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EFFECTIVE July 1, 2017
MEMBER PRESCRIPTION DRUG LIST
2017
For group HMO and PPO members with an insurance plan that
includes a prescription drug benefit
Blue Cross and Blue Shield of Kansas City 2017 Prescription Drug List
Introduction
Medications are evaluated on the basis of safety, effectiveness, adverse events, proven advantages over existing agents and cost. Tier 1 medications are typically generic drugs that contain the same active ingredients as brand name drugs and have the lowest copay. New drugs will require an exception or prior authorization until they are reviewed by the committee. While extensive, this is not an exhaustive list of all available medications and this list is subject to change. The most current PDL is available on our website at www.BlueKC.com. If you require additional information or clarification, contact our Clinical Pharmacy unit at 816-395-2176 or 800-228-1436. Please be aware that as new products are released and post-marketing information on existing therapies becomes available, changes in the PDL status may occur. The committee may also implement prior authorization or other utilization management processes as deemed necessary. Doctors and pharmacists will be notified of any such changes via direct mailings.
How to use this list:
1) Find the page number for your drug by searching the alphabetical index at the end 2) Locate your drug and identify the Drug Tier. You will also want to note restrictions and
preferred alternatives if applicable. 3) Refer to the Drug Tier description tables at the end of this introduction to identify the tier
copay for your drug (based on the benefit schedule described in your member certificate or in your Blue KC benefit summary).
Prior Authorization/Drug Utilization Management
Some drugs have coverage rules or have limits on the amount dispensed. In some cases, the prescriber must do something in order to obtain the drug. For example:
Prior approval (or prior authorization): For some drugs, the prescriber must get approval from BlueKC before the prescription can be filled. Without that approval, the drug may not be covered.
Quantity limits: For some drugs, there are limits to the amount of drug that may be obtained. Step Therapy: For some drugs, BlueKC requires step therapy. This means that drugs will have to be tried
in a certain order for a medical condition. If the doctor feels that the first drugs are not appropriate, the prescriber will have to submit a prior authorization request.
Prescribers may request exceptions to these coverage rules or limits by submitting an electronic prior authorization request form. www.BlueKC.com > Providers > Forms > Prior Authorizations for Medications.
HOW TO REACH US
The Prescription Drug List (PDL) has been developed and is maintained by the Medical and Pharmacy Management Committee of Blue Cross and Blue Shield of Kansas City (Blue KC). The committee is composed of practicing doctors and pharmacists within the Kansas City area. Quarterly meetings are held to evaluate new drug therapies and review drug utilization issues.
Blue Cross and Blue Shield of Kansas City Pharmacy Services P.O. Box 419169
Kansas City, MO 64141-2735 816-395-2176 or 800-228-1436
www.BlueKC.com
FREQUENTLY ASKED QUESTIONS
What is the difference between brand name drugs and generic drugs? When a drug company develops a new medication they apply for a patent. This patent protects the drug from being copied by other drug companies for a certain period of time. These drugs are brand name drugs. Once the patent period expires, other manufacturers can produce the same drug as long as they follow strict guidelines established by the Food and Drug Administration's (FDA) guidelines. These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose patents have expired. They are made with the same active ingredients of the brand name drug, but they may have a different color, shape or filler material. The cost of a generic drug is typically less than a brand name drug. All generic medications are approved by the FDA before they are released on the market.
What is the difference between a generic equivalent and a generic alternative? A generic equivalent is a medication that contains the same active ingredient and works the same way as the original brand name drug. A generic alternative is a generic medication that may not have the same active ingredient, but works in the same way as another drug.
What is a maintenance drug? A maintenance drug is a medication used to treat a chronic condition like diabetes or high blood pressure. The FDA must approve maintenance drugs as safe for long-term use. Blue KC uses a national drug information database called First DataBank to determine which medications are included on the maintenance drug list. If your prescription is a maintenance drug, you can have it filled for several months instead of just one prescription at a time.
Does Blue KC cover all prescription drugs? Blue KC covers most prescription drugs. However, some drug classes require an additional benefit be added to your health insurance plan in order to be covered. This additional benefit is referred to as a ‘rider.’ Examples of such drug classes are fertility, birth control, impotency, and weight loss.
How is the tier level status determined for medications? The PDL is a list of prescription medications that have been reviewed and recommended by the Blue KC Medical and Pharmacy Management Committee. The list has a combination of brand name and generic medications. Each of these medications has been reviewed for its safety, effectiveness, clinical outcomes, and cost. Doctors and pharmacists on the committee look at drug utilization issues, the number of adverse events, and any proven advantages over other drugs on the PDL. The most efficient and cost-effective drugs are on Tier 1 of the PDL.
Why does Blue KC require prior authorization for some drugs before they are covered? Blue KC may require prior authorization for some drugs or a class. Medications on the prior authorization list may have safety concerns or have FDA approval, only for a certain use. Some of the prior authorization medications may also have a lower-cost alternative that should be considered first or the drug may not be as effective as something else in the same drug class. Some medications are also on the prior authorization list because they have the potential to be misused. Your doctor and Blue KC will work together to get prior authorization and approval for your prescription when needed.
Do I need to show my member ID card at the pharmacy? Yes, show your member ID card to your pharmacist whenever you have a prescription filled. Your prescription claim is electronically transmitted to Blue KC when you fill your prescription. Please make sure the pharmacy has your most current health insurance information and correct birth date so there won’t be any delays or claim denials when we process your claim.
What do I do if I need to refill my prescription early (i.e., leaving on vacation, the doctor increased my dosage)? To have a prescription refilled early, have your pharmacist call the Pharmacy Customer Service unit at 816-395- 2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.
What if I am out of town and need to have a prescription filled? Blue KC contracts with most major pharmacy chains and has a network of over 44,000 pharmacies nationwide. If the pharmacy you are using has difficulty in processing your prescription claim, have them contact the Pharmacy Customer Service unit for assistance at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.
Why must some drugs be purchased through a Specialty Pharmacy?
Specialty drugs are those that require special ordering, handling, clinical monitoring and/or customer service. These drugs are best purchased through a Specialty Pharmacy. Blue KC has a network of Specialty Pharmacies available to provide specialized care for patients with complex chronic health conditions to obtain their medications and manage their health conditions. Specialty medications are limited to a 34 day supply.
What if I have questions about my prescription drug coverage? For more information on your prescription drug coverage, call the Pharmacy Customer Service unit at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.
Miscellaneous Information
Specialty Pharmacy
A Specialty Pharmacy is one that provides specialized care for patients with complex chronic health conditions such as Rheumatoid Arthritis, Multiple Sclerosis or Psoriasis. Specialty drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. These pharmacies do everything from dispense the specialty medication to help patients manage their health condition. Most specialty medications are covered under the pharmacy benefit. Specialty medications are limited to a 34 day supply. The following is a list of other services provided by the Specialty Pharmacies:
Assigns a Patient Care Coordinator who serves as a personal advocate and point of contact Offers access to a dedicated clinical staff of nurses and pharmacists who are knowledgeable about the
medications and conditions Provides the necessary supplies to administer the medications — at no additional cost Offers care management programs to help patients get the most from their medications Provides patients with refill reminder calls Allows the medications to be delivered to either the physician’s office or patients home Works directly with patients to arrange a convenient shipment date Ships all medications overnight Coordinates with Blue KC to take care of billing issues
These services are provided to you at no additional cost. Prescriptions for a specialty medication will need to be filled at the Specialty Pharmacy listed below.
Accredo Health Services Phone: 877-259-2295
Fax: 888-773-7386
DRUG TIER DESCRIPTIONS
To find out what prescription drug tier is on your plan, please see the benefit schedule in your member certificate or in your Blue KC benefit summary.
2‐Tier Benefit Drug TierGG-SPBPB-SNPBNPB-S
3‐Tier Benefit Drug TierGG-SPBPB-SNPBNPB-S
3‐Tier Retail/Specialty Benefit Drug TierTier 1 copay GTier 2 copay PBTier 3 copay NPBGeneric Specialty copay G-SPreferred Brand Specialty copay PB-S
Non-Preferred Brand Specialty copay NPB-S
GG-S
Tier 2 copay PBPB-SNPB
Tier 4 copay NPB-S
Tier 2 copay
Tier 3 copay
4‐Tier Benefit Drug Tier
Tier 3 copay
Tier 1 copay
Tier 1 copay
Tier 2 copay
Not Covered
Tier 1 copay
ANTI - INFECTIVES .............................................................................................................................................. 3
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ........................................................................... 14
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ............................................................................. 18
CARDIOVASCULAR, HYPERTENSION & LIPIDS ....................................................................................... 43
DERMATOLOGICALS/TOPICAL THERAPY ................................................................................................ 56
DIAGNOSTICS & MISCELLANEOUS AGENTS ............................................................................................ 71
EAR, NOSE & THROAT MEDICATIONS ........................................................................................................ 74
ENDOCRINE/DIABETES .................................................................................................................................... 76
GASTROENTEROLOGY .................................................................................................................................. 115
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ................................................................................. 124
MUSCULOSKELETAL & RHEUMATOLOGY ............................................................................................. 126
OBSTETRICS & GYNECOLOGY .................................................................................................................... 128
OPHTHALMOLOGY ......................................................................................................................................... 138
RESPIRATORY, ALLERGY, COUGH & COLD ........................................................................................... 144
UROLOGICALS .................................................................................................................................................. 153
VITAMINS, HEMATINICS & ELECTROLYTES ......................................................................................... 156
Table of Contents
List of Abbreviations G: Generic Drug. G-S: Generic Specialty Drug. NPB: Non-preferred Brand Drug. NPB-S: Non-preferred Brand Specialty Drug. PB: Preferred Brand Drug. PB-S: Preferred Brand Specialty Drug. 2ST: Drug requires trial of at least 2 preferred alternatives. ACA: Affordable Care Act. These preventative drugs may be covered at no cost (check your benefits to confirm). Tobacco use includes two tobacco cessation attempts per year (both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by an in-network health care provider without prior authorization. M: Maintenance Drug. OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, your plan may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
3
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ANCOBON NPB flucytosine
clotrimazole mucous membrane G
CRESEMBA ORAL PB
DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION
NPB fluconazole
DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG
NPB fluconazole
DIFLUCAN ORAL TABLET 150 MG NPB QL fluconazole
fluconazole oral suspension for reconstitution
G
fluconazole oral tablet 100 mg, 200 mg, 50 mg
G
fluconazole oral tablet 150 mg G QL
flucytosine G
griseofulvin microsize G
griseofulvin ultramicrosize G
GRIS-PEG (ULTRAMICROSIZE) NPB griseofulvin ultramicrosize
itraconazole G QL
ketoconazole oral G
LAMISIL ORAL TABLET NPB terbinafine
NOXAFIL ORAL PB
nystatin oral powder 150 million unit, 500 million unit
G
nystatin oral suspension G
nystatin oral tablet G
ONMEL NPB QL itraconazole
ORAVIG NPB nystatin, clotrimazole
SPORANOX ORAL SOLUTION PB
SPORANOX PULSEPAK NPB QL itraconazole
terbinafine hcl oral G
VFEND NPB voriconazole
voriconazole oral G
ANTIVIRALS
abacavir G-S QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
4
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
abacavir-lamivudine G-S QL
abacavir-lamivudine-zidovudine G-S QL
acyclovir oral capsule G
acyclovir oral suspension 200 mg/5 ml G
acyclovir oral tablet G
adefovir G
amantadine hcl G M
APTIVUS PB-S QL
ATRIPLA PB-S QL
BARACLUDE ORAL SOLUTION PB
BARACLUDE ORAL TABLET NPB entecavir
COMBIVIR NPB-S QL lamivudine-zidovudine
COMPLERA PB-S QL
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
PB-S QL
DAKLINZA NPB-S PA; 2ST HARVONI, VIEKIRA PAK, VIEKIRA XR
DESCOVY PB-S
didanosine G-S QL
EDURANT PB-S QL
EMTRIVA PB-S QL
entecavir G
EPCLUSA PB-S PA; 2ST HARVONI, VIEKIRA PAK, VIEKIRA XR
EPIVIR NPB-S QL lamivudine
EPIVIR HBV ORAL SOLUTION PB
EPIVIR HBV ORAL TABLET NPB QL lamivudine
EPZICOM NPB-S QL abacavir-lamivudine
EVOTAZ NPB-S QL REYATAZ, NORVIR
famciclovir G QL
FLUMADINE ORAL TABLET NPB rimantadine hcl
FUZEON SUBCUTANEOUS RECON SOLN
PB-S QL
GENVOYA PB-S
HARVONI PB-S PA; QL
HEPSERA NPB adefovir dipivoxil
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
5
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
INTELENCE PB-S QL
INVIRASE PB-S QL
ISENTRESS PB-S QL
ISENTRESS HD NPB-S
KALETRA ORAL SOLUTION PB-S QL LOPINAVIR-RITONAVIR
KALETRA ORAL TABLET PB-S QL
lamivudine oral solution G-S QL
lamivudine oral tablet 100 mg G QL
lamivudine oral tablet 150 mg, 300 mg G-S QL
lamivudine-zidovudine G-S QL
LEXIVA PB-S QL
lopinavir-ritonavir G-S QL
nevirapine G-S QL
NORVIR PB-S QL
ODEFSEY PB-S
OLYSIO NPB-S PA; 2ST HARVONI, VIEKIRA PAK, VIEKIRA XR
oseltamivir G QL
PREZCOBIX NPB-S PREZISTA, NORVIR
PREZISTA ORAL SUSPENSION PB-S QL
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
PB-S QL
RELENZA DISKHALER PB QL
RESCRIPTOR PB-S QL
RETROVIR ORAL CAPSULE NPB-S QL zidovudine
RETROVIR ORAL SYRUP NPB-S QL zidovudine
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
PB-S
REYATAZ ORAL POWDER IN PACKET
PB-S
ribavirin inhalation G-S
rimantadine G
SELZENTRY ORAL SOLUTION NPB-S
SELZENTRY ORAL TABLET 150 MG, 300 MG
PB-S QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
6
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
SELZENTRY ORAL TABLET 25 MG, 75 MG
PB-S
SITAVIG NPB 2ST acyclovir, acyclovir, famciclovir, valacyclovir, ZOVIRAX
SOVALDI NPB-S PA; QL; 2ST HARVONI, VIEKIRA PAK, VIEKIRA XR
stavudine G-S QL
STRIBILD PB-S QL
SUSTIVA PB-S QL
TAMIFLU ORAL CAPSULE NPB QL oseltamivir phosphate
TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION
PB QL
TECHNIVIE PB-S PA
TIVICAY ORAL TABLET 10 MG, 25 MG
PB-S
TIVICAY ORAL TABLET 50 MG PB-S QL
TRIUMEQ PB-S QL
TRIZIVIR NPB-S QL abacavir-lamivudine-zidovudine
TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG
PB-S
TRUVADA ORAL TABLET 200-300 MG
PB-S QL
TYBOST NPB-S QL NORVIR
valacyclovir G QL
VALCYTE NPB valganciclovir hcl
valganciclovir G
VALTREX NPB QL valacyclovir
VEMLIDY PB
VIDEX 2 GRAM PEDIATRIC PB-S QL
VIDEX EC NPB-S QL didanosine
VIEKIRA PAK PB-S PA; QL
VIEKIRA XR PB-S PA
VIRACEPT ORAL TABLET PB-S QL
VIRAMUNE NPB-S QL nevirapine
VIRAMUNE XR NPB-S QL nevirapine er
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
7
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
VIRAZOLE NPB-S RIBAVIRIN
VIREAD PB-S QL
ZEPATIER NPB-S PA; 2ST HARVONI, VIEKIRA PAK, VIEKIRA XR
ZERIT NPB-S QL stavudine
ZIAGEN ORAL SOLUTION PB-S QL
ZIAGEN ORAL TABLET NPB-S QL abacavir
zidovudine G-S QL
ZOVIRAX ORAL NPB acyclovir
CEPHALOSPORINS
CEDAX NPB ceftibuten
cefaclor oral capsule G
cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
G
cefaclor oral tablet extended release 12 hr
G
cefadroxil oral capsule G
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml
G
cefadroxil oral tablet G
cefdinir G
cefditoren pivoxil G
cefixime G
cefpodoxime G
cefprozil G
ceftibuten G
CEFTIN ORAL SUSPENSION FOR RECONSTITUTION
NPB amoxicillin-clavulanate potass, cefdinir, cefpodoxime proxetil
cefuroxime axetil oral tablet G
cephalexin G
DAXBIA NPB cephalexin
KEFLEX ORAL CAPSULE NPB cephalexin
SPECTRACEF ORAL TABLET 400 MG
NPB cefditoren pivoxil
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
8
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
SUPRAX ORAL CAPSULE NPB cefpodoxime proxetil, cefuroxime axetil, cefdinir
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION
NPB cefpodoxime proxetil, cefuroxime axetil, cefdinir
SUPRAX ORAL TABLET,CHEWABLE
NPB cefpodoxime proxetil, cefuroxime axetil, cefdinir
ERYTHROMYCINS & OTHER MACROLIDES
azithromycin oral G
BIAXIN ORAL TABLET 500 MG NPB clarithromycin
clarithromycin G
DIFICID NPB metronidazole, vancomycin hcl
e.e.s. 400 oral tablet G
E.E.S. GRANULES NPB azithromycin
ERYPED 200 NPB azithromycin
ERYPED 400 NPB azithromycin
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
G
ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG
NPB erythromycin
erythrocin (as stearate) oral tablet 250 mg
G
erythromycin ethylsuccinate oral suspension for reconstitution
G
erythromycin ethylsuccinate oral tablet G
erythromycin oral capsule,delayed release(dr/ec)
G
erythromycin oral tablet G
PCE NPB clarithromycin, erythromycin
ZITHROMAX ORAL NPB azithromycin
ZITHROMAX TRI-PAK NPB azithromycin
ZITHROMAX Z-PAK NPB azithromycin
ZMAX NPB azithromycin
MISCELLANEOUS ANTIINFECTIVES
ALBENZA PB
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
9
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ALINIA PB
atovaquone G
atovaquone-proguanil G QL
BILTRICIDE PB
CAYSTON PB-S QL
chloroquine phosphate G
CLEOCIN HCL NPB clindamycin hcl
CLEOCIN PEDIATRIC NPB clindamycin palmitate hcl
clindamycin hcl G
clindamycin palmitate hcl G
clindamycin pediatric G
COARTEM PB
colistin (colistimethate na) G
COLY-MYCIN M PARENTERAL NPB colistimethate sodium
CYCLOSERINE NPB
dapsone G M
DARAPRIM PB-S PA; QL
EMVERM PB
ethambutol G
FLAGYL NPB metronidazole
FLAGYL ER NPB metronidazole
gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml
G
GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML
PB
GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 120 MG/100 ML
NPB
gentamicin sulfate (ped) (pf) G
gentamicin sulfate (pf) intravenous solution 100 mg/10 ml
G
GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML
NPB
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
10
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
hydroxychloroquine G M
IMPAVIDO PB-S
isoniazid oral G
ivermectin G
KETEK NPB azithromycin, clarithromycin, erythromycin
KITABIS PAK PB-S
linezolid oral G
MALARONE NPB QL atovaquone-proguanil hcl
MALARONE PEDIATRIC NPB QL atovaquone-proguanil hcl
mefloquine G QL
MEPRON NPB atovaquone
metronidazole oral G
MYAMBUTOL ORAL TABLET 400 MG
NPB ethambutol hcl
MYCOBUTIN NPB rifabutin
NEBUPENT PB QL
neomycin G
paromomycin G
PASER NPB
PLAQUENIL NPB M hydroxychloroquine sulfate
PRIFTIN PB
PRIMAQUINE PB QL; M
pyrazinamide G
QUALAQUIN NPB quinine sulfate
quinine sulfate G
rifabutin G
RIFADIN ORAL NPB rifampin
RIFAMATE NPB isoniazid, rifampin
rifampin oral G
RIFATER NPB
SIRTURO PB
SIVEXTRO ORAL NPB linezolid
STROMECTOL NPB ivermectin
TINDAMAX ORAL TABLET 500 MG NPB tinidazole
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
11
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
tinidazole G
TOBI NPB QL tobramycin sulfate
TOBI PODHALER PB QL
tobramycin in 0.225 % nacl G QL
TOBRAMYCIN WITH NEBULIZER NPB-S tobramycin sulfate, BETHKIS, TOBI PODHALER
TRECATOR NPB
XIFAXAN PB
ZYVOX ORAL NPB linezolid
PENICILLINS
amoxicillin oral capsule G
amoxicillin oral suspension for reconstitution
G
amoxicillin oral tablet G
amoxicillin oral tablet,chewable 125 mg, 250 mg
G
amoxicillin-pot clavulanate G
ampicillin oral capsule G
ampicillin oral suspension for reconstitution 250 mg/5 ml
G
AUGMENTIN ES-600 NPB amoxicillin-clavulanate potass
AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML
PB
AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 250-62.5 MG/5 ML
NPB amoxicillin-clavulanate potass
AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG
NPB amoxicillin-clavulanate potass
AUGMENTIN XR NPB amoxicillin-clavulanate pot er
dicloxacillin G
MOXATAG NPB amoxicillin
penicillin v potassium G
QUINOLONES
AVELOX NPB moxifloxacin hcl
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
12
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
CIPRO ORAL SUSPENSION,MICROCAPSULE RECON
NPB ciprofloxacin
CIPRO ORAL TABLET 250 MG, 500 MG
NPB ciprofloxacin hcl
CIPRO XR NPB ciprofloxacin er
ciprofloxacin G
ciprofloxacin (mixture) G
ciprofloxacin hcl oral G
FACTIVE NPB QL ciprofloxacin hcl, levofloxacin hemihydrate, moxifloxacin hcl, ofloxacin
LEVAQUIN ORAL TABLET NPB levofloxacin hemihydrate
levofloxacin oral G
moxifloxacin oral G
ofloxacin oral tablet 300 mg, 400 mg G
SULFA'S & RELATED AGENTS
BACTRIM NPB sulfamethoxazole/trimethoprim
BACTRIM DS NPB sulfamethoxazole/trimethoprim
sulfadiazine G
sulfamethoxazole-trimethoprim oral G
sulfatrim G
TETRACYCLINES
ACTICLATE NPB ST doxycycline hyclate, doxycycline monohydrate
avidoxy G
demeclocycline G
DORYX MPC NPB ST doxycycline hyclate
DORYX ORAL TABLET,DELAYED RELEASE (DR/EC) 200 MG, 50 MG
NPB ST doxycycline hyclate
doxycycline hyclate oral capsule G
doxycycline hyclate oral tablet G
doxycycline hyclate oral tablet,delayed release (dr/ec)
G
doxycycline monohydrate oral capsule G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
13
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE
NPB 2ST doxycycline hyclate, doxycycline monohydrate, ORACEA
doxycycline monohydrate oral suspension for reconstitution
G
doxycycline monohydrate oral tablet G
MINOCIN ORAL NPB minocycline hcl
minocycline oral capsule G
minocycline oral tablet G
minocycline oral tablet extended release 24 hr
G ST; QL
mondoxyne nl G
MONODOX NPB ST doxycycline monohydrate
morgidox oral capsule 100 mg G
ORACEA PB ST
SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG
PB ST; QL
TARGADOX NPB ST doxycycline hyclate
tetracycline G
VIBRAMYCIN ORAL CAPSULE 100 MG
NPB ST doxycycline hyclate
VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION
NPB ST doxycycline monohydrate
VIBRAMYCIN ORAL SYRUP NPB ST doxycycline hyclate
URINARY TRACT AGENTS
FURADANTIN NPB nitrofurantoin
HIPREX NPB methenamine hippurate
MACROBID NPB nitrofurantoin macrocrystal
MACRODANTIN NPB nitrofurantoin
methenamine hippurate G
methenamine mandelate G
MONUROL NPB ciprofloxacin hcl, nitrofurantoin
nitrofurantoin G
nitrofurantoin macrocrystal G
nitrofurantoin monohyd/m-cryst G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
14
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
PRIMSOL NPB trimethoprim
trimethoprim G
VANCOMYCIN
VANCOCIN NPB vancomycin hcl
vancomycin oral capsule G
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium injection recon soln G-S
leucovorin calcium oral G
MESNEX ORAL PB
VISTOGARD PB
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS
AFINITOR PB-S QL
AFINITOR DISPERZ PB-S QL
ALECENSA NPB-S ZYKADIA
ALKERAN ORAL PB-S
anastrozole G
ARIMIDEX NPB-S anastrozole
AROMASIN NPB-S exemestane
ASTAGRAF XL NPB ST tacrolimus
AZASAN PB
azathioprine G
bexarotene G-S
bicalutamide G
BOSULIF PB-S
CABOMETYX NPB-S QL INLYTA, NEXAVAR, SUTENT, VOTRIENT
capecitabine G-S
CAPRELSA PB-S QL
CASODEX NPB-S bicalutamide
CELLCEPT NPB mycophenolate mofetil
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
15
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
COMETRIQ NPB-S QL CAPRELSA
COTELLIC PB-S
CYCLOPHOSPHAMIDE ORAL CAPSULE
PB-S
cyclosporine intravenous G-S
cyclosporine modified G
cyclosporine oral capsule G
DROXIA PB-S
ELIGARD PB-S
ELIGARD (3 MONTH) PB-S QL
ELIGARD (4 MONTH) PB-S
ELIGARD (6 MONTH) PB-S
EMCYT PB-S
ENVARSUS XR NPB ST tacrolimus
ERIVEDGE PB-S
etoposide oral G-S
exemestane G-S
FARESTON PB-S
FARYDAK NPB-S
DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, THALOMID, VELCADE
FEMARA NPB-S letrozole
FIRMAGON KIT W DILUENT SYRINGE
PB-S
flutamide G
gengraf G
GILOTRIF PB-S
GLEEVEC NPB-S QL imatinib mesylate
GLEOSTINE PB-S
HEXALEN PB-S
HYCAMTIN ORAL PB-S
HYDREA NPB-S hydroxyurea
hydroxyurea G-S
IBRANCE PB-S
ICLUSIG PB-S
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
16
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
imatinib G-S QL
IMBRUVICA PB-S
IMURAN NPB azathioprine
INLYTA PB-S QL
IRESSA PB-S
JAKAFI PB-S QL
LENVIMA PB-S
letrozole G-S
LEUKERAN PB-S
leuprolide subcutaneous kit G-S
LONSURF PB-S
LUPRON DEPOT PB-S
LUPRON DEPOT (3 MONTH) PB-S QL
LUPRON DEPOT (4 MONTH) PB-S
LUPRON DEPOT (6 MONTH) PB-S
LUPRON DEPOT-PED PB-S
LUPRON DEPOT-PED (3 MONTH) PB
LYNPARZA PB-S
LYSODREN PB-S
MATULANE PB-S
MEGACE ES NPB-S megestrol acetate
megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml
G
megestrol oral tablet G-S
MEKINIST PB-S
mercaptopurine G
methotrexate sodium G
methotrexate sodium (pf) G
mycophenolate mofetil G
mycophenolate sodium G
MYFORTIC NPB mycophenolic acid
MYLERAN PB-S
NEORAL NPB cyclosporine
NEXAVAR PB-S QL
NILANDRON NPB-S nilutamide
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
17
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
nilutamide G-S
NINLARO PB-S
octreotide acetate G-S
ODOMZO NPB-S ERIVEDGE
PROGRAF ORAL NPB TACROLIMUS
PURIXAN PB-S
RAPAMUNE ORAL SOLUTION PB
RAPAMUNE ORAL TABLET NPB sirolimus
RUBRACA PB PA
SANDIMMUNE INTRAVENOUS NPB-S cyclosporine
SANDIMMUNE ORAL CAPSULE NPB cyclosporine
SANDIMMUNE ORAL SOLUTION PB
SANDOSTATIN NPB-S octreotide acetate
sirolimus G
SOLTAMOX NPB-S tamoxifen citrate
SOMATULINE DEPOT PB-S
SPRYCEL PB-S QL
STIVARGA PB-S
SUTENT PB-S QL
TABLOID PB-S
tacrolimus oral G
TAFINLAR PB-S
TAGRISSO PB-S
tamoxifen G
TARCEVA PB-S QL
TARGRETIN ORAL NPB-S bexarotene
TARGRETIN TOPICAL PB
TASIGNA PB-S QL
TEMODAR ORAL NPB-S temozolomide
temozolomide G-S
THALOMID PB-S
tretinoin (chemotherapy) G-S
TREXALL PB-S
TYKERB PB-S QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
18
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
VENCLEXTA ORAL TABLET 100 MG
PB-S
VENCLEXTA STARTING PACK PB-S
VOTRIENT PB-S QL
XALKORI PB-S QL
XATMEP NPB
XELODA NPB-S capecitabine
XTANDI NPB-S QL ZYTIGA
ZELBORAF PB-S QL
ZOLINZA PB-S QL
ZORTRESS PB
ZYDELIG PB-S
ZYKADIA PB-S
ZYTIGA PB-S QL
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
ANTICONVULSANTS
APTIOM NPB carbamazepine, oxcarbazepine, topiramate, LYRICA, POTIGA, VIMPAT
BANZEL PB
BRIVIACT ORAL NPB levetiracetam
carbamazepine oral capsule, er multiphase 12 hr
G
carbamazepine oral suspension 100 mg/5 ml
G
carbamazepine oral tablet G
carbamazepine oral tablet extended release 12 hr
G
carbamazepine oral tablet,chewable G
CARBATROL NPB carbamazepine er
CELONTIN ORAL CAPSULE 300 MG PB
clonazepam G
DEPAKENE NPB valproic acid
DEPAKOTE NPB divalproex sodium
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
19
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
DEPAKOTE ER NPB divalproex sodium er
DEPAKOTE SPRINKLES NPB divalproex sodium
DIASTAT NPB diazepam
DIASTAT ACUDIAL NPB diazepam
DILANTIN PB
DILANTIN EXTENDED NPB phenytoin sodium
DILANTIN INFATABS NPB phenytoin
DILANTIN-125 NPB phenytoin
divalproex G
epitol G
EQUETRO NPB carbamazepine, carbamazepine er
ethosuximide G
felbamate G
FELBATOL NPB felbamate
FYCOMPA ORAL SUSPENSION PB
FYCOMPA ORAL TABLET PB
gabapentin oral capsule G
gabapentin oral solution 250 mg/5 ml G
gabapentin oral tablet 600 mg, 800 mg G
GABITRIL ORAL TABLET 12 MG, 16 MG
PB
GABITRIL ORAL TABLET 2 MG, 4 MG
NPB tiagabine hcl
GRALISE PB ST; QL
GRALISE 30-DAY STARTER PACK PB ST; QL
KEPPRA ORAL NPB levetiracetam
KEPPRA XR NPB levetiracetam
KLONOPIN NPB clonazepam
LAMICTAL ODT NPB lamotrigine odt
LAMICTAL ODT STARTER (BLUE) NPB lamotrigine odt
LAMICTAL ODT STARTER (GREEN) NPB lamotrigine odt
LAMICTAL ODT STARTER (ORANGE)
NPB lamotrigine odt
LAMICTAL ORAL TABLET NPB lamotrigine
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
20
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG
NPB lamotrigine
LAMICTAL STARTER (BLUE) KIT NPB lamotrigine
LAMICTAL STARTER (GREEN) KIT NPB lamotrigine
LAMICTAL STARTER (ORANGE) KIT
NPB lamotrigine
LAMICTAL XR NPB lamotrigine
LAMICTAL XR STARTER (BLUE) PB
LAMICTAL XR STARTER (GREEN) PB
LAMICTAL XR STARTER (ORANGE)
PB
lamotrigine oral tablet G
lamotrigine oral tablet disintegrating, dose pk
G
lamotrigine oral tablet extended release 24hr
G
lamotrigine oral tablet, chewable dispersible
G
lamotrigine oral tablet,disintegrating G
levetiracetam oral G
LYRICA PB ST
MYSOLINE NPB primidone
NEURONTIN NPB ST gabapentin
ONFI ORAL SUSPENSION PB
ONFI ORAL TABLET 10 MG, 20 MG PB
oxcarbazepine G
OXTELLAR XR NPB oxcarbazepine
PEGANONE PB
phenobarbital G
PHENYTEK NPB phenytoin sodium
phenytoin oral suspension 125 mg/5 ml G
phenytoin oral tablet,chewable G
phenytoin sodium extended G
primidone G
QUDEXY XR PB
roweepra G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
21
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
SABRIL PB-S PA
TEGRETOL ORAL SUSPENSION NPB carbamazepine
TEGRETOL ORAL TABLET NPB carbamazepine
TEGRETOL XR NPB carbamazepine er
tiagabine G
TOPAMAX NPB topiramate
topiramate oral capsule, sprinkle G
TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR
NPB topiramate
topiramate oral tablet G
TRILEPTAL NPB oxcarbazepine
TROKENDI XR NPB topiramate
valproic acid G
valproic acid (as sodium salt) oral solution 250 mg/5 ml
G
VIMPAT ORAL SOLUTION PB
VIMPAT ORAL TABLET PB
ZARONTIN NPB ethosuximide
ZONEGRAN ORAL CAPSULE 100 MG, 25 MG
NPB zonisamide
zonisamide G
ANTIPARKINSONISM AGENTS
APOKYN PB-S
AZILECT NPB M RASAGILINE MESYLATE
benztropine oral G
bromocriptine G
carbidopa G M
carbidopa-levodopa G M
carbidopa-levodopa-entacapone G M
COMTAN NPB M entacapone
ELDEPRYL NPB M selegiline hcl
entacapone G M
LODOSYN NPB M carbidopa
MIRAPEX NPB M pramipexole di-hcl
MIRAPEX ER NPB M pramipexole er
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
22
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
NEUPRO NPB M pramipexole di-hcl, pramipexole er, ropinirole hcl
PARLODEL NPB bromocriptine mesylate
pramipexole G M
rasagiline G M
REQUIP NPB M ropinirole hcl
REQUIP XL NPB M ropinirole hcl
ropinirole G M
RYTARY NPB M carbidopa/levodopa, carbidopa-levodopa er
selegiline hcl G M
SINEMET NPB M carbidopa/levodopa
SINEMET CR NPB M carbidopa-levodopa er
STALEVO 100 NPB M carbidopa-levodopa-entacapone
STALEVO 125 NPB M carbidopa-levodopa-entacapone
STALEVO 150 NPB M carbidopa-levodopa-entacapone
STALEVO 200 NPB M carbidopa-levodopa-entacapone
STALEVO 50 NPB M carbidopa-levodopa-entacapone
STALEVO 75 NPB M carbidopa-levodopa-entacapone
TASMAR ORAL TABLET 100 MG NPB M tolcapone
tolcapone G M
trihexyphenidyl G
XADAGO NPB PA; M
ZELAPAR NPB M RASAGILINE MESYLATE, selegiline hcl
MIGRAINE & CLUSTER HEADACHE THERAPY
almotriptan malate G QL
ALSUMA NPB ST; QL sumatriptan succinate
AMERGE NPB ST; QL naratriptan hcl
AXERT NPB ST; QL almotriptan malate
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
23
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
CAFERGOT NPB ergotamine-caffeine
D.H.E.45 NPB dihydroergotamine mesylate
dihydroergotamine injection G
dihydroergotamine nasal G QL
ERGOMAR NPB
ergotamine-caffeine G
frovatriptan G QL
IMITREX NASAL NPB ST sumatriptan succinate
IMITREX ORAL NPB ST; QL sumatriptan succinate
IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML
NPB ST; QL sumatriptan succinate
IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML
NPB ST; QL sumatriptan succinate
IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML
NPB ST; QL sumatriptan succinate
IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 6 MG/0.5 ML
NPB ST; QL sumatriptan succinate
IMITREX SUBCUTANEOUS NPB ST; QL sumatriptan succinate
isometh-dichloral-acetaminophn G QL
isomethepten-caf-acetaminophen oral tablet 65-20-325 mg
G QL
MAXALT NPB ST; QL rizatriptan
MAXALT-MLT NPB ST; QL rizatriptan
migergot G
MIGRANAL NPB QL dihydroergotamine mesylate
naratriptan G QL
nodolor G QL
ONZETRA XSAIL NPB ST sumatriptan succinate, ZOMIG
PRODRIN ORAL TABLET 65-20-325 MG
NPB QL isomethept-caffeine-apap
RELPAX PB ST; QL
rizatriptan G QL
sumatriptan G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
24
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
sumatriptan succinate oral G QL
sumatriptan succinate subcutaneous cartridge
G QL
sumatriptan succinate subcutaneous pen injector
G QL
sumatriptan succinate subcutaneous solution
G QL
sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml
G QL
SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML
PB ST sumatriptan succinate
SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML
PB ST; QL sumatriptan succinate
TREXIMET NPB ST; QL naproxen, naproxen sodium, sumatriptan succinate
ZEMBRACE SYMTOUCH NPB ST; QL sumatriptan succinate
zolmitriptan G QL
ZOMIG NASAL PB ST
ZOMIG ORAL NPB ST; QL zolmitriptan
ZOMIG ZMT NPB ST; QL zolmitriptan odt
MISCELLANEOUS NEUROLOGICAL THERAPY
AMPYRA PB-S PA; QL
ARICEPT NPB M donepezil hcl
donepezil G M
EXELON TRANSDERMAL NPB QL; M rivastigmine
galantamine oral capsule,ext rel. pellets 24 hr
G QL; M
galantamine oral solution G QL; M
galantamine oral tablet 12 mg G M
galantamine oral tablet 4 mg, 8 mg G QL; M
HORIZANT NPB ST; QL gabapentin, GRALISE, LYRICA
KEVEYIS NPB acetazolamide
memantine oral solution G M
memantine oral tablet G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
25
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
MEMANTINE ORAL TABLETS,DOSE PACK
NPB QL; M memantine hcl, NAMENDA XR
NAMENDA ORAL TABLET NPB M memantine hcl
NAMENDA TITRATION PAK NPB QL; M memantine hcl
NAMENDA XR PB QL; M
NAMZARIC PB
NUEDEXTA PB
RAZADYNE ER NPB QL; M GALANTAMINE ER
RAZADYNE ORAL TABLET 12 MG NPB M galantamine
RAZADYNE ORAL TABLET 4 MG, 8 MG
NPB QL; M galantamine
rivastigmine G QL; M
rivastigmine tartrate G QL; M
tetrabenazine G PA
XENAZINE NPB PA tetrabenazine
MUSCLE RELAXANTS & ANTISPASMODIC THERAPY
AMRIX NPB 2ST cyclobenzaprine hcl
baclofen G M
carisoprodol G metaxalone, tizanidine hcl
carisoprodol-asa-codeine G metaxalone, tizanidine hcl
carisoprodol-aspirin G metaxalone, tizanidine hcl
chlorzoxazone G
cyclobenzaprine oral tablet G
DANTRIUM ORAL CAPSULE 25 MG, 50 MG
NPB M dantrolene sodium
dantrolene G M
FEXMID NPB 2ST cyclobenzaprine hcl
LORZONE NPB 2ST chlorzoxazone
meprobamate G alprazolam, buspirone hcl, chlordiazepoxide hcl, diazepam, lorazepam
MESTINON ORAL SYRUP PB M
MESTINON ORAL TABLET NPB M pyridostigmine bromide
MESTINON TIMESPAN NPB M pyridostigmine bromide er
metaxall G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
26
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
metaxalone G
methocarbamol oral G
orphenadrine citrate oral G
PARAFON FORTE DSC NPB chlorzoxazone
pyridostigmine bromide G M
ROBAXIN ORAL NPB methocarbamol
ROBAXIN-750 NPB methocarbamol
SKELAXIN NPB metaxalone
SOMA NPB metaxalone, tizanidine hcl
tizanidine G
ZANAFLEX NPB tizanidine hcl
NARCOTIC ANALGESICS
ABSTRAL NPB PA; QL; 2ST fentanyl citrate, LAZANDA
acetaminophen-caff-dihydrocod oral capsule
G QL
ACETAMINOPHEN-CAFF-DIHYDROCOD ORAL TABLET 325-30-16 MG
NPB QL
acetaminophen-codeine oral solution 120-12 mg/5 ml
G QL
acetaminophen-codeine oral tablet G QL
ACTIQ NPB PA; QL fentanyl citrate
ALLZITAL NPB QL; 2ST acetaminophen w/butalbital
ARYMO ER NPB PA; ST
hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN
ascomp with codeine G
aspirin-caffeine-dihydrocodein G
BELBUCA NPB PA morphine sulfate cr, morphine sulfate er, oxymorphone hcl er
BUPAP ORAL TABLET 50-300 MG NPB QL; 2ST acetaminophen w/butalbital
BUPRENORPHINE NPB ST; QL fentanyl
buprenorphine hcl sublingual G PA
butalbital compound w/codeine G
butalbital-acetaminop-caf-cod G QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
27
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
butalbital-acetaminophen G QL
butalbital-acetaminophen-caff oral capsule
G QL
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
G QL
butalbital-aspirin-caffeine oral capsule G
BUTRANS PB ST; QL fentanyl
capacet G QL
CAPITAL WITH CODEINE NPB QL acetaminophen w/codeine
codeine sulfate oral tablet G
codeine-butalbital-asa-caff G
DEMEROL ORAL TABLET 100 MG NPB codeine sulfate, hydromorphone hcl, morphine sulfate, oxycodone hcl
DILAUDID ORAL LIQUID NPB hydromorphone hcl
DILAUDID ORAL TABLET 2 MG, 4 MG
NPB hydromorphone hcl
DILAUDID ORAL TABLET 8 MG NPB QL hydromorphone hcl
diskets G
DOLOPHINE ORAL NPB methadone hcl
DURAGESIC NPB fentanyl
EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL
NPB ST
hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
G QL
ESGIC NPB QL; 2ST butalbital/apap/caffeine
EXALGO ER NPB ST hydromorphone er
fentanyl citrate G PA; QL
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
G
FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR, 87.5 MCG/HOUR
NPB fentanyl
FENTORA NPB PA; QL; 2ST fentanyl citrate, LAZANDA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
28
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
FIORINAL NPB 2ST butalbital-asp-caffeine
FIORINAL-CODEINE #3 NPB 2ST asa-butalb-caff-cod
hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml
G QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
G QL
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
G
hydromorphone oral liquid G
hydromorphone oral tablet 2 mg, 4 mg G
hydromorphone oral tablet 8 mg G QL
hydromorphone oral tablet extended release 24 hr
G
hydromorphone rectal G
HYSINGLA ER PB ST
IBUDONE NPB hydrocodone bit-ibuprofen, reprexain
ibuprofen-oxycodone G
IONSYS NPB
KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG
NPB ST morphine sulfate er
KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG, 40 MG
NPB ST
hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN
LAZANDA PB PA
levorphanol tartrate G
lorcet (hydrocodone) G QL
lorcet hd G QL
lorcet plus oral tablet 7.5-325 mg G QL
LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML
NPB QL hydrocodone w/acetaminophen
marten-tab G QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
29
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
meperidine oral solution G hydromorphone hcl, morphine sulfate, oxycodone hcl
meperidine oral tablet G codeine sulfate, hydromorphone hcl, morphine sulfate, oxycodone hcl
methadone oral concentrate G
methadone oral solution G
methadone oral tablet G
methadone oral tablet,soluble G
methadose oral concentrate G
methadose oral tablet,soluble G
MORPHABOND ER NPB ST
morphine concentrate oral solution G
morphine oral G
morphine rectal G
MS CONTIN NPB ST MORPHINE SULFATE
NORCO NPB QL hydrocodone w/acetaminophen
OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR
PB ST
OPANA ORAL NPB oxymorphone hcl
OXAYDO ORAL TABLET, ORAL ONLY 5 MG
NPB QL oxycodone hcl
OXAYDO ORAL TABLET, ORAL ONLY 7.5 MG
NPB oxycodone hcl
oxycodone oral capsule G QL
oxycodone oral concentrate G QL
oxycodone oral solution G
oxycodone oral tablet 10 mg, 20 mg G
oxycodone oral tablet 15 mg, 30 mg, 5 mg
G QL
OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR
NPB ST; QL
hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN
oxycodone-acetaminophen oral solution G QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
30
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
G QL
oxycodone-aspirin G
OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR
PB ST; QL
oxymorphone G
PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG
NPB QL oxycodone w/acetaminophen
PRIMLEV NPB QL oxycodone w/acetaminophen
ROXICODONE NPB QL oxycodone hcl
SUBSYS NPB PA; 2ST fentanyl citrate, LAZANDA
SYNALGOS-DC NPB aspirin-caffeine-dihydrocodein
tencon oral tablet 50-325 mg G QL
TREZIX ORAL CAPSULE 320.5-30-16 MG
NPB QL apap-caffeine-dihydrocodeine
TYLENOL-CODEINE #3 NPB QL acetaminophen w/codeine
TYLENOL-CODEINE #4 NPB QL acetaminophen w/codeine
VANATOL LQ NPB QL; 2ST
verdrocet G QL
vicodin G QL
vicodin es G QL
vicodin hp G QL
XODOL 10/300 NPB QL hydrocodone w/acetaminophen
XODOL 5/300 NPB QL hydrocodone w/acetaminophen
XODOL 7.5/300 NPB QL hydrocodone w/acetaminophen
XTAMPZA ER NPB ST; QL
hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN
xylon 10 G
zamicet G QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
31
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
zebutal oral capsule 50-325-40 mg G QL
ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR
NPB ST
hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN
NON-NARCOTIC ANALGESICS
ANAPROX DS NPB ST; M naproxen sodium
ARTHROTEC 50 NPB ST; M diclofenac sodium-misoprostol
ARTHROTEC 75 NPB ST; M diclofenac sodium-misoprostol
aspir-81 G M; ACA; OTC
aspirin low dose G M; ACA; OTC
aspirin oral tablet G ACA; OTC
aspirin oral tablet,chewable G M; ACA; OTC
aspirin oral tablet,delayed release (dr/ec) 325 mg
G ACA; OTC
aspirin oral tablet,delayed release (dr/ec) 81 mg
G M; ACA; OTC
aspir-low G M; ACA; OTC
aspir-trin G ACA; OTC
bayer aspirin G ACA; OTC
BUNAVAIL NPB PA buprenorphine-naloxone, SUBOXONE, ZUBSOLV
buprenorphine-naloxone G PA; QL
butorphanol tartrate nasal G QL
CAMBIA NPB ST; QL diclofenac potassium, diclofenac sodium, diclofenac sodium
CELEBREX NPB ST; QL; M celecoxib
celecoxib G QL; M
children's aspirin G M; ACA; OTC
choline,magnesium salicylate G
CONZIP NPB QL tramadol hcl er
DAYPRO NPB ST; M oxaprozin
diclofenac potassium G
diclofenac sodium oral G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
32
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
diclofenac sodium topical drops G QL; M
diclofenac sodium topical gel 1 % G QL; M
diclofenac-misoprostol G M
diflunisal G M
DISALCID NPB salsalate
DUEXIS NPB ST; QL; M ibuprofen, famotidine
e.c. prin G ACA; OTC
EC-NAPROSYN NPB ST; M naproxen
ecotrin G ACA; OTC
ecotrin low strength G M; ACA; OTC
etodolac G M
EVZIO NPB 2ST naloxone hcl, naloxone hcl
FELDENE NPB ST; M piroxicam
FENOPROFEN ORAL CAPSULE NPB ST; M
fenoprofen oral tablet G M
FENORTHO NPB ST; M
fenoprofen calcium, diclofenac sodium, indomethacin, ibuprofen, meloxicam, naproxen sodium, nabumetone
FLECTOR PB ST; QL
flurbiprofen G M
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
G M
INDOCIN ORAL NPB ST ibuprofen, meloxicam, naproxen sodium
INDOCIN RECTAL NPB ST
indomethacin oral G
ketoprofen oral capsule G M
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg
G M
ketorolac oral G QL
klofensaid ii G QL; M
lite coat aspirin G ACA; OTC
LODINE ORAL TABLET NPB ST; M
meclofenamate G M
mefenamic acid G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
33
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
meloxicam oral suspension G M
meloxicam oral tablet 15 mg G M
meloxicam oral tablet 7.5 mg G QL; M
MOBIC ORAL TABLET 15 MG NPB ST; M meloxicam
MOBIC ORAL TABLET 7.5 MG NPB ST; QL; M meloxicam
nabumetone G M
NALFON ORAL CAPSULE 400 MG NPB ST; M
fenoprofen calcium, diclofenac sodium, indomethacin, ibuprofen, meloxicam, naproxen sodium, nabumetone
naltrexone G
NAPRELAN CR NPB ST; M naproxen sodium er
NAPROSYN ORAL SUSPENSION NPB ST; M naproxen
NAPROSYN ORAL TABLET 500 MG NPB ST; M naproxen
naproxen G M
naproxen sodium oral tablet 275 mg, 550 mg
G M
naproxen sodium oral tablet, er multiphase 24 hr
G M
NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION
PB
NUCYNTA PB QL
NUCYNTA ER PB ST
oxaprozin G M
PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP
NPB ST; QL; M diclofenac sodium, diclofenac sodium, FLECTOR
pentazocine-naloxone G codeine sulfate, hydromorphone hcl, morphine sulfate, oxycodone hcl
piroxicam G M
PONSTEL NPB ST mefenamic acid
REVIA NPB naltrexone hydrochloride
salsalate G
SPRIX NPB ST; QL
diclofenac sodium, etodolac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
34
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
SUBOXONE PB PA; QL
sulindac G M
TIVORBEX NPB ST; M
diclofenac sodium, indomethacin, ibuprofen, meloxicam, naproxen sodium, nabumetone, piroxicam
tolmetin G M
TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 17-83
NPB QL tramadol hcl er
TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 25-75
NPB QL tramadol hcl er
tramadol oral tablet G QL
tramadol oral tablet extended release 24 hr
G QL
tramadol oral tablet, er multiphase 24 hr G QL
tramadol-acetaminophen G QL
ULTRACET NPB QL tramadol hcl-acetaminophen
ULTRAM NPB QL tramadol hcl
ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 300 MG
NPB QL tramadol hcl er
VIMOVO NPB ST; QL; M naproxen sodium, omeprazole
VIVLODEX NPB ST; M meloxicam
VOLTAREN TOPICAL NPB ST; QL; M diclofenac sodium
VOLTAREN-XR NPB ST; M diclofenac sodium
ZIPSOR NPB ST; QL diclofenac potassium, diclofenac sodium, diclofenac sodium
ZORVOLEX PB ST; QL; M
ZUBSOLV PB PA
PSYCHOTHERAPEUTIC DRUGS
ABILIFY ORAL TABLET NPB QL aripiprazole
ADASUVE NPB
ADDERALL NPB QL dextroamphetamine-amphetamine
ADDERALL XR NPB QL dextroamphetamine-amphet er
ADDYI NPB PA; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
35
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ADZENYS XR-ODT NPB
dextroamphetamine sulfate er, dextroamphetamine-amphet er, dexmethylphenidate hcl er, methylphenidate er, VYVANSE
alprazolam G
alprazolam intensol G
AMBIEN NPB ST zolpidem tartrate
AMBIEN CR NPB ST zolpidem tartrate er
amitriptyline G
amitriptyline-chlordiazepoxide G
amoxapine G
ANAFRANIL NPB clomipramine hcl
APLENZIN NPB QL; M bupropion hcl xl
APTENSIO XR NPB
methylphenidate er, methylphenidate hcl cd, dexmethylphenidate hcl er, VYVANSE
aripiprazole oral solution G
aripiprazole oral tablet G QL
aripiprazole oral tablet,disintegrating G QL
armodafinil G ST; QL
ATIVAN ORAL NPB lorazepam
atomoxetine G QL
BELSOMRA NPB ST zolpidem tartrate, zolpidem tartrate er, eszopiclone, zaleplon, ROZEREM
BRISDELLE PB ST; M
bupropion hcl oral tablet G M
bupropion hcl oral tablet extended release 12 hr
G QL; M
bupropion hcl oral tablet extended release 24 hr
G QL; M
buspirone G M
BUTISOL ORAL TABLET 30 MG NPB phenobarbital sodium
CELEXA ORAL TABLET NPB ST; QL; M citalopram hbr
chlordiazepoxide hcl G
chlorpromazine G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
36
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
citalopram oral solution G M
citalopram oral tablet G QL; M
clomipramine G
clonidine hcl oral tablet extended release 12 hr
G QL
clorazepate dipotassium G
clozapine oral tablet G
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
G
CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG
NPB clozapine, clozapine odt
CLOZARIL NPB clozapine
CONCERTA NPB QL methylphenidate er
CYMBALTA NPB ST; QL; M duloxetine hcl
DAYTRANA PB QL
desipramine G
DESOXYN NPB QL methamphetamine hcl
DESVENLAFAXINE FUMARATE NPB QL; M
DESVENLAFAXINE SUCCINATE ER, duloxetine hcl, venlafaxine hcl er, FETZIMA
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR
NPB M
DESVENLAFAXINE SUCCINATE ER, duloxetine hcl, venlafaxine hcl er, FETZIMA
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR
NPB QL; M
DESVENLAFAXINE SUCCINATE ER, duloxetine hcl, venlafaxine hcl er, FETZIMA
desvenlafaxine succinate G QL; M
dexedrine G QL
DEXEDRINE SPANSULE NPB QL dextroamphetamine sulfate er
dexmethylphenidate G QL
dextroamphetamine G QL
dextroamphetamine-amphetamine G QL
diazepam intensol G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
37
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
diazepam oral solution 5 mg/5 ml (1 mg/ml)
G
diazepam oral tablet G
DORAL NPB temazepam
doxepin oral G
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg
G QL; M
duloxetine oral capsule,delayed release(dr/ec) 40 mg
G M
DYANAVEL XR NPB
dextroamphetamine sulfate er, dextroamphetamine-amphet er, dexmethylphenidate hcl er, methylphenidate er, VYVANSE
EDLUAR NPB ST; QL eszopiclone, zolpidem tartrate, zolpidem tartrate er
EFFEXOR XR NPB ST; QL; M venlafaxine hcl er
EMSAM NPB QL; M phenelzine sulfate, tranylcypromine sulfate
ergoloid G M
escitalopram oxalate oral solution G M
escitalopram oxalate oral tablet G QL; M
estazolam G
eszopiclone G
EVEKEO PB
FANAPT NPB QL
aripiprazole, olanzapine, quetiapine fumarate, quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA
FAZACLO NPB clozapine odt
FETZIMA PB QL; M
fluoxetine oral capsule G QL; M
fluoxetine oral capsule,delayed release(dr/ec)
G QL; M
fluoxetine oral solution G M
fluoxetine oral tablet 10 mg G QL; M
fluoxetine oral tablet 20 mg G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
38
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
FLUOXETINE ORAL TABLET 60 MG NPB ST citalopram hbr, fluoxetine hcl, paroxetine hcl, sertraline hcl, VIIBRYD
fluphenazine decanoate G
fluphenazine hcl G
flurazepam G
fluvoxamine G QL; M
FOCALIN NPB QL dexmethylphenidate hcl
FOCALIN XR NPB QL dexmethylphenidate hcl er
FORFIVO XL NPB ST; QL; M bupropion hcl xl
GEODON INTRAMUSCULAR NPB olanzapine
GEODON ORAL NPB QL ziprasidone hcl
guanfacine oral tablet extended release 24 hr
G QL
guanidine G
HALCION ORAL TABLET 0.25 MG NPB triazolam
HALDOL NPB haloperidol lactate
HALDOL DECANOATE NPB haloperidol decanoate
haloperidol G
haloperidol decanoate G
haloperidol lactate G
HETLIOZ NPB-S
imipramine hcl G
imipramine pamoate G
INTERMEZZO NPB ST; QL zolpidem tartrate
INTUNIV ER NPB QL guanfacine hcl er
INVEGA NPB QL paliperidone er
IRENKA NPB ST; M duloxetine hcl
KAPVAY NPB QL clonidine hcl er
KHEDEZLA NPB QL; M
DESVENLAFAXINE SUCCINATE ER, duloxetine hcl, venlafaxine hcl er, FETZIMA
LATUDA PB QL
LEXAPRO ORAL TABLET NPB ST; QL; M escitalopram oxalate
lithium carbonate G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
39
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
lithium citrate oral solution 8 meq/5 ml G
LITHOBID NPB lithium carbonate
lorazepam intensol G
lorazepam oral G
loxapine succinate G
LUNESTA NPB ST eszopiclone
maprotiline G
MARPLAN NPB M phenelzine sulfate, tranylcypromine sulfate
METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70 10 MG, 30 MG, 40 MG, 50 MG, 60 MG
NPB methylphenidate hcl cd
METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70 20 MG
NPB QL methylphenidate hcl cd
metadate er G QL
methamphetamine G QL
METHYLIN ORAL SOLUTION NPB QL methylphenidate hcl
METHYLIN ORAL TABLET,CHEWABLE
NPB QL methylphenidate hcl
methylphenidate oral capsule, er biphasic 30-70 10 mg, 30 mg, 40 mg, 50 mg, 60 mg
G
methylphenidate oral capsule, er biphasic 30-70 20 mg
G QL
methylphenidate oral capsule,er biphasic 50-50 20 mg
G QL
methylphenidate oral capsule,er biphasic 50-50 30 mg, 40 mg, 60 mg
G
methylphenidate oral solution G QL
methylphenidate oral tablet G QL
methylphenidate oral tablet extended release 10 mg
G
methylphenidate oral tablet extended release 20 mg
G QL
methylphenidate oral tablet extended release 24hr
G QL
methylphenidate oral tablet,chewable G QL
mirtazapine G QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
40
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
modafinil G ST; QL
NARDIL NPB M phenelzine sulfate
nefazodone G M bupropion hcl, mirtazapine, trazodone hcl
NORPRAMIN ORAL TABLET 10 MG, 25 MG
NPB desipramine hcl
nortriptyline G
NUPLAZID NPB-S clozapine, quetiapine fumarate
NUVIGIL NPB ST; QL armodafinil
olanzapine oral G QL
olanzapine-fluoxetine G
ORAP NPB pimozide
oxazepam G
paliperidone G QL
PAMELOR NPB nortriptyline hcl
PARNATE NPB M tranylcypromine sulfate
paroxetine hcl oral tablet G QL; M
paroxetine hcl oral tablet extended release 24 hr
G QL; M
PAXIL CR NPB ST; QL; M paroxetine er
PAXIL ORAL SUSPENSION NPB ST; M paroxetine hcl
PAXIL ORAL TABLET NPB ST; QL; M paroxetine hcl
perphenazine G
perphenazine-amitriptyline G
PEXEVA NPB ST; QL; M paroxetine hcl, citalopram hbr, escitalopram oxalate, fluoxetine hcl, sertraline hcl
phenelzine G M
pimozide G
PRISTIQ NPB ST; QL; M DESVENLAFAXINE SUCCINATE ER
procentra G QL
protriptyline G
PROVIGIL NPB ST; QL modafinil
PROZAC ORAL CAPSULE 10 MG, 40 MG
NPB ST; QL; M fluoxetine hcl
PROZAC ORAL CAPSULE 20 MG NPB ST; M fluoxetine hcl
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
41
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
PROZAC WEEKLY NPB ST; QL; M fluoxetine dr
quazepam G
quetiapine oral tablet G QL
quetiapine oral tablet extended release 24 hr 150 mg, 200 mg
G
quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg
G QL
QUILLICHEW ER PB
QUILLIVANT XR PB QL
REMERON NPB QL mirtazapine
REMERON SOLTAB NPB QL mirtazapine
RESTORIL NPB temazepam
REXULTI NPB QL
aripiprazole, olanzapine, quetiapine fumarate, quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA
RISPERDAL M-TAB NPB QL risperidone odt
RISPERDAL ORAL SOLUTION NPB risperidone
RISPERDAL ORAL TABLET NPB QL risperidone
risperidone oral solution G
risperidone oral tablet G QL
risperidone oral tablet,disintegrating G QL
RITALIN NPB QL methylphenidate hcl
RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG
NPB
methylphenidate er, methylphenidate hcl cd, dexmethylphenidate hcl er, QUILLIVANT XR, VYVANSE
RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 20 MG
NPB QL methylphenidate er
RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 30 MG, 40 MG
NPB methylphenidate er
ROZEREM PB ST; QL
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG, 5 MG
NPB QL
aripiprazole, olanzapine, quetiapine fumarate, quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
42
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
SARAFEM ORAL TABLET 10 MG NPB ST; QL; M fluoxetine hcl
SARAFEM ORAL TABLET 20 MG NPB ST; M fluoxetine hcl
seconal sodium G
SEROQUEL NPB QL quetiapine fumarate
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG
NPB QL quetiapine fumarate er
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG
NPB quetiapine fumarate er
sertraline oral concentrate G M
sertraline oral tablet G QL; M
SILENOR NPB ST; QL eszopiclone, zaleplon, zolpidem tartrate, zolpidem tartrate er, ROZEREM
SONATA NPB ST zaleplon
STRATTERA NPB QL ATOMOXETINE HCL
SURMONTIL NPB trimipramine maleate
SYMBYAX NPB olanzapine-fluoxetine hcl
temazepam G
thioridazine G
thiothixene G
TOFRANIL NPB imipramine hcl
TRANXENE T-TAB ORAL TABLET 7.5 MG
NPB clorazepate dipotassium
tranylcypromine G M
trazodone G
triazolam G
trifluoperazine G
trimipramine G
TRINTELLIX NPB ST citalopram hbr, escitalopram oxalate, fluoxetine hcl, sertraline hcl, VIIBRYD
VALIUM NPB diazepam
venlafaxine oral capsule,extended release 24hr
G QL; M
venlafaxine oral tablet G QL; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
43
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
venlafaxine oral tablet extended release 24hr
G ST; QL; M
VERSACLOZ NPB clozapine odt, clozapine
VIIBRYD ORAL TABLET PB ST; QL; M
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)
PB ST
VRAYLAR NPB
aripiprazole, olanzapine, quetiapine fumarate, quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA
VYVANSE PB QL
WELLBUTRIN SR NPB QL; M bupropion sr
WELLBUTRIN XL NPB ST; QL; M bupropion hcl xl
XANAX NPB alprazolam
XANAX XR NPB alprazolam er
XYREM PB-S PA; QL
zaleplon G
zenzedi oral tablet 10 mg, 5 mg G QL
ZENZEDI ORAL TABLET 15 MG NPB QL dextroamphetamine sulfate
ZENZEDI ORAL TABLET 2.5 MG, 20 MG, 30 MG, 7.5 MG
NPB dextroamphetamine sulfate
ziprasidone hcl G QL
ZOLOFT ORAL CONCENTRATE NPB ST; M sertraline hcl
ZOLOFT ORAL TABLET NPB ST; QL; M sertraline hcl
zolpidem oral G
zolpidem sublingual G QL
ZOLPIMIST NPB ST; QL eszopiclone, zolpidem tartrate, zolpidem tartrate er
ZYPREXA ORAL NPB QL olanzapine
ZYPREXA ZYDIS NPB QL olanzapine odt
CARDIOVASCULAR, HYPERTENSION & LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral G M
BETAPACE NPB M sotalol
BETAPACE AF NPB M sotalol af
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
44
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
disopyramide phosphate oral capsule G M amiodarone hcl, quinidine sulfate, sotalol
dofetilide G
flecainide G M
mexiletine G M
MULTAQ NPB M
amiodarone hcl, dofetilide, flecainide acetate, propafenone hcl, quinidine sulfate, sotalol
NORPACE NPB M amiodarone hcl, quinidine sulfate, sotalol
NORPACE CR NPB M amiodarone hcl, quinidine sulfate, sotalol
pacerone oral tablet 100 mg, 200 mg, 400 mg
G M
propafenone G M
quinidine gluconate oral G M
quinidine sulfate oral tablet G M
RYTHMOL SR NPB M propafenone hcl
sotalol af G M
sotalol oral G M
SOTYLIZE PB M
TIKOSYN NPB dofetilide
ANTIHYPERTENSIVE THERAPY
ACCUPRIL NPB M quinapril
ACCURETIC NPB M quinapril-hydrochlorothiazide
acebutolol G M
ADALAT CC NPB ST; M nifedipine er
afeditab cr G M
ALDACTAZIDE NPB M spironolactone w/hctz
ALDACTONE NPB M spironolactone
ALTACE NPB M ramipril
amiloride G M
amiloride-hydrochlorothiazide G M
amlodipine G M
amlodipine-benazepril G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
45
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
amlodipine-olmesartan G M
amlodipine-valsartan G M
amlodipine-valsartan-hcthiazid G M
ATACAND NPB ST; M candesartan cilexetil
ATACAND HCT NPB ST; M candesartan-hydrochlorothiazid
atenolol G M
atenolol-chlorthalidone G M
AVALIDE NPB ST; M irbesartan-hydrochlorothiazide
AVAPRO NPB ST; M irbesartan
AZOR NPB ST; M amlodipine-olmesartan
benazepril G M
benazepril-hydrochlorothiazide G M
BENICAR NPB ST; M olmesartan medoxomil
BENICAR HCT NPB ST; M olmesartan-hydrochlorothiazide
betaxolol oral G M
BIDIL NPB M isosorbide dinitrate, hydralazine hcl
bisoprolol fumarate G M
bisoprolol-hydrochlorothiazide G M
bumetanide oral G M
BYSTOLIC PB M
BYVALSON PB M
CALAN NPB ST; M verapamil hcl
CALAN SR NPB ST; M verapamil er
candesartan oral tablet 16 mg G
candesartan oral tablet 32 mg, 4 mg, 8 mg
G M
candesartan-hydrochlorothiazid G M
captopril G M
captopril-hydrochlorothiazide G M
CARDIZEM CD NPB M cartia xt, diltiazem 24hr cd, diltiazem er
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG
NPB M diltiazem 24hr cd
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
46
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG
NPB M diltiazem er, matzim la
CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG
NPB M diltiazem hcl
CARDURA NPB QL; M doxazosin mesylate
CARDURA XL NPB QL; M alfuzosin hcl er, doxazosin mesylate, tamsulosin hcl, terazosin hcl, RAPAFLO
cartia xt G M
carvedilol G M
CATAPRES NPB M clonidine hcl
CATAPRES-TTS-1 NPB QL; M clonidine hcl
CATAPRES-TTS-2 NPB QL; M clonidine hcl
CATAPRES-TTS-3 NPB QL; M clonidine hcl
chlorothiazide G M
chlorthalidone oral tablet 25 mg, 50 mg G M
clonidine G QL; M
clonidine hcl oral tablet G M
clorpres oral tablet 0.1-15 mg, 0.2-15 mg G M
CLORPRES ORAL TABLET 0.3-15 MG
NPB M clonidine hcl, chlorthalidone
COREG NPB M carvedilol
COREG CR PB M
CORGARD NPB M nadolol
CORZIDE NPB M nadolol-bendroflumethiazide
COZAAR NPB ST; M losartan potassium
DEMADEX ORAL TABLET 10 MG, 20 MG
NPB M torsemide
DEMSER PB
DIBENZYLINE NPB phenoxybenzamine hcl
diltiazem hcl oral capsule, extended release 420 mg
G M
diltiazem hcl oral capsule,ext release degradable 240 mg
G M
diltiazem hcl oral capsule,extended release 12 hr
G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
47
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
diltiazem hcl oral capsule,extended release 24hr
G M
diltiazem hcl oral tablet G M
diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg
G M
dilt-xr G M
DIOVAN NPB ST; M valsartan
DIOVAN HCT NPB ST; M valsartan-hydrochlorothiazide
DIURIL NPB M chlorothiazide
doxazosin G QL; M
DUTOPROL NPB M
metoprolol-hydrochlorothiazide, hydrochlorothiazide, metoprolol succinate
DYAZIDE NPB M triamterene w/hctz
DYRENIUM NPB M spironolactone
EDARBI NPB ST; M
candesartan cilexetil, irbesartan, losartan potassium, olmesartan medoxomil, telmisartan, valsartan
EDARBYCLOR NPB ST; M
chlorthalidone, valsartan, candesartan-hydrochlorothiazid, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, valsartan-hydrochlorothiazide
EDECRIN NPB M ethacrynic acid
enalapril maleate G M
enalapril-hydrochlorothiazide G M
EPANED ORAL SOLUTION NPB M enalapril maleate
eplerenone G M
eprosartan G M
ethacrynic acid G M
EXFORGE NPB ST; M amlodipine-valsartan
EXFORGE HCT NPB ST; M amlodipine-valsartan-hctz
felodipine G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
48
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
fosinopril G M
fosinopril-hydrochlorothiazide G M
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)
G M
furosemide oral tablet G M
guanfacine oral tablet G M
HEMANGEOL NPB propranolol hcl
hydralazine oral G M
hydrochlorothiazide G M
HYZAAR NPB ST; M losartan-hydrochlorothiazide
indapamide G M
INDERAL LA NPB M propranolol hcl er
INDERAL XL NPB M propranolol hcl
INNOPRAN XL NPB M propranolol hcl er
INSPRA NPB M eplerenone
irbesartan G M
irbesartan-hydrochlorothiazide G M
isradipine G M
labetalol oral G M
LASIX NPB M furosemide
LEVATOL NPB M atenolol, metoprolol tartrate, propranolol hcl
lisinopril G M
lisinopril-hydrochlorothiazide G M
LOPRESSOR HCT NPB M metoprolol-hydrochlorothiazide
LOPRESSOR ORAL NPB M metoprolol tartrate
losartan G M
losartan-hydrochlorothiazide G M
LOTENSIN HCT NPB M benazepril hcl-hctz
LOTENSIN ORAL TABLET 20 MG, 40 MG
NPB M benazepril hcl
LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG
NPB M amlodipine besylate-benazepril
matzim la G M
MAVIK ORAL TABLET 2 MG NPB M trandolapril
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
49
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
MAXZIDE NPB M triamterene w/hctz
MAXZIDE-25MG NPB M triamterene w/hctz
methyclothiazide G M
methyldopa G M
methyldopa-hydrochlorothiazide G M
metolazone G M
metoprolol succinate G M
METOPROLOL SU-HYDROCHLOROTHIAZ
NPB M
metoprolol-hydrochlorothiazide, hydrochlorothiazide, metoprolol succinate
metoprolol ta-hydrochlorothiaz G M
metoprolol tartrate oral G M
MICARDIS NPB ST; M telmisartan
MICARDIS HCT NPB ST; M telmisartan-hydrochlorothiazid
MICROZIDE NPB M hydrochlorothiazide
MINIPRESS NPB M prazosin hcl
minoxidil oral G M
moexipril G M
moexipril-hydrochlorothiazide G M
nadolol G M
nadolol-bendroflumethiazide G M
nicardipine oral G M
nifedipine oral capsule G M nicardipine hcl, isradipine
nifedipine oral tablet extended release G M
nifedipine oral tablet extended release 24hr
G M
nimodipine G
nisoldipine G M
NORVASC NPB ST; M amlodipine besylate
NYMALIZE NPB nimodipine
olmesartan G M
olmesartan-amlodipin-hcthiazid G M
olmesartan-hydrochlorothiazide G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
50
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ORENITRAM NPB-S M sildenafil citrate, ADCIRCA, ADEMPAS, LETAIRIS, OPSUMIT, TRACLEER
perindopril erbumine G M
phenoxybenzamine G
pindolol G M
prazosin G M
PRESTALIA NPB M
amlodipine besylate, perindopril erbumine, amlodipine besylate-benazepril
PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG
NPB M lisinopril
PROCARDIA NPB ST; M amlodipine besylate, diltiazem hcl, verapamil hcl
PROCARDIA XL NPB ST; M nifedical xl, nifedipine er
propranolol oral G M
propranolol-hydrochlorothiazid G M
QBRELIS NPB M lisinopril
quinapril G M
quinapril-hydrochlorothiazide G M
ramipril G M
spironolactone G M
spironolacton-hydrochlorothiaz G M
SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG
NPB ST; M nisoldipine
TARKA NPB M trandolapril-verapamil
taztia xt G M
TEKTURNA PB ST; M
TEKTURNA HCT PB ST; M
telmisartan G M
telmisartan-amlodipine G M
telmisartan-hydrochlorothiazid G M
TENORETIC 100 NPB M atenolol w/chlorthalidone
TENORETIC 50 NPB M atenolol w/chlorthalidone
TENORMIN NPB M atenolol
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
51
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
terazosin G QL; M
TIAZAC NPB M diltiazem er, taztia xt
timolol maleate oral G M
TOPROL XL NPB M metoprolol succinate
torsemide oral G M
trandolapril G M
trandolapril-verapamil G M
triamterene-hydrochlorothiazid G M
TRIBENZOR NPB ST; M olmesartan-amlodipine-hctz
TWYNSTA NPB ST; M telmisartan-amlodipine
UPTRAVI PB-S M
valsartan G M
valsartan-hydrochlorothiazide G M
VASERETIC NPB M enalapril maleate/hctz
VASOTEC NPB M enalapril maleate
verapamil oral G M
VERELAN NPB ST; M verapamil er
VERELAN PM NPB ST; M verapamil er pm
ZESTORETIC NPB M lisinopril-hctz
ZESTRIL NPB M lisinopril
ZIAC NPB M bisoprolol fumarate/hctz
CARDIAC GLYCOSIDES
digitek G M
digox G M
digoxin oral solution 50 mcg/ml G M
digoxin oral tablet G M
LANOXIN ORAL NPB M digoxin
COAGULATION THERAPY
AGGRENOX NPB M aspirin-dipyridamole er
AMICAR PB
ARIXTRA NPB fondaparinux sodium
aspirin-dipyridamole G M
BRILINTA PB M
cilostazol G M
clopidogrel oral tablet 300 mg G QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
52
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
clopidogrel oral tablet 75 mg G QL; M
COUMADIN ORAL NPB warfarin sodium
dipyridamole oral G M
DURLAZA NPB ST; M aspirin
EFFIENT PB M
ELIQUIS PB
enoxaparin subcutaneous syringe G
fondaparinux G
FRAGMIN SUBCUTANEOUS SOLUTION
PB
FRAGMIN SUBCUTANEOUS SYRINGE
PB
heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml
G
heparin (porcine) injection cartridge G
heparin (porcine) injection solution G
heparin (porcine) injection syringe 5,000 unit/ml
G
HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML
NPB
heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml
G
heparin, porcine (pf) injection G
jantoven G
LOVENOX SUBCUTANEOUS SYRINGE
NPB enoxaparin sodium
MEPHYTON PB
pentoxifylline G M
PLAVIX ORAL TABLET 300 MG NPB QL clopidogrel
PLAVIX ORAL TABLET 75 MG NPB QL; M clopidogrel
PRADAXA ORAL CAPSULE 150 MG, 75 MG
PB M
PROMACTA PB PA
SAVAYSA NPB ELIQUIS, XARELTO, PRADAXA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
53
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ticlopidine G M clopidogrel
warfarin G
XARELTO PB
YOSPRALA NPB M; 2ST
aspirin, omeprazole, esomeprazole magnesium, lansoprazole, pantoprazole sodium, rabeprazole sodium
ZONTIVITY PB M
LIPID/CHOLESTEROL LOWERING AGENTS
ALTOPREV NPB ST; QL; M
atorvastatin calcium, lovastatin, rosuvastatin calcium, simvastatin, LIVALO
amlodipine-atorvastatin G QL; M
ANTARA ORAL CAPSULE 30 MG, 90 MG
NPB ST; QL; M fenofibrate, fenofibric acid, LIPOFEN
atorvastatin G QL; M
CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG
NPB QL; M amlodipine-atorvastatin
cholestyramine (with sugar) G M
cholestyramine light G M
COLESTID NPB M colestipol hcl
COLESTID FLAVORED ORAL PACKET
NPB M colestipol hcl
colestipol G M
CRESTOR NPB ST; QL; M rosuvastatin calcium
ezetimibe G ST; M
ezetimibe-simvastatin G QL; M
fenofibrate micronized G QL; M
fenofibrate nanocrystallized G QL; M
FENOFIBRATE ORAL CAPSULE NPB ST; QL; M fenofibrate, fenofibric acid, LIPOFEN
fenofibrate oral tablet G QL; M
fenofibric acid G QL; M
fenofibric acid (choline) G QL; M
FENOGLIDE NPB ST; QL; M fenofibrate
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
54
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
FIBRICOR NPB ST; QL; M fenofibric acid
fluvastatin G QL; M
gemfibrozil G QL; M
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG
PB-S PA; QL
JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG
PB-S PA
KYNAMRO NPB-S PA; QL REPATHA PUSHTRONEX, REPATHA SURECLICK, REPATHA SYRINGE
LESCOL NPB ST; QL; M fluvastatin sodium
LESCOL XL NPB ST; QL; M fluvastatin er
LIPITOR NPB ST; QL; M atorvastatin calcium
LIPOFEN PB ST; QL; M
LIVALO PB ST; QL; M
LOPID NPB QL; M gemfibrozil
lovastatin G QL; M
LOVAZA NPB M omega-3 acid ethyl esters
niacin oral tablet extended release 24 hr G M
NIACOR NPB M niacin er
NIASPAN EXTENDED-RELEASE NPB M niacin er
omega-3 acid ethyl esters G M
PRALUENT PEN PB-S PA
PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG
NPB ST; QL; M pravastatin sodium
pravastatin G QL; M
prevalite G M
QUESTRAN NPB M cholestyramine
QUESTRAN LIGHT ORAL POWDER NPB M cholestyramine light
REPATHA PUSHTRONEX PB-S PA
REPATHA SURECLICK PB-S PA
REPATHA SYRINGE PB-S PA
rosuvastatin G QL; M
simvastatin G QL; M
TRICOR NPB ST; QL; M fenofibrate
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
55
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
TRIGLIDE ORAL TABLET 160 MG NPB ST; QL; M fenofibrate, fenofibric acid, LIPOFEN
TRILIPIX NPB ST; QL; M fenofibric acid
VASCEPA PB M
VYTORIN 10-10 NPB ST; QL; M EZETIMIBE-SIMVASTATIN
VYTORIN 10-20 NPB ST; QL; M EZETIMIBE-SIMVASTATIN
VYTORIN 10-40 NPB ST; QL; M EZETIMIBE-SIMVASTATIN
VYTORIN 10-80 NPB ST; QL; M EZETIMIBE-SIMVASTATIN
WELCHOL PB M
ZETIA NPB ST; M EZETIMIBE
ZOCOR NPB ST; QL; M simvastatin
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR PB M
ENTRESTO PB M
RANEXA PB M
VECAMYL NPB clonidine hcl, reserpine
NITRATES
DILATRATE-SR PB M
GONITRO NPB nitroglycerin, nitroglycerin
ISOCHRON NPB M isosorbide dinitrate
ISORDIL NPB M isosorbide dinitrate
ISORDIL TITRADOSE ORAL TABLET 5 MG
NPB M isosorbide dinitrate
isosorbide dinitrate oral G M
isosorbide mononitrate G M
MINITRAN NPB M nitroglycerin
nitro-bid G M
NITRO-DUR NPB M nitroglycerin
nitroglycerin oral G M
nitroglycerin sublingual G
nitroglycerin transdermal patch 24 hour G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
56
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
nitroglycerin translingual G
NITROLINGUAL NPB nitroglycerin
NITROMIST NPB nitroglycerin
NITROSTAT NPB nitroglycerin
nitro-time G M
DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin G
ANALPRAM-HC TOPICAL NPB ST
calcipotriene G QL
calcipotriene-betamethasone G QL
calcitrene G QL
calcitriol topical G QL
COAL TAR PB
COSENTYX PB-S PA; QL
COSENTYX (2 SYRINGES) PB-S PA; QL
COSENTYX PEN PB-S PA; QL
COSENTYX PEN (2 PENS) PB-S PA; QL
DOVONEX TOPICAL NPB QL calcipotriene
drithocreme hp G
ENSTILAR PB
EPIFOAM NPB ST hc pramoxine
hydrocortisone-pramoxine topical G
OVACE NPB sodium sulfacetamide
OVACE PLUS SHAMPOO NPB sodium sulfacetamide
OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE
NPB sodium sulfacetamide
OVACE PLUS TOPICAL CREAM NPB ST sodium sulfacetamide
OVACE PLUS TOPICAL FOAM NPB sodium sulfacetamide
OVACE PLUS TOPICAL LOTION NPB ST sodium sulfacetamide
OVACE PLUS WASH NPB sodium sulfacetamide
PRAMOSONE NPB ST hc pramoxine
PRAMOSONE E NPB ST hc pramoxine
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
57
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
seb-prev G
selenium sulfide topical lotion G
selenium sulfide topical shampoo 2.25 % G
SELRX NPB selenium sulfide
SILIQ NPB-S PA; ST
COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA
SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG
NPB acitretin
SORILUX NPB QL calcipotriene, calcitriol, ENSTILAR, TACLONEX
sulfacetamide sodium topical G
TACLONEX TOPICAL OINTMENT NPB QL calcipotriene-betamethasone dp
TACLONEX TOPICAL SUSPENSION PB
TALTZ AUTOINJECTOR NPB-S PA; 2ST
COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA
TALTZ AUTOINJECTOR (2 PACK) NPB-S PA; 2ST
COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA
TALTZ AUTOINJECTOR (3 PACK) NPB-S PA; 2ST
COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA
TALTZ SYRINGE NPB-S PA; 2ST
COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA
TALTZ SYRINGE (2 PACK) NPB-S PA; 2ST
COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
58
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
TALTZ SYRINGE (3 PACK) NPB-S PA; 2ST
COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA
TERSI FOAM NPB selenium sulfide
VECTICAL NPB QL calcitriol
ZITHRANOL NPB
BURN THERAPY
SILVADENE NPB silver sulfadiazine
silver sulfadiazine G
ssd G
thermazene G
KERATOLYTICS
BENSAL HP TOPICAL OINTMENT 3 %
NPB
INOVA 4-1 NPB ST benzoyl peroxide
KERALYT RX NPB salicylic acid
PODOCON NPB podofilox
POTASSIUM HYDROXIDE NPB
salacyn G
SALEX TOPICAL COMBO PACK NPB salicylic acid, salicylic acid
SALEX TOPICAL SHAMPOO NPB salicylic acid
salicylic acid topical cream G
salicylic acid topical cream,extended release
G
salicylic acid topical film forming liquid w/appl
G
salicylic acid topical film-forming soln er w/ appl
G
salicylic acid topical foam G
salicylic acid topical gel G
salicylic acid topical liquid 26 % G
salicylic acid topical lotion G
salicylic acid topical lotion,extended release
G
salicylic acid topical shampoo G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
59
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
SALKERA NPB salicylic acid
salvax G
SALVAX DUO PLUS NPB salicylic acid
ULTRASAL-ER NPB
VIRASAL NPB salicylic acid
MISCELLANEOUS DERMATOLOGICALS
ATOPICLAIR NPB pruclair
ATRAPRO CP NPB prumyx, prutect, sonafine
ATRAPRO HYDROGEL NPB
avo cream G
BIAFINE EMULSION NPB avo, prutect, sonafine
bp-50% urea G
CARAC PB QL
celacyn G
CONDYLOX TOPICAL GEL PB
CORTANE-B TOPICAL NPB hc pramoxine
DEXERYL NPB
diclofenac sodium topical gel 3 % G QL
doxepin topical G
DUPIXENT PB-S PA
EFUDEX TOPICAL CREAM NPB fluorouracil
eletone G
ELIDEL PB ST; QL
EPICERAM NPB emulsion sb
EUCRISA NPB PA; ST; QL tacrolimus, ELIDEL
FLUOROPLEX NPB QL
diclofenac sodium, fluorouracil, fluorouracil, imiquimod, CARAC, PICATO
FLUOROURACIL TOPICAL CREAM 0.5 %
NPB QL; 2ST
diclofenac sodium, fluorouracil, fluorouracil, imiquimod, CARAC, PICATO
fluorouracil topical cream 5 % G
fluorouracil topical solution G QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
60
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
GORDONS UREA TOPICAL OINTMENT 40 %
NPB
hpr G
hpr plus G
hpr plus hydrogel G
HPR PLUS-MB HYDROGEL NPB
HYDRO 35 NPB urea
HYDRO 40 NPB urea
HYLATOPIC NPB prumyx
HYLATOPICPLUS NPB hpr plus
KERAFOAM NPB umecta
KERALAC NPB urea
lactic acid G
lactic acid e G
latrix G
LOUTREX NPB ciclopirox, ketoconazole
luxamend G
methoxsalen G
NEOSALUS NPB prumyx
nivatopic plus G
OXSORALEN ULTRA NPB METHOXSALEN
PANRETIN NPB
PICATO PB QL
podofilox G
PRESERA NPB hpr
PROMISEB NPB selenium sulfide, sodium sulfacetamide
PROTOPIC NPB ST; QL tacrolimus
pruclair G
prudoxin G
prumyx G
prutect G
rea lo 39 G
rea lo 40 topical lotion G
REGRANEX PB QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
61
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
remeven G
RESTIZAN NPB
silver nitrate G
silver nitrate applicators G
SOLARAZE NPB QL diclofenac sodium
sonafine G
sp antipruritic G
sp scar management G
tacrolimus topical G ST; QL
TOLAK NPB QL
diclofenac sodium, fluorouracil, fluorouracil, imiquimod, CARAC, PICATO
umecta topical foam G
urea nail stick G
urea topical cream 39 %, 40 %, 45 %, 47 %, 50 %
G
urea topical foam G
urea topical gel 45 % G
urea topical lotion 40 %, 45 % G
UTOPIC NPB urea
VALCHLOR PB-S
VEREGEN NPB imiquimod, podofilox
XCLAIR NPB emulsion sb
ZANABIN NPB
ZONALON NPB prudoxin
THERAPY FOR ACNE
ABSORICA PB QL
ACANYA TOPICAL GEL WITH PUMP
PB ST; QL
ACZONE NPB ST benzoyl peroxide, clindamycin phosphate, erythromycin
adapalene topical cream G QL
adapalene topical gel 0.3 % G QL
adapalene topical gel with pump G QL
ADAPALENE TOPICAL LOTION NPB ST; QL adapalene, adapalene
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
62
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ATRALIN NPB QL tretinoin
AVAR LS NPB ST sulfacetamide sodium-sulfur
avar topical cleanser G
AVAR TOPICAL FOAM NPB ST sulfacetamide sodium-sulfur
AVAR TOPICAL PADS, MEDICATED NPB ST sulfacetamide sodium-sulfur
AVAR-E GREEN NPB ST sulfacetamide sodium-sulfur
AVAR-E LS NPB ST sulfacetamide sodium-sulfur
avita topical cream G QL
AVITA TOPICAL GEL NPB QL tretinoin, adapalene, EPIDUO
AZELEX NPB ST; QL adapalene, metronidazole, tretinoin, FINACEA, TAZORAC
BENZACLIN NPB ST clindamycin-benzoyl peroxide
BENZACLIN PUMP NPB ST; QL clindamycin-benzoyl peroxide
BENZAMYCIN NPB ST erythromycin-benzoyl peroxide
BENZEFOAM NPB ST benzoyl peroxide
BENZEFOAM ULTRA NPB ST benzoyl peroxide
benzepro topical towelette G
bp 10-1 G
bpo topical gel G
bpo topical towelette 6 % G
claravis G QL
cleansing wash topical cleanser G
CLEOCIN T NPB ST clindamycin phosphate
CLINDACIN ETZ TOPICAL KIT NPB ST clindamycin phosphate, clindacin etz
clindacin p G
CLINDACIN PAC NPB ST clindamycin phosphate, clindacin etz
CLINDAGEL NPB ST clindamycin phosphate
clindamycin phosphate topical G
clindamycin-benzoyl peroxide topical gel 1.2 %(1 % base) -5 %
G QL
clindamycin-benzoyl peroxide topical gel 1-5 %
G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
63
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
clindamycin-benzoyl peroxide topical gel with pump
G QL
clindamycin-tretinoin G
DIFFERIN TOPICAL CREAM NPB ST; QL adapalene
DIFFERIN TOPICAL GEL 0.3 % NPB ST; QL adapalene
DIFFERIN TOPICAL GEL WITH PUMP
NPB ST; QL adapalene
DIFFERIN TOPICAL LOTION NPB ST; QL adapalene, adapalene
DUAC NPB ST; QL clindamycin-benzoyl peroxide
EPIDUO FORTE PB ST
EPIDUO TOPICAL GEL WITH PUMP PB ST; QL
ery pads G
erygel G
erythromycin with ethanol G
erythromycin-benzoyl peroxide G
EVOCLIN NPB ST clindamycin phosphate
FABIOR NPB PA; QL TAZORAC
FINACEA PB ST
INOVA TOPICAL COMBO PACK 4-5 %
NPB ST benzoyl peroxide
METROCREAM NPB ST metronidazole
METROGEL TOPICAL GEL 1 % NPB ST metronidazole
METROGEL TOPICAL GEL WITH PUMP
NPB ST metronidazole
METROLOTION NPB ST metronidazole
metronidazole topical G
MIRVASO PB
neuac G QL
NEUAC KIT NPB ST
NORITATE NPB ST metronidazole
NUOX NPB ST
ONEXTON TOPICAL GEL WITH PUMP
PB ST; QL
PLEXION NPB ST sulfacetamide sodium-sulfur
PLEXION CLEANSING CLOTHS NPB ST sulfacetamide sodium-sulfur
RETIN-A MICRO NPB tretinoin microsphere
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
64
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.04 %, 0.1 %
NPB tretinoin microsphere
RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.08 %
NPB adapalene, tretinoin, EPIDUO
RETIN-A TOPICAL CREAM 0.025 % NPB QL tretinoin
RETIN-A TOPICAL CREAM 0.05 %, 0.1 %
NPB tretinoin
RETIN-A TOPICAL GEL 0.01 % NPB tretinoin
RETIN-A TOPICAL GEL 0.025 % NPB QL tretinoin
rosadan topical cream G
rosadan topical gel G
ROSADAN TOPICAL KIT, CLEANSER AND GEL
NPB ST metronidazole
ROSADAN TOPICAL KIT,CLEANSER AND CREAM
NPB ST metronidazole
ROSANIL NPB ST sulfacetamide sodium-sulfur
ROSULA NPB ST
rosula cleansing cloths G
SOOLANTRA PB ST
ss 10-2 G
sss 10-5 G
sulfacetamide sodium-sulfur topical cleanser
G
sulfacetamide sodium-sulfur topical cream
G
sulfacetamide sodium-sulfur topical lotion
G
sulfacetamide sodium-sulfur topical pads, medicated 10-4 %
G
sulfacetamide sodium-sulfur topical suspension
G
sulfacetamide sod-sulfur-urea topical cleanser
G
sulfacleanse 8-4 G
SUMADAN TOPICAL CLEANSER NPB ST sulfacetamide sodium-sulfur
SUMAXIN NPB ST sulfacetamide sodium-sulfur
SUMAXIN TS NPB ST sulfacetamide sodium-sulfur
tazarotene G QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
65
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
TAZORAC TOPICAL CREAM 0.05 % PB QL
TAZORAC TOPICAL CREAM 0.1 % NPB QL TAZAROTENE
TAZORAC TOPICAL GEL PB QL
tretinoin microspheres G
tretinoin topical cream 0.025 % G QL
tretinoin topical cream 0.05 %, 0.1 % G
tretinoin topical gel 0.01 % G
tretinoin topical gel 0.025 %, 0.05 % G QL
TRETIN-X CREAM KIT NPB tretinoin
TRETIN-X TOPICAL CREAM 0.075 % NPB tretinoin
VANOXIDE-HC NPB ST
VELTIN NPB 2ST
clindamycin phos-tretinoin, clindamycin phosphate, tretinoin, ACANYA, ONEXTON
zenatane G QL
zencia G
ZIANA NPB ST clindamycin phos-tretinoin
TOPICAL ANESTHETICS
BUCALSEP NPB
ethyl chloride G
glydo G
lidocaine hcl laryngotracheal G
lidocaine hcl mucous membrane jelly G
lidocaine hcl mucous membrane jelly in applicator
G
lidocaine hcl mucous membrane solution 4 % (40 mg/ml)
G
lidocaine hcl-hydrocortison ac topical G
lidocaine topical adhesive patch,medicated
G
lidocaine topical ointment G
lidocaine viscous G
lidocaine-prilocaine G
LIDOCAINE-TETRACAINE NPB ST lidocaine-prilocaine, lidocaine hcl
LIDODERM NPB lidocaine
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
66
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
lta pre-attached G
PLIAGLIS NPB
SYNERA NPB lidocaine, lidocaine-prilocaine
TOPICAL ANTIBACTERIALS
ALTABAX NPB mupirocin, mupirocin
BACTROBAN TOPICAL CREAM NPB mupirocin
CENTANY NPB mupirocin, mupirocin
CENTANY AT NPB mupirocin, mupirocin
CORTISPORIN TOPICAL NPB gentamicin sulfate
dermazene G
gentamicin topical G
hydrocortisone-iodoquinol-aloe G
iodoquinol-hc G
KLARON NPB ST sulfacetamide sodium
lugols topical G
mupirocin G
mupirocin calcium G
NEO-SYNALAR NPB
NEO-SYNALAR KIT NPB
SILVRSTAT NPB avo, prutect, sonafine
sulfacetamide sodium (acne) G
SULFAMYLON PB
TOPICAL ANTIFUNGALS
ciclodan G
CICLODAN KIT TOPICAL COMBO PACK
NPB
CICLODAN KIT TOPICAL SOLUTION
NPB ciclopirox
ciclopirox G
clotrimazole-betamethasone G
econazole G
ECOZA NPB econazole nitrate, ciclopirox, ketoconazole, naftifine hcl
ERTACZO NPB ciclopirox, econazole nitrate, ketoconazole, naftifine hcl
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
67
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
EXELDERM NPB
ciclopirox, ciclopirox, econazole nitrate, ketoconazole, oxiconazole nitrate
EXODERM NPB clotrimazole, ketoconazole, miconazole nitrate
EXTINA NPB ketoconazole
JUBLIA NPB QL ciclopirox
KERYDIN NPB QL ciclopirox
ketoconazole topical G
LOPROX (AS OLAMINE) NPB ciclopirox
LOPROX KIT NPB ciclopirox
LOPROX TOPICAL SHAMPOO NPB ciclopirox
LOTRISONE TOPICAL CREAM NPB clotrimazole/betamethasone
LUZU NPB QL
ciclopirox, ciclopirox, econazole nitrate, ketoconazole, oxiconazole nitrate
naftifine G
NAFTIN TOPICAL CREAM 2 % NPB naftifine hcl
NAFTIN TOPICAL GEL NPB
naftifine hcl, ciclopirox, clotrimazole, econazole nitrate, ketoconazole, oxiconazole nitrate
NIZORAL TOPICAL SHAMPOO NPB ketoconazole
nyamyc G
nyata G
nystatin topical G
nystatin-triamcinolone G
nystop G
oxiconazole G
OXISTAT TOPICAL CREAM NPB oxiconazole nitrate
OXISTAT TOPICAL LOTION NPB
oxiconazole nitrate, ciclopirox, clotrimazole, econazole nitrate, ketoconazole, naftifine hcl
PENLAC NPB ciclopirox
TRIACETIN PB
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
68
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
TRIPLE DYE NPB
VUSION NPB miconazole nitrate
XOLEGEL NPB
ciclopirox, ciclopirox, econazole nitrate, ketoconazole, oxiconazole nitrate
TOPICAL ANTIVIRALS
acyclovir topical G QL
DENAVIR NPB acyclovir, acyclovir, famciclovir, valacyclovir, ZOVIRAX
XERESE NPB QL acyclovir, acyclovir, famciclovir, valacyclovir, ZOVIRAX
ZOVIRAX TOPICAL CREAM PB QL
ZOVIRAX TOPICAL OINTMENT NPB QL acyclovir
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 2.5 % G
ALA-SCALP NPB ST hydrocortisone
alclometasone G
amcinonide G
apexicon e G QL
AQUA GLYCOLIC HC NPB ST
betamethasone dipropionate G
betamethasone valerate G
betamethasone, augmented G
CAPEX NPB ST; QL fluocinolone acetonide
clobetasol G
clobetasol-emollient G
CLOBEX NPB ST clobetasol propionate
CLOCORTOLONE PIVALATE NPB ST; QL
clodan G
CLODAN KIT NPB ST
CLODERM NPB ST; QL betamethasone valerate, fluocinolone acetonide, triamcinolone acetonide
CORDRAN TAPE LARGE ROLL NPB ST; QL flurandrenolide
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
69
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
CORDRAN TOPICAL CREAM NPB ST flurandrenolide
CORDRAN TOPICAL LOTION NPB ST flurandrenolide
CORDRAN TOPICAL OINTMENT NPB ST flurandrenolide
cormax scalp G
CUTIVATE TOPICAL CREAM NPB ST fluticasone propionate
CUTIVATE TOPICAL LOTION NPB ST fluticasone propionate
DERMA-SMOOTHE/FS BODY OIL NPB ST; QL fluocinolone acetonide
DERMA-SMOOTHE/FS SCALP OIL NPB ST; QL fluocinolone acetonide
DERMATOP NPB ST prednicarbate
DESONATE NPB ST desonide
desonide G QL
DESOWEN NPB ST; QL desonide
desoximetasone G QL
diflorasone G QL
DIPROLENE AF NPB ST betamethasone dipropionate
DIPROLENE TOPICAL OINTMENT NPB ST betamethasone dipropionate
ELOCON TOPICAL CREAM NPB ST mometasone furoate
ELOCON TOPICAL OINTMENT NPB ST mometasone furoate
fluocinolone G QL
fluocinolone and shower cap G QL
fluocinonide G
fluocinonide-e G
flurandrenolide G
fluticasone topical G
halobetasol propionate G QL
HALOG NPB ST
betamethasone dipropionate, betamethasone dipropionate, betamethasone valerate, fluocinonide, triamcinolone acetonide
hydrocortisone butyrate G
hydrocortisone butyr-emollient G
hydrocortisone topical cream 2.5 % G
hydrocortisone topical lotion 2.5 % G
hydrocortisone topical ointment 2.5 % G
hydrocortisone valerate G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
70
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
hydrocortisone-min oil-wht pet G
KENALOG TOPICAL NPB ST triamcinolone acetonide
LOCOID NPB ST hydrocortisone butyrate
LOCOID LIPOCREAM NPB ST hydrocortisone butyrate
LUXIQ NPB ST betamethasone valerate
mometasone topical G
nolix G
OLUX NPB ST clobetasol propionate
OLUX-E NPB ST clobetasol propionate
PANDEL NPB ST betamethasone valerate, hydrocortisone valerate, triamcinolone acetonide
prednicarbate G
PSORCON NPB ST; QL
scalacort G
SERNIVO NPB ST
betamethasone dipropionate, betamethasone valerate, desoximetasone, fluocinolone acetonide, fluocinonide, triamcinolone acetonide
SYNALAR NPB ST; QL fluocinolone acetonide
SYNALAR CREAM KIT NPB ST fluocinolone acetonide
SYNALAR OINTMENT KIT NPB ST fluocinolone acetonide
SYNALAR TS NPB ST fluocinolone acetonide
TEMOVATE TOPICAL CREAM NPB ST clobetasol propionate
TEMOVATE TOPICAL OINTMENT NPB ST clobetasol propionate
TEXACORT NPB ST hydrocortisone butyrate
TOPICORT TOPICAL CREAM NPB ST; QL desoximetasone
TOPICORT TOPICAL GEL NPB ST; QL desoximetasone
TOPICORT TOPICAL OINTMENT NPB ST; QL desoximetasone
TOPICORT TOPICAL SPRAY,NON-AEROSOL
NPB ST desoximetasone
triamcinolone acetonide topical aerosol G
triamcinolone acetonide topical cream G
triamcinolone acetonide topical lotion G
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %
G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
71
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
trianex G
triderm topical cream G
TRIDESILON NPB ST; QL
ULTRAVATE TOPICAL CREAM NPB ST; QL halobetasol propionate
ULTRAVATE TOPICAL LOTION NPB ST
halobetasol propionate, betamethasone dipropionate, clobetasol propionate, diflorasone diacetate, fluocinonide
ULTRAVATE TOPICAL OINTMENT NPB ST; QL halobetasol propionate
ULTRAVATE X NPB ST halobetasol propionate
VANOS NPB ST fluocinonide
VERDESO NPB ST desonide
TOPICAL ENZYMES
SANTYL PB
TOPICAL SCABICIDES / PEDICULICIDES
ELIMITE NPB permethrin
EURAX NPB permethrin, lindane
lindane topical shampoo G
malathion G
NATROBA NPB QL spinosad
OVIDE NPB malathion
permethrin topical cream G
SKLICE NPB lindane, malathion, permethrin, spinosad
spinosad G QL
ULESFIA NPB permethrin, malathion, spinosad, lindane
DIAGNOSTICS & MISCELLANEOUS AGENTS
ANOREXIANTS
BELVIQ NPB benzphetamine hcl, diethylpropion hcl, phentermine hcl
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
72
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
BELVIQ XR NPB benzphetamine hcl, diethylpropion hcl, phentermine hcl
QSYMIA NPB 2ST benzphetamine hcl, diethylpropion hcl, phentermine hcl
IRRIGATING SOLUTIONS
lactated ringers irrigation G
PHYSIOLYTE NPB
PHYSIOSOL IRRIGATION NPB
ringer's irrigation G
SORBITOL-MANNITOL NPB
tis-u-sol pentalyte G
VASHE WOUND THERAPY NPB
MISCELLANEOUS AGENTS
acamprosate G
ACTONEL ORAL TABLET 30 MG NPB QL risedronate sodium
AGRYLIN NPB-S M anagrelide hydrochloride
alendronate oral tablet 40 mg G QL; M
anagrelide G M
ANTABUSE NPB disulfiram
BUPHENYL ORAL POWDER NPB sodium phenylbutyrate
BUPHENYL ORAL TABLET PB
caffeine citrate oral G
CARBAGLU PB-S PA
CARNITOR (SUGAR-FREE) NPB M levocarnitine
CARNITOR ORAL NPB M levocarnitine
cevimeline G M
CHEMET PB
disulfiram G
etidronate disodium G M
EVOXAC NPB M cevimeline hcl
EXJADE PB-S
FERRIPROX PB-S
INCRELEX PB-S PA
JADENU PB-S
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
73
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
levocarnitine (with sugar) G M
levocarnitine oral tablet G M
LIPOCHOL PLUS NPB LIPOCHOL
LITHOSTAT NPB
METOPIRONE NPB
midodrine G
NORTHERA NPB-S fludrocortisone acetate, midodrine hcl
NUTRESTORE NPB
ORFADIN PB-S
pilocarpine hcl oral tablet 5 mg G
RAVICTI PB-S
RILUTEK NPB riluzole
riluzole G
risedronate oral tablet 30 mg G QL
SALAGEN (PILOCARPINE) ORAL TABLET 5 MG
NPB pilocarpine hcl
sodium phenylbutyrate G
SYPRINE NPB DEPEN
THIOLA NPB
water for irrigation, sterile G
XURIDEN PB
SMOKING DETERRENTS
bupropion hcl (smoking deter) G M; ACA
CHANTIX PB ACA
CHANTIX CONTINUING MONTH BOX
PB ACA
CHANTIX STARTING MONTH BOX PB ACA
NICODERM CQ TRANSDERMAL PATCH 24 HOUR 14 MG/24 HR, 7 MG/24 HR
PB ACA; OTC
NICODERM CQ TRANSDERMAL PATCH 24 HOUR 21 MG/24 HR
PB M; ACA; OTC
nicorelief G ACA; OTC
NICORETTE BUCCAL GUM 2 MG PB ACA; OTC
nicorette buccal gum 4 mg G ACA; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
74
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
NICORETTE BUCCAL LOZENGE PB ACA; OTC
NICORETTE BUCCAL MINI LOZENGE
PB ACA; OTC
nicotine (polacrilex) G ACA; OTC
nicotine transdermal patch 24 hour 14 mg/24 hr, 7 mg/24 hr
G ACA; OTC
nicotine transdermal patch 24 hour 21 mg/24 hr
G M; ACA; OTC
nicotine transdermal patch, td daily, sequential
G ACA; OTC
NICOTROL NPB ACA nicotine, nicotine gum
NICOTROL NS NPB ACA nicotine, nicotine gum
nts step 1 G M; ACA; OTC
quit 2 buccal gum G ACA; OTC
QUIT 2 BUCCAL LOZENGE PB ACA; OTC
quit 4 buccal gum G ACA; OTC
QUIT 4 BUCCAL LOZENGE PB ACA; OTC
stop smoking aid G ACA; OTC
ZYBAN NPB M; ACA bupropion sr
EAR, NOSE & THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ASTEPRO NASAL SPRAY,NON-AEROSOL
NPB QL azelastine hcl
azelastine nasal G QL
BACTROBAN NASAL NPB mupirocin
chlorhexidine gluconate mucous membrane
G
CLINPRO 5000 NPB M
DEBACTEROL NPB
denta 5000 plus G M
dentagel G M
EPISIL NPB
fluoride (sodium) dental G M
FLUORIDEX DAILY DEFENSE DENTAL PASTE
NPB M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
75
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
GELCLAIR NPB
GELX NPB
ipratropium bromide nasal G QL
MUGARD NPB
olopatadine nasal G QL
oralone G
ORAMAGICRX NPB
paroex oral rinse G
PATANASE NPB QL olopatadine hcl
PERIDEX NPB chlorhexidine gluconate
periogard G
pilocarpine hcl oral tablet 7.5 mg G
PREVIDENT NPB M
PREVIDENT 5000 BOOSTER PLUS NPB M
PREVIDENT 5000 DRY MOUTH NPB M
PREVIDENT 5000 ENAMEL PROTECT
NPB M denta 5000 plus, sf 5000 plus
PREVIDENT 5000 PLUS NPB M
PREVIDENT 5000 SENSITIVE NPB M denta 5000 plus, sf 5000 plus
Q-CARE RX Q4 NPB
SALAGEN (PILOCARPINE) ORAL TABLET 7.5 MG
NPB pilocarpine hcl
sf G M
sf 5000 plus G M
triamcinolone acetonide dental G
TYZINE NASAL DROPS 0.1 % NPB
TYZINE NASAL SPRAY,NON-AEROSOL
NPB
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic G
acetic acid-aluminum acetate G
CETRAXAL NPB 2ST ciprofloxacin hcl, ofloxacin, CIPRODEX, OTOVEL
ciprofloxacin hcl otic G
DERMOTIC OIL NPB fluocinolone acetonide oil
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
76
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
floxin otic drops G
fluocinolone acetonide oil G
hydrocortisone-acetic acid G
ofloxacin otic G
OTIPRIO NPB
OTIC STEROID / ANTIBIOTIC
CIPRO HC NPB CIPRODEX, OTOVEL
CIPRODEX PB
COLY-MYCIN S NPB neomycin/polymyxin/hc
neomycin-polymyxin-hc otic G
OTOVEL PB
ENDOCRINE/DIABETES
ADRENAL HORMONES
CORTEF NPB M hydrocortisone
cortisone G
deltasone oral tablet 20 mg G
dexamethasone G
dexamethasone intensol G
DEXPAK 10 DAY NPB ST dexamethasone
DEXPAK 13 DAY NPB ST dexamethasone
DEXPAK 6 DAY NPB ST dexamethasone
EMFLAZA NPB PA prednisone, prednisone
fludrocortisone G M
hydrocortisone oral G M
MEDROL NPB methylprednisolone
MEDROL (PAK) NPB methylprednisolone
methylprednisolone G
millipred dp G
MILLIPRED ORAL SOLUTION NPB prednisolone sodium phosphate
millipred oral tablet G
ORAPRED ODT NPB prednisolone sodium phosphate
PEDIAPRED NPB prednisolone sodium phosphate
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
77
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
prednisolone oral solution 15 mg/5 ml G
prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
G
prednisolone sodium phosphate oral tablet,disintegrating
G
prednisone G
prednisone intensol G
RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) 1 MG, 2 MG
NPB 2ST prednisone
RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG
NPB 2ST prednisone
veripred 20 G
ANTITHYROID AGENTS
methimazole oral tablet 10 mg, 5 mg G M
propylthiouracil G M
SSKI NPB M strong iodine
TAPAZOLE NPB M methimazole
BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES
ACCU-CHEK AVIVA PLUS TEST STRP
NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ACCU-CHEK COMPACT PLUS TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ACCU-CHEK GUIDE NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ACCU-CHEK SMARTVIEW TEST STRIP
NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ACCUTREND GLUCOSE NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
78
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ADVANCED GLUC METER TEST STRIP
NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ADVOCATE REDI-CODE NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ADVOCATE TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
AGAMATRIX AMP TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ASSURE 4 STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ASSURE PLATINUM STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ASSURE PRISM MULTI STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
BIONIME RIGHTEST TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
BLOOD GLUCOSE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
BREEZE 2 TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
CARESENS N TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
CLEVER CHOICE MICRO TEST STRIP
NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
CLEVER CHOICE PRO STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
CLEVER CHOICE TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
79
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
CLEVER CHOICE VOICE+ TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
CONTOUR NEXT STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
CONTOUR TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
COOL GLUCOSE TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
DIATRUE PLUS TEST STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EASY PLUS II TEST NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EASY STEP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EASY TALK GLUCOSE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EASY TOUCH TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EASY TRAK GLUCOSE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EASYGLUCO PLUS STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EASYGLUCO TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EASYMAX NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ELEMENT COMPACT TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
80
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ELEMENT TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EMBRACE BLOOD GLUCOSE SYSTEM STRIP
NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EMBRACE EVO TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EMBRACE PRO TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EVENCARE G2 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EVENCARE G3 TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EVENCARE MINI GLUCOSE TEST STR
NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EVOLUTION TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EZ SMART PLUS TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
EZ SMART TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FIFTY50 TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA D15G NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA D20 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA D40-G31 TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
81
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
FORA G20 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA G30A STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA GD50 TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA TN'G VOICE TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA V10 STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA V10-V12-D10-D20 STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA V12 GLUCOSE NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORA V20 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORACARE GD20 NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORACARE GD40 NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FORTISCARE GLUCOSE TEST STRIPS
NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FREESTYLE INSULINX STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FREESTYLE INSULINX TEST STRIPS
NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
82
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
FREESTYLE LITE STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FREESTYLE PRECISION NEO STRIPS
NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
FREESTYLE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GE100 BLOOD GLUCOSE TEST STRIP
NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GENSTRIP TEST STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GLUCO NAVII TEST STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GLUCOCARD 01 SENSOR PLUS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GLUCOCARD EXPRESSION STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GLUCOCARD SHINE TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GLUCOCARD VITAL SENSOR NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GLUCOCARD VITAL TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GLUCOCOM GLUCOSE NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GM100 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
GMATE TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
83
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
HEALTHPRO TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
INFINITY TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
LIBERTY TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
MICRO BLOOD GLUCOSE NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
MICRODOT BLOOD GLUCOSE SYSTEM STRIP
NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
MYGLUCOHEALTH STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
NEUTEK 2TEK TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
NOVA MAX GLUCOSE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ON CALL EXPRESS TEST STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ON CALL PLUS TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ON CALL VIVID TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ONETOUCH ULTRA TEST PB QL; OTC
ONETOUCH VERIO PB QL; OTC
OPTIUM EZ NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
OPTIUM TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
84
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
OPTUMRX STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
PHARMACIST CHOICE NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
PRECISION PCX PLUS TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
PRECISION PCX TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
PRECISION POINT OF CARE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
PRECISION Q-I-D TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
PRECISION XTRA TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
PREMIUM V10 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
PRODIGY NO CODING NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
QUINTET AC STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
REFUAH PLUS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
RELION CONFIRM-MICRO NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
RELION PRIME TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
REVEAL TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
85
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
RIGHTEST GS550 TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
SMART SENSE TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
SMARTEST TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
SOLUS V2 TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
SURE-TEST EASYPLUS MINI STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
TELCARE TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
TEST N'GO TEST NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
TRUE METRIX GLUCOSE TEST STRIP
NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
TRUETEST TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
TRUETRACK TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ULTIMA TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ULTRATRAK NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
ULTRATRAK ULTIMATE STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
UNISTRIP1 TEST STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
86
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
WAVESENSE JAZZ NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
WAVESENSE PRESTO STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT
GLUCAGEN DIAGNOSTIC KIT PB
GLUCAGON HCL NPB
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.5 ML 29 GAUGE X 1/2"
PB M
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT PB
GLUCAGON EMERGENCY KIT (HUMAN)
PB
PROGLYCEM PB M
INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU
2TEK GLUCOSE/BLOOD PRESSURE NPB QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ACCU-CHEK AVIVA CONNECT METER
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ACCU-CHEK AVIVA PLUS METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ACCU-CHEK COMPACT PLUS CONTROL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
87
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ACCU-CHEK GUIDE GLUCOSE METER
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ACCU-CHEK GUIDE L1-L2 CTRL SOL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ACCU-CHEK NANO NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ACCU-CHEK SMARTVIEW CONTRL SOL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ACCUTREND GLUCOSE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ADVANCED GLUCOSE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ADVOCATE BLOOD GLUCOSE MONITOR
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ADVOCATE DUO NPB QL; 2ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ADVOCATE LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ADVOCATE REDI-CODE DUO METER
NPB QL; 2ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
88
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ADVOCATE REDI-CODE GLU MONITOR
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ADVOCATE REDI-CODE+ CTRL LOW
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
AGAMATRIX AMP GLUC MONITOR SYS
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
AGAMATRIX CONTROL HIGH NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ASSURE 4 CONTROL SOLUTION NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ASSURE DOSE NORMAL CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ASSURE PLATINUM NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ASSURE PRISM CONTROL 1-2 SOLN NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ASSURE PRISM MULTI METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
AUTOJECT 2 INJECTION DEVICE PB OTC
AUTOPEN 1 TO 21 UNITS PB OTC
BIONIME RIGHTEST GM300 SYSTEM
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
89
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
BLOOD GLUCOSE CONTROL, NORMAL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
BLOOD-GLUCOSE METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
BREEZE 2 CONTROL SOLUTION,HIGH
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
CARESENS CONTROL A NORMAL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
CARESENS N NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
CARESENS N VOICE NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
CLEO 90 INFUSION SET 24" PB
CLEVER CHEK BLOOD GLUCOSE NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
CLEVER CHOICE GLUCOSE MONITOR
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
CLEVER CHOICE LEVEL 2 CONTROL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
CLEVER CHOICE MICRO NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
90
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
CLEVER CHOICE PRO NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
COMFORT SHORT INSULIN PUMP 23"
PB
CONTOUR CONTROL SOLUTION, NML
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
CONTOUR LINK NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
CONTOUR NEXT EZ METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
CONTOUR NEXT LEV 2 CONTROL SOL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
CONTOUR NEXT LINK NPB QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
CONTOUR NEXT METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
CONTOUR NEXT ONE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
CONTROL AST MONITORING SYSTEM
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
91
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
COOL BLOOD GLUCOSE METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
COOL CONTROL A SOLUTION NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
DEXCOM G4 RECEIVER PB QL
DEXCOM G5 RECEIVER PB QL
DIATRUE CONTROL SOLN NORMAL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
DIATRUE PLUS BLOOD GLUCOSE MET
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EASY PLUS II BLOOD GLUCOSE MET
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EASY STEP BLOOD GLUCOSE METER
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EASY TALK BLOOD GLUCOSE METER
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EASY TOUCH GLUCOSE MONITOR NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EASY TRAK LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
92
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
EASYGLUCO MONITORING SYSTEM
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EASYGLUCO PLUS KIT NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EASYGLUCO PLUS NORMAL CONTROL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
EASYMAX L BLOOD GLUCOSE METER
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EASYMAX LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
EASYMAX NG KIT NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EASYMAX NORMAL CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
EASYMAX V SPEAKING GLUCOSE SYS
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EASYMAX V2 BLOOD GLUCOSE METER
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
93
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ELEMENT COMPACT GLUCOSE METER
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ELEMENT COMPACT NORMAL CONTROL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ELEMENT COMPACT V GLUCOSE MTR
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ELEMENT NORMAL CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ELEMENT PLUS BLOOD GLUCOSE KIT
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EMBRACE BLOOD GLUCOSE SYSTEM
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EMBRACE EVO LEVEL 1 NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
EMBRACE GLUCOSE CONTROL LOW
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
EMBRACE PRO GLUCOSE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EVENCARE G2 NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
94
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
EVENCARE G3 GLUCOSE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EVENCARE MINI MONITOR SYSTEM
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EVOLUTION BLOOD GLUCOSE METER
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EVOLUTION NORMAL CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
EZ SMART PLUS SYSTEM NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
EZ SMART SYSTEM NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORA D10 NPB QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORA D20 KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORA G20 KIT NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
95
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
FORA G30A NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORA GD50 BLOOD GLUCOSE SYSTEM
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORA NORMAL CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
FORA PREMIUM V10 GLUCOSE METER
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORA TEST N'GO VOICE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORA TN'G VOICE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORA V10 KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORA V12 BLOOD GLUCOSE SYSTEM
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORA V20 KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
96
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
FORA V30A KIT NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORACARE GD20 GLUCOSE METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORACARE GD40A GLUCOSE METER
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORACARE GD40B GLUCOSE METER
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORACARE GDH LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
FORTISCARE BLOOD GLUCOSE SYST
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FORTISCARE NORMAL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
FREESTYLE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
FREESTYLE FLASH SYSTEM NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
97
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
FREESTYLE FREEDOM NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FREESTYLE FREEDOM LITE NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FREESTYLE INSULINX NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FREESTYLE LITE METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FREESTYLE PRECISION NEO METER
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FREESTYLE SIDEKICK II NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
FREESTYLE SYSTEM KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GE100 BLOOD GLUCOSE SYSTEM NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GE100 CONTROL SOLUTION NORMAL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
98
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
GLUCO NAVII GLUCOSE MONITOR NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GLUCOCARD 01 METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GLUCOCARD 01 NORMAL CONTROL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
GLUCOCARD EXPRESSION NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GLUCOCARD SHINE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GLUCOCARD VITAL NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GLUCOCOM BLOOD GLUCOSE NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GLUCOCOM CONTROL NORMAL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
GLUCOSE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
99
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
GM100 KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GMATE CONTROL SOLUTION, NORMAL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
GMATE SMART METER NPB QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GMATE SMART STARTER NPB QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
GMATE VOICE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
HEALTHPRO GLUCOSE MONITOR NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
HEALTHPRO HIGH-LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
HUMAPEN LUXURA HD PB
INFINITY CONTROL SOLUTION NORM
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
INFINITY STARTER KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
INSET 30 INFUSION SET 23" PB
INSET INFUSION SET 23" PB
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
100
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
JAZZ WIRELESS 2 METER KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
LANCETS 33 GAUGE PB OTC
LANCING DEVICE PB OTC
LIBERTY BLOOD GLUCOSE MONITOR
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
LIBERTY LEV 1 GLUCOSE CONTROL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
LIBERTY LEV 2 GLUCOSE CONTROL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
MEDISENSE NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
MEDISENSE GLUCOSE KETONE NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
MICRODOT BLOOD GLUCOSE SYSTEM
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
MYGLUCOHEALTH CONTROL SOLUTION
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
MYGLUCOHEALTH KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
NOVA MAX BLOOD GLUCOSE METER
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
101
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
NOVA MAX GLUCOSE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
NOVAMAX PLUS GLU-KET NPB OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
NOVOPEN ECHO NPB
ON CALL EXPRESS CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ON CALL EXPRESS METER KIT NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ON CALL PLUS CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ON CALL PLUS METER KIT NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ON CALL VIVID CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
ON CALL VIVID METER KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ON CALL VIVID PAL METER KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ONETOUCH ULTRA CONTROL PB OTC
ONETOUCH ULTRA2 PB QL; OTC
ONETOUCH ULTRAMINI PB QL; OTC
ONETOUCH VERIO FLEX PB ST; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
102
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ONETOUCH VERIO IQ METER PB QL; OTC
ONETOUCH VERIO SYNC PB OTC
ONETOUCH VERIO SYSTEM PB OTC
OPTUMRX KIT NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
PEN NEEDLE NEEDLE 31 GAUGE X 1/4"
PB M; OTC
PHARMACIST CHOICE GLUCOSE SYS
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
PRECISION XTRA MONITOR PB ST; QL; OTC
PREMIUM BLOOD GLUCOSE MONITOR
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
PREMIUM V10 NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
PRESTO PRO BLOOD GLUCOSE METER
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
PRODIGY AUTOCODE METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
PRODIGY AUTOCODE MONITOR SYST
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
103
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
PRODIGY CONTROL SOLUTION, LOW
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
PRODIGY CONTROL SOLUTION,HIGH
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
PRODIGY POCKET METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
PRODIGY VOICE GLUCOSE METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
QUINTET BLOOD GLUCOSE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
REFUAH PLUS GLUCOSE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
REFUAH PLUS GLUCOSE MONITOR NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
RELION ALL-IN-ONE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
RELION CONFIRM NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
104
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
RELION MICRO GLUCOSE MONITOR KIT
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
RELION PRIME METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
REVEAL BLOOD GLUCOSE METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
RIGHTEST CONTROL SOLUTION HIGH
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
RIGHTEST GM550 SYSTEM NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
SIDEKICK BLOOD GLUCOSE SYSTEM
NPB OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
SMART SENSE MONITORING SYSTEM
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
SMARTEST CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
SMARTEST EJECT NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
105
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
SMARTEST PERSONA STARTER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
SMARTEST PRONTO STARTER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
SMARTEST PROTEGE NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
SNAP INSULIN PUMP CONTROLLER
PB
SOLUS V2 AUDIBLE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
SOLUS V2 AUDIBLE METER KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
SOLUS V2 CONTROL SOLUTION,HIGH
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
SURE-TEST EASYPLUS MINI METER
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
T:30 INFUSION SET PB
T:90 INFUSION SET 23" PB
T:SLIM PB
T:SLIM G4 PB
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
106
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
TELCARE BGM NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
TELCARE BLOOD GLUCOSE KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
TELCARE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
TEST N'GO BLOOD GLUCOSE SYSTEM
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
TRUE METRIX AIR GLUCOSE METER
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
TRUE METRIX GLUCOSE METER NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
TRUE METRIX GO GLUCOSE METER
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
TRUE METRIX LEVEL 1 NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
TRUE2GO BLOOD GLUCOSE SYSTEM
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
107
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
TRUECONTROL LEVEL 0 NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
TRUERESULT BLOOD GLUCOSE SYSTM
NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
TRUERESULT BLOOD GLUCOSE SYSTM KIT
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
TRUETEST LOW GLUCOSE CONTROL
NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
TRUETRACK BLOOD GLUCOSE SYSTEM
NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
TRUETRACK SMART SYSTEM KIT NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ULTIMA MONITOR NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ULTRATRAK GLUCOSE METER NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
ULTRATRAK ULTIMATE NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
108
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
UNISTRIP LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
WAVESENSE AMP NPB ST; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
WAVESENSE CONTROL SOLUTION NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO
WAVESENSE PRESTO NPB ST; QL; OTC
ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC
INSULIN THERAPY
AFREZZA INHALATION CARTRIDGE WITH INHALER 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60)
NPB M HUMALOG
AFREZZA INHALATION CARTRIDGE WITH INHALER 4 UNIT, 4 UNIT (30)/ 8 UNIT (60), 4 UNIT (60)/ 8 UNIT (30), 8 UNIT (60)/ 12 UNIT (30)
NPB QL; M HUMALOG
APIDRA NPB ST; QL; M HUMALOG
APIDRA SOLOSTAR NPB ST; QL; M HUMALOG
BASAGLAR KWIKPEN PB QL; M
HUMALOG PB QL; M
HUMALOG KWIKPEN PB QL; M
HUMALOG MIX 50-50 PB QL; M
HUMALOG MIX 50-50 KWIKPEN PB QL; M
HUMALOG MIX 75-25 PB QL; M
HUMALOG MIX 75-25 KWIKPEN PB QL; M
HUMULIN 70/30 PB QL; M
HUMULIN 70/30 KWIKPEN PB QL; M
HUMULIN N PB QL; M
HUMULIN N KWIKPEN PB M
HUMULIN R U-100 PB QL; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
109
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
HUMULIN R U-500 (CONC) KWIKPEN
PB M
HUMULIN R U-500 (CONCENTRATED)
PB QL; M
LANTUS PB QL; M
LANTUS SOLOSTAR PB QL; M
LEVEMIR PB QL; M
LEVEMIR FLEXTOUCH PB QL; M
NOVOLOG NPB ST; QL; M HUMALOG
NOVOLOG FLEXPEN NPB ST; QL; M HUMALOG
NOVOLOG MIX 70-30 NPB ST; QL; M HUMALOG MIX 75-25
NOVOLOG MIX 70-30 FLEXPEN NPB ST; QL; M HUMALOG MIX 75-25
NOVOLOG PENFILL NPB ST; QL; M HUMALOG
RELION NOVOLIN 70/30 NPB ST; QL; M HUMULIN 70-30
RELION NOVOLIN N NPB ST; QL; M HUMULIN N
RELION NOVOLIN R NPB ST; QL; M HUMULIN R
SOLIQUA 100/33 NPB ST; QL; M
BASAGLAR KWIKPEN U-100, LANTUS SOLOSTAR, LEVEMIR FLEXTOUCH, TRESIBA FLEXTOUCH U-100, BYDUREON PEN, BYETTA, TRULICITY
TOUJEO SOLOSTAR PB QL; M
TRESIBA FLEXTOUCH U-100 PB M
TRESIBA FLEXTOUCH U-200 PB M
XULTOPHY 100/3.6 NPB PA; ST; M
BASAGLAR KWIKPEN U-100, LANTUS SOLOSTAR, LEVEMIR FLEXTOUCH, TRESIBA FLEXTOUCH U-100, BYDUREON PEN, BYETTA, TRULICITY
MISCELLANEOUS HORMONES
ANDRODERM NPB PA testosterone, ANDROGEL, AXIRON
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)
PB PA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
110
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)
NPB PA testosterone, ANDROGEL, AXIRON
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
PB PA
ANDROID NPB 2ST methyltestosterone, METHITEST
androxy G
AXIRON PB PA
cabergoline G QL; M
calcitonin (salmon) G M
calcitriol oral G M
CERDELGA PB-S
CETROTIDE SUBCUTANEOUS KIT 0.25 MG
PB
danazol G
DDAVP NASAL NPB M desmopressin acetate
DDAVP ORAL NPB M desmopressin acetate
DEPO-TESTOSTERONE NPB testosterone cypionate
desmopressin nasal solution G M
desmopressin nasal spray,non-aerosol G M
desmopressin oral G M
doxercalciferol oral G M
FORTESTA NPB PA; 2ST testosterone, ANDROGEL, AXIRON
GANIRELIX NPB-S ST CETROTIDE
HECTOROL ORAL NPB M doxercalciferol
KORLYM NPB-S PA ketoconazole, LYSODREN, SIGNIFOR
KUVAN ORAL POWDER IN PACKET 500 MG
PB-S PA
KUVAN ORAL TABLET,SOLUBLE PB-S PA
METHITEST PB
methyltestosterone oral capsule G
MIACALCIN NASAL NPB M calcitonin-salmon
MYALEPT PB-S
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
111
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
NATESTO NPB 2ST testosterone, ANDROGEL, AXIRON
NATPARA PB-S
paricalcitol oral G M
RAYALDEE NPB M calcitriol, doxercalciferol, paricalcitol
ROCALTROL NPB M calcitriol
SAMSCA PB PA; QL
SENSIPAR PB
SOMAVERT PB-S
STIMATE PB M
STRENSIQ PB-S
STRIANT NPB ANDROGEL, ANDROGEL, AXIRON
SYNAREL PB
TESTIM NPB PA; 2ST testosterone, ANDROGEL, AXIRON
TESTOPEL NPB testosterone cypionate, testosterone enanthate
testosterone cypionate G
testosterone enanthate G
TESTOSTERONE TRANSDERMAL GEL
NPB PA; 2ST testosterone, ANDROGEL, AXIRON
TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG/0.5 GRAM /ACTUATION
NPB PA; 2ST testosterone, ANDROGEL, AXIRON
testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)
G
testosterone transdermal gel in packet G
TESTRED NPB 2ST methyltestosterone, METHITEST
VOGELXO NPB PA; 2ST testosterone, ANDROGEL, AXIRON
ZAVESCA PB
ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG
NPB M paricalcitol
NON-INSULIN HYPOGLYCEMIC AGENTS
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
112
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
acarbose G M
ACTOPLUS MET NPB QL; M pioglitazone-metformin
ACTOPLUS MET XR PB QL; M
ACTOS NPB QL; M pioglitazone hcl
ADLYXIN NPB M; 2ST BYDUREON, BYDUREON PEN, BYETTA, TRULICITY
ALOGLIPTIN NPB QL; M; 2ST JANUVIA, TRADJENTA
ALOGLIPTIN-METFORMIN NPB QL; M; 2ST JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR
ALOGLIPTIN-PIOGLITAZONE NPB QL; M pioglitazone hcl, JANUVIA, TRADJENTA
AMARYL NPB M glimepiride
AVANDIA ORAL TABLET 2 MG, 4 MG
NPB QL; M pioglitazone hcl
BYDUREON SUBCUTANEOUS PEN INJECTOR
PB ST; M
BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON
PB ST; QL; M
BYETTA PB ST; QL; M
chlorpropamide G M glimepiride, glipizide, glyburide
CYCLOSET NPB QL; M metformin hcl, glimepiride, glipizide, glyburide
DUETACT NPB QL; M pioglitazone-glimepiride
FARXIGA PB ST; QL; M
FORTAMET NPB ST; M metformin hcl er
glimepiride G M
glipizide G M
glipizide-metformin G M
GLUCOPHAGE NPB ST; M metformin hcl
GLUCOPHAGE XR NPB ST; M metformin hcl er
GLUCOTROL NPB M glipizide
GLUCOTROL XL NPB M glipizide er
GLUCOVANCE NPB M glyburide-metformin hcl
GLUMETZA NPB QL; M; 2ST metformin hcl, metformin hcl er
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
113
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
glyburide G M
glyburide micronized G M
glyburide-metformin G M
GLYNASE NPB M glyburide micronized
GLYSET NPB M miglitol
GLYXAMBI PB ST; M
INVOKAMET PB ST; QL; M
INVOKAMET XR PB ST; QL; M
INVOKANA PB ST; QL; M
JANUMET PB ST; QL; M
JANUMET XR PB ST; QL; M
JANUVIA PB ST; QL; M
JARDIANCE PB ST; QL; M
JENTADUETO PB ST; QL; M
JENTADUETO XR PB ST; M
KAZANO NPB QL; M; 2ST JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR
KOMBIGLYZE XR NPB QL; M; 2ST JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR
metformin oral tablet G M
metformin oral tablet extended release 24 hr (generic GLUCOPHAGE XR)
G M
metformin oral tablet extended release 24hr (generic FORTAMET)
G ST; M
metformin oral tablet,er gast.retention 24 hr (generic GLUMETZA)
G ST; QL; M
miglitol G M
nateglinide G M
NESINA NPB QL; M; 2ST JANUVIA, TRADJENTA
ONGLYZA NPB QL; M; 2ST JANUVIA, TRADJENTA
OSENI NPB QL; M pioglitazone hcl, JANUVIA, TRADJENTA
pioglitazone G QL; M
pioglitazone-glimepiride G QL; M
pioglitazone-metformin G QL; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
114
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
PRANDIN ORAL TABLET 1 MG, 2 MG
NPB M repaglinide
PRECOSE NPB M acarbose
repaglinide G M
repaglinide-metformin G QL; M
RIOMET NPB ST; QL; M metformin hcl, metformin hcl er
STARLIX NPB M nateglinide
SYMLINPEN 120 PB QL; M
SYMLINPEN 60 PB QL; M
SYNJARDY PB ST; M
SYNJARDY XR PB ST; M
TANZEUM NPB QL; M; 2ST BYDUREON, BYDUREON PEN, BYETTA, TRULICITY
tolazamide G M
tolbutamide G M
TRADJENTA PB ST; QL
TRULICITY PB QL; M
VICTOZA 2-PAK NPB QL; M; 2ST BYDUREON, BYDUREON PEN, BYETTA, TRULICITY
VICTOZA 3-PAK NPB QL; M; 2ST BYDUREON, BYDUREON PEN, BYETTA, TRULICITY
XIGDUO XR PB ST; QL; M
THYROID HORMONES
ARMOUR THYROID PB M
CYTOMEL NPB M liothyronine sodium
LEVO-T NPB M levothyroxine sodium, levoxyl, unithroid
levothyroxine oral G M
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
G M
liothyronine oral G M
nature-throid G M
np thyroid G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
115
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
SYNTHROID NPB M levothyroxine sodium, levoxyl, unithroid
THYROLAR-1 NPB M levothyroxine sodium, levoxyl, liothyronine sodium, unithroid
THYROLAR-1/2 NPB M levothyroxine sodium, levoxyl, liothyronine sodium, unithroid
THYROLAR-1/4 NPB M levothyroxine sodium, levoxyl, liothyronine sodium, unithroid
THYROLAR-2 NPB M levothyroxine sodium, levoxyl, liothyronine sodium, unithroid
THYROLAR-3 NPB M levothyroxine sodium, levoxyl, liothyronine sodium, unithroid
TIROSINT NPB M levothyroxine sodium, levoxyl, unithroid
unithroid G M
westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg
G M
WP THYROID NPB M westhroid
GASTROENTEROLOGY
ANTIDIARRHEALS & ANTISPASMODICS
anaspaz G
belladonna alkaloids-opium G
belladonna-opium G
BENTYL ORAL CAPSULE NPB dicyclomine hcl
chlordiazepoxide-clidinium G
CUVPOSA NPB glycopyrrolate
dicyclomine oral capsule G
dicyclomine oral solution G
dicyclomine oral tablet G
diphenoxylate-atropine G
DONNATAL ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML
NPB belladonna-phenobarbital
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
116
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
DONNATAL ORAL TABLET NPB
ed-spaz G
glycopyrrolate oral G
hyoscyamine sulfate G
hyosyne G
LEVBID NPB hyoscyamine sulfate
LEVSIN ORAL NPB hyoscyamine sulfate
LEVSIN/SL NPB hyoscyamine sulfate
LIBRAX (WITH CLIDINIUM) NPB clidinium w/chlordiazepoxide
LOMOTIL NPB diphenoxylate w/atropine
methscopolamine G glycopyrrolate
MOTOFEN NPB diphenoxylate w/atropine
MYTESI NPB diphenoxylate w/atropine, loperamide hcl
NULEV NPB hyoscyamine sulfate
opium tincture G
oscimin G
oscimin sl G
oscimin sr G
paregoric G
phenobarb-hyoscy-atropine-scop oral tablet
G
phenohytro G
propantheline G dicyclomine hcl, glycopyrrolate
ROBINUL FORTE NPB glycopyrrolate
ROBINUL ORAL NPB glycopyrrolate
SYMAX DUOTAB NPB hyoscyamine sulfate
symax fastabs G
symax-sl G
symax-sr G
MISCELLANEOUS GASTROINTESTINAL AGENTS
ACTIGALL NPB M ursodiol
AKYNZEO PB
alosetron G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
117
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
AMITIZA PB
ANALPRAM-HC RECTAL CREAM NPB hc pramoxine, pramcort
ANALPRAM-HC SINGLES RECTAL CREAM 2.5-1 % (4G)
NPB hc pramoxine, pramcort
anucort-hc G
ANUSOL-HC RECTAL SUPPOSITORY
NPB hydrocortisone acetate
ANUSOL-HC TOPICAL CREAM WITH PERINEAL APPLICATOR
NPB ST
ANZEMET ORAL NPB QL granisetron hcl, ondansetron hcl
aprepitant G QL
APRISO PB M
ASACOL HD NPB M; 2ST balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA
AURYXIA NPB FOSRENOL, RENVELA
AZULFIDINE NPB M sulfasalazine
AZULFIDINE EN-TABS NPB M sulfasalazine
balsalazide G
budesonide oral G
calcium acetate oral capsule G
calcium acetate oral tablet 667 mg G
CANASA PB
CESAMET NPB QL ondansetron hcl
CHENODAL PB-S PA
CHOLBAM PB
CIMZIA NPB-S 2ST
ACTEMRA, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, STELARA, XELJANZ
CIMZIA POWDER FOR RECONST NPB-S 2ST
ACTEMRA, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, STELARA, XELJANZ
COLAZAL NPB balsalazide disodium
colocort G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
118
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
COLYTE WITH FLAVOR PACKS ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM
NPB gavilyte-c, peg 3350-electrolyte
COMPAZINE NPB prochlorperazine maleate
compro G
constulose G
CORTENEMA NPB hydrocortisone
CORTIFOAM PB
CREON PB
cromolyn oral G
CYSTADANE PB
DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS)
NPB M; 2ST balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA
DICLEGIS NPB UNISOM, pyridoxine hcl
DIPENTUM NPB M; 2ST balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA
dronabinol G
eliphos G
EMEND ORAL CAPSULE 125 MG, 40 MG
PB QL
EMEND ORAL CAPSULE 80 MG NPB QL
EMEND ORAL CAPSULE,DOSE PACK
NPB QL APREPITANT
EMEND ORAL SUSPENSION FOR RECONSTITUTION
PB
ENTOCORT EC NPB budesonide ec
enulose G
FOSRENOL PB
GASTROCROM NPB cromolyn sodium
GATTEX 30-VIAL NPB-S diphenoxylate w/atropine, loperamide hcl, opium, paregoric
gavilyte-c G ACA
gavilyte-g G ACA
gavilyte-h and bisacodyl G ACA
gavilyte-n G ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
119
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
generlac G
GIALAX NPB ACA glycolax, polyethylene glycol
GIAZO NPB balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA
GOLYTELY ORAL POWDER IN PACKET
NPB ACA
gavilyte-g, peg 3350-electrolyte, trilyte with flavor packets, PREPOPIK, SUPREP
GOLYTELY ORAL RECON SOLN NPB
gavilyte-g, peg 3350-electrolyte, trilyte with flavor packets, PREPOPIK, SUPREP
granisetron hcl oral G QL
hemmorex-hc G
hydrocortisone acetate rectal G
hydrocortisone rectal G
hydrocortisone topical cream with perineal applicator
G
hydrocortisone-pramoxine rectal G
KAYEXALATE NPB sodium polystyrene sulfonate
kionex G
kionex (with sorbitol) G
KRISTALOSE NPB M lactulose
lactulose oral solution 10 gram/15 ml G
LIALDA PB M
lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %
G
LINZESS PB
LOTRONEX NPB alosetron hcl
MAGNEBIND 400 NPB
MARINOL NPB dronabinol
MESALAMINE ORAL NPB M; 2ST balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA
mesalamine rectal G
mesalamine with cleansing wipe G
metoclopramide hcl oral G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
120
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
MICORT-HC NPB ST hydrocortisone
MOVANTIK PB
MOVIPREP NPB ACA
gavilyte-g, peg 3350-electrolyte, trilyte with flavor packets, PREPOPIK, SUPREP
NULYTELY WITH FLAVOR PACKS NPB gavilyte-n, peg-3350 with flavor packs, trilyte with flavor packets
OCALIVA PB-S PA
ondansetron G QL
ondansetron hcl oral G QL
OSMOPREP NPB ACA
gavilyte-g, peg 3350-electrolyte, trilyte with flavor packets, PREPOPIK, SUPREP
PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000-54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT
NPB 2ST CREON, ZENPEP
peg 3350-electrolytes G ACA
peg-electrolyte soln G ACA
PENTASA PB M
PERTZYE NPB 2ST CREON, ZENPEP
PHOSLYRA NPB
polyethylene glycol 3350 G ACA
pramcort G
PREPOPIK PB ACA
prochlorperazine G
prochlorperazine maleate G
PROCORT NPB hc pramoxine
PROCTOCORT RECTAL NPB hydrocortisone acetate
PROCTOFOAM HC PB
procto-med hc G
proctosol hc topical G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
121
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
proctozone-hc G
RECTIV PB
REGLAN ORAL NPB metoclopramide hcl
RELISTOR ORAL NPB bisacodyl, lactulose, milk of magnesia, senna, AMITIZA, MOVANTIK
RELISTOR SUBCUTANEOUS SOLUTION
PB
RELISTOR SUBCUTANEOUS SYRINGE
PB
RENAGEL NPB RENVELA
RENVELA PB
ROWASA NPB mesalamine
SANCUSO PB QL
sevelamer carbonate oral powder in packet
G
SFROWASA NPB mesalamine
sodium polystyrene sulfonate oral G
sodium polystyrene sulfonate rectal enema 30 gram/120 ml
G
SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML
NPB
sps (with sorbitol) G
SUCRAID PB-S
sulfasalazine G M
SUPREP BOWEL PREP KIT PB ACA
SYNDROS NPB
TIGAN ORAL CAPSULE 300 MG NPB trimethobenzamide hcl
TRANSDERM-SCOP NPB meclizine hcl
trilyte with flavor packets G ACA
trimethobenzamide oral G
TRULANCE NPB PA AMITIZA, LINZESS
UCERIS ORAL PB
UCERIS RECTAL NPB hydrocortisone, CORTIFOAM
URSO 250 NPB M ursodiol
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
122
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
URSO FORTE NPB M ursodiol
ursodiol G M
VARUBI PB
VELPHORO NPB FOSRENOL, RENVELA
VELTASSA PB-S
VIBERZI PB
VIOKACE PB
ZENPEP PB
ZOFRAN (AS HYDROCHLORIDE) ORAL
NPB QL ondansetron hcl
ZOFRAN ODT NPB QL ondansetron odt
ZUPLENZ NPB QL ondansetron odt, ondansetron hcl, granisetron hcl
ULCER THERAPY
ACIPHEX NPB ST; QL; M rabeprazole sodium
ACIPHEX SPRINKLE NPB ST; QL; M
esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole sodium, rabeprazole sodium, NEXIUM RX
amoxicil-clarithromy-lansopraz G QL
CARAFATE ORAL SUSPENSION PB M
CARAFATE ORAL TABLET NPB M sucralfate
cimetidine hcl oral G M
cimetidine oral tablet 300 mg, 400 mg, 800 mg
G M
CYTOTEC NPB M misoprostol
DEXILANT NPB ST; QL; M
esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole sodium, rabeprazole sodium, NEXIUM RX
esomeprazole magnesium PB QL; M
ESOMEPRAZOLE STRONTIUM NPB ST; QL; M
esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole sodium, rabeprazole sodium, NEXIUM RX
famotidine oral suspension G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
123
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
famotidine oral tablet 40 mg G M
lansoprazole oral capsule,delayed release(dr/ec)
PB QL; M
misoprostol G M
NEXIUM NPB ST; QL; M esomeprazole magnesium
NEXIUM PACKET PB ST; QL; M
nizatidine G M
OMECLAMOX-PAK NPB QL lansoprazol-amoxicil-clarithro, PYLERA
omeprazole oral capsule,delayed release(dr/ec)
PB M
omeprazole-sodium bicarbonate oral capsule
PB QL; M
omeprazole-sodium bicarbonate oral packet
PB QL
pantoprazole oral PB QL; M
PEPCID ORAL SUSPENSION NPB M famotidine
PEPCID ORAL TABLET 40 MG NPB M famotidine
PREVACID NPB ST; QL; M lansoprazole
PREVACID SOLUTAB NPB ST; QL; M lansoprazole
PREVPAC NPB QL lansoprazol-amoxicil-clarithro
PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON
NPB ST; QL; M
esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole sodium, rabeprazole sodium, NEXIUM RX
PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET
NPB ST; QL; M
esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole sodium, rabeprazole sodium, NEXIUM RX
PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC)
NPB ST; QL; M pantoprazole sodium
PYLERA PB
rabeprazole PB QL; M
ranitidine hcl oral capsule G M
ranitidine hcl oral syrup G M
ranitidine hcl oral tablet 150 mg, 300 mg G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
124
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
sucralfate oral tablet G M
ZANTAC ORAL TABLET 300 MG NPB M ranitidine hcl
ZEGERID ORAL CAPSULE NPB ST; QL; M omeprazole-sodium bicarbonate
ZEGERID ORAL PACKET NPB ST; QL omeprazole-sodium bicarbonate
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY
GROWTH HORMONES
EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG
PB-S PA
GENOTROPIN PB-S PA
GENOTROPIN MINIQUICK PB-S PA
HUMATROPE PB-S PA
NORDITROPIN FLEXPRO PB-S PA
NUTROPIN AQ NUSPIN NPB-S 2ST GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO
OMNITROPE NPB-S 2ST GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO
SAIZEN NPB-S 2ST GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO
SAIZEN CLICK.EASY NPB-S 2ST GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO
SAIZEN SAIZENPREP NPB-S PA GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG
PB-S PA
ZOMACTON NPB-S 2ST GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO
ZORBTIVE NPB-S PA GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO
INTERFERONS
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
125
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
AUBAGIO NPB-S QL
AVONEX (WITH ALBUMIN) PB-S QL
AVONEX INTRAMUSCULAR PEN INJECTOR KIT
PB-S QL
AVONEX INTRAMUSCULAR SYRINGE KIT
PB-S QL
BETASERON SUBCUTANEOUS KIT PB-S QL
COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML
NPB-S QL
COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML
PB-S
COPEGUS NPB-S
EXTAVIA SUBCUTANEOUS KIT PB-S QL
EXTAVIA SUBCUTANEOUS RECON SOLN
PB-S
GILENYA PB-S
glatopa G-S QL
moderiba G-S
moderiba dose pack G-S
PEGASYS PB-S PA; QL
PEGASYS PROCLICK PB-S PA; QL
PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML
NPB-S PA; QL PEGASYS, PEGASYS PROCLICK
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML
NPB-S PA; QL PEGASYS, PEGASYS PROCLICK
PLEGRIDY PB-S
POMALYST PB-S QL
REBETOL ORAL SOLUTION NPB-S
REBIF (WITH ALBUMIN) PB-S QL
REBIF REBIDOSE PB-S QL
REBIF TITRATION PACK PB-S QL
REVLIMID PB-S
ribasphere G-S 2ST
ribasphere ribapak G-S 2ST
ribavirin oral capsule G-S
ribavirin oral tablet 200 mg G-S
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
126
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
SYLATRON PB-S PA; QL
TECFIDERA PB-S QL
ZINBRYTA NPB-S
INTERLEUKINS
ACTIMMUNE PB-S
ALDARA NPB QL
ARCALYST PB-S PA
imiquimod G QL
INTRON A INJECTION PB-S
KINERET NPB-S QL; 2ST
ZYCLARA NPB QL; 2ST
VACCINES & MISCELLANEOUS IMMUNOLOGICALS
GRASTEK PB
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
NPB-S GRASTEK
RAGWITEK PB
MUSCULOSKELETAL & RHEUMATOLOGY
GOUT THERAPY
allopurinol G M
COLCHICINE NPB 2ST COLCRYS, MITIGARE
COLCRYS PB
MITIGARE PB
probenecid G M
probenecid-colchicine G M
ULORIC PB M
ZURAMPIC NPB ST; M probenecid
ZYLOPRIM NPB M allopurinol
OSTEOPOROSIS THERAPY
ACTONEL ORAL TABLET 150 MG, 35 MG, 5 MG
NPB QL; M risedronate sodium
alendronate oral solution G QL; M
alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg
G QL; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
127
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ATELVIA NPB QL; M risedronate sodium dr
BINOSTO NPB QL; M alendronate sodium
BONIVA ORAL NPB QL; M ibandronate sodium
EVISTA NPB PA; M raloxifene hcl
FORTEO PB-S QL
FOSAMAX ORAL TABLET 70 MG NPB QL; M alendronate sodium
FOSAMAX PLUS D NPB QL; M alendronate sodium
ibandronate oral G QL; M
raloxifene G PA; M
risedronate oral tablet 150 mg, 35 mg, 5 mg
G QL; M
risedronate oral tablet,delayed release (dr/ec)
G QL; M
TYMLOS PB-S PA
OTHER RHEUMATOLOGICALS
ACTEMRA SUBCUTANEOUS PB-S PA; QL
ARAVA NPB QL leflunomide
CUPRIMINE NPB ST; M DEPEN
DEPEN TITRATABS PB M
ENBREL PB-S PA; QL
ENBREL SURECLICK PB-S PA; QL
HUMIRA PB-S PA; QL
HUMIRA PEDIATRIC CROHN'S START
PB PA; QL
HUMIRA PEN CROHN'S-UC-HS START
PB-S PA; QL
HUMIRA PEN PSORIASIS-UVEITIS PB-S PA; QL
KEVZARA NPB-S PA
leflunomide G QL
ORENCIA CLICKJECT NPB-S 2ST ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR
ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML
NPB-S 2ST ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
128
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML, 87.5 MG/0.7 ML
NPB-S PA ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR
OTEZLA PB-S PA; QL
OTEZLA STARTER PB-S PA; QL
OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML
PB-S QL
RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML
PB-S QL
RIDAURA PB M
SAVELLA ORAL TABLET PB QL; M
SAVELLA ORAL TABLETS,DOSE PACK
PB QL
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML
PB-S PA; QL
SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML
NPB-S PA; QL; 2ST
ACTEMRA, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, STELARA, XELJANZ
SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML
PB-S PA; QL
SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML
NPB-S PA; QL; 2ST
ACTEMRA, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, STELARA, XELJANZ
XELJANZ PB-S PA; QL
XELJANZ XR PB-S PA; QL
OBSTETRICS & GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
CAYA CONTOURED NPB ACA
FC2 FEMALE CONDOM PB ACA; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
129
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
FEMCAP VAGINAL DEVICE 22 MM PB ACA
WIDE-SEAL DIAPHRAGM NPB ACA
ESTROGENS & PROGESTINS
ACTIVELLA NPB M estradiol-norethindrone acetat
ALORA NPB QL; M estradiol, MINIVELLE
amabelz G M
ANGELIQ NPB M estradiol-norethindrone acetat, jinteli, mimvey, PREMPHASE, PREMPRO
AYGESTIN NPB M norethindrone acetate
camila G QL; M; ACA
CLIMARA NPB QL; M estradiol
CLIMARA PRO NPB QL; M COMBIPATCH
COMBIPATCH PB M
covaryx G
covaryx h.s. G
CRINONE VAGINAL GEL 4 % PB
deblitane G QL; M; ACA
DELESTROGEN NPB estradiol valerate
DEPO-ESTRADIOL PB
DEPO-PROVERA INTRAMUSCULAR SUSPENSION
NPB QL; ACA medroxyprogesterone acetate
DEPO-PROVERA INTRAMUSCULAR SYRINGE
NPB QL; ACA medroxyprogesterone acetate
DEPO-SUBQ PROVERA 104 NPB QL; ACA medroxyprogesterone acetate
DIVIGEL PB QL; M
DUAVEE PB
eemt G
eemt hs G
ELESTRIN NPB QL; M DIVIGEL
ENDOMETRIN NPB 2ST CRINONE
errin G QL; M; ACA
ESTRACE ORAL NPB M estradiol
ESTRACE VAGINAL PB M
estradiol oral G M
estradiol transdermal G QL; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
130
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml
G
estradiol-norethindrone acet G M
ESTRING NPB QL; M yuvafem, ESTRACE, PREMARIN
ESTROGEL NPB QL; M; 2ST DIVIGEL
estrogens-methyltestosterone G
estropipate G M
EVAMIST NPB QL DIVIGEL
FEMHRT LOW DOSE NPB M jinteli, jevantique lo
FEMRING NPB QL; M estradiol, estradiol, yuvafem, ESTRACE, PREMARIN, PREMARIN
fyavolv G M
heather G QL; M; ACA
jencycla G QL; M; ACA
jevantique lo G M
jinteli G M
jolivette G QL; M; ACA
lopreeza G M
lyza G QL; M; ACA
medroxyprogesterone intramuscular G QL; ACA
medroxyprogesterone oral G M
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG
NPB M estradiol, estropipate, PREMARIN
MENOSTAR NPB QL; M estradiol, MINIVELLE
mimvey G M
mimvey lo G M
MINIVELLE PB QL; M
nora-be G QL; M; ACA
norethindrone (contraceptive) G QL; M; ACA
norethindrone acetate G M
norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg
G M
norlyda G QL; M; ACA
norlyroc G QL; M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
131
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ORTHO MICRONOR NPB QL; M errin, jolivette
PREFEST NPB M estradiol-norethindrone acetat, jinteli, mimvey, PREMPHASE, PREMPRO
PREMARIN ORAL PB M
PREMARIN VAGINAL PB M
PREMPHASE PB M
PREMPRO PB M
progesterone micronized G M
PROMETRIUM NPB M progesterone
PROVERA NPB M medroxyprogesterone acetate
sharobel G QL; M; ACA
VAGIFEM NPB M yuvafem
VIVELLE-DOT NPB QL; M estradiol
yuvafem G M
MISCELLANEOUS OB/GYN
AVC VAGINAL NPB fluconazole, terconazole
CERVIDIL NPB
CLEOCIN VAGINAL CREAM NPB
CLEOCIN VAGINAL SUPPOSITORY NPB clindamycin phosphate, metronidazole
clindamycin phosphate vaginal G
CLINDESSE NPB clindamycin phosphate, metronidazole
CONCEPTROL PB ACA; OTC
fem ph G
GYNAZOLE-1 NPB terconazole
gynol ii G ACA; OTC
INTRAROSA NPB PA
isoxsuprine G M
LUPANETA PACK (1 MONTH) NPB QL norethindrone acetate, LUPRON DEPOT
LUPANETA PACK (3 MONTH) NPB QL norethindrone acetate, LUPRON DEPOT
LYSTEDA NPB tranexamic acid
METROGEL VAGINAL NPB metronidazole
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
132
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
metronidazole vaginal G
MIFEPREX NPB-S
NUVARING PB QL; M; ACA
NUVESSA NPB metronidazole, clindamycin phosphate
OSPHENA NPB yuvafem, ESTRACE, PREMARIN
PREPIDIL NPB
PROSTIN E2 NPB
RELAGARD NPB fem ph
TERAZOL 7 NPB QL terconazole
terconazole G QL
TODAY CONTRACEPTIVE SPONGE PB ACA; OTC
tranexamic acid oral G
vaginal contraceptive foam G ACA; OTC
vandazole G
VCF CONTRACEPTIVE FILM PB ACA; OTC
VCF CONTRACEPTIVE GEL PB ACA; OTC
xulane G QL; M; ACA
ORAL CONTRACEPTIVES & RELATED AGENTS
AFTERA NPB QL; OTC
altavera (28) G QL; M; ACA
alyacen 1/35 (28) G QL; M; ACA
alyacen 7/7/7 (28) G QL; M; ACA
amethia G QL; M; ACA
amethia lo G QL; M; ACA
amethyst G QL; M; ACA
apri G QL; M; ACA
aranelle (28) G QL; M; ACA
ashlyna G QL; M; ACA
aubra G QL; M; ACA
aviane G QL; M; ACA
azurette (28) G QL; M; ACA
balziva (28) G QL; M; ACA
bekyree (28) G QL; M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
133
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
BEYAZ NPB QL; M drospirenone-eth estra-levomef, rajani
blisovi 24 fe G QL; M; ACA
blisovi fe 1.5/30 (28) G QL; M; ACA
blisovi fe 1/20 (28) G QL; M; ACA
BREVICON (28) NPB QL; M necon, nortrel, wera
briellyn G QL; M; ACA
camrese G QL; M; ACA
camrese lo G QL; M; ACA
caziant (28) G QL; M; ACA
chateal G QL; M; ACA
cryselle (28) G QL; M; ACA
cyclafem 1/35 (28) G QL; M; ACA
cyclafem 7/7/7 (28) G QL; M; ACA
CYCLESSA (28) NPB QL; M caziant, velivet
cyred G QL; M; ACA
dasetta 1/35 (28) G QL; M; ACA
dasetta 7/7/7 (28) G QL; M; ACA
daysee G QL; M; ACA
delyla (28) G QL; M; ACA
desog-e.estradiol/e.estradiol G QL; M; ACA
DESOGEN NPB QL; M apri, emoquette, enskyce, reclipsen
desogestrel-ethinyl estradiol G QL; M; ACA
drospirenone-e.estradiol-lm.fa G QL; M; ACA
drospirenone-ethinyl estradiol G QL; M; ACA
econtra ez G QL; ACA; OTC
elinest G QL; M; ACA
ELLA NPB QL; ACA econtra ez, fallback solo, my way, next choice one dose, react
emoquette G QL; M; ACA
enpresse G QL; M; ACA
enskyce G QL; M; ACA
estarylla G QL; M; ACA
ESTROSTEP FE-28 NPB QL; M tri-legest fe, tilia fe
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
134
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ethynodiol diac-eth estradiol G QL; M; ACA
fallback solo G QL; ACA; OTC
falmina (28) G QL; M; ACA
fayosim G QL; M; ACA
femynor G QL; M; ACA
GENERESS FE NPB QL kaitlib fe, layolis fe, norethin-eth estra ferrous fum
gianvi (28) G QL; M; ACA
gildagia G QL; M; ACA
introvale G QL; M; ACA
jolessa G QL; M; ACA
juleber G QL; M; ACA
junel 1.5/30 (21) G QL; M; ACA
junel 1/20 (21) G QL; M; ACA
junel fe 1.5/30 (28) G QL; M; ACA
junel fe 1/20 (28) G QL; M; ACA
junel fe 24 G QL; M; ACA
kaitlib fe G QL; ACA
kariva (28) G QL; M; ACA
kelnor 1/35 (28) G QL; M; ACA
kimidess (28) G QL; M; ACA
kurvelo G QL; M; ACA
l norgest/e.estradiol-e.estrad G QL; M; ACA
larin 1.5/30 (21) G QL; M; ACA
larin 1/20 (21) G QL; M; ACA
larin 24 fe G QL; M; ACA
larin fe 1.5/30 (28) G QL; M; ACA
larin fe 1/20 (28) G QL; M; ACA
larissia G QL; M; ACA
layolis fe G QL; ACA
leena 28 G QL; M; ACA
lessina G QL; M; ACA
levonest (28) G QL; M; ACA
levonorgestrel oral tablet 1.5 mg G QL; ACA; OTC
levonorgestrel-ethinyl estrad G QL; M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
135
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
levonorg-eth estrad triphasic G QL; M; ACA
levora-28 G QL; M; ACA
LO LOESTRIN FE PB QL; M; ACA
LOESTRIN 1.5/30 (21) NPB QL; M junel, microgestin
LOESTRIN 1/20 (21) NPB QL; M junel, microgestin
LOESTRIN FE 1.5/30 (28-DAY) NPB QL; M blisovi fe, junel fe, larin fe, microgestin fe, tarina fe
LOESTRIN FE 1/20 (28-DAY) NPB QL; M blisovi fe, junel fe, larin fe, microgestin fe, tarina fe
lomedia 24 fe G QL; M; ACA
loryna (28) G QL; M; ACA
LOSEASONIQUE NPB QL; M amethia lo, camrese lo
low-ogestrel (28) G QL; M; ACA
lutera (28) G QL; M; ACA
marlissa G QL; M; ACA
mibelas 24 fe G QL; M; ACA
microgestin 1.5/30 (21) G QL; M; ACA
microgestin 1/20 (21) G QL; M; ACA
MICROGESTIN 24 FE NPB QL; M
microgestin fe 1.5/30 (28) G QL; M; ACA
microgestin fe 1/20 (28) G QL; M; ACA
MINASTRIN 24 FE NPB QL; M; ACA MIBELAS 24 FE, NORETHIN-ETH ESTRA FERROUS FUM
MIRCETTE (28) NPB QL; M azurette, kariva, kimidess, pimtrea, viorele
mono-linyah G QL; M; ACA
mononessa (28) G QL; M; ACA
my way G QL; ACA; OTC
myzilra G QL; M; ACA
NATAZIA PB QL; M; ACA
necon 0.5/35 (28) G QL; M; ACA
necon 1/50 (28) G QL; M; ACA
necon 10/11 (28) G QL; M; ACA
necon 7/7/7 (28) G QL; M; ACA
next choice one dose G QL; ACA; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
136
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
nikki (28) G QL; M; ACA
noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7)
G QL; M; ACA
noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)
G QL; ACA
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg
G QL; M; ACA
norethindrone-e.estradiol-iron G QL; M; ACA
norgestimate-ethinyl estradiol G QL; M; ACA
NORINYL 1/35 (28) NPB QL; M alyacen, cyclafem, necon, nortrel
nortrel 0.5/35 (28) G QL; M; ACA
nortrel 1/35 (21) G QL; M; ACA
nortrel 1/35 (28) G QL; M; ACA
nortrel 7/7/7 (28) G QL; M; ACA
ocella G QL; M; ACA
ogestrel (28) G QL; M; ACA
opcicon one-step G QL; ACA; OTC
option-2 G QL; ACA; OTC
orsythia G QL; M; ACA
ORTHO TRI-CYCLEN (28) NPB QL; M trinessa, tri-previfem, tri-sprintec
ORTHO TRI-CYCLEN LO (28) NPB QL; M norgestimate-ethinyl estradiol, tri-lo-estarylla, tri-lo-marzia, tri-lo-sprintec, trinessa lo
ORTHO-CYCLEN (28) NPB QL; M mononessa, previfem, sprintec
ORTHO-NOVUM 1/35 (28) NPB QL; M alyacen, cyclafem, necon, nortrel
ORTHO-NOVUM 7/7/7 (28) NPB QL; M alyacen, cyclafem, necon, nortrel
OVCON-35 (28) NPB QL; M balziva, briellyn, philith, zenchent
philith G QL; M; ACA
pimtrea (28) G QL; M; ACA
pirmella G QL; M; ACA
PLAN B ONE-STEP PB QL; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
137
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
portia G QL; M; ACA
previfem G QL; M; ACA
QUARTETTE NPB QL; M FAYOSIM, RIVELSA
quasense G QL; M; ACA
rajani G QL; M; ACA
react G QL; ACA; OTC
reclipsen (28) G QL; M; ACA
rivelsa G QL; M; ACA
SAFYRAL PB QL; M; ACA
SEASONIQUE NPB QL; M amethia, camrese
setlakin G QL; M; ACA
sprintec (28) G QL; M; ACA
sronyx G QL; M; ACA
syeda G QL; M; ACA
TAKE ACTION NPB QL; OTC
tarina fe 1/20 (28) G QL; M; ACA
TAYTULLA PB QL; M; ACA
tilia fe G QL; M; ACA
tri femynor G QL; M; ACA
tri-estarylla G QL; M; ACA
tri-legest fe G QL; M; ACA
tri-linyah G QL; M; ACA
tri-lo-estarylla G QL; M; ACA
tri-lo-marzia G QL; M; ACA
tri-lo-sprintec G QL; M; ACA
trinessa (28) G QL; M; ACA
trinessa lo G QL; M; ACA
TRI-NORINYL (28) NPB QL; M aranelle, leena
tri-previfem (28) G QL; M; ACA
tri-sprintec (28) G QL; M; ACA
trivora (28) G QL; M; ACA
velivet triphasic regimen (28) G QL; M; ACA
vestura (28) G QL; M; ACA
vienva G QL; M; ACA
viorele (28) G QL; M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
138
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
vyfemla (28) G QL; M; ACA
wera (28) G QL; M; ACA
wymzya fe G QL; M; ACA
YASMIN (28) NPB QL; M ocella, syeda, zarah
YAZ (28) NPB QL; M gianvi, loryna, nikki, vestura
zarah G QL; M; ACA
zenchent (28) G QL; M; ACA
zenchent fe G QL; M; ACA
zovia 1/35e (28) G QL; M; ACA
zovia 1/50e (28) G QL; M; ACA
OXYTOCICS
methergine G
OPHTHALMOLOGY
ANTIBIOTICS
AZASITE PB
bacitracin ophthalmic G
bacitracin-polymyxin b ophthalmic G
BESIVANCE NPB
ciprofloxacin hcl, gatifloxacin, levofloxacin hemihydrate, ofloxacin, MOXEZA, VIGAMOX
BETADINE OPHTHALMIC PREP NPB
CILOXAN NPB ciprofloxacin hcl
ciprofloxacin hcl ophthalmic G
erythromycin ophthalmic G
gatifloxacin G
gentak ophthalmic ointment G
gentamicin ophthalmic G
levofloxacin ophthalmic G
MOXEZA PB
NATACYN PB
neomycin-bacitracin-polymyxin G M
neomycin-polymyxin-gramicidin G
neo-polycin G M
OCUFLOX NPB ofloxacin
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
139
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ofloxacin ophthalmic G
polycin G
polymyxin b sulf-trimethoprim G
POLYTRIM NPB polymyxin b sul-trimethoprim
tobramycin G
TOBREX NPB tobramycin sulfate
VIGAMOX PB
ZYMAXID NPB gatifloxacin
ANTIVIRALS
trifluridine G
VIROPTIC NPB trifluridine
ZIRGAN NPB trifluridine
BETA-BLOCKERS
BETAGAN OPHTHALMIC DROPS 0.5 %
NPB M levobunolol hcl
betaxolol ophthalmic G M
BETIMOL NPB M timolol maleate, ALPHAGAN P, COMBIGAN
BETOPTIC S NPB M betaxolol hcl, timolol maleate, ALPHAGAN P, COMBIGAN
carteolol G M
ISTALOL NPB M; 2ST timolol maleate, betaxolol hcl, levobunolol hcl, ALPHAGAN P, COMBIGAN
levobunolol ophthalmic drops 0.5 % G M
metipranolol G M
timolol maleate ophthalmic G M
TIMOPTIC NPB M timolol maleate
TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE 0.5 %
NPB M timolol maleate
TIMOPTIC-XE NPB M timolol maleate
CHOLINESTERASE INHIBITOR MIOTICS
PHOSPHOLINE IODIDE PB M
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
140
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
CYCLOGYL NPB M cyclopentolate hcl
cyclopentolate G M
homatropaire G M
homatropine hbr G M
MYDRIACYL NPB M tropicamide
PAREMYD NPB
tropicamide G M
DIRECT ACTING MIOTICS
ISOPTO CARPINE NPB M pilocarpine hcl
MIOCHOL-E NPB
pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 %
G M
MISCELLANEOUS OPHTHALMOLOGICS
acuicyn G
AKTEN (PF) NPB
ALOCRIL NPB ST azelastine hcl, olopatadine hcl, ALREX, BEPREVE, PAZEO
ALOMIDE NPB ST azelastine hcl, olopatadine hcl, ALREX, BEPREVE, PAZEO
altacaine G
altafluor G
azelastine ophthalmic G
BEPREVE PB ST
cromolyn ophthalmic G
CYSTARAN PB-S PA
ELESTAT NPB ST epinastine hcl
EMADINE NPB ST azelastine hcl, olopatadine hcl, ALREX, BEPREVE, PAZEO
epinastine G
flucaine G
fluorescein-proparacaine G
flurox G
LACRISERT NPB RESTASIS
LASTACAFT NPB ST azelastine hcl, olopatadine hcl, ALREX, BEPREVE, PAZEO
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
141
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
olopatadine ophthalmic G
PATADAY NPB ST olopatadine hcl
PATANOL NPB ST olopatadine hcl
PAZEO PB ST
proparacaine G
RESTASIS PB QL; M
RESTASIS MULTIDOSE PB M
tetcaine G
tetracaine hcl G
tetracaine hcl (pf) ophthalmic G
TETRAVISC NPB tetracaine hcl
TETRAVISC FORTE OPHTHALMIC DROPS,HYPERVISCOUS
NPB tetracaine hcl
XIIDRA PB M
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ACULAR NPB ketorolac tromethamine
ACULAR LS NPB ketorolac tromethamine
ACUVAIL (PF) NPB 2ST
bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, NEVANAC, PROLENSA
bromfenac G
BROMSITE NPB
bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, NEVANAC, PROLENSA
diclofenac sodium ophthalmic G QL
flurbiprofen sodium G
ILEVRO PB
ketorolac ophthalmic G
NEVANAC PB
OCUFEN NPB flurbiprofen sodium
PROLENSA PB
ORAL DRUGS FOR GLAUCOMA
acetazolamide G M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
142
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
DIAMOX SEQUELS NPB M acetazolamide
methazolamide G M
NEPTAZANE NPB M methazolamide
OTHER GLAUCOMA DRUGS
AZOPT NPB M
dorzolamide hcl, dorzolamide-timolol, betaxolol hcl, timolol maleate, latanoprost, ALPHAGAN P, COMBIGAN
bimatoprost ophthalmic G M
COMBIGAN PB M
COSOPT NPB M dorzolamide-timolol
COSOPT (PF) NPB M dorzolamide-timolol, ALPHAGAN P, COMBIGAN
dorzolamide G M
dorzolamide-timolol G M
latanoprost G M
LUMIGAN OPHTHALMIC DROPS 0.01 %
PB M
MITOSOL NPB
SIMBRINZA NPB M brimonidine tartrate, dorzolamide-timolol, ALPHAGAN P, COMBIGAN
TRAVATAN Z PB M
TRUSOPT NPB M dorzolamide hcl
XALATAN NPB M latanoprost
ZIOPTAN (PF) NPB M; 2ST bimatoprost, latanoprost, LUMIGAN, TRAVATAN Z
STEROID-ANTIBIOTIC COMBINATIONS
MAXITROL NPB neo/polymyxin/dexamethasone
neomycin-bacitracin-poly-hc G
neomycin-polymyxin b-dexameth G
neomycin-polymyxin-hc ophthalmic G
neo-polycin hc G
PRED-G NPB tobramycin-dexamethasone, ZYLET
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
143
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
PRED-G S.O.P. NPB TOBRADEX
TOBRADEX OPHTHALMIC DROPS,SUSPENSION
NPB tobramycin-dexamethasone
TOBRADEX OPHTHALMIC OINTMENT
PB
TOBRADEX ST PB
tobramycin-dexamethasone G
ZYLET PB
STEROIDS
ALREX PB
dexamethasone sodium phosphate ophthalmic
G
DUREZOL NPB
dexamethasone sodium phosphate, fluorometholone, prednisolone acetate, LOTEMAX
FLAREX NPB
dexamethasone sodium phosphate, fluorometholone, prednisolone acetate, LOTEMAX
fluorometholone G
FML FORTE NPB
dexamethasone sodium phosphate, fluorometholone, prednisolone acetate, LOTEMAX
FML LIQUIFILM NPB fluorometholone
FML S.O.P. PB
LOTEMAX PB
MAXIDEX NPB dexamethasone sodium phosphate
OMNIPRED NPB prednisolone acetate
PRED FORTE NPB prednisolone acetate
PRED MILD PB
prednisolone acetate G
prednisolone sodium phosphate ophthalmic
G
STEROID-SULFONAMIDE COMBINATIONS
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
144
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
BLEPHAMIDE NPB sulfacetamide w/prednisolone
BLEPHAMIDE S.O.P. NPB sulfacetamide w/prednisolone
sulfacetamide-prednisolone G
SULFONAMIDES
BLEPH-10 NPB sulfacetamide sodium
sulfacetamide sodium ophthalmic G
SYMPATHOMIMETICS
ALPHAGAN P OPHTHALMIC DROPS 0.1 %
PB M
ALPHAGAN P OPHTHALMIC DROPS 0.15 %
NPB M brimonidine tartrate
apraclonidine G M
brimonidine G M
IOPIDINE OPHTHALMIC DROPPERETTE
NPB M brimonidine tartrate, ALPHAGAN P
IOPIDINE OPHTHALMIC DROPS NPB M apraclonidine hcl
VASOCONSTRICTOR DECONGESTANTS
CYCLOMYDRIL NPB M
phenylephrine hcl ophthalmic G
RESPIRATORY, ALLERGY, COUGH & COLD
ANTIHISTAMINE & ANTIALLERGENIC AGENTS
ADRENACLICK NPB QL epinephrine, EPIPEN, EPIPEN JR.
AUVI-Q NPB PA; QL epinephrine, EPIPEN, EPIPEN JR.
carbinoxamine maleate G
cetirizine oral solution 1 mg/ml PB
CLARINEX ORAL SYRUP NPB desloratadine
CLARINEX ORAL TABLET NPB QL desloratadine
clemastine oral tablet 2.68 mg G
cyproheptadine G
desloratadine PB QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
145
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
EPINEPHRINE INJECTION AUTO-INJECTOR
PB QL epinephrine, EPIPEN, EPIPEN JR.
EPIPEN 2-PAK PB QL
EPIPEN JR 2-PAK PB QL
hydroxyzine hcl oral solution 10 mg/5 ml
G
hydroxyzine hcl oral tablet G
hydroxyzine pamoate G
KARBINAL ER NPB carbinoxamine
phenadoz G
phenergan rectal G
promethazine oral G
promethazine rectal G
promethegan G
RYVENT NPB carbinoxamine
VISTARIL NPB hydroxyzine pamoate
COUGH & COLD THERAPY
benzonatate G
BROMFED DM NPB
brompheniramine-pseudoeph-dm oral syrup
G
CAPCOF NPB promethazine vc w/codeine
centergy G
cheratussin ac G
CLARINEX-D 12 HOUR NPB QL desloratadine, fexofenadine-pse er
codeine-guaifenesin G
CODITUSSIN AC NPB
cheratussin ac, guaifenesin ac, guaifenesin with codeine, iophen c-nr, m-clear wc, virtussin ac
CODITUSSIN DAC NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac
FLOWTUSS NPB 2ST
cheratussin ac, guaifenesin ac, guaifenesin with codeine, iophen c-nr, m-clear wc, virtussin ac
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
146
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
g tussin ac G
guaiatussin ac G
guaifenesin ac G
guaifenesin dac G
HISTEX-AC NPB promethazine vc w/codeine
HYCOFENIX NPB 2ST cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac
hydrocodone-chlorpheniramine G
hydrocodone-cpm-pseudoephed G
hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml
G
hydrocodone-homatropine oral tablet G
hydromet G
lortuss ex oral syrup G
MAR-COF BP NPB promethazine vc w/codeine
MAR-COF CG NPB
cheratussin ac, guaifenesin ac, guaifenesin with codeine, iophen c-nr, m-clear wc, virtussin ac
m-clear wc G
M-END PE NPB promethazine vc w/codeine
NINJACOF-XG NPB
cheratussin ac, guaifenesin ac, guaifenesin with codeine, iophen c-nr, m-clear wc, virtussin ac
OBREDON NPB 2ST
cheratussin ac, guaifenesin ac, guaifenesin with codeine, iophen c-nr, m-clear wc, virtussin ac
POLY-TUSSIN AC ORAL LIQUID 4-10-10 MG/5 ML
NPB
promethazine vc-codeine G
promethazine-codeine G
promethazine-dm G
promethazine-phenyleph-codeine G
promethazine-phenylephrine G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
147
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
PRO-RED AC (W/ DEXCHLORPHENIR)
NPB
relcof c G
RESPA-AR NPB
REZIRA NPB hydrocod-cpm-pseudoephedrine
rydex G
SEMPREX-D NPB desloratadine, levocetirizine dihydrochloride
TESSALON PERLES NPB benzonatate
tusnel c G
TUSNEL PEDIATRIC ORAL LIQUID NPB
TUSSICAPS PB 2ST
tussigon G
TUSSIONEX PENNKINETIC ER NPB hydrocodone-chlorpheniramine
TUZISTRA XR NPB 2ST hydrocodone-chlorpheniramine, promethazine w/codeine
virtussin ac G
virtussin dac G
VITUZ NPB 2ST hydrocodone-chlorpheniramine, promethazine w/codeine
ZODRYL AC 25 NPB hydrocodone-chlorpheniramine, promethazine w/codeine
ZODRYL AC 30 NPB hydrocodone-chlorpheniramine, promethazine w/codeine
ZODRYL AC 35 NPB hydrocodone-chlorpheniramine, promethazine w/codeine
ZODRYL AC 40 PB
ZODRYL AC 50 NPB hydrocodone-chlorpheniramine, promethazine w/codeine
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
148
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ZODRYL AC 60 NPB hydrocodone-chlorpheniramine, promethazine w/codeine
ZODRYL AC 80 NPB hydrocodone-chlorpheniramine, promethazine w/codeine
ZODRYL DAC 25 NPB
ZODRYL DAC 30 NPB
ZODRYL DAC 35 NPB
ZODRYL DAC 40 NPB
ZODRYL DAC 50 NPB
ZODRYL DAC 60 NPB
ZODRYL DAC 80 NPB
ZODRYL DEC 25 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac
ZODRYL DEC 30 PB
ZODRYL DEC 35 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac
ZODRYL DEC 40 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac
ZODRYL DEC 50 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac
ZODRYL DEC 60 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac
ZODRYL DEC 80 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac
Z-TUSS AC NPB hydrocodone-chlorpheniramine, promethazine w/codeine
ZUTRIPRO NPB hydrocod-cpm-pseudoephedrine
PULMONARY AGENTS
ACCOLATE NPB QL; M zafirlukast
acetylcysteine G
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
149
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ADCIRCA PB-S PA; QL
ADEMPAS PB-S M
ADRENALIN NASAL NPB
ADVAIR DISKUS PB QL; M
ADVAIR HFA PB QL; M
AEROSPAN NPB M
ARNUITY ELLIPTA, ASMANEX, ASMANEX HFA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR
AIRDUO RESPICLICK NPB M ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, DULERA, SYMBICORT
albuterol sulfate inhalation solution for nebulization
G
albuterol sulfate oral G M
ALVESCO NPB QL; M; 2ST
ARNUITY ELLIPTA, ASMANEX, ASMANEX HFA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR
ANORO ELLIPTA PB M
ARCAPTA NEOHALER PB QL; M
ARNUITY ELLIPTA PB M
ASMANEX HFA PB M
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (14 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)
PB QL; M
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES)
PB M
ATROVENT HFA PB QL; M
BECONASE AQ NPB QL; 2ST budesonide, flunisolide, fluticasone propionate, mometasone furoate, QNASL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
150
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
BEVESPI AEROSPHERE PB M
BREO ELLIPTA PB QL; M
BROVANA NPB QL; M PERFOROMIST
budesonide inhalation G QL; M
budesonide nasal PB QL
COMBIVENT RESPIMAT PB QL
cromolyn inhalation G M
CUROSURF NPB
DALIRESP PB PA; QL
DULERA PB QL; M
DYMISTA PB ST; QL
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML
NPB M theophylline anhydrous
ESBRIET PB-S PA
FIRAZYR PB-S
FLOVENT DISKUS PB QL; M
FLOVENT HFA PB QL; M
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)
PB QL
fluticasone nasal PB QL
FLUTICASONE-SALMETEROL NPB M
FORADIL AEROLIZER NPB QL ARCAPTA NEOHALER, SEREVENT DISKUS, STRIVERDI RESPIMAT
HYPER-SAL NPB sodium chloride
INCRUSE ELLIPTA PB M
ipratropium bromide inhalation G M
ipratropium-albuterol G QL
KALYDECO PB-S PA
LETAIRIS PB-S PA; M
levalbuterol hcl G
LEVALBUTEROL TARTRATE NPB QL; 2ST PROAIR HFA, PROAIR RESPICLICK, VENTOLIN HFA
metaproterenol G M
mometasone nasal PB QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
151
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
montelukast oral granules in packet G M
montelukast oral tablet G QL; M
montelukast oral tablet,chewable G QL; M
NASONEX NPB ST; QL mometasone furoate
nebusal inhalation solution for nebulization 3 %
G
NEBUSAL INHALATION SOLUTION FOR NEBULIZATION 6 %
NPB
OFEV PB-S PA
OMNARIS NPB QL; 2ST budesonide, flunisolide, fluticasone propionate, mometasone furoate, QNASL
OPSUMIT PB-S M
ORKAMBI PB-S PA
PERFOROMIST PB QL; M
PROAIR HFA PB QL
PROAIR RESPICLICK PB
PROVENTIL HFA NPB QL; 2ST PROAIR HFA, PROAIR RESPICLICK, VENTOLIN HFA
PULMICORT NPB QL; M budesonide
PULMICORT FLEXHALER PB QL; M
pulmosal G
PULMOZYME PB
QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION
PB ST
QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION
PB ST; QL
QVAR PB QL; M
REVATIO INTRAVENOUS NPB-S PA sildenafil citrate
REVATIO ORAL SUSPENSION FOR RECONSTITUTION
NPB-S PA sildenafil citrate
REVATIO ORAL TABLET NPB-S PA; QL sildenafil citrate
SEEBRI NEOHALER NPB M
INCRUSE ELLIPTA, SPIRIVA, SPIRIVA RESPIMAT, TUDORZA PRESSAIR
SEREVENT DISKUS PB QL; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
152
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
sildenafil oral G-S PA; QL
SINGULAIR ORAL GRANULES IN PACKET
NPB M montelukast sodium
SINGULAIR ORAL TABLET NPB QL; M montelukast sodium
SINGULAIR ORAL TABLET,CHEWABLE
NPB QL; M montelukast sodium
sodium chloride inhalation solution for nebulization 10 %, 3 %, 7 %
G
SPIRIVA RESPIMAT PB M
SPIRIVA WITH HANDIHALER PB QL; M
STIOLTO RESPIMAT PB M
STRIVERDI RESPIMAT PB M
SYMBICORT PB QL; M
terbutaline oral G M
terbutaline subcutaneous G
THEO-24 NPB M theophylline anhydrous
theochron G M
theophylline oral solution G M
theophylline oral tablet extended release 12 hr
G M
theophylline oral tablet extended release 24 hr
G M
TRACLEER PB-S PA; M
triamcinolone acetonide nasal PB QL
TUDORZA PRESSAIR PB QL; M
UTIBRON NEOHALER NPB M ANORO ELLIPTA, BEVESPI AEROSPHERE, STIOLTO RESPIMAT
VENTAVIS PB-S PA
VENTOLIN HFA PB QL
XOPENEX NPB levalbuterol hcl
XOPENEX CONCENTRATE NPB levalbuterol hcl
XOPENEX HFA NPB QL; 2ST PROAIR HFA, PROAIR RESPICLICK, VENTOLIN HFA
zafirlukast G QL; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
153
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ZETONNA NPB QL; 2ST budesonide, flunisolide, fluticasone propionate, mometasone furoate, QNASL
zileuton G QL; M
ZYFLO NPB M; 2ST montelukast sodium, zafirlukast
ZYFLO CR NPB QL; M; 2ST ZILEUTON
UROLOGICALS
ANTICHOLINERGICS & ANTISPASMODICS
darifenacin G M
DETROL NPB ST; M tolterodine tartrate
DETROL LA NPB ST; M tolterodine tartrate er
DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG, 15 MG
NPB ST; M oxybutynin chloride er
DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 5 MG
NPB ST; QL; M oxybutynin chloride er
ENABLEX NPB ST; M darifenacin er
flavoxate G M
GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)
PB ST
GELNIQUE TRANSDERMAL GEL IN PACKET
PB ST; QL; M
MYRBETRIQ PB ST; M
oxybutynin chloride oral syrup G M
oxybutynin chloride oral tablet G M
oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg
G M
oxybutynin chloride oral tablet extended release 24hr 5 mg
G QL; M
OXYTROL NPB ST; QL; M
oxybutynin chloride er, tolterodine tartrate er, trospium chloride, GELNIQUE, TOVIAZ, MYRBETRIQ, VESICARE
tolterodine G M
TOVIAZ PB ST; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
154
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
trospium G M
VESICARE PB ST; M
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin G M
AVODART NPB M dutasteride
CIALIS ORAL TABLET 2.5 MG, 5 MG PB
dutasteride G M
dutasteride-tamsulosin G M
finasteride oral tablet 5 mg G M
FLOMAX NPB M tamsulosin hcl
JALYN NPB M dutasteride-tamsulosin
PROSCAR NPB M finasteride
RAPAFLO PB M
tamsulosin G M
UROXATRAL NPB M alfuzosin hcl er
CHOLINERGIC STIMULANTS
bethanechol chloride G
URECHOLINE NPB bethanechol chloride
MISCELLANEOUS UROLOGICALS
azuphen mb G
CIALIS ORAL TABLET 10 MG, 20 MG
PB
CYSTAGON PB-S PA
cytra k crystals G
cytra-2 G
cytra-3 G
cytra-k G
EDEX NPB CAVERJECT, MUSE
ELMIRON PB
hyolev mb G
hyophen G
INDIOMIN MB NPB
K-PHOS NO 2 NPB phospha 250 neutral
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
155
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
K-PHOS ORIGINAL PB
LEVITRA NPB 2ST CIALIS, VIAGRA
methen-sod phos-meth blue-hyos G
ORACIT NPB sodium citrate & citric acid
phosphasal G
pot,sodium citrate-citric acid G
potassium citrate G M
potassium citrate-citric acid G
PROCYSBI NPB-S PA; ST CYSTAGON
SHOHL'S MODIFIED NPB sodium citrate & citric acid
sodium citrate-citric acid G
STAXYN NPB 2ST CIALIS, VIAGRA
STENDRA ORAL TABLET 100 MG, 50 MG
NPB 2ST CIALIS, VIAGRA
tricitrates G
ur n-c G
uramit mb G
URELLE NPB phosphasal, ur n-c, uretron d-s
uretron d-s oral tablet 81.6-10.8-40.8 mg G
URIBEL NPB ustell
urimar-t G
urin ds G
uro-458 G
UROCIT-K 10 NPB M potassium citrate er
UROCIT-K 15 NPB M potassium citrate er
UROCIT-K 5 NPB M potassium citrate er
urogesic-blue G
uro-mp G
urophen mb G
UROQID-ACID NO.2 NPB methenamine mandelate
uryl G
ustell G
UTA NPB
utira-c G
VIAGRA PB
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
156
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
virtrate-2 G
virtrate-3 G
virtrate-k G
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg, 200 mg
G
PYRIDIUM NPB phenazopyridine hcl
VITAMINS, HEMATINICS & ELECTROLYTES
ELECTROLYTES
calcium 500 + d oral tablet 500 mg(1,250mg) -200 unit
G ACA; OTC
calcium 500 + d oral tablet,chewable G ACA; OTC
calcium 500 with d G ACA; OTC
calcium 600 + d(3) oral capsule G ACA; OTC
calcium 600 + d(3) oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit
G ACA; OTC
calcium 600 with vitamin d3 oral capsule
G ACA; OTC
calcium 600 with vitamin d3 oral tablet,chewable
G ACA; OTC
calcium carb and citrate-vitd3 G ACA; OTC
calcium carbonate-vitamin d3 oral capsule 600 mg(1,500mg) -400 unit
G ACA; OTC
calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit
G ACA; OTC
calcium carbonate-vitamin d3 oral tablet,chewable 500-100 mg-unit
G ACA; OTC
calcium citrate + d G ACA; OTC
calcium citrate-vitamin d2 G ACA; OTC
calcium citrate-vitamin d3 oral tablet 200-125 mg-unit, 250 mg calcium- 200 unit, 315-200 mg-unit, 315-250 mg-unit
G ACA; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
157
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
citrus calcium G ACA; OTC
EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ
NPB M potassium bicarbonate
effer-k oral tablet, effervescent 25 meq G M
GALZIN NPB
hi-cal plus vit d G ACA; OTC
k-effervescent G M
klor-con G M
klor-con 10 G M
klor-con 8 G M
klor-con m10 G M
klor-con m15 G M
klor-con m20 G M
klor-con sprinkle G M
KLOR-CON/25 NPB M potassium chloride
klor-con/ef G M
k-phos-neutral G
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ
NPB M potassium chloride
k-tab oral tablet extended release 8 meq G M
lugols oral G
oysco 500/d oral tablet G ACA; OTC
oyster shell + d3 G ACA; OTC
oyster shell calcium-vit d3 G ACA; OTC
oystercal-d G ACA; OTC
phospha 250 neutral G
POTABA ORAL CAPSULE NPB M
potassium bicarb and chloride G M
potassium bicarb-citric acid G M
potassium chloride oral G M
strong iodine oral G
virt-phos 250 neutral G
MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES
FORTAVIT NPB
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158
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
VITAMINS & HEMATINICS
ACTIVE FE NPB
cholecalciferol (vitamin d3) oral capsule 1,000 unit
G ACA; OTC
cholecalciferol (vitamin d3) oral drops 400 unit/ml
G ACA; OTC
cholecalciferol (vitamin d3) oral tablet 1,000 unit, 400 unit
G ACA; OTC
cholecalciferol (vitamin d3) oral tablet,chewable 1,000 unit
G ACA; OTC
delta d3 G ACA; OTC
d-vi-sol G ACA; OTC
d-vita G ACA; OTC
ergocalciferol (vitamin d2) oral tablet 400 unit
G ACA; OTC
ESCAVITE D NPB M
ESCAVITE LQ NPB M
FLORIVA NPB M
FLORIVA (FLUORIDE-VITAMIN D3) NPB M; ACA
FLORIVA PLUS NPB M
FLUORABON NPB M; ACA
FLUOR-A-DAY NPB M; ACA
fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg, 1 mg f (2.2 mg)-236.79 mg
G M
fluoride (sodium) oral drops G M; ACA
fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
G M; ACA
fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
G M
fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)
G M; ACA
fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
G M
FLURA-DROPS NPB M; ACA
folic acid oral tablet 1 mg G M
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159
Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES
ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
G M; ACA
ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
G M
multi-vit with fluoride-iron G ACA
multi-vitamin with fluoride oral drops G ACA
multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
G ACA
multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
G ACA
mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg
G ACA
mynephron G
NASCOBAL PB M
oyster shell calcium-vit d2 oral tablet 250 (625)-125 mg-unit
G ACA; OTC
POLY-VI-FLOR FS NPB M
PRENATAL PLUS DHA ORAL COMBO PACK
NPB pnv-dha, prena1 pearl, virt-pn dha
PURALOR CI NPB M
QUFLORA FE NPB M
QUFLORA FE (FERROUS SULFATE) NPB M; ACA
QUFLORA PEDIATRIC NPB M
QUFLORA PEDIATRIC DROPS NPB M
risacal-d G ACA; OTC
TEXAVITE LQ NPB M
tri-vit with fluoride and iron G ACA
tri-vitamin with fluoride G ACA
VIRT-VITE PLUS NPB M
vitajoy daily d G ACA; OTC
vitamin d3 oral capsule 1,000 unit, 400 unit
G ACA; OTC
vitamin d3 oral tablet 1,000 unit, 400 unit
G ACA; OTC
vitamin d3 oral tablet,chewable G ACA; OTC
vitamins a,c,d and fluoride G ACA
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160
2 2TEK GLUCOSE/BLOOD
PRESSURE ........................ 86 A abacavir .................................... 3 abacavir-lamivudine ................. 4 abacavir-lamivudine-zidovudine
.............................................. 4 ABILIFY ................................ 34 ABSORICA ............................ 61 ABSTRAL .............................. 26 acamprosate ............................ 72 ACANYA ............................... 61 acarbose ................................ 112 ACCOLATE ......................... 148 ACCU-CHEK AVIVA
CONNECT METER .......... 86 ACCU-CHEK AVIVA PLUS
METER .............................. 86 ACCU-CHEK AVIVA PLUS
TEST STRP ........................ 77 ACCU-CHEK COMPACT
PLUS CONTROL .............. 86 ACCU-CHEK COMPACT
PLUS TEST........................ 77 ACCU-CHEK GUIDE ........... 77 ACCU-CHEK GUIDE
GLUCOSE METER ........... 87 ACCU-CHEK GUIDE L1-L2
CTRL SOL ......................... 87 ACCU-CHEK NANO ............ 87 ACCU-CHEK SMARTVIEW
CONTRL SOL ................... 87 ACCU-CHEK SMARTVIEW
TEST STRIP ...................... 77 ACCUPRIL ............................ 44 ACCURETIC ......................... 44 ACCUTREND GLUCOSE .... 77 ACCUTREND GLUCOSE
CONTROL ......................... 87 acebutolol ............................... 44 acetaminophen-caff-dihydrocod
............................................ 26 ACETAMINOPHEN-CAFF-
DIHYDROCOD ................. 26
acetaminophen-codeine .......... 26 acetazolamide ....................... 141 acetic acid ............................... 75 acetic acid-aluminum acetate . 75 acetylcysteine ....................... 148 ACIPHEX ............................. 122 ACIPHEX SPRINKLE ........ 122 acitretin ................................... 56 ACTEMRA .......................... 127 ACTICLATE .......................... 12 ACTIGALL .......................... 116 ACTIMMUNE ..................... 126 ACTIQ .................................... 26 ACTIVE FE .......................... 158 ACTIVELLA........................ 129 ACTONEL ..................... 72, 126 ACTOPLUS MET ................ 112 ACTOPLUS MET XR ......... 112 ACTOS ................................. 112 acuicyn.................................. 140 ACULAR.............................. 141 ACULAR LS ........................ 141 ACUVAIL (PF) .................... 141 acyclovir ............................. 4, 68 ACZONE ................................ 61 ADALAT CC ......................... 44 adapalene ................................ 61 ADAPALENE ........................ 61 ADASUVE ............................. 34 ADCIRCA ............................ 149 ADDERALL .......................... 34 ADDERALL XR .................... 34 ADDYI ................................... 34 adefovir ..................................... 4 ADEMPAS ........................... 149 ADLYXIN ............................ 112 ADRENACLICK ................. 144 ADRENALIN ....................... 149 ADVAIR DISKUS ............... 149 ADVAIR HFA ..................... 149 ADVANCED GLUC METER
TEST STRIP....................... 78 ADVANCED GLUCOSE
METER .............................. 87
ADVOCATE BLOOD GLUCOSE MONITOR ...... 87
ADVOCATE DUO ................ 87 ADVOCATE LOW CONTROL
............................................ 87 ADVOCATE REDI-CODE.... 78 ADVOCATE REDI-CODE
DUO METER ..................... 87 ADVOCATE REDI-CODE
GLU MONITOR ................ 88 ADVOCATE REDI-CODE+
CTRL LOW ........................ 88 ADVOCATE TEST STRIPS . 78 ADZENYS XR-ODT ............. 35 AEROSPAN ......................... 149 afeditab cr ............................... 44 AFINITOR ............................. 14 AFINITOR DISPERZ ............ 14 AFREZZA ............................ 108 AFTERA............................... 132 AGAMATRIX AMP GLUC
MONITOR SYS ................. 88 AGAMATRIX AMP TEST
STRIPS ............................... 78 AGAMATRIX CONTROL
HIGH .................................. 88 AGGRENOX .......................... 51 AGRYLIN .............................. 72 AIRDUO RESPICLICK ....... 149 AKTEN (PF) ........................ 140 AKYNZEO ........................... 116 ala-cort .................................... 68 ALA-SCALP .......................... 68 ALBENZA ............................... 8 albuterol sulfate .................... 149 alclometasone ......................... 68 ALDACTAZIDE .................... 44 ALDACTONE ........................ 44 ALDARA ............................. 126 ALECENSA ........................... 14 alendronate ..................... 72, 126 alfuzosin ............................... 154 ALINIA .................................... 9 ALKERAN ............................. 14 allopurinol............................. 126
Index of Drugs
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161
ALLZITAL ............................. 26 almotriptan malate .................. 22 ALOCRIL............................. 140 ALOGLIPTIN ...................... 112 ALOGLIPTIN-METFORMIN
.......................................... 112 ALOGLIPTIN-
PIOGLITAZONE ............. 112 ALOMIDE ........................... 140 ALORA ................................ 129 alosetron ............................... 116 ALPHAGAN P ..................... 144 alprazolam .............................. 35 alprazolam intensol ................ 35 ALREX................................. 143 ALSUMA ............................... 22 ALTABAX ............................. 66 altacaine ................................ 140 ALTACE ................................ 44 altafluor ................................ 140 altavera (28) .......................... 132 ALTOPREV ........................... 53 ALVESCO ........................... 149 alyacen 1/35 (28) .................. 132 alyacen 7/7/7 (28) ................. 132 amabelz ................................. 129 amantadine hcl .......................... 4 AMARYL............................. 112 AMBIEN ................................ 35 AMBIEN CR .......................... 35 amcinonide ............................. 68 AMERGE ............................... 22 amethia ................................. 132 amethia lo ............................. 132 amethyst ............................... 132 AMICAR ................................ 51 amiloride ................................. 44 amiloride-hydrochlorothiazide44 amiodarone ............................. 43 AMITIZA ............................. 117 amitriptyline ........................... 35 amitriptyline-chlordiazepoxide
............................................ 35 amlodipine .............................. 44 amlodipine-atorvastatin .......... 53 amlodipine-benazepril ............ 44 amlodipine-olmesartan ........... 45 amlodipine-valsartan .............. 45
amlodipine-valsartan-hcthiazid ............................................ 45
amoxapine .............................. 35 amoxicil-clarithromy-lansopraz
.......................................... 122 amoxicillin .............................. 11 amoxicillin-pot clavulanate .... 11 ampicillin ................................ 11 AMPYRA ............................... 24 AMRIX ................................... 25 ANAFRANIL ......................... 35 anagrelide ............................... 72 ANALPRAM-HC ........... 56, 117 ANALPRAM-HC SINGLES117 ANAPROX DS ...................... 31 anaspaz ................................. 115 anastrozole .............................. 14 ANCOBON .............................. 3 ANDRODERM .................... 109 ANDROGEL ................ 109, 110 ANDROID............................ 110 androxy ................................. 110 ANGELIQ ............................ 129 ANORO ELLIPTA............... 149 ANTABUSE ........................... 72 ANTARA ............................... 53 anucort-hc ............................. 117 ANUSOL-HC ....................... 117 ANZEMET ........................... 117 apexicon e ............................... 68 APIDRA ............................... 108 APIDRA SOLOSTAR ......... 108 APLENZIN ............................ 35 APOKYN ............................... 21 apraclonidine ........................ 144 aprepitant .............................. 117 apri ........................................ 132 APRISO ................................ 117 APTENSIO XR ...................... 35 APTIOM ................................. 18 APTIVUS ................................. 4 AQUA GLYCOLIC HC ......... 68 aranelle (28) .......................... 132 ARAVA ................................ 127 ARCALYST ......................... 126 ARCAPTA NEOHALER ..... 149 ARICEPT ............................... 24 ARIMIDEX ............................ 14 aripiprazole ............................. 35
ARIXTRA .............................. 51 armodafinil ............................. 35 ARMOUR THYROID.......... 114 ARNUITY ELLIPTA ........... 149 AROMASIN ........................... 14 ARTHROTEC 50 ................... 31 ARTHROTEC 75 ................... 31 ARYMO ER ........................... 26 ASACOL HD ....................... 117 ascomp with codeine .............. 26 ashlyna .................................. 132 ASMANEX HFA ................. 149 ASMANEX TWISTHALER 149 aspir-81 ................................... 31 aspirin ..................................... 31 aspirin low dose ...................... 31 aspirin-caffeine-dihydrocodein
............................................ 26 aspirin-dipyridamole ............... 51 aspir-low ................................. 31 aspir-trin ................................. 31 ASSURE 4 CONTROL
SOLUTION ........................ 88 ASSURE 4 STRIPS ................ 78 ASSURE DOSE NORMAL
CONTROL ......................... 88 ASSURE PLATINUM ..... 78, 88 ASSURE PRISM CONTROL 1-
2 SOLN ............................... 88 ASSURE PRISM MULTI
METER............................... 88 ASSURE PRISM MULTI
STRIP ................................. 78 ASTAGRAF XL ..................... 14 ASTEPRO .............................. 74 ATACAND............................. 45 ATACAND HCT.................... 45 ATELVIA ............................. 127 atenolol ................................... 45 atenolol-chlorthalidone ........... 45 ATIVAN ................................. 35 atomoxetine ............................ 35 ATOPICLAIR ........................ 59 atorvastatin ............................. 53 atovaquone ................................ 9 atovaquone-proguanil ............... 9 ATRALIN............................... 62 ATRAPRO CP........................ 59 ATRAPRO HYDROGEL ...... 59
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162
ATRIPLA ................................. 4 atropine ................................. 139 ATROVENT HFA ............... 149 AUBAGIO ........................... 125 aubra ..................................... 132 AUGMENTIN ........................ 11 AUGMENTIN ES-600 ........... 11 AUGMENTIN XR ................. 11 AURYXIA ........................... 117 AUTOJECT 2 INJECTION
DEVICE ............................. 88 AUTOPEN 1 TO 21 UNITS .. 88 AUVI-Q ................................ 144 AVALIDE .............................. 45 AVANDIA ........................... 112 AVAPRO ............................... 45 avar ......................................... 62 AVAR..................................... 62 AVAR LS ............................... 62 AVAR-E GREEN .................. 62 AVAR-E LS ........................... 62 AVC VAGINAL .................. 131 AVELOX ............................... 11 aviane ................................... 132 avidoxy ................................... 12 avita ........................................ 62 AVITA ................................... 62 avo cream ............................... 59 AVODART .......................... 154 AVONEX ............................. 125 AVONEX (WITH ALBUMIN)
.......................................... 125 AXERT................................... 22 AXIRON .............................. 110 AYGESTIN .......................... 129 AZASAN ................................ 14 AZASITE ............................. 138 azathioprine ............................ 14 azelastine ........................ 74, 140 AZELEX ................................ 62 AZILECT ............................... 21 azithromycin ............................. 8 AZOPT ................................. 142 AZOR ..................................... 45 AZULFIDINE ...................... 117 AZULFIDINE EN-TABS .... 117 azuphen mb .......................... 154 azurette (28) .......................... 132
B bacitracin .............................. 138 bacitracin-polymyxin b......... 138 baclofen .................................. 25 BACTRIM .............................. 12 BACTRIM DS ........................ 12 BACTROBAN ....................... 66 BACTROBAN NASAL ......... 74 balsalazide ............................ 117 balziva (28) ........................... 132 BANZEL ................................ 18 BARACLUDE ......................... 4 BASAGLAR KWIKPEN ..... 108 bayer aspirin ........................... 31 BECONASE AQ .................. 149 bekyree (28) .......................... 132 BELBUCA ............................. 26 belladonna alkaloids-opium . 115 belladonna-opium ................. 115 BELSOMRA .......................... 35 BELVIQ ................................. 71 BELVIQ XR ........................... 72 benazepril ............................... 45 benazepril-hydrochlorothiazide
............................................ 45 BENICAR .............................. 45 BENICAR HCT ..................... 45 BENSAL HP .......................... 58 BENTYL .............................. 115 BENZACLIN ......................... 62 BENZACLIN PUMP ............. 62 BENZAMYCIN ..................... 62 BENZEFOAM........................ 62 BENZEFOAM ULTRA ......... 62 benzepro ................................. 62 benzonatate ........................... 145 benztropine ............................. 21 BEPREVE ............................ 140 BESIVANCE........................ 138 BETADINE OPHTHALMIC
PREP ................................ 138 BETAGAN ........................... 139 betamethasone dipropionate ... 68 betamethasone valerate........... 68 betamethasone, augmented ..... 68 BETAPACE ........................... 43 BETAPACE AF ..................... 43 BETASERON ...................... 125 betaxolol ......................... 45, 139
bethanechol chloride ............. 154 BETIMOL ............................ 139 BETOPTIC S ........................ 139 BEVESPI AEROSPHERE ... 150 bexarotene ............................... 14 BEYAZ ................................. 133 BIAFINE EMULSION ........... 59 BIAXIN .................................... 8 bicalutamide ........................... 14 BIDIL ..................................... 45 BILTRICIDE ............................ 9 bimatoprost ........................... 142 BINOSTO ............................. 127 BIONIME RIGHTEST GM300
SYSTEM ............................ 88 BIONIME RIGHTEST TEST
STRIPS ............................... 78 bisoprolol fumarate ................. 45 bisoprolol-hydrochlorothiazide
............................................ 45 BLEPH-10 ............................ 144 BLEPHAMIDE .................... 144 BLEPHAMIDE S.O.P. ......... 144 blisovi 24 fe .......................... 133 blisovi fe 1.5/30 (28) ............ 133 blisovi fe 1/20 (28) ............... 133 BLOOD GLUCOSE
CONTROL, NORMAL ...... 89 BLOOD GLUCOSE TEST .... 78 BLOOD-GLUCOSE METER 89 BONIVA............................... 127 BOSULIF ............................... 14 bp 10-1 .................................... 62 bp-50% urea............................ 59 bpo .......................................... 62 BREEZE 2 CONTROL
SOLUTION,HIGH ............. 89 BREEZE 2 TEST STRIPS ..... 78 BREO ELLIPTA .................. 150 BREVICON (28) .................. 133 briellyn .................................. 133 BRILINTA ............................. 51 brimonidine........................... 144 BRISDELLE........................... 35 BRIVIACT ............................. 18 BROMFED DM ................... 145 bromfenac ............................. 141 bromocriptine ......................... 21
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163
brompheniramine-pseudoeph-dm ..................................... 145
BROMSITE .......................... 141 BROVANA .......................... 150 BUCALSEP ........................... 65 budesonide .................... 117, 150 bumetanide ............................. 45 BUNAVAIL ........................... 31 BUPAP ................................... 26 BUPHENYL ........................... 72 BUPRENORPHINE ............... 26 buprenorphine hcl ................... 26 buprenorphine-naloxone ......... 31 bupropion hcl .......................... 35 bupropion hcl (smoking deter)73 buspirone ................................ 35 butalbital compound w/codeine
............................................ 26 butalbital-acetaminop-caf-cod 26 butalbital-acetaminophen ....... 27 butalbital-acetaminophen-caff 27 butalbital-aspirin-caffeine ...... 27 BUTISOL ............................... 35 butorphanol tartrate ................ 31 BUTRANS ............................. 27 BYDUREON ........................ 112 BYETTA .............................. 112 BYSTOLIC ............................ 45 BYVALSON .......................... 45 C cabergoline ........................... 110 CABOMETYX....................... 14 CADUET ................................ 53 CAFERGOT ........................... 23 caffeine citrate ........................ 72 CALAN .................................. 45 CALAN SR ............................ 45 calcipotriene ........................... 56 calcipotriene-betamethasone .. 56 calcitonin (salmon) ............... 110 calcitrene ................................ 56 calcitriol .......................... 56, 110 calcium 500 + d .................... 156 calcium 500 with d ............... 156 calcium 600 + d(3) ............... 156 calcium 600 with vitamin d3 156 calcium acetate ..................... 117 calcium carb and citrate-vitd3
.......................................... 156
calcium carbonate-vitamin d3 .......................................... 156
calcium citrate + d ................ 156 calcium citrate-vitamin d2 .... 156 calcium citrate-vitamin d3 .... 156 CAMBIA ................................ 31 camila ................................... 129 camrese ................................. 133 camrese lo ............................. 133 CANASA.............................. 117 candesartan ............................. 45 candesartan-hydrochlorothiazid
............................................ 45 capacet .................................... 27 CAPCOF .............................. 145 capecitabine ............................ 14 CAPEX ................................... 68 CAPITAL WITH CODEINE . 27 CAPRELSA............................ 14 captopril .................................. 45 captopril-hydrochlorothiazide 45 CARAC .................................. 59 CARAFATE ......................... 122 CARBAGLU .......................... 72 carbamazepine ........................ 18 CARBATROL ........................ 18 carbidopa ................................ 21 carbidopa-levodopa ................ 21 carbidopa-levodopa-entacapone
............................................ 21 carbinoxamine maleate ......... 144 CARDIZEM ........................... 46 CARDIZEM CD .................... 45 CARDIZEM LA ............... 45, 46 CARDURA ............................ 46 CARDURA XL ...................... 46 CARESENS CONTROL A
NORMAL ........................... 89 CARESENS N ........................ 89 CARESENS N TEST STRIPS
............................................ 78 CARESENS N VOICE .......... 89 carisoprodol ............................ 25 carisoprodol-asa-codeine ........ 25 carisoprodol-aspirin ................ 25 CARNITOR............................ 72 CARNITOR (SUGAR-FREE)72 carteolol ................................ 139 cartia xt ................................... 46
carvedilol ................................ 46 CASODEX ............................. 14 CATAPRES ............................ 46 CATAPRES-TTS-1 ................ 46 CATAPRES-TTS-2 ................ 46 CATAPRES-TTS-3 ................ 46 CAYA CONTOURED ......... 128 CAYSTON ............................... 9 caziant (28) ........................... 133 CEDAX .................................... 7 cefaclor ..................................... 7 cefadroxil .................................. 7 cefdinir ...................................... 7 cefditoren pivoxil ...................... 7 cefixime .................................... 7 cefpodoxime ............................. 7 cefprozil .................................... 7 ceftibuten .................................. 7 CEFTIN .................................... 7 cefuroxime axetil ...................... 7 celacyn .................................... 59 CELEBREX ........................... 31 celecoxib ................................. 31 CELEXA ................................ 35 CELLCEPT ............................ 14 CELONTIN ............................ 18 CENTANY ............................. 66 CENTANY AT ....................... 66 centergy ................................ 145 cephalexin ................................. 7 CERDELGA ......................... 110 CERVIDIL ........................... 131 CESAMET ........................... 117 cetirizine ............................... 144 CETRAXAL ........................... 75 CETROTIDE ........................ 110 cevimeline ............................... 72 CHANTIX .............................. 73 CHANTIX CONTINUING
MONTH BOX .................... 73 CHANTIX STARTING
MONTH BOX .................... 73 chateal ................................... 133 CHEMET ................................ 72 CHENODAL ........................ 117 cheratussin ac........................ 145 children's aspirin ..................... 31 chlordiazepoxide hcl ............... 35 chlordiazepoxide-clidinium .. 115
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164
chlorhexidine gluconate ......... 74 chloroquine phosphate .............. 9 chlorothiazide ......................... 46 chlorpromazine ....................... 35 chlorpropamide ..................... 112 chlorthalidone ......................... 46 chlorzoxazone ......................... 25 CHOLBAM .......................... 117 cholecalciferol (vitamin d3) . 158 cholestyramine (with sugar) ... 53 cholestyramine light ............... 53 choline,magnesium salicylate . 31 CIALIS ................................. 154 ciclodan .................................. 66 CICLODAN KIT.................... 66 ciclopirox ................................ 66 cilostazol ................................. 51 CILOXAN ............................ 138 cimetidine ............................. 122 cimetidine hcl ....................... 122 CIMZIA ................................ 117 CIMZIA POWDER FOR
RECONST ........................ 117 CIPRO .................................... 12 CIPRO HC.............................. 76 CIPRO XR.............................. 12 CIPRODEX ............................ 76 ciprofloxacin ........................... 12 ciprofloxacin (mixture) .......... 12 ciprofloxacin hcl ....... 12, 75, 138 citalopram ............................... 36 citrus calcium ....................... 157 claravis ................................... 62 CLARINEX .......................... 144 CLARINEX-D 12 HOUR .... 145 clarithromycin .......................... 8 cleansing wash........................ 62 clemastine ............................. 144 CLEO 90 INFUSION SET 24 89 CLEOCIN............................. 131 CLEOCIN HCL........................ 9 CLEOCIN PEDIATRIC ........... 9 CLEOCIN T ........................... 62 CLEVER CHEK BLOOD
GLUCOSE ......................... 89 CLEVER CHOICE GLUCOSE
MONITOR ......................... 89 CLEVER CHOICE LEVEL 2
CONTROL ......................... 89
CLEVER CHOICE MICRO .. 89 CLEVER CHOICE MICRO
TEST STRIP....................... 78 CLEVER CHOICE PRO .. 78, 90 CLEVER CHOICE TEST
STRIPS ............................... 78 CLEVER CHOICE VOICE+
TEST .................................. 79 CLIMARA............................ 129 CLIMARA PRO ................... 129 CLINDACIN ETZ .................. 62 clindacin p .............................. 62 CLINDACIN PAC ................. 62 CLINDAGEL ......................... 62 clindamycin hcl ........................ 9 clindamycin palmitate hcl ........ 9 clindamycin pediatric ............... 9 clindamycin phosphate ... 62, 131 clindamycin-benzoyl peroxide
...................................... 62, 63 clindamycin-tretinoin ............. 63 CLINDESSE ........................ 131 CLINPRO 5000 ...................... 74 clobetasol ................................ 68 clobetasol-emollient ............... 68 CLOBEX ................................ 68 CLOCORTOLONE PIVALATE
............................................ 68 clodan ..................................... 68 CLODAN KIT ........................ 68 CLODERM ............................ 68 clomipramine .......................... 36 clonazepam ............................. 18 clonidine ................................. 46 clonidine hcl ..................... 36, 46 clopidogrel ........................ 51, 52 clorazepate dipotassium ......... 36 clorpres ................................... 46 CLORPRES ............................ 46 clotrimazole .............................. 3 clotrimazole-betamethasone ... 66 clozapine ................................. 36 CLOZAPINE .......................... 36 CLOZARIL ............................ 36 COAL TAR ............................ 56 COARTEM .............................. 9 codeine sulfate ........................ 27 codeine-butalbital-asa-caff ..... 27 codeine-guaifenesin .............. 145
CODITUSSIN AC ................ 145 CODITUSSIN DAC ............. 145 COLAZAL ........................... 117 COLCHICINE ...................... 126 COLCRYS ............................ 126 COLESTID ............................. 53 COLESTID FLAVORED ...... 53 colestipol................................. 53 colistin (colistimethate na) ....... 9 colocort ................................. 117 COLY-MYCIN M
PARENTERAL .................... 9 COLY-MYCIN S ................... 76 COLYTE WITH FLAVOR
PACKS ............................. 118 COMBIGAN ........................ 142 COMBIPATCH .................... 129 COMBIVENT RESPIMAT .. 150 COMBIVIR .............................. 4 COMETRIQ ........................... 15 COMFORT SHORT INSULIN
PUMP 23 ............................ 90 COMPAZINE ....................... 118 COMPLERA ............................ 4 compro .................................. 118 COMTAN ............................... 21 CONCEPTROL .................... 131 CONCERTA ........................... 36 CONDYLOX .......................... 59 constulose ............................. 118 CONTOUR CONTROL
SOLUTION, NML ............. 90 CONTOUR LINK .................. 90 CONTOUR NEXT EZ METER
............................................ 90 CONTOUR NEXT LEV 2
CONTROL SOL ................. 90 CONTOUR NEXT LINK ....... 90 CONTOUR NEXT METER... 90 CONTOUR NEXT ONE
METER............................... 90 CONTOUR NEXT STRIPS ... 79 CONTOUR TEST STRIPS .... 79 CONTROL AST
MONITORING SYSTEM.. 90 CONZIP .................................. 31 COOL BLOOD GLUCOSE
METER............................... 91
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165
COOL CONTROL A SOLUTION ........................ 91
COOL GLUCOSE TEST STRIP ............................................ 79
COPAXONE ........................ 125 COPEGUS ............................ 125 CORDRAN ............................ 69 CORDRAN TAPE LARGE
ROLL ................................. 68 COREG .................................. 46 COREG CR ............................ 46 CORGARD ............................ 46 CORLANOR .......................... 55 cormax .................................... 69 CORTANE-B ......................... 59 CORTEF................................. 76 CORTENEMA ..................... 118 CORTIFOAM ...................... 118 cortisone ................................. 76 CORTISPORIN ...................... 66 CORZIDE............................... 46 COSENTYX ........................... 56 COSENTYX (2 SYRINGES) 56 COSENTYX PEN .................. 56 COSENTYX PEN (2 PENS) .. 56 COSOPT............................... 142 COSOPT (PF) ...................... 142 COTELLIC ............................. 15 COUMADIN .......................... 52 covaryx ................................. 129 covaryx h.s. .......................... 129 COZAAR ............................... 46 CREON ................................ 118 CRESEMBA ............................ 3 CRESTOR .............................. 53 CRINONE ............................ 129 CRIXIVAN .............................. 4 cromolyn ............... 118, 140, 150 cryselle (28) .......................... 133 CUPRIMINE ........................ 127 CUROSURF ......................... 150 CUTIVATE ............................ 69 CUVPOSA ........................... 115 cyclafem 1/35 (28) ............... 133 cyclafem 7/7/7 (28) .............. 133 CYCLESSA (28) .................. 133 cyclobenzaprine ...................... 25 CYCLOGYL ........................ 140 CYCLOMYDRIL................. 144
cyclopentolate ....................... 140 CYCLOPHOSPHAMIDE ...... 15 CYCLOSERINE ...................... 9 CYCLOSET ......................... 112 cyclosporine............................ 15 cyclosporine modified ............ 15 CYMBALTA.......................... 36 cyproheptadine ..................... 144 cyred ..................................... 133 CYSTADANE ...................... 118 CYSTAGON ........................ 154 CYSTARAN ........................ 140 CYTOMEL ........................... 114 CYTOTEC............................ 122 cytra k crystals ...................... 154 cytra-2 ................................... 154 cytra-3 ................................... 154 cytra-k ................................... 154 D D.H.E.45 ................................. 23 DAKLINZA ............................. 4 DALIRESP ........................... 150 danazol.................................. 110 DANTRIUM .......................... 25 dantrolene ............................... 25 dapsone ..................................... 9 DARAPRIM ............................. 9 darifenacin ............................ 153 dasetta 1/35 (28) ................... 133 dasetta 7/7/7 (28) .................. 133 DAXBIA .................................. 7 DAYPRO................................ 31 daysee ................................... 133 DAYTRANA.......................... 36 DDAVP ................................ 110 DEBACTEROL...................... 74 deblitane ............................... 129 DELESTROGEN ................. 129 delta d3 ................................. 158 deltasone ................................. 76 delyla (28)............................. 133 DELZICOL .......................... 118 DEMADEX ............................ 46 demeclocycline ....................... 12 DEMEROL ............................. 27 DEMSER ................................ 46 DENAVIR .............................. 68 denta 5000 plus ....................... 74 dentagel .................................. 74
DEPAKENE ........................... 18 DEPAKOTE ........................... 18 DEPAKOTE ER ..................... 19 DEPAKOTE SPRINKLES ..... 19 DEPEN TITRATABS .......... 127 DEPO-ESTRADIOL ............ 129 DEPO-PROVERA ................ 129 DEPO-SUBQ PROVERA 104
.......................................... 129 DEPO-TESTOSTERONE .... 110 DERMA-SMOOTHE/FS
BODY OIL ......................... 69 DERMA-SMOOTHE/FS
SCALP OIL ........................ 69 DERMATOP .......................... 69 dermazene ............................... 66 DERMOTIC OIL.................... 75 DESCOVY ............................... 4 desipramine ............................. 36 desloratadine ......................... 144 desmopressin ........................ 110 desog-e.estradiol/e.estradiol . 133 DESOGEN ........................... 133 desogestrel-ethinyl estradiol . 133 DESONATE ........................... 69 desonide .................................. 69 DESOWEN............................. 69 desoximetasone....................... 69 DESOXYN ............................. 36 DESVENLAFAXINE ............ 36 DESVENLAFAXINE
FUMARATE ...................... 36 desvenlafaxine succinate ........ 36 DETROL .............................. 153 DETROL LA ........................ 153 dexamethasone ....................... 76 dexamethasone intensol .......... 76 dexamethasone sodium
phosphate .......................... 143 DEXCOM G4 RECEIVER .... 91 DEXCOM G5 RECEIVER .... 91 dexedrine ................................ 36 DEXEDRINE SPANSULE .... 36 DEXERYL ............................. 59 DEXILANT .......................... 122 dexmethylphenidate ................ 36 DEXPAK 10 DAY ................. 76 DEXPAK 13 DAY ................. 76 DEXPAK 6 DAY ................... 76
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dextroamphetamine ................ 36 dextroamphetamine-
amphetamine ...................... 36 DIAMOX SEQUELS ........... 142 DIASTAT ............................... 19 DIASTAT ACUDIAL ............ 19 DIATRUE CONTROL SOLN
NORMAL........................... 91 DIATRUE PLUS BLOOD
GLUCOSE MET ................ 91 DIATRUE PLUS TEST STRIP
............................................ 79 diazepam ................................. 37 diazepam intensol ................... 36 DIBENZYLINE ..................... 46 DICLEGIS ............................ 118 diclofenac potassium .............. 31 diclofenac sodium ..... 31, 32, 59,
141 diclofenac-misoprostol ........... 32 dicloxacillin ............................ 11 dicyclomine .......................... 115 didanosine ................................. 4 DIFFERIN .............................. 63 DIFICID ................................... 8 diflorasone .............................. 69 DIFLUCAN .............................. 3 diflunisal ................................. 32 digitek ..................................... 51 digox ....................................... 51 digoxin .................................... 51 dihydroergotamine ................. 23 DILANTIN ............................. 19 DILANTIN EXTENDED ...... 19 DILANTIN INFATABS ........ 19 DILANTIN-125 ..................... 19 DILATRATE-SR ................... 55 DILAUDID ............................ 27 diltiazem ........................... 46, 47 dilt-xr ...................................... 47 DIOVAN ................................ 47 DIOVAN HCT ....................... 47 DIPENTUM ......................... 118 diphenoxylate-atropine ......... 115 DIPROLENE .......................... 69 DIPROLENE AF.................... 69 dipyridamole........................... 52 DISALCID ............................. 32 diskets ..................................... 27
disopyramide phosphate ......... 44 disulfiram................................ 72 DITROPAN XL ................... 153 DIURIL .................................. 47 divalproex ............................... 19 DIVIGEL .............................. 129 dofetilide ................................. 44 DOLOPHINE ......................... 27 donepezil ................................ 24 DONNATAL ................ 115, 116 DORAL .................................. 37 DORYX .................................. 12 DORYX MPC ........................ 12 dorzolamide .......................... 142 dorzolamide-timolol ............. 142 DOVONEX ............................ 56 doxazosin ................................ 47 doxepin ............................. 37, 59 doxercalciferol ...................... 110 doxycycline hyclate ................ 12 doxycycline monohydrate 12, 13 DOXYCYCLINE
MONOHYDRATE ............. 13 drithocreme hp ........................ 56 dronabinol ............................. 118 drospirenone-e.estradiol-lm.fa
.......................................... 133 drospirenone-ethinyl estradiol
.......................................... 133 DROXIA ................................ 15 DUAC ..................................... 63 DUAVEE.............................. 129 DUETACT ........................... 112 DUEXIS ................................. 32 DULERA .............................. 150 duloxetine ............................... 37 DUPIXENT ............................ 59 DURAGESIC ......................... 27 DUREZOL ........................... 143 DURLAZA ............................. 52 dutasteride ............................ 154 dutasteride-tamsulosin .......... 154 DUTOPROL ........................... 47 d-vi-sol.................................. 158 d-vita ..................................... 158 DYANAVEL XR ................... 37 DYAZIDE .............................. 47 DYMISTA ............................ 150 DYRENIUM .......................... 47
E e.c. prin ................................... 32 e.e.s. 400 ................................... 8 E.E.S. GRANULES .................. 8 EASY PLUS II BLOOD
GLUCOSE MET ................ 91 EASY PLUS II TEST ............. 79 EASY STEP ........................... 79 EASY STEP BLOOD
GLUCOSE METER ........... 91 EASY TALK BLOOD
GLUCOSE METER ........... 91 EASY TALK GLUCOSE TEST
............................................ 79 EASY TOUCH GLUCOSE
MONITOR ......................... 91 EASY TOUCH TEST STRIP 79 EASY TRAK GLUCOSE TEST
............................................ 79 EASY TRAK LOW CONTROL
............................................ 91 EASYGLUCO MONITORING
SYSTEM ............................ 92 EASYGLUCO PLUS ....... 79, 92 EASYGLUCO PLUS
NORMAL CONTROL ....... 92 EASYGLUCO TEST ............. 79 EASYMAX ............................ 79 EASYMAX L BLOOD
GLUCOSE METER ........... 92 EASYMAX LOW CONTROL
............................................ 92 EASYMAX NG...................... 92 EASYMAX NORMAL
CONTROL ......................... 92 EASYMAX V SPEAKING
GLUCOSE SYS ................. 92 EASYMAX V2 BLOOD
GLUCOSE METER ........... 92 EC-NAPROSYN .................... 32 econazole ................................ 66 econtra ez .............................. 133 ecotrin ..................................... 32 ecotrin low strength ................ 32 ECOZA ................................... 66 EDARBI ................................. 47 EDARBYCLOR ..................... 47 EDECRIN ............................... 47 EDEX ................................... 154
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EDLUAR ................................ 37 ed-spaz .................................. 116 EDURANT ............................... 4 eemt ...................................... 129 eemt hs .................................. 129 effer-k ................................... 157 EFFER-K .............................. 157 EFFEXOR XR........................ 37 EFFIENT ................................ 52 EFUDEX ................................ 59 EGRIFTA ............................. 124 ELDEPRYL ........................... 21 ELEMENT COMPACT
GLUCOSE METER ........... 93 ELEMENT COMPACT
NORMAL CONTROL ....... 93 ELEMENT COMPACT TEST
STRIPS ............................... 79 ELEMENT COMPACT V
GLUCOSE MTR ................ 93 ELEMENT NORMAL
CONTROL ......................... 93 ELEMENT PLUS BLOOD
GLUCOSE KIT .................. 93 ELEMENT TEST STRIPS ..... 80 ELESTAT ............................. 140 ELESTRIN ........................... 129 eletone .................................... 59 ELIDEL .................................. 59 ELIGARD .............................. 15 ELIGARD (3 MONTH) ......... 15 ELIGARD (4 MONTH) ......... 15 ELIGARD (6 MONTH) ......... 15 ELIMITE ................................ 71 elinest ................................... 133 eliphos .................................. 118 ELIQUIS ................................ 52 ELIXOPHYLLIN ................. 150 ELLA .................................... 133 ELMIRON ............................ 154 ELOCON ................................ 69 EMADINE ........................... 140 EMBEDA ............................... 27 EMBRACE BLOOD
GLUCOSE SYSTEM ... 80, 93 EMBRACE EVO LEVEL 1 ... 93 EMBRACE EVO TEST
STRIPS ............................... 80
EMBRACE GLUCOSE CONTROL LOW ............... 93
EMBRACE PRO GLUCOSE METER .............................. 93
EMBRACE PRO TEST STRIPS ............................................ 80
EMCYT .................................. 15 EMEND ................................ 118 EMFLAZA ............................. 76 emoquette ............................. 133 EMSAM ................................. 37 EMTRIVA ................................ 4 EMVERM ................................ 9 ENABLEX ........................... 153 enalapril maleate ..................... 47 enalapril-hydrochlorothiazide 47 ENBREL .............................. 127 ENBREL SURECLICK ....... 127 endocet.................................... 27 ENDOMETRIN.................... 129 enoxaparin .............................. 52 enpresse ................................ 133 enskyce ................................. 133 ENSTILAR ............................. 56 entacapone .............................. 21 entecavir ................................... 4 ENTOCORT EC................... 118 ENTRESTO............................ 55 enulose .................................. 118 ENVARSUS XR .................... 15 EPANED ................................ 47 EPCLUSA ................................ 4 EPICERAM ............................ 59 EPIDUO ................................. 63 EPIDUO FORTE .................... 63 EPIFOAM .............................. 56 epinastine .............................. 140 EPINEPHRINE .................... 145 EPIPEN 2-PAK .................... 145 EPIPEN JR 2-PAK ............... 145 EPISIL .................................... 74 epitol ....................................... 19 EPIVIR ..................................... 4 EPIVIR HBV ............................ 4 eplerenone .............................. 47 eprosartan ............................... 47 EPZICOM ................................ 4 EQUETRO ............................. 19 ergocalciferol (vitamin d2) ... 158
ergoloid ................................... 37 ERGOMAR ............................ 23 ergotamine-caffeine ................ 23 ERIVEDGE ............................ 15 errin....................................... 129 ERTACZO .............................. 66 ery pads ................................... 63 erygel ...................................... 63 ERYPED 200............................ 8 ERYPED 400............................ 8 ery-tab ....................................... 8 ERY-TAB ................................. 8 erythrocin (as stearate) ............. 8 erythromycin ..................... 8, 138 erythromycin ethylsuccinate ..... 8 erythromycin with ethanol ...... 63 erythromycin-benzoyl peroxide
............................................ 63 ESBRIET .............................. 150 ESCAVITE D ....................... 158 ESCAVITE LQ .................... 158 escitalopram oxalate ............... 37 ESGIC..................................... 27 esomeprazole magnesium ..... 122 ESOMEPRAZOLE
STRONTIUM ................... 122 estarylla ................................. 133 estazolam ................................ 37 ESTRACE ............................ 129 estradiol ................................ 129 estradiol valerate ................... 130 estradiol-norethindrone acet . 130 ESTRING ............................. 130 ESTROGEL .......................... 130 estrogens-methyltestosterone 130 estropipate ............................. 130 ESTROSTEP FE-28 ............. 133 eszopiclone ............................. 37 ethacrynic acid ........................ 47 ethambutol ................................ 9 ethosuximide........................... 19 ethyl chloride .......................... 65 ethynodiol diac-eth estradiol 134 etidronate disodium ................ 72 etodolac ................................... 32 etoposide ................................. 15 EUCRISA ............................... 59 EURAX .................................. 71 EVAMIST ............................ 130
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EVEKEO ................................ 37 EVENCARE G2 ............... 80, 93 EVENCARE G3 GLUCOSE
METER .............................. 94 EVENCARE G3 TEST .......... 80 EVENCARE MINI GLUCOSE
TEST STR .......................... 80 EVENCARE MINI MONITOR
SYSTEM ............................ 94 EVISTA ................................ 127 EVOCLIN .............................. 63 EVOLUTION BLOOD
GLUCOSE METER ........... 94 EVOLUTION NORMAL
CONTROL ......................... 94 EVOLUTION TEST STRIPS 80 EVOTAZ .................................. 4 EVOXAC ............................... 72 EVZIO .................................... 32 EXALGO ER ......................... 27 EXELDERM .......................... 67 EXELON ................................ 24 exemestane ............................. 15 EXFORGE ............................. 47 EXFORGE HCT .................... 47 EXJADE ................................. 72 EXODERM ............................ 67 EXTAVIA ............................ 125 EXTINA ................................. 67 EZ SMART PLUS SYSTEM . 94 EZ SMART PLUS TEST ....... 80 EZ SMART SYSTEM ........... 94 EZ SMART TEST .................. 80 ezetimibe ................................ 53 ezetimibe-simvastatin ............. 53 F FABIOR ................................. 63 FACTIVE ............................... 12 fallback solo ......................... 134 falmina (28) .......................... 134 famciclovir ............................... 4 famotidine ..................... 122, 123 FANAPT ................................ 37 FARESTON ........................... 15 FARXIGA ............................ 112 FARYDAK............................. 15 fayosim ................................. 134 FAZACLO ............................. 37 FC2 FEMALE CONDOM ... 128
felbamate ................................ 19 FELBATOL............................ 19 FELDENE .............................. 32 felodipine ................................ 47 fem ph ................................... 131 FEMARA ............................... 15 FEMCAP .............................. 129 FEMHRT LOW DOSE ........ 130 FEMRING ............................ 130 femynor ................................ 134 fenofibrate .............................. 53 FENOFIBRATE ..................... 53 fenofibrate micronized ........... 53 fenofibrate nanocrystallized ... 53 fenofibric acid......................... 53 fenofibric acid (choline) ......... 53 FENOGLIDE.......................... 53 fenoprofen .............................. 32 FENOPROFEN ...................... 32 FENORTHO ........................... 32 fentanyl ................................... 27 FENTANYL ........................... 27 fentanyl citrate ........................ 27 FENTORA.............................. 27 FERRIPROX .......................... 72 FETZIMA ............................... 37 FEXMID ................................. 25 FIBRICOR.............................. 54 FIFTY50 TEST STRIP .......... 80 FINACEA ............................... 63 finasteride ............................. 154 FIORINAL ............................. 28 FIORINAL-CODEINE #3 ..... 28 FIRAZYR ............................. 150 FIRMAGON KIT W DILUENT
SYRINGE ........................... 15 FLAGYL .................................. 9 FLAGYL ER ............................ 9 FLAREX .............................. 143 flavoxate ............................... 153 flecainide ................................ 44 FLECTOR .............................. 32 FLOMAX ............................. 154 FLORIVA ............................. 158 FLORIVA (FLUORIDE-
VITAMIN D3) ................. 158 FLORIVA PLUS .................. 158 FLOVENT DISKUS ............ 150 FLOVENT HFA ................... 150
FLOWTUSS ......................... 145 floxin....................................... 76 flucaine ................................. 140 fluconazole ............................... 3 flucytosine ................................ 3 fludrocortisone ........................ 76 FLUMADINE........................... 4 flunisolide ............................. 150 fluocinolone ............................ 69 fluocinolone acetonide oil ...... 76 fluocinolone and shower cap .. 69 fluocinonide ............................ 69 fluocinonide-e ......................... 69 FLUORABON ...................... 158 FLUOR-A-DAY ................... 158 fluor-a-day (with xylitol) ...... 158 fluorescein-proparacaine ...... 140 fluoride (sodium) ............ 74, 158 FLUORIDEX DAILY
DEFENSE........................... 74 fluoritab ................................ 158 fluorometholone ................... 143 FLUOROPLEX ...................... 59 fluorouracil ............................. 59 FLUOROURACIL ................. 59 fluoxetine ................................ 37 FLUOXETINE ....................... 38 fluphenazine decanoate .......... 38 fluphenazine hcl ...................... 38 FLURA-DROPS ................... 158 flurandrenolide ....................... 69 flurazepam .............................. 38 flurbiprofen ............................. 32 flurbiprofen sodium .............. 141 flurox .................................... 140 flutamide ................................. 15 fluticasone ....................... 69, 150 FLUTICASONE-
SALMETEROL ................ 150 fluvastatin ............................... 54 fluvoxamine ............................ 38 FML FORTE ........................ 143 FML LIQUIFILM ................ 143 FML S.O.P............................ 143 FOCALIN ............................... 38 FOCALIN XR ........................ 38 folic acid ............................... 158 fondaparinux ........................... 52 FORA D10.............................. 94
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FORA D15G .......................... 80 FORA D20 ....................... 80, 94 FORA D40-G31 TEST STRIPS
............................................ 80 FORA G20 ....................... 81, 94 FORA G30A .................... 81, 95 FORA GD50 BLOOD
GLUCOSE SYSTEM ......... 95 FORA GD50 TEST STRIPS .. 81 FORA NORMAL CONTROL
............................................ 95 FORA PREMIUM V10
GLUCOSE METER ........... 95 FORA TEST N'GO VOICE
METER .............................. 95 FORA TEST STRIP ............... 81 FORA TN'G VOICE METER 95 FORA TN'G VOICE TEST
STRIPS ............................... 81 FORA V10 ....................... 81, 95 FORA V10-V12-D10-D20
STRIPS ............................... 81 FORA V12 BLOOD GLUCOSE
SYSTEM ............................ 95 FORA V12 GLUCOSE .......... 81 FORA V20 ....................... 81, 95 FORA V30A .......................... 96 FORACARE GD20 ................ 81 FORACARE GD20 GLUCOSE
METER .............................. 96 FORACARE GD40 ................ 81 FORACARE GD40A
GLUCOSE METER ........... 96 FORACARE GD40B
GLUCOSE METER ........... 96 FORACARE GDH LOW
CONTROL ......................... 96 FORADIL AEROLIZER ..... 150 FORFIVO XL ........................ 38 FORTAMET ........................ 112 FORTAVIT .......................... 157 FORTEO .............................. 127 FORTESTA .......................... 110 FORTISCARE BLOOD
GLUCOSE SYST ............... 96 FORTISCARE GLUCOSE
TEST STRIPS .................... 81 FORTISCARE NORMAL ..... 96 FOSAMAX .......................... 127
FOSAMAX PLUS D ............ 127 fosinopril ................................ 48 fosinopril-hydrochlorothiazide
............................................ 48 FOSRENOL ......................... 118 FRAGMIN.............................. 52 FREESTYLE CONTROL ...... 96 FREESTYLE FLASH SYSTEM
............................................ 96 FREESTYLE FREEDOM ...... 97 FREESTYLE FREEDOM LITE
............................................ 97 FREESTYLE INSULINX 81, 97 FREESTYLE INSULINX TEST
STRIPS ............................... 81 FREESTYLE LITE METER.. 97 FREESTYLE LITE STRIPS .. 82 FREESTYLE PRECISION
NEO METER ..................... 97 FREESTYLE PRECISION
NEO STRIPS ...................... 82 FREESTYLE SIDEKICK II .. 97 FREESTYLE SYSTEM KIT . 97 FREESTYLE TEST ............... 82 frovatriptan ............................. 23 FURADANTIN ...................... 13 furosemide .............................. 48 FUZEON .................................. 4 fyavolv .................................. 130 FYCOMPA ............................. 19 G g tussin ac ............................. 146 gabapentin .............................. 19 GABITRIL ............................. 19 galantamine ............................ 24 GALZIN ............................... 157 GANIRELIX ........................ 110 GASTROCROM .................. 118 gatifloxacin ........................... 138 GATTEX 30-VIAL .............. 118 gavilyte-c .............................. 118 gavilyte-g .............................. 118 gavilyte-h and bisacodyl ....... 118 gavilyte-n .............................. 118 GE100 BLOOD GLUCOSE
SYSTEM ............................ 97 GE100 BLOOD GLUCOSE
TEST STRIP....................... 82
GE100 CONTROL SOLUTION NORMAL ........................... 97
GELCLAIR ............................ 75 GELNIQUE .......................... 153 GELX ..................................... 75 gemfibrozil ............................. 54 GENERESS FE .................... 134 generlac ................................. 119 gengraf .................................... 15 GENOTROPIN ..................... 124 GENOTROPIN MINIQUICK
.......................................... 124 GENSTRIP TEST STRIP....... 82 gentak ................................... 138 gentamicin ...................... 66, 138 gentamicin in nacl (iso-osm) .... 9 GENTAMICIN IN NACL (ISO-
OSM) .................................... 9 gentamicin sulfate (ped) (pf) .... 9 gentamicin sulfate (pf) .............. 9 GENTAMICIN SULFATE (PF)
.............................................. 9 GENVOYA .............................. 4 GEODON ............................... 38 GIALAX ............................... 119 gianvi (28) ............................ 134 GIAZO .................................. 119 gildagia ................................. 134 GILENYA ............................ 125 GILOTRIF .............................. 15 glatopa .................................. 125 GLEEVEC .............................. 15 GLEOSTINE .......................... 15 glimepiride ............................ 112 glipizide ................................ 112 glipizide-metformin .............. 112 GLUCAGEN DIAGNOSTIC
KIT ..................................... 86 GLUCAGEN HYPOKIT ........ 86 GLUCAGON EMERGENCY
KIT (HUMAN) ................... 86 GLUCAGON HCL ................. 86 GLUCO NAVII GLUCOSE
MONITOR ......................... 98 GLUCO NAVII TEST STRIP 82 GLUCOCARD 01 METER .... 98 GLUCOCARD 01 NORMAL
CONTROL ......................... 98
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GLUCOCARD 01 SENSOR PLUS .................................. 82
GLUCOCARD EXPRESSION ...................................... 82, 98
GLUCOCARD SHINE METER ............................................ 98
GLUCOCARD SHINE TEST STRIPS ............................... 82
GLUCOCARD VITAL .......... 98 GLUCOCARD VITAL
SENSOR............................. 82 GLUCOCARD VITAL TEST
STRIPS ............................... 82 GLUCOCOM BLOOD
GLUCOSE ......................... 98 GLUCOCOM CONTROL
NORMAL........................... 98 GLUCOCOM GLUCOSE...... 82 GLUCOPHAGE ................... 112 GLUCOPHAGE XR ............ 112 GLUCOSE CONTROL .......... 98 GLUCOTROL ...................... 112 GLUCOTROL XL ............... 112 GLUCOVANCE .................. 112 GLUMETZA ........................ 112 glyburide ............................... 113 glyburide micronized ............ 113 glyburide-metformin ............ 113 glycopyrrolate ....................... 116 glydo ....................................... 65 GLYNASE ........................... 113 GLYSET............................... 113 GLYXAMBI ........................ 113 GM100 ............................. 82, 99 GMATE CONTROL
SOLUTION, NORMAL..... 99 GMATE SMART METER .... 99 GMATE SMART STARTER 99 GMATE TEST STRIPS ......... 82 GMATE VOICE METER ...... 99 GOLYTELY ......................... 119 GONITRO .............................. 55 GORDONS UREA ................. 60 GRALISE ............................... 19 GRALISE 30-DAY STARTER
PACK ................................. 19 granisetron hcl ...................... 119 GRASTEK ........................... 126 griseofulvin microsize .............. 3
griseofulvin ultramicrosize ....... 3 GRIS-PEG
(ULTRAMICROSIZE) ........ 3 guaiatussin ac ....................... 146 guaifenesin ac ....................... 146 guaifenesin dac ..................... 146 guanfacine ........................ 38, 48 guanidine ................................ 38 GYNAZOLE-1 ..................... 131 gynol ii .................................. 131 H HALCION .............................. 38 HALDOL................................ 38 HALDOL DECANOATE ...... 38 halobetasol propionate ............ 69 HALOG .................................. 69 haloperidol .............................. 38 haloperidol decanoate ............. 38 haloperidol lactate .................. 38 HARVONI................................ 4 HEALTHPRO GLUCOSE
MONITOR ......................... 99 HEALTHPRO HIGH-LOW
CONTROL ......................... 99 HEALTHPRO TEST STRIPS 83 heather .................................. 130 HECTOROL ......................... 110 HEMANGEOL ....................... 48 hemmorex-hc ........................ 119 heparin (porcine) .................... 52 heparin (porcine) in nacl (pf) .. 52 heparin(porcine) in 0.45% nacl
............................................ 52 HEPARIN(PORCINE) IN
0.45% NACL ...................... 52 heparin, porcine (pf) ............... 52 HEPSERA ................................ 4 HETLIOZ ............................... 38 HEXALEN ............................. 15 hi-cal plus vit d ..................... 157 HIPREX.................................. 13 HISTEX-AC ......................... 146 homatropaire ......................... 140 homatropine hbr ................... 140 HORIZANT............................ 24 hpr ........................................... 60 hpr plus ................................... 60 hpr plus hydrogel .................... 60
HPR PLUS-MB HYDROGEL ............................................ 60
HUMALOG .......................... 108 HUMALOG KWIKPEN ...... 108 HUMALOG MIX 50-50 ....... 108 HUMALOG MIX 50-50
KWIKPEN ........................ 108 HUMALOG MIX 75-25 ....... 108 HUMALOG MIX 75-25
KWIKPEN ........................ 108 HUMAPEN LUXURA HD .... 99 HUMATROPE ..................... 124 HUMIRA .............................. 127 HUMIRA PEDIATRIC
CROHN'S START ........... 127 HUMIRA PEN CROHN'S-UC-
HS START ....................... 127 HUMIRA PEN PSORIASIS-
UVEITIS........................... 127 HUMULIN 70/30 ................. 108 HUMULIN 70/30 KWIKPEN
.......................................... 108 HUMULIN N ....................... 108 HUMULIN N KWIKPEN .... 108 HUMULIN R U-100 ............ 108 HUMULIN R U-500 (CONC)
KWIKPEN ........................ 109 HUMULIN R U-500
(CONCENTRATED) ....... 109 HYCAMTIN ........................... 15 HYCOFENIX ....................... 146 hydralazine ............................. 48 HYDREA ............................... 15 HYDRO 35 ............................. 60 HYDRO 40 ............................. 60 hydrochlorothiazide ................ 48 hydrocodone-acetaminophen .. 28 hydrocodone-chlorpheniramine
.......................................... 146 hydrocodone-cpm-pseudoephed
.......................................... 146 hydrocodone-homatropine .... 146 hydrocodone-ibuprofen .......... 28 hydrocortisone .......... 69, 76, 119 hydrocortisone acetate .......... 119 hydrocortisone butyrate .......... 69 hydrocortisone butyr-emollient
............................................ 69 hydrocortisone valerate .......... 69
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hydrocortisone-acetic acid ...... 76 hydrocortisone-iodoquinol-aloe
............................................ 66 hydrocortisone-min oil-wht pet
............................................ 70 hydrocortisone-pramoxine .... 56,
119 hydromet ............................... 146 hydromorphone ...................... 28 hydroxychloroquine ............... 10 hydroxyurea ............................ 15 hydroxyzine hcl .................... 145 hydroxyzine pamoate ........... 145 HYLATOPIC ......................... 60 HYLATOPICPLUS ............... 60 hyolev mb ............................. 154 hyophen ................................ 154 hyoscyamine sulfate ............. 116 hyosyne................................. 116 HYPER-SAL ........................ 150 HYSINGLA ER ..................... 28 HYZAAR ............................... 48 I ibandronate ........................... 127 IBRANCE .............................. 15 IBUDONE .............................. 28 ibuprofen ................................ 32 ibuprofen-oxycodone ............. 28 ICLUSIG ................................ 15 ILEVRO ............................... 141 imatinib................................... 16 IMBRUVICA ......................... 16 imipramine hcl ........................ 38 imipramine pamoate ............... 38 imiquimod ............................ 126 IMITREX ............................... 23 IMITREX STATDOSE KIT
REFILL .............................. 23 IMITREX STATDOSE PEN . 23 IMPAVIDO ............................ 10 IMURAN ................................ 16 INCRELEX ............................ 72 INCRUSE ELLIPTA............ 150 indapamide ............................. 48 INDERAL LA ........................ 48 INDERAL XL ........................ 48 INDIOMIN MB .................... 154 INDOCIN ............................... 32 indomethacin .......................... 32
INFINITY CONTROL SOLUTION NORM ........... 99
INFINITY STARTER KIT .... 99 INFINITY TEST STRIPS ...... 83 INLYTA ................................. 16 INNOPRAN XL ..................... 48 INOVA ................................... 63 INOVA 4-1 ............................. 58 INSET 30 INFUSION SET 23
............................................ 99 INSET INFUSION SET 23 .... 99 INSPRA .................................. 48 INSULIN SYRINGE-NEEDLE
U-100 .................................. 86 INTELENCE ............................ 5 INTERMEZZO ...................... 38 INTRAROSA ....................... 131 INTRON A ........................... 126 introvale ................................ 134 INTUNIV ER ......................... 38 INVEGA ................................. 38 INVIRASE ............................... 5 INVOKAMET ...................... 113 INVOKAMET XR ............... 113 INVOKANA ........................ 113 iodoquinol-hc.......................... 66 IONSYS.................................. 28 IOPIDINE ............................. 144 ipratropium bromide ....... 75, 150 ipratropium-albuterol............ 150 irbesartan ................................ 48 irbesartan-hydrochlorothiazide
............................................ 48 IRENKA ................................. 38 IRESSA .................................. 16 ISENTRESS ............................. 5 ISENTRESS HD ...................... 5 ISOCHRON............................ 55 isometh-dichloral-acetaminophn
............................................ 23 isomethepten-caf-
acetaminophen .................... 23 isoniazid.................................. 10 ISOPTO CARPINE .............. 140 ISORDIL ................................ 55 ISORDIL TITRADOSE ......... 55 isosorbide dinitrate ................. 55 isosorbide mononitrate ........... 55 isoxsuprine............................ 131
isradipine ................................ 48 ISTALOL ............................. 139 itraconazole ............................... 3 ivermectin ............................... 10 J JADENU................................. 72 JAKAFI .................................. 16 JALYN ................................. 154 jantoven .................................. 52 JANUMET ........................... 113 JANUMET XR ..................... 113 JANUVIA ............................. 113 JARDIANCE ........................ 113 JAZZ WIRELESS 2 METER
KIT ................................... 100 jencycla ................................. 130 JENTADUETO .................... 113 JENTADUETO XR .............. 113 jevantique lo ......................... 130 jinteli ..................................... 130 jolessa ................................... 134 jolivette ................................. 130 JUBLIA .................................. 67 juleber ................................... 134 junel 1.5/30 (21) ................... 134 junel 1/20 (21) ...................... 134 junel fe 1.5/30 (28) ............... 134 junel fe 1/20 (28) .................. 134 junel fe 24 ............................. 134 JUXTAPID ............................. 54 K KADIAN ................................ 28 kaitlib fe ................................ 134 KALETRA ............................... 5 KALYDECO ........................ 150 KAPVAY ............................... 38 KARBINAL ER ................... 145 kariva (28) ............................ 134 KAYEXALATE ................... 119 KAZANO ............................. 113 k-effervescent ....................... 157 KEFLEX ................................... 7 kelnor 1/35 (28) .................... 134 KENALOG ............................. 70 KEPPRA ................................. 19 KEPPRA XR .......................... 19 KERAFOAM .......................... 60 KERALAC ............................. 60 KERALYT RX ....................... 58
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172
KERYDIN .............................. 67 KETEK ................................... 10 ketoconazole ....................... 3, 67 ketoprofen ............................... 32 ketorolac ......................... 32, 141 KEVEYIS ............................... 24 KEVZARA ........................... 127 KHEDEZLA ........................... 38 kimidess (28) ........................ 134 KINERET ............................. 126 kionex ................................... 119 kionex (with sorbitol) ........... 119 KITABIS PAK ....................... 10 KLARON ............................... 66 klofensaid ii ............................ 32 KLONOPIN ........................... 19 klor-con ................................ 157 klor-con 10 ........................... 157 klor-con 8 ............................. 157 klor-con m10 ........................ 157 klor-con m15 ........................ 157 klor-con m20 ........................ 157 klor-con sprinkle .................. 157 KLOR-CON/25 .................... 157 klor-con/ef ............................ 157 KOMBIGLYZE XR ............. 113 KORLYM............................. 110 K-PHOS NO 2 ...................... 154 K-PHOS ORIGINAL ........... 155 k-phos-neutral ....................... 157 KRISTALOSE ..................... 119 k-tab ...................................... 157 K-TAB .................................. 157 kurvelo .................................. 134 KUVAN ............................... 110 KYNAMRO ........................... 54 L l norgest/e.estradiol-e.estrad . 134 labetalol .................................. 48 LACRISERT ........................ 140 lactated ringers ....................... 72 lactic acid ................................ 60 lactic acid e ............................. 60 lactulose ................................ 119 LAMICTAL ..................... 19, 20 LAMICTAL ODT .................. 19 LAMICTAL ODT STARTER
(BLUE) ............................... 19
LAMICTAL ODT STARTER (GREEN) ............................ 19
LAMICTAL ODT STARTER (ORANGE) ......................... 19
LAMICTAL STARTER (BLUE) KIT ....................... 20
LAMICTAL STARTER (GREEN) KIT .................... 20
LAMICTAL STARTER (ORANGE) KIT ................. 20
LAMICTAL XR ..................... 20 LAMICTAL XR STARTER
(BLUE) ............................... 20 LAMICTAL XR STARTER
(GREEN) ............................ 20 LAMICTAL XR STARTER
(ORANGE) ......................... 20 LAMISIL .................................. 3 lamivudine ................................ 5 lamivudine-zidovudine ............. 5 lamotrigine.............................. 20 LANCETS ............................ 100 LANCING DEVICE ............ 100 LANOXIN .............................. 51 lansoprazole .......................... 123 LANTUS .............................. 109 LANTUS SOLOSTAR......... 109 larin 1.5/30 (21) .................... 134 larin 1/20 (21) ....................... 134 larin 24 fe.............................. 134 larin fe 1.5/30 (28) ................ 134 larin fe 1/20 (28) ................... 134 larissia ................................... 134 LASIX .................................... 48 LASTACAFT ....................... 140 latanoprost ............................ 142 latrix........................................ 60 LATUDA................................ 38 layolis fe ............................... 134 LAZANDA ............................. 28 leena 28................................. 134 leflunomide ........................... 127 LENVIMA.............................. 16 LESCOL ................................. 54 LESCOL XL........................... 54 lessina ................................... 134 LETAIRIS ............................ 150 letrozole .................................. 16 leucovorin calcium ................. 14
LEUKERAN ........................... 16 leuprolide ................................ 16 levalbuterol hcl ..................... 150 LEVALBUTEROL
TARTRATE ..................... 150 LEVAQUIN ........................... 12 LEVATOL .............................. 48 LEVBID ............................... 116 LEVEMIR ............................ 109 LEVEMIR FLEXTOUCH.... 109 levetiracetam ........................... 20 LEVITRA ............................. 155 levobunolol ........................... 139 levocarnitine ........................... 73 levocarnitine (with sugar) ....... 73 levofloxacin .................... 12, 138 levonest (28) ......................... 134 levonorgestrel ....................... 134 levonorgestrel-ethinyl estrad 134 levonorg-eth estrad triphasic 135 levora-28 ............................... 135 levorphanol tartrate ................. 28 LEVO-T ................................ 114 levothyroxine ........................ 114 levoxyl .................................. 114 LEVSIN ................................ 116 LEVSIN/SL .......................... 116 LEXAPRO .............................. 38 LEXIVA ................................... 5 LIALDA ............................... 119 LIBERTY BLOOD GLUCOSE
MONITOR ....................... 100 LIBERTY LEV 1 GLUCOSE
CONTROL ....................... 100 LIBERTY LEV 2 GLUCOSE
CONTROL ....................... 100 LIBERTY TEST ..................... 83 LIBRAX (WITH CLIDINIUM)
.......................................... 116 lidocaine ................................. 65 lidocaine hcl............................ 65 lidocaine hcl-hydrocortison ac
.................................... 65, 119 lidocaine viscous .................... 65 lidocaine-prilocaine ................ 65 LIDOCAINE-TETRACAINE 65 LIDODERM ........................... 65 lindane .................................... 71 linezolid .................................. 10
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173
LINZESS .............................. 119 liothyronine .......................... 114 LIPITOR................................. 54 LIPOCHOL PLUS ................. 73 LIPOFEN ............................... 54 lisinopril ................................. 48 lisinopril-hydrochlorothiazide 48 lite coat aspirin ....................... 32 lithium carbonate .................... 38 lithium citrate ......................... 39 LITHOBID ............................. 39 LITHOSTAT .......................... 73 LIVALO ................................. 54 LO LOESTRIN FE............... 135 LOCOID ................................. 70 LOCOID LIPOCREAM ......... 70 LODINE ................................. 32 LODOSYN ............................. 21 LOESTRIN 1.5/30 (21) ........ 135 LOESTRIN 1/20 (21) ........... 135 LOESTRIN FE 1.5/30 (28-
DAY) ................................ 135 LOESTRIN FE 1/20 (28-DAY)
.......................................... 135 lomedia 24 fe ........................ 135 LOMOTIL ............................ 116 LONSURF .............................. 16 LOPID .................................... 54 lopinavir-ritonavir .................... 5 lopreeza ................................ 130 LOPRESSOR ......................... 48 LOPRESSOR HCT ................ 48 LOPROX ................................ 67 LOPROX (AS OLAMINE) .... 67 LOPROX KIT ........................ 67 lorazepam ............................... 39 lorazepam intensol .................. 39 lorcet (hydrocodone) .............. 28 lorcet hd .................................. 28 lorcet plus ............................... 28 LORTAB ELIXIR .................. 28 lortuss ex .............................. 146 loryna (28) ............................ 135 LORZONE ............................. 25 losartan ................................... 48 losartan-hydrochlorothiazide .. 48 LOSEASONIQUE ............... 135 LOTEMAX .......................... 143 LOTENSIN ............................ 48
LOTENSIN HCT ................... 48 LOTREL ................................. 48 LOTRISONE .......................... 67 LOTRONEX ........................ 119 LOUTREX ............................. 60 lovastatin ................................ 54 LOVAZA................................ 54 LOVENOX ............................. 52 low-ogestrel (28) .................. 135 loxapine succinate .................. 39 lta pre-attached ....................... 66 ludent fluoride ...................... 159 lugols .............................. 66, 157 LUMIGAN ........................... 142 LUNESTA .............................. 39 LUPANETA PACK (1
MONTH) .......................... 131 LUPANETA PACK (3
MONTH) .......................... 131 LUPRON DEPOT .................. 16 LUPRON DEPOT (3 MONTH)
............................................ 16 LUPRON DEPOT (4 MONTH)
............................................ 16 LUPRON DEPOT (6 MONTH)
............................................ 16 LUPRON DEPOT-PED ......... 16 LUPRON DEPOT-PED (3
MONTH) ............................ 16 lutera (28) ............................. 135 luxamend ................................ 60 LUXIQ.................................... 70 LUZU ..................................... 67 LYNPARZA ........................... 16 LYRICA ................................. 20 LYSODREN ........................... 16 LYSTEDA ............................ 131 lyza ....................................... 130 M MACROBID .......................... 13 MACRODANTIN .................. 13 MAGNEBIND 400............... 119 MALARONE ......................... 10 MALARONE PEDIATRIC ... 10 malathion ................................ 71 maprotiline.............................. 39 MAR-COF BP ...................... 146 MAR-COF CG ..................... 146 MARINOL ........................... 119
marlissa ................................. 135 MARPLAN............................. 39 marten-tab ............................... 28 MATULANE .......................... 16 matzim la ................................ 48 MAVIK................................... 48 MAXALT ............................... 23 MAXALT-MLT ..................... 23 MAXIDEX ........................... 143 MAXITROL ......................... 142 MAXZIDE .............................. 49 MAXZIDE-25MG .................. 49 m-clear wc ............................ 146 meclofenamate ........................ 32 MEDISENSE ........................ 100 MEDISENSE GLUCOSE
KETONE .......................... 100 MEDROL ............................... 76 MEDROL (PAK).................... 76 medroxyprogesterone ........... 130 mefenamic acid ....................... 32 mefloquine .............................. 10 MEGACE ES.......................... 16 megestrol ................................ 16 MEKINIST ............................. 16 meloxicam .............................. 33 memantine .............................. 24 MEMANTINE ........................ 25 M-END PE ........................... 146 MENEST .............................. 130 MENOSTAR ........................ 130 meperidine .............................. 29 MEPHYTON .......................... 52 meprobamate .......................... 25 MEPRON ............................... 10 mercaptopurine ....................... 16 mesalamine ........................... 119 MESALAMINE ................... 119 mesalamine with cleansing wipe
.......................................... 119 MESNEX ................................ 14 MESTINON ........................... 25 MESTINON TIMESPAN ...... 25 METADATE CD.................... 39 metadate er .............................. 39 metaproterenol ...................... 150 metaxall .................................. 25 metaxalone .............................. 26 metformin ............................. 113
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174
methadone .............................. 29 methadose ............................... 29 methamphetamine .................. 39 methazolamide ..................... 142 methenamine hippurate .......... 13 methenamine mandelate ......... 13 methen-sod phos-meth blue-
hyos .................................. 155 methergine ............................ 138 methimazole ........................... 77 METHITEST ........................ 110 methocarbamol ....................... 26 methotrexate sodium .............. 16 methotrexate sodium (pf) ....... 16 methoxsalen ............................ 60 methscopolamine .................. 116 methyclothiazide .................... 49 methyldopa ............................. 49 methyldopa-hydrochlorothiazide
............................................ 49 METHYLIN ........................... 39 methylphenidate ..................... 39 methylprednisolone ................ 76 methyltestosterone ................ 110 metipranolol ......................... 139 metoclopramide hcl .............. 119 metolazone ............................. 49 METOPIRONE ...................... 73 metoprolol succinate .............. 49 METOPROLOL SU-
HYDROCHLOROTHIAZ . 49 metoprolol ta-hydrochlorothiaz
............................................ 49 metoprolol tartrate .................. 49 METROCREAM .................... 63 METROGEL .......................... 63 METROGEL VAGINAL ..... 131 METROLOTION ................... 63 metronidazole ........... 10, 63, 132 mexiletine ............................... 44 MIACALCIN ....................... 110 mibelas 24 fe ........................ 135 MICARDIS ............................ 49 MICARDIS HCT ................... 49 MICORT-HC ....................... 120 MICRO BLOOD GLUCOSE . 83 MICRODOT BLOOD
GLUCOSE SYSTEM . 83, 100 microgestin 1.5/30 (21) ........ 135
microgestin 1/20 (21) ........... 135 MICROGESTIN 24 FE ........ 135 microgestin fe 1.5/30 (28) .... 135 microgestin fe 1/20 (28) ....... 135 MICROZIDE .......................... 49 midodrine................................ 73 MIFEPREX .......................... 132 migergot.................................. 23 miglitol ................................. 113 MIGRANAL .......................... 23 millipred ................................. 76 MILLIPRED ........................... 76 millipred dp ............................ 76 mimvey ................................. 130 mimvey lo ............................. 130 MINASTRIN 24 FE ............. 135 MINIPRESS ........................... 49 MINITRAN ............................ 55 MINIVELLE ........................ 130 MINOCIN .............................. 13 minocycline ............................ 13 minoxidil ................................ 49 MIOCHOL-E........................ 140 MIRAPEX .............................. 21 MIRAPEX ER ........................ 21 MIRCETTE (28) .................. 135 mirtazapine ............................. 39 MIRVASO.............................. 63 misoprostol ........................... 123 MITIGARE .......................... 126 MITOSOL ............................ 142 MOBIC ................................... 33 modafinil ................................ 40 moderiba ............................... 125 moderiba dose pack .............. 125 moexipril ................................ 49 moexipril-hydrochlorothiazide
............................................ 49 mometasone .................... 70, 150 mondoxyne nl ......................... 13 MONODOX ........................... 13 mono-linyah.......................... 135 mononessa (28)..................... 135 montelukast .......................... 151 MONUROL ............................ 13 morgidox ................................ 13 MORPHABOND ER ............. 29 morphine ................................. 29 morphine concentrate ............. 29
MOTOFEN ........................... 116 MOVANTIK ........................ 120 MOVIPREP .......................... 120 MOXATAG ............................ 11 MOXEZA ............................. 138 moxifloxacin ........................... 12 MS CONTIN .......................... 29 MUGARD .............................. 75 MULTAQ ............................... 44 multi-vit with fluoride-iron... 159 multi-vitamin with fluoride .. 159 multivitamins with fluoride .. 159 mupirocin ................................ 66 mupirocin calcium .................. 66 mvc-fluoride ......................... 159 my way ................................. 135 MYALEPT ........................... 110 MYAMBUTOL ...................... 10 MYCOBUTIN ........................ 10 mycophenolate mofetil ........... 16 mycophenolate sodium ........... 16 MYDRIACYL ...................... 140 MYFORTIC ........................... 16 MYGLUCOHEALTH .... 83, 100 MYGLUCOHEALTH
CONTROL SOLUTION .. 100 MYLERAN ............................ 16 mynephron ............................ 159 MYRBETRIQ....................... 153 MYSOLINE ........................... 20 MYTESI ............................... 116 myzilra .................................. 135 N nabumetone ............................. 33 nadolol .................................... 49 nadolol-bendroflumethiazide .. 49 naftifine ................................... 67 NAFTIN ................................. 67 NALFON ................................ 33 naltrexone ............................... 33 NAMENDA ............................ 25 NAMENDA TITRATION PAK
............................................ 25 NAMENDA XR ..................... 25 NAMZARIC ........................... 25 NAPRELAN CR .................... 33 NAPROSYN........................... 33 naproxen ................................. 33 naproxen sodium .................... 33
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175
naratriptan ............................... 23 NARCAN ............................... 33 NARDIL ................................. 40 NASCOBAL ........................ 159 NASONEX ........................... 151 NATACYN .......................... 138 NATAZIA ............................ 135 nateglinide ............................ 113 NATESTO ............................ 111 NATPARA ........................... 111 NATROBA............................. 71 nature-throid ......................... 114 NEBUPENT ........................... 10 nebusal .................................. 151 NEBUSAL ........................... 151 necon 0.5/35 (28) .................. 135 necon 1/50 (28)..................... 135 necon 10/11 (28) ................... 135 necon 7/7/7 (28) ................... 135 nefazodone ............................. 40 neomycin ................................ 10 neomycin-bacitracin-poly-hc 142 neomycin-bacitracin-polymyxin
.......................................... 138 neomycin-polymyxin b-
dexameth .......................... 142 neomycin-polymyxin-
gramicidin ......................... 138 neomycin-polymyxin-hc 76, 142 neo-polycin ........................... 138 neo-polycin hc ...................... 142 NEORAL ................................ 16 NEOSALUS ........................... 60 NEO-SYNALAR ................... 66 NEO-SYNALAR KIT ............ 66 NEPTAZANE ...................... 142 NESINA ............................... 113 neuac ....................................... 63 NEUAC KIT .......................... 63 NEUPRO ................................ 22 NEURONTIN ......................... 20 NEUTEK 2TEK TEST STRIPS
............................................ 83 NEVANAC .......................... 141 nevirapine ................................. 5 NEXAVAR ............................ 16 NEXIUM .............................. 123 NEXIUM PACKET ............. 123 next choice one dose ............ 135
niacin ...................................... 54 NIACOR ................................. 54 NIASPAN EXTENDED-
RELEASE .......................... 54 nicardipine .............................. 49 NICODERM CQ .................... 73 nicorelief ................................. 73 nicorette .................................. 73 NICORETTE .................... 73, 74 nicotine ................................... 74 nicotine (polacrilex) ............... 74 NICOTROL ............................ 74 NICOTROL NS ...................... 74 nifedipine ................................ 49 nikki (28) .............................. 136 NILANDRON ........................ 16 nilutamide ............................... 17 nimodipine .............................. 49 NINJACOF-XG.................... 146 NINLARO .............................. 17 nisoldipine .............................. 49 nitro-bid .................................. 55 NITRO-DUR .......................... 55 nitrofurantoin .......................... 13 nitrofurantoin macrocrystal .... 13 nitrofurantoin monohyd/m-cryst
............................................ 13 nitroglycerin ..................... 55, 56 NITROLINGUAL .................. 56 NITROMIST .......................... 56 NITROSTAT .......................... 56 nitro-time ................................ 56 nivatopic plus ......................... 60 nizatidine .............................. 123 NIZORAL .............................. 67 nodolor.................................... 23 nolix ........................................ 70 nora-be .................................. 130 NORCO .................................. 29 NORDITROPIN FLEXPRO 124 noreth-ethinyl estradiol-iron . 136 norethindrone (contraceptive)
.......................................... 130 norethindrone acetate ........... 130 norethindrone ac-eth estradiol
.................................. 130, 136 norethindrone-e.estradiol-iron
.......................................... 136
norgestimate-ethinyl estradiol .......................................... 136
NORINYL 1/35 (28) ............ 136 NORITATE ............................ 63 norlyda .................................. 130 norlyroc................................. 130 NORPACE ............................. 44 NORPACE CR ....................... 44 NORPRAMIN ........................ 40 NORTHERA .......................... 73 nortrel 0.5/35 (28) ................. 136 nortrel 1/35 (21) .................... 136 nortrel 1/35 (28) .................... 136 nortrel 7/7/7 (28) ................... 136 nortriptyline ............................ 40 NORVASC ............................. 49 NORVIR ................................... 5 NOVA MAX BLOOD
GLUCOSE METER ......... 100 NOVA MAX GLUCOSE
CONTROL ....................... 101 NOVA MAX GLUCOSE TEST
............................................ 83 NOVAMAX PLUS GLU-KET
.......................................... 101 NOVOLOG .......................... 109 NOVOLOG FLEXPEN ........ 109 NOVOLOG MIX 70-30 ....... 109 NOVOLOG MIX 70-30
FLEXPEN......................... 109 NOVOLOG PENFILL ......... 109 NOVOPEN ECHO ............... 101 NOXAFIL................................. 3 np thyroid.............................. 114 nts step 1 ................................. 74 NUCYNTA............................. 33 NUCYNTA ER ...................... 33 NUEDEXTA .......................... 25 NULEV................................. 116 NULYTELY WITH FLAVOR
PACKS ............................. 120 NUOX..................................... 63 NUPLAZID ............................ 40 NUTRESTORE ...................... 73 NUTROPIN AQ NUSPIN .... 124 NUVARING ......................... 132 NUVESSA ............................ 132 NUVIGIL ............................... 40 nyamyc ................................... 67
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176
nyata ....................................... 67 NYMALIZE ........................... 49 nystatin ............................... 3, 67 nystatin-triamcinolone ............ 67 nystop ..................................... 67 O OBREDON........................... 146 OCALIVA ............................ 120 ocella .................................... 136 octreotide acetate .................... 17 OCUFEN .............................. 141 OCUFLOX ........................... 138 ODEFSEY ................................ 5 ODOMZO .............................. 17 OFEV ................................... 151 ofloxacin ................... 12, 76, 139 ogestrel (28) .......................... 136 olanzapine ............................... 40 olanzapine-fluoxetine ............. 40 olmesartan .............................. 49 olmesartan-amlodipin-hcthiazid
............................................ 49 olmesartan-hydrochlorothiazide
............................................ 49 olopatadine ..................... 75, 141 OLUX ..................................... 70 OLUX-E ................................. 70 OLYSIO ................................... 5 OMECLAMOX-PAK .......... 123 omega-3 acid ethyl esters ....... 54 omeprazole ........................... 123 omeprazole-sodium bicarbonate
.......................................... 123 OMNARIS ........................... 151 OMNIPRED ......................... 143 OMNITROPE ....................... 124 ON CALL EXPRESS
CONTROL ....................... 101 ON CALL EXPRESS METER
.......................................... 101 ON CALL EXPRESS TEST
STRIP ................................. 83 ON CALL PLUS CONTROL
.......................................... 101 ON CALL PLUS METER ... 101 ON CALL PLUS TEST STRIP
............................................ 83 ON CALL VIVID CONTROL
.......................................... 101
ON CALL VIVID METER .. 101 ON CALL VIVID PAL METER
.......................................... 101 ON CALL VIVID TEST STRIP
............................................ 83 ondansetron .......................... 120 ondansetron hcl..................... 120 ONETOUCH ULTRA
CONTROL ....................... 101 ONETOUCH ULTRA TEST . 83 ONETOUCH ULTRA2 ........ 101 ONETOUCH ULTRAMINI . 101 ONETOUCH VERIO ............. 83 ONETOUCH VERIO FLEX 101 ONETOUCH VERIO IQ
METER ............................ 102 ONETOUCH VERIO SYNC
.......................................... 102 ONETOUCH VERIO SYSTEM
.......................................... 102 ONEXTON ............................. 63 ONFI ....................................... 20 ONGLYZA ........................... 113 ONMEL .................................... 3 ONZETRA XSAIL................. 23 OPANA .................................. 29 OPANA ER ............................ 29 opcicon one-step ................... 136 opium tincture....................... 116 OPSUMIT ............................ 151 option-2 ................................ 136 OPTIUM EZ ........................... 83 OPTIUM TEST ...................... 83 OPTUMRX .................... 84, 102 ORACEA................................ 13 ORACIT ............................... 155 ORALAIR ............................ 126 oralone .................................... 75 ORAMAGICRX ..................... 75 ORAP ..................................... 40 ORAPRED ODT .................... 76 ORAVIG .................................. 3 ORENCIA .................... 127, 128 ORENCIA CLICKJECT ...... 127 ORENITRAM ........................ 50 ORFADIN .............................. 73 ORKAMBI ........................... 151 orphenadrine citrate ................ 26 orsythia ................................. 136
ORTHO MICRONOR .......... 131 ORTHO TRI-CYCLEN (28) 136 ORTHO TRI-CYCLEN LO (28)
.......................................... 136 ORTHO-CYCLEN (28) ....... 136 ORTHO-NOVUM 1/35 (28) 136 ORTHO-NOVUM 7/7/7 (28)
.......................................... 136 oscimin ................................. 116 oscimin sl .............................. 116 oscimin sr.............................. 116 oseltamivir ................................ 5 OSENI .................................. 113 OSMOPREP ......................... 120 OSPHENA ............................ 132 OTEZLA............................... 128 OTEZLA STARTER ............ 128 OTIPRIO ................................ 76 OTOVEL ................................ 76 OTREXUP (PF).................... 128 OVACE .................................. 56 OVACE PLUS........................ 56 OVACE PLUS SHAMPOO ... 56 OVACE PLUS WASH ........... 56 OVCON-35 (28) ................... 136 OVIDE .................................... 71 oxaprozin ................................ 33 OXAYDO ............................... 29 oxazepam ................................ 40 oxcarbazepine ......................... 20 oxiconazole ............................. 67 OXISTAT ............................... 67 OXSORALEN ULTRA .......... 60 OXTELLAR XR .................... 20 oxybutynin chloride .............. 153 oxycodone............................... 29 OXYCODONE ....................... 29 oxycodone-acetaminophen .... 29,
30 oxycodone-aspirin .................. 30 OXYCONTIN ........................ 30 oxymorphone .......................... 30 OXYTROL ........................... 153 oysco 500/d ........................... 157 oyster shell + d3 ................... 157 oyster shell calcium-vit d2 .... 159 oyster shell calcium-vit d3 .... 157 oystercal-d ............................ 157
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P pacerone ................................. 44 paliperidone ............................ 40 PAMELOR ............................. 40 PANCREAZE ...................... 120 PANDEL ................................ 70 PANRETIN ............................ 60 pantoprazole ......................... 123 PARAFON FORTE DSC ....... 26 paregoric ............................... 116 PAREMYD .......................... 140 paricalcitol ............................ 111 PARLODEL ........................... 22 PARNATE ............................. 40 paroex oral rinse ..................... 75 paromomycin .......................... 10 paroxetine hcl ......................... 40 PASER ................................... 10 PATADAY ........................... 141 PATANASE ........................... 75 PATANOL ........................... 141 PAXIL .................................... 40 PAXIL CR .............................. 40 PAZEO ................................. 141 PCE........................................... 8 PEDIAPRED .......................... 76 peg 3350-electrolytes ........... 120 PEGANONE .......................... 20 PEGASYS ............................ 125 PEGASYS PROCLICK ....... 125 peg-electrolyte soln .............. 120 PEGINTRON ....................... 125 PEGINTRON REDIPEN ..... 125 PEN NEEDLE ...................... 102 penicillin v potassium ............. 11 PENLAC ................................ 67 PENNSAID ............................ 33 PENTASA ............................ 120 pentazocine-naloxone ............. 33 pentoxifylline ......................... 52 PEPCID ................................ 123 PERCOCET ........................... 30 PERFOROMIST .................. 151 PERIDEX ............................... 75 perindopril erbumine .............. 50 periogard ................................. 75 permethrin .............................. 71 perphenazine ........................... 40 perphenazine-amitriptyline ..... 40
PERTZYE ............................ 120 PEXEVA ................................ 40 PHARMACIST CHOICE ...... 84 PHARMACIST CHOICE
GLUCOSE SYS ............... 102 phenadoz ............................... 145 phenazopyridine ................... 156 phenelzine ............................... 40 phenergan ............................. 145 phenobarb-hyoscy-atropine-scop
.......................................... 116 phenobarbital .......................... 20 phenohytro ............................ 116 phenoxybenzamine ................. 50 phenylephrine hcl ................. 144 PHENYTEK ........................... 20 phenytoin ................................ 20 phenytoin sodium extended .... 20 philith.................................... 136 PHOSLYRA ......................... 120 phospha 250 neutral.............. 157 phosphasal ............................ 155 PHOSPHOLINE IODIDE .... 139 PHYSIOLYTE ....................... 72 PHYSIOSOL IRRIGATION .. 72 PICATO.................................. 60 pilocarpine hcl .......... 73, 75, 140 pimozide ................................. 40 pimtrea (28) .......................... 136 pindolol ................................... 50 pioglitazone .......................... 113 pioglitazone-glimepiride ...... 113 pioglitazone-metformin ........ 113 pirmella ................................. 136 piroxicam ................................ 33 PLAN B ONE-STEP ............ 136 PLAQUENIL.......................... 10 PLAVIX ................................. 52 PLEGRIDY .......................... 125 PLEXION ............................... 63 PLEXION CLEANSING
CLOTHS ............................ 63 PLIAGLIS .............................. 66 PODOCON ............................. 58 podofilox ................................ 60 polycin .................................. 139 polyethylene glycol 3350 ..... 120 polymyxin b sulf-trimethoprim
.......................................... 139
POLYTRIM .......................... 139 POLY-TUSSIN AC .............. 146 POLY-VI-FLOR FS ............. 159 POMALYST......................... 125 PONSTEL............................... 33 portia ..................................... 137 pot,sodium citrate-citric acid 155 POTABA .............................. 157 potassium bicarb and chloride
.......................................... 157 potassium bicarb-citric acid .. 157 potassium chloride ................ 157 potassium citrate ................... 155 potassium citrate-citric acid .. 155 POTASSIUM HYDROXIDE . 58 PRADAXA ............................. 52 PRALUENT PEN ................... 54 pramcort ................................ 120 pramipexole ............................ 22 PRAMOSONE ....................... 56 PRAMOSONE E .................... 56 PRANDIN ............................ 114 PRAVACHOL ........................ 54 pravastatin ............................... 54 prazosin................................... 50 PRECISION PCX PLUS TEST
............................................ 84 PRECISION PCX TEST ........ 84 PRECISION POINT OF CARE
TEST................................... 84 PRECISION Q-I-D TEST ...... 84 PRECISION XTRA MONITOR
.......................................... 102 PRECISION XTRA TEST ..... 84 PRECOSE............................. 114 PRED FORTE ...................... 143 PRED MILD ......................... 143 PRED-G ................................ 142 PRED-G S.O.P. .................... 143 prednicarbate .......................... 70 prednisolone ........................... 77 prednisolone acetate ............. 143 prednisolone sodium phosphate
.................................... 77, 143 prednisone............................... 77 prednisone intensol ................. 77 PREFEST ............................. 131 PREMARIN ......................... 131
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PREMIUM BLOOD GLUCOSE MONITOR .... 102
PREMIUM V10 ............. 84, 102 PREMPHASE ...................... 131 PREMPRO ........................... 131 PRENATAL PLUS DHA ..... 159 PREPIDIL ............................ 132 PREPOPIK ........................... 120 PRESERA .............................. 60 PRESTALIA .......................... 50 PRESTO PRO BLOOD
GLUCOSE METER ......... 102 PREVACID .......................... 123 PREVACID SOLUTAB ...... 123 prevalite .................................. 54 PREVIDENT .......................... 75 PREVIDENT 5000 BOOSTER
PLUS .................................. 75 PREVIDENT 5000 DRY
MOUTH ............................. 75 PREVIDENT 5000 ENAMEL
PROTECT .......................... 75 PREVIDENT 5000 PLUS ...... 75 PREVIDENT 5000 SENSITIVE
............................................ 75 previfem ............................... 137 PREVPAC ............................ 123 PREZCOBIX ............................ 5 PREZISTA ............................... 5 PRIFTIN ................................. 10 PRILOSEC ........................... 123 PRIMAQUINE ....................... 10 primidone ............................... 20 PRIMLEV .............................. 30 PRIMSOL............................... 14 PRINIVIL ............................... 50 PRISTIQ ................................. 40 PROAIR HFA ...................... 151 PROAIR RESPICLICK ....... 151 probenecid ............................ 126 probenecid-colchicine .......... 126 PROCARDIA ......................... 50 PROCARDIA XL .................. 50 procentra ................................. 40 prochlorperazine ................... 120 prochlorperazine maleate ..... 120 PROCORT ........................... 120 PROCTOCORT ................... 120 PROCTOFOAM HC ............ 120
procto-med hc ....................... 120 proctosol hc .......................... 120 proctozone-hc ....................... 121 PROCYSBI .......................... 155 PRODIGY AUTOCODE
METER ............................ 102 PRODIGY AUTOCODE
MONITOR SYST............. 102 PRODIGY CONTROL
SOLUTION, LOW ........... 103 PRODIGY CONTROL
SOLUTION,HIGH ........... 103 PRODIGY NO CODING ....... 84 PRODIGY POCKET METER
.......................................... 103 PRODIGY VOICE GLUCOSE
METER ............................ 103 PRODRIN .............................. 23 progesterone micronized ...... 131 PROGLYCEM ....................... 86 PROGRAF ............................. 17 PROLENSA ......................... 141 PROMACTA .......................... 52 promethazine ........................ 145 promethazine vc-codeine ...... 146 promethazine-codeine .......... 146 promethazine-dm .................. 146 promethazine-phenyleph-
codeine.............................. 146 promethazine-phenylephrine 146 promethegan ......................... 145 PROMETRIUM ................... 131 PROMISEB ............................ 60 propafenone ............................ 44 propantheline ........................ 116 proparacaine ......................... 141 propranolol ............................. 50 propranolol-hydrochlorothiazid
............................................ 50 propylthiouracil ...................... 77 PRO-RED AC (W/
DEXCHLORPHENIR) .... 147 PROSCAR ............................ 154 PROSTIN E2 ........................ 132 PROTONIX .......................... 123 PROTOPIC ............................. 60 protriptyline ............................ 40 PROVENTIL HFA ............... 151 PROVERA ........................... 131
PROVIGIL ............................. 40 PROZAC ................................ 40 PROZAC WEEKLY .............. 41 pruclair .................................... 60 prudoxin .................................. 60 prumyx .................................... 60 prutect ..................................... 60 PSORCON .............................. 70 PULMICORT ....................... 151 PULMICORT FLEXHALER
.......................................... 151 pulmosal ............................... 151 PULMOZYME ..................... 151 PURALOR CI ...................... 159 PURIXAN .............................. 17 PYLERA............................... 123 pyrazinamide .......................... 10 PYRIDIUM .......................... 156 pyridostigmine bromide .......... 26 Q QBRELIS ............................... 50 Q-CARE RX Q4 ..................... 75 QNASL ................................. 151 QSYMIA ................................ 72 QUALAQUIN ........................ 10 QUARTETTE ....................... 137 quasense ................................ 137 quazepam ................................ 41 QUDEXY XR ......................... 20 QUESTRAN ........................... 54 QUESTRAN LIGHT .............. 54 quetiapine ............................... 41 QUFLORA FE ...................... 159 QUFLORA FE (FERROUS
SULFATE) ....................... 159 QUFLORA PEDIATRIC ..... 159 QUFLORA PEDIATRIC
DROPS ............................. 159 QUILLICHEW ER ................. 41 QUILLIVANT XR ................. 41 quinapril .................................. 50 quinapril-hydrochlorothiazide 50 quinidine gluconate ................ 44 quinidine sulfate ..................... 44 quinine sulfate ........................ 10 QUINTET AC ........................ 84 QUINTET BLOOD GLUCOSE
METER............................. 103 quit 2 ....................................... 74
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QUIT 2 ................................... 74 quit 4 ....................................... 74 QUIT 4 ................................... 74 QVAR................................... 151 R rabeprazole ........................... 123 RAGWITEK ......................... 126 rajani ..................................... 137 raloxifene .............................. 127 ramipril ................................... 50 RANEXA ............................... 55 ranitidine hcl ......................... 123 RAPAFLO ............................ 154 RAPAMUNE ......................... 17 rasagiline ................................ 22 RASUVO (PF) ..................... 128 RAVICTI ................................ 73 RAYALDEE ........................ 111 RAYOS .................................. 77 RAZADYNE .......................... 25 RAZADYNE ER .................... 25 rea lo 39 .................................. 60 rea lo 40 .................................. 60 react ...................................... 137 REBETOL ............................ 125 REBIF (WITH ALBUMIN) . 125 REBIF REBIDOSE .............. 125 REBIF TITRATION PACK. 125 reclipsen (28) ........................ 137 RECTIV ............................... 121 REFUAH PLUS ..................... 84 REFUAH PLUS GLUCOSE
CONTROL ....................... 103 REFUAH PLUS GLUCOSE
MONITOR ....................... 103 REGLAN .............................. 121 REGRANEX .......................... 60 RELAGARD ........................ 132 relcof c .................................. 147 RELENZA DISKHALER ........ 5 RELION ALL-IN-ONE
METER ............................ 103 RELION CONFIRM ............ 103 RELION CONFIRM-MICRO 84 RELION MICRO GLUCOSE
MONITOR ....................... 104 RELION NOVOLIN 70/30 .. 109 RELION NOVOLIN N ........ 109 RELION NOVOLIN R ........ 109
RELION PRIME METER.... 104 RELION PRIME TEST STRIPS
............................................ 84 RELISTOR ........................... 121 RELPAX ................................ 23 REMERON ............................ 41 REMERON SOLTAB ............ 41 remeven .................................. 61 RENAGEL ........................... 121 RENVELA ........................... 121 repaglinide ............................ 114 repaglinide-metformin .......... 114 REPATHA PUSHTRONEX .. 54 REPATHA SURECLICK ...... 54 REPATHA SYRINGE ........... 54 REQUIP.................................. 22 REQUIP XL ........................... 22 RESCRIPTOR .......................... 5 RESPA-AR ........................... 147 RESTASIS............................ 141 RESTASIS MULTIDOSE ... 141 RESTIZAN ............................. 61 RESTORIL ............................. 41 RETIN-A ................................ 64 RETIN-A MICRO .................. 63 RETIN-A MICRO PUMP ...... 64 RETROVIR .............................. 5 REVATIO ............................ 151 REVEAL BLOOD GLUCOSE
METER ............................ 104 REVEAL TEST STRIP .......... 84 REVIA .................................... 33 REVLIMID .......................... 125 REXULTI ............................... 41 REYATAZ ............................... 5 REZIRA................................ 147 ribasphere ............................. 125 ribasphere ribapak ................ 125 ribavirin ............................ 5, 125 RIDAURA ............................ 128 rifabutin .................................. 10 RIFADIN ................................ 10 RIFAMATE............................ 10 rifampin .................................. 10 RIFATER ............................... 10 RIGHTEST CONTROL
SOLUTION HIGH ........... 104 RIGHTEST GM550 SYSTEM
.......................................... 104
RIGHTEST GS550 TEST STRIPS ............................... 85
RILUTEK ............................... 73 riluzole .................................... 73 rimantadine ............................... 5 ringer's .................................... 72 RIOMET ............................... 114 risacal-d ................................ 159 risedronate ...................... 73, 127 RISPERDAL .......................... 41 RISPERDAL M-TAB ............ 41 risperidone .............................. 41 RITALIN ................................ 41 RITALIN LA .......................... 41 rivastigmine ............................ 25 rivastigmine tartrate ................ 25 rivelsa ................................... 137 rizatriptan ................................ 23 ROBAXIN .............................. 26 ROBAXIN-750....................... 26 ROBINUL ............................ 116 ROBINUL FORTE ............... 116 ROCALTROL ...................... 111 ropinirole ................................ 22 rosadan .................................... 64 ROSADAN ............................. 64 ROSANIL ............................... 64 ROSULA ................................ 64 rosula cleansing cloths ............ 64 rosuvastatin ............................. 54 ROWASA ............................. 121 roweepra ................................. 20 ROXICODONE ...................... 30 ROZEREM ............................. 41 RUBRACA ............................. 17 rydex ..................................... 147 RYTARY ................................ 22 RYTHMOL SR ...................... 44 RYVENT .............................. 145 S SABRIL .................................. 21 SAFYRAL ............................ 137 SAIZEN ................................ 124 SAIZEN CLICK.EASY ....... 124 SAIZEN SAIZENPREP ....... 124 salacyn .................................... 58 SALAGEN (PILOCARPINE)
...................................... 73, 75 SALEX ................................... 58
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salicylic acid ........................... 58 SALKERA ............................. 59 salsalate .................................. 33 salvax ...................................... 59 SALVAX DUO PLUS ........... 59 SAMSCA ............................. 111 SANCUSO ........................... 121 SANDIMMUNE .................... 17 SANDOSTATIN .................... 17 SANTYL ................................ 71 SAPHRIS (BLACK CHERRY)
............................................ 41 SARAFEM ............................. 42 SAVAYSA ............................. 52 SAVELLA ............................ 128 scalacort .................................. 70 SEASONIQUE ..................... 137 seb-prev .................................. 57 seconal sodium ....................... 42 SEEBRI NEOHALER.......... 151 selegiline hcl ........................... 22 selenium sulfide ...................... 57 SELRX ................................... 57 SELZENTRY ....................... 5, 6 SEMPREX-D ....................... 147 SENSIPAR ........................... 111 SEREVENT DISKUS .......... 151 SERNIVO............................... 70 SEROQUEL ........................... 42 SEROQUEL XR .................... 42 SEROSTIM .......................... 124 sertraline ................................. 42 setlakin ................................. 137 sevelamer carbonate ............. 121 sf 75 sf 5000 plus ............................ 75 SFROWASA ........................ 121 sharobel ................................ 131 SHOHL'S MODIFIED ......... 155 SIDEKICK BLOOD
GLUCOSE SYSTEM ....... 104 sildenafil ............................... 152 SILENOR ............................... 42 SILIQ ...................................... 57 SILVADENE ......................... 58 silver nitrate ............................ 61 silver nitrate applicators ......... 61 silver sulfadiazine ................... 58 SILVRSTAT .......................... 66
SIMBRINZA ........................ 142 SIMPONI.............................. 128 simvastatin .............................. 54 SINEMET ............................... 22 SINEMET CR ........................ 22 SINGULAIR ........................ 152 sirolimus ................................. 17 SIRTURO ............................... 10 SITAVIG .................................. 6 SIVEXTRO ............................ 10 SKELAXIN ............................ 26 SKLICE .................................. 71 SMART SENSE
MONITORING SYSTEM 104 SMART SENSE TEST STRIPS
............................................ 85 SMARTEST CONTROL ..... 104 SMARTEST EJECT............. 104 SMARTEST PERSONA
STARTER ........................ 105 SMARTEST PRONTO
STARTER ........................ 105 SMARTEST PROTEGE ...... 105 SMARTEST TEST................. 85 SNAP INSULIN PUMP
CONTROLLER................ 105 sodium chloride .................... 152 sodium citrate-citric acid ...... 155 sodium phenylbutyrate ........... 73 sodium polystyrene sulfonate
.......................................... 121 SODIUM POLYSTYRENE
SULFONATE ................... 121 SOLARAZE ........................... 61 SOLIQUA 100/33 ................ 109 SOLODYN ............................. 13 SOLTAMOX .......................... 17 SOLUS V2 AUDIBLE METER
.......................................... 105 SOLUS V2 CONTROL
SOLUTION,HIGH ........... 105 SOLUS V2 TEST STRIPS ..... 85 SOMA .................................... 26 SOMATULINE DEPOT ........ 17 SOMAVERT ........................ 111 sonafine .................................. 61 SONATA ................................ 42 SOOLANTRA ........................ 64 SORBITOL-MANNITOL ...... 72
SORIATANE ......................... 57 SORILUX ............................... 57 sotalol ..................................... 44 sotalol af ................................. 44 SOTYLIZE ............................. 44 SOVALDI................................. 6 sp antipruritic .......................... 61 sp scar management ................ 61 SPECTRACEF ......................... 7 spinosad .................................. 71 SPIRIVA RESPIMAT .......... 152 SPIRIVA WITH
HANDIHALER ................ 152 spironolactone......................... 50 spironolacton-hydrochlorothiaz
............................................ 50 SPORANOX............................. 3 SPORANOX PULSEPAK ....... 3 sprintec (28) .......................... 137 SPRIX ..................................... 33 SPRYCEL............................... 17 sps (with sorbitol) ................. 121 sronyx ................................... 137 ss 10-2 ..................................... 64 ssd ........................................... 58 SSKI ....................................... 77 sss 10-5 ................................... 64 STALEVO 100 ....................... 22 STALEVO 125 ....................... 22 STALEVO 150 ....................... 22 STALEVO 200 ....................... 22 STALEVO 50 ......................... 22 STALEVO 75 ......................... 22 STARLIX ............................. 114 stavudine ................................... 6 STAXYN .............................. 155 STENDRA ............................ 155 STIMATE ............................. 111 STIOLTO RESPIMAT ......... 152 STIVARGA ............................ 17 stop smoking aid ..................... 74 STRATTERA ......................... 42 STRENSIQ ........................... 111 STRIANT ............................. 111 STRIBILD ................................ 6 STRIVERDI RESPIMAT .... 152 STROMECTOL ..................... 10 strong iodine ......................... 157 SUBOXONE .......................... 34
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SUBSYS ................................. 30 SUCRAID ............................ 121 sucralfate .............................. 124 SULAR ................................... 50 sulfacetamide sodium ..... 57, 144 sulfacetamide sodium (acne) .. 66 sulfacetamide sodium-sulfur .. 64 sulfacetamide sod-sulfur-urea 64 sulfacetamide-prednisolone .. 144 sulfacleanse 8-4 ...................... 64 sulfadiazine ............................. 12 sulfamethoxazole-trimethoprim
............................................ 12 SULFAMYLON..................... 66 sulfasalazine ......................... 121 sulfatrim ................................. 12 sulindac ................................... 34 SUMADAN ............................ 64 sumatriptan ............................. 23 sumatriptan succinate ............. 24 SUMAVEL DOSEPRO ......... 24 SUMAXIN ............................. 64 SUMAXIN TS ........................ 64 SUPRAX .................................. 8 SUPREP BOWEL PREP KIT
.......................................... 121 SURE-TEST EASYPLUS MINI
............................................ 85 SURE-TEST EASYPLUS MINI
METER ............................ 105 SURMONTIL......................... 42 SUSTIVA ................................. 6 SUTENT................................. 17 syeda ..................................... 137 SYLATRON ......................... 126 SYMAX DUOTAB .............. 116 symax fastabs ....................... 116 symax-sl ............................... 116 symax-sr ............................... 116 SYMBICORT....................... 152 SYMBYAX ............................ 42 SYMLINPEN 120 ................ 114 SYMLINPEN 60 .................. 114 SYNALAR ............................. 70 SYNALAR CREAM KIT ...... 70 SYNALAR OINTMENT KIT 70 SYNALAR TS ....................... 70 SYNALGOS-DC .................... 30 SYNAREL ........................... 111
SYNDROS ........................... 121 SYNERA ................................ 66 SYNJARDY ......................... 114 SYNJARDY XR................... 114 SYNTHROID ....................... 115 SYPRINE ............................... 73 T T
30 INFUSION SET .......... 105 90 INFUSION SET 23 ..... 105 SLIM ................................ 105 SLIM G4........................... 105
TABLOID .............................. 17 TACLONEX .......................... 57 tacrolimus ......................... 17, 61 TAFINLAR ............................ 17 TAGRISSO ............................ 17 TAKE ACTION ................... 137 TALTZ AUTOINJECTOR .... 57 TALTZ AUTOINJECTOR (2
PACK) ................................ 57 TALTZ AUTOINJECTOR (3
PACK) ................................ 57 TALTZ SYRINGE ................. 57 TALTZ SYRINGE (2 PACK) 57 TALTZ SYRINGE (3 PACK) 58 TAMIFLU ................................ 6 tamoxifen ................................ 17 tamsulosin ............................. 154 TANZEUM .......................... 114 TAPAZOLE ........................... 77 TARCEVA ............................. 17 TARGADOX.......................... 13 TARGRETIN ......................... 17 tarina fe 1/20 (28) ................. 137 TARKA .................................. 50 TASIGNA .............................. 17 TASMAR ............................... 22 TAYTULLA ......................... 137 tazarotene................................ 64 TAZORAC ............................. 65 taztia xt ................................... 50 TECFIDERA ........................ 126 TECHNIVIE ............................. 6 TEGRETOL ........................... 21 TEGRETOL XR ..................... 21 TEKTURNA .......................... 50 TEKTURNA HCT ................. 50 TELCARE BGM .................. 106
TELCARE BLOOD GLUCOSE KIT ................................... 106
TELCARE CONTROL ........ 106 TELCARE TEST STRIPS ..... 85 telmisartan .............................. 50 telmisartan-amlodipine ........... 50 telmisartan-hydrochlorothiazid
............................................ 50 temazepam .............................. 42 TEMODAR ............................ 17 TEMOVATE .......................... 70 temozolomide ......................... 17 tencon ..................................... 30 TENORETIC 100 ................... 50 TENORETIC 50 ..................... 50 TENORMIN ........................... 50 TERAZOL 7 ......................... 132 terazosin .................................. 51 terbinafine hcl ........................... 3 terbutaline ............................. 152 terconazole ............................ 132 TERSI FOAM ........................ 58 TESSALON PERLES .......... 147 TEST N'GO BLOOD
GLUCOSE SYSTEM ....... 106 TEST N'GO TEST .................. 85 TESTIM ................................ 111 TESTOPEL........................... 111 testosterone ........................... 111 TESTOSTERONE ................ 111 testosterone cypionate .......... 111 testosterone enanthate ........... 111 TESTRED............................. 111 tetcaine .................................. 141 tetrabenazine ........................... 25 tetracaine hcl ......................... 141 tetracaine hcl (pf) .................. 141 tetracycline ............................. 13 TETRAVISC ........................ 141 TETRAVISC FORTE .......... 141 TEXACORT ........................... 70 TEXAVITE LQ .................... 159 THALOMID ........................... 17 THEO-24 .............................. 152 theochron .............................. 152 theophylline .......................... 152 thermazene .............................. 58 THIOLA ................................. 73 thioridazine ............................. 42
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thiothixene .............................. 42 THYROLAR-1 ..................... 115 THYROLAR-1/2 .................. 115 THYROLAR-1/4 .................. 115 THYROLAR-2 ..................... 115 THYROLAR-3 ..................... 115 tiagabine ................................. 21 TIAZAC ................................. 51 ticlopidine ............................... 53 TIGAN ................................. 121 TIKOSYN .............................. 44 tilia fe .................................... 137 timolol maleate ............... 51, 139 TIMOPTIC ........................... 139 TIMOPTIC OCUDOSE (PF)
.......................................... 139 TIMOPTIC-XE .................... 139 TINDAMAX .......................... 10 tinidazole ................................ 11 TIROSINT ............................ 115 tis-u-sol pentalyte ................... 72 TIVICAY ................................. 6 TIVORBEX ............................ 34 tizanidine ................................ 26 TOBI....................................... 11 TOBI PODHALER ................ 11 TOBRADEX ........................ 143 TOBRADEX ST .................. 143 tobramycin ............................ 139 tobramycin in 0.225 % nacl .... 11 TOBRAMYCIN WITH
NEBULIZER ...................... 11 tobramycin-dexamethasone .. 143 TOBREX .............................. 139 TODAY CONTRACEPTIVE
SPONGE .......................... 132 TOFRANIL ............................ 42 TOLAK .................................. 61 tolazamide ............................ 114 tolbutamide ........................... 114 tolcapone ................................ 22 tolmetin................................... 34 tolterodine ............................. 153 TOPAMAX ............................ 21 TOPICORT ............................ 70 topiramate ............................... 21 TOPIRAMATE ...................... 21 TOPROL XL .......................... 51 torsemide ................................ 51
TOUJEO SOLOSTAR ......... 109 TOVIAZ ............................... 153 TRACLEER ......................... 152 TRADJENTA ....................... 114 tramadol .................................. 34 TRAMADOL ......................... 34 tramadol-acetaminophen ........ 34 trandolapril ............................. 51 trandolapril-verapamil ............ 51 tranexamic acid ..................... 132 TRANSDERM-SCOP .......... 121 TRANXENE T-TAB .............. 42 tranylcypromine...................... 42 TRAVATAN Z..................... 142 trazodone ................................ 42 TRECATOR ........................... 11 TRESIBA FLEXTOUCH U-100
.......................................... 109 TRESIBA FLEXTOUCH U-200
.......................................... 109 tretinoin .................................. 65 tretinoin (chemotherapy) ........ 17 tretinoin microspheres ............ 65 TRETIN-X.............................. 65 TRETIN-X CREAM KIT ....... 65 TREXALL .............................. 17 TREXIMET ............................ 24 TREZIX .................................. 30 tri femynor ............................ 137 TRIACETIN ........................... 67 triamcinolone acetonide .. 70, 75,
152 triamterene-hydrochlorothiazid
............................................ 51 trianex ..................................... 71 triazolam ................................. 42 TRIBENZOR.......................... 51 tricitrates ............................... 155 TRICOR ................................. 54 triderm .................................... 71 TRIDESILON ........................ 71 tri-estarylla............................ 137 trifluoperazine ........................ 42 trifluridine ............................. 139 TRIGLIDE.............................. 55 trihexyphenidyl ....................... 22 tri-legest fe ............................ 137 TRILEPTAL ........................... 21 tri-linyah ............................... 137
TRILIPIX ............................... 55 tri-lo-estarylla ....................... 137 tri-lo-marzia .......................... 137 tri-lo-sprintec ........................ 137 trilyte with flavor packets ..... 121 trimethobenzamide ............... 121 trimethoprim ........................... 14 trimipramine ........................... 42 trinessa (28) .......................... 137 trinessa lo .............................. 137 TRI-NORINYL (28) ............. 137 TRINTELLIX ......................... 42 TRIPLE DYE ......................... 68 tri-previfem (28) ................... 137 tri-sprintec (28) ..................... 137 TRIUMEQ ................................ 6 tri-vit with fluoride and iron . 159 tri-vitamin with fluoride ....... 159 trivora (28) ............................ 137 TRIZIVIR ................................. 6 TROKENDI XR ..................... 21 tropicamide ........................... 140 trospium ................................ 154 TRUE METRIX AIR
GLUCOSE METER ......... 106 TRUE METRIX GLUCOSE
METER............................. 106 TRUE METRIX GLUCOSE
TEST STRIP ....................... 85 TRUE METRIX GO
GLUCOSE METER ......... 106 TRUE METRIX LEVEL 1 ... 106 TRUE2GO BLOOD GLUCOSE
SYSTEM .......................... 106 TRUECONTROL LEVEL 0 107 TRUERESULT BLOOD
GLUCOSE SYSTM ......... 107 TRUETEST LOW GLUCOSE
CONTROL ....................... 107 TRUETEST TEST STRIPS ... 85 TRUETRACK BLOOD
GLUCOSE SYSTEM ....... 107 TRUETRACK SMART
SYSTEM .......................... 107 TRUETRACK TEST.............. 85 TRULANCE ......................... 121 TRULICITY ......................... 114 TRUSOPT ............................ 142 TRUVADA............................... 6
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TUDORZA PRESSAIR ....... 152 tusnel c .................................. 147 TUSNEL PEDIATRIC ......... 147 TUSSICAPS ......................... 147 tussigon................................. 147 TUSSIONEX PENNKINETIC
ER ..................................... 147 TUZISTRA XR .................... 147 TWYNSTA ............................ 51 TYBOST .................................. 6 TYKERB ................................ 17 TYLENOL-CODEINE #3...... 30 TYLENOL-CODEINE #4...... 30 TYMLOS ............................. 127 TYZINE ................................. 75 U UCERIS ................................ 121 ULESFIA ............................... 71 ULORIC ............................... 126 ULTIMA MONITOR ........... 107 ULTIMA TEST STRIPS ........ 85 ULTRACET ........................... 34 ULTRAM ............................... 34 ULTRAM ER ......................... 34 ULTRASAL-ER ..................... 59 ULTRATRAK ........................ 85 ULTRATRAK GLUCOSE
METER ............................ 107 ULTRATRAK ULTIMATE . 85,
107 ULTRAVATE ........................ 71 ULTRAVATE X .................... 71 umecta .................................... 61 UNISTRIP LOW CONTROL
.......................................... 108 UNISTRIP1 TEST STRIP ..... 85 unithroid ............................... 115 UPTRAVI............................... 51 ur n-c .................................... 155 uramit mb ............................. 155 urea ......................................... 61 urea nail stick ......................... 61 URECHOLINE .................... 154 URELLE ............................... 155 uretron d-s ............................ 155 URIBEL ............................... 155 urimar-t ................................. 155 urin ds ................................... 155 uro-458 ................................. 155
UROCIT-K 10 ...................... 155 UROCIT-K 15 ...................... 155 UROCIT-K 5 ........................ 155 urogesic-blue ........................ 155 uro-mp .................................. 155 urophen mb ........................... 155 UROQID-ACID NO.2.......... 155 UROXATRAL ..................... 154 URSO 250 ............................ 121 URSO FORTE ...................... 122 ursodiol ................................. 122 uryl........................................ 155 ustell ..................................... 155 UTA ...................................... 155 UTIBRON NEOHALER ...... 152 utira-c.................................... 155 UTOPIC.................................. 61 V VAGIFEM ............................ 131 vaginal contraceptive foam .. 132 valacyclovir .............................. 6 VALCHLOR .......................... 61 VALCYTE ............................... 6 valganciclovir ........................... 6 VALIUM ................................ 42 valproic acid ........................... 21 valproic acid (as sodium salt) . 21 valsartan.................................. 51 valsartan-hydrochlorothiazide 51 VALTREX ............................... 6 VANATOL LQ ...................... 30 VANCOCIN ........................... 14 vancomycin ............................ 14 vandazole .............................. 132 VANOS .................................. 71 VANOXIDE-HC .................... 65 VARUBI ............................... 122 VASCEPA .............................. 55 VASERETIC .......................... 51 VASHE WOUND THERAPY
............................................ 72 VASOTEC.............................. 51 VCF CONTRACEPTIVE FILM
.......................................... 132 VCF CONTRACEPTIVE GEL
.......................................... 132 VECAMYL ............................ 55 VECTICAL ............................ 58
velivet triphasic regimen (28) .......................................... 137
VELPHORO ......................... 122 VELTASSA .......................... 122 VELTIN .................................. 65 VEMLIDY ................................ 6 VENCLEXTA ........................ 18 VENCLEXTA STARTING
PACK ................................. 18 venlafaxine ....................... 42, 43 VENTAVIS .......................... 152 VENTOLIN HFA ................. 152 verapamil ................................ 51 VERDESO .............................. 71 verdrocet ................................. 30 VEREGEN ............................. 61 VERELAN ............................. 51 VERELAN PM ....................... 51 veripred 20 .............................. 77 VERSACLOZ......................... 43 VESICARE........................... 154 vestura (28) ........................... 137 VFEND ..................................... 3 VIAGRA............................... 155 VIBERZI .............................. 122 VIBRAMYCIN ...................... 13 vicodin .................................... 30 vicodin es ................................ 30 vicodin hp ............................... 30 VICTOZA 2-PAK ................ 114 VICTOZA 3-PAK ................ 114 VIDEX 2 GRAM PEDIATRIC 6 VIDEX EC................................ 6 VIEKIRA PAK ......................... 6 VIEKIRA XR ........................... 6 vienva ................................... 137 VIGAMOX ........................... 139 VIIBRYD ............................... 43 VIMOVO ................................ 34 VIMPAT ................................. 21 VIOKACE ............................ 122 viorele (28) ........................... 137 VIRACEPT............................... 6 VIRAMUNE............................. 6 VIRAMUNE XR ...................... 6 VIRASAL ............................... 59 VIRAZOLE .............................. 7 VIREAD ................................... 7 VIROPTIC ............................ 139
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virt-phos 250 neutral ............ 157 virtrate-2 ............................... 156 virtrate-3 ............................... 156 virtrate-k ............................... 156 virtussin ac ............................ 147 virtussin dac .......................... 147 VIRT-VITE PLUS ............... 159 VISTARIL ............................ 145 VISTOGARD ......................... 14 vitajoy daily d ....................... 159 vitamin d3 ............................. 159 vitamins a,c,d and fluoride ... 159 VITUZ .................................. 147 VIVELLE-DOT ................... 131 VIVLODEX ........................... 34 VOGELXO ........................... 111 VOLTAREN .......................... 34 VOLTAREN-XR ................... 34 voriconazole ............................. 3 VOTRIENT ............................ 18 VRAYLAR............................. 43 VUSION ................................. 68 vyfemla (28) ......................... 138 VYTORIN 10-10.................... 55 VYTORIN 10-20.................... 55 VYTORIN 10-40.................... 55 VYTORIN 10-80.................... 55 VYVANSE ............................. 43 W warfarin .................................. 53 water for irrigation, sterile ...... 73 WAVESENSE AMP ............ 108 WAVESENSE CONTROL
SOLUTION ...................... 108 WAVESENSE JAZZ ............. 86 WAVESENSE PRESTO 86, 108 WELCHOL ............................ 55 WELLBUTRIN SR ................ 43 WELLBUTRIN XL ................ 43 wera (28) .............................. 138 westhroid .............................. 115 WIDE-SEAL DIAPHRAGM
.......................................... 129 WP THYROID ..................... 115 wymzya fe ............................ 138 X XADAGO............................... 22 XALATAN ........................... 142 XALKORI .............................. 18
XANAX.................................. 43 XANAX XR ........................... 43 XARELTO ............................. 53 XATMEP................................ 18 XCLAIR ................................. 61 XELJANZ ............................ 128 XELJANZ XR ...................... 128 XELODA................................ 18 XENAZINE ............................ 25 XERESE ................................. 68 XIFAXAN .............................. 11 XIGDUO XR ........................ 114 XIIDRA ................................ 141 XODOL 10/300 ...................... 30 XODOL 5/300 ........................ 30 XODOL 7.5/300 ..................... 30 XOLEGEL.............................. 68 XOPENEX ........................... 152 XOPENEX CONCENTRATE
.......................................... 152 XOPENEX HFA .................. 152 XTAMPZA ER ...................... 30 XTANDI ................................. 18 xulane ................................... 132 XULTOPHY 100/3.6 ........... 109 XURIDEN .............................. 73 xylon 10 .................................. 30 XYREM.................................. 43 Y YASMIN (28) ...................... 138 YAZ (28) .............................. 138 YOSPRALA ........................... 53 yuvafem ................................ 131 Z zafirlukast ............................. 152 zaleplon .................................. 43 zamicet.................................... 30 ZANABIN .............................. 61 ZANAFLEX ........................... 26 ZANTAC .............................. 124 zarah ..................................... 138 ZARONTIN............................ 21 ZAVESCA............................ 111 zebutal .................................... 31 ZEGERID ............................. 124 ZELAPAR .............................. 22 ZELBORAF ........................... 18 ZEMBRACE SYMTOUCH ... 24 ZEMPLAR ........................... 111
zenatane .................................. 65 zenchent (28) ........................ 138 zenchent fe ............................ 138 zencia ...................................... 65 ZENPEP ............................... 122 zenzedi .................................... 43 ZENZEDI ............................... 43 ZEPATIER ............................... 7 ZERIT ....................................... 7 ZESTORETIC ........................ 51 ZESTRIL ................................ 51 ZETIA..................................... 55 ZETONNA ........................... 153 ZIAC ....................................... 51 ZIAGEN ................................... 7 ZIANA .................................... 65 zidovudine ................................ 7 zileuton ................................. 153 ZINBRYTA .......................... 126 ZIOPTAN (PF) ..................... 142 ziprasidone hcl ........................ 43 ZIPSOR .................................. 34 ZIRGAN ............................... 139 ZITHRANOL ......................... 58 ZITHROMAX .......................... 8 ZITHROMAX TRI-PAK ......... 8 ZITHROMAX Z-PAK ............. 8 ZMAX ...................................... 8 ZOCOR................................... 55 ZODRYL AC 25 .................. 147 ZODRYL AC 30 .................. 147 ZODRYL AC 35 .................. 147 ZODRYL AC 40 .................. 147 ZODRYL AC 50 .................. 147 ZODRYL AC 60 .................. 148 ZODRYL AC 80 .................. 148 ZODRYL DAC 25 ............... 148 ZODRYL DAC 30 ............... 148 ZODRYL DAC 35 ............... 148 ZODRYL DAC 40 ............... 148 ZODRYL DAC 50 ............... 148 ZODRYL DAC 60 ............... 148 ZODRYL DAC 80 ............... 148 ZODRYL DEC 25 ................ 148 ZODRYL DEC 30 ................ 148 ZODRYL DEC 35 ................ 148 ZODRYL DEC 40 ................ 148 ZODRYL DEC 50 ................ 148 ZODRYL DEC 60 ................ 148
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ZODRYL DEC 80 ................ 148 ZOFRAN (AS
HYDROCHLORIDE) ...... 122 ZOFRAN ODT ..................... 122 ZOHYDRO ER ...................... 31 ZOLINZA ............................... 18 zolmitriptan ............................ 24 ZOLOFT................................. 43 zolpidem ................................. 43 ZOLPIMIST ........................... 43 ZOMACTON ....................... 124 ZOMIG ................................... 24 ZOMIG ZMT ......................... 24 ZONALON ............................. 61
ZONEGRAN .......................... 21 zonisamide .............................. 21 ZONTIVITY .......................... 53 ZORBTIVE .......................... 124 ZORTRESS ............................ 18 ZORVOLEX .......................... 34 zovia 1/35e (28) .................... 138 zovia 1/50e (28) .................... 138 ZOVIRAX .......................... 7, 68 Z-TUSS AC .......................... 148 ZUBSOLV.............................. 34 ZUPLENZ ............................ 122 ZURAMPIC ......................... 126 ZUTRIPRO .......................... 148
ZYBAN .................................. 74 ZYCLARA ........................... 126 ZYDELIG ............................... 18 ZYFLO ................................. 153 ZYFLO CR ........................... 153 ZYKADIA .............................. 18 ZYLET ................................. 143 ZYLOPRIM .......................... 126 ZYMAXID ........................... 139 ZYPREXA .............................. 43 ZYPREXA ZYDIS ................. 43 ZYTIGA ................................. 18 ZYVOX .................................. 11