“Auto PA” = System automated criteria looks for …Florida Medicaid Preferred Drug List (updated...

Florida Medicaid Preferred Drug List (01-16-2020)

The Florida Medicaid Preferred Drug List (PDL) is subject to revision following consideration and recommendations by the

Pharmaceutical and Therapeutics (P&T) Committee and the Agency for Health Care Administration. The quarterly P&T Committee

meeting was held on December 13, 2019.

This list is in order by the therapeutic classification. To locate a specific drug or therapeutic class, use the search feature available in

Adobe Acrobat Reader. (keyboard shortcut: CTRL+F)

Phosphate Binders and Prescription Strength Vitamins are covered for dialysis patients.

Note: While a product name may be listed on the PDL, a specific NDC may or may not be reimbursable.

DEFINITIONS:

“Auto PA” = System automated criteria looks for specific requirements (e.g., diagnosis, age, previous therapies, etc.). If all requirements

are found, the claims will pay at the pharmacy counter without need of manual prior authorization submission.

“Clinical PA Required” = These drugs require prior authorization submission that must include clinical documentation. The drugs that

require clinical prior authorization review and the prior authorization forms can be found in this link:

http://ahca.myflorida.com/medicaid/Prescribed_Drug/preferred_drug.shtml

“Cystic Fib Diag Auto PA” = Claims for these products will pay at the pharmacy counter if the diagnosis of cystic fibrosis is found in the

system.

“Requires Med Cert 3” = The Food and Drug Administration (FDA) requires participation (by prescribers, pharmacies, and/or patients)

in certification, education, training, or agreements prior to dispensing certain drugs. By entering certification code “3”, the dispensing

pharmacy is confirming that FDA requirements were met.

Auto PA in progress:

Ingrezza oral

Thursday, January 16, 2020 of 192

hamiltov

Highlight

hamiltov

Highlight

hamiltov

Highlight

Class Generic Name Medicaid Min Age

Medicaid Max Age

Label Name Clinical PA Required

A1A DIGITALIS GLYCOSIDESA1A DIGOXIN 0 999DIGOXIN 0.125 MG TABLET No

A1A DIGOXIN 0 999DIGOXIN 0.25 MG TABLET No

A1A DIGOXIN 0 999DIGOXIN 125 MCG TABLET No

A1A DIGOXIN 0 999DIGOXIN 250 MCG TABLET No

A1A DIGOXIN 0 999DIGOXIN 0.05 MG/ML SOLUTION No

A1B XANTHINESA1B CAFFEINE CITRATE 1 999CAFFEINE CIT 60 MG/3 ML ORAL No

A1B CAFFEINE CITRATE 1 999CAFFEINE CIT 60 MG/3 ML VIAL No

A1B THEOPHYLLINE ANHYDROUS 0 999THEO-24 ER 200 MG CAPSULE No

A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE ER 450 MG TAB No

A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE ER 300 MG TAB No

A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE ER 200 MG TABLET No




A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE 80 MG/15 ML SOLN No



A1B THEOPHYLLINE ANHYDROUS 0 999ELIXOPHYLLIN 80 MG/15 ML ELIX No



Medicaid Max Age



A1C INOTROPIC DRUGSA1C DOBUTAMINE HCL 0 999DOBUTAMINE 12.5 MG/ML VIAL No

A1C DOBUTAMINE HCL 0 999DOBUTAMINE 250 MG/20 ML VIAL No

A1C DOBUTAMINE HCL IN DEXTROSE 5 % 0 999DOBUTAMINE 1 GM-D5W 250 ML No

A1C DOBUTAMINE HCL IN DEXTROSE 5 % 0 999DOBUTAMINE 250 MG-D5W 250 ML No

A1C DOBUTAMINE HCL IN DEXTROSE 5 % 0 999DOBUTAMINE 500 MG-D5W 250 ML No

A1C MILRINONE LACTATE 0 999MILRINONE LACT 10 MG/10 ML VL No



A1C MILRINONE LACTATE/D5W 0 999MILRINONE-D5W 20 MG/100 ML No

A1C MILRINONE LACTATE/D5W 0 999MILRINONE-D5W 40 MG/200 ML No

A2A ANTIARRHYTHMICSA2A AMIODARONE HCL 0 999AMIODARONE HCL 100 MG TABLET No

A2A AMIODARONE HCL 0 999AMIODARONE HCL 200 MG TABLET No

A2A DOFETILIDE 0 999TIKOSYN 125 MCG CAPSULE Requires Med Cert 3



A2A FLECAINIDE ACETATE 0 999FLECAINIDE ACETATE 150 MG TAB No



A2A MEXILETINE HCL 0 999MEXILETINE 150 MG CAPSULE No





Medicaid Max Age


A2A PROPAFENONE HCL 0 999PROPAFENONE HCL 150 MG TABLET No

A2A PROPAFENONE HCL 0 999PROPAFENONE HCL 300 MG TAB No

A2A PROPAFENONE HCL 0 999PROPAFENONE HCL 225 MG TAB No

A2A QUINIDINE SULFATE 0 999QUINIDINE SULFATE 200 MG TAB No

A2A QUINIDINE SULFATE 0 999QUINIDINE SULFATE 300 MG TAB No

A2C ANTIANGINAL, ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMICA2C RANOLAZINE 0 999RANEXA ER 1,000 MG TABLET No

A2C RANOLAZINE 0 999RANEXA ER 500 MG TABLET No

A4A ANTIHYPERTENSIVES, VASODILATORSA4A HYDRALAZINE HCL 0 999HYDRALAZINE 100 MG TABLET No

A4A HYDRALAZINE HCL 0 999HYDRALAZINE 25 MG TABLET No



A4A MINOXIDIL 0 999MINOXIDIL 10 MG TABLET No

A4A MINOXIDIL 0 999MINOXIDIL 2.5 MG TABLET No

A4B ANTIHYPERTENSIVES, SYMPATHOLYTICA4B CLONIDINE 0 999CATAPRES-TTS 1 PATCH No

A4B CLONIDINE 0 999CATAPRES-TTS 2 PATCH No

A4B CLONIDINE 0 999CATAPRES-TTS 3 PATCH No

A4B CLONIDINE HCL 0 999CLONIDINE HCL 0.2 MG TABLET No



A4B GUANFACINE HCL 0 999GUANFACINE 2 MG TABLET No

A4B GUANFACINE HCL 0 999GUANFACINE 1 MG TABLET No

A4B METHYLDOPA 0 999METHYLDOPA 250 MG TABLET No



Medicaid Max Age


A4B METHYLDOPA 0 999METHYLDOPA 500 MG TABLET No

A4D ANTIHYPERTENSIVES, ACE INHIBITORSA4D BENAZEPRIL HCL 0 999BENAZEPRIL HCL 5 MG TABLET No

A4D BENAZEPRIL HCL 0 999BENAZEPRIL HCL 10 MG TABLET No



A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 5 MG TABLET No

A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 20 MG TAB No

A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 10 MG TAB No

A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 2.5 MG TAB No

A4D FOSINOPRIL SODIUM 0 999FOSINOPRIL SODIUM 10 MG TAB No



A4D LISINOPRIL 0 999LISINOPRIL 40 MG TABLET No



A4D LISINOPRIL 0 999LISINOPRIL 2.5 MG TABLET No



A4D QUINAPRIL HCL 0 999QUINAPRIL 10 MG TABLET No




A4D RAMIPRIL 0 999RAMIPRIL 10 MG CAPSULE No



Medicaid Max Age


A4D RAMIPRIL 0 999RAMIPRIL 2.5 MG CAPSULE No

A4D RAMIPRIL 0 999RAMIPRIL 1.25 MG CAPSULE No

A4D RAMIPRIL 0 999RAMIPRIL 5 MG CAPSULE No

A4F ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONISTA4F IRBESARTAN 0 999IRBESARTAN 150 MG TABLET No

A4F IRBESARTAN 0 999IRBESARTAN 300 MG TABLET No

A4F IRBESARTAN 0 999IRBESARTAN 75 MG TABLET No

A4F LOSARTAN POTASSIUM 0 999LOSARTAN POTASSIUM 100 MG TAB No



A4F OLMESARTAN MEDOXOMIL 0 999OLMESARTAN MEDOXOMIL 40 MG TAB No



A4H ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKRA4H AMLODIPINE BES/OLMESARTAN MED 0 999AMLODIPINE-OLMESARTAN 10-40 MG No

A4H AMLODIPINE BES/OLMESARTAN MED 0 999AMLODIPINE-OLMESARTAN 5-20 MG No



A4H AMLODIPINE BESYLATE/VALSARTAN 0 999AMLODIPINE-VALSARTAN 10-160 MG No




A4I ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMBA4I LOSARTAN/HYDROCHLOROTHIAZIDE 0 999LOSARTAN-HCTZ 100-12.5 MG TAB No

A4I LOSARTAN/HYDROCHLOROTHIAZIDE 0 999LOSARTAN-HCTZ 100-25 MG TAB No



Medicaid Max Age


A4I LOSARTAN/HYDROCHLOROTHIAZIDE 0 999LOSARTAN-HCTZ 50-12.5 MG TAB No

A4J ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETICA4J ENALAPRIL/HYDROCHLOROTHIAZIDE 0 999ENALAPRIL-HCTZ 10-25 MG TABLET No

A4J ENALAPRIL/HYDROCHLOROTHIAZIDE 0 999ENALAPRIL-HCTZ 5-12.5 MG TAB No

A4J FOSINOPRIL/HYDROCHLOROTHIAZIDE 0 999FOSINOPRIL-HCTZ 10-12.5 MG TAB No

A4J FOSINOPRIL/HYDROCHLOROTHIAZIDE 0 999FOSINOPRIL-HCTZ 20-12.5 MG TAB No

A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 10-12.5 MG TAB No

A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 20-12.5 MG TAB No

A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 20-25 MG TAB No

A4J QUINAPRIL/HYDROCHLOROTHIAZIDE 0 999QUINAPRIL-HCTZ 10-12.5 MG TAB No

A4J QUINAPRIL/HYDROCHLOROTHIAZIDE 0 999QUINAPRIL-HCTZ 20-25 MG TAB No

A4J QUINAPRIL/HYDROCHLOROTHIAZIDE 0 999QUINAPRIL-HCTZ 20-12.5 MG TAB No

A4K ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATIONA4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 10-20 MG No

A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 10-40 MG No

A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 2.5-10 No




A4L ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)A4L SACUBITRIL/VALSARTAN 0 999ENTRESTO 24 MG-26 MG TABLET No

A4L SACUBITRIL/VALSARTAN 0 999ENTRESTO 49 MG-51 MG TABLET No

A4L SACUBITRIL/VALSARTAN 0 999ENTRESTO 97 MG-103 MG TABLET No

A7B VASODILATORS,CORONARYA7B ISOSORBIDE DINITRATE 0 999ISOSORBIDE DINITRATE 10 MG TAB No



Medicaid Max Age


A7B ISOSORBIDE DINITRATE 0 999ISOSORBIDE DINITRATE 20 MG TAB No




A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MONONIT ER 30 MG TB No

A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MONONIT ER 60 MG TB No

A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MONONIT 20 MG TAB No

A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MONONIT 10 MG TAB No

A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MONONIT ER 120 MG No

A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.4 MG TABLET SL No


A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.1 MG/HR PATCH No





A7M BRADYKININ B2 RECEPTOR ANTAGONISTSA7M ICATIBANT ACETATE 18 999FIRAZYR 30 MG/3 ML SYRINGE Auto PA

A9A CALCIUM CHANNEL BLOCKING AGENTSA9A AMLODIPINE BESYLATE 0 999AMLODIPINE BESYLATE 5 MG TAB No

A9A AMLODIPINE BESYLATE 0 999AMLODIPINE BESYLATE 10 MG TAB No

A9A AMLODIPINE BESYLATE 0 999AMLODIPINE BESYLATE 2.5 MG TAB No

A9A DILTIAZEM HCL 0 999DILTIAZEM 24H ER(CD) 180 MG CP No

A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 360 MG CAP No



Medicaid Max Age


A9A DILTIAZEM HCL 0 999DILTIAZEM 90 MG TABLET No
















A9A FELODIPINE 0 999FELODIPINE ER 10 MG TABLET No

A9A FELODIPINE 0 999FELODIPINE ER 2.5 MG TABLET No

A9A FELODIPINE 0 999FELODIPINE ER 5 MG TABLET No

A9A NIFEDIPINE 0 999NIFEDIPINE ER 60 MG TABLET No


A9A NIFEDIPINE 0 999NIFEDIPINE 20 MG CAPSULE No

A9A NIFEDIPINE 0 999NIFEDIPINE 10 MG CAPSULE No




Medicaid Max Age


A9A NIMODIPINE 18 999NIMODIPINE 30 MG CAPSULE No

A9A VERAPAMIL HCL 0 999VERAPAMIL ER 240 MG CAPSULE No

A9A VERAPAMIL HCL 0 999VERAPAMIL SR 240 MG CAPSULE No



A9A VERAPAMIL HCL 0 999VERAPAMIL 80 MG TABLET No


A9A VERAPAMIL HCL 0 999VERAPAMIL 360 MG CAP PELLET No

A9A VERAPAMIL HCL 0 999VERAPAMIL ER 240 MG TABLET No






B0A GENERAL INHALATION AGENTSB0A SODIUM CHLORIDE FOR INHALATION 0 999SODIUM CHLORIDE 10% VIAL Auto PA

B0A SODIUM CHLORIDE FOR INHALATION 0 999SODIUM CHLORIDE 0.9% INHAL VL No

B1B PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONISTB1B AMBRISENTAN 0 999LETAIRIS 5 MG TABLET Clinical PA Required

B1B AMBRISENTAN 0 999LETAIRIS 10 MG TABLET Clinical PA Required

B1B BOSENTAN 0 999TRACLEER 125 MG TABLET Clinical PA Required

B1B BOSENTAN 0 999TRACLEER 62.5 MG TABLET Clinical PA Required

B1C PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPEB1C EPOPROSTENOL SODIUM (GLYCINE) 0 999EPOPROSTENOL SODIUM 0.5 MG VL No

B1C EPOPROSTENOL SODIUM (GLYCINE) 0 999EPOPROSTENOL SODIUM 1.5 MG VL No



Medicaid Max Age


B1C ILOPROST TROMETHAMINE 0 999VENTAVIS 10 MCG/1 ML SOLUTION Clinical PA Required

B1C ILOPROST TROMETHAMINE 0 999VENTAVIS 20 MCG/1 ML SOLUTION Clinical PA Required

B1D PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIBB1D SILDENAFIL CITRATE 0 999SILDENAFIL 10 MG/ML ORAL SUSP Clinical PA Required

B1D SILDENAFIL CITRATE 0 999SILDENAFIL 20 MG TABLET Clinical PA Required

B1D TADALAFIL 0 999TADALAFIL 20 MG TABLET Clinical PA Required

B3A MUCOLYTICSB3A ACETYLCYSTEINE 0 999ACETYLCYSTEINE 10% VIAL No

B3A ACETYLCYSTEINE 0 999ACETYLCYSTEINE 20% VIAL No

B3A DORNASE ALFA 0 65PULMOZYME 1 MG/ML AMPUL Auto PA

B3J EXPECTORANTSB3J GUAIFENESIN 0 999ROBAFEN 200 MG/10 ML SYRUP No

B3J GUAIFENESIN 0 999MUCUS RELIEF ER 600 MG TABLET No

B3J GUAIFENESIN 0 999QC MUCUS RELIEF ER 1,200 MG TB No

B3J GUAIFENESIN 0 999QC TUSSIN MUCUS-CONG 200 MG/10 No

B3J GUAIFENESIN 0 999QC MUCUS RELIEF ER 600 MG TAB No

B3J GUAIFENESIN 0 999MUCUS RELIEF ER 1,200 MG TAB No

B3J GUAIFENESIN 0 999SM MUCUS RELIEF ER 600 MG TAB No

B3J GUAIFENESIN 0 999MUCUS-CHEST CONG 200 MG/10 ML No

B3J GUAIFENESIN 0 999MUCUS-ER MAX 1,200 MG TABLET No

B3J GUAIFENESIN 0 999SM MUCUS-ER MAX 1,200 MG TAB No

B3J GUAIFENESIN 0 999ROBAFEN 100 MG/5 ML SYRUP No

B3J GUAIFENESIN 0 999TUSSIN 100 MG/5 ML SYRUP No

B3J GUAIFENESIN 0 999TUSSIN 400 MG TABLET No

B3J GUAIFENESIN 0 999TUSSIN CHEST CONGESTION LIQUID No



Medicaid Max Age


B3J GUAIFENESIN 0 999TUSSIN HONEY SYRUP No

B3J GUAIFENESIN 0 999GS TUSSIN MUCUS-CONG 200 MG/10 No

B3J GUAIFENESIN 0 999SM TUSSIN MUCUS-CONG 200 MG/10 No

B3J GUAIFENESIN 0 999TUSSIN MUCUS-CONG 200 MG/10 No

B3J GUAIFENESIN 0 999MUCUS RLF CHEST CONGEST 200 MG No

B3J GUAIFENESIN 0 999GS TUSSIN MUCUS-CONG 100 MG/5 No

B3J GUAIFENESIN 0 999CHILD MUCINEX CHEST 100 MG PKT No

B3J GUAIFENESIN 0 999QC MUCUS RELIEF 400 MG CAPLET No

B3J GUAIFENESIN 0 999HM ADULT TUSSIN CHEST CONG LIQ No

B3J GUAIFENESIN 0 999CHEST CONGEST RLF 400 MG TAB No

B3J GUAIFENESIN 0 999HM CHEST CONGEST RLF 400 MG TB No

B3J GUAIFENESIN 0 999CHL MUCINEX CHEST CONGEST LIQ No

B3J GUAIFENESIN 0 999CHILDREN'S MUCUS RELIEF LIQ No

B3J GUAIFENESIN 0 999COUGH SYRUP 200 MG/10 ML No

B3J GUAIFENESIN 0 999DIABETIC SILTUSSIN DAS-NA LIQ No

B3J GUAIFENESIN 0 999GUAIFENESIN 100 MG/5 ML SOLN No

B3J GUAIFENESIN 0 999MUCINEX ER 600 MG TABLET No

B3J GUAIFENESIN 0 999MUCUS RELIEF 400 MG TABLET No

B3J GUAIFENESIN 0 999SM CHEST CONGESTION RELIEF CAP No

B3J GUAIFENESIN 0 999GUAIFENESIN 100 MG/5 ML SYRUP No

B3J GUAIFENESIN 0 999MUCOSA 400 MG TABLET No

B3J GUAIFENESIN 0 999MUCUS ER 600 MG TABLET No

B3J GUAIFENESIN 0 999MUCINEX ER 1,200 MG TABLET No

B3J GUAIFENESIN 0 999LIQUITUSS GG 200 MG/5 ML LIQ No



Medicaid Max Age




B3J GUAIFENESIN 0 999SILTUSSIN SA 100 MG/5 ML SYR No

B3R NON-OPIOID ANTITUS-1ST GEN.ANTIHISTAMINE-DECONGESTB3R BROMPHENIRAMINE/PSEUDOEPHED/DM 0 20BROMPHENIR-PSEUDOEPHED-DM SYR No

B3T NON-OPIOID ANTITUSSIVE AND EXPECTORANT COMBINATIONB3T GUAIFENESIN/DEXTROMETHORPHAN 0 20ROBAFEN DM COUGH SYRUP No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20MUCUS RLF DM MAX ER 1200-60 MG No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20ROBAFEN DM COUGH LIQUID No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20MUCUS RELIEF DM MAX LIQUID No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20TUSNEL DIABETIC LIQUID No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20SM TUSSIN DM 400-20 MG/20 ML No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20TUSSIN DM 400-20 MG/20 ML LIQ No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20GS TUSSIN DM MAX LIQUID No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20MUCUS RLF DM ER 600-30 MG TAB No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20TUSSIN DM LIQUID No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20MUCUS RELIEF DM COUGH TABLET No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20MUCUS RELIEF DM 20-400 MG TAB No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20MUCUS DM MAX ER 1,200-60 MG TB No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20MUCINEX DM ER 600-30 MG TABLET No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20GUAIFENESIN-DM ER 1,200-60 MG No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20GUAIFENESIN-DM 200-20 MG/10 ML No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20GUAIFENESIN-DM 100-10 MG/5 ML No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20GUAIFENESIN DM SYRUP No



Medicaid Max Age


B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20COUGH DM SYRUP No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20CHILD MUCINEX COUGH 5-100MG PK No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20HM TUSSIN DM MAX LIQUID No

B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20CHILD MUCUS-COUGH RELIEF LIQ No

B4C OPIOID ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONSB4C HYDROCODONE BIT/HOMATROP ME-BR 18 20HYDROCODONE-HOMATROPINE SYRUP No

B4C HYDROCODONE BIT/HOMATROP ME-BR 18 20HYDROCODONE-HOMATROPINE SOLN No

B4E NON-OPIOID ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB.B4E PROMETHAZINE/DEXTROMETHORPHAN 0 20PROMETHAZINE-DM SOLUTION No

B4E PROMETHAZINE/DEXTROMETHORPHAN 0 20PROMETHAZINE-DM SYRUP No

B60 ANTICHOLINERGICS, ORALLY INHALED SHORT ACTINGB60 IPRATROPIUM BROMIDE 0 999ATROVENT 17 MCG HFA INHALER No

B60 IPRATROPIUM BROMIDE 0 999IPRATROPIUM BR 0.02% SOLN No

B61 ANTICHOLINERGICS, ORALLY INHALED LONG ACTINGB61 TIOTROPIUM BROMIDE 18 999SPIRIVA 18 MCG CP-HANDIHALER No

B62 BETA-ADRENERGIC AND ANTICHOLINERGIC COMBO, INHALEDB62 GLYCOPYRROLATE/FORMOTEROL FUM 0 999BEVESPI AEROSPHERE INHALER No

B62 INDACATEROL/GLYCOPYRROLATE 0 999UTIBRON NEOHALER 27.5-15.6 MCG No

B62 IPRATROPIUM/ALBUTEROL SULFATE 0 999COMBIVENT RESPIMAT 20-100 MCG No

B62 IPRATROPIUM/ALBUTEROL SULFATE 0 999IPRAT-ALBUT 0.5-3(2.5) MG/3 ML No

B62 TIOTROPIUM BR/OLODATEROL HCL 0 999STIOLTO RESPIMAT INHAL SPRAY No

B63 BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALEDB63 BUDESONIDE/FORMOTEROL FUMARATE 5 999SYMBICORT 80-4.5 MCG INHALER No

B63 BUDESONIDE/FORMOTEROL FUMARATE 5 999SYMBICORT 160-4.5 MCG INHALER No

B63 FLUTICASONE PROPION/SALMETEROL 5 999ADVAIR HFA 45-21 MCG INHALER No

B63 FLUTICASONE PROPION/SALMETEROL 4 999ADVAIR 250-50 DISKUS No



Medicaid Max Age






B63 MOMETASONE/FORMOTEROL 5 999DULERA 100 MCG/5 MCG INHALER No

B63 MOMETASONE/FORMOTEROL 5 999DULERA 200 MCG/5 MCG INHALER No

B6M GLUCOCORTICOIDS, ORALLY INHALEDB6M BUDESONIDE 1 8BUDESONIDE 0.25 MG/2 ML SUSP No

B6M BUDESONIDE 1 8BUDESONIDE 1 MG/2 ML INH SUSP No

B6M BUDESONIDE 1 8BUDESONIDE 0.5 MG/2 ML SUSP No

B6M FLUTICASONE PROPIONATE 0 999FLOVENT HFA 220 MCG INHALER No



B6M MOMETASONE FUROATE 4 999ASMANEX TWISTHALER 220 MCG #60 No




B6M MOMETASONE FUROATE 4 999ASMANEX TWISTHALR 220 MCG #120 No

B6W BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTINGB6W ALBUTEROL SULFATE 0 999ALBUTEROL SUL 0.63 MG/3 ML SOL No

B6W ALBUTEROL SULFATE 0 999PROVENTIL HFA 90 MCG INHALER No

B6W ALBUTEROL SULFATE 0 999PROAIR HFA 90 MCG INHALER No

B6W ALBUTEROL SULFATE 0 999ALBUTEROL SUL 1.25 MG/3 ML SOL No

B6W ALBUTEROL SULFATE 0 999ALBUTEROL 5 MG/ML SOLUTION No



Medicaid Max Age


B6W ALBUTEROL SULFATE 0 999ALBUTEROL 2.5 MG/0.5 ML SOL No

B6W ALBUTEROL SULFATE 0 999ALBUTEROL SUL 2.5 MG/3 ML SOLN No

B6Y BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTINGB6Y SALMETEROL XINAFOATE 4 999SEREVENT DISKUS 50 MCG No

C0B WATERC0B WATER FOR INJ.,BACTERIOSTATIC 0 999BACTERIOSTATIC WATER VIAL No

C0B WATER FOR INJECTION,STERILE 0 999STERILE WATER FOR INJECTION No

C0B WATER FOR INJECTION,STERILE 0 999WATER FOR INJECTION VIAL No

C0B WATER FOR INJECTION,STERILE 0 999STERILE WATER FOR KCENTRA No

C0B WATER FOR INJECTION,STERILE 0 999STERILE WATER FOR IC-GREEN AMP No

C0B WATER/ME-PARABEN/PROPYLPARABEN 0 999BACTERIOSTATIC WATER VIAL No

C0D ANTI-ALCOHOLIC PREPARATIONSC0D ACAMPROSATE CALCIUM 0 999ACAMPROSATE CALC DR 333 MG TAB No

C0D DISULFIRAM 0 999DISULFIRAM 250 MG TABLET No

C0D DISULFIRAM 0 999DISULFIRAM 500 MG TABLET No

C0D NALTREXONE MICROSPHERES 18 999VIVITROL 380 MG VIAL Auto PA

C0D NALTREXONE MICROSPHERES 18 999VIVITROL 380 MG VIAL + DILUENT Auto PA

C0K BICARBONATE PRODUCING/CONTAINING AGENTSC0K SODIUM ACETATE 0 999SODIUM ACETATE 4 MEQ/ML VIAL No

C0K SODIUM ACETATE 0 999SODIUM ACETATE 40 MEQ/20 ML VL No

C0K SODIUM ACETATE 0 999SODIUM ACETATE 200 MEQ/100 ML No



C0K SODIUM BICARBONATE 0 999SODIUM BICARBONATE 4.2% VIAL No

C0K SODIUM LACTATE 0 999SODIUM LACTATE 50 MEQ/10 ML VL No



Medicaid Max Age


C1A ELECTROLYTE DEPLETERSC1A CALCIUM ACETATE 0 999CALCIUM ACETATE 667 MG CAPSULE No

C1A CALCIUM ACETATE 0 999CALCIUM ACETATE 667 MG GELCAP No

C1A SEVELAMER CARBONATE 0 11RENVELA 0.8 GM POWDER PACKET No

C1A SEVELAMER CARBONATE 0 11RENVELA 2.4 GM POWDER PACKET No

C1A SEVELAMER HCL 0 999SEVELAMER HCL 400 MG TABLET No

C1A SEVELAMER HCL 0 999SEVELAMER HCL 800 MG TABLET No

C1A SODIUM POLYSTYRENE SULFON/SORB 0 999SPS 15 GM/60 ML SUSPENSION No

C1A SODIUM POLYSTYRENE SULFON/SORB 0 999SPS 30 GM/120 ML ENEMA SUSP No

C1A SODIUM POLYSTYRENE SULFONATE 0 999SPS 50 GM/200 ML ENEMA No

C1A SODIUM POLYSTYRENE SULFONATE 0 999SODIUM POLYSTYRENE SULF POWDER No

C1A SODIUM POLYSTYRENE SULFONATE 0 999SPS 15 GM/60 ML SUSPENSION No

C1A SODIUM POLYSTYRENE SULFONATE 0 999SPS 30 GM/120 ML ENEMA No

C1B SODIUM/SALINE PREPARATIONSC1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% SOLN No

C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% SOLUTION No

C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% SOL-EXCEL No

C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% 500 ML No



C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% 1,000 ML No

C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% VIAL No


C1B BACTERIOSTATIC SODIUM CHLORIDE 0 999BACTERIOSTATIC SALINE VIAL No



Medicaid Max Age


C1B SODIUM CHLORIDE 0 999SODIUM CHLORIDE 4 MEQ/ML VL No

C1B SODIUM CHLORIDE 0 999SODIUM CHLORIDE 50 MEQ/20 ML No

C1B SODIUM CHLORIDE 0 999SODIUM CHLORIDE 100 MEQ/40 ML No

C1B SODIUM CHLORIDE 0.45 % 0 999SALINE 0.45% SOLN-EXCEL CON No

C1B SODIUM CHLORIDE 0.45 % 0 999SODIUM CHLORIDE 0.45% SOLN No

C1B SODIUM CHLORIDE 3 % 0 999SODIUM CHLORIDE 3% IV SOLN No

C1B SODIUM CHLORIDE 5 % 0 999SODIUM CHLORIDE 5% IV SOLN No

C1D POTASSIUM REPLACEMENTC1D POT CHLORIDE/POT BICARB/CIT AC 0 999POTASSIUM CL 25 MEQ TAB EFF No

C1D POTASSIUM ACETATE 0 999POTASSIUM ACET 40 MEQ/20 ML VL No

C1D POTASSIUM ACETATE 0 999POTASSIUM ACET 100 MEQ/50 ML No

C1D POTASSIUM BICARBONATE/CIT AC 0 999EFFER-K 10 MEQ TABLET EFF No


C1D POTASSIUM BICARBONATE/CIT AC 0 999POTASSIUM 25 MEQ TABLET EFF No

C1D POTASSIUM BICARBONATE/CIT AC 0 999KLOR-CON-EF 25 MEQ TAB EFF No


C1D POTASSIUM BICARBONATE/CIT AC 0 999K EFFERVESCENT 25 MEQ TABLET No

C1D POTASSIUM CHLORIDE 0 999KLOR-CON 10 MEQ TABLET No

C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 10% (20 MEQ/15ML) No

C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 2 MEQ/ML CONC No

C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 10 MEQ/5 ML CONC No

C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 20 MEQ PACKET No


C1D POTASSIUM CHLORIDE 0 999KLOR-CON SPRINKLE ER 8 MEQ CAP No



Medicaid Max Age


C1D POTASSIUM CHLORIDE 0 999KLOR-CON SPRINKLE ER 10 MEQ CP No

C1D POTASSIUM CHLORIDE 0 999KLOR-CON M20 TABLET No



C1D POTASSIUM CHLORIDE 0 999KLOR-CON 8 MEQ TABLET No


C1D POTASSIUM CHLORIDE 0 999KLOR-CON 20 MEQ PACKET No

C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL ER 10 MEQ TABLET No



C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL ER 10 MEQ CAPSULE No




C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL ER 8 MEQ CAPSULE No

C1D POTASSIUM CHLORIDE IN 0.9%NACL 0 999KCL 20 MEQ-NS 1,000 ML IV SOLN No

C1D POTASSIUM CHLORIDE IN 0.9%NACL 0 999KCL 40 MEQ-NS 1,000 ML IV SOLN No

C1D POTASSIUM CHLORIDE IN D5W 0 999KCL 40 MEQ IN D5W SOLUTION No

C1D POTASSIUM CHLORIDE IN D5W 0 999KCL 20 MEQ IN D5W SOLUTION No

C1D POTASSIUM CHLORIDE IN D5W 0 999D5W-KCL 30 MEQ/L IV SOLUTION No

C1D POTASSIUM CHLORIDE IN LR-D5 0 999KCL 40 MEQ IN D5W-LACT RINGER No

C1D POTASSIUM CHLORIDE IN LR-D5 0 999KCL 20 MEQ IN D5W-LACT RINGER No

C1D POTASSIUM CHLORIDE IN WATER 0 999POTASSIUM CL 20 MEQ/50 ML SOL No




Medicaid Max Age






C1D POTASSIUM CHLORIDE/D5-0.2%NACL 0 999D5%-1/4NS-KCL 10 MEQ/L IV SOL No

C1D POTASSIUM CHLORIDE/D5-0.2%NACL 0 999KCL 10 MEQ IN D5W-0.225% NACL No








C1D POTASSIUM CHLORIDE/D5-0.45NACL 0 999D5%-1/2NS-KCL 40 MEQ/L IV SOL No


C1D POTASSIUM CHLORIDE/D5-0.45NACL 0 999KCL 20 MEQ IN D5W-0.45% NACL No


C1D POTASSIUM CHLORIDE/D5-0.45NACL 0 999KCL 10 MEQ IN D5W-0.45% NACL No

C1D POTASSIUM CHLORIDE/D5-0.9%NACL 0 999KCL 40 MEQ IN D5W-NACL 0.9% No

C1D POTASSIUM CHLORIDE/D5-0.9%NACL 0 999KCL 20 MEQ IN D5W-NS No

C1D POTASSIUM CHLORIDE-0.45% NACL 0 999POTASSIUM CL 20 MEQ-0.45% NACL No

C1F CALCIUM REPLACEMENTC1F CALCIUM ACETATE 0 999CALCIUM ACETATE 668 MG TABLET No

C1F CALCIUM CARB, CITRATE/VIT D3 0 999CITRACAL + D ER TABLET Cystic Fib Diag Auto PA



Medicaid Max Age


C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999CALCIUM FOR WOMEN CHEWABLE TAB Cystic Fib Diag Auto PA

C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999CVS CALCIUM SOFT CHEW Cystic Fib Diag Auto PA

C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999SM CALCIUM SOFT TAB CHEW Cystic Fib Diag Auto PA

C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999CALCIUM + D SOFT CHEWABLE TAB Cystic Fib Diag Auto PA

C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999CHEWABLE CALCIUM TAB CHEW Cystic Fib Diag Auto PA

C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999CALCIUM-VIT D3-VIT K SOFT CHEW Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE 0 999CALCIUM CARB 1,250 MG/5 ML SUS No

C1F CALCIUM CARBONATE 0 999NATURAL CALCIUM 500 MG TABLET No

C1F CALCIUM CARBONATE 0 999CALCIUM 500 MG TABLET No

C1F CALCIUM CARBONATE 0 999CALCIUM 500 MG CHEWABLE TABLET No

C1F CALCIUM CARBONATE 0 999CALCIUM CARBONATE 1.25 GM TAB No

C1F CALCIUM CARBONATE 0 999CALCIUM CARB 500 (1,250) MG TB No

C1F CALCIUM CARBONATE 0 999OYSCO-500 TABLET No

C1F CALCIUM CARBONATE 0 999OYSTER SHELL CALCIUM 500 MG No

C1F CALCIUM CARBONATE 0 999OYSTER SHELL CALCIUM 500 MG TB No

C1F CALCIUM CARBONATE 0 999SM CALCIUM 500 MG TABLET No



C1F CALCIUM CARBONATE/BORON GLUC 0 999RA CALCIUM-BORON TABLET Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL 250 MG-VIT D 125 Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL 500-VIT D3 200 TB Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL-D 250 MG TABLET Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999RA OYSTER SHELL 500-VIT D3 200 Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL CALCIUM-VIT D TAB Cystic Fib Diag Auto PA



Medicaid Max Age


C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500-VIT D3 200 CAPLET Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 250-D TABLET Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500 MG CHEWABLE TABLET Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999SM CALCIUM 500-VIT D3 400 TAB Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM-500 MG TABLET CHEWABLE Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 250-VIT D3 125 TABLET Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500+D TABLET CHEW Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500 + VIT D CAPLET Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999CVS CALCIUM 500 + VIT D TABLET Cystic Fib Diag Auto PA


C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500-VIT D3 400 CHEW TB Cystic Fib Diag Auto PA


C1F CALCIUM CARBONATE/VITAMIN D3 0 999EQ CALCIUM 500-VIT D3 400 TAB Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999SM CALCIUM 500-VIT D3 200 CPLT Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999GNP CALCIUM 500-VIT D3 600 TAB Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500-VIT D3 600 CAPLET Cystic Fib Diag Auto PA

C1F CALCIUM CARBONATE/VITAMIN D3 0 999HM CALCIUM 500-VIT D3 200 CPLT Cystic Fib Diag Auto PA


C1F CALCIUM CHLORIDE 0 999CALCIUM CHLORIDE 10% VIAL No

C1F CALCIUM CITRATE 0 999CALCITRATE 200 MG (950 MG) TAB No

C1F CALCIUM CITRATE/VITAMIN D3 0 999CITRACAL-VIT D 250 MG-200 TAB Cystic Fib Diag Auto PA

C1F CALCIUM CITRATE/VITAMIN D3 0 999CITRACAL + D MAXIMUM CAPLET Cystic Fib Diag Auto PA

C1F CALCIUM CITRATE/VITAMIN D3 0 999CALCITRATE + VIT D CAPLET Cystic Fib Diag Auto PA

C1F CALCIUM GLUCONATE 0 999CALCIUM GLUC 10,000 MG/100 ML No



Medicaid Max Age


C1F CALCIUM GLUCONATE 0 999CALCIUM GLUCONATE 10% VIAL No

C1F CALCIUM GLUCONATE 0 999CALCIUM GLUC 5,000 MG/50 ML VL No

C1F CALCIUM GLUCONATE 0 999CALCIUM GLUC 1,000 MG/10 ML VL No

C1F CALCIUM PHOSPHATE TRIB/VIT D3 0 999CITRACAL + D3 GUMMIES Cystic Fib Diag Auto PA

C1F CALCIUM/MAG/D3/B12/FA/B6/BORON 0 999CALCIUM-FOLIC ACID PLUS D WFER Cystic Fib Diag Auto PA

C1H MAGNESIUM SALTS REPLACEMENTC1H MAGNESIUM CHLORIDE 0 999MAGNESIUM CHL 200 MG/ML VIAL No

C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 400 MG TABLET Cystic Fib Diag Auto PA


C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 500 MG CAPSULE Cystic Fib Diag Auto PA


C1H MAGNESIUM OXIDE 0 999SV MAGNESIUM OXIDE 400 MG TAB Cystic Fib Diag Auto PA

C1H MAGNESIUM OXIDE 0 999MAG-OXIDE MAGNESIUM 200 MG TAB Cystic Fib Diag Auto PA

C1H MAGNESIUM OXIDE 0 999MAGNESIUM 500 MG TABLET Cystic Fib Diag Auto PA

C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 250 MG CAPLET Cystic Fib Diag Auto PA

C1H MAGNESIUM OXIDE 0 999MAG-OXIDE 200 MG TAB Cystic Fib Diag Auto PA

C1H MAGNESIUM OXIDE 0 999CVS MAGNESIUM 500 MG TABLET Cystic Fib Diag Auto PA

C1H MAGNESIUM OXIDE 0 999GNP MAGNESIUM 250 MG TABLET Cystic Fib Diag Auto PA

C1H MAGNESIUM OXIDE 0 999RA MAGNESIUM 500 MG CAPSULE Cystic Fib Diag Auto PA

C1H MAGNESIUM OXIDE 0 999MAGNESIUM 500 MG SOFTGEL Cystic Fib Diag Auto PA


C1H MAGNESIUM OXIDE 0 999MAGNESIUM 400 MG SOFTGEL Cystic Fib Diag Auto PA

C1H MAGNESIUM OXIDE 0 999MAGNESIUM 400 MG CAPS Cystic Fib Diag Auto PA




Medicaid Max Age


C1H MAGNESIUM OXIDE 0 999HM MAGNESIUM 400 MG CAPLET Cystic Fib Diag Auto PA


C1H MAGNESIUM SULFATE 0 999MAGNESIUM SULFATE 50% VIAL No

C1H MAGNESIUM SULFATE IN WATER 0 999MAGNESIUM SULF 4 G/50 ML BAG No




C1H MAGNESIUM SULFATE IN WATER 0 999MAGNESIUM SULF 40 G/1,000 ML No

C1P PHOSPHATE REPLACEMENTC1P POTASSIUM PHOS,M-BASIC-D-BASIC 0 999POTASSIUM PHOSP 45 MMOL/15 ML No

C1P SOD PHOSPHATE,MONOBASIC-DIBAS 0 999SODIUM PHOSPHATE 3MM/ML VIAL No

C1P SOD PHOSPHATE,MONOBASIC-DIBAS 0 999SODIUM PHOSPHATE 45 MMOL/15 ML No

C1W ELECTROLYTE MAINTENANCEC1W ELECTROLYTE-148 SOLUTION 0 999PLASMA-LYTE 148 IV SOLUTION No

C1W ELECTROLYTE-48 SOLUTION/D5W 0 999DEXTROSE 5%-ELECTROLYTE 48 No

C1W ELECTROLYTE-A SOLUTION 0 999PLASMA-LYTE A PH 7.4 SOLN. No

C1W ELECTROLYTE-B SOLUTION/D5W 0 999IONOSOL B-D5W IV SOLUTION No

C1W ELECTROLYTE-M SOLUTION/D5W 0 999NORMOSOL-M AND DEXTROSE 5% No

C1W ELECTROLYTE-MB SOLUTION/D5W 0 999IONOSOL MB-D5W IV SOLUTION No

C1W ELECTROLYTE-P SOLUTION/D5W 0 999ISOLYTE P-DEXTROSE 5% SOLN No

C1W ELECTROLYTE-R (PH 7.4) 0 999NORMOSOL-R PH 7.4 IV SOLUTION No

C1W ELECTROLYTE-R SOLUTION 0 999NORMOSOL-R IV SOLUTION No

C1W ELECTROLYTE-R SOLUTION/D5W 0 999NORMOSOL-R-DEXTROSE 5% IV SOLN No

C1W ELECTROLYTE-S (PH 7.4) 0 999ISOLYTE S IV SOLN PH7.4 No



Medicaid Max Age


C1W ELECTROLYTE-S SOLUTION 0 999ISOLYTE S IV SOLUTION-EXCEL No

C1W RINGER'S SOLUTION 0 999RINGER'S IV SOLUTION No

C1W RINGER'S SOLUTION,LACTATED 0 999LACTATED RINGERS INJECTION No

C1W SODIUM/POT/MAG/CALC/CHLOR/ACET 0 999TPN ELECTROLYTES II IV SOLN No

C1W SODIUM/POT/MAG/CALC/CHLOR/ACET 0 999HYPERLYTE CR VIAL No

C1W SODIUM/POT/MAG/CALC/CHLOR/ACET 0 999TPN ELECTROLYTES VIAL No

C3B IRON REPLACEMENTC3B FERROUS FUM/VIT C/B12-IF/FOLIC 0 999TRICON CAPSULE No

C3B FERROUS FUMARATE 0 999HEMOCYTE TABLET No

C3B FERROUS FUMARATE 0 999FERRIMIN 150 TAB No

C3B FERROUS FUMARATE 0 999FERROUS FUMARATE 324 MG TAB No

C3B FERROUS FUMARATE/FOLIC ACID 0 999HEMOCYTE-F TABLET No

C3B FERROUS GLUCONATE 0 999FERROUS GLUCONATE 324 MG TAB No

C3B FERROUS GLUCONATE 0 999FERATE 27 MG TABLET No

C3B FERROUS SULFATE 0 999FERROUS SULF 15 MG IRON/ML DRP No

C3B FERROUS SULFATE 0 999CHILD FERROUS SULFATE 15 MG/ML No

C3B FERROUS SULFATE 0 999IRON 65 MG TABLET No

C3B FERROUS SULFATE 0 999FERROUSUL 325 MG TABLET No

C3B FERROUS SULFATE 0 999FERROUS SULFATE ER 140 MG TAB No

C3B FERROUS SULFATE 0 999FERROUS SULFATE 325 MG TABLET No

C3B FERROUS SULFATE 0 999FERROUS SULF EC 325 MG TABLET No

C3B FERROUS SULFATE 0 999FERROUS SULF EC 324 MG TABLET No

C3B FERROUS SULFATE 0 999FERROUS SULF 44 MG IRON/5ML LQ No

C3B FERROUS SULFATE 0 999FERRO-TIME 325 MG TABLET No



Medicaid Max Age


C3B FERROUS SULFATE 0 999FERROUS SULF 220 MG/5 ML ELIX No

C3B FERROUS SULFATE 0 999FEROSUL 220 MG/5 ML ELIXIR No

C3B FERROUS SULFATE 0 999FEROSUL 325 MG TABLET No

C3B FERROUS SULFATE 0 999FEOSOL 65 MG TABLET No

C3B FERROUS SULFATE 0 999FER-IN-SOL 15 MG/ML DROPS No

C3B FERROUS SULFATE 0 999HM SLOW RELEASE IRON TABLET No

C3B FERROUS SULFATE 0 999FERROUS SULF 300 MG/5 ML LIQ No

C3B FERROUS SULFATE, DRIED 0 999IRON 45 MG TABLET No

C3B IRON ASPGLY,PS/C/B12/FA/CA/SUC 0 999FERREX 150 FORTE PLUS CAPSULE Cystic Fib Diag Auto PA

C3B IRON ASPGLY,PS/C/SUCCINIC ACID 0 999FERREX 150 PLUS CAPSULE Cystic Fib Diag Auto PA

C3B IRON CARB,GL/FA/B12/C/DOCUSATE 0 999FERRALET 90 TABLET No

C3B IRON FM,PS NO.1/FOLIC/MV NO.18 0 999PUREVIT DUALFE PLUS CAPSULE No

C3B IRON FM,PS NO.1/FOLIC/MV NO.18 0 999SE-TAN PLUS CAPSULE No

C3B IRON FM,PS NO.1/FOLIC/MV NO.18 0 999TANDEM PLUS CAPSULE No

C3B IRON FUM,PS/FOLIC ACID/VITC/B3 0 999INTEGRA F CAPSULE No

C3B IRON FUM,PS/FOLIC/BCOMP,C NO.9 0 999INTEGRA PLUS CAPSULE No

C3B IRON FUM/FOLIC ACID/MV,MIN 15 0 999HEMOCYTE PLUS CAPSULE No

C3B IRON FUM/FOLIC ACID/MV,MIN 15 0 999CENTRATEX CAPSULE No

C3B IRON FUMARATE/VIT C/VIT B12/FA 0 999HEMATOGEN FA SOFTGEL No

C3B IRON POLYSACCHARIDE COMPLEX 0 999FERRIC X-150 CAPSULE Cystic Fib Diag Auto PA

C3B IRON POLYSACCHARIDE COMPLEX 0 999FERREX 150 CAPSULE Cystic Fib Diag Auto PA

C3B IRON POLYSACCHARIDE COMPLEX 0 999MYFERON 150 CAPSULE Cystic Fib Diag Auto PA

C3B IRON POLYSACCHARIDE COMPLEX 0 999NU-IRON 150 CAPSULE Cystic Fib Diag Auto PA

C3B IRON POLYSACCHARIDE COMPLEX 0 999POLY-IRON 150 MG CAPSULE Cystic Fib Diag Auto PA



Medicaid Max Age


C3B IRON POLYSACCHARIDE COMPLEX 0 999IFEREX 150 CAPSULE Cystic Fib Diag Auto PA

C3B IRON PS COMPLEX/B12/FOLIC ACID 0 999IFEREX 150 FORTE CAPSULE No

C3B IRON PS COMPLEX/B12/FOLIC ACID 0 999FERREX 150 FORTE CAPSULE Cystic Fib Diag Auto PA

C3B IRON PS COMPLEX/B12/FOLIC ACID 0 999MYFERON-150 FORTE CAPSULE No

C3B IRON PS COMPLEX/B12/FOLIC ACID 0 999POLY-IRON 150 FORTE CAPSULE No

C3B IRON PS COMPLEX/B12/FOLIC ACID 0 999IFEREX 150 FORTE CAPSULE Cystic Fib Diag Auto PA

C3B IRON,CARBONYL 0 999FEOSOL 45 MG CAPLET No

C3B IRON,FM,PS/FOLIC/B,C18/L.CASEI 0 999FUSION PLUS CAPSULE No

C3B IRON/C/FOLIC ACD/MV CMB11/CALC 0 999FERREX 28 TABLET Cystic Fib Diag Auto PA

C3C ZINC REPLACEMENTC3C ZINC CHLORIDE 0 999ZINC CHLORIDE 10 MG/10 ML VIAL No

C3C ZINC SULFATE 0 999ZINC SULFATE 25 MG/5 ML VIAL No

C3H IODINE CONTAINING AGENTSC3H SODIUM IODIDE 0 999IODOPEN 100 MCG/ML VIAL No

C3M MINERAL REPLACEMENT, MISCELLANEOUSC3M CHROMIC CHLORIDE 0 999CHROMIUM CL 40 MCG/10 ML VIAL No

C3M CUPRIC CHLORIDE 0 999COPPER CHLORIDE 4 MG/10 ML VL No

C3M MANGANESE CHLORIDE 0 999MANGANESE 1 MG/10 ML VIAL No

C3M MANGANESE SULFATE 0 999MANGANESE SULF 1 MG/10 ML VIAL No

C3M ZINC/COPPER/MANGAN/CHROM/SELEN 0 999MULTITRACE-5 VIAL No

C3M ZINC/COPPER/MANGAN/CHROM/SELEN 0 999MULTITRACE-5 CONC VIAL No

C3M ZINC/COPPER/MANGAN/CHROMIC CHL 0 999MULTITRACE-4 VIAL No

C3M ZINC/COPPER/MANGAN/CHROMIC CHL 0 999MULTITRACE-4 CONC VIAL No

C4D ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIBC4D CANAGLIFLOZIN 0 999INVOKANA 100 MG TABLET No



Medicaid Max Age


C4D CANAGLIFLOZIN 0 999INVOKANA 300 MG TABLET No

C4D DAPAGLIFLOZIN PROPANEDIOL 0 999FARXIGA 10 MG TABLET No

C4D DAPAGLIFLOZIN PROPANEDIOL 0 999FARXIGA 5 MG TABLET No

C4D EMPAGLIFLOZIN 0 999JARDIANCE 10 MG TABLET No

C4D EMPAGLIFLOZIN 0 999JARDIANCE 25 MG TABLET No

C4E ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS.C4E CANAGLIFLOZIN/METFORMIN HCL 0 999INVOKAMET 150-1,000 MG TABLET No

C4E CANAGLIFLOZIN/METFORMIN HCL 0 999INVOKAMET 50-500 MG TABLET No

C4E CANAGLIFLOZIN/METFORMIN HCL 0 999INVOKAMET 150-500 MG TABLET No

C4E CANAGLIFLOZIN/METFORMIN HCL 0 999INVOKAMET 50-1,000 MG TABLET No

C4F ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS.C4F LINAGLIPTIN/METFORMIN HCL 18 999JENTADUETO 2.5 MG-500 MG TAB No

C4F LINAGLIPTIN/METFORMIN HCL 18 999JENTADUETO 2.5 MG-1000 MG TAB No

C4F LINAGLIPTIN/METFORMIN HCL 18 999JENTADUETO 2.5 MG-850 MG TAB No

C4F SAXAGLIPTIN HCL/METFORMIN HCL 18 999KOMBIGLYZE XR 5-500 MG TABLET No

C4F SAXAGLIPTIN HCL/METFORMIN HCL 18 999KOMBIGLYZE XR 5-1,000 MG TAB No

C4F SAXAGLIPTIN HCL/METFORMIN HCL 18 999KOMBIGLYZE XR 2.5-1,000 MG TAB No

C4F SITAGLIPTIN PHOS/METFORMIN HCL 18 999JANUMET XR 50-1,000 MG TABLET No

C4F SITAGLIPTIN PHOS/METFORMIN HCL 18 999JANUMET XR 100-1,000 MG TABLET No

C4F SITAGLIPTIN PHOS/METFORMIN HCL 18 999JANUMET 50-500 MG TABLET No

C4F SITAGLIPTIN PHOS/METFORMIN HCL 18 999JANUMET 50-1,000 MG TABLET No

C4F SITAGLIPTIN PHOS/METFORMIN HCL 18 999JANUMET XR 50-500 MG TABLET No

C4G INSULINSC4G INSULIN ASPART 0 999NOVOLOG 100 UNIT/ML FLEXPEN No

C4G INSULIN ASPART 0 999NOVOLOG 100 UNIT/ML VIAL No



Medicaid Max Age


C4G INSULIN ASPART 0 999NOVOLOG 100 UNIT/ML CARTRIDGE No

C4G INSULIN ASPART PROT/INSULN ASP 0 999NOVOLOG MIX 70-30 VIAL No

C4G INSULIN ASPART PROT/INSULN ASP 0 999NOVOLOG MIX 70-30 FLEXPEN No

C4G INSULIN DETEMIR 0 999LEVEMIR FLEXTOUCH 100 UNIT/ML No

C4G INSULIN DETEMIR 0 999LEVEMIR 100 UNIT/ML VIAL No

C4G INSULIN GLARGINE,HUM.REC.ANLOG 0 999LANTUS 100 UNIT/ML VIAL No

C4G INSULIN GLARGINE,HUM.REC.ANLOG 0 999LANTUS SOLOSTAR 100 UNIT/ML No

C4G INSULIN LISPRO 0 999HUMALOG 100 UNITS/ML CARTRIDGE No

C4G INSULIN LISPRO 0 999HUMALOG 100 UNIT/ML VIAL No

C4G INSULIN LISPRO 0 999HUMALOG 100 UNITS/ML KWIKPEN No

C4G INSULIN LISPRO PROTAMIN/LISPRO 0 999HUMALOG MIX 75-25 KWIKPEN No

C4G INSULIN LISPRO PROTAMIN/LISPRO 0 999HUMALOG MIX 50-50 VIAL No

C4G INSULIN LISPRO PROTAMIN/LISPRO 0 999HUMALOG MIX 75-25 VIAL No

C4G INSULIN LISPRO PROTAMIN/LISPRO 0 999HUMALOG MIX 50-50 KWIKPEN No

C4G INSULIN NPH HUM/REG INSULIN HM 0 999HUMULIN 70-30 VIAL No

C4G INSULIN NPH HUM/REG INSULIN HM 0 999HUMULIN 70/30 KWIKPEN No

C4G INSULIN NPH HUMAN ISOPHANE 0 999RELION NOVOLIN N 100 UNIT/ML No

C4G INSULIN NPH HUMAN ISOPHANE 0 999HUMULIN N 100 UNIT/ML VIAL No

C4G INSULIN NPH HUMAN ISOPHANE 0 999NOVOLIN N 100 UNIT/ML VIAL No

C4G INSULIN NPH HUMAN ISOPHANE 0 999HUMULIN N 100 UNITS/ML KWIKPEN No

C4G INSULIN REGULAR, HUMAN 0 999NOVOLIN R 100 UNIT/ML VIAL No

C4G INSULIN REGULAR, HUMAN 0 999HUMULIN R 100 UNIT/ML VIAL No

C4G INSULIN REGULAR, HUMAN 0 999RELION NOVOLIN R 100 UNIT/ML No

C4I ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)



Medicaid Max Age


C4I EXENATIDE 0 999BYETTA 10 MCG DOSE PEN INJ No

C4I EXENATIDE 0 999BYETTA 5 MCG DOSE PEN INJ No

C4I EXENATIDE MICROSPHERES 0 999BYDUREON 2 MG PEN INJECT No

C4I EXENATIDE MICROSPHERES 0 999BYDUREON 2 MG VIAL No

C4J ANTIHYPERGLYCEMIC, DPP-4 INHIBITORSC4J LINAGLIPTIN 18 999TRADJENTA 5 MG TABLET No

C4J SAXAGLIPTIN HCL 18 999ONGLYZA 2.5 MG TABLET No

C4J SAXAGLIPTIN HCL 18 999ONGLYZA 5 MG TABLET No

C4J SITAGLIPTIN PHOSPHATE 18 999JANUVIA 25 MG TABLET No



C4K ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPEC4K GLIMEPIRIDE 0 999GLIMEPIRIDE 1 MG TABLET No

C4K GLIMEPIRIDE 0 999GLIMEPIRIDE 2 MG TABLET No

C4K GLIMEPIRIDE 0 999GLIMEPIRIDE 4 MG TABLET No

C4K GLIPIZIDE 0 999GLIPIZIDE ER 2.5 MG TABLET No

C4K GLIPIZIDE 0 999GLIPIZIDE XL 5 MG TABLET No

C4K GLIPIZIDE 0 999GLIPIZIDE XL 2.5 MG TABLET No

C4K GLIPIZIDE 0 999GLIPIZIDE ER 5 MG TABLET No

C4K GLIPIZIDE 0 999GLIPIZIDE ER 10 MG TABLET No

C4K GLIPIZIDE 0 999GLIPIZIDE 5 MG TABLET No

C4K GLIPIZIDE 0 999GLIPIZIDE 10 MG TABLET No

C4K GLIPIZIDE 0 999GLIPIZIDE XL 10 MG TABLET No

C4K GLYBURIDE 0 999GLYBURIDE 1.25 MG TABLET No



Medicaid Max Age


C4K GLYBURIDE 0 999GLYBURIDE 2.5 MG TABLET No

C4K GLYBURIDE 0 999GLYBURIDE 5 MG TABLET No

C4K GLYBURIDE,MICRONIZED 0 999GLYBURIDE MICRO 1.5 MG TAB No

C4K GLYBURIDE,MICRONIZED 0 999GLYBURIDE MICRO 3 MG TABLET No

C4K GLYBURIDE,MICRONIZED 0 999GLYBURIDE MICRO 6 MG TABLET No

C4K REPAGLINIDE 0 999REPAGLINIDE 0.5 MG TABLET No

C4K REPAGLINIDE 0 999REPAGLINIDE 1 MG TABLET No

C4K REPAGLINIDE 0 999REPAGLINIDE 2 MG TABLET No

C4L ANTIHYPERGLYCEMIC, BIGUANIDE TYPEC4L METFORMIN HCL 0 999METFORMIN HCL 850 MG TABLET No

C4L METFORMIN HCL 0 999METFORMIN HCL ER 500 MG TABLET No

C4L METFORMIN HCL 0 999METFORMIN HCL 500 MG TABLET No

C4L METFORMIN HCL 0 999METFORMIN HCL 1,000 MG TABLET No

C4L METFORMIN HCL 0 999METFORMIN HCL ER 750 MG TABLET No

C4M ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIBITORSC4M ACARBOSE 0 999ACARBOSE 100 MG TABLET No

C4M ACARBOSE 0 999ACARBOSE 25 MG TABLET No

C4M ACARBOSE 0 999ACARBOSE 50 MG TABLET No

C4M MIGLITOL 0 999GLYSET 25 MG TABLET No



C4N ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE(PPARG AGONIST)C4N PIOGLITAZONE HCL 0 999PIOGLITAZONE HCL 30 MG TABLET No

C4N PIOGLITAZONE HCL 0 999PIOGLITAZONE HCL 45 MG TABLET No

C4N PIOGLITAZONE HCL 0 999PIOGLITAZONE HCL 15 MG TABLET No



Medicaid Max Age


C4S ANTIHYPERGLYCEMIC,INSULIN-RELEASE STIM.-BIGUANIDEC4S GLIPIZIDE/METFORMIN HCL 0 999GLIPIZIDE-METFORMIN 2.5-250 MG No

C4S GLIPIZIDE/METFORMIN HCL 0 999GLIPIZIDE-METFORMIN 2.5-500 MG No

C4S GLIPIZIDE/METFORMIN HCL 0 999GLIPIZIDE-METFORMIN 5-500 MG No

C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURIDE-METFORMIN 2.5-500 MG No

C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURID-METFORMIN 1.25-250 MG No

C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURIDE-METFORMIN 5-500 MG No

C4W ANTIHYPERGLYCEMIC, SGLT-2 AND DPP-4 INHIBITOR COMBC4W EMPAGLIFLOZIN/LINAGLIPTIN 18 999GLYXAMBI 10 MG-5 MG TABLET No

C4W EMPAGLIFLOZIN/LINAGLIPTIN 18 999GLYXAMBI 25 MG-5 MG TABLET No

C5B PROTEIN REPLACEMENTC5B CYSTEINE HCL 0 999L-CYSTEINE 50 MG/ML VIAL No

C5F DIETARY SUPPLEMENT, MISCELLANEOUSC5F COCONUT OIL 0 999COCONUT OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

C5F COCONUT OIL 0 999EQL COCONUT OIL 1,000 MG SFTGL Cystic Fib Diag Auto PA

C5F OMEGA3/DHA/EPA/FISH OIL/VIT D3 0 999OMEGA-3 + VITAMIN D3 TAB CHEW Cystic Fib Diag Auto PA

C5F OMEGA-3S/DHA/EPA/FISH OIL 0 999OMEGA-3 GUMMIES Cystic Fib Diag Auto PA

C5J IV SOLUTIONS: DEXTROSE-WATERC5J DEXTROSE 10 % IN WATER 0 999DEXTROSE 10%-WATER IV SOLUTION No

C5J DEXTROSE 20 % IN WATER 0 999DEXTROSE 20%-WATER IV SOLN No

C5J DEXTROSE 25 % IN WATER 0 999DEXTROSE 25%-WATER SYRINGE No



C5J DEXTROSE 5 % IN WATER 0 999GLUCOSE 5%-WATER 100 ML No

C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%-WATER VIAL No



Medicaid Max Age


C5J DEXTROSE 5 % IN WATER 0 999GLUCOSE 5%-WATER 50 ML No

C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%-WATER 100 ML No

C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%-WATER 50 ML No


C5J DEXTROSE 50 % IN WATER 0 999DEXTROSE 50%-WATER ABBOJECT No


C5J DEXTROSE 50 % IN WATER 0 999DEXTROSE 50%-WATER SYRINGE No

C5J DEXTROSE 50 % IN WATER 0 999DEXTROSE 50%-WATER VIAL No


C5K IV SOLUTIONS: DEXTROSE-SALINEC5K DEXTROSE 10 % AND 0.2 % NACL 0 999DEXTROSE 10%-0.2% NACL IV SOLN No

C5K DEXTROSE 10 % AND 0.45 % NACL 0 999DEXTROSE 10%-0.45% NACL IV SOL No

C5K DEXTROSE 2.5 % AND 0.45 % NACL 0 999DEXTROSE 2.5%-0.45% NACL IV No

C5K DEXTROSE 5 % AND 0.3 % NACL 0 999DEXTROSE 5%-0.33% NACL IV SOLN No



C5K DEXTROSE 5 %-0.2 % SOD CHLORID 0 999DEXTROSE 5%-0.225% NACL IV SOL No

C5K DEXTROSE 5 %-0.2 % SOD CHLORID 0 999DEXTROSE 5%-0.2% NACL IV SOLN No

C5K DEXTROSE 5 %-0.45 % SOD CHLORD 0 999DEXTROSE 5%-0.45% NACL IV SOLN No

C5M IV SOLUTIONS: DEXTROSE AND LACTATED RINGERSC5M DEXTROSE 5%-LACTATED RINGERS 0 999DEXTROSE 5%-LR IV SOLUTION No

C6A VITAMIN A PREPARATIONSC6A VITAMIN A 0 999VITAMIN A 10,000 UNIT CAPSULE Cystic Fib Diag Auto PA

C6A VITAMIN A 0 999VITAMIN A 8,000 UNIT SOFTGEL Cystic Fib Diag Auto PA

C6A VITAMIN A 0 999VITAMIN A 10,000 UNIT SOFTGEL Cystic Fib Diag Auto PA



Medicaid Max Age


C6A VITAMIN A 0 999RA VITAMIN A 10,000 UNIT SFTGL Cystic Fib Diag Auto PA

C6A VITAMIN A 0 999GNP VITAMIN A 10,000 UNIT SFGL Cystic Fib Diag Auto PA

C6A VITAMIN A 0 999CVS VITAMIN A 8,000 UNIT SFTGL Cystic Fib Diag Auto PA

C6A VITAMIN A 0 999VITAMIN A 8,000 UNIT CAPSULE Cystic Fib Diag Auto PA

C6B VITAMIN B PREPARATIONSC6B B CMPLX 4/VIT D3/C/FOLIC/ZINC 0 999VITAL-D RX TABLET No

C6B B COMP NO3/FOLIC/C/BIOTIN/ZINC 0 999NEPHPLEX RX TABLET No

C6B B COMPLEX 11/FOLIC/C/BIOT/ZINC 0 999DIALYVITE WITH ZINC TABLET No

C6B FOLIC ACID/B CPLX/C/SELEN/ZINC 0 999DIALYVITE 3,000 TABLET No

C6B FOLIC ACID/VIT B COMPLEX AND C 0 999DIALYVITE TABLET No

C6B MULTIVIT-MINS 25/FOLIC ACID/D3 0 999DIALYVITE SUPREME D TABLET No

C6B MULTIVIT-MINS NO.11/FOLIC ACID 0 999DIALYVITE 5000 TABLET No

C6B VIT B COMP C NO.24/IRON/FOLIC 0 999NEPHRON FA TABLET No

C6B VIT B COMP NO.3/FOLIC/C/BIOTIN 0 999NEPHRO-VITE RX TABLET No

C6B VIT B COMP NO.3/FOLIC/C/BIOTIN 0 999VP-VITE RX TABLET No

C6C VITAMIN C PREPARATIONSC6C ASCORBATE CALCIUM 0 999CALCIUM ASCORBATE 500 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBATE CALCIUM 0 999VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C 500 MG TABLET CHEW Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C DROPS Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C TR 500 MG CAPLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C 500 MG CAPSULE SA Cystic Fib Diag Auto PA



Medicaid Max Age


C6C ASCORBIC ACID 0 999VITAMIN C-500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C-500 MG TABLET CHEW Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C ER 500 MG CAPSULE Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C 500 MG CHEW TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C-500 MG TR CAPSULE Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C 250 MG TABLET CHEW Cystic Fib Diag Auto PA


C6C ASCORBIC ACID 0 999VITAMIN C 1,500 MG TABLET SA Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C 125 MG GUMMY Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS TR 1,000 MG Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C 125 MG GUMMIES Cystic Fib Diag Auto PA


C6C ASCORBIC ACID 0 999VITAMIN C 500 MG SOFTGEL Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VIT C-ROSE HIPS 500 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C TR 1,000 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C 1,000 MG CAPLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS TR 500 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS TR 500 MG CPLT Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS 1,000 MG CPLT Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SV VIT C-ROSE HIPS 500 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SV VIT C-ROSE HIPS 1,000 MG TB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS 1,000 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VITAMIN C WITH ROSE HIPS Cystic Fib Diag Auto PA



Medicaid Max Age


C6C ASCORBIC ACID 0 999V-R VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999HM VIT C-ROSE HIPS 500 MG CPLT Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999HM VIT C-ROSE HIP 1,000 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999GNP VIT C-ROSE HIPS 500 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999EQL VIT C-ROSE HIPS 500 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999EQL VIT C-ROSE HIP 1,000 MG TB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999V-R VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999V-R VITAMIN C 500 MG TAB CHEW Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999V-R VITAMIN C 250 MG TAB CHEW Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SV VIT C-ROSE HIP 1,000 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999C-500 ER TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999GNP VITAMIN C 500 MG TAB CHEW Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999GNP VITAMIN C 250 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999GNP VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999EQL VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999CVS VITAMIN C 500 MG CAPLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999CVS VITAMIN C 250 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999CVS VITAMIN C 1,000 MG CAPLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999C-1,000 MG TABLET SA Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999GNP VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999C-500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999C-1,000 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999C-1,000 MG WITH ROSE HIPS TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999C-1,000 MG WITH ROSE HIPS CPLT Cystic Fib Diag Auto PA



Medicaid Max Age


C6C ASCORBIC ACID 0 999C-1000 ER CAPLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999ASCORBIC ACID GRANULES Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999ASCORBIC ACID 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999ACEROLA C 500 MG TABLET CHEW Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999VITAMIN C TR 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SV VITAMIN C TR 1,000 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999C-500 MG TABLET CHEWABLE Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VITAMIN C SR 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VITAMIN C WITH ROSE HIPS Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SV VITAMIN C 500 MG TAB CHEW Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999ASCORBIC ACID 500 MG/ML VIAL No

C6C ASCORBIC ACID 0 999GNP VITAMIN C DROPS Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VITAMIN C TR 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VITAMIN C DROPS Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VITAMIN C 500 MG TAB CHEW Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VITAMIN C 500 MG CAPLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VITAMIN C 250 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999RA VITAMIN C TR 500 MG CAPLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999RA VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999RA VITAMIN C 500 MG TAB CHEW Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999RA VITAMIN C 250 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999GNP VITAMIN C ER 500 MG TABLET Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999RA VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA



Medicaid Max Age


C6C ASCORBIC ACID 0 999HM VITAMIN C 500 MG TAB CHEW Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999RA VIT C-ROSE HIPS 500 MG TAB Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999RA VITAMIN C 1,000 MG TAB SA Cystic Fib Diag Auto PA

C6C ASCORBIC ACID 0 999SM VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA

C6D VITAMIN D PREPARATIONSC6D CALCITRIOL 0 999CALCITRIOL 1 MCG/ML AMPUL No

C6D CALCITRIOL 0 999CALCITRIOL 1 MCG/ML SOLUTION No

C6D CALCITRIOL 0 999CALCITRIOL 0.25 MCG CAPSULE No

C6D CALCITRIOL 0 999CALCITRIOL 0.5 MCG CAPSULE No

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VIT D3 5,000 UNIT FAST DISSOLV Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 10,000 UNIT SOFTGEL Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 10 MCG/ML LIQUID Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNIT/10 ML LQ Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNIT TABLET Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SM VITAMIN D3 2,000 UNIT SFTGL Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SV VITAMIN D3 400 UNIT SOFTGEL Cystic Fib Diag Auto PA


C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SM VITAMIN D3 1,000 UNIT TAB Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SV VITAMIN D3 5,000 UNIT SFTGL Cystic Fib Diag Auto PA





C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 400 UNIT TABLET Cystic Fib Diag Auto PA



Medicaid Max Age


C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D-400 TABLET Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNIT GUMMIES Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999RA VITAMIN D3 5,000 UNIT SFTGL Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 50,000 UNIT CAPSULE Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 5,000 UNIT/ML DROPS Cystic Fib Diag Auto PA


C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 5,000 UNIT CAPSULE Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 400 UNIT/5 ML LIQ Cystic Fib Diag Auto PA


C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 400 UNIT TAB CHEW Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 400 UNIT SOFTGEL Cystic Fib Diag Auto PA



C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 2,000 UNIT TAB CHEW Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 2,000 UNIT SPRAY Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 400 UNIT/ML LIQUID Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999EQL VITAMIN D3 2,000 UNIT SFGL Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999KIDS VITAMIN D3 TAB CHEW Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999REPLESTA 50,000 UNITS WAFER Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999RA VITAMIN D3 2,000 UNIT SFTGL Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VIT D3 1,000 UNIT GUMMIES Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999BABY VIT D3 400 UNIT/DROP CONC Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNIT TAB CHEW Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VIT D3 1,000 UNIT GUMMIES Cystic Fib Diag Auto PA



Medicaid Max Age


C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VIT D3 1,000 UNIT SOFT CHW Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VIT D3 400 UNIT/DROP CONC Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VITAMIN D3 1,000 UNIT SFGL Cystic Fib Diag Auto PA


C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VITAMIN D3 400 UNIT SFTGL Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999D3-50 50,000 UNIT CAPSULE Cystic Fib Diag Auto PA


C6D CHOLECALCIFEROL (VITAMIN D3) 0 999REPLESTA NX 14,000 UNITS WAFER Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999EQL VITAMIN D3 400 UNIT SFTGL Cystic Fib Diag Auto PA


C6D CHOLECALCIFEROL (VITAMIN D3) 0 999GNP VIT D3 400 UNIT TAB CHEW Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999GNP VITAMIN D3 1,000 UNIT TAB Cystic Fib Diag Auto PA


C6D CHOLECALCIFEROL (VITAMIN D3) 0 999GNP VITAMIN D3 400 UNIT TABLET Cystic Fib Diag Auto PA


C6D CHOLECALCIFEROL (VITAMIN D3) 0 999HM VITAMIN D3 1,000 UNIT TAB Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999HM VITAMIN D3 2,000 UNIT SFTGL Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999HM VITAMIN D3 4,000 UNIT SFTGL Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999RA VITAMIN D3 1,000 UNIT TAB Cystic Fib Diag Auto PA

C6D CHOLECALCIFEROL (VITAMIN D3) 0 999RA VITAMIN D3 2,000 UNIT SFGL Cystic Fib Diag Auto PA


C6D ERGOCALCIFEROL (VITAMIN D2) 0 999VITAMIN D2 2,000 UNIT TABLET Cystic Fib Diag Auto PA

C6D ERGOCALCIFEROL (VITAMIN D2) 0 999VITAMIN D2 400 UNIT TABLET Cystic Fib Diag Auto PA

C6D ERGOCALCIFEROL (VITAMIN D2) 0 999ERGOCALCIFEROL 8,000 UNITS/ML Cystic Fib Diag Auto PA



Medicaid Max Age


C6D ERGOCALCIFEROL (VITAMIN D2) 0 999VITAMIN D2 1.25MG(50,000 UNIT) No

C6F PRENATAL VITAMIN PREPARATIONSC6F PNV 102/IRON/FOLATE 1/DSS/DHA 12 999VITAFOL FE+ DOCUSATE COMBO PCK No

C6F PNV 112/IRON/FOLIC/OM3/DHA/EPA 12 999VITAFOL GUMMIES No

C6F PNV 119/IRON FUM/FOLIC ACID 12 999SE-NATAL-19 TABLET No

C6F PNV 15/IRON FUM,PS/FOLIC ACID 12 999FOLIVANE-OB CAPSULE No

C6F PNV 15/IRON FUM,PS/FOLIC ACID 12 999CONCEPT OB CAPSULE No

C6F PNV 16/IRON FUM,PS/FOLIC/OM-3 12 999CONCEPT DHA CAPSULE No

C6F PNV 16/IRON FUM,PS/FOLIC/OM-3 12 999TARON-C DHA CAPSULE No

C6F PNV 16/IRON FUM,PS/FOLIC/OM-3 12 999VIRT-C DHA SOFTGEL No

C6F PNV 66/IRON/FOLIC/DOCUSATE/DHA 12 999PNV-DHA + DOCUSATE SOFTGEL No

C6F PNV 67/IRON PS/FOLATE NO.1/DHA 12 999VITAFOL ULTRA SOFTGEL No

C6F PNV 69/IRON/FOLIC/DOCUSATE/DHA 12 999PRENAISSANCE PLUS SOFTGEL No

C6F PNV 76/IRON,GLUC/FOLIC/DSS/DHA 12 999CITRANATAL DHA PACK No

C6F PNV NO.118/IRON FUMARATE/FA 12 999SE-NATAL 19 CHEWABLE TABLET No

C6F PNV,CALCIUM 72/IRON/FOLIC ACID 12 999PRENATAL VITAMIN PLUS LOW IRON No

C6F PNV,CALCIUM 72/IRON/FOLIC ACID 12 999PREPLUS CA-FE 27 MG-FA 1 MG TB No

C6F PNV,CALCIUM 72/IRON/FOLIC ACID 12 999M-NATAL PLUS TABLET No

C6F PNV59/IRON,CARB,FUM/FA/DSS/DHA 12 999CITRANATAL HARMONY CAPSULE No

C6F PNV72/IRON,GLUC/FOLIC/DSS/DHA 12 999CITRANATAL 90 DHA COMBO PACK No

C6F PNV73/IRON,GLUC/FOLIC/DSS/DHA 12 999CITRANATAL ASSURE COMBO PACK No

C6F PRENATAL 2/IRON/FOLIC ACID/OM3 12 999COMPLETE NATAL DHA No

C6F PRENATAL 2/IRON/FOLIC ACID/OM3 12 999TRUST NATAL DHA No

C6F PRENATAL 26/IRON PS/FOLIC/DHA 12 999VITAFOL-ONE CAPSULE No



Medicaid Max Age


C6F PRENATAL 48/IRON/FOLIC ACID/B6 12 999CITRANATAL B-CALM COMBO PACK No

C6F PRENATAL 53/IRON/FOLIC AC/OMG3 12 999TRIVEEN-DUO DHA COMBO PACK No

C6F PRENATAL NO13/IRON PS/FOLATE 1 12 999SELECT-OB CHEWABLE CAPLET No

C6F PRENATAL VIT 10/IRON FUM/FOLIC 12 999VITAFOL-OB CAPLET No

C6F PRENATAL VIT 10/IRON/FOLIC/DHA 12 999VITAFOL-OB+DHA COMBO PACK No

C6F PRENATAL VIT 33/IRON/FOLIC/DHA 12 999SELECT-OB + DHA PACK No

C6F PRENATAL VIT,CAL 73/IRON/FOLIC 12 999VIRT-NATE TABLET No

C6F PRENATAL VIT,CALC76/IRON/FOLIC 12 999THRIVITE RX TABLET No

C6F PRENATAL VIT,CALC76/IRON/FOLIC 12 999PNV 29-1 TABLET No

C6F PRENATAL VIT128/IRON/FOLIC ACD 12 999SELECT-OB CHEWABLE CAPLET No

C6F PRENATAL VIT27,CALCIUM/IRON/FA 12 999TRINATAL RX 1 TABLET No

C6F PRENATAL81/IRON/FOLIC/DOCUSATE 12 999CITRANATAL RX TABLET No

C6H PEDIATRIC VITAMIN PREPARATIONSC6H MULTIVIT INFUSION,PEDI 1,VIT K 0 999INFUVITE PEDIATRIC BULK VIAL No

C6H MULTIVIT INFUSION,PEDI 1,VIT K 0 999INFUVITE PEDIATRIC VIAL No

C6H MULTIVIT INFUSION,PEDI 2,VIT K 0 999M.V.I. PEDIATRIC VIAL No

C6H PED MVIT A,C,D3 NO.38/FLUORIDE 0 12TRI-VI-FLOR 0.5 MG DROPS No

C6H PED MVIT A,C,D3 NO.38/FLUORIDE 0 12TRI-VI-FLOR 0.25 MG DROPS No

C6H PEDI MULTIVIT 22/VIT D3/VIT K 0 999MVW COMPLETE FORM MULTIVIT CHW Cystic Fib Diag Auto PA

C6H PEDI MULTIVIT 22/VIT D3/VIT K 0 999MVW COMPLETE FORMUL D3000 CHEW Cystic Fib Diag Auto PA

C6H PEDI MULTIVIT 33/FLUORIDE/IRON 0 12POLY-VI-FLOR WITH IRON 0.5 MG No

C6H PEDI MULTIVIT 37/FLUORIDE/IRON 0 12POLY-VI-FLOR WITH IRON 0.25 MG No

C6H PEDI MULTIVIT 40/PHYTONADIONE 0 3AQUADEKS PEDIATRIC LIQUID No

C6H PEDI MULTIVIT 77/VIT D3/VIT K 0 999MVW COMPLETE FORMUL PEDIA DRPS Cystic Fib Diag Auto PA



Medicaid Max Age


C6H PEDI MULTIVIT NO.128/VITAMIN K 0 999DEKAS PLUS LIQUID Cystic Fib Diag Auto PA

C6H PEDI MULTIVIT NO.17 W-FLUORIDE 0 12MULTIVIT-FLUOR 0.25 MG TAB CHW No

C6H PEDI MULTIVIT NO.17 W-FLUORIDE 0 12MULTIVIT-FLUORIDE 1 MG TAB CHW No

C6H PEDI MULTIVIT NO.17 W-FLUORIDE 0 12MULTIVIT-FLUOR 0.5 MG TAB CHEW No

C6H PEDI MULTIVIT NO.33/FLUORIDE 0 12POLY-VI-FLOR 0.25 MG TAB CHEW No

C6H PEDI MULTIVIT NO.33/FLUORIDE 0 12POLY-VI-FLOR 0.5 MG TAB CHEW No

C6H PEDI MULTIVIT NO.33/FLUORIDE 0 12POLY-VI-FLOR 1 MG TAB CHEW No

C6H PEDI MULTIVIT NO.37 W-FLUORIDE 0 12POLY-VI-FLOR 0.25 MG DROPS No

C6H PEDIATRIC MULTIVIT 61/D3/VIT K 0 999MVW COMPLETE FORMUL D5000 SFGL Cystic Fib Diag Auto PA

C6H PEDIATRIC MULTIVIT 61/D3/VIT K 0 999MVW COMPLETE FORMUL D3000 SFGL Cystic Fib Diag Auto PA

C6H PEDIATRIC MULTIVIT 61/D3/VIT K 0 999MVW COMPLETE FORM MULTIVI SFGL Cystic Fib Diag Auto PA

C6K VITAMIN K PREPARATIONSC6K PHYTONADIONE (VIT K1) 0 999VITAMIN K-1 10 MG/ML AMPUL No

C6K PHYTONADIONE (VIT K1) 0 999VITAMIN K-1 1 MG/0.5 ML AMPUL No

C6K PHYTONADIONE (VIT K1) 0 999PHYTONADIONE 10 MG/ML AMPUL No

C6K PHYTONADIONE (VIT K1) 0 999PHYTONADIONE 1 MG/0.5 ML SYR No

C6K PHYTONADIONE (VIT K1) 0 999MEPHYTON 5 MG TABLET No

C6L VITAMIN B12 PREPARATIONSC6L CYANOCOBALAMIN (VITAMIN B-12) 0 999CYANOCOBALAMIN 1,000 MCG/ML No

C6L CYANOCOBALAMIN (VITAMIN B-12) 0 999CYANOCOBALAMIN 10,000 MCG/10 No

C6L CYANOCOBALAMIN (VITAMIN B-12) 0 999CYANOCOBALAMIN 30,000 MCG/30 No

C6L CYANOCOBALAMIN/FOLIC ACID 0 999FOLTRATE TABLET No

C6M FOLIC ACID PREPARATIONSC6M FOLIC ACID 0 999FOLIC ACID 5 MG/ML VIAL No

C6M FOLIC ACID 0 999FOLIC ACID 1 MG TABLET No



Medicaid Max Age


C6M FOLIC ACID/B6/CA PHOS/GINGER 12 999VP-GGR-B6 TABLET No

C6Q VITAMIN B6 PREPARATIONSC6Q PYRIDOXINE HCL (VITAMIN B6) 0 999PYRIDOXINE 100 MG/ML VIAL No

C6T VITAMIN B1 PREPARATIONSC6T THIAMINE HCL 0 999THIAMINE 200 MG/2 ML VIAL No

C6Z MULTIVITAMIN PREPARATIONSC6Z FOLIC/MVI THER-MIN/LYCOP/LUT 0 999CORVITA TABLET No

C6Z MULTIVIT INFUSN,ADULT 1,VIT K 0 999M.V.I. ADULT VIAL No

C6Z MULTIVIT INFUSN,ADULT 4,VIT K 0 999INFUVITE ADULT VIAL No

C6Z MULTIVIT-MINS 53/FOLIC/K/COQ10 0 999DEKAS PLUS SOFTGEL Cystic Fib Diag Auto PA

C6Z MULTIVIT-MINS 56/FOLIC/K/COQ10 0 999DEKAS PLUS CHEWABLE TABLET Cystic Fib Diag Auto PA

C6Z MULTIVIT-MINS NO.20/IRON/FOLIC 0 999BACMIN CAPLET No

C6Z MV, MIN 59/IRON/FOLIC/DOCUSATE 12 999THRIVITE 19 TABLET No

C6Z MV,MIN10/FOLIC ACID/D3/ALA/LUT 0 999STROVITE ONE CAPLET No

C6Z MV-MIN 51/FOLIC ACID/VIT K/UBI 4 999AQUADEKS CHEWABLE TABLET No

C6Z VIT A/D3/TOCOPHERSOLAN/VIT K 0 999DEKAS ESSENTIAL LIQUID Cystic Fib Diag Auto PA

C6Z VIT A/VIT D3/E/TOCOPHERSOLAN/K 0 999DEKAS ESSENTIAL CAPSULE Cystic Fib Diag Auto PA

C7A HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORSC7A ALLOPURINOL 0 999ALLOPURINOL 100 MG TABLET No

C7A ALLOPURINOL 0 999ALLOPURINOL 300 MG TABLET No

C7D METABOLIC DEFICIENCY AGENTSC7D BETAINE 0 999CYSTADANE 1 GRAM/1.7 ML POWDER No

C7D LEVOCARNITINE 0 999LEVOCARNITINE 330 MG TABLET No

C7D LEVOCARNITINE (WITH SUGAR) 0 999LEVOCARNITINE 1 G/10 ML SOLN No

C7F APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND.C7F MEGESTROL ACETATE 0 999MEGESTROL ACET 40 MG/ML SUSP No



Medicaid Max Age


C7F MEGESTROL ACETATE 0 999MEGESTROL ACET 400 MG/10 ML No

C7F MEGESTROL ACETATE 0 999MEGESTROL 625 MG/5 ML SUSP No

C7I CYTOCHROME P450 INHIBITORSC7I COBICISTAT 12 999TYBOST 150 MG TABLET Auto PA

C8A METALLIC POISON,AGENTS TO TREATC8A DEFEROXAMINE MESYLATE 0 999DEFEROXAMINE 2 GRAM VIAL No

C8A DEFEROXAMINE MESYLATE 0 999DEFEROXAMINE 500 MG VIAL No

C8E ANTIDOTES,MISCELLANEOUSC8E ACETYLCYSTEINE 0 999ACETYLCYSTEINE 6 GRAM/30 ML VL No

C9C PARENTERAL AMINO ACID SOLUTIONS AND COMBINATIONSC9C AA 2.36%/D6.8W/FAT/E-LYTES NO9 0 999PERIKABIVEN IV EMULSION No

C9C AA 2.75 %/CALCIUM/LYTES/D5W 0 999CLINIMIX E 2.75%-5% SOLUTION No

C9C AA 3.31 %/D9.8W/FAT/E-LYTES 10 0 999KABIVEN IV EMULSION No

C9C AA 4.25 %/CALCIUM/LYTES/D5W 0 999CLINIMIX E 4.25%-5% SOLUTION No

C9C AA 4.25%/CALCIUM/LYTES/DEX 10% 0 999CLINIMIX E 4.25%-10% SOLUTION No

C9C AA 5 %/CALCIUM/LYTES/DEXT 20 % 0 999CLINIMIX E 5%-20% SOLUTION No

C9C AA 5 %/CALCIUM/LYTES/DEXT 25 % 0 999CLINIMIX E 5%-25% SOLUTION No

C9C AA 5%/D15W/ELECTROLYTES 0 999CLINIMIX E 5%-15% SOLUTION No

C9C AMINO AC 2.75%/DEX 10%/LYTE 29 0 999CLINIMIX N9G20E 2.75%-D10W SOL No

C9C AMINO AC 3%/ELECTROLYTE/GLYCER 0 999PROCALAMINE IV SOLUTION No

C9C AMINO ACID 4.25 %/DEXTROSE 25% 0 999CLINIMIX 4.25%-25% SOLUTION No

C9C AMINO ACIDS 10 % 0 999TROPHAMINE 10% IV SOLUTION No

C9C AMINO ACIDS 3.5%/ELECTROLYTE M 0 999AMINOSYN M 3.5% IV SOLUTION No

C9C AMINO ACIDS 4.25 %/DEXTROSE 5% 0 999CLINIMIX 4.25%-5% SOLUTION No

C9C AMINO ACIDS 4.25%/DEXTROSE 10% 0 999CLINIMIX 4.25%-10% SOLUTION No



Medicaid Max Age


C9C AMINO ACIDS 5 %/DEXTROSE 15 % 0 999CLINIMIX 5%-15% SOLUTION No



C9C AMINO ACIDS 5.4 % 0 999NEPHRAMINE 5.4% IV SOLUTION No

C9C AMINO ACIDS 6 % 0 999TROPHAMINE 6% IV SOLUTION No

C9C AMINO ACIDS 6.9 % 0 999FREAMINE HBC 6.9% IV SOLN No

C9C AMINO ACIDS 7 % 0 999AMINOSYN-HBC 7% IV SOLUTION No

C9C AMINO ACIDS 7 %/ELECTROLYTES 0 999AMINOSYN 7%-ELECTROLYTE SOL No

C9C AMINO ACIDS 8 % 0 999HEPATAMINE 8% IV SOLUTION No

C9C AMINO ACIDS 8.5 %/ELECTROLYTES 0 999AMINOSYN 8.5%-ELECTROLYTES SOL No

C9C AMINO ACIDS 8.5 %/ELECTROLYTES 0 999AMINOSYN II 8.5%-ELECTROLYTES No

C9C PARENT AMINO AC 5.2 % (RENAL) 0 999AMINOSYN-RF 5.2% IV SOLUTION No

C9C PARENT. AMINO ACID 8.5 % NO.2 0 999AMINOSYN 8.5% IV SOLUTION No

C9C PARENT. AMINO ACID 8.5 % NO.3 0 999AMINOSYN II 8.5% IV SOLUTION No

C9C PARENT.AMINO ACID 10% NO5(PED) 0 999AMINOSYN-PF 10% IV SOLUTION No

C9C PARENT.AMINO ACID 7 % NO1(PED) 0 999AMINOSYN-PF 7% IV SOLUTION No

C9C PARENTERAL AMINO ACID 10% NO.1 0 999AMINOSYN II 10% IV SOLUTION No

C9C PARENTERAL AMINO ACID 10% NO.2 0 999AMINOSYN 10% IV SOLUTION No

C9C PARENTERAL AMINO ACID 10% NO.4 0 999FREAMINE III 10% IV SOLN. No

C9C PARENTERAL AMINO ACID 10% NO.6 0 999SYNTHAMIN 17 WITHOUT ELYTE 10% No

C9C PARENTERAL AMINO ACID 10% NO.6 0 999TRAVASOL 10% SOLN VIAFLEX No

C9C PARENTERAL AMINO ACID 10% NO.7 0 999PREMASOL 10% IV SOLUTION No

C9C PARENTERAL AMINO ACID 15% NO.1 0 999PLENAMINE 15% SOLUTION No

C9C PARENTERAL AMINO ACID 15% NO.2 0 999AMINOSYN II 15% IV SOLUTION No



Medicaid Max Age


C9C PARENTERAL AMINO ACID 15% NO.5 0 999CLINISOL 15% SOLUTION No

C9C PARENTERAL AMINO ACID 20% NO.1 0 999PROSOL 20% INJECTION No

C9C PARENTERAL AMINO ACID 6 % NO.1 0 999PREMASOL 6% IV SOLUTION No

C9C PARENTERAL AMINO ACID 7 % NO.2 0 999AMINOSYN II 7% IV SOLUTION No

D1A PERIODONTAL COLLAGENASE INHIBITORSD1A DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 20 MG TAB No

D1D DENTAL AIDS AND PREPARATIONSD1D CHLORHEXIDINE GLUCONATE 0 999CHLORHEXIDINE 0.12% RINSE No

D1D TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.1% PASTE No

D2A FLUORIDE PREPARATIONSD2A FLUORIDE (SODIUM) 0 999SODIUM FLUORIDE 0.5 MG/ML DROP No

D2A FLUORIDE (SODIUM) 0 999FLUORIDE 0.25 MG TABLET CHEW No

D2A FLUORIDE (SODIUM) 0 999FLUORIDE 0.5 MG TABLET CHEW No

D2A FLUORIDE (SODIUM) 0 999FLUORIDE 1 MG TABLET CHEWABLE No

D4B ANTACIDSD4B CALCIUM CARBONATE 0 999CALCIUM ANTACID 750 MG TB CHEW No

D4B CALCIUM CARBONATE 0 999CALCIUM ANTACID EX-STR TABLET No

D4B CALCIUM CARBONATE 0 999GS CAL ANTACID 500 MG CHEW TAB No

D4B CALCIUM CARBONATE 0 999GS CAL ANTACID 750 MG CHEW TAB No

D4B CALCIUM CARBONATE 0 999HM CAL ANTACID 1000 MG CHEW TB No

D4B CALCIUM CARBONATE 0 999HM CAL ANTACID 750 MG CHEW TAB No

D4B CALCIUM CARBONATE 0 999SM CAL ANTACID 500 MG CHEW TAB No

D4B CALCIUM CARBONATE 0 999CALCIUM CARBONATE 648 MG TAB No

D4B CALCIUM CARBONATE 0 999SM CALCIUM ANTACID TAB CHEW No

D4B CALCIUM CARBONATE 0 999CALCIUM ANTACID 500 MG CHW TAB No



Medicaid Max Age


D4B CALCIUM CARBONATE 0 999CAL-GEST 500 MG TABLET CHEW No

D4B CALCIUM CARBONATE 0 999ANTACID EX-STR TABLET CHEW No

D4B CALCIUM CARBONATE 0 999ANTACID ULTRA STR 1,000 MG CHW No

D4B CALCIUM CARBONATE 0 999ANTACID XTRA STRENGTH CHEW TAB No

D4B CALCIUM CARBONATE 0 999ANTACID EX-STR 750 MG TAB CHEW No

D4B CALCIUM CARBONATE 0 999ANTACID 750 MG CHEWABLE TABLET No

D4B CALCIUM CARBONATE 0 999ANTACID CALCIUM 500 MG CHW TAB No

D4B CALCIUM CARBONATE 0 999GS ANTACID 500 MG CHEWABLE TAB No


D4B CALCIUM CARBONATE 0 999ANTACID 500 MG CHEW TABLET No

D4B CALCIUM CARBONATE 0 999CALCIUM ANTACID 1,000 MG TAB No


D4B MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 400 MG TABLET Cystic Fib Diag Auto PA

D4D ANTIDIARRHEAL MICROORGANISMS AGENTSD4D B INFANTIS/B ANI/B LON/B BIFID 0 999SM PROBIOTIC 4X CAPLET Cystic Fib Diag Auto PA

D4D B INFANTIS/B ANI/B LON/B BIFID 0 999PROBIOTIC 4X CAPLET Cystic Fib Diag Auto PA

D4D B INFANTIS/B ANI/B LON/B BIFID 0 999HM PROBIOTIC 4X CAPLET Cystic Fib Diag Auto PA

D4D B INFANTIS/B ANI/B LON/B BIFID 0 999GNP PROBIOTIC 4X CAPLET Cystic Fib Diag Auto PA

D4D BACILLUS COAGULANS 0 999DIGESTIVE ADVANTAGE GUMMIES Cystic Fib Diag Auto PA

D4D BACILLUS COAGULANS 0 999CVS PROBIOTIC DR 10 BIL CELL Cystic Fib Diag Auto PA

D4D BACILLUS COAGULANS 0 999CVS PROBIOTIC GUMMIES Cystic Fib Diag Auto PA

D4D BACILLUS COAGULANS 0 999RA PROBIOTIC GUMMIES Cystic Fib Diag Auto PA

D4D BACILLUS COAGULANS/INULIN 0 999PROBIOTIC WITH PREBIOTIC CAP Cystic Fib Diag Auto PA

D4D BACILLUS COAGULANS/INULIN 0 999PROBIOTIC FORMULA CAPSULE Cystic Fib Diag Auto PA



Medicaid Max Age


D4D L GASSERI/B BIFIDUM/B LONGUM 0 999RA PROBIOTIC COLON CARE CAP Cystic Fib Diag Auto PA

D4D L GASSERI/B BIFIDUM/B LONGUM 0 999KRO PROBIOTIC COLON SUPPT CAP Cystic Fib Diag Auto PA

D4D L GASSERI/B BIFIDUM/B LONGUM 0 999PHILLIPS' COLON HEALTH CAPSULE Cystic Fib Diag Auto PA

D4D L. ACIDOPHILUS/BIFID. ANIMALIS 0 999PROBIOTIC 5 BILLION CELL CAP Cystic Fib Diag Auto PA

D4D L. ACIDOPHILUS/BIFIDO LONGUM 0 999CVS PROBIOTIC PEARLS 15 MG CAP Cystic Fib Diag Auto PA

D4D L. ACIDOPHILUS/DIG ENZ CMB 5 0 999PROBIOTIC-DIGESTIVE ENZYMES Cystic Fib Diag Auto PA

D4D L. ACIDOPHILUS/L. RHAMNOSUS 0 999PROBIOTIC 15 BILLION CELL CAP Cystic Fib Diag Auto PA

D4D L. ACIDOPHILUS/PECTIN, CITRUS 0 999PROBIOTIC ACIDOPHIL-PECTIN CAP Cystic Fib Diag Auto PA

D4D L. ACIDOPHILUS/PECTIN, CITRUS 0 999EQL PROBIOTIC ACIDOPHIL-PECTIN Cystic Fib Diag Auto PA

D4D L.ACID/B.BIFIDUM/B.ANIMAL/FOS 0 999RA PROBIOTIC COMPLEX CAPSULE Cystic Fib Diag Auto PA

D4D L.ACID/B.INF/B.BIFID/B.ANIMAL 0 999EQ PROBIOTIC 5 BILL CELL CAP Cystic Fib Diag Auto PA

D4D L.ACID/L.CASEI/B.BIF/B.LON/FOS 0 999PROBIOTIC BLEND CAPSULE Cystic Fib Diag Auto PA

D4D L.ACIDOP/L.GASS/B.BIFID/B.LONG 0 999KRO PROBIOTIC COLON SUPPORT Cystic Fib Diag Auto PA

D4D L.ACIDOPH,PARACASEI, B.LACTIS 0 999PROBIOTIC 10 BILLION CELL CAP Cystic Fib Diag Auto PA

D4D L.ACIDOPH/B.LONG/L.PLANT/B.LAC 0 999PROBIOTIC ACIDOPHILUS BEADS Cystic Fib Diag Auto PA

D4D L.ACIDOPH/L.RHAMN/B.BIF/B.LONG 0 999PROBIOTIC ACIDOPHILUS BIOBEADS Cystic Fib Diag Auto PA

D4D L.ACIDOPHILUS/B.BIFIDUM,LONGUM 0 999GNP PROBIOTIC 240 MG CAPSULE Cystic Fib Diag Auto PA

D4D L.RHAMN A-191/L.AC/B.BRE/B.LON 0 999CVS PROBIOTIC 20 BIL CELL CAPS Cystic Fib Diag Auto PA

D4D LACTO NO.41/B.BIFID/B.ANIMALIS 0 999ADVANCED PROBIOTIC-10 3B CELL Cystic Fib Diag Auto PA

D4D LACTOBAC 40/BIFIDO 3/S.THERMOP 0 999CVS PROBIOTIC 100 BIL CELL CAP Cystic Fib Diag Auto PA

D4D LACTOBAC 42/BIFID 8/COLOST/FOS 0 999PROBIOTIC PLUS COLOSTRUM POWD Cystic Fib Diag Auto PA

D4D LACTOBAC NO.21/BIFIDOBACT NO.6 0 999UP-UP PROBIOTIC SUPPLEMENT Cystic Fib Diag Auto PA

D4D LACTOBACILLUS 3/FOS/PANTETHINE 0 999PROBIOTIC & ACIDOPHILUS CAP Cystic Fib Diag Auto PA

D4D LACTOBACILLUS ACIDOPHILUS 0 999PROBIOTIC GOLD ACIDOPHILUS CAP Cystic Fib Diag Auto PA



Medicaid Max Age


D4D LACTOBACILLUS ACIDOPHILUS 0 999EQL DIGESTIVE PROBIOTIC CAP Cystic Fib Diag Auto PA

D4D LACTOBACILLUS ACIDOPHILUS 0 999SV PROBIOTIC ACIDOPHILUS CPLT Cystic Fib Diag Auto PA

D4D LACTOBACILLUS ACIDOPHILUS 0 999PROBIOTIC SOFTGEL Cystic Fib Diag Auto PA

D4D LACTOBACILLUS ACIDOPHILUS 0 999PROBIOTIC ACIDOPHILUS 250 MILL Cystic Fib Diag Auto PA

D4D LACTOBACILLUS COMBINATION NO.4 0 999CVS PROBIOTIC 3 BIL CELL CAPS Cystic Fib Diag Auto PA

D4D LACTOBACILLUS COMBO NO.10 0 999CVS PROBIOTIC 20 BIL CELL CAP Cystic Fib Diag Auto PA

D4D LACTOBACILLUS COMBO NO.11 0 999PROBIOTIC 15 BILLION CELL CAP Cystic Fib Diag Auto PA

D4D LACTOBACILLUS COMBO NO.13 0 999PROBIOTIC PEARLS COMPLETE SFGL Cystic Fib Diag Auto PA

D4D LACTOBACILLUS REUTERI 0 999BIOGAIA TABLET CHEWABLE Cystic Fib Diag Auto PA

D4D LACTOBACILLUS REUTERI 0 999FLEET PEDIA-LAX PROBIOTIC YUMS Cystic Fib Diag Auto PA

D4D LACTOBACILLUS RHAMNOSUS R0011 0 999RA PROBIOTIC DIGESTIVE CARE CP Cystic Fib Diag Auto PA

D4D SACCHAROMYCES BOULARDII 0 999CVS DIGESTIVE PROBIOTIC CAP Cystic Fib Diag Auto PA

D4D SACCHAROMYCES BOULARDII 0 999PROBIOTIC 250 MG CAPSULE Cystic Fib Diag Auto PA

D4D SACCHAROMYCES BOULARDII 0 999FLORASTOR 250 MG CAPSULE Cystic Fib Diag Auto PA

D4E ANTI-ULCER PREPARATIONSD4E MISOPROSTOL 0 999MISOPROSTOL 100 MCG TABLET No

D4E MISOPROSTOL 0 999MISOPROSTOL 200 MCG TABLET No

D4E SUCRALFATE 0 999SUCRALFATE 1 GM TABLET No

D4E SUCRALFATE 0 999SUCRALFATE 1 GM/10 ML SUSP No

D4F ANTI-ULCER-H.PYLORI AGENTSD4F BISMUTH/METRONID/TETRACYCLINE 0 999PYLERA CAPSULE No

D4J PROTON-PUMP INHIBITORSD4J ESOMEPRAZOLE MAGNESIUM 0 11NEXIUM DR 40 MG PACKET No

D4J ESOMEPRAZOLE MAGNESIUM 0 11NEXIUM DR 5 MG PACKET No




Medicaid Max Age



D4J ESOMEPRAZOLE MAGNESIUM 0 11NEXIUM DR 2.5 MG PACKET No

D4J LANSOPRAZOLE 1 11PREVACID 30 MG SOLUTAB No

D4J LANSOPRAZOLE 1 11PREVACID 15 MG SOLUTAB No

D4J OMEPRAZOLE 1 999OMEPRAZOLE DR 10 MG CAPSULE No



D4J OMEPRAZOLE MAGNESIUM 0 999ACID REDUCER DR 20 MG CAP Cystic Fib Diag Auto PA

D4J OMEPRAZOLE MAGNESIUM 0 999CVS OMEPRAZOLE MAG DR 20.6 MG Cystic Fib Diag Auto PA

D4J OMEPRAZOLE MAGNESIUM 0 999EQ OMEPRAZOLE MAG DR 20.6 MG Cystic Fib Diag Auto PA

D4J OMEPRAZOLE MAGNESIUM 0 999KRO OMEPRAZOLE MAG DR 20.6 MG Cystic Fib Diag Auto PA

D4J OMEPRAZOLE MAGNESIUM 0 999OMEPRAZOLE MAG DR 20 MG CAP Cystic Fib Diag Auto PA

D4J OMEPRAZOLE MAGNESIUM 0 999OMEPRAZOLE MAG DR 20.6 MG CAP Cystic Fib Diag Auto PA

D4J OMEPRAZOLE MAGNESIUM 0 999QC OMEPRAZOLE MAG DR 20.6 MG Cystic Fib Diag Auto PA

D4J PANTOPRAZOLE SODIUM 5 11PROTONIX 40 MG SUSPENSION No

D4J PANTOPRAZOLE SODIUM 5 999PANTOPRAZOLE SOD DR 20 MG TAB No

D4J PANTOPRAZOLE SODIUM 5 999PANTOPRAZOLE SOD DR 40 MG TAB No

D6C IRRITABLE BOWEL SYNDROME AGENTS, 5-HT3 ANTAGONISTD6C ALOSETRON HCL 0 999ALOSETRON HCL 0.5 MG TABLET Requires Med Cert 3

D6C ALOSETRON HCL 0 999ALOSETRON HCL 1 MG TABLET Requires Med Cert 3

D6C ALOSETRON HCL 0 999LOTRONEX 0.5 MG TABLET Requires Med Cert 3

D6C ALOSETRON HCL 0 999LOTRONEX 1 MG TABLET Requires Med Cert 3

D6D ANTIDIARRHEALSD6D DIPHENOXYLATE HCL/ATROPINE 0 999DIPHENOXYLATE-ATROP 2.5-0.025 No



Medicaid Max Age


D6D LOPERAMIDE HCL 0 999LOPERAMIDE 2 MG CAPSULE No

D6F DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLATD6F BALSALAZIDE DISODIUM 0 999BALSALAZIDE DISODIUM 750 MG CP No

D6F MESALAMINE 0 999APRISO ER 0.375 GRAM CAPSULE No

D6F MESALAMINE 0 999MESALAMINE DR 400 MG CAPSULE No

D6F SULFASALAZINE 0 999SULFASALAZINE 500 MG TABLET No

D6F SULFASALAZINE 0 999SULFASALAZINE DR 500 MG TAB No

D6G IBS-C/CIC AGENTS, GUANYLATE CYCLASE-C AGONISTD6G LINACLOTIDE 18 999LINZESS 145 MCG CAPSULE Auto PA

D6G LINACLOTIDE 18 999LINZESS 290 MCG CAPSULE Auto PA

D6G LINACLOTIDE 18 999LINZESS 72 MCG CAPSULE Auto PA

D6S LAXATIVES AND CATHARTICSD6S LACTULOSE 0 999LACTULOSE 20 GM/30 ML SOLUTION No

D6S LACTULOSE 0 999LACTULOSE 10 GM/15 ML SOLUTION No

D6S PEG3350/SOD SULF,BICARB,CL/KCL 0 999PEG-3350 AND ELECTROLYTES SOLN No

D6S PEG3350/SOD SULF,BICARB,CL/KCL 0 999PEG 3350 ELECTROLYTE SOLN No

D6S PEG3350/SOD SULF,BICARB,CL/KCL 0 999GOLYTELY SOLUTION No

D6S PEG3350/SOD SULF,BICARB,CL/KCL 0 999GOLYTELY PACKET No

D6S POLYETHYLENE GLYCOL 3350 0 999CLEARLAX POWDER No

D6S POLYETHYLENE GLYCOL 3350 0 999POLYETHYLENE GLYCOL 3350 POWD No

D6S SOD PICOSULF/MAG OX/CITRIC AC 9 999CLENPIQ SOLUTION No

D6S SODIUM CHLORIDE/NAHCO3/KCL/PEG 0 999PEG 3350-ELECTROLYTE SOLUTION No

D6S SODIUM CHLORIDE/NAHCO3/KCL/PEG 0 999TRILYTE WITH FLAVOR PACKETS No

D7A BILE SALTSD7A URSODIOL 0 999URSODIOL 250 MG TABLET No



Medicaid Max Age


D7A URSODIOL 0 999URSODIOL 300 MG CAPSULE No

D7A URSODIOL 0 999URSODIOL 500 MG TABLET No

D7D DRUGS TO TREAT HEREDITARY TYROSINEMIAD7D NITISINONE 0 999ORFADIN 20 MG CAPSULE Clinical PA Required

D7D NITISINONE 0 999ORFADIN 4 MG/ML SUSPENSION Clinical PA Required

D7D NITISINONE 0 999ORFADIN 2 MG CAPSULE Clinical PA Required



D7D NITISINONE 0 999NITYR 2 MG TABLET Clinical PA Required



D7L BILE SALT SEQUESTRANTSD7L CHOLESTYRAMINE (WITH SUGAR) 0 999CHOLESTYRAMINE PACKET No

D7L CHOLESTYRAMINE (WITH SUGAR) 0 999CHOLESTYRAMINE POWDER No

D7L CHOLESTYRAMINE/ASPARTAME 0 999CHOLESTYRAMINE LIGHT PACKET No

D7L CHOLESTYRAMINE/ASPARTAME 0 999CHOLESTYRAMINE LIGHT POWDER No

D7L COLESTIPOL HCL 0 999COLESTIPOL HCL 1 GM TABLET No

D7L COLESTIPOL HCL 0 999COLESTIPOL MICRONIZED 1 GM TAB No

D8A PANCREATIC ENZYMESD8A LIPASE/PROTEASE/AMYLASE 0 999PERTZYE DR 16,000 UNIT CAPSULE No

D8A LIPASE/PROTEASE/AMYLASE 0 999VIOKACE 20,880-78,300 UNITS TB No

D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 3,000 UNIT CAPSULE No






Medicaid Max Age



D8A LIPASE/PROTEASE/AMYLASE 0 999VIOKACE 10,440-39,150 UNITS TB No

D8A LIPASE/PROTEASE/AMYLASE 0 999PERTZYE DR 8,000 UNIT CAPSULE No




D8A LIPASE/PROTEASE/AMYLASE 0 999CREON DR 3,000 UNITS CAPSULE No

D8A LIPASE/PROTEASE/AMYLASE 0 999PANCREAZE DR 4,200 UNIT CAP No










D9A AMMONIA INHIBITORSD9A LACTULOSE 0 999LACTULOSE 10 GM/15 ML SOLUTION No

F1A ANDROGENIC AGENTSF1A TESTOSTERONE 18 999ANDRODERM 4 MG/24HR PATCH Clinical PA Required

F1A TESTOSTERONE 18 999ANDROGEL 1%(2.5G) GEL PACKET Clinical PA Required

F1A TESTOSTERONE 18 999ANDROGEL 1.62%(2.5G) GEL PCKT Clinical PA Required

F1A TESTOSTERONE 18 999ANDROGEL 1.62%(1.25G) GEL PCKT Clinical PA Required



Medicaid Max Age


F1A TESTOSTERONE 18 999ANDROGEL 1.62% GEL PUMP Clinical PA Required

F1A TESTOSTERONE 18 999ANDROGEL 1%(5G) GEL PACKET Clinical PA Required

F1A TESTOSTERONE 18 999ANDRODERM 2 MG/24HR PATCH Clinical PA Required

F1A TESTOSTERONE CYPIONATE 0 999TESTOSTERONE CYP 100 MG/ML No

F1A TESTOSTERONE CYPIONATE 0 999TESTOSTERONE CYP 200 MG/ML No

F1A TESTOSTERONE CYPIONATE 0 999TESTOSTERON CYP 2,000 MG/10 ML No

F1A TESTOSTERONE CYPIONATE 0 999TESTOSTERON CYP 1,000 MG/10 ML No

F1A TESTOSTERONE ENANTHATE 0 999TESTOSTERONE ENAN 200 MG/ML No

F1A TESTOSTERONE ENANTHATE 0 999TESTOSTERON ENAN 1,000 MG/5 ML No

G1A ESTROGENIC AGENTSG1A ESTRADIOL 0 999ESTRADIOL TDS 0.1 MG/DAY No

G1A ESTRADIOL 0 999ESTRADIOL TDS 0.075 MG/DAY No


G1A ESTRADIOL 0 999ESTRADIOL 0.5 MG TABLET No




G1A ESTRADIOL 0 999ESTRADIOL 2 MG TABLET No

G1A ESTRADIOL 0 999ESTRADIOL 1 MG TABLET No

G1A ESTRADIOL 0 999ESTRADIOL 0.06 MG/DAY PATCH No



G1A ESTRADIOL VALERATE 0 999ESTRADIOL VALERATE 20 MG/ML VL No

G1A ESTRADIOL VALERATE 0 999ESTRADIOL VALERATE 40 MG/ML VL No



Medicaid Max Age


G1A ESTRADIOL/LEVONORGESTREL 0 999CLIMARA PRO PATCH No

G1A ESTRADIOL/NORETHINDRONE ACET 0 999COMBIPATCH 0.05-0.25 MG PTCH No

G1A ESTRADIOL/NORETHINDRONE ACET 0 999COMBIPATCH 0.05-0.14 MG PTCH No

G1A ESTRADIOL/NORETHINDRONE ACET 18 999ESTRADIOL-NORETH 0.5-0.1 MG TB No

G1A ESTRADIOL/NORETHINDRONE ACET 18 999ESTRADIOL-NORETH 1-0.5 MG TAB No

G1A ESTROGEN,CON/M-PROGEST ACET 0 999PREMPRO 0.625-2.5 MG TABLET No

G1A ESTROGEN,CON/M-PROGEST ACET 0 999PREMPRO 0.625-5 MG TABLET No

G1A ESTROGEN,CON/M-PROGEST ACET 0 999PREMPRO 0.45-1.5 MG TABLET No

G1A ESTROGEN,CON/M-PROGEST ACET 0 999PREMPRO 0.3 MG-1.5 MG TABLET No

G1A ESTROGEN,CON/M-PROGEST ACET 0 999PREMPHASE 0.625-5 MG TABLET No

G1A ESTROGENS, CONJUGATED 0 999PREMARIN 0.3 MG TABLET No





G1A NORETHINDRONE AC-ETH ESTRADIOL 0 999NORETHIN-ETH ESTRAD 1 MG-5 MCG No

G1A NORETHINDRONE AC-ETH ESTRADIOL 0 999FEMHRT 0.5 MG-2.5 MCG TABLET No

G1A NORETHINDRONE AC-ETH ESTRADIOL 0 999NORETHIND-ETH ESTRAD 0.5-2.5 No

G1B ESTROGEN/ANDROGEN COMBINATIONSG1B ESTROGEN,ESTER/ME-TESTOSTERONE 0 999ESTROGEN-METHYLTESTOS F.S. TAB No

G1B ESTROGEN,ESTER/ME-TESTOSTERONE 0 999ESTROGEN-METHYLTESTOS H.S. TAB No

G2A PROGESTATIONAL AGENTSG2A MEDROXYPROGESTERONE ACETATE 0 999MEDROXYPROGESTERONE 5 MG TAB No

G2A MEDROXYPROGESTERONE ACETATE 0 999MEDROXYPROGESTERONE 2.5 MG TAB No



Medicaid Max Age


G2A MEDROXYPROGESTERONE ACETATE 0 999MEDROXYPROGESTERONE 10 MG TAB No

G2A NORETHINDRONE ACETATE 18 999NORETHINDRN 5 MG TB (LUPANETA) Auto PA

G2A NORETHINDRONE ACETATE 0 999NORETHINDRONE 5 MG TABLET No

G2A PROGESTERONE 0 999PROGESTERONE 500 MG/10 ML VIAL No

G2A PROGESTERONE, MICRONIZED 0 999PROGESTERONE 100 MG CAPSULE No

G2A PROGESTERONE, MICRONIZED 0 999PROGESTERONE 200 MG CAPSULE No

G2A PROGESTERONE, MICRONIZED 0 999PROMETRIUM 100 MG CAPSULE No

G2A PROGESTERONE, MICRONIZED 0 999PROMETRIUM 200 MG CAPSULE No

G3A OXYTOCICSG3A METHYLERGONOVINE MALEATE 0 999METHYLERGONOVINE 0.2 MG TABLET No

G8A CONTRACEPTIVES,ORALG8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999AZURETTE 28 DAY TABLET No

G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999BEKYREE 28 DAY TABLET No

G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999KARIVA 28 DAY TABLET No

G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999MIRCETTE 28 DAY TABLET No

G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999PIMTREA 28 DAY TABLET No

G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999SIMLIYA 28 DAY TABLET No

G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999VIORELE 28 DAY TABLET No

G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999DESOGESTR-ETH ESTRAD ETH ESTRA No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999CAZIANT 28 DAY TABLET No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999CYRED 28 DAY TABLET No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999CYRED EQ 28 DAY TABLET No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999ISIBLOOM 28 DAY TABLET No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999DESOGEST-ETH ESTRA 0.15-0.03MG No



Medicaid Max Age


G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999EMOQUETTE 28 DAY TABLET No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999ENSKYCE 28 TABLET No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999APRI 28 DAY TABLET No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999RECLIPSEN 28 DAY TABLET No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999KALLIGA 28 DAY TABLET No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999VELIVET 28 DAY TABLET No

G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999JULEBER 28 DAY TABLET No

G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999DROSP-EE-LEVOMEF 3-0.03-0.451 No

G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999TYDEMY TABLET No

G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999RAJANI 28 TABLET No

G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999SAFYRAL TABLET No

G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999BEYAZ 28 TABLET No

G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999DROSP-EE-LEVOMEF 3-0.02-0.451 No

G8A DROSPIRENONE 12 999SLYND 4 MG TABLET No

G8A ESTRADIOL VALERATE/DIENOGEST 12 999NATAZIA 28 TABLET No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999OCELLA 3 MG-0.03 MG TABLET No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999NIKKI 3 MG-0.02 MG TABLET No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999LO-ZUMANDIMINE 3 MG-0.02 MG TB No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999LORYNA 3 MG-0.02 MG TABLET No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999DROSPIRENONE-EE 3-0.02 MG TAB No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999DROSPIRENONE-EE 3-0.03 MG TAB No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999YAZ 28 TABLET No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999YASMIN 28 TABLET No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999JASMIEL 3 MG-0.02 MG TABLET No



Medicaid Max Age


G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999ZUMANDIMINE 3 MG-0.03 MG TAB No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999SYEDA 28 TABLET No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999GIANVI 3 MG-0.02 MG TABLET No

G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999ZARAH TABLET No

G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999ETHYNODIOL-ETH ESTRA 1MG-35MCG No

G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999KELNOR 1-50 TABLET No

G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999ETHYNODIOL-ETH ESTRA 1MG-50MCG No

G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999KELNOR 1-35 28 TABLET No

G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999ZOVIA 1-35E TABLET No

G8A LEVONORGEST/ETH.ESTRADIOL/IRON 12 999BALCOLTRA TABLET No

G8A LEVONORGESTREL 12 999OPCICON ONE-STEP 1.5 MG TABLET No

G8A LEVONORGESTREL 12 999NEW DAY 1.5 MG TABLET No

G8A LEVONORGESTREL 12 999PLAN B ONE-STEP 1.5 MG TABLET No

G8A LEVONORGESTREL 12 999MY WAY 1.5 MG TABLET No

G8A LEVONORGESTREL 12 999MY CHOICE 1.5 MG TABLET No

G8A LEVONORGESTREL 12 999ECONTRA EZ 1.5 MG TABLET No

G8A LEVONORGESTREL 12 999TAKE ACTION 1.5 MG TABLET No

G8A LEVONORGESTREL 12 999ECONTRA ONE-STEP 1.5 MG TABLET No

G8A LEVONORGESTREL 12 999AFTERA 1.5 MG TABLET No

G8A LEVONORGESTREL 12 999LEVONORGESTREL 1.5 MG TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999AFIRMELLE-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONOR-ETH ESTRAD 0.15-0.03 No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LESSINA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LILLOW-28 TABLET No



Medicaid Max Age


G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONEST-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999KURVELO TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999AUBRA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999AUBRA EQ-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONOR-ETH ESTRA 0.09-0.02 MG No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999AMETHYST 90-20 MCG TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999JOLESSA 0.15 MG-0.03 MG TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999MARLISSA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONOR-ETH ESTRAD 0.1-0.02 MG No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999ALTAVERA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONOR-ETH ESTRAD TRIPHASIC No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVORA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LARISSIA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999ENPRESSE-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999SRONYX 0.10-0.02 MG TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999TRIVORA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999FALMINA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999VIENVA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999SETLAKIN 0.15 MG-0.03 MG TAB No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999INTROVALE 0.15-0.03 MG TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999ORSYTHIA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999AVIANE-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999CHATEAL-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999MYZILRA-28 TABLET No



Medicaid Max Age


G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LUTERA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999CHATEAL EQ-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999AYUNA-28 TABLET No

G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999PORTIA-28 TABLET No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999LEVONO-E ESTRAD 0.10-0.02-0.01 No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999QUARTETTE TABLET No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999RIVELSA TABLET No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999LEVONO-E ESTRAD 0.15-0.03-0.01 No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999LEVONORG 0.15MG-EE 20-25-30MCG No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999SIMPESSE 0.15-0.03-0.01 MG TAB No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999LOSEASONIQUE TABLET No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999AMETHIA 0.15-0.03-0.01 MG TAB No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999CAMRESE LO TABLET No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999ASHLYNA 0.15-0.03-0.01 MG TAB No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999FAYOSIM TABLET No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999DAYSEE 0.15-0.03-0.01 MG TAB No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999AMETHIA LO TABLET No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999CAMRESE 0.15-0.03-0.01 MG TAB No

G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999SEASONIQUE 0.15-0.03-0.01 TAB No

G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999WYMZYA FE CHEWABLE TABLET No

G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999KAITLIB FE CHEWABLE TABLET No

G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999LAYOLIS FE CHEWABLE TABLET No

G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999NORET-ESTR-FE 0.4-0.035(21)-75 No

G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999NORETHIN-ESTRA-FE 0.8-0.025 MG No



Medicaid Max Age


G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999GENERESS FE CHEWABLE TABLET No

G8A NORETHINDRONE 12 999TULANA 0.35 MG TABLET No

G8A NORETHINDRONE 12 999NORA-BE TABLET No

G8A NORETHINDRONE 12 999NORLYDA 0.35 MG TABLET No

G8A NORETHINDRONE 12 999NORETHINDRONE 0.35 MG TABLET No

G8A NORETHINDRONE 12 999ORTHO MICRONOR 0.35 MG TABLET No

G8A NORETHINDRONE 12 999DEBLITANE 0.35 MG TABLET No

G8A NORETHINDRONE 12 999CAMILA 0.35 MG TABLET No

G8A NORETHINDRONE 12 999LYZA 0.35 MG TABLET No

G8A NORETHINDRONE 12 999ERRIN 0.35 MG TABLET No

G8A NORETHINDRONE 12 999SHAROBEL 0.35 MG TABLET No

G8A NORETHINDRONE 12 999INCASSIA 0.35 MG TABLET No

G8A NORETHINDRONE 12 999JOLIVETTE TABLET No

G8A NORETHINDRONE 12 999JENCYCLA 0.35 MG TABLET No

G8A NORETHINDRONE 12 999HEATHER 0.35 MG TABLET No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999NORETHIND-ETH ESTRAD 1-0.02 MG No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999NORETHIN-EE 1.5-0.03 MG(21) TB No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999JUNEL 1 MG-20 MCG TABLET No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999HAILEY 21 1.5 MG-30 MCG TAB No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999JUNEL 1.5 MG-30 MCG TABLET No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999AUROVELA 1 MG-20 MCG TABLET No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999AUROVELA 21 1.5-30 TABLET No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999MICROGESTIN 21 1-20 TABLET No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999LOESTRIN 21 1.5-30 TABLET No



Medicaid Max Age


G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999LARIN 1.5 MG-30 MCG TABLET No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999LARIN 21 1-20 TABLET No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999LOESTRIN 21 1-20 TABLET No

G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999MICROGESTIN 21 1.5-30 TAB No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TILIA FE 28 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999JUNEL FE 1.5 MG-30 MCG TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TARINA 24 FE 1 MG-20 MCG TAB No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LARIN FE 1-20 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999JUNEL FE 1 MG-20 MCG TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999AUROVELA FE 1.5 MG-30 MCG TAB No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999AUROVELA 24 FE 1 MG-20 MCG TAB No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LOESTRIN FE 1.5-30 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TARINA FE 1-20 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999JUNEL FE 24 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TAYTULLA 1 MG-20 MCG CAPSULE No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LO LOESTRIN FE 1-10 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TRI-LEGEST FE-28 DAY TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999ESTROSTEP FE-28 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LARIN FE 1.5-30 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LARIN 24 FE 1 MG-20 MCG TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MICROGESTIN 24 FE 1 MG-20 MCG No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999HAILEY 24 FE 1 MG-20 MCG TAB No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TARINA FE 1-20 EQ TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999AUROVELA FE 1-20 TABLET No



Medicaid Max Age


G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MIBELAS 24 FE CHEWABLE TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LOESTRIN FE 1-20 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MELODETTA 24 FE CHEWABLE TAB No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999BLISOVI FE 1-20 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999BLISOVI FE 1.5-30 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999NORETH-EE-FE 1.5-0.03MG(21)-75 No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999BLISOVI 24 FE TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999NORETH-ESTRAD-FE 1-0.02(24)-75 No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MINASTRIN 24 FE CHEWABLE TAB No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MICROGESTIN FE 1.5-30 TAB No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MICROGESTIN FE 1-20 TABLET No

G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999NORETH-ESTRAD-FE 1-0.02(21)-75 No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999LEENA 28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999ALYACEN 7-7-7-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999ARANELLE 28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999WERA 0.5/0.035 MG 28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999BRIELLYN TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999VYFEMLA 28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999CYCLAFEM 1-35-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999NORTREL 7-7-7-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999NORTREL 1-35 28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999NECON 7-7-7-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999NORTREL 1-35 21 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999NORTREL 0.5-35-28 TABLET No



Medicaid Max Age


G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999CYCLAFEM 7-7-7-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999PIRMELLA 1-35 28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999ORTHO-NOVUM 1-35-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999ORTHO-NOVUM 7-7-7-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999PHILITH 0.4-0.035 MG TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999BALZIVA 28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999PIRMELLA 1-35-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999PIRMELLA 7-7-7-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999DASETTA 1-35-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999ALYACEN 1-35 28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999DASETTA 7/7/7-28 TABLET No

G8A NORETHINDRONE-ETHIN. ESTRADIOL 12 999NECON 0.5-35-28 TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-MILI 28 TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRINESSA TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRINESSA LO TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-PREVIFEM TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-SPRINTEC TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999MILI 0.25-0.035 MG TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-VYLIBRA LO TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-VYLIBRA 28 TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999MONONESSA 28 TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999VYLIBRA 28 TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999FEMYNOR 28 TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999MONO-LINYAH 28 TABLET No



Medicaid Max Age


G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999ORTHO-CYCLEN 28 TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999NORG-ETHIN ESTRA 0.25-0.035 MG No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999NORG-EE 0.18-0.215-0.25/0.035 No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-LINYAH TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999ORTHO TRI-CYCLEN LO TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-LO-SPRINTEC TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999NORG-EE 0.18-0.215-0.25/0.025 No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999PREVIFEM TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999SPRINTEC 28 DAY TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-LO-MILI TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999ORTHO TRI-CYCLEN 28 TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI FEMYNOR 28 TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-ESTARYLLA TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-LO-ESTARYLLA TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-LO-MARZIA TABLET No

G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999ESTARYLLA 0.25-0.035 MG TABLET No

G8A NORGESTREL-ETHINYL ESTRADIOL 12 999OGESTREL TABLET No

G8A NORGESTREL-ETHINYL ESTRADIOL 12 999LOW-OGESTREL-28 TABLET No

G8A NORGESTREL-ETHINYL ESTRADIOL 12 999CRYSELLE-28 TABLET No

G8A NORGESTREL-ETHINYL ESTRADIOL 12 999ELINEST-28 TABLET No

G8A ULIPRISTAL ACETATE 12 999ELLA 30 MG TABLET No

G8C CONTRACEPTIVES,INJECTABLEG8C MEDROXYPROGESTERONE ACETATE 12 999MEDROXYPROGESTERONE 150 MG/ML No

G8C MEDROXYPROGESTERONE ACETATE 12 999DEPO-SUBQ PROVERA 104 SYRINGE No



Medicaid Max Age


G8F CONTRACEPTIVES,TRANSDERMALG8F NORELGESTROMIN/ETHIN.ESTRADIOL 12 999XULANE PATCH No

G9B CONTRACEPTIVES, INTRAVAGINAL, SYSTEMICG9B ETONOGESTREL/ETHINYL ESTRADIOL 12 999ELURYNG VAGINAL RING No

G9B ETONOGESTREL/ETHINYL ESTRADIOL 12 999ETONOGESTREL-EE VAGINAL RING No

G9B ETONOGESTREL/ETHINYL ESTRADIOL 12 999NUVARING VAGINAL RING No

G9B SEGESTERONE AC/ETHIN ESTRADIOL 12 999ANNOVERA VAGINAL RING No

H0A LOCAL ANESTHETICSH0A BUPIVACAINE HCL 0 999BUPIVACAINE 0.25% VIAL No

H0A BUPIVACAINE HCL 0 999BUPIVACAINE 0.5% VIAL No

H0A BUPIVACAINE HCL IN DEXTROSE/PF 0 999BUPIVACAIN 0.75%-DEXTROS 8.25% No

H0A BUPIVACAINE HCL/EPINEPHRINE 0 999BUPIVACAINE 0.5%-EPI 1:200,000 No

H0A BUPIVACAINE HCL/EPINEPHRINE 0 999BUPIVACAINE 0.25%-EPI 1:200000 No

H0A BUPIVACAINE HCL/EPINEPHRINE BI 0 999BUPIVACAINE 0.5%-EPI 1:200,000 No

H0A BUPIVACAINE HCL/EPINEPHRINE/PF 0 999BUPIVACAINE 0.5%-EPI 1:200,000 No

H0A BUPIVACAINE HCL/EPINEPHRINE/PF 0 999BUPIVACAINE 0.25%-EPI 1:200000 No

H0A BUPIVACAINE HCL/PF 0 999BUPIVACAINE 0.5% VIAL No

H0A BUPIVACAINE HCL/PF 0 999BUPIVACAINE 0.5% (5 MG/ML) AMP No


H0A BUPIVACAINE HCL/PF 0 999BUPIVACAINE 0.25% (2.5 MG/ML) No


H0A BUPIVACAINE HCL/PF 0 999BUPIVACAINE 0.75% AMPUL No

H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 2% JEL UROJET AC No

H0A LIDOCAINE HCL 0 999LIDOCAINE 2% VISCOUS SOLN No

H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 4% SOLUTION No



Medicaid Max Age


H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 2% VIAL No

H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 2% JELLY URO-JET No

H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 2% JELLY No

H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 1% VIAL No

H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 0.5% VIAL No

H0A LIDOCAINE HCL/DEXTROSE 7.5%/PF 0 999LIDOCAINE 5% IN D7.5W AMPUL No

H0A LIDOCAINE HCL/EPINEPHRINE 0 999LIDOCAINE 2%-EPI 1:200,000 No


H0A LIDOCAINE HCL/EPINEPHRINE 0 999LIDOCAINE 1.5%-EPI 1:200,000 No


H0A LIDOCAINE HCL/EPINEPHRINE 0 999LIDOCAINE 0.5%-EPI 1:200,000 No

H0A LIDOCAINE HCL/EPINEPHRINE BIT 0 999LIDOCAINE 2%-EPI 1:50,000 CART No

H0A LIDOCAINE HCL/EPINEPHRINE BIT 0 999LIDOCAINE 2%-EPI 1:100,000 No

H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 2% AMPUL No



H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 2% 40 MG/2 ML No

H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1% 50 MG/5 ML VL No

H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1% VIAL No

H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 0.5% VIAL No


H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 2% VIAL No





Medicaid Max Age





H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1.5% AMPUL No

H0A MEPIVACAINE HCL/PF 0 999MEPIVACAINE HCL 3% CARTRIDGE No

H0E AGENTS TO TREAT MULTIPLE SCLEROSISH0E DIMETHYL FUMARATE 18 999TECFIDERA DR 120 MG CAPSULE No

H0E DIMETHYL FUMARATE 18 999TECFIDERA STARTER PACK No

H0E DIMETHYL FUMARATE 18 999TECFIDERA DR 240 MG CAPSULE No

H0E FINGOLIMOD HCL 10 999GILENYA 0.25 MG CAPSULE No

H0E FINGOLIMOD HCL 10 999GILENYA 0.5 MG CAPSULE No

H0E GLATIRAMER ACETATE 18 999COPAXONE 20 MG/ML SYRINGE No

H0E INTERFERON BETA-1A 18 999AVONEX PEN 30 MCG/0.5 ML KIT No

H0E INTERFERON BETA-1A 18 999AVONEX PREFILLED SYR 30 MCG KT No

H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF 22 MCG/0.5 ML SYRINGE No

H0E INTERFERON BETA-1A/ALBUMIN 18 999AVONEX 30 MCG VIAL KIT No

H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF REBIDOSE 44 MCG/0.5 ML No

H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF REBIDOSE 22 MCG/0.5 ML No

H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF 44 MCG/0.5 ML SYRINGE No

H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF REBIDOSE TITRATION PACK No

H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF TITRATION PACK No

H0E INTERFERON BETA-1B 18 999BETASERON 0.3 MG VIAL No

H0E INTERFERON BETA-1B 18 999BETASERON 0.3 MG KIT No

H0E TERIFLUNOMIDE 18 999AUBAGIO 7 MG TABLET No



Medicaid Max Age


H0E TERIFLUNOMIDE 18 999AUBAGIO 14 MG TABLET No

H0F AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKRH0F DALFAMPRIDINE 18 999DALFAMPRIDINE ER 10 MG TABLET No

H1A ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTSH1A MEMANTINE HCL 18 999MEMANTINE HCL 10 MG TABLET No

H1A MEMANTINE HCL 18 999MEMANTINE HCL 5 MG TABLET No

H1D CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORSH1D GALCANEZUMAB-GNLM 18 999EMGALITY 100 MG/ML SYR(1 OF 3) No

H1D GALCANEZUMAB-GNLM 18 999EMGALITY 300 MG (100 MG X3SYR) No

H20 ANTI-ANXIETY - BENZODIAZEPINESH20 ALPRAZOLAM 7 999ALPRAZOLAM 1 MG TABLET No

H20 ALPRAZOLAM 7 999ALPRAZOLAM 2 MG TABLET No

H20 ALPRAZOLAM 7 999ALPRAZOLAM 0.5 MG TABLET No

H20 ALPRAZOLAM 7 999ALPRAZOLAM 0.25 MG TABLET No

H20 CHLORDIAZEPOXIDE HCL 6 999CHLORDIAZEPOXIDE 25 MG CAPSULE No



H20 CLORAZEPATE DIPOTASSIUM 9 999CLORAZEPATE 15 MG TABLET No

H20 CLORAZEPATE DIPOTASSIUM 9 999CLORAZEPATE 3.75 MG TABLET No

H20 CLORAZEPATE DIPOTASSIUM 9 999CLORAZEPATE 7.5 MG TABLET No

H20 DIAZEPAM 0 999DIAZEPAM 2 MG TABLET No


H20 DIAZEPAM 0 999DIAZEPAM 5 MG/5 ML SOLUTION No


H20 LORAZEPAM 0 999LORAZEPAM 0.5 MG TABLET No



Medicaid Max Age


H20 LORAZEPAM 0 999LORAZEPAM 1 MG TABLET No

H20 LORAZEPAM 0 999LORAZEPAM 2 MG TABLET No

H20 LORAZEPAM 0 999LORAZEPAM 2 MG/ML ORAL CONCENT No

H20 LORAZEPAM 0 999LORAZEPAM INTENSOL 2 MG/ML No

H20 OXAZEPAM 6 999OXAZEPAM 10 MG CAPSULE No



H21 SEDATIVE-HYPNOTICS - BENZODIAZEPINESH21 LORAZEPAM 0 999LORAZEPAM 2 MG/ML CARPUJECT No

H21 LORAZEPAM 0 999LORAZEPAM 2 MG/ML VIAL No

H21 LORAZEPAM 0 999LORAZEPAM 20 MG/10 ML VIAL No

H21 LORAZEPAM 0 999LORAZEPAM 4 MG/ML CARPUJECT No

H21 LORAZEPAM 0 999LORAZEPAM 4 MG/ML VIAL No

H21 LORAZEPAM 0 999LORAZEPAM 40 MG/10 ML VIAL No

H21 TEMAZEPAM 18 999TEMAZEPAM 15 MG CAPSULE No

H21 TEMAZEPAM 18 999TEMAZEPAM 30 MG CAPSULE No

H2D BARBITURATESH2D PHENOBARBITAL 0 999PHENOBARBITAL 32.4 MG TABLET No

H2D PHENOBARBITAL 0 999PHENOBARBITAL 97.2 MG TABLET No

H2D PHENOBARBITAL 0 999PHENOBARBITAL 100 MG TABLET No



H2D PHENOBARBITAL 0 999PHENOBARBITAL 20 MG/5 ML SOLN No

H2D PHENOBARBITAL 0 999PHENOBARBITAL 20 MG/5 ML ELIX No



Medicaid Max Age





H2E SEDATIVE-HYPNOTICS,NON-BARBITURATEH2E ZALEPLON 18 999ZALEPLON 10 MG CAPSULE No

H2E ZALEPLON 18 999ZALEPLON 5 MG CAPSULE No

H2E ZOLPIDEM TARTRATE 18 999ZOLPIDEM TARTRATE 10 MG TABLET Auto PA

H2E ZOLPIDEM TARTRATE 18 999ZOLPIDEM TARTRATE 5 MG TABLET No

H2F ANTI-ANXIETY DRUGSH2F BUSPIRONE HCL 0 999BUSPIRONE HCL 7.5 MG TABLET No

H2F BUSPIRONE HCL 0 999BUSPIRONE HCL 15 MG TABLET No




H2G ANTIPSYCHOTICS,PHENOTHIAZINESH2G CHLORPROMAZINE HCL 18 999CHLORPROMAZINE 50 MG TABLET No

H2G CHLORPROMAZINE HCL 18 999CHLORPROMAZINE 10 MG TABLET No




H2G CHLORPROMAZINE HCL 18 999CHLORPROMAZINE 25 MG/ML AMP No

H2G FLUPHENAZINE DECANOATE 18 999FLUPHENAZINE DEC 125 MG/5 ML No

H2G FLUPHENAZINE HCL 6 999FLUPHENAZINE 10 MG TABLET No

H2G FLUPHENAZINE HCL 6 999FLUPHENAZINE 2.5 MG TABLET No

H2G FLUPHENAZINE HCL 6 999FLUPHENAZINE 2.5 MG/5 ML ELIX No



Medicaid Max Age


H2G FLUPHENAZINE HCL 18 999FLUPHENAZINE 2.5 MG/ML VIAL No


H2G FLUPHENAZINE HCL 6 999FLUPHENAZINE 5 MG/ML CONC No


H2G PERPHENAZINE 6 999PERPHENAZINE 8 MG TABLET No




H2G THIORIDAZINE HCL 18 999THIORIDAZINE 100 MG TABLET No




H2G TRIFLUOPERAZINE HCL 18 999TRIFLUOPERAZINE 5 MG TABLET No




H2M BIPOLAR DISORDER DRUGSH2M CARBAMAZEPINE 6 999EQUETRO 300 MG CAPSULE Auto PA

H2M CARBAMAZEPINE 6 999EQUETRO 100 MG CAPSULE Auto PA

H2M CARBAMAZEPINE 6 999EQUETRO 200 MG CAPSULE Auto PA

H2M LITHIUM CARBONATE 6 999LITHIUM CARBONATE 150 MG CAP No


H2M LITHIUM CARBONATE 6 999LITHIUM CARBONATE 300 MG TAB No




Medicaid Max Age


H2M LITHIUM CARBONATE 6 999LITHIUM CARBONATE ER 300 MG TB No

H2M LITHIUM CARBONATE 6 999LITHIUM CARBONATE ER 450 MG TB No

H2S SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)H2S CITALOPRAM HYDROBROMIDE 6 11CITALOPRAM HBR 20 MG/10 ML SOL No

H2S CITALOPRAM HYDROBROMIDE 6 999CITALOPRAM HBR 40 MG TABLET No


H2S CITALOPRAM HYDROBROMIDE 6 11CITALOPRAM HBR 10 MG/5 ML SOLN No


H2S ESCITALOPRAM OXALATE 6 999ESCITALOPRAM 20 MG TABLET No



H2S FLUOXETINE HCL 6 11FLUOXETINE 20 MG/5 ML SOLUTION No

H2S FLUOXETINE HCL 6 999FLUOXETINE HCL 10 MG CAPSULE No



H2S FLUVOXAMINE MALEATE 6 999FLUVOXAMINE MALEATE 25 MG TAB No



H2S PAROXETINE HCL 6 999PAROXETINE HCL 20 MG TABLET No




H2S SERTRALINE HCL 6 11SERTRALINE 20 MG/ML ORAL CONC No

H2S SERTRALINE HCL 6 999SERTRALINE HCL 100 MG TABLET No



Medicaid Max Age




H2U TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIBH2U AMITRIPTYLINE HCL 12 999AMITRIPTYLINE HCL 10 MG TAB No

H2U AMITRIPTYLINE HCL 12 999AMITRIPTYLINE HCL 75 MG TAB No





H2U AMOXAPINE 16 999AMOXAPINE 100 MG TABLET No




H2U CLOMIPRAMINE HCL 10 999CLOMIPRAMINE 75 MG CAPSULE Auto PA



H2U DESIPRAMINE HCL 13 999DESIPRAMINE 75 MG TABLET No






H2U DOXEPIN HCL 12 999DOXEPIN 25 MG CAPSULE No




Medicaid Max Age





H2U DOXEPIN HCL 12 999DOXEPIN 10 MG/ML ORAL CONC No


H2U IMIPRAMINE HCL 6 999IMIPRAMINE HCL 10 MG TABLET No



H2U NORTRIPTYLINE HCL 13 999NORTRIPTYLINE HCL 10 MG CAP No



H2U NORTRIPTYLINE HCL 13 999NORTRIPTYLINE 10 MG/5 ML SOLN No


H2V TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYH2V DEXMETHYLPHENIDATE HCL 6 999FOCALIN XR 20 MG CAPSULE No

H2V DEXMETHYLPHENIDATE HCL 0 999DEXMETHYLPHENIDATE 2.5 MG TAB No

H2V DEXMETHYLPHENIDATE HCL 0 999DEXMETHYLPHENIDATE 5 MG TAB No

H2V DEXMETHYLPHENIDATE HCL 6 999FOCALIN XR 10 MG CAPSULE No





H2V DEXMETHYLPHENIDATE HCL 0 999DEXMETHYLPHENIDATE 10 MG TAB No




Medicaid Max Age



H2V METHYLPHENIDATE 6 999DAYTRANA 15 MG/9 HR PATCH No

H2V METHYLPHENIDATE 6 999DAYTRANA 10 MG/9 HR PATCH No

H2V METHYLPHENIDATE 6 999DAYTRANA 20 MG/9 HOUR PATCH No

H2V METHYLPHENIDATE 6 999DAYTRANA 30 MG/9 HOUR PATCH No

H2V METHYLPHENIDATE HCL 6 999QUILLICHEW ER 20 MG CHEW TAB No

H2V METHYLPHENIDATE HCL 6 999QUILLIVANT XR 25 MG/5 ML SUSP No

H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE CD 40 MG CAP No



H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER(CD) 10MG CP No









H2V METHYLPHENIDATE HCL 6 999APTENSIO XR 40 MG CAPSULE No







Medicaid Max Age





H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER 10 MG TAB No

H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER 20 MG TAB No

H2V METHYLPHENIDATE HCL 0 999METHYLPHENIDATE 10 MG TABLET No




H2W TRICYCLIC ANTIDEPRESSANT-PHENOTHIAZINE COMBINATNSH2W PERPHENAZINE/AMITRIPTYLINE HCL 18 999PERPHEN-AMITRIP 4 MG-50 MG TAB No

H2W PERPHENAZINE/AMITRIPTYLINE HCL 18 999PERPHEN-AMITRIP 2 MG-10 MG TAB No




H2X TRICYCLIC ANTIDEPRESSANT-BENZODIAZEPINE COMBINATNSH2X AMITRIPTYLINE/CHLORDIAZEPOXIDE 18 999CHLORDIAZEPO-AMITRIPTYL 5-12.5 No

H2X AMITRIPTYLINE/CHLORDIAZEPOXIDE 18 999CHLORDIAZEPOX-AMITRIPTYL 10-25 No

H3A OPIOID ANALGESICSH3A CODEINE SULFATE 12 999CODEINE SULFATE 60 MG TABLET No

H3A CODEINE SULFATE 12 999CODEINE SULFATE 15 MG TABLET No

H3A CODEINE SULFATE 12 999CODEINE SULFATE 30 MG TABLET No

H3A FENTANYL 18 999FENTANYL 50 MCG/HR PATCH No





Medicaid Max Age




H3A HYDROCODONE BITARTRATE 18 999HYSINGLA ER 80 MG TABLET Auto PA







H3A HYDROMORPHONE HCL 0 999HYDROMORPHONE 4 MG TABLET No

H3A HYDROMORPHONE HCL 0 999HYDROMORPHONE 0.5 MG/0.5 ML No



H3A MORPHINE SULFATE 0 999MORPHINE SULFATE IR 30 MG TAB No

H3A MORPHINE SULFATE 18 999MORPHINE SULF ER 60 MG TABLET No




H3A MORPHINE SULFATE 0 999MORPHINE SULFATE IR 15 MG TAB No

H3A MORPHINE SULFATE 0 999MORPHINE SULF 20 MG/5 ML SOLN No

H3A MORPHINE SULFATE 0 999MORPHINE SULF 100 MG/5 ML CONC No

H3A MORPHINE SULFATE 0 999MORPHINE SULF 10 MG/5 ML SOLN No

H3A MORPHINE SULFATE 18 999MORPHABOND ER 60 MG TABLET Auto PA




Medicaid Max Age




H3A MORPHINE SULFATE 18 999ARYMO ER 15 MG TABLET Auto PA




H3A MORPHINE SULFATE/NALTREXONE 18 999EMBEDA ER 100-4 MG CAPSULE No

H3A MORPHINE SULFATE/NALTREXONE 18 999EMBEDA ER 60-2.4 MG CAPSULE No

H3A MORPHINE SULFATE/NALTREXONE 18 999EMBEDA ER 50-2 MG CAPSULE No




H3A OPIUM/BELLADONNA ALKALOIDS 0 999BELLADONNA-OPIUM 16.2-60 SUPP No

H3A OPIUM/BELLADONNA ALKALOIDS 0 999BELLADONNA-OPIUM 16.2-30 SUPP No

H3A OXYCODONE HCL 0 999OXYCODONE HCL 10 MG TABLET No

H3A OXYCODONE HCL 0 999OXYCODONE HCL 5 MG/5 ML SOLN No

H3A OXYCODONE HCL 18 999ROXYBOND 5 MG TABLET Auto PA






H3A OXYCODONE HCL 18 999OXAYDO 5 MG TABLET Auto PA




Medicaid Max Age


H3A OXYCODONE MYRISTATE 18 999XTAMPZA ER 13.5 MG CAPSULE Auto PA

H3A OXYCODONE MYRISTATE 18 999XTAMPZA ER 18 MG CAPSULE Auto PA




H3A TRAMADOL HCL 12 999TRAMADOL HCL 50 MG TABLET No

H3D ANALGESIC/ANTIPYRETICS, SALICYLATESH3D ASPIRIN 0 999ASPIRIN 325 MG TABLET No

H3D ASPIRIN 0 999ASPIRIN EC 325 MG TABLET No

H3D ASPIRIN 0 999HM ASPIRIN 325 MG TABLET No

H3D SALSALATE 0 999SALSALATE 500 MG TABLET No

H3D SALSALATE 0 999SALSALATE 750 MG TABLET No

H3E ANALGESIC/ANTIPYRETICS,NON-SALICYLATEH3E ACETAMINOPHEN 0 6INFANT PAIN-FEVER 160 MG/5 ML No

H3E ACETAMINOPHEN 0 6SM CHLD PAIN-FEVER 160 MG/5 ML No

H3E ACETAMINOPHEN 0 6CHILDREN'S SILAPAP ELIXIR No

H3E ACETAMINOPHEN 0 6ED-APAP 160 MG/5 ML LIQUID No

H3E ACETAMINOPHEN 0 6INFANT PAIN-FEVER 160 MG/5 ML No

H3E ACETAMINOPHEN 0 6INF ACETAMINOPHEN 160 MG/5 ML No

H3E ACETAMINOPHEN 0 6INFANT PAIN RELIEF 160 MG/5 ML No

H3E ACETAMINOPHEN 0 6QC INFANT PAIN RLF 160 MG/5 ML No

H3E ACETAMINOPHEN 0 6HM INFANT PAIN-FEVER 160 MG/5 No

H3E ACETAMINOPHEN 0 6CHILD PAIN-FEVER 160 MG/5 ML No

H3E ACETAMINOPHEN 0 6INFANTS PAIN-FEVER 160 MG/5 ML No



Medicaid Max Age


H3E ACETAMINOPHEN 0 6SM INFANT PAIN-FEVER 160 MG/5 No

H3E ACETAMINOPHEN 0 6QC JR. NON-ASPIRIN 160 MG TAB No

H3E ACETAMINOPHEN 0 6MAPAP 160 MG/5 ML LIQUID No

H3E ACETAMINOPHEN 0 6M-PAP 160 MG/5 ML LIQUID No

H3E ACETAMINOPHEN 0 6SM PAIN REL JR STR TAB CHEW No

H3E ACETAMINOPHEN 0 6GS INFANT PAIN-FEVER 160 MG/5 No

H3E ACETAMINOPHEN 0 999HM ARTHRITIS PAIN ER 650 MG No

H3E ACETAMINOPHEN 0 9998 HOUR ACETAMINOPHEN ER 650 MG No

H3E ACETAMINOPHEN 0 9998HR ARTHRITIS PAIN ER 650 MG No

H3E ACETAMINOPHEN 0 9998HR MUSCLE ACHE-PAIN ER 650 MG No

H3E ACETAMINOPHEN 0 6ACETAMINOPHEN 160 MG/5 ML LIQ No

H3E ACETAMINOPHEN 0 6HM CHLD PAIN-FEVER 160 MG/5 ML No

H3E ACETAMINOPHEN 0 999HM ARTHRIT PAIN RLF ER 650 MG No

H3E ACETAMINOPHEN 0 6GS CHLD PAIN-FEVER 160 MG/5 ML No

H3E ACETAMINOPHEN 0 999SM ARTHRIT PAIN RLF ER 650 MG No

H3E ACETAMINOPHEN 0 6CHILD ACETAMINOPHEN 160 MG No

H3E ACETAMINOPHEN 0 6CHLD ACETAMINOPHEN 160 MG/5 ML No

H3E ACETAMINOPHEN 0 6HM CHILD ACETAMINOPHEN 160 MG No

H3E ACETAMINOPHEN 0 6CHILD'S MAPAP 160 MG TAB CHEW No

H3E ACETAMINOPHEN 0 6CHILD PAIN-FEVER 160 MG/5 ML No

H3E ACETAMINOPHEN 0 6CHILD PAIN RLF 160 MG/5 ML SUS No

H3E ACETAMINOPHEN 0 6QC CHILD PAIN RLF 160 MG/5 ML No

H3E ACETAMINOPHEN 0 6CHILD'S PAIN RELIEVER SUSP No

H3E ACETAMINOPHEN 0 999ARTHRITIS PAIN ER 650 MG CAPLT No



Medicaid Max Age


H3F ANTIMIGRAINE PREPARATIONSH3F GALCANEZUMAB-GNLM 18 999EMGALITY 120 MG/ML PEN No

H3F GALCANEZUMAB-GNLM 18 999EMGALITY 120 MG/ML SYRINGE No

H3F RIZATRIPTAN BENZOATE 6 999RIZATRIPTAN 10 MG ODT No

H3F RIZATRIPTAN BENZOATE 6 999RIZATRIPTAN 5 MG TABLET No

H3F RIZATRIPTAN BENZOATE 6 999RIZATRIPTAN 10 MG TABLET No

H3F RIZATRIPTAN BENZOATE 6 999RIZATRIPTAN 5 MG ODT No

H3F SUMATRIPTAN 18 999SUMATRIPTAN 20 MG NASAL SPRAY No

H3F SUMATRIPTAN 18 999SUMATRIPTAN 5 MG NASAL SPRAY No

H3F SUMATRIPTAN SUCCINATE 18 999SUMATRIPTAN 6 MG/0.5 ML VIAL No

H3F SUMATRIPTAN SUCCINATE 18 999SUMATRIPTAN SUCC 100 MG TABLET No



H3K ANALGESIC, NON-SALICYLATE AND BARBITURATE COMBINATH3K BUTALBITAL/ACETAMINOPHEN 0 999BUTALBITAL-ACETAMINOPHN 50-325 No

H3K BUTALBITAL/ACETAMINOPHEN 0 999BUTALBITAL-ACETAMINOPHN 50-300 No

H3L ANALGESIC,NON-SALICYLATE,BARBITURATE,XANTHINE COMBH3L BUTALB/ACETAMINOPHEN/CAFFEINE 0 999BUTALB-ACETAMIN-CAFF 50-300-40 No

H3L BUTALB/ACETAMINOPHEN/CAFFEINE 0 999BUTALB-ACETAMIN-CAFF 50-325-40 No

H3M OPIOID,NON-SALICYL.ANALGESIC,BARBITURATE,XANTHINEH3M BUTALBIT/ACETAMIN/CAFF/CODEINE 12 999BUTALB-CAFF-ACETAMINOPH-CODEIN No

H3N OPIOID ANALGESIC AND NSAID COMBINATIONH3N HYDROCODONE/IBUPROFEN 0 999HYDROCODONE-IBUPROFEN 10-200 No

H3N HYDROCODONE/IBUPROFEN 0 999HYDROCODONE-IBUPROFEN 5-200 MG No

H3N HYDROCODONE/IBUPROFEN 0 999HYDROCODONE-IBUPROFEN 7.5-200 No

H3O ANALGESIC, SALICYLATE, BARBITURATE, XANTHINE COMB.



Medicaid Max Age


H3O BUTALBITAL/ASPIRIN/CAFFEINE 0 999BUTALB-ASPIRIN-CAFFE 50-325-40 No

H3O BUTALBITAL/ASPIRIN/CAFFEINE 0 999BUTALBITAL-ASA-CAFFEINE CAP No

H3T OPIOID ANTAGONISTSH3T NALOXONE HCL 0 999NARCAN 4 MG NASAL SPRAY No

H3T NALOXONE HCL 0 999NALOXONE 4 MG/10 ML VIAL No

H3T NALOXONE HCL 0 999NALOXONE 0.4 MG/ML VIAL No

H3T NALOXONE HCL 0 999NALOXONE 0.4 MG/ML CARPUJECT No

H3T NALOXONE HCL 0 999NALOXONE 2 MG/2 ML SYRINGE No

H3T NALTREXONE HCL 0 999NALTREXONE 50 MG TABLET No

H3U OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICSH3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMIN-CODEIN 300-30 MG/12.5 No

H3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMINOP-CODEINE 120-12 MG/5 No

H3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMINOPHEN-COD #2 TABLET No



H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 2.5-108/5 No

H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMN 7.5-325/15 No

H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 7.5-325 No

H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 7.5-300 No

H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 5-325 MG No

H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 5-217/10 No






Medicaid Max Age


H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODONE-ACETAMINOPHEN 5-325 No

H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODON-ACETAMINOPHEN 2.5-325 No

H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODON-ACETAMINOPHEN 7.5-325 No

H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODONE-ACETAMINOPHEN 10-325 No

H3W OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPEH3W BUPRENORPHINE 18 999SUBLOCADE 300 MG/1.5 ML SYRING Auto PA

H3W BUPRENORPHINE 18 999SUBLOCADE 100 MG/0.5 ML SYRING Auto PA

H3W BUPRENORPHINE HCL 16 999BUPRENORPHINE 2 MG TABLET SL Clinical PA Required

H3W BUPRENORPHINE HCL 16 999BUPRENORPHINE 8 MG TABLET SL Clinical PA Required

H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999ZUBSOLV 8.6-2.1 MG TABLET SL Clinical PA Required

H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999BUPRENORPHN-NALOXN 2-0.5 MG SL Clinical PA Required

H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999SUBOXONE 12 MG-3 MG SL FILM Clinical PA Required

H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999SUBOXONE 2 MG-0.5 MG SL FILM Clinical PA Required








H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999BUPRENORPHIN-NALOXON 8-2 MG SL Clinical PA Required

H3Y MU-OPIOID RECEPTOR ANTAGONISTS,PERIPHERALLY-ACTINGH3Y NALOXEGOL OXALATE 0 999MOVANTIK 12.5 MG TABLET Auto PA

H3Y NALOXEGOL OXALATE 0 999MOVANTIK 25 MG TABLET Auto PA

H4A ANTICONVULSANT - BENZODIAZEPINE TYPE



Medicaid Max Age


H4A CLOBAZAM 2 999SYMPAZAN 20 MG FILM Auto PA

H4A CLOBAZAM 2 999CLOBAZAM 10 MG TABLET No

H4A CLOBAZAM 2 999CLOBAZAM 2.5 MG/ML SUSPENSION No

H4A CLOBAZAM 2 999CLOBAZAM 20 MG TABLET No

H4A CLOBAZAM 2 999ONFI 2.5 MG/ML SUSPENSION Auto PA

H4A CLOBAZAM 2 999ONFI 20 MG TABLET Auto PA



H4A CLOBAZAM 2 999ONFI 10 MG TABLET Auto PA

H4A CLONAZEPAM 0 999CLONAZEPAM 0.125 MG DIS TAB No

H4A CLONAZEPAM 0 999KLONOPIN 1 MG TABLET Auto PA

H4A CLONAZEPAM 0 999KLONOPIN 2 MG TABLET Auto PA

H4A CLONAZEPAM 0 999KLONOPIN 0.5 MG TABLET Auto PA

H4A CLONAZEPAM 0 999CLONAZEPAM 2 MG TABLET No

H4A CLONAZEPAM 0 999CLONAZEPAM 2 MG ODT No

H4A CLONAZEPAM 0 999CLONAZEPAM 1 MG TABLET No

H4A CLONAZEPAM 0 999CLONAZEPAM 1 MG ODT No

H4A CLONAZEPAM 0 999CLONAZEPAM 1 MG DIS TABLET No

H4A CLONAZEPAM 0 999CLONAZEPAM 0.5 MG TABLET No

H4A CLONAZEPAM 0 999CLONAZEPAM 0.5 MG ODT No

H4A CLONAZEPAM 0 999CLONAZEPAM 0.5 MG DIS TABLET No



H4A DIAZEPAM 0 18DIASTAT ACUDIAL 12.5-15-20 MG Auto PA



Medicaid Max Age


H4A DIAZEPAM 0 18DIAZEPAM 2.5 MG RECTAL GEL SYS No

H4A DIAZEPAM 0 18DIASTAT ACUDIAL 5-7.5-10 MG KT Auto PA

H4A DIAZEPAM 0 18DIASTAT 2.5 MG PEDI SYSTEM Auto PA

H4A DIAZEPAM 0 18DIAZEPAM 10 MG RECTAL GEL SYST No

H4A DIAZEPAM 0 18DIAZEPAM 20 MG RECTAL GEL SYST No

H4B ANTICONVULSANTSH4B BRIVARACETAM 4 999BRIVIACT 10 MG TABLET Auto PA

H4B BRIVARACETAM 4 999BRIVIACT 75 MG TABLET Auto PA

H4B BRIVARACETAM 16 999BRIVIACT 50 MG/5 ML VIAL Auto PA



H4B BRIVARACETAM 4 999BRIVIACT 10 MG/ML ORAL SOLN Auto PA


H4B CARBAMAZEPINE 0 999CARBAMAZEPINE ER 300 MG CAP No

H4B CARBAMAZEPINE 0 999CARBATROL ER 100 MG CAPSULE Auto PA



H4B CARBAMAZEPINE 0 999TEGRETOL XR 200 MG TABLET Auto PA

H4B CARBAMAZEPINE 0 999CARBAMAZEPINE ER 200 MG TABLET No


H4B CARBAMAZEPINE 0 999TEGRETOL 200 MG TABLET Auto PA

H4B CARBAMAZEPINE 0 999EPITOL 200 MG TABLET Auto PA

H4B CARBAMAZEPINE 0 999TEGRETOL 100 MG/5 ML SUSP Auto PA




Medicaid Max Age



H4B CARBAMAZEPINE 0 999CARBAMAZEPINE 200 MG TABLET No

H4B CARBAMAZEPINE 0 999CARBAMAZEPINE 100 MG/5 ML SUSP No

H4B CARBAMAZEPINE 0 999CARBAMAZEPINE 100 MG TAB CHEW No




H4B DIVALPROEX SODIUM 0 999DEPAKOTE DR 250 MG TABLET Auto PA

H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD DR 250 MG TAB No


H4B DIVALPROEX SODIUM 0 999DIVALPROEX DR 125 MG CAP SPRNK No

H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD ER 250 MG TAB No

H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD ER 500 MG TAB No

H4B DIVALPROEX SODIUM 0 999DEPAKOTE ER 500 MG TABLET Auto PA



H4B DIVALPROEX SODIUM 0 999DEPAKOTE DR 125 MG SPRINKLE CP Auto PA


H4B DIVALPROEX SODIUM 0 999DEPAKOTE ER 250 MG TABLET Auto PA

H4B ESLICARBAZEPINE ACETATE 4 999APTIOM 400 MG TABLET Auto PA




H4B ETHOSUXIMIDE 0 999ETHOSUXIMIDE 250 MG CAPSULE No



Medicaid Max Age


H4B ETHOSUXIMIDE 0 999ETHOSUXIMIDE 250 MG/5 ML SOLN No

H4B ETHOSUXIMIDE 0 999ZARONTIN 250 MG CAPSULE Auto PA

H4B FELBAMATE 0 999FELBATOL 400 MG TABLET Auto PA

H4B FELBAMATE 0 999FELBAMATE 600 MG/5 ML SUSP No

H4B FELBAMATE 0 999FELBATOL 600 MG/5 ML SUSP Auto PA

H4B FELBAMATE 0 999FELBAMATE 600 MG TABLET No

H4B FELBAMATE 0 999FELBATOL 600 MG TABLET Auto PA

H4B FELBAMATE 0 999FELBAMATE 400 MG TABLET No

H4B GABAPENTIN 0 999NEURONTIN 400 MG CAPSULE Auto PA



H4B GABAPENTIN 0 999NEURONTIN 600 MG TABLET Auto PA

H4B GABAPENTIN 0 999NEURONTIN 800 MG TABLET Auto PA

H4B GABAPENTIN 0 999GABAPENTIN 800 MG TABLET No

H4B GABAPENTIN 0 999GABAPENTIN 600 MG TABLET No

H4B GABAPENTIN 0 999GABAPENTIN 400 MG CAPSULE No

H4B GABAPENTIN 0 999GABAPENTIN 300 MG/6 ML SOLN No

H4B GABAPENTIN 0 999NEURONTIN 250 MG/5 ML SOLN Auto PA

H4B GABAPENTIN 0 999GABAPENTIN 250 MG/5 ML SOLN No



H4B LACOSAMIDE 0 999VIMPAT 10 MG/ML SOLUTION Auto PA

H4B LACOSAMIDE 0 999VIMPAT STARTER KIT Auto PA

H4B LACOSAMIDE 0 999VIMPAT 150 MG TABLET Auto PA



Medicaid Max Age





H4B LAMOTRIGINE 0 999LAMOTRIGINE 25 MG TABLET No

H4B LAMOTRIGINE 13 999LAMOTRIGINE ER 100 MG TABLET No





H4B LAMOTRIGINE 0 999LAMOTRIGINE TAB START KT-ORANG Auto PA

H4B LAMOTRIGINE 0 999LAMOTRIGINE TAB START KT-GREEN Auto PA


H4B LAMOTRIGINE 0 999LAMOTRIGINE 5 MG DISPER TABLET No

H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT KIT (GREEN) No

H4B LAMOTRIGINE 0 999LAMOTRIGINE 25 MG DISPER TAB No



H4B LAMOTRIGINE 0 999LAMOTRIGINE TAB START KIT-BLUE Auto PA

H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT 100 MG TABLET Auto PA



H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT KIT (BLUE) No

H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT KIT (ORANGE) No




Medicaid Max Age


H4B LAMOTRIGINE 0 999SUBVENITE 25 MG TABLET Auto PA

H4B LAMOTRIGINE 0 999SUBVENITE TAB START KIT (BLUE) Auto PA

H4B LAMOTRIGINE 0 999LAMICTAL TB START KIT (ORANGE) No

H4B LAMOTRIGINE 0 999SUBVENITE TAB START KIT(GREEN) Auto PA

H4B LAMOTRIGINE 0 999SUBVENITE TAB START KT(ORANGE) Auto PA





H4B LAMOTRIGINE 0 999LAMICTAL TAB START KIT (GREEN) No

H4B LAMOTRIGINE 0 999LAMICTAL 150 MG TABLET Auto PA

H4B LAMOTRIGINE 13 999LAMICTAL XR START KIT (ORANGE) Auto PA

H4B LAMOTRIGINE 0 999LAMICTAL ODT 200 MG TABLET No


H4B LAMOTRIGINE 0 999LAMICTAL 25 MG DISPER TABLET Auto PA


H4B LAMOTRIGINE 0 999LAMICTAL 5 MG DISPER TABLET Auto PA


H4B LAMOTRIGINE 0 999LAMICTAL TAB START KIT (BLUE) No



H4B LAMOTRIGINE 13 999LAMICTAL XR 300 MG TABLET Auto PA

H4B LAMOTRIGINE 0 999LAMICTAL ODT START KIT (BLUE) Auto PA

H4B LAMOTRIGINE 13 999LAMICTAL XR START KIT (GREEN) Auto PA



Medicaid Max Age


H4B LAMOTRIGINE 0 999LAMICTAL ODT START KIT (GREEN) Auto PA

H4B LAMOTRIGINE 0 999LAMICTAL ODT START KT (ORANGE) Auto PA






H4B LAMOTRIGINE 13 999LAMICTAL XR START KIT (BLUE) Auto PA


H4B LEVETIRACETAM 0 999KEPPRA XR 750 MG TABLET Auto PA

H4B LEVETIRACETAM 0 999KEPPRA 750 MG TABLET Auto PA


H4B LEVETIRACETAM 0 999KEPPRA 100 MG/ML ORAL SOLN Auto PA

H4B LEVETIRACETAM 0 999KEPPRA 1,000 MG TABLET Auto PA

H4B LEVETIRACETAM 0 999ROWEEPRA 750 MG TABLET Auto PA

H4B LEVETIRACETAM 0 999ROWEEPRA 500 MG TABLET Auto PA

H4B LEVETIRACETAM 0 999KEPPRA XR 500 MG TABLET Auto PA

H4B LEVETIRACETAM 0 999ROWEEPRA XR 500 MG TABLET Auto PA

H4B LEVETIRACETAM 0 999ROWEEPRA 1,000 MG TABLET Auto PA

H4B LEVETIRACETAM 0 999LEVETIRACETAM ER 750 MG TABLET No

H4B LEVETIRACETAM 0 999LEVETIRACETAM ER 500 MG TABLET No

H4B LEVETIRACETAM 0 999LEVETIRACETAM 750 MG TABLET No

H4B LEVETIRACETAM 0 999LEVETIRACETAM 500 MG/5 ML VIAL No

H4B LEVETIRACETAM 0 999LEVETIRACETAM 500 MG/5 ML SOLN No



Medicaid Max Age


H4B LEVETIRACETAM 0 999ROWEEPRA XR 750 MG TABLET Auto PA

H4B LEVETIRACETAM 0 999LEVETIRACETAM 1,000 MG TABLET No

H4B LEVETIRACETAM 0 999LEVETIRACETAM 100 MG/ML SOLN No




H4B OXCARBAZEPINE 0 999TRILEPTAL 300 MG/5 ML SUSP Auto PA

H4B OXCARBAZEPINE 0 999TRILEPTAL 150 MG TABLET Auto PA



H4B OXCARBAZEPINE 0 999OXCARBAZEPINE 150 MG TABLET No


H4B OXCARBAZEPINE 0 999OXCARBAZEPINE 300 MG/5 ML SUSP No

H4B OXCARBAZEPINE 6 999OXTELLAR XR 600 MG TABLET Auto PA




H4B PERAMPANEL 4 999FYCOMPA 6 MG TABLET Auto PA

H4B PERAMPANEL 4 999FYCOMPA 0.5 MG/ML ORAL SUSP Auto PA








Medicaid Max Age


H4B PHENYTOIN 0 999PHENYTOIN 50 MG INFATAB No

H4B PHENYTOIN 0 999PHENYTOIN 100 MG/4 ML SUSP No

H4B PHENYTOIN 0 999PHENYTOIN 125 MG/5 ML SUSP No

H4B PHENYTOIN 0 999DILANTIN 125 MG/5 ML SUSP Auto PA

H4B PHENYTOIN 0 999PHENYTOIN 50 MG TABLET CHEW No

H4B PHENYTOIN SODIUM EXTENDED 0 999PHENYTOIN SOD EXT 300 MG CAP No

H4B PHENYTOIN SODIUM EXTENDED 0 999DILANTIN 30 MG CAPSULE Auto PA

H4B PHENYTOIN SODIUM EXTENDED 0 999DILANTIN 100 MG CAPSULE Auto PA



H4B PREGABALIN 0 999PREGABALIN 200 MG CAPSULE No








H4B PRIMIDONE 0 999MYSOLINE 250 MG TABLET Auto PA

H4B PRIMIDONE 0 999PRIMIDONE 250 MG TABLET No

H4B PRIMIDONE 0 999PRIMIDONE 50 MG TABLET No

H4B PRIMIDONE 0 999MYSOLINE 50 MG TABLET Auto PA

H4B RUFINAMIDE 1 999BANZEL 40 MG/ML SUSPENSION Auto PA

H4B RUFINAMIDE 1 999BANZEL 400 MG TABLET Auto PA



Medicaid Max Age


H4B RUFINAMIDE 1 999BANZEL 200 MG TABLET Auto PA

H4B TIAGABINE HCL 0 999GABITRIL 2 MG TABLET Auto PA

H4B TIAGABINE HCL 0 999TIAGABINE HCL 4 MG TABLET No







H4B TOPIRAMATE 0 999TOPIRAMATE ER 150 MG CAPSULE No

H4B TOPIRAMATE 6 999TROKENDI XR 50 MG CAPSULE Auto PA





H4B TOPIRAMATE 0 999QUDEXY XR 50 MG CAPSULE Auto PA



H4B TOPIRAMATE 0 999TOPAMAX 200 MG TABLET Auto PA





H4B TOPIRAMATE 0 999TOPAMAX 15 MG SPRINKLE CAP Auto PA



Medicaid Max Age



H4B TOPIRAMATE 0 999TOPAMAX 25 MG SPRINKLE CAP Auto PA


H4B TOPIRAMATE 0 999TOPIRAMATE 25 MG TABLET No




H4B TOPIRAMATE 0 999TOPIRAMATE 25 MG SPRINKLE CAP No


H4B TOPIRAMATE 0 999TOPIRAMATE 15 MG SPRINKLE CAP No


H4B VALPROIC ACID 0 999VALPROIC ACID 250 MG CAPSULE No

H4B VALPROIC ACID (AS SODIUM SALT) 0 999VALPROIC ACID 500 MG/10 ML SOL No

H4B VALPROIC ACID (AS SODIUM SALT) 0 999VALPROIC ACID 250 MG/5 ML SOLN No

H4B VIGABATRIN 0 999VIGABATRIN 500 MG TABLET Requires Med Cert 3

H4B VIGABATRIN 0 999VIGADRONE 500 MG POWDER PACKET Auto PA

H4B VIGABATRIN 0 999SABRIL 500 MG POWDER PACKET Auto PA

H4B VIGABATRIN 0 999SABRIL 500 MG TABLET Auto PA

H4B VIGABATRIN 0 999VIGABATRIN 500 MG POWDER PACKT Requires Med Cert 3

H4B ZONISAMIDE 0 999ZONISAMIDE 25 MG CAPSULE No



H6A ANTIPARKINSONISM DRUGS,OTHERH6A AMANTADINE HCL 1 999AMANTADINE 100 MG TABLET No



Medicaid Max Age


H6A AMANTADINE HCL 1 999AMANTADINE 100 MG/10 ML SOLN No

H6A AMANTADINE HCL 1 999AMANTADINE 50 MG/5 ML SOLUTION No

H6A AMANTADINE HCL 1 999AMANTADINE 100 MG CAPSULE No

H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVODOPA 10-100 TAB No



H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO ER 25-100 TAB No

H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO ER 50-200 TAB No

H6A CARBIDOPA/LEVODOPA/ENTACAPONE 18 999CARBIDOPA-LEVODOPA 200 MG-ENTA No






H6A PRAMIPEXOLE DI-HCL 18 999PRAMIPEXOLE 1 MG TABLET No

H6A PRAMIPEXOLE DI-HCL 18 999PRAMIPEXOLE 1.5 MG TABLET No





H6A ROPINIROLE HCL 18 999ROPINIROLE HCL 0.5 MG TABLET No

H6A ROPINIROLE HCL 18 999ROPINIROLE HCL 1 MG TABLET No





Medicaid Max Age




H6A ROPINIROLE HCL 18 999ROPINIROLE HCL 0.25 MG TABLET No

H6A SELEGILINE HCL 18 999SELEGILINE HCL 5 MG CAPSULE No

H6A SELEGILINE HCL 18 999SELEGILINE HCL 5 MG TABLET No

H6B ANTIPARKINSONISM DRUGS,ANTICHOLINERGICH6B BENZTROPINE MESYLATE 3 999BENZTROPINE MES 0.5 MG TAB No

H6B BENZTROPINE MESYLATE 3 999BENZTROPINE MES 1 MG TABLET No

H6B BENZTROPINE MESYLATE 3 999BENZTROPINE MES 2 MG TABLET No

H6B TRIHEXYPHENIDYL HCL 18 999TRIHEXYPHENIDYL 2 MG TABLET No

H6B TRIHEXYPHENIDYL HCL 18 999TRIHEXYPHENIDYL 2 MG/5 ML ELX No

H6B TRIHEXYPHENIDYL HCL 18 999TRIHEXYPHENIDYL 5 MG TABLET No

H6C ANTITUSSIVES, NON-OPIOIDH6C BENZONATATE 0 20BENZONATATE 150 MG CAPSULE No

H6C BENZONATATE 0 20BENZONATATE 200 MG CAPSULE No

H6C BENZONATATE 0 20BENZONATATE 100 MG CAPSULE No

H6H SKELETAL MUSCLE RELAXANTSH6H BACLOFEN 0 999BACLOFEN 20 MG TABLET No

H6H BACLOFEN 0 999BACLOFEN 5 MG TABLET No

H6H BACLOFEN 0 999BACLOFEN 10 MG TABLET No

H6H CHLORZOXAZONE 0 999CHLORZOXAZONE 500 MG TABLET No

H6H CYCLOBENZAPRINE HCL 0 999CYCLOBENZAPRINE 10 MG TABLET No

H6H CYCLOBENZAPRINE HCL 0 999CYCLOBENZAPRINE 5 MG TABLET No

H6H CYCLOBENZAPRINE HCL 0 999CYCLOBENZAPRINE 7.5 MG TABLET No

H6H METHOCARBAMOL 0 999METHOCARBAMOL 750 MG TABLET No



Medicaid Max Age


H6H METHOCARBAMOL 0 999METHOCARBAMOL 500 MG TABLET No

H6H TIZANIDINE HCL 0 999TIZANIDINE HCL 4 MG TABLET No

H6H TIZANIDINE HCL 0 999TIZANIDINE HCL 2 MG TABLET No

H6I AMYOTROPHIC LATERAL SCLEROSIS AGENTSH6I RILUZOLE 0 999RILUZOLE 50 MG TABLET No

H6J ANTIEMETIC/ANTIVERTIGO AGENTSH6J APREPITANT 0 999APREPITANT 125 MG CAPSULE No

H6J APREPITANT 0 999APREPITANT 40 MG CAPSULE No

H6J APREPITANT 0 999APREPITANT 80 MG CAPSULE No

H6J DOXYLAMINE SUCCINATE/VIT B6 18 999DICLEGIS DR 10-10 MG TABLET No

H6J GRANISETRON HCL 0 999GRANISETRON HCL 1 MG TABLET No

H6J GRANISETRON HCL/PF 0 999GRANISETRON HCL 0.1 MG/ML VIAL No

H6J GRANISETRON HCL/PF 0 999GRANISETRON HCL 1 MG/ML VIAL No

H6J MECLIZINE HCL 0 999MECLIZINE 12.5 MG TABLET No

H6J MECLIZINE HCL 0 999MECLIZINE 25 MG TABLET No

H6J ONDANSETRON 0 999ONDANSETRON ODT 4 MG TABLET No

H6J ONDANSETRON 0 999ONDANSETRON ODT 8 MG TABLET No

H6J ONDANSETRON HCL 0 999ONDANSETRON HCL 8 MG TABLET No

H6J ONDANSETRON HCL 0 999ONDANSETRON 40 MG/20 ML VIAL No

H6J ONDANSETRON HCL 0 999ONDANSETRON 4 MG/5 ML SOLUTION No

H6J ONDANSETRON HCL 0 999ONDANSETRON HCL 4 MG TABLET No

H6J ONDANSETRON HCL/PF 0 999ONDANSETRON HCL 4 MG/2 ML SYR No

H6J ONDANSETRON HCL/PF 0 999ONDANSETRON 4 MG/2 ML ISECURE No

H6J ONDANSETRON HCL/PF 0 999ONDANSETRON HCL 4 MG/2 ML VIAL No



Medicaid Max Age


H6J PROCHLORPERAZINE MALEATE 0 999PROCHLORPERAZINE 10 MG TAB No

H6J PROCHLORPERAZINE MALEATE 0 999PROCHLORPERAZINE 5 MG TABLET No

H6J PROMETHAZINE HCL 0 999PROMETHEGAN 12.5 MG SUPPOS No

H6J PROMETHAZINE HCL 0 999PROMETHEGAN 25 MG SUPPOSITORY No

H6J PROMETHAZINE HCL 0 999PROMETHAZINE 25 MG SUPPOSITORY No

H6J PROMETHAZINE HCL 0 999PROMETHAZINE 12.5 MG SUPPOS No

H6J PROMETHAZINE HCL 0 999PROMETHEGAN 50 MG SUPPOSITORY No

H6J SCOPOLAMINE 18 999TRANSDERM-SCOP 1.5 MG (1MG/3D) Auto PA

H6L DRUGS TO TREAT MOVEMENT DISORDERSH6L DEUTETRABENAZINE 18 999AUSTEDO 12 MG TABLET Auto PA

H6L DEUTETRABENAZINE 18 999AUSTEDO 6 MG TABLET Auto PA

H6L DEUTETRABENAZINE 18 999AUSTEDO 9 MG TABLET Auto PA

H6L TETRABENAZINE 18 999TETRABENAZINE 12.5 MG TABLET Auto PA

H6L TETRABENAZINE 18 999TETRABENAZINE 25 MG TABLET Auto PA

H7B ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTSH7B MIRTAZAPINE 6 999MIRTAZAPINE 45 MG TABLET No

H7B MIRTAZAPINE 6 999MIRTAZAPINE 7.5 MG TABLET No

H7B MIRTAZAPINE 6 999MIRTAZAPINE 45 MG ODT No


H7B MIRTAZAPINE 6 999MIRTAZAPINE 15 MG TABLET No


H7B MIRTAZAPINE 6 999MIRTAZAPINE 30 MG TABLET No

H7C SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)H7C DESVENLAFAXINE SUCCINATE 18 999DESVENLAFAXINE SUC ER 100 MG No

H7C DESVENLAFAXINE SUCCINATE 18 999DESVENLAFAXINE SUC ER 25 MG TB No



Medicaid Max Age


H7C DESVENLAFAXINE SUCCINATE 18 999DESVENLAFAXINE SUC ER 50 MG TB No

H7C DULOXETINE HCL 6 999DULOXETINE HCL DR 20 MG CAP No




H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL ER 37.5 MG CAP No

H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL ER 75 MG CAP No

H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL ER 150 MG CAP No

H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL 75 MG TABLET No

H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL 37.5 MG TABLET No




H7D NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)H7D BUPROPION HCL 6 999BUPROPION HCL XL 300 MG TABLET No

H7D BUPROPION HCL 6 999BUPROPION HCL 100 MG TABLET No

H7D BUPROPION HCL 18 999BUPROPION HCL XL 450 MG TABLET No

H7D BUPROPION HCL 6 999BUPROPION HCL XL 150 MG TABLET No

H7D BUPROPION HCL 6 999BUPROPION HCL SR 200 MG TABLET No



H7D BUPROPION HCL 6 999BUPROPION HCL 75 MG TABLET No

H7E SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS)H7E TRAZODONE HCL 6 999TRAZODONE 150 MG TABLET No



Medicaid Max Age


H7E TRAZODONE HCL 6 999TRAZODONE 300 MG TABLET No



H7N SMOKING DETERRENTS, OTHERH7N BUPROPION HCL 18 999BUPROPION HCL SR 150 MG TABLET No

H7O ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONESH7O DROPERIDOL 18 999DROPERIDOL 2.5 MG/ML AMPUL No

H7O DROPERIDOL 18 999DROPERIDOL 2.5 MG/ML VIAL No

H7O HALOPERIDOL 6 999HALOPERIDOL 2 MG TABLET No



H7O HALOPERIDOL 6 999HALOPERIDOL 0.5 MG TABLET No



H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 100 MG/ML AMP No

H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 100 MG/ML VIAL No

H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 50 MG/ML VIAL No

H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 500 MG/5 ML VL No

H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DECAN 50 MG/ML AMP No

H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 100 MG/ML AMP No

H7O HALOPERIDOL LACTATE 18 999HALOPERIDOL LAC 5 MG/ML AMPUL No

H7O HALOPERIDOL LACTATE 18 999HALOPERIDOL LAC 5 MG/ML VIAL No

H7O HALOPERIDOL LACTATE 6 999HALOPERIDOL LAC 2 MG/ML CONC No

H7O HALOPERIDOL LACTATE 18 999HALOPERIDOL LAC 50 MG/10 ML VL No

H7P ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES



Medicaid Max Age


H7P THIOTHIXENE 18 999THIOTHIXENE 1 MG CAPSULE No




H7R ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINESH7R PIMOZIDE 18 999PIMOZIDE 2 MG TABLET No

H7R PIMOZIDE 18 999PIMOZIDE 1 MG TABLET No

H7T ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNSTH7T CLOZAPINE 6 999CLOZARIL 100 MG TABLET Requires Med Cert 3

H7T CLOZAPINE 6 999CLOZARIL 50 MG TABLET Requires Med Cert 3



H7T CLOZAPINE 6 999CLOZAPINE 50 MG TABLET Requires Med Cert 3




H7T ILOPERIDONE 18 999FANAPT 1 MG TABLET No







H7T LURASIDONE HCL 10 999LATUDA 20 MG TABLET No



Medicaid Max Age






H7T OLANZAPINE 6 999OLANZAPINE ODT 10 MG TABLET No



H7T OLANZAPINE 6 999OLANZAPINE 7.5 MG TABLET No

H7T OLANZAPINE 6 999OLANZAPINE 5 MG TABLET No


H7T OLANZAPINE 6 999OLANZAPINE 2.5 MG TABLET No




H7T PALIPERIDONE PALMITATE 18 999INVEGA TRINZA 410 MG/1.315 ML Auto PA

H7T PALIPERIDONE PALMITATE 18 999INVEGA SUSTENNA 117 MG/0.75 ML Auto PA







H7T PALIPERIDONE PALMITATE 18 999INVEGA SUSTENNA 156 MG/ML SYRG Auto PA

H7T QUETIAPINE FUMARATE 6 999QUETIAPINE FUMARATE 100 MG TAB No



Medicaid Max Age



H7T QUETIAPINE FUMARATE 6 999QUETIAPINE ER 50 MG TABLET No









H7T RISPERIDONE 6 999RISPERIDONE 3 MG TABLET No


H7T RISPERIDONE 6 999RISPERIDONE 0.25 MG ODT No

H7T RISPERIDONE 6 999RISPERIDONE 1 MG ODT No

H7T RISPERIDONE 6 999RISPERIDONE 1 MG/ML SOLUTION No





H7T RISPERIDONE 6 999RISPERIDONE 0.5 MG TABLET No

H7T RISPERIDONE 6 999RISPERIDONE 0.25 MG TABLET No

H7T RISPERIDONE 18 999PERSERIS ER 90 MG SYRINGE KIT Auto PA

H7T RISPERIDONE 18 999PERSERIS ER 120 MG SYRINGE KIT Auto PA

H7T RISPERIDONE 6 999RISPERIDONE 0.5 MG ODT No



Medicaid Max Age



H7T RISPERIDONE MICROSPHERES 18 999RISPERDAL CONSTA 50 MG SYR Auto PA

H7T RISPERIDONE MICROSPHERES 18 999RISPERDAL CONSTA 37.5 MG SYR Auto PA

H7T RISPERIDONE MICROSPHERES 18 999RISPERDAL CONSTA 25 MG SYR Auto PA

H7T RISPERIDONE MICROSPHERES 18 999RISPERDAL CONSTA 12.5 MG SYR Auto PA

H7T ZIPRASIDONE HCL 6 999ZIPRASIDONE HCL 20 MG CAPSULE No




H7U ANTIPSYCHOTICS, DOPAMINE AND SEROTONIN ANTAGONISTSH7U LOXAPINE SUCCINATE 18 999LOXAPINE 10 MG CAPSULE No

H7U LOXAPINE SUCCINATE 18 999LOXAPINE 25 MG CAPSULE No



H7X ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXEDH7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE 10 MG TABLET No

H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE 30 MG TABLET No




H7X ARIPIPRAZOLE 18 999ABILIFY MAINTENA ER 400 MG VL Auto PA

H7X ARIPIPRAZOLE 18 999ABILIFY MAINTENA ER 400 MG SYR Auto PA

H7X ARIPIPRAZOLE 18 999ABILIFY MAINTENA ER 300 MG VL Auto PA

H7X ARIPIPRAZOLE 18 999ABILIFY MAINTENA ER 300 MG SYR Auto PA



Medicaid Max Age


H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE 1 MG/ML SOLUTION No


H7X ARIPIPRAZOLE LAUROXIL 18 999ARISTADA ER 1064 MG/3.9 ML SYR Auto PA

H7X ARIPIPRAZOLE LAUROXIL 18 999ARISTADA ER 441 MG/1.6 ML SYRN Auto PA



H7X ARIPIPRAZOLE LAUROXIL,SUBMICR. 18 999ARISTADA INITIO ER 675 MG/2.4 Auto PA

H7Y TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPEH7Y ATOMOXETINE HCL 6 999ATOMOXETINE HCL 100 MG CAPSULE No

H7Y ATOMOXETINE HCL 6 999ATOMOXETINE HCL 80 MG CAPSULE No






H8B HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTSH8B RAMELTEON 65 999ROZEREM 8 MG TABLET No

H8M TX FOR ADHD - SELECTIVE ALPHA-2 RECEPTOR AGONISTH8M GUANFACINE HCL 0 999GUANFACINE HCL ER 1 MG TABLET No

H8M GUANFACINE HCL 0 999GUANFACINE HCL ER 2 MG TABLET No



H8O PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTSH8O DEXTROMETHORPHAN HBR/QUINIDINE 18 999NUEDEXTA 20-10 MG CAPSULE No

H8P SSRI AND 5HT1A PARTIAL AGONIST ANTIDEPRESSANTS



Medicaid Max Age


H8P VILAZODONE HCL 18 999VIIBRYD 20 MG TABLET No



H8Q NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTSH8Q MODAFINIL 18 999MODAFINIL 100 MG TABLET Auto PA

H8Q MODAFINIL 18 999MODAFINIL 200 MG TABLET Auto PA

H8T SSRI, SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTSH8T VORTIOXETINE HYDROBROMIDE 18 999TRINTELLIX 10 MG TABLET Auto PA

H8T VORTIOXETINE HYDROBROMIDE 18 999TRINTELLIX 20 MG TABLET Auto PA

H8T VORTIOXETINE HYDROBROMIDE 18 999TRINTELLIX 5 MG TABLET Auto PA

J1A PARASYMPATHETIC AGENTSJ1A BETHANECHOL CHLORIDE 0 999BETHANECHOL 10 MG TABLET No

J1A BETHANECHOL CHLORIDE 0 999BETHANECHOL 25 MG TABLET No



J1A GUANIDINE HCL 0 999GUANIDINE HCL 125 MG TABLET No

J1A PILOCARPINE HCL 0 999PILOCARPINE HCL 5 MG TABLET No

J1A PILOCARPINE HCL 0 999PILOCARPINE HCL 7.5 MG TABLET No

J1B CHOLINESTERASE INHIBITORSJ1B DONEPEZIL HCL 18 999DONEPEZIL HCL 10 MG TABLET No

J1B DONEPEZIL HCL 18 999DONEPEZIL HCL ODT 5 MG TABLET No

J1B DONEPEZIL HCL 18 999DONEPEZIL HCL 5 MG TABLET No

J1B DONEPEZIL HCL 18 999DONEPEZIL HCL ODT 10 MG TABLET No

J1B PYRIDOSTIGMINE BROMIDE 0 999MESTINON 60 MG/5 ML SYRUP No

J1B PYRIDOSTIGMINE BROMIDE 0 999PYRIDOSTIGMINE 60 MG/5 ML SOLN No



Medicaid Max Age


J1B PYRIDOSTIGMINE BROMIDE 0 999PYRIDOSTIGMINE BR 30 MG TABLET No

J1B PYRIDOSTIGMINE BROMIDE 0 999PYRIDOSTIGMINE BR 60 MG TABLET No

J1B PYRIDOSTIGMINE BROMIDE 0 999PYRIDOSTIGMINE ER 180 MG TAB No

J1B RIVASTIGMINE 18 999EXELON 13.3 MG/24HR PATCH No



J2A BELLADONNA ALKALOIDSJ2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE 0.125 MG/ML DROP No

J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE 0.125 MG ODT No

J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE ER 0.375 MG TAB No

J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE SULF 0.125 MG TAB No

J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE 0.125 MG TAB SL No

J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE 0.125 MG/5 ML ELIX No

J2A PHENOBARB/HYOSCY/ATROPINE/SCOP 0 999BELLADONNA-PHENOBARBITAL TAB No

J2B ANTICHOLINERGICS,QUATERNARY AMMONIUMJ2B GLYCOPYRROLATE 0 999GLYCOPYRROLATE 1 MG TABLET No

J2B GLYCOPYRROLATE 0 999GLYCOPYRROLATE 2 MG TABLET No

J2B GLYCOPYRROLATE/PF 0 999GLYRX-PF 0.2 MG/ML VIAL No

J2B GLYCOPYRROLATE/PF 0 999GLYRX-PF 0.4 MG/2 ML VIAL No

J2B PROPANTHELINE BROMIDE 0 999PROPANTHELINE 15 MG TABLET No

J2D ANTICHOLINERGICS/ANTISPASMODICSJ2D DICYCLOMINE HCL 0 999DICYCLOMINE 20 MG TABLET No

J2D DICYCLOMINE HCL 0 999DICYCLOMINE 10 MG CAPSULE No

J2D DICYCLOMINE HCL 0 999DICYCLOMINE 10 MG/5 ML SOLN No

J3A SMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)



Medicaid Max Age


J3A NICOTINE 18 999NICOTINE 21 MG/24HR PATCH No

J3A NICOTINE 18 999HM NICOTINE 21 MG/24HR PATCH No





J3A NICOTINE 18 999NICOTINE TRANSDERMAL SYSTEM No

J3A NICOTINE 18 999SM NICOTINE 21 MG/24HR PATCH No



J3A NICOTINE POLACRILEX 18 999NICOTINE 4 MG LOZENGE No

J3A NICOTINE POLACRILEX 18 999NICORETTE 2 MG CHEWING GUM No

J3A NICOTINE POLACRILEX 18 999SM NICOTINE 4 MG LOZENGE No

J3A NICOTINE POLACRILEX 18 999SM NICOTINE 2 MG LOZENGE No

J3A NICOTINE POLACRILEX 18 999NICOTINE 4 MG MINI LOZENGE No

J3A NICOTINE POLACRILEX 18 999SM NICOTINE 4 MG CHEWING GUM No

J3A NICOTINE POLACRILEX 18 999HM NICOTINE 2 MG CHEWING GUM No

J3A NICOTINE POLACRILEX 18 999NICOTINE 2 MG MINI LOZENGE No

J3A NICOTINE POLACRILEX 18 999HM NICOTINE 4 MG CHEWING GUM No

J3A NICOTINE POLACRILEX 18 999NICOTINE 2 MG CHEWING GUM No

J3A NICOTINE POLACRILEX 18 999SM NICOTINE 2 MG CHEWING GUM No

J3A NICOTINE POLACRILEX 18 999NICORETTE 4 MG CHEWING GUM No

J3A NICOTINE POLACRILEX 18 999GS NICOTINE 2 MG MINI LOZENGE No

J3A NICOTINE POLACRILEX 18 999GS NICOTINE 4 MG MINI LOZENGE No



Medicaid Max Age


J3A NICOTINE POLACRILEX 18 999HM NICOTINE 2 MG LOZENGE No

J3A NICOTINE POLACRILEX 18 999HM NICOTINE 2 MG MINI LOZENGE No

J3A NICOTINE POLACRILEX 18 999HM NICOTINE 4 MG LOZENGE No

J3A NICOTINE POLACRILEX 18 999NICOTINE 2 MG LOZENGE No

J3A NICOTINE POLACRILEX 18 999NICOTINE 4 MG CHEWING GUM No

J3C SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONISTJ3C VARENICLINE TARTRATE 18 999CHANTIX 1 MG TABLET No

J3C VARENICLINE TARTRATE 18 999CHANTIX STARTING MONTH BOX No

J3C VARENICLINE TARTRATE 18 999CHANTIX 1 MG CONT MONTH BOX No

J3C VARENICLINE TARTRATE 18 999CHANTIX 0.5 MG TABLET No

J5B ADRENERGICS, AROMATIC, NON-CATECHOLAMINEJ5B AMPHETAMINE 6 999DYANAVEL XR 2.5 MG/ML SUSP No

J5B DEXTROAMPHETAMINE SULFATE 0 999DEXTROAMPHETAMINE 10 MG TAB No

J5B DEXTROAMPHETAMINE SULFATE 0 999DEXTROAMPHETAMINE 5 MG TAB No

J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAMINE 5 MG TAB No

J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAMIN 30 MG TAB No



J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAM 7.5 MG TAB No

J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAM 12.5 MG TAB No

J5B DEXTROAMPHETAMINE/AMPHETAMINE 6 999DEXTROAMP-AMPHET ER 30 MG CAP No






Medicaid Max Age





J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 20 MG CAPSULE No


J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 60 MG CHEWABLE TABLET No











J5D BETA-ADRENERGIC AGENTSJ5D ALBUTEROL SULFATE 0 999ALBUTEROL SULF 2 MG/5 ML SYRUP No

J5D TERBUTALINE SULFATE 0 999TERBUTALINE SULF 1 MG/ML VIAL No

J5F ANAPHYLAXIS THERAPY AGENTSJ5F EPINEPHRINE 0 999EPINEPHRINE 0.15 MG AUTO-INJCT No

J5F EPINEPHRINE 0 999EPINEPHRINE 0.3 MG AUTO-INJECT No

J5H ADRENERGIC VASOPRESSOR AGENTSJ5H MIDODRINE HCL 0 999MIDODRINE HCL 10 MG TABLET No

J5H MIDODRINE HCL 0 999MIDODRINE HCL 2.5 MG TABLET No



Medicaid Max Age


J5H MIDODRINE HCL 0 999MIDODRINE HCL 5 MG TABLET No

J7A ALPHA/BETA-ADRENERGIC BLOCKING AGENTSJ7A CARVEDILOL 0 999CARVEDILOL 12.5 MG TABLET No

J7A CARVEDILOL 0 999CARVEDILOL 25 MG TABLET No

J7A CARVEDILOL 0 999CARVEDILOL 3.125 MG TABLET No

J7A CARVEDILOL 0 999CARVEDILOL 6.25 MG TABLET No

J7A LABETALOL HCL 0 999LABETALOL HCL 100 MG TABLET No



J7B ALPHA-ADRENERGIC BLOCKING AGENTSJ7B DOXAZOSIN MESYLATE 0 999DOXAZOSIN MESYLATE 1 MG TAB No

J7B DOXAZOSIN MESYLATE 0 999DOXAZOSIN MESYLATE 2 MG TAB No



J7B PRAZOSIN HCL 0 999PRAZOSIN 5 MG CAPSULE No



J7B TERAZOSIN HCL 0 999TERAZOSIN 5 MG CAPSULE No




J7C BETA-ADRENERGIC BLOCKING AGENTSJ7C ACEBUTOLOL HCL 0 999ACEBUTOLOL 200 MG CAPSULE No

J7C ACEBUTOLOL HCL 0 999ACEBUTOLOL 400 MG CAPSULE No

J7C ATENOLOL 0 999ATENOLOL 100 MG TABLET No



Medicaid Max Age




J7C BISOPROLOL FUMARATE 0 999BISOPROLOL FUMARATE 10 MG TAB No

J7C BISOPROLOL FUMARATE 0 999BISOPROLOL FUMARATE 5 MG TAB No

J7C METOPROLOL SUCCINATE 0 999METOPROLOL SUCC ER 200 MG TAB No




J7C METOPROLOL TARTRATE 0 999METOPROLOL TARTRATE 100 MG TAB No



J7C PROPRANOLOL HCL 0 999PROPRANOLOL 20 MG/5 ML SOLN No

J7C PROPRANOLOL HCL 0 999PROPRANOLOL 80 MG TABLET No

J7C PROPRANOLOL HCL 0 999PROPRANOLOL ER 60 MG CAPSULE No







J7C PROPRANOLOL HCL 0 999PROPRANOLOL 40 MG/5 ML SOLN No


J7C SOTALOL HCL 0 999SOTALOL 240 MG TABLET No

J7C SOTALOL HCL 0 999SOTALOL AF 80 MG TABLET No



Medicaid Max Age







J7H BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICSJ7H ATENOLOL/CHLORTHALIDONE 0 999ATENOLOL-CHLORTHALIDONE 100-25 No

J7H ATENOLOL/CHLORTHALIDONE 0 999ATENOLOL-CHLORTHALIDONE 50-25 No

J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL-HCTZ 5-6.25 MG TAB No

J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL-HCTZ 10-6.25 MG TAB No

J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL-HCTZ 2.5-6.25 MG TB No

J9A INTESTINAL MOTILITY STIMULANTSJ9A METOCLOPRAMIDE HCL 0 999METOCLOPRAMIDE 10 MG/10 ML SOL No

J9A METOCLOPRAMIDE HCL 0 999METOCLOPRAMIDE 5 MG TABLET No

J9A METOCLOPRAMIDE HCL 0 999METOCLOPRAMIDE 5 MG/5 ML SOLN No

J9A METOCLOPRAMIDE HCL 0 999METOCLOPRAMIDE 10 MG TABLET No

L0B TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMESL0B COLLAGENASE CLOSTRIDIUM HIST. 0 999SANTYL OINTMENT No

L0B HYALURONIDASE, HUMAN RECOMB. 0 999HYQVIA HY CMPNT 1,600 UNIT/10 Clinical PA Required

L0B HYALURONIDASE, HUMAN RECOMB. 0 999HYQVIA HY CMPNT 2,400 UNIT/15 Clinical PA Required

L0B HYALURONIDASE, HUMAN RECOMB. 0 999HYQVIA HY CMPNT 200 UNIT/1.25 Clinical PA Required

L0B HYALURONIDASE, HUMAN RECOMB. 0 999HYQVIA HY CMPNT 400 UNIT/2.5 Clinical PA Required

L0B HYALURONIDASE, HUMAN RECOMB. 0 999HYQVIA HY CMPNT 800 UNIT/5 ML Clinical PA Required

L1A ANTIPSORIATIC AGENTS,SYSTEMICL1A ACITRETIN 0 999ACITRETIN 25 MG CAPSULE No



Medicaid Max Age


L1A ACITRETIN 0 999ACITRETIN 10 MG CAPSULE No

L1A ACITRETIN 0 999ACITRETIN 17.5 MG CAPSULE No

L1A SECUKINUMAB 18 999COSENTYX 150 MG/ML SYRINGE Auto PA

L1A SECUKINUMAB 18 999COSENTYX 300 MG DOSE-2 PENS Auto PA

L1A SECUKINUMAB 18 999COSENTYX 300 MG DOSE-2 SYRINGE Auto PA

L1A SECUKINUMAB 18 999COSENTYX 150 MG/ML PEN INJECT Auto PA

L1B ACNE AGENTS,SYSTEMICL1B ISOTRETINOIN 12 999ISOTRETINOIN 40 MG CAPSULE Requires Med Cert 3

L1B ISOTRETINOIN 12 999ZENATANE 40 MG CAPSULE Requires Med Cert 3




L1B ISOTRETINOIN 12 999MYORISAN 40 MG CAPSULE Requires Med Cert 3




L1B ISOTRETINOIN 12 999CLARAVIS 40 MG CAPSULE Requires Med Cert 3

L1B ISOTRETINOIN 12 999ISOTRETINOIN 10 MG CAPSULE Requires Med Cert 3





L1B ISOTRETINOIN 12 999AMNESTEEM 40 MG CAPSULE Requires Med Cert 3




Medicaid Max Age




L2A EMOLLIENTSL2A AMMONIUM LACTATE 0 999AMMONIUM LACTATE 12% CREAM No

L2A AMMONIUM LACTATE 0 999AMMONIUM LACTATE 12% LOTION No

L3P ANTIPRURITICS,TOPICALL3P DOXEPIN HCL 18 999DOXEPIN 5% CREAM Auto PA

L5A KERATOLYTICSL5A PODOFILOX 0 999PODOFILOX 0.5% TOPICAL SOLN No

L5A SALICYLIC ACID 0 999SALICYLIC ACID 6% CREAM No

L5A UREA 0 999UREA 40% CREAM No

L5A UREA 0 999UREA 40% LOTION No

L5E ANTISEBORRHEIC AGENTSL5E SELENIUM SULFIDE 0 999SELENIUM SULFIDE 2.25% SHAMPOO No

L5E SELENIUM SULFIDE 0 999SELENIUM SULFIDE 2.5% LOTION No

L5F ANTIPSORIATICS AGENTSL5F CALCIPOTRIENE 18 999CALCIPOTRIENE 0.005% CREAM Auto PA

L5F CALCIPOTRIENE 18 999CALCIPOTRIENE 0.005% OINTMENT Auto PA

L5F CALCITRIOL 0 999CALCITRIOL 3 MCG/G OINTMENT No

L5G ROSACEA AGENTS, TOPICALL5G AZELAIC ACID 0 999FINACEA 15% GEL No

L5G METRONIDAZOLE 0 999METRONIDAZOLE TOP 1% GEL PUMP No

L5G METRONIDAZOLE 0 999METRONIDAZOLE TOPICAL 0.75% GL No

L5G METRONIDAZOLE 0 999METRONIDAZOLE TOPICAL 1% GEL No

L5G METRONIDAZOLE 0 999METRONIDAZOLE 0.75% CREAM No

L5H ACNE AGENTS,TOPICAL



Medicaid Max Age


L5H AZELAIC ACID 12 999AZELEX 20% CREAM No

L5H CLINDAMYCIN PHOS/BENZOYL PEROX 12 999CLINDA-BENZOYL PEROX 1-5% PUMP No

L9B VITAMIN A DERIVATIVESL9B ADAPALENE 12 999DIFFERIN 0.1% LOTION No

L9B ADAPALENE 12 999DIFFERIN 0.1% CREAM No

L9B TRETINOIN 12 999RETIN-A 0.1% CREAM No


L9B TRETINOIN 12 999AVITA 0.025% CREAM No


M0B PLASMA PROTEINSM0B ALBUMIN HUMAN 0 999ALBURX (HUMAN) 5% VIAL Clinical PA Required

M0B ALBUMIN HUMAN 0 999ALBUTEIN 5% VIAL Clinical PA Required

M0B ALBUMIN HUMAN 0 999PLASBUMIN-25 IV SOLUTION Clinical PA Required

M0B ALBUMIN HUMAN 0 999KEDBUMIN 25% VIAL Clinical PA Required

M0B ALBUMIN HUMAN 0 999FLEXBUMIN 5% IV SOLUTION Clinical PA Required

M0B ALBUMIN HUMAN 0 999BUMINATE 5% IV SOLUTION Clinical PA Required

M0B ALBUMIN HUMAN 0 999PLASBUMIN-5 IV SOLUTION Clinical PA Required

M0B ALBUMIN HUMAN 0 999ALBUTEIN 25% VIAL Clinical PA Required

M0B ALBUMIN HUMAN 0 999ALBUMINAR-25 IV SOLUTION Clinical PA Required

M0B ALBUMIN HUMAN 0 999ALBUMIN (HUMAN) 5% IV SOLUTION Clinical PA Required

M0B ALBUMIN HUMAN 0 999ALBUMIN (HUMAN) 25% IV SOLN Clinical PA Required

M0B ALBUMIN HUMAN 0 999ALBUKED-5 VIAL Clinical PA Required

M0B ALBUMIN HUMAN 0 999ALBUKED-25 VIAL Clinical PA Required

M0B ALBUMIN HUMAN 0 999FLEXBUMIN 25% IV SOLUTION Clinical PA Required



Medicaid Max Age


M0B ALBUMIN HUMAN 0 999ALBURX (HUMAN) 25% VIAL Clinical PA Required

M0B ALBUMIN HUMAN-KJDA 0 999ALBUMINEX 5% VIAL Clinical PA Required

M0B ALBUMIN HUMAN-KJDA 0 999ALBUMINEX 25% VIAL Clinical PA Required

M0B PLASMA PROTEIN FRACTION 0 999PLASMANATE 5% IV SOLUTION Clinical PA Required

M0N C1 ESTERASE INHIBITORSM0N C1 ESTERASE INHIBITOR 12 999BERINERT 500 UNIT KIT Auto PA

M0N C1 ESTERASE INHIBITOR 12 999BERINERT 500 UNIT VIAL Auto PA

M4B IV FAT EMULSIONSM4B FAT EMULSIONS 0 999INTRALIPID 20% IV FAT EMUL No

M4B FAT EMULSIONS 0 999INTRALIPID 30% IV FAT EMUL No

M4D ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS)M4D ATORVASTATIN CALCIUM 0 999ATORVASTATIN 20 MG TABLET No

M4D ATORVASTATIN CALCIUM 0 999ATORVASTATIN 40 MG TABLET No



M4D LOVASTATIN 0 999LOVASTATIN 10 MG TABLET No



M4D PRAVASTATIN SODIUM 0 999PRAVASTATIN SODIUM 10 MG TAB No




M4D ROSUVASTATIN CALCIUM 0 999ROSUVASTATIN CALCIUM 40 MG TAB No





Medicaid Max Age



M4D SIMVASTATIN 0 999SIMVASTATIN 10 MG TABLET No





M4E LIPOTROPICSM4E DOCOSAHEXANOIC ACID/EPA 0 999FISH OIL CONCENTRATE SOFTGEL Cystic Fib Diag Auto PA

M4E DOCOSAHEXANOIC ACID/EPA 0 999RA FISH OIL 120-180 SOFTGEL Cystic Fib Diag Auto PA

M4E EZETIMIBE 10 999EZETIMIBE 10 MG TABLET No

M4E FENOFIBRATE NANOCRYSTALLIZED 0 999FENOFIBRATE 145 MG TABLET No

M4E FENOFIBRATE NANOCRYSTALLIZED 0 999FENOFIBRATE 48 MG TABLET No

M4E GEMFIBROZIL 0 999GEMFIBROZIL 600 MG TABLET No

M4E NIACIN 0 999NIACIN ER 500 MG TABLET No

M4E NIACIN 0 999NIACIN ER 750 MG TABLET No

M4E NIACIN 0 999NIACIN ER 1,000 MG TABLET No

M4E OMEGA-3 FATTY ACIDS 0 999CVS OMEGA-3 GUMMY FISH Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS 0 999OMEGA-3 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS 0 999SM FISH OIL CONCENTRATE SFG Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999RA FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA-3 FISH OIL 1,000 MG SFGL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999SM FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL CONC 1,000 MG SOFTGEL Cystic Fib Diag Auto PA



Medicaid Max Age


M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999EQL FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA 3 FISH OIL SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA-3 FISH OIL 1,760 MG STGL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA 3 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA-3 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999SM FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999HM FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999EQL OMEGA-3 FISH OIL 1,000 MG Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL 1,000 MG CAPSULE Cystic Fib Diag Auto PA

M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL CONCENTRATE SOFTGEL Cystic Fib Diag Auto PA


M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999CVS FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA



M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL 1,400 MG SOFTGEL Cystic Fib Diag Auto PA



M4E OMEGA-3/DHA/EPA/FISH OIL 0 999GNP FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA 3 500 SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL 1,600 MG/5 ML LIQUID Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999EQL FISH OIL EC 1,200 MG SFTGL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999CVS FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,000 MG SFGL Cystic Fib Diag Auto PA



Medicaid Max Age


M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,000 MG SFTG Cystic Fib Diag Auto PA



M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL EC 1,000 MG Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 EC SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL GUMMIES Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999GNP FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999GNP FISH OIL EC 1,000 MG SFTGL Cystic Fib Diag Auto PA


M4E OMEGA-3/DHA/EPA/FISH OIL 0 999GNP FISH OIL SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999HM FISH OIL 554 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999HM FISH OIL EC 1,000 MG SFTGL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGAMINT FISH OIL 750 MG SFGL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL EC 1,200 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999RA FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL EC 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999SM FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999SM FISH OIL 554 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL CONC 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL 500 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL OMEGA-3 EC 1,200 MG Cystic Fib Diag Auto PA

M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL DR 500 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA3/DHA/EPA/FISH OIL/VIT D3 0 999OMEGA-3-FISH OIL-VIT D3 SFTGL Cystic Fib Diag Auto PA

M4E OMEGA3/DHA/EPA/FISH OIL/VIT D3 0 999GNP FISH OIL-VIT D3 SOFTGEL Cystic Fib Diag Auto PA



Medicaid Max Age


M4E OMEGA3/DHA/EPA/FISH OIL/VIT D3 0 999FISH OIL-VIT D3 SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999FISH OIL DR 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,200 MG SFGL Cystic Fib Diag Auto PA

M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999FISH OIL OMEGA-3 SOFTGEL Cystic Fib Diag Auto PA

M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,400 MG SFGL Cystic Fib Diag Auto PA

M4E OMEGA-3S/DHA/EPA/FISH OIL/D3 0 999OMEGA-3-FISH OIL-VIT D3 SFTGL Cystic Fib Diag Auto PA

M4E OMEGA-3S/DHA/EPA/FISH OIL/D3 0 999FISH OIL-OMEGA-3-VIT D SOFTGEL Cystic Fib Diag Auto PA

M4G AGENTS TO TREAT HYPOGLYCEMIA (HYPERGLYCEMICS)M4G DIAZOXIDE 0 999PROGLYCEM 50 MG/ML ORAL SUSP No

M4G GLUCAGON,HUMAN RECOMBINANT 0 999GLUCAGEN 1 MG HYPOKIT No

M4G GLUCAGON,HUMAN RECOMBINANT 0 999GLUCAGON 1 MG EMERGENCY KIT No

M9D ANTIFIBRINOLYTIC AGENTSM9D AMINOCAPROIC ACID 0 999AMINOCAPROIC ACID 5 G/20 ML VL No

M9D AMINOCAPROIC ACID 0 999AMICAR 0.25 GRAM/ML ORAL SOLN No

M9D AMINOCAPROIC ACID 0 999AMICAR 1,000 MG TABLET No

M9D AMINOCAPROIC ACID 0 999AMICAR 500 MG TABLET No

M9D TRANEXAMIC ACID 0 999TRANEXAMIC ACID 1,000 MG/10 ML No

M9D TRANEXAMIC ACID 0 999TRANEXAMIC ACID 650 MG TABLET No

M9D TRANEXAMIC ACID IN NACL,ISO-OS 0 999TRANEXAMIC 1,000 MG/100ML-NACL No

M9F THROMBOLYTIC ENZYMESM9F ALTEPLASE 0 999CATHFLO ACTIVASE 2 MG VIAL No

M9K HEPARIN AND RELATED PREPARATIONSM9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 60 MG/0.6 ML SYR No



Medicaid Max Age


M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 300 MG/3 ML VIAL No

M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 80 MG/0.8 ML SYR No



M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 150 MG/ML SYRINGE No

M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 100 MG/ML SYRINGE No


M9K HEPARIN SODIUM,PORCINE 0 999HEPARIN SOD 5,000 UNIT/ML VIAL No

M9K HEPARIN SODIUM,PORCINE 0 999HEPARIN SOD 5,000 UNIT/ML SYRG No

M9K HEPARIN SODIUM,PORCINE 0 999HEPARIN SOD 20,000 UNIT/ML VL No

M9K HEPARIN SODIUM,PORCINE 0 999HEPARIN SOD 10,000 UNIT/ML VL No

M9K HEPARIN SODIUM,PORCINE 0 999HEPARIN 5,000 UNIT/ML CARPUJCT No

M9K HEPARIN SODIUM,PORCINE 0 999HEPARIN SOD 1,000 UNIT/ML VIAL No

M9K HEPARIN SODIUM,PORCINE/PF 0 999HEPARIN SOD 5,000 UNIT/ 0.5 ML No

M9K HEPARIN SODIUM,PORCINE/PF 0 999HEPARIN SOD 5,000 UNIT/0.5 ML No

M9K HEPARIN SODIUM,PORCINE/PF 0 999HEPARIN 2,000 UNIT/2 ML VIAL No

M9K HEPARIN SODIUM,PORCINE/PF 0 999HEPARIN 500 UNIT/5 ML (100/ML) No

M9K HEPARIN SODIUM,PORCINE/PF 0 999HEPARIN SOD 5,000 UNIT/ML SYRG No

M9L ANTICOAGULANTS,COUMARIN TYPEM9L WARFARIN SODIUM 0 999WARFARIN SODIUM 6 MG TABLET No

M9L WARFARIN SODIUM 0 999JANTOVEN 4 MG TABLET No


M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 1 MG TABLET No




Medicaid Max Age



M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 2.5 MG TABLET No



M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 7.5 MG TABLET No




M9L WARFARIN SODIUM 0 999COUMADIN 4 MG TABLET No

M9L WARFARIN SODIUM 0 999JANTOVEN 7.5 MG TABLET No

M9L WARFARIN SODIUM 0 999JANTOVEN 2.5 MG TABLET No







M9L WARFARIN SODIUM 0 999COUMADIN 7.5 MG TABLET No




M9L WARFARIN SODIUM 0 999COUMADIN 2.5 MG TABLET No

M9P PLATELET AGGREGATION INHIBITORSM9P ASPIRIN 0 999ASPIRIN 81 MG CHEWABLE TABLET No



Medicaid Max Age


M9P ASPIRIN 0 999SM ASPIRIN 81 MG CHEWABLE TAB No

M9P ASPIRIN 0 999CHILD ASPIRIN 81 MG CHEW TAB No

M9P ASPIRIN 0 999HM ASPIRIN EC 81 MG TABLET No

M9P ASPIRIN 0 999SM CHILD ASPIRIN 81 MG CHW TAB No

M9P ASPIRIN 0 999ASPIRIN EC 81 MG TABLET No

M9P ASPIRIN 0 999QC ASPIRIN 81 MG CHEWABLE TAB No

M9P ASPIRIN 0 999GS ASPIRIN 81 MG CHEWABLE TAB No

M9P ASPIRIN 0 999ADULT ASPIRIN REGIMEN EC 81 MG No

M9P ASPIRIN 0 999QC ASPIRIN EC 81 MG TABLET No

M9P ASPIRIN 0 999HM ASPIRIN 81 MG CHEWABLE TAB No

M9P ASPIRIN/DIPYRIDAMOLE 0 999AGGRENOX 25 MG-200 MG CAPSULE No

M9P CILOSTAZOL 0 999CILOSTAZOL 100 MG TABLET No

M9P CILOSTAZOL 0 999CILOSTAZOL 50 MG TABLET No

M9P CLOPIDOGREL BISULFATE 0 999CLOPIDOGREL 75 MG TABLET No

M9P DIPYRIDAMOLE 0 999DIPYRIDAMOLE 75 MG TABLET No



M9P PRASUGREL HCL 0 999PRASUGREL 5 MG TABLET No

M9P PRASUGREL HCL 0 999PRASUGREL 10 MG TABLET No

M9P TICAGRELOR 0 999BRILINTA 60 MG TABLET No

M9P TICAGRELOR 0 999BRILINTA 90 MG TABLET No

M9S HEMORRHEOLOGIC AGENTSM9S PENTOXIFYLLINE 0 999PENTOXIFYLLINE ER 400 MG TAB No

M9T THROMBIN INHIBITORS, SELECTIVE, DIRECT, REVERSIBLE



Medicaid Max Age


M9T DABIGATRAN ETEXILATE MESYLATE 18 999PRADAXA 110 MG CAPSULE No



M9V DIRECT FACTOR XA INHIBITORSM9V APIXABAN 18 999ELIQUIS 2.5 MG TABLET No

M9V APIXABAN 18 999ELIQUIS 5 MG TABLET No

M9V APIXABAN 18 999ELIQUIS DVT-PE TREAT START 5MG No

M9V RIVAROXABAN 18 999XARELTO 10 MG TABLET No

M9V RIVAROXABAN 18 999XARELTO STARTER PACK No



M9V RIVAROXABAN 18 999XARELTO 2.5 MG TABLET No

N1B ERYTHROPOIESIS-STIMULATING AGENTSN1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 25 MCG/0.42 ML SYRING Clinical PA Required

N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 60 MCG/ML VIAL Clinical PA Required

N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 60 MCG/0.3 ML SYRINGE Clinical PA Required

N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 500 MCG/1 ML SYRINGE Clinical PA Required










Medicaid Max Age






N1B EPOETIN ALFA 0 999PROCRIT 20,000 UNITS/ML VIAL Clinical PA Required






N1C LEUKOCYTE (WBC) STIMULANTSN1C FILGRASTIM 0 999NEUPOGEN 480 MCG/0.8 ML SYR Clinical PA Required

N1C FILGRASTIM 0 999NEUPOGEN 300 MCG/ML VIAL Clinical PA Required

N1C FILGRASTIM 0 999NEUPOGEN 480 MCG/1.6 ML VIAL Clinical PA Required

N1C FILGRASTIM 0 999NEUPOGEN 300 MCG/0.5 ML SYR Clinical PA Required

N1C PEGFILGRASTIM 0 999NEULASTA 6 MG/0.6 ML SYRINGE Clinical PA Required

N1C PEGFILGRASTIM 0 999NEULASTA ONPRO 6 MG/0.6 ML KIT Clinical PA Required

N1C SARGRAMOSTIM 0 999LEUKINE 250 MCG VIAL Clinical PA Required

N1C TBO-FILGRASTIM 0 999GRANIX 300 MCG/0.5 ML SYRINGE Clinical PA Required

N1C TBO-FILGRASTIM 0 999GRANIX 480 MCG/0.8 ML SYRINGE Clinical PA Required

N1C TBO-FILGRASTIM 0 999GRANIX 300 MCG/ML VIAL Clinical PA Required

N1C TBO-FILGRASTIM 0 999GRANIX 300 MCG/0.5 ML SAFE SYR Clinical PA Required

N1C TBO-FILGRASTIM 0 999GRANIX 480 MCG/1.6 ML VIAL Clinical PA Required

N1C TBO-FILGRASTIM 0 999GRANIX 480 MCG/0.8 ML SAFE SYR Clinical PA Required



Medicaid Max Age


N1D PLATELET REDUCING AGENTSN1D ANAGRELIDE HCL 0 999ANAGRELIDE HCL 0.5 MG CAPSULE No

N1D ANAGRELIDE HCL 0 999ANAGRELIDE HCL 1 MG CAPSULE No

N1G CXCR4 CHEMOKINE RECEPTOR ANTAGONISTN1G PLERIXAFOR 0 999MOZOBIL 24 MG/1.2 ML VIAL Clinical PA Required

P0G PREGNANCY MAINTAINING AGENT,HORMONALP0G HYDROXYPROGESTERONE CAPROAT/PF 16 999MAKENA 250 MG/ML VIAL Clinical PA Required

P0G HYDROXYPROGESTERONE CAPROAT/PF 16 999MAKENA 275 MG/1.1 ML AUTOINJCT Clinical PA Required

P0G HYDROXYPROGESTERONE CAPROAT/PF 16 999HYDROXYPROGEST 250 MG/ML VIAL Clinical PA Required

P1A GROWTH HORMONESP1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 2 MG Clinical PA Required

P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 1.6 MG Clinical PA Required

P1A SOMATROPIN 18 999SEROSTIM 5 MG VIAL Clinical PA Required


P1A SOMATROPIN 0 16NORDITROPIN FLEXPRO 5 MG/1.5 Clinical PA Required

P1A SOMATROPIN 0 16NORDITROPIN FLEXPRO 30 MG/3 ML Clinical PA Required







P1A SOMATROPIN 0 16GENOTROPIN 5 MG CARTRIDGE Clinical PA Required





Medicaid Max Age



P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 1 MG Clinical PA Required


P1A SOMATROPIN 0 16GENOTROPIN 12 MG CARTRIDGE Clinical PA Required

P1B SOMATOSTATIC AGENTSP1B OCTREOTIDE ACETATE 0 999OCTREOTIDE 5,000 MCG/5 ML VIAL No

P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE ACET 50 MCG/ML AMP No

P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE ACET 500 MCG/ML SYR No


P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE ACET 500 MCG/ML VL No

P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE ACET 50 MCG/ML VIAL No





P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE ACET 0.05 MG/ML VL No

P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE 1,000 MCG/ML VIAL No

P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE 1,000 MCG/5 ML VIAL No


P1E ADRENOCORTICOTROPHIC HORMONESP1E CORTICOTROPIN 0 999ACTHAR GEL 400 UNIT/5 ML VIAL Clinical PA Required

P1F PITUITARY SUPPRESSIVE AGENTSP1F CABERGOLINE 0 999CABERGOLINE 0.5 MG TABLET No

P1F DANAZOL 0 999DANAZOL 50 MG CAPSULE No




Medicaid Max Age



P1M LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTSP1M LEUPROLIDE ACETATE 18 999LUPRON DEPOT 11.25 MG 3MO KIT Auto PA

P1M LEUPROLIDE ACETATE 18 999LUPRON DEPOT 3.75 MG KIT Auto PA

P1M LEUPROLIDE ACETATE 18 999LUPRON DEPO 11.25MG (LUPANETA) Auto PA

P1M LEUPROLIDE ACETATE 18 999LUPRON DEPOT 3.75MG (LUPANETA) Auto PA

P1M NAFARELIN ACETATE 0 999SYNAREL 2 MG/ML NASAL SPRAY Auto PA

P1N LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTSP1N ELAGOLIX SODIUM 0 999ORILISSA 150 MG TABLET Clinical PA Required

P1N ELAGOLIX SODIUM 0 999ORILISSA 200 MG TABLET Clinical PA Required

P1O LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMBP1O LEUPROLIDE/NORETHINDRONE ACET 18 999LUPANETA PK 11.25-5 MG 3MO KIT Auto PA

P1O LEUPROLIDE/NORETHINDRONE ACET 18 999LUPANETA PK 3.75-5 MG 1MO KIT Auto PA

P1P LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTYP1P LEUPROLIDE ACETATE 2 12LUPRON DEPOT-PED 11.25 MG KIT Auto PA

P1P LEUPROLIDE ACETATE 2 12LUPRON DEPOT-PED 15 MG KIT Auto PA

P1P LEUPROLIDE ACETATE 2 12LUPRON DEPOT-PED 30 MG 3MO KIT Auto PA

P1P LEUPROLIDE ACETATE 2 12LUPRON DEPOT-PED 7.5 MG KIT Auto PA

P1P LEUPROLIDE ACETATE 2 12LUPRON DEPOT-PED 11.25 MG 3MO Auto PA

P1P TRIPTORELIN PAMOATE 2 12TRIPTODUR 22.5 MG KIT Auto PA

P1P TRIPTORELIN PAMOATE 2 12TRIPTODUR 22.5 MG VIAL Auto PA

P2B ANTIDIURETIC AND VASOPRESSOR HORMONESP2B DESMOPRESSIN (NONREFRIGERATED) 0 999DESMOPRESSIN 10 MCG/0.1 ML SPR No

P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN ACETATE 0.1 MG TB No

P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN ACETATE 0.2 MG TB No



Medicaid Max Age


P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN AC 4 MCG/ML AMPUL No

P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN 40 MCG/10 ML VIAL No

P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN AC 4 MCG/ML VIAL No

P3A THYROID HORMONESP3A LEVOTHYROXINE SODIUM 0 999UNITHROID 137 MCG TABLET No

P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 112 MCG TABLET No










P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 125 MCG TABLET No











Medicaid Max Age




P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 137 MCG TABLET No


P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 100 MCG/5 ML VL No














P3A LIOTHYRONINE SODIUM 0 999LIOTHYRONINE SOD 5 MCG TAB No



P3A LIOTRIX 0 999THYROLAR-1/4 STRENGTH TAB No

P3A LIOTRIX 0 999THYROLAR-1 STRENGTH TABLET No




Medicaid Max Age


P3A LIOTRIX 0 999THYROLAR-1/2 STRENGTH TAB No


P3A THYROID,PORK 0 999ARMOUR THYROID 240 MG TABLET No

P3A THYROID,PORK 0 999NP THYROID 120 MG TABLET No


P3A THYROID,PORK 0 999THYROID 60 MG TABLET No















P3L ANTITHYROID PREPARATIONSP3L METHIMAZOLE 0 999METHIMAZOLE 10 MG TABLET No

P3L METHIMAZOLE 0 999METHIMAZOLE 5 MG TABLET No

P3L PROPYLTHIOURACIL 0 999PROPYLTHIOURACIL 50 MG TABLET No



Medicaid Max Age


P4D HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPEP4D DOXERCALCIFEROL 0 999DOXERCALCIFEROL 4 MCG/2 ML VL No

P4D DOXERCALCIFEROL 0 999DOXERCALCIFEROL 2.5 MCG CAP No

P4D DOXERCALCIFEROL 0 999DOXERCALCIFEROL 0.5 MCG CAP No

P4D DOXERCALCIFEROL 0 999DOXERCALCIFEROL 1 MCG CAPSULE No

P4D PARICALCITOL 0 999PARICALCITOL 1 MCG CAPSULE No

P4D PARICALCITOL 0 999PARICALCITOL 10 MCG/2 ML VIAL No


P4D PARICALCITOL 0 999PARICALCITOL 2 MCG/ML VIAL No


P4D PARICALCITOL 0 999PARICALCITOL 5 MCG/ML VIAL No

P4L BONE RESORPTION INHIBITORSP4L ALENDRONATE SODIUM 0 999ALENDRONATE SODIUM 40 MG TAB No

P4L ALENDRONATE SODIUM 0 999ALENDRONATE SODIUM 5 MG TABLET No

P4L ALENDRONATE SODIUM 0 999ALENDRONATE SODIUM 35 MG TAB No



P4L CALCITONIN,SALMON,SYNTHETIC 18 999CALCITONIN-SALMON 200 UNITS SP No

P4L PAMIDRONATE DISODIUM 0 999PAMIDRONATE 30 MG/10 ML VIAL No



P4L PAMIDRONATE DISODIUM 0 999PAMIDRONATE DISOD 30 MG VIAL No

P4L PAMIDRONATE DISODIUM 0 999PAMIDRONATE DISOD 90 MG VIAL No

P4L ZOLEDRONIC AC/MANNITOL/0.9NACL 0 999ZOLEDRONIC ACID 4 MG/100 ML No



Medicaid Max Age


P4L ZOLEDRONIC ACID 0 999ZOLEDRONIC ACID 4 MG VIAL No

P4L ZOLEDRONIC ACID 0 999ZOLEDRONIC ACID 4 MG/5 ML VIAL No

P4L ZOLEDRONIC ACID/MANNITOL-WATER 0 999ZOLEDRONIC ACID 5 MG/100 ML No

P5A GLUCOCORTICOIDSP5A BETAMETHASONE ACETATE,SOD PHOS 0 999CELESTONE SOLUSPAN 30 MG/5 ML No

P5A BETAMETHASONE ACETATE,SOD PHOS 0 999BETAMETHASONE SP-AC 30 MG/5 ML No

P5A BUDESONIDE 0 999BUDESONIDE EC 3 MG CAPSULE No

P5A DEXAMETHASONE 0 999DEXAMETHASONE 0.5 MG/5 ML ELX No

P5A DEXAMETHASONE 0 999DEXAMETHASONE 0.5 MG/5 ML LIQ No

P5A DEXAMETHASONE 0 999DEXAMETHASONE 0.75 MG TABLET No

P5A DEXAMETHASONE 0 999DEXAMETHASONE 1 MG TABLET No






P5A DEXAMETHASONE SODIUM PHOSP/PF 0 999DEXAMETHASONE 10 MG/ML SYRING No

P5A DEXAMETHASONE SODIUM PHOSP/PF 0 999DEXAMETHASONE 10 MG/ML VIAL No

P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 20 MG/5 ML VIAL No

P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 4 MG/ML VIAL No

P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 120 MG/30 ML VL No

P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 100 MG/10 ML VL No

P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 10 MG/ML VIAL No

P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 4 MG/ML SYRINGE No



Medicaid Max Age


P5A HYDROCORTISONE 0 999HYDROCORTISONE 10 MG TABLET No



P5A HYDROCORTISONE SOD SUCCINATE 0 999SOLU-CORTEF 100 MG VIAL No

P5A HYDROCORTISONE SODIUM SUCC/PF 0 999SOLU-CORTEF 250 MG ACT-O-VIAL No



P5A HYDROCORTISONE SODIUM SUCC/PF 0 999SOLU-CORTEF 1,000 MG ACT-O-VL No

P5A METHYLPREDNISOLONE 0 999METHYLPREDNISOLONE 4 MG TABLET No

P5A METHYLPREDNISOLONE 0 999METHYLPREDNISOLONE 8 MG TAB No

P5A METHYLPREDNISOLONE 0 999METHYLPREDNISOLONE 4 MG DOSEPK No

P5A METHYLPREDNISOLONE 0 999METHYLPREDNISOLONE 32 MG TAB No

P5A METHYLPREDNISOLONE ACETATE 0 999METHYLPREDNISOLONE 80 MG/ML VL No

P5A METHYLPREDNISOLONE ACETATE 0 999METHYLPREDNISOLONE 40 MG/ML VL No

P5A METHYLPREDNISOLONE SOD SUCC 0 999METHYLPREDNISOLONE SS 40 MG VL No

P5A METHYLPREDNISOLONE SOD SUCC 0 999METHYLPREDNISOLONE SS 500 MG No

P5A METHYLPREDNISOLONE SOD SUCC 0 999METHYLPREDNISOLONE SS 125 MG No

P5A METHYLPREDNISOLONE SOD SUCC 0 999METHYLPREDNISOLONE SS 1 GM VL No

P5A PREDNISOLONE 0 999PREDNISOLONE 15 MG/5 ML SOLN No

P5A PREDNISOLONE SODIUM PHOSPHATE 0 11PREDNISOLONE ODT 15 MG TABLET No


P5A PREDNISOLONE SODIUM PHOSPHATE 0 999PREDNISOLONE 15 MG/5 ML SOLN No

P5A PREDNISOLONE SODIUM PHOSPHATE 0 999PREDNISOLONE 5 MG/5 ML SOLN No

P5A PREDNISOLONE SODIUM PHOSPHATE 0 999PREDNISOLONE SOD PH 25 MG/5 ML No



Medicaid Max Age



P5A PREDNISONE 0 999PREDNISONE 2.5 MG TABLET No

P5A PREDNISONE 0 999PREDNISONE 50 MG TABLET No



P5A PREDNISONE 0 999PREDNISONE 5 MG/5 ML SOLUTION No


P5A PREDNISONE 0 999PREDNISONE 10 MG TAB DOSE PACK No


P5A PREDNISONE 0 999PREDNISONE 5 MG TAB DOSE PACK No

P5S MINERALOCORTICOIDSP5S FLUDROCORTISONE ACETATE 0 999FLUDROCORTISONE 0.1 MG TABLET No

Q2C OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPEQ2C CYCLOSPORINE 0 999RESTASIS 0.05% EYE EMULSION No

Q2C CYCLOSPORINE 0 999RESTASIS MULTIDOSE 0.05% EYE No

Q2L OPHTHALMIC CYSTINE DEPLETING AGENTSQ2L CYSTEAMINE HCL 0 999CYSTARAN 0.44% EYE DROPS No

Q3B RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)Q3B HYDROCORTISONE 0 999HYDROCORTISONE 100 MG/60 ML No

Q3E CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TXQ3E MESALAMINE 0 999MESALAMINE 1,000 MG SUPP No

Q3I HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHETQ3I HYDROCORTISONE/LIDOCAINE/ALOE 0 999LIDOCAINE-HC 2.8-0.55% GEL No

Q3I HYDROCORTISONE/LIDOCAINE/ALOE 0 999LIDOCAINE-HC 3-2.5% GEL KIT No

Q3I HYDROCORTISONE/PRAMOXINE 0 999HYDROCORT-PRAMOXINE 2.5-1% CRM No

Q3I HYDROCORTISONE/PRAMOXINE 0 999PROCTOFOAM-HC 1%-1% FOAM No



Medicaid Max Age


Q3I LIDOCAINE/HYDROCORTISONE AC 0 999LIDOCAINE-HC 3-0.5% CREAM No

Q4F VAGINAL ANTIFUNGALSQ4F BUTOCONAZOLE NITRATE 0 999GYNAZOLE 1 2% CREAM No

Q4F CLOTRIMAZOLE 0 9993-DAY VAGINAL CREAM No

Q4F CLOTRIMAZOLE 0 999SM 3-DAY VAGINAL CREAM No

Q4F CLOTRIMAZOLE 0 999CLOTRIMAZOLE 1% VAGINAL CREAM No

Q4F CLOTRIMAZOLE 0 999SM CLOTRIMAZOLE 1% VAG CREAM No

Q4F CLOTRIMAZOLE 0 999CLOTRIMAZOLE-3 2% CREAM No

Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 3 4% CREAM No

Q4F MICONAZOLE NITRATE 0 999QC MICONAZOLE-7 CREAM No

Q4F MICONAZOLE NITRATE 0 999SM MICONAZOLE 2% VAGINAL CREAM No

Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 2% VAGINAL CREAM No

Q4F MICONAZOLE NITRATE 0 999SM MICONAZOLE 7 CREAM No

Q4F MICONAZOLE NITRATE 0 999SM MICONAZOLE 7 100 MG VAG SUP No

Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 7 CREAM No

Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 3 200 MG VAG SUPP No

Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 1 COMBINATION PACK No

Q4F MICONAZOLE NITRATE 0 999QC 3 DAY VAGINAL 4% CREAM No

Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 7 100 MG VAG SUPP No

Q4F TERCONAZOLE 0 999TERCONAZOLE 0.4% CREAM No

Q4F TERCONAZOLE 0 999TERCONAZOLE 0.8% CREAM No

Q4K VAGINAL ESTROGEN PREPARATIONSQ4K ESTRADIOL 0 999ESTRING 2 MG VAGINAL RING No

Q4K ESTRADIOL 0 999VAGIFEM 10 MCG VAGINAL TAB No



Medicaid Max Age


Q4K ESTROGENS, CONJUGATED 0 999PREMARIN VAGINAL CREAM-APPL No

Q4W VAGINAL ANTIBIOTICSQ4W CLINDAMYCIN PHOSPHATE 0 999CLEOCIN 100 MG VAGINAL OVULE No

Q4W CLINDAMYCIN PHOSPHATE 0 999CLINDESSE 2% VAGINAL CREAM No

Q4W METRONIDAZOLE 0 999METRONIDAZOLE VAGINAL 0.75% GL No

Q5B TOPICAL PREPARATIONS,ANTIBACTERIALSQ5B HYDROCORTISONE/IODOQUINOL 0 999HYDROCORTISONE-IODOQUINOL CRM No

Q5B SILVER NITRATE 0 999SILVER NITRATE 0.5% SOLN No

Q5E TOPICAL ANTI-INFLAMMATORY, NSAIDSQ5E DICLOFENAC SODIUM 0 999DICLOFENAC SODIUM 1% GEL No

Q5F TOPICAL ANTIFUNGALSQ5F CICLOPIROX 0 999CICLOPIROX 8% SOLUTION No

Q5F CICLOPIROX OLAMINE 0 999CICLOPIROX 0.77% CREAM No

Q5F CICLOPIROX OLAMINE 0 999CICLOPIROX 0.77% TOPICAL SUSP No

Q5F CLOTRIMAZOLE 0 999CLOTRIMAZOLE 1% SOLUTION No

Q5F CLOTRIMAZOLE 0 999CLOTRIMAZOLE 1% TOPICAL CREAM No

Q5F ECONAZOLE NITRATE 0 999ECONAZOLE NITRATE 1% CREAM No

Q5F KETOCONAZOLE 0 999KETOCONAZOLE 2% CREAM No

Q5F KETOCONAZOLE 0 999KETOCONAZOLE 2% SHAMPOO No

Q5F MICONAZOLE NITRATE 0 999MICONAZOLE 2% TOPICAL CREAM No

Q5F NYSTATIN 0 999NYSTATIN 100,000 UNIT/GM POWD No

Q5F NYSTATIN 0 999NYSTATIN 100,000 UNIT/GM OINT No

Q5F NYSTATIN 0 999NYSTATIN 100,000 UNIT/GM CREAM No

Q5F NYSTATIN/TRIAMCIN 0 999NYSTATIN-TRIAMCINOLONE CREAM No

Q5F NYSTATIN/TRIAMCIN 0 999NYSTATIN-TRIAMCINOLONE OINTM No



Medicaid Max Age


Q5H TOPICAL LOCAL ANESTHETICSQ5H LIDOCAINE 0 999LIDOCAINE 3% CREAM No

Q5H LIDOCAINE 0 999LIDOCAINE 5% OINTMENT No

Q5H LIDOCAINE 0 999LIDOCAINE 5% PATCH Auto PA

Q5H LIDOCAINE 0 999ZTLIDO 1.8% TOPICAL SYSTEM Auto PA

Q5H LIDOCAINE HCL 0 999LIDOCAINE 3% CREAM No

Q5H LIDOCAINE/PRILOCAINE 0 999LIDOCAINE-PRILOCAINE CREAM No

Q5K TOPICAL IMMUNOSUPPRESSIVE AGENTSQ5K PIMECROLIMUS 0 999ELIDEL 1% CREAM No

Q5K TACROLIMUS 16 999PROTOPIC 0.1% OINTMENT No

Q5K TACROLIMUS 0 999PROTOPIC 0.03% OINTMENT No

Q5M TOPICAL ANTIFUNGAL/ANTI-INFLAMMATORY,STEROID AGENTQ5M CLOTRIMAZOLE/BETAMETHASONE DIP 0 999CLOTRIMAZOLE-BETAMETHASONE CRM No

Q5N TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTSQ5N ALITRETINOIN 0 999PANRETIN 0.1% GEL Clinical PA Required

Q5N DICLOFENAC SODIUM 18 999DICLOFENAC SODIUM 3% GEL Auto PA

Q5N FLUOROURACIL 0 999FLUOROURACIL 2% TOPICAL SOLN No

Q5N FLUOROURACIL 0 999FLUOROURACIL 5% CREAM No

Q5N FLUOROURACIL 0 999FLUOROURACIL 5% TOPICAL SOLN No

Q5P TOPICAL ANTI-INFLAMMATORY STEROIDALQ5P BETAMETHASONE VALERATE 0 999BETAMETHASONE VA 0.1% CREAM No

Q5P BETAMETHASONE/PROPYLENE GLYC 0 999BETAMETHASONE DP AUG 0.05% CRM No

Q5P CLOBETASOL PROPIONATE 0 999CLOBETASOL 0.05% SOLUTION No

Q5P CLOBETASOL PROPIONATE 0 999CLOBETASOL 0.05% CREAM No

Q5P CLOBETASOL PROPIONATE 0 999CLOBETASOL 0.05% GEL No



Medicaid Max Age


Q5P CLOBETASOL PROPIONATE 0 999CLOBETASOL 0.05% OINTMENT No

Q5P CLOBETASOL PROPIONATE/EMOLL 0 999CLOBETASOL EMOLLIENT 0.05% CRM No

Q5P FLUOCINOLONE ACETONIDE 0 999DERMA-SMOOTHE-FS BODY OIL No

Q5P FLUOCINOLONE/SHOWER CAP 0 999DERMA-SMOOTHE-FS SCALP OIL No

Q5P FLUTICASONE PROPIONATE 0 999FLUTICASONE PROP 0.005% OINT No

Q5P FLUTICASONE PROPIONATE 0 999FLUTICASONE PROP 0.05% CREAM No

Q5P HALOBETASOL PROPIONATE 0 999HALOBETASOL PROP 0.05% CREAM No

Q5P HALOBETASOL PROPIONATE 0 999HALOBETASOL PROP 0.05% OINTMNT No

Q5P HYDROCORTISONE 0 999PROCTO-MED HC 2.5% CREAM No

Q5P HYDROCORTISONE 0 999PROCTOSOL-HC 2.5% CREAM No

Q5P HYDROCORTISONE 0 999ANUSOL-HC 2.5% CREAM No

Q5P HYDROCORTISONE 0 999HYDROCORTISONE 2.5% OINTMENT No

Q5P HYDROCORTISONE 0 999HYDROCORTISONE 1% OINTMENT No

Q5P HYDROCORTISONE 0 999HYDROCORTISONE 1% CREAM No

Q5P HYDROCORTISONE 0 999HYDROCORTISONE 2.5% CREAM No

Q5P HYDROCORTISONE 0 999PROCTOZONE-HC 2.5% CREAM No

Q5P MOMETASONE FUROATE 0 999MOMETASONE FUROATE 0.1% CREAM No

Q5P MOMETASONE FUROATE 0 999MOMETASONE FUROATE 0.1% OINT No

Q5P MOMETASONE FUROATE 0 999MOMETASONE FUROATE 0.1% SOLN No

Q5P TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.025% OINT No

Q5P TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.5% OINTMENT No

Q5P TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.5% CREAM No





Medicaid Max Age


Q5P TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.1% OINTMENT No

Q5R TOPICAL ANTIPARASITICSQ5R PERMETHRIN 0 999PERMETHRIN 5% CREAM No

Q5R PIPERONYL BUTOXIDE/PYRETHRINS 0 999VANALICE GEL No

Q5R SPINOSAD 0 999NATROBA 0.9% TOPICAL SUSP No

Q5S TOPICAL SULFONAMIDESQ5S SILVER SULFADIAZINE 0 999SILVER SULFADIAZINE 1% CREAM No

Q5V TOPICAL ANTIVIRALSQ5V ACYCLOVIR 12 999ZOVIRAX 5% CREAM No

Q5V ACYCLOVIR 12 999ZOVIRAX 5% OINTMENT No

Q5V PENCICLOVIR 0 999DENAVIR 1% CREAM No

Q5W TOPICAL ANTIBIOTICSQ5W CLINDAMYCIN PHOSPHATE 12 999CLINDAMYCIN PH 1% SOLUTION No

Q5W CLINDAMYCIN PHOSPHATE 12 999CLINDAMYCIN PHOS 1% PLEDGET No

Q5W GENTAMICIN SULFATE 0 999GENTAMICIN 0.1% CREAM No

Q5W MUPIROCIN 0 999MUPIROCIN 2% OINTMENT No

Q5X TOPICAL ANTIBIOTIC AND ANTI-INFLAMMATORY STEROIDQ5X NEOMYC/BACIT/POLYMYX/HYDROCORT 0 999CORTISPORIN OINTMENT No

Q5X NEOMYCIN/POLYMYXIN B/HYDROCORT 0 999CORTISPORIN CREAM No

Q6C EYE VASOCONSTRICTORSQ6C PHENYLEPHRINE HCL 0 999PHENYLEPHRINE 10% EYE DROPS No

Q6C PHENYLEPHRINE HCL 0 999PHENYLEPHRINE 2.5% EYE DROP No

Q6E EYE IRRIGATIONSQ6E BALANCED SALT IRRIG SOLN NO.2 0 999BALANCED SALT SOLUTION No

Q6G MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERSQ6G BRIMONIDINE TARTRATE 0 999BRIMONIDINE 0.2% EYE DROP No



Medicaid Max Age


Q6G BRIMONIDINE TARTRATE/TIMOLOL 0 999COMBIGAN 0.2%-0.5% EYE DROPS No

Q6G CARTEOLOL HCL 0 999CARTEOLOL HCL 1% EYE DROPS No

Q6G DORZOLAMIDE HCL 0 999DORZOLAMIDE HCL 2% EYE DROPS No

Q6G DORZOLAMIDE HCL/TIMOLOL MALEAT 0 999DORZOLAMIDE-TIMOLOL EYE DROPS No

Q6G LATANOPROST 0 999LATANOPROST 0.005% EYE DROPS No

Q6G LEVOBUNOLOL HCL 0 999LEVOBUNOLOL 0.5% EYE DROPS No

Q6G NETARSUDIL MESYLAT/LATANOPROST 18 999ROCKLATAN 0.02%-0.005% EYE DRP No

Q6G NETARSUDIL MESYLATE 18 999RHOPRESSA 0.02% OPHTH SOLUTION No

Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.25% GEL-SOLUTION No

Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.25% GFS GEL-SOLUTION No

Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.5% EYE DROP No

Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.5% GEL-SOLUTION No

Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.5% GFS GEL-SOLUTION No

Q6G TIMOLOL MALEATE 0 999TIMOLOL MALEATE 0.25% EYE DROP No

Q6G TIMOLOL MALEATE 0 999TIMOLOL MALEATE 0.5% EYE DROPS No

Q6G TRAVOPROST 0 999TRAVATAN Z 0.004% EYE DROP No

Q6I EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONSQ6I NEOMYCIN/BACIT/P-MYX/HYDROCORT 0 999NEO-BACIT-POLY-HC EYE OINTMENT No

Q6I NEOMYCIN/POLYMYXIN B/DEXAMETHA 0 999NEOMYC-POLYM-DEXAMET EYE OINTM No

Q6I NEOMYCIN/POLYMYXIN B/DEXAMETHA 0 999NEOMYC-POLYM-DEXAMETH EYE DROP No

Q6I TOBRAMYCIN/DEXAMETHASONE 0 999TOBRADEX EYE OINTMENT No

Q6I TOBRAMYCIN/DEXAMETHASONE 0 999TOBRADEX EYE DROPS No

Q6I TOBRAMYCIN/LOTEPRED ETAB 0 999ZYLET EYE DROPS No

Q6J MYDRIATICS



Medicaid Max Age


Q6J ATROPINE SULFATE 0 999ATROPINE 1% EYE DROPS No

Q6J ATROPINE SULFATE 0 999ATROPINE 1% EYE OINTMENT No

Q6J CYCLOPENTOLATE HCL 0 999CYCLOPENTOLATE 0.5% EYE DROPS No

Q6J CYCLOPENTOLATE HCL 0 999CYCLOPENTOLATE 1% EYE DROPS No

Q6J CYCLOPENTOLATE HCL 0 999CYCLOPENTOLATE HCL 2% DROPS No

Q6P EYE ANTI-INFLAMMATORY AGENTSQ6P DEXAMETHASONE 0 999MAXIDEX 0.1% EYE DROPS No

Q6P DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 0.1% EYE DROP No

Q6P DICLOFENAC SODIUM 0 999DICLOFENAC 0.1% EYE DROPS No

Q6P DIFLUPREDNATE 0 999DUREZOL 0.05% EYE DROPS No

Q6P FLUOROMETHOLONE 0 999FML FORTE 0.25% EYE DROPS No

Q6P FLUOROMETHOLONE 0 999FML S.O.P. 0.1% OINTMENT No

Q6P FLUOROMETHOLONE ACETATE 0 999FLAREX 0.1% EYE DROPS No

Q6P KETOROLAC TROMETHAMINE 0 999KETOROLAC 0.5% OPHTH SOLUTION No

Q6P LOTEPREDNOL ETABONATE 0 999ALREX 0.2% EYE DROPS No

Q6P LOTEPREDNOL ETABONATE 0 999LOTEMAX 0.5% EYE DROPS No

Q6P NEPAFENAC 0 999ILEVRO 0.3% OPHTH DROPS No

Q6P PREDNISOLONE ACETATE 0 999PREDNISOLONE AC 1% EYE DROP No

Q6R EYE ANTIHISTAMINESQ6R OLOPATADINE HCL 0 999OLOPATADINE HCL 0.1% EYE DROPS No

Q6R OLOPATADINE HCL 0 999PAZEO 0.7% EYE DROPS No

Q6S EYE SULFONAMIDESQ6S SULFACETAMIDE/PREDNISOLONE SP 0 999SULF-PRED 10-0.23% EYE DROPS No

Q6U EYE MAST CELL STABILIZERSQ6U CROMOLYN SODIUM 0 999CROMOLYN 4% EYE DROPS No



Medicaid Max Age


Q6V EYE ANTIVIRALSQ6V TRIFLURIDINE 0 999TRIFLURIDINE 1% EYE DROPS No

Q6W OPHTHALMIC ANTIBIOTICSQ6W BACITRACIN/POLYMYXIN B SULFATE 0 999BACITRACIN-POLYMYXIN EYE OINT No

Q6W BACITRACIN/POLYMYXIN B SULFATE 0 999AK-POLY-BAC EYE OINTMENT No

Q6W BACITRACIN/POLYMYXIN B SULFATE 0 999POLYCIN EYE OINTMENT No

Q6W CIPROFLOXACIN HCL 0 999CIPROFLOXACIN 0.3% EYE DROP No

Q6W ERYTHROMYCIN BASE 0 999ERYTHROMYCIN 0.5% EYE OINTMENT No

Q6W GENTAMICIN SULFATE 0 999GENTAMICIN 0.3% EYE DROP No

Q6W GENTAMICIN SULFATE 0 999GENTAMICIN 3 MG/ML EYE DROP No

Q6W MOXIFLOXACIN HCL 0 999MOXEZA 0.5% EYE DROPS No

Q6W MOXIFLOXACIN HCL 0 999MOXIFLOXACIN 0.5% EYE DROP No

Q6W MOXIFLOXACIN HCL 0 999MOXIFLOXACIN 0.5% EYE DROPS No

Q6W NEOMYCIN SULF/BACITRACIN/POLY 0 999NEOMYC-BACIT-POLYMIX EYE OINT No

Q6W OFLOXACIN 0 999OFLOXACIN 0.3% EYE DROP No

Q6W OFLOXACIN 0 999OFLOXACIN 0.3% EYE DROPS No

Q6W POLYMYXIN B SULF/TRIMETHOPRIM 0 999POLYMYXIN B-TMP EYE DROPS No

Q6W TOBRAMYCIN 0 999TOBRAMYCIN 0.3% EYE DROP No

Q7E NASAL ANTIHISTAMINEQ7E AZELASTINE HCL 0 999AZELASTINE 0.1% (137 MCG) SPRY No

Q7E AZELASTINE HCL 0 999AZELASTINE 0.15% NASAL SPRAY No

Q7P NASAL ANTI-INFLAMMATORY STEROIDSQ7P FLUTICASONE PROPIONATE 0 999FLUTICASONE PROP 50 MCG SPRAY No

Q7W NOSE PREPARATIONS ANTIBIOTICSQ7W MUPIROCIN CALCIUM 0 999BACTROBAN NASAL 2% OINTMENT No

Q8B EAR PREPARATIONS, MISC. ANTI-INFECTIVES



Medicaid Max Age


Q8B ACETIC ACID 0 999ACETIC ACID 2% EAR SOLUTION No

Q8F OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICSQ8F CIPROFLOXACIN HCL/DEXAMETH 0 999CIPRODEX OTIC SUSPENSION No

Q8P EAR PREPARATIONS ANTI-INFLAMMATORYQ8P FLUOCINOLONE ACETONIDE OIL 0 999DERMOTIC OIL 0.01% EAR DROPS No

Q8W EAR PREPARATIONS,ANTIBIOTICSQ8W NEOMYCIN/POLYMYXIN B/HYDROCORT 0 999NEOMYCIN-POLYMYXIN-HC EAR SUSP No

Q8W NEOMYCIN/POLYMYXIN B/HYDROCORT 0 999NEOMYCIN-POLYMYXIN-HC EAR SOLN No

Q8W OFLOXACIN 0 999OFLOXACIN 0.3% EAR DROPS No

Q9B BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTSQ9B ALFUZOSIN HCL 0 999ALFUZOSIN HCL ER 10 MG TABLET No

Q9B DUTASTERIDE 0 999DUTASTERIDE 0.5 MG CAPSULE No

Q9B FINASTERIDE 0 999FINASTERIDE 5 MG TABLET No

Q9B TAMSULOSIN HCL 0 999TAMSULOSIN HCL 0.4 MG CAPSULE No

R1A URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENTR1A FESOTERODINE FUMARATE 18 999TOVIAZ ER 4 MG TABLET No

R1A FESOTERODINE FUMARATE 18 999TOVIAZ ER 8 MG TABLET No

R1A OXYBUTYNIN CHLORIDE 0 999OXYBUTYNIN 5 MG/5 ML SYRUP No

R1A OXYBUTYNIN CHLORIDE 0 999OXYBUTYNIN CL ER 5 MG TABLET No

R1A OXYBUTYNIN CHLORIDE 0 999OXYBUTYNIN 5 MG TABLET No



R1E CARBONIC ANHYDRASE INHIBITORSR1E ACETAZOLAMIDE 0 999ACETAZOLAMIDE 125 MG TABLET No

R1E ACETAZOLAMIDE 0 999ACETAZOLAMIDE 250 MG TABLET No

R1E ACETAZOLAMIDE 0 999ACETAZOLAMIDE ER 500 MG CAP No



Medicaid Max Age


R1E METHAZOLAMIDE 0 999METHAZOLAMIDE 25 MG TABLET No

R1E METHAZOLAMIDE 0 999METHAZOLAMIDE 50 MG TABLET No

R1F THIAZIDE AND RELATED DIURETICSR1F CHLOROTHIAZIDE 0 11DIURIL 250 MG/5 ML ORAL SUSP No

R1F CHLOROTHIAZIDE 0 999CHLOROTHIAZIDE 250 MG TABLET No

R1F CHLOROTHIAZIDE 0 999CHLOROTHIAZIDE 500 MG TABLET No

R1F CHLORTHALIDONE 0 999CHLORTHALIDONE 25 MG TABLET No

R1F CHLORTHALIDONE 0 999CHLORTHALIDONE 50 MG TABLET No

R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 50 MG TAB No

R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 25 MG TAB No

R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 12.5 MG CP No

R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 12.5 MG TB No

R1F INDAPAMIDE 0 999INDAPAMIDE 1.25 MG TABLET No

R1F INDAPAMIDE 0 999INDAPAMIDE 2.5 MG TABLET No

R1F METOLAZONE 0 999METOLAZONE 10 MG TABLET No

R1F METOLAZONE 0 999METOLAZONE 2.5 MG TABLET No

R1F METOLAZONE 0 999METOLAZONE 5 MG TABLET No

R1H POTASSIUM SPARING DIURETICSR1H AMILORIDE HCL 0 999AMILORIDE HCL 5 MG TABLET No

R1H EPLERENONE 0 999EPLERENONE 25 MG TABLET No

R1H EPLERENONE 0 999EPLERENONE 50 MG TABLET No

R1H SPIRONOLACTONE 0 999SPIRONOLACTONE 100 MG TABLET No



R1I URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.



Medicaid Max Age


R1I SOLIFENACIN SUCCINATE 18 999SOLIFENACIN 10 MG TABLET No

R1I SOLIFENACIN SUCCINATE 18 999SOLIFENACIN 5 MG TABLET No

R1L POTASSIUM SPARING DIURETICS IN COMBINATIONR1L AMILORIDE/HYDROCHLOROTHIAZIDE 0 999AMILORIDE HCL-HCTZ 5-50 MG TAB No

R1L SPIRONOLACT/HYDROCHLOROTHIAZID 0 999SPIRONOLACTONE-HCTZ 25-25 TAB No

R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE-HCTZ 37.5-25 MG CP No

R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE-HCTZ 37.5-25 MG TB No

R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE-HCTZ 75-50 MG TAB No

R1M LOOP DIURETICSR1M BUMETANIDE 0 999BUMETANIDE 1 MG/4 ML VIAL No

R1M BUMETANIDE 0 999BUMETANIDE 2 MG TABLET No

R1M BUMETANIDE 0 999BUMETANIDE 0.25 MG/ML VIAL No

R1M BUMETANIDE 0 999BUMETANIDE 0.5 MG TABLET No

R1M BUMETANIDE 0 999BUMETANIDE 1 MG TABLET No

R1M BUMETANIDE 0 999BUMETANIDE 2.5 MG/10 ML VIAL No

R1M FUROSEMIDE 0 999FUROSEMIDE 20 MG TABLET No


R1M FUROSEMIDE 0 999FUROSEMIDE 40 MG/5 ML SOLN No

R1M FUROSEMIDE 0 999FUROSEMIDE 40 MG/4 ML VIAL No

R1M FUROSEMIDE 0 999FUROSEMIDE 40 MG/4 ML SYRINGE No



R1M FUROSEMIDE 0 999FUROSEMIDE 100 MG/10 ML SYRING No

R1M FUROSEMIDE 0 999FUROSEMIDE 10 MG/ML SOLUTION No



Medicaid Max Age



R1M TORSEMIDE 0 999TORSEMIDE 5 MG TABLET No




R1R URICOSURIC AGENTSR1R PROBENECID 0 999PROBENECID 500 MG TABLET No

R1R PROBENECID/COLCHICINE 0 999PROBENECID-COLCHICINE TABLET No

R1S URINARY PH MODIFIERSR1S CITRIC AC/GLUCONOLACT/MAG CARB 0 999RENACIDIN IRRIGATION SOLUTION No

R1S CITRIC ACID/SODIUM CITRATE 0 999SOD CITRATE-CITRIC ACID SOLN No

R1S CITRIC ACID/SODIUM CITRATE 0 999ORACIT ORAL SOLUTION No

R1S POTASSIUM CITRATE 0 999POTASSIUM CITRATE ER 10 MEQ TB No

R1S POTASSIUM CITRATE 0 999POTASSIUM CITRATE ER 15 MEQ TB No

R1S POTASSIUM CITRATE 0 999POTASSIUM CITRATE ER 5 MEQ TAB No

R1S POTASSIUM CITRATE/CITRIC ACID 0 999VIRTRATE-K SOLUTION No

R1S POTASSIUM CITRATE/CITRIC ACID 0 999POTASSIUM CIT-CITRIC ACID SOLN No

R1S POTASSIUM PHOSPHATE,MONOBASIC 0 999K-PHOS ORIGINAL TABLET No

R1S SOD PHOS DI, MONO/K PHOS MONO 0 999VIRT-PHOS 250 NEUTRAL TABLET No

R1S SOD PHOS DI, MONO/K PHOS MONO 0 999K-PHOS NEUTRAL TABLET No

R1S SOD PHOS DI, MONO/K PHOS MONO 0 999PHOSPHA 250 NEUTRAL TABLET No

R1S SOD PHOS,M-B/K PHOS,MONOB 0 999K-PHOS #2 TABLET No

R1S SOD/POT/K CIT/SOD CIT/CIT ACID 0 999POTASS CIT-SOD CIT-CITRIC SOLN No

R1S SOD/POT/K CIT/SOD CIT/CIT ACID 0 999TRICITRATES ORAL SOLUTION No



Medicaid Max Age


R1S SOD/POT/K CIT/SOD CIT/CIT ACID 0 999VIRTRATE-3 SOLUTION No

R1W CYSTINE-DEPLETING AGENTS, NEPHROPATHIC CYSTINOSISR1W CYSTEAMINE BITARTRATE 0 999CYSTAGON 150 MG CAPSULE No

R1W CYSTEAMINE BITARTRATE 0 999CYSTAGON 50 MG CAPSULE No

R4A KIDNEY STONE AGENTSR4A TIOPRONIN 0 999THIOLA 100 MG TABLET No

R5A URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)R5A PHENAZOPYRIDINE HCL 0 999PHENAZOPYRIDINE 100 MG TAB No

R5A PHENAZOPYRIDINE HCL 0 999PHENAZOPYRIDINE 200 MG TAB No

S2A COLCHICINES2A COLCHICINE 18 999COLCHICINE 0.6 MG CAPSULE No

S2A COLCHICINE 4 999COLCHICINE 0.6 MG TABLET No

S2B NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICSS2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD DR 75 MG TAB No

S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD EC 75 MG TAB No


S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD DR 25 MG TAB No

S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD DR 50 MG TAB No


S2B IBUPROFEN 0 999IBUPROFEN 100 MG/5 ML SUSP No

S2B IBUPROFEN 0 999IBUPROFEN 800 MG TABLET No


S2B IBUPROFEN 0 999IBU 800 MG TABLET No





Medicaid Max Age



S2B INDOMETHACIN 0 999INDOMETHACIN 50 MG CAPSULE No

S2B INDOMETHACIN 0 999INDOMETHACIN 25 MG CAPSULE No

S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 30 MG/ML ISECURE SYR No

S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 60 MG/2 ML SYRINGE No

S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 60 MG/2 ML CARPUJECT No

S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 30 MG/ML VIAL No

S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 60 MG/2 ML VIAL No

S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 30 MG/ML SYRINGE No

S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 30 MG/ML CARPUJECT No

S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 15 MG/ML VIAL No

S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 10 MG TABLET No

S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 15 MG/ML SYRINGE No

S2B MELOXICAM 0 999MELOXICAM 15 MG TABLET No

S2B MELOXICAM 0 999MELOXICAM 7.5 MG TABLET No

S2B NABUMETONE 0 999NABUMETONE 750 MG TABLET No

S2B NABUMETONE 0 999NABUMETONE 500 MG TABLET No

S2B NAPROXEN 0 999NAPROXEN 500 MG TABLET No

S2B NAPROXEN 0 999NAPROXEN DR 375 MG TABLET No

S2B NAPROXEN 0 999NAPROXEN DR 500 MG TABLET No

S2B NAPROXEN 0 999EC-NAPROXEN DR 500 MG TABLET No

S2B NAPROXEN 0 999EC-NAPROXEN DR 375 MG TABLET No





Medicaid Max Age


S2I ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITORS2I LEFLUNOMIDE 0 999LEFLUNOMIDE 10 MG TABLET No

S2I LEFLUNOMIDE 0 999LEFLUNOMIDE 20 MG TABLET No

S2J ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITORS2J ADALIMUMAB 0 999HUMIRA(CF) PEN 80 MG/0.8 ML Auto PA

S2J ADALIMUMAB 0 999HUMIRA(CF) 10 MG/0.1 ML SYRING Auto PA



S2J ADALIMUMAB 0 999HUMIRA(CF) PEDI CROHN 80-40 MG Auto PA

S2J ADALIMUMAB 0 999HUMIRA PEN PS-UV-ADOL HS 40 MG Auto PA

S2J ADALIMUMAB 0 999HUMIRA(CF) PEN 40 MG/0.4 ML Auto PA

S2J ADALIMUMAB 0 999HUMIRA 40 MG/0.8 ML SYRINGE Auto PA

S2J ADALIMUMAB 0 999HUMIRA(CF) PEN CRHN-UC-HS 80MG Auto PA

S2J ADALIMUMAB 0 999HUMIRA(CF) PEN PS-UV-AHS 80-40 Auto PA

S2J ADALIMUMAB 0 999HUMIRA(CF) PEDI CROHN 80MG/0.8 Auto PA

S2J ADALIMUMAB 0 999HUMIRA PEN CROHN-UC-HS 40 MG Auto PA

S2J ADALIMUMAB 0 999HUMIRA PEDI CROHN 40 MG/0.8 ML Auto PA



S2J ADALIMUMAB 0 999HUMIRA PEN 40 MG/0.8 ML Auto PA

S2J ETANERCEPT 2 999ENBREL 50 MG/ML SURECLICK Auto PA

S2J ETANERCEPT 2 999ENBREL 50 MG/ML MINI CARTRIDGE Auto PA

S2J ETANERCEPT 2 999ENBREL 50 MG/ML SYRINGE Auto PA

S2J ETANERCEPT 2 999ENBREL 25 MG/0.5 ML SYRINGE Auto PA



Medicaid Max Age


S2J ETANERCEPT 2 999ENBREL 25 MG KIT Auto PA

S2L NSAIDS,CYCLOOXYGENASE-2(COX-2) SELECTIVE INHIBITORS2L CELECOXIB 0 999CELECOXIB 200 MG CAPSULE No

S2L CELECOXIB 0 999CELECOXIB 400 MG CAPSULE No



T0I TOP. ANTI-INFLAM.,PHOSPHODIESTERASE-4 (PDE4) INHIBT0I CRISABOROLE 2 999EUCRISA 2% OINTMENT No

U5B HERBAL DRUGSU5B ALOE VERA 0 999ALOE VERA 5,000 (25) MG SFTGEL Cystic Fib Diag Auto PA

U5B ALOE VERA 0 999SV ALOE VERA 25 MG SOFTGEL Cystic Fib Diag Auto PA

U5B BLUE-GREEN ALGAE 0 999SPIRULINA 500 MG TABLET Cystic Fib Diag Auto PA

U5B CRAN/C/B.COAG/FOS/L.ACID/L.RHA 0 999PROBIOTIC PLUS & CRANBERRY CAP Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999CVS FLAXSEED OIL 1,000 MG CAPS Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999SV FLAXSEED OIL 1,000 MG SFTGL Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999SM FLAXSEED OIL 1,000 MG SFTGL Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999RA FLAXSEED 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999HM FLAXSEED OIL 1,000 MG SFTGL Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999OMEGA-3 FLAXSEED OIL 1,000 MG Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999FLAXSEED OIL 1,000 MG CAPSULE Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999GNP FLAXSEED 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999FLAX SEED OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999SM FLAX OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

U5B FLAXSEED OIL 0 999FLAXSEED OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA

U5B FLAXSEED OIL/OMEGA 3,6,9 0 999SV FLAXSEED OIL 1,300 MG SFTGL Cystic Fib Diag Auto PA



Medicaid Max Age


U5B MILK THISTLE 0 999MILK THISTLE 150 MG CAPSULE Cystic Fib Diag Auto PA

U5B MILK THISTLE 0 999MILK THISTLE 500 MG CAPSULE Cystic Fib Diag Auto PA

U5B MILK THISTLE 0 999MILK THISTLE 175 MG TABLET Cystic Fib Diag Auto PA

U5B MILK THISTLE SEED EXTRACT 0 999MILK THISTLE EXTRACT CAPSULE Cystic Fib Diag Auto PA

U5B MILK THISTLE SEED EXTRACT 0 999MILK THISTLE 175 MG TABLET Cystic Fib Diag Auto PA

U5B MILK THISTLE SEED EXTRACT 0 999MILK THISTLE 175 MG CAPSULE Cystic Fib Diag Auto PA

V1A ANTINEOPLASTIC - ALKYLATING AGENTSV1A BENDAMUSTINE HCL 0 999TREANDA 25 MG VIAL No

V1A BENDAMUSTINE HCL 0 999TREANDA 100 MG VIAL No

V1A BUSULFAN 0 999MYLERAN 2 MG TABLET No

V1A CARBOPLATIN 0 999CARBOPLATIN 150 MG/15 ML VIAL No




V1A CARMUSTINE 0 999BICNU 100 MG VIAL No

V1A CHLORAMBUCIL 0 999LEUKERAN 2 MG TABLET No

V1A CISPLATIN 0 999CISPLATIN 100 MG/100 ML VIAL No



V1A CISPLATIN 0 999CISPLATIN 50 MG VIAL No

V1A CYCLOPHOSPHAMIDE 0 999CYCLOPHOSPHAMIDE 2 GM VIAL No

V1A CYCLOPHOSPHAMIDE 0 999CYCLOPHOSPHAMIDE 25 MG CAPSULE No

V1A CYCLOPHOSPHAMIDE 0 999CYCLOPHOSPHAMIDE 50 MG CAPSULE No

V1A CYCLOPHOSPHAMIDE 0 999CYCLOPHOSPHAMIDE 500 MG VIAL No



Medicaid Max Age


V1A CYCLOPHOSPHAMIDE 0 999CYCLOPHOSPHAMIDE 1 GM VIAL No

V1A HYDROXYUREA 0 999HYDROXYUREA 500 MG CAPSULE No

V1A IFOSFAMIDE 0 999IFOSFAMIDE 1 GM/20 ML VIAL No

V1A IFOSFAMIDE 0 999IFOSFAMIDE 3 GM VIAL No

V1A IFOSFAMIDE 0 999IFOSFAMIDE 1 GM VIAL No

V1A IFOSFAMIDE 0 999IFOSFAMIDE 3 GM/60 ML VIAL No

V1A MELPHALAN 18 999ALKERAN 2 MG TABLET No

V1A MELPHALAN HCL 0 999MELPHALAN 50 MG VIAL W-DILUENT No

V1A MELPHALAN HCL 0 999MELPHALAN HCL 50 MG VIAL No

V1A OXALIPLATIN 0 999OXALIPLATIN 100 MG VIAL No

V1A OXALIPLATIN 0 999OXALIPLATIN 50 MG/10 ML VIAL No

V1A OXALIPLATIN 0 999OXALIPLATIN 100 MG/20 ML VIAL No

V1A OXALIPLATIN 0 999OXALIPLATIN 50 MG VIAL No

V1A TEMOZOLOMIDE 0 999TEMODAR 100 MG VIAL No

V1A TEMOZOLOMIDE 0 999TEMOZOLOMIDE 100 MG CAPSULE No






V1A THIOTEPA 0 999THIOTEPA 15 MG VIAL No

V1B ANTINEOPLASTIC - ANTIMETABOLITESV1B AZACITIDINE 0 999AZACITIDINE 100 MG VIAL No

V1B CAPECITABINE 18 999XELODA 150 MG TABLET No



Medicaid Max Age


V1B CAPECITABINE 18 999XELODA 500 MG TABLET No

V1B CLADRIBINE 0 999CLADRIBINE 10 MG/10 ML VIAL No

V1B CYTARABINE 0 999CYTARABINE 20 MG/ML VIAL No

V1B CYTARABINE/PF 0 999CYTARABINE 100 MG/5 ML VIAL No

V1B CYTARABINE/PF 0 999CYTARABINE 1000 MG/50 ML VIAL No

V1B CYTARABINE/PF 0 999CYTARABINE 2 G/20 ML VIAL No

V1B CYTARABINE/PF 0 999CYTARABINE 20 MG/ML VIAL No

V1B DECITABINE 0 999DECITABINE 50 MG VIAL No

V1B FLOXURIDINE 0 999FLOXURIDINE 500 MG VIAL No

V1B FLUDARABINE PHOSPHATE 0 999FLUDARABINE 50 MG VIAL No

V1B FLUDARABINE PHOSPHATE 0 999FLUDARABINE 50 MG/2 ML VIAL No

V1B FLUOROURACIL 0 999FLUOROURACIL 5,000 MG/100 ML No

V1B FLUOROURACIL 0 999FLUOROURACIL 500 MG/10 ML VIAL No

V1B FLUOROURACIL 0 999FLUOROURACIL 5 GM/100 ML VIAL No

V1B FLUOROURACIL 0 999FLUOROURACIL 5 GM/100 ML BTL No

V1B FLUOROURACIL 0 999FLUOROURACIL 2.5 GM/50 ML BTL No

V1B FLUOROURACIL 0 999FLUOROURACIL 1,000 MG/20 ML VL No

V1B FLUOROURACIL 0 999FLUOROURACIL 2,500 MG/50 ML VL No

V1B FLUOROURACIL 0 999FLUOROURACIL 2.5 GM/50 ML VIAL No

V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 1.5 GRAM/15 ML No

V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 200 MG/2 ML VL No

V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 200 MG VIAL No

V1B GEMCITABINE HCL 0 999GEMCITABINE 1 GRAM/26.3 ML VL No

V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 2 GRAM VIAL No



Medicaid Max Age


V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 1 GRAM/10 ML No

V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 1 GRAM VIAL No

V1B GEMCITABINE HCL 0 999GEMCITABINE 200 MG/5.26 ML VL No

V1B GEMCITABINE HCL 0 999GEMCITABINE 2 GRAM/52.6 ML VL No

V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 2 GRAM/20 ML No

V1B MERCAPTOPURINE 0 999MERCAPTOPURINE 50 MG TABLET No

V1B METHOTREXATE SODIUM 0 999METHOTREXATE 2.5 MG TABLET No

V1B METHOTREXATE SODIUM 0 999METHOTREXATE 250 MG/10 ML VIAL No

V1B METHOTREXATE SODIUM 0 999METHOTREXATE 50 MG/2 ML VIAL No

V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 250 MG/10 ML VIAL No

V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 50 MG/2 ML VIAL No

V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 25 MG/ML VIAL No

V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 1 GRAM/40 ML VIAL No

V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 1 GM VIAL No

V1B PEMETREXED DISODIUM 0 999ALIMTA 500 MG VIAL No

V1B PEMETREXED DISODIUM 0 999ALIMTA 100 MG VIAL No

V1C ANTINEOPLASTIC - VINCA ALKALOIDSV1C VINBLASTINE SULFATE 0 999VINBLASTINE 1 MG/ML VIAL No

V1C VINCRISTINE SULFATE 0 999VINCRISTINE 1 MG/ML VIAL No

V1C VINCRISTINE SULFATE 0 999VINCRISTINE 2 MG/2 ML VIAL No

V1C VINORELBINE TARTRATE 0 999VINORELBINE 10 MG/ML VIAL No

V1C VINORELBINE TARTRATE 0 999VINORELBINE 50 MG/5 ML VIAL No

V1D ANTIBIOTIC ANTINEOPLASTICSV1D BLEOMYCIN SULFATE 0 999BLEOMYCIN SULFATE 30 UNIT VIAL No



Medicaid Max Age


V1D BLEOMYCIN SULFATE 0 999BLEOMYCIN SULFATE 15 UNIT VIAL No

V1D DAUNORUBICIN HCL 0 999DAUNORUBICIN 20 MG VIAL No

V1D DAUNORUBICIN HCL 0 999DAUNORUBICIN 20 MG/4 ML VIAL No

V1D DAUNORUBICIN HCL 0 999DAUNORUBICIN 50 MG/10 ML VIAL No

V1D DOXORUBICIN HCL 0 999DOXORUBICIN 200 MG/100 ML VIAL No





V1D DOXORUBICIN HCL 0 999DOXORUBICIN 10 MG VIAL No

V1D DOXORUBICIN HCL 0 999DOXORUBICIN 50 MG VIAL No

V1D DOXORUBICIN HCL PEG-LIPOSOMAL 0 999DOXORUBICIN LIPOSOME 20MG/10ML No

V1D DOXORUBICIN HCL PEG-LIPOSOMAL 0 999DOXORUBICIN LIPOSOME 50MG/25ML No

V1D EPIRUBICIN HCL 0 999EPIRUBICIN HCL 200 MG VIAL No

V1D EPIRUBICIN HCL 0 999EPIRUBICIN 200 MG/100 ML VIAL No

V1D EPIRUBICIN HCL 0 999EPIRUBICIN 50 MG/25 ML VIAL No

V1D IDARUBICIN HCL 0 999IDARUBICIN HCL 5 MG/5 ML VIAL No

V1D IDARUBICIN HCL 0 999IDARUBICIN HCL 10 MG/10 ML VL No

V1D IDARUBICIN HCL 0 999IDARUBICIN HCL 20 MG/20 ML VL No

V1D MITOMYCIN 0 999MITOMYCIN 20 MG VIAL No



V1D MITOMYCIN 0 999MUTAMYCIN 20 MG VIAL No




Medicaid Max Age



V1D VALRUBICIN 0 999VALSTAR 40 MG/ML VIAL No

V1E STEROID ANTINEOPLASTICSV1E MEGESTROL ACETATE 0 999MEGESTROL 20 MG TABLET No

V1E MEGESTROL ACETATE 0 999MEGESTROL 40 MG TABLET No

V1F ANTINEOPLASTICS,MISCELLANEOUSV1F DACARBAZINE 0 999DACARBAZINE 100 MG VIAL No

V1F DACARBAZINE 0 999DACARBAZINE 200 MG VIAL No

V1F DOCETAXEL 18 999DOCETAXEL 20 MG/ML VIAL No

V1F DOCETAXEL 18 999DOCETAXEL 80 MG/8 ML VIAL No






V1F ETOPOSIDE 0 999ETOPOSIDE 1,000 MG/50 ML VIAL No

V1F ETOPOSIDE 0 999ETOPOSIDE 100 MG/5 ML VIAL No

V1F ETOPOSIDE 0 999ETOPOSIDE 500 MG/25 ML VIAL No

V1F MITOXANTRONE HCL 18 999MITOXANTRONE 20 MG/10 ML VIAL No

V1F MITOXANTRONE HCL 18 999MITOXANTRONE 25 MG/12.5 ML VL No

V1F MITOXANTRONE HCL 18 999MITOXANTRONE 30 MG/15 ML VIAL No

V1F PACLITAXEL 0 999PACLITAXEL 100 MG/16.7 ML VIAL No

V1F PACLITAXEL 0 999PACLITAXEL 150 MG/25 ML VIAL No




Medicaid Max Age



V1F PEGASPARGASE 0 999ONCASPAR 3,750 UNIT/5 ML VIAL No

V1F PROCARBAZINE HCL 0 999MATULANE 50 MG CAPSULE No

V1F TRETINOIN 1 999TRETINOIN 10 MG CAPSULE No

V1I CHEMOTHERAPY RESCUE/ANTIDOTE AGENTSV1I AMIFOSTINE CRYSTALLINE 0 999AMIFOSTINE 500 MG VIAL No

V1I DEXRAZOXANE HCL 18 999DEXRAZOXANE 500 MG VIAL No

V1I DEXRAZOXANE HCL 18 999DEXRAZOXANE 250 MG VIAL No

V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 350 MG VIAL No


V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 5 MG TAB No

V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 500 MG VL No




V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CAL 500 MG/50 ML VL No

V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CAL 100 MG/10 ML VL No



V1I MESNA 0 999MESNA 1 GRAM/10 ML VIAL No

V1I MESNA 0 999MESNA 100 MG/ML VIAL No

V1J ANTINEOPLASTIC - ANTIANDROGENIC AGENTSV1J ABIRATERONE ACETATE 18 999ZYTIGA 500 MG TABLET No

V1J ABIRATERONE ACETATE 18 999ZYTIGA 250 MG TABLET No



Medicaid Max Age


V1J BICALUTAMIDE 18 999BICALUTAMIDE 50 MG TABLET No

V1J ENZALUTAMIDE 18 999XTANDI 40 MG CAPSULE No

V1J FLUTAMIDE 18 999FLUTAMIDE 125 MG CAPSULE No

V1K ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXESV1K ALEMTUZUMAB 0 999CAMPATH 30 MG/ML VIAL No

V1M ANTINEOPLASTIC IMMUNOMODULATOR AGENTSV1M LENALIDOMIDE 18 999REVLIMID 10 MG CAPSULE Requires Med Cert 3

V1M LENALIDOMIDE 18 999REVLIMID 25 MG CAPSULE Requires Med Cert 3




V1M LENALIDOMIDE 18 999REVLIMID 2.5 MG CAPSULE Requires Med Cert 3

V1M POMALIDOMIDE 18 999POMALYST 3 MG CAPSULE Requires Med Cert 3




V1O ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.V1O GOSERELIN ACETATE 18 999ZOLADEX 3.6 MG IMPLANT SYRN Auto PA

V1O GOSERELIN ACETATE 18 999ZOLADEX 10.8 MG IMPLANT SYRN Auto PA

V1O LEUPROLIDE ACETATE 18 999LUPRON DEPOT 45 MG 6MO KIT Auto PA

V1O LEUPROLIDE ACETATE 18 999LUPRON DEPOT 7.5 MG KIT Auto PA

V1O LEUPROLIDE ACETATE 18 999LUPRON DEPOT 22.5 MG 3MO KIT Auto PA

V1O LEUPROLIDE ACETATE 0 999LEUPROLIDE 2WK 14 MG/2.8 ML VL Auto PA

V1O LEUPROLIDE ACETATE 0 999LEUPROLIDE 2WK 14 MG/2.8 ML KT Auto PA

V1O LEUPROLIDE ACETATE 0 999LEUPROLIDE 2WK 1 MG/0.2 ML KIT Auto PA



Medicaid Max Age


V1O LEUPROLIDE ACETATE 18 999LUPRON DEPOT-4 MONTH KIT Auto PA

V1Q ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORSV1Q BORTEZOMIB 0 999BORTEZOMIB 3.5 MG VIAL No

V1Q GEFITINIB 18 999IRESSA 250 MG TABLET Requires Med Cert 3

V1Q IMATINIB MESYLATE 1 999IMATINIB MESYLATE 100 MG TAB No

V1Q IMATINIB MESYLATE 1 999IMATINIB MESYLATE 400 MG TAB No

V1Q PAZOPANIB HCL 18 999VOTRIENT 200 MG TABLET No

V1Q SUNITINIB MALATE 18 999SUTENT 50 MG CAPSULE No

V1Q SUNITINIB MALATE 18 999SUTENT 12.5 MG CAPSULE No

V1Q SUNITINIB MALATE 18 999SUTENT 25 MG CAPSULE No

V1Q SUNITINIB MALATE 18 999SUTENT 37.5 MG CAPSULE No

V1T SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)V1T TAMOXIFEN CITRATE 18 999TAMOXIFEN 10 MG TABLET No

V1T TAMOXIFEN CITRATE 18 999TAMOXIFEN 20 MG TABLET No

V3E ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORSV3E IRINOTECAN HCL 0 999IRINOTECAN HCL 100 MG/5 ML VL No

V3E IRINOTECAN HCL 0 999IRINOTECAN HCL 40 MG/2 ML VIAL No

V3E IRINOTECAN HCL 0 999IRINOTECAN HCL 500 MG/25 ML VL No

V3E TOPOTECAN HCL 0 999TOPOTECAN HCL 4 MG VIAL No

V3E TOPOTECAN HCL 6 999TOPOTECAN HCL 4 MG VIAL No

V3E TOPOTECAN HCL 0 999TOPOTECAN HCL 4 MG/4 ML VIAL No

V3F ANTINEOPLASTIC - AROMATASE INHIBITORSV3F ANASTROZOLE 18 999ANASTROZOLE 1 MG TABLET No

V3F EXEMESTANE 18 999EXEMESTANE 25 MG TABLET No

V3F LETROZOLE 18 999LETROZOLE 2.5 MG TABLET No



Medicaid Max Age


W0B HEP C VIRUS-NS5B POLYMERASE AND NS5A INHIB. COMBO.W0B SOFOSBUVIR/VELPATASVIR 18 999SOFOSBUVIR-VELPATASVIR 400-100 Clinical PA Required

W0E HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMBW0E GLECAPREVIR/PIBRENTASVIR 12 999MAVYRET 100-40 MG TABLET Clinical PA Required

W0G HEP C - NS5A, NS3/4A, NUCLEOTIDE NS5B INHIB COMBOW0G SOFOSBUVIR/VELPATAS/VOXILAPREV 18 999VOSEVI 400-100-100 MG TABLET Clinical PA Required

W0H ANTIRETROVIRAL-NUCLEOSIDE,NUCLEOTIDE,PROTEASE INH.W0H DARUNAVIR/COB/EMTRI/TENOF ALAF 0 999SYMTUZA 800-150-200-10 MG TAB Auto PA

W0I ANTIRETROVIRAL-INTEGRASE INHIBITOR AND NNRTI COMB.W0I DOLUTEGRAVIR/RILPIVIRINE 18 999JULUCA 50-25 MG TABLET Auto PA

W0J ANTIRETROVIRAL - ANTI-CD4 DOMAIN 2 MONOCLONAL ABW0J IBALIZUMAB-UIYK 18 999TROGARZO 200 MG/1.33 ML VIAL Clinical PA Required

W0K ANTIRETROVIRAL-INTEGRASE INHIBITOR AND NRTI COMB.W0K DOLUTEGRAVIR SODIUM/LAMIVUDINE 18 999DOVATO 50-300 MG TABLET Auto PA

W1A PENICILLIN ANTIBIOTICSW1A AMOXICILLIN 0 999AMOXICILLIN 400 MG/5 ML SUSP No

W1A AMOXICILLIN 0 999AMOXICILLIN 200 MG/5 ML SUSP No

W1A AMOXICILLIN 0 999AMOXICILLIN 875 MG TABLET No

W1A AMOXICILLIN 0 999AMOXICILLIN 500 MG TABLET No

W1A AMOXICILLIN 0 999AMOXICILLIN 500 MG CAPSULE No

W1A AMOXICILLIN 0 999AMOXICILLIN 125 MG TAB CHEW No

W1A AMOXICILLIN 0 999AMOXICILLIN 250 MG CAPSULE No

W1A AMOXICILLIN 0 999AMOXICILLIN 250 MG TAB CHEW No



W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX-CLAV 600-42.9 MG/5 ML SUS No



Medicaid Max Age


W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX-CLAV 875-125 MG TABLET No


W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX-CLAV 400-57 MG/5 ML SUSP No




W1A AMPICILLIN SODIUM 0 999AMPICILLIN 1 GM VIAL No

W1A AMPICILLIN SODIUM 0 999AMPICILLIN 10 GM BOTTLE No


W1A AMPICILLIN SODIUM 0 999AMPICILLIN 125 MG VIAL No

W1A AMPICILLIN SODIUM 0 999AMPICILLIN 2 GM ADD-VANTAGE VL No




W1A AMPICILLIN SODIUM 0 999AMPICILLIN 1 GM ADD-VANTAGE VL No

W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULBACTAM 1.5 GM VL No

W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULBACTAM 15 GM VL No

W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULB 1.5 G ADD VIAL No

W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULB 3 GM ADD VIAL No

W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULBACTAM 3 GM VIAL No

W1A AMPICILLIN TRIHYDRATE 0 999AMPICILLIN 500 MG CAPSULE No

W1A DICLOXACILLIN SODIUM 0 999DICLOXACILLIN 250 MG CAPSULE No

W1A DICLOXACILLIN SODIUM 0 999DICLOXACILLIN 500 MG CAPSULE No

W1A PEN G BENZ/PEN G PROCAINE 0 999BICILLIN C-R 1.2 MILLION UNIT No



Medicaid Max Age


W1A PEN G BENZ/PEN G PROCAINE 0 999BICILLIN C-R 900-300 SYRINGE No

W1A PENICILLIN G BENZATHINE 0 999BICILLIN L-A 2,400,000 UNITS No

W1A PENICILLIN G BENZATHINE 0 999BICILLIN L-A 1,200,000 UNITS No

W1A PENICILLIN G BENZATHINE 0 999BICILLIN L-A 600,000 UNIT/ML No

W1A PENICILLIN G PROCAINE 0 999PEN G 1.2 MILLION UNIT/2 ML No

W1A PENICILLIN G PROCAINE 0 999PENICILLIN G 600,000 UNIT/1 ML No

W1A PENICILLIN G SODIUM 0 999PENICILLIN G NA 5 MILLION UNIT No

W1A PENICILLIN V POTASSIUM 0 999PENICILLIN VK 500 MG TABLET No

W1A PENICILLIN V POTASSIUM 0 999PENICILLIN VK 250 MG/5 ML SOLN No

W1A PENICILLIN V POTASSIUM 0 999PENICILLIN VK 125 MG/5 ML SOLN No

W1A PENICILLIN V POTASSIUM 0 999PENICILLIN VK 250 MG TABLET No

W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZOBACT 40.5 GRAM No

W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZO 2.25 GM ADD VL No

W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZO 3.375 GM ADD VL No

W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZO 4.5 GM ADD VIAL No

W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZOBACT 13.5 GM VL No



W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZOBACT 4.5 GM VIAL No

W1C TETRACYCLINE ANTIBIOTICSW1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 75 MG TAB No

W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 50 MG CAP No

W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 100 MG CAP No

W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 100 MG TAB No



Medicaid Max Age


W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 150 MG TAB No

W1C MINOCYCLINE HCL 0 999MINOCYCLINE 100 MG CAPSULE No



W1D MACROLIDE ANTIBIOTICSW1D AZITHROMYCIN 0 999AZITHROMYCIN 600 MG TABLET No

W1D AZITHROMYCIN 0 999AZITHROMYCIN I.V. 500 MG VIAL No

W1D AZITHROMYCIN 0 999AZITHROMYCIN 500 MG TABLET No

W1D AZITHROMYCIN 0 999AZITHROMYCIN 200 MG/5 ML SUSP No

W1D AZITHROMYCIN 0 999AZITHROMYCIN 100 MG/5 ML SUSP No

W1D AZITHROMYCIN 0 999AZITHROMYCIN 1 GM PWD PACKET No

W1D AZITHROMYCIN 0 999AZITHROMYCIN 250 MG TABLET No

W1D CLARITHROMYCIN 0 999CLARITHROMYCIN 500 MG TABLET No

W1D CLARITHROMYCIN 0 11CLARITHROMYCIN 125 MG/5 ML SUS No

W1D CLARITHROMYCIN 0 999CLARITHROMYCIN ER 500 MG TAB No

W1D CLARITHROMYCIN 0 11CLARITHROMYCIN 250 MG/5 ML SUS No

W1D CLARITHROMYCIN 0 999CLARITHROMYCIN 250 MG TABLET No

W1D ERYTHROMYCIN ETHYLSUCCINATE 0 999E.E.S. 200 MG/5 ML SUSPENSION No

W1F AMINOGLYCOSIDE ANTIBIOTICSW1F GENTAMICIN IN NACL, ISO-OSM 0 999ISO GENTAMICIN 100 MG/100 ML No

W1F GENTAMICIN IN NACL, ISO-OSM 0 999ISOTON GENTAMICIN 80 MG/50 ML No






Medicaid Max Age


W1F GENTAMICIN IN NACL, ISO-OSM 0 999ISO GENTAMICIN 120 MG/100 ML No

W1F GENTAMICIN IN NACL, ISO-OSM 0 999GENTAMICIN 70 MG/NS 50 ML PB No

W1F GENTAMICIN SULFATE 0 999GENTAMICIN 800 MG/20 ML VIAL No


W1F GENTAMICIN SULFATE 0 999GENTAMICIN 40 MG/ML VIAL No


W1F NEOMYCIN SULFATE 0 999NEOMYCIN 500 MG TABLET No

W1F TOBRAMYCIN 0 999BETHKIS 300 MG/4 ML AMPULE Auto PA

W1F TOBRAMYCIN SULFATE 0 999TOBRAMYCIN 40 MG/ML VIAL No

W1F TOBRAMYCIN SULFATE 0 999TOBRAMYCIN 80 MG/2 ML VIAL No

W1F TOBRAMYCIN SULFATE 0 999TOBRAMYCIN 10 MG/ML VIAL No

W1F TOBRAMYCIN/NEBULIZER 0 999KITABIS PAK 300 MG/5 ML Auto PA

W1G ANTITUBERCULAR ANTIBIOTICSW1G RIFAMPIN 0 999RIFAMPIN 300 MG CAPSULE No

W1G RIFAMPIN 0 999RIFAMPIN IV 600 MG VIAL No

W1G RIFAMPIN 0 999RIFAMPIN 150 MG CAPSULE No

W1J VANCOMYCIN ANTIBIOTICS AND DERIVATIVESW1J VANCOMYCIN HCL 0 999FIRVANQ 25 MG/ML SOLUTION No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 10 GM VIAL No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 750 MG VIAL No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 5 GM VIAL No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 250 MG VIAL No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 250 MG CAPSULE No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 125 MG CAPSULE No



Medicaid Max Age


W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 1.5 GRAM VIAL No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 1.25 GRAM VIAL No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN 500 MG VIAL No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN 500 MG A-V VIAL No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN 1 GM VIAL No

W1J VANCOMYCIN HCL 0 999FIRVANQ 50 MG/ML SOLUTION No

W1J VANCOMYCIN HCL 0 999VANCOMYCIN 1 GM ADD-VAN VIAL No

W1J VANCOMYCIN HCL IN 5 % DEXTROSE 0 999VANCOMYCIN-D5W 500 MG/100 ML No

W1J VANCOMYCIN/0.9 % SOD CHLORIDE 0 999VANCO 500 MG/100 ML-0.9% NACL No

W1J VANCOMYCIN/0.9 % SOD CHLORIDE 0 999VANCOMYCIN 1 G/200ML-0.9% NACL No

W1J VANCOMYCIN/0.9 % SOD CHLORIDE 0 999VANCO 750 MG/150 ML-0.9% NACL No

W1K LINCOSAMIDE ANTIBIOTICSW1K CLINDAMYCIN HCL 0 999CLINDAMYCIN HCL 150 MG CAPSULE No

W1K CLINDAMYCIN HCL 0 999CLINDAMYCIN HCL 300 MG CAPSULE No

W1K CLINDAMYCIN HCL 0 999CLINDAMYCIN HCL 75 MG CAPSULE No

W1K CLINDAMYCIN PALMITATE HCL 0 11CLINDAMYCIN 75 MG/5 ML SOLN No

W1K CLINDAMYCIN PALMITATE HCL 0 11CLINDAMYCIN PEDIATR 75 MG/5 ML No

W1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN PH 300 MG/2 ML VL No



W1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN 900 MG/6 ML ADDVAN No


W1K CLINDAMYCIN PHOSPHATE 0 999CLEOCIN PHOS 900 MG/6 ML VIAL No




Medicaid Max Age



W1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN PH 9 G/60 ML VIAL No


W1K LINCOMYCIN HCL 0 999LINCOMYCIN HCL 600 MG/2 ML VL No

W1K LINCOMYCIN HCL 0 999LINCOMYCIN HCL 3 GM/10 ML VIAL No

W1N POLYMYXIN ANTIBIOTICS AND DERIVATIVESW1N COLISTIN (COLISTIMETHATE NA) 0 999COLISTIMETHATE 150 MG VIAL No

W1N POLYMYXIN B SULFATE 0 999POLYMYXIN B SULFATE VIAL No

W1O OXAZOLIDINONE ANTIBIOTICSW1O LINEZOLID 0 999LINEZOLID 600 MG TABLET No

W1P BETALACTAMSW1P AZTREONAM 0 999AZACTAM 1 GM VIAL No

W1P AZTREONAM 0 999AZACTAM 2 GM VIAL No

W1Q QUINOLONE ANTIBIOTICSW1Q CIPROFLOXACIN 0 11CIPRO 5% SUSPENSION No

W1Q CIPROFLOXACIN 0 11CIPRO 10% SUSPENSION No

W1Q CIPROFLOXACIN HCL 12 999CIPROFLOXACIN HCL 750 MG TAB No




W1Q CIPROFLOXACIN IN 5 % DEXTROSE 0 999CIPROFLOXACIN 200 MG/100ML-D5W No

W1Q CIPROFLOXACIN IN 5 % DEXTROSE 0 999CIPROFLOXACIN 400 MG/200ML-D5W No

W1Q LEVOFLOXACIN 12 999LEVOFLOXACIN 250 MG TABLET No





Medicaid Max Age


W1Q LEVOFLOXACIN IN DEXTROSE 5 % 0 999LEVOFLOXACIN 250 MG/50 ML-D5W No



W1S CARBAPENEM ANTIBIOTICS (THIENAMYCINS)W1S IMIPENEM/CILASTATIN SODIUM 0 999IMIPENEM-CILASTATIN 250 MG VL No

W1S IMIPENEM/CILASTATIN SODIUM 0 999IMIPENEM-CILASTATIN 500 MG VL No

W1S MEROPENEM 0 999MEROPENEM IV 1 GM VIAL No

W1S MEROPENEM 0 999MEROPENEM IV 500 MG VIAL No

W1S MEROPENEM-0.9% SODIUM CHLORIDE 0 999MEROPENEM-0.9% NACL 500 MG/50 No

W1S MEROPENEM-0.9% SODIUM CHLORIDE 0 999MEROPENEM-0.9% NACL 1 GRAM/50 No

W1W CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATIONW1W CEFADROXIL 0 999CEFADROXIL 500 MG CAPSULE No

W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 1 GM ADD-VAN VIAL No

W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 1 GM VIAL No

W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 10 GM VIAL No

W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 20 GM BULK VIAL No

W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 500 MG VIAL No

W1W CEPHALEXIN 0 999CEPHALEXIN 750 MG CAPSULE No

W1W CEPHALEXIN 0 999CEPHALEXIN 125 MG/5 ML SUSP No


W1W CEPHALEXIN 0 999CEPHALEXIN 250 MG/5 ML SUSP No


W1X CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATIONW1X CEFACLOR 0 999CEFACLOR 250 MG CAPSULE No

W1X CEFACLOR 0 999CEFACLOR 500 MG CAPSULE No



Medicaid Max Age


W1X CEFOTETAN DISOD/ISOSM DEXTROSE 0 999CEFOTETAN-DEXTR 1 G DUPLEX BAG No

W1X CEFOTETAN DISOD/ISOSM DEXTROSE 0 999CEFOTETAN-DEXTR 2 G DUPLEX BAG No

W1X CEFOTETAN DISODIUM 0 999CEFOTETAN 1 GM VIAL No



W1X CEFOXITIN SODIUM 0 999CEFOXITIN 1 GM VIAL No



W1X CEFOXITIN SODIUM/DEXTROSE,ISO 0 999CEFOXITIN 1 GM PIGGYBACK BAG No

W1X CEFOXITIN SODIUM/DEXTROSE,ISO 0 999CEFOXITIN 2 GM PIGGYBACK BAG No

W1X CEFPROZIL 0 999CEFPROZIL 125 MG/5 ML SUSP No

W1X CEFPROZIL 0 999CEFPROZIL 500 MG TABLET No

W1X CEFPROZIL 0 999CEFPROZIL 250 MG TABLET No

W1X CEFPROZIL 0 999CEFPROZIL 250 MG/5 ML SUSP No

W1X CEFUROXIME AXETIL 0 999CEFUROXIME AXETIL 250 MG TAB No

W1X CEFUROXIME AXETIL 0 999CEFUROXIME AXETIL 500 MG TAB No

W1X CEFUROXIME SODIUM 0 999CEFUROXIME SOD 1.5 GM VIAL No

W1X CEFUROXIME SODIUM 0 999CEFUROXIME SOD 7.5 GM VIAL No

W1X CEFUROXIME SODIUM 0 999CEFUROXIME SOD 750 MG VIAL No

W1Y CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATIONW1Y CEFDINIR 0 999CEFDINIR 125 MG/5 ML SUSP No

W1Y CEFDINIR 0 999CEFDINIR 250 MG/5 ML SUSP No

W1Y CEFDINIR 0 999CEFDINIR 300 MG CAPSULE No

W1Y CEFIXIME 0 999CEFIXIME 400 MG CAPSULE No



Medicaid Max Age


W1Y CEFOTAXIME SODIUM 0 999CEFOTAXIME SODIUM 500 MG VIAL No

W1Y CEFOTAXIME SODIUM 0 999CEFOTAXIME SODIUM 2 GM VIAL No

W1Y CEFOTAXIME SODIUM 0 999CEFOTAXIME SODIUM 1 GM VIAL No

W1Y CEFTRIAXONE IN IS-OSM DEXTROSE 0 999CEFTRIAXONE 1 GM PIGGYBACK No

W1Y CEFTRIAXONE IN IS-OSM DEXTROSE 0 999CEFTRIAXONE 1 GM-D5W BAG No

W1Y CEFTRIAXONE IN IS-OSM DEXTROSE 0 999CEFTRIAXONE 2 GM PIGGYBACK No

W1Y CEFTRIAXONE IN IS-OSM DEXTROSE 0 999CEFTRIAXONE 2 GM-D5W BAG No

W1Y CEFTRIAXONE SODIUM 0 999CEFTRIAXONE 1 GM VIAL No


W1Y CEFTRIAXONE SODIUM 0 999CEFTRIAXONE 2 GM ADD VIAL No


W1Y CEFTRIAXONE SODIUM 0 999CEFTRIAXONE 250 MG VIAL No

W1Y CEFTRIAXONE SODIUM 0 999CEFTRIAXONE 500 MG VIAL No

W1Y CEFTRIAXONE SODIUM 0 999CEFTRIAXONE 1 GM ADD-VANT VIAL No

W1Z CEPHALOSPORIN ANTIBIOTICS - 4TH GENERATIONW1Z CEFEPIME HCL 0 999CEFEPIME HCL 2 GRAM VIAL No

W1Z CEFEPIME HCL 0 999CEFEPIME HCL 1 GM VIAL No

W2A ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTSW2A SULFAMETHOXAZOLE/TRIMETHOPRIM 0 999SULFAMETHOXAZOLE-TMP SUSP No

W2A SULFAMETHOXAZOLE/TRIMETHOPRIM 0 999SULFAMETHOXAZOLE-TMP DS TABLET No

W2A SULFAMETHOXAZOLE/TRIMETHOPRIM 0 999SULFAMETHOXAZOLE-TMP SS TABLET No

W2E ANTI-MYCOBACTERIUM AGENTSW2E ETHAMBUTOL HCL 0 999ETHAMBUTOL HCL 100 MG TABLET No

W2E ETHAMBUTOL HCL 0 999ETHAMBUTOL HCL 400 MG TABLET No

W2E ISONIAZID 0 999ISONIAZID 100 MG TABLET No



Medicaid Max Age


W2E ISONIAZID 0 999ISONIAZID 300 MG TABLET No

W2E ISONIAZID 0 999ISONIAZID 50 MG/5 ML SOLUTION No

W2E PYRAZINAMIDE 0 999PYRAZINAMIDE 500 MG TABLET No

W2E RIFABUTIN 0 999RIFABUTIN 150 MG CAPSULE No

W2F NITROFURAN DERIVATIVES ANTIBACTERIAL AGENTSW2F NITROFURANTOIN 0 999NITROFURANTOIN 25 MG/5 ML SUSP No

W2F NITROFURANTOIN MACROCRYSTAL 0 999NITROFURANTOIN MCR 50 MG CAP No



W2F NITROFURANTOIN MONOHYD/M-CRYST 0 999NITROFURANTOIN MONO-MCR 100 MG No

W2G ANTIBIOTIC, ANTIBACTERIAL, MISC.W2G METHENAMINE HIPPURATE 0 999METHENAMINE HIPP 1 GM TABLET No

W2G METHENAMINE MANDELATE 0 999METHENAMINE MD 1 GM TABLET No

W2G METHENAMINE MANDELATE 0 999METHENAMINE MD 500 MG TABLET No

W2G TRIMETHOPRIM 0 999TRIMETHOPRIM 100 MG TABLET No

W3A ANTIFUNGAL ANTIBIOTICSW3A AMPHOTERICIN B 0 999AMPHOTERICIN B 50 MG VIAL No

W3A ANIDULAFUNGIN 0 999ERAXIS(WATER DIL) 50 MG VIAL No

W3A ANIDULAFUNGIN 0 999ERAXIS(WATER DIL) 100 MG VIAL No

W3A GRISEOFULVIN, MICROSIZE 0 999GRISEOFULVIN 125 MG/5 ML SUSP No

W3A GRISEOFULVIN, MICROSIZE 0 999GRISEOFULVIN MICRO 500 MG TAB No

W3A NYSTATIN 0 999NYSTATIN 100,000 UNIT/ML SUSP No

W3A NYSTATIN 0 999NYSTATIN 500,000 UNIT ORAL TAB No

W3A NYSTATIN 0 999NYSTATIN 500,000 UNIT/5 ML SUS No

W3B ANTIFUNGAL AGENTS



Medicaid Max Age


W3B CLOTRIMAZOLE 0 999CLOTRIMAZOLE 10 MG TROCHE No

W3B FLUCONAZOLE 0 999FLUCONAZOLE 200 MG TABLET No

W3B FLUCONAZOLE 0 999FLUCONAZOLE 40 MG/ML SUSP No



W3B FLUCONAZOLE 0 999FLUCONAZOLE 10 MG/ML SUSP No


W3B FLUCONAZOLE IN DEXTROSE,ISO-OS 0 999FLUCONAZOLE-DEXT 400 MG/200 ML No

W3B FLUCONAZOLE IN NACL,ISO-OSM 0 999FLUCONAZOLE-NS 200 MG/100 ML No

W3B FLUCONAZOLE IN NACL,ISO-OSM 0 999FLUCONAZOLE-NACL 200 MG/100 ML No

W3B FLUCONAZOLE IN NACL,ISO-OSM 0 999FLUCONAZOLE-NACL 400 MG/200 ML No

W3B TERBINAFINE HCL 0 999TERBINAFINE HCL 250 MG TABLET No

W4A ANTIMALARIAL DRUGSW4A CHLOROQUINE PHOSPHATE 0 999CHLOROQUINE PH 250 MG TABLET No

W4A CHLOROQUINE PHOSPHATE 0 999CHLOROQUINE PH 500 MG TABLET No

W4A HYDROXYCHLOROQUINE SULFATE 0 999HYDROXYCHLOROQUINE 200 MG TAB No

W4A MEFLOQUINE HCL 0 999MEFLOQUINE HCL 250 MG TABLET No

W4A PRIMAQUINE PHOSPHATE 0 999PRIMAQUINE 26.3 MG TABLET No

W4E ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTSW4E METRONIDAZOLE 0 999METRONIDAZOLE 250 MG TABLET No

W4E METRONIDAZOLE 0 999METRONIDAZOLE 500 MG TABLET No

W4E METRONIDAZOLE/SODIUM CHLORIDE 0 999METRONIDAZOLE 500 MG/100 ML No

W4G 2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIALW4G TINIDAZOLE 0 999TINIDAZOLE 250 MG TABLET No

W4G TINIDAZOLE 0 999TINIDAZOLE 500 MG TABLET No



Medicaid Max Age


W4K ANTIPROTOZOAL DRUGS,MISCELLANEOUSW4K ATOVAQUONE 0 999ATOVAQUONE 750 MG/5 ML SUSP No

W4K PENTAMIDINE ISETHIONATE 0 999NEBUPENT 300 MG INHAL POWDER No

W4L ANTHELMINTICSW4L ALBENDAZOLE 0 999ALBENDAZOLE 200 MG TABLET No

W4L IVERMECTIN 0 999IVERMECTIN 3 MG TABLET No

W4L PRAZIQUANTEL 0 999BILTRICIDE 600 MG TABLET No

W4P ANTILEPROTICSW4P DAPSONE 0 999DAPSONE 25 MG TABLET No

W4P DAPSONE 0 999DAPSONE 100 MG TABLET No

W5A ANTIVIRALS, GENERALW5A ACYCLOVIR 0 999ACYCLOVIR 800 MG TABLET No

W5A ACYCLOVIR 0 999ACYCLOVIR 400 MG TABLET No

W5A ACYCLOVIR 0 999ACYCLOVIR 200 MG CAPSULE No

W5A ACYCLOVIR 0 17ACYCLOVIR 200 MG/5 ML SUSP No

W5A GANCICLOVIR SODIUM 0 999GANCICLOVIR 500 MG VIAL No

W5A GANCICLOVIR SODIUM 0 999GANCICLOVIR 500 MG/10 ML VIAL No

W5A OSELTAMIVIR PHOSPHATE 0 12OSELTAMIVIR 6 MG/ML SUSPENSION No

W5A OSELTAMIVIR PHOSPHATE 0 999OSELTAMIVIR PHOS 30 MG CAPSULE No



W5A RIBAVIRIN 5 999RIBAVIRIN 6 GM INHALATION VIAL Auto PA

W5A VALACYCLOVIR HCL 0 999VALACYCLOVIR HCL 1 GRAM TABLET No

W5A VALACYCLOVIR HCL 0 999VALACYCLOVIR HCL 500 MG TABLET No

W5A VALGANCICLOVIR HCL 0 999VALGANCICLOVIR 450 MG TABLET No



Medicaid Max Age


W5A VALGANCICLOVIR HCL 0 999VALGANCICLOVIR HCL 50 MG/ML No

W5C ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORSW5C ATAZANAVIR SULFATE 0 999REYATAZ 50 MG POWDER PACKET Auto PA

W5C ATAZANAVIR SULFATE 0 999REYATAZ 300 MG CAPSULE Auto PA



W5C ATAZANAVIR SULFATE/COBICISTAT 18 999EVOTAZ 300 MG-150 MG TABLET Auto PA

W5C FOSAMPRENAVIR CALCIUM 0 999LEXIVA 50 MG/ML SUSPENSION Auto PA

W5C FOSAMPRENAVIR CALCIUM 0 999LEXIVA 700 MG TABLET Auto PA

W5C INDINAVIR SULFATE 0 999CRIXIVAN 200 MG CAPSULE Auto PA

W5C INDINAVIR SULFATE 0 999CRIXIVAN 400 MG CAPSULE Auto PA

W5C NELFINAVIR MESYLATE 0 999VIRACEPT 250 MG TABLET Auto PA

W5C NELFINAVIR MESYLATE 0 999VIRACEPT 625 MG TABLET Auto PA

W5C RITONAVIR 0 999NORVIR 100 MG TABLET Auto PA

W5C RITONAVIR 0 999NORVIR 100 MG POWDER PACKET Auto PA

W5C RITONAVIR 0 999NORVIR 80 MG/ML SOLUTION Auto PA

W5C SAQUINAVIR MESYLATE 0 999INVIRASE 500 MG TABLET Auto PA

W5F HEPATITIS B TREATMENT AGENTSW5F ENTECAVIR 0 999ENTECAVIR 0.5 MG TABLET No

W5F ENTECAVIR 0 999ENTECAVIR 1 MG TABLET No

W5F LAMIVUDINE 0 999LAMIVUDINE HBV 100 MG TABLET No

W5F LAMIVUDINE 0 11EPIVIR HBV 25 MG/5 ML SOLN No

W5G HEPATITIS C TREATMENT AGENTSW5G PEGINTERFERON ALFA-2A 3 999PEGASYS PROCLICK 180 MCG/0.5 Auto PA

W5G PEGINTERFERON ALFA-2A 3 999PEGASYS 180 MCG/ML VIAL Auto PA



Medicaid Max Age


W5G PEGINTERFERON ALFA-2A 3 999PEGASYS 180 MCG/0.5 ML SYRINGE Auto PA

W5G PEGINTERFERON ALFA-2B 3 999PEGINTRON 50 MCG KIT Auto PA

W5G RIBAVIRIN 5 999RIBASPHERE RIBAPAK 600-400 MG Auto PA

W5G RIBAVIRIN 5 999RIBAVIRIN 200 MG TABLET Auto PA

W5G RIBAVIRIN 5 999RIBAVIRIN 200 MG CAPSULE Auto PA

W5G RIBAVIRIN 5 999RIBASPHERE RIBAPAK 600-600 MG Auto PA

W5G RIBAVIRIN 5 999RIBASPHERE 200 MG CAPSULE Auto PA

W5G RIBAVIRIN 5 999MODERIBA 600-600 MG DOSEPACK Auto PA

W5G RIBAVIRIN 5 999RIBASPHERE 200 MG TABLET Auto PA



W5I ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTIW5I TENOFOVIR DISOPROXIL FUMARATE 0 999TENOFOVIR DISOP FUM 300 MG TB No

W5I TENOFOVIR DISOPROXIL FUMARATE 0 999VIREAD 150 MG TABLET No



W5I TENOFOVIR DISOPROXIL FUMARATE 0 999VIREAD POWDER No

W5J ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTIW5J ABACAVIR SULFATE 0 999ABACAVIR 300 MG TABLET Auto PA

W5J ABACAVIR SULFATE 0 999ZIAGEN 20 MG/ML SOLUTION Auto PA

W5J DIDANOSINE 0 999DIDANOSINE DR 250 MG CAPSULE Auto PA

W5J DIDANOSINE 0 999DIDANOSINE DR 400 MG CAPSULE Auto PA

W5J DIDANOSINE 0 999VIDEX 2 GM PEDIATRIC SOLN Auto PA

W5J EMTRICITABINE 0 999EMTRIVA 10 MG/ML SOLUTION Auto PA



Medicaid Max Age


W5J EMTRICITABINE 0 999EMTRIVA 200 MG CAPSULE Auto PA

W5J LAMIVUDINE 0 999LAMIVUDINE 10 MG/ML ORAL SOLN Auto PA

W5J LAMIVUDINE 0 999LAMIVUDINE 150 MG TABLET Auto PA

W5J LAMIVUDINE 0 999LAMIVUDINE 300 MG TABLET Auto PA

W5J LAMIVUDINE 0 999EPIVIR 10 MG/ML ORAL SOLN Auto PA

W5J STAVUDINE 0 999STAVUDINE 15 MG CAPSULE Auto PA




W5J ZIDOVUDINE 0 999ZIDOVUDINE 300 MG TABLET Auto PA

W5J ZIDOVUDINE 0 999ZIDOVUDINE 100 MG CAPSULE Auto PA

W5J ZIDOVUDINE 0 999RETROVIR 200 MG/20 ML VIAL Auto PA

W5J ZIDOVUDINE 0 999ZIDOVUDINE 50 MG/5 ML SYRUP Auto PA

W5K ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTIW5K DELAVIRDINE MESYLATE 0 999RESCRIPTOR 200 MG TABLET Auto PA

W5K DORAVIRINE 18 999PIFELTRO 100 MG TABLET Auto PA

W5K EFAVIRENZ 0 999SUSTIVA 200 MG CAPSULE Auto PA

W5K EFAVIRENZ 0 999SUSTIVA 50 MG CAPSULE Auto PA

W5K EFAVIRENZ 0 999SUSTIVA 600 MG TABLET Auto PA

W5K ETRAVIRINE 0 999INTELENCE 25 MG TABLET Auto PA



W5K NEVIRAPINE 0 999VIRAMUNE 50 MG/5 ML SUSP Auto PA

W5K NEVIRAPINE 0 999NEVIRAPINE 50 MG/5 ML SUSP Auto PA



Medicaid Max Age


W5K NEVIRAPINE 0 999NEVIRAPINE ER 100 MG TABLET Auto PA

W5K NEVIRAPINE 0 999NEVIRAPINE ER 400 MG TABLET Auto PA

W5K NEVIRAPINE 0 999NEVIRAPINE 200 MG TABLET Auto PA

W5K RILPIVIRINE HCL 12 999EDURANT 25 MG TABLET Auto PA

W5L ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBW5L ABACAVIR SULFATE/LAMIVUDINE 0 999ABACAVIR-LAMIVUDINE 600-300 MG Auto PA

W5L ABACAVIR/LAMIVUDINE/ZIDOVUDINE 0 999TRIZIVIR TABLET Auto PA

W5L LAMIVUDINE/ZIDOVUDINE 0 999LAMIVUDINE-ZIDOVUDINE TABLET Auto PA

W5M ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMBW5M LOPINAVIR/RITONAVIR 0 999KALETRA 100-25 MG TABLET Auto PA

W5M LOPINAVIR/RITONAVIR 0 999KALETRA 200-50 MG TABLET Auto PA

W5M LOPINAVIR/RITONAVIR 0 999KALETRA 80 MG-20 MG/ML SOLN Auto PA

W5N ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORSW5N ENFUVIRTIDE 6 999FUZEON 90 MG VIAL Clinical PA Required

W5O ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOGW5O EMTRICITABINE/TENOFOV ALAFENAM 0 999DESCOVY 200-25 MG TABLET Auto PA

W5O EMTRICITABINE/TENOFOVIR (TDF) 0 999TRUVADA 100 MG-150 MG TABLET Auto PA




W5O LAMIVUDINE/TENOFOVIR DISOP FUM 0 999CIMDUO 300-300 MG TABLET Auto PA

W5O LAMIVUDINE/TENOFOVIR DISOP FUM 0 999TEMIXYS 300-300 MG TABLET Auto PA

W5P ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIBW5P DARUNAVIR ETHANOLATE 0 999PREZISTA 100 MG/ML SUSPENSION Auto PA

W5P DARUNAVIR ETHANOLATE 0 999PREZISTA 150 MG TABLET Auto PA



Medicaid Max Age





W5P DARUNAVIR/COBICISTAT 18 999PREZCOBIX 800 MG-150 MG TABLET Auto PA

W5P TIPRANAVIR 0 999APTIVUS 250 MG CAPSULE Auto PA

W5P TIPRANAVIR/VITAMIN E TPGS 0 999APTIVUS 100 MG/ML SOLUTION Auto PA

W5Q ARTV NUCLEOSIDE,NUCLEOTIDE,NON-NUCLEOSIDE RTI COMBW5Q DORAVIRINE/LAMIVU/TENOFOV DISO 18 999DELSTRIGO 100-300-300 MG TAB Auto PA

W5Q EFAVIRENZ/EMTRICIT/TENOFOVR DF 12 999ATRIPLA TABLET Auto PA

W5Q EFAVIRENZ/LAMIVU/TENOFOV DISOP 0 999SYMFI 600-300-300 MG TABLET Auto PA

W5Q EFAVIRENZ/LAMIVU/TENOFOV DISOP 0 999SYMFI LO 400-300-300 MG TABLET Auto PA

W5Q EMTRICITA/RILPIVIRINE/TENOF DF 12 999COMPLERA TABLET Auto PA

W5Q EMTRICITAB/RILPIVIRI/TENOF ALA 12 999ODEFSEY TABLET Auto PA

W5T ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG.W5T MARAVIROC 16 999SELZENTRY 150 MG TABLET Clinical PA Required

W5T MARAVIROC 16 999SELZENTRY 20 MG/ML ORAL SOLN Clinical PA Required

W5T MARAVIROC 16 999SELZENTRY 25 MG TABLET Clinical PA Required



W5U ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTRW5U DOLUTEGRAVIR SODIUM 0 999TIVICAY 10 MG TABLET Auto PA

W5U DOLUTEGRAVIR SODIUM 0 999TIVICAY 50 MG TABLET Auto PA

W5U DOLUTEGRAVIR SODIUM 0 999TIVICAY 25 MG TABLET Auto PA

W5U RALTEGRAVIR POTASSIUM 0 999ISENTRESS 400 MG TABLET Auto PA

W5U RALTEGRAVIR POTASSIUM 0 999ISENTRESS 25 MG TABLET CHEW Auto PA



Medicaid Max Age


W5U RALTEGRAVIR POTASSIUM 0 999ISENTRESS 100 MG TABLET CHEW Auto PA

W5U RALTEGRAVIR POTASSIUM 0 999ISENTRESS 100 MG POWDER PACKET Auto PA

W5U RALTEGRAVIR POTASSIUM 0 999ISENTRESS HD 600 MG TABLET Auto PA

W5X ARV-NUCLEOSIDE,NUCLEOTIDE RTI,INTEGRASE INHIBITORSW5X BICTEGRAV/EMTRICIT/TENOFOV ALA 6 999BIKTARVY 50-200-25 MG TABLET Auto PA

W5X ELVITEG/COB/EMTRI/TENOF ALAFEN 12 999GENVOYA TABLET Auto PA

W5X ELVITEG/COB/EMTRI/TENOFO DISOP 12 999STRIBILD TABLET Auto PA

W5Z ANTIRETROVIRAL-NRTIS AND INTEGRASE INHIBITORS COMBW5Z ABACAVIR/DOLUTEGRAVIR/LAMIVUDI 18 999TRIUMEQ 600-50-300 MG TABLET Auto PA

W7K ANTISERAW7K CYTOMEGALOVIRUS IMMUNE GLOBULN 0 999CYTOGAM 2.5 GM/50 ML VIAL Clinical PA Required

W7K HEPATITIS B IMMUNE GLOBULIN 0 999HYPERHEP B S-D SYRINGE Clinical PA Required

W7K HEPATITIS B IMMUNE GLOBULIN 0 999HYPERHEP B S-D VIAL Clinical PA Required

W7K HEPATITIS B IMMUNE GLOBULIN 0 999HYPERHEP B S-D NEONATAL SYRIN. Clinical PA Required

W7K HEPATITIS B IMMUNE GLOBULIN 0 999NABI-HB VIAL Clinical PA Required

W7K IGG/HYALURONIDASE,RECOMBINANT 0 999HYQVIA 5 GM-400 UNIT PACK Clinical PA Required

W7K IGG/HYALURONIDASE,RECOMBINANT 0 999HYQVIA 30 GM-2,400 UNIT PACK Clinical PA Required

W7K IGG/HYALURONIDASE,RECOMBINANT 0 999HYQVIA 20 GM-1,600 UNIT PACK Clinical PA Required

W7K IGG/HYALURONIDASE,RECOMBINANT 0 999HYQVIA 2.5 GM-200 UNIT PACK Clinical PA Required

W7K IGG/HYALURONIDASE,RECOMBINANT 0 999HYQVIA 10 GM-800 UNIT PACK Clinical PA Required

W7K IMM GLOB G (IGG)/SORB/IGA 0-50 0 999FLEBOGAMMA DIF 5% VIAL Clinical PA Required

W7K IMM GLOB G (IGG)/SORB/IGA 0-50 0 999FLEBOGAMMA DIF 10% VIAL Clinical PA Required

W7K IMMUN GLOB G(IGG)/GLY/IGA 0-50 0 999GAMMAPLEX 20 GRAM/200 ML VIAL Clinical PA Required





Medicaid Max Age


W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999HYQVIA IG CMPNT 2.5 GM/25 ML Clinical PA Required

W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999HYQVIA IG CMPNT 20 GM/200 ML Clinical PA Required




W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999CUVITRU 2 GRAM/10 ML VIAL Clinical PA Required

W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999BIVIGAM LIQUID 10% VIAL Clinical PA Required



W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999CUVITRU 8 GRAM/ 40 ML VIAL Clinical PA Required

W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999GAMMAGARD LIQUID 10% VIAL Clinical PA Required


W7K IMMUN GLOB G(IGG)/PRO/IGA 0-50 0 999PRIVIGEN 10% VIAL Clinical PA Required

W7K IMMUN GLOB G(IGG)/PRO/IGA 0-50 0 999HIZENTRA 1 GRAM/5 ML VIAL Clinical PA Required




W7K IMMUN GLOB G/GLY/GLUC/IGA 0-50 0 999GAMMAGARD S-D 5 G (IGA<1) SOLN Clinical PA Required

W7K IMMUN GLOB G/GLY/GLUC/IGA 0-50 0 999GAMMAGARD S-D 10 G (IGA<1) SOL Clinical PA Required

W7K IMMUN GLOB G/SORB/GLY/IGA 0-50 0 999GAMMAPLEX 10 GRAM/200 ML VIAL Clinical PA Required



W7K IMMUN GLOBG(IGG)/MALT/IGA OV50 0 999OCTAGAM 5% VIAL Clinical PA Required

W7K IMMUN GLOBG(IGG)/MALT/IGA OV50 0 999OCTAGAM 10% VIAL Clinical PA Required



Medicaid Max Age


W7K IMMUN GLOBG(IGG)/SUCR/IGA OV50 0 999CARIMUNE NF 6 GM VIAL Clinical PA Required

W7K IMMUN GLOBG(IGG)/SUCR/IGA OV50 0 999CARIMUNE NF 12 GM VIAL Clinical PA Required

W7K IMMUNE GLOBUL G (IGG)/GLYCINE 0 999GAMASTAN S-D VIAL Clinical PA Required

W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMUNEX-C 1 GRAM/10 ML VIAL Clinical PA Required

W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMMAKED 2.5 GRAM/25 ML VIAL Clinical PA Required


W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMUNEX-C 2.5 GRAM/25 ML VIAL Clinical PA Required



W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMMAKED 20 GRAM/200 ML VIAL Clinical PA Required





W8F IRRIGANTSW8F ACETIC ACID 0 999ACETIC ACID 0.25% IRRIG SOLN No

W8F MANNITOL/SORBITOL SOLUTION 0 999SORBITOL-MANNITOL IRRIG No

W8F NEOMYCIN SULF/POLYMYXIN B SULF 0 999NEOMY-POLYMYXIN B 40 MG/ML AMP No

W8F NEOMYCIN SULF/POLYMYXIN B SULF 0 999NEOMY-POLYMYXIN B 40 MG/ML VL No

W8F RINGER'S SOLUTION 0 999RINGERS IRRIGATION SOLUTION No

W8F RINGER'S SOLUTION,LACTATED 0 999LACTATED RINGERS IRRIGATION No

W8F SODIUM CHLORIDE IRRIG SOLUTION 0 999SODIUM CHLORIDE 0.9% IRRIG. No

W8F SODIUM CHLORIDE IRRIG SOLUTION 0 999SODIUM CHLORIDE 0.9% PRCSS SOL No

W8F SORBITOL SOLUTION 0 999SORBITOL 3% UROLOGIC IRRIG No



Medicaid Max Age


W8F SORBITOL SOLUTION 0 999SORBITOL 3.3% UROLOGIC SOLN No

Z1G DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCINGZ1G MIGLUSTAT 18 999ZAVESCA 100 MG CAPSULE Auto PA

Z1H METABOLIC DISEASE ENZYME REPLACEMENT, FABRY'S DXZ1H AGALSIDASE BETA 8 999FABRAZYME 35 MG VIAL Auto PA

Z1H AGALSIDASE BETA 8 999FABRAZYME 5 MG VIAL Auto PA

Z1I METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DXZ1I TALIGLUCERASE ALFA 4 999ELELYSO 200 UNITS VIAL Auto PA

Z1K METABOLIC DX ENZYME REPLACEMT,SEV.COMB.IMMUNE DEF.Z1K PEGADEMASE BOVINE 0 999ADAGEN 250 UNIT/ML VIAL No

Z21 MAST CELL STABILIZERS, ORALLY INHALEDZ21 CROMOLYN SODIUM 0 999CROMOLYN 20 MG/2 ML NEB SOLN No

Z2D HISTAMINE H2-RECEPTOR INHIBITORSZ2D FAMOTIDINE 0 999FAMOTIDINE 40 MG TABLET No

Z2D FAMOTIDINE 0 999FAMOTIDINE 200 MG/20 ML VIAL No

Z2D FAMOTIDINE 0 999FAMOTIDINE 20 MG TABLET No

Z2D FAMOTIDINE 0 999FAMOTIDINE 40 MG/4 ML VIAL No

Z2D FAMOTIDINE IN NACL,ISO-OSM/PF 0 999FAMOTIDINE 20 MG PIGGYBACK No

Z2D FAMOTIDINE/PF 0 999FAMOTIDINE 20 MG/2 ML VIAL No

Z2D RANITIDINE HCL 0 999RANITIDINE 15 MG/ML SYRUP No

Z2D RANITIDINE HCL 0 999RANITIDINE 150 MG TABLET No

Z2D RANITIDINE HCL 0 999RANITIDINE 150 MG/10 ML SYRUP No

Z2D RANITIDINE HCL 0 999RANITIDINE 300 MG TABLET No

Z2E IMMUNOSUPPRESSIVESZ2E ANTI-THYMOCYTE GLOBULIN,RABBIT 0 999THYMOGLOBULIN 25 MG VIAL Clinical PA Required

Z2E AZATHIOPRINE 0 999AZATHIOPRINE 50 MG TABLET No



Medicaid Max Age


Z2E CYCLOSPORINE 0 999CYCLOSPORINE 250 MG/5 ML AMPUL No

Z2E CYCLOSPORINE 0 999SANDIMMUNE 50 MG/ML AMPUL No

Z2E CYCLOSPORINE, MODIFIED 0 999CYCLOSPORINE MODIFIED 50 MG No



Z2E CYCLOSPORINE, MODIFIED 0 11CYCLOSPORINE MODIFIED 100MG/ML No

Z2E LYMPHOCYTE IG,ANTITHYMOCYT,EQU 0 999ATGAM 50 MG/ML AMPUL Clinical PA Required

Z2E MYCOPHENOLATE MOFETIL 0 11CELLCEPT 200 MG/ML ORAL SUSP No

Z2E MYCOPHENOLATE MOFETIL 0 999MYCOPHENOLATE 250 MG CAPSULE No

Z2E MYCOPHENOLATE MOFETIL 0 999MYCOPHENOLATE 500 MG TABLET No

Z2E MYCOPHENOLATE MOFETIL HCL 0 999CELLCEPT 500 MG VIAL No

Z2E MYCOPHENOLATE MOFETIL HCL 0 999MYCOPHENOLATE 500 MG VIAL No

Z2E SIROLIMUS 0 999RAPAMUNE 1 MG/ML ORAL SOLN No

Z2E SIROLIMUS 0 999SIROLIMUS 0.5 MG TABLET No

Z2E SIROLIMUS 0 999SIROLIMUS 1 MG TABLET No

Z2E SIROLIMUS 0 999SIROLIMUS 2 MG TABLET No

Z2E TACROLIMUS 0 999TACROLIMUS 1 MG CAPSULE No

Z2E TACROLIMUS 0 999TACROLIMUS 5 MG CAPSULE No

Z2E TACROLIMUS 0 999TACROLIMUS 0.5 MG CAPSULE No

Z2F MAST CELL STABILIZERSZ2F CROMOLYN SODIUM 0 999CROMOLYN 100 MG/5 ML ORAL CONC No

Z2G IMMUNOMODULATORSZ2G ALDESLEUKIN 0 999PROLEUKIN 22 MILLION UNIT VIAL Clinical PA Required

Z2G IMIQUIMOD 12 999IMIQUIMOD 5% CREAM PACKET No



Medicaid Max Age


Z2G INTERFERON ALFA-2B,RECOMB. 0 999INTRON A 10 MILLION UNITS VIAL No

Z2G INTERFERON ALFA-2B,RECOMB. 0 999INTRON A 18 MILLION UNIT/3 ML No


Z2G INTERFERON ALFA-2B,RECOMB. 0 999INTRON A 25 MILLION UNIT/2.5ML No


Z2G INTERFERON GAMMA-1B,RECOMB. 0 999ACTIMMUNE 100 MCG/0.5 ML VIAL No

Z2H SYSTEMIC ENZYME INHIBITORSZ2H ALPHA-1-PROTEINASE INHIBITOR 18 999GLASSIA 1 GM/50 ML VIAL Auto PA

Z2H ALPHA-1-PROTEINASE INHIBITOR 18 999ZEMAIRA 1,000 MG VIAL Auto PA

Z2H ALPHA-1-PROTEINASE INHIBITOR 18 999PROLASTIN C 1,000 MG VIAL Auto PA

Z2H ALPHA-1-PROTEINASE INHIBITOR 18 999ARALAST NP 500 MG VIAL Auto PA

Z2H ALPHA-1-PROTEINASE INHIBITOR 18 999ARALAST NP 1,000 MG VIAL Auto PA

Z2H ALPHA-1-PROTEINASE INHIBITOR 18 999PROLASTIN C 1,000 MG/20 ML VL Auto PA

Z2N 1ST GEN ANTIHISTAMINE AND DECONGESTANT COMBINATIONZ2N PHENYLEPHRINE HCL/PROMETH HCL 0 20PROMETHAZINE-PHENYLEPHRINE SYR No

Z2O 2ND GEN ANTIHISTAMINE AND DECONGESTANT COMBINATIONZ2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999CETIRIZINE-PSE ER 5-120 MG TAB No

Z2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999ALL DAY ALLERGY-D TABLET No

Z2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999GNP ALL DAY ALLERGY-D TABLET No

Z2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999SM ALL DAY ALLERGY-D TABLET No

Z2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999HM ALLERGY COMPLETE-D TABLET No

Z2O LORATADINE/PSEUDOEPHEDRINE 0 999ALLERGY RELIEF D-24HR TABLET No

Z2O LORATADINE/PSEUDOEPHEDRINE 0 999QC LORATADINE-D 24HR TABLET No

Z2O LORATADINE/PSEUDOEPHEDRINE 0 999SM LORATADINE-D 12 HOUR TABLET No

Z2O LORATADINE/PSEUDOEPHEDRINE 0 999LORATADINE-D 24HR TABLET No



Medicaid Max Age


Z2O LORATADINE/PSEUDOEPHEDRINE 0 999LORATADINE-D 12 HOUR TABLET No

Z2O LORATADINE/PSEUDOEPHEDRINE 0 999ALLERGY-CONGES RELF ER TABLET No

Z2O LORATADINE/PSEUDOEPHEDRINE 0 999HM ALLERGY-CONGESTION 12HR TAB No

Z2O LORATADINE/PSEUDOEPHEDRINE 0 999ALLERGY RELIEF-NASAL DECONG TB No

Z2O LORATADINE/PSEUDOEPHEDRINE 0 999SM LORATA-DINE D 24HR TABLET No

Z2O LORATADINE/PSEUDOEPHEDRINE 0 999HM ALLERGY RLF-NASAL DECONG TB No

Z2P ANTIHISTAMINES - 1ST GENERATIONZ2P CARBINOXAMINE MALEATE 0 999CARBINOXAMINE 4 MG/5 ML LIQUID No

Z2P CARBINOXAMINE MALEATE 0 999CARBINOXAMINE MALEATE 4 MG TAB No

Z2P CLEMASTINE FUMARATE 0 999CLEMASTINE FUM 2.68 MG TAB No

Z2P CYPROHEPTADINE HCL 0 999CYPROHEPTADINE 2 MG/5 ML SOLN No

Z2P CYPROHEPTADINE HCL 0 999CYPROHEPTADINE 2 MG/5 ML SYRUP No

Z2P CYPROHEPTADINE HCL 0 999CYPROHEPTADINE 4 MG TABLET No

Z2P CYPROHEPTADINE HCL 0 999CYPROHEPTADINE 4 MG/10 ML SYRP No

Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 12.5 MG/5 ML No

Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 50 MG/ML VIAL No

Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 50 MG/ML SYRNG No

Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 25 MG/10 ML No

Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 50 MG/ML CRPJT No

Z2P HYDROXYZINE HCL 0 999HYDROXYZINE HCL 50 MG TABLET No

Z2P HYDROXYZINE HCL 0 999HYDROXYZINE 10 MG/5 ML SOLN No

Z2P HYDROXYZINE HCL 0 999HYDROXYZINE 10 MG/5 ML SYRUP No

Z2P HYDROXYZINE HCL 0 999HYDROXYZINE 100 MG/2 ML VIAL No

Z2P HYDROXYZINE HCL 0 999HYDROXYZINE 25 MG/ML VIAL No



Medicaid Max Age


Z2P HYDROXYZINE HCL 0 999HYDROXYZINE 50 MG/ML VIAL No



Z2P HYDROXYZINE PAMOATE 0 999HYDROXYZINE PAM 50 MG CAP No



Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 50 MG/ML AMPUL No

Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 50 MG/ML VIAL No

Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 50 MG TABLET No

Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 25 MG/ML VIAL No

Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 25 MG/ML AMPUL No

Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 25 MG TABLET No

Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 12.5 MG TABLET No

Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 6.25 MG/5 ML SYRP No

Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 6.25 MG/5 ML SOLN No

Z2Q ANTIHISTAMINES - 2ND GENERATIONZ2Q CETIRIZINE HCL 0 11CHILD ALLERGY RELIEF 1 MG/ML No

Z2Q CETIRIZINE HCL 0 999CETIRIZINE HCL 5 MG TABLET No

Z2Q CETIRIZINE HCL 0 11CETIRIZINE HCL 1 MG/ML SOLN No

Z2Q CETIRIZINE HCL 0 11HM CHILD CETIRIZINE 1 MG/ML No

Z2Q CETIRIZINE HCL 0 11CETIRIZINE HCL 1 MG/ML SYRUP No

Z2Q CETIRIZINE HCL 0 999CETIRIZINE HCL 10 MG TABLET No

Z2Q CETIRIZINE HCL 0 11CHILD ALL DAY ALLERGY 1 MG/ML No

Z2Q CETIRIZINE HCL 0 11GS CHILD ALL DAY ALLER 1 MG/ML No



Medicaid Max Age


Z2Q CETIRIZINE HCL 0 11HM CHILD ALL DAY ALLER 1 MG/ML No

Z2Q CETIRIZINE HCL 0 11SM CHILD ALL DAY ALLER 1 MG/ML No

Z2Q CETIRIZINE HCL 0 11QC CHILDREN'S ALLERGY 1 MG/ML No

Z2Q CETIRIZINE HCL 0 11CHILD CETIRIZINE HCL 1 MG/ML No

Z2Q CETIRIZINE HCL 0 999SM CHILD ALL DAY ALLER 1 MG/ML No

Z2Q CETIRIZINE HCL 0 999ALL DAY ALLERGY 10 MG TABLET No

Z2Q CETIRIZINE HCL 0 999GS ALL DAY ALLERGY 10 MG TAB No

Z2Q CETIRIZINE HCL 0 999ALLERGY RLF (CETRZN) 10 MG TAB No

Z2Q CETIRIZINE HCL 0 999HM ALL DAY ALLERGY 10 MG TAB No

Z2Q CETIRIZINE HCL 0 999QC ALL DAY ALLERGY 10 MG TAB No

Z2Q CETIRIZINE HCL 0 999SM ALL DAY ALLERGY 10 MG TAB No

Z2Q FEXOFENADINE HCL 0 999SM FEXOFENADINE HCL 60 MG TAB Cystic Fib Diag Auto PA

Z2Q FEXOFENADINE HCL 0 999HM FEXOFENADINE HCL 180 MG TAB Cystic Fib Diag Auto PA

Z2Q FEXOFENADINE HCL 0 999FEXOFENADINE HCL 60 MG TABLET Cystic Fib Diag Auto PA

Z2Q FEXOFENADINE HCL 0 999FEXOFENADINE HCL 30 MG/5 ML Cystic Fib Diag Auto PA

Z2Q FEXOFENADINE HCL 0 999HM FEXOFENADINE HCL 60 MG TAB Cystic Fib Diag Auto PA

Z2Q FEXOFENADINE HCL 0 999FEXOFENADINE HCL 180 MG TABLET Cystic Fib Diag Auto PA

Z2Q FEXOFENADINE HCL 0 999QC FEXOFENADINE HCL 180 MG TAB Cystic Fib Diag Auto PA

Z2Q FEXOFENADINE HCL 0 999SM FEXOFENADINE HCL 180 MG TAB Cystic Fib Diag Auto PA

Z2Q LEVOCETIRIZINE DIHYDROCHLORIDE 0 999LEVOCETIRIZINE 5 MG TABLET No

Z2Q LEVOCETIRIZINE DIHYDROCHLORIDE 0 999LEVOCETIRIZINE 2.5 MG/5 ML SOL Cystic Fib Diag Auto PA

Z2Q LORATADINE 0 11LORATADINE ALLERGY 5 MG/5 ML No

Z2Q LORATADINE 0 11LORATADINE 5 MG/5 ML SYRUP No

Z2Q LORATADINE 0 999QC LORATADINE 10 MG TABLET No



Medicaid Max Age


Z2Q LORATADINE 0 999LORATADINE 10 MG TABLET No

Z2Q LORATADINE 0 999HM LORATADINE 10 MG TABLET No

Z2Q LORATADINE 0 999SM LORATADINE 10 MG TABLET No

Z2Q LORATADINE 0 11SM LORATADINE 5 MG/5 ML SYRUP No

Z2Q LORATADINE 0 999NON-DROWSY ALLERGY 10 MG TAB No

Z2Q LORATADINE 0 999ALLERGY (LORATADINE) 10 MG TAB No

Z2Q LORATADINE 0 999SM ALLERGY RELIEF 10 MG ODT No

Z2Q LORATADINE 0 999ALLERGY (LORATADINE) 10 MG TAB No

Z2Q LORATADINE 0 11SM CHILD LORATADINE 5 MG/5 ML No

Z2Q LORATADINE 0 999ALLERGY RELIEF 10 MG ODT No

Z2Q LORATADINE 0 999ALLERGY RELIEF 10 MG TABLET No

Z2Q LORATADINE 0 11ALLERGY RELIEF 5 MG/5 ML SOLN No

Z2Q LORATADINE 0 11CHILD ALLERGY 5 MG/5 ML SOLN No

Z2Q LORATADINE 0 11SM CHILD ALLERGY 5 MG/5 ML SOL No

Z2Q LORATADINE 0 11CHILD LORATADINE 5 MG/5 ML SOL No

Z2Q LORATADINE 0 11CHILD LORATADINE 5 MG/5 ML SYR No

Z2Q LORATADINE 0 11HM CHILD LORATADINE 5 MG/5 ML No

Z2Q LORATADINE 0 999GS ALLERGY RELIEF 10 MG TABLET No

Z2W ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODYZ2W OFATUMUMAB 0 999ARZERRA 100 MG/5 ML VIAL No

Z2W OFATUMUMAB 0 999ARZERRA 1,000 MG/50 ML VIAL No

Z2W RITUXIMAB 0 999RITUXAN 100 MG/10 ML VIAL No

Z2W RITUXIMAB 0 999RITUXAN 500 MG/50 ML VIAL No

Z2Z JANUS KINASE (JAK) INHIBITORS



Medicaid Max Age


Z2Z TOFACITINIB CITRATE 18 999XELJANZ 10 MG TABLET Auto PA

Z2Z TOFACITINIB CITRATE 18 999XELJANZ 5 MG TABLET Auto PA

Z4B LEUKOTRIENE RECEPTOR ANTAGONISTSZ4B MONTELUKAST SODIUM 0 999MONTELUKAST SOD 10 MG TABLET No

Z4B MONTELUKAST SODIUM 0 999MONTELUKAST SOD 4 MG TAB CHEW No

Z4B MONTELUKAST SODIUM 0 999MONTELUKAST SOD 5 MG TAB CHEW No

Z9D DIAGNOSTIC PREPARATIONS,MISCELLANEOUSZ9D GLUCAGON HCL 0 999GLUCAGON 1 MG VIAL No


“Auto PA” = System automated criteria looks for …Florida Medicaid Preferred Drug List (updated...

Documents

Transcript of “Auto PA” = System automated criteria looks for …Florida Medicaid Preferred Drug List (updated...