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Bienvenido(a) a Nebraska Total Care
¿Qué es la Lista de medicamentos recomendados de Nebraska Total Care?
La lista de medicamentos incluye medicamentos usados para tratar enfermedades comunes o problemas de salud. Un equipo de médicos y farmacéuticos se reúne regularmente para decidir qué medicamentos deberían estar en la lista de medicamentos. El equipo revisa medicamentos nuevos y existentes y elije medicamentos que funcionan mejor y son seguros. La lista de medicamentos es una combinación de la Lista de medicamentos preferidos del Estado y el formulario de Nebraska Total Care.
¿Cómo uso la Lista de medicamentos recomendados de Nebraska Total Care?
Busque su medicamento en el índice que está al final de este folleto. El índice muestra todos los medicamentos de la lista de medicamentos. En el índice aparecen tanto medicamentos de marca como genéricos. Junto a su medicamento, usted verá el número de página en el que puede encontrar su medicamento.
La tabla siguiente le dice qué significan las abreviaturas de la Lista de medicamentos.
Abreviatura Término Qué significa AL Límite por edad Algunos medicamentos solo están cubiertos para ciertas
edades. F Formulario Estos medicamentos están cubiertos en la Lista de
medicamentos. PA Autorización previa Su médico debe pedir aprobación de Nebraska Total Care
antes de que se cubran algunos medicamentos.
QL Límite de cantidad Algunos medicamentos solo están cubiertos por cierta cantidad.
NP No preferido Estos medicamentos están en el formulario que puede que todavía necesite cumplir con criterios de autorización previa/clase antes de que sean cubiertos.
RX/OTC Recetados y de venta sin receta (OTC)
Estos medicamentos se producen tanto en forma para venta con receta como en forma para venta sin receta (OTC).
ST Terapia escalonada En algunos casos, primero debe probar ciertos medicamentos antes de que Nebraska Total Care cubra otro medicamento para su condición médica.
Por ejemplo, si tanto el medicamento A como el medicamento B tratan su condición médica, puede que Nebraska Total Care no cubra el medicamento B a menos que usted pruebe el medicamento A primero.
¿Qué pasa si mi medicamento no está en la Lista de medicamentos recomendados de Nebraska Total Care?
Si su medicamento no está en la lista de medicamentos, llame a Servicios para los Miembros al 1-844-385-2192 y pregunte si su medicamento está cubierto. Si su medicamento no está cubierto, puede pedir a su médico que recete un medicamento similar que esté cubierto. Si su médico cree que usted debe tener el medicamento que no está cubierto, su médico puede pedirnos que hagamos una excepción.
¿Puedo ir a cualquier farmacia?
Los miembros deben usar farmacias que están en la red. Estas farmacias tienen contrato con Nebraska Total Care. Para encontrar una farmacia, llame a Servicios para los Miembros al 1844-385-2192.
¿Tiene límites mi cobertura de medicamentos?
Algunos medicamentos tienen límites en la cobertura. Si un medicamento tiene límites, se indicará en la columna de requisitos/límites en la Lista de medicamentos.
¿Cómo puedo obtener excepción a las reglas para cobertura de medicamentos?
Su médico puede pedir una excepción a nuestras reglas para cobertura de medicamentos.
• Su médico puede pedirnos que cubramos su medicamento incluso si no está en la lista de medicamentos.
• Su médico puede pedirnos que hagamos una excepción para límites en su medicamento. Por ejemplo, si su medicamento tiene un límite a la cantidad de 1 tableta por día, su médico puede pedirnos que cubramos más.
Para solicitar una excepción, su médico puede enviarnos por fax un formulario de autorización previa al 1-866-399-0929. Una vez que recibamos la solicitud de su médico, normalmente tomamos nuestra decisión dentro de un plazo de un día hábil. Si necesitamos más información, su médico tiene cinco días hábiles para darnos esa información antes de que tomemos nuestra decisión.
¿Qué pasa si soy un miembro nuevo?
Si es miembro nuevo en nuestro plan, puede que usted esté tomando medicamentos que no están en nuestra lista de medicamentos. Puede que también esté tomando un medicamento que está en nuestra lista de medicamentos, pero el medicamento puede tener algunos límites. En estos casos, debe hablar con su médico para ver si debería cambiar a medicamentos que cubrimos. Su médico puede solicitar una excepción así que podríamos cubrir el medicamento que ha estado tomando. Consulte la sección, “¿Cómo obtengo una excepción a las reglas para la cobertura de medicamentos?” para más información.
¿Qué son medicamentos de venta sin receta?
Los medicamentos de venta sin receta (OTC) son medicamentos que puede comprar sin una
receta. La Lista de medicamentos recomendados de Nebraska Total Care cubre medicamentos OTC similares a los que aparecen en la Lista de medicamentos por contrato de Medicaid del Estado de Nebraska. Sin embargo, si quiere que Nebraska Total Care cubra un medicamento OTC de la lista de medicamentos, su médico debe escribir una receta para ese medicamento.
¿Están cubiertos los medicamentos de marca?
Su beneficio de farmacia no cubre medicamentos de marca cuando hay disponibles medicamentos genéricos a menos que el estado requiera el uso de la marca. Los medicamentos de marca pueden estar cubiertos cuando los medicamentos genéricos no están disponibles. Si su médico dice que el medicamento de marca es necesario desde el punto de vista médico o es preferido por el formulario del estado.
¿Qué es un medicamento genérico?
Un medicamento genérico contiene el mismo ingrediente activo y funciona igual al medicamento de marca. Los medicamentos genéricos deben ser seguros y eficaces.
¿Me dará el farmacéutico un medicamento genérico si hay uno disponible?
Sí. Las farmacias le pueden dar un medicamento genérico, a menos que su médico diga que usted debe tomar el medicamento de marca o preferido por el estado.
¿Hay medicamentos excluidos o con excepción?
Medicamentos excluidos
La Lista de medicamentos recomendados de Nebraska Total Care es similar a la Lista de medicamentos por contrato de Medicaid del Estado de Nebraska y no incluye ciertos medicamentos. Los siguientes tipos de medicamentos no están incluidos en la lista de medicamentos porque están excluidos de cobertura:
• Medicamentos que no tienen aprobación de la FDA • Medicamentos experimentales o en investigación • Medicamentos para ayudarla a quedar embarazada • Medicamentos usados para perder peso • Medicamentos cosméticos o para hacer crecer el cabello • Medicamentos usados para tratar los problemas eréctiles • Medicamentos que no están en el formulario de medicamentos de venta sin receta
¿Necesita más información?
Para más información sobre sus beneficios de farmacia, revise su Manual para Miembros o llame a Servicios para los Miembros al 1-844-385-2192.
Nebraska Total Care cumple con las leyes federales de derechos civiles aplicables y no discrimina en base a raza, color, origen nacional, edad, discapacidad o sexo.
Nebraska Total Care no excluye a las personas ni las trata de manera distinta debido a su raza, color, origen nacional, edad, discapacidad o sexo.
Nebraska Total Care:
• Ofrece ayudas y servicios gratuitos a personas con discapacidades para que se comuniquen eficazmente con nosotros, como intérpretes de lenguaje de señas calificados e información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos).
• Ofrece servicios de idiomas gratuitos a personas cuyo idioma principalno es el inglés, como intérpretes calificados e información escrita en otros idiomas
Si necesita estos servicios, llame al Centro de contacto de Nebraska Total Care al
1-844-385-2192, TTY: 1-844-307-0342, Retransmisión 711.
Si cree que Nebraska Total Care no le ha proporcionado estos servicios o lo(a) ha discriminado de otra manera en base a raza, color, origen nacional, edad,discapacidad o sexo, puede presentar una queja llamando al número anterior ydiciéndoles que necesita ayuda para presentar una queja; el Centro de Servicios para los Miembros de Nebraska Total Care está disponible para ayudarle.
Además, puede usar el portal para miembros en nuestro sitio web en:
www.NebraskaTotalCare.com
Dénosla en persona o por correo:
Nebraska Total Care ATTN: Grievances:
2525 North 117th Ave
Omaha NE, 68164
Cuando presente una queja asegúrese de incluir:
• Su primer nombre y apellido • Su número de identificación de Medicaid de Nebraska • Su dirección y número telefónico • Lo que lo tiene descontento • Qué le gustaría que pase
Drug Name DrugTier
Requirements/Limits
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS 1.25MG-1.25MG-1.25MG-1.25MG (Amphetamine-Dextroamphetamine)
F
QL(12 eadaily); AL; Atleast 5 yrs old
ADDERALL TABS 1.875MG-1.875MG-1.875MG-1.875MG (Amphetamine-Dextroamphetamine)
F
QL(8 ea daily);AL; At least 5 yrs old
ADDERALL TABS 2.5MG-2.5MG-2.5MG-2.5MG (Amphetamine-Dextroamphetamine)
F
QL(6 ea daily);AL; At least 5 yrs old
ADDERALL TABS 3.125MG-3.125MG-3.125MG-3.125MG (Amphetamine-Dextroamphetamine)
F
QL(4.8 eadaily); AL; Atleast 5 yrs old
ADDERALL TABS 3.75MG-3.75MG-3.75MG-3.75MG (Amphetamine-Dextroamphetamine)
F
QL(4 ea daily);AL; At least 5 yrs old
ADDERALL TABS 5MG-5MG-5MG-5MG (Amphetamine-Dextroamphetamine)
F
QL(3 ea daily);AL; At least 5 yrs old
ADDERALL TABS 7.5MG-7.5MG-7.5MG-7.5MG (Amphetamine-Dextroamphetamine)
F
QL(2 ea daily);AL; At least 5 yrs old
ADDERALL XR CP24 1.25MG-1.25MG-1.25MG-1.25MG (Amphetamine-Dextroamphetamine)
F
QL(12 eadaily); AL; Atleast 5 yrs old
ADDERALL XR CP24 2.5MG-2.5MG-2.5MG-2.5MG (Amphetamine-Dextroamphetamine)
F
QL(6 ea daily);AL; At least 5 yrs old
ADDERALL XR CP24 3.75MG-3.75MG-3.75MG-3.75MG (Amphetamine-Dextroamphetamine)
F
QL(4 ea daily);AL; At least 5 yrs old
Drug Name DrugTier
Requirements/Limits
ADDERALL XR CP24 5MG-5MG-5MG-5MG (Amphetamine-Dextroamphetamine)
F
QL(3 ea daily);AL; At least 5 yrs old
ADDERALL XR CP24 6.25MG-6.25MG-6.25MG-6.25MG (Amphetamine-Dextroamphetamine)
F
QL(2 ea daily)
ADDERALL XR CP24 7.5MG-7.5MG-7.5MG-7.5MG (Amphetamine-Dextroamphetamine)
F
QL(2 ea daily);AL; At least 5 yrs old
ADZENYS XR-ODT TBED NP AL; At least 6 yrs old amphetamine-dextroamphetamine cp241.25mg-1.25mg-1.25mg-1.25mg
NP
QL(12 eadaily); AL; Atleast 5 yrs old
amphetamine-dextroamphetamine cp242.5mg-2.5mg-2.5mg-2.5mg
NP QL(6 ea daily);AL; At least 5 yrs old
amphetamine-dextroamphetamine cp243.75mg-3.75mg-3.75mg-3.75mg
NP
QL(4 ea daily);AL; At least 5 yrs old
amphetamine-dextroamphetamine cp245mg-5mg-5mg-5mg
NP QL(3 ea daily);AL; At least 5 yrs old
amphetamine-dextroamphetamine cp246.25mg-6.25mg-6.25mg-6.25mg
NP
QL(2 ea daily)
amphetamine-dextroamphetamine cp247.5mg-7.5mg-7.5mg-7.5mg
NP QL(2 ea daily);AL; At least 5 yrs old
amphetamine-dextroamphetamine tabs1.25mg-1.25mg-1.25mg-1.25mg
F
QL(12 eadaily); AL; Atleast 5 yrs old
amphetamine-dextroamphetamine tabs1.875mg-1.875mg-1.875mg-1.875mg
F
QL(8 ea daily);AL; At least 5 yrs old
amphetamine-dextroamphetamine tabs2.5mg-2.5mg-2.5mg-2.5mg
F QL(6 ea daily);AL; At least 5 yrs old
Nebraska Total Care Updated December 1, 2017
1
Drug Name DrugTier
Requirements/Limits
amphetamine-dextroamphetamine tabs3.125mg-3.125mg-3.125mg-3.125mg
F
QL(4.8 eadaily); AL; Atleast 5 yrs old
amphetamine-dextroamphetamine tabs3.75mg-3.75mg-3.75mg-3.75mg
F
QL(4 ea daily);AL; At least 5 yrs old
amphetamine-dextroamphetamine tabs5mg-5mg-5mg-5mg
F QL(3 ea daily);AL; At least 5 yrs old
amphetamine-dextroamphetamine tabs7.5mg-7.5mg-7.5mg-7.5mg
F QL(2 ea daily);AL; At least 5 yrs old
DESOXYN TABS (Methamphetamine HCl) NP
PA; QL(1 eadaily); AL; Atleast 5 yrs old
DEXEDRINE CP24 10 MG (DextroamphetamineSulfate)
NP
PA; QL(6 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old
DEXEDRINE CP24 15 MG (DextroamphetamineSulfate)
NP
PA; QL(4 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old
DEXEDRINE CP24 5 MG (DextroamphetamineSulfate)
NP
PA; QL(12 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old
dextroamphetamine sulfatecp24 10 mg F
PA; QL(6 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old
dextroamphetamine sulfatecp24 15 mg F
PA; QL(4 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old
dextroamphetamine sulfatecp24 5 mg F
PA; QL(12 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old
dextroamphetamine sulfatesoln 5 mg/5ml F
PA; QL(12 mldaily); AL; Atleast 5 yrs old -Up to 18 yrs old
Drug Name DrugTier
Requirements/Limits
dextroamphetamine sulfatetabs 10 mg NP
QL(6 ea daily);AL; At least 5 yrs old - Up to18 yrs old
dextroamphetamine sulfatetabs 5 mg NP
QL(12 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old
EVEKEO TABS NP AL; At least 5 yrs old
methamphetamine hcl tabs F PA; QL(1 eadaily); AL; Atleast 5 yrs old
MYDAYIS CP24 12.5MG-12.5MG-12.5MG-12.5MG, 3.125MG-3.125MG-3.125MG-3.125MG
NP
AL; At least 5 yrs old
MYDAYIS CP24 6.25MG-6.25MG-6.25MG-6.25MG, 9.375MG-9.375MG-9.375MG-9.375MG
NP
PROCENTRA SOLN (DextroamphetamineSulfate)
NP
PA; QL(12 mldaily); AL; Atleast 5 yrs old -Up to 18 yrs old
VYVANSE CAPS 70 MG, 50 MG, 20 MG, 30 MG, 10 MG, 40 MG, 60 MG
F AL; At least 5 yrs old
VYVANSE CHEW 10 MG NP QL(1 ea daily);AL; At least 5 yrs old
VYVANSE CHEW 30 MG, 50 MG, 20 MG, 60 MG, 40 MG
F QL(1 ea daily);AL; At least 5 yrs old
ZENZEDI TABS 15 MG NP
QL(4 ea daily);AL; At least 5 yrs old - Up to18 yrs old
ZENZEDI TABS 2.5 MG NP
QL(24 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old
ZENZEDI TABS 20 MG NP
QL(3 ea daily);AL; At least 5 yrs old - Up to18 yrs old
Nebraska Total Care Updated December 1, 2017
2
Drug Name DrugTier
Requirements/Limits
ZENZEDI TABS 30 MG NP
QL(2 ea daily);AL; At least 5 yrs old - Up to18 yrs old
ZENZEDI TABS 7.5 MG NP
QL(8 ea daily);AL; At least 5 yrs old - Up to18 yrs old
Analeptics CAFCIT SOLN (Caffeine Citrate) NP
caffeine citrate soln F
caffeine tabs F
VIVARIN TABS (Caffeine) NP
Attention-Deficit/Hyperactivity Disorder (ADHD)
atomoxetine hcl caps 25mg, 18 mg, 10 mg, 40 mg NP
QL(2 ea daily);AL; At least 6 yrs old
atomoxetine hcl caps 60mg, 80 mg, 100 mg NP
QL(1 ea daily);AL; At least 6 yrs old
clonidine hcl (adhd) tb12 NP QL(2 ea daily);AL; At least 6 yrs old
guanfacine hcl (adhd) tb24 F PA; QL(1 eadaily); AL; Atleast 6 yrs old
INTUNIV TB24 (Guanfacine HCl (ADHD)) NP
PA; QL(1 eadaily); AL; Atleast 6 yrs old
KAPVAY TB12 (Clonidine HCl (ADHD)) NP
QL(2 ea daily);AL; At least 6 yrs old
STRATTERA CAPS 10 MG, 25 MG, 18 MG, 40 MG (Atomoxetine HCl)
F QL(2 ea daily);AL; At least 6 yrs old
STRATTERA CAPS 100 MG, 60 MG, 80 MG (Atomoxetine HCl)
F QL(1 ea daily);AL; At least 6 yrs old
Stimulants - Misc.
APTENSIO XR CP24 NP QL(1 ea daily);AL; At least 5 yrs old
Drug Name DrugTier
Requirements/Limits
armodafinil tabs NP QL(1 ea daily);AL; At least 18 yrs old
CONCERTA TBCR 18 MG (Methylphenidate HCl) NP PA
CONCERTA TBCR 27 MG, 54 MG (MethylphenidateHCl)
NP PA; QL(1 eadaily); AL; Atleast 5 yrs old
CONCERTA TBCR 36 MG (Methylphenidate HCl) NP
PA; QL(2 eadaily); AL; Atleast 5 yrs old
DAYTRANA PTCH F
PA; QL(1 eadaily); AL; Atleast 5 yrs old -Up to 18 yrs old
dexmethylphenidate hclcp24 10 mg, 25 mg, 30 mg,40 mg, 15 mg, 5 mg, 35mg, 20 mg
NP
QL(1 ea daily);AL; At least 5 yrs old
dexmethylphenidate hcltabs 10 mg NP
QL(5 ea daily);AL; At least 5 yrs old
dexmethylphenidate hcltabs 2.5 mg NP
QL(20 eadaily); AL; Atleast 5 yrs old
dexmethylphenidate hcltabs 5 mg NP
QL(10 eadaily); AL; Atleast 5 yrs old
FOCALIN TABS 10 MG (Dexmethylphenidate HCl) F
QL(5 ea daily);AL; At least 5 yrs old
FOCALIN TABS 2.5 MG (Dexmethylphenidate HCl) F
QL(20 eadaily); AL; Atleast 5 yrs old
FOCALIN TABS 5 MG (Dexmethylphenidate HCl) F
QL(10 eadaily); AL; Atleast 5 yrs old
FOCALIN XR CP24 (Dexmethylphenidate HCl) F
QL(1 ea daily);AL; At least 5 yrs old
METADATE CD CPCR 20 MG, 30 MG, 10 MG (Methylphenidate HCl)
NP PA; QL(1 eadaily)
METADATE CD CPCR 60 MG, 40 MG, 50 MG (Methylphenidate HCl)
NP PA; QL(1 eadaily); AL; Atleast 5 yrs old
METHYLIN CHEW (Methylphenidate HCl) NP
Nebraska Total Care Updated December 1, 2017
3
Drug Name DrugTier
Requirements/Limits
METHYLIN SOLN (Methylphenidate HCl) NP
METHYLPHENIDATE HCL CHEW 10 MG, 5 MG, 2.5 MG
NP
methylphenidate hcl cp2440 mg, 30 mg, 20 mg F PA; QL(1 ea
daily) methylphenidate hcl cpcr30 mg, 20 mg, 10 mg F PA; QL(1 ea
daily)
methylphenidate hcl cpcr40 mg, 60 mg, 50 mg F
PA; QL(1 eadaily); AL; Atleast 5 yrs old
METHYLPHENIDATE HCL ER (LA) CP24 F ST; QL(1 ea
daily) METHYLPHENIDATE HCL ER TB24 18 MG, 54 MG, 36 MG, 27 MG
F PA
METHYLPHENIDATE HCL ER TBCR 18 MG F PA
methylphenidate hcl soln10 mg/5ml, 5 mg/5ml NP
methylphenidate hcl tabs10 mg, 20 mg, 5 mg F
methylphenidate hcl tbcr 10 mg F
QL(2 ea daily);AL; At least 5 yrs old
methylphenidate hcl tbcr 18 mg F PA
methylphenidate hcl tbcr 20 mg F
QL(3 ea daily);AL; At least 5 yrs old
methylphenidate hcl tbcr 27mg, 54 mg F
PA; QL(1 eadaily); AL; Atleast 5 yrs old
methylphenidate hcl tbcr 36 mg F
PA; QL(2 eadaily); AL; Atleast 5 yrs old
modafinil tabs NP QL(2 ea daily);AL; At least 18 yrs old
NUVIGIL TABS (Armodafinil) NP
QL(1 ea daily);AL; At least 18 yrs old
PROVIGIL TABS (Modafinil) NP
QL(2 ea daily);AL; At least 18 yrs old
Drug Name DrugTier
Requirements/Limits
QUILLICHEW ER CHER F AL; At least 5 yrs old
QUILLIVANT XR SUSR F
RITALIN LA CP24 10 MG F PA; QL(1 eadaily)
RITALIN LA CP24 20 MG, 30 MG, 40 MG (Methylphenidate HCl)
NP PA; QL(1 eadaily)
RITALIN LA CP24 60 MG F ST; QL(1 eadaily)
RITALIN TABS (Methylphenidate HCl) NP
ALLERGENIC EXTRACTS/BIOLOGICALS MISC
Allergenic Extracts GRASTEK SUBL F
ORALAIR ADULT SAMPLE KIT SUBL F
ORALAIR ADULT STARTER PACK SUBL F
ORALAIR CHILDREN/ADOLESCENTS STARTER PACK SUBL
F
ORALAIR SUBL F
RAGWITEK SUBL F
ALTERNATIVE MEDICINES
Alternative Medicine - M's melatonin tabs or 5 mg, 10mg, 1 mg, 3 mg F
Alternative Medicine Combinations MELATONIN TABS OR 3MG-10MG F
AMINOGLYCOSIDES - Drugs to Treat BacterialInfections Aminoglycosides BETHKIS NEBU F PA
KITABIS PAK NEBU F
neomycin sulfate tabs F
Nebraska Total Care Updated December 1, 2017
4
Drug Name DrugTier
Requirements/Limits
TOBI NEBU (Tobramycin) NP
TOBI PODHALER CAPS F PA
TOBRAMYCIN NEBU 4
tobramycin nebu 4
tobramycin sulfate soln ij1.2 gm/30ml, 10 mg/ml, 80mg/2ml, 40 mg/ml
F
TOBRAMYCIN SULFATE SOLN IJ 10 MG/ML, 40MG/ML
F
tobramycin sulfate solr ij1.2 gm F
ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditions Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT
F QL(4 ea per fillretail)
HUMIRA PEN PNKT F QL(4 ea per fillretail)
HUMIRA PEN-CROHNS DISEASESTARTER PNKT F QL(4 ea per fill
retail) HUMIRA PEN-PSORIASIS STARTER PNKT F QL(4 ea per fill
retail) HUMIRA PSKT 20 MG/0.4ML, 10 MG/0.2ML F QL(2 ea per fill
retail) HUMIRA PSKT 40 MG/0.8ML F QL(4 ea per fill
retail)
SIMPONI SOAJ NP
SIMPONI SOSY NP
Antirheumatic - Enzyme Inhibitors XELJANZ TABS NP QL(2 ea daily)
XELJANZ XR TB24 NP
Antirheumatic Antimetabolites
OTREXUP SOAJ 7.5 MG/0.4ML F
PA; Limit 4ml permonth;QL(0.1334 ml daily)
Drug Name DrugTier
Requirements/Limits
RHEUMATREX TABS F
Interleukin-1 Blockers ARCALYST SOLR NP
Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET SOSY NP
Interleukin-6 Receptor Inhibitors ACTEMRA SOSY SC 162 MG/0.9ML NP
Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL CAPS (Ibuprofen) NP
ADVIL MIGRAINE CAPS (Ibuprofen) NP
ADVIL TABS (Ibuprofen) NP
ALEVE ARTHRITIS TABS (Naproxen Sodium) NP
ALEVE CAPS (NaproxenSodium) NP
ALEVE TABS (NaproxenSodium) NP
ANAPROX DS TABS (Naproxen Sodium) NP
ARTHROTEC 50 TBEC (Diclofenac w/ Misoprostol) NP
ARTHROTEC 75 TBEC (Diclofenac w/ Misoprostol) NP
CELEBREX CAPS (Celecoxib) NP
celecoxib caps NP
CHILDRENS ADVIL SUSP (Ibuprofen) NP RX/OTC
CHILDRENS MOTRIN SUSP (Ibuprofen) NP RX/OTC
DAYPRO TABS (Oxaprozin) NP
diclofenac potassium tabs NP
diclofenac sodium tb24 or 100 mg F
diclofenac sodium tbec or 25 mg, 50 mg, 75 mg F
Nebraska Total Care Updated December 1, 2017
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Drug Name DrugTier
Requirements/Limits
diclofenac w/ misoprostoltbec NP
DUEXIS TABS NP
EC-NAPROSYN TBEC (Naproxen) NP
etodolac caps NP
etodolac tabs NP
etodolac tb24 NP
FELDENE CAPS (Piroxicam) NP QL(1 ea daily)
FENOPROFEN CALCIUM CAPS 200 MG, 400 MG NP
fenoprofen calcium tabs600 mg NP
FENORTHO CAPS NP
flurbiprofen tabs NP
ibuprofen caps 200 mg NP
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 600 mg, 800mg, 100 mg, 400 mg, 200 mg
F
INDOCIN SUPP NP
INDOCIN SUSP NP
indomethacin caps 50 mg,25 mg F
indomethacin cpcr 75 mg NP
INFANTS ADVIL SUSP (Ibuprofen) NP
ketoprofen caps NP
KETOPROFEN ER CP24 NP
Drug Name DrugTier
Requirements/Limits
ketorolac tromethamine tabs or 10 mg F QL(4 ea daily,5
day(s) limit)
LODINE TABS (Etodolac) NP
MECLOFENAMATE SODIUM CAPS NP
mefenamic acid caps NP
MELOXICAM SUSP 7.5 MG/5ML F PA; AL; Up to
11 yrs old meloxicam tabs 7.5 mg, 15 mg F
MOBIC SUSP 7.5 MG/5ML F PA; AL; Up to11 yrs old
MOBIC TABS 7.5 MG, 15 MG (Meloxicam) NP
MOTRIN INFANTS DROPS SUSP (Ibuprofen) NP
nabumetone tabs F
NALFON CAPS NP
NAPRELAN TB24 375 MG, 500 MG (NaproxenSodium)
NP
NAPRELAN TB24 750 MG NP
NAPROSYN SUSP (Naproxen) NP
NAPROSYN TABS (Naproxen) NP
naproxen sodium caps 220 mg F
naproxen sodium tabs 220 mg 4
naproxen sodium tabs 220 mg F
naproxen sodium tabs 550mg, 275 mg NP
naproxen sodium tb24 500mg, 375 mg NP
NAPROXEN SUSP 125 MG/5ML F
naproxen susp 125 mg/5ml F
naproxen tabs 250 mg, 500mg, 375 mg F
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Drug Name DrugTier
Requirements/Limits
naproxen tbec 375 mg NP
naproxen tbec 500 mg F
naproxen tbec 500 mg 4
oxaprozin tabs NP
piroxicam caps NP QL(1 ea daily)
PONSTEL CAPS (Mefenamic Acid) NP
SPRIX SOLN NP
sulindac tabs F
TIVORBEX CAPS NP
TOLMETIN SODIUM CAPS 400 MG NP
tolmetin sodium caps 400 mg NP
TOLMETIN SODIUM TABS 200 MG, 600 MG NP
VIMOVO TBEC NP
VIVLODEX CAPS NP QL(1 ea daily)
ZIPSOR CAPS NP
ZORVOLEX CAPS NP
Phosphodiesterase 4 (PDE4) Inhibitors OTEZLA TABS NP QL(2 ea daily)
OTEZLA TBPK NP
Pyrimidine Synthesis Inhibitors ARAVA TABS (Leflunomide) NP
leflunomide tabs F
Selective Costimulation Modulators ORENCIA CLICKJECT SOAJ NP
Drug Name DrugTier
Requirements/Limits
ORENCIA SOSY SC 125 MG/ML, 50 MG/0.4ML,87.5 MG/0.7ML
NP
Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT NP
ENBREL SOLR 25 MG F QL(8 ea per fillretail)
ENBREL SOSY 25 MG/0.5ML F QL(4.08 ml per
fill retail)
ENBREL SOSY 50 MG/ML F QL(7.84 ml perfill retail)
ENBREL SURECLICK SOAJ F QL(7.84 ml per
fill retail) ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions Analgesic Combinations aspirin-acetaminophen-caffeine tabs F
butalbital-acetaminophentabs 325mg-50mg F
butalbital-acetaminophen-caffeine caps 325mg-50mg-40mg
F
butalbital-acetaminophen-caffeine tabs 325mg-50mg-40mg
F
butalbital-aspirin-caffeine caps F
BUTALBITAL/ASPIRIN/CAFFEINE TABS F QL(4 ea daily)
ESGIC TABS (Butalbital-Acetaminophen-Caffeine) NP
EXCEDRIN EXTRA STRENGTH TABS (Aspirin-Acetaminophen-Caffeine)
NP
EXCEDRIN MENSTRUAL COMPLETE TABS (Aspirin-Acetaminophen-Caffeine)
NP
EXCEDRIN MIGRAINE TABS (Aspirin-Acetaminophen-Caffeine)
NP
FIORINAL CAPS (Butalbital-Aspirin-Caffeine) NP
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Drug Name DrugTier
Requirements/Limits
TENCON TABS F
Analgesics Other acetaminophen caps or500 mg F
acetaminophen chew or 80 mg F
acetaminophen liqd or 160mg/5ml, 1000 mg/30ml,500 mg/15ml
F
acetaminophen soln or 650mg/20.3ml, 160 mg/5ml,325 mg/10.15ml
F
acetaminophen supp re120 mg, 650 mg, 325 mg F QL(0.4 ea
daily) acetaminophen susp or160 mg/5ml, 80 mg/0.8ml,80 mg/2.5ml
F
acetaminophen tabs or 325mg, 500 mg F
acetaminophen tbcr or 650 mg F
acetaminophen tbdp or 80mg, 160 mg F
FEVERALL INFANTS SUPP F
TRIAMINIC FEVER REDUCERPAIN RELIEVER CHILDRENS SYRP
F
TRIAMINIC FEVER REDUCERPAIN RELIEVER INFANTS SYRP
F
TYLENOL 8 HOUR ARTHRITISPAIN TBCR (Acetaminophen)
NP
TYLENOL 8 HOUR TBCR (Acetaminophen) NP
TYLENOL CHILDRENS SUSP (Acetaminophen) NP
TYLENOL EXTRA STRENGTH TABS (Acetaminophen)
NP
TYLENOL INFANTS PAIN+FEVER SUSP (Acetaminophen)
NP
Drug Name DrugTier
Requirements/Limits
TYLENOL INFANTS SUSP (Acetaminophen) NP
TYLENOL SORE THROAT DAYTIME LIQD (Acetaminophen)
NP
TYLENOL TABS (Acetaminophen) NP
Salicylates aspirin buffered (cal carb-mag carb-mag oxide) tabs F
aspirin chew or 81 mg F
ASPIRIN LOW DOSE TABS F
aspirin supp re 300 mg F QL(0.4 eadaily)
aspirin supp re 600 mg F
aspirin tabs or 325 mg F
aspirin tbec or 325 mg, 81mg, 324 mg F
BUFFERIN TABS (AspirinBuffered (Cal Carb-MagCarb-Mag Oxide))
NP
diflunisal tabs NP
ECOTRIN REGULAR STRENGTH TBEC (Aspirin)
NP
ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint Conditions Opioid Agonists ABSTRAL SUBL NP
ACTIQ LPOP (FentanylCitrate) NP
ARYMO ER TBEA 30 MG, 15 MG NP QL(3 ea daily)
ARYMO ER TBEA 60 MG NP QL(2 ea daily)
CODEINE SULFATE TABS 15 MG (Codeine Sulfate) NP
QL(5 ea daily);AL; At least 12 yrs old
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Drug Name DrugTier
Requirements/Limits
CODEINE SULFATE TABS 30 MG, 60 MG (Codeine Sulfate)
F QL(5 ea daily);AL; At least 12 yrs old
codeine sulfate tabs 60 mg,15 mg, 30 mg F
QL(5 ea daily);AL; At least 12 yrs old
CONZIP CP24 NP AL; At least 18 yrs old DEMEROL TABS OR 50 MG, 100 MG (MeperidineHCl)
NP QL(5 ea daily)
DILAUDID LIQD OR 1 MG/ML (HydromorphoneHCl)
NP
DILAUDID TABS OR 2 MG, 8 MG, 4 MG (Hydromorphone HCl)
NP QL(5 ea daily)
DOLOPHINE TABS (Methadone HCl) NP
DURAGESIC PT72 12 MCG/HR (Fentanyl) NP PA; QL(0.5 eadaily) DURAGESIC PT72 75 MCG/HR, 25 MCG/HR, 50MCG/HR, 100 MCG/HR(Fentanyl)
NP
QL(0.5 eadaily)
EMBEDA CPCR NP QL(2 ea daily)
EXALGO T24A 12 MG, 8 MG, 16 MG (Hydromorphone HCl)
NP QL(1 ea daily)
EXALGO T24A 32 MG (Hydromorphone HCl) NP QL(2 ea daily)
fentanyl citrate lpop bu1200 mcg, 800 mcg, 600mcg, 1600 mcg, 200 mcg,400 mcg
NP
fentanyl pt72 12 mcg/hr F PA; QL(0.5 eadaily)
fentanyl pt72 25 mcg/hr,100 mcg/hr, 75 mcg/hr, 50mcg/hr
F QL(0.5 eadaily)
FENTANYL PT72 87.5 MCG/HR, 62.5 MCG/HR,37.5 MCG/HR
NP QL(0.5 eadaily)
FENTORA TABS NP
Drug Name DrugTier
Requirements/Limits
hydromorphone hcl liqd or1 mg/ml NP
HYDROMORPHONE HCL SUPP RE 3 MG NP
hydromorphone hcl t24a or12 mg, 8 mg, 16 mg, 8mg NP QL(1 ea daily)
hydromorphone hcl t24a or32 mg NP QL(2 ea daily)
hydromorphone hcl tabs or4 mg, 2 mg, 8 mg F QL(5 ea daily)
HYSINGLA ER T24A F QL(1 ea daily)
KADIAN CP24 100 MG, 80 MG, 20 MG, 30 MG, 10 MG, 60 MG, 50 MG (Morphine Sulfate)
NP
QL(4 ea daily)
KADIAN CP24 40 MG, 200 MG NP QL(4 ea daily)
LAZANDA SOLN NP
LEVORPHANOL TARTRATE TABS NP QL(5 ea daily)
MEPERIDINE HCL SOLN OR 50 MG/5ML NP
meperidine hcl tabs or 50mg, 100 mg NP QL(5 ea daily)
methadone hcl conc or 10 mg/ml NP
METHADONE HCL SOLN OR 10 MG/5ML, 5 MG/5ML(Methadone HCl)
NP
methadone hcl soln or 5 mg/5ml, 10 mg/5ml NP
methadone hcl tabs or 10 mg, 5 mg NP
methadone hcl tbso or 40 mg NP
QL(6 eadaily,180day(s) limit)
METHADOSE CONC (Methadone HCl) NP
METHADOSE SUGAR-FREE CONC (Methadone HCl)
NP
morphine sulfate cp24 or30 mg, 60 mg, 50 mg, 10mg, 20 mg, 80 mg, 100 mg
NP QL(4 ea daily)
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Drug Name DrugTier
Requirements/Limits
MORPHINE SULFATE ER CP24 NP QL(1 ea daily)
morphine sulfate soln or 10mg/5ml, 20 mg/5ml, 100mg/5ml, 20 mg/ml
F PA
MORPHINE SULFATE SUPP RE 20 MG, 10 MG, 30 MG, 5 MG
NP
MORPHINE SULFATE TABS OR 30 MG, 15 MG F QL(5 ea daily)
morphine sulfate tbcr or200 mg, 60 mg, 15 mg, 30mg, 100 mg
F
MS CONTIN TBCR (Morphine Sulfate) NP
NUCYNTA ER TB12 NP
NUCYNTA TABS NP QL(5 ea daily)
OPANA ER (CRUSH RESISTANT) T12A NP QL(3 ea daily)
OPANA TABS OR 10 MG, 5 MG (Oxymorphone HCl) NP QL(5 ea daily)
OXAYDO TABA NP
oxycodone hcl caps 5 mg NP QL(5 ea daily)
oxycodone hcl conc 100mg/5ml F
oxycodone hcl conc 100mg/5ml 4
OXYCODONE HCL ER T12A 30 MG, 60 MG, 10 MG, 20 MG, 15 MG, 40 MG
4 QL(3 ea daily)
OXYCODONE HCL ER T12A 80 MG 4 QL(4 ea daily)
oxycodone hcl soln 5mg/5ml F
oxycodone hcl tabs 30 mg 4 QL(5 ea daily)
oxycodone hcl tabs 30 mg,10 mg, 20 mg, 5 mg, 15 mg F QL(5 ea daily)
OXYCONTIN T12A 15 MG, 10 MG, 60 MG, 20 MG, 40 MG, 30 MG
F QL(3 ea daily)
OXYCONTIN T12A 80 MG F QL(4 ea daily)
Drug Name DrugTier
Requirements/Limits
oxymorphone hcl tabs 5mg, 10 mg NP QL(5 ea daily)
oxymorphone hcl tb12 10mg, 20 mg, 7.5 mg, 15 mg,40 mg, 30 mg, 5 mg
NP QL(3 ea daily)
OXYMORPHONE HYDROCHLORIDE ER TB12
NP QL(3 ea daily)
ROXICODONE TABS (Oxycodone HCl) NP QL(5 ea daily)
SUBSYS LIQD NP
TRAMADOL HCL ER CP24 300 MG, 200 MG, 100 MG NP AL; At least 18 yrs old
tramadol hcl tabs 50 mg F QL(8 ea daily);AL; At least 17 yrs old
tramadol hcl tb24 100 mg,300 mg, 200 mg NP AL; At least 16 yrs old tramadol hcl tb24 200 mg,300 mg, 100 mg NP AL; At least 18 yrs old ULTRAM ER TB24 (Tramadol HCl) NP AL; At least 18 yrs old
ULTRAM TABS (Tramadol HCl) NP
QL(8 ea daily);AL; At least 17 yrs old
XTAMPZA ER C12A 13.5 MG, 9 MG, 18 MG, 27 MG NP
QL(3 ea daily);AL; At least 18 yrs old
XTAMPZA ER C12A 36 MG NP
QL(8 ea daily);AL; At least 18 yrs old
ZOHYDRO ER C12A NP
Opioid Combinations acetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml F AL; At least 12
yrs old acetaminophen w/ codeinetabs 300mg-30mg, 300mg-60mg, 300mg-15mg
F QL(5 ea daily);AL; At least 12 yrs old
ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINECAPS
NP QL(5 ea daily);AL; At least 12 yrs old
ASPIRIN-CAFFEINE-DIHYDROCODEINE CAPS NP
QL(5 ea daily);AL; At least 12 yrs old
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Drug Name DrugTier
Requirements/Limits
butalbital-acetaminophen-caffeine w/ codeine caps325mg-50mg-40mg-30mg
F
butalbital-aspirin-caffeinew/cod caps F
CAPITAL/CODEINE SUSP NP AL; At least 12 yrs old FIORINAL/CODEINE #3CAPS (Butalbital-Aspirin-Caffeine w/Cod)
NP
hydrocodone-acetaminophen soln10mg/15ml-325mg/15ml
NP
hydrocodone-acetaminophen tabs 5mg-325mg, 7.5mg-300mg,7.5mg-325mg, 2.5mg-325mg, 10mg-325mg,10mg-300mg, 5mg-300mg
F
QL(5 ea daily)
hydrocodone-ibuprofentabs 200mg-5mg, 200mg-10mg
4 QL(5 ea daily)
hydrocodone-ibuprofentabs 200mg-7.5mg,200mg-10mg, 200mg-5mg
F QL(5 ea daily)
IBUDONE TABS (Hydrocodone-Ibuprofen) NP QL(5 ea daily)
LORTAB ELIX NP
NORCO TABS (Hydrocodone-Acetaminophen)
NP QL(5 ea daily)
oxycodone w/acetaminophen tabs F QL(5 ea daily)
oxycodone-aspirin tabs NP QL(5 ea daily)
OXYCODONE/ACETAMINOPHEN SOLN NP
OXYCODONE/IBUPROFEN TABS NP QL(5 ea daily)
PERCOCET TABS (Oxycodone w/Acetaminophen)
NP QL(5 ea daily)
PRIMLEV TABS NP QL(5 ea daily)
REPREXAIN TABS (Hydrocodone-Ibuprofen) NP QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
SYNALGOS-DC CAPS NP QL(5 ea daily);AL; At least 12 yrs old
tramadol-acetaminophentabs NP
QL(5 ea daily);AL; At least 12 yrs old
TREZIX CAPS NP QL(5 ea daily);AL; At least 12 yrs old
TYLENOL/CODEINE #3TABS (Acetaminophen w/Codeine)
NP QL(5 ea daily);AL; At least 12 yrs old
TYLENOL/CODEINE #4TABS (Acetaminophen w/Codeine)
NP QL(5 ea daily);AL; At least 12 yrs old
ULTRACET TABS (Tramadol-Acetaminophen) NP
QL(5 ea daily);AL; At least 12 yrs old
VICOPROFEN TABS (Hydrocodone-Ibuprofen) NP QL(5 ea daily)
XARTEMIS XR TBCR NP QL(4 ea daily)
XODOL TABS (Hydrocodone-Acetaminophen)
NP QL(5 ea daily)
ZAMICET SOLN NP
Opioid Partial Agonists
BELBUCA FILM NP QL(2 ea daily);AL; At least 18 yrs old
BUNAVAIL FILM 2.1MG-0.3MG NP
QL(1 ea daily);AL; At least 16 yrs old
BUNAVAIL FILM 6.3MG-1MG, 4.2MG-0.7MG NP
QL(2 ea daily);AL; At least 16 yrs old
buprenorphine hcl subl NP QL(3 ea daily);AL; At least 16 yrs old
buprenorphine hcl-naloxone hcl dihydrate subl NP
BUPRENORPHINE PTWK 10 MCG/HR 4
4 per 28days;QL(4 eaper 28 daysretail)
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Drug Name DrugTier
Requirements/Limits
BUPRENORPHINE PTWK 15 MCG/HR, 10 MCG/HR 4
Limit 4 per 28days;QL(4 eaper 28 daysretail)
BUPRENORPHINE PTWK 5 MCG/HR 4
Limit 4 per 28days;QL(0.143ea daily)
BUPRENORPHINE PTWK 7.5 MCG/HR 4 QL(0.143 ea
daily) butorphanol tartrate soln na10 mg/ml NP QL(0.334 mldaily)
BUTRANS PTWK 15 MCG/HR, 10 MCG/HR, 20MCG/HR
F
Limit 4 per 28days;QL(4 eaper 28 daysretail)
BUTRANS PTWK 5 MCG/HR F
Limit 4 per 28days;QL(0.143ea daily)
BUTRANS PTWK 7.5 MCG/HR F QL(0.143 ea
daily) pentazocine w/ naloxonetabs NP QL(5 ea daily)
SUBOXONE FILM 12MG-3MG, 4MG-1MG F
QL(2 ea daily);AL; At least 16 yrs old
SUBOXONE FILM 8MG-2MG, 2MG-0.5MG F
QL(3 ea daily);AL; At least 16 yrs old
ZUBSOLV SUBL 11.4MG-2.9MG, 0.7MG-0.18MG NP
QL(1 ea daily);AL; At least 16 yrs old
ZUBSOLV SUBL 2.9MG-0.71MG, 8.6MG-2.1MG NP
QL(2 ea daily);AL; At least 16 yrs old
ZUBSOLV SUBL 5.7MG-1.4MG, 1.4MG-0.36MG NP
QL(3 ea daily);AL; At least 16 yrs old
ANDROGENS-ANABOLIC - Drugs to RegulateHormones Androgens ANDRODERM PT24 NP
ANDROGEL GEL 20.25 MG/1.25GM, 40.5MG/2.5GM
F
Drug Name DrugTier
Requirements/Limits
ANDROGEL GEL 50 MG/5GM, 25 MG/2.5GM(Testosterone)
F
ANDROGEL PUMP GEL F
AXIRON SOLN (Testosterone) NP
DEPO-TESTOSTERONE SOLN (Testosterone Cypionate)
NP
FORTESTA GEL NP
NATESTO GEL NP
TESTIM GEL (Testosterone) NP
TESTONE CIK KIT F
testosterone cypionate soln F
TESTOSTERONE GEL TD 1 %, 25 MG/2.5GM, 50MG/5GM
4
TESTOSTERONE GEL TD 10 MG/ACT NP
testosterone gel td 25mg/2.5gm, 1 %, 50 mg/5gm 4
testosterone gel td 25mg/2.5gm, 50 mg/5gm 4 PA
TESTOSTERONE PUMP GEL 4
testosterone soln td 30 mg/act NP
VOGELXO GEL 4
VOGELXO PUMP GEL 4
ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Hydrocortisone(Intrarectal))
NP
hydrocortisone (intrarectal) enem F
UCERIS FOAM NP
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Drug Name DrugTier
Requirements/Limits
Rectal Combinations ANALPRAM-HC LOTN 1%-2.5% F
phenylephrine in hard fat supp F
phenylephrine-cocoa buttersupp 88.44%-0.25% F
phenylephrine-mineral oil-petrolatum oint 14%-74.9%-0.25%
F
phenylephrine-shark liveroil-cocoa butter supp F
phenylephrine-shark liveroil-mineral oil-petrolatumoint
F
phenylephrine-witch hazelgel F
pramoxine-phenylephrine-glycerin-petrolatum crea F
PREPARATION H CREA (Pramoxine-Phenylephrine-Glycerin-Petrolatum)
NP
PREPARATION H GEL (Phenylephrine-WitchHazel)
NP
PREPARATION H OINT (Phenylephrine-Mineral Oil-Petrolatum)
NP
PREPARATION H TOTABLES BURN RELIEF GEL (Phenylephrine-WitchHazel)
NP
PREPARATION H TOTABLES PAIN RELIEF CREA (Pramoxine-Phenylephrine-Glycerin-Petrolatum)
NP
Rectal Local Anesthetics dibucaine (rectal) oint F
NUPERCAINAL OINT (Dibucaine (Rectal)) NP
pramoxine hcl (rectal) foam F
PROCTOFOAM FOAM (Pramoxine HCl (Rectal)) NP
Drug Name DrugTier
Requirements/Limits
Rectal Steroids ANUSOL-HC CREA (Hydrocortisone (Rectal)) F
hydrocortisone (rectal) crea F
PROCTOCORT CREA (Hydrocortisone (Rectal)) NP
ANTACIDS - Ulcer and Stomach Acid Drugs
Antacid Combinations alum & mag hydrox-simethicone liqd200mg/5ml-20mg/5ml-200mg/5ml
F
QL(24 ml daily)
alum & mag hydrox-simethicone liqd400mg/5ml-40mg/5ml-400mg/5ml
F
alum & mag hydrox-simethicone susp200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml,200mg/5ml-20mg/5ml-200mg/5ml
F
QL(24 ml daily)
alum & mag hydrox-simethicone susp400mg/5ml-400mg/5ml-40mg/5ml-40mg/5ml-400mg/5ml-400mg/5ml,400mg/5ml-40mg/5ml-400mg/5ml
F
HYVEE ADVANCED ANTACID MAXIMUM STRENGTH SUSP (Alum & Mag Hydrox-Simethicone)
NP
Antacids - Calcium Salts calcium carbonate (antacid)chew 500 mg F
calcium carbonate (antacid)tabs 648 mg F
CALCIUM CARBONATE TABS 648 MG F
TUMS CHEW (Calcium Carbonate (Antacid)) NP
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Drug Name DrugTier
Requirements/Limits
TUMS LASTING EFFECTS CHEW (Calcium Carbonate (Antacid))
NP
Antacids - Magnesium Salts magnesium oxide tabs 400 mg F
ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial Infections Anti-infective Agents - Misc. CAYSTON SOLR NP
FLAGYL CAPS (Metronidazole) NP
FLAGYL TABS (Metronidazole) NP
metronidazole caps 375 mg NP
metronidazole tabs 500 mg, 250 mg F
TINDAMAX TABS (Tinidazole) NP
tinidazole tabs NP
VANCOCIN HCL CAPS (Vancomycin HCl) NP
vancomycin hcl caps or250 mg, 125 mg NP
vancomycin hcl solr iv 1000 mg F QL(2 ea daily)
vancomycin hcl solr iv 500 mg F QL(4 ea daily)
XIFAXAN TABS NP
Anti-infective Misc. - Combinations BACTRIM DS TABS (Sulfamethoxazole-Trimethoprim)
NP
BACTRIM TABS (Sulfamethoxazole-Trimethoprim)
NP
sulfamethoxazole-trimethoprim susp or40mg/5ml-200mg/5ml
F
Drug Name DrugTier
Requirements/Limits
sulfamethoxazole-trimethoprim tabs or160mg-800mg, 80mg-400mg
F
Antiprotozoal Agents ALINIA SUSR 100 MG/5ML NP QL(50 ml daily)
ALINIA TABS 500 MG NP QL(2 ea daily,6ea per fill retail) Ketolides KETEK TABS NP
Leprostatics dapsone tabs F
Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG (ClindamycinHCl)
NP
CLEOCIN PEDIATRIC GRANULES SOLR (Clindamycin PalmitateHydrochloride)
NP
clindamycin hcl caps 300mg, 150 mg F
clindamycin palmitatehydrochloride solr F
Oxazolidinones
SIVEXTRO TABS OR F PA; QL(6 eaper fill retail)
ANTIANGINAL AGENTS - Drugs to Treat ChestPain Nitrates DILATRATE SR CPCR NP
GONITRO PACK NP
ISORDIL TITRADOSE TABS 40 MG NP
ISORDIL TITRADOSE TABS 5 MG (Isosorbide Dinitrate)
NP
ISOSORBIDE DINITRATE ER TBCR F
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Drug Name DrugTier
Requirements/Limits
isosorbide dinitrate tabs F
isosorbide mononitrate tabs F
isosorbide mononitrate tb24 F
NITRO-BID OINT NP
NITRO-DUR PT24 0.2 MG/HR, 0.4 MG/HR, 0.1MG/HR, 0.6 MG/HR(Nitroglycerin)
NP
NITRO-DUR PT24 0.3 MG/HR, 0.8 MG/HR NP
nitroglycerin cpcr or 9 mg,2.5 mg, 6.5 mg F
NITROGLYCERIN LINGUAL AERS NP
nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr
F
nitroglycerin soln tl 0.4mg/spray NP
nitroglycerin subl sl 0.4 mg,0.6 mg, 0.3 mg F
NITROLINGUAL PUMPSPRAY SOLN (Nitroglycerin)
NP
NITROMIST AERS NP
NITROSTAT SUBL (Nitroglycerin) F
ANTIANXIETY AGENTS - Drugs to Treat Anxiety
Antianxiety Agents - Misc. buspirone hcl tabs F
HYDROXYZINE HCL SOLN IM 25 MG/ML F
hydroxyzine hcl syrp or 10mg/5ml F
hydroxyzine hcl tabs or 25mg, 50 mg, 10 mg F
HYDROXYZINE PAMOATE CAPS 100 MG F
hydroxyzine pamoate caps50 mg, 25 mg F
Drug Name DrugTier
Requirements/Limits
meprobamate tabs NP
VISTARIL CAPS (Hydroxyzine Pamoate) NP
Benzodiazepines ALPRAZOLAM INTENSOL CONC NP
alprazolam tabs 0.5 mg, 1mg, 2 mg, 0.25 mg F
alprazolam tb24 2 mg, 0.5mg, 1 mg, 3 mg NP
alprazolam tbdp 0.5 mg, 2mg, 1 mg, 0.25 mg NP
ATIVAN SOLN IJ 2 MG/ML(Lorazepam) NP
ATIVAN TABS OR 0.5 MG, 1 MG, 2 MG (Lorazepam) NP
chlordiazepoxide hcl caps F
clorazepate dipotassiumtabs NP
diazepam conc or 5 mg/ml NP
DIAZEPAM SOLN OR 1 MG/ML F
diazepam tabs or 2 mg, 5mg, 10 mg F
lorazepam conc or 2 mg/ml F
lorazepam soln ij 2 mg/ml,20 mg/10ml F
lorazepam tabs or 2 mg, 1mg, 0.5 mg F
oxazepam caps NP
TRANXENE T TABS (Clorazepate Dipotassium) NP
VALIUM TABS (Diazepam) NP
XANAX TABS (Alprazolam) NP
XANAX XR TB24 (Alprazolam) NP
ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms Antiarrhythmics Type I-A
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Drug Name DrugTier
Requirements/Limits
disopyramide phosphate caps F
NORPACE CAPS (Disopyramide Phosphate) NP
NORPACE CR CP12 150 MG F
quinidine gluconate tbcr or324 mg F
QUINIDINE SULFATE ER TBCR F
QUINIDINE SULFATE TABS OR 200 MG, 300 MG
F
Antiarrhythmics Type I-B mexiletine hcl caps F
Antiarrhythmics Type I-C flecainide acetate tabs F
propafenone hcl tabs 225mg, 300 mg, 150 mg F
RYTHMOL TABS (Propafenone HCl) NP
Antiarrhythmics Type III amiodarone hcl tabs or 200 mg F
CORDARONE TABS (Amiodarone HCl) NP
dofetilide caps F
TIKOSYN CAPS (Dofetilide) NP
ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu F
Bronchodilators - Anticholinergics ATROVENT HFA AERS F
INCRUSE ELLIPTA AEPB NP
ipratropium bromide soln F
Drug Name DrugTier
Requirements/Limits
SEEBRI NEOHALER CAPS NP
SPIRIVA HANDIHALER CAPS F
SPIRIVA RESPIMAT AERS NP
TUDORZA PRESSAIR AEPB NP
Leukotriene Modulators ACCOLATE TABS (Zafirlukast) NP
montelukast sodium chew 4 mg F
QL(1 ea daily);AL; Up to 11yrs old
montelukast sodium chew 5 mg F
QL(1 ea daily);AL; Up to 14yrs old
montelukast sodium pack 4 mg NP
QL(1 ea daily);AL; Up to 11yrs old
montelukast sodium tabs 10 mg F QL(1 ea daily)
SINGULAIR CHEW 4 MG (Montelukast Sodium) NP
QL(1 ea daily);AL; Up to 11yrs old
SINGULAIR CHEW 5 MG (Montelukast Sodium) NP
QL(1 ea daily);AL; Up to 14yrs old
SINGULAIR PACK 4 MG (Montelukast Sodium) NP
QL(1 ea daily);AL; Up to 11yrs old
SINGULAIR TABS 10 MG (Montelukast Sodium) NP QL(1 ea daily)
zafirlukast tabs NP
zileuton tb12 NP
ZYFLO CR TB12 (Zileuton) NP
ZYFLO TABS NP
Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TABS NP
Steroid Inhalants
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Drug Name DrugTier
Requirements/Limits
AEROSPAN AERS NP
ALVESCO AERS NP AL; At least 12 yrs old ARMONAIR RESPICLICK 113 AEPB NP AL; At least 12 yrs old ARMONAIR RESPICLICK 232 AEPB NP AL; At least 12 yrs old ARMONAIR RESPICLICK 55 AEPB NP AL; At least 12 yrs old
ARNUITY ELLIPTA AEPB NP
ASMANEX HFA AERO NP QL(3 gm per fillretail); AL; Atleast 12 yrs old
ASMANEX TWISTHALER 120 METERED DOSES AEPB
F QL(3 ea per fillretail)
ASMANEX TWISTHALER 14 METERED DOSES AEPB
F QL(3 ea per fillretail)
ASMANEX TWISTHALER 30 METERED DOSES AEPB 110 MCG/INH
F QL(3 ea per fillretail); AL; Upto 11 yrs old
ASMANEX TWISTHALER 30 METERED DOSES AEPB 220 MCG/INH
F QL(3 ea per fillretail)
ASMANEX TWISTHALER 60 METERED DOSES AEPB
F QL(3 ea per fillretail)
ASMANEX TWISTHALER 7 METERED DOSES AEPB
F QL(3 ea per fillretail); AL; Upto 11 yrs old
budesonide (inhalation) susp F AL; Up to 8 yrs
old
FLOVENT DISKUS AEPB NP
FLOVENT HFA AERO NP
PULMICORT FLEXHALER AEPB NP
PULMICORT SUSP (Budesonide (Inhalation)) NP AL; Up to 8 yrsold
QVAR AERS F
Sympathomimetics
Drug Name DrugTier
Requirements/Limits
ADVAIR DISKUS AEPB F QL(2 ea daily)
ADVAIR HFA AERO NP
Limit 1 inhaler per month;QL(1gm per fillretail,1 gm per30 days retail)
AIRDUO RESPICLICK 113/14 AEPB NP AL; At least 12 yrs old AIRDUO RESPICLICK 232/14 AEPB NP AL; At least 12 yrs old albuterol sulfate nebu in 0.5 %, 0.083 % F
albuterol sulfate nebu in 1.25 mg/3ml, 0.63 mg/3ml NP
albuterol sulfate syrp or 2mg/5ml F
albuterol sulfate tabs or 4 mg, 2 mg NP
albuterol sulfate tb12 or 4 mg, 8 mg F
ANORO ELLIPTA AEPB NP
ARCAPTA NEOHALER CAPS F ST
BEVESPI AEROSPHERE AERO NP
BREO ELLIPTA AEPB NP
BROVANA NEBU NP
COMBIVENT RESPIMAT AERS F
DULERA AERO F
FLUTICASONE PROPIONATE/SALMETEROL AEPB
NP AL; At least 12 yrs old
FORADIL AEROLIZER CAPS F
ipratropium-albuterol soln F
levalbuterol hcl nebu NP
LEVALBUTEROL TARTRATE HFA AERO NP
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Drug Name DrugTier
Requirements/Limits
METAPROTERENOL SULFATE SYRP NP
METAPROTERENOL SULFATE TABS NP
PERFOROMIST NEBU NP
PROAIR HFA AERS F QL(1 gm per fillretail,2 gm per30 days retail)
PROAIR RESPICLICK AEPB NP
QL(1 ea per fillretail,2 ea per30 days retail)
PROVENTIL HFA AERS F QL(1 gm per fillretail,2 gm per30 days retail)
SEREVENT DISKUS AEPB F ST
STIOLTO RESPIMAT AERS NP
STRIVERDI RESPIMAT AERS NP
SYMBICORT AERO F
terbutaline sulfate tabs or 5 mg, 2.5 mg F
TRELEGY ELLIPTA AEPB NP
QL(28 ea per14 days retail);AL; At least 18 yrs old
UTIBRON NEOHALER CAPS NP
VENTOLIN HFA AERS 4
QL(18 gm perfill retail,36 gmper 30 daysretail)
VENTOLIN HFA AERS 4 QL(8 gm per fillretail,16 gm per30 days retail)
VOSPIRE ER TB12 (Albuterol Sulfate) NP
XOPENEX CONCENTRATE NEBU (Levalbuterol HCl)
NP
XOPENEX HFA AERO NP
XOPENEX NEBU (Levalbuterol HCl) NP
Drug Name DrugTier
Requirements/Limits
Xanthines ELIXOPHYLLIN ELIX F
THEO-24 CP24 F
theophylline soln F
theophylline tb12 F
theophylline tb24 F
ANTICOAGULANTS - Blood Thinners
Coumarin Anticoagulants COUMADIN TABS (Warfarin Sodium) NP
warfarin sodium tabs F
Direct Factor Xa Inhibitors ELIQUIS TABS F
SAVAYSA TABS NP QL(1 ea daily)
XARELTO STARTER PACK TBPK F
XARELTO TABS 10 MG F QL(35 ea perfill retail)
XARELTO TABS 15 MG F QL(2 ea daily)
XARELTO TABS 20 MG F QL(1 ea daily)
Heparins And Heparinoid-Like Agents ARIXTRA SOLN (Fondaparinux Sodium) NP
enoxaparin sodium soln ij300 mg/3ml F QL(15 ml per
fill retail) enoxaparin sodium soln sc100 mg/ml, 150 mg/ml F QL(30 ml per
fill retail) enoxaparin sodium soln sc120 mg/0.8ml, 40 mg/0.4ml F QL(24 ml per
fill retail) enoxaparin sodium soln sc30 mg/0.3ml F QL(18 ml per
fill retail) enoxaparin sodium soln sc60 mg/0.6ml F QL(36 ml per
fill retail) enoxaparin sodium soln sc80 mg/0.8ml F QL(48 ml per
fill retail)
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Drug Name DrugTier
Requirements/Limits
fondaparinux sodium soln NP
FRAGMIN SOLN NP
heparin sodium (porcine)soln F
LOVENOX SOLN IJ 300 MG/3ML (EnoxaparinSodium)
NP QL(15 ml perfill retail)
LOVENOX SOLN SC 100 MG/ML, 150 MG/ML(Enoxaparin Sodium)
NP QL(30 ml perfill retail)
LOVENOX SOLN SC 120 MG/0.8ML, 40 MG/0.4ML(Enoxaparin Sodium)
NP QL(24 ml perfill retail)
LOVENOX SOLN SC 30 MG/0.3ML (EnoxaparinSodium)
NP QL(18 ml perfill retail)
LOVENOX SOLN SC 60 MG/0.6ML (EnoxaparinSodium)
NP QL(36 ml perfill retail)
LOVENOX SOLN SC 80 MG/0.8ML (EnoxaparinSodium)
NP QL(48 ml perfill retail)
Thrombin Inhibitors PRADAXA CAPS F
ANTICONVULSANTS - Drugs to Treat Seizures
AMPA Glutamate Receptor Antagonists FYCOMPA SUSP F
FYCOMPA TABS F
Anticonvulsants - Benzodiazepines clonazepam tabs F
clonazepam tbdp F
DIASTAT ACUDIAL GEL F AL; Up to 21yrs old
DIASTAT PEDIATRIC GEL F AL; Up to 21yrs old
DIAZEPAM GEL RE 2.5 MG, 10 MG, 20 MG F AL; Up to 21
yrs old DIAZEPAM RECTAL GEL GEL F AL; Up to 21
yrs old
Drug Name DrugTier
Requirements/Limits
KLONOPIN TABS (Clonazepam) NP
ONFI SUSP F
ONFI TABS F
Anticonvulsants - Misc. APTIOM TABS F
BANZEL SUSP 40 MG/ML F AL; Up to 11yrs old
BANZEL TABS 200 MG, 400 MG F
PA; QL(3 eadaily); AL; Upto 11 yrs old
BRIVIACT SOLN IV 50 MG/5ML F PA
BRIVIACT SOLN OR 10 MG/ML F
BRIVIACT TABS OR 10 MG, 25 MG, 75 MG, 50 MG, 100 MG
F
carbamazepine chew or100 mg F PA; AL; At least
4 yrs old carbamazepine cp12 or200 mg, 300 mg, 100 mg F AL; At least 4
yrs old CARBAMAZEPINE POWD XX F PA; AL; At least
4 yrs old carbamazepine susp or100 mg/5ml F PA; AL; At least
4 yrs old carbamazepine tabs or 200 mg F PA; AL; At least
4 yrs old carbamazepine tb12 or 400mg, 100 mg, 200 mg F PA; AL; At least
4 yrs old CARBATROL CP12 (Carbamazepine) NP AL; At least 4 yrs old FANATREX FUSEPAQ SUSP F PA
gabapentin caps F
gabapentin soln F
gabapentin tabs F
KEPPRA SOLN IV 500 MG/5ML (Levetiracetam) NP PA
KEPPRA SOLN OR 100 MG/ML (Levetiracetam) NP
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Drug Name DrugTier
Requirements/Limits
KEPPRA TABS OR 1000 MG, 250 MG, 750 MG, 500 MG (Levetiracetam)
NP
KEPPRA XR TB24 (Levetiracetam) NP
LAMICTAL CHEWABLE DISPERSIBLE CHEW 25 MG (Lamotrigine)
NP PA; QL(4 eadaily)
LAMICTAL CHEWABLE DISPERSIBLE CHEW 5 MG (Lamotrigine)
NP PA; QL(4 eadaily); AL; Upto 11 yrs old
LAMICTAL ODT KIT (Lamotrigine) NP
LAMICTAL ODT TBDP (Lamotrigine) NP
LAMICTAL STARTER/NOTTAKING CARBAMAZEPINE KIT (Lamotrigine)
NP
LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATE KIT (Lamotrigine)
NP
LAMICTAL STARTER/TAKINGVALPROATE KIT (Lamotrigine)
NP
LAMICTAL TABS (Lamotrigine) NP PA; QL(4 eadaily)
LAMICTAL XR KIT F PA
LAMICTAL XR TB24 300 MG, 50 MG, 200 MG, 25 MG, 100 MG, 250 MG (Lamotrigine)
NP
PA
lamotrigine chew 25 mg F PA; QL(4 eadaily)
lamotrigine chew 5 mg F PA; QL(4 eadaily); AL; Upto 11 yrs old
lamotrigine kit 25 mg, F
lamotrigine tabs 25 mg,150 mg, 200 mg, 100 mg F PA; QL(4 ea
daily) lamotrigine tb24 100 mg,50 mg, 25 mg, 300 mg, 200mg, 250 mg
F PA
Drug Name DrugTier
Requirements/Limits
lamotrigine tbdp 25 mg,100 mg, 200 mg, 50 mg F
levetiracetam in sodium chloride soln 1000mg/100ml-750mg/100ml
F
levetiracetam in sodium chloride soln 1500mg/100ml-540mg/100ml,500mg/100ml-820mg/100ml
F
PA
LEVETIRACETAM SOLN IV 1000MG/100ML-750MG/100ML(Levetiracetam in Sodium Chloride)
NP
levetiracetam soln iv 500 mg/5ml F PA
LEVETIRACETAM SOLN IV 500MG/100ML-820MG/100ML,1500MG/100ML-540MG/100ML(Levetiracetam in Sodium Chloride)
NP
PA
levetiracetam soln or 100 mg/ml, 500 mg/5ml F
levetiracetam tabs or 250 mg, 500 mg, 1000 mg, 750 mg
F
levetiracetam tb24 or 750 mg, 500 mg F
LYRICA CAPS 225 MG, 300 MG F QL(2 ea daily)
LYRICA CAPS 25 MG, 150 MG, 50 MG, 200 MG, 75 MG, 100 MG
F QL(3 ea daily)
LYRICA SOLN 20 MG/ML F QL(30 ml daily)
MYSOLINE TABS (Primidone) NP
NEURONTIN CAPS (Gabapentin) NP
NEURONTIN SOLN (Gabapentin) NP
NEURONTIN TABS (Gabapentin) NP
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Drug Name DrugTier
Requirements/Limits
oxcarbazepine susp 60mg/ml, 300 mg/5ml F PA
oxcarbazepine tabs 300mg, 150 mg F PA; AL; At least
4 yrs old oxcarbazepine tabs 600 mg F AL; At least 4
yrs old
OXTELLAR XR TB24 F PA
POTIGA TABS 200 MG, 400 MG, 300 MG F
QL(3 ea daily);AL; At least 18 yrs old
POTIGA TABS 50 MG F QL(9 ea daily);AL; At least 18 yrs old
primidone tabs F
QUDEXY XR CS24 F
SPRITAM TB3D F
TEGRETOL SUSP (Carbamazepine) NP PA; AL; At least 4 yrs old TEGRETOL TABS (Carbamazepine) NP PA; AL; At least 4 yrs old TEGRETOL-XR TB12 (Carbamazepine) NP PA; AL; At least 4 yrs old TOPAMAX SPRINKLE CPSP (Topiramate) NP AL; At least 11 yrs old TOPAMAX TABS (Topiramate) NP
topiramate cpsp 15 mg, 25 mg F AL; At least 11
yrs old
TOPIRAMATE ER CS24 F
topiramate tabs 200 mg, 25mg, 100 mg, 50 mg F
TRILEPTAL SUSP 300 MG/5ML (Oxcarbazepine) NP PA
TRILEPTAL TABS 150 MG, 300 MG (Oxcarbazepine)
NP PA; AL; At least 4 yrs old
TRILEPTAL TABS 600 MG (Oxcarbazepine) NP AL; At least 4 yrs old
TROKENDI XR CP24 F
VIMPAT SOLN F PA
Drug Name DrugTier
Requirements/Limits
VIMPAT TABS F PA
ZONEGRAN CAPS (Zonisamide) NP
zonisamide caps F
Carbamates felbamate susp F
felbamate tabs F
FELBATOL SUSP (Felbamate) NP
FELBATOL TABS (Felbamate) NP
GABA Modulators GABITRIL TABS 16 MG, 12 MG F
GABITRIL TABS 2 MG, 4 MG (Tiagabine HCl) NP
SABRIL PACK (Vigabatrin) NP PA
SABRIL TABS F PA; QL(6 eadaily)
tiagabine hcl tabs F
vigabatrin pack F PA
Hydantoins CEREBYX SOLN (Fosphenytoin Sodium) NP PA
DILANTIN CAPS 100 MG (Phenytoin SodiumExtended)
NP
DILANTIN CAPS 30 MG F
DILANTIN INFATABS CHEW (Phenytoin) NP
DILANTIN-125 SUSP (Phenytoin) NP
fosphenytoin sodium soln F PA
PEGANONE TABS F
PHENYTEK CAPS (Phenytoin SodiumExtended)
NP
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Drug Name DrugTier
Requirements/Limits
phenytoin chew F
phenytoin sodium extended caps F
phenytoin sodium soln F PA
phenytoin susp F
Succinimides CELONTIN CAPS F
ethosuximide caps F
ethosuximide soln F
ZARONTIN CAPS (Ethosuximide) NP
ZARONTIN SOLN (Ethosuximide) NP
Valproic Acid DEPACON SOLN (Valproate Sodium) NP PA
DEPAKENE CAPS (Valproic Acid) NP
DEPAKENE SOLN (Valproate Sodium) NP
DEPAKOTE ER TB24 (Divalproex Sodium) NP PA; AL; At least 4 yrs old DEPAKOTE SPRINKLES CSDR (Divalproex Sodium) NP PA; AL; At least 4 yrs old DEPAKOTE TBEC (Divalproex Sodium) NP PA; AL; At least 4 yrs old divalproex sodium csdr or125 mg F PA; AL; At least
4 yrs old divalproex sodium tb24 or250 mg, 500 mg F PA; AL; At least
4 yrs old divalproex sodium tbec or500 mg, 125 mg, 250 mg F PA; AL; At least
4 yrs old valproate sodium soln iv100 mg/ml, 500 mg/5ml F PA
valproate sodium soln or250 mg/5ml F
valproic acid caps F
ANTIDEPRESSANTS - Drugs to Treat Depression
Drug Name DrugTier
Requirements/Limits
Alpha-2 Receptor Antagonists (Tetracyclics)
mirtazapine tabs F AL; At least 4 yrs old
mirtazapine tbdp F AL; At least 4 yrs old
REMERON SOLTAB TBDP (Mirtazapine) NP AL; At least 4 yrs old REMERON TABS (Mirtazapine) NP AL; At least 4 yrs old Antidepressant Combinations PRAMLYTE THPK F
Antidepressants - Misc.
APLENZIN TB24 F QL(1 ea daily);AL; At least 4 yrs old
bupropion hcl tabs 75 mg,100 mg F AL; At least 4
yrs old bupropion hcl tb12 200 mg,100 mg, 150 mg F AL; At least 4
yrs old
bupropion hcl tb24 300 mg,150 mg F
QL(1 ea daily);AL; At least 4 yrs old
FORFIVO XL TB24 F QL(1 ea daily);AL; At least 4 yrs old
MAPROTILINE HCL TABS F AL; At least 4 yrs old
WELLBUTRIN SR TB12 (Bupropion HCl) NP AL; At least 4 yrs old WELLBUTRIN TABS (Bupropion HCl) NP AL; At least 4 yrs old
WELLBUTRIN XL TB24 (Bupropion HCl) NP
QL(1 ea daily);AL; At least 4 yrs old
Monoamine Oxidase Inhibitors (MAOIs)
EMSAM PT24 F QL(1 ea daily);AL; At least 18 yrs old
MARPLAN TABS F AL; At least 4 yrs old
NARDIL TABS (Phenelzine Sulfate) NP AL; At least 4 yrs old PARNATE TABS (Tranylcypromine Sulfate) NP AL; At least 4 yrs old
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Drug Name DrugTier
Requirements/Limits
phenelzine sulfate tabs F AL; At least 4 yrs old
tranylcypromine sulfatetabs F AL; At least 4
yrs old Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS (CitalopramHydrobromide) NP AL; At least 4 yrs old citalopram hydrobromidesoln 10 mg/5ml F
citalopram hydrobromidetabs 10 mg, 20 mg, 40 mg F AL; At least 4
yrs old
escitalopram oxalate soln F AL; At least 6 yrs old
escitalopram oxalate tabs F AL; At least 6 yrs old
FLUOXETINE DR CPDR F AL; At least 4 yrs old
fluoxetine hcl caps 20 mg,10 mg, 40 mg F AL; At least 4
yrs old fluoxetine hcl soln 20 mg/5ml F
fluoxetine hcl tabs 20 mg,60 mg, 10 mg F AL; At least 4
yrs old FLUOXETINE HCL TABS 60 MG F AL; At least 4
yrs old FLUOXETINE HCL TABS 60 MG (Fluoxetine HCl) NP AL; At least 4 yrs old fluvoxamine maleate cp24150 mg, 100 mg F
fluvoxamine maleate tabs 100 mg, 50 mg, 25 mg F AL; At least 8
yrs old LEXAPRO SOLN (Escitalopram Oxalate) NP AL; At least 6 yrs old LEXAPRO TABS (Escitalopram Oxalate) NP AL; At least 6 yrs old paroxetine hcl tabs 10 mg,40 mg, 20 mg, 30 mg F AL; At least 13
yrs old paroxetine hcl tb24 12.5 mg F AL; At least 13
yrs old paroxetine hcl tb24 37.5mg, 25 mg F
PAXIL CR TB24 12.5 MG (Paroxetine HCl) NP AL; At least 13 yrs old PAXIL CR TB24 25 MG, 37.5 MG (Paroxetine HCl) NP
Drug Name DrugTier
Requirements/Limits
PAXIL SUSP 10 MG/5ML F
PAXIL TABS 20 MG, 30 MG, 10 MG, 40 MG (Paroxetine HCl)
NP AL; At least 13 yrs old
PEXEVA TABS F PA; AL; At least 13 yrs old
PROZAC CAPS (Fluoxetine HCl) NP AL; At least 4 yrs old PROZAC WEEKLY CPDR (Fluoxetine HCl) NP AL; At least 4 yrs old sertraline hcl conc 20 mg/ml F
sertraline hcl tabs 25 mg,100 mg, 50 mg F AL; At least 4
yrs old ZOLOFT CONC 20 MG/ML(Sertraline HCl) NP
ZOLOFT TABS 50 MG, 100 MG, 25 MG (Sertraline HCl)
NP AL; At least 4 yrs old
Serotonin Modulators
BRINTELLIX TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old
NEFAZODONE HCL TABS 200 MG, 100 MG, 150 MG F AL; At least 4
yrs old nefazodone hcl tabs 50 mg,250 mg F AL; At least 4
yrs old trazodone hcl tabs or 100 mg, 50 mg F AL; At least 14
yrs old
trazodone hcl tabs or 150 mg F
QL(1 ea daily);AL; At least 19 yrs old
trazodone hcl tabs or 300 mg F
QL(2 ea daily);AL; At least 19 yrs old
TRINTELLIX TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old
VIIBRYD STARTER PACK KIT F
PA; QL(1 eadaily); AL; Atleast 18 yrs old
VIIBRYD TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old
Serotonin-Norepinephrine Reuptake Inhibitors
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Drug Name DrugTier
Requirements/Limits
CYMBALTA CPEP (Duloxetine HCl) NP AL; At least 13 yrs old
DESVENLAFAXINE ER TB24 100 MG, 50 MG F
QL(1 ea daily);AL; At least 13 yrs old
desvenlafaxine succinate tb24 F ST
duloxetine hcl cpep 20 mg,60 mg, 30 mg F AL; At least 13
yrs old DULOXETINE HCL CPEP 40 MG F AL; At least 13
yrs old EFFEXOR XR CP24 (Venlafaxine HCl) NP AL; At least 13 yrs old
FETZIMA CP24 F PA; AL; At least 18 yrs old
FETZIMA TITRATION PACK C4PK F PA; AL; At least
18 yrs old
KHEDEZLA TB24 F QL(1 ea daily);AL; At least 13 yrs old
PRISTIQ TB24 (Desvenlafaxine Succinate) NP ST
venlafaxine hcl cp24 F AL; At least 13 yrs old
VENLAFAXINE HCL ER TB24 225 MG F AL; At least 13
yrs old VENLAFAXINE HCL ER TB24 37.5 MG, 75 MG, 150 MG (Venlafaxine HCl)
NP AL; At least 13 yrs old
venlafaxine hcl tabs F AL; At least 13 yrs old
venlafaxine hcl tb24 F AL; At least 13 yrs old
Tricyclic Agents
amitriptyline hcl tabs F AL; At least 4 yrs old
AMOXAPINE TABS F AL; At least 4 yrs old
ANAFRANIL CAPS (Clomipramine HCl) NP AL; At least 4 yrs old
clomipramine hcl caps F AL; At least 4 yrs old
desipramine hcl tabs F AL; At least 4 yrs old
Drug Name DrugTier
Requirements/Limits
doxepin hcl caps 100 mg,75 mg, 150 mg, 50 mg, 10mg, 25 mg
F AL; At least 4 yrs old
doxepin hcl conc 10 mg/ml F
ELAVIL TABS (Amitriptyline HCl) NP AL; At least 4 yrs old
imipramine hcl tabs F AL; At least 4 yrs old
imipramine pamoate caps F AL; At least 4 yrs old
NORPRAMIN TABS (Desipramine HCl) NP AL; At least 4 yrs old nortriptyline hcl caps 50mg, 25 mg, 75 mg, 10 mg F AL; At least 4
yrs old NORTRIPTYLINE HCL SOLN 10 MG/5ML F
PAMELOR CAPS (Nortriptyline HCl) NP AL; At least 4 yrs old
protriptyline hcl tabs F AL; At least 4 yrs old
SURMONTIL CAPS (Trimipramine Maleate) NP AL; At least 4 yrs old TOFRANIL TABS (Imipramine HCl) NP AL; At least 4 yrs old TOFRANIL-PM CAPS (Imipramine Pamoate) NP AL; At least 4 yrs old
trimipramine maleate caps F AL; At least 4 yrs old
ANTIDIABETICS - Drugs to Regulate Blood Sugar
Alpha-Glucosidase Inhibitors acarbose tabs F
GLYSET TABS (Miglitol) F
miglitol tabs NP
PRECOSE TABS (Acarbose) NP
Antidiabetic - Amylin Analogs SYMLINPEN 120 SOPN NP
SYMLINPEN 60 SOPN NP
Antidiabetic Combinations
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Drug Name DrugTier
Requirements/Limits
ACTOPLUS MET TABS (Pioglitazone HCl-Metformin HCl)
NP
ACTOPLUS MET XR TB24 NP
ALOGLIPTIN/METFORMINHCL TABS NP
QL(2 ea daily);AL; At least 18 yrs old
ALOGLIPTIN/PIOGLITAZONE TABS NP
QL(1 ea daily);AL; At least 18 yrs old
DUETACT TABS (Pioglitazone HCl-Glimepiride)
NP
glipizide-metformin hcl tabs F
GLUCOVANCE TABS (Glyburide-Metformin) NP
glyburide-metformin tabs F
GLYXAMBI TABS NP QL(1 ea daily);AL; At least 18 yrs old
INVOKAMET TABS F PA
INVOKAMET XR TB24 NP
JANUMET TABS F QL(2 ea daily);AL; At least 18 yrs old
JANUMET XR TB24 F QL(1 ea daily);AL; At least 18 yrs old
JENTADUETO TABS F QL(2 ea daily);AL; At least 18 yrs old
JENTADUETO XR TB24 2.5MG-1000MG NP
QL(2 ea daily);AL; At least 18 yrs old
JENTADUETO XR TB24 5MG-1000MG NP
QL(1 ea daily);AL; At least 18 yrs old
KAZANO TABS NP QL(2 ea daily);AL; At least 18 yrs old
KOMBIGLYZE XR TB24 NP QL(1 ea daily);AL; At least 18 yrs old
Drug Name DrugTier
Requirements/Limits
OSENI TABS NP QL(1 ea daily);AL; At least 18 yrs old
pioglitazone hcl-glimepiridetabs NP
pioglitazone hcl-metforminhcl tabs NP
PRANDIMET TABS (Repaglinide-MetforminHCl)
NP
QTERN TABS NP QL(1 ea daily)
REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS
NP
SOLIQUA 100/33 SOPN NP
SYNJARDY TABS NP QL(2 ea daily);AL; At least 18 yrs old
SYNJARDY XR TB24 NP QL(1 ea daily)
XIGDUO XR TB24 10MG-500MG, 5MG-500MG, 10MG-1000MG
NP QL(1 ea daily)
XIGDUO XR TB24 5MG-1000MG NP QL(2 ea daily)
XULTOPHY 100/3.6 SOPN NP
Biguanides FORTAMET TB24 (Metformin HCl) NP
GLUCOPHAGE TABS (Metformin HCl) NP
GLUCOPHAGE XR TB24 (Metformin HCl) NP
GLUMETZA TB24 (Metformin HCl) NP
metformin hcl tabs 500 mg,850 mg, 1000 mg F
metformin hcl tb24 1000 mg, 500 mg NP
metformin hcl tb24 750 mg,500 mg F
RIOMET SOLN NP
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Drug Name DrugTier
Requirements/Limits
Diabetic Other CVS GLUCOSE CHEW 4 GM F QL(1.67 ea
daily) CVS GLUCOSE CHEW 4GM-6MG F
DEX4 CHEW F
DEX4 FAST ACTING GLUCOSE CHEW 4GM-6MG
F
DEX4 NATURALS CHEW F
DEX4 POUCH PACK CHEW F
DEX4 QUICK DISSOLVE GLUCOSE CHEW F QL(1.67 ea
daily) dextrose (diabetic use) gel15 gm/38gm, 40 % F
GLUCAGEN HYPOKIT SOLR F
GLUCAGON EMERGENCY KIT KIT F
GLUCOSE CHEW 4 GM F QL(1.67 eadaily)
GLUCOSE CHEW 4GM-4GM-6MG, 4GM-6MG F
GLUCOSE INSTANT ENERGY CHEW F
GNP GLUCOSE CHEW 4 GM F QL(1.67 ea
daily) GNP GLUCOSE CHEW 4GM-6MG F
GNP QUICK DISSOLVE GLUCOSE CHEW F QL(1.67 ea
daily) GOODSENSE GLUCOSE CHEW F
HM GLUCOSE CHEW F
HY-VEE GLUCOSE CHEW F
INSTA-GLUCOSE GEL F
KROGER GLUCOSE CHEW F
LEADER GLUCOSE CHEW F
Drug Name DrugTier
Requirements/Limits
LEADER QUICK DISSOLVE GLUCOSE CHEW
F QL(1.67 eadaily)
LONGS GLUCOSE CHEW F
MEIJER GLUCOSE CHEW F
PREFERRED PLUS GLUCOSE CHEW F
PX GLUCOSE CHEW F
RA GLUCOSE CHEW F
RELION GLUCOSE CHEW F
SM GLUCOSE CHEW 4 GM F QL(1.67 ea
daily) SM GLUCOSE CHEW 4GM-6MG F
SMART SENSE GLUCOSE CHEW F
SMART SENSE GLUCOSE TABLETS CHEW
F
TGT GLUCOSE CHEW F
UP & UP GLUCOSE CHEW F
VALUE PLUS GLUCOSE CHEW F
WALGREENS GLUCOSE CHEW 4 GM F QL(1.67 ea
daily) WALGREENS GLUCOSE CHEW 4GM-6MG F
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
ALOGLIPTIN TABS NP QL(1 ea daily);AL; At least 18 yrs old
JANUVIA TABS F QL(1 ea daily);AL; At least 18 yrs old
NESINA TABS NP QL(1 ea daily);AL; At least 18 yrs old
ONGLYZA TABS NP QL(1 ea daily);AL; At least 18 yrs old
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Drug Name DrugTier
Requirements/Limits
TRADJENTA TABS F QL(1 ea daily);AL; At least 18 yrs old
Incretin Mimetic Agents (GLP-1 Receptor ADLYXIN SOPN NP
ADLYXIN STARTER PACK PNKT NP
BYDUREON BCISE AUIJ NP
BYDUREON PEN PEN F
PA; QL(4 eaper 28 daysretail); AL; Atleast 18 yrs old
BYDUREON SRER F
PA; QL(4 eaper 28 daysretail); AL; Atleast 18 yrs old
BYETTA SOPN F PA; AL; At least 18 yrs old
TANZEUM PEN NP
TRULICITY SOPN NP
VICTOZA SOPN F
Insulin Sensitizing Agents ACTOS TABS (Pioglitazone HCl) NP
AVANDIA TABS NP
pioglitazone hcl tabs F
Insulin AFREZZA POWD NP
APIDRA SOLN F ST
APIDRA SOLOSTAR SOPN F ST
BASAGLAR KWIKPEN SOPN 4
FIASP FLEXTOUCH SOPN 4
FIASP SOLN F
Drug Name DrugTier
Requirements/Limits
HUMALOG JUNIOR KWIKPEN SOPN 4
HUMALOG KWIKPEN SOPN 100 UNIT/ML F
HUMALOG KWIKPEN SOPN 200 UNIT/ML NP
HUMALOG MIX 50/50KWIKPEN SUPN NP
HUMALOG MIX 50/50SUSP F
HUMALOG MIX 75/25KWIKPEN SUPN NP
HUMALOG MIX 75/25SUSP F
HUMALOG SOCT F
HUMALOG SOLN F
HUMULIN 70/30 KWIKPENSUPN NP
HUMULIN 70/30 SUSP F Limit 40ml permonth;QL(1.334 ml daily)
HUMULIN N KWIKPEN SUPN NP
HUMULIN N SUSP F Limit 40ml permonth;QL(1.334 ml daily)
HUMULIN R SOLN F Limit 40ml permonth;QL(1.334 ml daily)
HUMULIN R U-500 (CONCENTRATED) SOLN F
HUMULIN R U-500 KWIKPEN SOPN NP
LANTUS SOLN F
LANTUS SOLOSTAR SOPN F
LEVEMIR FLEXTOUCH SOPN F
LEVEMIR SOLN F
NOVOLIN 70/30 RELIONSUSP 4
Limit 40ml permonth;QL(1.334 ml daily)
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Drug Name DrugTier
Requirements/Limits
NOVOLIN 70/30 SUSP 4 Limit 40ml permonth;QL(1.334 ml daily)
NOVOLIN N RELION SUSP 4
Limit 40ml permonth;QL(1.334 ml daily)
NOVOLIN N SUSP 4 Limit 40ml permonth;QL(1.334 ml daily)
NOVOLIN R RELION SOLN 4
Limit 40ml permonth;QL(1.334 ml daily)
NOVOLIN R SOLN 4 Limit 40ml permonth;QL(1.334 ml daily)
NOVOLOG FLEXPEN SOPN F
NOVOLOG MIX 70/30PREFILLED FLEXPEN SUPN
F
NOVOLOG MIX 70/30SUSP F
NOVOLOG PENFILL SOCT F
NOVOLOG SOLN F
TOUJEO SOLOSTAR SOPN NP
TRESIBA FLEXTOUCH SOPN NP
Meglitinide Analogues nateglinide tabs NP
PRANDIN TABS (Repaglinide) NP
repaglinide tabs F
STARLIX TABS (Nateglinide) NP
Sodium-Glucose Co-Transporter 2 (SGLT2) FARXIGA TABS F
INVOKANA TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old
JARDIANCE TABS NP QL(1 ea daily)
Drug Name DrugTier
Requirements/Limits
Sulfonylureas AMARYL TABS (Glimepiride) NP
CHLORPROPAMIDE TABS NP
DIABETA TABS F
glimepiride tabs F
glipizide tabs F
glipizide tb24 F
GLUCOTROL TABS (Glipizide) NP
GLUCOTROL XL TB24 (Glipizide) NP
glyburide micronized tabs F
glyburide tabs F
GLYNASE TABS (Glyburide Micronized) NP
TOLAZAMIDE TABS NP
TOLBUTAMIDE TABS NP
ANTIDIARRHEALS - Drugs to Treat Diarrhea
Antidiarrheal Agents - Misc. bismuth subsalicylate susp525 mg/30ml, 262mg/15ml, 527 mg/30ml
F
PEPTO-BISMOL SUSP 524 MG/30ML, 262MG/15ML (Bismuth Subsalicylate)
NP
Antidiarrheal Combinations lactobacillus acidophilus-pectin caps F
Antiperistaltic Agents diphenoxylate w/ atropinetabs F
DIPHENOXYLATE/ATROPINE LIQD F
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Drug Name DrugTier
Requirements/Limits
IMODIUM A-D CAPS 2 MG (Loperamide HCl) NP RX/OTC
IMODIUM A-D TABS 2 MG (Loperamide HCl) NP
LOMOTIL TABS (Diphenoxylate w/Atropine)
NP
loperamide hcl caps 2 mg NP RX/OTC
loperamide hcl caps 2 mg F RX/OTC
loperamide hcl tabs 2 mg F
ANTIDOTES AND SPECIFIC ANTAGONISTS
Antidotes - Chelating Agents CHEMET CAPS F
JADENU TABS F PA
Opioid Antagonists EVZIO SOAJ NP
NALOXONE HCL SOCT 0.4 MG/ML F
naloxone hcl soln 4 mg/10ml, 0.4 mg/ml F
NALOXONE HCL SOSY 2 MG/2ML F
naltrexone hcl tabs F AL; At least 19 yrs old
NARCAN LIQD F
ANTIEMETICS - Drugs to Treat Nausea andVomiting 5-HT3 Receptor Antagonists ANZEMET TABS OR 100 MG, 50 MG NP
granisetron hcl tabs or 1 mg NP
ondansetron hcl soln ij 40mg/20ml, 4 mg/2ml F QL(16 ml daily)
ondansetron hcl soln or 4 mg/5ml F
QL(16 mldaily,150 mlper fill retail)
Drug Name DrugTier
Requirements/Limits
ondansetron hcl tabs or 8 mg, 4 mg F QL(2 ea daily)
ondansetron tbdp F
SANCUSO PTCH NP
ZOFRAN ODT TBDP (Ondansetron) NP
ZOFRAN SOLN 4 MG/5ML(Ondansetron HCl) NP
QL(16 mldaily,150 mlper fill retail)
ZOFRAN TABS 4 MG, 8 MG (Ondansetron HCl) NP QL(2 ea daily)
ZUPLENZ FILM NP
Antiemetics - Anticholinergic dimenhydrinate tabs or 50 mg F
DRAMAMINE TABS (Dimenhydrinate) NP
meclizine hcl chew 25 mg F
meclizine hcl tabs 12.5 mg,25 mg F RX/OTC
scopolamine pt72 NP
TIGAN CAPS OR 300 MG (Trimethobenzamide HCl) NP
TRANSDERM-SCOP PT72 F
TRANSDERM-SCOP PT72 (Scopolamine) F
trimethobenzamide hcl caps NP
Antiemetics - Miscellaneous AKYNZEO CAPS NP
CESAMET CAPS NP
DICLEGIS TBEC F PA; QL(2 eadaily)
dronabinol caps F AL; At least 18 yrs old
EMETROL SOLN (Fructose-Dextrose-Phosphoric Acid)
NP
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Drug Name DrugTier
Requirements/Limits
fructose-dextrose-phosphoric acid liqd F
fructose-dextrose-phosphoric acid soln F
MARINOL CAPS (Dronabinol) NP AL; At least 18 yrs old Substance P/Neurokinin 1 (NK1) Receptor aprepitant caps NP
EMEND CAPS OR 125 MG, 40 MG, 80 MG (Aprepitant)
NP
EMEND SUSR OR 125 MG NP
EMEND TRIPACK CAPS (Aprepitant) NP
VARUBI TABS NP
ANTIFUNGALS - Drugs to Treat Fungal Infections
Antifungals ANCOBON CAPS (Flucytosine) NP
flucytosine caps NP
GRIFULVIN V TABS (Griseofulvin Microsize) NP
GRIS-PEG TABS (Griseofulvin Ultramicrosize)
NP
griseofulvin microsize susp F
griseofulvin microsize tabs F
griseofulvin ultramicrosizetabs NP
LAMISIL PACK 187.5 MG, 125 MG NP
LAMISIL TABS 250 MG (Terbinafine HCl) NP
nystatin tabs F
terbinafine hcl tabs F
Imidazole-Related Antifungals
Drug Name DrugTier
Requirements/Limits
CRESEMBA CAPS OR 186 MG NP
DIFLUCAN SUSR (Fluconazole) NP
DIFLUCAN TABS (Fluconazole) NP
fluconazole susr F
fluconazole tabs F
itraconazole caps NP
ketoconazole tabs NP
NOXAFIL SUSP 40 MG/ML NP
NOXAFIL TBEC 100 MG NP AL; At least 13 yrs old
ONMEL TABS NP
SPORANOX CAPS 100 MG (Itraconazole) NP
SPORANOX PULSEPAK CAPS (Itraconazole) NP
SPORANOX SOLN 10 MG/ML NP
VFEND SUSR (Voriconazole) NP
VFEND TABS (Voriconazole) NP
voriconazole susr or 40 mg/ml NP
voriconazole tabs or 200 mg, 50 mg NP
ANTIHISTAMINES - Drugs to Treat Allergies
Antihistamines - Alkylamines CHLOR-TRIMETON ALLERGY TBCR (ChlorpheniramineMaleate)
NP
CHLOR-TRIMETON SYRP (ChlorpheniramineMaleate)
NP
CHLOR-TRIMETON TABS (ChlorpheniramineMaleate)
NP
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Drug Name DrugTier
Requirements/Limits
chlorpheniramine maleate syrp F
chlorpheniramine maleatetabs F
chlorpheniramine maleatetbcr F
Antihistamines - Ethanolamines BENADRYL ALLERGY CAPS (DiphenhydramineHCl)
NP QL(4 ea daily)
BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML(Diphenhydramine HCl)
NP
BENADRYL ALLERGY TABS (DiphenhydramineHCl)
NP
clemastine fumarate tabs 1.34 mg F QL(4 ea daily)
diphenhydramine hcl capsor 25 mg F QL(4 ea daily)
diphenhydramine hcl capsor 50 mg F RX/OTC
diphenhydramine hcl elix or12.5 mg/5ml F RX/OTC
diphenhydramine hcl liqd or12.5 mg/5ml, 25 mg/10ml,50 mg/20ml
F
diphenhydramine hcl tabsor 25 mg F
TAVIST ALLERGY TABS (Clemastine Fumarate) NP QL(4 ea daily)
Antihistamines - Non-Sedating ALLEGRA ALLERGY CHILDRENS SUSP 30 MG/5ML (Fexofenadine HCl)
NP
ST
ALLEGRA ALLERGY TABS 180 MG (Fexofenadine HCl)
NP QL(1 ea daily)
ALLEGRA ALLERGY TABS 60 MG (Fexofenadine HCl)
NP
cetirizine hcl chew 5 mg,10 mg NP
Drug Name DrugTier
Requirements/Limits
cetirizine hcl soln 1 mg/ml,5 mg/5ml F
QL(240 ml perfill retail); AL;Up to 12 yrsold; RX/OTC
cetirizine hcl syrp 1 mg/ml,5 mg/5ml F
QL(240 ml perfill retail); AL;Up to 12 yrsold; RX/OTC
cetirizine hcl tabs 10 mg, 5 mg F QL(1 ea daily)
CLARINEX SYRP 0.5 MG/ML F ST
CLARINEX TABS 5 MG (Desloratadine) NP
CLARITIN CAPS 10 MG (Loratadine) NP
CLARITIN REDITABS TBDP 10 MG (Loratadine) NP
CLARITIN REDITABS TBDP 5 MG F
CLARITIN SYRP 5 MG/5ML (Loratadine) NP
CLARITIN TABS 10 MG (Loratadine) NP QL(1 ea daily)
DESLORATADINE ODT TBDP NP
desloratadine tabs NP
fexofenadine hcl susp or 30mg/5ml F ST
fexofenadine hcl tabs or 180 mg NP QL(1 ea daily)
fexofenadine hcl tabs or 60 mg NP
levocetirizine dihydrochloride soln 2.5mg/5ml
NP RX/OTC
levocetirizine dihydrochloride tabs 5 mg F RX/OTC
loratadine caps 10 mg NP
loratadine soln 5 mg/5ml F
loratadine syrp 5 mg/5ml F
loratadine tabs 10 mg F QL(1 ea daily)
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Drug Name DrugTier
Requirements/Limits
loratadine tbdp 10 mg NP
XYZAL ALLERGY 24HR CHILDRENS SOLN (Levocetirizine Dihydrochloride)
NP
RX/OTC
XYZAL ALLERGY 24HR TABS (Levocetirizine Dihydrochloride)
NP RX/OTC
XYZAL SOLN (Levocetirizine Dihydrochloride)
NP RX/OTC
XYZAL TABS (Levocetirizine Dihydrochloride)
NP RX/OTC
ZYRTEC ALLERGY TABS (Cetirizine HCl) NP QL(1 ea daily)
ZYRTEC CHILDRENS ALLERGY SYRP (Cetirizine HCl)
NP
QL(240 ml perfill retail); AL;Up to 12 yrsold; RX/OTC
Antihistamines - Phenothiazines promethazine hcl soln or6.25 mg/5ml F
promethazine hcl supp re12.5 mg, 25 mg, 50 mg F
promethazine hcl supp re50 mg 4
promethazine hcl syrp or6.25 mg/5ml F
promethazine hcl tabs or25 mg, 12.5 mg, 50 mg F
Antihistamines - Piperidines cyproheptadine hcl syrp F
cyproheptadine hcl tabs F
ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Antihyperlipidemics - Combinations ezetimibe-simvastatin tabs NP
VYTORIN TABS (Ezetimibe-Simvastatin) NP
Antihyperlipidemics - Misc.
Drug Name DrugTier
Requirements/Limits
KYNAMRO SOSY NP
LOVAZA CAPS (Omega-3-acid Ethyl Esters) NP
omega-3-acid ethyl esters caps NP
VASCEPA CAPS NP
Bile Acid Sequestrants cholestyramine light pack F
cholestyramine light powd F
cholestyramine pack F
cholestyramine powd F
COLESTID FLAVORED GRAN (Colestipol HCl) NP
COLESTID FLAVORED PACK (Colestipol HCl) NP
COLESTID GRAN (Colestipol HCl) NP
COLESTID PACK (Colestipol HCl) NP
COLESTID TABS (Colestipol HCl) NP
colestipol hcl gran 5 gm NP
colestipol hcl pack 5 gm NP
colestipol hcl tabs 1 gm F
QUESTRAN LIGHT POWD (Cholestyramine Light) NP
QUESTRAN PACK (Cholestyramine) NP
QUESTRAN POWD (Cholestyramine) NP
WELCHOL PACK NP
WELCHOL TABS NP
Fibric Acid Derivatives ANTARA CAPS NP
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Drug Name DrugTier
Requirements/Limits
choline fenofibrate cpdr F
FENOFIBRATE CAPS 150 MG, 50 MG NP
fenofibrate micronized caps NP
fenofibrate tabs 145 mg, 48 mg F
fenofibrate tabs 160 mg,120 mg, 54 mg, 40 mg NP
FENOFIBRIC ACID TABS NP
FENOGLIDE TABS (Fenofibrate) NP
FIBRICOR TABS NP
gemfibrozil tabs F
LIPOFEN CAPS NP
LOFIBRA CAPS (Fenofibrate Micronized) NP
LOFIBRA TABS (Fenofibrate) NP
LOPID TABS (Gemfibrozil) NP
TRICOR TABS (Fenofibrate) NP
TRIGLIDE TABS NP
TRILIPIX CPDR (Choline Fenofibrate) NP
HMG CoA Reductase Inhibitors ALTOPREV TB24 NP
atorvastatin calcium tabs F
CRESTOR TABS (Rosuvastatin Calcium) NP
fluvastatin sodium caps NP
fluvastatin sodium tb24 NP
LESCOL XL TB24 (Fluvastatin Sodium) NP
LIPITOR TABS (Atorvastatin Calcium) NP
Drug Name DrugTier
Requirements/Limits
LIVALO TABS NP
lovastatin tabs F
MEVACOR TABS (Lovastatin) NP
PRAVACHOL TABS (Pravastatin Sodium) NP
pravastatin sodium tabs F
rosuvastatin calcium tabs F
simvastatin tabs F
ZOCOR TABS (Simvastatin) NP
Intestinal Cholesterol Absorption Inhibitors ezetimibe tabs NP
ZETIA TABS (Ezetimibe) NP
Microsomal Triglyceride Transfer Protein (MTP) JUXTAPID CAPS NP
Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr F
NIACOR TABS NP
NIASPAN TBCR (Niacin (Antihyperlipidemic)) NP
Proprotein Convertase Subtilisin/Kexin Type 9
PRALUENT SOPN NP QL(0.0667 mldaily); AL; Atleast 18 yrs old
PRALUENT SOSY NP QL(0.0667 mldaily); AL; Atleast 18 yrs old
REPATHA PUSHTRONEX SYSTEM SOCT NP
Limit 3.5ml permonth;QL(0.117 ml daily); AL;At least 13 yrsold
REPATHA SOSY NP
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Drug Name DrugTier
Requirements/Limits
REPATHA SURECLICK SOAJ NP
QL(0.034 mldaily); AL; Atleast 13 yrs old
ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure ACE Inhibitors ACCUPRIL TABS (Quinapril HCl) NP
ACEON TABS (PerindoprilErbumine) NP
ALTACE CAPS (Ramipril) NP
benazepril hcl tabs F
captopril tabs or 50 mg, 25mg, 12.5 mg, 100 mg NP
enalapril maleate tabs F
EPANED SOLN NP
EPANED SOLR NP
fosinopril sodium tabs NP
lisinopril tabs F
LOTENSIN TABS (Benazepril HCl) NP
MAVIK TABS (Trandolapril) NP
moexipril hcl tabs NP
perindopril erbumine tabs NP
PRINIVIL TABS (Lisinopril) NP
QBRELIS SOLN NP
quinapril hcl tabs F
ramipril caps F
trandolapril tabs NP
VASOTEC TABS (EnalaprilMaleate) NP
ZESTRIL TABS (Lisinopril) NP
Drug Name DrugTier
Requirements/Limits
Angiotensin II Receptor Antagonists ATACAND TABS (Candesartan Cilexetil) NP
AVAPRO TABS (Irbesartan) NP
BENICAR TABS (Olmesartan Medoxomil) NP
candesartan cilexetil tabs NP
COZAAR TABS (Losartan Potassium) NP
DIOVAN TABS (Valsartan) NP
EDARBI TABS NP
EPROSARTAN MESYLATE TABS NP
irbesartan tabs F
losartan potassium tabs F
MICARDIS TABS (Telmisartan) NP
olmesartan medoxomil tabs or 20 mg, 40 mg, 5 mg NP
telmisartan tabs NP
valsartan tabs F
Antiadrenergic Antihypertensives CARDURA TABS (Doxazosin Mesylate) NP
CATAPRES TABS (Clonidine HCl) NP
CATAPRES-TTS-1 PTWK (Clonidine HCl) F
CATAPRES-TTS-2 PTWK (Clonidine HCl) F
CATAPRES-TTS-3 PTWK (Clonidine HCl) F
clonidine hcl ptwk td 0.1mg/24hr, 0.2 mg/24hr, 0.3mg/24hr
NP
clonidine hcl tabs or 0.3 mg, 0.2 mg, 0.1 mg F
doxazosin mesylate tabs F
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Drug Name DrugTier
Requirements/Limits
guanfacine hcl tabs F
methyldopa tabs F
MINIPRESS CAPS (Prazosin HCl) NP
prazosin hcl caps F
RESERPINE TABS NP
TENEX TABS (Guanfacine HCl) NP
terazosin hcl caps F
Antihypertensive Combinations ACCURETIC TABS (Quinapril-Hydrochlorothiazide)
NP
amlodipine besylate-benazepril hcl caps F
amlodipine besylate-olmesartan medoxomil tabs NP
amlodipine besylate-valsartan tabs NP
amlodipine-valsartan-hydrochlorothiazide tabs NP
ATACAND HCT TABS (Candesartan Cilexetil-Hydrochlorothiazide)
NP
atenolol & chlorthalidone tabs F
AVALIDE TABS (Irbesartan-Hydrochlorothiazide)
NP
AZOR TABS (AmlodipineBesylate-OlmesartanMedoxomil)
NP
benazepril &hydrochlorothiazide tabs F
BENICAR HCT TABS (Olmesartan Medoxomil-Hydrochlorothiazide)
NP
bisoprolol &hydrochlorothiazide tabs F
BYVALSON TABS NP QL(1 ea daily)
Drug Name DrugTier
Requirements/Limits
candesartan cilexetil-hydrochlorothiazide tabs NP
CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS NP
CLORPRES TABS NP
CORZIDE TABS (Nadolol & Bendroflumethiazide) NP
DIOVAN HCT TABS (Valsartan-Hydrochlorothiazide)
NP
DUTOPROL TB24 NP
EDARBYCLOR TABS NP
enalapril maleate &hydrochlorothiazide tabs F
EXFORGE HCT TABS (Amlodipine-Valsartan-Hydrochlorothiazide)
NP
EXFORGE TABS (Amlodipine Besylate-Valsartan)
NP
fosinopril sodium &hydrochlorothiazide tabs NP
HYZAAR TABS (Losartan Potassium & Hydrochlorothiazide)
NP
irbesartan-hydrochlorothiazide tabs F
lisinopril &hydrochlorothiazide tabs F
LOPRESSOR HCT TABS (Metoprolol &Hydrochlorothiazide)
NP
losartan potassium &hydrochlorothiazide tabs F
LOTENSIN HCT TABS (Benazepril &Hydrochlorothiazide)
NP
LOTREL CAPS (Amlodipine Besylate-Benazepril HCl)
NP
METHYLDOPA/HYDROCHLOROTHIAZIDE TABS NP
metoprolol &hydrochlorothiazide tabs NP
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Drug Name DrugTier
Requirements/Limits
METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE TB24
NP
METOPROLOL/HYDROCHLOROTHIAZIDE TABS NP
MICARDIS HCT TABS (Telmisartan-Hydrochlorothiazide)
NP
moexipril-hydrochlorothiazide tabs NP
nadolol & bendroflumethiazide tabs NP
olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs
NP
olmesartan medoxomil-hydrochlorothiazide tabs NP
PRESTALIA TABS NP QL(1 ea daily)
PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS NP
quinapril-hydrochlorothiazide tabs NP
TARKA TBCR (Trandolapril-VerapamilHCl)
NP
TEKTURNA HCT TABS NP
telmisartan-amlodipine tabs NP
telmisartan-hydrochlorothiazide tabs NP
TENORETIC 100 TABS (Atenolol & Chlorthalidone) NP
TENORETIC 50 TABS (Atenolol & Chlorthalidone) NP
trandolapril-verapamil hcltbcr NP
TRIBENZOR TABS (Olmesartan Medoxomil-Amlodipine-Hydrochlorothiazide)
NP
TWYNSTA TABS (Telmisartan-Amlodipine) NP
valsartan-hydrochlorothiazide tabs F
Drug Name DrugTier
Requirements/Limits
VASERETIC TABS (Enalapril Maleate &Hydrochlorothiazide)
NP
ZESTORETIC TABS (Lisinopril &Hydrochlorothiazide)
NP
ZIAC TABS (Bisoprolol &Hydrochlorothiazide) NP
Direct Renin Inhibitors TEKTURNA TABS NP QL(1 ea daily)
Selective Aldosterone Receptor Antagonists eplerenone tabs NP
INSPRA TABS (Eplerenone) NP
Vasodilators hydralazine hcl tabs or 100mg, 50 mg, 25 mg, 10 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
chloroquine phosphate tabs500 mg, 250 mg F
hydroxychloroquine sulfatetabs F
mefloquine hcl tabs F
MEFLOQUINE HCL TABS F
PLAQUENIL TABS (HydroxychloroquineSulfate)
NP
PRIMAQUINE PHOSPHATE TABS F
ANTIMYASTHENIC/CHOLINERGIC AGENTS
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Drug Name DrugTier
Requirements/Limits
Antimyasthenic/Cholinergic Agents MESTINON TABS 60 MG (Pyridostigmine Bromide) NP
MESTINON TIMESPAN TBCR (PyridostigmineBromide)
NP
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 (Ethambutol HCl) NP
pyrazinamide tabs F
RIFADIN CAPS OR 150 MG, 300 MG (Rifampin) NP
rifampin caps or 150 mg,300 mg F
TRECATOR TABS F
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN TABS OR 2 MG (Melphalan) F
CYCLOPHOSPHAMIDE CAPS OR 25 MG, 50 MG F
GLEOSTINE CAPS F
HEXALEN CAPS NP
LEUKERAN TABS F
LOMUSTINE CAPS F
melphalan tabs NP
Drug Name DrugTier
Requirements/Limits
MYLERAN TABS F
TEMODAR CAPS OR 20 MG, 180 MG, 100 MG, 5 MG, 140 MG, 250 MG (Temozolomide)
NP
temozolomide caps F
Antimetabolites capecitabine tabs F PA
mercaptopurine tabs F
methotrexate sodium soln ij1 gm/40ml, 200 mg/8ml,100 mg/4ml, 250 mg/10ml,50 mg/2ml
F
METHOTREXATE SODIUM SOLN IJ 250 MG/10ML
F
methotrexate sodium solr ij1 gm F
methotrexate sodium tabs or 2.5 mg F
PURIXAN SUSP NP
TABLOID TABS NP AL; Up to 18yrs old
TREXALL TABS F
XELODA TABS (Capecitabine) NP PA
Antineoplastic - BCL-2 Inhibitors VENCLEXTA STARTING PACK TBPK F PA
VENCLEXTA TABS F PA
Antineoplastic - Hedgehog Pathway Inhibitors ERIVEDGE CAPS F
ODOMZO CAPS F
Antineoplastic - Hormonal and Related Agents
anastrozole tabs F AL; At least 18 yrs old
ARIMIDEX TABS (Anastrozole) NP AL; At least 18 yrs old
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Drug Name DrugTier
Requirements/Limits
AROMASIN TABS (Exemestane) NP AL; At least 18 yrs old
bicalutamide tabs F AL; At least 18 yrs old
CASODEX TABS (Bicalutamide) NP AL; At least 18 yrs old
EMCYT CAPS NP
exemestane tabs F AL; At least 18 yrs old
FARESTON TABS NP AL; At least 18 yrs old
FEMARA TABS (Letrozole) NP AL; At least 18 yrs old
flutamide caps F AL; At least 18 yrs old
letrozole tabs F AL; At least 18 yrs old
MEGACE ORAL SUSP (Megestrol Acetate) NP
megestrol acetate susp F
megestrol acetate tabs F
NILANDRON TABS (Nilutamide) NP AL; At least 18 yrs old
nilutamide tabs NP AL; At least 18 yrs old
tamoxifen citrate tabs F AL; At least 18 yrs old
XTANDI CAPS NP QL(4 ea daily);AL; At least 19 yrs old
ZYTIGA TABS NP QL(2 ea daily);AL; At least 18 yrs old
Antineoplastic - Immunomodulators POMALYST CAPS NP
Antineoplastic Combinations LONSURF TABS NP
Antineoplastic Enzyme Inhibitors AFINITOR DISPERZ TBSO NP
Drug Name DrugTier
Requirements/Limits
AFINITOR TABS F
ALECENSA CAPS F PA
ALUNBRIG TABS NP
BOSULIF TABS NP
CABOMETYX TABS F PA
CALQUENCE CAPS NP QL(2 ea daily)
CAPRELSA TABS F
COMETRIQ KIT NP
COTELLIC TABS F
FARYDAK CAPS NP
GILOTRIF TABS F
GLEEVEC TABS (Imatinib Mesylate) F
IBRANCE CAPS NP QL(1 ea daily)
ICLUSIG TABS 15 MG NP QL(2 ea daily)
ICLUSIG TABS 45 MG NP QL(1 ea daily)
IDHIFA TABS NP QL(1 ea daily)
imatinib mesylate tabs NP
IMBRUVICA CAPS F
INLYTA TABS F
IRESSA TABS F
JAKAFI TABS F
LENVIMA 10 MG DAILY DOSE CPPK NP
LENVIMA 14 MG DAILY DOSE CPPK NP
LENVIMA 18 MG DAILY DOSE CPPK NP
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Drug Name DrugTier
Requirements/Limits
LENVIMA 20 MG DAILY DOSE CPPK NP
LENVIMA 24 MG DAILY DOSE CPPK NP
LENVIMA 8 MG DAILY DOSE CPPK NP
LYNPARZA CAPS NP
LYNPARZA TABS NP
MEKINIST TABS F
NERLYNX TABS NP
NEXAVAR TABS F
NINLARO CAPS F PA
RUBRACA TABS NP QL(4 ea daily)
RYDAPT CAPS NP QL(8 ea daily)
SPRYCEL TABS F
STIVARGA TABS NP
SUTENT CAPS F
TAFINLAR CAPS F
TAGRISSO TABS NP QL(1 ea daily)
TARCEVA TABS F
TASIGNA CAPS F QL(4 ea daily)
TYKERB TABS NP
VOTRIENT TABS F
XALKORI CAPS F
ZEJULA CAPS NP QL(3 ea daily)
ZELBORAF TABS F
ZOLINZA CAPS NP
Drug Name DrugTier
Requirements/Limits
ZYDELIG TABS NP
ZYKADIA CAPS NP
Antineoplastics Misc. HYDREA CAPS (Hydroxyurea) NP
hydroxyurea caps F
MATULANE CAPS F
tretinoin (chemotherapy) caps NP
Chemotherapy Rescue/Antidote Agents amifostine solr F
ETHYOL SOLR F
LEUCOVORIN CALCIUM TABS OR 15 MG, 10 MG F
leucovorin calcium tabs or 5 mg, 25 mg F
Topoisomerase I Inhibitors HYCAMTIN CAPS OR 1 MG, 0.25 MG F
ANTIPARKINSON AGENTS - Drugs to TreatParkinson's Disease Antiparkinson Adjuvants carbidopa tabs NP
LODOSYN TABS (Carbidopa) NP
Antiparkinson Anticholinergics benztropine mesylate tabsor 2 mg, 1 mg, 0.5 mg F
trihexyphenidyl hcl elix F
trihexyphenidyl hcl tabs F
Antiparkinson COMT Inhibitors COMTAN TABS (Entacapone) NP
entacapone tabs NP
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Drug Name DrugTier
Requirements/Limits
TASMAR TABS (Tolcapone) NP
tolcapone tabs NP
Antiparkinson Dopaminergics amantadine hcl caps 100 mg F
amantadine hcl syrp 50mg/5ml F
amantadine hcl tabs 100 mg NP
bromocriptine mesylate caps F
bromocriptine mesylatetabs F
carbidopa-levodopa tabs25mg-250mg, 10mg-100mg, 25mg-100mg
F
carbidopa-levodopa tbcr25mg-100mg, 50mg-200mg
F
carbidopa-levodopa tbdp10mg-100mg, 25mg-250mg, 25mg-100mg
NP
CARBIDOPA/LEVODOPA/ENTACAPONE TABS F
DUOPA SUSP NP
MIRAPEX ER TB24 (PramipexoleDihydrochloride)
NP
MIRAPEX TABS (PramipexoleDihydrochloride)
NP
NEUPRO PT24 NP
PARLODEL CAPS (Bromocriptine Mesylate) NP
PARLODEL TABS (Bromocriptine Mesylate) NP
pramipexoledihydrochloride tabs 1.5mg, 0.25 mg, 0.125 mg, 0.5mg, 0.75 mg, 1 mg
F
Drug Name DrugTier
Requirements/Limits
pramipexoledihydrochloride tb24 2.25mg, 0.375 mg, 1.5 mg, 0.75mg, 3 mg, 4.5 mg, 3.75 mg
NP
REQUIP TABS (RopiniroleHydrochloride) NP
REQUIP XL TB24 (Ropinirole Hydrochloride) NP
ropinirole hydrochloridetabs 2 mg, 0.25 mg, 5 mg,3 mg, 0.5 mg, 1 mg, 4 mg
F
ropinirole hydrochloridetb24 4 mg, 6 mg, 12 mg, 8mg, 2 mg
NP
RYTARY CPCR NP
SINEMET CR TBCR (Carbidopa-Levodopa) NP
SINEMET TABS (Carbidopa-Levodopa) NP
STALEVO 100 TABS 4
STALEVO 125 TABS 4
STALEVO 150 TABS 4
STALEVO 200 TABS 4
STALEVO 50 TABS 4
STALEVO 75 TABS 4
Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (RasagilineMesylate) NP QL(1 ea daily)
ELDEPRYL CAPS (Selegiline HCl) NP
rasagiline mesylate tabs or0.5 mg, 1 mg NP QL(1 ea daily)
selegiline hcl caps NP
selegiline hcl tabs F
XADAGO TABS NP QL(1 ea daily)
ZELAPAR TBDP NP
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Drug Name DrugTier
Requirements/Limits
ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders Antimanic Agents LITHIUM CARBONATE CAPS 150 MG, 600 MG (Lithium Carbonate)
F AL; At least 4 yrs old
lithium carbonate caps 150mg, 600 mg, 300 mg F AL; At least 4
yrs old lithium carbonate tabs 300 mg F AL; At least 4
yrs old lithium carbonate tbcr 300 mg, 450 mg F AL; At least 4
yrs old
LITHIUM SOLN F
LITHOBID TBCR (Lithium Carbonate) NP AL; At least 4 yrs old Antipsychotics - Misc. EQUETRO CP12 F PA
GEODON CAPS OR 20 MG (Ziprasidone HCl) NP
QL(8 ea daily);AL; At least 6 yrs old
GEODON CAPS OR 40 MG (Ziprasidone HCl) NP
QL(4 ea daily);AL; At least 6 yrs old
GEODON CAPS OR 60 MG (Ziprasidone HCl) NP
QL(3 ea daily);AL; At least 6 yrs old
GEODON CAPS OR 80 MG (Ziprasidone HCl) NP
QL(2 ea daily);AL; At least 6 yrs old
GEODON SOLR IM 20 MG F PA; QL(6 eadaily)
LATUDA TABS 60 MG, 40 MG, 20 MG, 120 MG F
PA; QL(1 eadaily); AL; Atleast 18 yrs old
LATUDA TABS 80 MG F PA; QL(2 eadaily); AL; Atleast 18 yrs old
NUPLAZID TABS F QL(2 ea daily);AL; At least 18 yrs old
VRAYLAR CAPS F PA; QL(1 eadaily); AL; Atleast 18 yrs old
Drug Name DrugTier
Requirements/Limits
VRAYLAR CPPK F PA; QL(1 eadaily); AL; Atleast 18 yrs old
ziprasidone hcl caps 20 mg F QL(8 ea daily);AL; At least 6 yrs old
ziprasidone hcl caps 40 mg F QL(4 ea daily);AL; At least 6 yrs old
ziprasidone hcl caps 60 mg F QL(3 ea daily);AL; At least 6 yrs old
ziprasidone hcl caps 80 mg F QL(2 ea daily);AL; At least 6 yrs old
Benzisoxazoles
FANAPT TABS F PA; AL; At least 6 yrs old
FANAPT TITRATION PACK TABS F PA; AL; At least
6 yrs old INVEGA SUSTENNA SUSP F PA
INVEGA TB24 6 MG (Paliperidone) NP
QL(2 ea daily);AL; At least 12 yrs old
INVEGA TB24 9 MG, 3 MG, 1.5 MG (Paliperidone) NP
QL(1 ea daily);AL; At least 12 yrs old
INVEGA TRINZA SUSP F PA
paliperidone tb24 6 mg F QL(2 ea daily);AL; At least 12 yrs old
paliperidone tb24 9 mg, 3mg, 1.5 mg F
QL(1 ea daily);AL; At least 12 yrs old
RISPERDAL CONSTA SUSR F QL(1 ea per 14
days retail) RISPERDAL M-TAB TBDP (Risperidone) NP AL; At least 5 yrs old RISPERDAL SOLN (Risperidone) NP AL; At least 5 yrs old RISPERDAL TABS (Risperidone) NP AL; At least 5 yrs old
risperidone soln F AL; At least 5 yrs old
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Drug Name DrugTier
Requirements/Limits
risperidone tabs F AL; At least 5 yrs old
risperidone tbdp F AL; At least 5 yrs old
Butyrophenones HALDOL DECANOATE 100 SOLN (HaloperidolDecanoate)
NP
HALDOL DECANOATE 50 SOLN (HaloperidolDecanoate)
NP
HALDOL SOLN (Haloperidol Lactate) NP
haloperidol decanoate soln F
haloperidol lactate conc F
haloperidol lactate soln F
haloperidol tabs or 10 mg,1 mg, 2 mg, 20 mg, 5 mg,0.5 mg
F AL; At least 6 yrs old
Dibenzapines ADASUVE AEPB F
CLOZAPINE ODT TBDP F AL; At least 6 yrs old
clozapine tabs F AL; At least 6 yrs old
clozapine tbdp F AL; At least 6 yrs old
CLOZARIL TABS (Clozapine) NP AL; At least 6 yrs old FAZACLO TBDP 100 MG, 25 MG (Clozapine) NP AL; At least 6 yrs old FAZACLO TBDP 12.5 MG, 150 MG, 200 MG F AL; At least 6
yrs old
loxapine succinate caps F AL; At least 6 yrs old
olanzapine solr F AL; At least 6 yrs old
olanzapine tabs F AL; At least 6 yrs old
olanzapine tbdp F AL; At least 6 yrs old
Drug Name DrugTier
Requirements/Limits
quetiapine fumarate tabs400 mg, 100 mg, 200 mg,25 mg, 300 mg, 50 mg
F AL; At least 6 yrs old
quetiapine fumarate tb24200 mg, 150 mg F
QL(1 ea daily);AL; At least 6 yrs old
quetiapine fumarate tb24300 mg, 50 mg, 400 mg F
QL(2 ea daily);AL; At least 6 yrs old
SAPHRIS SUBL F PA; QL(2 eadaily); AL; Atleast 10 yrs old
SEROQUEL TABS (Quetiapine Fumarate) NP AL; At least 6 yrs old SEROQUEL XR TB24 150 MG, 200 MG (QuetiapineFumarate)
NP QL(1 ea daily);AL; At least 6 yrs old
SEROQUEL XR TB24 300 MG, 50 MG, 400 MG (Quetiapine Fumarate)
NP QL(2 ea daily);AL; At least 6 yrs old
VERSACLOZ SUSP F
ZYPREXA RELPREVV SUSR F
ZYPREXA SOLR (Olanzapine) NP AL; At least 6 yrs old ZYPREXA TABS (Olanzapine) NP AL; At least 6 yrs old ZYPREXA ZYDIS TBDP (Olanzapine) NP AL; At least 6 yrs old Dihydroindolones MOLINDONE HYDROCHLORIDE TABS F AL; At least 6
yrs old Phenothiazines CHLORPROMAZINE HCL SOLN IJ 50 MG/2ML, 25MG/ML
F
chlorpromazine hcl tabs or50 mg, 10 mg, 100 mg, 25mg, 200 mg
F AL; At least 6 yrs old
fluphenazine decanoatesoln ij F AL; At least 6
yrs old FLUPHENAZINE HCL CONC OR 5 MG/ML F AL; At least 6
yrs old FLUPHENAZINE HCL ELIX OR 2.5 MG/5ML F AL; At least 6
yrs old
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Drug Name DrugTier
Requirements/Limits
FLUPHENAZINE HCL SOLN IJ 2.5 MG/ML F AL; At least 6
yrs old fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg F AL; At least 6
yrs old
perphenazine tabs 16 mg F QL(4 ea daily);AL; At least 6 yrs old
perphenazine tabs 2 mg F QL(32 eadaily); AL; Atleast 6 yrs old
perphenazine tabs 4 mg F QL(16 eadaily); AL; Atleast 6 yrs old
perphenazine tabs 8 mg F QL(8 ea daily);AL; At least 6 yrs old
prochlorperazine edisylatesoln F
prochlorperazine maleatetabs F
prochlorperazine supp NP
thioridazine hcl tabs F AL; At least 6 yrs old
trifluoperazine hcl tabs F AL; At least 6 yrs old
Quinolinone Derivatives
ABILIFY TABS 10 MG, 15 MG, 5 MG (Aripiprazole) NP
QL(1.5 eadaily); AL; Atleast 6 yrs old
ABILIFY TABS 2 MG (Aripiprazole) NP
QL(2 ea daily);AL; At least 6 yrs old
ABILIFY TABS 30 MG, 20 MG (Aripiprazole) NP
QL(1 ea daily);AL; At least 6 yrs old
aripiprazole soln 1 mg/ml F
aripiprazole tabs 15 mg, 5mg, 10 mg F
QL(1.5 eadaily); AL; Atleast 6 yrs old
aripiprazole tabs 2 mg F QL(2 ea daily);AL; At least 6 yrs old
aripiprazole tabs 20 mg, 30 mg F
QL(1 ea daily);AL; At least 6 yrs old
Drug Name DrugTier
Requirements/Limits
aripiprazole tbdp 15 mg, 10 mg F
QL(1.5 eadaily); AL; Atleast 6 yrs old
ARISTADA PRSY F
REXULTI TABS F QL(1 ea daily);AL; At least 18 yrs old
Thioxanthenes
thiothixene caps F AL; At least 6 yrs old
ANTISEPTICS & DISINFECTANTS - Drugs toPrevent Bacterial Skin Infections Antiseptics & Disinfectants formaldehyde soln 10%, 10% F
Chlorine Antiseptics chlorhexidine gluconateliqd ex 4 % F
chlorhexidine gluconatesoln ex 4 % F
HIBICLENS LIQD (Chlorhexidine Gluconate) NP
ANTIVIRALS - Drugs to Treat Viral Infections
Antiretrovirals abacavir sulfate soln 20 mg/ml F QL(30 ml daily)
abacavir sulfate tabs 300 mg F QL(2 ea daily)
abacavir sulfate-lamivudine tabs F QL(1 ea daily)
abacavir sulfate-lamivudine-zidovudine tabs F QL(2 ea daily)
APTIVUS CAPS 250 MG F QL(4 ea daily)
APTIVUS SOLN 100 MG/ML F QL(10 ml daily)
ATRIPLA TABS F QL(1 ea daily)
COMBIVIR TABS (Lamivudine-Zidovudine) NP QL(2 ea daily)
COMPLERA TABS F QL(1 ea daily)
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Drug Name DrugTier
Requirements/Limits
CRIXIVAN CAPS 200 MG F QL(9 ea daily)
CRIXIVAN CAPS 400 MG F QL(6 ea daily)
DESCOVY TABS F QL(1 ea daily);AL; At least 12 yrs old
didanosine cpdr F QL(1 ea daily)
EDURANT TABS F QL(1 ea daily)
EMTRIVA CAPS 200 MG F QL(1 ea daily)
EMTRIVA SOLN 10 MG/ML F QL(24 ml daily)
EPIVIR SOLN 10 MG/ML(Lamivudine) NP QL(30 ml daily)
EPIVIR TABS 150 MG (Lamivudine) NP QL(2 ea daily)
EPIVIR TABS 300 MG (Lamivudine) NP QL(1 ea daily)
EPZICOM TABS (Abacavir Sulfate-Lamivudine) NP QL(1 ea daily)
EVOTAZ TABS F QL(1 ea daily)
fosamprenavir calcium tabs F QL(4 ea daily)
GENVOYA TABS F QL(1 ea daily);AL; At least 12 yrs old
INTELENCE TABS 100 MG, 25 MG F QL(4 ea daily)
INTELENCE TABS 200 MG F QL(2 ea daily)
INVIRASE CAPS 200 MG F QL(10 ea daily)
INVIRASE TABS 500 MG F QL(4 ea daily)
ISENTRESS CHEW 100 MG F QL(6 ea daily)
ISENTRESS CHEW 25 MG F QL(12 ea daily)
ISENTRESS PACK 100 MG F QL(2 ea daily)
ISENTRESS TABS 400 MG F QL(2 ea daily)
Drug Name DrugTier
Requirements/Limits
KALETRA SOLN 400MG/5ML-100MG/5ML(Lopinavir-Ritonavir)
NP QL(16 ml daily)
KALETRA TABS 100MG-25MG F QL(4 ea daily)
KALETRA TABS 200MG-50MG F QL(6 ea daily)
lamivudine soln 10 mg/ml F QL(30 ml daily)
lamivudine tabs 150 mg F QL(2 ea daily)
lamivudine tabs 300 mg F QL(1 ea daily)
lamivudine-zidovudine tabs F QL(2 ea daily)
LEXIVA SUSP 50 MG/ML F QL(56 ml daily)
LEXIVA TABS 700 MG (Fosamprenavir Calcium) NP QL(4 ea daily)
lopinavir-ritonavir soln F QL(16 ml daily)
NEVIRAPINE SUSP 50 MG/5ML F QL(40 ml daily)
nevirapine tabs 200 mg F QL(2 ea daily)
nevirapine tb24 100 mg F QL(3 ea daily)
nevirapine tb24 400 mg F QL(1 ea daily)
NORVIR CAPS 100 MG F QL(12 ea daily)
NORVIR SOLN 80 MG/ML F QL(15 ml daily)
NORVIR TABS 100 MG F QL(12 ea daily)
ODEFSEY TABS F
PREZCOBIX TABS F QL(1 ea daily)
PREZISTA SUSP 100 MG/ML F QL(12 ml daily)
PREZISTA TABS 150 MG F QL(3 ea daily)
PREZISTA TABS 600 MG, 75 MG F QL(2 ea daily)
PREZISTA TABS 800 MG F QL(1 ea daily)
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Drug Name DrugTier
Requirements/Limits
RESCRIPTOR TABS 100 MG F QL(12 ea daily)
RESCRIPTOR TABS 200 MG F QL(6 ea daily)
RETROVIR CAPS 100 MG (Zidovudine) NP QL(6 ea daily)
RETROVIR SYRP 50 MG/5ML (Zidovudine) NP QL(60 ml daily)
REYATAZ CAPS 150 MG, 200 MG F QL(2 ea daily)
REYATAZ CAPS 300 MG F
REYATAZ PACK 50 MG F QL(6 ea daily)
SELZENTRY TABS 150 MG, 75 MG F QL(2 ea daily)
SELZENTRY TABS 25 MG F QL(3 ea daily)
SELZENTRY TABS 300 MG F QL(4 ea daily)
stavudine caps 40 mg, 30mg, 15 mg, 20 mg F QL(2 ea daily)
stavudine solr 1 mg/ml F QL(80 ml daily)
STRIBILD TABS F QL(1 ea daily)
SUSTIVA CAPS 200 MG F QL(1 ea daily)
SUSTIVA CAPS 50 MG F QL(2 ea daily)
SUSTIVA TABS 600 MG F QL(1 ea daily)
TIVICAY TABS 25 MG, 10 MG F
TIVICAY TABS 50 MG F QL(2 ea daily)
TRIUMEQ TABS F QL(1 ea daily);AL; At least 18 yrs old
TRIZIVIR TABS (Abacavir Sulfate-Lamivudine-Zidovudine)
NP QL(2 ea daily)
TRUVADA TABS F QL(1 ea daily)
TYBOST TABS F QL(1 ea daily);AL; At least 18 yrs old
Drug Name DrugTier
Requirements/Limits
VIDEX EC CPDR (Didanosine) NP QL(1 ea daily)
VIDEXPEDIATRIC SOLR F QL(20 ml daily)
VIRACEPT TABS 250 MG F QL(9 ea daily)
VIRACEPT TABS 625 MG F QL(4 ea daily)
VIRAMUNE SUSP 50 MG/5ML F QL(40 ml daily)
VIRAMUNE TABS 200 MG (Nevirapine) NP QL(2 ea daily)
VIRAMUNE XR TB24 100 MG (Nevirapine) NP QL(3 ea daily)
VIRAMUNE XR TB24 400 MG (Nevirapine) NP QL(1 ea daily)
VIREAD POWD 40 MG/GM F QL(8 gm daily)
VIREAD TABS 250 MG, 150 MG, 200 MG, 300 MG F QL(1 ea daily)
VITEKTA TABS F QL(1 ea daily);AL; At least 18 yrs old
ZERIT CAPS 20 MG, 30 MG, 15 MG, 40 MG (Stavudine)
NP QL(2 ea daily)
ZERIT SOLR 1 MG/ML F QL(80 ml daily)
ZIAGEN SOLN 20 MG/ML(Abacavir Sulfate) NP QL(30 ml daily)
ZIAGEN TABS 300 MG (Abacavir Sulfate) NP QL(2 ea daily)
zidovudine caps 100 mg F QL(6 ea daily)
zidovudine syrp 50 mg/5ml F QL(60 ml daily)
zidovudine tabs 300 mg F QL(2 ea daily)
CMV Agents VALCYTE TABS 450 MG (Valganciclovir HCl) NP QL(2 ea daily)
valganciclovir hcl tabs 450 mg F QL(2 ea daily)
Hepatitis Agents adefovir dipivoxil tabs F PA
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Drug Name DrugTier
Requirements/Limits
BARACLUDE SOLN 0.05 MG/ML F PA
BARACLUDE TABS 1 MG, 0.5 MG (Entecavir) NP PA
COPEGUS TABS (Ribavirin (Hepatitis C)) NP PA
DAKLINZA TABS F PA; QL(1 eadaily)
entecavir tabs F PA
EPCLUSA TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old
EPIVIR HBV SOLN 5 MG/ML F PA
EPIVIR HBV TABS 100 MG (Lamivudine (HBV)) NP PA
HARVONI TABS F PA; QL(28 eaper fill retail)
HEPSERA TABS (Adefovir Dipivoxil) NP PA
lamivudine (hbv) tabs F PA
MAVYRET TABS F PA; QL(3 eadaily); AL; Atleast 18 yrs old
OLYSIO CAPS NP
PEG-INTRON KIT F PA; QL(0.143ea daily)
PEG-INTRON REDIPEN KIT F PA; QL(0.143
ea daily) PEG-INTRON REDIPEN PAK 4 KIT F PA; QL(0.143
ea daily) PEGASYS PROCLICK SOLN F PA
PEGASYS SOLN F PA
PEGINTRON KIT F PA; QL(0.143ea daily)
REBETOL CAPS 200 MG (Ribavirin (Hepatitis C)) NP PA
REBETOL SOLN 40 MG/ML NP
ribavirin (hepatitis c) caps F PA
Drug Name DrugTier
Requirements/Limits
ribavirin (hepatitis c) tabs F PA
SOVALDI TABS NP QL(28 ea perfill retail)
TECHNIVIE TABS F PA; QL(2 eadaily)
TYZEKA TABS F PA
VIEKIRA PAK TBPK F PA; QL(4 eadaily,28 day(s)limit)
VIEKIRA XR TB24 F PA; QL(3 eadaily); AL; Atleast 18 yrs old
VOSEVI TABS NP QL(1 ea daily);AL; At least 18 yrs old
ZEPATIER TABS NP
Herpes Agents acyclovir caps F
acyclovir susp F
acyclovir tabs F
famciclovir tabs F
FAMVIR TABS (Famciclovir) NP
SITAVIG TABS NP
valacyclovir hcl tabs 1 gm,1000 mg F
QL(3 eadaily,10 day(s)limit)
valacyclovir hcl tabs 500 mg F
VALTREX TABS 1 GM (Valacyclovir HCl) NP
QL(3 eadaily,10 day(s)limit)
VALTREX TABS 500 MG (Valacyclovir HCl) NP
ZOVIRAX CAPS OR 200 MG (Acyclovir) NP
ZOVIRAX SUSP OR 200 MG/5ML (Acyclovir) NP
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Drug Name DrugTier
Requirements/Limits
ZOVIRAX TABS OR 400 MG, 800 MG (Acyclovir) NP
Influenza Agents FLUMADINE TABS (Rimantadine Hydrochloride)
NP
oseltamivir phosphate caps30 mg, 45 mg NP
Limit 10ea in 180 days;QL(12 eaper fill retail)
oseltamivir phosphate caps75 mg NP QL(12 ea perfill retail) oseltamivir phosphate susr6 mg/ml F QL(120 ml per
fill retail) RELENZA DISKHALER AEPB F AL; At least 5
yrs old rimantadine hydrochloridetabs F
TAMIFLU CAPS 30 MG, 45 MG (Oseltamivir Phosphate)
F
Limit 10ea in 180 days;QL(12 eaper fill retail)
TAMIFLU CAPS 75 MG (Oseltamivir Phosphate) F QL(12 ea per
fill retail) TAMIFLU SUSR 6 MG/ML(Oseltamivir Phosphate) NP QL(120 ml perfill retail) BETA BLOCKERS - Drugs to Treat High BloodPressure Alpha-Beta Blockers carvedilol phosphate cp24 NP
carvedilol tabs F
COREG CR CP24 (Carvedilol Phosphate) NP
COREG TABS (Carvedilol) NP
labetalol hcl tabs or 100 mg, 200 mg, 300 mg F
Beta Blockers Cardio-Selective acebutolol hcl caps NP
atenolol tabs F
betaxolol hcl tabs NP
Drug Name DrugTier
Requirements/Limits
bisoprolol fumarate tabs NP
BYSTOLIC TABS NP
LOPRESSOR TABS (Metoprolol Tartrate) NP
metoprolol succinate tb24 F
metoprolol tartrate tabs or50 mg, 25 mg, 100 mg F
METOPROLOL TARTRATE TABS OR 75 MG, 37.5 MG
F
SECTRAL CAPS (Acebutolol HCl) NP
TENORMIN TABS (Atenolol) NP
TOPROL XL TB24 (Metoprolol Succinate) NP
ZEBETA TABS (BisoprololFumarate) NP
Beta Blockers Non-Selective BETAPACE AF TABS (Sotalol HCl (AFIB/AFL)) NP
BETAPACE TABS (Sotalol HCl) NP
CORGARD TABS (Nadolol) NP
HEMANGEOL SOLN NP
INDERAL LA CP24 (Propranolol HCl) NP
INDERAL XL CP24 NP
INNOPRAN XL CP24 NP
nadolol tabs NP
pindolol tabs NP
propranolol hcl cp24 or 160mg, 80 mg, 120 mg, 60 mg F
PROPRANOLOL HCL SOLN OR 40 MG/5ML, 20MG/5ML
F
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Drug Name DrugTier
Requirements/Limits
propranolol hcl tabs or 40mg, 60 mg, 10 mg, 80 mg,20 mg
F
sotalol hcl (afib/afl) tabs F
sotalol hcl tabs F
SOTYLIZE SOLN NP
TIMOLOL MALEATE TABS NP
CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure Calcium Channel Blockers ADALAT CC TB24 (Nifedipine) NP
amlodipine besylate tabs F
CALAN SR TBCR (Verapamil HCl) NP
CALAN TABS (VerapamilHCl) NP
CARDIZEM CD CP24 (Diltiazem HCl Coated Beads)
NP
CARDIZEM LA TB24 120 MG NP
CARDIZEM LA TB24 300 MG, 360 MG, 180 MG, 420 MG, 240 MG (Diltiazem HCl Coated Beads)
NP
CARDIZEM TABS (Diltiazem HCl) NP
diltiazem hcl coated beads cp24 120 mg, 240 mg, 180mg, 360 mg, 300 mg
F
diltiazem hcl coated beads tb24 360 mg, 180 mg, 300mg, 240 mg, 420 mg
NP
diltiazem hcl cp12 or 90mg, 60 mg, 120 mg F
diltiazem hcl cp24 or 180mg, 120 mg, 240 mg F
diltiazem hcl extended release beads cp24 F
diltiazem hcl tabs or 30 mg,90 mg, 60 mg, 120 mg F
Drug Name DrugTier
Requirements/Limits
felodipine tb24 NP
isradipine caps NP
nicardipine hcl caps or 30mg, 20 mg NP
nifedipine caps F
nifedipine tb24 F
nimodipine caps NP
NISOLDIPINE ER TB24 NP
nisoldipine tb24 NP
NORVASC TABS (Amlodipine Besylate) NP
NYMALIZE SOLN NP
PROCARDIA CAPS (Nifedipine) NP
PROCARDIA XL TB24 (Nifedipine) NP
SULAR TB24 (Nisoldipine) NP
TIAZAC CP24 (Diltiazem HCl Extended Release Beads)
NP
verapamil hcl cp24 or 120mg, 100 mg, 180 mg, 360mg, 200 mg, 240 mg, 300 mg
NP
verapamil hcl tabs or 40mg, 120 mg, 80 mg F
verapamil hcl tbcr or 240mg, 120 mg, 180 mg F
VERELAN CP24 (Verapamil HCl) NP
VERELAN PM CP24 (Verapamil HCl) NP
CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm Cardiac Glycosides DIGOXIN SOLN OR 0.05 MG/ML F
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Drug Name DrugTier
Requirements/Limits
digoxin tabs or 250 mcg,0.125 mg, 125 mcg, 0.25 mg
F
LANOXIN TABS OR 250 MCG, 125 MCG (Digoxin) NP
CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation Conditions Cardiovascular Agents Misc. - Combinations amlodipine besylate-atorvastatin calcium tabs NP
BIDIL TABS NP
CADUET TABS (Amlodipine Besylate-Atorvastatin Calcium)
NP
ENTRESTO TABS F PA; QL(2 eadaily)
Peripheral Vasodilators inositol niacinate caps F
Prostaglandin Vasodilators ORENITRAM TBCR NP
TYVASO REFILL SOLN F QL(81.2 ml perfill retail)
TYVASO SOLN F QL(81.2 ml perfill retail)
TYVASO STARTER SOLN F QL(81.2 ml perfill retail)
VENTAVIS SOLN 10 MCG/ML F QL(5 ml daily)
VENTAVIS SOLN 20 MCG/ML F QL(3 ml daily)
Pulmonary Hypertension - Endothelin Receptor LETAIRIS TABS F
OPSUMIT TABS NP
TRACLEER TABS F
Pulmonary Hypertension - Phosphodiesterase
ADCIRCA TABS F PA; QL(3 eadaily)
REVATIO SUSR OR 10 MG/ML F PA
Drug Name DrugTier
Requirements/Limits
REVATIO TABS OR 20 MG (Sildenafil Citrate (Pulmonary Hypertension))
NP PA; QL(3 eadaily)
sildenafil citrate (pulmonaryhypertension) tabs or 20 mg
F PA; QL(3 eadaily)
Pulmonary Hypertension - Prostacyclin Receptor UPTRAVI TABS NP
UPTRAVI TBPK NP
Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS NP
Sinus Node Inhibitors CORLANOR TABS NP QL(2 ea daily)
CEPHALOSPORINS - Drugs to Treat BacterialInfections Cephalosporins - 1st Generation cefadroxil caps 500 mg F
cefadroxil susr 250 mg/5ml,500 mg/5ml F
cefadroxil tabs 1 gm NP
cephalexin caps 250 mg,750 mg, 500 mg F
cephalexin susr 250mg/5ml, 125 mg/5ml F
CEPHALEXIN TABS 250 MG, 500 MG NP
KEFLEX CAPS (Cephalexin) NP
Cephalosporins - 2nd Generation cefaclor caps 500 mg, 250 mg NP
CEFACLOR ER TB12 NP
CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML,375 MG/5ML
NP
cefprozil susr F
cefprozil tabs F
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Drug Name DrugTier
Requirements/Limits
CEFTIN SUSR 125 MG/5ML, 250 MG/5ML NP
CEFTIN TABS 250 MG, 500 MG (Cefuroxime Axetil)
NP
cefuroxime axetil tabs F
Cephalosporins - 3rd Generation CEDAX CAPS NP
CEDAX SUSR NP
cefdinir caps F
cefdinir susr F
cefixime susr F
cefpodoxime proxetil susr NP
cefpodoxime proxetil tabs NP
CEFTIBUTEN CAPS NP
CEFTIBUTEN SUSR NP
ceftriaxone sodium solr ij500 mg, 250 mg, 1 gm F QL(10 ea per
fill retail) ceftriaxone sodium solr iv 1 gm F
SUPRAX CAPS 400 MG F
SUPRAX CHEW 100 MG, 200 MG NP
SUPRAX SUSR 200 MG/5ML, 100 MG/5ML(Cefixime)
NP
SUPRAX SUSR 500 MG/5ML NP
CHEMICALS
Liquids GLYCERIN LIQD F RX/OTC
GLYCERINE LIQD F RX/OTC
GLYCEROL FORMAL LIQD F RX/OTC
Drug Name DrugTier
Requirements/Limits
CONTRACEPTIVES - Drugs to PreventPregnancy Combination Contraceptives - Oral BEYAZ TABS (Drospirenone-EthinylEstradiol-Levomefolate Calcium)
F
BREVICON-28 TABS (Norethindrone & Eth Estradiol)
F
CYCLESSA TABS (Desogestrel-EthinylEstradiol (Triphasic))
F
DESOGEN TABS (Desogestrel & EthinylEstradiol)
NP
desogestrel & ethinylestradiol tabs F
desogestrel-ethinylestradiol (biphasic) tabs F
desogestrel-ethinylestradiol (triphasic) tabs F
drospirenone-ethinylestradiol tabs F
drospirenone-ethinylestradiol-levomefolate calcium tabs
F
DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM TABS
F
ESTROSTEP FE TABS (Norethindrone Acetate-Ethinyl Estradiol-Fe)
F
ethynodiol diacet & ethestrad tabs F
FEMCON FE CHEW (Norethindrone & EthinylEstradiol-Fe)
F
GENERESS FE CHEW (Norethindrone & EthinylEstradiol-Fe)
F
levonorgestrel & ethestradiol tabs F
LEVONORGESTREL AND ETHINYL ESTRADIOL TABS
F
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Drug Name DrugTier
Requirements/Limits
levonorgestrel-eth estradiol(triphasic) tabs F
levonorgestrel-ethinylestradiol (91-day) tabs F
levonorgestrel-ethinylestradiol (continuous) tabs F
LO LOESTRIN FE TABS F
LOESTRIN 1.5/30-21TABS (Norethindrone Acet & Eth Estra)
F
LOESTRIN 1/20-21 TABS(Norethindrone Acet & Eth Estra)
F
LOESTRIN FE 1.5/30TABS (Norethin Acet & Estrad-Fe)
F
LOESTRIN FE 1/20 TABS(Norethin Acet & Estrad-Fe)
F
LOSEASONIQUE TABS (Levonorgestrel-EthinylEstradiol (91-Day))
F
MINASTRIN 24 FE CHEW (Norethin Acet & Estrad-Fe)
F
MIRCETTE TABS (Desogestrel-EthinylEstradiol (Biphasic))
F
MODICON TABS (Norethindrone & Eth Estradiol)
F
NATAZIA TABS F
NECON 1/50-28 TABS F
NECON 10/11-28 TABS F
norethin acet & estrad-fe chew F
norethin acet & estrad-fe tabs F
norethindrone & eth estradiol tabs F
norethindrone & ethinylestradiol-fe chew F
Drug Name DrugTier
Requirements/Limits
norethindrone acet & eth estra tabs F
norethindrone acetate-ethinyl estradiol-fe tabs F
norethindrone-eth estradiol (triphasic) tabs F
norgestimate-ethinylestradiol (triphasic) tabs F
norgestimate-ethinylestradiol tabs F
norgestrel & ethinylestradiol tabs F
NORINYL 1+35 TABS (Norethindrone & Eth Estradiol)
F
NORINYL 1+50 TABS F
OGESTREL TABS F
ORTHO TRI-CYCLEN LO TABS (Norgestimate-Ethinyl Estradiol(Triphasic))
F
ORTHO TRI-CYCLEN TABS (Norgestimate-Ethinyl Estradiol(Triphasic))
F
ORTHO-CYCLEN TABS (Norgestimate-EthinylEstradiol)
F
ORTHO-NOVUM 1/35TABS (Norethindrone & Eth Estradiol)
F
ORTHO-NOVUM 7/7/7TABS (Norethindrone-Eth Estradiol (Triphasic))
F
OVCON-35 TABS (Norethindrone & Eth Estradiol)
F
QUARTETTE TABS (Levonorgestrel-EthinylEstradiol (91-Day))
F
SAFYRAL TABS F
SEASONIQUE TABS (Levonorgestrel-EthinylEstradiol (91-Day))
F
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Drug Name DrugTier
Requirements/Limits
TAYTULLA CAPS F
TRI-NORINYL 28 TABS (Norethindrone-Eth Estradiol (Triphasic))
F
YASMIN 28 TABS (Drospirenone-EthinylEstradiol)
F
YAZ TABS (Drospirenone-Ethinyl Estradiol) F
Combination Contraceptives - Vaginal NUVARING RING F
Emergency Contraceptives ELLA TABS F
levonorgestrel (emergencyoc) tabs F QL(4 ea per
350 days retail) PLAN B ONE-STEP TABS (Levonorgestrel(Emergency OC))
F QL(4 ea per350 days retail)
Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSP (MedroxyprogesteroneAcetate (Contraceptive))
NP
QL(1 ml per fillretail)
DEPO-PROVERA CONTRACEPTIVE SUSY (MedroxyprogesteroneAcetate (Contraceptive))
4
medroxyprogesteroneacetate (contraceptive) susp
F QL(1 ml per fillretail)
medroxyprogesteroneacetate (contraceptive) susy
F
Progestin Contraceptives - Oral NOR-QD TABS (Norethindrone (Contraceptive))
F
norethindrone (contraceptive) tabs F
ORTHO MICRONOR TABS (Norethindrone (Contraceptive))
F
Drug Name DrugTier
Requirements/Limits
CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions Glucocorticosteroids CORTEF TABS (Hydrocortisone) NP
CORTISONE ACETATE TABS F
dexamethasone elix 0.5 mg/5ml F
dexamethasone sodium phosphate soln ij 20mg/5ml, 4 mg/ml, 120mg/30ml
F
DEXAMETHASONE SOLN 0.5 MG/5ML F
DEXAMETHASONE TABS 2 MG, 1 MG F
dexamethasone tabs 4 mg,1.5 mg, 0.5 mg, 0.75 mg, 6 mg
F
hydrocortisone tabs F
MEDROL DOSEPAK TBPK (Methylprednisolone) NP
MEDROL TABS 4 MG, 8 MG (Methylprednisolone) NP
methylprednisolone tabs 4mg, 8 mg F
methylprednisolone tbpk 4 mg F
MILLIPRED TABS 5 MG F
PEDIAPRED SOLN (Prednisolone Sodium Phosphate)
NP
prednisolone sodiumphosphate soln or 20mg/5ml, 6.7 mg/5ml, 15mg/5ml, 5 mg/5ml
F
prednisolone soln F
prednisolone syrp F
PREDNISONE INTENSOL CONC F
PREDNISONE SOLN 5 MG/5ML F
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Drug Name DrugTier
Requirements/Limits
prednisone tabs 1 mg, 5mg, 2.5 mg, 20 mg, 10 mg F
PREDNISONE TABS 50 MG F
PREDNISONE TBPK 10 MG, 5 MG F
UCERIS TB24 NP
VERIPRED 20 SOLN (Prednisolone Sodium Phosphate)
NP
Mineralocorticoids fludrocortisone acetate tabs F
COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy Symptoms Antitussives benzonatate caps 100 mg F
benzonatate caps 200 mg F QL(1 ea daily)
hydrocodone w/homatropine syrp 5mg/5ml-1.5mg/5ml
F
TESSALON PERLES CAPS (Benzonatate) NP
Cough/Cold/Allergy Combinations brompheniramine &phenyleph elix 1mg/5ml-2.5mg/5ml, 1mg/5ml-1mg/5ml-2.5mg/5ml-2.5mg/5ml
F
brompheniramine &pseudoeph elix F
brompheniramine &pseudoeph liqd F
CHERACOL PLUS LIQD (Dextromethorphan-Guaifenesin)
NP
CHERACOL-D COUGH LIQD (Dextromethorphan-Guaifenesin)
NP
chlorpheniramine &pseudoeph tabs 60mg-4mg F
chlorpheniramine-acetaminophen tabs F
Drug Name DrugTier
Requirements/Limits
CLARITIN-D 24 HOUR TB24 (Loratadine & Pseudoephedrine)
NP
CORICIDIN HBP COLD & FLU TABS (Chlorpheniramine-Acetaminophen)
NP
DECON-A ELIX 2MG/5ML-5MG/5ML F
dextromethorphan-guaifenesin liqd20mg/10ml-200mg/10ml,10mg/5ml-100mg/5ml,10mg/5ml-10mg/5ml-100mg/5ml-100mg/5ml,15mg/7.5ml-150mg/7.5ml,10mg/5ml-200mg/5ml
F
dextromethorphan-guaifenesin soln20mg/10ml-200mg/10ml,10mg/5ml-100mg/5ml
F
dextromethorphan-guaifenesin syrp 10mg/5ml-100mg/5ml, 10mg/5ml-10mg/5ml-100mg/5ml-100mg/5ml
F
dextromethorphan-guaifenesin tb12 30mg-600mg
F QL(2 ea daily)
DIMETAPP COLD & ALLERGY ELIX 1MG/5ML-2.5MG/5ML(Brompheniramine &Phenyleph)
NP
guaifenesin-codeine liqd100mg/5ml-10mg/5ml F AL; At least 12
yrs old guaifenesin-codeine soln100mg/5ml-10mg/5ml F AL; At least 12
yrs old guaifenesin-codeine syrp100mg/5ml-10mg/5ml F AL; At least 12
yrs old loratadine & pseudoephedrine tb2410mg-10mg-240mg-240mg, 10mg-240mg
F
MUCINEX D TB12 (Pseudoephedrine-Guaifenesin)
NP
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Drug Name DrugTier
Requirements/Limits
MUCINEX DM TB12 (Dextromethorphan-Guaifenesin)
NP QL(2 ea daily)
NEXAFED SINUS PRESSURE +PAIN TABS F
NORTUSS-EX LIQD F
phenylephrine-brompheniramine-dm elix1mg/5ml-5mg/5ml-2.5mg/5ml, 1mg/5ml-1mg/5ml-5mg/5ml-5mg/5ml-2.5mg/5ml-2.5mg/5ml
F
phenylephrine-chlorphen-dm liqd 15mg/5ml-4mg/5ml-10mg/5ml
F
phenylephrine-dm-gg w/apap tabs 10mg-325mg-200mg-5mg, 10mg-10mg-325mg-325mg-200mg-200mg-5mg-5mg
F
promethazine &phenylephrine soln F AL; At least 2
yrs old promethazine &phenylephrine syrp F AL; At least 2
yrs old promethazine w/codeine syrp F AL; At least 2
yrs old
promethazine-dm syrp F AL; At least 2 yrs old
promethazine-phenylephrine-codeine syrp
F
PROMETHAZINE/PHENYLEPHRINE SYRP F AL; At least 2
yrs old pseudoephed-bromphen-dm syrp 2mg/5ml-30mg/5ml-10mg/5ml
F
pseudoephedrine w/codeine-gg soln F
pseudoephedrine-guaifenesin tb12 60mg-600mg
F
ROBITUSSIN DM SYRP (Dextromethorphan-Guaifenesin)
NP
Drug Name DrugTier
Requirements/Limits
ROBITUSSIN PEAK COLD COUGH+ CHEST CONGESTION DM MAX STRENGTH LIQD (Dextromethorphan-Guaifenesin)
NP
ROBITUSSIN PEAK COLD DM SYRP (Dextromethorphan-Guaifenesin)
NP
TRIAMINIC COLD & ALLERGY SYRP F
TUSNEL C SYRP F
TYLENOL COLD & FLU SEVERE TABS (Phenylephrine-DM-GG w/APAP)
NP
Expectorants guaifenesin liqd 400mg/20ml, 100 mg/5ml F
guaifenesin soln 100mg/5ml, 200 mg/10ml, 300mg/15ml
F
guaifenesin syrp 100mg/5ml, 200 mg/10ml F
guaifenesin tabs 200 mg F
guaifenesin tb12 600 mg F QL(40 ea perfill retail)
MUCINEX TB12 (Guaifenesin) NP QL(40 ea perfill retail) Misc. Respiratory Inhalants camphor-eucalyptus-menthol oint ex 1.2%-2.6%-4.8%
F
camphor-eucalyptus-menthol-turpentine oil-whitepetrolatum oint
F
HYPER-SAL NEBU (Sodium Chloride (Inhalant))
NP
HYPERSAL NEBU 3.5 % F
HYPERSAL NEBU 7 % (Sodium Chloride (Inhalant))
NP
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Drug Name DrugTier
Requirements/Limits
MEDICATED CHEST RUB OINT F
NEBUSAL NEBU F
sodium chloride (inhalant) aers F
sodium chloride (inhalant)nebu F
VAPORX BALM OINT F
VICKS VAPORUB OINT F
Mucolytics acetylcysteine soln F
DERMATOLOGICALS - Drugs to Treat SkinConditions Acne Products ABSORICA CAPS 30 MG, 40 MG, 20 MG, 10 MG F
ACANYA GEL NP
ACNE MEDICATION 10 LOTN F
ACNE MEDICATION 5 LOTN F
ACZONE GEL 5 % (Dapsone (Topical)) NP
ACZONE GEL 7.5 % NP
adapalene crea 0.1 % NP
adapalene gel 0.1 % 4 RX/OTC
adapalene gel 0.3 % NP
ADAPALENE LOTN 0.1 % F
adapalene-benzoylperoxide gel NP
AKTIPAK PACK NP
ATRALIN GEL (Tretinoin) NP AL; Up to 25yrs old AVAR LS CLEANSER LIQD (Sulfacetamide Sodium w/ Sulfur)
NP
Drug Name DrugTier
Requirements/Limits
AVAR-E LS CREA (Sulfacetamide Sodium w/Sulfur)
NP
AZELEX CREA F AL; Up to 18yrs old
BENZAC AC WASH LIQD (Benzoyl Peroxide) NP RX/OTC
BENZACLIN GEL (Clindamycin Phosphate-Benzoyl Peroxide)
NP
BENZACLIN WITH PUMP GEL (ClindamycinPhosphate-BenzoylPeroxide)
F
Limit 50ea permonth;QL(1.667 gm daily)
BENZAMYCIN GEL (Benzoyl Peroxide-Erythromycin)
NP
BENZEFOAM FOAM (Benzoyl Peroxide) NP RX/OTC
BENZEFOAM ULTRA FOAM (Benzoyl Peroxide) NP
BENZEFOAMULTRA FOAM (Benzoyl Peroxide) NP
benzoyl peroxide foam 5.3% NP RX/OTC
benzoyl peroxide foam 9.8% NP
benzoyl peroxide gel 10 % F RX/OTC
BENZOYL PEROXIDE GEL 2.5 % F
benzoyl peroxide gel 5 % F
benzoyl peroxide gel 8 % NP
benzoyl peroxide liqd 10 %,5 % F RX/OTC
benzoyl peroxide liqd 4 % F
benzoyl peroxide liqd 7 % NP
benzoyl peroxide lotn 6 % NP RX/OTC
benzoyl peroxide misc 6 % NP
benzoyl peroxide-erythromycin gel NP
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Drug Name DrugTier
Requirements/Limits
BP CLEANSING WASH EMUL NP
CLARIFOAM EF FOAM (Sulfacetamide Sodium w/Sulfur)
NP
CLEAN & CLEAR ADVANTAGE 3-IN-1 EXFOLIATING CLEANSER LOTN
F
CLEOCIN-T GEL (Clindamycin Phosphate(Topical))
NP
CLEOCIN-T LOTN (Clindamycin Phosphate(Topical))
NP
CLEOCIN-T SOLN (Clindamycin Phosphate(Topical))
NP
CLEOCIN-T SWAB (Clindamycin Phosphate(Topical))
NP
CLINDAGEL GEL NP
clindamycin phosphate(topical) foam NP
clindamycin phosphate(topical) gel NP
clindamycin phosphate(topical) lotn NP
clindamycin phosphate(topical) soln F
clindamycin phosphate(topical) swab NP
clindamycin phosphate-benzoyl peroxide(refrigerate) gel
NP
clindamycin phosphate-benzoyl peroxide gel 4
Limit 50ea permonth;QL(1.667 gm daily)
clindamycin phosphate-benzoyl peroxide gel 4
Limit 50gms permonth;QL(1.667 gm daily)
clindamycin phosphate-benzoyl peroxide gel 4 QL(1.667 gm
daily) clindamycin phosphate-tretinoin gel NP
Drug Name DrugTier
Requirements/Limits
dapsone (topical) gel NP
DESQUAM-X WASH LIQD (Benzoyl Peroxide) NP RX/OTC
DIFFERIN CREA 0.1 % (Adapalene) F
DIFFERIN GEL 0.1 % (Adapalene) F RX/OTC
DIFFERIN GEL 0.1 % (Adapalene) NP RX/OTC
DIFFERIN GEL 0.3 % (Adapalene) F
DIFFERIN LOTN 0.1 % F
DUAC GEL (ClindamycinPhosphate-BenzoylPeroxide (Refrigerate))
NP
EPIDUO FORTE GEL NP
EPIDUO GEL (Adapalene-Benzoyl Peroxide) NP
ERYGEL GEL (Erythromycin (Acne Aid)) NP
erythromycin (acne aid) gel NP
erythromycin (acne aid)pads NP
erythromycin (acne aid)soln F
EVOCLIN FOAM (Clindamycin Phosphate(Topical))
NP
FABIOR FOAM NP
isotretinoin caps F
KLARON LOTN (Sulfacetamide Sodium (Acne))
NP
ONEXTON GEL NP
PANOXYL-4 CREAMY WASH LIQD (BenzoylPeroxide)
NP
RETIN-A CREA (Tretinoin) F
PA; QL(20 gmper fill retail);AL; Up to 25yrs old
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Drug Name DrugTier
Requirements/Limits
RETIN-A GEL (Tretinoin) F
PA; QL(20 gmper fill retail);AL; Up to 25yrs old
RETIN-A MICRO GEL (Tretinoin Microsphere) NP
PA; QL(50 gmper fill retail);AL; Up to 25yrs old
RETIN-A MICRO PUMP GEL 0.04 %, 0.1 % (Tretinoin Microsphere)
NP
PA; QL(50 gmper fill retail);AL; Up to 25yrs old
RETIN-A MICRO PUMP GEL 0.08 % F
PA; QL(50 gmper fill retail);AL; Up to 25yrs old
ROSULA PADS 5%-10% NP
SODIUM SULFACETAMIDE/SULFUR CLEANSER IN UREA EMUL
NP
SODIUM SULFACETAMIDE/SULFUR LOTN
NP
SODIUM SULFACETAMIDE/SULFUR SUSP
NP
SSS 10-5 FOAM NP
sulfacetamide sodium (acne) lotn NP
sulfacetamide sodium (acne) susp NP
sulfacetamide sodium w/sulfur crea 2%-10% NP
sulfacetamide sodium w/sulfur emul 1%-10%, 5%-10%
NP
sulfacetamide sodium w/sulfur liqd 4%-9%, 2%-2%-10%-10%, 2%-10%, 4.5%-9%
NP
sulfacetamide sodium w/sulfur lotn 5%-10% NP
sulfacetamide sodium w/sulfur pads 4%-10%, 4%-4%-10%-10%
NP
Drug Name DrugTier
Requirements/Limits
sulfacetamide sodium w/sulfur susp 4%-8% NP
SUMADAN WASH LIQD (Sulfacetamide Sodium w/Sulfur)
NP
SUMAXIN PADS (Sulfacetamide Sodium w/Sulfur)
NP
SUMAXIN TS SUSP (Sulfacetamide Sodium w/Sulfur)
NP
SUMAXIN WASH LIQD (Sulfacetamide Sodium w/Sulfur)
NP
tretinoin crea 0.025 %, 0.1%, 0.05 % NP
PA; QL(20 gmper fill retail);AL; Up to 25yrs old
tretinoin gel 0.025 %, 0.01% NP
PA; QL(20 gmper fill retail);AL; Up to 25yrs old
tretinoin gel 0.05 % NP AL; Up to 25yrs old
tretinoin microsphere gel F
PA; QL(50 gmper fill retail);AL; Up to 25yrs old
VELTIN GEL NP
ZIANA GEL (ClindamycinPhosphate-Tretinoin) NP
Agents for Wrinkles/Lipoatrophy/Other Aesthetic
REFISSA CREA F
PA; QL(60 gmper fill retail);AL; Up to 25yrs old
TRETINOIN EMOLLIENT CREA F
PA; QL(60 gmper fill retail);AL; Up to 25yrs old
Analgesics - Topical menthol (topical analgesic)gel 2 % F
Anti-inflammatory Agents - Topical diclofenac sodium (topical)gel NP
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Drug Name DrugTier
Requirements/Limits
diclofenac sodium (topical)soln NP
FLECTOR PTCH NP
LEXIXRYL THPK NP
PENNSAID SOLN NP
VOLTAREN GEL (Diclofenac Sodium (Topical))
NP
VOPAC MDS KIT NP
XRYLIX THPK NP
Antibiotics - Topical ALTABAX OINT NP
BACIGUENT OINT (Bacitracin (Topical)) NP
bacitracin (topical) oint F
bacitracin zinc oint F
bacitracin-polymyxin b oint F
BACTROBAN CREA (Mupirocin Calcium(Topical))
NP
BACTROBAN OINT (Mupirocin) NP
CENTANY AT KIT NP
CENTANY OINT 4
gentamicin sulfate (topical) crea NP
GENTAMICIN SULFATE OINT EX 0.1 % NP
mupirocin calcium (topical) crea NP
mupirocin oint F
neomycin-bacitracin-polymyxin oint F
neomycin-bacitracin-polymyxin-pramoxine oint F
Drug Name DrugTier
Requirements/Limits
neomycin-polymyxin w/pramoxine crea F
NEOSPORIN ORIGINAL OINT (Neomycin-Bacitracin-Polymyxin)
NP
NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH CREA (Neomycin-Polymyxin w/Pramoxine)
NP
POLYSPORIN OINT (Bacitracin-Polymyxin B) NP
Antifungals - Topical ALEVAZOL OINT NP
ALOE VESTA ANTIFUNGAL OINT (Miconazole Nitrate (Topical))
NP
ALOE VESTA CLEAR ANTIFUNGAL OINT (Miconazole Nitrate (Topical))
NP
AZOLEN TINCTURE SOLN NP
butenafine hcl crea NP RX/OTC
CICLODAN CREAM KIT KIT NP
ciclopirox gel NP
ciclopirox olamine crea NP
ciclopirox olamine susp NP
ciclopirox sham NP
ciclopirox soln NP
clotrimazole (topical) crea F RX/OTC
clotrimazole (topical) soln F QL(60 ml perfill retail);RX/OTC
clotrimazole (topical) soln NP RX/OTC
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Drug Name DrugTier
Requirements/Limits
clotrimazole (topical) soln 4 QL(60 ml perfill retail);RX/OTC
clotrimazole w/betamethasone crea F
clotrimazole w/betamethasone lotn NP
econazole nitrate crea NP
ERTACZO CREA NP
EXELDERM CREA NP
EXELDERM SOLN NP
EXTINA FOAM (Ketoconazole (Topical)) NP
FUNGOID TINCTURE KIT NP
FUNGOID TINCTURE SOLN NP
JUBLIA SOLN NP
ketoconazole (topical) crea F
ketoconazole (topical) foam NP
ketoconazole (topical)sham F
LAMISIL ADVANCED GEL NP
LAMISIL AT CREA (Terbinafine HCl (Topical)) F
LAMISIL AT JOCK ITCH CREA (Terbinafine HCl (Topical))
F
LAMISIL AT SPRAY SOLN F
LOPROX CREA 0.77 % (Ciclopirox Olamine) NP
LOPROX KIT 0.77% NP
LOPROX KIT KIT NP
LOPROX SHAMPOO SHAM (Ciclopirox) NP
LOPROX SUSP 0.77 % (Ciclopirox Olamine) NP
Drug Name DrugTier
Requirements/Limits
LOTRIMIN AF AERO 2 % F
LOTRIMIN AF CREA 1 % (Clotrimazole (Topical)) NP RX/OTC
LOTRIMIN AF FOR HER CREA (Clotrimazole (Topical))
NP RX/OTC
LOTRIMIN AF JOCK ITCH CREA (Clotrimazole (Topical))
NP RX/OTC
LOTRIMIN ULTRA CREA NP RX/OTC
LOTRIMIN ULTRA CREA (Butenafine HCl) NP RX/OTC
LOTRISONE CREA (Clotrimazole w/Betamethasone)
NP
LUZU CREA NP
MENTAX CREA NP RX/OTC
MICATIN CREA (Miconazole Nitrate (Topical))
NP
miconazole nitrate (topical) aero F
miconazole nitrate (topical) aerp F
miconazole nitrate (topical) crea F
miconazole nitrate (topical)oint NP
miconazole nitrate (topical)powd F
naftifine hcl crea NP
NAFTIN CREA 2 % (Naftifine HCl) NP
NAFTIN GEL 1 %, 2 % NP
NIZORAL SHAM (Ketoconazole (Topical)) NP
nystatin (topical) crea F
nystatin (topical) oint F
nystatin (topical) powd F
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Drug Name DrugTier
Requirements/Limits
nystatin-triamcinolone crea NP
nystatin-triamcinolone oint NP
oxiconazole nitrate crea NP
OXISTAT CREA (Oxiconazole Nitrate) NP
OXISTAT LOTN NP
PENLAC NAIL LACQUER SOLN (Ciclopirox) NP
terbinafine hcl (topical) crea F
TINACTIN AERO (Tolnaftate) NP
TINACTIN AERP (Tolnaftate) NP
TINACTIN CREA (Tolnaftate) NP
TINACTIN DEODORANT AERP (Tolnaftate) NP
TINACTIN JOCK ITCH AERP (Tolnaftate) NP
TINACTIN JOCK ITCH CREA (Tolnaftate) NP
TINACTIN POWD (Tolnaftate) NP
tolnaftate aero F
tolnaftate aerp F
tolnaftate crea F
tolnaftate liqd F
tolnaftate powd F
tolnaftate soln F
VUSION OINT NP
Antihistamines-Topical BENADRYL EXTRA STRENGTH CREA (Diphenhydramine-ZincAcetate)
NP
Drug Name DrugTier
Requirements/Limits
diphenhydramine-zincacetate crea 0.1%-2%,0.1%-0.1%-2%-2%
F
Antineoplastic or Premalignant Lesion Agents -CARAC CREA F
EFUDEX CREA (Fluorouracil (Topical)) NP
fluorouracil (topical) crea F
fluorouracil (topical) soln F
FLUOROURACIL CREA 0.5 % F
FLUOROURACIL SOLN 5 %, 2 % F
Antipruritics - Topical camphor & menthol lotn0.5%-0.5% F
SARNA LOTN (Camphor &Menthol) NP
Antipsoriatics 8-MOP CAPS NP
acitretin caps NP
calcipotriene crea F
calcipotriene oint NP
calcipotriene soln F
CALCITRIOL OINT EX 3 MCG/GM NP
COSENTYX SENSOREADY PEN SOAJ NP
COSENTYX SOSY NP
DOVONEX CREA (Calcipotriene) NP
methoxsalen rapid caps NP
OXSORALEN ULTRA CAPS (Methoxsalen Rapid) NP
SORIATANE CAPS (Acitretin) F
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Drug Name DrugTier
Requirements/Limits
SORILUX FOAM NP
TALTZ SOAJ NP
tazarotene crea NP
TAZORAC CREA 0.05 % NP
TAZORAC CREA 0.1 % (Tazarotene) NP
TAZORAC GEL 0.1 %, 0.05 % NP
TREMFYA SOSY NP QL(1 ml per 28days retail)
VECTICAL OINT NP
Antiseborrheic Products DHS ZINC SHAM (Pyrithione Zinc) NP
OVACE PLUS WASH LIQD (Sulfacetamide Sodium) NP
OVACE WASH LIQD (Sulfacetamide Sodium) NP
pyrithione zinc sham 2 %, F
salicylic acid & sulfur sham F
SEBULEX SHAM (SalicylicAcid & Sulfur) NP
selenium sulfide lotn 2.5 % F
sulfacetamide sodium liqd ex NP
Antivirals - Topical ABREVA CREA F
acyclovir topical oint NP
DENAVIR CREA NP
XERESE CREA NP
ZOVIRAX CREA EX 5 % NP
ZOVIRAX OINT EX 5 % (Acyclovir Topical) NP
Burn Products
Drug Name DrugTier
Requirements/Limits
SILVADENE CREA (Silver Sulfadiazine) NP
silver sulfadiazine crea F
Corticosteroids - Topical ACLOVATE CREA (Alclometasone Dipropionate)
NP
alclometasone dipropionate crea NP
alclometasone dipropionateoint NP
AMCINONIDE CREA NP
AMCINONIDE LOTN NP
AMCINONIDE OINT NP
APEXICON E CREA NP
AUGMENTED BETAMETHASONE DIPROPIONATE GEL
NP
betamethasone dipropionate (topical) crea NP
betamethasone dipropionate (topical) lotn NP
betamethasone dipropionate (topical) oint NP
betamethasone dipropionate augmented crea
NP
betamethasone dipropionate augmentedgel
NP
betamethasone dipropionate augmentedlotn
NP
betamethasone dipropionate augmentedoint
NP
betamethasone valerate crea 0.1 % F
betamethasone valerate foam 0.12 % NP
betamethasone valerate lotn 0.1 % F
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Drug Name DrugTier
Requirements/Limits
betamethasone valerate oint 0.1 % F
calcipotriene-betamethasone dipropionate oint
NP AL; At least 18 yrs old
CAPEX SHAM NP
clobetasol propionate crea F
clobetasol propionateemollient base crea F
clobetasol propionateemulsion foam NP
clobetasol propionate foam NP
clobetasol propionate gel F
clobetasol propionate liqd NP
clobetasol propionate lotn NP
clobetasol propionate oint F
clobetasol propionate sham NP
clobetasol propionate soln F
CLOBEX LIQD (Clobetasol Propionate) NP
CLOBEX LOTN (Clobetasol Propionate) NP
CLOBEX SHAM (Clobetasol Propionate) NP
CLOCORTOLONE PIVALATE CREA NP
CLOCORTOLONE PIVALATE PUMP CREA NP
CLODERM CREA NP
CLODERM PUMP CREA NP
CORDRAN CREA 0.05 % (Flurandrenolide) NP
CORDRAN LOTN 0.05 % (Flurandrenolide) NP
CORDRAN OINT 0.05 % (Flurandrenolide) NP
Drug Name DrugTier
Requirements/Limits
CORDRAN TAPE 4 MCG/SQCM NP
CORDRAN TAPE TAPE NP
CUTIVATE CREA (Fluticasone Propionate) NP
CUTIVATE LOTN (Fluticasone Propionate) NP
CVS HDYROCORTISONE ACETATE CREA F
DERMA-SMOOTHE/FSBODY OIL (Fluocinolone Acetonide)
NP
DERMA-SMOOTHE/FSSCALP OIL (Fluocinolone Acetonide)
NP
DERMACINRX SILAPAK KIT (Triamcinolone Acetonide-Dimethicone-Silicone)
NP
DERMATOP CREA (Prednicarbate) NP
DERMATOP OINT (Prednicarbate) NP
DESONATE GEL NP
desonide crea NP
desonide lotn NP
desonide oint NP
DESOWEN CREA (Desonide) NP
DESOWEN LOTN (Desonide) NP
desoximetasone crea NP
desoximetasone gel NP
desoximetasone oint NP
DIFLORASONE DIACETATE CREA NP
DIFLORASONE DIACETATE OINT NP
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Drug Name DrugTier
Requirements/Limits
DIPROLENE AF CREA (Betamethasone Dipropionate Augmented)
NP
DIPROLENE LOTN (Betamethasone Dipropionate Augmented)
NP
DIPROLENE OINT (Betamethasone Dipropionate Augmented)
NP
ELOCON CREA (Mometasone Furoate) NP
ELOCON LOTN (Mometasone Furoate) NP
ELOCON OINT (Mometasone Furoate) NP
ENSTILAR FOAM NP
EPIFOAM FOAM F
fluocinolone acetonide crea NP
fluocinolone acetonide oil NP
fluocinolone acetonide oint NP
fluocinolone acetonide soln NP
fluocinonide crea NP
fluocinonide emulsified base crea NP
fluocinonide gel NP
fluocinonide oint NP
fluocinonide soln NP
flurandrenolide crea NP
flurandrenolide lotn NP
flurandrenolide oint NP
fluticasone propionate crea0.05 % F
fluticasone propionate lotn0.05 % NP
Drug Name DrugTier
Requirements/Limits
fluticasone propionate oint0.005 % F
halobetasol propionate crea F
halobetasol propionate oint F
HALOG CREA NP
HALOG OINT NP
hydrocortisone (topical)crea 0.5 %, 2.5 % F
hydrocortisone (topical)crea 1%, 1 % F RX/OTC
hydrocortisone (topical) lotn2.5 %, 1 % F
hydrocortisone (topical) oint1 % F QL(2 gm daily);
RX/OTC hydrocortisone (topical) oint2.5 %, 0.5 % F
hydrocortisone (topical)soln 1 % F
hydrocortisone acetate(topical) crea F
hydrocortisone butyrate crea NP
hydrocortisone butyratehydrophilic lipo base crea NP
hydrocortisone butyrateoint NP
hydrocortisone butyratesoln NP
hydrocortisone valerate crea NP
hydrocortisone valerate oint NP
hydrocortisone-aloe vera crea F
KENALOG AERS (Triamcinolone Acetonide (Topical))
NP
LOCOID CREA (Hydrocortisone Butyrate) NP
LOCOID LIPOCREAM CREA (HydrocortisoneButyrate Hydrophilic LipoBase)
NP
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Drug Name DrugTier
Requirements/Limits
LOCOID OINT (Hydrocortisone Butyrate) NP
LOCOID SOLN (Hydrocortisone Butyrate) NP
LUXIQ FOAM (Betamethasone Valerate) NP
MICORT-HC CREA NP
mometasone furoate crea F
mometasone furoate oint F
mometasone furoate soln F
MONISTAT SOOTHING CARE ITCH RELIEF CREA (Hydrocortisone (Topical))
NP RX/OTC
OLUX FOAM (Clobetasol Propionate) NP
OLUX-E FOAM (Clobetasol Propionate Emulsion) NP
PANDEL CREA NP
prednicarbate crea NP
prednicarbate oint NP
PSORCON CREA NP
SERNIVO EMUL NP
SYNALAR CREA (Fluocinolone Acetonide) NP
SYNALAR OINT (Fluocinolone Acetonide) NP
SYNALAR SOLN (Fluocinolone Acetonide) NP
TACLONEX OINT (Calcipotriene-Betamethasone Dipropionate)
NP
AL; At least 18 yrs old
TACLONEX SUSP NP AL; At least 18 yrs old TEMOVATE CREA (Clobetasol Propionate) NP
TEMOVATE E CREA (Clobetasol PropionateEmollient Base)
NP
Drug Name DrugTier
Requirements/Limits
TEMOVATE GEL (Clobetasol Propionate) NP
TEMOVATE OINT (Clobetasol Propionate) NP
TEMOVATE SOLN (Clobetasol Propionate) NP
TEXACORT SOLN NP
TOPICORT CREA 0.05 %, 0.25 % (Desoximetasone) NP
TOPICORT GEL 0.05 % (Desoximetasone) NP
TOPICORT LIQD 0.25 % NP
TOPICORT OINT 0.25 %, 0.05 % (Desoximetasone) NP
triamcinolone acetonide (topical) aers 0.147 mg/gm NP
triamcinolone acetonide (topical) crea 0.5 %, 0.1 %,0.025 %
F
triamcinolone acetonide (topical) lotn 0.025 %, 0.1%
F
triamcinolone acetonide (topical) oint 0.5 %, 0.1 %,0.025 %
F
triamcinolone acetonide-dimethicone-silicone kit NP
TRIANEX OINT NP
TRIDESILON CREA (Desonide) NP
ULTRAVATE CREA (Halobetasol Propionate) NP
ULTRAVATE LOTN NP
ULTRAVATE OINT (Halobetasol Propionate) NP
VANOS CREA (Fluocinonide) NP
WESTCORT OINT (Hydrocortisone Valerate) NP
Eczema Agents DUPIXENT SOSY NP
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Drug Name DrugTier
Requirements/Limits
Emollient/Keratolytic Agents CARMOL 20 CREA (Urea) NP
urea crea 20 %, 40 % F
urea lotn 40 % F
Emollients
A + D PERSONAL CARE LOTION LOTN F
AL; Up to 18yrs old;RX/OTC
ALBOLENE CREA F AL; Up to 18yrs old;RX/OTC
ALOE AFTERSUN LOTION LOTN F
AL; Up to 18yrs old;RX/OTC
AMLACTIN CERAPEUTIC LOTN F
AL; Up to 18yrs old;RX/OTC
AMLACTIN ULTRA CREA F AL; Up to 18yrs old;RX/OTC
AQUA GLYCOLIC FACE CREAM CREA F
AL; Up to 18yrs old;RX/OTC
AQUA GLYCOLIC HAND & BODYLOTION LOTN F
AL; Up to 18yrs old;RX/OTC
AQUA LACTEN LOTN F AL; Up to 18yrs old;RX/OTC
AQUADERM CREA F AL; Up to 18yrs old;RX/OTC
AQUADERM TREATMENT/MOISTURIZER LOTN
F AL; Up to 18yrs old;RX/OTC
AQUAMED LOTN F AL; Up to 18yrs old;RX/OTC
AQUAPHILIC OINT F AL; Up to 18yrs old
AQUAPHOR ADVANCED THERAPY OINT F AL; Up to 18
yrs old
AQUAPHOR OINT F AL; Up to 18yrs old
Drug Name DrugTier
Requirements/Limits
AVEENO ACTIVE NATURALS DAILY MOISTURIZING BODY YOGURT LOTN
F
AL; Up to 18yrs old;RX/OTC
AVEENO ACTIVE NATURALS DAILY MOISTURIZING BODY YOGURT/APRICO LOTN
F
AL; Up to 18yrs old;RX/OTC
AVEENO ACTIVE NATURALS SKIN RELIEF MOISTURE REPAIR CREA
F
AL; Up to 18yrs old;RX/OTC
AVEENO DAILY MOISTURIZINGSPF 15 LOTN
F AL; Up to 18yrs old;RX/OTC
AVEENO INTENSE RELIEF HAND CREA F
AL; Up to 18yrs old;RX/OTC
AVEENO POSITIVELY AGELESS LIFT & FIRM EYE CREA
F AL; Up to 18yrs old;RX/OTC
AVEENO POSITIVELY AGELESS NIGHT CREA F
AL; Up to 18yrs old;RX/OTC
AVEENO POSITIVELY AGELESSFIRMING BODY LOTN
F AL; Up to 18yrs old;RX/OTC
AVEENO POSITIVELY AGELESSSKIN STRENGTHENING BODY CREAM CREA
F
AL; Up to 18yrs old;RX/OTC
AVEENO POSITIVELY AGELESSSKIN STRENGTHENING HAND CREAM CREA
F
AL; Up to 18yrs old;RX/OTC
AVEENO POSITIVELY NOURISHING 24-HOUR ULTRA-HYDRATING CREA
F
AL; Up to 18yrs old;RX/OTC
AVEENO POSITIVELY NOURISHING ENERGIZING LOTN
F AL; Up to 18yrs old;RX/OTC
AVEENO POSITIVELY RADIANT LOTN F
AL; Up to 18yrs old;RX/OTC
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Drug Name DrugTier
Requirements/Limits
AVEENO POSITIVELY RADIANTOVERNIGHT HYDRATING FACIAL MOISTURI CREA
F
AL; Up to 18yrs old;RX/OTC
AVEENO STRESS RELIEF MOISTURIZING LOTN F
AL; Up to 18yrs old;RX/OTC
BASLE CREA F AL; Up to 18yrs old;RX/OTC
BETA CARE CREA F AL; Up to 18yrs old;RX/OTC
BETA CARE LOTN F AL; Up to 18yrs old;RX/OTC
BETA XMA CREA F AL; Up to 18yrs old;RX/OTC
BOUDREAUXS BABY BUTT SMOOTH DRY SKIN OINT
F AL; Up to 18yrs old
CAM LOTN F AL; Up to 18yrs old;RX/OTC
CARB-O-LAN 10 CREA F AL; Up to 18yrs old;RX/OTC
CARB-O-LAN 20 CREA F AL; Up to 18yrs old;RX/OTC
CARB-O-PHILIC/20 CREA F AL; Up to 18yrs old;RX/OTC
CARB-O-SAL 5 CREA F AL; Up to 18yrs old;RX/OTC
CERAVE AM SPF 30 LOTN F
AL; Up to 18yrs old;RX/OTC
CERAVE CREA F AL; Up to 18yrs old;RX/OTC
CERAVE LOTN F AL; Up to 18yrs old;RX/OTC
Drug Name DrugTier
Requirements/Limits
CERAVE PM LOTN F AL; Up to 18yrs old;RX/OTC
CERAVE RENEWING SA CREA F
AL; Up to 18yrs old;RX/OTC
CERAVE SA RENEWING LOTN F
AL; Up to 18yrs old;RX/OTC
CETAPHIL CREA F AL; Up to 18yrs old;RX/OTC
CETAPHIL DAILY ADVANCE ULTRA HYDRATING LOTN
F AL; Up to 18yrs old;RX/OTC
CETAPHIL DAILY FACIAL MOISTURIZER LOTN F
AL; Up to 18yrs old;RX/OTC
CETAPHIL DERMACONTROL MOISTURIZER/SPF 30LOTN
F
AL; Up to 18yrs old;RX/OTC
CETAPHIL MOISTURIZING CREA (Emollient)
NP AL; Up to 18yrs old;RX/OTC
CETAPHIL MOISTURIZING LOTN F
AL; Up to 18yrs old;RX/OTC
CETAPHIL RESTORADERM LOTN F
AL; Up to 18yrs old;RX/OTC
CETAPHIL THERAPEUTIC HAND CREA F
AL; Up to 18yrs old;RX/OTC
CLN FACIAL MOISTURIZER NOURISHING LOTN
F AL; Up to 18yrs old;RX/OTC
COCOA BUTTER HAND & BODYLOTION LOTN F
AL; Up to 18yrs old;RX/OTC
COCOA BUTTER LOTN F AL; Up to 18yrs old;RX/OTC
COCONUT OIL BEAUTY CREA F
AL; Up to 18yrs old;RX/OTC
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Drug Name DrugTier
Requirements/Limits
CVS DAILY ULTRA MOISTURELOTION LOTN F
AL; Up to 18yrs old;RX/OTC
CVS MOISTURIZING CREAM CREA F
AL; Up to 18yrs old;RX/OTC
DAILY CONDITIONING TREATMENT OINT F AL; Up to 18
yrs old
DERMABASEOIL IN WATER CREA F
AL; Up to 18yrs old;RX/OTC
DERMAIDE ALOE CREA F AL; Up to 18yrs old;RX/OTC
DERMAL THERAPY EXTRA STRENGTH BODY LOTION LOTN
F AL; Up to 18yrs old;RX/OTC
DERMAL THERAPY FACE CAREMOISTURIZING LOTION LOTN
F AL; Up to 18yrs old;RX/OTC
DERMAL THERAPY FOOT MASSAGE LOTN F
AL; Up to 18yrs old;RX/OTC
DERMAL THERAPY HAND ELBOW & KNEE CREAM LOTN
F AL; Up to 18yrs old;RX/OTC
DERMAL THERAPY HEEL CARE LOTN F
AL; Up to 18yrs old;RX/OTC
DERMALUBE DAILY MOISTURIZING LOTION LOTN
F AL; Up to 18yrs old;RX/OTC
DERMEND MOISTURIZING BRUISE FORMULA CREA
F AL; Up to 18yrs old;RX/OTC
DHEA CREA EX 1% F AL; Up to 18yrs old;RX/OTC
DIABETIDERM CREA F AL; Up to 18yrs old;RX/OTC
DIABETIDERM FOOT REJUVENATING CREA F
AL; Up to 18yrs old;RX/OTC
DIABETIDERM HAND & BODY LOTN F
AL; Up to 18yrs old;RX/OTC
Drug Name DrugTier
Requirements/Limits
DIABETIDERM LOTN F AL; Up to 18yrs old;RX/OTC
DMAE CREA F AL; Up to 18yrs old;RX/OTC
DML FORTE CREA F AL; Up to 18yrs old;RX/OTC
DROXY CREAM CREA F AL; Up to 18yrs old;RX/OTC
ELON SKIN REPAIR SYSTEM CREA F
AL; Up to 18yrs old;RX/OTC
ELTA CREA F AL; Up to 18yrs old;RX/OTC
EMOLLIA-CREME CREA F AL; Up to 18yrs old;RX/OTC
EMOLLIA-LOTION LOTN F AL; Up to 18yrs old;RX/OTC
emollient crea F AL; Up to 18yrs old;RX/OTC
emollient lotn 1.25 % F AL; Up to 18yrs old;RX/OTC
emollient oint 52 %,0.16gm/30gm-300mg/30gm-100unit/30gm, 41 %
F
AL; Up to 18yrs old
EPILYT LOTN F AL; Up to 18yrs old;RX/OTC
EQ THERAPEUTIC MOISTURIZING CREAM CREA
F AL; Up to 18yrs old;RX/OTC
EQL ADVANCED RECOVERY SKIN CARE LOTN
F AL; Up to 18yrs old;RX/OTC
EQL MOISTURIZING CREAM CREA F
AL; Up to 18yrs old;RX/OTC
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Drug Name DrugTier
Requirements/Limits
EQL ULTRA MOISTURIZING DAILY LOTION LOTN
F AL; Up to 18yrs old;RX/OTC
EUCERIN BABY LOTN F AL; Up to 18yrs old;RX/OTC
EUCERIN CALMING DAILY MOISTURIZER CREA (Emollient)
NP AL; Up to 18yrs old;RX/OTC
EUCERIN DAILY PROTECTION/SPF 30LOTN
F AL; Up to 18yrs old;RX/OTC
EUCERIN INTENSIVE REPAIR LOTN F
AL; Up to 18yrs old;RX/OTC
EUCERIN INTENSIVE REPAIRHAND CREA F
AL; Up to 18yrs old;RX/OTC
EUCERIN LOTN F AL; Up to 18yrs old;RX/OTC
EUCERIN ORIGINAL HEALINGSOOTHING REPAIR LOTN
F AL; Up to 18yrs old;RX/OTC
EUCERIN PLUS CREA F AL; Up to 18yrs old;RX/OTC
EUCERIN PLUS INTENSIVE REPAIR CREA (Emollient)
NP AL; Up to 18yrs old;RX/OTC
EUCERIN PLUS LOTN F AL; Up to 18yrs old;RX/OTC
EUCERIN SKIN CALMING DAILY MOISTURIZING CREA (Emollient)
NP AL; Up to 18yrs old;RX/OTC
EUCERIN SMOOTHING REPAIRADVANCED FORMULA LOTN
F AL; Up to 18yrs old;RX/OTC
FORMULA 405 ENRICHED EYE CREA F
AL; Up to 18yrs old;RX/OTC
FORMULA 405 FACE CREAM CREA F
AL; Up to 18yrs old;RX/OTC
FORMULA 405 LIGHT TEXTURED MOISTURIZER CREA
F AL; Up to 18yrs old;RX/OTC
Drug Name DrugTier
Requirements/Limits
FORMULA 405 MOISTURIZING LOTN F
AL; Up to 18yrs old;RX/OTC
GENTLE CREA F AL; Up to 18yrs old;RX/OTC
GERI-SOFT LOTN F AL; Up to 18yrs old;RX/OTC
glycerin (topical) liqd F
GNP ADVANCED RECOVERY LOTN F
AL; Up to 18yrs old;RX/OTC
GOLD BOND MEDICATED BODYLOTION EXTRA STRENGTH LOTN
F AL; Up to 18yrs old;RX/OTC
GOLD BOND MEDICATED BODYLOTION LOTN F
AL; Up to 18yrs old;RX/OTC
GOLD BOND ULTIMATE DIABETICS' DRY RELIEF LOTN
F AL; Up to 18yrs old;RX/OTC
GOLD BOND ULTIMATE HEALING CREA F
AL; Up to 18yrs old;RX/OTC
GOLD BOND ULTIMATE HEALING LOTN F
AL; Up to 18yrs old;RX/OTC
GOLD BOND ULTIMATE HEALING OINT F AL; Up to 18
yrs old
GOLD BOND ULTIMATE LOTN F
AL; Up to 18yrs old;RX/OTC
GOLD BOND ULTIMATE PROTECTION LOTN F
AL; Up to 18yrs old;RX/OTC
GOLD BOND ULTIMATE RESTORING LOTN F
AL; Up to 18yrs old;RX/OTC
GOLD BOND ULTIMATE SHEERRIBBONS PEARLRADIANCE LOTN
F AL; Up to 18yrs old;RX/OTC
GOLD BOND ULTIMATE SHEERRIBBONS SILKSOFTNESS LOTN
F AL; Up to 18yrs old;RX/OTC
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Drug Name DrugTier
Requirements/Limits
GOLD BOND ULTIMATE SOFTENING LOTN F
AL; Up to 18yrs old;RX/OTC
GOLD BOND ULTIMATE SOOTHING CREA F
AL; Up to 18yrs old;RX/OTC
GOLD BOND ULTIMATE SOOTHING LOTN F
AL; Up to 18yrs old;RX/OTC
GRX VITAMIN E LOTN F AL; Up to 18yrs old;RX/OTC
HYDRASYN25 CREA F AL; Up to 18yrs old;RX/OTC
HYDRO-LAN CREA F AL; Up to 18yrs old;RX/OTC
J & J BURN CREAM CREA F AL; Up to 18yrs old;RX/OTC
KERADAN CREA F AL; Up to 18yrs old;RX/OTC
KERI ADVANCED MOISTURE THERAPY LOTN
F AL; Up to 18yrs old;RX/OTC
KERI BASIC ESSENTIALS LOTN F
AL; Up to 18yrs old;RX/OTC
KERI LONG LASTING CREA F
AL; Up to 18yrs old;RX/OTC
KERI NOURISHING SHEA BUTTER LOTN F
AL; Up to 18yrs old;RX/OTC
KERI ORIGINAL LOTN F AL; Up to 18yrs old;RX/OTC
KERI OVERNIGHT LOTN F AL; Up to 18yrs old;RX/OTC
KERI RENEWAL MILK BODY LOTN F
AL; Up to 18yrs old;RX/OTC
KERI RENEWAL SKIN FIRMING LOTN F
AL; Up to 18yrs old;RX/OTC
Drug Name DrugTier
Requirements/Limits
KERI RENEWAL STRETCH MARK MINIMIZER LOTN
F AL; Up to 18yrs old;RX/OTC
KERI SENSITIVE SKIN LOTN F
AL; Up to 18yrs old;RX/OTC
LAC-HYDRIN CREA (Lactic Acid (AmmoniumLactate))
NP AL; Up to 18yrs old;RX/OTC
LAC-HYDRIN LOTN (Lactic Acid (Ammonium Lactate)) NP
AL; Up to 18yrs old;RX/OTC
LAC-HYDRIN TWELVE LOTN (Lactic Acid (Ammonium Lactate))
NP AL; Up to 18yrs old;RX/OTC
lactic acid (ammoniumlactate) crea 12 % F
AL; Up to 18yrs old;RX/OTC
lactic acid (ammoniumlactate) lotn 12 % F
AL; Up to 18yrs old;RX/OTC
LACTINOL HX CREA F AL; Up to 18yrs old;RX/OTC
LADY ESTHER 4 PURPOSE FACE CREAM CREA
F AL; Up to 18yrs old;RX/OTC
LANAPHILIC OINT F AL; Up to 18yrs old
LANOLOR CREA F AL; Up to 18yrs old;RX/OTC
LANTISEPTIC THERAPEUTIC CREA F
AL; Up to 18yrs old;RX/OTC
LEADER FINGER CREAM CREA F
AL; Up to 18yrs old;RX/OTC
LUBRIDERM ADVANCED THERAPY LOTN F
AL; Up to 18yrs old;RX/OTC
LUBRIDERM DAILY MOISTURE/NORMAL TODRY SKIN LOTN
F AL; Up to 18yrs old;RX/OTC
LUBRIDERM DAILY MOISTURESHEA + CALMING LAVENDER JASMINE LOTN
F
AL; Up to 18yrs old;RX/OTC
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Drug Name DrugTier
Requirements/Limits
LUBRIDERM INTENSE SKIN REPAIR LOTN F
AL; Up to 18yrs old;RX/OTC
LUBRIDERM LOTN F AL; Up to 18yrs old;RX/OTC
LUBRIDERM MENS 3-IN-1 LOTN F
AL; Up to 18yrs old;RX/OTC
LUBRIDERM SERIOUSLY SENSITIVE LOTN F
AL; Up to 18yrs old;RX/OTC
LUBRIDERM SKIN NOURISHINGWITH SHEA AND COCOA BUTTERS LOTN
F
AL; Up to 18yrs old;RX/OTC
LUBRIDERM SOOTHING RELIEF/COOLING LOTN F
AL; Up to 18yrs old;RX/OTC
LUBRISOFT LOTN F AL; Up to 18yrs old;RX/OTC
MAXAM LOTN F AL; Up to 18yrs old;RX/OTC
MEDELA TENDER CARE LANOLIN CREA F
AL; Up to 18yrs old;RX/OTC
MEDERMA AG FACE CREAM CREA F
AL; Up to 18yrs old;RX/OTC
MEDERMA AG HAND & BODY LOTION LOTN F
AL; Up to 18yrs old;RX/OTC
MEDERMA STRETCH MARKS THERAPY CREA F
AL; Up to 18yrs old;RX/OTC
MOISTURIZING CREAM CREA F
AL; Up to 18yrs old;RX/OTC
MOTHERS FRIEND CREA F AL; Up to 18yrs old;RX/OTC
MOTHERS FRIEND LOTN F AL; Up to 18yrs old;RX/OTC
Drug Name DrugTier
Requirements/Limits
MSM SKIN LOTION LOTN F AL; Up to 18yrs old;RX/OTC
NEOSALUS LOTN F AL; Up to 18yrs old;RX/OTC
NEUTROGENA BODY LIGHT SESAME FORMULA LOTN
F AL; Up to 18yrs old;RX/OTC
NEUTROGENA HAND CREA F
AL; Up to 18yrs old;RX/OTC
NEUTROGENA HAND/NORWEGIANFORMULA/FAST ABSORBINGCREA
F
AL; Up to 18yrs old;RX/OTC
NEUTROGENA HEALTHY SKIN CREA F
AL; Up to 18yrs old;RX/OTC
NEUTROGENA HEALTHY SKIN FACE SPF 15 LOTN F
AL; Up to 18yrs old;RX/OTC
NEUTROGENA MOISTURE SENSITIVE SKIN LOTN
F AL; Up to 18yrs old;RX/OTC
NISEKO HYDRATING FACIAL MOISTURIZER CREA
F AL; Up to 18yrs old;RX/OTC
NIVEA CREA F AL; Up to 18yrs old;RX/OTC
NIVEA EXTRA ENRICHED LOTION LOTN F
AL; Up to 18yrs old;RX/OTC
NIVEA EXTRA ENRICHED LOTN F
AL; Up to 18yrs old;RX/OTC
NIVEA GENTLE BODY EXFOLIATOR LOTN F
AL; Up to 18yrs old;RX/OTC
NIVEA LIGHT CREA F AL; Up to 18yrs old;RX/OTC
NIVEA LIGHT LOTN F AL; Up to 18yrs old;RX/OTC
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Drug Name DrugTier
Requirements/Limits
NIVEA LOTN F AL; Up to 18yrs old;RX/OTC
NIVEA ORIGINAL LOTN F AL; Up to 18yrs old;RX/OTC
NIVEA ORIGINAL MOISTURE LOTN F
AL; Up to 18yrs old;RX/OTC
NIVEA SOFT CREA F AL; Up to 18yrs old;RX/OTC
NIVEA VISAGE CREA F AL; Up to 18yrs old;RX/OTC
NIVEA VISAGE INNER BEAUTY NIGHTTIME RENEWAL CREA
F AL; Up to 18yrs old;RX/OTC
NIVEA VISAGE LOTN F AL; Up to 18yrs old;RX/OTC
NUTRADERM ADVANCED FORMULA LOTN F
AL; Up to 18yrs old;RX/OTC
NUTRADERM CREA 2.5%-2.5%-2.5%-2.5%-2.5%-2.5%
F AL; Up to 18yrs old;RX/OTC
NUTRADERM LOTN 2.5%-2.5%-2.5%-2.5%-2.5% F
AL; Up to 18yrs old;RX/OTC
NUTRASEB CREA F AL; Up to 18yrs old;RX/OTC
OINTMENT BASE OINT F AL; Up to 18yrs old
PEN-KERA CREA F AL; Up to 18yrs old;RX/OTC
PENTRAVAN CREA F AL; Up to 18yrs old;RX/OTC
PENTRAVAN PLUS CREA F AL; Up to 18yrs old;RX/OTC
PETROLATUM OINT F AL; Up to 18yrs old
Drug Name DrugTier
Requirements/Limits
PRETTY FEET & HANDS CREA F
AL; Up to 18yrs old;RX/OTC
RA GENTLE SKIN CREAM CREA F
AL; Up to 18yrs old;RX/OTC
RA RENEWAL DRY SKIN THERAPY LOTN F
AL; Up to 18yrs old;RX/OTC
RADIAGUARD ADVANCED LOTN F
AL; Up to 18yrs old;RX/OTC
RESTA CREA F AL; Up to 18yrs old;RX/OTC
RESTA LITE LOTN F AL; Up to 18yrs old;RX/OTC
RISABAL-PH CREA F AL; Up to 18yrs old;RX/OTC
ROC DEEP WRINKLE SERUM LOTN F
AL; Up to 18yrs old;RX/OTC
ROC MULTI CORREXION 5 IN1 RESTORING EYE CREAM CREA
F AL; Up to 18yrs old;RX/OTC
ROC MULTI CORREXION 5 IN1 RESTORING NIGHT CREAM CREA
F AL; Up to 18yrs old;RX/OTC
ROC MULTI CORREXION LIFTANTI-GRAVITY NIGHT CREA
F AL; Up to 18yrs old;RX/OTC
ROC RETINOL CORREXION CREA F
AL; Up to 18yrs old;RX/OTC
ROC RETINOL CORREXION MAX CREA F
AL; Up to 18yrs old;RX/OTC
ROC RETINOL CORREXION NIGHT CREA
F AL; Up to 18yrs old;RX/OTC
ROC RETINOL CORREXION SENSITIVE EYE CREA
F AL; Up to 18yrs old;RX/OTC
ROC RETINOL CORREXION SENSITIVE NIGHT CREA
F AL; Up to 18yrs old;RX/OTC
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Drug Name DrugTier
Requirements/Limits
ROSE MILK LOTN F AL; Up to 18yrs old;RX/OTC
SKIN REPAIR LOTN F AL; Up to 18yrs old;RX/OTC
SOOTHE & COOL MOISTURIZING BODY LOTION WITH ALOE LOTN
F
AL; Up to 18yrs old;RX/OTC
SOOTHE & COOL SKIN CREAMWITH ALOE & VITAMINS A, D & E CREA
F AL; Up to 18yrs old;RX/OTC
SORBOLENE CREA F AL; Up to 18yrs old;RX/OTC
SPECIAL CARE CREAM CREA F
AL; Up to 18yrs old;RX/OTC
ST IVES SWISS FORMULA 24HOUR MOISTURE LOTN
F AL; Up to 18yrs old;RX/OTC
STUDIO 35 EXTRA MOISTURIZING LOTION LOTN
F AL; Up to 18yrs old;RX/OTC
STUDIO 35 MOISTURIZING SKIN CREA
F AL; Up to 18yrs old;RX/OTC
SWEEN CREAM CREA F AL; Up to 18yrs old
THERABETIC SKIN CARE LOTN F
AL; Up to 18yrs old;RX/OTC
THERAPEUTIC MOISTURIZING CREA F
AL; Up to 18yrs old;RX/OTC
THERAPLEX HYDROLOTION LOTN F
AL; Up to 18yrs old;RX/OTC
TRIPLE CREAM CREA F AL; Up to 18yrs old;RX/OTC
TROPAZONE LOTN F AL; Up to 18yrs old;RX/OTC
UDDERLY SMOOTH CREA F
AL; Up to 18yrs old;RX/OTC
Drug Name DrugTier
Requirements/Limits
UDDERLY SMOOTH EXTRA CARE CREA F
AL; Up to 18yrs old;RX/OTC
UDDERLY SMOOTH EXTRA CARE20 CREA F
AL; Up to 18yrs old;RX/OTC
VANICREAM CREA F AL; Up to 18yrs old;RX/OTC
VANICREAM LITE LOTN F AL; Up to 18yrs old;RX/OTC
VELVACHOL CREA F AL; Up to 18yrs old;RX/OTC
VITAMIN E WITH PANTHENOL CREA F
AL; Up to 18yrs old;RX/OTC
vitamins a & d (topical) oint F AL; Up to 18yrs old
VP DERMABASE CREA F AL; Up to 18yrs old;RX/OTC
WIBI LOTN F AL; Up to 18yrs old;RX/OTC
ZIMS CRACK CREME DAYTIME CREA F
AL; Up to 18yrs old;RX/OTC
Enzymes - Topical SANTYL OINT F
Immunomodulating Agents - Topical ALDARA CREA (Imiquimod) NP QL(0.2667 eadaily)
imiquimod crea F QL(0.2667 eadaily)
ZYCLARA CREA NP
ZYCLARA PUMP CREA NP
Immunosuppressive Agents - Topical
ELIDEL CREA F AL; At least 2 yrs old
PROTOPIC OINT (Tacrolimus (Topical)) NP AL; At least 2 yrs old
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Drug Name DrugTier
Requirements/Limits
tacrolimus (topical) oint NP AL; At least 2 yrs old Keratolytic/Antimitotic Agents BENSAL HP OINT NP
BETASAL SHAM F
COMPOUND W LIQD (Salicylic Acid) NP
COMPOUND W MAXIMUM STRENGTH GEL (SalicylicAcid)
NP
CONDYLOX SOLN (Podofilox) NP
CVS PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER SHAM
F
CVS THERAPEUTIC MAXIMUM STRENGTH SHAM
F
DENOREX EXTRA STRENGTH 2-IN-1 SHAM F
DERMAREST PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER SHAM
F
NEUTROGENA T/SALSHAM F
P & S SHAM F
podofilox soln F
salicylic acid gel 17 % F
salicylic acid liqd 17 % F
salicylic acid soln 17 % F
SELSUN BLUE DEEP CLEANSING SHAM F
SELSUN BLUE NATURALS DRYSCALP SHAM
F
SELSUN BLUE NATURALS SHAM F
Drug Name DrugTier
Requirements/Limits
THERAPEUTIC T+PLUS MAXIMUM STRENGTH SHAM
F
Liniments ASPERCREME/ALOECREA (Trolamine Salicylate)
NP
BENGAY GREASELESS CREA (Menthol-MethylSalicylate (Liniments))
NP
BENGAY ULTRA STRENGTH CREA (Camphor-Menthol-MethylSalicylate)
NP
BLUE-EMU SUPER STRENGTH CREA F
camphor-menthol-methylsalicylate crea 10%-30%-4%
F
liniments & rubs crea 10%-0.025%-15%, 0.01%-5%-10%, 1.2%-2.6%-4.7%,
F
menthol-methyl salicylate(liniments) crea 8%-30%,1%-15%, 3%-10%, 10%-30%, 10%-15%, 4%-25%
F
menthol-methyl salicylate(liniments) oint 6%-14%,7.6%-29%, 10%-15%
F
MOBISYL CREA (Trolamine Salicylate) NP
MYOFLEX CREA (Trolamine Salicylate) NP
SPORTSCREME CREA (Trolamine Salicylate) NP
TRIXAICIN CREA F
trolamine salicylate crea F
VICKS BABYRUB CREA F
Local Anesthetics - Topical ARTHRITIS PAIN RELIEVING CREA F
capsaicin crea 0.075 %, 0.1%, 0.025 % F
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Drug Name DrugTier
Requirements/Limits
CAPZASIN-HP CREA (Capsaicin) NP
dibucaine oint F
EMLA CREA (Lidocaine-Prilocaine) NP
lidocaine hcl crea ex 3 % F
lidocaine hcl gel ex 2 % F RX/OTC
lidocaine oint 5 % F
lidocaine ptch 5 % F
lidocaine-prilocaine crea F
LIDODERM PTCH (Lidocaine) NP
pramoxine-zinc acetate lotn F
ZOSTRIX DIABETIC FOOT PAIN CREA (Capsaicin) NP
Misc. Topical A+D FIRST AID OINT F
ABSORBASE OINT F
ALOE VESTA PROTECTIVE OINT F
AMERIDERM PERISHIELD OINT F
AQUAPHOR LIP REPAIR OINT F
BASIS FACIAL MOISTURIZER CREA F
AL; Up to 18yrs old;RX/OTC
BASIS OVERNIGHT CREA F AL; Up to 18yrs old;RX/OTC
BAZA CLEANSE & PROTECT LOTN F
BODI PROTECT OINT F
CARRINGTON MOISTURE BARRIER CREA F
AL; Up to 18yrs old;RX/OTC
Drug Name DrugTier
Requirements/Limits
CARRINGTON MOISTURE BARRIER/ZINC CREA F
AL; Up to 18yrs old;RX/OTC
CERAVE OINT F
CHAPSTICK OVERNIGHT OINT F
CHAPSTICK ULTRA MOISTUREDAYTIME FORMULA OINT
F
CHAPSTICK ULTRASMOOTH FORTIFY OINT
F
CHAPSTICK ULTRASMOOTH NOURISH OINT
F
CHAPSTICK ULTRASMOOTH REJUVENATE OINT
F
CHAPSTICK ULTRASMOOTH SOOTHE OINT
F
CRITIC-AID CLEAR MOISTUREBARRIER OINT
F
DERMADROX OINT F
DR SMITHS DIAPER OINT (Zinc Oxide (Topical)) NP
DRYSOL SOLN F
EUCERIN CREA (Skin Protectants, Misc.) NP
AL; Up to 18yrs old;RX/OTC
GERI PROTECT OINT F
GOLD BOND EXTRA STRENGTH POWD F
GOLD BOND POWD F
HYDROCERIN CREA F AL; Up to 18yrs old;RX/OTC
LANTISEPTIC SKIN PROTECTANT OINT F
lubricants gel F
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Drug Name DrugTier
Requirements/Limits
menthol-zinc oxide powd0.15%-1% F
NEOSPORIN LIP HEALTH OVERNIGHT RENEWAL THERAPY OINT
F
PALOMAR E OINT F
PELEVERUS CLEAR OINT F
PELEVERUS GOLD OINT F
PELEVERUS OINT F
PETROLEUM JELLY LIP TREATMENT OINT F
PROSHIELD PROTECTIVE HANDCREAM CREA
F AL; Up to 18yrs old;RX/OTC
RA RENEWAL ADVANCED HEALING OINT
F
REMEDY CLEAR-AID OINT F
RESTORE CLEANSER & MOISTURIZER LIQD F
SENSI-CARE MOISTURIZING CREA F
AL; Up to 18yrs old;RX/OTC
SENSI-CARE PROTECTIVE BARRIER OINT
F
skin protectants, misc. crea F AL; Up to 18yrs old;RX/OTC
skin protectants, misc. oint51.1 %, , 0.7%-0.4%-1.7%,0.5%-6.3%-70%
F
SOOTHE & COOL FREE MEDSEPTIC OINT F
SOOTHE & COOL FREE MOISTURE BARRIER OINT
F
SOOTHE & COOL FREE SKIN PASTE OINT F
SOOTHE & COOL MOISTURE BARRIER OINT
F
Drug Name DrugTier
Requirements/Limits
SOOTHE & COOL PROTECT MOISTURE BARRIER OINT
F
SORBIDON HYDRATE CREA F
AL; Up to 18yrs old;RX/OTC
witch hazel (hamamelisvirginiana) pads 20 %, , 50%
F
witch hazel-glycerin pads F
zinc oxide (topical) oint 10%, 20 %, 40 % F
Phosphodiesterase 4 (PDE4) Inhibitors - Topical
EUCRISA OINT NP AL; At least 2 yrs old Rosacea Agents DOXYCYCLINE CPDR NP
METROCREAM CREA (Metronidazole (Topical)) NP
METROLOTION LOTN (Metronidazole (Topical)) NP
metronidazole (topical)crea 0.75 % F
metronidazole (topical) gel0.75 % F
metronidazole (topical) lotn0.75 % F
ORACEA CPDR NP
Scabicides & Pediculicides ELIMITE CREA (Permethrin) NP
EURAX CREA NP
EURAX LOTN NP
LINDANE LOTN F ST
lindane lotn F ST
lindane sham NP
LINDANE SHAM NP
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Drug Name DrugTier
Requirements/Limits
malathion lotn NP
NATROBA SUSP F
NIX CREME RINSE LIQD (Permethrin) NP
OVIDE LOTN (Malathion) NP
permethrin crea ex 5 % F
permethrin liqd ex 1 % F
permethrin lotn ex 1 % F
pyrethrins-piperonylbutoxide liqd 0.33%-4% F
pyrethrins-piperonylbutoxide sham 0.33%-4%,0.3%-0.33%-4%
F
RID ESSENTIAL LICE ELIMINATION KIT KIT F
RID LIQD EX 0.33%-4% (Pyrethrins-PiperonylButoxide)
NP
SKLICE LOTN F
SPINOSAD SUSP 4
Tar Products coal tar extract sham 0.5 %, 1 % F
DHS TAR GEL SHAM (Coal Tar Extract) NP
DHS TAR SHAM (Coal Tar Extract) NP
NEUTROGENA T/GELCONDITIONER LIQD F
NEUTROGENA T/GELSHAM (Coal Tar Extract) NP
NEUTROGENA T/GELSTUBBORN ITCH CONTROL SHAM (Coal Tar Extract)
NP
THERAPLEX T SHAM (Coal Tar Extract) NP
Wound Care Products
Drug Name DrugTier
Requirements/Limits
2ND SKIN MOIST BURN PADS1.5"X2" PADS F RX/OTC
2ND SKIN MOIST BURN PADS2"X3" PADS F RX/OTC
2ND SKIN MOIST BURN PADS3"X4" PADS F RX/OTC
2ND SKIN MOIST DRESSING KIT PADS F RX/OTC
2ND SKIN MOIST GEL PADS 1"X1" PADS F RX/OTC
2ND SKIN MOIST GEL PADS 3" ROUND PADS F RX/OTC
ACTICOAT 7 2"X2" PADS F RX/OTC
ACTICOAT 7 4"X5" PADS F RX/OTC
ACTICOAT ABSORBENT ANTIMICROBIAL DRESSING 4"X5" PADS
F RX/OTC
ACTICOAT ANTIMICROBIAL DRESSING 2"X2" PADS
F RX/OTC
ACTICOAT ANTIMICROBIAL DRESSING 4"X4" PADS
F RX/OTC
ACTICOAT FLEX 3 BARRIER DRESSING 4"'X4" PADS
F RX/OTC
ADAPTIC NON-ADHERING DRESSING 3" X 3" PADS
F RX/OTC
ALLEVYN ADHESIVE PADS F RX/OTC
ALLEVYN AG ADHESIVE PADS F RX/OTC
ALLEVYN AG GENTLE BORDER PADS F RX/OTC
ALLEVYN AG NON-ADHESIVE PADS F RX/OTC
ALLEVYN AG SACRUM PADS F RX/OTC
ALLEVYN COMPRESSION PADS F RX/OTC
ALLEVYN GENTLE BORDER HEEL PADS F RX/OTC
ALLEVYN GENTLE BORDER LITE PADS F RX/OTC
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Drug Name DrugTier
Requirements/Limits
ALLEVYN GENTLE BORDER MULTISITE PADS
F RX/OTC
ALLEVYN GENTLE BORDER PADS F RX/OTC
ALLEVYN GENTLE BORDER SACRUM PADS F RX/OTC
ALLEVYN GENTLE PADS F RX/OTC
ALLEVYN HEEL PADS F RX/OTC
ALLEVYN LIFE HEEL PADS F RX/OTC
ALLEVYN LIFE PADS F RX/OTC
ALLEVYN LIFE SACRUM PADS F RX/OTC
ALLEVYN NON-ADHESIVE PADS F RX/OTC
ALLEVYN PLUS ADHESIVE PADS F RX/OTC
ALLEVYN PLUS CAVITY PADS EX F RX/OTC
ALLEVYN PLUS SACRUM PADS F RX/OTC
ALLEVYN SACRUM PADS F RX/OTC
ALLEVYN TRACHEOSTOMY 3-1/2"X3-1/2" PADS
F RX/OTC
AMERIGEL HYDROGEL SATURATED GAUZE DRESSING 2" X 2" PADS
F RX/OTC
AQUACEL EXTRA/HYDROFIBERPADS
F RX/OTC
AQUACEL FOAM 3.2"X3.2" PADS F RX/OTC
AQUACEL FOAM 4"X4" PADS F RX/OTC
AQUACEL FOAM 5"X5" PADS F RX/OTC
AQUACEL FOAM 6"X6" PADS F RX/OTC
AQUACEL FOAM 6"X8" PADS F RX/OTC
Drug Name DrugTier
Requirements/Limits
AQUACEL FOAM 7"X7" PADS F RX/OTC
AQUACEL FOAM 8"X5.5" PADS F RX/OTC
AQUACEL FOAM 8"X7" PADS F RX/OTC
AQUASITE IMPREGNATED DRESSING 2"X2" PADS
F RX/OTC
AQUASITE IMPREGNATED DRESSING 4"X4" PADS
F RX/OTC
AQUASITE IMPREGNATED DRESSING 4"X8" PADS
F RX/OTC
AQUASITE IMPREGNATED GAUZE 2"X2" PADS
F RX/OTC
AQUASITE IMPREGNATED GAUZE 4"X4" PADS
F RX/OTC
AQUASITE SHEET DRESSING 4"X4" PADS F RX/OTC
ARGLAES FILM 2-3/8" X 3-1/8" PADS F RX/OTC
ARGLAES FILM 3" X 14" PADS F RX/OTC
ARGLAES FILM 4" X 4-3/4"PADS F RX/OTC
ARGLAES FILM 4-3/4" X10" PADS F RX/OTC
ARGLAES ISLAND 2-3/8"X 3-1/8" PADS F RX/OTC
ARGLAES ISLAND 4" X 4-3/4" PADS F RX/OTC
ARGLAES ISLAND 4-3/4"X 10" PADS F RX/OTC
BIOBRANE 10"X15" PADS F RX/OTC
BIOBRANE 15"X20" PADS F RX/OTC
BIOBRANE 5"X15" PADS F RX/OTC
BIOBRANE 5"X5" PADS F RX/OTC
BIOBRANE-L 10"X15" PADS F RX/OTC
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Drug Name DrugTier
Requirements/Limits
BIOBRANE-L 5"X15" PADS F RX/OTC
BIOBRANE-L 5"X5" PADS F RX/OTC
CARBOFLEX ODOR CONTROL DRESSING PADS
F RX/OTC
CARRAGAUZE 2 X 2 PADS F RX/OTC
CARRAGAUZE 4 X 4 PADS F RX/OTC
COMFEEL PLUS CLEARDRESSING PADS F RX/OTC
COMFEEL PLUS CONTOURDRESSING PADS
F RX/OTC
COMFEEL PLUS DRESSING PADS F RX/OTC
COMFEEL PLUS TRIANGLEDRESSING PADS
F RX/OTC
COMFEEL PLUS ULCER DRESSING PADS F RX/OTC
COMFEEL PLUS ULCERDRESSING PADS F RX/OTC
COMFEEL ULCER CAREDRESSING PADS F RX/OTC
COMFORT-AID 1.5"X2.5" PADS F RX/OTC
CONTREET FOAM CAVITY PADS F RX/OTC
CONTREET FOAM HEEL PADS F RX/OTC
CONTREET FOAM PADS F RX/OTC
CONTREET FOAM SACRAL PADS F RX/OTC
CONTREET HYDROCOLLOID PADS F RX/OTC
CURITY HEAVY DRAINAGE PACK PADS F RX/OTC
CURITY SALINE DRESSING 8"X4" PADS F RX/OTC
CURITY SODIUM CHLORIDE DRESSING 6"X6-3/4" PADS
F RX/OTC
Drug Name DrugTier
Requirements/Limits
DERMA-GEL 4" X 4" PADS F RX/OTC
DERMAGAUZE DRESSING PADS F RX/OTC
DERMAGRAN HYDROPHILIC WOUND DRESSING 2"X2" PADS
F RX/OTC
DERMAGRAN HYDROPHILIC WOUND DRESSING 4"X4" PADS
F RX/OTC
DERMAGRAN HYDROPHILIC WOUND DRESSING 8"X4" PADS
F RX/OTC
DOCTORS CHOICE BURNS/SCALDS/ABRASIONS PADS
F RX/OTC
DOME-PASTE BANDAGE PADS F RX/OTC
DRAWTEX ADVANCED WOUND CARE 2"X2" PADS
F RX/OTC
DRAWTEX ADVANCED WOUND CARE 3"X3" PADS
F RX/OTC
DRAWTEX ADVANCED WOUND CARE 4"X4" PADS
F RX/OTC
DRAWTEX ADVANCED WOUND CARE 6"X8" PADS
F RX/OTC
DRAWTEX ADVANCED WOUND CARE 8"X8" PADS
F RX/OTC
DUDRESS ISLAND DRESSING 4"X4" PADS F RX/OTC
DUDRESS ISLAND DRESSING 6"X6" PADS F RX/OTC
ELASTO-GEL 12"X12" PADS F RX/OTC
ELASTO-GEL 2"X3" PADS F RX/OTC
ELASTO-GEL 3" ROUND PADS F RX/OTC
ELASTO-GEL 4"X4" PADS F RX/OTC
ELASTO-GEL 5"X5" PADS F RX/OTC
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Drug Name DrugTier
Requirements/Limits
ELASTO-GEL 6"X8" PADS F RX/OTC
ELASTO-GEL 8"X16" PADS F RX/OTC
ELASTO-GEL CAST/SPLINT 12"X12"PADS
F RX/OTC
ELASTO-GEL CAST/SPLINT 4"X4" PADS F RX/OTC
ELASTO-GEL CAST/SPLINT 6"X8" PADS F RX/OTC
ELASTO-GEL CAST/SPLINT 8"X16"PADS
F RX/OTC
ELASTO-GEL FACE MASK PADS F RX/OTC
ELASTO-GEL PLUS 2"X3" PADS F RX/OTC
ELASTO-GEL PLUS 4"X4" PADS F RX/OTC
ELASTO-GEL PLUS 8"X8" PADS F RX/OTC
ELTA DERMAL WOUND DRESSING PADS F RX/OTC
EXU-DRY 15"X18" PADS F RX/OTC
EXU-DRY 15"X24" PADS F RX/OTC
EXU-DRY 20"X28" PADS F RX/OTC
EXU-DRY 3"X4" PADS F RX/OTC
EXU-DRY 4"X6" PADS F RX/OTC
EXU-DRY 6"X9" PADS F RX/OTC
EXU-DRY 9"X15" PADS F RX/OTC
EXU-DRY ARM 27"X31" PADS F RX/OTC
EXU-DRY ARM/SHOULDER TIES27"X31" PADS
F RX/OTC
EXU-DRY BURN JACKET 31"X32" PADS F RX/OTC
EXU-DRY BURN JACKET CHILD 17"X20" PADS F RX/OTC
Drug Name DrugTier
Requirements/Limits
EXU-DRY BUTTOCKS 23"X53" PADS F RX/OTC
EXU-DRY ELBOW/KNEE/HEEL10"X17" PADS
F RX/OTC
EXU-DRY FACE 9"X14" PADS F RX/OTC
EXU-DRY INCISION 3"X9" PADS F RX/OTC
EXU-DRY NON-PERMEABLE PAD 24"X36" PADS
F RX/OTC
EXU-DRY PADDED HAND 12"X13" PADS F RX/OTC
EXU-DRY PADDED HAND CHILD 8"X8" PADS F RX/OTC
EXU-DRY PADDED NECK 6"X25" PADS F RX/OTC
EXU-DRY PERMEABLE PAD 24"X36" PADS F RX/OTC
EXU-DRY SCALP 3"X14" PADS F RX/OTC
EXU-DRY SLIT TUBE 2"X3" PADS F RX/OTC
FIBRACOL COLLAGEN-ALGINATE WOUND DRESSING/2" X 2" PADS
F RX/OTC
FIBRACOL COLLAGEN-ALGINATE WOUND DRESSING/4" X 8-3/4"PADS
F
RX/OTC
FOAM DRESSING BORDERED PADS F RX/OTC
FOAM DRESSING CIRCULAR BORDERED PADS
F RX/OTC
FOAM DRESSING NON-BORDERED PADS F RX/OTC
GRX HYDROGEL GAUZE 2X2 PADS F RX/OTC
GRX HYDROGEL GAUZE 4X4 PADS F RX/OTC
HYCOLOID-GRX PADS F RX/OTC
HYDROCOL II PADS F RX/OTC
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Drug Name DrugTier
Requirements/Limits
HYDROCOL II SACRAL PADS F RX/OTC
HYDROCOL II THIN PADS F RX/OTC
HYDROFERA BLUE 4"X4" PADS F RX/OTC
HYDROFERA BLUE FOAM DRESSING 2"X2" PADS
F RX/OTC
HYDROFERA BLUE FOAM DRESSING 4"X4" PADS
F RX/OTC
HYDROFERA BLUE FOAM DRESSING 6"X6" PADS
F RX/OTC
HYDROFERA BLUE FOAM DRESSING PADS F RX/OTC
HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE FILM PADS
F
RX/OTC
HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE FILM/2-1/4X8PADS
F
RX/OTC
HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE FILM/4"X4"PADS
F
RX/OTC
HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE FILM/ISLANDPADS
F
RX/OTC
HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE/OSTOMY/2.5"PADS
F
RX/OTC
HYDROFERA BLUE FOAM DRESSING/TUNNELING/9MM PADS
F
RX/OTC
HYDROFERA BLUE HEAVY DRAINAGE 4"X4" PADS
F RX/OTC
Drug Name DrugTier
Requirements/Limits
HYDROFERA BLUE HEAVY DRAINAGE 6"X6" PADS
F RX/OTC
HYDROFERA BLUE READY FOAMDRESSING 2.5"X2.5" PADS
F RX/OTC
HYDROFERA BLUE READY FOAMDRESSING 4"X5" PADS
F RX/OTC
HYDROFERA BLUE READY FOAMDRESSING 8"X8" PADS
F RX/OTC
KALTOSTAT FORTEX PADS F RX/OTC
KALTOSTAT PADS F RX/OTC
KALTOSTAT WOUND DRESSING PADS F RX/OTC
KENDALL ALGINATE HYDROCOLLOID DRESSING 4"X4" PADS
F RX/OTC
KENDALL ALGINATE HYDROCOLLOID DRESSING 4"X5" PADS
F RX/OTC
KENDALL ALGINATE HYDROCOLLOID DRESSING 6"X6" PADS
F RX/OTC
KENDALL ALGINATE HYDROCOLLOID DRESSING 6"X7" PADS
F RX/OTC
KENDALL ALGINATE HYDROCOLLOID DRESSING 8"X8" PADS
F RX/OTC
KENDALL ZINC CALCIUM ALGINATE DRESSING 2"X2" PADS
F RX/OTC
KENDALL ZINC CALCIUM ALGINATE DRESSING 4"X4" PADS
F RX/OTC
KENDALL ZINC CALCIUM ALGINATE DRESSING 4"X8" PADS
F RX/OTC
KERAMATRIX REPLICINE 10CMX10CM PADS F RX/OTC
KERAMATRIX REPLICINE 5CMX5CM PADS F RX/OTC
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Drug Name DrugTier
Requirements/Limits
KERLIX SUPER SPONGE SALINE DRESSING PADS F RX/OTC
MAXORB EXTRA AG+ PADS F RX/OTC
MEDI-PAK PERFORMANCE PLUSCOMBINE ABD PAD/8" X 7.5" PADS
F
RX/OTC
MEDIHONEY CALCIUM ALGINATE DRESSING 4"X5" PADS
F RX/OTC
MEDIHONEY CALCIUM ALGINATE DRESSING/2"X2" PADS
F RX/OTC
MEDIHONEY WOUND & BURN DRESSING 3/4"X12" PADS
F RX/OTC
MEDIHONEY WOUND/BURNDRESSING4"X5" PADS
F RX/OTC
NU-GEL WOUND DRESSING/3-3/4" X 3-3/4"PADS
F RX/OTC
NU-GEL WOUND DRESSING/6"X 8" PADS F RX/OTC
POLYMEM ALGINATE DRESSING/3" X 3" PADS F RX/OTC
POLYMEM ALGINATE DRESSING/4" X 4" PADS F RX/OTC
POLYMEM ALGINATE DRESSING/5" X 5" PADS F RX/OTC
POLYMEM ALGINATE DRESSING/6.5" X 7.5"PADS
F RX/OTC
POLYMEM SILVER DRESSING/4.25" X 4.25"PADS
F RX/OTC
PRIMACOL BORDERED DRESSING 2"X2" PADS F RX/OTC
PRIMACOL BORDERED DRESSING 4"X4" PADS F RX/OTC
PRIMACOL BORDERED DRESSING 6"X6" PADS F RX/OTC
PRIMACOL DRESSING 4"X4" PADS F RX/OTC
PRIMACOL DRESSING 6"X6" PADS F RX/OTC
Drug Name DrugTier
Requirements/Limits
PRIMACOL DRESSING 8"X8" PADS F RX/OTC
PRIMACOL SPECIALTY DRESSING PADS F RX/OTC
REPLICARE 1-1/2"X2-1/2"PADS F RX/OTC
REPLICARE 4"X4" PADS F RX/OTC
REPLICARE 6"X6" PADS F RX/OTC
REPLICARE 8"X8" PADS F RX/OTC
REPLICARE THIN 2"X2.75" PADS F RX/OTC
REPLICARE THIN 3.5"X5.5" PADS F RX/OTC
REPLICARE THIN 6"X8" PADS F RX/OTC
REPLICARE ULTRA 4"X4" PADS F RX/OTC
REPLICARE ULTRA 6"X6" PADS F RX/OTC
REPLICARE ULTRA SACRUM 7"X8" PADS F RX/OTC
RESTORE CX WOUND CARE DRESSING-STERILE PADS
F RX/OTC
RESTORE DRESSING FOR PSORIASIS-STERILE PADS
F RX/OTC
RESTORE EXTRA THIN DRESSING 4"X4" PADS F RX/OTC
RESTORE EXTRA THIN DRESSING 6"X8" PADS F RX/OTC
RESTORE EXTRA THIN DRESSING 8"X8" PADS F RX/OTC
RESTORE HYDROGEL GAUZE PAD 4"X4" PADS F RX/OTC
RESTORE PLUS WOUND CARE DRESSING 4"X4" PADS
F RX/OTC
RESTORE PLUS WOUND CARE DRESSING 4"X4" TAPERED EDGE PADS
F RX/OTC
RESTORE PLUS WOUND CARE DRESSING 6"X6" TAPERED EDGE PADS
F RX/OTC
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Drug Name DrugTier
Requirements/Limits
RESTORE PLUS WOUND CARE DRESSING 6"X8" PADS
F RX/OTC
RESTORE PLUS WOUND CARE DRESSING 6"X8" TAPERED EDGE PADS
F RX/OTC
RESTORE PLUS WOUND CARE DRESSING 8"X8" PADS
F RX/OTC
RESTORE PLUS WOUND CARE DRESSING 8"X8" TAPERED EDGE PADS
F RX/OTC
RESTORE PLUS WOUND CARE DRESSING TRIANGLE PADS
F RX/OTC
RESTORE SILVER DRESSING 2"X2" PADS F RX/OTC
RESTORE SILVER DRESSING 4"X4" NON-ADHESIVE PADS
F RX/OTC
RESTORE SILVER DRESSING 4"X4.75" PADS
F RX/OTC
RESTORE SILVER DRESSING 4"X5" CONTACT LAYER PADS
F RX/OTC
RESTORE SILVER DRESSING 6"X8" CONTACT LAYER PADS
F RX/OTC
RESTORE SILVER DRESSING 6"X8" NON-ADHESIVE PADS
F RX/OTC
RESTORE WOUND CARE DRESSING 4"X4" ADHESIVE PADS
F RX/OTC
RESTORE WOUND CARE DRESSING 4"X4" NON-ADHESIVE PADS
F RX/OTC
RESTORE WOUND CARE DRESSING 4"X4" PADS F RX/OTC
RESTORE WOUND CARE DRESSING 4"X5" CONTACT LAYER PADS
F RX/OTC
RESTORE WOUND CARE DRESSING 6"X6" ADHESIVE PADS
F RX/OTC
Drug Name DrugTier
Requirements/Limits
RESTORE WOUND CARE DRESSING 6"X8" ADHESIVE PADS
F RX/OTC
RESTORE WOUND CARE DRESSING 6"X8" CONTACT LAYER PADS
F RX/OTC
RESTORE WOUND CARE DRESSING 6"X8" NON-ADHESIVE PADS
F RX/OTC
RESTORE WOUND CARE DRESSING 6"X8" PADS F RX/OTC
RESTORE WOUND CARE DRESSING 8"X8" PADS F RX/OTC
RTD WOUND CARE DRESSING2" X 2" PADS F RX/OTC
RTD WOUND CARE DRESSING4" X 4" PADS F RX/OTC
RTD WOUND CARE DRESSING4" X 5" PADS F RX/OTC
SEASORB-AG PADS F RX/OTC
SKINTEGRITY 2" X 2" PADS F RX/OTC
SKINTEGRITY 4" X 4" PADS F RX/OTC
SOLOSITE CONFORMABLE WOUND 2"X2" PADS
F RX/OTC
SOLOSITE CONFORMABLE WOUND 4"X4" PADS
F RX/OTC
SORBACELL FOAM DRESSING 4"X4" PADS F RX/OTC
SORBACELL FOAM DRESSINGSTRIP 1"X8" PADS
F RX/OTC
SORBSAN TOPICAL WOUND DRESSING 12" PADS
F RX/OTC
SORBSAN TOPICAL WOUND DRESSING 2" X 2" PADS
F RX/OTC
SORBSAN TOPICAL WOUND DRESSING 3 X 3 PADS
F RX/OTC
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Drug Name DrugTier
Requirements/Limits
SORBSAN TOPICAL WOUND DRESSING 4 X 4 PADS
F RX/OTC
SORBSAN TOPICAL WOUND DRESSING 4" X 8" PADS
F RX/OTC
STRATASORB COMPOSITE ISLAND DRESSING 4" X 4" PADS
F RX/OTC
TEGADERM AG MESH DRESSING WITH SILVER 2"X2" PADS
F RX/OTC
TEGADERM AG MESH DRESSING WITH SILVER 4"X5" PADS
F RX/OTC
TEGADERM AG MESH DRESSING WITH SILVER 4"X8" PADS
F RX/OTC
TEGADERM AG MESH DRESSING WITH SILVER 8"X8" PADS
F RX/OTC
TEGADERM ALGINATE AG DRESSING PADS F RX/OTC
TEGADERM HIGH GELLING ALGINATE DRESSING 4"X4" PADS
F RX/OTC
TEGADERM HIGH INTEGRITY ALGINATE DRESSING 4"X4" PADS
F RX/OTC
TEGADERM MATRIX DRESSING PADS F RX/OTC
TOE-AID PADS F RX/OTC
TRIPLE HELIX COLLAGEN 2"X2" PADS F RX/OTC
ULTEC HYDROCOLLOID DRESSING PADS F RX/OTC
VASELINE PETROLATUM GAUZE PADS F RX/OTC
VASELINE PETROLATUM GAUZECISION DRESSING OVERWRAP PADS
F
RX/OTC
VASELINE PETROLATUM GAUZECISION DRESSING PADS
F RX/OTC
Drug Name DrugTier
Requirements/Limits
VASELINE PETROLATUM GAUZEOVERWRAP PADS F RX/OTC
VASELINE PETROLATUM GAUZESTRIP OVERWRAP PADS
F RX/OTC
VASELINE PETROLATUM GAUZESTRIP PADS F RX/OTC
VASELINE PETROLATUM GAUZETUBE FOIL OVERWRAP PADS
F RX/OTC
VIGILON PRIMARY WOUND DRESSING/13" X24" PADS
F RX/OTC
VIGILON PRIMARY WOUND DRESSING/3" X8" PADS
F RX/OTC
VIGILON PRIMARY WOUND DRESSING/4" X4" PADS
F RX/OTC
VIGILON PRIMARY WOUND DRESSING/6" X8" PADS
F RX/OTC
wound dressings pads F RX/OTC
WOUNDGARD 2-1/2"X2-1/2" PADS F RX/OTC
WOUNDGARD 4"X4-1/4"PADS F RX/OTC
WOUNDGARD 4"X6" PADS F RX/OTC
XEROFLO DRESSING 1"X8" PADS F RX/OTC
XEROFLO DRESSING 2"X2" PADS F RX/OTC
XEROFLO DRESSING 5"X9" PADS F RX/OTC
DIAGNOSTIC PRODUCTS
Diagnostic Drugs GLUCAGEN DIAGNOSTIC SOLR F
Diagnostic Tests ACCU-CHEK ACTIVE STRIPS STRP NP RX/OTC
ACCU-CHEK AVIVA PLUS STRP VI NP RX/OTC
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Drug Name DrugTier
Requirements/Limits
ACCU-CHEK AVIVA STRP VI NP RX/OTC
ACCU-CHEK COMPACT PLUS STRP NP RX/OTC
ACCU-CHEK COMPACT TEST DRUM STRP NP RX/OTC
ACCU-CHEK SMARTVIEW STRIPS STRP NP RX/OTC
ACCUTREND GLUCOSE STRP NP RX/OTC
ACURA BLOOD GLUCOSE TESTSTRIPS STRP
NP RX/OTC
ADVANCE INTUITION TEST STRIPS STRP NP RX/OTC
ADVANCE MICRO-DRAW TEST STRIPS STRP NP RX/OTC
ADVOCATE REDI-CODE STRP VI NP RX/OTC
ADVOCATE REDI-CODE+ TESTSTRIPS STRP NP RX/OTC
ADVOCATE TEST STRIPS STRP NP RX/OTC
AGAMATRIX AMP NO CODE TEST STRIPS STRP
NP RX/OTC
AGAMATRIX JAZZ TEST STRIPS STRP NP RX/OTC
AGAMATRIX KEYNOTE TEST STRIPS STRP NP RX/OTC
AGAMATRIX PRESTO TEST STRIPS STRP NP RX/OTC
ASSURE 3 TEST STRIPS STRP NP RX/OTC
ASSURE 4 TEST STRIPS STRP NP RX/OTC
ASSURE II CHECK STRIP STRP NP RX/OTC
ASSURE II STRP NP RX/OTC
ASSURE II TEST STRIPS STRP NP RX/OTC
ASSURE PLATINUM TEST STRIPS STRP NP RX/OTC
ASSURE PRISM MULTI TEST STRIPS STRP NP RX/OTC
Drug Name DrugTier
Requirements/Limits
ASSURE PRO TEST STRIPS STRP NP RX/OTC
AT LAST TEST STRIPS STRP NP RX/OTC
BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
BAYER CONTOUR NEXT BLOODGLUCOSE TEST STRP
NP RX/OTC
BG STAR BLOOD GLUCOSE TEST STRP NP RX/OTC
BIOSCANNER GLUCOSE TEST STRIPS STRP NP RX/OTC
BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NP RX/OTC
BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC
CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM STRP
NP RX/OTC
CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE STRP
NP RX/OTC
CARESENS N BLOOD GLUCOSETEST STRIPS STRP
NP RX/OTC
CHEK-STIX COMBO PAK URINALYSIS CONTROL STRP
F
CHEK-STIX CONTROL STRP F
CHEMSTRIP-K STRP F
CLEVER CHEK AUTO-CODE TEST STRIPS STRP
NP RX/OTC
CLEVER CHEK AUTO-CODE VOICE TEST STRIPS STRP
NP RX/OTC
CLEVER CHEK TEST STRIPS STRP NP RX/OTC
CLEVER CHOICE AUTO-CODE PRO TEST STRIPS STRP
NP RX/OTC
CLEVER CHOICE MICRO TESTSTRIPS STRP NP RX/OTC
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Drug Name DrugTier
Requirements/Limits
CONTROL AST STRP NP RX/OTC
CONTROL TEST STRIPS STRP NP RX/OTC
COOL BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC
CVS ADVANCED GLUCOSE METER TEST STRIPS STRP
NP RX/OTC
DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
DUO-CARE TEST STRIPS STRP NP RX/OTC
EASY PLUS BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
EASY PLUS II BLOOD GLUCOSE TEST STRP NP RX/OTC
EASY STEP TEST STRIPS STRP NP RX/OTC
EASY TALK BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
EASY TOUCH GLUCOSE TEST STRIPS STRP NP RX/OTC
EASY TOUCH HEALTHPRO GLUCOSE TEST STRIPS STRP
NP RX/OTC
EASY TRAK BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
EASYGLUCO PLUS STRP NP RX/OTC
EASYGLUCO STRP VI NP RX/OTC
EASYMAX 15 TEST STRIPS STRP NP RX/OTC
EASYMAX TEST STRIPS STRP NP RX/OTC
EASYPLUS BLOOD GLUCOSE TEST STRIP STRP
NP RX/OTC
EASYPRO BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
Drug Name DrugTier
Requirements/Limits
EASYPRO PLUS STRP VI NP RX/OTC
ELEMENT COMPACT TEST STRIPS STRP NP RX/OTC
ELEMENT TEST STRIPS STRP NP RX/OTC
EMBRACE BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
EMBRACE EVO BLOOD GLUCOSETEST STRIPS STRP
NP RX/OTC
EMBRACE PRO BLOOD GLUCOSETEST STRIPS STRP
NP RX/OTC
EQ BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC
EQL TRUETEST BLOOD GLUCOSE TEST STRP NP RX/OTC
EQL TRUETRACK TEST STRP NP RX/OTC
EVENCARE + BLOOD GLUCOSETEST STRIP STRP
NP RX/OTC
EVENCARE BLOOD GLUCOSE TEST STRIP STRP
NP RX/OTC
EVENCARE G2 TEST STRIPS STRP NP RX/OTC
EVENCARE G3 TEST STRIPS STRP NP RX/OTC
EVENCARE MINI BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
EVOLUTION AUTOCODE STRP VI NP RX/OTC
EXACTECH R-S-G TEST STRIPS STRP NP RX/OTC
EXACTECH TEST STRIPS STRP NP RX/OTC
EZ SMART BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
EZ SMART PLUS BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
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Drug Name DrugTier
Requirements/Limits
FIFTY50 GLUCOSE TEST STRIP 2.0 STRP NP RX/OTC
FORA BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC
FORA D15G BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FORA D20 BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FORA D40/G31 BLOODGLUCOSE TEST STRIPS STRP
NP RX/OTC
FORA G20 BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FORA G30A BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FORA GD20 TEST STRIPS STRP NP RX/OTC
FORA GD50 BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FORA TN'G/TN'G VOICEBLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FORA V10 BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FORA V12 BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FORA V20 BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FORA V30A BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FORACARE GD40 STRP NP RX/OTC
FORACARE PREMIUM V10 TESTSTRIPS STRP NP RX/OTC
FORACARE TEST N GO TEST STRIPS STRP NP RX/OTC
Drug Name DrugTier
Requirements/Limits
FORTISCARE BLOOD GLUCOSETEST STRIP STRP
NP RX/OTC
FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS STRP
NP RX/OTC
FREESTYLE INSULINX BLOODGLUCOSE TEST STRP
NP RX/OTC
FREESTYLE LITE TEST STRIPS STRP NP RX/OTC
FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
FREESTYLE TEST STRIPS STRP NP RX/OTC
GE100 BLOOD GLUCOSE TESTSTRIPS STRP NP RX/OTC
GENSTRIP 50 STRP NP RX/OTC
GHT TEST STRIPS STRP NP RX/OTC
GLUCO PERFECT 3 TEST STRIPS STRP NP RX/OTC
GLUCOCARD 01 SENSOR PLUS STRP NP RX/OTC
GLUCOCARD 01 SENSOR PLUSTEST STRIPS STRP NP RX/OTC
GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS STRP
NP
RX/OTC
GLUCOCARD SHINE TEST STRIPS STRP NP RX/OTC
GLUCOCARD VITAL TEST STRIPS STRP NP RX/OTC
GLUCOCARD X-SENSOR STRP NP RX/OTC
GLUCOCOM TEST STRIPS STRP NP RX/OTC
GLUCONAVII BLOOD GLUCOSETEST STRIPS STRP
F QL(5 ea daily);RX/OTC
GLUCONAVII BLOOD GLUCOSETEST STRIPS STRP
NP RX/OTC
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Drug Name DrugTier
Requirements/Limits
GLUCOSE METER TEST STRIPS ADVANCED STRP
NP RX/OTC
GMATE BLOOD GLUCOSE TESTSTRIPS STRP
NP RX/OTC
GNP EASY TOUCH GLUCOSE TEST STRIPS STRP
NP RX/OTC
IN TOUCH BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
INFINITY BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
KETOCARE STRP F
KETONE TEST STRIPS STRP F
KETOSTIX STRP F
KROGER BLOOD GLUCOSE TESTSTRIPS STRP
NP RX/OTC
KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
KROGER TEST STRIPS STRP NP RX/OTC
LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS STRP
NP
RX/OTC
LIBERTY TEST STRIPS STRP NP RX/OTC
LIBERTY TEST STRIPS STRP F QL(6.67 ea
daily); RX/OTC MAXIMA BLOOD GLUCOSE TESTSTRIPS STRP
NP RX/OTC
MEIJER BLOOD GLUCOSE TESTSTRIPS STRP
NP RX/OTC
MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
Drug Name DrugTier
Requirements/Limits
MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
MICRODOT TEST STRIPS STRP NP RX/OTC
MYGLUCOHEALTH BLOOD GLUCOSE TEST STRP
NP RX/OTC
NEUTEK 2TEK TEST STRIPS STRP NP RX/OTC
NEXGEN TEST STRIPS STRP NP RX/OTC
NOVA MAX GLUCOSE TEST STRIPS STRP NP RX/OTC
NOVA MAX PLUS KETONE TESTSTRIPS STRP
F
ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
ON CALL PLUS BLOOD GLUCOSE TEST STRP NP RX/OTC
ON CALL VIVID BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
ON CALL VIVID BLOOD GLUCOSE TEST STRP NP RX/OTC
ONETOUCH ULTRA BLUE STRP NP RX/OTC
ONETOUCH VERIO TEST STRIPS STRP NP RX/OTC
OPTIUM TEST STRIPS STRP NP RX/OTC
OPTIUMEZ TEST STRIPS STRP NP RX/OTC
OPTUMRX BLOOD GLUCOSE TEST STRP NP RX/OTC
PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS STRP
NP
RX/OTC
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Drug Name DrugTier
Requirements/Limits
PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS STRP
NP
RX/OTC
POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
PRECISION PCX PLUS TEST STRIPS STRP NP RX/OTC
PRECISION PCX STRP NP RX/OTC
PRECISION POINT OF CARE TEST STRIPS STRP
NP RX/OTC
PRECISION QID TEST STRIPS STRP NP RX/OTC
PRECISION SOF-TACT TEST STRIPS STRP NP RX/OTC
PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
PRECISION XTRA STRP VI F
PREMIUM BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
PTS PANELS GLUCOSE TEST STRP NP RX/OTC
PTS PANELS KETONE TEST STRP NP
PTS PANELS KETONE TEST STRP F
QUICKTEK TEST STRIPS STRP NP RX/OTC
QUINTET AC BLOOD GLUCOSETEST STRIPS STRP
NP RX/OTC
QUINTET BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
RA TRUETEST STRIPS STRP NP RX/OTC
Drug Name DrugTier
Requirements/Limits
REFUAH PLUS BLOOD GLUCOSETEST STRIPS STRP
NP RX/OTC
RELION BLOOD GLUCOSE TESTSTRIPS STRP
NP RX/OTC
RELION CONFIRM/MICROTEST STRIPS STRP NP RX/OTC
RELION KETONE STRP F
RELION KETONE TEST STRIPS STRP F
RELION PRIME BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
RELION ULTIMA BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
RELION ULTIMA TEST STRIPS STRP NP RX/OTC
REVEAL BLOOD GLUCOSE TEST STRP NP RX/OTC
REXALL BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
SMART SENSE PREMIUM BLOODGLUCOSE STRIPS STRP
NP RX/OTC
SMART SENSE VALUE BLOOD GLUCOSE STRIPS STRP
NP RX/OTC
SMARTEST BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
SOLUS V2 AUDIBLE TEST STRP NP RX/OTC
SUPREME TEST STRIPS STRP NP RX/OTC
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Drug Name DrugTier
Requirements/Limits
SURE EDGE BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
SURECHEK BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
TELCARE BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
TGT BLOOD GLUCOSE TEST STRIPS PREMIUM STRP
NP RX/OTC
TGT BLOOD GLUCOSE TEST STRIPS STRP NP RX/OTC
TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP
F QL(6.67 eadaily); RX/OTC
TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP
NP RX/OTC
TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP
NP RX/OTC
TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP
F QL(6.67 eadaily); RX/OTC
TRUETEST BLOOD GLUCOSE TEST STRIPS STRP
F QL(6.67 eadaily); RX/OTC
TRUETEST BLOOD GLUCOSE TEST STRP F QL(6.67 ea
daily); RX/OTC
TRUETEST STRIPS STRP F QL(6.67 eadaily); RX/OTC
TRUETEST STRIPS STRP NP RX/OTC
TRUETRACK BLOOD GLUCOSE TEST STRP F QL(6.67 ea
daily); RX/OTC
TRUETRACK TEST STRP NP RX/OTC
TRUETRACK TEST STRP F QL(6.67 eadaily); RX/OTC
ULTIMA TEST STRIPS STRP NP RX/OTC
Drug Name DrugTier
Requirements/Limits
ULTRATRAK PRO TEST STRIPS STRP NP RX/OTC
ULTRATRAK ULTIMATE TEST STRIPS STRP NP RX/OTC
UNISTRIP1 GENERIC STRP NP RX/OTC
VERASENS BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
VICTORY AGM-4000 TEST STRIPS STRP NP RX/OTC
VOCAL POINT BLOOD GLUCOSE TEST STRIPS STRP
NP RX/OTC
WAVESENSE PRESTO TEST STRIPS STRP NP RX/OTC
DIETARY PRODUCTS/DIETARY MANAGEMENTPRODUCTS Dietary Management Products CARDIOTEK-RX TABS F
DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes Digestive Enzymes CREON CPEP F
LACTAID FAST ACT CHEW (Lactase) NP
LACTAID FAST ACT TABS (Lactase) NP
LACTAID TABS (Lactase) NP
lactase chew 9000 unit F
lactase tabs 9000 unit,3000 unit F
PANCREAZE CPEP NP
PERTZYE CPEP NP
ULTRESA CPEP NP PA
VIOKACE TABS NP
ZENPEP CPEP F
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Drug Name DrugTier
Requirements/Limits
DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood Pressure Carbonic Anhydrase Inhibitors acetazolamide cp12 F
acetazolamide tabs F
DIAMOX CP12 (Acetazolamide) NP
methazolamide tabs F
NEPTAZANE TABS (Methazolamide) NP
Diuretic Combinations ALDACTAZIDE TABS 25MG-25MG (Spironolactone &Hydrochlorothiazide)
NP
ALDACTAZIDE TABS 50MG-50MG NP
amiloride & hydrochlorothiazide tabs F
DYAZIDE CAPS (Triamterene & Hydrochlorothiazide)
NP
MAXZIDE TABS (Triamterene & Hydrochlorothiazide)
NP
MAXZIDE-25 TABS (Triamterene & Hydrochlorothiazide)
NP
spironolactone &hydrochlorothiazide tabs F
triamterene & hydrochlorothiazide caps F
triamterene & hydrochlorothiazide tabs F
TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS F
Loop Diuretics bumetanide tabs or 0.5 mg,1 mg, 2 mg F
BUMEX TABS (Bumetanide) NP
DEMADEX TABS (Torsemide) NP
Drug Name DrugTier
Requirements/Limits
EDECRIN TABS (Ethacrynic Acid) NP
ethacrynic acid tabs NP
furosemide soln ij 10 mg/ml F
furosemide soln or 10 mg/ml F
FUROSEMIDE SOLN OR 8 MG/ML F
furosemide tabs or 20 mg,80 mg, 40 mg F
LASIX TABS (Furosemide) NP
torsemide tabs F
Potassium Sparing Diuretics ALDACTONE TABS (Spironolactone) NP
amiloride hcl tabs F
CAROSPIR SUSP NP
DYRENIUM CAPS NP
spironolactone tabs or 25mg, 100 mg, 50 mg F
Thiazides and Thiazide-Like Diuretics CHLOROTHIAZIDE TABS 250 MG F
chlorothiazide tabs 500 mg F
chlorthalidone tabs F
DIURIL SUSP NP
hydrochlorothiazide caps F
hydrochlorothiazide tabs F
indapamide tabs F
METHYCLOTHIAZIDE TABS F
metolazone tabs F
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Drug Name DrugTier
Requirements/Limits
MICROZIDE CAPS (Hydrochlorothiazide) NP
ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate Hormones Bone Density Regulators ACTONEL TABS 150 MG (Risedronate Sodium) NP QL(0.034 eadaily) ACTONEL TABS 30 MG (Risedronate Sodium) NP
ACTONEL TABS 35 MG (Risedronate Sodium) NP
Limit 4ea in 28 days;QL(0.143ea daily)
ACTONEL TABS 5 MG (Risedronate Sodium) NP QL(1 ea daily)
ALENDRONATE SODIUM SOLN 70 MG/75ML NP
Limit 320ml permonth;QL(10.715 ml daily)
alendronate sodium tabs 10 mg, 5 mg F QL(1 ea daily)
alendronate sodium tabs 35 mg, 70 mg F
Limit 4ea in 28 days;QL(0.143ea daily)
ALENDRONATE SODIUM TABS 40 MG F
ATELVIA TBEC (Risedronate Sodium) NP
Limit 4ea in 28 days;QL(0.143ea daily)
BINOSTO TBEF NP
BONIVA TABS OR 150 MG (Ibandronate Sodium) NP QL(0.034 eadaily)
calcitonin (salmon) soln F QL(0.124 mldaily)
ETIDRONATE DISODIUM TABS 200 MG NP QL(4 ea daily)
ETIDRONATE DISODIUM TABS 400 MG NP QL(1 ea daily)
FORTEO SOLN NP
FORTICAL SOLN F QL(0.124 mldaily)
FOSAMAX PLUS D TABS NP QL(0.143 eadaily)
Drug Name DrugTier
Requirements/Limits
FOSAMAX TABS (Alendronate Sodium) NP
Limit 4ea in 28 days;QL(0.143ea daily)
ibandronate sodium tabs or 150 mg NP QL(0.034 eadaily) MIACALCIN SOLN IJ 200 UNIT/ML F QL(0.07 ml
daily) MIACALCIN SOLN NA 200 UNIT/ACT (Calcitonin (Salmon))
NP QL(0.124 mldaily)
risedronate sodium tabs 150 mg NP QL(0.034 eadaily) risedronate sodium tabs 30 mg NP
risedronate sodium tabs 35 mg NP
Limit 4ea in 28 days;QL(0.143ea daily)
risedronate sodium tabs 5 mg NP QL(1 ea daily)
risedronate sodium tbec 35 mg NP
Limit 4ea in 28 days;QL(0.143ea daily)
TYMLOS SOPN NP 1 per 30days;QL(0.052ml daily)
Growth Hormones GENOTROPIN MINIQUICK SOLR F PA
GENOTROPIN SOLR F PA
HUMATROPE COMBO PACK SOLR NP
HUMATROPE SOLR NP
NORDITROPIN FLEXPRO SOLN F PA
NUTROPIN AQ NUSPIN 10 SOLN F PA
NUTROPIN AQ NUSPIN 20 SOLN F PA
NUTROPIN AQ NUSPIN 5 SOLN F PA
NUTROPIN AQ PEN SOLN F PA
OMNITROPE SOLN 10 MG/1.5ML NP
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Drug Name DrugTier
Requirements/Limits
OMNITROPE SOLN 10 MG/1.5ML, 5 MG/1.5ML 4 PA
OMNITROPE SOLR 5.8 MG NP
SAIZEN CLICK.EASY SOLR F PA
SAIZEN SOLR F PA
SAIZENPREP RECONSTITUTIONKIT SOLR
F PA
SEROSTIM SOLR NP
ZOMACTON SOLR 10 MG NP
ZOMACTON SOLR 5 MG 4 PA
ZORBTIVE SOLR NP
Hormone Receptor Modulators EVISTA TABS (Raloxifene HCl) NP QL(1 ea daily)
raloxifene hcl tabs F QL(1 ea daily)
Metabolic Modifiers calcitriol caps or 0.5 mcg,0.25 mcg F
calcitriol soln or 1 mcg/ml F AL; Up to 11yrs old
CARNITOR SF SOLN (Levocarnitine (MetabolicModifiers))
NP
CARNITOR SOLN OR 1 GM/10ML (Levocarnitine (Metabolic Modifiers))
NP
CARNITOR TABS OR 330 MG (Levocarnitine (Metabolic Modifiers))
NP RX/OTC
levocarnitine (metabolicmodifiers) soln 1 gm/10ml F
levocarnitine (metabolicmodifiers) tabs 330 mg F RX/OTC
RAYALDEE CPCR F QL(2 ea daily)
ROCALTROL CAPS 0.5 MCG, 0.25 MCG (Calcitriol) NP
Drug Name DrugTier
Requirements/Limits
ROCALTROL SOLN 1 MCG/ML (Calcitriol) NP AL; Up to 11yrs old Posterior Pituitary Hormones DDAVP SOLN NA 0.01 % (Desmopressin AcetateRefrigerated)
NP
DDAVP SOLN NA 0.01 % (Desmopressin AcetateSpray)
NP PA
DDAVP TABS OR 0.1 MG, 0.2 MG (DesmopressinAcetate)
NP
desmopressin acetaterefrigerated soln F
desmopressin acetatespray refrigerated soln F PA
desmopressin acetatespray soln F PA
desmopressin acetate tabsor 0.1 mg, 0.2 mg F
Somatostatic Agents SIGNIFOR LAR SRER F PA
ESTROGENS - Hormone Replacement/ModifyingDrugs Estrogen Combinations ACTIVELLA TABS (Estradiol & Norethindrone Acetate)
NP
COMBIPATCH PTTW F
estradiol & norethindrone acetate tabs F
PREMPRO TABS F
Estrogens ALORA PTTW F
CLIMARA PTWK (Estradiol) NP
ESTRACE TABS OR 2 MG, 1 MG, 0.5 MG (Estradiol)
NP
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Drug Name DrugTier
Requirements/Limits
estradiol pttw td 0.025mg/24hr, 0.1 mg/24hr,0.0375 mg/24hr, 0.075mg/24hr, 0.05 mg/24hr
F
estradiol ptwk td 0.1mg/24hr, 0.05 mg/24hr,0.06 mg/24hr, 0.025mg/24hr, 37.5 mcg/24hr,0.075 mg/24hr
F
estradiol tabs or 0.5 mg, 2mg, 1 mg F
ESTROPIPATE TABS F
MINIVELLE PTTW F
PREMARIN TABS OR 0.45 MG, 1.25 MG, 0.3 MG, 0.625 MG, 0.9 MG
F
VIVELLE-DOT PTTW (Estradiol) NP
FLUOROQUINOLONES - Drugs to Treat BacterialInfections Fluoroquinolones AVELOX ABC PACK TABS (Moxifloxacin HCl) NP
AVELOX TABS OR 400 MG (Moxifloxacin HCl) NP
CIPRO SUSR (Ciprofloxacin) NP
CIPRO TABS (Ciprofloxacin HCl) NP
CIPRO XR TB24 (Ciprofloxacin-CiprofloxacinHCl)
NP
CIPROFLOXACIN HCL TABS 100 MG F
ciprofloxacin hcl tabs 750mg, 500 mg, 250 mg F
ciprofloxacin susr or 500mg/5ml, 250 mg/5ml NP
ciprofloxacin-ciprofloxacinhcl tb24 NP
LEVAQUIN TABS (Levofloxacin) NP
LEVOFLOXACIN SOLN OR 25 MG/ML NP
Drug Name DrugTier
Requirements/Limits
levofloxacin soln or 25 mg/ml NP
levofloxacin tabs or 500 mg, 750 mg, 250 mg F
moxifloxacin hcl tabs or 400 mg NP
OFLOXACIN TABS 300 MG NP
ofloxacin tabs 400 mg NP
GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal Drugs Antiflatulents GAS-X CHEW (Simethicone) NP
GAS-X EXTRA STRENGTH CHEW 125 MG (Simethicone)
NP
MYLICON INFANTS GAS RELIEF SUSP (Simethicone)
NP
MYLICON SUSP (Simethicone) NP
PHAZYME CAPS (Simethicone) NP
PHAZYME ULTRA STRENGTH CAPS (Simethicone)
NP
simethicone caps 180 mg,125 mg, 125mg F
simethicone chew 125 mg,80 mg F
simethicone susp 20mg/0.3ml, 40 mg/0.6ml F
Bile Acid Synthesis Disorder Agents CHOLBAM CAPS NP
Farnesoid X Receptor (FXR) Agonists OCALIVA TABS NP QL(1 ea daily)
Gallstone Solubilizing Agents ACTIGALL CAPS (Ursodiol) NP
CHENODAL TABS NP
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Drug Name DrugTier
Requirements/Limits
URSO 250 TABS (Ursodiol) NP
URSO FORTE TABS (Ursodiol) NP
ursodiol caps 300 mg NP
ursodiol tabs 500 mg, 250 mg F
Gastrointestinal Chloride Channel Activators
AMITIZA CAPS F QL(2 ea daily);AL; At least 18 yrs old
Gastrointestinal Stimulants metoclopramide hcl soln or10 mg/10ml, 5 mg/5ml F
metoclopramide hcl tabs or5 mg, 10 mg F
METOCLOPRAMIDE ODT TBDP NP
METOZOLV ODT TBDP (Metoclopramide HCl) NP
REGLAN TABS (Metoclopramide HCl) NP
Inflammatory Bowel Agents APRISO CP24 F
ASACOL HD TBEC NP
AZULFIDINE EN-TABS TBEC (Sulfasalazine) NP
AZULFIDINE TABS (Sulfasalazine) NP
balsalazide disodium caps F
CANASA SUPP F
CIMZIA KIT NP QL(1 ea per fillretail)
CIMZIA STARTER KIT KIT NP QL(3 ea per fillretail) COLAZAL CAPS (Balsalazide Disodium) NP
DELZICOL CPDR NP
DIPENTUM CAPS NP
Drug Name DrugTier
Requirements/Limits
GIAZO TABS NP
LIALDA TBEC (Mesalamine) NP
MESALAMINE DR TBEC NP
mesalamine enem NP
mesalamine tbec NP
mesalamine w/ cleanser kit NP
PENTASA CPCR F PA
ROWASA KIT (Mesalamine w/ Cleanser) NP
SFROWASA ENEM NP
sulfasalazine tabs F
sulfasalazine tbec F
Intestinal Acidifiers lactulose (encephalopathy)soln F
Irritable Bowel Syndrome (IBS) Agents alosetron hcl tabs NP
LINZESS CAPS F QL(1 ea daily);AL; At least 18 yrs old
LOTRONEX TABS (Alosetron HCl) NP
VIBERZI TABS NP QL(2 ea daily);AL; At least 18 yrs old
Peripheral Opioid Receptor Antagonists MOVANTIK TABS NP QL(1 ea daily)
RELISTOR TABS OR 150 MG NP
QL(3 ea daily);AL; At least 18 yrs old
SYMPROIC TABS NP QL(2 ea daily);AL; At least 18 yrs old
Phosphate Binder Agents
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Drug Name DrugTier
Requirements/Limits
AURYXIA TABS NP
calcium acetate (phosphatebinder) caps F
calcium acetate (phosphatebinder) tabs F RX/OTC
ELIPHOS TABS (Calcium Acetate (PhosphateBinder))
NP RX/OTC
FOSRENOL CHEW 1000 MG, 750 MG, 500 MG (Lanthanum Carbonate)
NP
FOSRENOL PACK 1000 MG, 750 MG NP
lanthanum carbonate chew NP
PHOSLYRA SOLN F
RENAGEL TABS F
RENVELA PACK (Sevelamer Carbonate) NP
RENVELA TABS (Sevelamer Carbonate) NP
sevelamer carbonate pack NP
sevelamer carbonate tabs NP
VELPHORO CHEW NP
GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System Alkalinizers potassium citrate(alkalinizer) tbcr 1080 mg,540 mg
F
SHOHLS SOLUTION MODIFIED SOLN (Sodium Citrate & Citric Acid)
NP RX/OTC
sodium citrate & citric acid soln F RX/OTC
UROCIT-K 10 TBCR (Potassium Citrate (Alkalinizer))
NP
Drug Name DrugTier
Requirements/Limits
UROCIT-K 5 TBCR (Potassium Citrate (Alkalinizer))
NP
Genitourinary Irrigants neomycin/polymyxin b gusoln F
NEOSPORIN GU IRRIGANT SOLN (Neomycin/Polymyxin BGU)
NP
sodium chloride (guirrigant) soln F
Interstitial Cystitis Agents ELMIRON CAPS F
Prostatic Hypertrophy Agents alfuzosin hcl tb24 F
AVODART CAPS (Dutasteride) NP
CARDURA XL TB24 NP
dutasteride caps F
dutasteride-tamsulosin hcl caps NP
finasteride tabs F AL; At least 13 yrs old
FLOMAX CAPS (Tamsulosin HCl) NP
JALYN CAPS (Dutasteride-Tamsulosin HCl) NP
PROSCAR TABS (Finasteride) NP AL; At least 13 yrs old
RAPAFLO CAPS NP
tamsulosin hcl caps F
UROXATRAL TB24 (Alfuzosin HCl) NP
Urinary Analgesics phenazopyridine hcl tabs200 mg, 95 mg, 100 mg F
PYRIDIUM TABS (Phenazopyridine HCl) NP
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Drug Name DrugTier
Requirements/Limits
GOUT AGENTS - Drugs to Treat Gout
Gout Agent Combinations colchicine w/ probenecidtabs F
Gout Agents allopurinol tabs F
COLCHICINE CAPS NP
COLCHICINE TABS NP
COLCRYS TABS NP
MITIGARE CAPS NP
ULORIC TABS NP
ZURAMPIC TABS NP QL(1 ea daily);AL; At least 18 yrs old
ZYLOPRIM TABS (Allopurinol) NP
Uricosurics probenecid tabs F
HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood Disorders Hematorheologic Agents pentoxifylline tbcr F
Plasma Kallikrein Inhibitors KALBITOR SOLN F PA
Platelet Aggregation Inhibitors AGGRENOX CP12 (Aspirin-Dipyridamole) F
aspirin-dipyridamole cp12 NP
BRILINTA TABS F
cilostazol tabs F
clopidogrel bisulfate tabs F
Drug Name DrugTier
Requirements/Limits
dipyridamole tabs or 25mg, 50 mg, 75 mg F
DURLAZA CP24 NP QL(1 ea daily)
EFFIENT TABS (PrasugrelHCl) NP
PERSANTINE TABS (Dipyridamole) NP
PLAVIX TABS (ClopidogrelBisulfate) NP
PLETAL TABS (Cilostazol) NP
prasugrel hcl tabs NP
YOSPRALA TBEC NP QL(1 ea daily)
ZONTIVITY TABS NP
HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders Cobalamins B-12 DOTS TBDP F
cyanocobalamin soln ij1000 mcg/ml F QL(1 ml per fill
retail) cyanocobalamin tabs or500 mcg, 100 mcg, 250mcg, 1000 mcg
F
cyanocobalamin tbcr or1000 mcg F
Folic Acid/Folates FOLIC ACID SOLN IJ 5 MG/ML F PA
folic acid tabs or 1 mg F RX/OTC
folic acid tabs or 400 mcg,800 mcg F
Hematopoietic Growth Factors EPOGEN SOLN F
GRANIX SOSY NP
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Drug Name DrugTier
Requirements/Limits
MIRCERA SOSY 50 MCG/0.3ML, 200MCG/0.3ML, 100MCG/0.3ML, 75MCG/0.3ML
NP
NEUPOGEN SOLN 300 MCG/ML, 480 MCG/1.6ML F
NEUPOGEN SOSY 300 MCG/0.5ML, 480MCG/0.8ML
NP
PROCRIT SOLN 10000 UNIT/ML, 40000 UNIT/ML,4000 UNIT/ML, 3000UNIT/ML, 2000 UNIT/ML,20000 UNIT/ML
F
ZARXIO SOSY NP
Hematopoietic Mixtures CENTRATEX CAPS NP
ferrous fumarate-fa-b complex-c-zn-mg-mn-cutabs
F
folic acid-vitamin b6-vitamin b12 tabs 115mcg-800mcg-10mg
F
HEMOCYTE PLUS CAPS NP
ICAR-C PLUS TABS (Iron-Vitamin C-Vitamin B12-Folic Acid)
NP RX/OTC
INTEGRA CAPS F
iron polysaccharidecomplex-vit b12-folic acid caps
F
iron-vitamin c-vitamin b12-folic acid tabs NP RX/OTC
PUREFE PLUS CAPS NP
Iron FEOSOL TABS 200 MG (Ferrous Sulfate Dried) NP
FER-IN-SOL SOLN (Ferrous Sulfate) NP
FERGON TABS (Ferrous Gluconate) NP
Drug Name DrugTier
Requirements/Limits
ferrous fumarate tabs 324 mg F
FERROUS GLUCONATE TABS 225 MG F
ferrous gluconate tabs 240mg, 27 mg, 324 mg F
ferrous sulfate dried tabs 65 mg, 200 mg F
ferrous sulfate elix 220 mg/5ml F
FERROUS SULFATE LIQD 220 MG/5ML F
ferrous sulfate soln 15 mg/ml F
FERROUS SULFATE SYRP 300 MG/5ML F
ferrous sulfate tabs 325 mg, 65 mg F
FERROUS SULFATE TBCR 140 MG F
ferrous sulfate tbcr 142 mg,45 mg F
FERROUS SULFATE TBEC 324 MG F
HEMOCYTE TABS (Ferrous Fumarate) NP
polysaccharide ironcomplex caps 150 mg F
SLOW FE TBCR (Ferrous Sulfate) NP
HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood Disorders Hemostatics - Systemic AMICAR TABS 500 MG F PA
LYSTEDA TABS (Tranexamic Acid) NP Limit 1ea permonth tranexamic acid tabs or 650 mg F Limit 1ea per
month HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS Antihistamine Hypnotics diphenhydramine hcl(sleep) caps 50 mg F
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Drug Name DrugTier
Requirements/Limits
diphenhydramine hcl(sleep) tabs 25 mg F QL(1 ea daily)
diphenhydramine hcl(sleep) tabs 50 mg F
diphenhydramine-acetaminophen (sleep)tabs 25mg-500mg, 30unit-50mg-15mg-1.5mg-25mg-18mg-2500unit-500mg-10mg-1.7mg-6mcg-400mcg-2mg, 25mg-25mg-500mg-500mg
F
doxylamine succinate(sleep) tabs F
NYTOL MAXIMUM STRENGTH TABS (Diphenhydramine HCl(Sleep))
NP
TYLENOL PM EXTRA STRENGTH TABS (Diphenhydramine-Acetaminophen (sleep))
NP
UNISOM SLEEPGELS CAPS (DiphenhydramineHCl (Sleep))
NP
UNISOM TABS (Doxylamine Succinate(Sleep))
NP
Barbiturate Hypnotics phenobarbital elix 20mg/5ml F
phenobarbital soln 20mg/5ml F
PHENOBARBITAL TABS 100 MG, 60 MG, 15 MG, 30 MG
F
phenobarbital tabs 64.8mg, 97.2 mg, 16.2 mg, 32.4 mg
F
Hypnotics - Tricyclic Agents SILENOR TABS NP
Non-Barbiturate Hypnotics AMBIEN CR TBCR (Zolpidem Tartrate) NP ST; QL(1 eadaily) AMBIEN TABS (ZolpidemTartrate) NP QL(1 ea daily)
Drug Name DrugTier
Requirements/Limits
EDLUAR SUBL F ST; QL(1 eadaily)
estazolam tabs NP
eszopiclone tabs F PA; QL(1 eadaily); AL; Atleast 18 yrs old
FLURAZEPAM HCL CAPS F ST
HALCION TABS (Triazolam) NP ST
INTERMEZZO SUBL (Zolpidem Tartrate) NP QL(1 ea daily)
LUNESTA TABS (Eszopiclone) NP
PA; QL(1 eadaily); AL; Atleast 18 yrs old
RESTORIL CAPS (Temazepam) NP
SONATA CAPS (Zaleplon) NP
temazepam caps 22.5 mg,7.5 mg NP
temazepam caps 30 mg,15 mg F
TRIAZOLAM TABS 0.125 MG F ST
triazolam tabs 0.25 mg F ST
zaleplon caps F
zolpidem tartrate subl sl1.75 mg, 3.5 mg NP QL(1 ea daily)
zolpidem tartrate tabs or 5mg, 10 mg F QL(1 ea daily)
zolpidem tartrate tbcr or12.5 mg, 6.25 mg F ST; QL(1 ea
daily)
ZOLPIMIST SOLN NP
Orexin Receptor Antagonists
BELSOMRA TABS NP QL(1 ea daily);AL; At least 19 yrs old
Selective Melatonin Receptor Agonists HETLIOZ CAPS NP QL(1 ea daily)
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Drug Name DrugTier
Requirements/Limits
ROZEREM TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old
LAXATIVES - Bowel Treatment Drugs
Bulk Laxatives calcium polycarbophil tabs F
CITRUCEL FIBER LAXATIVE POWD (Methylcellulose (Laxative))
NP
EVAC POWD (Psyllium) NP
FIBERCON TABS (Calcium Polycarbophil) NP
HYDROCIL INSTANT POWD (Psyllium) NP
KONSYL POWD 100 % (Psyllium) NP
METAMUCIL CAPS 0.52 GM (Psyllium) NP
methylcellulose (laxative)powd 2 gm/10.2gm, 2gm/19gm,
F
psyllium caps 0.52 gm, 520 mg F
psyllium powd 95 %, 58.6%, 28.3 %, 100 % F
Laxative Combinations COLYTE-FLAVOR PACKS SOLR (PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)
NP
GOLYTELY SOLR 236GM-22.74GM-5.86GM-2.97GM-6.74GM (PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)
NP
NULYTELY/FLAVORPACKS SOLR (PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride)
NP
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr
F
Drug Name DrugTier
Requirements/Limits
peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr
F
sennosides-docusate sodium tabs F QL(4 ea daily)
SENOKOT S TABS (Sennosides-Docusate Sodium)
NP QL(4 ea daily)
Laxatives - Miscellaneous glycerin (laxative) supp 1gm, 80.7 %, 2 gm, 1.2 gm F
GLYCERIN ADULT SUPP (Glycerin (Laxative)) NP
lactulose soln F
MIRALAX POWD (Polyethylene Glycol 3350) NP QL(34 gmdaily); RX/OTC PEDIA-LAX SUPP RE 1 GM (Glycerin (Laxative)) NP
polyethylene glycol 3350powd or F QL(34 gm
daily); RX/OTC Saline Laxatives FLEET ENEMA ENEM (Sodium Phosphates) NP
FLEET ENEMA SIX PACK ENEM (Sodium Phosphates)
NP
FLEET PEDIATRIC ENEM (Sodium Phosphates) NP
magnesium citrate soln1.745gm/30ml, , 1.745gm/30ml
F
magnesium hydroxide susp400 mg/5ml, 1200mg/15ml, , 7.75 %
F QL(32 ml daily)
sodium phosphates enemre 9.5gm/59ml-3.5gm/59ml,19gm/118ml-7gm/118ml,16gm/133ml-6gm/133ml,19gm/118ml-19gm/118ml-7gm/118ml-7gm/118ml
F
Stimulant Laxatives bisacodyl supp F
bisacodyl tbec F
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Drug Name DrugTier
Requirements/Limits
DULCOLAX SUPP (Bisacodyl) NP
DULCOLAX TBEC (Bisacodyl) NP
EX-LAX MAXIMUM STRENGTH TABS (Sennosides)
NP
sennosides liqd 8.8 mg/5ml F
sennosides syrp 8.8mg/5ml F
sennosides tabs 8.6 mg, 25 mg F
SENOKOT TABS (Sennosides) NP
Surfactant Laxatives COLACE CAPS (Docusate Sodium) NP QL(3 ea daily)
docusate calcium caps F
docusate sodium caps 100 mg F QL(3 ea daily)
docusate sodium liqd 150mg/15ml, 50 mg/5ml F
docusate sodium syrp 60mg/15ml F
MACROLIDES - Drugs to Treat BacterialInfections Azithromycin AZITHROMYCIN PACK OR 1 GM F
azithromycin susr or 100mg/5ml, 200 mg/5ml F
azithromycin tabs or 600mg, 500 mg, 250 mg F
ZITHROMAX PACK OR 1 GM 4
ZITHROMAX SUSR OR 200 MG/5ML, 100 MG/5ML(Azithromycin)
NP
ZITHROMAX TABS OR 600 MG, 250 MG, 500 MG (Azithromycin)
NP
ZITHROMAX TRI-PAK TABS (Azithromycin) NP
Drug Name DrugTier
Requirements/Limits
ZITHROMAX Z-PAK TABS (Azithromycin) NP
ZMAX SUSR NP QL(1 ea per fillretail) Clarithromycin BIAXIN SUSR (Clarithromycin) NP
BIAXIN TABS (Clarithromycin) NP
CLARITHROMYCIN SUSR 125 MG/5ML, 250 MG/5ML F
clarithromycin susr 250mg/5ml, 125 mg/5ml F
clarithromycin tabs 500 mg,250 mg F
clarithromycin tb24 500 mg NP
Erythromycins E.E.S. 400 TABS NP
E.E.S. GRANULES SUSR (ErythromycinEthylsuccinate)
NP
ERY-TAB TBEC NP
ERYPED 200 SUSR (ErythromycinEthylsuccinate)
NP
ERYPED 400 SUSR NP
ERYTHROCIN STEARATE TABS NP
erythromycin base cpep250 mg NP
ERYTHROMYCIN BASE TABS 250 MG, 500 MG NP
erythromycinethylsuccinate susr 200mg/5ml
NP
ERYTHROMYCIN ETHYLSUCCINATE TABS 400 MG
NP
PCE TBEC NP
Fidaxomicin
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Drug Name DrugTier
Requirements/Limits
DIFICID TABS NP
MEDICAL DEVICES AND SUPPLIES
Contraceptives AIMSCO LUBRICATED MISC F
ATLAS COLORED LUBRICATEDCONDOM DEVI
F
ATLAS LUBRICATED CONDOM DEVI F
ATLAS LUBRICATED CONDOM/SPERMICIDEDEVI
F
CLASS ACT LUBRICATED MISC F
DUREX EXTRA SENSITIVE DEVI F
ELEXA NATURAL FEEL MISC F
ELEXA STIMULATING MISC F
ELEXA ULTRA SENSITIVE MISC F
EXTRA SENSITIVE SPERMICIDAL DEVI F
FANTASY LUBRICATED MISC F
FANTASY LUBRICATED/SPERMICIDE MISC
F
HIGH SENSATION SPERMICIDAL DEVI F
INTENSE SENSATION DEVI F
KAMELEON LUBRICATED MISC F
KIMONO COLORS DEVI F
KIMONO LUBRICATED MISC F
KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED MISC
F
Drug Name DrugTier
Requirements/Limits
KIMONO PLUS SPERMICIDE LUBRICATED MISC
F
KIMONO PLUS SPERMICIDE/LUBRICATED MISC
F
KIMONO PS LUBRICATED MISC F
KIMONO PS PLUS SPERMICIDE/LUBRICATED MISC
F
KIMONO SENSATION LUBRICATED MISC F
KIMONO SENSATION PLUS SPERMICIDE LUBRICATED MISC
F
KIMONO SPECIAL DEVI F
MAXX LUBRICATED MISC F
MAXX PLUS SPERMICIDE LUBRICATED MISC F
PREMIUM CONDOMS LUBRICATED MISC F
REALITY LATEX CONDOMS/LUBRICATEDMISC
F
REALITY LATEX/ULTRATEXTURED DEVI F
REALITY LATEX/ULTRATHIN DEVI F
TROJAN EXTENDED PLEASURE/LUBRICATEDDEVI
F
TROJAN MAGNUM MISC F
TROJAN MAGNUM WARM SENSATIONS DEVI F
TROJAN MAGNUM XL LUBRICATED DEVI F
TROJAN PLEASURE MESH/SPERMICIDALDEVI
F
TROJAN RIBBED W/SPERMICIDAL MISC F
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Drug Name DrugTier
Requirements/Limits
TROJAN SHARED SENSATION/LUBRICATED DEVI
F
TROJAN SUPRAS SPERMICIDAL DEVI F
TROJAN TWISTED PLEASURE DEVI F
TROJAN ULTRA PLEASURE/LUBRICATEDDEVI
F
TROJAN VERY SENSITIVE LUBRICATED MISC
F
TROJAN VERY SENSITIVE SPERMICIDAL LUBRICANT MISC
F
TROJAN VERY THIN LUBRICATED MISC F
TROJAN VERY THIN SPERMICIDAL LUBRICANT MISC
F
TROJAN-ENZ LUBRICANT MISC F
TROJAN-ENZ LUBRICATED MISC F
TROJAN-ENZ W/SPERMICIDAL MISC F
TRUSTEX COLOR CONDOMS + LUBE MISC F
TRUSTEX LUBRICATED EXTRALARGE MISC F
TRUSTEX LUBRICATED EXTRASTRENGTH MISC F
TRUSTEX LUBRICATED MISC F
TRUSTEX LUBRICATED/RIBBED/STUDDED MISC
F
TRUSTEX LUBRICATED/SPERMICIDE EXTRA LARGE MISC
F
TRUSTEX LUBRICATED/SPERMICIDE EXTRA STRENGTH MISC
F
Drug Name DrugTier
Requirements/Limits
TRUSTEX LUBRICATED/SPERMICIDE MISC
F
TRUSTEX NATURAL CONDOMS +LUBE/LUBRICATEDMISC
F
TRUSTEX WITH NONOXYNOL-9/RIBBED/STUDDEDMISC
F
TRUSTEX/RIALUBRICATED MISC F
TRUSTEX/RIALUBRICATED SPERMICIDE MISC
F
TRUSTEX/RIALUBRICATED/SPERMICIDE MISC
F
ULTIMATE FEELING DEVI F
Diabetic Supplies 1ST CHOICE LANCETS SUPERTHIN MISC F QL(6.67 ea
daily) 1ST CHOICE LANCETS THIN MISC F QL(6.67 ea
daily) 1ST CHOICE LANCETS ULTRATHIN MISC F QL(6.67 ea
daily) 1ST TIER UNILET COMFORTOUCH LANCETS 28G MISC
F QL(6.67 eadaily)
1ST TIER UNILET COMFORTOUCH LANCETS 30G MISC
F QL(6.67 eadaily)
ACCU-CHEK ACTIVE GLUCOSECONTROL SOLUTION LIQD
NP
ACCU-CHEK AVIVA SOLN VI NP
ACCU-CHEK COMPACT PLUS CLEAR CONTROL SOLUTION (2 LEVELS) SOLN
NP
ACCU-CHEK FASTCLIX LANCETS MISC NP
ACCU-CHEK MULTICLIX LANCETS MISC NP
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Drug Name DrugTier
Requirements/Limits
ACCU-CHEK SAFE-T-PRO LANCETS MISC NP
ACCU-CHEK SAFE-T-PRO PLUSLANCETS MISC NP
ACCU-CHEK SMARTVIEW CONTROL LIQD NP
ACCU-CHEK SOFT TOUCH LANCETS MISC NP
ACCU-CHEK SOFTCLIX LANCETS MISC NP
ACCUTREND GLUCOSE CONTROL SOLN NP
ACTI-LANCE LANCETS 28G MISC NP
ACTI-LANCE LITE SAFETY LANCETS 28G MISC
NP
ACTI-LANCE SPECIAL SAFETY LANCETS 17G MISC
NP
ACTI-LANCE SPECIAL SAFETYLANCETS 17G MISC
NP
ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G MISC
NP
ACTIVE 1ST BLOOD LANCETS30G/EASYTWIST CAP MISC
NP
ACURA CONTROL SOLUTION HIGH SOLN NP
ACURA CONTROL SOLUTION LOW SOLN NP
ACURA CONTROL SOLUTION NORMAL SOLN
NP
ADJUSTABLE LANCING DEVICE MISC F QL(1 ea per
160 days retail) ADVANCE INTUITION CONTROL SOLUTION LIQD
NP
ADVANCE MICRO-DRAW CONTROL LEVEL 1-2 LIQD
NP
ADVANCE MICRO-DRAW NORMAL CONTROL LIQD NP
Drug Name DrugTier
Requirements/Limits
ADVOCATE CONTROL SOLUTIONHIGH LIQD NP
ADVOCATE CONTROL SOLUTIONLOW LIQD NP
ADVOCATE LANCETS 30G MISC NP
ADVOCATE LANCETS MISC NP
ADVOCATE LANCING DEVICE MISC F QL(1 ea per
160 days retail) ADVOCATE RAPID-SAFE LANCING DEVICE MISC F QL(1 ea per
160 days retail) ADVOCATE REDI-CODE+ CONTROL SOLUTION HIGH SOLN
NP
ADVOCATE REDI-CODE+ CONTROL SOLUTION LOW SOLN
NP
ADVOCATE SAFETY LANCETS 26G MISC NP
ADVOCATE SAFETY LANCETS MISC NP
AGAMATRIX CONTROL HIGH SOLN NP
AGAMATRIX CONTROL NORMAL SOLN NP
AGAMATRIX CONTROL NORMAL& HIGH SOLN NP
AGAMATRIX ULTRA-THIN LANCETS 33G MISC F QL(6.67 ea
daily) ALTERNATE SITE LANCING DEVICE MISC F QL(1 ea per
160 days retail) AQUA LANCE ADJUSTABLE LANCING DEVICE DEVI
F QL(1 ea per160 days retail)
ASSURE 3 CONTROL LEVEL 1/2 LIQD NP
ASSURE 4 CONTROL LEVEL 1/2 LIQD NP
ASSURE COMFORT LANCETS ULTRA THIN 28G MISC
NP
ASSURE COMFORT LANCETS ULTRA THIN 30G MISC
NP
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Drug Name DrugTier
Requirements/Limits
ASSURE DOSE NORMAL CONTROL SOLN NP
ASSURE DOSE NORMAL/HIGH CONTROLSOLN
NP
ASSURE HAEMOLANCE PLUS HIGH FLOW 18G MISC
NP
ASSURE HAEMOLANCE PLUS LOW FLOW 25G MISC
NP
ASSURE HAEMOLANCE PLUS MICRO FLOW 28G MISC
NP
ASSURE HAEMOLANCE PLUS NORMAL FLOW 21G MISC
NP
ASSURE HAEMOLANCE PLUS PEDIATRIC BLADE MISC
NP
ASSURE II CONTROL LEVEL 1 LIQD NP
ASSURE II CONTROL LEVEL 1/2 LIQD NP
ASSURE LANCE LANCETS 21G MISC NP
ASSURE LANCE LANCETS MISC NP
ASSURE LANCE PLUS SAFETYLANCETS 25G MISC
NP
ASSURE LANCE PLUS SAFETYLANCETS 30G MISC
NP
ASSURE LANCETS MISC NP
ASSURE PRISM CONTROL LEVEL 1/2SOLN
NP
ASSURE PRO CONTROL LEVEL1/2 LIQD NP
AT LAST CONTROL SOLUTION SOLN NP
AT LAST LANCETS MISC NP
AURORA LANCET SUPER THIN30G MISC F QL(6.67 ea
daily)
Drug Name DrugTier
Requirements/Limits
AURORA LANCET THIN 23G MISC F QL(6.67 ea
daily)
AUTO-LANCET MINI MISC F QL(1 ea per160 days retail)
AUTO-LANCET MISC F QL(1 ea per160 days retail)
AUTOLET IMPRESSION LANCING DEVICE MISC F QL(1 ea per
160 days retail) AUTOLET LANCING DEVICE MISC F QL(1 ea per
160 days retail)
AUTOLET MINI MISC F QL(1 ea per160 days retail)
AUTOLET PLUS MISC F QL(1 ea per160 days retail)
BAYER BREEZE 2 HIGH CONTROL LIQD NP
BAYER BREEZE 2 LOW CONTROL LIQD NP
BAYER BREEZE 2 NORMAL CONTROL LIQD NP
BAYER CONTOUR HIGH CONTROL LIQD NP
BAYER CONTOUR LOW CONTROL LIQD NP
BAYER CONTOUR NEXT CONTROL LEVEL 1 SOLN NP
BAYER CONTOUR NEXT CONTROL LEVEL 2 SOLN NP
BAYER CONTOUR NORMAL CONTROL LIQD NP
BAYER MICROLET 2 LANCING DEVICE MISC F QL(1 ea per
160 days retail) BAYER MICROLET LANCETS MISC NP
BD LANCET DEVICE MISC F QL(1 ea per
160 days retail) BD LANCET ULTRAFINE 30G MISC NP
BD LANCET ULTRAFINE 30G MISC F QL(6.67 ea
daily) BD LANCET ULTRAFINE 33G MISC NP
BD MICROTAINER LANCETS MISC NP
BULLSEYE MINI SAFETY LANCETS MISC NP
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Drug Name DrugTier
Requirements/Limits
BULLSEYE SAFETY LANCETS MISC NP
CARDIOCOM LANCING DEVICE MISC F QL(1 ea per
160 days retail) CAREONE ADVANCED LANCINGDEVICE MISC F QL(1 ea per
160 days retail) CAREONE LANCET THIN MISC F QL(6.67 ea
daily) CAREONE LANCET ULTRA THIN MISC F QL(6.67 ea
daily) CARESENS CONTROL A SOLUTION SOLN NP
CARETOUCH LANCING DEVICEWITH EJECTOR MISC
F QL(1 ea per160 days retail)
CARETOUCH TWIST LANCETS 28G MISC NP
CARETOUCH TWIST LANCETS 30G MISC NP
CARETOUCH TWIST LANCETS 33G MISC NP
CLEANLET LANCETS 28G MISC F QL(6.67 ea
daily) CLEVER CHEK LANCETS ULTRATHIN 30G MISC NP
CLEVER CHEK LANCETS ULTRATHIN MISC NP
CLEVER CHOICE GLUCOSE CONTROL HIGH LIQD
NP
CLEVER CHOICE GLUCOSE CONTROL LOW LIQD
NP
CLOSERCARE MISC F QL(1 ea per160 days retail)
COAGUCHEK LANCETS MISC NP
COMFORT ASSURED LANCETS MICRO THIN 33G MISC
NP
COMFORT ASSURED LANCETS SUPER THIN 28G MISC
F QL(6.67 eadaily)
COMFORT ASSURED LANCETS SUPER THIN 28G MISC
NP
Drug Name DrugTier
Requirements/Limits
COMFORT LANCETS MISC F QL(6.67 ea
daily) CONTROL SOLUTION NORMAL SOLN NP
COOL CONTROL SOLUTION A SOLN NP
COOL CONTROL SOLUTION B SOLN NP
CVS LANCETS 21G MISC F QL(6.67 eadaily)
CVS LANCETS MICRO THIN 33G MISC F QL(6.67 ea
daily) CVS LANCETS MICRO-THIN 33G MISC F QL(6.67 ea
daily) CVS LANCETS ORIGINAL MISC F QL(6.67 ea
daily) CVS LANCETS THIN 26G MISC F QL(6.67 ea
daily) CVS LANCETS ULTRA THIN 30G MISC F QL(6.67 ea
daily) CVS LANCETS ULTRA-THIN 30G MISC F QL(6.67 ea
daily) CVS LANCING DEVICE MISC F QL(1 ea per
160 days retail) CVS ULTRA THIN LANCETS MISC F QL(6.67 ea
daily) DIASTAR EASY TEST II LANCETS 30G MISC NP
DIASTAR EASY TEST LANCETS30G MISC NP
DIATRUE GLUCOSE CONTROL SOLUTION LEVEL 1 SOLN
NP
DIATRUE GLUCOSE CONTROL SOLUTION LEVEL 2 SOLN
NP
DIATRUE GLUCOSE CONTROL SOLUTION LEVEL 3 SOLN
NP
DROPLET LANCETS ULTRA THIN 30G MISC F QL(6.67 ea
daily) DROPLET LANCING DEVICE MISC F QL(1 ea per
160 days retail) DRUG MART ADJUSTABLE LANCING DEVICE MISC
F QL(1 ea per160 days retail)
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Drug Name DrugTier
Requirements/Limits
DRUG MART LANCETS THIN MISC F QL(6.67 ea
daily) DRUG MART ON-THE-GO LANCETS GENTLE 30G MISC
NP
DRUG MART UNILET LANCETSSUPER THIN 30G MISC
F QL(6.67 eadaily)
DRUG MART UNILET LANCETSULTRA THIN 28G MISC
F QL(6.67 eadaily)
DUANE READE LANCET ALTERNATE SITE 26G MISC
F QL(6.67 eadaily)
DUANE READE LANCET SUPERTHIN 30G MISC F QL(6.67 ea
daily) DUANE READE LANCET ULTRATHIN 28G MISC F QL(6.67 ea
daily) DUO-CARE CONTROL SOLUTION LIQD NP
E-Z JECT LANCETS 21G MISC F QL(6.67 ea
daily) E-Z JECT LANCETS COLOR MISC F QL(6.67 ea
daily)
E-Z JECT LANCETS MISC F QL(6.67 eadaily)
E-Z JECT LANCETS SUPER THIN 30G MISC F QL(6.67 ea
daily) E-Z JECT LANCETS THIN 26G MISC F QL(6.67 ea
daily) E-ZJECT LANCETS MICRO-THIN 33G MISC F QL(6.67 ea
daily) EASY COMFORT LANCETS 30G/PULL TOPMISC
NP
EASY COMFORT LANCETS 30G/THIN TOPMISC
NP
EASY COMFORT LANCETS MISC NP
EASY MINI EJECT LANCING DEVICE MISC F QL(1 ea per
160 days retail) EASY MINI LANCING DEVICE MISC F QL(1 ea per
160 days retail) EASY PLUS II CONTROL SOLUTION HIGH SOLN NP
Drug Name DrugTier
Requirements/Limits
EASY PLUS II CONTROL SOLUTION LOW SOLN NP
EASY STEP CONTROL SOLUTION HIGH SOLN NP
EASY STEP CONTROL SOLUTION LOW SOLN NP
EASY STEP CONTROL SOLUTION NORMAL SOLN
NP
EASY TALK CONTROL SOLUTION HIGH SOLN NP
EASY TALK CONTROL SOLUTION LOW SOLN NP
EASY TALK CONTROL SOLUTION NORMAL SOLN
NP
EASY TOUCH CONTROL SOLUTION/HIGH & LOWSOLN
NP
EASY TOUCH HEALTHPRO CONTROL SOLUTION/HIGH & LOWSOLN
NP
EASY TOUCH LANCETS 21G/PRESSUREACTIVATED MISC
NP
EASY TOUCH LANCETS 23G/PRESSUREACTIVATED MISC
NP
EASY TOUCH LANCETS 26G/PRESSUREACTIVATED MISC
NP
EASY TOUCH LANCETS 26G/PULL-TOP MISC F QL(6.67 ea
daily) EASY TOUCH LANCETS 26G/TWIST MISC F QL(6.67 ea
daily) EASY TOUCH LANCETS 28G/PRESSUREACTIVATED MISC
NP
EASY TOUCH LANCETS 28G/PULL-TOP MISC F QL(6.67 ea
daily) EASY TOUCH LANCETS 28G/TWIST MISC F QL(6.67 ea
daily) EASY TOUCH LANCETS 30G/BUTTON-ACTIVATEDMISC
NP
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Drug Name DrugTier
Requirements/Limits
EASY TOUCH LANCETS 30G/PRESSUREACTIVATED MISC
NP
EASY TOUCH LANCETS 30G/PULL-TOP MISC F QL(6.67 ea
daily) EASY TOUCH LANCETS 30G/TWIST MISC F QL(6.67 ea
daily) EASY TOUCH LANCETS 32G/PRESSUREACTIVATED MISC
NP
EASY TOUCH LANCETS 32G/PULL-TOP MISC F QL(6.67 ea
daily) EASY TOUCH LANCETS 32G/TWIST MISC F QL(6.67 ea
daily) EASY TOUCH LANCETS 33G/TWIST MISC F QL(6.67 ea
daily) EASY TOUCH LANCING DEVICE/EJECTOR MISC F QL(1 ea per
160 days retail) EASY TOUCH SAFETY LANCETS21G/PRESSUREACTIVATED MISC
NP
EASY TOUCH SAFETY LANCETS23G/PRESSUREACTIVATED MISC
NP
EASY TOUCH SAFETY LANCETS26G/BUTTONACTIVATED MISC
NP
EASY TOUCH SAFETY LANCETS26G/PRESSUREACTIVATED MISC
NP
EASY TOUCH SAFETY LANCETS28G/BUTTONACTIVATED MISC
NP
EASY TOUCH SAFETY LANCETS28G/PRESSUREACTIVATED MISC
NP
EASY TRAK GLUCOSE CONTROLSOLUTION HIGH SOLN
NP
EASY TRAK GLUCOSE CONTROLSOLUTION LOW SOLN
NP
EASY TRAK GLUCOSE CONTROLSOLUTION NORMAL SOLN
NP
EASY TWIST & CAP LANCETS MISC NP
Drug Name DrugTier
Requirements/Limits
EASYGLUCO CONTROL SOLUTION HIGH SOLN NP
EASYGLUCO CONTROL SOLUTION LOW SOLN NP
EASYGLUCO CONTROL SOLUTION NORMAL SOLN
NP
EASYGLUCO PLUS CONTROL SOLUTION LEVEL 1 SOLN
NP
EASYMAX 15 LEVEL 1 GLUCOSE CONTROL SOLUTION SOLN
NP
EASYMAX 15 LEVEL 2 GLUCOSE CONTROL SOLUTION SOLN
NP
EASYMAX CONTROL SOLUTIONHIGH SOLN NP
EASYMAX CONTROL SOLUTIONLOW SOLN NP
EASYMAX CONTROL SOLUTIONNORMAL SOLN
NP
EASYTEST II LANCETS MISC F QL(6.67 ea
daily) EASYTEST LANCETS MISC F QL(6.67 ea
daily) ELEMENT COMPACT CONTROL SOLUTION LEVEL 2 SOLN
NP
ELEMENT COMPACT CONTROL SOLUTION LEVEL 3 SOLN
NP
ELEMENT HIGH CONTROL LIQD NP
ELEMENT LOW CONTROL LIQD NP
ELEMENT NORMAL CONTROL LIQD NP
EMBRACE CONTROL SOLUTIONLOW SOLN NP
EMBRACE EVO GLUCOSE CONTROL SOLUTION LEVEL 1 LIQD
NP
EMBRACE EVO GLUCOSE CONTROL SOLUTION LEVEL 2 LIQD
NP
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Drug Name DrugTier
Requirements/Limits
EMBRACE GLUCOSE CONTROL SOLUTION HIGH LIQD
NP
EMBRACE LANCETS ULTRA THIN 30G MISC NP
EMBRACE PRO GLUCOSE CONTROL SOLUTION LIQD
NP
EQL COLOR LANCETS 21G MISC F QL(6.67 ea
daily) EQL COLOR LANCETS MICRO THIN 33G MISC F QL(6.67 ea
daily) EQL SUPER THIN LANCETS 30G MISC F QL(6.67 ea
daily) EQL THIN LANCETS 26G MISC F QL(6.67 ea
daily) EVENCARE CONTROL SOLUTION LIQD NP
EVENCARE G2 GLUCOSE CONTROL SOLUTION/LOW-HIGHSOLN
NP
EVENCARE G3 GLUCOSE CONTROL SOLUTION/LOW-HIGHSOLN
NP
EVENCARE MINI GLUCOSE CONTROL SOLUTION NORMAL SOLN
NP
EVOLUTION CONTROL SOLUTION NORMAL SOLN
NP
EZ SMART BLOOD GLUCOSE LANCETS MISC
F QL(6.67 eadaily)
EZ-LETS LANCETS 21G MISC NP
EZ-LETS LANCETS 23G MISC F QL(6.67 ea
daily) EZ-LETS LANCETS 26G SUPER-SOFT MISC F QL(6.67 ea
daily) EZ-LETS LANCETS 28G ULTRA-SOFT MISC F QL(6.67 ea
daily) EZ-LETS LANCETS 30G MISC F QL(6.67 ea
daily)
Drug Name DrugTier
Requirements/Limits
FIFTY50 CONTROL SOLUTION2.0 SOLN NP
FIFTY50 LANCING DEVICE MISC F QL(1 ea per
160 days retail) FIFTY50 SAFETY SEAL LANCETS 30G MISC NP
FIFTY50 SAFETY SEAL LANCETS 32G MISC NP
FIFTY50 UNILET LANCETS 33G MISC NP
FINE 30 MISC NP
FINGERSTIX LANCETS MISC NP
FORA CONTROL SOLUTION HIGH SOLN NP
FORA CONTROL SOLUTION LOW SOLN NP
FORA CONTROL SOLUTION NORMAL SOLN
NP
FORA LANCETS MISC NP
FORA LANCETS MISC F QL(6.67 eadaily)
FORA LANCING DEVICE MISC F QL(1 ea per
160 days retail) FORA LANCING DEVICE/CLEARCAP MISC F QL(1 ea per
160 days retail) FORACARE GDH CONTROL SOLUTION HIGH SOLN
NP
FORACARE GDH CONTROL SOLUTION LOW SOLN
NP
FORACARE GDH CONTROL SOLUTION NORMAL SOLN
NP
FORTISCARE CONTROL SOLUTIONS HIGH SOLN NP
FORTISCARE CONTROL SOLUTIONS LOW SOLN NP
FORTISCARE CONTROL SOLUTIONS NORMAL SOLN
NP
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Drug Name DrugTier
Requirements/Limits
FREDS PHARMACY AUTOLET LANCING DEVICE MISC
F QL(1 ea per160 days retail)
FREDS PHARMACY UNILET LANCETS SUPER THIN 30G MISC
F QL(6.67 eadaily)
FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G MISC
F QL(6.67 eadaily)
FREESTYLE CONTROL SOLUTION HIGH/LOWLIQD
NP
FREESTYLE CONTROL SOLUTION LIQD NP
FREESTYLE LANCETS MISC NP
FREESTYLE UNISTICK II LANCETS MISC NP
GE100 CONTROL SOLUTION NORMAL SOLN
NP
GENTLE-LET GP LANCETS MISC F QL(6.67 ea
daily) GENTLE-LET LANCETS GENERAL PURPOSE STYLE/FINE POINT MISC
F QL(6.67 eadaily)
GENTLE-LET LANCETS GENERAL PURPOSE STYLE/MEDIUM POINTMISC
F
QL(6.67 eadaily)
GENTLE-LET LANCETS SAFETY STYLE/FINEPOINT MISC
F QL(6.67 eadaily)
GENTLE-LET LANCETS SAFETY STYLE/MEDIUMPOINT MISC
F QL(6.67 eadaily)
GLOBAL INJECT EASE LANCETS 28G MISC NP
GLOBAL INJECT EASE LANCETS 30G MISC NP
GLOBAL LANCING DEVICE MISC F QL(1 ea per
160 days retail) GLUCOCARD 01 CONTROL SOLUTION NORMAL/HIGH LIQD
NP
Drug Name DrugTier
Requirements/Limits
GLUCOCARD 01 CONTROL SOLUTION/NORMALSOLN
NP
GLUCOCARD EXPRESSION CONTROL SOLUTION LEVEL 1 SOLN
NP
GLUCOCARD SHINE CONTROL SOLUTION LEVEL 1 SOLN
NP
GLUCOCARD X-METER CONTROLSOLUTION/NORMAL SOLN
NP
GLUCOCOM HIGH CONTROL LIQD NP
GLUCOCOM LANCETS 28G MISC NP
GLUCOCOM LANCETS 30G MISC NP
GLUCOCOM LANCETS 33G MISC NP
GLUCOCOM NORMAL CONTROL LIQD NP
GLUCOLET 2 AUTOMATIC LANCING DEVICE MISC
F QL(1 ea per160 days retail)
GLUCOSE CONTROL NORMAL SOLN NP
GLUCOSE CONTROL SOLUTION SOLN NP
GLUCOSOURCE LANCET DEVICE MISC F QL(1 ea per
160 days retail) GLUCOSOURCE LANCETS MISC F QL(6.67 ea
daily) GMATE CONTROL SOLUTION LEVEL 2 SOLN
NP
GMATE LANCETS 30G MISC NP
GMATE LANCING DEVICE MISC F QL(1 ea per
160 days retail) GNP EASY TOUCH CONTROL SOLUTION HIGH/LOW SOLN
NP
GNP LANCETS 21G MISC F QL(6.67 eadaily)
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Drug Name DrugTier
Requirements/Limits
GNP LANCETS MICRO THIN 33G MISC F QL(6.67 ea
daily)
GNP LANCETS MISC F QL(6.67 eadaily)
GNP LANCETS SUPER THIN 30G MISC F QL(6.67 ea
daily) GNP LANCETS THIN 26G MISC F QL(6.67 ea
daily) GNP LANCETS THIN MISC F QL(6.67 ea
daily) GNP MICRO THIN LANCETS 33G MISC F QL(6.67 ea
daily) GNP SUPER THIN LANCETS/30G MISC F QL(6.67 ea
daily) GOODSENSE LANCING DEVICE MISC F QL(1 ea per
160 days retail) H-E-B INCONTROL ADVANCEDLANCING DEVICE MISC
F QL(1 ea per160 days retail)
H-E-B INCONTROL LANCETS MICRO THIN 33G MISC
F QL(6.67 eadaily)
H-E-B INCONTROL LANCETS SUPER THIN 30G MISC
F QL(6.67 eadaily)
H-E-B INCONTROL LANCETS ULTRA THIN 28G MISC
F QL(6.67 eadaily)
HAEMOLANCE LOW FLOW LANCETS MISC NP
HAEMOLANCE MISC NP
HAEMOLANCE PLUS HIGH FLOW MISC NP
HAEMOLANCE PLUS LOW FLOW MISC NP
HAEMOLANCE PLUS MAX FLOW MISC NP
HAEMOLANCE PLUS MISC NP
HAEMOLANCE PLUS PEDIATRIC FLOW MISC NP
HEALTH CARE LANCING DEVICE MISC F QL(1 ea per
160 days retail) HEALTHWISE LANCETS 30G MISC NP
Drug Name DrugTier
Requirements/Limits
HEALTHWISE LANCING PEN MISC F QL(1 ea per
160 days retail) HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE MISC
F QL(1 ea per160 days retail)
HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G MISC
F QL(6.67 eadaily)
HY-VEE LANCETS MISC F QL(6.67 eadaily)
HY-VEE THIN LANCETS MISC F QL(6.67 ea
daily) IN TOUCH GLUCOSE CONTROLSOLUTION SOLN
NP
IN TOUCH LANCING DEVICE MISC F QL(1 ea per
160 days retail) IN TOUCH STERILE LANCETS30G MISC NP
INFINITY CONTROL SOLUTION HIGH SOLN NP
INFINITY CONTROL SOLUTION LOW SOLN NP
INFINITY CONTROL SOLUTION NORMAL SOLN
NP
KINNEY LANCETS MISC F QL(6.67 eadaily)
KINNEY THIN LANCETS MISC F QL(6.67 ea
daily) KROGER LANCETS 21G MISC F QL(6.67 ea
daily) KROGER LANCETS MICRO THIN33G MISC F QL(6.67 ea
daily)
KROGER LANCETS MISC F QL(6.67 eadaily)
KROGER LANCETS SUPER THIN MISC F QL(6.67 ea
daily) KROGER LANCETS THIN 26G MISC F QL(6.67 ea
daily) KROGER LANCETS THIN MISC F QL(6.67 ea
daily) KROGER LANCETS ULTRATHIN30G MISC F QL(6.67 ea
daily) KROGER LANCING DEVICE MISC F QL(1 ea per
160 days retail)
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Drug Name DrugTier
Requirements/Limits
LANCET DEVICE ADJUSTABLE MISC F QL(1 ea per
160 days retail) LANCET DEVICE WITH EJECTOR MISC F QL(1 ea per
160 days retail) LANCETS 26G TWIST TOP MISC F QL(6.67 ea
daily)
LANCETS 28G MISC F QL(6.67 eadaily)
LANCETS 30G MISC F QL(6.67 eadaily)
LANCETS 30G MISC NP
LANCETS 30G TWIST TOP MISC NP
LANCETS 30G/TWISTTOP MISC NP
LANCETS 31G TWIST TOP MISC NP
LANCETS 33G UNIVERSAL DESIGN MISC
NP
LANCETS MICRO THIN 33G MISC NP
LANCETS MISC F QL(6.67 eadaily)
LANCETS MISC NP
LANCETS SAFETY SEAL 21G MISC F QL(6.67 ea
daily) LANCETS SAFETY SEAL 26G MISC F QL(6.67 ea
daily) LANCETS SAFETY SEAL 28G MISC F QL(6.67 ea
daily) LANCETS SAFETY SEAL 30G MISC NP
LANCETS SUPER THIN 28G MISC NP
LANCETS THIN MISC F QL(6.67 eadaily)
LANCETS TWIST TOP MISC NP
LANCETS ULTRA FINE MISC NP
LANCETS ULTRA THIN 30G MISC NP
Drug Name DrugTier
Requirements/Limits
LANCETS ULTRA THIN MISC F QL(6.67 ea
daily) LANCETSBULLSEYE SAFETY MISC NP
LANCING DEVICE ADJUSTABLE MISC F QL(1 ea per
160 days retail)
LANCING DEVICE MISC F QL(1 ea per160 days retail)
LANZO MISC F QL(1 ea per160 days retail)
LEADER ADVANCED LANCING DEVICE MISC F QL(1 ea per
160 days retail) LIBERTY CONTROL SOLUTION HIGH SOLN NP
LIBERTY CONTROL SOLUTIONNORMAL SOLN
NP
LIBERTY GLUCOSE CONTROL LEVEL 1 SOLN NP
LIBERTY GLUCOSE CONTROL LEVEL 2 SOLN NP
LIBERTY GLUCOSE CONTROL MID SOLN NP
LIBERTY GLUCOSE CONTROL NORMAL LIQD NP
LIBERTY MEDICAL LANCETS 30G MISC NP
LIBERTY MINI LANCING DEVICE MISC F QL(1 ea per
160 days retail) LIFESCAN UNISTIK 2 DEEP PENETRATION MISC
NP
LIFESCAN UNISTIK II LANCETS MISC NP
LITE TOUCH LANCETS MISC NP
LITE TOUCH LANCING DEVICE MISC F QL(1 ea per
160 days retail) LITE TOUCH LANCING PEN MISC F QL(1 ea per
160 days retail) LITETOUCH LANCETS MICRO THIN 33G MISC NP
LIVE BETTER ADVANCED LANCING DEVICE MISC F QL(1 ea per
160 days retail) LIVE BETTER LANCET SUPERTHIN 30G MISC F QL(6.67 ea
daily)
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Drug Name DrugTier
Requirements/Limits
LIVE BETTER LANCET ULTRATHIN 28G MISC F QL(6.67 ea
daily) LONGS LANCETS STANDARD MISC F QL(6.67 ea
daily) LONGS LANCETS THIN MISC F QL(6.67 ea
daily) LONGS LANCETS ULTRA THIN MISC NP
MAXIMA CONTROL SOLUTION SOLN NP
MAXIMA CONTROL SOLUTION/NORMALSOLN
NP
MEDICHOICE PRE-SET SAFETY LANCET DUAL USE MISC
NP
MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW MISC
NP
MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW MISC
NP
MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW MISC
NP
MEDICHOICE SAFETY LANCETEXTRA MISC NP
MEDICHOICE SAFETY LANCETNORMAL MISC NP
MEDISENSE GLUCOSE KETONECONTROL SOLUTION 1-LOW,1-MED,1 HIGH LIQD
NP
MEDISENSE GLUCOSE KETONECONTROL SOLUTION 1-NORMAL LIQD
NP
MEDISENSE HIGH/LOWCONTROL SOLUTION LIQD
NP
MEDISENSE HIGH/MID/LOWCONTROL SOLUTION LIQD
NP
MEDISENSE MID CONTROL SOLUTION LIQD
NP
Drug Name DrugTier
Requirements/Limits
MEDISENSE THIN LANCETS MISC F QL(6.67 ea
daily) MEDLANCE PLUS EXTRA LANCETS 21G MISC NP
MEDLANCE PLUS LANCETS LITE 25G MISC NP
MEDLANCE PLUS LANCETS MISC NP
MEDLANCE PLUS LITE LANCETS 25G MISC NP
MEDLANCE PLUS SPECIAL LANCETS 0.8MM MISC
NP
MEDLANCE PLUS SUPERLITE 30G MISC NP
MEDLANCE PLUS SUPERLITE 30G/COMFORT MAXMISC
NP
MEDLANCE PLUS UNIVERSAL LANCETS 21G MISC
NP
MEDLANCE PLUS/LITE25G MISC NP
MEDLANCE/EXTRA MISC NP
MEDLANCE/LITE MISC NP
MEDLANCE/UNIVERSALMISC NP
MEIJER COLOR LANCETS UNIVERSAL 33G MISC
F QL(6.67 eadaily)
MEIJER LANCETS MISC F QL(6.67 eadaily)
MEIJER LANCETS THIN MISC F QL(6.67 ea
daily) MEIJER LANCETS UNIVERSAL21G MISC F QL(6.67 ea
daily) MEIJER LANCETS UNIVERSAL30G MISC F QL(6.67 ea
daily) MEIJER LANCETS UNIVERSAL33G MISC F QL(6.67 ea
daily) MEIJER SUPER THIN LANCETS MISC F QL(6.67 ea
daily)
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Drug Name DrugTier
Requirements/Limits
MICRODOT CONTROL SOLUTIONHIGH/LOWSOLN
NP
MICROLET LANCETS MISC NP
MICROLET NEXT MISC F QL(1 ea per160 days retail)
MICROTAINER SAFETY FLOW LANCET/STERILE/SINGLE-USE MISC
NP
MINI LANCING DEVICE MISC F QL(1 ea per
160 days retail) MONOLET LANCETS MISC NP
MONOLET LANCETS MISC F QL(6.67 ea
daily) MONOLET OPD LANCETS MISC F QL(6.67 ea
daily) MONOLETTOR SAFETY LANCETS MISC NP
MULTI-LANCET DEVICE MISC F QL(1 ea per
160 days retail) MYGLUCOHEALTH CONTROL LOW/NORMAL/HIGHSOLN
NP
MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G MISC
NP
NETGROUP LANCETS MISC NP
NEUTEK 2TEK CONTROL SOLUTIONS SOLN NP
NEXGEN NORMAL CONTROL LIQD NP
NOVA MAX PLUS GLU/KET CONTROLSOLUTION-MID LIQD
NP
NOVA SAFETY LANCETS 23G MISC NP
NOVA SAFETY LANCETS 28G MISC NP
NOVA SUREFLEX LANCETS MISC NP
NOVA SUREFLEX LANCETS MISC F QL(6.67 ea
daily)
Drug Name DrugTier
Requirements/Limits
NOVA SUREFLEX LANCING DEVICE MISC F QL(1 ea per
160 days retail) ON CALL EXPRESS GLUCOSE CONTROL SOLUTION SOLN
NP
ON CALL LANCETS MISC NP
ON CALL LANCING DEVICE MISC F QL(1 ea per
160 days retail) ON CALL PLUS GLUCOSE CONTROL LEVEL 1/2 SOLN
NP
ON CALL PLUS LANCETS MISC NP
ON CALL PLUS LANCING DEVICE MISC F QL(1 ea per
160 days retail) ON CALL VIVID GLUCOSE CONTROL LEVEL 1/2 SOLN
NP
ONETOUCH CLUB LANCETS FINE POINT MISC
NP
ONETOUCH COMBO PACK MISC NP
ONETOUCH DELICA LANCETS EXTRA FINE 33G MISC
NP
ONETOUCH DELICA LANCETS FINE 30G MISC NP
ONETOUCH DELICA LANCING DEVICE MISC F QL(1 ea per
160 days retail) ONETOUCH FINEPOINT LANCETS MISC NP
ONETOUCH LANCETS MISC F QL(6.67 ea
daily) ONETOUCH ULTRA CONTROL SOLN NP
ONETOUCH ULTRASOFT LANCETS MISC NP
ONETOUCH VERIO CONTROL SOLUTION HIGH SOLN
NP
ONETOUCH VERIO MID CONTROL SOLUTION SOLN
NP
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Drug Name DrugTier
Requirements/Limits
OPTUMRX GLUCOSE CONTROL LEVEL 1/2SOLN
NP
PC LANCETS SUPER THIN 30G MISC F QL(6.67 ea
daily) PERFECT LANCETS 30G MISC F QL(6.67 ea
daily) PERFECT PRESSURE ACTIVATED SAFETY LANCETS 28G MISC
NP
PHARMACIST CHOICE ULTRA THIN LANCETS 28G MISC
NP
PHARMACIST CHOICE ULTRA THIN LANCETS 30G MISC
NP
PHARMACIST CHOICE ULTRA THIN LANCETS 31G MISC
NP
PHARMACIST CHOICE ULTRA THIN LANCETS 33G MISC
NP
PHARMACIST CHOICE ULTRA THIN LANCETS MISC
NP
PHARMACY COUNTER LANCETS MISC F QL(6.67 ea
daily) POCKETCHEM EZ CONTROL LEVEL 1 SOLN NP
PRECISION GLUCOSE CONTROL LIQD NP
PRECISION GLUCOSE CONTROLSOLUTION (TRI-LEVEL/HI/LO/NORMAL) SOLN
NP
PRECISION GLUCOSE KETONECONTROL SOLUTION 1-LOW, 1-HIGH LIQD
NP
PRECISION GLUCOSE/KETONECONTROL SOLUTIONS 1-HI 1-LO LIQD
NP
PRECISION THIN LANCETS MISC F QL(6.67 ea
daily)
Drug Name DrugTier
Requirements/Limits
PRECISION THINS GP LANCET MISC F QL(6.67 ea
daily) PRECISION ULTRA LANCET MISC F QL(6.67 ea
daily) PREFERRED PLUS LANCETS COLORED 21G MISC
F QL(6.67 eadaily)
PREFERRED PLUS LANCETS SUPER THIN 30G MISC
F QL(6.67 eadaily)
PREFERRED PLUS LANCETS THIN 26G MISC F QL(6.67 ea
daily) PRESSURE ACTIVATED SAFETYLANCET 21G MISC
NP
PRO COMFORT LANCETS 30G MISC NP
PRO COMFORT LANCETS 31G MISC F QL(6.67 ea
daily) PRODIGY CONTROL SOLUTIONHIGH SOLN NP
PRODIGY CONTROL SOLUTIONLOW SOLN NP
PRODIGY LANCING DEVICE MISC F QL(1 ea per
160 days retail) PRODIGY PRESSURE ACTIVATED SAFETY LANCETS MISC
NP
PRODIGY SAFETY LANCETS MISC NP
PRODIGY TWIST TOP LANCETS MISC F QL(6.67 ea
daily) PRODIGY TWIST TOP LANCETS MISC NP
PSS SELECT GP LANCETS MISC F QL(6.67 ea
daily) PSS SELECT SAFETY LANCETS MISC F QL(6.67 ea
daily) PUSH BUTTON SAFETY LANCETS 21G MISC NP
PUSH BUTTON SAFETY LANCETS 28G MISC NP
PX ADVANCED LANCING DEVICE MISC F QL(1 ea per
160 days retail) PX LANCET AUTO INJECTOR MISC F QL(1 ea per
160 days retail)
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Drug Name DrugTier
Requirements/Limits
PX LANCETS ULTRA THIN 28G MISC NP
PX LANCETS ULTRA THIN MISC F QL(6.67 ea
daily) QC ADVANCED LANCING DEVICE MISC F QL(1 ea per
160 days retail) QC LANCETS SUPER THIN MISC F QL(6.67 ea
daily) QC LANCETS ULTRA THIN MISC F QL(6.67 ea
daily) QC UNILET LANCETS 28G/ULTRA THIN MISC F QL(6.67 ea
daily) QC UNILET LANCETS 33G/MICRO THIN MISC F QL(6.67 ea
daily) QUICKTEK CONTROL SOLUTION LIQD NP
QUINTET GLUCOSE CONTROL/HIGH/NORMALSOLN
NP
RA E-ZJECT COLOR LANCETSMICRO-THIN 33G MISC
F QL(6.67 eadaily)
RA E-ZJECT LANCETS 28G MISC F QL(6.67 ea
daily) RA E-ZJECT LANCETS THIN 26G MISC F QL(6.67 ea
daily) RA E-ZJECT LANCETS THIN 28G MISC F QL(6.67 ea
daily) RA E-ZJECT LANCETS ULTRATHIN 30G MISC F QL(6.67 ea
daily) RA LANCING DEVICE MISC F QL(1 ea per
160 days retail) READYLANCE SAFETY LANCETS/21G/2.2MMMISC
NP
READYLANCE SAFETY LANCETS/23G/1.8MMMISC
NP
READYLANCE SAFETY LANCETS/26G/1.8MMMISC
NP
READYLANCE SAFETY LANCETS/28G/1.8MMMISC
NP
READYLANCE SAFETY LANCETS/30G/1.6MMMISC
NP
Drug Name DrugTier
Requirements/Limits
REALITY LANCETS MISC F QL(6.67 eadaily)
REALITY TRIGGER LANCETS MISC NP
REFUAH PLUS GLUCOSE CONTROL SOLUTION SOLN
NP
RELION 2-IN-1 LANCING DEVICE 25G MISC F QL(1 ea per
160 days retail) RELION 2-IN-1 LANCING DEVICE 30G MISC F QL(1 ea per
160 days retail) RELION LANCETS MICRO-THIN33G MISC F QL(6.67 ea
daily) RELION LANCETS STANDARD 21G MISC F QL(6.67 ea
daily) RELION LANCETS THIN 26G MISC F QL(6.67 ea
daily) RELION LANCETS ULTRA-THIN30G MISC F QL(6.67 ea
daily) RELION LANCING DEVICE MISC F QL(1 ea per
160 days retail) RELION ULTRA THIN LANCETS30G MISC F QL(6.67 ea
daily) RELION ULTRA THIN PLUS LANCETS 32G MISC
F QL(6.67 eadaily)
RELION ULTRA THIN PLUS LANCETS 33G MISC
F QL(6.67 eadaily)
REXALL LANCETS ULTRA THIN MISC F QL(6.67 ea
daily) RIGHTEST GC300 HIGH CONTROL LIQD NP
RIGHTEST GC300 NORMAL CONTROL LIQD NP
RIGHTEST GD500 LANCING DEVICE MISC F QL(1 ea per
160 days retail) RIGHTEST GL300 LANCETS MISC F QL(6.67 ea
daily) SAFE-T-LANCE LOW FLOW 25G MISC NP
SAFE-T-LANCE NORMAL FLOW21G MISC NP
SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW MISC
NP
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Drug Name DrugTier
Requirements/Limits
SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW MISC
NP
SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW MISC
NP
SAFETY LANCET 21G/PRESSUREACTIVATED MISC
NP
SAFETY LANCET 28G/PRESSUREACTIVATED MISC
NP
SAFETY LANCETS 21G MISC NP
SAFETY LANCETS 28G MISC NP
SAFETY LANCETS MISC NP
SAFETY LET LANCETS MISC NP
SAFETY SEAL LANCETS 28G MISC F QL(6.67 ea
daily) SAFETY SEAL LANCETS 30G MISC F QL(6.67 ea
daily) SAPSCARE TWIST TOP LANCETS 30G MISC NP
SB LANCETS THIN MISC F QL(6.67 eadaily)
SB LANCETS ULTRA THIN MISC F QL(6.67 ea
daily) SELECT-LITE LANCING DEVICE MISC F QL(1 ea per
160 days retail) SHOPKO AUTOLET LANCING DEVICE MISC F QL(1 ea per
160 days retail) SHOPKO ON-THE-GO COMFORTLANCETS 30G MISC
NP
SHOPKO UNILET LANCETS SUPER THIN 30G MISC
F QL(6.67 eadaily)
SHOPKO UNILET LANCETS ULTRA THIN 28G MISC
F QL(6.67 eadaily)
SIDE BUTTON SAFETY LANCET21G MISC NP
SIMPLE DIAGNOSTICS LANCING DEVICE MISC F QL(1 ea per
160 days retail)
Drug Name DrugTier
Requirements/Limits
SINGLE-LET MISC NP
SM MICRO THIN LANCETS 33G MISC F QL(6.67 ea
daily) SM TRUEDRAW LANCING DEVICE MISC F QL(1 ea per
160 days retail) SMART DIABETES VANTAGE LANCING DEVICE MISC
F QL(1 ea per160 days retail)
SMART SENSE COLOR LANCETS UNIVERSAL 33G MISC
F QL(6.67 eadaily)
SMART SENSE STANDARD LANCETS UNIVERSAL 21G MISC
F QL(6.67 eadaily)
SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G MISC
F QL(6.67 eadaily)
SMART SENSE THIN LANCETSUNIVERSAL 26G MISC
F QL(6.67 eadaily)
SMARTEST CONTROL SOLUTIONMEDIUM SOLN NP
SMARTEST LANCETS 28G MISC NP
SOLARTEK GLUCOSE CONTROLSOLUTIONS LIQD
NP
SOLUS V2 CONTROL HIGH SOLN NP
SOLUS V2 CONTROL LOW SOLN NP
SOLUS V2 LANCING DEVICE MISC F QL(1 ea per
160 days retail) SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G MISC
NP
SOLUS V2 TWIST LANCETS 30G MISC NP
STERILANCE TL MISC F QL(6.67 eadaily)
SUPER THIN LANCETS MISC F QL(6.67 ea
daily) SUPREME II HIGH/LOWCONTROL SOLUTION LIQD
NP
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Drug Name DrugTier
Requirements/Limits
SURE COMFORT LANCETS 28G MISC NP
SURE COMFORT LANCETS 30G MISC NP
SURE COMFORT LANCING PEN MISC F QL(1 ea per
160 days retail) SURE-LANCE FLAT LANCETS MISC NP
SURE-LANCE LANCETS 26G MISC NP
SURE-LANCE THIN LANCETS 28G MISC NP
SURE-LANCE ULTRA THIN LANCETS MISC NP
SURE-PEN MISC F QL(1 ea per160 days retail)
SURE-TOUCH LANCETS UNIVERSAL MISC NP
SURELITE LANCETS MISC F QL(6.67 ea
daily) SURESTEP GLUCOSE CONTROL SOLN NP
SURESTEP GLUCOSE CONTROLSOLUTION SOLN
NP
SURESTEP PRO HIGH GLUCOSECONTROL LIQD
NP
SURESTEP PRO LOW GLUCOSECONTROL LIQD
NP
SURESTEP PRO NORMAL GLUCOSE CONTROL LIQD
NP
TAI DOC CONTROL SOLN NP
TECHLITE AST LANCETS MISC F QL(6.67 ea
daily) TECHLITE LANCETS 30G MISC F QL(6.67 ea
daily) TECHLITE LANCETS MISC F QL(6.67 ea
daily) TELCARE GLUCOSE CONTROL SOLUTION LEVEL 1/2 SOLN
NP
Drug Name DrugTier
Requirements/Limits
TGT ADVANCED LANCING DEVICE MISC F QL(1 ea per
160 days retail) TGT LANCET ALTERNATE SITE MISC F QL(6.67 ea
daily) TGT LANCET MICRO THIN 33G MISC F QL(6.67 ea
daily) TGT LANCET SUPER THIN 30G MISC F QL(6.67 ea
daily) TGT LANCET THIN 23G MISC F QL(6.67 ea
daily) TGT LANCET THIN 26G MISC F QL(6.67 ea
daily) TGT LANCET ULTRA THIN 28G MISC F QL(6.67 ea
daily) TGT LANCET ULTRA THIN 30G MISC F QL(6.67 ea
daily) TGT LANCING DEVICE MISC F QL(1 ea per
160 days retail) THINLETS GP LANCETS MISC F QL(6.67 ea
daily)
THINLETS LANCET MISC F QL(6.67 eadaily)
TODAYS HEALTH ADVANCED LANCING DEVICE MISC
F QL(1 ea per160 days retail)
TODAYS HEALTH SUPER THINLANCETS 30G MISC F QL(6.67 ea
daily) TODAYS HEALTH ULTRA THINLANCETS 28G MISC F QL(6.67 ea
daily) TRAVEL LANCETS 30G MISC NP
TRUE METRIX CONTROL SOLUTION LEVEL 1 SOLN
F
TRUE METRIX CONTROL SOLUTION LEVEL 2 SOLN
F QL(1 ea per 75days retail)
TRUE METRIX CONTROL SOLUTION LEVEL 3 SOLN
F QL(1 ea per 75days retail)
TRUECONTROL GLUCOSE CONTROL LEVEL 0 LIQD
F QL(1 ea per 75days retail)
TRUECONTROL GLUCOSE CONTROL LEVEL 1 LIQD
F QL(1 ea per 75days retail)
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Drug Name DrugTier
Requirements/Limits
TRUEDRAW LANCING DEVICE MISC F QL(1 ea per
160 days retail) TRUEPLUS LANCETS 26G MISC F QL(6.67 ea
daily) TRUEPLUS LANCETS 28G MISC F QL(6.67 ea
daily) TRUEPLUS LANCETS 28G SUPER THIN MISC NP
TRUEPLUS LANCETS 28G SUPER THIN MISC F QL(6.67 ea
daily) TRUEPLUS LANCETS 30G MISC F QL(6.67 ea
daily) TRUEPLUS LANCETS 30G ULTRA THIN MISC F QL(6.67 ea
daily) TRUEPLUS LANCETS 30G ULTRA THIN MISC NP
TRUEPLUS LANCETS 33G MICRO THIN MISC NP
TRUEPLUS LANCETS 33G MISC F QL(6.67 ea
daily) TRUEPLUS SAFETY LANCETS 28G MISC NP
TRUETEST GLUCOSE CONTROLLEVEL 1 LIQD F QL(1 ea per 75
days retail) TRUETEST GLUCOSE CONTROLLEVEL 2 LIQD F QL(1 ea per 75
days retail) TRUETEST GLUCOSE CONTROLLEVEL 3 LIQD F QL(1 ea per 75
days retail) ULTI-LANCE AUTOMATIC/CLEAR TIP MISC F QL(1 ea per
160 days retail) ULTICARE THIN LANCETS 30G MISC NP
ULTILET CLASSIC LANCETS MISC NP
ULTILET CLASSIC LANCETS MISC F QL(6.67 ea
daily) ULTILET LANCETS 33G MISC NP
ULTILET LANCETS MISC NP
ULTILET SAFETY LANCETS 23G MISC NP
ULTRA THIN LANCETS 28G MISC F QL(6.67 ea
daily) ULTRA THIN LANCETS 30G MISC F QL(6.67 ea
daily)
Drug Name DrugTier
Requirements/Limits
ULTRA-THIN II AUTO LANCET MISC NP
ULTRA-THIN II LANCETS 28G MISC NP
ULTRA-THIN II LANCETS 30G MISC NP
ULTRA-THIN II SAFETY AUTOLANCETS 26G MISC
NP
ULTRATRAK PRO CONTROL SOLUTION 2 LEVELS SOLN
NP
ULTRATRAK PRO NORMAL CONTROL SOLN
NP
ULTRATRAK ULTIMATE CONTROL SOLUTION 2 LEVELS SOLN
NP
UNILET COMFORTOUCH LANCET MISC F QL(6.67 ea
daily)
UNILET EXCELITE II MISC F QL(6.67 eadaily)
UNILET EXCELITE MISC F QL(6.67 eadaily)
UNILET G.P. LANCET MISC F QL(6.67 ea
daily) UNILET G.P. SUPERLITE LANCET MISC F QL(6.67 ea
daily) UNILET GP 28 ULTRA THIN MISC F QL(6.67 ea
daily)
UNILET LANCET MISC F QL(6.67 eadaily)
UNILET LANCETS MICRO-THIN33G MISC F QL(6.67 ea
daily) UNILET LANCETS SUPER-THIN30G MISC F QL(6.67 ea
daily) UNILET LANCETS ULTRA-THIN 28G MISC F QL(6.67 ea
daily) UNILET SUPERLITE LANCET MISC F QL(6.67 ea
daily)
UNISTIK 3 GENTLE MISC NP
UNISTIK SAFETY LANCETS 28G MISC NP
UNISTIK SAFETY LANCETS 30G MISC NP
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Drug Name DrugTier
Requirements/Limits
UNISTIK TOUCH SAFETY LANCETS 21G MISC NP
UNISTIK TOUCH SAFETY LANCETS 23G MISC NP
UNISTIK TOUCH SAFETY LANCETS 28G MISC NP
UNISTIK TOUCH SAFETY LANCETS 30G MISC NP
UNISTRIP CONTROL SOLUTIONHIGH SOLN NP
UNISTRIP CONTROL SOLUTIONLOW SOLN NP
UNIVERSAL 1 LANCETS THIN26G MISC F QL(6.67 ea
daily) UNIVERSAL 1 LANCETS ULTRA THIN 30G MISC F QL(6.67 ea
daily) UNIVERSAL 1 LANCETS/33G/MICRO-THIN MISC
NP
VALUE PLUS LANCETS STANDARD 21G MISC F QL(6.67 ea
daily) VALUE PLUS LANCETS SUPERTHIN 30G MISC F QL(6.67 ea
daily) VALUE PLUS LANCETS THIN 26G MISC F QL(6.67 ea
daily) VALUE PLUS LANCING DEVICE MISC F QL(1 ea per
160 days retail) VALUMARK LANCET SUPER THIN 30G MISC F QL(6.67 ea
daily) VALUMARK LANCET ULTRA THIN 28G MISC F QL(6.67 ea
daily) VERASENS GLUCOSE CONTROLLEVEL 1 LIQD NP
VICTORY CONTROL LEVEL 1/2 SOLN NP
VIDA MIA AUTOLET LANCINGDEVICE MISC F QL(1 ea per
160 days retail) VIDA MIA UNILET LANCETS SUPER THIN 30G MISC
F QL(6.67 eadaily)
VIDA MIA UNILET LANCETS ULTRA THIN 28G MISC
F QL(6.67 eadaily)
VITALET PRO LANCETS MISC NP
Drug Name DrugTier
Requirements/Limits
VITALET PRO PLUS LANCETS MISC NP
W&F LANCETS 26G MISC F QL(6.67 eadaily)
W&F LANCETS COLORED 21G MISC F QL(6.67 ea
daily) WALGREENS ADVANCED TRAVELLANCETS 28G MISC
NP
WALGREENS COMFORT ASSUREDLANCETS MICRO THIN/33G MISC
F QL(6.67 eadaily)
WALGREENS COMFORT ASSUREDLANCETS SUPER THIN/28G MISC
F QL(6.67 eadaily)
WALGREENS LANCETS MISC NP
WALGREENS THIN LANCETS MISC F QL(6.67 ea
daily) WALGREENS THIN LANCETS MISC NP
WALGREENS ULTRA THIN LANCETS MISC NP
Misc. Devices ALCOH-GLOVE CONTOURED WIPE PADS NP RX/OTC
ALCOHOL PADS PADS NP RX/OTC
ALCOHOL PREP PADS PADS F QL(13.34 ea
daily); RX/OTC ALCOHOL PREP PADS PADS NP RX/OTC
ALCOHOL PREPS PADS F QL(13.34 eadaily); RX/OTC
ALCOHOL SWABS PADS NP RX/OTC
ALCOHOL SWABS PADS F QL(13.34 eadaily); RX/OTC
ALCOHOL SWABSTICK PADS NP RX/OTC
ALCOHOL WIPES PADS F QL(13.34 eadaily); RX/OTC
BD SWABS SINGLE USE BUTTERFLY PADS F QL(13.34 ea
daily); RX/OTC BD SWABS SINGLE USE PADS F QL(13.34 ea
daily); RX/OTC
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Drug Name DrugTier
Requirements/Limits
CARETOUCH ALCOHOL PREP PADS PADS NP RX/OTC
CURITY ALCOHOL PREPS/MEDIUM 2 PLYPADS
F QL(13.34 eadaily); RX/OTC
CURITY ALCOHOL SWABS PADS F QL(13.34 ea
daily); RX/OTC CVS ALCOHOL PREP SWABS PADS F QL(13.34 ea
daily); RX/OTC CVS ALCOHOL SWABS PADS F QL(13.34 ea
daily); RX/OTC
CVS PREP PADS PADS F QL(13.34 eadaily); RX/OTC
EASY TOUCH ALCOHOL PREP PADS/MEDIUMPADS
F QL(13.34 eadaily); RX/OTC
EQL ALCOHOL SWABS PADS F QL(13.34 ea
daily); RX/OTC FIFTY50 ALCOHOL PREP PADS PADS F QL(13.34 ea
daily); RX/OTC GLOBAL ALCOHOL PREP EASEPADS PADS NP RX/OTC
GNP ALCOHOL SWABS PADS F QL(13.34 ea
daily); RX/OTC H-E-B INCONTROL ALCOHOL PADS PADS F QL(13.34 ea
daily); RX/OTC HEALTHWISE ALCOHOL PREP PADS PADS NP RX/OTC
MEIJER ALCOHOL SWABS EXTRA-THICK PADS
F QL(13.34 eadaily); RX/OTC
PHARMACIST CHOICE ALCOHOLPREP PADS PADS
NP RX/OTC
PRO COMFORT ALCOHOL PADS PADS NP RX/OTC
QC ALCOHOL SWABS PADS F QL(13.34 ea
daily); RX/OTC RA ALCOHOL SWABS PADS F QL(13.34 ea
daily); RX/OTC
REALITY SWABS PADS F QL(13.34 eadaily); RX/OTC
RELION ALCOHOL SWABS PADS F QL(13.34 ea
daily); RX/OTC SAPS CARE ALCOHOL PREP PADS PADS NP RX/OTC
Drug Name DrugTier
Requirements/Limits
SB ALCOHOL PREP PADS PADS F QL(13.34 ea
daily); RX/OTC SHOPKO ALCOHOL SWABS PADS F QL(13.34 ea
daily); RX/OTC SM ALCOHOL PREP PADS PADS F QL(13.34 ea
daily); RX/OTC SURE COMFORT ALCOHOL PREP PADS PADS
NP RX/OTC
SURE-PREP ALCOHOL PREP PADS PADS NP RX/OTC
TGT ALCOHOL SWABS PADS F QL(13.34 ea
daily); RX/OTC ULTICARE ALCOHOL SWABS PADS F QL(13.34 ea
daily); RX/OTC WEBCOL ALCOHOL PREP LARGE 1 PLY PADS
F QL(13.34 eadaily); RX/OTC
WEBCOL ALCOHOL PREP LARGE 2 PLY PADS
F QL(13.34 eadaily); RX/OTC
WEBCOL ALCOHOL PREP MEDIUM 2 PLY PADS
F QL(13.34 eadaily); RX/OTC
Oral Hygiene Products AQUAFRESH CAVITY PROTECTION PSTE F RX/OTC
AQUAFRESH EXTREME CLEAN PSTE F RX/OTC
AQUAFRESH FOR KIDS PSTE F RX/OTC
AQUAFRESH SENSITIVE PSTE F RX/OTC
AQUAFRESH TARTAR CONTROL PSTE F RX/OTC
AQUAFRESH TOOTHPASTE PSTE F RX/OTC
AQUAFRESH WHITENING PSTE F RX/OTC
BIOTENE DRY MOUTH GENTLEFORMULA PSTE F RX/OTC
BIOTENE DRY MOUTH PSTE F RX/OTC
BIOTENE PBF DRY MOUTH PSTE F RX/OTC
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Drug Name DrugTier
Requirements/Limits
COLGATE PLATINUM PSTE F RX/OTC
CREST TARTAR CONTROL PSTE F RX/OTC
CREST TARTAR CONTROL/BAKING SODATOOTHPASTE PSTE
F RX/OTC
CREST TOOTHPASTE PSTE F RX/OTC
CREST TOOTHPASTE/REGULARPSTE
F RX/OTC
CREST TOOTHPASTEREGULAR PSTE
F RX/OTC
MI PASTE PLUS PSTE F RX/OTC
MI PASTE PSTE F RX/OTC
PEARL DROPS EXTRA STRENGTH PSTE F RX/OTC
RA FLUORIDE TOOTHPASTE PSTE F RX/OTC
RA SENSITIVE TOOTHPASTE/FLUORIDEPSTE
F RX/OTC
RA WHITENING TOOTHPASTE/FLUORIDEPSTE
F RX/OTC
SENSITIVE TOOTHPASTE EXTRA WHITENING/FLUORIDEMAX ST PSTE
F
RX/OTC
SENSITIVE TOOTHPASTE/FLUORIDE/MAXIMUM STRENGTHPSTE
F
RX/OTC
SENSODYNE MAXIMUM STRENGTH PSTE F RX/OTC
SENSODYNE MAXIMUM STRENGTH TARTAR CONTROL PLUS WHITENING PSTE
F
RX/OTC
SENSODYNE PRONAMEL FRESHBREATH PSTE F RX/OTC
SENSODYNE PRONAMEL PSTE F RX/OTC
Drug Name DrugTier
Requirements/Limits
VIADENT ADVANCED CARE TOOTHPASTE PSTE
F RX/OTC
VIADENT TOOTHPASTE FLUORIDE PSTE F RX/OTC
VIADENT TOOTHPASTE PLAQUEFIGHTING PSTE F RX/OTC
VIADENT TOOTHPASTE PSTE F RX/OTC
Parenteral Therapy Supplies 1ST TIER UNIFINE PENTIPS/MINI/31GX5MMMISC
F QL(5 ea daily);RX/OTC
1ST TIER UNIFINE PENTIPS29GX12MM MISC
F QL(5 ea daily);RX/OTC
1ST TIER UNIFINE PENTIPS31GX6MM MISC F QL(5 ea daily)
1ST TIER UNIFINE PENTIPS31GX8MM MISC F QL(5 ea daily);
RX/OTC 1ST TIER UNIFINE PENTIPS32GX4MM MISC F QL(5 ea daily);
RX/OTC 1ST TIER UNIFINE PENTIPSPLUS 31GX8MM MISC
F QL(5 ea daily);RX/OTC
1ST TIER UNIFINE PENTIPSPLUS 32GX4MM MISC
F QL(5 ea daily);RX/OTC
1ST TIER UNIFINE PENTIPSPLUS/MINI/31GX5MM MISC
F QL(5 ea daily);RX/OTC
1ST TIER UNIFINE PENTIPSPLUS/ORIGINAL/29GX12MM MISC
F QL(5 ea daily);RX/OTC
1ST TIER UNIFINE PENTIPSPLUS/ULTRASHORT/31GX6MM MISC
F QL(5 ea daily)
ADVOCATE INSULIN PEN NEEDLES 29GX12.7MM MISC
F QL(5 ea daily)
ADVOCATE INSULIN PEN NEEDLES 31GX5MM MISC
F QL(5 ea daily);RX/OTC
ADVOCATE INSULIN PEN NEEDLES 31GX8MM MISC
F QL(5 ea daily);RX/OTC
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Drug Name DrugTier
Requirements/Limits
ADVOCATE INSULIN SYRINGE/U-100/0.3ML/29GX1/2" MISC
F QL(5 ea daily);RX/OTC
ADVOCATE INSULIN SYRINGE/U-100/0.3ML/30GX5/16"MISC
F
QL(5 ea daily);RX/OTC
ADVOCATE INSULIN SYRINGE/U-100/0.3ML/31GX5/16"MISC
F
QL(5 ea daily)
ADVOCATE INSULIN SYRINGE/U-100/0.5ML/29GX1/2" MISC
F QL(5 ea daily);RX/OTC
ADVOCATE INSULIN SYRINGE/U-100/0.5ML/30GX5/16"MISC
F
QL(5 ea daily);RX/OTC
ADVOCATE INSULIN SYRINGE/U-100/0.5ML/31GX5/16"MISC
F
QL(5 ea daily)
ADVOCATE INSULIN SYRINGE/U-100/1ML/29GX1/2" MISC
F QL(5 ea daily);RX/OTC
ADVOCATE INSULIN SYRINGE/U-100/1ML/30GX5/16" MISC
F QL(5 ea daily);RX/OTC
ADVOCATE INSULIN SYRINGE/U-100/1ML/31GX5/16" MISC
F QL(5 ea daily)
ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
ANTI-STICK INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
ASSURE ID INSULIN SAFETYSYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
ASSURE ID INSULIN SAFETYSYRINGE/U-100/1ML/29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
AURORA PEN NEEDLES 29GX12MM MISC F QL(5 ea daily);
RX/OTC AURORA PEN NEEDLES 31G X6MM MISC F QL(5 ea daily)
AURORA PEN NEEDLES 31G X8MM MISC F QL(5 ea daily);
RX/OTC AURORA UNIFINE PENTIPS/32GX5/32" MISC F QL(5 ea daily);
RX/OTC AURORA UNIFINE PENTIPS/MINI/31GX3/16"MISC
F QL(5 ea daily);RX/OTC
B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31GX 5/16" MISC
F QL(5 ea daily)
B-D INSULIN SYRINGE ULTRAFINE II/0.5ML/31GX 5/16" MISC
F QL(5 ea daily)
B-D INSULIN SYRINGE ULTRAFINE II/1ML/31G X5/16" MISC
F QL(5 ea daily)
B-D INSULIN SYRINGE ULTRAFINE/0.3ML/30G X1/2" MISC
F QL(5 ea daily)
B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X1/2" MISC
F QL(5 ea daily)
BD LO-DOSE INSULIN SYRINGE MICROFINE IV/0.5ML/28G X 1/2" MISC
F QL(5 ea daily);RX/OTC
BD AUTOSHIELD 29G X 5/16" MISC F QL(5 ea daily)
BD INSULIN SYRINGE LUER-LOK/U-100/1MLMISC
F QL(5 ea daily);RX/OTC
BD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X 1/2"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE MICROFINE IV/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
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Drug Name DrugTier
Requirements/Limits
BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/27G X 5/8" MISC
F QL(5 ea daily)
BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/28G X 1/2" MISC
F QL(5 ea daily);RX/OTC
BD INSULIN SYRINGE MICROFINE/U-100/0.3ML/28G X 1/2"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE MICROFINE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
BD INSULIN SYRINGE MICROFINE/U-100/1ML/27G X 5/8" MISC
F QL(5 ea daily)
BD INSULIN SYRINGE MICROFINE/U-100/1ML/28G X 1/2" MISC
F QL(5 ea daily);RX/OTC
BD INSULIN SYRINGE SAFETYGLIDE/0.5ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
BD INSULIN SYRINGE SAFETYGLIDE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE SLIP TIP/U-100/1ML MISC F QL(5 ea daily);
RX/OTC BD INSULIN SYRINGE ULTRAFINE HALF-UNIT/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE II/SHORT/0.5ML/31G X5/16" MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE II/SHORT/1ML/31G X 5/16"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/0.3ML/30G X1/2" MISC
F QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X1/2" MISC
F QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/1ML/30G X1/2" MISC
F QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X5/16" MISC
F QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/30G X 1/2"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/30G X 1/2"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/30G X 1/2" MISC
F QL(5 ea daily)
Nebraska Total Care Updated December 1, 2017
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Drug Name DrugTier
Requirements/Limits
BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X 15/64"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X 5/16"MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/25GX 1" MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/25GX 5/8" MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/26GX 1/2" MISC
F
QL(5 ea daily)
BD INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC
F QL(5 ea daily)
BD INSULIN SYRINGE/U-100/1ML/27G X 1/2" MISC F QL(5 ea daily);
RX/OTC BD INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC F QL(5 ea daily);
RX/OTC BD INTEGRA INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
BD INTEGRA SYRINGE/RETRACTINGNEEDLE/1ML/25G X 1"MISC
F
QL(5 ea daily)
BD PEN NEEDLE/MINI/ULTRAFINE/31G X 3/16" MISC
F QL(5 ea daily);RX/OTC
BD PEN NEEDLE/NANO/ULTRAFINE/32G X 4MM MISC
F QL(5 ea daily);RX/OTC
BD PEN NEEDLE/SHORT/ULTRAFINE/31G X 5/16" MISC
F QL(5 ea daily);RX/OTC
BD PEN NEEDLE/ULTRAFINE/29GX 12.7MM MISC
F QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
BD PEN NEEDLE/ULTRAFINE/29GX1/2" 12.7MM MISC
F QL(5 ea daily)
BD PEN NEEDLES SHORT/ULTRAFINE/31GX 5/16" MISC
F QL(5 ea daily);RX/OTC
BD SAFETY-GLIDE INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
BD SAFETY-LOK INSULIN SYRINGE/PERMNEEDLE/UF/1ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
BD SAFETYGLIDE INSULIN SYSYRINGE/0.5ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
BD ULTRA-FINE MICRO PEN NEEDLES 6MM X 32G MISC
F QL(5 ea daily)
CAREFINE PEN NEEDLE 32GX4MM MISC F QL(5 ea daily);
RX/OTC CAREFINE PEN NEEDLES 29GX1/2" MISC F QL(5 ea daily);
RX/OTC CAREFINE PEN NEEDLES 30GX5/16"MISC
F QL(5 ea daily);RX/OTC
CAREFINE PEN NEEDLES 31GX6MM MISC
F QL(5 ea daily)
CAREFINE PEN NEEDLES 31GX8MM MISC
F QL(5 ea daily);RX/OTC
CAREFINE PEN NEEDLES 32GX5MM MISC
F QL(5 ea daily);RX/OTC
CAREFINE PEN NEEDLES 32GX6MM MISC
F QL(5 ea daily)
CAREONE INSULIN SYRINGES/0.3ML/30G X1/2" MISC
F QL(5 ea daily)
CAREONE INSULIN SYRINGES/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
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Drug Name DrugTier
Requirements/Limits
CAREONE INSULIN SYRINGES/0.5ML/30G X1/2" MISC
F QL(5 ea daily)
CAREONE INSULIN SYRINGES/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
CAREONE INSULIN SYRINGES/1ML/30G X1/2" MISC
F QL(5 ea daily)
CAREONE INSULIN SYRINGES/1ML/31GX5/16" MISC
F QL(5 ea daily)
CAREONE UNIFINE PENTIPS 29GX12MM MISC
F QL(5 ea daily);RX/OTC
CAREONE UNIFINE PENTIPS 31GX5MM MISC F QL(5 ea daily);
RX/OTC CAREONE UNIFINE PENTIPS 31GX6MM MISC F QL(5 ea daily)
CAREONE UNIFINE PENTIPS 31GX8MM MISC F QL(5 ea daily);
RX/OTC CAREONE UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC
F QL(5 ea daily);RX/OTC
CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 29GX12MM MISC
F
QL(5 ea daily);RX/OTC
CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX5MM MISC
F
QL(5 ea daily);RX/OTC
CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX6MM MISC
F
QL(5 ea daily)
CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX8MM MISC
F
QL(5 ea daily);RX/OTC
CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 32GX4MM MISC
F
QL(5 ea daily);RX/OTC
CARETOUCH PEN NEEDLES 31G X 6 MM MISC
F QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
CARETOUCH PEN NEEDLES 31GX 5MM MISC
F QL(5 ea daily);RX/OTC
CARETOUCH PEN NEEDLES 31GX 8MM MISC
F QL(5 ea daily);RX/OTC
CARETOUCH PEN NEEDLES 32GX 4MM MISC
F QL(5 ea daily);RX/OTC
CARETOUCH PEN NEEDLES 32GX 5MM MISC
F QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES 31GX8MM MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/30G X1/2" MISC
F
QL(5 ea daily)
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/31G X5/16" MISC
F
QL(5 ea daily)
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/28G X1/2" MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/30G X1/2" MISC
F
QL(5 ea daily)
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
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Drug Name DrugTier
Requirements/Limits
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/31G X5/16" MISC
F
QL(5 ea daily)
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1.0ML/30G X1/2" MISC
F
QL(5 ea daily)
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZINSULIN SYRINGE/U-100/1ML/31GX5/16" MISC
F
QL(5 ea daily)
CLEVER CHOICE COMFORT EZPEN NEEDLES 29GX12MM MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZPEN NEEDLES 31GX5MM MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZPEN NEEDLES 31GX6MM MISC
F
QL(5 ea daily)
CLEVER CHOICE COMFORT EZPEN NEEDLES 31GX8MM MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZPEN NEEDLES 32GX4MM MISC
F
QL(5 ea daily);RX/OTC
CLEVER CHOICE COMFORT EZPEN NEEDLES 32GX5MM MISC
F
QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
CLEVER CHOICE COMFORT EZPEN NEEDLES 32GX6MM MISC
F
QL(5 ea daily)
CLICKFINE PEN NEEDLE 32GX5/32" MISC F QL(5 ea daily);
RX/OTC CLICKFINE PEN NEEDLE UNIVERSAL/31GX1/4"MISC
F QL(5 ea daily)
CLICKFINE PEN NEEDLE UNIVERSAL/31GX5/16"MISC
F QL(5 ea daily);RX/OTC
CLICKFINE PEN NEEDLES/31GX1/4" MISC F QL(5 ea daily)
CLICKFINE PEN NEEDLES/31GX5/16"MISC
F QL(5 ea daily);RX/OTC
CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16"MISC
F QL(5 ea daily);RX/OTC
COMFORT ASSIST INSULIN SYRINGE 0.3ML/29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
COMFORT ASSIST INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
COMFORT ASSIST INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F
QL(5 ea daily)
COMFORT ASSIST INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
COMFORT ASSIST INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
COMFORT ASSIST INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F
QL(5 ea daily)
COMFORT ASSIST INSULIN SYRINGE/1ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
126
Drug Name DrugTier
Requirements/Limits
COMFORT ASSIST INSULIN SYRINGE/1ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
COMFORT ASSIST INSULIN SYRINGE/1ML/31G X5/16" MISC
F
QL(5 ea daily)
DROPLET PEN NEEDLES 29GX12MM MISC F QL(5 ea daily);
RX/OTC DROPLET PEN NEEDLES 31GX5MM MISC F QL(5 ea daily);
RX/OTC DROPLET PEN NEEDLES 31GX6MM MISC F QL(5 ea daily)
DROPLET PEN NEEDLES 31GX8MM MISC F QL(5 ea daily);
RX/OTC DROPLET PEN NEEDLES 32GX4MM MISC F QL(5 ea daily);
RX/OTC DROPLET PEN NEEDLES 32GX5MM MISC F QL(5 ea daily);
RX/OTC DROPLET PEN NEEDLES 32GX6MM MISC F QL(5 ea daily)
DRUG MART UNIFINE PENTIPS 31GX5MM MISC F QL(5 ea daily);
RX/OTC DRUG MART UNIFINE PENTIPS29G X 12MM MISC
F QL(5 ea daily);RX/OTC
DRUG MART UNIFINE PENTIPS31GX6MM MISC F QL(5 ea daily)
DRUG MART UNIFINE PENTIPS31GX8MM MISC F QL(5 ea daily);
RX/OTC DRUG MART UNIFINE PENTIPS32GX4MM MISC F QL(5 ea daily);
RX/OTC DRUG MART UNIFINE PENTIPSPLUS 32GX4MM MISC
F QL(5 ea daily);RX/OTC
DUANE READE UNIFINE PENTIPS 29G X 12MM MISC
F QL(5 ea daily);RX/OTC
DUANE READE UNIFINE PENTIPS 31G X 6MM ULTRA SHORT MISC
F QL(5 ea daily)
DUANE READE UNIFINE PENTIPS 31G X 8MM SHORT MISC
F QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
EASY COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
EASY COMFORT INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
EASY COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
EASY COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
EASY COMFORT INSULIN SYRINGE/1ML/31G X5/16" MISC
F QL(5 ea daily)
EASY COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC
F
QL(5 ea daily)
EASY COMFORT INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC
F QL(5 ea daily)
EASY COMFORT PEN NEEDLES31GX1/4" MISC F QL(5 ea daily)
EASY COMFORT PEN NEEDLES31GX3/16" MISC F QL(5 ea daily);
RX/OTC EASY COMFORT PEN NEEDLES31GX5/16" MISC F QL(5 ea daily);
RX/OTC EASY COMFORT PEN NEEDLES32GX5/32" MISC F QL(5 ea daily);
RX/OTC EASY TOUCH 32GX5MM MISC F QL(5 ea daily);
RX/OTC EASY TOUCH 32GX6MM MISC F QL(5 ea daily)
EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2"MISC
F
QL(5 ea daily);RX/OTC
EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/30GX1/2"MISC
F
QL(5 ea daily)
EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/30GX5/16"MISC
F
QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
127
Drug Name DrugTier
Requirements/Limits
EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/31GX5/16"MISC
F
QL(5 ea daily)
EASY TOUCH INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
EASY TOUCH INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/30G X 1/2" MISC
F QL(5 ea daily)
EASY TOUCH INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC
F
QL(5 ea daily)
EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/27G X 1/2"MISC
F
QL(5 ea daily)
EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC
F
QL(5 ea daily)
EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
EASY TOUCH INSULIN SYRINGE/U-100/1ML/27GX 1/2" MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC
F QL(5 ea daily)
EASY TOUCH INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC
F QL(5 ea daily)
EASY TOUCH PEN NEEDLE 30G X 5/16"MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH PEN NEEDLES 29GX1/2" MISC F QL(5 ea daily);
RX/OTC EASY TOUCH PEN NEEDLES 31GX1/4" MISC F QL(5 ea daily)
EASY TOUCH PEN NEEDLES 31GX5/16"MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH PEN NEEDLES 32GX1/4" MISC F QL(5 ea daily)
EASY TOUCH PEN NEEDLES 32GX3/16"MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH PEN NEEDLES 32GX5/32"MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH PEN NEEDLES/31G X 3/16"MISC
F QL(5 ea daily);RX/OTC
EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2" MISC
F
QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
128
Drug Name DrugTier
Requirements/Limits
EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/30GX5/16" MISC
F
QL(5 ea daily);RX/OTC
EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/31GX5/16" MISC
F
QL(5 ea daily)
EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML/30GX1/2"MISC
F
QL(5 ea daily)
ELITE-THIN INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
ELITE-THIN INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
ELITE-THIN INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
ELITE-THIN INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
ELITE-THIN INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC
F QL(5 ea daily);RX/OTC
ELITE-THIN INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
ELITE-THIN INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC
F QL(5 ea daily)
EQL INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
EQL INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
EQL INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
EQL INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
EQL INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
EQL INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
EQL INSULIN SYRINGE/1ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
EQL INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
EQL INSULIN SYRINGE/1ML/31G X5/16" MISC
F QL(5 ea daily)
EQL INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
EQL INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
EQL INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
EQL SHORT PEN NEEDLES 31G X 8MM MISC
F QL(5 ea daily);RX/OTC
EQL ULTRA COMFORT INSULINSYRINGE/0.3ML/31G X 5/16" MISC
F QL(5 ea daily)
EQL ULTRA COMFORT INSULINSYRINGE/1ML/30G X 5/16" MISC
F QL(5 ea daily);RX/OTC
EQL ULTRA SHORT PEN NEEDLES 31G X 6MM MISC
F QL(5 ea daily)
EXEL COMFORT POINT INSULIN PEN NEEDLES 29G X 12MM MISC
F QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
129
Drug Name DrugTier
Requirements/Limits
EXEL COMFORT POINT INSULIN PEN NEEDLES 31G X 6MM MISC
F QL(5 ea daily)
EXEL COMFORT POINT INSULIN PEN NEEDLES 31G X 8MM MISC
F QL(5 ea daily);RX/OTC
EXEL COMFORT POINT INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
EXEL COMFORT POINT INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
EXEL COMFORT POINT INSULIN SYRINGE/0.5ML/28G X1/2" MISC
F
QL(5 ea daily);RX/OTC
EXEL COMFORT POINT INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
EXEL COMFORT POINT INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
EXEL COMFORT POINT INSULIN SYRINGE/1ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
EXEL COMFORT POINT INSULIN SYRINGE/1ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
EXEL COMFORT POINT INSULIN SYRINGE/1ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
FIFTY50 PEN NEEDLES 31G X3/16" (5MM) MISC F QL(5 ea daily);
RX/OTC FIFTY50 PEN NEEDLES 31G X5/16" (8MM) MISC F QL(5 ea daily);
RX/OTC FIFTY50 PEN NEEDLES 31GX5MM MISC F QL(5 ea daily);
RX/OTC FIFTY50 PEN NEEDLES/31GX8MMMISC
F QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
FIFTY50 PEN NEEDLES/32GX4MMMISC
F QL(5 ea daily);RX/OTC
FIFTY50 PEN NEEDLES/32GX6MMMISC
F QL(5 ea daily)
FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.3ML/31G X5/16" MISC
F
QL(5 ea daily)
FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.5ML/31G X5/16" MISC
F
QL(5 ea daily)
FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/1ML/31G X5/16" MISC
F
QL(5 ea daily)
FREDS PHARMACY UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC
F
QL(5 ea daily);RX/OTC
FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX5MM MISC
F QL(5 ea daily);RX/OTC
FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX8MM MISC
F QL(5 ea daily);RX/OTC
FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
FREESTYLE PRECISION INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC
F
QL(5 ea daily)
FREESTYLE PRECISION INSULIN SYRINGES/U-100/1ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
GLOBAL EASE INJECT PEN NEEDLES 29GX12MM MISC
F QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
130
Drug Name DrugTier
Requirements/Limits
GLOBAL EASE INJECT PEN NEEDLES 31GX8MM MISC
F QL(5 ea daily);RX/OTC
GLOBAL EASE INJECT PEN NEEDLES 32GX4MM MISC
F QL(5 ea daily);RX/OTC
GLOBAL EASE INJECT PEN NEEEDLES 31GX5MM MISC
F QL(5 ea daily);RX/OTC
GLOBAL EASY GLIDE INSULINSYRINGE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
GLOBAL EASY GLIDE PEN NEEDLES 32GX4MM MISC
F QL(5 ea daily);RX/OTC
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC
F
QL(5 ea daily)
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC
F
QL(5 ea daily)
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC
F QL(5 ea daily);RX/OTC
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC
F QL(5 ea daily)
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC
F
QL(5 ea daily)
GLOBAL INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC
F
QL(5 ea daily)
GLOBAL INSULIN SYRINGES/U-100/0.3ML/30GX5/16"MISC
F
QL(5 ea daily);RX/OTC
GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC
F
QL(5 ea daily)
GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC
F
QL(5 ea daily)
Nebraska Total Care Updated December 1, 2017
131
Drug Name DrugTier
Requirements/Limits
GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
GLUCOPRO INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC
F QL(5 ea daily)
GLUCOPRO INSULIN SYRINGE/U-100/1ML/30GX 5/16" MISC
F QL(5 ea daily);RX/OTC
GLUCOPRO INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC
F QL(5 ea daily)
GNP CLICKFINE PEN NEEDLEUNIVERSAL/31GX5/16" MISC
F QL(5 ea daily);RX/OTC
GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX1/4" MISC
F QL(5 ea daily)
GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16"MISC
F
QL(5 ea daily);RX/OTC
GNP INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
GNP INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
GNP INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
GNP INSULIN SYRINGE/0.5ML/28G X1/2" MISC
F QL(5 ea daily);RX/OTC
GNP INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
GNP INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
GNP INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
GNP INSULIN SYRINGE/1ML/28G X 1/2"MISC
F QL(5 ea daily);RX/OTC
GNP INSULIN SYRINGE/1ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
GNP INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
GNP INSULIN SYRINGE/1ML/31G X5/16" MISC
F QL(5 ea daily)
GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" SHORT MISC
F
QL(5 ea daily);RX/OTC
GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X5/16" SHORT MISC
F
QL(5 ea daily)
GNP ULTRA COMFORT INSULIN SYRINGE/0.5ML/28G X1/2" MISC
F
QL(5 ea daily);RX/OTC
GNP ULTRA COMFORT INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
GNP ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X5/16" SHORT MISC
F
QL(5 ea daily);RX/OTC
GNP ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" SHORT MISC
F
QL(5 ea daily)
GNP ULTRA COMFORT INSULIN SYRINGE/1ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
GNP ULTRA COMFORT INSULIN SYRINGE/1ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
132
Drug Name DrugTier
Requirements/Limits
GNP ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" SHORT MISC
F
QL(5 ea daily);RX/OTC
GNP ULTRA COMFORT INSULIN SYRINGE/1ML/31G X5/16" SHORT MISC
F
QL(5 ea daily)
H-E-B IN CONTROL PEN NEEDLES 31GX5MM MISC
F QL(5 ea daily);RX/OTC
H-E-B IN CONTROL PEN NEEDLES 31GX6MM MISC
F QL(5 ea daily)
H-E-B IN CONTROL PEN NEEDLES 31GX8MM MISC
F QL(5 ea daily);RX/OTC
H-E-B IN CONTROL PEN NEEDLES/NANO/32GX4MM MISC
F QL(5 ea daily);RX/OTC
H-E-B IN CONTROL UNIFINEPENTIPS PLUS 31GX5MM MISC
F QL(5 ea daily);RX/OTC
H-E-B IN CONTROL UNIFINEPENTIPS PLUS 32GX4MM MISC
F QL(5 ea daily);RX/OTC
H-E-B INCONTROL PEN NEEDLES 29GX12MM MISC
F QL(5 ea daily);RX/OTC
HEALTHWISE MINI PEN NEEDLES 31GX6MM MISC
F QL(5 ea daily)
HEALTHWISE PEN NEEDLES 29GX12MM MISC
F QL(5 ea daily);RX/OTC
HEALTHWISE SHORT PEN NEEDLES 31GX8MM MISC
F QL(5 ea daily);RX/OTC
HEALTHWISE UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC
F QL(5 ea daily);RX/OTC
HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 29GX12MM MISC
F
QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 31GX5MM MISC
F
QL(5 ea daily);RX/OTC
HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 31GX6MM MISC
F
QL(5 ea daily)
HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 31GX8MM MISC
F
QL(5 ea daily);RX/OTC
HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC
F
QL(5 ea daily);RX/OTC
INSULIN SYRINGE/0.3ML/29G X 1"MISC
F QL(5 ea daily)
INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
INSULIN SYRINGE/0.5ML/27G X1/2" MISC
F QL(5 ea daily)
INSULIN SYRINGE/0.5ML/28G X1/2" MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/0.5ML/30G X1/2" MISC
F QL(5 ea daily)
INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
Nebraska Total Care Updated December 1, 2017
133
Drug Name DrugTier
Requirements/Limits
INSULIN SYRINGE/1ML/28G X 1/2"MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/1ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/1ML/31G X5/16" MISC
F QL(5 ea daily)
INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC F QL(5 ea daily);
RX/OTC INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC F QL(5 ea daily);
RX/OTC INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC
F QL(5 ea daily)
INSULIN SYRINGES/0.5ML/27GX1/2" MISC
F QL(5 ea daily)
INSULIN SYRINGES/0.5ML/28GX1/2" MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGES/0.5ML/29GX1/2" MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGES/0.5ML/30GX5/16" MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGES/0.5ML/31GX5/16" MISC
F QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
INSULIN SYRINGES/0.5ML/31GX5/16" MISC
F QL(5 ea daily)
INSULIN SYRINGES/1ML/27GX/1/2"MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGES/1ML/27GX1/2"MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGES/1ML/28GX1/2"MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGES/1ML/29GX1/2"MISC
F QL(5 ea daily);RX/OTC
INSULIN SYRINGES/1ML/30GX1/2"MISC
F QL(5 ea daily)
INSULIN SYRINGES/1ML/31GX5/16" MISC
F QL(5 ea daily)
INSUPEN 29G X 12MM MISC F QL(5 ea daily);
RX/OTC INSUPEN 31G X 5MM MISC F QL(5 ea daily);
RX/OTC INSUPEN 31G X 8MM MISC F QL(5 ea daily);
RX/OTC INSUPEN 32G X 4MM MISC F QL(5 ea daily);
RX/OTC INSUPEN PEN NEEDLES 32G X4MM MISC F QL(5 ea daily);
RX/OTC INSUPEN SENSITIVE 32GX6MM MISC F QL(5 ea daily)
INSUPEN ULTRAFIN 29GX12MM MISC F QL(5 ea daily);
RX/OTC INSUPEN ULTRAFIN 30GX8MM MISC F QL(5 ea daily);
RX/OTC INSUPEN ULTRAFIN 31GX6MM MISC F QL(5 ea daily)
INSUPEN ULTRAFIN 31GX8MM MISC F QL(5 ea daily);
RX/OTC KINRAY INSULIN SYRINGE PREFERRED PLUS/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
Nebraska Total Care Updated December 1, 2017
134
Drug Name DrugTier
Requirements/Limits
KINRAY INSULIN SYRINGE PREFERRED PLUS/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
KINRAY INSULIN SYRINGE PREFERRED PLUS/1ML/31G X 5/16"MISC
F
QL(5 ea daily)
KINRAY INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
KMART VALU PLUS INSULIN SYRINGE/1ML/29G MISC
F QL(5 ea daily);RX/OTC
KMART VALU PLUS INSULIN SYRINGE/1ML/30G MISC
F QL(5 ea daily);RX/OTC
KROGER INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
KROGER INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
KROGER INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
KROGER INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
KROGER INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
KROGER INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
KROGER INSULIN SYRINGE/1ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
KROGER INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
KROGER INSULIN SYRINGE/1ML/31G X5/16" MISC
F QL(5 ea daily)
KROGER PEN NEEDLES 29G X12MM MISC F QL(5 ea daily);
RX/OTC KROGER PEN NEEDLES 31G X8MM MISC F QL(5 ea daily);
RX/OTC
Drug Name DrugTier
Requirements/Limits
KROGER PEN NEEDLES 31GX1/4" MISC F QL(5 ea daily)
LEADER INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
LEADER INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
LEADER INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
LEADER INSULIN SYRINGE/0.5ML/28G X1/2" MISC
F QL(5 ea daily);RX/OTC
LEADER INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
LEADER INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
LEADER INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
LEADER INSULIN SYRINGE/1ML/28G X 1/2"MISC
F QL(5 ea daily);RX/OTC
LEADER INSULIN SYRINGE/1ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
LEADER INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
LEADER INSULIN SYRINGE/1ML/31G X5/16" MISC
F QL(5 ea daily)
LEADER UNIFINE PENTIPS PLUS/MINI/31GX3/16"MISC
F
QL(5 ea daily);RX/OTC
LEADER UNIFINE PENTIPS PLUS/SHORT/31GX5/16"MISC
F
QL(5 ea daily);RX/OTC
LEADER UNIFINE PENTIPS/MINI/31GX3/16"MISC
F QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
135
Drug Name DrugTier
Requirements/Limits
LEADER UNIFINE PENTIPS/NANO/32GX5/32" MISC
F QL(5 ea daily);RX/OTC
LEADER UNIFINE PENTIPS/PLUS/32GX5/32" MISC
F QL(5 ea daily);RX/OTC
LITE TOUCH PEN NEEDLES/31G X 3/16"MISC
F QL(5 ea daily);RX/OTC
LITETOUCH INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
LITETOUCH INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
LITETOUCH INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
LITETOUCH INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
LITETOUCH INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
LITETOUCH INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
LITETOUCH INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
LITETOUCH INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
LITETOUCH INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC
F QL(5 ea daily);RX/OTC
LITETOUCH INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
LITETOUCH INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC
F QL(5 ea daily)
LITETOUCH PEN NEEDLES 29GX12.7MM MISC
F QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
LITETOUCH PEN NEEDLES 31G X 6MM MISC
F QL(5 ea daily)
LITETOUCH PEN NEEDLES 31GX8MM SHORT MISC
F QL(5 ea daily);RX/OTC
LIVE BETTER PEN NEEDLES 29G X 12MM MISC
F QL(5 ea daily);RX/OTC
LIVE BETTER PEN NEEDLES 31G X 12MM MISC
F QL(5 ea daily);RX/OTC
LIVE BETTER PEN NEEDLES 31G X 6MM MISC
F QL(5 ea daily)
LONGS INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
MARATHON MEDICAL PENTIPS29GX12MM MISC
F QL(5 ea daily);RX/OTC
MARATHON MEDICAL PENTIPS31GX5MM MISC F QL(5 ea daily);
RX/OTC MARATHON MEDICAL PENTIPS31GX8MM MISC F QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated December 1, 2017
136
Drug Name DrugTier
Requirements/Limits
MARATHON MEDICAL PENTIPS32GX4MM MISC F QL(5 ea daily);
RX/OTC MAXI-COMFORT INSULIN SYRINGE/U-100/0.5ML/28GX1/2" MISC
F QL(5 ea daily);RX/OTC
MAXI-COMFORT INSULIN SYRINGE/U-100/1ML/28GX1/2" MISC
F QL(5 ea daily);RX/OTC
MEDIC INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
MEDIC INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
MEDICINE SHOPPE PEN NEEDLES 29G X 12MM MISC
F QL(5 ea daily);RX/OTC
MEDICINE SHOPPE PEN NEEDLES 31G X 6MM MISC
F QL(5 ea daily)
MEDICINE SHOPPE PEN NEEDLES 31G X 8MM MISC
F QL(5 ea daily);RX/OTC
MEIJER PEN NEEDLES 29G X12MM MISC F QL(5 ea daily);
RX/OTC MEIJER PEN NEEDLES 31G X6MM MISC F QL(5 ea daily)
MEIJER PEN NEEDLES 31G X8MM MISC F QL(5 ea daily);
RX/OTC MM PEN NEEDLES 31G X 1/4" MISC F QL(5 ea daily)
MM PEN NEEDLES 31G X 3/16" MISC F QL(5 ea daily);
RX/OTC MM PEN NEEDLES 31G X 5/16" MISC F QL(5 ea daily);
RX/OTC MM PEN NEEDLES 32G X 5/32" MISC F QL(5 ea daily);
RX/OTC MONOJECT INSULIN SYRINGE/1ML MISC F QL(5 ea daily);
RX/OTC MONOJECT INSULIN SYRINGE/1ML/31G X5/16" MISC
F QL(5 ea daily)
MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/25G X 5/8"MISC
F
QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/27G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/PERMNEEDLE/1ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/PERMNEEDLE/U-100/0.5ML/28GX 1/2" MISC
F
QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29GX1/2"MISC
F
QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/SOFTPACK/1ML/27G X 1/2" MISC
F QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/SOFTPACK/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
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Drug Name DrugTier
Requirements/Limits
MONOJECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC
F QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGE/U-100/1ML/30GX 5/16" MISC
F QL(5 ea daily);RX/OTC
MONOJECT INSULIN SYRINGEREGULAR LUER TIP/SOFTPACK/1ML MISC
F QL(5 ea daily);RX/OTC
MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F
QL(5 ea daily)
MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/28G X1/2" MISC
F
QL(5 ea daily);RX/OTC
MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F
QL(5 ea daily)
MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
MOORE MED MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MOORE MED MONOJECT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
MOORE MED MONOJECT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC
F QL(5 ea daily);RX/OTC
MOORE MED MONOJECT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
MS INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F QL(5 ea daily)
MS INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F QL(5 ea daily)
MS INSULIN SYRINGE/1ML/31G X5/16" MISC
F QL(5 ea daily)
NOVOFINE 30GX8MM MISC F QL(5 ea daily);
RX/OTC NOVOFINE 32GX6MM MISC F QL(5 ea daily)
NOVOFINE AUTOCOVER 30GX8MM MISC F QL(5 ea daily);
RX/OTC NOVOFINE PLUS 32GX4MM MISC F QL(5 ea daily);
RX/OTC NOVOTWIST 30GX8MM MISC F QL(5 ea daily);
RX/OTC NOVOTWIST 32GX5MM MISC F QL(5 ea daily);
RX/OTC PC UNIFINE PENTIPS 29G X1/2" MISC F QL(5 ea daily);
RX/OTC PC UNIFINE PENTIPS 31G X5MM MINI MISC F QL(5 ea daily);
RX/OTC PC UNIFINE PENTIPS 31G X6MM ULTRA SHORT MISC
F QL(5 ea daily)
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Drug Name DrugTier
Requirements/Limits
PC UNIFINE PENTIPS 31G X8MM SHORT MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 29G X 12MM MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 29GX1/2"MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 30GX5/16"MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 30GX8MM MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 31G X 1/4"SHORT MISC F QL(5 ea daily)
PEN NEEDLES 31G X 3/16" MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 31G X 5MM MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 31G X 6MM MISC F QL(5 ea daily)
PEN NEEDLES 31G X 8MM MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 31GX5/16"MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 31GX6MM (1/4") MISC F QL(5 ea daily)
PEN NEEDLES 31GX8MM (5/16") MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 31GX8MM MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 32G X 4MM MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 32G X 5MM MISC F QL(5 ea daily);
RX/OTC PEN NEEDLES 32G X 6MM MISC F QL(5 ea daily)
PEN NEEDLES 32GX4MM MISC F QL(5 ea daily);
RX/OTC PENTIPS 29G X 12MM MISC F QL(5 ea daily);
RX/OTC PENTIPS 29GX12MM MISC F QL(5 ea daily);
RX/OTC PENTIPS 31G X 5MM MISC F QL(5 ea daily);
RX/OTC PENTIPS 31G X 8MM MISC F QL(5 ea daily);
RX/OTC
PENTIPS 31GX5MM MISC F QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
PENTIPS 31GX6MM MISC F QL(5 ea daily)
PENTIPS 31GX8MM MISC F QL(5 ea daily);RX/OTC
PENTIPS 32G X 4MM MISC F QL(5 ea daily);
RX/OTC
PENTIPS 32GX4MM MISC F QL(5 ea daily);RX/OTC
PRECISION SURE-DOSE INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/28G X1/2" MISC
F
QL(5 ea daily);RX/OTC
PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/30G X3/8" MISC
F
QL(5 ea daily)
PRECISION SURE-DOSE INSULIN SYRINGE/1ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
PRECISION SURE-DOSE PLUSINSULIN SYRINGE/0.3ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
PRECISION SURE-DOSE PLUSINSULIN SYRINGE/1ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
PREFERRED PLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
PREFERRED PLUS INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
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Drug Name DrugTier
Requirements/Limits
PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC
F QL(5 ea daily);RX/OTC
PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
PREFERRED PLUS UNIFINE PENTIPS 29G X 12MM MISC
F QL(5 ea daily);RX/OTC
PREFERRED PLUS UNIFINE PENTIPS 31G X 6MM ULTRA SHORT MISC
F
QL(5 ea daily)
PREFERRED PLUS UNIFINE PENTIPS 31G X 8MM SHORT MISC
F QL(5 ea daily);RX/OTC
PREFERRED PLUS UNIFINE PENTIPS 32GX4MM MISC
F QL(5 ea daily);RX/OTC
PREFERRED PLUS UNIFINE PENTIPS/MINI/31GX5MMMISC
F
QL(5 ea daily);RX/OTC
PRO COMFORT PEN NEEDLES/31G X 8MMMISC
F QL(5 ea daily);RX/OTC
PRO COMFORT PEN NEEDLES/32G X 4MMMISC
F QL(5 ea daily);RX/OTC
PRO COMFORT PEN NEEDLES/32G X 5MMMISC
F QL(5 ea daily);RX/OTC
PRO COMFORT PEN NEEDLES/32G X 6MMMISC
F QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
PRODIGY INSULIN SYRING/U-100/0.3ML/31GX 5/16" MISC
F QL(5 ea daily)
PRODIGY INSULIN SYRINGE/1/2ML/31G X5/16" MISC
F QL(5 ea daily)
PRODIGY INSULIN SYRINGE/1ML/28G X 1/2"MISC
F QL(5 ea daily);RX/OTC
PX EXTRA SHORT PEN NEEDLES 31GX6MM MISC
F QL(5 ea daily)
PX INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC
F QL(5 ea daily)
PX INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC
F QL(5 ea daily)
PX INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC
F QL(5 ea daily)
PX INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F QL(5 ea daily)
PX INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC F QL(5 ea daily)
PX INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC
F QL(5 ea daily)
PX MINI PEN NEEDLES 31GX5MM MISC F QL(5 ea daily);
RX/OTC PX PEN NEEDLE 29GX12MM MISC F QL(5 ea daily);
RX/OTC PX PEN NEEDLE 31GX8MM MISC F QL(5 ea daily);
RX/OTC PX SHORTLENGTH PEN NEEDLES/31GX8MMMISC
F QL(5 ea daily);RX/OTC
QC PEN NEEDLES 29G X 12MM MISC F QL(5 ea daily);
RX/OTC QC PEN NEEDLES 31G X 6MM MISC F QL(5 ea daily)
QC PEN NEEDLES 31G X 8MM MISC F QL(5 ea daily);
RX/OTC QC UNIFINE PENTIPS 32GX4MM MISC F QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated December 1, 2017
140
Drug Name DrugTier
Requirements/Limits
RA INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
RA INSULIN SYRINGE/1ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
RA INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F QL(5 ea daily);RX/OTC
RA INSULIN SYRINGE/U-100/1 ML/30G X 5/16"MISC
F QL(5 ea daily);RX/OTC
RA PEN NEEDLES 31G X 5MM3/16" MISC F QL(5 ea daily);
RX/OTC RA PEN NEEDLES 31G X 8MM5/16" MISC F QL(5 ea daily);
RX/OTC REALITY INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
REALITY INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
REALITY INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC
F QL(5 ea daily);RX/OTC
REALITY INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
RELION INSULIN SYRINGE 1ML/31GX15/64" MISC
F QL(5 ea daily)
RELION INSULIN SYRINGE/U-00/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
RELION INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
RELION INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
RELION INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
RELION INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
RELION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
RELION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
RELION INSULIN SYRINGE/U-100/1ML/30GX 5/16" MISC
F QL(5 ea daily);RX/OTC
RELION INSULIN SYRINGE/U-100/1ML/31GX 15/64" MISC
F QL(5 ea daily)
RELION INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC
F QL(5 ea daily)
RELION MINI PEN NEEDLES 31GX6MM MISC
F QL(5 ea daily)
RELION PEN NEEDLES 29GX12MM MISC F QL(5 ea daily);
RX/OTC RELION PEN NEEDLES 31GX6MM MISC F QL(5 ea daily)
RELION PEN NEEDLES 31GX8MM MISC F QL(5 ea daily);
RX/OTC RELION PEN NEEDLES 32GX4MM MISC F QL(5 ea daily);
RX/OTC RELION SHORT PEN NEEDLES31GX8MM MISC F QL(5 ea daily);
RX/OTC SAFESNAP INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
SAFESNAP INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
SAFESNAP INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
SAFESNAP INSULIN SYRINGE/1ML/28G X 1/2"MISC
F QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
141
Drug Name DrugTier
Requirements/Limits
SAFESNAP INSULIN SYRINGE/1ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
SAFETY INSULIN SYRINGES 0.5ML/29GX1/2" MISC
F QL(5 ea daily);RX/OTC
SAFETY INSULIN SYRINGES 0.5ML/30GX5/16" MISC
F QL(5 ea daily);RX/OTC
SAFETY INSULIN SYRINGES 1ML/27GX1/2"MISC
F QL(5 ea daily);RX/OTC
SAFETY INSULIN SYRINGES 1ML/29GX1/2"MISC
F QL(5 ea daily);RX/OTC
SAFETY INSULIN SYRINGES 1ML/30GX1/2"MISC
F QL(5 ea daily)
SAFETY-GLIDE INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
SB INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
SB INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F QL(5 ea daily);RX/OTC
SB INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC F QL(5 ea daily);
RX/OTC SB INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC
F QL(5 ea daily);RX/OTC
SB INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC
F QL(5 ea daily)
SCHNUCKS INSULIN SYRINGEULTI-FINE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
SCHNUCKS INSULIN SYRINGEULTI-FINE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
SHOPKO UNIFINE PENTIPS PEN NEEDLES/MICRO/32GX4MM MISC
F
QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
SHOPKO UNIFINE PENTIPS PEN NEEDLES/MINI/31GX5MMMISC
F
QL(5 ea daily);RX/OTC
SHOPKO UNIFINE PENTIPS PEN NEEDLES/ORIGINAL/29GX12MM MISC
F
QL(5 ea daily);RX/OTC
SHOPKO UNIFINE PENTIPS PEN NEEDLES/SHORT/31GX8MM MISC
F
QL(5 ea daily);RX/OTC
SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/MICRO/REMOVR/32GX4MM MISC
F
QL(5 ea daily);RX/OTC
SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/MINI/REMOVER/31GX5MM MISC
F
QL(5 ea daily);RX/OTC
SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/REMOVER/29GX12MM MISC
F
QL(5 ea daily);RX/OTC
SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/SHORT/REMOVR/31GX8MM MISC
F
QL(5 ea daily);RX/OTC
SM INSULIN SYRINGE/1ML/31G X5/16" MISC
F QL(5 ea daily)
SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC
F
QL(5 ea daily)
SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16MISC
F
QL(5 ea daily)
Nebraska Total Care Updated December 1, 2017
142
Drug Name DrugTier
Requirements/Limits
SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC
F
QL(5 ea daily)
SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X 5/16MISC
F
QL(5 ea daily)
SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC
F QL(5 ea daily);RX/OTC
SURE COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC
F QL(5 ea daily)
SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC
F
QL(5 ea daily)
SURE COMFORT PEN NEEDLES29GX1/2"12.7MM MISC
F QL(5 ea daily)
SURE COMFORT PEN NEEDLES30GX5/16"SHORT MISC
F QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
SURE COMFORT PEN NEEDLES31GX3/16"(5MM) MISC
F QL(5 ea daily);RX/OTC
SURE COMFORT PEN NEEDLES31GX5/16"(8MM) MISC
F QL(5 ea daily);RX/OTC
SURE COMFORT PEN NEEDLES32GX5/32" MISC F QL(5 ea daily);
RX/OTC SURE COMFORT PEN NEEDLES32GX6MM MISC F QL(5 ea daily)
SURE-FINE PEN NEEDLES 29GX1/2"12.7MM MISC
F QL(5 ea daily)
SURE-FINE PEN NEEDLES 31GX3/16" 5MMMISC
F QL(5 ea daily);RX/OTC
SURE-FINE PEN NEEDLES 31GX5/16" 8MMMISC
F QL(5 ea daily);RX/OTC
SURE-JECT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
SURE-JECT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
SURE-JECT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
SURE-JECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
SURE-JECT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
SURE-JECT INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
SURE-JECT INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
Nebraska Total Care Updated December 1, 2017
143
Drug Name DrugTier
Requirements/Limits
SURE-JECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC
F QL(5 ea daily);RX/OTC
SURE-JECT INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
SURE-JECT INSULIN SYRINGE/U-100/1ML/30GX 5/16" MISC
F QL(5 ea daily);RX/OTC
SURE-JECT INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC
F QL(5 ea daily)
TECHLITE PEN NEEDLES 29GX 12 MM MISC F QL(5 ea daily);
RX/OTC TECHLITE PEN NEEDLES 31GX 5MM MISC F QL(5 ea daily);
RX/OTC TECHLITE PEN NEEDLES/31GX 5MMMISC
F QL(5 ea daily);RX/OTC
TECHLITE PEN NEEDLES/31GX 6 MMMISC
F QL(5 ea daily)
TECHLITE PEN NEEDLES/31GX 8MMMISC
F QL(5 ea daily);RX/OTC
TECHLITE PEN NEEDLES/32GX 4MMMISC
F QL(5 ea daily);RX/OTC
TECHLITE PEN NEEDLES/32GX 6MMMISC
F QL(5 ea daily)
TODAYS HEALTH MINI PEN NEEDLES 31G X 1/4"MISC
F QL(5 ea daily)
TODAYS HEALTH ORIGINAL PEN NEEDLES 29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
TODAYS HEALTH SHORT PEN NEEDLES 31G X 5/16" MISC
F QL(5 ea daily);RX/OTC
TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX1/4" MISC
F QL(5 ea daily)
TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX5/16" MISC
F QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X5/16" MISC
F
QL(5 ea daily)
TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" MISC
F
QL(5 ea daily)
TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC
F
QL(5 ea daily);RX/OTC
TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/31G X5/16" MISC
F
QL(5 ea daily)
TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F
QL(5 ea daily);RX/OTC
TOPCO INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
TOPCO INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
144
Drug Name DrugTier
Requirements/Limits
TOPCO INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
TOPCO INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC
F QL(5 ea daily);RX/OTC
TOPCO INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
TRUEPLUS INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC
F QL(5 ea daily);RX/OTC
TRUEPLUS INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
TRUEPLUS INSULIN SYRINGE/U-100/1ML/30GX 5/16" MISC
F QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
TRUEPLUS INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC
F QL(5 ea daily)
TRUEPLUS PEN NEEDLES 29GX12MM MISC
F QL(5 ea daily);RX/OTC
TRUEPLUS PEN NEEDLES 31GX5MM MISC
F QL(5 ea daily);RX/OTC
TRUEPLUS PEN NEEDLES 31GX6MM MISC
F QL(5 ea daily)
TRUEPLUS PEN NEEDLES 31GX8MM MISC
F QL(5 ea daily);RX/OTC
TRUEPLUS PEN NEEDLES 32GX4MM MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X1/2" MISC
F
QL(5 ea daily);RX/OTC
ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/0.3ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/0.3ML/30G X1/2" MISC
F QL(5 ea daily)
ULTICARE INSULIN SYRINGE/0.3ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/0.5ML/28G X1/2" MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/0.5ML/29G X1/2" MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/0.5ML/30G X1/2" MISC
F QL(5 ea daily)
ULTICARE INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
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Drug Name DrugTier
Requirements/Limits
ULTICARE INSULIN SYRINGE/1ML/28G X 1/2"MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/1ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/1ML/30G X 1/2"MISC
F QL(5 ea daily)
ULTICARE INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/SHORT/0.3ML/30G X 5/16" MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/SHORT/0.3ML/31G X 5/16" MISC
F QL(5 ea daily)
ULTICARE INSULIN SYRINGE/SHORT/0.5ML/30G X 5/16" MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/SHORT/0.5ML/31G X 5/16" MISC
F QL(5 ea daily)
ULTICARE INSULIN SYRINGE/SHORT/1ML/30G X 5/16" MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/SHORT/1ML/31G X 5/16" MISC
F QL(5 ea daily)
ULTICARE INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC
F
QL(5 ea daily)
ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
ULTICARE INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC
F
QL(5 ea daily)
ULTICARE INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
ULTICARE INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC
F QL(5 ea daily)
ULTICARE INSULIN SYRINGE/U-100/1ML/30GX 5/16" MISC
F QL(5 ea daily);RX/OTC
ULTICARE INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC
F QL(5 ea daily)
ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
ULTICARE INSULIN SYRINGEULTRAFINE U-100/1ML/31G X 5/16"MISC
F
QL(5 ea daily)
ULTICARE MICRO PEN NEEDLES 31G X 8MM MISC
F QL(5 ea daily);RX/OTC
ULTICARE MICRO PEN NEEDLES 32G X 4MM MISC
F QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
146
Drug Name DrugTier
Requirements/Limits
ULTICARE MICRO PEN NEEDLES/32G X 4MMMISC
F QL(5 ea daily);RX/OTC
ULTICARE MINI PEN NEEDLES 31GX6MM MISC
F QL(5 ea daily)
ULTICARE MINI PEN NEEDLES ULTI-FINE IV MISC
F QL(5 ea daily)
ULTICARE MINI PEN NEEDLES/31G X 6MMMISC
F QL(5 ea daily)
ULTICARE MINI PEN NEEDLES31GX6MM MISC F QL(5 ea daily)
ULTICARE ORIGINAL PEN NEEDLES ULTI-FINE MISC
F QL(5 ea daily);RX/OTC
ULTICARE PEN NEEDLES 31GX 5MM/MINI MISC F QL(5 ea daily);
RX/OTC ULTICARE PEN NEEDLES/29GX 12.7MMMISC
F QL(5 ea daily)
ULTICARE SHORT PEN NEEDLES 31GX8MM MISC
F QL(5 ea daily);RX/OTC
ULTICARE SHORT PEN NEEDLES ULTI-FINE IV MISC
F QL(5 ea daily);RX/OTC
ULTICARE SHORT PEN NEEDLES/31G X 8MMMISC
F QL(5 ea daily);RX/OTC
ULTILET INSULIN SYRINGE/0.3ML/30G X8MM MISC
F QL(5 ea daily);RX/OTC
ULTILET INSULIN SYRINGE/0.3ML/31G X8MM MISC
F QL(5 ea daily)
ULTILET INSULIN SYRINGE/0.5ML/30G X8MM MISC
F QL(5 ea daily);RX/OTC
ULTILET INSULIN SYRINGE/1ML/30G X8MM MISC
F QL(5 ea daily);RX/OTC
ULTILET INSULIN SYRINGE/1ML/31G X8MM MISC
F QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X 12.7MM MISC
F QL(5 ea daily)
ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X 5/16" MISC
F QL(5 ea daily);RX/OTC
ULTILET INSULIN SYRINGE/SHORT/0.3ML/31G X 5/16" MISC
F QL(5 ea daily)
ULTILET INSULIN SYRINGE/SHORT/0.5ML/30G X 5/16" MISC
F QL(5 ea daily);RX/OTC
ULTILET INSULIN SYRINGE/SHORT/0.5ML/31G X 5/16" MISC
F QL(5 ea daily)
ULTILET INSULIN SYRINGE/SHORT/1ML/30G X 5/16" MISC
F QL(5 ea daily);RX/OTC
ULTILET INSULIN SYRINGE/SHORT/1ML/31G X 5/16" MISC
F QL(5 ea daily)
ULTILET INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC
F
QL(5 ea daily)
ULTILET INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC
F QL(5 ea daily)
ULTILET PEN NEEDLE 29GX12.7MM MISC F QL(5 ea daily)
ULTILET PEN NEEDLE 31GX5MM MISC F QL(5 ea daily);
RX/OTC ULTILET PEN NEEDLE 31GX8MM MISC F QL(5 ea daily);
RX/OTC ULTILET PEN NEEDLE 32GX4MM MISC F QL(5 ea daily);
RX/OTC ULTILET PEN NEEDLE 32GX4MM/SHORT MISC F QL(5 ea daily);
RX/OTC ULTILET SHORT PEN NEEDLES 31GX5/16"MISC
F QL(5 ea daily);RX/OTC
ULTILET SHORT PEN NEEDLES31GX3/16" MISC F QL(5 ea daily);
RX/OTC ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
Nebraska Total Care Updated December 1, 2017
147
Drug Name DrugTier
Requirements/Limits
ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC
F
QL(5 ea daily)
ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC
F
QL(5 ea daily)
ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC
F QL(5 ea daily);RX/OTC
ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC
F QL(5 ea daily);RX/OTC
ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC
F
QL(5 ea daily);RX/OTC
ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC
F
QL(5 ea daily)
ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.3ML/30GX5/16"MISC
F
QL(5 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.3ML/31GX5/16"MISC
F
QL(5 ea daily)
ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.5ML/30GX5/16"MISC
F
QL(5 ea daily);RX/OTC
ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.5ML/31GX5/16"MISC
F
QL(5 ea daily)
ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/30GX5/16" MISC
F QL(5 ea daily);RX/OTC
ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/31GX5/16" MISC
F QL(5 ea daily)
ULTRA-THIN II INSULIN SYRINGE/U-100/0.3ML/29GX1/2" MISC
F QL(5 ea daily);RX/OTC
ULTRA-THIN II INSULIN SYRINGE/U-100/0.5ML/29GX1/2" MISC
F QL(5 ea daily);RX/OTC
ULTRA-THIN II INSULIN SYRINGE/U-100/1ML/29GX1/2" MISC
F QL(5 ea daily);RX/OTC
ULTRA-THIN II MINI PEN NEEEDLES/31GX3/16"MISC
F QL(5 ea daily);RX/OTC
ULTRA-THIN II PEN NEEDLES 29GX1/2" MISC F QL(5 ea daily)
ULTRA-THIN II PEN NEEDLES/SHORT/31GX5/16" MISC
F QL(5 ea daily);RX/OTC
UNIFINE PENTIPS 29GX12MM MISC F QL(5 ea daily);
RX/OTC UNIFINE PENTIPS 31G X 3/16" MISC F QL(5 ea daily);
RX/OTC UNIFINE PENTIPS 31GX5MM MISC F QL(5 ea daily);
RX/OTC UNIFINE PENTIPS 31GX6MM MISC F QL(5 ea daily)
UNIFINE PENTIPS 31GX8MM MISC F QL(5 ea daily);
RX/OTC UNIFINE PENTIPS 32GX4MM MISC F QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated December 1, 2017
148
Drug Name DrugTier
Requirements/Limits
UNIFINE PENTIPS PLUS 29GX12MM MISC F QL(5 ea daily);
RX/OTC UNIFINE PENTIPS PLUS 31GX5MM MISC F QL(5 ea daily);
RX/OTC UNIFINE PENTIPS PLUS 31GX6MM MISC F QL(5 ea daily)
UNIFINE PENTIPS PLUS 31GX8MM MISC F QL(5 ea daily);
RX/OTC UNIFINE PENTIPS PLUS 32GX4MM MISC F QL(5 ea daily);
RX/OTC V-R MONOJECT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
V-R MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
V-R MONOJECT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
V-R MONOJECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC
F QL(5 ea daily);RX/OTC
V-R MONOJECT INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
VALUE HEALTH INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC
F
QL(5 ea daily);RX/OTC
VALUE HEALTH INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC
F QL(5 ea daily);RX/OTC
VALUMARK PEN NEEDLES 29GX12MM MISC
F QL(5 ea daily);RX/OTC
VALUMARK PEN NEEDLES 31GX 6MM MISC
F QL(5 ea daily)
VALUMARK PEN NEEDLES 31GX 8MM MISC
F QL(5 ea daily);RX/OTC
VANISHPOINT INSULIN SYRINGE/0.5ML/30G X1/2" MISC
F QL(5 ea daily)
Drug Name DrugTier
Requirements/Limits
VANISHPOINT INSULIN SYRINGE/0.5ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
VANISHPOINT INSULIN SYRINGE/1ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
VANISHPOINT INSULIN SYRINGE/1ML/30G X5/16" MISC
F QL(5 ea daily);RX/OTC
VIDA MIA UNIFINE PENTIPS32GX4MM MISC F QL(5 ea daily);
RX/OTC VIDA MIA UNIFINE PENTIPSMINI 31GX6MM MISC
F QL(5 ea daily)
VIDA MIA UNIFINE PENTIPSORIGINAL 29GX12MM MISC
F QL(5 ea daily);RX/OTC
VIDA MIA UNIPFINE PENTIPSSHORT 31GX8MM MISC
F QL(5 ea daily);RX/OTC
VP INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC
F QL(5 ea daily);RX/OTC
WEGMANS UNIFINE PENTIPS PLUS 32GX4MM MISC
F QL(5 ea daily);RX/OTC
WEGMANS UNIFINE PENTIPS PLUS/MINI/31GX5MMMISC
F
QL(5 ea daily);RX/OTC
WEGMANS UNIFINE PENTIPS PLUS/SHORT/31GX8MMMISC
F
QL(5 ea daily);RX/OTC
WEGMANS UNIFINE PENTIPS PLUS/ULTRASHORT/31GX6MM MISC
F QL(5 ea daily)
Respiratory Therapy Supplies
ACE AEROSOL CLOUD ENHANCER MISC F
QL(1 ea per350 daysretail); RX/OTC
ACTIVITY POUCH MISC F QL(1 ea per350 daysretail); RX/OTC
ADULT AEROSOL MASK MISC F
QL(1 ea per350 daysretail); RX/OTC
Nebraska Total Care Updated December 1, 2017
149
Drug Name DrugTier
Requirements/Limits
ADULT MASK LARGE MISC F
QL(1 ea per350 daysretail); RX/OTC
ADULT MASK MISC F QL(1 ea per350 daysretail); RX/OTC
AEROCHAMBER MINI AEROSOLCHAMBER DEVI
F QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER MV MISC F
QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER PLUS FLOW VU MISC F
QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER PLUS FLOW-VU MISC F
QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER PLUS FLOW-VU/LARGE MASKMISC
F QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER PLUS FLOW-VU/MASK MISC F
QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER PLUS FLOW-VU/MEDIUM MASKMISC
F QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER PLUS FLOW-VU/SMALL MASKMISC
F QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VUMISC
F
QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL MISC F
QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER Z-STAT PLUS/LARGE MASK MISC F
QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER Z-STAT PLUS/MEDIUM MASKMISC
F QL(2 ea per350 daysretail); RX/OTC
AEROCHAMBER Z-STAT PLUS/SMALL MASK MISC F
QL(2 ea per350 daysretail); RX/OTC
Drug Name DrugTier
Requirements/Limits
AEROCHAMBER/FLOWSIGNAL MISC F
QL(2 ea per350 daysretail); RX/OTC
AEROTRACH PLUS MISC F QL(1 ea per350 daysretail); RX/OTC
AEROVENT PLUS HOLDING CHAMBER/COLLAPSIBLEDEVI
F
QL(2 ea per350 daysretail); RX/OTC
AIRS PEDIATRIC AEROSOL MASK MISC F
QL(1 ea per350 daysretail); RX/OTC
ALL FLOW 1000 PULMONARY FUNCTION FILTER MISC
F QL(1 ea per350 daysretail); RX/OTC
ARIAL CHAMBER DEVI F QL(2 ea per350 daysretail); RX/OTC
BREATHERITE COLLAPSIBLEADULT SPACER W/MASK MISC
F QL(2 ea per350 daysretail); RX/OTC
BREATHERITE COLLAPSIBLECHILD SPACER W/MASK MISC
F QL(2 ea per350 daysretail); RX/OTC
BREATHERITE COLLAPSIBLEINFANT SPACER W/MASK MISC
F QL(2 ea per350 daysretail); RX/OTC
BREATHERITE COLLAPSIBLESMALL CHILD SPACER W/MASKMISC
F
QL(2 ea per350 daysretail); RX/OTC
BREATHERITE COLLAPSIBLESPACER W/ NEONATE MASK MISC
F QL(2 ea per350 daysretail); RX/OTC
BREATHERITE MISC F QL(2 ea per350 daysretail); RX/OTC
BREATHERITE RIGID SPACERW/MASK MISC F
QL(2 ea per350 daysretail); RX/OTC
BREATHERITE W/LARGEMASK MISC F
QL(2 ea per350 daysretail); RX/OTC
BREATHERITE W/MEDIUM MASK MISC F
QL(2 ea per350 daysretail); RX/OTC
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Drug Name DrugTier
Requirements/Limits
BREATHERITE W/SMALLMASK MISC F
QL(2 ea per350 daysretail); RX/OTC
BUBBLES THE FISH II PEDIATRIC MASK/PVCMISC
F QL(1 ea per350 daysretail); RX/OTC
CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/ADULT LARGEDEVI
F
QL(2 ea per350 daysretail); RX/OTC
CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM DEVI
F
QL(2 ea per350 daysretail); RX/OTC
CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/SMALL DEVI
F
QL(2 ea per350 daysretail); RX/OTC
CO MONITOR REPLACEMENT TPIECES MISC
F QL(1 ea per350 daysretail); RX/OTC
COMPACT SPACE CHAMBER/ANTI-STATICDEVI
F QL(2 ea per350 daysretail); RX/OTC
COMPACT SPACE CHAMBER/ANTI-STATIC/LARGE MASKDEVI
F
QL(2 ea per350 daysretail); RX/OTC
COMPACT SPACE CHAMBER/ANTI-STATIC/MEDIUM MASKDEVI
F
QL(2 ea per350 daysretail); RX/OTC
COMPACT SPACE CHAMBER/ANTI-STATIC/SMALL MASKDEVI
F
QL(2 ea per350 daysretail); RX/OTC
CONE MASK MISC F QL(1 ea per350 daysretail); RX/OTC
E-Z SPACER DEVI F QL(2 ea per350 daysretail); RX/OTC
E-Z SPACER THE BODY GUARDS PACK DEVI F
QL(2 ea per350 daysretail); RX/OTC
Drug Name DrugTier
Requirements/Limits
EARLOOP MASK MISC F QL(1 ea per350 daysretail); RX/OTC
EASIVENT MISC F QL(2 ea per350 daysretail); RX/OTC
EASIVENT/MASK-LARGEMISC F
QL(2 ea per350 daysretail); RX/OTC
EASIVENT/MASK-MEDIUM MISC F
QL(2 ea per350 daysretail); RX/OTC
EASIVENT/MASK-SMALLMISC F
QL(2 ea per350 daysretail); RX/OTC
EBASE CONTROLLER KIT MISC F
QL(1 ea per350 daysretail); RX/OTC
EFLOW SCF AEROSOL HEAD MISC F
QL(1 ea per350 daysretail); RX/OTC
ELITE DC AUTO ADAPTER MISC F
QL(1 ea per350 daysretail); RX/OTC
FILTER AIR PP MISC F QL(1 ea per350 daysretail); RX/OTC
FLEXICHAMBER DEVI F QL(2 ea per350 daysretail); RX/OTC
FULL KIT NEBULIZER SET MISC F
QL(1 ea per350 daysretail); RX/OTC
HEALTHY LIVING REPLACEMENT FILTERS MISC
F QL(1 ea per350 daysretail); RX/OTC
HEALTHY LIVING REPLACEMENT KIT FOR NEBULIZER MISC
F QL(1 ea per350 daysretail); RX/OTC
HEALTHY LIVING REPLACEMENT MASKS MISC
F QL(1 ea per350 daysretail); RX/OTC
HUDSON RCI SEE-THRU AEROSOL MASK ELONGATED/ADULTMISC
F
QL(1 ea per350 daysretail); RX/OTC
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Drug Name DrugTier
Requirements/Limits
INNOSPIRE REPLACEMENT FILTER MISC
F QL(1 ea per350 daysretail); RX/OTC
INSPIRACHAMBER/ANTI-STATIC VALVED/MOUTHPIECEDEVI
F
QL(2 ea per350 daysretail); RX/OTC
INSPIRACHAMBER/LARGE DEVI F
QL(2 ea per350 daysretail); RX/OTC
INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM DEVI
F QL(2 ea per350 daysretail); RX/OTC
INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL DEVI
F QL(2 ea per350 daysretail); RX/OTC
INSPIREASE DRUG DELIVERYSYSTEM MISC F
QL(2 ea per350 daysretail); RX/OTC
INSPIREASE RESERVOIR BAGS MISC F
LITEAIRE DEVI F QL(2 ea per350 daysretail); RX/OTC
LITETOUCH MASK LARGE MISC F
QL(1 ea per350 daysretail); RX/OTC
LITETOUCH MASK MEDIUM MISC F
QL(1 ea per350 daysretail); RX/OTC
LITETOUCH MASK SMALL MISC F
QL(1 ea per350 daysretail); RX/OTC
MICROCHAMBER MISC F QL(2 ea per350 daysretail); RX/OTC
MICROELITE FILTER REPLACEMENTS MISC F
QL(1 ea per350 daysretail); RX/OTC
MICROELITE RECHARGEABLE BATTERY MISC
F QL(1 ea per350 daysretail); RX/OTC
MICROSPACER MISC F QL(2 ea per350 daysretail); RX/OTC
MINIELITE FILTER REPLACEMENTS MISC F
QL(1 ea per350 daysretail); RX/OTC
Drug Name DrugTier
Requirements/Limits
MINIELITE RECHARGEABLE BATTERY MISC
F QL(1 ea per350 daysretail); RX/OTC
NEBULIZER AIR TUBE/PLUGS MISC F
QL(1 ea per350 daysretail); RX/OTC
NEBULIZER PEDIATRIC MASK MISC F
QL(1 ea per350 daysretail); RX/OTC
NOSE CLIP MISC F QL(1 ea per350 daysretail); RX/OTC
OPTICHAMBER ADVANTAGE MISC F
QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER ADVANTAGE/LARGEMASK MISC
F QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER ADVANTAGE/MEDIUMFACE MASK MISC
F QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER ADVANTAGE/SMALLFACE MASK MISC
F QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER DIAMOND DEVI F
QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER DIAMOND MISC F
QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER DIAMOND/LARGEFACEMASK DEVI
F QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER DIAMOND/MEDIUM FACEMASK MISC
F QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER DIAMOND/SMALLFACEMASK MISC
F QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER FACE MASK/LARGE MISC F
QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER FACE MASK/MEDIUM MISC F
QL(2 ea per350 daysretail); RX/OTC
OPTICHAMBER FACE MASK/SMALL MISC F
QL(2 ea per350 daysretail); RX/OTC
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Drug Name DrugTier
Requirements/Limits
OPTIHALER MDI DRUG DELIVERY SYSTEM DEVI F
QL(2 ea per350 daysretail); RX/OTC
OPTIHALER MISC F QL(2 ea per350 daysretail); RX/OTC
PARI ALTERA NEBULIZER HANDSET MISC
F QL(1 ea per350 daysretail); RX/OTC
PARI BABY CONVERSION KITSIZE 1 MISC F
QL(1 ea per350 daysretail); RX/OTC
PARI BABY CONVERSION KITSIZE 2 MISC F
QL(1 ea per350 daysretail); RX/OTC
PARI BABY CONVERSION KITSIZE 3 MISC F
QL(1 ea per350 daysretail); RX/OTC
PARI ERAPID NEBULIZER HANDSET MISC F
QL(1 ea per350 daysretail); RX/OTC
PARI EXPIRATORY FILTER VALVE SET DEVI F
QL(1 ea per350 daysretail); RX/OTC
PARI MASK SET MISC F QL(1 ea per350 daysretail); RX/OTC
PARI SOFT PLASTIC ADULT MASK MISC F
QL(1 ea per350 daysretail); RX/OTC
PARI SOFT PLASTIC PEDIATRIC MASK MISC F
QL(1 ea per350 daysretail); RX/OTC
PEDIATRIC AEROSOL MASK MISC F
QL(1 ea per350 daysretail); RX/OTC
PEDIATRIC MOUTHPIECE/DISPOSABLE MISC
F QL(1 ea per350 daysretail); RX/OTC
PFLEX MISC F QL(1 ea per350 daysretail); RX/OTC
PILLOW MASK/ADULTMISC F
QL(1 ea per350 daysretail); RX/OTC
PILLOW MASK/CHILDMISC F
QL(1 ea per350 daysretail); RX/OTC
Drug Name DrugTier
Requirements/Limits
PILLOW MASK/PEDIATRIC MISC F
QL(1 ea per350 daysretail); RX/OTC
POCKET CHAMBER DEVI F QL(2 ea per350 daysretail); RX/OTC
POCKET SPACER DEVI F QL(2 ea per350 daysretail); RX/OTC
REPLACEMENT AIR FILTER MISC F
QL(1 ea per350 daysretail); RX/OTC
REPLACEMENT FILTERS MISC F
QL(1 ea per350 daysretail); RX/OTC
RITEFLO DEVI F QL(2 ea per350 daysretail); RX/OTC
SAMI THE SEAL REPLACEMENTFILTERS MISC
F QL(1 ea per350 daysretail); RX/OTC
SIDESTREAM ADULT FACE MASK MISC F
QL(1 ea per350 daysretail); RX/OTC
SIDESTREAM PEDIATRIC FACEMASK MISC F
QL(1 ea per350 daysretail); RX/OTC
SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL MISC
F QL(1 ea per350 daysretail); RX/OTC
SIDESTREAM PEDIATRIC FACEMASK/TUCKER THETURTLE MISC
F QL(1 ea per350 daysretail); RX/OTC
SIDESTREAM PLUS ADULT FACE MASK MISC F
QL(1 ea per350 daysretail); RX/OTC
SILICONE MASK FOR BREATHERITE CHAMBER/ADULT MISC
F QL(1 ea per350 daysretail); RX/OTC
SILICONE MASK FOR BREATHERITE CHAMBER/INFANT MISC
F QL(1 ea per350 daysretail); RX/OTC
SILICONE MASK FOR BREATHERITE CHAMBER/PEDIATRICMISC
F
QL(1 ea per350 daysretail); RX/OTC
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Drug Name DrugTier
Requirements/Limits
SILICONE MASK FOR BREATHRITE CHAMBER/ADULT MISC
F QL(1 ea per350 daysretail); RX/OTC
SOOTHENEB NBL 100 CHILD MASK MISC F
QL(1 ea per350 daysretail); RX/OTC
SOOTHENEB NBL 100 MEDICATION CUP MISC F
QL(1 ea per350 daysretail); RX/OTC
SOOTHENEB NBL 100 MESH CAP MISC F
QL(1 ea per350 daysretail); RX/OTC
SOOTHENEB NBL100 ADULT MASK MISC F
QL(1 ea per350 daysretail); RX/OTC
THRESHOLD IMT MISC F QL(1 ea per350 daysretail); RX/OTC
TUBING/WING TIP MISC F QL(1 ea per350 daysretail); RX/OTC
VALVED HOLDING CHAMBER DEVI F
QL(2 ea per350 daysretail); RX/OTC
VORTEX VALVED HOLDING CHAMBER DEVI
F QL(2 ea per350 daysretail); RX/OTC
WATCHHALER DEVI F QL(2 ea per350 daysretail); RX/OTC
WINDMILL TRAINER MISC F
QL(1 ea per350 daysretail); RX/OTC
MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches Migraine Combinations CAFERGOT TABS (Ergotamine w/ Caffeine) NP
ergotamine w/ caffeine tabs NP
isometheptene-caffeine-acetaminophen tabs NP
isometheptene-dichloralphenazone-acetaminophen caps
NP
MIGERGOT SUPP NP
Drug Name DrugTier
Requirements/Limits
MIGRANOW THPK NP
PRODRIN TABS (Isometheptene-Caffeine-Acetaminophen)
NP
SUMATRIPTAN/NAPROXEN SODIM TABS NP QL(2 ea per 29days retail) TREXIMET TABS 85MG-500MG, 10MG-60MG NP QL(2 ea per 29days retail) Migraine Products - NSAIDs CAMBIA PACK NP
Migraine Products DIHYDROERGOTAMINE MESYLATE SOLN NA 4 MG/ML
NP
ERGOMAR SUBL NP
MIGRANAL SOLN NP
Serotonin Agonists
almotriptan malate tabs NP QL(0.62 eadaily)
AMERGE TABS (Naratriptan HCl) NP
Limit 18ea permonth;QL(0.6ea daily)
AXERT TABS (AlmotriptanMalate) NP QL(0.62 eadaily) eletriptan hydrobromidetabs NP QL(18 ea per29 days retail) FROVA TABS (FrovatriptanSuccinate) NP QL(0.62 eadaily)
frovatriptan succinate tabs NP QL(0.62 eadaily)
IMITREX SOLN NA 20 MG/ACT (Sumatriptan) NP
6 per monthQL(0.2 eadaily); AL; Atleast 12 yrs old
IMITREX SOLN NA 5 MG/ACT (Sumatriptan) NP
QL(0.2 eadaily); AL; Atleast 12 yrs old
IMITREX SOLN SC 6 MG/0.5ML (SumatriptanSuccinate)
NP Limit 18ml permonth;QL(0.6ml daily)
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Drug Name DrugTier
Requirements/Limits
IMITREX STATDOSE REFILL SOCT 4 MG/0.5ML(Sumatriptan Succinate)
NP QL(0.6 mldaily)
IMITREX STATDOSE REFILL SOCT 6 MG/0.5ML(Sumatriptan Succinate)
NP
Limit 18ml permonth;QL(18ml per 29 daysretail)
IMITREX STATDOSE SYSTEM SOAJ 4 MG/0.5ML (SumatriptanSuccinate)
NP
QL(0.3 mldaily); AL; Atleast 12 yrs old
IMITREX STATDOSE SYSTEM SOAJ 6 MG/0.5ML (SumatriptanSuccinate)
NP
Limit 18ml permonth
IMITREX TABS OR 50 MG, 25 MG, 100 MG (Sumatriptan Succinate)
NP Limit 18ea permonth;QL(0.6ea daily)
MAXALT TABS (RizatriptanBenzoate) NP
Limit 18ea permonth;QL(0.6ea daily)
MAXALT-MLT TBDP (Rizatriptan Benzoate) NP QL(0.6 eadaily)
naratriptan hcl tabs NP Limit 18ea permonth;QL(0.6ea daily)
ONZETRA XSAIL EXHP NP QL(0.62 eadaily) RELPAX TABS (EletriptanHydrobromide) F QL(18 ea per
29 days retail)
rizatriptan benzoate tabs10 mg, 5 mg F
Limit 18ea permonth;QL(0.6ea daily)
rizatriptan benzoate tbdp 5mg, 10 mg F QL(0.6 ea
daily)
sumatriptan soln 20 mg/act F
6 per monthQL(0.2 eadaily); AL; Atleast 12 yrs old
sumatriptan soln 5 mg/act F QL(0.2 eadaily); AL; Atleast 12 yrs old
sumatriptan succinate soajsc 4 mg/0.5ml F
QL(0.3 mldaily); AL; Atleast 12 yrs old
sumatriptan succinate soajsc 6 mg/0.5ml F QL(18 ml per
fill retail)
Drug Name DrugTier
Requirements/Limits
sumatriptan succinate soajsc 6 mg/0.5ml 4
Limit 18ml permonth;QL(18ml per fill retail)
sumatriptan succinate soctsc 4 mg/0.5ml F QL(0.6 ml
daily)
sumatriptan succinate soctsc 6 mg/0.5ml F
Limit 18ml permonth;QL(18ml per 29 daysretail)
sumatriptan succinate solnsc 6 mg/0.5ml F
Limit 18ml permonth;QL(0.6ml daily)
SUMATRIPTAN SUCCINATE SOSY SC 6 MG/0.5ML
F
Limit 18ml permonth;QL(18ml per 29 daysretail)
sumatriptan succinate tabsor 100 mg, 25 mg, 50 mg F
Limit 18ea permonth;QL(0.6ea daily)
SUMAVEL DOSEPRO SOTJ NP QL(0.62 mldaily)
ZECUITY PTCH NP QL(0.62 eadaily) ZEMBRACE SYMTOUCH SOAJ NP
zolmitriptan tabs 5 mg, 2.5 mg NP QL(0.62 eadaily) zolmitriptan tbdp 5 mg, 2.5 mg NP
ZOMIG SOLN NA 5 MG, 2.5 MG NP
ZOMIG TABS OR 2.5 MG, 5 MG (Zolmitriptan) NP QL(0.62 eadaily) ZOMIG ZMT TBDP (Zolmitriptan) NP
MINERALS & ELECTROLYTES
Calcium calcium carbonate tabs 1500 mg, 600mg, 1250 mg,600 mg, 500 mg
F
calcium carbonate-cholecalciferol chew 500mg-400unit, 500mg-100unit
F
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Drug Name DrugTier
Requirements/Limits
calcium carbonate-cholecalciferol tabs 500mg-200unit, 500mg-400unit,500mg-500mg-400unit-400unit, 250mg-125unit,600mg-800unit, 600mg-400unit, 600mg-200unit,600mg-600mg-800unit-400unit
F
calcium carbonate-ergocalciferol tabs F
calcium carbonate-vitamin d tabs 125unit-500mg,600mg-400unit, 200unit-500mg, 500mg-200unit,500mg-500mg-200unit-200unit, 600mg-200unit,125unit-250mg, 500mg-125unit, 200unit-600mg,500mg-400unit, 250mg-125unit, 400unit-600mg
F
calcium citrate tabs 200 mg, 950 mg F
calcium citrate-vitamin d tabs 315mg-250unit,315mg-200unit
F
CALCIUM GLUCONATE TABS OR 500 MG F
calcium tabs 500 mg F
CALCIUM TABS 600MG-200UNIT F
calcium w/ vitamin d tabs F
calcium-magnesium-zinctabs 333mg-5mg-133mg,5mg-133.333mg-333.333mg, 5mg-134mg-334mg, 5mg-133.33mg-333.33mg, 5mg-133mg-333mg
F
CALTRATE 600+D TABS (Calcium Carbonate-Cholecalciferol)
NP
CITRACAL + D3 MAXIMUM TABS (Calcium Citrate-Vitamin D)
NP
Drug Name DrugTier
Requirements/Limits
CITRACAL MAXIMUM TABS (Calcium Citrate-Vitamin D)
NP
GNP VITAMIN D-400 TABS F
oyster shell tabs F
RA OYSTER SHELL CALCIUM/VITAMIN DTABS
F
Electrolyte Mixtures CERALYTE 70 SOLN 60MEQ/L-70MEQ/L-20MEQ/L-30MEQ/L
F QL(6084 ml perfill retail)
CERASPORT EX1 SOLN F QL(6084 ml perfill retail)
CERASPORT SOLN 4MEQ/L-18MEQ/L-20MEQ/L-6MEQ/L
F QL(6084 ml perfill retail)
ENFAMIL ENFALYTE SOLN F QL(6084 ml per
fill retail) EQUALYTE SOLN (Oral Electrolytes) NP QL(6084 ml perfill retail)
oral electrolytes soln F QL(6084 ml perfill retail)
PEDIALYTE ADVANCED CARE SOLN (Oral Electrolytes)
NP QL(6084 ml perfill retail)
PEDIALYTE FREEZER POPS SOLN (Oral Electrolytes)
NP QL(6084 ml perfill retail)
PEDIALYTE SINGLES SOLN (Oral Electrolytes) NP QL(6084 ml perfill retail)
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Drug Name DrugTier
Requirements/Limits
PEDIALYTE SOLN 4.7MEQ/237ML-10.6MEQ/237ML-8.3MEQ/237ML, 20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L,2.1MEQ/59ML-2.7MEQ/59ML-0.5MG/59ML-1.2MEQ/59ML-1.5GM/59ML, 35MEQ/L-45MEQ/L-7.8MG/L-20MEQ/L-25GM/L,20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L(Oral Electrolytes)
NP
QL(6084 ml perfill retail)
Fluoride LURIDE SOLN (Sodium Fluoride) NP QL(50 ml perfill retail) sodium fluoride chew 2.2 mg, 1.1 mg, 0.25 mg, 1 mg,0.5 mg
F
sodium fluoride soln 0.125 mg/drop, 0.5 mg/ml F QL(50 ml per
fill retail) Iodine Products SSKI SOLN F
Magnesium MAG64 TBCR F
MAGNESIUM GLUCONATE TABS 500 MG
F
magnesium gluconate tabs500 mg F
magnesium oxide (mgsupplement) tabs 400 mg,241.3 mg
F
MAGONATE LIQD F
MAGOX 400 TABS (Magnesium Oxide (MgSupplement))
NP
NU-MAG TBEC F
SLOW-MAG TBEC F
Drug Name DrugTier
Requirements/Limits
Manganese MANGANESE GLUCONATE TABS NP
Mineral Combinations ADVANCED CALCIUM/VITAMIND/MAGNESIUM TABS
F
BONE DENSITY BUILDER TABS F
CAL MAG ZINC +D3 TABS F
CAL-MAG-ZINC-D TABS F
CAL-MAG-ZINC-D3 TABS F
CALCIUM/MAGNESIUM/ZINC TABS 5MG-133MG-333MG-200UNIT
F
CALCIUM/MAGNESIUM/ZINC/VITAMIN D3 TABS F
CITRACAL PLUS TABS F
FEM-CAL CITRATE TABS F
MULTI MEGA MINERALS TABS F
multiple minerals w/vitamins tabs F
MULTISOURCE CALCIUM MAGNESIUM & D FORMULA TABS
F
NATRUL-CAL TABS F
PROSTEON TABS F
THERACAL D2000 TABS F
THERACAL D4000 TABS F
THERACAL RAPID REPLETION TABS F
Phosphate K-PHOS NEUTRAL TABS (Pot Phosphate Monobasicw/ Sod Phosphate Dibasic& Monobasic)
NP
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Drug Name DrugTier
Requirements/Limits
PHOS-NAK POWDER CONCENTRATE PACK F
pot phosphate monobasicw/ sod phosphate dibasic &monobasic tabs
F
Potassium K-TAB TBCR 10 MEQ (Potassium Chloride) NP
K-TAB TBCR 8 MEQ F
KLOR-CON M15 TBCR F
MICRO-K CPCR (Potassium Chloride) NP
potassium bicarbonate tbef F
potassium chloride cpcr or8 meq, 10 meq F
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 or10 meq, 8 meq F
POTASSIUM GLUCONATE TABS 2.5 MEQ
F
potassium tabs 99 mg F
Sodium sodium chloride soln ij 0.9% F
sodium chloride soln iv 0.9 % F
sodium chloride tabs or 1 gm F
Trace Minerals SE PLUS PROTEIN TABS (Selenium) NP
Drug Name DrugTier
Requirements/Limits
selenium tabs or 200 mcg F
SELENIUM TBCR OR 200 MCG F
Zinc zinc gluconate tabs or 50 mg F
zinc sulfate caps or 220 mg F
zinc tabs or 50 mg F
MISCELLANEOUS THERAPEUTIC CLASSES
Chelating Agents CUPRIMINE CAPS F
Immunomodulators REVLIMID CAPS F QL(1 ea daily)
THALOMID CAPS NP
Immunosuppressive Agents AZASAN TABS F
azathioprine tabs or 50 mg F
CELLCEPT CAPS (Mycophenolate Mofetil) NP
CELLCEPT SUSR (Mycophenolate Mofetil) NP
CELLCEPT TABS (Mycophenolate Mofetil) NP
cyclosporine caps or 100mg, 25 mg F
cyclosporine modified (formicroemulsion) caps F
cyclosporine modified (formicroemulsion) soln F
CYCLOSPORINE MODIFIED CAPS (Cyclosporine Modified (ForMicroemulsion))
NP
IMURAN TABS (Azathioprine) NP
mycophenolate mofetil caps F
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Drug Name DrugTier
Requirements/Limits
mycophenolate mofetil susr F
mycophenolate mofetil tabs F
mycophenolate sodiumtbec F
MYFORTIC TBEC (Mycophenolate Sodium) NP
NEORAL CAPS (Cyclosporine Modified(For Microemulsion))
NP
NEORAL SOLN (Cyclosporine Modified(For Microemulsion))
NP
PROGRAF CAPS OR 1 MG, 0.5 MG, 5 MG (Tacrolimus)
NP
RAPAMUNE SOLN 1 MG/ML F
RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (Sirolimus)
NP
SANDIMMUNE CAPS OR 100 MG, 25 MG (Cyclosporine)
NP
sirolimus tabs F
tacrolimus caps F
Irrigation Solutions water for irrigation, sterilesoln F
Potassium Removing Agents KAYEXALATE POWD (Sodium PolystyreneSulfonate)
NP
sodium polystyrenesulfonate powd or F
sodium polystyrenesulfonate susp or 15gm/60ml
F
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral ANBESOL MAXIMUM STRENGTH LIQD (Benzocaine (Dental))
NP
Drug Name DrugTier
Requirements/Limits
benzocaine (dental) liqd 20% F
benzocaine-menthol (mouth-throat) lozg 3.6mg-15mg, 2.6mg-15mg
F
CEPACOL SORE THROAT EXTRA STRENGTH LOZG (Benzocaine-Menthol (Mouth-Throat))
NP
CEPACOL SORE THROAT EXTRASTRENGTH LOZG (Benzocaine-Menthol (Mouth-Throat))
NP
CEPACOL SORE THROAT LOZG 2.6MG-15MG, 3.6MG-15MG (Benzocaine-Menthol (Mouth-Throat))
NP
CEPACOL SORE THROAT MAXIMUM NUMBING LOZG
F
lidocaine hcl (mouth-throat)soln F
Anti-infectives - Throat clotrimazole lozg F
clotrimazole troc F
nystatin (mouth-throat) susp F
ORAVIG TABS NP
Antiseptics - Mouth/Throat CHERACOL SORE THROAT LIQD (Phenol (Antiseptic))
NP
chlorhexidine gluconate(mouth-throat) soln F
PAIN-A-LAY LIQD (Phenol (Antiseptic)) NP
PERIDEX SOLN (Chlorhexidine Gluconate (Mouth-Throat))
NP
phenol (antiseptic) liqd F
Dental Products
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Drug Name DrugTier
Requirements/Limits
PREVIDENT 5000 DRY MOUTH GEL (Sodium Fluoride (Dental))
NP
PREVIDENT 5000 PLUS CREA (Sodium Fluoride (Dental))
NP
PREVIDENT FLUORIDE GEL (Sodium Fluoride (Dental))
NP
sodium fluoride (dental)crea dt 1.1 % F
sodium fluoride (dental) geldt 1.1 % F
THERA-FLUR-N GEL (Sodium Fluoride (Dental)) NP
Lozenges CEPASTAT LOZG F
DENTIVA LOZG F
DIABETIC TUSSIN COUGH DROPS LOZG F
SALESE LOZG F
throat lozenges lozg F
ZINC W/A&C LOZG F
Steroids - Mouth/Throat triamcinolone acetonide (mouth) pste F
Throat Products - Misc. AQUORAL SOLN F RX/OTC
BIOTENE DRY MOUTH MOISTURIZING SPRAY SOLN
F RX/OTC
CAPHOSOL SOLN F RX/OTC
CVS DRY MOUTH SPRAY SOLN F RX/OTC
DRY MOUTH SPRAY SOLN F RX/OTC
EQL DRY MOUTH ORAL RINSE SOLN F RX/OTC
MOI-STIR SOLN F RX/OTC
Drug Name DrugTier
Requirements/Limits
MOUTHKOTE SOLN F RX/OTC
NUMOISYN LIQD F RX/OTC
ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT SOLN
F RX/OTC
pilocarpine hcl (oral) tabs 5 mg F
RA DRY MOUTH SOLN F RX/OTC
SALAGEN TABS 5 MG (Pilocarpine HCl (Oral)) NP
MULTIVITAMINS
B-Complex Vitamins b-complex vitamins caps or60mg-60mg-5mg-20mg-3mg-1mcg-3mg-0.5mg,70mg-100mg-1mg-10mg-2mg-1.5mg-100mcg,60mg-60mg-3mg-5mg-20mg-3mg-1mcg-0.5mg
F
b-complex vitamins tabs or0.1mg-20mg-2mg-5mcg-3mg-1mg, 15mg-2mg-5mg-2mcg-2mg-2mg, 3mg-3mg-20mg-20mg-3mg-3mg-10mg-10mg-6mcg-6mcg-2mg-2mg, 3mg-20mg-3mg-10mg-6mcg-2mg, 10mg-10mg-2mg-1.5mg-0.2mg,100mg-50mg-40mg-10mg-20mg-5mg-4.6mg-1mcg-5mg-1mg, 3mg-10mg-20mg-3mg-6mcg-2mg,83mg-3mg-20mg-2mg-5mcg-1mg, 30mg-50mg-50mg-50mg-50mg-50mg-50mcg-50mg-100mcg-50mcg-50mg, 10mg-14mg-25mcg-7mg-4.5mg
F
B-Complex w/ C
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Drug Name DrugTier
Requirements/Limits
b complex w/ c caps 10mg-50mg-10mg-15mg-5mg-300mg, 10.2mg-10mg-15mg-50mg-5mg-300mg, F 10mg-50mg-10.2mg-15mg-5mg-300mg, 15mg-10mg-50mg-10mg-5mg-300mg b complex w/ c tabs 15mg-10mg-50mg-10.2mg-6mcg-400mcg-5mg-300mg,50mg-10.2mg-10mg-15mg-5mg-300mg, 15mg-50mg-10.2mg-10mg-5mg-300mg,10.2mg-10.2mg-10mg-10mg-50mg-50mg-15mg-15mg-5mg-5mg-300mg-300mg, 15mg-10mg-50mg-10.2mg-5mg-300mg,100mg-100mg-5.5mg-20mg-15mcg-25mg-400mcg-5mcg-2mg-150mg, 10mg-10mg-15mg-50mg-5mg-300mg, 50mg-15mg-10mg-10.2mg-5mg-300mg, 50mg-10mg-10mg- F 15mg-5mg-300mg, 15mg-150mg-10mg-50mg-10.2mg-5mg-300mg,100mg-10mg-20mg-10mcg-15mg-5mg-500mg,15mg-10.2mg-10mg-50mg-5mg-300mg, 100mg-100mg-25mg-20mg-6mg-15mcg-100mg-5mcg-2mg-150mg, 15mg-20mg-50mg-10mg-10mcg-5mg-300mg,15mg-10mg-50mg-10mg-5mg-300mg, 100mg-20mg-5.5mg-15mcg-2mg-25mg-150mg-400mcg-5mcg-150mg, 10.2mg-10mg-15mg-50mg-5mg-300mg b-complex w/ c & calciumtabs F
b-complex w/ c & e + zntabs F
PRONUTRIENTS SUPER B-COMPLEX+ANTIOXIDANT S TABS
F
Drug Name DrugTier
Requirements/Limits
B-Complex w/ Folic Acid B-100 COMPLEX TABS F
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
b-complex w/ c & folic acidtabs 5mg-25mg-20mg-15mcg-100mg-400mcg-30mcg-2mg-150mg, 50mg-50mg-50mg-50mg-50mcg-400mcg-50mcg-50mg-500mg, 30unit-10mg-100mg-10mg-20mg-12mcg-400mcg-45mcg-5mg-500mg, 18mg-5mg-45mg-10mg-10mcg-400mcg-5mg-250mg,25mg-5mg-10mg-250mcg-5mg-400mcg-300mcg-5mg-120mg, 15mg-50mg-10.2mg-10mg-400mcg-300mcg-5mg-300mg,30unit-100mg-10mg-1mg-20mg-1mg-1mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 5mg-25mg-50mg-5mg-37.5mcg-200mcg-15mcg-5mg-150mg, 100mg-100mg-5.5mg-25mg-20mg-30mcg-400mcg-45mcg-5mg-180mg, 50mg-50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-500mg,25mg-5.5mg-25mg-20mg-100mcg-400mcg-1000mcg-5mg-60mg, 15mg-50mg-10.2mg-10mg-6mcg-400mcg-5mg-300mg,30unit-10mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 15mg-100mg-15mg-18mg-5mcg-0.5mg-4mg-500mg,100mg-5.5mg-25mg-20mg-15mcg-400mcg-30mcg-2mg-150mg
F
RX/OTC
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161
Drug Name DrugTier
Requirements/Limits
b-complex w/ folic acid tabs10mg-20mg-1.7mg-6mcg-1.5mg-400mcg-2mg,40mcg-1mg-6mg-5mcg-3mg-2mcg-19mcg, 1.5mg-20mg-1.7mg-6mcg-400mcg-2mg, 100mg-100mg-100mg-100mg-10mcg-400mcg-100mcg-100mg, 50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg, 100mg-100mg-100mg-100mcg-400mcg-100mg, 15mg-100mg-200mg-17mg-60mcg-400mcg-20mg,10mg-10mg-50mg-10mg-10mg-10mg-10mcg-10mg-400mcg-10mcg-10mg,30mg-20mg-50mg-30mg-10mg-10mcg-400mcg-8mg, 1.7mg-10mg-6mcg-1.2mg-20mg-0.4mg-2mg
F
Drug Name DrugTier
Requirements/Limits
b-complex w/biotin & folicacid tabs 50mg-50mg-50mg-50mg-0.4mg-50mcg-50mg, 50mg-50mg-50mg-50mg-50mcg-100mcg-50mcg-50mg, 50mg-50mg-12.5mg-50mg-12.5mcg-400mcg-45mcg-5mg-180mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-400mcg-100mcg-100mg,100mg-30mg-100mg-100mcg-100mg-100mg-100mg-100mcg-400mcg-100mcg-100mg, 50mg-50mg-50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg-50mg, 5mg-25mg-12.5mg-125mcg-125mg-7.5mg-50mg-12.5mcg-200mcg-50mcg-5mg, 50mg-200mg-100mg-50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg, 10mg-10mg-10mg-10mg-10mcg-100mcg-10mcg-10mg, 40mg-20mg-50mg-50mcg-50mcg-5mg-25mcg-5mg-100mcg-25mcg-5mg, 100mg-100mg-100mg-100mcg-100mg-400mcg-100mcg-100mg, 50mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-400mcg-100mcg, 50mg-50mg-50mg-50mg-50mcg-400mcg-50mcg-50mg,25mg-100mg-25mg-25mcg-25mg-400mcg-25mcg-25mg, 50mg-50mg-50mg-50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg, 100mg-100mg-100mg-100mg-100mcg-400mcg-100mcg-100mg, 20mg-1.7mg-6mcg-1.5mg-200mcg-30mcg-2mg, 50mg-50mg-50mg-50mg-50mcg-50mg-50mg-50mcg-400mcg-
F
Nebraska Total Care Updated December 1, 2017
162
Drug Name DrugTier
Requirements/Limits
50mcg-50mg, 50mg-50mg-50mg-12.5mg-12.5mcg-50mcg-25mcg-12.5mg,10mg-30mg-10mg-100mg-20mg-20mg-10mg-25mcg-100mcg-10mcg-10mg-200mg, 25mg-25mg-25mg-25mcg-25mg-25mg-25mcg-0.3mg, 100mg-30mg-100mg-100mg-100mcg-100mg-100mg-100mcg-0.4mg-100mcg-100mg MILCO-B-FORTE TABS (B-Complex w/ C & FolicAcid)
NP RX/OTC
SM B-COMPLEX/VITAMINC TABS F RX/OTC
B-Complex w/ Minerals b-complex w/ minerals liqd F
Bioflavonoid Products ADRENAL C FORMULA TABS F RX/OTC
ADVANCED C PLUS TABS F RX/OTC
ASCOCID-1000 TBCR F
ASCOCID-500-D TBCR F
Drug Name DrugTier
Requirements/Limits
bioflavonoid products tabs6mg-500mg, 500mg-50mg-500mg, 1mg-10mg-100mg-25mg-50mg-500mg, 25mg-50mg-25mg-25mg-25mg-40mg-500mg, 20mg-100mg-110mg-20mg-1000mg, 150mg-250mg-500mg-250mg, 100mg-100mg-500mg, 2mg-20mg-200mg-50mg-100mg-1000mg, 900mg-100mg,18mg-30mg-1000mg,200mg-50mg-500mg,100mg-100mg-50mg,1000mg, 100mg-50mg-500mg, 200mg-10mg-10mg-500mg, 550mg-500mg, 200mg-110mg-1000mg, 500mg, 200mg-65mg-10mg-10mg-500mg,100mg-50mg-100mg,25mg-50mg-50mg-10mg-5mg-1000mg, 200mg-500mg, 25mg-1000mg,200mg-55mg-500mg,300mg-200mg
F
RX/OTC
bioflavonoid products tbcr50mg-500mg, 1500mg,100mg-1000mg, 50mg-50mg-1000mg, 20mg-20mg-20mg-1000mg,25mg-1000mg, 50mg-50mg-1500mg, 40mg-25mg-25mg-5mg-500mg
F
CEMILL PLUS TABS F RX/OTC
DAFLONEX-XL TBCR F
ESTER-C TABS 200MG-60MG-500MG F RX/OTC
FRUIT C 200 CHEW F
NAT-RUL C-COMPLEX TABS F RX/OTC
NAT-RUL C-COMPLEX TR TBCR F
PERIDIN-C TABS (Bioflavonoid Products) NP RX/OTC
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Drug Name DrugTier
Requirements/Limits
SUPER C-500 COMPLEX TBCR F
VITAMIN C CHEW 500MG, 25MG-500MG F
Multiple Vitamins w/ Calcium HM ONE DAILY ESSENTIAL TABS F
multiple vitamins w/calcium tabs F
ONE-A-DAY WOMENS FORMULA TABS (MultipleVitamins w/ Calcium)
NP
SM ONE DAILY ESSENTIAL TABS F
Multiple Vitamins w/ Iron DAILY MULTIPLE VITAMIN PLUS IRON TABS
F
multiple vitamins w/ irontabs F
Multiple Vitamins w/ Minerals ADULT ONE DAILY GUMMIES CHEW F
ADVANCED DIABETIC MULTIVITAMIN FORMULA TABS
F RX/OTC
AIRBORNE LOZG F
ALIVE ENERGY 50+ TABS F RX/OTC
ALIVE MENS ENERGY TABS F RX/OTC
ALIVE ONCE DAILY WOMENS 50+ ULTRA POTENCY TABS
F RX/OTC
ALIVE ONCE DAILY WOMENS ULTRA POTENCY TABS
F RX/OTC
ALIVE WOMENS 50+ TABS F RX/OTC
ALIVE WOMENS ENERGY TABS F RX/OTC
ALIVE WOMENS GUMMY VITAMINS CHEW F
ANTIOXIDANT FORMULA SG CPCR F
Drug Name DrugTier
Requirements/Limits
ANTIOXIDANT FORTE TABS F RX/OTC
AP-ZEL TABS F RX/OTC
APATATE FORTE LIQD F RX/OTC
AQUADEKS CAPS 18167UNIT-10MG-10MG-75MCG-80MG-1.5MG-10MG-12MG-75MG-10MG-700MCG-1.7MG-12MCG-800UNIT-200MCG-150UNIT-100MCG-1.9MG
F
RX/OTC
AQUADEKS CHEW 5MG-5MG-37.5MCG-15MG-0.75MG-5MG-6MG-35MG-5MG-350MCG-0.85MG-9083.5UNIT-6MCG-400UNIT-100MCG-50UNIT-50MCG-0.95MG
F
BACMIN TABS F RX/OTC
BARIATRIC FUSION CHEW F
BASIC AM TABS F RX/OTC
BASIC PM TABS F RX/OTC
BIO-35 GLUTEN-FREE CAPS F RX/OTC
BIO-35 IRON FREE CAPS F RX/OTC
BIOCAL CAPS F RX/OTC
BIOSUPP LIQD F RX/OTC
BIOTECT PLUS CAPS F RX/OTC
BIOTECT PLUS LIQD F RX/OTC
BIOVOL SYRP F
BURIED TREASURE ACTIVE 55PLUS SENIOR COMPLEX LIQD
F RX/OTC
C-BUFF POWD F
CAL-DAY 1000 TABS F RX/OTC
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Drug Name DrugTier
Requirements/Limits
CELLULAR SECURITY CAPS F RX/OTC
CENTRAVITES 50 PLUS TABS F RX/OTC
CENTRAVITES ADULTS TABS F RX/OTC
CENTRUM ADULTS TABS (Multiple Vitamins w/Minerals)
NP RX/OTC
CENTRUM CARDIO TABS F RX/OTC
CENTRUM CHEW 18MG-30UNIT-20MCG-1MG-50MG-150MCG-20MCG-108MG-40MG-2MG-15MG-1.5MG-10MG-3500UNIT-20MG-10MCG-1.7MG-6MCG-400MCG-45MCG-2MG-60MG-400UNIT
F
CENTRUM FLAVOR BURST ADULT CHEW F
CENTRUM FLAVOR BURST CHEW F
CENTRUM FLAVOR BURST KIDS CHEW F
Drug Name DrugTier
Requirements/Limits
CENTRUM LIQD 2500UNIT/15ML-150MCG/15ML-3MG/15ML-25MCG/15ML-25MCG/15ML-2.5MG/15ML-9MG/15ML-30UNIT/15ML-400UNIT/15ML-20MG/15ML-1.7MG/15ML-10MG/15ML-6MCG/15ML-1.5MG/15ML-300MCG/15ML-2MG/15ML-60MG/15ML,150MCG/15ML-3MG/15ML-25MCG/15ML-25MCG/15ML-2MG/15ML-9MG/15ML-20MG/15ML-1.7MG/15ML-10MG/15ML-1300UNIT/15ML-6MCG/15ML-400UNIT/15ML-1.1MG/15ML-30UNIT/15ML-300MCG/15ML-2MG/15ML-60MG/15ML(Multiple Vitamins w/Minerals)
NP
RX/OTC
CENTRUM MEN TABS F RX/OTC
CENTRUM MULTIGUMMIES ADULTS CHEW
F
CENTRUM MULTIGUMMIES MEN CHEW
F
CENTRUM MULTIGUMMIES WOMEN CHEW
F
CENTRUM MULTIVITAMIN FLAVOR BURST DRINK PACK
F
CENTRUM SILVER 50+MEN TABS (MultipleVitamins w/ Minerals)
NP RX/OTC
CENTRUM SILVER 50+WOMEN TABS (Multiple Vitamins w/Minerals)
NP
RX/OTC
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Drug Name DrugTier
Requirements/Limits
CENTRUM SILVER ADULT 50+ TABS (MultipleVitamins w/ Minerals)
NP RX/OTC
CENTRUM SILVER CHEW 4MG-10MCG-22.5MCG-100MCG-4.5MG-10MCG-125MG-70UNIT-100MCG-25MCG-200MG-5MCG-50MG-2MG-15MG-2.2MG-10MG-4000UNIT-250MCG-12MG-2.7MG-25MCG-400UNIT-500MCG-45MCG-7MG-75MG
F
CENTRUM SILVER TABS 2MG-72MG-10MCG-20MCG-150MCG-2MG-5MCG-48MG-150MCG-75MCG-200MG-150MCG-80MG-100MG-45UNIT-2MG-15MG-1.5MG-300MCG-10MG-3500UNIT-250MCG-20MG-10MCG-1.7MG-25MCG-400MCG-30MCG-3MG-60MG-400UNIT, 45MCG-2MG-72MG-10MCG-55MCG-2.3MG-5MCG-0.5MG-20MG-50UNIT-150MCG-45MCG-220MG-80MG-50MG-150MCG-11MG-1.5MG-10MG-2500UNIT-20MG-30MCG-1.7MG-25MCG-500UNIT-400MCG-30MCG-3MG-60MG (Multiple Vitamins w/Minerals)
NP
RX/OTC
CENTRUM SILVER ULTRA MENS TABS F RX/OTC
CENTRUM SILVER ULTRA WOMENS TABS F RX/OTC
CENTRUM SPECIALIST HEART TABS F RX/OTC
CENTRUM SPECIALIST IMMUNE SUPPORT TABS F RX/OTC
CENTRUM SPECIALIST VISION TABS F RX/OTC
Drug Name DrugTier
Requirements/Limits
CENTRUM TABS 35MCG-2MG-72MG-10MCG-55MCG-75MCG-2.3MG-10MCG-5MCG-0.5MG-20MG-150MCG-45MCG-80MG-200MG-30UNIT-11MG-50MG-1.5MG-18MG-10MG-3500UNIT-20MG-25MCG-1.7MG-6MCG-400UNIT-400MCG-30MCG-2MG-60MG (Multiple Vitamins w/Minerals)
NP
RX/OTC
CENTRUM ULTRA MENS TABS (Multiple Vitamins w/Minerals)
NP RX/OTC
CENTRUM ULTRA WOMENS TABS F RX/OTC
CENTRUM VITAMINTS CHEW F
CENTRUM WOMEN TABS (Multiple Vitamins w/Minerals)
NP RX/OTC
CEROVITE ADVANCED FORMULA LIQD F RX/OTC
CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS TABS
F RX/OTC
CHOICEFUL MULTIVITAMIN CAPS 15MG-1MG-8MG-18MG-700MCG-1.5MG-14000UNIT-5MCG-1000UNIT-180MCG-170UNIT-80MCG-1.9MG-30MG
F
RX/OTC
CHOICEFUL MULTIVITAMIN CHEW 15MG-1.2MG-10MG-8MG-600MCG-1.4MG-13000UNIT-6MCG-800UNIT-180MCG-180UNIT-80MCG-1.5MG-60MG
F
CLINICAL NUTRIENTS 45-PLUS WOMEN TABS F RX/OTC
CLINICAL NUTRIENTS 50-PLUS MEN TABS F RX/OTC
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166
Drug Name DrugTier
Requirements/Limits
CLINICAL NUTRIENTS ANTIOXIDANT CAPS F RX/OTC
CLINICAL NUTRIENTS FOR FEMALE TEENS TABS
F RX/OTC
CLINICAL NUTRIENTS FOR MALE TEENS TABS F RX/OTC
CLINICAL NUTRIENTS FOR MEN TABS F RX/OTC
CLINICAL NUTRIENTS FOR WOMEN TABS F RX/OTC
COMPLETE FORMULATION D3000 CAPS
F RX/OTC
COMPLETE FORMULATION MULTIVITAMIN SUPPLEMENT CAPS
F
RX/OTC
CONCEPTIONXR MOTILITY SUPPORT FORMULA MISC
F
CORVITE TABS (MultipleVitamins w/ Minerals &Folic Acid)
NP
CVS AIRSHIELD IMMUNITY SUPPORT CHEW
F
CVS DIABETES HEALTH SUPPORT MISC F
CVS ONE DAILY MENS 50+ ADVANCED TABS F RX/OTC
CVS SPECTRAVITE ADULT 50+ CHEW 4MG-10MCG-25MCG-100MCG-4.5MG-10MCG-5MCG-125MG-70UNIT-100MCG-25MCG-200MG-150MCG-2MG-15MG-50MG-2.2MG-10MG-4000UNIT-250MCG-12MG-2.7MG-25MCG-400UNIT-500MCG-45MCG-7MG-75MG
F
Drug Name DrugTier
Requirements/Limits
CVS SPECTRAVITE ADULT 50+ TABS 45MCG-2MG-72MG-10MCG-55MCG-2.3MG-5MCG-0.5MG-20MG-50UNIT-150MCG-45MCG-220MG-150MCG-80MG-11MG-50MG-1.5MG-300MCG-10MG-2500UNIT-250MCG-20MG-30MCG-1.7MG-25MCG-500UNIT-400MCG-30MCG-3MG-60MG
F
RX/OTC
CVS SPECTRAVITE ADULT GUMMIES CHEW F
CVS SPECTRAVITE ULTRA MEN50+ TABS F RX/OTC
CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR TABS
F RX/OTC
CVS SPECTRAVITE ULTRA MENS HEALTH TABS
F RX/OTC
CVS SPECTRAVITE ULTRA WOMEN TABS F RX/OTC
CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR TABS
F RX/OTC
CVS SPECTRAVITE ULTRA WOMENS HEALTH TABS
F RX/OTC
DAILY HEART HEALTH SUPPORT MISC F
DAILY PAK MAXIMUM MULTIVITAMIN/ASIANGINSENG EXTRACT MISC
F
DECUBI-VITE CAPS F RX/OTC
DEKAS BARIATRIC CHEW F
DEKAS PLUS CAPS 75MCG-10MG-150UNIT-10MG-12MG-75MG-10MG-1000MCG-1.7MG-18167UNIT-12MCG-3000UNIT-1.5MG-200MCG-100MCG-1.9MG
F
RX/OTC
Nebraska Total Care Updated December 1, 2017
167
Drug Name DrugTier
Requirements/Limits
DEKAS PLUS CHEW 10MG-75MCG-100UNIT-10MG-12MG-70MG-10MG-1000MCG-1.7MG-18167UNIT-12MCG-2000UNIT-1.5MG-200MCG-100MCG-1.9MG
F
DERMAVITE TABS F RX/OTC
DIABETES HEALTH PACK MISC F
DIABETES SUPPORT PACK MISC F
ELDERTONIC ELIX F
ELLIS TONIC ELIX F
EMERGEN-C BLUE PACK F
EMERGEN-C FIVE PACK F
EMERGEN-C HEART HEALTH PACK F
EMERGEN-C IMMUNE PACK F
EMERGEN-C IMMUNE PLUS PACK F
EMERGEN-C IMMUNE PLUS/VITAMIN D CHEW F
EMERGEN-C IMMUNE+ WARMERS PACK F
EMERGEN-C JOINT HEALTH PACK F
EMERGEN-C KIDZ PACK F
EMERGEN-C MSM LITE PACK F
EMERGEN-C PINK PACK F
EMERGEN-C SUPER FRUIT PACK F
EMERGEN-C VITAMIN C CHEW F
EMERGEN-C VITAMIN C LITE PACK F
EMERGEN-C VITAMIN C PACK F
Drug Name DrugTier
Requirements/Limits
EMERGEN-C VITAMIN D & CALCIUM PACK F
END FATIGUE DAILY ENERGYENFUSION POWD
F
ENERGY BOOSTER PACK F
EQ COMPLETE MULTIVITAMINADULTS UNDER 50 TABS
F RX/OTC
EQ MULTIVITAMINS ADULT GUMMY CHEW F
EQ ONE DAILY MENS 50+ TABS F RX/OTC
EQ ONE DAILY MENS HEALTH TABS F RX/OTC
EQ ONE DAILY WOMENS 50+ TABS F RX/OTC
EQ ONE DAILY WOMENS HEALTH TABS F RX/OTC
EQL CENTURY MATURE ADULTS50+ TABS F RX/OTC
EQL CENTURY MENS TABS F RX/OTC
EQL CENTURY WOMENS TABS F RX/OTC
EQL MEGA SELECT MENS TABS F RX/OTC
EQL MEGA SELECT WOMENS TABS F RX/OTC
EQL ONE DAILY ADULT GUMMIES CHEW F
EQL ONE DAILY DIET SUPPORT TABS F RX/OTC
EQL ONE DAILY MENS 50+ ADVANCED TABS F RX/OTC
EQL ONE DAILY MENS TABS F RX/OTC
EQL PROTECTAVISION CAPS F RX/OTC
EQL SUPER ENERGY BOOSTER PACK F
EYE HEALTH CAPS F RX/OTC
FITNESS TABS FOR MEN AM/PM/LYCOPENE TABS F RX/OTC
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Drug Name DrugTier
Requirements/Limits
FITNESS TABS FOR WOMEN AM/PM/LYCOPENE TABS
F RX/OTC
FORTAVIT CAPS F RX/OTC
FORTAVIT LIQD F RX/OTC
FOSFREE TABS (MultipleVitamins w/ Minerals) NP RX/OTC
FREEDAVITE TABS F RX/OTC
GERI-FREEDA SENIOR FORMULA TABS F RX/OTC
HAIR-VITES TABS F RX/OTC
HAIR/SKIN/NAILS TABS F RX/OTC
HM COMPLETE 50+ MENS ULTIMATE TABS F RX/OTC
HM COMPLETE 50+ WOMENS ULTIMATE TABS
F RX/OTC
HM COMPLETE TABS F RX/OTC
HM HAIR/SKIN/NAILSTABS F RX/OTC
HM ONE DAILY MENS TABS F RX/OTC
HM ONE DAILY WOMENS TABS F RX/OTC
HYALEX TABS F RX/OTC
ICAPS AREDS FORMULA TABS F RX/OTC
ICAPS PLUS TABS F RX/OTC
IMMUNE SUPPORT CHEW F
IMMUNE SUPPORT VITAMIN C PACK F
K-PAX IMMUNE SUPPORT FORMULA DOUBLE STRENGTH CAPS
F
RX/OTC
K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH TABS
F
RX/OTC
Drug Name DrugTier
Requirements/Limits
K-PAX IMMUNE SUPPORT FORMULA SINGLE STRENGTH CAPS
F
RX/OTC
KP MENS DAILY PACK MISC F
KP WOMENS DAILY PACK MISC F
LIFE PACK MENS MISC F
LIFE PACK WOMENS MISC F
M2 B-60 TBCR F
MACULAR VITAMIN BENEFIT TABS F RX/OTC
MAXIMIN PACK PACK F
MEGA MULTI MEN TBCR F
MEGA MULTI WOMEN TBCR F
MEGA MULTIVITAMIN FOR MEN TABS F RX/OTC
MEGA MULTIVITAMIN FOR WOMEN TABS F RX/OTC
MEGA MULTIVITAMIN POWD F
MEGAVITE FRUITS & VEGGIES TABS F RX/OTC
MEGAVITE GOLDEN YEARS 55+ TABS F RX/OTC
MENS 50+ ADVANCED CAPS F RX/OTC
MENS 50+ MULTI VITAMIN &MINERAL FORMULA TABS
F RX/OTC
MENS MULTI VITAMIN & MINERAL FORMULA TABS
F RX/OTC
MENS PACK MISC F
MH MACULAR HEALTH MISC F
MULTI FOR HER PACK F
Nebraska Total Care Updated December 1, 2017
169
Drug Name DrugTier
Requirements/Limits
MULTI FOR HIM PACK F
MULTI-BETIC DIABETES TABS F RX/OTC
MULTI-VITAMIN MONOCAPS TABS F RX/OTC
multiple vitamins w/minerals & folic acid tabs F
Drug Name DrugTier
Requirements/Limits
multiple vitamins w/minerals caps 1mg-200unit-12.5mg-1mg-5mg-250mg, 50mcg-7.5mg-400unit-500mg, 70mcg-120mcg-4mg-60unit-150mcg-75mcg-2500unit-2mg-15mg-100mg-1.5mg-200mg-10mg-20mg-80mcg-1.7mg-25mcg-1000unit-400mcg-30mcg-6mg-60mg, 250mg-160mg-1mg-90mg-9mg-1mg-5mg-30unit-150mg, 18mg-90mg-30mcg-70mcg-15mg-400unit-300mcg-20mg-25mg-10mg, 25mg-20mg-12500unit-7.5mg-200unit-100mcg-1mg-40mg-25mg-1.75mg-5mg-250mg, 375mg-0.5mg-300mg-3.75mg-5mcg-68.75unit-100mcg-0.5mg-25mg, 12500unit-200unit-7.5mg-1mg-40mg-250mg,2973unit-14mcg-42.3mg-42.3mcg-4.3mg-14mcg-56.7mg-4.3mcg-2.7mg-56.7mg-1mg-11.3mg-1mg-5.7mg-3.3mcg-106.3unit-255mcg-8.3unit-42.3mcg-1.7mg-85mg, 90mcg-4mg-552mcg-2mg-10mcg-6mg-105mcg-180mcg-10mcg-5mcg-33unit-150mcg-150mcg-16mg-2mg-22.5mg-4mg-4.5mg-234mcg-100mcg-10mg-21mg-20mg-2500unit-9.5mg-20mg-20mcg-3.4mg-25mcg-1000unit-400mcg-30mcg-6mg-72mg,33.3mg-20mg-6.7mg-20mg-33.3mcg-166.7mcg-0.33mg-83.3mg-6.7mg-16.7mcg-33.3mg-33.3mcg-0.33mg-16.5mg-1.67mcg-20.8mcg-33.3mg-0.83mg-66.7unit-33.3mcg-25mg-33.3mg-4mg-0.5mg-3.3mg-0.67mg-8.3mg-1.67mg-83.3mg-41.7mg-16.7mcg-
F
RX/OTC
Nebraska Total Care Updated December 1, 2017
170
Drug Name DrugTier
Requirements/Limits
1.67mg-833.3unit-66.7unit-3.3mg-133.3mcg-50mcg-16.7mg-83.3mg, 20mcg-120mcg-4mg-50unit-150mcg-45mcg-100mg-2500unit-2mg-15mg-40mg-1.5mg-18mg-10mg-20mg-40mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 200unit-0.8mg-34.8mg-5mg-226mg,0.75mg-0.5mg-100unit-500unit-7.5mcg-3.75mg-125mg, 105mcg-120mcg-2mg-45unit-100mg-2mg-15mg-120mg-1.2mg-600mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 22mg-30unit-2mg-15mg-6mg-60mg, 22mg-2mg-15mg-6mg-30unit-60mg, 0.667mg-10unit-83.333mg-50mcg-66.667mg-133.333mg-2000unit-3.333mg-1.667mg-33.333mg-3mg-20mg-5mg-33.333mg-166.667mg-0.567mg-2mcg-0.5mg-6.667mg-133.333mcg-200mcg-0.667mg-20mg, 75mcg-2mg-552mcg-2mg-10mcg-6mg-70mcg-120mcg-10mcg-5mcg-33unit-150mcg-150mcg-16mg-2mg-15mg-4mg-3mg-234mcg-100mcg-10mg-21mg-18mg-20mg-2500unit-9.5mg-20mg-20mcg-1.7mg-15mcg-1000unit-600mcg-30mcg-4mg-72mg, 30unit-2mg-15mg-6mg-60mg, 200unit-12500unit-1mg-40mg-250mg, 280mg-34mcg-1mg-7mg-0.9mg-2.3mg-10unit-2mg-45mg-600mcg-10mg-1.3mg-2.4mcg-1.3mg-16mg-1.2mg-240mcg, 10mg-7.5mg-
Drug Name DrugTier
Requirements/Limits
1mg-200unit-25mcg-20mg-10mg-1mg-5mg-5mg-500unit-100mcg-10mg-250mg, 40mcg-120mcg-4mg-50unit-150mcg-45mcg-100mg-2500unit-2mg-15mg-40mg-1.5mg-10mg-20mg-40mcg-1.7mg-18mcg-1000unit-400mcg-30mcg-4mg-60mg, 50mcg-25000unit-400unit-500mg,10mg-23.333mcg-1mg-10mg-5mg-25mcg-40mcg-10mg-0.667mg-50mcg-133.333mg-10unit-10mg-33.333mg-15mg-6.667mg-3333.333unit-16.667mg-3.333mg-3.333mg-1.133mg-33.333mcg-1000unit-4mg-266.667mcg-200mcg-1.333mg-40mg,3964unit-19mcg-56.7mg-56.7mcg-5.7mg-19mcg-75.7mg-5.7mcg-3.7mg-75.7mg-1mg-15mg-1.3mg-7.7mg-4.7mcg-141.7unit-0.33mg-11.3unit-56.7mcg-2.3mg-113.3mg, 25mcg-5000unit-100unit-200mg,613.5mg-250mg-175mg-0.75mg-135mg-0.85mg-1500mcg-200unit-215mg-150mcg-0.5mg-30mg,70mg-4mg-80mg-50unit-10mg-10mg-25mg-5mg-8000unit-10mcg-1mg-2mg-150mg, 15mg-2mg-200mcg-200mcg-150mcg-150mcg-25mg-5mg-7.2mg-5000unit-5mg-100unit-25mg-25mg-50mg-100mg-25mg-25mg-25mg-100mcg-400unit-400mcg-300mcg-25mg-150mg,15mcg-1.5mg-200unit-10000unit-1mg-7.5mg-250mg, 200unit-1mg-10mg-1mg-5mg-250mg,166.667mg-133.333mg-6.667mg-16.667unit-3.333mg-33.333mg,70mcg-120mcg-4mg-
Nebraska Total Care Updated December 1, 2017
171
Drug Name DrugTier
Requirements/Limits
150mcg-75mcg-200mg-2500unit-2mg-15mg-100mg-1.5mg-10mg-20mg-80mcg-1.7mg-25mcg-1000unit-400mcg-60unit-30mcg-6mg-60mg, 20mcg-120mcg-4mg-50unit-150mcg-45mcg-2500unit-2mg-15mg-40mg-1.5mg-100mg-18mg-10mg-20mg-40mcg-1.7mg-6mcg-1000unit-600mcg-30mcg-2mg-60mg, 20mcg-120mcg-4mg-50unit-150mcg-45mcg-100mg-2500unit-2mg-15mg-40mg-1.5mg-18mg-10mg-20mg-40mcg-1.7mg-6mcg-1000unit-600mcg-30mcg-2mg-60mg, 12500unit-200unit-7.5mg-1mg-40mg-3mg-250mg, 70mcg-1mg-120mcg-150mcg-75mcg-5000unit-2mg-120mg-40mg-15mg-1.5mg-500mcg-30mg-2mg-20mg-100mcg-1.7mg-10mg-6mcg-2000unit-200mcg-30unit-30mcg-2mg,200unit-14320unit-0.8mg-34.8mg-226mg, 25mg-20mg-200unit-100mcg-1mg-40mg-25mg-1.75mg-5mg-250mg, 70mcg-120mcg-4mg-60unit-150mcg-75mcg-200mg-2500unit-2mg-15mg-100mg-1.5mg-10mg-20mg-80mcg-1.7mg-25mcg-1000unit-400mcg-30mcg-6mg-60mg, 200mg-14320unit-0.8mg-34.8mg-226mg, 50mg-2mg-15unit-2500unit-25mcg-25mg-25mg-50mg-3mg-12mcg-500unit-3mg-800mcg-25mcg-6mg-250mg,491.667mg-88.333mg-1mg-5mg-1000unit-273.333unit-20unit-26.667mg, 5mg-70mcg-25mg-1mg-35mg-5mg-
Drug Name DrugTier
Requirements/Limits
5mg-1mg-7.5mg-75mcg-100mcg-10mg-10000unit-25mg-25unit-150mcg-50mg-15mg-25mg-25mg-25mcg-50mg-100mg-250mcg-150mcg-25mg-100mcg-400unit-400mcg-30mcg-25mg-150mg,833.33unit-16.67mg-33.33mcg-66.67unit-33.33mcg-66.67mg-2.5mg-3.33mcg-200mcg-33.33mcg-0.25mg-16.5mg-8.33mcg-1.67mg-66.67mg-2.5mg-2500unit-12.5mg-8.33mg-30mg-12.5mg-12.5mg-6.33mg-16.67mg-12.5mcg-33.33unit-6.67mg-66.67mcg-50mcg-12.5mg-4.17mg-166.67mg, 200unit-1mg-40mg-3mg-250mg,25mcg-10000unit-125unit-200mg, 15mg-16000unit-1.5mg-12mg-20mg-800mcg-1.7mg-6mcg-1000unit-200mcg-200unit-100mcg-1.9mg-100mg,2.6mg-10mcg-100mg-150mcg-130mg-15mg-2mg-10mcg-37.5mg-10mcg-100mg-27mg-5000unit-30unit-400unit-1500unit-1.7mg-10mg-6mcg-1.5mg-20mg-0.4mg-30mcg-2mg-60mg,8000unit-70mg-4mg-80mg-50unit-10mg-10mg-25mg-5mg-10mcg-1mg-2mg-150mg, 4.167mcg-8.333mg-20mg-1mg-10mg-0.333mg-10mg-2.5mg-1.667mg-3.333mg-5mg-8.333mg-1.667mg-1666.667unit-2.667mcg-666.667unit-133.333mcg-10unit-1666.667mcg-1.667mg-30mg, 25mg-100unit-45mg-500mg
Nebraska Total Care Updated December 1, 2017
172
Drug Name DrugTier
Requirements/Limits
multiple vitamins w/minerals chew 1.25mg-20mcg-2.5mg-1000unit-10mcg-19mg-2.5mcg-100unit-100mcg-10unit-37.5mcg-0.5mg-15mg,2.5mg-20unit-40mcg-5mg-2000unit-4mcg-400unit-200mcg-75mcg-1mg-30mg, 55mcg-2.5mg-15unit-75mcg-5mg-20mcg-30mcg-2000unit-7.5mcg-200unit-200mcg-300mcg-2.5mg-37.5mg, 15unit-37.5mcg-3.75mg-5mg-1250unit-10mg-3mcg-500unit-200mcg-75mcg-1mg-30mg, 20mcg-1mg-50mg-30unit-150mcg-20mcg-108mg-2mg-15mg-40mg-18mg-10mg-3500unit-20mg-10mcg-1.7mg-6mcg-400unit-1.5mg-400mcg-45mcg-2mg-60mg, 55mcg-2.5mg-15unit-75mcg-5mg-2000unit-20mcg-30mcg-7.5mcg-200unit-200mcg-300mcg-2.5mg-37.5mg,16000unit-15mg-1.5mg-12mg-100mg-10mg-800mcg-1.7mg-6mcg-1000unit-200mcg-200unit-100mcg-1.9mg, 1mg-7.5mg-1mg-60mcg-1mg-75mg-75mcg-25mcg-7.5mg-25mg-35mcg-15mg-75unit-6.25mg-5mg-22.5mg-10mg-10mg-10mg-500mcg-1.7mg-5000unit-500mcg-1500unit-400mcg-300mcg-2mg-45mg, 5mcg-3.333mg-0.033mg-0.333mg-66.666unit-3.333unit-333.333mg,50mg-15unit-20mcg-1.25mg-1250unit-4.5mcg-400unit-200mcg-75mcg-1mg-15mg, 50mg-1.25mg-20mcg-1250unit-4.5mcg-400unit-200mcg-15unit-75mcg-1mg-15mg, 4mg-
F
Drug Name DrugTier
Requirements/Limits
10mcg-22.5mcg-100mcg-4.5mg-10mcg-5mcg-125mg-70unit-25mcg-100mcg-2mg-15mg-50mg-2.2mg-200mg-10mg-4000unit-250mcg-12mg-2.7mg-25mcg-400unit-500mcg-45mcg-7mg-75mg,15unit-4.5mg-0.5mg-2.5mg-50mg, 4mg-10mcg-22.5mcg-100mcg-4.5mg-10mcg-5mcg-125mg-70unit-100mcg-25mcg-200mg-2mg-15mg-50mg-2.2mg-10mg-4000unit-250mcg-12mg-2.7mg-25mcg-400unit-500mcg-45mcg-7mg-75mg, 2.5mg-20unit-40mcg-5mg-2000unit-20mcg-30mcg-5mcg-200unit-200mcg-75mcg-1mg-30mg, 10unit-20mcg-1.25mg-10mcg-15mcg-1000unit-2.5mcg-100unit-37.5mcg-0.5mg-15mg, 3.75mcg-2mg-7.5unit-10mg-0.75mg-11.25mg-500unit-250mg,3.75mcg-0.75mg-7.5unit-10mg-2mg-500unit-250mg,40mcg-2.5mg-5mg-20mcg-30mcg-2000unit-5mcg-200unit-200mcg-20unit-75mcg-1mg-30mg, 75mcg-18.75mcg-60mcg-7.5unit-5mg-137.5mcg-1.5mg-20mcg-1250unit-6mcg-400unit-5mg-200mcg-7.5mcg-2mg-15mg, 25mg-20unit-40mcg-5mg-2000unit-20mcg-30mcg-5mcg-200unit-200mcg-75mcg-1mg-30mg, 20mcg-1mg-50mg-60unit-150mcg-20mg-108mg-2mg-15mg-40mg-1.5mg-18mg-10mg-3500unit-20mg-10unit-1.7mg-6mcg-400unit-400mcg-45mcg-2mg-60mg,75mcg-9.4mcg-1.9mg-60mcg-15unit-19mcg-1mg-5mg-3mcg-20mcg-
Nebraska Total Care Updated December 1, 2017
173
Drug Name DrugTier
Requirements/Limits
1250unit-9mcg-200unit-10mg-150mcg-15mcg-2mg-15mg, 140mg-7.5unit-1mg-2.5mg-2.5mg-5mg-30mcg-20mcg-1250unit-3mcg-400unit-200mcg-150mcg-1mg-30mg,20unit-40mcg-2.5mg-5mg-20mcg-30mcg-2000unit-5mcg-200unit-200mcg-75mcg-1mg-30mg, 5mg-113.5mg-1.9mg-10unit-5mg-25mg-25mg-1250unit-10mg-3mcg-1000unit-200mcg-0.9mg, 55mcg-15unit-75mcg-2.5mg-5mg-20mcg-30mcg-2000unit-7.5mcg-200unit-200mcg-300mcg-2.5mg-37.5mg,50mg-1.25mg-15unit-20mcg-1250unit-4.5mcg-400unit-200mcg-75mcg-1mg-15mg
Drug Name DrugTier
Requirements/Limits
multiple vitamins w/minerals liqd 25mcg/15ml-2mg/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-9mg/15ml-20mg/15ml-1.7mg/15ml-10mg/15ml-1300unit/15ml-6mcg/15ml-400unit/15ml-2mg/15ml-1.5mg/15ml-30unit/15ml-300mcg/15ml-60mg/15ml,1000mg/15ml-2mg/15ml-15mg/15ml-15mcg/15ml-10mg/15ml-50mg/15ml-15mg/15ml-50mg/15ml-5000unit/15ml-50mcg/15ml-50mg/15ml-800mcg/15ml-150mcg/15ml-50mg/15ml,25mcg/15ml-2mg/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-9mg/15ml-1.7mg/15ml-10mg/15ml-20mg/15ml-1300unit/15ml-6mcg/15ml-400unit/15ml-1.5mg/15ml-30unit/15ml-300mcg/15ml-2mg/15ml-60mg/15ml, 25mcg/15ml-2mg/15ml-30unit/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-9mg/15ml-20mg/15ml-1.7mg/15ml-10mg/15ml-1300unit/15ml-6mcg/15ml-1000unit/15ml-2mg/15ml-1.5mg/15ml-300mcg/15ml-60mg/15ml,7.5mg/5ml-2500unit/5ml-750mcg/5ml-25mcg/5ml-5mg/5ml-2.5unit/5ml-75mg/5ml-100unit/5ml-12.5mg/5ml-10mg/5ml-5mcg/5ml-7.5mg/5ml-200mcg/5ml-25mcg/5ml-225mg/5ml-250mg/5ml,37mg/15ml-112.5mcg/15ml-75mg/15ml-15mg/15ml-15mg/15ml-45mg/15ml-2.55mg/15ml-5250unit/15ml-18mcg/15ml-600unit/15ml-2.25mg/15ml-300mcg/15ml-45unit/15ml-
F
RX/OTC
Nebraska Total Care Updated December 1, 2017
174
Drug Name DrugTier
Requirements/Limits
150mcg/15ml-3mg/15ml-90mg/15ml, 1.7mg/15ml-25mcg/15ml-2mg/15ml-30unit/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-9mg/15ml-10mg/15ml-20mg/15ml-6mcg/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml,2mg/15ml-30unit/15ml-150mcg/15ml-25mcg/15ml-25mcg/15ml-3mg/15ml-400unit/15ml-9mg/15ml-1.7mg/15ml-20mg/15ml-10mg/15ml-2500unit/15ml-6mcg/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml, 2500unit/15ml-150mcg/15ml-3mg/15ml-25mcg/15ml-25mcg/15ml-2.5mg/15ml-9mg/15ml-30unit/15ml-400unit/15ml-20mg/15ml-1.7mg/15ml-10mg/15ml-6mcg/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml,250mcg/15ml-2mg/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-30unit/15ml-9mg/15ml-20mg/15ml-1.7mg/15ml-10mg/15ml-6mcg/15ml-400unit/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml
Drug Name DrugTier
Requirements/Limits
multiple vitamins w/minerals tabs 72mg-25mcg-2500unit-5mcg-20mcg-2mg-109mg-150mcg-162mg-10mcg-65mcg-150mcg-10mcg-2mg-80mg-160mcg-3.5mg-100mg-400unit-15mg-1.5mg-18mg-20mg-1.7mg-10mg-6mcg-400mcg-30unit-30mg-2mg-60mg,16.667mcg-133.333unit-53.333mg-8333.333unit-166.667mg, 32mg-70mcg-200mcg-2mg-30unit-300mg-2500unit-2mg-15mg-50mg-1.9mg-18mg-12.5mg-25mg-80mcg-2.125mg-7.5mcg-400unit-400mcg-2.5mg-60mg,15mcg-2500unit-500mg-7.5mg-1mg-50mg-18mg-15unit-200unit-6mcg-0.4mg-90mg, 10mcg-5mg-2mg-15mg-30unit-150mcg-15mcg-10mg-40mg-15mcg-100mg-3mg-27mg-10mg-30mg-3.4mg-5500unit-9mcg-400unit-400mcg-15mcg-3mg-120mg, 120mg-20mcg-180mcg-4mg-2mg-33unit-150mcg-90mcg-22.5mg-50mg-4.5mg-405mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg,35mcg-72mg-10mcg-100mcg-2.3mg-10mcg-5mcg-0.9mg-20mg-45unit-150mcg-50mcg-80mg-210mg-100mg-2mg-150mcg-11mg-1.2mg-600mcg-8mg-15mg-3500unit-16mg-60mcg-1.3mg-6mcg-600unit-200mcg-40mcg-2mg-90mg,200unit-2500unit-25mcg-75mg, 5000unit-30unit-40mcg-2mg-40mg-2mg-60mg, 66.667mcg-4.167mcg-66.667unit-
F
RX/OTC
Nebraska Total Care Updated December 1, 2017
175
Drug Name DrugTier
Requirements/Limits
33.333mg-33.333mcg-50mcg-83.333mg-7.5mg-11.667mg-33.333mg-3.333mg-333.333mg-33.333mg-33.333mg-16.667mg-1666.667unit-33.333mcg-16.667mg-266.667mcg-100mcg-16.667mg-133.333unit,200mcg-70mcg-5mg-150mcg-75mcg-50unit-2mg-15mg-150mg-3mg-100mg-20mg-5000unit-25mg-10mcg-3.4mg-30mcg-500unit-500mcg-666mcg-4mg-100mg,600mcg-12mg-72mg-10mcg-35mcg-1.5mg-2.3mg-5mcg-110mg-50unit-150mcg-45mcg-2mg-80mg-220mg-150mcg-50mg-1.5mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-30mcg-600unit-500mcg-300mcg-3mg-90mg,10mcg-20mcg-25mcg-120mcg-2mg-10mcg-5mcg-72mg-2mg-108mg-30unit-75mcg-150mcg-162mg-150mcg-2mg-80mg-15mg-100mg-1.5mg-18mg-10mg-5000unit-250mcg-20mg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 10mcg-0.5mg-35mg-107.5unit-37.5mcg-30mcg-18.75mcg-0.9mg-21.15mg-25mg-0.38mg-0.075mg-83.25mg-0.83mg-2.5mg-1.67mg-2.5mg-6.25mcg-2.5mg-1.5mcg-100unit-0.5mg-100mcg-7.5mcg-128mg,34mg-10mcg-100mg-150mcg-130mg-15mg-2mg-10mcg-37.5mg-10mcg-2.5mg-100mg-18mg-30unit-400unit-5000unit-1.7mg-10mg-6mcg-1.5mg-20mg-400mcg-30mcg-2mg-
Drug Name DrugTier
Requirements/Limits
60mg, 150mcg-72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-5mcg-109mg-30unit-150mcg-160mcg-80mg-162mg-2mg-2mg-15mg-100mg-1.5mg-18mg-10mg-5000unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,7.5mg-10mcg-150mcg-41mg-15mg-2mg-15mcg-7.5mg-15mcg-5mg-100mg-27mg-30unit-400unit-5500unit-30mg-3.4mg-10mg-9mcg-3mg-0.4mg-15mcg-3mg-120mg,110mcg-120mcg-2mg-22.5unit-100mg-2mg-15mg-120mg-1.2mg-300mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-700unit-400mcg-30mcg-3mg-60mg,72mg-10mcg-3500unit-20mcg-48mg-150mcg-200mg-15mg-10mcg-2mg-150mcg-150mcg-2mg-80mg-5mcg-75mcg-2mg-100mg-45unit-400unit-300mcg-250mcg-1.7mg-10mg-25mcg-20mg-1.5mg-400mcg-30mcg-3mg-60mg,40mcg-5000unit-30mg-2mg-40mg-60mg, 120mg-105mcg-180mcg-4mg-2mg-33unit-150mcg-90mcg-40mg-22.5mg-100mg-4.5mg-600mcg-120mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg,25mcg-300mcg-25mcg-25mcg-27mg-5mg-2mg-125mg-34unit-150mcg-162mg-30mg-5000unit-15mg-100mg-2.25mg-27mg-10mg-20mg-25mcg-2.6mg-9mcg-400unit-400mcg-45mcg-3mg-90mg,2mg-12mg-8mg-500mcg,
Nebraska Total Care Updated December 1, 2017
176
Drug Name DrugTier
Requirements/Limits
72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-2mg-109mg-30unit-150mcg-160mcg-2mg-80mg-100mg-150mcg-15mg-1.5mg-162mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 25mcg-50mcg-200mg-10.5mg-25mcg-500mcg-50mcg-500mcg-2.4mg-32mg-50mcg-5mg-100mg-3.6mg, 1mg-5mg-45mg-150mcg-60mg-15mg-2mg-16mg-1.5mg-5000unit-1.7mg-10mg-6mcg-400unit-20mg-400mcg-30unit-2mg-60mg,18mg-0.8mg-1.3mg-7mg-50unit-25mg-100mg-10mg-25mg-25mcg-10mg-0.4mg-300mg, 46mg-60mg-3mg-24mg-20mg-20mg-5mg-20mcg-100mg-400mcg-100mcg-20mg-500mg,105mcg-2500unit-60unit-4mg-75mcg-150mcg-162mg-2mg-120mcg-100mg-20mg-15mg-1.5mg-80mcg-1.7mg-10mg-25mcg-1000unit-400mcg-30mcg-6mg-180mg,0.2mg-35mcg-150mcg-30mg-2mg-50unit-15mg-7.5mg-10mg-30mg-100mg-30mg-5000unit-30mcg-30mg-400mcg-30mcg-30mg-300mg-400unit,25mg-1mg-12.5mg-1mg-75mcg-50mcg-1mg-50mcg-1mg-25mcg-2.5mg-13.5mg-12.5mg-7.5mg-100mg-40mg-250mg-5mg-40mg-250mcg-40mg-10mcg-5mg-37.5mcg-40mg-5000unit-40mcg-200unit-200mcg-50unit-40mcg-40mg-100mg, 2mg-72mg-20mcg-150mcg-5mcg-48mg-75mcg-200mg-10mcg-150mcg-
Drug Name DrugTier
Requirements/Limits
150mcg-80mg-2mg-100mg-300mcg-10mg-20mg-10mcg-1.7mg-25mcg-400unit-1.5mg-400mcg-30mcg-3mg, 7mg-10mcg-50mcg-25mcg-7.5mg-10mcg-5mcg-125mg-30unit-50mcg-2mg-150mcg-162mg-50mcg-150mcg-7.7mg-3mg-15mg-100mg-5mg-300mcg-25mg-3500unit-275mcg-30mg-5mg-10mg-12mcg-400unit-400mcg-40mcg-5mg-90mg, 1mg-1.5mg-15mg-5.5unit-0.15mg-1mg-5mg-10mg-10mg-10000unit-30mg-5mg-3mcg-400unit-1.7mg-100mg, 35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-2mg-80mg-75mcg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 10mg-25mg-10mg-10mg-75mg-15mcg-105mcg-4mg-15mcg-7.5mcg-48mg-60unit-150mcg-112.5mcg-200mg-180mg-225mcg-10mg-2mg-80mg-3000unit-2mg-22.5mg-100mg-1.5mg-350mcg-3000unit-300mcg-20mg-1.7mg-15mg-30mcg-400unit-400mcg-30mcg-3mg-120mg, 120mg-27mcg-4.2mg-180mcg-30unit-150mcg-90mcg-500mg-50mg-2.2mg-24mg-4.5mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-1000unit-400mcg-30mcg-6mg-120mg, 2mg-72mg-10mcg-20mcg-120mcg-2mg-5mcg-2mg-109mg-30unit-150mcg-75mcg-162mg-10mcg-80mg-150mcg-15mg-
Nebraska Total Care Updated December 1, 2017
177
Drug Name DrugTier
Requirements/Limits
100mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-1.5mg-400mcg-30mcg-2mg-60mg, 2mg-72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-5mcg-2mg-109mg-30unit-150mcg-160mcg-162mg-80mg-150mcg-15mg-100mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-400unit-1.5mg-400mcg-30mcg-2mg-60mg, 35mcg-2mg-72mg-10mcg-100mcg-150mcg-2.3mg-10mcg-5mcg-0.9mg-20mg-45unit-150mcg-50mcg-210mg-80mg-11mg-100mg-1.2mg-600mcg-8mg-15mg-3500unit-16mg-60mcg-1.3mg-6mcg-600unit-200mcg-40mcg-2mg-90mg, 3333.3unit-0.66mg-25mg-115mg-5mg-0.033mg-15mg-10mg-0.33mg-25mcg-26.6mg-20unit-133.3unit-16.6mg-5mg-5mg-5mcg-15mg-10mg-0.025mg-5mcg-5mg-10mg-66.6mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-50mg-150mcg-11mg-1.5mg-300mcg-220mg-10mg-250mcg-20mg-30mcg-1.7mg-2500unit-25mcg-500unit-400mcg-30mcg-3mg-60mg, 70mcg-2500unit-60unit-4mg-75mcg-150mcg-200mg-2mg-120mcg-100mg-20mg-15mg-1.5mg-80mcg-1.7mg-10mg-25mcg-1000unit-400mcg-30mcg-6mg-180mg, 120mg-105mcg-4mg-180mcg-2mg-33unit-150mcg-90mcg-40mg-22.5mg-
Drug Name DrugTier
Requirements/Limits
100mg-4.5mg-600mcg-120mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg,40mcg-5000unit-2mg-40mg-30unit-60mg,110mcg-120mcg-2mg-210mg-140mg-22.5unit-2mg-15mg-1.35mg-300mcg-16mg-3500unit-18mg-20mcg-1.7mg-18mcg-700unit-400mcg-75mcg-3mg-60mg,5000unit-10mcg-31mg-150mcg-40mg-15mg-2mg-15mcg-10mg-15mcg-5mg-100mg-27mg-30unit-400unit-3mg-3.4mg-10mg-9mcg-20mg-400mcg-30mcg-3mg-90mg, 32mg-70mcg-200mcg-2mg-2mg-30unit-300mg-50mg-2500unit-15mg-1.9mg-18mg-12.5mg-25mg-80mcg-2.125mg-7.5mcg-400unit-400mcg-2.5mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-50mg-75mcg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 20mcg-120mcg-2mg-2mg-30unit-450mg-50mg-15mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-800unit-1.5mg-0.4mg-30mcg-2mg-60mg, 50mcg-2mg-72mg-19mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mg-45mcg-80mg-10mcg-11mg-50mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-1000unit-400mcg-30mcg-3mg-60mg, 30unit-10mg-
Nebraska Total Care Updated December 1, 2017
178
Drug Name DrugTier
Requirements/Limits
70mcg-5000unit-10mg-25mcg-100mcg-100mg-30mg-25mcg-2mg-200mcg-2.4mg-25mg-100mcg-6mg-100mg-5000unit-10mg-8mg-10mg-10mg-15mg-25mg-25mcg-400unit-15mg-25mg-400mcg-300mcg-25mg-100mg, 2mg-72mg-72mg-10mcg-10mcg-20mcg-20mcg-120mcg-120mcg-2mg-2mg-10mcg-10mcg-30unit-30unit-75mcg-75mcg-80mg-80mg-162mg-162mg-100mg-100mg-150mcg-150mcg-15mg-15mg-1.5mg-1.5mg-300mcg-300mcg-150mcg-150mcg-10mg-10mg-3500unit-3500unit-250mcg-250mcg-20mg-20mg-25mcg-25mcg-1.7mg-1.7mg-6mcg-6mcg-400unit-400unit-400mcg-400mcg-30mcg-30mcg-2mg-2mg-60mg-60mg,32mg-70mcg-80mcg-200mcg-2mg-2mg-30unit-2500unit-15mg-50mg-1.9mg-300mg-18mg-12.5mg-25mg-2.125mg-7.5mcg-400unit-400mcg-2.5mg-60mg, 7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-2mg-31mg-60unit-150mcg-75mcg-40mg-2mg-7.5mg-100mg-150mcg-15mg-3mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-400mcg-30mcg-6mg-90mg, 37mg-121mg-2.2mg-15mcg-15mg-1mg-125mg, 20mcg-120mcg-2mg-2mg-30unit-15mg-50mg-5mg-450mg-15mg-5mg-10mg-25mcg-1.7mg-2500unit-5mcg-500unit-400mcg-30mcg-2mg-60mg, 120mcg-2mg-2500unit-2mg-30unit-
Drug Name DrugTier
Requirements/Limits
20mcg-50mg-15mg-1.5mg-450mg-18mg-5mg-25mcg-1.7mg-6mcg-400unit-10mg-400mcg-30mcg-2mg-60mg, 0.6mg-10mg-10mg-897mcg-58mg-25unit-150mcg-125mg-0.6mg-20mg-5mg-10mg-3.3mg-15mg-10mg-10mg-25mg-5mg-2500unit-25mcg-50unit-7.2mg-7.5mg-25mcg-25mcg-6.5mg-3.5mg-50mg, 25mg-120mcg-25mg-70mcg-80mcg-5000unit-2mg-50unit-150mcg-75mcg-150mcg-2mg-15mg-100mg-225mg-9mg-275mcg-20mg-1.7mg-10mg-12mcg-400unit-1.5mg-400mcg-30mcg-2mg-120mg, 35mcg-1mg-1mg-60mcg-7mg-25unit-75mcg-37.5mcg-100mg-50mg-500unit-11.5mg-0.75mg-150mcg-1mg-5mg-5mg-10mg-15mcg-0.85mg-3mcg-200unit-200mcg-15mcg-1mg-75mg, 45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.9mg-110mg-50unit-150mcg-220mg-80mg-45mcg-50mg-2mg-150mcg-11mg-1.5mg-300mcg-2500unit-250mcg-20mg-30mcg-1.7mg-10mg-25mcg-500unit-500mcg-30mcg-3mg-90mg, 30unit-10mg-18mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,25mcg-30mg-60mg-30unit-
Nebraska Total Care Updated December 1, 2017
179
Drug Name DrugTier
Requirements/Limits
5mg-100mg-50mg-50mg-25mcg-50mg-400mcg-50mg-600mg, 17.5mcg-20mg-0.5mg-10mg-75unit-5mg-125mg, 180mg-20mcg-120mcg-2mg-30unit-300mg-2mg-15mg-50mg-2.4mg-18mg-5mg-2500unit-10mg-25mcg-2.7mg-9.5mcg-800unit-400mcg-30mcg-3.2mg-60mg, 10unit-150mcg-125mg-1mg-5mg-400unit-5000unit-20mg-1.7mg-3mcg-1.5mg-100mcg-1mg-50mg, 72mg-10mcg-5000unit-20mcg-46mg-150mcg-200mg-15mg-10mcg-2mg-130mcg-150mcg-2mg-60mg-5mcg-160mcg-3.5mg-100mg-4mg-45unit-400unit-15mg-1.7mg-10mg-25mcg-3mg-20mg-400mcg-30mcg-60mg, 50mg-25mg-60mg-45mg-72.5mg-10mcg-18mg-70mcg-4mg-10mcg-5mcg-48mg-60unit-150mcg-75mcg-100mg-120mcg-150mcg-4mg-80mg-2000unit-2mg-15mg-40mg-4.5mg-3000unit-250mcg-35mg-25mcg-5.1mg-10mg-21mcg-400unit-400mcg-40mcg-6mg-120mg, 15unit-20mg-30mg-1.5mg-20mg-1.5mg-2500unit-50mcg-400unit-400mcg-5mg-30mg,105mcg-120mcg-2mg-45unit-100mg-2mg-15mg-120mg-1.2mg-600mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 50mcg-1.75mg-5mg-0.5mg-1.5mg-25mcg-32mg-12.5mcg-200mg-0.75mg-3.75mg-75mg-1.25mg-11.25mcg-5mg-5mg-12.5mg-75mcg-5mg-12.5mcg-200unit-
Drug Name DrugTier
Requirements/Limits
5mg-200mcg-6.25mg-30mg, 60mg-50mg-4mg-72mg-10mcg-70mcg-120mcg-4mg-10mcg-5mcg-2mg-48mg-60unit-150mcg-75mcg-100mg-80mg-60mcg-15mg-40mg-18mg-10mg-5000unit-40mg-25mcg-5.1mg-18mcg-4.5mg-400mcg-40mcg-6mg-120mg-400unit,0.6mg-10mg-50mg-10mg-897mcg-73mg-54mg-25unit-150mcg-0.5mg-20mg-5mg-10mg-3.3mg-15mg-10mg-10mg-25mg-5mg-2500unit-25mcg-50unit-7.2mg-7.5mg-25mcg-25mcg-6.5mg-3.5mg-50mg, 60mg-50mg-72mg-70mcg-4mg-5mcg-48mg-60unit-75mcg-150mcg-100mg-10mcg-120mcg-60mcg-10mcg-4mg-80mg-40mg-2mg-15mg-4.5mg-18mg-3500unit-40mg-25mcg-5.1mg-10mg-18mcg-400mcg-40mcg-6mg-120mg-400unit, 35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-80mg-2mg-150mcg-11mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg,5mg-200mcg-30unit-200mg-60mg-15mg-50mg-1.5mg-5mg-2500unit-10mg-1mg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg, 72mg-20mcg-3500unit-45unit-2mg-48mg-150mcg-75mcg-80mg-200mg-10mcg-2mg-150mcg-150mcg-2mg-5mcg-15mg-100mg-1.5mg-300mcg-10mg-250mcg-
Nebraska Total Care Updated December 1, 2017
180
Drug Name DrugTier
Requirements/Limits
20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 70mcg-200mcg-2mg-2mg-30unit-50mg-15mg-1.9mg-200mg-18mg-12.5mg-2500unit-25mg-80mcg-2.1mg-7.5mcg-400unit-400mcg-2.5mg-10mg-60mg,8.333mg-1mg-15mg-1.667mg-50mg-37.5mcg-236.667mg-3.333mg-1.667mg-2.5mg-4.167mcg-33.333mg-8.333mg-1mg-4.167mg-8.333mg-5mg-8.333mg-10mg-8.333mg-0.667mg-1666.666unit-2.667mcg-33.333unit-1.667mg-66.667mcg-5unit-1000mcg-1.667mg-40mg,30unit-10mg-70mcg-5000unit-10mg-25mcg-100mcg-100mg-30mg-25mcg-2mg-200mcg-2.4mg-25mg-100mcg-6mg-100mg-20mg-5000unit-10mg-8mg-10mg-10mg-15mg-25mg-25mcg-400unit-15mg-25mg-400mcg-300mcg-25mg-100mg, 7mg-5mg-30unit-200mg-60mg-15mg-50mg-1.5mg-5mg-2500unit-10mg-1mg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg, 150mcg-50mcg-10mcg-72mg-55mcg-35unit-2.3mg-20mg-150mcg-50mcg-15mg-80mg-500mg-5mcg-50mg-0.5mg-15mg-1.1mg-8mg-3500unit-300mcg-14mg-50mcg-1.1mg-5mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 35mg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-
Drug Name DrugTier
Requirements/Limits
400unit-30mcg-2mg-60mg,35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,2mg-72mg-10mcg-55mcg-25mcg-35mcg-2.3mg-10mcg-5mcg-109mg-30unit-45mcg-150mcg-150mcg-80mg-0.9mg-11mg-100mg-1.5mg-300mcg-200mg-18mg-10mg-3500unit-250mcg-20mg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 105mcg-120mcg-2mg-45unit-100mg-120mg-2mg-15mg-1.2mg-0.6mg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400mcg-30mcg-3mg-90mg-400unit,15mg-30unit-20mg-10mg-4mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-300mg, 60mcg-2mg-72mg-10mcg-100mcg-4mg-5mcg-0.7mg-20mg-60unit-150mcg-50mcg-250mg-80mg-150mcg-15mg-50mg-1.5mg-600mcg-10mg-3500unit-300mcg-20mg-60mcg-1.7mg-100mcg-600unit-300mcg-30mcg-6mg-120mg, 55mcg-5mg-100unit-1000unit-2mg-40mg-2mg-40mg-3mg-5mg-300mg, 25mg-200mcg-25mg-200mcg-200mcg-7.5mg-13mcg-6.5mcg-60unit-200mcg-150mcg-79.95mg-13mcg-2500unit-500mcg-3.5mg-17mg-100mg-4.5mg-200mg-12.5mg-500mcg-25mg-10mcg-5.1mg-
Nebraska Total Care Updated December 1, 2017
181
Drug Name DrugTier
Requirements/Limits
30mcg-400unit-400mcg-60mcg-6mg-75mg, 20mcg-120mcg-2mg-2mg-22.5unit-150mcg-15mg-1.5mg-500mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg, 50mcg-2mg-72mg-10mcg-50mcg-55mcg-150mcg-2.3mg-5mcg-0.5mg-20mg-150mg-80mg-500mg-50mg-35unit-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 50mg-162mg-0.25mg-25000unit-15mg-24.3mg-0.1mg-53.5mg-50mg-6.15mg-2.2mg-7.2mg-12.5unit-400unit-25mg-5mg-15mg-12.5mg-50mg-250mg-150mg-25mg-50mcg-25mg-0.4mg-1mcg-15mg-150mg, 3mg-30mg-23.9mg-30unit-70mg-25mg-10mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 20mcg-120mcg-2mg-2mg-22.5unit-500mg-15mg-50mg-1.5mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 8.333mg-1mg-10mg-50mg-37.5mcg-244.333mg-3.333mg-1.667mg-2.5mg-4.167mcg-33.333mg-8.333mg-1mg-4.167mg-8.333mg-5mg-8.333mg-10mg-25mg-1.667mg-1666.667unit-2.667mcg-33.333unit-1.667mg-66.667mcg-5unit-1000mcg-1.667mg-40mg,150mcg-15mg-2mg-5mg-18mg-30mg-65mg-125mg-100mg-6mcg-35mg-400mcg-300mcg, 5000unit-125mg-18mg-150mcg-
Drug Name DrugTier
Requirements/Limits
160mg-100mg-15mg-400unit-1.7mg-6mcg-1.2mg-20mg-0.4mg-2mg-60mg, 40mcg-30unit-44mg-5000unit-2mg-40mg-60mg,20mcg-2mg-120mcg-2mg-30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-800unit-400mcg-30mcg-2mg-60mg,5000unit-450mg-15mg-27mg-30unit-400unit-1.5mg-1.7mg-10mg-6mcg-20mg-400mcg-2mg-60mg,100mcg-50mcg-25mcg-2.5mg-7.5mg-75mcg-50mg-30unit-100mg-50mg-1.5mg-100mg-10mg-250mcg-20mg-1.7mg-2500unit-5mcg-200unit-200mcg-75mcg-2.5mg-60mg, 30unit-5000unit-1.7mg-10mg-6mcg-1.5mg-20mg-0.4mg-2mg-60mg-400unit, 50mg-20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-2.4mg-300mg-18mg-5mg-2500unit-10mg-25mcg-2.7mg-9.5mcg-600unit-400mcg-30mcg-3.2mg-120mg-60mg, 16.67mg-66.67unit-2500unit-16.67mg-33.33mg-25mcg-83.33mg-5mg-4.17mcg-33.33mcg-0.4mg-16.5mg-8.33mcg-3.33mg-83.33mg-8.33mg-16.67mg-33.33mg-8.33mg-66.67mg-16.67mcg-16.67unit-16.67mg-31.67mg-133.33mcg-50mcg-16.67mg-100mg-200mg,70mcg-30unit-15mg-1.5mg-20mg-1.7mg-10mg-6mcg-2000unit-800mcg-300mcg-10mg-80mg,45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-220mg-
Nebraska Total Care Updated December 1, 2017
182
Drug Name DrugTier
Requirements/Limits
80mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.05mg-20mg-35unit-150mcg-50mcg-500mg-80mg-150mcg-15mg-50mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 16.666mg-1mg-3.333mg-42.666mg-5unit-86.666mg-0.666mg-2.5mg-16.666mg-3.333mg-3.333mg-5mg-8.333mg-10mg-3.333mg-1.666mg-1666.666unit-2.666mcg-333.333unit-1.666mg-66.666mcg-1666.666mcg-1.666mg-20mg, 2mg-7.5mg-10mcg-70mcg-120mcg-2mg-10mcg-5mcg-31mg-60unit-150mcg-75mcg-40mg-150mcg-7.5mg-2mg-15mg-100mg-9mg-10mg-5000unit-250mcg-20mg-28mcg-3.4mg-12mcg-400unit-3mg-400mcg-30mcg-6mg-90mg,150mcg-5mg-15mg-2mg-30mg-100mg-125mg-500mg-6mcg-35mg-400mcg-100mcg, 30unit-45mg-1.5mg-10mg-3000unit-20mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg, 45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.9mg-110mg-50unit-150mcg-45mcg-80mg-220mg-2mg-50mg-150mcg-11mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-500mcg-30mcg-3mg-
Drug Name DrugTier
Requirements/Limits
90mg, 36mg-10mcg-25mcg-25mcg-120mcg-2mg-10mcg-5mcg-77mg-50unit-150mcg-25mcg-100mg-2mg-40mg-100mg-20mg-150mcg-2mg-15mg-1.5mg-9mg-10mg-3000unit-250mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-120mg,35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-50mg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,117mcg-180mcg-4.2mg-2.2mg-25.5unit-150mcg-90mcg-110mg-24mg-4.5mg-370mcg-120mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-6mg-120mg, 7.5mg-28mcg-5000unit-21mcg-31mg-150mcg-40mg-15mg-10mcg-2mg-26mcg-150mcg-10mcg-2mg-7.5mg-5mcg-32mcg-3.5mg-100mg-18mg-30unit-400unit-3.4mg-10mg-9mcg-3mg-20mg-3mg-400mcg-30mcg-90mg,7.5mg-10mcg-31mg-150mcg-40mg-15mg-2mg-15mcg-7.5mg-15mcg-5mg-100mg-27mg-2500unit-30unit-400unit-2500unit-20mg-3.4mg-10mg-9mcg-3mg-0.4mg-30mcg-3mg-90mg, 100mcg-70mcg-150mcg-75mcg-10mcg-2mg-60unit-250mcg-2mg-15mg-100mg-10mg-100mg-18mg-10mg-25mg-100mg-100mcg-10mg-3000unit-25mcg-2000unit-400mcg-30mcg-6mg-100mg, 27mcg-180mcg-
Nebraska Total Care Updated December 1, 2017
183
Drug Name DrugTier
Requirements/Limits
4.2mg-30unit-150mcg-90mcg-50mg-2.2mg-24mg-4.5mg-500mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-1000unit-400mcg-30mcg-6mg-120mg, 35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-2mg-50mg-75mcg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 120mcg-50mg-4mg-72mg-10mcg-70mcg-4mg-10mcg-5mcg-0.9mg-48mg-60unit-150mcg-75mcg-80mg-100mg-40mg-60mcg-11mg-4.5mg-18mg-12mg-3500unit-40mg-25mcg-5.1mg-18mcg-400unit-400mcg-50mcg-6mg-120mg,110mcg-120mcg-2mg-22.5unit-210mg-100mg-2mg-15mg-120mg-1.2mg-300mcg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-700unit-400mcg-30mcg-3mg-60mg, 55mcg-60unit-1000unit-2mg-40mg-200mg, 70mcg-2mg-150mcg-2mg-30unit-2500unit-15mg-50mg-1.9mg-300mg-18mg-12.5mg-25mg-80mcg-2.1mg-7.5mcg-400unit-400mcg-2.5mg-60mg,10000unit-25mcg-200unit-200mg, 0.5mg-25000unit-30mg-0.15mg-6mg-25mg-7mg-100unit-1000unit-30mg-5mg-10mg-50mg-10mg-30mg-80mg-30mg-80mg-80mg-80mg-80mg-80mg-80mcg-80mg-400mcg-80mcg-80mg-250mg, 2mg-72mg-10mcg-55mcg-25mcg-1.8mg-10mcg-5mcg-20mg-
Drug Name DrugTier
Requirements/Limits
150mcg-50mcg-80mg-150mcg-100mg-35unit-0.9mg-8mg-1.1mg-500mg-18mg-15mg-3500unit-14mg-50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-20mg-30unit-150mcg-45mcg-200mg-75mcg-80mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,12.5mg-100mcg-9mg-1mg-1mg-25unit-75mcg-37.5mcg-5mcg-2500unit-50mcg-7.5mg-50mg-12.5mg-25mg-375mcg-250mg-50mcg-25mg-375mcg-17.5mg-40mcg-25mg-40mcg-200unit-200mcg-150mcg-25mg-50mg, 2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-45mcg-50mg-150mcg-11mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,110mcg-120mcg-2mg-2mg-22.5unit-15mg-140mg-1.35mg-300mcg-210mg-16mcg-3500unit-18mg-20mcg-1.7mg-18mcg-700unit-400mcg-75mcg-3mg-60mg, 25mg-10mg-25mg-170mg-5unit-150mcg-1.8mg-20mg-16mg-200mg-6mcg-400mcg-300mcg, 110mcg-120mcg-2mg-2mg-22.5unit-15mg-140mg-1.35mg-300mcg-210mg-16mg-3500unit-18mg-20mcg-1.7mg-18mcg-700unit-400mcg-75mcg-
Nebraska Total Care Updated December 1, 2017
184
Drug Name DrugTier
Requirements/Limits
3mg-60mg, 7160unit-100unit-0.4mg-17.4mg-113mg, 7.5mg-10mcg-31mg-150mcg-40mg-15mg-2mg-15mcg-7.5mg-15mcg-5mg-100mg-27mg-1250unit-30unit-400unit-5000unit-30mg-3.4mg-10mg-9mcg-3mg-0.4mg-35mcg-3mg-90mg, 2mg-72mg-10mcg-20mcg-10mcg-150mcg-2mg-5mcg-48mg-45unit-75mcg-150mcg-150mcg-80mg-2mg-15mg-100mg-1.5mg-300mcg-200mg-10mg-3500unit-250mcg-20mg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 2mg-7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-31mg-60unit-150mcg-75mcg-7.5mg-40mg-150mcg-2mg-15mg-100mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-3mg-400mcg-30mcg-6mg-90mg, 2mg-72mg-10mcg-20mcg-25mcg-120mcg-2mg-10mcg-5mcg-109mg-30unit-75mcg-150mcg-150mcg-80mg-2mg-15mg-100mg-1.5mg-300mcg-162mg-18mg-10mg-3500unit-250mcg-20mg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-150mcg-80mg-11mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 72mg-20mcg-2mg-5mcg-48mg-45unit-75mcg-150mcg-200mg-10mcg-150mcg-2mg-
Drug Name DrugTier
Requirements/Limits
80mg-150mcg-2mg-15mg-100mg-1.5mg-300mcg-3500unit-250mcg-20mg-10mcg-1.7mg-10mg-25mcg-400mcg-30mcg-3mg-60mg-400unit, 2mg-10mcg-20mcg-120mcg-2mg-10mcg-5mcg-2mg-109mg-30unit-150mcg-75mcg-72mg-162mg-150mcg-80mg-15mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-500mg-80mg-50mg-150mcg-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 117mcg-180mcg-4.2mg-25.5unit-150mcg-90mcg-110mg-2.2mg-24mg-4.5mg-370mcg-120mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-6mg-120mg, 50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-500mg-150mcg-80mg-15mg-50mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 20mcg-120mcg-2mg-22.5unit-150mcg-20mg-2mg-15mg-1.5mg-500mg-18mg-10mg-2500unit-25mcg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg,35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-
Nebraska Total Care Updated December 1, 2017
185
Drug Name DrugTier
Requirements/Limits
150mcg-45mcg-200mg-80mg-2mg-75mcg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 12.5mg-2.5mg-1mg-5mg-5mg-12.5mg-0.5mg-12.5mg-12.5mg-12.5mg-5mg-36mg-6.5mcg-100mcg-3.75mg-100mcg-6.5mcg-2.5mg-2.5mg-3.25mcg-65mg-30unit-75mcg-104mcg-250mg-1mg-40mg-1.75mg-7.5mg-100mg-6mg-13.5mg-15mg-3750unit-37.5mcg-20mg-40mcg-8.5mg-9mcg-200unit-200mcg-30mcg-5mg-60mg, 40mcg-30unit-5000unit-2mg-40mg-60mg,105mcg-120mcg-2mg-45unit-210mg-99mg-2mg-15mg-120mg-1.2mg-600mcg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400mcg-30mcg-3mg-90mg-400unit,20mcg-120mcg-2mg-2mg-30unit-50mg-15mg-1.5mg-450mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 60mcg-72mg-10mcg-100mcg-4mg-5mcg-0.7mg-20mg-60unit-150mcg-50mcg-80mg-250mg-2mg-50mg-150mcg-15mg-1.5mg-600mcg-10mg-3500unit-300mcg-20mg-60mcg-1.7mg-100mcg-600unit-300mcg-30mcg-6mg-120mg, 5000unit-450mg-15mg-27mg-30unit-1.5mg-1.7mg-10mg-6mcg-20mg-0.4mg-2mg-60mg-400unit,10000unit-0.125mg-150mcg-0.161mg-15mg-2mg-1.25mg-100mg-24mg-30unit-400unit-100mg-
Drug Name DrugTier
Requirements/Limits
10mg-20mg-6mcg-10mg-0.4mg-5mg-250mg,55mcg-2mg-60unit-1000unit-40mg-2mg-200mg, 34mg-105mcg-180mcg-4mg-2mg-33unit-150mcg-90mcg-40mg-22.5mg-100mg-4.5mg-120mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg, 5mg-90mg-10mcg-45mcg-3500unit-2mg-10mcg-5mcg-30unit-150mcg-25mcg-2mg-100mcg-99mg-40mg-150mcg-15mg-3mg-250mg-9mg-10mg-40mg-25mcg-3.4mg-12mcg-400unit-400mcg-300mcg-4mg-60mg, 10mg-25mcg-25mcg-4000unit-15mg-50mg-5mcg-50unit-100mg-15mg-0.25mg-1mg-10mg-5mg-15mg-1000unit-10mg-100unit-10mg-10mcg-5mg-15mg-10mg-25mg-10mg-10mg-25mg-15mg-25mg-200mcg-1mcg-100mg, 120mg-20mcg-100mcg-33unit-150mcg-90mcg-4mg-2mg-22.5mg-50mg-4.5mg-405mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg, 40mcg-2mg-30unit-5000unit-40mg-60mg, 10mg-70mcg-20mcg-120mcg-2mg-33unit-100mg-2mg-15mg-120mg-1.1mg-240mg-5mg-3000unit-14mg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-75mg, 25mcg-72mg-10mcg-55mcg-1.8mg-10mcg-5mcg-0.9mg-20mg-35unit-150mcg-50mcg-80mg-500mg-2mg-100mg-150mcg-8mg-1.1mg-18mg-15mg-3500unit-14mg-
Nebraska Total Care Updated December 1, 2017
186
Drug Name DrugTier
Requirements/Limits
50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 12.667mg-1mg-30mg-5unit-66.667mg-0.667mg-2.5mg-16.667mg-16.667mg-3.333mg-5mg-8.333mg-10mg-3.333mg-0.667mg-1666.667unit-2.667mcg-333.333unit-1.667mg-66.667mcg-1mg-1.667mg-20mg, 105mcg-20mcg-120mcg-2mg-45unit-100mg-2mg-15mg-120mg-1.2mg-600mcg-210mg-5mg-3500unit-16mg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 22.5mg-27mg-45unit-400unit-2mg-5000unit-30mg-2.6mg-9mcg-0.4mg-20.6mg-90mg, 200unit-1mg-40mg-1mg-5mg-250mg, 12.5mg-1.5mg-10mg-20mg-1.7mg-6mcg-800mcg-300mcg-10mg-60mg, 16.67mg-66.67unit-2500unit-16.67mg-33.33mg-25mcg-83.33mg-5mg-4.17mcg-0.33mg-33.33mcg-0.4mg-16.5mg-8.33mcg-3.33mg-83.33mg-3.33mg-8.33mg-16.67mg-33.33mg-8.33mg-66.67mg-16.67mcg-66.67unit-16.67mg-31.67mg-133.33mcg-50mcg-16.67mg-100mg-200mg, 16.7unit-16.7mcg-12.5mcg-4.16mg-0.08mg-16.7mcg-7.9mg-1.67mg-41.7mg-2.5mg-16.7unit-4.16mg-4.16mg-52.08mg-4.16mg-2083.3unit-10.4mcg-4.16mg-33.3mcg-4.16mg-250mg, 2mg-72mg-72mg-10mcg-10mcg-20mcg-20mcg-150mcg-150mcg-2mg-2mg-5mcg-5mcg-48mg-48mg-45unit-45unit-150mcg-150mcg-75mcg-
Drug Name DrugTier
Requirements/Limits
75mcg-80mg-80mg-200mg-200mg-100mg-100mg-150mcg-150mcg-2mg-2mg-15mg-15mg-1.5mg-1.5mg-300mcg-300mcg-10mg-10mg-3500unit-3500unit-250mcg-250mcg-20mg-20mg-10mcg-10mcg-1.7mg-1.7mg-25mcg-25mcg-400unit-400unit-400mcg-400mcg-30mcg-30mcg-3mg-3mg-60mg-60mg,27mg-70mcg-150mcg-2mg-2mg-30unit-2500unit-15mg-50mg-1.9mg-300mg-18mg-12.5mg-25mg-80mcg-2.125mg-7.5mcg-400unit-400mcg-2.5mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-15mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,12.5mcg-2.5mg-1mg-2.5mg-37.5mcg-75mg-15unit-2500unit-1mg-11.25mg-50mg-15mg-2.5mg-10mg-9mg-10mg-10mg-200unit-300mcg,72mg-50unit-55mcg-110mg-150mcg-220mg-11mg-10mcg-0.9mg-45mcg-150mcg-2mg-80mg-5mcg-45mcg-2.3mg-50mg-300mcg-2500unit-250mcg-20mg-30mcg-1.7mg-10mg-25mcg-500unit-1.5mg-500mcg-30mcg-3mg-90mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-150mcg-45mcg-80mg-50mg-50unit-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-
Nebraska Total Care Updated December 1, 2017
187
Drug Name DrugTier
Requirements/Limits
1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 1mg-1.5mg-5.5unit-0.15mg-1mg-5mg-15mg-15mg-10mg-10000unit-100mg-10mg-7.5mcg-400unit-2mg-150mg, 2mg-72mg-10mcg-20mcg-3.5mg-65mcg-10mcg-5mcg-2mg-109mg-30unit-150mcg-160mcg-80mg-162mg-150mcg-15mg-100mg-1.5mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 1mg-1mg-25mg-1mg-0.5mg-1mg-25mg-5mg-2mg-13mcg-90mg-200mcg-10mg-80mcg-5000unit-7.5mg-2mg-10mg-6.5mcg-80mg-60unit-200mcg-150mcg-165mg-200mcg-1mg-13mcg-2mg-100mg-0.5mg-3.5mg-15mg-100mg-300mcg-18mg-275mcg-40mg-5.1mg-10mg-24mcg-400unit-4.5mg-400mcg-60mcg-6mg-120mg,200mcg-5mg-50mcg-66mg-2.5mg-50unit-400unit-20mg-50mg-20mg-5000unit-100mg-20mg-25mg-50mcg-1000mcg-200mcg-25mg-500mg,52mcg-2mg-72mg-10mcg-50mcg-22mcg-2.3mg-5mcg-0.5mg-20mg-150mcg-80mg-100mg-35unit-15mg-1.1mg-300mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 34mg-25mcg-6000unit-10mcg-15mcg-125mg-150mcg-162mg-15mg-10mcg-2mg-15mcg-80mcg-37.5mg-5mcg-15mcg-2.5mg-100mg-18mg-30unit-400unit-
Drug Name DrugTier
Requirements/Limits
1.7mg-10mg-6mcg-1.5mg-20mg-400mcg-45mcg-2mg-60mg, 400mg-16mcg-1mg-29mg-5mcg-10mcg-60mcg-1mg-5mcg-2.5mcg-0.35mg-40mg-15unit-75mcg-37.5mcg-54mg-32mg-3.75mg-20mg-0.75mg-3mg-5mg-1750unit-10mg-12.5mcg-0.85mg-100mcg-200unit-200mcg-15mcg-2.5mg-30mg, 5mcg-5mcg-1mg-15.8mg-11.6mg-4.5mg-150mcg-3.75mg-10mg-1mg-5000unit-20mg-2.5mg-1mcg-400unit-2mg-1mg-50mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-80mg-100mg-150mcg-11mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg,120mg-20mcg-180mcg-4mg-2mg-22.5unit-150mcg-90mcg-500mg-22.5mg-50mg-4.5mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-1000unit-400mcg-30mcg-6mg-60mg, 7.5mg-21mcg-26mcg-3.5mg-2mg-31mg-30unit-150mcg-32mcg-7.5mg-15mg-100mg-3mg-40mg-18mg-10mg-5000unit-20mg-28mcg-3.4mg-9mcg-400unit-400mcg-30mcg-3mg-90mg,150mcg-70mcg-2mg-2mg-7.5mg-2mg-5mcg-31mg-60unit-150mcg-75mcg-40mg-10mcg-50mcg-10mcg-7.5mg-15mg-100mg-3mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-400mcg-30mcg-6mg-90mg,
Nebraska Total Care Updated December 1, 2017
188
Drug Name DrugTier
Requirements/Limits
150mcg-120mcg-70mcg-2mg-2mg-30unit-150mcg-75mcg-15mg-50mg-4.5mg-700mcg-500mg-18mg-15mg-3500unit-100mcg-20mg-60mcg-5.1mg-18mcg-1000unit-400mcg-300mcg-6mg-60mg, 2mg-72mg-10mcg-20mcg-65mcg-3.5mg-5mcg-2mg-109mg-15mg-30unit-150mcg-160mcg-162mg-10mcg-80mg-150mcg-100mg-1.5mg-18mg-2500unit-20mg-25mcg-1.7mg-10mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-1.5mg-500mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 40mcg-5000unit-30unit-2mg-40mg-60mg,72mg-10mcg-20mcg-150mcg-2mg-5mcg-48mg-45unit-150mcg-75mcg-200mg-2mg-80mg-150mcg-2mg-15mg-100mg-1.5mg-300mcg-10mg-3500unit-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-220mg-150mcg-80mg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 105mcg-200mcg-2mg-154mg-45unit-75mcg-99mg-200mg-2500unit-2mg-22.5mg-100mg-2.2mg-15mg-25mg-25mcg-2.5mg-9mcg-400unit-400mcg-450mcg-3mg-
Drug Name DrugTier
Requirements/Limits
90mg, 25mg-50mg-50mcg-1mg-10000unit-5mg-100mcg-7.5mg-18mg-75mcg-35mg-25mg-1mg-10mg-25unit-400unit-150mcg-15mg-5mg-6mg-25mg-25mcg-50mg-100mg-250mcg-150mcg-25mg-100mcg-25mg-400mcg-30mcg-25mg-150mg, 105mcg-120mcg-2mg-45unit-100mg-2mg-15mg-120mg-1.2mg-600mcg-210mg-5mg-1500unit-18mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg,40mcg-6000unit-50unit-5mg-2mg-40mg-40mg-3mg-5mg-200mg, 2mg-72mg-10mcg-20mcg-45unit-150mcg-2mg-5mcg-2mg-48mg-150mcg-75mcg-80mg-200mg-150mcg-15mg-100mg-1.5mg-300mcg-10mg-3500unit-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 77mg-24mg-30unit-3mg-10mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 10mcg-15mcg-5mg-31mg-30unit-150mcg-15mcg-7.5mg-40mg-2mg-15mg-100mg-3mg-18mg-10mg-5500unit-30mg-3.4mg-9mcg-400unit-400mcg-15mcg-3mg-120mg, 120mg-20mcg-4mg-180mcg-2mg-33unit-150mcg-90mcg-50mg-22.5mg-4.5mg-405mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg, 120mcg-20mcg-22.5unit-2mg-2mg-150mcg-15mg-1.5mg-500mg-18mg-10mg-2500unit-20mg-25mcg-
Nebraska Total Care Updated December 1, 2017
189
Drug Name DrugTier
Requirements/Limits
1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg, 20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-1.6mg-500mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 105mcg-120mcg-2mg-45unit-99mg-210mg-120mg-2mg-15mg-1.2mg-600mcg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 60mcg-10mcg-72mg-10mcg-100mcg-4mg-5mcg-0.7mg-20mg-150mcg-50mcg-250mg-80mg-150mcg-15mg-50mg-1.5mg-600mcg-10mg-300mcg-20mg-60mcg-1.7mg-3500unit-100mcg-600unit-300mcg-60unit-30mcg-6mg-120mg,70mcg-2500unit-50unit-4mg-75mcg-150mcg-162mg-2mg-120mcg-20mg-15mg-100mg-1.5mg-80mcg-1.7mg-10mg-18mcg-1000unit-400mcg-30mcg-4mg-180mg, 60mg-50mg-72mg-10mcg-70mcg-4mg-10mcg-5mcg-48mg-60unit-150mcg-75mcg-80mg-120mcg-4mg-40mg-60mcg-2mg-15mg-4.5mg-100mg-18mg-10mg-3500unit-40mg-25mcg-5.1mg-16mcg-400mcg-40mcg-6mg-120mg-400unit, 0.05mg-50mcg-60unit-20mcg-3mg-15mg-50mg-20mg-10mg-100mg-20mg-25mg-50mcg-1mg-0.15mg-25mg-500mg-400unit, 150mcg-65mcg-72mg-10mcg-20mcg-3.5mg-10mcg-5mcg-2mg-125mg-30unit-150mcg-160mcg-162mg-15mg-80mg-2mg-20mg-
Drug Name DrugTier
Requirements/Limits
100mg-1.5mg-18mg-10mg-5000unit-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-90mg,110mcg-120mcg-2mg-22.5unit-2mg-15mg-140mg-1.35mg-300mcg-210mg-16mg-3500unit-18mg-20mcg-1.7mg-18mcg-700unit-400mcg-75mcg-3mg-60mg,833.33unit-0.03mg-8.33mg-1mg-0.33mg-0.33mg-11.33mg-3.33mg-4.67unit-66.67unit-10mg-43.55mg-0.67mg-2.5mg-1.67mg-3.33mg-0.03mg-1.33mg-33.33mg, 12.5mg-100mcg-25mg-5mg-15mg-0.5mg-12.5mg-20mg-5mg-36mg-6.5mcg-100mcg-3.75mg-100mcg-6.5mcg-2.5mg-2.5mg-12.5mg-3.25mcg-65mg-30unit-75mcg-82.5mg-1mg-40mg-1.75mg-12.5mg-50mg-2.25mg-3750unit-37.5mcg-20mg-40mcg-2.55mg-5mg-9mcg-200unit-200mcg-150mcg-3mg-90mg,5000unit-5mcg-10mg-150mcg-19mg-3.75mg-5mcg-1mg-10mg-4.5mg-2.5mg-1mg-1mcg-400unit-1mg-20mg-2mg-50mg,50mg-30mg-150mcg-1.35mg-75mg-30unit-100mg-1.1mg-100mg-15mg-10mg-6.5mg-5mg-10mg-5000unit-12mcg-400unit-5mg-20mg-400mcg-2mg-150mg,0.5mg-0.375mg-1.5mg-80mg-15unit-75mcg-100mg-2.5mg-7.5mg-5mg-5000unit-15mg-2.5mg-1mcg-400unit-400mcg-1mg-60mg, 33.333mg-33.333mcg-50mcg-83.333mg-7.5mg-66.667mcg-11.667mg-4.167mcg-33.333mg-
Nebraska Total Care Updated December 1, 2017
190
Drug Name DrugTier
Requirements/Limits
3.333mg-333.333mg-6mg-33.333mg-33.333mg-16.667mg-33.333mcg-16.667mg-266.667mcg-66.667unit-100mcg-16.667mg-1666.667unit-133.333unit, 25mcg-3mg-2mg-500mg-30unit-2mg-10mg-2mg-10mg-10mg,6.25mcg-72.5mg-50mg-30unit-100mg-2.5mg-0.5mg-7.5mg-0.75mg-2500unit-250mcg-10mg-0.85mg-500unit-50mg-100mcg-1500mcg-60mg,2mg-72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-5mcg-109mg-30unit-150mcg-160mcg-162mg-80mg-150mcg-2mg-15mg-100mg-1.5mg-600mcg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg-400unit, 1mg-25mg-5mg-25mg-1mg-500mcg-1mg-1mg-5mg-2mg-90mg-13mcg-200mcg-10mg-200mcg-7.5mg-13mcg-2mg-5mg-6.5mcg-130mg-60unit-150mcg-200mcg-165mg-2mg-100mg-500mcg-3.5mg-15mg-100mg-4.5mg-3.6mg-10mg-7500unit-500mcg-40mg-80mcg-5.1mg-24mcg-400mcg-60mcg-6mg-120mg-400unit, 2mg-36mg-250mg-25mcg-50unit-2mg-5mcg-77mg-25mcg-150mcg-10mcg-2mg-120mcg-10mcg-40mg-18mg-20mg-400unit-150mcg-15mg-100mg-1.5mg-3000unit-250mcg-100mcg-1.7mg-10mg-6mcg-400mcg-30mcg-2mg-120mg, 45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.9mg-50unit-45mcg-150mcg-220mg-80mg-2mg-150mcg-11mg-
Drug Name DrugTier
Requirements/Limits
50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-500mcg-30mcg-3mg-90mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.9mg-110mg-50unit-150mcg-45mcg-220mg-150mcg-80mg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-500mcg-30mcg-3mg-90mg,5000unit-40mcg-40mg-2mg-30unit-60mg, 30unit-0.1mg-5mg-3mg-22.5mg-50mg-20mg-27mg-5000unit-100mg-20mg-25mg-50mcg-0.8mg-0.15mg-25mg-500mg,30unit-1.5mg-75mg-18mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg,45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-2mg-50mg-150mcg-11mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,2mg-72mg-10mcg-55mcg-200mg-35mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-80mg-150mcg-11mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 45mcg-45mcg-72mg-72mg-10mcg-10mcg-55mcg-55mcg-2.3mg-2.3mg-5mcg-5mcg-0.9mg-0.9mg-110mg-110mg-50unit-50unit-150mcg-150mcg-45mcg-
Nebraska Total Care Updated December 1, 2017
191
Drug Name DrugTier
Requirements/Limits
45mcg-220mg-220mg-2mg-2mg-80mg-80mg-50mg-50mg-150mcg-150mcg-11mg-11mg-1.5mg-1.5mg-300mcg-300mcg-10mg-10mg-2500unit-2500unit-250mcg-250mcg-20mg-20mg-30mcg-30mcg-1.7mg-1.7mg-25mcg-25mcg-500unit-500unit-500mcg-500mcg-30mcg-30mcg-3mg-3mg-90mg-90mg,50mcg-2mg-72mg-10mcg-19mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-50mg-20mg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 200mcg-12mg-72mg-1.5mg-2.3mg-35mcg-110mg-50unit-150mcg-2mg-80mg-220mg-10mcg-150mcg-5mcg-45mcg-50mg-1.5mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-30mcg-600unit-500mcg-300mcg-3mg-90mg, 72mg-5mcg-20mcg-109mg-150mcg-162mg-10mcg-120mcg-10mcg-2mg-80mg-75mcg-2mg-150mcg-2mg-15mg-100mg-1.5mg-300mcg-18mg-3500unit-250mcg-20mg-25mcg-1.7mg-10mg-6mcg-400mcg-30unit-30mcg-2mcg-60mg-400unit, 27mcg-180mcg-4.2mg-30unit-150mcg-90mcg-2.2mg-24mg-50mg-4.5mg-500mg-10mg-3500unit-20mg-20mcg-3.4mg-25mcg-1000unit-400mcg-30mcg-6mg-120mg, 4.58mg-16.66unit-4.58mg-1.66mg-0.0125mg-25mg-16.66mg-12.5mg-
Drug Name DrugTier
Requirements/Limits
25mg-2.5mg-0.33mg-0.16mg-12.5mg-0.016mg-0.83mg-41.66mg-1.66mg-16.66mg-1.66mg-66.66unit-4.16mg-4.16mg-8.33mg-4.16mg-2.5mg-16.66mg-833.33unit-33.33mg-16.66mg-25mg-1.66mg-16.66mcg-4.16mg-8.33mg-0.16mg-4.16mg-8.33mg-33.33mg, 30unit-1.5mg-45mg-10mcg-3000unit-20mg-1.7mg-6mcg-400unit-0.4mg-2mg-60mg, 50mg-20mcg-120mcg-2mg-22.5unit-300mg-50mg-2mg-15mg-2.4mg-18mg-5mg-2500unit-10mg-25mcg-2.7mg-9.5mcg-800unit-400mcg-30mcg-3.2mg-120mg-60mg, 70mcg-120mcg-4mg-2mg-50unit-150mcg-75mcg-100mg-15mg-1.5mg-162mg-18mg-10mg-2500unit-20mg-80mcg-1.7mg-6mcg-1000unit-400mcg-30mg-2mg-180mg, 72mg-10mcg-5000unit-45unit-20mcg-48mg-150mcg-200mg-15mg-10mcg-2mg-130mcg-150mcg-2mg-80mg-5mcg-160mcg-3.5mg-100mg-4mg-400unit-1.5mg-20mg-1.7mg-10mg-25mcg-400mcg-30mcg-3mg-60mg,7.5mg-5000unit-10mcg-31mcg-150mcg-40mg-15mg-2mg-15mcg-7.5mg-15mcg-5mg-100mg-27mg-30unit-400unit-3.4mg-10mg-9mcg-3mg-20mg-0.04mg-30mcg-3mg-90mg,117mcg-180mcg-4.2mg-2.2mg-25.5unit-150mcg-90mcg-24mg-110mg-4.5mg-370mcg-120mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-
Nebraska Total Care Updated December 1, 2017
192
Drug Name DrugTier
Requirements/Limits
6mg-120mg, 12.667mg-1mg-30mg-5unit-5unit-66.667mg-0.667mg-2.5mg-2.5mg-16.667mg-4.167mcg-16.667mg-4.167mg-3.333mg-5mg-8.333mg-10mg-3.333mg-0.667mg-1666.667unit-1666.667unit-2.667mcg-333.333unit-1.667mg-1.667mg-66.667mcg-1mg-1.667mg-20mg, 20mcg-120mcg-150mcg-75mcg-10mcg-2mg-250mcg-2mg-15mg-100mg-5mg-100mg-10mg-20mg-100mg-5mg-3500unit-30mcg-400mcg-30unit-30mcg-5mg-100mg,10000unit-57mg-0.15mg-125mg-5mg-2mg-2mg-40mg-15mg-100unit-400unit-25mg-10mg-25mg-15mcg-10mg-400mcg-25mcg-10mg-250mg, 8mg-30unit-10mcg-150mcg-40mg-15mg-2mg-15mcg-8mg-15mcg-2mg-60mg-9mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-1.5mg-400mcg-30mcg-2mg-90mg, 2500unit-30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-10mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg,50mcg-2mg-10mcg-7.5mg-70mcg-2mg-10mcg-5mcg-2mg-31mg-60unit-150mcg-75mcg-40mg-150mcg-7.5mg-15mg-100mg-3mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-400mcg-30mcg-6mg-90mg, 72mg-2.5mg-5mcg-20mcg-48mg-45unit-150mcg-2mg-200mg-10mcg-130mcg-150mcg-80mg-160mcg-4mg-2mg-15mg-100mg-1.5mg-5000unit-20mg-10mcg-1.7mg-10mg-25mcg-400mcg-30mcg-3mg-
Drug Name DrugTier
Requirements/Limits
60mg-400unit, 7.5mg-5mg-10mcg-2mg-31mg-30unit-150mcg-15mg-40mg-15mcg-7.5mg-15mcg-1250unit-100mg-3mg-27mg-5000unit-30mg-3.4mg-10mg-9mcg-0.4mg-35mcg-3mg-90mg-400unit,35mcg-72mg-10mcg-55mcg-10mcg-5mcg-109mg-30unit-150mcg-45mcg-80mg-200mg-0.9mg-2.3mg-100mg-1250unit-2mg-150mcg-11mg-1.5mg-300mcg-18mg-3500unit-250mcg-20mg-25mcg-1.7mg-10mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 120mg-110mcg-180mcg-4mg-2mg-22.5unit-150mcg-90mcg-120mg-22.5mg-100mg-4.5mg-300mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-6mg-60mg, 35mcg-35mcg-72mg-72mg-10mcg-10mcg-55mcg-55mcg-2.3mg-2.3mg-10mcg-10mcg-5mcg-5mcg-0.9mg-0.9mg-109mg-109mg-30unit-30unit-150mcg-150mcg-45mcg-45mcg-80mg-80mg-200mg-200mg-2mg-2mg-100mg-100mg-150mcg-150mcg-11mg-11mg-1.5mg-1.5mg-300mcg-300mcg-18mg-18mg-10mg-10mg-3500unit-3500unit-250mcg-250mcg-20mg-20mg-25mcg-25mcg-1.7mg-1.7mg-6mcg-6mcg-400unit-400unit-500mcg-500mcg-30mcg-30mcg-2mg-2mg-90mg-90mg, 33.333mcg-0.667mg-1.667mg-3.333mg-26.667mg-5mcg-66.667unit-5mg-66.667mg-1666.667unit-5mg-16.667mg-66.667mg-
Nebraska Total Care Updated December 1, 2017
193
Drug Name DrugTier
Requirements/Limits
133.333mg-16.667mcg-133.333unit-16.667mg-133.333mg-16.667mg-333.333mcg-50mcg-16.667mg-333.333mg-166.667mg, 60mg-5000unit-50mcg-12mg-1.5mg-75mg-13.5mg-25mg-15mg-1.3mg-200mg-1.25mg-30unit-500mg,150mcg-60mcg-10mcg-72mg-100mcg-60unit-4mg-20mg-150mcg-50mcg-15mg-80mg-250mg-5mcg-50mg-0.7mg-15mg-1.5mg-600mcg-3500unit-300mcg-20mg-60mcg-1.7mg-10mg-100mcg-600unit-300mcg-30mcg-6mg-120mg,120mg-20mcg-2500unit-4mg-180mcg-2mg-33unit-150mcg-90mcg-22.5mg-50mg-4.5mg-405mg-15mg-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg, 72mg-65mcg-3.5mg-5mcg-20mcg-2mg-109mg-30unit-150mcg-10mcg-150mcg-10mcg-2mg-80mg-160mcg-100mg-15mg-1.5mg-162mg-18mg-2500unit-20mg-25mcg-1.7mg-10mg-6mcg-400mcg-30mcg-2mg-60mg-400unit, 5mg-25mg-100mcg-1mg-5mg-5mcg-1mg-1mg-25unit-75mcg-37.5mcg-60mcg-2500unit-12.5mg-50mg-12.5mg-25mg-475mcg-100mg-12.5mg-25mg-475mcg-25mg-5mg-5mg-40mcg-25mg-25mcg-100unit-200mcg-150mcg-25mg-150mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-50mg-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-
Drug Name DrugTier
Requirements/Limits
20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 25mcg-12.5mg-2.5mg-1mg-5mcg-50mcg-250mg-75mcg-2mg-50mcg-1mg-25mcg-2.5mg-13.5mcg-12.5mg-7.5mg-50mg-40mg-5mg-40mg-250mcg-40mg-10mcg-5mg-37.5mcg-40mg-5000unit-40mg-200unit-200mg-50unit-40mg-40mg-100mg,833unit-41.7mg-1.7mg-83mcg-250mcg-28.3mg-5unit-33unit-5mg-5mg-16.7mg-16.7mg-2.5mg-8.3mg-1.7mcg-1.7mg-2.5mg-66.7mcg-8.3mcg-83mg-83mg, 7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-2mg-31mg-60unit-150mcg-75mcg-40mg-2mg-7.5mg-150mcg-15mg-100mg-3mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-400mcg-30mcg-6mg-90mg, 45mg-25mg-40mg-1mg-37.5mcg-100mcg-25mcg-35mcg-1mg-75mcg-1mg-15unit-200mg-7.5mg-0.75mg-125mg-5mg-10mg-0.85mg-2500unit-3mcg-200unit-1mg-200mcg-150mcg-30mg, 30unit-15mg-1.5mg-450mg-27mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg, 72mg-10mcg-6000unit-5mcg-25mcg-48mg-150mcg-200mg-15mg-10mcg-2mg-100mcg-10mcg-80mg-25mcg-2.5mg-100mg-9mg-45unit-400unit-1.5mg-20mg-1.7mg-10mg-25mcg-200mcg-30mcg-3mg-60mg,33.333mg-33.333mg-0.667mg-3.333mcg-73.333mcg-0.667mg-
Nebraska Total Care Updated December 1, 2017
194
Drug Name DrugTier
Requirements/Limits
1.667mcg-16mg-133.333unit-50mcg-25mcg-24mg-166.667mg-116.667mcg-50mcg-26.667mg-0.667mg-5mg-33.333mg-16.667mg-0.5mg-100mcg-3.333mg-1666.667unit-83.333mcg-6.667mg-3.333mcg-0.567mg-8.333mcg-133.333unit-166.667mcg-10mcg-1mg-166.667mg,5000unit-5000unit-450mg-450mg-15mg-15mg-27mg-27mg-30unit-30unit-400unit-400unit-1.7mg-1.7mg-10mg-10mg-6mcg-6mcg-20mg-20mg-1.5mg-1.5mg-400mcg-400mcg-2mg-2mg-60mg-60mg,16.667mcg-53mg-133.333unit-8333.333unit-166.667mg, 110mcg-120mcg-2mg-22.5unit-2mg-15mg-120mg-1.2mg-300mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-700unit-400mcg-30mcg-3mg-60mg, 2mg-72mg-10mcg-55mcg-45mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-50mg-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,23.9mg-30unit-3mg-10mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 16.67mg-66.67unit-2500unit-16.67mg-33.33mg-25mcg-83.33mg-5mg-4.17mcg-0.33mg-33.33mcg-0.4mg-16.5mg-8.33mcg-3.33mg-83.33mg-8.33mg-16.67mg-33.33mg-8.33mg-66.67mg-16.67mcg-16.67unit-16.67mg-31.67mg-
Drug Name DrugTier
Requirements/Limits
133.33mcg-50mcg-16.67mg-100mg-200mg,32mcg-2mg-72mg-10mcg-18mcg-1.8mg-10mcg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-100mg-8mg-1.1mg-200mg-18mg-15mg-3500unit-14mg-50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 30unit-450mg-15mg-27mg-2500unit-2500unit-20mg-1.7mg-10mg-6mcg-1.5mg-400mcg-2mg-60mg-400unit, 72mg-10mcg-5000unit-20mcg-48mg-150mcg-200mg-15mg-10mcg-2mg-130mcg-150mcg-2mg-80mg-5mcg-160mg-3.5mg-100mg-4mg-45unit-400unit-20mg-1.7mg-10mg-25mcg-3mg-1.5mg-400mcg-30mcg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-150mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-80mg-11mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-2500unit-1.7mg-6mcg-400unit-10mg-400mcg-2mg-60mg,45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-2mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,36.3mg-25mcg-5000unit-10mcg-5mcg-20mcg-109mg-150mcg-162mg-
Nebraska Total Care Updated December 1, 2017
195
Drug Name DrugTier
Requirements/Limits
15mg-10mcg-2mg-25mcg-150mcg-2mcg-40mg-25mcg-2.5mg-100mg-18mg-30unit-400unit-1.5mg-20mg-1.7mg-10mg-6mcg-400mcg-30mcg-2mg-60mg, 50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-500mg-50mg-150mcg-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 50mg-20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-2.4mg-300mg-18mg-5mg-2500unit-10mg-25mcg-2.7mg-9.5mcg-800unit-400mcg-30mcg-3.2mg-120mg-60mg, 50mcg-10mg-80mg-125mg-200unit-33mg-25mg-5000unit-50mg-25mg-25mg-25mg-1mg-100unit-300mcg-500mg, 72mg-25mcg-5000unit-20mcg-109mg-150mcg-162mg-15mg-10mcg-2mg-65mcg-150mcg-10mcg-2mg-80mg-5mcg-160mg-3.5mg-100mg-18mg-30unit-400unit-20mg-1.7mg-10mg-6mcg-2mg-1.5mg-400mcg-30mcg-60mg,2500unit-0.9mg-11mg-2500mcg-100mg, 36.3mg-10mcg-5000unit-25mcg-2.5mg-10mcg-5mcg-20mcg-109mg-30unit-150mcg-25mcg-150mcg-162mg-2mg-40mg-400unit-150mcg-2mg-15mg-100mg-1.5mg-18mg-10mg-20mg-25mcg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg, 45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-45mcg-100mcg-80mg-
Drug Name DrugTier
Requirements/Limits
2mg-150mcg-11mg-50mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 120mg-105mcg-2500unit-180mcg-33unit-150mcg-90mcg-40mg-4mg-2mg-22.5mg-100mg-4.5mg-600mcg-120mg-15mg-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg, 105mcg-120mcg-2mg-45unit-100mg-210mg-2mg-15mg-120mg-1.2mg-600mcg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 0.5mg-15mg-155mcg-9.5mg-15unit-150mg-9.5mg-22mg-12.5mcg-99mg-12.5mg-1mg-222mcg-99mg-122mg-22mcg, 50mcg-2mg-72mg-10mcg-55mcg-3500unit-2.3mg-5mcg-0.5mg-20mg-8mg-150mcg-50mcg-500mg-80mg-150mcg-15mg-50mg-1.1mg-5mg-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-35unit-30mcg-5mg-100mg,400mg-1mg-29mg-5mcg-10mcg-60mcg-1mg-5mcg-2.5mcg-0.35mg-40mg-15unit-75mcg-37.5mcg-32mg-54mg-20mg-16mcg-3.75mg-0.75mg-3mg-5mg-1750unit-10mg-12.5mcg-0.85mg-100mcg-200unit-200mcg-15mcg-2.5mg-30mg, 0.12mg-3.75mg-5unit-15mg-10mg-3.33mg-0.33mcg-1.67mg, 10mcg-10mcg-2.5mg-2mg-15mg-100mg-30unit-150mcg-40mg-130mg-10mcg-100mg-1.5mg-10mg-5000unit-20mg-1.7mg-
Nebraska Total Care Updated December 1, 2017
196
Drug Name DrugTier
Requirements/Limits
6mcg-400mcg-30mcg-2mg-60mg-400unit, 2mg-72mg-10mcg-20mcg-150mcg-2mg-5mcg-2mg-48mg-45unit-150mcg-75mcg-200mg-80mg-150mcg-15mg-100mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-1.5mg-400mcg-30mcg-2mg-60mg, 7.5mg-10mcg-15mcg-5mg-31mg-30unit-150mcg-15mcg-44mg-7.5mg-2mg-15mg-100mg-18mg-10mg-5500unit-30mg-3.4mg-9mcg-400unit-3mg-400mcg-15mcg-3mg-120mg, 30mg-2mg-72mg-10mcg-20mcg-120mcg-10mcg-5mcg-2mg-109mg-30unit-150mcg-0.75mcg-150mcg-80mg-2mg-300mcg-10mg-18mg-3500unit-250mcg-10mg-10mg-25mcg-400unit-400mcg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-50mg-150mcg-11mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-2500unit-10mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg, 20mcg-5250unit-120mcg-2mg-2mg-15mg-1.5mg-450mg-27mg-10mg-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30unit-30mcg-2mg-60mg, 7160unit-0.4mg-17.4mg-100unit-113mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-
Drug Name DrugTier
Requirements/Limits
30unit-150mcg-45mcg-200mg-75mcg-80mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 35mcg-72mg-10mcg-100mcg-2.3mg-10mcg-5mcg-0.9mg-20mg-45unit-150mcg-50mcg-80mg-210mg-2mg-100mg-150mcg-11mg-1.2mg-600mcg-8mg-15mg-3500unit-16mg-60mcg-1.3mg-6mcg-600unit-200mcg-40mcg-2mg-90mg,20mcg-120mcg-2mg-150mcg-500mg-22.5unit-2mg-15mg-1.5mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg, 5000unit-30unit-40mcg-2mg-40mg-60mg, 1mg-25mg-5mg-25mg-10mg-72mg-80mcg-5mg-10mg-200mcg-130mg-60unit-150mcg-165mg-15mg-13mcg-3.5mg-200mcg-200mcg-13mcg-2mg-80mg-6.5mcg-208mcg-7.5mg-100mg-18mg-7500unit-5mg-5.1mg-10mg-18mcg-6mg-40mg-4.5mg-400mcg-60mcg-120mg-400unit,72mg-10mcg-20mcg-25mcg-2mg-10mcg-5mcg-109mg-75mcg-150mcg-162mg-120mcg-2mg-80mg-100mg-30unit-150mcg-2mg-15mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg-400unit,2mg-72mg-10mcg-20mcg-150mcg-2mg-5mcg-48mg-45unit-150mcg-75mcg-80mg-150mcg-2mg-15mg-100mg-1.5mg-200mg-10mg-3500unit-250mcg-
Nebraska Total Care Updated December 1, 2017
197
Drug Name DrugTier
Requirements/Limits
20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 2mg-72mg-10mcg-20mcg-120mcg-2mg-10mcg-5mcg-109mg-30unit-150mcg-75mcg-162mg-80mg-150mcg-2mg-15mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg-400unit,30unit-2mg-15mg-6mg-60mg, 2mg-72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-5mcg-2mg-15mg-109mg-30unit-150mcg-160mcg-162mg-80mg-150mcg-100mg-1.5mg-18mg-10mcg-2500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 45mg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-220mg-150mcg-80mg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-75mcg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 117mcg-180mcg-4.2mg-25.5unit-150mcg-90mcg-120mg-110mg-2.2mg-24mg-4.5mg-370mcg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-6mg-120mg, 72mg-10mcg-20mcg-65mcg-3.5mg-
Drug Name DrugTier
Requirements/Limits
10mcg-5mcg-2mg-109mg-30unit-150mcg-160mcg-162mg-2mg-80mg-150mcg-15mg-100mg-1.5mg-18mg-10mg-20mg-25mcg-1.7mg-2500unit-6mcg-400unit-400mcg-30mcg-2mg-50mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-75mcg-80mg-50mg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,5mg-0.5mg-250mcg-1.5mg-50mg-750mcg-50mg-15unit-100mg-60mg-7.5mg-5mg-0.75mg-6.75mg-2500unit-5mg-10mg-0.85mg-100unit-50mg-25mg-100mcg-1500mcg-100mg, 100unit-7160unit-0.4mg-17.4mg-113mg, 25mcg-2mg-72mg-10mcg-55mcg-1.8mg-10mcg-5mcg-0.9mg-20mg-35unit-150mcg-50mcg-80mg-500mg-100mg-150mcg-8mg-1.1mg-18mg-15mg-3500unit-14mg-50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 60mcg-2mg-72mg-10mcg-100mcg-4mg-5mcg-0.7mg-20mg-60unit-150mcg-50mcg-80mg-250mg-50mg-150mcg-15mg-1.5mg-600mcg-10mg-3500unit-300mcg-20mg-60mcg-1.7mg-100mcg-600unit-300mcg-30mcg-6mg-120mg, 7.5mg-28mcg-5000unit-21mcg-31mg-150mcg-40mg-15mg-10mcg-2mg-26mcg-150mcg-10mcg-2mg-7.5mg-5mcg-32mcg-3.5mg-100mg-18mg-
Nebraska Total Care Updated December 1, 2017
198
Drug Name DrugTier
Requirements/Limits
30unit-400unit-3.4mg-10mg-9mcg-3mg-20mg-400mcg-30mcg-3mg-90mg, 40mcg-2mg-30unit-1000unit-40mg-60mg,35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 69mg-30unit-10mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg, 25mcg-5mg-2mg-5mg-75mcg-150mg-30unit-150mg-2mg-22.5mg-100mg-30mg-5mg-10mg-18mg-5000unit-10mg-10mg-400unit, 2mg-72mg-10mcg-55mcg-45mcg-2.3mg-5mcg-0.5mg-20mg-20mg-150mcg-45mcg-80mg-50mg-50unit-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 1666.67unit-8.33mg-4.17mcg-50mg-37.5mcg-100mg-2.5mg-1.67mg-33.33mg-1mg-5unit-33.33unit-8.33mg-4.17mg-8.33mg-10mg-8.33mg-10mg-1.67mg-5mg-2.67mcg-1.67mg-25mg-66.67mcg-66.67mcg-1.67mg-20mg,20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-1.5mg-500mg-18mg-5mg-2500unit-25mcg-1.7mg-6mcg-1000unit-10mg-400mcg-30mcg-2mg-60mg, 36.3mg-10mcg-25mcg-5000unit-25mcg-2.5mg-10mcg-5mg-125mg-
Drug Name DrugTier
Requirements/Limits
30unit-150mcg-25mcg-162mg-10mcg-40mg-400unit-2mg-15mg-100mg-1.5mg-18mg-10mg-20mg-25mcg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg,105mcg-2mg-45unit-99mg-120mcg-2mg-15mg-120mg-1.2mg-600mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-90mg, 45mcg-2mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 72mg-10mcg-20mcg-2mg-10mcg-5mcg-109mg-30unit-150mcg-75mcg-162mg-120mg-150mcg-2mg-80mg-2mg-15mg-100mg-1.5mg-300mcg-3500unit-250mcg-20mg-1.7mg-10mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,50mcg-100unit-10000unit-400unit, 120mg-105mcg-180mcg-4mg-2mg-33unit-150mcg-90mcg-40mg-100mg-22.5mg-4.5mg-600mcg-120mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg, 34mg-105mcg-180mcg-4mg-60unit-150mcg-90mcg-37.5mg-100mg-2mg-22.5mg-4.5mg-120mg-15mg-5000unit-20mg-20mcg-3.4mg-30mcg-400unit-400mcg-30mcg-6mg-120mg, 117mcg-180mcg-4.2mg-2.2mg-150mcg-90mcg-110mg-24mg-4.5mg-370mcg-120mg-
Nebraska Total Care Updated December 1, 2017
199
Drug Name DrugTier
Requirements/Limits
15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-25.5unit-30mcg-6mg-120mg,30unit-10mg-70mcg-10000unit-10mg-25mcg-52mg-100mcg-100mg-30mg-25mcg-2mg-500mcg-2.4mg-25mg-100mcg-6mg-100mg-20mg-10mg-8mg-10mg-10mg-15mg-25mg-25mcg-400unit-15mg-25mg-400mcg-300mcg-25mg-100mg, 10mg-25mg-10mg-10mg-10mg-36mg-10mcg-27mg-70mcg-120mcg-2mg-10mcg-5mcg-77mg-45unit-150mcg-75mcg-250mg-150mcg-40mg-2mg-15mg-100mg-1.875mg-12.5mg-5000unit-300mcg-25mg-80mcg-2.1mg-7.5mcg-400unit-400mcg-37.5mcg-2.5mg-120mg, 60mcg-72mg-21mcg-4mg-0.5mg-20mg-60unit-150mcg-50mcg-80mg-210mg-15mg-75mg-1.5mg-600mcg-10mg-3500unit-300mcg-20mg-60mcg-1.7mg-100mcg-600unit-300mcg-30mcg-6mg-120mg, 1mg-150mcg-125unit-125mcg-35mg-35mg-10mg-25mg-125mcg-35mg-400mcg-35mg-3.4mg-5mg-70mcg-400unit-1.25mg-75mcg-35mg-500mg, 10mcg-15mcg-5mg-2mg-15mg-30unit-150mcg-15mcg-10mg-40mg-100mg-3mg-27mg-10mg-30mg-3.4mg-5500unit-9mcg-400unit-400mcg-15mcg-3mg-120mg, 0.5mg-1mg-50mg-50mg-100mg-7.5mg-30unit-0.75mg-2500unit-250mcg-10mg-0.85mg-100unit-50mg-25mg-100mcg-1250mcg-50mg-
Drug Name DrugTier
Requirements/Limits
60mg, 10000unit-150mcg-1.5mg-2mg-1mg-65mg-12mg-15unit-100mg-10mg-20mg-5mcg-10mg-0.4mg-5mg-120mg-400unit,72mg-10mcg-20mcg-150mcg-2mg-5mcg-48mg-45unit-150mcg-75mcg-80mg-200mg-150mcg-100mg-2mg-2mg-15mg-1.5mg-10mg-5000unit-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg,117mcg-180mcg-4.2mg-2.2mg-30unit-150mcg-90mcg-24mg-110mg-4.5mg-370mcg-120mg-15mg-3500unit-20mg-20mcg-3.4mg-25mcg-700unit-400mcg-30mcg-6mg-120mg, 1mg-5mg-25mg-10mg-25mg-10mg-13mcg-72mg-200mcg-5mg-80mcg-5000unit-7.5mg-5mg-10mg-6.5mcg-80mg-60unit-200mcg-150mcg-165mg-200mcg-200mcg-13mcg-2mg-80mg-3.5mg-15mg-100mg-300mcg-18mg-275mcg-40mg-5.1mg-10mg-18mcg-400unit-4.5mg-400mcg-60mcg-6mg-120mg, 2mg-72mg-10mcg-20mcg-150mcg-2mg-5mcg-48mg-45unit-150mcg-75mcg-200mg-80mg-150mcg-2mg-15mg-100mg-1.5mg-300mcg-10mg-3500unit-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg,35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-50mg-75mcg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,
Nebraska Total Care Updated December 1, 2017
200
Drug Name DrugTier
Requirements/Limits
2mg-7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-40mg-31mg-60unit-150mcg-75mcg-7.5mg-150mcg-2mg-15mg-100mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-3mg-400mcg-30mcg-6mg-90mg, 8.333mg-3.333mg-3.333mg-3.333mg-33.333mg-33.333mg-16.666mg-3.333mg-3.333mg-3.333mg-33.333mg-3.333mg-11.666mg-0.833mg-1.666mg-6.666mg-1.666mg-6.666mg-1.666mg-8.333mg-33.333mg-3.333mg-25mcg-10mg-50mcg-83.333mg-5mg-0.333mg-33.333mcg-0.333mg-20mg-16.666mcg-1.333mg-33.333mg-5mg-5000unit-33.333mg-83.333unit-333.333mg-1.333mg-8.333mg-6.666mg-8.333mg-8.333mg-8.333mg-8.333mg-8.333mg-8.333mg-8.333mg-8.333mcg-133.333unit-8.333mg-8.333mg-133.333mcg-16.666mcg-8.333mg-333.333mg,10mcg-20mcg-120mcg-2mg-10mcg-5mcg-2mg-109mg-30unit-150mcg-75mcg-150mcg-2mg-300mcg-10mg-18mg-3500unit-250mcg-10mg-10mg-25mcg-400unit,32mcg-72mg-18mcg-1.8mg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-200mg-8mg-100mg-1.1mg-18mg-15mg-3500unit-14mg-50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 110mcg-120mcg-2mg-210mg-
Drug Name DrugTier
Requirements/Limits
22.5unit-2mg-15mg-120mg-1.2mg-300mcg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-700unit-400mcg-30mcg-3mg-60mg, 25mg-75mg-10mcg-18mg-70mcg-2.5mg-10mcg-5mcg-77mg-45unit-150mcg-75mcg-162mg-120mcg-150mcg-2mg-80mg-2000unit-2mg-15mg-100mg-1.9mg-3000unit-300mcg-25mg-25mcg-2.1mg-12.5mg-7.5mcg-400unit-400mcg-37.5mcg-2.5mg-120mg,16.6mcg-16.66mg-16.6mcg-66unit-5mg-8333unit-33.3unit-16.66mcg-8.33mg-133.33mcg-8.3mg-166mg,0.5mg-0.37mg-1.5mg-80mg-15unit-75mcg-100mg-2.5mg-2.5mg-5000unit-15mg-2.5mg-5mg-1mcg-400unit-400mcg-1mg-60mg,50mcg-10mg-60mg-100unit-125mg-33mg-25mg-5000unit-50mg-25mg-25mg-200unit-1mg-300mcg-25mg-500mg,36.3mg-25mcg-10mcg-25mcg-125mg-150mcg-162mg-15mg-10mcg-2mg-25mcg-150mcg-10mcg-40mg-5mcg-25mcg-2.5mg-100mg-18mg-30unit-400unit-5000unit-20mg-2mg-10mg-6mcg-1.7mg-400mcg-30mcg-3mg-60mg,20mcg-120mcg-2mg-2mg-30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg,55mcg-60unit-1000unit-2mg-40mg-2mg-200mg,20mg-0.5mg-12.5mg-100mcg-25mg-15mg-12.5mg-5mg-6.5mcg-
Nebraska Total Care Updated December 1, 2017
201
Drug Name DrugTier
Requirements/Limits
100mcg-100mcg-3.75mg-6.5mcg-2.5mg-2.5mg-5mg-12.5mg-3.25mcg-36mg-65mg-30unit-75mcg-82.5mg-1mg-40mg-1.75mg-12.5mg-50mg-2.25mg-5mg-3750unit-37.5mcg-20mg-40mcg-2.55mg-9mcg-200unit-200mcg-150mcg-3mg-90mg, 2mg-72mg-10mcg-55mcg-45mcg-2.3mg-5mcg-0.5mg-20mg-150mcg-45mcg-80mg-50mg-50unit-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 17mcg-53mg-133unit-8333unit-167mg,10mg-0.5mg-10mg-17.5mcg-75mcg-120mg-1mg-30unit-60mg-35mg-7.5mg-9mg-10mg-100mg-10mg-10mg-5000unit-10mcg-10mg-400mcg-30mcg-10mg-200mg-400unit, 120mcg-50mg-72mg-10mcg-70mcg-4mg-10mcg-5mcg-0.9mg-48mg-60unit-150mcg-75mcg-100mg-80mg-4mg-60mcg-11mg-40mg-4.5mg-18mg-12mg-3500unit-40mg-25mcg-5.1mg-18mcg-400unit-400mcg-50mcg-6mg-120mg, 100mcg-200unit-5000unit-250mg,5000unit-5000unit-40mcg-40mcg-40mg-40mg-2mg-2mg-30unit-30unit-60mg-60mg, 21mcg-28mcg-5000unit-26mcg-3.5mg-2mg-31mg-30unit-150mcg-32mcg-7.5mg-40mg-10mcg-150mcg-10mcg-2mg-7.5mg-5mcg-15mg-100mg-18mg-10mg-20mg-3.4mg-9mcg-400unit-3mg-400mcg-30mcg-3mg-
Drug Name DrugTier
Requirements/Limits
90mg, 25mg-25mg-35mg-50mcg-12.5mg-35mg-25mcg-15mg-15mg-35mg-5mcg-25mg-100mg-75mcg-5000unit-2.5mg-1mg-12.5mg-50mg-2.5mg-15mg-175mcg-5mg-15mg-250mcg-15mg-5mg-5mg-37.5mcg-15mg-15mcg-100unit-5mg-200mcg-50unit-125mcg-15mg-25mg-150mg, 15mg-25mg-1.5mg-50mg-5mg-64mg-7.5unit-25mg-1mg-3.75mg-5mg-130mg-4mg-5mg-7.5mg-12.5mg-15mg-5mg-2.5mg-2500unit-4mcg-500unit-2.5mg-100mcg-2500mcg-2.5mg-30mg,34mg-105mcg-4mg-2mg-33unit-90mcg-150mcg-120mg-180mcg-37.5mg-20mg-22.5mg-100mg-4.5mg-2500unit-20mcg-3.4mg-15mg-25mcg-400unit-400mcg-30mcg-6mg-120mg, 72mg-25mcg-5000unit-10mcg-20mcg-109mg-30unit-150mcg-162mg-15mg-10mcg-2mg-65mcg-150mcg-2mg-80mg-5mcg-160mcg-3.5mg-100mg-18mg-400unit-1.5mg-20mg-1.7mg-10mg-6mcg-400mcg-30mcg-2mg-60mg,18mcg-20mcg-2mg-105mcg-99mg-2mg-120mcg-45unit-400unit-15mg-120mg-1.2mg-0.6mg-210mg-3500unit-1.7mg-5mg-3mg-16mg-400mcg-30mcg-90mg,20mcg-120mcg-2mg-2mg-30unit-300mg-50mg-15mg-2.3mg-18mg-10mg-2500unit-30mg-25mcg-2.6mg-9mcg-800unit-400mcg-300mcg-3mg-120mg, 20mcg-120mcg-2mg-2mg-22.5unit-150mcg-500mg-15mg-
Nebraska Total Care Updated December 1, 2017
202
Drug Name DrugTier
Requirements/Limits
1.5mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-150mcg-80mg-11mg-100mg-1.5mg-300mcg-18mg-3500unit-250mcg-20mg-25mcg-1.7mg-10mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 3.333mg-66.667mcg-50mg-10mg-15mg-5mg-50mcg-0.667mg-100mcg-25mcg-100mg-5mg-50mg-0.667mg-5.333mg-66.667mcg-22.333unit-0.667mg-33.333mg-0.667mg-25mcg-20mg-1666.667unit-0.5mg-10mg-71.667mg-26.667mcg-20mg-166.667mcg-266.667unit-20mg-30mg-266.667mcg-200mcg-8.333mg-100mg, 120mg-20mcg-2500unit-180mcg-33unit-150mcg-90mcg-4mg-2mg-22.5mg-50mg-4.5mg-405mg-15mcg-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg,1400unit-0.67mg-5unit-140unit-41.7mg-3.3mg-66.7mg-11.7mg-100mg-33.3mg-3.3mg-50mcg-0.33mg-3.3mg, 50mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-500mg-2mg-50mg-150mcg-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 72mg-10mcg-20mcg-3500unit-150mcg-2mg-5mcg-48mg-
Drug Name DrugTier
Requirements/Limits
45unit-150mcg-75mcg-150mcg-2mg-80mg-2mg-15mg-100mg-1.5mg-300mcg-200mg-10mg-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg
Nebraska Total Care Updated December 1, 2017
203
Drug Name DrugTier
Requirements/Limits
multiple vitamins w/minerals tbcr 5mg-90mg-10mcg-45mcg-100mcg-2mg-10mcg-5mcg-2mg-30unit-150mcg-25mcg-99mg-250mg-40mg-150mcg-15mg-3mg-25mg-9mg-10mg-3500unit-40mg-25mcg-3.4mg-12mcg-400unit-400mcg-300mcg-4mg-60mg, 12.5mg-25mg-50mg-35mcg-5mg-60mcg-18mg-37.5mcg-75mcg-35mg-1mg-5000unit-25mg-1mg-7.5mg-4mg-200unit-25mg-25mg-12.5mg-6mg-20mg-15mg-25mg-50mg-50mg-125mcg-125mcg-25mg-25mcg-200mcg-50unit-150mcg-25mg-125mg, 25mg-20mg-25000unit-100unit-15mg-15mg-180mcg-15mg-50mg-100mcg-50mg-15mg-10mcg-100mcg-100mcg-10mcg-50mg-10mcg-100mcg-25mg-18mg-1000unit-30mg-50mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-400mcg-100mcg-100mg-300mg, 6.1mg-75mcg-5mcg-25mcg-10mcg-0.25mg-150unit-150mcg-10mg-10000unit-25mcg-15mg-7.2mg-25mcg-50mg-25mcg-75mcg-10mg-75mg-75mg-75mcg-75mcg-75mg-75mg-400mcg-75mcg-75mg-250mg-400unit, 5mg-25mg-25mcg-0.225mg-50mg-20mg-25mcg-25mg-6.1mg-20mg-25mg-6000unit-25mg-100unit-600unit-25mg-25mg-100mg-9000unit-100mg-100mg-100mg-100mg-100mg-150mcg-100mg-400mcg-100mcg-100mg-200mg, 10mcg-10mcg-
F
Drug Name DrugTier
Requirements/Limits
25mg-150mcg-5mg-150unit-4.6mg-25mg-0.66mg-1.9mg-0.3mg-25mg-4mg-1.65mg-25mg-75mg-75mg-10000unit-75mg-75mg-75mg-75mg-75mcg-75mg-400mcg-75mcg-75mg-250mg-1000unit, 30mcg-25mg-100mcg-20mg-15mg-15mg-180mcg-50mg-100mcg-100unit-50mg-50mg-10mcg-100mcg-50mcg-25000unit-100mcg-15mg-25mg-30mg-18mg-50mg-100mg-100mg-100mg-100mcg-100mg-100mg-100mg-1000unit-100mg-100mcg-100mcg-100mg-500mg MULTIVITAL PLATINUM TABS F RX/OTC
MULTIVITAMIN ADULT CHEW F
MULTIVITAMIN ADULT EXTRAVITAMIN C CHEW F
MULTIVITAMIN ADULTS TABS F RX/OTC
MULTIVITAMIN MEN TABS F RX/OTC
MULTIVITAMINS W/A,B,D,E,AND K PLUS ZINC CAPS
F RX/OTC
MVW COMPLETE FORMULATIONCHEWABL ES MULTIVITAMIN CHEW
F
NAT-RUL THERAVITE-M/HIGHPOTENCY TABS F RX/OTC
NATRUL-100 TBCR F
NATRUL-CHEWS CHEW F
NATRUL-MEGA-75 TABS F RX/OTC
NATRUL-VITES TABS F RX/OTC
NICADAN TABS F RX/OTC
Nebraska Total Care Updated December 1, 2017
204
Drug Name DrugTier
Requirements/Limits
NICADAN ZX TABS F RX/OTC
NICAZEL FORTE TABS F RX/OTC
NICAZEL TABS F RX/OTC
NO IRON MULTIPLE VITAMIN/MINERALSTABS
F RX/OTC
NUTRICAP TABS F RX/OTC
OCUVITE ADULT 50+ CAPS F RX/OTC
OCUVITE ADULT FORMULA CAPS F RX/OTC
OCUVITE LUTEIN CAPS F RX/OTC
ONCOVITE TABS F RX/OTC
ONE DAILY MENS FORMULA W/O IRONTABS
F RX/OTC
ONE DAILY PLUS IRON TABS F RX/OTC
ONE-A-DAY ENERGY TABS F RX/OTC
ONE-A-DAY FOR HER VITACRAVES TEEN MULTI GUMMIES CHEW
F
ONE-A-DAY FOR HIM/VITACRAVES TEENMULTI GUMMIES CHEW
F
ONE-A-DAY MENOPAUSE FORMULA TABS F RX/OTC
ONE-A-DAY MENS 50+ ADVANTAGE TABS F RX/OTC
ONE-A-DAY MENS HEALTH FORMULA TABS F RX/OTC
ONE-A-DAY MENS PRO EDGE TABS F RX/OTC
ONE-A-DAY MENS VITACRAVES GUMMIES CHEW
F
ONE-A-DAY TEEN ADVANTAGEFOR HIM TABS
F RX/OTC
Drug Name DrugTier
Requirements/Limits
ONE-A-DAY VITACRAVES CHEW F
ONE-A-DAY VITACRAVES GUMMIES/IMMUNITYSUPPORT CHEW
F
ONE-A-DAY VITACRAVES SOURGUMMIES CHEW F
ONE-A-DAY VITACRAVES WOMENS MULTI CHEW F
ONE-A-DAY WEIGHT SMART ADVANCED TABS (Multiple Vitamins w/Minerals)
NP
RX/OTC
ONE-A-DAY WOMENS 50+ ADVANTAGE TABS (Multiple Vitamins w/Minerals)
NP
RX/OTC
ONE-A-DAY WOMENS ACTIVE MIND & BODY TABS (Multiple Vitamins w/Minerals)
NP
RX/OTC
ONE-A-DAY WOMENS PETITES TABS (MultipleVitamins w/ Minerals)
NP RX/OTC
ONE-A-DAY WOMENS PLUS HEALTHY SKIN SUPPORT TABS (MultipleVitamins w/ Minerals)
NP
RX/OTC
ONE-A-DAY WOMENS VITACRAVES GUMMIES CHEW
F
OPTI-WOMAN TABS F RX/OTC
OPTIMUM AIRVITES CHEW F
OPTISOURCE POST BARIATRIC SURGERY CHEW
F
OPTIVITE P.M.T. TABS (Multiple Vitamins w/Minerals)
NP RX/OTC
OPURITY TABS F RX/OTC
OPURITY/BYPASSOPTIMIZED CHEW F
PA MENS 50 PLUS VITAPAK MISC F
Nebraska Total Care Updated December 1, 2017
205
Drug Name DrugTier
Requirements/Limits
PA MENS VITAPAK MISC F
PA WOMENS 50 PLUS VITAPAK MISC F
PA WOMENS VITAPAK MISC F
PARVLEX TABS F RX/OTC
PHLEXY-VITS POWD F
PHYTOMULTI TABS F RX/OTC
PREMIUM PACKETS MISC F
PRESCRIPTIVE FORMULAS OPTIMAL VITAMIN PACKS MENS MISC
F
PRESCRIPTIVE FORMULAS OPTIMAL VITAMIN PACKS WOMENS MISC
F
PRESERVISION AREDS 2 + MULTI VITAMIN CAPS F RX/OTC
PRESERVISION AREDS 2 CAPS F RX/OTC
PRESERVISION AREDS CAPS F RX/OTC
PRESERVISION AREDS TABS F RX/OTC
PRESERVISION/LUTEINCAPS F RX/OTC
PRO-CAL TABS 145MG-187.5MG-40MG-100UNIT-7.5MG
F RX/OTC
PROCERV HP TABS F RX/OTC
PRORENAL+D TABS F RX/OTC
PRORENAL+D/OMEGA-3CAPS F RX/OTC
PROTECT CARDIO AF CAPS F RX/OTC
PROTECT PLUS CAPS F RX/OTC
PROTECT PLUS NF LIQD F RX/OTC
Drug Name DrugTier
Requirements/Limits
PROTECT PLUS SO CAPS F RX/OTC
QUENCH TABS F RX/OTC
QUIN B STRONG TABS F RX/OTC
QUINTABS-M TABS F RX/OTC
RA CENTRAL-VITE UNDER 50MENS TABS F RX/OTC
RA CENTRAL-VITE UNDER 50WOMENS TABS
F RX/OTC
RA ESSENCE-C PACK F
RAGUS TABS (MultipleVitamins w/ Minerals) NP RX/OTC
RENAPLEX-D TABS F RX/OTC
REPLACE CAPS F RX/OTC
REQ 49+ TABS F RX/OTC
SAVISION CAPS F RX/OTC
SENIOR VITES TBCR F
SENTRY SENIOR TABS F RX/OTC
SENTRY SENIOR/LUTEINTABS F RX/OTC
SENTRY TABS F RX/OTC
SIDEROL TABS F RX/OTC
SKIN BEAUTY & WELLNESS PACK F
SM ONE DAILY MENS TABS F RX/OTC
SM ONE DAILY WOMENS TABS F RX/OTC
SOLO TABS F RX/OTC
Nebraska Total Care Updated December 1, 2017
206
Drug Name DrugTier
Requirements/Limits
STROVITE FORTE SYRP 55MCG/15ML-5MG/15ML-3MG/15ML-50MCG/15ML-15MG/15ML-50MG/15ML-10MG/15ML-17MG/15ML-100MG/15ML-25MG/15ML-4000UNIT/15ML-20MCG/15ML-400UNIT/15ML-15MG/15ML-1MG/15ML-30UNIT/15ML-150MCG/15ML-20MG/15ML-300MG/15ML
F
STROVITE FORTE TABS 0.1MG-50MCG-60UNIT-25MCG-1000UNIT-15MG-3MG-50MG-20MG-10MG-25MG-3000UNIT-100MG-20MG-50MCG-0.8MG-0.15MG-25MG-500MG (Multiple Vitamins w/Minerals)
NP
RX/OTC
STROVITE ONE TABS F RX/OTC
SUPER ANTIOXIDANT CAPS F RX/OTC
SUPER NU-THERA POWD F
SUPERB NAILS TABS F RX/OTC
SUPERVITE EC TBEC F
SUPPORT LIQD F RX/OTC
SYNAGEX CAPS F
SYNATEK CAPS F
T-VITES TABS F RX/OTC
THERA M PLUS TABS F RX/OTC
THERA-M TABS F RX/OTC
THERA-TABS M TABS F RX/OTC
THERABETIC MULTI-VITAMIN TABS F RX/OTC
Drug Name DrugTier
Requirements/Limits
THERAGRAN-M ADVANCED 50 PLUS TABS
F RX/OTC
THERAGRAN-M ADVANCED TABS F RX/OTC
THERAGRAN-M PREMIER 50 PLUS TABS F RX/OTC
THERAGRAN-M PREMIER TABS F RX/OTC
THERAGRAN-M TABS F RX/OTC
THERAMILL FORTE CAPS (Multiple Vitamins w/Minerals)
NP RX/OTC
THERANATAL LACTATION COMPLETE MISC
F
THERANATAL LACTATION ONE CAPS F RX/OTC
THERANATAL LACTATION SUPPORT MISC
F
THEREMS-H TABS F RX/OTC
THEREMS-M TABS F RX/OTC
ULTRA MEGA GOLD TBCR F
ULTRA MEGA TBCR F
ULTRA MEGA TWO TBCR F
ULTRA MENS PACK MISC F
ULTRA WOMENS PACK MISC F
UNICOMPLEX-M TABS F RX/OTC
VITA-BOB CAPS F RX/OTC
VITABEX CAPS F RX/OTC
VITALINE TOTAL FORMULA 2 TABS F RX/OTC
VITALINE TOTAL FORMULA 3 TABS F RX/OTC
VITAMENT PACK F
Nebraska Total Care Updated December 1, 2017
207
Drug Name DrugTier
Requirements/Limits
VITAMIN C EFFERVESCENT BLEND PACK
F
VITAMIN C/ELECTROLYTES PACK F
VITAMIN D3 COMPLETE TABS F RX/OTC
VITAMINS TO GO MAXIMUM MISC F
VITAMINS TO GO MEN MISC F
VITAMINS TO GO WOMEN MISC F
VITAROCA PLUS TABS (Multiple Vitamins w/Minerals)
NP RX/OTC
VITASANA TABS F RX/OTC
VITATRUM TABS F RX/OTC
VITRUM 50+ SENIOR MULTI TABS F RX/OTC
VP-ZEL TABS F RX/OTC
WHOLE FOOD MULTIVITAMIN TABS F RX/OTC
WOMENS 50+ MULTI VITAMIN& MINERAL FORMULA TABS
F RX/OTC
WOMENS BIOMULTIPLE TABS F RX/OTC
WOMENS MULTI VITAMIN & MINERAL FORMULA TABS
F RX/OTC
WOMENS PACK MISC F
YELETS TEENAGE FORMULA TABS F RX/OTC
YOUR LIFE MULTI ADULT GUMMIES CHEW F
YOUR LIFE TEEN MULTIVITAMIN GUMMIES CHEW
F
Drug Name DrugTier
Requirements/Limits
ZINC LOZG OR 50MG-15MG-10MG-500UNIT-100MG, 50MG-15MG-500UNIT-100MG, 10MG-5MG-10MG-10MG-15MG-500UNIT-60MG
F
Multivitamins CARDENZ TABS (MultipleVitamin) NP
DEKAS ESSENTIAL CAPS 150UNIT-1000MCG-2000UNIT-2000UNIT
F
multiple vitamin caps F
multiple vitamin tabs F
OMNICAP TABS F
ONE-A-DAY ESSENTIAL TABS (Multiple Vitamin) NP
ONE-A-DAY MENS TABS (Multiple Vitamin) NP
QUINTABS TABS F
THERA TABS F
ZE-PLUS CAPS (MultipleVitamin) NP
Ped MV w/ Fluoride FLORIVA PLUS SOLN F
MULTIVITAMIN/FLUORIDE CHEW F
pediatric multivitamins w/flchew F
pediatric multivitamins w/flsoln F
pediatric vitamins acd w/fluoride soln F
POLY-VI-FLOR CHEW F
POLY-VI-FLOR FS STRP F
POLY-VI-FLOR SUSP F
QUFLORA PEDIATRIC CHEW F
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Drug Name DrugTier
Requirements/Limits
QUFLORA PEDIATRIC SOLN F
Ped MV w/ Iron pediatric multiple vitaminsw/ iron chew F
pediatric multiple vitaminsw/ iron soln F
POLY-VI-SOL/IRON SOLN(Pediatric Multiple Vitaminsw/ Iron)
F
Ped Multi Vitamins w/Fl & FE ESCAVITE LQ LIQD F
ped multivitamins w/fl &iron soln F
TRI-VIT/FLUORIDE/IRONSOLN F
Ped Multiple Vitamins w/ Minerals FLINTSTONES GUMMIES CHEW (Pediatric MultipleVitamin w/ Minerals & C)
NP
FLINTSTONES GUMMIES COMPLETE CHEW 1.25MG-15MCG-2.5MG-1000UNIT-1.5MCG-300UNIT-100MCG-9UNIT-37.5MCG-0.5MG-15MG (Pediatric Multiple Vitaminw/ Minerals & C)
NP
FLINTSTONES GUMMIES COMPLETE CHEW 1.25MG-15MCG-2.5MG-1000UNIT-1.5MG-300UNIT-100MCG-9UNIT-37.5MCG-0.5MG-15MG
F
FLINTSTONES GUMMIES PLUSIMMUNITY SUPPORT/EXTRA CCHEW (Pediatric MultipleVitamin w/ Minerals & C)
NP
FLINTSTONES SOUR GUMMIES CHEW (Pediatric Multiple Vitaminw/ Minerals & C)
NP
FLINTSTONES TODDLER/TASTISMOOTHCHEW
F
Drug Name DrugTier
Requirements/Limits
GNP CHILDRENS COMPLETE CHEWABLES CHEW
F
HEALTHY KIDS GUMMIES CHEW F
NF FORMULAS CHILDRENS CHEWABLE CHEW
F
ONE-A-DAY SCOOBY-DOO GUMMIES CHEW (Pediatric Multiple Vitaminw/ Minerals & C)
NP
ONE-A-DAY/JOLLYRANCHER CHEW (Pediatric Multiple Vitaminw/ Minerals & C)
NP
Nebraska Total Care Updated December 1, 2017
209
Drug Name DrugTier
Requirements/Limits
pediatric multiple vitamin w/minerals & c chew 10unit-20mcg-1.25mg-10mcg-15mcg-1000unit-2.5mcg-100unit-37.5mcg-0.5mg-15mg, 1.3mg-9unit-15mcg-2.5mg-1000unit-1.5mcg-300unit-100mcg-38mcg-0.5mg-15mg, 8.25unit-20mcg-1.2mg-2.75mg-10mcg-10mcg-1300unit-2.15mcg-40unit-130mcg-33mcg-0.4mg-10mg,1.05mg-200mg-60mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-300mcg-15unit-1.05mg, 16.5unit-42mcg-2.7mg-5.2mg-40mcg-40mcg-2100unit-6mcg-400unit-260mcg-60mcg-2mg-20mg, 18mg-20mcg-1mg-50mg-30unit-150mcg-20mcg-108mg-40mg-2mg-15mg-1.5mg-10mg-3500unit-20mg-10mcg-1.7mg-6mcg-400mcg-45mcg-2mg-60mg-400unit, 9unit-15mcg-1.25mg-2.5mg-19mg-1000unit-3mcg-200unit-100mcg-37.5mcg-0.5mg-15mg, 10unit-37.5mcg-1.5mg-187.5mcg-2.5mg-2.5mg-212.5mcg-1250unit-3mcg-200unit-200mcg-75mcg-1mg-20mg, 100mg-150mcg-100mg-30unit-2mg-12mg-20mg-1.5mg-18mg-3000unit-15mg-1.7mg-10mg-6mcg-400mcg-40mcg-2mg-60mg-400unit,5000unit-100mg-30unit-150mcg-100mg-2mg-15mg-20mg-1.5mg-18mg-20mg-1.7mg-10mg-6mcg-400mcg-40mcg-2mg-60mg-400unit, 100mg-30unit-150mcg-100mg-20mg-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-38mg-1.7mg-6mcg-
F
Drug Name DrugTier
Requirements/Limits
400mcg-40mcg-2mg-60mg-400unit, 2.5mg-20unit-40mcg-5mg-2000unit-20mcg-38mg-5mcg-200unit-200mcg-75mcg-1mg-30mg,6.25mg-6.25mg-5mg-1667unit-10unit-40mg,9unit-15mcg-1.25mg-2.5mg-1000unit-1.5mcg-300unit-100mcg-37.5mcg-0.5mg-15mg, 30unit-150mcg-100mg-8mg-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-1.7mg-6mcg-600unit-400mcg-40mcg-2mg-60mg, 200unit-21mg-1.35mg-2.6mg-20mcg-20mcg-1050unit-3mcg-200unit-130mcg-30mcg-1mg-10mg, 5mg-10mg-2mg-10mg-5mg-10mcg-10mcg-5mcg-100mg-30unit-150mcg-125mg-2mg-15mg-1mg-40mg-2mg-18mg-300mg-5000unit-25mg-2.2mg-10mg-8mcg-400unit-2mg-400mcg-40mcg-2.5mg,100mg-30unit-150mcg-130mg-2mg-15mg-20mg-1.5mg-18mg-10mg-5000unit-13.5mg-1.7mg-6mcg-400mcg-40mcg-2mg-60mg-400unit, 1mg-1mg-3mg-2.5mg-30mcg-0.5mg-5mg-25mg-75mcg-50mg-0.5mg-15unit-10mcg-5mg-0.75mg-2.5mg-1.25mg-2500unit-2.5mg-20mcg-0.85mg-3mcg-200unit-200mcg-75mcg-0.5mg-60mg, 100mg-30unit-150mcg-100mg-10mg-2mg-12mg-20mg-1.5mg-18mg-10mg-60mg-3000unit-15mg-38mg-1.7mg-400unit-400mcg-40mcg-2mg, 15mg-1.5mg-12mg-10mg-1000mcg-1.7mg-16000unit-6mcg-1500unit-200mcg-200unit-
Nebraska Total Care Updated December 1, 2017
210
Drug Name DrugTier
Requirements/Limits
100mcg-1.9mg-100mg,1.35mg-8.25unit-21mcg-2.6mg-20mcg-20mcg-1050unit-3mcg-200unit-70mcg-30mcg-1mg-10mg,100mg-5000unit-150mcg-100mg-15mg-2mg-8mg-20mg-18mg-30unit-400unit-1.7mg-10mg-6mcg-1.5mg-20mg-400mcg-40mcg-2mg-60mg, 16.5unit-42mcg-2.7mg-5.2mg-40mcg-40mcg-2100unit-6mcg-600unit-260mcg-60mcg-2mg-20mg, 100mg-100mg-150mcg-20mg-2mg-12mg-1.5mg-18mg-10mg-60mg-3000unit-15mg-38mg-1.7mg-6mcg-400unit-400mcg-30unit-40mcg-2mg, 1.25mg-9unit-15mcg-2.5mg-1000unit-20mcg-20mcg-1.5mcg-200unit-100mcg-37.5mcg-0.5mg-10mg, 15mcg-1mg-2mg-1mg-1.25mg-5mcg-5mcg-1250unit-1.5mcg-25unit-100mcg-7.5unit-22.5mcg-0.25mg-7.5mg, 100mg-30unit-150mcg-100mg-20mg-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-1.7mg-6mcg-400unit-400mcg-40mcg-2mg-60mg, 15unit-1.05mg-1998unit-10mg-1.2mg-4.5mcg-400unit-300mcg-1.05mg-60mg, 100mg-150mcg-100mg-10mg-20mg-400unit-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-38mg-1.7mg-6mcg-400mcg-30unit-40mcg-2mg-60mg,50mg-20mcg-150mcg-20mcg-160mg-15mg-2mg-20mcg-1mg-40mg-30unit-18mg-10mg-5000unit-20mg-10mcg-1.7mg-6mcg-1.5mg-45mcg-2mg-60mg-400unit, 9unit-21mcg-
Drug Name DrugTier
Requirements/Limits
1.35mg-2.6mg-20mcg-20mcg-1050unit-3mcg-300unit-100mcg-37.5mcg-1mg-20mg, 7.5unit-15mcg-50mcg-1mg-1mg-1.25mg-5mcg-750unit-1.5mcg-200unit-100mcg-22.5mcg-0.25mg-7.5mg, 1.3mg-15mcg-2.5mg-1000unit-1.5mcg-300unit-100mcg-9unit-38mcg-0.5mg-15mg,20mcg-1mg-50mg-30unit-150mcg-20mcg-108mg-2mg-15mg-40mg-1.5mg-18mg-10mg-3500unit-20mg-10mcg-1.7mg-6mcg-400unit-400mcg-45mcg-2mg-60mg, 100mg-30unit-150mcg-100mg-20mg-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-1.7mg-6mcg-400mcg-40mcg-2mg-60mg-400unit,15mg-15mcg-15unit-1mg-75mcg-37.5mcg-12.5mg-6.25mg-2.5mg-1.5mg-2.5mg-7.5mg-2500unit-10mg-1.7mg-3.75mcg-300unit-200mcg-50mcg-2mg-60mg, 183unit-500mcg-1.33mg-6mg-0.6mcg-150mcg-6mcg-1.1mg-45mg, 1.3mg-10unit-20mcg-2.5mg-1000unit-10mcg-19mg-2.5mcg-100unit-100mcg-38mcg-0.5mg-15mg,8.25unit-21mcg-1.35mg-2.6mg-20mcg-20mcg-1050unit-3mcg-200unit-70mcg-30mcg-1mg-10mg,15mg-1.5mg-12mg-100mg-10mg-1000mcg-1.7mg-16000unit-6mcg-1500unit-200mcg-200unit-100mcg-1.9mg, 15mg-1.5mg-12mg-100mg-10mg-1000mcg-1.7mg-16000unit-6mcg-3000unit-200mcg-200unit-100mcg-1.9mg, 20unit-40mcg-2.5mg-5mg-2000unit-20mcg-38mg-
Nebraska Total Care Updated December 1, 2017
211
Drug Name DrugTier
Requirements/Limits
5mcg-200unit-200mcg-75mcg-1mg-30mg, 15unit-0.8mg-8mg-1.05mg-12mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 1.3mg-9unit-15mcg-2.5mg-1000unit-19mg-1.5mg-200unit-100mcg-38mcg-0.5mg-15mg, 2.5mg-40mcg-5mg-2000unit-20mcg-38mg-5mcg-200unit-200mcg-20unit-75mcg-1mg-30mg, 1.3mg-9unit-15mcg-2.5mg-1000unit-19mg-1.5mcg-200unit-100mcg-38mcg-0.5mg-15mg, 200unit-16000unit-15mg-1.5mg-12mg-100mg-10mg-800mcg-1.7mg-6mcg-1000unit-200mcg-100mcg-1.9mg, 100mg-100mg-30unit-150mcg-10mg-20mg-2mg-12mg-1.5mg-18mg-10mg-60mg-3000unit-15mg-38mg-1.7mg-6mcg-400unit-400mcg-40mcg-2mg pediatric multiple vitamin w/minerals & c liqd 0.6mg/ml-5751unit/ml-3mg/ml-5mg/ml-10mcg/ml-15mg/ml-2mg/ml-3mg/ml-6mg/ml-400mcg/ml-400unit/ml-0.6mg/ml-50unit/ml-15mcg/ml-0.6mg/ml-45mg/ml
F
RX/OTC
Drug Name DrugTier
Requirements/Limits
pediatric multiple vitamin w/minerals & c soln 5mg/ml-3mg/ml-6mg/ml-400mcg/ml-0.6mg/ml-4627unit/ml-4mcg/ml-500unit/ml-0.5mg/ml-50unit/ml-15mcg/ml-0.6mg/ml-45mg/ml,50unit/ml-5mg/ml-3mg/ml-45mg/ml-6mg/ml-400mcg/ml-0.6mg/ml-4627unit/ml-4mcg/ml-500unit/ml-0.5mg/ml-15mcg/ml-0.6mg/ml,0.6mg/ml-300mcg/ml-7.5mg/ml-50unit/ml-3mg/ml-6mg/ml-3170unit/ml-4mcg/ml-400unit/ml-0.5mg/ml-15mcg/ml-0.6mg/ml-45mg/ml
F
RX/OTC
VITALETS CHEW F
VITALETS CHILDRENS CHEW F
VITAMAX CHEW F
ZOO FRIENDS COMPLETE CHEW F
Pediatric Multiple Vitamins ONE-A-DAY VITACRAVES GUMMIES+OMEGA-3 DHA CHEW (Pediatric Multiple Vitamin w/ C & FA)
NP
pediatric multiple vitamin w/c & fa chew F
pediatric multiple vitamin w/c soln F
pediatric multiple vitamin w/extra c & fa chew F
pediatric multiple vitaminsliqd F
POLY-VI-SOL SOLN (Pediatric Multiple Vitaminw/ C)
NP
Pediatric Vitamins BPROTECTED PEDIA TRI-VITE SOLN F
Nebraska Total Care Updated December 1, 2017
212
Drug Name DrugTier
Requirements/Limits
HONEY BEARS CHEW F
MULTIVITAMIN GUMMIES CHILDRENS CHEW F
pediatric vitamins adc soln F
Prenatal Vitamins ACTIVE OB CAPS NP
BAL-CARE DHA MISC NP
BP FOLINATAL PLUS B TABS F
BP MULTINATAL PLUS CHEW 3.5UNIT-2MG-15MG-50MG-250MG-40MG-6MCG-1MG-2MG-50MG
F
RX/OTC
BP MULTINATAL PLUS TABS 30UNIT-2MG-15MG-100MG-3MG-200MG-30MG-20MG-3.4MG-12MCG-1MG-50MG-60MG
F
C-NATE DHA CAPS NP
CALCIUM PNV CAPS NP
CITRANATAL 90 DHA MISC NP
CITRANATAL ASSURE MISC NP
CITRANATAL B-CALM MISC NP
CITRANATAL DHA MISC NP
CITRANATAL HARMONY CAPS NP
CITRANATAL RX TABS NP
CLASSIC PRENATAL TABS NP
CO-NATAL FA TABS NP
COMPLETE NATAL DHA MISC F
COMPLETENATE CHEW F AL; Up to 49yrs old
Drug Name DrugTier
Requirements/Limits
CONCEPT DHA CAPS F
CONCEPT OB CAPS F
CVS PRENATAL TABS NP
DOTHELLE DHA CAPS F
ELITE-OB TABS NP
ENBRACE HR CAPS NP
ENFAMIL EXPECTA MISC F
EQL PRENATAL FORMULA TABS NP
EXTRA-VIRT PLUS DHA CAPS NP
EZFE FORTE CAPS F
FOCALGIN 90 DHA MISC NP
FOCALGIN CA MISC NP
FOLCAL DHA CAPS NP
FOLCAPS OMEGA 3 CAPS NP
FOLIVANE-OB CAPS F
GNP DAILY PRENATAL MISC F
GNP PRENATAL TABS NP
GOODSENSE PRENATAL VITAMINS TABS NP
HEMENATAL OB + DHA MISC F
HEMENATAL OB TABS NP
HM ONE DAILY PRENATAL COMBO MISC F
HM PRENATAL TABS NP
INATAL ADVANCE TABS F
INATAL GT TABS F
Nebraska Total Care Updated December 1, 2017
213
Drug Name DrugTier
Requirements/Limits
INATAL ULTRA TABS F
INFANATE BALANCE CAPS NP
KP PRENATAL MULTIVITAMINS TABS NP
KPN PRENATAL TABS NP
M-VIT TABS F AL; Up to 50yrs old;RX/OTC
MACNATAL CN DHA CAPS NP
MARNATAL-F CAPS NP
MTERYTI FOLIC 5 TBPK NP
MTERYTI TBPK NP
MULTI PRENATAL TABS NP
MYNATAL ADVANCE TABS F
MYNATAL PLUS TABS NP
MYNATAL ULTRACAPLET TABS F
MYNATAL-Z TABS NP
NAT-RUL PRENATAL VITAMINS TABS NP
NATALVIT TABS F
NATELLE ONE CAPS NP
NEEVO DHA CAPS NP
NESTABS ABC MISC NP
NESTABS DHA MISC NP
NESTABS ONE CAPS NP
NESTABS TABS NP
NEWGEN TABS NP
NEXA PLUS CAPS NP
Drug Name DrugTier
Requirements/Limits
NIVA-PLUS TABS F AL; Up to 50yrs old;RX/OTC
O-CAL FA TABS 4 AL; Up to 50yrs old;RX/OTC
O-CAL PRENATAL TABS NP
OB COMPLETE GOLD CAPS NP
OB COMPLETE ONE CAPS NP
OB COMPLETE PETITE CAPS NP
OB COMPLETE PREMIER TABS NP
OB COMPLETE TABS NP
OB COMPLETE/DHACAPS F
ONE-A-DAY WOMENS PRENATAL MISC F
PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID TABS
NP
PNV FOLIC ACID + IRON MULTIVITAMIN TABS F
AL; Up to 50yrs old;RX/OTC
PNV OB+DHA MISC NP
PNV PRENATAL PLUS MULTIVITAMIN + DHA MISC
NP
PNV PRENATAL PLUS MULTIVITAMIN TABS F
AL; Up to 50yrs old;RX/OTC
PNV TABS 29-1 TABS NP
PNV-DHA CAPS F
PNV-DHA+DOCUSATE CAPS NP
PNV-OMEGA CAPS NP
PNV-SELECT TABS F
PNV-TOTAL CAPS F
Nebraska Total Care Updated December 1, 2017
214
Drug Name DrugTier
Requirements/Limits
PNV-VP-U CAPS NP
PR NATAL 400 EC MISC NP
PR NATAL 400 MISC NP
PR NATAL 430 EC MISC NP
PR NATAL 430 MISC NP
PREFERA OB TABS NP
PREFERAOB +DHA MISC NP
PREFERAOB ONE CAPS NP
PRENAISSANCE BALANCE CAPS NP
PRENAISSANCE CAPS NP
PRENAISSANCE HARMONY DHA MISC F
PRENAISSANCE NEXT TABS NP
PRENAISSANCE NEXT-B TABS F
PRENAISSANCE PLUS CAPS NP
PRENATA CHEW F
PRENATABS FA TABS NP
PRENATABS RX TABS NP
PRENATAL 19 CHEW 30UNIT-1000UNIT-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG, 1000UNIT-400UNIT-20MG-25MG-3MG-200MG-29MG-7MG-6MG-3MG-12MCG-1MG-30UNIT-20MG-100MG
F
AL; Up to 49yrs old
Drug Name DrugTier
Requirements/Limits
PRENATAL 19 TABS 1000UNIT-30UNIT-20MG-25MG-3MG-200MG-29MG-15MG-3MG-7MG-12MCG-400UNIT-20MG-1MG-100MG, 30UNIT-1000UNIT-20MG-25MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG
NP
PRENATAL FORMULA A-FREE TABS F
PRENATAL FORMULA TABS 30UNIT-200MG-4000UNIT-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-800MCG-2.6MG-120MG-400UNIT
NP
PRENATAL LOW IRON TABS NP
PRENATAL MULTIVITAMIN + DHA MISC
F
PRENATAL MULTIVITAMIN TABS NP
PRENATAL ONE DAILY TABS NP
PRENATAL PLUS IRON TABS NP
PRENATAL PLUS TABS F AL; Up to 50yrs old;RX/OTC
Nebraska Total Care Updated December 1, 2017
215
Drug Name DrugTier
Requirements/Limits
PRENATAL TABS 160MG-11UNIT-200MG-25MG-1.84MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-800MCG-2.6MG-100MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 3.75UNIT-0.5MG-50MG-0.5MG-25MG-15MG-3.75MG-6.75MG-2.5MG-5MG-0.75MG-500UNIT-2.5MCG-0.5MG-200MCG-25MCG-0.75MG-100UNIT, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-0.8MG-2.6MG- NP
120MG, 11UNIT-263MG-25MG-1.5MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG, 4000UNIT-30UNIT-200MG-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-4000UNIT-8MCG-400UNIT-800MCG-2.6MG-120MG, 4000UNIT-30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG PRENATAL TABS 22MG- AL; Up to 502MG-25MG-1.84MG- yrs old;200MG-27MG-4000UNIT-20MG-3MG-12MCG- F RX/OTC
400UNIT-1MG-10MG-120MG PRENATAL VITAMIN & MINERAL TABS NP
PRENATAL VITAMIN TABS NP
PRENATAL VITAMIN/IRON TABS NP
Drug Name DrugTier
Requirements/Limits
PRENATAL VITAMINS PLUS LOW IRON TABS F
AL; Up to 50yrs old;RX/OTC
PRENATAL VITAMINS TABS 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG
NP
PRENATAL-U CAPS NP
PRENATE AM TABS NP
PRENATE CHEW NP
PRENATE DHA CAPS 18MG-600MCG-40UNIT-300MG-50MG-155MG-25MCG-400UNIT-400MCG-26MG-90MG
NP
PRENATE DHA CAPS 600MCG-10UNIT-300MG-50MG-145MG-28MG-13MCG-220UNIT-400MCG-26MG-90MG
F
PRENATE ELITE TABS 20MG-600MCG-40UNIT-150MCG-2600UNIT-1.5MG-15MG-25MG-155MG-3MG-21MG-3.5MG-13MCG-600UNIT-400MCG-330MCG-21MG-75MG
NP
PRENATE ELITE TABS 600MCG-10UNIT-150MCG-2600UNIT-1.5MG-15MG-15MG-25MG-3MG-100MG-26MG-6MG-21MG-3.5MG-13MCG-450UNIT-400MCG-330MCG-21MG-75MG, 600MCG-10UNIT-150MCG-2600UNIT-1.5MG-15MG-25MG-3MG-100MG-26MG-6MG-21MG-3.5MG-13MCG-450UNIT-400MCG-330MCG-21MG-75MG
F
PRENATE ENHANCE CAPS NP
Nebraska Total Care Updated December 1, 2017
216
Drug Name DrugTier
Requirements/Limits
PRENATE ESSENTIAL CAPS 18MG-40MG-600MCG-10UNIT-150MCG-300MG-50MG-155MG-13MCG-220UNIT-400MCG-280MCG-26MG-90MG
NP
PRENATE ESSENTIAL CAPS 29MG-600MCG-40MG-10UNIT-150MCG-300MG-50MG-145MG-13MCG-220UNIT-400MCG-280MCG-26MG-90MG
F
PRENATE MINI CAPS 25MG-600MCG-10UNIT-150MCG-18MG-350MG-25MG-80MG-13MCG-1000UNIT-400MCG-280MCG-26MG-60MG
NP
PRENATE MINI CAPS 25MG-600MCG-29MG-10UNIT-150MCG-350MG-25MG-100MG-13MCG-220UNIT-400MCG-280MCG-26MG-60MG
F
PRENATE PIXIE CAPS NP
PRENATE RESTORE CAPS NP
PRENATE STAR TABS NP
PREPLUS TABS F AL; Up to 50yrs old;RX/OTC
PREQUE 10 TABS NP
PRETAB TABS NP
PRIMACARE CAPS NP
PROFE FORTE CAPS F
PROVIDA DHA CAPS NP
PROVIDA OB CAPS NP
PUREFE OB PLUS CAPS NP
Drug Name DrugTier
Requirements/Limits
PX PRENATAL MULTIVITAMINS TABS NP
QC PRENATAL TABS NP
R-NATAL OB CAPS NP
RA ONE DAILY MISC F
RA PRENATAL FORMULA/FOLICACIDTABS
NP
RA PRENATAL TABS NP
RELNATE DHA CAPS NP
RIGHT STEP PRENATAL TABS NP
RULAVITE DHA CAPS F
SE-NATAL 19 CHEW 30UNIT-1000UNIT-100MG-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG
4
AL; Up to 49yrs old
SE-NATAL 19 TABS 30UNIT-1000UNIT-20MG-25MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-3MG-20MG-1MG-100MG
NP
SE-TAN DHA CAPS F
SELECT-OB CHEW NP
SELECT-OB+DHA MISC NP
SM ONE DAILY PRENATAL MISC F
SM PRENATAL VITAMINS TABS NP
STUART ONE CAPS NP
TARON-BC MISC F
TARON-C DHA CAPS F
TARON-PREX CAPS F
Nebraska Total Care Updated December 1, 2017
217
Drug Name DrugTier
Requirements/Limits
THERANATAL CORE NUTRITION TABS F
AL; Up to 50yrs old;RX/OTC
THRIVITE 19 TABS NP
THRIVITE RX TABS NP
TL FOLATE TABS F
TL-CARE DHA CAPS NP
TL-SELECT CAPS NP
TRI-TABS DHA MISC NP
TRIADVANCE TABS F
TRICARE PRENATAL 1 CHEW NP
TRICARE PRENATAL CHEW NP
TRICARE PRENATAL COMPLEAT MISC F
TRICARE PRENATAL DHA ONE CAPS NP
TRICARE PRENATAL THPK NP
TRICARE TABS 4 AL; Up to 50yrs old;RX/OTC
TRINATAL GT TABS F
TRINATAL RX 1 TABS NP
TRINATE TABS NP
TRISTART DHA CAPS NP
TRIVEEN-DUO DHA MISC NP
TRIVEEN-PRX RNF CAPS NP
ULTIMATECARE ONE CAPS NP
ULTIMATECARE ONE NF CAPS NP
VEMAVITE-PRX 2 CAPS NP
Drug Name DrugTier
Requirements/Limits
VENA-BAL DHA MISC NP
VINATE CARE CHEW F RX/OTC
VINATE DHA RF CAPS NP
VINATE II TABS F
VINATE M TABS F AL; Up to 49yrs old
VINATE ONE TABS NP
VIRT NATE TABS NP
VIRT-ADVANCE TABS F
VIRT-C DHA CAPS F
VIRT-NATE DHA CAPS NP
VIRT-PN DHA CAPS F
VIRT-PN PLUS CAPS NP
VIRT-PN TABS F
VIRT-SELECT CAPS NP
VIRT-VITE GT TABS F
VIRTPREX CAPS NP
VITAFOL FE+ CPPK NP
VITAFOL GUMMIES CHEW NP
VITAFOL ULTRA CAPS NP
VITAFOL-NANO TABS NP
VITAFOL-OB TABS NP
VITAFOL-OB+DHA MISC NP
VITAFOL-ONE CAPS NP
VIVA DHA CAPS NP
VOL-NATE TABS NP
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Drug Name DrugTier
Requirements/Limits
VOL-PLUS TABS F AL; Up to 50yrs old;RX/OTC
VOL-TAB RX TABS NP
VP-CH PLUS CAPS NP
VP-CH-PNV CAPS NP
VP-GGR-B6 PRENATAL TABS NP
VP-HEME OB + DHA MISC F
VP-HEME OB TABS NP
VP-HEME ONE CAPS NP
VP-PNV-DHA CAPS NP
ZATEAN-CH CAPS NP
ZATEAN-PN DHA CAPS F
ZATEAN-PN PLUS CAPS NP
Specialty Vitamins Products ADRENAL STRESS CALM TABS F RX/OTC
ADVANCED COLLAGEN TABS F RX/OTC
ALLERWELL ALLERGY FORMULA TABS F RX/OTC
BIOTIN PLUS KERATIN TABS F RX/OTC
BRAIN MIGHT/DHA & COQ10 TABS F RX/OTC
BRAIN TABS F RX/OTC
CA-PLUS TABS F RX/OTC
CARDIO TONE TABS F RX/OTC
CENTRUM PERFORMANCE TABS F RX/OTC
CENTRUM SPECIALIST ENERGY TABS F RX/OTC
CU-PLUS TABS F RX/OTC
Drug Name DrugTier
Requirements/Limits
CVS HAIR/SKIN/NAILSTABS F RX/OTC
ELON MATRIX 5000 TABS F RX/OTC
ELON MATRIX PLUS TABS F RX/OTC
ELON MATRIX 5000 COMPLETE TABS F RX/OTC
ELON MATRIX COMPLETE TABS F RX/OTC
ELON R3 TABS F RX/OTC
GREEN SOURCE TABS F RX/OTC
HAIR FARE TABS F RX/OTC
HAIR NOURISHING SUPPLEMENT TABS F RX/OTC
HEALTHY HEART COMPLEX TABS F RX/OTC
HEART TABS F RX/OTC
HM ESTROPLUS TABS F RX/OTC
KIDNEY TABS 280 MG F RX/OTC
LIPIDSHIELD PLUS TABS F RX/OTC
LUNG TABS F RX/OTC
LYMPH TABS F RX/OTC
M2 CALCIUM TABS F RX/OTC
M2 CHROMIUM TABS F RX/OTC
MAMMARY TABS F RX/OTC
MENOPAUSE RELIEF TABS F RX/OTC
MG-PLUS PROTEIN TABS F RX/OTC
MIL ADREGEN TABS F RX/OTC
MILADRENE FORTE TABS F RX/OTC
MILPAN TABS F RX/OTC
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Drug Name DrugTier
Requirements/Limits
MULTI-GLAN TABS F RX/OTC
NEW LIFE HAIR TABS F RX/OTC
ORCHIC TABS F RX/OTC
OVARY TABS F RX/OTC
PARATHYROID TABS F RX/OTC
PITUITARY TABS F RX/OTC
PROSTATE TABS F RX/OTC
RA EAR CARE TABS F RX/OTC
Drug Name DrugTier
Requirements/Limits
specialty vitamins productstabs 32mg-70mcg-200mg-2mg-30unit-2500unit-15mg-50mg-300mg-18mg-12.5mg-25mg-80mcg-2.125mg-7.5mcg-400unit-1.9mg-400mcg-2.5mg-60mg, 80mg-120mcg-8.25mg-25mg-80mg-70mcg-50mg-1.5mg-5mg-100mg-20mg-5mg-25mcg-400mcg-30unit-20mg, 9mg-100mcg-75mg-75mg-100mg-15unit-2mg-5mg-500mcg-2mg, 100mg-10%-100mg-100mg-100mg-10mg-25mg-40mg-30mg-8mcg-25unit-30mg-25mg,200mg-150mg-50unit-200mg-50mg, 5unit-6mcg-10mg-5mg-0.15mg-15mg-15mg-30mg-100mg-50mg-250mg-35mg-400mcg-111mcg, 8.333mg-1mg-10mg-50mg-5unit-37.5mcg-237mg-1.67mg-2.5mg-4.167mcg-33.333mg-8.333mg-1mg-4.167mg-8.333mg-5mg-8.333mg-10mg-25mg-1.67mg-1666.67unit-2.67mcg-33.333unit-1.67mg-66.67mcg-1mg-1.67mg-40mg, 50mg-60mg-72mg-10mcg-70mcg-120mcg-4mg-10mcg-5mcg-48mg-60unit-150mcg-75mcg-60mcg-4mg-80mg-2mg-15mg-40mg-4.5mg-100mg-18mg-10mg-5000unit-40mg-25mcg-5.1mg-18mcg-400unit-400mcg-40mcg-6mg-120mg, 50mg-60mg-4mg-10mcg-70mcg-120mcg-4mg-10mcg-5mcg-72mg-48mg-75mcg-150mcg-100mg-60mcg-80mg-2mg-15mg-40mg-4.5mg-18mg-10mg-5000unit-40mg-25mcg-5.1mg-18mcg-400mcg-
F
RX/OTC
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Drug Name DrugTier
Requirements/Limits
60unit-40mcg-6mg-120mg-400unit, 2mg-150mcg-5mg-15mg-18mg-100mg-125mg-250mg-6mcg-100mg-400mcg-400mcg,15mg-4mg-150mcg-2mg-35mg-100mg-5000unit-35mg-125mg-250mg-2mg-6mcg-400mcg-300mcg-2mg, 50mg-60mg-4mg-72mg-10mcg-70mcg-120mcg-4mg-10mcg-5mcg-48mg-150mcg-75mcg-100mg-60mcg-80mg-2mg-15mg-40mg-4.5mg-18mg-10mg-5000unit-40mg-25mcg-5.1mg-18mcg-400mcg-60unit-40mcg-6mg-120mg-400unit, 25mg-100mg-25mg-25mg-125mcg-150mg-10mg-10mg-25mg-5mg-12.5mg-5mg-5mcg-12.5mg-5mg, 60mg-120mcg-50mg-10mcg-70mcg-4mg-10mcg-5mcg-48mg-60unit-150mcg-75mcg-72mg-100mg-0.9mg-4mg-60mcg-11mg-40mg-4.5mg-18mg-12mg-3500unit-40mg-25mcg-5.1mg-18mcg-400unit-400mcg-50mcg-6mg-120mg, 60mg-120mcg-50mg-72mg-10mcg-70mcg-4mg-10mcg-5mcg-0.9mg-48mg-150mcg-75mcg-80mg-100mg-4mg-60mcg-11mg-40mg-4.5mg-18mg-12mg-3500unit-40mg-25mcg-5.1mg-18mcg-400unit-400mcg-60unit-50mcg-6mg-120mg,400mg-5mcg-10mcg-1mg-5mcg-2.5mcg-40mg-15unit-75mcg-18.75mcg-32mg-54mg-0.35mg-60mcg-1mg-16mcg-3.75mg-20mg-0.75mg-3mg-5mg-1750unit-10mg-12.5mcg-0.85mg-100mcg-200unit-200mcg-15mcg-
Drug Name DrugTier
Requirements/Limits
2.5mg-30mg, 25mg-25mg-12.5mg-1mg-17.5mcg-50mg-7.5mg-10mcg-0.5mg-50mg-10mg-3.75mg-17.5mg-7.5mg-15mg-12.5mg-12.5mcg-100mcg-18.75mg-500mg,80mg-120mcg-25mg-80mg-70mcg-50mcg-100mg-1.5mg-30unit-5mg-20mg-5mg-25mcg-800unit-400mcg-20mg SPLEEN TABS F RX/OTC
STOMACH TABS F RX/OTC
THERABETIC EYE HEALTH TABS F RX/OTC
THYMUS TABS 140 MG F RX/OTC
UTERUS TABS F RX/OTC
VITAMINS FOR THE HAIR TABS F RX/OTC
ZN-PLUS TABS F RX/OTC
Vitamin Mixtures cod liver oil caps 20mg-35mg-1250unit-45mg-133.333unit, 1250unit-133unit, 50mg-110mg-250unit-110mg-100unit-10unit, 1250unit-130unit,200unit-4000unit, 34mg-1250unit-415mg-32mg-135unit, 1250unit-135unit,1250unit-133.33unit, 52mg-2500unit-600mg-52mg-270unit, , 530mg-1250unit-130unit, 110mg-2664unit-1000mg-100mg-200unit, 10minim, 90mg-37mg-415mg-36mg-1250unit-135unit
F
COD LIVER OIL FOR KIDS OIL F RX/OTC
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Drug Name DrugTier
Requirements/Limits
COD LIVER OIL OIL 4000UNIT/5ML-400UNIT/5ML,5000UNIT/5ML-500UNIT/5ML
F
RX/OTC
CVS COD LIVER OIL OIL F RX/OTC
NORWEGIAN COD LIVER OIL OIL F RX/OTC
QC COD LIVER OIL OIL F RX/OTC
RA COD LIVER OIL OIL F RX/OTC
vitamins a & d caps700unit-400unit, 1250unit-135unit, 10000unit-5000unit, 8000unit-400unit,10000unit-400unit,1250unit-133unit, 5000unit-400unit
F
Vitamins w/ Lipotropics ACTIFLOVIT EAR HEALTH TABS F
LIPOTRIAD TABS (Vitamins w/ Lipotropics) NP
Drug Name DrugTier
Requirements/Limits
vitamins w/ lipotropics tabs500mg-29mg-0.333mg-1.67mg-3.33mg-1mg-1.67mcg-0.333mg-100mg,100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-200mcg-100mcg-100mg,50mg-0.5mg-7.5mg-25mg-5mg-50mg-50mg-125mg-12.5mcg-5mg-125mg-50mcg-50mg, 100mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg,50mg-50mg-50mg-50mg-50mg-50mg-50mg-50mcg-400mcg-50mcg-50mg,266.667mg-29mg-0.333mg-1.667mg-3.333mg-111.333mg-111.333mg-1mg-1.667mcg-0.333mg-100mg,100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mcg-100mcg-100mg, 77mg-100mcg-100mg-100mg-100mcg-100mcg-100mg-100mcg-100mg-400mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg, 20mg-50mg-30mg-10mg-10mcg-30mg-8mg,60mg-60mg-60mg-60mg-60mg-60mg-60mcg-60mg-100mcg-60mcg-60mg-600mg, 29mg-0.333mg-1.666mg-3.333mg-1mg-1.666mcg-0.333mg-100mg,100mg-43.33mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg, 25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mcg-30mcg-4mg-150mg, 200mg-29mg-0.33mg-1.67mg-3.33mg-111.33mg-111.33mg-1mg-
F
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Drug Name DrugTier
Requirements/Limits
1.67mcg-0.33mg-100mg,25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mg-30mcg-4mg,200mg-29mg-0.34mg-1.67mg-3.34mg-111mg-111mg-1mg-1.67mcg-0.34mg-100mg, 50mg-50mg-50mg-50mg-50mg-50mg-50mcg-50mg-100mcg-50mcg-50mg,50mg-50mg-50mg-50mcg-50mg-50mcg-50mcg-50mg, 10000unit-10mg-18mg-100unit-225mcg-10mg-150mg-100mg-30mg-10mg-25mg-25mg-50mg-50mg-10mg-50mg-50mg-200mcg-400unit-50mg-400mcg-50mg-250mg, 50mg-50mg-50mg-50mg-50mg-50mg-50mg-50mcg-100mcg-50mcg-50mg, 100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg,30mg-56mg-2mg-10mg-83mg-240mg-3mg-2mcg-3mg-110mg-2mg MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms Central Muscle Relaxants AMRIX CP24 NP
baclofen tabs or 10 mg, 20 mg F
carisoprodol tabs 250 mg NP
carisoprodol tabs 350 mg NP QL(4 ea daily)
chlorzoxazone tabs F
cyclobenzaprine hcl tabs F
FEXMID TABS (Cyclobenzaprine HCl) NP
GABLOFEN SOSY F
LORZONE TABS NP
Drug Name DrugTier
Requirements/Limits
METAXALONE TABS 400 MG NP
metaxalone tabs 800 mg NP
methocarbamol tabs or 500 mg, 750 mg F
orphenadrine citrate tb12 or100 mg NP
PARAFON FORTE DSC TABS (Chlorzoxazone) NP
ROBAXIN TABS OR 500 MG (Methocarbamol) NP
ROBAXIN-750 TABS (Methocarbamol) NP
SKELAXIN TABS (Metaxalone) NP
SOMA TABS 250 MG (Carisoprodol) NP
SOMA TABS 350 MG (Carisoprodol) NP QL(4 ea daily)
tizanidine hcl caps 6 mg, 4mg, 2 mg NP
tizanidine hcl tabs 4 mg, 2 mg F
ZANAFLEX CAPS (Tizanidine HCl) NP
ZANAFLEX TABS (Tizanidine HCl) NP
Direct Muscle Relaxants DANTRIUM CAPS (Dantrolene Sodium) NP
dantrolene sodium caps or100 mg, 25 mg, 50 mg NP
Muscle Relaxant Combinations carisoprodol w/ aspirin tabs NP
NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus Nasal Agent Combinations DYMISTA SUSP NP
Nasal Agents - Misc. AYR NASAL DROPS SOLN F
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Drug Name DrugTier
Requirements/Limits
DERMACINRX TICANASE PAK THPK NP
OCEAN NASAL SPRAY SOLN (Saline) NP
saline gel na F
saline soln na 0.65%-0.002%, 0.65%, 0.65 % F
Nasal Antiallergy ASTEPRO SOLN (Azelastine HCl) NP
azelastine hcl soln NP
cromolyn sodium (nasal) aers F QL(0.867 ml
daily) NASALCROM AERS (Cromolyn Sodium (Nasal)) NP QL(0.867 mldaily)
olopatadine hcl (nasal) soln NP
PATANASE SOLN (Olopatadine HCl (Nasal)) F
Nasal Anticholinergics ATROVENT SOLN (Ipratropium Bromide(Nasal))
NP
ipratropium bromide (nasal)soln F
Nasal Steroids BECONASE AQ SUSP NP
budesonide (nasal) susp NP RX/OTC
FLONASE ALLERGY RELIEF CHILDRENS SUSP (Fluticasone Propionate (Nasal))
NP
QL(0.534 mldaily); RX/OTC
FLONASE ALLERGY RELIEF SUSP (Fluticasone Propionate (Nasal))
NP QL(0.534 mldaily); RX/OTC
FLONASE SENSIMIST SUSP NP RX/OTC
FLUNISOLIDE SOLN NP
fluticasone propionate(nasal) susp F QL(0.534 ml
daily); RX/OTC
Drug Name DrugTier
Requirements/Limits
mometasone furoate (nasal) susp F AL; Up to 12
yrs old NASACORT ALLERGY 24HR AERO NP RX/OTC
NASACORT ALLERGY 24HR AERO (Triamcinolone Acetonide (Nasal))
NP
RX/OTC
NASACORT ALLERGY 24HR CHILDRENS AERO (Triamcinolone Acetonide (Nasal))
NP
RX/OTC
NASONEX SUSP (Mometasone Furoate (Nasal))
NP AL; Up to 12yrs old
OMNARIS SUSP NP
QNASL AERS NP
QNASL CHILDRENS AERS NP
RHINOCORT AQUA SUSP (Budesonide (Nasal)) NP RX/OTC
triamcinolone acetonide (nasal) aero NP RX/OTC
triamcinolone acetonide (nasal) aero F RX/OTC
VERAMYST SUSP NP RX/OTC
ZETONNA AERS NP
Sympathomimetic Decongestants AFRIN 12 HOUR SOLN (Oxymetazoline HCl) NP
AFRIN ALL NIGHT NODRIP SOLN (Oxymetazoline HCl)
NP
AFRIN NASAL SPRAY SOLN (Oxymetazoline HCl) NP
AFRIN NODRIP EXTRA MOISTURIZING SOLN (Oxymetazoline HCl)
NP
AFRIN NODRIP ORIGINAL SOLN (Oxymetazoline HCl) NP
AFRIN NODRIP SEVERE CONGESTION SOLN (Oxymetazoline HCl)
NP
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Drug Name DrugTier
Requirements/Limits
AFRIN NODRIP SINUS SOLN (Oxymetazoline HCl) NP
AFRIN SINUS SOLN (Oxymetazoline HCl) NP
AFRIN SOLN (Oxymetazoline HCl) NP
DRISTAN SPRAY SOLN (Oxymetazoline HCl) NP
DURATION 12 HOUR SOLN (Oxymetazoline HCl) NP
DURATION SPRAY SOLN (Oxymetazoline HCl) NP
NASAL DECONGESTANT SYRP F
NEO-SYNEPHRINE 12 HOUR EXTRA MOISTURIZING SOLN (Oxymetazoline HCl)
NP
oxymetazoline hcl soln F
phenylephrine hcl (oral)tabs F
pseudoephedrine hcl liqd F
pseudoephedrine hcl tabs F
pseudoephedrine hcl tb12 F
SUDAFED CHILDRENS LIQD (PseudoephedrineHCl)
NP
SUDAFED CONGESTION TABS (PseudoephedrineHCl)
NP
SUDAFED NASAL DECONGESTANT MAXIMUM STRENGTH TABS (PseudoephedrineHCl)
NP
SUDAFED PE CONGESTION TABS (Phenylephrine HCl (Oral))
NP
VICKS SINEX 12 HOUR DECONGESTANT SOLN (Oxymetazoline HCl)
NP
Drug Name DrugTier
Requirements/Limits
VICKS SINEX 12 HOUR DECONGESTANT ULTRA FINE MIST SOLN (Oxymetazoline HCl)
NP
VICKS SINEX 12 HOUR DECONGESTANT ULTRA FINE MIST/MOISTURIZNGSOLN (Oxymetazoline HCl)
NP
VICKS SINEX MOISTURIZING SOLN (Oxymetazoline HCl)
NP
VICKS SINEX SEVERE NASALDECONGESTANT SOLN (Oxymetazoline HCl)
NP
VICKS SINEX SOLN (Oxymetazoline HCl) NP
NUTRIENTS
Misc. Nutritional Substances
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Drug Name DrugTier
Requirements/Limits
omega-3 fatty acids caps210mg-1000mg-75mg-90mg, 300mg-180mg-1000mg-120mg-1unit,300mg-200mg-1unit,300mg-180mg-120mg,300mg-1000mg-1unit,400mg-1000mg-300mg,180mg-120mg-1.8unit,300mg-1000mg-200mg,180mg-1unit-1000mg-120mg, 180mg-1000mg-120mg-1unit, 350mg-1000mg-250mg, 300mg-1000mg, 1000mg,1000mg-180mg-120mg,300mg-180mg-1000mg-120mg, 1000mg-180mg-120mg-1unit, 300mg-1000mg-200mg-1unit,600mg-1000mg, 100mg- F 1000mg-500mg-10unit,500mg-1000mg-250mg,300mg-1unit-1000mg,1000mg-180mg-120mg-1mg, 160mg-1000mg-100mg, 40mg-340mg-180mg-1000mg-120mg-5unit, 100mg-300mg-1000mg-200mg, 270mg-1000mg-180mg, 300mg-180mg-1gm-120mg,700mg-350mg-1000mg-250mg, 180mg-1000mg-120mg, 1000 mg, 350mg-1000mg, 180mg-120mg-5unit, 340mg-180mg-1000mg-120mg-5unit,180mg-120mg, 340mg-180mg-1unit-1000mg-120mg
OPHTHALMIC AGENTS - Drugs to Treat the Eye
Artificial Tears and Lubricants artificial tear ointment oint F
artificial tear solution soln F
ARTIFICIAL TEARS SOLN F
Drug Name DrugTier
Requirements/Limits
carboxymethylcellulosesodium (ophth) soln F
carboxymethylcellulose-glycerin soln F
carboxymethylcellulose-hypromellose gel F
GENTEAL GEL (Carboxymethylcellulose-Hypromellose)
NP
GENTEAL MILD SOLN F
GENTEAL MILD TO MODERATE SOLN (Hypromellose (Ophth))
NP
GENTEAL SEVERE GEL F
GENTEAL TEARS MODERATEPF SOLN F
GONAK SOLN (Hypromellose(Gonioscopic))
NP
GONIOSOL SOLN (Hypromellose(Gonioscopic))
NP
HYPOTEARS SOLN F
hypromellose (gonioscopic)soln F
hypromellose (ophth) soln F
ISOPTO TEARS SOLN F
polyethylene glycol-propylene glycol (ophth)soln
F
polyvinyl alcohol soln F
polyvinyl alcohol-povidone(ophth) soln F
REFRESH LIQUIGEL SOLN F
REFRESH OPTIVE ADVANCED SENSITIVE SOLN
F
REFRESH OPTIVE ADVANCED SOLN F
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Drug Name DrugTier
Requirements/Limits
REFRESH OPTIVE MEGA-3 SOLN F
REFRESH OPTIVE SENSITIVE SOLN F
REFRESH OPTIVE SOLN (Carboxymethylcellulose-Glycerin)
NP
REFRESH SOLN (Polyvinyl Alcohol-Povidone (Ophth))
NP
REFRESH TEARS SOLN (CarboxymethylcelluloseSodium (Ophth))
NP
SYSTANE OVERNIGHT THERAPY LUBRICANT EYE GEL
F
SYSTANE SOLN (Polyethylene Glycol-Propylene Glycol (Ophth))
NP
SYSTANE ULTRA HOME & AWAY PACK SOLN (Polyethylene Glycol-Propylene Glycol (Ophth))
NP
SYSTANE ULTRA SOLN (Polyethylene Glycol-Propylene Glycol (Ophth))
NP
TEARS NATURALE PM OINT (White Petrolatum-Mineral Oil)
NP
white petrolatum-mineral oiloint F
Beta-blockers - Ophthalmic BETAGAN SOLN (Levobunolol HCl) NP
betaxolol hcl (ophth) soln NP
BETIMOL SOLN 0.5 % NP
BETOPTIC-S SUSP NP
carteolol hcl (ophth) soln F
COMBIGAN SOLN F
COSOPT PF SOLN NP
Drug Name DrugTier
Requirements/Limits
COSOPT SOLN (Dorzolamide HCl-Timolol Maleate)
NP
dorzolamide hcl-timolol maleate soln F
ISTALOL SOLN NP
ISTALOL SOLN (Timolol Maleate (Ophth)) NP
levobunolol hcl soln F
timolol maleate (ophth) solg0.25 %, 0.5 % F
timolol maleate (ophth) soln0.5 % NP
timolol maleate (ophth) soln0.5 %, 0.25 % F
TIMOPTIC OCUDOSE SOLN NP
TIMOPTIC SOLN (Timolol Maleate (Ophth)) NP
TIMOPTIC-XE SOLG (Timolol Maleate (Ophth)) NP
Cycloplegic Mydriatics ATROPINE SULFATE SOLN OP 1 % F
CYCLOGYL SOLN (Cyclopentolate HCl) NP
cyclopentolate hcl soln F
MYDRIACYL SOLN (Tropicamide) NP
tropicamide soln F
Miotics ISOPTO CARPINE SOLN (Pilocarpine HCl) F
PHOSPHOLINE IODIDE SOLR NP
pilocarpine hcl soln F
Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.1 % NP
ALPHAGAN P SOLN 0.15 % (Brimonidine Tartrate) F
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Drug Name DrugTier
Requirements/Limits
apraclonidine hcl soln NP
brimonidine tartrate soln op0.15 % NP
brimonidine tartrate soln op0.2 % F
IOPIDINE SOLN 0.5 % (Apraclonidine HCl) NP
IOPIDINE SOLN 1 % NP
SIMBRINZA SUSP F
Ophthalmic Anti-infectives
AZASITE SOLN NP QL(2.5 ml perfill retail) BACITRACIN OINT OP 500 UNIT/GM NP
bacitracin-polymyxin b(ophth) oint NP
BESIVANCE SUSP NP
BLEPH-10 SOLN (Sulfacetamide Sodium (Ophth))
NP
CILOXAN OINT NP
CILOXAN SOLN (Ciprofloxacin HCl (Ophth)) NP
ciprofloxacin hcl (ophth)soln F
erythromycin (ophth) oint F
gatifloxacin (ophth) soln NP
GENTAK OINT F
gentamicin sulfate (ophth)oint F
gentamicin sulfate (ophth)soln F
levofloxacin (ophth) soln NP
MOXEZA SOLN F
moxifloxacin hcl (ophth)soln NP
Drug Name DrugTier
Requirements/Limits
NATACYN SUSP NP
neomycin-bacitracin zn-polymyxin oint NP
neomycin-polymyxin-gramicidin soln NP
NEOSPORIN SOLN (Neomycin-Polymyxin-Gramicidin)
NP
OCUFLOX SOLN (Ofloxacin (Ophth)) NP
ofloxacin (ophth) soln F
polymyxin b-trimethoprimsoln F
POLYTRIM SOLN (Polymyxin B-Trimethoprim)
NP
sulfacetamide sodium (ophth) soln NP
SULFACETAMIDE SODIUM OINT OP NP
tobramycin (ophth) soln F
TOBREX OINT F
TOBREX SOLN (Tobramycin (Ophth)) NP
trifluridine soln F
VIGAMOX SOLN (Moxifloxacin HCl (Ophth)) F
VIROPTIC SOLN (Trifluridine) NP
ZYMAXID SOLN (Gatifloxacin (Ophth)) NP
Ophthalmic Decongestants NAPHAZOLINE HCL SOLN F
phenylephrine hcl (ophth)soln 2.5 % F
tetrahydrozoline hcl (ophth)soln F
tetrahydrozoline w/polyethylene glycol soln F
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Drug Name DrugTier
Requirements/Limits
tetrahydrozoline-dextran-polyethylene glycol-povidone soln
F
VISINE ADVANCED RELIEF SOLN (Tetrahydrozoline-Dextran-Polyethylene Glycol-Povidone)
NP
VISINE EXTRA SOLN (Tetrahydrozoline HCl(Ophth))
NP
VISINE SOLN (Tetrahydrozoline HCl(Ophth))
NP
Ophthalmic Immunomodulators RESTASIS EMUL F
RESTASIS MULTIDOSE EMUL 4
Ophthalmic Integrin Antagonists XIIDRA SOLN NP
Ophthalmic Steroids ALREX SUSP F
bacitracin-poly-neomycin-hc oint NP
BLEPHAMIDE S.O.P. OINT NP
BLEPHAMIDE SUSP NP
DEXAMETHASONE SODIUM PHOSPHATE SOLN OP 0.1 %
F
DUREZOL EMUL F
FLAREX SUSP F
fluorometholone (ophth) susp F
FML FORTE SUSP NP
FML LIQUIFILM SUSP (Fluorometholone (Ophth)) NP
FML OINT NP
Drug Name DrugTier
Requirements/Limits
LOTEMAX GEL NP
LOTEMAX OINT NP
LOTEMAX SUSP F
MAXIDEX SUSP F
MAXITROL OINT (Neomycin-Polymy-Dexameth)
NP
MAXITROL SUSP (Neomycin-Polymy-Dexameth)
NP
neomycin-polymy-dexameth oint F
neomycin-polymy-dexameth susp F
NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP
NP
OMNIPRED SUSP (Prednisolone Acetate (Ophth))
NP
PRED FORTE SUSP (Prednisolone Acetate (Ophth))
NP
PRED MILD SUSP F
PRED-G S.O.P. OINT F
PRED-G SUSP F
prednisolone acetate(ophth) susp NP
PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 %
NP
sulfacetamide sod-prednisolone soln F
TOBRADEX OINT F
TOBRADEX ST SUSP NP
TOBRADEX SUSP (Tobramycin-Dexamethasone)
F
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Drug Name DrugTier
Requirements/Limits
tobramycin-dexamethasone susp NP
VEXOL SUSP NP
ZYLET SUSP NP
Ophthalmics - Misc. ACULAR LS SOLN (Ketorolac Tromethamine (Ophth))
NP
ACULAR SOLN (Ketorolac Tromethamine (Ophth)) NP
ACUVAIL SOLN NP
ALOCRIL SOLN NP
ALOMIDE SOLN NP
azelastine hcl (ophth) soln NP
AZOPT SUSP F
BEPREVE SOLN NP
bromfenac sodium (ophth)soln NP
BROMFENAC SOLN NP
BROMSITE SOLN NP
cromolyn sodium (ophth)soln F
diclofenac sodium (ophth)soln F
dorzolamide hcl soln F
ELESTAT SOLN (Epinastine HCl (Ophth)) NP
EMADINE SOLN NP
epinastine hcl (ophth) soln NP
EYEAID IRRIGATING SOLUTION SOLN (Ophthalmic IrrigationSolution)
NP
FLURBIPROFEN SODIUM SOLN F
Drug Name DrugTier
Requirements/Limits
flurbiprofen sodium soln F
ILEVRO SUSP NP
ketorolac tromethamine (ophth) soln NP
ketotifen fumarate (ophth)soln F
LASTACAFT SOLN NP
MURO 128 OINT 5 % (Sodium Chloride Hypertonic)
NP
MURO 128 SOLN 2 % F
MURO 128 SOLN 5 % (Sodium Chloride Hypertonic)
NP
NEVANAC SUSP NP
OCUFEN SOLN (Flurbiprofen Sodium) NP
olopatadine hcl soln NP
ophthalmic irrigationsolution soln F
PATADAY SOLN (Olopatadine HCl) F
PATANOL SOLN (Olopatadine HCl) NP
PAZEO SOLN F
PROLENSA SOLN NP
sodium chloride hypertonicoint F
sodium chloride hypertonicsoln F
TRUSOPT SOLN (Dorzolamide HCl) NP
ZADITOR SOLN (Ketotifen Fumarate (Ophth)) NP
Prostaglandins - Ophthalmic BIMATOPROST SOLN NP
latanoprost soln F
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Drug Name DrugTier
Requirements/Limits
LUMIGAN SOLN NP
TRAVATAN Z SOLN F
TRAVOPROST SOLN NP
XALATAN SOLN (Latanoprost) NP
ZIOPTAN SOLN NP
OTIC AGENTS - Drugs to Treat the Ear
Otic Agents - Miscellaneous acetic acid (otic) soln F
ACETIC ACID/ALUMINUMACETATE SOLN NP
carbamide peroxide (otic)soln F
DEBROX SOLN (Carbamide Peroxide (Otic))
NP
Otic Anti-infectives CETRAXAL SOLN F
CIPROFLOXACIN SOLN OT 0.2 % F
FLOXIN OTIC SOLN (Ofloxacin (Otic)) F
ofloxacin (otic) soln F
Otic Combinations CIPRO HC SUSP NP
CIPRODEX SUSP F
COLY-MYCIN S SUSP NP
CORTISPORIN-TC SUSP NP
neomycin-polymyxin-hc(otic) soln F
neomycin-polymyxin-hc(otic) susp F
OTOVEL SOLN NP
Drug Name DrugTier
Requirements/Limits
PRAMOTIC LIQD F
Otic Steroids DERMOTIC OIL (Fluocinolone Acetonide (Otic))
NP
fluocinolone acetonide (otic) oil F
hydrocortisone w/aceticacid soln NP
OXYTOCICS - Drugs to Prevent/Control UterineBleeding Oxytocics METHERGINE TABS F
methylergonovine maleatetabs or 0.2 mg F
PENICILLINS - Drugs to Treat Bacterial Infections
Aminopenicillins amoxicillin caps 500 mg,250 mg F
AMOXICILLIN CHEW 125 MG, 250 MG F
AMOXICILLIN ER TB24 NP
amoxicillin susr 200 mg/5ml, 250 mg/5ml, 125mg/5ml, 400 mg/5ml
F
amoxicillin tabs 500 mg,875 mg F
AMPICILLIN CAPS 500 MG F
ampicillin caps 500 mg,250 mg F
AMPICILLIN SUSR 250 MG/5ML, 125 MG/5ML F
MOXATAG TB24 NP
Natural Penicillins penicillin v potassium solr250 mg/5ml, 125 mg/5ml F
PENICILLIN V POTASSIUM SOLR 250 MG/5ML, 125 MG/5ML
F
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Drug Name DrugTier
Requirements/Limits
penicillin v potassium tabs250 mg, 500 mg F
Penicillin Combinations amoxicillin & potclavulanate susr 250mg/5ml-62.5mg/5ml,600mg/5ml-42.9mg/5ml,200mg/5ml-28.5mg/5ml,400mg/5ml-57mg/5ml
F
amoxicillin & potclavulanate tabs 500mg-125mg, 875mg-125mg,250mg-125mg
F
amoxicillin & potclavulanate tb12 1000mg-62.5mg
NP
AMOXICILLIN/CLAVULANATE POTASSIUM CHEW F
AUGMENTIN ES-600 SUSR (Amoxicillin & Pot Clavulanate)
NP
AUGMENTIN SUSR 125MG/5ML-31.25MG/5ML NP
AUGMENTIN SUSR 250MG/5ML-62.5MG/5ML(Amoxicillin & Pot Clavulanate)
NP
AUGMENTIN TABS 875MG-125MG, 500MG-125MG (Amoxicillin & Pot Clavulanate)
NP
AUGMENTIN XR TB12 (Amoxicillin & Pot Clavulanate)
NP
Penicillinase-Resistant Penicillins dicloxacillin sodium caps F
PROGESTINS - Hormone Replacement/ModifyingDrugs Progestins AYGESTIN TABS (Norethindrone Acetate) NP
MAKENA OIL F
medroxyprogesteroneacetate tabs or 2.5 mg, 10mg, 5 mg
F
Drug Name DrugTier
Requirements/Limits
norethindrone acetate tabs F
progesterone micronized caps F
PROMETRIUM CAPS (Progesterone Micronized) NP
PROVERA TABS (MedroxyprogesteroneAcetate)
NP
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental andEmotional Conditions Agents for Chemical Dependency ANTABUSE TABS 250 MG (Disulfiram) NP
disulfiram tabs 250 mg F
Anti-Cataplectic Agents XYREM SOLN F PA
Antidementia Agents ARICEPT TABS (DonepezilHydrochloride) NP
donepezil hydrochloridetabs 23 mg NP
donepezil hydrochloridetabs 5 mg, 10 mg F
donepezil hydrochloridetbdp 5 mg, 10 mg F
EXELON CAPS OR 3 MG, 4.5 MG, 6 MG, 1.5 MG (Rivastigmine Tartrate)
NP
EXELON PT24 TD 13.3 MG/24HR (Rivastigmine) F
EXELON PT24 TD 9.5 MG/24HR, 4.6 MG/24HR(Rivastigmine)
F QL(1 ea daily)
galantamine hydrobromidecp24 16 mg, 8 mg, 24 mg NP
GALANTAMINE HYDROBROMIDE SOLN 4 MG/ML
NP
galantamine hydrobromidetabs 4 mg, 8 mg, 12 mg NP
memantine hcl soln 2 mg/ml NP QL(10 ml daily)
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Drug Name DrugTier
Requirements/Limits
memantine hcl tabs 5 mg,10 mg, F
NAMENDA SOLN 10 MG/5ML (Memantine HCl) NP QL(10 ml daily)
NAMENDA TABS 5 MG, 10 MG (Memantine HCl) NP
NAMENDA TITRATION PAK TABS (Memantine HCl)
NP
NAMENDA XR CP24 NP
NAMENDA XR TITRATION PACK CP24 NP
NAMZARIC C4PK NP
NAMZARIC CP24 NP
RAZADYNE ER CP24 (Galantamine Hydrobromide)
NP
RAZADYNE TABS (Galantamine Hydrobromide)
NP
rivastigmine pt24 13.3mg/24hr NP
rivastigmine pt24 4.6mg/24hr, 9.5 mg/24hr NP QL(1 ea daily)
rivastigmine tartrate caps NP
Combination Psychotherapeutics olanzapine-fluoxetine hcl caps F AL; At least 6
yrs old PERPHENAZINE/AMITRIPTYLINE TABS F AL; At least 6
yrs old SYMBYAX CAPS (Olanzapine-FluoxetineHCl)
NP AL; At least 6 yrs old
Fibromyalgia Agents
SAVELLA TABS F PA; QL(2 eadaily); AL; Atleast 13 yrs old
SAVELLA TITRATION PACK MISC F
PA; QL(2 eadaily); AL; Atleast 13 yrs old
Movement Disorder Drug Therapy
Drug Name DrugTier
Requirements/Limits
INGREZZA CAPS F QL(1 ea daily);AL; At least 19 yrs old
Multiple Sclerosis Agents AMPYRA TB12 NP QL(2 ea daily)
AUBAGIO TABS NP QL(1 ea daily)
AVONEX KIT 30 MCG/VIAL F
Limit 4ea in 28 days;QL(0.143ea daily)
AVONEX PEN AJKT F QL(0.1429 eadaily)
AVONEX PSKT 30 MCG/0.5ML F QL(0.1429 ml
daily)
BETASERON KIT F Limit 15ea permonth;QL(0.5ea daily)
BETASERON KIT 4 Limit 15ea permonth;QL(0.5ea daily)
COPAXONE SOSY 20 MG/ML (Glatiramer Acetate)
F QL(1 ml daily)
COPAXONE SOSY 40 MG/ML (Glatiramer Acetate)
NP Limit 12ml in 28 days;QL(0.43ml daily)
EXTAVIA KIT 4 Limit 15ea permonth;QL(0.5ea daily)
GILENYA CAPS F QL(1 ea daily)
glatiramer acetate sosy 20mg/ml NP QL(1 ml daily)
glatiramer acetate sosy 40mg/ml NP
Limit 12ml in 28 days;QL(0.43ml daily)
PLEGRIDY SOPN NP Limit 1ml in 28 days;QL(0.036ml daily)
PLEGRIDY SOSY NP Limit 1ml in 28 days;QL(0.036ml daily)
PLEGRIDY STARTER PACK SOPN NP
Limit 1ml in 28 days;QL(0.036ml daily)
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Drug Name DrugTier
Requirements/Limits
PLEGRIDY STARTER PACK SOSY NP
Limit 1ml in 28 days;QL(0.036ml daily)
REBIF REBIDOSE SOAJ F PA; QL(0.2 mldaily)
REBIF REBIDOSE TITRATIONPACK SOAJ F PA; QL(0.2 ml
daily)
REBIF SOSY F PA; QL(0.2 mldaily)
REBIF TITRATION PACK SOSY F PA; QL(0.2 ml
daily)
TECFIDERA CPDR NP
TECFIDERA STARTER PACK MISC NP
ZINBRYTA SOSY NP
Premenstrual Dysphoric Disorder (PMDD) Agents FLUOXETINE CAPS F
Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATES TABS F
ORAP TABS 1 MG (Pimozide) NP
QL(10 eadaily); AL; Atleast 6 yrs old
ORAP TABS 2 MG (Pimozide) NP
QL(5 ea daily);AL; At least 6 yrs old
pimozide tabs 1 mg F QL(10 eadaily); AL; Atleast 6 yrs old
pimozide tabs 2 mg F QL(5 ea daily);AL; At least 6 yrs old
Smoking Deterrents
bupropion hcl (smokingdeterrent) tb12 F
PA; QL(2 eadaily); AL; Atleast 18 yrs old
CHANTIX CONTINUING MONTHPAK TABS F
PA; QL(2 eadaily); AL; Atleast 18 yrs old
CHANTIX STARTING MONTH PAK TABS F
PA; QL(2 eadaily); AL; Atleast 18 yrs old
Drug Name DrugTier
Requirements/Limits
CHANTIX TABS F PA; QL(2 eadaily); AL; Atleast 18 yrs old
NICODERM CQ PT24 14 MG/24HR, 21 MG/24HR(Nicotine)
NP PA; AL; At least 18 yrs old
NICODERM CQ PT24 7 MG/24HR (Nicotine) NP
PA; QL(1 eadaily); AL; Atleast 18 yrs old
NICORETTE GUM (Nicotine Polacrilex) NP PA; AL; At least 18 yrs old NICORETTE LOZG (Nicotine Polacrilex) NP PA; AL; At least 18 yrs old NICORETTE MINI LOZG (Nicotine Polacrilex) NP PA; AL; At least 18 yrs old NICORETTE STARTER KIT GUM (Nicotine Polacrilex)
NP PA; AL; At least 18 yrs old
nicotine polacrilex gum F PA; AL; At least 18 yrs old
nicotine polacrilex lozg F PA; AL; At least 18 yrs old
nicotine pt24 14 mg/24hr,21 mg/24hr F PA; AL; At least
18 yrs old
nicotine pt24 7 mg/24hr F PA; QL(1 eadaily); AL; Atleast 18 yrs old
NICOTINE TRANSDERMAL SYSTEM KIT
F PA; AL; At least 18 yrs old
NICOTROL INHALER INHA F PA; AL; At
least 18 yrs old
NICOTROL NS SOLN F PA; AL; At least 18 yrs old
ZYBAN TB12 (BupropionHCl (Smoking Deterrent)) NP
PA; QL(2 eadaily); AL; Atleast 18 yrs old
Vasomotor Symptom Agents BRISDELLE CAPS (Paroxetine Mesylate(Vasomotor))
NP
paroxetine mesylate(vasomotor) caps F
RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung Conditions Cystic Fibrosis Agents
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Drug Name DrugTier
Requirements/Limits
KALYDECO PACK 50 MG, 75 MG F PA; QL(2 ea
daily)
KALYDECO TABS 150 MG F PA
ORKAMBI TABS 100MG-125MG NP
QL(4 ea daily);AL; At least 6 yrs old
ORKAMBI TABS 200MG-125MG F
PA; QL(4 eadaily); AL; Atleast 6 yrs old
PULMOZYME SOLN F PA
Pulmonary Fibrosis Agents ESBRIET CAPS NP
OFEV CAPS NP QL(2 ea daily)
TETRACYCLINES - Drugs to Treat BacterialInfections Tetracyclines ACTICLATE TABS (Doxycycline Hyclate) NP
ADOXA CAPS (Doxycycline(Monohydrate))
NP
ADOXA PAK 1/100 TABS(Doxycycline(Monohydrate))
NP
ADOXA PAK 1/150 TABS(Doxycycline(Monohydrate))
NP
ADOXA PAK 2/100 TABS(Doxycycline(Monohydrate))
NP
ADOXA TABS (Doxycycline(Monohydrate))
NP
demeclocycline hcl tabs F PA
DORYX MPC TBEC NP
DORYX TBEC (Doxycycline Hyclate) NP
doxycycline (monohydrate)caps 100 mg, 50 mg F
doxycycline (monohydrate)caps 75 mg, 150 mg NP
Drug Name DrugTier
Requirements/Limits
doxycycline (monohydrate)susr 25 mg/5ml NP
doxycycline (monohydrate)tabs 100 mg, 50 mg, 75mg, 150 mg
NP
doxycycline hyclate caps or100 mg, 50 mg F
doxycycline hyclate tabs or75 mg, 150 mg, 20 mg, 100 mg
F
doxycycline hyclate tbec or100 mg, 50 mg, 150 mg, 75mg, 200 mg
NP
MINOCIN CAPS (Minocycline HCl) NP
minocycline hcl caps 50mg, 75 mg, 100 mg F
MINOCYCLINE HCL ER TB24 NP
minocycline hcl tabs 75 mg,50 mg, 100 mg NP
minocycline hcl tb24 90mg, 135 mg, 45 mg NP
MONODOX CAPS (Doxycycline(Monohydrate))
NP
MORGIDOX 1X100MG KIT NP
MORGIDOX 1X50MG KIT KIT NP
MORGIDOX 2X100MG KIT NP
SOLODYN TB24 NP
tetracycline hcl caps 250mg, 500 mg NP
TETRACYCLINE HCL CAPS 500 MG, 250 MG (Tetracycline HCl)
NP
VIBRAMYCIN CAPS 100 MG (Doxycycline Hyclate) NP
VIBRAMYCIN SUSR 25 MG/5ML (Doxycycline(Monohydrate))
NP
VIBRAMYCIN SYRP 50 MG/5ML NP
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Drug Name DrugTier
Requirements/Limits
XIMINO CP24 NP QL(1 ea daily);AL; At least 12 yrs old
THYROID AGENTS - Drugs to Regulate ThyroidHormones Antithyroid Agents methimazole tabs F
propylthiouracil tabs F
TAPAZOLE TABS (Methimazole) NP
Thyroid Hormones ARMOUR THYROID TABS 30 MG, 90 MG, 15 MG, 60 MG, 120 MG (Thyroid)
F
ARMOUR THYROID TABS 300 MG, 240 MG, 180 MG F
CYTOMEL TABS (Liothyronine Sodium) NP
levothyroxine sodium tabsor 150 mcg, 112 mcg, 300mcg, 50 mcg, 88 mcg, 125mcg, 75 mcg, 175 mcg,100 mcg, 137 mcg, 200mcg, 25 mcg
F
liothyronine sodium tabs or5 mcg, 50 mcg, 25 mcg F
SYNTHROID TABS (Levothyroxine Sodium) NP
thyroid tabs F
THYROLAR-1 TABS NP
THYROLAR-1/2 TABS NP
THYROLAR-1/4 TABS NP
THYROLAR-2 TABS NP
THYROLAR-3 TABS NP
TIROSINT CAPS NP
ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach Conditions Antispasmodics
Drug Name DrugTier
Requirements/Limits
ANASPAZ TBDP (Hyoscyamine Sulfate) NP
ATROPINE SULFATE SOSY IJ 0.25 MG/5ML F
BENTYL CAPS OR 10 MG (Dicyclomine HCl) NP
BENTYL TABS OR 20 MG (Dicyclomine HCl) NP
dicyclomine hcl caps or 10 mg F
dicyclomine hcl soln or 10mg/5ml F
dicyclomine hcl tabs or 20 mg F
glycopyrrolate tabs or 1mg, 2 mg F
hyoscyamine sulfate elix F
hyoscyamine sulfate soln F
hyoscyamine sulfate subl F
hyoscyamine sulfate tabs F
hyoscyamine sulfate tb12 F
hyoscyamine sulfate tbdp F
LEVBID TB12 (Hyoscyamine Sulfate) NP
LEVSIN TABS OR 0.125 MG (Hyoscyamine Sulfate) NP
LEVSIN/SL SUBL(Hyoscyamine Sulfate) NP
ROBINUL FORTE TABS (Glycopyrrolate) NP
ROBINUL TABS OR 1 MG (Glycopyrrolate) NP
H-2 Antagonists CIMETIDINE HCL SOLN NP
cimetidine hcl soln NP
cimetidine tabs 200 mg NP RX/OTC
cimetidine tabs 800 mg,300 mg, 400 mg NP
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Drug Name DrugTier
Requirements/Limits
famotidine susr 40 mg/5ml NP
famotidine tabs 20 mg F RX/OTC
famotidine tabs 40 mg, 10 mg F
nizatidine caps 300 mg,150 mg NP
NIZATIDINE SOLN 15 MG/ML NP
PEPCID AC MAXIMUM STRENGTH TABS (Famotidine)
NP RX/OTC
PEPCID AC TABS (Famotidine) NP
PEPCID SUSR 40 MG/5ML(Famotidine) NP
PEPCID TABS 20 MG (Famotidine) NP RX/OTC
PEPCID TABS 40 MG (Famotidine) NP
ranitidine hcl caps or 300mg, 150 mg NP
ranitidine hcl syrp or 75mg/5ml, 150 mg/10ml, 15mg/ml
F
ranitidine hcl tabs or 150 mg F RX/OTC
ranitidine hcl tabs or 300 mg, 75 mg F
TAGAMET HB TABS (Cimetidine) NP RX/OTC
ZANTAC 150 MAXIMUM STRENGTH TABS (Ranitidine HCl)
NP RX/OTC
ZANTAC 75 TABS (Ranitidine HCl) NP
ZANTAC TABS OR 150 MG (Ranitidine HCl) NP RX/OTC
ZANTAC TABS OR 300 MG (Ranitidine HCl) NP
Misc. Anti-Ulcer CARAFATE SUSP 1 GM/10ML F AL; Up to 6 yrs
old CARAFATE TABS 1 GM (Sucralfate) NP
Drug Name DrugTier
Requirements/Limits
sucralfate tabs F
Proton Pump Inhibitors ACIPHEX SPRINKLE CPSP NP
ACIPHEX TBEC (Rabeprazole Sodium) NP QL(1 ea daily)
DEXILANT CPDR NP
esomeprazole magnesiumcpdr 20 mg NP QL(1 ea daily);RX/OTC esomeprazole magnesiumcpdr 40 mg NP QL(1 ea daily)
ESOMEPRAZOLE STRONTIUM CPDR 49.3 MG, 24.65 MG
NP
lansoprazole cpdr 15 mg NP QL(1 ea daily);RX/OTC
lansoprazole cpdr 30 mg NP QL(1 ea daily)
NEXIUM 24HR CLEAR MINIS CPDR (EsomeprazoleMagnesium)
NP
QL(1 ea daily);RX/OTC
NEXIUM 24HR CPDR (EsomeprazoleMagnesium)
NP QL(1 ea daily);RX/OTC
NEXIUM CPDR 20 MG (EsomeprazoleMagnesium)
NP QL(1 ea daily);RX/OTC
NEXIUM CPDR 40 MG (EsomeprazoleMagnesium)
NP QL(1 ea daily)
NEXIUM PACK 20 MG, 40 MG, 5 MG, 2.5 MG, 10 MG NP QL(1 ea daily)
omeprazole cpdr 10 mg F
omeprazole cpdr 20 mg F QL(4 ea daily)
omeprazole cpdr 40 mg F QL(2 ea daily)
pantoprazole sodium tbecor 40 mg, 20 mg F QL(2 ea daily)
PREVACID 24HR CPDR (Lansoprazole) NP QL(1 ea daily);RX/OTC PREVACID CPDR 15 MG (Lansoprazole) NP QL(1 ea daily);RX/OTC
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Drug Name DrugTier
Requirements/Limits
PREVACID CPDR 30 MG (Lansoprazole) NP QL(1 ea daily)
PREVACID SOLUTAB TBDP NP QL(1 ea daily)
PRILOSEC CPDR 10 MG (Omeprazole) NP
PRILOSEC CPDR 20 MG (Omeprazole) NP QL(4 ea daily)
PRILOSEC CPDR 40 MG (Omeprazole) NP QL(2 ea daily)
PRILOSEC PACK 2.5 MG, 10 MG NP
PROTONIX PACK OR 40 MG NP QL(2 ea daily)
PROTONIX TBEC OR 20 MG, 40 MG (PantoprazoleSodium)
NP QL(2 ea daily)
rabeprazole sodium tbec NP QL(1 ea daily)
Ulcer Drugs - Prostaglandins CYTOTEC TABS (Misoprostol) NP
misoprostol tabs F
Ulcer Therapy Combinations amoxicillin-clarithromycinw/ lansoprazole misc NP
OMECLAMOX-PAK MISC NP QL(30 ea per365 days retail) omeprazole-sodiumbicarbonate caps 20mg-1100mg
NP QL(1 ea daily);RX/OTC
omeprazole-sodiumbicarbonate caps 40mg-1100mg
NP QL(1 ea daily)
omeprazole-sodiumbicarbonate pack 20mg-1680mg, 40mg-1680mg
NP
PREVPAC MISC (Amoxicillin-Clarithromycinw/ Lansoprazole)
NP
PYLERA CAPS F
ZEGERID CAPS 20MG-1100MG (Omeprazole-Sodium Bicarbonate)
NP QL(1 ea daily);RX/OTC
Drug Name DrugTier
Requirements/Limits
ZEGERID CAPS 40MG-1100MG (Omeprazole-Sodium Bicarbonate)
NP QL(1 ea daily)
ZEGERID OTC CAPS (Omeprazole-SodiumBicarbonate)
NP QL(1 ea daily);RX/OTC
ZEGERID PACK 40MG-1680MG, 20MG-1680MG (Omeprazole-SodiumBicarbonate)
NP
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
Urinary Anti-infectives FURADANTIN SUSP (Nitrofurantoin) NP
HIPREX TABS (Methenamine Hippurate) NP
MACROBID CAPS (Nitrofurantoin MonohydMacro)
NP
MACRODANTIN CAPS (Nitrofurantoin Macrocrystal)
NP
methenamine hippuratetabs F
METHENAMINE MANDELATE TABS 0.5 GM
F
methenamine mandelate tabs 1 gm F
nitrofurantoin macrocrystal caps F
nitrofurantoin monohyd macro caps F
nitrofurantoin susp F
URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms Urinary Antispasmodic - Antimuscarinics
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Drug Name DrugTier
Requirements/Limits
darifenacin hydrobromidetb24 NP QL(1 ea daily)
DETROL LA CP24 (Tolterodine Tartrate) NP
DETROL TABS (Tolterodine Tartrate) NP
DITROPAN XL TB24 (Oxybutynin Chloride) NP
ENABLEX TB24 (Darifenacin Hydrobromide)
NP QL(1 ea daily)
GELNIQUE GEL NP
GELNIQUE PUMP GEL NP
oxybutynin chloride syrp F
oxybutynin chloride tabs F
oxybutynin chloride tb24 F
OXYTROL FOR WOMEN PTTW NP RX/OTC
OXYTROL PTTW NP RX/OTC
tolterodine tartrate cp24 NP
tolterodine tartrate tabs NP
TOVIAZ TB24 F
trospium chloride cp24 NP
trospium chloride tabs NP
VESICARE TABS F
Urinary Antispasmodics - Beta-3 Adrenergic MYRBETRIQ TB24 NP
Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs F
URECHOLINE TABS (Bethanechol Chloride) NP
Urinary Antispasmodics - Direct Muscle Relaxants
Drug Name DrugTier
Requirements/Limits
flavoxate hcl tabs F
VACCINES
Bacterial Vaccines
BEXSERO SUSY F
QL(1 ml per350 daysretail,1 ml per350 days mail);AL; At least 19 yrs old
MENACTRA INJ F
QL(1 ml per350 daysretail,1 ml per350 days mail);AL; At least 19 yrs old
MENOMUNE-A/C/Y/W-135INJ F
QL(1 ea per350 daysretail,1 ea per350 days mail);AL; At least 19 yrs old
MENVEO SOLR F
QL(1 ea per350 daysretail,1 ea per350 days mail);AL; At least 19 yrs old
PNEUMOVAX 23 INJ F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
PNEUMOVAX 23/1 DOSEINJ F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
PREVNAR 13 SUSP F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
TRUMENBA SUSY F
QL(1 ml per350 daysretail,1 ml per350 days mail);AL; At least 19 yrs old
Viral Vaccines AFLURIA 2015-2016 SUSP NP
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Drug Name DrugTier
Requirements/Limits
AFLURIA 2016-2017 SUSP F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
AFLURIA 2017-2018 SUSP F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
AFLURIA PF 2015-2016 SUSY NP
AFLURIA PF 2016-2017 SUSY F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
AFLURIA PF 2017-2018 SUSY F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
AFLURIA QUADRIVALENT 2016-2017 SUSY NP
AFLURIA QUADRIVALENT 2017-2018 SUSP F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
AFLURIA QUADRIVALENT 2017-2018 SUSY F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUAD 2016-2017 SUSY F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUAD 2017-2018 SUSY F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUARIX QUADRIVALENT 2015-2016 SUSY NP
FLUARIX QUADRIVALENT 2016-2017 SUSY F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUARIX QUADRIVALENT 2017-2018 SUSY F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUBLOK 2015-2016 SOLN NP
FLUBLOK 2016-2017 SOLN F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUCELVAX QUADRIVALENT 2016-2017 SUSY
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUCELVAX QUADRIVALENT 2017-2018 SUSP
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
Drug Name DrugTier
Requirements/Limits
FLUCELVAX QUADRIVALENT 2017-2018 SUSY
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLULAVAL QUADRIVALENT 2014-2015 SUSY
NP
FLULAVAL QUADRIVALENT 2015-2016 SUSP
NP
FLULAVAL QUADRIVALENT 2016-2017 SUSP
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLULAVAL QUADRIVALENT 2016-2017 SUSY
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLULAVAL QUADRIVALENT 2017-2018 SUSP
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLULAVAL QUADRIVALENT 2017-2018 SUSY
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUVIRIN 2015-2016 SUSP NP
FLUVIRIN 2015-2016 SUSY NP
FLUVIRIN 2016-2017 SUSP F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUVIRIN 2016-2017 SUSY F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUVIRIN 2017-2018 SUSP F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUVIRIN 2017-2018 SUSY F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUZONE HIGH-DOSE PF 2015-2016 SUSY NP
FLUZONE HIGH-DOSE PF 2016-2017 SUSY F
QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUZONE HIGH-DOSE PF 2017-2018 SUSY NP
FLUZONE INTRADERMAL QUADRIVALENT 2015-2016 SUPN
NP
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Drug Name DrugTier
Requirements/Limits
FLUZONE INTRADERMAL QUADRIVALENT 2016-2017 SUPN
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUZONE INTRADERMAL QUADRIVALENT 2017-2018 SUPN
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUZONE QUADRIVALENT 2015-2016 SUSP
NP
FLUZONE QUADRIVALENT 2015-2016 SUSY
NP
FLUZONE QUADRIVALENT 2016-2017 SUSP
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUZONE QUADRIVALENT 2016-2017 SUSY
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUZONE QUADRIVALENT 2017-2018 SUSP
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUZONE QUADRIVALENT 2017-2018 SUSY
F QL(0.5 ml perfill retail); AL; Atleast 19 yrs old
FLUZONE SPLIT 2015-2016 SUSP NP
ZOSTAVAX SUSR F
QL(1 ea per350 daysretail); AL; Atleast 19 yrs old
VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low Hormones Vaginal Anti-infectives CLEOCIN CREA VA 2 % (Clindamycin PhosphateVaginal)
NP
CLEOCIN SUPP VA 100 MG F
clindamycin phosphatevaginal crea F
CLINDESSE CREA F
clotrimazole vaginal crea F
GYNAZOLE-1 CREA F
Drug Name DrugTier
Requirements/Limits
GYNE-LOTRIMIN 3 CREA (Clotrimazole Vaginal) NP
GYNE-LOTRIMIN CREA (Clotrimazole Vaginal) NP
METROGEL-VAGINAL GEL (Metronidazole Vaginal)
NP
metronidazole vaginal gel F
metronidazole vaginal gel 4
miconazole nitrate vaginalcrea 2 % F
miconazole nitrate vaginalkit F
miconazole nitrate vaginalsupp 100 mg F
MONISTAT 3 COMBINATION PACK KIT (Miconazole Nitrate Vaginal)
NP
MONISTAT 7 SIMPLY CURE CREA (Miconazole Nitrate Vaginal)
NP
NUVESSA GEL NP
TERAZOL 3 CREA (Terconazole Vaginal) NP
TERAZOL 7 CREA (Terconazole Vaginal) NP
terconazole vaginal crea F
terconazole vaginal supp F
Vaginal Estrogens ESTRACE CREA VA 0.1 MG/GM F
PREMARIN CREA VA 0.625 MG/GM F
Vaginal Progestins CRINONE GEL F
VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions Anaphylaxis Therapy Agents
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Drug Name DrugTier
Requirements/Limits
ADRENACLICK SOAJ 0.15 MG/0.15ML 4
ADRENACLICK SOAJ 0.3 MG/0.3ML 4 QL(4 ea per fill
retail)
AUVI-Q SOAJ 4
epinephrine (anaphylaxis)soaj 0.15 mg/0.15ml F
epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml 4
QL(2 ea per fillretail,30 claims per fill retail)
epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml 4
Limit 2 permonth;QL(2 eaper 30 daysretail)
EPINEPHRINE SOAJ F QL(4 ea per fillretail)
EPINEPHRINE SOAJ 4 QL(4 ea per fillretail)
EPIPEN 2-PAK SOAJ F QL(4 ea per fillretail)
EPIPEN-JR 2-PAK SOAJ F Limit 2 permonth;QL(0.067 ea daily)
Vasopressors midodrine hcl tabs F
VITAMINS
Oil Soluble Vitamins BETA CAROTENE CAPS 10000 UNIT F
beta carotene caps 25000unit F
cholecalciferol caps 2000unit, 1000 unit F
cholecalciferol caps 5000unit F QL(2 ea daily)
cholecalciferol caps 50000unit F QL(0.267 ea
daily) cholecalciferol liqd 400unit/ml F
cholecalciferol tabs 400 unit, 1000 unit, 50000 unit,2000 unit
F
Drug Name DrugTier
Requirements/Limits
D-VI-SOL LIQD (Cholecalciferol) NP
DECARA CAPS F
DRISDOL CAPS 50000 UNIT (Ergocalciferol) NP AL; At least 17 yrs old DRISDOL SOLN 8000 UNIT/ML (Ergocalciferol) NP QL(2 ml daily)
ergocalciferol caps 50000unit F AL; At least 17
yrs old ergocalciferol soln 8000unit/ml F QL(2 ml daily)
MEPHYTON TABS F
vitamin a caps 8000 unit,10000 unit F
vitamin a tabs 10000 unit F
vitamin e caps or 1000 unit,100 unit, 400 unit, 200 unit F
vitamin e soln or 15 unit/0.3ml F
Water Soluble Vitamins ascorbic acid chew or 250 mg, 500mg, 500 mg,7.5mg-500mg, 250mg
F
ascorbic acid liqd or 500mg/5ml F
ascorbic acid tabs or 1000 mg, 1000mg, 37mg-1000mg
F
ascorbic acid tabs or 37mg-500mg, 500 mg, 14mg-25mg-500mg, 250 mg,500mg, 10mg-500mg
F
QL(3.34 eadaily)
ascorbic acid tbcr or 500 mg, 1000 mg, 500mg F
B-1 TABS F
biotin caps 5 mg, 5000 mcg F
biotin tabs 300 mcg F
niacin cpcr 250 mg, 500 mg F
niacin tabs 50 mg, 500 mg F
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Drug Name DrugTier
Requirements/Limits
niacin tbcr 250 mg, 500 mg F
niacinamide tabs 500 mg F
pyridoxine hcl tabs or 25mg, 50 mg, 100 mg F
riboflavin tabs 100 mg F QL(3.34 eadaily)
SLO-NIACIN TBCR 500 MG (Niacin) NP
thiamine hcl tabs or 100 mg, 50 mg F QL(3.34 ea
daily) thiamine mononitrate tabs or F QL(3.34 ea
daily) VITAMIN C SYRP 500 MG/5ML F
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Index 1ST CHOICE LANCETS ABSORBASE 74 ACIPHEX 237 SUPERTHIN 102 ABSORICA 55 ACIPHEX SPRINKLE 2371ST CHOICE LANCETS THIN
ABSTRAL 8 acitretin 60102 1ST CHOICE LANCETS ACANYA 55 ACLOVATE 61 ULTRATHIN 102 acarbose 24 ACNE MEDICATION 10 551ST TIER UNIFINE ACCOLATE 16 ACNE MEDICATION 5 55PENTIPS/MINI/31GX5MM 121
ACCU-CHEK ACTIVE ACTEMRA 51ST TIER UNIFINE GLUCOSECONTROLPENTIPS29GX12MM 121 ACTI-LANCE LANCETS
1ST TIER UNIFINE SOLUTION 102 28G 103ACCU-CHEK ACTIVEPENTIPS31GX6MM 121 ACTI-LANCE LITE SAFETYSTRIPS 831ST TIER UNIFINE LANCETS 28G 103
PENTIPS31GX8MM 121 ACCU-CHEK AVIVA 84 ACTI-LANCE SPECIAL SAFETY 1ST TIER UNIFINE LANCETS 17G 103ACCU-CHEK AVIVA PLUS83 PENTIPS32GX4MM 121 ACTI-LANCE SPECIALACCU-CHEK COMPACT1ST TIER UNIFINE SAFETYLANCETS 17G 103PLUS 84PENTIPSPLUS 31GX8MM 121 ACTI-LANCE UNIVERSALACCU-CHEK COMPACT PLUS1ST TIER UNIFINE SAFETY LANCETS 23G 103CLEAR CONTROL SOLUTIONPENTIPSPLUS 32GX4MM 121 ACTICLATE 235(2 LEVELS) 1021ST TIER UNIFINE ACCU-CHEK COMPACT TEST ACTICOAT 7 2"X2" 76PENTIPSPLUS/MINI/31GX5MM DRUM 84 ACTICOAT 7 4"X5" 76121 ACCU-CHEK FASTCLIX1ST TIER UNIFINE ACTICOAT ABSORBENTLANCETS 102PENTIPSPLUS/ORIGINAL/29GX ANTIMICROBIAL DRESSINGACCU-CHEK MULTICLIX12MM 121 4"X5" 76LANCETS 1021ST TIER UNIFINE ACTICOAT ANTIMICROBIALACCU-CHEK SAFE-T-PROPENTIPSPLUS/ULTRA DRESSING 2"X2" 76LANCETS 103SHORT/31GX6MM 121 ACTICOAT ANTIMICROBIALACCU-CHEK SAFE-T-PRO1ST TIER UNILET DRESSING 4"X4" 76PLUSLANCETS 103COMFORTOUCH LANCETS ACTICOAT FLEX 3 BARRIERACCU-CHEK SMARTVIEW28G 102 DRESSING 4"'X4" 76CONTROL 1031ST TIER UNILET ACTIFLOVIT EAR HEALTH222ACCU-CHEK SMARTVIEWCOMFORTOUCH LANCETS STRIPS 84 ACTIGALL 93 30G 102 ACCU-CHEK SOFT TOUCH ACTIQ 82ND SKIN MOIST BURN LANCETS 103 ACTIVE 1ST BLOODPADS1.5"X2" 76 ACCU-CHEK SOFTCLIX LANCETS30G/EASY TWIST2ND SKIN MOIST BURN LANCETS 103 CAP 103PADS2"X3" 76 ACCUPRIL 342ND SKIN MOIST BURN ACTIVE OB 213
ACCURETIC 35PADS3"X4" 76 ACTIVELLA 92 2ND SKIN MOIST DRESSING ACCUTREND GLUCOSE 84 ACTIVITY POUCH 149KIT 76 ACCUTREND GLUCOSE ACTONEL 912ND SKIN MOIST GEL PADS CONTROL 103 1"X1" 76 ACE AEROSOL CLOUD ACTOPLUS MET 25 2ND SKIN MOIST GEL PADS 3" ENHANCER 149 ACTOPLUS MET XR 25ROUND 76 acebutolol hcl 47 ACTOS 278-MOP 60 ACEON 34 ACULAR 230A + D PERSONAL CARE acetaminophen 8LOTION 65 ACULAR LS 230
acetaminophen w/ codeine 10 ACURA BLOOD GLUCOSEA+D FIRST AID 74 ACETAMINOPHEN/CAFFEINE TESTSTRIPS 84abacavir sulfate 43 /DIHYDROCODEINE 10 ACURA CONTROL SOLUTION
abacavir sulfate-lamivudine 43 acetazolamide 90 HIGH 103 abacavir sulfate-lamivudine- ACURA CONTROL SOLUTIONacetic acid (otic) 231zidovudine 43 LOW 103ACETIC ACID/ALUMINUMABILIFY 43 ACURA CONTROL SOLUTIONACETATE 231 NORMAL 103ABREVA 61 acetylcysteine 55 ACUVAIL 230
Index 1
acyclovir 46 acyclovir topical 61 ACZONE 55 ADALAT CC 48 adapalene 55 ADAPALENE 55 adapalene-benzoyl peroxide 55 ADAPTIC NON-ADHERING DRESSING 3" X 3" 76 ADASUVE 42 ADCIRCA 49 ADDERALL 1 ADDERALL XR 1 adefovir dipivoxil 45 ADEMPAS 49 ADJUSTABLE LANCING DEVICE 103 ADLYXIN 27 ADLYXIN STARTER PACK 27 ADOXA 235 ADOXA PAK 1/100 235 ADOXA PAK 1/150 235 ADOXA PAK 2/100 235 ADRENACLICK 242 ADRENAL C FORMULA 163 ADRENAL STRESS CALM 219 ADULT AEROSOL MASK 149
ADVIL MIGRAINE 5 ADVOCATE CONTROL SOLUTIONHIGH 103 ADVOCATE CONTROL SOLUTIONLOW 103 ADVOCATE INSULIN PEN NEEDLES 29GX12.7MM 121 ADVOCATE INSULIN PEN NEEDLES 31GX5MM 121 ADVOCATE INSULIN PEN NEEDLES 31GX8MM 121 ADVOCATE INSULIN SYRINGE/U-100/0.3ML/29GX1/2" 122 ADVOCATE INSULIN SYRINGE/U-100/0.3ML/30GX5/16" 122 ADVOCATE INSULIN SYRINGE/U-100/0.3ML/31GX5/16" 122 ADVOCATE INSULIN SYRINGE/U-100/0.5ML/29GX1/2" 122 ADVOCATE INSULIN SYRINGE/U-100/0.5ML/30GX5/16" 122 ADVOCATE INSULIN SYRINGE/U-100/0.5ML/31GX5/16" 122 ADVOCATE INSULIN SYRINGE/U-100/1ML/29GX1/2" 122 ADVOCATE INSULIN
ADVOCATE TEST STRIPS 84 ADZENYS XR-ODT 1 AEROCHAMBER MINI AEROSOLCHAMBER 150 AEROCHAMBER MV 150 AEROCHAMBER PLUS FLOW VU 150 AEROCHAMBER PLUS FLOW-VU 150 AEROCHAMBER PLUS FLOW-VU/LARGE MASK 150 AEROCHAMBER PLUS FLOW-VU/MASK 150 AEROCHAMBER PLUS FLOW-VU/MEDIUM MASK 150 AEROCHAMBER PLUS FLOW-VU/SMALL MASK 150 AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VU 150 AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL 150 AEROCHAMBER Z-STAT PLUS/LARGE MASK 150 AEROCHAMBER Z-STAT PLUS/MEDIUM MASK 150 AEROCHAMBER Z-STAT PLUS/SMALL MASK 150 AEROCHAMBER/FLOWSIGNAL
150 AEROSPAN 17 AEROTRACH PLUS 150
ADULT MASK ADULT MASK LARGE ADULT ONE DAILY GUMMIES ADVAIR DISKUS ADVAIR HFA
150 150
164 17 17
SYRINGE/U-100/1ML/30GX5/16"ADVOCATE INSULIN SYRINGE/U-100/1ML/31GX5/16" ADVOCATE LANCETS ADVOCATE LANCETS
122
122 103
AEROVENT PLUS HOLDING CHAMBER/COLLAPSIBLE 150 AFINITOR 38 AFINITOR DISPERZ 38 AFLURIA 2015-2016 239 AFLURIA 2016-2017 240
ADVANCE INTUITION 30G 103 AFLURIA 2017-2018 240 CONTROL SOLUTION 103 ADVANCE INTUITION TEST STRIPS 84 ADVANCE MICRO-DRAW
ADVOCATE LANCING DEVICE 103 ADVOCATE RAPID-SAFE LANCING DEVICE 103
AFLURIA PF 2015-2016 AFLURIA PF 2016-2017 AFLURIA PF 2017-2018
240 240 240
CONTROL LEVEL 1-2 103 ADVANCE MICRO-DRAW NORMAL CONTROL 103 ADVANCE MICRO-DRAW TEST STRIPS 84 ADVANCED C PLUS 163
ADVOCATE REDI-CODE 84 ADVOCATE REDI-CODE+ CONTROL SOLUTION HIGH 103 ADVOCATE REDI-CODE+ CONTROL SOLUTION
AFLURIA QUADRIVALENT 2016-2017 240 AFLURIA QUADRIVALENT 2017-2018 240 AFREZZA 27 AFRIN 225
ADVANCED CALCIUM/VITAMIND/MAGNESIUM 157 ADVANCED COLLAGEN 219 ADVANCED DIABETIC MULTIVITAMIN FORMULA164 ADVIL 5
LOW 103 ADVOCATE REDI-CODE+ TESTSTRIPS 84 ADVOCATE SAFETY LANCETS 103 ADVOCATE SAFETY LANCETS 26G 103
AFRIN 12 HOUR AFRIN ALL NIGHT NODRIP AFRIN NASAL SPRAY AFRIN NODRIP EXTRA MOISTURIZING
224
224 224
224
Index 2
AFRIN NODRIP ORIGINAL224 ALEVE ARTHRITIS 5 ALLEVYN TRACHEOSTOMY 3-AFRIN NODRIP SEVERE alfuzosin hcl 95 1/2"X3-1/2" 77 CONGESTION 224 allopurinol 96ALINIA 14AFRIN NODRIP SINUS 225 almotriptan malate 154ALIVE ENERGY 50+ 164AFRIN SINUS 225 ALOCRIL 230ALIVE MENS ENERGY 164AGAMATRIX AMP NO CODE ALOE AFTERSUN LOTION 65ALIVE ONCE DAILY WOMENSTEST STRIPS 84 50+ ULTRA POTENCY 164 ALOE VESTA ANTIFUNGAL58AGAMATRIX CONTROL ALIVE ONCE DAILY WOMENS ALOE VESTA CLEARHIGH 103 ULTRA POTENCY 164 ANTIFUNGAL 58AGAMATRIX CONTROL
ALIVE WOMENS 50+ 164 ALOE VESTA PROTECTIVE74NORMAL 103 AGAMATRIX CONTROL ALIVE WOMENS ALOGLIPTIN 26 NORMAL& HIGH 103 ENERGY 164 ALOGLIPTIN/METFORMINAGAMATRIX JAZZ TEST ALIVE WOMENS GUMMY HCL 25 STRIPS 84 VITAMINS 164 ALOGLIPTIN/PIOGLITAZONEAGAMATRIX KEYNOTE TEST ALKERAN 37 25 STRIPS 84 ALL FLOW 1000 PULMONARY ALOMIDE 230AGAMATRIX PRESTO TEST FUNCTION FILTER 150 ALORA 92STRIPS 84 ALLEGRA ALLERGY 31AGAMATRIX ULTRA-THIN alosetron hcl 94ALLEGRA ALLERGYLANCETS 33G 103 ALPHAGAN P 227CHILDRENS 31AGGRENOX 96 ALLERWELL ALLERGY alprazolam 15 AIMSCO LUBRICATED 101 FORMULA 219 ALPRAZOLAM INTENSOL 15 AIRBORNE 164 ALLEVYN ADHESIVE 76 ALREX 229 AIRDUO RESPICLICK ALLEVYN AG ADHESIVE 76 ALTABAX 58113/14 17 ALLEVYN AG GENTLE ALTACE 34AIRDUO RESPICLICK BORDER 76 232/14 17 ALLEVYN AG NON- ALTERNATE SITE LANCING AIRS PEDIATRIC AEROSOL ADHESIVE 76 DEVICE 103 MASK 150 ALTOPREV 33ALLEVYN AG SACRUM 76 AKTIPAK 55 ALLEVYN alum & mag hydrox-
simethicone 13AKYNZEO 29 COMPRESSION 76 ALUNBRIG 38ALBOLENE 65 ALLEVYN GENTLE 77
ALLEVYN GENTLE ALVESCO 17albuterol sulfate 17 BORDER 77 amantadine hcl 40alclometasone dipropionate 61 ALLEVYN GENTLE BORDER AMARYL 28ALCOH-GLOVE CONTOURED HEEL 76
WIPE 119 AMBIEN 98ALLEVYN GENTLE BORDER ALCOHOL PADS 119 LITE 76 AMBIEN CR 98 ALCOHOL PREP PADS 119 ALLEVYN GENTLE BORDER AMCINONIDE 61MULTISITE 77ALCOHOL PREPS 119 AMERGE 154ALLEVYN GENTLE BORDERALCOHOL SWABS 119 SACRUM 77 AMERIDERM PERISHIELD 74 ALCOHOL SWABSTICK 119 ALLEVYN HEEL 77 AMERIGEL HYDROGEL
SATURATED GAUZEALCOHOL WIPES 119 ALLEVYN LIFE 77 DRESSING 2" X 2" 77ALDACTAZIDE 90 ALLEVYN LIFE HEEL 77 AMICAR 97ALDACTONE 90 ALLEVYN LIFE SACRUM 77 amifostine 39ALDARA 72 ALLEVYN NON- amiloride &ADHESIVE 77ALECENSA 38 hydrochlorothiazide 90ALLEVYN PLUSALENDRONATE SODIUM 91 amiloride hcl 90ADHESIVE 77 alendronate sodium 91 amiodarone hcl 16ALLEVYN PLUS CAVITY 77 ALENDRONATE SODIUM 91 94ALLEVYN PLUS SACRUM77 AMITIZA ALEVAZOL 58 ALLEVYN SACRUM 77 amitriptyline hcl 24 ALEVE 5 AMLACTIN CERAPEUTIC 65
Index 3
AMLACTIN ULTRA 65 ANTI-STICK INSULIN AQUAFRESH
amlodipine besylate 48 amlodipine besylate-atorvastatincalcium 49 amlodipine besylate-benazeprilhcl 35 amlodipine besylate-olmesartanmedoxomil 35 amlodipine besylate-valsartan 35 amlodipine-valsartan-hydrochlorothiazide 35 AMOXAPINE 24 amoxicillin 231 AMOXICILLIN 231 amoxicillin 231 amoxicillin & potclavulanate 232 AMOXICILLIN ER 231 amoxicillin-clarithromycin w/lansoprazole 238 AMOXICILLIN/CLAVULANATEPOTASSIUM 232 amphetamine-dextroamphetamine 1,2 AMPICILLIN 231 ampicillin 231 AMPICILLIN 231 AMPYRA 233 AMRIX 223 ANAFRANIL 24 ANALPRAM-HC 13 ANAPROX DS 5 ANASPAZ 236 anastrozole 37 ANBESOL MAXIMUMSTRENGTH 159 ANCOBON 30 ANDRODERM 12 ANDROGEL 12 ANDROGEL PUMP 12 ANORO ELLIPTA 17 ANTABUSE 232 ANTARA 32 ANTI-STICK INSULINSYRINGE/U-100/0.5ML/28G X1/2" 122 ANTI-STICK INSULINSYRINGE/U-100/0.5ML/29G X1/2" 122
SYRINGE/U-100/1ML/29G X1/2" 122 ANTIOXIDANT FORMULASG 164 ANTIOXIDANT FORTE 164 ANUSOL-HC 13 ANZEMET 29 AP-ZEL 164 APATATE FORTE 164 APEXICON E 61 APIDRA 27 APIDRA SOLOSTAR 27 APLENZIN 22 apraclonidine hcl 228 aprepitant 30 APRISO 94 APTENSIO XR 3 APTIOM 19 APTIVUS 43 AQUA GLYCOLIC FACECREAM 65 AQUA GLYCOLIC HAND &BODYLOTION 65 AQUA LACTEN 65 AQUA LANCE ADJUSTABLELANCING DEVICE 103 AQUACELEXTRA/HYDROFIBER 77 AQUACEL FOAM3.2"X3.2" 77 AQUACEL FOAM 4"X4" 77 AQUACEL FOAM 5"X5" 77 AQUACEL FOAM 6"X6" 77 AQUACEL FOAM 6"X8" 77 AQUACEL FOAM 7"X7" 77 AQUACEL FOAM 8"X5.5" 77 AQUACEL FOAM 8"X7" 77 AQUADEKS 164 AQUADERM 65 AQUADERM TREATMENT/MOISTURIZER
65 AQUAFRESH CAVITYPROTECTION 120 AQUAFRESH EXTREMECLEAN 120 AQUAFRESH FOR KIDS 120 AQUAFRESHSENSITIVE 120 AQUAFRESH TARTARCONTROL 120
TOOTHPASTE 120 AQUAFRESH WHITENING 120 AQUAMED 65 AQUAPHILIC 65 AQUAPHOR 65 AQUAPHOR ADVANCEDTHERAPY 65 AQUAPHOR LIP REPAIR 74 AQUASITE IMPREGNATEDDRESSING 2"X2" 77 AQUASITE IMPREGNATEDDRESSING 4"X4" 77 AQUASITE IMPREGNATEDDRESSING 4"X8" 77 AQUASITE IMPREGNATEDGAUZE 2"X2" 77 AQUASITE IMPREGNATEDGAUZE 4"X4" 77 AQUASITE SHEET DRESSING4"X4" 77 AQUORAL 160 ARAVA 7 ARCALYST 5 ARCAPTA NEOHALER 17 ARGLAES FILM 2-3/8" X 3-1/8" 77 ARGLAES FILM 3" X 14" 77 ARGLAES FILM 4" X 4-3/4" 77 ARGLAES FILM 4-3/4" X 10"77 ARGLAES ISLAND 2-3/8" X 3-1/8" 77 ARGLAES ISLAND 4" X 4-3/4" 77 ARGLAES ISLAND 4-3/4" X10" 77 ARIAL CHAMBER 150 ARICEPT 232 ARIMIDEX 37 aripiprazole 43 ARISTADA 43 ARIXTRA 18 armodafinil 3 ARMONAIR RESPICLICK113 17 ARMONAIR RESPICLICK232 17 ARMONAIR RESPICLICK55 17 ARMOUR THYROID 236 ARNUITY ELLIPTA 17 AROMASIN 38
Index 4
ARTHRITIS PAIN ASSURE HAEMOLANCE ATRIPLA 43 RELIEVING 73 PLUS PEDIATRIC ATROPINE SULFATE 227,236ARTHROTEC 50 5 BLADE 104 ATROVENT 224ASSURE ID INSULINARTHROTEC 75 5 SAFETYSYRINGE/U- ATROVENT HFA 16artificial tear ointment 226 100/0.5ML/29G X 1/2" 122 AUBAGIO 233artificial tear solution 226 ASSURE ID INSULIN AUGMENTED ARTIFICIAL TEARS 226 SAFETYSYRINGE/U- BETAMETHASONE100/1ML/29G X 1/2" 122ARYMO ER 8 DIPROPIONATE 61
ASSURE II 84 AUGMENTIN 232ASACOL HD 94 ASSURE II CHECK STRIP84 AUGMENTIN ES-600 232ASCOCID-1000 163 ASSURE II CONTROL LEVEL AUGMENTIN XR 232ASCOCID-500-D 163 1 104 AURORA LANCET SUPERascorbic acid 242 ASSURE II CONTROL LEVEL THIN30G 1041/2 104ASMANEX HFA 17 AURORA LANCET THINASSURE II TEST STRIPS 84ASMANEX TWISTHALER 120 23G 104ASSURE LANCEMETERED DOSES 17 AURORA PEN NEEDLES
ASMANEX TWISTHALER 14 LANCETS 104 29GX12MM 122ASSURE LANCE LANCETSMETERED DOSES 17 AURORA PEN NEEDLES 31G ASMANEX TWISTHALER 30 21G 104 X6MM 122ASSURE LANCE PLUSMETERED DOSES 17 AURORA PEN NEEDLES 31G ASMANEX TWISTHALER 60 SAFETYLANCETS 25G 104 X8MM 122ASSURE LANCE PLUSMETERED DOSES 17 AURORA UNIFINE ASMANEX TWISTHALER 7 SAFETYLANCETS 30G 104 PENTIPS/32GX5/32" 122 METERED DOSES 17 ASSURE LANCETS 104 AURORA UNIFINE ASPERCREME/ALOE 73 ASSURE PLATINUM TEST PENTIPS/MINI/31GX3/16" 122 aspirin 8 STRIPS 84 AURYXIA 95
ASSURE PRISM CONTROLaspirin buffered (cal carb-mag AUTO-LANCET 104LEVEL 1/2 104carb-mag oxide) 8 ASSURE PRISM MULTI TEST AUTO-LANCET MINI 104 ASPIRIN LOW DOSE 8 STRIPS 84 AUTOLET IMPRESSION aspirin-acetaminophen- ASSURE PRO CONTROL LANCING DEVICE 104 caffeine 7 LEVEL1/2 104 AUTOLET LANCING ASPIRIN-CAFFEINE- ASSURE PRO TEST DEVICE 104 DIHYDROCODEINE 10 STRIPS 84 AUTOLET MINI 104 aspirin-dipyridamole 96 ASTEPRO 224 AUTOLET PLUS 104ASSURE 3 CONTROL LEVEL AT LAST CONTROL AUVI-Q 2421/2 103 SOLUTION 104 AVALIDE 35ASSURE 3 TEST STRIPS 84 AT LAST LANCETS 104 ASSURE 4 CONTROL LEVEL AVANDIA 27AT LAST TEST STRIPS 841/2 103 AVAPRO 34ATACAND 34ASSURE 4 TEST STRIPS 84 AVAR LS CLEANSER 55ATACAND HCT 35ASSURE COMFORT LANCETS AVAR-E LS 55ULTRA THIN 28G 103 ATELVIA 91 AVEENO ACTIVE NATURALSASSURE COMFORT LANCETS atenolol 47 DAILY MOISTURIZING BODYULTRA THIN 30G 103 atenolol & chlorthalidone 35 YOGURT 65ASSURE DOSE NORMAL
ATIVAN 15 AVEENO ACTIVE NATURALSCONTROL 104 DAILY MOISTURIZING BODYASSURE DOSE NORMAL/HIGH ATLAS COLORED CONTROL 104 LUBRICATEDCONDOM 101 YOGURT/APRICO 65
AVEENO ACTIVE NATURALSASSURE HAEMOLANCE PLUS ATLAS LUBRICATED SKIN RELIEF MOISTUREHIGH FLOW 18G 104 CONDOM 101 REPAIR 65ASSURE HAEMOLANCE PLUS ATLAS LUBRICATED
LOW FLOW 25G 104 CONDOM/SPERMICIDE 101 AVEENO DAILY MOISTURIZINGSPF 15 65ASSURE HAEMOLANCE PLUS atomoxetine hcl 3 AVEENO INTENSE RELIEFMICRO FLOW 28G 104 atorvastatin calcium 33 HAND 65ASSURE HAEMOLANCE PLUS ATRALIN 55NORMAL FLOW 21G 104
Index 5
AVEENO POSITIVELY B-1 242 BASIS OVERNIGHT 74 AGELESS LIFT & FIRM EYE 65 AVEENO POSITIVELY AGELESS NIGHT 65 AVEENO POSITIVELY AGELESSFIRMING BODY 65 AVEENO POSITIVELY AGELESSSKIN STRENGTHENING BODY CREAM 65 AVEENO POSITIVELY AGELESSSKIN STRENGTHENING HAND CREAM 65 AVEENO POSITIVELY NOURISHING 24-HOUR ULTRA-HYDRATING 65 AVEENO POSITIVELY NOURISHING ENERGIZING65 AVEENO POSITIVELY RADIANT 65 AVEENO POSITIVELY RADIANTOVERNIGHT HYDRATING FACIAL MOISTURI 66 AVEENO STRESS RELIEF MOISTURIZING 66 AVELOX 93 AVELOX ABC PACK 93
B-100 COMPLEX 161 B-12 DOTS 96 b-complex vitamins 160 b-complex w/ c & calcium 161 b-complex w/ c & e + zn 161 b-complex w/ c & folicacid 161 b-complex w/ folic acid 162 b-complex w/ minerals 163 b-complex w/biotin & folicacid 162 B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X5/16" 122 B-D INSULIN SYRINGE ULTRAFINE II/0.5ML/31G X5/16" 122 B-D INSULIN SYRINGE ULTRAFINE II/1ML/31G X5/16" 122 B-D INSULIN SYRINGE ULTRAFINE/0.3ML/30G X1/2" 122 B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X1/2" 122 BACIGUENT 58
BASLE 66 BAYER BREEZE 2 HIGH CONTROL 104 BAYER BREEZE 2 LOW CONTROL 104 BAYER BREEZE 2 NORMAL CONTROL 104 BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS 84 BAYER CONTOUR HIGH CONTROL 104 BAYER CONTOUR LOW CONTROL 104 BAYER CONTOUR NEXT BLOODGLUCOSE TEST 84 BAYER CONTOUR NEXT CONTROL LEVEL 1 104 BAYER CONTOUR NEXT CONTROL LEVEL 2 104 BAYER CONTOUR NORMAL CONTROL 104 BAYER MICROLET 2 LANCING DEVICE 104 BAYER MICROLET LANCETS 104 BAZA CLEANSE & PROTECT 74 BD LO-DOSE INSULIN SYRINGE MICROFINE
AVODART AVONEX AVONEX PEN
95 233 233
BACITRACIN bacitracin (topical) bacitracin zinc
228 58 58
IV/0.5ML/28G X 1/2" 122 BD AUTOSHIELD 29G X 5/16" 122 BD INSULIN SYRINGE LUER-
AXERT AXIRON AYGESTIN AYR NASAL DROPS AZASAN AZASITE
154 12
232 223 158 228
bacitracin-poly-neomycin-hc229
bacitracin-polymyxin b 58 bacitracin-polymyxin b(ophth) 228 baclofen 223 BACMIN 164
LOK/U-100/1MLBD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X 1/2"BD INSULIN SYRINGE MICROFINE IV/U-100/0.5ML/28G X 1/2"BD INSULIN SYRINGE
122
122
122
azathioprine azelastine hcl azelastine hcl (ophth) AZELEX AZILECT
158 224 230 55 40
BACTRIM BACTRIM DS BACTROBAN BAL-CARE DHA balsalazide disodium
14 14 58
213 94
MICROFINE IV/U-100/1ML/27GX 5/8" 123 BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/28GX 1/2" 123 BD INSULIN SYRINGE
AZITHROMYCIN azithromycin
100 100
BANZEL BARACLUDE
19 46
MICROFINE/U-100/0.3ML/28G X1/2" 123 BD INSULIN SYRINGE
AZOLEN TINCTURE AZOPT AZOR AZULFIDINE AZULFIDINE EN-TABS
58 230 35 94 94
BARIATRIC FUSION BASAGLAR KWIKPEN BASIC AM BASIC PM BASIS FACIAL
164 27
164 164
MICROFINE/U-100/0.5ML/28G X1/2" 123 BD INSULIN SYRINGE MICROFINE/U-100/1ML/27G X5/8" 123 BD INSULIN SYRINGE
b complex w/ c 161 MOISTURIZER 74 MICROFINE/U-100/1ML/28G X1/2" 123
Index 6
BD INSULIN SYRINGE BD INSULIN SYRINGE BD PEN NEEDLES SAFETYGLIDE/0.5ML/29G X ULTRAFINE/U-100/1ML/29G X SHORT/ULTRAFINE/31G X1/2" 123 1/2" 123 5/16" 124 BD INSULIN SYRINGE BD INSULIN SYRINGE BD SAFETY-GLIDE INSULIN SAFETYGLIDE/1ML/29G X ULTRAFINE/U-100/1ML/30G X SYRINGE/0.5ML/29G X1/2" 123 1/2" 123 1/2" 124 BD INSULIN SYRINGE BD INSULIN SYRINGE BD SAFETY-LOK INSULIN SAFETYGLIDE/U- ULTRAFINE/U-100/1ML/31G X SYRINGE/PERM100/0.3ML/31G X 5/16" 123 15/64" 124 NEEDLE/UF/1ML/29G XBD INSULIN SYRINGE SLIP BD INSULIN SYRINGE 1/2" 124 TIP/U-100/1ML 123 ULTRAFINE/U-100/1ML/31G X BD SAFETYGLIDE INSULIN BD INSULIN SYRINGE 5/16" 124 SYSYRINGE/0.5ML/30G XULTRAFINE HALF- BD INSULIN 5/16" 124 UNIT/0.3ML/31G X 5/16" 123 SYRINGE/DETACHABLE BD SWABS SINGLE USE 119 BD INSULIN SYRINGE NEEDLE/U-100/1ML/25G X BD SWABS SINGLE USEULTRAFINE 1" 124 BUTTERFLY 119II/SHORT/0.5ML/31G X BD INSULIN BD ULTRA-FINE MICRO PEN5/16" 123 SYRINGE/DETACHABLE NEEDLES 6MM X 32G 124BD INSULIN SYRINGE NEEDLE/U-100/1ML/25G X BECONASE AQ 224ULTRAFINE II/SHORT/1ML/31G 5/8" 124 BELBUCA 11X 5/16" 123 BD INSULIN BD INSULIN SYRINGE SYRINGE/DETACHABLE BELSOMRA 98 ULTRAFINE/0.3ML/30G X NEEDLE/U-100/1ML/26G X BENADRYL ALLERGY 31 1/2" 123 1/2" 124 BENADRYL ALLERGYBD INSULIN SYRINGE BD INSULIN SYRINGE/U- CHILDRENS 31ULTRAFINE/0.3ML/31G X 100/0.5ML/30G X 1/2" 124 BENADRYL EXTRA5/16" 123 BD INSULIN SYRINGE/U- STRENGTH 60BD INSULIN SYRINGE 100/1ML/27G X 1/2" 124 benazepril &ULTRAFINE/0.5ML/30G X BD INSULIN SYRINGE/U- hydrochlorothiazide 351/2" 123 100/1ML/28G X 1/2" 124 benazepril hcl 34BD INSULIN SYRINGE BD INTEGRA INSULIN
BENGAY GREASELESS 73ULTRAFINE/0.5ML/31G X SYRINGE/U-100/1ML/29G X5/16" 123 1/2" 124 BENGAY ULTRA BD INSULIN SYRINGE BD INTEGRA STRENGTH 73 ULTRAFINE/1ML/30G X SYRINGE/RETRACTING BENICAR 34 1/2" 123 NEEDLE/1ML/25G X 1" 124 BENICAR HCT 35BD INSULIN SYRINGE BD LANCET DEVICE 104 BENSAL HP 73ULTRAFINE/1ML/31G X BD LANCET ULTRAFINE5/16" 123 30G 104 BENTYL 236 BD INSULIN SYRINGE BENZAC AC WASH 55BD LANCET ULTRAFINEULTRAFINE/U-100/0.3ML/29G X 33G 104 BENZACLIN 551/2" 123 BD MICROTAINER BENZACLIN WITH PUMP 55BD INSULIN SYRINGE LANCETS 104ULTRAFINE/U-100/0.3ML/30G X BD PEN BENZAMYCIN 55 1/2" 123 NEEDLE/MINI/ULTRAFINE/31 BENZEFOAM 55 BD INSULIN SYRINGE G X 3/16" 124 BENZEFOAM ULTRA 55ULTRAFINE/U-100/0.3ML/31G X BD PEN BENZEFOAMULTRA 555/16" 123 NEEDLE/NANO/ULTRAFINE/3BD INSULIN SYRINGE 2G X 4MM 124 benzocaine (dental) 159 ULTRAFINE/U-100/0.5ML/29G X BD PEN benzocaine-menthol (mouth-1/2" 123 NEEDLE/SHORT/ULTRAFINE/ throat) 159 BD INSULIN SYRINGE 31G X 5/16" 124 benzonatate 53ULTRAFINE/U-100/0.5ML/30G X BD PEN benzoyl peroxide 551/2" 123 NEEDLE/ULTRAFINE/29G XBD INSULIN SYRINGE BENZOYL PEROXIDE 5512.7MM 124ULTRAFINE/U-100/0.5ML/31G X BD PEN benzoyl peroxide 55 5/16" 123 NEEDLE/ULTRAFINE/29GX1/2 benzoyl peroxide-
" 12.7MM 124 erythromycin 55
Index 7
benztropine mesylate 39 BIOTENE DRY MOUTH 120 BREATHERITE BEPREVE 230 BIOTENE DRY MOUTH COLLAPSIBLESPACER W/
NEONATE MASK 150GENTLEFORMULA 120BESIVANCE 228 BREATHERITE RIGIDBIOTENE DRY MOUTHBETA CARE 66 MOISTURIZING SPRAY 160 SPACERW/MASK 150
BREATHERITE W/LARGEBETA CAROTENE 242 BIOTENE PBF DRY MASK 150MOUTH 120beta carotene 242 BREATHERITE W/MEDIUMbiotin 242BETA XMA 66 MASK 150BIOTIN PLUS KERATIN 219BETAGAN 227 BREATHERITE W/SMALL
betamethasone dipropionate BIOVOL 164 MASK 151 (topical) 61 bisacodyl 99 BREO ELLIPTA 17 betamethasone dipropionate bismuth subsalicylate 28 BREVICON-28 50 augmented 61 bisoprolol & BRILINTA 96betamethasone valerate 61 hydrochlorothiazide 35 brimonidine tartrate 228BETAPACE 47 bisoprolol fumarate 47 BRINTELLIX 23BETAPACE AF 47 BLEPH-10 228 BRISDELLE 234BETASAL 73 BLEPHAMIDE 229 BRIVIACT 19BETASERON 233 BLEPHAMIDE S.O.P. 229 BROMFENAC 230betaxolol hcl 47 BLOOD GLUCOSE TEST bromfenac sodium (ophth) 230STRIPS 84betaxolol hcl (ophth) 227 BLOOD GLUCOSE TEST bromocriptine mesylate 40bethanechol chloride 239 STRIPS PREMIUM 84 brompheniramine &BETHKIS 4 BLUE-EMU SUPER phenyleph 53 BETIMOL 227 STRENGTH 73 brompheniramine &
BODI PROTECT 74 pseudoeph 53BETOPTIC-S 227 BONE DENSITY BROMSITE 230BEVESPI AEROSPHERE 17 BUILDER 157 BROVANA 17BEXSERO 239 BONIVA 91 BUBBLES THE FISH II
BEYAZ 50 BOSULIF 38 PEDIATRIC MASK/PVC 151 BG STAR BLOOD GLUCOSE BOUDREAUXS BABY BUTT budesonide (inhalation) 17TEST 84 SMOOTH DRY SKIN 66 budesonide (nasal) 224BIAXIN 100 BP CLEANSING WASH 56 BUFFERIN 8bicalutamide 38 BP FOLINATAL PLUS B 213 BULLSEYE MINI SAFETYBIDIL 49 BP MULTINATAL PLUS 213 LANCETS 104 BIMATOPROST 230 BULLSEYE SAFETYBPROTECTED PEDIA TRI-
LANCETS 105BINOSTO 91 VITE 212 bumetanide 90BIO-35 GLUTEN-FREE 164 BRAIN 219
BRAIN MIGHT/DHA & CO BUMEX 90BIO-35 IRON FREE 164 Q10 219 BUNAVAIL 11BIOBRANE 10"X15" 77 BREATHERITE 150 BUPRENORPHINE 11,12BIOBRANE 15"X20" 77 BREATHERITE buprenorphine hcl 11BIOBRANE 5"X15" 77 COLLAPSIBLEADULT buprenorphine hcl-naloxone hclBIOBRANE 5"X5" 77 SPACER W/MASK 150 dihydrate 11BREATHERITEBIOBRANE-L 10"X15" 77 bupropion hcl 22COLLAPSIBLECHILD SPACERBIOBRANE-L 5"X15" 78 W/MASK 150 bupropion hcl (smokingBIOBRANE-L 5"X5" 78 BREATHERITE deterrent) 234
COLLAPSIBLEINFANT BURIED TREASURE ACTIVEBIOCAL 164 SPACER W/MASK 150 55PLUS SENIOR
bioflavonoid products 163 BREATHERITE COMPLEX 164 BIOSCANNER GLUCOSE TEST COLLAPSIBLESMALL CHILD buspirone hcl 15STRIPS 84 SPACER W/MASK 150 butalbital-acetaminophen 7BIOSUPP 164 butalbital-acetaminophen-BIOTECT PLUS 164 caffeine 7
Index 8
butalbital-acetaminophen- calcium citrate 156 carbidopa-levodopa 40 caffeine w/ codeine 11 calcium citrate-vitamin d 156 CARBIDOPA/LEVODOPA/ENTAbutalbital-aspirin-caffeine 7 CAPONE 40CALCIUM GLUCONATE 156butalbital-aspirin-caffeine CARBOFLEX ODOR CONTROL
CALCIUM PNV 213w/cod 11 DRESSING 78 BUTALBITAL/ASPIRIN/CAFFEIN calcium polycarbophil 99 carboxymethylcellulose sodiumE 7 (ophth) 226calcium w/ vitamin d 156 butenafine hcl 58 carboxymethylcellulose-glycerincalcium-magnesium-zinc 156 butorphanol tartrate 12 226
CALCIUM/MAGNESIUM/ZINC carboxymethylcellulose-BUTRANS 12 157 hypromellose 226
CALCIUM/MAGNESIUM/ZINC/BYDUREON 27 CARDENZ 208VITAMIN D3 157BYDUREON BCISE 27 CARDIO TONE 219CALQUENCE 38BYDUREON PEN 27 CARDIOCOM LANCINGCALTRATE 600+D 156 DEVICE 105BYETTA 27 CAM 66 CARDIOTEK-RX 89BYSTOLIC 47 CAMBIA 154 CARDIZEM 48BYVALSON 35 camphor & menthol 60 CARDIZEM CD 48C-BUFF 164 camphor-eucalyptus-menthol CARDIZEM LA 48C-NATE DHA 213 54 CA-PLUS 219 camphor-eucalyptus-menthol- CARDURA 34
turpentine oil-white CARDURA XL 95CABOMETYX 38 petrolatum 54 CAREFINE PEN NEEDLECADUET 49 camphor-menthol-methyl 32GX4MM 124 CAFCIT 3 salicylate 73 CAREFINE PEN NEEDLES CAFERGOT 154 CANASA 94 29GX1/2" 124
CAREFINE PEN NEEDLEScaffeine 3 candesartan cilexetil 34 30GX5/16" 124candesartan cilexetil-caffeine citrate 3 CAREFINE PEN NEEDLEShydrochlorothiazide 35CAL MAG ZINC +D3 157 31GX6MM 124capecitabine 37 CAREFINE PEN NEEDLESCAL-DAY 1000 164 CAPEX 62 31GX8MM 124CAL-MAG-ZINC-D 157 CAREFINE PEN NEEDLESCAPHOSOL 160CAL-MAG-ZINC-D3 157 32GX5MM 124CAPITAL/CODEINE 11 CAREFINE PEN NEEDLESCALAN 48 CAPRELSA 38 32GX6MM 124CALAN SR 48 capsaicin 73 CAREONE ADVANCED calcipotriene 60 LANCINGDEVICE 105captopril 34calcipotriene-betamethasone CAREONE BLOOD GLUCOSECAPTOPRIL/HYDROCHLOROdipropionate 62 TEST STRIPS/PREMIUM 84THIAZIDE 35calcitonin (salmon) 91 CAREONE BLOOD GLUCOSECAPZASIN-HP 74 TEST STRIPS/VALUE 84CALCITRIOL 60 CARAC 60 CAREONE INSULINcalcitriol 92 CARAFATE 237 SYRINGES/0.3ML/30G Xcalcium 156 1/2" 124CARB-O-LAN 10 66 CAREONE INSULINCALCIUM 156 calcium acetate (phosphate CARB-O-LAN 20 66 SYRINGES/0.3ML/31G Xbinder) 95 CARB-O-PHILIC/20 66 5/16" 124
CAREONE INSULINCALCIUM CARBONATE 13 CARB-O-SAL 5 66 SYRINGES/0.5ML/30G X
calcium carbonate 155 carbamazepine 19 1/2" 125 calcium carbonate (antacid) 13 CARBAMAZEPINE 19 CAREONE INSULIN calcium carbonate- carbamazepine 19 SYRINGES/0.5ML/31G Xcholecalciferol 155,156 5/16" 125carbamide peroxide (otic) 231 CAREONE INSULINcalcium carbonate- CARBATROL 19ergocalciferol 156 SYRINGES/1ML/30G Xcalcium carbonate-vitamin carbidopa 39 1/2" 125 d 156
Index 9
CAREONE INSULIN CARNITOR 92 CENTRUM FLAVOR SYRINGES/1ML/31GX5/16"
125 CAREONE LANCET THIN 105 CAREONE LANCET ULTRA THIN 105 CAREONE UNIFINE PENTIPS
CARNITOR SF 92 CAROSPIR 90 CARRAGAUZE 2 X 2 78 CARRAGAUZE 4 X 4 78 CARRINGTON MOISTURE
BURST 165 CENTRUM FLAVOR BURST ADULT 165 CENTRUM FLAVOR BURST KIDS 165 CENTRUM MEN 165
29GX12MM 125 BARRIER 74 CENTRUM MULTIGUMMIES CAREONE UNIFINE PENTIPS CARRINGTON MOISTURE ADULTS 165 31GX5MM 125 CAREONE UNIFINE PENTIPS 31GX6MM 125 CAREONE UNIFINE PENTIPS
BARRIER/ZINC carteolol hcl (ophth) carvedilol
74 227 47
CENTRUM MULTIGUMMIES MEN 165 CENTRUM MULTIGUMMIES WOMEN 165
31GX8MM 125 CAREONE UNIFINE PENTIPS PEN NEEDLES 32GX4MM 125 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES
carvedilol phosphate CASODEX CATAPRES CATAPRES-TTS-1
47 38 34 34
CENTRUM MULTIVITAMIN FLAVOR BURST DRINK 165 CENTRUM PERFORMANCE 219 CENTRUM SILVER 166
29GX12MM 125 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX5MM 125 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX6MM 125 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX8MM 125 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 32GX4MM 125 CARESENS CONTROL A
CATAPRES-TTS-2 CATAPRES-TTS-3 CAYSTON CEDAX cefaclor CEFACLOR CEFACLOR ER cefadroxil cefdinir cefixime cefpodoxime proxetil
34 34 14 50 49 49 49 49 50 50 50
CENTRUM SILVER 50+MEN 165 CENTRUM SILVER 50+WOMEN 165 CENTRUM SILVER ADULT 50+ 166 CENTRUM SILVER ULTRA MENS 166 CENTRUM SILVER ULTRA WOMENS 166 CENTRUM SPECIALIST ENERGY 219 CENTRUM SPECIALIST HEART 166
SOLUTION 105 CARESENS N BLOOD GLUCOSETEST STRIPS 84 CARETOUCH ALCOHOL PREP PADS 120 CARETOUCH LANCING DEVICEWITH EJECTOR 105 CARETOUCH PEN NEEDLES 31G X 6 MM 125 CARETOUCH PEN NEEDLES
cefprozil CEFTIBUTEN CEFTIN ceftriaxone sodium cefuroxime axetil CELEBREX celecoxib CELEXA
49 50 50 50 50 5 5
23
CENTRUM SPECIALIST IMMUNE SUPPORT 166 CENTRUM SPECIALIST VISION 166 CENTRUM ULTRA MENS 166 CENTRUM ULTRA WOMENS 166 CENTRUM VITAMINTS 166 CENTRUM WOMEN 166
31GX 5MM 125 CARETOUCH PEN NEEDLES 31GX 8MM 125 CARETOUCH PEN NEEDLES 32GX 4MM 125 CARETOUCH PEN NEEDLES 32GX 5MM 125 CARETOUCH TWIST LANCETS 28G 105 CARETOUCH TWIST LANCETS 30G 105 CARETOUCH TWIST LANCETS 33G 105 carisoprodol 223 carisoprodol w/ aspirin 223 CARMOL 20 65
CELLCEPT 158 CELLULAR SECURITY 165 CELONTIN 22 CEMILL PLUS 163 CENTANY 58 CENTANY AT 58 CENTRATEX 97 CENTRAVITES 50 PLUS 165 CENTRAVITES ADULTS 165 CENTRUM 165,166 CENTRUM ADULTS 165 CENTRUM CARDIO 165
CEPACOL SORE THROAT159 CEPACOL SORE THROAT EXTRA STRENGTH 159 CEPACOL SORE THROAT EXTRASTRENGTH 159 CEPACOL SORE THROAT MAXIMUM NUMBING 159 CEPASTAT 160 cephalexin 49 CEPHALEXIN 49 CERALYTE 70 156 CERASPORT 156 CERASPORT EX1 156 CERAVE 66
Index 10
CERAVE AM SPF 30 66 CERAVE PM 66 CERAVE RENEWING SA 66 CERAVE SA RENEWING 66 CEREBYX 21 CEROVITE ADVANCED FORMULA 166 CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS 166 CESAMET 29 CETAPHIL 66 CETAPHIL DAILY ADVANCE ULTRA HYDRATING 66 CETAPHIL DAILY FACIAL MOISTURIZER 66 CETAPHIL DERMACONTROL MOISTURIZER/SPF 30 66 CETAPHIL MOISTURIZING 66 CETAPHIL RESTORADERM 66 CETAPHIL THERAPEUTIC
CHLOR-TRIMETON 30 CHLOR-TRIMETON ALLERGY 30 chlordiazepoxide hcl 15 chlorhexidine gluconate 43 chlorhexidine gluconate(mouth-throat) 159 CHLOROQUINE PHOSPHATE 36 chloroquine phosphate 36 CHLOROTHIAZIDE 90 chlorothiazide 90 chlorpheniramine &pseudoeph 53 chlorpheniramine maleate 31 chlorpheniramine-acetaminophen 53 CHLORPROMAZINE HCL 42 chlorpromazine hcl 42 CHLORPROPAMIDE 28 chlorthalidone 90
ciprofloxacin-ciprofloxacinhcl citalopram hydrobromide CITRACAL + D3 MAXIMUM CITRACAL MAXIMUM CITRACAL PLUS CITRANATAL 90 DHA CITRANATAL ASSURE CITRANATAL B-CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX CITRUCEL FIBER LAXATIVE CLARIFOAM EF CLARINEX CLARITHROMYCIN clarithromycin CLARITIN
93 23
156 156 157 213 213 213 213 213 213
99 56 31
100 100 31
HAND 66 chlorzoxazone 223 CLARITIN REDITABS 31 cetirizine hcl 31 CHOICEFUL CLARITIN-D 24 HOUR 53 CETRAXAL CHANTIX CHANTIX CONTINUING
231 234
MULTIVITAMIN CHOLBAM cholecalciferol
166 93
242
CLASS ACT LUBRICATED 101 CLASSIC PRENATAL 213 CLEAN & CLEAR ADVANTAGE
MONTHPAK 234 CHANTIX STARTING MONTH PAK 234 CHAPSTICK OVERNIGHT 74 CHAPSTICK ULTRA MOISTUREDAYTIME FORMULA 74 CHAPSTICK ULTRASMOOTH FORTIFY 74 CHAPSTICK ULTRASMOOTH
cholestyramine cholestyramine light choline fenofibrate CICLODAN CREAM KIT ciclopirox ciclopirox olamine cilostazol CILOXAN
32 32 33 58 58 58 96
228
3-IN-1 EXFOLIATING CLEANSER 56 CLEANLET LANCETS 28G105 clemastine fumarate 31 CLEOCIN 14,241 CLEOCIN PEDIATRIC GRANULES 14 CLEOCIN-T 56 CLEVER CHEK AUTO-CODE
NOURISH 74 CHAPSTICK ULTRASMOOTH REJUVENATE 74 CHAPSTICK ULTRASMOOTH
cimetidine CIMETIDINE HCL cimetidine hcl
236 236 236
TEST STRIPS 84 CLEVER CHEK AUTO-CODE VOICE TEST STRIPS 84 CLEVER CHEK LANCETS
SOOTHE CHEK-STIX COMBO PAK URINALYSIS CONTROL CHEK-STIX CONTROL CHEMET CHEMSTRIP-K CHENODAL CHERACOL PLUS CHERACOL SORE THROAT CHERACOL-D COUGH CHILDRENS ADVIL
74
84 84 29 84 93 53
159 53 5
CIMZIA CIMZIA STARTER KIT CIPRO CIPRO HC CIPRO XR CIPRODEX ciprofloxacin CIPROFLOXACIN CIPROFLOXACIN HCL ciprofloxacin hcl ciprofloxacin hcl (ophth)
94 94 93
231 93
231 93
231 93 93
228
ULTRATHIN 105 CLEVER CHEK LANCETS ULTRATHIN 30G 105 CLEVER CHEK TEST STRIPS 84 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/ADULT LARGE151 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM 151 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/SMALL 151
CHILDRENS MOTRIN 5
Index 11
CLEVER CHOICE AUTO-CODE CLEVER CHOICE COMFORT CLINICAL NUTRIENTS 50-PLUS PRO TEST STRIPS 84 EZPEN NEEDLES MEN 166 CLEVER CHOICE COMFORT 29GX12MM 126 CLINICAL NUTRIENTS EZINSULIN PEN NEEDLES CLEVER CHOICE COMFORT ANTIOXIDANT 167 31GX8MM 125 EZPEN NEEDLES CLINICAL NUTRIENTS FOR CLEVER CHOICE COMFORT 31GX5MM 126 FEMALE TEENS 167 EZINSULIN CLEVER CHOICE COMFORT CLINICAL NUTRIENTS FOR SYRINGE/0.3ML/29G X EZPEN NEEDLES MALE TEENS 167 1/2" 125 31GX6MM 126 CLINICAL NUTRIENTS FOR CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT MEN 167 EZINSULIN EZPEN NEEDLES CLINICAL NUTRIENTS FOR SYRINGE/0.3ML/30G X 31GX8MM 126 WOMEN 167 1/2" 125 CLEVER CHOICE COMFORT CLN FACIAL MOISTURIZER CLEVER CHOICE COMFORT EZPEN NEEDLES NOURISHING 66 EZINSULIN 32GX4MM 126 clobetasol propionate 62 SYRINGE/0.3ML/30G X CLEVER CHOICE COMFORT clobetasol propionate emollient5/16" 125 EZPEN NEEDLES base 62 CLEVER CHOICE COMFORT 32GX5MM 126 clobetasol propionateEZINSULIN CLEVER CHOICE COMFORT emulsion 62 SYRINGE/0.3ML/31G X EZPEN NEEDLES CLOBEX 62
32GX6MM 1265/16" 125 CLOCORTOLONECLEVER CHOICE COMFORT CLEVER CHOICE GLUCOSE PIVALATE 62EZINSULIN CONTROL HIGH 105 CLOCORTOLONE PIVALATESYRINGE/0.5ML/28G X CLEVER CHOICE GLUCOSE PUMP 621/2" 125 CONTROL LOW 105 CLODERM 62CLEVER CHOICE COMFORT CLEVER CHOICE MICRO EZINSULIN TESTSTRIPS 84 CLODERM PUMP 62 SYRINGE/0.5ML/29G X CLICKFINE PEN NEEDLE clomipramine hcl 24 1/2" 125 32GX5/32" 126 clonazepam 19 CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLE clonidine hcl 34EZINSULIN UNIVERSAL/31GX1/4" 126
CLICKFINE PEN NEEDLE clonidine hcl (adhd) 3SYRINGE/0.5ML/30G X1/2" 125 UNIVERSAL/31GX5/16" 126 clopidogrel bisulfate 96
CLICKFINE PENCLEVER CHOICE COMFORT clorazepate dipotassium 15EZINSULIN NEEDLES/31GX1/4" 126
CLICKFINE PEN CLORPRES 35SYRINGE/0.5ML/30G X5/16" 125 NEEDLES/31GX5/16" 126 CLOSERCARE 105
CLICKFINE UNIVERSAL PENCLEVER CHOICE COMFORT clotrimazole 159NEEDLES 31GX5/16" 126EZINSULIN clotrimazole (topical) 58SYRINGE/0.5ML/31G X CLIMARA 92 clotrimazole vaginal 2415/16" 126 CLINDAGEL 56
CLEVER CHOICE COMFORT clotrimazole w/clindamycin hcl 14 betamethasone 59EZINSULIN clindamycin palmitateSYRINGE/1.0ML/30G X clozapine 42hydrochloride 141/2" 126 CLOZAPINE ODT 42clindamycin phosphateCLEVER CHOICE COMFORT (topical) 56 CLOZARIL 42EZINSULIN SYRINGE/1ML/28G clindamycin phosphate CO MONITOR REPLACEMENTX 1/2" 126 vaginal 241 TPIECES 151CLEVER CHOICE COMFORT clindamycin phosphate-benzoyl CO-NATAL FA 213EZINSULIN SYRINGE/1ML/29G peroxide 56X 1/2" 126 COAGUCHEK LANCETS 105clindamycin phosphate-benzoylCLEVER CHOICE COMFORT peroxide (refrigerate) 56 coal tar extract 76 EZINSULIN SYRINGE/1ML/30G clindamycin phosphate- COARTEM 36X 5/16" 126 tretinoin 56 COCOA BUTTER 66CLEVER CHOICE COMFORT CLINDESSE 241EZINSULIN SYRINGE/U- COCOA BUTTER HAND &
CLINICAL NUTRIENTS 45-100/1ML/31GX5/16" 126 BODYLOTION 66PLUS WOMEN 166 COCONUT OIL BEAUTY 66
Index 12
cod liver oil 221 COMFORT ASSIST INSULIN CONTREET SYRINGE/1ML/29G X HYDROCOLLOID 78COD LIVER OIL 222 1/2" 126 CONTROL AST 85COD LIVER OIL FOR KIDS221 COMFORT ASSIST INSULIN CONTROL SOLUTION
CODEINE SULFATE 8,9 SYRINGE/1ML/30G X NORMAL 1055/16" 127codeine sulfate 9 CONTROL TEST STRIPS 85COMFORT ASSIST INSULINCOLACE 100 CONZIP 9SYRINGE/1ML/31G X
COLAZAL 94 5/16" 127 COOL BLOOD GLUCOSE TEST COLCHICINE 96 COMFORT ASSURED STRIPS 85
COOL CONTROL SOLUTIONLANCETS MICRO THINcolchicine w/ probenecid 96 A 10533G 105COLCRYS 96 COOL CONTROL SOLUTIONCOMFORT ASSURED B 105COLESTID 32 LANCETS SUPER THIN
28G COPAXONECOLESTID FLAVORED 32 105 233
colestipol hcl 32 COMFORT LANCETS 105 COPEGUS 46 COMFORT-AID 1.5"X2.5" 78 CORDARONE 16COLGATE PLATINUM 121 COMPACT SPACE CORDRAN 62COLY-MYCIN S 231 CHAMBER/ANTI-STATIC CORDRAN TAPE 62COLYTE-FLAVOR PACKS 99 151 COREG 47COMBIGAN 227 COMPACT SPACE
COMBIPATCH 92 CHAMBER/ANTI- COREG CR 47 STATIC/LARGE MASK 151 CORGARD 47COMBIVENT RESPIMAT 17 COMPACT SPACE CORICIDIN HBP COLD &COMBIVIR 43 CHAMBER/ANTI- FLU 53
COMETRIQ 38 STATIC/MEDIUM MASK 151 CORLANOR 49COMPACT SPACECOMFEEL PLUS CLEARDRESSING 78 CHAMBER/ANTI- CORTEF 52 COMFEEL PLUS STATIC/SMALL MASK 151 CORTENEMA 12 CONTOURDRESSING 78 COMPLERA 43 CORTISONE ACETATE 52 COMFEEL PLUS COMPLETE FORMULATION CORTISPORIN-TC 231DRESSING 78 D3000 167 CORVITE 167COMFEEL PLUS COMPLETE FORMULATION TRIANGLEDRESSING 78 MULTIVITAMIN CORZIDE 35 COMFEEL PLUS ULCER SUPPLEMENT 167 COSENTYX 60DRESSING 78 COMPLETE NATAL DHA213 COSENTYX SENSOREADYCOMFEEL PLUS COMPLETENATE 213 PEN 60ULCERDRESSING 78 COSOPT 227COMFEEL ULCER COMPOUND W 73 CAREDRESSING 78 COMPOUND W MAXIMUM COSOPT PF 227 COMFORT ASSIST INSULIN STRENGTH 73 COTELLIC 38 SYRINGE 0.3ML/29G X COMTAN 39 COUMADIN 181/2" 126 CONCEPT DHA 213 COZAAR 34COMFORT ASSIST INSULIN CONCEPT OB 213SYRINGE/0.3ML/30G X CREON 89 5/16" 126 CONCEPTIONXR MOTILITY CRESEMBA 30COMFORT ASSIST INSULIN SUPPORT FORMULA 167 CREST TARTARSYRINGE/0.3ML/31G X CONCERTA 3 CONTROL 1215/16" 126 CONDYLOX 73 CREST TARTARCOMFORT ASSIST INSULIN CONE MASK 151 CONTROL/BAKING SODASYRINGE/0.5ML/29G X TOOTHPASTE 121CONTREET FOAM 781/2" 126 CREST TOOTHPASTE 121COMFORT ASSIST INSULIN CONTREET FOAM
CRESTSYRINGE/0.5ML/30G X CAVITY 78 TOOTHPASTE/REGULAR 1215/16" 126 CONTREET FOAM HEEL 78 CRESTCOMFORT ASSIST INSULIN CONTREET FOAM TOOTHPASTEREGULAR 121SYRINGE/0.5ML/31G X SACRAL 78 CRESTOR 335/16" 126
Index 13
CRINONE 241 CVS PREP PADS 120 dantrolene sodium 223 CRITIC-AID CLEAR MOISTUREBARRIER 74 CRIXIVAN 44 cromolyn sodium 16 cromolyn sodium (nasal) 224 cromolyn sodium (ophth) 230 CU-PLUS 219 CUPRIMINE 158 CURITY ALCOHOL PREPS/MEDIUM 2 PLY 120 CURITY ALCOHOL SWABS 120 CURITY HEAVY DRAINAGE PACK 78 CURITY SALINE DRESSING 8"X4" 78 CURITY SODIUM CHLORIDE DRESSING 6"X6-3/4" 78 CUTIVATE 62 CVS ADVANCED GLUCOSE
CVS PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER 73 CVS SPECTRAVITE ADULT 50+ 167 CVS SPECTRAVITE ADULT GUMMIES 167 CVS SPECTRAVITE ULTRA MEN50+ 167 CVS SPECTRAVITE ULTRA MENS HEALTH 167 CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR 167 CVS SPECTRAVITE ULTRA WOMEN 167 CVS SPECTRAVITE ULTRA WOMENS HEALTH 167 CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR 167 CVS THERAPEUTIC MAXIMUM STRENGTH 73
dapsone 14 dapsone (topical) 56 darifenacin hydrobromide 239 DAYPRO 5 DAYTRANA 3 DDAVP 92 DEBROX 231 DECARA 242 DECON-A 53 DECUBI-VITE 167 DEKAS BARIATRIC 167 DEKAS ESSENTIAL 208 DEKAS PLUS 167,168 DELZICOL 94 DEMADEX 90 demeclocycline hcl 235 DEMEROL 9
METER TEST STRIPS 85 CVS ULTRA THIN DENAVIR 61 CVS AIRSHIELD IMMUNITY LANCETS 105 DENOREX EXTRA STRENGTH SUPPORT CVS ALCOHOL PREP SWABS CVS ALCOHOL SWABS CVS COD LIVER OIL CVS DAILY ULTRA MOISTURELOTION
167
120 120 222
67
cyanocobalamin CYCLESSA cyclobenzaprine hcl CYCLOGYL cyclopentolate hcl CYCLOPHOSPHAMIDE
96 50
223 227 227 37
2-IN-1 DENTIVA DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER
73 160 22 22 22 22
CVS DIABETES HEALTH SUPPORT 167 CVS DRY MOUTH SPRAY 160
cyclosporine CYCLOSPORINE MODIFIED
158
158
DEPAKOTE SPRINKLES DEPO-PROVERA CONTRACEPTIVE
22
52 CVS GLUCOSE 26 CVS HAIR/SKIN/NAILS 219 CVS HDYROCORTISONE ACETATE 62 CVS LANCETS 21G 105 CVS LANCETS MICRO THIN 33G 105 CVS LANCETS MICRO-THIN
cyclosporine modified (formicroemulsion) 158 CYMBALTA 24 cyproheptadine hcl 32 CYTOMEL 236 CYTOTEC 238 D-VI-SOL 242
DEPO-TESTOSTERONE DERMA-GEL 4" X 4" DERMA-SMOOTHE/FSBODY DERMA-SMOOTHE/FSSCALP DERMABASEOIL IN WATER
12 78
62
62
67 33G 105 DAFLONEX-XL 163 DERMACINRX SILAPAK 62 CVS LANCETS ORIGINAL 105 DAILY CONDITIONING DERMACINRX TICANASE CVS LANCETS THIN 26G 105 CVS LANCETS ULTRA THIN 30G 105 CVS LANCETS ULTRA-THIN 30G 105 CVS LANCING DEVICE 105 CVS MOISTURIZING CREAM 67 CVS ONE DAILY MENS 50+ ADVANCED 167
TREATMENT 67 DAILY HEART HEALTH SUPPORT 167 DAILY MULTIPLE VITAMIN PLUS IRON 164 DAILY PAK MAXIMUM MULTIVITAMIN/ASIANGINSENG EXTRACT 167 DAKLINZA 46 DALIRESP 16
PAK 224 DERMADROX 74 DERMAGAUZE DRESSING 78 DERMAGRAN HYDROPHILIC WOUND DRESSING 2"X2" 78 DERMAGRAN HYDROPHILIC WOUND DRESSING 4"X4" 78 DERMAGRAN HYDROPHILIC WOUND DRESSING 8"X4" 78 DERMAIDE ALOE 67
CVS PRENATAL 213 DANTRIUM 223
Index 14
DERMAL THERAPY EXTRA STRENGTH BODY LOTION 67 DERMAL THERAPY FACE CAREMOISTURIZING LOTION 67 DERMAL THERAPY FOOT MASSAGE 67 DERMAL THERAPY HAND ELBOW & KNEE CREAM 67 DERMAL THERAPY HEEL CARE 67 DERMALUBE DAILY MOISTURIZING LOTION 67 DERMAREST PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER 73 DERMATOP 62 DERMAVITE 168 DERMEND MOISTURIZING BRUISE FORMULA 67 DERMOTIC 231 DESCOVY 44 desipramine hcl 24 desloratadine 31 DESLORATADINE ODT 31 desmopressin acetate 92 desmopressin acetaterefrigerated 92 desmopressin acetate spray 92 desmopressin acetate sprayrefrigerated 92 DESOGEN 50 desogestrel & ethinylestradiol 50 desogestrel-ethinyl estradiol(biphasic) 50 desogestrel-ethinyl estradiol(triphasic) 50 DESONATE 62 desonide 62 DESOWEN 62 desoximetasone 62 DESOXYN 2 DESQUAM-X WASH 56 DESVENLAFAXINE ER 24 desvenlafaxine succinate 24 DETROL 239 DETROL LA 239 DEX4 26 DEX4 FAST ACTING GLUCOSE 26 DEX4 NATURALS 26 DEX4 POUCH PACK 26
DEX4 QUICK DISSOLVE GLUCOSE 26 dexamethasone 52 DEXAMETHASONE 52 dexamethasone 52 dexamethasone sodium phosphate 52 DEXAMETHASONE SODIUM PHOSPHATE 229 DEXEDRINE 2 DEXILANT 237 dexmethylphenidate hcl 3 dextroamphetamine sulfate 2 dextromethorphan-guaifenesin
53 dextrose (diabetic use) 26 DHEA 67 DHS TAR 76 DHS TAR GEL 76 DHS ZINC 61 DIABETA 28 DIABETES HEALTH PACK 168 DIABETES SUPPORT PACK 168 DIABETIC TUSSIN COUGH DROPS 160 DIABETIDERM 67 DIABETIDERM FOOT REJUVENATING 67 DIABETIDERM HAND & BODY 67 DIAMOX 90 DIASTAR EASY TEST II LANCETS 30G 105 DIASTAR EASY TEST LANCETS30G 105 DIASTAT ACUDIAL 19 DIASTAT PEDIATRIC 19 DIATRUE GLUCOSE CONTROL SOLUTION LEVEL 1 105 DIATRUE GLUCOSE CONTROL SOLUTION LEVEL 2 105 DIATRUE GLUCOSE CONTROL SOLUTION LEVEL 3 105 DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS 85 diazepam 15 DIAZEPAM 15 diazepam 15
DIAZEPAM 19 DIAZEPAM RECTAL GEL 19 dibucaine 74 dibucaine (rectal) 13 DICLEGIS 29 diclofenac potassium 5 diclofenac sodium 5 diclofenac sodium (ophth) 230 diclofenac sodium (topical) 57 diclofenac w/ misoprostol 6 dicloxacillin sodium 232 dicyclomine hcl 236 didanosine 44 DIFFERIN 56 DIFICID 101 DIFLORASONE DIACETATE 62 DIFLUCAN 30 diflunisal 8 DIGOXIN 48 digoxin 49 DIHYDROERGOTAMINE MESYLATE 154 DILANTIN 21 DILANTIN INFATABS 21 DILANTIN-125 21 DILATRATE SR 14 DILAUDID 9 diltiazem hcl 48 diltiazem hcl coated beads 48 diltiazem hcl extended release beads 48 dimenhydrinate 29 DIMETAPP COLD & ALLERGY 53 DIOVAN 34 DIOVAN HCT 35 DIPENTUM 94 diphenhydramine hcl 31 diphenhydramine hcl(sleep) 97,98 diphenhydramine-acetaminophen(sleep) 98 diphenhydramine-zinc acetate 60 diphenoxylate w/ atropine 28 DIPHENOXYLATE/ATROPINE
28 DIPROLENE 63 DIPROLENE AF 63
Index 15
dipyridamole 96 disopyramide phosphate 16 disulfiram 232 DITROPAN XL 239 DIURIL 90 divalproex sodium 22 DMAE 67
DROPLET PEN NEEDLES 29GX12MM 127 DROPLET PEN NEEDLES 31GX5MM 127 DROPLET PEN NEEDLES 31GX6MM 127 DROPLET PEN NEEDLES 31GX8MM 127 DROPLET PEN NEEDLES
DUANE READE UNIFINE PENTIPS 31G X 6MM ULTRA SHORT 127 DUANE READE UNIFINE PENTIPS 31G X 8MM SHORT 127 DUDRESS ISLAND DRESSING 4"X4" 78 DUDRESS ISLAND DRESSING
DML FORTE 67 32GX4MM 127 6"X6" 78 DROPLET PEN NEEDLESDOCTORS CHOICE DUETACT 25
BURNS/SCALDS/ABRASIONS 32GX5MM 127 DUEXIS 6DROPLET PEN NEEDLES78 DULCOLAX 10032GX6MM 127docusate calcium 100 drospirenone-ethinyl DULERA 17docusate sodium 100 estradiol 50 duloxetine hcl 24dofetilide 16 drospirenone-ethinyl estradiol- DULOXETINE HCL 24levomefolate calcium 50DOLOPHINE 9 DROSPIRENONE/ETHINYL DUO-CARE CONTROL DOME-PASTE BANDAGE 78 ESTRADIOL/LEVOMEFOLATE SOLUTION 106 donepezil hydrochloride 232 CALCIUM 50 DUO-CARE TEST STRIPS 85 DORYX 235 DROXY CREAM 67 DUOPA 40
DRUG MART ADJUSTABLEDORYX MPC 235 DUPIXENT 64 LANCING DEVICE 105dorzolamide hcl 230 DURAGESIC 9DRUG MART LANCETSdorzolamide hcl-timolol DURATION 12 HOUR 225THIN 106maleate 227 DRUG MART ON-THE-GO DURATION SPRAY 225
DOTHELLE DHA 213 LANCETS GENTLE 30G 106 DUREX EXTRA DOVONEX 60 DRUG MART UNIFINE SENSITIVE 101
PENTIPS 31GX5MM 127doxazosin mesylate 34 DUREZOL 229DRUG MART UNIFINEdoxepin hcl 24 DURLAZA 96PENTIPS29G X 12MM 127 DOXYCYCLINE 75 DRUG MART UNIFINE dutasteride 95 doxycycline (monohydrate) 235 PENTIPS31GX6MM 127 dutasteride-tamsulosin hcl 95
DRUG MART UNIFINEdoxycycline hyclate 235 DUTOPROL 35PENTIPS31GX8MM 127doxylamine succinate DRUG MART UNIFINE DYAZIDE 90 (sleep) 98 PENTIPS32GX4MM 127 DYMISTA 223DR SMITHS DIAPER 74 DRUG MART UNIFINE DYRENIUM 90DRAMAMINE 29 PENTIPSPLUS E-Z JECT LANCETS 106DRAWTEX ADVANCED WOUND 32GX4MM 127
DRUG MART UNILET E-Z JECT LANCETS 21G 106CARE 2"X2" 78 DRAWTEX ADVANCED WOUND LANCETSSUPER THIN E-Z JECT LANCETS CARE 3"X3" 78 30G 106 COLOR 106 DRAWTEX ADVANCED WOUND DRUG MART UNILET E-Z JECT LANCETS SUPER CARE 4"X4" 78 LANCETSULTRA THIN THIN 30G 106 DRAWTEX ADVANCED WOUND 28G 106 E-Z JECT LANCETS THIN CARE 6"X8" 78 DRY MOUTH SPRAY 160 26G 106 DRAWTEX ADVANCED WOUND E-Z SPACER 151DRYSOL 74CARE 8"X8" 78 E-Z SPACER THE BODYDUAC 56DRISDOL 242 GUARDS PACK 151DUANE READE LANCET E-ZJECT LANCETS MICRO-DRISTAN SPRAY 225 ALTERNATE SITE 26G 106 THIN 33G 106dronabinol 29 DUANE READE LANCET E.E.S. 400 100DROPLET LANCETS ULTRA SUPERTHIN 30G 106 THIN 30G 105 DUANE READE LANCET E.E.S. GRANULES 100 DROPLET LANCING ULTRATHIN 28G 106 EARLOOP MASK 151 DEVICE 105 DUANE READE UNIFINE EASIVENT 151PENTIPS 29G X 12MM 127
Index 16
EASIVENT/MASK-LARGE 151 EASY TALK BLOOD EASY TOUCH INSULIN EASIVENT/MASK-MEDIUM GLUCOSE TEST STRIPS 85 SYRINGE/SAFETY/U-
151 EASY TALK CONTROL 100/1ML/30G X 1/2" 128 SOLUTION HIGH 106 EASY TOUCH INSULINEASIVENT/MASK-SMALL 151 EASY TALK CONTROL SYRINGE/U-100/0.3ML/30G XEASY COMFORT INSULIN SOLUTION LOW 106 1/2" 128SYRINGE/0.3ML/30G X EASY TALK CONTROL EASY TOUCH INSULIN5/16" 127 SOLUTION NORMAL 106 SYRINGE/U-100/0.5ML/27G XEASY COMFORT INSULIN EASY TOUCH 1/2" 128SYRINGE/0.5ML/30G X 32GX5MM 127 EASY TOUCH INSULIN5/16" 127 EASY TOUCH SYRINGE/U-100/0.5ML/28G XEASY COMFORT INSULIN 32GX6MM 127 1/2" 128SYRINGE/0.5ML/31G X EASY TOUCH ALCOHOL EASY TOUCH INSULIN5/16" 127 PREP PADS/MEDIUM 120 SYRINGE/U-100/0.5ML/30G XEASY COMFORT INSULIN EASY TOUCH CONTROL 1/2" 128SYRINGE/1ML/30G X SOLUTION/HIGH & LOW106 EASY TOUCH INSULIN5/16" 127 EASY TOUCH FLIPLOCK SYRINGE/U-100/0.5ML/31G XEASY COMFORT INSULIN SAFETY INSULIN SYRINGE 5/16" 128SYRINGE/1ML/31G X 1ML/29GX1/2" 127 EASY TOUCH INSULIN5/16" 127 EASY TOUCH FLIPLOCK SYRINGE/U-100/1ML/27G XEASY COMFORT INSULIN SAFETY INSULIN SYRINGE 1/2" 128SYRINGE/U-100/0.5ML/30G X 1ML/30GX1/2" 127 EASY TOUCH INSULIN1/2" 127 EASY TOUCH FLIPLOCK SYRINGE/U-100/1ML/28G XEASY COMFORT INSULIN SAFETY INSULIN SYRINGE 1/2" 128SYRINGE/U-100/1ML/30G X 1ML/30GX5/16" 127 EASY TOUCH INSULIN1/2" 127 EASY TOUCH FLIPLOCK SYRINGE/U-100/1ML/29G XEASY COMFORT SAFETY INSULIN SYRINGE 1/2" 128LANCETS 106 1ML/31GX5/16" 128 EASY TOUCH INSULINEASY COMFORT LANCETS EASY TOUCH GLUCOSE SYRINGE/U-100/1ML/30G X30G/PULL TOP 106 TEST STRIPS 85 1/2" 128EASY COMFORT LANCETS EASY TOUCH HEALTHPRO EASY TOUCH INSULIN30G/THIN TOP 106 CONTROL SOLUTION/HIGH & SYRINGE/U-100/1ML/31G XEASY COMFORT PEN LOW 106 5/16" 128NEEDLES31GX1/4" 127 EASY TOUCH HEALTHPRO EASY TOUCH LANCETSEASY COMFORT PEN GLUCOSE TEST STRIPS 85 21G/PRESSURENEEDLES31GX3/16" 127 EASY TOUCH INSULIN ACTIVATED 106EASY COMFORT PEN SYRINGE/0.3ML/30G X EASY TOUCH LANCETSNEEDLES31GX5/16" 127 5/16" 128 23G/PRESSUREEASY COMFORT PEN EASY TOUCH INSULIN ACTIVATED 106NEEDLES32GX5/32" 127 SYRINGE/0.3ML/31G X EASY TOUCH LANCETSEASY MINI EJECT LANCING 5/16" 128 26G/PRESSUREDEVICE 106 EASY TOUCH INSULIN ACTIVATED 106EASY MINI LANCING SYRINGE/0.5ML/29G X EASY TOUCH LANCETSDEVICE 106 1/2" 128 26G/PULL-TOP 106EASY PLUS BLOOD GLUCOSE EASY TOUCH INSULIN EASY TOUCH LANCETSTEST STRIPS 85 SYRINGE/0.5ML/30G X 26G/TWIST 106EASY PLUS II BLOOD 5/16" 128 EASY TOUCH LANCETSGLUCOSE TEST 85 EASY TOUCH INSULIN 28G/PRESSUREEASY PLUS II CONTROL SYRINGE/1ML/30G X ACTIVATED 106SOLUTION HIGH 106 5/16" 128 EASY TOUCH LANCETSEASY PLUS II CONTROL EASY TOUCH INSULIN 28G/PULL-TOP 106SOLUTION LOW 106 SYRINGE/SAFETY/U- EASY TOUCH LANCETSEASY STEP CONTROL 100/0.5ML/29G X 1/2" 128 28G/TWIST 106SOLUTION HIGH 106 EASY TOUCH INSULIN EASY TOUCH LANCETSEASY STEP CONTROL SYRINGE/SAFETY/U- 30G/BUTTON-ACTIVATEDSOLUTION LOW 106 100/0.5ML/30G X 5/16" 128 106EASY STEP CONTROL EASY TOUCH INSULIN EASY TOUCH LANCETSSOLUTION NORMAL 106 SYRINGE/SAFETY/U- 30G/PRESSUREEASY STEP TEST STRIPS 85 100/1ML/29G X 1/2" 128 ACTIVATED 107
Index 17
EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK EDARBYCLOR 35 30G/PULL-TOP 107 SAFETY SYRINGE EDECRIN 90EASY TOUCH LANCETS 1ML/30GX1/2" 129 EDLUAR 9830G/TWIST 107 EASY TRAK BLOOD EASY TOUCH LANCETS GLUCOSE TEST STRIPS 85 EDURANT 44 32G/PRESSURE EASY TRAK GLUCOSE EFFEXOR XR 24ACTIVATED 107 CONTROLSOLUTION EFFIENT 96EASY TOUCH LANCETS HIGH 107 EFLOW SCF AEROSOL32G/PULL-TOP 107 EASY TRAK GLUCOSE
HEAD 151EASY TOUCH LANCETS CONTROLSOLUTION 32G/TWIST 107 LOW 107 EFUDEX 60 EASY TOUCH LANCETS EASY TRAK GLUCOSE ELASTO-GEL 12"X12" 78 33G/TWIST 107 CONTROLSOLUTION ELASTO-GEL 2"X3" 78EASY TOUCH LANCING NORMAL 107 ELASTO-GEL 3" ROUND 78DEVICE/EJECTOR 107 EASY TWIST & CAP EASY TOUCH PEN NEEDLE LANCETS 107 ELASTO-GEL 4"X4" 78 30G X 5/16" 128 85 78EASYGLUCO ELASTO-GEL 5"X5"EASY TOUCH PEN NEEDLES EASYGLUCO CONTROL ELASTO-GEL 6"X8" 7929GX1/2" 128 SOLUTION HIGH 107EASY TOUCH PEN NEEDLES ELASTO-GEL 8"X16" 79EASYGLUCO CONTROL31GX1/4" 128 ELASTO-GEL CAST/SPLINTSOLUTION LOW 107EASY TOUCH PEN NEEDLES 12"X12" 79EASYGLUCO CONTROL31GX5/16" 128 ELASTO-GEL CAST/SPLINTSOLUTION NORMAL 107EASY TOUCH PEN NEEDLES 4"X4" 79EASYGLUCO PLUS 8532GX1/4" 128 ELASTO-GEL CAST/SPLINTEASYGLUCO PLUSEASY TOUCH PEN NEEDLES 6"X8" 79CONTROL SOLUTION LEVEL32GX3/16" 128 ELASTO-GEL CAST/SPLINT
1 107EASY TOUCH PEN NEEDLES 8"X16" 79EASYMAX 15 LEVEL 132GX5/32" 128 ELASTO-GEL FACE MASK 79GLUCOSE CONTROLEASY TOUCH PEN ELASTO-GEL PLUS 2"X3" 79NEEDLES/31G X 3/16" 128 SOLUTION 107 EASYMAX 15 LEVEL 2 ELASTO-GEL PLUS 4"X4" 79EASY TOUCH SAFETY
LANCETS21G/PRESSURE GLUCOSE CONTROL ELASTO-GEL PLUS 8"X8" 79SOLUTION 107ACTIVATED 107 ELAVIL 24EASYMAX 15 TESTEASY TOUCH SAFETY ELDEPRYL 40LANCETS23G/PRESSURE STRIPS 85 EASYMAX CONTROL ELDERTONIC 168ACTIVATED 107 SOLUTIONHIGH 107EASY TOUCH SAFETY ELEMENT COMPACTEASYMAX CONTROLLANCETS26G/BUTTON CONTROL SOLUTION LEVELSOLUTIONLOW 107ACTIVATED 107 2 107EASYMAX CONTROLEASY TOUCH SAFETY ELEMENT COMPACTSOLUTIONNORMAL 107LANCETS26G/PRESSURE CONTROL SOLUTION LEVEL EASYMAX TEST STRIPS 85ACTIVATED 107 3 107
EASY TOUCH SAFETY EASYPLUS BLOOD ELEMENT COMPACT TEST LANCETS28G/BUTTON GLUCOSE TEST STRIP 85 STRIPS 85 ACTIVATED 107 EASYPRO BLOOD GLUCOSE ELEMENT HIGH EASY TOUCH SAFETY TEST STRIPS 85 CONTROL 107 LANCETS28G/PRESSURE EASYPRO PLUS 85 ELEMENT LOW ACTIVATED 107 CONTROL 107EASYTEST II LANCETS 107EASY TOUCH SHEATHLOCK ELEMENT NORMALEASYTEST LANCETS 107SAFETY INSULIN SYRINGE CONTROL 107
EBASE CONTROLLER1ML/29GX1/2" 128 ELEMENT TEST STRIPS 85KIT 151EASY TOUCH SHEATHLOCK ELESTAT 230SAFETY INSULIN SYRINGE EC-NAPROSYN 6
eletriptan hydrobromide 1541ML/30GX5/16" 129 econazole nitrate 59 EASY TOUCH SHEATHLOCK ELEXA NATURAL FEEL 101ECOTRIN REGULARSAFETY INSULIN SYRINGE ELEXA STIMULATING 101STRENGTH 81ML/31GX5/16" 129 EDARBI 34 ELEXA ULTRA SENSITIVE101
Index 18
ELIDEL 72 EMBRACE CONTROL enalapril maleate &SOLUTIONLOW 107 hydrochlorothiazide 35ELIMITE 75 EMBRACE EVO BLOOD ENBRACE HR 213ELIPHOS 95 GLUCOSETEST STRIPS 85 ENBREL 7ELIQUIS 18 EMBRACE EVO GLUCOSE
ENBREL MINI 7ELITE DC AUTO CONTROL SOLUTION LEVEL ADAPTER 151 1 107 ENBREL SURECLICK 7
EMBRACE EVO GLUCOSE END FATIGUE DAILYELITE-OB 213 CONTROL SOLUTION LEVEL ENERGYENFUSION 168ELITE-THIN INSULIN 2 107SYRINGE/0.3ML/31G X ENERGY BOOSTER 168EMBRACE GLUCOSE5/16" 129 ENFAMIL ENFALYTE 156CONTROL SOLUTIONELITE-THIN INSULIN ENFAMIL EXPECTA 213HIGH 108SYRINGE/0.5ML/29G X EMBRACE LANCETS ULTRA enoxaparin sodium 181/2" 129 THIN 30G 108ELITE-THIN INSULIN ENSTILAR 63EMBRACE PRO BLOODSYRINGE/0.5ML/30G X entacapone 39GLUCOSETEST STRIPS 855/16" 129 EMBRACE PRO GLUCOSE entecavir 46ELITE-THIN INSULIN CONTROL SOLUTION 108SYRINGE/1ML/30G X ENTRESTO 49 EMCYT 385/16" 129 EPANED 34
ELITE-THIN INSULIN EMEND 30 EPCLUSA 46SYRINGE/U-100/0.5ML/28G X EMEND TRIPACK 30 EPIDUO 561/2" 129 EMERGEN-C BLUE 168ELITE-THIN INSULIN EPIDUO FORTE 56 SYRINGE/U-100/0.5ML/31G X EMERGEN-C FIVE 168 EPIFOAM 63 5/16" 129 EMERGEN-C HEART EPILYT 67ELITE-THIN INSULIN HEALTH 168
epinastine hcl (ophth) 230SYRINGE/U-100/1ML/28G X EMERGEN-C IMMUNE 168 1/2" 129 EMERGEN-C IMMUNE EPINEPHRINE 242 ELITE-THIN INSULIN PLUS 168 epinephrine (anaphylaxis) 242SYRINGE/U-100/1ML/29G X EMERGEN-C IMMUNE EPIPEN 2-PAK 2421/2" 129 PLUS/VITAMIN D 168 ELITE-THIN INSULIN EMERGEN-C IMMUNE+ EPIPEN-JR 2-PAK 242 SYRINGE/U-100/1ML/31G X WARMERS 168 EPIVIR 44 5/16" 129 EMERGEN-C JOINT EPIVIR HBV 46ELIXOPHYLLIN 18 HEALTH 168 eplerenone 36ELLA 52 EMERGEN-C KIDZ 168
EPOGEN 96ELLIS TONIC 168 EMERGEN-C MSM LITE 168
EPROSARTAN MESYLATE 34ELMIRON 95 EMERGEN-C PINK 168
EPZICOM 44EMERGEN-C SUPERELOCON 63 EQ BLOOD GLUCOSE TESTFRUIT 168ELON MATRIX 5000 219 STRIPS 85EMERGEN-C VITAMIN C168 EQ COMPLETEELON MATRIX PLUS 219 EMERGEN-C VITAMIN C MULTIVITAMINADULTS UNDERELON MATRIX 5000 LITE 168 50 168COMPLETE 219 EMERGEN-C VITAMIN D & EQ MULTIVITAMINS ADULTELON MATRIX CALCIUM 168 GUMMY 168COMPLETE 219 EMETROL 29 EQ ONE DAILY MENS 50+ 168ELON R3 219 EMLA 74 EQ ONE DAILY MENSELON SKIN REPAIR EMOLLIA-CREME 67 HEALTH 168SYSTEM 67 EQ ONE DAILY WOMENSELTA 67 EMOLLIA-LOTION 67 50+ 168ELTA DERMAL WOUND emollient 67 EQ ONE DAILY WOMENSDRESSING 79 EMSAM 22 HEALTH 168
EMADINE 230 EMTRIVA 44 EQ THERAPEUTIC EMBEDA 9 MOISTURIZING CREAM 67ENABLEX 239EMBRACE BLOOD GLUCOSE EQL ADVANCED RECOVERY
enalapril maleate 34TEST STRIPS 85 SKIN CARE 67
Index 19
EQL ALCOHOL SWABS 120 EQL PROTECTAVISION 168 estazolam 98 EQL CENTURY MATURE EQL SHORT PEN NEEDLES ESTER-C 163 ADULTS50+ 168 31G X 8MM 129 ESTRACE 92,241EQL CENTURY MENS 168 EQL SUPER ENERGY
estradiol 93BOOSTER 168EQL CENTURY WOMENS 168 EQL SUPER THIN LANCETS estradiol & norethindroneEQL COLOR LANCETS 30G 108 acetate 9221G 108 EQL THIN LANCETS ESTROPIPATE 93EQL COLOR LANCETS MICRO 26G 108 ESTROSTEP FE 50THIN 33G 108 EQL TRUETEST BLOODEQL DRY MOUTH ORAL eszopiclone 98GLUCOSE TEST 85RINSE 160 EQL TRUETRACK TEST 85 ethacrynic acid 90EQL INSULIN
EQL ULTRA COMFORT ethambutol hcl 37SYRINGE/0.3ML/29G XINSULINSYRINGE/0.3ML/31G ethosuximide1/2" 129 22
EQL INSULIN X 5/16" 129 ethynodiol diacet & ethEQL ULTRA COMFORTSYRINGE/0.3ML/30G X estrad 50INSULINSYRINGE/1ML/30G X5/16" 129 ETHYOL 39
EQL INSULIN 5/16" 129 ETIDRONATE DISODIUM 91EQL ULTRA MOISTURIZINGSYRINGE/0.3ML/31G XDAILY LOTION 68 etodolac 65/16" 129 EQL ULTRA SHORT PENEQL INSULIN EUCERIN 68NEEDLES 31G X 6MM 129SYRINGE/0.5ML/29G X EUCERIN BABY 68
1/2" 129 EQUALYTE 156 EUCERIN CALMING DAILYEQL INSULIN EQUETRO 41 MOISTURIZER 68SYRINGE/0.5ML/30G X ergocalciferol 242 EUCERIN DAILY5/16" 129 ERGOLOID PROTECTION/SPF 30 68EQL INSULIN MESYLATES 234 EUCERIN INTENSIVESYRINGE/0.5ML/31G X REPAIR 68ERGOMAR 1545/16" 129 EUCERIN INTENSIVEEQL INSULIN ergotamine w/ caffeine 154 REPAIRHAND 68SYRINGE/1ML/29G X 1/2" 129 ERIVEDGE 37 EUCERIN ORIGINALEQL INSULIN ERTACZO 59 HEALINGSOOTHINGSYRINGE/1ML/30G X REPAIR 68ERY-TAB 1005/16" 129 EUCERIN PLUS 68EQL INSULIN ERYGEL 56 EUCERIN PLUS INTENSIVESYRINGE/1ML/31G X ERYPED 200 100 REPAIR 685/16" 129 ERYPED 400 100 EUCERIN SKIN CALMINGEQL INSULIN SYRINGE/U-
ERYTHROCIN DAILY MOISTURIZING 68100/0.3ML/29G X 1/2" 129 EUCERIN SMOOTHINGEQL INSULIN SYRINGE/U- STEARATE 100 REPAIRADVANCED100/0.5ML/29G X 1/2" 129 erythromycin (acne aid) 56 FORMULA 68EQL INSULIN SYRINGE/U- erythromycin (ophth) 228 EUCRISA 75100/1ML/29G X 1/2" 129 erythromycin base 100EQL MEGA SELECT EURAX 75
ERYTHROMYCIN BASE 100MENS 168 EVAC 99EQL MEGA SELECT erythromycinEVEKEO 2WOMENS 168 ethylsuccinate 100
EQL MOISTURIZING ERYTHROMYCIN EVENCARE + BLOOD ETHYLSUCCINATE 100 GLUCOSETEST STRIP 85CREAM 67
EVENCARE BLOOD GLUCOSEEQL ONE DAILY ADULT ESBRIET 235 TEST STRIP 85GUMMIES 168 ESCAVITE LQ 209 EVENCARE CONTROLEQL ONE DAILY DIET escitalopram oxalate 23 SOLUTION 108SUPPORT 168
ESGIC 7 EVENCARE G2 GLUCOSEEQL ONE DAILY MENS 168 CONTROL SOLUTION/LOW-EQL ONE DAILY MENS 50+ esomeprazoleADVANCED 168 magnesium 237 HIGH 108
EVENCARE G2 TESTESOMEPRAZOLEEQL PRENATAL STRIPS 85STRONTIUM 237FORMULA 213
Index 20
EVENCARE G3 GLUCOSE EXEL COMFORT POINT EZ SMART BLOOD GLUCOSE CONTROL SOLUTION/LOW- INSULIN SYRINGE/1ML/29G X LANCETS 108 HIGH 108 1/2" 130 EZ SMART BLOOD GLUCOSE EVENCARE G3 TEST EXEL COMFORT POINT TEST STRIPS 85 STRIPS 85 INSULIN SYRINGE/1ML/30G X EZ SMART PLUS BLOOD EVENCARE MINI BLOOD 5/16" 130 GLUCOSE TEST STRIPS 85 GLUCOSE TEST STRIPS 85 EXELDERM 59 EZ-LETS LANCETS 21G 108 EVENCARE MINI GLUCOSE EXELON 232 EZ-LETS LANCETS 23G 108CONTROL SOLUTION EZ-LETS LANCETS 26Gexemestane 38NORMAL 108 SUPER-SOFT 108EVISTA 92 EXFORGE 35 EZ-LETS LANCETS 28G EVOCLIN 56 EXFORGE HCT 35 ULTRA-SOFT 108 EVOLUTION AUTOCODE 85 EXTAVIA 233 EZ-LETS LANCETS 30G 108 EVOLUTION CONTROL EXTINA 59 ezetimibe 33 SOLUTION NORMAL 108 EXTRA SENSITIVE ezetimibe-simvastatin 32EVOTAZ 44 SPERMICIDAL 101 EZFE FORTE 213EVZIO 29 EXTRA-VIRT PLUS DHA 213 FABIOR 56EX-LAX MAXIMUM EXU-DRY 15"X18" 79 famciclovir 46STRENGTH 100 EXU-DRY 15"X24" 79EXACTECH R-S-G TEST famotidine 237EXU-DRY 20"X28" 79STRIPS 85 FAMVIR 46EXU-DRY 3"X4" 79EXACTECH TEST STRIPS 85 FANAPT 41EXU-DRY 4"X6" 79EXALGO 9 FANAPT TITRATION PACK 41EXCEDRIN EXTRA EXU-DRY 6"X9" 79 FANATREX FUSEPAQ 19STRENGTH 7 EXU-DRY 9"X15" 79 EXCEDRIN MENSTRUAL FANTASY LUBRICATED 101EXU-DRY ARM 27"X31" 79COMPLETE 7 FANTASYEXU-DRY ARM/SHOULDEREXCEDRIN MIGRAINE 7 LUBRICATED/SPERMICIDETIES 27"X31" 79 101EXEL COMFORT POINT EXU-DRY BURN JACKETINSULIN PEN NEEDLES 29G X FARESTON 3831"X32" 7912MM 129 EXU-DRY BURN JACKET FARXIGA 28 EXEL COMFORT POINT CHILD 17"X20" 79 FARYDAK 38INSULIN PEN NEEDLES 31G X EXU-DRY BUTTOCKS FAZACLO 426MM 130 23"X53" 79EXEL COMFORT POINT felbamate 21EXU-DRYINSULIN PEN NEEDLES 31G X ELBOW/KNEE/HEEL FELBATOL 21 8MM 130 10"X17" 79 FELDENE 6EXEL COMFORT POINT EXU-DRY FACE 9"X14" 79INSULIN SYRINGE/0.3ML/29G X felodipine 48
EXU-DRY INCISION 3"X9"791/2" 130 FEM-CAL CITRATE 157 EXEL COMFORT POINT EXU-DRY NON-PERMEABLE FEMARA 38INSULIN SYRINGE/0.3ML/30G X PAD 24"X36" 79 5/16" 130 EXU-DRY PADDED HAND FEMCON FE 50 EXEL COMFORT POINT 12"X13" 79 FENOFIBRATE 33 INSULIN SYRINGE/0.5ML/28G X EXU-DRY PADDED HAND fenofibrate 33 1/2" 130 CHILD 8"X8" 79 fenofibrate micronized 33EXU-DRY PADDED NECKEXEL COMFORT POINT
6"X25" 79 FENOFIBRIC ACID 33INSULIN SYRINGE/0.5ML/29G X1/2" 130 EXU-DRY PERMEABLE PAD FENOGLIDE 33
24"X36" 79EXEL COMFORT POINT FENOPROFEN CALCIUM 6INSULIN SYRINGE/0.5ML/30G X EXU-DRY SCALP 3"X14" 79
fenoprofen calcium 65/16" 130 EXU-DRY SLIT TUBE EXEL COMFORT POINT 2"X3" 79 FENORTHO 6 INSULIN SYRINGE/1ML/28G X EYE HEALTH 168 fentanyl 9 1/2" 130 EYEAID IRRIGATING FENTANYL 9
SOLUTION 230 fentanyl citrate 9
Index 21
FENTORA 9 FIFTY50 PEN FLONASE ALLERGY RELIEF NEEDLES/32GX6MM 130 CHILDRENS 224FEOSOL 97 FIFTY50 SAFETY SEAL FLONASE SENSIMIST 224FER-IN-SOL 97 LANCETS 30G 108 FLORIVA PLUS 208FERGON 97 FIFTY50 SAFETY SEAL
FLOVENT DISKUS 17LANCETS 32G 108ferrous fumarate 97 FIFTY50 SUPERIOR FLOVENT HFA 17ferrous fumarate-fa-b complex-c-zn-mg-mn-cu 97 COMFORTINSULIN FLOXIN OTIC 231
SYRINGE/0.3ML/31G XFERROUS GLUCONATE 97 FLUAD 2016-2017 2405/16" 130 ferrous gluconate 97 FIFTY50 SUPERIOR FLUAD 2017-2018 240 ferrous sulfate 97 COMFORTINSULIN FLUARIX QUADRIVALENT
SYRINGE/0.5ML/31G X 2015-2016 240FERROUS SULFATE 97 5/16" 130 FLUARIX QUADRIVALENTferrous sulfate 97 FIFTY50 SUPERIOR 2016-2017 240 FERROUS SULFATE 97 COMFORTINSULIN FLUARIX QUADRIVALENT ferrous sulfate 97 SYRINGE/1ML/31G X 2017-2018 240
5/16" 130 FLUBLOK 2015-2016 240FERROUS SULFATE 97 FIFTY50 UNILET LANCETS FLUBLOK 2016-2017 240ferrous sulfate 97 33G 108 FLUCELVAX QUADRIVALENTFERROUS SULFATE 97 FILTER AIR PP 151 2016-2017 240 ferrous sulfate dried 97 finasteride 95 FLUCELVAX QUADRIVALENT
2017-2018 240FETZIMA 24 FINE 30 108 fluconazole 30FETZIMA TITRATION PACK24 FINGERSTIX LANCETS 108 flucytosine 30FEVERALL INFANTS 8 FIORINAL 7 fludrocortisone acetate 53FEXMID 223 FIORINAL/CODEINE #3 11 FLULAVAL QUADRIVALENTfexofenadine hcl 31 FITNESS TABS FOR MEN 2014-2015 240AM/PM/LYCOPENE 168FIASP 27 FLULAVAL QUADRIVALENTFITNESS TABS FOR WOMENFIASP FLEXTOUCH 27 2015-2016 240AM/PM/LYCOPENE 169 FLULAVAL QUADRIVALENTFIBERCON 99 FLAGYL 14 2016-2017 240FIBRACOL COLLAGEN- FLAREX 229 FLULAVAL QUADRIVALENTALGINATE WOUND flavoxate hcl 239 2017-2018 240DRESSING/2" X 2" 79 FLUMADINE 47FIBRACOL COLLAGEN- flecainide acetate 16
ALGINATE WOUND FLUNISOLIDE 224FLECTOR 58DRESSING/4" X 8-3/4" 79 fluocinolone acetonide 63FLEET ENEMA 99FIBRICOR 33 fluocinolone acetonideFLEET ENEMA SIX PACK 99FIFTY50 ALCOHOL PREP (otic) 231
FLEET PEDIATRIC 99PADS 120 fluocinonide 63 FIFTY50 CONTROL FLEXICHAMBER 151 fluocinonide emulsified base 63SOLUTION2.0 108 FLINTSTONESFIFTY50 GLUCOSE TEST fluorometholone (ophth) 229GUMMIES 209STRIP 2.0 86 FLINTSTONES GUMMIES FLUOROURACIL 60 FIFTY50 LANCING COMPLETE 209 fluorouracil (topical) 60DEVICE 108 FLINTSTONES GUMMIES FLUOXETINE 234FIFTY50 PEN NEEDLES 31G PLUSIMMUNITYX3/16" (5MM) 130 SUPPORT/EXTRA C 209 FLUOXETINE DR 23 FIFTY50 PEN NEEDLES 31G FLINTSTONES SOUR fluoxetine hcl 23 X5/16" (8MM) 130 GUMMIES 209 FLUOXETINE HCL 23FIFTY50 PEN NEEDLES FLINTSTONES fluphenazine decanoate 4231GX5MM 130 TODDLER/TASTISMOOTHFIFTY50 PEN 209 FLUPHENAZINE HCL 42,43NEEDLES/31GX8MM 130 FLOMAX 95 fluphenazine hcl 43FIFTY50 PEN FLONASE ALLERGY flurandrenolide 63NEEDLES/32GX4MM 130 RELIEF 224 FLURAZEPAM HCL 98
Index 22
flurbiprofen 6 folic acid 96 FORMULA 405 ENRICHED EYE 68FLURBIPROFEN SODIUM 230 folic acid-vitamin b6-vitamin FORMULA 405 FACEb12 97flurbiprofen sodium 230 CREAM 68FOLIVANE-OB 213flutamide 38 FORMULA 405 LIGHT
fondaparinux sodium 19 TEXTURED MOISTURIZER 68fluticasone propionate 63 FORA BLOOD GLUCOSE FORMULA 405fluticasone propionate TEST STRIPS 86 MOISTURIZING 68(nasal) 224 FORA CONTROL SOLUTION FORTAMET 25FLUTICASONE HIGH 108PROPIONATE/SALMETEROL FORTAVIT 169FORA CONTROL SOLUTION17 LOW 108 FORTEO 91
fluvastatin sodium 33 FORA CONTROL SOLUTION FORTESTA 12 FLUVIRIN 2015-2016 240 NORMAL 108 FORTICAL 91FORA D15G BLOODFLUVIRIN 2016-2017 240 FORTISCARE BLOODGLUCOSE TEST STRIPS 86FLUVIRIN 2017-2018 240 GLUCOSETEST STRIP 86FORA D20 BLOOD GLUCOSE FORTISCARE CONTROLfluvoxamine maleate 23 TEST STRIPS 86 SOLUTIONS HIGH 108FLUZONE HIGH-DOSE PF 2015- FORA D40/G31 BLOOD FORTISCARE CONTROL2016 240 GLUCOSE TEST STRIPS 86 SOLUTIONS LOW 108FLUZONE HIGH-DOSE PF 2016- FORA G20 BLOOD GLUCOSE FORTISCARE CONTROL2017 240 TEST STRIPS 86 SOLUTIONS NORMAL 108FLUZONE HIGH-DOSE PF 2017- FORA G30A BLOOD FOSAMAX 912018 240 GLUCOSE TEST STRIPS 86 FLUZONE INTRADERMAL FORA GD20 TEST FOSAMAX PLUS D 91 QUADRIVALENT 2015- STRIPS 86 fosamprenavir calcium 44 2016 240 FORA GD50 BLOOD FOSFREE 169FLUZONE INTRADERMAL GLUCOSE TEST STRIPS 86 QUADRIVALENT 2016- FORA LANCETS 108 fosinopril sodium 34 2017 241 fosinopril sodium &FORA LANCING DEVICE108 hydrochlorothiazide 35FLUZONE INTRADERMAL FORA LANCINGQUADRIVALENT 2017- fosphenytoin sodium 21DEVICE/CLEARCAP 1082018 241 FORA TN'G/TN'G VOICE FOSRENOL 95FLUZONE QUADRIVALENT BLOOD GLUCOSE TEST FRAGMIN 192015-2016 241 STRIPS 86 FREDS PHARMACY AUTOLETFLUZONE QUADRIVALENT FORA V10 BLOOD GLUCOSE LANCING DEVICE 1092016-2017 241 TEST STRIPS 86 FREDS PHARMACY UNIFINEFLUZONE QUADRIVALENT FORA V12 BLOOD GLUCOSE PENTIPS PEN NEEDLES2017-2018 241 TEST STRIPS 86FLUZONE SPLIT 2015- 32GX4MM 130FORA V20 BLOOD GLUCOSE FREDS PHARMACY UNIFINE2016 241 TEST STRIPS 86 PENTIPS PLUS 31GX5MM130FML 229 FORA V30A BLOOD FREDS PHARMACY UNIFINEFML FORTE 229 GLUCOSE TEST STRIPS 86 PENTIPS PLUS 31GX8MM130 FML LIQUIFILM 229 FORACARE GD40 86 FREDS PHARMACY UNILET FOAM DRESSING FORACARE GDH CONTROL LANCETS SUPER THIN BORDERED 79 SOLUTION HIGH 108 30G 109 FOAM DRESSING CIRCULAR FORACARE GDH CONTROL FREDS PHARMACY UNILET BORDERED 79 SOLUTION LOW 108 LANCETS ULTRA THIN FOAM DRESSING NON- FORACARE GDH CONTROL 28G 109 BORDERED 79 SOLUTION NORMAL 108 FREEDAVITE 169
FORACARE PREMIUM V10FOCALGIN 90 DHA 213 FREESTYLE CONTROLTESTSTRIPS 86FOCALGIN CA 213 SOLUTION 109FORACARE TEST N GO TEST FREESTYLE CONTROLFOCALIN 3 STRIPS 86 SOLUTION HIGH/LOW 109FOCALIN XR 3 FORADIL AEROLIZER 17 FREESTYLE INSULINX FOLCAL DHA 213 FORFIVO XL 22 BLOODGLUCOSE TEST 86 FOLCAPS OMEGA 3 213 formaldehyde 43 FOLIC ACID 96
Index 23
FREESTYLE INSULINXBLOODGLUCOSE TESTSTRIPS 86 FREESTYLE LANCETS 109 FREESTYLE LITE TESTSTRIPS 86 FREESTYLE PRECISIONINSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 130 FREESTYLE PRECISIONINSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 130 FREESTYLE PRECISIONINSULIN SYRINGE/U-100/1ML/31G X 5/16" 130 FREESTYLE PRECISIONINSULIN SYRINGES/U-100/1ML/30G X 5/16" 130 FREESTYLE PRECISION NEOBLOOD GLUCOSE TESTSTRIPS 86 FREESTYLE TEST STRIPS 86 FREESTYLE UNISTICK IILANCETS 109 FROVA 154 frovatriptan succinate 154 fructose-dextrose-phosphoricacid 30 FRUIT C 200 163 FULL KIT NEBULIZERSET 151 FUNGOID TINCTURE 59 FURADANTIN 238 furosemide 90 FUROSEMIDE 90 furosemide 90 FYCOMPA 19 gabapentin 19 GABITRIL 21 GABLOFEN 223 galantamine hydrobromide 232 GALANTAMINEHYDROBROMIDE 232 galantamine hydrobromide 232 GAS-X 93 GAS-X EXTRA STRENGTH 93 gatifloxacin (ophth) 228 GE100 BLOOD GLUCOSETESTSTRIPS 86 GE100 CONTROL SOLUTIONNORMAL 109 GELNIQUE 239 GELNIQUE PUMP 239
gemfibrozil 33 GENERESS FE 50 GENOTROPIN 91 GENOTROPINMINIQUICK 91 GENSTRIP 50 86 GENTAK 228 GENTAMICIN SULFATE 58 gentamicin sulfate(ophth) 228 gentamicin sulfate (topical) 58 GENTEAL 226 GENTEAL MILD 226 GENTEAL MILD TOMODERATE 226 GENTEAL SEVERE 226 GENTEAL TEARSMODERATEPF 226 GENTLE 68 GENTLE-LET GPLANCETS 109 GENTLE-LET LANCETSGENERAL PURPOSESTYLE/FINE POINT 109 GENTLE-LET LANCETSGENERAL PURPOSESTYLE/MEDIUM POINT 109 GENTLE-LET LANCETSSAFETY STYLE/FINEPOINT 109 GENTLE-LET LANCETSSAFETY STYLE/MEDIUMPOINT 109 GENVOYA 44 GEODON 41 GERI PROTECT 74 GERI-FREEDA SENIORFORMULA 169 GERI-SOFT 68 GHT TEST STRIPS 86 GIAZO 94 GILENYA 233 GILOTRIF 38 glatiramer acetate 233 GLEEVEC 38 GLEOSTINE 37 glimepiride 28 glipizide 28 glipizide-metformin hcl 25 GLOBAL ALCOHOL PREPEASEPADS 120
GLOBAL EASE INJECT PENNEEDLES 29GX12MM 130 GLOBAL EASE INJECT PENNEEDLES 31GX8MM 131 GLOBAL EASE INJECT PENNEEDLES 32GX4MM 131 GLOBAL EASE INJECT PENNEEEDLES 31GX5MM 131 GLOBAL EASY GLIDEINSULINSYRINGE/U-100/0.3ML/31G X 5/16" 131 GLOBAL EASY GLIDE PENNEEDLES 32GX4MM 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.3ML/29G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.3ML/30G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.3ML/30G X5/16" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.3ML/31G X5/16" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/28G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/29G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/30G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/30G X5/16" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/31G X5/16" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/28G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/29G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/30G X1/2" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/30G X5/16" 131 GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/31G X5/16" 131 GLOBAL INJECT EASELANCETS 28G 109 GLOBAL INJECT EASELANCETS 30G 109
Index 24
GLOBAL INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" 131 GLOBAL INSULIN SYRINGES/U-100/0.3ML/30GX5/16" 131 GLOBAL LANCING DEVICE 109 GLUCAGEN DIAGNOSTIC 83 GLUCAGEN HYPOKIT 26 GLUCAGON EMERGENCY KIT 26 GLUCO PERFECT 3 TEST STRIPS 86 GLUCOCARD 01 CONTROL SOLUTION NORMAL/HIGH 109 GLUCOCARD 01 CONTROL SOLUTION/NORMAL 109 GLUCOCARD 01 SENSOR PLUS 86 GLUCOCARD 01 SENSOR PLUSTEST STRIPS 86 GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS 86 GLUCOCARD EXPRESSION CONTROL SOLUTION LEVEL 1 109 GLUCOCARD SHINE CONTROL SOLUTION LEVEL 1 109 GLUCOCARD SHINE TEST STRIPS 86 GLUCOCARD VITAL TEST
GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 131 GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 131 GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 131 GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 132 GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 132 GLUCOPRO INSULIN SYRINGE/U-100/1ML/30G X1/2" 132 GLUCOPRO INSULIN SYRINGE/U-100/1ML/30G X5/16" 132 GLUCOPRO INSULIN SYRINGE/U-100/1ML/31G X5/16" 132 GLUCOSE 26 GLUCOSE CONTROL NORMAL 109 GLUCOSE CONTROL SOLUTION 109 GLUCOSE INSTANT ENERGY 26 GLUCOSE METER TEST
GMATE BLOOD GLUCOSE TESTSTRIPS 87 GMATE CONTROL SOLUTION LEVEL 2 109 GMATE LANCETS 30G 109 GMATE LANCING DEVICE109 GNP ADVANCED RECOVERY 68 GNP ALCOHOL SWABS 120 GNP CHILDRENS COMPLETE CHEWABLES 209 GNP CLICKFINE PEN NEEDLEUNIVERSAL/31GX5/16"
132 GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX1/4" 132 GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16" 132 GNP DAILY PRENATAL 213 GNP EASY TOUCH CONTROL SOLUTION HIGH/LOW 109 GNP EASY TOUCH GLUCOSE TEST STRIPS 87 GNP GLUCOSE 26 GNP INSULIN SYRINGE/0.3ML/29G X1/2" 132 GNP INSULIN SYRINGE/0.3ML/30G X5/16" 132 GNP INSULIN
STRIPS 86 GLUCOCARD X-METER CONTROLSOLUTION/NORMAL
109 GLUCOCARD X-SENSOR 86 GLUCOCOM HIGH CONTROL 109 GLUCOCOM LANCETS 28G 109 GLUCOCOM LANCETS 30G 109 GLUCOCOM LANCETS 33G 109 GLUCOCOM NORMAL CONTROL 109 GLUCOCOM TEST STRIPS 86 GLUCOLET 2 AUTOMATIC LANCING DEVICE 109 GLUCONAVII BLOOD GLUCOSETEST STRIPS 86 GLUCOPHAGE 25 GLUCOPHAGE XR 25 GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 131
STRIPS ADVANCED 87 GLUCOSOURCE LANCET DEVICE 109 GLUCOSOURCE LANCETS 109 GLUCOTROL 28 GLUCOTROL XL 28 GLUCOVANCE 25 GLUMETZA 25 glyburide 28 glyburide micronized 28 glyburide-metformin 25 GLYCERIN 50 glycerin (laxative) 99 glycerin (topical) 68 GLYCERIN ADULT 99 GLYCERINE 50 GLYCEROL FORMAL 50 glycopyrrolate 236 GLYNASE 28 GLYSET 24 GLYXAMBI 25
SYRINGE/0.3ML/31G X5/16" 132 GNP INSULIN SYRINGE/0.5ML/28G X1/2" 132 GNP INSULIN SYRINGE/0.5ML/29G X1/2" 132 GNP INSULIN SYRINGE/0.5ML/30G X5/16" 132 GNP INSULIN SYRINGE/0.5ML/31G X5/16" 132 GNP INSULIN SYRINGE/1ML/28G X 1/2" 132 GNP INSULIN SYRINGE/1ML/29G X 1/2" 132 GNP INSULIN SYRINGE/1ML/30G X5/16" 132 GNP INSULIN SYRINGE/1ML/31G X5/16" 132 GNP LANCETS 110 GNP LANCETS 21G 109
Index 25
GNP LANCETS MICRO THIN GOLD BOND ULTIMATE H-E-B IN CONTROL PEN 33G 110 DIABETICS' DRY RELIEF 68 NEEDLES/NANO/32GX4MMGNP LANCETS SUPER THIN GOLD BOND ULTIMATE 133 30G 110 HEALING 68 H-E-B IN CONTROL GNP LANCETS THIN 110 GOLD BOND ULTIMATE UNIFINEPENTIPS PLUS
PROTECTION 68 31GX5MM 133GNP LANCETS THIN 26G 110 GOLD BOND ULTIMATE H-E-B IN CONTROLGNP MICRO THIN LANCETS RESTORING 68 UNIFINEPENTIPS PLUS33G 110 GOLD BOND ULTIMATE 32GX4MM 133GNP PRENATAL 213 SHEERRIBBONS H-E-B INCONTROLGNP QUICK DISSOLVE PEARLRADIANCE 68 ADVANCEDLANCINGGLUCOSE 26 GOLD BOND ULTIMATE DEVICE 110GNP SUPER THIN SHEERRIBBONS H-E-B INCONTROL ALCOHOLLANCETS/30G 110 SILKSOFTNESS 68 PADS 120GNP ULTRA COMFORT GOLD BOND ULTIMATE H-E-B INCONTROL LANCETSINSULIN SYRINGE/0.3ML/29G X SOFTENING 69 MICRO THIN 33G 1101/2" 132 GOLD BOND ULTIMATE H-E-B INCONTROL LANCETSGNP ULTRA COMFORT SOOTHING 69 SUPER THIN 30G 110INSULIN SYRINGE/0.3ML/30G X H-E-B INCONTROL LANCETSGOLYTELY 995/16" SHORT 132 ULTRA THIN 28G 110GONAK 226GNP ULTRA COMFORT H-E-B INCONTROL PEN INSULIN SYRINGE/0.3ML/31G X GONIOSOL 226 NEEDLES 29GX12MM 133 5/16" SHORT 132 14GONITRO HAEMOLANCE 110GNP ULTRA COMFORT GOODSENSE GLUCOSE 26 HAEMOLANCE LOW FLOWINSULIN SYRINGE/0.5ML/28G X GOODSENSE LANCING LANCETS 1101/2" 132 DEVICE 110 HAEMOLANCE PLUS 110GNP ULTRA COMFORT GOODSENSE PRENATAL HAEMOLANCE PLUS HIGHINSULIN SYRINGE/0.5ML/29G X VITAMINS 213 FLOW 1101/2" 132 granisetron hcl 29 HAEMOLANCE PLUS LOWGNP ULTRA COMFORT
FLOW 110INSULIN SYRINGE/0.5ML/30G X GRANIX 96 HAEMOLANCE PLUS MAX5/16" SHORT 132 GRASTEK 4 FLOW 110GNP ULTRA COMFORT GREEN SOURCE 219 HAEMOLANCE PLUSINSULIN SYRINGE/0.5ML/31G X
GRIFULVIN V 30 PEDIATRIC FLOW 1105/16" SHORT 132 HAIR FARE 219GNP ULTRA COMFORT GRIS-PEG 30
INSULIN SYRINGE/1ML/28G X griseofulvin microsize 30 HAIR NOURISHING 1/2" 132 SUPPLEMENT 219griseofulvin ultramicrosize 30GNP ULTRA COMFORT HAIR-VITES 169GRX HYDROGEL GAUZEINSULIN SYRINGE/1ML/29G X HAIR/SKIN/NAILS 1692X2 791/2" 132 GRX HYDROGEL GAUZE HALCION 98GNP ULTRA COMFORT INSULIN SYRINGE/1ML/30G X 4X4 79 HALDOL 42
GRX VITAMIN E 695/16" SHORT 133 HALDOL DECANOATE 100 42 GNP ULTRA COMFORT guaifenesin 54 HALDOL DECANOATE 50 42INSULIN SYRINGE/1ML/31G X guaifenesin-codeine 53 halobetasol propionate 635/16" SHORT 133 guanfacine hcl 35GNP VITAMIN D-400 156 HALOG 63
guanfacine hcl (adhd) 3GOLD BOND 74 haloperidol 42 GYNAZOLE-1 241GOLD BOND EXTRA haloperidol decanoate 42
STRENGTH 74 GYNE-LOTRIMIN 241 haloperidol lactate 42GOLD BOND MEDICATED GYNE-LOTRIMIN 3 241 HARVONI 46BODYLOTION 68 H-E-B IN CONTROL PEN HEALTH CARE LANCINGGOLD BOND MEDICATED NEEDLES 31GX5MM 133 DEVICE 110BODYLOTION EXTRA H-E-B IN CONTROL PEN HEALTHWISE ALCOHOL PREPSTRENGTH 68 NEEDLES 31GX6MM 133 PADS 120GOLD BOND ULTIMATE 68 H-E-B IN CONTROL PEN HEALTHWISE LANCETS
NEEDLES 31GX8MM 133 30G 110
Index 26
HEALTHWISE LANCING HIPREX 238 HY-VEE LANCETS 110 PEN 110 HM COMPLETE 169 HY-VEE THIN LANCETS 110HEALTHWISE MINI PEN HM COMPLETE 50+ MENS HYALEX 169NEEDLES 31GX6MM 133 ULTIMATE 169HEALTHWISE PEN NEEDLES HYCAMTIN 39HM COMPLETE 50+29GX12MM 133 HYCOLOID-GRX 79WOMENS ULTIMATE 169HEALTHWISE SHORT PEN
HM ESTROPLUS 219 hydralazine hcl 36NEEDLES 31GX8MM 133 HEALTHWISE UNIFINE HM GLUCOSE 26 HYDRASYN25 69 PENTIPS PEN NEEDLES HYDREA 39HM HAIR/SKIN/NAILS 16932GX4MM 133 HM ONE DAILY HYDRO-LAN 69HEALTHY ACCENTS AUTOLET ESSENTIAL 164 HYDROCERIN 74IMPRESSION LANCING HM ONE DAILY MENS 169DEVICE 110 hydrochlorothiazide 90HM ONE DAILY PRENATALHEALTHY ACCENTS UNIFINE HYDROCIL INSTANT 99COMBO 213PENTIPS PEN NEEDLES HM ONE DAILY hydrocodone w/29GX12MM 133 WOMENS 169 homatropine 53HEALTHY ACCENTS UNIFINE hydrocodone-HM PRENATAL 213PENTIPS PEN NEEDLES acetaminophen 1131GX5MM 133 HONEY BEARS 213 hydrocodone-ibuprofen 11HEALTHY ACCENTS UNIFINE HUDSON RCI SEE-THRU HYDROCOL II 79PENTIPS PEN NEEDLES AEROSOL MASK 31GX6MM 133 ELONGATED/ADULT 151 HYDROCOL II SACRAL 80 HEALTHY ACCENTS UNIFINE HUMALOG 27 HYDROCOL II THIN 80PENTIPS PEN NEEDLES HUMALOG JUNIOR hydrocortisone 5231GX8MM 133 KWIKPEN 27HEALTHY ACCENTS UNIFINE hydrocortisone (intrarectal) 12
HUMALOG KWIKPEN 27PENTIPS PEN NEEDLES hydrocortisone (rectal) 13 32GX4MM 133 HUMALOG MIX 50/50 27 hydrocortisone (topical) 63HEALTHY ACCENTS UNILET HUMALOG MIX 50/50 hydrocortisone acetateLANCETS SUPER THIN KWIKPEN 27 (topical) 6330G 110 HUMALOG MIX 75/25 27 hydrocortisone butyrate 63HEALTHY HEART HUMALOG MIX 75/25COMPLEX 219 hydrocortisone butyrateKWIKPEN 27 hydrophilic lipo base 63HEALTHY KIDS GUMMIES209 HUMATROPE 91 hydrocortisone valerate 63HEALTHY LIVING HUMATROPE COMBOREPLACEMENT FILTERS 151 PACK 91 hydrocortisone w/aceticHEALTHY LIVING acid 231HUMIRA 5REPLACEMENT KIT FOR hydrocortisone-aloe vera 63HUMIRA PEDIATRIC CROHNSNEBULIZER 151 HYDROFERA BLUE 4"X4" 80DISEASE STARTER PACK 5HEALTHY LIVING HYDROFERA BLUE FOAMHUMIRA PEN 5REPLACEMENT MASKS 151 DRESSING 80HUMIRA PEN-CROHNSHEART 219 HYDROFERA BLUE FOAMDISEASESTARTER 5HEMANGEOL 47 DRESSING 2"X2" 80HUMIRA PEN-PSORIASIS HYDROFERA BLUE FOAMHEMENATAL OB 213 STARTER 5 DRESSING 4"X4" 80HEMENATAL OB + DHA 213 HUMULIN 70/30 27 HYDROFERA BLUE FOAM
HUMULIN 70/30HEMOCYTE 97 DRESSING 6"X6" 80KWIKPEN 27 HYDROFERA BLUE FOAMHEMOCYTE PLUS 97 HUMULIN N 27 DRESSING/MOISTUREheparin sodium (porcine) 19 HUMULIN N KWIKPEN 27 RETENTIVE FILM 80
HEPSERA 46 HYDROFERA BLUE FOAMHUMULIN R 27HETLIOZ 98 DRESSING/MOISTUREHUMULIN R U-500 RETENTIVE FILM/2-1/4X8 80HEXALEN 37 (CONCENTRATED) 27 HYDROFERA BLUE FOAMHIBICLENS 43 HUMULIN R U-500 DRESSING/MOISTUREHIGH SENSATION KWIKPEN 27 RETENTIVE FILM/4"X4" 80SPERMICIDAL 101 HY-VEE GLUCOSE 26
Index 27
HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE FILM/ISLAND 80 HYDROFERA BLUE FOAM DRESSING/MOISTURERETENTIVE/OSTOMY/2.5" 80 HYDROFERA BLUE FOAM DRESSING/TUNNELING/9MM
80 HYDROFERA BLUE HEAVY DRAINAGE 4"X4" 80 HYDROFERA BLUE HEAVY DRAINAGE 6"X6" 80 HYDROFERA BLUE READY FOAMDRESSING 2.5"X2.5" 80 HYDROFERA BLUE READY FOAMDRESSING 4"X5" 80 HYDROFERA BLUE READY FOAMDRESSING 8"X8" 80 hydromorphone hcl 9 HYDROMORPHONE HCL 9 hydromorphone hcl 9 hydroxychloroquine sulfate 36 hydroxyurea 39 HYDROXYZINE HCL 15 hydroxyzine hcl 15 HYDROXYZINE PAMOATE 15 hydroxyzine pamoate 15 hyoscyamine sulfate 236 HYPER-SAL 54 HYPERSAL 54 HYPOTEARS 226 hypromellose (gonioscopic) 226 hypromellose (ophth) 226 HYSINGLA ER 9 HYVEE ADVANCED ANTACID MAXIMUM STRENGTH 13 HYZAAR 35 ibandronate sodium 91 IBRANCE 38 IBUDONE 11 ibuprofen 6 ICAPS AREDS FORMULA 169 ICAPS PLUS 169 ICAR-C PLUS 97 ICLUSIG 38 IDHIFA 38 ILEVRO 230 imatinib mesylate 38 IMBRUVICA 38 imipramine hcl 24
imipramine pamoate 24 imiquimod 72 IMITREX 154,155 IMITREX STATDOSE REFILL 155 IMITREX STATDOSE SYSTEM 155 IMMUNE SUPPORT 169 IMMUNE SUPPORT VITAMIN C 169 IMODIUM A-D 29 IMURAN 158 IN TOUCH BLOOD GLUCOSE TEST STRIPS 87 IN TOUCH GLUCOSE CONTROLSOLUTION 110 IN TOUCH LANCING DEVICE 110 IN TOUCH STERILE LANCETS30G 110 INATAL ADVANCE 213 INATAL GT 213 INATAL ULTRA 214 INCRUSE ELLIPTA 16 indapamide 90 INDERAL LA 47 INDERAL XL 47 INDOCIN 6 indomethacin 6 INFANATE BALANCE 214 INFANTS ADVIL 6 INFINITY BLOOD GLUCOSE TEST STRIPS 87 INFINITY CONTROL SOLUTION HIGH 110 INFINITY CONTROL SOLUTION LOW 110 INFINITY CONTROL SOLUTION NORMAL 110 INGREZZA 233 INLYTA 38 INNOPRAN XL 47 INNOSPIRE REPLACEMENT FILTER 152 inositol niacinate 49 INSPIRACHAMBER/ANTI-STATIC VALVED/MOUTHPIECE 152 INSPIRACHAMBER/LARGE
152 INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM 152
INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL
152 INSPIREASE DRUG DELIVERYSYSTEM 152 INSPIREASE RESERVOIR BAGS 152 INSPRA 36 INSTA-GLUCOSE 26 INSULIN SYRINGE/0.3ML/29G X1" 133 INSULIN SYRINGE/0.3ML/29G X1/2" 133 INSULIN SYRINGE/0.3ML/30G X5/16" 133 INSULIN SYRINGE/0.3ML/31G X5/16" 133 INSULIN SYRINGE/0.5ML/27G X1/2" 133 INSULIN SYRINGE/0.5ML/28G X1/2" 133 INSULIN SYRINGE/0.5ML/29G X1/2" 133 INSULIN SYRINGE/0.5ML/30G X1/2" 133 INSULIN SYRINGE/0.5ML/30G X5/16" 133 INSULIN SYRINGE/0.5ML/31G X5/16" 133 INSULIN SYRINGE/1ML/28G X1/2" 134 INSULIN SYRINGE/1ML/29G X1/2" 134 INSULIN SYRINGE/1ML/30G X5/16" 134 INSULIN SYRINGE/1ML/31G X5/16" 134 INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 134 INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 134 INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 134 INSULIN SYRINGE/U-100/1ML/28G X 1/2" 134 INSULIN SYRINGE/U-100/1ML/29G X 1/2" 134 INSULIN SYRINGE/U-100/1ML/30G X 5/16" 134 INSULIN SYRINGE/U-100/1ML/31G X 5/16" 134 INSULIN SYRINGES/0.5ML/27GX1/2"
134 INSULIN SYRINGES/0.5ML/28GX1/2"
134
Index 28
INSULIN IOPIDINE 228 K-PAX IMMUNE SUPPORTSYRINGES/0.5ML/29GX1/2" FORMULA SINGLEipratropium bromide 16
134 STRENGTH 169ipratropium bromideINSULIN K-PHOS NEUTRAL 157(nasal) 224SYRINGES/0.5ML/30GX5/16" ipratropium-albuterol 17 K-TAB 158134 KADIAN 9INSULIN irbesartan 34
SYRINGES/0.5ML/31GX irbesartan-hydrochlorothiazide KALBITOR 96 5/16" 134 35 KALETRA 44INSULIN IRESSA 38 KALTOSTAT 80SYRINGES/0.5ML/31GX5/16" iron polysaccharide complex-vit KALTOSTAT FORTEX 80134 b12-folic acid 97INSULIN KALTOSTAT WOUNDiron-vitamin c-vitamin b12-folicSYRINGES/1ML/27GX/1/2" DRESSING 80acid 97
134 KALYDECO 235ISENTRESS 44INSULIN isometheptene-caffeine- KAMELEON LUBRICATED 101SYRINGES/1ML/27GX1/2" 134 acetaminophen 154 KAPVAY 3INSULIN isometheptene-SYRINGES/1ML/28GX1/2" 134 KAYEXALATE 159dichloralphenazone-INSULIN KAZANO 25acetaminophen 154SYRINGES/1ML/29GX1/2" 134 KEFLEX 49ISONIAZID 37INSULIN SYRINGES/1ML/30GX1/2" 134 isoniazid 37 KENALOG 63 INSULIN KENDALL ALGINATEISOPTO CARPINE 227SYRINGES/1ML/31GX5/16" HYDROCOLLOID DRESSINGISOPTO TEARS 226134 4"X4" 80
ISORDIL TITRADOSE 14 KENDALL ALGINATEINSUPEN 29G X 12MM 134 HYDROCOLLOID DRESSINGisosorbide dinitrate 15INSUPEN 31G X 5MM 134 4"X5" 80ISOSORBIDE DINITRATEINSUPEN 31G X 8MM 134 KENDALL ALGINATEER 14INSUPEN 32G X 4MM 134 HYDROCOLLOID DRESSINGisosorbide mononitrate 15INSUPEN PEN NEEDLES 32G 6"X6" 80
X4MM 134 isotretinoin 56 KENDALL ALGINATE INSUPEN SENSITIVE isradipine 48 HYDROCOLLOID DRESSING 32GX6MM 134 ISTALOL 227 6"X7" 80 INSUPEN ULTRAFIN KENDALL ALGINATEitraconazole 3029GX12MM 134 HYDROCOLLOID DRESSING
J & J BURN CREAM 69INSUPEN ULTRAFIN 8"X8" 80 30GX8MM 134 JADENU 29 KENDALL ZINC CALCIUM INSUPEN ULTRAFIN ALGINATE DRESSINGJAKAFI 3831GX6MM 134 2"X2" 80JALYN 95INSUPEN ULTRAFIN KENDALL ZINC CALCIUM 31GX8MM 134 JANUMET 25 ALGINATE DRESSING INTEGRA 97 JANUMET XR 25 4"X4" 80
KENDALL ZINC CALCIUMINTELENCE 44 JANUVIA 26 ALGINATE DRESSINGINTENSE SENSATION 101 JARDIANCE 28 4"X8" 80 INTERMEZZO 98 JENTADUETO 25 KEPPRA 19,20 INTUNIV 3 JENTADUETO XR 25 KEPPRA XR 20 INVEGA 41 JUBLIA 59 KERADAN 69 INVEGA SUSTENNA 41 JUXTAPID 33 KERAMATRIX REPLICINE INVEGA TRINZA 41 K-PAX IMMUNE SUPPORT 10CMX10CM 80
KERAMATRIX REPLICINEFORMULA DOUBLEINVIRASE 44 5CMX5CM 80STRENGTH 169INVOKAMET 25 KERI ADVANCED MOISTUREK-PAX IMMUNE SUPPORT THERAPY 69INVOKAMET XR 25 FORMULA PROFESSIONAL
STRENGTH KERI BASIC ESSENTIALSINVOKANA 28 169 69 KERI LONG LASTING 69
Index 29
KERI NOURISHING SHEA KINRAY INSULIN SYRINGE KROGER LANCETS 21G 110 BUTTER 69 PREFERRED KROGER LANCETS MICRO KERI ORIGINAL 69 PLUS/0.5ML/31G X 5/16" 135 THIN33G 110
KINRAY INSULIN SYRINGEKERI OVERNIGHT 69 KROGER LANCETS SUPERPREFERRED PLUS/1ML/31G THIN 110KERI RENEWAL MILK X 5/16" 135BODY 69 KROGER LANCETS THIN 110KINRAY INSULINKERI RENEWAL SKIN KROGER LANCETS THINSYRINGE/0.5ML/29G XFIRMING 69 26G 1101/2" 135KERI RENEWAL STRETCH KROGER LANCETSKITABIS PAK 4MARK MINIMIZER 69 ULTRATHIN30G 110
KERI SENSITIVE SKIN 69 KLARON 56 KROGER LANCING DEVICE 110KERLIX SUPER SPONGE KLONOPIN 19 KROGER PEN NEEDLES 29GSALINE DRESSING 81 KLOR-CON M15 158 X12MM 135KETEK 14 KMART VALU PLUS INSULIN KROGER PEN NEEDLES 31G
KETOCARE 87 SYRINGE/1ML/29G 135 X8MM 135KMART VALU PLUS INSULINketoconazole 30 KROGER PEN NEEDLESSYRINGE/1ML/30G 135 31GX1/4" 135ketoconazole (topical) 59 KOMBIGLYZE XR 25 KROGER PREMIUM BLOODKETONE TEST STRIPS 87 KONSYL 99 GLUCOSE TEST STRIPS 87
ketoprofen 6 KROGER TEST STRIPS 87KP MENS DAILY PACK 169KETOPROFEN ER 6 KP PRENATAL KYNAMRO 32 ketorolac tromethamine 6 MULTIVITAMINS 214 labetalol hcl 47 ketorolac tromethamine KP WOMENS DAILY LAC-HYDRIN 69(ophth) 230 PACK 169
LAC-HYDRIN TWELVE 69KETOSTIX 87 KPN PRENATAL 214 LACTAID 89ketotifen fumarate (ophth) 230 KROGER BLOOD GLUCOSE
TESTSTRIPS 87 LACTAID FAST ACT 89KHEDEZLA 24 KROGER GLUCOSE 26 lactase 89KIDNEY 219 KROGER INSULIN lactic acid (ammoniumKIMONO COLORS 101 SYRINGE/0.3ML/29G X lactate) 69 KIMONO LUBRICATED 101 1/2" 135 LACTINOL HX 69 KIMONO MICRO THIN PLUS KROGER INSULIN lactobacillus acidophilus-SPERMICIDE SYRINGE/0.3ML/30G X pectin 28LUBRICATED 101 5/16" 135 lactulose 99KIMONO PLUS SPERMICIDE KROGER INSULIN LUBRICATED 101 SYRINGE/0.3ML/31G X lactulose (encephalopathy) 94 KIMONO PLUS 5/16" 135 LADY ESTHER 4 PURPOSE SPERMICIDE/LUBRICATED KROGER INSULIN FACE CREAM 69
101 SYRINGE/0.5ML/29G X LAMICTAL 20 1/2" 135KIMONO PS LUBRICATED101 LAMICTAL CHEWABLEKROGER INSULINKIMONO PS PLUS DISPERSIBLE 20SYRINGE/0.5ML/30G XSPERMICIDE/LUBRICATED LAMICTAL ODT 205/16" 135101 LAMICTAL STARTER/NOTKROGER INSULINKIMONO SENSATION TAKING CARBAMAZEPINE 20SYRINGE/0.5ML/31G XLUBRICATED 101 LAMICTAL STARTER/TAKING5/16" 135KIMONO SENSATION PLUS CARBAMAZEPINE/NOT TAKINGKROGER INSULINSPERMICIDE VALPROATE 20SYRINGE/1ML/29G XLUBRICATED 101 LAMICTAL STARTER/TAKING1/2" 135KIMONO SPECIAL 101 VALPROATE 20KROGER INSULIN LAMICTAL XR 20KINERET 5 SYRINGE/1ML/30G X
KINNEY LANCETS 110 5/16" 135 LAMISIL 30 KROGER INSULIN LAMISIL ADVANCED 59KINNEY THIN LANCETS 110 SYRINGE/1ML/31G XKINRAY INSULIN SYRINGE LAMISIL AT 595/16" 135PREFERRED PLUS/0.3ML/31G LAMISIL AT JOCK ITCH 59KROGER LANCETS 110X 5/16" 134
Index 30
LAMISIL AT SPRAY 59 LANTUS 27 LEADER UNIFINE
lamivudine lamivudine (hbv)
44 46
LANTUS SOLOSTAR LANZO
27 111
PENTIPS/NANO/32GX5/32"136
LEADER UNIFINE lamivudine-zidovudine 44 lamotrigine 20 LANAPHILIC 69 LANCET DEVICE ADJUSTABLE 111 LANCET DEVICE WITH EJECTOR 111 LANCETS 111 LANCETS 26G TWIST TOP 111 LANCETS 28G 111 LANCETS 30G 111 LANCETS 30G TWIST TOP 111 LANCETS 30G/TWISTTOP 111 LANCETS 31G TWIST TOP 111 LANCETS 33G UNIVERSAL DESIGN 111 LANCETS MICRO THIN 33G 111 LANCETS SAFETY SEAL 21G 111 LANCETS SAFETY SEAL 26G 111 LANCETS SAFETY SEAL 28G 111 LANCETS SAFETY SEAL 30G 111 LANCETS SUPER THIN 28G 111 LANCETS THIN 111 LANCETS TWIST TOP 111 LANCETS ULTRA FINE 111 LANCETS ULTRA THIN 111 LANCETS ULTRA THIN 30G 111 LANCETSBULLSEYE SAFETY 111 LANCING DEVICE 111 LANCING DEVICE ADJUSTABLE 111 LANOLOR 69 LANOXIN 49 lansoprazole 237 lanthanum carbonate 95 LANTISEPTIC SKIN
LASIX 90 LASTACAFT 230 latanoprost 230 LATUDA 41 LAZANDA 9 LEADER ADVANCED LANCING DEVICE 111 LEADER FINGER CREAM69 LEADER GLUCOSE 26 LEADER INSULIN SYRINGE/0.3ML/29G X1/2" 135 LEADER INSULIN SYRINGE/0.3ML/30G X5/16" 135 LEADER INSULIN SYRINGE/0.3ML/31G X5/16" 135 LEADER INSULIN SYRINGE/0.5ML/28G X1/2" 135 LEADER INSULIN SYRINGE/0.5ML/29G X1/2" 135 LEADER INSULIN SYRINGE/0.5ML/30G X5/16" 135 LEADER INSULIN SYRINGE/0.5ML/31G X5/16" 135 LEADER INSULIN SYRINGE/1ML/28G X1/2" 135 LEADER INSULIN SYRINGE/1ML/29G X1/2" 135 LEADER INSULIN SYRINGE/1ML/30G X5/16" 135 LEADER INSULIN SYRINGE/1ML/31G X5/16" 135 LEADER QUICK DISSOLVE GLUCOSE 26 LEADER UNIFINE PENTIPS PLUS/MINI/31GX3/16" 135 LEADER UNIFINE PENTIPS PLUS/SHORT/31GX5/16"
135 LEADER UNIFINE
PENTIPS/PLUS/32GX5/32"136
leflunomide 7 LENVIMA 10 MG DAILY DOSE 38 LENVIMA 14 MG DAILY DOSE 38 LENVIMA 18 MG DAILY DOSE 38 LENVIMA 20 MG DAILY DOSE 39 LENVIMA 24 MG DAILY DOSE 39 LENVIMA 8 MG DAILY DOSE 39 LESCOL XL 33 LETAIRIS 49 letrozole 38 LEUCOVORIN CALCIUM 39 leucovorin calcium 39 LEUKERAN 37 levalbuterol hcl 17 LEVALBUTEROL TARTRATE HFA 17 LEVAQUIN 93 LEVBID 236 LEVEMIR 27 LEVEMIR FLEXTOUCH 27 LEVETIRACETAM 20 levetiracetam 20 LEVETIRACETAM 20 levetiracetam 20 levetiracetam in sodium chloride 20 levobunolol hcl 227 levocarnitine (metabolicmodifiers) 92 levocetirizine dihydrochloride31 LEVOFLOXACIN 93 levofloxacin 93 levofloxacin (ophth) 228 levonorgestrel & ethestradiol 50 levonorgestrel (emergencyoc) 52 LEVONORGESTREL AND
PROTECTANT LANTISEPTIC THERAPEUTIC
74
69
PENTIPS/MINI/31GX3/16"135
ETHINYL ESTRADIOL levonorgestrel-eth estradiol(triphasic)
50
51
Index 31
levonorgestrel-ethinyl estradiol lisinopril 34 LITHIUM 41 (91-day) 51 lisinopril & LITHIUM CARBONATE 41levonorgestrel-ethinyl estradiol hydrochlorothiazide 35 lithium carbonate 41(continuous) 51 LITE TOUCH LANCETS 111LEVORPHANOL TARTRATE 9 LITHOBID 41LITE TOUCH LANCING levothyroxine sodium 236 DEVICE 111 LIVALO 33
LITE TOUCH LANCING LIVE BETTER ADVANCEDLEVSIN 236 PEN 111 LANCING DEVICE 111LEVSIN/SL 236 LITE TOUCH PEN LIVE BETTER LANCET
LEXAPRO 23 NEEDLES/31G X 3/16" 136 SUPERTHIN 30G 111 LIVE BETTER LANCETLEXIVA 44 LITEAIRE 152 ULTRATHIN 28G 112LEXIXRYL 58 LITETOUCH INSULIN LIVE BETTER PEN NEEDLESSYRINGE/0.3ML/29G XLIALDA 94 29G X 12MM 1361/2" 136LIBERTY CONTROL SOLUTION LIVE BETTER PEN NEEDLESLITETOUCH INSULINHIGH 111 31G X 12MM 136SYRINGE/0.3ML/30G XLIBERTY CONTROL LIVE BETTER PEN NEEDLES5/16" 136SOLUTIONNORMAL 111 31G X 6MM 136LITETOUCH INSULINLIBERTY GLUCOSE CONTROL LO LOESTRIN FE 51SYRINGE/0.3ML/31G XLEVEL 1 111 5/16" 136 LOCOID 63LIBERTY GLUCOSE CONTROL
LEVEL 2 111 LITETOUCH INSULIN LOCOID LIPOCREAM 63 SYRINGE/0.5ML/30G XLIBERTY GLUCOSE CONTROL LODINE 65/16" 136MID 111 LODOSYN 39LITETOUCH INSULINLIBERTY GLUCOSE CONTROL
NORMAL 111 SYRINGE/0.5ML/31G X LOESTRIN 1.5/30-21 51 LIBERTY MEDICAL LANCETS 5/16" 136 LOESTRIN 1/20-21 51LITETOUCH INSULIN30G 111 LOESTRIN FE 1.5/30 51LIBERTY MINI LANCING SYRINGE/1ML/30G X
LOESTRIN FE 1/20 51DEVICE 111 5/16" 136 LIBERTY NEXT GENERATION LITETOUCH INSULIN LOFIBRA 33 BLOOD GLUCOSE TEST SYRINGE/U-100/0.5ML/28G X LOMOTIL 29 STRIPS 87 1/2" 136 LOMUSTINE 37LITETOUCH INSULINLIBERTY TEST STRIPS 87 SYRINGE/U-100/0.5ML/29G X LONGS GLUCOSE 26lidocaine 74 1/2" 136 LONGS INSULIN lidocaine hcl 74 LITETOUCH INSULIN SYRINGE/0.5ML/31G Xlidocaine hcl (mouth-throat) 159 SYRINGE/U-100/1ML/28G X 5/16" 136
1/2" 136 LONGS LANCETSlidocaine-prilocaine 74 LITETOUCH INSULIN STANDARD 112LIDODERM 74 SYRINGE/U-100/1ML/29G X LONGS LANCETS THIN 112 LIFE PACK MENS 169 1/2" 136 LONGS LANCETS ULTRALITETOUCH INSULINLIFE PACK WOMENS 169 THIN 112SYRINGE/U-100/1ML/31G XLIFESCAN UNISTIK 2 DEEP LONSURF 385/16" 136PENETRATION 111 LITETOUCH LANCETS MICRO loperamide hcl 29LIFESCAN UNISTIK II THIN 33G 111 LOPID 33LANCETS 111 LITETOUCH MASKLINDANE 75 lopinavir-ritonavir 44LARGE 152 LOPRESSOR 47lindane 75 LITETOUCH MASK
MEDIUM LOPRESSOR HCTliniments & rubs 73 152 35 LITETOUCH MASK LOPROX 59LINZESS 94 SMALL 152
liothyronine sodium 236 LITETOUCH PEN NEEDLES LOPROX KIT 59 LOPROX SHAMPOO 59LIPIDSHIELD PLUS 219 29GX12.7MM 136
LITETOUCH PEN NEEDLES loratadine 31LIPITOR 33 31G X 6MM 136 loratadine &LIPOFEN 33 LITETOUCH PEN NEEDLES pseudoephedrine 53LIPOTRIAD 222 31GX8MM SHORT 136 lorazepam 15
Index 32
LORTAB 11 LYSTEDA 97 MARINOL 30 LORZONE 223 M-VIT 214 MARNATAL-F 214 losartan potassium 34 losartan potassium &hydrochlorothiazide 35 LOSEASONIQUE 51 LOTEMAX 229 LOTENSIN 34 LOTENSIN HCT 35 LOTREL 35 LOTRIMIN AF 59 LOTRIMIN AF FOR HER 59 LOTRIMIN AF JOCK ITCH 59 LOTRIMIN ULTRA 59 LOTRISONE 59 LOTRONEX 94 lovastatin 33 LOVAZA 32 LOVENOX 19 loxapine succinate 42 lubricants 74 LUBRIDERM 70 LUBRIDERM ADVANCED THERAPY 69 LUBRIDERM DAILY MOISTURE/NORMAL TO DRYSKIN 69 LUBRIDERM DAILY MOISTURESHEA + CALMING LAVENDER JASMINE 69 LUBRIDERM INTENSE SKIN REPAIR 70 LUBRIDERM MENS 3-IN-1 70 LUBRIDERM SERIOUSLY SENSITIVE 70 LUBRIDERM SKIN NOURISHINGWITH SHEA AND COCOA BUTTERS 70 LUBRIDERM SOOTHING RELIEF/COOLING 70 LUBRISOFT 70 LUMIGAN 231 LUNESTA 98 LUNG 219 LURIDE 157 LUXIQ 64 LUZU 59 LYMPH 219 LYNPARZA 39
M2 B-60 169 M2 CALCIUM 219 M2 CHROMIUM 219 MACNATAL CN DHA 214 MACROBID 238 MACRODANTIN 238 MACULAR VITAMIN BENEFIT 169 MAG64 157 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/29G X1/2" 136 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/30G X5/16" 136 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/29G X1/2" 136 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/30G X5/16" 136 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X1/2" 136 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/30G X5/16" 136 magnesium citrate 99 MAGNESIUM GLUCONATE 157 magnesium gluconate 157 magnesium hydroxide 99 magnesium oxide 14 magnesium oxide (mgsupplement) 157 MAGONATE 157 MAGOX 400 157 MAKENA 232 malathion 76 MAMMARY 219 MANGANESE GLUCONATE 157 MAPROTILINE HCL 22 MARATHON MEDICAL PENTIPS29GX12MM 136 MARATHON MEDICAL PENTIPS31GX5MM 136 MARATHON MEDICAL PENTIPS31GX8MM 136 MARATHON MEDICAL
MARPLAN 22 MATULANE 39 MAVIK 34 MAVYRET 46 MAXALT 155 MAXALT-MLT 155 MAXAM 70 MAXI-COMFORT INSULIN SYRINGE/U-100/0.5ML/28GX1/2" 137 MAXI-COMFORT INSULIN SYRINGE/U-100/1ML/28GX1/2"
137 MAXIDEX 229 MAXIMA BLOOD GLUCOSE TESTSTRIPS 87 MAXIMA CONTROL SOLUTION 112 MAXIMA CONTROL SOLUTION/NORMAL 112 MAXIMIN PACK 169 MAXITROL 229 MAXORB EXTRA AG+ 81 MAXX LUBRICATED 101 MAXX PLUS SPERMICIDE LUBRICATED 101 MAXZIDE 90 MAXZIDE-25 90 meclizine hcl 29 MECLOFENAMATE SODIUM 6 MEDELA TENDER CARE LANOLIN 70 MEDERMA AG FACE CREAM 70 MEDERMA AG HAND & BODY LOTION 70 MEDERMA STRETCH MARKS THERAPY 70 MEDI-PAK PERFORMANCE PLUSCOMBINE ABD PAD/8" X7.5" 81 MEDIC INSULIN SYRINGE/0.3ML/30G X5/16" 137 MEDIC INSULIN SYRINGE/0.5ML/30G X5/16" 137 MEDICATED CHEST RUB 55 MEDICHOICE PRE-SET SAFETY LANCET DUAL
LYRICA 20 PENTIPS32GX4MM 137 USE 112
Index 33
MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW 112 MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW 112 MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW 112 MEDICHOICE SAFETY
MEDLANCE PLUS UNIVERSAL LANCETS 21G 112 MEDLANCE PLUS/LITE25G 112 MEDLANCE/EXTRA 112 MEDLANCE/LITE 112 MEDLANCE/UNIVERSAL112 MEDROL 52
MEIJER SUPER THIN LANCETS 112 MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS 87 MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS 87 MEKINIST 39 melatonin 4 MELATONIN 4
LANCETEXTRA 112 MEDICHOICE SAFETY LANCETNORMAL 112 MEDICINE SHOPPE PEN NEEDLES 29G X 12MM 137 MEDICINE SHOPPE PEN NEEDLES 31G X 6MM 137 MEDICINE SHOPPE PEN NEEDLES 31G X 8MM 137 MEDIHONEY CALCIUM ALGINATE DRESSING 4"X5" 81 MEDIHONEY CALCIUM ALGINATE DRESSING/2"X2" 81 MEDIHONEY WOUND & BURN
MEDROL DOSEPAK 52 medroxyprogesterone acetate 232 medroxyprogesterone acetate(contraceptive) 52 mefenamic acid 6 mefloquine hcl 36 MEFLOQUINE HCL 36 MEGA MULTI MEN 169 MEGA MULTI WOMEN 169 MEGA MULTIVITAMIN 169 MEGA MULTIVITAMIN FOR MEN 169 MEGA MULTIVITAMIN FOR
MELOXICAM 6 meloxicam 6 melphalan 37 memantine hcl 232,233 MENACTRA 239 MENOMUNE-A/C/Y/W-135
239 MENOPAUSE RELIEF 219 MENS 50+ ADVANCED 169 MENS 50+ MULTI VITAMIN &MINERAL FORMULA 169 MENS MULTI VITAMIN & MINERAL FORMULA 169 MENS PACK 169
DRESSING 3/4"X12" 81 MEDIHONEY WOUND/BURNDRESSING4"X5" 81 MEDISENSE GLUCOSE KETONECONTROL SOLUTION 1-LOW,1-MED,1 HIGH 112 MEDISENSE GLUCOSE KETONECONTROL SOLUTION 1-NORMAL 112 MEDISENSE HIGH/LOWCONTROL SOLUTION 112 MEDISENSE HIGH/MID/LOWCONTROL SOLUTION 112 MEDISENSE MID CONTROL SOLUTION 112 MEDISENSE THIN LANCETS 112 MEDLANCE PLUS EXTRA LANCETS 21G 112 MEDLANCE PLUS LANCETS 112 MEDLANCE PLUS LANCETS LITE 25G 112 MEDLANCE PLUS LITE LANCETS 25G 112 MEDLANCE PLUS SPECIAL LANCETS 0.8MM 112 MEDLANCE PLUS SUPERLITE 30G 112 MEDLANCE PLUS SUPERLITE 30G/COMFORT MAX 112
WOMEN 169 MEGACE ORAL 38 MEGAVITE FRUITS & VEGGIES 169 MEGAVITE GOLDEN YEARS 55+ 169 megestrol acetate 38 MEIJER ALCOHOL SWABS EXTRA-THICK 120 MEIJER BLOOD GLUCOSE TESTSTRIPS 87 MEIJER COLOR LANCETS UNIVERSAL 33G 112 MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS 87 MEIJER GLUCOSE 26 MEIJER LANCETS 112 MEIJER LANCETS THIN 112 MEIJER LANCETS UNIVERSAL21G 112 MEIJER LANCETS UNIVERSAL30G 112 MEIJER LANCETS UNIVERSAL33G 112 MEIJER PEN NEEDLES 29G X12MM 137 MEIJER PEN NEEDLES 31G X6MM 137 MEIJER PEN NEEDLES 31G X8MM 137 MEIJER PREMIUM BLOOD
MENTAX 59 menthol (topical analgesic) 57 menthol-methyl salicylate(liniments) 73 menthol-zinc oxide 75 MENVEO 239 MEPERIDINE HCL 9 meperidine hcl 9 MEPHYTON 242 meprobamate 15 mercaptopurine 37 mesalamine 94 MESALAMINE DR 94 mesalamine w/ cleanser 94 MESTINON 37 MESTINON TIMESPAN 37 METADATE CD 3 METAMUCIL 99 METAPROTERENOL SULFATE 18 METAXALONE 223 metaxalone 223 metformin hcl 25 methadone hcl 9 METHADONE HCL 9 methadone hcl 9
GLUCOSE TEST STRIPS 87 METHADOSE 9
Index 34
METHADOSE SUGAR-FREE 9 MEVACOR 33 MINIVELLE 93 methamphetamine hcl 2 mexiletine hcl 16 MINOCIN 235 methazolamide 90 MG-PLUS PROTEIN 219 minocycline hcl 235 methenamine hippurate METHENAMINE
238 MH MACULAR HEALTH 169 MI PASTE 121
MINOCYCLINE HCL ER minoxidil
235 36
MANDELATE 238 methenamine mandelate 238 methenamine-hyosc-methyleneblue-sod phos-phenyl sal 238 METHERGINE 231
MI PASTE PLUS MIACALCIN MICARDIS MICARDIS HCT
121 91 34 36
MIRALAX MIRAPEX MIRAPEX ER MIRCERA
99 40 40 97
methimazole 236 MICATIN 59 MIRCETTE 51 methocarbamol 223 methotrexate sodium 37 METHOTREXATE SODIUM 37 methotrexate sodium 37 methoxsalen rapid 60 METHYCLOTHIAZIDE 90 methylcellulose (laxative) 99 methyldopa 35 METHYLDOPA/HYDROCHLOROTHIAZIDE 35 methylergonovine maleate 231 METHYLIN 3 METHYLPHENIDATE HCL 4 methylphenidate hcl 4 METHYLPHENIDATE HCL ER 4 METHYLPHENIDATE HCL ER (LA) 4 methylprednisolone 52 metoclopramide hcl 94 METOCLOPRAMIDE ODT 94 metolazone 90 metoprolol &hydrochlorothiazide 35 metoprolol succinate 47 METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE
36
miconazole nitrate (topical)59 miconazole nitrate vaginal 241 MICORT-HC 64 MICRO-K 158 MICROCHAMBER 152 MICRODOT CONTROL SOLUTIONHIGH/LOW 113 MICRODOT TEST STRIPS 87 MICROELITE FILTER REPLACEMENTS 152 MICROELITE RECHARGEABLE BATTERY 152 MICROLET LANCETS 113 MICROLET NEXT 113 MICROSPACER 152 MICROTAINER SAFETY FLOW LANCET/STERILE/SINGLE-USE 113 MICROZIDE 91 midodrine hcl 242 MIGERGOT 154 miglitol 24 MIGRANAL 154 MIGRANOW 154 MIL ADREGEN 219
mirtazapine 22 misoprostol 238 MITIGARE 96 MM PEN NEEDLES 31G X 1/4" 137 MM PEN NEEDLES 31G X 3/16" 137 MM PEN NEEDLES 31G X 5/16" 137 MM PEN NEEDLES 32G X 5/32" 137 MOBIC 6 MOBISYL 73 modafinil 4 MODICON 51 moexipril hcl 34 moexipril-hydrochlorothiazide
36 MOI-STIR 160 MOISTURIZING CREAM 70 MOLINDONE HYDROCHLORIDE 42 mometasone furoate 64 mometasone furoate (nasal) 224 MONISTAT 3 COMBINATION PACK 241 MONISTAT 7 SIMPLY CURE 241 MONISTAT SOOTHING CARE
metoprolol tartrate 47 METOPROLOL TARTRATE 47
MILADRENE FORTE MILCO-B-FORTE
219 163
ITCH RELIEF MONODOX
64 235
METOPROLOL/HYDROCHLOROTHIAZIDE 36 METOZOLV ODT 94 METROCREAM 75 METROGEL-VAGINAL 241 METROLOTION 75 metronidazole 14 metronidazole (topical) 75 metronidazole vaginal 241
MILLIPRED 52 MILPAN 219 MINASTRIN 24 FE 51 MINI LANCING DEVICE 113 MINIELITE FILTER REPLACEMENTS 152 MINIELITE RECHARGEABLE BATTERY 152 MINIPRESS 35
MONOJECT INSULIN SYRINGE/1MLMONOJECT INSULIN SYRINGE/1ML/31G X5/16"MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/25G X 5/8"MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/27G X 1/2"
137
137
137
137
Index 35
MONOJECT INSULIN SYRINGE/PERMNEEDLE/1ML/28G X 1/2" 137 MONOJECT INSULIN SYRINGE/PERM NEEDLE/U-100/0.5ML/28G X 1/2" 137 MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29G X 1/2" 137 MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29GX1/2" 137 MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2" 137 MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2" 137 MONOJECT INSULIN SYRINGE/SOFTPACK/1ML/27GX 1/2" 137 MONOJECT INSULIN SYRINGE/SOFTPACK/U-100/0.5ML/28G X 1/2" 137 MONOJECT INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 137 MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 137 MONOJECT INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 137 MONOJECT INSULIN SYRINGE/U-100/1ML/28G X1/2" 138 MONOJECT INSULIN SYRINGE/U-100/1ML/30G X5/16" 138 MONOJECT INSULIN SYRINGEREGULAR LUER TIP/SOFTPACK/1ML 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X1/2" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X5/16" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/28G X1/2" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/29G X1/2" 138
MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X5/16" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/28G X1/2" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/29G X1/2" 138 MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" 138 MONOLET LANCETS 113 MONOLET OPD LANCETS 113 MONOLETTOR SAFETY LANCETS 113 montelukast sodium 16 MOORE MED MONOJECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 138 MOORE MED MONOJECT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 138 MOORE MED MONOJECT INSULIN SYRINGE/U-100/1ML/28G X 1/2" 138 MOORE MED MONOJECT INSULIN SYRINGE/U-100/1ML/29G X 1/2" 138 MORGIDOX 1X100MG 235 MORGIDOX 1X50MG KIT 235 MORGIDOX 2X100MG 235 morphine sulfate 9,10 MORPHINE SULFATE 10 morphine sulfate 10 MORPHINE SULFATE ER 10 MOTHERS FRIEND 70 MOTRIN INFANTS DROPS 6 MOUTHKOTE 160 MOVANTIK 94 MOXATAG 231 MOXEZA 228 moxifloxacin hcl 93 moxifloxacin hcl (ophth) 228
MS CONTIN 10 MS INSULIN SYRINGE/0.3ML/31G X5/16"MS INSULIN
138
SYRINGE/0.5ML/31G X5/16" 138 MS INSULIN SYRINGE/1ML/31GX 5/16" 138 MSM SKIN LOTION 70 MTERYTI 214 MTERYTI FOLIC 5 214 MUCINEX 54 MUCINEX D 53 MUCINEX DM 54 MULTI FOR HER 169 MULTI FOR HIM 170 MULTI MEGA MINERALS 157 MULTI PRENATAL 214 MULTI-BETIC DIABETES 170 MULTI-GLAN 220 MULTI-LANCET DEVICE 113 MULTI-VITAMIN MONOCAPS 170 multiple minerals w/vitamins 157 multiple vitamin 208 multiple vitamins w/ calcium164 multiple vitamins w/ iron 164 multiple vitamins w/minerals 175,204 multiple vitamins w/ minerals &folic acid 170 MULTISOURCE CALCIUM MAGNESIUM & D FORMULA 157 MULTIVITAL PLATINUM 204 MULTIVITAMIN ADULT 204 MULTIVITAMIN ADULT EXTRAVITAMIN C 204 MULTIVITAMIN ADULTS 204 MULTIVITAMIN GUMMIES CHILDRENS 213 MULTIVITAMIN MEN 204 MULTIVITAMIN/FLUORIDE
208 MULTIVITAMINS W/A,B,D,E,AND K PLUS ZINC 204 mupirocin 58 mupirocin calcium (topical) 58 MURO 128 230
Index 36
MVW COMPLETE naproxen sodium 6 neomycin-polymyxin w/FORMULATIONCHEWABLES pramoxine 58naratriptan hcl 155MULTIVITAMIN 204 neomycin-polymyxin-gramicidin
NARCAN 29MYAMBUTOL 37 228 NARDIL 22 neomycin-polymyxin-hcmycophenolate mofetil 158 NASACORT ALLERGY (otic) 231
mycophenolate sodium 159 24HR 224 neomycin/polymyxin b gu 95 MYDAYIS 2 NASACORT ALLERGY 24HR NEOMYCIN/POLYMYXIN/HYDRMYDRIACYL 227 CHILDRENS 224 OCORTISONE 229
NASALMYFORTIC 159 NEORAL 159DECONGESTANT 225MYGLUCOHEALTH BLOOD NEOSALUS 70NASALCROM 224GLUCOSE TEST 87 NEOSPORIN 228
MYGLUCOHEALTH CONTROL NASONEX 224 NEOSPORIN GU IRRIGANT95LOW/NORMAL/HIGH 113 NAT-RUL C-COMPLEX 163 NEOSPORIN LIP HEALTHMYGLUCOHEALTH MGH NAT-RUL C-COMPLEX OVERNIGHT RENEWALSOFTLANCE LANCETS TR 163 THERAPY 7530G 113 NAT-RUL PRENATAL NEOSPORIN ORIGINAL 58MYLERAN 37 VITAMINS 214 NEOSPORIN PLUS PAINNAT-RUL THERAVITE-MYLICON 93
MYLICON INFANTS GAS M/HIGHPOTENCY 204 RELIEF MAXIMUM STRENGTH 58NATACYN 228RELIEF 93 NEPTAZANE 90MYNATAL ADVANCE 214 NATALVIT 214 NERLYNX 39MYNATAL PLUS 214 NATAZIA 51 NESINA 26MYNATAL ULTRACAPLET 214 nateglinide 28 NESTABS 214MYNATAL-Z 214 NATELLE ONE 214 NESTABS ABC 214MYOFLEX 73 NATESTO 12 NESTABS DHA 214MYRBETRIQ 239 NATROBA 76 NESTABS ONE 214MYSOLINE 20 NATRUL-100 204 NETGROUP LANCETS 113nabumetone 6 NATRUL-CAL 157 NEUPOGEN 97nadolol 47 NATRUL-CHEWS 204 NEUPRO 40nadolol & NATRUL-MEGA-75 204
bendroflumethiazide 36 NEURONTIN 20NATRUL-VITES 204naftifine hcl 59 NEUTEK 2TEK CONTROLNEBULIZER AIR SOLUTIONS 113NAFTIN 59 TUBE/PLUGS 152 NEUTEK 2TEK TESTNEBULIZER PEDIATRICNALFON 6 STRIPS 87MASK 152NALOXONE HCL 29 NEUTROGENA BODY LIGHTNEBUSAL 55 SESAME FORMULA 70naloxone hcl 29 NECON 1/50-28 51 NEUTROGENA HAND 70NALOXONE HCL 29 NECON 10/11-28 51 NEUTROGENAnaltrexone hcl 29 NEEVO DHA 214 HAND/NORWEGIANFORMULA/NAMENDA 233 FAST ABSORBING 70NEFAZODONE HCL 23NAMENDA TITRATION NEUTROGENA HEALTHY
nefazodone hcl 23PAK 233 SKIN 70 NAMENDA XR 233 NEO-SYNEPHRINE 12 HOUR NEUTROGENA HEALTHY SKIN
EXTRA MOISTURIZING 225 FACE SPF 15 70NAMENDA XR TITRATION PACK 233 neomycin sulfate 4 NEUTROGENA MOISTURE NAMZARIC 233 neomycin-bacitracin zn- SENSITIVE SKIN 70
polymyxin 228 NEUTROGENA T/GEL 76NAPHAZOLINE HCL 228 neomycin-bacitracin-polymyxin NEUTROGENA T/GELNAPRELAN 6 58 CONDITIONER 76 NAPROSYN 6 neomycin-bacitracin-polymyxin- NEUTROGENA T/GEL
pramoxine 58 STUBBORN ITCHNAPROXEN 6 neomycin-polymy- CONTROL 76 naproxen 6,7 dexameth 229 NEUTROGENA T/SAL 73
Index 37
NEVANAC NEVIRAPINE nevirapine NEW LIFE HAIR NEWGEN
230 44 44
220 214
NITRO-DUR nitrofurantoin nitrofurantoin macrocrystalnitrofurantoin monohyd macro
15 238
238
238
norgestimate-ethinylestradiol 51 norgestimate-ethinyl estradiol(triphasic) 51 norgestrel & ethinyl estradiol 51 NORINYL 1+35 51
NEXA PLUS 214 NEXAFED SINUS PRESSURE +PAIN 54 NEXAVAR 39 NEXGEN NORMAL
nitroglycerin NITROGLYCERIN LINGUAL NITROLINGUAL PUMPSPRAY
15
15
15
NORINYL 1+50 NORPACE NORPACE CR NORPRAMIN
51 16 16 24
CONTROL 113 NITROMIST 15 nortriptyline hcl 24 NEXGEN TEST STRIPS 87 NITROSTAT 15 NORTRIPTYLINE HCL 24 NEXIUM 237 NIVA-PLUS 214 NORTUSS-EX 54 NEXIUM 24HR 237 NIVEA 70 NORVASC 48 NEXIUM 24HR CLEAR NIVEA EXTRA NORVIR 44 MINIS 237 NF FORMULAS CHILDRENS CHEWABLE 209 niacin 242 niacin (antihyperlipidemic) 33 niacinamide 243 NIACOR 33 NIASPAN 33
ENRICHED 70 NIVEA EXTRA ENRICHED LOTION 70 NIVEA GENTLE BODY EXFOLIATOR 70 NIVEA LIGHT 70 NIVEA ORIGINAL 71 NIVEA ORIGINAL MOISTURE 71
NORWEGIAN COD LIVER OIL 222 NOSE CLIP 152 NOVA MAX GLUCOSE TEST STRIPS 87 NOVA MAX PLUS GLU/KETCONTROL SOLUTION-MID 113 NOVA MAX PLUS KETONE
NICADAN 204 NICADAN ZX 205 nicardipine hcl 48 NICAZEL 205 NICAZEL FORTE 205 NICODERM CQ 234 NICORETTE 234 NICORETTE MINI 234 NICORETTE STARTER KIT 234 nicotine 234 nicotine polacrilex 234 NICOTINE TRANSDERMAL
NIVEA SOFT NIVEA VISAGE NIVEA VISAGE INNER BEAUTY NIGHTTIME RENEWAL NIX CREME RINSE nizatidine NIZATIDINE NIZORAL NO IRON MULTIPLE VITAMIN/MINERALS NOR-QD NORCO
71 71
71 76
237 237 59
205 52 11
TESTSTRIPS 87 NOVA SAFETY LANCETS 23G 113 NOVA SAFETY LANCETS 28G 113 NOVA SUREFLEX LANCETS 113 NOVA SUREFLEX LANCING DEVICE 113 NOVOFINE 30GX8MM 138 NOVOFINE 32GX6MM 138 NOVOFINE AUTOCOVER 30GX8MM 138 NOVOFINE PLUS 32GX4MM 138
SYSTEM NICOTROL INHALER NICOTROL NS nifedipine NILANDRON
234 234 234 48 38
NORDITROPIN FLEXPRO91 norethin acet & estrad-fe 51 norethindrone & eth estradiol 51 norethindrone & ethinylestradiol-fe 51
NOVOLIN 70/30 NOVOLIN 70/30 RELION NOVOLIN N NOVOLIN N RELION NOVOLIN R
28 27 28 28 28
nilutamide 38 norethindrone NOVOLIN R RELION 28 nimodipine 48 NINLARO 39 NISEKO HYDRATING FACIAL MOISTURIZER 70 nisoldipine 48
(contraceptive) 52 norethindrone acet & eth estra 51 norethindrone acetate 232 norethindrone acetate-ethinylestradiol-fe 51
NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG MIX 70/30PREFILLED FLEXPEN
28 28 28
28 NISOLDIPINE ER 48 norethindrone-eth estradiol NOVOLOG PENFILL 28 NITRO-BID 15 (triphasic) 51 NOVOTWIST 30GX8MM 138
Index 38
NOVOTWIST 32GX5MM 138 ODEFSEY 44 ON CALL VIVID GLUCOSE NOXAFIL 30 NU-GEL WOUND DRESSING/3-3/4" X 3-3/4" 81 NU-GEL WOUND DRESSING/6"X 8" 81 NU-MAG 157 NUCYNTA 10
ODOMZO OFEV OFLOXACIN ofloxacin ofloxacin (ophth) ofloxacin (otic)
37 235 93 93
228 231
CONTROL LEVEL 1/2 113 ONCOVITE 205 ondansetron 29 ondansetron hcl 29 ONE DAILY MENS FORMULA W/O IRON 205 ONE DAILY PLUS IRON 205
NUCYNTA ER 10 OGESTREL 51 ONE-A-DAY ENERGY 205 NULYTELY/FLAVORPACKS 99 NUMOISYN 160 NUPERCAINAL 13 NUPLAZID 41 NUTRADERM 71 NUTRADERM ADVANCED FORMULA 71 NUTRASEB 71 NUTRICAP 205
OINTMENT BASE 71 olanzapine 42 olanzapine-fluoxetine hcl 233 olmesartan medoxomil 34 olmesartan medoxomil-amlodipine-hydrochlorothiazide
36 olmesartan medoxomil-hydrochlorothiazide 36 olopatadine hcl 230
ONE-A-DAY ESSENTIAL 208 ONE-A-DAY FOR HER VITACRAVES TEEN MULTI GUMMIES 205 ONE-A-DAY FOR HIM/VITACRAVES TEEN MULTIGUMMIES 205 ONE-A-DAY MENOPAUSE FORMULA 205 ONE-A-DAY MENS 208 ONE-A-DAY MENS 50+
NUTROPIN AQ NUSPIN 10 91 NUTROPIN AQ NUSPIN 20 91 NUTROPIN AQ NUSPIN 5 91 NUTROPIN AQ PEN 91 NUVARING 52 NUVESSA 241 NUVIGIL 4
olopatadine hcl (nasal) 224 OLUX 64 OLUX-E 64 OLYSIO 46 OMECLAMOX-PAK 238 omega-3 fatty acids 226 omega-3-acid ethyl esters 32
ADVANTAGE 205 ONE-A-DAY MENS HEALTH FORMULA 205 ONE-A-DAY MENS PRO EDGE 205 ONE-A-DAY MENS VITACRAVES GUMMIES 205 ONE-A-DAY SCOOBY-DOO GUMMIES 209
NYMALIZE nystatin nystatin (mouth-throat)
48 30
159
omeprazole omeprazole-sodiumbicarbonate OMNARIS
237
238 224
ONE-A-DAY TEEN ADVANTAGEFOR HIM 205 ONE-A-DAY VITACRAVES 205 ONE-A-DAY VITACRAVES
nystatin (topical) 59 OMNICAP 208 GUMMIES+OMEGA-3 nystatin-triamcinolone NYTOL MAXIMUM STRENGTH O-CAL FA O-CAL PRENATAL OB COMPLETE
60
98 214 214 214
OMNIPRED 229 OMNITROPE 91,92 ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS 87 ON CALL EXPRESS GLUCOSE CONTROL
DHA 212 ONE-A-DAY VITACRAVES GUMMIES/IMMUNITYSUPPORT 205 ONE-A-DAY VITACRAVES SOURGUMMIES 205 ONE-A-DAY VITACRAVES
OB COMPLETE GOLD OB COMPLETE ONE OB COMPLETE PETITE
214 214 214
SOLUTION ON CALL LANCETS ON CALL LANCING DEVICE
113 113
113
WOMENS MULTI 205 ONE-A-DAY WEIGHT SMART ADVANCED 205 ONE-A-DAY WOMENS 50+
OB COMPLETE PREMIER 214 ON CALL PLUS BLOOD ADVANTAGE 205 OB COMPLETE/DHA OCALIVA OCEAN NASAL SPRAY
214 93
224
GLUCOSE TEST 87 ON CALL PLUS GLUCOSE CONTROL LEVEL 1/2 113 ON CALL PLUS
ONE-A-DAY WOMENS ACTIVE MIND & BODY 205 ONE-A-DAY WOMENS FORMULA 164
OCUFEN OCUFLOX OCUVITE ADULT 50+ OCUVITE ADULT FORMULA
230 228 205
205
LANCETS 113 ON CALL PLUS LANCING DEVICE 113 ON CALL VIVID BLOOD GLUCOSE TEST 87 ON CALL VIVID BLOOD
ONE-A-DAY WOMENS PETITES 205 ONE-A-DAY WOMENS PLUS HEALTHY SKIN SUPPORT205 ONE-A-DAY WOMENS PRENATAL 214
OCUVITE LUTEIN 205 GLUCOSE TEST STRIPS 87
Index 39
ONE-A-DAY WOMENS VITACRAVES GUMMIES 205 ONE-A-DAY/JOLLYRANCHER 209 ONETOUCH CLUB LANCETS FINE POINT 113 ONETOUCH COMBO PACK 113 ONETOUCH DELICA LANCETS EXTRA FINE 33G 113 ONETOUCH DELICA LANCETS FINE 30G 113 ONETOUCH DELICA LANCING DEVICE 113 ONETOUCH FINEPOINT LANCETS 113 ONETOUCH LANCETS 113 ONETOUCH ULTRA BLUE 87 ONETOUCH ULTRA CONTROL 113 ONETOUCH ULTRASOFT LANCETS 113 ONETOUCH VERIO CONTROL SOLUTION HIGH 113 ONETOUCH VERIO MID CONTROL SOLUTION 113 ONETOUCH VERIO TEST STRIPS 87 ONEXTON 56 ONFI 19 ONGLYZA 26 ONMEL 30 ONZETRA XSAIL 155 OPANA 10 OPANA ER (CRUSHRESISTANT) 10 ophthalmic irrigationsolution 230 OPSUMIT 49 OPTI-WOMAN 205 OPTICHAMBER ADVANTAGE 152 OPTICHAMBER ADVANTAGE/LARGEMASK 152 OPTICHAMBER ADVANTAGE/MEDIUM FACEMASK 152 OPTICHAMBER ADVANTAGE/SMALL FACEMASK 152 OPTICHAMBER DIAMOND152 OPTICHAMBER DIAMOND/LARGEFACEMASK 152
OPTICHAMBER DIAMOND/MEDIUM FACEMASK 152 OPTICHAMBER DIAMOND/SMALLFACEMASK 152 OPTICHAMBER FACE MASK/LARGE 152 OPTICHAMBER FACE MASK/MEDIUM 152 OPTICHAMBER FACE MASK/SMALL 152 OPTIHALER 153 OPTIHALER MDI DRUG DELIVERY SYSTEM 153 OPTIMUM AIRVITES 205 OPTISOURCE POST BARIATRIC SURGERY 205 OPTIUM TEST STRIPS 87 OPTIUMEZ TEST STRIPS 87 OPTIVITE P.M.T. 205 OPTUMRX BLOOD GLUCOSE TEST 87 OPTUMRX GLUCOSE CONTROL LEVEL 1/2 114 OPURITY 205 OPURITY/BYPASSOPTIMIZED 205 ORACEA 75 oral electrolytes 156 ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT 160 ORALAIR 4 ORALAIR ADULT SAMPLE KIT 4 ORALAIR ADULT STARTER PACK 4 ORALAIR CHILDREN/ADOLESCENTSSTARTER PACK 4 ORAP 234 ORAVIG 159 ORCHIC 220 ORENCIA 7 ORENCIA CLICKJECT 7 ORENITRAM 49 ORKAMBI 235 orphenadrine citrate 223 ORTHO MICRONOR 52 ORTHO TRI-CYCLEN 51 ORTHO TRI-CYCLEN LO 51 ORTHO-CYCLEN 51
ORTHO-NOVUM 1/35 51 ORTHO-NOVUM 7/7/7 51 oseltamivir phosphate 47 OSENI 25 OTEZLA 7 OTOVEL 231 OTREXUP 5 OVACE PLUS WASH 61 OVACE WASH 61 OVARY 220 OVCON-35 51 OVIDE 76 oxaprozin 7 OXAYDO 10 oxazepam 15 oxcarbazepine 21 oxiconazole nitrate 60 OXISTAT 60 OXSORALEN ULTRA 60 OXTELLAR XR 21 oxybutynin chloride 239 oxycodone hcl 10 OXYCODONE HCL ER 10 oxycodone w/acetaminophen 11 oxycodone-aspirin 11 OXYCODONE/ACETAMINOPHEN 11 OXYCODONE/IBUPROFEN 11 OXYCONTIN 10 oxymetazoline hcl 225 oxymorphone hcl 10 OXYMORPHONE HYDROCHLORIDE ER 10 OXYTROL 239 OXYTROL FOR WOMEN 239 oyster shell 156 P & S 73 PA MENS 50 PLUS VITAPAK 205 PA MENS VITAPAK 206 PA WOMENS 50 PLUS VITAPAK 206 PA WOMENS VITAPAK 206 PAIN-A-LAY 159 paliperidone 41 PALOMAR E 75 PAMELOR 24
Index 40
PANCREAZE 89 PEDIALYTE ADVANCED PEN NEEDLES 31G X CARE 156 5MM 139PANDEL 64 PEDIALYTE FREEZER PEN NEEDLES 31G XPANOXYL-4 CREAMY POPS 156 6MM 139WASH 56 PEDIALYTE SINGLES 156 PEN NEEDLES 31G X
pantoprazole sodium 237 8MM 139PEDIAPRED 52PARAFON FORTE DSC 223 PEN NEEDLES 31GX5/16" 139PEDIATRIC AEROSOLPARATHYROID 220 PEN NEEDLES 31GX6MMMASK 153 PARI ALTERA NEBULIZER PEDIATRIC (1/4") 139 HANDSET 153 MOUTHPIECE/DISPOSABLE PEN NEEDLES 31GX8MM 139 PARI BABY CONVERSION 153 PEN NEEDLES 31GX8MM KITSIZE 1 153 pediatric multiple vitamin w/ (5/16") 139 PARI BABY CONVERSION c 212 PEN NEEDLES 32G X KITSIZE 2 153 pediatric multiple vitamin w/ c & 4MM 139 PARI BABY CONVERSION fa 212 PEN NEEDLES 32G X KITSIZE 3 153 pediatric multiple vitamin w/ 5MM 139 PARI ERAPID NEBULIZER extra c & fa 212 PEN NEEDLES 32G X HANDSET 153 pediatric multiple vitamin w/ 6MM 139 PARI EXPIRATORY FILTER minerals & c 210,212 PEN NEEDLES 32GX4MM 139VALVE SET 153 pediatric multiple vitamins212 PEN-KERA 71PARI MASK SET 153 pediatric multiple vitamins w/ penicillin v potassium 231PARI SOFT PLASTIC ADULT iron 209 PENICILLIN VMASK 153 pediatric multivitaminsPARI SOFT PLASTIC w/fl 208 POTASSIUM 231 PEDIATRIC MASK 153 pediatric vitamins acd w/ penicillin v potassium 232 PARLODEL 40 fluoride 208 PENLAC NAIL LACQUER 60 PARNATE 22 pediatric vitamins adc 213 PENNSAID 58
peg 3350-kcl-sod bicarb-sodparoxetine hcl 23 PENTASA 94chloride-sod sulfateparoxetine mesylate 99 pentazocine w/ naloxone 12peg 3350-potassium chloride-(vasomotor) 234 sod bicarbonate-sod PENTIPS 29G X 12MM 139
PARVLEX 206 chloride 99 PENTIPS 29GX12MM 139PATADAY 230 PEG-INTRON 46 PENTIPS 31G X 5MM 139PATANASE 224 PEG-INTRON REDIPEN 46 PENTIPS 31G X 8MM 139PATANOL 230 PEG-INTRON REDIPEN PAK PENTIPS 31GX5MM 139PAXIL 23 4 46 PENTIPS 31GX6MM 139PEGANONE 21PAXIL CR 23 PENTIPS 31GX8MM 139PEGASYS 46PAZEO 230 PENTIPS 32G X 4MM 139PC LANCETS SUPER THIN PEGASYS PROCLICK 46
PENTIPS 32GX4MM 13930G 114 PEGINTRON 46 PC UNIFINE PENTIPS 29G pentoxifylline 96PELEVERUS 75X1/2" 138 PENTRAVAN 71PELEVERUS CLEAR 75PC UNIFINE PENTIPS 31G PENTRAVAN PLUS 71X5MM MINI 138 PELEVERUS GOLD 75 PC UNIFINE PENTIPS 31G PEN NEEDLES 29G X PEPCID 237 X6MM ULTRA SHORT 138 12MM 139 PEPCID AC 237 PC UNIFINE PENTIPS 31G PEN NEEDLES PEPCID AC MAXIMUMX8MM SHORT 139 29GX1/2" 139 STRENGTH 237 PCE 100 PEN NEEDLES PEPTO-BISMOL 28 PEARL DROPS EXTRA 30GX5/16" 139 PERCOCET 11STRENGTH 121 PEN NEEDLES ped multivitamins w/fl & 30GX8MM 139 PERFECT LANCETS 30G 114 iron 209 PEN NEEDLES 31G X 1/4" PERFECT PRESSURE
SHORT 139 ACTIVATED SAFETY LANCETSPEDIA-LAX 99 PEN NEEDLES 31G X 28G 114PEDIALYTE 157 3/16" 139 PERFOROMIST 18
Index 41
PERIDEX 159 PERIDIN-C 163 perindopril erbumine 34 permethrin 76 perphenazine 43 PERPHENAZINE/AMITRIPTYLINE 233
phenylephrine-mineral oil-petrolatum 13 phenylephrine-shark liver oil-cocoa butter 13 phenylephrine-shark liver oil-mineral oil-petrolatum 13 phenylephrine-witch hazel 13 PHENYTEK 21
PNV PRENATAL PLUS MULTIVITAMIN + DHA PNV TABS 29-1 PNV-DHA PNV-DHA+DOCUSATE PNV-OMEGA PNV-SELECT
214 214 214 214 214 214
PERSANTINE PERTZYE PETROLATUM PETROLEUM JELLY LIP TREATMENT
96 89 71
75
phenytoin phenytoin sodium phenytoin sodiumextended PHLEXY-VITS
22 22
22 206
PNV-TOTAL 214 PNV-VP-U 215 POCKET CHAMBER 153 POCKET SPACER 153 POCKETCHEM EZ BLOOD
PEXEVA 23 PHOS-NAK POWDER GLUCOSE TEST STRIPS 88 PFLEX PHARMACIST CHOICE
153 CONCENTRATE PHOSLYRA
158 95
POCKETCHEM EZ CONTROL LEVEL 1 114
ALCOHOLPREP PADS 120 PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS 87 PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS 88 PHARMACIST CHOICE ULTRA THIN LANCETS 114 PHARMACIST CHOICE ULTRA THIN LANCETS 28G 114 PHARMACIST CHOICE ULTRA THIN LANCETS 30G 114 PHARMACIST CHOICE ULTRA THIN LANCETS 31G 114 PHARMACIST CHOICE ULTRA THIN LANCETS 33G 114 PHARMACY COUNTER LANCETS 114 PHAZYME 93 PHAZYME ULTRA STRENGTH 93 phenazopyridine hcl 95 phenelzine sulfate 23 phenobarbital 98 PHENOBARBITAL 98 phenobarbital 98 phenol (antiseptic) 159 phenylephrine hcl (ophth) 228 phenylephrine hcl (oral) 225 phenylephrine in hard fat 13 phenylephrine-brompheniramine-dm 54 phenylephrine-chlorphen-dm
54 phenylephrine-cocoa butter 13 phenylephrine-dm-gg w/ apap 54
PHOSPHOLINE IODIDE 227 PHYTOMULTI 206 PILLOW MASK/ADULT 153 PILLOW MASK/CHILD 153 PILLOW MASK/PEDIATRIC 153 pilocarpine hcl 227 pilocarpine hcl (oral) 160 pimozide 234 pindolol 47 pioglitazone hcl 27 pioglitazone hcl-glimepiride 25 pioglitazone hcl-metforminhcl 25 piroxicam 7 PITUITARY 220 PLAN B ONE-STEP 52 PLAQUENIL 36 PLAVIX 96 PLEGRIDY 233 PLEGRIDY STARTER PACK 233 PLETAL 96 PNEUMOVAX 23 239 PNEUMOVAX 23/1DOSE 239 PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID 214 PNV FOLIC ACID + IRON MULTIVITAMIN 214 PNV OB+DHA 214 PNV PRENATAL PLUS MULTIVITAMIN 214
podofilox 73 POLY-VI-FLOR 208 POLY-VI-FLOR FS 208 POLY-VI-SOL 212 POLY-VI-SOL/IRON 209 polyethylene glycol 3350 99 polyethylene glycol-propyleneglycol (ophth) 226 POLYMEM ALGINATE DRESSING/3" X 3" 81 POLYMEM ALGINATE DRESSING/4" X 4" 81 POLYMEM ALGINATE DRESSING/5" X 5" 81 POLYMEM ALGINATE DRESSING/6.5" X 7.5" 81 POLYMEM SILVER DRESSING/4.25" X 4.25" 81 polymyxin b-trimethoprim 228 polysaccharide iron complex 97 POLYSPORIN 58 POLYTRIM 228 polyvinyl alcohol 226 polyvinyl alcohol-povidone(ophth) 226 POMALYST 38 PONSTEL 7 pot phosphate monobasic w/ sodphosphate dibasic &monobasic 158 potassium 158 potassium bicarbonate 158 potassium chloride 158 POTASSIUM CHLORIDE 158 potassium chloride 158 POTASSIUM CHLORIDE ER 158
Index 42
potassium chloride PRECISION SURE-DOSE PREFERRED PLUS INSULIN microencapsulated crystals INSULIN SYRINGE/0.5ML/29G SYRINGE/U-100/0.5ML/28G Xer 158 X 1/2" 139 1/2" 139 potassium citrate PRECISION SURE-DOSE PREFERRED PLUS INSULIN (alkalinizer) 95 INSULIN SYRINGE/0.5ML/30G SYRINGE/U-100/0.5ML/29G XPOTASSIUM X 3/8" 139 1/2" 140 GLUCONATE 158 PRECISION SURE-DOSE PREFERRED PLUS INSULIN POTIGA 21 INSULIN SYRINGE/1ML/28G X SYRINGE/U-100/0.5ML/30G X
1/2" 139 5/16" 140PR NATAL 400 215 PRECISION SURE-DOSE PREFERRED PLUS INSULINPR NATAL 400 EC 215 PLUSINSULIN SYRINGE/U-100/1ML/28G XPR NATAL 430 215 SYRINGE/0.3ML/29G X 1/2" 140 PR NATAL 430 EC 215 1/2" 139 PREFERRED PLUS INSULIN
PRECISION SURE-DOSE SYRINGE/U-100/1ML/29G XPRADAXA 19 PLUSINSULIN 1/2" 140PRALUENT 33 SYRINGE/1ML/29G X PREFERRED PLUS INSULIN pramipexole dihydrochloride 40 1/2" 139 SYRINGE/U-100/1ML/30G X
PRECISION THIN 5/16" 140PRAMLYTE 22 LANCETS 114 PREFERRED PLUS LANCETSPRAMOTIC 231 PRECISION THINS GP COLORED 21G 114
pramoxine hcl (rectal) 13 LANCET 114 PREFERRED PLUS LANCETS pramoxine-phenylephrine- PRECISION ULTRA SUPER THIN 30G 114 glycerin-petrolatum 13 LANCET 114 PREFERRED PLUS LANCETS pramoxine-zinc acetate 74 PRECISION XTRA 88 THIN 26G 114
PREFERRED PLUS UNIFINEPRANDIMET 25 PRECISION XTRA BLOOD PENTIPS 29G X 12MM 140GLUCOSE TEST STRIPS 88PRANDIN 28 PREFERRED PLUS UNIFINEPRECOSE 24prasugrel hcl 96 PENTIPS 31G X 6MM ULTRA
PRED FORTE 229 SHORT 140PRAVACHOL 33 PRED MILD 229 PREFERRED PLUS UNIFINEpravastatin sodium 33 PENTIPS 31G X 8MMPRED-G 229prazosin hcl 35 SHORT 140PRED-G S.O.P. 229PRECISION GLUCOSE PREFERRED PLUS UNIFINE
CONTROL 114 prednicarbate 64 PENTIPS 32GX4MM 140 PRECISION GLUCOSE prednisolone 52 PREFERRED PLUS UNIFINE CONTROLSOLUTION (TRI- prednisolone acetate PENTIPS/MINI/31GX5MM 140 LEVEL/HI/LO/NORMAL) 114 (ophth) 229 PREMARIN 93,241PRECISION GLUCOSE prednisolone sodium PREMIUM BLOOD GLUCOSEKETONECONTROL SOLUTION phosphate 52 TEST STRIPS 881-LOW, 1-HIGH 114 PREDNISOLONE SODIUM PREMIUM CONDOMSPRECISION PHOSPHATE 229 LUBRICATED 101GLUCOSE/KETONECONTROL PREDNISONE 52 PREMIUM PACKETS 206SOLUTIONS 1-HI 1-LO 114 prednisone 53 PREMPRO 92PRECISION PCX 88
PREDNISONE 53 PRENAISSANCE 215PRECISION PCX PLUS TEST STRIPS 88 PREDNISONE INTENSOL 52 PRENAISSANCE PRECISION POINT OF CARE BALANCE 215PREFERA OB 215 PRENAISSANCE HARMONYTEST STRIPS 88 PREFERAOB +DHA 215PRECISION QID TEST DHA 215 STRIPS 88 PREFERAOB ONE 215 PRENAISSANCE NEXT 215 PRECISION SOF-TACT TEST PREFERRED PLUS PRENAISSANCE NEXT-B 215 STRIPS 88 GLUCOSE 26 PRENAISSANCE PLUS 215PRECISION SURE-DOSE PREFERRED PLUS INSULIN INSULIN SYRINGE/0.3ML/30G X SYRINGE/U-100/0.3ML/29G X PRENATA 215 5/16" 139 1/2" 139 PRENATABS FA 215 PRECISION SURE-DOSE PREFERRED PLUS INSULIN PRENATABS RX 215INSULIN SYRINGE/0.5ML/28G X SYRINGE/U-100/0.3ML/30G X PRENATAL 2161/2" 139 5/16" 139
PRENATAL 19 215
Index 43
PRENATAL FORMULA 215 PRETTY FEET & HANDS 71 PROCARDIA XL 48 PRENATAL FORMULA A-FREE 215 PRENATAL LOW IRON 215 PRENATAL MULTIVITAMIN 215 PRENATAL MULTIVITAMIN + DHA 215 PRENATAL ONE DAILY 215 PRENATAL PLUS 215 PRENATAL PLUS IRON 215
PREVACID 237,238 PREVACID 24HR 237 PREVACID SOLUTAB 238 PREVIDENT 5000 DRY MOUTH 160 PREVIDENT 5000 PLUS 160 PREVIDENT FLUORIDE 160 PREVNAR 13 239 PREVPAC 238
PROCENTRA PROCERV HP prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCTOCORT PROCTOFOAM PRODIGY CONTROL
2 206 43 43 43 97 13 13
PRENATAL VITAMIN 216 PREZCOBIX 44 SOLUTIONHIGH 114 PRENATAL VITAMIN & PREZISTA 44 PRODIGY CONTROL MINERAL 216 PRENATAL VITAMIN/IRON 216 PRENATAL VITAMINS 216 PRENATAL VITAMINS PLUS LOW IRON 216 PRENATAL-U 216 PRENATE 216 PRENATE AM 216 PRENATE DHA 216 PRENATE ELITE 216
PRILOSEC 238 PRIMACARE 217 PRIMACOL BORDERED DRESSING 2"X2" 81 PRIMACOL BORDERED DRESSING 4"X4" 81 PRIMACOL BORDERED DRESSING 6"X6" 81 PRIMACOL DRESSING 4"X4" 81 PRIMACOL DRESSING 6"X6" 81
SOLUTIONLOW 114 PRODIGY INSULIN SYRING/U-100/0.3ML/31G X 5/16" 140 PRODIGY INSULIN SYRINGE/1/2ML/31G X5/16" 140 PRODIGY INSULIN SYRINGE/1ML/28G X 1/2" 140 PRODIGY LANCING DEVICE 114 PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS 88 PRODIGY PRESSURE
PRENATE ENHANCE 216 PRIMACOL DRESSING ACTIVATED SAFETY PRENATE ESSENTIAL PRENATE MINI PRENATE PIXIE PRENATE RESTORE
217 217 217 217
8"X8" PRIMACOL SPECIALTY DRESSING PRIMAQUINE PHOSPHATE
81
81
36
LANCETS PRODIGY SAFETY LANCETS PRODIGY TWIST TOP LANCETS
114
114
114 PRENATE STAR 217 primidone 21 PRODRIN 154
PREPARATION H 13 PRIMLEV 11 PROFE FORTE 217 PREPARATION H TOTABLES BURN RELIEF 13 PREPARATION H TOTABLES PAIN RELIEF 13 PREPLUS 217 PREQUE 10 217 PRESCRIPTIVE FORMULAS OPTIMAL VITAMIN PACKS MENS 206 PRESCRIPTIVE FORMULAS OPTIMAL VITAMIN PACKS WOMENS 206 PRESERVISION AREDS 206 PRESERVISION AREDS 2 206 PRESERVISION AREDS 2 + MULTI VITAMIN 206 PRESERVISION/LUTEIN 206 PRESSURE ACTIVATED SAFETYLANCET 21G 114 PRESTALIA 36 PRETAB 217
PRINIVIL 34 PRISTIQ 24 PRO COMFORT ALCOHOL PADS 120 PRO COMFORT LANCETS 30G 114 PRO COMFORT LANCETS 31G 114 PRO COMFORT PEN NEEDLES/31G X 8MM 140 PRO COMFORT PEN NEEDLES/32G X 4MM 140 PRO COMFORT PEN NEEDLES/32G X 5MM 140 PRO COMFORT PEN NEEDLES/32G X 6MM 140 PRO-CAL 206 PROAIR HFA 18 PROAIR RESPICLICK 18 probenecid 96 PROCARDIA 48
progesterone micronized 232 PROGRAF 159 PROLENSA 230 promethazine &phenylephrine 54 promethazine hcl 32 promethazine w/codeine 54 promethazine-dm 54 promethazine-phenylephrine-codeine 54 PROMETHAZINE/PHENYLEPHRINE 54 PROMETRIUM 232 PRONUTRIENTS SUPER B-COMPLEX+ANTIOXIDANTS
161 propafenone hcl 16 propranolol hcl 47 PROPRANOLOL HCL 47 propranolol hcl 48
Index 44
PROPRANOLOL/HYDROCHLOROTHIAZIDE 36 propylthiouracil 236 PRORENAL+D 206 PRORENAL+D/OMEGA-3 206 PROSCAR 95 PROSHIELD PROTECTIVE HANDCREAM 75 PROSTATE 220 PROSTEON 157 PROTECT CARDIO AF 206 PROTECT PLUS 206 PROTECT PLUS NF 206 PROTECT PLUS SO 206 PROTONIX 238 PROTOPIC 72 protriptyline hcl 24 PROVENTIL HFA 18
PX ADVANCED LANCING DEVICE 114 PX EXTRA SHORT PEN NEEDLES 31GX6MM 140 PX GLUCOSE 26 PX INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" 140 PX INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 140 PX INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" 140 PX INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 140 PX INSULIN SYRINGE/U-100/1ML/30G X 1/2" 140 PX INSULIN SYRINGE/U-100/1ML/31G X 5/16" 140 PX LANCET AUTO INJECTOR 114 PX LANCETS ULTRA THIN 115 PX LANCETS ULTRA THIN
QC PRENATAL QC UNIFINE PENTIPS 32GX4MM QC UNILET LANCETS 28G/ULTRA THINQC UNILET LANCETS 33G/MICRO THIN QNASL QNASL CHILDRENS QTERN QUARTETTE QUDEXY XR QUENCH QUESTRAN QUESTRAN LIGHT quetiapine fumarate QUFLORA PEDIATRIC QUICKTEK CONTROL SOLUTION
217
140
115
115 224 224 25 51 21
206 32 32 42
208
115 PROVERA PROVIDA DHA PROVIDA OB PROVIGIL
232 217 217
4
28G PX MINI PEN NEEDLES 31GX5MM PX PEN NEEDLE 29GX12MM
115
140
140
QUICKTEK TEST STRIPS QUILLICHEW ER QUILLIVANT XR QUIN B STRONG
88 4 4
206 PROZAC 23 PROZAC WEEKLY 23 pseudoephed-bromphen-dm 54 pseudoephedrine hcl 225 pseudoephedrine w/ codeine-gg 54 pseudoephedrine-guaifenesin
54 PSORCON 64 PSS SELECT GP LANCETS 114 PSS SELECT SAFETY LANCETS 114 psyllium 99 PTS PANELS GLUCOSE TEST 88 PTS PANELS KETONE TEST 88 PULMICORT 17 PULMICORT FLEXHALER 17 PULMOZYME 235
PX PEN NEEDLE 31GX8MM 140 PX PRENATAL MULTIVITAMINS 217 PX SHORTLENGTH PEN NEEDLES/31GX8MM 140 PYLERA 238 pyrazinamide 37 pyrethrins-piperonylbutoxide 76 PYRIDIUM 95 pyridostigmine bromide 37 pyridoxine hcl 243 pyrithione zinc 61 QBRELIS 34 QC ADVANCED LANCING DEVICE 115 QC ALCOHOL SWABS 120 QC COD LIVER OIL 222 QC LANCETS SUPER THIN 115
quinapril hcl 34 quinapril-hydrochlorothiazide
36 quinidine gluconate 16 QUINIDINE SULFATE 16 QUINIDINE SULFATE ER 16 QUINTABS 208 QUINTABS-M 206 QUINTET AC BLOOD GLUCOSETEST STRIPS 88 QUINTET BLOOD GLUCOSE TEST STRIPS 88 QUINTET GLUCOSE CONTROL/HIGH/NORMAL
115 QVAR 17 R-NATAL OB 217 RA ALCOHOL SWABS 120 RA CENTRAL-VITE UNDER 50MENS 206 RA CENTRAL-VITE UNDER
PUREFE OB PLUS PUREFE PLUS PURIXAN PUSH BUTTON SAFETY LANCETS 21G PUSH BUTTON SAFETY LANCETS 28G
217 97 37
114
114
QC LANCETS ULTRA THIN 115 QC PEN NEEDLES 29G X 12MM 140 QC PEN NEEDLES 31G X 6MM 140 QC PEN NEEDLES 31G X 8MM 140
50WOMENS RA COD LIVER OIL RA DRY MOUTH RA E-ZJECT COLOR LANCETSMICRO-THIN 33G RA E-ZJECT LANCETS 28G
206 222 160
115
115
Index 45
RA E-ZJECT LANCETS THIN RAZADYNE 233 REFUAH PLUS GLUCOSE 26G 115 RA E-ZJECT LANCETS THIN 28G 115 RA E-ZJECT LANCETS ULTRATHIN 30G 115 RA EAR CARE 220
RAZADYNE ER READYLANCE SAFETY LANCETS/21G/2.2MMREADYLANCE SAFETY LANCETS/23G/1.8MMREADYLANCE SAFETY
233
115
115
CONTROL SOLUTION REGLAN RELENZA DISKHALER RELION 2-IN-1 LANCING DEVICE 25G RELION 2-IN-1 LANCING
115 94 47
115
RA ESSENCE-C RA FLUORIDE
206 LANCETS/26G/1.8MMREADYLANCE SAFETY
115 DEVICE 30G RELION ALCOHOL
115
TOOTHPASTE 121 RA GENTLE SKIN CREAM 71
LANCETS/28G/1.8MMREADYLANCE SAFETY
115 SWABS 120 RELION BLOOD GLUCOSE
RA GLUCOSE 26 RA INSULIN SYRINGE/0.5ML/29G X1/2" 141 RA INSULIN SYRINGE/1ML/29GX 1/2" 141 RA INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 141 RA INSULIN SYRINGE/U-100/1ML/30G X 5/16" 141 RA LANCING DEVICE 115 RA ONE DAILY 217 RA OYSTER SHELL CALCIUM/VITAMIN D 156 RA PEN NEEDLES 31G X 5MM3/16" 141 RA PEN NEEDLES 31G X 8MM5/16" 141 RA PRENATAL 217 RA PRENATAL FORMULA/FOLICACID 217 RA RENEWAL ADVANCED HEALING 75 RA RENEWAL DRY SKIN THERAPY 71 RA SENSITIVE
LANCETS/30G/1.6MM 115 REALITY INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 141 REALITY INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 141 REALITY INSULIN SYRINGE/U-100/1ML/28G X1/2" 141 REALITY INSULIN SYRINGE/U-100/1ML/29G X1/2" 141 REALITY LANCETS 115 REALITY LATEX CONDOMS/LUBRICATED 10 1 REALITY LATEX/ULTRATEXTURED 101 REALITY LATEX/ULTRATHIN 101 REALITY SWABS 120 REALITY TRIGGER LANCETS 115 REBETOL 46 REBIF 234
TESTSTRIPS 88 RELION CONFIRM/MICROTEST STRIPS 88 RELION GLUCOSE 26 RELION INSULIN SYRINGE 1ML/31GX15/64" 141 RELION INSULIN SYRINGE/U-00/1ML/29G X 1/2" 141 RELION INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 141 RELION INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 141 RELION INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 141 RELION INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 141 RELION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 141 RELION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 141 RELION INSULIN SYRINGE/U-100/1ML/30G X 5/16" 141 RELION INSULIN SYRINGE/U-100/1ML/31G X 15/64" 141 RELION INSULIN SYRINGE/U-100/1ML/31G X 5/16" 141 RELION KETONE 88
TOOTHPASTE/FLUORIDE 121
REBIF REBIDOSE REBIF REBIDOSE
234 RELION KETONE TEST STRIPS 88
RA TRUETEST STRIPS 88 TITRATIONPACK 234 RELION LANCETS MICRO-RA WHITENING TOOTHPASTE/FLUORIDE
121 rabeprazole sodium 238 RADIAGUARD ADVANCED 71 RAGUS 206 RAGWITEK 4 raloxifene hcl 92 ramipril 34 ranitidine hcl 237 RAPAFLO 95 RAPAMUNE 159 rasagiline mesylate 40 RAYALDEE 92
REBIF TITRATION PACK234 REFISSA 57 REFRESH 227 REFRESH LIQUIGEL 226 REFRESH OPTIVE 227 REFRESH OPTIVE ADVANCED 226 REFRESH OPTIVE ADVANCED SENSITIVE 226 REFRESH OPTIVE MEGA-3 227 REFRESH OPTIVE SENSITIVE 227 REFRESH TEARS 227 REFUAH PLUS BLOOD GLUCOSETEST STRIPS 88
THIN33G 115 RELION LANCETS STANDARD 21G 115 RELION LANCETS THIN 26G 115 RELION LANCETS ULTRA-THIN30G 115 RELION LANCING DEVICE 115 RELION MINI PEN NEEDLES 31GX6MM 141 RELION PEN NEEDLES 29GX12MM 141 RELION PEN NEEDLES 31GX6MM 141 RELION PEN NEEDLES 31GX8MM 141
Index 46
82
RELION PEN NEEDLES RESCRIPTOR 45 RESTORE WOUND CARE 32GX4MM 141 DRESSING 4"X4"RESERPINE 35RELION PRIME BLOOD ADHESIVERESTA 71GLUCOSE TEST STRIPS 88 RESTORE WOUND CARE RELION SHORT PEN RESTA LITE 71 DRESSING 4"X4" NON-NEEDLES31GX8MM 141 ADHESIVE 82RESTASIS 229RELION ULTIMA BLOOD RESTORE WOUND CARERESTASIS MULTIDOSE 229GLUCOSE TEST STRIPS 88 DRESSING 4"X5" CONTACTRESTORE CLEANSER &RELION ULTIMA TEST LAYER 82MOISTURIZER 75STRIPS 88 RESTORE WOUND CARERESTORE CX WOUND CARERELION ULTRA THIN DRESSING 6"X6"DRESSING-STERILE 81LANCETS30G 115 ADHESIVE 82RESTORE DRESSING FORRELION ULTRA THIN PLUS RESTORE WOUND CAREPSORIASIS-STERILE 81LANCETS 32G 115 DRESSING 6"X8" 82RESTORE EXTRA THINRELION ULTRA THIN PLUS RESTORE WOUND CAREDRESSING 4"X4" 81LANCETS 33G 115 DRESSING 6"X8"RESTORE EXTRA THINRELISTOR 94 ADHESIVE 82DRESSING 6"X8" 81 RESTORE WOUND CARERELNATE DHA 217 RESTORE EXTRA THIN DRESSING 6"X8" CONTACTRELPAX 155 DRESSING 8"X8" 81 LAYER 82RESTORE HYDROGELREMEDY CLEAR-AID 75 RESTORE WOUND CAREGAUZE PAD 4"X4" 81REMERON 22 DRESSING 6"X8" NON-RESTORE PLUS WOUND ADHESIVE 82REMERON SOLTAB 22 CARE DRESSING 4"X4" 81 RESTORE WOUND CARERENAGEL 95 RESTORE PLUS WOUND DRESSING 8"X8" 82CARE DRESSING 4"X4"RENAPLEX-D 206 RESTORIL 98TAPERED EDGE 81RENVELA 95 RESTORE PLUS WOUND RETIN-A 56 repaglinide 28 CARE DRESSING 6"X6" RETIN-A MICRO 57 REPAGLINIDE/METFORMIN TAPERED EDGE 81 RETIN-A MICRO PUMP 57HYDROCHLORIDE 25 RESTORE PLUS WOUND
RETROVIR 45CARE DRESSING 6"X8" 82REPATHA 33 RESTORE PLUS WOUND REVATIO 49REPATHA PUSHTRONEX CARE DRESSING 6"X8" REVEAL BLOOD GLUCOSESYSTEM 33 TAPERED EDGE 82 TEST 88REPATHA SURECLICK 34 RESTORE PLUS WOUND REVLIMID 158REPLACE 206 CARE DRESSING 8"X8" 82 REXALL BLOOD GLUCOSEREPLACEMENT AIR RESTORE PLUS WOUND TEST STRIPS 88FILTER 153 CARE DRESSING 8"X8" REXALL LANCETS ULTRAREPLACEMENT FILTERS 153 TAPERED EDGE 82 THIN 115RESTORE PLUS WOUNDREPLICARE 1-1/2"X2-1/2" 81 REXULTI 43CARE DRESSINGREPLICARE 4"X4" 81 REYATAZ 45TRIANGLE 82
REPLICARE 6"X6" 81 RESTORE SILVER DRESSING RHEUMATREX 5 REPLICARE 8"X8" 81 2"X2" 82 RHINOCORT AQUA 224RESTORE SILVER DRESSINGREPLICARE THIN 2"X2.75" 81 ribavirin (hepatitis c) 464"X4" NON-ADHESIVE 82REPLICARE THIN 3.5"X5.5" 81 RESTORE SILVER DRESSING riboflavin 243 REPLICARE THIN 6"X8" 81 4"X4.75" 82 RID 76
RESTORE SILVER DRESSINGREPLICARE ULTRA 4"X4" 81 RID ESSENTIAL LICE4"X5" CONTACT LAYER 82 ELIMINATION KIT 76REPLICARE ULTRA 6"X6" 81 RESTORE SILVER DRESSING RIFADIN 37REPLICARE ULTRA SACRUM 6"X8" CONTACT LAYER 827"X8" 81 RESTORE SILVER DRESSING rifampin 37 REPREXAIN 11 6"X8" NON-ADHESIVE 82 RIGHT STEP PRENATAL 217 REQ 49+ 206 RESTORE WOUND CARE RIGHTEST GC300 HIGH REQUIP 40 DRESSING 4"X4" 82 CONTROL 115
RIGHTEST GC300 NORMALREQUIP XL 40 CONTROL 115
Index 47
RIGHTEST GD500 LANCING DEVICE 115 RIGHTEST GL300 LANCETS 115 RIGHTEST GS100 BLOOD
ropinirole hydrochloride ROSE MILK ROSULA rosuvastatin calcium
40 72 57 33
SAFETY INSULIN SYRINGES 1ML/30GX1/2" 142 SAFETY LANCET 21G/PRESSUREACTIVATED 116
GLUCOSE TEST STRIPS RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS rimantadine hydrochloride RIOMET RISABAL-PH risedronate sodium
88
88
88 47 25 71 91
ROWASA ROXICODONE ROZEREM RTD WOUND CARE DRESSING2" X 2" RTD WOUND CARE DRESSING4" X 4" RTD WOUND CARE DRESSING4" X 5"
94 10 99
82
82
82
SAFETY LANCET 28G/PRESSUREACTIVATED SAFETY LANCETS SAFETY LANCETS 21G SAFETY LANCETS 28G SAFETY LET LANCETS SAFETY SEAL LANCETS 28G
116 116 116 116 116
116 RISPERDAL 41 RUBRACA 39 SAFETY SEAL LANCETS RISPERDAL CONSTA RISPERDAL M-TAB risperidone RITALIN
41 41 41 4
RULAVITE DHA RYDAPT RYTARY RYTHMOL
217 39 40 16
30G SAFETY-GLIDE INSULIN SYRINGE/0.3ML/29G X1/2" SAFYRAL
116
142 51
RITALIN LA 4 SABRIL 21 SAIZEN 92 RITEFLO 153 rivastigmine 233 rivastigmine tartrate 233 rizatriptan benzoate 155 ROBAXIN 223 ROBAXIN-750 223 ROBINUL 236 ROBINUL FORTE 236 ROBITUSSIN DM 54 ROBITUSSIN PEAK COLD COUGH+ CHEST CONGESTION DM MAX STRENGTH 54 ROBITUSSIN PEAK COLD DM 54 ROC DEEP WRINKLE SERUM 71 ROC MULTI CORREXION 5 IN1 RESTORING EYE CREAM 71 ROC MULTI CORREXION 5 IN1 RESTORING NIGHT CREAM 71 ROC MULTI CORREXION LIFTANTI-GRAVITY NIGHT 71 ROC RETINOL CORREXION 71 ROC RETINOL CORREXION MAX 71 ROC RETINOL CORREXION NIGHT 71 ROC RETINOL CORREXION SENSITIVE EYE 71 ROC RETINOL CORREXION SENSITIVE NIGHT 71 ROCALTROL 92
SAFE-T-LANCE LOW FLOW 25G 115 SAFE-T-LANCE NORMAL FLOW21G 115 SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW 115 SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW 116 SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW 116 SAFESNAP INSULIN SYRINGE/0.3ML/30G X5/16" 141 SAFESNAP INSULIN SYRINGE/0.5ML/29G X1/2" 141 SAFESNAP INSULIN SYRINGE/0.5ML/30G X5/16" 141 SAFESNAP INSULIN SYRINGE/1ML/28G X1/2" 141 SAFESNAP INSULIN SYRINGE/1ML/29G X1/2" 142 SAFETY INSULIN SYRINGES 0.5ML/29GX1/2" 142 SAFETY INSULIN SYRINGES 0.5ML/30GX5/16" 142 SAFETY INSULIN SYRINGES 1ML/27GX1/2" 142 SAFETY INSULIN SYRINGES 1ML/29GX1/2" 142
SAIZEN CLICK.EASY 92 SAIZENPREP RECONSTITUTIONKIT 92 SALAGEN 160 SALESE 160 salicylic acid 73 salicylic acid & sulfur 61 saline 224 SAMI THE SEAL REPLACEMENTFILTERS 153 SANCUSO 29 SANDIMMUNE 159 SANTYL 72 SAPHRIS 42 SAPS CARE ALCOHOL PREP PADS 120 SAPSCARE TWIST TOP LANCETS 30G 116 SARNA 60 SAVAYSA 18 SAVELLA 233 SAVELLA TITRATION PACK 233 SAVISION 206 SB ALCOHOL PREP PADS 120 SB INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 142 SB INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 142 SB INSULIN SYRINGE/U-100/1ML/29G X 1/2" 142
Index 48
SB INSULIN SYRINGE/U-100/1ML/30G X 5/16"SB INSULIN SYRINGE/U-100/1ML/31G X 5/16" SB LANCETS THIN
142
142 116
SENSODYNE MAXIMUM STRENGTH 121 SENSODYNE MAXIMUM STRENGTH TARTAR CONTROL PLUS
SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/REMOVER/29GX12MM 142 SHOPKO UNIFINE PENTIPS
SB LANCETS ULTRA THIN SCHNUCKS INSULIN SYRINGEULTI-FINE/U-100/0.5ML/29G X 1/2"SCHNUCKS INSULIN SYRINGEULTI-FINE/U-100/0.5ML/30G X 5/16" scopolamine SE PLUS PROTEIN SE-NATAL 19
116
142
142 29
158 217
WHITENING 121 SENSODYNE PRONAMEL 121 SENSODYNE PRONAMEL FRESHBREATH 121 SENTRY 206 SENTRY SENIOR 206 SENTRY SENIOR/LUTEIN 206 SEREVENT DISKUS 18 SERNIVO 64
PLUS PEN NEEDLES/SHORT/REMOVR/31GX8MM 142 SHOPKO UNILET LANCETS SUPER THIN 30G 116 SHOPKO UNILET LANCETS ULTRA THIN 28G 116 SIDE BUTTON SAFETY LANCET21G 116 SIDEROL 206 SIDESTREAM ADULT FACE MASK 153
SE-TAN DHA 217 SEROQUEL 42 SIDESTREAM PEDIATRIC SEASONIQUE SEASORB-AG SEBULEX
51 82 61
SEROQUEL XR SEROSTIM sertraline hcl
42 92 23
FACEMASK 153 SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL 153
SECTRAL 47 sevelamer carbonate 95 SIDESTREAM PEDIATRIC SEEBRI NEOHALER SELECT-LITE LANCING DEVICE SELECT-OB SELECT-OB+DHA selegiline hcl selenium
16
116 217 217 40
158
SFROWASA 94 SHOHLS SOLUTION MODIFIED 95 SHOPKO ALCOHOL SWABS 120 SHOPKO AUTOLET LANCING DEVICE 116 SHOPKO ON-THE-GO
FACEMASK/TUCKER THETURTLE 153 SIDESTREAM PLUS ADULT FACE MASK 153 SIGNIFOR LAR 92 sildenafil citrate (pulmonaryhypertension) 49 SILENOR 98
SELENIUM 158 selenium sulfide 61 SELSUN BLUE DEEP CLEANSING 73 SELSUN BLUE NATURALS 73 SELSUN BLUE NATURALS
COMFORTLANCETS 30G 116 SHOPKO UNIFINE PENTIPS PEN NEEDLES/MICRO/32GX4MM
142 SHOPKO UNIFINE PENTIPS
SILICONE MASK FOR BREATHERITE CHAMBER/ADULTSILICONE MASK FOR BREATHERITE CHAMBER/INFANTSILICONE MASK FOR
153
153
DRYSCALP 73 PEN BREATHERITE SELZENTRY SENIOR VITES sennosides sennosides-docusate sodium SENOKOT SENOKOT S
45 206 100
99 100 99
NEEDLES/MINI/31GX5MM142
SHOPKO UNIFINE PENTIPS PEN NEEDLES/ORIGINAL/29GX12MM 142 SHOPKO UNIFINE PENTIPS PEN
CHAMBER/PEDIATRICSILICONE MASK FOR BREATHRITE CHAMBER/ADULT SILVADENE silver sulfadiazine SIMBRINZA
153
154 61 61
228
SENSI-CARE MOISTURIZING 75 SENSI-CARE PROTECTIVE BARRIER 75 SENSITIVE TOOTHPASTE EXTRA WHITENING/FLUORIDEMAX ST 121 SENSITIVE
NEEDLES/SHORT/31GX8MM142
SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/MICRO/REMOVR/32GX4MM 142 SHOPKO UNIFINE PENTIPS PLUS PEN
simethicone SIMPLE DIAGNOSTICS LANCING DEVICE SIMPONI simvastatin SINEMET SINEMET CR
93
116 5
33 40 40
TOOTHPASTE/FLUORIDE/MAXIMUM STRENGTH 121
NEEDLES/MINI/REMOVER/31GX5MM 142
SINGLE-LET SINGULAIR
116 16
Index 49
sirolimus 159 SMARTEST BLOOD SOOTHE & COOL SITAVIG SIVEXTRO
46 14
GLUCOSE TEST STRIPS 88 SMARTEST CONTROL SOLUTIONMEDIUM 116
MOISTURIZING BODY LOTION WITH ALOE 72 SOOTHE & COOL PROTECT
SKELAXIN 223 SMARTEST LANCETS MOISTURE BARRIER 75 SKIN BEAUTY & 28G 116 SOOTHE & COOL SKIN WELLNESS 206 sodium chloride 158 CREAMWITH ALOE & skin protectants, misc. SKIN REPAIR SKINTEGRITY 2" X 2" SKINTEGRITY 4" X 4" SKLICE SLO-NIACIN
75 72 82 82 76
243
sodium chloride (guirrigant) 95 sodium chloride (inhalant) 55 sodium chloride hypertonic 230 sodium citrate & citric acid 95 sodium fluoride 157
VITAMINS A, D & E 72 SOOTHENEB NBL 100 CHILD MASK 154 SOOTHENEB NBL 100 MEDICATION CUP 154 SOOTHENEB NBL 100 MESH CAP 154 SOOTHENEB NBL100 ADULT
SLOW FE 97 SLOW-MAG 157 SM ALCOHOL PREP PADS 120 SM B-COMPLEX/VITAMINC 163 SM GLUCOSE 26 SM INSULIN SYRINGE/1ML/31GX 5/16" 142 SM MICRO THIN LANCETS
sodium fluoride (dental) 160 sodium phosphates 99 sodium polystyrenesulfonate 159 SODIUM SULFACETAMIDE/SULFUR
57 SODIUM SULFACETAMIDE/SULFURCLEANSER IN UREA 57
MASK 154 SORBACELL FOAM DRESSING 4"X4" 82 SORBACELL FOAM DRESSINGSTRIP 1"X8" 82 SORBIDON HYDRATE 75 SORBOLENE 72 SORBSAN TOPICAL WOUND DRESSING 12" 82 SORBSAN TOPICAL WOUND
33G 116 SOLARTEK GLUCOSE DRESSING 2" X 2" 82 SM ONE DAILY CONTROLSOLUTIONS 116 SORBSAN TOPICAL WOUND ESSENTIAL 164 SM ONE DAILY MENS 206 SM ONE DAILY PRENATAL 217 SM ONE DAILY WOMENS 206 SM PRENATAL VITAMINS 217 SM TRUEDRAW LANCING DEVICE 116
SOLIQUA 100/33 25 SOLO 206 SOLODYN 235 SOLOSITE CONFORMABLE WOUND 2"X2" 82 SOLOSITE CONFORMABLE WOUND 4"X4" 82 SOLUS V2 AUDIBLE
DRESSING 3 X 3 82 SORBSAN TOPICAL WOUND DRESSING 4 X 4 83 SORBSAN TOPICAL WOUND DRESSING 4" X 8" 83 SORIATANE 60 SORILUX 61 sotalol hcl 48
SMART DIABETES VANTAGE LANCING DEVICE 116 SMART SENSE COLOR LANCETS UNIVERSAL
TEST SOLUS V2 CONTROL HIGH SOLUS V2 CONTROL
88
116
sotalol hcl (afib/afl) SOTYLIZE SOVALDI
48 48 46
33G 116 LOW 116 SPECIAL CARE CREAM 72 SMART SENSE GLUCOSE 26 SMART SENSE GLUCOSE TABLETS 26 SMART SENSE PREMIUM BLOODGLUCOSE STRIPS 88 SMART SENSE STANDARD LANCETS UNIVERSAL 21G 116 SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G 116 SMART SENSE THIN LANCETSUNIVERSAL 26G 116 SMART SENSE VALUE BLOOD GLUCOSE STRIPS 88
SOLUS V2 LANCING DEVICE 116 SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G 116 SOLUS V2 TWIST LANCETS 30G 116 SOMA 223 SONATA 98 SOOTHE & COOL FREE MEDSEPTIC 75 SOOTHE & COOL FREE MOISTURE BARRIER 75 SOOTHE & COOL FREE SKIN PASTE 75 SOOTHE & COOL MOISTURE BARRIER 75
specialty vitamins products 220 SPINOSAD 76 SPIRIVA HANDIHALER 16 SPIRIVA RESPIMAT 16 spironolactone 90 spironolactone &hydrochlorothiazide 90 SPLEEN 221 SPORANOX 30 SPORANOX PULSEPAK 30 SPORTSCREME 73 SPRITAM 21 SPRIX 7 SPRYCEL 39
Index 50
SSKI 157 sulfasalazine 94 SURE COMFORT INSULIN SSS 10-5 57 ST IVES SWISS FORMULA 24HOUR MOISTURE 72 STALEVO 100 40 STALEVO 125 40 STALEVO 150 40 STALEVO 200 40 STALEVO 50 40 STALEVO 75 40 STARLIX 28 stavudine 45 STERILANCE TL 116 STIOLTO RESPIMAT 18 STIVARGA 39 STOMACH 221 STRATASORB COMPOSITE ISLAND DRESSING 4" X 4" 83 STRATTERA 3 STRIBILD 45 STRIVERDI RESPIMAT 18 STROVITE FORTE 207 STROVITE ONE 207 STUART ONE 217 STUDIO 35 EXTRA MOISTURIZING LOTION 72 STUDIO 35 MOISTURIZING SKIN 72 SUBOXONE 12 SUBSYS 10 sucralfate 237 SUDAFED CHILDRENS 225 SUDAFED CONGESTION 225
sulindac 7 SUMADAN WASH 57 sumatriptan 155 sumatriptan succinate 155 SUMATRIPTAN SUCCINATE 155 sumatriptan succinate 155 SUMATRIPTAN/NAPROXENSODIM 154 SUMAVEL DOSEPRO 155 SUMAXIN 57 SUMAXIN TS 57 SUMAXIN WASH 57 SUPER ANTIOXIDANT 207 SUPER C-500 COMPLEX 164 SUPER NU-THERA 207 SUPER THIN LANCETS 116 SUPERB NAILS 207 SUPERVITE EC 207 SUPPORT 207 SUPRAX 50 SUPREME II HIGH/LOWCONTROL SOLUTION 116 SUPREME TEST STRIPS 88 SURE COMFORT ALCOHOL PREP PADS 120 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 142 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 142 SURE COMFORT INSULIN
SYRINGE/U-100/0.5ML/30G X5/16" 143 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X5/16 143 SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X1/2" 143 SURE COMFORT INSULIN SYRINGE/U-100/1ML/29G X1/2" 143 SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X1/2" 143 SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X5/16" 143 SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X5/16" 143 SURE COMFORT LANCETS 28G 117 SURE COMFORT LANCETS 30G 117 SURE COMFORT LANCING PEN 117 SURE COMFORT PEN NEEDLES29GX1/2"12.7MM 143 SURE COMFORT PEN NEEDLES30GX5/16"SHORT 143 SURE COMFORT PEN NEEDLES31GX3/16"(5MM) 143 SURE COMFORT PEN NEEDLES31GX5/16"(8MM) 143 SURE COMFORT PEN
SUDAFED NASAL DECONGESTANT MAXIMUM STRENGTH 225
SYRINGE/U-100/0.3ML/30G X5/16" 142 SURE COMFORT INSULIN
NEEDLES32GX5/32"SURE COMFORT PEN NEEDLES32GX6MM
143
143 SUDAFED PE CONGESTION SULAR
225 48
SYRINGE/U-100/0.3ML/31G X5/16 142 SURE COMFORT INSULIN
SURE EDGE BLOOD GLUCOSE TEST STRIPS 89 SURE-FINE PEN NEEDLES
sulfacetamide sod-prednisolone 229 sulfacetamide sodium 61 SULFACETAMIDE SODIUM 228 sulfacetamide sodium (acne)57 sulfacetamide sodium (ophth) 228 sulfacetamide sodium w/sulfur 57 sulfamethoxazole-trimethoprim
14
SYRINGE/U-100/0.3ML/31G X5/16" 143 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 143 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 143 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 143
29GX1/2" 12.7MM 143 SURE-FINE PEN NEEDLES 31GX3/16" 5MM 143 SURE-FINE PEN NEEDLES 31GX5/16" 8MM 143 SURE-JECT INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 143 SURE-JECT INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 143
Index 51
SURE-JECT INSULIN SUTENT 39 TEARS NATURALE PM 227 SYRINGE/U-100/0.3ML/31G X5/16" 143 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 143 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 143 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 143 SURE-JECT INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 143 SURE-JECT INSULIN SYRINGE/U-100/1ML/28G X1/2" 144 SURE-JECT INSULIN SYRINGE/U-100/1ML/29G X1/2" 144 SURE-JECT INSULIN SYRINGE/U-100/1ML/30G X5/16" 144 SURE-JECT INSULIN SYRINGE/U-100/1ML/31G X5/16" 144 SURE-LANCE FLAT LANCETS 117 SURE-LANCE LANCETS 26G 117 SURE-LANCE THIN LANCETS 28G 117 SURE-LANCE ULTRA THIN LANCETS 117 SURE-PEN 117 SURE-PREP ALCOHOL PREP PADS 120 SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS 89 SURE-TOUCH LANCETS UNIVERSAL 117 SURECHEK BLOOD GLUCOSE TEST STRIPS 89 SURELITE LANCETS 117 SURESTEP GLUCOSE CONTROL 117 SURESTEP GLUCOSE
SWEEN CREAM 72 SYMBICORT 18 SYMBYAX 233 SYMLINPEN 120 24 SYMLINPEN 60 24 SYMPROIC 94 SYNAGEX 207 SYNALAR 64 SYNALGOS-DC 11 SYNATEK 207 SYNJARDY 25 SYNJARDY XR 25 SYNTHROID 236 SYSTANE 227 SYSTANE OVERNIGHT THERAPY LUBRICANT EYE 227 SYSTANE ULTRA 227 SYSTANE ULTRA HOME & AWAY PACK 227 T-VITES 207 TABLOID 37 TACLONEX 64 tacrolimus 159 tacrolimus (topical) 73 TAFINLAR 39 TAGAMET HB 237 TAGRISSO 39 TAI DOC CONTROL 117 TALTZ 61 TAMIFLU 47 tamoxifen citrate 38 tamsulosin hcl 95 TANZEUM 27 TAPAZOLE 236 TARCEVA 39 TARKA 36 TARON-BC 217 TARON-C DHA 217
TECFIDERA 234 TECFIDERA STARTER PACK 234 TECHLITE AST LANCETS 117 TECHLITE LANCETS 117 TECHLITE LANCETS 30G 117 TECHLITE PEN NEEDLES 29GX 12 MM 144 TECHLITE PEN NEEDLES 31GX 5MM 144 TECHLITE PEN NEEDLES/31GX5MM 144 TECHLITE PEN NEEDLES/31GX6 MM 144 TECHLITE PEN NEEDLES/31GX8MM 144 TECHLITE PEN NEEDLES/32GX4MM 144 TECHLITE PEN NEEDLES/32GX6MM 144 TECHNIVIE 46 TEGADERM AG MESH DRESSING WITH SILVER 2"X2" 83 TEGADERM AG MESH DRESSING WITH SILVER 4"X5" 83 TEGADERM AG MESH DRESSING WITH SILVER 4"X8" 83 TEGADERM AG MESH DRESSING WITH SILVER 8"X8" 83 TEGADERM ALGINATE AG DRESSING 83 TEGADERM HIGH GELLING ALGINATE DRESSING 4"X4" 83 TEGADERM HIGH INTEGRITY ALGINATE DRESSING 4"X4" 83 TEGADERM MATRIX DRESSING 83 TEGRETOL 21 TEGRETOL-XR 21 TEKTURNA 36
CONTROLSOLUTION 117 SURESTEP PRO HIGH GLUCOSECONTROL 117 SURESTEP PRO LOW GLUCOSECONTROL 117 SURESTEP PRO NORMAL GLUCOSE CONTROL 117 SURMONTIL 24 SUSTIVA 45
TARON-PREX TASIGNA TASMAR TAVIST ALLERGY TAYTULLA tazarotene TAZORAC
217 39 40 31 52 61 61
TEKTURNA HCT 36 TELCARE BLOOD GLUCOSE TEST STRIPS 89 TELCARE GLUCOSE CONTROL SOLUTION LEVEL 1/2 117 telmisartan 34 telmisartan-amlodipine 36 telmisartan-hydrochlorothiazide
36
Index 52
temazepam 98 TGT LANCET ULTRA THIN thioridazine hcl 43 28G 117TEMODAR 37 thiothixene 43TGT LANCET ULTRA THIN
TEMOVATE 64 THRESHOLD IMT 15430G 117 TEMOVATE E 64 TGT LANCING DEVICE 117 THRIVITE 19 218 temozolomide 37 THALOMID 158 THRIVITE RX 218 TENCON 8 THEO-24 18 throat lozenges 160 TENEX TENORETIC 100
35 36
theophylline THERA
18 208
THYMUS thyroid
221 236
TENORETIC 50 36 THERA M PLUS 207 THYROLAR-1 236 TENORMIN 47 THERA-FLUR-N 160 THYROLAR-1/2 236 TERAZOL 3 241 THERA-M 207 THYROLAR-1/4 236 TERAZOL 7 241 THERA-TABS M 207 THYROLAR-2 236 terazosin hcl 35 THERABETIC EYE THYROLAR-3 236 terbinafine hcl terbinafine hcl (topical)
30 60
HEALTH THERABETIC MULTI-VITAMIN
221
207
tiagabine hcl TIAZAC
21 48
terbutaline sulfate 18 THERABETIC SKIN CARE72 TIGAN 29 terconazole vaginal 241 THERACAL D2000 157 TIKOSYN 16 TESSALON PERLES 53 THERACAL D4000 157 TIMOLOL MALEATE 48 TESTIM TESTONE CIK
12 12
THERACAL RAPID REPLETION 157
timolol maleate (ophth) TIMOPTIC
227 227
TESTOSTERONE testosterone testosterone cypionate
12 12 12
THERAGRAN-M 207 THERAGRAN-M ADVANCED 207 THERAGRAN-M ADVANCED
TIMOPTIC OCUDOSE TIMOPTIC-XE TINACTIN
227 227 60
TESTOSTERONE PUMP 12 50 PLUS 207 TINACTIN DEODORANT 60 tetracycline hcl TETRACYCLINE HCL
235 235
THERAGRAN-M PREMIER 207 THERAGRAN-M PREMIER 50
TINACTIN JOCK ITCH TINDAMAX
60 14
tetrahydrozoline hcl (ophth) 228 tetrahydrozoline w/ polyethyleneglycol 228 tetrahydrozoline-dextran-polyethylene glycol-povidone 229 TEXACORT 64
PLUS 207 THERAMILL FORTE 207 THERANATAL CORE NUTRITION 218 THERANATAL LACTATION COMPLETE 207 THERANATAL LACTATION
tinidazole TIROSINT TIVICAY TIVORBEX tizanidine hcl TL FOLATE
14 236 45 7
223 218
TGT ADVANCED LANCING DEVICE 117 TGT ALCOHOL SWABS 120 TGT BLOOD GLUCOSE TEST STRIPS 89 TGT BLOOD GLUCOSE TEST STRIPS PREMIUM 89 TGT GLUCOSE 26 TGT LANCET ALTERNATE SITE 117 TGT LANCET MICRO THIN 33G 117 TGT LANCET SUPER THIN 30G 117 TGT LANCET THIN 23G 117 TGT LANCET THIN 26G 117
ONE 207 THERANATAL LACTATION SUPPORT 207 THERAPEUTIC MOISTURIZING 72 THERAPEUTIC T+PLUS MAXIMUM STRENGTH 73 THERAPLEX HYDROLOTION 72 THERAPLEX T 76 THEREMS-H 207 THEREMS-M 207 thiamine hcl 243 thiamine mononitrate 243 THINLETS GP LANCETS117 THINLETS LANCET 117
TL-CARE DHA TL-SELECT TOBI TOBI PODHALER TOBRADEX TOBRADEX ST TOBRAMYCIN tobramycin tobramycin (ophth) tobramycin sulfate TOBRAMYCIN SULFATE tobramycin sulfate tobramycin-dexamethasone
218 218
5 5
229 229
5 5
228 5 5 5
230
Index 53
TOBREX 228 TOPCARE ULTRA COMFORT TRI-TABS DHA 218 TODAYS HEALTH ADVANCED LANCING DEVICE 117 TODAYS HEALTH MINI PEN NEEDLES 31G X 1/4" 144 TODAYS HEALTH ORIGINAL PEN NEEDLES 29G X 1/2" 144 TODAYS HEALTH SHORT PEN NEEDLES 31G X 5/16" 144 TODAYS HEALTH SUPER THINLANCETS 30G 117 TODAYS HEALTH ULTRA THINLANCETS 28G 117 TOE-AID 83 TOFRANIL 24 TOFRANIL-PM 24 TOLAZAMIDE 28 TOLBUTAMIDE 28
INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" 144 TOPCO INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 144 TOPCO INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 144 TOPCO INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 145 TOPCO INSULIN SYRINGE/U-100/1ML/28G X 1/2" 145 TOPCO INSULIN SYRINGE/U-100/1ML/29G X 1/2" 145 TOPICORT 64 topiramate 21 TOPIRAMATE ER 21
TRI-VIT/FLUORIDE/IRON 209 TRIADVANCE 218 triamcinolone acetonide (mouth) 160 triamcinolone acetonide (nasal) 224 triamcinolone acetonide (topical) 64 triamcinolone acetonide-dimethicone-silicone 64 TRIAMINIC COLD & ALLERGY 54 TRIAMINIC FEVER REDUCERPAIN RELIEVER CHILDRENS 8 TRIAMINIC FEVER REDUCERPAIN RELIEVER INFANTS 8
tolcapone TOLMETIN SODIUM tolmetin sodium TOLMETIN SODIUM
40 7 7 7
TOPROL XL torsemide TOUJEO SOLOSTAR TOVIAZ
47 90 28
239
triamterene & hydrochlorothiazide 90 TRIAMTERENE/HYDROCHLOROTHIAZIDE 90 TRIANEX 64
tolnaftate 60 TRACLEER 49 TRIAZOLAM 98 tolterodine tartrate 239 TRADJENTA 27 triazolam 98 TOPAMAX 21 tramadol hcl 10 TRIBENZOR 36 TOPAMAX SPRINKLE 21 TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX1/4" 144 TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX5/16" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X5/16" 144 TOPCARE ULTRA COMFORT
TRAMADOL HCL ER 10 tramadol-acetaminophen 11 trandolapril 34 trandolapril-verapamil hcl 36 tranexamic acid 97 TRANSDERM-SCOP 29 TRANXENE T 15 tranylcypromine sulfate 23 TRAVATAN Z 231 TRAVEL LANCETS 30G 117 TRAVOPROST 231
TRICARE 218 TRICARE PRENATAL 218 TRICARE PRENATAL 1 218 TRICARE PRENATAL COMPLEAT 218 TRICARE PRENATAL DHA ONE 218 TRICOR 33 TRIDESILON 64 trifluoperazine hcl 43 trifluridine 228 TRIGLIDE 33
INSULIN SYRINGE/0.5ML/30G X5/16" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" 144 TOPCARE ULTRA COMFORT
trazodone hcl TRECATOR TRELEGY ELLIPTA TREMFYA TRESIBA FLEXTOUCH tretinoin tretinoin (chemotherapy)
23 37 18 61 28 57 39
trihexyphenidyl hcl TRILEPTAL TRILIPIX trimethobenzamide hcl trimipramine maleate TRINATAL GT TRINATAL RX 1
39 21 33 29 24
218 218
INSULIN SYRINGE/1ML/31G X5/16" 144 TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 144
TRETINOIN EMOLLIENT 57 tretinoin microsphere 57 TREXALL 37 TREXIMET 154 TREZIX 11
TRINATE 218 TRINTELLIX 23 TRIPLE CREAM 72 TRIPLE HELIX COLLAGEN 2"X2" 83
TRI-NORINYL 28 52 TRISTART DHA 218
Index 54
TRIUMEQ TRIVEEN-DUO DHA TRIVEEN-PRX RNF
45 218 218
TRUECONTROL GLUCOSE CONTROL LEVEL 0 117 TRUECONTROL GLUCOSE CONTROL LEVEL 1 117
TRUEPLUS PEN NEEDLES 31GX8MM 145 TRUEPLUS PEN NEEDLES 32GX4MM 145
TRIXAICIN 73 TRUEDRAW LANCING TRUEPLUS SAFETY LANCETS TRIZIVIR 45 TROJAN EXTENDED PLEASURE/LUBRICATED 101 TROJAN MAGNUM 101 TROJAN MAGNUM WARM SENSATIONS 101 TROJAN MAGNUM XL LUBRICATED 101 TROJAN PLEASURE MESH/SPERMICIDAL 101 TROJAN RIBBED W/SPERMICIDAL 101 TROJAN SHARED SENSATION/LUBRICATED
102 TROJAN SUPRAS SPERMICIDAL 102 TROJAN TWISTED PLEASURE 102 TROJAN ULTRA PLEASURE/LUBRICATED 102 TROJAN VERY SENSITIVE LUBRICATED 102 TROJAN VERY SENSITIVE SPERMICIDAL LUBRICANT 102 TROJAN VERY THIN LUBRICATED 102 TROJAN VERY THIN SPERMICIDAL LUBRICANT 102 TROJAN-ENZ LUBRICANT102 TROJAN-ENZ LUBRICATED 102 TROJAN-ENZ W/SPERMICIDAL 102 TROKENDI XR 21 trolamine salicylate 73 TROPAZONE 72 tropicamide 227 trospium chloride 239 TRUE METRIX BLOOD GLUCOSETEST STRIPS 89 TRUE METRIX CONTROL SOLUTION LEVEL 1 117 TRUE METRIX CONTROL SOLUTION LEVEL 2 117 TRUE METRIX CONTROL SOLUTION LEVEL 3 117 TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS 89
DEVICE 118 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 145 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 145 TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X1/2" 145 TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X1/2" 145 TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X5/16" 145 TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X5/16" 145 TRUEPLUS LANCETS 26G 118 TRUEPLUS LANCETS 28G 118 TRUEPLUS LANCETS 28G SUPER THIN 118 TRUEPLUS LANCETS 30G 118 TRUEPLUS LANCETS 30G ULTRA THIN 118 TRUEPLUS LANCETS 33G 118 TRUEPLUS LANCETS 33G MICRO THIN 118 TRUEPLUS PEN NEEDLES 29GX12MM 145 TRUEPLUS PEN NEEDLES 31GX5MM 145 TRUEPLUS PEN NEEDLES 31GX6MM 145
28G 118 TRUETEST BLOOD GLUCOSE TEST 89 TRUETEST BLOOD GLUCOSE TEST STRIPS 89 TRUETEST GLUCOSE CONTROLLEVEL 1 118 TRUETEST GLUCOSE CONTROLLEVEL 2 118 TRUETEST GLUCOSE CONTROLLEVEL 3 118 TRUETEST STRIPS 89 TRUETRACK BLOOD GLUCOSE TEST 89 TRUETRACK TEST 89 TRULICITY 27 TRUMENBA 239 TRUSOPT 230 TRUSTEX COLOR CONDOMS + LUBE 102 TRUSTEX LUBRICATED 102 TRUSTEX LUBRICATED EXTRALARGE 102 TRUSTEX LUBRICATED EXTRASTRENGTH 102 TRUSTEX LUBRICATED/RIBBED/STUDDED 102 TRUSTEX LUBRICATED/SPERMICIDE
102 TRUSTEX LUBRICATED/SPERMICIDEEXTRA LARGE 102 TRUSTEX LUBRICATED/SPERMICIDEEXTRA STRENGTH 102 TRUSTEX NATURAL CONDOMS +LUBE/LUBRICATED 102 TRUSTEX WITH NONOXYNOL-9/RIBBED/STUDDED 102 TRUSTEX/RIALUBRICATED 102 TRUSTEX/RIA LUBRICATEDSPERMICIDE 102 TRUSTEX/RIALUBRICATED/SPERMICIDE
102 TRUVADA 45 TUBING/WING TIP 154 TUDORZA PRESSAIR 16
Index 55
TUMS 13 ULTICARE INSULIN ULTICARE INSULIN TUMS LASTING EFFECTS TUSNEL C
14 54
SYRINGE/0.3ML/30G X5/16"ULTICARE INSULIN
145 SYRINGE/U-100/0.5ML/29G X1/2" 146 ULTICARE INSULIN
TWYNSTA TYBOST TYKERB TYLENOL TYLENOL 8 HOUR
36 45 39 8 8
SYRINGE/0.5ML/28G X1/2"ULTICARE INSULIN SYRINGE/0.5ML/29G X1/2"ULTICARE INSULIN
145
145
SYRINGE/U-100/0.5ML/30G X1/2" 146 ULTICARE INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 146 ULTICARE INSULIN
TYLENOL 8 HOUR ARTHRITISPAIN TYLENOL CHILDRENS TYLENOL COLD & FLU SEVERE TYLENOL EXTRA STRENGTH TYLENOL INFANTS TYLENOL INFANTS PAIN+FEVER TYLENOL PM EXTRA STRENGTH TYLENOL SORE THROAT DAYTIME TYLENOL/CODEINE #3 TYLENOL/CODEINE #4 TYMLOS TYVASO TYVASO REFILL
8 8
54
8 8
8
98
8 11 11 91 49 49
SYRINGE/0.5ML/30G X1/2" 145 ULTICARE INSULIN SYRINGE/0.5ML/30G X5/16" 145 ULTICARE INSULIN SYRINGE/1ML/28G X1/2" 146 ULTICARE INSULIN SYRINGE/1ML/29G X1/2" 146 ULTICARE INSULIN SYRINGE/1ML/30G X1/2" 146 ULTICARE INSULIN SYRINGE/1ML/30G X5/16" 146 ULTICARE INSULIN SYRINGE/SHORT/0.3ML/30GX 5/16" 146 ULTICARE INSULIN
SYRINGE/U-100/0.5ML/31G X5/16" 146 ULTICARE INSULIN SYRINGE/U-100/1ML/29G X1/2" 146 ULTICARE INSULIN SYRINGE/U-100/1ML/30G X1/2" 146 ULTICARE INSULIN SYRINGE/U-100/1ML/30G X5/16" 146 ULTICARE INSULIN SYRINGE/U-100/1ML/31G X5/16" 146 ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.3ML/31G X 5/16" 146 ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.5ML/31G X 5/16" 146 ULTICARE INSULIN
TYVASO STARTER 49 TYZEKA 46 UCERIS 12 UDDERLY SMOOTH 72 UDDERLY SMOOTH EXTRA CARE 72 UDDERLY SMOOTH EXTRA CARE20 72
SYRINGE/SHORT/0.3ML/31GX 5/16" 146 ULTICARE INSULIN SYRINGE/SHORT/0.5ML/30GX 5/16" 146 ULTICARE INSULIN SYRINGE/SHORT/0.5ML/31GX 5/16" 146 ULTICARE INSULIN
SYRINGEULTRAFINE U-100/1ML/31G X 5/16" 146 ULTICARE MICRO PEN NEEDLES 31G X 8MM 146 ULTICARE MICRO PEN NEEDLES 32G X 4MM 146 ULTICARE MICRO PEN NEEDLES/32G X 4MM 147 ULTICARE MINI PEN NEEDLES
ULORIC 96 ULTEC HYDROCOLLOID DRESSING 83 ULTI-LANCE AUTOMATIC/CLEAR TIP 118 ULTICARE ALCOHOL SWABS 120 ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X1/2" 145 ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2" 145 ULTICARE INSULIN SYRINGE/0.3ML/29G X1/2" 145 ULTICARE INSULIN SYRINGE/0.3ML/30G X1/2" 145
SYRINGE/SHORT/1ML/30G X5/16" 146 ULTICARE INSULIN SYRINGE/SHORT/1ML/31G X5/16" 146 ULTICARE INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 146 ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 146 ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 146 ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 146
31GX6MM 147 ULTICARE MINI PEN NEEDLES ULTI-FINE IV 147 ULTICARE MINI PEN NEEDLES/31G X 6MM 147 ULTICARE MINI PEN NEEDLES31GX6MM 147 ULTICARE ORIGINAL PEN NEEDLES ULTI-FINE 147 ULTICARE PEN NEEDLES 31GX 5MM/MINI 147 ULTICARE PEN NEEDLES/29GX 12.7MM 147 ULTICARE SHORT PEN NEEDLES 31GX8MM 147 ULTICARE SHORT PEN NEEDLES ULTI-FINE IV 147 ULTICARE SHORT PEN NEEDLES/31G X 8MM 147
Index 56
ULTICARE THIN LANCETS ULTILET SHORT PEN ULTRA-THIN II INSULIN 30G 118 ULTILET CLASSIC LANCETS 118 ULTILET INSULIN SYRINGE/0.3ML/30G X8MM 147 ULTILET INSULIN SYRINGE/0.3ML/31G X8MM 147 ULTILET INSULIN SYRINGE/0.5ML/30G X8MM 147 ULTILET INSULIN SYRINGE/1ML/30G X 8MM147 ULTILET INSULIN
NEEDLES31GX3/16" 147 ULTIMA TEST STRIPS 89 ULTIMATE FEELING 102 ULTIMATECARE ONE 218 ULTIMATECARE ONE NF 218 ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 147 ULTRA MEGA 207 ULTRA MEGA GOLD 207 ULTRA MEGA TWO 207 ULTRA MENS PACK 207
SYRINGE SHORT/U-100/0.3ML/31GX5/16"ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.5ML/30GX5/16"ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.5ML/31GX5/16"ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/30GX5/16"ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/31GX5/16"ULTRA-THIN II INSULIN
148
148
148
148
148
SYRINGE/1ML/31G X 8MM147 ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X12.7MM 147 ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X5/16" 147 ULTILET INSULIN SYRINGE/SHORT/0.3ML/31G X5/16" 147 ULTILET INSULIN SYRINGE/SHORT/0.5ML/30G X5/16" 147 ULTILET INSULIN SYRINGE/SHORT/0.5ML/31G X5/16" 147 ULTILET INSULIN SYRINGE/SHORT/1ML/30G X5/16" 147 ULTILET INSULIN SYRINGE/SHORT/1ML/31G X5/16" 147 ULTILET INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" 147 ULTILET INSULIN SYRINGE/U-100/1ML/30G X 1/2" 147 ULTILET LANCETS 118 ULTILET LANCETS 33G 118 ULTILET PEN NEEDLE 29GX12.7MM 147 ULTILET PEN NEEDLE 31GX5MM 147 ULTILET PEN NEEDLE 31GX8MM 147 ULTILET PEN NEEDLE 32GX4MM 147 ULTILET PEN NEEDLE 32GX4MM/SHORT 147 ULTILET SAFETY LANCETS 23G 118 ULTILET SHORT PEN NEEDLES 31GX5/16" 147
ULTRA THIN LANCETS 28G 118 ULTRA THIN LANCETS 30G 118 ULTRA WOMENS PACK 207 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/28G X1/2" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/29G X1/2" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X5/16" 148 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X5/16" 148 ULTRA-THIN II AUTO LANCET 118 ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.3ML/30GX5/16" 148
SYRINGE/U-100/0.3ML/29GX1/2" 148 ULTRA-THIN II INSULIN SYRINGE/U-100/0.5ML/29GX1/2" 148 ULTRA-THIN II INSULIN SYRINGE/U-100/1ML/29GX1/2"
148 ULTRA-THIN II LANCETS 28G 118 ULTRA-THIN II LANCETS 30G 118 ULTRA-THIN II MINI PEN NEEEDLES/31GX3/16" 148 ULTRA-THIN II PEN NEEDLES 29GX1/2" 148 ULTRA-THIN II PEN NEEDLES/SHORT/31GX5/16"
148 ULTRA-THIN II SAFETY AUTOLANCETS 26G 118 ULTRACET 11 ULTRAM 10 ULTRAM ER 10 ULTRATRAK PRO CONTROL SOLUTION 2 LEVELS 118 ULTRATRAK PRO NORMAL CONTROL 118 ULTRATRAK PRO TEST STRIPS 89 ULTRATRAK ULTIMATE CONTROL SOLUTION 2 LEVELS 118 ULTRATRAK ULTIMATE TEST STRIPS 89 ULTRAVATE 64 ULTRESA 89 UNICOMPLEX-M 207 UNIFINE PENTIPS 29GX12MM 148
Index 57
UNIFINE PENTIPS 31G X UNISTRIP1 GENERIC 89 VALUE PLUS LANCETS 3/16" 148 UNIVERSAL 1 LANCETS STANDARD 21G 119 UNIFINE PENTIPS VALUE PLUS LANCETSTHIN26G 11931GX5MM 148 SUPERTHIN 30G 119UNIVERSAL 1 LANCETSUNIFINE PENTIPS VALUE PLUS LANCETS THINULTRA THIN 30G 11931GX6MM 148 26G 119UNIVERSAL 1UNIFINE PENTIPS VALUE PLUS LANCINGLANCETS/33G/MICRO-THIN31GX8MM 148 DEVICE 119119UNIFINE PENTIPS VALUMARK LANCET SUPERUP & UP GLUCOSE 2632GX4MM 148 THIN 30G 119
UPTRAVI 49UNIFINE PENTIPS PLUS VALUMARK LANCET ULTRA 29GX12MM 149 urea 65 THIN 28G 119 UNIFINE PENTIPS PLUS VALUMARK PEN NEEDLESURECHOLINE 23931GX5MM 149 29GX12MM 149UROCIT-K 10 95UNIFINE PENTIPS PLUS VALUMARK PEN NEEDLES 31GX6MM 149 UROCIT-K 5 95 31GX 6MM 149 UNIFINE PENTIPS PLUS VALUMARK PEN NEEDLESUROXATRAL 95 31GX8MM 149 31GX 8MM 149URSO 250 94UNIFINE PENTIPS PLUS VALVED HOLDING
URSO FORTE 9432GX4MM 149 CHAMBER 154 UNILET COMFORTOUCH ursodiol 94 VANCOCIN HCL 14 LANCET 118 UTERUS 221 vancomycin hcl 14UNILET EXCELITE 118 UTIBRON NEOHALER 18 VANICREAM 72UNILET EXCELITE II 118 V-R MONOJECT INSULIN VANICREAM LITE 72UNILET G.P. LANCET 118 SYRINGE/U-100/0.3ML/29G X VANISHPOINT INSULINUNILET G.P. SUPERLITE 1/2" 149 SYRINGE/0.5ML/30G XLANCET 118 V-R MONOJECT INSULIN 1/2"UNILET GP 28 ULTRA SYRINGE/U-100/0.5ML/28G X 149
VANISHPOINT INSULINTHIN 118 1/2" 149 SYRINGE/0.5ML/30G XUNILET LANCET 118 V-R MONOJECT INSULIN 5/16" 149 UNILET LANCETS MICRO- SYRINGE/U-100/0.5ML/29G X VANISHPOINT INSULIN
1/2" 149THIN33G 118 SYRINGE/1ML/29G X 1/2" 149V-R MONOJECT INSULINUNILET LANCETS SUPER- VANISHPOINT INSULINSYRINGE/U-100/1ML/28G XTHIN30G 118 SYRINGE/1ML/30G X
UNILET LANCETS ULTRA-THIN 1/2" 149 5/16" 149V-R MONOJECT INSULIN28G 118 VANOS 64UNILET SUPERLITE SYRINGE/U-100/1ML/29G X
VAPORX BALM 55LANCET 118 1/2" 149 UNISOM 98 valacyclovir hcl 46 VARUBI 30
UNISOM SLEEPGELS 98 VALCYTE 45 VASCEPA 32 VASELINE PETROLATUMUNISTIK 3 GENTLE 118 valganciclovir hcl 45 GAUZE 83UNISTIK SAFETY LANCETS VALIUM 15 VASELINE PETROLATUM28G 118 valproate sodium 22 GAUZECISION DRESSING 83UNISTIK SAFETY LANCETS valproic acid 22 VASELINE PETROLATUM30G 118 GAUZECISION DRESSINGUNISTIK TOUCH SAFETY valsartan 34 OVERWRAP 83LANCETS 21G 119 valsartan-hydrochlorothiazide VASELINE PETROLATUMUNISTIK TOUCH SAFETY 36 GAUZEOVERWRAP 83LANCETS 23G 119 VALTREX 46 VASELINE PETROLATUMUNISTIK TOUCH SAFETY VALUE HEALTH INSULIN GAUZESTRIP 83LANCETS 28G 119 SYRINGE/U-100/0.5ML/29G X VASELINE PETROLATUMUNISTIK TOUCH SAFETY 1/2" 149 GAUZESTRIP OVERWRAP 83LANCETS 30G 119 VALUE HEALTH INSULIN VASELINE PETROLATUMUNISTRIP CONTROL SYRINGE/U-100/1ML/29G X GAUZETUBE FOILSOLUTIONHIGH 119 1/2" 149 OVERWRAP 83UNISTRIP CONTROL VALUE PLUS GLUCOSE 26 VASERETIC 36SOLUTIONLOW 119
Index 58
VASOTEC 34 VICOPROFEN 11 VIRT-ADVANCE 218 VECTICAL 61 VICTORY AGM-4000 TEST VIRT-C DHA 218 VELPHORO VELTIN VELVACHOL
95 57 72
STRIPS 89 VICTORY CONTROL LEVEL 1/2 119 VICTOZA 27
VIRT-NATE DHA VIRT-PN VIRT-PN DHA
218 218 218
VEMAVITE-PRX 2 218 VIDA MIA AUTOLET VIRT-PN PLUS 218 VENA-BAL DHA VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl VENLAFAXINE HCL ER VENTAVIS VENTOLIN HFA
218 37
37 24 24 49 18
LANCINGDEVICE 119 VIDA MIA UNIFINE PENTIPS32GX4MM 149 VIDA MIA UNIFINE PENTIPSMINI 31GX6MM149 VIDA MIA UNIFINE PENTIPSORIGINAL 29GX12MM 149 VIDA MIA UNILET LANCETS SUPER THIN 30G 119
VIRT-SELECT VIRT-VITE GT VIRTPREX VISINE VISINE ADVANCED RELIEF VISINE EXTRA VISTARIL
218 218 218 229
229 229 15
VERAMYST 224 VIDA MIA UNILET LANCETS VITA-BOB 207 verapamil hcl 48 VERASENS BLOOD GLUCOSE TEST STRIPS 89 VERASENS GLUCOSE CONTROLLEVEL 1 119
ULTRA THIN 28G VIDA MIA UNIPFINE PENTIPSSHORT 31GX8MM VIDEX EC
119
149 45
VITABEX VITAFOL FE+ VITAFOL GUMMIES VITAFOL ULTRA
207 218 218 218
VERELAN 48 VIDEXPEDIATRIC 45 VITAFOL-NANO 218 VERELAN PM 48 VIEKIRA PAK 46 VITAFOL-OB 218 VERIPRED 20 53 VIEKIRA XR 46 VITAFOL-OB+DHA 218 VERSACLOZ 42 vigabatrin 21 VITAFOL-ONE 218 VESICARE 239 VIGAMOX 228 VITALET PRO LANCETS 119 VEXOL 230 VFEND 30 VIADENT ADVANCED CARE TOOTHPASTE 121 VIADENT TOOTHPASTE 121 VIADENT TOOTHPASTE FLUORIDE 121 VIADENT TOOTHPASTE PLAQUEFIGHTING 121 VIBERZI 94 VIBRAMYCIN 235 VICKS BABYRUB 73 VICKS SINEX 225 VICKS SINEX 12 HOUR DECONGESTANT 225 VICKS SINEX 12 HOUR DECONGESTANT ULTRA FINE MIST 225 VICKS SINEX 12 HOUR DECONGESTANT ULTRA FINE
VIGILON PRIMARY WOUND DRESSING/13" X 24" 83 VIGILON PRIMARY WOUND DRESSING/3" X 8" 83 VIGILON PRIMARY WOUND DRESSING/4" X 4" 83 VIGILON PRIMARY WOUND DRESSING/6" X 8" 83 VIIBRYD 23 VIIBRYD STARTER PACK23 VIMOVO 7 VIMPAT 21 VINATE CARE 218 VINATE DHA RF 218 VINATE II 218 VINATE M 218 VINATE ONE 218 VIOKACE 89 VIRACEPT 45
VITALET PRO PLUS LANCETS 119 VITALETS 212 VITALETS CHILDRENS 212 VITALINE TOTAL FORMULA 2 207 VITALINE TOTAL FORMULA 3 207 VITAMAX 212 VITAMENT 207 vitamin a 242 VITAMIN C 164,243 VITAMIN C EFFERVESCENT BLEND 208 VITAMIN C/ELECTROLYTES 208 VITAMIN D3 COMPLETE 208 vitamin e 242 VITAMIN E WITH PANTHENOL 72
MIST/MOISTURIZNGVICKS SINEX MOISTURIZING VICKS SINEX SEVERE
225
225
VIRAMUNE VIRAMUNE XR VIREAD
45 45 45
vitamins a & d 222 vitamins a & d (topical) 72 VITAMINS FOR THE HAIR 221
NASALDECONGESTANT 225 VIROPTIC 228 VITAMINS TO GO VICKS VAPORUB 55 VIRT NATE 218 MAXIMUM
VITAMINS TO GO MEN 208 208
Index 59
VITAMINS TO GO WALGREENS COMFORT WOUNDGARD 2-1/2"X2-WOMEN 208 ASSUREDLANCETS MICRO 1/2" 83 vitamins w/ lipotropics 222 THIN/33G 119 WOUNDGARD 4"X4-1/4" 83
WALGREENS COMFORTVITAROCA PLUS 208 WOUNDGARD 4"X6" 83ASSUREDLANCETS SUPERVITASANA 208 XADAGO 40THIN/28G 119 VITATRUM 208 WALGREENS GLUCOSE 26 XALATAN 231 VITEKTA 45 WALGREENS LANCETS 119 XALKORI 39 VITRUM 50+ SENIOR WALGREENS THIN XANAX 15 MULTI 208 LANCETS 119 XANAX XR 15VIVA DHA 218 WALGREENS ULTRA THIN XARELTO 18LANCETS 119VIVARIN 3 XARELTO STARTER PACK 18warfarin sodium 18VIVELLE-DOT 93 XARTEMIS XR 11WATCHHALER 154VIVLODEX 7 VOCAL POINT BLOOD water for irrigation, sterile 159 XELJANZ 5
XELJANZ XR 5GLUCOSE TEST STRIPS 89 WAVESENSE PRESTO TEST VOGELXO 12 STRIPS 89 XELODA 37
WEBCOL ALCOHOL PREPVOGELXO PUMP 12 XERESE 61LARGE 1 PLY 120 XEROFLO DRESSINGVOL-NATE 218 WEBCOL ALCOHOL PREP 1"X8" 83VOL-PLUS 219 LARGE 2 PLY 120 XEROFLO DRESSINGWEBCOL ALCOHOL PREPVOL-TAB RX 219 2"X2" 83MEDIUM 2 PLY 120VOLTAREN 58 XEROFLO DRESSINGWEGMANS UNIFINE PENTIPS 5"X9" 83VOPAC MDS 58 PLUS 32GX4MM 149 XIFAXAN 14WEGMANS UNIFINE PENTIPSvoriconazole 30 PLUS/MINI/31GX5MM 149 XIGDUO XR 25VORTEX VALVED HOLDING WEGMANS UNIFINE PENTIPSCHAMBER 154 XIIDRA 229PLUS/SHORT/31GX8MM149VOSEVI 46 XIMINO 236WEGMANS UNIFINE PENTIPS
VOSPIRE ER 18 PLUS/ULTRA XODOL 11 VOTRIENT 39 SHORT/31GX6MM 149 XOPENEX 18
WELCHOL 32VP DERMABASE 72 XOPENEX CONCENTRATE 18 VP INSULIN SYRINGE/U- WELLBUTRIN 22 XOPENEX HFA 18 100/0.3ML/29G X 1/2" 149 WELLBUTRIN SR 22 XRYLIX 58VP-CH PLUS 219 WELLBUTRIN XL 22 XTAMPZA ER 10VP-CH-PNV 219 WESTCORT 64 XTANDI 38VP-GGR-B6 PRENATAL 219 white petrolatum-mineral XULTOPHY 100/3.6 25VP-HEME OB 219 oil 227 XYREM 232WHOLE FOODVP-HEME OB + DHA 219 MULTIVITAMIN 208 XYZAL 32VP-HEME ONE 219 WIBI 72 XYZAL ALLERGY 24HR 32VP-PNV-DHA 219 WINDMILL TRAINER 154 XYZAL ALLERGY 24HR VP-ZEL 208 witch hazel (hamamelis CHILDRENS 32 VRAYLAR 41 virginiana) 75 YASMIN 28 52 VUSION 60 witch hazel-glycerin 75 YAZ 52 VYTORIN 32 WOMENS 50+ MULTI YELETS TEENAGE
VITAMIN& MINERAL FORMULA 208VYVANSE 2 FORMULA 208 YOSPRALA 96W&F LANCETS 26G 119 WOMENS BIOMULTIPLE208 YOUR LIFE MULTI ADULTW&F LANCETS COLORED WOMENS MULTI VITAMIN & GUMMIES 20821G 119 MINERAL FORMULA 208 YOUR LIFE TEENWALGREENS ADVANCED WOMENS PACK 208 MULTIVITAMIN GUMMIES 208TRAVELLANCETS 28G 119 wound dressings 83 ZADITOR 230
zafirlukast 16
Index 60
zaleplon 98 ZAMICET 11 ZANAFLEX 223 ZANTAC 237 ZANTAC 150 MAXIMUMSTRENGTH 237 ZANTAC 75 237 ZARONTIN 22 ZARXIO 97 ZATEAN-CH 219 ZATEAN-PN DHA 219 ZATEAN-PN PLUS 219 ZE-PLUS 208 ZEBETA 47 ZECUITY 155 ZEGERID 238 ZEGERID OTC 238 ZEJULA 39 ZELAPAR 40 ZELBORAF 39 ZEMBRACE SYMTOUCH 155 ZENPEP 89 ZENZEDI 2,3 ZEPATIER 46 ZERIT 45 ZESTORETIC 36 ZESTRIL 34 ZETIA 33 ZETONNA 224 ZIAC 36 ZIAGEN 45 ZIANA 57 zidovudine 45 zileuton 16 ZIMS CRACK CREMEDAYTIME 72 ZINBRYTA 234 zinc 158 ZINC 208 zinc gluconate 158 zinc oxide (topical) 75 zinc sulfate 158 ZINC W/A&C 160 ZIOPTAN 231 ziprasidone hcl 41 ZIPSOR 7 ZITHROMAX 100
Index 61
ZITHROMAX TRI-PAK 100 ZITHROMAX Z-PAK 100 ZMAX 100 ZN-PLUS 221 ZOCOR 33 ZOFRAN 29 ZOFRAN ODT 29 ZOHYDRO ER 10 ZOLINZA 39 zolmitriptan 155 ZOLOFT 23 zolpidem tartrate 98 ZOLPIMIST 98 ZOMACTON 92 ZOMIG 155 ZOMIG ZMT 155 ZONEGRAN 21 zonisamide 21 ZONTIVITY 96 ZOO FRIENDSCOMPLETE 212 ZORBTIVE 92 ZORVOLEX 7 ZOSTAVAX 241 ZOSTRIX DIABETIC FOOTPAIN 74 ZOVIRAX 47,61 ZUBSOLV 12 ZUPLENZ 29 ZURAMPIC 96 ZYBAN 234 ZYCLARA 72 ZYCLARA PUMP 72 ZYDELIG 39 ZYFLO 16 ZYFLO CR 16 ZYKADIA 39 ZYLET 230 ZYLOPRIM 96 ZYMAXID 228 ZYPREXA 42 ZYPREXA RELPREVV 42 ZYPREXA ZYDIS 42 ZYRTEC ALLERGY 32 ZYRTEC CHILDRENSALLERGY 32 ZYTIGA 38
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