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Pharmacy Program
California Health & Wellness is committed to providing appropriate, high quality, and cost effective drug therapy to all California Health & Wellness members. California Health & Wellness works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. California Health & Wellness covers prescription medications and certain over-the-counter (OTC) medications when ordered by a licensed practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.
Preferred Drug List
The California Health & Wellness Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at retail pharmacies. The California Health & Wellness PDL is continually evaluated by the California Health & Wellness Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the California Health & Wellness Medical Director, California Health & Wellness Pharmacy Director, and several California physicians, pharmacists, and other healthcare professionals.
Pharmacy Benefit Manager
California Health & Wellness works with US Script to process pharmacy claims for prescribed drugs. Some drugs on the California Health & Wellness PDL may require PA and US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager.
Specialty Drugs
Certain medications are only covered when supplied by California Health & Wellness specialty pharmacy provider. AcariaHealth is the preferred specialty pharmacy provider of California Health & Wellness. All specialty drugs, such as biopharmaceuticals and injectables, require PA to be approved for payment by California Health & Wellness. The California Health & Wellness Medical Director and California Health & Wellness Pharmacy Director oversee the clinical review of these PA request.
AcariaHealth provides the following services:
A dedicated, multilingual team available 24 hours a day, 7 days a week to meet the unique needs of each patient
Disease-specific product education and training
Customized treatment programs and compliance monitoring
Prior authorization support
Timely delivery to your office or the patient’s home, as requested
Dispensing Limits
Drugs may be dispensed up to a maximum of thirty (30) days supply for each new prescription or refill. A total of 85% of the days supply must have elapsed before the prescription can be refilled for all drugs.
Prior Authorizations
Some medications listed on the California Health & Wellness PDL may require PA. The information should be submitted by the practitioner or pharmacist to US Script on the Medication Prior Authorization Form. This form should be faxed to US Script at 1-866-399-0929. This document can be found on the California Health & Wellness website.
California Health & Wellness will cover the medication if it is determined that:
1. There is a medical reason the member needs the specific medication.
2. Depending on the medication, other medications on the PDL have not worked.
Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the California Health & Wellness P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, California Health & Wellness will notify the member and their practitioner of alternatives and provide information regarding the appeal process.
Step Therapy
Some medications listed on the California Health & Wellness PDL may require specific medications to be used before the member can receive the step therapy medication. If California Health & Wellness has a record that the required medication was tried first the step therapy medications are automatically covered. If California Health & Wellness does not have a record that the required medication was tried, the member’s practitioner may be required to provide additional information. If authorization is not granted, California Health & Wellness will notify the member and their practitioner and provide information regarding the appeal process.
Quantity Limits
California Health & Wellness may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a PA may be requested. If California Health & Wellness does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.
Age Limits
Some medications on the California Health & Wellness PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.
Medical Necessity Requests
If the member requires a medication that does not appear on the PDL, the member’s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare as the PDL medications are appropriate to treat the vast majority of medical conditions.
For a MN request California Health & Wellness requires:
Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or
Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or
Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication.
These requests are reviewed by a licensed clinical pharmacist using the criteria established by the California Health & Wellness P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, California Health & Wellness will notify the member and their practitioner of alternatives and provide information regarding the appeal process.
72 Hour Emergency Supply Policy
State and Federal law require that a pharmacy dispense a 72 hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72 hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call US Script at 877-277-0413 for a prescription override to submit the 72 hour medication supply for payment.
Exclusions
The following drug categories are not part of the California Health & Wellness PDL and are not covered by the 72 hour emergency supply policy:
Drugs that are considered experimental
Drug Efficacy Study and Implementation (DESI) drugs
- Drugs prescribed for infertility
- Drugs prescribed for erectile dysfunction - Drugs prescribed for cosmetic purposes or hair growth -Over-the-counter (OTC) cough and cold preparations -Over-the-counter adult acetaminophen products
- Drugs carved-out of the California Health & Wellness contract with the DHCS (TARs/claims submitted to Medi-Cal Fee-For-Service directly)
o Select HIV AIDS treatment drugs
o Select alcohol and heroin detoxification and dependency treatment
o Select psychiatric drugs
Newly Approved Products
California Health & Wellness reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If California Health & Wellness does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.
Over-the-Counter Medications
California Health & Wellness covers a variety of OTC medications. These medications can be found throughout the California Health & Wellness PDL. California Health & Wellness covers OTC products listed in the PDL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.
Generic Drugs
When generic drugs are available, the brand name drug will not be covered without California Health & Wellness authorization. Generic drugs have the same active ingredient and work the same as brand name drugs. If the member or their practitioner feels a brand name drug is medically necessary, the practitioner requests the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If California Health & Wellness does not grant authorization, we will notify the member and their practitioner and provide information regarding the appeal process.
The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Carbamazepine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-Thyroxine, Lithium, Phenytoin, Procainamide, Theophylline, Thyroid, Valproic Acid, and Warfarin.
Drug Efficacy Study and Implementation Drugs
DESI products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by California Health & Wellness.
Filling a Prescription
A member can have prescriptions filled at a California Health & Wellness network pharmacy. If the member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting California Health & Wellness Member Services. At the pharmacy the member will need to provide the pharmacist with the prescription and their California Health & Wellness ID card.
Copayments
Copayments are not required for California Health & Wellness Medi-Cal members.
Abbreviations
The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column.
DS/DU: Days Supply per Dosage Unit
Max Days Sply: Maximum Days Supply
Max Fills: Maximum Fills (per a designated time period)
Max Qty: Maximum Quantity (per claim or designated time period)
Min DS: Minimum Days Supply
PA: Prior Authorization
Pkg Size: Package Size
Contact Information
California Health & Wellness Provider Services: 1-877-658-0305
US Script Prior Authorizations: 1-877-277-0413 Fax: 1-866-399-0929
US Script Help Desk: 1-855-330-2338
AcariaHealth Prior Authorizations: 1-855-535-1815 Fax: 1-855-815-9894
Provider Administered Drug Prior Authorizations 1-877-658-0305 Fax: 1-877-259-6961
Tier Description
F Preferred Drugs
NF Non-formulary
CO Carve Out Drugs
Legend Description AL Age Limit Drug is limited to specific age.
PA Prior Authorization Prior Authorization required before prescription can be filled.
QL Quantity Limit There is a limit on the amount of drug covered per prescription, or within a specific time frame.
Rx/OTC Rx/OTC Product has both Rx and OTC National Drug Codes.
SP Specialty Drug
Specialty drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia and may be limited to a specific
pharmacy.
ST Step Therapy Requires trial and failure of one or more preferred products prior to coverage.
Drug Name DrugTier
Requirements/Limits
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating Disorders
Amphetamines ADDERALL TABS (Use Amphetamine-Dextroamphetamine)
NF QL(2 ea daily);AL; At least 3 yrs old
ADDERALL XR CP24 (Use Amphetamine-Dextroamphetamine)
NF QL(1 ea daily);AL; At least 6 yrs old
amphetamine-dextroamphetamine cp245mg-5mg-5mg-5mg,2.5mg-2.5mg-2.5mg-2.5mg, 7.5mg-7.5mg-7.5mg-7.5mg, 1.25mg-1.25mg-1.25mg-1.25mg,3.75mg-3.75mg-3.75mg-3.75mg, 6.25mg-6.25mg-6.25mg-6.25mg
F
QL(1 ea daily);AL; At least 6 yrs old
amphetamine-dextroamphetamine tabs5mg-5mg-5mg-5mg,2.5mg-2.5mg-2.5mg-2.5mg, 7.5mg-7.5mg-7.5mg-7.5mg, 1.25mg-1.25mg-1.25mg-1.25mg,3.75mg-3.75mg-3.75mg-3.75mg, 1.875mg-1.875mg-1.875mg-1.875mg, 3.125mg-3.125mg-3.125mg-3.125mg
F
QL(2 ea daily);AL; At least 3 yrs old
DEXEDRINE CP24 10 MG, 15 MG (Use DextroamphetamineSulfate)
NF
QL(2 ea daily);AL; At least 6 yrs old
DEXEDRINE CP24 5 MG (Use DextroamphetamineSulfate)
NF QL(1 ea daily);AL; At least 6 yrs old
dextroamphetamine sulfatecp24 10 mg, 15 mg F
QL(2 ea daily);AL; At least 6 yrs old
dextroamphetamine sulfatecp24 5 mg F
QL(1 ea daily);AL; At least 6 yrs old
dextroamphetamine sulfatetabs 5 mg, 10 mg F
QL(3 ea daily);AL; At least 3 yrs old
Drug Name DrugTier
Requirements/Limits
VYVANSE CAPS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG
F PA; QL(1 eadaily)
Analeptics
caffeine citrate soln F QL(45 ml perfill retail)
Attention-Deficit/Hyperactivity Disorder (ADHD)
atomoxetine hcl caps F ST; AL; At least 6 yrs old
clonidine hcl (adhd) tb12 F
guanfacine hcl (adhd) tb24 F QL(1 ea daily);AL; At least 6 yrs old
INTUNIV TB24 (Use Guanfacine HCl (ADHD)) NF
QL(1 ea daily);AL; At least 6 yrs old
KAPVAY TB12 (Use Clonidine HCl (ADHD)) NF
STRATTERA CAPS (Use Atomoxetine HCl) NF ST; AL; At least
6 yrs old
Stimulants - Misc. CONCERTA TBCR 18 MG, 27 MG, 54 MG (Use Methylphenidate HCl)
NF QL(1 ea daily);AL; At least 6 yrs old
CONCERTA TBCR 36 MG (Use Methylphenidate HCl) NF
QL(2 ea daily);AL; At least 6 yrs old
dexmethylphenidate hcltabs 5 mg, 10 mg, 2.5 mg F
QL(2 ea daily);AL; At least 6 yrs old
FOCALIN TABS (Use Dexmethylphenidate HCl) NF
QL(2 ea daily);AL; At least 6 yrs old
METADATE CD CPCR (Use Methylphenidate HCl) NF
QL(1 ea daily);AL; At least 6 yrs old
methylphenidate hcl cpcr10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg
F QL(1 ea daily);AL; At least 6 yrs old
METHYLPHENIDATE HCL ER TB24 18 MG, 27 MG F
QL(1 ea daily);AL; At least 6 yrs old
METHYLPHENIDATE HCL ER TB24 36 MG, 54 MG F AL; At least 6
yrs old
CA Health & Wellness Preferred Drug List Update July 1, 2018
1
Drug Name DrugTier
Requirements/Limits
METHYLPHENIDATE HCL ER TBCR 18 MG F
QL(1 ea daily);AL; At least 6 yrs old
methylphenidate hcl tabs10 mg, 20 mg F
QL(3 ea daily);AL; At least 3 yrs old
methylphenidate hcl tabs 5 mg F
QL(6 ea daily);AL; At least 3 yrs old
methylphenidate hcl tbcr 10mg, 36 mg F
QL(2 ea daily);AL; At least 6 yrs old
methylphenidate hcl tbcr 18mg, 27 mg, 54 mg F
QL(1 ea daily);AL; At least 6 yrs old
methylphenidate hcl tbcr 20 mg F AL; At least 6
yrs old RITALIN TABS 10 MG, 20 MG (Use MethylphenidateHCl)
NF QL(3 ea daily);AL; At least 3 yrs old
RITALIN TABS 5 MG (Use Methylphenidate HCl) NF
QL(6 ea daily);AL; At least 3 yrs old
AMINOGLYCOSIDES - Drugs to Treat BacterialInfections
Aminoglycosides
KITABIS PAK NEBU F PA; SP
neomycin sulfate tabs F
paromomycin sulfate caps F PA
TOBI NEBU (Use Tobramycin) NF PA; SP
tobramycin nebu F PA; SP
TOBRAMYCIN NEBU F PA; SP
TOBRAMYCIN SULFATE SOLN 10 MG/ML, 40MG/ML
F PA
tobramycin sulfate soln 40mg/ml, 80 mg/2ml, 1.2gm/30ml
F PA
tobramycin sulfate solr 1.2 gm F PA
Drug Name DrugTier
Requirements/Limits
ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditions
Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT
F PA; SP
HUMIRA PEN PNKT F PA; SP
HUMIRA PEN-CROHNS DISEASESTARTER PNKT F PA; SP
HUMIRA PEN-PSORIASIS STARTER PNKT F PA; SP
HUMIRA PSKT 20 MG/0.4ML, 40 MG/0.8ML F PA; SP
Antirheumatic Antimetabolites
RHEUMATREX TABS F
Gold Compounds
RIDAURA CAPS F
Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL TABS (Use Ibuprofen) NF
ALEVE ARTHRITIS TABS (Use Naproxen Sodium) NF
ALEVE TABS (Use Naproxen Sodium) NF
ANAPROX DS TABS (Use Naproxen Sodium) NF
CELEBREX CAPS (Use Celecoxib) NF PA; QL(2 ea
daily)
celecoxib caps F PA; QL(2 eadaily)
CHILDRENS ADVIL SUSP (Use Ibuprofen) NF RX/OTC
CHILDRENS MOTRIN SUSP (Use Ibuprofen) NF RX/OTC
DAYPRO TABS (Use Oxaprozin) NF
diclofenac potassium tabs F
diclofenac sodium tb24 or 100 mg F
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
diclofenac sodium tbec or 25 mg, 50 mg, 75 mg F
EC-NAPROSYN TBEC (Use Naproxen) NF QL(2 ea daily)
etodolac caps F
etodolac tabs F
etodolac tb24 F
FELDENE CAPS (Use Piroxicam) NF
flurbiprofen tabs F
ibuprofen chew 100 mg F
ibuprofen susp 100 mg/5ml F RX/OTC
ibuprofen susp 40 mg/ml,50 mg/1.25ml F
ibuprofen tabs 200 mg, 400mg, 600 mg, 800 mg F
indomethacin caps F
indomethacin cpcr F
INFANTS ADVIL SUSP (Use Ibuprofen) NF
KETOPROFEN CAPS 50 MG, 75 MG F
ketoprofen caps 50 mg, 75 mg F
KETOPROFEN ER CP24 F
ketorolac tromethamine tabs or 10 mg F AL; At least 17
yrs old LODINE TABS (Use Etodolac) NF
meloxicam tabs F
MOBIC TABS 15 MG, 7.5 MG (Use Meloxicam) NF
MOTRIN INFANTS DROPS SUSP (Use Ibuprofen)
NF
nabumetone tabs F
Drug Name DrugTier
Requirements/Limits
NAPROSYN SUSP (Use Naproxen) NF
NAPROSYN TABS (Use Naproxen) NF
naproxen sodium tabs 220mg, 275 mg, 550 mg F
naproxen susp 125 mg/5ml F
naproxen tabs 250 mg, 375mg, 500 mg F
naproxen tbec 375 mg, 500 mg F QL(2 ea daily)
oxaprozin tabs F
piroxicam caps F
sulindac tabs F
TOLMETIN SODIUM CAPS F
TOLMETIN SODIUM TABS F
Pyrimidine Synthesis Inhibitors ARAVA TABS (Use Leflunomide) NF QL(1 ea daily)
leflunomide tabs F QL(1 ea daily)
Soluble Tumor Necrosis Factor Receptor Agents
ENBREL SOLR F PA; SP
ENBREL SOSY F PA; SP
ENBREL SURECLICK SOAJ F PA; SP
ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions
Analgesic Combinations butalbital-acetaminophentabs 325mg-50mg F
butalbital-acetaminophen-caffeine caps 325mg-50mg-40mg
F QL(4 ea daily)
butalbital-acetaminophen-caffeine tabs 325mg-50mg-40mg
F QL(4 ea daily)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
butalbital-aspirin-caffeine caps F QL(4 ea daily)
ESGIC TABS (Use Butalbital-Acetaminophen-Caffeine)
NF QL(4 ea daily)
FIORINAL CAPS (Use Butalbital-Aspirin-Caffeine) NF QL(4 ea daily)
TENCON TABS F
Analgesics Other acetaminophen elix or 160mg/5ml, 80 mg/2.5ml F
acetaminophen liqd or 160mg/5ml F
acetaminophen soln or 160mg/5ml, 650 mg/20.3ml,325 mg/10.15ml
F
acetaminophen supp re120 mg F
acetaminophen susp or160 mg/5ml, 80 mg/0.8ml,80 mg/2.5ml
F
NORTEMP INFANTS SUSP F
TYLENOL CHILDRENS SUSP (Use Acetaminophen)
NF
TYLENOL INFANTS PAIN+FEVER SUSP (Use Acetaminophen)
NF
TYLENOL INFANTS SUSP (Use Acetaminophen) NF
Salicylates aspirin buffered (cal carb-mag carb-mag oxide) tabs F
aspirin chew or 81 mg F
ASPIRIN SUPP RE 300 MG, 600 MG F
aspirin supp re 300 mg,600 mg F
aspirin tabs or 325 mg F
aspirin tbec or 81 mg, 324mg, 325 mg, 500 mg F
Drug Name DrugTier
Requirements/Limits
BUFFERIN TABS (Use Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide))
NF
choline & mag salicylateliqd F
diflunisal tabs F
DISALCID TABS (Use Salsalate) NF
ECOTRIN MAXIMUM STRENGTH TBEC (Use Aspirin)
NF
ECOTRIN REGULAR STRENGTH TBEC (Use Aspirin)
NF
salsalate tabs F
ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint Conditions
Opioid Agonists codeine sulfate tabs 15 mg,30mg, 60mg F QL (2 ea daily)
DEMEROL TABS OR 100 MG (Use Meperidine HCl) NF QL(6 ea daily)
DILAUDID TABS 2 MG, 4 MG, 8 MG (Use Hydromorphone HCl)
NF QL(8 ea daily)
DOLOPHINE TABS 10 MG (Use Methadone HCl) NF PA; QL(10 ea
daily) DOLOPHINE TABS 5 MG (Use Methadone HCl) NF PA; QL(4 ea
daily) DURAGESIC PT72 (Use Fentanyl) NF QL(0.34 ea
daily) fentanyl pt72 12 mcg/hr, 25mcg/hr, 50 mcg/hr, 75mcg/hr, 100 mcg/hr
F QL(0.34 eadaily)
HYDROMORPHONE HCL SUPP RE 3 MG F QL(12 ea per
fill retail) hydromorphone hcl tabs or2 mg, 4 mg, 8 mg F QL(8 ea daily)
MEPERIDINE HCL SOLN OR 50 MG/5ML F QL(500 ml per
fill retail) meperidine hcl tabs or 50mg, 100 mg F QL(6 ea daily)
methadone hcl tabs or 10 mg F PA; QL(10 ea
daily)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
methadone hcl tabs or 5 mg F PA; QL(4 ea
daily) morphine sulfate soln or 10mg/5ml, 20 mg/5ml F QL(500 ml per
fill retail) morphine sulfate soln or 20mg/ml, 100 mg/5ml F QL(240 ml per
fill retail) MORPHINE SULFATE SUPP RE 5 MG, 10 MG, 20 MG, 30 MG
F QL(24 ea perfill retail)
MORPHINE SULFATE TABS OR 15 MG, 30 MG F QL(6 ea daily)
morphine sulfate tbcr or 15mg, 30 mg, 60 mg, 100 mg,200 mg
F QL(3 ea daily)
MS CONTIN TBCR (Use Morphine Sulfate) NF QL(3 ea daily)
oxycodone hcl caps 5 mg F QL(6 ea daily)
oxycodone hcl conc 100mg/5ml F QL(6 ml daily)
OXYCODONE HCL ER T12A F PA; QL(2 ea
daily) oxycodone hcl soln 5mg/5ml F
oxycodone hcl tabs 5 mg,10 mg, 15 mg, 20 mg, 30 mg
F QL(6 ea daily)
ROXICODONE TABS (Use Oxycodone HCl) NF QL(6 ea daily)
tramadol hcl tabs 50 mg F QL(8 ea daily)
ULTRAM TABS (Use Tramadol HCl) NF QL(8 ea daily)
Opioid Combinations acetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml F QL(30 ml daily)
acetaminophen w/ codeinetabs 300mg-15mg, 300mg-30mg, 300mg-60mg
F QL(6 ea daily)
butalbital-acetaminophen-caffeine w/ codeine caps325mg-50mg-40mg-30mg
F QL(4 ea daily)
butalbital-aspirin-caffeinew/cod caps F QL(4 ea daily)
Drug Name DrugTier
Requirements/Limits
FIORINAL/CODEINE #3CAPS (Use Butalbital-Aspirin-Caffeine w/Cod)
NF QL(4 ea daily)
hydrocodone-acetaminophen soln2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml
F
QL(180 mldaily)
hydrocodone-acetaminophen tabs 10mg-325mg
F QL(6 ea daily)
hydrocodone-acetaminophen tabs 5mg-325mg
F QL(12 ea daily)
hydrocodone-acetaminophen tabs7.5mg-325mg
F QL(8 ea daily)
NORCO TABS 10MG-325MG (Use Hydrocodone-Acetaminophen)
NF QL(6 ea daily)
NORCO TABS 5MG-325MG (Use Hydrocodone-Acetaminophen)
NF QL(12 ea daily)
NORCO TABS 7.5MG-325MG (Use Hydrocodone-Acetaminophen)
NF QL(8 ea daily)
oxycodone w/acetaminophen tabs 5mg-325mg, 10mg-325mg,7.5mg-325mg
F
QL(6 ea daily)
oxycodone-aspirin tabs F QL(6 ea daily)
OXYCODONE/ACETAMINOPHEN SOLN F QL(30 ml daily)
PERCOCET TABS 5MG-325MG, 10MG-325MG, 7.5MG-325MG (Use Oxycodone w/Acetaminophen)
NF
QL(6 ea daily)
tramadol-acetaminophentabs F QL(4 ea daily)
TYLENOL/CODEINE #3TABS (Use Acetaminophenw/ Codeine)
NF QL(6 ea daily)
TYLENOL/CODEINE #4TABS (Use Acetaminophenw/ Codeine)
NF QL(6 ea daily)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
ULTRACET TABS (Use Tramadol-Acetaminophen) NF QL(4 ea daily)
Opioid Partial Agonists
BELBUCA FILM CO
BUNAVAIL FILM CO
BUPRENEX SOLN (Use Buprenorphine HCl) CO
buprenorphine hcl soln CO
buprenorphine hcl subl CO
buprenorphine hcl-naloxone hcl dihydrate film CO
buprenorphine hcl-naloxone hcl dihydrate subl CO
BUPRENORPHINE PTWK CO
BUTRANS PTWK CO
PROBUPHINE IMPLANT KIT IMPL CO
SUBLOCADE SOSY CO
SUBOXONE FILM 4MG-1MG, 12MG-3MG, 2MG-0.5MG
CO
SUBOXONE FILM 8MG-2MG (Use BuprenorphineHCl-Naloxone HCl Dihydrate)
CO
ZUBSOLV SUBL CO
ANDROGENS-ANABOLIC - Drugs to RegulateHormones
Androgens
ANDRODERM PT24 F QL(1 ea daily)
ANDROXY TABS F
DEPO-TESTOSTERONE SOLN (Use Testosterone Cypionate)
NF QL(0.134 mldaily)
METHITEST TABS F
Drug Name DrugTier
Requirements/Limits
testosterone cypionate soln F QL(0.134 mldaily)
ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and Itching
Intrarectal Steroids CORTENEMA ENEM (Use Hydrocortisone(Intrarectal))
NF QL(420 ml perfill retail)
hydrocortisone (intrarectal) enem F QL(420 ml per
fill retail) Rectal Combinations phenylephrine-shark liveroil-cocoa butter supp F
phenylephrine-shark liveroil-mineral oil-petrolatumoint
F QL(60 gm perfill retail)
Rectal Local Anesthetics
pramoxine hcl (rectal) foam F
PROCTOFOAM FOAM (Use Pramoxine HCl (Rectal))
NF
Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) NF QL(30 gm per
fill retail) hydrocortisone (rectal) crea2.5 % F QL(30 gm per
fill retail)
ANTACIDS
Antacid Combinations alum & mag hydrox-simethicone liqd200mg/5ml-20mg/5ml-200mg/5ml
F
alum & mag hydrox-simethicone susp200mg/5ml-20mg/5ml-200mg/5ml, 200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml
F
Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR F
Antacids - Bicarbonate
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
sodium bicarbonate (antacid) tabs F
Antacids - Calcium Salts calcium carbonate (antacid) chew 500 mg F
calcium carbonate (antacid) susp 1250mg/5ml
F
TUMS CHEW (Use Calcium Carbonate (Antacid))
NF
TUMS LASTING EFFECTS CHEW (Use Calcium Carbonate (Antacid))
NF
Antacids - Magnesium Salts
magnesium oxide tabs F
ANTHELMINTICS - Drugs to Treat WormInfections
Anthelmintics
EMVERM CHEW F
pyrantel pamoate susp F
ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial Infections
Anti-infective Agents - Misc. FLAGYL TABS 250 MG, 500 MG (Use Metronidazole)
NF
metronidazole tabs or 250 mg, 500 mg F
trimethoprim tabs F
VANCOCIN HCL CAPS 125 MG (Use VancomycinHCl)
NF QL(4 ea daily)
VANCOCIN HCL CAPS 250 MG (Use VancomycinHCl)
NF QL(8 ea daily)
vancomycin hcl caps or125 mg F QL(4 ea daily)
vancomycin hcl caps or250 mg F QL(8 ea daily)
Drug Name DrugTier
Requirements/Limits
vancomycin hcl solr iv 500mg, 1000 mg F QL(14 ea per
fill retail) Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Sulfamethoxazole-Trimethoprim)
NF
BACTRIM TABS (Use Sulfamethoxazole-Trimethoprim)
NF
sulfamethoxazole-trimethoprim susp or40mg/5ml-200mg/5ml
F
sulfamethoxazole-trimethoprim tabs or 80mg-400mg, 160mg-800mg
F
Antiprotozoal Agents
atovaquone susp F PA; QL(10 mldaily)
MEPRON SUSP (Use Atovaquone) NF PA; QL(10 ml
daily) Leprostatics
dapsone tabs F
Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG (Use Clindamycin HCl)
NF
CLEOCIN PEDIATRIC GRANULES SOLR (Use Clindamycin PalmitateHydrochloride)
NF
QL(100 ml perfill retail)
clindamycin hcl caps 150mg, 300 mg F
clindamycin palmitatehydrochloride solr F QL(100 ml per
fill retail) Oxazolidinones
SIVEXTRO TABS F PA; QL(6 eaper fill retail)
ANTIANGINAL AGENTS - Drugs to Treat ChestPain
Nitrates ISORDIL TITRADOSE TABS 5 MG (Use Isosorbide Dinitrate)
NF
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Drug Name DrugTier
Requirements/Limits
ISOSORBIDE DINITRATE ER TBCR F
isosorbide dinitrate tabs F
isosorbide mononitrate tabs 10 mg, 20 mg F QL(2 ea daily)
isosorbide mononitrate tb24 30 mg, 60 mg, 120 mg F QL(1 ea daily)
NITRO-BID OINT F
NITRO-DUR PT24 0.1 MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.6 MG/HR (Use Nitroglycerin)
NF
nitroglycerin cpcr or 9 mg,2.5 mg, 6.5 mg F
nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr
F
nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg F
NITROSTAT SUBL (Use Nitroglycerin) NF
ANTIANXIETY AGENTS - Drugs to Treat Anxiety
Antianxiety Agents - Misc. buspirone hcl tabs 15 mg F QL(4 ea daily)
buspirone hcl tabs 30 mg,7.5 mg F QL(3 ea daily)
buspirone hcl tabs 5 mg,10 mg F QL(6 ea daily)
hydroxyzine hcl syrp F
hydroxyzine hcl tabs F
HYDROXYZINE PAMOATE CAPS 100 MG F
hydroxyzine pamoate caps25 mg, 50 mg F
meprobamate tabs F
VISTARIL CAPS (Use Hydroxyzine Pamoate) NF
Benzodiazepines alprazolam tabs 0.25 mg,0.5 mg, 1 mg, 2 mg F QL(4 ea daily)
Drug Name DrugTier
Requirements/Limits
ATIVAN TABS 0.5 MG, 2 MG (Use Lorazepam) NF QL(3 ea daily)
ATIVAN TABS 1 MG (Use Lorazepam) NF QL(4 ea daily)
chlordiazepoxide hcl caps F QL(4 ea daily)
clorazepate dipotassiumtabs F QL(3 ea daily)
DIAZEPAM SOLN OR 1 MG/ML F QL(500 ml per
fill retail) diazepam tabs or 2 mg, 5mg, 10 mg F QL(4 ea daily)
lorazepam tabs 0.5 mg, 2 mg F QL(3 ea daily)
lorazepam tabs 1 mg F QL(4 ea daily)
oxazepam caps 10 mg, 15mg, 30 mg F QL(4 ea daily)
OXAZEPAM CAPS 30 MG F QL(4 ea daily)
TRANXENE T TABS (Use Clorazepate Dipotassium) NF QL(3 ea daily)
VALIUM TABS (Use Diazepam) NF QL(4 ea daily)
XANAX TABS (Use Alprazolam) NF QL(4 ea daily)
ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms
Antiarrhythmics Type I-A disopyramide phosphate caps F
NORPACE CAPS (Use Disopyramide Phosphate) F
NORPACE CR CP12 150 MG F
quinidine gluconate tbcr or324 mg F
QUINIDINE SULFATE TABS F
Antiarrhythmics Type I-B
mexiletine hcl caps F
Antiarrhythmics Type I-C
flecainide acetate tabs F
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Drug Name DrugTier
Requirements/Limits
propafenone hcl tabs 150mg, 225 mg, 300 mg F
RYTHMOL TABS (Use Propafenone HCl) NF
Antiarrhythmics Type III amiodarone hcl tabs 200 mg F
dofetilide caps F
MULTAQ TABS F
TIKOSYN CAPS (Use Dofetilide) NF
ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions
Anti-Inflammatory Agents
cromolyn sodium nebu F QL(240 ml perfill retail)
Bronchodilators - Anticholinergics
ATROVENT HFA AERS F QL(26 gm perfill retail)
INCRUSE ELLIPTA AEPB F QL(30 ea perfill retail)
ipratropium bromide soln F
TUDORZA PRESSAIR AEPB F QL(1 ea per fill
retail) Leukotriene Modulators
montelukast sodium chew F QL(1 ea daily)
montelukast sodium pack F QL(1 ea daily)
montelukast sodium tabs F QL(1 ea daily)
SINGULAIR CHEW (Use Montelukast Sodium) NF QL(1 ea daily)
SINGULAIR PACK (Use Montelukast Sodium) NF QL(1 ea daily)
SINGULAIR TABS (Use Montelukast Sodium) NF QL(1 ea daily)
Steroid Inhalants
AEROSPAN AERS F QL(8.9 gm perfill retail)
Drug Name DrugTier
Requirements/Limits
budesonide (inhalation) susp F
QL(4 ml daily);AL; At least 1 yrs old - Up to8 yrs old
FLOVENT DISKUS AEPB 100 MCG/BLIST, 250MCG/BLIST
F QL(2 ea daily)
FLOVENT DISKUS AEPB 50 MCG/BLIST F QL(60 ea per
25 days retail)
FLOVENT HFA AERO F
PULMICORT FLEXHALER AEPB F QL(1 ea per fill
retail)
PULMICORT SUSP (Use Budesonide (Inhalation)) NF
QL(4 ml daily);AL; At least 1 yrs old - Up to8 yrs old
Sympathomimetics ALBUTEROL SULFATE ER TB12 F
albuterol sulfate nebu in 0.5 % F QL(2 ml daily)
albuterol sulfate nebu in 0.63 mg/3ml, 0.083 %, 1.25mg/3ml
F
albuterol sulfate syrp or 2mg/5ml F QL(100 ml per
fill retail) albuterol sulfate tabs or 2 mg F QL(150 ea per
fill retail) albuterol sulfate tabs or 4 mg F QL(200 ea per
fill retail) albuterol sulfate tb12 or 4 mg, 8 mg F
BREO ELLIPTA AEPB 25MCG/INH-200MCG/INH F QL(60 ea per
fill retail) COMBIVENT RESPIMAT AERS F QL(4 gm per fill
retail)
DULERA AERO F QL(13 gm perfill retail)
ipratropium-albuterol soln F QL(12 ml daily)
METAPROTERENOL SULFATE SYRP 10 MG/5ML
F QL(30 ml daily)
METAPROTERENOL SULFATE TABS 10 MG, 20 MG
F
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
PROAIR HFA AERS F QL(17 gm per30 days retail)
SEREVENT DISKUS AEPB F QL(2 ea daily)
SYMBICORT AERO F QL(11 gm perfill retail)
terbutaline sulfate tabs F
VENTOLIN HFA AERS F QL(36 gm per30 days retail)
VENTOLIN HFA AERS F QL(16 gm per30 days retail)
VOSPIRE ER TB12 (Use Albuterol Sulfate) NF
Xanthines
ELIXOPHYLLIN ELIX F
THEO-24 CP24 F
theophylline soln 80mg/15ml F QL(475 ml per
fill retail) theophylline tb12 100 mg,200 mg, 300 mg, 450 mg F
theophylline tb24 400 mg,600 mg F
ANTICOAGULANTS - Blood Thinners
Coumarin Anticoagulants COUMADIN TABS (Use Warfarin Sodium) F
warfarin sodium tabs F
Direct Factor Xa Inhibitors ELIQUIS STARTER PACK TABS F QL(4 ea daily)
ELIQUIS TABS F QL(4 ea daily)
XARELTO STARTER PACK TBPK F
XARELTO TABS 10 MG F QL(1 eadaily,35 ea per180 days retail)
XARELTO TABS 15 MG F QL(2 ea daily)
XARELTO TABS 20 MG F QL(1 ea daily)
Drug Name DrugTier
Requirements/Limits
Heparins And Heparinoid-Like Agents
enoxaparin sodium soln F SP
heparin sodium (porcine)soln F
LOVENOX SOLN (Use Enoxaparin Sodium) NF SP
ANTICONVULSANTS - Drugs to Treat Seizures
Anticonvulsants - Benzodiazepines clonazepam tabs 0.5 mg, 1mg, 2 mg F QL(4 ea daily)
DIAZEPAM GEL RE 10 MG, 20 MG, 2.5 MG F
QL(1 ea per fillretail); AL; Atleast 2 yrs old
DIAZEPAM RECTAL GEL GEL F
QL(1 ea per fillretail); AL; Atleast 2 yrs old
KLONOPIN TABS (Use Clonazepam) NF QL(4 ea daily)
Anticonvulsants - Misc. carbamazepine chew 100 mg F
carbamazepine susp 100mg/5ml F
carbamazepine tabs 200 mg F
carbamazepine tb12 100mg, 200 mg, 400 mg F
gabapentin caps 100 mg,300 mg, 400 mg F QL(9 ea daily)
gabapentin soln 250mg/5ml, 300 mg/6ml F
gabapentin tabs 600 mg F QL(6 ea daily)
gabapentin tabs 800 mg F QL(4 ea daily)
KEPPRA SOLN 100 MG/ML (Use Levetiracetam)
NF QL(30 ml daily)
KEPPRA TABS 1000 MG (Use Levetiracetam) NF
KEPPRA TABS 250 MG, 750 MG (Use Levetiracetam)
NF QL(4 ea daily)
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Drug Name DrugTier
Requirements/Limits
KEPPRA TABS 500 MG (Use Levetiracetam) NF QL(6 ea daily)
KEPPRA XR TB24 (Use Levetiracetam) NF ST
LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use Lamotrigine)
NF
LAMICTAL TABS (Use Lamotrigine) NF
LAMICTAL XR TB24 25 MG, 50 MG, 100 MG, 200 MG, 250 MG, 300 MG (Use Lamotrigine)
NF
ST
lamotrigine chew 5 mg, 25 mg F
lamotrigine tabs 25 mg,100 mg, 150 mg, 200 mg F
lamotrigine tb24 25 mg, 50mg, 100 mg, 200 mg, 250mg, 300 mg
F ST
levetiracetam soln 100 mg/ml, 500 mg/5ml F QL(30 ml daily)
levetiracetam tabs 1000 mg F
levetiracetam tabs 250 mg,750 mg F QL(4 ea daily)
levetiracetam tabs 500 mg F QL(6 ea daily)
levetiracetam tb24 500 mg,750 mg F ST
MYSOLINE TABS (Use Primidone) NF
NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use Gabapentin)
NF QL(9 ea daily)
NEURONTIN SOLN 250 MG/5ML (Use Gabapentin) NF
NEURONTIN TABS 600 MG (Use Gabapentin) NF QL(6 ea daily)
NEURONTIN TABS 800 MG (Use Gabapentin) NF QL(4 ea daily)
oxcarbazepine susp F
oxcarbazepine tabs F
primidone tabs F
Drug Name DrugTier
Requirements/Limits
TEGRETOL SUSP (Use Carbamazepine) F
TEGRETOL TABS (Use Carbamazepine) F
TEGRETOL-XR TB12 (Use Carbamazepine) F
TOPAMAX SPRINKLE CPSP 15 MG (Use Topiramate)
NF QL(6 ea daily)
TOPAMAX SPRINKLE CPSP 25 MG (Use Topiramate)
NF QL(8 ea daily)
TOPAMAX TABS 100 MG (Use Topiramate) NF QL(4 ea daily)
TOPAMAX TABS 200 MG (Use Topiramate) NF QL(2 ea daily)
TOPAMAX TABS 25 MG, 50 MG (Use Topiramate) NF QL(6 ea daily)
topiramate cpsp 15 mg F QL(6 ea daily)
topiramate cpsp 25 mg F QL(8 ea daily)
topiramate tabs 100 mg F QL(4 ea daily)
topiramate tabs 200 mg F QL(2 ea daily)
topiramate tabs 25 mg, 50 mg F QL(6 ea daily)
TRILEPTAL SUSP (Use Oxcarbazepine) NF
TRILEPTAL TABS (Use Oxcarbazepine) NF
ZONEGRAN CAPS (Use Zonisamide) NF
zonisamide caps F
Carbamates
felbamate susp F
felbamate tabs F
FELBATOL SUSP (Use Felbamate) NF
FELBATOL TABS (Use Felbamate) NF
GABA Modulators
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Drug Name DrugTier
Requirements/Limits
GABITRIL TABS (Use Tiagabine HCl) NF
tiagabine hcl tabs F
Hydantoins DILANTIN CAPS 100 MG (Use Phenytoin SodiumExtended)
F
DILANTIN CAPS 30 MG F
DILANTIN INFATABS CHEW (Use Phenytoin) F
DILANTIN-125 SUSP (Use Phenytoin) F
phenytoin chew F
phenytoin sodium extendedcaps 100 mg F
phenytoin susp F
Succinimides
ethosuximide caps F
ethosuximide soln F
ZARONTIN CAPS (Use Ethosuximide) F
ZARONTIN SOLN (Use Ethosuximide) F
Valproic Acid DEPAKENE CAPS (Use Valproic Acid) F
DEPAKENE SOLN (Use Valproate Sodium) F
DEPAKOTE ER TB24 (Use Divalproex Sodium) NF
DEPAKOTE SPRINKLES CSDR (Use DivalproexSodium)
NF
DEPAKOTE TBEC (Use Divalproex Sodium) NF
divalproex sodium csdr F
divalproex sodium tb24 F
Drug Name DrugTier
Requirements/Limits
divalproex sodium tbec F
valproate sodium soln F
valproic acid caps F
ANTIDEPRESSANTS - Drugs to TreatDepression
Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 15 mg F QL(3 ea daily)
mirtazapine tabs 30 mg F QL(1.5 eadaily)
mirtazapine tabs 45 mg,7.5 mg F QL(1 ea daily)
mirtazapine tbdp 15 mg F QL(3 ea daily)
mirtazapine tbdp 30 mg F QL(1.5 eadaily)
mirtazapine tbdp 45 mg F QL(1 ea daily)
REMERON SOLTAB TBDP 15 MG (Use Mirtazapine) NF QL(3 ea daily)
REMERON SOLTAB TBDP 30 MG (Use Mirtazapine) NF QL(1.5 ea
daily) REMERON SOLTAB TBDP 45 MG (Use Mirtazapine) NF QL(1 ea daily)
REMERON TABS 15 MG (Use Mirtazapine) NF QL(3 ea daily)
REMERON TABS 30 MG (Use Mirtazapine) NF QL(1.5 ea
daily) REMERON TABS 45 MG (Use Mirtazapine) NF QL(1 ea daily)
Antidepressants - Misc. bupropion hcl tabs 75 mg,100 mg F QL(3 ea daily)
bupropion hcl tb12 100 mg F QL(4 ea daily)
bupropion hcl tb12 150 mg F QL(3 ea daily)
bupropion hcl tb12 200 mg F QL(2 ea daily)
bupropion hcl tb24 150 mg F QL(3 ea daily)
bupropion hcl tb24 300 mg F QL(1 ea daily)
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Drug Name DrugTier
Requirements/Limits
MAPROTILINE HCL TABS F
WELLBUTRIN SR TB12 100 MG (Use BupropionHCl)
NF QL(4 ea daily)
WELLBUTRIN SR TB12 150 MG (Use BupropionHCl)
NF QL(3 ea daily)
WELLBUTRIN SR TB12 200 MG (Use BupropionHCl)
NF QL(2 ea daily)
WELLBUTRIN XL TB24 150 MG (Use BupropionHCl)
NF QL(3 ea daily)
WELLBUTRIN XL TB24 300 MG (Use BupropionHCl)
NF QL(1 ea daily)
Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 CO
MARPLAN TABS CO
NARDIL TABS (Use Phenelzine Sulfate) CO
PARNATE TABS (Use Tranylcypromine Sulfate) CO
phenelzine sulfate tabs CO
tranylcypromine sulfatetabs CO
Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 10 MG (Use CitalopramHydrobromide)
NF QL(4 ea daily)
CELEXA TABS 20 MG (Use CitalopramHydrobromide)
NF QL(2 ea daily)
CELEXA TABS 40 MG (Use CitalopramHydrobromide)
NF QL(1 ea daily)
citalopram hydrobromidesoln 10 mg/5ml F QL(8 ml daily)
citalopram hydrobromidetabs 10 mg F QL(4 ea daily)
citalopram hydrobromidetabs 20 mg F QL(2 ea daily)
Drug Name DrugTier
Requirements/Limits
citalopram hydrobromidetabs 40 mg F QL(1 ea daily)
escitalopram oxalate tabs10 mg F QL(2 ea daily)
escitalopram oxalate tabs20 mg F QL(1 ea daily)
escitalopram oxalate tabs 5 mg F QL(4 ea daily)
fluoxetine hcl caps 10 mg,20 mg F QL(4 ea daily)
fluoxetine hcl caps 40 mg F QL(2 ea daily);AL; At least 7 yrs old
fluoxetine hcl soln 20 mg/5ml F
QL(20 mldaily); AL; Atleast 7 yrs old
fluoxetine hcl tabs 10 mg F QL(1 ea daily);AL; At least 7 yrs old
fluoxetine hcl tabs 20 mg F QL(4 ea daily)
fluvoxamine maleate tabs 100 mg F QL(3 ea daily)
fluvoxamine maleate tabs 25 mg, 50 mg F QL(2 ea daily)
LEXAPRO TABS 10 MG (Use Escitalopram Oxalate) NF QL(2 ea daily)
LEXAPRO TABS 20 MG (Use Escitalopram Oxalate) NF QL(1 ea daily)
LEXAPRO TABS 5 MG (Use Escitalopram Oxalate) NF QL(4 ea daily)
paroxetine hcl tabs 10 mg F QL(6 ea daily)
paroxetine hcl tabs 20 mg F QL(3 ea daily)
paroxetine hcl tabs 30 mg,40 mg F QL(2 ea daily)
paroxetine hcl tb24 25 mg,12.5 mg, 37.5 mg F
PAXIL CR TB24 (Use Paroxetine HCl) NF
PAXIL SUSP 10 MG/5ML F QL(40 ml daily)
PAXIL TABS 10 MG (Use Paroxetine HCl) NF QL(6 ea daily)
PAXIL TABS 20 MG (Use Paroxetine HCl) NF QL(3 ea daily)
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Drug Name DrugTier
Requirements/Limits
PAXIL TABS 30 MG, 40 MG (Use Paroxetine HCl) NF QL(2 ea daily)
PROZAC CAPS 10 MG, 20 MG (Use Fluoxetine HCl) NF QL(4 ea daily)
PROZAC CAPS 40 MG (Use Fluoxetine HCl) NF
QL(2 ea daily);AL; At least 7 yrs old
sertraline hcl conc 20 mg/ml F QL(10 ml daily)
sertraline hcl tabs 100 mg F QL(2 ea daily)
sertraline hcl tabs 25 mg,50 mg F QL(4 ea daily)
ZOLOFT CONC 20 MG/ML(Use Sertraline HCl) NF QL(10 ml daily)
ZOLOFT TABS 100 MG (Use Sertraline HCl) NF QL(2 ea daily)
ZOLOFT TABS 25 MG, 50 MG (Use Sertraline HCl) NF QL(4 ea daily)
Serotonin Modulators NEFAZODONE HCL TABS 100 MG, 150 MG, 200 MG F
nefazodone hcl tabs 50 mg, 250 mg F
trazodone hcl tabs 300 mg F QL(2 ea daily)
trazodone hcl tabs 50 mg,100 mg, 150 mg F
VIIBRYD TABS F PA; QL(1 eadaily)
Serotonin-Norepinephrine Reuptake Inhibitors
CYMBALTA CPEP (Use Duloxetine HCl) NF
QL(1 ea daily);AL; At least 7 yrs old
duloxetine hcl cpep 20 mg,30 mg, 60 mg F
QL(1 ea daily);AL; At least 7 yrs old
EFFEXOR XR CP24 150 MG (Use Venlafaxine HCl) NF QL(2 ea daily)
EFFEXOR XR CP24 37.5 MG (Use Venlafaxine HCl) NF QL(4 ea daily)
EFFEXOR XR CP24 75 MG (Use Venlafaxine HCl) NF QL(5 ea daily)
venlafaxine hcl cp24 150 mg F QL(2 ea daily)
Drug Name DrugTier
Requirements/Limits
venlafaxine hcl cp24 37.5 mg F QL(4 ea daily)
venlafaxine hcl cp24 75 mg F QL(5 ea daily)
VENLAFAXINE HCL ER TB24 225 MG F QL(1 ea daily)
VENLAFAXINE HCL ER TB24 75 MG, 150 MG, 37.5 MG (Use Venlafaxine HCl)
NF QL(1 ea daily)
venlafaxine hcl tabs 25 mg,50 mg, 75 mg, 100 mg,37.5 mg
F
venlafaxine hcl tb24 75 mg,150 mg, 225 mg, 37.5 mg F QL(1 ea daily)
Tricyclic Agents
amitriptyline hcl tabs 10 mg F QL(20 ea perfill retail)
amitriptyline hcl tabs 150 mg F QL(100 ea per
fill retail) amitriptyline hcl tabs 25mg, 100 mg F QL(150 ea per
fill retail)
amitriptyline hcl tabs 50 mg F QL(200 ea perfill retail)
amitriptyline hcl tabs 75 mg F QL(400 ea perfill retail)
AMOXAPINE TABS F
ANAFRANIL CAPS (Use Clomipramine HCl) NF
clomipramine hcl caps F
desipramine hcl tabs 10mg, 50 mg, 75 mg, 100 mg,150 mg
F
desipramine hcl tabs 25 mg F QL(2 ea daily)
doxepin hcl caps F
doxepin hcl conc F
ELAVIL TABS (Use Amitriptyline HCl) NF QL(150 ea per
fill retail)
imipramine hcl tabs F
NORPRAMIN TABS 10 MG (Use Desipramine HCl) NF
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
NORPRAMIN TABS 25 MG (Use Desipramine HCl) NF QL(2 ea daily)
nortriptyline hcl caps 10mg, 25 mg, 50 mg, 75 mg F
nortriptyline hcl soln 10mg/5ml F QL(20 ml daily)
PAMELOR CAPS (Use Nortriptyline HCl) NF
TOFRANIL TABS (Use Imipramine HCl) NF
ANTIDIABETICS - Drugs to Regulate BloodSugar Antidiabetic - Amylin Analogs
SYMLINPEN 120 SOPN F PA; QL(10.8 mlper 30 daysretail)
SYMLINPEN 60 SOPN F PA; QL(6 mlper 30 daysretail)
Antidiabetic Combinations ACTOPLUS MET TABS (Use Pioglitazone HCl-Metformin HCl)
NF QL(2 ea daily)
ALOGLIPTIN/METFORMINHCL TABS F PA; QL(2 ea
daily) ALOGLIPTIN/PIOGLITAZONE TABS F PA; QL(1 ea
daily)
glipizide-metformin hcl tabs F
GLUCOVANCE TABS (Use Glyburide-Metformin) NF
glyburide-metformin tabs F
JENTADUETO TABS F PA; QL(2 eadaily); AL; Atleast 18 yrs old
pioglitazone hcl-metforminhcl tabs F QL(2 ea daily)
Biguanides GLUCOPHAGE TABS 1000 MG (Use Metformin HCl)
NF QL(2 ea daily)
GLUCOPHAGE TABS 500 MG (Use Metformin HCl) NF QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
GLUCOPHAGE TABS 850 MG (Use Metformin HCl) NF QL(3 ea daily)
GLUCOPHAGE XR TB24 500 MG (Use Metformin HCl)
NF QL(4 ea daily)
GLUCOPHAGE XR TB24 750 MG (Use Metformin HCl)
NF QL(2 ea daily)
metformin hcl tabs 1000 mg F QL(2 ea daily)
metformin hcl tabs 500 mg F QL(5 ea daily)
metformin hcl tabs 850 mg F QL(3 ea daily)
metformin hcl tb24 500 mg F QL(4 ea daily)
metformin hcl tb24 750 mg F QL(2 ea daily)
Diabetic Other BD GLUCOSE CHEW F
CVS GLUCOSE CHEW 4 GM F
DEX4 QUICK DISSOLVE GLUCOSE CHEW F
GLUCAGEN HYPOKIT SOLR F
GLUCAGON EMERGENCY KIT KIT F QL(1 ea per fill
retail)
GLUCOSE CHEW 4 GM F
GNP GLUCOSE CHEW 4 GM F
GNP QUICK DISSOLVE GLUCOSE CHEW F
LEADER QUICK DISSOLVE GLUCOSE CHEW
F
SM GLUCOSE CHEW 4 GM F
WALGREENS GLUCOSE CHEW 4 GM F
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
ALOGLIPTIN TABS F PA; QL(1 eadaily)
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Drug Name DrugTier
Requirements/Limits
TRADJENTA TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old
Incretin Mimetic Agents (GLP-1 Receptor
BYDUREON BCISE AUIJ F
QL(18 ml per30 days retail);AL; At least 18 yrs old
BYDUREON PEN PEN F
PA; QL(4 eaper 30 daysretail); AL; Atleast 18 yrs old
BYDUREON SRER F
PA; QL(4 eaper 28 daysretail); AL; Atleast 18 yrs old
BYETTA SOPN 10 MCG/0.04ML F
PA; QL(2.4 mlper 30 daysretail); AL; Atleast 18 yrs old
BYETTA SOPN 5 MCG/0.02ML F
PA; QL(1.2 mlper 30 daysretail); AL; Atleast 18 yrs old
VICTOZA SOPN F PA; QL(1.8 mldaily)
Insulin Sensitizing Agents ACTOS TABS (Use Pioglitazone HCl) NF QL(1 ea daily)
AVANDIA TABS F QL(1 ea daily)
pioglitazone hcl tabs F QL(1 ea daily)
Insulin
ADMELOG SOLN F QL(40 ml per30 days retail)
ADMELOG SOLOSTAR SOPN F QL(30 ml per
30 days retail)
APIDRA SOLN F
APIDRA SOLOSTAR SOPN F QL(30 ml per
30 days retail)
BASAGLAR KWIKPEN SOPN F
Limit 50mls permonth;QL(1.67ml daily)
FIASP FLEXTOUCH SOPN F QL(30 ml per
30 days retail)
Drug Name DrugTier
Requirements/Limits
FIASP SOLN F QL(30 ml per30 days retail)
HUMALOG JUNIOR KWIKPEN SOPN F QL(30 ml per
30 days retail) HUMALOG KWIKPEN SOPN 100 UNIT/ML F QL(30 ml per
30 days retail) HUMALOG MIX 50/50KWIKPEN SUPN F QL(30 ml per
30 days retail) HUMALOG MIX 50/50SUSP F QL(40 ml per
30 days retail) HUMALOG MIX 75/25KWIKPEN SUPN F QL(30 ml per
30 days retail) HUMALOG MIX 75/25SUSP F QL(40 ml per
30 days retail)
HUMALOG SOCT F QL(30 ml per30 days retail)
HUMALOG SOLN F QL(40 ml per30 days retail)
HUMULIN 70/30 KWIKPENSUPN F
HUMULIN 70/30 SUSP F QL(40 ml per30 days retail)
HUMULIN N KWIKPEN SUPN F
HUMULIN N SUSP F QL(40 ml per30 days retail)
HUMULIN R SOLN F QL(40 ml per30 days retail)
NOVOLIN 70/30 RELIONSUSP F QL(40 ml per
30 days retail)
NOVOLIN 70/30 SUSP F QL(40 ml per30 days retail)
NOVOLIN N RELION SUSP F QL(40 ml per
30 days retail)
NOVOLIN N SUSP F QL(40 ml per30 days retail)
NOVOLIN R RELION SOLN F QL(40 ml per
30 days retail)
NOVOLIN R SOLN F QL(40 ml per30 days retail)
NOVOLOG FLEXPEN SOPN F QL(30 ml per
30 days retail) NOVOLOG MIX 70/30PREFILLED FLEXPEN SUPN
F QL(30 ml per30 days retail)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
NOVOLOG MIX 70/30SUSP F QL(40 ml per
30 days retail)
NOVOLOG SOLN F QL(30 ml per30 days retail)
Meglitinide Analogues
nateglinide tabs F QL(3 ea daily)
STARLIX TABS (Use Nateglinide) NF QL(3 ea daily)
Sodium-Glucose Co-Transporter 2 (SGLT2)
JARDIANCE TABS F PA; QL(1 eadaily)
Sulfonylureas AMARYL TABS 1 MG, 2 MG (Use Glimepiride) NF QL(4 ea daily)
AMARYL TABS 4 MG (Use Glimepiride) NF QL(2 ea daily)
glimepiride tabs 1 mg, 2 mg F QL(4 ea daily)
glimepiride tabs 4 mg F QL(2 ea daily)
glipizide tabs F
glipizide tb24 F
GLUCOTROL TABS (Use Glipizide) NF
GLUCOTROL XL TB24 (Use Glipizide) NF
glyburide micronized tabs F
glyburide tabs F
GLYNASE TABS (Use Glyburide Micronized) NF
ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat Diarrhea
Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chew262 mg F
bismuth subsalicylate susp262 mg/15ml, 525mg/15ml, 525 mg/30ml,527 mg/30ml
F
Drug Name DrugTier
Requirements/Limits
PEPTO-BISMOL CHEW 262 MG (Use Bismuth Subsalicylate)
NF
PEPTO-BISMOL INSTACOOL CHEW (Use Bismuth Subsalicylate)
NF
PEPTO-BISMOL MAX STRENGTH SUSP (Use Bismuth Subsalicylate)
NF
PEPTO-BISMOL SUSP 262 MG/15ML (Use Bismuth Subsalicylate)
NF
PEPTO-BISMOL TO-GO CHEW (Use Bismuth Subsalicylate)
NF
Antiperistaltic Agents diphenoxylate w/ atropinetabs F
DIPHENOXYLATE/ATROPINE LIQD F
IMODIUM A-D CAPS 2 MG (Use Loperamide HCl) NF QL(8 ea daily);
RX/OTC IMODIUM A-D TABS 2 MG (Use Loperamide HCl) NF QL(8 ea daily)
LOMOTIL TABS (Use Diphenoxylate w/ Atropine) NF
loperamide hcl caps 2 mg F QL(8 ea daily);RX/OTC
loperamide hcl liqd 1mg/5ml F QL(40 ml daily)
loperamide hcl tabs 2 mg F QL(8 ea daily)
PAREGORIC TINC F
ANTIDOTES AND SPECIFIC ANTAGONISTS
Antidotes - Chelating Agents
CHEMET CAPS F
JADENU SPRINKLE PACK F PA
JADENU TABS F PA; SP
Antidotes and Specific Antagonists
VISTOGARD PACK F
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
Opioid Antagonists NALOXONE HCL SOCT 0.4 MG/ML CO
naloxone hcl soln 0.4 mg/ml, 4 mg/10ml CO
NALOXONE HCL SOSY 2 MG/2ML CO
naltrexone hcl tabs CO
NARCAN LIQD CO
VIVITROL SUSR CO
ANTIEMETICS - Drugs to Treat Nausea andVomiting
5-HT3 Receptor Antagonists ondansetron hcl soln 4 mg/5ml F QL(50 ml per
fill retail) ondansetron hcl tabs 4 mg,8 mg F QL(20 ea per
30 days retail)
ondansetron tbdp F QL(20 ea per30 days retail)
ZOFRAN ODT TBDP (Use Ondansetron) NF QL(20 ea per
30 days retail) ZOFRAN SOLN 4 MG/5ML(Use Ondansetron HCl) NF QL(50 ml per
fill retail) ZOFRAN TABS 4 MG, 8 MG (Use Ondansetron HCl)
NF QL(20 ea per30 days retail)
Antiemetics - Anticholinergic dimenhydrinate tabs or 50 mg F
DRAMAMINE CHEW F
DRAMAMINE TABS (Use Dimenhydrinate) NF
meclizine hcl chew 25 mg F
meclizine hcl tabs 25 mg,12.5 mg F RX/OTC
Substance P/Neurokinin 1 (NK1) Receptor
aprepitant caps F 1 rtl pack lmtper fill,
aprepitant caps 40 mg, 125 mg F QL(1 ea per fill
retail)
Drug Name DrugTier
Requirements/Limits
aprepitant caps 80 mg F QL(2 ea per fillretail)
EMEND CAPS 40 MG, 125 MG (Use Aprepitant) NF QL(1 ea per fill
retail) EMEND CAPS 80 MG (Use Aprepitant) NF QL(2 ea per fill
retail) EMEND TRIPACK CAPS (Use Aprepitant) NF 1 rtl pack lmt
per fill,
ANTIFUNGALS - Drugs to Treat Fungal Infections
Antifungals GRIS-PEG TABS (Use Griseofulvin Ultramicrosize) NF
griseofulvin microsize susp F
griseofulvin microsize tabs F
griseofulvin ultramicrosizetabs F
LAMISIL TABS 250 MG (Use Terbinafine HCl) NF QL(1 ea daily)
nystatin tabs F QL(6 ea daily)
terbinafine hcl tabs F QL(1 ea daily)
Imidazole-Related Antifungals DIFLUCAN SUSR 10 MG/ML, 40 MG/ML (Use Fluconazole)
NF QL(70 ml perfill retail)
DIFLUCAN TABS 100 MG (Use Fluconazole) NF QL(1 ea daily)
DIFLUCAN TABS 150 MG (Use Fluconazole) NF QL(2 ea per fill
retail) DIFLUCAN TABS 200 MG (Use Fluconazole) NF QL(2 ea daily)
DIFLUCAN TABS 50 MG (Use Fluconazole) NF QL(7 ea per fill
retail) fluconazole susr 10 mg/ml,40 mg/ml F QL(70 ml per
fill retail)
fluconazole tabs 100 mg F QL(1 ea daily)
fluconazole tabs 150 mg F QL(2 ea per fillretail)
fluconazole tabs 200 mg F QL(2 ea daily)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
fluconazole tabs 50 mg F QL(7 ea per fillretail)
itraconazole caps F PA; QL(1 eadaily)
ketoconazole tabs F QL(2 ea daily)
SPORANOX CAPS 100 MG (Use Itraconazole) NF PA; QL(1 ea
daily) SPORANOX PULSEPAK CAPS (Use Itraconazole) NF PA; QL(1 ea
daily)
ANTIHISTAMINES - Drugs to Treat Allergies
Antihistamines - Alkylamines CHLOR-TRIMETON SYRP (Use ChlorpheniramineMaleate)
NF
CHLOR-TRIMETON TABS (Use ChlorpheniramineMaleate)
NF
chlorpheniramine maleatesyrp 2 mg/5ml F
chlorpheniramine maleatetabs 4 mg F
Antihistamines - Ethanolamines
ALER-DRYL TABS F
BENADRYL ALLERGY CAPS (Use Diphenhydramine HCl)
NF
BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML (Use Diphenhydramine HCl)
NF
BENADRYL ALLERGY TABS (Use Diphenhydramine HCl)
NF
clemastine fumarate tabs 1.34 mg F
diphenhydramine hcl caps25 mg F
diphenhydramine hcl caps50 mg F QL(4 ea daily);
RX/OTC
diphenhydramine hcl elix12.5 mg/5ml F
QL(240 ml perfill retail);RX/OTC
Drug Name DrugTier
Requirements/Limits
diphenhydramine hcl liqd25 mg/10ml, 50 mg/20ml,12.5 mg/5ml
F
diphenhydramine hcl syrp12.5 mg/5ml F
diphenhydramine hcl tabs25 mg F
SILPHEN COUGH SYRP F
TAVIST ALLERGY TABS (Use Clemastine Fumarate) NF
Antihistamines - Non-Sedating ALLEGRA ALLERGY TABS (Use Fexofenadine HCl)
NF
cetirizine hcl chew 5 mg, 10 mg F
cetirizine hcl soln 1 mg/ml,5 mg/5ml F
QL(240 ml perfill retail);RX/OTC
cetirizine hcl syrp 1 mg/ml,5 mg/5ml F
QL(240 ml perfill retail);RX/OTC
cetirizine hcl tabs 5 mg, 10 mg F
CLARITIN ALLERGY CHILDRENS SYRP (Use Loratadine)
NF
CLARITIN REDITABS TBDP 10 MG (Use Loratadine)
NF
CLARITIN SYRP 5 MG/5ML (Use Loratadine) NF
CLARITIN TABS 10 MG (Use Loratadine) NF
fexofenadine hcl tabs 60 mg, 180 mg F
levocetirizine dihydrochloride tabs 5 mg F RX/OTC
loratadine soln 5 mg/5ml F
loratadine syrp 5 mg/5ml F
loratadine tabs 10 mg F
loratadine tbdp 10 mg F
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
XYZAL ALLERGY 24HR TABS (Use Levocetirizine Dihydrochloride)
NF RX/OTC
XYZAL TABS 5 MG (Use Levocetirizine Dihydrochloride)
NF RX/OTC
ZYRTEC ALLERGY TABS (Use Cetirizine HCl) NF
ZYRTEC CHILDRENS ALLERGY SOLN (Use Cetirizine HCl)
NF QL(240 ml perfill retail);RX/OTC
Antihistamines - Phenothiazines
promethazine hcl soln or6.25 mg/5ml F
QL(240 ml perfill retail); AL; Atleast 2 yrs old
promethazine hcl supp re25 mg, 50 mg, 12.5 mg F
QL(12 ea perfill retail); AL; Atleast 2 yrs old
promethazine hcl syrp or6.25 mg/5ml F
QL(240 ml perfill retail); AL; Atleast 2 yrs old
promethazine hcl tabs or25 mg, 50 mg, 12.5 mg F AL; At least 2
yrs old
Antihistamines - Piperidines
cyproheptadine hcl syrp F
cyproheptadine hcl tabs F
ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Bile Acid Sequestrants
cholestyramine light pack F
cholestyramine light powd F
cholestyramine pack F
cholestyramine powd F
COLESTID FLAVORED GRAN 5 GM (Use Colestipol HCl)
NF
COLESTID GRAN 5 GM (Use Colestipol HCl) NF
COLESTID TABS 1 GM (Use Colestipol HCl) NF
Drug Name DrugTier
Requirements/Limits
colestipol hcl gran 5 gm F
colestipol hcl tabs 1 gm F
QUESTRAN LIGHT POWD (Use Cholestyramine Light) NF
QUESTRAN PACK (Use Cholestyramine) NF
QUESTRAN POWD (Use Cholestyramine) NF
Fibric Acid Derivatives fenofibrate micronized caps134 mg, 200 mg F QL(1 ea daily)
fenofibrate micronized caps67 mg F QL(2 ea daily)
fenofibrate tabs 160 mg F QL(1 ea daily)
fenofibrate tabs 54 mg F QL(3 ea daily)
gemfibrozil tabs F QL(2 ea daily)
LOFIBRA CAPS 134 MG, 200 MG (Use Fenofibrate Micronized)
NF QL(1 ea daily)
LOFIBRA CAPS 67 MG (Use Fenofibrate Micronized)
NF QL(2 ea daily)
LOFIBRA TABS 160 MG (Use Fenofibrate) NF QL(1 ea daily)
LOFIBRA TABS 54 MG (Use Fenofibrate) NF QL(3 ea daily)
LOPID TABS (Use Gemfibrozil) NF QL(2 ea daily)
TRIGLIDE TABS F QL(1 ea daily)
HMG CoA Reductase Inhibitors
atorvastatin calcium tabs F QL(1 ea daily)
CRESTOR TABS (Use Rosuvastatin Calcium) NF ST; QL(1 ea
daily) LIPITOR TABS (Use Atorvastatin Calcium) NF QL(1 ea daily)
lovastatin tabs 10 mg, 20 mg F QL(1 ea daily)
lovastatin tabs 40 mg F QL(2 ea daily)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
MEVACOR TABS (Use Lovastatin) NF QL(2 ea daily)
PRAVACHOL TABS (Use Pravastatin Sodium) NF QL(1 ea daily)
pravastatin sodium tabs F QL(1 ea daily)
rosuvastatin calcium tabs F ST; QL(1 eadaily)
simvastatin tabs 5 mg, 10mg, 20 mg, 40 mg F QL(1 ea daily)
simvastatin tabs 80 mg F PA
ZOCOR TABS 5 MG, 10 MG, 20 MG, 40 MG (Use Simvastatin)
NF QL(1 ea daily)
ZOCOR TABS 80 MG (Use Simvastatin) NF PA
Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr F
NIACOR TABS F
NIASPAN TBCR (Use Niacin (Antihyperlipidemic)) NF
ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure
ACE Inhibitors ACCUPRIL TABS (Use Quinapril HCl) NF QL(1 ea daily)
ALTACE CAPS (Use Ramipril) NF QL(2 ea daily)
benazepril hcl tabs 40 mg F QL(2 ea daily)
benazepril hcl tabs 5 mg,10 mg, 20 mg F QL(1 ea daily)
captopril tabs F QL(3 ea daily)
enalapril maleate tabs F QL(2 ea daily)
EPANED SOLR F PA
fosinopril sodium tabs F QL(1 ea daily)
lisinopril tabs F
Drug Name DrugTier
Requirements/Limits
LOTENSIN TABS 10 MG, 20 MG (Use BenazeprilHCl)
NF QL(1 ea daily)
LOTENSIN TABS 40 MG (Use Benazepril HCl) NF QL(2 ea daily)
MAVIK TABS (Use Trandolapril) NF QL(1 ea daily)
PRINIVIL TABS (Use Lisinopril) NF
quinapril hcl tabs F QL(1 ea daily)
ramipril caps F QL(2 ea daily)
trandolapril tabs 1 mg, 2 mg F QL(1 ea daily)
trandolapril tabs 4 mg F QL(2 ea daily)
VASOTEC TABS (Use Enalapril Maleate) NF QL(2 ea daily)
ZESTRIL TABS (Use Lisinopril) NF
Angiotensin II Receptor Antagonists ATACAND TABS (Use Candesartan Cilexetil) NF
AVAPRO TABS (Use Irbesartan) NF QL(1 ea daily)
BENICAR TABS (Use Olmesartan Medoxomil) NF ST
candesartan cilexetil tabs F
COZAAR TABS (Use Losartan Potassium) NF QL(1 ea daily)
DIOVAN TABS (Use Valsartan) NF QL(1 ea daily)
irbesartan tabs F QL(1 ea daily)
losartan potassium tabs F QL(1 ea daily)
MICARDIS TABS (Use Telmisartan) NF QL(1 ea daily)
olmesartan medoxomil tabs F ST
telmisartan tabs F QL(1 ea daily)
valsartan tabs F QL(1 ea daily)
Antiadrenergic Antihypertensives
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
CARDURA TABS (Use Doxazosin Mesylate) NF
CATAPRES TABS (Use Clonidine HCl) NF
clonidine hcl tabs or 0.1 mg, 0.2 mg, 0.3 mg F
doxazosin mesylate tabs F
guanfacine hcl tabs F
methyldopa tabs F
MINIPRESS CAPS (Use Prazosin HCl) NF
prazosin hcl caps F
TENEX TABS (Use Guanfacine HCl) NF
terazosin hcl caps F
Antihypertensive Combinations ACCURETIC TABS 10MG-12.5MG (Use Quinapril-Hydrochlorothiazide)
NF QL(3 ea daily)
ACCURETIC TABS 20MG-12.5MG (Use Quinapril-Hydrochlorothiazide)
NF QL(4 ea daily)
ACCURETIC TABS 20MG-25MG (Use Quinapril-Hydrochlorothiazide)
NF QL(2 ea daily)
amlodipine besylate-benazepril hcl caps F QL(1 ea daily)
amlodipine besylate-olmesartan medoxomil tabs F ST
amlodipine besylate-valsartan tabs F ST
amlodipine-valsartan-hydrochlorothiazide tabs F ST
ATACAND HCT TABS (Use Candesartan Cilexetil-Hydrochlorothiazide)
NF
atenolol & chlorthalidone tabs F QL(1 ea daily)
AVALIDE TABS (Use Irbesartan-Hydrochlorothiazide)
NF QL(1 ea daily)
Drug Name DrugTier
Requirements/Limits
AZOR TABS (Use Amlodipine Besylate-Olmesartan Medoxomil)
NF ST
benazepril &hydrochlorothiazide tabs F QL(1 ea daily)
BENICAR HCT TABS (Use Olmesartan Medoxomil-Hydrochlorothiazide)
NF ST
bisoprolol &hydrochlorothiazide tabs2.5mg-6.25mg
F
bisoprolol &hydrochlorothiazide tabs5mg-6.25mg, 10mg-6.25mg
F
QL(1 ea daily)
candesartan cilexetil-hydrochlorothiazide tabs F
CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS F QL(2 ea daily)
DIOVAN HCT TABS (Use Valsartan-Hydrochlorothiazide)
NF QL(1 ea daily)
enalapril maleate &hydrochlorothiazide tabs F QL(2 ea daily)
EXFORGE HCT TABS (Use Amlodipine-Valsartan-Hydrochlorothiazide)
NF ST
EXFORGE TABS (Use Amlodipine Besylate-Valsartan)
NF ST
fosinopril sodium &hydrochlorothiazide tabs F QL(1 ea daily)
HYZAAR TABS (Use Losartan Potassium & Hydrochlorothiazide)
NF QL(1 ea daily)
irbesartan-hydrochlorothiazide tabs F QL(1 ea daily)
lisinopril &hydrochlorothiazide tabs F
LOPRESSOR HCT TABS (Use Metoprolol &Hydrochlorothiazide)
NF QL(2 ea daily)
losartan potassium &hydrochlorothiazide tabs F QL(1 ea daily)
LOTENSIN HCT TABS (Use Benazepril &Hydrochlorothiazide)
NF QL(1 ea daily)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
LOTREL CAPS (Use Amlodipine Besylate-Benazepril HCl)
NF QL(1 ea daily)
metoprolol &hydrochlorothiazide tabs F QL(2 ea daily)
METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE TB24
F
QL(1 ea daily)
METOPROLOL/HYDROCHLOROTHIAZIDE TABS F QL(2 ea daily)
MICARDIS HCT TABS (Use Telmisartan-Hydrochlorothiazide)
NF QL(1 ea daily)
olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs
F ST
olmesartan medoxomil-hydrochlorothiazide tabs F ST
PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS F
quinapril-hydrochlorothiazide tabs10mg-12.5mg
F QL(3 ea daily)
quinapril-hydrochlorothiazide tabs20mg-12.5mg
F QL(4 ea daily)
quinapril-hydrochlorothiazide tabs20mg-25mg
F QL(2 ea daily)
TARKA TBCR (Use Trandolapril-VerapamilHCl)
NF
telmisartan-amlodipine tabs F
telmisartan-hydrochlorothiazide tabs F QL(1 ea daily)
TENORETIC 100 TABS (Use Atenolol & Chlorthalidone)
NF QL(1 ea daily)
TENORETIC 50 TABS (Use Atenolol & Chlorthalidone)
NF QL(1 ea daily)
trandolapril-verapamil hcltbcr F
TRANDOLAPRIL/VERAPAMIL HCL ER TBCR F
Drug Name DrugTier
Requirements/Limits
TRIBENZOR TABS (Use Olmesartan Medoxomil-Amlodipine-Hydrochlorothiazide)
NF
ST
TWYNSTA TABS (Use Telmisartan-Amlodipine) NF
valsartan-hydrochlorothiazide tabs F QL(1 ea daily)
VASERETIC TABS (Use Enalapril Maleate &Hydrochlorothiazide)
NF QL(2 ea daily)
ZESTORETIC TABS (Use Lisinopril &Hydrochlorothiazide)
NF
ZIAC TABS 2.5MG-6.25MG (Use Bisoprolol &Hydrochlorothiazide)
NF
ZIAC TABS 5MG-6.25MG, 10MG-6.25MG (Use Bisoprolol &Hydrochlorothiazide)
NF
QL(1 ea daily)
Vasodilators hydralazine hcl tabs or 10mg, 25 mg, 50 mg, 100 mg F
minoxidil tabs F
ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations
COARTEM TABS F QL(24 ea perfill retail)
Antimalarials CHLOROQUINE PHOSPHATE TABS 250 MG
F QL(2 ea daily)
chloroquine phosphate tabs500 mg F QL(8 ea per 56
days retail) hydroxychloroquine sulfatetabs F
mefloquine hcl tabs F
MEFLOQUINE HCL TABS F
PLAQUENIL TABS (Use HydroxychloroquineSulfate)
NF
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
ANTIMYASTHENIC/CHOLINERGIC AGENTS
Antimyasthenic/Cholinergic Agents MESTINON TABS 60 MG (Use PyridostigmineBromide)
NF
MESTINON TIMESPAN TBCR (Use PyridostigmineBromide)
NF
pyridostigmine bromidetabs F
pyridostigmine bromidetbcr F
ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Antimycobacterial Agents
ethambutol hcl tabs F
ISONIAZID SYRP OR 50 MG/5ML F
isoniazid tabs or 100 mg,300 mg F
MYAMBUTOL TABS (Use Ethambutol HCl) NF
PRIFTIN TABS F QL(72 ea per84 days retail)
pyrazinamide tabs F
RIFADIN CAPS (Use Rifampin) NF
rifampin caps F
TRECATOR TABS F
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN TABS (Use Melphalan) NF
LEUKERAN TABS F
melphalan tabs F
MYLERAN TABS F
Antimetabolites
Drug Name DrugTier
Requirements/Limits
mercaptopurine tabs F
methotrexate sodium soln ij1 gm/40ml, 50 mg/2ml, 100mg/4ml, 200 mg/8ml, 250mg/10ml
F
METHOTREXATE SODIUM SOLN IJ 250 MG/10ML
F
methotrexate sodium tabs or 2.5 mg F
PURIXAN SUSP F
TREXALL TABS F
Antineoplastic - Angiogenesis Inhibitors
AVASTIN SOLN F PA; SP
CYRAMZA SOLN F PA; SP
Antineoplastic - Antibodies HERCEPTIN SOLR 440 MG F PA; SP
KADCYLA SOLR F PA; SP
OPDIVO SOLN 40 MG/4ML, 100 MG/10ML F PA; SP
PERJETA SOLN F PA; SP
RITUXAN SOLN F PA; SP
Antineoplastic - Hedgehog Pathway Inhibitors
ERIVEDGE CAPS F PA; SP
Antineoplastic - Hormonal and Related Agents
anastrozole tabs F
ARIMIDEX TABS (Use Anastrozole) NF
AROMASIN TABS (Use Exemestane) NF SP
bicalutamide tabs F QL(1 ea daily)
CASODEX TABS (Use Bicalutamide) NF QL(1 ea daily)
ELIGARD KIT F PA; SP
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
exemestane tabs F SP
FARESTON TABS F PA
FEMARA TABS (Use Letrozole) NF
FIRMAGON SOLR F PA; SP
flutamide caps F
letrozole tabs F
leuprolide acetate kit F PA; SP
LUPRON DEPOT (1-MONTH) KIT F PA; SP
LUPRON DEPOT (3-MONTH) KIT F PA; SP
LUPRON DEPOT (4-MONTH) KIT F PA; SP
LUPRON DEPOT (6-MONTH) KIT F PA; SP
MEGACE ORAL SUSP (Use Megestrol Acetate) NF
megestrol acetate susp F
megestrol acetate tabs F
tamoxifen citrate tabs F
TRELSTAR MIXJECT SUSR F PA; SP
TRELSTAR SUSR F PA; SP
VANTAS KIT F PA; SP
XTANDI CAPS F PA; SP
ZOLADEX IMPL F PA; SP
ZYTIGA TABS 250 MG F PA; SP
Antineoplastic - Immunomodulators
POMALYST CAPS F PA; SP
Antineoplastic Enzyme Inhibitors
AFINITOR DISPERZ TBSO F PA; SP
Drug Name DrugTier
Requirements/Limits
AFINITOR TABS F PA; SP
ALECENSA CAPS F PA; SP
BOSULIF TABS 100 MG, 500 MG F PA; SP
CABOMETYX TABS F PA; SP
CAPRELSA TABS F PA; SP
COMETRIQ KIT F PA; SP
COTELLIC TABS F PA; SP
GILOTRIF TABS F PA; SP
GLEEVEC TABS (Use Imatinib Mesylate) NF PA; SP
IBRANCE CAPS F PA; SP
ICLUSIG TABS F PA; SP
imatinib mesylate tabs F PA; SP
IMBRUVICA CAPS 140 MG F PA; SP
INLYTA TABS F PA; SP
IRESSA TABS F PA; SP
MEKINIST TABS F PA; SP
NEXAVAR TABS F PA; SP
NINLARO CAPS F PA; SP
SPRYCEL TABS F PA; SP
STIVARGA TABS F PA; SP
SUTENT CAPS F PA; SP
TAFINLAR CAPS F PA; SP
TARCEVA TABS F PA; SP
TASIGNA CAPS 150 MG, 200 MG F PA; SP
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
VOTRIENT TABS F PA; SP
XALKORI CAPS F PA; SP
ZELBORAF TABS F PA; SP
ZOLINZA CAPS F PA; SP
Antineoplastics Misc. ACTIMMUNE SOLN F PA; SP
bexarotene caps F PA; SP
HYDREA CAPS (Use Hydroxyurea) NF
hydroxyurea caps F
SYLATRON KIT F PA; SP
TARGRETIN CAPS OR 75 MG (Use Bexarotene) NF PA; SP
Chemotherapy Rescue/Antidote Agents LEUCOVORIN CALCIUM TABS 10 MG, 15 MG F
leucovorin calcium tabs 5 mg, 25 mg F
Topoisomerase I Inhibitors HYCAMTIN CAPS OR 0.25 MG, 1 MG F PA; SP
HYCAMTIN SOLR IV 4 MG (Use Topotecan HCl) NF PA; SP
TOPOTECAN HCL SOLN 4 MG/4ML F PA; SP
topotecan hcl soln 4mg/4ml F PA; SP
TOPOTECAN HCL SOLN 4 MG/4ML (Use TopotecanHCl)
NF PA; SP
topotecan hcl solr 4 mg F PA; SP
ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease
Antiparkinson Adjuvants
carbidopa tabs F
Drug Name DrugTier
Requirements/Limits
LODOSYN TABS (Use Carbidopa) NF
Antiparkinson Anticholinergics
benztropine mesylate soln CO
benztropine mesylate tabs CO
COGENTIN SOLN (Use Benztropine Mesylate) CO
trihexyphenidyl hcl elix CO
trihexyphenidyl hcl tabs CO
Antiparkinson COMT Inhibitors COMTAN TABS (Use Entacapone) NF
entacapone tabs F
Antiparkinson Dopaminergics
amantadine hcl caps CO
amantadine hcl syrp CO
amantadine hcl tabs CO
bromocriptine mesylate caps F
bromocriptine mesylatetabs F
carbidopa-levodopa tabs10mg-100mg, 25mg-100mg, 25mg-250mg
F
carbidopa-levodopa tbcr25mg-100mg, 50mg-200mg
F
GOCOVRI CP24 CO
MIRAPEX TABS (Use PramipexoleDihydrochloride)
NF QL(3 ea daily);AL; At least 18 yrs old
PARLODEL CAPS (Use Bromocriptine Mesylate) NF
PARLODEL TABS (Use Bromocriptine Mesylate) NF
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Drug Name DrugTier
Requirements/Limits
pramipexoledihydrochloride tabs 0.125mg, 0.25 mg, 0.75 mg, 0.5mg, 1 mg, 1.5 mg
F
QL(3 ea daily);AL; At least 18 yrs old
REQUIP TABS 0.25 MG, 3 MG, 4 MG (Use RopiniroleHydrochloride)
NF QL(6 ea daily)
REQUIP TABS 0.5 MG, 1 MG, 2 MG, 5 MG (Use Ropinirole Hydrochloride)
NF QL(3 ea daily)
ropinirole hydrochloridetabs 0.25 mg, 3 mg, 4 mg F QL(6 ea daily)
ropinirole hydrochloridetabs 0.5 mg, 1 mg, 2 mg, 5 mg
F QL(3 ea daily)
SINEMET CR TBCR (Use Carbidopa-Levodopa) NF
SINEMET TABS (Use Carbidopa-Levodopa) NF
Antiparkinson Monoamine Oxidase Inhibitors ELDEPRYL CAPS (Use Selegiline HCl) NF
selegiline hcl caps F
selegiline hcl tabs F
ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders
Antimanic Agents lithium carbonate caps 150mg, 300 mg, 600 mg CO
LITHIUM CARBONATE CAPS 150 MG, 600 MG (Use Lithium Carbonate)
CO
lithium carbonate tabs 300 mg CO
lithium carbonate tbcr 300 mg, 450 mg CO
LITHIUM SOLN CO
LITHOBID TBCR (Use Lithium Carbonate) CO
Antipsychotics - Misc. EQUETRO CP12 CO
Drug Name DrugTier
Requirements/Limits
GEODON CAPS OR 20 MG, 40 MG, 60 MG, 80 MG (Use Ziprasidone HCl)
CO
GEODON SOLR IM 20 MG CO
LATUDA TABS CO
NUPLAZID TABS CO
VRAYLAR CAPS CO
VRAYLAR CPPK CO
ziprasidone hcl caps CO
Benzisoxazoles
FANAPT TABS CO
FANAPT TITRATION PACK TABS CO
INVEGA SUSTENNA SUSP CO
INVEGA TB24 (Use Paliperidone) CO
INVEGA TRINZA SUSP CO
paliperidone tb24 CO
RISPERDAL CONSTA SUSR CO
RISPERDAL M-TAB TBDP (Use Risperidone) CO
RISPERDAL SOLN (Use Risperidone) CO
RISPERDAL TABS (Use Risperidone) CO
RISPERIDONE ODT TBDP CO
risperidone soln CO
risperidone tabs CO
risperidone tbdp CO
Butyrophenones
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Drug Name DrugTier
Requirements/Limits
HALDOL DECANOATE 100 SOLN (Use Haloperidol Decanoate)
CO
HALDOL DECANOATE 50 SOLN (Use HaloperidolDecanoate)
CO
HALDOL SOLN (Use Haloperidol Lactate) CO
haloperidol decanoate soln CO
haloperidol lactate conc CO
haloperidol lactate soln CO
haloperidol tabs or 0.5 mg,1 mg, 2 mg, 5 mg, 10 mg,20 mg
CO
Dibenzapines
ADASUVE AEPB CO
CLOZAPINE ODT TBDP CO
clozapine tabs CO
clozapine tbdp CO
CLOZARIL TABS (Use Clozapine) CO
FAZACLO TBDP 150 MG, 200 MG CO
FAZACLO TBDP 25 MG, 100 MG, 12.5 MG (Use Clozapine)
CO
loxapine succinate caps CO
olanzapine solr CO
olanzapine tabs CO
olanzapine tbdp CO
quetiapine fumarate tabs CO
quetiapine fumarate tb24 CO
SAPHRIS SUBL CO
Drug Name DrugTier
Requirements/Limits
SEROQUEL TABS (Use Quetiapine Fumarate) CO
SEROQUEL XR TB24 (Use Quetiapine Fumarate) CO
VERSACLOZ SUSP CO
ZYPREXA RELPREVV SUSR CO
ZYPREXA SOLR (Use Olanzapine) CO
ZYPREXA TABS (Use Olanzapine) CO
ZYPREXA ZYDIS TBDP (Use Olanzapine) CO
Dihydroindolones MOLINDONE HYDROCHLORIDE TABS CO
Phenothiazines CHLORPROMAZINE HCL SOLN IJ 25 MG/ML, 50MG/2ML
CO
chlorpromazine hcl tabs or10 mg, 25 mg, 50 mg, 100mg, 200 mg
CO
fluphenazine decanoatesoln CO
FLUPHENAZINE HCL CONC OR 5 MG/ML CO
FLUPHENAZINE HCL ELIX OR 2.5 MG/5ML CO
FLUPHENAZINE HCL SOLN IJ 2.5 MG/ML CO
fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg CO
perphenazine tabs CO
prochlorperazine maleatetabs F
prochlorperazine supp F
thioridazine hcl tabs CO
trifluoperazine hcl tabs CO
Quinolinone Derivatives
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Drug Name DrugTier
Requirements/Limits
ABILIFY MAINTENA PRSY CO
ABILIFY MAINTENA SRER CO
ABILIFY TABS (Use Aripiprazole) CO
aripiprazole soln CO
aripiprazole tabs CO
aripiprazole tbdp CO
ARISTADA PRSY CO
REXULTI TABS CO
Thioxanthenes
thiothixene caps CO
ANTISEPTICS & DISINFECTANTS
Antiseptics & Disinfectants formaldehyde soln 10%, 10% F QL(90 ml per
fill retail)
ANTIVIRALS - Drugs to Treat Viral Infections
Antiretrovirals
abacavir sulfate soln CO
abacavir sulfate tabs CO
abacavir sulfate-lamivudine tabs CO
abacavir sulfate-lamivudine-zidovudine tabs CO
APTIVUS CAPS CO
APTIVUS SOLN CO
atazanavir sulfate caps CO
ATRIPLA TABS CO
BIKTARVY TABS CO
COMBIVIR TABS (Use Lamivudine-Zidovudine) CO
Drug Name DrugTier
Requirements/Limits
COMPLERA TABS CO
CRIXIVAN CAPS CO
DESCOVY TABS CO
EDURANT TABS CO
efavirenz caps CO
efavirenz tabs CO
EMTRIVA CAPS CO
EMTRIVA SOLN CO
EPIVIR SOLN (Use Lamivudine) CO
EPIVIR TABS (Use Lamivudine) CO
EPZICOM TABS (Use Abacavir Sulfate-Lamivudine)
CO
EVOTAZ TABS CO
fosamprenavir calcium tabs CO
FUZEON SOLR CO
GENVOYA TABS CO
INTELENCE TABS CO
INVIRASE CAPS CO
INVIRASE TABS CO
ISENTRESS CHEW CO
ISENTRESS HD TABS CO
ISENTRESS PACK CO
ISENTRESS TABS CO
JULUCA TABS CO
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Drug Name DrugTier
Requirements/Limits
KALETRA SOLN 400MG/5ML-100MG/5ML(Use Lopinavir-Ritonavir)
CO
KALETRA TABS 100MG-25MG, 200MG-50MG CO
lamivudine soln CO
lamivudine tabs CO
lamivudine-zidovudine tabs CO
LEXIVA SUSP 50 MG/ML CO
LEXIVA TABS 700 MG (Use FosamprenavirCalcium)
CO
lopinavir-ritonavir soln CO
nevirapine tabs CO
nevirapine tb24 CO
NORVIR CAPS 100 MG CO
NORVIR SOLN 80 MG/ML CO
NORVIR TABS 100 MG (Use Ritonavir) CO
ODEFSEY TABS CO
PREZCOBIX TABS CO
PREZISTA SUSP CO
PREZISTA TABS CO
RESCRIPTOR TABS CO
RETROVIR CAPS (Use Zidovudine) NF SP
RETROVIR SYRP (Use Zidovudine) NF SP
REYATAZ CAPS 150 MG, 200 MG, 300 MG (Use Atazanavir Sulfate)
CO
REYATAZ PACK 50 MG CO
ritonavir tabs CO
Drug Name DrugTier
Requirements/Limits
SELZENTRY SOLN CO
SELZENTRY TABS CO
stavudine caps CO
STRIBILD TABS CO
SUSTIVA CAPS (Use Efavirenz) CO
SUSTIVA TABS (Use Efavirenz) CO
SYMFI LO TABS CO
tenofovir disoproxilfumarate tabs CO
TIVICAY TABS CO
TRIUMEQ TABS CO
TRIZIVIR TABS (Use Abacavir Sulfate-Lamivudine-Zidovudine)
CO
TROGARZO SOLN CO
TRUVADA TABS CO
TYBOST TABS CO
VIRACEPT TABS CO
VIRAMUNE SUSP 50 MG/5ML CO
VIRAMUNE TABS 200 MG (Use Nevirapine) CO
VIRAMUNE XR TB24 (Use Nevirapine) CO
VIREAD POWD 40 MG/GM CO
VIREAD TABS 150 MG, 200 MG, 250 MG CO
VIREAD TABS 300 MG (Use Tenofovir DisoproxilFumarate)
CO
VITEKTA TABS CO
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Drug Name DrugTier
Requirements/Limits
ZERIT CAPS 15 MG, 20 MG, 30 MG, 40 MG (Use Stavudine)
CO
ZERIT SOLR 1 MG/ML CO
ZIAGEN SOLN (Use Abacavir Sulfate) CO
ZIAGEN TABS (Use Abacavir Sulfate) CO
zidovudine caps F SP
zidovudine syrp F SP
zidovudine tabs F SP
CMV Agents VALCYTE TABS (Use Valganciclovir HCl) NF QL(2 ea daily)
valganciclovir hcl tabs F QL(2 ea daily)
Hepatitis Agents
MAVYRET TABS F PA; QL(3 eadaily); SP
Herpes Agents
acyclovir caps 200 mg F QL(50 ea per30 days retail)
acyclovir susp 200 mg/5ml F QL(400 ml per30 days retail)
acyclovir tabs 400 mg F QL(3 ea daily)
acyclovir tabs 800 mg F QL(50 ea per30 days retail)
famciclovir tabs F
FAMVIR TABS (Use Famciclovir) NF
valacyclovir hcl tabs 1 gm,1000 mg F QL(42 ea per
21 days retail) valacyclovir hcl tabs 500 mg F QL(2 ea daily)
VALTREX TABS 1 GM (Use Valacyclovir HCl) NF QL(42 ea per
21 days retail) VALTREX TABS 500 MG (Use Valacyclovir HCl) NF QL(2 ea daily)
ZOVIRAX CAPS OR 200 MG (Use Acyclovir) NF QL(50 ea per
30 days retail)
Drug Name DrugTier
Requirements/Limits
ZOVIRAX SUSP OR 200 MG/5ML (Use Acyclovir) NF QL(400 ml per
30 days retail) ZOVIRAX TABS OR 400 MG (Use Acyclovir) NF QL(3 ea daily)
ZOVIRAX TABS OR 800 MG (Use Acyclovir) NF QL(50 ea per
30 days retail) Influenza Agents oseltamivir phosphate caps30 mg F QL(20 ea per
30 days retail) oseltamivir phosphate caps45 mg, 75 mg F QL(10 ea per
30 days retail) oseltamivir phosphate susr6 mg/ml F QL(120 ml per
30 days retail)
RELENZA DISKHALER AEPB F
QL(20 ea perfill retail); AL; Atleast 5 yrs old
TAMIFLU CAPS 30 MG (Use Oseltamivir Phosphate)
F QL(20 ea per30 days retail)
TAMIFLU CAPS 45 MG, 75 MG (Use Oseltamivir Phosphate)
F QL(10 ea per30 days retail)
TAMIFLU SUSR 6 MG/ML(Use Oseltamivir Phosphate)
F QL(120 ml per30 days retail)
BETA BLOCKERS - Drugs to Treat High BloodPressure
Alpha-Beta Blockers
carvedilol phosphate cp24 F QL(1 ea daily)
carvedilol tabs 12.5 mg,6.25 mg, 3.125 mg F QL(3 ea daily)
carvedilol tabs 25 mg F QL(4 ea daily)
COREG CR CP24 (Use Carvedilol Phosphate) NF QL(1 ea daily)
COREG TABS 12.5 MG, 6.25 MG, 3.125 MG (Use Carvedilol)
NF QL(3 ea daily)
COREG TABS 25 MG (Use Carvedilol) NF QL(4 ea daily)
labetalol hcl tabs 100 mg F QL(3 ea daily)
labetalol hcl tabs 200 mg F QL(6 ea daily)
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Drug Name DrugTier
Requirements/Limits
labetalol hcl tabs 300 mg F QL(8 ea daily)
Beta Blockers Cardio-Selective
acebutolol hcl caps F
atenolol tabs F QL(2 ea daily)
bisoprolol fumarate tabs F QL(1 ea daily)
LOPRESSOR TABS (Use Metoprolol Tartrate) NF QL(4 ea daily)
metoprolol succinate tb24100 mg F QL(1 ea daily)
metoprolol succinate tb24200 mg F QL(2 ea daily)
metoprolol succinate tb2425 mg, 50 mg F QL(4 ea daily)
metoprolol tartrate tabs 25mg, 50 mg, 100 mg F QL(4 ea daily)
SECTRAL CAPS (Use Acebutolol HCl) NF
TENORMIN TABS (Use Atenolol) NF QL(2 ea daily)
TOPROL XL TB24 100 MG (Use Metoprolol Succinate) NF QL(1 ea daily)
TOPROL XL TB24 200 MG (Use Metoprolol Succinate) NF QL(2 ea daily)
TOPROL XL TB24 25 MG, 50 MG (Use MetoprololSuccinate)
NF QL(4 ea daily)
ZEBETA TABS (Use Bisoprolol Fumarate) NF QL(1 ea daily)
Beta Blockers Non-Selective BETAPACE AF TABS (Use Sotalol HCl (AFIB/AFL)) NF QL(2 ea daily)
BETAPACE TABS (Use Sotalol HCl) NF QL(2 ea daily)
CORGARD TABS (Use Nadolol) NF QL(2 ea daily)
HEMANGEOL SOLN F PA
INDERAL LA CP24 (Use Propranolol HCl) NF QL(2 ea daily)
nadolol tabs F QL(2 ea daily)
Drug Name DrugTier
Requirements/Limits
pindolol tabs F
propranolol hcl cp24 or 60mg, 80 mg, 120 mg, 160 mg
F QL(2 ea daily)
PROPRANOLOL HCL SOLN OR 20 MG/5ML, 40MG/5ML
F
propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg
F
sotalol hcl (afib/afl) tabs F QL(2 ea daily)
sotalol hcl tabs 240 mg F
sotalol hcl tabs 80 mg, 120mg, 160 mg F QL(2 ea daily)
TIMOLOL MALEATE TABS F
CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure
Calcium Channel Blockers ADALAT CC TB24 30 MG, 90 MG (Use Nifedipine) NF QL(1 ea daily)
ADALAT CC TB24 60 MG (Use Nifedipine) NF QL(2 ea daily)
amlodipine besylate tabs F QL(1 ea daily)
CALAN SR TBCR (Use Verapamil HCl) NF QL(2 ea daily)
CALAN TABS (Use Verapamil HCl) NF QL(3 ea daily)
CARDIZEM CD CP24 120 MG, 180 MG (Use Diltiazem HCl Coated Beads)
NF
QL(1 ea daily)
CARDIZEM CD CP24 240 MG (Use Diltiazem HCl Coated Beads)
NF QL(2 ea daily)
CARDIZEM TABS (Use Diltiazem HCl) NF QL(3 ea daily)
diltiazem hcl coated beads cp24 120 mg, 180 mg, 300 mg
F QL(1 ea daily)
diltiazem hcl coated beads cp24 240 mg F QL(2 ea daily)
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Drug Name DrugTier
Requirements/Limits
diltiazem hcl cp12 60 mg,90 mg, 120 mg F QL(2 ea daily)
diltiazem hcl cp24 120 mg,180 mg F QL(1 ea daily)
diltiazem hcl cp24 240 mg F QL(2 ea daily)
diltiazem hcl extended release beads cp24 F QL(1 ea daily)
diltiazem hcl tabs 30 mg,60 mg, 90 mg, 120 mg F QL(3 ea daily)
felodipine tb24 F QL(1 ea daily)
nicardipine hcl caps F
nifedipine caps 10 mg, 20 mg F QL(2 ea daily)
nifedipine tb24 30 mg, 90 mg F QL(1 ea daily)
nifedipine tb24 60 mg F QL(2 ea daily)
NORVASC TABS (Use Amlodipine Besylate) NF QL(1 ea daily)
PROCARDIA CAPS (Use Nifedipine) NF QL(2 ea daily)
PROCARDIA XL TB24 30 MG, 90 MG (Use Nifedipine)
NF QL(1 ea daily)
PROCARDIA XL TB24 60 MG (Use Nifedipine) NF QL(2 ea daily)
TIAZAC CP24 (Use Diltiazem HCl Extended Release Beads)
NF QL(1 ea daily)
verapamil hcl cp24 or 100mg, 200 mg, 300 mg F
verapamil hcl cp24 or 120mg, 180 mg, 240 mg F QL(2 ea daily)
VERAPAMIL HCL SR CP24 F QL(1 ea daily)
verapamil hcl tabs or 40mg, 80 mg, 120 mg F QL(3 ea daily)
verapamil hcl tbcr or 120mg, 180 mg, 240 mg F QL(2 ea daily)
VERELAN CP24 120 MG, 180 MG, 240 MG (Use Verapamil HCl)
NF QL(2 ea daily)
VERELAN CP24 360 MG F QL(1 ea daily)
Drug Name DrugTier
Requirements/Limits
VERELAN PM CP24 (Use Verapamil HCl) NF
CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm
Cardiac Glycosides DIGOXIN SOLN OR 0.05 MG/ML F
digoxin tabs or 0.125 mg,0.25 mg, 125 mcg, 250 mcg
F
LANOXIN TABS OR 125 MCG, 250 MCG (Use Digoxin)
F
CEPHALOSPORINS - Drugs to Treat BacterialInfections
Cephalosporins - 1st Generation
cefadroxil caps F
cefadroxil susr F
cefadroxil tabs F
cephalexin caps 250 mg,500 mg F
cephalexin susr 125mg/5ml, 250 mg/5ml F
KEFLEX CAPS 250 MG, 500 MG (Use Cephalexin) NF
Cephalosporins - 2nd Generation cefaclor caps 250 mg, 500 mg F
CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML,375 MG/5ML
F
cefprozil susr 125 mg/5ml,250 mg/5ml F
QL(100 ml perfill retail); AL;Up to 12 yrs old
cefprozil tabs 250 mg, 500 mg F QL(20 ea per
fill retail)
CEFTIN SUSR 125 MG/5ML, 250 MG/5ML F
QL(100 ml perfill retail); AL;Up to 12 yrs old
CEFTIN TABS 500 MG (Use Cefuroxime Axetil) NF QL(20 ea per
fill retail)
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Drug Name DrugTier
Requirements/Limits
cefuroxime axetil tabs F QL(20 ea perfill retail)
Cephalosporins - 3rd Generation
cefdinir caps 300 mg F QL(20 ea perfill retail)
cefdinir susr 125 mg/5ml,250 mg/5ml F QL(20 ml per
fill retail) ceftriaxone sodium solr ij 1gm, 250 mg, 500 mg F QL(3 ea per fill
retail)
CHEMICALS
Bulk Chemicals - H's
HALOPERIDOL POWD XX CO
CONTRACEPTIVES - Drugs to PreventPregnancy
Combination Contraceptives - Oral BREVICON-28 TABS (Use Norethindrone & Eth Estradiol)
NF 365 day supplyallowed;QL(1ea daily)
CYCLESSA TABS (Use Desogestrel-EthinylEstradiol (Triphasic))
NF 365 day supplyallowed;QL(1ea daily)
DESOGEN TABS (Use Desogestrel & EthinylEstradiol)
NF 365 day supplyallowed;QL(1ea daily)
desogestrel & ethinylestradiol tabs F
365 day supplyallowed;QL(1ea daily)
desogestrel-ethinylestradiol (biphasic) tabs F
365 day supplyallowed;QL(1ea daily)
desogestrel-ethinylestradiol (triphasic) tabs F
365 day supplyallowed;QL(1ea daily)
drospirenone-ethinylestradiol tabs F
365 day supplyallowed;QL(1ea daily)
ESTROSTEP FE TABS (Use Norethindrone Acetate-Ethinyl Estradiol-Fe)
NF
365 day supplyallowed;
ethynodiol diacet & ethestrad tabs F
365 day supplyallowed;QL(1ea daily)
Drug Name DrugTier
Requirements/Limits
FEMCON FE CHEW (Use Norethindrone & EthinylEstradiol-Fe)
NF 365 day supplyallowed;
GENERESS FE CHEW (Use Norethindrone & Ethinyl Estradiol-Fe)
NF 365 day supplyallowed;
levonorgestrel & ethestradiol tabs F
365 day supplyallowed;QL(1ea daily)
levonorgestrel-eth estradiol(triphasic) tabs F
365 day supplyallowed;QL(1ea daily)
levonorgestrel-ethinylestradiol (91-day) tabs F
365 day supplyallowed;QL(1ea daily,91day(s) limit)
LOESTRIN 1.5/30-21TABS (Use Norethindrone Acet & Eth Estra)
NF 365 day supplyallowed;QL(1ea daily)
LOESTRIN 1/20-21 TABS(Use Norethindrone Acet & Eth Estra)
NF 365 day supplyallowed;QL(1ea daily)
LOESTRIN FE 1.5/30TABS (Use Norethin Acet & Estrad-Fe)
NF 365 day supplyallowed;QL(1ea daily)
LOESTRIN FE 1/20 TABS(Use Norethin Acet & Estrad-Fe)
NF 365 day supplyallowed;QL(1ea daily)
MIRCETTE TABS (Use Desogestrel-EthinylEstradiol (Biphasic))
NF 365 day supplyallowed;QL(1ea daily)
MODICON TABS (Use Norethindrone & Eth Estradiol)
NF 365 day supplyallowed;QL(1ea daily)
NECON 1/50-28 TABS F 365 day supplyallowed;QL(1ea daily)
NECON 10/11-28 TABS F 365 day supplyallowed;QL(1ea daily)
norethin acet & estrad-fe tabs 75mg-20mcg-1mg,75mg-30mcg-1.5mg
F 365 day supplyallowed;QL(1ea daily)
norethindrone & eth estradiol tabs F
365 day supplyallowed;QL(1ea daily)
norethindrone & ethinylestradiol-fe chew F 365 day supply
allowed;
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Drug Name DrugTier
Requirements/Limits
norethindrone acet & eth estra tabs F
365 day supplyallowed;QL(1ea daily)
norethindrone acetate-ethinyl estradiol-fe tabs F 365 day supply
allowed;
norethindrone-eth estradiol (triphasic) tabs F
365 day supplyallowed;QL(1ea daily)
norgestimate-ethinylestradiol (triphasic) tabs F
365 day supplyallowed;QL(1ea daily)
norgestimate-ethinylestradiol (triphasic) tabs F 365 day supply
allowed;
norgestimate-ethinylestradiol tabs F
365 day supplyallowed;QL(1ea daily)
norgestrel & ethinylestradiol tabs F
365 day supplyallowed;QL(2ea daily)
NORINYL 1+35 TABS (Use Norethindrone & Eth Estradiol)
NF 365 day supplyallowed;QL(1ea daily)
NORINYL 1+50 TABS F 365 day supplyallowed;QL(1ea daily)
OGESTREL TABS F 365 day supplyallowed;QL(1ea daily)
ORTHO TRI-CYCLEN LO TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))
NF
365 day supplyallowed;
ORTHO TRI-CYCLEN TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))
NF
365 day supplyallowed;QL(1ea daily)
ORTHO-CYCLEN TABS (Use Norgestimate-EthinylEstradiol)
NF 365 day supplyallowed;QL(1ea daily)
ORTHO-NOVUM 1/35TABS (Use Norethindrone & Eth Estradiol)
NF 365 day supplyallowed;QL(1ea daily)
ORTHO-NOVUM 7/7/7TABS (Use Norethindrone-Eth Estradiol (Triphasic))
NF 365 day supplyallowed;QL(1ea daily)
OVCON-35 TABS (Use Norethindrone & Eth Estradiol)
NF 365 day supplyallowed;QL(1ea daily)
Drug Name DrugTier
Requirements/Limits
SEASONIQUE TABS (Use Levonorgestrel-EthinylEstradiol (91-Day))
NF
365 day supplyallowed;QL(1ea daily,91day(s) limit)
TRI-NORINYL 28 TABS (Use Norethindrone-Eth Estradiol (Triphasic))
NF 365 day supplyallowed;QL(1ea daily)
YASMIN 28 TABS (Use Drospirenone-EthinylEstradiol)
NF 365 day supplyallowed;QL(1ea daily)
YAZ TABS (Use Drospirenone-EthinylEstradiol)
NF 365 day supplyallowed;QL(1ea daily)
Combination Contraceptives - Transdermal
XULANE PTWK F 365 day supplyallowed;QL(3ea per fill retail)
Combination Contraceptives - Vaginal
NUVARING RING F 365 day supplyallowed;QL(1ea per fill retail)
Emergency Contraceptives
ELLA TABS F QL(4 ea per365 days retail)
levonorgestrel (emergencyoc) tabs F QL(6 ea per
365 days retail) PLAN B ONE-STEP TABS (Use Levonorgestrel(Emergency OC))
NF QL(6 ea per365 days retail)
Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSP (Use MedroxyprogesteroneAcetate (Contraceptive))
NF
QL(1 ml per fillretail)
DEPO-PROVERA CONTRACEPTIVE SUSY (Use MedroxyprogesteroneAcetate (Contraceptive))
NF
QL(1 ml per fillretail)
DEPO-SUBQ PROVERA 104 SUSY F QL(1 ml per fill
retail) medroxyprogesteroneacetate (contraceptive) susp
F QL(1 ml per fillretail)
medroxyprogesteroneacetate (contraceptive) susy
F QL(1 ml per fillretail)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
Progestin Contraceptives - Oral NOR-QD TABS (Use Norethindrone (Contraceptive))
NF 365 day supplyallowed;QL(1ea daily)
norethindrone (contraceptive) tabs F
365 day supplyallowed;QL(1ea daily)
ORTHO MICRONOR TABS (Use Norethindrone (Contraceptive))
NF 365 day supplyallowed;QL(1ea daily)
CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions
Glucocorticosteroids CORTEF TABS (Use Hydrocortisone) NF
CORTISONE ACETATE TABS F
dexamethasone elix 0.5 mg/5ml F
DEXAMETHASONE INTENSOL CONC F
dexamethasone sodium phosphate soln ij 4 mg/ml,20 mg/5ml, 120 mg/30ml
F QL(5 ml daily)
DEXAMETHASONE SOLN 0.5 MG/5ML F
dexamethasone tabs 0.75 mg, 0.5 mg, 4 mg, 6 mg,1.5 mg
F
DEXAMETHASONE TABS 1 MG, 2 MG F
hydrocortisone tabs F
MEDROL DOSEPAK TBPK (Use Methylprednisolone) NF
MEDROL TABS 4 MG, 8 MG (Use Methylprednisolone)
NF
methylprednisolone tabs 4mg, 8 mg F
methylprednisolone tbpk 4 mg F
PEDIAPRED SOLN (Use Prednisolone Sodium Phosphate)
NF
Drug Name DrugTier
Requirements/Limits
prednisolone sodiumphosphate soln or 15mg/5ml
F QL(240 ml perfill retail)
prednisolone sodiumphosphate soln or 20mg/5ml
F QL(150 ml perfill retail)
prednisolone sodiumphosphate soln or 5mg/5ml, 6.7 mg/5ml
F
prednisolone soln F
PREDNISOLONE SOLN F
prednisolone syrp F
PREDNISONE INTENSOL CONC F
PREDNISONE SOLN 5 MG/5ML F
prednisone tabs 1 mg, 5mg, 10 mg, 20 mg, 2.5 mg F
PREDNISONE TABS 50 MG F
PREDNISONE TBPK 5 MG, 10 MG F
VERIPRED 20 SOLN (Use Prednisolone Sodium Phosphate)
NF QL(150 ml perfill retail)
Mineralocorticoids
fludrocortisone acetate tabs F
COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy Symptoms
Antitussives benzonatate caps 100 mg,200 mg F AL; At least 10
yrs old hydrocodone w/homatropine syrp 5mg/5ml-1.5mg/5ml
F
TESSALON PERLES CAPS (Use Benzonatate) NF AL; At least 10
yrs old
Cough/Cold/Allergy Combinations ADVIL COLD & SINUS TABS (Use Pseudoephedrine-Ibuprofen)
NF
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
brompheniramine &phenyleph elix F
brompheniramine &pseudoeph elix F
brompheniramine &pseudoeph liqd F
cetirizine-pseudoephedrinetb12 F
CHERACOL PLUS LIQD (Use Dextromethorphan-Guaifenesin)
NF
CHERACOL-D COUGH LIQD (Use Dextromethorphan-Guaifenesin)
NF
CLARITIN-D 12 HOUR TB12 (Use Loratadine & Pseudoephedrine)
NF
CLARITIN-D 24 HOUR TB24 (Use Loratadine & Pseudoephedrine)
NF
DECON-A ELIX F
DECON-A LIQD F
dextromethorphan-guaifenesin liqd F
dextromethorphan-guaifenesin soln F
DIMETAPP COLD & ALLERGY ELIX 1MG/5ML-2.5MG/5ML (Use Brompheniramine &Phenyleph)
NF
guaifenesin-codeine liqd F
guaifenesin-codeine soln F
guaifenesin-codeine syrp F
loratadine & pseudoephedrine tb12 F
loratadine & pseudoephedrine tb24 F
promethazine &phenylephrine soln F
QL(240 ml perfill retail); AL; Atleast 2 yrs old
Drug Name DrugTier
Requirements/Limits
promethazine &phenylephrine syrp F
QL(240 ml perfill retail); AL; Atleast 2 yrs old
promethazine w/codeinesoln F
QL(240 ml perfill retail); AL; Atleast 6 yrs old
promethazine w/codeine syrp F
QL(240 ml perfill retail); AL; Atleast 6 yrs old
PROMETHAZINE/PHENYLEPHRINE SYRP F
QL(240 ml perfill retail); AL; Atleast 2 yrs old
pseudoephedrine w/codeine-gg soln F
pseudoephedrine-ibuprofentabs F
ZYRTEC-D ALLERGY/CONGESTIONTB12 (Use Cetirizine-Pseudoephedrine)
NF
Misc. Respiratory Inhalants sodium chloride (inhalant)aers 0.9 % F
sodium chloride (inhalant)nebu 0.9 % F
Mucolytics
acetylcysteine soln F
DERMATOLOGICALS - Drugs to Treat SkinConditions
Acne Products ACNE MEDICATION 10 LOTN F
ACNE MEDICATION 5 LOTN F
BENZAC AC WASH LIQD (Use Benzoyl Peroxide) NF RX/OTC
benzoyl peroxide bar 10 % F
BENZOYL PEROXIDE CLEANSER LOTN 6 % F
benzoyl peroxide gel 10 % F RX/OTC
BENZOYL PEROXIDE GEL 2.5 % F
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
benzoyl peroxide gel 5 % F
benzoyl peroxide liqd 4 % F
benzoyl peroxide liqd 5 %,10 % F RX/OTC
benzoyl peroxide lotn 6 % F
CLEAN & CLEAR ADVANTAGE 3-IN-1 EXFOLIATING CLEANSER LOTN
F
CLEOCIN-T GEL (Use Clindamycin Phosphate(Topical))
NF QL(75 ml perfill retail)
CLEOCIN-T LOTN (Use Clindamycin Phosphate(Topical))
NF QL(60 ml perfill retail)
CLEOCIN-T SOLN (Use Clindamycin Phosphate(Topical))
NF
CLINDAGEL GEL F QL(75 ml perfill retail)
clindamycin phosphate(topical) gel F QL(75 ml per
fill retail) clindamycin phosphate(topical) lotn F QL(60 ml per
fill retail) clindamycin phosphate(topical) soln F
DESQUAM-X WASH LIQD (Use Benzoyl Peroxide) NF RX/OTC
ERYGEL GEL (Use Erythromycin (Acne Aid)) NF QL(60 gm per
fill retail)
erythromycin (acne aid) gel F QL(60 gm perfill retail)
erythromycin (acne aid)soln F
isotretinoin caps 10 mg, 20mg, 40 mg F
QL(2 ea daily);AL; At least 12 yrs old
KLARON LOTN (Use Sulfacetamide Sodium (Acne))
NF QL(120 ml perfill retail)
PANOXYL-4 CREAMY WASH LIQD (Use BenzoylPeroxide)
NF
Drug Name DrugTier
Requirements/Limits
RETIN-A CREA (Use Tretinoin) NF
QL(45 gm perfill retail); AL;Up to 35 yrs old
RETIN-A GEL (Use Tretinoin) NF
QL(45 gm perfill retail); AL;Up to 35 yrs old
SODIUM SULFACETAMIDE/SULFUR LOTN
F QL(60 gm perfill retail)
SODIUM SULFACETAMIDE/SULFUR SUSP
F QL(30 gm perfill retail)
sulfacetamide sodium (acne) lotn F QL(120 ml per
fill retail) sulfacetamide sodium w/sulfur lotn 5%-10% F QL(60 gm per
fill retail)
tretinoin crea 0.025 %, 0.05%, 0.1 % F
QL(45 gm perfill retail); AL;Up to 35 yrs old
tretinoin gel 0.025 %, 0.01% F
QL(45 gm perfill retail); AL;Up to 35 yrs old
Anti-inflammatory Agents - Topical diclofenac sodium (topical)gel 1 % F QL(6.68 gm
daily) VOLTAREN GEL (Use Diclofenac Sodium (Topical))
NF QL(6.68 gmdaily)
Antibiotics - Topical BACIGUENT OINT (Use Bacitracin (Topical)) NF QL(454 gm per
fill retail)
bacitracin (topical) oint F QL(454 gm perfill retail)
bacitracin zinc oint F QL(454 gm perfill retail)
BACTROBAN CREA (Use Mupirocin Calcium(Topical))
NF QL(30 gm perfill retail)
gentamicin sulfate (topical) crea F QL(30 gm per
fill retail) gentamicin sulfate (topical)oint F QL(30 gm per
fill retail) mupirocin calcium (topical) crea F QL(30 gm per
fill retail)
mupirocin oint F QL(30 gm perfill retail)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
neomycin-bacitracin-polymyxin oint F QL(454 gm per
fill retail) neomycin-polymyxin w/pramoxine crea F QL(30 gm per
fill retail) NEOSPORIN ORIGINAL OINT (Use Neomycin-Bacitracin-Polymyxin)
NF QL(454 gm perfill retail)
NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH CREA (Use Neomycin-Polymyxin w/Pramoxine)
NF
QL(30 gm perfill retail)
Antifungals - Topical
clotrimazole (topical) crea F QL(113 gm perfill retail);RX/OTC
clotrimazole (topical) soln F QL(60 ml perfill retail);RX/OTC
clotrimazole w/betamethasone crea F QL(45 gm per
fill retail) clotrimazole w/betamethasone lotn F QL(30 ml per
fill retail)
econazole nitrate crea F QL(85 gm perfill retail)
ketoconazole (topical) crea F QL(60 gm perfill retail)
ketoconazole (topical)sham F QL(120 ml per
fill retail) LAMISIL AT CREA (Use Terbinafine HCl (Topical)) NF QL(42 gm per
fill retail) LAMISIL AT JOCK ITCH CREA (Use Terbinafine HCl (Topical))
NF QL(42 gm perfill retail)
LOTRIMIN AF CREA 1 % (Use Clotrimazole (Topical))
NF QL(113 gm perfill retail);RX/OTC
LOTRIMIN AF FOR HER CREA (Use Clotrimazole (Topical))
NF QL(113 gm perfill retail);RX/OTC
LOTRIMIN AF JOCK ITCH CREA (Use Clotrimazole (Topical))
NF QL(113 gm perfill retail);RX/OTC
LOTRISONE CREA (Use Clotrimazole w/Betamethasone)
NF QL(45 gm perfill retail)
Drug Name DrugTier
Requirements/Limits
MICATIN CREA (Use Miconazole Nitrate (Topical))
NF QL(200 ml perfill retail)
miconazole nitrate (topical) crea F QL(200 ml per
fill retail)
NIZORAL A-D SHAM F QL(200 ml perfill retail)
NIZORAL SHAM (Use Ketoconazole (Topical)) NF QL(120 ml per
fill retail)
nystatin (topical) crea F QL(30 gm perfill retail)
nystatin (topical) oint F QL(30 gm perfill retail)
nystatin (topical) powd F QL(60 gm perfill retail)
nystatin-triamcinolone crea F QL(60 gm perfill retail)
nystatin-triamcinolone oint F QL(60 gm perfill retail)
terbinafine hcl (topical) crea F QL(42 gm perfill retail)
TINACTIN CREA (Use Tolnaftate) NF QL(144 gm per
fill retail) TINACTIN JOCK ITCH CREA (Use Tolnaftate) NF QL(144 gm per
fill retail)
tolnaftate crea F QL(144 gm perfill retail)
Antihistamines-Topical diphenhydramine hcl(topical) crea F
Antineoplastic or Premalignant Lesion Agents -
CARAC CREA F QL(30 gm perfill retail)
EFUDEX CREA (Use Fluorouracil (Topical)) NF QL(40 gm per
fill retail)
fluorouracil (topical) crea F QL(40 gm perfill retail)
FLUOROURACIL CREA 0.5 % F QL(30 gm per
fill retail) FLUOROURACIL SOLN 2 %, 5 % F QL(10 ml per
fill retail) Antipruritics - Topical
camphor & menthol lotn F QL(222 ml perfill retail)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
SARNA LOTN (Use Camphor & Menthol) NF QL(222 ml per
fill retail) Antipsoriatics
calcipotriene crea F QL(60 gm perfill retail)
calcipotriene soln F QL(60 ml perfill retail)
DOVONEX CREA (Use Calcipotriene) NF QL(60 gm per
fill retail)
tazarotene crea F QL(60 gm perfill retail)
TAZORAC CREA 0.05 % F QL(60 gm perfill retail)
TAZORAC CREA 0.1 % (Use Tazarotene) NF QL(60 gm per
fill retail) TAZORAC GEL 0.05 %, 0.1 % F QL(100 gm per
fill retail) Antiseborrheic Products OVACE PLUS WASH LIQD (Use Sulfacetamide Sodium)
NF QL(480 ml perfill retail)
OVACE WASH LIQD (Use Sulfacetamide Sodium) NF QL(480 ml per
fill retail)
selenium sulfide lotn 1 % F
selenium sulfide lotn 2.5 % F QL(120 ml perfill retail)
selenium sulfide sham 1 % F
SELSUN BLUE DAILY LOTN (Use Selenium Sulfide)
NF
SELSUN BLUE LOTN (Use Selenium Sulfide) NF
SELSUN BLUE MEDICATED LOTN (Use Selenium Sulfide)
NF
SELSUN BLUE MOISTURIZING LOTN (Use Selenium Sulfide)
NF
sulfacetamide sodium liqd ex F QL(480 ml per
fill retail) Antivirals - Topical
acyclovir topical oint F QL(30 gm perfill retail)
Drug Name DrugTier
Requirements/Limits
ZOVIRAX CREA EX 5 % F QL(5 gm per fillretail)
ZOVIRAX OINT EX 5 % (Use Acyclovir Topical) NF QL(30 gm per
fill retail) Burn Products SILVADENE CREA (Use Silver Sulfadiazine) NF QL(400 gm per
fill retail)
silver sulfadiazine crea F QL(400 gm perfill retail)
Corticosteroids - Topical
APEXICON E CREA F QL(60 gm perfill retail)
betamethasone dipropionate (topical) crea F 1 rtl pack lmt
per fill, betamethasone dipropionate augmented crea
F QL(50 gm perfill retail)
betamethasone valerate crea 0.1 % F QL(45 gm per
fill retail) betamethasone valerate lotn 0.1 % F QL(60 ml per
fill retail) betamethasone valerate oint 0.1 % F QL(45 gm per
fill retail)
clobetasol propionate crea F QL(60 gm perfill retail)
clobetasol propionateemollient base crea F QL(60 gm per
fill retail)
clobetasol propionate gel F QL(60 gm perfill retail)
clobetasol propionate oint F QL(60 gm perfill retail)
clobetasol propionate soln F QL(50 ml perfill retail)
DERMATOP CREA (Use Prednicarbate) NF QL(60 gm per
fill retail) desoximetasone crea 0.05 % F QL(300 gm per
fill retail) DIFLORASONE DIACETATE CREA F QL(60 gm per
fill retail) DIFLORASONE DIACETATE OINT F QL(60 gm per
fill retail) DIPROLENE AF CREA (Use Betamethasone Dipropionate Augmented)
NF QL(50 gm perfill retail)
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
ELOCON CREA (Use Mometasone Furoate) NF QL(50 gm per
fill retail) ELOCON OINT (Use Mometasone Furoate) NF QL(45 gm per
fill retail)
EPIFOAM FOAM F
fluocinonide crea 0.05 % F QL(120 gm perfill retail)
fluocinonide emulsified base crea F QL(60 gm per
fill retail)
fluocinonide gel 0.05 % F QL(60 gm perfill retail)
fluocinonide oint 0.05 % F QL(60 gm perfill retail)
fluocinonide soln 0.05 % F QL(60 ml perfill retail)
fluticasone propionate crea0.05 % F QL(60 gm per
fill retail) fluticasone propionate oint0.005 % F QL(60 gm per
fill retail) hydrocortisone (topical)crea 0.5 % F
hydrocortisone (topical)crea 1%, 1 % F
QL(454 gm perfill retail);RX/OTC
hydrocortisone (topical)crea 2.5 % F QL(454 gm per
fill retail) hydrocortisone (topical)lotn 1 % F QL(120 ml per
fill retail) hydrocortisone (topical)lotn 2.5 % F QL(118 ml per
fill retail)
hydrocortisone (topical)oint 1 % F
QL(454 gm perfill retail);RX/OTC
hydrocortisone (topical)oint 2.5 % F QL(454 gm per
fill retail) hydrocortisone butyratesoln F QL(60 ml per
fill retail) hydrocortisone-aloe veracrea 1% F QL(224 gm per
fill retail) LOCOID SOLN (Use Hydrocortisone Butyrate) NF QL(60 ml per
fill retail)
mometasone furoate crea F QL(50 gm perfill retail)
mometasone furoate oint F QL(45 gm perfill retail)
Drug Name DrugTier
Requirements/Limits
mometasone furoate soln F QL(60 ml perfill retail)
MONISTAT SOOTHING CARE ITCH RELIEF CREA (Use Hydrocortisone(Topical))
NF
QL(454 gm perfill retail);RX/OTC
PREDNICARBATE CREA F QL(60 gm perfill retail)
prednicarbate crea F QL(60 gm perfill retail)
PREDNICARBATE OINT F QL(60 gm perfill retail)
PSORCON CREA F QL(60 gm perfill retail)
TEMOVATE CREA (Use Clobetasol Propionate) NF QL(60 gm per
fill retail) TEMOVATE E CREA (Use Clobetasol PropionateEmollient Base)
NF QL(60 gm perfill retail)
TEMOVATE OINT (Use Clobetasol Propionate) NF QL(60 gm per
fill retail) TOPICORT CREA 0.05 % (Use Desoximetasone) NF QL(300 gm per
fill retail) triamcinolone acetonide (topical) crea 0.025 %, 0.1%
F QL(454 gm perfill retail)
triamcinolone acetonide (topical) crea 0.5 % F QL(15 gm per
fill retail) triamcinolone acetonide (topical) lotn 0.025 %, 0.1%
F QL(60 ml perfill retail)
triamcinolone acetonide (topical) oint 0.025 %, 0.1%
F QL(454 gm perfill retail)
triamcinolone acetonide (topical) oint 0.5 % F QL(15 gm per
fill retail) Emollient/Keratolytic Agents
urea crea 40 % F QL(200 gm perfill retail);RX/OTC
urea lotn 40 % F QL(325 ml perfill retail)
Emollients LAC-HYDRIN CREA (Use Lactic Acid (AmmoniumLactate))
NF QL(385 gm perfill retail);RX/OTC
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
LAC-HYDRIN LOTN (Use Lactic Acid (AmmoniumLactate))
NF QL(567 ml perfill retail);RX/OTC
LAC-HYDRIN TWELVE LOTN (Use Lactic Acid (Ammonium Lactate))
NF QL(567 ml perfill retail);RX/OTC
lactic acid (ammoniumlactate) crea 12 % F
QL(385 gm perfill retail);RX/OTC
lactic acid (ammoniumlactate) lotn 12 % F
QL(567 ml perfill retail);RX/OTC
Immunomodulating Agents - Topical ALDARA CREA (Use Imiquimod) NF
imiquimod crea F
Immunosuppressive Agents - Topical
ELIDEL CREA F
PA; QL(30 gmper fill retail);AL; At least 2 yrs old
Keratolytic/Antimitotic Agents CONDYLOX SOLN (Use Podofilox) NF QL(4 ml per fill
retail) KERALYT GEL (Use Salicylic Acid) NF QL(100 gm per
fill retail)
podofilox soln F QL(4 ml per fillretail)
salicylic acid gel F QL(100 gm perfill retail)
Local Anesthetics - Topical ARTHRITIS PAIN RELIEVING CREA F QL(60 gm per
fill retail)
capsaicin crea 0.025 % F
capsaicin crea 0.075 % F QL(60 gm perfill retail)
capsaicin crea 0.1 % F QL(43 gm perfill retail)
CAPZASIN-HP CREA (Use Capsaicin) NF QL(43 gm per
fill retail)
CAPZASIN-P CREA F QL(43 gm perfill retail)
Drug Name DrugTier
Requirements/Limits
dibucaine oint F QL(57 gm perfill retail)
lidocaine crea 4 % F QL(1 gm daily)
lidocaine hcl crea ex 3 % F QL(454 gm perfill retail)
lidocaine hcl crea ex 4 % F QL(2 ml daily)
lidocaine hcl gel ex 2 % F QL(30 ml perfill retail);RX/OTC
lidocaine-prilocaine crea F QL(30 gm perfill retail)
LMX 4 CREA (Use Lidocaine) NF QL(1 gm daily)
PREDATOR CREA (Use Lidocaine HCl) NF QL(2 ml daily)
Misc. Topical
DRYSOL SOLN F QL(60 ml perfill retail)
lanolin (topical) crea F
OFF DEEP WOODS AERO F QL(170 gm perfill retail)
OFF DEEP WOODS DRY AERO F QL(113 gm per
fill retail) ULTRATHON INSECT REPELLENT 8 AERO F QL(170 gm per
fill retail) zinc oxide (topical) oint 20% F QL(500 gm per
fill retail) Rosacea Agents METROCREAM CREA (Use Metronidazole (Topical))
NF QL(45 gm perfill retail)
METROLOTION LOTN (Use Metronidazole (Topical))
NF
metronidazole (topical)crea 0.75 % F QL(45 gm per
fill retail) metronidazole (topical) gel0.75 % F QL(45 gm per
fill retail) metronidazole (topical) lotn0.75 % F
Scabicides & Pediculicides
A-200 GEL EX 0.33%-4% F
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
ELIMITE CREA (Use Permethrin) NF QL(60 gm per
fill retail)
EURAX CREA F QL(60 gm perfill retail)
EURAX LOTN F QL(454 gm perfill retail)
KLOUT SHAM F
LICEMD GEL F
LICIDE TREATMENT KIT KIT F
malathion lotn F QL(59 ml perfill retail)
NIX CREME RINSE LIQD (Use Permethrin) NF
OVIDE LOTN (Use Malathion) NF QL(59 ml per
fill retail)
permethrin aero xx 0.5 % F
permethrin crea ex 5 % F QL(60 gm perfill retail)
permethrin liqd ex 1 % F
permethrin lotn ex 1 % F QL(120 ml perfill retail)
pyrethrins-piperonylbutoxide liqd 0.33%-4% F QL(240 ml per
fill retail) pyrethrins-piperonylbutoxide liqd 1.2%-0.3%-0.3%-2.4%-3%
F
pyrethrins-piperonylbutoxide sham 0.3%-0.33%-4%, 0.33%-4%
F
pyrethrins-piperonylbutoxide sham 0.33%-4% F QL(240 ml per
fill retail) pyrethrins-piperonylbutoxide-permethrin-nitremover kit
F
RA LICE SOLUTION KIT KIT F
RID AERO XX 0.5 % (Use Permethrin) NF
Drug Name DrugTier
Requirements/Limits
RID COMPLETE LICE ELIMINATION KIT (Use Pyrethrins-PiperonylButoxide-Permethrin-Nit Remover)
NF
RID ESSENTIAL LICE ELIMINATION KIT KIT F
RID LIQD EX 0.33%-4% (Use Pyrethrins-PiperonylButoxide)
NF QL(240 ml perfill retail)
SCHOOLTIME SHAMPOO SHAM F
SPINOSAD SUSP F
QL(120 ml perfill retail,240 ml per 30 daysretail)
Tar Products
coal tar extract sham 0.5 % F
DHS TAR GEL SHAM (Use Coal Tar Extract) NF
DHS TAR SHAM (Use Coal Tar Extract) NF
NEUTROGENA T/GELSHAM (Use Coal Tar Extract)
NF
NEUTROGENA T/GELSTUBBORN ITCH CONTROL SHAM (Use Coal Tar Extract)
NF
DIAGNOSTIC PRODUCTS
Diagnostic Tests CHEK-STIX COMBO PAK URINALYSIS CONTROL STRP
F QL(50 ea perfill retail)
CHEK-STIX CONTROL STRP F QL(50 ea per
fill retail)
CHEMSTRIP-K STRP F QL(50 ea perfill retail)
KETOCARE STRP F QL(50 ea perfill retail)
KETONE TEST STRIPS STRP F QL(50 ea per
fill retail)
KETOSTIX STRP F QL(50 ea perfill retail)
CA Health & Wellness Preferred Drug List Update July 1, 2018
43
Drug Name DrugTier
Requirements/Limits
NOVA MAX PLUS KETONE TESTSTRIPS STRP
F
PRECISION XTRA STRP VI F
PTS PANELS KETONE TEST STRP F
RELION KETONE STRP F QL(50 ea perfill retail)
RELION KETONE TEST STRIPS STRP F QL(50 ea per
fill retail) TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP
F QL(5 ea daily);RX/OTC
TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP
F QL(5 ea daily);RX/OTC
TRUETEST BLOOD GLUCOSE TEST STRIPS STRP
F QL(5 ea daily);RX/OTC
TRUETEST BLOOD GLUCOSE TEST STRP F QL(5 ea daily);
RX/OTC
TRUETEST STRIPS STRP F QL(5 ea daily);RX/OTC
TRUETRACK BLOOD GLUCOSE TEST STRP F QL(5 ea daily);
RX/OTC
TRUETRACK TEST STRP F QL(5 ea daily);RX/OTC
TRUETRACK TEST STRP F
INSULIN USERS LIMITED TO 150 PER 30 DAYS, NON-INSULIN USERS LIMITED TO 100 PER 90 DAYS;RX/OTC
DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes
Digestive Enzymes
CREON CPEP F
Drug Name DrugTier
Requirements/Limits
PANCREAZE CPEP 14200UNIT-4200UNIT-24600UNIT, 35500UNIT-10500UNIT-61500UNIT, 54700UNIT-21000UNIT-83900UNIT, 56800UNIT-16800UNIT-98400UNIT
F
DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood Pressure
Carbonic Anhydrase Inhibitors
acetazolamide cp12 F
acetazolamide tabs F
DIAMOX CP12 (Use Acetazolamide) NF
methazolamide tabs F
NEPTAZANE TABS (Use Methazolamide) NF
Diuretic Combinations ALDACTAZIDE TABS 25MG-25MG (Use Spironolactone &Hydrochlorothiazide)
NF
amiloride & hydrochlorothiazide tabs F QL(1 ea daily)
DYAZIDE CAPS (Use Triamterene & Hydrochlorothiazide)
NF QL(1 ea daily)
MAXZIDE TABS (Use Triamterene & Hydrochlorothiazide)
NF QL(1 ea daily)
MAXZIDE-25 TABS (Use Triamterene & Hydrochlorothiazide)
NF QL(1 ea daily)
spironolactone &hydrochlorothiazide tabs F
triamterene & hydrochlorothiazide caps F QL(1 ea daily)
triamterene & hydrochlorothiazide tabs F QL(1 ea daily)
TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS F QL(1 ea daily)
Loop Diuretics
CA Health & Wellness Preferred Drug List Update July 1, 2018
44
Drug Name DrugTier
Requirements/Limits
bumetanide tabs F
BUMEX TABS (Use Bumetanide) NF
DEMADEX TABS 20 MG (Use Torsemide) NF
DEMADEX TABS 5 MG, 10 MG (Use Torsemide) NF QL(1 ea daily)
furosemide soln or 10 mg/ml F
FUROSEMIDE SOLN OR 8 MG/ML F
furosemide tabs or 20 mg,40 mg, 80 mg F
LASIX TABS (Use Furosemide) NF
torsemide tabs 20 mg F
torsemide tabs 5 mg, 10mg, 100 mg F QL(1 ea daily)
Potassium Sparing Diuretics ALDACTONE TABS (Use Spironolactone) NF
amiloride hcl tabs F QL(4 ea daily)
spironolactone tabs F
Thiazides and Thiazide-Like Diuretics CHLOROTHIAZIDE TABS 250 MG F QL(2 ea daily)
chlorothiazide tabs 500 mg F QL(4 ea daily)
chlorthalidone tabs F
hydrochlorothiazide caps12.5 mg F
hydrochlorothiazide tabs 25mg, 50 mg F
indapamide tabs F
metolazone tabs F
MICROZIDE CAPS (Use Hydrochlorothiazide) NF
Drug Name DrugTier
Requirements/Limits
ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate Hormones
Bone Density Regulators ACTONEL TABS 35 MG (Use Risedronate Sodium) NF PA; QL(0.15 ea
daily) ACTONEL TABS 5 MG, 30 MG (Use Risedronate Sodium)
NF PA; QL(1 eadaily)
ALENDRONATE SODIUM SOLN 70 MG/75ML F QL(10.8 ml
daily) alendronate sodium tabs 35 mg, 70 mg F QL(0.15 ea
daily) ALENDRONATE SODIUM TABS 40 MG F QL(1 ea daily)
alendronate sodium tabs 5 mg, 10 mg F QL(1 ea daily)
ATELVIA TBEC (Use Risedronate Sodium) NF
calcitonin (salmon) soln F
FORTICAL SOLN F
FOSAMAX TABS (Use Alendronate Sodium) NF QL(0.15 ea
daily) MIACALCIN SOLN IJ 200 UNIT/ML F
MIACALCIN SOLN NA 200 UNIT/ACT (Use Calcitonin (Salmon))
NF
risedronate sodium tabs 35 mg F PA; QL(0.15 ea
daily) risedronate sodium tabs 5 mg, 30 mg F PA; QL(1 ea
daily) risedronate sodium tbec 35 mg F
Growth Hormones GENOTROPIN SOLR 5 MG F PA; SP
NORDITROPIN FLEXPRO SOLN F PA; SP
OMNITROPE SOLN 5 MG/1.5ML, 10 MG/1.5ML F PA; SP
ZOMACTON SOLR 5 MG F PA; SP
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Drug Name DrugTier
Requirements/Limits
Hormone Receptor Modulators EVISTA TABS (Use Raloxifene HCl) NF QL(1 ea daily)
raloxifene hcl tabs F QL(1 ea daily)
LHRH/GnRH Agonist Analog Pituitary LUPRON DEPOT-PED (1-MONTH) KIT F PA; SP
LUPRON DEPOT-PED (3-MONTH) KIT F PA; SP
SUPPRELIN LA KIT F PA; SP
Metabolic Modifiers calcitriol caps or 0.25 mcg,0.5 mcg F
CARNITOR SF SOLN (Use Levocarnitine (MetabolicModifiers))
NF QL(30 ml daily)
CARNITOR SOLN 1 GM/10ML (Use Levocarnitine (MetabolicModifiers))
NF
QL(30 ml daily)
CARNITOR TABS 330 MG (Use Levocarnitine (Metabolic Modifiers))
NF QL(3 ea daily);RX/OTC
levocarnitine (metabolicmodifiers) soln 1 gm/10ml F QL(30 ml daily)
levocarnitine (metabolicmodifiers) tabs 330 mg F QL(3 ea daily);
RX/OTC ROCALTROL CAPS 0.25 MCG, 0.5 MCG (Use Calcitriol)
NF
SENSIPAR TABS F PA; SP
Posterior Pituitary Hormones
DDAVP SOLN NA 0.01 % F QL(5 ml per fillretail)
DDAVP SOLN NA 0.01 % (Use DesmopressinAcetate Spray)
NF QL(5 ml per fillretail)
DDAVP TABS OR 0.1 MG, 0.2 MG (Use Desmopressin Acetate)
NF QL(6 ea daily)
desmopressin acetatespray refrigerated soln F QL(5 ml per fill
retail)
Drug Name DrugTier
Requirements/Limits
desmopressin acetatespray soln F QL(5 ml per fill
retail) desmopressin acetate tabsor 0.1 mg, 0.2 mg F QL(6 ea daily)
ESTROGENS - Hormone Replacement/ModifyingDrugs
Estrogen Combinations ACTIVELLA TABS (Use Estradiol & Norethindrone Acetate)
NF QL(1 ea daily)
COMBIPATCH PTTW F QL(0.29 eadaily)
esterified estrogens &methyltestosterone tabs F QL(1 ea daily)
estradiol & norethindrone acetate tabs F QL(1 ea daily)
FEMHRT LOW DOSE TABS (Use Norethindrone Acetate-Ethinyl Estradiol)
NF
norethindrone acetate-ethinyl estradiol tabs2.5mcg-0.5mg
F
PREMPHASE TABS F QL(1 ea daily)
PREMPRO TABS F QL(1 ea daily)
Estrogens
ALORA PTTW F QL(0.29 eadaily)
CLIMARA PTWK (Use Estradiol) NF QL(0.143 ea
daily) ESTRACE TABS OR 0.5 MG, 1 MG, 2 MG (Use Estradiol)
NF
estradiol pttw td 0.0375mg/24hr, 0.025 mg/24hr,0.075 mg/24hr, 0.05mg/24hr, 0.1 mg/24hr
F
QL(0.29 eadaily)
estradiol ptwk td 0.025mg/24hr, 0.075 mg/24hr,0.05 mg/24hr, 0.06mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr
F
QL(0.143 eadaily)
estradiol tabs or 0.5 mg, 1mg, 2 mg F
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
ESTROPIPATE TABS 0.75 MG, 1.5 MG F QL(1 ea daily)
ESTROPIPATE TABS 3 MG F QL(2 ea daily)
MINIVELLE PTTW F QL(0.29 eadaily)
PREMARIN TABS OR 0.625 MG, 0.45 MG, 0.3 MG, 0.9 MG, 1.25 MG
F QL(1 ea daily)
VIVELLE-DOT PTTW (Use Estradiol) NF QL(0.29 ea
daily) FLUOROQUINOLONES - Drugs to Treat BacterialInfections
Fluoroquinolones CIPRO TABS 250 MG, 500 MG (Use CiprofloxacinHCl)
NF
CIPROFLOXACIN HCL TABS 100 MG F QL(6 ea per fill
retail) ciprofloxacin hcl tabs 250mg, 500 mg, 750 mg F
LEVAQUIN TABS (Use Levofloxacin) NF
QL(1 eadaily,14 ea perfill retail)
levofloxacin tabs 250 mg,500 mg, 750 mg F
QL(1 eadaily,14 ea perfill retail)
ofloxacin tabs 400 mg F QL(56 ea perfill retail)
GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal Drugs
Antiflatulents GAS-X CHEW (Use Simethicone) NF
MYLICON INFANTS GAS RELIEF SUSP (Use Simethicone)
NF QL(60 ml perfill retail)
MYLICON SUSP (Use Simethicone) NF QL(60 ml per
fill retail)
simethicone chew 80 mg F
simethicone liqd 20mg/0.3ml, 40 mg/0.6ml F QL(30 ml per
fill retail) simethicone susp 20mg/0.3ml, 40 mg/0.6ml F QL(60 ml per
fill retail)
Drug Name DrugTier
Requirements/Limits
Bile Acid Synthesis Disorder Agents
CHOLBAM CAPS F PA; QL(5 eadaily); SP
Gallstone Solubilizing Agents ACTIGALL CAPS (Use Ursodiol) NF QL(3 ea daily)
URSO 250 TABS (Use Ursodiol) NF QL(7 ea daily)
ursodiol caps 300 mg F QL(3 ea daily)
ursodiol tabs 250 mg F QL(7 ea daily)
Gastrointestinal Chloride Channel Activators
AMITIZA CAPS F PA
Gastrointestinal Stimulants
metoclopramide hcl soln F
metoclopramide hcl tabs F
REGLAN TABS (Use Metoclopramide HCl) NF
Inflammatory Bowel Agents AZULFIDINE EN-TABS TBEC (Use Sulfasalazine) NF
AZULFIDINE TABS (Use Sulfasalazine) NF
balsalazide disodium caps F QL(9 ea daily)
COLAZAL CAPS (Use Balsalazide Disodium) NF QL(9 ea daily)
DELZICOL CPDR F QL(6 ea daily)
MESALAMINE DR TBEC F QL(3 ea daily)
mesalamine enem re 4 gm F QL(60 ml daily)
SFROWASA ENEM F
sulfasalazine tabs F
sulfasalazine tbec F
Intestinal Acidifiers lactulose (encephalopathy)soln F
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
Phosphate Binder Agents calcium acetate (phosphatebinder) caps F
GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System
Alkalinizers potassium citrate(alkalinizer) tbcr 540 mg,1080 mg
F
potassium citrate-citric acidpack 3300mg-1002mg F
SHOHLS SOLUTION MODIFIED SOLN (Use Sodium Citrate & Citric Acid)
NF
QL(500 ml perfill retail);RX/OTC
sodium citrate & citric acid soln F
QL(500 ml perfill retail);RX/OTC
UROCIT-K 10 TBCR (Use Potassium Citrate (Alkalinizer))
NF
UROCIT-K 5 TBCR (Use Potassium Citrate (Alkalinizer))
NF
Genitourinary Irrigants sodium chloride (guirrigant) soln F
Interstitial Cystitis Agents
ELMIRON CAPS F QL(3 ea daily)
Prostatic Hypertrophy Agents
finasteride tabs F QL(1 ea daily)
FLOMAX CAPS (Use Tamsulosin HCl) NF QL(2 ea daily)
PROSCAR TABS (Use Finasteride) NF QL(1 ea daily)
tamsulosin hcl caps F QL(2 ea daily)
Urinary Analgesics phenazopyridine hcl tabs100 mg, 200 mg F
PYRIDIUM TABS (Use Phenazopyridine HCl) NF
Drug Name DrugTier
Requirements/Limits
GOUT AGENTS - Drugs to Treat Gout
Gout Agent Combinations colchicine w/ probenecidtabs F
Gout Agents
allopurinol tabs F
COLCHICINE TABS F
QL(6 ea per fillretail)1 rtl MAXfill,30 rtl day(s)supply,
COLCRYS TABS F
QL(6 ea per fillretail)1 rtl MAXfill,30 rtl day(s)supply,
ZYLOPRIM TABS (Use Allopurinol) NF
Uricosurics
probenecid tabs F
HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood Disorders
Antihemophilic Products
ADVATE SOLR CO
ADYNOVATE SOLR CO
AFSTYLA KIT CO
ALPHANATE/VONWILLEBRANDFACTOR COMPLEX/HUMAN SOLR
CO
ALPHANINE SD SOLR CO
ALPROLIX SOLR CO
BEBULIN SOLR CO
BENEFIX KIT CO
COAGADEX SOLR CO
CORIFACT KIT CO
ELOCTATE SOLR CO
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
FEIBA SOLR CO
HELIXATE FS KIT CO
HEMOFIL M SOLR CO
HUMATE-P SOLR CO
IDELVION SOLR CO
IXINITY SOLR CO
KOATE SOLR CO
KOATE-DVI SOLR CO
KOGENATE FS BIO-SET KIT CO
KOGENATE FS KIT CO
KOVALTRY SOLR CO
MONOCLATE-P KIT CO
MONONINE SOLR CO
NOVOEIGHT SOLR CO
NOVOSEVEN RT SOLR CO
NUWIQ KIT CO
NUWIQ SOLR CO
OBIZUR SOLR CO
PROFILNINE SD SOLR CO
PROFILNINE SOLR CO
REBINYN SOLR CO
RECOMBINATE SOLR CO
RIXUBIS SOLR CO
TRETTEN SOLR CO
VONVENDI SOLR CO
Drug Name DrugTier
Requirements/Limits
WILATE KIT CO
XYNTHA KIT CO
XYNTHA SOLOFUSE KIT CO
Hematorheologic Agents
pentoxifylline tbcr F
Platelet Aggregation Inhibitors AGRYLIN CAPS (Use Anagrelide HCl) NF PA
anagrelide hcl caps F PA
BRILINTA TABS F QL(2 ea daily)
cilostazol tabs F QL(2 ea daily)
clopidogrel bisulfate tabs75 mg F QL(1 ea daily)
dipyridamole tabs F
EFFIENT TABS (Use Prasugrel HCl) NF QL(1 ea daily)
PERSANTINE TABS (Use Dipyridamole) NF
PLAVIX TABS 75 MG (Use Clopidogrel Bisulfate) NF QL(1 ea daily)
prasugrel hcl tabs F QL(1 ea daily)
HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders
Agents for Sickle Cell Anemia
DROXIA CAPS F
Cobalamins cyanocobalamin soln ij1000 mcg/ml F
Folic Acid/Folates
folic acid tabs or 1 mg F RX/OTC
folic acid tabs or 400 mcg,800 mcg F
Hematopoietic Growth Factors
EPOGEN SOLN F SP
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
ZARXIO SOSY F PA; SP
Hematopoietic Mixtures ferrous fumarate-fa-b complex-c-zn-mg-mn-cutabs
F QL(1 ea daily)
Iron FER-IN-SOL SOLN (Use Ferrous Sulfate) NF
FERRETTS TABS F
ferrous fumarate tabs 324 mg F
ferrous gluconate tabs 27mg, 240 mg F
FERROUS GLUCONATE TABS 324 MG F
ferrous sulfate dried tbcr 160 mg F
ferrous sulfate elix 220 mg/5ml F
ferrous sulfate soln 15 mg/ml F
ferrous sulfate tabs 28 mg,65 mg, 325 mg F
FERROUS SULFATE TBEC 324 MG F
ferrous sulfate tbec 325 mg F
HEMOCYTE TABS (Use Ferrous Fumarate) NF
IRON CHEWS PEDIATRIC CHEW F
polysaccharide ironcomplex caps F
HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood Disorders
Hemostatics - Systemic
AMICAR TABS 500 MG F QL(24 ea perfill retail); SP
LYSTEDA TABS (Use Tranexamic Acid) NF AL; At least 12
yrs old
tranexamic acid tabs F AL; At least 12 yrs old
Drug Name DrugTier
Requirements/Limits
HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS
Antihistamine Hypnotics diphenhydramine hcl(sleep) caps 50 mg F
diphenhydramine hcl(sleep) tabs 25 mg, 50 mg F
doxylamine succinate(sleep) tabs F
NYTOL MAXIMUM STRENGTH TABS (Use Diphenhydramine HCl(Sleep))
NF
UNISOM SLEEPGELS CAPS (Use Diphenhydramine HCl(Sleep))
NF
UNISOM TABS (Use Doxylamine Succinate(Sleep))
NF
Barbiturate Hypnotics phenobarbital elix 20mg/5ml F
phenobarbital soln 20mg/5ml F
PHENOBARBITAL TABS 15 MG, 30 MG, 60 MG, 100 MG
F
phenobarbital tabs 16.2mg, 32.4 mg, 64.8 mg, 97.2 mg
F
Non-Barbiturate Hypnotics AMBIEN TABS (Use Zolpidem Tartrate) NF QL(1 ea daily)
FLURAZEPAM HCL CAPS F QL(1 ea daily)
HALCION TABS (Use Triazolam) NF QL(1 ea daily)
midazolam hcl soln ij 5mg/ml, 2 mg/2ml, 5mg/5ml, 10 mg/2ml, 25mg/5ml, 10 mg/10ml, 50mg/10ml
F
RESTORIL CAPS 15 MG, 30 MG (Use Temazepam) NF
QL(1 ea daily);AL; At least 18 yrs old
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Drug Name DrugTier
Requirements/Limits
SONATA CAPS (Use Zaleplon) NF
QL(1 ea daily);AL; At least 18 yrs old
temazepam caps 15 mg,30 mg F
QL(1 ea daily);AL; At least 18 yrs old
TRIAZOLAM TABS 0.125 MG F QL(1 ea daily)
triazolam tabs 0.25 mg F QL(1 ea daily)
zaleplon caps F QL(1 ea daily);AL; At least 18 yrs old
zolpidem tartrate tabs or 5mg, 10 mg F QL(1 ea daily)
LAXATIVES - Bowel Treatment Drugs
Bulk Laxatives
calcium polycarbophil tabs F
EVAC POWD (Use Psyllium) NF
FIBERCON TABS (Use Calcium Polycarbophil) NF
KONSYL POWD 100 % (Use Psyllium) NF
METAMUCIL CAPS (Use Psyllium) NF
METAMUCIL ORIGINAL TEXTURE POWD (Use Psyllium)
NF
METAMUCIL POWD (Use Psyllium) NF
psyllium caps 0.52 gm, 520 mg F
psyllium powd 30 %, 33 %,68 %, 100 %, 28.3 %, 30.9%, 58.6 %, 48.57 %,
F
Laxative Combinations COLYTE-FLAVOR PACKS SOLR (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)
NF
QL(4000 ml perfill retail)
Drug Name DrugTier
Requirements/Limits
GOLYTELY SOLR 236GM-22.74GM-5.86GM-2.97GM-6.74GM (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)
NF
QL(4000 ml perfill retail)
NULYTELY/FLAVORPACKS SOLR (Use PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride)
NF
QL(4000 ml perfill retail)
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr
F QL(4000 ml perfill retail)
peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr
F QL(4000 ml perfill retail)
sennosides-docusate sodium tabs F
SENOKOT S TABS (Use Sennosides-Docusate Sodium)
NF
Laxatives - Miscellaneous glycerin (laxative) supp 2 gm F
GLYCERIN ADULT SUPP (Use Glycerin (Laxative)) NF
lactulose soln F
MIRALAX PACK (Use Polyethylene Glycol 3350) NF RX/OTC
MIRALAX POWD (Use Polyethylene Glycol 3350) NF QL(34 gm
daily); RX/OTC polyethylene glycol 3350pack F RX/OTC
polyethylene glycol 3350powd F QL(34 gm
daily); RX/OTC SORBITOL SOLN OR 70 % F
Saline Laxatives FLEET ENEMA ENEM (Use Sodium Phosphates) NF
FLEET ENEMA SIX PACK ENEM (Use Sodium Phosphates)
NF
FLEET PEDIATRIC ENEM (Use Sodium Phosphates) NF
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Drug Name DrugTier
Requirements/Limits
magnesium citrate soln1.745gm/30ml, 1.745gm/30ml,
F
magnesium hydroxide susp F
sodium phosphates enemre 16gm/133ml-6gm/133ml,19gm/118ml-7gm/118ml,9.5gm/59ml-3.5gm/59ml,19gm/118ml-19gm/118ml-7gm/118ml-7gm/118ml
F
Stimulant Laxatives
bisacodyl supp F
bisacodyl tbec F
DULCOLAX SUPP (Use Bisacodyl) NF
DULCOLAX TBEC (Use Bisacodyl) NF
sennosides tabs 8.6 mg F
SENOKOT TABS (Use Sennosides) NF
Surfactant Laxatives COLACE CAPS (Use Docusate Sodium) NF
COLACE CLEAR CAPS (Use Docusate Sodium) NF
docusate sodium caps or50 mg, 100 mg, 250 mg F
docusate sodium liqd or 50mg/5ml, 150 mg/15ml F
docusate sodium syrp or60 mg/15ml F
docusate sodium tabs or 100 mg F
MACROLIDES - Drugs to Treat BacterialInfections
Azithromycin AZITHROMYCIN PACK 1 GM F QL(2 ea per fill
retail) azithromycin susr 100mg/5ml F QL(15 ml per
fill retail) azithromycin susr 200mg/5ml F QL(30 ml per
fill retail)
Drug Name DrugTier
Requirements/Limits
azithromycin tabs 250 mg F QL(6 ea per fillretail)
azithromycin tabs 500 mg F QL(4 ea daily)
azithromycin tabs 600 mg F
ZITHROMAX SUSR 100 MG/5ML (Use Azithromycin)
NF QL(15 ml perfill retail)
ZITHROMAX SUSR 200 MG/5ML (Use Azithromycin)
NF QL(30 ml perfill retail)
ZITHROMAX TABS 250 MG (Use Azithromycin) NF QL(6 ea per fill
retail) ZITHROMAX TABS 500 MG (Use Azithromycin) NF QL(4 ea daily)
ZITHROMAX TABS 600 MG (Use Azithromycin) NF
ZITHROMAX TRI-PAK TABS (Use Azithromycin) NF QL(4 ea daily)
ZITHROMAX Z-PAK TABS (Use Azithromycin) NF QL(6 ea per fill
retail) Clarithromycin BIAXIN SUSR 250 MG/5ML (Use Clarithromycin)
NF QL(200 ml perfill retail)
BIAXIN TABS 250 MG, 500 MG (Use Clarithromycin) NF QL(28 ea per
fill retail) CLARITHROMYCIN SUSR 125 MG/5ML F QL(100 ml per
fill retail) clarithromycin susr 125mg/5ml F QL(100 ml per
fill retail) CLARITHROMYCIN SUSR 250 MG/5ML F QL(200 ml per
fill retail) clarithromycin susr 250mg/5ml F QL(200 ml per
fill retail) clarithromycin tabs 250 mg,500 mg F QL(28 ea per
fill retail)
clarithromycin tb24 500 mg F QL(14 ea perfill retail)
Erythromycins
E.E.S. 400 TABS F
E.E.S. GRANULES SUSR (Use ErythromycinEthylsuccinate)
NF
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
ERY-TAB TBEC F
ERYPED 200 SUSR (Use ErythromycinEthylsuccinate)
NF
ERYPED 400 SUSR F
ERYTHROCIN STEARATE TABS F
erythromycin base cpep F
erythromycin base tabs F
erythromycinethylsuccinate susr 200mg/5ml
F
ERYTHROMYCIN ETHYLSUCCINATE TABS 400 MG
F
PCE TBEC F
MEDICAL DEVICES AND SUPPLIES
Bandages-Dressings-Tape ALLEVYN PLUS CAVITY PADS F RX/OTC
ALLEVYN THIN PADS F RX/OTC
AMD FOAM DRESSING 4"X4" PADS F RX/OTC
AMD FOAM DRESSING/TOPSHEET4"X4" PADS
F RX/OTC
BAND-AID GAUZE PADS LARGE4" X 4" PADS F RX/OTC
BAND-AID GAUZE PADS MEDIUM 3" X 3" PADS F
BAND-AID GAUZE PADS SMALL2" X 2" PADS F RX/OTC
BAND-AID MIRASORB GAUZE SPONGES LARGE 4" X 4" PADS
F RX/OTC
BIATAIN ADHESIVE FOAM DRESSING 4"X4" PADS
F RX/OTC
BIATAIN FOAM DRESSING 4"X4" PADS F RX/OTC
Drug Name DrugTier
Requirements/Limits
BIOGUARD GAUZE SPONGE 2"X2" 8 PLY PADS
F RX/OTC
BIOGUARD GAUZE SPONGES 4"X4" 12 PLY PADS
F RX/OTC
BORDERED GAUZE PADS F RX/OTC
CARRASMART FOAM PADS F RX/OTC
CARRASMART PADS F RX/OTC
COPA ISLAND BORDERED FOAM DRESSING 4"X4" PADS
F RX/OTC
COPA PLUS HYDROPHILIC FOAM DRESSING 4"X4" PADS
F RX/OTC
COVRSITE COVER DRESSING PADS F RX/OTC
COVRSITE PLUS COMPOSITE DRESSING PADS
F RX/OTC
CUREX ALL-PURPOSE SPONGES 4"X4" 4 PLY PADS
F RX/OTC
CURITY ALL PURPOSE SPONGES 2"X2" 4PLY PADS
F RX/OTC
CURITY ALL PURPOSE SPONGES 2"X2" PADS F RX/OTC
CURITY ALL PURPOSE SPONGES 3"X3" 4PLY PADS
F
CURITY ALL PURPOSE SPONGES 4 PLY PADS F RX/OTC
CURITY ALL PURPOSE SPONGES 4"X4" 4PLY PADS
F RX/OTC
CURITY ALL PURPOSE SPONGES 4"X4" 4PLY/SOFT POUCH PADS
F RX/OTC
CURITY ALL PURPOSE SPONGES 4"X4" PADS F RX/OTC
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Drug Name DrugTier
Requirements/Limits
CURITY AMD ANTIMICROBIALGAUZE SPONGES 2"X2" 8 PLY PADS
F
RX/OTC
CURITY AMD ANTIMICROBIALGAUZE SPONGES 4"X4" 12 PLY PADS
F
RX/OTC
CURITY COVER SPONGE 4"X4" PADS F RX/OTC
CURITY COVER SPONGES 3"X3" PADS F
CURITY COVER SPONGES 4"X4" PADS F RX/OTC
CURITY DRESSING SPONGES 4"X4" 6 PLY PADS
F RX/OTC
CURITY GAUZE PADS 2"X2" 12 PLY PADS F RX/OTC
CURITY GAUZE PADS 2"X2" PADS F RX/OTC
CURITY GAUZE PADS 3"X3" PADS F
CURITY GAUZE PADS 4"X4" 12 PLY PADS F RX/OTC
CURITY GAUZE SPONGE 2"X2" 8 PLY PADS F RX/OTC
CURITY GAUZE SPONGE 2"X2"12 PLY PADS F RX/OTC
CURITY GAUZE SPONGE 3"X3" 12 PLY PADS F
CURITY GAUZE SPONGE 4"X4" 12 PLY PADS F RX/OTC
CURITY GAUZE SPONGE 4"X4" 16 PLY PADS F RX/OTC
CURITY GAUZE SPONGE 4"X4" 8 PLY PADS F RX/OTC
CURITY GAUZE SPONGE 4"X4"16 PLY PADS F RX/OTC
CURITY GAUZE SPONGES 4"X4" 12 PLY PADS
F RX/OTC
CURITY GAUZE SPONGES 4"X4" 8 PLY PADS
F RX/OTC
CURITY NON-ADHERENT STRIPS 3"X3" PADS F
Drug Name DrugTier
Requirements/Limits
CURITY SPONGES/CELLULOSEFILLED/2"X2" PADS
F RX/OTC
CURITY SPONGES/CELLULOSEFILLED/4"X4" PADS
F RX/OTC
CVS GAUZE PAD 3"X3" PADS F
CVS GAUZE PADS 2"X2" 12-PLY PADS F RX/OTC
CVS GAUZE PADS 4"X4" 12-PLY PADS F RX/OTC
CVS GAUZE PADS STERILE 4"X4" 12-PLY PADS
F RX/OTC
DERMACEA DRAIN SPONGES 4"X4" PADS F RX/OTC
DERMACEA GAUZE SPONGE 2"X2" 12 PLY PADS
F RX/OTC
DERMACEA GAUZE SPONGE 2"X2" 8 PLY PADS
F RX/OTC
DERMACEA GAUZE SPONGE 3"X3" 12 PLY PADS
F
DERMACEA GAUZE SPONGE 3"X3" 8 PLY PADS
F
DERMACEA GAUZE SPONGE 4"X4" 12 PLY PADS
F RX/OTC
DERMACEA GAUZE SPONGE 4"X4" 16 PLY PADS
F RX/OTC
DERMACEA GAUZE SPONGE 4"X4" 8 PLY PADS
F RX/OTC
DERMACEA I.V. DRAIN SPONGES 2"X2" PADS F RX/OTC
DERMACEA I.V. DRAIN SPONGES 4"X4" PADS F RX/OTC
DERMACEA I.V. SPONGES 2"X2" PADS F RX/OTC
DERMACEA NON-WOVEN SPONGES 2"X2" 4 PLY PADS
F RX/OTC
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Drug Name DrugTier
Requirements/Limits
DERMACEA NON-WOVEN SPONGES 3"X3" 4 PLY PADS
F
DERMACEA NON-WOVEN SPONGES 4"X4" 4 PLY PADS
F RX/OTC
DERMACEA NON-WOVEN SPONGES 4"X4" 6 PLY PADS
F RX/OTC
DERMACEA TYPE VII GAUZE 2"X2" 12 PLY PADS
F RX/OTC
DERMACEA TYPE VII GAUZE 2"X2" 8 PLY PADS F RX/OTC
DERMACEA TYPE VII GAUZE 3"X3" 12 PLY PADS
F
DERMACEA TYPE VII GAUZE 3"X3" 12PLY PADS
F
DERMACEA TYPE VII GAUZE 4"X4" 12 PLY PADS
F RX/OTC
DERMACEA TYPE VII GAUZE 4"X4" 16 PLY PADS
F RX/OTC
DERMACEA TYPE VII GAUZE 4"X4" 8 PLY PADS F RX/OTC
DERMACEA X-RAY SPONGES 4"X4" 16 PLY PADS
F RX/OTC
DERMALEVIN ADHESIVE FOAMDRESSING 4"X4" PADS
F RX/OTC
DRYMAX EXTRA PADS F RX/OTC
EQL GAUZE PADS 2"X2"/SMALL PADS F RX/OTC
EQL GAUZE PADS 4"X4"/LARGE PADS F RX/OTC
EQL GAUZE STERILE PADS 3"X3" PADS F
EXCILON AMD ANTIMICROBIALDRAIN SPONGES 4"X4" 6 PLY PADS
F
RX/OTC
Drug Name DrugTier
Requirements/Limits
EXCILON AMD ANTIMICROBIALNON-WOVEN SPONGES 4"X4" 6 PLY PADS
F
RX/OTC
EXCILON DRAIN SPONGE 4"X4" PADS F RX/OTC
EXCILON DRAIN SPONGES 4"X4" 6 PLY PADS
F RX/OTC
EXCILON I.V. SPONGES 2"X2" 6 PLY PADS F RX/OTC
FLEXZAN 4 X 4 PADS F RX/OTC
GAUZE DRESSING 4"X4" PADS F RX/OTC
GAUZE PADS 2"X2" PADS F RX/OTC
GAUZE PADS 3"X3" PADS F
GAUZE PADS 4"X4" 12 PLY PADS F RX/OTC
GAUZE PADS 4"X4" PADS F RX/OTC
GAUZE SPONGE TYPE VII MEDI-PAK 2"X2" 8PLY PADS
F RX/OTC
GAUZE SPONGES 4"X4" 12 PLY PADS F RX/OTC
GNP STERILE PADS 3"X3" PADS F
HM STERILE PADS 2"X2" PADS F RX/OTC
HM STERILE PADS PADS F RX/OTC
HYDROCELL ADHESIVE DRESSING 4"X4" PADS F RX/OTC
HYDROCELL DRESSING 4"X4" PADS F RX/OTC
J & J GAUZE 2"X2" 8 PLY PADS F RX/OTC
J & J GAUZE 4"X4" 12 PLY PADS F RX/OTC
J & J GAUZE 4"X4" 8 PLY PADS F RX/OTC
J & J GAUZE SPONGES 12-PLY 4" X 4" MISC F RX/OTC
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Drug Name DrugTier
Requirements/Limits
J & J GAUZE SPONGES 16-PLY 4" X 4" MISC F RX/OTC
J & J GAUZE SPONGES 8-PLY4" X 4" MISC F RX/OTC
KENDALL HYDROPHILIC FOAMDRESSING 2"X2" PADS
F RX/OTC
KENDALL HYDROPHILIC FOAMDRESSING 3"X3" PADS
F
KENDALL HYDROPHILIC FOAMDRESSING 4"X4" PADS
F RX/OTC
KENDALL HYDROPHILIC FOAMPLUS DRESSING 2"X2" PADS
F RX/OTC
KENDALL HYDROPHILIC FOAMPLUS DRESSING 3"X3" PADS
F
KERLIX SPONGES 4" X 4" 12 PLY PADS F RX/OTC
KERLIX SPONGES 4" X 4" 16 PLY PADS F RX/OTC
MIRASORB SPONGES 2" X 2" MISC F RX/OTC
MIRASORB SPONGES 4" X 4" MISC F RX/OTC
NU GAUZE 4PLY 4"X4" PADS F RX/OTC
NU GAUZE GENERAL-USE SPONGES 4"X4" 4 PLY MISC
F RX/OTC
OPTIFOAM PADS F RX/OTC
POLYMEM DRESSING/3"X 3" PADS F
POLYMEM DRESSING/4"X 4" PADS F RX/OTC
QC ALL PURPOSE DRESSINGS4"X4" PADS F RX/OTC
QC BORDER ISLAND GAUZE PAD 2"X2" PADS F RX/OTC
QC STERILE PADS PADS F
QC STERILE PADS PADS F RX/OTC
Drug Name DrugTier
Requirements/Limits
RA ALL PURPOSE DRESSINGS4"X4" PADS F RX/OTC
RA DRESSING SPONGES 4"X4" PADS F RX/OTC
RA GAUZE SPONGES 4"X4" PADS F RX/OTC
RA STERILE PADS 2"X2" PADS F RX/OTC
RA STERILE PADS 3"X3" PADS F
RA STERILE PADS 4"X4" PADS F RX/OTC
RAY-TEC X-RAY DETECTABLESPONGES 4" X 4" 16 PLY MISC
F RX/OTC
RESTORE CONTACT LAYER/NON-ADHERENT2"X2" PADS
F RX/OTC
RESTORE FOAM DRESSING BORDERED 4"X4" PADS
F RX/OTC
RESTORE FOAM DRESSING NON-BORDERED 4"X4" PADS
F RX/OTC
RESTORE ODOR ABSORBING DRESSING 4"X4" PADS
F RX/OTC
RESTORE TRIO ABSORBENT DRESSING 3"X3" PADS
F
SM GAUZE PADS 2"X2" PADS F RX/OTC
SM GAUZE PADS 3"X3" PADS F
SM GAUZE PADS 4"X4" PADS F RX/OTC
SM STERILE PADS 2"X2" PADS F RX/OTC
SM STERILE PADS PADS F RX/OTC
SOF-WICK 4"X4" PADS F RX/OTC
STERILE GAUZE PADS 2"X2" PADS F RX/OTC
STERILE GAUZE PADS 3"X3" PADS F
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Drug Name DrugTier
Requirements/Limits
STERILE PADS 2"X2" PADS F RX/OTC
STERILE PADS 3"X3" PADS F
STERILE PADS 4"X4" PADS F RX/OTC
SURGICAL GAUZE SPONGE PADS F RX/OTC
TEGADERM FOAM DRESSING 2"X2" PADS F RX/OTC
TEGADERM FOAM DRESSING 4"X4" PADS F RX/OTC
THERAGAUZE PADS F RX/OTC
TOPPER DRESSING SPONGES 4"X4" MISC F RX/OTC
VERSIVA XC 3" X 3" FOAM DRESSING/HYDROFIBERTECHNOLOGY PADS
F
VERSIVA XC 4" X 4" FOAM DRESSING/HYDROFIBERTECHNOLOGY PADS
F
RX/OTC
VISTEC X-RAY DETECTABLE SPONGES 4"X4" 16 PLY PADS
F RX/OTC
Contraceptives
CONDOMS F
Diabetic Supplies
LANCET DEVICE F
LANCETS F Limit 200 permonth
TRUE METRIX CONTROL SOLUTION LEVEL 1 SOLN
F QL(0.02 eadaily,90 day(s)limit)
TRUE METRIX CONTROL SOLUTION LEVEL 2 SOLN
F QL(0.02 eadaily,90 day(s)limit)
TRUE METRIX CONTROL SOLUTION LEVEL 3 SOLN
F QL(0.02 eadaily,90 day(s)limit)
TRUECONTROL GLUCOSE CONTROL LEVEL 0 LIQD
F QL(0.02 eadaily,90 day(s)limit)
Drug Name DrugTier
Requirements/Limits
TRUECONTROL GLUCOSE CONTROL LEVEL 1 LIQD
F QL(0.02 eadaily,90 day(s)limit)
TRUETEST GLUCOSE CONTROLLEVEL 1 LIQD F
QL(0.02 eadaily,90 day(s)limit)
TRUETEST GLUCOSE CONTROLLEVEL 2 LIQD F
QL(0.02 eadaily,90 day(s)limit)
TRUETEST GLUCOSE CONTROLLEVEL 3 LIQD F
QL(0.02 eadaily,90 day(s)limit)
Misc. Devices
ALCOHOL SWABS F
Parenteral Therapy Supplies INSULIN SYRINGE AND PEN NEEDLES F QL (5 ea daily)
Respiratory Therapy Supplies
ACE AEROSOL CLOUD ENHANCER MISC F
QL(1 ea per360 daysretail); RX/OTC
ACTIVITY POUCH MISC F QL(1 ea per360 daysretail); RX/OTC
ADULT AEROSOL MASK MISC F
QL(1 ea per360 daysretail); RX/OTC
ADULT MASK LARGE MISC F
QL(1 ea per360 daysretail); RX/OTC
ADULT MASK MISC F QL(1 ea per360 daysretail); RX/OTC
AEROTRACH PLUS MISC F QL(1 ea per360 daysretail); RX/OTC
AIRS PEDIATRIC AEROSOL MASK MISC F
QL(1 ea per360 daysretail); RX/OTC
ALL FLOW 1000 PULMONARY FUNCTION FILTER MISC
F QL(1 ea per360 daysretail); RX/OTC
BUBBLES THE FISH II PEDIATRIC MASK/PVCMISC
F QL(1 ea per360 daysretail); RX/OTC
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Drug Name DrugTier
Requirements/Limits
CO MONITOR REPLACEMENT TPIECES MISC
F QL(1 ea per360 daysretail); RX/OTC
EBASE CONTROLLER KIT MISC F
QL(1 ea per360 daysretail); RX/OTC
EFLOW SCF AEROSOL HEAD MISC F
QL(1 ea per360 daysretail); RX/OTC
ELITE DC AUTO ADAPTER MISC F
QL(1 ea per360 daysretail); RX/OTC
FILTER AIR PP MISC F QL(1 ea per360 daysretail); RX/OTC
FULL KIT NEBULIZER SET MISC F
QL(1 ea per360 daysretail); RX/OTC
HEALTHY LIVING REPLACEMENT FILTERS MISC
F QL(1 ea per360 daysretail); RX/OTC
HEALTHY LIVING REPLACEMENT KIT FOR NEBULIZER MISC
F QL(1 ea per360 daysretail); RX/OTC
HEALTHY LIVING REPLACEMENT MASKS MISC
F QL(1 ea per360 daysretail); RX/OTC
HUDSON RCI SEE-THRU AEROSOL MASK ELONGATED/ADULTMISC
F
QL(1 ea per360 daysretail); RX/OTC
INNOSPIRE REPLACEMENT FILTER MISC
F QL(1 ea per360 daysretail); RX/OTC
LITETOUCH MASK LARGE MISC F
QL(1 ea per360 daysretail); RX/OTC
LITETOUCH MASK MEDIUM MISC F
QL(1 ea per360 daysretail); RX/OTC
LITETOUCH MASK SMALL MISC F
QL(1 ea per360 daysretail); RX/OTC
MICROELITE FILTER REPLACEMENTS MISC F
QL(1 ea per360 daysretail); RX/OTC
Drug Name DrugTier
Requirements/Limits
MICROELITE RECHARGEABLE BATTERY MISC
F QL(1 ea per360 daysretail); RX/OTC
MINIELITE FILTER REPLACEMENTS MISC F
QL(1 ea per360 daysretail); RX/OTC
MINIELITE RECHARGEABLE BATTERY MISC
F QL(1 ea per360 daysretail); RX/OTC
NEBULIZER AIR TUBE/PLUGS MISC F
QL(1 ea per360 daysretail); RX/OTC
NEBULIZER PEDIATRIC MASK MISC F
QL(1 ea per360 daysretail); RX/OTC
NOSE CLIP MISC F QL(1 ea per360 daysretail); RX/OTC
PARI ALTERA NEBULIZER HANDSET MISC
F QL(1 ea per360 daysretail); RX/OTC
PARI BABY CONVERSION KITSIZE 1 MISC F
QL(1 ea per360 daysretail); RX/OTC
PARI BABY CONVERSION KITSIZE 2 MISC F
QL(1 ea per360 daysretail); RX/OTC
PARI BABY CONVERSION KITSIZE 3 MISC F
QL(1 ea per360 daysretail); RX/OTC
PARI ERAPID NEBULIZER HANDSET MISC F
QL(1 ea per360 daysretail); RX/OTC
PARI EXPIRATORY FILTER VALVE SET DEVI F
QL(1 ea per360 daysretail); RX/OTC
PARI MASK SET MISC F QL(1 ea per360 daysretail); RX/OTC
PARI SOFT PLASTIC ADULT MASK MISC F
QL(1 ea per360 daysretail); RX/OTC
PARI SOFT PLASTIC PEDIATRIC MASK MISC F
QL(1 ea per360 daysretail); RX/OTC
PEDIATRIC AEROSOL MASK MISC F
QL(1 ea per360 daysretail); RX/OTC
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
PEDIATRIC MOUTHPIECE/DISPOSABLE MISC
F QL(1 ea per360 daysretail); RX/OTC
PFLEX MISC F QL(1 ea per360 daysretail); RX/OTC
PILLOW MASK/ADULTMISC F
QL(1 ea per360 daysretail); RX/OTC
PILLOW MASK/CHILDMISC F
QL(1 ea per360 daysretail); RX/OTC
PILLOW MASK/PEDIATRIC MISC F
QL(1 ea per360 daysretail); RX/OTC
REPLACEMENT AIR FILTER MISC F
QL(1 ea per360 daysretail); RX/OTC
REPLACEMENT FILTERS MISC F
QL(1 ea per360 daysretail); RX/OTC
SAMI THE SEAL REPLACEMENTFILTERS MISC
F QL(1 ea per360 daysretail); RX/OTC
SIDESTREAM ADULT FACE MASK MISC F
QL(1 ea per360 daysretail); RX/OTC
SIDESTREAM PEDIATRIC FACEMASK MISC F
QL(1 ea per360 daysretail); RX/OTC
SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL MISC
F QL(1 ea per360 daysretail); RX/OTC
SIDESTREAM PEDIATRIC FACEMASK/TUCKER THETURTLE MISC
F QL(1 ea per360 daysretail); RX/OTC
SIDESTREAM PLUS ADULT FACE MASK MISC F
QL(1 ea per360 daysretail); RX/OTC
SILICONE MASK FOR BREATHERITE CHAMBER/ADULT MISC
F QL(1 ea per360 daysretail); RX/OTC
SILICONE MASK FOR BREATHERITE CHAMBER/INFANT MISC
F QL(1 ea per360 daysretail); RX/OTC
Drug Name DrugTier
Requirements/Limits
SILICONE MASK FOR BREATHERITE CHAMBER/PEDIATRICMISC
F
QL(1 ea per360 daysretail); RX/OTC
SILICONE MASK FOR BREATHRITE CHAMBER/ADULT MISC
F QL(1 ea per360 daysretail); RX/OTC
SOOTHENEB NBL 100 CHILD MASK MISC F
QL(1 ea per360 daysretail); RX/OTC
SOOTHENEB NBL 100 MEDICATION CUP MISC F
QL(1 ea per360 daysretail); RX/OTC
SOOTHENEB NBL 100 MESH CAP MISC F
QL(1 ea per360 daysretail); RX/OTC
SOOTHENEB NBL100 ADULT MASK MISC F
QL(1 ea per360 daysretail); RX/OTC
SPACER/AEROSOL-HOLDING CHAMBER F
THRESHOLD IMT MISC F QL(1 ea per360 daysretail); RX/OTC
TUBING/WING TIP MISC F QL(1 ea per360 daysretail); RX/OTC
WINDMILL TRAINER MISC F
QL(1 ea per360 daysretail); RX/OTC
MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches
Migraine Combinations CAFERGOT TABS (Use Ergotamine w/ Caffeine) NF AL; At least 18
yrs old
ergotamine w/ caffeine tabs F AL; At least 18 yrs old
Migraine Products D.H.E. 45 SOLN (Use DihydroergotamineMesylate)
NF AL; At least 18 yrs old
dihydroergotaminemesylate soln ij 1 mg/ml F AL; At least 18
yrs old DIHYDROERGOTAMINE MESYLATE SOLN NA 4 MG/ML
F AL; At least 18 yrs old
CA Health & Wellness Preferred Drug List Update July 1, 2018
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Drug Name DrugTier
Requirements/Limits
MIGRANAL SOLN F AL; At least 18 yrs old
Serotonin Agonists AMERGE TABS (Use Naratriptan HCl) NF AL; At least 18
yrs old eletriptan hydrobromidetabs F AL; At least 18
yrs old IMITREX SOLN NA 5 MG/ACT, 20 MG/ACT (Use Sumatriptan)
NF AL; At least 12 yrs old
IMITREX SOLN SC 6 MG/0.5ML (Use Sumatriptan Succinate)
NF
IMITREX STATDOSE SYSTEM SOAJ 6 MG/0.5ML (Use Sumatriptan Succinate)
NF
AL; At least 12 yrs old
IMITREX TABS OR 25 MG, 50 MG, 100 MG (Use Sumatriptan Succinate)
NF AL; At least 12 yrs old
MAXALT TABS (Use Rizatriptan Benzoate) NF
QL(12 ea per30 days retail);AL; At least 6 yrs old
MAXALT-MLT TBDP (Use Rizatriptan Benzoate) NF
QL(0.4 eadaily); AL; Atleast 6 yrs old
naratriptan hcl tabs F AL; At least 18 yrs old
RELPAX TABS (Use Eletriptan Hydrobromide) NF AL; At least 18
yrs old
rizatriptan benzoate tabs 5mg, 10 mg F
QL(12 ea per30 days retail);AL; At least 6 yrs old
rizatriptan benzoate tbdp 5mg, 10 mg F
QL(0.4 eadaily); AL; Atleast 6 yrs old
sumatriptan soln F AL; At least 12 yrs old
sumatriptan succinate soajsc 6 mg/0.5ml F AL; At least 12
yrs old sumatriptan succinate solnsc 6 mg/0.5ml F
SUMATRIPTAN SUCCINATE SOSY SC 6 MG/0.5ML
F AL; At least 12 yrs old
Drug Name DrugTier
Requirements/Limits
sumatriptan succinate tabsor 25 mg, 50 mg, 100 mg F AL; At least 12
yrs old
zolmitriptan tabs F AL; At least 18 yrs old
zolmitriptan tbdp F AL; At least 18 yrs old
ZOMIG SOLN NA 5 MG F AL; At least 12 yrs old
ZOMIG TABS OR 5 MG, 2.5 MG (Use Zolmitriptan) NF AL; At least 18
yrs old ZOMIG ZMT TBDP (Use Zolmitriptan) NF AL; At least 18
yrs old
MINERALS & ELECTROLYTES
Calcium calcium carbonate-cholecalciferol tabs 500mg-200unit
F
calcium carbonate-vitamin d tabs 125unit-250mg,125unit-500mg, 200unit-500mg, 200unit-600mg,250mg-125unit, 400unit-600mg, 500mg-125unit,500mg-200unit, 600mg-200unit, 600mg-400unit,500mg-500mg-200unit-200unit
F
oyster shell tabs F
RA OYSTER SHELL CALCIUM/VITAMIN DTABS 500MG-200UNIT
F
Electrolyte Mixtures
CERASPORT EX1 SOLN F
CERASPORT SOLN F
ENFAMIL ENFALYTE SOLN F
oral electrolytes soln F
PEDIALYTE FREEZER POPS SOLN (Use Oral Electrolytes)
NF
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Drug Name DrugTier
Requirements/Limits
PEDIALYTE SOLN 20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L,20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L (Use Oral Electrolytes)
NF
Fluoride
FLURA-DROPS SOLN F
LURIDE SOLN (Use Sodium Fluoride) NF
sodium fluoride chew 0.25 mg, 0.5 mg, 1 mg, 1.1 mg,2.2 mg
F
sodium fluoride soln 0.125 mg/drop, 0.5 mg/ml F
Magnesium MAGNESIUM CAPS 400 MG F
magnesium oxide (mgsupplement) tabs F
MAGNESIUM OXIDE CAPS F
Phosphate K-PHOS NEUTRAL TABS (Use Pot PhosphateMonobasic w/ SodPhosphate Dibasic &Monobasic)
NF
QL(8 ea daily)
pot phosphate monobasicw/ sod phosphate dibasic &monobasic tabs
F QL(8 ea daily)
Potassium K-TAB TBCR 10 MEQ (Use Potassium Chloride) NF
K-TAB TBCR 8 MEQ F
KLOR-CON M15 TBCR F
KLOR-CON/25 PACK F
MICRO-K CPCR 10 MEQ (Use Potassium Chloride) NF
MICRO-K CPCR 8 MEQ (Use Potassium Chloride) NF QL(1 ea daily)
Drug Name DrugTier
Requirements/Limits
potassium bicarbonate tbef F
potassium chloride cpcr or10 meq F
potassium chloride cpcr or8 meq F QL(1 ea daily)
POTASSIUM CHLORIDE ER TBCR 8 MEQ F
potassium chloridemicroencapsulated crystalser tbcr
F
potassium chloride pack or20 meq F
potassium chloride soln or10 %, 20 % F
POTASSIUM CHLORIDE SOLN OR 20 % F
potassium chloride tbcr or 8meq, 10 meq F
Zinc
zinc sulfate caps F
MISCELLANEOUS THERAPEUTIC CLASSES
Chelating Agents
DEPEN TITRATABS TABS F
Immunomodulators
REVLIMID CAPS F PA; SP
Immunosuppressive Agents
AZASAN TABS F QL(3 ea daily)
azathioprine tabs or 50 mg F
CELLCEPT CAPS 250 MG (Use MycophenolateMofetil)
NF QL(2 ea daily);SP
CELLCEPT SUSR 200 MG/ML (Use Mycophenolate Mofetil)
NF QL(15 mldaily); SP
CELLCEPT TABS 500 MG (Use MycophenolateMofetil)
NF QL(4 ea daily);SP
cyclosporine caps F SP
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Drug Name DrugTier
Requirements/Limits
cyclosporine modified (formicroemulsion) caps 25mg, 50 mg, 100 mg
F QL(4 ea daily);SP
cyclosporine modified (formicroemulsion) soln 100mg/ml
F QL(8 ml daily);SP
CYCLOSPORINE MODIFIED CAPS F QL(4 ea daily);
SP CYCLOSPORINE MODIFIED CAPS (Use Cyclosporine Modified (ForMicroemulsion))
NF
QL(4 ea daily);SP
IMURAN TABS (Use Azathioprine) NF
mycophenolate mofetilcaps 250 mg F QL(2 ea daily);
SP mycophenolate mofetil susr200 mg/ml F QL(15 ml
daily); SP mycophenolate mofetil tabs500 mg F QL(4 ea daily);
SP mycophenolate sodiumtbec 180 mg F QL(2 ea daily);
SP mycophenolate sodiumtbec 360 mg F QL(4 ea daily);
SP MYFORTIC TBEC 180 MG (Use MycophenolateSodium)
NF QL(2 ea daily);SP
MYFORTIC TBEC 360 MG (Use MycophenolateSodium)
NF QL(4 ea daily);SP
NEORAL CAPS 25 MG, 100 MG (Use CyclosporineModified (ForMicroemulsion))
NF
QL(4 ea daily);SP
NEORAL SOLN 100 MG/ML (Use CyclosporineModified (ForMicroemulsion))
NF
QL(8 ml daily);SP
PROGRAF CAPS (Use Tacrolimus) NF QL(3 ea daily);
SP RAPAMUNE SOLN 1 MG/ML F SP
RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (Use Sirolimus)
NF SP
Drug Name DrugTier
Requirements/Limits
SANDIMMUNE CAPS 25 MG, 100 MG (Use Cyclosporine)
F SP
SANDIMMUNE SOLN 100 MG/ML F SP
sirolimus tabs F SP
tacrolimus caps F QL(3 ea daily);SP
Potassium Removing Agents KAYEXALATE POWD (Use Sodium PolystyreneSulfonate)
NF QL(454 gm perfill retail)
sodium polystyrenesulfonate powd or F QL(454 gm per
fill retail) sodium polystyrenesulfonate susp or 15gm/60ml
F
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln F QL(100 ml per
fill retail) Anti-infectives - Throat nystatin (mouth-throat) susp F QL(120 ml per
fill retail) Antiseptics - Mouth/Throat chlorhexidine gluconate(mouth-throat) soln F
PERIDEX SOLN (Use Chlorhexidine Gluconate (Mouth-Throat))
NF
Dental Products GEL-KAM ORAL CARE RINSE CONC (Use Stannous Fluoride)
NF RX/OTC
PREVIDENT 5000 DRY MOUTH GEL (Use Sodium Fluoride (Dental))
NF QL(112 ml perfill retail)
PREVIDENT 5000 PLUS CREA (Use Sodium Fluoride (Dental))
NF QL(102 gm perfill retail)
PREVIDENT FLUORIDE GEL (Use Sodium Fluoride (Dental))
NF QL(112 ml perfill retail)
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Drug Name DrugTier
Requirements/Limits
sodium fluoride (dental)crea dt 1.1 % F QL(102 gm per
fill retail) sodium fluoride (dental) geldt 1.1 % F QL(112 ml per
fill retail) sodium fluoride (dental)soln mt 0.2 % F
stannous fluoride conc F RX/OTC
THERA-FLUR-N GEL (Use Sodium Fluoride (Dental)) NF QL(112 ml per
fill retail) Steroids - Mouth/Throat triamcinolone acetonide (mouth) pste F QL(5 gm per fill
retail) Throat Products - Misc.
AQUORAL SOLN F QL(900 ml perfill retail);RX/OTC
BIOTENE DRY MOUTH MOISTURIZING SPRAY SOLN
F QL(900 ml perfill retail);RX/OTC
CAPHOSOL SOLN F QL(900 ml perfill retail);RX/OTC
CVS DRY MOUTH SPRAY SOLN F
QL(900 ml perfill retail);RX/OTC
EQL DRY MOUTH ORAL RINSE SOLN F
QL(900 ml perfill retail);RX/OTC
MOI-STIR SOLN F QL(900 ml perfill retail);RX/OTC
MOUTHKOTE SOLN F QL(900 ml perfill retail);RX/OTC
NUMOISYN LIQD F QL(900 ml perfill retail);RX/OTC
ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT SOLN
F QL(900 ml perfill retail);RX/OTC
pilocarpine hcl (oral) tabs 5 mg F QL(6 ea daily)
RA DRY MOUTH SOLN F QL(900 ml perfill retail);RX/OTC
Drug Name DrugTier
Requirements/Limits
SALAGEN TABS 5 MG (Use Pilocarpine HCl(Oral))
NF QL(6 ea daily)
MULTIVITAMINS
B-Complex Vitamins
b-complex vitamins caps F
b-complex vitamins tabs F
B-Complex w/ C b complex w/ c caps 10mg-50mg-10mg-15mg-5mg-300mg, 10.2mg-10mg-15mg-50mg-5mg-300mg,10mg-50mg-10.2mg-15mg-5mg-300mg
F
B-Complex w/ Folic Acid b-complex w/ c & folic acidcaps 1.5mg-5mg-20mg-1.7mg-6mcg-1mg-150mcg-10mg-100mg, 5mg-1.7mg-6mcg-20mg-1.5mg-1mg-150mcg-10mg-100mg
F
QL(1 ea daily);RX/OTC
b-complex w/ c & folic acidtabs 1.5mg-10mg-20mg-1.7mg-6mcg-1mg-300mcg-10mg-60mg, 6mcg-1.5mg-10mg-20mg-1.7mg-1mg-300mcg-10mg-100mg,1.5mg-1.7mg-10mg-0.01mcg-20mg-1mg-300mcg-10mg-60mg,20mg-1.7mg-10mg-0.006mg-1.5mg-1mg-0.3mg-10mg-100mg
F
QL(1 ea daily)
NEPHRO-VITE RX TABS 1.5MG-10MG-20MG-1.7MG-6MCG-1MG-300MCG-10MG-60MG (Use B-Complex w/ C &Folic Acid)
NF
QL(1 ea daily)
NEPHROCAPS CAPS (Use B-Complex w/ C &Folic Acid)
NF QL(1 ea daily);RX/OTC
Multiple Vitamins w/ Iron multiple vitamins w/ irontabs F
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Drug Name DrugTier
Requirements/Limits
Multiple Vitamins w/ Minerals ADVANCED DIABETIC MULTIVITAMIN FORMULA TABS
F QL(1 ea daily);RX/OTC
ALIVE ENERGY 50+ TABS F QL(1 ea daily);RX/OTC
ALIVE MENS ENERGY TABS F QL(1 ea daily);
RX/OTC ALIVE ONCE DAILY WOMENS 50+ ULTRA POTENCY TABS
F QL(1 ea daily);RX/OTC
ALIVE ONCE DAILY WOMENS ULTRA POTENCY TABS
F QL(1 ea daily);RX/OTC
ALIVE WOMENS 50+ TABS F QL(1 ea daily);
RX/OTC ALIVE WOMENS ENERGY TABS F QL(1 ea daily);
RX/OTC ANTIOXIDANT FORTE TABS F QL(1 ea daily);
RX/OTC
AP-ZEL TABS F QL(1 ea daily);RX/OTC
BACMIN TABS F QL(1 ea daily);RX/OTC
BASIC AM TABS F QL(1 ea daily);RX/OTC
BASIC PM TABS F QL(1 ea daily);RX/OTC
CAL-DAY 1000 TABS F QL(1 ea daily);RX/OTC
CENTRAVITES 50 PLUS TABS F QL(1 ea daily);
RX/OTC CENTRAVITES ADULTS TABS F QL(1 ea daily);
RX/OTC CENTRUM ADULTS TABS (Use Multiple Vitamins w/Minerals)
NF QL(1 ea daily);RX/OTC
CENTRUM CARDIO TABS F QL(1 ea daily);RX/OTC
CENTRUM MEN TABS F QL(1 ea daily);RX/OTC
CENTRUM SILVER ULTRA MENS TABS F QL(1 ea daily);
RX/OTC CENTRUM SILVER ULTRA WOMENS TABS F QL(1 ea daily);
RX/OTC
Drug Name DrugTier
Requirements/Limits
CENTRUM SPECIALIST HEART TABS F QL(1 ea daily);
RX/OTC CENTRUM SPECIALIST IMMUNE SUPPORT TABS F QL(1 ea daily);
RX/OTC CENTRUM SPECIALIST VISION TABS F QL(1 ea daily);
RX/OTC CENTRUM ULTRA WOMENS TABS F QL(1 ea daily);
RX/OTC CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS TABS
F QL(1 ea daily);RX/OTC
CLINICAL NUTRIENTS 45-PLUS WOMEN TABS F QL(1 ea daily);
RX/OTC CLINICAL NUTRIENTS 50-PLUS MEN TABS F QL(1 ea daily);
RX/OTC CLINICAL NUTRIENTS FOR FEMALE TEENS TABS
F QL(1 ea daily);RX/OTC
CLINICAL NUTRIENTS FOR MALE TEENS TABS F QL(1 ea daily);
RX/OTC CLINICAL NUTRIENTS FOR MEN TABS F QL(1 ea daily);
RX/OTC CLINICAL NUTRIENTS FOR WOMEN TABS F QL(1 ea daily);
RX/OTC CVS ONE DAILY MENS 50+ ADVANCED TABS F QL(1 ea daily);
RX/OTC CVS SPECTRAVITE ADULT 50+ TABS F QL(1 ea daily);
RX/OTC CVS SPECTRAVITE ULTRA MEN50+ TABS F QL(1 ea daily);
RX/OTC CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR TABS
F QL(1 ea daily);RX/OTC
CVS SPECTRAVITE ULTRA MENS HEALTH TABS
F QL(1 ea daily);RX/OTC
CVS SPECTRAVITE ULTRA WOMEN TABS F QL(1 ea daily);
RX/OTC CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR TABS
F QL(1 ea daily);RX/OTC
CVS SPECTRAVITE ULTRA WOMENS HEALTH TABS
F QL(1 ea daily);RX/OTC
DERMAVITE TABS F QL(1 ea daily);RX/OTC
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Drug Name DrugTier
Requirements/Limits
EQ COMPLETE MULTIVITAMINADULTS UNDER 50 TABS
F QL(1 ea daily);RX/OTC
EQ ONE DAILY MENS 50+ TABS F QL(1 ea daily);
RX/OTC EQ ONE DAILY MENS HEALTH TABS F QL(1 ea daily);
RX/OTC EQ ONE DAILY WOMENS 50+ TABS F QL(1 ea daily);
RX/OTC EQ ONE DAILY WOMENS HEALTH TABS F QL(1 ea daily);
RX/OTC EQL CENTURY MATURE ADULTS50+ TABS F QL(1 ea daily);
RX/OTC EQL CENTURY MENS TABS F QL(1 ea daily);
RX/OTC EQL CENTURY WOMENS TABS F QL(1 ea daily);
RX/OTC EQL ONE DAILY MENS TABS F QL(1 ea daily);
RX/OTC FITNESS TABS FOR MEN AM/PM/LYCOPENE TABS F QL(1 ea daily);
RX/OTC FITNESS TABS FOR WOMEN AM/PM/LYCOPENE TABS
F QL(1 ea daily);RX/OTC
FREEDAVITE TABS F QL(1 ea daily);RX/OTC
GERI-FREEDA SENIOR FORMULA TABS F QL(1 ea daily);
RX/OTC
HAIR-VITES TABS F QL(1 ea daily);RX/OTC
HM COMPLETE 50+ MENS ULTIMATE TABS F QL(1 ea daily);
RX/OTC HM COMPLETE 50+ WOMENS ULTIMATE TABS
F QL(1 ea daily);RX/OTC
HM COMPLETE TABS F QL(1 ea daily);RX/OTC
HM HAIR/SKIN/NAILSTABS F QL(1 ea daily);
RX/OTC HM ONE DAILY MENS TABS F QL(1 ea daily);
RX/OTC HM ONE DAILY WOMENS TABS F QL(1 ea daily);
RX/OTC
HYALEX TABS F QL(1 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
ICAPS AREDS FORMULA TABS F QL(1 ea daily);
RX/OTC
ICAPS PLUS TABS F QL(1 ea daily);RX/OTC
K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH TABS
F
QL(1 ea daily);RX/OTC
MACULAR VITAMIN BENEFIT TABS F QL(1 ea daily);
RX/OTC MEGA MULTIVITAMIN FOR MEN TABS F QL(1 ea daily);
RX/OTC MEGA MULTIVITAMIN FOR WOMEN TABS F QL(1 ea daily);
RX/OTC MEGAVITE FRUITS & VEGGIES TABS F QL(1 ea daily);
RX/OTC MEGAVITE GOLDEN YEARS 55+ TABS F QL(1 ea daily);
RX/OTC MENS 50+ MULTI VITAMIN &MINERAL FORMULA TABS
F QL(1 ea daily);RX/OTC
MENS MULTI VITAMIN & MINERAL FORMULA TABS
F QL(1 ea daily);RX/OTC
MULTI-BETIC DIABETES TABS F QL(1 ea daily);
RX/OTC MULTI-VITAMIN MONOCAPS TABS F QL(1 ea daily);
RX/OTC multiple vitamins w/minerals tabs F QL(1 ea daily);
RX/OTC MULTIVITAMIN ADULTS TABS F QL(1 ea daily);
RX/OTC MULTIVITAMIN MEN TABS F QL(1 ea daily);
RX/OTC NAT-RUL THERAVITE-M/HIGHPOTENCY TABS F QL(1 ea daily);
RX/OTC
NATRUL-MEGA-75 TABS F QL(1 ea daily);RX/OTC
NATRUL-VITES TABS F QL(1 ea daily);RX/OTC
NICADAN TABS F QL(1 ea daily);RX/OTC
NICADAN ZX TABS F QL(1 ea daily);RX/OTC
NICAZEL FORTE TABS F QL(1 ea daily);RX/OTC
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Drug Name DrugTier
Requirements/Limits
NICAZEL TABS F QL(1 ea daily);RX/OTC
NO IRON MULTIPLE VITAMIN/MINERALSTABS
F QL(1 ea daily);RX/OTC
NUTRICAP TABS F QL(1 ea daily);RX/OTC
OCULAR VITAMINS TABS F QL(1 ea daily);RX/OTC
ONCOVITE TABS F QL(1 ea daily);RX/OTC
ONE DAILY MENS FORMULA W/O IRONTABS
F QL(1 ea daily);RX/OTC
ONE DAILY PLUS IRON TABS F QL(1 ea daily);
RX/OTC ONE DAILY WOMENS TABS F QL(1 ea daily);
RX/OTC ONE-A-DAY ENERGY TABS F QL(1 ea daily);
RX/OTC ONE-A-DAY MENOPAUSE FORMULA TABS F QL(1 ea daily);
RX/OTC ONE-A-DAY MENS 50+ ADVANTAGE TABS F QL(1 ea daily);
RX/OTC ONE-A-DAY MENS HEALTH FORMULA TABS F QL(1 ea daily);
RX/OTC ONE-A-DAY MENS PRO EDGE TABS F QL(1 ea daily);
RX/OTC ONE-A-DAY PROACTIVE 65+ TABS F QL(1 ea daily);
RX/OTC ONE-A-DAY TEEN ADVANTAGEFOR HIM TABS
F QL(1 ea daily);RX/OTC
OPTI-WOMAN TABS F QL(1 ea daily);RX/OTC
OPURITY TABS F QL(1 ea daily);RX/OTC
PARVLEX TABS F QL(1 ea daily);RX/OTC
PHYTOMULTI TABS F QL(1 ea daily);RX/OTC
PRESERVISION AREDS TABS F QL(1 ea daily);
RX/OTC PRO-CAL TABS 145MG-187.5MG-40MG-100UNIT-7.5MG
F QL(1 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
PROCERV HP TABS F QL(1 ea daily);RX/OTC
PRORENAL+D TABS F QL(1 ea daily);RX/OTC
PROVIT TABS F QL(1 ea daily);RX/OTC
QUENCH TABS F QL(1 ea daily);RX/OTC
QUIN B STRONG TABS F QL(1 ea daily);RX/OTC
QUINTABS-M TABS F QL(1 ea daily);RX/OTC
RA CENTRAL-VITE TABS F QL(1 ea daily);RX/OTC
RA CENTRAL-VITE UNDER 50MENS TABS F QL(1 ea daily);
RX/OTC RA CENTRAL-VITE UNDER 50WOMENS TABS
F QL(1 ea daily);RX/OTC
RENAPLEX-D TABS F QL(1 ea daily);RX/OTC
REQ 49+ TABS F QL(1 ea daily);RX/OTC
SENTRY SENIOR TABS F QL(1 ea daily);RX/OTC
SENTRY SENIOR/LUTEINTABS F QL(1 ea daily);
RX/OTC
SENTRY TABS F QL(1 ea daily);RX/OTC
SIDEROL TABS F QL(1 ea daily);RX/OTC
SM ONE DAILY MENS TABS F QL(1 ea daily);
RX/OTC SM ONE DAILY WOMENS TABS F QL(1 ea daily);
RX/OTC
SOLO TABS F QL(1 ea daily);RX/OTC
STROVITE ONE TABS F QL(1 ea daily);RX/OTC
SUPERB NAILS TABS F QL(1 ea daily);RX/OTC
T-VITES TABS F QL(1 ea daily);RX/OTC
THERA M PLUS TABS F QL(1 ea daily);RX/OTC
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Drug Name DrugTier
Requirements/Limits
THERA-M TABS F QL(1 ea daily);RX/OTC
THERA-TABS M TABS F QL(1 ea daily);RX/OTC
THERABETIC MULTI-VITAMIN TABS F QL(1 ea daily);
RX/OTC THERAGRAN-M ADVANCED 50 PLUS TABS
F QL(1 ea daily);RX/OTC
THERAGRAN-M ADVANCED TABS F QL(1 ea daily);
RX/OTC THERAGRAN-M PREMIER 50 PLUS TABS F QL(1 ea daily);
RX/OTC THERAGRAN-M PREMIER TABS F QL(1 ea daily);
RX/OTC
THERAGRAN-M TABS F QL(1 ea daily);RX/OTC
THEREMS-H TABS F QL(1 ea daily);RX/OTC
THEREMS-M TABS F QL(1 ea daily);RX/OTC
UNICOMPLEX-M TABS F QL(1 ea daily);RX/OTC
VITALINE TOTAL FORMULA 2 TABS F QL(1 ea daily);
RX/OTC VITALINE TOTAL FORMULA 3 TABS F QL(1 ea daily);
RX/OTC VITAMIN D3 COMPLETE TABS F QL(1 ea daily);
RX/OTC
VITASANA TABS F QL(1 ea daily);RX/OTC
VITATRUM TABS F QL(1 ea daily);RX/OTC
VITRUM 50+ SENIOR MULTI TABS F QL(1 ea daily);
RX/OTC
VP-ZEL TABS F QL(1 ea daily);RX/OTC
WHOLE FOOD MULTIVITAMIN TABS F QL(1 ea daily);
RX/OTC WOMENS 50+ MULTI VITAMIN& MINERAL FORMULA TABS
F QL(1 ea daily);RX/OTC
WOMENS BIOMULTIPLE TABS F QL(1 ea daily);
RX/OTC
Drug Name DrugTier
Requirements/Limits
WOMENS MULTI VITAMIN & MINERAL FORMULA TABS
F QL(1 ea daily);RX/OTC
YELETS TEENAGE FORMULA TABS F QL(1 ea daily);
RX/OTC
Multivitamins
ESTROFACTORS TABS F
MULTI VITAMIN TABS F
MULTI VITAMIN/D-3 TABS F
multiple vitamin tabs F
OMNICAP TABS F
QUINTABS TABS F
THERA TABS F
Ped MV w/ Fluoride
FLORIVA PLUS SOLN F QL(50 ml perfill retail); AL;Up to 13 yrs old
MULTIVITAMIN/FLUORIDE CHEW F
QL(1 ea daily);AL; Up to 13yrs old
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Drug Name DrugTier
Requirements/Limits
pediatric multivitamins w/flchew 0.25mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg,0.25mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg, 0.5mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 0.5mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg,0.5mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-15unit-1.05mg-60mg, 15unit-1mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg, 1mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 1mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg, 15unit-0.5mg-1.05mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 15unit-0.5mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg,15unit-0.25mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg
F
QL(1 ea daily);AL; Up to 13yrs old
Drug Name DrugTier
Requirements/Limits
pediatric multivitamins w/flsoln 0.25mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-5unit/ml-0.4mg/ml-35mg/ml,0.25mg/ml-5unit/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml,0.25mg/ml-5unit/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml,0.5mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-5unit/ml-0.4mg/ml-35mg/ml,0.5mg/ml-5unit/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml,0.5mg/ml-5unit/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.5mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.5mg/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.25mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml
F
QL(50 ml perfill retail); AL;Up to 13 yrs old
pediatric vitamins acd w/fluoride soln F
QL(50 ml perfill retail); AL;Up to 13 yrs old
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Drug Name DrugTier
Requirements/Limits
QUFLORA PEDIATRIC CHEW 108MCG-1MG-15UNIT-1MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG, 108MCG-1MG-15UNIT-0.5MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG, 108MCG-1MG-15UNIT-0.25MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG
F
QL(1 ea daily);AL; Up to 13yrs old
QUFLORA PEDIATRIC SOLN 150MCG/ML-1MG/ML-0.5MG/ML-12MG/ML-1100UNIT/ML-2MG/ML-1MG/ML-3MCG/ML-400UNIT/ML-1MG/ML-81MCG/ML-12UNIT/ML-1MG/ML-45MG/ML, 65MCG/ML-1MG/ML-0.25MG/ML-10MG/ML-1000UNIT/ML-0.8MG/ML-0.6MG/ML-2MCG/ML-400UNIT/ML-0.5MG/ML-35MCG/ML-5UNIT/ML-0.4MG/ML-35MG/ML
F
QL(50 ml perfill retail); AL;Up to 13 yrs old
TRI-VITAMIN/FLUORIDESOLN F
QL(50 ml perfill retail); AL;Up to 13 yrs old
Ped MV w/ Iron pediatric multiple vitaminsw/ iron soln F
Ped Multi Vitamins w/Fl & FE
ped multivitamins w/fl &iron soln F
QL(50 ml perfill retail); AL;Up to 13 yrs old
TRI-VIT/FLUORIDE/IRONSOLN F
QL(50 ml perfill retail); AL;Up to 13 yrs old
Pediatric Multiple Vitamins pediatric multiple vitamin w/c & fa chew F
Drug Name DrugTier
Requirements/Limits
pediatric multiple vitamin w/c soln F
Pediatric Vitamins pediatric vitamins adc soln1500unit/ml-400unit/ml-35mg/ml
F
Prenatal Vitamins
CALNA TABS F
CLASSIC PRENATAL TABS F
CO-NATAL FA TABS F QL(1 ea daily)
COMPLETENATE CHEW F QL(1 ea daily)
CVS PRENATAL TABS F
EQL PRENATAL FORMULA TABS F
GNP PRENATAL TABS F
GOODSENSE PRENATAL VITAMINS TABS F
HM PRENATAL TABS F
INATAL GT TABS F QL(1 ea daily)
KP PRENATAL MULTIVITAMINS TABS F
KPN PRENATAL TABS F
M-VIT TABS F QL(1 ea daily);RX/OTC
MULTI PRENATAL TABS F
MYNATAL ADVANCE TABS F QL(1 ea daily)
MYNATAL CAPS F QL(1 ea daily)
MYNATAL PLUS TABS F QL(1 ea daily)
MYNATAL ULTRACAPLET TABS F QL(1 ea daily)
MYNATAL-Z TABS F QL(1 ea daily)
MYNATE 90 PLUS TBCR F QL(1 ea daily)
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Drug Name DrugTier
Requirements/Limits
NAT-RUL PRENATAL VITAMINS TABS F
NATALVIT TABS F QL(1 ea daily)
NIVA-PLUS TABS F QL(1 ea daily);RX/OTC
NUTRICION PORVIDA TABS F
O-CAL FA TABS F QL(1 ea daily);RX/OTC
O-CAL PRENATAL TABS F QL(1 ea daily)
PERRY PRENATAL CAPS F
PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID TABS
F QL(1 ea daily)
PNV FOLIC ACID + IRON MULTIVITAMIN TABS F QL(1 ea daily);
RX/OTC PNV PRENATAL PLUS MULTIVITAMIN TABS F QL(1 ea daily);
RX/OTC
PNV TABS 29-1 TABS F QL(1 ea daily)
PRE-NATAL FORMULA TABS F
PRENATABS FA TABS F QL(1 ea daily)
PRENATABS RX TABS F QL(1 ea daily)
PRENATAL 19 CHEW F QL(1 ea daily)
PRENATAL 19 TABS F QL(1 ea daily)
PRENATAL AND IRON TABS F
PRENATAL FORTE TABS F
PRENATAL LOW IRON TABS F
PRENATAL MULTIVITAMIN TABS F
PRENATAL ONE DAILY TABS F
PRENATAL PLUS IRON TABS F QL(1 ea daily)
PRENATAL PLUS TABS F QL(1 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
PRENATAL TABS 11UNIT-263MG-25MG-1.5MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-0.8MG-2.6MG-120MG, 30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-4000UNIT-8MCG-400UNIT-800MCG-2.6MG-120MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT- F
800MCG-2.6MG-120MG, 4000UNIT-30UNIT-200MG-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 4000UNIT-30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 160MG-11UNIT-200MG-25MG-1.84MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-800MCG-2.6MG-100MG PRENATAL TABS 22MG- QL(1 ea daily);2MG-25MG-1.84MG- RX/OTC200MG-27MG-4000UNIT-20MG-3MG-12MCG- F
400UNIT-1MG-10MG-120MG PRENATAL TABS 4000UNIT-200MG-11UNIT-27MG-25MG-1.84MG-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG
F
PRENATAL VITAMIN & MINERAL TABS F
PRENATAL VITAMIN TABS F
PRENATAL VITAMIN/IRON TABS F
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Drug Name DrugTier
Requirements/Limits
PRENATAL VITAMINS PLUS LOW IRON TABS F QL(1 ea daily);
RX/OTC PRENATAL VITAMINS TABS F
PREPLUS TABS F QL(1 ea daily);RX/OTC
PRETAB TABS F QL(1 ea daily)
PX PRENATAL MULTIVITAMINS TABS F
QC PRENATAL TABS F
RA PRENATAL FORMULA/FOLICACIDTABS
F
RA PRENATAL TABS F
RIGHT STEP PRENATAL TABS F
SE-NATAL 19 CHEW F QL(1 ea daily)
SE-NATAL 19 TABS F QL(1 ea daily)
SM PRENATAL VITAMINS TABS F
THERANATAL CORE NUTRITION TABS F QL(1 ea daily);
RX/OTC
THRIVITE 19 TABS F QL(1 ea daily)
THRIVITE RX TABS F QL(1 ea daily)
TRIADVANCE TABS F QL(1 ea daily)
TRICARE TABS F QL(1 ea daily);RX/OTC
TRINATAL GT TABS F QL(1 ea daily)
TRINATAL RX 1 TABS F QL(1 ea daily)
VIL-RX TABS F QL(1 ea daily)
VINATE M TABS F QL(1 ea daily)
VINATE ONE TABS F QL(1 ea daily)
VIRT-ADVANCE TABS F QL(1 ea daily)
Drug Name DrugTier
Requirements/Limits
VIRT-VITE GT TABS F QL(1 ea daily)
VITAFOL-OB TABS F QL(1 ea daily)
VOL-PLUS TABS F QL(1 ea daily);RX/OTC
VOL-TAB RX TABS F QL(1 ea daily)
Vitamins w/ Lipotropics
vitamins w/ lipotropics caps F
MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms
Central Muscle Relaxants
baclofen tabs F
carisoprodol tabs 350 mg F PA
CHLORZOXAZONE TABS 500 MG F
cyclobenzaprine hcl tabs 5mg, 10 mg F QL(3 ea daily)
cyclobenzaprine hcl tabs7.5 mg F QL(4 ea daily)
FEXMID TABS (Use Cyclobenzaprine HCl) NF QL(4 ea daily)
methocarbamol tabs or 500 mg, 750 mg F
orphenadrine citrate tb12 or100 mg F
ROBAXIN TABS OR 500 MG (Use Methocarbamol) NF
ROBAXIN-750 TABS (Use Methocarbamol) NF
SOMA TABS 350 MG (Use Carisoprodol) NF PA
tizanidine hcl tabs 2 mg, 4 mg F
ZANAFLEX TABS 4 MG (Use Tizanidine HCl) NF
NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus
Nasal Agents - Misc. OCEAN NASAL SPRAY SOLN (Use Saline) NF QL(480 ml per
fill retail)
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Drug Name DrugTier
Requirements/Limits
saline soln 0.65%-0.002%,0.65 %, 0.65% F QL(480 ml per
fill retail) Nasal Anti-infectives BACTROBAN NASAL OINT F
Nasal Antiallergy ASTEPRO SOLN (Use Azelastine HCl) NF
azelastine hcl soln F
cromolyn sodium (nasal) aers F
NASALCROM AERS (Use Cromolyn Sodium (Nasal)) NF
Nasal Anticholinergics ATROVENT SOLN 0.03 % (Use Ipratropium Bromide(Nasal))
NF
ATROVENT SOLN 0.06 % (Use Ipratropium Bromide(Nasal))
NF QL(15 ml perfill retail)
ipratropium bromide (nasal)soln 0.03 % F
ipratropium bromide (nasal)soln 0.06 % F QL(15 ml per
fill retail) Nasal Steroids FLONASE ALLERGY RELIEF CHILDRENS SUSP (Use Fluticasone Propionate (Nasal))
NF
QL(16 ml perfill retail);RX/OTC
FLONASE ALLERGY RELIEF SUSP (Use Fluticasone Propionate(Nasal))
NF
QL(16 ml perfill retail);RX/OTC
FLUNISOLIDE SOLN F QL(25 ml perfill retail)
fluticasone propionate(nasal) susp F
QL(16 ml perfill retail);RX/OTC
NASACORT ALLERGY 24HR AERO (Use Triamcinolone Acetonide (Nasal))
NF
RX/OTC
Drug Name DrugTier
Requirements/Limits
NASACORT ALLERGY 24HR CHILDRENS AERO (Use Triamcinolone Acetonide (Nasal))
NF
RX/OTC
triamcinolone acetonide (nasal) aero F
QL(17 ml perfill retail);RX/OTC
Sympathomimetic Decongestants
ADRENALIN SOLN F
NASAL DECONGESTANT LIQD F
NASAL DECONGESTANT SYRP F
phenylephrine hcl (oral)tabs F
pseudoephedrine hcl liqd15 mg/5ml F
pseudoephedrine hcl tabs30 mg, 60 mg F
pseudoephedrine hcl tb12120 mg F
SUDAFED CHILDRENS LIQD (Use Pseudoephedrine HCl)
NF
SUDAFED CONGESTION TABS (Use Pseudoephedrine HCl)
NF
SUDAFED NASAL DECONGESTANT MAXIMUM STRENGTH TABS (Use Pseudoephedrine HCl)
NF
SUDAFED PE CHILDRENS NASAL DECONGESTANT SOLN
F
SUDAFED PE CONGESTION TABS (Use Phenylephrine HCl (Oral))
NF
NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze Muscles
ALS Agents RILUTEK TABS (Use Riluzole) NF
riluzole tabs F
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Drug Name DrugTier
Requirements/Limits
NUTRIENTS
Carbohydrates
POLYCOSE LIQD F QL(124 ml perfill retail)
POLYCOSE POWD F QL(350 gm perfill retail)
Misc. Nutritional Substances
Drug Name DrugTier
Requirements/Limits
omega-3 fatty acids caps1000mg, 1200mg, 1000mg, 1200 mg, 180mg-120mg, 1200mg-2unit,300mg-1000mg, 350mg-1000mg, 360mg-1200mg,600mg-1000mg, 600mg-1200mg, 180mg-120mg-5unit, 300mg-180mg-120mg, 300mg-200mg-1unit, 1000mg-180mg-120mg, 160mg-1000mg-100mg, 180mg-1000mg-120mg, 180mg-1200mg-144mg, 216mg-1200mg-144mg, 270mg-1000mg-180mg, 300mg-1000mg-1unit, 300mg-1000mg-200mg, 300mg-1unit-1000mg, 336mg-1200mg-276mg, 350mg-1000mg-250mg, 400mg-1000mg-300mg, 500mg-1000mg-250mg, 180mg-120mg-1.8unit, 300mg-180mg- F
1gm-120mg, 1000mg-180mg-120mg-1mg,210mg-1000mg-75mg-90mg, 60mg-180mg-1200mg-120mg, 60mg-360mg-1200mg-300mg,1000mg-180mg-120mg-1unit, 100mg-300mg-1000mg-200mg, 180mg-1000mg-120mg-1unit,180mg-1unit-1000mg-120mg, 300mg-1000mg-200mg-1unit, 300mg-180mg-1000mg-120mg,360mg-216mg-1200mg-144mg, 600mg-324mg-1200mg-216mg, 700mg-350mg-1000mg-250mg,100mg-1000mg-500mg-10unit, 216mg-1200mg-144mg-15unit, 340mg-180mg-1unit-1000mg-120mg
OPHTHALMIC AGENTS - Drugs to Treat the Eye
Artificial Tears and Lubricants
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Drug Name DrugTier
Requirements/Limits
artificial tear ointment oint F
HYPOTEARS SOLN F QL(30 ml perfill retail)
polyvinyl alcohol soln F
TEARS NATURALE PM OINT (Use White Petrolatum-Mineral Oil)
NF QL(42 gm perfill retail)
white petrolatum-mineral oiloint F QL(42 gm per
fill retail) Beta-blockers - Ophthalmic BETAGAN SOLN (Use Levobunolol HCl) NF QL(15 ml per
fill retail)
betaxolol hcl (ophth) soln F QL(15 ml perfill retail)
BETOPTIC-S SUSP F QL(15 ml perfill retail)
carteolol hcl (ophth) soln F
CARTEOLOL HCL SOLN F
COSOPT SOLN (Use Dorzolamide HCl-Timolol Maleate)
NF QL(10 ml perfill retail)
dorzolamide hcl-timolol maleate soln F QL(10 ml per
fill retail)
levobunolol hcl soln F QL(15 ml perfill retail)
METIPRANOLOL SOLN F
timolol maleate (ophth)solg 0.5 % F QL(5 ml per fill
retail) timolol maleate (ophth)soln 0.25 %, 0.5 % F QL(15 ml per
fill retail) TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG 0.5 %
F QL(5 ml per fillretail)
TIMOPTIC OCUDOSE SOLN F QL(60 ea per
fill retail) TIMOPTIC SOLN (Use Timolol Maleate (Ophth)) NF QL(15 ml per
fill retail) TIMOPTIC-XE SOLG 0.5 % F QL(5 ml per fill
retail) Cycloplegic Mydriatics
Drug Name DrugTier
Requirements/Limits
ATROPINE SULFATE OINT OP 1 % F QL(4 gm per fill
retail) ATROPINE SULFATE SOLN OP 1 % F QL(10 ml per
fill retail) CYCLOGYL SOLN 0.5 %, 1 % (Use CyclopentolateHCl)
NF QL(15 ml perfill retail)
cyclopentolate hcl soln 0.5%, 1 % F QL(15 ml per
fill retail) MYDRIACYL SOLN (Use Tropicamide) NF QL(15 ml per
fill retail)
tropicamide soln F QL(15 ml perfill retail)
Miotics ISOPTO CARPINE SOLN (Use Pilocarpine HCl) NF
pilocarpine hcl soln F
Ophthalmic Adrenergic Agents
apraclonidine hcl soln F
brimonidine tartrate soln 0.2 % F QL(15 ml per
fill retail) IOPIDINE SOLN 0.5 % (Use Apraclonidine HCl) NF
IOPIDINE SOLN 1 % F
Ophthalmic Anti-infectives bacitracin-polymyxin b(ophth) oint F QL(4 gm per fill
retail) BLEPH-10 SOLN (Use Sulfacetamide Sodium (Ophth))
NF QL(15 ml perfill retail)
CILOXAN OINT F QL(4 gm per fillretail)
CILOXAN SOLN (Use Ciprofloxacin HCl (Ophth)) NF QL(10 ml per
fill retail) ciprofloxacin hcl (ophth)soln F QL(10 ml per
fill retail)
erythromycin (ophth) oint F QL(4 gm per fillretail)
GENTAK OINT F QL(4 gm per fillretail)
gentamicin sulfate (ophth)oint F QL(4 gm per fill
retail)
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Drug Name DrugTier
Requirements/Limits
gentamicin sulfate (ophth)soln F QL(15 ml per
fill retail) moxifloxacin hcl (ophth)soln F QL(3 ml per fill
retail) neomycin-bacitracin zn-polymyxin oint F QL(4 gm per fill
retail) neomycin-polymyxin-gramicidin soln F QL(10 ml per
fill retail) NEOSPORIN SOLN (Use Neomycin-Polymyxin-Gramicidin)
NF QL(10 ml perfill retail)
OCUFLOX SOLN (Use Ofloxacin (Ophth)) NF QL(10 ml per
fill retail)
ofloxacin (ophth) soln F QL(10 ml perfill retail)
polymyxin b-trimethoprimsoln F QL(10 ml per
fill retail) POLYTRIM SOLN (Use Polymyxin B-Trimethoprim) NF QL(10 ml per
fill retail) sulfacetamide sodium (ophth) soln F QL(15 ml per
fill retail)
tobramycin (ophth) soln F QL(5 ml per fillretail)
TOBREX OINT F QL(4 gm per fillretail)
TOBREX SOLN (Use Tobramycin (Ophth)) NF QL(5 ml per fill
retail)
trifluridine soln F QL(8 ml per fillretail)
VIGAMOX SOLN (Use Moxifloxacin HCl (Ophth)) NF QL(3 ml per fill
retail) VIROPTIC SOLN (Use Trifluridine) NF QL(8 ml per fill
retail) Ophthalmic Decongestants naphazoline w/pheniramine soln F
NAPHCON-A SOLN (Use Naphazoline w/Pheniramine)
NF
OPCON-A SOLN (Use Naphazoline w/Pheniramine)
NF
phenylephrine hcl (ophth)soln 2.5 % F QL(30 ml per
fill retail) tetrahydrozoline hcl (ophth)soln F QL(30 ml per
fill retail)
Drug Name DrugTier
Requirements/Limits
VISINE EXTRA SOLN (Use Tetrahydrozoline HCl(Ophth))
NF QL(30 ml perfill retail)
VISINE SOLN (Use Tetrahydrozoline HCl(Ophth))
NF QL(30 ml perfill retail)
Ophthalmic Local Anesthetics ALCAINE SOLN (Use Proparacaine HCl) NF PA; QL(15 ml
per fill retail)
proparacaine hcl soln F PA; QL(15 mlper fill retail)
tetracaine hcl (ophth) soln F
Ophthalmic Steroids BLEPHAMIDE S.O.P. OINT F QL(4 gm per fill
retail)
BLEPHAMIDE SUSP F QL(10 ml perfill retail)
DEXAMETHASONE SODIUM PHOSPHATE SOLN OP 0.1 %
F QL(5 ml per fillretail)
fluorometholone (ophth) susp F QL(15 ml per
fill retail) FML LIQUIFILM SUSP (Use Fluorometholone (Ophth))
NF QL(15 ml perfill retail)
FML OINT F QL(4 gm per fillretail)
MAXITROL OINT 10000UNIT/GM-3.5MG/GM-0.1% (Use Neomycin-Polymy-Dexameth)
NF
QL(4 gm per fillretail)
MAXITROL SUSP 10000UNIT/ML-3.5MG/ML-0.1% (Use Neomycin-Polymy-Dexameth)
NF
QL(5 ml per fillretail)
neomycin-polymy-dexameth oint 10000unit/gm-3.5mg/gm-0.1%
F
QL(4 gm per fillretail)
neomycin-polymy-dexameth susp10000unit/ml-3.5mg/ml-0.1%
F
QL(5 ml per fillretail)
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Drug Name DrugTier
Requirements/Limits
NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP
F QL(8 ml per fillretail)
OMNIPRED SUSP (Use Prednisolone Acetate (Ophth))
NF QL(15 ml perfill retail)
PRED FORTE SUSP (Use Prednisolone Acetate (Ophth))
NF QL(15 ml perfill retail)
PRED MILD SUSP F QL(10 ml perfill retail)
PRED-G SUSP F QL(5 ml per fillretail)
prednisolone acetate(ophth) susp F QL(15 ml per
fill retail) PREDNISOLONE ACETATE P-F SUSP F QL(15 ml per
fill retail) sulfacetamide sod-prednisolone soln F QL(10 ml per
fill retail)
TOBRADEX OINT F QL(4 gm per fillretail)
TOBRADEX SUSP (Use Tobramycin-Dexamethasone)
NF QL(10 ml perfill retail)
tobramycin-dexamethasone susp F QL(10 ml per
fill retail)
VEXOL SUSP F QL(10 ml perfill retail)
Ophthalmics - Misc. ACULAR LS SOLN (Use Ketorolac Tromethamine (Ophth))
NF
ACULAR SOLN (Use Ketorolac Tromethamine (Ophth))
NF QL(10 ml perfill retail)
ALOCRIL SOLN F QL(5 ml per fillretail)
ALOMIDE SOLN F QL(10 ml perfill retail)
azelastine hcl (ophth) soln F QL(6 ml per fillretail)
AZOPT SUSP F QL(15 ml perfill retail)
cromolyn sodium (ophth)soln F QL(10 ml per
fill retail)
Drug Name DrugTier
Requirements/Limits
diclofenac sodium (ophth)soln F QL(5 ml per fill
retail)
dorzolamide hcl soln F QL(10 ml perfill retail)
flurbiprofen sodium soln F QL(3 ml per fillretail)
FLURBIPROFEN SODIUM SOLN F QL(3 ml per fill
retail) ketorolac tromethamine (ophth) soln 0.4 % F
ketorolac tromethamine (ophth) soln 0.5 % F QL(10 ml per
fill retail) ketotifen fumarate (ophth)soln F QL(240 ml per
fill retail) MURO 128 OINT 5 % (Use Sodium Chloride Hypertonic)
NF
MURO 128 SOLN 5 % (Use Sodium Chloride Hypertonic)
NF
OCUFEN SOLN (Use Flurbiprofen Sodium) NF QL(3 ml per fill
retail) sodium chloride hypertonicoint F
sodium chloride hypertonicsoln F
TRUSOPT SOLN (Use Dorzolamide HCl) NF QL(10 ml per
fill retail) ZADITOR SOLN (Use Ketotifen Fumarate (Ophth))
NF QL(240 ml perfill retail)
Prostaglandins - Ophthalmic
latanoprost soln F QL(3 ml per fillretail)
XALATAN SOLN (Use Latanoprost) NF QL(3 ml per fill
retail)
OTIC AGENTS - Drugs to Treat the Ear
Otic Agents - Miscellaneous
acetic acid (otic) soln F QL(15 ml perfill retail)
carbamide peroxide (otic)soln F
DEBROX SOLN (Use Carbamide Peroxide (Otic)) NF
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Drug Name DrugTier
Requirements/Limits
Otic Anti-infectives FLOXIN OTIC SOLN (Use Ofloxacin (Otic)) NF QL(10 ml per
fill retail)
ofloxacin (otic) soln F QL(10 ml perfill retail)
Otic Combinations CORTANE-B AQUEOUS SOLN F QL(10 ml per
fill retail) CORTANE-B-OTIC SOLN (Use Pramoxine-HC-Chloroxylenol)
NF QL(15 ml perfill retail)
neomycin-polymyxin-hc(otic) soln F QL(10 ml per
fill retail) neomycin-polymyxin-hc(otic) susp F QL(10 ml per
fill retail) OTICIN HC NR SOLN (Use Pramoxine-HC-Chloroxylenol)
NF QL(15 ml perfill retail)
pramoxine-hc-chloroxylenolsoln F QL(15 ml per
fill retail) Otic Steroids DERMOTIC OIL (Use Fluocinolone Acetonide (Otic))
NF QL(20 ml perfill retail)
fluocinolone acetonide (otic) oil F QL(20 ml per
fill retail) hydrocortisone w/aceticacid soln F QL(10 ml per
fill retail) OXYTOCICS - Drugs to Prevent/Control UterineBleeding
Oxytocics methylergonovine maleatetabs or 0.2 mg F
PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem
Immune Serums
HYPERRHO S/D SOSY F SP
RHOGAM ULTRA-FILTERED PLUS SOSY F SP
PENICILLINS - Drugs to Treat Bacterial Infections
Aminopenicillins
Drug Name DrugTier
Requirements/Limits
amoxicillin caps 250 mg,500 mg F
AMOXICILLIN CHEW 125 MG, 250 MG F
amoxicillin susr 125 mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml
F
amoxicillin tabs 875 mg F
ampicillin caps 250 mg,500 mg F
AMPICILLIN CAPS 500 MG F
Natural Penicillins PENICILLIN V POTASSIUM SOLR 125 MG/5ML, 250 MG/5ML
F
penicillin v potassium solr125 mg/5ml, 250 mg/5ml F
penicillin v potassium tabs250 mg, 500 mg F
Penicillin Combinations amoxicillin & potclavulanate susr 200mg/5ml-28.5mg/5ml
F QL(100 ml perfill retail)
amoxicillin & potclavulanate susr 250mg/5ml-62.5mg/5ml
F QL(150 ml perfill retail)
amoxicillin & potclavulanate susr 400mg/5ml-57mg/5ml
F QL(200 ml perfill retail)
amoxicillin & potclavulanate susr 600mg/5ml-42.9mg/5ml
F QL(400 ml perfill retail)
amoxicillin & potclavulanate tabs 250mg-125mg
F QL(30 ea perfill retail)
amoxicillin & potclavulanate tabs 500mg-125mg, 875mg-125mg
F QL(20 ea perfill retail)
amoxicillin & potclavulanate tb12 1000mg-62.5mg
F QL(40 ea per30 days retail)
AMOXICILLIN/CLAVULANATE POTASSIUM CHEW F QL(20 ea per
fill retail)
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Drug Name DrugTier
Requirements/Limits
AUGMENTIN ES-600 SUSR (Use Amoxicillin & Pot Clavulanate)
NF QL(400 ml perfill retail)
AUGMENTIN SUSR 125MG/5ML-31.25MG/5ML F QL(150 ml per
fill retail) AUGMENTIN SUSR 250MG/5ML-62.5MG/5ML(Use Amoxicillin & Pot Clavulanate)
NF
QL(150 ml perfill retail)
AUGMENTIN TABS 500MG-125MG, 875MG-125MG (Use Amoxicillin & Pot Clavulanate)
NF
QL(20 ea perfill retail)
AUGMENTIN XR TB12 (Use Amoxicillin & Pot Clavulanate)
NF QL(40 ea per30 days retail)
Penicillinase-Resistant Penicillins
dicloxacillin sodium caps F
PHARMACEUTICAL ADJUVANTS
Internal Vehicle Ingredients/Agents SIMPLYTHICK EASY MIX GEL F
SIMPLYTHICK GEL F
Semi Solid Vehicles
lanolin oint ex F RX/OTC
PROGESTINS - Hormone Replacement/ModifyingDrugs
Progestins AYGESTIN TABS (Use Norethindrone Acetate) NF
MAKENA OIL F PA; SP
medroxyprogesteroneacetate tabs F
norethindrone acetate tabs F
progesterone micronizedcaps 100 mg F
QL(1 eadaily,30 ea per30 days retail)
progesterone micronizedcaps 200 mg F
Drug Name DrugTier
Requirements/Limits
PROMETRIUM CAPS 100 MG (Use ProgesteroneMicronized)
NF QL(1 eadaily,30 ea per30 days retail)
PROMETRIUM CAPS 200 MG (Use ProgesteroneMicronized)
NF
PROVERA TABS (Use MedroxyprogesteroneAcetate)
NF
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental andEmotional Conditions
Agents for Chemical Dependency
acamprosate calcium tbec CO
ANTABUSE TABS 250 MG (Use Disulfiram) NF
disulfiram tabs 250 mg F
Antidementia Agents ARICEPT TABS 5 MG, 10 MG (Use DonepezilHydrochloride)
NF QL(1 ea daily)
donepezil hydrochloridetabs 5 mg, 10 mg F QL(1 ea daily)
EXELON CAPS OR 3 MG, 6 MG, 1.5 MG, 4.5 MG (Use Rivastigmine Tartrate)
NF PA; QL(2 eadaily)
EXELON PT24 TD 4.6 MG/24HR, 9.5 MG/24HR(Use Rivastigmine)
NF PA; QL(1 eadaily)
galantamine hydrobromidecp24 8 mg, 16 mg, 24 mg F QL(1 ea daily)
GALANTAMINE HYDROBROMIDE SOLN 4 MG/ML
F QL(6 ml daily)
galantamine hydrobromidetabs 4 mg, 8 mg, 12 mg F QL(2 ea daily)
memantine hcl soln 2 mg/ml F QL(2 ml daily)
memantine hcl tabs F QL(49 ea perfill retail)
memantine hcl tabs 5 mg,10 mg F QL(2 ea daily)
NAMENDA TABS 5 MG, 10 MG (Use Memantine HCl) NF QL(2 ea daily)
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Drug Name DrugTier
Requirements/Limits
NAMENDA TITRATION PAK TABS (Use Memantine HCl)
NF QL(49 ea perfill retail)
RAZADYNE ER CP24 (Use Galantamine Hydrobromide)
NF QL(1 ea daily)
RAZADYNE TABS (Use Galantamine Hydrobromide)
NF QL(2 ea daily)
rivastigmine pt24 4.6mg/24hr, 9.5 mg/24hr F PA; QL(1 ea
daily)
rivastigmine tartrate caps F PA; QL(2 eadaily)
Combination Psychotherapeutics olanzapine-fluoxetine hcl caps CO
PERPHENAZINE/AMITRIPTYLINE TABS F QL(4 ea daily)
SYMBYAX CAPS (Use Olanzapine-FluoxetineHCl)
CO
Fibromyalgia Agents
SAVELLA TABS F PA; QL(2 eadaily)
SAVELLA TITRATION PACK MISC F
PA; QL(55 eaper 365 daysretail)
Multiple Sclerosis Agents
AVONEX KIT F PA; SP
AVONEX PEN AJKT F PA; SP
AVONEX PSKT F PA; SP
COPAXONE SOSY (Use Glatiramer Acetate) NF PA; SP
GILENYA CAPS F PA; SP
glatiramer acetate sosy F PA; SP
LEMTRADA SOLN F PA; SP
PLEGRIDY SOPN F PA; SP
PLEGRIDY SOSY F PA; SP
Drug Name DrugTier
Requirements/Limits
PLEGRIDY STARTER PACK SOPN F PA; SP
PLEGRIDY STARTER PACK SOSY F PA; SP
TECFIDERA CPDR F PA; SP
TECFIDERA STARTER PACK MISC F PA; SP
Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATES TABS F
ORAP TABS (Use Pimozide) CO
pimozide tabs CO
Smoking Deterrents bupropion hcl (smokingdeterrent) tb12 F QL(2 ea daily)
CHANTIX CONTINUING MONTHPAK TABS F QL(2 ea daily)
CHANTIX STARTING MONTH PAK TABS F
CHANTIX TABS F QL(2 ea daily)
NICODERM CQ PT24 (Use Nicotine) NF
NICORETTE GUM (Use Nicotine Polacrilex) NF
NICORETTE LOZG (Use Nicotine Polacrilex) NF
NICORETTE MINI LOZG (Use Nicotine Polacrilex) NF
NICORETTE STARTER KIT GUM (Use Nicotine Polacrilex)
NF
nicotine polacrilex gum F
nicotine polacrilex lozg F
nicotine pt24 F
NICOTINE TRANSDERMAL SYSTEM KIT
F
NICOTROL INHALER INHA F QL(504 ea per
30 days retail)
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Drug Name DrugTier
Requirements/Limits
NICOTROL NS SOLN F
ZYBAN TB12 (Use Bupropion HCl (SmokingDeterrent))
NF QL(2 ea daily)
RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung Conditions
Cystic Fibrosis Agents
KALYDECO PACK F PA; SP
KALYDECO TABS F PA; SP
ORKAMBI TABS 200MG-125MG F PA; SP
TETRACYCLINES - Drugs to Treat BacterialInfections
Tetracyclines doxycycline hyclate caps50 mg, 100 mg F
doxycycline hyclate tabs100 mg F
MINOCIN CAPS (Use Minocycline HCl) NF
minocycline hcl caps 50mg, 75 mg, 100 mg F
VIBRAMYCIN CAPS 100 MG (Use DoxycyclineHyclate)
NF
THYROID AGENTS - Drugs to Regulate ThyroidHormones
Antithyroid Agents
methimazole tabs F
propylthiouracil tabs F
TAPAZOLE TABS (Use Methimazole) NF
Thyroid Hormones ARMOUR THYROID TABS 15 MG, 30 MG, 60 MG, 90 MG, 120 MG (Use Thyroid)
F
ARMOUR THYROID TABS 180 MG, 240 MG, 300 MG F
CYTOMEL TABS (Use Liothyronine Sodium) NF
Drug Name DrugTier
Requirements/Limits
levothyroxine sodium tabs F
liothyronine sodium tabs F
NATURE-THROID TABS 65 MG, 130 MG, 195 MG, 32.5 MG
F
SYNTHROID TABS (Use Levothyroxine Sodium) F
thyroid tabs F
THYROLAR-1 TABS F
THYROLAR-1/2 TABS F
THYROLAR-1/4 TABS F
THYROLAR-2 TABS F
THYROLAR-3 TABS F
WESTHROID TABS 65 MG, 130 MG, 195 MG, 32.5 MG
F
WP THYROID TABS 65 MG, 130 MG, 32.5 MG F
TOXOIDS
Toxoid Combinations
ADACEL SUSP F AL; At least 19 yrs old
BOOSTRIX SUSP F AL; At least 19 yrs old
TENIVAC INJ F AL; At least 19 yrs old
TETANUS/DIPHTHERIATOXOIDS-ADSORBED SUSP
F AL; At least 19 yrs old
ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach Conditions
Antispasmodics ANASPAZ TBDP (Use Hyoscyamine Sulfate) NF
BENTYL CAPS (Use Dicyclomine HCl) NF
BENTYL TABS (Use Dicyclomine HCl) NF
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Drug Name DrugTier
Requirements/Limits
dicyclomine hcl caps 10 mg F
dicyclomine hcl soln 10mg/5ml F QL(40 ml daily)
dicyclomine hcl tabs 20 mg F
DONNATAL ELIX (Use Phenobarbital-Hyoscyamine-Atropine-Scopolamine)
NF
DONNATAL TABS (Use Phenobarbital-Hyoscyamine-Atropine-Scopolamine)
NF
glycopyrrolate tabs 1 mg, 2 mg F QL(4 ea daily)
hyoscyamine sulfate elix or0.125 mg/5ml F
hyoscyamine sulfate solnor 0.125 mg/ml F
hyoscyamine sulfate subl sl0.125 mg F
hyoscyamine sulfate tabsor 0.125 mg F
hyoscyamine sulfate tb12or 0.375 mg F QL(4 ea daily)
hyoscyamine sulfate tbdpor 0.125 mg F
LEVBID TB12 (Use Hyoscyamine Sulfate) NF QL(4 ea daily)
LEVSIN TABS (Use Hyoscyamine Sulfate) NF
LEVSIN/SL SUBL (Use Hyoscyamine Sulfate) NF
phenobarbital-hyoscyamine-atropine-scopolamine elix
F
phenobarbital-hyoscyamine-atropine-scopolamine tabs
F
ROBINUL FORTE TABS (Use Glycopyrrolate) NF QL(4 ea daily)
ROBINUL TABS (Use Glycopyrrolate) NF QL(4 ea daily)
SYMAX DUOTAB TBCR F
H-2 Antagonists
Drug Name DrugTier
Requirements/Limits
CIMETIDINE HCL SOLN F QL(27 ml daily)
cimetidine tabs 200 mg F RX/OTC
cimetidine tabs 300 mg,400 mg, 800 mg F
famotidine susr 40 mg/5ml F
famotidine tabs 10 mg, 40 mg F
famotidine tabs 20 mg F RX/OTC
PEPCID AC MAXIMUM STRENGTH TABS (Use Famotidine)
NF RX/OTC
PEPCID AC TABS (Use Famotidine) NF
PEPCID SUSR 40 MG/5ML(Use Famotidine) NF
PEPCID TABS 20 MG (Use Famotidine) NF RX/OTC
PEPCID TABS 40 MG (Use Famotidine) NF
ranitidine hcl caps or 150 mg F QL(2 ea daily)
ranitidine hcl caps or 300 mg F QL(1 ea daily)
ranitidine hcl syrp or 15mg/ml, 75 mg/5ml, 150mg/10ml
F QL(40 ml daily)
ranitidine hcl tabs or 150 mg F QL(2 ea daily);
RX/OTC ranitidine hcl tabs or 300 mg F QL(2 ea daily)
ranitidine hcl tabs or 75 mg F
TAGAMET HB TABS (Use Cimetidine) NF RX/OTC
ZANTAC 150 MAXIMUM STRENGTH TABS (Use Ranitidine HCl)
NF QL(2 ea daily);RX/OTC
ZANTAC 75 TABS (Use Ranitidine HCl) NF
ZANTAC TABS OR 150 MG (Use Ranitidine HCl) NF QL(2 ea daily);
RX/OTC ZANTAC TABS OR 300 MG (Use Ranitidine HCl) NF QL(2 ea daily)
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Drug Name DrugTier
Requirements/Limits
Misc. Anti-Ulcer CARAFATE SUSP 1 GM/10ML F QL(420 ml per
fill retail) CARAFATE TABS 1 GM (Use Sucralfate) NF QL(4 ea daily)
sucralfate tabs F QL(4 ea daily)
Proton Pump Inhibitors
CVS OMEPRAZOLE TBEC F QL(1 ea daily)
EQ OMEPRAZOLE TBEC F QL(1 ea daily)
EQL OMEPRAZOLE TBEC F QL(1 ea daily)
esomeprazole magnesiumcpdr 20 mg F QL(2 ea daily);
RX/OTC GNP OMEPRAZOLE TBEC F QL(1 ea daily)
HM OMEPRAZOLE TBEC F QL(1 ea daily)
KLS OMEPRAZOLE TBEC F QL(1 ea daily)
lansoprazole cpdr 15 mg F QL(2 ea daily);RX/OTC
lansoprazole cpdr 15 mg F QL(1 ea daily);RX/OTC
lansoprazole cpdr 30 mg F QL(2 ea daily)
lansoprazole tbdp 15 mg,30 mg F
QL(1 ea daily);AL; Up to 6 yrsold
NEXIUM 24HR CLEAR MINIS CPDR (Use Esomeprazole Magnesium)
NF RX/OTC
NEXIUM 24HR CPDR (Use Esomeprazole Magnesium) NF RX/OTC
NEXIUM CPDR 20 MG (Use EsomeprazoleMagnesium)
NF RX/OTC
omeprazole cpdr 10 mg, 40 mg F QL(2 ea daily)
omeprazole cpdr 20 mg F QL(2 ea daily);RX/OTC
OMEPRAZOLE TBEC 20 MG F QL(1 ea daily)
pantoprazole sodium tbec20 mg F QL(1 ea daily)
Drug Name DrugTier
Requirements/Limits
pantoprazole sodium tbec40 mg F QL(2 ea daily)
PREVACID 24HR CPDR (Use Lansoprazole) NF RX/OTC
PREVACID CPDR 15 MG (Use Lansoprazole) NF RX/OTC
PREVACID CPDR 30 MG (Use Lansoprazole) NF QL(2 ea daily)
PREVACID SOLUTAB TBDP (Use Lansoprazole) NF
QL(1 ea daily);AL; Up to 6 yrsold
PRILOSEC CPDR 10 MG, 40 MG (Use Omeprazole) NF QL(2 ea daily)
PRILOSEC CPDR 20 MG (Use Omeprazole) NF QL(2 ea daily);
RX/OTC
PRILOSEC OTC TBEC F QL(1 ea daily)
PROTONIX TBEC 20 MG (Use Pantoprazole Sodium) NF QL(1 ea daily)
PROTONIX TBEC 40 MG (Use Pantoprazole Sodium) NF QL(2 ea daily)
PX OMEPRAZOLE TBEC F QL(1 ea daily)
RA OMEPRAZOLE TBEC F QL(1 ea daily)
SB OMEPRAZOLE TBEC F QL(1 ea daily)
SM OMEPRAZOLE TBEC F QL(1 ea daily)
SW OMEPRAZOLE TBEC F QL(1 ea daily)
TGT OMEPRAZOLE TBEC F QL(1 ea daily)
Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use Misoprostol) NF
misoprostol tabs F
URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney Infections
Urinary Anti-infective Combinations methenamine-hyosc-methylene blue-sod phos-phenyl sal tabs 40.8mg-0.12mg-36.2mg-81.6mg-10.8mg, 40.8mg-36.2mg-0.12mg-81.6mg-10.8mg
F
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Drug Name DrugTier
Requirements/Limits
Urinary Anti-infectives FURADANTIN SUSP (Use Nitrofurantoin) NF QL(40 ml daily)
MACROBID CAPS (Use Nitrofurantoin MonohydMacro)
NF
MACRODANTIN CAPS 50 MG, 100 MG (Use Nitrofurantoin Macrocrystal)
NF
METHENAMINE MANDELATE TABS 0.5 GM
F
methenamine mandelate tabs 1 gm F
nitrofurantoin macrocrystalcaps 50 mg, 100 mg F
nitrofurantoin monohyd macro caps F
nitrofurantoin susp F QL(40 ml daily)
URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms
Urinary Antispasmodic - Antimuscarinics DETROL LA CP24 (Use Tolterodine Tartrate) NF QL(1 ea daily)
DETROL TABS (Use Tolterodine Tartrate) NF QL(2 ea daily)
DITROPAN XL TB24 (Use Oxybutynin Chloride) NF QL(2 ea daily)
oxybutynin chloride syrp 5mg/5ml F QL(480 ml per
fill retail) oxybutynin chloride tabs 5 mg F QL(3 ea daily)
oxybutynin chloride tb24 5mg, 10 mg, 15 mg F QL(2 ea daily)
tolterodine tartrate cp24 2mg, 4 mg F QL(1 ea daily)
tolterodine tartrate tabs 1 mg, 2 mg F QL(2 ea daily)
trospium chloride tabs 20 mg F QL(2 ea daily)
Urinary Antispasmodics - Cholinergic Agonists
bethanechol chloride tabs F
Drug Name DrugTier
Requirements/Limits
URECHOLINE TABS (Use Bethanechol Chloride) NF
Urinary Antispasmodics - Direct Muscle Relaxants
flavoxate hcl tabs F
VACCINES
Bacterial Vaccines
ACTHIB SOLR F AL; At least 19 yrs old
BEXSERO SUSY F
Limit 2 fills perLifetime;2 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
HIBERIX SOLR F PA; AL; At least 19 yrs old
MENACTRA INJ F AL; At least 19 yrs old
MENOMUNE-A/C/Y/W-135INJ F AL; At least 19
yrs old
MENVEO SOLR F AL; At least 19 yrs old
PNEUMOVAX 23 INJ F
Limit 5 perlifetime;5 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
PNEUMOVAX 23/1 DOSEINJ F
Limit 5 perlifetime;5 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
PREVNAR 13 SUSP F
Limit 1 dose per lifetime;1 rtlMAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
TRUMENBA SUSY F
Limit 3 doses per lifetime;3 rtlMAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
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Drug Name DrugTier
Requirements/Limits
Viral Vaccines AFLURIA 2015-2016 SUSP F AL; At least 19
yrs old AFLURIA 2016-2017 SUSP F AL; At least 19
yrs old AFLURIA 2017-2018 SUSP F AL; At least 19
yrs old AFLURIA PF 2015-2016 SUSY F AL; At least 19
yrs old AFLURIA PF 2016-2017 SUSY F AL; At least 19
yrs old AFLURIA PF 2017-2018 SUSY F AL; At least 19
yrs old AFLURIA QUADRIVALENT 2016-2017 SUSY F AL; At least 19
yrs old AFLURIA QUADRIVALENT 2017-2018 SUSP F AL; At least 19
yrs old AFLURIA QUADRIVALENT 2017-2018 SUSY F AL; At least 19
yrs old
CERVARIX SUSP F
Limit 3 perlifetime;3 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
ENGERIX-B INJ F AL; At least 19 yrs old
ENGERIX-B SUSP F AL; At least 19 yrs old
FLUAD 2016-2017 SUSY F AL; At least 19 yrs old
FLUAD 2017-2018 SUSY F AL; At least 19 yrs old
FLUARIX QUADRIVALENT 2015-2016 SUSY F AL; At least 19
yrs old FLUARIX QUADRIVALENT 2016-2017 SUSY F AL; At least 19
yrs old FLUARIX QUADRIVALENT 2017-2018 SUSY F AL; At least 19
yrs old FLUBLOK 2015-2016 SOLN F AL; At least 19
yrs old FLUBLOK 2016-2017 SOLN F AL; At least 19
yrs old FLUBLOK 2017-2018 SOLN F AL; At least 19
yrs old
Drug Name DrugTier
Requirements/Limits
FLUCELVAX 2015-2016 SUSY F AL; At least 19
yrs old FLUCELVAX QUADRIVALENT 2016-2017 SUSY
F AL; At least 19 yrs old
FLUCELVAX QUADRIVALENT 2017-2018 SUSP
F AL; At least 19 yrs old
FLUCELVAX QUADRIVALENT 2017-2018 SUSY
F AL; At least 19 yrs old
FLULAVAL QUADRIVALENT 2014-2015 SUSY
F AL; At least 19 yrs old
FLULAVAL QUADRIVALENT 2015-2016 SUSP
F AL; At least 19 yrs old
FLULAVAL QUADRIVALENT 2016-2017 SUSP
F AL; At least 19 yrs old
FLULAVAL QUADRIVALENT 2016-2017 SUSY
F AL; At least 19 yrs old
FLULAVAL QUADRIVALENT 2017-2018 SUSP
F AL; At least 19 yrs old
FLULAVAL QUADRIVALENT 2017-2018 SUSY
F AL; At least 19 yrs old
FLUMIST QUADRIVALENT SUSP F PA; AL; At least
19 yrs old FLUVIRIN 2015-2016 SUSP F AL; At least 19
yrs old FLUVIRIN 2015-2016 SUSY F AL; At least 19
yrs old FLUVIRIN 2016-2017 SUSP F AL; At least 19
yrs old FLUVIRIN 2016-2017 SUSY F AL; At least 19
yrs old FLUVIRIN 2017-2018 SUSP F AL; At least 19
yrs old FLUVIRIN 2017-2018 SUSY F AL; At least 19
yrs old FLUZONE HIGH-DOSE PF 2015-2016 SUSY F AL; At least 19
yrs old FLUZONE HIGH-DOSE PF 2016-2017 SUSY F AL; At least 19
yrs old
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Drug Name DrugTier
Requirements/Limits
FLUZONE HIGH-DOSE PF 2017-2018 SUSY F AL; At least 19
yrs old FLUZONE INTRADERMAL QUADRIVALENT 2015-2016 SUPN
F AL; At least 19 yrs old
FLUZONE INTRADERMAL QUADRIVALENT 2016-2017 SUPN
F AL; At least 19 yrs old
FLUZONE INTRADERMAL QUADRIVALENT 2017-2018 SUPN
F AL; At least 19 yrs old
FLUZONE QUADRIVALENT 2015-2016 SUSP
F AL; At least 19 yrs old
FLUZONE QUADRIVALENT 2015-2016 SUSY
F AL; At least 19 yrs old
FLUZONE QUADRIVALENT 2016-2017 SUSP
F AL; At least 19 yrs old
FLUZONE QUADRIVALENT 2016-2017 SUSY
F AL; At least 19 yrs old
FLUZONE QUADRIVALENT 2017-2018 SUSP
F AL; At least 19 yrs old
FLUZONE QUADRIVALENT 2017-2018 SUSY
F AL; At least 19 yrs old
FLUZONE SPLIT 2015-2016 SUSP F AL; At least 19
yrs old
GARDASIL 9 SUSP F
Limit 3 perlifetime;3 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
GARDASIL 9 SUSY F
Limit 3 perlifetime;3 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
GARDASIL SUSP F AL; At least 19 yrs old
Drug Name DrugTier
Requirements/Limits
HAVRIX SUSP F
Limit 2 fills perLifetime;2 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
M-M-R II INJ F
Limit 2 fills perLifetime;2 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
MEDICAL PROVIDER EZ FLU SHOT 2015-2016 PSKT
F AL; At least 19 yrs old
MEDICAL PROVIDER SINGLE USE EZ FLU SHOT PSKT
F AL; At least 19 yrs old
RABAVERT SUSR F AL; At least 19 yrs old
RECOMBIVAX HB SUSP F AL; At least 19 yrs old
SHINGRIX SUSR F AL; At least 50 yrs old
TWINRIX SUSP F
Limit 5 perlifetime;5 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
VAQTA SUSP F
Limit 2 fills perLifetime;2 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
VARIVAX INJ F
Limit 2 fills perLifetime;2 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old
ZOSTAVAX SUSR F AL; At least 50 yrs old
VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low Hormones
Spermicides
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Drug Name DrugTier
Requirements/Limits
ENCARE SUPP F QL(12 ea perfill retail)
nonoxynol-9 gel F
OPTIONS CONCEPTROL VAGINAL CONTRACEPTIVE GEL (Use Nonoxynol-9)
NF
OPTIONS GYNOL II VAGINALCONTRACEPTIV E GEL
F
SHUR-SEAL GEL F QL(24 gm perfill retail)
VCF VAGINAL CONTRACEPTIVE FILM FILM
F QL(9 ea per fillretail)
Vaginal Anti-infectives CLEOCIN CREA VA 2 % (Use ClindamycinPhosphate Vaginal)
NF QL(40 gm perfill retail)
clindamycin phosphatevaginal crea F QL(40 gm per
fill retail) clotrimazole vaginal crea 1% F
clotrimazole vaginal crea 2% F QL(21 gm per
fill retail)
GYNAZOLE-1 CREA F
GYNE-LOTRIMIN 3 CREA (Use Clotrimazole Vaginal) NF QL(21 gm per
fill retail) GYNE-LOTRIMIN CREA (Use Clotrimazole Vaginal) NF
METROGEL-VAGINAL GEL (Use Metronidazole Vaginal)
NF QL(70 gm perfill retail)
metronidazole vaginal gel F QL(70 gm perfill retail)
MICONAZOLE 3 SUPP F QL(3 ea per fillretail)
miconazole nitrate vaginalcrea 2 %, 4 % F
miconazole nitrate vaginalkit F QL(24 gm per
fill retail) miconazole nitrate vaginalsupp 100 mg F
Drug Name DrugTier
Requirements/Limits
MONISTAT 3 COMBINATION PACK KIT (Use Miconazole Nitrate Vaginal)
NF
QL(24 gm perfill retail)
MONISTAT 3 CREA (Use Miconazole Nitrate Vaginal) NF
MONISTAT 7 SIMPLY CURE CREA (Use Miconazole Nitrate Vaginal)
NF
TERAZOL 3 CREA (Use Terconazole Vaginal) NF QL(20 gm per
fill retail) TERAZOL 7 CREA (Use Terconazole Vaginal) NF QL(45 gm per
fill retail)
TERCONAZOLE CREA F QL(20 gm perfill retail)
terconazole vaginal crea0.4 % F QL(45 gm per
fill retail) terconazole vaginal crea0.8 % F QL(20 gm per
fill retail) terconazole vaginal supp80 mg F QL(3 ea per fill
retail)
tioconazole vaginal oint F
VAGISTAT-1 OINT (Use Tioconazole Vaginal) NF
Vaginal Estrogens ESTRACE CREA VA 0.1 MG/GM (Use Estradiol Vaginal)
NF QL(43 gm perfill retail)
estradiol vaginal crea 0.1mg/gm F QL(43 gm per
fill retail) PREMARIN CREA VA 0.625 MG/GM F QL(43 gm per
fill retail) VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions
Anaphylaxis Therapy Agents
epinephrine (anaphylaxis)soaj F
QL(2 ea per fillretail,4 ea per365 days retail)
Vasopressors
midodrine hcl tabs F
VITAMINS
Oil Soluble Vitamins
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Drug Name DrugTier
Requirements/Limits
cholecalciferol caps 1000unit, 2000 unit, 5000 unit,50000 unit
F
DRISDOL CAPS 50000 UNIT (Use Ergocalciferol) NF
ergocalciferol caps 50000unit F
KEY-E CHEW F
MEPHYTON TABS (Use Phytonadione) NF
phytonadione tabs or 5 mg F
vitamin e caps or 100 unit,200 unit, 400 unit F
VITAMIN E CHEW OR 400 UNIT F
Water Soluble Vitamins ascorbic acid tabs or 500mg, 1000mg, 250 mg,500 mg, 1000 mg, 10mg-500mg, 37mg-500mg,37mg-1000mg, 14mg-25mg-500mg
F
B-1 TABS F
niacin cpcr 250 mg, 500 mg F
niacin tabs 500 mg F
niacin tbcr 250 mg, 500mg, 750 mg F
NIACIN TR TBCR F
pyridoxine hcl tabs or 25mg, 50 mg, 100 mg F
riboflavin tabs 25 mg, 50mg, 100 mg F
SLO-NIACIN TBCR (Use Niacin) NF
thiamine hcl soln F
thiamine hcl tabs F
thiamine mononitrate tabs F
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Index A-200 42 ADVIL COLD & SINUS 36 ALLEVYN THIN 53 abacavir sulfate 29 ADYNOVATE 48 allopurinol 48 abacavir sulfate-lamivudine 29 AEROSPAN 9 ALOCRIL 76 abacavir sulfate-lamivudine- AEROTRACH PLUS 57 ALOGLIPTIN 15 zidovudine ABILIFY ABILIFY MAINTENA acamprosate calcium ACCUPRIL ACCURETIC ACE AEROSOL CLOUD ENHANCER acebutolol hcl acetaminophen acetaminophen w/ codeine acetazolamide
29 29 29 78 21 22
57 32
4 5
44
AFINITOR 25 AFINITOR DISPERZ 25 AFLURIA 2015-2016 84 AFLURIA 2016-2017 84 AFLURIA 2017-2018 84 AFLURIA PF 2015-2016 84 AFLURIA PF 2016-2017 84 AFLURIA PF 2017-2018 84 AFLURIA QUADRIVALENT 2016-2017 84 AFLURIA QUADRIVALENT 2017-2018 84
ALOGLIPTIN/METFORMINHCL 15 ALOGLIPTIN/PIOGLITAZONE
15 ALOMIDE 76 ALORA 46 ALPHANATE/VONWILLEBRANDFACTOR COMPLEX/HUMAN 48 ALPHANINE SD 48 alprazolam 8 ALPROLIX 48 ALTACE 21
acetic acid (otic) acetylcysteine ACNE MEDICATION 10
76 37 37
AFSTYLA 48 AGRYLIN 49 AIRS PEDIATRIC AEROSOL
alum & mag hydrox-simethicone 6 ALUMINUM HYDROXIDE 6
ACNE MEDICATION 5 ACTHIB ACTIGALL ACTIMMUNE ACTIVELLA ACTIVITY POUCH ACTONEL ACTOPLUS MET ACTOS ACULAR ACULAR LS acyclovir acyclovir topical ADACEL ADALAT CC ADASUVE ADDERALL ADDERALL XR ADMELOG ADMELOG SOLOSTAR
37 83 47 26 46 57 45 15 16 76 76 31 40 80 32 28
1 1
16 16
MASK 57 albuterol sulfate 9 ALBUTEROL SULFATE ER 9 ALCAINE 75 ALCOHOL SWABS 57 ALDACTAZIDE 44 ALDACTONE 45 ALDARA 42 ALECENSA 25 ALENDRONATE SODIUM 45 alendronate sodium 45 ALENDRONATE SODIUM 45 alendronate sodium 45 ALER-DRYL 19 ALEVE 2 ALEVE ARTHRITIS 2 ALIVE ENERGY 50+ 64 ALIVE MENS ENERGY 64 ALIVE ONCE DAILY WOMENS 50+ ULTRA POTENCY 64 ALIVE ONCE DAILY WOMENS
amantadine hcl 26 AMARYL 17 AMBIEN 50 AMD FOAM DRESSING 4"X4" 53 AMD FOAM DRESSING/TOPSHEET4"X4" 53 AMERGE 60 AMICAR 50 amiloride & hydrochlorothiazide 44 amiloride hcl 45 amiodarone hcl 9 AMITIZA 47 amitriptyline hcl 14 amlodipine besylate 32 amlodipine besylate-benazeprilhcl 22 amlodipine besylate-olmesartanmedoxomil 22 amlodipine besylate-valsartan 22
ADRENALIN ADULT AEROSOL MASK ADULT MASK ADULT MASK LARGE ADVANCED DIABETIC MULTIVITAMIN FORMULA
72 57 57 57
64
ULTRA POTENCY 64 ALIVE WOMENS 50+ 64 ALIVE WOMENS ENERGY 64 ALKERAN 24 ALL FLOW 1000 PULMONARY FUNCTION FILTER 57
amlodipine-valsartan-hydrochlorothiazide 22 AMOXAPINE 14 amoxicillin 77 AMOXICILLIN 77 amoxicillin 77
ADVATE 48 ALLEGRA ALLERGY 19 amoxicillin & pot clavulanate 77 ADVIL 2 ALLEVYN PLUS CAVITY 53 AMOXICILLIN/CLAVULANATE
POTASSIUM 77
Index 1
amphetamine-dextroamphetamine ampicillin AMPICILLIN ANAFRANIL anagrelide hcl ANAPROX DS ANASPAZ anastrozole ANDRODERM ANDROXY ANTABUSE ANTIOXIDANT FORTE ANUSOL-HC AP-ZEL APEXICON E APIDRA APIDRA SOLOSTAR apraclonidine hcl aprepitant APTIVUS AQUORAL ARAVA ARICEPT ARIMIDEX aripiprazole ARISTADA ARMOUR THYROID AROMASIN ARTHRITIS PAIN RELIEVING
1 77 77 14 49
2 80 24
6 6
78 64
6 64 40 16 16 74 18 29 63
3 78 24 29 29 80 24
42
atorvastatin calcium 20 atovaquone 7 ATRIPLA 29 ATROPINE SULFATE 74 ATROVENT 72 ATROVENT HFA 9 AUGMENTIN 78 AUGMENTIN ES-600 78 AUGMENTIN XR 78 AVALIDE 22 AVANDIA 16 AVAPRO 21 AVASTIN 24 AVONEX 79 AVONEX PEN 79 AYGESTIN 78 AZASAN 61 azathioprine 61 azelastine hcl 72 azelastine hcl (ophth) 76 AZITHROMYCIN 52 azithromycin 52 AZOPT 76 AZOR 22 AZULFIDINE 47 AZULFIDINE EN-TABS 47 b complex w/ c 63 B-1 87 b-complex vitamins 63 b-complex w/ c & folic acid 63
BAND-AID MIRASORB GAUZE SPONGES LARGE 4" X 4" 53 BASAGLAR KWIKPEN 16 BASIC AM 64 BASIC PM 64 BD GLUCOSE 15 BEBULIN 48 BELBUCA 6 BENADRYL ALLERGY 19 BENADRYL ALLERGY CHILDRENS 19 benazepril &hydrochlorothiazide 22 benazepril hcl 21 BENEFIX 48 BENICAR 21 BENICAR HCT 22 BENTYL 80 BENZAC AC WASH 37 benzonatate 36 benzoyl peroxide 37 BENZOYL PEROXIDE 37 benzoyl peroxide 38 BENZOYL PEROXIDE CLEANSER 37 benztropine mesylate 26 BETAGAN 74 betamethasone dipropionate(topical) 40 betamethasone dipropionateaugmented 40 betamethasone valerate 40 BETAPACE 32
artificial tear ointment 74 BACIGUENT 38 BETAPACE AF 32 ascorbic acid 87 aspirin 4 ASPIRIN 4 aspirin 4 aspirin buffered (cal carb-magcarb-mag oxide) 4 ASTEPRO 72 ATACAND 21
bacitracin (topical) bacitracin zinc bacitracin-polymyxin b(ophth) baclofen BACMIN BACTRIM BACTRIM DS
38 38
74 71 64
7 7
betaxolol hcl (ophth) 74 bethanechol chloride 83 BETOPTIC-S 74 bexarotene 26 BEXSERO 83 BIATAIN ADHESIVE FOAM DRESSING 4"X4" 53 BIATAIN FOAM DRESSING
ATACAND HCT 22 BACTROBAN 38 4"X4" 53 atazanavir sulfate 29 BACTROBAN NASAL 72 BIAXIN 52
ATELVIA 45 balsalazide disodium 47 bicalutamide 24
atenolol atenolol & chlorthalidone ATIVAN
32 22
8
BAND-AID GAUZE PADS LARGE4" X 4" BAND-AID GAUZE PADS MEDIUM 3" X 3"
53
53
BIKTARVY 29 BIOGUARD GAUZE SPONGE 2"X2" 8 PLY 53 BIOGUARD GAUZE SPONGES
atomoxetine hcl 1 BAND-AID GAUZE PADS 4"X4" 12 PLY 53 SMALL2" X 2" 53
Index 2
BIOTENE DRY MOUTH MOISTURIZING SPRAY bisacodyl bismuth subsalicylate bisoprolol &hydrochlorothiazide bisoprolol fumarate BLEPH-10
63 52 17
22 32 74
BYETTA CABOMETYX CAFERGOT caffeine citrate CAL-DAY 1000 CALAN CALAN SR
16 25 59
1 64 32 32
carvedilol phosphate CASODEX CATAPRES cefaclor CEFACLOR cefadroxil cefdinir
31 24 22 33 33 33 34
BLEPHAMIDE 75 calcipotriene 40 cefprozil 33 BLEPHAMIDE S.O.P. 75 calcitonin (salmon) 45 CEFTIN 33 BOOSTRIX 80 calcitriol 46 ceftriaxone sodium 34 BORDERED GAUZE BOSULIF BREO ELLIPTA BREVICON-28
53 25
9 34
calcium acetate (phosphatebinder) 48 calcium carbonate (antacid) 7 calcium carbonate-cholecalciferol 60
cefuroxime axetil CELEBREX celecoxib CELEXA
34 2 2
13 BRILINTA 49 calcium carbonate-vitamin CELLCEPT 61 brimonidine tartrate bromocriptine mesylate brompheniramine &phenylephbrompheniramine &pseudoephBUBBLES THE FISH II PEDIATRIC MASK/PVC budesonide (inhalation) BUFFERIN bumetanide BUMEX BUNAVAIL
74 26
37
37
57 9 4
45 45
6
d 60 calcium polycarbophil 51 CALNA 69 camphor & menthol 39 candesartan cilexetil 21 candesartan cilexetil-hydrochlorothiazide 22 CAPHOSOL 63 CAPRELSA 25 capsaicin 42 captopril 21 CAPTOPRIL/HYDROCHLOROTHIAZIDE 22
CENTRAVITES 50 PLUS CENTRAVITES ADULTS CENTRUM ADULTS CENTRUM CARDIO CENTRUM MEN CENTRUM SILVER ULTRA MENS CENTRUM SILVER ULTRA WOMENS CENTRUM SPECIALIST HEART CENTRUM SPECIALIST IMMUNE SUPPORT CENTRUM SPECIALIST
64 64 64 64 64
64
64
64
64
BUPRENEX 6 CAPZASIN-HP 42 VISION 64 BUPRENORPHINE 6 CAPZASIN-P 42 CENTRUM ULTRA
buprenorphine hcl 6 buprenorphine hcl-naloxone hcldihydrate 6 bupropion hcl 12 bupropion hcl (smokingdeterrent) 79 buspirone hcl 8 butalbital-acetaminophen 3 butalbital-acetaminophen-caffeine 3 butalbital-acetaminophen-caffeine w/ codeine 5 butalbital-aspirin-caffeine 4 butalbital-aspirin-caffeinew/cod 5 BUTRANS 6
CARAC CARAFATE carbamazepine carbamide peroxide (otic) carbidopa carbidopa-levodopa CARDIZEM CARDIZEM CD CARDURA carisoprodol CARNITOR CARNITOR SF CARRASMART CARRASMART FOAM
39 82 10 76 26 26 32 32 22 71 46 46 53 53
WOMENS 64 cephalexin 33 CERASPORT 60 CERASPORT EX1 60 CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS 64 CERVARIX 84 cetirizine hcl 19 cetirizine-pseudoephedrine 37 CHANTIX 79 CHANTIX CONTINUING MONTHPAK 79 CHANTIX STARTING MONTH PAK 79 CHEK-STIX COMBO PAK
BYDUREON 16 URINALYSIS CONTROL 43CARTEOLOL HCL 74 CHEK-STIX CONTROL 43BYDUREON BCISE 16 carteolol hcl (ophth) 74 CHEMET 17BYDUREON PEN 16 carvedilol 31 CHEMSTRIP-K 43
Index 3
CHERACOL PLUS 37 CLEOCIN PEDIATRIC COLCHICINE 48 CHERACOL-D COUGH 37 CHILDRENS ADVIL 2 CHILDRENS MOTRIN 2 CHLOR-TRIMETON 19 chlordiazepoxide hcl 8 chlorhexidine gluconate (mouth-throat) 62 CHLOROQUINE PHOSPHATE 23 chloroquine phosphate 23 CHLOROTHIAZIDE 45
GRANULES 7 CLEOCIN-T 38 CLIMARA 46 CLINDAGEL 38 clindamycin hcl 7 clindamycin palmitatehydrochloride 7 clindamycin phosphate(topical) 38 clindamycin phosphatevaginal 86 CLINICAL NUTRIENTS 45-
colchicine w/ probenecid COLCRYS COLESTID COLESTID FLAVORED colestipol hcl COLYTE-FLAVOR PACKS COMBIPATCH COMBIVENT RESPIMAT COMBIVIR COMETRIQ
48 48 20 20 20 51 46
9 29 25
chlorothiazide chlorpheniramine maleate CHLORPROMAZINE HCL
45 19 28
PLUS WOMEN 64 CLINICAL NUTRIENTS 50-PLUS MEN 64 CLINICAL NUTRIENTS FOR
COMPLERA COMPLETENATE COMTAN
29 69 26
chlorpromazine hcl chlorthalidone CHLORZOXAZONE CHOLBAM cholecalciferol cholestyramine cholestyramine light choline & mag salicylate
28 45 71 47 87 20 20
4
FEMALE TEENS 64 CLINICAL NUTRIENTS FOR MALE TEENS 64 CLINICAL NUTRIENTS FOR MEN 64 CLINICAL NUTRIENTS FOR WOMEN 64 clobetasol propionate 40 clobetasol propionate emollientbase 40
CONCERTA 1 CONDOMS 57 CONDYLOX 42 COPA ISLAND BORDERED FOAM DRESSING 4"X4" 53 COPA PLUS HYDROPHILIC FOAM DRESSING 4"X4" 53 COPAXONE 79 COREG 31
cilostazol 49 clomipramine hcl 14 COREG CR 31 CILOXAN 74 clonazepam 10 CORGARD 32 cimetidine 81 clonidine hcl 22 CORIFACT 48 CIMETIDINE HCL 81 clonidine hcl (adhd) 1 CORTANE-B AQUEOUS 77 CIPRO 47 clopidogrel bisulfate 49 CORTANE-B-OTIC 77 CIPROFLOXACIN HCL 47 clorazepate dipotassium 8 CORTEF 36 ciprofloxacin hcl 47 clotrimazole (topical) 39 CORTENEMA 6 ciprofloxacin hcl (ophth) 74 citalopram hydrobromide 13 CLARITHROMYCIN 52 clarithromycin 52 CLARITHROMYCIN 52 clarithromycin 52 CLARITIN 19 CLARITIN ALLERGY CHILDRENS 19 CLARITIN REDITABS 19 CLARITIN-D 12 HOUR 37 CLARITIN-D 24 HOUR 37 CLASSIC PRENATAL 69 CLEAN & CLEAR ADVANTAGE 3-IN-1 EXFOLIATING CLEANSER 38 clemastine fumarate 19
clotrimazole vaginal 86 clotrimazole w/betamethasone 39 clozapine 28 CLOZAPINE ODT 28 CLOZARIL 28 CO MONITOR REPLACEMENT TPIECES58 CO-NATAL FA 69 COAGADEX 48 coal tar extract 43 COARTEM 23 codeine sulfate tabs 15 mg,30mg, 60mg 4 COGENTIN 26 COLACE 52 COLACE CLEAR 52
CORTISONE ACETATE 36 COSOPT 74 COTELLIC 25 COUMADIN 10 COVRSITE COVER DRESSING 53 COVRSITE PLUS COMPOSITE DRESSING 53 COZAAR 21 CREON 44 CRESTOR 20 CRIXIVAN 29 cromolyn sodium 9 cromolyn sodium (nasal) 72 cromolyn sodium (ophth) 76 CUREX ALL-PURPOSE SPONGES 4"X4" 4 PLY 53
COLAZAL 47 CURITY ALL PURPOSECLEOCIN 7,86 SPONGES 2"X2"
Index 4
53
CURITY ALL PURPOSE CURITY DEMADEX 45 SPONGES 2"X2" 4PLY 53 CURITY ALL PURPOSE SPONGES 3"X3" 4PLY 53 CURITY ALL PURPOSE SPONGES 4 PLY 53 CURITY ALL PURPOSE SPONGES 4"X4" 53 CURITY ALL PURPOSE SPONGES 4"X4" 4PLY 53 CURITY ALL PURPOSE SPONGES 4"X4" 4PLY/SOFTPOUCH 53
SPONGES/CELLULOSEFILLED/4"X4" 54 CVS DRY MOUTH SPRAY63 CVS GAUZE PAD 3"X3" 54 CVS GAUZE PADS 2"X2" 12-PLY 54 CVS GAUZE PADS 4"X4" 12-PLY 54 CVS GAUZE PADS STERILE 4"X4" 12-PLY 54 CVS GLUCOSE 15
DEMEROL DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES DEPEN TITRATABS DEPO-PROVERA CONTRACEPTIVE DEPO-SUBQ PROVERA 104
4 12 12 12 12 61
35
35 CURITY AMD CVS OMEPRAZOLE 82 DEPO-TESTOSTERONE 6 ANTIMICROBIALGAUZE SPONGES 2"X2" 8 PLY 54 CURITY AMD ANTIMICROBIALGAUZE SPONGES 4"X4" 12 PLY 54 CURITY COVER SPONGE 4"X4" 54 CURITY COVER SPONGES 3"X3" 54 CURITY COVER SPONGES 4"X4" 54 CURITY DRESSING SPONGES 4"X4" 6 PLY 54 CURITY GAUZE PADS 2"X2" 54 CURITY GAUZE PADS 2"X2" 12 PLY 54 CURITY GAUZE PADS 3"X3" 54 CURITY GAUZE PADS 4"X4" 12 PLY 54 CURITY GAUZE SPONGE 2"X2" 8 PLY 54 CURITY GAUZE SPONGE 2"X2"12 PLY 54 CURITY GAUZE SPONGE 3"X3" 12 PLY 54 CURITY GAUZE SPONGE 4"X4" 12 PLY 54 CURITY GAUZE SPONGE 4"X4" 16 PLY 54 CURITY GAUZE SPONGE 4"X4" 8 PLY 54 CURITY GAUZE SPONGE 4"X4"16 PLY 54 CURITY GAUZE SPONGES 4"X4" 12 PLY 54 CURITY GAUZE SPONGES 4"X4" 8 PLY 54 CURITY NON-ADHERENT STRIPS 3"X3" 54 CURITY SPONGES/CELLULOSEFILLED/2"X2" 54
CVS ONE DAILY MENS 50+ ADVANCED 64 CVS PRENATAL 69 CVS SPECTRAVITE ADULT 50+ 64 CVS SPECTRAVITE ULTRA MEN50+ 64 CVS SPECTRAVITE ULTRA MENS HEALTH 64 CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR 64 CVS SPECTRAVITE ULTRA WOMEN 64 CVS SPECTRAVITE ULTRA WOMENS HEALTH 64 CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR 64 cyanocobalamin 49 CYCLESSA 34 cyclobenzaprine hcl 71 CYCLOGYL 74 cyclopentolate hcl 74 cyclosporine 61 CYCLOSPORINE MODIFIED 62 cyclosporine modified (formicroemulsion) 62 CYMBALTA 14 cyproheptadine hcl 20 CYRAMZA 24 CYTOMEL 80 CYTOTEC 82 D.H.E. 45 59 dapsone 7 DAYPRO 2 DDAVP 46 DEBROX 76 DECON-A 37
DERMACEA DRAIN SPONGES 4"X4" 54 DERMACEA GAUZE SPONGE 2"X2" 12 PLY 54 DERMACEA GAUZE SPONGE 2"X2" 8 PLY 54 DERMACEA GAUZE SPONGE 3"X3" 12 PLY 54 DERMACEA GAUZE SPONGE 3"X3" 8 PLY 54 DERMACEA GAUZE SPONGE 4"X4" 12 PLY 54 DERMACEA GAUZE SPONGE 4"X4" 16 PLY 54 DERMACEA GAUZE SPONGE 4"X4" 8 PLY 54 DERMACEA I.V. DRAIN SPONGES 2"X2" 54 DERMACEA I.V. DRAIN SPONGES 4"X4" 54 DERMACEA I.V. SPONGES 2"X2" 54 DERMACEA NON-WOVEN SPONGES 2"X2" 4 PLY 54 DERMACEA NON-WOVEN SPONGES 3"X3" 4 PLY 55 DERMACEA NON-WOVEN SPONGES 4"X4" 4 PLY 55 DERMACEA NON-WOVEN SPONGES 4"X4" 6 PLY 55 DERMACEA TYPE VII GAUZE 2"X2" 12 PLY 55 DERMACEA TYPE VII GAUZE 2"X2" 8 PLY 55 DERMACEA TYPE VII GAUZE 3"X3" 12 PLY 55 DERMACEA TYPE VII GAUZE 3"X3" 12PLY 55 DERMACEA TYPE VII GAUZE 4"X4" 12 PLY 55 DERMACEA TYPE VII GAUZE 4"X4" 16 PLY 55 DERMACEA TYPE VII GAUZE 4"X4" 8 PLY 55
DELZICOL 47
Index 5
DERMACEA X-RAY SPONGES 4"X4" 16 PLY 55 DERMALEVIN ADHESIVE FOAMDRESSING 4"X4" 55
diclofenac sodium (ophth) 76 diclofenac sodium (topical) 38 dicloxacillin sodium 78
DOVONEX doxazosin mesylate doxepin hcl
40 22 14
DERMATOP 40 DERMAVITE 64 DERMOTIC 77 DESCOVY 29 desipramine hcl 14 desmopressin acetate 46 desmopressin acetate spray 46 desmopressin acetate sprayrefrigerated 46 DESOGEN 34 desogestrel & ethinylestradiol 34 desogestrel-ethinyl estradiol(biphasic) 34 desogestrel-ethinyl estradiol(triphasic) 34 desoximetasone 40 DESQUAM-X WASH 38 DETROL 83
dicyclomine hcl 81 DIFLORASONE DIACETATE 40 DIFLUCAN 18 diflunisal 4 DIGOXIN 33 digoxin 33 dihydroergotaminemesylate 59 DIHYDROERGOTAMINE MESYLATE 59 DILANTIN 12 DILANTIN INFATABS 12 DILANTIN-125 12 DILAUDID 4 diltiazem hcl 33 diltiazem hcl coated beads 32 diltiazem hcl extended release beads 33
doxycycline hyclate doxylamine succinate(sleep) DRAMAMINE DRISDOL drospirenone-ethinylestradiol DROXIA DRYMAX EXTRA DRYSOL DULCOLAX DULERA duloxetine hcl DURAGESIC DYAZIDE E.E.S. 400 E.E.S. GRANULES EBASE CONTROLLER KIT
80
50 18 87
34 49 55 42 52
9 14
4 44 52 52 58
DETROL LA DEX4 QUICK DISSOLVE GLUCOSE
83
15
dimenhydrinate DIMETAPP COLD & ALLERGY
18
37
EC-NAPROSYN econazole nitrate ECOTRIN MAXIMUM
3 39
dexamethasone 36 DIOVAN 21 STRENGTH 4 DEXAMETHASONE 36 dexamethasone 36 DEXAMETHASONE 36 DEXAMETHASONE INTENSOL 36 dexamethasone sodium phosphate 36 DEXAMETHASONE SODIUM PHOSPHATE 75
DIOVAN HCT 22 diphenhydramine hcl 19 diphenhydramine hcl(sleep) 50 diphenhydramine hcl(topical) 39 diphenoxylate w/ atropine 17 DIPHENOXYLATE/ATROPINE
17
ECOTRIN REGULAR STRENGTH EDURANT efavirenz EFFEXOR XR EFFIENT EFLOW SCF AEROSOL HEAD EFUDEX
4 29 29 14 49
58 39
DEXEDRINE 1 DIPROLENE AF 40 ELAVIL 14 dexmethylphenidate hcl 1 dipyridamole 49 ELDEPRYL 27 dextroamphetamine sulfate 1 dextromethorphan-guaifenesin
37 DHS TAR 43 DHS TAR GEL 43 DIAMOX 44 DIAZEPAM 8 diazepam 8 DIAZEPAM 10 DIAZEPAM RECTAL GEL 10 dibucaine 42 diclofenac potassium 2 diclofenac sodium 2,3
DISALCID disopyramide phosphate disulfiram DITROPAN XL divalproex sodium docusate sodium dofetilide DOLOPHINE donepezil hydrochloride DONNATAL dorzolamide hcl dorzolamide hcl-timolol maleate
4 8
78 83 12 52
9 4
78 81 76
74
eletriptan hydrobromide 60 ELIDEL 42 ELIGARD 24 ELIMITE 43 ELIQUIS 10 ELIQUIS STARTER PACK 10 ELITE DC AUTO ADAPTER 58 ELIXOPHYLLIN 10 ELLA 35 ELMIRON 48 ELOCON 41 ELOCTATE 48
Index 6
EMEND 18 ERIVEDGE 24 EXFORGE HCT 22 EMEND TRIPACK 18 ERY-TAB 53 famciclovir 31 EMSAM 13 ERYGEL 38 famotidine 81 EMTRIVA 29 ERYPED 200 53 FAMVIR 31 EMVERM 7 ERYPED 400 53 FANAPT 27 enalapril maleate 21 ERYTHROCIN FANAPT TITRATION PACK 27 enalapril maleate & STEARATE 53 FARESTON 25 hydrochlorothiazide 22 erythromycin (acne aid) 38 FAZACLO 28ENBREL 3 erythromycin (ophth) 74 FEIBA 49ENBREL SURECLICK 3 erythromycin base 53 felbamate 11ENCARE 86 erythromycin
FELBATOL 11ethylsuccinate 53ENFAMIL ENFALYTE 60 ERYTHROMYCIN FELDENE 3ENGERIX-B 84 ETHYLSUCCINATE 53 felodipine 33enoxaparin sodium 10 escitalopram oxalate 13 FEMARA 25 entacapone 26 ESGIC 4 FEMCON FE 34EPANED 21 esomeprazole magnesium 82 FEMHRT LOW DOSE 46EPIFOAM 41 esterified estrogens & fenofibrate 20methyltestosterone 46epinephrine (anaphylaxis) 86 fenofibrate micronized 20ESTRACE 46,86EPIVIR 29
estradiol 46 fentanyl 4EPOGEN 49 estradiol & norethindrone FER-IN-SOL 50EPZICOM 29 acetate 46 FERRETTS 50EQ COMPLETE estradiol vaginal 86 ferrous fumarate 50MULTIVITAMINADULTS UNDER 50 65 ESTROFACTORS 67 ferrous fumarate-fa-b complex-c-EQ OMEPRAZOLE 82 ESTROPIPATE 47 zn-mg-mn-cu 50
ESTROSTEP FE ferrous gluconate 50EQ ONE DAILY MENS 50+ 65 34 FERROUS GLUCONATE 50EQ ONE DAILY MENS ethambutol hcl 24
HEALTH 65 ferrous sulfate 50ethosuximide 12EQ ONE DAILY WOMENS ethynodiol diacet & eth FERROUS SULFATE 5050+ 65 estrad 34 ferrous sulfate 50EQ ONE DAILY WOMENS etodolac 3HEALTH 65 ferrous sulfate dried 50 EQL CENTURY MATURE EURAX 43 FEXMID 71 ADULTS50+ 65 EVAC 51 fexofenadine hcl 19EQL CENTURY MENS 65 EVISTA 46 FIASP 16EQL CENTURY WOMENS 65 EVOTAZ 29 FIASP FLEXTOUCH 16EQL DRY MOUTH ORAL EXCILON AMD FIBERCON 51RINSE 63 ANTIMICROBIALDRAINEQL GAUZE PADS FILTER AIR PP 58SPONGES 4"X4" 6 PLY 552"X2"/SMALL 55 EXCILON AMD finasteride 48EQL GAUZE PADS ANTIMICROBIALNON-WOVEN FIORINAL 44"X4"/LARGE 55 SPONGES 4"X4" 6 PLY 55EQL GAUZE STERILE PADS FIORINAL/CODEINE #3 5EXCILON DRAIN SPONGE3"X3" 55 4"X4" 55 FIRMAGON 25 EQL OMEPRAZOLE 82 EXCILON DRAIN SPONGES FITNESS TABS FOR MEN EQL ONE DAILY MENS 65 4"X4" 6 PLY 55 AM/PM/LYCOPENE 65
EXCILON I.V. SPONGES 2"X2" FITNESS TABS FOR WOMENEQL PRENATAL FORMULA 69 6 PLY 55 AM/PM/LYCOPENE 65EQUETRO 27 EXELON 78 FLAGYL 7 ergocalciferol 87 exemestane 25 flavoxate hcl 83 ERGOLOID MESYLATES 79 EXFORGE 22 flecainide acetate 8 ergotamine w/ caffeine 59
Index 7
FLEET ENEMA 51 FLURA-DROPS 61 FUROSEMIDE 45 FLEET ENEMA SIX PACK 51 FLURAZEPAM HCL 50 furosemide 45 FLEET PEDIATRIC 51 flurbiprofen 3 FUZEON 29 FLEXZAN 4 X 4 55 flurbiprofen sodium 76 gabapentin 10 FLOMAX 48 FLURBIPROFEN SODIUM76 GABITRIL 12 FLONASE ALLERGY RELIEF 72 FLONASE ALLERGY RELIEF CHILDRENS 72 FLORIVA PLUS 67 FLOVENT DISKUS 9 FLOVENT HFA 9 FLOXIN OTIC 77 FLUAD 2016-2017 84 FLUAD 2017-2018 84 FLUARIX QUADRIVALENT 2015-2016 84
flutamide 25 fluticasone propionate 41 fluticasone propionate(nasal) 72 FLUVIRIN 2015-2016 84 FLUVIRIN 2016-2017 84 FLUVIRIN 2017-2018 84 fluvoxamine maleate 13 FLUZONE HIGH-DOSE PF 2015-2016 84 FLUZONE HIGH-DOSE PF 2016-2017 84
galantamine hydrobromide GALANTAMINE HYDROBROMIDE galantamine hydrobromide GARDASIL GARDASIL 9 GAS-X GAUZE DRESSING 4"X4" GAUZE PADS 2"X2" GAUZE PADS 3"X3" GAUZE PADS 4"X4"
78
78 78 85 85 47 55 55 55 55
FLUARIX QUADRIVALENT 2016-2017 84
FLUZONE HIGH-DOSE PF 2017-2018 85
GAUZE PADS 4"X4" 12 PLY 55 GAUZE SPONGE TYPE VII
FLUARIX QUADRIVALENT 2017-2018 FLUBLOK 2015-2016
84 84
FLUZONE INTRADERMAL QUADRIVALENT 2015-2016 85
MEDI-PAK 2"X2" 8PLY 55 GAUZE SPONGES 4"X4" 12 PLY 55
FLUBLOK 2016-2017 84 FLUBLOK 2017-2018 84 FLUCELVAX 2015-2016 84 FLUCELVAX QUADRIVALENT 2016-2017 84
FLUZONE INTRADERMAL QUADRIVALENT 2016-2017 85 FLUZONE INTRADERMAL QUADRIVALENT 2017-2018 85
GEL-KAM ORAL CARE RINSE gemfibrozil GENERESS FE GENOTROPIN
62 20 34 45
FLUCELVAX QUADRIVALENT 2017-2018 84 fluconazole 18,19 fludrocortisone acetate 36 FLULAVAL QUADRIVALENT 2014-2015 84 FLULAVAL QUADRIVALENT 2015-2016 84 FLULAVAL QUADRIVALENT 2016-2017 84 FLULAVAL QUADRIVALENT 2017-2018 84 FLUMIST QUADRIVALENT 84 FLUNISOLIDE 72 fluocinolone acetonide (otic) 77 fluocinonide 41 fluocinonide emulsified base 41 fluorometholone (ophth) 75 FLUOROURACIL 39 fluorouracil (topical) 39 fluoxetine hcl 13 fluphenazine decanoate 28 FLUPHENAZINE HCL 28 fluphenazine hcl 28
FLUZONE QUADRIVALENT 2015-2016 85 FLUZONE QUADRIVALENT 2016-2017 85 FLUZONE QUADRIVALENT 2017-2018 85 FLUZONE SPLIT 2015-2016 85 FML 75 FML LIQUIFILM 75 FOCALIN 1 folic acid 49 formaldehyde 29 FORTICAL 45 FOSAMAX 45 fosamprenavir calcium 29 fosinopril sodium 21 fosinopril sodium &hydrochlorothiazide 22 FREEDAVITE 65 FULL KIT NEBULIZER SET 58 FURADANTIN 83 furosemide 45
GENTAK 74 gentamicin sulfate (ophth) 74 gentamicin sulfate (topical) 38 GENVOYA 29 GEODON 27 GERI-FREEDA SENIOR FORMULA 65 GILENYA 79 GILOTRIF 25 glatiramer acetate 79 GLEEVEC 25 glimepiride 17 glipizide 17 glipizide-metformin hcl 15 GLUCAGEN HYPOKIT 15 GLUCAGON EMERGENCY KIT 15 GLUCOPHAGE 15 GLUCOPHAGE XR 15 GLUCOSE 15 GLUCOTROL 17 GLUCOTROL XL 17 GLUCOVANCE 15
Index 8
glyburide 17 HERCEPTIN 24 hydrocodone w/homatropine 36glyburide micronized 17 HIBERIX 83 hydrocodone-acetaminophen 5glyburide-metformin 15 HM COMPLETE 65 hydrocortisone 36glycerin (laxative) 51 HM COMPLETE 50+ MENS
ULTIMATE 65 hydrocortisone (intrarectal) 6GLYCERIN ADULT 51 HM COMPLETE 50+ hydrocortisone (rectal) 6glycopyrrolate 81 WOMENS ULTIMATE 65 hydrocortisone (topical) 41GLYNASE 17 HM HAIR/SKIN/NAILS 65 hydrocortisone butyrate 41GNP GLUCOSE 15 HM OMEPRAZOLE 82 hydrocortisone w/acetic acid 77GNP OMEPRAZOLE 82 HM ONE DAILY MENS 65 hydrocortisone-aloe vera 41GNP PRENATAL 69 HM ONE DAILY WOMENS65 HYDROMORPHONE HCL 4GNP QUICK DISSOLVE HM PRENATAL 69GLUCOSE 15 hydromorphone hcl 4
HM STERILE PADS 55GNP STERILE PADS 3"X3" 55 hydroxychloroquine sulfate 23HM STERILE PADS 2"X2" 55GOCOVRI 26 hydroxyurea 26HUDSON RCI SEE-THRU
GOLYTELY 51 hydroxyzine hcl 8AEROSOL MASK GOODSENSE PRENATAL ELONGATED/ADULT 58 HYDROXYZINE PAMOATE 8 VITAMINS 69 HUMALOG 16 hydroxyzine pamoate 8GRIS-PEG 18 HUMALOG JUNIOR hyoscyamine sulfate 81griseofulvin microsize 18 KWIKPEN 16 HYPERRHO S/D 77griseofulvin ultramicrosize 18 HUMALOG KWIKPEN 16
HYPOTEARS 74guaifenesin-codeine 37 HUMALOG MIX 50/50 16
HYZAAR 22HUMALOG MIX 50/50guanfacine hcl 22 KWIKPEN 16 IBRANCE 25
guanfacine hcl (adhd) 1 HUMALOG MIX 75/25 16 ibuprofen 3GYNAZOLE-1 86 HUMALOG MIX 75/25 ICAPS AREDS FORMULA 65GYNE-LOTRIMIN 86 KWIKPEN 16 ICAPS PLUS 65GYNE-LOTRIMIN 3 86 HUMATE-P 49 ICLUSIG 25HAIR-VITES 65 HUMIRA 2 IDELVION 49HALCION 50 HUMIRA PEDIATRIC CROHNS
imatinib mesylate 25DISEASE STARTER PACK 2HALDOL 28 HUMIRA PEN 2 IMBRUVICA 25
HALDOL DECANOATE 100 28 HUMIRA PEN-CROHNS imipramine hcl 14HALDOL DECANOATE 50 28 DISEASESTARTER 2 imiquimod 42haloperidol 28 HUMIRA PEN-PSORIASIS IMITREX 60STARTER 2HALOPERIDOL 34 IMITREX STATDOSEHUMULIN 70/30 16haloperidol decanoate 28 SYSTEM 60HUMULIN 70/30haloperidol lactate 28 IMODIUM A-D 17KWIKPEN 16 HAVRIX 85 IMURAN 62HUMULIN N 16 HEALTHY LIVING INATAL GT 69HUMULIN N KWIKPEN 16REPLACEMENT FILTERS 58 INCRUSE ELLIPTA 9HUMULIN R 16HEALTHY LIVING REPLACEMENT KIT FOR HYALEX 65 indapamide 45 NEBULIZER 58 INDERAL LA 32HYCAMTIN 26HEALTHY LIVING hydralazine hcl 23 indomethacin 3REPLACEMENT MASKS 58 INFANTS ADVIL 3HYDREA 26HELIXATE FS 49
HYDROCELL ADHESIVE INLYTA 25HEMANGEOL 32 DRESSING 4"X4" 55 INNOSPIRE REPLACEMENTHEMOCYTE 50 HYDROCELL DRESSING FILTER 58 HEMOFIL M 49 4"X4" 55 INSULIN SYRINGE AND PEN heparin sodium (porcine) 10 hydrochlorothiazide 45 NEEDLES 57
INTELENCE 29
Index 9
INTUNIV 1 KAPVAY 1 KPN PRENATAL 69 INVEGA 27 KAYEXALATE 62 labetalol hcl 31,32 INVEGA SUSTENNA 27 KEFLEX 33 LAC-HYDRIN 41 INVEGA TRINZA 27 KENDALL HYDROPHILIC LAC-HYDRIN TWELVE 42 INVIRASE 29 IOPIDINE 74 ipratropium bromide 9 ipratropium bromide (nasal) 72 ipratropium-albuterol 9 irbesartan 21 irbesartan-hydrochlorothiazide
22 IRESSA 25 IRON CHEWS PEDIATRIC 50 ISENTRESS 29 ISENTRESS HD 29 ISONIAZID 24 isoniazid 24 ISOPTO CARPINE 74 ISORDIL TITRADOSE 7 isosorbide dinitrate 8 ISOSORBIDE DINITRATE ER8 isosorbide mononitrate 8 isotretinoin 38 itraconazole 19 IXINITY 49 J & J GAUZE 2"X2" 8 PLY 55 J & J GAUZE 4"X4" 12 PLY 55 J & J GAUZE 4"X4" 8 PLY 55 J & J GAUZE SPONGES 12-PLY 4" X 4" 55 J & J GAUZE SPONGES 16-PLY 4" X 4" 56 J & J GAUZE SPONGES 8-PLY4" X 4" 56 JADENU 17 JADENU SPRINKLE 17 JARDIANCE 17 JENTADUETO 15 JULUCA 29 K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH 65 K-PHOS NEUTRAL 61 K-TAB 61 KADCYLA 24 KALETRA 30 KALYDECO 80
FOAMDRESSING 2"X2" 56 KENDALL HYDROPHILIC FOAMDRESSING 3"X3" 56 KENDALL HYDROPHILIC FOAMDRESSING 4"X4" 56 KENDALL HYDROPHILIC FOAMPLUS DRESSING 2"X2" 56 KENDALL HYDROPHILIC FOAMPLUS DRESSING 3"X3" 56 KEPPRA 10,11 KEPPRA XR 11 KERALYT 42 KERLIX SPONGES 4" X 4" 12 PLY 56 KERLIX SPONGES 4" X 4" 16 PLY 56 KETOCARE 43 ketoconazole 19 ketoconazole (topical) 39 KETONE TEST STRIPS 43 KETOPROFEN 3 ketoprofen 3 KETOPROFEN ER 3 ketorolac tromethamine 3 ketorolac tromethamine (ophth) 76 KETOSTIX 43 ketotifen fumarate (ophth) 76 KEY-E 87 KITABIS PAK 2 KLARON 38 KLONOPIN 10 KLOR-CON M15 61 KLOR-CON/25 61 KLOUT 43 KLS OMEPRAZOLE 82 KOATE 49 KOATE-DVI 49 KOGENATE FS 49 KOGENATE FS BIO-SET 49 KONSYL 51 KOVALTRY 49 KP PRENATAL MULTIVITAMINS 69
lactic acid (ammoniumlactate) 42 lactulose 51 lactulose (encephalopathy) 47 LAMICTAL 11 LAMICTAL CHEWABLE DISPERSIBLE 11 LAMICTAL XR 11 LAMISIL 18 LAMISIL AT 39 LAMISIL AT JOCK ITCH 39 lamivudine 30 lamivudine-zidovudine 30 lamotrigine 11 LANCET DEVICE 57 LANCETS 57 lanolin 78 lanolin (topical) 42 LANOXIN 33 lansoprazole 82 LASIX 45 latanoprost 76 LATUDA 27 LEADER QUICK DISSOLVE GLUCOSE 15 leflunomide 3 LEMTRADA 79 letrozole 25 LEUCOVORIN CALCIUM 26 leucovorin calcium 26 LEUKERAN 24 leuprolide acetate 25 LEVAQUIN 47 LEVBID 81 levetiracetam 11 levobunolol hcl 74 levocarnitine (metabolicmodifiers) 46 levocetirizine dihydrochloride19 levofloxacin 47 levonorgestrel & ethestradiol 34 levonorgestrel (emergencyoc) 35
Index 10
levonorgestrel-eth estradiol(triphasic) 34 levonorgestrel-ethinyl estradiol(91-day) 34 levothyroxine sodium 80 LEVSIN 81 LEVSIN/SL 81 LEXAPRO 13 LEXIVA 30 LICEMD 43 LICIDE TREATMENT KIT 43 lidocaine 42 lidocaine hcl 42 lidocaine hcl (mouth-throat) 62 lidocaine-prilocaine 42 liothyronine sodium 80 LIPITOR 20 lisinopril 21 lisinopril &hydrochlorothiazide 22 LITETOUCH MASK LARGE 58 LITETOUCH MASK MEDIUM 58 LITETOUCH MASK SMALL 58 LITHIUM 27 lithium carbonate 27 LITHIUM CARBONATE 27 lithium carbonate 27 LITHOBID 27 LMX 4 42 LOCOID 41 LODINE 3
losartan potassium 21 losartan potassium &hydrochlorothiazide 22 LOTENSIN 21 LOTENSIN HCT 22 LOTREL 23 LOTRIMIN AF 39 LOTRIMIN AF FOR HER 39 LOTRIMIN AF JOCK ITCH 39 LOTRISONE 39 lovastatin 20 LOVENOX 10 loxapine succinate 28 LUPRON DEPOT (1-MONTH) 25 LUPRON DEPOT (3-MONTH) 25 LUPRON DEPOT (4-MONTH) 25 LUPRON DEPOT (6-MONTH) 25 LUPRON DEPOT-PED (1-MONTH) 46 LUPRON DEPOT-PED (3-MONTH) 46 LURIDE 61 LYSTEDA 50 M-M-R II 85 M-VIT 69 MACROBID 83 MACRODANTIN 83 MACULAR VITAMIN BENEFIT 65 MAGNESIUM 61
MAXZIDE-25 44 meclizine hcl 18 MEDICAL PROVIDER EZ FLU SHOT 2015-2016 85 MEDICAL PROVIDER SINGLE USE EZ FLU SHOT 85 MEDROL 36 MEDROL DOSEPAK 36 medroxyprogesterone acetate 78 medroxyprogesterone acetate(contraceptive) 35 mefloquine hcl 23 MEFLOQUINE HCL 23 MEGA MULTIVITAMIN FOR MEN 65 MEGA MULTIVITAMIN FOR WOMEN 65 MEGACE ORAL 25 MEGAVITE FRUITS & VEGGIES 65 MEGAVITE GOLDEN YEARS 55+ 65 megestrol acetate 25 MEKINIST 25 meloxicam 3 melphalan 24 memantine hcl 78 MENACTRA 83 MENOMUNE-A/C/Y/W-135 83 MENS 50+ MULTI VITAMIN &MINERAL FORMULA 65 MENS MULTI VITAMIN & MINERAL FORMULA 65 MENVEO 83
LODOSYN LOESTRIN 1.5/30-21 LOESTRIN 1/20-21 LOESTRIN FE 1.5/30 LOESTRIN FE 1/20 LOFIBRA LOMOTIL loperamide hcl LOPID lopinavir-ritonavir LOPRESSOR LOPRESSOR HCT loratadine loratadine &
26 34 34 34 34 20 17 17 20 30 32 22 19
magnesium citrate magnesium hydroxide magnesium oxide MAGNESIUM OXIDE magnesium oxide (mgsupplement) MAKENA malathion MAPROTILINE HCL MARPLAN MAVIK MAVYRET MAXALT MAXALT-MLT
52 52
7 61
61 78 43 13 13 21 31 60 60
MEPERIDINE HCL meperidine hcl MEPHYTON meprobamate MEPRON mercaptopurine mesalamine MESALAMINE DR MESTINON MESTINON TIMESPAN METADATE CD METAMUCIL METAMUCIL ORIGINAL TEXTURE
4 4
87 8 7
24 47 47 24 24
1 51
51 pseudoephedrine lorazepam
37 8
MAXITROL MAXZIDE
75 44
METAPROTERENOL SULFATE 9
Index 11
metformin hcl 15 MICROELITE FILTER MULTI PRENATAL 69 methadone hcl 4,5 methazolamide 44 METHENAMINE MANDELATE 83 methenamine mandelate 83 methenamine-hyosc-methyleneblue-sod phos-phenyl sal 82 methimazole 80 METHITEST 6 methocarbamol 71 methotrexate sodium 24 METHOTREXATE SODIUM 24 methotrexate sodium 24 methyldopa 22 methylergonovine maleate 77 methylphenidate hcl 1,2 METHYLPHENIDATE HCL ER 1,2 methylprednisolone 36 METIPRANOLOL 74
REPLACEMENTS 58 MICROELITE RECHARGEABLE BATTERY 58 MICROZIDE 45 midazolam hcl 50 midodrine hcl 86 MIGRANAL 60 MINIELITE FILTER REPLACEMENTS 58 MINIELITE RECHARGEABLE BATTERY 58 MINIPRESS 22 MINIVELLE 47 MINOCIN 80 minocycline hcl 80 minoxidil 23 MIRALAX 51 MIRAPEX 26 MIRASORB SPONGES 2" X 2" 56
MULTI VITAMIN 67 MULTI VITAMIN/D-3 67 MULTI-BETIC DIABETES 65 MULTI-VITAMIN MONOCAPS 65 multiple vitamin 67 multiple vitamins w/ iron 63 multiple vitamins w/ minerals 65 MULTIVITAMIN ADULTS 65 MULTIVITAMIN MEN 65 MULTIVITAMIN/FLUORIDE 67 mupirocin 38 mupirocin calcium (topical) 38 MURO 128 76 MYAMBUTOL 24 mycophenolate mofetil 62 mycophenolate sodium 62 MYDRIACYL 74 MYFORTIC 62
metoclopramide hcl 47 metolazone 45 metoprolol &hydrochlorothiazide 23 metoprolol succinate 32 METOPROLOL SUCCINATE
MIRASORB SPONGES 4" X 4" 56 MIRCETTE 34 mirtazapine 12 misoprostol 82 MOBIC 3
MYLERAN MYLICON MYLICON INFANTS GAS RELIEF MYNATAL MYNATAL ADVANCE
24 47
47 69 69
ER/HYDROCHLOROTHIAZIDE23
metoprolol tartrate 32 METOPROLOL/HYDROCHLOROTHIAZIDE 23 METROCREAM 42 METROGEL-VAGINAL 86 METROLOTION 42
MODICON 34 MOI-STIR 63 MOLINDONE HYDROCHLORIDE 28 mometasone furoate 41 MONISTAT 3 86 MONISTAT 3 COMBINATION PACK 86
MYNATAL PLUS MYNATAL ULTRACAPLET MYNATAL-Z MYNATE 90 PLUS MYSOLINE nabumetone nadolol
69 69 69 69 11
3 32
metronidazole 7 MONISTAT 7 SIMPLY NALOXONE HCL 18 metronidazole (topical) metronidazole vaginal
42 86
CURE 86 MONISTAT SOOTHING CARE ITCH RELIEF 41
naloxone hcl NALOXONE HCL
18 18
MEVACOR 21 MONOCLATE-P 49 naltrexone hcl 18 mexiletine hcl 8 MONONINE 49 NAMENDA 78 MIACALCIN 45 montelukast sodium 9 NAMENDA TITRATION PAK79 MICARDIS MICARDIS HCT
21 23
morphine sulfate MORPHINE SULFATE
5 5
naphazoline w/ pheniramine 75 NAPHCON-A 75
MICATIN MICONAZOLE 3
39 86
morphine sulfate 5 MOTRIN INFANTS DROPS 3
NAPROSYN naproxen
3 3
miconazole nitrate (topical) 39 MOUTHKOTE 63 naproxen sodium 3 miconazole nitrate vaginal MICRO-K
86 61
moxifloxacin hcl (ophth) MS CONTIN
75 5
naratriptan hcl NARCAN
60 18
MULTAQ 9 NARDIL 13
Index 12
NASACORT ALLERGY 24HR 72 NASACORT ALLERGY 24HR CHILDRENS 72 NASAL DECONGESTANT 72 NASALCROM 72 NAT-RUL PRENATAL VITAMINS 70 NAT-RUL THERAVITE-M/HIGHPOTENCY 65 NATALVIT 70 nateglinide 17 NATRUL-MEGA-75 65 NATRUL-VITES 65 NATURE-THROID 80 NEBULIZER AIR TUBE/PLUGS 58 NEBULIZER PEDIATRIC
NEXIUM 82 NEXIUM 24HR 82 NEXIUM 24HR CLEAR MINIS 82 niacin 87 niacin (antihyperlipidemic) 21 NIACIN TR 87 NIACOR 21 NIASPAN 21 NICADAN 65 NICADAN ZX 65 nicardipine hcl 33 NICAZEL 66 NICAZEL FORTE 65 NICODERM CQ 79 NICORETTE 79
norethindrone & ethinyl estradiol-fe 34 norethindrone (contraceptive) 36 norethindrone acet & eth estra 35 norethindrone acetate 78 norethindrone acetate-ethinylestradiol 46 norethindrone acetate-ethinylestradiol-fe 35 norethindrone-eth estradiol (triphasic) 35 norgestimate-ethinylestradiol 35 norgestimate-ethinyl estradiol(triphasic) 35 norgestrel & ethinyl estradiol 35 NORINYL 1+35 35
MASK 58 NICORETTE MINI 79 NORINYL 1+50 35 NECON 1/50-28 34 NICORETTE STARTER NORPACE 8 NECON 10/11-28 34 NEFAZODONE HCL 14 nefazodone hcl 14 neomycin sulfate 2 neomycin-bacitracin zn-polymyxin 75 neomycin-bacitracin-polymyxin
39 neomycin-polymy-dexameth 75 neomycin-polymyxin w/pramoxine 39 neomycin-polymyxin-gramicidin
75 neomycin-polymyxin-hc(otic) 77 NEOMYCIN/POLYMYXIN/HYDROCORTISONE 76 NEORAL 62 NEOSPORIN 75 NEOSPORIN ORIGINAL 39 NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH 39 NEPHRO-VITE RX 63 NEPHROCAPS 63 NEPTAZANE 44 NEURONTIN 11 NEUTROGENA T/GEL 43 NEUTROGENA T/GELSTUBBORN ITCH
KIT 79 nicotine 79 nicotine polacrilex 79 NICOTINE TRANSDERMAL SYSTEM 79 NICOTROL INHALER 79 NICOTROL NS 80 nifedipine 33 NINLARO 25 NITRO-BID 8 NITRO-DUR 8 nitrofurantoin 83 nitrofurantoin macrocrystal 83 nitrofurantoin monohyd macro 83 nitroglycerin 8 NITROSTAT 8 NIVA-PLUS 70 NIX CREME RINSE 43 NIZORAL 39 NIZORAL A-D 39 NO IRON MULTIPLE VITAMIN/MINERALS 66 nonoxynol-9 86 NOR-QD 36 NORCO 5 NORDITROPIN FLEXPRO 45 norethin acet & estrad-fe 34
NORPACE CR 8 NORPRAMIN 14,15 NORTEMP INFANTS 4 nortriptyline hcl 15 NORVASC 33 NORVIR 30 NOSE CLIP 58 NOVA MAX PLUS KETONE TESTSTRIPS 44 NOVOEIGHT 49 NOVOLIN 70/30 16 NOVOLIN 70/30 RELION 16 NOVOLIN N 16 NOVOLIN N RELION 16 NOVOLIN R 16 NOVOLIN R RELION 16 NOVOLOG 17 NOVOLOG FLEXPEN 16 NOVOLOG MIX 70/30 17 NOVOLOG MIX 70/30PREFILLED FLEXPEN 16 NOVOSEVEN RT 49 NU GAUZE 4PLY 4"X4" 56 NU GAUZE GENERAL-USE SPONGES 4"X4" 4 PLY 56 NULYTELY/FLAVORPACKS 51 NUMOISYN 63
CONTROL 43 norethindrone & eth NUPLAZID 27 nevirapine 30 estradiol 34 NUTRICAP 66 NEXAVAR 25
Index 13
NUTRICION PORVIDA 70 ONE-A-DAY MENS HEALTH paliperidone 27 FORMULA 66NUVARING 35 PAMELOR 15ONE-A-DAY MENS PRO
NUWIQ 49 PANCREAZE 44EDGE 66 nystatin 18 ONE-A-DAY PROACTIVE PANOXYL-4 CREAMY
65+ 66 WASH 38nystatin (mouth-throat) 62 ONE-A-DAY TEEN pantoprazole sodium 82nystatin (topical) 39 ADVANTAGEFOR HIM 66 PAREGORIC 17nystatin-triamcinolone 39 OPCON-A 75 PARI ALTERA NEBULIZERNYTOL MAXIMUM OPDIVO 24 HANDSET 58STRENGTH 50 PARI BABY CONVERSIONOPTI-WOMAN 66O-CAL FA 70 KITSIZE 1 58OPTIFOAM 56O-CAL PRENATAL 70 PARI BABY CONVERSIONOPTIONS CONCEPTROL KITSIZE 2 58OBIZUR 49 VAGINAL PARI BABY CONVERSIONOCEAN NASAL SPRAY 71 CONTRACEPTIVE 86 KITSIZE 3 58OPTIONS GYNOL IIOCUFEN 76 PARI ERAPID NEBULIZERVAGINALCONTRACEPTIVEOCUFLOX 75 HANDSET 58
86 PARI EXPIRATORY FILTEROCULAR VITAMINS 66 OPURITY 66 VALVE SET 58ODEFSEY 30 oral electrolytes 60 PARI MASK SET 58 OFF DEEP WOODS 42 ORAL RELIEF SPRAY FOR PARI SOFT PLASTIC ADULT OFF DEEP WOODS DRY 42 DRYMOUTH & MASK 58
DISCOMFORT 63 PARI SOFT PLASTICofloxacin 47 PEDIATRIC MASK 58ORAP 79ofloxacin (ophth) 75 PARLODEL 26ORKAMBI 80ofloxacin (otic) 77 PARNATE 13orphenadrine citrate 71OGESTREL 35 paromomycin sulfate 2ORTHO MICRONOR 36olanzapine 28 paroxetine hcl 13ORTHO TRI-CYCLEN 35olanzapine-fluoxetine hcl 79 PARVLEX 66ORTHO TRI-CYCLEN LO 35olmesartan medoxomil 21 PAXIL 13,14ORTHO-CYCLEN 35olmesartan medoxomil- PAXIL CR 13amlodipine-hydrochlorothiazide ORTHO-NOVUM 1/35 35 23 PCE 53ORTHO-NOVUM 7/7/7 35olmesartan medoxomil- ped multivitamins w/fl & iron 69oseltamivir phosphate 31hydrochlorothiazide 23 PEDIALYTE 61omega-3 fatty acids 73 OTICIN HC NR 77
PEDIALYTE FREEZER omeprazole 82 OVACE PLUS WASH 40 POPS 60
OVACE WASH 40OMEPRAZOLE 82 PEDIAPRED 36 OMNICAP 67 OVCON-35 35 PEDIATRIC AEROSOL
OVIDE 43 MASK 58OMNIPRED 76 PEDIATRICOMNITROPE 45 oxaprozin 3 MOUTHPIECE/DISPOSABLEoxazepam 8ONCOVITE 66 59 ondansetron 18 OXAZEPAM 8 pediatric multiple vitamin w/ ondansetron hcl 18 oxcarbazepine 11 c 69
pediatric multiple vitamin w/ c &ONE DAILY MENS FORMULA oxybutynin chloride 83 fa 69W/O IRON 66 5oxycodone hcl pediatric multiple vitamins w/ONE DAILY PLUS IRON 66 OXYCODONE HCL ER 5 iron 69 ONE DAILY WOMENS 66 oxycodone w/ pediatric multivitamins w/fl 68 ONE-A-DAY ENERGY 66 acetaminophen 5 pediatric vitamins acd w/ONE-A-DAY MENOPAUSE oxycodone-aspirin 5 fluoride 68 FORMULA 66 OXYCODONE/ACETAMINOPH pediatric vitamins adc 69 ONE-A-DAY MENS 50+ EN 5 peg 3350-kcl-sod bicarb-sodADVANTAGE 66 oyster shell 60 chloride-sod sulfate 51
Index 14
peg 3350-potassium chloride-sod pioglitazone hcl-metformin PRAVACHOL 21 bicarbonate-sod chloride 51 hcl 15 pravastatin sodium 21PENICILLIN V POTASSIUM 77 piroxicam 3 prazosin hcl 22penicillin v potassium 77 PLAN B ONE-STEP 35 PRE-NATAL FORMULA 70pentoxifylline 49 PLAQUENIL 23 PRECISION XTRA 44PEPCID 81 PLAVIX 49 PRED FORTE 76PEPCID AC 81 PLEGRIDY 79 PRED MILD 76PEPCID AC MAXIMUM PLEGRIDY STARTER
PRED-G 76STRENGTH 81 PACK 79 PEPTO-BISMOL 17 PNEUMOVAX 23 83 PREDATOR 42 PEPTO-BISMOL PNEUMOVAX 23/1 DOSE 83 PREDNICARBATE 41 INSTACOOL 17 PNV FERROUS prednicarbate 41PEPTO-BISMOL MAX FUMARATE/DOCUSATE/FOLI prednisolone 36STRENGTH 17 C ACID 70 PREDNISOLONE 36PEPTO-BISMOL TO-GO 17 PNV FOLIC ACID + IRON PERCOCET 5 MULTIVITAMIN 70 prednisolone acetate (ophth) 76
PNV PRENATAL PLUS PREDNISOLONE ACETATE P-PERIDEX 62 MULTIVITAMIN 70 F 76PERJETA 24 PNV TABS 29-1 70 prednisolone sodiumpermethrin 43 phosphate 36podofilox 42 perphenazine 28 PREDNISONE 36POLYCOSE 73PERPHENAZINE/AMITRIPTYLIN prednisone 36polyethylene glycol 3350 51E 79 PREDNISONE 36POLYMEM DRESSING/3" XPERRY PRENATAL 70 3" 56 PREDNISONE INTENSOL 36 PERSANTINE 49 POLYMEM DRESSING/4" X PREMARIN 47,86PFLEX 59 4" 56 PREMPHASE 46 phenazopyridine hcl 48 polymyxin b-trimethoprim 75 PREMPRO 46polysaccharide ironphenelzine sulfate 13 PRENATABS FA 70complex 50phenobarbital 50 POLYTRIM 75 PRENATABS RX 70 PHENOBARBITAL 50 polyvinyl alcohol 74 PRENATAL 70 phenobarbital 50 POMALYST 25 PRENATAL 19 70phenobarbital-hyoscyamine- pot phosphate monobasic w/ PRENATAL AND IRON 70atropine-scopolamine 81 sod phosphate dibasic &phenylephrine hcl (ophth) 75 PRENATAL FORTE 70
monobasic 61 phenylephrine hcl (oral) 72 potassium bicarbonate 61 PRENATAL LOW IRON 70 phenylephrine-shark liver oil- PRENATAL MULTIVITAMIN 70potassium chloride 61cocoa butter 6 PRENATAL ONE DAILY 70 phenylephrine-shark liver oil- POTASSIUM CHLORIDE 61
PRENATAL PLUS 70mineral oil-petrolatum 6 potassium chloride 61 PRENATAL PLUS IRON 70phenytoin 12 POTASSIUM CHLORIDE PRENATAL VITAMIN 70phenytoin sodium extended 12 ER 61
potassium chloride PRENATAL VITAMIN &PHYTOMULTI 66 microencapsulated crystals MINERAL 70 phytonadione 87 er 61 PRENATAL VITAMIN/IRON 70 PILLOW MASK/ADULT 59 potassium citrate PRENATAL VITAMINS 71(alkalinizer) 48PILLOW MASK/CHILD 59 PRENATAL VITAMINS PLUSpotassium citrate-citric acid48 LOW IRON 71PILLOW MASK/PEDIATRIC 59 pramipexolepilocarpine hcl 74 PREPLUS 71dihydrochloride 27 pilocarpine hcl (oral) 63 pramoxine hcl (rectal) 6 PRESERVISION AREDS 66
pimozide 79 pramoxine-hc-chloroxylenol PRETAB 71
pindolol 32 77 PREVACID 82 prasugrel hcl 49 PREVACID 24HR 82pioglitazone hcl 16
Index 15
PREVACID SOLUTAB PREVIDENT 5000 DRY MOUTH PREVIDENT 5000 PLUS PREVIDENT FLUORIDE PREVNAR 13 PREZCOBIX PREZISTA PRIFTIN PRILOSEC
82
62 62 62 83 30 30 24 82
pseudoephedrine hcl 72 pseudoephedrine w/ codeine-gg 37 pseudoephedrine-ibuprofen 37 PSORCON 41 psyllium 51 PTS PANELS KETONE TEST 44 PULMICORT 9 PULMICORT FLEXHALER 9
RA DRY MOUTH RA GAUZE SPONGES 4"X4" RA LICE SOLUTION KIT RA OMEPRAZOLE RA OYSTER SHELL CALCIUM/VITAMIN D RA PRENATAL RA PRENATAL FORMULA/FOLICACID RA STERILE PADS 2"X2"
63
56 43 82
60 71
71 56
PRILOSEC OTC 82 PURIXAN 24 RA STERILE PADS 3"X3" 56 primidone 11 PX OMEPRAZOLE 82 RA STERILE PADS 4"X4" 56 PRINIVIL 21 PX PRENATAL RABAVERT 85 PRO-CAL 66 PROAIR HFA 10 probenecid 48 PROBUPHINE IMPLANT KIT 6 PROCARDIA 33 PROCARDIA XL 33 PROCERV HP 66 prochlorperazine 28 prochlorperazine maleate 28 PROCTOFOAM 6 PROFILNINE 49 PROFILNINE SD 49 progesterone micronized 78 PROGRAF 62 promethazine &phenylephrine 37 promethazine hcl 20 promethazine w/codeine 37 PROMETHAZINE/PHENYLEPHRINE 37 PROMETRIUM 78
MULTIVITAMINS 71 pyrantel pamoate 7 pyrazinamide 24 pyrethrins-piperonylbutoxide 43 pyrethrins-piperonyl butoxide-permethrin-nit remover 43 PYRIDIUM 48 pyridostigmine bromide 24 pyridoxine hcl 87 QC ALL PURPOSE DRESSINGS4"X4" 56 QC BORDER ISLAND GAUZE PAD 2"X2" 56 QC PRENATAL 71 QC STERILE PADS 56 QUENCH 66 QUESTRAN 20 QUESTRAN LIGHT 20 quetiapine fumarate 28 QUFLORA PEDIATRIC 69 QUIN B STRONG 66
raloxifene hcl 46 ramipril 21 ranitidine hcl 81 RAPAMUNE 62 RAY-TEC X-RAY DETECTABLESPONGES 4" X 4" 16 PLY 56 RAZADYNE 79 RAZADYNE ER 79 REBINYN 49 RECOMBINATE 49 RECOMBIVAX HB 85 REGLAN 47 RELENZA DISKHALER 31 RELION KETONE 44 RELION KETONE TEST STRIPS 44 RELPAX 60 REMERON 12 REMERON SOLTAB 12 RENAPLEX-D 66
propafenone hcl 9 proparacaine hcl 75 propranolol hcl 32 PROPRANOLOL HCL 32 propranolol hcl 32 PROPRANOLOL/HYDROCHLOROTHIAZIDE 23 propylthiouracil 80 PRORENAL+D 66 PROSCAR 48 PROTONIX 82 PROVERA 78 PROVIT 66
quinapril hcl 21 quinapril-hydrochlorothiazide
23 quinidine gluconate 8 QUINIDINE SULFATE 8 QUINTABS 67 QUINTABS-M 66 RA ALL PURPOSE DRESSINGS4"X4" 56 RA CENTRAL-VITE 66 RA CENTRAL-VITE UNDER 50MENS 66 RA CENTRAL-VITE UNDER 50WOMENS 66 RA DRESSING SPONGES
REPLACEMENT AIR FILTER 59 REPLACEMENT FILTERS 59 REQ 49+ 66 REQUIP 27 RESCRIPTOR 30 RESTORE CONTACT LAYER/NON-ADHERENT2"X2" 56 RESTORE FOAM DRESSING BORDERED 4"X4" 56 RESTORE FOAM DRESSING NON-BORDERED 4"X4" 56 RESTORE ODOR ABSORBING DRESSING 4"X4" 56
PROZAC 14 4"X4" 56
Index 16
RESTORE TRIO ABSORBENT salsalate 4 SIDESTREAM PEDIATRIC DRESSING 3"X3" RESTORIL RETIN-A RETROVIR
56 50 38 30
SAMI THE SEAL REPLACEMENTFILTERS 59 SANDIMMUNE 62 SAPHRIS 28
FACEMASK/TUCKER THETURTLE 59 SIDESTREAM PLUS ADULT FACE MASK 59 SILICONE MASK FOR
REVLIMID 61 SARNA 40 BREATHERITE REXULTI 29 REYATAZ 30 RHEUMATREX 2 RHOGAM ULTRA-FILTERED PLUS 77
SAVELLA 79 SAVELLA TITRATION PACK 79 SB OMEPRAZOLE 82 SCHOOLTIME SHAMPOO43
CHAMBER/ADULTSILICONE MASK FOR BREATHERITE CHAMBER/INFANTSILICONE MASK FOR BREATHERITE
59
59
riboflavin RID RID COMPLETE LICE ELIMINATION RID ESSENTIAL LICE ELIMINATION KIT
87 43
43
43
SE-NATAL 19 SEASONIQUE SECTRAL selegiline hcl selenium sulfide
71 35 32 27 40
CHAMBER/PEDIATRICSILICONE MASK FOR BREATHRITE CHAMBER/ADULT SILPHEN COUGH SILVADENE
59
59 19 40
RIDAURA 2 SELSUN BLUE 40 silver sulfadiazine 40 RIFADIN 24 SELSUN BLUE DAILY 40 simethicone 47 rifampin RIGHT STEP PRENATAL
24 71
SELSUN BLUE MEDICATED SELSUN BLUE
40 SIMPLYTHICK SIMPLYTHICK EASY MIX
78 78
RILUTEK 72 MOISTURIZING 40 simvastatin 21 riluzole 72 SELZENTRY 30 SINEMET 27 risedronate sodium 45 sennosides 52 SINEMET CR 27 RISPERDAL RISPERDAL CONSTA RISPERDAL M-TAB risperidone RISPERIDONE ODT RITALIN ritonavir RITUXAN rivastigmine rivastigmine tartrate RIXUBIS rizatriptan benzoate ROBAXIN ROBAXIN-750 ROBINUL ROBINUL FORTE ROCALTROL ropinirole hydrochloride rosuvastatin calcium ROXICODONE
27 27 27 27 27
2 30 24 79 79 49 60 71 71 81 81 46 27 21
5
sennosides-docusate sodium 51 SENOKOT 52 SENOKOT S 51 SENSIPAR 46 SENTRY 66 SENTRY SENIOR 66 SENTRY SENIOR/LUTEIN66 SEREVENT DISKUS 10 SEROQUEL 28 SEROQUEL XR 28 sertraline hcl 14 SFROWASA 47 SHINGRIX 85 SHOHLS SOLUTION MODIFIED 48 SHUR-SEAL 86 SIDEROL 66 SIDESTREAM ADULT FACE MASK 59 SIDESTREAM PEDIATRIC FACEMASK 59
SINGULAIR 9 sirolimus 62 SIVEXTRO 7 SLO-NIACIN 87 SM GAUZE PADS 2"X2" 56 SM GAUZE PADS 3"X3" 56 SM GAUZE PADS 4"X4" 56 SM GLUCOSE 15 SM OMEPRAZOLE 82 SM ONE DAILY MENS 66 SM ONE DAILY WOMENS 66 SM PRENATAL VITAMINS 71 SM STERILE PADS 56 SM STERILE PADS 2"X2" 56 sodium bicarbonate (antacid) 7 sodium chloride (gu irrigant) 48 sodium chloride (inhalant) 37 sodium chloride hypertonic 76 sodium citrate & citric acid 48 sodium fluoride 61
RYTHMOL SALAGEN salicylic acid saline
9 63 42 72
SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL 59
sodium fluoride (dental) sodium phosphates sodium polystyrenesulfonate
63 52
62
Index 17
SODIUM SUDAFED PE TEARS NATURALE PM 74 SULFACETAMIDE/SULFUR
38 SOF-WICK 4"X4" 56 SOLO 66 SOMA 71 SONATA 51 SOOTHENEB NBL 100 CHILD MASK 59 SOOTHENEB NBL 100
CONGESTION sulfacetamide sod-prednisolone sulfacetamide sodium sulfacetamide sodium (acne)sulfacetamide sodium (ophth)sulfacetamide sodium w/sulfur
72
76 40
38
75
38
TECFIDERA 79 TECFIDERA STARTER PACK 79 TEGADERM FOAM DRESSING 2"X2" 57 TEGADERM FOAM DRESSING 4"X4" 57 TEGRETOL 11 TEGRETOL-XR 11
MEDICATION CUP 59 sulfamethoxazole- telmisartan 21 SOOTHENEB NBL 100 MESH CAP 59 SOOTHENEB NBL100 ADULT MASK 59 SORBITOL 51 sotalol hcl 32 sotalol hcl (afib/afl) 32 SPACER/AEROSOL-HOLDINGCHAMBER 59 SPINOSAD 43
trimethoprim sulfasalazine sulindac sumatriptan sumatriptan succinate SUMATRIPTAN SUCCINATE sumatriptan succinate SUPERB NAILS
7 47
3 60 60
60 60 66
telmisartan-amlodipine 23 telmisartan-hydrochlorothiazide
23 temazepam 51 TEMOVATE 41 TEMOVATE E 41 TENCON 4 TENEX 22 TENIVAC 80
spironolactone spironolactone &hydrochlorothiazide SPORANOX SPORANOX PULSEPAK SPRYCEL stannous fluoride STARLIX stavudine STERILE GAUZE PADS
45
44 19 19 25 63 17 30
SUPPRELIN LA SURGICAL GAUZE SPONGE SUSTIVA SUTENT SW OMEPRAZOLE SYLATRON SYMAX DUOTAB SYMBICORT SYMBYAX
46
57 30 25 82 26 81 10 79
tenofovir disoproxil fumarate 30 TENORETIC 100 23 TENORETIC 50 23 TENORMIN 32 TERAZOL 3 86 TERAZOL 7 86 terazosin hcl 22 terbinafine hcl 18 terbinafine hcl (topical) 39
2"X2" 56 SYMFI LO 30 terbutaline sulfate 10 STERILE GAUZE PADS 3"X3" STERILE PADS 2"X2" STERILE PADS 3"X3" STERILE PADS 4"X4" STIVARGA STRATTERA STRIBILD STROVITE ONE SUBLOCADE SUBOXONE sucralfate SUDAFED CHILDRENS SUDAFED CONGESTION SUDAFED NASAL
56 57 57 57 25
1 30 66
6 6
82 72 72
SYMLINPEN 120 SYMLINPEN 60 SYNTHROID T-VITES tacrolimus TAFINLAR TAGAMET HB TAMIFLU tamoxifen citrate tamsulosin hcl TAPAZOLE TARCEVA TARGRETIN TARKA
15 15 80 66 62 25 81 31 25 48 80 25 26 23
TERCONAZOLE terconazole vaginal TESSALON PERLES testosterone cypionate TETANUS/DIPHTHERIATOXOIDS-ADSORBED tetracaine hcl (ophth) tetrahydrozoline hcl (ophth) TGT OMEPRAZOLE THEO-24 theophylline THERA THERA M PLUS THERA-FLUR-N THERA-M
86 86 36
6
80 75 75 82 10 10 67 66 63 67
DECONGESTANT MAXIMUM STRENGTH 72 SUDAFED PE CHILDRENS NASAL DECONGESTANT 72
TASIGNA TAVIST ALLERGY tazarotene TAZORAC
25 19 40 40
THERA-TABS M THERABETIC MULTI-VITAMIN THERAGAUZE
67
67 57
Index 18
THERAGRAN-M 67 THERAGRAN-M ADVANCED 67 THERAGRAN-M ADVANCED 50 PLUS 67 THERAGRAN-M PREMIER 67 THERAGRAN-M PREMIER 50 PLUS 67 THERANATAL CORE NUTRITION 71 THEREMS-H 67 THEREMS-M 67 thiamine hcl 87 thiamine mononitrate 87 thioridazine hcl 28 thiothixene 29
tobramycin-dexamethasone TOBREX TOFRANIL TOLMETIN SODIUM tolnaftate tolterodine tartrate TOPAMAX TOPAMAX SPRINKLE TOPICORT topiramate TOPOTECAN HCL topotecan hcl TOPPER DRESSING SPONGES 4"X4"
76 75 15
3 39 83 11 11 41 11 26 26
57
TRIBENZOR TRICARE trifluoperazine hcl trifluridine TRIGLIDE trihexyphenidyl hcl TRILEPTAL trimethoprim TRINATAL GT TRINATAL RX 1 TRIUMEQ TRIZIVIR TROGARZO tropicamide
23 71 28 75 20 26 11
7 71 71 30 30 30 74
THRESHOLD IMT THRIVITE 19 THRIVITE RX
59 71 71
TOPROL XL torsemide TRADJENTA
32 45 16
trospium chloride TRUE METRIX BLOOD GLUCOSETEST STRIPS TRUE METRIX CONTROL
83
44
thyroid THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 tiagabine hcl TIAZAC TIKOSYN TIMOLOL MALEATE timolol maleate (ophth) TIMOLOL MALEATE OPHTHALMIC GEL
80 80 80 80 80 80 12 33
9 32 74
tramadol hcl 5 tramadol-acetaminophen 5 trandolapril 21 trandolapril-verapamil hcl 23 TRANDOLAPRIL/VERAPAMILHCL ER 23 tranexamic acid 50 TRANXENE T 8 tranylcypromine sulfate 13 trazodone hcl 14 TRECATOR 24 TRELSTAR 25 TRELSTAR MIXJECT 25
SOLUTION LEVEL 1 57 TRUE METRIX CONTROL SOLUTION LEVEL 2 57 TRUE METRIX CONTROL SOLUTION LEVEL 3 57 TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS 44 TRUECONTROL GLUCOSE CONTROL LEVEL 0 57 TRUECONTROL GLUCOSE CONTROL LEVEL 1 57 TRUETEST BLOOD GLUCOSE TEST 44 TRUETEST BLOOD GLUCOSE TEST STRIPS 44
FORMING 74 tretinoin 38 TRUETEST GLUCOSE TIMOPTIC TIMOPTIC OCUDOSE TIMOPTIC-XE
74 74 74
TRETTEN TREXALL TRI-NORINYL 28
49 24 35
CONTROLLEVEL 1 TRUETEST GLUCOSE CONTROLLEVEL 2 TRUETEST GLUCOSE
57
57
TINACTIN TINACTIN JOCK ITCH tioconazole vaginal TIVICAY tizanidine hcl TOBI TOBRADEX tobramycin TOBRAMYCIN tobramycin (ophth) TOBRAMYCIN SULFATE tobramycin sulfate
39 39 86 30 71
2 76
2 2
75 2 2
TRI-VIT/FLUORIDE/IRON 69 TRI-VITAMIN/FLUORIDE 69 TRIADVANCE 71 triamcinolone acetonide (mouth) 63 triamcinolone acetonide (nasal) 72 triamcinolone acetonide (topical) 41 triamterene & hydrochlorothiazide 44 TRIAMTERENE/HYDROCHLOROTHIAZIDE 44 TRIAZOLAM 51 triazolam 51
CONTROLLEVEL 3 TRUETEST STRIPS TRUETRACK BLOOD GLUCOSE TEST TRUETRACK TEST TRUMENBA TRUSOPT TRUVADA TUBING/WING TIP TUDORZA PRESSAIR TUMS TUMS LASTING EFFECTS TWINRIX
57 44
44 44 83 76 30 59
9 7 7
85
Index 19
TWYNSTA 23 VERIPRED 20 36 VOSPIRE ER 10 TYBOST 30 VERSACLOZ 28 VOTRIENT 26 TYLENOL CHILDRENS 4 VERSIVA XC 3" X 3" FOAM VP-ZEL 67 TYLENOL INFANTS 4 TYLENOL INFANTS PAIN+FEVER 4 TYLENOL/CODEINE #3 5 TYLENOL/CODEINE #4 5 ULTRACET 6 ULTRAM 5 ULTRATHON INSECT REPELLENT 8 42 UNICOMPLEX-M 67 UNISOM 50 UNISOM SLEEPGELS 50 urea 41 URECHOLINE 83 UROCIT-K 10 48 UROCIT-K 5 48 URSO 250 47 ursodiol 47 VAGISTAT-1 86 valacyclovir hcl 31 VALCYTE 31 valganciclovir hcl 31 VALIUM 8 valproate sodium 12 valproic acid 12 valsartan 21 valsartan-hydrochlorothiazide
23
DRESSING/HYDROFIBERTECHNOLOGY 57 VERSIVA XC 4" X 4" FOAM DRESSING/HYDROFIBERTECHNOLOGY 57 VEXOL 76 VIBRAMYCIN 80 VICTOZA 16 VIGAMOX 75 VIIBRYD 14 VIL-RX 71 VINATE M 71 VINATE ONE 71 VIRACEPT 30 VIRAMUNE 30 VIRAMUNE XR 30 VIREAD 30 VIROPTIC 75 VIRT-ADVANCE 71 VIRT-VITE GT 71 VISINE 75 VISINE EXTRA 75 VISTARIL 8 VISTEC X-RAY DETECTABLE SPONGES 4"X4" 16 PLY 57 VISTOGARD 17 VITAFOL-OB 71 VITALINE TOTAL FORMULA 2 67
VRAYLAR 27 VYVANSE 1 WALGREENS GLUCOSE 15 warfarin sodium 10 WELLBUTRIN SR 13 WELLBUTRIN XL 13 WESTHROID 80 white petrolatum-mineral oil 74 WHOLE FOOD MULTIVITAMIN 67 WILATE 49 WINDMILL TRAINER 59 WOMENS 50+ MULTI VITAMIN& MINERAL FORMULA 67 WOMENS BIOMULTIPLE 67 WOMENS MULTI VITAMIN & MINERAL FORMULA 67 WP THYROID 80 XALATAN 76 XALKORI 26 XANAX 8 XARELTO 10 XARELTO STARTER PACK 10 XTANDI 25 XULANE 35 XYNTHA 49 XYNTHA SOLOFUSE 49 XYZAL 20
VALTREX 31 VITALINE TOTAL FORMULA XYZAL ALLERGY 24HR 20 VANCOCIN HCL 7 3 67 YASMIN 28 35 vancomycin hcl 7 VANTAS 25
VITAMIN D3 COMPLETE 67 vitamin e 87
YAZ 35 YELETS TEENAGE
VAQTA 85 VARIVAX 85 VASERETIC 23 VASOTEC 21 VCF VAGINAL CONTRACEPTIVE FILM 86 venlafaxine hcl 14 VENLAFAXINE HCL ER 14 VENTOLIN HFA 10 verapamil hcl 33 VERAPAMIL HCL SR 33 VERELAN 33 VERELAN PM 33
VITAMIN E 87 vitamins w/ lipotropics 71 VITASANA 67 VITATRUM 67 VITEKTA 30 VITRUM 50+ SENIOR MULTI 67 VIVELLE-DOT 47 VIVITROL 18 VOL-PLUS 71 VOL-TAB RX 71 VOLTAREN 38 VONVENDI 49
FORMULA 67 ZADITOR 76 zaleplon 51 ZANAFLEX 71 ZANTAC 81 ZANTAC 150 MAXIMUM STRENGTH 81 ZANTAC 75 81 ZARONTIN 12 ZARXIO 50 ZEBETA 32 ZELBORAF 26 ZERIT 31
Index 20
ZESTORETIC 23
ZOVIRAX 31,40
ZYRTEC CHILDRENS
ZYRTEC-D
ZESTRIL 21 ZIAC 23 ZIAGEN 31 zidovudine 31 zinc oxide (topical) 42 zinc sulfate 61 ziprasidone hcl 27 ZITHROMAX 52 ZITHROMAX TRI-PAK 52 ZITHROMAX Z-PAK 52 ZOCOR 21 ZOFRAN 18 ZOFRAN ODT 18 ZOLADEX 25 ZOLINZA 26 zolmitriptan 60 ZOLOFT 14 zolpidem tartrate 51 ZOMACTON 45 ZOMIG 60 ZOMIG ZMT 60 ZONEGRAN 11 zonisamide 11 ZOSTAVAX 85
ZUBSOLV 6 ZYBAN 80 ZYLOPRIM 48 ZYPREXA 28 ZYPREXA RELPREVV 28 ZYPREXA ZYDIS 28 ZYRTEC ALLERGY 20
ALLERGY 20
ALLERGY/CONGESTION 37 ZYTIGA 25
Index 21