Vitamin E (Capsule)C1

Equalyte (Oral Solution)C1

Ergocalciferol (Solution)C1

Essentia (Tablet)C1

Essential Balance (Tablet)C1

Essential One Daily Multivitamin (Tablet)C1

Ester-E (Capsule)C1

Eye Vitamins (Capsule)C1

Eyeprotect (Tablet)C1

Eye-Vites (Tablet)C1

Fa-8 (Capsule)C1

Fa-8 (Tablet)C1

Fe Gluconate (Tablet)C1

Fe Tabs (Tablet)C1

Ferate (Tablet)C1

Fergon (Tablet)C1

Ferosul (Elixir)C1

Ferosul (Tablet)C1

Ferretts (Tablet)C1

Ferro-Bob (Tablet)C1

Ferrocite (Tablet)C1

Ferrotabs (Tablet)C1

Ferrous Fumarate (Tablet)C1

Ferrous Fumarate 324 (Tablet)C1

Ferrous Gluconate (Tablet)C1

Ferrous Sulfate (Elixir)C1

Ferrous Sulfate (Liquid)C1

Ferrous Sulfate (Solution)

169


OTC Drug NameC1

Ferrous Sulfate (Tablet Extended-Release)C1

Ferrous Sulfate (Tablet)C1

Ferrous Sulfate Iron (Tablet)C1

Ferrousul (Tablet)C1

Flintstones Complete (Tablet Chewable)C1

Flintstones Gummies Plus Bone Building Support (Tablet Chewable)

C1

Flintstones Gummies Plus Omega-3 DHA (Tablet Chewable)

C1

Flintstones Plus Calcium (Tablet Chewable)

C1

Flintstones Plus Extra C (Tablet Chewable)C1

Flintstones Plus Iron (Tablet Chewable)C1

Flintstones/My First (Tablet Chewable)C1

Fluoride Mouth Rinse (Rinse)C1

Folic Acid (Capsule)C1

Folic Acid (Tablet)C1

Formula E 400 (Capsule)C1

Fruit C 500 (Tablet Chewable)C1

Fruit C-100 (Tablet Chewable)C1

Fruity C (Tablet Chewable)C1

Fruity Chewables Multivitamin (Tablet Chewable)

C1

Fruity Chews (Tablet Chewable)C1

Fruity Chews/Iron (Tablet Chewable)C1

Gerivite Complete (Tablet)C1

Gluco Burst (Gel)C1

Glucose (Gel)C1

Glucose Liquid (Liquid)C1

Glucoten (Capsule)C1

Glutose 15 (Gel)C1

Glutose 45 (Gel)C1

Glutose 5 (Gel)C1

GNP Animal Shapes (Tablet Chewable)

OTC Drug NameC1

GNP Animal Shapes Plus Extra C (Tablet Chewable)

C1

GNP Animal Shapes Plus Iron (Tablet Chewable)

C1

GNP B-12 (Tablet)C1

GNP B-Complex Plus Vitamin C (Tablet)C1

GNP Calcium (Tablet)C1

GNP Calcium 1200 (Tablet Chewable)C1

GNP Calcium 500 +D3 (Tablet)C1

GNP Calcium 500/D (Tablet)C1

GNP Calcium 600 +D/Minerals (Tablet)C1

GNP Calcium 600 +D3 (Tablet)C1

GNP Calcium 600 +D3/Minerals (Tablet Chewable)

C1

GNP Calcium 600 Plus D/Minerals (Tablet)C1

GNP Calcium 600/D (Tablet)C1

GNP Calcium Citrate +D3 (Tablet)C1

GNP Calcium Citrate+D Maximum (Tablet)C1

GNP Calcium Citrate+D3 Maximum (Tablet)

C1

GNP Calcium Plus 600 +D (Tablet)C1

GNP Calcium/Magnesium/Zinc (Tablet)C1

GNP Calcuim/Vitamin D/Minerals (Tablet Chewable)

C1

GNP Century (Tablet)C1

GNP Century Adult Formula (Tablet)C1

GNP Century Adults 50+ Senior (Tablet)C1

GNP Century Cardio Healthformula (Tablet)

C1

GNP Century Mature (Tablet)C1

GNP Century Mature Formula/Women'S 50+ (Tablet)

C1

GNP Century Ultimate Mens Complete (Tablet)

C1

GNP Century Ultimate Mens Senior Formula (Tablet)

170


OTC Drug NameC1

GNP Century Ultimate Womens Complete (Tablet)

C1

GNP Century Ultimate Womens Senior Formula (Tablet)

C1

GNP Children's Chewables W/Extra C (Tablet Chewable)

C1

GNP Children's Chewables/Extra C (Tablet Chewable)

C1

GNP Children's Chewables/Iron (Tablet Chewable)

C1

GNP Children's Complete Chewables (Tablet Chewable)

C1

GNP Co Q10 (Capsule)C1

GNP Cod Liver Oil (Capsule)C1

GNP Coenzyme Q-10 (Capsule)C1

GNP D 1000 (Capsule)C1

GNP D 2000 (Tablet Chewable)C1

GNP Daily Prenatal (Capsule)C1

GNP Diabetic Support Formula (Tablet)C1

GNP Essential One Daily (Tablet)C1

GNP Folic Acid (Tablet)C1

GNP Hair/Skin/Nails (Tablet)C1

GNP Healthy Eyes (Tablet)C1

GNP Healthy Eyes Supervision (Capsule)C1

GNP Healthy Eyes Supervision 2 (Capsule)C1

GNP Immune Support (Tablet)C1

GNP Iron (Tablet Extended-Release)C1

GNP Iron (Tablet)C1

GNP Little Ones Children's (Tablet Chewable)

C1

GNP Magnesium (Tablet)C1

GNP Magnesium Citrate (Solution)C1

GNP Maximum One Daily (Tablet)C1

GNP Mega Multi For Men (Tablet)C1

GNP Mega Multi For Women (Tablet)C1

GNP Melatonin (Tablet)

OTC Drug NameC1

GNP Melatonin Maximum Strength (Tablet)C1

GNP Niacin (Tablet)C1

GNP Niacin TR (Tablet Extended-Release)C1

GNP Norwegian Cod Liver Oil (Capsule)C1

GNP One Daily Maximum (Tablet)C1

GNP One Daily Mens 50+ Advanced (Tablet)

C1

GNP One Daily Mens Health 50+ (Tablet)C1

GNP One Daily Mens Health/Lycopene (Tablet)

C1

GNP One Daily Womens 50+ Advanced (Tablet)

C1

GNP One Daily Womens Health (Tablet)C1

GNP One Daily Womens Health 50+ (Tablet)

C1

GNP One Daily Womens Metabolism Support (Tablet)

C1

GNP Opti-Vitamins (Tablet)C1

GNP Pediatric Electrolyte (Oral Solution)C1

GNP Potassium (Tablet)C1

GNP Prenatal (Tablet)C1

GNP Slow Release Iron (Tablet Extended-Release)

C1

GNP Therapeutic-M (Tablet)C1

GNP Vitamin A & D (Ointment)C1

GNP Vitamin A (Capsule)C1

GNP Vitamin B1 (Tablet)C1

GNP Vitamin B-1 (Tablet)C1


GNP Vitamin B-12 Prolonged Release (Tablet Extended-Release)

C1

GNP Vitamin B-12 TR (Tablet Extended-Release)

C1


GNP Vitamin C (Tablet Chewable)C1

GNP Vitamin C (Tablet)

171


OTC Drug NameC1

GNP Vitamin C Drops (Lozenge)C1

GNP Vitamin C PR (Tablet Extended-Release)

C1

GNP Vitamin C TR (Tablet Extended-Release)

C1

GNP Vitamin C W/Rose Hips (Tablet)C1

GNP Vitamin C W/Rose Hips TR (Tablet Extended-Release)

C1

GNP Vitamin C/Rose Hips (Tablet)C1

GNP Vitamin D (Tablet Chewable)C1

GNP Vitamin D (Tablet)C1

GNP Vitamin D Maximum Strength (Tablet)C1

GNP Vitamin D Super Strength (Tablet)C1

GNP Vitamin D3 Extra Strength (Tablet)C1

GNP Vitamin D-400 (Tablet)C1

GNP Vitamin E (Capsule)C1

GNP Vitamin E Water Dispersible (Capsule)

C1

GNP Womens One Daily (Tablet)C1

GNP Zoochews Gummies (Tablet Chewable)

C1

Goodsense Iron (Tablet)C1

Goodsense Magnesium Citrate (Solution)C1

Goodsense Prenatal Vitamins (Tablet)C1

Gummi Bear Multivitamin/Mineral (Tablet Chewable)

C1

H2Q (Capsule)C1

Hair Formula Extra Strength (Tablet)C1

Hair Skin And Nails Formula (Tablet)C1

Hair Vitamins (Tablet)C1

Hair/Skin/Nails (Capsule)C1

Hair/Skin/Nails (Tablet)C1

Hair/Skin/Nails/Biotin (Tablet)C1

Halls Defense Vitamin C Drops (Lozenge)C1

Healthy Eyes (Tablet)

OTC Drug NameC1

Healthy Eyes/Lutein (Tablet)C1

Healthy Hair Skin & Nails (Tablet)C1

Healthy Kids Gummies (Tablet Chewable)C1

Healthy Kids Overall Health Multivitamins (Tablet Chewable)

C1

Healthy Kids Vitamin D3 (Tablet Chewable)C1

H-E-B Oral Electrolyte Solution (Oral Solution)

C1

Hemenatal OB + DHA (Capsule)C1

High Potency Calcium (Tablet)C1

High Potency Iron (Tablet)C1

Hi-Kovite 2-Part Formula (Tablet)C1

Hi-Potency Multi-Vitamin/Mineral Supplement (Tablet)

C1

HM Animal Shapes (Tablet Chewable)C1

HM Antioxidant Vitamins (Tablet)C1

HM Calcium 600 & Vitamin D3 (Tablet)C1

HM Calcium 600 + D Plus Minerals (Tablet Chewable)

C1

HM Calcium 600 + Vitamin D3 (Tablet)C1

HM Calcium Citrate + Vitamin D (Tablet)C1

HM Calcium Citrate+D3 Petite (Tablet)C1

HM Calcium Magnesium & Zinc (Tablet)C1

HM Calcium/Vitamin D (Tablet)C1

HM Calcium/Vitamin D/Minerals (Tablet)C1

HM Complete (Tablet)C1

HM Complete 50+ (Tablet)C1

HM Complete 50+ Mens Ultimate (Tablet)C1

HM Complete 50+ Womens Ultimate (Tablet)

C1

HM Complete Women (Tablet)C1

HM Coq10 (Capsule)C1

HM E Vitamin (Capsule)C1

HM Folic Acid (Tablet)C1

HM Hair/Skin/Nails (Tablet)

172


OTC Drug NameC1

HM Iron (Tablet)C1

HM Iron Slow Release (Tablet Extended-Release)

C1

HM Magnesium Citrate (Solution)C1

HM Melatonin (Tablet)C1

HM Melatonin Quick Dissolve (Tablet)C1

HM Mens 50+ Advanced One Daily (Tablet)

C1

HM Multivitamin Adult Gummy (Tablet Chewable)

C1

HM Niacin (Tablet Extended-Release)C1

HM Niacin TR (Tablet Extended-Release)C1

HM One Daily Essential (Tablet)C1

HM One Daily Mens (Tablet)C1

HM One Daily Prenatal Combo (Capsule)C1

HM One Daily Womens (Tablet)C1

HM Pediatric Electrolyte (Oral Solution)C1

HM Prenatal (Tablet)C1

HM Slow Release Iron (Tablet Extended-Release)

C1

HM Super Vitamin B12 (Tablet Chewable)C1

HM Vitamin B1 (Tablet)C1

HM Vitamin B12 (Tablet Extended-Release)C1


HM Vitamin B12 TR (Tablet Extended-Release)

C1

HM Vitamin B12 Ultra Strength (Tablet)C1


HM Vitamin C (Tablet Chewable)C1

HM Vitamin C (Tablet)C1

HM Vitamin C TR (Tablet Extended-Release)

C1

HM Vitamin C/Rose Hips (Tablet)C1

HM Vitamin D (Tablet)C1

HM Vitamin D3 (Capsule)

OTC Drug NameC1

HM Vitamin E (Capsule)C1

HM Vita-Mini Multi Complete (Tablet)C1

HM Womens 50+ Advanced One Daily (Tablet)

C1

Icaps (Capsule)C1

Icaps Areds 2 (Capsule)C1

Icaps Lutein & Omega-3 (Capsule)C1

Icaps MV (Tablet)C1

Iron (Tablet Extended-Release)C1

Iron (Tablet)C1

Iron 27 (Tablet)C1

Iron ER (Tablet Extended-Release)C1

Iron High-Potency (Tablet Extended-Release)

C1

Iron High-Potency (Tablet)C1

Iron Slow Release (Tablet Extended-Release)

C1

Iron Supplement (Elixir)C1

Iron Supplement Children's (Solution)C1

I-Vite (Tablet)C1

I-Vite Protect (Tablet)C1

Kids First Vitamin D3 Gummies (Tablet Chewable)

C1

Kosher Prenatal Plus Iron (Tablet)C1

KP Adults 50+ Daily Formula (Tablet)C1

KP Adults Daily Formula (Tablet)C1

KP Calcium 600+D (Capsule)C1

KP Calcium 600+D (Tablet)C1

KP Calcium 600+D3 (Capsule)C1

KP Calcium Citrate+D (Tablet)C1

KP Calcium/Magnesium/Zinc (Tablet)C1

KP Ferrous Gluconate (Tablet)C1

KP Ferrous Sulfate (Tablet)C1

KP Folic Acid (Tablet)C1

KP Mag-Oxide Magnesium (Tablet)

173


OTC Drug NameC1

KP Melatonin (Tablet)C1

KP Mens 50+ Daily Formula (Tablet)C1

KP Mens Daily Formula (Tablet)C1

KP Niacin (Tablet)C1

KP Prenatal Multivitamins (Tablet)C1

KP Vision Formula (Tablet)C1

KP Vision Formula W/Lutein (Tablet)C1

KP Vitamin B-12 (Tablet)C1

KP Vitamin B-6 (Tablet)C1

KP Vitamin D (Capsule)C1

KP Vitamin D (Tablet Chewable)C1

KP Vitamin D3 (Capsule)C1

KP Vitamin E (Capsule)C1

KP Womens 50+ Daily Formula (Tablet)C1

KP Womens Daily Formula (Tablet)C1

KPN Prenatal (Tablet)C1

Land Before Time Multivitamin/Iron (Tablet Chewable)

C1

Land Before Time Multivitamin/Vitamin C (Tablet Chewable)

C1

Liquid B12 (Liquid)C1

Liquid Calcium With D3 Maximum Strength (Capsule)

C1

Liquid Calcium/D3 (Capsule)C1

Liquid Calcium/Magnesium Citrate Plus Vitamin D3 (Liquid)

C1

Liquid Calcium/Vitamin D (Capsule)C1

Liquid Calcium/Vitamins A & D (Capsule)C1

Listerine Healthy White Gentle (Rinse)C1

Listerine Healthy White Vibrant (Rinse)C1

Listerine Naturals With Fluoride (Rinse)C1

Listerine Nightly Reset (Rinse)C1

Listerine Restoring (Rinse)C1

Listerine Smart Rinse (Rinse)C1

Listerine Smart Rinse Anticavity (Rinse)

OTC Drug NameC1

Listerine Total Care (Rinse)C1

Listerine Total Care Pluswhitening

(Rinse)C1

Listerine Total Care Zero (Rinse)C1

Listerine Whitening/Restoring (Rinse)C1

Little Animals (Tablet Chewable)C1

Little Animals Plus Iron (Tablet Chewable)C1

Localnesium (Tablet)C1

Localnesium-C (Tablet)C1

Lysiplex Plus (Tablet)C1

M2 Magnesium (Capsule)C1

Macular Health Formula (Capsule)C1

Macuvite (Tablet)C1

Macuvite Eye Care (Tablet)C1

Macuvite/Lutein (Tablet)C1

Magdelay (Tablet)C1

Mag-G (Tablet)C1

Magnacaps (Capsule)C1

Magnebind 300 (Tablet)C1

Magnesium (Capsule)C1

Magnesium (Tablet)C1

Magnesium 27 (Tablet)C1

Magnesium Carbonate (Powder)C1

Magnesium Chloride (Injection)C1

Magnesium Citrate (Capsule)C1

Magnesium Citrate (Solution)C1

Magnesium Citrate (Tablet)C1

Magnesium Elemental (Capsule)C1

Magnesium Elemental (Tablet)C1

Magnesium Gluconate (Tablet)C1

Magnesium L-Lactate Dihyrate (Tablet Extended-Release)

C1

Magnesium Oxide (Capsule)C1

Magnesium Oxide (Powder)

174


OTC Drug NameC1

Magnesium Oxide (Tablet)C1

Magnesium Oxide 400 (Powder)C1

Magnesium Oxide 400 (Tablet)C1

Magnesium-Oxide (Tablet)C1

Magnum-75 (Tablet)C1

Mag-Oxide (Tablet)C1

Maximum Blue Label (Tablet)C1

Maximum Daily Green (Tablet)C1

Maximum Green Label (Tablet)C1

Maximum Red Label (Tablet)C1

Mediplex Plus (Tablet)C1

Mega Coq10 (Capsule)C1

Mega Coq-10 (Capsule)C1

Mega VM-80 (Tablet)C1

Mega-Marathon 100 TR (Tablet Extended-Release)

C1

Megavite Golden Years 55+ (Tablet)C1

Meijer Advanced Formula (Tablet)C1

Meijer Advanced Formula For Adults 50+ (Tablet)

C1

Meijer C (Tablet)C1

Meijer Ferrous Sulfate (Tablet)C1

Meladox (Tablet Extended-Release)C1

Melatin (Tablet)C1

Melatonex (Tablet Extended-Release)C1

Melatonin (Capsule)C1

Melatonin (Liquid)C1

Melatonin (Lozenge)C1

Melatonin (Tablet Chewable)C1

Melatonin (Tablet Extended-Release)C1

Melatonin (Tablet)C1

Melatonin Adult Gummies (Tablet Chewable)

C1

Melatonin Adult Gummy (Tablet Chewable)

OTC Drug NameC1

Melatonin CR (Tablet Extended-Release)C1

Melatonin Extra Strength (Liquid)C1

Melatonin Fast Dissolve (Tablet)C1

Melatonin Fast Meltz (Tablet)C1

Melatonin Gummies (Tablet Chewable)C1

Melatonin Maximum Strength (Capsule)C1

Melatonin Maximum Strength (Tablet)C1

Melatonin Quick Dissolve (Tablet)C1

Melatonin TR (Tablet Extended-Release)C1

Melatonin TR/Vitamin B6 (Tablet Extended-Release)

C1

Melatonin TR/Vitamin B-6 (Tablet Extended-Release)

C1

Melatonin/Vitamin B-6 Extra Strength (Tablet)

C1

Mens Daily Formula/Lycopene (Capsule)C1

Mens Hair Formula Ultra Man (Tablet)C1

Mens Life Pack (Tablet)C1

MGO (Tablet)C1

MH Macular Health (Pack)C1

Milltrium Advanced Formula With Beta Carotene (Tablet)

C1

Milltrium Cardio (Tablet)C1

Milltrium Senior (Tablet)C1

MM Melatonin TR (Tablet Extended-Release)

C1

Monoject Pharma Grade Flush Syringe (Solution)

C1

Monoject Sodium Chloride Flush (Solution)C1

Multi + Omega-3 Adult Gummies (Tablet Chewable)

C1

Multi Adult Gummies (Tablet Chewable)C1

Multi Complete (Capsule)C1

Multi Complete/Iron (Tablet)C1

Multi For Her (Capsule)C1

Multi For Her (Tablet)

175


OTC Drug NameC1

Multi For Her 50+ (Capsule)C1

Multi For Her 50+ (Tablet)C1

Multi For Him (Capsule)C1

Multi For Him (Tablet)C1

Multi For Him 50+ (Tablet)C1

Multi Prenatal (Tablet)C1

Multi Vit/Fl (Tablet Chewable)C1

Multi Vita-Bets/Fluoride (Tablet Chewable)C1

Multi Vitamin (Tablet)C1

Multi Vitamin And Minerals (Tablet)C1

Multi Vitamin Daily (Tablet)C1

Multi Vitamin Mens (Tablet)C1

Multi Vitamin/D-3 (Tablet)C1

Multi Vitamin/Minerals Full Spectrum (Tablet)

C1

Multi-Day (Tablet)C1

Multi-Day Plus Minerals (Tablet)C1

Multi-Day Vitamins (Tablet)C1

Multi-Day W/Calcium And Extra Iron (Tablet)

C1

Multi-Day Weight Trim (Tablet)C1

Multi-Delyn (Liquid)C1

Multi-Delyn/Iron (Liquid)C1

Multi-Lean (Tablet)C1

Multilex (Tablet)C1

Multilex-T&M (Tablet)C1

Multimineral Plus (Tablet)C1

Multi-Minerals (Tablet)C1

Multiple Vitamin (Tablet)C1

Multiple Vitamin/Folic Acid (Tablet)C1

Multiple Vitamin/Minerals/No Iron (Tablet)C1

Multiple Vitamins (Tablet)C1

Multiple Vitamins Essential (Tablet)C1

Multiple Vitamins Plain (Tablet)

OTC Drug NameC1

Multiple Vitamins/Fluoride (Tablet Chewable)

C1

Multiple Vitamins/Iron (Tablet Chewable)C1

Multiple Vitamins/Womens (Tablet)C1

Multi-Vit/Fluoride (Solution)C1

Multi-Vit/Iron/Fluoride (Drops)C1

Multivitamin & Mineral (Liquid)C1

Multivitamin (Liquid)C1

Multi-Vitamin (Tablet)C1

Multivitamin Adults (Tablet)C1

Multivitamin Adults 50+ (Tablet)C1

Multivitamin Children's (Tablet Chewable)C1

Multi-Vitamin Daily (Tablet)C1

Multivitamin Drops/Iron Infant & Toddler (Drops)

C1

Multi-Vitamin Gummies (Tablet Chewable)C1

Multivitamin Gummies Adult (Tablet Chewable)

C1

Multivitamin Gummies Children's (Tablet Chewable)

C1

Multivitamin Gummies Mens (Tablet Chewable)

C1

Multivitamin Gummies Womens (Tablet Chewable)

C1

Multivitamin Infant & Toddler (Drops)C1

Multivitamin Iron-Free (Tablet)C1

Multivitamin Men 50+ (Tablet)C1

Multivitamin Mens (Tablet)C1

Multi-Vitamin Monocaps (Tablet)C1

Multivitamin Plus Iron Children's (Tablet Chewable)

C1

Multivitamin With Fluoride (Solution)C1

Multivitamin With Fluoride (Tablet Chewable)

C1

Multivitamin With Fluoride (Tablet)C1

Multivitamin Women (Tablet)

176


OTC Drug NameC1

Multivitamin Women 50+ (Tablet)C1

Multivitamin Womens (Tablet)C1

Multivitamin/Extra Vitamin D3 Adult (Tablet Chewable)

C1

Multivitamin/Fluoride (Solution)C1

Multivitamin/Fluoride (Tablet Chewable)C1

Multi-Vitamin/Fluoride Drops (Solution)C1

Multivitamin/Fluoride/Iron (Drops)C1

Multi-Vitamin/Fluoride/Iron (Drops)C1

Multi-Vitamin/Menopausal Formula (Tablet)

C1

Multi-Vitamin/Multi-Mineral Adult/High Potency (Liquid)

C1

Multivitamins (Capsule)C1

Multi-Vitamins (Tablet)C1

Multivitamins/Fluoride (Tablet Chewable)C1

Mult-Vitamin/Fluoride (Tablet Chewable)C1

MVC-Fluoride (Tablet Chewable)C1

MV-One (Capsule)C1

MVW Complete Formulation (Tablet Chewable)

C1

MVW Complete Formulation D3000 (Tablet Chewable)

C1

MVW Complete Formulation D5000 (Tablet Chewable)

C1

Myamulti (Tablet)C1

My-Vitalife (Capsule)C1

Nanovm 1-3 Years (Powder)C1



Nanovm T/F (Liquid)C1

Nanovm T/F (Powder)C1

Nat-Rul Coenzyme Q-10 (Capsule)C1

Nat-Rul Iron (Tablet)C1

Natrul Magnesium (Tablet)

OTC Drug NameC1

Nat-Rul Oyster Calcium + D (Tablet)C1

Nat-Rul Vitamin D (Tablet)C1

Natural C/Rose Hips (Tablet)C1

Natural Coenzyme Q10 (Capsule)C1

Natural Vitamin A (Capsule)C1

Natural Vitamin D-3 (Tablet)C1

Natural Vitamin E (Capsule)C1

Natural Vitamin E (Tablet)C1

Naturalyte (Oral Solution)C1

Neuro-K-250 Vitamin B6 (Tablet)C1

Neuro-K-50 (Tablet)C1

Neuro-K-500 (Tablet)C1

Niacin (Tablet)C1

Niacin ER (Capsule Extended-Release)C1

Niacin ER (Tablet Extended-Release)C1

Niacin PR (Tablet Extended-Release)C1

Niacin SR (Capsule)C1

Niacin TD (Capsule Extended-Release)C1

Niacin TD (Tablet Extended-Release)C1

Niacin Time Release (Tablet Extended-Release)

C1

Niacin Timed Release (Tablet Extended-Release)

C1

Niacin TR (Capsule Extended-Release)C1

Niacin TR (Tablet Extended-Release)C1

Niacin-50 (Tablet)C1

Niacinamide (Tablet)C1

Niacinamide Prolonged Release (Tablet Extended-Release)

C1

Normal Saline Flush (Solution)C1

Normal Saline Flush For Flushing Vascular Access Devices (Solution)

C1

Normal Saline I.V. Flush (Solution)C1

Norwegian Cod Liver Oil (Capsule)C1

Novaferrum Pediatric Multivitamin (Liquid)

177


OTC Drug NameC1

Novaferrum Pediatric Multi-Vitamin/Iron (Drops)

C1

Nutr-E-Sol (Liquid)C1

Nutricion Porvida (Tablet)C1

Nutrifac ZX (Tablet)C1

Ocutabs (Tablet)C1

Ocutabs Vision Formula (Tablet)C1

Ocutabs/Lutein (Tablet)C1

Ocuvite Extra (Tablet)C1

Ocuvite Eye + Multi (Tablet)C1

Ocuvite Eye Health Formula (Capsule)C1

Ocuvite Eye Health Gummies (Tablet Chewable)

C1

Ocuvite/Lutein (Tablet)C1

Omnicap (Tablet)C1

Once Daily (Tablet)C1

One Daily (Tablet)C1

One Daily 50 Plus (Tablet)C1

One Daily Adults 50+ (Tablet)C1

One Daily Complete (Tablet)C1

One Daily Complete For Men (Tablet)C1

One Daily Essential (Tablet)C1

One Daily For Men 50+ Advanced (Tablet)C1

One Daily For Men/Lycopene (Tablet)C1

One Daily For Women (Tablet)C1

One Daily For Women 50+A Dvanced (Tablet)

C1

One Daily Healthy Weight (Tablet)C1

One Daily Healthy Weight Advanced (Tablet)

C1

One Daily Maximum (Tablet)C1

One Daily Mens (Tablet)C1

One Daily Mens 50+ Multivitamin (Tablet)C1

One Daily Mens Health/Lycopene (Tablet)C1

One Daily Multivitamin Adult (Tablet)

OTC Drug NameC1

One Daily Multivitamin Men (Tablet)C1

One Daily Multivitamin Mens 50+/Lycopene (Tablet)

C1

One Daily Multivitamin Women (Tablet)C1

One Daily Multivitamin/Iron-Free (Tablet)C1

One Daily Plus Iron (Tablet)C1

One Daily Plus Minerals (Tablet)C1

One Daily Womens (Tablet)C1

One Daily Womens 50 Plus (Tablet)C1

One Daily Womens 50+ (Tablet)C1

One Daily/Iron/Calcium (Tablet)C1

One Daily/Minerals (Tablet)C1

One-A-Day Teen Advantage For Her (Tablet)

C1

One-Daily Multi Vitamins (Tablet)C1

Optic-Vites (Tablet)C1

Optic-Vites With Lutein (Tablet)C1

Optimal-D (Capsule)C1

Optimal-D Pack (Capsule)C1

Optimum Airvites (Tablet Chewable)C1

Optimum Pms (Tablet)C1

Opurity Calcium Citrate Plus (Tablet

Chewable)C1

Opurity Vitamin D (Tablet Chewable)C1

Oral Electrolyte Solutionfreezer Pops Pediatric (Oral Solution)

C1

Oralyte (Oral Solution)C1

Oralyte Freezer Pops (Oral Solution)C1

Os-Cal (Tablet Chewable)C1

Os-Cal (Tablet Chewable)C1

Oscal 500/200 D-3 (Tablet)C1

Os-Cal Calcium + D3 (Tablet)C1

Os-Cal Extra D3 (Tablet)C1

Os-Cal Ultra (Tablet)C1

Osteo-Poretical (Tablet)

178


OTC Drug NameC1

Osteoprime Ultra (Tablet)C1

Ostigen C1

Oysco 500 (Tablet)C1

Oysco 500+D (Tablet Chewable)C1

Oysco 500+D (Tablet)C1

Oyst-Cal-D 500 (Tablet)C1

Oyster Calcium (Tablet)C1

Oyster Calcium/D3 (Tablet)C1

Oyster Calcium/Vitamin D (Tablet)C1

Oyster Shell (Tablet)C1

Oyster Shell Calcium (Tablet)C1

Oyster Shell Calcium + D (Tablet)C1

Oyster Shell Calcium + D3 (Tablet)C1

Oyster Shell Calcium + Vitamin D (Tablet)C1

Oyster Shell Calcium 250+D (Tablet)C1

Oyster Shell Calcium 500 (Tablet)C1

Oyster Shell Calcium 500 + D (Tablet)C1

Oyster Shell Calcium 500/D (Tablet)C1

Oyster Shell Calcium 500+D (Tablet Chewable)

C1

Oyster Shell Calcium Plus Vitamin D (Tablet)

C1

Oyster Shell Calcium Plusvitamin D (Tablet)

C1

Oyster Shell Calcium/D (Tablet)C1

Oyster Shell Calcium/D3 (Tablet)C1

Oyster Shell Calcium/Magnesium (Tablet)C1

Oyster Shell Calcium/Vitamin D (Powder)C1

Oyster Shell Calcium/Vitamin D (Tablet)C1

Oyster Shell Calcium+D (Tablet)C1

Oyster Shell/Vitamin D (Tablet)C1

Oystercal (Tablet)C1

Oystercal-D (Tablet)C1

PA B-Complex With B-12 (Tablet)

OTC Drug NameC1

PA Calcium 600/Vitamin D (Tablet)C1

PA Coenzyme Q-10 (Capsule)C1

PA Melatonin (Tablet)C1

PA Oyster Shell Calcium (Tablet)C1

PA Prenatal Formula (Tablet)C1

PA Vitamin B-12 TR (Tablet Extended-Release)

C1

PA Vitamin D-3 (Capsule)C1

PA Vitamin D-3 (Tablet)C1

PA Vitamin D-3 Gummy (Tablet Chewable)C1

PA Vitamin E (Capsule)C1

Parva-Cal (Tablet)C1

Parva-Cal 250 (Tablet)C1

PC Pediatric Electrolyte (Oral Solution)C1

Pedia Vance (Oral Solution)C1

Pediatric Electrolyte (Oral Solution)C1

Pediatric Electrolyte Freeze Pops (Oral Solution)

C1

Pediatric Electrolyte Freezer Pops (Oral Solution)

C1

Pediatric Electrolyte/With Zinc (Oral Solution)

C1

Pediatric Electrolyte/Zinc (Oral Solution)C1

Pediavit (Liquid)C1

Phos-Nak Powder Concentrate (Powder)C1

Phosphorus Supplement (Powder)C1

Plain Niacin (Tablet)C1

Pnv-Total (Capsule)C1

Poly Vitamin (Tablet Chewable)C1

Polyvitamin (Solution)C1

Poly-Vitamin/Fluoride (Solution)C1

Poly-Vitamin/Fluoride (Tablet Chewable)C1

Polyvitamin/Iron (Tablet Chewable)C1

Poly-Vitamin/Iron Drops (Drops)C1

Posture (Tablet)

179


OTC Drug NameC1

Posture-D Calcium/Magnesium (Tablet)C1

Potassimin (Tablet)C1

Potassium (Tablet)C1

Prenatal (Tablet)C1

Prenatal + Complete Multi/DHA/Choline/Folate (Capsule)

C1

Prenatal + Complete Multi/DHA/Choline/Folate (Tablet Chewable)

C1

Prenatal Adult Gummy/DHA/Folic Acid (Tablet Chewable)

C1

Prenatal And Iron (Tablet)C1

Prenatal Complete (Tablet)C1

Prenatal Formula (Capsule)C1

Pre-Natal Formula (Tablet)C1

Prenatal Formula A-Free (Tablet)C1

Prenatal Forte (Tablet)C1

Prenatal Gummies/DHA & Folic Acid (Tablet Chewable)

C1

Prenatal Low Iron (Tablet)C1

Prenatal Multi + DHA (Capsule)C1

Prenatal Multivitamin (Tablet)C1

Prenatal Multivitamin Plus DHA (Capsule)C1

Prenatal One Daily (Tablet)C1

Prenatal Tablets (Tablet)C1

Prenatal Vitamin & Mineral (Tablet)C1

Prenatal Vitamin (Tablet)C1

Prenatal Vitamin/Iron (Tablet)C1

Prenatal Vitamins (Tablet)C1

Prenatal/Omega-3/Folic Acid/Iron (Capsule)

C1

Prenatal+DHA (Capsule)C1

Prevent (Capsule)C1

Pronutrients Calcium+D3 (Tablet)C1

Pronutrients Coq10 (Capsule)C1

Pronutrients Vitamin D3 (Capsule)

OTC Drug NameC1

Prosight (Tablet)C1

Prosight W/Lutein (Capsule)C1

Pure C 500 (Capsule)C1

Pureway-C (Tablet)C1

PX Advanced Formula Multivitamins/Lycopene (Tablet)

C1

PX Calcium & D (Tablet)C1

PX Children's Vitamin (Tablet Chewable)C1

PX Complete Senior Multivitamins (Tablet)C1

PX Folic Acid (Tablet)C1

PX Iron (Tablet)C1

PX Mens Multivitamins (Tablet)C1

PX Niacin (Tablet)C1

PX Prenatal Multivitamins (Tablet)C1

PX Vitamin A (Capsule)C1

PX Vitamin C (Tablet)C1

PX Vitamin E (Capsule)C1

Pyri 500 (Tablet)C1

Pyridoxine HCl (Tablet)C1

Pyridoxine Hydrochloride (Tablet)C1

QC B-Complex + Vitamin C (Tablet)C1

QC C With Rose Hips (Tablet)C1

QC Calcium 600 +D3 Plus Minerals (Tablet Chewable)

C1

QC Calcium Fast Dissolution (Tablet)C1

QC Calcium Magnesium & Zinc +D3 (Tablet)

C1

QC Calcium/Minerals/Vitamin D (Tablet)C1

QC Children's Chewable Complete (Tablet Chewable)

C1

QC Children's Chewable Vitamins/Extra C (Tablet Chewable)

C1

QC Children's Chewable Vitamins/Iron (Tablet Chewable)

C1

QC Co Q-10 (Capsule)

180


OTC Drug NameC1

QC Cod Liver Oil (Capsule)C1

QC Essentials (Tablet)C1

QC Ferrous Sulfate (Tablet)C1

QC Folic Acid (Tablet)C1

QC Hair Skin & Nails (Tablet)C1

QC Magnesium Citrate (Solution)C1

QC Maximum Daily Multivitamin/Multimineral (Tablet)

C1

QC Melatonin Maximum Strength (Tablet)C1

QC Mens Daily Multivitamin (Tablet)C1

QC Multi-Vite (Tablet)C1

QC Multi-Vite 50 & Over (Tablet)C1

QC Multi-Vite Plus (Tablet)C1

QC Niacin (Tablet)C1

QC Prenatal (Tablet)C1

QC Therin-M (Tablet)C1

QC Vitamin B1 (Tablet)C1

QC Vitamin B12 (Tablet Extended-Release)C1



QC Vitamin C (Tablet Chewable)C1

QC Vitamin C (Tablet)C1

QC Vitamin D3 (Tablet)C1

QC Vitamin E (Capsule)C1

QC Womens Daily Multivitamin (Tablet)C1

Q-Gel Forte (Capsule)C1

Q-Gel Mega (Capsule)C1

Q-Gel Ultra (Capsule)C1

Q-Sorb (Capsule)C1

Q-Sorb Co Q-10 (Capsule)C1

Quin B Strong (Tablet)C1

Quintabs (Tablet)C1

Quintabs-M (Tablet)C1

RA Anticavity Fluoride Rinse (Rinse)

OTC Drug NameC1

RA B-Complex (Tablet)C1

RA B-Complex With B-12 (Tablet)C1

RA Calcium (Tablet)C1

RA Calcium 600 (Tablet)C1

RA Calcium 600 Plus Vitamin D-3 & Minerals (Tablet Chewable)

C1

RA Calcium 600 Plus Vitamin D-3 (Tablet)C1

RA Calcium 600/Vit D/Minerals (Tablet)C1

RA Calcium Citrate Plus Vitamin D (Tablet)C1

RA Calcium Citrate Plus Vitamin D-3 (Tablet)

C1

RA Calcium Citrate/Vitamin D-3 Petites (Tablet)

C1

RA Calcium Hi-Cal (Tablet)C1

RA Calcium Hi-Cal/Vitamind (Tablet)C1

RA Calcium High Potency (Tablet)C1

RA Calcium Plus Vitamin D (Tablet)C1

RA Calcium Soft Chews (Tablet Chewable)C1

RA Calcium/Boron (Tablet)C1

RA Calcium/Magnesium/Zinc (Tablet)C1

RA Calcium/Magnesium/Zinc/Copper (Tablet)

C1

RA Calcium/Minerals/Vitamin D (Tablet)C1

RA Central-Vite (Tablet)C1

RA Central-Vite Energy (Tablet)C1

RA Central-Vite Mens Mature (Tablet)C1

RA Central-Vite Select (Tablet)C1

RA Central-Vite Select Mature (Tablet)C1

RA Central-Vite Senior (Tablet)C1

RA Central-Vite Womens Mature (Tablet)C1

RA Central-Vite/Antioxidants (Tablet)C1

RA Chewable Vitamins Complete Children's (Tablet Chewable)

C1

RA Children's Chewable Vitamins/Iron (Tablet Chewable)

181


OTC Drug NameC1

RA Coenzyme Q-10 (Capsule)C1

RA Coral Calcium (Capsule)C1

RA Folic Acid (Tablet)C1

RA Glucose (Gel)C1

RA Gummy Vitamins & Minerals Children's (Tablet Chewable)

C1

RA Hair/Skin/Nails (Tablet)C1

RA Hi Cal (Tablet)C1

RA Hi-Cal (Tablet)C1

RA Hi-Cal Plus Vitamin D (Tablet)C1

RA High Potency Iron (Tablet)C1

RA Iron (Tablet)C1

RA Magnesium (Capsule)C1

RA Magnesium Citrate (Solution)C1

RA Mature Womens Dietary Supplement (Tablet)

C1

RA Melatonin (Tablet)C1

RA Natural Magnesium (Tablet)C1

RA Natural Vitamin E (Capsule)C1

RA Niacin (Tablet)C1

RA No Flush Niacin 500 (Tablet)C1

RA One Daily (Capsule)C1

RA One Daily Energy Formula (Tablet)C1

RA One Daily Essential (Tablet)C1

RA One Daily Gummy Vites (Tablet Chewable)

C1

RA One Daily Maximum (Tablet)C1

RA One Daily Mens 50+ With Vitamin D-3 (Tablet)

C1

RA One Daily Mens Multi (Tablet)C1

RA One Daily Mens/Vitamin D-3 (Tablet)C1

RA One Daily Multi-Vitamin (Tablet)C1

RA One Daily Womens/Vitamin D-3 (Tablet)

C1

RA Oyster Shell Calcium (Tablet)

OTC Drug NameC1

RA Oyster Shell Calcium/Vitamin D

(Tablet)C1

RA Pediatric Electrolyte (Oral Solution)C1

RA Pediatric Electrolyte Freezer Pops (Oral Solution)

C1

RA Prenatal (Tablet)C1

RA Prenatal Formula/Folicacid (Tablet)C1

RA Slow Release Iron (Tablet Extended-Release)

C1

RA Stress Formula Advanced (Tablet)C1

RA Stress Formula Energy (Tablet)C1

RA Therapeutic M Plus Beta Carotene (Tablet)

C1

RA Tooth Shield (Rinse)C1

RA Vision Vite Plus Zinc (Tablet)C1

RA Vitamin A (Capsule)C1

RA Vitamin B-1 (Tablet)C1

RA Vitamin B-12 (Liquid)C1

RA Vitamin B12 (Tablet Extended-Release)C1


RA Vitamin B-12 TR (Tablet Extended-Release)

C1


RA Vitamin B-6 TR (Tablet Extended-Release)

C1

RA Vitamin C (Tablet Chewable)C1

RA Vitamin C (Tablet)C1

RA Vitamin C Drops (Lozenge)C1

RA Vitamin C TR (Tablet Extended-Release)

C1

RA Vitamin C/Acerola (Tablet Chewable)C1

RA Vitamin C/Rose Hips (Tablet)C1

RA Vitamin C/Rose Hips TR (Tablet Extended-Release)

C1

RA Vitamin D-3 (Capsule)C1

RA Vitamin D-3 (Tablet)

182


OTC Drug NameC1

RA Vitamin E (Capsule)C1

RA Vitamin E Blend (Capsule)C1

RA Vitamin E Natural (Capsule)C1

RA Whole Source Complete Formula For Men (Tablet)

C1

RA Whole Source Dietary (Tablet)C1

RA Whole Source Dietary For Men (Tablet)C1

RA Whole Source Dietary Mature (Tablet)C1

RA Whole Source Womens (Tablet)C1

Rehydralyte (Oral Solution)C1

Relion Glucose (Gel)C1

Relion Glucose Drink (Liquid)C1

Renal Multivitamin Formula/Zinc (Tablet)C1

Renaplex (Tablet)C1

Revital Freezer Pops (Oral Solution)C1

Revital Jell Cups (Oral Solution)C1

Revital Liquid Squeezers (Oral Solution)C1

Riboflavin (Tablet)C1

Risacal-D (Tablet)C1

Saline Flush (Solution)C1

Saline Flush ZR/Sterile Field (Solution)C1

Savision (Tablet)C1

SB Calcium + D (Tablet)C1

SB Magnesium Citrate (Solution)C1

SB Oyster Shell Calcium (Tablet)C1

SB Pediatric Electrolyte (Oral Solution)C1

SB Vitamin C (Tablet)C1

Sclerex (Tablet)C1

Sea Buddies Daily Multiple (Tablet Chewable)

C1

Senior Tabs (Tablet)C1

Sentry (Tablet)C1

Sentry Adults Under 50 (Tablet)C1

Sentry Senior (Tablet)

OTC Drug NameC1

Signacal (Tablet)C1

Sigtab (Tablet)C1

Slo-Niacin (Tablet Extended-Release)C1

Slow Fe (Tablet Extended-Release)C1

Slow Iron (Tablet Extended-Release)C1

Slow Release Iron (Tablet Extended-Release)

C1

SM Animal Shapes Complete (Tablet Chewable)

C1

SM Animal Shapes Kids First (Tablet Chewable)

C1

SM Anticavity Fluoride Rinse (Rinse)C1

SM Antioxidant Vitamins (Tablet)C1

SM Calcium /Vitamin D (Tablet)C1

SM Calcium 500/Vitamin D3 (Tablet)C1

SM Calcium 600 + D Plus Minerals (Tablet Chewable)

C1

SM Calcium 600/Vitamin D (Tablet)C1

SM Calcium 600+D3 (Tablet)C1

SM Calcium Citrate + D (Tablet)C1

SM Calcium Citrate W/Vitamin D3 (Tablet)C1

SM Calcium Citrate/Vitamin D3 Petite (Tablet)

C1

SM Calcium Citrate+ W/Vitamin D (Tablet)C1

SM Calcium Soft Chews (Tablet Chewable)C1

SM Calcium/Magnesium/Zinc (Tablet)C1

SM Calcium/Vitamin D (Tablet)C1

SM Calcium/Vitamin D3 (Tablet)C1

SM Chewable Vitamin C (Tablet Chewable)C1

SM Co Q-10 (Capsule)C1

SM Cod Liver Oil (Capsule)C1

SM Coenzyme Q-10 (Capsule)C1

SM Complete (Tablet)C1

SM Complete 50+ (Tablet)C1

SM Complete 50+ Ultimate Mens (Tablet)

183


OTC Drug NameC1

SM Complete 50+ Ultimate Womens (Tablet)

C1

SM Complete Advanced Formula (Tablet)C1

SM Complete Senior Formula (Tablet)C1

SM Coq-10 (Capsule)C1

SM Daily Diet Support (Tablet)C1

SM Folic Acid (Tablet)C1

SM Hair/Skin/Nails (Tablet)C1

SM Iron (Tablet)C1

SM Iron Slow Release (Tablet Extended-Release)

C1

SM Magnesium (Tablet)C1

SM Magnesium Citrate (Solution)C1

SM Melatonin (Tablet)C1

SM Multiple Vitamins Essential (Tablet)C1

SM Niacin CR (Tablet Extended-Release)C1

SM One Daily Essential (Tablet)C1

SM One Daily Mens (Tablet)C1

SM One Daily Prenatal (Capsule)C1

SM One Daily Womens (Tablet)C1

SM Opti-Vitamins (Tablet)C1

SM Oyster Shell Calcium/Vitamin D (Tablet)

C1

SM Oyster Shell Calcium/Vitamin D3 (Tablet)

C1

SM Pediatric Electrolyte (Oral Solution)C1

SM Prenatal Vitamins (Tablet)C1

SM Slow Release Iron (Tablet Extended-Release)

C1

SM Vit C/Rose Hips (Tablet)C1

SM Vitamin B1 (Tablet)C1

SM Vitamin B-12 (Tablet)C1

SM Vitamin B12 TR (Tablet Extended-Release)

C1

SM Vitamin B-6 (Tablet)

OTC Drug NameC1

SM Vitamin C (Tablet Chewable)C1

SM Vitamin C (Tablet)C1

SM Vitamin C TR (Tablet Extended-Release)

C1

SM Vitamin C/Rose Hips (Tablet)C1

SM Vitamin D (Tablet)C1

SM Vitamin D3 (Capsule)C1

SM Vitamin D3 (Tablet)C1

SM Vitamin D3 Maximum Strength (Capsule)

C1

SM Vitamin E (Capsule)C1

SM Vitamin E Blended (Capsule)C1

Smarty Pants Kids Complete And Fiber (Tablet Chewable)

C1

Sodium Chloride (Tablet)C1

Sodium Chloride Flush (Solution)C1

Soluvita E (Solution)C1

Spider-Man Complete Multivitamin Gummies (Tablet Chewable)

C1

Spongebob Squarepants Gummies (Tablet Chewable)

C1

Stress B-Complex/C/Zinc (Tablet)C1

Stress Formula (Tablet)C1

Stress Formula/Iron (Tablet)C1

Stress Formula/Zinc (Tablet)C1

Stresstabs Advanced (Tablet)C1

Stresstabs Energy (Tablet)C1

Sunkist Vitamin C (Tablet Chewable)C1

Sunvite Active Adult 50+ (Tablet)C1

Sunvite Advanced (Tablet)C1

Super 28 Formula (Tablet)C1

Super Antioxidant/A/C/E/Selenium (Tablet)

C1

Super Antioxidants Protector (Capsule)C1

Super Aytinal 50 Plus (Tablet)

184


OTC Drug NameC1

Super Aytinal For Active Adults (Tablet)C1

Super Cal/Mag (Tablet)C1

Super Calcium (Tablet)C1

Super Calcium 600 + D3 (Tablet)C1

Super Calcium 600+D 400 (Tablet)C1

Super Calcium 600+D3 400 (Tablet)C1

Super Cal-Mag-D (Tablet)C1

Super Multiple (Capsule)C1

Super Multiple (Tablet)C1

Super Natrul-100 (Tablet Extended-Release)

C1

Super Nu-Thera (Tablet)C1

Super Thera Vite M (Tablet)C1

Super Vikaps (Tablet)C1

Super Vita-Mins (Tablet)C1

Superior 35 (Tablet Extended-Release)C1

Support (Liquid)C1

SV Melatonin (Tablet)C1

SV Vitamin B12 TR (Tablet Extended-Release)

C1

Swabflush Saline Flush (Solution)C1

Tab-A-Vite (Tablet)C1

Tab-A-Vite W/Beta Carotene (Tablet)C1

TGT Calcium + Vitamin D3 (Tablet)C1

TGT Calcium Dietary Supplement (Tablet Chewable)

C1

TGT Daily Multivitamin Womens (Tablet)C1

TGT Multivitamin/Multimineral Adults/Lycopene (Tablet)

C1

TGT Multivitamin/Multimineral/Adult (Tablet)

C1

TGT Vitamin C Drops (Lozenge)C1

Thera (Tablet)C1

Thera M Plus (Tablet)C1

Thera Vital M (Tablet)

OTC Drug NameC1

Thera Vital-M (Tablet)C1

Therabasic-M (Tablet)C1

Thera-D 2000 (Tablet)C1

Thera-D Rapid Repletion (Tablet)C1

Theradex "M" (Tablet)C1

Theradex "M"/Beta Carotene (Tablet)C1

Thera-M (Tablet)C1

Thera-Mill (Tablet)C1

Thera-Mill M (Tablet)C1

Theramill Plus (Capsule)C1

Therapeutic (Tablet)C1

Therapeutic Formula/Hematinics (Tablet)C1

Therapeutic M (Tablet)C1

Therapeutic Multi Vitaminmineral (Tablet)C1

Therapeutic-M (Tablet)C1

Therapeutic-M/Lutein (Tablet)C1

Thera-Tabs (Tablet)C1

Thera-Tabs M (Tablet)C1

Theratrum Complete (Tablet)C1

Theratrum Complete 50 Plus (Tablet)C1

Theravim -M (Tablet)C1

Therems (Tablet)C1

Therems-H (Tablet)C1

Therems-M (Tablet)C1

Thiamine HCL (Tablet)C1

Thrive For Life Womens (Tablet)C1

Total Formula (Tablet)C1

Total Formula 2 (Tablet)C1

Total Formula 3 (Tablet)C1

Totalday Multiple (Tablet Extended-Release)

C1

Tri-Vit/Fluoride (Solution)C1

Tri-Vit/Fluoride/Iron (Drops)C1

Tri-Vitamin/Fluoride (Solution)

185


OTC Drug NameC1

Tri-Vite/Fluoride (Solution)C1

Tropical Liquid Nutrition (Liquid)C1

Trueplus Diabetic Multivitamin (Tablet)C1

Ultra Antioxidant Formula (Tablet)C1

Ultra Choice Multivitamin Kids (Tablet Chewable)

C1

Ultra Freeda (Tablet)C1

Ultra Freeda/Iron (Tablet)C1

Ultra Multi Formula/Iron (Capsule)C1

Ultra Vita-Time (Tablet)C1

Ultrachoice Advanced Formula (Tablet)C1

Ultrachoice Advanced Formula Mature (Tablet)

C1

Ultra-Mega (Tablet Extended-Release)C1

Unicomplex-M (Tablet)C1

Upcal D (Powder)C1

UpSpring Baby Multivitamin/Iron (Liquid)C1

Value Plus Glucose (Gel)C1

Viactiv (Tablet Chewable)C1

Vicap Forte (Capsule)C1

Vic-Forte (Capsule)C1

Vinate II (Tablet)C1

Vinate M (Tablet)C1

Vision Formula 2 (Tablet)C1

Vision Formula Eye Health (Capsule)C1

Vision Formula/Lutein (Tablet)C1

Vision Plus (Capsule)C1

Vision Vitamins (Tablet)C1

Visivites (Tablet)C1

Visivites/Lutein (Tablet)C1

Vita Hair (Tablet)C1

Vita S Forte (Tablet)C1

Vitabasic Complete (Tablet)C1

Vitabasic Senior (Tablet)

OTC Drug NameC1

Vita-Calcium (Wafer)C1

Vitacel (Tablet)C1

Vitachew Multiple Vitamin Children's (Tablet Chewable)

C1

Vitachew Vitamin C Citrusburst Gummies (Tablet Chewable)

C1

Vitajoy Daily D Gummies (Tablet Chewable)

C1

Vitajoy Gummies (Tablet Chewable)C1

Vitalee (Tablet)C1

Vitaline Coq10 (Tablet)C1

Vitamelts Energy Vitamin B-12 (Tablet)C1

Vita-Min (Capsule)C1

Vitamin A & D (Ointment)C1

Vitamin A (Capsule)C1

Vitamin A Palmitate (Tablet)C1

Vitamin B 12 (Lozenge)C1

Vitamin B 6 (Tablet)C1

Vitamin B Complex (Tablet)C1

Vitamin B-1 (Tablet)C1

Vitamin B12 (Liquid)C1

Vitamin B-12 (Lozenge)C1

Vitamin B-12 (Tablet Extended-Release)C1


Vitamin B-12 CR (Tablet Extended-Release)

C1

Vitamin B-12 ER (Tablet Extended-Release)C1

Vitamin B-12 LA (Tablet Extended-Release)C1

Vitamin B-12 Natural (Tablet)C1

Vitamin B12 TR (Tablet Extended-Release)C1

Vitamin B-12 TR (Tablet Extended-Release)C1


Vitamin B-6 (Tablet Extended-Release)C1


Vitamin B-6 Repack (Tablet)

186


OTC Drug NameC1

Vitamin B-6 TR (Tablet Extended-Release)C1

Vitamin B-Complex (Tablet)C1

Vitamin B-Complex 100 (Injection)C1

Vitamin C (Liquid)C1

Vitamin C (Powder)C1

Vitamin C (Tablet Chewable)C1

Vitamin C (Tablet Extended-Release)C1

Vitamin C (Tablet)C1

Vitamin C Adult Gummies (Tablet Chewable)

C1

Vitamin C CR (Capsule)C1

Vitamin C Drops (Lozenge)C1

Vitamin C Gummie (Tablet Chewable)C1

Vitamin C Gummies (Tablet Chewable)C1

Vitamin C Immune Health (Tablet Chewable)

C1

Vitamin C Plus Bioflavonoids/Wild Rose Hips (Tablet)

C1

Vitamin C Plus Wild Rose Hips (Tablet Chewable)

C1

Vitamin C SR (Capsule)C1

Vitamin C TR (Capsule)C1

Vitamin C TR (Tablet Extended-Release)C1

Vitamin C TR/Rose Hips (Tablet Extended-Release)

C1

Vitamin C/Acerola (Tablet Chewable)C1

Vitamin C/Acerola (Tablet)C1

Vitamin C/Rose Hips (Tablet Chewable)C1

Vitamin C/Rose Hips (Tablet)C1

Vitamin C/Rose Hips TR (Tablet Extended-Release)

C1

Vitamin C-500 Timed Release (Capsule Extended-Release)

C1

Vitamin D (Capsule)C1

Vitamin D (Liquid)C1

Vitamin D (Tablet)

OTC Drug NameC1

Vitamin D 400 (Tablet Chewable)C1

Vitamin D High Potency (Capsule)C1

Vitamin D Infant (Liquid)C1

Vitamin D-1000 (Tablet)C1

Vitamin D-1000 Maximum Strength (Tablet)C1

Vitamin D2 (Tablet)C1

Vitamin D-3 (Capsule)C1

Vitamin D3 (Drops)C1

Vitamin D3 (Liquid)C1

Vitamin D3 (Tablet Chewable)C1

Vitamin D3 (Tablet)C1


Vitamin D3 400 (Capsule)C1

Vitamin D3 Adult Gummies (Tablet Chewable)

C1

Vitamin D3 Gummies (Tablet Chewable)C1

Vitamin D3 High Potency (Capsule)C1

Vitamin D3 Maximum Strength (Capsule)C1

Vitamin D3 Super Strength (Capsule)C1

Vitamin D3 Super Strength (Tablet)C1

Vitamin D3 Ultra Potency (Tablet)C1

Vitamin D3 Ultra Strength (Capsule)C1


Vitamin E (Capsule)C1

Vitamin E (Oil)C1

Vitamin E (Solution)C1

Vitamin E (Tablet)C1

Vitamin E Blend (Capsule)C1

Vitamin E Complex (Capsule)C1

Vitamin E Complex Natural (Capsule)C1

Vitamin E High Potency (Capsule)C1

Vitamin E Water Dispersible (Capsule)C1

Vitamin E Water Solubilized (Capsule)C1

Vitamin E Water Soluble (Capsule)

187


OTC Drug NameC1

Vitamin E/D-Alpha (Capsule)C1

Vitamin E/D-Alpha Natural (Capsule)C1

Vitamin E/Dl-Alpha (Capsule)C1

Vitamin E/Folic Acid/B-6/B-12 (Capsule)C1

Vitamin E/Vitamin C/Beta Carotene (Tablet)

C1

Vitamin E-200 (Capsule)C1

Vitamin E-400 (Capsule)C1

Vitamin Supplement E-1000 (Capsule)C1

Vitamin Supplement E-400 (Capsule)C1

Vitamin-D3 (Tablet)C1

Vitamins A/C/D/Fluoride (Solution)C1

Vitamins A/D/C/Fluoride (Solution)C1

Vitamins A-D-E/Selenium (Tablet)C1

Vita-Plus E (Capsule)C1

Vitatrum (Tablet Chewable)C1

Vitatrum (Tablet)C1

Vitatrum Complete (Tablet)C1

Viteyes Areds Advanced (Capsule)C1

Viteyes Areds Formula (Capsule)C1

Viteyes Areds Formula Plus Lutein (Capsule)

C1

Viteyes Complete (Capsule)C1

Viteyes Multivitamin Areds Companion With Lycopene (Tablet)

C1

Viteyes Smokers Advanced (Capsule)C1

Viteyes Smokers Formula Plus Lutein (Capsule)

C1

Vitrum 50+ Senior Multi (Tablet)C1

Vitrum Senior (Tablet)C1

VP-GGR-B6 Prenatal (Tablet)

OTC Drug NameC1

VP-Heme OB + DHA (Tablet)C1

Wegmans Complete Prenatal+DHA (Capsule)

C1

Womens 50+ Advanced (Capsule)C1

Womens Daily Formula (Tablet)C1

Womens Daily Formula/Folic Acid/Calcium/Iron (Tablet)

C1

Womens Life Pack (Tablet)C1

Womens Multi (Capsule)C1

Womens Multivitamin (Tablet)C1

Womens One Daily (Tablet)C1

Yl Coenzyme Q10 (Capsule)C1

Yl Folic Acid (Tablet)C1

Yl Vitamin B-6 (Tablet)C1

Yl Vitamin C (Tablet)C1

Yl Vitamin C/Rose Hips (Tablet)C1

Yl Vitamin E (Capsule)C1

Your Life Multi Mens 50+ (Tablet)C1

Your Life Multi Womens 50+ (Tablet)C1

Zoo Friends (Tablet Chewable)C1

Zoo Friends Complete (Tablet Chewable)C1

Zoo Friends Gummies (Tablet Chewable)C1

Zoo Friends Gummies Plus Extra C (Tablet Chewable)

C1

Zoo Friends Gummies Plus Extra D (Tablet Chewable)

C1

Zoo Friends Multi Gummies (Tablet Chewable)

C1

Zoo Friends Plus Iron (Tablet Chewable)C1

Zoo Friends/Extra C (Tablet Chewable)

188

Trackedtrack

D. Index of Covered Drugs

In this section, you can find a drug by searching for its name alphabetically. This will tell you the page number where you can find additional coverage information for your drug.

A

Abacavir Sulfate...................... 43

Abacavir Sulfate-Lamivudine............................................... 43

Abacavir-Lamivudine-Zidovudine............................ 43

Abelcet.....................................29

Abilify Maintena...................... 39

Abiraterone Acetate................33

Acamprosate Calcium............ 17

Acarbose................................. 46

Acebutolol HCl........................ 52

Acetaminophen-Codeine....... 15

Acetazolamide........................ 55

Acetazolamide ER.................. 55

Acetic Acid.............................. 85

Acetylcysteine......................... 88

Acitretin................................... 60

Actemra................................... 79

Actemra ACTPen.................... 79

ActHIB......................................79

Actimmune.............................. 79

Acyclovir.................................. 42

Acyclovir Sodium.................... 42

Adacel......................................79

Adapalene............................... 60

Adefovir Dipivoxil.................... 42

Adempas................................. 88

Advair Diskus.......................... 88

Advair HFA.............................. 88

Afinitor..................................... 35

Afinitor Disperz........................35

Aimovig.................................... 31

Ala-Cort.................................... 67

Albendazole............................ 37

Albuterol Sulfate..................... 87

Albuterol Sulfate HFA............. 87

Alclometasone Dipropionate............................................... 67

Alcohol Prep Pads.................. 82

Alecensa.................................. 35

Alendronate Sodium...............82

Alfuzosin HCl ER.....................67

Alinia........................................ 37

Aliskiren Fumarate..................54

Allopurinol............................... 31

Alocril....................................... 83

Alomide....................................84

Alosetron HCl.......................... 65

Alphagan P.............................. 84

Alprazolam.............................. 45

Altavera....................................71

Alunbrig................................... 35

Alyacen 1/35........................... 71

Alyq.......................................... 88

Amantadine HCl......................37

AmBisome............................... 29

Ambrisentan............................ 88

Amethia....................................71

Amethia Lo.............................. 71

Amikacin Sulfate..................... 17

Amiloride HCl.......................... 56

Amiloride-Hydrochlorothiazide............................................... 54

Aminosyn II.............................. 61

Aminosyn-PF........................... 61

Amiodarone HCl..................... 52

Amitiza..................................... 65

Amitriptyline HCl..................... 28

Amlodipine Besylate...............53

Amlodipine-Atorvastatin......... 54

Amlodipine-Benazepril........... 54

Amlodipine-Olmesartan..........54

Amlodipine-Valsartan............. 54

Amlodipine-Valsartan-HCTZ...54

Ammonium Lactate................ 60

Amoxapine.............................. 28

Amoxicillin............................... 21

Amoxicillin-Potassium Clavulanate........................... 21

Amoxicillin-Potassium Clavulanate ER..................... 21

Amphetamine-Dextroamphetamine.............58

Amphetamine-Dextroamphetamine ER.......58

Amphotericin B....................... 29

Ampicillin................................. 21

Ampicillin Sodium...................21

Ampicillin-Sulbactam Sodium............................................... 21

189

Tracked

Ampyra.................................... 59

Anadrol-50............................... 70

Anagrelide HCl........................ 50

Anastrozole............................. 34

Androderm.............................. 70

Anoro Ellipta............................ 88

Apokyn.....................................38

Apraclonidine HCl...................84

Aprepitant................................ 29

Apri...........................................71

Apriso.......................................81

Aptiom..................................... 26

Aptivus..................................... 44

Aralast NP................................66

Aranelle....................................71

Aranesp................................... 50

Arcalyst.................................... 79

Aripiprazole............................. 39

Aripiprazole ODT.................... 39

Aristada....................................39

Aristada Initio.......................... 39

Arnuity Ellipta.......................... 86

Ashlyna.................................... 71

Aspirin-Dipyridamole ER........ 51

Atazanavir Sulfate................... 44

Atenolol....................................52

Atenolol-Chlorthalidone..........54

Atomoxetine HCl.....................58

Atorvastatin Calcium.............. 56

Atovaquone............................. 37

Atovaquone-Proguanil HCl.....37

Atripla.......................................43

Atropine Sulfate...................... 83

Atrovent HFA........................... 86

Aubagio................................... 59

Aubra....................................... 71

Auryxia..................................... 64

Austedo................................... 58

Aviane...................................... 71

Avonex Pen............................. 59

Avonex Prefilled...................... 59

Ayvakit..................................... 35

Azasite..................................... 22

Azathioprine............................ 77

Azelaic Acid.............................60

Azelastine HCl...................84, 86

Azelastine-Fluticasone............88

Azithromycin........................... 22

Azopt........................................84

Aztreonam............................... 21

B

Bacitracin.................................18

Bacitracin-Polymyxin B...........83

Baclofen...................................89

Balsalazide Disodium............. 81

Balversa................................... 34

Balziva......................................71

Banzel...................................... 26

Baqsimi Two Pack.................. 47

Baraclude................................ 42

BCG Vaccine...........................79

Belsomra................................. 90

Benazepril HCl........................ 52

Benazepril-Hydrochlorothiazide............................................... 54

Benlysta................................... 79

Benznidazole...........................37

Benzoyl Peroxide-Erythromycin............................................... 60

Benztropine Mesylate............. 37

Bepreve................................... 84

Berinert.................................... 76

Besivance................................ 23

Betamethasone Dipropionate............................................... 68

Betamethasone Dipropionate Aug.................................. 67, 68

Betamethasone Valerate........ 68

Betaseron................................ 59

Betaxolol HCl.................... 52, 84

Bethanechol Chloride.............67

Bethkis..................................... 87

Betimol.....................................84

Bevespi Aerosphere............... 88

Bexarotene.............................. 36

Bexsero....................................79

Bicalutamide........................... 33

Bicillin C-R............................... 21

Bicillin C-R 900/300................21

Bicillin L-A................................ 21

BiDil..........................................54

Biktarvy.................................... 43

Binosto.....................................82

Bisoprolol Fumarate............... 52

Bisoprolol-Hydrochlorothiazide............................................... 54

BIVIGAM.................................. 78

Blephamide............................. 83

Blephamide S.O.P.................. 83

Blisovi 24 Fe............................ 71

Blisovi Fe 1.5/30..................... 71

Boostrix....................................80

190

Tracked

Bosentan................................. 88

Bosulif...................................... 35

Braftovi.....................................35

Breo Ellipta.............................. 88

Briellyn..................................... 71

Brilinta......................................51

Brimonidine Tartrate...............84

BRIVIACT.................................24

Bromocriptine Mesylate......... 38

Brukinsa...................................35

Budesonide.......................81, 86

Budesonide ER....................... 81

Bumetanide............................. 55

Buprenorphine........................ 14

Buprenorphine HCl.................17

Buprenorphine HCl-Naloxone HCl......................................... 17

Bupropion HCl........................ 27

Bupropion HCl SR............ 17, 27

Bupropion HCl XL...................27

Buspirone HCl.........................45

Butalbital-Acetaminophen-Caffeine................................. 14

Butalbital-Aspirin-Caffeine......14

Butorphanol Tartrate.............. 15

Bydureon................................. 46

Bydureon BCise...................... 46

Byetta 10MCG Pen................. 46

Byetta 5MCG Pen................... 46

Bystolic.................................... 52

C

Cabergoline.............................75

Cablivi...................................... 51

Cabometyx.............................. 35

Calcipotriene........................... 60

Calcitonin Salmon...................82

Calcitriol............................ 60, 82

Calcium Acetate......................64

Calquence............................... 35

Camila......................................74

Camrese Lo............................. 71

Canasa.....................................81

Candesartan Cilexetil............. 51

Candesartan Cilexetil-HCTZ............................................... 54

Caplyta.....................................39

Caprelsa.................................. 35

Captopril.................................. 52

Captopril-Hydrochlorothiazide............................................... 54

Carac........................................60

Carafate................................... 65

Carbaglu.................................. 61

Carbamazepine.......................26

Carbamazepine ER.................26

Carbidopa................................38

Carbidopa-Levodopa..............38

Carbidopa-Levodopa ER........38

Carbidopa-Levodopa ODT..... 38

Carbidopa-Levodopa-Entacapone...........................38

Carteolol HCl........................... 84

Cartia XT.................................. 53

Carvedilol.................................52

Cayston....................................87

Caziant..................................... 71

Cefaclor................................... 19

Cefadroxil................................ 19

Cefazolin Sodium....................19

Cefdinir.............................. 19, 20

Cefepime HCl.......................... 20

Cefixime...................................20

Cefotetan Disodium................20

Cefoxitin Sodium.................... 20

Cefpodoxime Proxetil............. 20

Cefprozil.................................. 20

Ceftazidime............................. 20

Ceftriaxone Sodium................ 20

Cefuroxime Axetil....................20

Cefuroxime Sodium................20

Celecoxib.................................14

Celontin................................... 25

Cephalexin...............................20

Cetirizine HCl.......................... 86

Chantix.....................................17

Chantix Continuing Month Pak............................................... 17

Chantix Starting Month Pak... 17

Chemet.................................... 63

Chenodal................................. 64

Chlordiazepoxide HCl............ 45

Chlorhexidine Gluconate....... 59

Chloroquine Phosphate......... 37

Chlorpromazine HCl............... 38

Chlorthalidone.........................56

Chlorzoxazone........................ 89

Cholbam.................................. 66

Cholestyramine....................... 56

Cholestyramine Light............. 56

Ciclopirox.......................... 29, 30

Ciclopirox Olamine................. 30

Cilostazol................................. 51

Ciloxan..................................... 23

191

Tracked

Cimduo.................................... 43

Cimetidine............................... 65

Cimetidine HCl........................ 65

Cimzia...................................... 77

Cimzia Prefilled....................... 77

Cinacalcet HCl........................ 82

Cinryze..................................... 76

Cipro HC.................................. 85

Ciprodex.................................. 85

Ciprofloxacin HCl....................23

Ciprofloxacin in D5W..............23

Citalopram Hydrobromide..... 27

Claravis.................................... 60

Clarithromycin......................... 22

Clarithromycin ER................... 22

Clenpiq.................................... 65

Climara Pro..............................71

Clindamycin HCl..................... 18

Clindamycin Palmitate HCl.... 18

Clindamycin Phosphate... 18, 60

Clindamycin Phosphate in D5W............................................... 18

Clindamycin Phosphate-Benzoyl Peroxide..................60

Clobazam................................ 25

Clobetasol Propionate............68

Clobetasol Propionate Emollient Base...................... 68

Clomipramine HCl.................. 28

Clonazepam............................ 45

Clonazepam ODT................... 45

Clonidine................................. 51

Clonidine HCl.......................... 51

Clonidine HCl ER.................... 58

Clopidogrel Bisulfate.............. 51

Clorazepate Dipotassium....... 45

Clotrimazole............................ 30

Clotrimazole-Betamethasone............................................... 60

Clovique...................................63

Clozapine.................................41

Clozapine ODT........................41

Coartem................................... 37

Codeine Sulfate...................... 15

Colchicine................................31

Colcrys..................................... 31

Colesevelam HCl.................... 56

Colestipol HCl................... 56, 57

Colistimethate Sodium........... 18

Combigan................................ 84

Combivent Respimat.............. 88

Cometriq..................................35

Complera................................. 43

Compro....................................29

Constulose.............................. 65

Copiktra................................... 34

Cordran....................................68

Corlanor................................... 54

Cortisone Acetate................... 68

Cortisporin...............................60

Cosentyx..................................60

Cosentyx Sensoready.............60

Cosopt PF................................84

Cotellic..................................... 35

Creon....................................... 66

Crinone.................................... 74

Crixivan.................................... 44

Cromolyn Sodium...... 64, 84, 87

Cryselle-28...............................71

Cuvposa...................................64

Cyclafem 1/35.........................71

Cyclafem 7/7/7....................... 71

Cyclobenzaprine HCl..............89

Cyclophosphamide.................33

Cycloset................................... 46

Cyclosporine........................... 77

Cyclosporine Modified........... 77

Cyproheptadine HCl............... 86

Cyred....................................... 71

Cystadane................................66

Cystagon..................................66

Cystaran...................................83

D

Dalfampridine ER....................59

Daliresp....................................87

Dalvance.................................. 18

Danazol.................................... 70

Dantrolene Sodium.................89

Dapsone.................................. 32

Daptacel.................................. 80

Daptomycin............................. 18

DARAPRIM.............................. 37

Daurismo................................. 35

Deblitane................................. 74

Deferasirox.............................. 64

Delstrigo.................................. 43

Demeclocycline HCl............... 24

Demser.................................... 54

Denavir.....................................42

Depen Titratabs...................... 67

Depo-Estradiol.........................71

Depo-Provera.......................... 74

Descovy................................... 43

192

Tracked

Desipramine HCl.....................28

Desmopressin Acetate........... 70

Desmopressin Acetate Spray............................................... 70

Desogestrel-Ethinyl Estradiol............................................... 71

Desonide................................. 68

Desoximetasone..................... 68

Desvenlafaxine Succinate ER............................................... 28

Dexamethasone...................... 68

Dexamethasone Intensol........68

Dexamethasone Sodium Phosphate............................. 84

Dexilant.................................... 66

Dexmethylphenidate HCl....... 58

Dexmethylphenidate HCl ER............................................... 58

Dextroamphetamine Sulfate............................................... 58

Dextroamphetamine Sulfate ER............................................... 58

Dextrose.................................. 62

Dextrose-NaCl......................... 62

Diastat AcuDial........................25

Diastat Pediatric...................... 25

Diazepam.......................... 25, 45

Diazepam Intensol.................. 45

Diazoxide................................. 47

Diclofenac Epolamine............ 14

Diclofenac Potassium.............14

Diclofenac Sodium.....14, 60, 85

Diclofenac Sodium ER........... 14

Dicloxacillin Sodium............... 21

Dicyclomine HCl..................... 64

Didanosine.............................. 43

Dificid....................................... 22

Diflunisal.................................. 14

Digitek......................................54

Digox........................................54

Digoxin.....................................54

Dihydroergotamine Mesylate............................................... 31

Dilantin.....................................26

Dilantin INFATABS..................26

Dilt-XR...................................... 53

Diltiazem HCl...........................53

Diltiazem HCl ER.....................53

Diltiazem HCl ER Beads.........53

Diltiazem HCl ER Coated Beads............................................... 53

Dipentum................................. 81

Diphenoxylate-Atropine.......... 64

Diphtheria-Tetanus Toxoids DT............................................... 80

Disulfiram.................................17

Diuril.........................................56

Divalproex Sodium........... 45, 46

Divalproex Sodium ER........... 45

Dofetilide................................. 52

Donepezil HCl......................... 27

Donepezil HCl ODT................ 27

Dorzolamide HCl.....................84

Dorzolamide HCl-Timolol Maleate..................................84

Dorzolamide HCl-Timolol Maleate Preservative Free... 84

Dovato......................................42

Doxazosin Mesylate................51

Doxepin HCl...................... 28, 60

Doxercalciferol........................ 82

Doxy 100..................................24

Doxycycline Hyclate............... 24

Doxycycline Monohydrate......24

Drizalma Sprinkle....................58

Dronabinol............................... 29

Drospirenone-Ethinyl Estradiol............................................... 71

Droxia.......................................33

Duavee..................................... 71

Dulera...................................... 88

Duloxetine HCl........................ 59

Durezol.....................................85

Dutasteride.............................. 67

Dymista.................................... 88

E

E.E.S. Granules....................... 22

Econazole Nitrate....................30

Edarbi.......................................51

Edarbyclor............................... 54

Edurant.................................... 43

Efavirenz.................................. 43

Elestrin..................................... 71

Eliquis...................................... 49

Eliquis Starter Pack................ 49

Elmiron.....................................67

EluRyng................................... 71

Emcyt....................................... 33

Emgality................................... 31

Emoquette............................... 71

Emsam..................................... 27

Emtriva..................................... 43

Enalapril Maleate.................... 52

Enalapril-Hydrochlorothiazide............................................... 55

193

Tracked

Enbrel.......................................77

Enbrel Mini.............................. 77

Enbrel SureClick..................... 77

Endocet................................... 15

Engerix-B................................. 80

Enoxaparin Sodium................ 49

Enpresse-28............................ 72

Enskyce................................... 72

Entacapone............................. 38

Entecavir.................................. 42

Entresto................................... 55

Enulose.................................... 65

Envarsus XR............................ 77

Epclusa.................................... 42

Epidiolex.................................. 24

Epinastine HCl.........................84

Epinephrine............................. 87

EpiPen 2-Pak........................... 87

EpiPen Jr 2-Pak.......................87

Epitol........................................ 26

Epivir HBV............................... 42

Eplerenone.............................. 56

Eraxis....................................... 30

Ergotamine-Caffeine............... 31

Erivedge...................................35

Erleada.....................................33

Erlotinib HCl............................ 35

Errin..........................................74

Ertapenem Sodium.................21

Ery............................................ 60

Erythrocin Lactobionate......... 22

Erythromycin..................... 23, 61

Erythromycin Base..................22

Erythromycin Ethylsuccinate............................................... 23

Esbriet......................................88

Escitalopram Oxalate............. 28

Esomeprazole Magnesium.... 66

Estarylla................................... 72

Estradiol...................................72

Estradiol Valerate....................72

Estring......................................72

Ethacrynic Acid....................... 55

Ethambutol HCl.......................32

Ethosuximide...........................25

Ethynodiol Diacetate-Ethinyl Estradiol................................ 72

Etodolac...................................14

Etodolac ER.............................14

Etonogestrel-Ethinyl Estradiol............................................... 72

Euthyrox...................................75

Everolimus.........................35, 77

Evotaz...................................... 44

Exemestane.............................34

Ezetimibe................................. 57

Ezetimibe-Simvastatin............ 57

F

Falmina.................................... 72

Famciclovir.............................. 42

Famotidine...............................65

Fanapt......................................39

Fanapt Titration Pack............. 39

Farydak.................................... 35

Fasenra.................................... 89

Fasenra Pen............................ 89

Fayosim................................... 72

Febuxostat...............................31

Felbamate................................26

Felodipine ER..........................53

Femring....................................72

Femynor...................................72

Fenofibrate.............................. 56

Fenofibrate Micronized.......... 56

Fenofibric Acid........................ 56

Fentanyl................................... 15

Fentanyl Citrate....................... 15

Ferriprox.................................. 64

Fetzima.................................... 28

Fetzima Titration..................... 28

Finacea.................................... 61

Finasteride...............................67

Fintepla.................................... 24

Firazyr...................................... 76

Firmagon........................... 75, 76

Flac...........................................85

Flarex....................................... 85

Flebogamma DIF.................... 78

Flecainide Acetate.................. 52

Flector...................................... 14

Flovent Diskus.........................86

Flovent HFA............................. 86

Fluconazole............................. 30

Fluconazole in Sodium Chloride............................................... 30

Flucytosine.............................. 30

Fludrocortisone Acetate.........68

Flunisolide............................... 86

Fluocinolone Acetonide... 68, 85

Fluocinolone Acetonide Scalp............................................... 68

Fluocinonide..................... 68, 69

194

Tracked

Fluocinonide Emulsified Base............................................... 68

Fluorometholone.....................85

Fluorouracil............................. 61

Fluoxetine HCl.........................28

Fluphenazine Decanoate....... 38

Fluphenazine HCl................... 38

Flurbiprofen............................. 14

Flurbiprofen Sodium...............85

Flutamide.................................33

Fluticasone Propionate.... 69, 86

Fluticasone-Salmeterol........... 89

Fluvastatin Sodium................. 56

Fluvoxamine Maleate..............28

FML.......................................... 85

FML Forte................................ 85

Fondaparinux Sodium............ 49

Forteo.......................................82

Fosamprenavir Calcium......... 44

Fosinopril Sodium...................52

Fosinopril Sodium-HCTZ........55

FreAmine HBC........................ 62

Furosemide............................. 56

Fuzeon..................................... 44

Fyavolv..................................... 72

Fycompa.................................. 26

G

Gabapentin..............................25

Galantamine Hydrobromide............................................... 27

Galantamine Hydrobromide ER............................................... 27

Gammagard............................ 78

Gammagard S/D Less IgA..... 78

Gammaked..............................78

Gammaplex............................. 78

Gamunex-C..............................79

Gardasil 9................................ 80

Gatifloxacin..............................23

Gattex.......................................64

Gauze.......................................82

GaviLyte-C............................... 65

GaviLyte-G............................... 65

GaviLyte-N with Flavor Pack............................................... 65

Gemfibrozil.............................. 56

Generlac.................................. 65

Gengraf....................................77

Genotropin.............................. 70

Genotropin MiniQuick............ 70

Gentak..................................... 17

Gentamicin Sulfate................. 18

Gentamicin Sulfate-0.9% Sodium Chloride...................18

Genvoya...................................42

Geodon.................................... 39

Gianvi....................................... 72

Gilenya..................................... 59

Gilotrif...................................... 35

Glassia..................................... 66

Glatiramer Acetate..................59

Glatopa.................................... 59

Gleostine................................. 33

Glimepiride.............................. 46

Glipizide................................... 46

Glipizide ER.............................46

Glipizide-Metformin HCl......... 46

GlucaGen HypoKit.................. 47

Glucagon................................. 47

Glyxambi..................................46

Granisetron HCl...................... 29

Granix.......................................50

Griseofulvin Microsize............ 30

Griseofulvin Ultramicrosize.... 30

Guanfacine HCl ER.................58

Guanidine HCl.........................32

Gvoke HypoPen 2-Pack......... 47

Gvoke PFS...............................48

H

Haegarda................................. 76

Hailey 24 Fe.............................72

Halobetasol Propionate..........69

Haloperidol.............................. 39

Haloperidol Decanoate.......... 39

Haloperidol Lactate................ 39

Havrix....................................... 80

Heparin Sodium...................... 49

HepatAmine............................ 62

Hetlioz...................................... 90

Hiberix......................................80

Humalog.................................. 48

Humalog Junior KwikPen.......48

Humalog KwikPen.................. 48

Humalog Mix 50/50................ 48

Humalog Mix 50/50 KwikPen............................................... 48

Humalog Mix 75/25................ 48

Humalog Mix 75/25 KwikPen............................................... 48

Humatrope.............................. 70

Humira..................................... 77

Humira Pediatric Crohns Start............................................... 77

Humira Pen..............................77

195

Tracked

Humira Pen Crohns Disease Starter.................................... 77

Humira Pen Psoriasis Starter............................................... 77

Humulin 70/30........................ 48

Humulin 70/30 KwikPen........ 48

Humulin N................................48

Humulin N KwikPen................48

Humulin R................................48

Humulin R U-500.....................48

Humulin R U-500 KwikPen..... 48

Hydralazine HCl...................... 57

Hydrochlorothiazide............... 56

Hydrocodone-Acetaminophen............................................... 16

Hydrocodone-Ibuprofen......... 16

Hydrocortisone................. 69, 81

Hydrocortisone Butyrate........ 69

Hydrocortisone Valerate.........69

Hydrocortisone-Acetic Acid... 85

Hydromorphone HCl.............. 16

Hydromorphone HCl ER........ 15

Hydromorphone HCl Preservative Free.................. 16

Hydroxychloroquine Sulfate............................................... 37

Hydroxyurea............................ 33

Hydroxyzine HCl..................... 45

Hydroxyzine Pamoate.............29

Hysingla ER............................. 15

I

Ibandronate Sodium............... 82

Ibrance.....................................35

Ibu............................................ 14

Ibuprofen................................. 14

Icatibant Acetate..................... 76

Iclusig.......................................35

IDHIFA......................................35

Ilevro........................................ 85

Imatinib Mesylate....................35

Imbruvica................................. 35

Imipenem-Cilastatin................ 21

Imipramine HCl....................... 29

Imipramine Pamoate.............. 29

Imiquimod............................... 61

Imiquimod Pump.................... 61

Imovax Rabies.........................80

Imvexxy Maintenance Pack... 72

Imvexxy Starter Pack.............. 72

Incassia....................................74

Increlex.................................... 70

Incruse Ellipta..........................86

Indapamide............................. 56

Indomethacin.......................... 14

Infanrix..................................... 80

Ingrezza................................... 58

Inlyta.........................................35

Inrebic...................................... 34

Insulin Lispro.....................48, 49

Insulin Lispro Junior KwikPen............................................... 48

Insulin Lispro Prot & Lispro....49

Insulin Syringes, Needles.......82

Intelence.................................. 43

Intralipid................................... 62

Intron A.................................... 42

Introvale................................... 72

Invega Sustenna..................... 40

Invega Trinza........................... 40

Invirase.....................................44

Invokamet................................ 46

Invokamet XR.......................... 46

Invokana.................................. 46

IPOL......................................... 80

Ipratropium Bromide.............. 86

Ipratropium-Albuterol..............89

Irbesartan................................ 51

Irbesartan-Hydrochlorothiazide............................................... 55

Iressa........................................35

Isentress.................................. 42

Isentress HD............................ 42

Isibloom................................... 72

Isolyte-P in D5W...................... 62

Isolyte-S................................... 62

Isoniazid...................................32

Isosorbide Dinitrate................ 57

Isosorbide Mononitrate.......... 57

Isosorbide Mononitrate ER.... 57

Isotretinoin...............................61

Itraconazole............................. 30

Ivermectin................................ 37

Ixiaro........................................ 80

J

Jadenu..................................... 64

Jadenu Sprinkle...................... 64

Jakafi........................................35

Jantoven.................................. 49

Janumet................................... 46

Janumet XR............................. 46

Januvia.....................................46

Jardiance................................. 46

Jasmiel.....................................72

196

Tracked

Jentadueto...............................46

Jentadueto XR.........................46

Jinteli........................................72

Jublia........................................30

Juleber..................................... 72

Juluca...................................... 43

Junel 1.5/30............................ 72

Junel 1/20............................... 72

Junel Fe 1.5/30....................... 72

Junel Fe 1/20.......................... 72

Junel Fe 24.............................. 72

Juxtapid................................... 57

K

Kaitlib Fe.................................. 72

Kaletra......................................44

Kalydeco.................................. 89

Kariva....................................... 72

KCl in Dextrose-NaCl.............. 62

KCl-Lactated Ringers-D5W.... 62

Kelnor 1/35............................. 72

Kelnor 1/50............................. 72

Ketoconazole.......................... 30

Ketoprofen...............................14

Ketorolac Tromethamine....... 85

Kineret......................................77

Kinrix........................................ 80

Kionex...................................... 64

Kisqali...................................... 34

Kisqali Femara........................ 34

Klor-Con................................... 62

Klor-Con 10..............................62

Klor-Con 8................................62

Klor-Con M10.......................... 62

Klor-Con M15.......................... 62

Klor-Con M20.......................... 62

Korlym......................................70

Koselugo..................................35

Kurvelo.....................................72

Kuvan....................................... 66

L

Labetalol HCl...........................52

Lacrisert................................... 83

Lactulose................................. 65

Lamivudine........................42, 43

Lamivudine-Zidovudine.......... 43

Lamotrigine............................. 26

Lanoxin.................................... 55

Lansoprazole...........................66

Lanthanum Carbonate........... 64

Lantus...................................... 49

Lantus SoloStar.......................49

LARIN 1.5/30.......................... 72

LARIN 1/20............................. 72

LARIN Fe 1.5/30..................... 72

LARIN Fe 1/20........................ 72

Larissia.....................................72

Lastacaft.................................. 83

Latanoprost............................. 85

Latuda......................................40

Layolis Fe.................................72

Leena....................................... 72

Leflunomide............................ 79

Lenvima 10MG Daily Dose.....35






Lenvima 4MG Daily Dose.......36

Lenvima 8MG Daily Dose.......36

Lessina.....................................73

Letrozole.................................. 34

Leucovorin Calcium................34

Leukeran..................................33

Leukine.................................... 50

Leuprolide Acetate................. 76

Levalbuterol HCl..................... 87

Levemir.................................... 49

Levemir FlexTouch................. 49

Levetiracetam..........................24

Levetiracetam ER....................24

Levo-T...................................... 75

Levobunolol HCl..................... 84

Levocarnitine...........................62

Levocetirizine Dihydrochloride............................................... 86

Levofloxacin............................ 23

Levofloxacin in D5W............... 23

Levonest.................................. 73

Levonorgestrel-Ethinyl Estradiol............................................... 73

Levonorgestrel-Ethinyl Estradiol & Ethinyl Estradiol................ 73

Levonorgestrel-Ethinyl Estradiol 91-Day....................................73

Levora 0.15/30........................73

Levorphanol Tartrate.............. 15

Levothyroxine Sodium............75

Levoxyl..................................... 75

Lexiva....................................... 44

Lidocaine...........................16, 17

Lidocaine HCl..........................17

Lidocaine Viscous...................17

197

Tracked

Lidocaine-Prilocaine............... 17

Lindane.................................... 37

Linezolid.................................. 18

Linzess..................................... 65

Liothyronine Sodium.............. 75

Lisinopril.................................. 52

Lisinopril-Hydrochlorothiazide............................................... 55

Lithium..................................... 46

Lithium Carbonate.................. 46

Lithium Carbonate ER............ 46

Lithostat................................... 67

Livalo........................................56

Lokelma................................... 64

Lonhala Magnair..................... 86

Lonsurf.....................................34

Loperamide HCl......................64

Lopinavir-Ritonavir.................. 44

Lorazepam...............................45

Lorbrena.................................. 34

Lorcet.......................................16

Lorcet HD................................ 16

Loryna...................................... 73

Losartan Potassium................ 51

Losartan Potassium-HCTZ..... 55

Lotemax................................... 85

Lotemax SM............................ 85

Loteprednol Etabonate...........85

Lovastatin................................ 56

Low-Ogestrel........................... 73

Loxapine Succinate................ 39

Lumigan...................................85

Lupaneta Pack........................ 76

Lupron Depot.......................... 76

Lutera.......................................73

Lynparza.................................. 36

Lysodren..................................75

Lyza.......................................... 74

M

M-M-R II....................................80

Magnesium Sulfate................. 62

Malathion................................. 37

Maprotiline HCl....................... 28

Marlissa................................... 73

Marplan....................................27

Matulane..................................33

Matzim LA................................53

Mavyret.................................... 42

Mayzent................................... 59

Meclizine HCl.......................... 29

Medroxyprogesterone Acetate......................................... 74, 75

Mefloquine HCl....................... 37

Megestrol Acetate...................75

Mekinist................................... 36

Mektovi.................................... 36

Melodetta 24 Fe...................... 73

Meloxicam............................... 14

Memantine HCl....................... 27

Memantine HCl ER................. 27

Memantine HCl Titration Pak............................................... 27

Menactra..................................80

Menest..................................... 73

Mentax..................................... 30

Menveo.................................... 80

Mercaptopurine...................... 33

Meropenem............................. 21

Mesalamine............................. 81

Mesalamine ER....................... 81

Mesnex.................................... 36

Metaproterenol Sulfate...........87

Metformin HCl...................46, 47

Metformin HCl ER................... 46

Methadone HCl....................... 15

Methazolamide........................55

Methenamine Hippurate........ 18

Methimazole............................ 76

Methotrexate........................... 77

Methotrexate Sodium............. 77

Methoxsalen Rapid.................61

Methscopolamine Bromide....64

Methyldopa..............................51

Methyldopa-Hydrochlorothiazide............. 55

Methylphenidate HCl.............. 58

Methylphenidate HCl ER........ 58

Methylprednisolone................ 69

Metoclopramide HCl.............. 29

Metolazone.............................. 56

Metoprolol Succinate ER....... 52

Metoprolol Tartrate................. 52

Metoprolol-Hydrochlorothiazide............................................... 55

Metronidazole................... 18, 19

Metronidazole in NaCl 0.79%............................................... 19

Mexiletine HCl......................... 52

Mibelas 24 Fe.......................... 73

Micafungin Sodium................ 30

Miconazole 3........................... 30

Microgestin 1.5/30................. 73

Microgestin 1/20.....................73

198

Tracked

Microgestin Fe 1.5/30............ 73

Microgestin Fe 1/20............... 73

Midodrine HCl......................... 51

Migergot.................................. 31

Miglitol..................................... 47

Miglustat.................................. 66

Mili............................................73

Minitran....................................57

Minocycline HCl...................... 24

Minoxidil.................................. 57

Mirtazapine..............................27

Mirtazapine ODT..................... 27

Mirvaso.................................... 61

Misoprostol..............................66

Modafinil.................................. 90

Moexipril HCl...........................52

Molindone HCl........................ 39

Mometasone Furoate....... 69, 86

Montelukast Sodium...............86

Morphine Sulfate.................... 16

Morphine Sulfate ER.............. 15

Moxifloxacin HCl..................... 23

Moxifloxacin HCl in NaCl....... 23

Multaq...................................... 52

Mupirocin................................ 19

Mupirocin Calcium................. 19

Myalept.................................... 65

Mycamine................................ 30

Mycophenolate Mofetil.... 77, 78

Mycophenolate Sodium......... 78

Myrbetriq................................. 67

N

Nabumetone........................... 14

Nadolol.................................... 52

Nafcillin Sodium......................22

Naftifine HCl............................ 30

Naftin........................................30

Naloxone HCl.......................... 17

Naltrexone HCl........................ 17

Namzaric..................................58

Naproxen................................. 14

Naproxen DR...........................14

Naratriptan HCl....................... 32

Narcan..................................... 17

Natacyn....................................30

Nateglinide.............................. 47

Natpara.................................... 82

Nayzilam.................................. 24

Nebupent.................................37

Necon 0.5/35.......................... 73

Nefazodone HCl......................28

Neomycin Sulfate....................18

Neomycin-Bacitracin-Polymyxin............................................... 83

Neomycin-Polymyxin-Bacitracin-Hydrocortisone..................... 83

Neomycin-Polymyxin-Dexamethasone....................83

Neomycin-Polymyxin-Gramicidin.............................83

Neomycin-Polymyxin-HC....... 83, 85, 86

NephrAmine............................ 62

Nerlynx.....................................36

Neulasta...................................50

Neupogen................................50

Neupro..................................... 38

Nevirapine............................... 43

Nevirapine ER......................... 43

Nexavar....................................36

Niacin ER................................. 57

Niacor...................................... 57

Nicardipine HCl.......................53

Nicotrol.................................... 17

Nicotrol NS.............................. 17

Nifedipine ER.......................... 53

Nifedipine ER Osmotic Release............................................... 53

Nikki......................................... 73

Nilutamide............................... 33

Nimodipine.............................. 53

Ninlaro..................................... 34

Nitisinone.................................66

Nitro-Bid...................................57

Nitrofurantoin.......................... 19

Nitrofurantoin Macrocrystal... 19

Nitrofurantoin Monohydrate...19

Nitroglycerin............................ 57

Nitrostat................................... 57

Nora-BE....................................75

Norditropin FlexPro................ 70

Norethindrone......................... 75

Norethindrone Acetate........... 75

Norethindrone Acetate-Ethinyl Estradiol................................ 73

Norethindrone Acetate-Ethinyl Estradiol-Fe........................... 73

Norgestimate-Ethinyl Estradiol............................................... 73

Norgestimate-Ethinyl Estradiol Triphasic................................73

Normosol-M in D5W............... 62

Normosol-R pH 7.4................. 62

Northera...................................51

199

Tracked

Nortrel 0.5/35.......................... 73

Nortrel 1/35............................. 73

Nortrel 7/7/7........................... 73

Nortriptyline HCl......................29

Norvir....................................... 44

Noxafil...................................... 30

Nubeqa.................................... 33

Nucala......................................89

Nucynta ER..............................15

Nuedexta................................. 58

Nuplazid...................................40

Nutrilipid.................................. 62

Nutropin AQ NuSpin 10......... 70

Nutropin AQ NuSpin 20......... 70

Nutropin AQ NuSpin 5............70

Nyamyc.................................... 30

Nymalize.................................. 53

Nystatin..............................30, 31

Nystop......................................31

O

Ocaliva..................................... 66

Ocella....................................... 73

Octagam.................................. 79

Octreotide Acetate..................76

Odefsey................................... 43

Odomzo................................... 36

Ofev..........................................88

Ofloxacin..................................23

Olanzapine.............................. 40

Olanzapine ODT......................40

Olmesartan Medoxomil.......... 51

Olmesartan Medoxomil-HCTZ............................................... 55

Olmesartan-Amlodipine-HCTZ............................................... 55

Olopatadine HCl..................... 84

Omega-3-Acid Ethyl Esters.....57

Omeprazole.............................66

Ondansetron HCl.................... 29

Ondansetron ODT.................. 29

Opsumit................................... 88

Orencia.................................... 78

Orencia ClickJect....................78

Orenitram.................................88

Orfadin..................................... 66

Orkambi................................... 87

Orsythia....................................73

Oseltamivir Phosphate..... 44, 45

Osphena.................................. 75

Otezla.......................................79

Oxacillin Sodium..................... 22

Oxacillin Sodium in Dextrose............................................... 22

Oxandrolone............................71

Oxcarbazepine........................ 26

Oxsoralen Ultra....................... 61

Oxybutynin Chloride............... 67

Oxybutynin Chloride ER......... 67

Oxycodone HCl.......................16

Oxycodone-Acetaminophen............................................... 16

Oxycodone-Aspirin................. 16

Ozempic.................................. 47

P

Pacerone................................. 52

Paliperidone ER...................... 40

Panretin................................... 36

Pantoprazole Sodium............. 66

Panzyga................................... 79

Paricalcitol............................... 82

Paromomycin Sulfate............. 18

Paroxetine HCl........................ 28

Paser........................................ 32

Paxil..........................................28

Pazeo....................................... 84

Pediarix.................................... 80

Pedvax HIB.............................. 80

PEG-3350-Electrolytes............ 65

PEG-3350-NaCl-Na Bicarbonate-KCl....................65

Peganone................................ 26

Pegasys................................... 42

Pegasys ProClick.................... 42

Pemazyre................................. 34

Penicillamine........................... 67

Penicillin G Potassium............22

Penicillin G Procaine.............. 22

Penicillin G Sodium................ 22

Penicillin V Potassium............ 22

PENTAM 300...........................37

Pentamidine Isethionate.........37

Pentasa.................................... 81

Pentoxifylline ER..................... 55

Perforomist.............................. 87

Perindopril Erbumine..............52

Permethrin...............................37

Perphenazine.......................... 29

Perseris.................................... 40

Phenelzine Sulfate.................. 27

Phenobarbital.......................... 25

Phenoxybenzamine HCl......... 51

Phenytek..................................26

200

Tracked

Phenytoin.................................26

Phenytoin Sodium Extended............................................... 26

Phoslyra................................... 64

Phospholine Iodide.................84

Picato....................................... 61

Pifeltro......................................43

Pilocarpine HCl................. 60, 84

Pimecrolimus.......................... 61

Pimozide.................................. 39

Pimtrea.....................................73

Pindolol....................................53

Pioglitazone HCl..................... 47

Pioglitazone HCl-Glimepiride............................................... 47

Pioglitazone HCl-Metformin HCl............................................... 47

Piperacillin-Tazobactam......... 22

Piqray....................................... 34

Pirmella 1/35...........................73

Piroxicam.................................14

Plasma-Lyte 148......................62

Plasma-Lyte A......................... 62

Plenamine................................63

Podofilox..................................61

Polymyxin B Sulfate................ 19

Polymyxin B-Trimethoprim.....83

Pomalyst.................................. 33

Portia-28.................................. 73

Posaconazole..........................31

Potassium Chloride................ 63

Potassium Chloride CR.......... 63

Potassium Chloride ER.......... 63

Potassium Chloride in Dextrose............................................... 63

Potassium Chloride in NaCl... 63

Potassium Citrate ER..............63

Praluent................................... 57

Pramipexole Dihydrochloride............................................... 38

Prasugrel HCl.......................... 51

Pravastatin Sodium.................56

Praziquantel............................ 37

Prazosin HCl............................51

Pred Mild................................. 85

Pred-G......................................83

Pred-G S.O.P........................... 83

Prednicarbate..........................69

Prednisolone........................... 69

Prednisolone Acetate............. 85

Prednisolone Sodium Phosphate.......................69, 85

Prednisone.............................. 69

Prednisone Intensol................69

Pregabalin............................... 59

Premarin............................ 73, 74

Premasol..................................63

Premphase.............................. 74

Prempro...................................74

Prevalite................................... 57

Previfem...................................74

Prezcobix................................. 44

Prezista.................................... 44

Priftin........................................32

Prilosec.................................... 66

Primaquine Phosphate...........37

Primidone................................ 25

Privigen.................................... 79

ProAir HFA...............................87

ProAir RespiClick....................87

Probenecid.............................. 31

Probenecid-Colchicine........... 31

Procalamine............................ 63

Prochlorperazine.....................29

Prochlorperazine Maleate...... 29

Procrit................................ 50, 51

Procto-Med HC....................... 81

Procto-Pak............................... 82

Proctosol HC........................... 82

Proctozone-HC........................ 82

Procysbi................................... 66

Progesterone Micronized.......75

Proglycem............................... 48

Prograf..................................... 78

Prolastin-C............................... 66

Prolensa...................................85

Prolia........................................ 82

Promacta................................. 51

Promethazine HCl................... 86

Promethegan...........................86

Propafenone HCl.................... 52

Propafenone HCl ER.............. 52

Proparacaine HCl....................83

Propranolol HCl...................... 53

Propranolol HCl ER................ 53

Propranolol-HCTZ................... 55

Propylthiouracil....................... 76

ProQuad.................................. 80

Prosol....................................... 63

Protriptyline HCl...................... 29

Pulmozyme..............................89

Purixan..................................... 33

Pyrazinamide...........................32

201

Tracked

Pyridostigmine Bromide.........32

Pyridostigmine Bromide ER...32

Pyrimethamine........................ 37

Q

Qinlock.....................................34

Quadracel................................ 80

Quetiapine Fumarate.............. 40

Quetiapine Fumarate ER........ 40

Quinapril HCl........................... 52

Quinapril-Hydrochlorothiazide............................................... 55

Quinidine Gluconate ER.........52

Quinidine Sulfate.................... 52

Quinine Sulfate........................37

R

RabAvert..................................80

Rabeprazole Sodium.............. 66

Raloxifene HCl........................ 75

Ramelteon............................... 90

Ramipril................................... 52

Ranolazine ER.........................55

Rasagiline Mesylate................38

Rasuvo..................................... 78

RAVICTI................................... 66

Rayaldee..................................82

Rebif.........................................59

Rebif Rebidose....................... 59

Rebif Rebidose Titration Pack............................................... 59

Rebif Titration Pack................ 59

Reclipsen.................................74

Recombivax HB...................... 80

Rectiv....................................... 57

Regranex................................. 61

Relenza Diskhaler................... 45

Relistor.....................................65

Repaglinide............................. 47

Repatha................................... 57

Repatha Pushtronex System............................................... 57

Repatha SureClick..................57

Restasis Single-Use Vials....... 83

Retacrit.................................... 51

Retevmo.................................. 34

Revlimid................................... 33

Rexulti...................................... 40

Reyataz.................................... 44

Rhopressa............................... 83

Ribavirin...................................42

Ridaura.................................... 79

Rifabutin.................................. 32

Rifampin.................................. 32

Riluzole.................................... 58

Rimantadine HCl.....................45

Riomet..................................... 47

Riomet ER............................... 47

Risedronate Sodium...............82

Risperdal Consta.............. 40, 41

Risperidone............................. 41

Risperidone ODT.................... 41

Ritonavir...................................44

Rivastigmine............................27

Rivastigmine Tartrate............. 27

Rivelsa..................................... 74

Rizatriptan Benzoate.............. 32

Rizatriptan Benzoate ODT..... 32

Rocklatan................................ 84

Ropinirole HCl.........................38

Rosuvastatin Calcium.............56

Rotarix......................................81

RotaTeq................................... 81

Roweepra................................ 24

Roweepra XR.......................... 24

Rozlytrek..................................34

Rubraca................................... 35

Ruconest................................. 76

Rukobia................................... 44

Rybelsus.................................. 47

Rydapt..................................... 36

Rytary....................................... 38

S

Saizen...................................... 70

Saizenprep.............................. 70

Sancuso................................... 29

Sandimmune........................... 78

Santyl....................................... 61

Saphris.....................................41

Savella......................................59

Savella Titration Pack............. 59

Scopolamine........................... 29

Secuado.................................. 41

Selegiline HCl..........................38

Selenium Sulfide..................... 61

Selzentry.................................. 44

Serevent Diskus...................... 87

Serostim...................................65

Sertraline HCl.......................... 28

Setlakin.................................... 74

Sevelamer Carbonate............. 64

Sharobel.................................. 75

Shingrix....................................81

Signifor.................................... 76

202

Tracked

Sildenafil Citrate......................88

Silodosin.................................. 67

Silver Sulfadiazine...................23

Simbrinza.................................84

Simponi....................................78

Simvastatin.............................. 56

Sirolimus..................................78

Sirturo...................................... 33

Sodium Chloride..................... 63

Sodium Fluoride......................63

Sodium Phenylbutyrate.......... 66

Sodium Polystyrene Sulfonate............................................... 64

Sofosbuvir-Velpatasvir............ 42

Solifenacin Succinate............. 67

Soliqua..................................... 47

Soltamox..................................33

Somatuline Depot................... 76

Somavert................................. 76

Sotalol HCl...............................52

Sotalol HCl AF......................... 52

Sovaldi..................................... 42

Spiriva HandiHaler.................. 87

Spiriva Respimat..................... 87

Spironolactone........................56

Spironolactone-HCTZ.............55

Sprintec 28.............................. 74

Spritam ODT........................... 24

Sprycel..................................... 36

SPS.......................................... 64

Sronyx...................................... 74

SSD.......................................... 23

Stavudine.................................43

Stelara......................................61

Stiolto Respimat......................89

Stivarga....................................36

Streptomycin Sulfate.............. 18

Stribild......................................42

Suboxone................................ 17

Sucraid.....................................66

Sucralfate................................ 66

Sulfacetamide Sodium........... 23

Sulfacetamide-Prednisolone............................................... 83

Sulfadiazine............................. 23

Sulfamethoxazole-Trimethoprim......................................... 23, 24

Sulfamylon...............................19

Sulfasalazine........................... 82

Sulindac...................................14

Sumatriptan.............................32

Sumatriptan Succinate........... 32

Sumatriptan Succinate Refill............................................... 32

Suprax......................................20

Suprep Bowel Prep Kit........... 65

Sutent.......................................36

Syeda....................................... 74

Symbicort................................ 89

Symfi........................................ 43

Symfi Lo...................................43

SymlinPen 120........................ 47

SymlinPen 60.......................... 47

Sympazan................................ 25

Symtuza................................... 44

Synarel..................................... 76

Synjardy................................... 47

Synjardy XR............................. 47

Synribo.....................................34

Synthroid................................. 75

T

Tabloid..................................... 33

Tabrecta.................................. 33

Tacrolimus........................ 61, 78

Tadalafil................................... 88

Tafinlar..................................... 36

Tagrisso................................... 36

Talzenna.................................. 35

Tamoxifen Citrate................... 33

Tamsulosin HCl.......................67

Targretin.................................. 36

Tarina 24 Fe............................ 74

Tarina Fe 1/20.........................74

Tasigna.................................... 36

Tazarotene...............................61

Tazicef..................................... 20

Tazorac.................................... 61

Taztia XT.................................. 53

Tazverik....................................34

TDVAX..................................... 81

Tecfidera..................................59

Tecfidera Starter Pack............59

Tegsedi.................................... 67

Telmisartan..............................51

Telmisartan-Amlodipine......... 55

Telmisartan-HCTZ...................55

Temazepam.............................89

Tenivac.................................... 81

Tenofovir Disoproxil Fumarate............................................... 43

Terazosin HCl..........................67

Terbinafine HCl....................... 31

Terconazole.............................31

203

Tracked

Teriparatide............................. 82

Testosterone........................... 71

Testosterone Cypionate......... 71

Testosterone Enanthate......... 71

Tetrabenazine......................... 58

Tetracycline HCl......................24

Thalomid..................................33

Theophylline............................88

Theophylline ER......................88

Thioridazine HCl..................... 39

Thiothixene..............................39

Tiadylt ER................................ 53

Tiagabine HCl......................... 25

Tibsovo.................................... 36

Tigecycline.............................. 19

Timolol Maleate................ 31, 84

Timolol Maleate Ophthalmic Gel Forming.......................... 84

Tinidazole................................ 19

Tivicay................................42, 43

Tivicay PD................................ 43

Tizanidine HCl......................... 89

TOBI Podhaler.........................87

TobraDex................................. 83

TobraDex ST........................... 83

Tobramycin....................... 18, 87

Tobramycin Sulfate.................18

Tobramycin-Dexamethasone............................................... 83

Tobrex......................................18

Tolak........................................ 61

Tolcapone................................38

Topiramate.............................. 26

Toremifene Citrate.................. 33

Torsemide............................... 56

Toujeo Max SoloStar.............. 49

Toujeo SoloStar...................... 49

TPN Electrolytes..................... 63

Tracleer....................................88

Tradjenta................................. 47

Tramadol HCl.......................... 16

Tramadol HCl ER.................... 15

Tramadol-Acetaminophen..... 16

Trandolapril............................. 52

Tranexamic Acid..................... 51

Transderm-Scop..................... 29

Tranylcypromine Sulfate........ 27

Travasol................................... 63

Travoprost............................... 85

Trazodone HCl........................ 28

Trecator................................... 33

Trelegy Ellipta..........................89

Trelstar Mixject........................76

Tresiba..................................... 49

Tresiba FlexTouch.................. 49

Tretinoin............................ 36, 61

Tretinoin Microsphere............ 61

Trexall...................................... 78

Trezix....................................... 16

Tri-Estarylla.............................. 74

Tri-Legest Fe............................74

Tri-Lo-Estarylla.........................74

Tri-Lo-Sprintec.........................74

Tri-Mili...................................... 74

Tri-Previfem............................. 74

Tri-Sprintec.............................. 74

Tri-VyLibra............................... 74

Tri-VyLibra Lo.......................... 74

Triamcinolone Acetonide...... 60, 70

Triamterene............................. 56

Triamterene-HCTZ.................. 55

Triderm.................................... 70

Trientine HCl........................... 64

Trifluoperazine HCl................. 39

Trifluridine............................... 42

Trihexyphenidyl HCl............... 37

TriLyte...................................... 65

Trimethoprim...........................19

Trimipramine Maleate............ 29

Trintellix................................... 28

Triumeq................................... 43

Trivora...................................... 74

TrophAmine.............................63

Trulicity.................................... 47

Trumenba................................ 81

Truvada....................................43

Tukysa..................................... 34

Turalio...................................... 36

Twinrix......................................81

Tybost...................................... 43

Tykerb...................................... 36

Tymlos..................................... 82

Typhim Vi.................................81

U

Udenyca...................................51

Unithroid.................................. 75

Ursodiol................................... 65

V

Valacyclovir HCl...................... 42

Valchlor....................................33

Valganciclovir HCl...................41

204

Tracked

Valproic Acid........................... 25

Valsartan.................................. 52

Valsartan-Hydrochlorothiazide............................................... 55

Valtoco 10 MG Dose...............25

Valtoco 15 MG Dose...............25

Valtoco 20 MG Dose...............25

Valtoco 5 MG Dose.................25

Vancomycin HCl..................... 19

Vandazole................................ 19

VAQTA..................................... 81

Varivax..................................... 81

Varizig...................................... 79

Vascepa................................... 57

Velivet...................................... 74

Velphoro.................................. 64

Veltassa................................... 64

Vemlidy.................................... 42

Venclexta................................. 36

Venclexta Starting Pack......... 36

Venlafaxine HCl.......................28

Venlafaxine HCl ER.................28

Ventavis................................... 88

Verapamil HCl......................... 54

Verapamil HCl ER................... 54

Versacloz................................. 41

Verzenio................................... 34

Vibramycin...............................24

Victoza..................................... 47

Vienva...................................... 74

Vigabatrin................................ 25

Vigadrone................................ 26

Viibryd...................................... 28

Viibryd Starter Pack................ 28

Vimpat......................................26

Viracept....................................44

Viread.......................................44

Vitrakvi..................................... 36

Vivitrol...................................... 17

Vizimpro...................................36

Voriconazole............................31

Vosevi...................................... 42

Votrient.................................... 36

VP-PNV-DHA............................64

Vraylar...................................... 41

Vyfemla.................................... 74

VyLibra.....................................74

Vyndamax................................55

Vyndaqel..................................55

Vyvanse....................................58

Vyzulta..................................... 85

W

Warfarin Sodium..................... 49

Wixela Inhub............................89

WYMZYA Fe............................ 74

X

Xalkori...................................... 36

Xarelto......................................49

Xarelto Starter Pack................49

Xatmep.....................................78

Xcopri................................ 24, 25

Xeljanz..................................... 78

Xeljanz XR............................... 78

Xgeva....................................... 82

Xifaxan..................................... 65

Xiidra........................................ 83

Xofluza..................................... 45

Xolair........................................ 79

Xospata....................................36

Xpovio................................33, 34

Xtampza ER.............................15

Xtandi....................................... 33

Xulane...................................... 74

Xyrem....................................... 90

Y

YF-Vax...................................... 81

Yuvafem................................... 74

Z

Zafirlukast................................ 86

Zaleplon................................... 89

Zarah........................................74

Zarxio....................................... 51

Zejula....................................... 35

Zelapar ODT............................ 38

Zelboraf................................... 36

Zemaira....................................67

Zenpep.................................... 67

Zerbaxa....................................21

Zidovudine...............................44

Zileuton ER..............................86

Zioptan.....................................85

Ziprasidone HCl...................... 41

Ziprasidone Mesylate............. 41

Zirgan.......................................42

Zolinza..................................... 34

Zolpidem Tartrate................... 89

Zonisamide..............................25

Zorbtive....................................65

Zortress....................................78

Zovia 1/35E............................. 74

Zyclara Pump.......................... 61

Zydelig..................................... 36

205

Tracked

Zyflo......................................... 86 Zykadia.................................... 36 Zyprexa Relprevv.................... 41

206

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2020 LIST OF COVERED DRUGS (FORMULARY)€¦ · 01-07-2020 · UnitedHealthcare® Senior Care...

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Transcript of 2020 LIST OF COVERED DRUGS (FORMULARY)€¦ · 01-07-2020 · UnitedHealthcare® Senior Care...