Supplemental Preferred Drug List (List of Covered Drugs)

Transcription

1 2015 Supplemental referred Drug List (List of Covered Drugs) WellCare of New Jersey 00 9 lease read: This document contains information about the drugs we cover in this plan. Last updated (7/01/2015) NJ08800_CAD_CVR_ENG WellCare 2015 NJ_01_

2 WellCare of New Jersey Supplemental Cough & Cold Drug List Non-referred Drugs referred Drugs ANTITUSSIVES,NON-NARCOTIC Benzonatate TESSALON 200 MG CASULE BENZONATATE 100 MG CASULE BENZONATATE 200 MG CASULE Dextromethorphan olistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSENSION Dextromethorphan HBr ROBITUSSIN EDIATRIC COUGH SY Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF LUS LOZENGE NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/seudoephedrine HCl ALLANHIST DX DROS BROMFED DM SYRU C-HEN DM D-COF SYRU BROMHIST DX DROS BROTA DM LIQUID ENDACOF-D DROS Brophenaramine/Dextromethorphan HBr/henylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM Chlorpheniramine/Dextromethorphan HBr/henylephrine HCl RONDEX-DM SYRU DE-CHLOR DM LIQUID SILDEC E-DM SYRU CORFEN DM Chlorpheniramine/Dextromethorphan HBr/seudoephedrine HCl EDIATRIC COUGH-COLD LIQUID KIDKARE COUGH/COLD Dexchlorpheniramine/seudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETA LONG-ACTING COUGH LIQ Q-TA DM ELIXIR DIMAHEN DM ELIXIR NOHIST-DM TRI-DEX E MESEHIST DM ROBITUSSIN LONG ACTING LIQUID romethazine HCl/Dextromethorphan HBr ROMETHAZINE-DM SYRU NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATION Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMTOM EXECTORANTS DECONGESTANT-EXECTORANT COMBINATIONS Guaifenesin/henylephrine HCl DONATUSSIN DROS E-GUAI DROS DESEC LIQUID RESCON-GG LIQUID Last updated 07/31/14 age 1 of 2

3 DURATUSS DM ELIXIR SIMUC-DM ELIXIR WellCare of New Jersey Supplemental Cough & Cold Drug List Non-referred Drugs NON-NARCOTIC DECONGESTANT-EXECTORANT-ANTITUSSIVE Guaifenesin/Dextromethorphan HBr/henylephreine ROBAFEN CF SYRU NON-NARCOTIC ANTITUSSIVE AND EXECTORANT COMB. Dextromethorphan HBr/Guaifenesin SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID GUAIFENESIN DM SYRU EXTRA ACTION COUGH REFENESEN DM referred Drugs DIABETIC TUSSIN DM LIQUID Q-TUSSIN-DM SYRU SILTUSSIN DM COUGH SYRU SILTUSSIN DM DAS COUGH SYRU MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Chlorpheniramine/Hydrocodone olistirex TUSSIONEX ENNKINETIC SUS TUSSICAS (min. age 6 years old) HYDROCODONE-CHLORHENIRAMINE SUSENSION (min. age 6 years old) Codeine hosphate/romethazine HCl ROMETHAZINE-CODEINE SYRU (min. age 6 years old) NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT Dexbrompheniramine/Hydrocodone Bit/henylephrine HCl Codeine/henylephrine HCl/romethazine CYTUSS-HC NR SYRU HC 2.5-E 5-DBROM 1 MG SYRU HYDROMET SYRU HYDROCODONE-GUAIFENESIN SYRU NARCOF SYRU HC/E/DBROM SYRU ROMETH VC W/COD SYRU seudoephedrine HCl/Codeine/Chlorpheniramine HENYLHISTINE DH NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROINE ROMETHAZINE VC/COD SYRU NARCOTIC ANTITUSSIVE-EXECTORANT COMBINATION Guaifenesin/Hydrocodone Bit Codeine hosphate/guaifenesin TUSSICLEAR DH SYRU CHERATUSSIN AC SYRU GUAIFENESIN-CODEINE SYRU NARCOTIC ANTITUSSIVE-DECONGESTANT-EXECTORANT COMBINATIONS Codeine hosphate/guaifenesin/seudoephedrine HCl CHERATUSSIN DAC SYRU IOHEN C-NR Last updated 07/31/14 age 2 of 2

4 This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *Alternative Medicines* *Alternative Medicine - M's**-*Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 mg *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 40 mg/ml ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 200 mg *Analgesics - Nonnarcotic* *Analgesics Other**-*Analgesics Other*** ACEHEN SUOSITORY 325 MG, 650 MG acetaminophen oral solution 160 mg/5ml acetaminophen oral tablet 325 mg ; QL (279 EA per 31 days) acetaminophen oral tablet 500 mg ; QL (186 EA per 31 days) apap extra strength oral tablet 500 mg ; QL (186 EA per 31 days) apap oral tablet 325 mg ; QL (279 EA per 31 days) childrens non-asa pain relief oral tablet chewable 80 mg childrens non-aspirin oral tablet chewable 80 mg childrens pain reliever oral tablet chewable 80 mg childrens silapap oral liquid 160 mg/5ml childrens tactinal oral tablet chewable 80 mg ed-apap oral liquid 160 mg/5ml infants silapap oral solution 100 mg/ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 1

5 Drug Name reference Details Coverage Details mapap arthritis pain oral tablet extendedrelease* 650 mg MAA CHILDRENS ORAL SUSENSION 160 MG/5ML ; QL (93 EA per 31 days) mapap oral capsule 500 mg ; QL (186 EA per 31 days) mapap oral liquid 160 mg/5ml mapap oral tablet 325 mg ; QL (279 EA per 31 days) mapap oral tablet 500 mg ; QL (186 EA per 31 days) mapap oral tablet chewable 80 mg maxapap maximum strength oral tablet 500 mg ; QL (186 EA per 31 days) maxapap regular strength oral tablet 325 mg ; QL (279 EA per 31 days) non-aspirin extra strength oral tablet 500 mg ; QL (186 EA per 31 days) non-aspirin oral tablet 325 mg ; QL (279 EA per 31 days) non-aspirin pain relief oral tablet 325 mg ; QL (279 EA per 31 days) nortemp infants oral suspension 80 mg/0.8ml pain & fever childrens oral solution 160 mg/5ml pain relief extra strength oral tablet 500 mg ; QL (186 EA per 31 days) pain relief oral tablet 500 mg ; QL (186 EA per 31 days) HARBETOL EXTRA STRENGTH ORAL TABLET 500 MG ; QL (186 EA per 31 days) HARBETOL ORAL TABLET 325 MG ; QL (279 EA per 31 days) q-pap oral tablet 325 mg ; QL (279 EA per 31 days) tactinal extra strength oral tablet 500 mg ; QL (186 EA per 31 days) tactinal oral tablet 325 mg ; QL (279 EA per 31 days) *Salicylates**-*Salicylate Combinations*** tri-buffered aspirin oral tablet 325 mg *Salicylates**-*Salicylates*** aspirin childrens oral tablet chewable 81 mg aspirin ec low dose oral tablet delayed release 81 mg aspirin ec oral tablet delayed release 325 mg, 81 mg aspirin low dose oral tablet 81 mg aspirin oral tablet 325 mg, 81 mg aspirin oral tablet chewable 81 mg aspirin oral tablet delayed release 81 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 2

6 Drug Name reference Details Coverage Details aspirin suppository 300 mg, 600 mg ECIRIN ORAL TABLET DELAYED RELEASE 325 MG *Anorectal Agents* *Rectal Combinations**-*Rectal Combinations - Misc.*** hem-prep suppository % *Antacids* *Antacid Combinations**-*Antacid & Simethicone*** alamag plus oral tablet chewable mg ALMACONE ORAL SUSENSION MG/5ML antacid anti-gas max strength oral suspension mg/5ml antacid anti-gas oral suspension mg/5ml antacid extra strength oral suspension mg/5ml antacid i oral suspension mg/5ml antacid iii oral suspension mg/5ml antacid oral suspension mg/5ml geri-lanta oral suspension mg/5ml MAALOX ADVANCED MAX ST ORAL SUSENSION MG/5ML MAALOX ADVANCED ORAL SUSENSION MG/5ML MAALOX MAX ORAL SUSENSION MG/5ML MAALOX MULTI SYMTOM MAX ST ORAL SUSENSION MG/5ML MAALOX REGULAR STRENGTH ORAL SUSENSION MG/5ML milantex extra strength oral suspension mg/5ml milantex oral suspension mg/5ml MINTOX LUS ORAL TABLET CHEWABLE MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 3

7 Drug Name reference Details Coverage Details *Antacid Combinations**-*Antacid Combinations*** ACID GONE ORAL TABLET CHEWABLE MG gnp foaming antacid oral tablet chewable mg MI-ACID ORAL TABLET CHEWABLE MG *Antacids - Aluminum Salts**-*Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 mg/5ml *Antacids - Bicarbonate**-*Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325 mg, 650 mg *Antacids - Calcium Salts**-*Antacids - Calcium Salts*** alcalak oral tablet chewable 420 mg antacid oral tablet chewable 420 mg, 500 mg calcium antacid extra strength oral tablet chewable 750 mg calcium antacid oral tablet chewable 500 mg calcium carbonate antacid oral tablet 648 mg calcium carbonate antacid oral tablet chewable 500 mg CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG MAALOX ORAL TABLET CHEWABLE 600 MG TITRALAC ORAL TABLET CHEWABLE 420 MG *Antacids - Magnesium Salts**-*Antacids - Magnesium Salts*** magnesium oxide oral tablet 250 mg, 400 mg, 420 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 4

8 Drug Name reference Details Coverage Details *Anthelmintics* *Anthelmintics**-*Anthelmintics*** reeses pinworm medicine oral suspension 144 mg/ml *Antidiabetics* *Diabetic Other**-*Diabetic Other*** BD GLUCOSE ORAL TABLET CHEWABLE 5 GM glucose oral tablet chewable 4 gm *Antidiarrheals* *Antidiarrheal Agents - Misc.**-*Antidiarrheal Agents - Misc.*** bismatrol oral suspension 262 mg/15ml bismatrol oral tablet chewable 262 mg bismuth oral tablet chewable 262 mg diotame oral tablet chewable 262 mg KAOECTATE EXTRA STRENGTH ORAL SUSENSION 525 MG/15ML KAOECTATE ORAL SUSENSION 262 MG/15ML kao-tin oral suspension 262 mg/15ml pink bismuth oral suspension 262 mg/15ml pink bismuth oral tablet chewable 262 mg stomach relief oral suspension 262 mg/15ml, 527 mg/30ml stomach relief oral tablet chewable 262 mg stomach relief plus oral suspension 525 mg/15ml *Antiperistaltic Agents**-*Antiperistaltic Agents*** anti-diarrheal oral liquid 1 mg/5ml LOERAMIDE A-D ORAL TABLET 2 MG loperamide hcl oral liquid 1 mg/5ml *Antidotes* *Antidotes**-*Antidotes*** ipecac oral syrup =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 5

9 Drug Name reference Details Coverage Details *Antiemetics* *Antiemetics - Anticholinergic**-*Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 mg, 25 mg travel sickness oral tablet chewable 25 mg *Antihistamines* *Antihistamines - Alkylamines**-*Antihistamines - Alkylamines*** aller-chlor oral syrup 2 mg/5ml aller-chlor oral tablet 4 mg allergy oral tablet 4 mg allergy relief oral tablet 4 mg chlorhist oral tablet 4 mg chlorphen oral tablet 4 mg DIABETIC TUSSIN ALLERGY ORAL SYRU 2 MG/5ML *Antihistamines - Ethanolamines**-*Antihistamines - Ethanolamines*** aler-cap oral capsule 25 mg aler-dryl oral tablet 50 mg alertab oral tablet 25 mg allergy relief childrens oral liquid 12.5 mg/5ml altaryl oral elixir 12.5 mg/5ml altaryl oral syrup 12.5 mg/5ml anti-hist allergy oral tablet 25 mg BANOHEN ORAL CASULE 25 MG BANOHEN ORAL LIQUID 12.5 MG/5ML BANOHEN ORAL TABLET 25 MG BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 MG/5ML complete allergy medication oral tablet 25 mg complete allergy relief oral tablet 25 mg diphenhist oral capsule 25 mg diphenhist oral liquid 12.5 mg/5ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 6

10 Drug Name reference Details Coverage Details diphenhist oral tablet 25 mg diphenhydramine hcl oral capsule 25 mg, 50 mg diphenhydramine hcl oral tablet 25 mg DORMIN ORAL CASULE 25 MG genahist oral capsule 25 mg pharbedryl oral capsule 25 mg, 50 mg q-dryl oral capsule 25 mg q-dryl oral liquid 12.5 mg/5ml quenalin oral syrup 12.5 mg/5ml SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID 12.5 MG/5ML siladryl allergy oral liquid 12.5 mg/5ml silphen cough oral syrup 12.5 mg/5ml SIMLY ALLERGY ORAL TABLET 25 MG TOTAL ALLERGY MEDICINE ORAL LIQUID 12.5 MG/5ML total allergy oral tablet 25 mg *Antihistamines - Non-Sedating**-*Antihistamines - Non-Sedating*** ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG allergy oral tablet dispersible 10 mg cetirizine hcl childrens alrgy oral syrup 1 mg/ml ; QL (300 ML per 31 days) cetirizine hcl childrens oral solution 1 mg/ml ; QL (300 ML per 31 days) cetirizine hcl oral syrup 5 mg/5ml ; QL (300 ML per 31 days) cetirizine hcl oral tablet 10 mg, 5 mg childrens loratadine oral syrup 5 mg/5ml ; QL (300 ML per 31 days) fexofenadine hcl oral tablet 180 mg, 60 mg loratadine childrens oral solution 5 mg/5ml ; QL (310 ML per 31 days) loratadine hives relief oral solution 5 mg/5ml ; QL (300 ML per 31 days) loratadine oral tablet 10 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 7

11 Drug Name reference Details Coverage Details *Antiseptics & Disinfectants* *Chlorine Antiseptics**-*Chlorine Antiseptic Combinations*** dakins (1/2 strength) external solution % dakins (1/4 strength) external solution % dakins external solution % *Chlorine Antiseptics**-*Chlorine Antiseptics*** chlorhexidine gluconate external liquid 4 % ; QL (480 ML per 31 days) *Iodine Antiseptics**-*Iodine Antiseptics*** OERAND OVIDONE-IODINE EXTERNAL SOLUTION 10 % povidone-iodine external solution 10 % *Cough/Cold/Allergy* *Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine*** ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* MG ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* MG allergy relief/nasal decongest oral tablet extended release 24 hr* mg BROTA ORAL LIQUID 1-15 MG/5ML cetirizine-pseudoephedrine er oral tablet extended release 12 hr* mg fexofenadine-pseudoephed er oral tablet extended release 24 hr* mg Q-TA ORAL ELIXIR 1-15 MG/5ML triprolidine-pse oral tablet mg *Expectorants**-*Expectorants*** chest congestion relief oral tablet 400 mg mucus relief oral tablet 400 mg refenesen 400 oral tablet 400 mg refenesen oral tablet 200 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 8

12 Drug Name reference Details Coverage Details robafen oral syrup 100 mg/5ml *Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants*** BRONCHO SALINE INHALATION AEROSOL, SOLUTION 0.9 % sodium chloride inhalation nebulization solution 0.9 % *Dermatologicals* *Acne roducts**-*acne roducts*** acne medication 5 external lotion 5 % benzoyl peroxide external 10 %, 5 % ANOXYL WASH EXTERNAL LIQUID 10 % *Antibiotics - Topical**-*Antibiotic Mixtures Topical*** bacitracin-neomycin-polymyxin external ointment double antibiotic external ointment unit/gm triple antibiotic external ointment , *Antibiotics - Topical**-*Antibiotics - Topical*** bacitracin external ointment 500 unit/gm bacitracin zinc external ointment 500 unit/gm *Antifungals - Topical**-*Antifungals - Topical*** anti-fungal external powder 1 % terbinafine hcl external cream 1 % *Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** clotrimazole external cream 1 % clotrimazole external solution 1 % *Antihistamines-Topical**-*Antihistamines - Topical*** anti-itch maximum strength external cream 2 % BENADRYL ITCH STOING EXTERNAL 2 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 9

13 Drug Name reference Details Coverage Details itch relief external cream 2 % *Corticosteroids - Topical**-*Corticosteroids - Topical*** AVEENO ANTI-ITCH MAX ST EXTERNAL CREAM 1 % hydrocortisone external cream 0.5 %, 1 % hydrocortisone external lotion 1 % hydrocortisone external ointment 0.5 %, 1 % hydrocortisone max st external cream 1 % hydrocortisone max st/12 moist external cream 1 % HYDROSKIN EXTERNAL CREAM 1 % kp hydrocortisone external cream 1 % REARATION H HYDROCORTISONE EXTERNAL CREAM 1 % tgt anti-itch/aloe/vit e external cream 1 % *Corticosteroids - Topical**-*Topical Steroid Combinations*** hydrocortisone-aloe external cream 1 % sm hydrocortisone plus external cream 1 % *Emollients**-*Emollients*** AMLACTIN EXTERNAL LOTION 12 % ; QL (400 GM per 31 days) ammonium lactate external cream 12 % ; QL (400 GM per 31 days) ammonium lactate external lotion 12 % ; QL (400 GM per 31 days) *Keratolytic/Antimitotic Agents**-*Keratolytic/Antimitotic Agents*** CLEAR AWAY 1-STE WART REMOVER EXTERNAL AD 40 % COMOUND W EXTERNAL LIQUID 17 % COMOUND W MAXIMUM STRENGTH EXTERNAL 17 % FREEZONE EXTERNAL LIQUID 17.6 % SALACTIC FILM EXTERNAL SOLUTION 17 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 10

14 Drug Name reference Details Coverage Details *Local Anesthetics - Topical**-*Local Anesthetics - Topical*** capsaicin external cream % *Scabicides & ediculicides**-*scabicides & ediculicides*** permethrin external lotion 1 % ; QL (60 ML per 31 days) *Tar roducts**-*tar roducts*** TERA-GEL TAR EXTERNAL SHAMOO 0.5 % *Gastrointestinal Agents - Misc.* *Antiflatulents**-*Antiflatulents*** mi-acid gas relief oral tablet chewable 80 mg mytab gas oral tablet chewable 80 mg simethicone oral suspension 40 mg/0.6ml simethicone oral tablet chewable 80 mg *Genitourinary Agents - Miscellaneous* *Urinary Analgesics**-*Urinary Analgesics*** phenazopyridine hcl oral tablet 100 mg, 200 mg *Hematopoietic Agents* *Cobalamins**-*Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml vitamin b-12 er oral tablet extendedrelease* 1000 mcg vitamin b-12 oral tablet 1000 mcg, 250 mcg, 500 mcg vitamin b-12 sublingual tablet sublingual 1000 mcg *Folic Acid/Folates**-*Folic Acid/Folates*** folic acid oral tablet 1 mg, 400 mcg, 800 mcg *Iron**-*Iron*** ferro-bob oral tablet 325 (65 fe) mg ferrous sulfate oral elixir 220 (44 fe) mg/5ml ferrous sulfate oral tablet 325 (65 fe) mg ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg ferrousul oral tablet 325 (65 fe) mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 11

15 Drug Name reference Details Coverage Details iron oral tablet 325 (65 fe) mg, 90 (18 fe) mg OLY-IRON 150 ORAL CASULE 150 MG slow release iron oral tablet extendedrelease* 160 (50 fe) mg *Hypnotics/Sedatives/Sleep Disorder Agents* *Antihistamine Hypnotics**-*Antihistamine Hypnotic Combinations*** headache pm oral tablet mg ; QL (62 EA per 31 days) mapap pm oral tablet mg ; QL (62 EA per 31 days) pain relief pm extra strength oral tablet mg ; QL (62 EA per 31 days) pain reliever pm oral tablet mg ; QL (62 EA per 31 days) *Antihistamine Hypnotics**-*Antihistamine Hypnotics*** compoz oral capsule 50 mg compoz oral tablet 50 mg NYTOL ORAL TABLET 25 MG SIMLY SLEE ORAL TABLET 25 MG sleep tabs oral tablet 25 mg sleep-tabs oral tablet 25 mg SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 MG SOMINEX ORAL TABLET 25 MG tetra-formula nighttime sleep oral tablet 50 mg *Laxatives* *Bulk Laxatives**-*Bulk Laxatives*** fiber laxative oral tablet 625 mg fiber oral tablet 625 mg fiber therapy oral powder 58.6 % FIBERGEN ORAL TABLET 625 MG fiber-lax oral tablet 625 mg KONSYL FIBER ORAL TABLET 625 MG KONSYL ORAL ACKET 100 % METAMUCIL MULTIHEALTH FIBER ORAL OWDER 58.6 % METAMUCIL ORAL CASULE 0.52 GM =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 12

16 Drug Name reference Details Coverage Details METAMUCIL ORAL OWDER 30.9 % METAMUCIL ORAL WAFER METAMUCIL SMOOTH TEXTURE ORAL ACKET 28 % METAMUCIL SMOOTH TEXTURE ORAL OWDER 28.3 %, 58.6 % natural fiber therapy oral powder 30.9 %, % natural vegetable fiber oral powder % REGULOID ORAL CASULE 0.52 GM *Laxative Combinations**-*Laxatives & Dss*** DOC-Q-LAX ORAL TABLET MG ERI-COLACE ORAL TABLET MG senna plus oral tablet mg senna s oral tablet mg senna-docusate sodium oral tablet mg SENNALAX-S ORAL TABLET MG senna-s oral tablet mg senna-time s oral tablet mg sennosides-docusate sodium oral tablet mg *Laxatives - Miscellaneous**-*Laxatives - Miscellaneous*** sorbitol oral solution 70 % *Saline Laxatives**-*Saline Laxative Mixtures*** enema enema 7-19 gm/118ml phosphate laxative oral solution gm/5ml *Saline Laxatives**-*Saline Laxatives*** citrate of magnesia oral solution gm/30ml CITROMA ORAL SOLUTION GM/30ML DULCOLAX MILK OF MAGNESIA ORAL SUSENSION 400 MG/5ML magnesium citrate oral solution gm/30ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 13

17 Drug Name reference Details Coverage Details milk of magnesia oral suspension 400 mg/5ml, 7.75 % *Stimulant Laxatives**-*Stimulant Laxatives*** BISAC-EVAC SUOSITORY 10 MG biscolax suppository 10 mg CARTERS LITTLE ILLS ORAL TABLET DELAYED RELEASE 5 MG correct oral tablet delayed release 5 mg CORRECTOL ORAL TABLET DELAYED RELEASE 5 MG ducodyl oral tablet delayed release 5 mg EX-LAX ORAL TABLET CHEWABLE 15 MG EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG FEENAMINT ORAL TABLET DELAYED RELEASE 5 MG FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG gentle laxative oral tablet delayed release 5 mg laxative suppository 10 mg natural senna laxative oral tablet mg senexon oral liquid 8.8 mg/5ml senexon oral tablet 8.6 mg senna lax oral tablet 8.6 mg senna laxative oral tablet 25 mg, 8.6 mg senna oral syrup 8.8 mg/5ml senna oral tablet 8.6 mg SENNA SMOOTH ORAL TABLET 15 MG SENNACON ORAL TABLET 8.6 MG senna-lax oral tablet 8.6 mg senna-tabs oral tablet 8.6 mg senna-time oral tablet 8.6 mg SENNO ORAL TABLET 8.6 MG stimulant laxative oral tablet delayed release 5 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 14

18 Drug Name reference Details Coverage Details womens laxative oral tablet delayed release 5 mg *Surfactant Laxatives**-*Surfactant Laxatives*** CORRECTOL EXTRA GENTLE ORAL CASULE 100 MG d.o.s. oral capsule 250 mg diocto oral liquid 50 mg/5ml diocto oral syrup 60 mg/15ml docqlace oral capsule 100 mg docu soft oral capsule 100 mg docusate calcium oral capsule 240 mg docusate sodium oral capsule 250 mg docusate sodium oral tablet 100 mg DOCUSIL ORAL CASULE 100 MG DOK ORAL CASULE 100 MG, 250 MG DOK ORAL TABLET 100 MG dss oral capsule 100 mg, 250 mg DULCOLAX STOOL SOFTENER ORAL CASULE 100 MG kao-tin oral capsule 240 mg laxa basic oral capsule 100 mg silace oral liquid 150 mg/15ml silace oral syrup 60 mg/15ml SOF-LAX ORAL CASULE 100 MG stool softener laxative dc oral capsule 240 mg stool softener oral capsule 100 mg, 250 mg SURFAK ORAL CASULE 240 MG sur-q-lax oral capsule 240 mg *Medical Devices* *Respiratory Therapy Supplies**-*Respiratory Therapy Supplies*** ACE AEROSOL CLOUD ENHANCER QL (2 EA per 365 days) IN-CHECK DIAL FLOW TRAINER DEVICE QL (2 EA per 365 days) FLEX QL (2 EA per 365 days) THRESHOLD IMT QL (2 EA per 365 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 15

19 Drug Name reference Details Coverage Details THRESHOLD E DEVICE QL (2 EA per 365 days) WINDMILL TRAINER QL (2 EA per 365 days) *Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER MV QL (2 EA per 365 days) AEROCHAMBER LUS FLO-VU QL (2 EA per 365 days) AEROCHAMBER LUS FLO-VU LARGE QL (2 EA per 365 days) AEROCHAMBER LUS FLO-VU SMALL QL (2 EA per 365 days) AEROCHAMBER LUS FLO-VU W/MASK QL (2 EA per 365 days) AEROCHAMBER W/FLOWSIGNAL QL (2 EA per 365 days) AEROCHAMBER Z-STAT LUS QL (2 EA per 365 days) AEROCHAMBER Z-STAT LUS CHAMBR QL (2 EA per 365 days) EASIVENT QL (2 EA per 365 days) MICROCHAMBER QL (2 EA per 365 days) MICROSACER QL (2 EA per 365 days) OTICHAMBER ADVANTAGE QL (2 EA per 365 days) OTICHAMBER FACE MASK-LARGE ; QL (2 EA per 365 days) OTICHAMBER FACE MASK-MEDIUM ; QL (2 EA per 365 days) OTICHAMBER FACE MASK-SMALL ; QL (2 EA per 365 days) OTIHALER QL (2 EA per 365 days) OTIHALER DEVICE QL (2 EA per 365 days) OCKET CHAMBER DEVICE QL (2 EA per 365 days) OCKET SACER DEVICE QL (2 EA per 365 days) WATCHHALER DEVICE QL (2 EA per 365 days) *Minerals & Electrolytes* *Calcium**-*Calcium Combinations*** calcium + d3 oral tablet mg-unit calcium 600-d oral tablet mg-unit calcium carbonate-vitamin d oral tablet mg-unit, mg-unit calcium high potency/vitamin d oral tablet mg-unit calcium oral tablet mg-unit =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 16

20 Drug Name reference Details Coverage Details calcium-carb d oral tablet mg-unit calcium-vitamin d oral tablet mg-unit, mg-unit, mg-unit CALTRATE 600+D ORAL TABLET MG-UNIT liquid calcium/vitamin d oral capsule mg-unit OYSCO 500+D ORAL TABLET MG-UNIT OYSCO D ORAL TABLET MG-UNIT oyst-cal d oral tablet mg-unit oyster calcium + d oral tablet mg-unit oyster shell calcium + d oral tablet mg-unit oyster shell calcium d oral tablet mg-unit oyster shell calcium/d oral tablet mg-unit, mg-unit oyster shell calcium/vitamin d oral tablet mg-unit oyster shell/vitamin d oral tablet mg-unit *Calcium**-*Calcium*** calcarb 600 oral tablet 1500 mg CAL-CARB FORTE ORAL TABLET 1250 MG CALCI-CHEW ORAL TABLET CHEWABLE 1250 MG calcium 600 oral tablet 600 mg calcium carbonate oral suspension 1250 mg/5ml calcium carbonate oral tablet 1250 mg, 600 mg calcium high potency oral tablet 600 mg calcium lactate oral tablet 648 mg calcium oral tablet 600 mg calcium oyster shell oral tablet 1250 mg calcium-carb 600 oral tablet 600 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 17

21 Drug Name reference Details Coverage Details cal-lac oral capsule 500 mg CALTRATE 600 ORAL TABLET 1500 MG OYSCO 500 ORAL TABLET 500 MG OYSTERCAL ORAL TABLET 500 MG *Electrolyte Mixtures**-*Electrolytes Oral*** ORALYTE FREEZER OS ORAL SOLUTION ; QL (4000 ML per 31 days) ORALYTE ORAL SOLUTION ; QL (4000 ML per 31 days) *Magnesium**-*Magnesium*** MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG mag-delay oral tablet extendedrelease* 535 (64 mg) mg magnacaps oral capsule 100 mg magnesium oral tablet 250 mg magnesium oxide oral tablet 400 (240 mg) mg MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG mag-sr oral tablet extendedrelease* 535 (64 mg) mg MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) *Sodium**-*Sodium*** sodium chloride oral tablet 1 gm *Zinc**-*Zinc*** ORAZINC ORAL CASULE 220 MG zinc gluconate oral tablet 50 mg zinc oral tablet 50 mg zinc sulfate oral capsule 220 mg zinc sulfate oral tablet 220 (50 zn) mg zinc-220 oral capsule 220 mg *Multivitamins* *B-Complex W/ C**-*B-Complex W/ C*** vitamin b complex-c oral capsule =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 18

22 Drug Name reference Details Coverage Details *B-Complex W/ Folic Acid**-*B-Complex W/ C & Folic Acid*** NEHRONEX ORAL TABLET RENAL ORAL CASULE 1 MG rena-vite rx oral tablet 1 mg reno caps oral capsule 1 mg *Multiple Vitamins W/ Minerals**-*Multiple Vitamins W/ Minerals*** centamin oral liquid centavite a-z complete-mineral oral tablet centavite oral liquid CEROVITE ADVANCED FORMULA ORAL TABLET CERTAVITE/ANTIOXIDANTS ORAL LIQUID formula twenty-one oral tablet gerivite complete oral tablet multivitamin & mineral oral liquid SUER NU-THERA ORAL TABLET thera vital m oral tablet therabasic-m oral tablet thera-m oral tablet therapeutic liquid oral solution therapeutic-m oral tablet TOTAL FORMULA 3 ORAL TABLET *Multivitamins**-*Multivitamins*** daily multiple vitamins oral tablet daily vite oral tablet daily vites oral tablet multi-day oral tablet multi-vitamin oral tablet multi-vitamins oral tablet once daily oral tablet one-daily multi vitamins oral tablet THERA ORAL TABLET =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 19

23 Drug Name reference Details Coverage Details THERA/BETA-CAROTENE ORAL TABLET therapeutic oral tablet thera-tabs oral tablet *ed Mv W/ Fluoride**-*ed Mv W/ Fluoride*** multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg multi-vitamin/fluoride oral tablet chewable 0.5 mg multivitamins/fluoride oral tablet chewable 0.25 mg *ed Mv W/ Iron**-*ed Mv W/ Iron*** polyvitamin/iron oral solution 10 mg/ml *ediatric Multiple Vitamins**-*ediatric Multiple Vitamins W/ C*** polyvitamin oral solution 35 mg/ml *ediatric Vitamins**-*ediatric Vitamins A & D W/ C*** tri-vitamin oral solution *renatal Vitamins**-*renatal Mv & Min W/Fe-Fa*** prenatal low iron oral tablet mg *Specialty Vitamins roducts**-*specialty Vitamins roducts*** vitamins for hair oral tablet *Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.**-*Nasal Agents - Misc.*** altamist spray nasal solution 0.65 % AYR NASAL SOLUTION 0.65 % deep sea nasal spray nasal solution 0.65 % HUMIST NASAL SOLUTION 0.65 % LITTLE NOSES SALINE NASAL SOLUTION 0.65 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 20

24 Drug Name reference Details Coverage Details NASAL MOIST NASAL SOLUTION 0.65 % na-zone nasal solution 0.65 % OCEAN FOR KIDS NASAL SOLUTION 0.65 % saline mist spray nasal solution 0.65 % saline nasal spray nasal solution 0.65 % sea soft nasal mist nasal solution 0.65 % *Nasal Antiallergy**-*Nasal Mast Cell Stabilizers*** cromolyn sodium nasal aerosol, solution 5.2 mg/act *Sympathomimetic Decongestants**-*Systemic Decongestants*** pseudoephedrine hcl oral tablet 30 mg, 60 mg SUDAFED 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR* 120 MG *Ophthalmic Agents* *Artificial Tears And Lubricants**-*Artificial Tear And Lubricant Combinations*** artificial tears ophthalmic ointment % HYOTEARS OHTHALMIC SOLUTION 1-1 % *Artificial Tears And Lubricants**-*Artificial Tear Ointments*** tears again ophthalmic ointment ULTRA FRESH M OHTHALMIC OINTMENT *Artificial Tears And Lubricants**-*Artificial Tear Solutions*** tears again ophthalmic solution *Artificial Tears And Lubricants**-*Artificial Tears And Lubricants*** artificial tears ophthalmic solution 1.4 % ; QL (15 ML per 31 days) liquitears ophthalmic solution 1.4 % ; QL (15 ML per 31 Days) polyvinyl alcohol ophthalmic solution 1.4 % ; QL (15 ML per 31 Days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 21

25 Drug Name reference Details Coverage Details *Ophthalmics - Misc.**-*Ophthalmic Antiallergic*** ALAWAY OHTHALMIC SOLUTION % ketotifen fumarate ophthalmic solution % *Otic Agents* *Otic Agents - Miscellaneous**-*Otic Agents - Miscellaneous*** auraphene-b otic solution 6.5 % ear drops earwax aid otic solution 6.5 % earwax treatment drops otic solution 6.5 % E-R-O EAR DROS OTIC SOLUTION 6.5 % E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % MURINE EAR OTIC SOLUTION 6.5 % MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % OTIX OTIC SOLUTION 6.5 % thera-ear otic solution 6.5 % *sychotherapeutic And Neurological Agents - Misc.* *Smoking Deterrents**-*Smoking Deterrents*** nicotine polacrilex mouth/throat gum 2 mg, 4 mg nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr *Ulcer Drugs* *H-2 Antagonists**-*H-2 Antagonists*** acid reducer oral tablet 75 mg cimetidine oral tablet 200 mg famotidine oral tablet 10 mg *roton ump Inhibitors**-*roton ump Inhibitors*** omeprazole oral tablet delayed release 20 mg ; QL (4032 EA per 365 days) ; QL (140 EA per 365 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 22

26 Drug Name reference Details Coverage Details *Vaginal roducts* *Vaginal Anti-Infectives**-*Imidazole-Related Antifungals*** GYNE-LOTRIMIN 3 VAGINAL CREAM 2 % miconazole 3 combo pack vaginal kit mg-% (9gm) miconazole nitrate vaginal cream 2 % miconazole nitrate vaginal suppository 100 mg MONISTAT 3 VAGINAL CREAM 4 % *Vitamins* *Oil Soluble Vitamins**-*Vitamin A*** vitamin a oral capsule unit, 8000 unit *Oil Soluble Vitamins**-*Vitamin D*** CALCIFEROL ORAL SOLUTION 8000 UNIT/ML vitamin d (ergocalciferol) oral capsule unit vitamin d oral capsule 1000 unit, 400 unit vitamin d oral tablet 400 unit vitamin d3 oral capsule 2000 unit vitamin d3 oral tablet 1000 unit, 400 unit vitamin d3 oral tablet chewable 400 unit vitamin d-400 oral tablet 400 unit *Oil Soluble Vitamins**-*Vitamin E*** vitamin e oral capsule 400 unit vitamin e oral tablet chewable 400 unit *Oil Soluble Vitamins**-*Vitamin K*** vitamin k (phytonadione) oral tablet 100 mcg *Water Soluble Vitamins**-*Vitamin B-1*** vitamin b-1 oral tablet 100 mg, 250 mg, 50 mg *Water Soluble Vitamins**-*Vitamin B-2*** vitamin b-2 oral tablet 100 mg *Water Soluble Vitamins**-*Vitamin B-3*** ENDUR-ACIN ORAL TABLET EXTENDEDRELEASE* 500 MG QL (4 EA per 28 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 23

27 Drug Name reference Details Coverage Details niacin er oral capsule extended release* 250 mg, 500 mg niacin er oral tablet extendedrelease* 250 mg niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg *Water Soluble Vitamins**-*Vitamin B-6*** vitamin b-6 er oral tablet extendedrelease* 200 mg vitamin b-6 oral tablet 100 mg, 25 mg, 250 mg, 50 mg, 500 mg *Water Soluble Vitamins**-*Vitamin C*** ascorbic acid oral tablet 1000 mg, 250 mg, 500 mg ascorbic acid oral tablet chewable 250 mg c-500 oral tablet chewable 500 mg vitamin c oral syrup 500 mg/5ml vitamin c oral tablet 100 mg, 1000 mg, 250 mg, 500 mg vitamin c oral tablet chewable 100 mg, 250 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 24

28 Index xedni ACE AEROSOL CLOUD ENHANCER ACEHEN... 1 acetaminophen... 1 ACID GONE... 4 acid reducer acne medication AEROCHAMBER MV AEROCHAMBER LUS FLO-VU AEROCHAMBER LUS FLO-VU LARGE AEROCHAMBER LUS FLO-VU SMALL AEROCHAMBER LUS FLO-VU W/MASK AEROCHAMBER W/FLOWSIGNAL AEROCHAMBER Z-STAT LUS AEROCHAMBER Z-STAT LUS CHAMBR alamag plus... 3 ALAVERT ALLERGY/SINUS... 8 ALAWAY alcalak... 4 aler-cap... 6 aler-dryl... 6 alertab... 6 ALLEGRA ALLERGY CHILDRENS... 7 ALLEGRA-D ALLERGY & CONGESTION... 8 aller-chlor... 6 allergy... 6, 7 allergy relief... 6 allergy relief childrens... 6 allergy relief/nasal decongest... 8 ALMACONE... 3 altamist spray altaryl... 6 aluminum hydroxide gel... 4 AMLACTIN ammonium lactate antacid... 3, 4 antacid anti-gas... 3 antacid anti-gas max strength... 3 antacid extra strength... 3 antacid i... 3 xedni antacid iii... 3 anti-diarrheal... 5 anti-fungal... 9 anti-hist allergy... 6 anti-itch maximum strength... 9 apap... 1 apap extra strength... 1 artificial tears ascorbic acid aspirin... 2, 3 aspirin childrens... 2 aspirin ec... 2 aspirin ec low dose... 2 aspirin low dose... 2 auraphene-b AVEENO ANTI-ITCH MAX ST AYR bacitracin... 9 bacitracin zinc... 9 bacitracin-neomycin-polymyxin... 9 BANOHEN... 6 BD GLUCOSE... 5 BENADRYL ALLERGY CHILDRENS... 6 BENADRYL ITCH STOING... 9 benzoyl peroxide... 9 BISAC-EVAC biscolax bismatrol... 5 bismuth... 5 BRONCHO SALINE... 9 BROTA... 8 c calcarb CAL-CARB FORTE CALCI-CHEW CALCIFEROL calcium... 16, 17 calcium + d calcium calcium 600-d calcium antacid... 4 calcium antacid extra strength... 4 calcium carbonate calcium carbonate antacid... 4 calcium carbonate-vitamin d calcium high potency xedni calcium high potency/vitamin d calcium lactate calcium oyster shell calcium-carb calcium-carb d calcium-vitamin d CAL-GEST ANTACID... 4 cal-lac CALTRATE CALTRATE 600+D capsaicin CARTERS LITTLE ILLS centamin centavite centavite a-z complete-mineral CEROVITE ADVANCED FORMULA CERTAVITE/ANTIOXIDANT S cetirizine hcl... 7 cetirizine hcl childrens... 7 cetirizine hcl childrens alrgy... 7 cetirizine-pseudoephedrine er... 8 chest congestion relief... 8 childrens ibuprofen... 1 childrens loratadine... 7 childrens non-asa pain relief... 1 childrens non-aspirin... 1 childrens pain reliever... 1 childrens silapap... 1 childrens tactinal... 1 chlorhexidine gluconate... 8 chlorhist... 6 chlorphen... 6 cimetidine citrate of magnesia CITROMA CLEAR AWAY 1-STE WART REMOVER clotrimazole... 9 complete allergy medication... 6 complete allergy relief... 6 COMOUND W COMOUND W MAXIMUM STRENGTH compoz correct CORRECTOL =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 25

29 xedni CORRECTOL EXTRA GENTLE cromolyn sodium cyanocobalamin d.o.s daily multiple vitamins daily vite daily vites dakins... 8 dakins (1/2 strength)... 8 dakins (1/4 strength)... 8 deep sea nasal spray DIABETIC TUSSIN ALLERGY... 6 diocto diotame... 5 diphenhist... 6, 7 diphenhydramine hcl... 7 docqlace DOC-Q-LAX docu soft docusate calcium docusate sodium DOCUSIL DOK DORMIN... 7 double antibiotic... 9 dss ducodyl DULCOLAX MILK OF MAGNESIA DULCOLAX STOOL SOFTENER ear drops earwax aid earwax treatment drops EASIVENT ECIRIN... 3 ed-apap... 1 ENDUR-ACIN enema E-R-O EAR DROS E-R-O EAR WAX REMOVAL SYSTEM EX-LAX EX-LAX ULTRA famotidine FEENAMINT ferro-bob ferrous sulfate ferrousul fexofenadine hcl... 7 fexofenadine-pseudoephed er... 8 xedni fiber fiber laxative fiber therapy FIBERGEN fiber-lax FLEET LAXATIVE folic acid formula twenty-one FREEZONE genahist... 7 gentle laxative geri-lanta... 3 gerivite complete glucose... 5 gnp foaming antacid... 4 GYNE-LOTRIMIN headache pm hem-prep... 3 HUMIST hydrocortisone hydrocortisone max st hydrocortisone max st/12 moist hydrocortisone-aloe HYDROSKIN HYOTEARS ibuprofen... 1 IN-CHECK DIAL FLOW TRAINER infants silapap... 1 ipecac... 5 iron itch relief KAOECTATE... 5 KAOECTATE EXTRA STRENGTH... 5 kao-tin... 5, 15 ketotifen fumarate KONSYL KONSYL FIBER kp hydrocortisone laxa basic laxative liquid calcium/vitamin d liquitears LITTLE NOSES SALINE LOERAMIDE A-D... 5 loperamide hcl... 5 loratadine... 7 loratadine childrens... 7 loratadine hives relief... 7 MAALOX... 4 xedni MAALOX ADVANCED... 3 MAALOX ADVANCED MAX ST... 3 MAALOX MAX... 3 MAALOX MULTI SYMTOM MAX ST... 3 MAALOX REGULAR STRENGTH... 3 MAG mag-delay magnacaps magnesium magnesium citrate magnesium oxide... 4, 18 MAGNESIUM-OXIDE mag-sr MAG-TAB SR mapap... 2 mapap arthritis pain... 2 MAA CHILDRENS... 2 mapap pm maxapap maximum strength... 2 maxapap regular strength... 2 meclizine hcl... 6 melatonin maximum strength... 1 METAMUCIL... 12, 13 METAMUCIL MULTIHEALTH FIBER METAMUCIL SMOOTH TEXTURE MI-ACID... 4 mi-acid gas relief miconazole 3 combo pack miconazole nitrate MICROCHAMBER MICROSACER milantex... 3 milantex extra strength... 3 milk of magnesia MINTOX LUS... 3 MONISTAT mucus relief... 8 multi-day multi-vit/fluoride multi-vitamin multivitamin & mineral multivitamin/fluoride multi-vitamin/fluoride multi-vitamins multivitamins/fluoride MURINE EAR =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 26

30 xedni MURINE EAR WAX REMOVAL SYSTEM mytab gas NASAL MOIST natural fiber therapy natural senna laxative natural vegetable fiber na-zone NEHRONEX niacin niacin er nicotine nicotine polacrilex non-aspirin... 2 non-aspirin extra strength... 2 non-aspirin pain relief... 2 nortemp infants... 2 NYTOL OCEAN FOR KIDS omeprazole once daily one-daily multi vitamins OERAND OVIDONE-IODINE... 8 OTICHAMBER ADVANTAGE OTICHAMBER FACE MASK-LARGE OTICHAMBER FACE MASK-MEDIUM OTICHAMBER FACE MASK-SMALL OTIHALER ORALYTE ORALYTE FREEZER OS ORAZINC OTIX OYSCO OYSCO 500+D OYSCO D oyst-cal d oyster calcium + d oyster shell calcium + d oyster shell calcium d oyster shell calcium/d oyster shell calcium/vitamin d oyster shell/vitamin d OYSTERCAL pain & fever childrens... 2 pain relief... 2 pain relief extra strength... 2 xedni pain relief pm extra strength pain reliever pm ANOXYL WASH... 9 ERI-COLACE permethrin FLEX pharbedryl... 7 HARBETOL... 2 HARBETOL EXTRA STRENGTH... 2 phenazopyridine hcl phosphate laxative pink bismuth... 5 OCKET CHAMBER OCKET SACER OLY-IRON polyvinyl alcohol polyvitamin polyvitamin/iron povidone-iodine... 8 prenatal low iron REARATION H HYDROCORTISONE pseudoephedrine hcl q-dryl... 7 q-pap... 2 Q-TA... 8 quenalin... 7 reeses pinworm medicine... 5 refenesen... 8 refenesen REGULOID RENAL rena-vite rx reno caps robafen... 9 SALACTIC FILM saline mist spray saline nasal spray SCOT-TUSSIN ALLERGY RELIEF... 7 sea soft nasal mist senexon senna senna lax senna laxative senna plus senna s SENNA SMOOTH SENNACON senna-docusate sodium senna-lax xedni SENNALAX-S senna-s senna-tabs senna-time senna-time s SENNO sennosides-docusate sodium silace siladryl allergy... 7 silphen cough... 7 simethicone SIMLY ALLERGY... 7 SIMLY SLEE sleep tabs sleep-tabs slow release iron sm hydrocortisone plus sodium bicarbonate... 4 sodium chloride... 9, 18 SOF-LAX SOMINEX SOMINEX MAXIMUM STRENGTH sorbitol stimulant laxative stomach relief... 5 stomach relief plus... 5 stool softener stool softener laxative dc SUDAFED 12 HOUR SUER NU-THERA SURFAK sur-q-lax tactinal... 2 tactinal extra strength... 2 tears again TERA-GEL TAR terbinafine hcl... 9 tetra-formula nighttime sleep tgt anti-itch/aloe/vit e THERA thera vital m THERA/BETA-CAROTENE therabasic-m thera-ear thera-m therapeutic therapeutic liquid therapeutic-m thera-tabs THRESHOLD IMT =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 27

31 xedni THRESHOLD E TITRALAC... 4 total allergy... 7 TOTAL ALLERGY MEDICINE... 7 TOTAL FORMULA travel sickness... 6 tri-buffered aspirin... 2 triple antibiotic... 9 triprolidine-pse... 8 tri-vitamin ULTRA FRESH M vitamin a vitamin b complex-c vitamin b vitamin b vitamin b-12 er vitamin b vitamin b vitamin b-6 er vitamin c vitamin d vitamin d (ergocalciferol) vitamin d vitamin d vitamin e vitamin k (phytonadione) vitamins for hair WATCHHALER WINDMILL TRAINER womens laxative zinc zinc gluconate zinc sulfate zinc =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, =-Covered w/rx, UERCASE= Brand name drugs/ 28